The solutions are mixed in equal proportions in the order in which they are given. Thirty c.c. of the mixed solution is placed in an evaporating dish of anhydrous sodium carbonate to increase the alkalinity. Then the solution is brought to a boil and the urine allowed to flow in from a burette as is the custom in the Fehling system. The advantage in this method is the ease with which the end-point of the reaction is read; that is, the complete disappearance of all the blue color. This point is very sharp, and accurate to a fraction of a cubic centimeter.1

The test for acetone adopted, which is a very convenient one and easy to perform, is as follows:

Fifteen c.c. of urine are placed in a test-tube and there is added 1 c.c. of glacial acetic acid. After the addition of a few drops of freshly prepared solution of sodium nitroprussic, ammonium hydrate is layered above the urine and a violet ring appears at the line of contact.2

The test for diacetic acid was the timehonored ferric chlorid. The total ammonia was estimated by a new and very convenient method, as follows (method of Ronchese):

Ten c.c. are measured off from a twentyfour-hour specimen and placed in a flask; there is added 100 c.c. of distilled water, previously boiled, and then as an indicator, a few drops of 1⁄2 per cent. alcoholic phenolphthalein, stirring constantly. One-tenth normal sodium hydrate is run in from a burette until a pale rose color makes its appearance throughout the liquid. Ten c.c. of commercial formalin are now added (which has been neutralized if necessary) with phenolphthalein as an indicator, and again 0.1 normal alkali is added until the same reaction appears. This is the end-point. To the quantity of alkali used, after the addition

rose

1. Benedict, S. R.: Jour. Biolog. Chem., 1907, vol. iii. 2. Lange, F.: Eine Ringprobe auf Ozeton, München. med. Wehnschr., 1906, lii, 1764.

of the formalin, there is added 0.1 c.c. for each 3 c.c. required in the titration. This is for correction. Obviously, this sum equals the ammonia content of each 10 c.c. of urine ex

pressed in centimeters of 0.1 normal ammonia. The sum is multiplied by 0.0017, to obtain the amount of ammonia in 10 c.c. of urine, and the quantity of ammonia for twenty-four hours is easily calculated.3

Realizing the importance of some means of determining the degree of diabetes, each patient was studied carefully and underwent a complete physicial examination, with its accompanying examinations - blood, blood-pressure, history, etc. No definite scheme of classification of disease was adopted, but the following was borne in mind: Mild cases, or those which could tolerate from 60 to 100 gm. of carbohydrates daily without the appearance of sugar in the urine; moderately severe cases, or those which became sugar-free on a constantly restricted diet; severe cases, or those which continued to have glucose in the urine on restricted diet or even on restricted protein. In our work, protein was not restricted, nor was there attempted any of the oatmeal cure, potato cures or other complex diets which were not practical in a dispensary.

It was our aim to render each patient sugarfree, since it is only when diabetics are sugarfree that their tolerance for carbohydrates materially rises. It was also our object to watch carefully and prevent the occurrence of acidosis and other complications (provided this could be done on the aforementioned strict diet). When acidosis appeared, or gave signs of appearing, a certain amount of carbohydrate was added to the diet. The prevention of acidosis should constantly be borne in mind and the indication promptly met by returning to the diet a certain amount of carbohydrate, as well as the ingestion internally of a half ounce or more of sodium bicarbonate each day. This was the only medication used.

It is a well-known fact that a diabetic (or for that matter a normal individual) will show acetone and diacetic acid in the urine when suddenly deprived of carbohydrate food. It is also a recognized fact that a diabetic who is excreting large amounts of sugar in the urine will manifest acidosis on a diet liberal in carbo

hydrate, due to his inability to assimilate these

in the normal manner.

Taking it for granted that it is the usual case of diabetes, a patient under treatment should retain his normal weight, or gain if there has been loss of flesh. The weight was carefully recorded in each case and effort made to keep it normal. We quote the following cases:

The case of J. B., 42, married, white, motorman. who presented himself at the dispensary for treat

3. Ronchese, A.: Nouveau procede de dosage de l'ammoniaque, Jour. de pharm. et de chem., 1907, 6th series, xxv, 611.

ment, Nov. 14, 1913, complaining of cramps in the abdomen and weakness. Past history uninteresting, except the history of appendicitis ten years ago, which was supposed to have recurred shortly before the patient applied at the dispensary, and it was in routine urinalysis prior to operation that glucose was discovered in the urine. The patient also had thirst and polyuria. He had lost 15 pounds in weight in the past six months. The subject was a well-nourished, muscular man, weight, 162 pounds.

