Diabetes Mellitos at tbc Massachusetts General 
Hospital From 1824 to 1898. A Study 
of the Medical Records. 
Presented to the Section on Practice of Medicine, at the Fortyminth 
Annual Meeting of the American Medical Association held at 
Denver, Colo., June 7-10,1898. 
BY REGINALD H. FITZ, M.D., 
and ELLIOTT P. JOSLIN, M.D. 
BOSTON, MASS. 
REPRINTED FROM THE 
JOURNAL OF THE AMERICAN'TSKQ^UAT'J^NQj^ATW^I 
JULY 4S. 1898j 
CHICAGO.: 
American Medical Association Press. 
1898. DIABETES MELLITUS AT THE MASSACHU 
SETTS GENERAL HOSPITAL FROM 1824 
TO 1898. A STUDY OF THE MEDI- 
CAL RECORDS. 
BY REGINAL H. FITZ, M.D. 
and ELLIOTT P. JOSLIN, M.D. 
The examination of the records of the cases of sac- 
charine diabetes treated in the wards of the Massa- 
chusetts General Hospital during the past seventy- 
four years was begun for the purpose of seeking 
evidence with regard to the pancreatic origin of this 
disease. (See Yale Medical Journal, 1898, iv, 275.) 
Since several hundred volumes were to be searched it 
seemed desirable to obtain at the same time informa- 
tion upon other points which might contribute to the 
statistics of diabetes. Facts of interest in diagnosis 
and treatment were elicited as the study progressed 
and this paper is offered rather as a historical sketch 
of the progress of a disease drawn from the original 
records than as an attempt to advance in any way our 
knowledge of the subject. Since diabetes mellitus 
was first sharply differentiated from diabetes insipi- 
dus early in the present century, the hospital records 
may be considered to be nearly as old as is our knowl- 
edge of the disease in question. 
During these seventy-four years the total number 
of cases of diabetes mellitus treated in the medical 
wards was 172, but of these, 9 were readmitted, mak- 
ing 181 separate entries. The following table shows 
the variation in the number of such patients during 
successive periods of years and their proportion to 2 
the total number of cases treated during the same 
periods. 
Period. 
Total num- 
ber of 
patients. 
Number of 
cases of 
diabetes. 
Per cent 
From 1824 to 1840 
5,328 
7 
.13 
From 1840 to 1855 
6,136 
16 
.26 
From 1855 to 1870 
8,660 
24 
.27 
From 1870 to 1885 
11,690 
39 
.38 
From 1885 to 1898 
16,085 
86 
.53 
It appears from this table that within the past 
thirteen years as many cases of diabetes were admit- 
ted to the hospital as in the previous sixty-one years 
and the per cent, in the past thirteen years in proper 
tion to the total number of hospital entries has in- 
creased fourfold over that of the first fifteen years. 
This fact is not due to any recent increase in the 
number of beds open to this class of patients, nor, 
presumably to any considerable excess in the fre- 
quency of this disease in the region from which the 
hospital receives its patients. Whatever may be its 
cause this occurrence is to be regarded as evidence of 
the wholesome tendency of diabetics to place them- 
selves under careful medical supervision for such 
length of time as shall permit suitable observations 
to determine tne severity and controllability of the 
disease, that the future conduct of the patient may 
accordingly be regulated. 
Age. 
Number of 
cases. 
Per cent. 
From 0 to 10 years 
3 
1.8 
From 10 to 20 years 
15 
8.8 
From 20 to 30 years 
41 
24.1 
From 30 to 40 years 
43 
25.3 
From 40 to 50 years 
29 
17.1 
From 50 to 60 years 
28 
16.5 
From 60 to 70 years • • . . 
11 
6.4 
Of the 172 cases, 127 (or disregarding fractions, 
74 per cent.) were males and 45 (or 26 per cent.) were 
females. The oldest patient was 73 years of age and 
the youngest 5 years, the average age of 161 patients 3 
being 33.4 years. The average age among 40 female 
patients was 39.1 years, being higher than that in 121 
males in whom it was 31.4 years. The proceeding table 
represents the time of life at which the disease began. 
Diabetes thus is shown to be a disease predomi- 
nantly affecting the middle third of life, though spar- 
ing neither the child of five nor the senior of seventy- 
three. 
