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        DIABETES
ITS CAUSE AND PERMANENT CURE 
y' 
DIABETES
CAUSE AND  PERMANENT CURE
FROM THE STANDPOINT OF EXPERIENCE AND

       SCIENTIFIC INVESTIGATION
EMIL  SCHNEE,  M.D.
CONSULTING PHYSICIAN AT CARLSBAD, AND PHYSICIAN OF THE IMPERIAL AND ROYAL

   CONSULATE OF AUSTRIA AND HUNGARY FOR THE RIVIERA, AT MONACO
    Translated from the German by

R. L.  TAFEL,  A.M., Ph.D.
ENGLISH EDITION REVISED AND ENLARGED BY THE AUTHOR




                                / >Z

P.  BLAKISTON,  SON,  & CO.
      1012 Walnut Street
           1889
 
    WKA
     S358^
     1889
f; Ui hlo . Is* 1 . i:" J 
       To  His Highness





           PRINCE






     HERMANN





              OF





SACHSEN - WEIMAR - EISENACH





   WITH HIS GRACIOUS PERMISSION
THIS  WORK IS  DEDICATED BY






      THE AUTHOR. 
 
PEEFAGE.
The author of one of the most important scientific
treatises on Diabetes, which has hitherto been declared
incurable, is Prof.  F. T. Frerichs, one of  my former
teachers.   His work  (Berlin, 1884), the result  of
exact, scientific observations, and the fruit of forty
years  of  study,  must  be  regarded as of  great
authoritative value.   Nevertheless,  at the  close  of
his work, he feels compelled to acknowledge that,
with our present knowledge of diabetes,  we are still
unable to explain the essential nature of this disease.
Baffled, he exclaims:  " For a long time perhaps the
enigma of this sphinx will yet remain unsolved, and
many a human being will yet  be  carried  off by it
before we shall find an adequate solution  of it."
   I, also, have felt compelled to subscribe to Prof.
Frerichs'  confession,  until the year  1881, when, as I
believe, I  succeeded in discovering  the real cause of
diabetes.   After  continuing, since  that time,  my
observations and experiments,  I am at last  in a con-
dition to lay before the profession the results of the
experience  I  have gained in  conquering  diabetes.
The present work, I  trust,  will be  instrumental in
directing  into different channels the views that have
hitherto prevailed  on  the nature of this disease ; and
it  is confidently hoped it will also render this disease 
vi                    Preface.
more tractable in the hands of the physician than it
has been hitherto.
   The present work  contains everything of impor-
tance that has thus far  been written and found out
concerning  " diabetes,"  and also  concerning " gly-
cosuria," which is frequently  confounded with it on
account of the sameness of its product of excretion.
The essential  points,  in fact, of the entire literature
of both these  diseases, from Celsus to Frerichs, and
respectively to the present work, will be found fully
treated in the following pages; and  on the ground
of observation and experience ranging over a period
of twenty-five years, it will be demonstrated, I hope,
to the satisfaction  of everyone that DIABETES, not
simply  " glycosuria," is curable.
   The method of cure which I  follow individualizes
every case ; for the success of  the method depends
upon the  time  when the disease first manifested
itself; upon its  progress; upon  the sex, age, and
condition in life of the patient;  further,  upon the
quality of his habitual food  and drink, his power of
resistance, the character of his mind and disposition,
and upon many other contingent circumstances.
   It is a source of great satisfaction to me to be thus
enabled to supply to the student of medicine a safe
guide through the labyrinth  of this mysterious and
perplexing  disease ;  and  to  afford to the  practical
physician, whose mind is taken up by  the duties  of
his profession, a  clear insight into the true nature of
Diabetes.   But  especially do I feel happy at being
able to minister  comfort  to those afflicted with this 
                     Preface.                   vii
malady ;  to instruct  them concerning their  bodily
condition, which has  hitherto been regarded as per-
fectly  hopeless ;  and to hold  out to those among
them who are reasonable and brave the prospect of
a lasting cure.
                              EMIL SCHNEE.
Carlsbad,
   September 16,  1888. 
 
TABLE   OF   CONTENTS.
                             I.

              Sugar in the Human Organism.

Normal quantity of sugar in the blood—Origin of the patho-
  logical sugar—Claude Bernard's view of the origin of the
  sugar in the liver—Investigations of the following authors :
  Pavy,  Nasse, Zimmer,  Briicke, Weiss,  Kiilz. v.  Mering,
  Ebstein—The Author's method of cure ........................


                             II.

                    Sugar in the Urine.

Definition of glycosuria, wherein it differs  from  diabetes-
  Transient glycosuria—Pathological glycosuria  of pregnant
  women—Temporary glycosuria after certain  diseases, i.e.,
  accidental  glycosuria—The opposite character of  diabetes
  mellitus..............................................................

                            III.

               How Does  Glycosuria  Arise?

Change in  the blood and the circulation—Injuries to certain
  portions of the nervous system—Disturbances  in the diges-
  tion—Interference with the  action of the nerves—Distur-
  bances in. iespiration-rAn excessive use of alcohol causes 
x                  Table of Contents.
                                                          PAGE
  glycosuria—Likewise breathing  for  some time an atmos-
  phere charged with oxide of carbon—Inhalations of chloro-
  form— Experiments  on animals — The  sugar-puncture—
  Hvperaemia of the liver—The diabetes of animals is transient
  glycosuria—Zimmer's  idea of  the  myogenous  origin  of
  glycosuria—Glycosuria, after  cholera, anthrax, diphtheria,
  abdominal  typhoid fever ;  after fever attending suppuration
  from  vaccination;  after meningitis, scarlet-fever, measles,
  catarrh of the stomach, &c.—Glycosuria arising from a dis-
  turbance in the action of the nerves, from an obstruction in
  the respiration and circulation ; from physical and psychical
  excitement; from a local, mechanical stimulation of the
  nerves; from neuralgia, a lesion  of the nervus  ischiadicus;
  from  stimulations of branches  of  the nerv.  trigeminus;
  from occipital neuralgia, trauma, concussion of  the brain, a
  luxation of the cervical  vertebrae  ; from blows on the dorsal
  vertebrae; from ear-ache, head-ache, &c.—The secretion of
  sugar : a  symptom—Ebstein's  view—The   duration  of
  glycosuria  ............................................................   20

                             IV.

   The Characteristic  Features of  Diabetes Mellitus.
Definition—A lasting secretion  of grape-sugar through the
  kidneys—The distinction  between diabetes mellitus  and
  alimentary glycosuria—Inheritance of diabetes mellitus—Its
  serological element:  lues—Is diabetes contagious?—The
  views of Rollo, Bouchardat, Seegen, &c.—The formation of
  sugar in  the liver, according to  Claude Bernard, a normal
  function  of the body ;  according to  Pavy, a  post-mortal
  process;  according to v. Pettenkofer and  v. Voit, the result
  of a too scanty reception of oxygen—The Author's view—
  Equilibrium in  the  change  of  substance—A  cardinal
  symptom of diabetes :  an increase in the  decomposition  of
  albumen—Hoffmann's view of diabetes—Neurogenous  dia-
  betes—A definition of  diabetes,  of  universal application__
  The diabetes of fat persons—Erroneous definitions—Gath-
  gens' experiments, showing the effect of the diet of diabetic
  patients on healthy persons—Ebstein's  view of hepatic  and
  muscular diabetes..............................                  o. 
Table  of  Contents.
                              V.
           Classification  of Diabetes Mellitus.

Ettmiiller's diabetes  verus—The diabetes Aretaei—Diabetes
  hystericus,  artificialis,  a  vino,  arthriticus,  febricosus —
  Cullen's and  P. Frank's  classifications—Diabetes mellitus
  and  insipidus—Diabetes  decipiens —Diabetes  inositus—
  Brain-diabetes,  liver  and  stomach  diabetes—Griesinger's
  transient and chronic diabetes—Redard's  ephemeral  and
  severe  glycosuria—Senator's  neurogenous,  gastro-entero-
  genous, and hepatogenous  diabetes—Lecorche's idiopathic
  diabetes—Seegen's  classification—Traube's  stages—Hoff-
  mann's post-mortem examinations—Zimmer's hepatogenous,
  muscular,  and  mixed  diabetes—Spuriousness of certain
  classifications—The  Author's  protest  against  the same—
  Frerichs'  classification—Other   standpoints—Oxy-butyric
  acid, the final result of the decomposition of sugar:—Ebstein's
  distinction  between alimentary  glycosuria  and  diabetes
  mellitus—Spurious or light, and genuine or severe diabetes,
  i.e., glycosuria and diabetes mellitus  ...........................

                              VI.
           The Etiology of  Diabetes Mellitus.
Frerichs'  view—Cures of real diabetes effected by the Author
  —Is trauma a cause of diabetes ?—False inferences with
  respect  to   the inheritance  of diabetes from diabetes—
  Seegen's demonstration of  14 per cent, of diabetic patients,
  by whom that disease was inherited—Similar proofs offered
  by Schmitz and others—Apoplexy, the result  of hereditary
  lues—Ebstein's declaration  with regard to an  individual pre-
  disposition for diabetes by inheritance  ......................

                             VII.

              Diagnosis of  Diabetes Mellitus.
The character of the urine—The test by tasting—Spots left
  on white linen  by   diabetic  urine—Moore's sugar-test—
  Trommer's  test—Bottcher's,  Nielander's,  and   Seegen's
  su°-ar-tests—Demonstrations of minimal quantities of sugar
  __The  sugar-tests of Fehling, Worm-Muller, and Rosenbach 
xii                  Table of Contents.
                                                         PAGE
  —Stiitz's  reagent capsules for  albumen  and  sugar—The
  test of fermentation—The test of polarization—Additional
  methods for determining  sugar—Increased secretion  of
  sugar—Increase  of  urea by  an  excessive consumption of
  meat—Phosphates and sulphates—Creatinine, inosite—Con-
  cerning sediments—Polyuria—Catarrhal nephritis, coupled
  with a copious secretion of albumen—Diabetes decipiens—
  Contingent  causes in the production of acute diabetes—
  Diseases  resulting  from  diabetes—Abnormal  thirst  and
  hunger—Pulse and stool—Scanty secretion of saliva—Fungi
  in the cavity of  the mouth—Loosening of the teeth—The
  tongue  and  its  appearance—Characteristic  odour of  the
  breath—Condition of the skin—Sluggishness in the activity
  of the skin—The Author's method of examining  a patient
  —Outward marks—Fits of ill-humour—Loss of memory—
  Convulsive movements in the muscles—Sciatica—Decrease
  in the power of  vision—Impotence—Additional symptoms
  —Rheumatism in the joints and  muscles—A wetting  of the
  bed with children—A wasting of babes—Loss in the power
  of reproduction and assimilation .................................   70

                           VIII.
The Progression,  Prognosis, Complications,  and  Ter-
                   mination of Diabetes.
The view of the profession hitherto, with respect to the incura-
  bility of diabetes—Seegen's  experience—Prognosis,  dura-
  tion,  and progression  of diabetes—Apparent standstill of
  the disease—Coma diabeticum—Cause of the same—The
  material  gathered  from  experience  by   Frerichs—The
  Author's  view of coma diabeticum—Fruitless attempts to
  prevent the  same—The connection of diabetes with diseases
   of  the central  nervous system; with epilepsy, gout,  and
  rheumatism—Curability of these diseases  .....................   04

                             IX.
The So-called Cures  of Diabetes  that have  hitherto
                  been  made  are Illusions.
Accidental  glycosuria is  curable—Mistaking glycosuria  for
   diabetes—Did Frerichs cure genuine diabetes ?—Senator's 
Table of  Contents.
   opinion with regard to the curableness of diabetes—Seegen's
   opinion on the same subject—The usual termination of the
   illness—The Author's thesis : Diabetes is curable ............

                              X.
   The Occurrence of Diabetes ;   Mortality, and the
          Results  of Post-mortem  Examinations.
 The  possibility of  a  climatic influence—At  what age is
   diabetes most frequent ?—Statistics—Frequency of diabetes
   among the Jews—The results of post-mortem  examinations
   —The pathological  changes—Changes  produced in  the
   organs  ...............................................................

                              XI.
           Treatment of Diabetes (Therapeutics).
 Progress in the art of healing—Secret of a rational method of
   healing—A change of substance  in agreement with nature
   —The  system  of organs engaged in bringing about  the
   change  of substance—The  processes   of  transformation
   through which the material  operated upon by the change of
   substance   passes—The procedure of  digestion—Import-
   ance of a  proper commingling of the  ingredients of  the
   blood, and  a normal formation of  protoplasm—Inferences
   drawn for therapeutics—Therapeutical views of Rollo, Prout,
   v. Tralles,  Ebstein—Therapeutics  of the  Author: mental
   diet, avoiding mental excitement—Bodily diet: movement,
   muscular  action—The  views  of Kulz,  Xasse,  Ebstein,
   v. Mering,  and Oppenheim—Care of the skin—Turkish and
   Russian baths according to   the Author's prescription—No
   baths  in  bath-tubs — Drawing deep  t>reath — Pneumatic
   apparatus — Vocke's  experience — Dwelling-rooms—Tem-
   perature—Massage—Electro-magnetism—Food and assimi-
   lation—Rollo's diet—The diet of  Bouchanlat, Dickinson,
   Pavy,   Cantani,  Seegen, v.  During—Senator's   diet—v.
   Frerichs' regimen—Ebstein's menu.
Conclusions  drawn  from  all  the   dietetic instructions  of
   acknotvhdged authorities and experienced practitioners:—■
Articles of food allowed—Forbidden  articles—Bread and  its
   substitutes—Milk—Arguments in favour of, and against, the 
xiv                  Table of Contents.
                                                          PAGF
  use  of  milk—The Authors dietetic  regimen for  diabetic
  patients—Freedom, with discretion, in the choice of articles
  of food—Eating  slowly and  masticating  the food well—
  Nourishment-cure, in lieu of  abstinence-cure—A change in
  the  bodily  constitution—Regeneration of  the organism—
  Articles of  food and beverages to be avoided—Medicines for
  combatting diabetes—Specifics—Strengthening remedies—
  Carlsbad's hot alkaline springs—Paquelin—A  summary  ...  115

                            XII.
  A Few Striking and Significant Accounts  of Cases
             of Diabetes from the Year 1881.
The first twelve cases of diabetes  cured, from among a  great
  number of  cases treated by the Author  ........................  164

                           XIII.
  Corollaries in Support of  the Thesis  of  the Present
                           Work.
The object of  the Author in presenting the  first twelve  cases
  of cure, from the year 1881—Proof of the Author's theses :
  1. Diabetes is the result of a hereditary predisposition;
  2. Diabetes is curable  .............................................  181

                            XIV.
Contributions to the History and Literature of Diabetes.
Celsus' first allusions to diabetes—Aretaeus' views—His thera-
  peutics—Galenus' deriving diabetes from a diseased state of
  the kidneys—Paracelsus' idea of an increased formation of
  salt— Cardano's measurements—Sylvius' derivation  of dia-
  betes from a  faulty  condition of the blood—Mead's sup-
  position of an abnormal preparation of bile—Willis discovers
  sugar  in  the urine—Later  demonstrations  of sugar  by
  Dobson, Poole, and Cowley—Howe demonstrates  the fer-
  mentation of diabetic  urine—Rollo's animal  diet__Nicolas
  and  Gueudeville consider diabetes a disease of the bowels—
  Ambrosiani proves the existence of sugar in the blood__
  Bouchardat supposes diabetes to be a disease of the stomach
  —Mialhe declares the seat of the disease to be in the blood
  —Artificially produced glycosuria by Claude Bernard—The 
Table of Contents.
xv
  sugar-puncture—Lehman's experiments—Pavy  considers
  the formation of sugar a post-mortal process—Schiff recom-
  mends  amylaceous  food—Claude Bernard's  school—His
  opponents—Voit's and Pettenkofer's  idea  that diabetes  is
  caused  by  a too  scanty  reception  of  oxygen—Cantani
  defines  diabetes  as a disease of the change of  substance—
  Ebstein demonstrates an insufficiency in the production of
  carbonic acid—Alphabetic enumeration of all authors who
  have written on diabetes.
A wish expressed to professional journals, professional libraries,
  and medical societies—Necessity  of  collecting the whole
  literary material concerning  diabetes—Necessity  for ex-
  hausting statistics—Importance  of an agreement in the
  dates concerning the disease—Importance of supplementing
  the experience  of   individual  practitioners—Observations
  ought to be made before and after the daily meals ............  183 
 
DIABETES.
                        i.

    SUGAR  IN THE  HUMAN  ORGANISM.
According to the  reliable investigations of  C.
Schmidt,  Bock,  Figuier,  Bohm,  Hoffmann  (who
experimented on cats, see "Archiv fur experimen-
telle Pathologie," 8), sugar occurs constantly, and,
indeed, from  o'i2 to  C33 per cent., and, according
to Pavy, even to 0-53 per cent, in the blood of every
normal, healthy person.  Further,  in  the general
nutritive fluid ; in the  glandular  substance  of  the
liver; in the  interfibrillary, so-called cement,  sub-
stance of the muscles ; in the cerebro-spinal liquid,
etc.   The chemical antecedent  of this  sugar is the
so-called glycogen, orglycogene, which, in a healthy
condition of the living human body, is stored up to a
considerable amount,  from 2*0 to  10*9 per cent., in
the liver; in a less degree, from  o*i  to 0*4per cent.
(as has been  observed first  by  W.  Kuhne), in the
muscles.  Further,  in the cartilage, in the white
blood-corpuscles, in the stratified  epithelia, in new
formations, etc. (see also Ziemssen's " Handbuch der
speciellen Pathologie  und Therapie," Leipzig, 1876 ;
xiii., 2, p. 187).
                                         B 
2
Diabetes.
   Amylum or starch, by the action  of  the  saliva, is
 first  altered  into  sugar;  the  sugar is  afterwards
 changed  into alcohol, alcohol into  acetic acid, and
 acetic acid  into  carbonic  acid ;  so  that  carbonic
 acid must be regarded as the final product of sugar.
 Whenever  the  production  of carbonic   acid  is
 diminished  or interfered  with,  the  sugar which  is
 very rapidly and in excess formed in the blood, is no
 longer subservient to the generation of heat in  the
 body ; for it is no  longer burnt  up, and ministers no
 longer to respiration ;  but  it  circulates in the blood
 as  a heterogeneous  substance, and is excreted by
 the kidneys.   Such is the  case in that condition of
 the body  which, in the following pages, is denomi-
 nated glycosuria.   On  account of  its  great diffusi-
 bility, the sugar rapidly passes through the capillaries
 of the blood-vessels, whence there  arises a possi-
 bility of its getting into the liver through  the vena
portce.  A portion of  the sugar is there changed into
 the above-mentioned  glycogen ; that is, into amylum
jecoris  (hepatine  or  amyloid substance), a kind  of
 starch, which is soluble in  hot water, and which, by
 being treated with iodine, assumes not a  blue, but a
 brown colour.  From the liver the sugar passes into
 the general circulation,  where  it combines with the
 white blood-corpuscles.   In the organs themselves
 this sugar is partly made use of in  the formation of
 glycogen; but through the action  of the serum  in
 the blood this glycogen is  partly changed back into
 sugar.
   Only this  latter sugar  which has been  obtained 
           Sugar in the Human Organism.         3
from glycogen can by combustion produce carbonic
 acid, and is thus able to generate heat.
   The blood-sugar which  has been diffused over all
 the organs is partly changed into glycogen through
 those processes, by  which  the tissues of  the body
 are renovated.  The liver, just like the muscles, is  a
 receptacle of the glycogen that  has been formed in
 it out of sugar and plasma.  This glycogen, through
 the action of the blood-serum,  is altered again into
 sugar,  in order finally  by  combustion  to  produce
 carbonic acid.
   If the  formation of glycogen is  interfered with,
 the sugar from the -vena portce, according to Luch-
 singer and Frerichs, passes directly into the general
 circulation without being changed first into glycogen.
 The  blood then becomes  flooded with  sugar,  and
 there arises glycosuria, or hyperglykcemia.
   For a long time the stomach, and respectively the
 process of digestion,  has  been looked upon as the
 principal  source of  sugar; and,  indeed,  for  this
 reason, that when a person lives on a vegetable diet
 the stomach changes the starch  of the food into
 sugar (that is,  into dextrose,  dextrine, lactic acid,
 laevulose  or fruit-sugar), for the use of the circulation
 of the blood (see Pfliiger's" Archiv," etc., for 1877).
   More  recently the liver,  according  to Claude
 Bernard,  has been  regarded as the principal source
 of sugar.   The function of  the  liver,  so far as  its
 power of  forming sugar  is concerned,  is, indeed,
 placed beyond doubt at the present  day.
   Claude Bernard found  that the venous  blood of 
4                    Diabetes.
the liver abounded in sugar, and simultaneously with
Hensen (1857), although independently of him, he
instituted  investigations in  order to find out whether
the sugar  is originally contained  in  the liver itself.
For this purpose he removed  from a living  frog a
piece of liver,  minced it quickly,  and in order to
prevent any possible decomposition  he put it into
boiling water.   He then  ground up the piece of liver
in a mortar, and made a decoction of it with a  small
quantity of acidulated water.  The filtrate  of this
substance he  treated with five  or  six  times the
quantity of alcohol, whence resulted a white precipi-
tate—a substance  akin  to  starch or amylum, and
which, just like starch,  possesses the property of
being turned into sugar by the action of the diastatic
ferments  contained  in all  blood.   The  above sub-
stance Claude Bernard called glycogen.
   Pavy describes glycogen as an "amyloid sub-
stance," Tscherinoff as  glycophthirium, Cantani as
storage sugar.  The latter  gentleman thinks that the
grape-sugar (glucose) formed by the ferment circu-
lates through the system in company with this storage
sugar.  This sugar, which  is destitute of  ferment,
he says, is altogether indifferent and void of action;
wherefore it is  not used up, but  is excreted at last
with  the  urine.  It used  to be  supposed  that the
substances entering into the composition of glycogen
—that is  hydrates  of carbon, namely,  grape-sugar,
cane-sugar, laevulose, inuline, sugar of milk, galactose,
etc.—are  turned into glycogen directly, by the recep-
tion of water, by division,  by synthesis, or any other 
           Sugar in the  Human Organism.         5
 complicated unknown chemical process (see Bunyus'
 and Schmiedeberg's " Nachweise").
   The property of forming glycogen possessed  by
 the liver is inherent in the normal function  of  the
 liver-cells.   It seems  exceedingly  plausible that,
 while  departing from these  cells, the  glycogen is
 constantly  being changed into sugar in the  venous
 blood of the liver.  A  ferment  is required for this
 purpose, namely, the so-called diastase—a substance
 generated,  e.g., out of the albuminous ingredients
 (vegetable  fi brine)  of  grains  of corn  when they
 germinate.   This  substance, which belongs  to  the
 albuminates, is  difficult to isolate.   It  is soluble in
 water, and possesses the property of changing starch
 into dextrine and grape-sugar.
   Claude Bernard already demonstrated how dias-
 tase— the  ferment which  is  productive  of sugar—
 originates  from albuminous bodies, but  he did  not
 succeed in isolating it.   J. Wortmann  only (" Zeit-
 schrift fur Physiol. Chemie,"  1882, p. 287)  was able
 actually to isolate the diastatic  ferments coming
 from bacteria, by which raw, undissolved, as well as
 dissolved,  starch,  and  likewise  boiled  starch, are
 changed into glucose.
   A pure ferment may be obtained, and thus may be
 isolated ;  or, more  precisely, a solution of it may be
obtained, by crushing newly germinated  barley, stir-
ring it up with  water, and pressing out  the  liquid.
This liquid is afterwards heated to 750 C. in order to
separate the albumen from it.  Alcohol throws down
from this liquid the diastase  in the form of a  flaky, 
6
Diabetes.
colourless precipitate, which by and by thickens and
dries up into a kind of gum-like mass.  It scarcely re-
quires to be noted here that the employment of barley
in the  production of beer is due  altogether to the
formation of diastase and  to its action, as a ferment,
upon the starch of the barley.
  According to Claude Bernard, the processes which
take place in the liver are  to be explained thus :  that
the substances producing  glycogen by the action of
a ferment are changed in  the  cells of  the liver  into
glycogen, and that, through the reciprocal action of
the  blood by which these cells  are  bathed,  the
glycogen  is altered into grape-sugar.
  Pavy assumed  a negative  position in respect to
the new  theory of  Claude Bernard,  so  far as the
sugar-forming function  of  the  liver is  concerned.
He maintains that the ferment of the liver-sugar is
contained in  the blood, and he calls  the formation
of sugar a post-mortal process.   He  also supposes
that the  glycogen  of  the liver serves a different
purpose, and is utilized, perhaps, in the formation of
fat.  On  p. 64 of his " Croonian Lecture,"  (London,
1878), he certainly expresses  a  different  opinion,
and thus  contradicts his former idea.
   Because  most  albuminates  are  altered  in the
stomach  into peptones, peptone  also has been re-
garded by some as a source of sugar.
   The former Carlsbad physician, Dr. Zimmer,  in
contradiction to  Claude Bernard  and to  those who
believe that  the liver is the sole source of diabetes,
agrees with Nasse, who holds that the glycogen of 
          Sugar in the  Human  Organism.         7
the liver is also consumed by muscular  action (see
Pfliiger's  " Archiv,"  etc., xxiv., 41, and " Biologi-
sches Centralblatt," 1884, iii., p. 251).  For Zimmer
is of the opinion that the muscles, too, have a share
in  the  production  of diabetes, both as  regards the
supply of sugar and its decomposition.   This view
was set forth already by Briicke (see " Vorlesungen
iiber Physiologie,"  second edition, Vienna,  1875, p.
323), who quotes  Sigmund Weiss,  according to
whom the glycogen of the muscles is not subject to
any considerable fluctuations, while the glycogen of
the liver is used up completely as soon as the food of
animals is deprived  of its  supply  of  hydrates of
carbon.   (The literature on  the above subject  has
been   collected by  Barfurth  in the " Archiv  fur
Mikroskopische Anatomie,"  Vol. xxv., p. 397.)
   The muscle, when at rest, stores up glycogen in
its  tissue  in order to change  it into sugar when in a
state of activity.    This sugar in a healthy organism
is  assimilated  totally,  but in  a diseased  organism
only partially.  If this  process of combustion by
muscular  action does  not take place,  and  if the
liver is no longer  able to store up the  glycogen
which is constantly being conveyed into  it, the con-
sequence is that, after the consumption of amylaceous
substances, that is, of  food  containing starch, such
as bread, potatoes,  etc., the blood is surcharged with
sugar,  and sugar passes into  the urine.
  According  to Kills,  sugar  is  beginning  to  be
excreted by a diabetic patient within  half-an-hour to
an  hour after he has partaken of bread ; within two 
8                    Diabetes.
or three hours the excretion of sugar reaches  its
climax,  and in five  to  six  hours it ceases.  Kills
found that when a patient partakes of bread, sugar
is rapidly  being formed  in the intestinal canal by a
ferment which is generated there ; that it  speedily
reaches the liver, which is unable to retain it, whence
it passes into  the  circulation, so that  it is  possible
for  urine free from sugar to become  charged with it
after  the  lapse  of half-an-hour.  According to  v.
Mering, the sugar in the ductus thoracicus does not
come from the liver, but arises  from  the saccharine
contents of the lymph.   This, theory, however, does
not exclude the idea that the liver is a storehouse of
sugar.
  Ebstein, on the one hand, considers it possible
that the sugar which  has passed from the intestinal
canal into the vena portae should be excreted by the
urine, and, on the  other  hand, he inclines  to  the
belief that considering  the  speedy alteration of  the
 sugar, in  consequence  of  a disturbance in the  for-
 mation of  carbonic  acid,  the excretion  of sugar
through the  urine ought  to  begin  with  a diabetic
 patient already half-an-hour after he has partaken of
 bread.
   When a diabetic patient  was fed with cane-sugar
 Weiss  found  2,369  times more sugar than  he did
 when he  was nourished with fibrine and  fat, while,
 on the other  hand, the quantity of glycogen in the
 musculus-pectoralis increased much more by a  diet
 of  fibrine (see experiment 3)  than it did by a diet of
 food rich in hydrates of carbon.   On the strength of 
         Sugar in  the Human Organism.        9
this Zimmer supposes that the muscles,  by them-
selves, produce sugar  from albuminates in a large
quantity, that they secrete it from the albuminates
and store it up in the form of glycogen, while the
liver is not able  to  do this.  Zimmer maintains that
the muscles from albuminates purvey to  the blood
six times more  sugar than the liver ;  wherefore he
holds that the source of the severer forms of diabetes
is to be sought for in the muscles.
   Meissner, Bitter, Seegen incline to Pavy's view,
since they  are unable  to  explain  the  alteration
caused  in  the  amylum of  the liver.
   Pavy, Dock,  Salomon,  Tscherinoff, Luchsinger,
Weiss (" Zur Statistik des Glykogens im Thierkor-
per," in " Sitzungsberichte  der  Wiener  Akademie
der Wiss.," Bd. 64) were unable to demonstrate the
genesis of sugar according to Claude's doctrine, as
this had been proved experimentally  by Ebstein.
My idea has always  been that  the  sugar  is the
product of a process of alteration which is constantly
going on,  during  life,  in  the cells  of  the living
body.
   The  only thing which the above gentlemen were
able to  demonstrate  was that when  a person  fasts
the  amount  of  sugar is diminished;  but that this
amount increases at the same rate in which  food is
purveyed to the body more  copiously,  no  matter
whether it contain  hydrates of carbon or albumen.
They were able to prove  only that  the purveyance
of sugar  to  the  blood  could  be  increased  also
 from the intestinal  canal  through the lacteals, or 
10                   Diabetes.
through the liver ;  further, from the muscles, and,
finally, from the milk-glands, by virtue of the sugar
of milk which is generated therein, and which from
thence passes into the blood.
  In respect to the origin of  the sugar in the blood,
as well  as  in  respect to its  purpose,  consumption,
and the use it serves, all inquirers—even those who
have  proceeded according to the strictly scientific
method—have dealt merely in guesses and hypothe-
ses.   By many who have laboured in this direction
it was thus supposed that the oxidation, that is, the
consumption,  does  not  take  place in the blood, but
in the tissues ;  consequently, that a priori  not the
alteration of  the substance  (Stoffumsats), but the
contents of the living cell are influenced by the oxygen
(see  Wolffberg in  " Zeitschrift fur Biologie," Vol.
xii.,  2, p. 290).
   Ebstein's experiments about  the origin and con-
sumption of   sugar  (see  his work entitled, " Die
Zuckerharnruhr"  or Diabetes,  1887),  on account
of the  final  settlement by  his experiments of the
pathogeny of  Diabetes mellitus, are deserving  of
the  greatest  praise.   They  command  the  highest
theoretical and  practical interest of  the profession,
and  when  these experiments are verified—which 1
believe they are already—they cannot fail to influence
largely the therapeutics  of  the future.  By these
experiments the process is demonstrated according
to which  the sugar  is  formed.   They teach  us
further that sugar is formed in a larger quantity after
death than during life ; which  fact, however, does 
          Sugar  in the Human  Organism.       11
not by any means invalidate the fact of the formation
of sugar in the liver during lifetime.
  The ground of the abnormal formation of sugar in
diabetic  patients, according  to this  inquirer, is  a
relatively  insufficient formation of  carbonic acid
in  the  tissues, which subject  will  be  treated  at
greater length below.
  Ebstein demonstrated  ad  oculos  the influence
exerted  by weak acids,  especially  carbonic  acid,
upon the sugar-forming  ferments which are con-
tained chiefly in  the tissues, organs, and secretions
of  certain glands in the animal organism.
   For this purpose  he employed the  method  of v.
 Wittich, according  to which the respective organs
or  tissues are first  minced  most minutely;  after-
wards they  are  digested  for 24 hours in  alcohol ;
 then they  are  dried in  the  air and ground in  a
 mortar.   The  pulverized  mass which is obtained by
 this means is then sifted  through gauze  in order to
 keep back  the  connective  tissue;  and the  mass
itself is afterwards digested with glycerine, etc.
   In the course  of  his experiments Ebstein showed
 that carbonic acid exerts a neutralizing influence on
 the action  of the sugar-forming secretions of  the
 glands, and  upon the diastatic  ferments which  are
 generated from the  organs and tissues of the animal
 organism.  Ebstein's investigations,  consequently,
 have definitely disclosed the secret of that  process,
 according to which sugar is formed in the organism.
   At the outset  we have  to start with the  proposi-
 tion that  the diastatic or  sugar-forming  ferments 
12                   Diabetes.
are  diffused  largely  through  the  entire  animal
organism.
   By placing minced portions of organs in floating
amylum, Lepine  proved the  presence  of  diastatic
ferments (see " Bericht iiber die Verhandlungen der
K.  Sachsischen Gesellschaft  d. Wiss. zu  Leipzig,"
Vol. xxii.,  1870,  p.  324).   This  inquirer,  by that
means,   demonstrated the  existence of  diastatic
ferments in the blood,  the mucous membrane of the
stomach and intestines,  the liver, gall,  kidneys, the
mucous membrane of the bladder, the brain, muscles,
etc.   Tiegl and  P.  Ploss  in like manner  (see
" Pfluger's  Archiv,"   etc.,  vii.)  discovered  these
ferments  in  the  blood, as  well  as in all  animal
organs  and tissues, etc.
   Now, inasmuch as the diastatic ferments are most
widely  diffused  in  the organs  and  tissues  of  the
living animal body, and  inasmuch as carbonic acid
also is  produced everywhere  in these  organs  and
tissues, according to Ebstein, it may also be taken
for  granted  that wherever glycogen occurs in the
living organism it  is under the influence of sugar-
forming ferments,  the action  of which  is  regulated
 by carbonic acid.   The production of carbonic acid,
however, is  at an end when the change of substance
(Stoffwechsel) and the circulation of  the blood in the
liver cease.   At the same time also  the influence of
the carbonic acid upon the protoplasm of the tissue
of the liver  ceases.  The action of the sugar-forming
ferment is  henceforth no  longer  regulated  by the
 carbonic acid;  the glycogen of the liver, conse- 
          Sugar in the Human  Organism.        13
quently,  is deprived of the protecting influence of
this acid, and there is  no longer anything to prevent
its being turned into  more simply  constituted and
more easily  diffused hydrates of carbon,  such as
grape-sugar,  etc.
  Ebstein proves that  wherever there is a sufficient
quantity  of  diastatic  ferments, but an insufficient
development of carbonic acid,  whereby  the action
of these  ferments is checked, the  glycogen which
exists in the  tissues  of the organs  is more quickly
and  more abundantly turned into  easily  diffusible
hydrates  of  carbon, -especially  into sugar, than  is
the case in a normally constituted body.
  The  forty-two   experimental  investigations  of
Ebstein  {Op. citat., pp. 20-92), which bear witness
of his untiring industry, are full of interest, and not
even his opponents will seek to detract from their im-
portance.  Their object is (1)  to explain the influence
exerted upon the sugar-forming ferments by diluted
acids, especially  carbonic  acid,  and further  by a
shaking movement  compared with  a state of  rest ;
(2) to demonstrate the effect of the above-mentioned
acids, and also of a shaking movement upon the secre-
tions of the  glands  wherein are contained diastatic
ferments ; and (3) to  show how a freshly-made pulp
of liver behaves  under the influence of  the various
above-mentioned contingent circumstances.
   From  his experiments Ebstein draws the conclu-
sion (pp. 108-115) that the carbonic acid checks the
action  of the  diastatic  ferments, by which the  less
diffusible, more composite hydrates of  carbon are 
14                   Diabetes.
altered  into more easily diffusible and  more simply
constituted  hydrates  of  carbon.   He then answers
the  following  cardinal  question, namely:  What
physiological  and pathological phenomena of life
may be explained by the checking influence which
is exerted  by the carbonic  acid upon  the  diastatic
ferments ?
  The swift alteration of glycogen in a liver taken
from a living animal he explains thus:—As soon as
the change of substance (Stoffwechsel),  as well as
the circulation of the blood, cease in the liver, there
is an end also to the generation in  it of carbonic
acid.   As soon  as the regulating influence of the
carbonic acid upon the diastatic ferment of the liver
ceases,  the glycogen of the  liver can  be  easily
altered into sugar.
  Through the  influence of the carbonic acid the
action  of the  diastatic  ferments  is  checked  and
paralyzed.   So long  as  the carbonic acid exerts its
regulating, restraining   influence,   there  does  not
ensue  any superabundant,  excessive  formation of
sugar—no over-production.  The  body  is in a state
of health.
  v. Wittich quotes Woroschiloff's statement, accord-
ing to which glycogen, the chief emporiums of which
are  situated in the liver and  in the  muscles, is an
invariable constituent of all animal tissues, subject
to continual fluctuations,  and conditioned or qualified
by the  energy of  the  chemical  change of  substance
(Stoffwechsel).
  Pfliiger  ("Archiv,"  ii.,  1869, No.  129)   and 
          Sugar in the Human  Organism.       15
Bogdljubow bear witness to the abundance of car-
bonic acid in the liver, whereby the possibility of its
action, as pointed out by Ebstein, is confirmed.
   Thus far the practitioner had to content himself
with  the supposition that  sugar,  which  must be
regarded  as the  product of a  chemical alteration
more or less independent of  the  food of the body—
which product is possibly made use of in the forma-
tion of fat by  that  process of metamorphosis or
chemical change which is constantly going on in the
cells  that are bathed by the current of the  animal
juices—serves the purposes of life in general, and is
utilized in the  economy of  the human body so long
as it does not exist in excess.
   Fortunately  the observations made  by Senator
(see  " Handbuch der Allgemeinen Ernahrungssto-
rungen,"  p. 213)  need  no  longer to  apply  at the
present day ; for this  author, who judges objectively,
says in a general way, " Everyone may suit himself,
whether he  considers  the one or the other hypothesis
as  more probable."   For every thinking physician,
since the time that Ebstein made his demonstrations,
is bound  to admit in the biological processes, and
especially in diabetes  mellitus, the action of carbonic
acid in  checking and regulating the ferments—and
not the action of those acids, e.g., lactic acid, which
are generated  in the  protoplasm of the tissues and
organs : for all the acids that might possibly be taken
into consideration  here are completely neutralized in
the tissues, while carbonic acid, on  the contrary,
is present in a  sufficient quantity, both in the form 
i6
Diabetes.
of a bicarbonate and also in a reabsorbed condition,
in order by its presence to exercise an effect.
   My view, based on experience, according to which
the aetiological tendency towards  diabetes is to be
sought for in a luetic (i.e., venereal) constitution by
inheritance,  acquires a scientific foundation through
Ebstein's demonstrations.  The  pathogenetic  con-
ception of diabetes henceforth has left the stage of
Claude Bernard, and has entered  into an altogether
new phase.
   It  becomes  plain, at  the same  time, why  the
curative method proposed by myself is able to effect
a lasting cure of diabetes, which fact borders on the
miraculous;  for my method, for  the first time, pur-
sues  a distinct aim,  whereby  the  protoplasm  is
renewed or regenerated. 
                        II.

            SUGAR IN  THE  URINE.

 (The Distinction between Glycosuria and Diabetes.)

 In the urine of a  healthy  person there  is no sugar.
 The secretion  of sugar by the urine, consequently, is
 not a physiological act.
   Although  Briicke, who has been controverted  by
 Wiederhold,  Leconte, and Friedlander, maintains
 that all normal urine does contain sugar, and although
 Worm-Muller  (in Pfliiger's "Archiv," etc., for 1884
 and 1885) declares that accidental, transitory glyco-
 suria is  caused also in healthy persons after they
 have partaken  in large  quantities of various kinds  of
 sugar, there  is, nevertheless, no  doubt that the secre-
 tion of sugar by the urine  is always a  pathological
 phenomenon, and not a normal  process of life.
   As soon as a higher  percentage of sugar than 0*3
per cent, is  formed  in  the  blood, the  urine at once
 secretes  sugar.  A morbid, pathological  condition  of
the body is indicated thereby.   This condition may
be  transitory,  as, for instance,   (1) in  the case  of
healthy  women during the  last  months  of their
pregnancy, as in the case  communicated by Benne-
witz in Hufeland's  "Journal"  (1865, 61, p.  114),
                                        C 
18                  Diabetes.
where a woman  from her fourth  pregnancy, during
each successive pregnancy, suffered from glycosuria
during the last months (thus regularly for six months),
and afterwards recovered ; or  (2)  during the period
when a suckling  babe is weaned;  or  (3)  when  the
breasts  begin to swell  at an  incipient mastitis, in
consequence  of the milk retreating into the system,
and  so  forth  (see  Blot  in " Gaz.  Hebdom.,"  1856,
No. 41 ;  also Lehmann  in his  " Lehrbuch der phys.
Chemie," i.,  p. 270; Kirsten  in " Monatsschr. fur
Geburtsk.," 1857 ;  Iwanoff  in " Beitrage zur Frage
uber die Glycosurie," etc., Dorpat, 1881 ; Abells in
the " Wiener med. Wochenschriften,"  1874, who dis-
covered sugar in the urine of twenty pregnant and of
twenty  suckling women ; Hempel in " Archiv fur
Gynakologie," hi., p. 312).
  The sugar  of milk which is  formed by the glands
of the  breast seems here to be  absorbed by  the
blood, to increase its percentage of sugar, and  pro-
duce glycosuria.
  Sugar also may appear transiently as the symptom
of a disease and disappear again.  This is an impor-
tant distinctive feature, for  such  is  never the case
with diabetes.  Vogel also (in " Handbuch fur spez.
Pathol,  u. Ther.,"  by Virchow, Vol. vi., Section 2),
as well as Pavy  ("On the Nature and Treatment of
Diabetes," London, 1869), declare that sugar some-
times appears in the urine  apart  from all the other
symptoms  of diabetes mellitus.
  This  transient  condition I  designate  as " acci-
dental, transient glycosuria  or mellituria," should it 
                Sugar in the  Urine.              in
even  not  disappear for several  months, as  in  the
case of the pregnant woman reported  by Bennewitz,
or  even  for  years, as  in  the  case  of  certain  fat
persons.
   But if the  secretion  of sugar by the inheritance of
a  morbid  constitution  assumes a  lasting form—on
which subject I shall treat at large below—if, there-
fore,  this  secretion is  a symptom of that terrible
bodily  condition which  results  in  organic  destruc-
tion, and  which no physician thus far has been able
to  heal,  I denominate  the constant,  " incurable"
glycosuria resulting thence  DIABETES.
   Glycosuria and  diabetes, which in outward appear-
ance  do not  differ much,  have thus  far very  often
been confounded,  even by the most exact inquirers,
but more especially by  the physicians residing at
Spas  and by practical  physicians generally ;  and
not unfrequently they  have been under the impres-
sion that  they had cured diabetes, while in reality
they had  only stopped  "glycosuria"  by removing
the causes through which this illness had been called
into existence. 
III.
    HOW  DOES GLYCOSURIA ARISE?

