Type 2 Diabetes

From Dr. Gerard, Liverpool 

The following case is that mentioned in Dr. Curriers letter to us, and we communicate it with the greatest pleasure to the public as being drawn up with the utmost accuracy, and containing details of procedure of the utmost importance towards perseeling our views of the nature and treatment of the disease, as well as of confirming them.

THE CASE. 

John Clarke, aged 38, was received into the Liverpool Infirmary, under Diabetes, on the 9th February, 1797.

 He was a soldier in Lord Darlington's Light Horse when they were reduced in February, 1796. 

At that time he was in good health ; thinks he might then have weighed about 140 pounds in his clothes; he is 5 feet 7.5 inches in height; has dark hair and grey eyes. He always enjoyed good health, but was subject to pyrosis, and accustomed to perspire much. Happening to reside near the seacoast, he has from a boy been used to bathe frequently during the summer months, not for any indisposition, but merely for gratification ; sometimes he went into the water twice the fame day, and staid in it 10 or 15 minutes; being always of a coflive habit, he also drank of the water occasionally. He discontinued the practice of bathing, however, while the weather still continued warm, as early, he thinks, as the beginning of August; his habitual perspiration leflened afterwards by degrees, and he continued in good health till about the end of November, 1796, when the perspiration entirely ceased, and the cuticle became unnaturally dry, harm, and rough, and is now to all appearance dead, and incapable either of perspiration or absorption, or any kind of transmission. About this time some headache also came on, and the bowels became in general more costive, though he was sometimes troubled with a lax for a few days. 

With the preceding symptoms he was afflicted with a most distressing thirst, which was not to be satisfied. His appetite was increased, and yet he loft flem daily, and grew weaker very felt, particularly in the thighs and small of the back, attended with pain in the region of the kidneys. He also observed, that he made much more urine than usual, and that the quantity increased from day to day. It should be remarked, that having no other means of getting here, he was under the necessity of walking from five, to eight miles each day, for three successive days, before he reached Liverpool ; but this was a whole day's work, and a great fatigue to him. Considering this to be a cafe, that from all former experience might almost be deemed incurable, I wished to consult my Colleagues, Dr. Brandreth and Dr. Currie ; therefore I only ordered him a dose of castor oil, to remove, the costive state of the body. Those gentlemen saw him with me on the 1 1th February. At this time Dr. Currie had just received a publication from Dr. Rollo, Surgeon General to the Royal Artillery, at Woolwich, of a case of Diabetes that he had treated with success ; he had not read it ; but he understood that much was attributed to animal diet. On this authority our patient was ordered to live chiefly on flesh and milk; he was also directed to use the warm bath, and with a view of ascertaining whether the generally received opinion that absorption takes place in this disease be true, he was defined to be weighed naked, both before he went into it, and upon coming out (Dr. Currie having observcd in a case of a different nature, that no absorption took place in the warm bath) ; the pulse to be counted; and the heat of the body ascertained by placing a thermometer under the tongue, and to note the whole down.

February 12th. He went into the bath for the first time, when the pulse was, before bathing, 

75, after it, 85. 

Heat of the body 91, —-—— 95. 

Weight of the body 112lb. 4oz. -- 112lb. 6oz.

February 15th. During the same time he took two pounds and a half of animal food, and twelve pounds of liquids, including milk, beer, and water. The directions for his living on animal food having been misunderstood, he has hitherto had only one meal of flesh daily, and with it a portion of potatoes and bread.

February 20th. Having read Dr. Rollo's publication, he was ordered this day to live entirely on animal food and broth, without either bread, beer, or any vegetable matter, and to persist in that plan without taking any medicine whatever; for as diet appeared to have had a principal share of the success experienced in Dr. Rollo's cafe, we wished to try whether that plan only was capable of effecting a cure.

Feb 24th. He took two pounds of beef, and 6 pounds of broth.

Feb 25th. The dead cuticle is peeling off, and he is obviously improving in every respect, and gaining weight. He continues the diet of animal food, with the daily allowance of a pound of beer.

March 2nd. Urine 6 pounds 5 ounces. The animal food,: with the beer, has been persisted in. I have hitherto thought the griping and looseness were accidental, but as they continue, they may perhaps be owing to the great change made in his diet ; on that idea, therefore, I have allowed him half a pound of bread daily, and have ordered him 30 drops of laudanum at bed-time. He feels himfelf considerably stronger, and can lit up much longer at a time. He has no extraordinary thirst ; the urine has neither sediment nor smell.

