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Public Health Aspects of Diabetic Therapy

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PUBLIC HEALTH ASPECTS OF DIABETIC THERAPY
Thesis for the Degree of M.D.
University of Glasgow
by
James Little Rennie
M.B.,Ch.B.,D.P.H.,F.R.F.P.S.(Glas.)
ProQuest Number: 13849766
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C O N T E N T S
Preface
ChaP ter
<
PART
X
1
Introduction ............................
2
The Treatment of Diabetics in
the Community
............... 19
3
The Clinic as a Diagnostic Centre....... 23
4
The Clinic as a Treatment and
Welfare Centre
............... 28
5
The Diabetic Clinic as part of the
Public Health Service.......... 48
PART
6
1
II
The Ammonia Coefficient of the Urine
in Treated Cases of Diabetes - The
Effect of Diet
...........
54
7
The Relationship of Cost of Diet to
Dietary D e l i n q u e n c y ....................64
8
The Relationship of the Calorific
Value of the Diet to Dietary Delinquency
70
9
Conclusion
............................ 75
Appendix 1
76
Appendix 2
91
Appendix 3
100
Appendix 4
104
Appendix 5
106
Appendix 6
110
Bibliography .......................
112
PREFACE
This thesis embodies the experience which the author
gained in organising and conducting a diabetic clinic
at the Western Infirmary of Glasgow and research work
which was undertaken at that clinic.
Part I deals with the need for a public diabetic
service in the treatment of poorer patients and its
organisation.
The establishment of such a clinic
might not be considered original work, but this
specialised type of clinic was a novel departure at
the above institution, new ground had to be opened
up and unforseen obstacles overcome.
Much experience
was thus gained which would be of value to others
embarking on a similar task.
Since leaving the Western
Infirmary I have been engaged in Public Health work
and am now able to view the treatment of this disease
from both the voluntary hospital and public health
administrative aspects.
In Part II are set forth investigations carried
out during the tenure of a Carnegie Research Scholarship
and while I was in charge of the clinic.
J.L.R.
Public Health Department,
Town Hall,
Leyton,
Essex.
P A R T
I
CHAPTER
I
INTRODUCTION
Diabetes Mellitus was, until recent years, regarded
as a relatively rare disease.
During the past three decades
its occurrence has been much more frequent and since the
discovery of insulin it has taken quite a prominent place
in the medical world.
Tables I and II, the figures of which have been
calculated from the Registrar General1s Statistical
Reviews of England and Wales for the years 1911 - 1937,
show that, while the general death rate has definitely
decreased and that due to tuberculosis has been reduced
by fully 50%, the diabetic death rate has increased by
over 60%.
Similar findings have been noted by Defries
and his co-workers (1) in Ontario for the years 1909 1937.
In New York Tiber (2) found at the Bellevue
Hospital that the percentage of deaths due to diabetes
during the period 1911 - 1916 was 0.95% compared with
2.1% in the years 1929 - 1934.
The corresponding
percentages for New York City were 1.26% and 2.63%.
Diabetics constituted 2.8 per 1,000 admissions to the
above hospital in the earlier period, while during the
later period this proportion was 9.7 per 1,000.
The
general admissions to the hospital had increased by 44.6%
and the diabetic by 395%.
Lemann (3) reports that in
the New Orleans Charity Hospital from 1909 - 1919 diabetics
-
1
-
- 2 T A B L E
I
Statistics for whole of England & Wales
Persons Death Rates per 100,000
Year
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
All Causes Tuberculosis Diabetes
1458
1338
1379
1398
1590
1473
1480
1828
1370
1242
1211
1277
1158
1221
1215
1162
1233
1166
1344
1144
1229
1204
1230
1190
1175
1214
1242
147
138
135
136
154
156
166
173
126
113
113
112
106
106
104
96
97
93
96
90
90
84
82
76
72
69
70
10.6
11.1
11.8
12.2
13.2
13.2
11.3
10.7
10.5
10.0
10.8
11.9
11.4
11.0
11.2
11.5
12.6
13.1
14.2
14.2
14.5
15.2
15.6
16.0
16.4
17.4
17.8
% of all
deaths due
to Diabetes
0.73
0.83
0.85
0.87
0.82
0.89
0.76
0.58
0.76
0.80
0.89
0.99
0.98
0.90
0.92
0.99
1.0
1.12
1.06
1.24
1.18
1.26
1.27
1.3
1.4
1.44
1.43
Ratio of deaths
due to tuber­
culosis to those
due to Diabetes
13.8
12.4
11.5
11.2
11.7
11.9
14.7
16.3
12.0
11.3
10.4
9.4
9.3
9.7
9.1
8.3
7.7
7.1
6.8
6.3
6.2
5.5
5.3
4.8
4.4
4.0
3.9
- 3 -
T A B L E
Year
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
II
Death Rates
from Diabetes per 100,000
England & Wales
Male
Female
11.1
11.7
12.0
12.6
14.6
15.4
13.7
12.9
11.0
9.9
10.5
11.6
10.5
10.2
9.8
10.6
10.9
11.6
12.2
12.1
11.8
12.7
12.7
12.9
13.0
13.9
14.2
10.3
10.6
11.6
11.8
12.0
11.4
9.6
9.0
10.0
10.1
11.1
12.2
12.2
11.8
12.5
12.4
14.2
14.5
16.1
16.1
17.0
17.6
18.2
18.9
19.6
20.7
21.0
Masculinity of
Diabetic Deaths
Male D
-i
T~l
n
T\ X XUUiJ
Female D
1010
1039
969
997
1005
1039
1022
1007
968
887
869
863
790
804
713
779
704
738
694
693
63 6
658
644
628
610
622
623
- 4 -
were admitted in the proportion of 1.2 per 1,000 general
admissions compared with 3 per 1,000 between 1921 and
1926.
The percentage of all deaths due to diabetes, in
England and Wales (Table I), has become doubled during
the period under review (1911 - 1937).
In 1911 deaths from all forms of tuberculosis were
almost fourteen times as frequent as those due to diabetes,
but by 1937 the proportion had dropped to less than 4 to
1 (Table I), a reduction of 72^.
In New York City during
1931 there were 2,000 deaths from diabetes compared with
5,000 from tuberculosis and 8,300 from cancer (4), while
in the United States Registration Area in 1932 the
tuberculosis death rate was 63 per 100,000 and that of
diabetes 22 per 100,000 (5).
The increasing importance
of diabetes mellitus as a cause of death is thus manifest.
When the sexes are considered separately it is seen
(Table II) that by far the greater increase in death rate
is among females.
Since 1918 the masculinity of deaths
has fallen steadily.
Table III, which gives the deaths
by age and sex for the years 1911 and 1936, shows that
this increase is mainly in women of 45 years and over,
the death rate having decreased in the younger age groups,
while in males there has been a definite decrease in
mortality except at ages over 55 years, where an increase
has taken place.
Graham (6), working on average death
TAB L E
III
M A L E S
(2)
(4)
(7)
(6)
(5)
o
1911
Diabeti
Deaths
O rH
All-Ages
17,490,847
1936
0 -
1,941,280
11
5 -
1,852,192
0
t>0
C
Population
d
1936
O
0 O
rQ O
cd
*
•H (D O
Q tO O
(J)rH
rH
o
•H
-P
0
d to
aj c O
•h a>
Q H
Actual
Deaths
H
rH
CT>
&
-P
Ctf rH
0 H
Q
CJi
rH
o u
•H
-P
Expecte
Deaths
4 x 5 t
Population
&
o
b
O
(3)
Diabeti
Rate pe
100,000
(1)
19,591,000
2972
2731
0.57
1,423,500
8.065
9
22
1.19
1,501,300
17.832
11
1,752,176
36
2.05
1,667,000
34.249
25
15 -
1,659,169
67
4.04
1,624,700
65.608
23
20
1,506,574
71
4.71
1,644,200
77.486
30
25 -
2,839,154
157
5.55
3,319,600
183.567
81
35 -
2,342,549
183
7.81
2,641,400
206.346
70
45 -
1,698,638
252
14.84
2,328,500
345.442
226
55 -
1,087,813
461
42.38
1,919,400
813.414
614
65 i
I 75 -
604,220
512
84.74
1,093,000
926.178
1058
207,082
164
79.20
371,500
294.211
583
10
-
-
I
■m
T A B L E
P E M A L E S
(5)
Population
1936
(6)
18,672,986
1917
0 -
1,923,455
9
0.47
1,377,000
5 -
1,854,463
24
1.29
1,471,100
19.038
14
■ 10 1
1,756,672
41
2.33
1,635,000
38.160
20
J 15 -
1,686,089
49
2.91
1,595,100
46.356
31
20 -
1,677,365
40
2.38
1,698,400
40.502
33
25 -
3,132,701
155
4.95
3,487,600
172.559
79
35 -
2,515,851
162
6.44
3,113,700
200.496
142
45 -
1,838,513
261
14.20
2,738,900
388.821
324
1,216,197
470
38.65
2,205,200
852.200
1094
; 65 -
759,419
512
67.41
1,338,600
902.483
1771
? 75 -
312,261
194
62.13
587,400
364.937
873
All Ages
j 55-
i
L------ —
21,248,000
3032
(V)
Diabetic
1936
(4)
Actual
Deaths
1911
Age
Group
Population
(3)
Expected Diabetic
Deaths 1936
4 x 5 i 100,000
(2)
Diabetic
Deaths 1911
(1)
Diabetic Death
Rate per
100,000 1911
1
IIIA
6.0
4388
7
rates over a ten year period, has obtained similar results.
It was found in England and Wales in 1928 (7) that since
the introduction of insulin the mortality from diabetes
of males under 55 years had fallen by 37$ and that of
females by 21$.
In U.S.A. from 1923 till 1933 the
probability of dying from diabetes had been increased by
50$ for baby girls and 15$ for baby boys (5).
It is
interesting to note that Bolduan (8) found that among
unmarried persons over 45 years of age the diabetic death
rates were the same for both sexes in the years 1931 and
1932.
