Type 2 Diabetes

From Doctor Pearson, Physiclan to St. George s Hospital, Lecturer on the Practice of Physic and Chemistry, &c. London.

CASE III. 

July, 1798. 

A Gentleman, aged about 56 years, who had lived rather in a fedentarv manner, was troubled for five succeffive winters with a cough, attended by a copious spitting. In the Summer he was almost free from these ailments. During the two last of these winters symptoms appeared, which, it was apprehended were those produced by pulmonary tubercles and vomicae. In the early part of the Summer succeeding the fifth Winter, namely, in May 1797, when the patient was considered as labouring under the chronic kind of pulmonary phthisis, besides taking the usual medicines in such disorders, he began to breathe hydrocarbonate gas; which was administered to him by Dr. Thornton. Soon after the use of this medicine, he experienced a very decisive amendment of his pulmonary disorder ; and continued almost entirely free from cough, spitting, and difficulty of breathing the whole of the Summer ; nor did these complaints return in October following, as they had constantly done for several preceding years. In October last it was observed that, notwithstanding the amendment of the disorder of the chest, a gradual wasting of the flesh had taken place ; so that instead of being, as in health, muscular, and rather corpulent, his body was become thin, and his limbs were emaciated. The appetite continued to be as great, and was frequently greater than in health. The pulse at the wrifl was most commonly about 80 in a minute, and never exceeded that number. The tongue had a healthy appearance, and there was pretty constant thirst. The patient had sweat profusely for the whole preceding year. 

I now learnt that he had been accustomed, for five or six years past, to drink to the amount of from five to eight pints of liquids, such as tea, capillaire, fmall beer, wine, water, coffee, &c. in the space of every twenty-four hours. A proportional quantity of urine was discharged ; that is, as much urine, or thereabouts, as he had taken of drink. As will be expected, the nightrest was difturbed by riling to pass urine. The quantity of urine being at first attended to without reckoning the quantity of drink ; and being perceived by the attendants to be sometimes sweet to the taste, the patient was pronounced to labour under the Diabetes. 

The urine also having been tasted by a person of unquestionable accuracy, it was discovered to be saccharine. A parcel which I examined was not decisively sweet, but I was struck with a smell which I had never perceived on any former occafton, namely, that of stale beer. Half a pint of this urine, on evaporation, yielded 400 grains of extract-like matter, which contained no sugar perceivable by the taste. Another parcel of the same urine, on standing ten days in a warm room, in a three pint bottle, which was half full, and closed with a glass stopper, became covered with a white scum, and a deposit took place of seemingly the same fort of matter ; but the urine itself, which was quite clear, smelled strongly of vinegar, and tasted sourish. On distillation, this sour urine afforded three-fourths of an ounce of liquid acetous acid, of nearly the strength of weak distilled vinegar. It may be useful to notice that the patient had lived principally on animal food for several months, and had drunk a pint of wine daily, instead of a larger quantity, as was his custom before his illness. During my attendance occasionally for three months, the urine generally had the beer smell, and on standing became sour. Two or three different times it had however, undoubtedly, the saccharine taste. Some parcels of this patient's urine, which had a fleshy and beerish smell, happening to stand in a closed vessel, in a warm room, from November, 1797, to May following, not one of them had the usual smell of urine of persons in health, nor of putrid urine ; but either smelled sourish, or musty ; and they deposited less, and were covered with white scum. The urine of the patient, however, sometimes smelt like ordinary urine ; but on keeping it did not grow ascetic, nor acquire an animal odour ; nor did it ferment, and became four. It was also found that this last mentioned sort of urine retained the usual acescency of urine of healthy persons, as betrayed by the test of turnsole, even after keeping in a warm room fix months.

The patient was directed to live four days entirely on vegetable food. The urine during this time proved fo irritating to the urethra and glans penis, as to inflame them, and a little of it was even paffed involuntarily. It was observed that the urine excreted during the ufe of this kind of food, contained none of the uric oxide, which is the usual basis of urinary concretions. According to my observation the urine voided, when the food was entirely animal matter, was equally acescent, and fermentable into vinegar, as when it was entirely vegetable matter.

