134

infer that the smaller proportion of sugar, with concomitant indications of favourable progress, are to be deduced from the use of the alkali.

The next case, which was admitted in October of last year, also affords illustration of the advantage to be derived from an alkaline treatment, attention being at the same time paid to diet and regimen.

[Edward G., a carpenter, aged 48, was admitted in October, 1852, with the usual signs of aggravated diabetes.]

He was placed on carbonate of ammonia, ten grains; carbonate of potass, ten grains; and carui water, one ounce; to be taken after each meal. He had complained of some gastric uneasiness, flatulence, and eructations, while taking opium; these symptoms disappeared on taking the alkalies. The urine was at this time of a bright lemon-yellow, and, like the breath, exhaling an odour remarkably like chloroform, but not so powerful as on admission. The average daily quantity was seven and a half to eight quarts; twelve days after taking the alkaline remedies the urine was five quarts, and the specific gravity 1037, and the amount of sugar 7.53 grains to the ounce; crystals of oxalate of lime were detected by the microscope, and urea was recognised by nitric acid. The bowels were more regular; thirst much diminished, and had become less urgent even at night; the appetite was less craving, but there was no improvement in the physical strength of the patient. He continued the alkalies, with the addition of hard-boiled eggs to his diet, and fish on alternate days, for a further period of nine days, when the specific gravity of the urine was 1038, and the quantity of sugar on two examinations was 6 and 6-5 grains to the ounce. He fancied himself a little better, and as he had been above two months in the hospital, he was desirous of going home, and trying what such a change might do for him. He died three months afterwards, reported from gradual exhaustion.

It would appear from this case that agents which out of the body possess the property of arresting the chemical conversion of sugar, exercise no remedial agency within the organism,-at least so far as to diminish the quantity of sugar excreted. It must not be forgotten, however, that observations on a single case are necessarily inconclusive, and particularly as the case just related was one of extreme severity. The action of opiates was at first favourable; the relief to the more distressing symptoms of thirst was evident; the urine became less abundant in consequence, but there was no diminution in the major morbid conditions; emaciation continued, and large quantities, although less than before, of sugar continued to be excreted by the kidneys. The alkaline treatment furnished the most favourable results, a gradual diminution in the daily amount of urine and a proportionate decrease in the quantity of sugar present. When he first came under treatment the daily average of sugar passed was 11.25 ounces; after the alkaline treatment it had become reduced to 3.66 ounces in the twenty-four hours. Even this lesser quantity is a large amount of solid sugar to be formed out of the alimentary matters, chiefly animal, taken by the patient. Nevertheless, the great reduction in the amount of fluid excreted, as well as of sugar, formed while under the influence of alkalies, and the larger share of improvement in all respects witnessed as compared with the results observed to follow the use of opium, justify us in placing great reliance on remedies of this class.

[In the next case, the patient left the hospital improved. Diaphoretics, warm baths, and subsequently hydrochloric acid, formed the basis of the treatment. The quantity of urine passed in the twenty-four hours, on admission, was about six quarts, specific gravity 1032. His age was 38.]

He was placed on a meat diet; a warm bath each alternate day; three grains of Dover's powder three times a day, and five grains of the same, with five of the antimonial powder, at bed-time; saline draughts of the phosphate of soda and tartrate of potash were given to regulate the bowels. He continued this treatment for a fortnight, with great advantage. The tongue became moist during the day, and the thirst much relieved, being for the most part troublesome only at night time. The bowels acted regularly. The specific gravity of the urine was reduced to 1026, and the presence of sugar, on one or two examinations, was very doubtful by Trommer's test; one sample contained a large proportion of urea. The branny exfoliation disappeared from the skin, and the surface of the body assumed a healthier appearance. Some dyspeptic symptoms, flatulent distension of the epigastrium, and gastrodynia, occurring, the antimonials and diaphoretics were discontinued; and he was ordered the dilute hydrochloric acid, in half-drachm doses, with compound infusion of orange

peel, to be taken three times daily, a quarter of an hour before each meal; and yielding to his craving solicitation for bread, he was allowed six ounces daily. The dyspeptic symptoms disappeared; the tongue continued moist throughout the twentyfour hours. The urine averaged about three quarts: one day it was reduced to five pints, and the specific gravity was about 1025; the faintest indication of sugar by Trommer's test. Urea abounded in the urine, and the last two days of the patient's residence in the hospital a plentiful deposit of urates occurred. The patient appeared to have gained in flesh, and he represented himself to have acquired a good deal of his former vigour and activity. He showed himself once after he was discharged. His urine continued free from sugar.