Pregnancy may, therefore, play some role in the
preponderence of females in the upper age groups.
Diabetes is a disease of middle and late middle life.
Table IV shows the age and sex distribution of diabetics
consulting me for the first time at the diabetic clinic
of the Western Infirmary, Glasgow between November 1933
and March 1936.
The proportions are set forth graphically
in Figure 1, and It is apparent that the maximum incidence
is in the age group 55 -.
TABLE
Age Group
IV
5 -
15 -
25 -
35 -
45 -
55 -
65 -
Males
5
12
16
16
22
26
9
1
Females
3
12
15
30
41
76
28
2
Total
8
24
31
46
63
102
37
3
75 - 85
- 8 -
2Z
'3a
V£
is-/s'
/■tf-PS--
Figure 1
Histogram showing the number of males, clear columns, and
the number of females, shaded columns, in the various age
groups who attended the Western Infirmary Diabetic Clinic.
- 9 -
This is in accord with the observations of American workers
(9), who show that the maximum susceptibility to diabetes
is in the sixth decade - 51 years among males and 55 years
among females.
They find a declining susceptibility in
old age and this is in accord with the ages of persons
seeking treatment at the Western Infirmary, Glasgow.
Mosenthal (10), however, regards diabetes as a senile
degeneration, but I cannot agree with this view on the
etiology of the disease.
In Australia a similar age
distribution of the disease is noted.
Of 487 diabetics
treated at the Coast Hospital, Sydney, 71% were over
40 years of age before the onset of diabetes (11).
The populations of this country and U.S.A. have been
aging and it is possible that this, associated with the
usual age incidence of the disease, might account in part
at least for the increase In diabetic mortality.
It was
accordingly decided to calculate the expected deaths in
1936, the year when the percentage of all deaths due to
diabetes was highest, if the 1911 rates had operated.
Tables 3 and 3A set forth the population, diabetic
deaths and death rates from that disease according to
age and sex for 1911, and the population, actual and
expected diabetic deaths for 1936.
In the case of males
the total expected deaths exceeds the actual by 241.
Closer investigation reveals that apart from the age
- 10 -
group under 5 years the expected deaths exceed the actual
in all ages till 65 years, after which the actual is greater
than the expected mortality.
Among females, on the other
hand, the actual deaths exceed the expected by 1356.
In
the age group under 5 years the actual Is greater than
the expected number of deaths, but in all subsequent
groups under 55 years the reverse Is the case.
Prom 55
years onwards the actual deaths far exceed the expected.
The greater proportion of deaths take place in the older
age groups, but this is not due solely to the altered age
and sex distribution of the population.
The death rate
from diabetes per 100,000 for females aged 55 to 60 was
38.65 in 1911 and 49.61 in 1936.
The corresponding figures
for ages 65 to 75 were 67.41 and 132.3;
the expected
deaths in persons amount to 6,004 and the actual 7119.
That is, there was apparently a real increase in diabetic
mortality in the country as a whole.
In New York City
an increase of 58% in the age standardised diabetic deaths
has been noted between 1901 and 1931 (12) .
The statistics
of the Industrial Department of the Metropolitan Life
Insurance Company, after compensation for age, sex and
colour distribution of the population, show that the
death rate is steadily rising (5).
Rabinowitch (13)
regards the rising death rate as more real than apparent.
Bolduan (14) on the other hand does not consider that
- 11 -
there Is any real increase in diabetes apart from the aging
of the population, but as stated above, I am not in agreement
with this observation.
The reason for this increase in diabetes has been
attributed to various factors.
Deaths of diabetics from
other causes may, in the absence of properly completed
death certificates, be erroneously attributed to diabetes.
In U.S.A. diabetes is given preference if it appears on
the death certificate (14), and Hekimian and Vogel (15)
refer to this by way of explanation for part of the rise
in mortality from diabetes.
In this country deaths by
violence and diseases included in groups 1, 2 and 3 of
infectious, parasitic and general diseases of the
international list of causes of death as adopted for use
in England and Wales, Scotland and Northern Ireland,
take precedence over diabetes, but even then the same
possibility exists.
One would however expect this error
to operate at all ages and not merely in the upper age
groups.
Other observers (16) maintain that in U.S.A.
4
recorded mortality represents
of true mortality as
measured by joint causes of death and about £ of mortality
o
of individuals.with diabetes.
Increased frequency In diagnosis of the condition
may play a not inconsiderable part in making the disease
appear to be on the increase.
The number and ability
- 12 -
of doctors and the number of hospital beds seem to govern
the frequency of diabetes mellitus (17).
In the New York
Hospital, routine examination of urine was not instituted
until 1890 (8).
Many diabetics would, under these
circumstances, be undetected, and thus reduce the number
of deaths attributed to that disease.
Routine examinations for insurance and employment
purposes have brought to light many unsuspected cases.
Bolduan (14) goes as far as to state that this caused the
former preponderence of diabetes among males, but only
15.9% of Joslin’s male patients were discovered under these
circumstances (17), and among my hospital patients who
belonged to the poorer classes about 2% were so discovered.
The position is, of course, much different in private
practice.
My experience in a diabetic clinic showed that
many of the patients, the majority of whom were females, had
consulted their medical advisers on account of diabetic
symptoms, complications or intercurrent disease and that
routine medical examinations played a very small part
In the diagnosis of diabetes among the hospital classes.
It is well known that many diabetics are obese before
the onset of the disease, and numerous workers regard
obesity as a predisposing cause.
Bolduan (18) on the
other hand states that from records of clothing manufacturers
there has been no general increase in obesity to account
- 13 -
for increased Incidence of diabetes.
Joslin and his co-
workers (17) maintain that lighter work, labour saving
devices and increased buying power of the people cause
diabetes by favouring overweight, and Dorlet (12) expresses
the same view.
The fact that those with high per capita
incomes tend to buy diets with relatively high fat is well
recognised, and if the incidence of diabetes in private
practice is examined it is found very frequently In those
who partake of a liberal quantity of fat.
In a hospital
clinic one is apt to encounter a large number of poor
diabetics, but this does not give an index of the
occurrence of the disease in the population as a whole.
The Increase in diabetes has been shown to take
place in the older age groups, and at these ages the
incidence of the disease rises with the social class (7).
It would therefore appear that diet plays some role in
the etiology of the condition, and Bolduan (4) maintains
that a high diabetic death rate is associated with high
sugar consumption, but Joslin and his co-workers (19)
hold the view that there is no relation between the two,
and I am in agreement with the latter view.
Towards the end of the Great War the death rate
fell in those countries which were subjected to blockade.
In Britain the submarine blockade started in 1917, and
in 1918 the percentage of all deaths due to diabetes
- 14 -
was the lowest recorded (Table I ) .
noted in Germany (20) and (4).
A similar fall was
The food shortage was mainly
in fat and the diet had to be made up by the consumption
of extra starchy foods.
If excess dietary carbohydrate
had been a cause of the increased diabetic death rate a
fall in this would not have been experienced.
The
admirable researches of Himsworth, and Himsworth and
Marshall (21) (22) and (23), confirm that it is not the
increase in carbohydrate but rather the lack of it which
may be a contributory factor in the etiology of the disease.
Heredity also plays some part in the etiology of
diabetes.
Pincus and White (24) point out that diabetes
may be transmitted as a Mendelian recessive.
If we assume
that potential diabetics are subject to the usual causes
of death and expectation of life before developing this
disease the Mendelian expectations are satisfied.
The
greater length of life now enjoyed would, under these
circumstances, enable a number of potential diabetics,
who would formerly have died from other causes, to live
to an age when diabetes would develop.
This may in part
account for the marked increase in deaths in the older
age groups.
Whatever the cause of the rising mortality from diabetes
the fact remains that there is an increased Incidence of
the disease and consequently a large number of patients
- 15 -
to be cared for.
The advent of insulin has greatly increased
the span of life of the average diabetic subject.
According
to a life table constructed on Joslin’s patients the
expectation of life of a diabetic child of 10 years has
been increased by 30 years (25) and he maintains (26) that
the number of diabetics in the community is increasing
partly because the individual diabetic is living longer.
This is bourne out by Hajek (27) who found that the
average age at death of diabetics in the pre-insulin and
early insulin eras was 55 years, whereas.in the late
insulin period it was 59.8 years, and by Flynn (28) who
gives the average duration of diabetes at death as 4.1
years in the period 1913 - 1922 and 5.1 years between
1923 - 1933.
Joslin and his associates (19) state that
the average duration of diabetes at the time of death is
10 years.
This time appears long compared with Flynn’s
observations, and it may be that many of the patients
included in Joslin’s survey attended his own clinic and
were thus under ideal supervision.
If the 1937 diabetic death rate for England and
Wales is taken and we assume a duration of the disease
of 10 years before death, then in a community of 100,000
people there would be 180 diabetics.
Grote (20) quotes
figures from an actual census in Stettin reported on by
Gottschalk -
This town, with a population of 268,000
- 16 -
inhabitants, had 640 diabetics, giving an incidence rate
of 237 per 100,000, which is in excess of the estimated
number of diabetics in this country on the above assumption.
Unfortunately it is not possible to carry out actual
enumerations of patients in different localities, and I
know of no other actual census of diabetics having been
taken for purposes of comparison.
It is evident from these observations that there is
in our midst a large number of diabetics; with modern
treatment and a co-operative patient there is no reason
why the expectation of life of these individuals should
not be very good indeed and why there should be loss of
time from work.
My experience at a diabetic clinic has
shown that after control has been established diabetics
can continue their work without interruption, and because
of the fine moral fibre which they develop and their
regular habits they make, to my mind, very desirable
employees.
Other workers (29) have had similar experience.
It is unfortunate that employers, in some instances, have
been slow to realise this.
These diabetics are in many
instances active members of the community, have families
and are very valuable citizens.
