DEP/DUA/1/36/06 (Normalised version)

William Robertson

(1784-1785)

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William Robertson. November

With regard to disease of this patient very little room for doubt.

Is distinctly marked both by [quantity] & other sensible qualities of urine.

And when consider extent to which discharged as well as peculiarly sweet taste can have no doubt in pronouncing it a case of diabetes.

But besides this patient affected also with every other symptom commonly attending the disease.

Such for example as uncommonly keen appetite, excessive thirst, bound belly, dry skin etc.

But above all affected with great loss of strength & of flesh.

Circumstances which may readily suppose must be unavoidable consequence of excessive discharge.

In short almost no symptom in case which does not frequently occur in this disease.

While again none of more common symptoms of disease which are not here present.

Among others have to remarkable degree that sweetness of urine, of late by medical writers particularly observed in this affection.

Probably however only from being but of late attended to.

Can I think be little doubt that existed in ancient as well as modern time

And only not described from being overlooked & not attended to.

This symptom indeed some have considered as marking a particular species of the disease.

And accordingly even in system of Dr Cullen, disease divided into Diabetes Mellitus & Insipidus

For this division however, as far as my own observation goes, am inclined to think, that no foundation in nature.

And indeed Dr Cullen though has adopted it speaks of it with great doubt.

Certain that even in same patient degree of sweet taste very much varied.

And that very generally increased in proportion to quantity of discharge & to discharge taking place soon after full meal.

A symptom therefore thus subjected to such varieties, ill suited from being characteristic of species.

And probably only not observed from want of accurate attention, from period of observation from properties of urine at time, or such like circumstances.

Can only say that in all cases which I have had occasion to treat never entirely wanting.

Though in different cases & at different times much varied in degree.

This sweetness of urine by [explanation] of Dr Dobson, published in London Medical observations¹, incontestably demonstrated, to arise from saccharine matter in the urine.

And indeed his observation now fully confirmed by those of Dr Black, & other chemists who have taken [trouble] of analysing & evaporating such urine.

As little doubt that this saccharine matter is same with what gives sweet taste to chyle.

And indeed diabetic urine more properly than any other entitled to appellation of Urina chyli.

And from this immediate discharge of chyle from system whatever may be cause inducing it, most [striking] symptom of disease, particularly wasting of habit, & loss of strength, unquestionably to be explained.

Respecting Pathology of this disease [illegible] many disputes

But very few as to Prognosis.

In almost every instance proves if not fatal at least [illegible] disease

Would not indeed affirm that in no cases has recovery taken place.

But in my own practice must acknowledge that have never been so successful as either to accomplish cure or to meet with spontaneous recovery.

In this case therefore expectations I own by no means sanguine.

And if after all trials that can make shall be obliged to dismiss patient in no better situation than when came under care, shall not be disappointed.

At same time in case before us circumstances by no means unfavourable.

Quantity of urine indeed increased to very considerable degree.

And what very common concomitant of that has remarkably sweet taste.

While as necessary consequence of these two very considerable loss of strength has ensued.

But hitherto no alarming symptoms at least such for example as hectic fever, have taken place.

Besides this, disease comparatively speaking but of short duration.

And although skin parched, yet not to that remarkable degree, which probably gives great difficulty in cure.

These therefore circumstances, at least somewhat favourable.

And give some ground to hope, that although may not be able to accomplish cure, shall yet have opportunity of trying remedy most extolled.

And on recommendation of eminent practitioners a variety of practices to which recourse may be had.

Of principles indeed on which these operate can by no means speak with confidence.

For concerning pathology of the disease many debates.

And still a matter of much controversy whether principle morbid affection, in alimentary canal or in kidney.

Whether disease principally depends on fault in assimilation of aliment, or in secretion of urine.

For my own part however, inclined to adopt latter opinion.

And to consider principle morbid affect as being vitiated secretion often depending even on [organ] affect of Kidney.

And hence I apprehend it is, that so frequently resists every remedy we can employ.

Great objective therefore is to remove this diseased state, & to restore secretion by kidney to natural standing.

And this chiefly to be brought about by restoring due tone & removing morbid sensibility.

For accomplishing these ends however, must endeavour, as much as possible, to remove circumstances augmenting these affects.

Must therefore be aim to diminish determination to kidney, & to prevent occurrence of superficial water in blood.

On these grounds, except what done with view of obviating particular symptoms, am inclined to think that operation of remedies which have been represented as successful in this disease, may be explained.

At same time must acknowledge that in treatment of former cases have often had recourse to remedies rather on Empirical [footing] than any other

Or at least on grounds of experience of those who have represented them as successful.

This a good deal the case, with respect to first practice to which will observe had here recourse.

The use viz of repeated emetics.

Emetics indeed by some represented as having considerable influence in increasing quantity of urine.

This however, when does take place, am inclined to consider only, as consequence in second way.

And to proceed from quantity of water introduced to promote operation of emetic, but not afterwards discharged by vomiting.

Accordingly is by no means a steady or constant effect of employment.

Much more uniformly emetics produce determination to surface

And by this, flow to kidney, is very generally in proportion diminished.

In so much that discharge by perspiration & urine often observed to alternate with & [compensate] each other.

A circumstance particularly remarked both on change of season & of climate.

