April 12, 1802
Dr Bardsley discusses the 4th case of diabetes, likely to be Type 1 considering the quick death of the patient within just a few months. The animal diet helped with symptoms, but bread and vegetable matter increased the urine output.
Medical reports of cases and experiments, with observations, chiefly derived from hospital practice: to which are added, an enquiry into the origin of canine madness; and thoughts on a plan for its extirpation from the British isles
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John Wild, age 33, Labourer.
Admitted an In-patient , April 12th, 1802;
Feels excessive thirst, an almost perpetual inclination to void sweet tasted urine, in profuse quantities, ( especially during the night) great clamminess in the mouth, and soreness of the gums; much pain and weakness in the loins, with an involuntary discharge of semen after voiding his urine.
His skin is dry, hard, and extremely rough ; pulse 125, weak and fluttering; and his countenance portrays the utmost anxiety and distress.
The emaciation is extreme, and his debility so great, that he was obliged to creep along the passages, leading to the physician's room, by laying hold of the walls for a support.
The excoriation, and swelling of the prepuce, are so considerable, as to have brought on a phymosis. He states his urine to be as sweet as honey, and to, amount to thirty pints in twenty-four hours. His appetite is so greedy, that his means are unable to gratify its longing; but after every indulgence of a full meal he feels loaded, and sick at his stomach, and often throws up its contents, which have a sour and unpleasant taste. He has lost several of his teeth, since the soreness of his gums came on, and many others are now loose in the sockets.
He describes his mode of life to have been very irregular; sometimes faring hardly, at other times indulging to excess, especially in the use of spirituous liquors.
About seven months ago, he had worked at the harvest, and getting intoxicated, he laid himself down to sleep near a pool of water, where he continued all the night.
From this period he dates the origin of his complaint; but has only noticed the increase in the quantity of his urine, and the peculiarity of its appearance and taste, five months from the present date.
He was ordered to be put upon a diet of animal food, without the least portion of bread, or any other vegetable matter; two blisters to be applied to the region of each kidney, and the ulcerated parts to be kept open, by irritating dressings: six drops of the hepatised ammonia, to be got down, mixed with mint water, three times a day, and also every night a bolus, containing one grain of opium, and five of rhubarb.
His thirst to be quenched with water, in which, at meals, toasted oat-cake was to be infused. The liquid ingesta and egesta to be accurately ascertained.
April 15th. (typo in text)
Urine 34 pints, Drink 27 pints
Has eaten, at least, from three to four pounds of cold beef, but has carefully abstained from every other kind of food; slept better, and feels easier.
The urine (which was kept in a bucket) appeared of a greenish straw colour, and was clear when first voided; but on standing some time in the vessel became turbid on agitation, and looked like thick small beer; it emitted a
faintish acid odour, although evidently sweet to the taste.
Urine 38 pints, Drink 36 pints
He complained of tormenting thirst, and begged to have his drink changed. Ordered weak barley water, acidulated with the spirit : vitriol: ten: and, to support his strength, four ounces of wine in the course of the day. The dose of ammon: hepatisat: was increased to ten drops, four times a day; and the opiate with rhubarb repeated. The nitric was afterwards substituted for the vitriolic acid, and constituted, when mixed with water, the common beverage of the patient.
Urine 28 pints, Drink 26 pints
Has perspired copiously in ihe night ; pulse reduced to 108; appetite moderate, but he begins to loathe his animal food. The sensible qualities of the urine are not much changed; One pint of this fluid yielded, on evaporation, two ounces, within half a drachm, of an extract, resembling coarse brown sugar, both in colour and taste; at the same time one pint of healthy , urine, was exposed to evaporation under similar circumstances; and afforded a residuum amounting only to two drachms and twenty six grains. Medicines and diet to be continued, with the addition of broth at supper and breakfast
April 17th.— April 27th.
The quantity of urine passed each twenty-four hours, within the last ten days, has greatly varied: on the 21st, thirty six pints were discharged, on the 27th only seventeen pints—- these being the maximum and minimum quantities within this period; but the average amount may be estimated at nineteen pints each twenty four hours.
The liquid ingesta were seldom equal to the egesta; and the relative proportions fluctuated considerably. On the 23d, the urine measured nineteen pints, and the drink only sixteen : On the 25th, urine twenty four pints, and drink twenty six ; yet these changes could not be attributed to any perceptible cause.
The patient has been almost daily improving in health and strength: his sleep is more refreshing, and prolonged (without the interruption of making water) to two hours at a time. The urine is become paler, and has lost some little of its faintish acid smell, and sweet taste. The pulse varies from eighty four to eighty eight. As he became disgusted with the hepatised ammonia, a solution of sulphurated kali, was administered as a substitute.
The bowels were to be kept open with castor oil, and his other medicines and diet to be repeated.
April 27th — May 8th.
During this period, and especially within these three or four days, a general amendment has taken place. The average quantity of urine has not exceeded fourteen pints in the twenty four hours, but has varied in quantity, at times, very considerably. On the first of May, it amounted to twenty two pints, and on the eighth, to no more than eight pints. The following extract from the register will point out the favorable changes which have taken place.
May 3rd: Urine 12 pounds, Drink 12 pounds
May 4th: Urine 11 pounds, Drink 9 pounds
May 5th: Urine 14 pounds, Drink 16 pounds
May 6th: Urine 12 pounds, Drink 16 pounds
May 7th: Urine 14 pounds, Drink 16 pounds
May 8th: Urine 8 pounds, Drink 12 pounds
The patient begins to feel his strength recruited, his countenance has lost its ghastly appearance, and he has evidently gained flesh, ai well as strength. He no longer complains of the offensive taste in his mouth, nor heat and tormenting pain in the bowels. His pulse is in general not more than eighty ; indeed his vigors arid spirits are such as to suffer him to be employed in assisting the patients, and performing several menial offices about the house; yet the urine has not lost its saccharine taste, although it has become, according to his own expression, "sharper and less pleasant."
