Type 2 Diabetes

4th May, 1797- I SEND you an extract of the case of Walker, with Dr. Hope's permission, and you may do with it whatever you please. The effects of the animal diet on the quantity and quality of the urine are perfectly evident, though the case could not be carried to an absolute termination, from the impatience and instability of the patient. In Hospitals, where patients three three or four times in the day every person about them eating vegetables, a trial of an entire diet of animal food can hardly be expected.

James Walker, a field-labourer, was admitted by Dr. Hope into the Clinical Ward, with a confirmed Diabetes, on the 1st November, 1796. 

"His appetite is voracious, and his thirst so urgent, as to make him defire from ten to fixteen quarts in twenty-four hours. His urine is praeternaturally copious, and he has a frequent inclination to pass it. It is limpid, of a light green colour, and having a slightest sweet taste. He is much emaciated ; and his feet and ankles swell towards evening. Pulse 96. Skin parched and rough. Body costive. 

He recollects, on a frosty morning in December 1795, having slept fome hours in an open cart, On the May following the above symptoms appeared, and have increased ever since. He has feveral times been the object of medical treatment; but without permanent relief. 

• 2d. Milk daily, and as much drink as he chooses. 

• 3d. Urine 22 pounds, Ingefta 20 pounds.. AtL 153

• 4d. Urine 13 pounds. Ingefta 17 pounds. The urine becomes turbid on the addition of lime water; when evaporated it affords an extract like molasses, which is sweet to the taste. This matter mixed with lime, exhales the odour of ammonia. 

• From this day to the 29th December, he remained nearly in the same state, the quantity of urine fluctuating between 12 and 18 pounds in 24 hours. During this interval he took some ferrum vitriolatum in the form of pills; ufed the cold shower bath, and took occassionally fome emetics and laxatives ; —the stomach being at times deranged, and the coflivenefs very obflinate. Under this treatment he feemed to get a little stronger, but without any important change in the general symptoms of the disease. It was agreed to try the effects of animal food, as lately given with success by Dr. Rollo at Woolwich, an account of which was tranfmitted by Dr. Woollcombe to Mr. Marcet. 

• December 29th, Dr. Hope gave the following report. Ingesta 17 pounds; urine 13 pounds. Five pounds of this urine have afforded 5ounces of a thick saccharine extract. He has had for a month, an unpleasant sense of burning heat in the soles of his feet during the night. He is directed to abstain from vegetable food in every shape. To have two eggs for breakfast. Boiled meat and fleaks alternately for dinner. Eggs, or cheefe for fopper. For drink eight pounds of weak beef tea, and two pounds of weak peppermint water. 

• 30th December. Solid ingested about two pounds ; drink ten pounds ; urine nine pounds. Let him have two pounds of flesh meat for dinner; half a pound of cheese for supper; and three eggs for breakfast—drink as before, Ingefta (drink, and food) ten pounds ; urine five pounds, which exhales an unusually strong urinous smell. Had a partial sweat over the trunk and head in the night. Mouth moist; no sourness. of stomach. 

• January 1st, 1797- Solid ingesta as usual ; drink nine pounds ; urine eight pounds, more limpid than yeflerday, and has a sharp acid odour. The breath has the fame smell . The colour of the urine, however, is not changed, on addition of syrup of violets. There is slight headache and sickness. The tongue appears much cleaner than usual. Has had a stool. Contin. diaeta animalis. 

• January 2d. Solid ingefta the fame; drink eight pounds; urine fix pounds. No flcknefs or hcadach ; tongue clear; the burning heat of the feet as before. One Joofe ftool. Contin. 

• 3d. Drink 10 pounds; urine 7 1 pounds, of a deeper yellow than formerly; tongue natural. Contin. 

• 4th. Drink ten pounds; urine feven pounds. Contin. 

• 5th. Drink nine pounds ; urine 6{ pounds, more yellow, with a peculiar (not urinous) odour. Contin. 

• 6th. No report, as laft night he went out, returned to the ward drunk, fo that his urine could not be meafured. 