Accidental glycosuria may arise from a  great
number of causes—(a) from a change in  the  blood
and in the circulation ;  (b) from  an injury suffered
by certain portions of the nervous system  ; (c) from
disturbances of the digestion and certain other ill-
nesses ;  (d) from an obstruction in the action of
the nerves, from disturbances of the  respiration, etc.
  (a) Changes in the blood and in the circulation.—
Claude Bernard, Bumm, Sauvage, Willis,  etc., have
shown that an  excessive  use  of  alcohol  alone,
particularly in the stage of delirium  tremens, results
in glycosuria ; likewise  breathing for several  hours
an atmosphere charged  with oxide  of  carbon (ac-
cording to Bernard) ; further, an inhalation of chloro-
form,  etc.
  Experiments made on animals have resulted  in the
formation of sugar after the administration of poisons
or poisonous gases ; after poisoning with strychnine ;
after  injection of  nitrate  of amyl (see Hoffmann's
experiment  on dogs in  " Archiv  fur Anatomie  u.
Physiologie,"  1872) ;  after the  introduction  of  a
solution of one per cent, of carbonate, phosphate, or
sulphate of sodium  administered with  gum  arabic
(see Kuntzel,  " Beitrage  zur Lehre  von  der  Melli- 
           How Does Glycosuria Arise ?         21
turie,"  Berlin,  1872) ;   after  subcutaneous  injec-
tions of nitrate of benzole administered to rabbits,
and an introduction of the same substance into the
mouth of dogs (see Ewald, " Centralblatt f. d. med.
Wissensch.," 1875,  No.  52) ;  after  methylate  of
delphinine (Kiilz's and Beschop's experiment) ; after
doses of hydrate of chloral administered to dogs (see
Teltz, Ritter, Eckhard, etc.) ; after the injection  of
lactic acid  into  the  stomach  of  rabbits ;  after
poisoning  dogs  with  phosphorus;  after   the ad-
ministration   of  orthonitro-phenylpropriolic   acid
(Hoppe-Seyler's  experiment) ;  after  injection  of
ether and spirits of ammonia  into the portal system
(Dr.  Harley) ;  after swallowing  curare  (Bernard),
when, after  a lapse  of  20 minutes  already, sweat,
saliva, and  sugar were caused ; further, after  swal-
lowing  decomposed  prussic   acid,  concentrated
sulphuric acid,  and heavy doses of mercury  (Sel-
kowski's experiment) ; further, after the injection of
considerable doses  of  morphium (Bock and Hoff-
mann's " Experimentalstudien iiber Diabetes," 1874),
or of a solution of one  per  cent, of common salt
(see  Bock  and   Hoffmann,  " Ueber   eine   neue
Entstehung von Melliturie "  in  " Arch, fur Anat. u.
Physiologie," 1871) ;  again,  after an injection of a
solution of one  per cent,  of carbonate, acetate, and
succinate of  sodium (experiments  of  Kiilz; see
" Beitrage zur  Hydramie und  Melliturie "  in  Eck-
hardt's  "Beitrage,"  etc., Vol.  vi.,  1871) ;  finally,
more recently, after phloridzine (C2l H_H O10), which
exists  in the  bark  of  the  roots  of  apple  trees 
22
Diabetes.
and  cherry trees,  had  been  introduced  into  the
stomach of dogs or rabbits  by v. Mering, which re-
sulted  in the formation of  15 per cent,  of  sugar in
the urine.
   (b)  Injuries suffered by certain portions of the
nervous  system.—Sugar has  also been formed  in
animals after portions  of their nervous system had
been injured ; e.g., by puncture,  that is,  the so-
called  sugar-puncture  (piqure) made  by  C.  Bernard
into the fourth  ventricle at the extremity  of  the
calamus scriptorius, etc.  Sometimes polyuria only
arose ;  which  may  be caused also  by cutting the
two nervi  splanchnici,  as well  as by  stimulating the
great sympathetic nerve.
   Pavy  discovered  sugar  in the  urine  after  an
injury of the vertebral plexus of the great sympathetic
nerve,  as  well as  after injuring  or  removing the
cervical ganglion ; Schiff, after destroying the spinal
cord in front of, as well as behind, the origin of the
bronchial nerves ; Eckhardt found it in dogs in which
the hinder lobe of the  vermis, in the cerebellum, had
been injured.
   Schiff insists in his declaration that he had pointed
out the effect of an injury to the nervous centre before
Bernard,  and  he maintains  that Bernard's puncture
causes a kind of  paralytic hyperaemia of the bowels
and liver,  from  which  results a stagnation of the
blood  whereby the ferment which brings about the
formation of sugar is  developed.  A common effect
of perhaps the whole of the above experiments is  a
flooding of the  liver with blood.   That  such  an 
           How  Does Glycosuria Arise f        23
effect is produced by  Pavy's injection of blood is
beyond doubt; that curare and nitrate of amyl react
in a  similar manner may be likewise assumed with
certainty from their well-known physiological effects.
The direct  mechanical stimulations of the liver, as
well as the introduction  of  stimulating substances
into the vena portae or into the intestinal canal, may
result, or rather must result, likewise in a hyperaemia
of the liver.  Whether  an  injury of the nerves be
caused by stimulation or by paralysis, in either case
the enlargement of the vessels of the portal system
which  has  been  directly  observed,  after  divers
nerves had been cut,  may be explained.
  With respect  to the so-called  animal  diabetes,
experiments made upon animals are very instructive ;
still  in animals glycosuria only can be  caused, NOT
diabetes.  Their so-called diabetes ceases as soon as
the effect of the  injections has passed away.
  Kiilz and others have always observed in  animals
that had  been operated upon that, as  soon as  the
forcible interference  was stopped, their urine in a
short time became normal again.
  Zimmer's idea is  that in  animals  poisoned  by
arsenic,  antimony,   or  phosphorus,  mellituria  is
caused  by  an  incomplete  transformation  of  the
sugar in the muscles, and he opposes the proposition
that glycogen in  formed in the liver from the sugar
contained in the food. His opinion  is that the active
muscles, along the whole course of the general  cir-
culation, constitute those organs which are  able to
bring about  a transformation of the sugar of  the 
24                   Diabetes.
food speedily and in a considerable quantity, and are
thus able to destroy it at once. The consumption of
hydrates of carbon in the muscles, according to  him,
is very considerable, for while they are at rest  they
use up  their own  supply of glycogen, and, besides,
when exerted very much  they consume the entire
mass of glycogen  in the liver.
  According to Zimmer, every kind of glycosuria is
caused in the organs of motion.   I share his opinion
so  far as to maintain  that  by  the  action of  the
muscles  there is started  the change of substance
(Stoffwechsel) ; and, further, that the muscles burn up
the glycogen furnished  to them  by  the current of
blood, and that they secrete it through the organs of
secretion.   Zimmer thinks (see  his work on " Mus-
keldiabetes," p. 17) that  a diminished consumption
of  glycogen in the  muscles, together with a too
speedy  and  copious absorption  of sugar from the
intestinal  canal,  causes the lighter form  of diabetes;
yet this is a mistake, because in that case all healthy
persons also would  be exposed to this  same lighter
form of diabetes.   Yet on no account  can this be
demonstrated and established.
   (c) Disturbances  of the digestion, and certain
other illnesses.—Glycosuria  arises in cholera,  after
the secretion of the urine has  been  suppressed or
diminished ;  it also regularly follows albuminuria.
   Sugar generally attends anthrax,  until the an-
thrax is healed.   Marchal de Calvi (see  " Medical
Times," ii., 1854)  supposes erroneously that glyco-
suria is the  cause of anthrax, when yet the reverse is 
           How Does Glycosuria Arise ?         25
everywhere the case, for when the anthrax is healed
the accidental glycosuria  disappears.  The case  is
quite different when anthrax occurs in " diabetes,"
which is a connate, constitutional, inherited inclina-
tion to glycosuria.   Anthrax, then, according to my
own numerous observations, is actually a consequence
of the severer  form of  persistent glycosuria.  The
latter form of glycosuria  continues even  after the
anthrax has been healed, which is one  of the proofs
of the existence of genuine diabetes.   I  refer the
reader on this subject to Griesinger's observations in
his " Studien " (p.  358  et. seq.,  and p. 413), also to
Hertzka's  communication  in his  work entitled " Die
Zuckerharnruhr " (p. 102, etc., etc.).
   Frerichs  mentions a  case where glycosuria  was
developed  into diabetes by diphtheritis.  What  a
host  of  diabetic patients  there  would be if every
case of diphtheritis  were to lead  to  diabetes !   That
glycosuria which is incident upon  diphtheritis will
certainly  lead  to   diabetes  whenever diphtheritis
attacks a patient who by inheritance is predisposed
to diabetes.   Such  a case, however, is as rare,  or, if
you please, it occurs as  frequently, as diabetes  itself
occurs under  the same conditions.
   Glycosuria  in a  transient form, until the disease
which it attends has been healed, has  also  been
proved  in  typhoid  fever   (see  Seiffert's  report)  ;
further, in  meningitis  cerebro-spinalis  (Sherrit) ; in
scarlet fever (Zinn's report) ; in  measles  (Bordier) ;
in abdominal  dropsy ;  in the fever attending suppu-
ration after vaccination  (Prevost). 
 26                   Diabetes.
   In malaria, according  to  Verneuil  (" Bull,  de
 l'Academ.,"  1881), and according to Bourdel (1882),
 glycosuria (glycosurie palustre) is caused during  the
 fever-stage.  It has likewise repeatedly been demon-
 strated  in  catarrh  of  the stomach, especially in
 gouty subjects ; also in a closure of the vena portae ;
 in a  hardening of the pancreas ; in diseases of  the
 liver, etc.
   '(d) Obstruction in the  action  of the nerves, and
 disturbances of the respiration.—Glycosuria finally
 has  been caused by a disturbance of  the  action of
 the  nerves, as well as by disturbances of the respi-
 ration and circulation, whereby the  kidneys become
 congested, and sugar is transmitted from  the blood
 into the  urine.
   As sugar is liable to be formed in the urine by all
 kinds of physical and psychical excitements,  such
 as anger, wrath, bodily and mental overwork, sexual
 excesses, etc. (see "Arch. Gener.," 1862, ii., p. 265),
 it  is  even more  especially generated  by  all local,
 mechanical stimulations  of the nerves; by neuralgia
 and  injuries of the  sciatic nerve ; by stimulations of
 branches of the nervus  trigeminus (e.g.,  in dental
 operations) ;  further, after neuralgia of the occiput;
 after trauma ; after severe concussions of  the  brain
 (G. Fischer, in "Arch. Gen.,"  1862, reports seven-
 teen cases of injuries of the head accompanied  by
transient, accidental glycosuria) ; in injuries of the
brain ; and, finally, after  a sprain of the cervical
vertebrae ;  likewise after blows  inflicted on the dorsal
vertebrae.  In a few cases, also, glycosuria arose in 
           How  Does Glycosuria  Arise f         27
affections of  the ear;  from running ears, headache,
vertigo, sickness, fainting-fits, etc.
   Since all of the  above cases of glycosuria  have
been  caused  by forcible interferences with the health
of the subject, or arose in cases of illness; and since
they have occurred  only as symptoms and as the re-
sults of such  definite interferences and illnesses, there
applies to this particular, curable, and—as it may be
called—accidental form of glycosuria what has been
declared  erroneously of " diabetes " in the " Tran-
sactions  of the  Medical  Congress"  for  1886  (p.
177):—"This pathological condition  is  no  illness,
but a symptom, just  as  is the case with fever or
icterus.   The most  diverse aetiological causes are at
work  in producing it [i.e., glycosuria, as I suggest],
and the secretion of sugar is only to be regarded as
a symptom," etc.
   Wherever, indeed, there is no hereditary predispo-
sition, accidental glycosuria only, not diabetes, will
arise  from such merely accidental causes.  Glycosuria
becomes chronic,  or, according to  the prevailing
idea,  it becomes " incurable," and thus  manifests
itself as  " diabetes,"  only in persons who are  here-
ditarily predisposed for it.
   A.Vulpian (in " Lecons sur l'appareil vasomoteur,"
Paris, 1875) is decidedly wrong in making the follow-
ing  general  declaration  :—" Glycosuria  is  only a
symptom of that malady which is  known as diabetes,
a malady which physiology has thus far been unable
to produce.   Glycosuria, in  the  form in which we
have  just determined it, lasts for one, two, and some- 
 28                   Diabetes.
 times for five, six, seven, and even eight days ; after
 that time has elapsed it  disappears, and it  is not
 possible to prolong its duration."
   All those cases  of diabetes, therefore, where the
 patients otherwise feel well, and where, by the use of
 the  Carlsbad waters, or by  the  help of a rational
 physician, they are restored to health, I think ought
 to  be  classed under " glycosuria,"  and  not under
 " diabetes."
   Lasting  mellituria, which,  according  to Seegen
 (" Diab.  Mell.," 1878, p. 16), ought never  to  be
 made light of, is called "diabetes."
   Gathgens', Pettenkofer's, and Voit's  idea  is that
 whenever the sugar contained in the chyle or  lymph,
 in spite of the  burning  up  of albuminates, is not
 sufficiently destroyed, the secretion of carbonic acid
 is diminished, and sugar makes its appearance in the
 urine.
  The experiments of Ebstein confirm this.  Hyper-
 glykaemia, as a  consequence, is  avoided whenever
 the carbonic acid which is formed  in  the  tissues of
 the organism is sufficient to protect against a speedy
 transformation the glycogen, which, free from nitro-
 gen, is separated from the albuminates.
  Through this fundamental principle, which Ebstein
 discovered experimentally  (see Op. citat., p.  128 et
 seq.), this  inquirer was brought into  the immediate
 presence of the pathogenesy of glycosuria.   He is,
 therefore, quite justified in declaring  that essentially
this  malady consists  in an insufficient formation of
carbonic  acid in the tissues, the consequence  of 
           How Does Glycosuria  Arise ?         29
which is that the glycogen stored  up in the organism
is not protected against  the attacks of the diastatic
ferment to the same extent as it is in a normally con-
stituted organism.   The equilibrium between the for-
mation and the consumption of sugar in the tissues
is thereby  disturbed, wherefore  the  unconsumed
sugar, by virtue  of its great diffusibility, passes
into  the current  of the juices of the body, the  result
of which  is hyperglykaemia.
   A  SUMMING UP.—First of all Ebstein demonstrated
experimentally the  cause of glycosuria ; that  is, of
the excessive  formation  of sugar.  He teaches that
in a  healthy  condition  of the body  the  material
which is used up  in  the tissues,  and by which the
supply of carbonic  acid, necessary for regulation, is
kept up, is fully replaced by the food.  A sufficient
amount  of substances   containing  nitrogen  (i.e.,
albuminates),  and   also  of  substances  free  from
nitrogen  (i.e., hydrates  of carbon and  fats) which
are conveyed into the body by the food, is deposited
in the organs  and  tissues in  order  to  replace the
consumed material.   For a  time  this stored-up
material,  during an  insufficient supply of food,  is
able to act as a medium  capable of forming in the
tissues  the carbonic acid necessary  for the main-
tenance of life.  A decrease in weight at last  becomes
apparent; in which case only  an excessively  large
amount  of fuel is  able to  furnish  the  quantity
of  carbonic  acid  required  for  the continuance
of  life.   This  carbonic  acid  is  the  agent  by
which the diastatic  ferments  of  the organism are 
 30                   Diabetes.
 checked in their action.  If, therefore, the quantity
 of carbonic acid generated, compared with the avail-
 able amount of glycogen and  diastatic ferment, is
 too  small, its  protecting influence  will not  suffice.
 A greater amount of glycogen, therefore,  than is the
 case where there is a sufficient quantity of  carbonic
 acid, will then  be exposed to the vigorous action of
 the sugar-forming ferment,  and  be transformed into
 sugar.  This sugar, which  is formed in  the  tissues
 from glycogen, becomes diffused easily and quickly
 throughout the juices of the body—so far as it is not
 used up, that is, oxidized into carbonic acid in those
 parts of the body where it was originally formed.  In a
 normal  condition  of the body there is  evidently an
 equilibrium in  the tissues  between the formation
 and the consumption  of sugar.  The percentage of
 sugar in the blood in  healthy persons is  essentially
 the same at all times ; only occasionally, under well-
 defined conditions, there is  an increase in  the per-
 centage of sugar in the blood  of healthy  persons.
 The case  is altogether different  if the consumption
 of the sugar in  the tissues of the organism  is either
 too limited, or its formation too excessive.
  In either case there arises a  hyperglykaemia, the
 duration  of  which  corresponds  exactly  with  the
 duration of its cause.  Here, therefore, we have a
scientific  explanation  of the origin of  accidental
glycosuria. 
IV.
THE   CHARACTERISTIC  FEATURES  OF
            DIABETES MELLITUS.

As in the case of  accidental " glycosuria," so also
in the case of " diabetes " under certain well-defined
conditions, there exists a continued lasting secretion
of grape-sugar through the kidneys, which is mostly
combined with disturbances in the entire organism,
resulting, without any doubt whatsoever, in the death
of the  patient.  Such a complex of symptoms  is
defined by pathology as  diabetes mellitus.
   There is an essential  marked difference  between
diabetes and  simple  glycosuria or mellituria.   The
former  is connate,  inherited,  and  presents  itself as
a chronic disease, which has hitherto been supposed
to be incurable.  In this disease, as is also  the case
with  curable  glycosuria,  there is an  excessive  per-
centage of sugar in the blood, from 0*22 to  0*44 per
cent., and this sugar is not consumed in the system.
Glycosuria  is  transient;  diabetes  constitutional.
Glycosuria is  caused  transiently by all those hurtful
agencies which have been enumerated in the preced-
ing chapter;  but diabetes  is never caused in  that
way—that is,  provided a person is not hereditarily
predisposed for diabetes.   Herein  lies  the  great
mystery, never before  discovered by anyone, of the 
32                   Diabetes.
cause of " diabetes;"  and here, according  to  my
conviction, hereditary lues on the part of one of  the
parents,  grand-parents, or great-grand-parents of
the patient, has  to  be taken  into  consideration.
A transmission  of lues through vaccination also is
not excluded.
  The diabetic predisposition begins  to  show  itself
when the blood—as is the  case  also in glycosuria—
contains  such  a  percentage of sugar  as to  be
compelled  to excrete some portion  of  it into the
urine.
  During many years,  and even in ripe old age, a
person may be diabetic in a  latent  state without
knowing  it.   Only when there is a change wrought
in the production of carbonic acid, and when in con-
sequence  of it there is an excessive formation  of
sugar—an over-production;  only when under such
circumstances the percentage of sugar in  the  blood
increases, and nature is no longer able to consume
it, latent diabetes becomes active;  and then  within
a longer or shorter period through accidental causes,
but  mostly  through  the  coma  diabeticiun,   death
ensues.
   Diabetes, consequently—as already stated—is  not
a symptom like glycosuria, but  it  is a well-defined,
primary,  independent, chronic form of disease,  the
existence of which is based  on  a connate, false dis-
position,  or a  wrong  composition  of  the  proto-
plasm.   In its  active  stage  this disease produces
deeply-seated, serious,  complicated disturbances in
the change of substance  (Stoffwechsel), and  in  the 
          Characteristic Features of Diabetes.       33
 course of time  causes a consumption of the physi-
 cal as well as of the psychical forces.
   A characteristic feature of diabetes is its freedom
from fever.   Sometimes, even, it pursues its course
 attended by an abnormally low  temperature, while
 cases of accidental glycosuria are mostly attended
 by a transient fever.   Whenever, therefore, diabetes
 is accompanied by fever,  this fever is  caused by a
 second, adscititious  illness,  of  which  the  patient
 suffers at the same time.
   Again, diabetes is not  infectious or contagious.
 The  blood of diabetic patients  has been inoculated
 into animals without any injurious effects.
   From Rollo to Bouchardat the cause of diabetes
 was sought for  in gastro-intestinal  disturbances—in
 a faulty digestion, which cause could no longer  be
 upheld as our  knowledge  of  the digestive  organs
 increased.
   Bouchardat,  indeed, supposed  that  the  normal
 gastric juice stops the secretion of sugar, but that a
 ferment favourable to the  formation of  sugar arises
 from a diseased stomach.   McGregor  also  was of
 the  opinion that a  diseased  stomach furnishes the
 aetiological element of the disease, until CI. Bernard
 pointed out the  liver as the organ in which the sugar
 is formed.
   Basing himself on the effect  of  certain poisons,
 after the administration of which, as well as  after a
 division of the  great sympathetic nerve, the  blood-
 vessels  are  enlarged,  allowing  the blood to  pass
 through without  first becoming  arterialized,  the
                                          D 
34                  Diabetes.
vivisector Pavy believed that  diabetes was due to a
[paralytic] enlargement of the vessels in the liver.
  Seegen traced the cause of diabetes to a morbid
transformation of the glycogen of  the  liver—to  an
abnormal transformation of substance, which in most
cases arises from a disturbance  in the province of the
nerve-centres.  " There is no  mellituria," he  says,
" which is not injurious, even as there is no tubercu-
losis which is not dangerous"  (p. 18).   More than
one-third  of   Seegen's patients  also   suffered   of
adiposis.  He is of opinion that fatness predisposes
to diabetes, and he considered  adiposis a precursor
of the formation of sugar.
  Dickinson also supposed that diabetes arose from
a disturbance in the  functions of the liver, which
instead of glycogen  prepared  sugar  out of  albu-
minous food.   All changes and disturbances within
the  nervous  system,  according to him,  cause an
abnormal state of the  circulation.
  Zimmer searches for the cause of the disease not
only in the liver, but also  in the muscles, which  at
first sounds  strangely, since an increase of sugar  in
the blood through the action of the muscles can only
be imagined in connection with, and in  dependence
upon,  the liver.
  Claude Bernard maintains that a deeper  disturb-
ance lies  at the  bottom of  diabetes  than at  that  of
glycosuria and  glykaemia,  the  nature of  which
" deeper  disturbance" he  thinks  will continue  to
remain unknown  to us so  long as  that complex  of
physiological processes which we comprise under the 
         Characteristic Features of Diabetes.       35
terms  " assimilation " and " change of substance "
(Stoffwechsel)  is  not made  clear  to us in all  its
particulars by physiological investigations.
   CI. Bernard's view  called forth an entire school,
according  to which  the  formation of  sugar  is a
normal bodily function,  which idea is  contested  by
the  opposite view  of  Pavy,  Schiff, Ritter,  etc.,
according  to whom the above is not the case, but
the formation of sugar is  explained as a  post-mortal
process.
   Every inquirer  before and after the rise of  the
above  school started a theory of  his own.  Accord-
ing to  Lecorche (see " Consideration sur le diabete
sucre," in  " Gaz. hebdomad.," 1873) the  true nature
of  diabetes  consists in a non-assimilation of  the
proteinous substances, which  manifests itself by the
enormous daily secretion of urea.
   Vocke supposes that  the true  nature of diabetes
consists in a kind of paralytic infirmity interfering
with the   formation  of  glycogen in  the liver and
the oxidation of the blood-sugar, wherefore our first
and essential object should be to increase the activity
of the nerves.
   The  profession  began to be exercised  by the fact
that in the presence of the wealth of data furnished
by the rising sciences of experimental chemistry and
experimental physiology, which applied  themselves
by preference to  the  investigation of diabetes,  no
one has as yet been  able  to solve the riddle of this
" sphinx,"  as Frerichs calls it.
   V. Pettenkofer and v. Voit, in the case of diabetic 
36                   Diabetes.
patients, find  a more extensive transformation of
substance (Stoffumsatz)  than  in healthy  persons,
coupled  with  a  diminished  reception of  oxygen.
The cause of this greater consumption of  material,
and of the decrease in the reception of oxygen, they
declare,  is that  the tissues of  diabetic patients are
ready  to  decompose, as is proved by the  furuncu-
losis of  which  they  suffer; further,  by  the  spon-
taneous gangrene of the  extremities, the softening of
the lungs, the shrinking of the  pancreas, the loosen-
ing of  the teeth and caries of the same, the loss of
hair, etc.
   The real  cause of  all  the above symptoms which
are exhibited by diabetic patients, namely, the here-
ditary transmission of lues, they did not discover.
   In battling with diabetes, the primary thing that
has to be attacked is not the formation of sugar, but
the  faulty composition of the protoplasm, and its
inability to produce carbonic acid.
   The  postulate,  therefore,  of my  theory, which  I
have tested practically ever since 1881, is  the reno-
vation of the entire protoplasm of the  body.  In this
theory  I start with  the following  proposition laid
down  by v. Pettenkofer and v. Voit:—"An under-
standing of that alteration in the normal processes of
decomposition,  that  is,  of that disturbance in the
assimilation  which is caused  by diabetes,  can be
obtained only by a study of the general processes
carried  on  in  the body,  such  as respiration and
decomposition  generally, and not   by  a  minute
examination of  organs torn  from their context, that 
         Characteristic Features of Diabetes.       37
is, from the series which they form with other organs
of the body."
   The  method of cure followed  by myself  is based
on  a thorough  study of  those  general processes
which are constantly carried on in the organism.
My  aim is an improvement in,  and  a transforma-
tion of, the protoplasm.   My entire secret  consists
in restoring the  equilibrium—the  balance in the
"change  of  substance"  (in  dem  Stoffwechsel),
which was aimed at by v. Pettenkofer and v. Voit.
These gentlemen, indeed, have defined the essential
nature  of  diabetes  as consisting  in  a diminished
reception of oxygen  and an increased transformation
of substance  (Stoffumsatz), while  I consider these
physiological conditions as of secondary importance,
and  attack at once the  fundamental  cause  which
resides  in  the protoplasm.   The disturbance in the
assimilation of the food, which they, in conjunction
with Seegen (see Op. citat., p. 33), have assumed is
indeed  only a consequence  of  a  wrongly-formed
protoplasm, and of an insufficient formation of car-
bonic acid.   Hence the lowering of the temperature
in diabetic patients.
  A cardinal symptom of diabetes  which v. Petten-
kofer and v. Voit met with in all their investigations
is a decomposition  or a  resolution  of  the albumen  :
increased resolution  of albumen.
  Ebstein  also  assumes, from  the  pathogenetic
standpoint, that glycosuria and an increased decom-
position of albumen are brought about in the organs
and tissues of diabetic persons under a similar con- 
3 8                   Diabetes.
dition, namely, under the influence of  an insufficient
development of carbonic acid.
   Ebstein  proves experimentally the insufficient for-
mation  of  carbonic  acid ; but  he raises difficulties
against his theory,  which is based on a defective
production  of  carbonic acid, by  asserting that  a
diabetic patient possesses   a  greater  amount of
diastatic ferments than a healthy person.  The equili-
brium in such a case could be re-established only by
an increase in the formation  of  carbonic acid.   The
normal  quantity of  carbonic acid required  by  a
healthy person would thus be insufficient in the case
of a diabetic person.
   That portion of Ebstein's theory, however, is fully
proved  where he declares that an excessive forma-
tion of sugar ensues whenever the glycogen which is
stored up in the tissues, on account of  an insufficient
formation of  carbonic  acid,  is  not protected in a
normal  manner against  the influence of the diastatic
ferments  (which  are likewise  in the  tissues) ;  a
lasting disturbance in such a case being caused  in the
equilibrium  between the  formation  and the  con-
sumption of sugar, so that that portion of the sugar
which is not used up, by virtue of its great diffusi-
bility,  passes speedily  into  the  circulation of the
vital juices.   According to this theory the copious
transmission of sugar into the urine  is due  to an
insufficient formation of carbonic acid  in the tissues.
This  same  theory  also  requires  that a  diminished
production  of  carbonic acid, in  its  character as a
symptom of diabetes mellitus, must be regarded as a 
         Characteristic Features of Diabetes.       39
primary disturbance, while a decreased reception of
oxygen would be only ^secondary disturbance. By this
means light at last is thrown on  the lower tempera-
ture of the body which prevails with diabetic patients.
   By means of Ebstein's experiments we are able to
obtain the only rational explanation of the generation
of sugar in an organism where  diabetes has  been
fully developed.  Although  his  experiments do not
explain fully and exhaustively the pathogenesy of
this disease, they nevertheless became at once of the
greatest consequence as soon as it was shown by my
experience that those symptoms which he laid down
experimentally, are identical with the symptoms of
hereditary lues.
   I was somewhat surprised by Hoffmann's definition
of diabetes at  the Medical  Congress held at Wies-
baden in 1886, where—certainly in agreement with
inquirers of the stamp  of Landrieux  and Iscovesco
(see " Progres Medic. " of June 27th, 1885, No. 26),
who declared  that  glycosuria of  long standing is
" diabetes,"  while a short transient glycosuria ought
to be called an " abortive diabetes "—he said : " If a
boundary line is to be drawn between glycosuria and
diabetes, the decisive criterion can be furnished only
by a shorter or longer continuance  of  the  disease."
By way of disproval, we  need to refer here only to
the  diabetes   of  pregnant  women,  according  to
Bennewitz's  observations,  to which  reference has
been  made  above.   Hoffmann  continued:  "  It is
very  plain  that we  still  lack  some  fundamental
symptom to aid us in drawing a distinction." 
40                   Diabetes.
  Such a  fundamental symptom is hereditary lues,
which,  as  shall  be  proved  more at  large  below,
serves as an  organic  basis to diabetes.   W'herefore
I am justified in giving for the first time the  follow-
ing definition of diabetes, drawing a  sharp distinc-
tion between it and glycosuria :  Glycosuria must be
looked upon by therapeutics as sometliing accidental
or symptomatic ;  but diabetes as something essential,
as a  state of the human  organism  corrupted  by
inheritance ; as a predisposition, consequently, for a
constant,  destructive mellituria, combined with an
increased decomposition of albumen.
  It  is not  correct  to  maintain  that  alimentary
glycosuria, according to circumstances, may become
the cause of  diabetes ; certainly not of what I  under-
stand by diabetes.
  Glycosuria, when it lasts long, under unfavourable
circumstances may, no doubt, lead to consumption;
in like manner a large accumulation of glycogen,
just like diabetes, under peculiar circumstances, may
lead  to  acute  intoxication.   Nevertheless,  glyco-
suria is not  on that  account diabetes;  nor  does it
become identical with  this  disease, because  certain
practitioners  define glycosuria as a " neurogenous "
form of diabetes.   I  am  acquainted  with  only one
kind  of diabetes ; and this one kind of diabetes I
treat as a  hereditary,  connate disease.   Only thus
unity can  be  obtained in  our conception, and hence
unity as a basis to start from.
  I shall  direct  the  attention of  my  readers here
only to one fact, namely,  that the diabetes  of many 
          Characteristic Features of Diabetes.       41
 fat persons—according to Pfeiffer they constitute 33
per cent, of  all cases of diabetes—is frequently a
 merely accidental glycosuria caused by an excess of
 sugar, which  by the use of  the Carlsbad waters can
 certainly be diminished, nay, even healed.
   The author  of  a popular  treatise  on  diabetes,
 which has  recently appeared, is not on a par with
 the present  state of  medical  science,  where  he
 maintains that  the whole  of  the  sugar  originates
 from the blood; and where he declares, without any
 limitation whatever, that all those persons suffer from
 the sugar disease,  or are  " diabetic," whose urine
 has been proved to contain sugar.
   There  are  diabetic  persons who, to the end of
 their life, use  up all the sugar secreted ;  so that an
 excessive accumulation of sugar becomes noticeable
 only at a  certain time of rest, when the action of
 the muscles  ceases,  and when  the production of
 carbonic acid becomes deficient;  as, for instance, in
 cases of illness, such as cholera,  small-pox, typhoid
fever, scarlet  fever, syphilis,  gout,  a diseased state
of the pancreas and liver, or, again, after catching a
cold, or getting wet.   Diabetes  is  never caused by
any infectious  disease,  although  wherever  there
exists  a hereditary  predisposition  for diabetes any
disease may  become  the  occasion  of the develop-
ment of  this  hereditary   malady.   If  a  patient,
during the continuance of  active  diabetes, becomes
infected  by  any  acute disease,  such  as  typhoid
fever or  pneumonia, his condition  mostly  becomes
critical.   For  the  same  reason  also  tuberculosis, 
42                  Diabetes.
wounds, etc.,  mostly cause the death of a diabetic
patient.
   Experiments were made with  healthy and diabetic
persons, where both partook of the same amylaceous
food ;  thus, Gathgens,  for instance,  partook of the
same nutriment as a diabetic patient (see Gathgens,
" Ueber den Stoffwechsel eines Diabetikers," Dorpat,
1866; also his report in Kuhne's  "Medic.  Central-
blatt," Berlin, 1887; Vol.  v., p. 147).   Portions of
the liver of living persons  were removed  in order to
test its percentage of sugar, and in order  to use this
percentage afterwards for a comparison ; which pro-
cedure,  however,  was  condemned  by  Ebstein as
unbecoming  (Op.  citat.,  pp.  150 and  188).   Con-
clusions also were drawn as to the gradual cessation
of the  formation of glycogen in the liver ; and as to
a direct conveyance of sugar from the bowels through
the blood of the vena portae into the general circula-
tion.   But has any  inquirer, before Ebstein,  ever
been able to  throw light  on the  procedures in the
protoplasm of the  liver-cells, etc. ?  According to
Luchsinger, the sugar  passes  into  the  blood  un-
changed, as soon as  the liver-cells lose their power
of action, that is, so far  as the formation of glycogen
is  concerned.
  This idea is favourable to that maintained by Eng-
lish physicians, according  to whom marasmus is the
most  frequent cause of  diabetes ;  for  marasmus
cannot help diminishing the power of action of the
liver-cells.
  In  his  work on Diabetes,  Ebstein  enters upon 
         Characteristic Features of Diabetes.       43
the standpoint which I announced at Wiesbaden in
1886.   He starts with the idea  that the quantity of
carbonic  acid  formed in the tissues of  a diabetic
person is too small, compared with the  carbon-hold-
ing substances there, which require to  be oxidized.
He regards a diabetic person, most significantly, as
an individual who, on account of the defective con-
stitution of the protoplasm of his tissues, is  unable,
out of the same given quantity of carbon-containing
fuel, to produce the same amount  of carbonic acid
as  a  healthy  person.    He  shows  that carbonic
acid possesses the property of  checking the action
of the diastatic ferments in  the tissues and  organs,
and  the ability of regulating the  transformation of
the glycogen, which is stored up nearly everywhere
in  the organism.    He  shows, further,  that  the
carbonic acid is able  to  change certain albuminates
—the globuline—from a liquid into  a solid state, and
that by an addition of oxygen these same substances
are again changed  back from the solid into the liquid
condition.
  Ebstein starts with the investigations of Voit  and
Pettenkofer,  according to whom a diabetic person
decomposes  more albumen than a healthy  person,
and also destroys more fat ; and yet under the same
circumstances absorbs less  oxygen, and yields  less
carbonic acid than  a  healthy person.   On the basis
of  these  investigations   he  sought  to  prove,  by
experiments based on  an examination of the entire
change of substance  (Stoffmnsatz), that  the proto-
plasm of a diabetic person is unable to form as much 
44                   Diabetes.
carbonic acid out of a given amount of carbon-con-
taining fuel as  the  tissue of  a  healthy person.  He
looks upon the  secretion of sugar in diabetes as the
result and  the  effect  of  a diseased  state of almost
the entire protoplasm of  most  tissues and  organs ;
since nearly everywhere, where the  juices circulate
in the living organism, and where the substance of
it undergoes change—hence  where there  is respira-
tion, and where carbonic acid is formed  in  the pro-
toplasm—there also diastatic ferments and glycogen
are present.
  In view of the great bulk and the extensive volume
of the liver and the muscles, Ebstein regards these
organs as those parts of the body which are affected
most, and are most concerned  in the various stages
of diabetes ; yet he does not  consider the profession
justified, at the present state of science,  to speak of
a special liver-diabetes, or muscle-diabetes.
  After  thus  disclosing  to  us, by his  theoretical
investigations,  the cause  of  the formation of sugar,
on the ground of a defective development of carbonic
acid, which is  surely  the real cause of the fatal
anomaly  in the change  of substance witnessed in
diabetes, Ebstein only needed to go a little farther,
and  discover the cause  why,  in the case  of  some
individuals,  at  certain  times,  the  development of
carbonic  acid  in  the protoplasm is thus interfered
with, and why it is not in the case of others. He stood
nearer  than anyone before him  to the head of that
source whence  alone the answer to  these questions
could come.  According to his theory he was bound 
         Characteristic Features of Diabetes.       45
to  say:—So long  as the  formation of carbonic
acid is able  to  regulate  or govern  the diastatic
ferment  the  predisposition  for  diabetes  remains
latent; but as soon as, through any cause whatsoever,
the formation of carbonic acid is interfered with, the
fatal predisposition for diabetes  is ushered actively
into the foreground,  by allowing the  sugar-forming
ferment to display its energy in an excessive manner.
Under such  circumstances the protoplasm becomes
defective ;  it loses the power of forming carbonic acid
in a normal manner ;  sugar is formed, and the patient
becomes consigned to death.
   Ebstein, as just mentioned, was very near drawing
this inference.  The  fact that  I  have succeeded
in tracing  the fundamental  cause  of diabetes to  a
hereditary  luetic disposition, lets a flood of light into
the chaotic darkness  of diabetes.   A  new epoch
in  the therapeutics  of diabetes  has  no doubt been
inaugurated  with this discovery. 
V.
CLASSIFICATION OF DIABETES MELLITUS.

