Type 2 Diabetes

Nineteenth century diets for diabetes were just as varied as those of the twentieth century. The Italian physician Cantani, who had a large and lucrative private practice, enforced starvation by locking his patients in their rooms and feeding them on lean meat, fat and dilute alcohol [5].

Cantani treated his diabetic patients by eliminating carbohydrates and prescribing an exclusive meat diet.[3] He believed that stopping glycosuria was the major method of controlling diabetes.[4] He allowed his patients as many calories as they could tolerate without glycosuria. Later he limited daily food intake to about one pound of cooked meat. If glucosuria persisted, he fasted his patients.[5] The exclusive meat diet would continue for several months but if urine was not free of sugar it would extend to six or nine months.[3] To control glycosuria, Cantani would enforce his diet restrictions. He would often lock his patients in a room, so they adhered to the strict diet.[6] He performed microscopic studies on the organs from thousands of cases and observed that atrophy and fatty changes were more frequently found in the pancreas of diabetic patients than of non-diabetics.[7][8]

https://en.wikipedia.org/wiki/Arnaldo_Cantani

Professor Arnoldo Cantani, one of the most brilliant and distinguished of Italian physicians, died on May 1st, aged fifty-seven. His death was caused by Bright's disease, a malady concerning which he had written much. He was at the time of his death Professor of Clinical Medicine in the University of Naples. While at Naples he wrote monographs upon the “ Diseases of Metabolism,” “ Progressive Atrophy of the Skin," “ Lathyrismus," “ Enteroklysma,” “ Different Morbid Aspects of Individual Infective Disease,” to say nothing of a vast number of occasional monographs and notes on his favorite themes of fever, inflammation, and infection. “ The predominant note in Cantani’s character," writes a Neapolitan correspondent of The Lancet, “ was serenity. No one possessed a calmer, more perfectly balanced judgment; no one was further removed from all that savors of flattery or assentation. He had in a rare degree what professional men call the ‘ clinical eye ’ —a possession all the more remarkable in that he did not lay himself out so much for consultant practice as for investigation in the pathological laboratory. The honors, of which he had more than his share, came to him unsought, and he never was heard or seen to set store by them. Called in 1889 to the Senate of the kingdom, his health, never robust, kept him from taking part in its deliberations, except in rare crises in the State. Outside his professional sphere, and that was an extensive one, he had but one predilection—he was passionately fond of music.”

ARNALDO CANTANI, M.D., Professor of Clinical Medicine in the University of Naples. WE regret to announce the death of Professor Arnaldo Cantani, one of the foremost physicians and teachers of Italy, which took place on April 29th. He had been disabled by illness for about two years, but the end came somewhat unexpectedly on the twenty-fifth anniversary of his induction into the chair in which he won distinction as one of the most influential reformers of medical teaching in Italy. Cantani was born at Hainsbach in Bohemia in 1837, but his father was a Neapolitan. In 1855 he entered on the study of medicine in the University of Prague, where he took his degree in 1860. Immediately afterwards he was chosen by Professor Jaksch to be his principal assistant, and for some years he was Privat-docent, taking the professor's place in the lecture room on several occasions with much acceptance. While at Prague he translated Niemeyer's work, Special Pathology and Therapeutics, into Italian. There also he became acquainted with bsalvatore Tommasi, who was destined to take an equally prominent part in the medical renascence of Italy In 1864 the Italian Government offered Cantani the Chair of Materia Medica and Toxicology in the University of Pavia. In 1867 he won by competition the appointment of Physician and head of the Medical Clinic at the Ospedale Maggiorept Milan. Finally, in 1868, the Italian Government invited him to fill the Chair of Clinical Medicine in the University of Naples, which he continued to occupy till his death. So attached was he to the country which had readopted him, that he declined an offer of one of the chairs of clinical medicine in the University of Vienna, which was made to him on the death of Bamberger. 

Cantani's influence as a teacher made itself felt chiefly In the infusion of the modern scientific spirit into Italian medicine, which even thirty years ago was still largely under the sway of " systems," in which facts were' made to fit the Procrustean bed of theory. Cantani laboured by precept and example to rehabilitate the accurate observation and careful collection of facts which had in the sixteenth and seventeenth centuries been the distinctive features of the Italian schools. 

Cantani contributed largely to medical literature on cholera, typhoid fever, rabies, and diabetes. His most important work was his Trattato di Aateria Medica e Farmacologia; his last publication was a work entitled Pro Sylvis, which was a plea for the preservation of forests from the hygienic not less than the aesthetic point of view. 

His funeral was attended by the whole medical faculty of Naples, by representatives of the Senate and Chamber of Deputies, by the Minister of Education, and by the administrative and executive authorities of the province of Naples, and an immense concourse of the general public. Funeral orations were delivered by Professor de Amicis, President of the Medical Faculty, by Professors Gallozzi, De Renzi, and others.

https://babel.hathitrust.org/cgi/ssd?id=uc1.31378008338645;page=ssd;view=plaintext;seq=28;num=14

