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Diet in Diabetes Mellitus. Editor MEDICAL WORLD:-Diabetes mellitus is not usually classt among the curable diseases. Of all the cases under treatment by any and all methods in the past 10 or 100 years, probably not one per cent. has been cured. I mean, of course, chronic diabetes involving a variant amount of urine, constant presence of sugar, and the typical constitutional disorders and debility. It is a disease that is often unrecognized until an obscure debilitated condition persists despite tonic treatment or the urinary function shows a markt departure from the normal, with persistent thirst and dry skin; or perhaps there is a succession of furuncles or carbuneles, or gangrene sets in, or phthisis pulmonalis. Not infrequently the state of the urine has not been observed until the patient is in extremis.

The kidneys, the liver, the villi of the intestines and the nervous system, have been successively considered the fons et origo of the malady. Whatever may be the true pathology, the treatment is at best but empiric, if not experimental and unsatisfactory.

The treatment is usually considered under three heads, hygienic, medicinal, dietetic.

Hygienic measures are no more requisite in this disease than in most other chronic disorders, and therefore call for no special consideration. The general consensus of opinion is that the drug treatment is only palliative. The aim is to alleviate distressing symptoms, and so far as possible foresee and prevent threatening complications. For these specific purposes many things may be "good for" diabetes, but one that is essentially curative is yet to be found.

The broadest claim for successful treatment by drugs that has lately appeared is

tion, but the fact should have been distinctly stated. But he seems to imply that by his peculiar treatment with lithia carbonate and soda arseniate he cured 67 out of 70 cases of true diabetes. This is too much for our credulity.

What of mineral waters whose name is legion? Read the advertisements.

There

is hardly a State in the Union that has not springs of healing waters that work speedy and effectual cures of diabetes-if credit the proprietary puffs with which we are constantly deluged. Many and miraculous are the cures certified to by physicians of more or less note.

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What nostrum has not been endorst by members of the medical profession? Distinguisht? Of course they are. Indeed the distinction of some men seems to lie chiefly in the frequency with which their names appear as endorsers of things proprietary-new and wonderful.

Cargoes of curative waters are brought to us from over the sea. The afflicted drink them. Are they cured? can count on the fingers of his left hand all the cases so cured within his personal knowledge, and have digits to spare. Some of these waters are extolled for the minerals they are said to contain (see analysis), others because they are free from minerals -because of their purity. Whoso will, may take his choice of them. Of the drug treatment, Flint gives an excellent summary. "There are many remedies which have been highly extolled by their introducers, and found to be worthless and even harmful by others who have tried them." Again he says, "Opium and its preparations are well borne and very valuable in diabetes. From 6 to 12 grains daily are required to produce the required impression. Yet it can not be said to be curative." For "opium" in the foregoing, substitute the name of almost any one of the much-lauded drugs said to be "good for" diabetes, and you have the whole story in a nut-shell.

Lastly, let us consider the matter of diet.

All systematic writers lay great stress upon regulation of the diet. On this they

base their strongest and almost exclusive hope of benefit to the patient. The sum and substance of these regulations consist in the avoidance of saccharine and starchy foods. The details of schematic dietaries amount to little more than this.

Prominent among the systems is the skim milk treatment of Donkin. It is one of the things usually suggested, always being tried, never curing, and, as has been aptly said by some one, it is an approved and respectable agent in starving the unfortunate patient to death. I seriously question the propriety of withholding entirely the carbohydrates. The theoretic reason for so doing is that in this way the elimination of sugar by the renal emunctories will be checkt, and the systemic derangements arrested. Experience does not substantiate this claim. The theory is a mistaken one, and the practice under it is unwarranted.

Diabetes is essentially a debilitating disease-a wasting-a marasmus-a consumption. The sensible loss of tissue, of weight, is not always immediate, but it is ultimately inevitable. The vitality is lowered. There is an increasing sense of fatigue-incapacity for active, sustained, laborious exertion. One of the most common terminations is phthisis-certainly a wasting disease.

Now if the carbohydrates are necessary to sustain vitality, or if they contribute to the maintenance of vital force, their withdrawal from the menu is evidently unscientific and unphilosophic-and unfortunate for the patient.

Some experiments conducted by the German War Office have a practical bearing upon this point. It was shown that by giving sugar (unknown to the men experimented on) better results were obtained in muscular work than when it was not given-in short, that the ingestion of sugar was essential to the highest muscular and vital power of the individual.