But one of the patients was a negro, a further illus- 
tration of the rarity of diabetes in this race, although 
Tyson (Practice of Medicine, 1896, 751) has met with 
several instances. Ninety-seven of the patients lived 
in the United States, and 83 claimed this country as 
their birthplace. Thirty-nine of the patients were 
born in Ireland, 11 in the British Provinces, 9 in 
England, 4 in Scotland, 7 in Germany, 2 in Sweden 
and lin Denmark. Forty-three of the patients were 
mechanics, 23 servants, 17 laborers and 13 farmers. 
Of merchants there were 5, and of clerks 7, There 
were 5 mariners and 4' teamsters. Although four of 
the patients were students there were but two profes- 
sions represented, a clergyman and an artist being 
included among the entries. There were single or a 
few representatives of several other occupations, and 
conspicuous for its absence was that of liquor dealer. 
In 42 cases the question of an inherited tendency 
to the disease was raised and this factor was stated to 
have been present in 10 patients and absent in 32. In 
one case the father died of possible diabetes and this 
disease was the cause of the death of a brother and his 
daughter. The brother of one diabetic patient fell 
upon the ice, striking his head and died of diabetes 
four days later. In three of the cases the symptoms 
of diabetes came on within a few weeks after severe 
injury. 
One of these patients while working in a mill in July 
so strained his back by lifting a heavy weight that he 
was unable to accomplish much afterward on account 
of supposed weakness of the spine. In August the 
appetite became increased and in December he entered 4 
the hospital for treatment of diabetes. The second 
was buried in d, sand bank three months before 
entrance and was taken out unconscious. Six weeks 
later thirst made its appearance as the first symptom 
indicative of the onset of the diabetes. The third 
fell fourteen feet and struck on the back of the head. 
He was unable to work for a fortnight. Very soon 
afterward he began to have great thirst, hunger, and 
frequent micturition of large quantities of urine. The 
disease began in a female patient one month after 
very hard work in caring for a sick sister. The pos- 
sibility of contagion was entertained in the case of a 
servant whose mistress was suffering from a severe 
variety of diabetes. 
Post-mortem examinations were made in 15 of the 
47 fatal oases. As is usual in this disease no charac- 
teristic lesions were found. The liver generally was 
normal in appearance although sometimes enlarged 
and in one instance it was rather small. The kidneys 
as a rule were normal, were enlarged in one instance, 
congested and with fat drops in the cortex in another, 
enlarged and hemorrhagic in a third, enlarged and 
infiltrated with round cells in a fourth. The stomach 
was large in two cases and Brunner’s glands were 
found “developed” in a case under the care of Henry 
I. Bowditch in 1848. The condition of the pancreas 
was not mentioned in seven of the cases. This gland 
was stated to be normal in five and small in three 
instances. In one of the three its tissues were not 
remarkable, in another there was a moderate infiltra- 
tion of fat tissue around the head of the gland, and in 
the third the weight was‘recorded as an ounce and a 
half, the section showing a coarsely granular surface. 
No attempt has been made to note the relative fre- 
quency and the severity of the various symptoms. 
Particular attention has been paid, however, to the 
records of the condition of the urine, since they fur- 
nish a valuable commentary of the progress of our 
knowledge concerning the methods of studying this 
secretion. In the earliest volumes of the records especial im- 
portance was attached to the measurements of the 
quantity of urine passed as compared with the quan- 
tity of liquids ingested, since formerly it was the belief 
that patients excreted more urine than they drank 
liquid. As an illustration the following table is cop- 
ied from the record of a case. 
Date. 
Water drank—Pints. 
Urine voided 
—Pints. 
Specific 
gravity. 
April 28 
7XA 
4J| 
23 
1030 
April 29 
9+ 
1030 
April 30 
4 
11 
1034 
May 1 
3 
8 
1033 
May 2 
4 
9 
? 
May 3 
4 
10 
1027 
May 4 
4^ 
10 
1025 
May 5 
About 4^| 
5 
1025 
May 6 
About 6 
10 
1027 
May 7 
About 7% 
11 
1025 
May 8 
Out of house. 
6 
1025 
May 9 
Out of house, 5. 
9 
1030 
May 10 
Not known. 
6 
1030 
May 11 
Not recorded, patient went 
frequently to stool. 
May 12 
6 A. 
10 
1033 
May 13 
4^ 
10 
1027 
M ay 14 
7 
11 
1025 
May 15 
7 
10 
1024 
May 16 
6A 
10 
May 17 
6, bread out. 
