Title: Diabetes: Its Cause and Its Treatment With Insulin
Author: Wilder, Russell M. (Russell Morse)
Language: English
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TREATMENT WITH INSULIN ***



  LITTLE BLUE BOOK NO. 875

  Edited by E. Haldeman-Julius

  Diabetes: Its Cause
  and Its Treatment
  With Insulin

  Russell M. Wilder, M. D.

  With an Introduction by
  Morris Fishbein, M. D.

  HALDEMAN-JULIUS COMPANY
  GIRARD, KANSAS



  LITTLE BLUE BOOK HEALTH SERIES

  Edited by

  MORRIS FISHBEIN, M. D.

  Editor, Journal of the American Medical Association
  and Associate Editor, Hygeia, a
  Journal of Individual and Community
  Health.


  Copyright, 1925,
  Haldeman-Julius Company.


  PRINTED IN THE UNITED STATES OF AMERICA



  DIABETES: ITS CAUSE AND ITS
  TREATMENT WITH INSULIN



  CONTENTS


                                                            Page
  Introduction                                                 5

  The Nature of Diabetes                                      17

  The Story of Insulin                                        26

  The Cause of Diabetes                                       33

  The Diet                                                    45

  Treatment in Cases of Mild Diabetes                         50

  The Treatment of Fevers Occurring in Diabetic Patients      53

  Operations on Diabetic Patients                             55

  Miscellaneous Complications                                 56



INTRODUCTION


When the scientific body that awards the Nobel prize each year met to
consider the award for 1923, there was no question or debate as to the
discovery that merited the honor. The prize was granted to Doctors
F. G. Banting and J. J. R. MacLeod of Toronto for their work in the
discovery of insulin, and each immediately donated one-half the award
to colleagues who had shared in this discovery, Doctors C. H. Best and
J. B. Collip.

In November, 1920, Dr. Banting, who had returned from war service,
was practicing medicine in London, Ontario, and was demonstrating
physiology in the medical school of Western University at that
place. While reading an article in a surgical magazine, he chanced
on a sentence which aroused the train of thought that finally led to
his discovery of insulin--a substance that means a longer and more
satisfactory life to diabetics.

The article which he read concerned a gland, known as the pancreas,
that lies close to the stomach and the upper part of the intestines.
This gland is composed of two portions, one of which creates a juice
poured into the intestine, which aids in the digestion of food; it is
the external secretion and it contains trypsin and two other digestive
ferments. The pancreas contains also certain cells which, when seen
through the microscope, are marked off from the remaining tissue and
which are known by the peculiar name “Islands of Langerhans,” the
latter being the name of their discoverer.


_Diabetes centuries old._--Now diabetes is no new disease.

It was described by Aretaeus, a Greek who lived in the third century,
A.D., and hundreds of scientists have worked steadily on the problem
ever since that time. Indeed the history of the discovery of insulin is
typical of all great medical discoveries of modern times. It represents
the summation of a vast amount of knowledge contributed bit by bit
by scientists all over the world. When Banting conceived his idea,
he took it to Dr. MacLeod, director of physiologic research in the
University of Toronto. Professor MacLeod, seeing the possibilities in
the investigation, gave him opportunity to work, and provided him with
a young assistant, Dr. C. H. Best. The particular problem on which
they were to work was the extraction from the pancreas of another
secretion, an internal secretion, not poured by the pancreas through a
special duct into any other organ or to the exterior, but going instead
into the blood stream.

_Pancreas yields substance._--Previous investigations had indicated
that this secretion was manufactured in the Islands of Langerhans.
It was known that when the tube which carries the external
secretion--trypsin--was tied, the trypsin would back up into the
pancreas, and by its digestive action would destroy the glandular
tissue, leaving an organ which consisted chiefly of island tissue.

The investigators did such an operation on a dog. It was also known
that an animal might be made diabetic by removing the pancreas; this
operation was performed on another dog. Then, when sufficient time
had elapsed to permit the breaking down of the pancreas in the first
animal, it was painlessly chloroformed, the pancreas removed and an
extract made from it. The extract consisted chiefly of island tissue,
and this extract was injected into the diabetic dog. The result was the
discovery that such injections produced a lower amount of sugar in the
dog’s blood and in its urine. This and similar experiments established
positively the fact that there was present within the pancreas, and
quite certainly in the island tissue chiefly, some substance, not
available in the body of the diabetic, which was capable of meeting a
deficiency and aiding the diabetic to make proper use of sugar.

_Drug dosage and animal experiments._--It now became necessary to
devise a method of obtaining the extract in such form as to permit
injections into the human being without danger from poisoning by
extraneous and unnecessary substances, in other words, a pure product.
It also became necessary to devise a method for measuring the dose to
be given. How many persons who receive a dose of a medicine realize
the amount of investigation necessary to determine these factors? It
is necessary to test the effects of a drug on animals before it can be
tried on the human being, and it is necessary to study very carefully
the changes in the body following the administration of the drug, in
order to be certain that no undesirable actions occur.

The Canadian investigators worked in a wholly scientific manner.
Their experiments show great attention to the matter of controls. For
each animal that was tested, there was a normal animal with which to
compare it. The investigators used many dogs, and a vast number of
rabbits in making these necessary tests. Not until all the factors of
danger had been thoroughly controlled was the drug administered to
man. Had it been given without the guiding knowledge obtained by the
observations on rabbits, it seems certain that overdoses might have
been administered and patients have died.

_Overdose of insulin dangerous._--The effects of an overdose of insulin
are striking; there is too great a lowering of the amount of sugar,
and severe convulsions ensue which may lead to death. Insulin is a
powerful remedy; its effects are certain and accurately measurable.
If a human being is given too much, his blood sugar falls to a lower
concentration. When he gets it around 0.07 per cent he begins to be
anxious and nervous about himself. He is likely to become pale, or
to flush and perspire profusely. If the blood sugar concentration
goes still lower his speech may become disturbed, and he may even
manifest mental disturbances. These things too may be prevented, and
immediately stopped once they have ensued, by the giving of a small
amount of sugar, as for example in the form of four to eight ounces of
orange juice. These facts also were discovered by properly conducted
experiments.

The investigators now turned their attention to the problem of this
disease in human beings, and the results have already been broadcasted
through medical periodicals, newspapers and magazines. They are far
beyond the early hopes of scientific investigators of the disease.
In that terminal stage of diabetes known as coma, when the patient
sinks into unconsciousness, insulin seems actually to restore life. Of
far greater importance, it offers for the vast majority of diabetics
comfort and extended existence. Its administration is closely bound
with a knowledge of the food taken into the body, for it is known that
a certain amount of insulin will aid the body in handling a certain
amount of sugar. When the physician decides to place his patient on
the insulin treatment, he usually asks that the patient come into a
hospital so that he may first find out the patient’s normal ability to
digest sugar, and it is this ability that the physician supplements by
the giving of insulin.