From a therapeutic point of view it is totally value-
less to assume various forms of diabetes ; still, in the
interest of science,  and in  that  of  the history of
literature, it seems worth while  to inquire  into this
subject.
   About 1680, Ettmuller drew a distinction between
diabetes  verus, in  which  liquids  pass  unchanged
through  the  body and  are  excreted, and  diabetes
spurius,  in which the solid  ingredients  of  the body
become liquefied, wherefore the quantity of the urine
exceeds then the quantity of the liquid imbibed.
   Afterwards  a diabetes chylosus was spoken of, in
which  it was  supposed  that  the chyle was secreted
in conjunction with  the urine;  whence the  sweet
taste of the latter.
   In  the beginning  of the last century  Sauvage
called  a particular species  of this disease diabetes
anglicus,  a  characteristic  feature  of which was  a
sweet, sacchariferous urine.   Another distinct species
he called  diabetes legitimus Aretaei, in which the
volume of the excretion was larger than that of the
liquid imbibed.
   He distinguished besides the  following five forms
of this disease :  Diabetes hystericus ; diabetes arti- 
          Classification of Diabetes Mellitus.        47
ficialis,  which  ought rather to be  called transient
glycosuria, since it was  caused by tying the vessels
of the spleen ;  diabetes a vino,  caused by high-life,
an abuse of spirituous  liquors, and by partaking of
young, sweet wine ;  diabetes arthriticus ;  diabetes
febricosus.
   Only towards the end  of  the last  century the per-
 centage of sugar in the urine was employed  as  a
 principle of classification  by Cullen and  P. Frank,
 who  distinguished  between  diabetes  mellitus  or
 verus, and false  diabetes  or diabetes  insipidus  or
spurius.    The  latter  species   Ewald  treated  as
azoturia, after  Ettmiiller's example.
   The disease  was  called  diabetes mellitus  when
 grape-sugar was contained in the  urine.   But when
 a large quantity  of  urine  only was passed, without
 any  sugar, they  called  it diabetes insipidus; this
 latter  disease,  consequently,   is   identical   with
polyuria.
   When the urine contained  sugar, but its quantity
 was  not in excess  of  that excreted by  a  healthy
 person,   Peter   Frank   denominated  that  species
 diabetes  decipiens.  He described  it  thus :  Urine
 scanty,  but  sweet   (" Spez.  Path.   u.  Therap.,"
 ubersetzt v.  Schernheim,  1840, i., p. 360).   This
 species, as Ch. Bouchard expresses it, is diabetes
 without polyuria.    Briicke  does  not regard diabetes
 insipidus as a definite disease ;  neither  does  he
 regard diabetes mellitus  without polyuria  as dia-
 betes.
   When the grape-sugar disappears, and  the urine 
 48                  Diabetes.
 instead exhibits  inosite,  which is incapable of fer-
 mentation ;  when, therefore,  there  is simply a case
 of inosituria, while all the remaining symptoms of
 diabetes continue (as was shown  by Vohl in 1858),
 that condition is called  diabetes inositus.   In cases
 where a great deal  of water  was  conveyed into the
 system Strauss  discovered inosite also in the urine
 of healthy persons.   Kiilz is  of the opinion that  a
 consumption of  upwards of seven  pints of any liquid
 beyond the  usual  allowance promotes the formation
 of inosite.   A distinction used to be made between
 brain-diabetes, liver-diabetes,  and stomach-diabetes,
 thus between neurogenous, hepatogenous, and gas-
 trogenous diabetes.   Diabetes was  called  neuro-
 genous, or brain-diabetes, when nervous symptoms
 predominated, such as weakness, ill-humour, itching
 of the skin, headache, disturbances in the sense of
 vision ;  but  it was called liver and stomach-diabetes
 when combined  with adiposis, furunculosis,  albu-
 minuria,  gout, irregularities  in the  digestion.  In
 brain-diabetes a stimulation of  the  vagus nerve in
 the brain was assumed ;  in the  other forms a stimula-
 tion  of the  same nerve  in the stomach.   In  the
 former case  diabetes was supposed to be caused by
a reflex-excitation of  the secretion of sugar; in the
latter case by the digestion of  hydrates  of  carbon.
 In the former case  lean  persons, thinkers, persons
labouring  with their brains were attacked  by  the
disease;   in the  latter   case  fat  persons,  etc.
Griesinger drew  a distinction  between transient and
chronic diabetes. 
         Classification of Diabetes JMellitus.       49
   Redard (in " Revue de Chirurg.,"  1866) reports a
number  of  cases  of  "ephemeral"  glycosuria,  to
which he opposes the " severe" illness bearing the
same name.
   Senator  (Op.  citat., p. 216) explains the origin
of  diabetes  in a  twofold  manner.   It  is  caused
by disturbances of the nerve-tracks within the  pro-
vince of the alimentary canal and the liver, which
arise either from  any point of these tracks,  or else
are produced by local causes, by which these organs
are affected immediately.   In this way are explained
the  following  forms of  the disease :  A form  of
diabetes (neurogenous) which  originates primarily
in the nervous system, and  another  (gastro-entero-
genous and hepatogenous) which originates primarily
in the intestinal canal or in the liver.
   The " severe" form of  diabetes Lecorche calls the
idiopathic.   Dickinson uses  the same term in order
to indicate  the condition under which the  disease
originates in the affected  organ  itself.  Seegen also
distinguishes  between  idiopathic and symptomatic
diabetes, and herein lays great stress  on  the circum-
stance whether the secretion of  the sugar  is  only
scanty,  and whether it occurs only after partaking of
a certain kind of food, and thus is merely temporary ;
or whether the affection is constant and independent
of the food of the patient.    Again,  Seegen  distin-
guishes between two other forms of diabetes, accord-
ing to the source whence  the glycogen is  introduced
into the  system :—
   (a) A form of diabetes, in which only that glyco-
                                         E 
 5°                  Diabetes.
 gen which has been produced of  hydrates of carbon
 is transformed into sugar.
   (b)  Another form, in which the glycogen which
 has been  formed from albuminates by division (Spal-
 tung)  is likewise transformed into sugar.
   In the former species of diabetes sugar is excreted
 only when hydrates of carbon are  introduced  into
 the system ; in  the latter species  sugar is  formed
 even if a patient lives altogether on a meat-diet.
   Seegen  distinguishes  further (Op.  citat., p.  66)
 between adipose and  slim  diabetic patients.   The
 former show sugar in  their urine only when they  feed
 on sugar  or  starch, while  the  latter  produce sugar
 even if they live exclusively on a  meat-diet.
   Traube  (see Virchow's "Archiv," etc., iv., 1852,
 p. 109) regards the above forms as different stages
 of  diabetes.   He  thinks  that in  the  first stage of
 diabetes, in which the cessation  of sugar is caused
 by an abstinence from hydrates of carbon, the sugar
 is derived immediately from the food, while in the
 second stage, in which such is not the case (or  only
 in a limited measure),  the  sugar is  derived imme-
 diately from  that  prepared  by the liver.   Here we
 have glycosuria  and genuine diabetes !   Seegen, it
 is true, admits that the second form presents itself
 at once in the severe cases  of the disease, without
 passing  first  through the  milder  form,  and Pavy
 declares that the formation of sugar is not a physio-
logical process.   Hoffmann adopts the neurogenous
 form, and also that presented  by adipose patients
and  repudiates  a  pancreatic form of  the  disease. 
          Classification of Diabetes Mellitus.       51
He tries to present an  image of the  neurogenous
form of the  disease by  noting the  changes in the
medulla oblongata or pons of forty persons who died
of diabetes,  whose heads were dissected,  and  to
these cases he adds forty  other cases in which the
active  form of the disease  had  set in soon  after an
injury  to the  head.
   Additional classifications were forced on the pro-
fession by the experiments of CI. Bernard, who was
of the  opinion that  he had discovered the real cause
of diabetes mellitus in the floor of the fourth ventricle
of the brain,  although in  the  animals  on which he
operated he  was able to  produce  only glycosuria,
and not diabetes.  Compare Hoist (in the " Petersb.
Med. W.," 1880), who arrives  at a number of forms
presented by diabetes ;  and also Pawlinoff (in  Vir-
chow's "Archiv," etc., 64), who speaks of muscle-dia-
betes;  likewise Zimmer, who endeavours to make out
a hepatogenous, a muscular, and a  mixed diabetes.
The profession was thus led into  error, just as it had
been  by those observers  who  in a one-sided  way
declared diabetes  mellitus to be either an affection
of the  stomach or the bowels, or, again, an affection of
the liver ; in  which assertion they based themselves
on the idea that the liver in a normal condition pro-
duces  the glycogen which, when a change occurs  in
the innervation of the liver, or when this organ under-
goes organic  alterations, is carried  as a matter  of
course into the blood and is  excreted thence into
the  urine.   Other  new  classifications  of  diabetes
which  originated with the  vivisectors are  the follow- 
5 2                   Diabetes.
ing : The " manacle-diabetes" (Fesselungsdiabetes;
see Bohm's  and  Hoffmann's experiments on cats)  ;
" diabetes  by   stimulation "   (Beizungsdiabetes,
which  Eckhard  caused  by stimulating  or  exciting
the vermis of the cerebellum) ; "strychnine-diabetes"
(see Schiff's experiments  on frogs) ;  " curare-dia-
betes "  (CI. Bernard) ; "oxide of  carbon diabetes"
(CI. Bernard);  "salt-water diabetes"  (Bock  and
Hoffmann), etc.   In connection with  these experi-
ments it may be  objected  that the animals operated
upon were affected with  glycosuria, but NOT WITH
DIABETES.
  Artificial  diabetes  (i.e.,  transient glycosuria), ac-
cording  to  Schiff,  may  extend over  several days,
while ordinarily it lasts only a few hours (Kiilz) ;  yet
this  artificial glycosuria  is no  analogue of human
diabetes.  Kahler,  therefore, says correctly ("  Die
dauernde Polyurie," etc., Prague, 1886),  " A pheno-
menon  extending  over  a  short  time,  in  matters
pathological, is not by any  means the correlative of
a phenomenon which  is permanent, lasting.  There
is  a much  greater probability  that such  transient
phenomena  are caused  by reflex action,  or reflex
stoppage (Hemmung) ; and this circumstance alone
forbids us to assume a definite connection  between
any  injured part in the   system  and an   outward
symptom of disease."
  As a  leading type  of  diabetes  alterna?is,  CI.
Bernard  (in " Lecons de  Physiologie," Paris, 1855)
points us to that  form  of diabetes  which  ensues
after attacks of gout or rheumatism. 
           Classification of Diabetes Mellitus.        53
    Since diabetes, as I am endeavouring to prove, is
 caused   by hereditary  lues, and  since this illness,
 whenever it becomes active, presupposes a diseased
 state of the protoplasm of the  whole body, from
 the  anatomico-aetiological standpoint I feel bound
 to protest, with Ebstein  (Op. citat., p. 180), against
 the  classification of  diabetes  into  brain-diabetes,
 liver-diabetes, pancreatic-diabetes, and  muscle-dia-
 betes.   To mention  here only one  thing : Hoffmann,
 at the Medical  Congress  held  in Wiesbaden  (see
 ' Verhandlungen," etc.,  of 1886), among 60 cases
 which he had collected, found only 10 where he was
 able to  apply the symptomatology of the  so-called
 pancreatic-diabetes.
   Again, the severest affections of  the  liver very
 often take their course without being attended in the
 least either by glycosuria or diabetes.
   Since the time  when Th. Willis  reported the case
 of a woman who, in the morning only, secreted a
 quantity of urine  far in  excess  of the liquid which
 she had  imbibed,  the profession spoke of an inter-
 mittent diabetes.
   Seegen says (Op.  citat., p. 44) : "In a  few indi-
 vidual cases  diabetes seems to  have arisen as  a
 consequence of  intermittent fever.   A definite con-
 nection can be proved only in one case.  In this case
 there was an intermittent  secretion  of sugar, and
 according to  the  observation  of  the physician  in
 charge, Dr. Lenzberg, who  instituted  a lengthy and
exact examination, sugar  showed itself in a moderate
quantity  only after a paroxysm of fever  had been 
54                  Diabetes.
passed through, or after it ought to have taken place
according to typical laws.   The intimate connection
between the intermittent fever  and  the  secretion of
sugar became more evident by the effect  exercised by
sulphate of quinine, which had the  power of com-
pletely stopping the periodically recurring secretion
of sugar.  This secretion, however, made its appear-
ance again as soon as the remedy was discontinued.
In  another case  the  patient  stated that, after a
journey to Holland,  he suffered for two years of a
periodically  recurring  intermittent  fever.    The
attacks,  he says,  always  took  place during  two or
three  consecutive  nights,  after which time they
stopped again.  The patient dates the first symptoms
of  diabetes from  that  time ; but only  after a lapse
of  years a serious form of diabetes  developed itself.
In  two cases, before the  diabetes showed  itself, the
patient had suffered of an obstinate attack of inter-
mittent fever in the South of Hungary.  The  follow-
ing case  is most  interesting :—A patient, 58 years
old, had  suffered  much of  intermittent fever.  The
fever stopped ;  but after  some  time he was troubled
by the most violent headache, and, indeed, at exactly
the same time when  the  fever usually had made
its appearance.   A  disproportionate state of weak-
ness  remained  after  the attacks;  when  the urine
was analyzed it was found to contain a considerable
quantity  of sugar."
    Bourdel  (" De la glycosurie  ephemere  dans les
fievres palustres,"  in  "Union Medicale,"   1872)
 frequently observed a secretion of  sugar during the 
         Classification of Diabetes Mellitus.        55
paroxysms of intermittent fever.   He says that he
discovered sugar  in  32  out  of 40 cases of highly-
developed  malarious  cachexy.
   Senator   (Op.  citat.,  p.  228)  pointed  out that
cases  like  the  above occur mostly  in  connection
with  malarious  diseases,  in which  sugar  is  found
periodically in the urine, with or without any typical
attack  of  fever.   He  continues :  " Those typical
secretions  of sugar,  however,  which  occur in con-
nection with intermittent fever, and  which, Bourdel
says, he has observed, do  not  present  the  char-
acteristic features of  diabetes  mellitus, but they are
mere instances  of transient glycosuria; wherefore
they must  not be put into the same category with
real  diabetes."
   Frerichs draws  the following distinctions :—
   I. Mild and severe forms.  A form, according to
him,  is  mild or light if the  secretion of  sugar
depends upon the character of the food.   He calls
it severe if the nature of the food exercises but little
influence, and if the urine preserves  its saccharine
quality  even  if the  patient lives on a pure  meat-
diet.
   II. Diabetes  with  polyuria—the   most  frequent
form ;  and  diabetes without  polyuria  (Diabetes
decipiens).
   III. Diabetes as a  consequence of brain-diseases :
     (a)  Organic diseases of the  brain.
     (b)  Disturbances of  a mental kind.
     (c) Mental excitements.
     (d)  Injuries to the head. 
5 6                  Diabetes.
     (e)  Reflex forms arising from a  stimulation of
            peripheral nerves (of the  vagus nerve,
            of  the trigeminus  nerve,  and  of  the
            sciatic nerve).
   IV. Diabetes in consequence of infectious diseases
 (cholera, diphtheria, small-pox, typhoid fever, scarlet
 fever, measles).
   V. Diabetes as the consequence of a chill.
   VI. Diabetes as the  consequence  of a  constitu-
 tional illness (syphilis, gout, adiposis).
   VII. Diabetes  coupled with  an affection  of the
pancreas.
   VIII.  Diabetes coupled with a liver-disease.
   IX. Diabetes of children and aged people.
   X. Intermittent diabetes, where the secretion of
 sugar frequently ceases ; but where it shows itself
anew after a disregard of the rules of  diet.
   Bouchardat, Harley, Pavy, Tommasi, Rosenstein,
 and  others, like  Frerichs and  Seegen,  distinguish
 between mild  and severe cases of diabetes.   This
 same classification was  accepted by Traube, Bence
 Jones, Dickinson, and others, but they limited it to
 two  stages  of  the same disease ;  while  Hertzka
 more recently amplified  this classification, and pre-
 sented it  thus :  (a)  a severe  form,  capable of
 improvement;   (b) a severe form, which  is  abso-
 lutely unfavourable ;   (c) a  mild form;  and  (d) a
 still  milder  form.
   Vocke assumes " stages" in the  disease.  The
first  stage  presents the  following  symptoms:—■
 Fatigue,  losing flesh, polyuria,  hunger,  thirst, dry-
 ness of the  skin, itching of the skin, eruptions, boils, 
          Classification of Diabetes Mellitus.       57
 inflammation, gangrene,  etc.   In  the  second stage,
 according to him, the  patient  really begins  to look
 ill and suffering.  The symptoms  of  the first stage
 become intensified,  both as regards the disturbances
 in the action of the nerves and the assimilation of
 the  food.   The  weakness  increases ; the  patient
 begins to cough ; thirst and polyuria increase.  The
 second stage is quickly run through, and terminates
 in coma.
   More recently,  not acetone and diacetic  acid, but
 oxy-butyric acid (C4 H8 03) which,  under the effect
 of polarized light, turns  towards the left, has  been
 put down as the final product of the decomposition
 of sugar, since it has  been shown by experiments
 made  on animals that oxy-butyric  acid  diminishes
 the  alkaline reaction of the  blood, and produces
 coma  and paralysis.  Vocke calls those cases severe
 and incurable  in which all the sugar which has been
 introduced  into the  system is found  in  the urine
 within the space of an hour.
   Bouchard  (" Maladies  par  ralentissement de  la
 nutrition," Paris,  1855)  defines every  case of  dia-
 betes,  irrespective of the reception of food, as severe
 or  serious  where the patient, within  24  hours,
 secretes more than  50 grammes of sugar ; and he
 defines every case  as mild where the patient secretes
less than 50 grammes of sugar during the  24 hours.
  Ebstein distinguishes an  alimentary  form of  dia-
 betes,  and a protoplasmatic  form ; thus he discrimi-
nates  between  the  mild,  curable  glycosuria  and
genuine diabetes.  That glycosuria which manifests
itself sometimes in a healthy person, after he  has 
5 8                   Diabetes.
partaken of sugar, he calls physiological glycosuria ;
but the  glycosuria  which shows itself in  diabetes
mellitus  he designates as pathological glycosuria.
Between alimentary glycosuria and diabetes mellitus
he finds  a sensible,  graduated difference, but not a
difference  in  principle.   Herein I have to  oppose
Ebstein, and,  indeed,  on  grounds  belonging  to the
aetiology and pathogeny of diabetes.
   I recognize only one cause of diabetes, namely,
hereditary lues.
   On this ground it  is wrong  to speak  of a " mild,"
or of  a " milder " form of diabetes ; for, according
to  the present  mode of treating the  disease,  the
victims of diabetes—whether more slowly or more
quickly, it does not matter—are irresistibly, and with-
out any hope  of being  saved,  drawn towards the
gates of death.  There are NO mild, only SERIOUS
cases of diabetes.
   Whenever  diabetes became active, even  at the
slightest  manifestation of that  illness, my  teacher
Frerichs always  became  serious, and I never heard
him, in ordinary conversation, describe  a pronounced
form  of active diabetes as being " mild."
   There  is no  need, however, to  alter the  existing
terminology.   It suffices to  regard the many forms
of diabetes as the effects  of hereditary lues.   If  the
profession still insists on  introducing glycosuria as a
form  of  diabetes, it may be  denominated a spurious,
 " mild " diabetes ; but to diabetes itself, as  charac-
terized by myself, in all its forms, there applies only
 the epithet severe and serious,  and it ought to be
 described as  " real, active diabetes." 
                       VI.

     THE  ETIOLOGY  OF   DIABETES
                  MELLITUS.

Frerichs makes a statement  to this effect, that
one-tenth of his patients inherited diabetes  from
diabetic  parents.  About the remaining nine-tenths
he is silent; but six-tenths, or more, out of these
nine-tenths, if I  am correct in my computation, were
afflicted only with glycosuria.
  In  many cases he  proved a hereditary transmis-
sion  from distant, and yet at the  same time directly
related, members of one  family;  for instance, sup-
posing an uncle and a nephew to  be afflicted by this
disease,  he inferred from this  that the grandfather
or grandmother, and eventually the great-grandfather
or great-grandmother, were the original  sources of
diabetes.
  This constitutes the  basis,  on  the  strength of
which, after  a lengthy  examination extending over
twenty years, I was led to make the following impor-
tant  discovery :—
  Diabetes is a hereditary, constitutional  disease ;
and  the cetiological element of this disease is lues
contracted by some ancestor !
  After I had discovered this truth in  1881, and in 
60                   Diabetes.
accordance with it  had originated a method of cure
which combined various curative agencies, and after
I had  improved this method from  year  to year, I
have at  last succeeded in curing  radically the most
difficult cases  of  diabetes ;   that  is,  I  have  suc-
ceeded  in healing  them in such a manner, that my
patients, after recovering from their illness, remained
thoroughly  healthy, and  were  not  compelled  to
return   and  undergo a  second  treatment, except
under exceptional  circumstances.
  Seventy-one  cases of  real  diabetes were treated
by me,  partly in Carlsbad and partly in Nice,  from
1881 to the  end of  1884.  From among these there
were radically cured
     53  PATIENTS,  as follows :—
       36 men,   aged from  21-64 years,
        8 women,   ,,     ,,    19-32 years,
        5  virgins,  „     „   17-23 years,
        4 children,  ,,     ,,    9-13 years.

  Ten among the remaining patients were dismissed
improved, and they might have recovered by under-
going a second  treatment, and obeying the  dietetic
rules which  were prescribed  ; while eight of  them
died in  the  course  of that time,  on account of the
disease  having  progressed  too  far;  and thus  on
account of some new complications having arisen.
  I  shall  be  prepared to  report  concerning  the
patients who were  treated  by  myself  during the
years 1885,  1886, and 1887, as soon as I shall be in
a condition to express a positive  opinion  as  to the 
        The ^Etiology of Diabetes Mellitus.       61
lasting character of  their cure.  Their number is as
follows :—
     In the year 1885, 24 cases of real diabetes.
     >>   „   ,,  1886, 54   ,,   ,,   ,,     ,,
     m   >)   »>  1 °°7»  7   »»   »»   »»     "
  Those theories which  claim for diabetes a hepato-
genous  or a  myotic  (muscular)  origin  fall  to the
ground  in the face of  the fact that all real diabetes
is hereditary, and is  caused  by a degeneracy of the
protoplasm.   The same applies to most  of what is
said, for  instance by Frerichs, concerning "  the more
immediate causes"  of  diabetes.   The  more "im-
mediate  causes " which  he enumerates  apply only
to  glycosuria;  and   they  produce  diabetes only
where there is a hereditary  predisposition for  it.
   The  marasmus of  old  age is  never a  cause of
diabetes,  as is  supposed by  Zimmer on the basis
of  some  English statistical  tables ;  although any
latent diabetes becomes developed  regularly  by the
marasmus of old age.
   Frerichs is likewise in error  where  he  supposes
that diabetes is caused by a reflex  action  of the
nervus trigeminus and the sciatic nerve.
  At the  Medical  Congress which  was  held at
Wiesbaden  stress was justly  laid  on  the  following
sentiment:—" If every case of trauma—of a severe
bodily injury—of intense fright, of heightened nervous-
ness ; and, again, if  every  sorrow,  every  misfortune
which befalls  a family, were productive of  diabetes,
fully one-half  of humanity would be diabetic." 
62                   Diabetes.
  Senator  observes  justly (Op. citat.,  p.  125)  that
trauma is only a mediate cause of the disease, since
in consequence  of it there is developed a more in-
tense change of structure, etc., within the province of
those nerve-centres which regulate the  formation of
sugar.  The source of these affections, he thinks, is
the medulla  oblongata or  its immediate neighbour-
hood ; or, again,  if the real cause of the  disease is
placed at a greater  distance, he thinks the  area of
the fourth  ventricle, as may  be plainly shown,  has
some share in its production ; or, again, disturbances
in the assimilation of the  food or in the circulation
may be caused from this area, etc.
   Is not the following case reported by Frerichs (Op.
citat., p. 187) a case of  glycosuria?  He says that
a speculator, after meeting with some  severe losses
of money,  became affected with  diabetes, but that
after three weeks  already he  had lost  every vestige
of sugar!
   Distinguished  medical inquirers have already been
on the road leading  to my  discovery, only they did
not go far  enough ;  they were not prepared  to draw
the necessary conclusions from  their premises ;  they
did not direct their inquiries to  some* definite point,
and afterwards test their theory by practice.  Again,
they  were one-sided; they drew conclusions from
diabetes concerning diabetes, from  effect concern-
ing  effect; and  they did  not  trace diabetes as an
effect to hereditary lues as its cause.
   Bondelet  already observed diabetes in a father
and his daughter; Morton  in a father and  a son, and 
         The Aetiology of Diabetes Mellitus.        63
in four brothers and sisters, all of whom were carried
off by the disease.
   Isenfiam  stated  a case  where  eight  children of
healthy parents after reaching their eighth year died
of diabetes.
   Marsh reports  (" Dublin Quarterly  Journal of
Medicine,"   18-54,  xvii.,  17) the  case of a family
where diabetes was hereditarily transmitted through
four generations.
   Langiewicz (Breslau) mentions  a diabetic patient,
seven of whose nearest blood-relations were epileptic.
   Griesinger treated a patient who  had suffered  of
epilepsy in childhood, and all of whose brothers and
sisters were  epileptic.
   Similar reports were made by Clarke, Eulenburg,
 Westphal, Bavy, Ebstein, and Midler.
   Among 140 cases Seegen noted eight cases where
 both parents were  diabetic,  but ten cases where the
 brothers and sisters of the  patient were afflicted with
 diabetes.  In  one case the father  of the patient
 suffered of  diabetes insipidus.  In  four cases  both
 parents  and several  of the  brothers and sisters had
 died of diabetes.   Seegen  treated a young English-
 man who in the course of  time  died of  diabetes;
 his  younger sister had  died of  the  same  disease,
 and his  father  came  to  Carlsbad  in  the  following
 year, likewise afflicted with diabetes.  In  one case
 Seegen  witnessed two  sisters dying of  diabetes.
 Unfortunately he did not inquire whether any of the
 relatives or ancestors of his diabetic patients  had
 been  luetic,  although  he  arrived  at a conclusion 
64                   Diabetes.
which confirms our present position, namely, that a
hereditary disposition for diabetes must be assumed,
even in  such cases where either  the father  or  the
mother suffered of an affection of the brain.  Seegen
treated a brother and sister who suffered of diabetes,
both of whom were of a highly nervous temperament,
and whose father and grandfather  had suddenly died
of an apoplectic stroke.   In two cases  the mothers
of patients died insane.  In one case the  brother of
a patient was an idiot, and all her children suffered
from  brain disease.   In another case the  father was
insane ;  the patient himself suffered much from head-
ache, and he noticed  an early loss of memory.  In
one case a brother and a sister committed suicide in
a fit of melancholia.                         ,
   A SUMMING up.—In 140 cases Seegen proved 20
times the hereditary  nature of diabetes, and thus in
one-seventh of the entire number.   If we  add to this
all those cases where there existed a hereditary cere-
bral affection, and if we take into  consideration that
only in the most recent times the connection between
affections of the  brain and diabetes  has been recog-
nized ; further, that only most recently  a  distinction
has been drawn  between real diabetes and the so-
called milder and more frequent form of this disease,
and that most probably many persons have hitherto
died of  diabetes,  the cause of whose death remained
unknown, the numbers  given above acquire a much
greater statistical importance, and bear an imposing
testimony  in favour of  the theory  advanced  by
myself. 
         The Aetiology of Diabetes Mellitus.       65
  Among  104 cases,  from  1868-1874,  B. Schmitz
proved  in  a most definite  manner  the hereditary
character  of diabetes; for in one  case the  grand-
father had been diabetic, in another case the  grand-
father and the  father,  in six  cases the father, in six
cases the  mother, together  with the brothers and
sisters,  in  eight  cases the brothers  and sisters.
In  these  cases, also,  he  witnessed the manifesta-
tion of  diabetes in consequence of  hurtful agencies
(nervous shocks).
  Hertzka infers a connection between the diabetes
of a patient 40 years old  and the ajithrax of which
an  uncle  was suffering.   In  this  connection  he ex-
presses  the same idea which already Blau had uttered
(who "  was forced " to admit and teach the doctrine
of a " diabetic predisposition," see Schmidt's " Jahr-
biicher," etc.,  1875,  p. 205), namely,  that  it was
possible for a predisposition for  diabetes  to be
handed  down by inheritance  without this disposition
becoming  active in the immediate progenitor.   A
case communicated by himself was to prove the fact
that the disposition for diabetes is de facto hereditary.
In the case of  a female patient 24  years  old, sugar
had been  discovered in   the  urine already  in  her
fifteenth year.   Two of her brothers and sisters died
of  diabetes,  another  brother perished of  phthisis,
and the remaining brothers  and sisters suffered  of
catarrh  of the lungs,  and discharged  blood  while
coughing.
  In quoting this  testimony  of  Hertzka, I am quite
pleased  to quote also the following question which he
                                          F 
66                   Diabetes.
propounded, and which speaks  in favour of my doc-
trine :  " In the face of such facts, are we not bound
to accept that  the slumbering  germ of the disease
was transmitted  by  inheritance,  and  are we not
compelled  thus to assume a predisposition  for the
disease in  the  progenitor?"   My  answer is: most
undoubtedly  must  we assume such  a hereditary
predisposition.
  Senator  relates that four children  of  a Polish Jew
perished of diabetes in  the  Polyclinical Institute  of
the University  at Berlin.
  According to the  same authority (Op.  citat.,  p.
260) a hereditary tendency has also repeatedly been
proved in the case of  diabetes  insipidus.
  Lecorche accepts a hereditary predisposition in the
so-called cerebral diabetes.
  Lacombe reports the case of a  family where the
mother, one daughter, and three sons, as well as the
mother's brother and  his  children, fell a  prey  to
diabetes.
  Other cases wThere tw7o or  more  blood-relations
suffered from diabetes insipidus are communicated in
the  "American Journal of Medicine"  of  1858,  p.
379-
  Trousseau mentions the case of  a female patient,
aged 19 years, whose grandfather had  suffered from
diabetes mellitus.
   Charcot (" Maladies des Vieillards," Paris, 1874)
furnishes  the  information that  persons who descend
from  a gouty  family are  sometimes  affected  by
diabetes mellitus. 
         The Aetiology of Diabetes Mellitus.       6j
   Bedon  shows in 32 cases where children suffered
from diabetes that their parents were affected with
scrofula, gout, mental diseases, etc.   The mother,
aunts, and other relatives of a girl 15 years old, who
died of diabetes, were all affected by diabetes.
   Beith reports the case of a woman,  24 years old,
whose  father and brother suffered from the same
disease.
   It was lately pointed out  that diabetes occurs with
persons of a  neuropathic and psychopathic disposi-
tion.
   Zimmer  reports 85  cases,  out of  which nine
could be traced to  a hereditary predisposition.   He
also mentions several  diseases  which  he regards as
causes  of  diabetes, but which, on the basis of  my
inquiries and  experience, are competent to produce
diabetes only where there is a hereditary predisposi-
tion  for  this  disease.  He  relates the case of  a
patient, 55 years old, whose father died of apoplexy,
while his mother perished from consumption.   The
latent diabetes of this  person  became immediately
active through trauma—an injury  (the fall from  a
horse).
   What a  striking example  for  our  proposition,
namely, for the presence of hereditary lues,  which
is the cause of apoplexy, as well as of  diabetes, and
which requires a mere outward contingency, in order
at once to become developed, and to be stirred into
activity!
   Senator writes (Op.  citat.,  p. 121) :  " In a by no
means inconsiderable number of cases of  diabetes, 
68                   Diabetes.
inheritance can be proved to have acted as a predis-
posing element.   These cases consist partly of such
where  several brothers and sisters, nay,  where all
children  of certain  parents have  suffered from this
disease ;  partly of such where one of the parents, or
one  of the grand-parents, was  diabetic, and trans-
mitted this predisposition to his  descendants.   It
seems  even that such cases are by no means  very
rare  ; nay, that  they  occur much more  frequently
than the profession has  been  inclined  to admit,
even to  within  a comparatively  short time.   For
lately,  since more attention has been paid to this
matter, reports concerning the hereditary  character
of diabetes are becoming more and more numerous."
  Ebstein, who  proves that only  a fraction of fat
persons become diabetic,  is of the opinion  that there
must exist a particular predisposition  for diabetes,
so that this disease may  be developed in company
with adiposis.   On p.  168 of his work he  puts forth
the proposition which I had proved by facts at Wies-
baden in  1886, namely, that apart fro?n  a definitey
morbific  predisposition, which is connate, and which
very frequently is  transmitted  by inheritance, no
uric  gout,  and no diabetes mellitus, are  developed.
Ebstein  declares verbally, on p. 180, "All the  facts
before us force us to the belief that the development
of diabetes requires a definite bodily tendency, an
individual predisposition, which in almost all cases
?nay be regarded as connate, and not rarely may be
considered as the result of inheritance."
   This  connate  predisposition,  first   characterized 
         The AStiology of Diabetes Mellitus.       69
by myself as  hereditary lues, is naturally  common
to all  the  organs and  all  the  tissues in  which
the  change  of substance  (Stoffewechsel)  is con-
stantly  going  on.   Ebstein  thus  corroborates  my
discovery ; although  by my discovery it is proved
that diabetes  descends  from  hereditary lues, and
NOT from diabetes, as is supposed by all those who
suspect its hereditary character.
   The  above weighty  proofs  and expressions can
scarcely avoid  creating some confidence in  the truth
of my proposition that diabetes is derived by inheri-
tance from luetic ancestors ; but any doubts that may
still linger in the minds of the profession cannot help
being  removed by the success which has  attended
my method  of  treatment.  The additional  words of
Frerichs  and  Senator will now be appreciated in
their full force : " Cases of diabetes occur also among
the more DISTANT relations of persons afflicted with
this disease." 
VII.
  DIAGNOSIS  OF DIABETES MELLITUS.