• 7th. Drink 7 pounds ; urine 6 pounds, having the same peculiar smell, 

• 8th. Drink 7 pounds; urine 6 pounds; body coftive. Contin. diaeta animalis. Sum: ftatim pil. rhoei. comp. ^ l'et iterum eras mane. 

• 9th. 156 Qtfa Drink iix pounds ; urine four pounds ; a copious ftool this morning; ftrength not changed fince he began the animal food. Contin. et habeat aq. menth. piper, lbiv pro potu. minuatur quantitas decocti carnis ad lbiv. 

• 10th. Solid food as formerly ; drink feven pounds ; urine five pounds ; no flool. Sum : flatim pil. rhcei. comp. B 1. 

• llth. Drink fix pounds ; urine four pounds ; three llools this morning. Contin. diaeta animalis, 

• 12th. Drink fix pounds ; urine four pounds ; two ftools—he thinks his ftrength is fomewhat impaired within thefe two or three days. Adeat eras mane balneum frigidum. Drink feven pounds ; urine five pounds ; bore, the bath well. Contin, 1 4th. Drink eight pounds; urine fix pounds. Contin* 

• 1 5th. Drink eight pounds ; urine fix pounds. 

• l6tk Solid food as before; drink eight pounds; urine fix pounds, of a light ftraw colour, and with the peculiar fmell it has had for fome time. The urine of the 14th being evaporated, afforded matter of confiderable confiftence, with a ftrong faline, but fcarcely perceptible fweetifh tafte. 

• 17th. Drink eight pounds ; urine fix pounds ; thinks he is weaker. 

• 18th. Drink eight pounds; urine 5| pounds. Contin, IQth and 10th. Drink each day eight pounds ; urine fix pounds. Contin. 1\Ji January. Drink feven pounds ; urine five pounds. He has left the Infirmary to-day, by his own defire, to return to the country." 

• 4th May. Dr. Hope told me a few days ago, that he had just then. received a letter from Walker, who says that since he left the Infirmary he has become weaker; and there is some expectation of his returning foon to the Hospital to resume his treatment. But it is doubtful whether when he was in the Clinical Ward he observed strictly the diet preferred. At least he was accustomed to go about freely; and the nurse told me repeatedly, that she suspected he did not entirely abstain from indulgencies of eating and drinking out of the house.

From Dr. Cleghorn, Lecturer in Chemistry, and one of the Physicians to the Infirmary at Glasgow. Glasgow May l9 1797. 

SOME months ago I was honoured with your excellent pamphlet on Diabetes. At that moment I had two diabetic patients in the Royal Infirmary of this place, and I began instantly to treat them on your plan. They are both cured ; and I have delayed so long to thank you for your politeness, in the hope that I might be able to inform you of this new success. 

CASE L John M'Lean, a Porter, age 38, December 9th, 1796. 

Four months ago had a fever, after which while yet weak, he began to work hard. Soon afterwards he observed his urine more abundant than usual, amounting daily to 24 pounds, or more. 

Though his appetite be voracious, he becomes leaner from clay to day, and is so weak that he cannot walk a few steps without panting. His mouth is parched, tongue red, thirst extreme, belly collive. Pulse 84. 

A few days ago he had a slight cough, with pain in the right breast ; but these complaints have abated. The feelings about the stomach when he thinks himfelf hungry, differ from those he formerly had; they are more uneasy, and the uneasiness is less removed by taking food. He is often troubled with flatulence ; and complains constantly of weakness or pain in the back and loins. Has used no medicines. On examining the urine it was found limpid and very sweet. A pound of it yielded by evaporation more than an ounce of a thick brown extract, like treacle in appearance and taste. 

December 10th. He was ordered an ounce of castor oil, and the same quantity of compound tincture of fenna. His loins were directed to be rubbed every evening and morning with anodyne balfam. Equal parts of kino and ruft of iron, formed into pills rcki pills of five grains, with extract of chamomile^ were to be given, two for a dofe thrice a day. His drink and urine were ordered to be meafured daily, and the following reports, abridged from the Infirmary Regifler, fhew the refult. 

11th and 12th. One stool ; urine 28 pounds ; has drank about 14 pounds, besides the usual allowance of beer and broth. 