_Manufacture and sale._--One of the unusual aspects of the insulin
discovery was the method of control in its sale. The discoverers did
not wish to profit unduly by their work, but they were anxious that
its manufacture and application on a large scale be scientifically
controlled. Arrangements were therefore made to have it manufactured
under accurate supervision in the United States by the Eli Lilly
Company, and in Canada by the Connaught Laboratories, and more recently
in certain other home and foreign laboratories.

The process of manufacture is an interesting one. The Islands of
Langerhans constitute a small portion of what is relatively a small
gland. In stock yards and packing houses this gland is called sweet
breads; the sweet breads served under glass in the restaurants are
usually the pancreas of the sheep or hog, since these are small. The
beef pancreas is a much larger organ, weighing about a pound or a pound
and a half.

The method devised by Collip for obtaining insulin from the pancreas
involves repeated extraction of the ground-up pancreas with alcohol,
in order to remove the unnecessary tissue substances. When this is
done on a small scale in the chemical laboratory, there is, of course,
considerable wastage of raw material and of substances used in the
extraction.

The application of the matter on a commercial scale involved additional
problems. They were not only overcome successfully, but continued
improvements have made possible the provision of the life-saving remedy
at a reasonable price.

_Juvenile diabetes._--One of the most striking effects of the work
was the result of the use of the remedy in the diabetes of children,
or juvenile diabetics. This condition had previously been considered
invariably fatal. Now the child may be treated satisfactorily, and it
seems possible that its development under the influence of the drug
may permit a gradual lowering of the dosage to amounts that may be
administered with little expense or difficulty.

After the investigators had completed the trials of the preparation
in their own hospital, plans were made for extensive clinical
investigation in other institutions in which there were men capable of
conducting scientific studies on diabetes. More than 50 institutions
were utilized in order to give the drug the most complete possible
scientific trial before offering it to the medical profession in
general; and when at last these trials were completed and the
co-operating manufacturing concerns had fully developed the machinery
for production of the drug on a large scale, it was released to the
medical profession throughout the world.

_Patients must do their part._--It should be understood that if the
patient is to receive the greatest benefit from this new remedy, he
must co-operate fully and intelligently with his physician. As soon as
he discovers through competent examination that he is excreting sugar
in his urine, he should consult his physician as to the use of the drug
and a proper diet.

In many instances, the use of insulin is unnecessary because the
patient is able to live satisfactorily without insulin on a diet
with the proper amount of sugar or carbohydrate material. In other
instances, the dosage of insulin may be very small, but this will
depend on a careful and intelligent study of each case.

It is now rather generally known by the public that insulin is a
preparation which is administered hypodermically, that is, injected
with a needle under the skin. It cannot be taken by mouth, because
the substance is digested before it can be absorbed into the blood.
This does not mean that the patient must seek his physician for every
treatment, because many competent specialists in the treatment of this
disease have found that patients may be taught to regulate their diet
and use the drug intelligently.

_Recognition of the work._--As soon as it became known that this
discovery was available, diabetics flocked to their physicians and
began to inquire as to the possibilities of its use to “cure” the
disease; but the drug is not in the usual sense of the word a “cure”
for diabetes. Diabetes represents the absence from the body, probably
as the result of disease, of certain substances which are responsible
for the control of the digestion and use of sugar, and insulin cannot
restore these tissues or substances any more than the injections
of other glands can restore youth to the aged. It can only replace
temporarily the substances that are absent; but in the case of a
diabetic, this constitutes the difference between life and death.

Naturally Doctors Banting, Best, Collip and MacLeod have received great
honors at the hands of their colleagues and of the world. The Canadian
government has granted to Dr. Banting the sum of $7,500 per year for
life; the Ontario government has provided $10,000 a year for a chair of
medical research, now held for the first time by Dr. Banting; learned
societies throughout the world have greeted him with the applause
usually accorded only to military heroes.

The victor in the conflict of science with disease is certainly
deserving of the wreath of the conqueror.

  MORRIS FISHBEIN.



DIABETES: ITS CAUSE AND ITS TREATMENT WITH INSULIN


_Insulin a welcome discovery._--The discovery of a method for obtaining
insulin in a form suitable for use in treating diabetes is a cause for
genuine rejoicing. The sensational newspaper and magazine articles
that greeted the discovery were, in a sense, a public expression of
such rejoicing, and their exaggerations may be forgiven if this is
remembered. The effort to gain an understanding and a sure method of
controlling diabetes has taken years, and while the scientist delved
in his laboratory, the seemingly unconquerable disease continued to
take an ever-increasing toll of young and aged victims. In New York
City, for instance, where statistics collected by Dr. Emerson are most
reliable, the deaths from diabetes in 1866 were only 1 for each 2,437
deaths from all causes. In 1923, one death in every fifty-one was due
to diabetes. The diabetic death rate in New York City was trebled
between 1880 and 1920 for ages up to forty-five years. For ages of
forty-five and more, it was quintupled. There are probably more than
a million patients with diabetes in the United States. No wonder then
that mankind in general was overjoyed when the news came that the young
Canadians, Banting and Best, had discovered insulin.


THE NATURE OF DIABETES

_Diabetes a disorder of metabolism._--What is this insulin and what
does it do? Before this is answered, the nature of the chemical
disorder that is called diabetes must be somewhat understood, and
to supply this understanding, a partial review of the chemistry and
physiology of nutrition must be made.

The processes of life are largely chemical. The warmth of the body is
provided by combustion, oxidation of food. If the supply of food is
discontinued, life ends, and the body cools exactly as a gasoline motor
stops and cools off when its supply of fuel is exhausted. Similarly,
if the machinery for transforming food into energy is impaired, life
will lag. This is what happens in diabetes; the disorder is much like
that of a motor which misses fire when its ignition system is out of
order. Food, like gasoline, contains energy, and life results from
the conversion of this potential energy into body heat and muscular
activity. The processes involved in this conversion are spoken of
collectively as “metabolism.” Diabetes is a disorder of metabolism.
There are other disorders of metabolism, but none so common as that of
diabetes.

_Carbohydrate, protein and fat._--The food supply of mankind is limited
to the tissues of plants and animals, and the fuel in all such foods
is either a carbohydrate, a fat, or a protein. Carbohydrates are
starches and sugars; fats are oils, lards and complex materials such
as may be found in brain, and egg yolk; protein is abundant in lean
meat and cheese. Compared to the protein, the carbohydrates and fats
are relatively simple chemical substances, fairly stable and, hence,
easy to study chemically. Proteins are excessively changeable, to which
character they owe their name. Some proteins are called albumins.
Egg albumin, egg white, is a typical protein possessing all of the
essential protein characteristics. The carbohydrates and fats serve
chiefly as fuels, while the proteins, besides providing energy, build
or rebuild the living tissues of the body. A diet may be deficient
in either fat or carbohydrate, and still remain adequate. It must,
however, provide a modicum of protein, since parts of the protoplasmic
machinery of the tissues are constantly wearing out and requiring
replacement.