"According to Vierordt, humans must necessarily absorb 120 grams per day. of albumin, 90 gram. of fat, 330 gram. of hydrated carbides, 2.635 gram. of water and 32 gram. mineral salts. These numbers would be an average. We can take them as such, and take them as a starting point in our studies or our experiences. Let us now study the toll of carnivores, and notice that meat does not is not only albumin, that it contains a quantity of combustible substances: gelatin, fats, muscle sugar, lactic acid. To feed a dog exclusively with meat, it is necessary to give him 40 to 50 grams each day. per kilogram. of its weight: below it will lose weight, above it it will increase in weight. Sees has found that under these conditions a dog absorbs more oxygen than with a mixed diet, and from the therapeutic point of view this is very important: this increase is due to albumin, not to fats nor with gelatins. Digested and assimilated albumin is not used in a single form: according to the uses to which it is to be employed, it will be transformed in various ways; it will take two main forms, which Voit has thus designated: tissue albumin (Organeiweiss), and circulating albumin or provisional albumin (Circulirendes Eiweiss, Vorrathseiweiss), or else blastema or plasma. On this point, Sees is agreement with Bischoff, J. Ranke and Weigelin, and also with our own research. "Tissue albumin" which we prefer to call organized albumin, constitutes the solid parts of tissues, membranes and cell nuclei, it is not as easily attacked by oxygen as "circulating albumin" which I call fluid albumin and which constitutes the amorphous liquid content of tissues. The more meat is eaten, and the more it accumulates in the body of circulating fluid albumin, the more oxygen it absorbs to burn this excess albumin, and produce urea or acid. uric. When a dog is fed on meat and fat, this last substance is an excellent fuel, which spares a lot of albuminates, by burning itself in their place, and taking their oxygen from them, which makes them less combustible. From this results this fact, that such a diet increases the weight of the body, the mass of the flesh, and sometimes also the fatty deposits. In the balance sheet of omnivores, it is about saving as much albuminates, supplying the organic oxidation process with another fuel that is even more economical than fats. By giving the dog meat and hydrocarbons, one could theoretically expect a greater saving of albuminates, since hydrocarbons are more combustible and more oxygenated than fats. In fact, this is what takes place: albuminates are spared, as well as fats, the accumulation of which is thus favored; if the hydrocarbons are introduced in excess, they very markedly decrease, according to Voit, the organic consumption. According to Pettenkofer and Voit, two parts of hydrocarbons are equivalent for the carnivore to one part of fat. Bread alone would not be enough to feed carnivores, or even man; to introduce a normal quantity of nitrogen, it would be necessary to absorb too much starch, which would not be tolerated for long. According to Ranke, collagens do not only spare albuminates, but also fats and even hydrocarbons circulating in the plasma stream: however this excellent fuel would provide little heat. The inorganic substances contained in our food are also of very great importance for nutrition and material exchange; the main ones are: sodium chloride, salts of soda, potash, lime, magnesia, phosphoric acid, water. All these inorganic bodies accelerate the endo- and exosmotic current, the plasma current, and increase the oxidation of circulating albumin. The salts of potash, and especially the phosphate of potash, promote, according to Kemmerich, the production of muscular tissue; according to Ranke, these potassium salts decrease the resistance to cells, would allow an easier passage of the plasma current, and would also promote the organization of albumin or albumin formation of tissue. The excess po- cup would become harmful by the too great depression of the vegetative activity. Water is essential as a liquid menstrual for all processes of diffusion or transformation, oxidation or decomposition, introduction or export. But the excess water in the tissues indicates a sluggish life, a slow and lazy renewal. The balance of herbivores is not essentially different from that of carnivores. The materials used are different, but the results are much the same. Herbivores introduce much more fuel, which promotes fatty deposits; it also seems that they digest at least part of the cellulose, which no carnivore does, including humans. By giving the herbivore nitrogenous food, we do not increase its musculature, but only its reserve of fat. Man is omnivorous, he eats everything: he offers considerable resistance, lives longer than most animals, thanks to his varied and restorative diet, but above all thanks to the influence of his system. nervous system so developed, on vegetative activity and the renewal of its tissues. Meat is certainly his primary food, for hunting, fishing and herding herds preceded agriculture; bread came in later. But the flesh, which man digests very well, remains his best food; it makes him stronger, more energetic, more resistant than is the man living exclusively on vegetables and fruits. And it is with peoples as with individuals: herbivorous peoples degenerate, carnivores progress, in this meaning we could say that the cuisine of peoples is part of their national history. The material renewal varies in intensity according to the various ages. The child oxidizes more, but produces more than he consumes: it is the most plastic age. Likewise, but to a lesser degree in the young man. In middle age, balance is established. In the elderly, despite less consumption, production was no longer sufficient to cover the deficit; regressive metamorphosis wins; it is the organism's first step towards returning to the inorganic state. Let us also note organic individuality as the cause of a variable renewal, too rapid in some, too slow in others. Assuming the correct proportions of the foods introduced, we can distinguish four ways of being of material renewal: 1 ° Regular and balanced renewal; 2 ° excessive consumption; 3 ° self-consumption or autophagy; 4 ° lack of water. In the first case, physiologists admit that all the albuminates introduced replace an equal quantity of organic substances; the more we introduce, the more tissues to renew will be consumed; all the decomposition products found in the urine and other excretions would therefore come from the tissues burned and consumed, and not from the albuminates introduced by the diet. In excessive consumption, there would be an excess introduction of albuminates, only a part of which would serve to renew the tissues, while the other would be burned directly in the blood. The body would not gain weight, since the amount of albuminates intended to increase body mass would be used as fuel. For me, I believe that even in humans well;

Page 21:

The fats introduced into the organism are burnt there, and give as the last residues water and carbonic acid. The hydrated carbides are starch and scre, and since starch always turns into sugar, all hydrocarbons should be considered sugar. By oxidation they are transformed into lactic acid, and give as last residues water and carbonic acid, as do fats

Page 33

To this order of abnormalities belong according to us: diabetes mellitus, oxaluria, gout, uric and calcareous gravel, adipose polysarchaia. (6) Renewal anomalies with consecutive systemopathy by abnormal elaboration of nutrient materials absorbed into the blood, among which we note: Rickets, Osteomalacia, (c) Renewal anomalies with consecutive systemopathy, for example excess or insufficiency in the absorption of certain food substances, which would be scurvy, hydremia and hydrorgania. 2 ° Renewal abnormalities with systemopathy by constitutional defect, which primarily resides in the tissues themselves, irregularly developed, and, for that, endowed with abnormal reactions or little resistance: the main ones are: Nervous erethism, Scrofulosis, Hemophilia, Chlorosis. 3 ° Anomalies of material renewal with systemopathy, having the character of reaction to agents hostile to organic life, which have penetrated into the tissues or into the circulating blood: these harmful agents come either from the economy itself , or from the outside world, and disturb the renewal of the chemical and morphological cular. Here we find: Fever, Primary phlogosis in general, and in particular acute or chronic rheumatism, certain generalized eczemas, certain fleeting erythemas, urticaria, etc., Virulent infection (contagious diseases and mias - matics), Chemical poisoning (acetonemia, cholemia, ammoniaemia, blood dissolution), Chemical poisoning (lead poisoning, arsenicism, hydrargyrosis, etc., ergotism, lathyria, etc.). In diseases where the whole organism changes its type of vegetation, of chemical direction, the organism transforms food substances to a certain point, without leading them to complete decomposition, thus interrupting the series of normal transformations. Its processes of biological chemistry are no longer sufficient for their task, and the imperfect products of their elaboration remain useless or harmful: these products, by accumulating, all become in the long run very harmful. Examples include diabetes, gout, polysarchaia, oxaluria. The diseases of this group can affect the entire economy more or less seriously, preferably without affecting any organ. Other times the abnormal or retained products almost exclusively affect certain organs or certain tissues, which should have eliminated them in another form, as happens with kidney stones, including oxaluria. At other times the whole organism is affected, but certain organs feel it especially and in a very special way,

Page 35:

By systemopathies I mean those diseases of renewal, those anomalies of organic chemism, in which the disturbance of the processes of chemical transformation affects the nutrition of the whole organism less than that of a specific type. of tissue, of a physiological and histological system of our tissues. Given an alteration of the blood crase, it is easily understood that certain tissues suffer from it more than others, and that this influence extends to all the tissues having between them a certain affinity of nutritional needs, and belonging to the same histological system. A chemical substance whose presence or preponderance in the blood will alter the nutrition of a bone, can and must interfere with the nutrition of other bones: from then on all other bones will be disposed to become diseased, if an occasional cause occurs. Likewise, a substance capable of making the serous membranes of the joints sick can act on the pericardium, endocardium, pleura and other serous membranes. This is the case in rickets, osteomalacia, scurvy, hydremia, hemophilia, scrofulosis, nervous erythema. Finally, in the diseases which have a character of reaction to the harmful agents which have penetrated into the blood, we find above all affected a physiological system: the skin and the mucous membranes in eruptive fevers, the hemocytopoetic and lymphatic glandules in the ileo - typhus, muscles and nerves in lead poisoning, muscles in lymphadenism, etc. In phlogoses which present several foci, It is understood that there is not a single disease without secondary alteration in the composition of the blood, and without at least a local disturbance of molecular renewal. This disorder can spread secondarily to the entire economy. In the course of these lessons, we will mainly deal with the diseases that have been studied in our studies from the point of view of molecular renewal. The most completely treated will be diabetes mellitus. We will speak of others, as much as is possible in the present state of our knowledge, from the pathologico-etiological and therapeutic point of view.