Lack of treatment or
inadequate treatment may result in invalidism, and in
the working classes the patient and his or her family,
if yDung, may become a charge to the state and valuable
- 17 -
lives may even be lost.
That such a state can exist is a
disgrace to modern civilisation and unfortunately it does
exist.
At a diabetic clinic patients occasionally came
under observation where in spite of symptoms of several
months duration only the most meagre attempt at treatment
had been made.
Flynn (28) reports that 58$ of fatal
hospital cases in elderly people had never had insulin
prior to admission to hospital.
Of 456 persons classified
as dying from diabetes in Ontario only 270 had received
medical care (1).
It has been reported from the diabetic
clinic of Edinburgh Royal Infirmary that in 21
or 14$ of
150 fatal cases death had resulted from improper treatment
outside the institution (30).
Joslin (31) states that the expectation of life of a
diabetic child of 10 years is 31.7 years and it is therefore
deplorable for one to die during the first or second decades
of diabetes.
He writes ”The death of a single child from
diabetic coma signifies pure and unadulterated neglect
and nothing else.”
Yet we are all aware that children
do die of diabetic coma.
Many diabetic deaths are
preventable.
This disease was the twenty-seventh cause of death
in U.S.A. at the beginning of the century, in 1933 it was
the tenth cause (5), and it is now responsible in England
and Wales for a number of deaths equal to a quarter of
- 18 -
those due to tuberculosis.
Surely such a disease is a
public health concern.
In the large cities there are already many well
organised clinics offering excellent treatment for diabetics,
but in our rural areas and smaller towns such facilities
are lacking.
Numerous patients are thus without adequate
treatment or receive it only at great personal inconvenience
and expense.
Many of my hospital diabetics had to pay
fares of over 3/- each time they visited the clinic while
others could only have special examinations when they
were visiting friends in town as the expense was otherwise
prohibitive.
It is consideration of these facts which
has prompted me to put on record my experience in the
organisation of a diabetic clinic together with the researches
which I conducted while in charge of it.
CHAPTER
II
The Treatment of Diabetics
_____ in the Community.____
What is the best way in which to tackle the treatment
of this ever growing diabetic community?
There are,
naturally, the private practitioners who, as indicated
before, are generally the first to see the patient.
They
might tackle the treatment with the aid of the general
hospitals for the very severe and complicated cases.
Dunlop and Pybus (32) suggest that all diabetics can be
treated by the general practitioner, and Joslin (26)
maintains that it is a disease to be treated by the family
physician.
Grote (20) on the other hand holds that the
family doctor is not equal to the constant necessity of
controlling the diabetic patient and that the cost of
treatment to the masses Is reduced when the work is
undertaken by a public health welfare authority, while
Young and Russell (33) cast doubts as to whether
practitioners and patients are making the best use of
insulin.
Singer (34) states that to make diabetics
attend clinics all the time would clash with the private
interests of physicians.
While one has no intention of
taking practice from private doctors, the well being of
the diabetic community must have precedence over all
other considerations.
'Alien I was conducting the diabetic clinic at the
- 20 -
Western Infirmary some neighbouring general practitioners
spoke highly of the service it rendered and how it was
filling a much felt want in the district.
They stated
that they were quite unable to devote adequate time to
the treatment’of their diabetic patients.
Table V shows the percentage of patients referred
to the clinic after treatment in the wards, from the
out-patient
department and directly from their private
practitioners for the years 1934 - 35.
TABLE
V.
Year
Prom Wards
Prom
Out Patient
Department.
1933
67.7%
27%
5.3$
1934
36,2%
4 1 ,3%
22.5$
1935
26,3%
27,6%
46. 1$
From
Private
Doctors
Many of the patients from the out-patient department
were poor and unable to consult a private doctor, and
others had been sent to that department by doctors who
were unaware of the existence of a special clinic.
It
is obvious from the table that general practitioners
were making increasing use of the service offered by the
clinic and that bed accommodation in the wards was thereby
being saved; all patients from the wards were automatically
sent to the clinic.
- 21 -
The difficulty of treating diabetics in general
practice was further brought home to me some years later
when I looked after the practice of a friend who had
been taken ill.
He had a few diabetics under his care
and he made a special request that I should visit them.
I found that, in spite of my special experience, I was
in the same position as the family practitioner.
The
many demands on my time and lack of facilities precluded
my giving these patients the attention and instruction
I was in the habit of giving to the clinic patients.
The conclusion was then forced upon me that, for the
patient who cannot afford specialist fees, the solution
of the problem lies in the diabetic clinic.
This
involves not the exclusion of the family practitioner
but rather a high degree of co-operation with him.
When details of investigation and treatment were sent
from the Western Infirmary Clinic to the doctor it was
suggested that the patient should attend regularly for
supervision.
The suggestion was generally welcomed by
the practitioner and when changes in treatment were
necessary he was notified accordingly, and it was
usually he who made any necessary local arrangements
for insulin supply and administration.
It has been advocated that the private practitioner
should conduct the treatment and send specimens to the
- 22 -
laboratory for blood sugar and other estimations.
Such
specimens must be obtained under known standard conditions
if the findings are to be of value, and the interpretation
of the results of such analyses is, in some cases, by no
means easy.
It is my opinion that the interpretation
should be made by the person under whose care the test
is executed, and the general practitioner should not be
expected to possess specialist knowledge.
He wishes
help with his diabetics and the clinic should furnish
this in a material form and not merely return him a
series of probably meaningless figures.
CHAPTER III
The Clinic as a Diagnostic Centre
In 1933 I was asked by the Medical Superintendent
of the 'Western Infirmary, Glasgow to organise a dietetic
clinic for the after care of diabetics and other petients
discharged from that institution.
As is pointed out in
a succeeding chapter, the clinic soon began to deal with
new cases of diabetes and so provision for the investi­
gation of suspected cases of diabetes had to be made.
The necessity for this diagnostic service is evident
from the fact that of 370 patients,
suffering from
glycosuria, who were seen at the clinic 45, or 12%,
did not suffer from diabetes but had renal glycosuria
or lag storage curves.
The facilities for biochemical
investigations were afforded me in the Clinical
Laboratory by Professor C. H. Browning and In the
University Department of Medicine by Professor T.K. Monro.
At his first attendance each patient had an accurate
history taken, was given a thorough clinical examination
and the urine was tested.
Benedict’s qualitative solution
was used for the detection of urinary sugar and
quantitative estimations were not made as such procedures
occupy much time and afford little material help with
diagnosis or treatment.
Rothera’s nitroprusside and the
ferric chloride tests were employed for the detection of
- 23 -
- 24 ketone bodies.
On the findings thus obtained a clinical
diagnosis of diabetes mellitus could frequently be made
and the presence of complications detected.
Those with
glycosuria, ketonuria and typical symptoms might have
been put on treatment without further investigation, but
as many of them were being subsequently used for research
purposes the diagnosis was in each case confirmed by blood
sugar examinations.
If, for example, in a clinic serving
a landward area, such blood analyses could only be carried
out at great inconvenience to the patient I should not
hesitate to dispense with them in typical cases.
Lawrence
(35) is in agreement with this, and he also maintains
that quantitative determination of urinary sugar is quite
unnecessary.
The preliminary examinations having been completed,
an appointment was made for the patient to attend at the
Clinical Laboratory for blood sugar examinations.
Experience showed that where a subject had been on a
restricted diet the sugar tolerance was not infrequently
poor and in one such case, a man aged 49 years, the
fasting blood sugar was 0.13 mgm.%, the post-prandial
level exceeded 0.2 mgm.^ and the sugar level did not
return to normal in two hours.
At the time I wrongly
regarded him as a mild diabetic and prescribed diet
accordingly.
He subsequently developed vertigo, and
- 25
on reviewing his case and repeating my investigations
I found that he suffered from innocent glycosuria but
had been on a restricted diet prior to my first
investigation.
Lawrence and McCance (36) state that
carbohydrate starvation may produce a diabetic type of
blood sugar curve, and the work of Himsworth (21),
and (23), throws further light on this subject.
(22)
Leyton
(37) states that hyperglycaemic glycosuria is not
necessarily diabetes and he reports five cases (38) where
a diagnosis of diabetes was made on the strength of
glucose tolerance tests in the absence of symptoms and
in which the subsequent history and further tests did not
bear out this diagnosis.
He does not state, however,
whether there had been marked dietetic restrictions prior
to the original investigations.
Patients were accordingly
instructed to take a normal diet until the day appointed
for the examination when they reported at 9.15 a.m. in
the fasting state.
Samples of blood and urine were
obtained, 50 grammes of glucose dissolved in a glass of
water and suitably flavoured were administered, and 1-ghours after this drink had been consumed further samples
of blood and urine were taken.
The necessity of travelling
before the examination is, strictly speaking, undesirable,
as the exercise tends to increase carbohydrate utilisation
and so disturb the test, but in a large series of cases
- 26 -
I found no evidence to justify routine admission to
hospital for such investigations.
The two test method
does not give the amount of information a full blood
sugar curve would yield, but in the great majority of
cases these estimations furnished sufficient evidence to
enable a diagnosis to be made.
I had no technical
assistance in the execution of these analyses and it was
therefore impossible to attempt full glucose tolerance
tests in the time which I could devote to this part of
the work.
The urine was examined for the presence of
sugar, and the glucose in 0.2 ml. blood was estimated
by a modification of the Polin Wu method (39) which was
found very suitable when a large number of specimens
had to be handled.
The necessity of a colorimeter is
a disadvantage in this method.
Where such an instrument
cannot be procured one of the titration methods of
analysis, such as Maclean’s (40), can be employed.
It is a good plan to set aside one day each week
for this work.
If the apparatus is prepared on the
previous evening the investigation of six patients can
be completed during the morning, and diet sheets may
then be drawn up and letters written to the patients'
private practitioners.
Such an arrangement ensures
smooth running of the clinic and prevents unnecessary
delay in the institution of treatment.
- 27 -
The cost of the above investigations should not be
great.