Two days after application to the dispensary, urinalysis showed 6.25 gm. of glucose in a twenty-fourhour specimen, as well as acetone and diacetic acid. A trace of albumin was present and there were hyaline and granular casts. The carbohydrate was gradually withdrawn from his diet, and on the given diet glycosuria disappeared. From December 5, the patient having been glucose free, he was given 150 gm. of bread, in addition to his usual diet, for a tolerance test. Assuming the carbohydrate content of bread to be 55 per cent., the urine resulting from this test showed 9.9 gm. glucose, which, subtracted from 83.0 gm. (the amount of carbohydrate contained in bread), gives a tolerance of 73.0 gm. carbohydrate.

The patient has again returned to a strict diet for tolerance of oatmeal, the result of which was very similar to the foregoing. The weight on the last day of December was 167 pounds, a total glucose of 5.45 gm. in twenty-four hours. The patient was continued on a moderately strict diet and became glucose-free Feb. 25, 1914, and continued so without the sign of acidosis until the 25th of March, when the total ammonia in twenty-four hours rose to 2.7. At this time, it was interesting to note that the patient developed fluid in the right chest. My notes of the case end at this time.

A word in regard to the total ammonia. The object in estimating the total ammonia is to keep a quantitative record on acidosis, and as acidosis occurs, the ammonia rises accordingly, a conservative effort on the part of Nature is made to combat this complication. Normally, the ammonia in a twenty-four-hour specimen of urine is from 0.6 to 0.8 gm. for the average adult on a mixed diet. The upper limit of normal is 1.2 gm. In a healthy individual, the ammonia nitrogen represents about 5 per cent. for the total. This simple method of estimating the acidosis proved of great value to us in our work.

P. H., aged 66, widower, farmer. He came to the clinic complaining of grippe, Jan. 12, 1914. He had formerly been a patient in our dispensary in 1909, at which time glycosuria was noted and some treatment given. On present admission he showed no further interesting signs except those of mild chronic bronchitis. The urine was tested and showed 7 per cent. of sugar. I wish to pause a minute and make clear one point in regard to the sugar determinations in diabetes.

Seven per cent. of sugar means nothing; it simply means that a specimen passed at a given time had a known amount of sugar and hence no idea of a total for twenty-four hours, and it is the total for twenty-four hours that interests us, that determines treatment, and which can be compared with the amount ingested.

The patient was put at once on our carbohydratefree diet, according to list given January 16, and showed 4 gm. glucose in twenty-four hours; no signs of acidosis. By January 30, or eighteen days after admission, he was sugar-free. In February he was

given a tolerance test of two slices of bread each day. Urine remained sugar-free. The highest ammonia estimation was 1.6. He was again put on a free diet and an accurate test of 150 gm. of bread was given. Urinalysis showed that no glycosuria resulted from this. From this day, the 6th of March, he took from 150 to 200 gm. of bread, without glycosuria and without signs of acidosis. It was evident in this case, within a very short time, that the proper diet increased the patient's tolerance, and there was marked improvement in his general health.

T. G., aged 49, laborer, married, white. He was admitted to the clinic Sept. 24, 1913. He gave a history of being a great beer drinker, frequently getting drunk and averaging 3 quarts of beer a day. His symptoms were loss of flesh-30 pounds-polyuria. Physical examination showed a marked alcoholic facies; his breath had an acetone odor; heart and lungs were negative; a very pendulous abdomen. He was put at once on a carbohydrate-free diet. The urinalysis test on admission showed acetone to be present and a considerable amount of sugar. incomplete specimen prevented accurate figures.

