BIOMEP 
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 1868 
 
 ABETES MELLITUS: 
 
 G 000 005 528 5 
 
 AN ESSAY TO WHICH WAS AWARDED 
 
 THE FIRST PRIZE OF TflE BOYLSTON MEDICAL 
 S0CIP:TY for 1868. 
 
 / 
 
 By CHARLES B. HRIGHAM. 
 
 TICK KNOWI.EDfiK OK A J'AHT IS BETTKl; TCrAN KiNOKANCt; HT THE 
 \VH» ILE. ' ' — A 1! ABIAX PKOV EKT.. 
 
 BOSTON: 
 
 PRESS OF ABNEE A. KINGMAN. 
 1868.
 
 THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT 
 A. Van Tienhoven
 
 AN ESSAY 
 
 UPON 
 
 DIABETES MELLITUS
 
 DIABETES MELLITUS: 
 
 AN ESSAY TO WHICH WAS AWARDED 
 
 THE FIRST PRIZE OF THE BOYLSTON MEDICAL 
 SOCIETY FOR 1868. 
 
 By CHARLES B. BRIGHAM. 
 
 ' THE KNOWLEDGE OF A PART IS BETTER THAN IGNORANCE OF THE 
 
 « 
 
 WHOLE." — ARABIAN PROVERB. 
 
 BOSTON: 
 
 PRESS OF ABNER A. KINGMAN. 
 1868.
 
 Ik the following Essay, the term Diabetes is used for Diabetes 
 Mellitus throughout, to avoid pedantry. Dr. Roberts' sugar test is 
 inserted on account of its simplicity, and the word diet is used in 
 the most general sense of the term.
 
 OCffMfd. 
 
 
 ?/0 
 
 AUTHORITY. 
 
 Facts and Opinions concerning Diabetes . . . John Latham. 
 
 On Stomach and Renal Diseases Wm. Prout. 
 
 Urinary and Renal Diseases Wm. Roberts. 
 
 The Science and Practice of Medicine . . . Wm. Aitken. 
 
 On Enuresis and Diabetes Wm. Abbots Smith. 
 
 Cases of the Diabetes Mellitus John Rollo. 
 
 A Practical Treatise on Diabetes Robert Venables. 
 
 On the Urine Neubauer and Vogel. 
 
 On the Composition of the Urine E. A. Parkes. 
 
 Heller's Pathological Chemistry of the Urine . Ludvig Dahl. 
 
 The Microscope in Clinical Medicine .... Lionel S. Beale. 
 
 London Hospital Reports, Vol. IH Dr. Fraser. 
 
 Revue Medicale, Vol. CXXXIX Bouchardat. 
 
 Braithwaite's Retrospect, July to December, 
 
 1865 G. Harley. 
 
 American Journal of Medical Sciences, Vol. 
 
 Lin., N. S Abel Jordao. 
 
 New Sydenham Society's Year Book, 1861 . . F. W. Pavy. 
 
 Lectures on Pathology and Therapeutics . . . H. Bence Jones. 
 
 On the Pathology of the Urine J. L. W. Thudichum. 
 
 Synthesis of Cataract ' . B. W. Richardson. 
 
 A Treatise on Human Physiology .... John C. Dalton, Jr. 
 
 St. George's Hospital Reports, Vol. L ... Dr. Ogle. 
 A Treatise on the Principles and Practice of 
 
 Medicine Austin Flint.
 
 CONTENTS 
 
 PAKT I. 
 
 PAOB 
 
 Definition 9 
 
 PART II. 
 Etiology 12 
 
 PART m. 
 Symptoms 16 
 
 PART IV. 
 Complications 27 
 
 PART V.' 
 Morbid Anatomy 32 
 
 PART VI. 
 Opinions of Authors 39 
 
 PART VII. 
 Diagnosis and Prognosis 42 
 
 PART vm. 
 
 Treatment 43
 
 AN ESSAY 
 
 UPON 
 
 DIABETES MELLITUS 
 
 PART I. 
 
 What is Diabetes ? Dunglison tells us that it is " a disease 
 characterized by great augmentation and often manifest alter- 
 ation in the secretion of the urine, with excessive thirst and 
 progressive emaciation." FHnt says that " the term Diabetes 
 signifies simply an increased flow of urine, or diuresis." While 
 Prout gives the following : "The term Diabetes implying sim- 
 ply an increased flow of urine, is applicable to any disease in 
 which that symptom is present in a remarkable degree ; this 
 general use of the term, however, has caused a great deal 
 of confusion, as a variety of diseases, differing altogether in 
 their nature except in the accidental circumstance of being 
 accompanied by diuresis, or a large flow of urine, have, in 
 consequence, been confounded one with another" : and to 
 avoid confusion he says, "Hence I define Diabetes to be a 
 disease in which the saccharine state of the urine is the 
 characteristic symptom." 
 2
 
 lU 
 
 Most authors acknowledge three varieties of this disease, 
 namely, Diabetes mellitus. Diabetes insipidus, and Diabetes 
 chjlosus. Of these varieties. Diabetes mellitus, by far the 
 commonest of all. is known by different writers on the sub- 
 ject by various names, aniong which are Mehturia, Glycosu- 
 ria, Diabetes angelicus, Glucohaemia, Dyspepsia saccharigena, 
 Saccharorrhoea urinosa and many others. Now, as little save 
 novelty, is gained by any of these terms, and as that of 
 Diabetes mellitus is well known and amply indicative of the 
 disease, it seems hardly worth while to change it for an 
 other perhaps less known and less characteristic. 
 
 Aitken thus defines Diabetes mellitus : "A constitutional 
 disease, obviously produced through errors in the processes 
 of assimilation, either in the stomach, m solid organs or in the 
 blood, and characterized especially by an excessive discharge of 
 urine more or less constantly saccharine, excessive thirst, and 
 associated with progressive emaciation of the body." We 
 know nothing positively as to the cause of the disease, and 
 it seems as if it were better to leave out in the definition any 
 theory which may be held with regard to it: acting on this 
 principle, the following definition, though necessarily incom- 
 plete, may be passable. Diabetes melhtus is a constitutional 
 disease, the marked symptoms of which are, an increased 
 discharge of urine containing an abnormally large quantity 
 of sugar, thirst and progressive emaciation. 
 
 If we go a step farther and adopt the plan of Roberts, this 
 disease may be divided into two divisions, a temporary and a 
 persistent class. Under the temporary class belong those cases 
 in which the urine is saccharine but for a short period, as is often 
 the case after traumatic injuries, mental excitement, excessive
 
 11 
 
 use of amylaceous food, disturbances of the functions of the va- 
 rious organs, and in many other hke conditions of the system. 
 
 In the second class abnonnally saccharine urine is a perma- 
 nent symptom, combined with thirst, emaciation and serious 
 debihty. Roberts says, " To this class alone is the term dia- 
 betes at all applicable." Still another class is embraced under 
 the second group, " in which sugar is present in the urine, 
 sometimes abundantly, sometimes scantily, sometimes persist- 
 ently, sometimes intermittently, always with a weakly condition 
 of health, but without thirst or conspicuous emaciation, often, 
 mdeed, with corpulence, without any, or only slight, increase 
 in the quantity of urine, and without that fixed tendency to 
 death which stamps the first group." 
 
 This subdivision of the second class, that of the milder 
 type of the disease, comprises so great a variety of forms that 
 a distinct class can hardly be recognized. It is exceedingly 
 difficult to draw the line between the mild and serious forms 
 of Diabetes mellitus, so closely interwoven are their s}Tnp- 
 toms. We cannot prove by any means that the persistent is 
 but a further development of the temporary form ; nor the 
 more that if we cure a case of what seems a serious t^y-pe of 
 persistent Diabetes, that it may not be a mild t}^e of the 
 same affection with exaggerated symptoms. 
 
 It will perhaps render the subject clearer if we discard en- 
 tirely the subdivision of the second class, and consider only 
 the two forms of temporary and persistent Diabetes mellitus ; 
 of these the latter form — the classical Diabetes, involving as 
 it does the health and fife of the patient — is natui'ally the 
 object of especial interest.
 
 12 
 
 •PART II. 
 
 Diabetes spares neither age nor sex, and accordingly it is 
 detected in the child of a few months of age and in persons 
 advanced in life. The various statistics show that the disease 
 is one of middle age rather than of youth, and that the max- 
 imum mortality is between the ages of twenty-five and sixty- 
 five years. If we examine still farther, we shall find that 
 the maximum mortahty in females is between the ages of 
 twenty-five and thirty-five ; while that of males is between 
 forty-five and fifty-fiA^e years. Again, the disease is more 
 common in the male than in the female, in the proportion 
 of three to one : it is more common, comparatively, in crowded 
 cities than in thinly settled towns, and seems, fi'om some 
 reason, yet inexplicable, to abound in certain locahties, and to 
 be almost absent from others, Harley says, "It is a well- 
 known fact that cases of Diabetes are much more common in 
 Great Britain than on the Continent ; and I, like many others, 
 attribute this to the fact of a much greater quantity of alco- 
 holic drinks bemg used among us than among European 
 nations." 
 
 If we can judge of the prevalence of Diabetes in our own 
 country fi'om the statistics of a very small part of it, we 
 should say that the disease is not a common one. In looking
 
 13 
 
 over the City Registrar's reports, we find the mortality for the 
 twelve years, 1854 to 1866,i to be as follows: — 
 
 
 MONTHS. 
 
 
 w 
 
 I. 
 
 II. 
 
 III. 
 
 IV. 
 
 V. 
 
 VI. 
 
 VII. 
 
 VIII. 
 
 IX. 
 
 X. 
 
