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the alkalies act favorably in diabetes. You will recall the fact that Cagniard, by watering with alkaline solutions the sugarproducing vegetables, has prevented the production of sugar. For myself, I believe that it is especially in regulating the nutrition that the alkalies act.
The recent researches of Frémont, who has studied the coefficient of oxidation in diabetics, by the aid of the method given by A. Robin, supports this view. Whatever explanation may be given, the administration of alkalies in diabetes is always favorable. Lithium, and especially alkaline waters, may be utilized, to which may be added strontium, which, under the form of lactate of strontium, gives such good results in the cure of albumi
To these alkalies it is necessary to add arsenic, which is a valuable drug in diabetes. Experimentally, Quinquaud has shown us that when an animal is submitted to prolonged arsenical treatment, diabetes can no longer be produced by a lesion of the bulb. Arsenic and the alkalies may be associated with advantage, and the formula of Martineau appears to be the best. You give, in a glass of Vichy water, one of the following doses: Carbonate of lithium, 5 grams; Fowler's liquid, 2 drops. The patient should take a glass of this mixture before breakfast and before dinner.
Baths are of special value in these cases. Arsenical waters and waters impregnated with bicarbonate of soda, dispute priority. Vichy, Bourboule, Saint Nectaire, and Miers, in France, and Carlsbad in Germany, occupy the first rank in the thermal treatment of diabetes.
It cannot be doubted that thermal treatment happily modifies the nutrition in diabetes, and secures the disappearance of sugar, while allowing a considerable latitude in diet.
Such are the curative means to be employed. Let us now see what results may be obtained, and what modifications must be made in the treatment, during a prolonged course of this disease. The results which are obtained in the treatment of diabetes by a rigorous dietary, allow us to group our patients in three classes according as the severity of the disease is light, medium, or grave.
In the first class of cases, we obtain, in a short time, complete disappearance of sugar, no matter how large a quantity
may have been observed at the beginning. I have known patients to eliminate more than 400 grams of sugar daily, from whose urine the last trace of sugar had disappeared at the end of eight days' treatment. In cases of this class, the sugar tends to reappear when either sugars or starches are used in excess.
In cases of medium severity, the disappearance of sugar is never complete ; even when baths and medication are added to a strict regimen, from twenty to thirty grams of sugar in twenty-four hours will always remain.
Finally, in grave diabetes (diabetes with emaciation), the quantity of sugar eliminated in twenty-four hours is only slightly modified by the dietary, and the patient continues to eliminate 100, 200, and even 500 grams of sugar daily. To these grave conditions the name of "pancreatic diabetes" has been given. Taken in its strict sense, the name is not exact, since, while all cases of pancreatic diabetes are grave, the reverse is not true. I have myself observed cases of fatal diabetes without lesion of the pancreas. It matters not whether or not grave diabetes is accompanied by lesions of the pancreas; our therapeutic efforts always fail in these cases; and no matter what methods are employed, the patient becomes more and more emaciated, and finally succumbs, in the majority of cases, with symptoms of coma.
What therapeutic course should be pursued in each of these three forms of diabetes? In grave diabetes, I confess that, impressed by the failure of a special diabetic regimen and the danger of comatose symptoms, when these patients are submitted to an exclusively flesh diet, and especially by lack of appetite which follows when one regulates the dietary too rigorously, I allow grave diabetics to eat whatever they like, avoiding only sugar and fruits. In cases of medium severity, however, I maintain a special and severe diabetic regimen.
In mild cases of diabetes, I regulate the dietary by the results obtained by frequent analyses of the urine, suppressing sugar and fruits, although I allow bread and some starches. Duhomme's analysis enables the patient to make daily analyses of his urine, by means of which the dietary of mild and medium cases of diabetes may be regulated. When the sugar reappears in the urine in too great
quantity, as the result of digressions in diet or violent emotions, it is necessary to return to a more severe regimen, and make use of antipyrine.
Esbach, in his "Traité du Diabéte," has remarked that it is necessary to disaccustom the liver to the manufacture of sugar. Without absolutely adopting his view, I think, however, that when the sugar reappears, it is necessary to prescribe a severe regimen for a week; then, when the sugar diminishes to 10 grams or less in twenty-four hours, let the severity. of the regimen be relaxed a little. It may be said that there are some diabetics in whom the equilibrium of health is maintained by eliminating, through the urine, a certain quantity of sugar every twenty-four hours. In such cases, when the diabetic regimen is carried too far, the patients become emaciated, lose appetite and sleep, and find themselves in a condition worse than before. Here is a question of tact which requires careful attention from the physician.