An

The patient appeared again November 6, and was again put on a Janeway diet and presented the following urinalysis: 2,180 c.c. total; no acidosis; no glucose. He was then given 100 gm. bread for a tolerance test. The return from this was no sugar. In January the patient broke the diet rules and relapsed. On February 2 he returned and was given the diet mentioned, with a small quantity of rolled oats in the morning and from 150 to 200 gm. bread each day, glucose or acidosis never appearing; evidently a mild case due to diet error and easily corrected.

P. S., married, white, aged 51, a tailor; had been treated for glycosuria since 1911; came to the dispensary in December to see if he had sugar in the urine; sugar was present. He was placed on the usual diet. He returned again the middle of January, sugar-free, having gained 30 pounds in weight. The ammonia content in twenty-four hours was 1.37, and a few days later 1.89. He was returned to a strict diet, to which he apparently did not adhere, and on February 21, there were 13 gm. of glucose to a twenty-four-hour specimen. The ammonia was 1.5. Owing to the acidosis, the carbohydrate was now reduced gradually, the patient being allowed two slices of bread each day. A few days later he showed 3.5 gm. sugar, positive reaction for acetone, with 1.0 ammonia. In March the patient was put on a strict diet and soon became sugar-free. Ammonia was 1.5. In April, the patient remained sugar-free, but the ammonia was as high as 1.78. This case did fairly well on treatment, showed a great tendency to have acidosis, the only treatment being bicarbonate of soda. This patient did not show the same interest and intelligence in following the diet as some of the previous ones, though the result was very good.

M. S., aged 42, married, white; who was known to have had diabetes for several years, came to the dispensary Dec. 3, 1913. Twenty-four-hour specimen of urine, 1,580 c.c.; acid; clear; 1,020; 17.6 gm. glucose in twenty-four hours; no acetone, no albumin. She was placed on the diet list given but allowed to retain two slices of bread each day, the sugar remaining about the same amount. On the 19th of December she was put on the strict diet, and showed a total of glucose on this diet of 13.7 gm. for twentyfour hours; no signs of acidosis. The patient at this time was instructed to have one day each week as a fast day, on which she could have only coffee, perhaps a little brandy. January 6, glucose 23 gm., twenty-four hours. The fast day was replaced by a green day, allowing only green vegetables one day a week, glucose remaining constant. At this time, after some investigation on the part of the patient,

she obtained at quite a high rate, some gluten flour, and prepared for herself some gluten bread according to a very excellent recipe which she had. This bread was analyzed in our laboratory and had almost as much carbohydrate content as ordinary bread. This is mentioned here for the purpose of stamping our disapproval of the use of gluten bread or any other variety from any source whatsoever, unless it is subjected to chemical analysis. Now, the patient showed a total ammonia of 2.38, the condition remaining about as stated. The ammonia fell to 1.4, and on February 11, glucose was as low as 9.5 gm. On March 25 glucose was only 4 gm. in twenty-four hours. The weight on the latter date was 195 pounds, a considerable gain since admission.