Page 39:

The Portuguese Amato Lusitano says he cured two diabetics by a very nourishing diet and the use of purgatives. Maybe' Were there cases beginning treated by the diet especially meat. Another Portuguese, Zacuto Lusitano, cures two cases with donkey milk: this is very interesting if we think of the undoubted advantages that we have obtained from the use. lactic acid, and the cure by the milk diet proposed today in England by Donkin. The Italian Cardano had the opportunity to study diabetes on himself, probably it was diabetes insipidus. He also describes a case observed in a young girl, and the first he weighed the urine: according to her calculation, this young girl absorbed only 7 pounds of solid food or drink each day, and gave 36 pounds of urine.

Page 41:

Sydenham came up with an idea, which is like the prelude to current ideas. According to him diabetes is an assimilation disease, in the sense that the chyle is not fully digested in the blood, and should therefore be eliminated by the kidneys as a foreign body. For treatment he strongly recommended a rich diet in meat, and narcotics, especially theriac.

Page 42:

Morton regarded diabetes as a kind of phthisis, and attributed the mild flavor of the urine to the flow of the sweet chyle to the kidneys. In etiology, he cites the influence of heredity, kinship, race. He encountered diabetes in the father and son, and another time in a small child who had lost three brothers to diabetes. 

Mead maintains that diabetes is a disease of the liver: he wants to prove it by autopsies which all showed him steatomatosis of the liver. He explains the sweet taste of urine by the separation of salt from bile. 

Dobson demonstrated that diabetic urine can produce alcohol and vinegar by fermentation: he succeeded in preparing very clearly sugar by evaporating the urine: he also discovered the sweet flavor of the serum of the blood of diabetics, and thus demonstrated that sugar exists in the blood of these patients and is not formed in the kidneys.  According to him, it is a defect of assimilation of the chyle which causes the glycosuria: the sugar of the chyle accumulating unaltered in the blood, would come out by the urine. This shows that Dobson already admitted the passage of sugar from food into the blood; he also admitted an abnormal fermentation, and believed that the acidic breath of diabetics was due to the acid fermentation of the sugar contained in saliva. 

Cullen said the diabetes was neuropathy, a spastic disease. However, he recognized the vice of assimilation of chyle. He denounced the ineffectiveness of all remedies. 

Home recognized that by weighing not only the drinks introduced, but also the more or less liquid foods, the quantity of urine does not exceed the quantity of liquids absorbed; he also noticed that the quantity of urine emitted is greater at certain times. Home made quantitative analyzes, and weighed the sugar obtained; he had in one patient an ounce of sugar for a pound of urine, in another an ounce and a half. He confirmed the fermentation capacity of urine with the addition of yeast, and thus showed that it lost its sweet flavor to take on that of small beer. As for the theory, he accepted Dobson's: he treated his patients with a diet consisting mainly of meat.

Page 44: 

Here we close our second period by noting that several of the authors cited lived after the publication of Rollo's works, works intended to prepare for the era of experimental studies. The third period, therapeutic period, is again inaugurated by an Englishman, John Rollo, who at the end of the last century published the story of two cases of diabetes. Rollo was the first to emit, on the pathogenesis of diabetes, a theory which, modified on various points, became widely later; many authors attribute their authorship to Bouchardat. According to this theory, diabetes is a disease of the stomach with overactivity, with exaggerated secretion of abnormal gastric juice, which converts all starchy substances into sugar; this sugar absorbed in the blood would come out with the urine. Note, however, that Rollo did not know that starch normally turns into sugar. This is why he advises to treat diabetes with an especially animal diet, and with drugs that slow down the activity of the stomach: vines and fats only at dinner and at supper: at breakfast one and a half liters of milk, with buttered bread. As drugs, ammonium sulphide, opium and emetics. This treatment, as we can see, somewhat resembled the Bouchardat or Seegen regime. In the hands of Rollo and his contemporaries, he gave mediocre results, which the author attributes to the inaccuracy of patients in following their diet: he notes that they have frequent indigestion, disgust for meat, gastroenteric catarrhs, and he attributes all this to the meat diet: it seems to us that one could, with all appearance, attribute to the drugs indicated above ammonium sulphide, ipecac, stibiae tartar, etc. My patients tolerate a much more rigorous diet and that for several months; they digest very well and eat perfectly. 

After Rollo we have Bouchardat who adopted the same theories, however modifying them so as to adapt them: 1 ° to the discovery made by Tiedemann and Gmelin, that starch is normally transformed into sugar in the intestine, by action of saliva, pancreatic and enteric juice, 2 ° to this fact, demonstrated by Magendie, that this sugar is normally absorbed in the blood. Bouchardat, also admitting that the cause of diabetes is stomach disease, says that starch is transformed into sugar so quickly that too much of it enters the blood in a given time, and the blood, overloaded with sugar, lets part of it escape through the urine. This is Rollo's theory and the same overactivity of the stomach: it is still the same therapy. Bouchardat menus have become famous: meat, cabbages, peaches, lemons, gluten bread, which should only contain nitrogenous substances, and which, in fact, contains far too much starch. It cannot be denied that, of all the treatments offered so far, that of Bouchardat, which basically is that of Rollo, minus ammonium sulphide and emetics, has had the best fortune and deserved it. The goal was not completely achieved, because the regime is not severe enough, but it is very close to the truth: none of the authors and practitioners who came after Bouchardat could neglect the use of his culinary menu. 

Prout also believed that diabetes is a form of dyspepsia: but he saw it as a defect in stomach activity, a difficulty in assimilating sugary foods. 

Gregor, from London, argued that diabetes resides in the stomach. 

Griesinger expressed the opinion that diabetes depends on rather qualitative disturbances in the digestive functions of the stomach, because the disease often begins with noticeable disturbances in digestion. According to him, the great thirst of the diabetic who eats starches, his less thirst when he eats meat, cannot be explained, with the hepatic theories of diabetes, but rather by gastric digestion disorders, by the rapid transformation of starch into sugar, and rapid absorption of sugar into the blood. In addition, the alteration of the digestive ferment of the stomach is a proven fact; the stomach juice of a diabetic on an empty stomach, obtained by vomiting, would contain a ferment which rapidly transforms starch into sugar, which normal gastric sugar would not. Griesinger regrets that this difference has not been sufficiently taken into account; he also admits as possible that, in the stomach and intestines, the albuminates ingested provide sugar in diabetics.

LESSON SEVEN Observations of diabetics not completely cured or dead. 