Pavy says that "the indications for treatment are evident. Prevent the sugar from getting into the urine. Keep it from the intestine-and this is easy. Stop the carbohydrates for a time." This is a summary way of doing it, but is it effectual? Whether it is or not may be easily proven.

The conclusions of Dr. A. Munson may be set over against those of Pavy. He finds that "Withholding carbohydrates does not wholly stop the elimination of sugar by the kidneys. This must evidently

come from the metabolism in the tissues, tending to their destruction. It would seem needful therefore to supply this waste by giving the necessary carbohydrates." The diabetic has by no means lost the power of burning sugar, therefore sugar must, even more than in health, be allowed, in order to prevent the loss of weight and muscular weakness, which may terminate in one of the natural endings of diabetes death by asthenia.

Hare admits that in a certain class of diabetics, the total deprivation of sugar certainly hastens the fatal termination.

So long ago as 1884, Prof. Pepper, in a clinical lecture, pointed out the fact that in some cases the complete withdrawal of the carbohydrates was followed by great debility and loss of vitality, and he stated that in such cases the allowance of sugars and starches is necessary in order to sustain the patient.

The idea seems to be prevalent among physicians that the first and proper thing to do with diabetics is to cut off sugar and starch from the regimen. Few patients with this disease have escaped from this experiment. Very few have been able to follow this course without at least occasional lapses, and usually final abandonment of it from very necessity. The system cries out for these necessary alimentary substances, and refuses to be satisfied without them.

I believe that if all diabetics were allowed to have the ordinary mixt diet of meats, fruits and vegetables, bread and pastry and sugar for the ordinary sweetening of food, each in due proportion, the average duration of the life of diabetics would be lengthened, and their comfort greatly enhanced. I emphasize comfort for it is well-known that the regulation restricted diet entails a life of suffering and misery that few have the self-denial to endure with patience.

As for substituting saccharin for cane or beet sugar, it is a delusion and a snare. It does not even gratify the palate, and it wholly fails to satisfy the craving for vegetable sugars. Levulose may answer somewhat better.

I have watcht patients that were held to the strictest exclusion diet, drank skimmed milk by the barrel, mineral waters by the hogshead and swallowed oceans of drugs; and yet they steadily declined and yielded to the natural outcome of the disease. Beside them I have seen others that kept up their usual mixt

and unrestricted style of living, took few drugs, lived under no undue restraint; and they, as a rule, have done much better, lasted much longer than their much-treated compeers, and in a state of comparative comfort.

It is hardly necessary to go into the history of cases. I give a single typical one: Mrs. A., 45 years of age, of the obese type, has been under my care for a dozen years. During all this time her urine has been heavily loaded with sugar. Other members of her family have had the same disease and despite the best (?) and most vigorous treatment, have died from it. This lady has no suspicion of her disease, and no restriction has been placed upon her diet. Indeed she indulges in course dinners, and after-theater suppers and is not afraid of "the cup that cheers." She takes little medicine, but much exercise in the open air. She is not in perfect health, has some ailments, but I am satisfied that if she had been treated as her relatives were, kept on skimmed milk and deprived of carbohydrates, she would have passt in her checks years ago.

If observation counts for anything, it - leads me to the conclusion that diabetic patients as a rule will live longer, and be far more useful, comfortable and happy when not in any way restricted in the matter of diet. Some cases may be benefited by diminishing temporarily the ingestion of carbohydrates, but such cases should form the rare exceptions, and not the general rule.

Why Do We Die? Editor MEDICAL WORLD:-No sane person in good health wants to die. In early life death is a terror even to think of. When I began the study of medicine, one of the questions suggesting themselves to me was whether I would be able to see and handle the dead body in dissecting. As one grows older, experience familiarizes us with the thought, until in time it is impresst upon us that death must come to every human being sooner or later; and even the thought of its coming a few years sooner does not seriously impress us. It may even happen that, overburdened by the cares and fatigues of this endless battle for existence, the pangs of disease, grief for the loss of our loved ones or disappointment of our hopes and aspirations, we may get to look on death as desirable.

No provision of Nature is more God-given than that by which our interests are gradually transferred to the next world, as our friends grow fewer here and multiply in the great Beyond.

"Death, what art thou,
To whom all bow,

The sceptered king and slave?
The last, best friend

Our cares to end.

Thy empire is the grave."