G. S., aged 58, married, white, housewife; came to the clinic Nov. 13, 1913, with a history of pain in the back and abdomen. Past history showed that she had diabetes for eight years and had always had marked polyuria and thirst, with edema of the legs. Habits good, past history negative, family history negative. For the past two weeks had been having marked lumbar pains, pains in the epigastrium, and was very much below par in weight, there having been a loss of 40 pounds since the onset of her disease. Examination showed a large, obese, German Jewess, suffering from pyorrhea alveolaris; heart, second sound was accentuated, abdomen was pendulous, showed a scar of some previous operation of the uterus (said to be for a tumor fourteen years ago). She was very tender in the gall-bladder region, though there was no mass, tender also in the appendix region. The patient came to us from the Washington University Hospital, to which she had been admitted July 15, and on very careful diet showed no carbohydrate tolerance and did not become sugarfree. The urine on discharge from the hospital was 2,500 c.c.; 145 gm glucose in twenty-four hours. Now the Wassermann reaction was taken, which was negative. She was put at once on a carbohydrate-free diet and glucose fell to 25 gm. The patient then refused any further dietetic treatment and she was discharged from the dispensary. She returned to the dispensary Dec. 1, 1913, with 3,880 c.c. of urine, marked reaction of diacetic, acetone, albumin, hyaline and granular casts, and a total glucose of 170 gm. in twenty-four hours. It was again demanded that she follow the diet list given her, and which she did. Then glucose began to fall, acetone only was present, albuminuria persisted, and glucose in twenty-four hours was 45 gm. On February 13 urine showed 26.9 gm. of glucose in twenty-four hours, acetone remaining positive and the ammonia was 0.8 gm. The patient had been on a strict diet in the interim. Ammonia rose at times as high as 1.64. She gained 2 pounds in weight and then again became careless with her diet. This case was the most unsatisfactory one in the group and proved beyond doubt that benefit can only be derived from dispensary treatment if patients can be persuaded to follow the diet. The next case is that of W. R., aged 55, white, single, a salesman. He presented himself to the clinic Oct. 28, 1913, for a sore toe of five years duration. Personal history showed that he had formerly been a heavy drinker. He had no other symptoms except beginning gangrene in the right great toe. I did not see the patient again until December 1, when he presented himself. There were 1,970 c.c. of urine, specific gravity, 1.013, urine clear, acid, no albumin, 18.3 gm. glucose, no diacetic acid, no acetone. Following this urinalysis the patient disregarded instructions, drank beer to excess, ate freely of bread and potatoes. He came in with 1,500 c.c. of urine, and, strange as it may appear, no glucose. He was, however, persuaded the necessity of treatment and again put on a free diet, and remained glucose free. He was then given 150 gm. of white bread, and returned

December 12 with 2,150 c.c. of urine, no glucose, a trace of albumin, no acidosis. There was marked improvement in the toe. Unfortunately our control of this patient was not sufficient to get any further tolerance test. It is certain that he had a tolerance for 150 gm. bread, or, in other words, 80 gm. carbohydrate. He came in again December 27, with a trace of sugar. He had been eating according to our instructions 150 gm. of bread each day. The bread was reduced, and when seen last, the 17th of January, was still glucose free and his total ammonia was 1 gm. This was evidently a mild case and easily corrected.

We have no new things to offer you in conclusion. None of the more elaborate means of dietetic treatment were attempted. These cases are presented to you with the sole idea in mind of demonstrating that diabetes can be treated in the office, in the clinic and in the dispensary with a considerable degree of success. In several of the cases, phenolsulphonephthalein test was made and showed no deviation from the normal except in those cases which had accompanying nephritis, where there was decrease in the output. The Wassermann reaction was

negative in all cases.

In conclusion, I wish to express my thanks to Dr. Robinson of Washington University for the many kind suggestions and help with the patients. I wish also to express my thanks to Dr. Larramore, who took charge of the laboratory end of the problem, and whose assistance was indispensable.

314 Humboldt Building.

DISCUSSION

DR. G. H. HOXIE, Kansas City: Diabetes is not the name for a simple disease-but rather a term covering several conditions, the common symptom of which is glycosuria. Therefore before we can institute intelligent treatment we must form a definite notion of the pathogenesis of the case before us. Some cases require nothing more than a proper diet to enable them to raise their tolerance for sugar. Other patients seem to be loaded with diastatic ferments, which unless saturated or neutralized tear down the body tissues. In this latter class of cases Dr. Knerr of Kansas City has had brilliant success by feeding raw starches and by neutralizing the acidosis. Therefor the presence of diastatic ferments in the urine and the acidity of the urine should be carefully investigated before outlining a carbohydrate-free diet. Again the condition of the pancreas should be studied by examining the stools for undigested fats and similar evidence of insufficiency. And still again the condition of the pituitary gland may be responsible for the glycosuria and should at least be considered. In the absence of a definite lesion Dr. McBaine's procedures are excellent and should bring relief to his patients.

DR. R. H. MCBAINE, St. Louis (closing): I quite agree with what Dr. Hoxie has said. The study of diabetes is more than the study of the quantity of sugar in the urine or the patient's ability to tolerate the sugar, and in some of the histories which time did not allow me to include in the reading, this afterwork was done. Many of the other cases, which were too complicated to be handled in our dispensary, we sent to the hospital. Perhaps we can give you a report on those cases next year. I think that in some the estimation of the total glucose in the blood was attempted.

