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In this case, the patient being a young and vigorous man, the glycosuria was readily controllable, and an apparent cure was effected.
The fourth case is that of a man, fifty-nine years of age, in whom the disease, although of at least a year's standing, yielded promptly to treatment.
CASE LII. The patient, a married man, fifty-nine years of age, was 5 feet 8 inches in height, and weighed 227 pounds. He was robust, had always enjoyed good health, and had been rather a free liver, but without excesses of any kind. The family history gave no evidence of hereditary tendency to disease. For the nine months previous to the time when he came under my observation, he had suffered from excessive urination, annoying thirst, abnormal weariness, and impairment of appetite. During this period he had lost about twenty pounds in weight.
August 11, 1884.-I examined a specimen of the urine. Its quantity in twenty-four hours had not been measured, but was undoubtedly excessive. It had a specific gravity of 1023 and contained considerable sugar, with abundant uric-acid crystals. He was at once put upon a rigid anti-diabetic diet, with three drops of Clemens's solution of arsenite of bromine three times daily.
19th. The general diabetic symptoms had entirely disappeared. The urine was normal, with a specific gravity of 1.020, and free from sugar. The weight was unchanged at 227 pounds.
26th. The patient felt perfectly well. The urine had a specific gravity of 10124 and was free from sugar. The dose of Clemens's solution was increased to five drops.
September 28th.-The patient continued to feel perfectly well. The urine had a specific gravity of 1.030 and was free from sugar. The weight had increased to 235 pounds. The Clemens's solution was stopped, and the patient was allowed to eat a little bread.
October 11th. The patient felt that he was entirely cured. His weight was 233 pounds. The urine was perfectly normal, had a specific gravity of 1020, and was free from sugar. He was directed to follow a reasonable diet, not abstaining entirely from starchy matters, but avoiding sugar and sweets. He was requested to have his urine examined again in about six weeks.
The limited time at my disposal prevents me from giving the diet-table for diabetics and other details of treatment, which would be merely a repetition of what is contained in my paper on the "Treatment of Diabetes Mellitus," published in the "Journal of the American Medical Association," July 12, 1884, and in the sixth edition of my little book on the "Chemical Examination of the Urine in Disease." The diet-table is very varied and is not difficult to follow, the greatest hardship to patients being deprivation of bread. It is a curious fact, however, that, after following a strict diet for two or three weeks, diabetics lose their craving for prohibited articles of food, and the diet becomes by no means irksome.. Hecker's gluten-bread and porridge and cakes made of Hecker's farina are sometimes much relished. These articles contain between three and four per cent of starch and do not seem to be injurious. The patients, in all of the cases here reported, were in good circumstances and both willing and able to follow strictly the prescribed diet.
In presenting an account of these four typical cases to the Association, I have purposely put the unfavorable case first. This is the second case that I have met with in which, patients being willing to submit absolutely to treatment, I have not been able to arrest the glycosuria. In this case, for many months the patient indulged inordinately in sweets; and the disease, which was complicated with albuminuria, had become so thoroughly confirmed that, although the general symptoms were controlled, even total abstinence from food would not remove the sugar from the urine. In the three remaining cases, sugar never appeared in the urine after the first week of treatment. The effects of treatment in these cases and in others that I have reported lead me to repeat the quotation from Cantani that I have already made in the paper read by me before the Medical Section of the American Medical Association:
"Diabetes has become to-day a disease easily and certainly curable, provided that the treatment (cure) be not begun too late."
DR. FLINT said, in reply to a question by Dr. Leale, that his dietary table had been prepared with great care, and that it presented such a variety of food that patients were practically but little restricted, as regards the pleasures of the table, except that they were deprived of bread. He had seen dinners served according to this dietary table which were even luxurious in quality and in variety.
