in some degree to its severity, set in. Frequently the sensorium becomes affected at an advanced stage; hence headach, vertigo, and even temporary delirium, occasionally attend. When a fatal termination takes place, the patient often dies comatose, and sometimes apoplectic.

"The skin is usually dry and harsh to the touch, and this whether there be fever or not. Generally, however, at an advanced period, there is a considerable degree of fever. As the disease advances, the patient is attacked with remittent fever, occasionally accompanied with profuse perspiration at night. This fever has been regarded as partaking of the character of hectic; and should any cough, with or without expectoration, be present, (by no means an unfrequent occurrence,) the patient may be considered as labouring under phthisis, instances of which I have occasionally seen.

"When diabetes has continued for a long period, it frequently terminates in anasarca or general dropsy. Hence the ancles become edematous, and the patient, from having been reduced to nearly a skeleton by emaciation, becomes bloated from the accumulation of dropsical fluid in the cellular membrane.

"In children, about this period, the abdomen becomes sensibly enlarged. This enlargement, by a careless observer, may be mistaken for ascites, or some mesenteric affection. Ascites frequently supervenes in adults, but more rarely in children. Disease of the mesentery is to be regarded as an adventitious rather than an essential occurrence." 16.

In diabetes the digestive function is, of all others, the most liable to disorder. Dr. Venables thinks it the consequence rather than the cause of the diabetes.

Morbid Anatomy.

This our author confines to the kidneys and urinary organs. He avers that “diabetes never exists to any extent, without the kidneys presenting on dissection manifest changes."

"These changes vary from a trifling vascularity to severe organic derange. ment. Sometimes the kidneys are much inflamed, and present a florid vascular appearance, in other cases the venous system of these organs seems enlarged and turgid with blood. In a case which I examined about five years ago, the kidneys were enlarged in size, dark-coloured, and seemed turgid with blood. On catting into the substance, there was an instantaneous effusion of fluid darkcoloured blood, as happens when a congested liver is cut into. Sometimes the veins, on their external surface, form a complete net-work of vessels. In some cases the kidneys are found in a loose, flabby state, being at the same time much increased beyond their ordinary size. They are often of a pale or ash-colour. "In some instances the substance of the kidneys is much inflamed, and then they present an appearance of a high degree of arterial vascularity. Their substance feels dense, and their structure firm. Frequently, under such circumstances, a whitish fluid resembling pus is found secreted in some quantity in the infundibula.

"The kidneys do not often contain abscesses, but I have seen two cases in which they were ulcerated. In these cases, the pus occasionally passed with the urine, and was mistaken for flakes of coagulable lymph, which it very much resembled. The ureters are often enlarged in diameter; and a respected medical friend informed me, that he once saw a case in which the internal surface of one ureter was ulcerated. It is natural enough to expect that these vessels should be enlarged in such a disease; but I have not met with a case of ulceration. This, however, may have been owing to my not having been prepared to expect, and, consequently, not having uniformly looked for such an effect. The renal or emulgent arteries are very often found larger in diameter than natural. Generally speaking, both kidneys are diseased, but sometimes only one, or at least only one to any great extent.

"The bladder is sometimes found rather vascular, and turgid on its mucous surface; sometimes the mucous surface is inflamed. The substance of this organ, is, in some cases thickened, and very firm in its texture. I saw

case, which

was examined by an eminent surgeon* in Dublin, about fifteen or sixteen years ago, in which the mucous coat of the bladder was tuberculated, and elevated into large, thickened, hard, and irregular plicæ. In several spots it was exulcerated, and, in this case, I learned that there was frequently a considerable discharge of sanio-purulent urine.

"There are diseased appearances occasionally observed in the other viscera, as the brain, lungs, heart, liver, spleen, pancreas, and the other digestive organs; but, as a great variety of these occur, and as diabetes frequently prevails without as well as with them, and sometimes with one description, and sometimes with another, they are to be regarded rather as accidental occurrences, than as absolutely and essentially a part of the morbid anatomy of the disease; and therefore their consideration can have no place here." 20.

Remote Causes.

Among these our author ranks all those agents which inordinately stimulate the kidneys, as spirituous liquors, excesses in acids, alkalies, strong diuretics, mercurial courses, eruptive diseases, particular articles of diet, as asparagus, foreign acescent wines, intemperance of every kind, inordinate bodily exertions, blows upon the loins and region of the kidneys, strong mental emotions, hereditary disposition depending on peculiar structure of the kidneys, derangement of the digestive organs, though not so frequently as Dr. Rollo would wish us to believe.