_Foods are disintegrated by catalysts._--While the conversion of
the energy in carbohydrates, fats and proteins into the life flame
is a process of combustion or oxidation, it is not a simple burning
or explosion, as in the case of the fuel ignited in the cylinder of
the gasoline motor, but proceeds by successive steps or stages. The
earliest of these steps is taken in the kitchen where food is prepared
by cooking. There the starches are softened and partly broken up,
and the proteins are coagulated. The next stages are passed during
digestion, beginning in the mouth, where the ptyalin, a ferment in the
salivary juice, attacks starches, and continuing as the food passes
successively through the stomach and the intestine. Ferments are also
called catalysts. At each and every stage of digestion and assimilation
some catalyst facilitates and accelerates the process of decomposition
in a manner similar to the action of ptyalin on starch, or of yeast in
brewing beer. Consequently, the food, before it has descended more than
half way down the length of the small intestine, has been disintegrated
chemically into fragments that are smaller and, chemically, much
less complex than the original foodstuffs. The starches are split
into sugars, the chief of which is glucose; the fats are broken into
fatty acid and glycerin; the proteins are torn apart and comparatively
simpler structures, the so-called amino-acids, result.

_Sugar in the blood._--The food fragments resulting from digestion
are soaked up through the intestinal wall into the blood and lymph,
both of which fluids circulate freely around the intestine, and in the
blood and lymph they can always be found, if suitable chemical means
are adopted for detecting them. They are abundant in the blood during
the hours following meal-taking, and diminish in fasting. The sugar
glucose, for instance, is present in blood taken early in the morning
in a concentration of about one part in each thousand, or 0.1 per cent,
but when carbohydrates are being digested, one and one-half parts of
glucose in each thousand, or 0.15 per cent are found.

_The rôle of the liver._--The next stages of metabolism occur in
the liver, to which the blood passes immediately after leaving the
intestine. Here is a veritable chemical laboratory wherein innumerable
transformations are worked. Some of them are now understood, and here,
as later elsewhere, at every step of change, a catalyst is present to
facilitate each separate chemical alteration. Many catalysts are very
specific, accomplishing one definite task; others are more generally
active. They have been likened to keys, which, fitting into certain
locks, permit the locks to be turned. Without these catalysts or
accelerators, transformations would occur so slowly that active life,
such as ours, would be impossible.

In the liver much of the sugar is removed from the blood and organized
into a starch-like substance called glycogen. Thus stored, it is
available later, when the blood may be poor in sugar. One of the main
functions of the liver is to maintain a nearly constant concentration
of sugar in the blood, which it does by subtracting sugar whenever, as
after meals, the blood stream is flooded, and adding sugar at those
times between meals, and at night, when the sugar level in the blood is
low.

In the liver, the amino-acid fragments of proteins are partly
destroyed, ammonia is split off from them and changes into a waste
product, urea, which is later excreted by the kidneys. Also sugar is
made from many of the fragments of protein, and this sugar is either
stored away as glycogen with the sugar originating from carbohydrate,
or added to the blood. Nearly 60 per cent, by dry weight, of the
protein eaten is thus changed to sugar, and as a final result of the
normal processes of digestion, and action of the liver, we find that
all of the carbohydrate, approximately 58 per cent of the protein, and
it is supposed, 10 per cent of the fat of the food, eventually finds
its way into sugar.

If we desire to know how much sugar a certain food will add to the
metabolism, that is, the sugar value of the food, we must know both
the weight of the food and how much of this weight is carbohydrate,
how much is protein, and how much is fat. The sugar value will be the
sum obtained by adding the weight of the carbohydrate, 58 per cent of
the weight of the protein, and 10 per cent of the weight of the fat.
For instance, a slice of bread weighing 2 ounces or 60 gm., spread
with one-third of an ounce or 10 gm. of butter would be 32 gm. of
carbohydrate, 6 gm. of protein and 11 gm. of fat. The sugar value of
this mixture would be 32 plus 3.5 plus 1.1 or 36.6 gm. A glass of whole
milk, 6 ounces or 180 gm. of milk, would contain 9 gm. of carbohydrate,
5 gm. of protein and 7 gm. of fat, and its sugar value would be 9 plus
3 plus 0.7, or nearly 13 gm.

After passing the liver, the blood enters the heart which then pumps
it throughout the system of tubes called arteries into all the crevices
of the body. Every tissue is thus bathed constantly with circulating
fluids which contain sugar and the other elements of nutrition in forms
suitable for utilization.

_The liberation of energy in the tissues._--In the blood itself, no
important chemical transformation occurs. The food fragments are picked
out of the blood by the tissues and in the living protoplasms of
each tissue, those important changes occur which constitute the most
essential processes of life. These are, first, the building up of new
protoplasmic matter, namely, growth and tissue repair, and, second,
the liberation of energy by further decomposition and final burning or
oxidation. Again each step of transformation requires the aid of some
energizer or catalyst. The presence of many of these catalysts is only
surmised. Some of them, however, have been captured and their mysteries
are exposed. Among these is thyroxin, which Kendall showed to be the
chief product of the thyroid gland. Thyroxin sets the pace of life.
The rate of oxygen utilization is governed largely by it, so that when
the thyroid gland is destroyed or not functioning, as in some forms of
goiter, energy transformation proceeds at a slower tempo.

_Insulin a catalyst._--We come now to diabetes, a condition which
results from the lack or deficiency of a catalyst called insulin. The
function of insulin, it seems, is to prepare sugar for utilization.

_Diabetes a lack of insulin._--In diabetes, sugar escapes utilization
in whole or in part. As it circulates normally in the blood, it is
locked up, so to speak, and is unavailable either for storage as
glycogen, or for oxidation or other transformation. Its energy is
sealed, and before it becomes available a lock must be turned. The key
to this lock is insulin, and in the absence of this key the normal
means by which sugar is removed from the blood are unavailing, and in
consequence, the level of sugar in the blood rises, and sugar appears
in the urine.

_Symptoms of diabetes._--The symptoms of diabetes are due for the
greater part to the accumulation in the blood and excretion in the
urine of unused sugar. On leaving the body, sugar carries water with
it. A diabetic patient may pass many quarts of urine daily. This is a
phenomenon like the drying of meats or fish by salting them. Water is
subtracted in such amounts that the body dries; even the skin becomes
dry, and the tongue may cleave to the roof of the mouth. Furthermore,
much otherwise available food energy is lost with sugar in the urine.
As much as a pound of sugar may be passed in a day. Consequently,
the tissues starve in the midst of plenty. The appetite, therefore,
is sharpened, but the more the patient eats, the greater becomes the
wastage of food energy, and the more severe the symptoms.