The quantity of urine, in October and November last, never exceeded, according to eflimation, the quantity of drink ; and the quantity of urine seemed to vary proportionally, or nearly so, as the quantity of liquor varied. Except for some slight incidental colds, the patient was quite free from pulmonic complaints the whole of the last Winter, as well as during the prefent Summer. The thirst has abated a little ; the appetite for food has been of late about the fame as it was in health, instead of being greater than formerly. The pulse at the wrift has varied between 70 and 80 in a minute. The wasting of the flesh has scarce continued to go on of late, and the strength has decreased very little for several months past. The urine, however, does not appear to have diminished in quantity; nor to have been altered in its properties, in proportion to the general amendment. The amount of this excretion has been for fome months, at least, five to six pints in the face of twenty-four hours. It flill commonly has a beerifh fmell, and on Handing in a warm room does not ordinarily fmell urinous, and putrefy like common urine, but becomes acefcent, and deposits lees, and throws up fcum as malt liquor does, on growing four. There is no room to suppofe that the quantity of urine exceeds the quantity of drink.

The patient has continued to live almost entirely on animal food, even breakfasting usually on what is called beef-tea, in place of the vegetable matter commonly taken at this meal. When vegetable substances were occasionally taken as food, the urine was increased in quantity, but no effects were otherwise experienced different from those during the ufe of animal food. It was thought advisable to continue, however, the animal food, as it agreed very well with the patient, and as the urine was less in quantity than when vegetable food was taken.

Remarks.

Saccharine matter is not the immediate cause of Diabetes, but the effect of this disease ; and if animal food is beneficial, and vegetable food is detrimental, it cannot, I think, be shown, that it is because the former does not afford sugar and the latter does. In support of your theory, that the Diabetes is not seated in the kidneys, it may be asserted that the kidneys do not appear to be secretory organs, or organs which compound matters of a different kind from those which enter into them from the blood ; for excepting, perhaps, the secreted mucus from the urinary passages, there is nothing in urine that does not exist in the same state of composition in the blood itself.

It has been attested by persons whose abatements cannot be doubted, that the blood has, in some instances of Diabetes, tasted sweet, and that it had other properties denoting sugar. A single positive evidence of this sort ought not to rejected by any number of negative ones. But, in short, blood and urine to most persons taste is commonly somewhat sweet ; and therefore, it seems not improbable, that there is in general, sugar both in the blood and urine of all animals at certain times. It is not doubted that the sweetness of chyle, and of milk, is from sugar. It seems also that the digestive and assimilating organs of animals compound sugar from merely animal, as well as vegetable aliment ; as appears on examining the chyle and milk of animals which live entirely on animal food ; namely, either those which are purposely fed or which are naturally carnivorous. It does not seem that the fluids of animals which feed on saccharine matters, contain more sugar than those which feed on animal substances. Vegetables manured with merely animal matter contain as much sugar in their fluids as when manured with vegetable matter, or probably with sugar itself. But fugar can also be compounded by fermentation, without the aid of live powers, from dead animal matter and tasteless farina. These facts, it may be proper to notice, seem to justify the observation above made, that, on a theoretical ground, we might conclude that animal food was not likely to be either more beneficial, or less hurtful, than vegetable. In this place it will be proper to point out that fermentation is a more delicate criterion of the preference of sugar in urine than the taste ; for the urine of the above patient did not taste sweet, but it fermented into acetous acid.