10 
1027 
May 18 
7 
10 
1030 
May 19 
8 
10 
1030 
May 20 
7 
12 
1030 
May 21 
8/4 
14 
1031 
May 22 
8 
18 
1031 
May 23 
7A 
14 
1033 
May 24 
10 
17 
1031 
May 25 
7. bread renewed. 
16 
May 26 
16 
1031 
May 27 
14 
15 
1031 
May 28 
16 
1033 
May 29 
8 
16 
1034 
May 30 
10 
1032 
May 31 
10 
1032 
June 1 
m 
12 
1030 
June 2 
6 M 
9 
1031 
June 3 
7 
12 
1030 
June 4 
7 H 
9 
1030 
June 5 
11 
1030 
June 6 
e'A 
12 
1025 
June 7 
7A 
12 
1026 
June 8 
10 
1023 
June 9 
9 
14 
1022 
June 10 
18 
1022 
June 11 
11 
18 
1020 
June 12 
11 
18 
1020 
June 13 
Out of the house. 
1021 
TREATED IN 1861. 6 
It is noted, for instance, in Vol. i, that a patient 
with diabetes simplex from Dec. 2 to Dec. 11, 1821, 
ingested forty-five pints and seven gills, but excreted 
forty-five pints and four gills. The first patient who 
is recorded to have had diabetes mellitus entered the 
hospital in 1824, and during the first three days of 
his stay is credited with drinking twenty and one- 
half pints of fluid, and is charged with passing 
twenty-five pints of urine. 
This doctrine of an excess of outgo of urine over 
income of fluids appears in 1847 in Watson’s Practice 
of Physic (3d American Edition, p. 869) as a state- 
ment that the “quantity of urine secreted and voided 
is sometimes enormous, far more than could be sup- 
plied by the quantity of fluid taken as a drink.” 
Twenty years later, Harley in his work on diabetes 
says (p. 50), “diabetic patients generally pass more 
liquid than they take, about one-fifth or one-fourth 
more.” 
Lauder Brunton in 1879 (Reynold’s System of 
Medicine, 1879, p. 887) opposes this view in the fol- 
lowing words: “It has been said that the quantity 
of urine excreted by the patients is greater than that 
of their beverages, but tliis can hardly be the case, 
and the observations which seem to support this view 
have probably been made for too short a time, the 
apparent excess being most likely derived from water 
lodged in the system.” 
The difficulty of eradicating this erroneous idea is 
indicated by the fact that a recent graduate of the Har- 
vard Medical School and of the Massachusetts General 
Hospital, seriously asserted that “ it is perfectly well 
known that a person passes more urine than he drinks 
fluids.” Such a view is based probably upon a mis- 
interpretation of the physiologic teaching that more 
fluid is eliminated from the body in respiration and 
in secretion from the various glands than is taken in 
as liquid. In this connection it is interesting to note 
that a metabolism experiment in diabetes was made 
at the hospital in 1845. For it is then recorded that thirty-six times; voided thirty-six pints. ... It 
contained 3 per cent, of sugar, corresponding to 227 
grains in one pint.” Only six of 166 patients passed 
over 300 ounces in one day. The highest sp. gravity 
recorded is 1054, although repeatedly it was found 
above 1045. The highest percentage of sugar men- 
tioned was 12.5 per cent. In many instances there 
was present between 9 and 10 per cent, of sugar. 
The finding of sugar in the urine was determined 
in the first instance until 1851 by means of the taste. These rude methods of testing the saccharine con- 
dition of the urine were supplemented in 1827 by 
evaporating the specimen. It is recorded “ urine 
yesterday sixteen ounces, . . . seven ounces this 
morning, . , . sixteen being boiled about two re- 
mains (sic), resembling molasses, of saccharine smell 
and taste.” In the following year, “ urine seven pints, 
natural appearance, without sediment, not giving 
syrup on evaporation.” It is stated also that eight 
ounces of urine yielded one ounce of syrup, and at 9 
It seems worthy of reproduction as an illustration of 
the scientific methods employed even fifty years ago 
in the investigation of disease. 
Dr. J. B. S. Jackson. 
Boston, May 12, 1846, 
Dear Sir:—The microscopic examination which I have made 
at your request, of the sugar from diabetic urine has afforded 
some results worthy of mention. The specimens of saccharine 
urine placed in my hands were from two diabetic patients now 
in the hospital. My first attempt was to obtain the sugar in a 
crystallized state by the evaporation of successive portions of 
the urine on slips of glass, both spontaneously and by the aid 
of a gentle heat. But the results obtained in this way were 
unsatisfactory from the difficulty with which this variety of 
sugar crystallizes, and the following process was substituted. 
