point in the treatment of diabetes, and that its influence upon the disease is so preponderating that when we do not succeed in reducing the sugar by the rigorous exclusion of farinaceous elements from the dietary, it may be confidently affirmed that all other means of treatment will fail, and that the case is one of grave diabetes. The dietetic regimen required in cases of this kind consists, as you know, in the suppression of all foods capable of furnishing sugar to the body. Of the four dietetic methods heretofore employed,that of Dongkin, that of Cantani, that of Seegen, and that of Bouchardat,— one alone has been adopted in all its parts. The treatment of Dongkin, which has for its basis an exclusive milk regimen, is dangerous. That of Cantani, who employs exclusively fats and meat, and which introduces a rigorous diet only at certain times, is too limited, and under its influence the patient loses appetite. It should never be forgotten that any treatment which destroys the intense appetite of the diabetic patient, is a dangerous treatment. As to the alimentary treatment of Seegen, it is precisely analogous to that of Bouchardat. This method has been termed the mixed treatment. It consists in giving meats of all sorts, eggs, corn, vegetables, cheese, and gluten bread. The question of bread is one of the most important in the diabetic regimen. Accustomed from infancy to this food, we suffer greatly when deprived of it, and there are some patients who cannot be nourished without bread, which is one of the weak points of the fat-andmeat diet of Cantani. So, when Bouchardat introduced gluten bread as a food for diabetics, he afforded great relief to patients suffering from this disease. But there is gluten bread and gluten bread; and recently, Carles has given us a very interesting analysis of different gluten breads compared with ordinary bread. [This analysis, which comprised gluten breads from Marseilles, Toulouse, Paris, and Bordeaux, showed a proportion of starch varying from 19 to 32 per cent. Ordinary white bread contains 70 per cent of starch. The amount of gluten varied from 45 to 50 per cent. The proportion of gluten contained in ordinary dry white bread is 9 per cent.] The difference between the amount of starch contained in gluten bread and that contained in ordinary white bread is certainly very great; but here, as elsewhere, it is a question of quantity. If a patient, instead of eating 100 grams of ordinary bread, eats 200 grams of gluten bread containing 31 per cent of starch, his ordinary diet would not be materially or beneficially modified. It is for this reason that I prefer the crust to the soft portion of bread, although recognizing the fact that the inner portion of the loaf contains less sugar than the crust. Thus the crust contains 76 per cent of sugar, while the soft portion of the loaf contains but 52 per cent. But one eats much less of crust than of soft bread, hence the advantage of the crust. There are made and sold to-day, commercially, breads which are all crust, and these are especially adapted to the treatment of diabetics, since the weight of a loaf does not exceed one ounce, and one of these loaves may suffice for a meal.' The bad teeth of diabetics often prevent the use of bread crust, and lead them to employ a considerably larger quantity of soft bread. It is also this question of weight which determines whether or not potatoes should be eaten. The potato contains less sugarproducing substances than does gluten bread. [While this is true of the gluten bread of Paris, it is still more emphatically true concerning the so-called gluten breads sold in this country, which, without exception, so far as the writer knows, contain nearly if not quite as much starch as ordinary whole-wheat bread. We except only the gluten biscuit already referred to in a foot note.] But a potato of the average size weighs about three and one third ounces, while the same weight of bread has a much greater volume. An invalid might satisfy his desire for farinaceous foods with an ounce of gluten bread, or an equal quantity of bread crust, while he would be scarcely satisfied with a single potato; and, as the potato would weigh three times as much, it is evident that in eating a single potato, the patient would eat a much larger quantity of sugar-producing matter. 1 These loaves, as generally sold by the bakers in Paris, are about five or six inches in length, half as thick, and hollow, consisting solely of a crust or shell of bread about one eighth of an inch thick, baked until as brown as molasses, and slightly burned. They have a bitter flavor, due to the presence of caramel or burned sugar. The writer has never seen anything of this sort in the United States. The only genuine gluten biscuit made in this country, are those manufactured by the Sanitarium Food Co., Battle Creek, Mich., whose gluten biscuit contain less than three per cent of starch, or less than one sixth the amount contained in the best gluten bread sold in Paris. J. H. K. 52 17 Melons.. Raspberries.. Currants... Per cent. 1.5 to.8 7.5 8 to 10 IO 10.3 Soft portion of ordinary bread. The attempts which have been made to substitute other substances for gluten have not been successful. First of all, there is soja, a curious Japanese bean, which contains no starchy matters, and which I have indorsed. Unhappily, the oil contained in this seed renders its use in bread-making