_Acid poisoning._--This is not all or, by any means, the worst. It
so happens that fat, which under suitable circumstances, is readily
metabolized, fails to oxidize smoothly when less than a certain minimum
of sugar is being used. The fats, it is said, burn in the fire of
carbohydrates. If a perfectly normal person is deprived of carbohydrate
and fed only fat and a little protein, certain products of incompleted
combustion of fat will accumulate in the body. These substances are
acetone, aceto-acetic acid, and the hydroxybutyric acid. Acetone is
not very poisonous, nor is hydroxybutyric acid, but aceto-acetic acid
behaves somewhat after the manner of the anesthetics like chloroform.
If a person has diabetes of some severity, acetone bodies may arise
even when carbohydrate is fed because only _burning_ sugar prevents
their formation, and in severe diabetes the carbohydrates fail to burn.

_Diabetic coma._--In diabetes, therefore, such amounts of aceto-acetic
acid may be formed that the patient is actually anesthetized and falls
into unconsciousness. This is diabetic coma, which in the past has been
the chief cause of death in the diabetes of children and young persons.
The proper use of insulin should prevent these deaths from coma.


THE STORY OF INSULIN

_Minkowski’s discovery._--The story of insulin began a generation ago
with the discovery of German investigators, Minkowski and von Mehring.
This was in 1889, and until then the relation of the pancreas to
diabetes was scarcely suspected, and no one had an idea where to look
for the means to check the disease. The pancreas is an organ about the
size of one’s hand which pours digestive juices into the intestine.

_Removal of pancreas causes diabetes._--Minkowski was studying
digestion and it happened in the course of certain investigations, that
it became necessary to operate on a dog and remove this organ. A few
days later it was noticed that flies were attracted in great numbers
by the urine of this dog. The urine was examined, and the reason for
the flies and the relation of the pancreas to diabetes was at once
apparent. The urine contained sugar. Another animal was operated on,
the pancreas removed and diabetes followed. Cats, swine, and frogs were
then experimented with. In every case, complete removal of the pancreas
resulted in severe diabetes, while partial removal caused a more
chronic and milder diabetes.

_The islands of Langerhans._--Previously, in 1869, Paul Langerhans,
described peculiar clumps or islands of cells which differ in
appearance from the bulk of the tissue in the pancreas. In 1890,
Scobolew and Schulze showed that if the ducts leading from the pancreas
were tied off, the islands withstood the destruction that was wrought
in the rest of the organ by backing up of the pancreatic secretions.
Animals treated in this manner did not develop diabetes, and it was
concluded, therefore, that it was the islands that manufactured
the anti-diabetic material of the pancreas. The name “insulin” was
suggested for this material in 1916 by an Englishman, Shafer.

_Previous attempts to obtain insulin._--In the meantime, efforts were
being made by numerous scientists to extract from the pancreas the
anti-diabetic principle. Some of these attempts nearly succeeded. Many
of them failed because it was not known then that insulin is rendered
inactive when it is given by mouth and subjected to the disintegrating
action of the juices in the digestive tract. Innumerable attempts were
made to control diabetes by feeding either fresh pancreas, or pills
and pellets manufactured from the pancreas. Thus far, all such efforts
have been in vain, and yet various drug companies continue to sell
pancreatic pills as diabetic remedies. The results obtained by grafting
pieces of pancreas into dogs previously made diabetic by the removal of
the pancreas have been more successful. The experimental diabetes of
animals so treated can be controlled, but such procedures offer nothing
to mankind, because grafts made from a lower animal to man invariably
atrophy, that is, shrink up and disappear.

_Banting’s idea._--Thus the subject stood when, in the autumn of 1920,
Frederick Banting, recently home from the war, began his work. The idea
came, he writes, while reading an article dealing with the relation of
the islands of Langerhans to diabetes. In his own words, it was this:
“From the passage in this article, which gives a resumé of degenerative
changes in the acini (cells connected with the ducts or passageway
system) of the pancreas following ligation of the ducts, the idea
presented itself that since the acinous, but not the islet tissue,
degenerates after this operation, advantage might be taken of this fact
to prepare an active extract of islet tissue. The subsidiary hypothesis
was that trypsinogen (one of the digestive ferments prepared by the
acinous cells) or its derivatives was antagonistic to the internal
secretion of the gland. The failures of other investigators in this
much worked field were thus accounted for.” In other words, the failure
of his predecessors, Banting thought, was due to the probability that
the digestive juices of the pancreas destroyed insulin before it could
be extracted from the islands, and his plan was to circumvent this
difficulty by first destroying the part of the pancreas concerned in
making these juices.

_The first insulin._--Banting took his idea to Professor Macleod of
the University of Toronto. He received encouragement and facilities
for work, and in the laboratory of Professor Macleod, with the skilled
assistance of Mr. C. H. Best, he put the idea to the test, and it
worked. Dogs made diabetic by removing their pancreas were treated
with material obtained from degenerated pancreas, and could be kept
alive. The sugar in their blood decreased each time this material was
injected beneath the skin and the sugar in their urines diminished.
This was the first insulin. The next step was taken soon after. Banting
and Best knew from the work of their predecessors that the pancreas of
animals in the womb, that is, of embryos or fetuses, show island tissue
some time in their development before the tissue responsible for the
digestive juices is fully formed. It occurred to them, therefore, that
they could circumvent the destructive action of the juices by making
insulin from embryo calves. This was tried, and it succeeded. Enough
insulin was obtained to try on a patient. Later developments permitted
the preparation of insulin from adult animals. Swine and beef pancreas
from the slaughter house became the source of insulin. At first these
preparations contained some protein which made it poisonous, and
unsuitable for use in patients. Another chemist in the University of
Toronto, Professor J. B. Collip, overcame this difficulty, and, with
the co-operation of a group of able physicians in the university,
Doctors Graham, Campbell and Fletcher, the new insulin was used on
a large group of patients, and its value thus became definitely
established.

_Insulin now available for everyone._--Insulin can now be obtained
in every drug store and fortunately, thanks to wise provisions for
maintaining control of its manufacture arranged for by the University
of Toronto, it is everywhere of uniform strength. This matter of
constant strength is of the greatest importance. As will appear later,
danger attends its indiscriminate use, and the dose must be made to
match the amount of sugar derivable from the diet. Unless the strength
of various lots of insulin is constant, accurate treatment would be
impossible. This was recognized early by the workers in Toronto and,
to protect the public, it was decided that insulin must be patented
so that its manufacture could be restricted to those firms who
would permit the control of their products by an insulin committee
in Toronto. The firm of Eli Lilly and Company of Indianapolis put
their plant at the disposal of the insulin committee and assisted in
developing methods of large scale production. Subsequently, other firms
have been licensed, by the insulin committee, to make insulin.

       *       *       *       *       *

The patenting of discoveries by physicians is usually frowned on by
physicians. It is opposed to the ethical code of the profession. The
patenting of insulin, however, does not violate this ethical code
because the patent, while secured in the name of Doctor Banting
and his associates, was given outright by them to the University of
Toronto to be used, not for any commercial advantage, but as a means to
guarantee that this splendid discovery would not be exploited by others
to its discredit.

