I here present micro-photographs made for me by Dr. Wm. F. Becker, showing a normal Island of Langerhans in the one, and in the other, the inflammatory invasion with destructive changes, the one specimen having been taken from a diabetic patient.

We have next to consider symptoms of the disease which are so common that your time need not be taken up with a lengthy description. We are all familiar with the classical symptoms of polyuria, high specific gravity of the urine, the varving percentages of the sugar, its constancy, the thirst, the great appetite, the digestive disturbances, the loss of weight, the increasing weakness, the neuralgias and the neuritis simulating tabes. We are accustomed to the dryness and red

The organ shows a slight general fibrosis and a very marked degeneration and fibrosis of Langerhans' Islands. a. Island of Langerhans, entirely devoid of nuclei.

ness of the tongue, buccal and pharyngeal surfaces, the burning sensation about the meatus urinarius and the genital excoriations, the dryness of the skin and the various infections of it. We all dread the gangrene, the abscesses, the purulent otitis media, and the purulent infiltrations of the structures of the neck, and we all look with fear upon any simple infectious bronchitis, believing coma to be in sight. But the symptoms are not always classical, and we may be thrown off our guard. Our fleshy man may have no symptoms to point to the disease, whilst amongst the gouty, overfed, an amount of sugar in the urine is looked upon as salutary, rather than otherwise. In some, we have the disease extending over a period of many years without serious inconvenience. In others, a few weeks only is sufficient to bring

about a fatal issue. Nor does the age of the person invariably determine this, although generally speaking, an individual who is past 45, and who is moderately fleshy, has a good prospect, as far as length of days is concerned. In youth, especially if associated with obesity, the disease runs a rapidly fatal course.

Two cases in young boys during the past year were of interest to me. The one, aged 16, well built, working in a mill, complained for about two weeks of weakness, when he was obliged to take to bed. Dullness of intellect rapidly supervened, which deepened into coma, death resulting in three weeks from first complaint. The urine was copious, loaded with sugar, and there was the characteristic loss of reflexes. I am indebted to Dr. Kaumheimer for seeing this case.

The other was a lad 15 years of age, 6 ft. 2 in. tall, weighing about 130 pounds, slight but active and unusually intelligent. He came to me because of a larger quantity of urine passing. He had a stumbling gait, loss of knee jerk, neuralgic pains, urine with specific gravity of 1040, 4 per cent. sugar, constipation, intestinal indigestion, dryness of mouth, intense thirst, and great appetite. Yet this boy gained in weight and strength, lost much of his thirst and his enormous appetite, passed through a severe tonsillitis and later a facial ervsipelas, went deer hunting, lived on corn bread and molasses for some weeks, was exposed to a snowstorm for several hours, and lived for a year and a half after first presenting himself. finally developing gangrene, abscesses, otitis media, infiltrating nus, an accumulation of which in the neighborhood of the larynx caused death by suffocation when rupture took place.

In this case a trial of a week on a carbohydrate free diet resulted in bringing the percentage of sugar down from 10 to 7 per cent., but his weakness was greatly increased. Later, when the utter uselessness of treatment was apparent, he was allowed all the carbohydrates he craved for, and still the percentage did not rise above 10. This case was further interesting in the pronounced atrophy of the skin which occurred in parallel stripes transversly across the back and above and below the knees. In these boys the disease certainly presented very diverse pictures.

We cannot say very much about prognosis. As a rule, in the young it is a rapidly fatal one, while in those of middle life and fairly fleshy, it is good, as far as time is concerned, but every case is a law unto itself, and none permanently recover. We believe that the majority of these cases are influenced by treatment, which is to be divided into hygienic, medicinal and dietetic.

The principles underlying the treatment are those of promoting oxidation, that a greater amount of sugar be consumed (for sugar the blood will have from some source. even from the fat of the body), the lessening of the amount of carbohydrates ingested, and the substitution of its caloric value.

The first indication is met by the hygienic methods employed to bring about good nutrition, and such medicines as are supposed to. stimulate the metabolic functions of the body, preserve the digestive tract in as nearly normal condition as possible, and neutralize the various acids which are the results of faulty digestion and metabolism, and which conspire to reduce the alkalinity of the blood.

To fulfill these requirements we have the various bitter tonics, the acids, and antiseptics. It is surprising how a judicious use of these with a moderately restricted diet will lessen the amount of sugar and increase the patient's well being. Opium also has a place in reducing the sugar and lessening the nervous symptoms.

Personally, I have had the greatest satisfaction from the antiseptic (so-called) treatment of the digestive tract, with the use of arsenic, preferably a 1 per cent. solution of bromide of arsenic. The regulation of the diet presents the greatest trouble. How best to supply the needed caloric values, and at the same time give the cells concerned in producing the glycolytic ferment a rest, in the hope that they may recover, is not easily answered. That the organism does recover for a time its ability to consume carbohydrates after a more or less complete freedom from their ingestion, is a clinical fact, and warrants us in making the trial in every case. We furthermore observe that in many cases the patient's well being is enhanced thereby.