Immediale Causes. Dissection, according to our author, has shewn that this disease is invariably attended with some manifest change in the structure of the kidneys, and hence he thinks that a mere functional disorder is hardly adequate to the production of the permanent affection. Of the precise nature of these organic changes we are at present ignorant.

Pathology. By this term our author means "those morbid operations by which morbid effects are produced"-in other words, the mode in which the remote or exciting causes act in producing diseases. Dr. Venables makes several weighty objections to Dr. Rollo's doctrine of diabetes.

"Were Dr. Rollo's views not otherwise objectionable, the fact that the urine, in many instances, is not saccharine, until after some continuance of the disease, would be alone sufficient to invalidate them. If the saccharine properties of the urine were owing to the separation of this substance by the kidneys, from its commixture with the blood through the faulty action of the stomach, it naturally follows that the urine, from the first augmentation of its quantity, should contain saccharine matter. Here, then, are two strong objections to Dr. Rollo's theory; first, the blood does not in every instance contain sugar; secondly, the urine is not saccharine until the disease has lasted for some considerable time." 32.

After some experiments which our author made on the state of the urine upon the ingurgitation of certain fluids, he comes to the conclusion "that diabetes more frequently arises from a peculiar excitement of the kidneys originating in the direct application of stimuli to their substance."

* Mr. Peter Harkan.

"At first the excitement is only occasional, and the effect subsides; but the repeated irritation of organs, we well know, brings on inflammatory action, and at last disorganisation. It has been observed, in discussing the morbid anatomy of the kidneys in diabetes, that they generally exhibit morbid vascular appearances, and frequently considerable disorganisation of their structure. The first effect of the irritation is merely an increase of their natural functions, and more urine is separated, than under their natural action would be effected. The quali ties of the urine, too, are not affected, or at least not sensibly so, at first, nor until after the repeated application of the stimuli. But, by repeated excitement, not only are their functions increased and sensibly perverted, as is indicated by the coagulation of the urine, and its saccharine properties, but also their structure and organization become seriously affected." 38.

We shall pass over a great deal of this chapter, and also that on diagnosis, since few people can mistake the disease, if they make a proper investigation of the symptoms. We have seen these, however, overlooked by men of great capacity, til! a patient was at the verge of the grave, and that from mere inattention. Emaciation, thirst, voracious appetite, dry harsh skin, with a frequent and copious discharge of urine, especially if it be saccharine, are sufficiently characteristic of this terrible malady.

The Prognosis in diabetes has been generally unfavourable. Dr. Venables is not quite so desponding, especially where the disease is early detected.

"We may generally infer, (cæteris paribus,) the earlier medical treatment has been instituted, the greater the probability of a perfect recovery. When, from the duration of the disease, we have reason to suspect serious organic changes in the structure and mechanism of the kidneys, we must then be more guarded in our prognosis, and not excite hopes or expectations which probably will never be realised." 48.

Our author has seen recoveries effected "under the most unpromising circumstances," but these are no more than exceptions to the general rule. Our prognosis, in fact, must be founded on the state of the constitution as a whole. Where it is bad there is little hope-where no other particular organ or function is threatened than the kidneys and their secretion, some chance is left.

TREATMENT.

The first object, in our author's therapoia, is to restrain the inordinate action of the kidneys, and therefore it will be necessary to search for the real exciting causes, and remove them, if possible. No treatment can be

successful while the causes that produced them continue to act. If an infant, the nurse's milk should be examined, and if found to be acescent, the nurse should be changed. If an adult, a strict inquiry should be made into the diet, habits of life, &c. The mere removal of causes or correction of bad habits, however, will not cure the disease, if established. There is one fact, which we have learnt from experience, namely, that excessive discharges from the system are moderated by bleeding, independent of any inflammatory condition obtaining at the time; and in this way, Dr. V. observes. venesection may have often proved a powerful means of restraining the urinary flux, in cases where there was no indication of inflammatory action in the kidneys. But as dissection has often shewn a turgid vascu

larity of those organs, the utility of venesection becomes still more evident. Dr. Venables' experience coincides with that of Dr. Watt of Glasgow, and some other writers, on this point of practice in diabetes; and he almost invariably adopts venesection, either as a preparatory or curative measure.

"We should not be deterred from repeating the bleedings, merely because the blood does not exhibit the buffy coat, the usually received characteristic of inflamed blood. I have in another place suggested the probability of the characters of the serum being capable of indicating an inflammatory state of the system. I have generally found that a dense milky appearance of this part of the blood indicates inflammatory action, and this independently of the appearances presented by the coagulable part. I have found the pulse rise under such circumstances after venesection, and a repetition of the operation required; although the crassamentum should not exhibit the buffy coat, but even seem infirm and dissolved." 59.

