(salipyrine) in 10 grain (0.66) doses repeated. Morphine should be used
only as a last resort.

In certain cases a sea voyage or change of climate will prove of benefit.

DIABETES MELLITUS.

Synonyms. Glycosuria; Melituria.

Definition. Diabetes mellitus is a chronic disease characterized by an
excessive secretion of urine, which contains glucose, and which is the result
of a disordered metabolism.



DIABETES MELLITUS. 255

^Etiology. The disease is more common in males than in females, and is
most frequently seen between the ages of 30 and 60, although it ma,y occur in
childhood and even in infancy. Certain races, notably the Hebrew, possibly
because this is an essentially dyspeptic people, are more prone to the disease
than others. Heredity according to certain authorities seems to influence
its occurrence and while the disease is seen more often in the well-to-do
it has also been observed in those of poor circumstances. It is a rare condition
but seems to be becoming more common. Its definite causation is very
obscure but it is in essence a disease of incomplete oxidation and is nearly
related to gout and purinsemia. The fact has been observed that diabetics
often alternate between the excessive elimination of urid acic and of sugar.

Pathogenesis. Notwithstanding the immense amount of research done
in connection with diabetes the pathology of the disease remains exceedingly
obscure; however, we may consider as recognizable three classes of the morbid
condition.

a. The pancreatic form.

b. The alimentary form.
r. The nervous form.

Disease of the pancreas has for a number of years been known to be a
factor in the production of glycosuria. Opie has demonstrated that partic-
ular elements, namely, the islands of Langerhans in the pancreas must be
affected to produce this symptom. The most frequent pathological change
in these elements which results in the appearance of sugar in the urine is a
sclerosis or degeneration of other form, hyaline, for instance. The glycosuria
appearing in cases of cysts of the pancreas, cancer, etc., is probably the result
of a temporary involvement of these so-called islands. Also the frequent
association of arteriosclerosis and diabetes renders it probable that this con-
dition by its interference with the nutrition of the pancreas may result in
changes which lead to diabetes.

Alimentary diabetes is brought about by some disorder of the digestive
system producing an interference with proper carbohydrate metabolism,
which results in an hyperglycaemia, which is due to the presence in the
organism of an amount of glucose with which the body is unable to cope.
For instance, in certain infectious diseases, exophthalmic goitre, alcoholism
and lesions of the liver, the presence of an amount of sugar, of which the
normal organism might easily dispose, in these conditions may result in gly-
cosuria, due possibly, as pertinently suggested by Pearce, to a temporary
interference with the function of the pancreas due to circulatory or toxic dis-
turbances of the islands of Langerhans.

The nervous type of diabetes occurs in various diseases of the central
nervous system; tumors, and other lesions of the floor of the fourth ventricle;
traumatic and other neuroses, acromegaly, etc.



256 CONSTITUTIONAL DISEASES.

Unfortunately the facts known to us concerning this disease are few but a
summing up of our knowledge would seem to show, according to Edsall, that
in the pancreas resides an important influence over carbohydrate metabolism.
How this organ acts is not known but it is not merely through the production
of a glycolytic ferment. It is also apparent that carbohydrate metabolism
is associated not only with the pancreas but with other organs> notably the
liver, as weU, and that the more deeply the subject is studied the more complex
does it become.

Pathology. The only definite pathology so far as is at present known is
showrb as a sclerosis or degeneration of the islands of Langerhans in the
pancreas. Also this organ may be atrophied, the seat of an interstitial inflam-
mation, of malignant growths, or cystic.

The liver is often congested, cirrhotic or the seat of fatty or amyloid degen-
eration.

The kidneys, while they primarily have no influence over the disease, are
frequently found in a state of hypergemia, catarrhal inflammation, or, more
rarely, may be in a state of interstitial inflammation.

The lungs may present advanced tuberculous changes or may be the seat
of a pneumonia.

The heart is often affected with an interstitial myocarditis, fibrous or fatty.

The brain may be congested or oedematous, the seat of small haemorrhages
or softened. Tumors of the pons, the medulla, or the cerebellum have been
observed.

Symptoms. Often the first symptom noticed by the patient is an excessive
passage of iirine, the characteristic urine of a diabetic being light in color,
sweetish in odor and taste, and of high specific gravity. It contains glucose
in varying quantity and may contain albumin. The lu-ea and uric acid are
usually increased.