From the albuminoids sufficient carbohydrates cannot be formed to keep up the normal sugar percentage, and to prevent the patient from drawing too freely on his own fat for the manufacture of sugar, it is necessary to feed him fat in abundance with his albuminoids, thus supplying his needs and keeping up the caloric values. Clinically it is found necessary in the majority of cases to allow some carbohydrates in the form of potatoes or bread, or else he will rebel. Rebellion, however, will not be so likely if he be allowed fat in the form of butter, cream, bacon, etc. Complications must be treated as they appear, and coma is probably best averted by large doses of sodium bicarbonate. Normal salt solution is used in coma, but when a patient reaches that stage, there is verv little but a rapidly fatal issue to be expected.

To sum up: diabetes mellitus is a disease in which there is interference with the consumption of sugar; that this is due to the absence in the blood of a glycolytic enzyme: that the evidence is accumulating in favor of the Islands of Langerhans as the producers of this enzyme and that their invasion and destruction is the constant pathologic entity. The treatment is that which will best improve nutrition and not tax the carbohydrate consuming powers.

THE TREATMENT OF GRAVES' DISEASE.

BY ARTHUR W. ROGERS, M. D.,

WAUWATOSA, WIS.

This article is not written with the idea of presenting some new or startling therapeutic measure, but with the purpose of emphasizing those etiological factors which suggest the most rational course of treatment.

Until quite recently so many and varying theories have been advanced to explain the origin of Graves' disease that great confusion has resulted in its treatment, which has been mostly empirical. During the past few years, however, these different theories have been approximating and resolving themselves into two chief ones, viz.: the glandular and the neurotic, and at the present time the great majority of the profession claim that these patients are almost invariably neurotic. In fact, a close examination into their heredity, a careful survey of the symptom-complex and a knowledge of the pathological findings, must convince the most skeptical that the patient is suffering from a malady of pre-eminently neurotic origin and affecting chiefly the nervous centers. A well known teacher of therapeutics has remarked that the only correct method of studying the cure of disease is by mastering etiology and pathology. Following this dictum we must treat Graves' disease as a nervous phenomenon, as practically all the pathological findings are confined to nerve tissues, while its symptoms and course point to a "primary disturbance of the cerebral centers particularly those which control the nutrition of the thyroid gland and regulate the action of the circulation." We fully realize that no arbitrary line of treatment has as yet been established for this class of patients, but vet there is undoubtedly the most good to be derived for the majority in certain suggestions to follow, which are the result of observing the effect of treatment on thirteen cases of Graves' disease, some of a very pronounced type and all accompanied by three or more of the classical symptoms of the disease.

Of the thirteen cases all but one recovered, this one passing on to a fatal termination. In most of them one or more of the physical symptoms disappeared. The length of time since discharge varies from two to six years, thus affording ample time to form reliable conclusions as to what can be accomplished by treatment.

Trusting that we have thus far demonstrated the most probable origin of Graves' disease, we shall now endeavor to establish what

occurs to us as the most rational course of treatment, and first call your attention to a few cardinal points.

All these patients are reduced physically and call for constitutional measures. All cases will not improve under the same treatment. Some few yield only to surgical interference.

Several years ago Gowers remarked that the most important element in the treatment of exophthalmic goitre was "tranquility of mind and rest of body," and many writers since have laid stress upon this point, but we find a tendency to advise this mostly in very acute and pronounced cases. We desire to emphasize the advantage of rest and to further state that no case can be so slight but that rest and rest in bed should be considered the primary and most important thing. In no class of patients does the Weir Mitchell method prove as successful as here. I realize that the physician is often at a great disadvantage in advising this, since the patient rebels, especially if the case is mild and the symptoms in their incipiency. However, a strict "rest cure" should be advised, and, if possible, carried out faithfully with careful regard to details for at least six weeks. The diet should be carefully regulated, allowing the patient simple yet nourishing food from four to six times in each twenty-four hours, avoiding all articles of diet tending to produce gastric or intestinal fermentation and thus avoid further irritation to an already highly irritable heart. Many of these cases have an annoying and exhausting diarrhea and hence all the more need of careful attention to diet. In some instances the lax condition of the bowel yields only to a liquid diet and astringent medication such as Dovers' powder, bismuth subnitrate and beta-naphthol.

The muscular tone should be improved by daily salt sponge baths, Swedish movements, general massage and faradization. During the first two weeks it is best not to have the patient leave his bed, but after this, sitting up in bed from two to three hours daily and gradually increasing the time can be permitted. Later a warm bath and getting about gradually should be tried, always closely observing the effect of exercise on the cardiac movement and regulating it accordingly. Most of these patients are nervous and irritable and find decided relief in the exhibition of the bromides and other sedatives. We are in the habit of prescribing a solution containing two grains each of potassium, sodium and ammonium bromide, two minims of Fowler's solution and four minims of tincture of nux vomica to the drachm of camphor water, and giving half an ounce of this solution well diluted three to four times daily. Codeine in doses of one-fourth to one grain three to four times daily is more satisfactory where the bromides