5. If the Diabetes be essentially an organic disease of the kidneys, one might expect to see air-ways such a diseased state on dissection ; which, however, could not be perceived in Laurie's cafe above related. There are also deflections published by various persons, in a few of which only was any disease {etn in the kidneys ; nor are there, in general, any complaints of the loins, urinary passages, hips, &c. in diabetic cases. Wherefore if organic affection takes place, it should be considered as an accidental attendant, or consequence ; and in this light mould be regarded the diseased state of the liver, spleen, lungs, &c. observed in some instances. At the most, such organic disease can only be confidered as productive of one species of Diabetes, in which, on examination, it is probable the urine will be found to be very different from that in the other species of this disease. The state of the mesentery should be more accurately attended to on diffection of diabetic patients. In Laurie's cafe above described, it was observed to be diseased, but I was not prepared at that time for examination of this part with a view to any theory. The urine ought also to be examined after the death of the patient, as well as while alive. In fome cafes, as the appetite fails the urine diminishes in quantity, and loses its sweetness a short time before death. The theory that Diabetes is a diseased state of the assimilatory organs, accounts for fome of its molt characteristic symptoms ; namely, for the urine containing fugar and other nutritious matters, the walling of the flesh, frequent discharges of urine, thirst, hunger, weakness of the organs of voluntary action, &c* but it does not account for the quantity of urine much exceeding the quantity of drink.

Glasgow, July 6th, 1798. 

If your book be not printed off, perhaps you may think it necessary to mention the following circumstances, in addition to the cafes which I lately fent you. Mr. Baird, Physician's Clerk in the Infirmary, infpecled the Patient, and sent me the following account, which I have transcribed. " Isabel Harvey (the married patient) having nearly recovered her usual strength, and being completely cured of Diabetes, was dismissed from the Infirmary by Dr. Freer on the 13th of June. She continued well till the 21st, when her belly became costive, and she was seized with fever, attended with acute pain and tension over all the belly. (She went home, four or five miles from Glasgow ; no person was called, consequently nothing was attempted for her relief.) 

On the morning of the 22d, the disorder increased ; in the forenoon she became delirious, and in the evening she lay quiet for about two hours when she expired.  On opening the body, 36 hours after death, the following appearances were observed. " All the thoracic viscera were perfectly found in the abdomen, the small intestines appeared loaded with red vessels, as did several parts of the Colon also, particularly about two inches above the Caecum, where several spots of a black colour, and easily torn, were interspersed among the red. The whole colon was much distended with air, the lower part, from the sigmoid flexure to the neighbourhood of the anus, being plugged up with hard faeces. " The kidneys were enlarged, uncommonly soft, and pale. " The liver, spleen, pancreas, and mesenteric glands, were found." The widow whom I mentioned, Hill continues in the Infirmary ; and concerning her Mr. Baird fent me the following report, which I give in his words. " For the last eight weeks her appetite and third: have been nearly natural; and though, along with animal food, fhe has had 1 lb. of sweet milk and a roll daily, her urine has retained the natural taste and smell, and has rarely exceeded 4 lb. daily. A few weeks ago, several phlegmons rose on her hands, and remained very painful for ten days, during which time she had little appetite, and became languid and listless. These phlegmons are now whole ; her skin is soft ; her appetite and third are natural ; she recovers strength daily, and abating occasional pains through the belly, her feelings are perfectly comfortable." These cases show the great danger of inflammation after the cure of Diabetes by animal food; a danger which increases in proportion to the preceding debility of the Patient, and against which it is necessary to be particularly on our guard.

From Doctor Willan, London.

August 6th, 1798. 

A Gentleman about 25 years of age, tall and thin, has been engaged in a fatiguing, though sedentary occupation, but always conducted himself with sobriety and regularity. For more than a year past he had found his health and strength gradually declining ; he became pale, emaciated, and skeletal; his hands and feet were unusually dry and hot; he had sometimes a trifling cough, and was affected with a great shortness of breathing, on going up stairs, or any ascent. 

The case being deemed consumptive, he had been recommended to confine himself to a vegetable diet, and to spend as much time as possible in the country. This plan, however, was not attended with any tangible benefit: on the contrary, the wasting and general debility seemed to be daily increasing under it. 

I did not see this young Gentleman till the middle of May last. In addition to the symptoms above mentioned, he then complained of a clamminess in the mouth, a parched tongue, and an unquenchable thirst. His pulse was from 76 to 86, weak, and unequal. He was in general very costive. From these circumstances, I was induced to examine the state of the urinary secretion, before anything was administered to him medicinally.