It is, of course, uneconomic to employ highly
paid personnel on work which could be adequately under­
taken by a technical assistant.
Most hospital and
public health laboratories have such technicians, or
if no such assistant were available a nurse or dietitian
could be easily trained.
One of the dietitians at the
Western Infirmary soon learned to carry out these
analyses with extreme accuracy although she had not
previously had experience of such work.
The necessary
chemicals can be purchased ready for use from the
larger drug houses, but I preferred to make up my own
solutions.
With the exception of the colorimeter the
apparatus required is inexpensive.
The diagnostic service above described gives some
idea of what should be aimed at by a small clinic.
There is no need for a centre in a small town to be
equipped for all varieties of chemical analyses, which
would be seldom if ever employed.
The cost of such a
scheme is not beyond the means of the average large
Burgh in Scotland or urban district in England.
CHAPTER
IV
The Clinic as a Treatment and Welfare Centre.
The treatment of diabetes does not end with the
prescription of diet and insulin.
Cognisance must be
taken of many factors which may directly or indirectly
influence the patients’ health and happiness and which
may therefore render him an asset or a liability to
the community of which he is a member.
With these
observations in view the various factors affecting
clinic organisation and treatment are discussed below
under their appropriate headings.
'
I.
Should all Diabetics have preliminary
Treatment in Hospital?
It was formerly the custom to admit most patients
to hospital or nursing home as soon as diabetes was
suspected.
When the Western Infirmary Clinic was
started this principle was adhered to, but the fact
soon became obvious that many patients referred to
hospital lost valuable weeks of treatment while they
awaited admission to the wards.
It was therefore
decided to treat the milder cases as outpatients.
The results were so encouraging that soon all patients
except those with complications or severe forms of
- 28 -
- 29 -
the disease were so treated.
Pew children attended the
clinic, hut it was found much more satisfactory to admit
them to the wards for preliminary treatment.
Professor
Morris (41) advocates this procedure in the case of
children.
Earl (42) treats mild cases only at a
diabetic clinic, but Lawrence (43) maintains that all
diabetics apart from coma cases and children can be so
dealt with.
The treatment of such patients without admission
to hospital results in a considerable saving of
accommodation and funds to the institution, especially
when it is considered that up to a short time ago
diabetes took third place as regards length of stay
in hospital (20).
Moreover, it was observed that many
patients referred to the clinic from the wards required
rebalancing of the diet and insulin shortly afterwards.
In order to investigate the frequency of this occurrence
162 consecutive cases were observed after discharge
from the wards.
rebalanced.
Fifty-seven, or 35$, required to be
Not only does this absorb time, but it
causes the patient to lose confidence in the treatment,
and in many of these the cost of the stay in hospital
has been wasted.
\iThile in hospital the patient leads an unnatural
existence and does not take part in his usual activities.
(
- 30 -
It Is only natural that a diet and insulin dosage which
suited him under these circumstances may entirely fail
when he returns to his home and his work with the
resulting alteration in expenditure of physical and
mental energy.
In addition, even though well Instructed
in dietetics and in the administration of insulin while
in hospital, on discharge the patient and his family
have for the first time to tackle these problems unaided.
It is therefore not sirprising that breakdowns occasionally
occur.
When a diabetic is treated from the start at
the clinic it may take longer to get the urine sugar
free and the blood sugar brought within normal limits,
but the balance has been attained under the conditions
of his normal existence and subsequent breakdown Is
thus rendered less likely.
In view of the above findings taxation of hospital
accommodation by the admission of cases of uncomplicated
diabetes does not appear justifiable.
The decision to
admit a patient to hospital should properly be left in
the hands of the clinic medical officer.
H.
Continuity of Supervision of the Diabetic.
Whether the patient is admitted to hospital and
then referred to the clinic for supervision or attends
the clinic from the first it is highly desirable that
- 31 -
there should be continuity of treatment.
The post of
medical officer should, therefore, be a permanent
position and the practice of leaving the supervision
to resident medical officers who will be changed at
six-monthly or yearly Intervals should be avoided.
Apart from the temporary nature nature of these
appointments, such medical officers would not possess
sufficient experience and would be leaving as soon as
they had gained proficiency in running of the clinic.
It is very helpful if the medical officer of the
clinic has charge of beds in the hospital to which he
can admit cases requiring indoor treatment.
At the
Western Infirmary I had not charge of beds, but
Professor Monro allowed me to supervise the treatment
of patients admitted to his wards, and the surgeons
in charge of the ’’septic wards” in which were treated
cases of gangrene and septic conditions, among whom
there was a number of undetected diabetics, generally
asked me to control the medical treatment and prepare
the patient for operation.
This co-operation proved
very effective in the control of the disease.
Where
no such co-operation existed it would be difficult
to prevent the patient from being the sufferer.
III.
The Keeping of Clinic Records.
No clinic can be successfully conducted unless there
is an adequate system of keeping the record of each
patient.
These records must be accurate, concise and
easily kept.
A system which involves turning over
pages of journals and reading through copious manuscripts
can have no place in a busy clinic.
Up till recently the Western Infirmary adhered to
the book system of keeping records, and this method was
naturally used in the dietetic clinic.
As the clinic
increased in size the system proved slow and cumbersome
and a special filing system was evolved.
Each patient
had a folder containing a case sheet and a progress
chart and the folders were filed in alphabetical order.
The case sheet, which was of foolscap size, was
headed with the patient’s particulars and subheadings
for history, symptoms, signs, and the examination of the
various systems were set out below this.
In practice
this sheet was not as successful as one had hoped it
to be, and I should now advise one with merely the
patient’s name and address, etc. and his doctor’s name,
address and telephone number.
- 32 -
- 33 -
A progress chart, is of great importance.
The one
devised at the clinic was of foolscap size and was ruled
lengthwise.
All the findings at any one visit could he
recorded on a single line under the appropriate headings.
The exact state of the patient and the treatment could
he seen at a glance and the recording of the findings
was very simple.
Columns ruled off on the chart set
forth in tabular form:
(1) the date
(2) the weight
(3) the results of examination of a
24 hour specimen of urine
(4) the findings in specimens of hlood
(5) the diet in grammes of:
Carbohydrate (C)
Protein (P) and
Pat (P)
and
the total Calories per day
the balance of the diet in four
columns marked:
Breakfast (B)
Dinner (D)
Tea (T) and
Supper (S)
If Lawrence Line diets were being used the number of
lines for each meal could be inserted, and if other
systems were in use marks could be made to indicate
at which meals most food was taken for future reference
when prescribing insulin.
(6) The amount of insulin before breakfast,
dinner, tea and supper, and the total.
- 34 -
(7) Date of next attendance
(8) Remarks
There were blank columns included under the headings
of urine and blood examinations which could be used for
particular investigations.
Special notes could be made
on the reverse side with an appropriate reference under
remarks.
The chart was capable of holding the record
of thirty visits to the clinic.
The above chart fulfilled its purpose exceedingly
well and I never had reason to consider any alterations
to its layout.
Joslin (26) is in favour of a chart of
this type, and Morris (41) used a similar chart in
his diabetic clinic.
Records of future appointments were made in a
diary so that those failing to attend could be readily
detected.
To prevent confusion each patient had a
clinic card on which was marked the date when he was
next due to attend.
IV
Dietetic Treatment through the Clinic.
The particular method of dieting employed will
naturally depend on the views of the physician in
charge of the clinic.
How the patient is instructed
regarding his diet is equally as important as the
- 35 -
exact number of Calories prescribed.
As will be shown
in a subsequent chapter, the price of the diet is a
matter of moment, and among poorer patients this should
be given constant consideration.
Variety of foodstuffs
is also an essential factor in any diet.
For simplicity in prescribing the Lawrence Line
Ration System (44) is hard to improve upon.
It was
used with success in Professor Monro’s wards in the
Western Infirmary before the establishment of the clinic
and at the clinic of the Royal Hospital for Sick
Children, Glasgow (41).
Unfortunately all physicians at the Western Infirmary
did not use this system.
A uniform diet sheet which
would be applicable to all had therefore to be drawn
up and the one prepared by the hospital dietitian is
shown on page 36.
This diet table was very successful,
but one had always the able assistance of a dietitian
to calculate the quantities of food and fill in the
table when prescribing a diet.
Without this assistance
the table would have presented some difficulties.
Variety in the choice of foodstuffs was ensured by
giving the patient a series of exchange tables, two
samples of which are set forth on page 37.
I should
strongly advise anyone embarking on the organisation
of a diabetic clinic to adopt Lawrence’s system of
- 36 D I E T
T A B L E
ALL POOD MUST BE ACCURATELY WEIGHED
Breakfast
Oz.
Porridge .. • • • •
Wholemeal Bread ...
Butter, from Ration
Eggs ... ......
Bacon...........
Milk, from Ration
Tea or Coffee...
Oz.
Tea
Vegetables ......
Wholemeal Bread...
Butter, from Ration
• •
• • •
Eggs ...
• it
• • •
Cheese
Milk, from Ration
Tea or Coffee
Supper
Dinner
Vegetables.. • • • •
Wholemeal Bread
Butter, from Ration
...........
Fish
Eggs
... ... ...
Milk, from Ration
Bovril or Oxo or Tea
Bovril or Oxo
or Clear Soup
Lean Me a t ......
Vegetables.....
Fruit...........
Rations per Day
Butter
Milk
6# Vegetables
3# Vegetables
Cabbage
Lettuce
Leeks
G&Lery
7.5# Fruits
Watermeloii
Grapefruit
Lemon
Cauliflower
Tomato
Rhubarb
Brussel Sprouts
10# Fruits
Orange
Cranberries
Blackberries
Gooseberries
Carrot
Turnip
Onion
Beetroot
15# Fruits
Apple
Pear
- 37 -
D I E T
T A B L E
In place of 1 Egg one of the following may he taken, making
the necessary alteration in the daily butter allowance
Butter
Oz
Omit Oz.
Add Oz.
