3. Treatment with illiner«1 Waters.—Here we have to consider: (a) simple alkaline waters, such as those of Assmanshauseu, Neuen ahr, Salzbrnnn, Vichy, etc. ; (b) alkaline sulphur waters, such as those of Bertrich, Carlsbad, Marienbad, Tarasp, etc. ; and (c) saline waters, such as those of Homburg, Kissingen, Salzschlirf, etc. Those of the first two groups are the most frequently employed, the saline waters—perhaps wrongly—being used less often. Adjuvants to the treatment at these resorts are the pleasant surroundings, much time spent in the open air, freedom from domestic cares, diminished sup ply of carbohydrates, and a proper amount of bodily exercise together with the regulated use of the waters. It is a fact that in many cases of diabetes the tolerance of carbohydrates is so increased by this therapeutic regimen that the patients find, after returning to their homes, that the ingestion of equal amounts of carbohydrates is fol lowed by a much less marked increase of glycosuria than before. These results are especially and most strikingly observed in the mild forms of glycosuria occurring in obese or gouty subjects. For these cases the alkaline sulphur waters are in most favor, but it seems to me that for weakly and anaemic diabetics, who need to be spared in every way possible, the mild saline waters (at the head of which are Kissingen and Homburg) should be given the preference. On the other hand, for very irritable, neurasthenic patients of spare build, and further where gout is accompanied by marked nervous irrita bility, the simple alkaline waters are better suited.
The results of this treatment are incomparably less, absolutely as well as relatively, in the severe forms of glycosuria. Such patients usually return home without any increase of tolerance for carbohy drates, often enough with even diminished tolerance. The greater the intensity of the glycosuria, the more useless and even injurious are the alkaline and alkaline sulphur waters. There must be a con siderable resisting power in order that mineral-water cures may be well borne and do good. Very young, aged, and greatly reduced diabetic patients are out of place in these spas. The latter suffer from digestive disturbances and heart weakness either at once or soon after their return home. Caution is demanded also in cases in which nephritis exists as a complication, for after the use of the waters of Carlsbad or Marienbad a previously harmless nephritis (granular atrophy) often begins to grow rapidly worse. The niuriatic and alkaline muriatic waters are much better borne by diabetics with In this matter experience is our only guide. Why Carlsbad and other similar waters should act so favorably under certain circum stances, we cannot explain theoretically. It is difficult also to ap preciate the part taken by the individual factors in the general plan of treatment employed at these baths (see above), and to arrive at any definite assurance that an essential part of the treatment con sists in the use of the mineral water itself. Nevertheless, resting upon the ground of experience, we cannot doubt that such is the case. What is attained in suitable cases is certainly more than an appar ent result; there is an actual increase in power of the sugar-destroy ing function.
4. _Medicinal Treatment.—The number of drugs which have been recommended in the treatment of diabetes is legion—an evidence of the small benefit of any individual one. Even the most optimistic believers in materia medica, rendered cautious by oft-repeated dis appointments, become sceptical when any one praises a remedy for diabetes. The question is not whether many drugs are not useful and even necessary in diabetes in order to meet one or another of the special indications or to combat the complications, but rather whether we possess any remedy which can increase the energy of the sugar destroying function. It often seems as though we did possess such
a remedy. I have already shown that the glycosuria may become less pronounced after the use of many drugs classed as nervines, such as opium, codeine, bromide of potassium, antipyrin, phenacetin, anti febrin, exalgiu, sulphonal, thallin, valerian, belladonna, etc. I added also that the action of these remedies was probably an indirect one, since the condition of nervous irritability was first improved, the de crease in the intensity of the glycosuria being secondary.
It is out of the question to present here a complete list of all the old and new preparations which have been recommended from time to time, whose popularity has been for the most part very ephemeral. The following are a few only of these drugs : Salicylic acid, benzoic acid, salol, benzosol, guaiacol, creosote, turpentine, tincture of iodine, the iodides, oxygen, ozone, permanganate of potassium, lactic acid, strychnine, brewers' yeast, quinine, iron, arsenic, pilule myrtilli Jasperi (whortleberry), and testicular juice. I do not doubt the trust worthiness of those who have reported favorable results from these drugs, but I myself have never observed any effect when I adhered strictly to the rule of making no change whatever in the diet either before, during, or after the administration of the remedy under trial. I cannot help thinking that in many cases the successful result is due to suggestion. Diabetics are very fond of trying new methods o_ treat ment, and the belief that they will be helped by the new cure gives great comfort to many of them; their self-confidence is increased, worry diminishes, sleep returns, and the subjective symptoms are improved—and all of these are unquestionably factors of far-reaching importance in regard to the glycosuria in nervous diabetics. We do not understand the connection, but are compelled to recognize it.
In many cases syzygium jambolanum (the bark and seeds of the Java plum) appears to have a more direct action. Personally I have never seen any results worth mentioning from the use of this drug, but the many cases on record in which good results have been ob tained cannot be ignored. Perhaps in the course of time we shall learn to distinguish the cases in which a diminution of the glycosuria may be expected from the use of syzygium and those in which no such result can be looked for.
I do not deny, as may be gathered from what has been already said, that something may be accomplished by drugs, and I freely admit that by their employment we may pass beyond the limits of symptomatic treatment and may directly or indirectly exert a favorable influence upon the main disease. But that every rational or empirical indication for the medicinal treatment of the abnormal metabolism of diabetes is wanting is a fact that rests on a much firmer basis than does this concession. When we prescribe any drug in diabetes we are groping in the dark, and must learn by experience in each individual case whether we are following the right path or not.
Having regard to the uncertain basis for medicinal treatment and to the manifold by-effects of the drugs employed, the administration of medicinal remedies should be undertaken only when the physician is in position to control their action by careful observation of the general condition and of the glycosuria. Poisonous substances, such as opium, codeine, antipyrin, salol, etc., should be administered for long periods only when a favorable action is very evident, and it is unjustifiable to prescribe any of these drugs unless the patient can be kept under constant surveillance—indeed, to do so would be little short of malpractice.