The result of the first trial was as follows. He took in 24 hours 11 pints of fluid, consisting of milk, or milk and water, with two slices of toasted bread, and within the same time made 12 pints of urine, a portion of which was evaporated by Mr. Moore, of Apothecaries Hall; the result will be subjoined. The urine was of the highest straw colour, had a faint disagreeable smell, and was sweetish to the taste. His breath had, at this time, an unpleasant acidulous smell, nearly the same as that produced by the effluvia of decaying apples. He observed to me, that for several days past he had felt a pain in the head, and a stiffness, or drawing in of the eyes, with imperfect vision, the letters appearing double whenever he attempted to read or write. 

A total change of diet seemed the only means of preserving this worthy young man from almost immediate dissolution. He commenced the plan without hesitation, abstaining wholly from bread, or other vegetable substances, and from all fermented liquors. For breakfast he took milk, with yolk of egg; for dinner, occasionally fish, but, in general, beef or mutton which had been long kept, sometimes a little ham; for supper, a poached egg, or calve's foot jelly, prepared without wine or acid. 

On the eighth clay of this course, a second examination was made of the state of the urine, which amounted only to 2 pints in 24 hours, 3 pints of milk, or tnxlk and water, having been drank within the same time. The urine was more high coloured than before, but had not wholly lost its faint smell. A third trial of the same kind was made on the 10th of June. He drank 3 pints of fluid, and made exactly the same quantity of water. It must, however, be remarked, that the day was extremely chilly, and that he did not ride out, nor take any exercise through the whole of it. 

On the 12th of June, he informed me that his thirst was nearly removed, but that he felt a soreness of the stomach, and great oppression of it after eating, with sickness. These symptoms continued the three following days, which he spent in the country, and then ceased. From that time his stomach became reconciled to animal diet; his appetite and strength increased; he eat with a proper relish, and was not troubled with thirst. 

On the 18th of June he drank 3 pints of liquid, and discharged only 2.75 pints of urine, which had the usual smell and colour. He stated that he had begun to perspire at night, which had not been the case for some time before; alfo, that he felt his hands and feet more moist and comfortable. The complaint of his head and eyes was likewise removed.

June 20th his pulse was more firm; and he found himself recovering strength, so that he could walk a mile or two without fatigue. He eat heartily, slept well, and seldom drank between meals.

On the 12d June some family concerns obliged him to set off for Yorkshire. He went, however, with the resolution of adhering to the plan of diet which had already so much relieved him, without the use of any medicine, excepting a little castor oil, as an occasional laxative. On Saturday Iast, August 4th, in a letter, he informed me, that he bore the journey very well ; but that fome fatigue, and agitation of mind since, had much depressed, and enfeebled him. From this state, however, he recovered in two or three weeks; and he is now able to take considerable exercise either by walking or on horseback. He hopes to be in town soon, and thinks himself qualified to undertake business with as much activity as usual.

Page 345

Some Remarks on These Communications.

THESE communications are of great importance in the further elucidation of the history, nature, and treatment of the Diabetes Mellitus; and they will probably supersede any more cases in detail. A concise account, however, of such as are attended with new circumstances, and which have terminated, either successfully or fatally, with diffections, must still be required. The continuation of Walker's case, as described by Doctor de la Rive, shows the same unsteadiness, and inefficacy of any other means than the animal diet, and likewise that his patient, by more perseverance, might have obtained a perfect cure.

Doctor Gerard's first case points out a corresponding effect in the female as in the male, by the irritating stimulus of the saccharine matter in the extremity of the urethra ; it also exhibits the effect of vomiting in diminishing the quantity of the urine ; and alludes to some advantage having been obtained from the carbonate of ammonia. 

The second case marks a dropsy previous to the diabetic accession; also the same affection of the urethra as the other; and the patient having more resolution in complying with the means of cure, was likely to obtain a restoration of health. Both show the propensity to deviate from a rigid observance of the animal diet, and the conviction that it is efficacious when strictly pursued. 