Great longevity is compatible with diabetes of medium intensity, and patients of this class have been known to attain to a very advanced age, although eliminating in the urine each day a small quantity of sugar. The same is still more emphatically true of patients suffering from the mild form of diabetes. However, in spite of these favorable circumstances, it must be remembered that the fact of being a diabetic, or predisposed to diabetes, indicates an inability to resist other diseases which may occur coincidently, so that when a diabetic suffers from an infectious or an inflammatory disease, his enfeebled system very easily succumbs to the shock. In the epidemic of influenza which occurred in 1889-90, this fact was strikingly confirmed by the extreme mortality of diabetics suffering from the epidemic.
As to grave diabetes, the prognosis is most serious, and death is always a consequence in these cases. Lancereaux fixed the duration of pancreatic diabetes at four years as the maximum.
These three species of diabetes are classified according to their respective origins, and one never sees diabetes of light or medium intensity transformed into a grave diabetes, it being understood, of course, that the patients follow the prescribed dietetic regimen. To explain Here is a diabetic who passes 300
grams of sugar daily, but eight days of regimen suffice to bring the quantity of sugar to zero. If, however, the patient should continue to eat as before, taking no care of his health, he would find himself in the same conditions as a grave diabetic passing the same quantity of sugar; his strength would fail, and various complications would arise, such as ordinarily terminate the life of this class of diabetics.
These complications are four in number:
1. Nervous troubles, of which diabetic coma is the highest expression.
2. Gangrene, and sometimes a true gangrenous septicemia.
3. In the consequence of the presence of sugar in the secretions, which thus constitute favorable media for the culture of certain micro-organisms, and in particular, that of tuberculosis, these patients become tuberculous.
4. The passage of saccharine urine through the glomerule of the kidney produces sclerosis of this organ, which results in albuminuria. This is one of the most common conditions found in old diabetics with excessive urine. It may be said that there are few who escape this complication.
In concluding this lesson, I should say a few words respecting the treatment of these complications.
There is very little to be said respecting the treatment of diabetic coma. Coma is a symptom which often occurs in grave diabetes. In these cases, the odor of acetone in the breath enables one to make a diagnosis of diabetes at a distance by simply entering the patient's room. Acetonæmia has been given a preponderant role in the pathogeny of diabetic coma, but this is not the only hypothesis by which these nervous symptoms may be explained. Some have supposed it to be due to aceto-acetic acid. Others have attributed the intoxication to the action of oxybutyric acid 3.
I shall not enter into a detail of all these hypotheses. I shall confine myself wholly to therapeutic considerations. I confess that up to the present time, I have had only failures in the treatment of diabetic coma. I have employed injections of caffein and inhalations of oxygen, and have always failed. It is true that I have not employed more active methods, and in particular, that sug
gested by Stadelmann, who has recommended subcutaneous and intra-venous injections of alkaline liquids. Lépine has employed, without success, injections of solutions of chloride and bicarbonate of soda. Others have recommended alkaline preparations, but in the great majority of cases, failure has been the result.
As the gangrene is a complication, everything depends upon the extent of the suppuration and the gangrene. certain cases, there is a true gangrenous septicemia which attacks all portions of the body at nearly the same time. These frightful cases are all beyond the resources of therapeutics. When, however, the case is one of limited gangrene, or of gangrenous anthrax, unhappily so frequent in diabetes, the question presented is one of surgical intervention. Some affirm that in spite of the presence of sugar in the urine, active intervention is required, laying freely open the anthrax, or removing the dead parts. Others, on the contrary, maintain that in such cases, surgical intervention is more dangerous than useful. I am myself disposed to take the last view. In diabetics who still have sugar in the urine, I have always seen the fatal termination hastened rather than retarded where surgery has been resorted It is better, in such cases, to wait until the patient's vital forces have been rallied by tonic medication and by rigor ous diet, and the sugar has been reduced to less than ten grams in twenty-four hours; then surgical intervention may be made with some chance of success., Before this has been accomplished, it is better to modify the antiseptic dressings, and especially the means recommended by Prof. Verneuil, viz., sprays of a twoper-cent carbolic acid solution.
There is little to be said concerning the phthisis of diabetics, which is most frequently a slowly progressive phthisis, the phthisis of old persons, but sometimes having a rapid course, always, however, inducing loss of appetite, which is a matter of the greatest gravity in diabetics. So long as the tuberculous diabetic can eat, one may hope, not to cure him, but to prolong his life for some time, in spite of the tuberculosis. But if the appetite fails, the vital forces fail very rapidly, hectic fever appears, and rapidly hastens the death of the patient.
