Type 2 Diabetes

W. Rhubarb was given, by Doctor Wittman, to a patient for four days; a portion of blood was then taken from the arm, and the serum was, as well as the urine, evidently tinged with its yellow

colour, staining linen.

(Rhubard is high in oxalates)

EXCLUSIVE of the cases of the Diabetes Mellitus, which have been published in this Work, we have heard of several others, particularly of one in Guy's Hospital, but we remain unacquainted with all the circumstances. Doctor Odier, of Geneva, mentions a cafe in the Bibliotheque Britannique, vol. vii. p. 321, and vol. viii. -p. 168. Doctor Wilmot, at Hawkehurft, in Kent, has also had a case under his charge ; and Doctor Yeats, at Bedford, informs us of a patient he has successfully treated by the animal food; but as he intends to communicate an account of it, we defer any detail. Doctor Beddoes has very lately mentioned to us four cases of the disease, one of which has been cured by the diet alone. He observes, “that in one case, he endeavoured to please the palate by recommending occasionally articles of food, as nearly resembling dishes made of the farinacea as possible. Tripe, fried in a certain way resembles pancake. Buttered eggs offered an agreeable variety. He also advised a method of trying to reduce dried fish and flesh into a kind of flour. These culinary considerations are extremely important; and he has no doubt a diet might be contrived under which patients would feel little privation." We have likewise received indistinct accounts of four cases of the disease in London and its neighbourhood. There is, besides, one which Doctor Marcet has visited. In order, therefore, to show the necessity of attending to this peculiar disease, which has been hitherto deemed uniformly fatal, we shall recapitulate the number of cases we have either seen or heard of since the dispersion of the notes of Captain Meredith's cafe in January 1797-

• Captain Meredith's Cafe — Page 17:    1

• General Officer's do. — Page 63:           1

• Cafes in Chap. II. Sect. I. — Page 142: 10 and upwards

• Cases in Chap. II. Sect. II. Page 237:     23

• this Appendix:                                                 13

• Total:                                                                    48 and upwards

Along with this number may be examined the account of cases given in the third Chapter, p. 356, being those described previous to that of Captain Meredith. From the whole it will appear, that the disease occurs more frequently than has been generally supposed; and of course, its discussion claims the attention of the medical enquirer. It also is entitled to it in another point of view, as tending to illustrate many other complaints depending on a morbid affection of the stomach, and constituting the most troublesome of our chronic diseases.

Case I.

Benjamin Piggin, Weaver, Mt 40.

Admitted an In-Patient, August 26th, 1799.

Complaints of a troublesome coughs pain in the right side and considerable thirst. Has gradually lost flesh and is so far debilitated as to be unable to follow his employment; pulse 102. Body somewhat costive, appetite not much impaired. Considering this to be a case of incipient Phthisis; digitalis, opiates, a blister, and milk diet, were prescribed.

27th. Cough easier, pain in the side abated, and the pulse reduced to 90.

31st On examining the patient more minutely, on account of his extreme debility, and emaciation, ( which far exceeded what might have been expected to arise from the symptom already enumerated) he then, for the first time, mentioned having noticed a large increase in the quantity, and change in the quality, of his urine. Its peculiar smell first led him to discover, that it had a taste like honey. He had undergone various hardships, and had been addicted to dram drinking; but his health had sustained no material injury until about three months ago when he suffered exceedingly from a harassing journey out of Norfolk, on foot, during wet weather ; and which he considered as the origin of his present malady, Upon examining the urine, it was found to be of a pale straw color, and had a sweet taste, and faintish violet odour. The quantity varied, from six to eight pints, in the twenty-four hours, according to the amount of the liquid he drank. His mouth was clammy, skin hot, and rather dry, and his countenance expressed great anxiety. He could give no account of the exact time when the diabetic symptoms first appeared, but supposed it was about a month since he first noticed the sweetness of his urine.

Having at this period been casually informed, by a medical friend, of the great advantage derived from a strict adherence to animal diet, in the case of diabetes, recorded by Dr. Rollo; I ordered the patient strictly to abstain from bread and vegetables of every kind, and to live solely on broth and animal food. A bolus, composed of five grains of rhubarb, with one grain of opium, was ordered every night, and live grains of asafetida, and ten grains of extract of bark, made into pills, three times a-day.

September 3rd. Pulse 96. thirst and clamminess in the mouth abated makes less urine during the nighty and his sleep is longer and more refreshing.

