Pavy, of Guy's Hospital, Dalton, Bernard, and Bennett, showing the formation of sugar, and said: Such are the leading facts which seem to be known in connection with the pathogensis of diabetes mellitus. There seems to be a direct connection between an irritation of a certain portion of the brain and diabetes, and there seems to be an indirect, or reflex one, which stimulate the liver to increased action; both of which tend to place this disease under the head of functional nervous disease, or diseases of disordered innervation, and to localize it in the nervous system, not as a disease however of the brain, for the floor of the fourth ventricle, though sometimes, is not always found diseased. What is the nature-what is the cause of this morbid action? Morbid anatomy throws no light upon this inquiry. There is no characteristic lesion. Cases occur which last for years, in which no evidence of cerebral irritation is discoverable during life, or on post mortem examination. The liver presents no constant appreciable lesion. The floor of the fourth ventricle has been found sometimes diseased and sometimes healthy. Tubercle of the lungs occurs, I believe, rather in the course of, than as a cause of diabetes mellitus.

If a constitutional disease be one which is developed under the influence of agencies generated within the body itself, and acting through continuous exercise of its functions, then glycosuria is one. If it depend upon cerebral or cerebro-spinal irritation, direct or reflex, then it is a neurosis. If under this influence, or in consequence of the presence of the sugar in the blood which it is called upon to excrete so profusely, the kidney be stimulated to increased action, the disease does not originate in the kidney, and is not a local disease in that organ. Neither, unless it occurs solely from direct local irritation of the liver, which it never does, so far as I know, is it a local disease of that organ. It depends chiefly, at least, upon increased glycogenesis in the liver, under the influence, in part at least, of what the French call a "vice d'innovation," a perversion or disorder of nervous influence, what we cannot say for there seems no reason why it should sometimes suddenly attack, without appreci

able cause, persons in apparently good health and unexposed to morbid influences, except such as do not ordinarily produce it. That the stomach is never wholly in fault is certain; for although Watson says it may cease to perform its accustomed chemistry upon the food, and upon sugar as an article of food, and secrete from the starchy, and even the nitrogenous elements of the food, a surplus of saccharine matter, yet it cannot be said to originate in, or be wholly confined to the stomach; and this morbid secretion, like the increased glycogenesis of the liver, must have a starting point elsewhere. Abstinence from starchy and saccharine food, while it does lessen, does not wholly remove the sugar from the urine; nor is it well tolerated, nor absolutely indispensable. I I suppose it may be said safely that a mere perversion of the gastric nutrition, or assimilation function, is a sufficient cause of melituria; and I suppose that the same may be said, while admitting its influence as a combined cause with that of the stomach, of the imperfect performance of the functions of the lungs, primary or secondary. That it is ever a sole cause, I do not believe. That by failing to decompose an excess of sugar in the blood, it may aggravate, or perhaps even assist in stimulating, by a reflex action, the glycogenic secretion of the liver, is both possible and probable.

Dr. Roberts spoke of the two kinds of blood diseases, viz., those in which the poison is absorbed from without, as in glanders and syphilis, or in the typhoid and exanthematous fevers, and those in which the poisonous agent is generated intra-corporeally, as in glycohæmia and uræmia.

Glycosuria is to all intents and purposes a disorder of the nervous system; but of what kind, and how developed or superinduced, is unkown.

There would seem to be, in some at least, a predispositon to the disease, which makes common causes of disease to take this particular direction. It is a very rare disease. Many medical men, of long practical experience, may go through life without meeting with it; and of 80,000 certificates of death within a few past years, so laboriously examined by my painstaking

friend, Dr. Gouverneur M. Smith, 58 only were from this cause. Nevertheless something, nay much, has already been attained. The quantity of sugar supplied to the blood can be lessened by appropriate diet and regimen, and by Trousseau and Roberts it is affirmed that we may hope to cure a few, and to relieve a large number. The attempt to cure diabetes by confining the patient to a non-saccharine-producing diet, although it may be useful in an early stage, fails, because it does not affect the starting point of the disease, and, addressed wholly to the stomach, it but slightly modifies or interferes with the glycogenic function, or changes the morbid action of that part of the liver.

Dr. J. C. Peters. It is surprising that diabetes is so rare a disease, for Bence Jones and Professor Brucke have demonstrated that healthy urine always contains a small, but appreciable amount of sugar; i. e., the amount of sugar derived from food, or from the changes going on in the liver and textures, is at all times more than can be destroyed in the circulation, in the lungs, and in the tissues.