SUMMARY. Cases of diabetes which cannot be cured due to lack or insufficient treatment. Cases which do not heal completely with the treatment. Absolutely incurable cases. · Clinical observations of the cases of diabetes observed by me, and which are not cured completely (LXXIV to XCVII). 

Observations of cases of diabetes followed by death (XCVIII to CV). GENTLEMEN, If the cases exposed in the preceding lesson are to be regarded as cases of cure, since the patients can return to the mixed feeding, provided that they never again abuse mealy and sweets, the cases that I will report to you today must be regarded as improved: one could say that their diabetes is suppressed, that the diabetic symptoms are overcome; however, since glycosuria persists, or recurs on the first attempt at sugary foods, these cases cannot be considered cured. 

Let us note first that among all these patients, there are some who could not be cured, only because they did not take the cure for a sufficient time, in fact because they do not want to be cured; this is the greatest number. The sugar disappeared, the patients quickly left the cure, and the sugar returned. I have seen many of these cases, and others have seen them as well. A month, and even two, of very rigorous cure seldom suffices, and only in recent diabetes: it takes at least three months, and three more months to arrange for a gradual return to the mixed diet, when these cases cannot be considered cured. the patient will not have sufficient confidence and patience to continue the treatment, it will be better for the doctor not to recommend it: he will spare himself a disillusion and will spare his patient a painful and fruitless treatment. There is another series of patients who do not recover because, with them, the disease is too advanced: treatment can improve their condition, but no longer eliminate the disease. Others, who can be considered almost cured, can eat anything except cane sugar and starch: still others can only tolerate vegetables low in glycosides, but milk and fruit. bring back melituria: finally others can only eat meat and fat, and are forced to continue the rigorous cure indefinitely, under penalty of seeing glycosuria reappear: in the long run, the sugar reappears in the urine despite the diet. There is another group of cases in which diabetes has to be declared incurable, although it improves steadily as long as the patients remain under our treatment. Indeed, we see the painful symptoms that we can really call diabetic disappear, thirst, polyuria, impotence, progressive slimming; the individual lives in a tolerable situation, he can satisfy his obligations, provided he continues a rigorous cure or so. But there is still glycosuria, which cannot be suppressed by any means (except chronic man-made poisonings with opium, etc.). It goes without saying that you cannot cure a diabetic, nor logically have this claim when consumption and the general stagnation have brought about the irreparable atrophy or the destruction of an organ essential to the continuation of life

ON THE TREATMENT OF DIABETES. A CLINICAL LECTURE DY PROFESSOR DOJARDIN-BEAUMETZ, Member of the Academy of Medicine Physician to the Hôspital St. Antoine, Paris, France 

GENTLEMEN, 

The dietetic treatment of diabetes deserves the first place. Ever since John Rollo at the end of the last century first called attention to the influence of foods in the production of glycosuria, all authorties have felt the obligation to regulate rigorously the diet of diabetic patients. At their head is Bouchardat; after him I will mention especially Seegen, a German writer, and Cantani, an Italian, and what I have now to offer respecting the hygienic regime of this affection will be based on a careful study of the contributions of these three men. The hygienic treatment is founded on the endeavor, far as possible, to exclude from the food all substances capable of forming glucose. This glucose may be derived from sugar in the ingesta, or from starch which has undergone conversion in the alimentary canal. These glycogenous principles, then, should bo suppressed. All this, however, though simple in theory, is difficult in practice.

DIABETES MELLITUS.

BY JAMES TYSON, A.M., M.D.

Diabetes mellitus is a term applied to a group of symptoms more or less complex, of which the most conspicuous is an increased flow of saccharine urine—whence the symptomatic title. It is associated with a derangement of the sugar-assimilating office of the liver, as the result of which an abnormally large quantity of glucose is passed into the hepatic vein and thence into the systemic blood, from which it is secreted by the kidneys. The condition is sometimes associated with alterations in the nervous system, at others with changes in the liver or pancreas, while at others, still, it is impossible to discover any structural alterations accompanying it.

Dr. Pavy has recently put forward some chemical theories which explain the action of the hyperæmia in producing glycosuria, but they do not account for the hyperæmia itself. In healthy digestion the carbohydrates (starch and sugar) are converted, not into glucose, but into maltose, C12H22O11, dextrin being intermediate in composition. Maltose is absorbed and assimilated, converted into glycogen. So, too, when glucose is ingested as such, it is converted by the glucose ferment into maltose in the stomach and intestines. For the proper production of maltose and its assimilation a good venous blood, producing a maltose-forming ferment, is necessary. In diabetes, in consequence of the dilatation of the arteries of the chylopoëtic viscera, the blood enters the liver too little deoxygenated, and a glucose-forming ferment is produced. The glucose thus formed is not assimilable, but passes off into the circulation and the urine.

ETIOLOGY.—The problem of the etiology of diabetes mellitus is as unsatisfactorily solved as is that of its pathogenesis. Certainly, a majority of cases of diabetes cannot be accounted for. A certain number may be ascribed to nervous shock, emotion, or mental anxiety; a few to overwork; some to injury and disease of the nervous system; others to abuses in eating and drinking. Among the injuries said to have caused diabetes are blows upon the skull and concussions communicated to the brain, spinal cord, or vaso-motor centres through other parts of the body. Hereditation is held responsible for a certain number of cases. Malarial and continued fevers, gout, rheumatism, cold, and sexual indulgence have all been charged with producing diabetes.

Diabetes mellitus is most common in adult life, although Dickinson reports a case at six years which was fatal, Bence Jones a case aged three and a half, and Roberts another three years old; and in the reports of the Registrar-General of England for the years 1851-60 ten deaths under the age of one and thirty-two under the age of three are included. This statement, in view of the experience of the difficulties of diagnosis in children so young, seems almost incredible. I have never myself met a case in a child under twelve years. At this age I have known two, of which one, a boy, passed from under my notice, while the second, a girl, recovered completely. The disease is most common between the ages of thirty and sixty. The oldest patient I have ever had died of the disease at seventy-two years, having been under my observation for three and a half years.

It is decidedly more frequent in men than in women, carefully prepared statistics of deaths in Philadelphia during the eleven years from 1870 to 1880, inclusive, giving a total of 206 deaths, of which 124, or three-fifths, were males, and 82, or two-fifths, females. This is the experience of all.

My own experience has been singular and interesting. Up to April, 1881, I had never met a case in a woman. Of 18 cases outside of hospital practice which I have noted since that date, 9 were men and 9 women. But I still do not recall an instance of a woman in hospital practice, although I have constantly cases among men.

Not much that is accurate can be said of the geographical distribution of the disease. It seems to be more common in England and Scotland than in this country, at least if the statistics of New York and Philadelphia are considered. In the former city, statistics extending over three and a fourth years show that out of 1379 deaths, 1 was caused by diabetes; in Philadelphia, in eleven years, 1 out of 875; in England and Wales, according to Dickinson from observations extending over ten years, 1 out of 632; and in Scotland, 1 out of 916. According to the same authority, the disease is more prevalent in the agricultural counties of England, and of these the cooler ones, Norfolk, Suffolk, Berkshire, and Huntingdon. According to Senator, it is more common in Normandy in France; rare, statistically, in Holland, Russia, Brazil, and the West Indies, while it is common in India, especially in Ceylon, and relatively very frequent in modern times in Wurtemberg and Thuringia. Seegen says it is more [p. 204]frequent among Jews than among Christians, but I have never seen a case in a Hebrew.