The griping and looseness do not abate by the admixture of vegetable matter, on which idea only the bread, as it may be remembered, was allowed. He loses weight daily. This reverse of the success we experienced in the beginning, would prompt me strongly to have recourse to the fulphurated kali, or hepatifed ammonia ; but the circumstance of his having gained so much advantage, and so rapidly, while he lived on animal food entirely, and the wish to try what that diet alone would effect (which should be remembered was the plan we set out upon), determines me to return to it again, especially as it may enable us to decide whether it is alone equal to the cure. I therefore ordered both the bread and beer to be discontinued ; and to rely on the laudanum, absorbents, to correct the diarrhoea. He was allowed milk in place of the beer.

March 14th. He is rather more thirsty ; his appetite is not so good, being satiated with animal food ; he was allowed an onion to his meal.

March 19th. Being desirous of gratifying my patient with any change of diet that could be indulged in without impeding the cure, I ordered him to have a meal of fish, two or three times a week, meaning at the same time to ascertain whether that deviation from the plan of animal diet might be allowed with impunity.

March 20th. He disliked the fish, and said it was not so satisfying to his appetite as the meat; he thinks his thirst and appetite are more craving. He had a very good night, with some perspiration over the whole body; griping quite left him ; and flatulency greatly relieved.

March 26th. He has bad a restless night, and vomited frequently till 3 o'clock in the morning ; his spirits are better, and he thinks himself stronger. He had a pudding made of milk, suet, and eggs, for his dinner, which he was fond of.

March 28th. The diet, with the pudding of milk, eggs, and suet, were given as directed.

March 31st. He continues better, and feels a more comfortable warmth than he has been accustomed to do lately. His pulse has been from 85 to 90 for a week past. He is so tired with broth, that he has refused to take any for some time, and owing to his fondness for the eggs and milk, either baked or boiled with suet, he has eaten too little meat lately. I therefore ordered that he should at leail eat one pound daily.

April 6th. It becomes very irksome to keep him to animal food, even with a very large allowance of milk; and I learn that he takes the suet off the milk when it cools. He feels himfelf better today. He continues the animal food with milk, eggs &c.

April 19th. The diet is continued.

April 25th. Finding that he has upon the whole been losing weight since the 17th, I questioned him very closely about his getting other food than what was allowed him, but he denied it, and shewed much impatience about staying longer with us, saying that he thought himself well and strong again, and that he would rather go, as he was watched like a thief. Though I do not confider him to be so well as he thinks he is, yet as the quantity of his urine is so much reduced, and its former nature so entirely reversed, I have, notwithstanding his having lost weight, allowed him four ounces of flour in his pudding, and two ounces of bread with his meat ; for fear he would run away, and leave us uncertain of the event.

May 6th. I have at length discovered, through the information of another patient in the fame ward, that Clarke adhered rigidly to the regimen prefcribed him, only for about 14 days at the first. In the course of the disease we have often had reasonto suspect that he was deviating from our plan, and three or four times the necessity of a fine attention on his part was particularly infilled on. After these cautions he attended to his regimen strictly for a day or two, but again relaxed, through the almost irresistible propensity to more or less of vegetable diet, which seems to be one of the characteristic symptoms of this disease. With thefe exceptions, it appears that he has generally partaken with the other patients in the common mixed diet of the house, and that he has drank water when thirsty, if he had no milk. I cannot learn that he ever gave any part of the flesh meat to the other patients. It is extremely vexatious to have been so much deceived, yet I don't think it lessens the inference, that animal diet has been the means of effecting the very great alteration in the quantity and quality of his urine ; for though he has eaten more promiscuoufly than was supposed, he has at all times taken a large proportion of animal matter, and a marked effect: has at different periods of the disease followed the more entire use of it, particularly in the beginning, when his apprehension made him adhere rigidly to the plan. The discovery, though vexatious, has perhaps made this a better case, in as much as it shows that an absolute exclusion of vegetable matter is not necessary, at least not for so long a time ; and also as it proves that he is nearer being cured than he was thought to be, by the characteristic symptoms of the disease not having been reproduced by the superior quantity of vegetable matter he has eaten to what he was supposed to have done. Whether his appetite is so strong as to constitute it a remnant of the disease I know not ; but from the impossibility of retraining him, and for the purpose of ascertaining whether the care was complete, he is ordered to have the diet of the house only.

