« SebelumnyaLanjutkan »
and thirst, and suffered from a feeling of exhaustion after moderate exercise. At that time she passed, as was stated, from six to eight quarts of urine in the day, which was loaded with sugar. Before the diabetes had become developed, she had enjoyed perfect health with the exception of dysmenorrhea which had existed since the age of eighteen. She began to menstruate at the age of thirteen, and at the age of eighteen fell from a wagon, striking on her feet, and sustaining no apparent injury at the time. Since this fall, however, she had persistent dysmenorrhea, suffering intense pain for six or eight hours at every period. She has not menstruated since February, 1884; and in January and February, 1884, she suffered no pain. She was examined in October, 1884, by Dr. James B. Hunter, who found retroversion, but advised no interference unless menstruation should return.
When the patient consulted me on August 25, 1884, she presented all the characteristic general symptoms of diabetes mellitus, including excessive appetite and thirst, weariness after slight exercise, some pruritus vulvæ, and an increased quantity of urine. Her weight was ninety-two pounds. During the winter of 1883-'84, and the summer of 1884, she had indulged excessively in starchy matters and sweets, and since January had taken various remedies without experiencing any benefit.
August 26th.-The urine of the twenty-four hours measured 152 fluidounces, was pale, of a sweetish odor, and had a specific gravity of 1.037. It contained 28 grains of sugar to the fluidounce, giving a discharge of 4,256 grains (8 ounces, 416 grains) in the twenty-four hours. There was no albumen. Microscopical examination revealed the presence of a few octahedra of oxalate of lime with some vaginal epithelium. She was at once put upon a strict anti-diabetic diet, all starch and sugar being rigidly excluded, and was ordered to take three drops of Clemens's solution. of arsenite of bromine three times daily.
September 1st.-The quantity of urine was reduced to 112 fluidounces. The sugar was reduced to 12 grains to the ounce, or 1,400 grains in the twenty-four hours. The excessive appetite and thirst and the pruritus vulva had disappeared. The dose of the Clemens's solution was increased to five drops. She felt better and stronger, and the weight (taken September 3d) was increased to 99 pounds.
10th. The weight had increased to 103 pounds, and the quantity of urine was reduced to 96 fluidounces, with a specific gravity of 10231. The total discharge of sugar for the day was 1,152 grains. The urine, however, presented a trace of albumen. The treatment was continued, with the addition of two grains of quinine three times daily. She had slight uterine pains on September 8th, 9th, and 10th, this being the time in the month when her periods occurred, but there was no menstruation. There was no unusual thirst, and the appetite was normal. She bore the strict anti-diabetic diet very well.
24th. The weight had slightly decreased, being reduced to 101 pounds. The quantity of urine was 80 fluid ounces, with a specific gravity of 1·025, and containing in all 800 grains of sugar. Since September 10th she had been losing strength as well as weight. The treatment was continued, with the addition of one quarter of a pint of cream and a tablespoonful of whisky twice daily.
October 10th.-The weight was reduced to 96 pounds. The quantity of urine was 80 fluidounces, with a specific gravity of 1.023, and containing in all 720 grains of sugar. The patient had followed the treatment, dietetic and medicinal, most faithfully. She had taken, for about four weeks, griddle-cakes made of Hecker's farina, which contains only eight or ten per cent of starch. Notwithstanding the rigid diet, however, I had been unable to reduce the quantity of sugar below 9 or 10 grains to the fluidounce of urine, or 700 to 800 grains in the twenty-four hours, and the strength and general health showed no improvement since September 24th. I decided to try to arrest the discharge of sugar by an absolute fast of twenty-eight hours-a method recommended by Cantani. To this plan the patient cheerfully assented. She accordingly fasted from 8 A. M., October 10th, to 12 M., October 11th, remaining in bed most of the time, and taking nothing but water. The urine passed at the close of the fast contained two grains of sugar to the fluidounce; but it presented oxalate of lime, a small quantity of albumen, and a few small, granular casts. She bore the fast very well, had a good appetite the next day, and for several days felt better than she had for weeks. Following the fast, the former treatment was resumed.
15th-The quantity of urine was somewhat reduced. Its specific gravity was 1.030, and it contained nine grains of sugar to the fluidounce. There was still a little albumen, with a few granular casts. The patient left for her home in Georgia on the following day. She was in much better general health than when I first saw her on August 25th, but I had found it impossible to arrest the discharge of sugar.