difficult, and it has a special taste which is not well liked by diabetics, especially when required to use soja bread for a long time; consequently in spite of the small quantity of sugarproducing substances contained in soja bread, the attempt to manufacture it in Paris has been abandoned. This The same is true of fromentine. name has been given to a flour made from the embryos of wheat which the new process of milling enables us easily to separate from the other constituent parts of the grain. Unhappily, in this also the oil of wheat, purgative like that of the soja bean, renders its panification difficult; and in spite of the attempts made by Bovet and Douliot, fromentine has not yet come to be largely used as a food. The same is true of attempts made by Bovet with legumine, and, finally, those made to-day under the name of embryonine. All these attempts are very interesting, but they are only attempts, and it is greatly to be desired that they may be carried to an industrial success, as the flour obtained from these embryos has not the disagreeable taste of the soja bean, and it contains, as does the soja, a large proportion of nitrogenous substances, with a very small proportion of starchy matters. Milk is absolutely contra-indicated in the dietetic regimen for diabetics. The same is true of fruits. The latter restriction is not sufficiently insisted upon by physicians in the prescription of a diabetic regimen; and these patients, feeling the need of a refreshing food, sometimes make a large use of fruits. Fruits contain sugar, which is very easy of assimilation, and I think must nearly Oranges. IO 15 71 16 42 79 As to alcoholic drinks, I maintain more than ever the absolute necessity for the restriction of their use. I have stated that it is possible, by the abuse of alcoholic drinks, to cure diabetes by destroying the liver, and I have made a number of clear observations of this sort among those diabetics in whom one observes the disappearance of sugar at the same time that ascites makes its appearance,―ascites produced by alcoholic cirrhosis. But I see no advantage in transforming a curable malady into an incurable one. It is necessary, then, that the diabetic patient should be temperate, and that, if the use of a tonic is required, alcohol should not be employed. I am very partial to kola in diabetics. Unhappily, there is still a certain difficulty in the administration of this drug. It is necessary to employ kola in the form of an infusion or powder, or, what is preferable, the fluid extract, of which 20 drops should be administered two or three times a day. If As to saccharine, I expressed myself with reference to this drug long ago. saccharine sometimes produces cramps in the stomach and digestive disturbances, it is the result of its too prolonged use, or of individual circumstances. If care is taken to interrupt its use from time to time, and to avoid the use of too great quantities, saccharine renders great service to diabetics who are unable to dispense with the use of sugar. In conclusion, as regards hygiene, I must speak of exercise and the care of the skin and the mouth. We have seen in the preceding lesson that sugar is burned by respiration and by muscular exercise. It is then necessary, in diabetics, to com bat the morbid condition present by exercises adapted to the strength of the patient. It I indorse all that Bouchardat has said upon this subject. Certainly it is necessary not to go to excess in exercise, not to carry it to the point of exhaustion, which is attended by even greater dangers than sedentary habits in diabetics. should not be forgotten, however, that in diabetics the excessive production of sugar induces the phenomenon of depression; and in spite of the appearance of the most robust health, the diabetic is feeble, and cannot endure fatigue. It is necessary, then, to restrict him to such exercises as are appropriate to his taste and strength. Alpine excursions at a proper season, hunting, gardening, walking in the open air, massage, fencing, horseback riding, and carpentry, are all exercises which, under proper circumstances, may be profitably employed. This necessity for exercise explains how certain diabetics observe that the In sugar appears in the winter season. winter, the diabetic goes out very little, and lives high,- circumstances very unfavorable. In summer and hot weather, he goes out into the country, undergoes a real training, and from the effect of these exercises the proportion of sugar in the urine reaches its minimum. All-important also is the care of the skin. Hydrotherapy, or sponging with hot water to which a little cologne water has been added, followed by energetic friction of the dry skin with a hair glove, are absolutely necessary. Finally the care of the mouth, which appears to be neglected by many physicians, is also indispensable. Let us recall that by the presence of sugar in the saliva, and the fermentations to which it gives rise, the cavity of the mouth becomes a favorable culture-medium for a great number of microbes, of which some are pathogenic. Furthermore, the gums soften, become separated from the teeth, and suppurate, while the teeth decay, crumble, and fall away. It is necessary, then, that diabetics should give great attention to their teeth and gums, with gentle friction after each meal. The following prescription in the morning and evening has given me the best results: Great