April 7th. His. diet now consists of milk, meat, potatoes, and bread.

April 25th. He was discharged from the Infirmary to all appearance cured of the disease; which, to his own thinking, has long been the case ; and to the opinion of his being even cured I have no hesitation in subscribing.

Mr. Astley Cooper, at St. Thomas's Hospital, having mentioned in one of his anatomical de- ?nonflrations, our views of the nature of diabetic disease, a young gentleman prefent, who had a relation in the country with the complaint, expressed a wish to be more particularly informed, and was referred to us. He gave a concise account of the Patient ; and it was suggested, as the Patient was so far advanced in life, an immediate application of our treatment to its whole extent might not be advisable ; the gradual adoption of it was therefore recommended. As the Patient, however, had been a Physician of long practice, though now retired, and being immediately under the care of a recyclable Physician in extensive business, we requested that our opinion in general might he conveyed along with the printed notes of Captain Meredith''s Case. This was on the 19th March 1797.

 The following account, written by the Patient himself,. we received on the 18th May, being only a period of two months. 

Guys Hospital, 18th May, 1797

 Sir, The enclosed account is drawn up by my friend the patient himself. I think it incumbent on me to return my best thanks for your kind and ready advice, from which the patient has derived so much advantage. 

I am, 

Sir, 

yours, &e

G. B. 

Dr. Rollo may make what use he pleases of the under described case, provided he does not insert the name of the Patient or that of his Physician. A gentleman far advanced in life, being now in his 77th year, and during the greater part of that time in pretty uniform good health, except some attacks of erysipelas about mid-age, and latterly a chronic rheumatism in the loins, occasioning more of stiffness than pain. He has been accustomed to live after the common mode of sober persons, or if prone to any excess, it was chiefly in the use of sugar. He began about two years ago to feel a great increase of general debility, to which was soon adjoined an unusual frequency of discharge by the bladder. The urine exceeded the quantity taken in by one third, and it was voided with a forcing kind of pain, both at the commencement and close of the emission; made softly in small quantities at a time. These calls became soon so multiplied in the night as greatly to disturb natural rest ; and the mouth and sauces grew so dry as to oblige the patient to keep small pebbles rolling continually in the mouth during the day time. The inflation of the saliva was such as to make it difficult to spit it out, unless previously diluted. The hands shook to such a degree that rendered it dangerous to shave, and hardly possible to write legibly, while the lower limbs felt as if force able to support the trunk of the body ; the feet and ankles swelled considerably ; the thirst was intense, but there was very little show of fever by the pulse. 

Under these circumstances the opinion of an eminent Physician in the neighbourhood was asked, who recommended lime water, earth of alum, afterwards pills of catechu, alum, and a small portion of vitriolated zinc. By these remedies the forcing at the neck of the bladder was a good deal relieved; but the very distressing dryness of the mouth and fauces still continued, and was by nothing so much solaced, as by moistening with milk and water. The urine remained, as it had always been, well coloured, frothy upon first emission, and favouring strongly of that sweetness, to scent and taste, charateristic of diabetic urine. 

Upon receiving from a young friend, a pupil at the Hospitals in Southwark, Dr. Rollo's notes on a case of this fort, the Patient and his Physician agreed to avail themselves of this plan of treatment, with some accommodation to the circumstances of the individual, and they have found reason to be satisfied with the adoption of it. 

Vegetable articles of diet had been long discarded; and the use of pure sugar, since the excellent hints in that communication, had been entirely laid aside. Rancid fats and putrescent flesh could not be admitted even in idea, without inducing nausea: instead of these were employed fresh mutton, animal gluten, mucilage, &;c. At breakfast he takes milk, with some cocoa, or chocolate; for supper, calves' feet jelly with milk, and sometimes an addition of sweet almonds. 