Doctor Cleghorn's continuation of the cases of Roger and Maclean, afford additional satisfaction, but more particularly that of the latter. This man died evidently under the effects of a lung disease, during which the Diabetes had not returned. From the appearance of the lungs on dissection, it was supposed that they had been affected previously to the diabetic attack; or, at least, that they were dissused to inflammation, on getting cold, while in the infirmary with the disease. Dissection, while it exhibited no morbid derangement of the kidneys, neither did it of other parts. It is said, the kidneys, though found, were more flaccid than usual, and that the bowels were very pale.

He gives also a concise account of four other cases of the Diabetes Mellitus, treated in the Glasgow Infirmary. The first-of whom was a man who caught cold under mercury, to which the patient described his disease: he got completely well by the animal diet. The insensibility of his stomach to emetic medicines is attributed to an original peculiarity of constitution, which had no connection with the Diabetes. 

The remaining three patients were women, one of whom had the disease while giving suck, which obliged her to wean her child. Had this patient been admitted during her nurfing, it might have been ascertained whether the milk contained more than the usual proportion of saccharine matter. The other two cases show only the efficacy of the animal food. There is a fifth mentioned as being under the treatment, with equal hopes of success. 

The Doctor takes notice of a singular disease among horses, which had some general resemblance to the Diabetes in the human subject:. The urine of one of them was hastily examined, and it was found sour. 

In his letter of the first of July, he gives an account of an acute disease, which attacked one of the diabetic patients, after her dismissal from the infirmary, terminating fatally. The dissection showed inflammation of the bowels ; it also exhibited the kidneys as being enlarged, uncommonly soft, and pale. From this case, and that of Maclean the Doctor supposes, that animal food, when so rigidly persevered in, strongly disposes to inflammatory affections.

(explained at end by Dr. Rollo)

Doctor Storer had met with seven distinct cases of the disease, and he avers with Doctor Currie, that after it had been completely formed, he had never seen it cured by the former methods of practice. He gives a satisfactory account of Doctor Aldrich's case, the Gentleman of 77 years of age ; which shows the effects of our plan of treatment in a very favourable and impartial point of view. He joins in the common regret, that the great desire for variety of aliment, forms a strong bar to the successful application of a diet confining entirely of animal food. He describes a case where Bulimia preceded as well as accompanied the diabetic disease. The account of a mild or chronic species of it, as prevailing in families is important. In this form it is said to be occasionally suspended, and the patient may live to a tolerable age. It does not seem, so far as the Doctor's observation has gone, to depend on any constitutional disposition ; neither does he determine whether this constitutes a difference in the nature, or merely in the degree of the disease. https://www.carniway.nyc/history/animal-food-may-alone-cure-the-disease

https://www.carniway.nyc/history/doctor-aldridge-uses-carnivore-to-cure-diabetes

Doctor Jameson's case of Nixon exhibits a distinct history of the disease, which had been of eighteen months standing. The animal food reduced the saccharine and extractive matter from three ounces, which had been obtained from a quart of the urine to one ounce and two drachma in the short space of 19 days. On the whole, it furnishes an instance of the efficacy of our plan of cure.

Mr. Shirreff's attentive observation has rendered his diabetic case interesting. The subject of it is of an earlier age than that in which the disease commonly appears ; a stomach affection evidently preceded it, during which she eat freely of fruits and sweetmeats. It would seem, that the urine undergoes manifest changes, at different hours after eating, which is more remarkable, according to the substances eaten. In this case, after partaking of vegetable matter, it was found clear, and sweet ; the next portion higher coloured, and insipid ; and when the interval was long, as in the night, the urine was more natural. This is an important fact: in support of the opinion, that the saccharine matter is evolved during the process of digestion.

Mr. Houston's patient shows also, a long continued stomach affection, previous to the detection of the Diabetes, during which she likewise indulged in the liberal use of fruit : but in this case the mind was particularly concerned, being under the influence of the depressing passions. The circumstance of the acid urine is singularly curious ; but it remains to be further ascertained.

Doctor Cleghorn, it may be remembered has mentioned that he found the urine sour, in the case of the horse disease.