Before mentioning the complication which is the most frequent — albuminuria I wish to say a few words re
specting cerebral or spinal softening which may be connected with the nervous disorders of diabetics. Bouchardat pointed out the fact that there is often a tendency to cerebral softening in diabetics, and I have found this statement to be true. In such cases, nothing can be done. The same is not true, however, in albuminuria. The point most difficult in these cases, is to establish a proper dietary. I have often presented to you the regimen required in renal insufficiency, which is based entirely upon the vegetarian regimen, that is to say, a regimen which reduces to a minimum the quantity of toxines introduced with the food. Unhappily, this regimen comprises milk, farinaceous foods, fruits, and foods which are discarded from the diabetic regimen, so that we have nothing left with which to nourish our diabetic and albuminuric patient, except eggs and legumes, which are manifestly insufficient. In these cases, we may, however, add certain meats, as very well cooked meats, gelatinous meats, such as veal, beef, chicken with rice, beef-tongue, etc. It should be well understood that fish, game, clams, oysters, crabs, lobsters, and all mollusks and crustaceans should be forbidden. Only fresh cheese can be permitted. As regards the question of a milk diet, one must be guided by the state of the patient.
When the symptoms of renal impermeability are more prominent than those of diabetes, a milk diet should be ordered without a moment's hesitation. Frequent analysis of the urine should be made, to see if the quantity of sugar increases.
To the milk diet should be added inhalations of oxygen and caffein, which are useful both in diabetes and in albuminuria. The lactate of strontium may also be employed, as this drug is efficacious in both conditions. Lactic acid has been highly recommended by Cantani, in diabetes. As to the lactate of strontium, I have shown, after G. Sée and C. Paul, its utility in albuminuric nephritis.
To Increase the Intensity of Heart Sounds.-Have the patient lie upon the back, and elevate the arms and legs, the head being supported upon a cushion. This causes contractions of the bloodvessels of the arms and legs and an accumulation of the blood in the trunk, thus increasing the arterial tension and the intensity of the heart's action.
LIVING AND CHEMICAL FERMENTATION.
[Extract by Paul Paquin, M. D.] FERMENTATION, as is well known, is classed in two categories, the one depending on living beings (vital fermentation), the other depending exclusively on chemical processes independent of life, and capable of developing in absolutely sterile. media (chemical fermentation). The fluoride of sodium which at one per cent stops instantly and definitely all vital fermentation, and with it all manifestations of life without suspending chemical fermentation, permits the appreciation of the phenomena of the other group.
The addition of one per cent solution of fluoride of sodium preserves organic matter from all putrefaction, even at a temperature of 40° to 45° C All substances thus preserved, such as milk, blood, urine, bile, beaten eggs, fruits, fragments of animal tissue, saliva, pancreatine, gelatine, etc., presented after several months at 40° C., neither odor or any other alteration characteristic of the development of microbes. The sugar, the disappearance of which from an organic medium is one of the first microbic phenomena in living fermenta-. tion, is preserved totally in fluorated liquors. It is not in the precipitation of the salts calcium that the fluoride is sterilized; for the oxalate of sodium at one per cent has not the same property it retards only the beginning, and moderates the march of putrefaction.
The lactic ferment is destroyed by the fluoride of sodium at one per cent; it suffices generally to add to the milk 0.4 per cent of fluoride. The sugar of milk is preserved in toto in the fluorated liquors.
The ammoniacal ferments of urine are inactive in the presence of fluoride of per cent. The resistance to the action of this salt, as to that of the lactic ferment, is less than that of the micro-organisms of putrefaction and of that of the molds. The quantity of the urea in fluorated urine is invariable.
The fluoride of sodium at a dose of 0.3 per cent arrests the alcoholic fermentation of sugar instantaneously.
The fluoride of sodium at the stated dose then prevents the development of living elements in organic liquors and tissues. Inferior doses are even sometimes sufficient to completely sterilize;
but always, even in very small doses, the appearance of fermentation is retarded and the intensity is diminished. The soluble ferments invertine, trypsine, emulsine, etc.- preserve their activity in the presence of fluoride of sodium. The products of fermentation are the same whether the fermentation occurs in the presence or the absence of this salt. The natural digestive juices-gastric juice, pancreatic juice, and the digestive juice of masceration - preserve in the presence of the fluoride their normal property. After several months these soluble ferments are not destroyed by the salts by I per cent at a temperature of 40° C.
The alcoholic fermentation of saccharose presents two phases: one is an inversion of the sugar, a chemical phenomenon; the other is the splitting of the inverted sugar, a vital phenomenon ; the fluoride of sodium stops only at the second fermentation.
The blood may transform the glycogen into reductive sugar, by means of the diastase that it contains; the fluoride of sodium does not prevent this fermentation.