A moderate allowance of wine has been continued, as indefensibly necessary for support; but the least acid foreign wines have been used, and a gradual reduction is making in this hitherto necessary, indulgence. Of medicines, the saturated solution of soda, and Schweppe's soda water, have been only employed: from the last there is every reason to believe a share of the amendment may be attributed. See Dr. Falconer's letter to use where he points out the mephitic alkaline water as likely to be of advantage in this disease. 

Results:

The urine does not now considerably exceed the liquid taken in. In the day time it is voided frequently, but without pain ; the night calls are diminished to one, very rarely two occur. Its colour is good, and its sweetness can hardly be said to be perceptible. The excessive dryness pf the mouth and fauces, that depraved the taste for any aliment, particularly bread, and in consequence impaired the appetite, is nearly removed. The feet and ankles swell a little at times, which may be in some measure owing to the large proportion of the vvxQfittepov, during which, though the days are so long, yet the patient is unrecumbent sixteen or seventeen hours at least. With this hasty sketch you will please present my best compliments and thanks to Dr. Rollo.

From Mr. Houston, Brewer Street, London. 

L........... , aged about 30, fair complexion, light hair, and naturally of an extremely irritable constitution, in the month of February, 1793, received a violent shock by the death of one of her parents. On this melancholy occasion her grief was so very poignant, and at times so frantic, that serious apprehensions were entertained of a total derangement of intellect, and in this state she continued several weeks.

(several pages discussing the deterioration of her health leading to diabetes)

On their quitting the Wells, they, on their way home, stopped at Bath; and as her parent received benefit from the use of the waters of that place, they remained there eight weeks ; but before the expiration of the first fortnight, she found her stomach again disordered with heat and acidity, which in a short time increased to a height almost intolerable; the fauces were so sore, that it was a pain to swallow anything; and her tongue was equally so, being covered with a emit, or hardened slough on the top, and blisters round the edge. Her thirst was insatiable; to quench which, she ate a great quantity of fruit, and drank profusely of Seltzer Seltzer water and hock, but to no purpose.

Her skin was so parched, that the pores did not seem to emit the least moisture. To remedy this evil, some doses ofJames's powders were given, but to no effect ; towards the close of her time at Bath, she drank the waters for about a fortnight, they were supposed, however, to do more harm than good ; and growing daily worse there, she set out for London, where she arrived the 4th December, 1796. She immediately sent for her apothecary, who was greatly shocked ; as to all outward appearance, she seemed to be in the last stage of a consumption. Her pulse was exceedingly quick, but so feeble, that he could scarcely feel it, and so tremulous, that he could not with any certainty count or distinguish the strokes. For two days, he gave her every six hours a draught with kali ppt. magnef. alb. aa ^i, taken with half an ounce of lemon juice in the state of effervescence ; they agreed with her, and, as (he thought, cooled her; (he had no cough, but for some time back had loft her appetite, the stomach rejecting almost all solids; and when it did receive any, they generally laid heavy on it, or disagreed ; as some nourishment, however, was necessary, she was advised to eat eggs raw, or done very soft ; as also oysters and other shell-fish, as having a tendency to correct acidity. On the 3d day after her arrival in town (Dec. 6th) an eminent physician was sent for, who ordered a blister to be applied to her breast ; magnef. alb. qr. xv. in a draught every eight hours. These she took till the 15th, when she was ordered a draught with myrrh pulv. gr. xij. ferr. vitriol gr. iij. kali ppt. gr. viij. three times a day. This course she continued, with some trifling variations, but little interruption, till about the 19th February, 1797. By this time those medicines had the effect: of greatly recovering her appetite, and she had been allowed to eat such light animal food as she fancied ; but from this indulgence, of which she availed herself, with the return of her night's rest, which by this time she began to enjoy, she derived no other advantage than a small acquisition of strength ; for there was not the least appearance of bodily nurture, or any abatement of heat and acidity. 

The physician having compared the tardy, if any progress in amendment, with the quantity of food she was able to take, (for her appetite was greater than before her illness) began to discover symptoms of diabetes, and therefore gave orders to measure the quantity of fluids drank, and the quantity of urine she made and finding the latter exceed the former, he had some of it evaporated, and found it to contain a considerable portion of saccharine matter ; upon which she was advised to eat less vegetables and more animal food.