_Insulin described._--Today, insulin, as sold, is a clear, watery
solution. A small vial contains 50, 100 or 200 units, as indicated on
the label. The strength of the unit is standard. A unit of insulin will
have a certain definite lowering effect on the sugar in the blood of a
normal animal. The rabbit is chosen as the test animal. In the patient
with diabetes, a unit of insulin will increase tolerance, that is, it
will add to the amount of sugar that can be utilized, from 0.5 gram to
4 grams, depending on the character of the diet and the presence or
absence of complications. The average patient uses between 10 and 30
units a day. The cost has been reduced to below one cent a unit, so
that insulin is now brought within the reach of everyone. Indeed, the
cost is negligible when we consider that patients who, without insulin,
were helpless invalids, dependent on relatives or charity, are now as
fit and strong as their neighbors, and able to work again.



THE CAUSE OF DIABETES


_Disease of the pancreas a cause of diabetes._--The pancreas, whose
removal Minkowski showed caused diabetes, is located in the abdomen
near the stomach and pours its digestive juices through a channel
or duct into the intestine. The organ has a second function, as has
been told above, namely, to make insulin. This second product, which
is elaborated by the islands of Langerhans, goes into the blood. The
Langerhans islands are properly regarded as a distinct and separate
organ. They are, however, so intimately associated and intermingled
with the rest of the pancreas that any disease or injury of the
pancreas may affect them seriously, reduce their insulin-making
capacity and thus cause diabetes. Actually a large part of the pancreas
may be destroyed before diabetes results. In dogs, little more than
one-tenth of the gland remaining intact is sufficient to prevent the
excretion of sugar. Men are more susceptible to diabetes than dogs, but
even in men the pancreas may be seriously affected by inflammation or
cancer before its insulin capacity is reduced to the point where actual
insulin shortage is manifest.

The body is so constructed that every organ has a factor of safety. A
very large amount of the liver, for instance, can be diseased before
any failure in its function is detectable. The same is true of the
kidneys and of the heart, and the factor of safety in the case of the
pancreas explains why we do not all have diabetes. Very few people have
a normal pancreas, because inflammations in organs near the pancreas
are fairly common; for instance, inflammation of the gallbladder, and
very frequently the pancreas is involved in such inflammation. However,
the number of persons with known gallbladder disease who develop
diabetes, is not appreciably greater than that of persons without any
evidence of such inflammations.

_Hardening of arteries a cause of diabetes._--The pancreas may be
injured, as is true of all of the organs of the body, by disturbance
of its blood supply, especially through hardening of the walls of
the arterial tubes which bring it its blood, and narrowing of their
lumens or passageways. Older persons with hardened arteries may develop
diabetes in this manner. On the other hand, many persons have extreme
arterial disease and consequent destruction of pancreatic islands
without diabetes.

_Infections a cause of diabetes._--The delicate tissues of the
pancreas, just as in the case of other organs, may be poisoned in
the course of a general disease, such as scarlet fever, mumps, or
influenza and, in consequence, diabetes may result from such diseases.
There is, however, nothing specific in this. A certain number of
cases of diabetes can be traced to a preceding acute intoxication of
this character, but it is by no means true that any one of the known
infections is always followed by diabetes.

_Functional overstrain the chief cause of diabetes._--Functional
overstrain is a recognized cause of disease, especially of the heart,
but also of other organs. The heart may be irreparably injured by
excessive exertion. Functional overstrain of the pancreatic islands
resulting from long continued overeating is a cause of much diabetes.
Persons who persistently overeat are usually markedly overweight. Some
thin people are also equally prone to overeat, and yet, for some thus
far unknown reason, remain thin.

_Obesity a mark of overeating and functional overstrain of the
pancreas._--The rule, however, is that overeating leads to obesity,
and it is a well known fact that many diabetic patients are, or have
been, overweight. Dr. Joslin, for instance, found among 1,000 diabetic
patients, 75 per cent who either were, or had been, over normal
weight. Dr. Joslin says that it takes ten diabetic patients to make a
ton of diabetes. Overeating with attendant long continued functional
overstrain of Langerhans islands is probably the most common of all
causes of diabetes.

_Sugar eating._--It is of considerable significance that the increasing
incidence of diabetes in America is coincident with the enormous
increase in the sugar consumption. In the decade 1880 to 1890, the
annual sugar consumption was 44 pounds per capita. In 1921, it had
risen to 84 pounds, and in 1922 to 103 pounds. The death rate for
diabetes in 1890 was 5.5 for each 100,000; in 1921, it was 16.8 for
each 100,000. It is easier to overeat of sugar than of almost any other
food known, and it is probable that sugar imposes a greater functional
strain on the pancreas than do the starches or fats. Starches swell up
and fill the stomach readily, thus checking the appetite; furthermore
they are slowly absorbed into the blood. Sugar goes into solution,
passes the stomach quickly, is absorbed almost instantly and at
once demands attention from the pancreas. The common desserts are
sweets. When we are glutted with meat and potatoes, we still have
room for sweets and we can always find room for candies. The rage for
soft drinks since the abolition of alcoholic beverages is certain
to increase the crop of new cases of diabetes. I have seen several
patients who have been suddenly precipitated into an extreme stage of
diabetes and coma by a soft drink spree.

_Diabetes may occur without provocation._--Not infrequently, among
younger persons and children, diabetes appears out of a clear sky with
apparently no provoking cause. No inflammation has occurred in the
pancreas of these patients, so far as any good evidence shows; they are
young and therefore not afflicted with arterial disease, and they have
never been overweight and have not overeaten. How can we explain the
diabetes of these children and young persons, and how can we explain
why some fat persons and not all escape diabetes, and why some patients
with very little disease of their pancreas have diabetes and others
with very extensive destruction of the pancreas do not have it?

_Heredity of the tendency to diabetes._--The answer, probably, lies in
the more or less shadowy realm of heredity. Some of us are born with
weak eyes and others with weak islands, and the degree of original
island weakness determines the susceptibility of the islands both to
functional overstrain from overeating and to injury from infectious
diseases or from poor circulation of the blood. If the diabetic
tendency of an individual is marked, diabetes may develop, in very
early life. The pancreas here is too weak to withstand the normal
functional strain of growth. When this is the case, the disease is
of extreme severity. If the diabetic tendency is slight, it may not
show itself except as the result of long continued overeating. If the
pancreatic islands are functionally strong, they withstand infections
and injury from disease or poor blood supply; if weak, they fail and
diabetes results. Diabetes rather infrequently occurs in several
members of the same family, but the fact that this happens rather
infrequently does not mean that the tendency fails to pass by heredity.
Many persons who are considered normal may have this tendency without
showing any evidence of it throughout life.