The urine was evaporated over a salt water bath, to the con- 
sistence of a thick syrup, and drops of this, spread very thinly 
on slips of glass, were left to spontaneous evaporation. In the 
course of a few days the liquid disappeared, leaving on the 
glass little hemispherical grains of a white color (none of them 
as large as the head of a pin), either isolated or collected into 
mammillated crusts. With the urine of the male patient, Pet- 
tigrew, two or three days were sufficient for this purpose ; that 
of the female patient, Gould, which appeared to contain less 
sugar in proportion to the other constituents, required more 
than a week’s exposure. 
The objects thus procured were prepared for the microscope 
by covering them with Canada balsam. Being now examined 
with moderate powers, each little grain resolved itself into a 
compact group of fibers radiating from a central point, many 
of their ends projected beyond the mass, but exhibited no dis- 
tinct crystalline faces. This radiated structure, with a fine 
silky lustre, becomes distinctly visible to the naked eye in the 
larger grains, when they are covered with the balsam. The 
aid of the polarizing attachment to the microscope was now 
called in to decide the question as to the crystalline structure 
of the grains, when the rich and varied colors exhibited in the 
polarized light left no doubt of their really being groups of 
radiating acicular crystals. Among these masses of sugar 
there were noticed a few groups of more distinct crystal, not 
arranged like them in a stellate manner, and presenting 
entirely different appearances in polarized light. These are 
doubtless some of the saline constituents of the urine. As 
diabetic sugar is classed with that variety, to which from its 
abundance in the juice of ripe grapes the name of grape 
sugar is given, it became of interest to compare the appear- 
ance of the two under the microscope. Grape sugar is present 
in large quantity in honey, and is the variety formed from 
starch or from cane sugar by long continued boiling with dilute 10 
sulphuric acid. This variety is entirely distinct in its charac- 
ter from the common or cane sugar. A portion was prepared 
from honey and dissolved in alcohol, the solution, evaporated 
to a syrup and prepared for the microscope in the same man 
ner as the diabetic urine, crystallized in groups of radiating 
fibers like the diabetic sugar, and presented similar appear- 
ances under the microscope, both with and without the polar- 
izing attachment. An alcoholic solution of the diabetic sugar 
was also prepared, which crystallized in the same manner; 
a similar solution of cane sugar afforded no radiated groups, 
but distinct prismatic crystals which gave fine colored rings 
in polarized light. Under the microscope the urine of both 
patients (before evaporation) is seen to contain great numbers 
of colorless globules, often connected in chains or groups of 
half a dozen or more. I made a cursory examination for urea, 
by evaporating an ounce of the urine from each patient to one 
quarter and adding an equal volume of nitric acid. Pearly 
crystalline plates of nitrate of urea soon made their appear- 
ance in both, showing urea to be present in considerable 
amount, but the quantity of urine operated upon was too 
small to allow of a correct determination of the amount. 
Yours respectfully, John Bacon, Jr. 
Although Moore’s test had been made known in 
1844, the first mention of its use in the hospital was 
in 1851, when the following record appears “glucose 
strongly marked on the addition of heat and liquor 
potassee.” 
In 1852 Dr. Bacon determined, by what means it is 
not stated, that the per cent, of sugar in a given urine 
was 4 per cent, and two years later the fermentation 
method was employed for ascertaining the percentage. 
The breath of diabetic patients first attracted atten- 
tion in 1835, when a man entered the hospital with a 
note from his physician stating that it had a “pecu- 
liar sour smell.” The observation made of this 
patient while in the hospital was of “a curious smell 
in breath which he has had since entrance.” In three 
cases the breath is stated to have the odor of new 
milk. In 1846 it is noted of one of these “odor of 
breath considered by some of aromatic sweetness.” 
Other expressions are in 1846 “odor of boiled milk;” 
in 1848 “ward distinctly tainted with smell peculiar 
to diabetes,” “fruity odor;” in 1869 “sweet chloro- 
form-like smell in neighborhood of patient’s bed.” 11 
That the acetone odor of the breath then was attract- 
ing general attention is apparent in 1847 from the 
statement made in Watson’s Practice (op. cit. p. 868) 
that “according to Dr. Front the scent somewhat 
resembles that of sweet hay, but to my nose it is more 
like the smell of certain apples or rather of an apple 
chamber.” He attributes the peculiar odor to the 
sugar. In 1866 in Harley on Diabetes (op. cit.) there 
is no mention of acetone or of diacetic acid, although 
Fetters (Prager Vierteljahrsch. 1857, Iv) several years 
before had attributed the coma of diabetes to the 
former agent. 