13th. Urine 27 pounds ; drink 8 pounds ; has had double allowance of food. Belly natural. To take 8 pills daily. 

14th. Feels himfelf a little eafier and stronger. To drink a pint of alum whey daily at different times. To have the oil and tincture of fennawhen coftive. In this courfe he persevered till the 17th of January, 1797. The quantity of his urine diminifhed daily. On the 16th December it amounted only to 20 pounds ; next day to 1 8 ; next to 1 5 ; next to 13; but on the 20th it rose to 16 pounds, without any cause that could be pointed out, unlefs the increafe proceeded from coftivenefs. Next day it fell again to 13; on the 24th it rofe to 1 5 : after which it varied from 13 to 7 J pounds. This was the quantity voided on the 17th January. It never fell below 71; most commonly it was between 8 and 10 pounds. Meantime the patient confidered himfelf as cured. He slept comfortably, sometimes not rising during the nighty never oftener than once. The feelings about his stomach were more agreeable ; his countenance looked less ghastly, and he felt his strength returning apace. On examining his urine, however, I had the mortification to find it nearly as sweet as ever. I confidered the cure therefore as very incomplete, and I expected that the urine would soon begin to increase, as it had uniformly done in every cafe that I have hitherto feen, and I have feen a confiderable number. 

While under this painful apprehension I received Dr. Rollo's pamphlet, which seemed to me to contain a more distinct theory, and a more reasonable practice, than I had ever met with before. As I could not immediately procure the hepatifed ammonia, I ordered him to use for drink four pounds of water, containing a drachm of lixiva fulphurata. The alum whey to be continued. 

Jan 20 Urine 8 pounds, sweet. Has used vegetables and milk freely. Took 3 pounds of the ammoniated water. The necessity of abstaining from vegetables was explained, and enforced, and he was ordered to continue the water. 

February 10th. This morning took 15 drops at once, with no other effect than a sense of heat in the stomach. Urine 6 pounds, less natural in tafte and smell. Finding himself strong enough, he asked leave to go home, (to the fuburbs of Glafgos) to manage some business which required his prefence. He promised to abstain from vegetables, to take his drops, and to return if he became worse. I have seen him several times at work, and this day, being the 10th of May, I received from his own mouth the following account. 

In 24 hours his urine is about 5 pounds. He taftes it very often, and it has never been fweet, but after getting little animal food for days together (which has happened more than once) it has fometimes been of a four fmell. Formerly he could carry on a wheelbarrow three hundred weight ; at present he carries one hundred weight, and he can walk as well as ever. Two days ago he went express to Paisley, received an answer to the letter he carried, and returned to Glasgow in three hours and a half (about 14§ miles). 

Occafionally he has taken 60 drops a day of the hepatifed ammonia, which he likes, because it gives him an agreeable feeling of warmth, and never produces any inconvenience. For two weeks, however, he has had none, since which his urine has not increas›ed in quantity, has not been sweet, and when evaporated lately by himself, and by a neighbour of his, whose curiosity he has excited, it yielded no sugar. The residuum could not be diftinguished from that of an equal quantity of healthful urine, evaporated at the same time with great care and sagacity. The only kind of animal food that he can procure in sufficient quantity is blood, which he mixes with fat and a little meal. Even this homely fare he finds it difficult at prefent to procure regularly. He was always lean, and is now rather more so than before his fever ; but though he works very hard, he thinks himself stronger, and more fleshy, than when he left the Infirmary. He sleeps well; is regular in his belly, and free from every complaint, except occasional pains about the muscles of his breast and arms, anting obviously from the intense colds to which he has been very much exposed, as he plies near the river from morning to night. He is the father of several children, but since he has been seized with Diabetes—Coitus nullus. Erigitum nunquam : ne quidem femel rigefcit. About a month before he left the Infirmary, the other patient gave the same account of himfelf.