Excessive thirst, due to the increased elimination of fluids through the
kidneys, and an abnormally large appetite are frequent symptoms.

Itching of the skin, especially about the vulva in women, and the prepuce
in men, where this symptom is due to the irritation of frequent urination, is
common and likely to result in eczema.

The breath may have a sweetish odor and symptoms of indigestion are
common; vomiting may occur. The bowels are usually constipated, but
diarrhoea may be present.

There is often emaciation and the patient complains of bodily weakness.

The lungs frequently are the seat of a chronic bronchitis and complicating
pulmonary tuberculosis is common, due to the fact that the powers of resistance
of the organism to the tubercle bacillus are lessened by the disease and the
restriction of the diet, rather than to any direct influence of the diabetes itself.

Outbreaks of boils and carbuncles are not rare; the former may occur



DIABETES MELLITUS. 257

early in the disease but the latter seldom appear until the later stages. It
should be remembered that during the course of a carbuncle in a non-diabetic
patient glycosuria may be temporarily present.

Diabetic gangrene is a symptom not infrequently met. It begins in the
extremities, usually the toes, and while it may appear spontaneously from
chronic proHferative endarteritis, is usually the result of traumatism, often
one of vejy slight character. The gangrene is usually of the dry or senile
type, though moist gangrene has been observed.

Coma is a serious symptom; usually it appears in the later stages and often
results in death. Its onset may be sudden or gradual. If the latter the
prodromata are dizziness and irritability, the patient's condition becomes
more and more stuporous and finally ends in profound coma. Convulsions
and delirium are rare. While many theories have been advanced as to the
causation of the coma the most probable one is that it is due to an acid intoxi-
cation, the result of the continued presence of oxybutyric acid in the organism.

The blood contains glucose and the red cells and hiemoglobin are likely
to be diminished.

Other body fluids, such as the saliva and perspiration, contain sugar and
this has also been found in the transudates and exudates in diabetic patients.

Peripheral neuritis has been described as a concomitant of diabetes.

Abnormalities of the eyes occur such as cataract, retinal haemorrhages,
choroiditis, dilatation of the retinal vessles, retinal atrophy and retinitis.

The prognosis varies with the type of the disease, with the age of the patient
and with the length of time which the affection has existed, without proper
treatment. Patients in whom the disease begins in early adult life are seldom
cured. The chances of recovery for the patient inclined to stoutness and in '
whom the disease appears in middle life or later are much better. The form
of diabetes resulting from disease of the central nervous system and that due
to permanent sclerotic changes in the islands of Langerhans are hopeless as
regards cure but not as regards improvement. The alimentary type of the
disease is most amenable to treatment. While we may consider as cured the
patient who no longer excretes sugar in his urine, such a one must most care-
fully guard against a recurrence.

Treatment. In this the first step is to ascertain with which type of diabetes
we have to deal; consequently we prescribe an absolute proteid diet in connec-
tion with the drinking of plenty of the alkaline waters for five days, for diag-
nostic purposes. After this period of time the patient is required to present for
examination two specimens of urine, one the first passed in the morning, the
other the last voided before retiring at night. If the sugar content is as when
first examined it is probable that we have a diabetes due to nervous lesion.
Such patients are, however, to some extent amenable to dietetic and hygienic
treatment. If we find a smaller amount of glucose in the morning specimen
17



258 CONSTITUTIONAL DISEASES.

than in that passed at night the diabetes is of the pancreatic variety. If we
find no sugar in the morning urine while the evening specimen shows a positive
sugar reaction an ahmentary diabetes confronts us.

In each of these three types of cases treatment may be considered as
being a, medicinal; b, dietetic; c, hygienic.

Medicinal Treatment. The drugs to be preferred are those which act
chemically by retarding the formation of glycogen into glucose. Of these
the author prefers uranium nitrate, which may be administered in doses of
i of a grain (0.016) three times daily and increased gradually up to a maxi-
mum of from 3 to 4 grains (0.20 to 0.25) per day.

Jambul acts in the same fashion by delaying carbohydrate conversion
and thus enabling the organism to complete the process, and may be given,
in powdered form, 5 to 30 grains (0.33 to 2.00) per day and gradually increased.
As much as an ounce may be administered during 24 hours. This drug is
said to act well in some patients and not in others and considerable difficulty
may be experienced in selecting proper cases.