Acetone was sought for in the breath of 19 oases, 
and in the urine of 24 cases. Its presence was 
indicated by the odor in 16 of the former, and 
by chemical tests in 14 of the latter series. It 
is interesting to note in connection with the result 
of recent investigations on the increase of acetone in 
consequence of a change to an absolute proteid diet, 
that the records state in 1894 that the “acetone smell 
has been more since disappearance of sugar than at 
any other time.” Ten days later, however, without 
any change in diet there had been no return of sugar 
and no smell to the breath. 
The ferric chlorid reaction, which, when positive, 
is considered generally to be evidence of the presence 
of diacetic acid, was sought for in 22 oases and found 
in 13, Albuminuria was present in the urine in 67 
cases and was absent in 60 cases. Casts were found 
in 86 cases. 
In four instances only is there a record of the exam- 
ination of the feces. In 1844 a patient reported that 
his “food frequently passes away in lumps undigested” 
and fat is reported as absent in the stools of three 
patients. 
In six cases there was tinnitus aurium and two 
patients had sciatica. Sexual power is noted as absent 
in 9 oases and present in 4. The catamenia were pres- 
ent in 11 cases and absent in 9. Jaundice is men- 
tioned to have occurred in five cases, and three of 12 
these patients died in the hospital, one of pneumonia 
and one of atrophied pancreas. Syphilis is stated to 
have existed in one case. Diabetes and myxedema 
coexisted in one patient and in another diabetic there 
was a tumor of the thyroid body. Three of the patients 
suffered from gangrene of the toe, a fourth had a gan- 
grenous slough of the tissues of the leg, and a fifth 
died with a carbunoular-like inflammation of the thigh. 
Three of the patients had abscesses, one being of the 
hip, another of the wrist, both cases ending fatally. 
The third abscess was of the jaw, but the patient grew 
better. In one case there was a round ulcer of the 
toe, which improved under treatment. 
The records afford some evidence concerning the 
duration of the disease, which in one case is stated to 
have existed for twelve years, while three patients had 
suffered but two weeks. Of the latter, one died, one 
was relieved and one unrelieved. The average dura- 
tion was one year and a half. 
The length of the illness in the fatal cases is indi- 
cated in the following table: 
DUEATION. 
NUMBER OF CASES. 
From 0 to 1 year 
27 
From 1 to 2 years 
From 2 to 8 years 
From 3 to 4 years 
1 
From 4 to 5 years 
0 
From 5 to 6 years 
1 
From 6 to 7 years 
Unknown 
47 
These cases, necessarily those of grave diabetes, 
thus ended fatally in nearly three-fourths of the 
number in which this point could be determined 
within one year after the disease made itself manifest, 
and within two years in nearly seven-eighths of the 
entire series. That diabetes may prove fatal at the 
end of a longer period of time, from 6 to 7 years as 
in one instance, is attributable to the well known fact 
that cases of mild diabetes may become suddenly 
severe, and that the symptoms of this disease may for 
a while disappear to return at a later period. An 
illustration of the latter condition, one which may be 13 
called recurrent diabetes, is to be found in the record 
of a patient who was in the hospital in 1862. In 
March, 1861, he suffered from cough with abundant 
yellow expectoration. In the latter part of the month 
the thirst increased and became excessive; the patient 
drank freely and passed large quantities of pale urine. 
The appetite failed and there was progressive debility. 
At the end of four months the quantity of urine be- 
came normal. The patient remained apparently well 
until the following February, when excessive thirst, 
polyuria and debility returned, and it was observed 
that the urine left a sticky and sparkling deposit on 
cloth. Another instance of recurrence is noted in 1866. 
Two years previous to the entrance of this patient he 
observed that an abnormally large quantity of urine 
was being passed in the twenty-four hours and that 
the thirst was excessive. These and other symptoms 
continued for three months and then disappeared 
without treatment. At the end of eighteen months, 
however, they returned, accompanied by general weak- 
ness and faintness. It is recorded that the house 
physician tasted the urine of this patient. 