MEDICAL LEGISLATION *

CHARLES P. EMERSON, M.D. Dean, Indiana University School of Medicine INDIANAPOLIS, IND.

When I heard the meeting was to consider the subject which was presented this evening, it was a great delight to me that I was to be in the city to hear the papers that were to be read, because we in Indiana have this problem before us. Our State Medical School is the only medical school in the state, and it is the State Medical School. We, therefore, feel that it is our duty to instruct the public of the state and, if possible, the lawmakers-instruct them in such a way that the laws will be, as we think, suitable. I do not say that the public think it is our duty; I do not say that the lawmakers think that it is our duty; but we feel that the one medical school in the state and the State Medical School has as its special function the instruction of the public and especially the lawmakers concerning public hygiene and public health in order that the laws enacted may be rational laws, created not for the benefit of any one class, but for the whole people. Allow me to say that I am delighted to have been present this evening and to have heard the paper that has been read.

Why is it that physicians are still following the practices and still living in the times of their grandfathers? I do not know. We don't wear the hats nor coats, nor do we carry the canes that our fathers and grandfathers used. In so far as our practice toward the public is concerned-I am not speaking now of the way we treat the patient, but so far as our attitude to the public is concerned-physicians still feel that it is their duty to be very quiet, to be silent. We cannot do that now. Why not? Because medicine has been advanced and at such a speed that there is no exaggeration to the statement that medicine has advanced more

in the last fifty years than in the preceding twenty-five hundred. The advance has not only been in the therapy of the individual patient, but in prophylaxis, in hygiene, in preventive medicine, and, therefore, we doctors cannot maintain that very dignified silence on this matter that has been our attitude in the past. What is the matter? There is no doubt but that any increase in knowledge means an increased responsibility. The man who knows best what ought to be done under certain circumstances owes it to the public to tell them what ought to be done under those circumstances. There is no

doubt that the medical profession is the most self-sacrificing of all professions so far as indi

*Stenographer's report of remarks before the St. Louis Medical Society, April 25, 1914.

vidual practice goes, in my opinion. Yet no profession has the appearance of evil more than the medical profession. That appearance is produced by the silence it maintains as an organized body on medicine and public health, and why do we maintain this deceitful-for it is deceitful this very misleading attitude toward the public health? We realize that it is our duty to give the public the benefit of that which we know. We know that the more education we give the public the less our benefit will be under the changed conditions, but we have not admitted the public to that view.

I remember a good old doctor up in New Hampshire saying that whenever he educated the public he injured himself. "When Eberth discovered the typhoid bacillus," he said to a friend of mine, "I saw it was my duty to get better water in the city and I went on a crusade against the water-supply until that water-supply was improved. Formerly I made thousands of dollars from my typhoid fever practice, and now I make very little because, as a result of my teaching, there is not very much typhoid. I used to depend on three or four thousand each winter from the diphtheria practice. When diphtheria antitoxin came into general use, I first educated my patients to it-they were adverse to its use in the beginning-and now instead of having cases which go on for days and weeks, making calls every day, a few visits suffice and, therefore, my diphtheria practice is is almost gone. I used to have a large practice from minor surgery in the mills of the town where I practice, but I saw that most of that minor surgery was unnecessary, so I made myself obnoxious to the owners of those mills until they put in appliances that would prevent these accidents, and now my minor surgery amounts to very little. In other words, the more I have taught the more I have limited my practice, but I knew it was my duty and I have done my duty in this particular."

There is not a single doctor, I believe, that tainly not a member of the state societies, nor is not doing his best in this particular. Certainly not a member of the state societies, nor of the county societies, because their member

ship in these societies proves that they have that purpose. But there are very few of them who have not hidden their light under a bushel so that the public does not "get" their attitude. Each advance in medicine, each increase in medical knowledge imposes new responsibilities on the medical profession. Our modern preventive medicine, our modern social service-which is not a different, not merely a superimposed function of our clinics, which is no fungus growth at all-all of this work in social service, in preventive medicine, etc., is just as truly the result of the research laboratory as our various antitoxins and various drugs that are named by words of twenty or twenty-five let