My prognosis in this case is not entirely favorable. It is probable that the excessive indulgence in sweets and in starchy articles of food for several months during the height of the disease has rendered the glycosuria uncontrollable beyond a certain point. Her present safety undoubtedly lies in an anti-diabetic diet, and a return to sweets and starch would probably be promptly followed by a return of the grave general symptoms of the disease.1
The following case is in striking contrast to the one just recited:
CASE LV.-The patient was a young girl, of medium height and development, fifteen years of age. Her father and mother are living and in good health, and there is no hereditary tendency to disease. A sister of the patient died at the age of nineteen, probably of diabetes mellitus. The patient began to menstruate at the age of thirteen and has menstruated regularly ever since that time. She was in perfect health up to January, 1884, when she began to lose flesh slightly, and was "ailing" for a few weeks. She soon improved in general health and was apparently well until the middle of August, 1884, when she was found to be passing about two quarts of urine daily, the specific gravity of which was said to be 1.052. Since that time she has been on a moderately restricted diet and has taken various remedies. She suffered somewhat from thirst during August and September. Her urine was found sometimes to contain a little sugar and sometimes it was free from sugar.
1 I received a letter from the father of this patient, dated November 2, 1884, stating that "she arrived safely without detention, and bore the fatigue of the trip astonishingly well. She is, I think, evidently stronger and better than when she first placed herself under your treatment."
October 8th.-I made a thorough physical examination of the patient and found no disease. The urine was rather less in quantity than normal, had a specific gravity of 1·031, and contained no sugar. The only abnormal condition of the urine was the presence of a large number of octahedra of oxalate of lime. The diet had been moderately restricted. I ordered that the diet be unrestricted for twenty-four hours.
10th.-After twenty-four hours of unrestricted diet, the quantity of urine was slightly increased. It had a specific gravity of 1.0361, and contained thirty-one grains of sugar to the fluidounce. There were none of the characteristic general symptoms of diabetes. I ordered a strict anti-diabetic diet, three drops of Clemens's solution of arsenite of bromine three times daily, the dose to be gradually increased to five drops, and a pill of one quarter of a grain of codeine and one twelfth of a grain of podophyllin at night, to relieve constipation should it be troublesome. The patient then left for her home in Virginia.
16th. I heard from this patient and received a specimen of urine. The treatment had been followed strictly. She had felt perfectly well since her return to Virginia and was passing urine in normal quantity. The urine had a specific gravity of 1.015 and contained no sugar.
In this case the glycosuria seemed to be easily controllable. After examining the urine, I wrote to the friends as follows:
I suggest that the dietetic and other measures of treatment be strictly followed until the middle of December. If, at the end of that time, the urine should continue free from sugar, the patient may begin to eat a little bread and gradually return to the usual diet, except that she should never eat sugar or sweets. The urine should be examined from time to time while she is in process of returning to the normal diet.
My prognosis in this case is favorable. With proper attention to the diet, I should expect a cure; but it will be necessary to examine the urine occasionally for a long time, in order to detect, at the earliest moment, any tendency to a return of the disease.
CASE LI. This patient was a robust man, unmarried, thirtyfour years of age, five feet seven inches in height, and weighing 177 pounds. He had always eaten largely of bread and sweets. For several weeks he had a moderate increase in thirst and had not been "feeling very well." His urine had been examined, and it was said to contain sugar. His previous health had been good. He had occasionally committed sexual excesses.
I examined this patient on April 8, 1884, and found no disease. The urine was somewhat less in quantity than normal, with a specific gravity of 1.035, and was turbid with urates. It contained no sugar. During the day on which this urine was passed, the patient had abstained from bread and sweets.
April 10th.-I examined a specimen of the urine passed during the day, the diet having been unrestricted. It had a specific gravity of 1.026 and contained a small quantity of sugar.
June 2d. Since April 10th, the patient had followed a strict anti-diabetic diet and had taken three drops of Clemens's solution of arsenite of bromine three times daily. His urine had a specific gravity of 1.030, was normal in quantity, and contained no sugar. The patient felt perfectly well, but his weight had been reduced to 167 pounds. The dose of Clemens's solution was increased to five drops.
July 16th. The patient was still perfectly well, the diet was not irksome, and the urine was normal, free from sugar, and had a specific gravity of 1.024. The weight had been reduced to 161 pounds. The treatment was continued.
August 1st. The patient continued well, but the weight was reduced to 159 pounds. The urine was normal, free from sugar, and had a specific gravity of 1.029. The treatment was continued.
14th. The patient continued well, and the weight had increased to 161 pounds. The urine contained no sugar and had a specific gravity of 1.026.
20th. The patient continued in the same condition. The weight was 157 pounds, and he looked and felt in perfect health. The urine contained no sugar and had a specific gravity of 1.031. The patient then passed from under my observation. The Clemens's solution was stopped, and he was instructed to gradually return to a normal diet, but never to eat sugar or sweets, and to carefully abstain from all excesses of any kind.