Arsenic is another remedy, the action of which is the same as that of the
two preceding, but which has the disadvantage that its prolonged administration
is likely to produce digestive disturbances, neiiritis, herpes zoster and fatty
liver. It may be given as Fowler's solution, 2 to 3 drops (0.12 to 0.20) 3 times
a day, or as Clemens' solution (3 to 5 drops — 0.20-0.33 — 3 times a day).

Opium has enjoyed extended use in diabetes and seems to have the power
to diminish the excretion of glucose. Its great disadvantages are the proba-
bility of engendering the habit and the constipation attendant upon its con-
tinued administration. The employment of codeine obviates these difficulties
and this drug may be given in doses of J to ^ a grain (0.016 to 0.032) 3 times
a day, gradually increased. Given in connection with uranium nitrate its
good effect may be augmented.

Lithium salts act by assisting oxidation and in combination with the sali-
cylates are useful in gouty patients.

Aceto-salicylic acid (aspirin) in mild forms of diabetes has, according
to Williamson, good effects. It should be given in acid solution — such as
lemon juice — to prevent digestive disturbances — in doses of 5 grains (0.33)
4 to 6 times a day.

Calcium phosphate and carbonate have lately been employed with good
results, perhaps due to the affinity of sugar for calcium.

Potassium iodide has achieved results in glycosm-ia due to cerebral gum-
mata and should also serve in the gouty form of the condition.

Antipyrine, acetphenetidine (phenacetine) and other coal tar derivatives
may lessen the excretion of sugar in the nervous type of the condition because
of the control which they exert over the conversion of proteid into sugar.
They may also may be found useful in other varieties of diabetes. They may



DIABETES MELLITUS. 259

be given in doses of 10 to 15 grains (0.66 to i.oo) three times a day in com-
bination with sodium bicarbonate and preferably when the stomach is
empty.

Potassium or sodium bromide may be given with good results in the diabetes
of neurasthenics or in that of mental disturbance.

Lactic acid in doses of 75 to 150 grains (5.0 to 10. o) daily, dissolved in water,
has been recommended by certain Italian physicians.

Gold and sodium chloride and ergot have their advocates but are not in
general use.

The various preparations made from the pancreas of animals of which much
was expected have so far failed to find any place in the treatment of diabetes,
and the same may be said of the extract of the supra-renal body.

In concluding the discussion of drug treatment it may be said that too
much medication in diabetes mellitus should not be advised. Drugs should
not be given when we are able to cause the disappearance of the sugar from
the irrine by dietetic and hygienic treatment. ,

Dietetic Treatment. An exclusive diet of proteids and fats is not advisable
unless absolutely necessary, for it has been proven that coma is more likely
to occur in patients who are getting absolutely no carbohydrate food. When
carbohydrate food is allowed a diabetic we must see to it that the organism
is able to take care of it and does not excrete it as glucose. In this connection
regulation of the amount of carbohydrate intake and proper exercise wiU
do much. For instance, in an obese diabetic of the alimentary type who is
accustomed to little exercise we may at first cut out most of the carbohydrate
foods until the glycosuria has disappeared and then gradually aUow a return
to a mixed diet, slowly increasing the patient's physical exercise the while
so that he may be able thus to convert the steadily augmenting intake of
starchy food. Thin patients of this type we can hardly deprive of carbohy-
drates, since they need a certain amount of this class of food to keep up their
nutrition, otherwise this deteriorates and the diet consisting of fats and proteids
alone is almost certain to engender a cirrhosis of the liver. Consequently,
the thin alimentary diabetic may be allowed starchy foods in certain quantity
and we should be content if we reduce the quantity of sugar in his urine to
0.5 percent.

With regard to the articles of diet which diabetics may be allowed it may be
said that such food stuffs should be selected as contain: c, no carbohydrate
whatever; h, very little carbohydrate or carbohydrate in easily assimilable
form which may be converted by the organism. To the first class belong
all varieties of fresh and salt meat, liver excepted, clear meat soups, poultry,
fish, shell-fish, butter and eggs, fats and oils, and cheese.