The second case which Dr Rollo has here very minutely detailed, but into the particulars of which we cannot propose to enter, is that of a general officer in the 57th year of his age, with whom the urinary discharge amounted to ten or twelve pints in/the twenty-four hours; and, while the urine had a very sweet taste, he was at the same time subjected to the other common symptoms of diabetes. After his disease had been of at least three years Handing, and after recourse had been had to the assistance of several eminent physicians, without benefit, he came under Dr Rollo's care, in the beginning of January 1797. 

Nearly the same plan of treatment, particularly with respect to the diet of animal food, was here directed, as in the case of Captain Meredith. In a very short time, a remarkable change for the better was produced. His thirst was diminished, and his urine rarely exceeded two, three, or at the most, four pints, in twenty-four hours, being at the same time of the natural sensible quantities. In this way he continued to the end of February, gradually recovering flesh and strength. He now resolved on returning to his residence at Portsmouth. He had very great impatience under refraction. But on parting from Dr Rollo, he was told, that, for preventing the return of his disease, everything depended on himself; and he acknowledged the truth of the observation. He bore his journey very well, and arrived at Portsmouth on the 27th of February. But having eaten something improper on the road the day before, he was attacked with a bowel-complaint. On the 6th of March he had a return of his bowel-complaint, from eating beet-root. On the 9th he had the sanction of a physician to eat what he pleased, and to drink wine. The disease was soon reproduced, for his urine became sweet, and was increased in quantity, with a return of thirst and feverishness. Yet this case, Dr Rollo justly observes, adds strength to the conclusions derived from the former case. From these two cases Dr Rollo draws some general inferences. He concludes, 

1. That the diabetes mellitus is a disease of the stomach, proceeding from some morbid changes in the natural powers of digestion and allimulation. 

2. That the kidneys and other parts of the system, as the head and skin, are affected Secondarily, and generally by sympathy, as Well as by a peculiar Stimulus. 

3. That the stomach-affection consists in an increased action and secretion, with vitiation of the gastric fluid, and, probably, on too afiive a state of the ladteal absorbents. 

4. That the cure of the disease is accomplished by regimen, and medicines preventing the formation of sugar, and diminishing the increased action of the stomach. 

5. That confinement, an entire abstinence from every species of vegetable matter, a diet solely of animal food, with emetics, hepatifed ammonia, and narcotics, comprehend the principal means to be employed. 

6. That the success of the treatment in a feat measure establishes the five preceding inferences. 

7. That the saccharine matter of the disease is formed in the stomach, and chiefly from vegetable matter, as has been shown by the immediate effects produced by the abstinence from vegetable matter, and the life animal food solely. 

8. That acescency is predominant in diabetic stomachs, which continues even sometime after the entire abstinence from vegetable matter, and after the formation of sugar; and that while such acescency remains, the disposition to the disease may be supposed to continue. 

9. That the saccharine matter may be removed in three days, and, by avoiding vegetable matter, will not again be reproduced ; but we are not yet able to state accurately, when the disease, and the disposition to it, can be finally removed. 

10. That there are two circumstances to be considered in this disease, which we may separate in the progress of the treatment. As it has been shown, that though the formation of sugar was prevented,yet the increased action of the stomach remained, and maintained the defect of assimilation, which prevented nutrition. Hence two objects occur in the cure ; for it is not yet determined, whether the preventing the formation of sugar, by an entire abstinence from vegetable matter, and the use of animal food, with fats, if properly persevered in, might not ultimately comprehend the other, namely, the removal of the morbid action of the stomach. 

11.  That the lungs and skin have no connection with the production of the disease. 

12. That the quantity of urine is probably in proportion to the quantity of fluids taken in, and has but little dependence on absorption of fluids, from the surface of either skin or lungs. 

13. That though the disease has been shown to consist in an increased morbid action of the stomach, and probably too great a secretion, with vitiation of the gastric fluid ; yet the peculiar specific condition of either, as forming the disease, is acknowledged to lie in obscurity, and must remain so till the physiology of healthful digestion be properly explained and established. 

14. That the first case had only been of about seven or eight months duration when the treatment commenced ; but the Second case had been upwards of three years continuance. The age of the one thirty-four; of the other, fifty-seven ; circumstances which constituted material differences, though they seemed not to create corresponding difficulties in the treatment, so far as the direct removal of the complaint was concerned. They may however retard, in the one instance, the entire restoration of health. 

