A. H. WRIGHT, B.A., M.B., M.R.C.S. England.

Original Communications.

SOME REMARKS ON DIABETES.

BY THOS. R. Dupuis, M.D., M.R.C.S. Eng.

were directed to it by the English, have taken notice of the sweetness of the urine, it does not persuade me that either in ancient or in modern times the urine in diabetes was of another kind. I myself, indeed, think I have met with one instance of diabetes in which the

at Quebec.

In discussing diabetes, my object is to direct attention to a few interesting facts in connection with its pathology, its prevalence in this country, and to institute a comparison between the older authorized treatment, and the latest treatment by bromide of arsenic, as far as my experience has extended.

Diabetes, or distinctively diabetes mellitus, is, as you all know, a disease characterized by an increased flow of saccharine urine. The disease has been known for many years, and the term diabetes was formerly applied to any augmentation of the uninary flux. In 1674, Willis discovered the sweetness of the urine, previous to which time the true nature of the disease had not, as we know of, been suspected; since that time, however, the presence of sugar has been regarded as a character of the disease, and the name diabetes has now become almost synonymous with glycosuria. Dr. Cullen, over one hundred years ago, wrote as follows: "Dr. Willis seems to me to have been the first who took notice of the sweetness of the urine in diabetes, and almost every physician of England has, since his time, taken notice of the same. Though neither the ancients, nor in other countries of Europe, the moderns, till the latter

what at the present time we all know.

Although this disease is not of very great frequency, its generally fatal character, and when not fatal, the slavish restriction which it imposes upon its subjects, are sufficient to induce us to hail with welcome any and every method of treatment which holds out a fair prospect of cure, or of a large measure of relief. The disease is not common in childhood, although I have found a number of cases in children reported in the medical journals, and other works which I have consulted, some of them in subjects as young as 3, 21 and 2 years of age, and such were all fatal. In the early part of adult life, death is more certain from it than in the latter part; elderly persons bearing the loss of assimilated nutriment entailed by it, better than younger ones. The tables of mortality in the "Reports of Deaths" in Ontario for 1884, afford us a great many interesting facts relative to this disease. I shall qnote some of them here. Out of 21,702 deaths reported in that year, 70 were from diabetes; or 1 in 310. The males were 48, and the females 22. The proportionate number of deaths at different ages are given as follows: Under 5 years, none; from 5 to 10 years, 3; from 10 to 15 years, 6; from 15 to 20 years, 5; from 20 to

30 years, 10; from 30 to 40 years, 13; from 40 to 50 years, 3; from 50 to 60 years, 10; from 60 to 70 years, 7; from 70 to 80 years, 6; from 80 to 90 years, 2; over 90 years, none. Accord ing to this tabulation men suffer more than twice as frequently as women from this disease; childhood is comparatively exempt from it, and the greatest number of deaths from it occur during the most active periods of life. All the deaths from diabetes which have come under my notice have occurred before, or about, the middle periods of life; but I know of several elderly persons who have had the disease for a number of years, and who by a little proper medication, and severe restrictions in diet, are enabled to remain in comparatively good health. It is evident that diabetes is neither epidemic nor endemic, but there seems to be something in the manner of living amongst certain classes of the community, that renders them more liable to the disease than others are. Amongst the country population, it proves to be more prevalent, according to our own "Death Reports," than amongst those of the cities; and the larger the city, apparently the smaller the proportion of deaths from diabetes. According to reports, in the great city of New York, out of 1,379 deaths, only one was caused by diabetes, and in Philadelphia, only one in 875. Taking the five largest cities of Ontario, viz., Toronto, Hamilton, Ottawa, London and Kingston together, we find 7 deaths from diabetes in 4,524 deaths, or 1 in 6463. Taking all the cities and towns together, and we get 11 from diabetes in 6,737 deaths, or 1 in 612. Taking the smaller cities and towns by themselves, and we find 4 deaths from diabetes in 1,421 deaths, or 1 in 355. Taking the whole Province, and we find 70 deaths from diabetes, in the grand total of 21,702 deaths, or 1 in 310. But taking the counties alone, leaving out all the towns and cities, and we are confronted with the large proportion of 59 deaths from diabetes in 15,657 deaths, or 1 in every 2533. Again, out of the 31 cities and towns in Ontario, nearly one-half (14), viz, Brantford, Walkerton, St. Thomas, Windsor, Kingston, Owen Sound, Belleville, Goderich, Sarnia, Napanee, St. Catharines, Cobourg, Whitby and Berlin, report no cases of diabetes, and the large city of Toronto reports

only 4; the cities of Hamilton, Ottawa and London, 1 each, and the city of Kingston, none. But when we turn to the counties, the facts are quite different, and add stronger confirmation to the theory which I venture to propound, that diabetes is more prevalent in agricultural regions than in towns and cities, that it is, in fact, a “country disease."

Thirty-nine counties in Ontario have reported deaths, and only 8 out of the 39, or about onefifth, have reported no deaths from diabetes. These are the counties of Algoma, Elgin, Frontenac, Hastings, Norfolk, Oxford, Prescott and Russell, and Welland.

