March 30, 1889
Dr Purdy has caustic words for medicine when it comes to treating diabetes. "It remains, to speak of the medicinal treatment of glycosuria, and I may as well state frankly at the beginning that I have little faith in the curative power of medication over the disease, while on the contrary I am satisfied that the use of drugs in these cases is often productive of harm."
Treatment of glycosuria
[This is the second half of the paper.]
In accustoming the patient to the more strict form of diet, care should be exercised not to permit the stomach to be overloaded. The beneficial effects of temperate eating in glycosuria were very prominently illustrated during the siege of Paris, as Bouchard observed that sugar entirely disappeared from the urine of diabetics in whom up to that time it had persisted, even though they had been living on a carefully regulated diet. The diminution in the quantity of food, occasioned by its great scarcity during the siege, effected that which alteration in quality had failed to accomplish.
The more slowly food is submitted to the digestive forces, the more completely is it likely to become assimilated. Tight meals frequently repeated is the better rule to follow, at least until the patient becomes accustomed to the change. It is important also that the diet be varied as greatly from day to day as the range of food in the list will permit.
I have repeatedly placed diabetic patients that were considerably under 20 years of age upon the strict lines of diet herein indicated, with the result of completely eliminating the sugar from the urine for weeks and months together, and without resort to medication. Thus it may be seen how much may be expected from proper dieting, even in cases that we are forced to consider as ultimately hopeless ones.
By way of illustration—a year ago this month a lad of 18 years came to me from a distant State with a history of diabetes of over a year’s standing. His symptoms, as is usual in such cases, were great thirst, morbid appetite, polyuria, and advancing emaciation, with a very considerable amount of sugar in his urine. His physician at home had put him upon a diet scarcely so limited as the ‘ ‘ first step ’ ’ laid down in this paper, and but a slight check was put upon the disease. I gradually restricted his food allowance until it conformed to the strict diabetic diet already laid down. His thirst gradually subsided, the quantity of urine diminished, and at the end of six weeks no trace of sugar was to be found in his urine, and he began to regain his lost weight. •Under a continuance of this course the urine remained normal in quantity and free from sugar for about three months, when he returned to his home with directions to follow as closely as possible the course that had so greatly benefited him. This case may be fairly ranked among the most unpromising ones, chiefly on account of the patient’s age; for it is a rare exception to meet with a case under 20 years of age in which the disease does not rapidly prove fatal unless the patient be very strictly dieted.
It may be said of glycosuria in general that its severity is usually in inverse ratio to the age of the patient. The youngest diabetic I have seen came under my care a short time since, in the person of a little boy 3 years and 2 months old. In this case the polyuria was so pronounced that a nurse had to be provided to attend him at night, as he “ wet the bed’’ from six to eight or more times each night. It may be of interest to note that he was put upon an animal diet, including milk, which soon lessened his polyuria so that the patient did not urinate during the whole night. I believe milk is more easily assimilated by children than by adults ; at any rate it seems to agree better with them in these cases ; and this is very fortunate, since we are almost driven to its use in diabetics of tender age. As a rule, in patients under middle age, we shall be obliged to bring to bear against glycosuria all our resources of dieting in the more strict form. I have met with an exception to this rule in the case of a Jewess, 29 years of age, in whom moderate restrictions of diet have kept the urine practically free from sugar for the past year and a half, only exceptional traces having appeared occasionally. It has been remarked by several observers that diabetes is frequent among Hebrews, and that in them the disease is always of. mild form. My own experience tends to confirm the latter statement. I have, indeed, at the present time, three cases in Hebrew women under treatment, and they are all of mild form.
For the most part the milder forms of glycosuria are met with in people that have passed the age of 40 or 50 years. In this class of cases our resources against the disease are always more effective ; indeed, one or two years careful dieting not infrequently leads to permanent cure.
It remains, to speak of the medicinal treatment of glycosuria, and I may as well state frankly at the beginning that I have little faith in the curative power of medication over the disease, while on the contrary I am satisfied that the use of drugs in these cases is often productive of harm. My conclusions upon this point have been reached through separating the dietetic from the medicinal treatment, and then comparing the results of each. When a system of diet and medication are employed together from the beginning, the benefits accruing from diet may be attributed to the medicines, while the unfavorable influence of medication may be attributed to the disease. Our faith has become so supreme in the efficiency of medication in these days, that we are apt both to permit ourselves to be misled in its favor, and to overlook its possible injurious effects.
Of the various drugs that have been recommended in glycosuria, opium, perhaps, maintains its reputation best and has become the most popular. Opium undoubtedly tends to restrain the excretion of sugar in these cases, but the doses necessary to accomplish this result are so large that the drug is likely to induce constipation and impaired digestion, and thus any good accomplished through its use is more than counterbalanced by resulting evil. I have recently gone over this ground very carefully in a series of trials systematically conducted. Three cases were selected, in each of which the sugar excretion had been reduced by strict diet to about i per cent. They were all typical cases of true diabetes of central origin; and no little pains had been expended in reducing the sugar to so small a percentage, and maintaining a good general condition with excellent digestion and assimilation. Under gradually increasing doses of opium the sugar excretion was reduced Somewhat in all the cases, but sooner or later constipation, loss of appetite, or nervous disturbances compelled the dis- continuence of the drug without exception. This has always been my experience in the use of opium in glycosuria ; nor have I found any material advantage in the use of morphia, its bimeconate, or the use of codeine. They all comport themselves much the same as does opium when used in equal physiological doses.
