URINARY DEPOSITS. 415 mer cases, we must have recourse to the tonic aperient, or if the bowels be irritable we may employ the infusion of cascarilla or columba instead of the mixture of gentian and senna. If the tongue be coated, the pill of hydrarg. cum cret. and soda (F. 77)* may be used every second or third night, for a short time; but any prolonged use of mercury is to be rigidly abstained from. And when the nervine depression has subsided sufficiently to enable us to dispense with the ammonia, the nitric or nitrohydrochloric acid may be given in the bitter infusion, and at the same time the nervous power may be improved, and the nervine irritability relieved by a combination of sulphate of zinc with extract of henbane, or extract of hop. The zine may be first given in grain doses, three times a day; and the dose may be gradually increased to four or five. Moderate dietmutton once a day, and two or three glasses of sherry-avoidance of strong tea or coffee; cocoa for breakfast where it agrees is to be given. In those cases, again, in which, with phosphatic sediment in the urine, there is a marasmus and much nervous debility, great anxiety of countenance, a red tongue, thirst, and symptoms in general closely allied to those of diabetes, and probably referable to shock or injury to the spine, and in which too the deposit is chiefly phosphate of lime, we must pursue the same tonic treatment, combining bismuth with the zinc; and besides this, endeavouring to allay the nervous irritability. For this purpose, Dr. Prout and Dr. Golding Bird concur in recommending opium, or what is better, the salts of morphia. Dr. Bird recommends from one-third of a grain to half a grain of the acetate to be given three or four times in the twenty-four hours, and persevered with for some weeks. In some cases the constitutional symptoms are not very urgent; for this reason the deposit attracts less attention, and the formation of a calculus may ensue. To obviate this, mineral acids have been prescribed, but it is doubtful if any of them, except the phosphoric, ever reach the urine, unless given in doses which are hardly safe. But the nitric, though it may not act chemically upon the secretion, often corrects its alkalescence, probably by its tonic action upon the stomach, and is less likely to cause irritation. In the last class of cases, in which the urine is ammoniacal from mucus secreted by diseased bladder, our attention must be directed to the primary cause, and our remedies to obviating as much as possible every cause of irritation. The diet should be light and unstimulating, demulcent drinks may be employed, and the nitric or nitrohydrochloric acid administered; care must be, from time to time, taken to ascertain that the urine is really ammoniacal, and it must not be hastily presumed to be so merely by its odour. When there is much restlessness and uneasiness opiates may be employed, and a suppository of ten grains of pil. sap. co. will often give great *(77) R. Hyd. cum Cret. Soda Carb. exsic. āā gr. ij. relief. The washing out the bladder from time to time with warm water, should also be steadily persevered in. DIABETES. Diabetes is a disease about the true nature of which there was formerly, and still exists, much obscurity. Its cause used to be referred to the kidneys, it was thence transferred to the stomach; it then acquired a temporary occupation of the cerebellum; and is now, whether permanently or not, placed in the liver. Still, as the one prominent symptom is the remarkable change in the renal secretion, we have connected it with the urinary deposits. The invasion of diabetes is generally very gradual. The patient commonly feels weak and languid, and complains of thirst, and it may be that he notices that his urine is becoming very abundant; though in a very large proportion of cases, patients do not mention this symptom till questioned concerning it. Subsequently the patient loses flesh and strength, though his appetite is often good, sometimes excessive. He complains much of thirst, and of dryness of the fauces; the breath has a sweetish odour, or, if the expression may be used, a sourish sweet one; the tongue is clammy, red, and raw-looking at the edges, with sometimes a whitish-brown streak down the middle. With the loss of bodily strength, that of the mind also fails. The patient loses the power of continued attention, becomes infirm of purpose, irritable, anxious, or desponding. The symptoms in the majority of cases slowly advance, and, after a period of months, or sometimes years, he gradually sinks exhausted; or phthisis rapidly develops itself, and speedily puts an end to his life. Sometimes there is sudden death. The one