During summer, & in warm weather while perspiration increases urine diminishes.

And in opposite climate & seasons, is in contrary situation.

This so much case, even with morbid affect of urine, that instances of Diabetes induced by transition from cold to warm climate, & of cure by opposite change.

Hence then as giving determination from kidney to surface, some grounds I think, to expect benefit from Emetic.

But was not I own upon this footing that had first recourse to use in present disease.

Was led to employment on what reckon better foundation than any [specific] reasoning, [unsupported] to practice.

Was informed by a very accurate & observant practitioner, of a natural cure of diabetes which had fallen under his observation in consequence of spontaneous vomiting.

From this, consider repeated Emetics as well meriting future trial.

Accordingly, had recourse to use with a patient, whom had occasion to treat, at Collegium Casuale² during course of last summer.

These however, as well as several other remedies, were not product of any material benefit.

But This want of success in a case where other practitioners had failed, I consider as by no means a sufficient reason for declining farther trials.

And present case seemed fit opportunity for having again recourse to them.

But in this instance have not been more successful than formerly.

And after employment of four different emetics without any material benefit to patient, reckoned it improper to push present trial farther.

Have now therefore you will observe had here recourse to another remedy viz Tincture of Cantharides.

For introduction of this article, in cure of Diabetes, we are indebted to Dr Brisbane of London.

In a volume of select cases, which he published some years ago³, will find several related, of Diabetic patients, with whom successfully employed.

To judge of it a priori, several circumstances which might seem to occur as objections to its employment.

Has always, from its action on urinary passage, been esteemed in some respects hazardous.

And in doubt that in many instances product of very considerable inconvenience.

But besides this hitherto chiefly employed as means of increasing not of diminishing discharge of urine.

For my own part, disposed to think that affects in general particularly strangury affections which produced, principally the consequence of action on neck of bladder.

But that also does act on kidney, cannot I think be matter of doubt.

And even by affect of stimulation, from which on some occasions increased discharge, may in others, where morbidity increased have affect of diminishing.

Particularly where that morbid increase arises from an atonic or paralytic state.

But theoretical observations, either for or against use, not to be put in competition with well attested facts.

And from observations of Dr Brisbane, may consider it, as at least well entitled, to future trials.

Cannot however say, that in my practice use has been attended with equal success.

Have tried it, with several diabetic patients & with some have pushed it to very great extent, without deriving from it any benefit.

These, however, by no means sufficiently numerous, to give grounds for concluding that will never succeed.

Hence with view to farther trial, have had recourse to it with present patient.

Have begun however, you will observe, by directing use in small quantity only.

A circumstance which with a medicine, the influence of which on human system very various, reckon in every case necessary.

For with some, as appears from the affects of blisters, even very small quantity sufficient to produce very violent strange affections.

If however from trial now made, find that borne without inconvenience shall not only persist in use, but gradually direct an increase of quantity.

For to extent to which now employed cannot expect from it much influence, as tending to counteract the affection.

But by increasing dose, & persisting in use, mean to give full & fair trial.

And if successful, shall at least have done more, by means if it, than have ever yet been able to do in any other instance of Diabetes.

Shall not however be much disappointed if after fullest trial find it product of no benefit.

In that case, is my intention to try another practice, of which have of late heard, very favourable account.

The use viz of Doves powder continued for some length of time.

Had lately a case communicated to me by Dr McCormick of Antrim, & which will soon be published, in Medical Commentaries in which was employed with success.

And am informed by same Gentleman that has since treated another, with similar good affects.

Operation, as far as production of such good affects probably to be explained not from discharge under form of sweat, but from determination which gives to surface.

And in this manner opportunity at least may be afforded, for vessels of Kidney to recover tone.

If this also unsuccessful, or if gives merely alleviation of affection shall probably endeavour still farther to strengthen vessels by use of tonics & astringents.

Particularly by Peruvian Bark & Alum which, at least, among most powerful.

If these also fail of success, still another practice which have an intention of trying use viz of Electricity.

Particularly by drawing electrical sparks from region of kidney.

To this suggestion led, from idea, that excessive discharge may arise from atonia approaching even to Paralysis.

If indeed, other practices fail, must own, that from this can have but little hopes of cure.

At same time, is a trial which may be made without any hazard

And in an affection such obstinacy, trials of new remedies not only allowed but even [preferable].

In this way indeed, other suggestions might be thrown out.

But what already hinted at, perhaps more than shall have opportunity of putting in practice.

And not improbable that plans may be interrupted from being obliged to have recourse to practices, for obviating particular symptoms.

These however must very much depend on symptoms, which occur.

Shall only observe, that if necessary to obviate costiveness, will with this view, have recourse to Oleum Ricini or to olive oil with mixture of Tincture of Jalap.

To this led from hopes that oleaginous matter may also tend to allay [this]

At least in one case, observed in this way, a very remarkable affect from fat meat.

A circumstance which has led me to consider oleaginous purgatives as being here [superior] to others

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Explanatory notes:

1) Mathew Dobson, 'Experiments and observations on the urine in diabetes', Medical Observations and Inquiries (1776) 5: pp.298-316.

2) A term used in the 1700s in Leiden, Padua and elsewhere to describe clinical teaching, using demonstrations of outpatients.

3) John Brisbane, Select cases in the practice of medicine (1772).