Patients afflicted  with diabetes usually consult
their medical adviser only when they  are  compelled
to do so by an increase in  their desire to  urinate;
when there is a  constant  dryness in the mouth ;
when they experience a general  feeling of lassitude
and weakness  ; when their  skin  itches ; when they
are affected by furunculosis, and when  carbuncles
are beginning to  be formed;  when  their sense  of
vision is  debilitated ; when  there is a tearing sensa-
tion in their limbs, as though caused by rheumatism ;
when there are abnormal  sensations in the muscles,
especially in those  of  the  loins  and of the lower
extremities ; and  especially when  there is a striking
decrease in weight.
  The  first  attention  of  the  physician  must  be
directed  to the condition of  the urine, which is  most
important for  the purposes of diagnosis, since the
two cardinal symptoms of diabetes are (i) glycosuria
and  (2) an increased decomposition of albuminates.
  Urine  of this kind usually has no settlement, and
in proportion to  the increase of active diabetes it is
generally as clear as water ;  or  it is of a pale colour;
or again it exhibits a  greenish  yellow tint, or one
which has a  greenish  tinge.   Ordinarily its  reac- 
           Diagnosis of Diabetes Meltitus.         71
tion  is  sour,  and  its  odour  is  fruity,  chloroform-
like,  aromatic—reminding one  of  damp hay—and
sweetish ; which  is due to  the  presence in  it of
alcohol and acetone.
  The specific gravity rises  from  roio to  ro6o  ;
yea,  according to Bouchardat, even to 1*074.
  Albumen.—Albumen was  discovered by Latham
and Erasmus Darwin in the urine  of diabetic patients
at a time when a relaxation, of the kidneys was still
supposed to be the cause of diabetes.   Their results
were  confirmed by a treatment of  the urine with
nitric acid, as taught  by Haller-Hammerstein ; but
of course only in those cases where there was albu-
minuria at the same time.
  My experience has  taught me that it is not at all
essential for the urine in diabetes to contain albumen.
In case there is  any,  it  has  to be removed, before
testing it for sugar.
  The sugar in the urine  is  grape-sugar (dextrose,
glucose).  Its presence  can be proved  by its power
of reduction, its  property of  fermenting, and by its
rotating the plane of  polarization of a  ray of light
to the  right,  which peculiarity justifies the  name
" dextrose," as well as that of its preceding stage,
which is called " dextrine."
  The best known, and  most approved methods for
establishing  the presence  of grape-sugar,  are the
following:—
  I.  (1)  The  test  by tasting.—The  ancient  phy-
sicians  were obliged to resort to the sense of taste.
  In order to  escape this disgusting test, they after- 
 72                  Diabetes.
 wards tried whether the urine left any spots on white
 linen;  or whether on  cloth there was  left  a floury
 dust  of the kind which is  noticed  in vessels where
 water is  evaporated,  or as appears  sometimes  on
 cabbage or rose-leaves, or on plums, etc.
   A  simple  method for  proving the  presence of
 sugar is by evaporating the urine.   If  the  residue
 is  soluble in  water or alcohol the urine contains
 sugar.
   (2) Moore's sugar-test  by caustic potash.—Pour
 some urine  into a test-tube ; add some liquid  caustic
 potash ; heat the mixture (while constantly shaking
 it) to the boiling point.   The heated  portion of  the
 liquid turns brown if  there is any sugar present.
 The  darker  the  colour  the greater the quantity of
 sugar contained in the urine.
   (3)  Trommer's sugar-test by a solution of sulphate
 of copper.—This test is more sensitive than the pre-
 ceding one.  Urine, free  from  albumen, is  made
 alkaline in a test tube by the addition of one-fourth
 of its volume of liquid caustic potash or caustic soda.
 Add in drops a concentrated (1:5) solution  of sul-
 phate of  copper.  One drop more may  be  added
 than is dissolved.   On  shaking  the mixture  a frac-
 tion of the sulphate of copper is turned  into a clear,
 blue liquid,  if there is any  sugar in  the  urine. The
 upper part of the liquid is now heated, almost to the
 boiling  point.   A  reddish-yellow  or  brownish~red
zone is noticed then even before the boiling  point ;
this zone soon permeates the whole urine and  yields
a precipitate of cuprous oxide.   N.B.—Before pro- 
           Diagnosis of Diabetes Mellitus.         73
ceeding with this, and all other tests, dark urine is
made colourless by  filtering it  through pulverized
animal  charcoal,  or by  adding  one-ninth  part of
acetate of lead.  The animal charcoal requires to be
purified first of all reducing substances by treating
it with muriatic acid, and afterwards washing it with
water.
   (4)  Butcher's test by basic nitrate of suboxide of
bismuth.—Saturate the urine with soda ; add  a small
quantity of the basic nitrate of suboxide of bismuth,
and then boil the whole.  If any sugar is present the
liquid itself, or its precipitate, will turn black.
   (5)  The sugar-test of Nielander or Almen.—Mix
two grammes of basic nitrate of  bismuth with four
grammes of  Rochelle salts and  100 grammes  of  a
solution of eight per cent, of caustic soda;  add ten
times as much urine, and boil the whole.  The mix-
ture turns  black if sugar is present.
   (6)  Seegen's sugar-test. —Hq filters the urine twice
or three times  through animal charcoal until it is per-
fectly colourless.   He then  washes the coal on the
filter with some distilled  water.   This  water  he em-
ploys for the tests of Trommer or Fehling.   Through
it, as well  as through any  equally weak solution of
suo-ar in water, there is produced a beautiful  deposit
of cuprous oxide along the inner surface of the test-
tube.   If the urine contains 0-05 per cent, of sugar,
the reaction caused by the water  used for washing
the  charcoal  is  always very  characteristic.   The
second and third  waters employed in  the washing
process cause  an equally energetic reaction. 
74                   Diabetes.
  (7)  The sugar-test  of Fehling.—The method of
Fehling, the so-called method of " titration,"  is de-
scribed in every text-book of  chemistry.  It consists
in an alkaline solution of Rochelle  salts, with  a cer-
tain quantity of sulphate of copper.   The solution of
Rochelle salts is made in one vessel, that of the sul-
phate of copper in another.   Pour three-parts  of the
first solution into one part of the second ; by shaking
the mixture you  obtain  the so-called   solution  of
Fehling.  One part of this  solution is  now heated
to the boiling  point  with  one  part of the  urine.
Before the boiling point is reached, a reddish-yellow
zone of cuprous oxide is produced ; if  only a very
small quantity of sugar is contained in the urine, a
reddish-yellow  precipitate is thrown down after  a
while.
  (8)  The sugar-test of   Worm-Muller.—Worm-
Miiller,  in Christiania,  perfected  the   method  of
Fehling.  In order  to determine small  quantities of
sugar, he  titrates  the  urine  with  the liquid  of
Knapp, before and after its being treated with  yeast.
He takes 2*5 per  cent, of  a solution of  sulphate of
copper, and a  solution of Rochelle  salts—ten parts
of double tartrate of sodium and potassium  in 100
parts of a solution of four per cent, of  caustic soda
(four parts of liquid  caustic soda in  100 parts of
water).  He  now fills the  first test-tube with  five
ccm. of  urine  ; the second tube with 2*5 ccm. of  an
alkaline  solution  of Rochelle salts, and 1*5 ccm. of
a solution of  sulphate of  copper; whereupon  he
heats both tubes  to the boiling point.   Both tubes 
           Diagnosis of Diabetes Mellitus.         75
are now allowed to cool down to 70 or 6o° C.   He
then slowly pours the reacting liquid into the urine;
and if much sugar is contained in it, it immediately
assumes the colour of cuprous oxide.   But if the
percentage of sugar is  small  (under o-i) the colour
develops only very gradually,  generally in five to ten
minutes.
   Sugar, to the  amount  of 0*25 per cent., can  be
traced by this  test.   The precipitate in this  latter
case does  not  exhibit a  reddish-yellow, but a  dirty
yellowish-green colour.
   If there is no precipitate, the test is repeated with
from 2\ to 4 ccm. of a strengthened solution of sul-
phate of copper.
   Worm-Muller  (in Pfliiger's "Archiv,"  etc.,  Vol.
xxxvi.)  proves  that  healthy  persons,  after  par-
taking  of  large  quantities of  cane or milk-sugar,
secrete  through  the  urine a  fraction of this  same
sugar ;  but they never pass grape-sugar.   He also
discovered that   healthy  persons,  different   from
diabetic  persons,  after partaking of starch, do not
pass any grape-sugar by the urine.  In order, there-
fore, to  prove definitely the existence of diabetes,  he
gets all who wish  their urine  to be  examined to eat
food containing starch before  their examination.
   (9)  The sugar-test of J. Bosenbach.—After satis-
fying yourself  of the  reducing  effect  of a certain
quantity of urine upon a definite quantity of Fehling's
solution (add one ccm.  of urine to one ccm. of  Feh-
ling's solution,  when an incomplete reduction below
0*5 per cent, still proves the existence of sugar), boil 
76                   Diabetes.
a small quantity of urine after adding  to  it one or
two drops of tartaric acid,  which prevents the pre-
cipitation of phosphates.  The boiled urine, after it
has cooled off, is distributed into two test-tubes ; in
one  of  the  tubes the urine is  mixed  with a little
pressed yeast, after which it is placed  near  a warm
stove.   If after a few  hours  the same quantity of
liquid is taken out of  each of  the tubes, to  have it
tested by an equal quantity  of  Fehling's  solution, it
will be found that one of the liquids, as before, exerts
a positive effect,  and thus has  a reducing  power ;
while the second liquid,  according to  the degree in
which  the  sugar had  been decomposed,  exerts  a
negative effect,  or, at all events, manifests  a much
feebler,  reducing  power.   By comparing  the   two
test-tubes, it is easy to discover the difference.   An
unprofessional examiner even can discover  by this
method whether a diminution in the reduction of
Fehling's solution caused by the  urine is due to the
presence of sugar or not.   The  test is not  vitiated
by the  presence of albumen.
   (10) Dr.  Ed. Stiitz's  reagent  capsules.—The
test for sugar and albumen  has lately  been much
facilitated by   the introduction  of  easily  portable
reagent capsules.  With the aid of these gelatinous
capsules, which contain the requisite quantity of the
most approved reagents, every practitioner can make
his tests for sugar or albumen on the  spot  with the
 most  satisfactory  results.   Concerning the use  of
these capsules, which are  exported by  the firm  of
" Martin  Wallach's   Successors," in  Cassel, 
           Diagnosis of Diabetes Mellitus.         77
Germany, we read in the circular issued to the pro-
fession by Dr.  Ed. Stutz, apothecary in Jena, as
follows :—
  " I. Beagent-capsules for Albumen.—The idea of
providing practitioners with an  easily portable re-
agent for albumen in the form  of gelatine capsules,
filled with a mixture  which,  even  at  the ordinary
temperature, should produce a reaction,  we owe to
Professor Fiirbringer.  The discovery of a suitable
reagent  was left to  the  undersigned, who  at  the
same time undertook  to carry out the invention in
a  practical shape.  Particulars  may  be found in
Prof. Fiirbringer's essay  in the ' Deutsche  medicin.
Wochenschrift,' No. 27,  1885.
  " The  reagent consists of a mixture of  chloride of
mercury  and sodium,  with citric acid.   The preci-
pitate  obtained  from  urine containing albumen is
albuminate of mercury.
  " Directions for use.—A capsule, both ends
of which are cut off  close,  is dropped into a  test-
tube about half-full of  urine (any other small vessel
of clear glass will answer).  More than half a table-
spoonful of urine should never be taken.   Close the
mouth of the tube with  the thumb,  shake the  con-
tents thoroughly, then  tilt  the tube  so  that  the
glutinous envelope  can  sink  down  to the mouth,
where it  adheres ; then let the liquid  run slowly back
into the  lower  part  of  the  test-tube.  When  the
bubbles  caused  by the reaction have  disappeared an
opinion can be  formed as  to the result.  According
to Fiirbringer only a pronounced clouding, occurring 
 78                  Diabetes.
 a few minutes after, can be held as proving the pres-
 ence of albumen.   Opalescent traces, even if coming
 from a slight quantity of albumen, are not worth the
 practitioner's consideration.
   " Concentrated urines, containing much uric acid,
 should  be diluted  with  an equal quantity of water
 before testing.   Urate sediment  should be warmed,
 the urine being somewhat diluted  with water for  this
 purpose.   Entirely fresh alkaline urines,  even  if
 clouded  by phosphates, require no preparation.
   " II.  Beagent-capsules for  Sugar.—It  was  the
 endeavour of the undersigned  to  apply  Fiirbringer's
 idea likewise to the sugar-test, and in this connec-
 tion to extend the test to its  quantitative determina-
 tion.   This endeavour was so far successful that he
 was enabled to prepare the approved reagents (solu-
 tions of bismuth and copper) in a  form which insures
 their preservation  in  gelatine envelopes, the com-
 position  of which by repeated  trials has been found
 best for the purpose intended.
   " The  copper   reagent-capsules  are  especially
 designed for cases  where the patient is  bed-ridden;
 the  white bismuth  capsules  for  consultations  and
 observation.
   " For determining the quantity of sugar the follow-
 ing articles are required : Specially prepared cap-
 sules, filled with an exactly-weighed portion  of  the
 salt  of  copper; likewise a dropping-tube provided
with a hollow rubber globe, which, upon light pressure,
when held vertically, permits a drop weighing  five
centigr. to escape;  and also a graduated measuring- 
           Diagnosis of Diabetes Mellitus.         79
tube for diluting urines containing much sugar  with
several volumes of vater,  since without such a  dilu-
tion no accurate resuH can be obtained in such cases.
The dropping-glass and  measuring-tube should be
rinsed before being used with the liquid which  is to
be tested or diluted.
  " Directions for use.—(a) The white bismuth
capsules.—Empty a  capsule,  as directed for  the
albumen test, into  a  test-tube containing about two
teaspoonfuls of urine.   After removing the envelope
with a knife-point heat the liquid over a low flame,
letting it boil  several minutes.  Where  a blacken-
ing of  the liquid or of the  precipitate (by the pro-
toxide of  bismuth)  does  not occur  sugar  is  not
present.
  " Urine containing albumen cannot be tested for
sugar with thebismuth reagent.
  " (b) The blue copper reagent-capsules.—Proceed
as above, only  that the contents  of the capsule must
be dissolved in 20—30 drops of  water, not in urine.
Heat this solution nearly to  the  boiling point (if
more convenient over  the  chimney of a kerosene
lamp, or by plunging the  test-tube  into hot water) ;
then let five or six small  drops of urine fall rapidly
into the  test-tube, held obliquely so that the urine
runs down its inner side.  The presence of sugar is
indicated if  within a minute (during which time a
fusion of the strata is to  be  avoided) there appears
between  the strata, even with the light shining upon
it, a distinct  zone of a yellowish red colour, resulting
from the formation of cuprous oxide. 
80                   Diabetes.
  " (c)  The quantitative sugar reagent.—After shak-
ing up well and opening the cover of a capsule pour
its  contents  into  a test-tube ; add about  3 cc. of
water, heat the liquid to the boiling point, at which
point it is to  be kept  while the urine is  added, drop  |
by drop, so long  as the blue colour of  the reagent  1
remains, which can be observed by holding the test-  1
tube  against the  light.  It must  be borne  in  mind  1
that the precipitation of the cuprous oxide becomes  ',
easier the nearer  the  point  of  total  precipitation
approaches.  Therefore, as soon as the particles of  ;
the cuprous oxide betray any inclination to sink, the
heating process may be  suspended  until the liquid,
which is in the process of clearing, has been examined
for a remaining bluish tinge.
20 drops of o*5°/0 urine reduce contents of one capsule.
*^   jj   n  *  /o    jj     .•>      >>     j>  >,      ,,
 5   jj  >»    /o     »>     jj      jj     jj  jj     >)
 ^   j>  jj  5  /o     jj     jj      jj     jj  jj      ,)
 1 drop  „io%    „  reduces  ,,     „  „
  " In general terms the percentage of sugar is cal-
culated  by dividing the  number of  drops  employed
by 10.
  " The quantitative reagents are accompanied by a
portable glass for the waistcoat pocket;  the qualita-
tive  sugar reagents  are furnished  besides with  a
sample  of pure grape-sugar."
  In  another circular  Dr. Stiitz gives the follow-
ing  caution  in  respect to  the  qualitative sugar-
reagents :— 
           Diagnosis of Diabetes Mellitus.          81
   " Darkly  coloured,  concentrated  urines,  when
treated with  bismuth,  sometimes yield  a reaction,
even  if there is  no sugar contained in them.   The
precipitate in such a case is  of a grey colour.   No
notice should be taken of such  a greyish  sediment,
for even should it be partly due to a trace of sugar
the practitioner will be quite justified in disregarding
it, because by other  means also it will  be impossible
for him to prove the presence of such small quan-
tities of  sugar.   If the urine contains  o*i  per cent.
of sugar the precipitate is coloured  black ; a larger
per cent,  of sugar  causes at  the same time a dark-
brown or even a  black colour in the  liquid overhead.
Should this test  produce  a black colour, and should
the copper-test  also furnish  a corroborating  result,
the presence of sugar is absolutely certain."
   If a difficulty should be experienced in  emptying
any of the gelatine-capsules Dr. Stiitz  suggests the
following expedient:—
   " Rinse a suitable test-tube either with water  or
urine, and insert the capsule,  which  has  been cut at
both  ends, into the neck  of the tube.  After a short
time it will  adhere there  so firmly that  after intro-
ducing the  requisite quantity  of urine,  by gently
rolling the liquid against  the  capsule,  it will empty
its  contents  without  any  difficulty, and without the
gelatinous case getting into the liquid.   The case is
afterwards removed with a knife."
   II.  The  quantitative determination of sugar by
the test of fermentation :—
   (a)  The long arm of a so-called fermenting tube
                                          G 
 82                   Diabetes.
 is filled with urine and with a piece of pressed yeast
 of the size of  a pea, which  has been well washed.
 The tube is filled so that no air remains in it.  For
 24—48 hours the tube is left in a place, the tempera-
 ture of which is from 700 to  900 Fahrenheit.   Gas is
 now developed, which  gas,  if any  sugar has been
 present,  is carbonic acid.  The open arm  is  now
 filled  with  liquid  caustic  potash,  whereupon the
 opening is closed and the liquid shaken.   If the gas
 disappears the  urine contains  sugar, which, through
 the process of fermentation, has been decomposed
 into carbonic acid and  water.
  This test yields a reliable result, and is not very
 complicated.
  (b.) The following  method   is  a little  different.
 Filter  half a litre (a little less than half a pint)  of
 urine ; determine its specific gravity ; mix with it one
per  cent, of well-washed brewer's yeast  which has
 been dried in the air; cover it lightly,  and expose it
 for  one or two  days to the heat of a stove (from
 700—900 Fahrenheit).   Determine again the specific
 gravity of the urine at the first temperature.  Multiply
 now the difference in  number  with 219, and  divide
 the product by  1,000, in which  case the difference of
 crooi corresponds to a percentage of sugar amount-
 ing to 0*219 Per cent-   The yeast which has been
 precipitated, the  transparency of the urine, the dis-
 appearance of foam, and, again,  the fact that the fer-
 mented urine,  when subjected to the copper test, is
 unable to  reduce the  sulphate of copper, all  this
 shows  that the  fermentation has been accomplished. 
          Diagnosis of Diabetes Mellitus.         83
  In order to test the purity of the yeast repeat the
experiment with normal urine or with water.
  III.  The test of polarization.—The examination of
the urine by means of the polarizing apparatus of
Soleil-Ventzke,  or  by  that of  Mitscherlich,  or,
again,  by that  of  Wild,  can be executed easily and
quickly ;  for,  if  any grape-sugar is  present in the
urine,  the plane  of  the  polarized beam of  light is
rotated to the right,  while  fruit-sugar (laevulose), as
is well  known, rotates it to the left. According to the
greater or less amount  of  rotation  caused by the
greater or less  amount of sugar, the lines of gradua-
tion in the apparatus indicate a greater or less per-
centage  of  sugar.   The  optic test, it is true, does
not always tally with the chemical analysis.
  A popular description of  the apparatus of polari-
zation, intelligible to all,  is furnished by Bernstein.
  Additional  methods for determining sugar have
been recommended by others, e.g., by Pavy,  Knapp,
Vogel.   The latter gentleman draws his inferences
as  to  the percentage of sugar from  the lighter or
darker colour of the test by caustic potash.   Canary-
yellow, according to him, corresponds to 2 per cent.
of  sugar, the colour of  dark Jamaica rum  to 5 per
cent., a dark blackish brown colour to 10 per  cent.,
etc.
  The amount  of sugar.—The quantity of sugar in
the urine, according to the food, mental excitement,
movement of the  body, etc., differs from one-half to
8 per  cent.; according  to  Segalas  and  Lehmann it
reaches  even  14 per cent.,  and a still higher per- 
84                  Diabetes.
centage.   Such  a  high  quantity I  have  never
observed myself, and I have  to take it  for granted,
provided there is no cause for doubting the accuracy
of the observation.
  The daily amount of sugar by weight may  reach
500  grammes and   beyond,  although  the  average
weight is from 200—300 grammes.   The highest
quantity of sugar secreted, as observed by  Seegen,
amounted to 600 grammes per day.
   In  addition to  the  secretion  of sugar,  another
element of importance in the diagnosis of  diabetes
is the increased secretion  of urine.   It increases daily
from  two to five, yea, to  14 litres (= from i|  to 4|,
yea, to 12A pints).   Still, there are  cases of  diabetes
in which no considerable increase in the secretion of
the urine is noticed.
   Urea, also, owing  to the excessive consumption of
meat, increases in volume from 100 to 200 per cent.,
so  that  80,  and even more, grammes  have been
formed per day.   Gathgens discovered urea  and uric
acid  in still greater quantities during the febricose
state of patients.  Fiirbringer reports 160 grammes,
and Dickinson 142 grammes.
   Bhosphates and sulphates increase  at the same
rate.  Other substances also were found to  increase
in like manner.
   In some cases,  for instance,  Seegen discovered
phosphoric acid to the amount of 6'6 grammes per
day.   Senator found  creatinine,  Frerichs inosite.
Others  demonstrated  the  presence   of  salts  of
ammonia, of diacetic acid, of leucine,  acetone, etc.
Winogradoff,  Stopczanski, and  Gathgens, on  the 
           Diagnosis of Diabetes Mellitus.         85
other hand, noticed a diminution in  the secretion of
creatine.
  Sediments are mostly found only in the  beginning
of the active state of diabetes, namely,  uric acid and
oxalate of lime.   The  urine of polyuria, which is a
later  stage of the disease,  as  said  above, is  clear.
Nevertheless, it becomes turbid when  left standing
for a  considerable time, and the yeast-cells which are
then  formed yield whitish precipitates.
  A  characteristic  symptom of diabetic patients, in
addition  to the  polyuria  which gradually interferes
materially with  the process  of assimilation,  is  a
catarrhal  nephritis,  coupled  with a copious secretion
of albumen.
   The diagnosis of diabetes is more difficult, when
its  characteristic   symptom,  namely,  polyuria,  is
wanting; when,  therefore,  as the profession  calls
it, there is a case of diabetes decipiens.
  An  interesting property of diabetes,  for  the pur-
poses of  diagnosis, is  presented  by the fact that a
latent diabetes very often, by certain contingencies,
is instantaneously made  active ; for instance, by a
kick,  a blow, a fall; further, by mental  excitements ;
by  cares, over-exertion, a reflex action of the nervus
vagus or nervus trigeminus in  dental or ophthalmic
operations ; again, by a reflex action of the  sciatic
nerve;  by infectious  diseases,  such as Asiatic
cholera, diphtheria, typhoid  fever, small-pox,  scarlet
fever  ;  by chills, or constitutional  diseases, such  as
syphilis,  gout,  adiposis,  disease  of the  pancreas,
liver,  etc.
  There  is  no  doubt whatever,  that  in all  those 
86                   Diabetes.
cases where  diabetes  becomes manifest under the
influence of any of the above contingent causes, the
disease has previously been latent in the system.
  Diabetes,  consequently,  does  not  arise   from
marasmus, furunculosis, etc.; but,  on the contrary,
diabetes,  on account  of the faulty  assimilation of
the food, causes marasmus, furunculosis, diseases of
the eyes, ears, and lungs, nephritis, etc.
  Another  circumstance that has to  be borne in
mind in the diagnosis is this,  that in  active diabetes
the character of the food  is of comparatively small
import.  While, therefore, in  accidental glycosuria,
by abstaining from certain kinds of food, the per-
centage of sugar is diminished, or ceases altogether,
in diabetes  the urine contains  sugar, even  if the
patient lives on meat exclusively.
  A  further symptom  by  which  diabetes may  be
diagnosed,  is an  abnormal  feeling of  thirst  and
hunger.  V. Pettenkofer and  v. Voit explain the ex-
cessive thirst of diabetic  patients by the fact that
they secrete less carbonic acid and  less water than
healthy persons.   This thirst may be explained thus,
that healthy persons burn up more sugar, i.e., alter it
into carbonic acid and  water,  which are  excreted
through the skin and  the lungs ; while the diabetic
patients pass all  their  surplus  of  sugar  into the
urine.
  Other symptoms that often  strike  the diagnosing
physician in  a person suffering from diabetes, are an
abnormal  greediness, a  dryness of  the throat  and
larynx,  as   has long ago  been observed  bv  the 
            Diagnosis of Diabetes Mellitus.         87
 laryngologist Dr. Ch.  Fauvel;  further,  an emacia-
 tion  of  his  whole body,  and a  diminution  in  his
 power of resistance.
   I have noticed several exceptions to  this  rule in
 cases where active diabetes nevertheless did exist.
   The pulse of diabetic patients is usually sluggish ;
 their stool indolent ; although diarrhoea, on the other
 hand, has also been observed.
   An important symptom is  the  scanty secretion of
 saliva.   The reaction of the tough saliva  is sour;
 which may be explained by the growth of a certain
 fungus (Soorpilz) first  mentioned  by Friedreich.   It
 grows in the cavity of the mouth, and frequently
 causes a disease in the gums, by which they redden ;
 at  last  the teeth become loosened, and  drop  out
 without pain.
   The tongue is often  normal, yet frequently  also it
 is thickened, chapped, furrowed, and reddened. The
 papillae are  swollen, sometimes to  the size of  a pin-
 head, and even larger, which was pointed out already
 by Seegen,  with whom I agree on the  main.   He
 says, " On  closer examination it will be found that
 the tongue of persons suffering from diabetes is rarely
 quite normal, and repeatedly  I have been induced,
 by changes  that I noticed in the tongue, to examine
 the urine of patients, which was then found to con-
 tain sugar.  The changes I noticed are as  follows:
 (a) the tongue, almost always, is increased in  thick-
 ness ; it  is  wider  and  more bulky.  The  edges  of
the tongue  exhibit a fine, symmetrical' indentation,
 and appear  swollen,   (b)  After the changes have 
 88                   Diabetes.
 proceeded  further, the upper surface of the tongue
 exhibits  a  peculiar design, somewhat similar to the
 skin of a crocodile.  This  design originates from a
 network of fine, superficial fissures, which intertwine
 in  a  manifold manner,   (c)  These  fissures  some-
 times penetrate more  deeply into the tongue ;  some-
 times they  do so to the depth  of §'", and they  cross
 the tongue in all directions.  A deep fissure some-
 times passes  through  the middle of the tongue, while
 smaller fissures  extend sidewards and  transversely.
 These fissures, however,  are  by no  means bloody,
 nor are  they ulcerated ;  but  they are  sensitive on
 coming into  contact  with sour and sharp articles of
 food.   As  an illustration  of  the looks of such a
 fissured tongue, and  also as  an illustration  of its
 origin, I may point  to a lump  of clay which, when it
 begins to dry up, contracts and is   full of cracks.
 (d) Individual papillae and groups   of  papillae are
 very much  enlarged ;  they protrude   in the form of
 islands, like red  spots.  I observed some papillae, of
 the size  of moderate pin-heads.  In  one  case the
 papillae along the  edge of the  tongue were very
 much enlarged; the  whole edge was  unequal ;  it
 consisted of  excrescences and inlets, and  the indi-
vidual  enlarged papillae had the appearance of con-
 dylomes  on  top of them,  (e)  While  the normal
 tongue always makes  an impression  on the eye as
well as on the touching finger, as though it were not
always symmetrical; and again while it rather  looks
and feels like artists'  pencils closely pressed against
one another (papillae filiformes), on the  tongue  of a 
            Diagnosis of Diabetes Mellitus.         89
 person suffering from diabetes entire portions of this
 pencil-like  structure seem  to  be wanting.  These
 portions are  smooth, shining, bluish-red ; and while
 the normal tongue is often more or less covered, the
 above portions are entirely free of any deposit. These
 spots,  which sometimes  occupy only a small por-
 tion, of the size  of  1  ccm., often increase in  size,
 and fill the entire half  of  the tongue.   Such places
 often have a peculiar smell, like raw meat.   In these
 portions, again, you  meet with dense, white, dimly
 shining places.  The  histiological  significance of
 these  alterations is not yet  clear to me.  At first it
 seems as if  these portions were deprived of epithe-
 lium ;  yet the  above white  places seem rather to
 indicate a luxuriance of epithelium.  In some cases,
 also, there  are  ulcers of  the size  of lentils or peas,
 which are very  painful.
   " The changes described under the head of (e)
 remind  one of  those  syphilitic  affections of  the
 tongue  which  are  described  under  the  name of
 psoriasis linguae  and  keratosis.   Yet  in  the  first
 place  they  are not entirely analogous  to them;
 and, secondly,  I have repeatedly seen them in  per-
 sons where  a syphilitic  origin  could  be definitely
 denied." [?]
   Again, it  ought to be  mentioned  here  that  the
 breath of diabetic patients has an aromatic odour,
 like their urine;  it smells  like apples which have
 been sliced, or  like rotten  apples, and like damp
hay ; or again like fruit in process of  fermentation.
The cause of this phenomenon  seems to be a dimi- 
90                   Diabetes.
nution in the reception of oxygen, and a decrease in
the giving out of carbonic  acid.
  The skin of such persons is frequently rough and
brittle;  it scales off like bran ; it  has folds, and is
mostly dry.   Usually it feels cool, and exhibits a low
degree  of  warmth; although patients  with  good
lungs, who have been debilitated very much, some-
times are able to give out a considerable quantity of
perspiration,  which,  according  to  some (Forster,
Vogel,   Fiirbringer,   Griesinger,  Hebra),  likewise
contains sugar;  others  (e.g., Frerichs, Kiilz in Op.
citat., p. 68) found the perspiration  free from sugar.
  According to  Reich  and Liebermeister the  skin
and  lungs  of diabetic  patients  exhale  about  one-
third  of  the amount  of  water  evaporated  by  healthy
persons.   The  activity  of the  skin I  sometimes
found reduced to zero.
  Since  I regard diabetes as predestined in a certain
sense, that is, as transmitted  by  lues  from  ances-
tors, in  contradistinction from the physicians of the
new as well as of the old school, in  my diagnosis, I
direct my chief attention to the suppressed  activity
of the skin.
  Every patient  whom  I suspect of diabetes I ask
to undress, and I first of all  endeavour to examine
his  skin—an element of  diagnosis on which hereto-
fore no physician has laid much stress.
  Marks of  hereditary  lues, and  therefore of im-
portance  to  me, are the so-called beauty-spots,
warts, deposits of pigment, rank growths of  epithe-
lium,  white spots on  the  finger-nails, gouty deposits 
           Diagnosis of Diabetes Mellitus.         91
in the joints  of  the  fingers and toes,  especially in
those of the big toe ; further, barky epithelial growths
in the feet, etc.
   An unsafe symptom, and yet one which ought
still to be taken into consideration, is a vivid itching
of the  skin.  Another suspicious symptom  is  the
formation of fungi, caused by the sugar in the urine,
whereby an inflammation  is produced  in the male
genitals ;  and with women  an  insufferable itching
(pruritus pudendi) in their genital organs (the large
labia of the pudendum), which  itching may be over-
come by cleanliness.   One  single drop of  sacchari-
ferous urine which has dried up at the orifice of the
urethra  may cause there an itching and burning
sensation, with inflammation. In consequence of this
there arises sometimes with  men balanitis (gonorrhea
of the gland), phimosis, paraphimosis, psoriasis  in
the upper parts of the thigh, on either side  of  the
testicles; and with  women a  wearisome  eczema
(eczeme glycosurique) or prurigo of the labia, etc.
(See  Winckel's  article  in the " Zeitschrift  fur
praktische Medizin,"  1876).
   Often  boils and carbuncles seem  to form them-
selves by preference on the  labia of  the pudendum ;
again,  phlegmonous inflammations,  gangrene,  dis-
eases of the lungs.
   A  local cure in such cases by well-known remedies
is impossible ; for so  long as the fundamental cause
is not removed, a  mere palliative treatment can effect
nothing.
   Fits of ill-humour,   loss   of  memory, convulsive 
92                   Diabetes.
movements in  the  muscles,  sciatica (according  to
Berger, in " Breslauer arztliche Zeitschrift," 1883),
neuralgias (which  Drasche,  in  " Wien med.  Zeit-
schrift,"  1882, regards  as the consequences of a
toxical  effect  of  sugar  on the  peripheral  nerves),
may eventually raise a suspicion of  the existence  of
diabetes.
  In  advanced cases of this disease the power  of
vision decreases,  even as to lead to the formation  of
cataract, and to the production of other ophthalmic
troubles.   It also  gives rise to  mental  diseases,
sclerosis of the vessels, carcinomas in the pancreas,
rectum, breasts, and liver,  cedemas of the feet, face,
etc.    Sexual  languor,  also,  heightened into impo-
tence, sometimes serves to indicate  the presence  of
the disease.  With  women there occur disturbances
in the menses.
  So long as  there are  no inflammatory complica-
tions, there is no  fever.   On  the  contrary, the tem-
perature of the body, as mentioned above, frequently
is below the normal warmth, namely, between 340 and
36*5°, which observation was already made by Vogel
and  Dickinson.  The pulse  at  the same  time  is
mostly  big and  hard,  since  the arteries are  over-
filled.
  It is  an interesting feature that  in proportion  to
the progress  of  the disease,  hydrates of  carbon,
without being utilized,  i.e., without  being   decom-
posed  into  carbonic acid and  hydrogen,  appear
remarkably soon in  the urine in the  form of sugar •
and  that  the  albuminates, even in  an  exclusively 
           Diagnosis of Diabetes Mellitus.         93
animal  diet, are  not able to re-establish the equi-
librium  in the organism, so that the patient  loses in
weight.
  The fundamental cause of the illness sometimes
also causes  at first a  general  rheumatism of the
joints and muscles, etc.
   In children diabetes  frequently manifests itself—
a thing often overlooked—by a wetting of the bed.
Sucking  babes that  lose flesh  ought to have their
urine examined.
   A valuable help in the  diagnosis is furnished  by
the fact that the deteriorated organism of a diabetic
patient gradually  loses the  power of reproduction
and  assimilation, so  that,  for  instance,  wounds
which ordinarily close in a very short time require a
 proportionably  long  time  to  heal;   they incline
 towards suppuration, form chronic ulcers, etc. 
VIII.
THE  PROGRESSION,  PROGNOSIS,   COM-
     PLICATIONS,  AND  TERMINATION OF
     DIABETES.

After diabetes has entered upon its active stage, it
mostly runs its  course without fever,  and assumes
either an acute or a chronic character.
   Until within the most recent times diabetes has
been declared  incurable.   Seegen  (Op.  citat., p.
 125) says that among nearly 400 cases of diabetes
in his own practice he has  never witnessed a case of
perfect  cure.  He grants,  however, that by absti-
nence  from amylaceous  food it is possible  for
 diabetic persons to preserve themselves for years in
 a state  of  health,  and  that the body acquires  a
 tolerance for a certain quantity of  sugar, and gradu-
 ally accommodates itself to the sugar.   Senator (Op.
 citat., pp. 137, 231)  speaks of a cure extending over
 several years as being only a conditional, imperfect
 cure.  The  same term he applies to the transition of
 diabetes mellitus [?] into diabetes  insipidus, when
 followed by a cure.   Compare, also, the case which
 was observed by Plagge  (see Virchow's  " Archiv,"
 etc., xiii., p. 93).  Vocke,  therefore, exclaims (Op.
 citat.,  p.  84),   " Beat diabetes  is  equivalent  to
 death" 
           The Progression of Diabetes.          g$
  The prognosis,  namely, how  long  it is possible
to preserve life after diabetes  has become active,
depends :  (a) upon the  tolerance of  the  system for
amylaceous food ; (b) upon  the consistency of  the
patient in  following  the  dietetic  prescriptions ;  (c)
upon  the  physical  or moral  disposition  of   the
patient, since a patient of  a cheerful temperament
will progress more favourably than a hypochondriac ;
(d) upon the age, etc.
   The duration of active diabetes  differs very much
in the various stages  of life.
   In children it mostly leads  precipitously to death.
In my own practice, up to the year 1881,  I often  saw
diabetes acutus and acutissimus  cause death in
children, already in the short space  of from four to
eight weeks.  Becquerel even communicates the case
of a boy nine years  old, who died six days after he
had been seized with diabetes.
   Adult persons who, by a  rational  life, that is, by
an appropriate physical  and bodily diet, as well as
by the use  of the  Carlsbad  waters in  Carlsbad
itself, know how to  regulate  the consumption of
glycogen  and  to prevent  an over-production of
sugar, often enjoy a tolerable  degree of  health  for
years after the active form  of diabetes  has mani-
fested  itself.   Nevertheless,  according  to my  own
plentiful experience,  they are  not able  to  prolong
their sad existence much beyond  six years, although
in a few individual  cases such patients  have been
kept  alive for upwards of  seven or eight years.
Cases of longer duration I  have  always  considered 
g6                   Diabetes.
as  examples  of  simple  glycosuria,  which  I was
competent to heal even by the old-fashioned method
of treatment before 1881.
   Not unfrequently I  have come across communica-
tions from  even distinguished  inquirers,  such  as
Bence Jones, Lebert,  Dickinson, by  whom we are
informed  that in mild cases of diabetes the course
of  the  disease  has  been observed for upwards  of
20  years.  Doubts arise  in my mind whether such
communications are  really not due  to a mistake  on
the  part  of  the inquirers,  who  have  confounded
accidental glycosuria  with  constitutional  diabetes.
In  the  course of my  large  practice, which has ex-
tended  over  many  years,  I  have  not  become
acquainted with a single case of genuine  diabetes
the duration of which  was longer than  eight years,
although  I am acquainted with cases of accidental
glycosuria (especially among well-to-do,  corpulent
persons who lead a rational  life) which  have lasted
for 20 years.
  Sometimes  the disease seems to be  at  a stand-
still.  The abnormal thirst, the greediness  for food,
and the increased secretion of urine stop.   The loss
of flesh and the feeling of lassitude disappear.   The
physician who allows himself to  be deceived  calls
it  a cure, when all at  once the  enemy reappears,
more threatening than ever, and this time he will not
allow himself to be driven away again.
  Unless  one of the  usual  complications,  such  as
pulmonary consumption  (owing  to   a  defective
assimilation  of the food), or  carbuncle, gangrene 
            The Progression of Diabetes.          97
etc., cause  death, it mostly ensues  unsuspectedly,
instantaneously,  without  any outward  cause;  or,
again,  it  results in  consequence of over-exertion,
mental  excitement,  catarrh  of  the stomach.    It
occurs then with apoplexy, attended with attacks  of
paralysis, loss  of consciousness, and, indeed, it  is
caused by a peculiar complex of nervous disturbances
and brain symptoms, which are comprised under the
general term of " coma diabeticum," the terror of all
medical practitioners.
   The cause of death in diabetes is often marasmus,
exhaustion of the nervous centres, exhaustion of the
heart, which  brings about paralysis of the heart; and
this on the other hand presupposes a wasting away,
and a degeneracy of  the muscle  of the heart.  Coma
also ensues in the so-called diabetes insipidus, if the
patient  does not pass  away before by some inter-
current disease, or an affection of the brain or spinal
marrow.
   Prout, who proved the injurious effect of fatiguing
marches on  the  nerve-life, was  the first who made
mention  of  the complex of  symptoms  in coma
diabeticum.  Notable physicians, such as Griesinger,
Dusch,  Hilton-Fagge,  Taylor, but  especially Kuss-
maul, have noted and described similar observations.
Frerichs also devotes  a considerable portion of his
monograph on diabetes to a proof of the fact that
most  cases  of  this illness terminate in coma,  in
sudden death, which  is certainly  a discouraging sign
for practical therapeutists.
   But of what use to the  practical physician would
                                         H 
98                  Diabetes.
be this great number of  instances showing in  what
manner death overtakes those who are afflicted with
diabetes, if the discovery and the prevention of the
cause of this  mysterious  termination of human life
were to be regarded as impossible?
  That  portion  of his  material  which  Frerichs
gathered from experience for the purposes  of theory
and instruction, and which has a bearing  upon the
subject before us,  he divides into three groups.
Group  I. embraces those  persons  suffering  from
diabetes who all at once, perhaps after having made
an exertion, are seized  with a general weakness, and
who pass away in a few hours with cold extremities,
a small, sinking pulse, loss of consciousness,  and
somnolence in consequence of paralysis of the heart.
Group  II. comprises  those cases which  run  their
course in  from one to five days, and  with whom the
preliminary  stage  may be  diagnosed thus  : General
weakness, gastric  disturbances, sickness,  vomiting,
sluggish stools, pharyngitis, phlegmons of  limited
extent with inclination  towards gangrene, bronchitis,
pains in the head, chest,  and abdomen, a feeling  of
anxiety, dyspnoea,  accelerated breath with or without
cyanosis, a weak pulse, a sinking of the temperature,
until somnolence and coma  intervene.   Group  III.
includes those cases where diabetic patients, without
dyspnoea  and with no  feeling  of  anxiety, with a
moderate tension  of the  radial arteries,  and with
their  bodily  strength  in  a  comparatively  good
condition, are  seized  with  headache,  a feeling  of 
            The Progression of Diabetes.          99
intoxication, and  somnolence,  out of which  they
never awake.  Frerichs explains the " coma diabeti-
cum " by  an  alteration  in  the  nervous  centres,
brought about by a change in, and a  thickening of,
the blood owing to an increase in the  percentage of
sugar;  further,  by  uraemia,   embolisms  of  fat,
acetonaemia, as well  as by a  disturbance  in  the
secretions.   Petters,  Kaulich,  Cantani,  and others
suggest  a chloroform-like effect of, and poisoning
by,  acetone.  Griesinger  assumes  an  accelerated
formation of lactic acid ; Ebstein supposes uraemia ;
Loeb a gradual paralysis of the vagus nerve; Taylor,
Starr  and  Hamilton  suggest  embolisms  of  fat,
intoxication by carbonic acid, etc.
   I am of the opinion  that in most cases nephritis
is caused by the exciting,  stimulating substances
contained in the blood of diabetic patients ;  that in
consequence of the inflammation of the kidneys there
is a diminution in the excretion of the excrementitious
matters of  the blood through the urine; and that in
conjunction with the suppression of the  activity of the
skin, there is produced at  last through this cause
that blood-poisoning, that uraemia, and, indeed, that
self-intoxication which results  in the  coma diabeti-
cum, which manifests  itself  by  a kind of delirium,
intoxication, and giddiness.  Such is my  opinion,
although  Senator (Op. citat., p.  171) thinks that the
symptoms of coma do not correspond to an intoxica-
tion by uraemia.   Again, although  he seems  rather
inclined, in conjunction with Petters (who, however, 
ioo                 Diabetes.
was opposed by Frerichs), to regard the presence in
the blood of acetone as the cause of  those peculiar
symptoms,  the  experiments  made  by  Prof.   Dr.
Brieger in Berlin are certainly  contradictory to this
assumption.  Stadelmann (see " Archiv fur exper.
Path. u. Pharm.," xvii., p. 443)  suspects an intoxica-
tion by an acid, probably by crotonic acid.
   Anyone who adopts my theory of  self-poisoning
will  regard with  suspicion  all attempts  at com-
batting the "coma diabeticum."  What  possible
and impossible  things have  not been  recommended
and  done in order to overcome this coma!   One
medical practitioner thought the existing dyspnoea
ought to be relieved ; another that the action of the
heart  ought  to  be  stimulated   by  appropriate
remedies ;  still  another that the  secretion  of  the
urine ought to be increased; while a fourth main-
tained that  the excrementitious matters that have
accumulated in  the blood ought to be diminished.
It is a great pity that none of these gentlemen have
been  able  to point out the remedy  by  which  the
desired result is to be attained.
   Some of them, and among them the great clinical
authority, Kussmaul, proposed  a physiological solu-
tion of common salt, a  transfusion  of blood, an
intravenous injection of a solution of bicarbonate of
sodium, saline and  stimulant aperients ; again,  they
advised a return to a mixed diet, lavements, rubbings
of the  body with lukewarm water, in order to prevent
a recurrence of the attack.  But have their sugges- 
            The Progression of Diabetes.         101
tions  and proposals been  crowned  with  success in
practice ?
  There is  only one  means by which  coma can be
prevented ;  and this  one  means is combatting its
efficient cause, namely, hereditary lues.
  Here I  wish to point out that already  Seegen  in
his  work on Diabetes (p. 65) suspected a hereditary
diabetic tendency in cases where either the father or
mother have suffered  from affections  of  the  brain;
and, further, that Senator, like Seegen before  him,
assumed a  connection of  diabetes with diseases of
the central nervous system, especially with  epilepsy
and mental  diseases.
  I am able, at this day, to furnish an incontestable
proof of this connection ;  nay, I am able to declare
that there exists a primal consanguinity  among all
these diseases.
  At all events therapeutics are aided but little by
inquiries into  the character of the anatomical  sub-
stratum of this disease, the  changes  caused  in the
nerves, etc.   But  the  declarations  of Formad,
Veraguth, Schottelius (see   Virchow's  "Archiv,"
etc.,  1882), with regard to  the  state  of the  body
favourable  for  the development of  diabetes   are
simply surprising ;  for the first regards the disposi-
tion of the lymphatic  vessels, the second that  of the
alveolar epithelia, and the last the configuration  of
the  bronchia, as that  anatomical  element which  pre-
disposes for diabetes.
  Finally, I wish to  extend  Cornillaus' idea—who 
102
Diabetes.
teaches the connection of diabetes with gout and
rheumatism—so far as to define all these diseases
as branches of  one and the same root; and  I here-
with declare that in all those cases where it has been
possible  for a morbid  condition of the structure of
the protoplasm to be reformed and regenerated, such
a  condition  has  most assuredly  been healed  by
myself, and will be healed by myself again in  the
future. 
IX.
THE  SO-CALLED  CURES  OF   DIABETES
     THAT  HAVE  HITHERTO BEEN MADE
     ARE  ILLUSIONS.

Between 1861 and 1881  I have met in my practice
with many (over 200)  cases  of so-called  " neuro-
genous  diabetes "  (glycosuria), and of diabetes of
corpulent persons,  which cases,  according to my
present  system  of classification, are to be  classed
simply  under the  head of accidental glycosuria.
Such cases also I have frequently encountered after-
wards ;  and I have cured them. Other practitioners
have effected similar cures, without, on that score,
being able to declare that they have actually healed
genuine diabetes.
  Numberless cases  of accidental glycosuria may be
stopped almost without the aid of  drugs, simply by
a combination of an  appropriate  mental and bodily
diet, which shall be explained  below.  The cure will
be speedier if the warm, alkaline waters of Carlsbad,
etc., are applied.
  Claude Bernard says (in " Lecons sur le Diabete,"
1877, p. 70) :  " While  diabetes was formerly con-
sidered a rare, but always  deadly, disease, it is now,
in most  cases,  considered less serious  and capable
of being healed." 
104                  Diabetes.
  But Zimmer justly complains that with all that has
been  done by Bernard, the therapeutics  of  diabetes
have  not  been  advanced  by him in the least,  and
that the profession is still where it was when Rollo
determined  upon  his  empirical  treatment of the
disease, namely, upon a  diet of  meat and  fat.  In
making the above declaration Bernard had evidently
in his mind only accidental glycosuria.
  Frerichs  enumerates  some  few  cases  where
diabetes  has been healed.   Such  cases, according
to  his  declaration,  are  cases  of diabetes  after
neuralgia,  after  paralysis,  after  apoplexy,  after
mental excitements,  after  cholera,  after gout, etc.
  It is hard for me to contradict my former teacher;
nevertheless, in accordance with  the facts of my
experience, I am compelled to believe that he  also
mistook accidental glycosuria for  diabetes.   Let us
examine his so-called cures :—
  He maintains that in eight weeks Lady v. B., who
was 58 years old, after using the Carlsbad waters
and by being placed afterwards under  the influence
of kreosote, was  cured  of  an attack  of  diabetes
brought on  by  an  ophthalmic operation.   [Acci-
dental glycosuria!]
  Castellan  Hanel,  60 years  old, who, in conse-
quence  of  an  extensive carbuncle in the  nech
became diabetic, is said to have been radically cured
by the Carlsbad waters in eight weeks.  [Accidental
glycosuria !]
  The corpulent Mr. J. W., 70 years old, is said to
have  been relieved of all  his troubles at Carlsbad 
             Illusory Cures of Diabetes.          105
and  to have been thoroughly  healed  of diabetes.
[Accidental glycosuria !]
  The apoplectic landed proprietor, Barth, whom /
am inclined to regard as truly diabetic, was freed
from  sugar  after three years,  but he  died of an
effusion of blood in the brain [arterio-sclerosis.  Can
this be called a cure ?]
  The Cabinet-minister  v. G. was cured after three
years ; but he died of an effusion of the  blood in the
brain [arterio-sclerosis.  Was that a cure ?]
  A diabetic professor lost his  sugar, but he DIED
after a few months of marasmus, by a quickly grow-
ing cancerous swelling.  [Was that a cure ?]
  Diabetes after cholera was healed.   [Accidental
glycosuria!]
  Patient  No.  8,  who  suffered  from diabetes after
mental excitement, did not exhibit  any more sugar,
but he remained ILL of catarrh in the stomach.
  Case No. 9 RETAINED catarrh of the bladder.
  Bookseller  Sch. (case  No.  10) did  not  die  of
coma; but, after attempts  had been made for 20
years to cure  him,  he died of  inflammation of the
lungs !  [Does this prove a cure ?]
  In case  No. 11 the sugar disappeared after two
years,  but " cataract was fully developed."
  Lady v.  St., from P., who was plethoric and corpu-
lent,  was  healed; but she  DIED of nephritis and
dropsy, which are  regular consequences  of diabetes,
and which  prove the existence of active  diabetes.
  In summing up  the  cases quoted by  Frerichs, he
has not, in my opinion, cured a  single case  of true 
106                  Diabetes.
diabetes.   Feeling the  insufficiency  of  his  own
method of cure, he  exclaims,  "Alas!  the  termina-
tion of diabetes by a cure is very rare indeed ! "
  In  the  course of  his monograph Frerichs states
that  sometimes diabetes  mellitus   gives  way  to
another disease, of   which  the patients  die,  e.g.,
nephritis,  arterio-sclerosis,  diabetes  insipidus, etc.
But  he  forgets  altogether  that   these  so-called
" succedaneous  diseases"  lie  in  the  very  current
of diabetes mellitus,  and  that  in the end it matters
little  what direction  the  enemy  takes, since  his
victim, without  any  hope  of escape, remains in his
clutches for all that.   Thus, for instance, a lady,  56
years old, dies of marasmus, although, according to
his account, diabetes mellitus had already  been suc-
ceeded  by diabetes  insipidus.   Another patient  he
dismissed as  cured,  whose  diabetes, I suspect, was
simply accidental glycosuria.
  I am  inclined to apply  to Frerichs and to others
who  declare  that they  have  cured true  diabetes
the following language of  Senator which he  used
in respect  to Morton: " Morton's statements that
he healed completely his  three patients makes  it
doubtful whether  they really  suffered  of diabetes
mellitus."
   This opinion of Senator is significant as express-
ing his view in respect to the general  curability of
diabetes, which is also doubted by Seegen, who says
(Op.  citat., p.  124),  " Of the  140  cases of diabetes
which I had  occasion to observe  I have not seen a
single case which was completely healed." 
            Illusory Cures of Diabetes.          107
  Frerichs was often in doubt whether he had before
him  a case of real diabetes  or merely a case  of
accidental glycosuria.  It is possible that where he
claims to have effected a cure  of  diabetes he  had  in
his mind  only  what I would  call glycosuria.  The
following  circumstance  seems to prove this,  for he
closes his monograph with an enumeration of those
cases where diabetes resulted in  death, and where
he uses the words of Senator (Op. citat., p. 230) :—
" The usual termination is   death; death by pul-
monary consumption (34 times);  by marasmus (18
times) ; by pneumonia (seven times) ;  by nephritis
(eight times) ;  by paralysis of the brain (twice) ;  by
effusion of blood  (once) ; by  softening  of the  brain
(twice) ; by meningitis cerebro-spinalis (three  times);
by formation of carbuncles (seven times) ; by coma
 (seven times) ; by other complications  (nine times ;
among which were six cases of  carcinoma).
   What a shocking confession  of those authorities
who have written on diabetes  !
   Let us rejoice  that we are  able nowadays to pro-
 claim : Diabetes mellitus is curable  ! 
X.
THE OCCURRENCE  OF  DIABETES ;  MOR-
     TALITY AND THE RESULTS OF POST-
     MORTEM EXAMINATIONS.