characteristic symptom is the presence of sugar in the urine; the prominent one, sooner or later, is the excessive quantity of that secretion; hence its name, diabetes, from Siasa, "I pass through," though the connection between the excessive flow of urine, highly charged with sugar, and the other symptoms, is not at first sight very apparent. Into the extended investigation connected with this subject it is not our province to enter, we therefore content ourselves with a very brief summary of the facts which have been ascertained. A considerable proportion of sugar is contained in the food we eat, but in addition to this, a larger quantity is produced by the transformation of the amylaceous substances which enter so largely into most articles of vegetable diet; which transformation is effected by the pancreatic secretion. This sugar is dissolved and taken up and conveyed by the veins from the intestines into the portal vein, dis tributed through the liver, whence it is brought in the course of the circulation to the right ventricle; but in its passage through the liver it is found to have undergone a remarkable change: this hepatic sugar, or glucose, though isomerically the same, is now found to be capable of being oxidised in the lungs, so that it is made subservient to the purposes of forming carbonic acid, in the generation of animal heat, and also, in all probability, of nourishing the non-nitrogenised tissues, fat, cartilage, &c. We say that the sugar has acquired the remarkable property of being thus changed in the lungs, for ordinary sugar will not be acted upon in the lungs, neither will that which has been changed in the liver, unless it be dissolved in perfect blood, that is to say, that if common sugar be exposed in the blood to the air in the lungs, it remains unchanged; and so with the sugar taken from the blood in the right ventricle, if the blood in which it is exposed to the air in the lungs have been deprived of its fibrine. So that two things are essential. The action of the liver, and perfect blood for a solvent, in order that the sugar may be fitted for its purposes in the animal economy. Now, in' diabetes, the sugar is unchanged in the liver, and therefore it remains unchanged in the lungs, the consequence of which is, that being unfitted for the purposes of nutrition or combustion, it remains in solution, and is eliminated from the blood by the kidneys, whose office it is to remove from the blood all soluble matters not capable of serving any further purpose in the system, which substances act as stimulants to those organs, and promote the flow of urine.* From what has been just stated, it must be very easy to understand the subsequent phenomena of diabetes, namely, the failure of nutrition, the wasting, the hunger, the thirst, the profuse diuresis, the sugar in the urine, the saccharine smell of the breath; but of the nature of the lesion which prevents the healthy action of the liver upon the blood, we know nothing. It has indeed been ascertained, that sugar was present in the urine of animals in whom the fourth ventricle of the brain had been irritated, and hence it was supposed that there was the origin of the malady; but the observations of Dr. Pavey have shown that the sugar has, under such circumstances, been duly acted upon in the liver, and that it is not diabetic or morbid sugar which has thus found its way into the general circulation, but only an excess of glycose, or sugar of the hepatic cavæ. The diagnosis of diabetes depends upon the detection of the sugar. This may be discovered as follow:-To a small quantity of the urine, in a test-tube, add about half its bulk of liquor potassæ, then boil for about two minutes over a spirit-lamp. If sugar be present, the urine will assume a rich brown colour; this is a very convenient test for clinical purposes; but in some rare cases it may mislead: in all doubtful cases, the Trommer's test, of the sulphate of copper and liquor potassæ should be employed. Another sign of diabetes is the high specific gravity of the urine, which may be as high as 1050, or more; whenever it is abundant, and 1030, or near it, we may suspect diabetes; but we are not to overlook the possibility of diabetes without very abundant urine; such cases have occurred, and perhaps are more liable than others to terminate suddenly. For most of the above we are indebted to the researches of M. Bernard and Dr. Pavey. The treatment of diabetes, from the secresy of the nature of the disease, must be obscure and unsatisfactory. The use of amylaceous and saccharine articles of food seems to be contraindicated, and they do, except in very small quantities, increase the flow of urine, and consequent