 XI. 
 
 XII. 
 
 
 M. 
 
 P. 
 
 M. 
 
 F. 
 
 M. 
 
 P. 
 
 M. 
 
 F. 
 
 M. 
 
 F. 
 
 M. 
 
 F. 
 
 M. 
 
 F. 
 
 M. 
 
 F. 
 
 M. 
 
 F. 
 
 M. 
 
 F. 
 
 M. 
 
 F. 
 
 M 
 
 V. 
 
 
 1854. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 1 
 
 1855. 
 
 1 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 1 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 
 
 
 
 
 
 
 2 
 
 1856. 
 
 
 2 
 
 1 
 
 
 
 
 
 3 
 
 1857. 
 
 
 
 
 
 1 
 
 1 
 
 
 
 2 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 1 
 
 6 
 
 1858. 
 
 
 2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2 
 
 1859. 
 
 — 
 
 — 
 
 — 
 
 1 
 1 
 
 1 
 
 — 
 
 1 
 
 — 
 
 — 
 
 1 
 
 — 
 
 — 
 
 — 
 
 — 
 
 
 
 
 
 
 
 
 
 1 
 
 
 3 
 
 ISGO. 
 
 
 
 
 
 
 
 
 
 
 
 3 
 
 18152. 
 
 
 
 
 1 
 
 
 
 
 2 
 
 
 1 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 5 
 
 18G3. 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 1 
 
 
 1 
 
 4 
 
 1SG4. 
 
 
 
 
 
 1 
 
 
 1 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3 
 
 1865. 
 
 
 2 
 
 
 
 1 
 
 
 1 
 
 
 
 
 1 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 6 
 
 1866. 
 
 
 
 
 
 1 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2 
 
 It will be seen from this table that, during these twelve 
 years, there have been but forty deaths from Diabetes, making 
 an average of about three deaths a year. If we consider the 
 mortality of the months, we shall find that the late winter 
 and early spring months have the greatest share of deaths. 
 
 There are various opinions among authors as to whether 
 Diabetes is an hereditary disease or not. Prout thinks that 
 the causes of the mal-assimilation of the saccharine principle 
 are innate, and to this effect he says, " a predisposition to 
 Diabetes is, I believe, much more frequently inherited than 
 acquired." Roberts, on the other hand, states that "hered- 
 
 1 There being no report for 1861.
 
 14 
 
 itaiy influence is not a prominent predisposing cause of 
 Diabetes." 
 
 Statistics on which we can most rely show tliat not a few 
 instances are on record in which the disease has existed in 
 several members of one family, and in families for genera- 
 tions. A case is recorded in which three brothers were 
 affected with Diabetes, although the disease was not traceable 
 to either of the parents (Rollo). By far the most marked 
 case, however, is that reported by Sir Henry Marsh, in which 
 Diabetes could be traced through four generations of one fam- 
 ily. Cases in which diabetics have married and produced 
 healthy children are reported. The instances of Diabetes in 
 very young children would rather point to hereditary influ- 
 ence ; but in the great majority of cases hereditary predispo- 
 sition cannot be traced in the diabetic patient. 
 
 Diabetes is said to be more common among those who live 
 in damp and wet places, and among those who have light 
 hair, than among others. 
 
 The immediate causes of Diabetes are nearly as obscure as 
 the remote. The advent of the disease is generally referred 
 to some previous illness, such as low forms of fevers, cold 
 from exposure, mental troubles, or traumatic injuries. Dr. 
 Jordao of Lisbon, reports three cases in which Diabetes 
 directly followed intermittent fever ; and he thus explains the 
 sequence : he thinks that the intermittent attacks are irrita- 
 tions of the sympathetic nerve, followed by its unavoidable 
 paresis ; during the paroxysms there is hepatic congestion, 
 similar to that which results from paralysis of the sympathetic 
 in physiological experiments. In intermittent fever the sym- 
 pathetic is paralyzed ; the same takes place in Diabetes — in
 
 15 
 
 the one temporarily, in the other continuously. "Intermit- 
 tent," he says, " if we may be allowed the term, is the 
 microscopic photograph of Diabetes." ^ Cases are reported in 
 which Diabetes was apparently induced by standing for a long 
 time in cold water ; and also those in which Diabetes occurred 
 in sailors who were exposed to wet and cold from shipwreck. 
 Venables thought that the acescency of the mother's or nvirse's 
 milk might give a tendency, if not actually produce, a pre- 
 disposition to Diabetes. 
 
 Mental troubles are thought to be closely connected with 
 Diabetes. " Rayer mentions a case of Diabetes coming on 
 after a violent fit of anger, and Landouzy another after vio- 
 lent grief" (Roberts). Diseases of the brain, hemiplegia, 
 apoplexy and convulsions are sometimes followed by Diabetes. 
 The temporary variety of Diabetes is thus caused much 
 oftener than the persistent form. 
 
 The cases in which Diabetes has appeared after traumatic 
 injuries, such as are caused by blows, wounds, or burns are 
 not rare. Ogle gives the case of a diabetic who, five years 
 before the disease appeared, fell from a scaffold on which he 
 was at work ; and although not insensible at the time, had 
 been ill ever since. Of two hundred and twenty-five cases 
 of Diabetes, twenty are reported by Griesinger as of trau- 
 matic origin. Gudlestone reported the case of a boy Avho 
 had "honey-tasted lu'ine until dentition was completed" 
 (Ogle). Roberts says, "it is probable that in all traumatic 
 cases the injury (however different its seat) implicated some 
 part of the sympathetic nervous system, either within the 
 cranium or spinal cord, or in its peripheral distribution." 
 
 1 American Journal of Medical Science, Vol. LIIL, New Series.
 
 16 
 
 PART III. 
 
 So stealthily does Diabetes creep upon its "vactims that the 
 earliest symptoms are in most cases obscure : slight fever 
 turns, loss of strength and general malaise, with more or less 
 constipation, are the initial sjTnptoms. The patient's attention 
 is first attracted to the disease by the frequent desire to mic- 
 turate ; pains in the back and loins, a burning sensation in 
 the stomach, and an extreme thirst are then noticed ; the 
 appetite, however, remains good, and the condition of the 
 body is apparently that of health. Two cases are reported 
 by Dr. Jordao in which epistaxis occurred in the beginning 
 of the affection ; and he refers to the hemorrhagic diathesis 
 in Diabetes and the facility with which the blood flows from 
 the gums, producing from a rose-colored saliva a taste of 
 blood in the mouth, which diabetics experience on rising. 
 Sir Henry Marsh thinks that the earliest distm'bance in most 
 cases can be traced to some derangement in the functions of 
 the skin. However this may be, as the disease goes on, the 
 skin becomes hard and dry, the pores being impeded so that 
 perspiration can only be induced with difficulty. 
 
 In the next stage, as it were, of the disease, the symptoms 
 are more characteristic ; the quantity of urine discharged is 
 now much larger than at first, in some extreme cases amount- 
 ing to thirty-two pints daily ; it is veiy light-colored and sac- 
 charine ; the patient is disturbed in the night by the necessity
 
 17 
 
 of micturition : fi'om the excessive discharge of urine the 
 urethra and its orifice often become inflamed, even producing 
 phymosis in the male, and an intense itching about the vulva 
 in the female. 
 
 Emaciation is now apparent, and increases day by day ; the 
 patient has an anxious and desponding look, and is peevish 
 and u'ritable ; the tongue becomes reddened and coated ; a 
 tenacious mucus collects in the mouth ; the throat is of a 
 dark red color, and feels dry and clammy, and the breath, 
 in many instances, has the odor of over-ripe apples. In most 
 cases all sexual desire becomes extinguished, neither the 
 power nor the will remaining, and in the female the men- 
 strual discharge is suppressed. The appetite is not inordinate 
 at any period of the disease, but is often capricious. CEdema 
 of the extremities is not an unfi'equent sjTuptom. 
 
 General debility, sooner or later, is invariable, and, as the 
 disease approaches its termination, loss of memory and weak- 
 ness of vision ensue. The disease may terminate by the 
 slow exhaustion of the patient, the renal secretions becoming 
 suppressed, coma comes on, and the patient dies in this con- 
 dition ; or some of the numerous complications of Diabetes, 
 such as pulmonary troubles resembling phthisis, apoplexy, 
 gangrene, and many others may intervene and temiinate the 
 disease. 
 
 DIABETIC URINE. 
 
 The m'ine of diabetics is generally of a light straw color, 
 with a greenish tint. Flint states that " the urine is defi- 
 cient in color in proportion to the amount of sugar which it 
 contains." It is usually quite clear, with little if any sedi- 
 3
 
 18 
 
 merit. It has a faint smell, resembling rather that of damp 
 and mouldy straw than that of violets, new mown hay, or 
 whey, as usually described. It is characterized by the pres- 
 ence of sugar in an abnormally large quantity — abnormally, 
 for the experiments of Briicke have shown that in one thou- 
 sand cubic centimeters of the urine of a healthy man, the 
 quantity of sugar varies from 1.4 to 2.2 grains.^ Bernard, 
 Schiff, and Bence Jones have confirmed this result by similar 
 experiments. 
 
 Schunck, however, found that when healthy m'ine was 
 boiled with acids it gi-adually deposited a resinous substance, 
 which reduced the oxide of copper ; and Roberts on this ac- 
 count thinks that the sugar found by Briicke and others 
 " was either partly or wholly an educt of the analysis and 
 not a pre-existing constituent of the urine." 
 
