effect upon the test, nor does the coloring matter of normal urine,
according to Johnson; but he says there is a coloring matter associated
with ser-albumen in albuminous urine, and with egg-albumen as well,
which has a reducing action on picric acid. This is partly separated by
filtering off the precipitated albumen, and entirely removed by
repeated filtration through animal charcoal. So, too, the albumen
removed by coagulation and filtration, if thoroughly washed, does not
give any red reaction if boiled with picric acid and potash diluted in
the same proportion as when testing for sugar. Neither do any other
unoxidized sulphur compounds found in urine decompose the picric acid
and render the test fallacious.
Johnson and his son, G. Stillingfleet Johnson, claim that the
picric-acid test is as accurate as any other, and that it is even more
accurate than either Fehling's or Pavy's process, because the picric
acid is not acted upon by uric acid or urates, which do reduce the
oxide of copper. The method of analysis by the picro-saccharimeter,
they claim, is at least as speedy and as easy as any other. The
materials and apparatus required are easily prepared, inexpensive, and
not, like Fehling's copper solution, liable to undergo rapid changes.
But while Johnson claims that neither coloring matters of normal urine
nor uric acid reduce the picric acid, he admits that he has tested with
picric acid and potash a large number of specimens of normal urine with
the almost uniform result of a depth of color indicating the proportion
of .6 of a grain of sugar to the fluidounce, the indication varying
between the limits of .5 to .7 grain. The ammonio-cupric method used at
the same time gave results of from .7 to .9 grain to the fluidounce, or
an excess of .1 to .3 grain. Now, if my own views, the grounds for
which are announced elsewhere,[43] are correct, strictly normal urine
contains no sugar, and any reducing action upon oxide of copper is due
to uric acid, either picric acid is reduced to a degree by uric acid or
by some other constituent of normal urine. This, in the light of
Oliver's[44] recent investigations, may be kreatinin. For he has shown
that kreatinin strikes in a few seconds a red color with the cold
alkaline picric solution, which is quickened by heat. From this it
would seem that the exact value of the picric-acid test has as yet to
be determined.
[Footnote 43: Tyson, _Practical Examination of Urine_, 4th ed.,
Philadelphia, 1884.]
[Footnote 44: _On Bedside Urine-Testing, including Qualitative Albumen
and Sugar_, by Geo. Oliver, M.D., London, Member of the Royal College
of Physicians of Lond., etc., 2d ed., London, 1884.]
{216} The Indigo-Carmine Test.--The fact that indigotine, the coloring
matter of commercial indigo, is converted into indigo when heated with
an alkali in the presence of glucose and certain carbohydrates, has
recently been applied by George Oliver of London in the construction of
a test-paper. Carmine of indigo is the sulph-indigotate of sodium, an
intensely blue salt, soluble in 120 parts of water. Sulph-indigotic
acid is made by heating indigo with sulphuric acid, and when combined
with a base, sodium, produces indigo-carmine. When sodium carbonate is
mixed with a solution of indigo-carmine, the latter is precipitated in
a minute state of division, but is redissolved on heating, when there
results a greenish-blue solution. A freshly-made mixture of the indigo
solution and sodium carbonate furnishes a fluid not unlike Fehling's
solution, which gives the reaction to be described with glucose.
Unfortunately, such a mixture will not keep, and the reagent would be
useless but for the happy idea of Oliver of making the test-paper. In
doing this bibulous paper is immersed in a solution of indigo-carmine
with carbonate of sodium.[45] The paper is then cut into strips an inch
long and one-quarter of an inch wide.
[Footnote 45: No more precise directions than this are given by Oliver,
either in his papers in the _Lancet_ for 1883 or in his little book
just published, _On Bedside Urine-Testing_. The sugar test-papers, as
well as the entire series of albumen test-papers, suggested by Oliver,
are now made by Parke, Davis & Co. of New York, and by Wilson & Son,
Harrogate, London.]
Mode of Testing.--One of the test-papers and a sodium carbonate
paper[46] are dropped into a half-inch test-tube, and water added until
the upper end is just covered; a column of fluid one inch in height and
half an inch in diameter will thus be produced, so that the solution of
carmine obtained on boiling will always acquire the same concentration.
Heat is now applied, the tube being gently shaken, and boiling kept up
for a second or two. A beautiful blue solution will result. The
test-paper may now be removed or allowed to remain.
