who had never before manifested any symptom of diabetes, wrote to me saying that she had begun to suffer in the same sort of way as her son had done, and that she had thus been led to fancy that she was affected with the same complaint. Although thinking it not unlikely that her supposition would turn out to be the result of a groundless alarm, I desired her to come up to town in order that I might ascertain the truth; and upon investigation I found that diabetes in reality existed.

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SYMPTOMATOLOGY.

AMONGST the symptoms of diabetes that which, on the score of importance, claims attention first is an excessive flow of urine. It is by this symptom that the patient's attention is generally first aroused to the existence of something wrong. He finds that he is not only called upon to be frequently micturating during the day, passing a considerable quantity at each time, but that he is obliged to rise, it may be, several times during the night for the purpose of emptying the bladder. The actual quantity passed varies much in different cases, and according to the nature and success of the treatment adopted. It is not uncommon where the disease exists in a severe form and the patient is allowed to eat and drink what he chooses, for from ten or twelve to fifteen or twenty pints to be passed in the twenty-four hours. Instances have been recorded, however, where much larger quantities than this have been voided, and one has fallen under my observation where double the amount named was passed. The patient first came under my notice in the out-patient department at Guy's Hospital, and according to his account, he had ascertained by measurement that he was passing twenty quarts of urine a day. To ascertain if such a prodigious quantity really was being passed, I

took him into the hospital and gave instructions that he should be supplied as nearly as possible with what he had been eating and drinking outside. His urine was collected and measured, and although the quantity did not quite come up to what he stated he had before been passing, yet it amounted upon one occasion to as much as sixteen quarts or thirty-two pints for the twenty-four hours, and upon other days also, before he was subjected to treatment, did not fall very far short of this.

In an uncomplicated case of diabetes, the quantity of urine may be taken as affording a very good rough index of the state of severity of the disease; and a diminution of it forms the first sign of improvement perceived by the patient under recourse to the appropriate measures of treatment. It is found that the

patient has not to rise so many times in the night, and also that there is a less frequent call to pass urine during the day. In many cases the disease can, in the course of a short time, be controlled in such a way that the urine falls in quantity to about what is natural. Patients who may have been previously passing many pints in the twenty-four hours, may find the quantity sink to two or three pints and even less. I have at the present time a patient in the hospital who, upon admission, was voiding five pints in the twenty-four hours and now rarely passes above two-sometimes, indeed, only a pint and a half, and it has been upon two or three occasions as low as a pint and a quarter. Astonishment is not unfrequently excited at the rapid fall that is sometimes produced by treatment.

It must be acknowledged that it sometimes happens that the quantity cannot be reduced below five and six

pints a day, and when such is the case it generally augurs badly for the future.

I have said that the quantity of urine may be taken as affording an index of the state of severity of the disease. It is found to fluctuate indeed, as a rule, very closely with the quantity of sugar escaping. The sugar in escaping may be said to entail an escape of liquid to carry it off, and thus the larger the quantity of sugar reaching the circulation for elimination the larger, cæteris paribus, will be the amount of fluid likewise carried off. I do not mean to assert that there is invariably a strict correspondence between quantity of sugar and quantity of urine discharged, for the latter is open to the influence of other circumstances besides the passage of sugar, but that the two, generally speaking, present a very close conformity is strikingly exemplified by the report of North's case to be found at the end of the volume-a case in which much fluctuation was induced by the different articles of diet that were administered. Upon giving attention to the report, it may be observed that with each rise and fall in the amount of sugar there was, excepting on but a few occasions, a corresponding variation in the amount of urine. If a line were introduced into the plan framed from the daily record of the case and introduced opposite page 238 to represent the daily amount of urine in drachms, it would be found to pursue a course throughout the greatest portion of its extent harmonising with the one which represents the daily amount of sugar. There is only one point, indeed, at which the lines would be found to cross each other, and this is under February 15th, upon which day the diet consisted of jelly, meat, and beef-tea. There was upon that day a

considerable descent in the amount of sugar without, from some cause or other, a corresponding fall in the amount of urine.

Whilst speaking of an excessive flow of urine as a symptom of diabetes, the altered characters which the secretion presents may also be referred to.

The presence of sugar gives to the urine an increased density. Now, the quantity of sugar passed varies much in different cases and at different periods in a particular case, according to the circumstances existing. I have met with as much as forty-eight grains of sugar to the fluid ounce, but beyond about this, the quantity is never exceeded, the amount of urine being increased instead of a higher saturation occurring.

Where the degree of saturation with sugar is high, the density cannot fail to be at a high point also, but the converse does not happen invariably to hold good; a high density, in other words, may exist without being necessarily dependent upon the presence of a correspondingly large amount of sugar. This is owing to the weight of diabetic urine being influenced by the natural solids of the secretion as well as sugar. It may happen, from the circumstances of the case, that the urine is highly saturated with these, and thus a high sp. gr. will at once be given. This is not to be unlooked for under treatment by restriction to an animal diet. From the less quantity of sugar thereby discharged, the urine is diminished in quantity, and the large amount of animal food consumed gives rise to an extensive elimination of the ordinary solid urinary products. In this manner the sp. gr. may be maintained at a high point without there being any sugar passed. I have before me the notes of a case in which a medical