As belonging to the second class may be mentioned the green vegetables,
such as cabbage, cauliflower, Brussels sprouts, string beans, onions, cucumbers,



26o CONSTITUTIONAL DISEASES.

tomatoes, lettuce, escarole, romaine, chicory, water-cress, spinach, dandelion,
beet tops, asparagus, all nuts except chestnuts, all the acid fruits, and jellies
(unsweetened) prepared from meat juices and gelatin.

Many of these substances contain a considerable quantity of sugar but
not in the form of grape sugar. The various sugars and starches which they
contain are more easily converted than glucose and consequently are taken
care of by the organism. Fortunately milk sugar is of this class and milk
may be freely given to diabetics. Other sugars which are likely to prove
more rapidly convertible than glucose are Isevulose, the sugar of fruit and
inosite^the sugar of muscle.

With regard to bread it may be said that the toast of wheat bread 24 hours
old is preferable to gluten or graham breads. Gluten flour may, however,
be used, to make bread or biscuit for diabetics, but it is necessary to obtain
a pure gluten, which is impossible in the United States. Cakes and biscuit
made of flour of the soya bean are admissible and are said to be palatable.
When stale they are likely to be rancid since the flour contains an oil. Bread
made from aleuronat flour is highly recommended.

Butter may be eaten by diabetic patients but it is best to limit its quantity.

Beverages. Tea, coffee and cocoa, with cream or milk and sweetened
with beet, not cane sugar are allowable. Saccharin may also be used as a
sweetening but not in greater quantity than \ grain (0.016) to the cup. Gly-
cerin has been employed in this connection but is inferior to the above named
substances.

Malt liquors, cider and other fermented liquors are not permissible since
they all contain sugar or starch.

Wines which contain no sugar or only a very smaU quantity, such as Bur-
gundies, Bordeaux, Rhine and still Moselle wines and dry sherry, may be
allowed.

Whiskey, gin and brandy when unsweetened may be given if necessary.
Schreiber's dietetic wines, which contain no sugar, are largely employed.

The drinking of considerable quantities of water between meals is to be
encouraged. Patients who dislike ordinary water often will take large amounts
of mineral waters when prescribed by a physician. For such it is wise to
suggest a water containing as little mineral as possible, such as Highland
Spring water.

The Potato Treatment. Some authorities believe that a diet of potatoes
may be prescribed to advantage in almost all cases. One to two pounds (500
to 1000) of this vegetable may be eaten daily with the result of diminishing
the thirst and the glycosuria and of impro\dng the general condition. If a
diet containing bread is resumed the symptoms recur, only to disappear upon
a return to potatoes. The reduction in the sugar is said to be due to the
incomplete absorption of the carbohydrate. It is also possible that the good



DIABETES MELLITUS. 261

of the potato diet may result in part from the alkaline salts which these vege-
tables contain.

Codliver oil may be found helpful, especially in weak and emaciated patients,
and may be regarded as a food. It acts well given in connection with brandy
or whiskey.

Hygienic Treatment. Exercise within proper limits is a valuable factor
in the treatment of diabetes, for sugar is burned in the muscles as well as in
other parts of the body. Excessive bodily fatigue must, however, be avoided,
since it results in the overwhelming of the system with ox}'butyric acid which
is likely to be followed by coma. Patients whose bodily strength is good
should be instructed to use a pedometer and walk a certain distance each day.
With proper attention to the attire pedestrian exercise may be taken almost
every day in the year. A moderate amount of gymnasium exercise maybe
taken and such games as golf and croquet are to be recommended. The
important point with regard to exercise is to take care lest it be carried to
excess. Even light exercise may be impossible for the advanced and ema-
ciated cases.

Massage is indicated in patients unable to take active exercise and in the
more vigorous it may be found a useful adjunct to the other forms of treat-
ment. It is said that under systematic massage, the quantity of iirine and
its sugar content may be diminished and the glucose may even be caused
to disappear. Of course regulation of the diet is also necessary to produce
this result.

Diabetics should clothe themselves in a hygienic manner and particular
attention should be paid to the wearing of proper undergarments during the
colder months. Frequent changes may be necessary since the skin in this
condition excretes certain irritating substances which if allowed to remain in
contact with it may induce an eczema. Proper foot covering in wet weather
is a necessity.