THE TREATMENT OF DIABETES

_Prevention._--A stitch in time will save nine diabetic patients.
Typhoid, small-pox, diphtheria, yellow fever and a number of other
diseases have been practically eliminated. Tuberculosis, otherwise
known as the white plague, is rapidly being chained. Why not do
the same with diabetes? We have seen that overeating is the common
cause. Let us, therefore, teach the virtues of keeping lean and fit.
Incidentally, such teaching may help to control other chronic diseases.
There is reason to believe that heart trouble, high blood pressure,
gallstone and cancer, occur in the obese with greater frequency than in
the lean. Obesity is a mark of long continued functional overstrain of
all the organs of the body. Overeating of carbohydrates and proteins
is especially injurious to the pancreas. In Berlin, during the war
when the food supplies of the populace were greatly reduced and sugar
and meat in particular were scarce, the number of new patients with
diabetes decreased immensely. In America, with growing luxury and
rising sugar consumption, diabetes is increasing by leaps and bounds.
The Jews, as a race, have much diabetes, not because they are Jews,
but because so many of them are luxury lovers, overeaters, and fat
Jews. Diabetes cannot be entirely eliminated by preventing overeating.
As we have seen, thin people are not immune if the heredity tendency
in them is strong; and they develop the severest form of diabetes at
a relatively tender age, and yet it is possible that even the number
of these may be reduced in time. A leading authority once published
the family trees of a number of diabetic families and these family
trees suggest that the tendency to diabetes becomes stronger with each
succeeding generation. In the grandparents the disease was mild and
came on late in life--not until they had overeaten, presumably, for
many years and were fat. In the parents the disease was more severe and
appeared earlier in life, the result, presumably, of less overeating.
In the third generation, the disease occurred in the children with
still less provocation from overeating. Perhaps we can save our
grandchildren, therefore, by keeping ourselves fit, and thus stamp out
the diabetes of childhood which is always severe and, therefore, the
most dreaded. It is worth a trial.

_Detection of early cases._--Doctor Joslin, who has done more than
anyone else to teach the diabetic people of America how to keep well
and strong, urges that everyone have the urine tested annually on his
or her birthday. Life insurance examinations, are now fortunately
much more frequent than formerly, and reveal numerous early cases of
diabetes. Diabetic patients, who have been properly treated, are
trained to make the sugar test of the urine. It is the duty of everyone
of these to examine the other members of their families at frequent
intervals. Why not teach this simple test to the students in the
classes in chemistry in our high schools and urge them to keep a watch
on the members of their families? Every druggist certainly should be
familiar with the test and should be willing to make it on request, for
a nominal fee.

It makes a great deal of difference whether a patient comes to the
doctor early or late. With the better methods of treatment, the
earliest cases are being arrested, if not cured. Some of them may
be cured. It is still too soon to know. There is little hope of
strengthening a severely weakened pancreas, or of accomplishing
curative results in patients who have had the disease very long.

_Treatment._--The treatment of the patient is based on certain
principles which follow logically from the foregoing about the nature
of the disease.

_Principles guiding treatment._--If diabetes is due, as seems most
likely, to the overstrain of a pancreas weak by heredity, the obvious
way to manage it is to reduce the strain. This is exactly the same
principle that guides us in treating heart disease. Physical rest
accomplishes wonders for the heart. Careful dieting does the same for
the pancreas. By so arranging the diet that the total amount of sugar,
that is, the load on the pancreas, is reduced, we accomplish, first,
the disappearance of sugar from the urine, second, its decrease in
the blood, third, the control of annoying symptoms, such as excessive
urination, excessive thirst, and dryness and itching of the skin.
Simultaneously, we give the pancreas a chance to pick up and regain
some strength.

In mild cases of diabetes the results obtainable by diet are entirely
satisfactory and the milder the case the less the food restriction
necessary. In severe cases of diabetes the dietary treatment alone
is less satisfactory because the diet has to be cut so low that the
patient is improperly nourished. Before the discovery of insulin was
made, every such case presented a bitter dilemma. Either the diet
was restricted to the point where the patient literally starved to
death, or the patient could be fed; but, in that case, death from
diabetic coma was to be anticipated. It is in such cases, particularly,
that insulin is proving a boon. With insulin at our disposal, cases
of severe diabetes can be converted into mild cases. All that is
necessary is to give enough extra insulin every day to raise the
patient’s tolerance for sugar, and then, with a careful but adequate
diet, he can enjoy normal strength and health and carry on with his
usual occupation. This is not curing diabetes, but it is eliminating
the worst of its terrors.

_The diet can not be disregarded._--Some persons may ask why dieting
is necessary with insulin? If, as seems true, the only metabolic
disturbance in diabetes is a lack of sufficient insulin, then we should
be able to correct this fault completely by giving sufficient insulin,
and to eat what we want. This may be sound, theoretically, but is
impractical for the following reason.

An uncontrolled normal diet contains approximately 300 grams, or 10
ounces of carbohydrate, 150 grams, or 5 ounces of protein, and 90
grams, or 3 ounces of fat. In the course of assimilation, about 400
grams of sugar are derived therefrom, and, to metabolize such an amount
of sugar, 150 to 300 units of insulin must be necessary. A normal
person probably makes, in his pancreas, 200 or 300 units of insulin
a day, which is sufficient for any normal demand, but this natural
insulin is doled out to his tissues, a bit at a time, so that there is
never an excess of insulin in the blood.

_Excessive insulin harmful._--In severe diabetes the pancreas
manufactures very little insulin, not more than 20 or 30 units, and
the balance necessary for the day’s work must be given by hypodermic
syringe in two or three doses. If the total amount of extra insulin
necessary daily were 150 units, each hypodermic injection would be 50
units, and it is difficult to give such large doses as this without
causing a temporary excess of insulin in the blood. Unfortunately,
excessive insulin is as disagreeable as inadequate insulin. When too
much insulin is present in the blood, the blood sugar falls to very low
levels and a reaction occurs with symptoms that may be alarming, and
results that may be serious. Consequently, very large single doses of
insulin must be avoided and the total amount of sugar entering the body
daily must be measured and made to balance with the insulin doses. This
means dieting.

Furthermore, it proves to be very difficult to keep the level of the
blood sugar low with insulin when diets are very rich in carbohydrate.
The normal sugar level, as I have said, is 0.1 per cent. In
uncontrolled diabetic conditions, it may be found as high as 0.5 per
cent, or higher. This can be reduced by an insulin injection, but as
soon as food rich in carbohydrate is eaten, back comes the sugar to a
high level. In order to rest the pancreas, the blood sugar must be kept
low, which can only be accomplished when the diet contains relatively
little carbohydrate.