The possibility was  suggested  that the occurrence
of diabetes in  certain places and localities (e.g., in
Ceylon) was due  to the  influences of the climate.
There would be a meaning  in such a suggestion if
it were possible to trace the history of  the disease
and to observe its development; and if those places
could  be  determined where   luetic  or  venereal
diseases, the  consequences of which  are  manifest-
ing themselves in the  present generation, were once
prevalent.
   From 1861-1870 no less than 6,494 persons died
in England and Wales of diabetes.   It is interesting
to note that 1,194 of these cases  were  reported of
persons from 55 to 65 years old, and only 830 cases
of persons from 65 to 75 years of age.
   Among 104 diabetic patients Schmitz reports 38
cases of persons whose  age ranges between  50  and
60 years.
  Among  165 diabetic  patients  Griesinger  found
that  the  age   of  the majority, namely,  91,  was
between 20 and 40 years.  Only two persons  among
the  165 ^ere seventy years old; while  Schmitz
counted four among his 104 cases. 
      Statistics and Post-mortem Examinations.    109
  Seegen, among whose 140 diabetic patients there
were 100 men and 40 women, compiled the following
table: —From  ist-ioth  year=o ;  from 1 ith-20th
year=5 ;  from 2ist-3oth year=40 ;  from 3ist-4oth
year=2i ; from 4ist-5oth year=33 ; from 5ist-6oth
year=43 ; from 61 st-70th year=i4 ; from 7ist-8oth
year=i.
   My own  experience  and  my  own notes confirm
these  communications, and  I  might multiply them
if it were of consequence.  According to  my notes
also  active diabetes  occurs  most  frequently  in
persons  between the  35th and 55th  year of  their
life.
   It would be  interesting to  know  what circum-
stances  conspired in keeping  the diabetes of some
of  the above patients latent until they had reached
such a high old age?—provided their medical advisers
did not mistake  transitory, accidental glycosuria for
 diabetes—why,  therefore,  the sugar in their  case
was used up without being conveyed into the urine ?
 Or, better  still:  Why  the production of  carbonic
 acid proved  sufficient  to  check the  formation  of
 sugar in their case,  and to make it normal ?
    If Senator (Op. citat., p.  122) is of the opinion
 that diabetes frequently begins in  early years, and
 continues  into  high old age  ; in my opinion  acci-
 dental glycosuria only can be meant by him.
    In  order  to  find out  the causes of  diabetes,
 Frerichs also subjected  no less  than 400 cases to
 a  careful examination.   In his list there were five
 diabetic patients between the  1st and the 10th year ; 
no
Diabetes.
29  between the 11th and  20th year; and thus  in
succession in every  additional space  of  ten years,
42, 71,  101,   105,  42  and  5  persons; so  that
according to Frerichs'  observations the highest per-
centage occurs between the 40th and 60th years of
human life.  Two-thirds  of his patients were male,
and one-third female patients.
   Among  Frerichs'  400   diabetic  patients,   102
belonged to the Semitic  race.  Seegen found  36
Israelites among 140 diabetic persons ; thus 25 per
cent., just like  Frerichs.   Zimmer noticed 22  per
cent, of Israelites ; and  Hertzka  50 per cent.—that
is, among 86 diabetic  patients there were 40 Jews.
He believed that this was due to the Jews frequently
marrying elderly wives.
   My  opinion  is,  that  on  the one  hand,  Jewish
patients  prefer to be treated  by physicians of their
own religious  persuasion,  many of whom practice
medicine in the convenient Carlsbad.   But another
reason why relatively more  Jews than  Christians
(according to  Seegen the  former constitute 10 per
cent, of  all the  frequenters of Carlsbad)  prefer the
costly experiment of regaining their health at Carls-
bad to a  treatment  at home or at a hospital, must
be sought for in the fact that the Jews are generally
better provided  with pecuniary  means.  Moreover,
the Jews are usually more anxious about their health,
and this anxiety with  them  has frequently become
intensified.  The same is the case with ladies, only,
from  a  sense  of economy or from  attachment  to
their families,  they often  prefer to await death  at 
      Statistics and Post-mortem Examinations.    111
home rather than to suffer from nostalgia in a distant
watering place.
  In order to furnish an anatomical foundation of
the disease,  some  physicians have carefully noted
the condition which the bodies of persons who died of
diabetes exhibited in post-mortem examinations.
   Seegen carefully examined the records of the post-
mortem examinations at  the  general hospital (Allge-
meine Krankenhaus)  in Vienna  from 1838 to 1870.
He found 30 reports of  the anatomical condition of
such bodies.   Not a single case  could he find where
a change had been  undergone by any organ.
   Richardson, on the contrary,  mentions a tumour
of  the   size of a  bean  in the  brain  of  a diabetic
patient,  caused  by  brain  disease.  Seegen ^also
mentions such a tumour  of the size of a nut.   Some
dissectors found an alteration in the pancreas (e.g.,
Recklinghausen, Fles, Hartsen).   Others, again, in
several cases, found  the kidneys  morbidly altered ;
also  in  most  cases  the  lungs.   Diseases  of  the
stomach and  bowels also  have  been  mentioned;
these diseases were  probably the result of a change
in the assimilation of the food.
   Frerichs shows in  five cases  that the  local affec-
tions  of the nervous system have  " mostly "  been
confined to the medulla  oblongata, the pons  Varolii,
and the cerebellum ; and  that they " rarely " extended
into the hemispheres.  In syphilitic affections of the
coatings and vessels of the brain the case is the same.
 Six times he found new  growths ;  as was shown also
 by  Rosenthal, Recklinghausen,  Mosler, Perotow, 
112
Diabetes.
Lionville,  Reimer, Weichselbaum,  Dombling,  and
others.
  The spinal marrow  he found altered in one case
only.   The smaller vessels of the medulla oblongata
were much enlarged.
  In half of the cases  he found the lungs and the air
passages diseased  [tuberculosis] ;  inflammation of
the lungs in these cases had frequently caused death.
  The heart appeared to him  mostly  small  and
affected by atrophy;  not unfrequently he  found a
development of chronic arteritis.
  The stomach  sometimes  was   unaffected,  and
sometimes  it was enlarged.  The liver  and spleen
were mostly normal, only now and  then  they  were
abnormal as regards size.
  Twenty-eight times  the pancreas  was normal;  12
times it was abnormally  affected  by atrophy.  The
kidneys often  appeared  normal ;  in  some  special
cases he found them  small and  pale, or large  and
abounding  with  blood.  Still  Frerichs  considered
himself obliged to assume a glycogenous  degene-
racy of the small canals of the   kidneys, whereby
they lost their  power  of resistance as a constant,
anatomical  product.    [A  succedaneous  stage  of
diabetes ?]
  Frerichs  enumerates  58 cases  of  post-mortem
examinations which I  have studied carefully.   Of
what  great  therapeutical  value  are they ?  Alas !
he has been as little able by these cases to demon-
strate the organic changes and causes of diabetes as
their anatomical foundation. 
      Statistics and Post-mortem Examinations.    113
   The  declaration  that  a tumour of the size of a
 hazel-nut  in  the hinder convolution  of the  right
 temporal lobe ;  and, again,  that  a tumour of the
 size of  a pea in the  cerebellum actually serve as an
 anatomical foundation   to diabetes, ought to  be
 opposed most strenuously ; for wherever there is no
 hereditary lues, such tumours will  always run  their
 course  apart from diabetes, yea,  even  without  any
 accidental glycosuria.  In  spite of the most scrupu-
 lously exact post-mortem examinations of the bodies
 of  persons who  died of diabetes,  surprisingly  few
 bodies were found in which the changes  in the brain,
 so far as  their anatomical  localities are concerned,
 were of such a kind that  I would dare to derive from
 them the cause  of  diabetes.   In by far the greater
 number of the bodies of persons who died of diabetes,
 where changes in the  brain have been proved, these
 changes,  without doubt,  have to  be looked upon
 rather as consequences of diabetes than as the causes
 of the disease.
  Serious  objections  also  may  be  raised  against
 other theories raised  on  the ground of post-mortem
 examinations.   Thus  the severest kind  of diseases
 of the  lungs  have   been observed, in   which  the
 reception of oxygen  was  greatly disturbed (dys-
 pnoea), and yet not  even the  slightest secretion of
 sugar in the urine was noticed.
  The derivation  of  diabetes  from  diseases of the
stomach and liver can be refuted in like manner; for
in the most serious  affections of  the stomach  and
liver the  urine is often  free from  sugar.  On  the
                                          I 
114                  Diabetes.
other hand,  again,  in severe  cases  of  diabetes the
stomach,  as well  as  the liver, have  been  found
perfectly normal.
  After communicating  the  sum  of his  58 post-
mortem examinations, Frerichs confesses  that  he
is not able to give an account of the processes that
take place in the  protoplasm of  the liver-cells.  His
learned disciple, G. Salomon, knows as little concern-
ing these processes, as other mortals have found out
since his time.   Ebstein only is on the right track.
   Thus far it has not been possible to prove in a single
 case that diabetes depends upon any alteration in any
 particular organ.    How  many physicians since the
 time of Celsus have looked for the cause  of diabetes
 among the  consequences  of  this  malady!  How
 many have  looked  for organical causes, for a visible
 anatomical  substratum, for gross anatomical changes
 without discovering anything whatever except purely
 accidental  complications or  secondary affections,
 like phthisis, which were consequences of  diabetes.
   Some  interest in the subject and  patience are
 required  in order to wade through the heaps of barren
 and prolix dissertations and papers on the subject of
 diabetes  ; and to consider  and digest all the unripe,
 ripe, and over-ripe lucubrations of practical and un-
 practical physicians, medical candidates, and theoriz-
 ing medical lecturers on this  same subject.  Most
 authors have battled against the  devastating waves
 of  this disease at the mouth of the river, and not at
 the distant fountain-head. 
XI.
TREATMENT OF  DIABETES  (THERAPEU-
                     TICS).

The steps in  advance that have successively been
made in the art of healing have ever exhibited the
same  kind of  progression  which we also notice  in
the advancing course of human nature, as well as in
the world  of outward phenomena around us.
  The secret of a rational  method of healing is the
maintenance  of the  change  of  substance  (Stoff-
wechsel)  in agreement with nature.   The object of
this method is, to direct  into  normal channels the
disturbed  transformation  necessarily  undergone by
the bodily fluids, and to correct the wrongly consti-
tuted  protoplasm which has become incompetent to
perform its functions, so  as to prevent diseases,  or
to remove them.
  A rational practitioner, therefore,  will direct  his
attention first of all to the entire system of the organs
engaged in carrying  out  the  change of substance,
namely, (a) to those  organs which are receptive  of
substance, i.e., which prepare the blood, namely, the
digestive  organs and those which minister to respira-
tion ;  (b)   to those which  distribute the substance,
namely, the heart and the vessels which are put in
charge of  the circulation ;  (c) to those organs which 
n6
Diabetes.
excrete substance and purge the blood, which organs
include the lungs (also mentioned under  a), further,
the liver,  the spleen, the  secretive organs  of  the
urinary apparatus, the bowels, and the  outer skin.
  The material operated upon by the change of sub-
stance (Stoffwechsel) has  to pass   through sundry
processes of transformation  before it is rendered fit
to serve in the building  up, and in  the maintenance
of, the bodily organism.  Through the action of the
saliva upon  the food  which is masticated in  the
mouth it is first  prepared  for reception  in  the
stomach.
  The soluble ingredients  (e.g., the sugar) are  dis-
solved,  and  the insoluble  starch  is  changed  into
dextrine and grape-sugar.  Through the chemically
dissolving action of the secretions of the stomach
(stomachic  mucus  and gastric juice, which juice
consists chiefly of  free muriatic acid and a ferment
called pepsine) the food is rendered  fit to  be  pro-
perly digested, and the continued transformation of
starch into  sugar  which  was  commenced  by the
saliva is accomplished.
   Before the chyme (the pulp  of food) passes from
the stomach into the intestinal canal  it has to pass
through the  supervision of the pylorus, which,  in a
normal  condition,  does  not  suffer  any  undigested
food to leave the stomach.   A  new digestion ensues
in the intestinal canal.   The chyme is  there exposed
to the action of the intestinal  juice, which consists
of the bile that enters into the duodenum, and  also
of the pancreatic  jui£e.  The acid reaction of the 
              Therapeutics of Diabetes.           117
chyme is changed  thereby  into  an  alkaline one.
The starch which has hitherto remained unchanged
is  altered by  the  pancreatic  juice into  sugar, etc.,
and  the undissolved albuminates  are altered into
peptones.   The latter substances,  the formation of
which was started already in the stomach through the
action of pepsine, are easily diffused through animal
membranes.
   Additional transformations take place through the
action of the intestinal juice, e.g., the transformation
of cane-sugar into grape-sugar.  The fermentation of
butyric acid and of alcohol likewise takes place there.
   The so-called chyle is  extracted from the chyme
and  transferred into the blood  by  the absorbing
lymphatics  and by  the  glands  and intestinal villi,
which  consist of least ducts (about four millions of
them).
   All depends  upon this chyle and upon the forma-
tion of the blood, the quality of which is determined
by that of the chyle; for the blood  has to furnish
the material for the maintenance  of the change of
substance and  for the building up  of  the organism,
wherefore this  chyle may be styled the dissolved,
liquid, organism of the human body.
   The excretion of useless material is carried on by
various organs.  The lungs excrete in great abun-
dance  altered  sugar,  namely,  carbonic acid and
water, while renovating at the same time the venous
blood by conveying oxygen to it, and also by impart-
ing to it the faculty of assimilation and  the possibility
of building  up the organism, vindicating  thereby 
n8
Diabetes.
for the work of respiration the highest mission in the
continuance of  life.  The  intestines  cast out the
useless residuum of the food.   The urinary organs
dispatch  the residuum of the albuminous and fibrous
ingredients out of the body, while the skin excretes
the sebaceous and other matters which when con-
densed appear in the form of perspiration.
  A glance upon these processes which are carried
out in the daily change of substance (Stoffwechsel)
shows that all the organs in the body can exist only
when the requisite ingredients of the blood are duly
commingled in it, and when there is  a normal forma-
tion of protoplasm as its natural result.
  Good  curative results,  therefore,  can be obtained
by a physician only when in the case of a hereditary,
faulty protoplasm he does not undertake any merely
symptomatic cures, but regards  the peculiar assimi-
lation of the food by the  body as the chief cause of
the progression of a disease.  A disturbance in the
change   of substance   (Stoffwechsel), as Blumberg
and Steinbacher justly  observe,  is the  root of most
diseases, and, therefore,  a  faulty formation of the
protoplasm.
  Healing, in the modern sense, means maintaining
in a normal  condition  the change of substance,
regulating  that  change  when  it is  disturbed and
directing it again into its proper channels.
  This is  the fundamental principle  of my thera-
peutics in  all specific diseases,  and  particularly  in
dealing with diabetes.
  Like nature's practitioners (Steinbacher, Priessnitz, 
              Therapeutics of Diabetes.          119
Schroth, and others), by exciting in the system new
activities, and, indeed, by employing in a rational
way all those factors or agencies which are indicated
by the pathogeny of a disease, I endeavour to elimi-
nate from the human system the elements by which
the change of substance is disturbed.
  Although  our  art  of healing, even in the most
recent times, has not been able to heal a single case
of diabetes,   since  hereditary or  connate  defects
in the protoplasm cannot be removed by  a  mere
application of medicinal  remedies  (see Ebstein in
Op.  citat., p.  193);  nevertheless,  by its  sympto-
matic, empirical method of treatment it has limited
in an essential degree the deadly nature of diabetes,
and it has at  least  mitigated the  symptoms  of the
disease.
  The best results are obtained, and will be obtained
in the future,  by a proper combination of hygienic,
dietetic, and  remedial agencies.
  Scientific attempts, based  on  definite  principles,
to combat diabetes  by dietetic agencies have only
been made since the close of the last century.
  J.  Rollo in his memorable  treatise " On Diabetes
Mellitus" (London,  1797) was the first who recom-
mended a dietetic treatment  of diabetes as a thera-
peutic remedy.  His recommendation has gained the
approval of the profession even to the present day.
  Rollo  prescribed almost exclusively  animal food
and  fats,  and  especially  rancid   fats,  which  he
rendered more effective by alkaline and calcareous
substances. 
120                 Diabetes.
   Wm. Prout, in his work entitled "On the Nature
 and Treatment of the  Diseases of the Stomach and
 the  Urinary Organs "  (translated from the English
 by Krupp, Leipzig, 1843), likewise recommends fats,
 because they increase the secretion of saliva, and
 diminish  thirst.  Butter he calls the most agreeable
 form of fat.
   Nourishing food, difficult to digest, such as fish,
 tripe, the mouth of oxen, etc., was recommended for
 combatting  diabetes by Alexander v. Tralles.
   Many practitioners  after him prescribed fats, and
 justly so ; for  they  are  burnt  up into carbonic acid
 and  water, and  thus  protect the glycogen and the
 albuminates  in  the  system,   and,  consequently,
 diminish  the  sensation  of hunger and thirst  in
 diabetic  patients,  and  counteract autophagy—the
 process of consuming one's own self.
   Whoever  withholds fats from diabetic patients
 commits  a  blunder,  since patients  by  eating  fat
 neither  become fat  themselves, nor is  their blood-
 supply  diminished (see Ebstein, Op citat., p.  199).
  An exclusive meat-diet, carried out consistently,
 may become  fatal, as is  proved by the so-called
 Banting-cures.    Voit  says (in " Physiol, des allg.
 Stoffwechsels," Leipzig,  1881) that in such a treat-
 ment the most abundant supply of albuminates does
 not suffice to preserve  the body in a proper albumin-
ized condition.
  Following the precedent of Rollo, other physicians,
such as Bouchardat, Dickinson, v. During, Cantani,
Seegen,  Naunyn,  Voit,  Pavy, Boucheron, Bence 
              Therapeutics of Diabetes.           121
 Jones,  M.  Traube,  and  others, prepared  dietetic
 instructions for diabetic patients.   These  we shall
 examine below.
   Ebstein, in giving  his noteworthy advice to resort
 only  to  dietetic treatment, starts from  the position
 that  in a normal condition  of the body, under the
 influence of  diastatic ferments, only so much of  the
 glycogen stored up in the body is altered into species
 of dextrine and sugar as  is oxidized completely into
 carbonic acid and  water ; while in  diabetic persons
 the  amount  of carbonic  acid formed  in  the  pro-
 toplasm no longer suffices to  regulate the diastatic
 ferments, which therefore exert in them  a  more
 powerful effect.   Glycogen, consequently,  being no
 longer protected is transformed into easily diffusible
 species of sugar, which quickly pass into the liquid
 portions of the  body,  where  they  produce hyper-
 glykaemia, and generate what is  known  as  constant
 glycosuria.
   The defective protoplasm has to be made normal
 again.  Can the medical practitioner effect this ?
   My answer  is,  Yes,  if he  aims at altering  the
 disposition of the protoplasm, and  at  regenerating
 the protoplasm and the entire blood; if he makes up
 for the considerable loss of organic substances in a
natural  manner, and  if in addition to the medicinal
agencies,  wherever they are indicated, he prescribes
as a conditio sine qua non, 2, hygienic treatment, as
well as a careful mental and bodily diet.
  In respect  to  mental diet, Franciscus Place, in his
inaugural dissertation, " Concerning the  true cause 
122
Diabetes.
of Diabetes" (1784), 'uses the following language
which still holds true at the present time, " Frustra
remedia  exhibentur, nisi  adsit  placida  ilia mentis
tranquillitas,  animi ilia serenitas,  quae   non modo
remediorum efficaciam auget,  sed  ipsa remedii prae-
stantissimi  instar  vitia  corporis medetur."  These
words, in an English translation, read as follows, " It
is vain to apply medicines, unless a patient possesses
that tranquillity of  the soul, that serenity of the
mind, which not  only  heighten the  effect of the
medicines,  but which, like the most potent remedy,
even heal the infirmities of the body."
  The object of mental  diet  is to avoid rigorously
all  physical excitement, all fatiguing  mental work,
all  care  and all troubles, since  it has been proved
that all  kinds  of mental excitement increase the
amount  of  sugar  in  the  urine.  Some  propose  to
conceal from the diabetic  patient his condition ; but
on  psychological  grounds  I  must protest against
such a course.
  Under the head of mental diet also comes placing
a diabetic patient, if possible,  under the  influence of
a  pleasant,  home-like,  new  climate, and among
cheerful  people, not worried by care.   Thus an in-
habitant of the North, where often the  summer is
nothing  else than a winter  painted  green, outfit
during winter-time to be  transferred  to the sunny,
lively Riviera, which exerts an exhilarating effect on
the mind, as well as upon  the  heart.
  In  summer, during the time which is generally
devoted to  the care of the health,  a diabetic patient 
              Therapeutics of Diabetes.          123
ought  to select  as a place of  abode a  watering-
place containing warm, alkaline springs, like Carls-
bad.   As  a central intermediate station  between
Carlsbad and the  Riviera, and vice versa, and also
for an after-cure I would  recommend the superbly
situated  Hotel Belle Vue  au Lac, in the  mild and
cheerful  Zurich, where there is a prospect that the
patient will  find  all those appliances which are
required  for  the treatment suggested by myself.
   A warm  climate  is recommended  to  patients
suffering from  diabetes also on  this ground, that a
warm  climate,  as has  already  been observed by
Dancel (in " De l'influence des voyages sur l'homme
et sur les malades," .Paris,  1858),  stimulates the
secretion  of  the  perspiration,   and  relieves the
kidneys.
   Movement.  Muscular activity.—The  plan  of
life  prescribed for  diabetic  patients  requires  first
of  all regular exercise in open, fresh, good air.
While formerly (e.g., by Rollo) the patient was for-
bidden to take any exercise at  all, on the ground  of
its being injurious,  ever since the  time of Trousseau,
who prescribed daily exercise and muscular exertion,
especially  for corpulent persons,  muscular  activity
has been introduced as affording great assistance  in
the  therapeutic treatment of  diabetes.   As to the
rest, Trousseau regards diabetes simply as an indis-
position, and not as a disease.  Bouchardat also (see
" Supplement a l'Annuaire de  Therapeutique," etc.,
Paris,  1846,  p. 217), whose diabetic patient while
doing  rustic work  in summer bore amylaceous food 
124                  Diabetes.
very well,  is  in  favour  of regular  exercise.   The
necessary muscular activity for such persons is ob-
tained by  light work in  the  garden, by playing at
billiards  and skittles, by  using dumb-bells, fencing,
rowing, splitting wood, taking gymnastic exercise,
by walking  moderately uphill, by hunting, and  par-
ticularly  also by riding on horseback.
  Kiilz made  the influence of muscular labour in
five persons the subject of careful investigation, and
he  showed  that  bodily  exertion  is  indeed  able  to
control the formation of sugar, although he was also
obliged  to  confess that  in  some individual cases
muscular labour had an indifferent effect, nay, acted
even  injuriously.
  O.  Nasse ("Berl.  Centralblatt,"   1884,  p.  250)
deems it very probable that the muscles destroy the
sugar which has made its way into the blood, i.e.,
that they use it for forming carbonic acid.
  According to Ebstein, the  decrease in the forma-
tion  of  sugar  during muscular activity,  and its
increase  during  a state  of rest, is  due to an in-
creased formation of  carbonic acid during muscular
action, and  to  a  decrease in  its formation during a
state  of  muscular rest.
  K.  Zimmer, formerly  a consulting physician  in
Carlsbad, is  of the  opinion  that in all cases  of
hepatogenous diabetes the real cause of the disease
is attacked  by muscular  exertion;  yea,  he is  con-
vinced that  cautious, consistent  muscular move-
ments which are extended to  all the large muscular
groups, in conjunction with a  plentiful  meat  diet 
              Therapeutics of Diabetes.           125
are able to heal many  cases  of  hepatogenous  dia-
betes,  or, at  least, that by them the patient is kept
for a longer time in a condition in which he is able to
act. He further declares that the effect of muscular
exertion  is more lasting than that of a diet accord-
ing to  Rollo.
   Cantani endorses these views.
   Those who are opposed  to  exercise and muscular
action in diabetes,  object that  it  is   immaterial
whether the sugar is  secreted through the kidneys,
or  whether it is  burned  up  during  exercise,  and
during muscular labour, etc.   Nevertheless,  if  you
consider that during muscular exertion the rush of
blood is led away from  the liver, as well  as from all
abdominal organs,  and  is directed  towards  the
muscles ; that the sugar therefore is conveyed  then
into the muscles in order  to be utilized there for the
production of heat;  if you take into consideration
therefore that  through exercise there  is brought
about  a consumption of glycogen and  a production
of carbonic  acid  and heat;  and,  further, that the
muscles  are  strengthened  by  this  means,  and that
the change of substance  and  the transformation of
substance is  promoted thereby, whence there arises
an improvement in the whole  condition of the body,
you must needs hold in high  estimation a means of
bodily culture whereby the change or alteration in
the composition of the body is promoted.
   V.  Mering  reports, on  the basis of observation,
that the  secretion of sugar  was stopped for some
time by increased bodily exertion.   His patient was 
 126                 Diabetes.
 allowed to turn the wheel of a  machine  by which
 soda-water  siphons  were filled, of which work  he
 was very fond.   After one hour  and a half  already
 he was free from sugar, and, indeed, at a time when
 he lived altogether on a meat diet.
   This statement, however, is counterbalanced by a
 case reported   by  H.  Oppenheim,  in  Pfliiger's
 "Archiv," etc., for 1881.  He states that a  woman
 was visibly reduced in  health by  pumping water
 every day, and  that the secretion of sugar was not
 influenced at  all  by her  exercise.   [Who  knows,
 however, what  kind of food this  poor woman was
 obliged to  live  upon, and whether  she performed
 this severe labour willingly or unwillingly /]
   In every particular case you have to individualize -.
 This fundamental rule  must never  be lost  out  of
 sight,  least of  all in diabetes.  What  is easy for
 persons of a strong constitution,  persons of  a weak
 constitution will   not  be able to  bear.   What  is
advisable for young men and the male sex generally,
is  not  necessarily so for old  men and  the  female
 sex.
   In medicine you must guard against working by
rote, and against applying one general  rule  to all
things  and  all  persons.   Zimmer's  examples  also
prove this.   In  14 cases he demonstrated the great
use  of  muscular  exertion,  while  in  his remaining
cases he is obliged to confess  the  reverse, so that
he  felt bound to advise a CAUTIOUS and SYSTE-
MATIC training of muscular activity.
   It is very important to  remember  this,  for with 
              Therapeutics of Diabetes.           127
patients  whose  constitution has  run  down,  you
cannot be circumspect and systematic enough.  One
single  exertion  may  cause their sudden death  by
coma diabeticum.
   Care of  the  Skin.—An additional most impor-
tant element  of  bodily  diet is an intelligent  care
of the skin.   The skin is cared for  by the patient
washing his whole body quickly every day with  luke-
warm water.  If  the  accommodations at home are
limited, the patient should undress and stand in a
small wooden tub, the bottom of which is covered
with warm water, so that the feet are kept warm. In
winter the room must  be heated.  A basin filled with
lukewarm water,  into  which some  rectified  alcohol
or some French brandy has been poured, is placed on
a chair close  to the tub.   With a  large sponge the
patient now washes  himself from  top  to toe.   He
then quickly  rubs and dries himself with  a rough
towel, and dresses himself in  a woollen or cashmere
shirt, and in drawers,  stockings, and a suit of clothes
of the same material.  Linen is prohibited.  Woollen
garments have been recommended already by Prout
in 1843, an<^ Bouchardat in 1846.
   After the patient has dressed himself, there comes
the important cleansing of the cavity of the mouth
and of the teeth. For this  purpose  it  is  best to
use a solution  of chlorate of potassium (this salt
dissolves in water in  the  proportion  of 1*19)  ; one
or two  spoonfuls of  which solution may  be put
into one pint of water.  By using this preparation a
diseased state of the gums as well  as of the tongue 
128
Diabetes.
 is avoided.  Adding to the above mixture a solution
 of thymol in alcohol I have also found useful.
   For almost all patients, especially for those who
 have a dry skin, I prescribe Irish, Roman, Russian,
 or Turkish baths, as well as a combination of baths
 according to a special method  ; for every one accord-
 ing  to his own individuality ;  BUT I NEVER ALLOW
 ANY Ox\E TO  BATHE  IN  A  BATH  TUB.
   The prescribed baths have this effect that they
 revive and discharge  the sebaceous glands and the
 sweat glands which deposit  their secretion on the
 surface of the body.   This  secretion combines  there
 with the dust particles floating in the  atmosphere,
 and  condenses  into a  stratum whereby the respira-
 tion  of the skin is checked.   The above baths, there-
 fore, are  of a  sanitary  as well as  of an aesthetic
 importance for the diabetic patient.
   In patients whose skin had been entirely neglected,
 and whose nerve-life, in consequence, was very much
 depressed, I have employed with great advantage —
 partly also in connection with  electricity and gal-
 vanism—my regenerative method, which is a modi-
 fication of the method prescribed  by Steinbacher,
 Priessnitz, and  Schroth.  The nervous  system is
 strengthened by its application ; the sexual potency
 is  revived ;  the  enfeebled  digestive  organs  are
 strengthened,  etc.   The incitative action  of the
above-named baths improves  not  only  the state of
the skin, but the whole vascular system also is bene-
fited thereby.  The circulation of the blood becomes
more animated, and the  change of substance more 
              Therapeutics of Diabetes.          129
 energetic.   By  the Russian bath  the  fluids  of the
 body press more  towards the  skin,  whereby the
 interior organs are relieved, and a compulsory excre-
 tion  through  the skin  is  brought   about.   The
 heightened stimulation of the  cutaneous nerves  is
 continued  towards  the  brain  and spinal marrow,
 and by reflex action it  operates upon all  the organs
 which are  capable  of being  incited; as a matter  of
 course, also, it operates upon all the diseased parts.
 A regulating  effect is  thus  exercised upon the con-
 ditions whereby the state  of the equilibrium  of the
 body is  influenced, and  by  an improvement in the
 quality of  the protoplasm other accidental diseases
 are prevented.  The bath recommended by myself
 is similar to the Hamam  of  the Turks, to the warm
 baths of the  Greeks,  or also  to the  baths of the
 Romans.   It  is a  combination  of  agreeable influ-
 ences by which health is  promoted.  It is an  essen-
 tial means  for improving the  condition of  the body.
   In the Turkish bath I get  the patients first of all
 to transpire in  a dry,  hot air, the temperature  of
 which towards the close is raised to  1600 Fahrenheit,
 in order to compel the body to give out an  excre-
 tion.  This is followed by a lukewarm  douche  or
 shower-bath;  whereupon the body is  soaped  and
 shampooed until  every vestige of the  dead  and
withered superficial stratum  of  the epidermis is re-
moved, together with every trace of grease, dirt, and
dust,  and  until the sallow,  yellow, and withered
colour  of the  skin  is succeeded by a healthy, rosy
colour.
                                         K 
130                 Diabetes.
  From the Turkish bath the patient passes into the
Russian vapour-bath, the temperature of which must
not exceed ioo° Fahrenheit.  By breathing its watery
vapours the activity  of  the lungs is stimulated, and
the excretion  through the  skin is promoted.   After
a shorter stay in this bath the skin is cooled off by a
lukewarm,  but never by a cold shower.   At last the
patient is allowed  to have a secondary perspiration
on  a  couch, and  according to the measure of his
strength is allowed  to rest  for upwards  of one
hour.  After the  reaction  has set  in,  which often
takes place only after the twelfth bath,  the feeling of
thirst peculiar to a diabetic patient begins to cease.
About an  hour  before entering into  the bath the
patient ought to drink a cup of beef-tea.  All feeling
of lassitude will then disappear.
   Drawing  deep breath.   Quality of the air.—
Of great importance for a diabetic patient is learn-
ing and practising  the art of breathing correctly.
In order that the lungs may be properly ventilated,
it is especially necessary  that our  ladies who wear
corsets  should  be trained to  breathe  in a rational
manner, for instance, as  is prescribed  and  realized
by Dettweiler's  method of taking a deep breath.
   The air, in order to be suitable for  a  diabetic
patient,  must first of all  be  free  of all substances
injurious to  the  health.   A  chief requisite  is an
abundance of ozone.   The percentage of ozone in
the air can easily be determined by the ozonometer
of  Lender, which consists  of strips  of  paper painted
with a paste of starch containing iodide of potassium. 
              Therapeutics of Diabetes.          131
These strips  are  exposed for some time to the influ-
ence  of the air, by the action of which, according
to the quantity of ozone which is present in it, they
are turned more or  less  blue.   The scale  of  the
shades  of colour enables  you  to   determine  the
degree  of the  intensity of the blue  colour.  Ozone
refreshes  the nerves and the blood ;  it is subservient
to the oxydation  of  the  blood, since the blood cor-
puscles possess the  property  of  imbibing ozone as
well as  common oxygen.
   If diabetes is attended by an insufficient oxydation
of the blood-sugar, an increased absorption of oxygen
and ozone must  be  of the greatest importance to
those  who are suffering from this disease.  Unfor-
tunately, the experiments which have thus far  been
made were limited to the inhalation of artificially-
prepared  oxygen;   and  since  these experiments,
apparently, did not result in  much  good, they were
not followed  up.  Artificially-prepared oxygen, how-
ever, is only  a make-shift.  A stay  in the sunny air
of the country is  worth much more than  all artificial
supplies.   Such  a change of air ought never to be
undervalued,  especially  not in the   case of town-
patients,  if even, as  was shown by Buchheim, only
1 per cent, of  additional oxygen  is imbibed by the
system.
   What result  may  be obtained by living in a pure
air (of course in combination  with  a  carefully-
guarded  mode  of  life,  and  a  most  scrupulously
observed  method of  cure)  we  can see  from the
example of Dr.  Vocke,  which  is worthy of being 
13 2                  Diabetes.
followed.   He  relates  of himself:  " After an ex-
hausting medical practice in Berlin,  which extended
over 25 years, I was attacked by diabetes.   At first
1 thought that I might conquer the disease by giving
up my town-practice and commencing another in a
neighbouring  village, where I  might breathe the
country air.   Whether the  fault lay in the mental
excitement which is inseparable from  all medical
practice, and which is  so very injurious to diabetic
patients, or whether the morphium injections which
I used at the time were at fault ;  in short, within two
years, on  account of increasing  feebleness,  I was
compelled  to give up my medical practice altogether.
I now removed  to my  villa  in the forest  of  Fried-
richshagen, and  transformed its  spacious balcony
into  a kind of dwelling and sleeping-room by cover-
ing  it with a marquee  of  sail-cloth.    During the
seven summer months, from April 1 to November 1, I
lived there during the day and at night; thus breath-
ing the air, rich  in  ozone, not only for six, but for
twenty-four hours daily.   In  the  winter I  walked in
the woods from four  to six hours, and at night I slept
with  an  open  window.   The  same treatment  I
repeated during the second  year; and, in the third
summer,  at last I accomplished  my cure by staying
for six months at the seaside  on the Baltic coast.
The   sugar disappeared  already  during  the  first
months, and  on  account of  the  polyuria which re-
mained yet for  a very  long  time I  utilized the
remainder of  the time in  confirming this result, for
the  presence  of  polyuria made  me doubt  of the
radicalness of my cure." 
              Therapeutics of Diabetes.           133
   Alas,  there are  only too  many  patients who  are
unable to lead such an idyllic life as Dr. Vocke was
able  to  do !  With  the  feebler of  my  patients  I
employ the pneumatic apparatuses of Geigel, Meyer}
and Waldenburg in order to regulate the gymnastic
of their lungs, and  to administer it to them in proper
doses.   I thereby expel the residual air in their lungs,
supply oxygen to them, and strengthen their pectoral
muscles.
   By a methodic climbing of hills also, according to
Oertel's  prescription,  I  teach  my patients to take
deep breath.  For this purpose I find the air-breath-
ing-stations (Terrain Kurorte) Carlsbad,  Nice, and
especially Monaco, of great use.
   Dwelling-rooms.—The sleeping-room of  a diabetic
patient in winter ought to be towards  the south
or  south-west,  in  summer, towards  the  east.   It
ought always to be furnished with a hygrometer in
order, if necessary, to have water evaporated.  High
situations ought  to be selected, and the suite of rooms
ought to be thoroughly ventilated.   Apparatuses for
ventilation  are   recommended.    The  air-passage
through  the stove  or fire-side ought  never to  be
blocked up.  The windows ought to be left open as
long  as  possible.   A window  in the room  next to
that in which  the  patient sleeps, the door of which
should be left open, ought  always to  remain open in
summer, even at night.
  The tetnperature  of the dwelling-rooms in winter
ought never to be below 560 Fahrenheit (160 C).
  Considering  the  temperature  of  all   northern
countries during winter,  a  stay in  the Riviera di 
134                 Diabetes.
Ponente  during  winter  is  recommended  to  the
diabetic patient ;  but not  a stay in Cairo or Alex-
andria, where the  air is so  dry  that the hydromania
of the patient  is  only  increased.  Since  the year
1882 I have succeeded  in  curing diabetes radically
during winter-time in the Riviera, altogether  in the
same  way  as I have been  able to do  at  Carlsbad
during summer ; a result which I could scarcely have
attained in other places on  account of  the changes
in the temperature and the prevailing cold of winter.
Besides, as  Fleckles also has mentioned  with com-
mendation, the warm climate of the  Riviera enables a
patient to breathe freely and in  great abundance an
open and pure air, rich in ozone ; for in the middle of
winter he is able to sit  there for hours in the open
air, while listening to  public exhilarating  concerts,
or he is able to undertake long walks through forests
and  fields,  in  orange and olive groves.   Even in
January and February he can go about without an
overcoat,  and  is  not compelled, after a long  walk,
to take refuge in the  oppressive,  hot  and smoky
rooms of a restaurant.
   Massage.—In many cases, following  the example
of Reibmayr (see his " Technik  der Massage des
Unterleibs"),   I   have  declared in  favour of his
method of  rubbing, namely, in favour  of  massage.
Massage  constitutes an  important  factor  in my
method of treating diabetes.  My method, however,
differs from the  usual practice of massage in this
respect—that  in rubbing I do not  employ a greasy
substance, but a preparation of  mercury ;  ordinarily 
              Therapeutics of Diabetes.          135
I prescribe  a mild solution of corrosive  sublimate
in alcohol with an addition of vaseline.  I employ the
massage daily once, between breakfast and dinner ;
only exceptionally I allow a patient to  be rubbed
before breakfast.
  Heynsius von Hart in Amsterdam already recog-
nized the value and use of massage.  The influence
of  a  mechanical treatment of  living  tissues by
kneading, pressing, and beating is indeed of great
therapeutic value.  The conditions under which the
change of substance (Stoffwechsel) is brought about
are most favourably influenced by such a treatment.
An improvement is  effected in the assimilation  of
the food by the muscles, and the muscular apparatus
of the body is rendered  more fit to  do its work.
Again, the  circulation of  the  blood is  promoted
thereby,  and  the products  of the  change  of  sub-
stance are separated and excreted.   The volume  of
the body of  a diabetic person  is  seen to increase
visibly under the treatment of massage.
  Finkler in  Bonn inquired, in 13  cases, whether
the change  of substance (Stoffwechsel) in a  person
afflicted  with  diabetes underwent  any alteration by
the  mechanical  treatment  of  the muscles  of the
body by  massage.  He found that a considerable
influence was exerted thereby upon the secretion of
sugar, and the general well-being of the body.  The
influence upon the  secretion  of  sugar,  within  24
hours, amounted  to an average reduction of  400  to
 120 grammes ; the muscular energy became invigor-
ated ;  the weight of the body increased; the thirst 
136                 Diabetes.
decreased ; and the patient began to perspire.  Yea,
in one case the secretion of sugar ceased for three
months.   All  these  results  were obtained  with  a
mixed diet, the patients drank water, and  no  change
was made in the use of hydrates of carbon.
  In  company with  Dr.  Brockhaus, of Godesberg,
Finkler tried  the  influence  of massage  also  upon
the muscles in cases of paresis, hysteria, etc.
  Electro-magnetic influences.—Zabludowsky noticed
remarkable changes in the muscular tone of the body
in consequence of electric and magnetic  reactions.
Likewise Clemens, who after  an electric shock of the
liver,  combined with  a faradization  of  the entire
muscular  system, saw  changes taking place in the
formation of sugar.
  I also have repeatedly  tried the wholesome in-
fluences of electric and magnetic reactions.  Under
their  influence the volume of the muscles and their
vigour increased, their sensitive properties were en-
hanced, and  the  physical as well as  the  psychical
well-being of the patients was improved.
  In  regard  to  sexual  intercourse,  many  practi-
tioners when dealing with diabetes forbid what during
the progression of the illness need not be forbidden
at all, since it ceases of its own accord.
  Although I  am of the  opinion  that in the first
stage  of  the disease, and also  afterwards, trans-
gressions in  this line are followed by serious conse-
quences, so that a  rational  abstinence ought to be
recommended ; still my method of nourishment and
the  principle which underlies my method  of cure 
              Therapeutics of Diabetes.           137
are able to prevent the injurious consequences of a
moderate intercourse.   This moderate intercourse
I deem admissible  in  the  interest of  the  building
up of the substance of the body, and in that of the
regular circulation of the juices.
  Food and nourishment.—The fact that the excre-
tion of the  sugar into  the  urine ensues but a short
time after a patient has  partaken  of hydrates  of
carbon,  induced  the  profession  many  years  ago
to prohibit  them, and  to  subject  the selection  of
food for a diabetic patient, in every particular case,
to the  greatest care.
  Unfortunately, not much harmony  has  prevailed
in this respect among  the physicians in  modern
times.
  Although,  on the whole, they have assented to
Rollo's view,  namely,  that in  order  to  avoid  the
formation of sugar  all amylaceous substances,  as
well as all hydrates of carbon, such as grape-sugar,
fruit-sugar, cane-sugar, sugar of milk, etc., ought to
be  forbidden, and  albuminous  food  to be  recom-
mended ;  and  that only a few green vegetables, as
being  less injurious, ought to  be  allowed;  still  in
practice the physicians very often follow very diver-
gent courses.
  Some demand  most rigorously a  most  copious
supply  of  animal  food;   while  others  (Cantani,
Fleckles, v.  During, Ewald, etc.)  advocate a most
painful theory of fasting ; and, at variance with the
former, not only forbid  an excess of food, but with
the view of reducing the quantity of sugar, sacrifice 
138                 Diabetes.
even the proper nourishment of the body.   I  will
only mention here  Naunyn, who, in accordance with
the principles of  Cantani,   demands  the strictest
meat-diet.
   I consider it useful  to present  here the essential
parts of  the dietetic  instructions  of  the leading
authorities in the field of diabetes, in order to enable
the reader to form a judgment as to what is common
to all, and what the various authorities have  bor-
rowed  from each other ; likewise, in  order that the
question may be answered whether any progress can
be noticed at all in the matter of diet for the  use of
diabetic patients.
   BolWs Diet.—He allowed for breakfast:  1^ pints
of milk mixed with \ of a pint of lime-water, together
with some bread and butter.
   For dinner: Tender meat, sausages prepared of
blood and fat.
   For supper :  The same.
   Beverage : Water with sulphate of ammonium.
   Bouchardafs  Diet.—In  the  place  of milk he
orders  cream,  all kinds  of meat,  from  150-200
grammes  of  fat  per  day,  and  those vegetables
which  contain  only a  small  quantity of  starch,
such as  spinach,  artichokes, cabbage,  lettuce, as-
paragus, beans ; peaches, strawberries.  In the place
of  ordinary  bread  he  recommends  gluten-bread.
Men he allows  to drink daily  from i-ii pints of
claret or Burgundy.   He thinks that by the quantity
of alcohol contained in  the  wines he is able to re-
place amylaceous  food. 
             Therapeutics of Diabetes.           139
  Dickinson's Diet.—He allows all kinds of meat,
including  pickled and smoked meats, soups without
flour and  spices, sauces without sugar;  further, oil,
lard, butter, cream, green vegetables, such as cauli-
flower,  spinach, rape-cole   (Kohlrabi),  Brussels
sprouts, French beans, asparagus, lettuce, radishes,
nuts,  almonds,  as well as the almond-bread pre-
scribed by Pavy.
  Beverages allowed:  Water,  tea, coffee,  cocoa,
brandy, rum,  claret,  Burgundy,  chablis, hock, and
Moselle wines,  some  good beer  [to which exception
was made].
  He  forbids : Sugar, honey, bread, milk puddings,
carrots, beets,  onions, rhubarb, cucumbers,  milk,
whey,  chocolate, champagne,  sweet wines, etc.
  Bavys  Diet.— He allows all  kinds  of meat and
fish, the  liver excepted.    Soups  not  prepared  of
plants; cheese, eggs, butter, cream. Further, green
vegetables, such  as  spinach, cucumbers,  lettuce,
radishes, and celery [which is forbidden by Dickin-
son].   He permits  blanc mange prepared of  cream
and  the white of  eggs.   Instead of bread he pre-
scribes almond-bread.
  Beverages allowed:  Tea, coffee, soda-water  [to
which  exception was taken], wines and spirituous
drinks, not sweetened, bitter ale.
  He forbids: Sugar, rice, sago, vermicelli, potatoes,
all fruits  and puddings.  He allows milk in a small
quantity.   [See the ideas of  others on  this subject
below.]
  Cantani"s Diet.—Whether a patient is fat or lean, 
140                 Diabetes.
for all meals he only allows the meat and the fat of
all vertebrata.   Even the viscera, the liver excepted,
he permits to be eaten.   Meat and fishes he allows
cooked  in any fashion.    Spices,  sugar, and  flour
must  not be used in their preparation.   He forbids
butter [in  a most  unjustifiable way] on account of
the traces of sugar of milk which it contains.  [They
amount to \ per cent., which  amount is surpassed
by the hydrates of carbon contained  in  the meat.]
In the place of butter he permits sweet ©il.
  Patients whose digestion  is  weak he advises to
eat fats in  a pancreatic  state, that is, he  soaks  them
for three hours with the fresh pancreas minced of
calves,  lambs,  oxen, or goats,  and afterwards has
them roasted before the fire.
  As a beverage he prescribes water (in  exceptional
cases mixed per day with 10-30 grammes of rectified
spirits of wine),  sometimes  a little coffee, tea, etc.
He forbids milk, butter,  cheese,  oranges,  peaches,
and other fruit, as well as all green  vegetables ;
further,  puddings, sweet  drinks,  etc.   He allows
salt to be used in preparing the food, yet sparingly.
   Cantani continues his exclusive diet of fats  in
mild cases of  diabetes during two  or three months ;
in severe cases from six to nine months.   After he
has stopped the formation  of  sugar in  mild  cases
he  gradually returns to the former diet.
   Eggs he allows only in exceptional cases.
   Pavy's almond-bread is the only bread which he
allows in the place of real bread.
   Seegen's Diet.—He allows meat and fish in any 
              Therapeutics of Diabetes.           141
quantity,-  jelly, aspic,  eggs, caviar, cream,  butter,
cheese, bacon.
   Among vegetables he permits :  Spinach, lettuce,
endive, cucumbers, asparagus,  water-cresses,  arti-
chokes, mushrooms, nuts.
   In moderate quantities  he  allows:  Cauliflower,
carrots,  turnips,   savoy,   French  beans,  berries,
oranges, almonds.
   He forbids absolutely : Farinaceous food of every
kind ;  in some  special cases bread may be allowed.
He also forbids sugar, potatoes, rice, sago, semelina,
beans, peas and lentils, green peas, cole-rape, sweet
fruits, grapes, etc.
   Beverages, in any quantity,  he permits : Water,
carbonized waters  [to which exception was taken],
tea,  coffee,  clarets, Rhine wines,  Moselle wines,
Austrian and Hungarian table-wines.  In short, all
wines which  are not sweet and which do not contain
an excessive amount of alcohol.
   In moderate quantities he permits : Milk,  brandy,
bitter ale;  milk of almonds not sweetened ; lemon-
ade not sweetened.  «
   Beverages  forbidden:  Champagne,  sweet beers,
must,  cider,  liqueurs,  fruit-juices, ice-cream  and
water-ices, cocoa, chocolate, wine prepared of fruits.
   v.  During's Diet.—Diiring's diet  differs  from
other diets  by  his  admitting  many hydrates  of
carbon.   For  early  breakfast  he  permits:  Milk,
containing some  unsugared coffee, with stale wheat-
bread ; alternately  rice-soup and  porridge  without
butter. 
 142                 Diabetes.
   For second breakfast:  Wheat-bread with butter,
a boiled egg with a glass of good claret in water;  or
alternately a cup of rice-soup, or semelina-soup with
or without milk.
   For dinner: Soup of cereals,  250  grammes  of
meat  without  fat,  together  with  stewed   dried
apples, prunes,  or cherries.   Among  vegetables,
which are not  to  be  prepared  with soup or fat,
 but  simply  boiled  in  salt  water,  he  permits :
Carrots,  cauliflower,  French  beans,  cabbage,  as-
 paragus.
   For dessert:  Fresh fruit, such as apples, cherries,
 with a glass of claret in water.
   For supper : Rice-soup  or semelina-soup without
 butter; sometimes milk may be added.
   Beverage : Ice-water, water, etc.
   Senator's Diet.—He permits : Meat  of mammalia
and   birds ;  further,  oysters,  mussels,   craw-fish,
 fish.   Again,  meagre  cheese,   eggs,   salad,  cu-
 cumbers,   water-cresses,   spinach,  asparagus,   all
 kinds of   cabbages,  scorzonera,  radishes, carrots,
 truffles, butter,  bacon, oil,  sour  or acidulous fruit,
 etc.
   He forbids:  Grapes, cane-sugar,  honey,  farina-
 ceous food, such as bread, etc.;  further,  potatoes,
 leguminous plants, rice, maize, semelina, sago, chest-
 nuts, etc.
   Frerichs' regimen.—He requires  an  avoidance
 of amylaceous  food;   a  shunning  of  hydrates  of
 carbon.   But he  allows a small  quantity  of bread.
 As a condiment for meat  and fish he generally uses 
              Therapeutics of Diabetes.          143
green vegetables  and other  vegetable substances
free  from  starch.   Only once Frerichs noticed a
favourable result  from the use of milk ;  more fre-
quently  he saw bad results.  Especially while , using
the milk cure  of  Donkin he  noticed  an increase in
the secretion of urine  and sugar.   He prefers, as a
beverage,  good, thoroughly fermented  beer, which
contains but  little sugar ;  also claret in  moderate
quantities, only the sugary  Spanish and Hungarian
wines he prohibits  most strenuously.   He permits a
moderate use of unadulterated brandy.  (See Frerichs,
Op.  citat., p. 261.)
  Ebstein's  Menu.—(See  Ebstein,  Op.  citat.,  p.
204.)
   Early breakfast: One  cup  of coffee  or black
tea, without milk  and without sugar.  Eat with it
from 30 to 50 grammes  toasted white  bread,  or
respectively brown bread richly buttered (from 20 to
30 grammes of butter).  Add to this, if required,
the yolk of one egg, a little  fat ham, or some  German
sausage (Mettwurst).
   Second breakfast:  It is best to do without such a
meal; but, if required, let it constitute a part of the
first breakfast; or else  take  one  cup of broth with
the yolk of one egg.
   Dinner: Broth with yolk of egg, or the marrow of
marrow-bones,  or with  both.   The marrow-bone is
boiled for  half an hour,  so that the  marrow may be
served  in a solid form. Some peptone may be added
to the  broth.   Meat: Roasted,  boiled, or  stewed ;
either  beef,  pork, mutton,  veal,  fowl, or  venison. 
144                  Diabetes.
Fat meat is preferred.  Gravies are to be prepared
with  the  yolks  of eggs or cream in the place of
flour.   For  a change, eat  fish cooked with butter.
The amount of meat to be eaten at dinner  is upwards
of 180  grammes of meat,  apart  from the bones,
together  with  one  of  the  vegetables  mentioned
below, prepared richly  with fat.  Persons who  do
not like fat meat  will  perhaps eat  richly-prepared
vegetables.   Every case should be individualized !
Let the food be well salted and spiced.  Some puree
of leguminous plants,  prepared with  fat.   Salads
dressed with vinegar and  oil, or sour cream.  After
dinner, or in the afternoon,  one cup of coffee or of
black tea.
   Supper: One cup of tea or bouillon, some  roast
meat,  ham  or cheese,  or one  egg,  or fish, caviar,
from 30-50 grammes of bread  with  20-30 grammes
of butter.
   Small quantities  of apples,  pears, etc.  (i.e., fruit
with kernels) are allowed.
   Among alcoholic liquors Ebstein forbids absolutely
the use of beer.   He permits about half a bottle of
wine.   The  use  of  spirits he limits.  Milk-cures he
condemns on the ground  of  their  being modified
abstinence treatments.  He tries the patient whether
he assimilates milk, in which case he allows moderate
doses  of good  milk,  especially  of  cream.   The
character  of the food which he prescribes depends
upon  the  age and  the  individuality of the patient.
Spare persons he treats to greater quantities of  fat
than fat persons. 
              Therapeutics of Diabetes.          145
  Conclusions drawn from all the dietetic instruc-
tions of acknowledged  authorities and experienced
practitioners .-
  The  specialists from whom  we  have  just  now
quoted  agree in recommending  the  following course
of diet :—
   (a) All  kinds of meat, with the exception of the
liver, which contains sugar, also all kinds of fowl, all
fishes, oysters, likewise butter and other kinds of fat.
   (b) Among  vegetables  they permit  spinach and
the like, salads, water-cresses, mushrooms, cabbage,
green asparagus, nuts, prunes, etc.
   (c)   The  beverages  permitted,   it  seems, are
seltzer-water with brandy,  koumiss, genuine hocks
when light, cream with raw eggs, coffee without milk,
etc.
   Absolutely  forbidden articles  are:  Farinaceous
food, potatoes, rice, leguminous  plants, sweet sugary
wines, etc.
   Konig systematized all  articles of  food  and all
beverages in   the  following  work:  " Prozentige
Zusammensetzung  und  Nahrgehaltwerth der men-
schlichen  Nahrungsmittel,  etc.   Graphisch darge-
stellt."   Berlin, 1882.
  A similar classification  is contained  in my pam-
phlet :  " Hygieine und  Diat" (Geneva, Pfeiffer).
   Particular information on the  subject is contained
in Ebstein's  meritorious treatise  on  the articles  of
food for man, entitled :  " Das diatetische Regimen
beim Diabetes  mellitus "  (a   reprint from the
" Deutsch-arztl. Vereinsblatt," May, 1883).
                                         L 
146                 Diabetes.
  Bread:   Since  bread  contains   much   starch
various substitutes have been proposed in  the  place
of it.
  The gluten-bread prescribed by  Dr.  Budde  in
Copenhagen, as prepared  in  the  bakery  of  Ras-
mussen and  Heegard  in  the same  town, is  most
worthy of recommendation, since  it  contains  only
two per cent, of starch.  (By washing the flour nearly
the whole of  the starch is removed, so that only the
albuminate of the grain, the gluten, remains.)
  The gluten-bread of Dr.  Budde is preferable to
the breads of Henry and Bouchardat  (who first pro-
posed  gluten-bread in  1840) ;  further,  to the bran-
bread of Prout, to the breads introduced at Neuenahr,
to the wheat-bread of Dahmens,  to  the  expensive
almond-bread of  Pavy, as well as  to the  inuline-
bread of Kiilz.  The only bread that comes near it in
point of excellency is the gluten-bread recommended
by  Fiirbringer  ("Arch, fur Klin.  Med.," xxi., 1878,
P- 5°3)> which vis  prepared  in  the establishment of
" Bassermann,  Herschel,   and Dieffenbacher,"  in
Mannheim, and  is free from  any farinaceous ad-
mixture.   In Carlsbad are sold so-called "Diabetes-
brodchen" (diabetic biscuits) which sometimes bear
the name of  a  Carlsbad physician.   They are cer-
tainly to be preferred to the ordinary bread.
  My former teacher, v. Frerichs, and also Fleckles
etc.,  permit  small quantities  of  bread.    In  my
practice, before 1881, I also permitted small quanti-
ties  of bread in  order to  meet the feeling of dis-
appointment  in  patients, and I have  always  found 
              Therapeutics of Diabetes.          147
that the psychical gain  richly counter-balanced the
bodily harm caused by eating bread.
  Milk:  Rollo expressed doubts about the use  of
milk.  Pavy shares this  doubt, and a great number
of able specialists have rejected milk on the ground
of its  forming glycogen.   Seegen  also expressed
himself against milk ;  he allows  it  only  sparingly
because it contains from 4—5 per  cent, of  sugar.
Frerichs decided against the  use  of  milk.  Ebstein
also condemns milk-cures, although he likewise ad-
vises  careful  trials  in  order  to see  whether milk
agrees  with a patient, in which case  he allows  small
portions.   My experience also, respecting the use  of
milk, has been most unsatisfactory, wherefore I only
allow cream.
   Nevertheless, there are left a considerable number
of physicians  who do not unconditionally reject the
use  of milk,  even  in  the  face of  authorities like
Seegen, Frerichs, Rollo, etc.   Th. Wille maintains
that he has healed diabetes by a milk-cure consis-
tently carried  out.   The Englishman Donkin, who
allows even the use of skimmed milk,  makes a similar
statement;  he was opposed  by Frerichs.  Cantani
recommends lactic acid as of  great service in dia-
betes.   Hoffmann allows milk after a patient   by
abstaining from hydrates of sugar has lost his sugar,
and when he  is about  to  return to his usual diet.
[He  allows it, consequently, after the "glycosuria"
has  been healed?]   Hertzka,  who  is in  favour  of
a  copious  consumption  of  fat,  and  recommends
a meat-diet, allows milk "when it  agrees  with  a 
148                  Diabetes.
patient."  He does not dread the hydrates of carbon
so much, but is rather of the opinion that  nervous
symptoms, and even the diabetic coma, are connected
with,  and partly caused  by a  purely  animal diet.
Dr. Vocke,  who is himself a diabetic  subject, de-
clares unreservedly  that sour  milk  makes up his
supper, both during summer and  winter.  He whips
the sour milk until it becomes liquid and then drinks
it  out of  a  cup like sweet milk, for, says he, " cold
liquids are not enjoyed when eaten with a spoon."
   Senator, who permits pieces of ice and  milk for
 quenching  the  thirst, pronounces against a whole-
sale arrangement of  a system of  diet suitable for all
diabetic patients.
   Finkler agrees  with him.   In five severe cases of
diabetes he  allowed his patients to partake of bread
and potatoes, to  drink beer  and wine, but, on the
other hand, he fed them richly with meat and eggs.
 Here, however, it must be mentioned that  he para-
 lyzed the  influence of the food by the massage, and
 therefore  succeeded in diminishing the  secretion of
sugar.  With  one of his  patients  who used  the
ordinary diet, the secretion of sugar became reduced
in 100 days from 700 to 200 grammes. The quantity
of the urine also grew less.   The thirst diminished,
the perspiration returned, the bodily weight increased,
and the general well-being of the patient improved
visibly.
   Finkler approaches more  nearly than any one else
 to the standpoint occupied by myself in respect to a
rational treatment of diabetes.   For he  also opposes 
              Therapeutics of Diabetes.          149
the  draconic  severity  of  the  abstinence-cures,
although he is ignorant of the premises from which I
started in the elaboration  of  my theory, and also
is not aware of the object which I seek to realize.
   Janicke (" Arch, fiir Klin. Med.,"  Vol. xxx.) and
Block  (Ibid., Vol. xxv.) declare  most emphatically
against a one-sided  meat-diet, which causes  many
patients to run down quickly  in  their health, while
an ordinary mixed  diet  preserves, at  least,  their
former, valuable cheerfulness.
   CI. Bernard also, as well as Boussingault, condemn
a diabetic diet  which is carried to an extreme ; for
they do not consider the doctrine of digestion suffi-
ciently advanced to enable us to determine scientifi-
cally the  influence of food on a diabetic patient.
   Unfortunately, the profession,  even down to the
most  recent period, has aimed only  at  suppressing
the  secretion  of sugar,  without  considering  that
it matters much less whether the sugar is  formed
than  whether  the sugar is assimilated  and con-
sumed in  a  regular manner ;  for only by this means
can the protoplasm be regenerated  and the  over-
production of  sugar be checked in a lasting manner.
   Hertzka is quite right  where he  exclaims :  " Of
what use  is it for a diabetic  patient if through  a
course of  diet the secretion of  sugar is stopped, but
if, at the  same time,  his system has been reduced,
and he has altogether run  down  in health ?   Tests
of the urine, showing the decrease of sugar, are not
decisive,  in my opinion.   I do  not worry myself
about  the fact whether  the  urine contains a few 
150                 Diabetes.
tenths of sugar more or less.  My first question is
always :  ' How does the patient feel ?   What is  the
state of his mind ? ' "
  Although Hertzka's  question does not contribute
anything to the cure,  nor to any improvement in the
condition of  a patient, his standpoint,  nevertheless,
is correct, and, indeed, so much the more since it is
a known fact that  the increase of sugar is in exact
proportion  to the increase  of food.    In this con-
nection I should  like to direct  the reader to  the
proofs  furnished by Kiilz (in  " Arch,  fiir  experim.
Pathol.," etc., 1876, p.  141), whose patient on  five
successive days was fed with caseine at  the following
rate:  (a), 200 grammes ; (b), 240; (c), 300;   (d),
500 ;  (e), 240.  He secreted sugar in  the following
proportions :   (a),  66 grammes ; (b), 65^7 ; (c), g6'"] ;
(d), 126*9;  (^), 86'6 grammes.

