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Diabetes Detectives

Oliver also observed that diabetes "is difficult to cure . . . particularly when it arises in broken constitutions and intemperate habits." But he nonetheless suggested a laundry list of possible therapies—including Rollo's animal diet, "Peruvian bark" (a source of quinine), and "chalibeate [sic] tonics." Chalybeate waters (iron- and mineral-rich waters) were used widely at the time to promote health.

In addition, Oliver suggested bloodletting and inducing "blisters on the loins" as treatment options that "may always be tried unless there is a broken constitution." These two ancient practices were widely used for many maladies until the end of the 19th century. Oliver's advocacy for blistering implies a lingering suspicion that maybe diabetes was, after all, a disease of the kidneys—that blisters on the loins would allow what physicians of the time termed "bad humors" to exit from the kidneys.

In August of 1798, the Dartmouth Board of Trustees voted that everymedical student "shall read and defend a dissertation on some medical subject . . . sixteen copies thereof to be delivered to the President for the use of the College and the Trustees." In 1812, the Trustees amended the requirement, calling for each dissertation's "principles [to be] defended by the author at a public examination in the University Chapel." Over the next 84 years—until the practice was discontinued following an 1882 vote by the faculty—Dartmouth medical students wrote more than 1,200 theses on a variety of subjects. All of them reside today in the Dartmouth archives; six are on the topic of diabetes. These six theses provide further insight into the evolution in what Dartmouth medical students were taught about the disease.

In his 1825 "Dissertation on Diabetes,"William Pratt—while "confessing" that diabetes was a disease of "rare occurrence" and one he was not "personally acquainted" with—reviewed many of its aspects. He vacillated between attributing it to a "morbid state of the liver" and "a disordered state of the stomach." Seemingly unaware of Dobson's observations about elevated glucose in the blood, he rehabilitated a theory that had been proposed by a granduncle of the famous naturalist Charles Darwin, suggesting that chyle (a lymphatic fluid in the intestine) could pass

DMS founder Nathan Smith clearly relied heavily in his teachings about diabetes on this early clinical study of the disease by British surgeon John Rollo. It was published in 1797, the same year that Smith founded DMS.

Dartmouth medical student Ezekiel Allen chronicled a lecture that Nathan Smith delivered at 8:00 a.m. on November 7, 1816. Smith said diabetes "is apt to be fatal; the urine in this case is sweet. It varnishes the floor, stiffens cloth, the breath has a peculiar odor."

directly to the kidneys by "retrograde action." The saccharine contents of the stomach could thus, Pratt proposed,make their way into the urine without appearing in the blood. Alternatively, he suggested that the kidneys may become "morbidly excited" and as a consequence "form the saccharine matter found in the urine of diabetic patients."

Jonathan Brown, in his 1828 thesis "On Diabetes," correctly predicted that sugar would always be found in the blood of diabetics "once sufficient testing

techniques are developed." The ultimate "cure" for the disease, he wrote, lay in perfecting a regimen of "strict diet control"—an idea in line with modern thinking. He appears to be the only one of the six thesis-writers who had actually seen a case of diabetes. He lamented not having used a purgative—a drug that cleans out the bowels—to deal with this patient's "morbid irritation," as he put it. "My remarks in relation to purgatives in diabetes were suggested by a case which came under my inspection, where my neglect of the bowels was followed by a sudden increase in the quantity of urine. And were another case presented to me from the impression of this fact, I should be led to the efficiency of regular purging."

In 1835, William Brown titled his thesis simply "Diabetes." He made a conceptual leap, suggesting that the body itself produces the glucose present in diabetics' urine, presaging our current-day recognition of the impact of gluconeogenesis (the production of new glucose) in hyperglycemia. "The blood contains plenty of Carbon, Hydrogen, and Oxygen," he wrote, "and why may not they be combined in the proportions to form sugar in preference to the combination which constitutes the composition of urea?"

Story Goss wrote a thesis in 1856 on "Diabetes Mellitus." He drew in part on an important text in the Dartmouth library, William Prout's Inquiry Into The Nature and Treatment of Diabetes, Calculus, and Other Affections of the Urinary Organs, published in 1826. Goss's paper indicates that he had knowledge of two important developments in the emerging science of metabolism. First, he was clearly aware of the important observations of Dr. Claude Bernard, a French physiologist who in 1848 demonstrated that the liver could be a source of glucose and identified glycogen as its storage form. But rather than postulate that the liver was synthesizing and releasing excessive glucose, Goss claimed that the problem lay in the lungs. Glucose metabolism was known to generate carbon dioxide, and Goss assumed that process occurred exclusively in the lungs. He went on to suggest that hyperglycemia arises because the lungs are limited in the amount of glucose they can metabolize, so they dump unmetabolized glucose into the bloodstream.

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