Ergot is probably the next most popular drug employed in the treatment of glycosuria. In the necessarily large doses required to effect the disease it is unsuitable for lengthy periods of administration. Its controlling power over glycosuria is very feeble and uncertain, and on the whole it may be regarded as unworthy of much confidence.
Bromide of arsenic and syzygium jambolanum have recently been highly lauded in the treatment of glycosuria. I have known the former to be administered in the largest doses (25 drops Gilliford’s solution), during which time the patient continued to excrete urine that contained 30 grains of sugar to the ounce. Upon withdrawing the bromide of arsenic and placing the patient upon a restricted diet, I had the satisfaction of seeing the sugar speedily reduced to 2]/i grains to the ounce. I have administered jambul to a number of my patients, but without noticing any favorable change that I could fairly ascribe to its use. A number of other drugs have been more or less highly extolled for their alleged specific influence over glycosuria. Among these may be mentioned iodoform, bromide of potassium, iodide of potassium, arsenic, sodium phosphate, nitrate of uranium, salicylic acid, picric acid and Calabar bean. There does not, however, appear to be sufficient evidence in favor of any one of these to entitle it to any degree of confidence. Carefully discriminated from the benefits derivable from dieting, these drugs are probably nearly inert so far as their influence over glycosuria is concerned.
The legitimate field of therapeutics in glycosuria becomes practically narrowed down to the treatment of its accompanying symptoms, and upon this point but few words will be here added. It has already been stated that disordered digestion is so frequent in glycosuria as to constitute it an accompanying rule. Indeed, many of the milder cases owe their origin without doubt to this cause. The digestive and assimilative functions should therefore receive especial support through such agents as experience has taught us prove the most efficient. Among these may be mentioned, pepsin and the vegetable bitters— and especially strychnia. The latter I have come to regard with increasing favor.
Constipation, so frequent an accompaniment of glycosuria, should be especially guarded against, as this condition reacts very markedly in enfeebling the digestive and assimilative powers. I have an especial preference for the natural alkaline purgative waters to meet such requirements, since they relieve the over-acid condition of the intestinal canal so common to the disease. Fried- richshall or Sprudel—or the salt made by the evaporation of the latter—given before breakfast,
in hot water, seem especially appropriate. In middle-aged people inclined to stoutness and overeating, a course of purgation by either of these agents often proves highly beneficial.
The various nervous disturbances accompatiy- ing glycosuria are, on the whole, perhaps best met by the use of bromides—especially that of sodium or lithium. It is not uncommon to meet cases of glycosuria complicated by anaemia. When pronounced, this condition is frequently attended by oedema of the extremities, and under such circumstances the liberal use of iron and arsenic is attended by excellent results. The appearance of multiple boils is not uncommon in glycosuric patients; a complication generally considered ominous of approaching danger. I have seen a disappearance of this complication in two weeks under the use of quinine—8 to io grs. daily— after having resisted other measures for nearly three months.
The most dangerous, and certainly the most rapidly fatal, of all the complications of glycosuria is that of Kussmaul’s coma—sometimes called acetonaemia. Since the treatment of this complication has thus far proved so unsatisfactory, a knowledge of the conditions commonly leading thereto should be borne in mind, in order to guard the patient against it. Constipation, mental emotion, and fatigue seem especially to predispose to this complication, while a highly acid state of the urine often precedes it. I have repeatedly, in these cases, observed sudden death by coma to constitute the penalty of a hunting expedition, or long railway journey entailing unusual fatigue. If the early indications of approaching coma are observed, stimulants and hot baths should l>e resorted to without delay. It is believed that diabetic coma is brought about by some toxic agent in the blood, perhaps derived from alcoholic fermentation of glucose. Whether this be acetone, or some other agent, we are warranted by certain f facts in believing that it is of an acid nature and, therefore, large doses of alkalies seem the most appropriate remedies to employ. An ounce of tartrate or citrate of soda dissolved in a pint of water may be given three or four times a day. The intravenous injection of sodium carbonate, with chloride of sodium, is strongly advised if coma has already become established. Under the latter circumstances, however, recovery is extremely rare under any form of treatment. On the whole, then, promising results are only to be expected by attempts at warding off the attack through such measures as have already been suggested.
In concluding what has been intended as a practical review of the management of glycosuria, it seems desirable to emphasize the immense importance of careful dieting as greatly outweighing all our other resources combined. This fact should be strongly impressed upon the patient from the beginning. He should be taught to rely little upon medication, and the most effective means of doing this is to show him how much can be accomplished by careful dieting alone. When he has once learned through experience that the amount of sugar in his urine always bears a direct ratio to the prohibited foods indulged in, he is less likely to overstep the proper limits imposed. With his thirst, polyuria, and other discomforts relieved—a sure sequence of careful conformance to the rules—unless he be greatly lacking in intelligence and gratitude, he will cheerfully submit to the conditions imposed, since he will see and feel how greatly he is indebted to them.
163 State St., Chicago.