emaciation. But patients will not, or rather cannot, endure the restrictions sometimes imposed. Most vegetables are objectionable, except the cruciferous plants; malt liquor is to be shunned; bread, and potatoes, and turnips, sparingly used. Let the patient have tea or coffee, with plenty of milk, a rasher of bacon, and a little toasted bread. For dinner, beef or mutton, game or fish, with greens or spinach, and Italian maccaroni boiled in milk. Let him drink a little brandy and water. He may have some tea, with a little well-toasted bread in the evening; and as he will want some supper, he may have a mutton-chop with maccaroni, or a mess of maccaroni and milk. Of medicines we know of none that have any direct control over the disease. Some years ago, the author recommended the use of ammonia in considerable doses, and although the chemical theory upon which that recommendation was based has since proved to be erroneous, the remedy has certainly been found useful by the late Dr. Golding Bird and others, as well as by the author. He has generally given the annexed form (F. 78).* The cod-liver oil may be given at the same time about twice a-day; rennet has been recommended, as has also pepsine, but the author has obtained no result from them. The fixed alkalies are not without good effect: and a course of liq. potassæ and taraxacum certainly deserves a trial. When the urine is very abundant, about three or four minims of laudanum may be added to each dose of the ammonia mixture; and about five grains of Dover's powder given at night will promote perspiration. The patient should take moderate exercise, and his mind should be engaged either by a moderate attention to business, travelling, or light reading. As the bowels are apt to be constipated, a little castor-oil may be given from time to time. * (78) R. Ammon. Sesquicarb.ij. Infus. Cascarilla, 3 viij. Misce. From 3 ij to 3 i. to be taken every fourth or sixth hour. INFLAMMATORY DISEASES OF THE BRAIN. 419 XXIV. INFLAMMATORY DISEASE OF THE ENCEPHALON. THE contents of the cranium, like those of the other cavities of the body, are liable to attacks of inflammation, but it unfortunately happens that, important as are those affections, there are none of which the diagnosis is attended with greater difficulties. These inflammations have been by most authors included under the term phreni tis, though some have restricted this term to inflammation of the membranes, commonly known as meningitis, whilst inflammation of the substance of the brain has been described as cerebritis, a barbarous word for which, nevertheless, we are in want of a substitute. Whilst, however, it is highly convenient for the purposes of patholo gical anatomy to restrict the terms meningitis and cerebritis to inflammation of the membranes and the cerebrum respectively, it is perhaps more expedient for the purposes of practical medicine to retain the term phrenitis in its original signification of inflammation of the encephalon; and the reason why we would do so is, that, notwithstanding the careful observations of Abercrombie and others, we are not as yet in a position to speak of the two diseases as capable of separation in practice, however distinct they may be in their anatomical condition. By phrenitis then, or encephalitis, we wish to express a group of anatomical changes, which, as a group, are allied. to a certain class of symptoms, but which symptoms cannot at present be individually connected with corresponding anatomical changes; just as we might have spoken of thoracic inflammation generally, before the introduction of auscultation, as including a variety of anatomical changes, and presenting a large group of symptoms which we were unable upon the instant to connect severally with the appropriate pathological changes. The inflammatory appearances to which we refer are 1. Thickening or opacity of the arachnoid, effusion of lymph or pus between the layers of the arachnoid, or between the attached surface of that membrane and the pia mater. 2. Softening of the substance of the brain; the softened substance being sometimes of a red colour, constituting the ramollissementrouge of the French authors, or it may be of a yellowish colour, sometimes from infiltration of puriform matter, at others from change in the red corpuscles of the blood. Effused blood may sometimes have been the cause of the disorganisation, but there is equal reason to believe that in many cases its presence has been the effect. Another form of softening is simple loss of cohesion without change of colour. 3. The formation of circumscribed abscess in the cerebral matter. 4. Induration, with increased vascularity of some portion of the cerebral matter. |