Changes in diet of course modify the secretion of sugar, starches and saccharine foods increasing it, while nitrogenous and oily foods diminish it. So, too, the urine secreted on rising in the morning has almost always less sugar in it than that passed on retiring; and it is not rare to find no sugar in urine passed on rising, when that passed on retiring at night may contain a small amount of sugar—from ¼ to 1 per cent. On the other hand, I have found a small amount of sugar in the morning urine when the evening urine contained none. Anxiety and excitement both increase the proportion of sugar.

DURATION.—Diabetes is a disease of which the duration is measured by months and years, and although cases are reported in which death supervened in from six days to six weeks after the recognition of the disease, it is evident that such periods do not necessarily measure its actual duration. The disease may have existed some time before coming under observation. On the other hand, a case is reported by Lebert which lasted eighteen years; another, under the successive observation of Prout and Bence Jones, sixteen years; and a third, under Bence Jones and Dickinson, fifteen years. The younger the patient the shorter usually is the course run and the earlier the fatal termination. Yet I have known a girl of twelve recover completely. After middle age the disease is usually so easily controlled by suitable dietetic measures, if the patient is willing to submit to them, that its duration is only limited by that of an ordinary life, while carelessness in this respect is apt to be followed by early grave consequences.

Again, it is well known that the later in life diabetes occurs the more amenable it is to treatment, and that if a proper diabetic diet be adhered to by the patient his life need scarcely be shortened. On the other hand, diabetes mellitus is a disease in which the expectant plan is dangerous. If it does not improve it usually gets worse; and many a patient has fallen a victim to his own indifference and indisposition to adhere to a regimen under which he could have lived his natural term of life. This is especially the case when the disease appears after middle life.

If, on the other hand, the condition becomes thoroughly established before twenty-five years of age, it is less amenable to treatment; but even in such cases a promptly vigorous treatment is sometimes followed by recovery. I have already mentioned the case of a child twelve years old in which complete recovery took place.

TREATMENT.—The treatment of the aggregate of symptoms known as diabetes mellitus is conveniently divided into the dietetic, the medicinal, and the hygienic, of which the first is by far the most important. The efficiency of this treatment depends upon the successful elimination from the diet of all articles containing grape-sugar, cane-sugar, beetroot-sugar, and starch, it being universally recognized that in the early stages of the disease these foods are the sole source of the glucose in the urine. The normal assimilative action of the liver, by which the carbohydrates are first stored up as glycogen, and then gradually given out as glucose or maltose to be oxidized, being deranged, such foods not only become useless as aliments, but if continued seem to aggravate the glycosuria, and the excretion of sugar steadily increases. There is, therefore, a double reason for excluding them from the food. This is easiest accomplished by an exclusive milk diet. The exclusive milk treatment of diabetes was suggested by A. Scott Donkin in 1868. That he is correct in his assertion that in the early stages of diabetes lactin or sugar of milk is quite assimilable, and does not in the slightest degree contribute to the production of glycosuria, I cannot doubt; that it is in this respect even superior to casein, as claimed by Donkin, I am not prepared to state from actual knowledge; but that casein itself resists the sugar-forming progress immeasurably greater than any other albuminous substance, so that in all but the most sure and advanced or complicated cases its arrest is complete, I am also satisfied. Certain it is that in a large number of diabetics the use of a pure skim-milk regimen results in a total disappearance of the sugar from the urine. That in a certain proportion of these cases a [p. 219]gradual substitution of the articles of a mixed diet may be resumed without a return of the symptoms is also true. In other more confirmed cases the use of skim-milk results in a decided reduction in the amount of sugar, with an abatement of other symptoms, which continues as long as the diet is rigidly observed. In still other cases, while the skim-milk treatment makes a decided impression upon the quantity of sugar, it still remains present in considerable amount, while the disease progresses gradually to an unfavorable issue. These three classes of cases represent, ordinarily, different stages of the disease, so that it may be said that as a rule cases recognized sufficiently early may be successfully treated with skim-milk, although it may occasionally happen that cases pursue a downward course from the very beginning despite all treatment. Yet I have never seen a case which, when taken in hand when a few grains of sugar only to the ounce were present, failed to yield to this treatment.

While I am confident that the promptest and most effectual method of eliminating sugar from the urine is by a milk diet, it occasionally happens that a patient cannot or will not submit to so strict a regimen. In other instances, again, it is not necessary to resort to it, because a less restricted diet answers every purpose.

A suitable diabetic diet would also be obtained by eliminating from the bill of fare all saccharine and amylaceous and other sugar-producing substances. Such a diet is, strictly speaking, impossible. For, apart from the fact just mentioned that even fats, as well as albuminous substances to a degree, are capable of producing glycogen, the monotony of a pure meat diet soon becomes unbearable, to say nothing of other derangements it may produce. Fortunately, it is not necessary that such an exclusive diet should be maintained, for certain saccharine foods seem capable of resisting the conversion into sugar more than others. Sugar of milk, or lactin, has already been mentioned as one of these, and to it may be added the sugar of some fruits, and probably also inosit or muscle-sugar, mannite or sugar of manna, and inulin, a starchy principle abundant in Iceland moss. It is found also that there are many vegetable substances containing small quantities of sugar and sugar-producing principles which may be used with impunity in at least the milder forms of diabetes. This being the case, a bill of fare for diabetics may be constructed quite liberal enough to satisfy the palate of most reasonable persons by whom it is attainable.

FOOD AND DRINK ADMISSIBLE.—Shell-fish.—Oysters and clams, raw and cooked in any way, without the addition of flour.

Fish of all kinds, fresh or salted, including lobsters, crabs, sardines, and other fish in oil.

Meats of every variety except livers, including beef, mutton, chipped dried beef, tripe, ham, tongue, bacon, and sausages; also poultry and game of all kinds, with which, however, sweetened jellies and sauces should not be used.

Soup.—All made without flour, rice, vermicelli, or other starchy substances, or without the vegetables named below as inadmissible. Animal soups not thickened with flour, beef-tea, and broths.

Vegetables.—Cabbage, cauliflower, brussels-sprouts, broccoli, green [p. 221]string-beans, the green ends of asparagus, spinach, dandelion, mushrooms, lettuce, endive, coldslaw, olives, cucumbers fresh or pickled, radishes, young onions, water-cresses, mustard and cress, turnip-tops, celery-tops, or any other green vegetables.

Fruits.—Cranberries, plums, cherries, gooseberries, red currants, strawberries, apples, without sugar. Or they may be stewed with the addition of bicarbonate of sodium instead of sugar. (See below.)

Bread and cakes made of gluten, bran, or almond flour, or inulin, with or without eggs and butter. Griddle-cakes, pancakes, biscuit, porridges, etc. made of these flours. Where especial stringency is required these should be altogether omitted.