On the 18th, a gentle opening draught was given, though she usually took magnefia when any thing of the kind was necessary. On the 20th March, Dr. R. was consulted with her former physician ; and as he is already so well acquainted with all that has since been done, or happened, it is unnecessary for the writer of this to carry it any further.

Continuation by the Author.

On the 20th March, 1797, I visited the patient, with her physician and apothecary; she complained of a burning sensation at her stomach, which she faid was intolerable, with the sense of a sharp and hot acid rising into her throat ; her teeth were on edge, tongue red, and gums full ; she had little thirst, and was occasionally sensible of a moisture on the palms of her hands, and on other parts of her body ; her appetite was keen, and she never felt satisfied, but said that this degree of appetite had only been lately remarkable ; and she complained much of a burning sensation in her stomach, and of great acidity ; she was extremely emaciated, feeble, and inactive ; her skin dry, and rather warm ; pulse about 88 ; her urine of a pale colour, but to the taste scarcely sweet ; the quantity could not be distinctly ascertained ; it did not seem, however, to have been so increased as to engage any particular notice ; a little of the urine was evaporated; the residuum resembled treacle, but was salty to the taste, and the extractive matter did not seem much to exceed the quantity in healthy urine. On the whole, the adoption of light animal food, with less vegetable matter, and the medicines, had mitigated the disease. The physician who attended had a copy of the notes of Captain Meredith's case the preceding January, and he now very readily agreed to the animal diet entirely.

On the 14th April I saw the patient, with the physician and apothecary ; her looks had more the appearance of returning health ; she moved about with more agility and strength, though she complained of not gaining flesh ; her appetite is now good ; the tongue is clean, but not so florid ; she has no thirst ; the urine does not exceed a quart, a small portion of which being evaporated, the residuum was quite saline, and urinous in smell, but it was not evaporated so much as to determine the tenacity. The burning sensation in her stomach is diminished, and there is less acidity ; however, another emetic is prescribed, and the matter thrown up is to be examined, in order to ascertain whether it possesses acid properties. The patient informed me to-day, that for several years she has indulged in fruit, pickles, and sweetmeats.

April 25th. The emetic ordered on the 14th brought up very acid matter, which was found by the apothecary to effervesce with an alkali ; the urine deposits a reddish sediment ; she has less uneasiness at the fiomach, has more strength, and a more natural appetite ; her skin is moister.

May 10th. Very little change. Asafoetida is added to the pills, with calcined soda, and the quantity of the hepatized ammonia increased. From the delicacy of circumstances, an accurate enquiry cannot be made ; deviation of diet may happen ; in this cafe, we can only hope for a certain compliance with regimen, and a certain information with regard to appearances, and ultimately a recovery with tardy and irregular advances ; it merits much attention however, even with the view of discovering points of importance in the treatment, under the most unfavourable progress.

June 8th. Very sensible of an increase of strength, and that health is returning, the urine continues in a natural state, at least there is no saccharine matter. The heat of the stomach is much diminished ; the appetite feels natural ; no thirst or hectic symptoms ; she has discontinued our medicines, and only takes Schweppe's acidulous soda water, which she likes, and says it has been of much service in relieving the uneasiness of her stomach. To be allowed about four ounces of bread in the day.

June 16th. Since the use of the bread, the disease has been reproduced ; the urine is clear, and of a sensibly sweetish taste ; 18 ounces yielded a saccharine residuum of 1 ounce and 5 drachms ; her skin is again hot and dry ; the pulse quicker, thirst: intenfe, appetite keen, tongue florid and red ; alfo the heat of the stomach extremely unpleasant. She promises to return to the entire use of animal food ; her antimonial opiate to be taken at night; Schweppe's water for drink ; and a blister to be applied to the region of the stomach.

lid. The urine, in smell and taste urinous, having become so in twenty-four hours after leaving off the bread; her appetite is not so keen ; the tongue is not more florid than common, and the uneasy hot fenfation of the stomach is much less, though occasionally troublesome ; the thirst is gone ; the blister relieved the stomach ; the regimen, with Schweppe's water, to be continued.

July 14th. In a state of apparent recovery ; me occasionally takes a biscuit or two, but perseveres in the diet generally, and Schweppe's soda water. Next week she goes to Bristol, where she is to observe the fame conduct, being fully sensible of the influence of a change of diet, and equally so, that everything depends on her own steadiness. No accurate account could be obtained with regard to the quantity of urine ; in general terms it was said that it corresponded with the quantity of drink.