Of the 172 patients 47 or 27 per cent. died. The 
mortality among the 127 male patients wTas 39 or 30.7 
percent.; of the 45 female patients 8 died, a mortality 
of 17.7 per cent. The death rate among the males 
thus proved nearly twice as high as among the females. 
The following table illustrates the variation in the 
rate of mortality during successive periods of years. 
Period. 
No. of 
cases. 
No. Of 
deaths. 
Percentage 
of deaths. 
From 1824 to 1840 
7 
1 
14 
From 1840 to 1855 
16 
7 
44 
From 1855 to 1870 
24 
5 
20 
From 1870 to 1885. . 
39 
11 
28 
From 1885 to 1898 
86 
23 
27 
From 1824 to 1898 
172 
47 
27 
It has previously been remarked that from 1824 to 
1885 there were treated 86 cases, the same number of 
cases as in the period from 1885 to 1898. It is cer- 14 
tainly noteworthy that in each of these intervals there 
was an average of 27 per cent, of fatal cases, which 
again was the average mortality rate of the cases 
treated throughout the entire period from 1824 to 
to 1898. It might be thought from the inspection of 
this table that the method of treatment was superior 
from 1824 to 1840 and from 1855 to 1870 and that in 
the intervening years it was inferior. The informa- 
tion on this point later given affords no justification 
for such an inference. 
Although it appears from the study of the records 
that most cases of grave diabetes die within a year or 
two of the onset of the disease and that 27 per cent, 
of all cases are fatal, some evidence has been obtained 
with regard to the prognosis in the individual case. 
Heredity appears to have less importance than is 
usually assigned to it. Of ten cases in which hered- 
ity may have been of etiologic significance three 
died, while of thirty-two cases in which heredity had 
no influence eight died. Thus the percentage of 
deaths was merely a trifle higher in those cases in 
which an inherited tendency to diabetes may have 
played a part than in those in which no such influ- 
ence existed. 
The time of life at which the patient suffers from 
the disease appears to be of greater prognostic im- 
portance, as may be inferred from the following table: 
Age. 
No. of 
Cases. 
Deaths. 
Per cent. 
Prom 0 to 10 years 
3 
1 
33 
From 10 to 20 years 
15 
3 
20 
From 20 to 30 years 
41 
14 
34 
From 80 to 40 years 
43 
13 
30 
From 40 to 50 years 
29 
4 
14 
From 59 to 60 years 
28 
5 
18 
From 60 to 70 years 
11 
5 
45 
170 
45 
Thus about one-third of the patients suffering 
from diabetes during the first ten years of life and 
between the ages of 20 and 40 years die, and nearly 
one-half of the cases between 60 and 70 years prove 15 
fatal. The number of cases of diabetes in young 
children, however, is so small as not to be of much 
value in generalizing. The high rate of mortality 
after the age of 60 is due, possibly, only indirectly to 
the diabetes, the patients perhaps being unable to 
resist the effects of other disease, even if mild, in the 
presence of so grave an affection. 
Thirty-eight of the 47 fatal cases died comatose, the 
coma lasting one day in 10 cases, two days in 14 and 
three days in 5 patients. In the remaining 9 cases 
the duration of the coma was not to be determined. 
The frequency of the coma in relation to the age of 
the patient is indicated in the following table: 
Age. 
No. of 
cases. 
Deaths 
from coma. 
Per cent. 
From 0 to 10 years 
3 
1 
S3 
From 10 to 20 years 
15 
3 
20 
From 20 to 30 years 
41 
12 
29 
From 30 to 40 vears 
43 
9 
21 
From 40 to 50 i ears 
29 
3 
10 
From 50 to 00 years 
28 
4 
14 
From 60 to 70 years 
11 
3 
27 
The suddenness of its onset in certain instances is 
apparent from the record of a patient in 1828 who was 
able to leave the hospital for a few hours, at the end 
of which he became comatose and died. In 1846 
another patient absented himself from the hospital 
without leave and became intoxicated; two days later 
he was comatose and died at the end of another 
two days. On the other hand, a third patient while 
in the hospital became intoxicated, had no coma and 
lived. 
It is to be observed that of twenty fatal cases of 
diabetes there was present chronic nephritis in six, 
pulmonary tuberculosis and carbuncle or gangrene 
each in three, myocarditis in two and pneumonia, 
pleurisy, cerebral thrombosis, alveolar abscess and 
atrophied pancreas each in one. A patient with dia- 
betes suffered at the same time from acute catarrhal 
cholangitis, acute rheumatism and chronic bronchitis. 