Eggs in any quantity and prepared in all possible ways, without sugar or ordinary flours.

Nuts.—All except chestnuts, including almonds, walnuts, Brazil-nuts, hazel-nuts, filberts, pecan-nuts, butternuts, cocoanuts.

Condiments.—Salt, vinegar, and pepper in moderate quantities.

Jellies.—None except those unsweetened. They may be made of calf's-foot or gelatin and flavored with wine.

Drinks.—Coffee, tea, and cocoa-nibs, with milk or cream, but without sugar; also milk, cream, soda- (carbonated) water, and all mineral waters freely; acid wines, including claret, Rhine, and still Moselle wines, very dry sherry; unsweetened brandy, whiskey, and gin. No malt liquors, except those ales and beers which have been long bottled, and in which the sugar has all been converted into carbonic acid and alcohol.

Vegetables to be especially Avoided.—Potatoes, white and sweet, rice, beets, carrots, turnips, parsnips, peas, and beans; all vegetables containing starch or sugar in any quantity.

The following list, including essentially the same articles, but arranged in the shape of a true bill of fare, by Austin Flint, Jr.,49 will be found very convenient:

BILL OF FARE FOR DIABETES.—Breakfast.—Oysters stewed, without flour; clams stewed, without flour. Beefsteak, beefsteak with fried onions, broiled chicken, mutton or lamb chops; kidneys, broiled, stewed, or devilled; tripe, pigs' feet, game, ham, bacon, devilled turkey or chicken, sausage, corned-beef hash without potato, minced beef, turkey, chicken, or game with poached eggs. All kinds of fish, fish-roe, fish-balls, without potato. Eggs cooked in any way except with flour or sugar, scrambled eggs with chipped smoked beef, picked salt codfish with eggs, omelets plain or with ham, with smoked beef, kidneys, asparagus-points, fine herbs, parsley, truffles, or mushrooms. Radishes, cucumbers, water-cresses, butter, pot-cheese. Tea or coffee, with a little cream and no sugar. (Glycerin may be used instead of sugar if desired.) Light red wine for those who are in the habit of taking wine at breakfast.

Lunch or Tea.—Oysters or clams cooked in any way except with flour; chicken, lobster, or any kind of salad except potato; fish of all kinds; chops, steaks, ham, tongue, eggs, crabs, or any kind of meat; head-cheese. Red wine, dry sherry, or Bass's ale.

[p. 222]Dinner.—Raw oysters, raw clams.

Soups.—Consommé of beef, of veal, of chicken, or of turtle; consommé with asparagus-points; consommé with okra, ox-tail, turtle, terrapin, oyster, or clam, without flour; chowder, without potatoes, mock turtle, mullagatawny, tomato, gumbo filet.

Fish, etc.—All kinds of fish, lobsters, oysters, clams, terrapin, shrimps, crawfish, hard-shell crabs, soft-shell crabs, (No sauces containing flour.)

Relishes.—Pickles, radishes, celery, sardines, anchovies, olives.

Meats.—All kinds of meat cooked in any way except with flour; all kinds of poultry without dressings containing bread or flour; calf's head, kidneys, sweetbreads, lamb-fries, ham, tongue; all kinds of game; veal, fowl, sweetbreads, etc., with curry, but not thickened with flour. (No liver.)

Vegetables.—Truffles, lettuce, romaine, chicory, endive, cucumbers, spinach, sorrel, beet-tops, cauliflower, cabbage, brussels-sprouts, dandelions, tomatoes, radishes, oyster-plant, celery, onions, string-beans, water-cresses, asparagus, artichoke, Jerusalem artichokes, parsley, mushrooms, all kinds of herbs.

Substitutes for Sweets.—Peaches preserved in brandy without sugar; wine-jelly without sugar, gelée au kirsch without sugar, omelette au rhum without sugar; omelette à la vanille without sugar; gelée au rhum without sugar; gelée au café without sugar.

Miscellaneous.—Butter, cheese of all kinds, eggs cooked in all ways except with flour or sugar, sauces without sugar or flour. Almonds, hazel-nuts, walnuts, cocoanuts. Tea or coffee with a little cream and without sugar. (Glycerin may be used instead of sugar if desired.) Moderately palatable ice-creams and wine-jellies may be made, sweetened with pure glycerin; but although these may be quite satisfactory for a time, they soon become distasteful.

Alcoholic Beverages.—Claret, burgundy, dry sherry, Bass's ale or bitter beer. (No sweet wines.)

Prohibited.—Ordinary bread; cake, etc. made with flour or sugar; desserts made with flour or sugar; vegetables, except those mentioned above; sweet fruits.

49 "On the Treatment of Diabetes Mellitus," a paper read before the American Medical Association at its meeting in Washington, May, 1884, and published in the Journal of the association July 12, 1884. I have so far modified the bill of fare as to permit the use of milk, which Flint excludes.

One of the foods the omission of which is most illy borne by the diabetic, however great his previous indifference to it, is wheaten bread, while the substitutes which have been at different times suggested for it very imperfectly supply its place. Perhaps the best known of these is the bread made of gluten flour. It was suggested by Bouchardat in 1841, and is made by washing the ordinary wheat flour to free it from starch.50

50 The Health Food Company, of 74 Fourth Avenue, N.Y., prepare a gluten flour by first removing the five bran-coats, pulverizing the cleaned berry by the cold-blast process, stirring the powder into iced water, and precipitating the gluten, cellulose, and mineral matters, siphoning off the water holding in suspension the starch, and drying out the precipitate. In this manner the salts of the wheat are retained. A purified gluten made by the Health Food Company is deprived of the cellulose walls of the cells in which the gluten granules are held. Directions for making gluten bread and cakes of various kinds are furnished by the company on application.

Gluten flour, however prepared, contains some starch, as indeed it must if bread is to be made out of it; and I confess to having been a good deal disappointed in its use. I have known the sugar absent in a [p. 223]selected diet to return when gluten bread was permitted, and again disappear on its withdrawal. Of course gluten flour contains less starch than the ordinary wheat flour, and there may be cases where the starch in the former can be assimilated when the quantity in the latter cannot be. The gluten may be made into porridge.51

51 Gluten porridge is made by stirring the gluten into boiling water until thick enough, and then keeping up the boiling process for fifteen minutes. A little salt and butter are added at the close to improve the flavor, and it may be eaten with milk or cream.

A method of getting rid of the starch and sugar in bread, suggested by Liebig and tried by Vogel, consists in converting the starch into sugar by the action of diastase and dissolving out the sugar thus produced. This is accomplished by treating thin slices of bread with an infusion of malt. The bread is then washed, dried, and slightly toasted.