ters. Each advance in medicine imposes new responsibility on the medical profession. Are they ready to meet it? Are they ready to accept it? For instance, if there is one piece of medical research which we adopt in clinical diagnosis and insist on our students studying, it is that piece of research by Koch, the result of which was the discovery of the tubercle bacillus, a most painstaking, accurate and scientific piece of work which has scarcely been modified. The results of Koch's discovery were therapeutic measures, measures for sanitation in the care of tuberculosis, new health laws concerning spitting on the streets, new ordinances of our state boards of health concerning the cleaning up of houses that had been inhabited by consumptives, a new social conscience concerning the consumptive and the practice of spitting in general. All of these were just as truly the result of that scientific work in Koch's laboratory as any other therapeutic measure for which the discovery is responsible. It is the It is the duty of the medical profession that the public have the results of these discoveries; it is their duty to see that the public protect themselves; it is their duty to continue this crusade which has already cut down over 50 per cent. of the cases of consumption in some cities, until there shall be very few cases indeed.

It was a splendid piece of research work that demonstrated the importance of the typhoid bacillus, and just as we have proper prophylactic vaccine for typhoid fever we have the crusade against filthy water, filthy dairies and filthy grocers in handling green vegetables not cooked in preparation, and these are also the fruits of this discovery by medical research, and it is the duty of the doctors, who understand this better than anybody else, to see that the public have the benefit of their knowledge. This education of the people can be brought in other parts of the country to the point which it has reached in St. Louis, where typhoid is one of the rare diseases. It was a splendid piece of research work that Schaudinn did in his discovery of the organism of syphilis. We have several results from that discovery, the discovery of the fact that many diseases formerly not known to be associated with this disease were caused by it, and its effect on the second generation, and since nobody better than doctors understand the importance of this disease it is their moral duty to see that the public is educated concerning the dangers of this disease and that the proper laws are passed protecting marriage, and protecting the child that will in some measure mitigate the terrible scourge from which America is now suffering. It was a splendid piece of research work by Neisser when he discovered the organism of gonorrhea. This led to many discoveries in medicine and surgery of the part it plays in the causation of different diseases,

and it certainly is the duty of the doctor to be the moral crusader, to be the moral teacher of the young men who come under his care as to the dangers of this disease; and is not only a duty which he may or may not assume at will, but it is a duty that he cannot avoid unless he desires later on to be termed a traitor to his public trust.

So it is that every advance of medicine imposes new responsibilities concerning new ordinances on the part of our state boards of health, concerning new state laws, and it is only our medical societies, it is only our medical schools who have the proper knowledge whereby they can give the public the results of this work and thereby teach the public how they can protect themselves. Nobody else can do it as well as they; should anyone else try, it will be borrowing thunder. Medicine has advanced very, very rapidly. Now, are we keeping up with it as medical organizations As individuals, yes; but as members of the medical organizations to which we belong, which are the only engines that can produce changes in the public sentiment, in the laws, we are certainly not giving to the public that which we owe them, and although we may not recognize our guilt now it certainly will be held against us later by those who will realize their loss because of our unwillingness to appear as those teaching, educating, favoring the enactment of and seeing to the enforcement of the laws in question.

What are some of these medical advancements that we want to put before the public? I have named a few, but it all hinges on the changed attitude concerning our therapeutic measures. We now recognize that we know nothing about disease, but we know more and more about diseased patients. We recognize now that there is no such thing as disease, we never saw pneumonia under the microscope and we never saw typhoid fever walking up and down the street, but we recognize that John Smith has pneumonia and that Mary Brown is suffering with typhoid fever. This personification of processes under the name of disease has led us astray. We recognize that we know practically nothing about typhoid fever as a disease, but we know more and more about each patient who is suffering from typhoid fever. You cannot mention one symptom of typhoid fever. I wish you would try. I doubt if you can. But you can mention a good many phenomena that patients with typhoid fever present these are symptoms not of the disease; for instance, rise of temperature which we call fever is not a fever, but a part of the man's reaction against the infection. I wish to enlarge on that a little in order to come back to the problem with which we started. The rise of temperature is not a part of the attack, but a part of the defense. Those patients who are so