3rd-6th. Continues to improve in strength and general health makes less urine, which he is confident is not so sweet as usual.

9th. Complaints of spasms in the stomach and bowels with a sense of emptiness and sinking, is much troubled with eructations, and feels great distaste to his animal food, but is persuaded rigidly to persist in its use. Tinct. Ferri mur. ordered along with his other medicines.

11th. The spasms in the stomach not having yet disappeared, three grains of the Extractum cicutce were joined to each dose of the pills. His appetite is become more regular, and his urine neither so sweet, nor so much in quantity.

18th. The spasms in his stomach are much relieved, his strength and looks improved, he has gained flesh considerably within the last week, and the diabetic symptoms have nearly vanished. He says his urine has lost its sweetness; and does not equal the amount of his drink. He can now sleep during the night without a call to make water, and estimates its quantity from three to four pints daily. He was put upon the common diet of the house, and ordered to continue the use of his medicines.

27th. Has gradually improved in his strength and appearance, and is ordered to be discharged cured, at the next weekly board.

Remarks.

This appears to be an instance of diabetes mellitus, under its mildest form. There was neither canine appetite, extreme dryness and harshness of the skin, nor acid taste, and viscid appearance of the saliva, as in the severe, and more strongly marked cases of diabetes. Perhaps the emaciation, and feverish heat, may in part be attributed to the pulmonic affection, which had preceded, and still accompanied the diabetic symptoms. The history of the case must indeed be considered as incomplete, for the urine was not evaporated nor its residuum examined and no regular method was adopted to ascertain the quantity, and relative proportion of the ingesta and egesta; still however, from the colour, taste, and smell of the urine, and its increased quantity, no doubt can be entertained of the nature of the complaint. I have no reason to suspect the patient of either error or falsehood in the description of his symptoms, nor of irregularity in his attention to the sole use of animal diet. It is to this regimen I would attribute the speedy recovery of the patient; but at the same time it must be admitted, that the phenomena of the disease were not so accurately ascertained, nor the practice sufficiently uniform and simple(My knowledge of diabetes at this time, was very limited, and I had not been fortunate enough to meet with Dr. Rollo's interesting publications.), to admit of a positive inference, as to the efficiency of animal diet, in curing this patient. For it may be contended, that such powerful remedies as bark, opium, steel, and cicuta, are adequate singly, but especially if combined, to the removal of a slight diabetic affection. My own subsequent experience, however, and the frequent failure of tonics and antispasmodics, in counteracting this disease, especially when the saccharine impregnation of the urine had existed for any length of time incline me to ascribe the success, in this case,  to the effects of abstinence from vegetable, and the employment of animal diet. No doubt the other remedies proved useful in restoring the tone of the system, and relieving occasional symptoms. The cicuta was evidently beneficial in allaying the spasmodic affection of the stomach and bowels; which, more or less, is to be met with in every instance of genuine diabetes. As I was informed of the patient's intention to return into Norfolk, I obtained a promise from him, that in case of a relapse, he would acquaint me with the fact, and enter into some particulars of his health. I have heard no tidings of him, and therefore am willing to hope, that he has remained free from any diabetic complaint.

Mary Middleton, Mt 30. Unmarried.

Admitted an In-Patient, March 15th, 1800:

Complains of a great flow of urine, especially during the night, which is of a pale colour, and has a smell, (according- to her own expression ) '"resembling sweet flowers". Thirst unquenchable^ with a dry hot skin, and at times, she feels intolerable heat in her stomach, and bowels.

The quantity of urine, from four to five quarts each twenty-four hours, and she believes it exceeds the amount of her drink.

Pulse 96 : appetite irregular, but never keen ; she has long laboured under dyspeptic complaints, with a disposition to hysteria.

It is about four months since she first noticed the violent thirst, and increased urinary discharge. Her occupation is weaving, and that in a damp cellar. Has suffered much from cold, hard fare, and distress of mind, the urine (examined by myself) is of a pale straw-colour, devoid of any urinous smell, has rather a grateful odour, and a faintish sweet taste, which the patient, upon tasting, compared to weak and new small beer. She complains, that at times, the discharge is nearly involuntary.

One pint of urine yielded on evaporation only 5iifs. of a dark-coloured extract, totally devoid of sweetness, but not strongly impregnated with urinary salts; the smell, at least, was only slightly urinous.