The ingestion and manufacture of sugar in the system is always very great; for every grain of starch that is taken as food is converted into sugar. Pytalin alone will convert 2,000 times its own weight of starch into sugar; fresh pancreatic juice transforms four times its weight; the mucus of the stomach, and the strongly alkaline intestinal juice will do the same. Then we have the great amyloid or glycogenic function of the liver, by which the hepatic cells separate from the blood a substance called glycogen, or animal starch, which rapidly becomes transformed into glucose, or grape-sugar.

All this vast amount of sugar must be oxidized or destroyed in the circulation, in the respiratory process, and in the tissues, and should pass out of the body as carbonic acid and water. The only aid in this process is that afforded by the bile, which slowly converts cane-sugar into lactic acid, and by a healthy and vigorous state of the vaso-motor nervous system. For deblility of the sympathetic nervous system causes dilatation and paralysis of the small arteries of the liver and abdominal system

generally, followed by a larger flow of blood through the portal system and liver, and more rapid and copious formation of glycogen. This explanation applies to irritation of the fourth ventricle, division of the sympathetic nerves in the neck, irritation of the cerebro-spinal axis from the cerebral peduncles down to the roots of the pneumogastric nerves, etc., etc.; for all these operations and others cause paralysis of the vaso-motor nerves, and congestion of the liver.

The indications for treatment are the free use of oxygen gas; of those remedies that promote the oxidation of sugar, of which iron and the alkalies are the most energetic; and those remedies which promote the healthy secretion of bile, and depress the glycogenic function of the liver.

Among the alkaline mineral waters, the most useful are Vichy, more particularly from the Celestin spring, containing ninety-six grains of alkali; the Carlsbad water, with one-fourth less alkali than Vichy, but with half a drachm more of sulphate of soda in each quart, thus having an aperient action which Vichy rarely possesses. The carbonate of soda has been used successfully by Professor Alonzo Clark; the bromide of potassium by Dr. Bigbie; lime-water by Kepel, Willis, Fothergill, Watt, Frank, and others; magnesia, by Eberlee, Willis, Hufeland, and Phillips; the phosphate of soda by Latham and Starkey, while Prout considers it an admirable saline purgative; the permanganate of potash by Sampson, Basham, and Bence Jones.

But it has been noticed that the alkalies are particularly useful when diabetes is associated with obesity, while they are useless or injurious in debilitated, emaciated, pale, and nervous subjects. In these latter the best alkali is the carbonate of ammonia, which has been found so useful by Barlow, Golding Bird, and Bouchardat; and it may have to be associated with iron, in the form of the ammonio-citrate, with an excess of ammonia. Prout thinks that the citrate of ammonia is the best diaphoretic we can employ.

But in emaciated, debilitated, and anæmic patients the preparations of iron are the best remedies. The iodide of iron is

a remedy of great

promise, but its use should be persevered in

for a long time; the peroxide of iron is praised by Prout; the phosphate of iron by Venables and Prout.

Next to iron, the best tonic is nur vomica, which may be aided by astringents-such as alum, creosote, kino, opium, nitric and phosphoric acids.

The best bilious remedies are rhubarb, which has been found so useful by Copland, Boglin, Lester, Brocklesby, Morton, Buckwald, and Harris; sulphur, which has been advised by many German physicians, and by Copland; ox-gall by Hufeland and Copland; aloes by Copland.

Among the palliatives, opium is the most useful, but its debilitating effects should be obviated by nux vomica, iron, etc.

Every conceivable remedy has been tried in vain; but in this connection I will mention that in the case of the wife of a physician in this city, who passed eighteen ounces of sugar and three gallons of urine daily, much advantage has been gained, and strength and embonpoint restored by the use of arsenicum albi, one-tenth of a grain three times a day, which Legroux thinks he also derived benefit from. In cases of failure of pulmonary energy, the use of oxygen by inhalation, now getting into common use, suggests itself, and has been recommended by Richardson of London, and Berenger and Feraud in France. So, too, it may be with the use of cod-liver oil and roasted fats, so grateful to the poor patient of whom Dr. Smith told us, who, in his delirious dreams, looked forward with rapture to the delicious repasts the angels in Heaven were preparing for him. These, as fuel for combustion in the lungs, may tend to modify or improve their inefficient or diminished action, and lessen by so much the quantity of sugar in the blood.

These thoughts are crude and immature, but I hope they may stimulate to further discussion, which, I hope, may not cease until our learned President shall have expressed his views on this obscure but interesting subject.

The President, in summing up, thought that the ground gone over in the discussion was not altogether profitless, although the