[Footnote 46: Test-papers of the same size, charged with a saturated
solution of sodium carbonate.]
Not more than one drop of the suspected urine is let fall into the tube
from a pipette held in an upright position. Drops of equal size are
thus secured. The contents of the tube are again freely boiled for a
few seconds, after which the tube should be raised an inch or more from
the flame and held without shaking, while the solution is kept quite
hot, but not boiling, for exactly one minute. If glucose be present in
abnormal amount, the soft rich blue will be seen first of all to darken
into violet; then, according to the quantity of sugar, there will
appear in succession, purple, red, reddish-yellow, and finally
straw-yellow. When the last-named color has been developed the
slightest shaking of the tube will cause red streaks to fall from the
surface and mingle with the pale yellowness of the solution, while
further agitation will cause the return of purple and violet and the
restoration of the original blue.
The time required for the commencement of the reaction after the
boiling of the test liquid is in inverse proportion to the amount of
glucose present. When the latter is large, over 20 grains to the ounce,
it will be but a few seconds; but when small, 2 or 3 grains, from
thirty to sixty seconds may elapse. If the urine do not contain more
than the normal amount of sugar[47]--_i.e._ under half a grain to the
ounce--the color of the solution {217} at the end of the heating for
one minute will be unchanged. The test is available by artificial light
as well as by daylight.
[Footnote 47: It will be noted from this that Oliver accepts the view
that there is a small amount of sugar in normal urine.]
Precautions.--1. Care should be taken during the testing not to shake
the tube or to permit free ebullition. 2. While keeping the contents of
the tube hot, the latter should not be held up between the eye and the
sky, for then the early color-changes will probably escape observation.
The tube should be kept below the eye-level and its contents viewed by
the reflected light of some bright object, such as a sheet of white
paper propped up an inch or two beyond the tube as a background. 3.
Oliver is not aware that the presence of earthy carbonates will prevent
the carmine reaction, but as a precautionary measure he suggests the
use of a soda-paper whenever the water is exceptionally hard. 4. The
acids of the urine rob the carmine-paper of much alkali, so that the
addition of more than a certain number of drops of urine--varying of
course with the degree of acidity--will at first retard and then
prevent the reaction. The addition of the soda-paper will prevent any
such interference, although Oliver says that by invariably submitting
only one drop of saccharine urine to the test-paper, and keeping up the
heating for not less than two minutes, he has never failed to obtain
the characteristic reaction without using a soda-paper. It is well to
remember, however, that an excessively acid urine may thus interfere,
and that the soda-paper will prevent it. 5. The blue color of the
carmine is discharged by caustic alkali--liquor potassæ or sodæ. The
only chance of being misled by this reaction lies in using an
imperfectly cleansed test-tube which may have contained Fehling's
solution or the alkaline picric solution. The caustic alkali converts
the blue carmine into a green solution, which, on heating, disappears;
nor does it return by again shaking the contents of the tube.
Critical comparison of this test with Fehling's solution and picric
acid by Oliver has shown that of sixty-four substances experimented
upon, normal and abnormal constituents of urine or medicines which
after ingestion are eliminated in the urine, Fehling's was reduced by
fifteen, picric acid by eleven, and indigo-carmine by eight. The only
substances producing the characteristic play of colors with
indigo-carmine test-papers reacted with both picric acid and Fehling's
solution. They were unoxidized phosphorus, ammonium sulphide,
milk-sugar, dextrin, inosit, gallic acid, tannic acid, and iron
sulphate. Both the carmine and picric acid were reduced by inosit,
which merely turned Fehling's solution green. On the other hand, uric
acid and urates, which reduce Fehling's solution, do not react with the
carmine test, while kreatinin, which reacts with picric acid also, does
not respond to the carmine. Albumen, if abundant, interferes with
Fehling, but not with the indigo-carmine.
Detection of Inosit.--It has been said that inosit sometimes
accompanies, and even substitutes, grape-sugar in the course of
diabetes. It has been mentioned that it does not reduce Fehling's
solution, but turns it olive-green. It reduces the carmine and alkaline
picric acid solution, and is therefore not recognizable by these. The
methods recommended for its recognition in the books are troublesome,
and as its presence in the absence of sugar indicates a favorable
change, it is not likely that a more precise recognition than is
furnished by the olive-green reaction will be needed for clinical
purposes.