But to most of us, during most of our lives, indifference concerning death applies only to other persons' deaths. when we realize that such a thing is possible to us, fills us, if not with dread, at least with a lively desire to postpone it to the latest possible date. No matter how well-founded is the hope of a happy future, this world seems plenty good enuf just now. No one doubts the personal piety of the good old men who fill the throne of St. Peter, and yet it has been centuries since one of them ascended the throne without changing his name. Why? Because there is a tradition that if this is not done he will die within a year. And as the last four who retained their original names as popes really did die within a year, the change has become an unwritten, but wellobserved law.

And yet, how little we do to preserve the life we prize so highly! Daily, hourly, we break the laws of hygiene, do the things that shorten life, waste our scanty stock of vital force uselessly, recklessly, and hasten the advent of old age as if the only object of life was "killing time."

Every human being arrives at the age of discretion endowed with a certain quantity of what we call vital force. What it is we know not. It cannot be weighed, measured, seen or felt, and yet we recognize it, we know it is present, and even learn to estimate its amount, variable as it is in various persons at various times, and to reckon with it in our prognoses and therapy. As the duration and comfort of our lives, the degree of "success" we achieve, depends directly upon this vital force, it would seem that our first consideration should be as to how much we have, how best we can increase and utilize it.

Such a reckoning we should make of our vital capital as we would of our financial resources, were we about to embark in any business enterprise. Men who embark in an enterprise requiring thousands when they have only hundreds at their com

mand, are fools. But what if they embark in this enterprise, requiring a great expenditure of vital force, when they have but a tithe of it? Are they not ten times the fool? And yet that is just what ninetynine men out of every hundred do. Some one told me that statistics showed failure to be the fate of ninety-five per cent. of humanity. How much of this is due to physical failure to to withstand the

strain?

Much of this might be obviated were men to consider carefully for what objects they are going to try. Too many fail by neglecting to distinguish between character and reputation. They try to rise as high in the world as possible, instead of trying to attain the place for which they are best fitted. Louis XVI. would have made a useful, happy and contented locksmith; he gave up life and all it could have held of happiness to be a very poor king. Many a man wears out his life and dies prematurely, trying to take care of fifty thousand dollars, who could have lived an ideal life on five thousand. So it happens that many of us who have strained our mental faculties to the bursting point to attain certain objects, win them only to ask ourselves what we are going to do with them now that we have them. Like the fabulous king of France, we march up the hill and then-march down again.

The true life-work of most men is, first, to fit themselves for the work they have selected; second, to get a wife, rear a family, support them suitably; third, to do as much good as comes to their hands, for neighbors, country and humanity. All All beyond this is superfluous, unworthy or culpable.

Now all this screed has grown out of the fact that the writer has been ailing lately; his muscles grow weary quickly; sleep deserts him; his breath gets short on slight exertion, and it takes his heart 104 beats to do the work that should be done by 70. Not being in the least degree morbid or world-weary, he at once had his blood subjected to laboratory examination, finding the red cells sadly deficient, from the efforts of some unwelcome guests known as plasmodia. So the heart must be toned up, the malaria extirpated and the blood restored to its normal condition. Meanwhile work is light, and I must chat to you of what comes to mind readily, instead of exhausting my little remainder of

vital force.

Some years since chance threw in my

hands a little work entitled "The Art of Prolonging Life." I read it with the keenest interest. This art seemed to me better worth study and practice as a specialist than any other. I have since thought much and read everything I could lay hands on concerning this topic. Would my good friends of the WORLD family like me to depart from my custom of dealing with every-day maladies, and give the results of my study of this subject?

In the December WORLD, page 516, Dr. Fordyce H. Benedict has somewhat to say about other men's reports on pneumonia and typhoid fever. It is hard for any of us to believe that other men are doing better work and getting better results than ourselves. It is easier for us to believe they are wrong in their diagnoses. Nevertheless I really believe I can diagnose pneumonia and typhoid fever, and if Dr. Benedict will try the remedies I mentioned (not those he quoted) he may learn something. Meanwhile I wish he would teach me a little. What is an alterative? What is the exact pathologic condition at which he aims his singular combination of iodin, bromin, phosphorus and fir balsams, and what does he expect each of these to do? When I say that in pneumonic hyperemia there is vaso motor spasm of the skin and that aconitin (not aconite) relaxes this and allows some of the blood to enter the cutaneous capillaries and thus relieve the congestion, I am talking what every doctor can clearly comprehend. And when I say that there is also vaso motor paresis in the byperemic area, and that I give strychnin to stimulate these vaso-motor nerves and contract the vessels, thus driving out the blood, it is no more difficult to understand than the multiplication table. But no living man ever gave a comprehensible statement of the effect of an alterative. It was a cognomen of despair, a confession of ignorance.