15. That, in both cases, deviations occurred in the management, and were respecttively followed by reproductions of the disease, and, though disadvantageous to the patients, have confirmed our views of its nature and treatment. 

16. And, lastly, That from both cases we may warrant this general conclusion, that the diabetes mellitus is so far understood as to be successfully cured. 

To these histories and observations, Dr Rollo has subjoined some remarks respecting the diabetes mellitus, which have been communicated to him by different correspondents, since the dispersion of his notes on the case of Captain Meredith. With regard to the causes of the disease, he observes, that from Dr Falconer's letter it appears, that one case was produced by excessive indulgence diligence in spruce-beer; that in one patient of Dr Cleghorn's, the disease seemed to have arisen from hard work when recovering from a fever, and in another from his being much addicted to the use of large quantities of sugar; and that the patient Whose case is related by Dr Gerard, had been subject to pyrosis, and an excessive discharge under the form of perspiration, previous to the attack of diabetes. With regard to the nature of the disease, Dr Rollo observes, that the appearances found by Dr Baillie, on direction, an account of which will probably soon be published, may have been sequelae of the disease. Mr Abernethy, he remarks, found the serum of the blood in diabetes to be turbid ; and observed, that sugar taken into the stomach increased the saccharine matter in the urine. With regard to the treatment, Dr Rollo informs us, that in one case of diabetes mellitus, Dr Duncan found fat meats serviceable; that Dr Falconer recommends mephitic alkaline water; that Dr Beddoes Mentions a case where Bristol water cured the disease ; but that Dr Currie, who has seen several cases of the disease, never saw one of these cured in which the urine was sweet.

The case of James Walker, treated in the Royal Infirmary of Edinburgh, by Dr Hope, shows, according to Dr Rollo, the good effects of animal food. The treatment in this manner was begun on the 29th of December, when the daily quantity of clear urine of a sweet taste amounted to thirteen pounds. On the 31ft of the month, two days only after the commencement of this treatment, the quantity of urine was reduced to five pounds, and it had acquired a strong urinous smell. The two cases treated at Glasgow, by Dr Cleghorn, show also the good effects of a diet consisting entirely of animal food ; and prove also the influence of commotion in the bowels on the quantity of urine. But the most striking case, Dr Rollo observes, is that related by Dr Gerard of Liverpool, from which it appears, that in diabetes there is no absorption of fluids by the skin, and that animal food alone, if duly persevered in, may cure the disease, though such perseverance be only of a very limited duration. Dr Rollo concludes his remarks on diabetes, by observing, that hepatifed ammonia appeared to him to be a very powerful medicine. But it must, he tells us, be prepared according to Mr Cruickfhanks's method. The ammonia must be pure, and completely saturated with the hepatic gas. To produce its narcotic effects, full and sudden doses of it must be given ; but these require judgement, and an acquaintance with the exhibition of the medicine. It should not be mixed up in-draughts, or in any other form, as it is readily decomposed; but it should be dropt from the P^ial, at the time of using it, into a proper Vehicle, and taken immediately. Distilled water is, he thinks, the best vehicle.

"It was agreed to try the effects of animal food. He is directed to abstain from vegetable food in every shape. To have two eggs for breakfast. Boiled meat and steaks alternately for dinner. Eggs, or cheese for supper. For drink eight pounds of weak beef tea, and two pounds of weak peppermint water. Solid ingested about two pounds. "

From Dr. Cleghorn, Lecturer in Chemistry, and one of the Physicians to the Infirmary at Glasgow. Glasgow May 19 1797. 

SOME months ago I was honoured with your excellent pamphlet on Diabetes. At that moment I had two diabetic patients in the Royal Infirmary of this place, and I began infiantly to treat them on your plan. They are both cured ; and I have delayed fo long to thank you for your politenefs, in the hope that I might be able to inform you of this new fuccefs. 