PROGNOSIS.--The prognosis in diabetes depends upon the organ whose
{218} involvement is responsible for the symptoms, upon the stage at
which the condition comes under observation, and upon the age of the
patient. It has appeared to me that the cases of diabetes depending
upon pancreatic disease are the most intractable, that their progress
is scarcely checked by treatment, and that they are comparatively
rapidly fatal in their termination. In the others, where the symptom is
one of a central nervous lesion, it has always seemed to me to be of
secondary importance that the glycosuria is itself less marked, that it
is unattended by the other distinctive symptoms of diabetes, and that
its issue is that of the nervous malady.
Again, it is well known that the later in life diabetes occurs the more
amenable it is to treatment, and that if a proper diabetic diet be
adhered to by the patient his life need scarcely be shortened. On the
other hand, diabetes mellitus is a disease in which the expectant plan
is dangerous. If it does not improve it usually gets worse; and many a
patient has fallen a victim to his own indifference and indisposition
to adhere to a regimen under which he could have lived his natural term
of life. This is especially the case when the disease appears after
middle life.
If, on the other hand, the condition becomes thoroughly established
before twenty-five years of age, it is less amenable to treatment; but
even in such cases a promptly vigorous treatment is sometimes followed
by recovery. I have already mentioned the case of a child twelve years
old in which complete recovery took place.
If tubercular phthisis supervenes, recovery is not to be expected,
while intercurrent disease, as pneumonia, which is rather prone to
occur, is very much more serious and apt to terminate fatally.
TREATMENT.--The treatment of the aggregate of symptoms known as
diabetes mellitus is conveniently divided into the dietetic, the
medicinal, and the hygienic, of which the first is by far the most
important. The efficiency of this treatment depends upon the successful
elimination from the diet of all articles containing grape-sugar,
cane-sugar, beetroot-sugar, and starch, it being universally recognized
that in the early stages of the disease these foods are the sole source
of the glucose in the urine. The normal assimilative action of the
liver, by which the carbohydrates are first stored up as glycogen, and
then gradually given out as glucose or maltose to be oxidized, being
deranged, such foods not only become useless as aliments, but if
continued seem to aggravate the glycosuria, and the excretion of sugar
steadily increases. There is, therefore, a double reason for excluding
them from the food. This is easiest accomplished by an exclusive milk
diet. The exclusive milk treatment of diabetes was suggested by A.
Scott Donkin in 1868. That he is correct in his assertion that in the
early stages of diabetes lactin or sugar of milk is quite assimilable,
and does not in the slightest degree contribute to the production of
glycosuria, I cannot doubt; that it is in this respect even superior to
casein, as claimed by Donkin, I am not prepared to state from actual
knowledge; but that casein itself resists the sugar-forming progress
immeasurably greater than any other albuminous substance, so that in
all but the most sure and advanced or complicated cases its arrest is
complete, I am also satisfied. Certain it is that in a large number of
diabetics the use of a pure skim-milk regimen results in a total
disappearance of the sugar from the urine. That in a certain proportion
of these cases a {219} gradual substitution of the articles of a mixed
diet may be resumed without a return of the symptoms is also true. In
other more confirmed cases the use of skim-milk results in a decided
reduction in the amount of sugar, with an abatement of other symptoms,
which continues as long as the diet is rigidly observed. In still other
cases, while the skim-milk treatment makes a decided impression upon
the quantity of sugar, it still remains present in considerable amount,
while the disease progresses gradually to an unfavorable issue. These
three classes of cases represent, ordinarily, different stages of the
disease, so that it may be said that as a rule cases recognized
sufficiently early may be successfully treated with skim-milk, although
it may occasionally happen that cases pursue a downward course from the
very beginning despite all treatment. Yet I have never seen a case
which, when taken in hand when a few grains of sugar only to the ounce
were present, failed to yield to this treatment.