 My own Dietetic Begimen for Diabetic Batients :
    My  own  ideas concerning an appropriate  diet
for diabetic  patients have undergone  a  consider-
able change since I  recognized the real  character
and cause of diabetes;  for  since then I have been
led to look upon  the so-called injurious effects of
certain kinds of  food simply  as accidental causes,
and I have also learned  by experience what a great
mistake it is when physicians, like Seegen, among
all the manifold  symptoms  by  which diabetes is
characterized, single  out the formation  of  sugar as
the only cause of  this malady.   Taking all this  into
consideration, I have been induced to favour freedom 
              Therapeutics of Diabetes.          151
in the choice of the articles  of  food, that  is, a free-
dom based on the temperate  use of food, and which
is determined by  the  individual condition of the
patient.   The only thing on which  I  lay  stress  is
eating slowly, and masticating  the food  well.   In
the  place  of  an ABSTINENCE-CURE  I  prescribe a
NOURISHMENT-CURE,  which results in the proper
assimilation of the food ; for  my object is to produce
A CHANGE IN  THE  BODILY CONSTITUTION AND
TO  REGENERATE  THE ORGANISM.
   For my  dietetic regimen I therefore laid down the
following rules : Articles  of food which have  an
immediately strengthening and nourishing effect, and
which  are  free  from  any particular acids,  are to be
allowed ; further, wines which have a quiescent effect,
and do not heat the system—for which  purpose I
prescribe a  claret  which  contains  but  little sugar,
and light Moselle  wines.  As  to the rest I permit
my  patients   to  select easy digestible  animal and
vegetable  articles  of  food which  are  free  from
starch.
   As a preparation for my treatment, that is up to
the  time when  the  real  treatment  begins,  I insist
upon the diabetic  patient, according to his bodily
condition,  observing the  following  dietetic rules:
(one of the objects  to be attained is  breaking the
habit of a second breakfast,  so as not to disturb the
process of digestion too often.)
   Breakfast.—200 grammes of beef-tea, with as
many grammes of beef-broth,  and 50 grammes  of
gluten-bread  with  fresh  butter; or  else  use the 
1^2                  Diabetes.
chrome-bread introduced several years ago by myself
(bichromate of potassium 0^05, distilled water 20*0,
mixed  with  two pounds  of  dough  used for white
bread) ; of this bread patients are very fond.  Tea
or coffee  without  milk (in  the  place  of  milk  use
cream  and eggs),  unsweetened with sugar  (in  the
place of sugar use saccharine).
  The above chemical substance prepared, in 1879,
by Dr.  Fehlberg, of New York, out of the products of
coal-tar, which on  account of  its similarity to sugar
is called saccharine, dissolves easily in  alcohol and
ether, and also in  hot water, tea, coffee.  It is 280
times sweeter than the common sugar, and possesses
the  property  of leaving  the  body without  being
decomposed, and  of appearing  again in the urine
in the form of saccharine.   It does not interfere with
the digestion, nor  does  it exert any injurious effect
on the organism.   Besides, it  possesses slight anti-
fermentative properties.   At present it is offered for
sale  in easily soluble tablets prepared with carbonate
of sodium.
  Dinner. — Oysters,  snails,  mussels,  crawfish,
lobster, crabs ; dishes prepared of eggs without any
flour;  fish, fried or stewed with butter,  served with
a sauce made of eggs (caper-sauce or lemon-sauce).
Meat  of all  kinds, which must either be roasted
or stewed.  Beef-tea and stewed vegetables pre-
pared with soup and butter, such as  spinach,  sorrel,
French beans,  scorzonera,  cauliflower,  Brussels
sprouts,  savoy,  and  fresh  mushrooms.   Salads :
Watercresses, lettuce, endive, dressed with oil and 
              Therapeutics of Diabetes.           153
 citric  acid,  for  a change.   Radishes,  cucumbers
 pickled in salt-water, but  not in vinegar.
   Blanc-mange, prepared of the white of eggs beaten
 up and flavoured with vanilla, lemon, raspberries, or
 whortle-berries   (bilberries),  and   sweetened  with
 saccharine.
   For DESSERT,  only  a few nuts  and almonds are
 allowed, since they dry up the mucous membranes
 too  much.   The patient  also  may eat one apple,
 not sweet;  also all kinds of cheese.
   When the bowels are  constipated the patient may
 partake of sour  milk as a dietetic remedy.
   The SUPPER  ought to  consist of the very same
 ingredients as the dinner,  only  the  dishes ought to
 be fewer in number.
   With most patients  I  prescribe the exact quantity
 of food.
   For DRINKING I allow good spring water, not too
 cold.  When the  thirst  is excessive  I administer
 light, warm tea with a lemon-slice.
   For the meals, or, still  better, immediately after
 the meals, I allow old claret, if it  is unadulterated.
 It is preferable to other wines, since it contains only
 o"2 per  cent, of sugar,  and   also  contains  more
 tannin, and  is less  acid  than  wines  of the  hock
 kind.
  After every meal the patient has to remain passive
 from 30  to 60 minutes.   It is  best for  him to sit
 during this period in an easy chair.
  Articles  to  be avoided : Sugar, and dishes
prepared with sugar, also  farinaceous   dishes, and 
15 4                 Diabetes.
gravies  prepared with flour and  the like.   I also
forbid : asparagus, parsnip,  all leguminous  plants,
potatoes, chestnuts, and  sweet fruits.
  Absolutely prohibited are all kinds of soda
water and sweet beverages.
  Smoking  must be reduced in quantity, or is to
be abstained from altogether.  According to circum-
stances I allow from  one to  two light, good cigars.
The orders as to smoking change  according to the
development of the disease.

        Medicines against Diabetes.

  The application of medicines is determined  by the
object which  it is sought  to realize.   Medicines are
prescribed differently where the object to be attained
is simply  to  suppress symptoms  and  their  conse-
quences,  from  what  is  the case—as in my own
practice—where the  physician attacks  the very
fundamental cause of a disease.
  A countless  number of medicines and remedies
(without mentioning bleeding, which was  still advo-
cated by  Prout) have been proposed, and  in the
course of time have again been abandoned.  Rubri-
cating and  enumerating  them  results  in a total
condemnation of the  therapeutics of diabetes so far
as the application of medicines is   concerned,  for
thus far  not a single specific  medicinal remedy
against diabetes has been discovered.
  Emetics  and purgatives have been employed in
order to regulate the action of  the stomach ; rennet, 
              Therapeutics of Diabetes.          155
acids, and alkaline salts in order to replace the diges-
tive fluids;  oxygen, chlorine, etc., in order to promote
the combustion of the sugar;  narcotics in order to
react on  the nervous system ; alcohol and lactic
acid in order to replace the sugar,  etc.
   In  order to handle more conveniently the  vast
number of  medicines which have  been tried, I  pro-
pose  to  classify  them:  (a)  into  specifics  and (b)
into  such as  are calculated  to improve the tone of
the system.

                  (a) Specifics.

   Among  these, narcotics  have  hitherto  occupied
the first rank, to which, however, I take exception.
   The chief  remedy  has been  opium, which  was
recommended by Rollo, as well as  by Jos. Frank,
and  which  was strongly advised  by M.  Gregor, in
1837, on tne grounQl of its diminishing the secretion
of the sugar.  It was also recommended by Kratsch-
mer (" Wiener acad. Sitzungsber.," Vol. lxv., Vienna,
1872) ; further, by Fiirbringer, while the practitioner
Dickinson  declared   that  he  reaped  more harm
than good  by prescribing opium !   In  small doses,
opium sometimes  reduces  the   feeling  of  thirst
and hunger, since  it diminishes the secretion of the
urine, interferes with  the excretion  of  sugar,  and
causes a patient to put up  more  readily  with  the
monotony  of  the  diabetic diet;  it  also preserves
the weight of the  body.   Frerichs, like  myself,
pronounced against the derivative use of morphium
which  had  been successfully employed by others 
156                 Diabetes.
(e.g.,  by  Kretschy, "Wiener   Med.  Zeitschrift,"
1873, Nos. 3  and 4), and also against the  use  of
codein, which Smith and Pavy preferred among the
alkaloids of  opium, and  which they prescribed three
times per day in doses from one to  four grammes
(even as other narcotics have also been prescribed,
e.g., belladonna, cannabis, calabar, and ergotine—an
ingredient of secale cornutum, together with bromide
of potassium,  strychnine, quinine,  etc.).   Frerichs
administered opium up  to 2^04 per day.   But, like
Seegen and others, he had to make the unpleasant
experience that the body soon  gets accustomed  to
opium,  so that  in the course of time  a diminished
influence, or none at all, is obtained from it.
   Besides opium, only a few other specifics exert a
decided  influence upon  the  symptoms of  diabetes,
and either one or the other of these medicines—but
only in  very definite, individual cases,  and solely
with the view  of counteracting  such symptoms, I
include  in that  combination of  curative  agencies
which makes up my method of  treatment.
   The  modern  practitioners have applied  the anti-
zymotic remedy, salicylic acid.  Frerichs recommends
it as worthy of being tried. Hoffmann finds it effective
in " recent cases " [probably in glycosuria], and  he
orders from  five to ten grammes daily. In prolonged
cases [hence in active diabetes ?] he finds its effect
injurious.
   Salicylate of  sodium  (from eight to ten  grammes
per day) was first prescribed by Ebstein, afterwards
by Kamen, Fiirbringer, Petters, Hoffmann, etc.  The 
              Therapeutics of Diabetes.          157
latter gentleman maintains  that by means  of  it he
cured three-sevenths of all his cases [?].
  Ebstein maintains that salicylic acid has a decided
effect upon diabetes, and Hoffmann is of the opinion
that of all the medicines employed against  diabetes
mellitus, it possesses more than  any other the  char-
acter of  a specific.
  In recent cases the sodium preparation of salicylic
acid is almost exclusively employed (from five to ten
grammes per day).  Fiirbringer  is of  the opinion
that in the most obstinate form of diabetes,  when no
medicine seems  to be able to act  any more, the
salicylate of sodium, as well as phenol,  by reducing
the elimination of nitrogen, are able to bring about a
favourable turn.
  Ebstein and J. R. Miiller have first employed suc-
cessfully phenol (carbolic acid) in diabetes  mellitus.
Nevertheless,  Ebstein,' who  at  first claimed  that
opium, phenol, and salicyline were  the chief remedies
which exert a specific influence  upon diabetes, was
obliged  to acknowledge afterwards that he did not
estimate their  practical importance  very highly,
although by means of  them you are able to exert an
influence upon some of the complications of diabetes,
for  instance, upon neuralgia.   The aim of his thera-
peutics   is now to increase in the tissues the forma-
tion of   carbonic  acid, which is too  scanty in com-
parison  with  the  food  introduced into  the system ;
and indeed  (a) indirectly through a diet, which will.
supply the  appropriate material  for this purpose;
and (b)  by  stimulating the development  of  carbonic 
158                 Diabetes.
acid in the protoplasm  of  the  tissues and  in  the
organs of the body by intensifying the activity of the
muscles.   He asks here whether by  an increased
introduction of carbonic acid (by the drinking of
carbonated waters) we are  not really able to com-
pensate for a  relatively insufficient  development of
that gas in the tissues ?   This  question,  however,
does not seem at all indicated, for practical  experi-
ence  in  many  cases  has  deemed it  necessary to
reject the use of carbonated waters.
   Habershon  employed carbolic  acid  as  early as
1870 ; Ebstein and Jos. Miiller have  used it  after
him.   Both found that the sugar disappeared in the
same degree in which the introduction of  food  was
reduced.
   Felizet more recently maintains that  by  an appli-
cation of  bromide  of potassium he has stopped the
irritation  of  the medulla oblongata, which  he re-
gards as the cause  of diabetes.
   Forster  combined chloride of  iron  with bromide
of potassium.   Clemens declares  (" Allg.  mediz.
Centr. Blatt.,"  1882) that by  bromide of arsenic he
cured radically severe cases of diabetes [?]
   Laube  administered  daily \ gramme of  arsenic
(solut. Fowl.  30 gutt).  Likewise  Kiilz  and  Leh-
mann.  Lecorche also  used it;  he showed  by his
experiments that in the animal on  which he operated
the glycogen of the liver was diminished in quantity.
Kretschy,  however, says that he was not successful
in the administration of arsenic.
   Frick  experimented with secale cornutum;  Hunt 
              Therapeutics of Diabetes.          159
with ergotine.   Other substances  that  have been
employed are as follows :  copaiba, benzoic acid, and
benzoate  of  sodium; tincture of iodine by Seegen,
chloral by Eckhard, eucalyptole by  Carlatti, potas-
sium permanganate by Masoin.
   Cantani considered lactic acid as a substitute for
sugar for  the purposes of respiration.   He adminis-
tered from 5—10 grammes  of acid. lact. purum, and
250—300 grammes of aromatic water after the meals.
By this means he intended to remove the  sugar from
the urine.   I did not notice any beneficial  result from
their use ;  neither could I become convinced of the
beneficial result of glycerine which was  applied by
Schultzen (see " Berl.  klin.  Wochenschrift,"  1872),
and more recently by  Hoist,  Petersburg;  other
physicians also, e.g.,  Blumenthal,  J.  Mayer, Kiilz,
Ziemssen, Kussmaul, either obtained no effect from
it, or a merely negative one.
   Moleschott  reports  that  he  successfully  used
iodoform.
   Yeast also was  prescribed  by some.   Kussmaul
obtained  a favourable result by injecting diastase
into the blood.
   Ley den reports (in  " Berl. klin. Wochenschrift,"
1877) that pilocarpine injections  exercise  a stimulat-
ing effect upon the nerves by which the vessels are
enlarged ; just as, for instance, the drinking of water
heated to  140—1600 F. produces an increase in the
action of the heart and an increase in the tempera-
ture (see  Glax,  "  Mittheil. in Sitz. Ber. d. Akad. d.
Wissenschaft."  1877).  Cantani, indeed, after the 
i6o
Diabetes.
use of pilocarpine, no longer discovered any  sugar
in the transpiration of the skin.  v. Hoffer  also em-
ployed sub-cutaneous  injections of pilocarpine  at
intervals of 10 days, thus  five injections in 50 days, of
a solution of two per cent, of the alkaloid.  It exerted
such an effect  on polyuria that the daily amount of
urine decreased 5,900 Cc, and the  secretion of sugar
diminished from 564 to 224 grammes per day.
  I have employed experimentally  this last medicine,
as well as all those that have been enumerated above;
I prescribed it internally, and as a palliative medicine
it has exercised a remarkable effect.
  Finally, I introduced into my combination-method
with extraordinary effect  both chromate of potassium
and preparations of mercury, and,  indeed, internally,
as well as externally in the massage, as these remedies
seemed to be indicated by  the case in question.
  Internally I employ the  corros.  sublimate-albumi-
nate, prepared according to Bamberger's well-known
prescription ; but  I never employ  it subcutaneously.
I also prescribe  chrome-water after  the  carbonic
acid has  escaped from  it, which  remedy  has been
tested in  cases  of lues  by Giinze in  Dresden, and
the curative effect of which has been  confirmed by
myself.

           (b)  Strengthening Berne dies.
   Under  the above head  the following  remedies
have acquired some  distinction:  Breparations of
iron, quinine  in  small doses  (Blumenthal adminis-
tered daily from 0-4—2  gr. of  muriate of  quinine); 
              Therapeutics of Diabetes.          161
cod-liver oil, recommended especially by Buchheim
and Senator, and lastly, alkaline salts.
   Alkaline salts.   Carlsbad.—Although  in
some special  cases  the sodium 'bicarbonate,  which
was frequently employed  by myself, has proved  very
effective, the hot alkaline  waters of Carlsbad in parti-
cular, which were recommended already by Hufeland,
have produced  most wonderful effects, especially
in cases of glycosuria; while  the waters of Vichy,
Neuenahr (which Vocke recommends on account  of
the absence of Glauber-salts),  Vals, and other alka-
line springs containing carbonic  acid, only  promote
the thirst and the secretion of urine, and increase the
dryness in  the mouth.  During winter  Seegen  pre-
scribed daily one bottle of Celestin or Grande grille
of Vichy.   Schmitz sings the  praises of Neuenahr
as furnishing a specific remedy against diabetes  (see
" Four cases of diabetes  cured " [?], in " Berl. klin.
Wochenschrift,"  1873).
  The Carlsbad waters certainly do not exercise  any
specific effect on genuine diabetes, but their effects
upon the conditions of the blood-circulation in  the
liver, upon the raising of the tone of the whole system,
upon the transformation of constitutional states  and
complications,  upon  increasing  the  tolerance  for
amylaceous substances, etc., are  so  much the more
striking.   In thousands and thousands of cases they
have caused the sugar to disappear from the  urine,
and have healed glycosuria. Statistical proofs of the
efficiency and significance  of  the Carlsbad waters
have been  furnished by  Anger, Senator,  Seegen,
                                         M 
162
Diabetes.
Griesinger, L. Fleckles, F.  Fleckles, Hoppe-Seyler,
Emil  Pfeiffer (in  " Balneol.  Studien,"  Wiesbaden,
1880), Hlawacek,  Kiilz, Loignard, and others.
  Carlsbad   certainly  brings  relief  also  to  those
afflicted  with   diabetes,  if,  in   addition  to  the
" sprudel,"  rich in  alkalies,  there are  applied the
requisite medicines  and a rational method of  cure.
  The use of the Carlsbad waters has thus far not
been  able to cure diabetes radically!   But it has
justly  been  considered  as  a matter of  importance
that Carlsbad is able to  stop temporarily the feeling
of thirst, the greedy hunger, and polyuria, and further
that  it increases  the tolerance  of the  system  for
hydrates of carbon, and  has prolonged life for years.
  Senator, Kiilz, Riess, and others prescribed Carls-
bad waters for their patients in  hospitals,  but they
did  not  meet with  any success !   Most assuredly
they would  fail  to do so.   For those efficient, col-
lateral elements  by which the action of the waters in
Carlsbad itself is supported, namely, a cheerful state
of mind, relieved of cares and freed from anxiety—
further, muscular action by climbing the forest-clad
hills of Carlsbad,  with leisurely  walks on  its sunny
heights—cannot be administered in the hospitals at
the same time with the waters.
  Since  I claim  " hereditary lues" as the aetiological
element  of  diabetes, the use of  the  hot  Carlsbad
waters, regulated for individual cases, is of especial
value as one of the factors in my therapeutical system.
  PAQUELIN.   Where there are  complications with
albuminuria I have obtained most  favourable results 
              Therapeutics of Diabetes.           163
 by a simultaneous cauterization of the back with this
 instrument.
   A Summary.   After numberless experiments, by
 combining a hygienic treatment with a careful bodily
 and mental diet;  by thus utilizing and uniting in  one
 system the various agencies detailed in the present
 chapter, and by applying the  few approved medi-
 cines, I  have succeeded in bringing about a trans-
 formation of the defective protoplasm, and in effecting
 a lasting cure of diabetes.
   I am now enabled to prognosticate with certainty :
 Such  a  case  of genuine diabetes  is curable, while
 another  case, on account of the advanced state of
 the  sclerotic  processes, is indeed  capable  of being
 ameliorated, but not of being radically cured, because
 the protoplasm is no longer capable of being recon-
 structed.
   In bringing the present monograph to a close I
 shall confine  myself to a report of the first twelve
 cases of diabetes in which I have applied my method
 of cure,  and  by  which I  have  demonstrated  the
 curability of diabetes.
  I  selected by preference cases  which  date from
 the first period when my efforts of curing  diabetes
 became  successful, namely,  from  the year  1881.
 My object  has been to  show that the disease which
 was cured then has not reappeared during the ensuing
six, and  respectively seven  years.   I hope  at some
 future time to be able  to communicate an  account
of a great number of additional cures in a strictly
scientific treatise on the Therapeutics of Diabetes. 
XII.
A   FEW  STRIKING   AND   SIGNIFICANT
    ACCOUNTS OF CASES  OF DIABETES
    FROM  THE  YEAR  1881.

The first twelve cases of diabetes cured from among
    a great number of cases successfully treated by
    myself.