The study of the records of these cases affords some 16 
evidence relating to the prognostic value of the pres- 
ence of acetone and diacetic acid. Although the odor 
of acetone was present in the breath of 12 out of 14 
fatal cases, that is, in more than 85 per cent., and in 
the urine of 6 out of 9 fatal cases, namely 66 percent., 
in which the records show that attention was directed 
to this point, it was present also in the breath of 4 
out of 5 non-fatal cases, 80 per cent., and in the urine 
of 8 out of 15 non-fatal cases, 58 per cent. It is evi- 
dent from this comparison that the presence of an 
acetone odor in the breath or in the urine throws 
but little light upon the severity or mildness of the 
disease. 
The ferric chlorid reaction was present in 6 out of 
8 fatal oases and in one-half of the 14 non-fatal oases 
in which it was sought for. This evidence, so far as 
it goes, therefore, is in support of the view that this 
reaction has a somewhat serious significance. 
It is interesting to note that in the earliest days of 
the hospital the improvement of the patient’s condi- 
tion was based upon an increase in weight. 
It is to be remembered that John Rollo (Notes of a 
Diabetic Case, 1897) first ascertained that an animal 
diet not only decreased the quantity of urine, but 
also diminished the amount of sugar. The diet, 
therefore, from 1824 to 1840 was based evidently upon 
this discovery and the first diabetic patient in the 
hospital was fed on “animal food and bread in small 
quantities. Only one potato (sic) at dinner.” Later 
molasses, beer and apples were excluded from his diet. 
In 1827 a patient’s fare consisted of two eggs, at a 
meal, meat, milk, butter and salt. Such a diet, how- 
ever, was not exclusive, for mention is made that vege- 
table food and sugar were not to be taken, but rice 
and milk porridge were allowed. Toast water and 
broth were permitted, and crackers were given instead 
of bread. Thirst was quenched with chamomile tea 
or balm tea, and lemons also served for this purpose. 
The unlimited use of liquids was not permitted, for 
one patient was allowed only a “teacup of liquid at 17 
meals.” Another was given, “balm tea as little as will 
suffice,” and it is stated of a third that he “thinks he 
has not drank all his allowance.” 
The first treatment the first patient received was a 
warm bath, and as the quantity of urine appeared to 
be less after the bath had been taken it was ordered 
to be repeated every other day. Warm salt baths 
also were used. 
The advantages of exercise were appreciated at an 
early period, for one patient in 1881 was advised to 
ride horseback, and another was recommended to take 
as much exercise as his strength would permit. 
Alcohol was given as early as 1828, when the phy- 
sician in charge ordered, “let her take some brandy 
and water, taking one teaspoonful of brandy in hot or 
cold water, repeating it once in 3 or 4 hours if the 
effects are grateful.” There is nothing in the record 
to show that its action was displeasing to the patient. 
The recent investigations of von Noorden (“Die 
Zuckerkranheit und Ihre Behandlung,” 1895, 146), 
show that this treatment has a sound scientific basis 
since one gram of alcohol is the equivalent of 
seven calories, while the same quantity of proteids 
and carbohydrates is equivalent only to four calories. 
This patient was treated also with opium and “by 
error took following in A. m. 
ft Infus. Sennse Comp., 3iij.” 
On the next day he “was uncomfortable in head 
with some depression of spirits.” During this patient’s 
stay in the hospital he was ordered powdered rhubarb 
and the infusion of rhubarb and magnesia; a trial was 
made also of uva ursi and of the sodium and potassium 
tartrate. 
During the first fifteen years the treatment in gen- 
eral consisted of opium, either alone or with camphor 
and aloes. Cathartics were used liberally, and fre- 
quent mention is made of rhubarb, aloes, colocynth, 
senna, calomel, magnesium sulphate, castor oil and 
croton oil. Enemata were employed freely, some of 
them being especially designated “active.” One 18 
patient who complained of nausea promptly received 
a dose of ipecac. 
Among other drugs in use during this period were 
quinin and dilute nitric acid, the decoction of sumac 
and powdered guiac. 
Blisters and cupping often were used, and one 
patient “thinks opium and blisters have been fol- 
lowed by the greatest improvement.” More severe 
counter-irritation was ordered sometimes, as appears 
from the record, “apply caustic issue on each side of 
the spine.” In one case this application proved to 
be directly injurious. 