As to the method of administration, my practice with adults is to give
eight ounces (an ordinary tumblerful) every two hours, beginning at
seven or eight o'clock in the morning, and continuing to the same hour
in the evening. Sometimes it is well to begin with half as much at
first, but rapidly to increase to the required amount. This method
ensures the ingestion of three to four quarts daily--a quantity
generally sufficient to maintain the body-weight of an adult person of
average size and taking moderate exercise, although a slight reduction
may take place at first. But if the individual is very active or of
large size, it will not be found sufficient. In such event the quantity
must be increased as demanded by a feeling of unsatisfied hunger. I
have known fourteen pints to be taken in twenty-four hours. But when
the quantity becomes thus large, the inconvenience in ingesting it is
very great, and it is much more convenient to coagulate the casein of a
part of the milk and use the curd thus obtained, while the second part
is drunk. Curd may be seasoned with salt to make it more palatable, and
should be thoroughly masticated before it is swallowed.
The milk should not be taken too cold, especially if the amount
ingested is large, else it is likely to reduce the temperature of the
stomach below the point necessary for gastric digestion. The
temperature should not be less than 60° F., nor much over 100°.
Something depends upon the idiosyncrasies of the patient, which must be
the guide as to temperatures intermediate between those named.
The chief advantage of the skim-milk over the unskimmed is simply that
it is more easy of digestion. Many persons who cannot take unskimmed
milk for any length of time without its deranging the digestion, or, as
is commonly said, making them bilious, can take with impunity milk from
which the cream is removed. Although Salomon[48] claims to have shown
that glycogen is produced in the liver of rabbits fed upon pure olive
oil, it is at least probable that fat is among the last of the
substances undergoing this conversion, and in ordinary cases of
diabetes it is rather its indigestible nature which renders it prudent
to remove from milk the greater proportion of fat by skimming it off.
[Footnote 48: _Virchow's Archiv_, Bd. 61, Heft 3, 1874, 18.]
Still more easily assimilable is the peptonized milk, in which the
casein is at least partially digested, and it should be employed where
there is any {220} difficulty in the way of using the ordinary milks.
Either skimmed or unskimmed milk may be used for peptonizing, the
latter peptonized being quite as easy of digestion as the former
unpeptonized. I have found the extractum pancreatis of Fairchild
Brothers & Foster most successful in the peptonizing of milk, and
according to the following directions: Into a clean quart bottle put 5
grains of extractum pancreatis, 15 of bicarbonate of sodium, and a gill
of cool water; shake, and add a pint of fresh cool milk. Place the
bottle in a pitcher of hot water or set the bottle aside in a warm
place, usually for three-quarters of an hour. When the milk has
acquired a slightly bitter taste, it has been completely
peptonized--that is, the casein has been completely converted into
peptone. After the process is complete the milk must be immediately put
on ice.
It is not always necessary to completely peptonize the milk, and if the
bitter taste is unpleasant the process may be stopped short of this by
putting the milk on ice, the degree of digestion depending upon the
length of time the milk is kept warm.
While I am confident that the promptest and most effectual method of
eliminating sugar from the urine is by a milk diet, it occasionally
happens that a patient cannot or will not submit to so strict a
regimen. In other instances, again, it is not necessary to resort to
it, because a less restricted diet answers every purpose.
A suitable diabetic diet would also be obtained by eliminating from the
bill of fare all saccharine and amylaceous and other sugar-producing
substances. Such a diet is, strictly speaking, impossible. For, apart
from the fact just mentioned that even fats, as well as albuminous
substances to a degree, are capable of producing glycogen, the monotony
of a pure meat diet soon becomes unbearable, to say nothing of other
derangements it may produce. Fortunately, it is not necessary that such
an exclusive diet should be maintained, for certain saccharine foods
seem capable of resisting the conversion into sugar more than others.
Sugar of milk, or lactin, has already been mentioned as one of these,
and to it may be added the sugar of some fruits, and probably also
inosit or muscle-sugar, mannite or sugar of manna, and inulin, a
starchy principle abundant in Iceland moss. It is found also that there
are many vegetable substances containing small quantities of sugar and
sugar-producing principles which may be used with impunity in at least
the milder forms of diabetes. This being the case, a bill of fare for
diabetics may be constructed quite liberal enough to satisfy the palate
of most reasonable persons by whom it is attainable.
FOOD AND DRINK ADMISSIBLE.--Shell-fish.--Oysters and clams, raw and
cooked in any way, without the addition of flour.
Fish of all kinds, fresh or salted, including lobsters, crabs,
sardines, and other fish in oil.
Meats of every variety except livers, including beef, mutton, chipped
dried beef, tripe, ham, tongue, bacon, and sausages; also poultry and
game of all kinds, with which, however, sweetened jellies and sauces
should not be used.