care must also be taken of the mucous membrane of the genitals. It is well known that sugar in the urine gives rise, in women, to a most distressing pruritis, often accompanied by eczematous eruptions which may extend to the inner surface of the thighs, and in men, the irritation of the prepuce gives rise to phymosis. It is necessary, then, that the patient suffering from this disease should be instructed to bathe the genitals after urinating, with antiseptic solutions, as naphthol [hydro-naphthol dissolved in water, and used in the proportion of one dram to a gallon of water]. AUTO-INTOXICATION OF INTESTINAL ORIGIN.' (Concluded from October No.) ONE may recognize in these facts, something analogous to poisoning by sausages, which has been known for a century and a half, since 1735. Similar facts abound. Muller, in 1869, had collected 263 observations. Many investigations have been made of the extracts of meats. These researches were without result until Hoppe-Seyler discovered the existence of an alkaloid, but without demonstrating its toxic character. Brouardel and Boutmy, more fortunate, demonstrated the toxicity of the alkaloid found in the viscera of a woman who died after having eaten of preserved goose. This alkaloid presented some analogies to conine, though in some particulars different. It is certain that true poisoning may result from eating tainted meats. Gaspald and Panum have demonstrated that the putrefaction of meats engenders a poison capable of producing grave and fatal symptoms; but in these cases the symptoms appear early. They begin within half an hour after the tainted meats have been eaten. Besides, in general, one does not eat meats which are actually putrefied, and those already capable of producing poisonous symptoms. In flesh as used for food, putrefaction has only begun. 1 Translated from M Bouchard' swork entitled, “Leçons sur les Auto-Intoxications dans les Maladies," by J. H. K. In the interior of the flesh, microbes are at work setting up a process of decomposition which will continue, under favorable conditions, after the tainted flesh has been introduced into the digestive tube. In these cases, the symptoms which result are slow in making their appearance. They appear only eight or ten hours after the suspected foods have been swallowed. In this period of incubation, no symptom indicates the explosion which is about to occur, but when once the poison is formed, the toxic symptoms appear with rapidity. Krautzer gives an account of sausage poisoning. Four persons regaled themselves with Wurtemberg sausages, very slightly cooked, for gormands prefer sausages of which the superficial portion alone has undergone the action of heat. Of these four persons, only one escaped; the other three were sick, and one of them died. After eighteen hours of incubation, the symptoms experienced were identical and of nearly the same intensity. They consisted of disturbance of vision, strabismus, double vision, ptosis, dilatation of the pupils, and symptoms of paralysis. The injections of pilocarpine which were made did not produce sweat. We see here intoxication by a poison which dilates the pupil and prevents perspiration, and which, consequently, is not without analogy to atropine. Now, among putrid alkaloids there is one with analogous properties, which I have extracted from the fæcal matters of patients suffering from typhoid fever, a disease in the course of which the intestinal putrefactions are intense. We sometimes see family epidemics, and also analogous epidemics, affecting all the people of a locality. The unsound flesh. of animals is consumed by the people of an entire village on the occasion of a feast in which everybody participates. The incubation of the symptoms being long, the first symptoms do not appear, and the distribution of the tainted meat is continued to the people from neighboring villages. These return to their homes, are taken with identical symptoms, and a series of little epidemics present themselves, having for their origin the infection caused by the tainted meat consumed in the village where the feast occurred. A dozen years ago I had a controversy with Lebert respecting the interpretation of an epidemic at Andelfingen. In this little Swiss village, numerous deaths resulted from poisoning by tainted meat. However, there was in every case a slow incubation, and a long duration which eliminated the idea of poisoning. It appeared much more like a disease which little by little developed itself in an individual, and continued after the complete elimination of the tainted flesh. In such cases even the sound matters taken afterward undergo putrefaction in their turn. Apropos of this disease, trichiniasis and typhoid fever were proposed. Griesinger was a partisan of the last opinion. Lebert, on the contrary, leaned toward intoxication by tainted meat. Having come into possession of the facts, I insisted upon the long duration of the incubation which was observed in the patients. It has been demonstrated since that trichiniasis was not the cause of the epidemic. The autopsy of some of those who had been sick at the time and recovered having been made a long time afterward, no calcified cysts were found in their muscles. Why had certain persons no symptoms of the disease in spite of the fact that they had eaten the same flesh as those who were sick, or had died? It is probable that they ate the exterior parts, in