 It is not very important in Diabetes to know whether mi- 
 nute quantities of sugar exist in the healthy urine or not, 
 for in this disease sugar is always present in a sensible quan- 
 tity. This diabetic sugar is chemically identical Avith grape 
 suo-ar [Ci2 Hi2 O12], and crystallizes in rhombic prisms, more 
 or less confused. It exists in the proportion of from eight to 
 twelve parts in one hundred, this proportion being increased 
 by food and diminished by fasting; but even when no food 
 at all is taken, or purely animal food only, the urine con- 
 tinues still saccharine, showing in the former case that the 
 suo-ar is formed from the tissues themselves. 
 
 This suo-ar, formed fi'om muscles and other animal tissues, 
 called inosite [C2 H2 O2], may be detected in the urine in 
 varying quantities up to eighteen or twenty grammes per 
 day. Aitken quotes the following : " M. Hohl records a case 
 
 1 Lnncef, January 19, 1861.
 
 19 
 
 of Diabetes in which, while the proportion of sugar gradually 
 diminished, the inosite gradually increased in amount, till 
 upwards of three hundred grains were passed in the twenty- 
 four hours." 
 
 The proportion of sugar is also diminished by the inter- 
 vention of any acute disease, in which case the sugar may be 
 altogether absent for a time. 
 
 The specific gravity of diabetic urine varies from 1.010 to 
 1.074 ; it is commonly m the vicinity of 1.035. 
 
 Before we can judge whether the quantity of iu*ine passed 
 by the diabetic is abnormally great in amount or not, we 
 must know the quantity passed by the individual in a state 
 of health. Dalton states that " the ordinary quantity of 
 urine discharged daily by a healthy adult is about twenty- 
 five ounces." This quantity varies from day to day, and 
 even fi-om hour to horu", it being largest in quantity at noon, 
 least at night, and medium m the morning. Various causes 
 may increase the quantity of the m'uie, such as over mental 
 excitement, the use of certain drugs, and the drinking of 
 much water. It is a well-known fact that, in the late war 
 with the South, our sokhers were often obhged to stop to 
 micturate just before or durmg an engagement, thereby un- 
 deservingly incurring the charge of cowardice. 
 
 It has been stated by Vogel that the more watery the 
 blood the greater is the increase of the m-ine, and the less 
 watery the less the increase. Towards the fatal termination 
 of diseases, especially m febrile complaints, where the perspi- 
 ration is very copious, the amomit of urme is considerably 
 duninished. 
 
 Diabetic ui'ine may exceed thu'ty-two pints a day in quan-
 
 20 
 
 tity ; the average amount, however, is about six pints daily. 
 The quantity of the m*ine is about equal to that of the 
 liquids imbibed (Roberts). It is a curious fact that when 
 diabetic urine is emitted upon the ground, flies and bees are 
 attracted by it. Trousseau ^ thus mentions it : " II avait de 
 plus remarqu^ que, lors qu'il pissait dans son jardin ses urines 
 laissaient sur le sol et sur I'herbe une trace inaccoutumde, 
 que sm' la place qu'elles avaient humect^e, les abeilles ven- 
 aient s'abattre, et restaient pour y puiser les sues, qu'elles 
 butinent ordinairement dans la corolle des fleurs." 
 
 The reaction of diabetic urine is usually feebly acid ; it is, 
 however, in some cases, neutral, and very rarely alkaline. 
 The usual changes which take place in the constituents of 
 diabetic urine are as follows : excess of uroxanthin, diminu- 
 tion of urophsein, diminution or absence of m-ea, chlorides nor- 
 mal or in excess, diminution of earthy phosphates, sulphates 
 normal (Heller). Roberts states that " Uric acid is often dif-" 
 ficult to detect, owing to the immense proportion of water ; but 
 it is not really absent, as has been alleged ; . . . . more rarely 
 have I seen oxalate of hme ; and in one instance a persistent 
 deposit of crystallized phosphate of lime." Albumen is not 
 common in diabetic lu'ine ; .and when it does exist it is not a 
 favorable sjTiiptom.U.'-Tlie old fashioned manner of detectmg 
 the sugar in the urine by taste has given way to the more 
 agreeable and more exact tests of modern science. Those 
 most commonly used are Trommer's, Moore's, Maumen^'s, 
 and the fermentation test. 
 
 \ /-Roberts gives the following: "The best method of detect- 
 ing sugar in urine is as folloAvs : pour some of the prepared 
 
 1 CUnique Medicale, T. ii., p. 576.
 
 2t 
 
 test liquor^ into a narrow test tube, to the depth of three- 
 quarters of an inch ; heat until it begins to boil ; then add 
 two or three di'ops of the suspected urine. If sugar be 
 abundant, a thick yellowish opacity and deposit of yellow 
 sub-oxide are produced (and this changes to a brick red at 
 once if the blue color of the test remains dominant). If no 
 such reaction ensue, go on adding tlie urine mi til a bulk 
 nearly equal to the test employed has been poured in ; heat 
 again to ebulhtion, and, no change occurring, set aside with- 
 out further boiling. If no niilkmess is produced as the mix- 
 ture cools, the mine may be confidently pronounced free 
 from sugar, for no quantity above a fortieth of a grain per 
 cent, can escape such a search." 
 
 If diabetic m'me be allowed to remain for a short time in 
 a high temperature, a white scum appears just beneath the 
 surface : if this scum is examined with the microscope, it will 
 be found to consist of small oval confervoid vesicles, about 
 one seventh-thousandth of an inch in diameter; these vesi- 
 cles iu com'se of time sink, form a fawn-colored stratum, 
 become tubular in form and produce new vesicles, which 
 branch out from the parent vesicle, forming an uTegularly- 
 jointed stem. These vesicles, the Torulse Cerevisise, were 
 first brought to notice by Dr. Hassall, who stated that this 
 ftmgus was developed in specimens of diabetic urine contain- 
 ing even very minute traces of sugar, and that it might be 
 regarded as characteristic of the presence of this substance, 
 as it 'occurred in no other condition of the urine. The ap- 
 pearance of these ftmgi is shown in the accompanying fig- 
 
 1 Sulphate of copper, 90.5 grains: neutral tartrate of pota«h, 364 grains; solution 
 of caustic soda (Sp. gr. 1.12), 4 fluid ounces; add water to make up six fluid ounces.
 
 22 
 
 ures. In Figure A, a, the fungi are represented in the spo- 
 rule state ; b represents a more advanced stage of the same ; 
 c, the sporules still farther advanced; d, the mycelium of 
 the fiingi ; e, the manner of growth by branching. In Figure 
 B, the method of fructification and the development of new 
 spores are represented. ^ 
 
 X320 
 
 .0 '^r. " €~i ft 
 
 '§&i 
 
 p. % 
 
 Among the many immediate causes whicli produce sugar in 
 the urine, for a greater or less time, are the following : the ex- 
 cessive use of amylaceous and saccharine foods ; certain drugs 
 in excess, such as mercury ; an interference with respiration 
 [Dr. Garrod ^ thinks that, owing to an interference of respira- 
 tion, the sugar nonnally formed from amylaceous matter is inca- 
 pable of being further changed into carbonic acid, and relates 
 the case of a woman, subject to acute bronchitis, whose urine 
 Avas found to contain sugar and albumen] ; the inhalation of 
 
 1 After Beale, Plate XXXV., Figs. 259 and 263. 
 
 2 Transactions of Pathological Societj', Vol. V.
 
 23 
 
 chloroform [Pavy gives twenty cases from the operating theatre 
 at Guy's Hospital, with the examination of the urine before and 
 after the inhalation of chloroform, in all of which, with one 
 exception, he found sugar after its administration, though in 
 but four was there any trace of sugar previously] ; mental 
 exertions when extreme, and mental excitement, such as is 
 caused by grief, anger or anxiety [from this it might seem 
 possible that saccharine urine after the use of chloroform, 
 might be due to mental excitement: Roberts denies that 
 chloroform ever produces sugar in the urine] ; affections ot 
 the liver and lungs ; cutaneous eruptions more or less se- 
 vere ; traumatic injuries ; indigestion [Harley states that 
 sugar has been found in the urine after eatino; cheese and 
 other ill-digested substances] ; certain diseases may have a 
 tendency to render the urine saccharine [Prout states that 
 "a saccharine condition of the urine exists m gouty and dys- 
 peptic individuals much oftener than is supposed "] ; ^ certain 
 conditions of the system [Nebauer and Vogel state that, ac- 
 cording to Lehmann, saccharine urine is observed in women 
 from twenty-four to forty-eight hom-s after weaning]. "Ray- 
 noso and Michen state that the urine of hysterical and epileptic 
 patients contains sugar after the attacks."^ 
 
 In all of the above conditions the urine is but temporarily 
 saccharine, the instances in which this saccharine condition of 
 the urine occurs are not rare, but are not so common as is 
 generally supposed. Ogle, who has examined the urine in a 
 large number of patients with various diseases, has never 
 yet found one case in which there was an appreciable 
 amount of sugar, excluding, of course, the cases of Diabetes. 
 
 1 This, however, is denied by Bence Joues. 
 
 2 Ogle.
 
 24 
 
 Thirst is a very common symptom of Diabetes : some 
 patients will drink over thii'ty pints a day, and yet the 
 thirst will be excessive : the presence of the sugar in the 
 blood may explain this symptom, for it must have water to 
 enable it to be dissolved and then eliminated from the sys- 
 tem, and the immense amount of water taken only increases 
 the destructive metamorphosis of tissue, and aggravates the 
 s;yTnptoms of the disease. 
 
 The appetite is capricious throughout the disease, bvit 
 toward the termination may be entirely absent, the patient 
 even loathing food. 
 