The quantity of water discharged the first twenty-four hours after her admission, amounted to eight pints, and a half; and the drink to six pints. An accurate register was ordered to be kept of the quantity of liquid ingesta and egesta, and the patient to be put upon a strict diet of animal food, with broths ; and to take opium with rhubarb, at bed time ; and the bark, with bitters, and vitriolic acid, three times in the day; when very low and faint, she was to be indulged with a little spirit and water ; and her bowels to be kept open with rhubarb and magnesia.

March 15th 1800

During this interval, the liquid ingesta and egesta have nearly balanced each other, and are both reduced in quantity; the average not exceeding six pints in the twenty-four hours, there is little change in the colour, taste, or smell of the urine. The patient's strength and spirits seem to be recruiting. As it was found, however, nearly impossible to restrain her from the use of tea, with bread (which she had contrived to procure by stealth) a sort of compromise was entered into, by which she was permitted to take it once a day; provided she would, in every other respect, confine herself to animal diet.

March 22-30th 1800

The symptoms have remained nearly stationary, except, that the quantity of urine, in some days, amounted to eight or nine pints, while on others, it did not exceed five pints and a half.

30th.. The patient complains of sickness, and indigestion her strength continues to increase slowly; and her general appearance is far from healthy. The medicines and regimen were repeated, an emetic was occasionally interposed to obviate indigestion, and a gentle purgative to remove costiveness.

30th of March–16th of April.

She has been gradually gaining ground, until within these few days, when the thirst and discharge of urine were both augmented; still the excess has always been on the side of the liquid ingesta : the register gives the following report.

April 13th. Drinks 9 pints, Urine 8 pints

April 14th. Drinks 9.5 pints, Urine 8 pints.

April 15th. Drinks 9 pints, Urine 8 pints.

April 16th. Drinks 10 pints, Urine 8 pints.

The bark, and other medicines, are ordered to be discontinued, and the hepatis ammonia (prepared according to Mr. Cruickshank's directions) to the amount of five drops three times a-day, and a bolus composed of alum, tinct. of cantharides, and opium, substituted in their place.

April 16th. — May 10th. During this period, the register points out only a very inconsiderable variation from the former report, with respect to the quantities of urine and drink: the qualities of the former, however, have been gradually approaching to a more natural state. The patient's strength, looks, and general health, have also improved. Medicines and diet to be continued.

May 10th, — June 5th. It appears from the register, that an extraordinary variation in the quantities of the liquid ingesta and egesta, had taken place, during this interval ; on some days, the urine and drink have each reached to only three pints and a half, while on others, they have amounted to seven pints ; and once so high as ten pints.

In order to promote a determination to the skin ( which was still harsh and dry ) she was ordered a warm bath, three nights a week. The first twenty-four hours from the patient's use of the bath (which produced a copious perspiration ) the urinary discharge was diminished from six to four pints and a half; but subsequent trials of this remedy, did not produce the same effects, and therefore it was discontinued. The hepatised ammonia having created nausea, and heaviness, it was laid aside; and the bark, with bitters and klum, in the form of whey, resumed. She was allowed bread and milk, with potatoes to her meat at dinner, and a little porter. This alteration in the diet, did not occasion any change in the quantity or quality of the urine, which amounted to six pints in twenty-four hours; but neither the colour nor odour, were completely urinous.

June 5-20th With the exception of making too large a quantity of urine, she may be now pronounced convalescent,' she is able to lie in bed without being disturbed more than once in the nighty her appetite is firm and regular, her spirits more cheerful, and her whole appearance, denotes a speedy return to a condition of health, equal to what she has generally enjoyed. Being herself persuaded of her entire recovery, she was very solicitous to be discharged. It was thought desirable however, for her to remain a week or two longer, for fear of a relapse; but all opposition proving vain, she was discharged cured on the 25th.

Remarks.

It is liable to doubt, whether this is to be considered an instance of the true diabetes mellitus. - The saccharine impregnation of the urine was certainly slight, and no signs of it were discovered in the residuum after evaporation ; which, in quantity, was inferior to what is usually obtained from this liquid, even in a healthy subject. One very important symptom indeed of well marked diabetes mellitus, was altogether wanting, viz. the voracious or canine appetite. In hysteria, and dyspepsia, to which complaints the patient was liable, great irregularity is observable, both in quantity, and quality of the urine ; but the changes are both sudden; and of short duration. The increased flow, and altered appearance of the urine, in hysteria, frequently disappear after the fit, and recur upon any fresh accession; and in dyspepsia, the least irregularity in diet will modify the urinary secretion in a surprising manner; but in the above case, the increased flow, and altered properties of the urine were permanent, and had existed with little or no taxation for months.