[The connexion of glucosuria with gastric derangement would seem to be proved by the fact, that the remedies employed to remove the state of atonic dyspepsia diminished the quantity of sugar in the urine. John O., aged 20, was admitted Jan. 1850. His urine amounted to ten quarts daily;]

The bowels were regulated with salines. He was placed on a meat diet; warm baths every other day, and the soap-and-opium pill, in five grain doses, given night and morning. The opium affected the head so much that it was discontinued after the third day. He was then ordered fifteen grains of the carbonate of ammonia, three times a day, after each period of eating. The ward-book contains a daily register of the amount of urine, the specific gravity and the quantity of fluid drunk, and three calculations of the quantity of sugar present during the six weeks that he took no other remedy but the alkali. The following is an abstract :-For the first ten days the daily average amount of urine was five quarts; average specific gravity, 1037; average daily drink, four quarts; proportion of sugar, present in the ounce, seven grains. The symptoms remained the same. He had a warm bath twice a week. In the second period of ten days the daily average of urine was four quarts; specific gravity 1035; daily drink, three quarts; and sugar calculated at about eight grains to the ounce. The patient notwithstanding had improved; the thirst was much less distressing; a moisture from time to time appeared on the forehead and in the axilla, and he felt stronger, and the flatulence and dyspeptic symptoms were much abated. During the next period of ten days the mean daily amount of urine was reduced to three quarts: specific gravity 1030; mean daily drink was not recorded, the patient having twice forgotten to observe it; the amount of sugar had become reduced to three grains to the ounce. The patient's progress continued so satisfactory, that he was desirous of leaving the hospital to obtain a situation. He had gained much in bodily vigour; his appetite had become more natural; there were no unpleasant symptoms generated after eating; the bowels acted regularly; the tongue, although red, was clean and moist; and he stated that he had but little thirst, except when awaking from sleep, when he usually craved for water. The alkaline draughts were reduced to two daily, and he took four grains of the citrate of iron twice a-day. On taking the account of his symptoms during the last period of twelve days, the daily average of urine was three quarts; the specific gravity 1028; and the last sample of urine examined gave very doubtful results as to the presence of sugar. Urea was detected, and hydrochloric acid threw down, after standing a few hours, a pretty abundant crop of crystals of uric acid. This patient was lost sight of till the March of the following year, 1851, when he was again admitted. The symptoms of diabetes were as urgent as on his first admission, and in addition there were undoubted manifestations of tubercular disease in the lungs. There was dulness in the upper part of the right lung; bronchial respiration; strong vocal echo or resonance, and a copious expectoration of a yellow, muco-purulent, but frothy sputa. The urine contained sugar in abundance, and numerous crystals of oxalate of lime were observed by the microscope. The patient left the hospital before the end of the week, and was not seen afterwards.

From this last point of view the case suggests an interesting reflection on the relation between imperfect digestion and assimilation, the formation of an unhealthy plasma, and the development of the tubercular diathesis.

These cases illustrate the, comparative value of certain remedies proposed for the treatment of diabetes. It may be objected that the cases are not sufficiently numerous to permit any very definite conclusion as to their relative value. This is certainly true; but it may be observed that these cases are intended to illustrate the effects of particular remedies in individual cases, rather than to determine absolutely

the positive value of any given plan of treatment. In this disease, accepting the amount of sugar excreted as constituting the essence of the malady, the object has been to ascertain the influence exercised in this respect by various medicinal agents. Results. [The principles upon which the remedies have been employed have been already expressed; and taking them in the order in which they have been classed, Dr. Basham finds that during the administration of the permanganate of potass in two cases, the quantity of sugar gradually increased. By those agents which were administered with the idea of retarding the conversion of the amylaceous elements of the food into sugar, glycerine and sulphite of soda, only negative results could be deduced. By opium and opiates the amount of sugar was not materially lessened. Hydrochloric acid seemed to be of use in one case. It should be taken some minutes before food.]

Diaphoretics. These may be administered in conjunction with opium. The suppressed function of the skin is so very evident in all cases of diabetes, becoming harsh, wrinkled, and furfuraceous, patients seldom perspiring, and relief being always apparent as soon as any moisture is obtained on the surface, that remedies which excite or assist in promoting cutaneous excretion are always more or less indicated. Opium itself tends to promote diaphoresis, even when given alone, and its action in this respect may be much increased by combining it with antimonials. Flannel clothing should be strictly enjoined. Several of these cases illustrate the advantage of warm baths in conjunction with these agents.