 Emaciation is a very constant symptom : it is in propor- 
 tion to the intensity and duration of the disease. Dr. 
 Jordao speaks of the healthy and plump aspect of diabetics 
 in the first stage of the disease ; he says, "When Diabetes 
 is chronic in its progress diabetics grow fat, and the reason 
 of the phenomena is easily understood, for animals are fat- 
 tened by giving them faeculent and sweet substances in 
 abundance." In this same way man may be fattened by a 
 moderate quantity of sugar in the system. During the sea- 
 son of the gathering of the sugar-cane, in the West Indies, 
 the negroes grow fat by living on this substance, and al- 
 though they take into the system such an abundance of 
 sugar, Diabetes is a very rare disease among them. On this 
 same principle of sugar fattening, many of the fairer sex, 
 ashamed of the skeleton-like appearance which their shoiild- 
 ers and arms present when exposed, are in the habit of tak- 
 ing fi'equently a glass of eau sueree in hopes of an amendment. 
 
 It has been ascertained that, if solids are taken into the 
 system with an equal proportion of Hquids, the disintegration
 
 25 
 
 of the tissues will not go on, but that the general condition 
 wUl be improved: now in Diabetes, the quantity of water 
 taken is immense, but the defective assimilating powers of 
 the alimentary canal prevent the absorption of an equal 
 amount of solids ; the water then only weakens the system, 
 and emaciation is the result. Emaciation, however, is not 
 always present. Prout mentions a case of Diabetes in which 
 the patient weighed twenty-three stone. Roberts had a 
 patient ill with Diabetes weighing over fifteen stone. 
 
 As to the oedema of diabetics : "Dr. Garrod states that 
 the oedema of the legs is a constant feature in Diabetes. It 
 is certainly veiy common ; and the flat srufaces of the tibi» 
 can nearly always be made to pit on firm pressure, even 
 when no fulness exists about the ankles. I am satisfied, 
 however, that this pitting, when very slight, is not due to 
 oedema, but rather to the soft atonic state of the subcutane- 
 ous tissues " (Roberts). 
 
 The digestion is generally well performed in the early 
 stages of the affection, but after a while, owing perhaps to 
 the intolerance of so much food as diabetics generally con- 
 sume, or to the peculiar character of it, dyspepsia begins to 
 show itself; vomiting after eating is not uncommon. The 
 constipation in Diabetes, as in other diseases, may alternate 
 with diarrhoea ; should the cHarrhoea be of a dysenteric char- 
 acter, it becomes "a formidable and generally speedily fatal 
 comphcation." Venables says that "diarrhoea more fre- 
 quently attacks diabetic children than adults." 
 
 The dryness of the skin is a very constant symptom. 
 Sir Henry Marsh thinks that every case of Diabetes is ac- 
 companied by a morbid condition of the skin ; there are 
 
 4
 
 exceptions to this, however. Ogle had a patient who per- 
 spu'ed to an extent throughout the disease. When so 
 great a portion of the fluids excreted pass out by the ui'ine, 
 it is not strange that the skin should be indolent. 
 
 In the blood, as well as in every tissue and fluid of the 
 body, sugar is found in abundance in Diabetes. Pavy 
 thinks that the presence of sugar in the blood is the cause 
 of the structural and functional disturbances in Diabetes, but 
 he says, "In some cases there exists a source of interference 
 with nutrition, beyond what can be accounted for by the 
 mere presence of sugar in the blood " (Ogle). Prout states 
 that the absence of injury from sugar in the blood "probably 
 arises no less from its mild and innoxious character than 
 from its great solubility in water." Fraser states that "more 
 than five-tenths per cent, of sugar in the blood will give rise 
 fo Diabetes."
 
 27 
 
 PART IV. 
 
 Although Hippocrates has not described the disease of 
 Diabetes by name, he has recorded such symptoms of un- 
 named diseases, that many writers are induced to beheve 
 that this malady was not unknown to him. Galen was 
 probably the first to call the disease by name, although from 
 his own statement we may infer that the disease was known 
 to his cotemporaries, if not to his predecessors. In the. fol- 
 lowing passage, translated by Latham, Galen, speaking of 
 Diabetes, says, " Here the kidneys seem to be affected with 
 that very uncommon disease which some have called the 
 dropsy into the chamber-pot, some the diarrhoea into urine, 
 some the Diabetes, and some the dipsacus." 
 
 The next step in advance was made by Aretaeus, who de- 
 scribed the disease as " a colHquation of the flesh and hmbs 
 into urine" (Latham). So graphically does he describe the 
 various symptoms of the disease that I would give his ac- 
 count in full would space permit. Speaking of the thirst of 
 the diabetics, he says, " Should they awliile refrain from 
 drinking, the mouth becomes dry, the fi-ame parched, and 
 the viscera seem to be on fire ; . . . . overcome with nausea, 
 distressed with perplexity ; in no long time they die, so burn- 
 ing is their thirst. But what device can prevent the propen- 
 sity to urine, or what sense of shame is superior to the painful
 
 28 
 
 necessity? But if for a time they do possess the power of 
 retaining it, they swell in the neighborhood of the loins, the 
 privates and the hips ; and when again they let it pass, they 
 emit the urine with a scalding heat, and the swelling of the 
 parts is removed, for the superabundant water is distributed 
 into the bladder." 
 
 In another portion he thus refers to the origin of the name 
 dipsacus : " For if a person be bitten by the dipsas, a similar 
 affection arises fi'om the wound. Now the dipsas, which is a 
 serpent, if it bite any one, kindles an insatiable tliirst; for 
 then men drink abimdantly, without effecting a cure for the 
 thirst." Again : " Some, indeed, do not emit their urine, 
 neither is there any other vent for the liquid imbibed ; there- 
 fore fi.-om the continued desire of drinking and the super- 
 abundance of liquid and the distension of the belly, they 
 quickly burst asunder." 
 
 It is imdoubtedly due to Willis that, in the year 1684, 
 the presence of sweetness in diabetic lu'ine was made known. 
 Speaking of the urine he says, "Why it should be so won- 
 derfully sweet, like sugar or honey, is a difficulty not easy 
 to be explained." Matthew Dobson, of Livei-pool, in the 
 year 1799, was the first to show by experiment that this 
 sweetness was produced by sugar. Sydenham, Cullen, Bail- 
 he, Rollo and Venables, by adding their portion, miite the 
 ancient with the more modem account of Diabetes. 
 
 In most instances Diabetes is chronic in its character, last- 
 ins for a number of years ; but in a few cases the disease 
 terminates rapidly. Galen says, " As the nature of this dis- 
 ease is chronic, it is generated by length of time ; but short 
 is the life of man when its establishment is once com pleated"
 
 29 
 
 (Latham). " Becquerel mentions the case of a hoy of nine 
 years who died in six days" (Roberts). The disease, ac- 
 cording to Griesinger, usually lasts fi*om two to three years; 
 yet he mentions one case in which the disease was of eight 
 years' duration. Bence Jones mentions the case of one of 
 his patients who "had been diabetic for twenty-nine years, 
 during wliich time he married, and has now healthy cliil- 
 dren." Cases in which the disease appears only at intervals 
 are not mfrequent. Usually Diabetes passes through its course 
 with regularity, terminating in some one of its usual compH- 
 cations. Cases of sudden death in Diabetes have been 
 recorded. Roberts says, " One of my patients fell back dead 
 while eating his dinner." • 
 
 The earliest complications with which we meet m Diabetes 
 are aflPections of the skin, consistmg of pustules, boils, or car- 
 buncles. Dr. Jordao refers to the slight subepidermic hem- 
 orrhages, which are noticed chiefly in the hands and arms, 
 appearing m the form of small, isolated, rose-colored spots, 
 two or three millemeters in diameter, in which there are 
 varicose vessels, surromided by extravasated blood. 
 
 Mental derangement, in some one or other of its forms, is 
 a very constant attendant on Diabetes. Persons whose tem- 
 per, pi'evious to the disease, was of the most amiable charac- 
 ter, become now morose and fi-etful, the powers of memory 
 seem to flag, and a drowsiness more or less marked troubles 
 them. Marked cases of softening of the brain are on record. 
 Ogle has come to the conclusion " that there are cases in 
 which brain lesion may follow in the train of Diabetes and 
 grow out of it, being in no wise antecedent to or the cause 
 of it."
 
 30 
 
 The eyes of a diabetic often have a pretematurally glassy 
 look, and a dimness of vision is not an unusual occurrence. 
 Roberts thinks that tliis dinuiess is owing to an atrophy of 
 the retina. Wliere Diabetes has existed for a length of time, 
 it may be complicated by cataract. Bence Jones says 
 " there is no special complication belonging to Diabetes, 
 unless it be cataract." Richardson, in his paper on the 
 " Synthesis of Cataract," gives the result of his experiments 
 with various substances, injecting them into the blood of ani- 
 mals to produce cataract: he made use of cane, milk, and 
 grape sugar, mannite, liquorice, diabetic urine, glycerine alco- 
 hol, ammonium, soda and potassa ; and he found that in order 
 to produce the condition of cataract, the specific gravity of 
 the fluid injected should exceed the specific gravity of the 
 blood (1.055), and that as long as the blood remained in the 
 abnormal state, so long the cataract lasted. 
 
 Of the substances which he injected, Richardson found 
 that the sugars produced a " large, soft and pearly- white " 
 cataract, salines " one rather shrunken and finn in structure, 
 but of the same whiteness." "Amongst the salines, the 
 chlorides act most energetically, after these the sulphates." 
 Cataract occm's in Diabetes, according to Griesinger, once in 
 eleven cases ; others place the proportion as one in five, or 
 one in thirty-eight. " We must look for diabetic cataract," 
 says Richardson, " in cases where, with the existence of sugar 
 in excess in the economy, the outward sign of the diseased 
 condition is deficient or absent." 
 