The defect in the assimilating powers does not appear indeed, to have been far advanced, as little or no sugar was apparent in the urinary residuum ; nor had there been a rapid wasting of the patient's flesh and strength. The powers of digestion seem therefore to have been more in fault, than the deficiency of the animalizing principle. That the animal diet greatly contributed to her restoration, can scarcely be doubted ; but in what degree, it is not an easy matter to ascertain. In the interval, from April 16th, to May the 10th, during the trial of the hepatised ammonia, the most evident, and material change, in the diabetic properties of the urine, and general improvement of the patient's health, were to be observed. The practice was certainly too complex to afford decisive evidence of the efficacy of this medicine, in subduing the saccharine properties of the urine. Its effects however in creating nausea, and injuring the appetite, prevented such & steady perseverance in its use, as might have led to a more decidedly beneficial result. This person has been removed from the neighborhood of Manchester, and I have been unable to learn any particulars of her subsequent state of health.

Case III. Thomas Kay, age 24

Admitted an In-Patient, September 29, 1800.

Complains of great thirst, weakness in his loins, and an incessant inclination to make water, which is of a light colour, and very sweet taste. He first discovered the latter quality about four months ago, when being urged by extreme thirst in the night, he drank copiously of his urine, which practice he has since occasionally repeated.

His appetite is generally very voracious, and when he can indulge his inclination, he eats until the stomach is often obliged to disgorge its contents. What he throws up varies in taste and smell ; being sometimes sweet, but more frequently of a pungent acid taste, and odor. The saliva is white and frothy; the mouth peculiarly clammy ; he has a sour taste, and the corners of his lips are covered with fur. The heat in his bowels is frequently distressing, and to use his own expression, "they seem at times burned up." His skin is dry and shriveled, and he seldom perspires.

Pulse 80 ; his figure is lean and gaunt, his complexion sallow, and he has a dejected air. He enjoyed a tolerable state of health till within the last twelve months ; and attributes his present malady to a frequent exposure to wet and cold, and a habit of drinking spirits. He has frequently, when intoxicated, laid out all night in the open fields. His occupations have been various, but of late he has been employed as a laborer to bricklayers. Upon examination, he was found to be afflicted with a painful phimosis. He had never measured the quantity of his urine for any given time, but thinks it must amount to some gallons in 24 hours. This being considered as an undoubted instance of Diabetes Mellitus, under its most aggravated form, an accurate register of the liquid ingesta and egesta, was ordered to be kept, and every material circumstance, connected with the progress, and treatment of the malady, to be carefully noted down. From these documents, the following abridged statement is copied.

September 30th. One pint of urine yielded by evaporation, two ounces and one drachm of a thick sweet syrup, of the colour and consistency of treacle.

In the last twenty-four hours, he has passed thirteen pints of urine, and drank twelve of liquids. The urine is of a whitish colour, sweet to the taste, smells like wort, and exhibits air bubbles on the surface. This decrease in the quantity of urine, compared with what he had usually passed in the same time, he attributed to his being abridged by the nurse(from mistake) in the indulgence of his appetite for liquids.

He was directed to pursue a strict plan of animal diet, consisting of cold fat meat, with beef-tea; and to use daily, one drachm of the nitric acid, diluted with a sufficient quantity of water, as a part of his common beverage. To take five grains of rhubarb, and one of opium, each night.

A remarkable increase in the quantity of urine, and an aggravation of some of the most distressing symptoms, led to an inquiry as to the patient's strict adherence to the plan of animal diet; when it was found, that for three evenings past, he had, by a mistake of the nurse, been indulged in a liberal allowance of bread and cheese for supper, instead of cold meat.

This error was ordered to be rectified, and the greatest attention enjoined, to confine the patient in the future, solely to animal food; medicines and acid drink to be repeated.

October 8-13th.

October 10th - Urine 13 pints, Drink: 12 pints

October 11th - Urine 8 pints, Drink: 9 pints

October 12th - Urine 8 pints, Drink: 9 pints

October 13th - Urine 8 pints, Drink: 9 pints

This diminution in the quantity of urine (as appears from the register) was accompanied with a mitigation of the thirst, internal sense of heat, and stricture of the skin.