February 5th, 1798. Returned a few days ago from Bristol and Bath ; at the latter place she bathed in the warm bath, and was relieved, by its being followed by a moist skin. The Bristol water was very grateful to her stomach, and generally superfeded the use of Schweppe's soda water. She appears much in the same state as when I saw her in July ; the disposition to the disease still remains, and the feels better or worse according to her diet ; she eats daily some biscuit, and has done fo generally all the time the has been away ; the acidity of her stomach still continues a distressing symptom ; the urine yields a saccharine extract. 

March 6th. Since the first, has been strictly on animal diet ; the several symptoms are removed, and she appears altogether better than I have yet seen her.

March 21st. Continues better, perseveres in the diet. On the l7th she ate a sweet cake which was soon vomited in a sour state.

April 2nd. She assures me no change in the diet has yet been made ; she begins to loath food, but believes it is only animal food, as she feels a strong desire for vegetables ; and alleges that, even under the animal food, she has had the acid state of her stomach, especially at times when her mind has been uneasy ; tongue less red, indeed it is rather pallid ; the urine smells strongly, and has a greasy scum ; on evaporation, it yielded a saline and bitterish tailed residuum, without tenacity ; and when treated with nitrous acid, furnished scales. She was allowed a small quantity of broccoli, spinach, or salad, without sauce.

April 16th. In all respects better, and for these eight days has been eating broccoli and salad occasionally, without any reproduction of the disease.

April 18th. A portion of urine was examined, which was found clear, but of a urinous taste and smell ; its residuum, however, yielded oxalic acid when treated with the nitrous acid.

May 5 th. It was ascertained that she had eaten some biscuit between the l6th and 24th April.] Her skin is moist ; pulse 72, and regular; her appetite less keen, and she feels more uneasiness after eating, or rather has a sense of indigestion ; tongue clear, but not florid; she has gained flesh. She promises to leave off bread, and to take only cauliflower and spinach. The salad does not agree with her; she assures me, and so does her maid, that the other day, after eating more vegetables than usual, the urine smelt and tasted sour immediately after it was voided.

May 10th. Is again to visit Bath and Bristol ; she promises an adherence to the plan, though she acknowledges that her resolution is often likely to fail her; she will, however, be as steady as she can, being perfectly persuaded she has no other prospect of recovery but by so doing. She has again been sensible of the acid smell and taste in the urine, after vegetables. I examined her urine today, but it did not smell or taste of anything, except the urinous flavour and impression.

This Case, though not as yet completely terminated, appears to me of so much importance, that I have inserted it in its present progress. There can be little doubt, that the adherence which has been bestowed on the animal diet since the 20th March, 1797, has not only prolonged life, but given strong hopes of the re-establishment of as great a degree of health, as can possibly be expected, under a long continued stomach complaint. The exact period when Diabetes Mellitus was actually formed cannot be determined : it was probably when the keenness of the appetite took place, but when that happened cannot be accurately ascertained. She had been long subject to stomach complaints, and the keenness of the appetite is only noticed in the account about the lft March, 1797 whereas the cardialgia is mentioned as long before as May, 1796 ; and before these periods the health was much impaired. These complaints had been partly brought on by the circumstances so well related by Mr. Houfton, and partly by the frequent use of fruit, pickles, &c. The animal diet, though not unremittingly perilled in, yet by a more steady use of it in March and the beginning of April, the disease was so far overcome, that the urine became as near as possible to the standard of health. It is to be regretted that a further perseverance did not at that time follow ; however, the progress shows, that certain vegetables, such as broccoli, spinach, salad, &c. may be eaten at a proper time of the treatment, without reproducing the disease, while bread could not be eaten with impunity. This fact we consider of much advantage, as it enables us to guard against the effects of a long continued use of animal diet, and at the same time gratify, in some measure, our longing patient ; we say in some measure, because even these vegetables do not long check the ardent desire for bread ; indeed, the stomach appears very whimsical, for when it obtains its desires, other things are soon solicited. The circumstance of the urine having become acid after the use of more than the usual quantity of vegetables, is a curious fact, but as it merely rests on the testimony of taste and smell, we do not hold it, in this case, as satisfactorily ascertained; it deserves, however, to be kept in view.