 Spontaneous gangrene, allied to that occurring in old per- 
 sons, now and then makes its appearance. Trousseau thinks 
 that it may be due to the obliteration of the small arterial
 
 31 
 
 branches, or of the larger trunks. It is thought by some to 
 be caused by excessive drinking of alcoholic liquors, by others 
 to be a disease of the arterial coats. I have been able to 
 find seventeen cases of diabetic gangrene, but with them no 
 satisfactory explanation. 
 
 The most common of the fatal compHcations of Diabetes is 
 some pulmonary complaint. Roberts says that this trouble 
 " affects nearly one half the cases protracted to the third 
 year." There is a difference of opinion as to whether the 
 affection is tubercular or not ; Pavy and Wilks thinking that 
 it is not true phthisis, but allied to it ; wliile Griesinger, in 
 sixty-four autopsies, found tubercle in thirty-one. 
 
 The tendency which there is in Diabetes to inflammation 
 in the tissues, will account, to a great extent, for the various 
 compHcations.
 
 32 
 
 PART V. 
 
 So little, if any, knowledge of the nature of Diabetes is 
 gained by a post mortem examination that it might seem 
 useless to describe any morbid changes that present them- 
 selves on inspection ; yet, as Diabetes is so intimately con- 
 nected with other diseases, the morbid changes which the 
 various organs undergo may, in the course of time, give an 
 insight into the seat of the malady, and cannot be fairly 
 overlooked. In whatever light the older writers on Diabetes 
 regarded its morbid anatomy, modern research, by the naked 
 eye, or by the most careful examination with the microscope, 
 has not yet succeeded in discovering any characteristic mor-- 
 bid appearances whatsoever. In not a few cases the post 
 mortem examination reveals nothing abnormal in any organ ; 
 in other instances disease appears in the organs according to 
 the complication. 
 
 Our knowledge of the formation of sugar by the liver 
 would naturally lead us to suspect a morbid condition of that 
 viscus in Diabetes ; but this is so far from being the fact, 
 that in most cases the liver has undergone no perceptible 
 change at all : in some cases it is found enlarged, and of a 
 darker color than usual ; in others, atrophied and of a yel- 
 lowish red color. "Wilks believes that the diabetic liver 
 presents differences to the eye which enable it to be distin-
 
 33 
 
 gulshed from others : it is firm, tougli, homogeneous or uni- 
 form in its appearance, and dark in color " (Roberts). That 
 the hver is usually hard and firm in Diabetes is, I think, 
 generally conceded ; but at the same time the majority of 
 writers on this subject deny the e^dstence of a characteristic 
 morbid appearance m the diabetic liver, or in any other organ. 
 As to the presence or absence of fat in the cells, microscop- 
 ical examinations have been contradictory ; some observers, as 
 Beale and Frerichs, finding a cUminution of fat ; while others, 
 such as Pavy and Forster, found the fat undiminished. 
 
 The changes most frequently noticed in the kidneys, are 
 enlargement and a certain flabbiness ; sometimes cysts and 
 cicatrices are met with. Prout says, "a section exposed to 
 air gives in some cases a peculiar orange red tint." The 
 enlargement is probably due to the increased amount of 
 work which the kidneys have to perform, while the flaccid- 
 ity may be accounted for by the tissue being kept on the 
 stretch and thus losing its tone, just as the uterus, after a 
 certain form of service, becomes shapeless and flabby. 
 
 From an extreme case of those given below, the enlarge- 
 ment of the kidneys will be seen to have reached (together) 
 fifteen ounces ; the usual weight singly being, according to 
 Sharpey and Quain, four and a half ounces, the left being 
 one-sixth of an ounce heavier than the right. The altera- 
 tion of the kidney, whether in size or in other respects, 
 diifers according to the duration of the disease, there being 
 httle change at the most. 
 
 In nearly one half of those who die of Diabetes, some 
 trouble, more or less serious, is found in the lungs. The 
 lesion closely resembles tubercle, but there is a difference of 
 5
 
 34 
 
 opinion as to whether it is really tubercle or not. Wilks, 
 in his "Lectures on Pathology," says, "the lung mischief, 
 attendant on Diabetes, is not of a tubercular nature, but 
 the result of simple inflammation, 0"sving to a depressed state 
 of the constitution " ; he also states that he has only once 
 seen tubercle in Diabetes, once gangrene of the lungs. 
 Willet says, "I think it also very difficult to state whether 
 the suppurative condition arises from tubercle or chronic 
 pneumonia, as on feeling very careftilly over both lungs I 
 could not trace a single hard substance between my fingers." 
 Fraser thinks that the lung lesion is not tubercular. Be- 
 sides the breaking do-v\Ti of the lung tissue from chronic 
 inflammation, pneumonic consolidation and gangrene, with or 
 without foetor, at times occur. 
 
 Of late years, the morbid appearances of the brain and 
 nerves have been the especial object of interest in the post 
 mortem examinations of diabetics, owing to the connection 
 thought to exist between Diabetes and nervous disturbances. 
 The symptoms of cerebral disease in the last stages of Dia- 
 betes are often noticed. 
 
 As Diabetes has been produced by pricking the mesial line 
 of the floor of the fourth ventricle, in the centre of the 
 space between the auditory and pneimaogastric nerves, the 
 examination of that portion of tlie brain is made with some 
 curiosity as to the result. Flint and Roberts both state that 
 the floor of the fourth ventricle has presented morbid ap- 
 pearances in Diabetes. "Tarcheu records a case of Diabetes 
 in which there existed slight paralysis of the left side for 
 three months ; the Diabetes persisted until death, two years 
 afterwards, from phthisis ; the medulla oblongata was found
 
 35 
 
 congested, and of a dark grey color" (Fraser). An ossific 
 growth pressing upon the pons varoHi and abscess in the 
 posterior cerebral lobes have been found by Dr. Richardson. 
 
 The arteries of the affected portion of the brain are often 
 found plugged up. Ogle thinks that this is due to the soft- 
 ening of the brain, which, breaking down the tissues of the 
 arteries, is the cause of their occlusion ; he says "The dia- 
 betic state stands in relation of cause to the deterioration or 
 dilapidation of the brain, and this, in its timi, as the cause 
 of the occlusion of the arteries." 
 
 In a patient of Venables, the following morbid appear- 
 ances of the spinal cord Avere. found : "A degree of low 
 inflammation seemed to have pervaded a considerable portion 
 of the colimm both above and below the excavated part, as 
 several flakes of coagulated lymph were found deposited 
 upon the marrow and internal surface of the theca, or 
 sheath, which was itself inflamed in several spots." 
 
 Further researches, it is evident, are necessary to prove 
 anything \Aath regard to the seat of Diabetes ; at present, all 
 that can be said is that there is nothing known of it from 
 the morbid appearances of the organs. 
 
 From fourteen cases of fatal Diabetes, taken from the 
 report of Ogle, I have copied the accounts of the post mor- 
 tem examinations, thinking that, being reports correctly 
 taken, they would best illustrate the variety of morbid lesions 
 found in the disease. 
 
 I. 
 
 Pleural adhesion ; tubercular deposits with vomicae in the lungs ; 
 heart pale and softish ; liver large and nutmeggy ; one kidney large 
 pale aud mottled, the other atrophied with several calculi, two of
 
 36 
 
 which were involved in a false membrane in the pelvis of the 
 organ. 
 
 II. 
 
 Heart softened ; purulent deposits in knee joint and below the 
 fascia? and in the rectus muscle of one leg ; also beneath the mu- 
 cous membrane of the larynx ; kidneys congested. 
 
 in. 
 
 Thirty-four hours after death (winter) ; organs so putrified that it 
 could hardly be ascertained what state they were in. 
 
 IV. 
 
 Slight pleural adhesions ; patches of scrofidous matter were infil- 
 trated in the left lung ; no tubercular masses ; upper lobe of right 
 lung almost converted into a large, foul, sloughy cavity ; kidneys 
 
 coarse. 
 
 V. 
 
 The upper part of the lobe (lower) of the left lung changed to 
 an abscess, the surrounding parts being hepatized ; upper lobe of 
 right lung contained several patches of tubercles ; lower part a 
 smaller abscess ; kidneys congested and coarse. 
 
 VI. 
 
 Both lungs contained much scrofulous deposit and several vom- 
 icae ; kidneys ten ounces weight, cortex narrow, and with few C3'sts ; 
 cortices open and pelvis injected and red. 
 
 VII. 
 
 Lower parts of both lungs containing patches of a dark brown 
 reddish color, easily broken, and giving out a grey fluid ; kidneys 
 large ; cortices of a light fawn color ; tubes containing much gran-
 
 37 
 
 ular and fatty matter ; stomach lining much ecchymosed ; slight 
 subarachnoid fluid. 
 
 vni. 
 
 Lower part of left lung much hepatized, the gray form predomi- 
 nating ; liver large, rounded and fatty ; kidneys granular and con- 
 taining cysts ; much subarachnoid fluid. 
 
 IX. 
 
 Vessels of the brain congested ; liver fatty ; kidneys coarse and 
 congested. 
 
 X. 
 
 Scrofulous tubercles and vomicae found in both lungs ; much 
 fibiin on the pleura of right lung ; kidneys large, thirteen and one 
 half ounces, lobulated v^ith congested cortices. 
 
 XI. 
 
 Lungs tuberculous ; vomica in ujjper part of the right lung, 
 lower part infiltrated with a grayish fluid ; liver and kidneys nat- 
 ural ; suprarenal capsules both finely mottled with an appearance 
 like that of liver, each with a small patch of fibrinous material in 
 the centre. 
 