Bacon
1
Tinned Tongue
1
No change
Cold Lean Ham
1
No change
Sardines
1
No change
White Pish
1
Cheese
3
4-
D I E T
good i
Mo change
T A B L E
In place of 2 oz. White Pish, one of the following may
be taken, making the necessary alteration in the daily
butter allowance
Omit Butter
Oz
Oz.
Bacon
2
•• •
• ••
1
Tinned Tongue
2
•••
• ••
i
3
Cold Lean Ham
2
• ••
• ••
1
8
Sardines
2
•• •
•••
1
8
Salmon
2
• ••
• ••
1
4
Fresh Herring
2
•• •
•• •
small -J-
- 38 -
dieting.
Excellent recipes for sweet dishes for diabetics
are included in The Diabetic Life (44) and in his book
for patients and nurses, The Diabetic A.B.C.
(45).
Patients were instructed by the dietitian or a
member of the nursing staff in the preparation and
measurement of the diet.
Advice was given on the choice
of foods to suit the purse and the season.
All patients
were encouraged to ask questions and make known their
difficulties.
It was possible in this way to clear up
most of these.
Some patients required redistribution
of food because they worked on odd shifts, while others
had to have the diet altered on account of carried meals.
When there was glycosuria without apparent cause the
dietitian went over the diet in detail with the patient,
and not infrequently this demonstrated some breach of
treatment.
Where this examination fails
to reveal
delinquency in a suspicious case, it is sometimes
helpful if the medical officer conducts a crossexamination; the patient then frequently admits his
transgression.
What has to be done with the patient who habitually
departs from his diet?
The first thing should be to
review the diet and make sure that it is adequate and
not too expensive.
Many dietary transgressions are as
much the fault of the physician as of the patient.
I
- 39 -
can recall cases, treated on low carbohydrate diets,
and eventually completely abandoned by their physicians
on account of dietary delinquency, who on being given
a reasonable carbohydrate intake became quite good
patients.
Some people require coaxing, exhortation or
even scolding to prevent departures from diet.
Visitation
by a home visitor has been shown to be very beneficial
(41)
(46), but there was no home visiting service operating
from the Western Infirmary clinic, and the want was much
felt.
On no account must a patient be abandoned because
of his dietary indiscretions.
To do this is to admit
defeat and there is no place for defeatism in the
fight against diabetes.
It was conclusively proved at the Western Infirmary
that, with co-operative patients of average intelligence,
dietetic treatment of diabetes could be easily taught
to and mastered by outpatients.
V
The Control of Insulin Treatment
from the Clinic
There is no need to admit a patient to hospital
if insulin has to be started, but one must go slowly
when increasing the dose.
The first object should be
to teach the patient to give his own insulin.
Many
patients state that they cannot do this, but a little
- 40 -
persuasion and firmness combined with competent instruction
should overcome any difficulty in most cases.
Where a patient was referred to the clinic by his
private doctor I wrote him giving details of the insulin
dosage and requested that he get the district nurse to
supervise the treatment and instruct the patient.
If
the patient was poor and could not afford a' private
doctor, a letter was sent to the Lady Superintendent of
the District Nursing Association making a similar request.
The co-operation received from this body contributed
materially to the success of Insulin treatment with
outpatients.
The value of co-operation with this
Association has also been stressed by Himsworth (47).
Insulin therapy controlled from the clinic proved
highly successful.
There were very few instances of
delinquency on the part of the patient and remarkably
few experienced hypoglycaemic symptoms.
The majority
of insulin cases had two Injections per day, though
a considerable number required three injections.
When difficulty In controlling glycosuria was
encountered specimens of urine passed at various times
of the day were brought to the clinic for examination.
Special specimen bottles with the times marked thereon
re supplied for this purpose.
The more intelligent
patients tested the urine themselves and brought a
- 41 chart showing the result.
In this way it was possible to
keep the urine sugar free in practically every case where
reasonable co-operation was forthcoming.
Where glycosuria
could not be controlled by urine tests alone, blood sugar
estimations were made, but these were seldom required.
Persuasion, explanation of the action of insulin and
the demonstration of its beneficial effects on other
patients usually overcame the reluctance which many patients
have to starting its use.
The fewer injections required
with the newer insulins will mitigate to some extent
the fear which patients used to have of this form of
treatment.
Patients were instructed in the symptoms of hypoglycaemia and the advisability of carrying sugar with
them, but this point was not overstressed as otherwise
sugar was taken when there was really no hypoglycaemia.
On reviewing the results of treatment at the clinic
it may be stated that insulin therapy can, in most cases,
be successfully controlled from the start at such a centre.
VI
The Recognition and Treatment
of Complications at the Clinic
It is very Important that complications should be
prevented if possible and in any case their early
recognition and treatment is of prime importance.
The presence of ketones as demonstrated b y the
ferric chloride test was taken as the signal for active
measures to combat the onset of coma at the Western
Infirmary Clinic.
On the slightest suspicion of lung
trouble X-ray examinations and sputum tests were under­
taken to exclude tuberculosis.
Patients found to have
this disease should have increased diet and insulin
and be referred for sanatorium treatment.
The importance
of this complication in diabetes has been demonstrated
by Root (48), (49),
(50) and Himsworth (47) advises
an annual X-ray examination for all patients.
When the
tuberculosis is quiescent they can be adequately managed
at the clinic, but to prevent further cases I took steps
to ensure that such patients were not allowed to wait
among the other diabetics.
Any infection was dealt with as soon as discovered
and the highest degree of co-operation existed between
the hospital surgeons, dental surgeons and the clinic.
Special attention was paid to the state of the arteries,
and where disease of these vessels was causing gangrene
of the foot a surgeon was consulted on the advisability
of lumbar ganglionectomy.
One outstanding example of
this was in a woman aged 64 years.
When first seen one
leg had been amputated above the knee for gangrene of
the foot.
A few months later she developed a small
- 43 -
area of gangrene on the remaining foot.
She was admitted
to hospital and after thorough preparation had lumbar
ganglionectomy performed by the late Professor Archibald
Young.
The circulation in the leg became much better and,
after the superficial slough had separated,
in the foot healed completely.
the lesion
All patients with defective
circulation were given special exercises for its improvement.
Any patients with eye symptoms, apart from those
merely due to rapid changes in sugar concentration at the
commencement of treatment, were examined by an occulist
so that defects could be dealt with.
Among the females
there was a considerable number with gynaecological
conditions.
After treatment at the clinic most of these
women were fit to stand operation successfully.
Above all one must have complete co-operation between
the clinic and the various specialists.
This has been
stressed by Joslin (51) whose clinic is one of the best.
VII
The Staff and Routine of the Diabetic
Clinic of the Western Infirmary
The staff consisted of a Medical Officer and a
Dietitian.
Later the dietitian was replaced by a
Sister-Dietitian.
They were assisted in the work by
probationer nurses and student dietitians.
- 44 -
A large dispensary consulting room was used for
interviewing the patients.
At one side of this room
a part was set aside for urine testing and at the other
were the weighing machine and filing cabinet.
In the
centre, placed side by side, were tables for the SisterDietitian and the Doctor.
There were small male and
female examination rooms adjacent to the consulting room.
The following is a resume of a routine session of
the clinic.
Each patient brought a 24-hour specimen of
urine in a bottle bearing his name.
by a probationer nurse and tested.
These were collected
The test-tubes were
suitably marked and left in a rack so that they could
if necessary be inspected by the medical officer.
While
this was in progress new patients were examined in the
examination rooms, their charts were made out and they
were given appointments for blood sugar estimations as
indicated above.
Meanwhile old patients were brought in and weighed.
They were then interviewed by the sister-dietitian, who
marked in the weight and urinary findings.
She answered
any dietetic queries, and if there was no need for medical
advice, allowed the patient to go after settling the date
of the next visit.
Patients whose conditions were not
perfectly controlled were all seen by the medical officer,
and in any case no patient was allowed to go longer than
- 45 -
two or three months without being seen, even though his
condition were satisfactory.
When alterations in the diet or new diets were required
one of the student dietitians made the necessary calculations
and these were checked by the sister-dietitian.
Investigation
of suspected departures from diet were usually undertaken
by one of the students in the first instance.
Patients were given personal instruction in the treat­
ment of their disease, and those who were capable of doing
so were instructed in urine testing.
Some actually gave
much assistance to the nurse engaged on this work.
Mosenthal (10) does not advocate daily examination of urine
by the patient.
He states this is the physician's responsibility,
but I am not in agreement with him, as a diabetic who is
able to test his own urine and adjust his diet if necessary
can go much further afield than one who is wholly dependent
on his doctor.
In view of the number of patients giving a family
history of the disease and the views expressed by certain
workers,
(24) (52)
(53) (54) (55)
(56) and (57), on the
hereditary nature of diabetes, patients were encouraged
to bring any relatives with suspicious symptoms for
examination.
By this means it was discovered that the
two daughters of one patient were also diabetic though
their condition had not been previously detected.
- 46 -
Joslin (51) states that we should hunt for the symptomless
diabetic as he has the best prognosis.
As the clinic was held in the afternoon many patients
could not attend on account of their work, but in some
cases a relative brought up a specimen of urine and reported
on his condition.
In such instances arrangements for
seeing the patient at suitable times were periodically
made.
An evening clinic would be of great advantage for
this purpose, but this would, of course, raise the cost.
Evening clinics have been advocated by Lawrence and
Madders (29).
Patients found to have non-diabetic glycosuria were
asked to attend at three monthly intervals for observation
purposes.
These patients were not put on a restricted
diet, but they were advised to observe moderation in eating
and drinking.
Those with suspected diabetes were naturally
also kept under close observation.
No marked reduction
of their carbohydrate intake was made.
Tyner (58), who
carried out investigations on obese subjects, maintains
that the carbohydrate should be reduced, but the work
of Himsworth (21) (22) and (23) suggests rather that in
such cases the fat should be reduced in other words they
should be given obesity diets.
Conditions other than diabetes were also treated at
the clinic.