He has suffered little disturbance in the night, and finds his strength recruiting, but his urine has not quite acquired its natural smell and taste. Pulse 80, one pound of urine, yielded, by evaporation, one ounce and seven drachms of a thick tenacious extract, not quite so sweet nor so fluid as the last, and less in quantity by one drachm and a half.

As he complained of griping, and soreness of the mouth and gums, from the use of the acid ; he was ordered to be laid aside, and the rest of the plan to be continued.

October 12-20th 

In this interval no material change has occurred; except that on the average, the daily quantity of liquid egesta, rather exceeds that of the liquid ingesta. He has never passed more than eleven pints of urine, nor less than eight in twenty-four hours. On one day, this discharge exceeded, by two pints, the liquids taken in. He complains of a tickling cough, and flight pains in the chest; to appease which, he was ordered an oily linctus, and a warm stimulating plaster.

Pulse 68, urine more natural. Prescribed for daily consumption, one drachm of Kali-sulphuratum, in two pints of soft water. Regimen and opiate to be continued.

October 23rd. 

He was attacked with a violent colic, attended with rigor, which was succeeded by a hot fit. After clearing the stomach, he took a carminative opening mixture, which was ordered to be repeated, with or without an opiate, according to circumstances.

He soon obtained relief, but has suffered, every other, or third day, in a slight degree, from griping pains in his bowels, which have been always mitigated by the carminative mixture. The disorder in his bowels has generally come on after a full meal.

The quantities of urine and drink, have born nearly a relative proportion to each other-; nine pints and a half form the highest, and seven pints and a half, the lowest amount of urine in twenty-four hours.

October 27th

An augmentation was noticed of nearly two pints in the quantity of urine, compared with that of the preceding twenty-four hours. On being interrogated by the House-Surgeon, who suspected some irregularity on account of the change which had taken place, both in the quantity, and sensible qualities of the urine, the patient freely confessed, that he had seized an opportunity to indulge privately in bread and cheese for supper. He has been admonished of his faults and seems determined to act with more discretion) in future.

October 31st — November 12th,

November 9th.

Pulse 76. Obtained, by evaporating one pound of urine, an ounce and five drachms of a thick residuum, of a mixed saccharine and urinary taste and smell; but the latter rather predominated.

The register affords nearly the same result as the last report, except that within the last four days the urine and drink have diminished to seven pints and a half; but the latter is still rather sweet. He gains but little strength and flesh, and complains of weariness and general debility. On the 2d. he began to take a bolus, composed of half a drachm of Kali sulphuratum, and ginger, thrice in the day ; and as he suffered from pain in the lumbar region, blisters were applied over each kidney, and the blistered parts ordered to be kept open. This plan was continued till the 10th. when, on account of the nausea excited by the Kali sulphuratum, and the stationary point of debility, at which the patient remained, notwithstanding the removal of the most formidable of the diabetic symptoms, an infusion of bark in lime water was substituted for the solution, and alum and gum kino were added to his opiate at bed time.

November 12th —20th.

 The urine is scarcely, if at all, sweet; and has varied little since the I2th, either in quality, or quantity. The average amount may be reckoned at eight pints each twenty-four hours. His appetite is fickle, and for the most part puny; the clamminess and sour taste in the mouth have disappeared; the patient has been allowed a small portion of toasted bread at his dinner, without any increase of the diabetic symptoms. He has for two or three days past complained of a fixed dull pain in the back, underneath the right shoulder-blade, to which a warm plaster was applied.

November 20th – December 10th.

Continued the medicines, and the regimen. The pain under the shoulder, having gradually increased, and a tumor appearing; surgical aid was requested. The Surgeon gave it as his opinion, that an abscess was forming, and treated the patient accordingly. The urine has remained stationary in quantity and quality. He has been troubled with flying pains in his knees and ankles ; for the relief of which, a stimulant liniment was ordered. On the 9th, he had transient chills and flushings, with a regular febrile paroxysm in the evening, which, together with the increased size of the tumor, sufficiently indicated the formation of matter. Under these circumstances, it was thought necessary to change his diet; milk was allowed for breakfast, and supper, and the common broths of the house, with animal food at dinner. The bark, and anodyne to be continued.