 XII. . 
 
 Lungs congested posteriorly ; kidneys coarse, weighing fifteen 
 ounces. 
 
 XIIL 
 
 Lungs congested ; heart soft and fatty ; liver (nine pounds two 
 ounces) hard, yellow and granular on surface ; deep clay color on 
 section ; gall bladder containing a number of small black gall stones ; 
 kidneys softer than usual ; mucous folds of tlie stomach thickened.
 
 38 
 
 XIV. 
 
 Tlie fourth ventricle was the seat of a finely granular deposit ; 
 central part of pons seemed rather more vascular than usual ; one 
 hard tubercle the size of a pea in apex of right lung ; liver pale 
 and fatty ; kidneys twelve ounces, soft, flabby, and smooth ; cortical 
 parts large, and the tubules full of epithelium ; no oedema. 
 
 From the above cases we find that in ten of the fourteen 
 there was lung trouble ; in twelve cases there was some 
 lesion of the kidney, either congestion, hypertrophy, or atro- 
 phy ; one case of calculi, two of cysts ; in four cases there 
 was more or less lesion of the brain ; in four cases affections 
 of the liver. These cases, though few in number, may be 
 enough to illustrate the general proportion of the various 
 lesions : first those of the lung, next of the kidney, next of 
 the liver, and lastly of the brain.
 
 39 
 
 PART VI. 
 
 The glycogenic ftinction of the liver, discovered by Ber- 
 nard in 1848, has given rise to various speculations with 
 regard to the true nature and seat of Diabetes. Still later 
 the same physiologist found that certain injuries of the ner- 
 vous system would produce sugar, for a greater or less time, 
 in tEe^urine : from this last discovery, and fi'om the mental 
 disturbance noticed in diabetics, the disease has been classed 
 by many as a nervous one. 
 
 It may not be uninteresting to review, briefly, the theo- 
 ries of certain authors with regard to this disease. 
 
 Galen thouo;ht that the urine was strained fi-om the vena 
 cava into the kidneys, by a certain disposition on the part 
 of these organs, and he defines Diabetes to be "a peculiar 
 affection of the kidneys themselves, analogous to the canine 
 appetite at the orifice of the stomach, with atony of the 
 retentive power" (Latham). Willis says, "I conclude that 
 Diabetes is rather and more immediately an affection of the 
 blood than of the kidneys, and that it thence has its origin, 
 inasmuch as the mass of blood becomes, as it were, melted 
 down, and is too copiously dissolved into a state of serosity ; 
 which indeed is very manifest from the quantity of mine so 
 immensely increased, which cannot have arisen fi-om any 
 other cause than from this solution and waste of the blood." 
 
 Baillie concluded "fi'om the morbid appearances in the
 
 40 
 
 kidneys that the disease was in them." Rollo says "the 
 proximate cause of Diabetes mellitus seems to us to consist 
 in a morbidly increased action of the stomach with conse- 
 quent secretion and irritation of the gastric juice, marked by 
 an eagerness of appetite and acidity." Venables, "I am in- 
 clmed to consider the kidneys as the seat of the disease." 
 
 FHnt thinks that Diabetes "clearly depends on an undue 
 introduction or a deficient destruction of sugar, or both com- 
 bined." Bernard, "that it is due to the hyper-secretion of 
 sugar by the liver, dependent on morbid excitation received 
 through the nervous system" (Flint). Von Durch, that "it 
 depends on the sugar normally existing in the blood be- 
 ing undestroyed and unappropriated" (Fraser). Bouchardat, 
 that "the disease consists in a measure in an abnormal pro- 
 duction of sugar from the ingesta within the ahmentary 
 canal, and that this is proved by excluding all ingesta, such 
 as are readily converted into sugar, when the notable effect 
 of the decrease of sugar is observed (Flint). Frerichs, "It 
 arises from the aiTested metamorphosis of the sugar fonned 
 in the Hver." 
 
 Carter says, "I am inclined to the physiological theory of 
 M. Bernard, to ascribe the primary cause of the disease to 
 a deficiency of nervous power, from some morbid impression 
 at or about the origin of the pneumogastric nerves." Bence 
 Jones thinks that "Diabetes must be considered as an exag- 
 geration of a healthy state, and not as a distinct and pecu- 
 liar condition of the system." 
 
 The results of Bernard's experiments in producing Dia- 
 betes by injimes inflicted on the nerves, spinal cord or 
 brain, have led many to regard Diabetes as the result of
 
 41 
 
 the lesion of some portion or other of the nervovis system. 
 Now as every disease has certain symptoms which can be 
 referred to a deficiency of nervous power, we are apt to 
 give up to nerve disease those symptoms which are other- 
 wise inexphcable, and in the comparative obscurity in which 
 diseases of the nerves are wrapped, the recourse is a con- 
 venient one. Yet, as Bence Jones says, "he would be but 
 a poor physician who overlooked the influence of the ner- 
 vous system, either in the origin, the progress ^r the treat- 
 ment of every disease."
 
 42 
 
 PART VII. 
 
 Diabetes mellitus is not a difficult disease to diagnosticate. 
 "^f sugar is jgresent in the urine, persistently and in large 
 quantities, it* is enough to determine the disease ; the other 
 s^Tuptoms by themselves are of no great value. Fraser 
 states that "gi'eat thirst and great appetite are rarely, if 
 ever, conjoined in other diseases." 
 
 The prognosis depends upon the advance which the dis- 
 ease has made upon the patient, and upon the complications 
 which may intervene during its course. Where the patient 
 has been affected with the disease for a length of time, the 
 prognosis is very unfavorable, unless no compKcations appear, 
 and there is little general debility, which is seldom the case. 
 In attacks of what have been called temporary glycosuria, 
 the patients have every chance of recovery ; of the compU- 
 cations, the affections of the Imigs are the most likely to 
 prove fatal, and are recovered fi'om with the most difficulty ; 
 "the existence of cataract is a very unfavorable indication" 
 (Roberts). As a general rule, the younger the patient the 
 more unfavorable the prognosis. The obese class of diabet- 
 ics, mentioned by Prout, seem to have a better chance of 
 recovery than those who are natm-ally thin. As to the 
 eflPect of treatment on the prognosis, Roberts says " it must 
 be remembered that when by treatment the chsease has 
 been brought apparently to a stand-still, a diabetic patient 
 still holds his life bv a verv frail tenure."
 
 43 
 
 PART VIII. 
 
 If we examine the chemistry, as it were, of Diabetes, we 
 shall be more rationally guided in onr treatment ; we know 
 that when starch is taken into the system it becomes 
 chansed into sug-ar throuo-h the action of the saliva and the 
 pancreatic fluid ; it then serves to nourish and give power 
 to the body, and in the end is ehminated as water and car- 
 bonic acid. 
 
 This same change of starch into sugar goes on in Dia- 
 betes, but the power of transformation into carbonic acid 
 and water is wanting; the sugar then accumulates as such 
 in the system, and in the attempt which nature makes to 
 free itself, every fluid and tissue of the body becomes 
 charged with it, a part remaining in the blood, a part being 
 excreted by the urine. This want of conversion of sugar 
 into carbonic acid and water, is the means of depriving the 
 system of its proper nutrition, and accomits to some extent 
 for the inanition observed in diabetics. 
 
 Bence Jones states that the conditions by which the sugar 
 is changed into carbonic acid, are as follows : — 
 I. The proper temperature. 
 II. The presence of a not immoderate quantity of sugar. 
 
 III. The presence and activity of the proper ferment. 
 
 What the proper temperature should be for this change to 
 go on within the body, is not yet determined; but by ex-
 
 44 
 
 periments it has been found that the internal temperature of 
 the body varies very shghtly under different circumstances. 
 Should there be too much sugar present, the change will 
 not take place; this is known by the fact, that when sac- 
 charine food is taken into the system in abundance, a kind 
 of temporary Diabetes ensues. 
 
 Bence Jones states that "the ferment, the prime cause of 
 change, has not been yet insulated. Whether it be the albu- 
 minous substance of the saliva, or pancreatic fluid, or some 
 other of the many albuminous substances in the blood, it 
 requires for its action, heat, the presence of an alkah, and an 
 undisturbed circulation of the changincT fluid." 
 
 In mild forms of Diabetes there is a want of power to 
 change, the food-sugar into carbonic acid ; in persistent forms 
 there is a want of power to change both the food-sugar 
 (the starch, etc.) and the tissue-sugar (inosite) of the body. 
 We can see fi'om this the reason why the mild forms of 
 Diabetes are easier to treat successfully than the persistent 
 forms, for in the one we have but a single obstacle to com- 
 bat with, in the other, two. We can understand also why 
 the treatment, by excluding all sugar-producing substances 
 from^ the food, has been successful in so many cases. 
 ^'''vV^hat treatment then is indicated in Diabetes? Treatment 
 through drugs, through diet, and through exercise. 
 
 Knowing that almost every diaig in the Materia Medica 
 has been tried and found wanting, as far as a permanent 
 amelioration of the spnptoms of Diabetes is concerned, we 
 cannot expect much service from them ; yet the assistance 
 which they do give should not be discarded. Drugs may 
 aid in producing the oxidation of sugar, and in building up 
 the general health, which the loss of oxidation impairs.
 