Many of these patients suffered from obesity.
- 47 -
They were not separated from the diabetics as is done in
some clinics.
It was found advantageous to have a variety
of diseases at the clinic as this prevented the work
becoming monotonous to the staff.
Where patients were poor and unable to afford adequate
treatment steps were taken through voluntary bodies and
the public assistance department to give them the necessary
help.
In a voluntary institution, however,
it was not
possible to afford them the aid in this direction which
could have been given in a centre controlled by a local
public health authority.
There was an excellent team spirit among the staff
of the clinic, all of whom were very enthusiastic and
frequently as many as fifty patients were seen at a
single session.
I was able to conduct research work
on diabetes and this is given in later chapters.
Prom what has been stated in this chapter it is
clear that the diabetic clinic can be utilised as a
centre for the treatment and welfare of diabetics.
CHAPTER
V
The Diabetic Clinic as part of the
______Public Health Service_______
It has been shown in previous chapters that the
number of. diabetics in the community is increasing,
that
for the supervision of the poorer patients the clinic
forms a very suitable centre and that it can, by early
out-door treatment, conserve hospital accommodation
for more urgent cases.
At present there are few clinics provided by local
authorities, most being attached to voluntary hospitals.
Such institutions have not the necessary funds to supply
insulin and assistance in obtaining a proper diet to
needy patients and application for these has to be made
to the local authority.
General hospitals moreover do
not have an efficient system of home visitation.
What remedy is there for these imperfections in
the treatment of diabetes mellitus?
The local public
health authorities already possess the necessary
machinery for the operation of a diabetic service, and
there is no reason why the onus of maintaining such a
service should not be placed on these bodies.
Where a
council is fortunate enough to have in its area an
efficient diabetic clinic run on a voluntary basis
a rival one should not be organised, but *the managers
-
49
-
of tiie clirrLa: should be approache<i with. & view to establish­
ing an adequate joint diabetic service for the area.
Xf no special provision for diabetic treatment has
been mart*- in their area the authority should consider
establishing the appropriate facilities or requesting
the co-operation of a voluntary institution in the
formation of such a service.
Where a general hospital
is maintained by the council it could with advantage
be used as the centre for the clinic, but failing this
a child welfare or school clinic would meet the need.
The utilisation of such premises removes the need for
capital expenditure on buildings.
If a laboratory is
already in existence the cost of equipping it for blood
sugar analysis would be small, and where there was no
laboratory a test-room could be suitably furnished for
Maclean's method of analysis at a cost of about £10.
The apparatus required for the Folin Wu method of
analysis would be more expensive In view of the fact
that a colorimeter and a centrifuge are required.
The running costs of a service would be due mainly
to wages and help afforded to patients.
No account is
being taken of the cost of upkeep of buildings etc. as
It is assumed that these premises are already in use
and though a portion of the outlay would be chargeable
to the diabetic clinic, it would not materially alter
- 50 -
the charge to the public health department as a whole.
Assistance in procuring insulin and diet is already
given through the public health and public assistance
departments, and though it could with advantage be
controlled through the clinic, it would not represent
an additional burden to the ratepayer.
The Western Infirmary, being a voluntary hospital
with an unpaid visiting staff, was in a position to
.
operate a clinic at a minimum cost, and the charges
are set out below:
(1) Medical Officer - a dispensary physician
with honorarium of £25 per annum.
i of dispensary hours in clinic
(2) Sister Dietitian - salary £120 and
emoluments £100.
\ of time charged
to clinic (59).
£8.
6.
8.
55.
0.
0.
7. 11.
0.
(3) Probationer Nurse - salary £35 and
emoluments £60. (59)
of time at clinic
(4) Student Dietitians unpaid.
Total cost for year
...
£ 70. 17.
There was little extra cost on account of
biochemical examinations.
During the year 1935 there were treated at the
Western Infirmary Clinic without admission to hospital
seventy-eight new cases of diabetes.
Prior to the
opening of the clinic the majority of these would have
8,
- 51 -
been admitted to the wards for investigation and treatment
at a cost of 9/9 per patient per day (59) for periods
varying from two to six weeks.
If an average duration
of three weeks residence is taken that number of patients
would have cost the infirmary £798. 10. 6., and as shown
above, 35 per cent of them would probably have required
the diet and insulin rebalanced afterwards.
The clinic
might thus be regarded as the most economic means of
treating diabetes.
It would not be possible for a local authority to
maintain a diabetic clinic at the low costs obtaining in
the Western Infirmary.
The medical officer, dietitian,
nurses and laboratory assistant would all have to be
paid, but the cost would not be formidable, and a home
visiting service operated by the school nurses and health
visitors could be economically arranged.
The medical officer might be an assistant medical
officer of health, a specialist or a local practitioner
who took a special interest in diabetes.
A dietitian,
while of great assistance at the clinic, is not indispensible
provided a simple system of dieting is employed.
Himsworth (47) however advocates the employment of a
dietitian and a chiropodist.
The nurses can be drawn
from the public health nursing service, the members of
Which are well qualified and could, with a little special
- 52 -
instruction from the clinic medical officer, make quite
efficient diabetic nurses for the clinic and for the
visitation of diabetics in their own areas.
Joslin (46)
maintains that it costs no more to keep a diabetic
travelling nurse for a year than endow a diabetic bed
for a similar period.
Blood sugar examinations could
be made by the public health laboratory technician or one
of the nurses who had been suitably trained.
The cost in respect of salaries of the above service
with, say, 48 sessions of the clinic per annum would be:
(1) Medical Officer
(B.M.A. Specialist Rate per
session)
£126.
0.
0.
5.
6.
(2) One Health Visitor - Salary £300
for -g- day each w e e k
27.
(3) One School Nurse - Salary £260
for
day each w e e k ......
23.. 12.
9.
(4) Technician’s or Nurse’s time on
blood sugar examinations
23.
12.
9.
(5) Home Visitation
Estimated as one nurse for one day
each week
.................
...
50.
0.
0.
Total Cost
£ 250. 11.
0.
The total cost would be reduced to £200 if a
general practitioner were employed, and to. £190 if
the clinic were in charge of an assistant medical officer
of health.
Allowing 50J= on the maximum estimate to
cover administrative charges and leave a margin for
error the scheme would cost £375 per annum and would
be capable of serving a borough with a population between
100,000 and 200,000.
In such an area this sum would
represent about 0.1 of $. penny for general rate purposes.
For smaller authorities a clinic meeting once a fortnight
would be sufficient.
The administration of insulin to those patients
who are incapable of doing this job for themselves will
always cause a certain amount of difficulty.
The District
Nursing Association has always been ready to co-operate
in this matter, and local authorities would do well to
make an annual grant to this body in respect of such
work.
Care must be taken to ensure that each patient
has his insulin at the correct time.
A public health diabetic clinic by home visitation,
and close co-operation between practitioners, other
public health clinics and the hospital can adequately
supervise the treatment of the diabetic subject and
so provide an efficient diabetic service.
CHAPTER VI
The Ammonia Coefficient of
the
Urine in Treated Cases of Diabetes
Mellitus - The Effect of diet.
(The substance of this chapter was published in the
"Glasgow Medical Journal" (1936) vol. 126, p. 323)
The advent of insulin has appreciably increased the
span of life for the diabetic subject, but there is still
a high death-rate from the disease for which many factors
may be responsible.
Proper management of these patients
certainly presents many difficulties, and even under
optimum conditions restoration of normal metabolism is 1
practically impossible.
Treatment demands intelligent
co-operation on the part of the patient which is not always
forthcoming and, indeed, experience in the supervision of a
large number of cases at a diabetic clinic shows that many
lapses occur.
Perhaps the most frequent are deviations
from the prescribed diet.
It is almost certain that such
defects in treatment give rise to slight errors in metabolism
which when persisting for extended periods may predispose
to complications.
Even while the disease is apparently
under control there may be a tendency to acidosis.
The
possibility of some slight disturbance in acid-base
equilibrium occurring during the course of treatment appeared
worthy of investigation, and it was decided to ascertain
54.
- 55 -
whether in a considerable proportion of cases the ammonia
coefficient of the urine was at times abnormally high.
A
survey of the literature since 1921 failed to reveal any
reference to work on this particular aspect of the subject.
METHOD
The present investigation was made principally on out­
patients attending the Dietetic Clinic at the Western
Infirmary, Glasgow.
Subjects selected for examination
included those where the disease could be controlled by
diet alone and others who required insulin in addition.
They were instructed to carry out their usual treatment
and to report at the hospital shortly after breakfast,
when a freshly passed specimen of urine was obtained for
examination and particularly for the determination of the
ammonia coefficient (A.C.)
^
q
_
Ammonia Nitrogen________
Ammonia Nitrogen + Urea Nitrogen
In normal healthy individuals not on special diet this
value does not exceed 5.0.
In diabetics, however, a finding
less than 6.0 might be considered satisfactory and this
standard has been adopted in assessing results.
- 56 -
RESULTS
The findings in 117 patients examined may conveniently
be divided into five groups, these patients were all
established diabetics.
The results and the diets are
set forth in Appendices 1 to 6.
Those in Groups 4 and
5 were subjected to repeated investigations at intervals
over varying periods.
Group 1 (Appendix 1) consisted of 57 patients who
had followed strictly the prescribed treatment and
whose condition, from a clinical standpoint, was satisfactory.
The subjects were on diets of low or medium carbohydrate
content, and some required insulin.
The values of the
ammonia coefficient varied from 3.7 to 13.8 and were
distributed as shown in Table 6:
TABLE
A. C.
3 -;
4 -;
No. of
cases
A.C.
£;.?
11
9 -;
10
6
5 -;
6 -;
7 -;
8 -;
11
16
12
4
11
i
12 -;
0
13
1
Only twenty-three of these values were less than
six, and thirty-four of them were six or over.
Figure
2a shows in the form of a Histogram the percentage of
cases at each class interval.
The mean and the median
57.
337676732245
//•r/o.