   (1)  Marie  H., 13   years old, from  New York,
arrived in  Carlsbad on May 13, 1881,  in company
with  her father.  The patient  was somewhat ema-
ciated ; her countenance  had  an intelligent expres-
sion.   Her person was not yet developed.
   The skin was very well  taken care of, but very dry.
The complexion of the face and  of  the whole body
 being pale, its lymphatic habit exhibited consider-
 able deposits of pigment, and in various  parts of  the
 body and of the lower extremities epithelial growths
 of the size of lentils, in groups of ten or twelve, were
 scattered ; there were also warts  of  the size  of
 lentils, and even  of peas.  The hair was of a dark-
 brown colour and bristly ; the  nails  of the two great
 toes  were much  thickened  and out of shape.   So-
 called white  lucky spots were on the nails of the
 hands, the results of disturbances in the assimilation
 of the food, of the kind very frequently met with  in
 youth and even as late as the thirtieth year. 
           Accounts of Cases of Diabetes.         165
   The lymphatic glands on both sides of the cervical
vertebrae, as well as the inguinal lymphatic glands
were  swollen ;  the  former felt as though hardened.
Several of the teeth were carious.
   The left side of the surface of the tongue had deep
indentations ;  while  the right side was normal.  It
was reported that she had been a healthy child, but
had a difficulty in teething.  From  her seventh year
she attended school, was diligent in her studies,  and
had a quick apprehension.
   In  January of the present  year (1881) she  was
overtaken  by  a cold shower, and  came  home from
school wetted through.   Soon after, she complained
of headache, and especially of pains in the occiput;
she lost her appetite, but  in a few days she became
ravenously hungry and her thirst increased.
   The physician who was consulted kept the young
patient for a few days in bed in order to observe  her,
and on analyzing her urine he found that while its
specific gravity was  1*036, it contained 4*2 per cent.
of sugar.
   The well-known diet  and a corresponding treat-
ment  were  prescribed; and as  her  condition  was
only temporarily relieved during  the ensuing weeks,
it was resolved to send her to Carlsbad.
   After gathering all the  above information I  felt
compelled to examine the  father as well, who com-
plained  of all  kinds of troubles  of the digestive
organs.   I learned from him that he was a captain
in the navy ; that while a midshipman,, when 18 years
of age,  and ONE YEAR BEFORE HIS MARRIAGE, 
166                 Diabetes.
HE WAS LUETIC ;  that  he was  pronounced cured
by the doctors,  and that only  then he resolved  to
marry.  The mother, he said, was perfectly healthy.
  21 st May.—While undergoing the well-known diet,
the urine  of  24 hours  amounted  to 2,100 ccm. ; it
was nearly of the colour of water ;  its specific gravity
was 1 '038 ; and it contained 4*6 per cent, of sugar.
  22nd May.—The treatment  began, consisting  of
the drinking  of Carlsbad water  and the  taking  of
baths, together  with   the  internal   remedies  men-
tioned above, and the  massage of the whole body.
The thermometer, which was  applied between  six
and seven  o'clock in the mornings and  evenings,
constantly  exhibited the  following  minute  fluctua-
tions :  36*2—36*5—36*7° C.
  The intelligent father himself examined the urine
daily, most accurately.    He was also very expert in
the use of the apparatus for polarization.
  On July 28th the patient left  Carlsbad with  the
instruction to continue the prescribed diet and  the
internal treatment, together with the massage and
the baths, until November.  From  that date I  per-
mitted her at intervals  to  return  to  the  ordinary
diet, but  the  Turkish  baths,  which  I had ordered,
were to be continued.
  From time to time I received the gratifying news
that  the sugar  had  not reappeared and  that Miss
Marie  H. was enjoying the best health.
  She married in the month of  May of 1886.
  (2)  Lady  v.  S., aged  28  years,  of  a  delicate
constitution,  daughter  of  a landed proprietor  in 
          Accounts of Cases of Diabetes.         167
 Northern Germany, who had been in the army, and
 who had died  in  his  6ind year of diabetes.   She
 reported that in her youth, when she  was 16 years
 of  age,  she, and also  an elder  sister,  suffered from
 green sickness.
   When 20 years  of  age she married, and quickly
 in succession bare six children.   After the birth of
 the fifth child already, in  1879, she did not feel quite
 well;  her stomach was frequently out of  sorts.  In
 the year 1880, in  the  third week after the birth of
 her last healthy child,  she was suddenly seized with
 a ravenous hunger and a violent thirst, coupled with
 dryness of the mouth.
   Her  teeth, which   had  hitherto  been  perfectly
 healthy, became  sensitive during mastication,  and
 the two upper incisors  came out without pain.
   After she had become emaciated her urine showed
 7 per cent, of sugar.
   WThen an  examination  was made on July 24th,
 1881, her skin  appeared dry;  epithelial growths
were here  and there over  the  whole  body ;  there
 were  strongly  developed varices  on  each of  the
 lower thighs, especially on the right  side ; all the
 toe-nails were deformed,  without being thickened ;
 the lungs and heart  were healthy; the  right lobe
 of the liver  was  enlarged.   The  quantity of urine
 passed  during  24 hours was from 4^—9 pints ; its
 specific gravity was 1*038, and  it contained 6-4 per
 cent, of  sugar.
   The treatment lasted until the end of September,
 with interruptions during the menses.  On September 
168                 Diabetes.
26th the quantity of the urine was reduced to  1,500
ccm., and the sugar had reached zero.
  The hygienic treatment and the diet were continued
until  December.   On  Christmas eve she was able
to try farinaceous food with milk, after she had been
allowed to eat bread and  fruit (an apple) since Sep-
tember.  The urine remained normal.   The patient
has remained healthy to the present day !
   (3) On July 3rd, 1881, General N., from  Russia,
presented  himself.  He was  59  years of age, of a
herculean  stature, and had scarcely any hair left on
his head.   He reported  that he had  enjoyed good
health while a young officer, until in the Caucasus,
where he was stationed, he was repeatedly attacked
by intermittent fever.
   After he had been removed from the  Caucasus to
Odessa, and thence to  Warsaw, he recovered his
health, but he often complained of headache. When
36  years of age  he  married.   He  is the father of
three children who are  all very scrofulous.
  His father frequently suffered  of  tetter, and
he died of tuberculosis when 42 years of age ; as a
young man he had been  twice treated  for venereal
disorders.
  The  body of the patient, which  was  somewhat
emaciated, exhibited  a very dry skin.   Epithelial
growths in the form of jagged, little warts were on
the neck,  abdomen, upper thigh ; and on either side
of the vertebral column there were dark red spots of
the size of pin-heads to the size  of a pea; deposits of
pigment were  here and there, and  the  nails of the 
           Accounts of Cases of Diabetes.         169
big toes were  much  thickened.  On either  side of
the scrotum there was  prurigo, and  in the palm of
both hands psoriasis.
  Three years  previously five healthy teeth  had
fallen out without pains.   The surface of the tongue
exhibited deep  indentations ;  the  mouth great dry-
ness.
  The patient had always enjoyed a good appetite ;
for about the space of a  year he had experienced a
violent  thirst, and on examination a percentage of
5*6 of  sugar  was discovered.   The remedies which
were  applied  (bromide of potassium, Vichy-water,
opium) had only a temporary effect.
  Lungs and heart healthy, stomach extended, liver
and spleen enlarged.  Frequent  constipation alter-
nated with diarrhoea.   The percentage of sugar was
5*3 ; during  24 hours there  were secreted 6^ pints
of urine.
  A treatment  at Carlsbad for three months, with
the aid  of the  proper medicines,   massage,  and
Russian baths produced  a  complete  cure.   The
patient  is enjoying  good  health  at the present
day.
   (4)  Anna  B., 9 years  old, was brought to me by
her healthy  mother.    I  was informed  that since
March,  1881,  the child had  fallen off very much ;
that she was tired,  complained always  of  fatigue,
drank much,  and constantly craved to eat.   All this
was attributed to the quick growth of  the child, until
at last the physician proved the existence of diabetes
mellitus. 
170                  Diabetes.
  The father had  led a  very  irregular  life,  and
was treated, among other  things, for condylomes of
the rectum.
  I saw the child for  the  first time on July 16th.   I
was struck by the  strongly developed head of the
very emaciated young patient.
  The prevailing tendency of the body was scrofu-
lous,  the  skin  dry and  cracked,  the  complexion
dark; there were very many scars  of furunculous
ulcers which the  child had passed  through;  the
nails  of the  hands and   feet  were  deformed  and
brittle.
  An iritis which the  child had gone  through had
left a synechia  in  the right eye.  The  teeth  were
carious, the gums bulged  out,  the  tongue  was
normal, and there was  an odour  of acetone.
  The body  was bloated, and  there was an accele-
rated action of  the heart, but the respiration was
normal.    The   temperature  indicated  36*4°;  the
urine which was  passed during 24 hours amounted
to 1,800  ccm. ;  it  was very pale, and its  specific
gravity was 1*040. The percentage of sugar was 5*4.
  After the  use of the  Carlsbad  waters  for  two
months, in conjunction   with  Russian  baths  and
wet  sheet  packings, together  with the  medicines
specified above, and massage,  as explained in the
last  chapter, there resulted a  complete  cure ; the
use of the medicines and  a  dietetic treatment were
continued  for six months.  The patient has remained
healthy  to the present day.
  (5) Lieutenant B. passed successfully through the 
           Accounts of Cases of Diabetes.        171
Franco-Germanic war of  1870-1871 ; only he  con-
tracted a chronic catarrh of the stomach and bowels.
  For several years he  suffered  of  this illness,  until
at last there was added  to it a fistula of the rectum.
The fistula was operated upon and healed,  where-
upon  the  patient  underwent a regular  treatment
with the view  of being  freed of his catarrhal affec-
tion.
  The medical man who  treated him  noticed some
furunculous ulcers  on his back and along his  legs,
which the patient informed him he had been troubled
with for several months.
  The patient, who  complained of  great thirst, but
who had a craving for food  only  at intervals, was
very much  emaciated, and in  a  low state of  health.
After his urine had  been examined it was found that
he  had  6 per cent, of sugar,  when the usual remedies
against  this illness were  employed.  He got alter-
nately better  and worse,  until at last  he presented
himself before me in Carlsbad in the month of August,
1881.
  He was then 31 years old ; he was very emaciated,
the hair on his head  was  very scanty, his skin was
excessively dry ; there were many epithelial growths
on his body and neck;  his teeth were carious; his
tongue  was plowed  through by deep  fissures, and
very dry.   His urine during 24  hours  amounted  to
4! pints, and contained  6*7 per cent, of sugar.
  The parents, brothers,  and sisters of  the  patient
were  said  to be healthy,  but  his grandfather had
suffered of dry tetter, and had died of consumption. 
 172                 Diabetes.
   The  treatment  of  the patient  lasted for  four
 months.  During that time he constantly increased in
 flesh; he was perfectly  healed, and up to the present
 time he  is a railway officer in the Brussian state.
   (6) Nicholas  0., 34 years  old, from  Bavaria, a
 commercial traveller, middle-sized ; for many years
 he had  complained of troubles in his digestion.   He
 was frequently compelled to interrupt  his journeys
 by bleedings from piles, until at last he resolved to
 undergo an operation.
   In the year 1880, after undergoing this operation,
 he had an anthrax on the right shoulder-blade, which
 healed only very  slowly, and reduced him very much.
 After recovering  from  it he rejoiced  at his  good
 appetite and his  desire for much beer, until at last
 his thirst could no longer be quenched.
   At Strasburg he  consulted a  medical  man with
 whom  he was acquainted.   He discovered  9 per
 cent,  of sugar, and  sent  him to  Neuenahr (see the
 "  Literature " below, under the head of " Schmitz ").
 He left  the watering-place apparently healed, in order
 to follow his avocation.   Business exertions soon re-
 duced  him to his  former condition,  and he was
 advised to go to  Carlsbad during the same year.
   Mr. N. O. called on me, on August 2, 1881.   He
 had a considerable accumulation of  fat, his health
 had very much run down, and he soon got fatigued
 in walking.   He  was the son of  a butcher, who had
 inclined  to  apoplexy,  and  had died  in his fifty-
fourth year.   In his  youth the  father had been
 treated several times for venereal infections. 
          Accounts of Cases of Diabetes.        173
  The complexion and skin of my patient were pale;
he  had a large mole  on his  upper  arm.  His toes
were contracted ;  the nails of  his  big toes were
thickened ;  the action of  his heart was very weak,
84  beats of the pulse.
  His  teeth,  which had been carious  even during
childhood,  showed  many chasms.   His  digestion
was sluggish ;  the  urine  which  he passed during
twenty-four  hours amounted to 3,200 ccm., and con-
tained 5'6 per cent, of sugar, with traces of albumen.
  After remaining under my treatment at Carlsbad
to the end of September he had  by that  time lost
the sugar and  the accumulation of fat, without having
diminished  very much in weight.    At Nice  he re-
mained from  November to  February.   The usual
experiments which he underwent in respect to food
showed  no  sugar;  the  albumen had disappeared ;
the patient  felt vigorous, and began to enjoy life
again, for the pulsation of the heart also had become
more energetic.  He has preserved his  health to the
present day.
   (7)   Dr.  med.  N., from  the   southern  part  of
 Russia, whose father  was diseased in his lungs, and
 whose  grandfather  on his mother's  side had been
 luetic, enjoyed very good health until his 32nd year.
 By over-exerting  himself  in his practice, which was
 in  the country, he contracted an inflammation of the
 lungs  in the spring  of 1877.  Since that  time con-
 stant  catarrhal affections of the  bronchia took the
 place  of  his  former robust  state of health.  After
some  time  asthmatic affections, with  thirst and a 
 174                 Diabetes.
 feeling of hunger, manifested themselves ; and these
 affections became more and  more pronounced, until
 at last the patient  began to lose flesh ;  4 per cent.
 of sugar were discovered.   The remedies known at
 that time  were employed  in order to combat the
 diabetes, but only with a slight effect.
   Prof. Tscherinoff, of Moscow, advised him to go
 to  Carlsbad.   Family  arrangements  forbade  the
 patient, who  was very low in  his  bodily condition,
 to undertake  the journey to Carlsbad before  August,
 1881.
   The skin of  the patient was dry,  covered with
 many pigmental spots ;  epithelial growths were in
 various places  of the body ;  the  nails  of  the two
 big toes  were thickened, and  embedded much in the
 flesh.  In the year 1878 he lost all his teeth except
 three of the grinders ;  they were perfectly sound,
 and could be  removed  without  pain and without
 instruments.
   He complained of being much troubled with piles,
 without  any  loss of  blood ;  and  of  atony of the
 bowels,  which  lasted for entire days.   Heart  and
 lungs were normal.
   After  a  treatment which lasted  for six months he
 recovered his full health ; and at present the former
patient enjoys a better state  of health than he ever
 did before.
   (8)  Herr  v. F.,  43 years  old,  landed  proprietor
 from  Saxony,  had  been  suffering of diabetes for
 one and  a half  years.
   When a young  man he had been  infected by a 
           Accounts of Cases of Diabetes.        175
venereal (luetic) disease, and  when  upwards of 20
years old he had painful  enlargements of the right
tibia, so that three times he was ordered to go to
Aix-la-Chapelle.
   His  uncle on his  mother's  side  had died of
diabetes.   The mother is gouty ; but the father, he
said, was a strong,  vigorous man,  70 years of age.
   The  patient had fallen off in  flesh; he had but
little hair on his head ; his  skin was dry with many
pigmental spots on  the body ; the nails of  the feet,
especially those of the  big toes, were much thickened
and  painful;  the teeth were remarkably  well pre-
served ;  the tongue was dry, with many  fissures;
there  were a few  plaques;  much thirst, but  no
abnormal hunger;  the digestion had  been disturbed
for many years, and he had used the  most drastic
cathartics.
   The  quantity  of  urine during  twenty-four hours
was  three pints ;  its specific gravity 1*042 ;  and the
percentage of sugar 6*7.
   A treatment of three months at  Carlsbad  removed
all the ailments of  the patient with the exception of
some  traces  of  sugar;  and an  after-cure of six
months restored his health completely.
   (9)  Mrs. G., 28 years old, from Russia, had been
married for nine years  ; she had no children, and led
a  life  under the  happiest  circumstances.  Three
years ago the patient suffered of  violent toothache,
and  had four back-teeth pulled out.  From that time
she felt very much weakened, so that she could walk
only with  great  difficulty ;  and  yet  to  her great 
176                 Diabetes.
astonishment her appetite and her  thirst  kept on
increasing.
  There was a remarkable increase in the secretion
of  the  urine;  diabetes was diagnosed, with  one
gallon of urine  secreted  during twenty-four hours,
and 3 per cent, of sugar.
  A treatment of eight  months, of which ten weeks
were  spent  in Carlsbad, produced a thorough cure
in the mild climate of Nice.    Meanwhile she gave
birth  to  a healthy  child,  and  enjoys the very best
health.
  Her father died early  of consumption.   Her grand-
father is said to have been treated several times with
mercury and iodide of potassium.
  (10)  University  student,  N.,  25 years old,  a
Frenchman, born in  Tunis;   the son  of  wealthy
parents, both living.   He has two older sisters, both
sickly and scrofulous; and he had  also a twin-sister,
who  died soon after  being vaccinated.  The patient
himself, as a child, was  sickly ;   he was troubled with
all kinds of scrofulous  affections, so that the family
physician,  a doctor  of medicine  of  the  famous
medical school at Montpellier,  advised the  young
student to undertake a journey around the world.
  The youth overjoyed his  family in France by re-
turning to them after his journey as a stately young
man.   He now  considered himself  sufficiently pre-
pared by  his  studies to be  able  to follow  at once
a  mercantile  pursuit.   Various  attacks  of inter-
mittent  fever, however,  by which  he was overtaken
in his new home at Bordeaux, induced  him  to visit 
           Accounts of Cases of Diabetes.         177
 Nice, where I became acquainted with  him.  After
 examining the patient carefully, who had lost much
 flesh, it appeared that he had 6 per cent, of sugar.
 The hot, alkaline springs of Carlsbad, as well as an
 energetic application  of my remedies, restored him
 permanently to a state of health.
   (n)  John L., 41  years  old, from Holland,  the
 descendant of an ancient,  noble  family, introduced
 himself to me on July 29, 1881, with these words —
   " For four years I am suffering from diabetes, yet,
 different  from other  diabetic  persons,  I  have  not
 fallen off in flesh, but I have become feeble ;  besides,
 I  am no longer young.  My  power  of  vision  has
 decreased, perhaps  in  consequence  of  my  having
 enjoyed prohibited dishes at a wedding last year."
   The patient stated  that he had as much as 4 per
 cent, of sugar.  His three brothers and sisters died
 in earliest infancy.  His father, upwards of 70 years
 of age, is still hale,  but his  mother died in her $\th
year, in consequence of cancer in the  breast.
   A considerable accumulation  of  fat  adorns  the
 patient, who weighs  14-J stone.   A scanty supply of
 hair is on his head, while his  back is covered with
 strongly-developed hair.  The nails of  his  hands,
all except the thumb of the left hand, which is almost
entirely wanting,  are normal ; those of the  feet  are
very thickened and deformed.
   His teeth are preserved all except two ; the tongue
exhibits deep indentations.   Considerable accumula-
tion  of  fat  about the heart; fatness of the  liver.
Digestion : great tendency towards diarrhoea.  Alter-
                                       N 
178                  Diabetes.
nately a feeling of hunger and thirst.   Result of the
ophthalmoscope—turbidity of the crystalline lens on
each side.
  Quantity of urine per day, 6J pints ; 4*8 per cent.
of sugar ;  traces of albumen.   Temperature, 35*8—
36°C.
  A treatment of six weeks at Carlsbad,  and an
after-cure in  the Riviera of  three months, produced
a lasting cure.
  (12)  Baron F. (the son of a Russian general), who
had been luetic in his  youth, and  had suffered from
tetter during his whole life, put himself under my
treatment on October 17, 1881.  His grandfather
had died of consumption.   He was  educated at the
law school  in St.  Petersburg.  When  a child he
suffered from scrofula, which was proved  by several
scars (scars  of the lymphatic  glands) on the  neck,
but, thanks  to the bodily training and the generous
treatment  he received  at  the  above   institution,
he  developed into a  man  of a herculean  stature.
 Being intelligent and very talented, after  completing
 his  studies  he entered  into the civil service of his
 country, already when  21  years  of  age.   When 24
 years old he married, and for 10 years, until he was
 34 years of  age, he felt perfectly well.
   A sense  of duty,  as  well as  ambition,  induced
 him to over-exert himself in his function ; his health
 broke down, and he passed through a severe attack
 of  typhoid fever; after the lapse of months only he
 was able to  undertake again the responsibilities of
 his public office.   He dragged in  the performance 
           Accounts of Cases of Diabetes.         179
of his duties.  A leave of absence of twelve months
restored him to a comparative state of health.   He
returned to  St. Petersburg, and entered anew into
the public  service.  As a special mark of distinction
for his past services, and in acknowledgment of  his*
talents, he received the appointment of an assistant-
ship  to a  governor general in the far north, which
entailed upon  him renewed  exertions.   When  39
years of age he  quitted his onerous duties in order
to take care of himself, for an indescribable sense of
lassitude had come over him.   About  that  time  his
eldest son  was seized  with epilepsy,  which worked
so much upon the feelings of  the father  that he was
seized with  another  attack of  typhoid  fever, and
regained his consciousness only after a number of
weeks.   He now began  rapidly to fall off  in  flesh,
notwithstanding  his  good appetite  and an  ever-
increasing  thirst.   They  told  him  that  he was
nervous, until at last sugar was discovered  in  his
urine.  He was sent to Vichy, and for  three  years
into the Caucasian mountains (Esentuki), and again,
a year ago, to Neuenahr, with only a temporary im-
provement.
   The  patient was tall,  had  broad shoulders, was
very  emaciated, had a  dry skin, with  epithelial
growths on his neck of the size of lentils. The nails
of the hands were well preserved ;  those of the feet,
and especially those of the big toes, were thickened
and had imbedded themselves into the flesh ; at the
slightest  touch they were painful.  His hair was
scanty; on the body and  along  the extremities  the 
180                  Diabetes.
hair  had developed almost in the form of bristles.
His  teeth, all except four, had fallen out painlessly;
the first tooth had come out as far back as six years
ago.   The tongue was full of fissures ; the lungs and
the heart normal.  The liver and spleen were enlarged.
The  stomach  was bloated,  the  digestion  sluggish.
 For  two years he had been impotent.   The quantity
 of urine passed during 24 hours amounted to 4,700
 ccm., with 8*4 per  cent, of sugar.  After he had
 been treated according to my method for two months
 the  sugar showed o.  When, after an after-cure of
 two  months, without the use of the Carlsbad waters,
 but with a continuance of the medicines, he returned
 to the ordinary diet in Russia, the sugar  reappeared
 after 20 days to the amount of 0*3 per cent.
   The  patient resumed his diabetic diet, and in the
 November of  1882  rejoined  me at  Nice.   My
 treatment, which affects the change  of substance
 and  the regeneration of the protoplasm,  was con-
 tinued  till March.   The patient then returned to
 the  ordinary diet, and has remained healthy up to
 the  present time, i.e., to February 28, 1887, conse-
 quently for nearly  six years, during which time he
 resided at Malta.
   Case 12 exhibits lues  in a patient whose father, as
 well as himself, had been  born  with scrofula, the
 consequences of hereditary lues. 
XIII.
   COROLLARIES  IN  SUPPORT OF  THE
     THESIS  OF THE  PRESENT  WORK.

 In presenting,  from  among the  great  number of
 cures of diabetes  which I have succeeded in effect-
 ing since 1881, the first twelve cases, I had a distinct
 object in view.
   For, although  I have  still numerous  interesting
 cases  to communicate, I  nevertheless  considered it
 my duty to report, without choice, the first twelve
 cases where a cure had been effected ; and, indeed,
 for this  reason, that  the  period from 1881 to 1887,
 during which my patients  have  remained  healthy, is
 long  enough to answer definitely in  an  affirmative
 sense the question whether actually a radical, lasting
 cure has been effected in those cases ; which, indeed,
from a therapeutical point of view, is the chief thing
 to be considered.
   In  a  certain  sense, also, the above  twelve cases
 are entitled to represent the hundreds of cures which
 I have been enabled  to make since 1881, for they
 make up the first dozen of those successful cases by
 which  I was encouraged to make renewed exertions,
 and to institute experiments on an extended scale.
 They also  have imparted to me that encouragement
 which  I  needed in order  by further treatment  and 
182                 Diabetes.
additional cures to perfect my system of therapeutics
in all its parts, so that  at last it stands before me as
a fixed, accomplished fact.
   It has been proved by experience  that in all  the
above  twelve cases a radical cure has been effected.
   The lasting character of these cures was confirmed
and  attested by annual reports received from each
of my former patients.
   The  whole of these twelve cases, therefore,  fur-
nish a  final  and  striking confirmation  of  my  two
theses —
   (1)  Diabetes is  the  result of a hereditary predis-
position, namely, of hereditary lues.
   (2)  Diabetes  is curable ! 
XIV.
 CONTRIBUTIONS  TO THE  HISTORY  AND
        LITERATURE  OF  DIABETES.*