 45 
 
 In the first place to prodvice oxidation. The various 
 preparations of u-on, the sesquichloride, phosphate, iodide, 
 ammonio citrate, and many others, are of use ; in these we 
 have a means of improving the quality of the blood when 
 it becomes impoverished by disease. The manner in wliich 
 iron serves to promote oxidation, can only be understood 
 by examining its physiological action in the system. Bence 
 Jones traces this action out as follows : — 
 
 When a soluble salt of iron is taken, in a few hours a 
 part of it is changed mto a sulphru'et, or is reduced to an 
 oxide in the bowels, and losing its solubihty and power of 
 diffusion, is thrown off" as useless. Another part, escaping 
 precipitation, remains dissolved, and passes, in fi'om seven 
 to ten minutes, if the stomach is empty, into the urine, 
 where it may be detected partly oxidized. A third part "dif- 
 fiises from the liquor sanguinis into every texture, and into 
 the blood globules and wliite corpuscles, making a greater 
 formation of haemoglobin and thereby promoting that com- 
 bination with protagon (Cue H241 N4 O2 P) on which the 
 production of new blood globules depends." These globules, 
 together with the fibrin, meeting the oxygen of the air trans- 
 mitted through the membrane of the air vesicles, "appropri- 
 ate the incoming oxygen and carry it to the capillaries whence 
 it must diffuse into each structure to support the oxidation 
 which takes place everywhere." 
 
 The more iron then we .absorb, the more globules we 
 form, and the more oxygen is taken into the capUlaries ; we 
 should bear in mind that there is often a deficiency of ner- 
 vous power which prevents the combination of iron with 
 the blood.
 
 46 
 Another means of promoting oxidation is through alkahes. 
 
 On this point Bence Jones says, " The alkah disturbs the 
 equihbrium of the elements in the organic body, by its affin- 
 ity for acids. Aided by oxygen and heat, more or less com- 
 plex acids are formed from the neutral substances, and if 
 the action of the alkali is sufficiently continued, carbonic acid, 
 water and ammonia alone remain." Such^alkahes as the 
 carbonates of soda and ammonia, potassa, lime and mag- 
 nesia ; and such alkaline drinks as Vichy, Carlsbad Sprudel, 
 Seltzer and soda waters, may be used to advantage. ^ 
 
 Many other substances, such as chlorine, iodine, salts of 
 zinc, copper, antimony, mercury, croton and castor oils, elate- 
 rium, aloes and jalap promote oxidation in the system ; but 
 we should remember, in gi^'ing them, that the caustic alka- 
 lies are greater promoters of oxidation than the sub-carbo- 
 nates, and the carbonates than the bicarbonates. Coimter- 
 irritation by friction or by external applications to produce 
 heat, especially by electricity, are also useful in promoting 
 oxidation. 
 
 The second indication which drugs have _ to fulfil is in 
 the building up of the general health ; this may be brought 
 about by the use of tonics, such as quinine, gentiana, man- 
 ganese ; the various tonic acids ; vegetable and animal oils 
 and fats, such as cod liver oil, sweet oil, glycerine and cream 
 have been used with good results ; the use of cream, how- 
 
 1 " The use of acid drinks, and especially dilute phosphoric acid, has been highly 
 spoken of in some quarters. Griesinger reports unfavorably of their effects. He 
 pushed dilute phosphoric acid to the extent of an ounce daUy. At first, and under the 
 smaller doses, the patient seemed to do very well; but after ten days, and with the full 
 quantity, the volume of urine and the proportion of sugar slightly increased, and the 
 general state of the patient grew worse. I have frequently employed bitartrate of 
 potash water for the purpose of allaying thirst, with good effect " (Roberts).
 
 47 
 
 ever, is not possible after the tongue becomes coated, for it 
 then becomes nauseating to the patient and is rejected ; many 
 patients are nauseated with fats or oils of any kind. 
 
 Still another use of drags in Diabetes is to relieve the 
 constipation by gentle purgatives, such as castor oil, colocynth 
 or Seidlitz powders : as a general rule saline cathartics which 
 are of such use in other diseases should be avoided in Dia- 
 betes, as they increase the thu'st of the patient. This desire 
 for drinks, as well as the excessive appetite, may be relieved 
 by opium given in small quantities (5-10 grains of Dover's 
 powders once or twice a day). Roberts says, "If no re- 
 striction be placed on the diet, opium in doses of fi'om six 
 to twenty grains a day has always in my experience had the 
 power of reducing the flow of urine by about one half . . . 
 and this without increasing its density." Opium has also its 
 advantages in freeing the patient from the irritability of 
 temper and despondency which the disease brings with it. 
 To assist the skin in recovering its healthy action diaphoretics 
 may be used. ^ 
 
 Let us now pass to the consideration of the treatment by 
 bloodletting, sinapisms and setons ; as to blood-letting, we 
 are told by Druitt that, "by diminishing the mass of blood, 
 it lessens the labor of the heart and lungs, and allows the 
 remaining blood to be oxygenated and purified by natural 
 influences." On the other hand, by diminishing the quantity 
 of blood, we diminish the means which the system has of 
 oxidation, for the number of corpuscles becomes less, and 
 
 1 " The patient should be clad from head to foot in flannel, in order to encourage 
 the action of the skin, and defend the patient fi-om the chilly sensations so common 
 in this complaint. A warm bath once or twice a week is also very grateful to the 
 patient, and abates the harsh, arid condition of the skin " (Roberts).
 
 48 
 
 the body is deprived of its nutrition in proportion to the 
 amount of blood taken away. 
 
 It would seem then as if blood-letting were contra-indicated 
 in Diabetes, yet Venables stated that he knew by experience 
 that blood-letting considerably diminished the discharges of 
 urine in Diabetes, and he quotes a diabetic case of Dr. Watts's, 
 in wliich, by repeated Aenesections, one hmidi'ed and eighty 
 ounces of blood were drawn off, the patient's health being 
 perfectly restored. The emaciation and debility almost always 
 present in Diabetes would I think, contra-indicate blood- 
 letting. 
 
 The use of sinapisms has been thought by some to be pro- 
 ductive of good results ; the pain and tenderness in the loins 
 has been relieved by their apphcation, and, if an ulcerated 
 and discharging sm'face be produced, the symptoms of Dia- 
 betes seem to be amehorated in some cases. Kunkler relates 
 the case of a patient who had had Diabetes for seven months, 
 and who, in spite of animal diet and various remedies, got 
 worse ; there were several tender spots in the upper part of the 
 dorsal region of the spine, which chsappeared on cupping ; the 
 disease, however, being unchanged. Immediately after a blister 
 to the neck, the presence of sugar and the unusual excretion 
 of urine ceased, as if by enchantment. By a repetition of the 
 blisters, the Diabetes permanently disappeared, notwithstanding 
 the varied diet.^ Dr. Buttura mentions the only case that I 
 could find of permanent cm'e by the introduction of a seton 
 into the neck. 
 
 T reatment by d iet is next to occupy our attention. Bence 
 Jones says of it, " The effect of diet is far beyond that of 
 
 1 Year Book of Sledicine and Surgery, 1862.
 
 49 
 
 any known remedy." What do we wish to obtain by a re- 
 stricted diet? We wish to prevent the introduction of sugar 
 by food into the system, so that, should the disease depend 
 upon the inabihty to assimilate and oxidize the food-sugar 
 alone, we could treat it more successfully than if no atten- 
 tion whatever were paid to the diet. On the one hand, G. 
 Owen Rees says, in regard to diet, " What I venture to 
 insist on is this, that they (the diabetics) do better on a 
 natural diet ; that saccharine and farinaceous food is necessary 
 to the comfort and well-being of the diabetic as it is to the 
 healthy stomach ; that abstinence from starchy and saccharine 
 matter is injvirious to the diabetic, and that the circulation 
 of sugar in the blood is not productive of bad symptoms either 
 immediately or remotely." ^ 
 
 Goolding on this point says, " The appetite and thirst are 
 to be considered as natural indications, to be gratified with 
 prudence, and more with reference to the wants of the system, 
 than any fear of increasing either the sugar or the amount of 
 fluid." 2 
 
 Signor Burresi, of Siena, has maintained the use of a saccha- 
 rine diet, as a change after one exclusively animal ; and thinks 
 that although the benefit derived from it is attended with 
 much uncertainty, in some cases the relief is both speedy and 
 continuous ; indeed he thinks that a release from the monotonv 
 of animal food alone is highly desirable. ^ On the other hand, 
 Aitken observes, " It is necessary to abstain from all amylaceous 
 food, as well as from every solid and liquid containing suo-ar, 
 or any substance directly convertible into sugar." Abbotts 
 
 1 Lancet July, 17, 1866. 
 
 2 Lancet, July 15, 1854. 
 
 8 Medical awl Chh-ugical Renta-, Vol. xxxvii.
 
 50 
 
 Smith says, " The first point to be attended to in Diabetes 
 is the diet, from which all saccharine and amylaceous substances 
 should be rigorously excluded." 
 
 It is a disputed point among many as to whether an anti- 
 farinaceous diet is a natural one or not ; it seems that, if we 
 consider for a moment that the Laplanders and Patagonians, 
 and many other people, subsist on an exclusively animal diet, 
 and yet live in perfect health, the saying that " bread is the 
 staff of life " is proA^ed a fallacious one, and that the question 
 is once and for all settled. Diet is rather a slave to custom 
 than to nature ; and where persons have been brought up to 
 live on both animal and vegetable food, it is not strange that 
 the deprivation of one or the other should have a marked effect 
 on them. 
 
 The effect of a restricted diet is to diminish the quantity 
 of sugar in the urine to a great extent, if not altogether. 
 By this diminution of sugar excreted, in the majority of cases, 
 the symptoms are ameliorated, and the system, taking a rest, 
 as it were, is placed upon the road to improvement. Great 
 care should be taken to vary the food which the diabetic has 
 to take ; for if one kind of food is continued for a length of 
 time, the patient has such a loathing for it that it has to be 
 eliminated from his hst of eatables. 
 