DR. S. S. CLARK, of St. Albans, Vermont.-I have listened to Dr. Flint's remarks with a great deal of interest. I have found, however, from practical experience, certain difficulties in regulating the diet for patients suffering from diabetes, which have not been mentioned by the author. In 1879, I discovered that I had glycosuria. At that time I weighed about 230 pounds. The specific gravity of the urine about 1.040. I placed myself upon an antidiabetic diet, and within a month lost five pounds in weight, and previous to beginning this diet my weight had fallen to 215 pounds. At the end of a month, nearly all my symptoms were intensified, and I suffered greatly from dyspepsia and constipation. The quantity of sugar in the urine, however, had decreased, and the specific gravity was reduced to 1028. I was obliged to take some starch, and immediately on doing so the symptoms were improved. I also took various remedies. Last spring, the specific gravity of the urine was 1022, or nearly normal; but I again tried the strict diet and found that the specific gravity, instead of decreasing, increased to 1.026, and each ounce of urine contained twenty-six grains of sugar-a larger quantity than at any previous time. I then lived on an exclusively animal diet; and, when the specific gravity of the urine had fallen to 1.012, it contained, even then, twelve grains of sugar to the ounce. I then, by continuing this diet, reduced the specific gravity of the urine to 1.003, but it still contained sugar. I then supposed that I must have Bright's disease; but examination of the urine failed to reveal albumen. It contained, however, a few hyaline, mucous, and epithelial casts. There was slight swelling of the feet and face, and some headache. I again lost five pounds of flesh within two or three weeks after adopting the rigid diet. There was great loss of strength, and I
was obliged to fall back upon starchy food for relief. I mention these facts because I have not seen it stated in books that sugar exists in urine of a specific gravity less that 1.008.
DR. FLINT said the lowest specific gravity of urine containing any sugar, which he had observed, was 1.011. He further desired to impress the fact that, if attention were paid to the preparation of the food mentioned in his diet-table, the demands of the most capricious appetite would probably be met. He thought that if medicinal remedies were constantly employed, both patients and physicians were liable to attach too much importance to the drugs, and thus be induced to neglect the diet, which is always the most important measure of treatment.
DR. W. C. B. FIFIELD.-I have not heard the entire paper, and I should be glad to know what success has been obtained from the dietetic treatment in patients of different ages. It is generally stated that persons advanced in life almost always recover from diabetes, while in the young adult the disease certainly proves fatal. I can not help recalling how useless all treatment, including the strictest observance of dietetic directions, had proven in the case of my only son, fourteen years of age, who presented symptoms of diabetes shortly after he had been injured by a savage bull-dog. There were times when, under strict diet, the specific gravity of the urine would be diminished and the quantity of sugar would be lessened; but the glycosuria never entirely disappeared, and the case went on to a fatal termination.
DR. FLINT briefly reviewed the histories of some of his cases, and said that he thought that what we called a cure might be effected, even in patients who had not passed the fifteenth year.
A CASE OF PISTOL-SHOT WOUND THROUGH THE STOMACH, FOLLOWED BY RECOVERY.
By JOHN H. HINTON, M. D., of New York County.
THE case of pistol-shot wound of the stomach, which I am about to describe, came under my care at the Presbyterian Hospital, on February 12, 1884; and, from the fact that there are but few reported cases of recovery from wounds of the stomach, and possibly no other on record in which the stomach was actually shot through, I venture to give the case somewhat at length, together with a brief consideration of the literature of the subject. That the case was considered to be very grave, may be inferred from the fact that two of my associates suggested laparotomy, and that all gave an unfavorable prognosis.
The subject of the injury was a young man about twenty-one years old, blonde, five feet eight inches in height, and weighing about 155 pounds. He was shot in the back, at an elevated railroad station, a few minutes after his breakfast, at about 8.30 A. m. He immediately fell upon the floor, and was thence carried to a station-house one square distant. From there he was taken carefully to the hospital in an ambulance. On admission, his condition was fairly good, without much shock. An inspection of his coat showed it to be blackened or burned by the powder, on account of the proximity of the muzzle of the pistol to his back. An examination of the body showed a wound over the tenth rib, about five inches to the left of the spine. The ball could be felt under the