During the period of high mortality, that is from 
1840 to 1855, the following dietary is ordered: “Lean 
meat, with a small quantity of stale, dry or toasted 
bread, avoiding all fatty, farinaceous and saccharine 
articles. For drink, cold water and weak tea.” The 
use of liquids continued to be restricted, although 
slippery elm tea now came into use. Alcohol was 
not given regularly, and blisters no longer were 
applied. Leeches appeared to serve in the place of 
the latter and of issues for it is recorded, “Leach (sic) 
bites now ulcerated.” 
Opium continued to be given, but not so largely as 
previous to 1840. Cathartics were prescribed with 
freedom, and the liberal use of calomel is suggested 
by the frequent records of spongy gums and myrrh 
mouth washes. Iron now was used in the form of 
the tincture of the chlorid or the carbonate. Other 
remedies employed were argentic nitrate, ammonium 
hydrosulphuret, ammonium carbonate, conium, hyos- 
cyamus and valerian, aromatic sulphuric acid and 
creosote. During this period the use of yeast was 
tried by McGregor (Watson’s Practice, p. 872), who 
stated that it made the patients feel as if they were 
“on the eve of being blown up.” A patient in the 
hospital was ordered to “take yeast 3ss. in milk ter 
die” This quantity was increased to an ounce daily 
and then was resumed and omitted at intervals dur- 
ing a month, the yeast being taken five-sixths of the 19 
time. The effect was not that mentioned by Watson, 
but a sense of constant nausea was the chief result- 
ing complaint. 
From 1855 to 1870 especial attention was paid to 
the selection of a suitable bread, and bran bread, stale 
bread, brown dyspepsia bread, toasted dyspepsia 
bread, ship biscuit and toasted ship bread were or- 
dered. Butter, cabbage, cheese and greens were 
allowed, but shellfish and liver were excluded. 
Liquids at times were restricted, and cocoa was given 
somewhat frequently. Alcohol was ordered occasion- 
ally, and one patient, notwithstanding milk punch 
was prescribed p. r. n., remained in the hospital but 
a single day, at the end of which he was discharged 
unrelieved. Opium was but little used, counter-irri- 
tants were discontinued and there was but little va- 
riety in the use of drugs. One patient received a 
half pint of iron rust water at dinner. To another 
in 1866 was given a half ounce of cod liver oil three 
times daily. As “ she likes it and don’t have enough,” 
the dose was increased to three ounces three times 
daily. This maximum dose was reduced in conse- 
quence of the production of loose movements of the 
bowels. 
From 1870 to 1885 gluten bread was used, but was 
discovered to contain 83 per cent, of starch. Patients 
were advised “ to drink as little water as possible,” 
but as much as four quarts of skim-milk were given 
daily. Opium and codeia were used frequently, but 
alcohol, blisters, baths and exercise were not advised 
as a part of the routine treatment. On the contrary, 
a large number of drugs were employed, including 
tier’s solution, bromid of arsenic, antimony, bis- 405). On the day after his admission he was given 
thirty-three ounces of glycerin and died comatose on 
the same day. The coma was accompanied by spasms, 
to relieve which ether was given, but the house phy- 
sician apparently feared that the death might be 
attributed to the effects of the ether. 
In the period since 1885, Soya bean bread has been 
added to the dietary, and fats are used with freedom. 
The use of water is frequently, by no means always, 
restricted, and the use of skim-milk gradually has 
lessened. Alcohol, baths and exercise, are not made 
matters of routine. Opium and codeia are more often 
used than before, and trials have been made with potas- 
sium citrate, lithium carbonate, jambul, salol, salicin, 
antipyrin and urethan. Saccharin occasionally is used. 
Up to this period comatose patients had been treated 
solely with stimulants and diuretics, and brandy, 
nitroglycerin and oxygen were given frequently at 
the onset of coma. The use of solutions of sodium 
ohlorid or sodium bicarbonate in enema, subcutane- 
ous injection or by transfusion was begun and eight 
patients were thus treated. Although these patients 
died, as had those otherwise treated, it appears from the 
records that in certain instances life was somewhat 
prolonged. The patient’s mind usually became clearer 
after the administration of the saline, and one per- 
son was aroused to such a degree that he is recorded to 
have said, “ Oh! doctor, I’m glad you did that; I have 
not felt so well for a long time.” 
The practical outcome of this examination of the 
records of cases of diabetes treated at the Massa- 
chusetts General Hospital during the past seventy- 
four years can be stated in a very tew words.