Which peripheral nerves does phosphorus stimulate? If I understand the sentence it attributes to phosphorus the action of strychnin-to relieve stasis in the capillary circulation. Does it? Everyone knows that strychnin does, but what proof is there that phosphorus exerts a similar action?

Taken as he has written it, I must say that Dr. Benedict must be a pretty good doctor to obtain as good results as he claims from such ineffective remedies as he uses. If he could lay aside his unbelief long enough to give a fair trial to the

treatment of pneumonia and typhoid fever recommended, he would learn why men not as skillful as himself obtain so much better results. And a man who talks of real typhoid fever in these days when every case can be verified by bacteriologic examination, is just a trifle ancient.

Dr. Priestley (page 517) deserves my thanks for his suggestion of calcium chlorid in hemorrhagic pneumonia. This valuable hemostatic has been repeatedly advocated but it seems impossible to get it into general use. It has no advertising interests back of it. I shall give it in my

next case.

On page 536 Dr. Price asks about morning diarrhea. This often depends upon an ulcer just within the sphincter, a dangerous lesion, as it is apt to dissect out the muscle or form sinuses. Dilate the sphincter, scrape the ulcer and treat it with iodoform. If there is no ulcer, empty the bowels by colonic flushing on going to bed, and give corrosive sublimate, half a milligram three times a day.

The case of metrorrhagia on the same page should be curetted; follow by intrauterine injections of europhen, one grain in ten minims of fluid petrolatum every third day. Internally give hydrastin, one milligram every four hours. Profuse hemorrhage requires atropin in doses enuf to redden the skin. If the blood is thus attracted to the surface of the body there will be that much less to flow from the bleeding vessels.

Why doesn't Dr. Lloyd (page 537) disinfect that man's bowels? Give him a seidlitz powder every morning, and follow with five grains calcium sulfocarbolate and 1-500 grain physostigmin salicylate every hour for seven doses.

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Dr. Harwood's case (page 538). will assume that the baby at six weeks age weighed ten pounds. Assuming the average man's weight as 150 pounds, the child should receive 1-15 the dose. that the dose of one grain given would represent a dose of fifteen grains given every four or five hours to an adult. Would that be good treatment for gastroenteritis? Doctor, where have you been for the past ten years? Quinin is an irritant to the stomach and contra-indicated in the case, even in doses of proper size. Next time try the virtues of sodium sulfocarbolate, bismuth subnitrate and a well-chosen diet.

WILLIAM F. WAUGH, M. D. Ravenswood, Chicago.

Treatment of Pneumonia.

Editor MEDICAL WORLD:-As the treatment of pneumonia is under discussion, I have taken the liberty of using Dr. Benedict's communication to the December WORLD as a basis for my remarks on this subject. I do so for the reason that he makes the following assertions: "All who have practised medicine any number of years have experienced periods of success in the treatment of disease, ** then come times when almost every case of the same disease proves fatal in our hands."

In speaking of physicians who report having met with continuous success in treating pneumonia, typhoid fever, etc., he says: "should we believe all that they tell us," etc.; and concludes his complimentary remarks by saying: "Where lies the discrepancy between the success of different physicians in the treatment of the same disease? I think it is in calling a disease what it is not, and, out of that fact, building up a reputation on a false basis."

The doctor's extreme modesty prevented his suggesting the possibility of his method of treatment being at fault, and, after admitting that at times "almost every case proved fatal in his hands", he proceeds to make known to other physicians how they may achieve the same happy results. This reminds me of the story of the preacher who one morning made the following announcement: "Sister A is very ill; she is being attended by our dear brother Dr. G.; let us all pray for her safety."

Let us briefly review what Dr. Benedict says and see if we may not discover some of the reasons for the "discrepancy between the success of different physicians in treating the same diseases." He first speaks of failure in spite of the use of our vaunted specifics. Then he criticises Dr. Waugh for his remarks on the use of aconite, digitalis and strychnin, and says: "I do not believe these remedies alone can so equalize the circulation as to relieve the extraneous deposit existing in the lungs." He then says he believes that in pronounced pneumonia alteratives are of the first value.

I would respectfully suggest that one chief reason why Dr. Benedict meets with so many failures is because he does what he accuses others of trying to do, viz.— makes a mere routine of the practise of medicine. He lumps all cases of pneu. monia into one class and proceeds to give them "vaunted specifics" for pneumonia.