The phymosis continues, but the swelling and excoriation are abated.
He still complains of occasional weakness in the loins, which is always aggravated by the involuntary seminal discharge.
The improvement has been so marked and rapid, within the last four days, that he feels assured of his speedy recovery, and begs to have an allowance of vegetable food, and is very desirous to be discharged in a short time.
May 8th — June 1st.
On the 9th, one pint of urine yielded, on evaporation, one ounce, two drachms, and forty grains of an extract of the consistence and colour of treacle; but with rather a saltish taste, and urinous smell.
Important changes for the worse have un- expectedly occurred within this period. For on the 9th, the patient injured his leg severely by a fall, in running up stairs; this accident occasioned the opening to a very considerable extent of the cicatrise of an old wound upon the shin bone. At this time he expressed a longing desire to be indulged with bread and vegetables, and from an apprehension, that a refusal might induce him to obtain them surreptitiously, he was allowed a small portion with his meat.
From this period, the diabetic symptoms increased, and the average daily quantity of urine amounted to twenty pints; but the ingesta were nearly upon a balance with the egesta. Bread and vegetables were again forbidden ; yet I have reason to believe that he contrived to purloin from the other patients, part of their vegetable diet.
The ulcer on the leg spread rapidly, and discharged a large quantity of ill conditioned pus.
He was now confined entirely to bed, and lost both his strength and flesh.
He was ordered to take wine, bark, and lime water, and to omit his other medicines. One of his legs becoming anasarcous, small doses of digitalis and calomel were prescribed, in conjunction with the bark. By this treatment the swelling was nearly subdued, but the diabetic symptoms remained stationary. He was again ordered rigidly to abstain from vegetable food, and to drink daily a quart of fresh lime-water, mixed with milk; and to make use of a bath every night, heated to ninety-five degrees : by these means, the progress of the disease seemed at least to be arrested; but no permanent change of the characteristic diabetic symptoms was effected.
One pint of urine, taken from twenty-four pints which had been discharged on this day, was again evaporated. The residuum resembled the last in colour, consistency, and smell ; and weighed one ounce, seven drachms and a half.
June 1st — July 1st.
During this month, the register points out little or no variation in the daily quantities of the liquid ingesta and egesta, when compared with the proceeding fortnight: twenty-six pints was the greatest, and eighteen the smallest quantity of urine discharged on any one day: the ulcer on the leg, so far from being healed, has assumed a phagedenic appearance, and ex- cites much pain and inconvenience — alum with galls, and opium, were prescribed at bedtime,
in addition to the bark and lime-water, during the day. He now complains of increased soreness in the gums, and an irregular voracious appetite, attended by frequent vomitings of food in an undigested state. Pulse 103. feeble and irregular. Finding there was little, or no chance of restraining him from the occasional use of vegetable food, and despairing of his recovery, he was permitted to combine bread and vegetables with his animal diet.
July 1st – July 19th.
The patient has been evidently sinkings although the quantity of urine, voided each day, does not exceed the former statement. The average being twenty two pints every twenty-four hours. The swelling of the lower extremities has much increased, and, he is troubled with a teazing dry cough: the hopelessness of his situation was strongly depicted in his countenance, and his dissolution seemed evidently approaching.
Notwithstanding his extreme debility, on the 18th, and 19th, he was able to walk about the ward, and expressed himself even with cheerfulness; but on the 19th, at 2 o'clock p. m he was suddenly attacked with a pain in the stomach, succeeded by violent convulsions, which shortly put a period to his existence.(he died)
This, at first view, seemed to be a hopeless case. The disease had been so rapid in it's progress, and had made such ravages in the patient's constitution, that little could be expected from any plan of cure. The quantity of urine (thirty-six pints) discharged in twenty-four hours, is equal to, if it does not exceed that of any other instance which has been recorded by authors of credit. The proportion of residuum ( nearly two ounces to one pint ) is also very extraordinary, especially when we take into the account that it only formed a twenty-eighth part of the solid matter, drained off from the body in twenty-four hours.
This immense and rapid waste was, however, nearly supplied by the patient's greedy appetite, for both solid and liquid nourishment. It is worthy of remark, that on some days, the register pointed out an excess in the liquid egesta considerably beyond that of the whole amount, both of the solid and liquid ingesta; now as this superiority of the egesta to the ingesta has been often insisted upon by some practitioners, and denied by others. I felt very anxious to ascertain the fact in the present instance: and, therefore, when the register denoted that such a circumstance had happened, I was very cautious and diligent in my enquiries concerning the accuracy of the report ; and in no instance was I able to detect any irregularity or imposition on the part of the patient or attendants.
In this case, as in the foregoing ones, much advantage was derived from the use of the nitric acid. It greatly assuaged the thirst, and was grateful to the palate, but its effects on the bowels often prevented a further trial. Opium, with rhubarb, was generally serviceable in allaying irritation, and probably the diminishing the morbidly increased action of the stomach. Perhaps success could not reasonably have been expected in the treatment of this deplorable instance of diabetes mellitus; and I must confess, that at first, my most sanguine hopes did not extend beyond a palliation of the more urgent symptoms; but from the unexpected, rapid, and important improvement, which the patient experienced soon after his admission, I am inclined to believe, that had he steadily persisted in the plan of cure, and no accident to his leg had occurred, his life might have been considerably prolonged ; and perhaps the diabetic symptoms eventually subdued.