THE DIET

_Calories and sugar should be low._--All of the principal authorities
on diabetes are agreed that a diabetic patient must not overeat and
become fat. In other words, the total amount of food energy, that is,
calories, must be limited. All are agreed also that the diet must be
kept low in sugar producing foods. This means little carbohydrate and
little protein. The diet in health, as I have said, includes a great
deal of carbohydrate, probably more than is wise even for perfectly
normal persons. The diet in diabetes must get more of its calories from
fat and less from the starches and meats. Authorities are furthermore
agreed that an excessive restriction of carbohydrate (sugar and starch)
may be dangerous, because with such very low carbohydrate diets the
fats may fail to be properly assimilated, with resulting acid poisoning.

_The authorities agree on general principles._--The actual procedures
in diet-planning employed by various authorities differ but little,
and only as to details. Doctor Allen, for instance, believes in much
greater restriction of total food than do others. Doctor Joslin also
favors rather low total food amounts and disbelieves in allowing much
fat unless rather large amounts of carbohydrate can be taken. Doctor
Woodyat of Chicago, the doctors in the Toronto Clinic, and Doctor
McCann at the University of Rochester, New York, plan their diets in
such a way that approximately one part of carbohydrate will be taken
for every two and one-half parts of fat. Professor Petren of Lund,
Sweden, now the leading authority in Europe, and Doctor Newburgh and
Doctor Marsh of the University of Michigan, believe that restricting
protein is of extreme importance, and that if this is done acidosis
can be avoided even when larger proportions of fat are fed. In the
Mayo Clinic, the practice is to limit protein rigidly and to limit
carbohydrate rather more strictly than is done elsewhere, making the
diet consist to a greater extent of fat, but planning this so that the
total energy of the daily food supply will meet quite closely actual
energy requirements. The procedures for arriving at these several diets
can be found in various manuals that have been written for patients.

_Books on diabetes for patients._--Doctor Joslin’s “Diabetic Manual,”
Lea and Febiger, is one of these. Doctor Petty’s “Diabetes, Its
Treatment by Insulin and Diet,” F. A. Davis Company, Philadelphia,
is another. Wilder, Foley and Ellithorpe’s “A Primer for Diabetic
Patients,” W. B. Saunders Company, Philadelphia, may be consulted for
more complete descriptions of the methods employed in the Mayo Clinic
than can be given here.

_Patients must be trained._--The results of accurate management are so
encouraging that they are almost as good as cures. They are not cures,
because the fundamental island weakness is rarely if ever completely
corrected, and treatment must continue for month after month. Success,
therefore, rests largely in the patient’s hands and the doctors’ most
important task is teaching the patient all that he can be taught about
his diet and about the use of insulin. The books mentioned were written
to help in this training of patients. In various clinics over the
country, patients attend classes and are instructed in the subject of
dietetics until they can weigh food and plan meals accurately so that
each will contain a set number of calories and yield to the metabolism
a predetermined amount of sugar. The hospital management of a case of
diabetes is not complete until the patient can live a healthy life
in spite of his disease. He may arrive at the hospital in a state of
coma and be dragged from the very jaws of death with insulin, but
afterwards, when he goes home, unless he has learned how to continue
the use of insulin and combine with it an accurate diet, he will slip
again into the same dangerous predicament.

It is best always to start treatment in a hospital where a systematic
course of instruction can be obtained. Unfortunately, we have no
schools for diabetic patients other than the hospitals, and some
persons dislike hospitals. Good results can be obtained at home,
provided one has the good fortune to consult a physician who will take
the time to give this training. What are the essentials?

_What the patient must know._--First, a knowledge of how to read
food tables and, with their aid, to plan accurate diets. Food tables
are lists of foods showing the composition of each, in protein,
carbohydrate and fat. The books mentioned here all contain such
lists. The most complete table is that published by the United States
Department of Agriculture, Bulletin No. 28, “The Chemical Composition
of American Food Materials,” a pamphlet that may be had from the
Superintendent of Documents, Government Printing Office, Washington,
D. C., for the small sum of ten cents.

Second, instruction in the manner of injecting insulin, that is, in
the use of the hypodermic syringe. Insulin, as has been stated, must
be given hypodermically, under the skin. The technic is not difficult,
but sterile precautions must be observed in order to avoid introducing
disease germs with the insulin.

Third, instruction in how to test the urine for sugar. This is a simple
task but of great importance. Sugar in the urine is the first signal of
inadequate treatment. To postpone correcting the mistake until other
signs appear such as thirst, excessive urination, and loss of strength,
is to court disaster. The sugar test can be completed in three minutes,
and should be made every day, preferably on a specimen of urine passed
just before the patient retires for the night. This specimen should be
sugar-free. If it is not, more insulin is needed or the diet requires
readjustment.

Fourth, advice concerning how to meet certain complications which I
shall discuss later.



TREATMENT IN CASES OF MILD DIABETES


There are instances of patients with diabetes who have lived for twenty
years or more without any effort at treatment. This consoling thought
must not make unwary the patient with a moderately severe or severe
form of the disease. It is safer to overrate the seriousness of the
condition than to commit an irreparable blunder and neglect the careful
management of a serious condition. Children and young adults, for
instance, may seem well during the first year after the appearance of
sugar, but with few exceptions they develop the severest form of the
disease later unless they are very carefully treated from the first.

A good many older persons may be treated satisfactorily with much less
dietary restriction than is necessary in the severe cases. When this
is possible, insulin is not needed and should not be used, or, in
other words, if a condition is serious enough to require insulin, it
is serious enough to require an accurately weighed diet. Occasionally
patients have so little intelligence that it is hopeless to expect
them to carry on the weighed diet in their homes. For such, and also
for patients with very mild diabetes, the following general advice is
usually beneficial:

1. Avoid sugar and all foods made with sugar, such as candy, jelly,
marmalade, syrup and molasses, pies, cakes, puddings and pastries.
Saccharin may be used if desired: one-fourth grain saccharin will equal
one teaspoonful of sugar in sweetening value.

2. Avoid cereals (breakfast foods) and cereal products, such as mush,
macaroni, spaghetti and noodles.

3. Use bread only in very small amounts, not over one ounce at a meal.
Whole wheat or white breads are preferable to any so-called diabetic
breads. Gluten bread, brown bread and corn bread vary widely in
compositions and it is safer to avoid them.

4. Potatoes, bananas, apples, peas, dried beans, carrots, beets,
turnips and onions should be used in small quantities, and not oftener
than once a day.

5. Dried fruits should be avoided. Use fresh fruits whenever possible.
Fruits canned without sugar are permissible. They may be purchased
on the market or prepared at home. Fruits may be taken every day as
substitutes for other desserts.

6. Vegetables that grow above the ground, except peas and dried beans,
should be eaten in quantities sufficient to avoid hunger. Three
ordinary servings of these vegetables may be included in each meal.
Canned vegetables are palatable and wholesome. Fresh vegetables are,
however, preferable.