Another substitute for wheaten flour is the bran flour whence the starch is removed by washing.52 The bran itself, according to Parkes,53 sometimes contains as much as 15 per cent. of nitrogenous matter, 3.5 per cent. of fats, and 5.7 per cent. of salts. It is therefore not wholly innutritious, although the salts are washed out in removing the starch. It is considered especially useful when there is constipation, the slightly irritant properties of the bran aiding in maintaining a proper peristalsis and action of the bowels. These irritant properties are, however, inversely as the degree of comminution. The bran flour may be made with milk and eggs into a variety of cakes, of which the best known are those made according to Camplin's directions.54

52 A very carefully prepared bran flour, as well as a wheat-gluten flour, is prepared by John W. Sheddon, pharmacist, corner of Broadway and Thirty-fourth street, New York City.

53 Practical Hygiene, 5th ed., Philadelphia, 1878, p. 222.

54 The following are Camplin's directions for making biscuit of bran flour: To one quarter of a pound of flour add three or four fresh eggs, one and a half ounces of butter, and half a pint of milk; mix the eggs with a little of the milk, and warm the butter with the other portion; then stir the whole together well; add a little nutmeg or ginger or other agreeable flavoring, and bake in small forms or patterns. The cake, when baked, should be about the thickness of an ordinary captain's biscuit. The pans must be well buttered. Bake in rather a quick oven for half an hour. These cakes or biscuits may be eaten by the diabetic with meat or cheese for breakfast, dinner, or supper; at tea they require rather a free allowance of butter, or they may be eaten with curd or any soft cheese.

Where extreme restriction of diet is not required the ordinary bran bread of the bakers may be used. The unbolted flour of which this is made of course contains the starchy principles, but in consequence of the retention of the bran the proportion of starch is less. The cold-blast flour of the Health Food Company is said to contain the nutritious, but not the innutritious, parts of the bran.55

55 It is made by pulverizing the carefully cleaned wheat by a compressed, cold air blast, which strikes the wheat and dashes it to atoms.

The almond food suggested by Pavy is another substitute for bread. The almond is composed of 54 per cent. of oil, 24 per cent. of nitrogenized matter known as emulsin, 6 per cent. of sugar, and 3 per cent. of gum, but no starch enters into its composition. Theoretically, therefore, the food should be everything that can be desired if the gum and sugar can be removed. The latter is done by treating the powdered almonds with boiling water slightly acidulated with tartaric acid, or soaking the almonds in a boiling acidulated liquid which may form a part of the process for blanching. The boiling and acid are necessary to precipitate [p. 224]the emulsin, which would otherwise emulsify the oil of the almond. Pavy speaks well of biscuit made of almond flour and eggs, which he says go very well with a little sherry or other wine, although he admits they are found too rich by some for ordinary consumption. One person only under my observation has used the almond food, and found it unpalatable.

Seegen recommends an almond food made as follows: Beat a quarter of a pound of blanched sweet almonds in a stone mortar for about three-quarters of an hour, making the flour as fine as possible; put the flour thus obtained into a linen bag, which is then immersed for an hour and a quarter in boiling water acidulated with a few drops of vinegar. The mass is thoroughly mixed with three ounces of butter and two eggs; the yolks of three eggs and a little salt are added, and the whole is to be stirred briskly for a long time. A fine froth made by beating the white of the three eggs is added. The whole paste is now put into a form smeared with melted butter and baked by a gentle fire.

Biscuits made of inulin, the starchy principle largely contained in Iceland moss, were suggested by Kuelz. Although a starch, it is one of the assimilable ones alluded to, of which small quantities at least may be taken as food without appearing in the urine as sugar. The biscuits are made with the addition of milk, eggs, and salt, and are inexpensive.

To some persons sugar is almost as imperative a necessity as bread, although to many it is not a very great sacrifice to omit it from ordinary cooking, if not from tea and coffee. For the latter it is just as well to dispense with sugar altogether. But where patients feel that they must have some substitute for sugar, glycerin has been suggested for this purpose, at least for sweetening tea and coffee. But Pavy has noted56 that under the use of glycerin the urine increased from three and three and three-fourth pints to between five and six pints, and the sugar from 1100 grains to 3000 grains per diem, in the course of three days. Its withdrawal was followed by a prompt fall in both the urine and sugar, a return to it by a second increase, and subsequent withdrawal by another decline. Along with the increase of urine and sugar came also more thirst and discomfort. An examination of the chemical composition of glycerin would seem to confirm these results of experience. Glycerin is represented by C3H8O3, sugar by C6H12O3, and glycogen by C6H10O5; whence it is evident that a conversion of glycerin into sugar may take place in the liver. These facts seem to show conclusively that glycerin is no suitable substitute for sugar. I therefore do not use it.

56 On Diabetes, London, 1869, p. 259.

From what has been said it may be inferred that sugar of milk, mannite, and lævulose, or fruit-sugar, are admissible where sugar is demanded. They may be tried, but the urine should be carefully examined under their use, and if glycosuria occur or be increased they should be promptly omitted.

Almost every purpose of sugar in the cooking of acid vegetables is served by bicarbonate of sodium or potassium. As much bicarbonate of potassium to the pound as will lie upon a quarter of a dollar will neutralize the acidity of most fruits which require a large amount of sugar to mask this property. In this manner cranberries, plums, cherries, gooseberries, red currants, strawberries, apples, peaches, and indeed [p. 225]all fruits to which sugar is usually added in the cooking, become available to the diabetic.

In the matter of drinks, where the patient is not on a skim-milk diet, which usually affords as much liquid as is required by the economy, little restraint need be placed upon the consumption of water, which is demanded to replace that secreted with the sugar. Instead of water, Apollinaris water, Vichy, or the ordinary carbonated water may be used if preferred, and to many they are much more refreshing by reason of the carbonic acid they hold in suspension. Apollinaris water is particularly so, and one of my patients, who recovered completely under a suitable selected diet with which this mineral water was permitted, insists that it was that which cured her.

Where a simple selected diet is adopted, tea and coffee without sugar are usually permitted. The propriety of the substitutes for sugar already referred to must be determined by circumstances.

Of distilled and fermented liquors, moderate quantities of whiskey and brandy, dry sherry and madeira, the acid German and French wines—in fact, any non-saccharine wines—may be permitted. A medical friend who reports himself about cured of diabetes writes me that he has consumed eighty gallons of Rhine wine since he began to adhere closely to a diabetic diet. On the other hand, the free use of the stronger alcoholic drinks has been charged with causing diabetes, and I have known such use to produce a recurrence of sugar. No malt liquors, except those in which the sugar has been completely converted into carbonic acid and alcohol, should be used. Bass's ale may be allowed where no especial stringency is required.

Bernhard Naunyn (born 1839) was the pupil of Lieberkiihn, Reichert, and von Frerichs. Though the author of a number of researches, they include no important discovery. His position as the foremost diabetic authority of the time rests upon his influence for the advancement of both clinical and experimental knowledge; upon his judgment, his teaching, and his pupils; upon the fact that from his great Strassburg school have come the soundest theories, the most fruitful investigations, and the most effective treatment. 