 The Roman  physician  Aulus  Celsus  (30  years
 before Christ, to 38 years after Christ) is the first
 who has  alluded  to diabetes.   He  may  justly  be
 called the Cicero of physicians, and  he has handed
 down to us, in a  spirited and  elegant style (in his
 work De artibus of which, since the Florence edition
 of  1478, at  least 60  editions  have appeared)  the
 entire medical  knowledge and skill of the masters of
 the earliest medical  science even to those of his own
 time.
   In speaking  of diabetes, he  alludes especially to
 the  increased   secretion  of  urine,  which  causes
 emaciation  and  endangers  life.   The  respective
 passage (Celsus de Medic, 1.  8 rec Daremberg,
 Lips. MDCCCLIX, lib.  iv.,  c.  xxvii., 2)  reads ver-
 bally as follows :—" Quum  urina super  potionum
 modum etiam sine dolore profluens maciem et peri-
 culum  facit,  si  tenuis  est, opus est exercitatione et
frictione, maximeque in sole, vel ad ignem :  balneum
rarum  esse  debet, neque longa  in eo  mora :  cibus
  * Also a guide  to the publications which  are important  for
obtaining an understanding of the subject of diabetes, and to which
reference  is made in the present work. 
184                  Diabetes.
comprimens : vinum austerum meracum per aestatem
frigidum, perhiemem egelidum, sed tantum, quantum
minimum sit.  Alvus  quoque vel ducenda  vel lacte
purganda est.   Si crassa urina est, vehementior esse
debet  et  exercitatio  et frictio : longior in  balneo
mora:   cibis opus  est teneris :  vino  eodem.   In
utroque  morbo vitanda omnia  sunt,  quae  urinam
movere consuerunt."   In an English translation this
passage reads as follows :—" If  the  quantity of the
urine which is  passed is larger than the quantity of
the liquids imbibed, even if such takes place without
pains, emaciation is caused, and life  is  endangered.
If the  urine is thin, motion is required, and friction,
chiefly in the heat of the sun or before a fire.  A
bath should  not often  be taken, nor ought  you  to
stay in it long.   The  food should be astringent: the
wine rough and unmixed,  in  summer cold,  and in
winter  a little  warmed,  but very little  ought to be
taken of it.  The bowels also should be kept open,
or purged with milk.  If the urine is thick, the motion
and the friction should be more energetic ; you ought
also to stay longer in  the bath.   The food must be
light, and also  the wine.   Everything  ought to be
avoided  which  is wont to act upon  the  urinary
organs."
   The  history proper  of diabetes begins, therefore,
with Celsus,  1,900 years ago.
   Aretaus, a Greek physician of the  eclectic  school,
from Cappadocia (a contemporary of Nero), was the
most  shining light that adorned  the times  of the
early Roman emperors, and, next to Hippocrates, he 
          History and Literature of Diabetes.      185
was  renowned in  antiquity as  the  best observer of
diseases.   He wrote in the Ionic dialect concerning
the causes, symptoms, and cure  of acute and chronic
diseases.    He derived the term " diabetes," which
was known before his time, from  Bia^aivco  (a flowing
through of liquids into the urine), and he considered
the stomach as the seat of the disease (see the edition
of Kiihn., Vol. xxv., Leipzig, 1828).
   The  description  which Aretseus  gives of  the
disease seems  so  strikingly faithful that we cannot
refrain from quoting it here in  a free translation:—
" Diabetes is a strange  disease, which fortunately
is not very  frequent.   It consists  in  the flesh and
bones running together into urine.   It  is like dropsy
in this  respect that the cause of both is moisture
and coldness ;  yet so that in  diabetes the moisture
escapes   through  the kidneys  and bladder.   The
patients  urinate  unceasingly;   the   urine  keeps
running like a rivulet.   The  illness originates very
slowly.   Its final development is death.   The emacia-
tion increases very suddenly, so that the existence of
the patient is a sad and painful one.   The patients
are tortured  by an unquenchable  thirst; they never
cease drinking  and urinating,  and the quantity of
the urine  exceeds  that of the liquid imbibed.  There
is no  use  either in trying to prevent the patient  from
urinating  and from drinking ;  for if he abstains only
a  short  time  from drinking  his  mouth  becomes
parched,  and  he feels as  if a  consuming fire  were
raging in  his  bowels.   The patient  is  tortured in a
terrible  manner by thirst.   If  he retains  the  urine 
186                 Diabetes.
the hips,  loins,  and testicles begin to  swell;  the
swelling subsides as soon as he  passes the urine.
When  the illness  begins, the  mouth  begins to be
parched, and  the  saliva  is  white and  frothy.  A
sensation  of heat  and cold  extends down into the
bladder as the  illness  progresses ;  and as it pro-
gresses still more there is a  consuming  heat in the
bowels.  The  integuments of the  abdomen become
wrinkled,  and the whole  body  wastes away.   The
secretion  of  the urine  becomes more copious, and
the thirst increases  more and  more.   The  illness
was  called diabetes, as  though it were  a  syphon,
because it converts  the  human  body into  a pipe
for the transflux of liquid humours.  Now, since the
patient goes on drinking and urinating, while only
the smallest portion of what  he drinks is assimilated
by the body, life naturally cannot  be preserved very
long, for  a portion of the  flesh  also  is excreted
through the urine.   The cause of  the illness  may be
that some malignity has been left in the system by
some acute malady, which  afterwards is developed
into  this disease.  It is possible also that it is caused
by a poison contained in the  kidneys or  bladder, or
by the bite of the thirst-adder or dipsas.   The bite of
this snake causes an almost unquenchable thirst, and
in trying to satisfy it the stomach is filled with water.
With some who suffer of this disease no urine passes
at all,  so that  they finally  burst."
   Aret&us excels  Celsus in this respect,  that he
dwells upon  the unquenchable thirst,  which is  a
characteristic feature  of the disease.   As regards 
         History and Literature of Diabetes.     187
the  treatment  which  Aretaeus advises, it  is as
follows :
   " The disease of diabetes is  a  kind  of dropsy,
only  that  the  water in diabetes runs towards the
kidneys and bladder, and is discharged in this way.
In treating it your purpose  must be  to diminish the
thirst.  For drinking stimulates the desire to urinate,
and  by  the  urine  many parts of  the body  which
have  become  liquid are carried off;  wherefore such
remedies must be applied as lessen the thirst.   The
treatment  also  must have  regard to  the stomach ;
for there lies the cause of diabetes.   Let the body
be cleansed by the  hiera [a sort of antidote against
poisons] ;  make a poultice  of ointment of spikenard,
mastix, dates, and quinces.   The juice  of quinces,
together with  the  oil of spikenard  and the oil of
roses, is  useful for pouring over the body.   The
pulp  of quinces also may  be  used  as a  cataplasm;
wax and the ointment of spikenards may  likewise be
mixed with it.  The juice of  the  acacia and of
kytinus hypocystis may also be used for this purpose.
  " For a beverage use water in which summer-fruits
have  been  boiled.
  " For  food  use milk, dishes prepared with milk,
starch,  pearled barley,  soups.   Astringent  wines,
especially  very strong ones,  are   serviceable  for
strengthening  the stomach,  and for evaporating  and
diluting the other fluids of the body.   A wine which
is astringent, and at the same time cooling, is useful
on account of  its  transforming and cooling pro-
perties ;  while  a sweet  wine,  just  like  the  blood, 
i88
Diabetes.
increases  the  strength,  because it generates blood.
Of compound  remedies, apply that of Vestinus, that
of  Mithridates, the juice of fruits,  as well as  all
the other remedies, which are also useful in dropsy.
The whole diet and mode of  living is identical with
that which ought also to be applied in dropsy."
  The celebrated physician in ordinary of the young
Emperor  Commodus,  Claudius  Galen  (born  131
A.D.),  the most influential medical  practitioner  of
antiquity (in  " De loc affect.," libr.  vi., cap. hi.), is
of opinion that the cause of  diabetes is a diseased
state of the kidneys.
  Baracelsus  (born in 1493,  at Maria  Einsiedeln),
the  reformer of  the art of healing, which had been
condemned to remain stationary, returned to Hippo-
crates' treatment  of diseases in conformity  with
nature.  He introduced the chemico-metallic medi-
cines ;  he was the first author who treated  syphilis
systematically;  and he demanded  that " science
among the Germans  should  be  German."   In his
work " De tartaro," lib. ii., he  laid down as the cause
of diabetes  "an increased formation of salt,  pro-
ducing an irritation of the kidneys."
  The renowned Italian physician and mathematician,
Geronimo Cardano (died 1575), who was  called the
wisest fool, and the most foolish wise man of his age,
and whose writings are among the most important
literary monuments of the sixteenth century, compiled
already a table of the quantity of  liquid nourishment
received by the body on  the one hand and of the
urine which was discharged on the other. 
         History and Literature of Diabetes.      189
  Sylvius (1478-1555), who most earnestly  recom-
mended the dissection of dead bodies, maintains (in
his  " Opera med.," Amsterdam, 1680, p. 724) that
diabetes  originates from  a faulty condition of the
blood; which definition I write upon my own banner
to-day where I speak of the  defective  formation
of the protoplasm in persons suffering from diabetes.
  Bichard Mead ("Opera  med.,"  London,  1744)
supposes diabetes to  be a disease of  the liver, and
to arise in  consequence  of an abnormal preparation
of bile, which,  however, is pathologically false.   To
mention only one  thing—among the 64 dissections
of  the bodies  of persons  who died  of  diabetes,
which are described by  Griesinger,  an enlargement
of the liver could be  demonstrated only three times.
  The Englishman Thomas Willis,  with the excep-
tion  of the  Indian  physicians, was the  first who
about the year 1674 (see "  Pharmaceutica rationalis
Oxenofordi ") discovered sugar in the urine  by the
sweet taste of  diabetic  urine ; he therefore was the
first who diagnosed diabetes  mellitus.  Henceforth
there existed diabetes mellitus;  and able experi-
menters,  such  as M.   Dobson  (1775,  who  first
obtained  sugar  by evaporating urine), Bool,  and
especially  Th.  Cowley and others, demonstrated  the
existence  of sugar (i.e., of  crumbling,  crystalline
sugar)  beyond any shadow of doubt.
  F. Howe  proved  the fermentation of  diabetic
urine.
  The  Englishman  John  Bollo (1797)  acquired
great merit  by  his  dietetic prescriptions,  recom- 
 190                 Diabetes.
 mending  animal  food.   He  first  recognized the
 injurious effects of  vegetable food on the formation
 of sugar  in  the organism, and  demanded a  meat
 diet for  those  afflicted  with diabetes.  His two
 works  entitled: " On diabetes mellitus,"  London,
 1797 ; and his treatise  "On diabetes mellitus, with
 chemical  experiments by W. Cruikshank," Vienna,
 1801, are still consulted at the present day.
   Henceforth the attention  of the  profession  was
 directed to the  processes  which  take place during
 digestion.  Many dissertations and articles on this
 subject appeared in the  medical  journals, as well as
 the following treatises :—
   W.  Br out, " Inquiry into  the nature and the
 treatment of  diabetes, calculus,"  etc., 2nd edition,
 London, 1825 ;  and "On the  nature and treatment
 of  stomach  and  renal  diseases,"  London,   1848,
 with additional editions.
   Venables,  " A practical   treatise  on  diabetes,"
 London, 1825.
  Nicolas and Gueudeville supposed diabetes  to be
a " phthisurie sucree," caused by a disease of the
 bowels.
  With the view of obtaining an understanding of
the  substances  which  contain   and form  sugar,
and also for the purpose of  inquiring into the con-
stituents of the  blood and urine,  chemistry, which
was  then  beginning to grow strong and powerful,
was drawn upon for help.
  Already, in  1835,  tne  apothecary Ambrosiani
proved the existence of  sugar in the blood, without, 
         History and Literature of Diabetes.     191
on that account, being able to trace the cause  of
the disease.
  About this time  (1835) Bouchardat returned  to
the standpoint of  Aretaeus, and  declared that the
seat of  the disease was in the stomach (see  his
articles in  the  " Gaz.  med.," of  1835, No.  11 ;
further, in  the  "Rev.  med.," 1839, Juin;  in the
"Annuaire  de Ther.,"  1842,  pp.  46, 48;   in the
" Clinique europ,," of 1859, p. 58 ;  and, finally,  in
the " Bull,  de Ther.,"  p. 145, where he treats  of
glycosuria.)
  Mialhe looked for the seat  of  the  disease in the
blood.- in consideration of the fact that owing to an
obstruction  in the secretion of  the skin the alkaliza-
tion of the  blood is diminished, and the  combustion
of the sugar, which is possible only in the presence
of  free  alkalies,  is  interfered  with, he urgently
advised the use of alkalies, which  is really the only
remedy used by the profession up to the  present
time, either  in the  form of  medicine, or in  that  of
waters drunk at the various alkaline springs.
  The French physician  Biorry,  between 1840 and
1850, ordered his patients to use as much sugar  as
possible  in  order to replace the  sugar which  was
lost.
  A new  epoch  in the  history of diabetes  was in-
augurated  by the  Frenchman  Claude Bernard,  in
so  far as  by  the artificially  produced  glycosuria
through  his  so-called  celebrated  sugar-puncture
(piqure),   and  also  through  curare,  as well  as
through his experiments upon the liver, with the view 
 192                 Diabetes.
 of  throwing  light upon the formation  of  sugar, he
 created the physiological experiment for the purpose
 of ferreting out the cause of diabetes—which also is
 the  task I have proposed  to myself  (see  Claude
 Bernard's  " Lecons  de physiologie experimentale,"
 Paris, 1855, ff. ;  further, " Lecons sur le Diabete et la
 Glykogenese animale,"  Paris, 1877.   " Vorlesungen
 iiber den  Diabetes  und  die thierische Zuckerbil-
 dung," translated into German by C. Posner, Berlin,
 1878.   Finally,  see  also C. Bernard's work entitled
 " New functions of the liver as an organ which forms
 sugar in man and animals," translated into German
 by  Dr. Schwarzenbach, Wiirzburg,  1853).
  Lehmann entered  upon the physiological experi-
 ment almost  at  the same time  as  Bernard (see
 Lehmann,  " Bericht der Gesellschaft der  Wissens-
 chaft. zu Leipzig," 1850).
  Bernard, the originator of experimental  diabetes,
 gave rise to  numberless  investigations from  1848
 upwards, which were profitable to the physiology of
 the production of glycogen, as well  as to the patho-
 logy  of diabetes.   He  is  of the opinion  that his
 operations and injections cause a vasomotory irrita-
tion, and thereby a  hyperaemia  of  the  liver, which
results in glycosuria.   At  all events he  considers
the glycogen of  the  liver as a preparatory step for
the formation of sugar.   Nevertheless, he still left
two questions involved in darkness; namely, (a) the
origin  and  use of glycogen;  and (b) the  nervous
tracks by which  the circulation of glycogen is deter-
mined. 
          History and Literature of Diabetes.      193
   The Englishman  Pavy is of the  opinion that
 glycogen  is  subservient  to  the formation  of  fat.
 According to him glycogen is caused by the reception
 of  sugar and starch, which through the agency of a
 ferment contained  in the blood is transformed into
 sugar.  Pavy,  a disciple of Bernard, differs from his
 master in supposing  that  the  formation of sugar is
 a post-mortal process.
  Schiff—who still recommended, in 1859, amylaceous
 food, lest  the  sugar be  formed at the expense  of
 the elements  of the body—Tommasi, Naunyn, and
 others, on  the  basis  of  Bernard's  investigations,
 instituted the most minute inquiries.   The  majority
 of the learned favoured now the idea of the  origin of
 diabetes in the  liver ; while some inquirers still  as-
 sumed other causes, as, for instance,  atrophy, i.e.,
 a fatty degeneration of the pancreas ; namely, Skoda,
 Oppolzer,  and  more recently Biiumel, who  distin-
 guishes between a fat,  a  lean, and a mixed form of
 the pancreas, and recommends artificial preparations
 of pancreas for the purpose of curing diabetes.
   Voit  and  Bettenkofer  maintain  that   diabetes
 mellitus  is  caused  by a  too scanty reception  of
 oxygen.
  Bence  Jones,  Leube,  and  others  share  this
 opinion,  but especially Prof.  Cantani, of  Naples
 (" Diabetes mellitus,"  translated into  German  by
 Hahn.   Berlin,  1880).    This  latter gentleman
regards the  sugar  in  the diabetic  blood not  as
glucose, but  as paraglucose;  and  he  interested
himself most actively in  the spread of  this  view.
                                         O 
194                 Diabetes.
Cantani says : " Diabetes is a disease of the change
of substance (Stoffwechsel).   In this disease there
is no abnormal production of sugar, either quantita-
tively  or  qualitatively ;  but the  sugar which  has
been introduced into the system, or which  has  been
generated  there in a normal manner, is  not made
use of  for the purpose of being burned in the manner
in which this is done in animal organisms, nor is it
employed  as  a substance  capable  of  undergoing
fermentation.  It remains as a foreign  substance  in
the body,  which is not  utilized in the economy  of
the organism ;  for it cannot be made use of in the
processes which enter into the change of substance.
Wherefore it passes  through the system in the form
of sugar,  without  undergoing a final transforma-
tion ; and  it leaves the system through  the  urine
and the other secretions."
   In  animals  in  which  glycosuria  was  produced
artificially it disappears by the injection of bicar-
bonate of  sodium.   This is explained by Cantani in
this wise—that the sugar is thereby rendered capable
of fermentation, and thus capable  of being burned.
   It was  reserved  for  Ebstein to  enter  into the
mystery of the pathogeny of diabetes mellitus, which
disease is as interesting for the  physiologist as it
is for the pathologist.   In his  treatise  on diabetes,
which appeared only a short time ago, he has endea-
voured,  by a remarkable series of experiments,  to
present a relatively insufficient formation of carbonic
acid in the tissues and organs  of a  person affected
by diabetes, as that  element which acts the part  of 
           History and Literature of Diabetes.      195
 an instrumental cause in the production of diabetes.
 By demanding a correction  of  the defective forma-
 tion of carbonic acid, he pointed out to the medical
 practitioners a means by  which  to cope with  dia-
 betes ;  and  he directed them to a method of  thera-
 peutics, such as I practised before him, ever since
 the year 1881.
   Many  things worthy of  notice are  contained  in
 the  treatises  and articles  which have  appeared  in
 the  present  century on  the  subject  of diabetes.
 Some  of  these  works,  as,  for instance, those  of
 Seegen, Frerichs, Ebstein, may even be regarded as
 marking an epoch in the  treatment  of  this  disease.
 The whole of these publications, which at the same
 time  furnish  a complete  bibliography  of diabetes
 in an alphabetical order, are  as  follows:—
 Abeles, Wien. med. Jahrb. II. 176 ; also Ibid., 1874. Uber mini-
     male Mengen Zucker  im menschlichen Ham., in  C.-Bl.  d.
     medic. Wissensch. 1885, No. 26, S. 449.
 Albertoni, Peter, Die Wirkungen und die Verwandlungen einiger
     Stoffe in Beziehung zur Pathogenese der Acetonamie und des
     Diab.  Virch. Arch. 18, 1884.
 Arnold, tTber das Vorkommen " heller "  Muskeln beim Menschen.
    Heidelberg 1886.
 Astaschewsky, Med. Centralbl. 1877, p. 531.  30.
 Balfour,  G. W., On  the treatm. of diabetes  etc.  Edinb. Med.
    Journ. XV. Febr. 1870.
 Barfurth, Arch. f. mikr. Anat.  Vol. 25.
Baxtels, Mitteil. f. d. Ver. Schleswig-Holst. Arzte.  6. H.  1877.
 Baswitz, Ber. d. chem. Ges. XI. u. XII.  1878 and 1879.
Bechamp, Compt. rend. T. 60. p. 445.
Berenger-Ferand, Compt. rend. Paris 1864.
Bergeon,  Injection de medicaments gaseux dans le rectum.  Paris
    1887. 
196                     Diabetes.
Berger, Walt., " Mitteilungen iiber Diabetes."  Gathered from the
    Scandinavian literature in  " Schmidt's Jahrbuchern der  ges.
    Med." 1885,No.  207, pp. 135—I47and 250—258.  Berger's
    " Mitteilungen" contain the following  references: 1) Dr. V.
    Budde, on Diabetes mell. u. s.  w. Kjobenhavn  1872.   (He
    maintains like myself, that  in treating diabetes you must indi-
    vidualize.  He also orders almond-bread, and carries out Kiilz's
    idea in respect to Icelandic moss.)   2) J. Worm-Muller iiber
    Modification des Trommerschen Verfahrens.
Bexgmann, Lehre von der Kopfverletzung.  1880, Stuttgart.
Bernhardi, W.,  Pathol, u. Therap. des Diab. mell.  Berl. 1881.
Bertin, E., Recherch. s. la pathogenie d. diabete.   L'Union 48.
    1868.
Betz,  F., Erster Bericht iiber den Diabetes mell. in Wurttemberg.
    Wiirtt. Corresp.-Bl. u. s. w.  X. III. 4.  1873.
Bischoff, E.,  Ein Beitrag zur Pathalog. des Diab. mell.   Arztl. In-
    telligenzbl. 1873.   Nr. 23.
Blau, L., Tiber Diab. mell.  und  insipidus  in Schmidt's Jahrb.  d.
    ges. Med. 1875.  Bd. 165  and 166.   (He  concerns himself
    chiefly with the experimental diabetes of CI. Bernard.)
Blumenthal, J., Zur Therapie des Diab. mell.  Berl. klin. Wochen-
    schr. X,  13.   1873.
Bock, C. und F. A. Hoffmann, 1) tlber eine neue Entstehungsweise
    v. Melliturie.  Arch. f.  Anat., Phys. u. wiss. Med. 1871.   2)
    Experimentalstudien iiber Diab.   Berlin 1874.
Boese, Zur Diabetesbehandlung.  (Deutsch. Arch. f. klin. Med. 16.
    p. 96).
Bogolubow, Arbeit des physiolog. Laborat. in Kasan.   II. 1872.
Borg, un caso di diabete mellito etc.   II Morgagni XIV, 1872.
Bouchard, Ch., Maladies  par ralentissement de la nutrition,  deux.
    edit.  1885.
Bouchardat,  1) Nouv. recherch. sur le diab. Compt. rend.  1841.
             2) Suppl. a l'ann. d. ther.  1846.
             3) De la glycosur. 1875.
Boucheron, Compt. rend, de l'Acad.  T. 101.  1885.
Bourneville  et Teinturier, Du Coma diabetique.  1875.
Boyron, G., Op§rat. du phimosis chez un diab. Gaz. des Hop. 40.
    1869. 
            History and Literature of Diabetes.       197
 Breusing, Virch. Arch. 107.  1887.
 Brincken, v., Deutsch. med. Wochenschrift 1877, No. 39.
 Brongniart, Diabet. gott. 1876.
 Brouardel, P., Etud. crit. des diverses medic, employ, c. le diabete
     sucre.   Par.  1869.
 Briicke, Sitz.-Ber. d. Wien. Ac. 1871.  II.  Abt. 63.
    „    Vorles. iiber Physiolog.   I. B.  2. Aufl. 1875.
    „    IJber  Glykosurie  bei  Wochnerinnen.    Wien.  mediz.
          Wochenschrift.
 Buchwald, Alf., Uroskopie.  Stuttg.   1883.
 Budde, Die quant. Bestimmung v. Traubenzucker im Harne nach
     Roberts Methode.   Pfliig. Arch. f. d. ges.  Phys. des Mensch.
     u. d. Tiere.
 Burger, F., i) Untersuch. iiber perspiratio  insensibilis'bei Diabetes
     mellit. u. insipid.  Tub. 1872.  2) Uber die persp. ins. u. s. w.
     Deutsch. Arch.  f. klin. Med.   VI. und XI. p.  323.  1873.
 Buhl, tiber diabet. Coma.  Ztschr. f.  Biol.  B. XVI.   p.  413.
 Buxdel, De  la glycosurie ephem. d.  1. flevres pall.  Union med.
     1872.
 Burklay, W., On  the skim milk treatment of diabetes m. Lancet I,
     21 May,  1873.
 Canstatt, C,  Handb. d. medicin. Klinik v.  E. H. Henoch (3. Aufl.
     von " spec. Pathologie  u. Therap. v. klin.  Standp.,''  3. vols.
     1854-56).
 Cantani,  A.,  1) Casi guariti di diab. mell.   II Morgagni.   Febbr.
                1872.
              2) Klin.  Vortrage iiber  Diabet. mell.  Ubers. v.  S.
                Hahn.   Berl. 1877.
              3) Diabetes mellitus.  Deutsch von  S. Hahn.   Berl.
                 1880.    (French  transl.  by H.  Charvet.   Paris
                 1870.)
Capland, Diet, of pract. med. I, 507.
Carey, R. F., Case of diab. mell.  Lancet I. 24. June p. 835.  1874.
Chambard,  E.,  Du  xanthome temporaine des diabetiques  etc.
    Ann. de Dermatol. V, p. 348; s. Schmidt, Jahrb. 1885.   206.
    p. 254.
Charcot, Maladies des vieillards.   Paris 1874. 
198                     Diabetes.
Chauveau, Compt. rend,  de l'acad. des sc.  Paris 1886.  T.  103.
    N. 21.
Cohnheim, Virch. Arch.   B. 28.   1863.
Colin, Diabete Sucre etc.   Gaz. hebd.  2. S. X. 30.  1868.
da Costa, J. M., Clinical lecture  on the treatment  of  diabetes.
            Philad.  med. andsurg. Reporter. XXVIII. 11. March,
            1873-
    ,,       Handbuch der medizin. Diagnostik.   Berlin 1883.
 Croix, de la, Jalan, Arch. f. exp. Path. VIII, 1880.
Cruppi, Zur Theor.  des  Diab. mell.   Inaug.-Dissert. Gottingen
    1879.
Cyon und Aladoff, Die Rolle der Nerven bei Erzeugung v. kunstl.
    Diab. mell.   Bull, de l'acactem. imp.  de St. Peterb.   VIII.
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Deichmiiller, A., C.-Bl. f. kl. Med.   1882, No. 1. p. 1.
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    Dechambre.  Par. 1883.
De-verge et Foville, Du traitementdu diabete aumoyen de l'arsenic.
    Gaz. d. Par. 22.   1870 und 1871.
Dickinson, Howship, 1)  On certain morbid changes in the nervous
            system  associated with Diabetes.  Brit.  med. Journ.,
            Febr. 16,  1870.   Med. Tim. and Gaz. 1870.   March
            9-
            2) Diseases  of the kidney.  I. Diab.  London 1875.
Dock, F.  W.,  Uber  Glykogenbildung in  der Leber und ihre Be-
    ziehung zum Diab.  Pfliiger's  Arch. V, p. 571.
Donkin Scott, A., 1) On a purely milk diet in the treatm. of diab.
    mell.  The Lane.  II, 22,  23.  Jun. 1869.  Lane.  I,  18.  May
     1871. I, 2. Jan.  1873 J and l875- Vol. II.   2)  Milk diet in
    diabetes.   Med. Times and Gaz. Febr. 1870.  3) Skimmed
     milk in diabetes.  Brit. med.  Journ.  June 7, 1873.   4) Diab.
     mell. successfully treated,  etc.   Ibid. June 27, 1874.
 M'Donnell, Observations  on  the  function of the  liver.   Dublin,
     1865.
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     nover 1880. 
            History and Literature of Diabetes.       199
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             d. Par. 17.  1869.
          2)  Note sur la pathogenie du  diabete.  L'Union 46. 48.
             1869.  Bull, de TAcad. XXXIV. Avril 15 et 30. Mai
             15, 1869.
          3)  Traite clin. et ther. du diab.   Paris 1869.
          4)  Du regime alimentaire dans le diabete.  Paris 1882.
 Ebstein,  W. und J.  Miiller, 1) Uber die Behandlung  der Zucker-
             harnruhr mit Carbolsaure.   Berl. klin. Wochenschr.
             1873. No. 43, X, 49 and 1876.  Nr. 24.
          2)  Verhandl. der Ges.  d. Ntrfrsch. und Aerzte  1874  zu
             Breslau.  p. 103.
          3) Weitere Mitteilungen nebst Bemerk. iiber Anwendung
             der Salicylsiiure.  Berl. klin. Wochenschr.  5.   1875.
          4)  Bericht d.  d. chem. Ges. zu Berlin.  Bd. VIII.  Berl.
             1875.
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             Arch. f. klin. Mediz.   28. Bd.
          2)  Weiteres  iiber  Diab. mell. D. Arch. f.  klin. Mediz.
             30. Bd.
         3) Die Fettleibigkeit u. s. w.   7.  Aufl.  Wiesb. 1887.
          4)  Natur u. Behandlung der Gicht.   1882.
          5)  Das Regimen bei der Gicht.   1885.
          6)  Natur u. Behandlung der Harnsteine.   1884.
          7)  Dtsch. Arch. f. klin. Med. 23.   1879.
          8)  Das diiit. Regimen beim Diab. m.  Sep.-Abdr. aus  d.
             dtsch. iirztl. Vereinsblatt.   Mai 1883.
          9)  Die Zukerharnruhr, ihre Theorie und  Praxis.  Wies-
             baden 1887.
Eckard, E., 1)  Die Stell. der Nerv. beim  kiinstl.  Diab.  Beitrage
             zur Anatomie u. Phys. IV.  1867.
Eckard, E., 2) Uber die zur Zeit feststehendeii Thatsachen, welche
             sich  auf die Lehre  von Diabet. u.  s.  w.  beziehen.
             Pest, med.-chir. Presse IX, 7—9.  1873.
          3)  Beitr. Bd.  VI.   Untersuchungen iiber Hydrurie.
Einhorn,  K.,  Die Gahrungsprpbe  zum qualit.  Nachweise von
     Zucker im Harn.   Arch. f. path. Anat. u. Phys. 2.   1885. 
200                     Diabetes.
Engesser, H., Das Pankreas.  Stuttgart 1877.
Eulenburg und Guttman,  D.  Pathol,  d.  Sympathikus.   Berl.
     1873-
Evers, Fl., Journ. of physiol.   V.  p. 342.   Febr. 1885.
Ewald, 1) Centralblatt f. d. med. Wiss. 1873. No. 52.
        2) Berl. kl. Wochenschr. 1875. Nr.  51. 52. 1877, No. 44i
           p. 651.
        3) Diabet. mell.  in Eulenburg, Real-Encykl.  d. ges. Heil-
           kunde IV.   1880.
Ewer, Therapie des Diabetes  in  Osc. Liebreich, Therap.  Monats-
     hefte.
Falck, C. Ph., 1) Zur  Kenntnis  der Zuckerharnruhr, Dtsch. Klin.
     1853.   22.  ff.
         2) Beitrage   zur   Lehre  von d.  einfachen  Polyurie.
            Ibid. 41.
Fauconneau-Dufresne, lettr.  s.  1.  diabete 1. d.    1) Production du
             sucre.  L'Union 143.  1867.
         2) Etiologie du diabete.  Ibid. 37,  1868.
Fleckles, L.,  1) Zur Balneotherapie gegen Gicht, Melliturie u. s. w.
            Prag 1861.
         2) Die  Geschichte  der  gangbar.  Theorien  vom Diab.
             mellit. von Willis 1674 bis auf Pavy.  1864.  Dtsch.
            Klinik 10.  1865.
         3) Uber Diab.  mell.   Prag  1865.
         4) Zur Balneotherapie  des Diab. mell. mit Riicksicht auf
            die Saison 1865 in Karlsbad.  Berl. kl. Wochenschrift.
             III. 29.   1866.
         5) Zur Path, und Bain, des  Diab. mell. mit bes. Beriick-
            sichtigung der Wirksamkeit der Karlsbad.  Thermen
             gegen dies.  Leid.   Dtsch. Klin. 9.  10.  1871.
Fleckles, Ferdin., Die Dieiatik des Diabetikers, etc.
Fleury, A. de, Theorie  du diabete.   Gaz. hebd.  2. Ser.    IX. 33.
     1872.
Folet, Chute  des  ongles dans le  diabet.  Gaz.  hebd. 2.  S.  XI.
     1874.
Frank, J. P.,  Spez. Path. u. Therap. Deutsch  von J. F. Sobern-
     heim.  3. Ausg.  Berl.  u. Wien  1840.  I. 
            History and Literature of Diabetes.       201
 Frerichs,  1)  Uber den Diabetes, Berlin  1884.
           2)  Plotzlicher Tod u. Coma  bei Diabetes.   Ztschr. f.
              klin. Med.   Bd. VI, p. 1.
           3)  Uber  Verdauung,  in  Wagner's  Handworterb.  d.
              Physiol. Ill, 1.
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 Friedreich, N., i) Uber das constante Vorkommen von Pilzen bei
             Diabet.  Virch.  Arch. 30. B., p. 476.
 Friedreich, N., 2) Uber Krankheiten des Pankreas in v. Ziemssen's
             Handbuch der spez. Path. u. Therap. VIII,  2. 2. Aufl.
             1878.
 Fiirbringer, P., D. Arch. f. klin. Med. XXI, 1878.  p. 469 ff.
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             e.  Gesunden. Dorp.  1866.  Reported by Kiihne in
             Med. C.-Bl. V. Berl. 1867.  P- H7-
         2) Uber Kreatin und Harnsaureausscheidung etc. Hoppe-
             Seylers med. chem. Untersuchg. Berlin 1868. 3. Heft
            p. 301.
 Gerhardt, Diab. in.  u. Typhoid.  Corr.-Bl. d. allg. arztl. Ver. von
     Thiiringen.  Ill, 11.   1874.
 Gigon, C, Note  sur  l'elimination des liquides par les voies urin,
     role des  reins et de la veine cave ;  Glycosurie, theor. nouv.
     L'Union,  154, f.  1867.  De la glycosurie et de la  glycoemie.
     L'Union, 72, 73.   1872.
 Giovanni, A.  de, Annotationi  sul diabete mellito.  Riv.  klin. XI.
     Nov. 1867.
 Glax, Sitzungsber. d.  k. k.  Ak. d. Wiss. III.  Jan. 1877.
Gmelin, R., Uber die diiitet. Behandlung des Diab. mell. Deutsch.
     med. Wochenschr.  1884.  X.
Goltz, 1) Melliturie u. Milchsaureinj.  Med. C.-Bl. 1876. No. 45.
       2) Wirk. d. Milchs.  auf den tier. Org.   Diss, inaug.   Berl.
          1868.                                       \
Greenhow, i) Case of diabetes etc.   Lancet I, 24. June  1873.
           2) Treatment of diabetes, etc.   Brit. med. Journ. June
              7>  1873.
Griesinger, Studien  iiber Diabetes.   Arch.  f. phys. Heilk. 1859.
     Ill,  1. (" Gesammelte Abhandlungen." 2.   Berlin  1872). 
202
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 Griitzner,  Bresl. arztl. Ztschr. 1882.  No. 17, cf. Pfliiger's Arch.
     Vol. 12.
 Gueneau de Mussy, Sur l'odeur  special etc.   Gaz. hebh.   2.
     S. IX, 29.  1872.  (See also  on  Polyuria Nr.  98. 1871
     Ibid.).
 Giinzler, Uber Diab. mell.   Tubingen 1856.
 Habershon, Guys Hosp. Rep. 1870, p.  535.
 Haeser, H., Lehrb. d. Gesch. d. Med. u. d. epid.  Krankh.  2. Aufl.
     2. Abd. 1. B. Jena 1867-68.  3. Aufl. 1. Bd.  Gesch. der Med.
     im Altert. u. Mittelalter.  1875.
 Harley, G., Diabetes. London 1866.
 Harnack, E.,  1) Zur Pathogenese des Diab. mell.   Dorpat 1873.
        2)  Deutsch. Arch. f.  klin. Med. XIII, 6.   1874.
 Hartsen, Noch etwas  iiber  Diab.  mellit.  Donders and  Berlin's
     Arch.  III.
 Heidenhain, G., Diss,  inaug. Konigsberg  1874, see M. C.-Bl.
     Berlin 1875.   Bd. XIII.
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     1870.
 Kelfreich,  F. C, Zur Pathogenese des D. m.  Wiirzb. 1866.
 Kerter, Ztschr. f. physiol. Chemie. IV. 1880.
 Hertzka, Die Zuckerharnruhr u. s.  w.   1884.
 Hirsch, Handbuch u. s. w.  Erlangen i860.
Hirschmann,  Jac,  Ein Beitrag zur Lehre der diabet.  Retinal-
     affecktionen.   1886.
 Hofmann und Ultzmann, Anleitung zur Untersuchung des Harns.
     Wien 1878.
Holoctschiner, Virchow's Arch. 104.  Bd. 1886.
Homburger, Mediz. C.-Bl.  1877.
Hoppe-Seyler,  1) Virchow's Arch. Bd. X, p. 144, XI.  1857.
        2) Physiolog. Chemie.   1881.
Huizinga, Uber den Nachweis von  Traubenzucker im normalen
     Harne. Pfliig. Arch.  10. 11.   1870.
Huppert, Uber die Glycosurie bei Cholera.  Arch. f. Heilk. VIII.
Jaffe, M. Dr., Uber das Vorkommen zuckerbildender Substanzen in
     den Organen der Diabetiker, in Virchow's Arch. B. 36, p. 20.
Jeannezet, L'uree dans le diabete artif.   Bern 1872. 
            History and Literature of Diabetes.       203
Jones, Bence, Medic. Times and Gaz.   1852.  Vol. 1.
     „   On Sugar in the urine.   Quarterly journal etc.  1862.
     „   Lectures  of chimical diseases, Med. Tim. and Gaz. 1865.
Jordad, Considerations sur un cas de diabete.  Paris 1857.
Kahler,  O., die  dauernde Polyurie als cerebrales Herdsymptom.
     Sept.-Abd. aus d. Ztschr. f. Heilk. VII.   Prag 1886.
Kamen, L., Prag.  med.  Wchnschr. 1880.  No. 17.
Kamocki, V., Patholog-anatom. Untersuchungen von Augen diabe-
     tischer  Individuen in Knapp u. Schweigger's Arch. f. Augen-
     heilk.   17. B., 3. Heft.
Kisch, H. E , Diat und diatet. Kuren in Real-Encyklop. IV.  1880.
Klebs und Munk, Tageblatt der 43. Vers, dtsch.  Naturf. u. Aerzte
     in Innsbruck.  1869 ; and Handbuch der path. Anatomie 1870.
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Kobrak, G., Zum Nachweis kleiner Zuckermengen in Ham. Bresl.
     Kohler.
Koch, Mitteil. aus dem Kais.  Gesundheitsamte. I, 1881.  (Compare
     also Koch's Dissert, iiber Diab. mell.  Jena 1867).
Konig, J., Prozent. Zusammenstellung u.  Nahrgehaltwert der men-
     schl. Genussmittel u. s. w.  Berlin 1882.
Koschlakoff, Analyse des Urins.   Petersb. 1887.
Kraske, Diabetes und Sepsis, in Centr.-Bl.  f.  Chir.  18S1,  No.
     35-
Kratschmer,  1) Uber Zucker- und  Hamstoffausscheidung beim
             Diab.  mell. unter  dem  Einflusse  von  Morphium,
             kohlensaurem  und  schwefelsaurem  Natron.  Wien
             1872.  Wien. akad. Sitzungsber. 65. Bd., 3. Abt., p.
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         2) Weitere  Versuche betr. die Behandl. des. Diab. mell.
             Wien 1874.
         3) Wien. Med. Wchnschr.  1885, No.  13.
Kraussold,  Zur  Path. u. Ther. des Diab. mell.  Erlangen 1874.
Kretschy, Uber  Diab. mell.   Wien. med. Wchnschr. 3.  1873.
Kronser, V.  N., Uber Zuckerruhr (d. mell.), u. ihre Heilungen in
     Karlsbad.  Wien. Ztschr. 18, 160.
Kiihne, W.,  Lehrb.  der physiol. Chemie.   Leipz.  1868.   (See
     also Virch. Arch. XXX. S. 476). 
 204                     Diabetes.
 Kiilz, E., i)  Beitrage zur Hydrurie u.  Melliturie.  Marburg 1872.
          2)  Uber Harnsaureausscheidung  in  einem  Falle  von
             Diab. m. Arch. f. Anat., Physiol, u. wissensch. Med.
             1872.  pp. 293—303.
          3)  Studien  iiber Diab. mell. u. insip.  D. Arch. f. klin.
             Med. XII., 248.
          4)  Beitr. zur Path. u. Therap.  des. Diab.  Mell. Marburg
             1. B. 1874 u. 2. B. 1875.   (See Sitz.-Ber. d. Marb.
             Ges. z.  Beford. d. Naturw.   1876 Aug.)
          5)  Gerhardt's Handb.  der.  Kinderkrankh.   Bd.  Ill,
             1878.
          6)  Pfliiger's Arch.  1880.   B. XXIV.
          7)  Zur Kenntnis  d.  linksdrehenden  Oxybuttersaure.
             Arch. f.  experim.  Path. u. Pharm. 1884;  compare
             Vol. VI, 1877.
         8)  Uber eine linksdrehende  Saure  (Pseudooxybutter-
             saure) in Zeitschr. f. Biologie, No.  2, 1884.
          9)  Zur Prioritatsfrage bez. der Oxybuttersaure im diab.
             Harn.  Ibid. p. 290.
        10)  Kann in der  schwer. Form des Diab. die Zuckeraus-
             fuhr  durch  vermehrte  Zufuhr  von  Albuminaten
             gesteigert werden ?  Arch. f. exp. Path.  u.  Ph. 6,
             1877, PP- 14°—x42>
        n)  Bericht  d. dtsch.  chem.  Gesellsch.  XV, Jan.—Juni.
             Berlin 1882.
        12)  Dtsch.  Ztsch.  f.  prct.  Med. 1876, No. 23;  compare
             Report  in Maly's  Jahresber. iiber  die Fortschr.  der
             Tierchemie. VI, p. 260.  Wiesb. 1877.
 Kiilz, R., Ztschr. f. Biol.  Bd. 22.   Sep.-Abdr.
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     1872.
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    klin. Med. XIV,  1.  1874.
Landrieux und  Iscovesco, Progr. medic,  27. Juni 1885, No;  26.
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    Leber.   Arch. f. Ant. und Phys. von Hils, Braun u. Du Bois-
    Reymond.   1886.  Phys. Abt. Suppl.-Band. 
           History and Literature of Diabetes.      205
Langley, J. N. and Eves, F., Journ. of Physiol. Vol. IV, No. 1, p.
     18.  Compare Fortsch. d.  Med. Bd.  4,  1886, p. 666.  Report
     by C. Lehmann.
Latham, Lane. No. 5.   Febr.  1881.
Leber  und Wiesinger, Uber das Vorkommen von Keratitis, Iritis
     Iridocharioideitis bei Diab. mell. (Arch. f. Ophthalmol. XXXI,
     1885).
Leblanc, Gaz. des h6p.   1850, No.  23.
Lecorche, 1) L'amblyapie diabetique.  Gaz. hebd.  1861. p. 717.
         2) Consider,  theor.  et therap. sur le Diab. sucre\  Gaz.
            hebd. 2. S£r. X. 44. 27. 1873.
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Leo, Hans, Zur Kenntnis der " reduzierenden " Substanzen in dia-
     betischen Harnen,  in Virchow's  Arch., 10.  Folge,  7. B., 1
     Heft.
Lepine, Ber.  iiber die Verh. der k. sachs. Ges. d. W. in Leipzig.
     Math.-phys. Klass.   22. Bd., p. 324.   1870.
Leube, W., Zur Patholog. u. Ther. des D.  mell.   Deutsch. Arch.
     f.  klin. Med. V. 3.  4.   1869.
Leube und Salkowski, Die Lehre vom Harne.  1882.
Leudet, E., Du diab. sucre.  Clin. med. de I'hotel de Rouen.  Paris
     1874.  p. 269.
Leupoldt, R.,Uber die  Harnruhr.  Erlangen 1853.
Leval-Picquechef, 1) " Des Pseudotabes."  Lille 1885.  He collects
                      the tabes-like exhibitions in  diabetes, etc.
                  2). These.   Paris 1885.
Leyroux, Du diabete sucre\  Gaz. des Hop. 19.20.  1870.
Lintner, Journ. f. pr. Chemie.   1886.  N.  F. Bd. 34.  p. 370.
Lippmann, Die Zuckerarten und ihre  Derivate.   1882.
Loebisch, Anleitung zur Harnanalyse.   Wien 1878.
Lorazza, L.,  Diabete   succherino.  Bull,  delle  sc.  medich.   di
     Bologna. Febr. Marzo 1870.
Luchau, Med. Centralbl. 1877.
Luchsinger,  Experimentelle u. kritisch. Beitrage  zur Physiolog.
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     Bl. f. d. med. Wiss. 1882.   p.  131. 
206
Diabetes.
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 Iiuys, Diabete avec lesion du 4rieme ventricule.  Gaz.  med. i860
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 Maack, v., Zur Therapie des D. mell.  Arch, des Ver. f. gem. Ar-
     beiten.   i860,  p. 129.
 Mahe, J., Hop. de Brest Compt. rend, de  1. cliniq. med. pend.
     1867—1869.  Arch. med. nav. Oct.—Dec. 1870.
 Maly, Uber die Trommersche Zuckerreaktion im Harn.  Sitzungs-
     Ber.  d. k. Akad. d. Wissensch.   63. B.   1871.   Jahresbericht
     iiber  die  Fortschr. der Thierchemie.   VI,  p. 260.   Wiesb.
     1877.  Chemie der  Verdauungssafte  u. der  Verdauung, in
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 Marchal  (de Calvi), Comp. rend. 37. 43 ; and Recherches sur les
     accidents diabet.  et  essai  d'une theorie g6n6rale du diabSte.
     Paris 1864.
 Mayer, J. Beitrag zur Symptom, u. Ther. des Diab. mell.   Berl.
     klin.  Wochenschr. 1875.
 Mayet, Note sur les fruits sucres etc.   L'Union 130.  1873.
 Meissner, 1) Nachrichten v. d. G.  A. Univ. in  Giessen.   1861.
     No. 15 ;  1862. 10.
 Meissner, 2) Ztschr. f. rat. Med.  3. Reihe, B. 16.   1863.
          3) Bericht iiber die Fortschr. d. Anat. u. Phys. i. J. 1867.
              p. 405.
          4)  Ibid.  B. 33.  1868.   (Beitrage zur  Kenntnis  des
              Stoffwechsels).   Compare also Schmidt's Jahrb.  B.
              127.   1865.
 Meyer, H., Arch. f. exp. Path.    1882.  XVII.
 Meyer, T., Ber. d. D. chem. Ges.  B. 17.  1884.
Minkowski, O.,  Uber das Vorkommen  von Oxybuttersaure  im
     Harn bei Diab. mell.  Ein Beitrag zurn Coma diab.  Arch. f.
     exp. Path. u. Pharm.   1884, 18,  and 1885,  19.
 Miquel, Uber  Diabetes mellitus.  Arch. f. phys. Heilk.  X.   1851.
Mitchell,  On  the production  of Cataract etc.   Amer.  Jour,  of
     med.  sc.  i860.
Moleschott, Die Physiologie der Nahrungsmittel.   1869.
Montegazza Paolo, Zur Physiol, u. Therapie des  Diab. mell. Gaz.
     Lomb. 1.  1854.  See Schmidt's Jahrb. B. 85, p. 302. 
           History and Literature of Diabetes.       207
Mosler, F., Neuropathische  Entstehung der einfachen  Harnruhr.
     Compare also  Uber Beschaff. d. Parotidensekrets  bei D.  m.
     Arch. f.  Heilk. 1864 and Berl. klin. Wochenschr. 1866.  Also
     " Kleinhirnlasion."   D.  Arch.  f. klin.  Med.  XV.   Uber
     Harnanalyse etc. Virch. Arch. 43.
Mulier-Warneck, Berl. klin.  Wochenschr.  1877, No.  8.
Munch, Diab. mellitus, Chron. Leberleiden. Mosk. med. Ztg. 37.
     1869.
Munk, J., 1)  Verh.  d. Phys.  Ges. z. Berlin.  Sitzg. vom. 24. Nov.
              1870 ; see Maly's Jahresbericht iiber die Fortschr. d.
              Tierchemie.   6. p. 271.   1877.
           2) Zur quant. Bestimmung des Zuckers u. der sog.  re
              duzierenden Substanzen  im Harn mittelst Fehling-
              scher Losung.  Arch.  f.  path. Anat. u. Phys. p. 63.
              1886.
Murray, Glycosuria by the pressure of a clot etc.  Lancet,   i860.
Nasse, O., 1) Pfliig. Arch. B. 15.   1877.
           2) Zur Anat. und Phys.  der quer gestr.  Muskelsubst.
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           3) Biol.  Centralbl. II, 1882—83.  Ill, 1884.  IV, 1885.
           4) Beitrage zur Physiologie der contractilen Substanz.
              Arch. f. d. ges. Phys.  II.   Compare also De mat.
              amy], in sanguin.   Halle 1866.
Naunynund Riess, Uber die Harnsaureausscheidung. Reichert's u.
     du Boys-Reymond's Arch. 1868, pp.  413, 414.  1869,  3. 381.
Naunyn, Beitrage  zur  Lehre vom  Diab. mell. in Arch.  f. exp.
     Path, und Pharm.   1874, 1875.
Neubauer und Vogel, Anl. zur Analysis des Hams.   1872.
Nicol, Case of diabetes etc.  Brit.  med. Journ. July.  1871.
Pavy,  Philos. Transactions,   i860.  On the alleged sugar form-
     ing function of  the liver.  Lond.  1861.  The influence of
     diet on the liver.   Med. Tim. Jane 1865.   Researches on the
     nature and  treatment of diabetes.  Lond. 1863.  Second edit.
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208
Diabetes.
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     on certains points connected with  diabetes.   London  1878.
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     Zuckerharnruhr. S.  Sitzgs.-Ber. der  k. bayr.  Akad. d.  Wiss.
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     Reviewed in Med. C.-Bl. Berl. 1875.  B. XIII, p. 43.
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     Arzneistoffe bei der Zuckerharnruhr. Berl. klin. Wochenschr.
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     sucht.   Ostr. Ztschr. f.  prakt Heilk.  XIV, 11.  1868.
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     Magens u. d. Hamorgane.   Translated from  the English  by
     Krupp. Leipz.   1843.
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     compare Ibid. 1876,  Nos. 37 and 38.
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     B. 30, p. 360.
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     1871. 
            History and Literature of Diabetes.       209
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     Dorp. 1885.
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     2) On diabetic phthisis and  its treatment.  Med. Tim.  and
     Gaz. March 2. 1867.   3) Remarks  on D. especially with
     reference  to treatment.   Lond. 1871.
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     1865.
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     Manchester 1861.  2) Case of diabetes etc. Brit. med. Journ.
     Jan. 27, 1872.
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     1876.
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     Tiibingen.  Die Diabetes-Kur in Karlsbad.  1888.
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     Centralbl.  f. d. med. Wiss.   1874.
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     1866.
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     1871.
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     med. Wiss. 1874, p. 179.
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     des 19. Jahrh.  Leipzig 1871.
Schaetzke, Berl. klin. Wochenschr. 1879, No. 22.
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     Diss.  Gottingen 1873.
Scharlau, Die  Zuckerharnruhr.   Berl. 1846.
Schiff, J. M., Untersuchungen iiber die Zuckerbildung in der Leber
     und den Einfl. d. Nervensyst. auf die Erzeug'ung d. Diabetes.
     Wiirzburg  1859.
Schiff, M., Nouv. recherch. sur la glycogenic anim. Journ. de I'Anat.
     et d. 1. Phys. Ill, 4. Juill. et Aout 1866.
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                                                P 
2IO
Diabetes.
Schirmer, Iritis bei Diabetes in Zehender. Klin. Monatsblt.  25.
    Jahrg. April.
Schleich, G., Aus d. med. Klin, in Tubingen.   Erfahrungen iiber
    diiit.  Behandlung bei  D. m.   Wiirtt. Corr.-Bl.  XLIV,  34.
    1874.
Schmidt, Jahrbuch der ges. Med. 1885. 2°6—256 contains the ac-
    counts of diseases by which to show the relation which diabetes
    holds to xanthoma.
Schmiedeberg, Grundriss der Arzneimittellehre.  1883.
Schmitz, 1) Zwei Falle v. D. m. Brl. kl. Wochenschr. V, 32. 1869.
    2) Ueber Bad Neuenahr. Ibid. IX, 12. 13.   1872.   3) 4 Falle
    von geheiltem Diab. mell. u. kurz. Bemerkungen iiber die Ent-
    stehung dess.   Ibid. X, 18. 19.  1873.   4) Zur Aetiologie
    des Diabetes mell.  Ibid. XI, 44.   1874.
Schopffer, E., Beitrage zur Kenntnis der Glykogenbildung in  der
    Leber.  Arch. f. exp. Path. I.   1873.
Schroder, W., Diat und Wegweiser  fur  Zuckerkranke  mit bes.
    Beriicks. des Saccharin.  Berlin.  Steinitz.   1887.
Schtscherbakoff, Ueber Glykogen.  Ber. d. dtsch. chem. Ges. in
    Berlin.   1870.   pag. 200.
Schultzen, C, Beitrage zur Patholog. und Therap. des. Diab. mell.
    Brl. klin. Wochenschr. IX, 35.   1872.
Seegen, J., 1) Phys. chem. Unters.^iiber den Einfluss  des Karlsb.
    Wassers auf einige Formen d. Stoffwchs.  Wien. med. Wochen-
    schr.  i860.  2) Beobachtungen iiber Diab.  m. Ibid. 1866.
    No- 34-   3)  Die  diatet. Behandl. des D.  Ibid. XX.  1870.
    16. 17. 4) Aphorismen iiber D. m.  Ibid. 18. 5) Der Diabet.
    mell., auf Grundl. zahlr. Beobachtungen dargestellt. Leipzig
    1870,  2. Aufl.  Berlin.   1875.  (a classical work!).   6) Ge-
    niigen die bis jetzt angewendeten Methoden, urn kleine Mengen
    Zucker mit Bestimmtheit  im Harn  nachzuweisen ?  Wien.
     1871.   7) Beitrage zur Kasuistik der Melliturie in the Arch. f.
    path. Anat. u. s. w. B.  21, 30 u. 36 (he enumerates 89 cases).
    8)  Ein Fall  von Lavulose  im diab. Harn.  (Med. Centr.-Bl.
     1884.  43,  p. 753).   9)  Die  physiol.  Grundlage  fur  die
    Theorie  des  Diabetes.  Ztschr.  f.  Klin.  Med.   1884.  10)
    Seegen und Kratschmer.  Pfliig. Arch. B. XIV, p. 593. 
           History and  Literature of Diabetes.       111
Senator, i) Ueber  Diabetes  bei Kindern.  Brl. kl. Wochenschr.
     1872. No. IX. 48.   2)  Diab. mell. und insipidus, in Handb. d.
     spez. Path. u. Therap.  von Dr. H. v. Ziemssen.  Bd. XIII.  2.
     Halfte.   1876.   2. Aufl. XIV,  1.  1879.   See Unters.  iiber
     d. fieberh. Prozess.   1873.
Senff, L., Ueber den Diab.  nach der Kohlenoxydatmung.  Leipz.
     1871.
Skerrit,  M., Brit. med. Journ.  Dec. 5, 1885.
Stadelmann, E., 1) Ueber die  im Harn v. Diabetikern vorkom-
     menden patholog. Siiuren.  (Ztschr. f. Biol. 21.  N. F. 3.1885).
     2)  Ueber die  Ursachen  der path.  Ammoniakausscheidung
     beim Diab. mell. und das Coma  diab.,  in  the Arch. f. exp.
     Path, und Pharm.   1883.   17. p. 419.
St. Cyr,  A case  of diabetes mellitus in a  dog.  Journ. de med.
     vet.   1870.
Stokvis, Beitrage zur  Kenntnis  der Zuckerbildung in der Leber.
     1856.   See Wiener mediz. Wochenschr.   1857.  Stockvis, B.
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     u.  Therap. of Diab.  mell.  in  the  " Verhandlungen des  5.
     Kongresses fur innere  Medizin," II. Wiesb.   1886.
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     London, IV, 1871.
Thiersteiner und Uhle, Ueber die Harnstoffausscheidung im. Diab.
     mell. in Arch. f. Heilk.  1858.
Thome,  F., The treat,  of diabetes etc.  Lane. I., 8.  1870.
Tiegel,  Ueber  eine Fermententwicklg. des  Blutes.  Centr.  f. d.
     med. W.
Traube,  M., Ueber die Gesetze der Zuckerausscheidung.  Virch.
     Arch. Bd. IV.  p.  109.  1852.
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     1867, and Virch. Arch. 47.   1869; also Sitzungsber. d. k. Ak.
     Wien. B. 51 (iiber  die Abhangigkeit des  Glykogengehaltes der
     Leber etc.).
Tumas, Petersb. med. Wochenschr.  1881.  No.  18.
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     Diab. m., im Umrisse dargestellt. Bliitt. f. Heilwissench. 13. 14.
     1870. 
212
Diabetes.
Virchow-Hirsch, Jahresberichte.
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Vogel, Diab. mell. Hdb. d. spez. Path. u. Therap., redig. v. Virchow.
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     1881.  Ueber d. Urs. der Fettablag. im Tierkorper.   Miinchen.
     1883.
Vulpian, A., Lecons sur l'appareil vasomoteur.   T. II.   1875.
Vulpian und Philippeaux, Gaz. Hebd.   1861.
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     B. 36, p.  297.
Walter, Arch. f. exp. Path. VII.   1877.
Weiss, 1) Zur Stat, des Glykogens  im  Tierkorper.  Sitzungsber.
     d. Wien. Ak. d. Wiss. Bd. LXIV.  2) Ueber  die  Quelle des
     Leberglykogens.  Sitzungsber. etc.  LXVII.  3.
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Wolpe, H. Arch. f. exp. Pathol. 21.   1886.
Worm-Miiller.   Pfliig.   Arch. Bd. 34.  1884.   Bd.  35.   1885.
Wortmann, J., Ztsch. f.  phys. Chemie.  Bd. VI.  1882.
Zalesky, Stan., Zur Patholog. d. Zucherharnruhru. zur Eisenfrage.
     Arch. f. Path. X, Folg. 4.  1884.
Zimmer, K,  1)  Ein Beitrag  zur  Lehre  vom Diab. mell.   Dtsch.
     Klin. 14.  15. 17. 18. 1867. 2) Under the same title, Karlsbad,
     Feller.    3) Der D. m.,  sein Wes. u. seine Behandl.  1. Heft.
     Leipz. 1871.  4) Die nachste Urs. des D. mell.  Dtsch. Klin. 5.
     1871.   5) Die Muskeln, eine Quelle des Zuckers  im Diabet.
     Ibid. 7.   1873.  6)  D. Musk.,  e.  Quelle,  Muskelarbeit ein.
     Heilmittel bei Diabetes.   Karlsbad, Feller.  188c.
Zuntz, Beitrag zur Physiolog. des  Diabetes.   He thinks that the
     formation of  acid is favoured in a blood which is saturated
     with carbonate of sodium. 
         History and Literature of Diabetes.      213


A  WISH  EXPRESSED  TO PROFESSIONAL
 JOURNALS, PROFESSIONAL LIBRARIES,
         AND  MEDICAL  SOCIETIES.

In glancing over the mass of literary material which
has  accumulated on  the subject  of diabetes,  and
which I have endeavoured to master, and especially
in  surveying the by no means inconsiderable number
of special accounts of cases of diabetes, it seems at
first as if a great deal had been done already in this
department.   Still, admitting all this, a great outlay
of time  is entailed upon an inquirer,  and  it is ex-
tremely  difficult for him to obtain all the existing
material and to make a proper use  of it.  For the
material itself is difficult of access, and the observa-
tions are not always  made  according  to  the same
plan.  The summing-up, also, is not always done  in
the same way.
   It seems to me, therefore, that it would be a most
grateful  task, and one  fraught with  good results, if
the medical societies  and editors of medical journals
would agree among themselves as to a definite plan
according  to which  reports  and accounts  of the
above  disease are to  be made ; further, as to some
definite  place to which such communications might
be sent, and where the  specialist  might  find  them
and work them up, in order afterwards to publish the
result of his labours in some journal, where it would
become  accessible to all interested in this special
subject. 
214                  Diabetes.
  In this way it would be possible to obtain a statis-
tical ensemble of  all cases of diabetes ;  as regards
the course they have taken, and as regards their final
result.   Everyone would then be able to have access
to the whole modern literature on this important sub-
ject ; he would be able to examine it and make use
of it.  Every year, also, a general report ought to be
made,  which would enable  anyone  to  survey  the
ever-increasing literature on this subject, and which
literature  might  be  found  and  consulted in some
given library.
  Griesinger, in  his statistical table,  mentions the
time when the disease first showed itself ; Dickinson
notes the time of  death ;  while others  report only
the time  during which the  patient was treated by
them.
  Some physicians report only  those cases which
have occurred at  watering-places ; and  hence they
have almost nothing to say about  children.   Others
relate only hospital cases, etc.
   It would be very desirable  if authors would make
their daily observations at one and  the same hour.
Thus Otto reckons the day from  10 o'clock to 10 ;
Lambe, from 6 to  6 ; Krausold, from  7  to 7.   For
forming a judgment also it would be valuable to make
observations before, and  after, the meals.
   At some future  occasion  I  intend  to  give an
account of those  literary communications and ob-
servations that  I  have received already, and of any
that I  may receive in the future; and  I  shall also
express myself as to the  best form in which such 
         History and Literature of Diabetes.      2,15
communications ought to be made.  Very  gladly I
shall  examine  and take notice of any  wishes ex-
pressed and any communications  sent to me by any
of my medical colleagues.  They will kindly address
me during the summer-months  at Carlsbad, Villa
Schnee, and  during  the winter-months at  Monte
Carlo, Hotel Beau Rivage.
THE  END. 
 
 
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