DEP/DUA/1/33/02 (Normalised version)

William Dods

(1783-1784)

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William Dods. November 15

With regards to name of this patients disease no doubt in pronouncing it an example of Diabetes.

The Diarrhoea urinosa or Profuse urinae of the ancients.

From these appellations need hardly observe that great characteristic of the affection immoderate discharge of urine.

And accordingly by this mark alone all the nosological¹ writers have defined it.

When consider that discharge in this case now to extent only of pound VI in 24 hours may be doubtful how far disease still exists.

For unquestionably some with whom even in state of health, particularly in winter season urine to that quantity

But in [judging] of disease, in present advanced state this circumstance alone must not influence determination

Must take into account condition in which has been during former progression of affection.

Must attend to other symptoms with which patient then was & still is affected.

And must also pay due regard to state of urine in other respects as well as to quantity.

Disease when patient first applied at Dispensary near four months standing

And although now to quantity only of six pounds yet during greater part of course at 20 in day.

By this discharge there was soon induced general wasting of the habit, languor, loss of strength, & some degree of hectic fever as indicated by quick & feeble pulse.

And these symptoms constituting at least dangerous part of diabetes, still continue in some degree

With diminishment of quantity of urine others indeed have in great measure ceased.

Thus both appetite & thirst once excessive have now nearly returned to natural standing.

But from state of both particulars of former have strong characteristics of the affection

In most instances of Diabetes which have occurred in my practice uncommon appetite for food one of most striking symptoms.

In this affection patients neither satisfied nor, as would appear from gradual wasting of habit properly nourished by double or even triple quantity of aliment formerly sufficient.

Probably as nutritious matter carried off & discharged almost as soon as [assimilated] into chyle.

That this the cure probably from another very common mark of disease, sweet taste & smell of urine.

From this review then appears that all the characteristic symptoms of this affection either have taken place or are still present with this patient.

As of last kind may mention that remarkable circumstance peculiarly sweet taste of urine.

For although according to account of patient now much diminished, yet still manifestly present to no inconsiderable degree.

This we may observe is a symptom not only characterising disease in general but with almost every nosologist fixing a particular species of it.

Thus Mr Sauvages in his system gives diabetes with sweet urine the title Diabetes Anglica.

Concluding that was a more frequent affection in England than other countries as accurately described by Dr Mead & some other English writers.

Dr Cullen again to this species has given name of Diabetes Mellitus.

A circumstance to which has been led from resemblance which this diabetes [urine] has, to other urine in which some proportion of honey dissolved.

But were we to suppose honey either cause, which might be inferred from name, or in any other way [concerned] in affection, opinion would be very erroneous.

This name therefore I am inclined to think is exceptional.

And other Diabetes Anglica when consider that disease by no means peculiar to England is no less so.

Pathological writers particularly Dr Gaubius in treating of urine have pointed out three different kinds

Urina potus, Urina chyle & Urina sanguinis

There can be no doubt that diabetic urine affords strongest example of second of these the urina chyle.

And as little that its peculiar qualities arise from its containing the constituents of chyle, particularly sweetness from Sugar of chyle

Better therefore distinguished from other dropsies by title of Diabetes chylosus than any other term.

Into pathology of this disease, which still involved in great [observations] cannot pretend to enter.

May only remark that the experiments made by Dr Dobson, since repeated by others, leave no room to doubt, that urine of such patients contain real saccharine matter.

And as this can be only saccharine part of chyle, before conversion into saline of blood, has been question how thus suddenly thrown off.

Some suppose that happens from diseased state in alimentary canal or imperfect assimilation.

Others again attribute to fault in kidney.

But in both cases has been imagined that [reaches] urinary organs only, through channel of circulatory system.

On this subject however a different supposition thrown out, by late ingenious Mr Darwin.

Endeavouring to render it probable, from variety of phenomena, that matter discharged, may without intervention of circulatory system be immediately carried from alimentary canal to bladder.

This he supposes effected by retrograde motion taking place in some of the Lymphatics.

To this opinion though supported with much ingenuity must own cannot be a convert.

But here would be out of place either to enter into consideration of proof, or objections that may be urged against it.

And without farther [remarks] on pathology of affection, may observe, that whatever morbid condition may be, disease a very obstinate one.

If were to form a conjecture as to event of present case, from those I have before treated, should without hesitation give it as my opinion that endeavours to serve this patient of no avail.

But when consider history of case several circumstances apparently very favourable.

And indeed more so than any instance of this affection, which have had formerly occasion to treat

For although of several months standing, yet this may be considered as but incipient state of Diabetes.

For in many cases has subsisted even for years before product of any such inconvenience as to lead patient to apply for assistance.

When that however the case may naturally be supposed more obstinate disease than when only of few weeks.

Cause also to which disease of present patient attributed another favourable circumstance.

According to his own account, arose as immediate consequence of hard labour.

By this, profuse sweating induced, during which drank large quantity of cold water.

That from sudden impression of cold, acting on a body [remaining] peculiarly irritated by heat, very powerful effects [should] be produced, is by no means surprising.

And accordingly, from condition of habit on which acts, produces very various nay opposite affects.

That among others should sometimes give rise to uncommon determination to kidney, may readily be supposed.

Hence then whether conjecture of patient really well founded or not, must at least admit that is a cause adequate to effect.

And probability of conjecture not a little confirmed, from accident of this nature being enumerated by every accurate observer among causes inducing the affection.

If however has proceeded from this cause, reason to presume that no permanent local affect has taken place in kidney.

Hence then at least better chance of recovery.

But to these two circumstances, still a third to be added more favourable than either

That is change for better which has lately taken place in disease of patient.