The liver separated from the organism. and free from blood by intravascular washing, transforms its glycogen into sugar. This transformation is possible in the presence of one per cent of fluoride of sodium, that is to say, in the very conditions in which the life of the cellular elements is impossible; hepatic glycogenia, therefore, is a phenomenon of chemical fermentation. Furthermore, hepatic mascerations kept sterile by the fluoride of sodium, preserve the power of transforming the glycogen into sugar, during weeks and months, that is to say, during a time infinitely longer than the possible duration of life of the cellular elements of the liver.
The defibrinated or oxalated blood consumes its oxygen, and produces carbonic acid gas. The fluoride of sodium stops completely and definitely this phenomenon of oxydation; the nature and the gas of the fluorated blood remain invariable. The transformations which occur in the non-fluorated blood are the phenomena of the vital respiration.
The green parts of the vegetables lose by the action of fluoride of sodium, the property of decomposing carbonic acid. gas and liberating oxygen. The chlorofilian function, then, is a vital phenomenon.
Finally, the fluoride of sodium at one per cent kills every living thing, and opposes the development of vital fermentation without arresting chemical fermentation. It permits the determination of the nature of the phenomena having their seat in an organic medium, and explains whether they belong to a vital action or to a diastasic action.
A New Treatment for Glanders. Owing to the pathological relations that seem to exist in the neoplasms between tuberculosis and glanders, M. M. Nourry and Nichel have attempted the treatment of glanders by hypodermic injections of creosote in oil, to produce the resorption of the pulmonary tubercles and the glandular adenites, with chloride of zinc as a wash in the nostril, to combat the ulcerous destructions and discharges therefrom. After two months, two horses thus treated appeared totally cured. The injections were made with a Pravaz syringe, at first with oil at 10 per cent, and then at 25 per cent, and finally at 50 per cent. A student of the Pasteur Institute who was accidentally inoculated with glanders, was treated by injections of creosote and oil by Dr. Burereaux, but in vain.
Etiology of Leprosy. Dr. Geo. L. Fitch, in the New York Medical Record for September, concludes an important paper on leprosy as follows:
"I. We have the clearest and most unmistakable proof that leprosy is a noncommunicable disease, as leprosy, under any circumstances.
"2. Leprosy invariably follows the introduction of syphilis among virgin races so quickly as to point most strongly to a common origin.
"3. It is a well-known fact that syphilis, in an immense majority of cases, cannot be acquired under any circumstances a second time. While the twenty cases in which I inoculated syphilis on lepers are not absolutely conclusive, still it is a point worth consideration.
"4. By accepting the view I have put forth, we have an easy, natural solution of leprosy, a non-communicable disease after it declares itself as leprosy, spreading as it does spread, and still being in itself non-contagious and non-communicable. In this way, also, we are able to
account for those isolated cases of leprosy which now and again appear in communities otherwise free from the disease, and in which the subjects affected with it can never by any possibility have come in contact with it."
He considers that leprosy is not a disease of individual and special characteristics, but is in fact a fourth stage of syphilis. It occurs epidemically in races virgin to this disease. This opinion is not fully sustained, if at all, by experimental research, and it is interesting to note that bacteriological investigations have failed to produce any evidence in support of it. The bacillus of leprosy has been demonstrated and is plainly visible by exact microscopical and bacteriological methods, while no such germ has ever been found in syphilis.
Pancreatic Diabetes. In the year 1877, M. Lancereaux demonstrated the existence of a sugar diabetes with a rapid evolution, connected with the destruction of the pancreas. In 1888, the same author classified diabetes as follows: First, nervous traumatic or spontaneous diabetes; second, constitutional or fatty diabetes; third, pancreatic or lean diabetes. Experiments made since then upon animals confirm the existence of the latter kind.
The total extirpation of the pancreas in dogs, produces every time the sugar diabetes between 28 and 120 days.
From other experiments and observations, MM. Lancereaux and Thirolvix conclude that there is a form of diabetes connected with the destruction of the pancreas; this diabetes does not come from the absence of external glandular secretion, but simply from the absence of sugar secreted internally by the gland, and resorbed by the blood and lymphatics.
Treatment of Cholera.- Christmas, in his studies at the Pasteur Institute, found that I gm. of citric acid per liter of water produced an inoffensive beverage, capable of preventing the growth of the bacilli of cholera and typhoid fever.
Lowenthal recommends for the treatment of cholera the administration of salol, which, according to him, is almost specific. He gives at first 2 grams, then 50 centigrams to 1 gram every half hour. A physician, in treating 53 cases by this method, had only three deaths.