Some Remarks on these Communications. 

The only circumstances leading to fix on the predisposing causes of the Diabetes Mellitus are contained, 

• 1ft. In Doctor Falconer's letter, where a case of the disease is related, as having apparently been produced by excessive indulgence in spruce beer, to reduce corpulency. 

• 2d. In Doctor Cleghorn's first cafe, where the patient had worked hard while under convalescence from fever. 

• 3d. In the cafe of the Gentleman of 77 years of age, who had been addicted to the use of large quantities of sugar.

• 4th. In Doctor Gerard's case, the patient had been subject to pyrosis, and liable to much perspiration previous to the diabetic attack

With respect to the treatment of the disease Doctor Duncan found, in one case, fat meats serviceable. 

Doctor Falconer recommends the mephitic alkaline water; and from the advantage the Gentleman of 77 derived from Schweppe's soda water, it may be of service. There is no doubt it will relieve the acescency of the stomach. We would prefer the soda water, as we think it may act less on the kidneys than that made with the vegetable alkali. 

Doctor Beddoes mentions a cafe where the Bristol water cured the disease. 

Doctor Currie has feen several cases of the disease ; but never saw a case of it with sweet urine cured. 

The Case of Walker shews the effects of the animal food. It was begun on the 29th December, when the daily quantity of clear sweet urine amounted to 13 pounds; on the 31 ft day, being two days only, the quantity of the urine was reduced to 5 pounds, and it had acquired a strong urinous smell. The two Cases, treated at Glasgow, by Doctor Cleghorn, shew also the good effects of the animal food, and of the influence of commotions in the bowels on the quantity of the urine.

The Case of the Gentleman of 77, likewise shews the efficacy of animal food ; but the most striking case is that of Clark, as related by Doctor Gerard. This important case points out, 

First. That in this disease there is no absorption of fluids by the skin. 

Secondly, That animal food may alone, if duly persevered in, cure the disease; and such perseverance may probably be of a very limited duration.

SECT. II. - Cases and Communications

the first Edition of the Work. From Doctor Marcet. London, January 12, 1798

MY friend and countryman Doctor de la Rive, having informed me that Walker had been readmitted into the Infirmary at Edinburgh, and placed under the care of Doctor Gregory, I requested him to send me an account of the further progress and treatment of the case, which I now have the pleasure to transmit to you. 

Continuation of the Case of Walker. 

June 12th, 1797. 

He had continued perfectly well till within this fortnight, though his urine, which amounted to 5.5 lb. when he left the Hospital, increased gradually to 16 lb. His thirst is at present urgent; his tongue is dry, as well as his skin, which is also hot; says that he sweats frequently ; pulse 108. He complains of a burning pain in the palms of his hands and soles of his feet; of confiderable weakness) and occasional sourness in his stomach, with pain and flatulence. His fleep is disturbed ; his ankles often swell at night. 

June 14th. In the last 24 hours he has passed 17 lb. of urine, which is of the common diabetic appearance. Su.aj. pulv. alum. comp. jfs. 4. in die; libat aquae calcis 2 lb. in die. Full diet, with meat for dinner. 

June 17th. Urine l6 lb. The dose of the compound powder of alum to be increafed to a drachm. 

June 19th. Urine 14 lb. and rather more limpid. The alum powder to be omitted, the lime water continued, and an entire diet of animal food to be adopted, confining of the following articles ; three eggs for breakfaft, four ounces of cheese for fupper, two pounds of meat for dinner, with three pounds of beef-tea in the day. 

June 21st. Urine 8 lb, ftill pale, though less so than before.

June 29th. Urine 5 lb. yellower than it has yet been and of a more natural smell.

July 7th. Urine 5 lb. To be allowed 4 ounces of bread daily, in addition to his diet. 

July 9th. Urine 5.5 lb. He has drank two cups of tea with sugar

July 11th. Urine 5.5 lb.; a portion of yesterday's was evaporated, and the residuum evidently contained saccharine matter.

July l6th. The bread to be omitted, and the animal diet strictly adhered to.

July 27th. Urine 5 lb. Within these few days his strength has been recruited. He is to be discharged. This Patient was detected in following his habits of irregularity and intemperance; indeed he could not be depended upon.