Soup.--All made without flour, rice, vermicelli, or other starchy
substances, or without the vegetables named below as inadmissible.
Animal soups not thickened with flour, beef-tea, and broths.
Vegetables.--Cabbage, cauliflower, brussels-sprouts, broccoli, green
{221} string-beans, the green ends of asparagus, spinach, dandelion,
mushrooms, lettuce, endive, coldslaw, olives, cucumbers fresh or
pickled, radishes, young onions, water-cresses, mustard and cress,
turnip-tops, celery-tops, or any other green vegetables.
Fruits.--Cranberries, plums, cherries, gooseberries, red currants,
strawberries, apples, without sugar. Or they may be stewed with the
addition of bicarbonate of sodium instead of sugar. (See below.)
Bread and cakes made of gluten, bran, or almond flour, or inulin, with
or without eggs and butter. Griddle-cakes, pancakes, biscuit,
porridges, etc. made of these flours. Where especial stringency is
required these should be altogether omitted.
Eggs in any quantity and prepared in all possible ways, without sugar
or ordinary flours.
Nuts.--All except chestnuts, including almonds, walnuts, Brazil-nuts,
hazel-nuts, filberts, pecan-nuts, butternuts, cocoanuts.
Condiments.--Salt, vinegar, and pepper in moderate quantities.
Jellies.--None except those unsweetened. They may be made of
calf's-foot or gelatin and flavored with wine.
Drinks.--Coffee, tea, and cocoa-nibs, with milk or cream, but without
sugar; also milk, cream, soda- (carbonated) water, and all mineral
waters freely; acid wines, including claret, Rhine, and still Moselle
wines, very dry sherry; unsweetened brandy, whiskey, and gin. No malt
liquors, except those ales and beers which have been long bottled, and
in which the sugar has all been converted into carbonic acid and
alcohol.
Vegetables to be especially Avoided.--Potatoes, white and sweet, rice,
beets, carrots, turnips, parsnips, peas, and beans; all vegetables
containing starch or sugar in any quantity.
The following list, including essentially the same articles, but
arranged in the shape of a true bill of fare, by Austin Flint, Jr.,[49]
will be found very convenient:
BILL OF FARE FOR DIABETES.--Breakfast.--Oysters stewed, without flour;
clams stewed, without flour. Beefsteak, beefsteak with fried onions,
broiled chicken, mutton or lamb chops; kidneys, broiled, stewed, or
devilled; tripe, pigs' feet, game, ham, bacon, devilled turkey or
chicken, sausage, corned-beef hash without potato, minced beef, turkey,
chicken, or game with poached eggs. All kinds of fish, fish-roe,
fish-balls, without potato. Eggs cooked in any way except with flour or
sugar, scrambled eggs with chipped smoked beef, picked salt codfish
with eggs, omelets plain or with ham, with smoked beef, kidneys,
asparagus-points, fine herbs, parsley, truffles, or mushrooms.
Radishes, cucumbers, water-cresses, butter, pot-cheese. Tea or coffee,
with a little cream and no sugar. (Glycerin may be used instead of
sugar if desired.) Light red wine for those who are in the habit of
taking wine at breakfast.
Lunch or Tea.--Oysters or clams cooked in any way except with flour;
chicken, lobster, or any kind of salad except potato; fish of all
kinds; chops, steaks, ham, tongue, eggs, crabs, or any kind of meat;
head-cheese. Red wine, dry sherry, or Bass's ale.
{222} Dinner.--Raw oysters, raw clams.
Soups.--Consommé of beef, of veal, of chicken, or of turtle; consommé
with asparagus-points; consommé with okra, ox-tail, turtle, terrapin,
oyster, or clam, without flour; chowder, without potatoes, mock turtle,
mullagatawny, tomato, gumbo filet.
Fish, etc.--All kinds of fish, lobsters, oysters, clams, terrapin,
shrimps, crawfish, hard-shell crabs, soft-shell crabs, (No sauces
containing flour.)
Relishes.--Pickles, radishes, celery, sardines, anchovies, olives.
Meats.--All kinds of meat cooked in any way except with flour; all
kinds of poultry without dressings containing bread or flour; calf's
head, kidneys, sweetbreads, lamb-fries, ham, tongue; all kinds of game;
veal, fowl, sweetbreads, etc., with curry, but not thickened with
flour. (No liver.)