Decency requires the taking of at least two warm cleansing baths per week
and more than these will do no harm. A cool or tepid sponge, according to
the temperament of the patient, may be taken daily.

Fresh air is a necessity and the diabetic should spend much of his time
out of doors and should sleep, warmly covered, if necessary, in a large, airy
chamber with the window open.

The various water cures and spa treatments of diabetes are often found
to be valuable but their good effects are probably due to the change of air,
scene and diet, together with a regulation of the mode of life, rather than
to any peculiar virtue of the waters. Alkaline waters may give benefit on
account of their purgative properties.

Coma. When coma is feared, either from the existence of cerebral symp-
toms, from a sudden diminution of the glycosuria or when acetone is present



262 CONSTITUTIONAL DISEASES.

in the urine large doses of sodium bicarbonate (i to 2 drachms — 4.0 to 8.0 —
3 or 4 times a day) should be given.

Coma itself should be treated by the infusion of 2 quarts (litres) of 0.9
percent, sodium chloride solution at 112° F. (44.5° C.) into the median basilic
vein. If instruments are not at hand the same quantity of the solution may
be given by hypodermatoclysis at 110° F. (43.3° C.) or per rectum at 116°
to 118° F. (46.7° to 47.8° C).

In any case the bowels should be freely evacuated in order to rid the body
of toxiq substances in so far as is possible and hypodermatic stimulation should
be administered as indicated.

Surgery in diabetic patients. Surgical operations in diabetics are dan-
gerous and often of unsuccessful outcome because of the co-existing endar-
teritis proliferans. However, if the disease is of mild type and the sugar can,
by treatment, be caused to disappear, operations of necessity, such as, for
instance, amputations, may be performed, but with a guarded prognosis.

DIABETES INSIPIDUS.

Definition. A chronic condition characterized by the passage of large
amounts of a urine, pale in color and of low specific gravity, but otherwise
normal.

etiology. Congenital and hereditary instances of the disease have been
observed. It affects young adults most frequently, being rare after middle
life; it may occur in infancy. Females are rather more often affected than
males.

Clinically two types of the condition may be described, the idiopathic
and the symptomatic. The former occurs primarily and is associated with
no morbid lesion; it may be met in poorly nourished children, after the drink-
ing of excessive amounts of cold liquids, after an alcoholic excess, as a result
of fright and in convalescent states.

The symptomatic type usually accompanies cephalic injuries and such
nervous lesions as cerebral tumors and haemorrhages, lesions of the fourth ven-
tricle, syphilitic growths of brain and cord, etc. Diabetes insipidus may also
be associated with abdominal aneurysm, tumor and tuberculosis.

The pathogenesis of this condition is best explained upon the ground that
it is caused by a chronic renal congestion due to some vaso-motor disorder
of the blood-vessels of the kidneys which may result from direct irritation, as
in lesions of the abdomen, from central disturbance, as in cerebral lesions
or from irritation of the medulla oblongata.

Pathology. There are no constant morbid changes found in this disease.
Often the nerve lesions are impossible of discovery; when these are demon-
strable they are usually at the base of the brain. In certain instances there



DIABETES INSIPIDUS. 263

have been enlargement and congestion of the kidneys and bladder; the ureters
and pelves of the kidneys may be dilated.

Sjrmptoins. The onset of the disease is usually gradual; more rarely it
appears suddenly after a debauch or an injury to the head. The most char-
acteristic symptoms are the excretion of greatly increased quantities of clear,
light colored urine of a specific gravity sometimes as low as 1000, and an
excessive thirst. Associated manifestations which are not constantly present
are a lessened perspiration and a consequent dryness of the skin, diminished
salivary secretion and dryness of the mouth. The appetite is usually not
abnormally large as a rule but occasionally it is increased. The digestion
is sometimes impaired but in most instances the general health remains good.
More rarely, and particularly when the cause of the disease is an organic one,
weakness and emaciation are observed. There may be pains in the back,
especially at the beginning of the affection, which extend down the thighs;
diarrhoea, mental weakness and disordered sexual function may be noted
and a body temperature a few tenths of a degree lower than normal is some-
times a feature of the disease.

The urine is often passed in extraordinary quantity, a daily excretion of
25 to 40 pints (12 to 20 litres) being not unusual and even much larger amounts