which the action of the heat had in part neutralized the poison. In the family epidemic of which I have spoken, in which the four persons ate sausages, one remained without symptoms. This fortunate person was the apprentice, to whom his master had given the crust of the sausage, much less prized than the center, but in which the microbes had been destroyed by the action of the heat. The infection in the case to which I refer, is not an infection without some relation to the intoxication, for there is not a general infection of the body, but an infection of the surface. Without doubt there is, then, an increase more or less rapid and enormous of the quantity of infectious agents introduced into the digestive tube, but the intoxication occurs secondarily to the infection. There are some infectious maladies in which the microbes inhabit the blood. They may extract oxygen from the globules, or produce embolisms in the little vessels. There are other infectious maladies in which the microbes are present in certain tissues and provoke anatomical lesions. In all these cases the symptoms and the death are easily explicable; but it is otherwise with infectious maladies in which the microbes exist only upon a mucous surface; in which they do not penetrate the tissues and do not affect the limiting membrane. How, in these cases of surface infection, may we explain the general symptoms and death, if not by poisoning by the intoxication? The peril for the organism may result only from its absorption of the toxic products. secreted by the infectious agents. minute microbe manufactures poison as well as the great mushroom. The There are some cases in which the affection does not act in an acute, transitory manner, but during some months, or even years. It is due to habitual putrefactions, of which the digestive tube is the seat in many chronic maladies which affect it, and which prevent the complete digestion and elaboration of the food. This is seen in cancer of the stomach, and in certain chronic dyspepsias, and in dilatation of the stomach. Then, besides the inconveniences which, from the point of view of nutrition, result from imperfect digestion and insufficient alimentation, we see other symptoms and disturbances which attest the chronic deterioration of the organism by an intoxication. Transfusion of the Blood of Dogs Vaccinated against Tuberculosis for the Treatment of this Disease.- In 1888, Messrs. J. Hericourt and Chas. Richet published a note concerning their experiments in the transfusion of dog blood emanating from animals having been vaccinated against tuberculosis, and its effect in producing immunity. Since then the experiments of these specialists have been repeated in many parts of the world, with more or less variations. The above named writers have carried out numerous investigations, and tested their method of treatment of tuberculosis on numerous dogs, the canine, as is well established now, being exceedingly sensitive to the infection of human tuberculosis. Thirteen dogs having received a dose of o. I c. c. of culture per kilogram (about two pounds), the death rate was 100 per cent. Death occurred usually between 26 and 50 days after the inoculation; minimum, 12 days. Eighteen other dogs, treated previously by various methods which had neither favorable results nor unfavorable, received a similar dose of culture, and death occurred mostly between 32 and 59 days; minimum, 149 days. Here is, then, a total of 31 dogs, all killed in the average period of 31 days by inoculation of cultures of tuberculosis. This fact being plain, it is possible to appreciate the influence that any treatment tried on dogs infected with human tuberculosis may have. We have observed that in the transfusion to these infected dogs, of blood of vaccinated dogs, the disease was retarded and even arrested. We had demonstrated before, that aviary tuberculosis vaccinates against human tuberculosis; likewise the blood of vaccinated dogs employed as a means of treatment is very efficacious, as the following will show : In the first experiment (June, 1892), four dogs were inoculated for human tuberculosis; dog A witness, died the sixteenth day; dog B, having been vaccinated once, died on the 104th day; dogs C and D received three days after the inoculation of virus, some blood of a vaccinated dog, and died on the 84th and 51st days respectively. On the 5th of August, ten dogs were inoculated for tuberculosis, two of which had been previously vaccinated and are still alive and healthy. Four witnesses died after a survival of 32 days (maximum, 47). The last four received, the tenth day of the infection, a transfusion of blood of a vaccinated dog. One died the 22nd day, another the 43rd day. The other two, though very sick after the transfusion, are still living, and are well after 105 days of survival. This seems to use the secondary action, that the transfusion of vaccinated animals experiences the development of tuberculosis, and it may be possible in the future. to specify the most favorable conditions in which this malady may be applied for treatment. Peroxide of Hydrogen as an Aid to Diagnosis. E. Stuver has suggested the injection of peroxide of hydrogen as an aid to diagnosis, in cases in which pus in a closed cavity is suspected. The injection of peroxide of hydrogen (Marchand's), with a small syringe, is very quickly followed by distention of the part when pus is present. |