Dr. Pearson's three cases, with the ingenious remarks accompanying them, are valuable. The first, shows the same infeasibility to emetics, as in one of the cases related by Doctor Cleghorn. The direction exhibited no morbid appearance, or even any change of the kidneys, or any other part, except in the myfentery and bladder, which were found thickened. The urine contained in the latter was not sweet. This case is peculiarly important to us, from the detection having shown no change whatever, in the natural appearance of the kidneys; a fact strongly supporting our doctrines. The second gives a very distinct account of the disease, which was treated in the best manner, by the remedies usually employed at that time; but without relief. The third contains facts and arguments, in opposition to the theory of the disease, as depending on a primary affection of the kidneys, which must have their weight. The opinion, with regard to the effects of animal and vegetable food, in the formation of saccharine matter, differs from that we entertain. It is an incontrovertible fact, that animal food solely used, deprives the urine of every portion of saccharine matter, so completely, as not to be discoverable by any chemical process, nor by fermentation. See Doctor Gerard's case, page 215.

The experiments of Mr. Cruikshank not only show the difference between what may be termed animal and vegetable sugar; but that the sugar in diabetic urine is very probably the entire product of vegetable substances. There are also some other points in which we cannot perfectly agree ; but these will appear from our general account of the disease.

Doctor Marshal's case is valuable. The appearances on dissection show the state of the kidneys, which has been frequently met with in this disease : but the peculiar condition of the stomach and blood have not been hitherto found, at least not described. The stomach exhibited marks of disease ; and as the villous coat was of a red colour, an increased action of its vessels having happened was apparent. The peculiar smell of the blood, pointed out a great deviation from the natural state ; but it is to be regretted that it had not been more particularly examined. The circumstance of the unmixed chyle is singular. The whole, we apprehend, justifies this conclusion that more morbid changes in the organic powers of assimilation, than of any others in the body, were manifested ; of course, we deem it a fact strongly in favour of our doctrines of the disease.

Doctor Willan's case exhibits a very successful adoption of the animal food, without the use of any other remedy. The disease had been probably of twelve months duration, and was attended with nearly its worst symptoms. In eight days the urine was reduced from 12 to 2.125 pints in the 24 hours ; and in 14 days more, it was probably deprived of the unnatural proportion of extractive, as well as saccharine matter. In five weeks, the recovery seemed to be far advanced. If the same steadiness of conduct, in adhering to the dietetic treatment, continues, there is every reason to expect a perfect restoration of health ; and it will furnish an additional fact, in support of our opinions of the nature and treatment of the disease. 

Mr. Thomas's case, from the minuteness, accuracy, and result of the direction, throws considerable light on the nature of the Diabetes Mellitus, and affords another remarkable fact in favour of our ideas on the subject. The apparent natural condition of the abdominal viscera, demonstrated that the disease did not depend on the derangement of the structure of any organ. The morbid changes which may have been found in other dissections, must have arisen from the long continued morbid action upon particular parts, forwarded, probably, in some instances, by a favourable pre-disposition, especially that connected with scrofula. The circumstance of three brothers having the disease, thews some pre-disposition, which may be hereditary. The effects of various vegetable substances on the urine will improve the practice. The observation that the urine had been voided in an acid date, corresponds with what has been mentioned in Mr. Houston's case, and by Doctor Cleghorn. This, with several other cases, shows the pre-disposition in diabetic patients to inflammatory diseases. The failure of tonic and astringent remedies, with the effects of vegetable food, and the successful administration of opposite means, confirm the opinion that this peculiar disease is accompanied with a state of constitution very different from that in scurvy. In this case, the patient had an attack of pleurisy, in the month of March preceding that of July, which proved fatal. As active diseases of this nature have been found to suspend the Diabetes Mellitus, the intervening circumstances which occurred in it, between the two attacks of the pleurisy, might somewhat have depended on the sequel of the first, as it was the opinion of Mr. Thomas, part of the diseased appearance of the right lung, with the effusion in the chest, was the effect of that attack.

SECT. III

Of the appropriate Treatment of the Diabetes Mellitus.

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

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

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

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

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

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

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

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

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

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

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