The extent to which the measure should be carried can only be judged of by the practitioner in attendance. Repeated small bleedings, however, are preferred by our author to fewer large ones. General bleeding is the best; but if in infants, leeches to the region of the kidneys may be a good substitute. Blisters to the neighbourhood of the plethoric organ are advised by Dr. V. but caution is necessary lest they stimulate the kidneys. They should be kept open by the ceret. sabine rather than the lytta. If there is reason to suppose that considerable organic disease obtains in the kidneys or spinal marrow (a part suspected by our author) then caustic issues should be employed.

Our author makes many judicious observations on the various internal medicines which have been recommended in diabetes. He thinks they have acted more by increasing other secretions than by restraining directly the urinary discharge. After speaking of various tonics and restringents, our author proceeds thus:

"These facts led me to the conclusion, that some of the metallic phosphates might be advantageously substituted for those with an alkaline base. The tonic and astringent properties of iron and zinc pointed them out as the best suited to the object in view. I selected iron for my first trial, and I have felt so satisfied with its powers, that I have not attempted any farther investigation. I have been really struck with the efficacy of the phosphate of iron in excessive discharges of urine. The quantity is rapidly reduced under the use of this salt, and indeed its qualities sensibly altered. The bulimia which also attends on diabetes is reduced, and the powers of digestion invigorated and increased.

"The phosphate of iron is readily formed by the admixture of solutions of sulphate of iron and phosphate of soda. The resulting salts are sulphate of soda, which, being soluble, passes through, while the insoluble phosphate of iron remains on the filter.

"Phosphate of iron may be given as an astringent in doses of one or two grains, which may be gradually increased to a scruple or half a drachm three or four times in the day. In children, smaller doses should be given, but the

• "In rickets, carbonate of iron is usually combined with the phosphate of lime, and the combination is found more efficacious than either singly, I have no doubt that decomposition takes place, for in the animal laboratory, the laws of chemical affinity are set at defiance, and those compounds evolved which are most suited to the living purposes.”

exposition of the rules for apportioning them according to the ages of patients, belong to a different branch of medicine. It may be observed, that after a continued use of any medicine the dose must be gradually increased, or otherwise its effects will begin to diminish. Sometimes it is useful to suspend the use of the medicine for a short time, and then to recommence it again. In this way the susceptibility of the system is often revived, when it would not be safe to attempt the same object by any other means." 72.

Of the various disorders which accompany diabetes, and which are looked upon by some as the causes of the disease, Dr. Venables has given a full account, with very clear and judicious directions for the treatment of them. We refer the reader to the seventh chapter for very excellent therapeutical and dietetic observations. The eighth chapter also, on Prophylaxis, is worthy of attentive perusal.

In an extensive appendix, our author has detailed eighteen cases, and two dissections of diabetes. Of these, ten are examples of the urinary flux of children, and form the most novel, and, we think, the most important part of the work. On this account we shall endeavour to convey to our readers a sketch of some of the cases to which we allude.

Case 1. A little boy, aged five years, had been ailing for nearly two years. He first became dull and listless, and then emaciated. He frequently complained of his head-eyes were prominent-pupils rather dilated-bowels Occasionally disordered. In the progress of the complaint the abdomen swelled a little, and mesenteric affection was suspected. The appetite was always good. Cough took place, and then phthisis was feared. Several practitioners were consulted, and various plans of treatment were adopted, without benefit. The child ultimately came under Dr. Venables. He also tried various means, abandoning one after the other. The little patient at length became generally dropsical and died. It was now ascertained that, previously to the dropsical symptoms, the boy had had a great flow of urine-sometimes as much as eight pints per diem. When the dropsy supervened, the urinary secretion diminished.

Dissection. There was nothing remarkable in any of the abdominal viscera, except the kidneys. These organs were found in a very diseased state. The right kidney was enlarged, and its vessels turgid with blood. The substance of the viscus felt soft and flabby to the touch, and on cutting into it, a dark-coloured fluid flowed out in abundance. The left kidney presented nearly a similar appearance, but not to so great an extent.

Case 2. A woman, who had suffered from diabetes for a long time, at length became dropsical and died. She had always complained of severe pain in the loins. On dissection, the spinal marrow was examined, and the theca vertebralis was found very vascular-the medulla spinalis itself felt unusually hard throughout its whole extent. In one spot it seemed dissolved or softened down into a kind of excavation, not apparently from any thing like ulceration, but as if it had been scooped out at that spot. The excavation was about half an inch in length, situated between the last dorsal and first lumbar vertebrææ. A degree of low inflammation seemed to have pervaded a considerable portion of the column, both above and below the excavated part, as evinced by depositions of coagulable lymph, &c.