 In general all kinds of animal food may be taken, and all 
 sorts of vegetable food should be avoided. There are excep- 
 tions, however, for in the list of vegetables, lettuce, cabbage, 
 cauliflower, watercresses and asparagus tops may be allowed ; 
 some vegetable substances, too, are more productive of sugar 
 than others ; and when vegetables must be given, on account 
 of - the ill symptoms which a total deprivation of them now
 
 51 
 
 and then causes, it may be well to know which we may select. 
 The following table, taken from the " Lectures on Pathology 
 and Therapeutics," by Bence Jones, shows the amount per 
 cent, of dextrine, sugar or starch, in various vegetable sub- 
 stances and in liquids : — 
 
 DEXTRINE, SUGAR OR STARCH. 
 
 Apricots, 
 
 93 
 
 ler cent. 
 
 Figs, 
 
 79 per cent. 
 
 Potatoes, 
 
 76 per cent 
 
 Plums. 
 
 92 
 
 " 
 
 GoosebeiTies, 
 
 37 " 
 
 Oat meal, 
 
 70 " 
 
 Peaches, 
 
 86 
 
 " 
 
 Dry rice. 
 
 90 " 
 
 Peas, 
 
 67 " 
 
 Cherries, 
 
 85 
 
 " 
 
 Maize, 
 
 88 " 
 
 Beans, 
 
 67 " 
 
 Pears, 
 
 84 
 
 u 
 
 ArrowTOOt, 
 
 77 " 
 
 Bread, 
 
 61 " 
 
 
 
 GRAINS OF SUGAR 
 
 TO THE OUNCE. 
 
 
 Stout, 
 
 45 
 
 -64. 
 
 Sweet cider. 
 
 18-44. 
 
 Champagne, 
 
 6-28. 
 
 Porter, 
 
 23 
 
 -40. 
 
 Port, 
 
 16-34. 
 
 Sherry, 
 
 4-18. 
 
 Bitter ale, 
 
 12- 
 
 130. 
 
 Madeira, 
 
 6-20. 
 
 Cyprus, 
 
 102. 
 
 Cow's milk contains 4.7 per cent. 
 
 We see from this list that common bread contains about 
 sixty-one parts of sugar-producing substance ; now as diabetics 
 have an intense desire to eat bread, it has been an object to 
 contrive a substitute which shall be palatable, and yet free 
 from injurious qualities. Such bread has been prepared by 
 Camplin, who, using simply wheat bran very carefully washed 
 and finely ground, and mixing with it butter, eggs and milk, 
 with seasoning of spice to the taste, has succeeded in making 
 a palatable article of food. Pavy has made bread from the 
 poAvder of finely-ground almonds ; and Bouchardat has prepared 
 what is called " gluten bread," by washing all the starch fi'om 
 the wheat flour. When the patient is unable to bear either 
 of these preparations, Roberts mentions the use of thin slices 
 of ordinary bread, well toasted before the fire. 
 
 Although from the above list milk might seem to be inju- 
 rious, it has been shown by experiment, " that this sugar is
 
 52 
 
 often partly or entirely consumed." Again, " Milk is more or 
 less injurious according to the stage of the complaint. When 
 animal sugar can be consumed, milk is comparatively harm- 
 less " (Bence Jones). Chambers mentions the fact that the 
 Circassians never drink milk uncooked, but always boil it, 
 mixing with it some alkaline substance by which it is rendered 
 more digestible. All kinds of fish may be eaten freely, and 
 form a pleasant change of food in many cases. If also we 
 regard Diabetes as the result of a deficient nervous power, 
 the phosphorus supplied by fish may be a means of making 
 up that deficiency. 
 
 Bence Jones has quoted the elaborate bill of fare for dia- 
 betics of M. Bouchardat. It is too ample to give in full, 
 but from it I have taken certain articles %vhich, with those 
 already familiar, will serve to point out in a degree the diet 
 of the diabetic patient. 
 
 Bread. — Bran bread, gluten bread, almond bread, terrified 
 bread. 
 
 Soups. — Broths, meat soups, cabbage soup, poached egg soup, 
 game soup. 
 
 Side Dishes. — Fresh eggs, sausages, pickled pork, black pud- 
 ding, ham, pigs' feet, dried herrings, oysters on shell. 
 
 Fish. — All kinds of fresh and salt water fish, also lobster, 
 crawfish, crabs and prawns. 
 
 Meats. — Boiled beef, roast beef, minced beef, beefsteaks, leg of 
 lamb, larded lamb, fricassee of lamb, mutton chops, sweetbreads, , 
 fricasee of veal, calves' head, veal cutlets, turkey, chicken, duck, 
 pigeon. 
 
 Game. — Partridge, venison, woodcock, snipe, quail, teal, plover. 
 
 Vegetables. — Artichokes, cauliflower, cabbage, aspai-agus, cu- 
 cumbers, water-creas, lettuce.
 
 58 
 
 Drinks. — Vichy with claret, Carlsbad Sprudel, soda water, 
 cream, tea and coffee without sugar but with glycerine. 
 Dessert. — Neufchatel cheese. 
 
 The treatment of Diabetes by forced exercise is strongly 
 advocated by Bouchardat, Trousseau and others. Let us see 
 on what principles exercise may be of use. First, as to oxi- 
 dation ; in speaking of the mechanical treatment of diseases, 
 Bence Jones says, "Motion in two ways increases chemical 
 action, first directly, by conversion of force, and second in- 
 directly, by bringing the molecules more closely into contact, 
 so that the latent energy can be changed into active force. 
 This is chiefly effected by the circulation bringing fresh and 
 larger amounts of oxygen in contact with the hydrogen and 
 carbon, phosphorus and sulphur of the textures." Rest on 
 the other hand directly hinders oxidation, by diminishing the 
 chemical action of the tissues. 
 
 On this point Abbotts Smith, without doubt thinking of 
 the suddenly fatal terminations of Diabetes, says, "Patients 
 therefore, in the confirmed stages of Diabetes, should be 
 cautioned against taking long journeys or otherwise fatiguing 
 themselves, particularly in very cold or in very hot weather." 
 Thudichum, in speaking of some of the causes of sugar in 
 the urine, says, by "perfect rest in bed sugar becomes less 
 in quantity, and disappears for a day or two ; it reappears 
 as before on the patient taking exercise." 
 
 Secondly ; by exercise we restore in a measure, healthy 
 action to the skin. Sir Henry Marsh states that " no remedy 
 is of use until the skin relaxes and sweat begins to appear 
 on the surface." 
 
 Thirdly ; constipation, one of the early and frequent symp-
 
 54 
 
 toms in Diabetes, is seldom if ever radically cured by drugs ; 
 exercise and diet are generally acknowledged to be the only 
 methods of affording permanent relief. 
 
 It is not intended that by forced exercise a patient shall 
 be obliged to exert himself to a greater degree than his 
 strength Avill allow, but that, by doing a little one day, and 
 a little more the next, and so on, the patient may gain 
 strength by degrees. This treatment of Diabetes is not one 
 of recent date. Latham speaks of its efficacy in the follow- 
 ing case in Avhich the patient, "weary of life and destitute 
 of every ray of hope, had wandered about as well as 
 his strength would allow him for a few days among his 
 fellow-laborers of the neighboi'hood, and finding from this 
 exertion that his strength did not decrease was tempted 
 to take part in the work that was going forwards ; (that) 
 a copious perspiration very soon ensued under which he did 
 not feel himself weakened in bodily powers but rather im- 
 proved in spirits ; (that) he renewed the same sort of easy 
 occupation from day to day with the same comfortable eveiit, 
 and that at last not only his spirits but his bodily strength 
 was manifestly increased ; his urine, however, was then neither 
 perfectly natural in smell or taste or quantity, although in all 
 these respects it was certainly much amended." From the 
 subsequent circumstances of the case Latham concluded that 
 the patient was cured. 
 
 Bouchardat's treatment is on this very principle. Li the 
 case of one of his patients he required him to work for a 
 short time (a minute or less) at first, with a shovel in a 
 garden. The first time the patient fell down quite exhausted ; 
 but day by day there was evident improvement in his strength,
 
 55 
 
 until finally his health was quite restored. In speaking of 
 exercise, Bouchardat says : "La gymnastique doit etre prdferee 
 avant tout ; mais il iniporte de prendre certaines precautions. 
 Quand les exercises ont ete continues pendant une heure et 
 que le corps est inonde de sueur, il faut changer de flanelle, se 
 laver vivement avec des linges, imbibes d'eau froide, puis se 
 frictionner avec de gros linges ; enfin se masser afin d'obtenir 
 une reaction complete que Ton sontiendra par une marche d'un 
 quart d'heure au moins, le corps ^tant protege par de bons 
 vetements en laine." 
 
 Trousseau also to this effect says : " Un diabetic qui, chaque 
 jour, fait a pied un exercise violent, peut sans rien modifier k 
 son rdgime recuperer temporairement la sante qu'il avait per- 
 due, Jai connu des glycosuriques qui au moment des chasses, 
 cessaient de boire et d'uriner avec autant d'abondance, re- 
 trouvaient leurs forces, leur appetit ; recuperaient, malgre les 
 fatigues, leurs facultes viriles perdues depuls le debut de la 
 maladie." 
 
 Bence Jones mentions several cases in which the patients 
 were so prostrated, by even short journeys, that they died 
 in consequence. This is not inconsistent, however, with the 
 theory of exercise in Diabetes, for sudden and too great ex- 
 ercise all would acknowledge an injury, but in a giadual and 
 slight exercise very many are discovering a benefit. 
 
 January 30, 1868.
 
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