In birth, it is to be noted that Naunyn preceded Kiilz, and was only two years younger than Cantani. He came into this field in the pioneer period when the principle of dietetic management was generally recognized, but the average practice, especially in regard to severe cases, was still a mass of ignorance and inefficiency. As late as 1886, Naunyn stood as the champion of strict carbohydrate-free diet in a German medical congress where most of the speakers opposed it. As one of the few early German followers of the Cantani system, he maintained its feasibility and ultimate benefit, and locked patients in their rooms for five months when necessary for sugar-freedom. 

With experience, he gradually introduced modifications, until the rigid and inhuman method, which a majority of physicians and patients would never adopt, became a rational individualized treatment, with a diet reckoned according to the tolerance and caloric requirements of each patient. The work of various pupils requires mention in this connection. Important investigations of metabolism established the basis for this treatment, the most notable being that of Weintraud, who proved that, instead of having an increased food requirement, diabetics could maintain equilibrium of weight and nitrogen on a diet as low as or a little lower than the normal. Minkowski discovered with von Mering the diabetes following total pancreatectomy in dogs, and established the doctrine of the internal secretion of the pancreas, as well as the first clear conception of a dextrose-nitrogen ratio. After the early acetone investigations and Gerhardt's discovery of the ferric chloride reaction had failed to reveal the cause of coma, the Naunyn school accomplished almost the entire development of the subject of clinical acidosis in the following sequence. Hallervorden (1880) discovered the high ammonia excretion, confirming an earlier discredited observation of Boussingault. Stadelmann (1883) established the presence in the urine of considerable quantities of a non-volatile acid supposed to be acrotonic, correlated the condition with Walter's previous acid intoxication experiments, and theoretically suggested the treatment with intravenous alkali infusions. Minkowski proved the excreted acid to be /8-oxybutyric, and demonstrated the presence of this acid in the blood and a diminished carbon dioxide content of the blood. He, also Naunyn and Magnus-Levy, applied the alkali therapy in practice, and the latter carried out chemical and metabolism studies which made him the recognized authority in this field. Naunyn introduced the word acidosis, saying in definition ( (4), p. 15): "With this name I designate the formation of /8-oxybutyric acid in metabolism." The Naunyn school have consistently maintained that this acidosis is an acid intoxication in the sense of Walter's experiments. They demonstrated striking temporary benefits from the alkali therapy, particularly in diminishing the danger of the change from mixed to carbohydrate-free diet; but the practical results were never equal to the theoretical expectations. With Naunyn, also, acidosis became the principal criterion of severity for the clinical classification of cases. As regards other theories, the Naunyn school have upheld the deficient utilization as opposed to the simple overproduction of sugar in diabetes. They have clearly recognized the necessary distinction between diabetes and non-diabetic glycosurias." Naunyn was next after Klemperer to recognize clinical renal glycosuria. Though observing that "the course of the disease is as variable as can be conceived," he nevertheless upholds the essential unity of diabetes, finding in heredity a link which often connects cases of the most varied types. In regard to the etiology, he considers that "it is certain that disease of the nervous system and of the pancreas can produce diabetes;" other causes seem more doubtful. The nervous disorder supposedly acts indirectly by setting up a functional disturbance in the pancreas or other organs directly concerned. Underlying everything in most cases is, in his opinion, the diabetic "Anlage" or inherited; constitutional predisposition. Naunyn has particularly supported; the conception of diabetes as a functional deficiency, to be treated by sparing the weakened function. He wisely emphasized the importance of doing this at as early a stage as possible, before the tolerance has been damaged and the glycosuria has become "ha- bitual." His plan of treatment is to withdraw carbohydrate gradually, giving large doses of sodium bicarbonate in cases with acidosis as ii, further precaution against coma. A brief increase of the ferric chloride ; reaction is not allowed to interfere with the program. When the glycosuria is successfully cleared up, the aim is if possible to place the patient on a Rubner diet, representing 35 to 40 calories; per kilogram of body weight and about 125 gm. protein, carbohydrate being gradually added and then kept at a figure safely below the tested tolerance. The views concerning exercise agree with those of previous authors; brisk walking, etc., is found beneficial; but overexertion is harmful, especially in severe cases; and some patients seem to do best on a rest cure. When sugar-freedom is not attained on simple withdrawal of carbohydrate, protein may be reduced as low as 40 to 50 gm. daily and the calories also diminished, since diabetics may remain in equilibrium on as little as 25 to 30 calories per kilogram. When necessary as a final resort, temporary under- nutrition may be employed; but prolonged under-nutrition or the loss of more than 2 kilos weight should be avoided. Loss of weight continuing over the third week of treatment requires adding carbohydrate and abandoning the attempt to stop glycosuria. Occasional fast-days are advised if necessary, but only when previous treatment has reduced the glycosuria below 1 per cent; otherwise their effect is indecisive. It is stated that such fast-days are practicable for even the severest cases, and heavy acidosis is not a contraindication; the ferric chloride reaction may diminish on a fast-day. Naunyn has not stated what limitations apply to the use of such occasional fast-days, but Magnus-Levy stipulates that they must never be more frequent than one in eight or ten days, and in very thin patients must be avoided altogether. 

Fasting is nowhere recommended as a treatment for coma by Naunyn. On the contrary, when restriction of diet produces really threatening symptoms, his plan is to add carbohydrate and give up the attempt to abolish glycosuria. Even the persistence of a very heavy ferric chloride reaction longer than two or three days is a signal for adding carbohydrate. The treatment for impending coma consists in maximal doses of bicarbonate and the free use of carbohydrates, especially milk. Naunyn had some conception of limiting the total metabolism, but meant by it only a bare maintenance diet, or the slight and temporary undernutrition mentioned above. Naunyn states that fat does not appreciably increase glycosuria; elsewhere that in very severe cases it may slightly increase glycosuria; Magnus-Levy that it never gives rise to glycosuria. Like others, Naunyn considers that fat is the chief food for the diabetic; that the introduction of fat is the most important art in diabetic cookery . He uses it to complete the full number of calories when other foods are restricted; this applies even to the severest cases on carbohydrate-free diet with strict limitation of protein, where accordingly much fat is given; his principal care is that the patient shall take enough of it; the only reason for limiting the quantity is the danger of indigestion , except when coma impends, in which case fats are replaced by carbohydrates, and butter is especially shunned because of its content of lower fatty acids. Even when sugar-freedom is attainable, certain cases are believed to show an inherent progressive downward tendency. Concerning patients emaciated down to 50 kilograms, with heavy ferric chloride reaction and the usual accompaniments, it is said: "In the face of these great difficulties and dangers, which accompany the energetic management of these very severe cases, the prospects of being successful in permanently removing glycosuria are in general not very great, and usually one will be content with a limitation of it which suffices to bring the patient into nutritive equilibrium, that is, down to 60 to 80 gm. sugar in 24 hours."

" This is commonly supposed to have been an intentional following up of the observations of Cawley, Bouchardat, and others. But according to Dr. A. E. Taylor (personal commumication) the epoch-making discovery was accidental. Dogs depancreatized for another purpose were in a courtyard with other dogs. Naunyn, perhaps mindful of the part played by insects in the history of diabetes, asked, 

"Have you tested the urine for sugar?" 

"No." 

"Do it. For where these dogs pass urine, the flies settle."