A.c.
s-
Fiffure 2
Histogram to show the percentage
distribution of the values of the
A.C. of subjects in (a) Group 1;
(b) Group 2 8c (c) Group 3.
- 58 -
value is 6.3, while the Standard Deviation is 1.65;
it was thus apparent that by the methods of treatment
employed the glycosuria and ketonuria were controlled,
but in a number of cases the ammonia coefficient was
definitely above normal limits.
Group 2 (Appendix 2) which was used for comparison
with Group 1, consisted of 34 diabetic subjects who had
completely neglected to follow the treatment prescribed.
The values of the ammonia coefficient in this group
varied from 2.4 to 7.9 and were distributed as shown
in Table 7:
TABLE
A.C.
7
2-;
3 -;
4 -;
5 -;
2
10
9
8
5°: °f
cases
6
1
7
4
The mean was 4.8; the median 4.55 and the Standard
Deviation from the mean 1.37.
The percentage distribution
of the cases in the various class intervals is shewn
in Figure 26.
Thus, while all these patients had
glycosuria and many ketonuria, a much larger proportion
than in Group 1 had an ammonia coefficient below 6;
this is well shown in the histogram.
It is interesting
to note that Hubbard and Allen, (60) found the urine
of treated diabetics to be more acid than the urine
of the untreated.
Unfortunately they did not state
- 59 -
the diets employed in their investigations.
The patients were questioned with regard to their
departure from treatment.
Very few to whom insulin
was prescribed had discontinued its use, but practically
all had deviated from the prescribed diet.
Excess of
carbohydrate (C) and omission of protein (P) and fat
(P) were the most frequent transgressions.
These
delinquencies were largely due to carelessness or
indifference on the part of the patient, but not
infrequently financial inability to procure the diet
was a cause.
It seemed reasonable to assume that
since the proportion of carbohydrate to fat had been
considerably raised in this group there might be
less tendency to acidosis and possibly a lower ammonia
coefficient.
The 13 diabetic subjects in Group 3 (Appendix 3)
were examined in order to test the validity of this
assumption.
These patients were given diets rich in
carbohydrates, poor in fat and containing 65 to 75 gms.
protein per day.
At first the proportion employed
was C .150 gms.; P.70 gms. and P.50 gms.
Glycosuria
and ketonuria were adequately controlled on this
diet.
The values of the ammonia coefficient varied
from 3.5 to 7.5 as shown in Table 8:
- 60 -
TABLE
A.C.
No. of
cases
3
2
4
6
8
5
6
3
7
0
2
and are set forth in the form of a percentage histogram
in Figure 2c.
The mean was 5.0, the median 4.9 and the Standard
Deviation from the mean, 1.15.
Although the number of
cases is not large the results would appear to support
the view that on a diet rich in carbohydrate and poor
in fat the ammonia coefficient may be kept nearly within
normal limits.
In Group 4, consisting of 9 patients, examinations
were made to ascertain Y/hether a reduction of the ammonia
coefficient could be effected solely by raising the
carbohydrate and lowering the fat intake.
The first 4
subjects (Appendix 4) had been on a fairly high fat
intake for a considerable period, and the effect of
increasing the proportion of carbohydrate to fat was,
in each case, to reduce the value of the ammonia
coefficient.
The remaining 5 patients (Appendix 5) who had not
received previous treatment, were put on a diet of 8 to
19 (old) Lawrence Line Rations (44) (C. 5 gms., P.
7 -5 gms., F. 15 gms. per line).
After repeated exam-
- 61 -
inations of the urine had heen made, a diet consisting
of C. 150 gms., P. 70 gms. and P. 50 gms. was substituted
and was, in most cases, raised as shown in the Appendix.
The ammonia coefficient was estimated while on these
diets and was found, on the average, to be lower than
while on the Lawrence Line diets.
In all cases the
urine remained sugar free after the change of diet.
Prom these results it is clear that the ammonia
coefficient is lowered by raising the carbohydrate and
diminishing the fat intake.
High carbohydrate diets generally contain a con­
siderable quantity of fruit, and so the possibility of
lowering the ammonia coefficient by the ingestion of
f^base-forming substances (organic acids) had to be
considered.
The 4 patients in Group 5 (Appendix 6)
were examined while on a high carbohydrate, low fat
diet containing the minimum quantity of fruit, and
subsequently on one of the same food value with a
high fruit content.
The results seem to indicate
that fruit is not more effective than other forms
of carbohydrate in lowering the ammonia coefficient,
it would, therefore, appear that it is the increase
in available glucose or the diminution of fat and
not the base derived from the fruit which is the chief
- 62 -
factor in this process.
DISCUSSION
In a considerable proportion of diabetic subjects
adhering strictly to accredited methods of treatment the
ammonia coefficient is definitely above normal limits,
which indicates that ammonia formation is necessary to
prevent acidosis.
As these patients (Group 1) had
given excellent co-operation it could be assumed that
any defect lay in the treatment prescribed.
The results
obtained in the succeeding groups show that the ammonia
coefficient can be lowered by adjusting the diet so that
the proportion of carbohydrate to fat is increased.
This
is especially well shown in in Figure 2 where the results
in Groups 1, 2 and 3 are shown in the form of histograms.
The vertical line divides the values less than 6 from those
of 6 and over.
It is significant that in Group 2 where
extra carbohydrate was taken by the patients, and in
Group 3 where the carbohydrate was purposely increased
and the fat curtailed, the percentage of subjects with
ammonia coefficients of 6 or over was very low.
It is problematical to what extent and in what ways
the conditions causing a raised ammonia coefficient may
affect adversely the patient's health, but they can
evidently be controlled and the value maintained wi tiiin
- 63 -
normal limits by this dietetic adjustment.
Of the twenty-
six patients so treated one only (Case 117) gave a
persistently high value.
Here the administration of
alkali had a beneficial effect.
Rabinowitch (61) has been largely responsible for
the introduction of the high carbohydrate low fat diets
in diabetes.
He has shown (62) that whereas on a low
carbohydrate high fat intake the blood cholesterol is
raised, it is, on the other hand, kept within normal
limits on a high carbohydrate low fat consumption.
On
the latter diet which resembles very closely that of a
working-class family, and which is one of the cheapest
to procure, the patients remain well.
With careful
adjustment such a diet does not necessitate an increased
consumption of insulin, and it might therefore be used
more frequently in treating cases of diabetes mellitus.
On account of its low fat content it is eminently suitable
for obese patients and those with disease of the biliary
system.
CHAPTER VII
The Relationship of Cost of Diet to
________Dietary Delinquency_______
In view of the fact that many instances of dietary
delinquency in diabetes consisted of the replacement of
expensive foods by carbohydrate, the part played by
the greater cost of diabetic compared with normal diet
in the production of dietetic indiscretions seemed
worthy of investigation.
If the amount of delinquency
increased with a rise in cost of the diet, then the
expense of diabetic diet could be regarded as a possible
cause of failure in treatment.
The patients attending
the Western Infirmary Clinic were by no means well off,
and therefore formed a suitable group for an investiga­
tion such as the present.
Those with large incomes
would not be suitable as the purchase and use of food
would be dictated rather by the palate than the purse.
METHOD
The prescribed diets of 393 diabetic subjects 141 males and 252 females - attending the diabetic
clinic were priced according to the January Price
List of a large Glasgow store with the assistance
of the dietitian.
No allowance was made for the cost
of preparing the food.
Patients on diets with unweighed
protein and fat were not included in the investigation.
- 64 -
- 65 -
The subsequent behaviour of these patients with regard
to dietary delinquency was observed.
RESULTS
The results are set forth in Table 9 which
gives for males, females and persons the number of
patients on diets of various prices and the number
and percentage of those who departed from them.
Figure 3 gives the percentage findings in the form
of a graph.
The results in males, when smoothed
by the method of moving averages, gives the curve
C, while those for females when similarly treated
result in curve E.
Consideration of the findings relating to
persons shows that there is less delinquency when
the cost of the diet is low than there is when it
is high.
In the case of females 3 1 % of the total departed
from diet and it is evident that as the price of
the diet increases so does the percentage of
patients who depart from it.
Diets costing between
8/- and 10/- per week belong mainly to the high
carbohydrate and moderate or low fat type, and it
is in these price groups that dietary delinquency
is at a minimum.
The slight increase in dietetic
i
I
i
00
i
o>
i
o
1
—1
39
100
100
11
02
00
02
to
to
to
02
27
to
to
o>
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rH
to
35
CO
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43
19
35
39
...
to
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02
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iH
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and
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i
Oi
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i
32
I
92
17
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02
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00
27
36
24
67
o>
H
49
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18
03
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t
22
100
00
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to
18
Eh
16
75
24
02
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I!
i
18
to
09
34
02
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SI
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ed
•P
0
25
<d
£
W
R
P E R S O N
M A L E
Number
[Percentage
Percentage
Number
Percentage
1 Number
of
of
Delin­ Total
of
of
delinof Delin­ Total
of
Delinquents
quency
Delinquents | quency
quency
Delinquents
i. ...... .
W
lO
IS
Price of
Diet per
week
GO
02
to
to
to
to
67
/OO
P BRSO^S .
MALE;**
(
D—
A
SM OOTHB
k M A I &S.
F £ M A UBS- (SMOOT,iBb C
U3
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OF
Figure 5
Graph showing oercentase delinquency with
diets of various prices.
- 68 -
indiscretions when the cost is less than 8/- may be due
to these diets being too restricted.
With diets of
12/- and over the number of patients is so small that
no conclusion can be drawn from the fact that all
departed from treatment.
27$ of males failed to keep to the prescribed
diet.
Dietary delinquency did not rise with increased
cost of diet and curve C, Fig. 3 actually shows that
there is a slight trend towards reduction of ,fdietbreaking” with the more expensive diets.
DISCUSSION
The fact that price does not influence adversely
the adherence to diet among males may be due to several
factors.