Ammonia and Alkalies. The testimony of almost all writers on this disease is in favour of the remedial power of alkalies, particularly of the carbonate of ammonia; and the cases detailed corroborate the opinions of the most experienced physicians on their efficacy. One case presented the most satisfactory proofs of this plan of treatment, as the patient left the hospital temporarily cured. Of the mode of action of alkalies in this disease, little is known beyond what is hypothetical. Mialhe states that the blood in diabetes is deficient in alkaline salts; and he affirms that the ultimate conversion of the sugar formed out of the food, into products capable of being eliminated by the respiratory function, is not effected in consequence of the deficiency. To supply this defect should be the leading principle in the treatment of glucosuria. Whether we adopt this theory or not the fact remains indisputable, that a larger amount of relief is obtained by a steady and persevering use of ammonia and alkaline salts than can be procured by any other class of remedies. However, to render them efficient a well-regulated diet must be rigidly followed, and this should be limited as much as possible to animal or nitrogenous food. In the opinion of Bouchardat, clothing ranks next to diet. Moreover, the intelligent co-operation of the patient is absolutely necessary; for, unless he can be made to understand and enter into the object for which so strict a diet is prescribed, the effects of the alkaline plan of treatment will prove uncertain and unsatisfactory. The progress of cases in private practice is for the most part always more satisfactory than among hospital patients, principally for this reason, that intelligence lends force to the efforts of self-denial, and developes a more powerful control over the appetites and habits the less educated are but little inclined to abstain even from things which they know to be positively injurious, and they with difficulty can be brought to comprehend the necessity for refraining from bread and vegetables, which their necessities have always taught them to be the staple articles of their food.

I cannot take leave of this subject of diabetes without referring to Dr. Hassall's very valuable paper, in the Medico-Chirurgical Transactions,' on the Development of Torulæ in the Urine. When sugar is present in urine in smaller quantities than can be detected by the action of chemical reagents, he has shown that the sporules of the sugar fungus, or even a higher stage of development, may be readily detected by the microscope.-Lancet, Jan. 21 and 28, pp. 66, 96.

68.-Diabetes treated by Alkalies.-Sir H. MARSH, Вt., says: "Amongst the agents capable of controlling the saccharine diathesis may be enumerated the alkalies. Of these, that which I have found the most useful is a combination of lime water, ammonia, and soda, given about an hour after each meal. Years ago I met the late Dr. Colles in consultation. The case was a severe one of diabetes; I asked

him what he would propose to give. He replied lime water and hartshorn. I asked him on what principle he proposed the remedy? His answer was: 'I know nothing about the principle, but I know the fact, that it does more good than any other medicine.' And so it did in the case we consulted about. I state the answer in his own words because it was so characteristic of that eminent man whose departure from amongst us we have all had such reason to deplore. In the observation, memory, and application of facts he greatly excelled."-Dublin Quarterly Journal, Feb. 1854, p. 7.

69.-Treatment of Diabetes Mellitus by Rennet. By DR. H. FEARNSIDE, Physician to the Preston Dispensary-[Dr. Gray, of Glasgow, mentions the use of rennet in this disease, and speaks from his experience of it in three cases very favourably. Dr. Fearnside was induced from these remarks to try it in the following case :]

Mrs. H., a tall, spare woman, aged 55 years, had suffered from bad health for some time, without being able to indicate the existence of any special ailment. She had lost strength and flesh, and for some months before she fell under my notice, her debility had increased so much that it was with difficulty that she attended to her ordinary domestic duties. For a considerable time she had remarked that the quantity of urine passed was excessive, and she had been harassed by constant thirst. When I first saw her the expression of the countenance was haggard and anxious; the skin was hot and dry; the pulse quick; the tongue was loaded with a yellow fur; she complained of inodorous eructations, heartburn, and flatulence; the bowels were confined; the thirst inordinate. There was great muscular weakness, and severe pains in the back and limbs. The quantity of urine passed in twenty-four hours was five quarts; it was acid; specific gravity 1046, and gave evidence on the application of the potash and copper tests of containing sugar.

After the use of some gentle aperient medicine, the diluted mineral and hydrocyanic acids were prescribed, and with more or less regularity, were taken for some months. The diet was strictly limited to butcher-meat, fish, eggs, milk, and bran. bread. Fresh vegetables, as cabbages, were taken occasionally. Brandy and water was allowed as a beverage. A dose of rennet was taken after each meal.

A fortnight after the adoption of this plan, the patient became so conscious of its good effects, that notwithstanding the vigorous exercise of self-denial which is required, no further exhortations from me were needed to ensure its steady employment. The digestion improved, the thirst subsided; the quantity of urine passed in twentyfour hours fell from five quarts to two quarts, and eventually to three pints, and its specific gravity descended in three months from 1046 to 1020. It has now for some months been free from sugar, although the patient has cautiously and gradually returned to her ordinary mode of life. She has recovered in a considerable degree her strength, but remains spare and thin.—Monthly Journal of Med. Science, March, 1854, p. 252.

70.-ON THE CHARACTERS OF URINE DEPOSITING OXALATE OF LIME.