From the scattered situation of the foregoing counties, and the proportionately small number which have been exempt from the disease, all notion of an endemic influence is dispelled, but the presumable fact remains that there is something in the habits of life of our agricultural population, which predisposes them to this disease.

Of 11 cases of which I have taken note, 7 were farmers, or farm laborers; and I think the remaining four lived either in small villages or in country places. Authorities state that it is more prevalent in the agricultural counties of England than elsewhere, and in Normandy in France, which is largely an agricultural section of that country. Regarding its geographical distribution in the various countries of the world, there does not seem to be a sufficient difference in its occurrence amongst them, to lead to any definite conclusion respecting its origin. India, and a few other places, are said to be more liable to it than the rest of the world. The pathology of diabetes is a most difficult problem; perhaps for two hundred years the best minds in the profession have been directed to its investigation, and of late years volumes have been written upon its proximate and remote causes.

"Old Cullen," as we call him, came to a conclusion, by his acute powers of observation, that no "topical affection of the kidneys has a share in producing this disease, and that a fault in the assimilation of the fluids is rather to be blamed, and that even the solid food taken in increases the quantity of the urine voided, at the same time with an increase of the saccha

while other, and perhaps equally as acute observers, have not been quite satisfied as to the origin and value of such lesions, or whether they were a cause or a consequence in their relation to diabetes.

Of the abdominal organs, the pancreas is the one most frequently affected- —a thing we should expect to find on account of the important part which it plays in the digestion of fatty and amylaceous matters. According to "Tyson's Statements" it undergoes a pseudo-hypertrophy, consisting chiefly in a hyperplasia of the con. nective tissue, fatty degeneration of the glandcells, and atrophy of the glandular structure. Cancerous disease, calculous concretions in the ducts, cystic dilatation, etc., have all been enumerated amongst the post-mortem conditions of the pancreas after diabetes. But I may remark just here that cancerous disease of the pancreas does not necessarily cause diabetes; for, less than two years ago I assisted at a postmortem examination of a professional brother, dead from cancer of the pancreas, and amongst his symptoms had been loss of appetite, little thirst, scanty and high-colored urine, and ascites; symptoms entirely opposite to those indicating diabetes.

The liver is occasionally changed in character, sometimes being more or less enlarged; at other times being found atrophied. But either of these conditions might be a consequence of the pancreatic disease. Other authors, from the time of Cullen down to the present, have not been able to connect a diseased state of the liver with diabetes in all cases, inasmuch as it is frequently found quite unchanged and apparently healthy after death from this disease. What might be termed the nervo-chemical theory; a theory that would result from a combination of the views of Claude Bernard and Pavy; the former holding in general terms that the process of sugar-formation in the liver is governed and regulated by the nervous system; the latter holding that the hydrocarbons of the food are stored up in the liver in the form of glycogen, and that under certain abnormal conditions the glycogen is converted into sugar, thus producing diabetes; this composite theory has, I say, received an able advocate in the person of P. W. Latham, A. M., M.D., F.R.

C.P., of Cambridge, England. In the "Croonian Lectures," delivered by him at the R.C. P.L., April, 1886, he classes rheumatism, gout, and diabetes in the same pathogenetic category, and ably argues that the whole cause of the incomplete metabolism, which is the great characteristic of diabetes, results from an imperfect condition of the vaso-motor system of nerves. With your permission I will quote some of his statements; but I can make use of only some of them, as they are too elaborately exemplified by abstruse chemical formula to make many of them available in a paper like this. He says, "It remains for me to say a very few words with regard to the pathology of diabetes, and to explain why I have classed it together with gout and rheumatism. If the function of the liver be interfered with, so that there is imperfect metabolism of glucose as it passes through the organ, this would be a satisfactory explanation of the origin of the disease, and we should expect in such cases that the urgency of some of the symptoms would be lessened by careful diet, and abstention from saccharine and starchy food." But there are other cases in which the diet seems to have much less effect in controlling the symptoms. It is this form which I wish briefly to discuss. "I have endeavored to show," he says, "that in acute rheumatism by the separation of the cyan-alcohols from the rest of the albuminous chain, we have glycocine, and glycollic and lactic acids formed; the glycollic acid being oxidized into CO2 and water; the lactic acid in some measure being oxidized into these products, and in some measure passing off by the skin. But suppose that whilst the vaso-motor fibres of the muscular nerve are paralyzed and the vessels dilated, the molecules of a cyanalcohol are detached and hydrated into glycollic acid, but only partially oxidized, the result would be that the glycollic acid would be transformed into carbonic acid and methyl-aldehyde water. Condensation of six molecules of the aldehyde may then take place as it does in plants, and form glucose." He then continues to show how, when the vaso-motor nerves are in a certain paralyzed condition we may get the formation of not only glucose, but para-aldehyde, a hypnotic, oxybutyric acid, and acetone;