CASE II. John Roger, age 40, a Shoemaker. January 10th 1797:

 For two months his urine has been profuse, amounting daily to 20 pounds or more. It is limpid and sweet, yielding by evaporation an ounce of thick sweet matter, like treacle, from every pound. He is thin and weak; habitually thirsty; for some days pain has felt a pain between his shoulders, and for a week his legs have been cedematous. Appetite keen ; pulse and belly natural. Knows nothing to which he can attribute his complaint. Has used bitters, and other medicines, without material benefit. The astringent pills, and alum whey, were ordered for him, as for M'Lean, 

12th. Urine 36 pounds. 

13th. Urine 30 pounds. 

14th Urine 23 pounds. 

15th. Urine 20 pounds.

16th Urine 21 pounds; thirst excessive ; sleeps ill ; pulse full and hard. The medicines were omitted. He was directed to drink a folution of lixiva fulphurata, one drachm to four pounds of water, and to use animal food. 

April 3d. Issues by means of caustic were ordered to be formed over each kidney. He was directed to drink sparingly, chiefly lime water, and his diet was regulated with more care. For it was found, that all along he had used a great proportion of vegetables for food, and had been guilty of irregularity also in drinking. He was ordered to get no vegetables ; however, he was allowed one roll a day ; the rest of his diet consisted of soup, blood-puddings, and butcher's meat roasted, or boiled, as he chose. 

11th. Three stools. Feels himfelf stronger, and in better spirits. Pulfe 80. Drink 3 pounds (no lime water) ; urine 6§ pounds, nearly natural. 

12th, 13th and 14th. Thirst abated ; urine from 6 to 7 pounds/of natural taste and smell, and when evaporated yielded no sugar. Thus he continued free from thirst, though his mouth was parched and dry during the night ; he gained ftrength and flesh ; his urine never exceeded 6 pounds, and seemed perfectly natural till the 30th, When it again became sweet; having been strictly questioned, he confessed that he drank a quantity of small beer yesterday afternoon, and we have found that he has committed several other irregularities. 

May 1st. Urine again natural. This day he left the Infirmary, having promised to persist in the use of animal food, and to return if he should relapse. He is gone to Irvine, about 30 miles distant, and nothing has been heard from him since. 

These patients were examined daily in the Royal Infirmary of Glasgow, and the reports were dictated before the Students of whom many examined very scrupulously the changes of the urine, and all other circumstances respecting a disease to which their attention was strongly attracted both by the novelty of the treatment, and their having seen a case which ended fatally not long ago. In copying the reports I have omitted every circumstance that seemed uninfluential, and I have abridged the language so far as I thought consistent with perspicuity. I have dropped the Latin form of prescribing, though it gave me some trouble to exprefs the prescriptions shortly in English (and many of them look awkward enough) because I was desirous of making the cases intelligible to those who do not practise physic, as I hope this very interesting inquiry will soon excite the attention of the public. After stripping the cases of every necessary detail, I shall not load them with many additional remarks. They seem to me very strong confirmations of your doctrine, in every point, except what regards the hepatifed ammonia. At first perhaps it was not properly prepared, after a little while, however, it was ; and it seemed to have very little power over the urine. In one patient (but he was querulous and fanciful) it seemed to affect the head ; in the other, it seemed to act like common volatile alkali, by producing an agreeable sensation of warmth in the stomach. Our patients, indeed, were in many respects different from yours ; and it is very common to find the operation of medicines strangely modified by the varying habits and susceptibilities of patients. The alum whey (formed by boiling a drachm of alum in a pint of milk) seemed to produce considerable effect, at least in reducing the quantity of urine. The castor oil appears to be the most useful laxative; but no medicine was of any permanent advantage without the aid of animal food. This is more powerful than any medicine, and very probably this alone, properly managed, may be found sufficient for the cure in many cases. Whether the cure in our two patients be complete or not, is a question which I shall not labour to decide by argument. For my own part I think they are cured, though they may never perhaps be strong as they were, and both may probably relapse ; because, being poor, they are exposed to the double risk of severe labour, and improper food. Besides, on many other occasions, a tendency to relapse is not considered as a proof of imperfect cure. Is an intermittent not cured, because one who has had it this spring, will be found very subject to it next season, if he shall be exposed to the cause which commonly produces it?