Greater expenditure of energy may create
a desire for the fatty foods even though they are
expensive, and a man does not usually have to cook
his own food.
Not infrequently this is prepared and
measured by his wife or other member of the household
and pains are taken to ensure that the correct diet
is presented and adhered to.
With women, on the other hand, there is constant
temptation in the kitchen to take some extra carbohydrate.
Moreover, the housewife has to buy the food, and when
short of money she may neglect her own diet rather than
- 69 adhere to it at the expense of the family.
Many female
patients frankly admitted at the clinic that they had
had extra carbohydrate because they had not the where­
withal to buy the protein and fat included in the
prescribed diet.
Lapp (63) stresses the need for a
diet which the patient can afford but he does not
produce any evidence to show that price per se may
be a cause of dietary delinquency.
CONCLUSION
The cost of diet obviously plays a part in
determining the strictness with which a patient
adheres to treatment.
This is especially noticed
in females, and in planning the treatment of working
class patients the question of expense must always
be kept in mind.
CHAPTER VIII
The Relationship of the Calorific Value
of the Diet to Dietary Delinquency.
In the Allen era patients were treated by under­
nutrition diets.
Restriction in the amount of food
was less severe after the introduction of insulin, but
even now diabetics are given diets lower in calorific
value than the normal.
An insufficient supply of
energy giving foods might induce a patient to break
from treatment, and in order to find out if this were
the case the following investigation was undertaken.
METHOD
The calorific content of the diets of 379
diabetic subjects - 133 males and 246 females - attend­
ing the clinic was noted and the subsequent history
of each with special reference to adherence to diet
was investigated.
RESULTS
In table 10 is set forth the numbers of males,
females and persons on diets of varying energy value.
The number of those who departed from treatment and
the percentage of delinquency in each group is also
shown.
Figure 4 gives a graphic representation of
these results.
- 70 -
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- 72 -
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Figure 4
Graph showing percentage of dietary delinquency
of patients on diets of various calorific value.
The findings for persons indicate that departures
from treatment are more frequent -with high calorie
diets, but as the majority of patients were females
and the reaction to dieting differs in the sexes,
this generalisation is misleading.
In women there is a very definite increase in
delinquency as the calorific value of the diet rises
above 1500 calories.
The curve for females in
Figure 4 corresponds very closely to the one in
Figure 3 which refers to delinquency relative to the
cost of diet.
Very few men receive diets of less than 1299
calories, and such cases can therefore be left out
of consideration.
Delinquency appears to increase
with rise in the calorific intake until diets of
1900 calories are reached, after which there is a
decrease in departure from treatment.
DISCUSSION
High calorie are more expensive than low calorie
diets on account of the larger amount of fat which
they contain.
It may therefore be the increase
in cost which accounts for the departure from treat­
ment of a considerable number of women on such diets.
The large amount of fat in them may not appeal to
- 74 -
some patients, especially those who lead relatively
sedentary lives.
Among men the decrease in "diet-breaking" with
increase in calorific intake above 1900 calories suggests
that some departures from diet may be caused by allowing
the patient insufficient food for his energy require­
ments.
It Is difficult to account for the decreased
delinquency with the diets of low calorific value,
but here reduced cost may play a part.
CONCLUSIONS
It would appear essential in planning diets,
especially in male subjects, to allow a sufficient
number of calories as well as to supply a reasonably
priced diet.
Many workers in the past gave very
low diets, but one must remember that diabetics are
only human and that the pangs of hunger will readily
overcome the better judgment of the average patient.
It has been my experience that a little extra food
allowed judiciously will do infinitely less harm
to the diabetic than that which he takes surreptitiously.
CHAPTER IX
CONCLUSION
It has been shown that the number of diabetics
in our midst is increasing and that the family
practitioner cannot, without outside help, maintain
these valuable members of the state in good health.
A diabetic clinic such as the one at the Western
Infirmary of Glasgow goes far to supply the necessary
assistance to the family doctors in the treatment of
this disease, but it cannot fulfill this need
completely.
A Public Health Diabetic Service in co-operation
with local hospitals and practitioners appears to be
a very suitable means of securing the very best
supervision and treatment for the working class
diabetic.
In such a service the patient should be
taught to control his disease by diet and insulin.
The diet prescribed should be adequate, as near as
possible to the normal, and should not be expensive.
Finally It should be emphasised that the
diabetic is generally a relatively intelligent person
who has a genuine wish to earn his own living, and
tt seems only reasonable that he should receive all
the help which the community can afford him.
- 75 -
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A married woman who, a year "before,
had "been admitted to hospital with
severe diabetes.
She had not followed
instructions regarding diet and insulin
and had been brought back to hospital
in coma.
She made an uneventful
recovery and the ammonia coefficient
of the urine was estimated just prior
to her leaving hospital.
A married woman.
She had suffered
from diabetes for a year.
Neuritic
pains in the ams had been a trouble­
some feature but these had been
relieved at the time of the investi­
gation.
This woman died a year later from
rupture of a basilar aneurism.
JNSIOIddEOO
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Diabetes discovered
when she was admitted to hospital
for operation for prolapse of uterus.
She had operation after diabetes was
under control.
This girl had diabetes of very acute
onset four months previously.
She
responded well to diet and insulin.
She subsequently died after a
streptococcal infection of throat.
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Responded well to treatment.
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IN UNITS
PER
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Married woman.
Diabetes found when
she v/as admitted to hospital for a
gynaecological operation six months
before.
She responded well to
treatment.
H
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m
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Married woman.
Diabetes of eleven
! years duration.
She had been in
hospital several times.
She had not
had any severe complication.
1A
JNNIOIddSOO
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135
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1A
Married woman.
Had been admitted to
hospital 3 months previously with
diabetes of gradual onset.
No
complications.
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Married woman with symptoms of 4-6
months duration.
Disease controlled
“by dieting without indoor treatment.
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Had been discharged from hospital
after treatment for diabetes three
months previously.
He was a worker
in Imperial Chemical Industries Ltd.
and had suffered from T.N.T. poisoning
during the 1914-18 war.
Married woman.
She was very thin.
Had had diabetes for about six months
and had received hospital treatment.
She load had no complications.
Suffered from diabetes of recent onset
for which he had received treatment
in the wards.
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This man came to the clinic 8 months
previously with marked diabetes of
recent onset.
It was not found possible
to get the condition completely under
control as an out-patient and he had
to be admitted to hospital for a few
weeks.
The above estimation was made
after his discharge from hospital.
Three months before this lad had
noticed the gradual onset of diabetic
symptoms.
He responded to treatment.
Subsequently, after an infection, his
tolerance became less and he had to
take insulin.
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Married woman.
Duration of disease
two years.
Had been in wards for
adjustment of diet and insulin.
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Married woman.
A diabetic of two
years standing.
First came to this
hospital with septic finger 3 months
ago.
She had treatment in the wards.
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A diabetic of several years standing
who had previously been in the wards
for regulation of his diet.
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This married woman had suffered from
diabetes for several years.
She had
previously been in the wards and the
diet and insulin had been balanced.
She subsequently died after a
gynaecological operation.
3
CO
Diabetes of a few months duration.
Had diet balanced as out-patient.
Was subsequently rebalanced in
hospital on a diet of C120, P. & P.
unweighed and i+0 units of insulin.
V“
vo
6.3
Married woman.
Two months before
she had been admitted to hospital
with a gangrenous patch on the foot.
She was found to have diabetes and
admitted having had symptoms for some
time previously.
She made a good
recovery.
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Married woman.
She had come to clinic
3 months previously having symptoms
of diabetes of gradual onset.
She
required 15 units of insulin per day
but had been able to dispense with
this at time of observation.
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Came to clinic four months previously
complaining of symptoms of diabetes
of gradual onset.
Condition was
readily controlled on the above diet
and insulin.
Married woman with diabetes of Ui
years duration.
She had thickened
arteries and later suffered from
cerebral thrombosis.
Had been admitted six months
previously with gangrene of toe.
Pound to have diabetes.
He required
insulin in hospital but was later
able to omit this.
Married v/oman with fairly mild
diabetes of at least six months
duration.
She responded to out| door treatment.
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brought to the clinic very acutely ill
and had been immediately admitted to
hospital, where she made an uneventful
recovery.
A history of diabetes of
many mon t h s ’ duration was given.
Married woman.
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hospital 4 months before on account of
a septic toe.
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was found to have diabetes.
ft
Had recently been admitted to medical
wards with marked diabetes of short
duration.
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insulin but had to be given 10 units
per day shortly after dismissal.
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lung condition radiologically similar
to tuberculosis.
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positive sputum.
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air, increased diet C180; PI 00;
F125; Cals.2110 and 55 units insulin.
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Married woman.
Had diabetes of 7
months' duration.
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of gall bladder disease and tenderness
in epigastrium when she first came
under observation.
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as an in-patient to begin with, but
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attended the out-patient department.
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She was admitted to
hospital on account of weakness and
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origin.
Discovered to be a diabetic.
Later an Electro-cardiogram gave a
picture compatible with coronary
artery disease.
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Married woman.
Diabetes of 2i y e a r s 1
duration.
She had been in hospital
for treatment when she first developed
the disease.
Apart from some giddiness
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previously.
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diabetes and was treated for this
disease but failed to follow treat­
ment after her discharge.
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This man had suffered from diabetes
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received indoor treatment hut had not
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This girl had been referred to the clinic
seven months before on account of
diabetic symptoms of gradual onset.
She responded to outpatient treatment.
This man v/as found to have diabetes
when, two months previously, he was
admitted to the v/ards with an abscess
of neck.
The ammonia coefficient was
estimated while he attended the clinic
after discharge.
A married v/oman, she had had diabetes
for at least six months.
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treated as an outpatient.
This married woman had diabetes of
about 2 years' duration.
She responded
to treatment on high C, low F after
other diets had failed.
She refused to
take insulin.
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This married woman had first
noticed diabetic symptoms six
months previously.
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successfully treated as an
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A married woman who
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BIBLIOGRAPHY
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