7. Meat and eggs should be eaten sparingly. As much harm may result
from excessive protein as from excessive carbohydrate. The diet for
the day should never contain more than 60 grams (2 ounces) of lean
meat, weighed cooked, and three eggs. Thirty grams (1 ounce) of bacon,
weighed cooked, may be included. Meat includes chicken, game, and fish.

8. Fats, including butter or oleomargarine, nut butter, bacon fat,
olive oil, Wesson oil, or other salad oil may be eaten freely.

9. Cream is a very useful food for diabetic patients, and may be taken
freely. Milk is relatively high in carbohydrate and less nutritious.

10. The amount of fat, such as butter or cream, should be adjusted
so as to provide adequate, but not excessive, nutrition. A rising
body-weight calls for less food and, under such circumstances, the
amount of fat should be reduced.

11. Coffee and tea should be used sparingly, not in excess of one
cupful of either at each meal.

12. Condiments, such as salt, pepper and vinegar, may be used in
reasonable amount.

If sugar appears in the urine, bread should be omitted. If it persists
after thus reducing the carbohydrate intake, the condition of the
patient is severe enough to warrant instituting the more accurate
management discussed herein.



THE TREATMENT OF FEVERS OCCURRING IN DIABETIC PATIENTS


_Fevers increase the need for insulin._--Today, with insulin, a
properly dieted patient is as robust and capable as his normal
neighbor. His handicap is the continued necessity for keeping his
enemy under control, but if this control is watchfully maintained, he
should live as long and as useful a life as do his fellows. However,
throughout his life he is exposed, as are his fellows, to diseases
other than diabetes. Measles, mumps, scarlet fever, diphtheria, acute
colds, influenza, pneumonia, and other germ diseases, the so-called
infectious diseases, will attack him, and when they do they invariably
aggravate his diabetes and, by preventing the utilization of his
sugars, subject him to the danger of acid poisoning from smoldering
fats. Therefore, when such complications occur, a patient must have
insulin, whether he has been able to do without it before or not, and
usually the doses necessary to control these critical emergencies
must be large. For instance, a patient on a set diet, whose urine
remains free from sugar with 20 units of insulin, may require 40 units
daily whenever he takes cold. A serious infection like pneumonia may
make it necessary to use 80 units of insulin daily. Under normal
circumstances, a patient taking 20 or 30 units of insulin daily, does
very well when this is divided into two doses of 15 units each, and one
dose is injected before breakfast, and the second before the evening
meal. During an attack of pneumonia or any other fever-producing
complication, it may be necessary to resort to four injections, spaced
at six-hour intervals. It is usually necessary to modify and reduce
the diet when a patient is sick. It is always wise to eat less. In
particular, the fat allowance of the diet should be reduced. It is
wise not to reduce the carbohydrate. The patient with fever may be
nauseated during the course of a fever and refuse all food. Under
such circumstances, less insulin may be required; usually, however,
large doses are still necessary. The reason for this is not clear,
but apparently the poisons created in the course of germ diseases
counteract the effect of insulin. During disease, the urine should
be examined every six hours and the dose of insulin necessary may be
judged from the amount of sugar found.



OPERATIONS ON DIABETIC PATIENTS


_Special precautions necessary in operating on diabetic patients._--It
is self-evident that a person with diabetes is no less likely
to develop appendicitis, gallstones, or cancer than he would be
without diabetes. Consequently, serious operations are occasionally
necessary. The danger from such procedures is many times greater in
diabetic patients than in others, unless the diabetes is closely
controlled. Formerly one out of every three operations on diabetic
patients terminated fatally. This was because the anesthetic, ether
or chloroform, provoked acid poisoning, and because the enfeebled
patient was little prepared to withstand the shock of loss of blood,
and injury. The added danger of diabetes may be avoided if the patient
is in good condition before he goes to operation, and if acidosis is
promptly combated with insulin. It is wise for the diabetic patient to
employ only a very skillful surgeon, and to make certain either that he
is familiar with the treatment of diabetes, or that he has associated
with him some physician who has had a considerable experience with
diabetes.



MISCELLANEOUS COMPLICATIONS


_Arteriosclerosis._--When we pass the age of thirty-eight, we are
enjoying life which was denied our grandparents. The expectancy of life
for a newborn baby in 1860 was thirty-eight years. Now it is nearly
sixty years. This accounts, in a large measure, for the specially rapid
increase in the amount of diabetes among people more than forty-five,
and for the larger incidence today of other diseases of a chronic type.
Hardening of the arteries, or arteriosclerosis, is a complication with
which older diabetic patients are frequently afflicted. As has been
said, arteriosclerosis may be a cause of diabetes in a predisposed
person, but be that as it may, diabetes, once established, unless
controlled, aggravates and intensifies disease of the arteries. It is,
therefore, important for the older diabetic patient to make a serious
effort to avoid arteriosclerosis by keeping his diabetes checked.
Most of the complications which harass and endanger the older patient
are due to hardening of the arteries. In this disease, the elastic
contracting tissue in the hollow muscular tubes that carry blood is
replaced, bit by bit, with scar tissue.

_Apoplexy, heart trouble, gangrene._--The walls of the tubes thicken,
become brittle, and what results? A vessel in the brain breaks, and
hemorrhage in the brain may cause apoplexy. A vessel may also break
in the eye. The amount of blood that can pass through the narrowed
tubes is too little to supply the beating heart, and pain results,
called angina, or irregular heart action or even heart failure. The
circulation in the legs is restricted, and pains result, and sometimes
gangrene. Coma, it will be remembered, is the chief cause of death
among younger diabetic patients. Coma can now be prevented and no
one should die from coma. Gangrene is the chief cause of death among
older patients. In gangrene, usually of the legs, the tissues lose
their vitality because of lack of blood; infection follows and blood
poisoning results.

_Prevent gangrene._--We must prevent these deaths from gangrene. It can
be done by watchfulness and attention. Keeping the urine sugar-free is
the first requisite. Gangrenous ulcers of the feet can be made to heal
by vigorous treatment with insulin, and diet. It is of great importance
to encourage the circulation in the feet by massage and proper
exercises. Finally, care in avoiding bruises and cuts of the skin of
the feet will prevent much trouble. Every old diabetic patient should
wash his feet daily, wear clean stockings, and very comfortable shoes.
Watch and guard the feet. Achilles, the Greek hero, must have been
a diabetic. The only vulnerable spot on his body was his heel. When
before the walls of Troy the spear of Paris touched him on the heel, he
died. Watch and guard the feet.



Transcriber’s Notes

Page 18: “fairly stabile” changed to “fairly stable”

Page 25: “like coloroform” changed to “like chloroform”

Page 39: “Overeating of carboydrates” changed to “Overeating of
carbohydrates”

Page 52: “excessive carhobydrate” changed to “excessive carbohydrate”

Page 55: “one out of overy” changed to “one out of every” “with a
diabetes” changed to “with diabetes”

Page 56: “be that is it may” changed to “be that as it may”

Page 57: “my cause apoplexy” changed to “may cause apoplexy”



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