December 12th — January 1st. 1801

The symptoms have been nearly stationary within this period. The discharge of urine has been reduced, at times, to five pints within twenty four hours, but the average quantity may be reckoned at seven pints. It is improved, both in natural colour, and smell; but the patient says it has acquired a sweeter taste, since vegetable diet was entered upon. The tumor, having pointed outwards, was opened by the Surgeon, and discharged a considerable quantity of laudable pus. The bark, with Vitriolic acid, and a mixture of vegetable, with animal food were continued.

Pulse 80, soft and regular. His countenance, and general appearance, rather improved; notwithstanding the discharge from the abscess was considerable. The excoriation, and swelling of the prepuce, are nearly gone, and the pain in his loins, and sense of internal heat, are very little troublesome. He does not appear to have gained flesh ; but his spirits are good, and he expresses a full confidence of his recovery.

January 1st — February 1st. 1801

The report of this month has varied more than the last. The register points out as much as eleven pints of urine, in twenty four hours; and the average quantity may be estimated at eight pints.

The abscess is not yet healed, but the discharge daily decreases. The bowels are with difficulty kept open, and his evening feverish paroxysms, attended with a short dry cough, have been constant and troublesome. Ordered to wear a flannel waistcoat, and to take opiates, with mucilaginous pectorals. The other medicines to be continued. On the 18th, one pint of urine afforded one ounce and six drachms of an extract, nearly resembling the last; except that there was rather more sweetness, both to the smell and taste. His diet was again ordered to be restricted to animal food; but this was found difficult to accomplish, not only on account of the patient haying been for some time past indulged in the agreeable article of vegetable diet, but also from the persuasion he entertained of his being already cured of his ordinal disorder.

February 1st. — 16th. The patient has remained nearly stationary. His urine is natural, in appearance and smell, though (in his own opinion) rather sweet: The average quantity amounts to nine pints in a day/ yet his thirst, heat, and dyspepsia are all abated. His strength is certainly increasing, the skin feels more soft and natural, and his visage is less sallow and dejected. The cough is troublesome occasionally, but without any fixed pain in the side, or purulent expectoration; yet, notwithstanding these favorable changes, his bulk is little, if any increased. His impatience to quit the infirmary, in order to complete (what he considers to be) his cure, among his friends in the country: and his increasing aversion to any restriction of diet, have led to a compliance with his wishes; and he was accordingly discharged, relieved, on February the 16th.

Remarks.

This appears to be a decisive and aggravated instance of diabetes mellitus. The sweet taste and smell, and profuse discharge of the urine, thirst, dry skin, voracious appetite, and wasting of the body, with hectic fever, (all which symptoms were apparent in this patient's case) are sufficient indications of the nature of the disease. An indulgence in spirituous liquors, and exposure to hard fare, cold and moisture, seem to have operated as remote causes in the production both of Piggin's and Kay's disorder. The efficacy of animal diet, in mitigating the patient's diabetic symptoms, is sufficiently evident; and it is probable, if this case had not been complicated with a pulmonic affection, and the formation of a large abscess under the shoulder, that its termination would have been successful. For the hectic fever arising from these latter causes, contributed greatly to the patient's extreme emaciation and exhausted strength. It may therefore be presumed that the slight remains of the diabetic affection would have given way ; provided the patient had strictly persisted in his regimen and diet. Indeed the changes which so remarkably followed every irregularity in the plan of abstinence from vegetable food ( especially in the first stages of the treatment of the disorder) sufficiently point out the necessity of a strict adherence to this essential part of the method of cure. The quantity of solid matter carried off by this patient's urine is very extraordinary. It amounted, in the first experiment, to two ounces and thirty grains, troy weight, from one pint (wine measure) of the fluid. This is nearly the largest quantity ever before collected by a similar experiment on diabetic urine; at least in all the cases hitherto published, which have come to my knowledge, there is but one instance of more than two ounces of extractive matter having been obtained from one pint of urine ; but the medium quantity in even very aggravated cases of diabetes mellitus, may be fairly estimated at not more than ten drachms of solid extract. The gross ignorance of this patient, joined to his habit of self indulgence, rendered it highly necessary to keep a constant watch upon his conduct; but in spite of every precaution, I believe he succeeded too often latterly, in eluding the vigilance of the man-nurse, and house apothecary. He was strongly urged, and he promised a compliance with the request, to send occasional information of the state of his health; but since he left the infirmary, and went into a distant county, no account from him has been received ; and consequently the termination of his complaint, although most likely to be unfavorable, cannot be ascertained.