Independent of any remedy quantity of urine spontaneously diminished from 20 to 10 pounds

And since treatment begun still farther diminished so that now reduced pound VI

With this remarkable change has in other respects also come [nearer] to natural state.

And in particular sweet taste indicating immediate discharge of chyle much less considerable.

Accordingly not wonderful that attended also with diminishment of immoderate appetite.

Hence then reason to infer that here even spontaneous tendency to recovery.

And that from being promoted by aid of medicine, cure may in no long time be accomplished.

On these grounds notwithstanding obstinate nature of disease must own that have some hopes.

At same time must also remark that in former instances have seen very considerable remissions which were followed by more severe attacks than ever.

Hence from present relief cannot be confident as to future state.

While at the same time weak & very exhausted condition of patient against him.

And also not a little so that is a poor labourer exposed to cold, fatigue, & all vicissitudes of weather.

To all this must also add, that doubtful how far he will either give regular attendance, or be disposed faithfully to employ medicines we direct.

For while resides at distance in the country seems to have some disposition to prescribe for himself.

As far however as does attend us & will follow directions given, may afford opportunity for different trials in way of [Practice].

In this disease Pathology so far obscure, that difficult to say on what principle rational cure can be conducted.

But from suppositions generally entertained that arises from want of due tone in secretory vessels of kidney, conjoined with morbid irritability there, such medicines have in general been recommended, as will increase former & diminish latter.

With one of these intentions, recourse has been had to different astringents, & peculiar stimulants, while with the other sedatives have been employed.

But if benefit sometimes from these, as far as my observation goes, still more from diminishment of determination of fluids to kidney & from preventing occurrence of [superficial] water in general mass of fluids.

On the latter ground benefit from moderating thirst by other means than by large quantity of diluents.

And on former from supporting [equable] circulation & even increased determination to surface by warm clothing but still more by warm temperature.

And hence perhaps more real benefit in this disease by change from cold to warm climate, than by any other means.

Did circumstances of patient therefore admit of it, would have no hesitation in recommending it to him, to exchange this country for more southern Sun at least for winter season.

But as this impractical must content ourselves with enjoining it to him, to avoid cold as far as can, and to defend against it by proper clothing.

While at same time may have recourse to different remedies with other [intentions]

Since began treatment of this case, have you will observe had recourse to repeated Emetics.

From operation of these it is well known that by sickness induced as well as severe action, powerful [determination] is given to surface.

May suppose them serviceable therefore as diminishing determination to kidney.

But [here] must observe, that have had recourse to this mode of cure, more on footing of experiment, than from any reasoning.

Not however, I must acknowledge from any experience of my own, for in this disease have not before employed them.

But from having received information I can depend upon of a case of Diabetes cured by occurrence of an obstinate spontaneous vomiting.

From that fact, although a solitary one, I own have long wished to have opportunity of giving Emetics, in this disease a fair trial.

Have accordingly ordered to this patient five successive Emetics, since he came under care.

And may at least venture to say, without any bad effect.

Nay since he began employment appearance from which might infer, that attended with good consequences.

For urine now diminished from extent of twenty pounds in day, to six.

All this change however we cannot with any justice ascribe to the Emetic.

For before use, even of first was considerably diminished.

And indeed whole of diminishment may have arisen from spontaneous change which had then begun to take place in the disease

But whether reduction to present low quantity to be attributed to nature or to art, cannot yet be considered as complete cure.

For still retains manifestly sweet taste.

At one time indeed, during course of last week, this quality had entirely disappeared.

And urine both became scanty & at same time acquired high colour

This we are told, the consequence of excessive spontaneous looseness.

And probably more from alimentary matters being discharged, before chyle formed, than from any change, in morbid affection before existing.

While at same time fluids also taken in as well as solids immediately hurried off by stool.

And accordingly on Diarrhoea ceasing [disease] returned to same state as before.

But although no ground for positively attributing much to Emetic yet appear sufficiently favourable, to excite desire of persisting in use.

Is therefore my intention, if patient will comply with it, to persist in use for some time longer.

And to avoid, what he may think appearance of inactivity, shall probably conjoin emetic with some articles, to be taken daily with view of engaging attention.

For this purpose, have thought of ordering him a combination of Rhubarb & Magnesium.

From which, while will not interrupt present plan of cure, may expect some good effects, as keeping belly gently open, & at same time strengthening tone of alimentary canal.

Besides this if appears progress to recovery shall probably also prescribe vomit less frequently

If under course of Emetic cure should here be accomplished will I own be disposed to look upon it as important fact.

And not perhaps of very great consequence whether we can give a satisfactory explanation of mode of action or not.

But besides what already suggested of influence as give determination to surface other suppositions also may be entertained.

And must own that for my own part will be disposed to consider this practice as in some degree favouring Mr. Darwins theory of disease already mentioned.

At least not impossible that operates as counteracting retrograde motion of Lymphatics if such take place

But before hazard any conjecture as to method in which good effects to be explained first necessary to determine with certainty that has such effects.

Should Emetic in this case prove unsuccessful or be deserted without proper trial, another mode of cure which I wish to employ in this disease.

Remedy to which I allude Electricity

If disease depends on atonia at kidney in any degree approaching to Paralysis, may I think be means of removing it

But for this mode of cure our patients residing in the country is very unfavourable.

Shall probably therefore rather have recourse to trial of Tincture of [ Canith] or Serum alum.

Former, although has failed in instances in which have before used it may succeed in present which of slighter nature.

And although far from looking on latter as [efficacious] remedy Dr Dover [represents] may yet alleviate if cannot cure disease

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Explanatory notes:

1) Nosology is the branch of medical science dealing with the classification of diseases. Individuals referred to in the case notes as nosologists were commonly those who had published nosological, or classificatory, medical texts.