BY DR. DOUGLAS MACLAGAN, F.R.S.E., &c.

[After giving an elaborate table of thirty-four cases of this kind of urine, Dr. Maclagan observes :]

The principal characters which have been noticed as belonging to urine containing oxalates, are the following:-(1.) A density somewhat higher than natural, indicating an excessive elimination of urea, or of the indeterminate extractive matters of the urine. In the series of cases recorded by Dr. Golding Bird, one-half of the specimens ranged from 1015 to 1025. Some were as low as 1009; some as high as 1030. In the cases recorded by Dr. J. W. Begbie (Monthly Journal, March, 1848), the average density was 1028; the extremes being from below 1015 to above 1030, and in one case 1040. Dr. Prout states, in general terms, that the urine in such cases is of moderate density. (2.) A colour, according to Dr. Prout, pale citron yellow, or greenish; according to Golding Bird, amber, never greenish; according to Dr. Begbie, amber, darker than in health. (3.) An odour generally natural, rarely aro

matic, like mignonette (Golding Bird); on the other hand, aromatic, occasionally approaching to that of the sweet-briar, noticed in urine containing the cystic oxide (J. W. Begbie). (4.) A reaction almost always more or less acid, frequently powerfully so.

Very contradictory opinions have been expressed regarding the pathological importance of the oxalate of lime in the urine. On one hand, we are told of the "miseries which flow from the oxalic diathesis,”—that from it sometimes the bodily suffering is considerable, and the mental excitement verges on insanity," that it is so generally important in its pathological bearings that it merits special attention." On the other hand, it is as confidently affirmed, that "oxalate of lime scarcely indicates a more serious derangement of the bodily health than a deposit of urate of ammonia does," and that to "set up such a diathesis as the oxalic is unreasonable, and contrary to the spirit of rational medicine." As usual in cases of such discrepancy of opinion, the truth will probably be found to lie between the two extremes. It does appear to me that, pathologically speaking, too much has been made of the expression, oxalic diathesis. Invested as the subject is with all the interest of a zoo-chemical question, its designation of oxalic diathesis leads, I suspect, though it does not directly express it, too much to fix attention upon the mere idea of an inveterate tendency on the part of the elements of the food, or the elements of the tissues, to undergo a certain abnormal chemical metamorphosis, and excludes too much from view what is the really important question,-can we attain to any knowledge of the cause why such an abnormal chemical change should occur at all? The objection to the phrase oxalic diathesis appears to me to be, not that it involves an erroneous pathological theory, but that it is no theory at all. It is the mere expression of the fact, that, in a certain class of cases, oxalate of lime does occur in the urine in large quantity, and often for a considerable length of time: it gives no enlightenment as to the reasons why this should be the fact. The same is true of the expressions lithic and phosphatic diathesis. When we have got the length of designating certain cases by these names, and when we have by the usual process of chemical formulation shown how oxalic, uric, and phosphoric acid compounds can be formed in the body, we have not, I apprehend, made out their pathology. We have only cleared the ground so far as to reach the point of inquiry,Why in three cases where the nutritive function is perverted, shall a series of actions be set up which shall lead in A, to the deposit of oxalate of lime; in B, of uric acid; and in C, of phosphatic salts from the urine? It is only when these questions are settled that we shall be able to say that we know what is really meant by the expression oxalic, uric, or phosphatic diathesis.

I have been much struck in the perusal of the standard works and memoirs on this subject with the circumstance, that while it is generally stated that the exciting causes of the disease are easily traced, comparatively little attempt has been made to impress the reader with the importance of paying attention to these exciting causes and yet I believe that an attention to them is of more importance than any thing else, as a guide both towards proper discrimination and successful treatment of such cases. If there be anything more established than another regarding wellmarked oxalic urine it is this, that it always is accompanied by a train of symptoms which points very decidedly to something wrong in the nervous system. Languor, inaptitude for the performance of duty or enjoyment of recreation, fretfulness, and hypochondriasis, are among the phenomena which are presented. Now, it seems to me to be an essential point to come to some understanding, as to whether these precede or follow the formation of oxalic acid in the system, whether they are, in whole or in part, its effects or its cause? It is, perhaps, not easy to determine this. Patients often do not come under medical treatment until both these phenomena are in full activity, and the history of the case does not always enable us to form any plausible opinion on this point. But it will, I think, generally be found, that when good information is afforded us as to the previous history of the patient, his ailments can be traced to something which would tend to impair the energy of his nervous system, or something which entailed upon it too great tear and wear; and which in either case prevented it from duly performing its duty of regulating and controlling the organic functions. For example, the exhaustion of the system by recent acute disease, as pointed out by Dr. Walshe, or long-continued chronic disease of some other kind, especially if involving the organs of digestion; or direct injury or organic