USA History

THE TREATMENT OF DIABETES MELLITUS 

BY ELLIOTT P. JOSLIN, M.D. 

Boston 

RATHER more success is achieved by surgeons in the treatment of general peritonitis than is attained by physicians in the treatment of diabetic coma. In neither condition are the statistics flattering to the profession; but the successes obtained by our surgical colleagues in the prevention of general peritonitis make the failure to prevent coma as a cause of two out of every three diabetic deaths mortifying to say the least. We physicians should begin to regard diabetic coma in the same light as your British brother, Mr. Moynihan, has taught the medical fraternity to look upon the late stages of a neglected gastric ulcer-namely, as an emergency which should not have been allowed to arise. With this issue of the prevention of diabetic coma plainly to the fore as the cardinal point in the treatment of diabetes, it is pertinent to inquire what diabetic patients are most susceptible to coma? And your own experience will enable you to anticipate that the answer, which an analysis of my own fatal cases shows, will be children. Of the sixty-two diabetic children under the age of fifteen who have died under my care, coma was the cause of death in all, and the significance of this melancholy fact is this: that where diabetes appears in its most severe type, as in children, coma is its expression. The propositions are simpler to state than to execute -first, that the best way to avoid coma is to prevent the progress of a case of diabetes from the mild into the severe type, and second, to protect the patient from all those agencies such as infections, anesthetics like chloroform and ether, undue exertion (mental or physical), which tend toward intensifying the severity of the disease. For if the diabetes is kept mild or moderate the coma need not be feared. Next to the children in the frequency of death from coma, strange as it may appear, were those of my cases who succumbed during the first year of the disease. The cause of death in 87 per cent. of these was coma. But diabetes is a chronic disease and the first year of its course should be mild rather than severe, and in mild diabetes coma should find no place.

Diabetes should be sought in the families of diabetic patients and in order to allay anxiety from urinary examinations, it is a good plan to have these made with such frequency that they will become simply a matter of routine. Such individuals should be taught to regulate the quantity of food eaten by the body weight, and never to indulge in unusual quantities of carbohydrate.

Alternate feeding and fasting are adopted when it is found that the glycosuria persists after a preliminary four days' fast. The method which I have found most successful has been to allow, following the first fasting period, 20 to 40 grams carbohydrate not far from half a gram per kilogram body weight-and about one gram of protein per kilogram for two days

On Dec. 1916, Boston pathologist Elliott Joslin compiles 1,000 of his own cases and creates the textbook The Treatment of Diabetes Mellitus. In it he reports that ‘the mortality of patients was approximately 20 per cent lower than for the previous year’, due to ‘the introduction of fasting and the emphasis on regular exercise.’ This book and Joslin’s subsequent research over the next five decades establishes his reputation as one of the world’s leading expert in diabetes.

https://www.youtube.com/watch?v=qTYjR1H-SqM

"It was now Fry's opinion that I had had typhoid fever. When my friends thought of what they had been letting me eat, they were shocked and alarmed. During the first period of high fever I had been without appetite, but as soon as the fever dropped to 100 degrees, I had begun to eat steaks and fried potatoes or whatever else the police were having for their meals. An hour before my sudden relapse, I had eaten a large meal of macaroni and cheese. There were some who believed that this heavy food was responsible. The relapse, they felt, served me right. What eles could have been expected of a sick man who ate macaroni and cheese!"

page 208

"My convalescence was not going well. When it was decided that I must have had typhoid, I was put on the orthodox typhoid diet. Nothing but tinned and Argentitian powdered milk was available. My belief was that if I was allowed to eat the hearty foods for which I hungered I would probably have a better chance of getting well, and I used to reason elaborately and, it seemed to me, convincingly that I should be allowed a chance at a square meal. Arguments that seemed lucid to me were, unfortunately, considered the cunning of delirium."

page 209

"My condition kept growing worse. Finally, everyone agreed that I was going to die. At that point Police Inspector Phillips took the position that, if I was going to die, I might as well die as I wanted: in an effort to get to Fort Yukon. This did not meet the views of some of the others. There was at Herschel Island a very respectable graveyard where whalers and other white men had been buried with supposedly civilized pomp and circumstance. I felt sure that, if I died, there would be a thoroughly orthodox funeral. However, I preferred to die elsewhere and, if possible, later."

"It was in the first week of April, 1918, that I left Herschel Island in a sled equipped with springs from an old cot. Constable Brockie, Henry Fry, my Indian teen-ager, and two Eskimos accompanied me.

Fry, now that we were away from the settlement, was less inclined to insist on the orthodox liquid diet for a typhoid convalescent. I was allowed to eat one of my favorite foods, frozen raw fish. This seemed to do me good, and my second day out from Herschel saw me free of fever. It seemed unnecessary for Fry to continue with us. He said that, since I apparently got along better the more my conduct differed from what his medical books said it ought to be, I might as well take the entire responsibility for doing as I liked. Having come to this conclusion, he returned to his mission at Herschel Island. 

From then on, my breakfasts and suppers consisted of caribou and fish, sometimes frozen and raw, sometimes cooked. I felt better each day and regained weight until finally, when we arrived at the mouth of the Old Crow River, at the trading post of Schultz and Johnson, I was no longer in real need of the expert care that I could get from Mrs. Schultz, who before her marriage had been a trained nurse at Fort Yukon. While I did not need the care, I shall never forget the kindness of Mrs. Schultz and her husband." 

Page 210

On April 27th, when we arrived at St. Stephen's Hospital, Fort Yukon, I was so far recovered that I walked without assistance from the gate to the house. A month before, when I had been about to leave Herschel, Inspector Philips had had to guide my hand as I made the penciled cross by which I agreed that if I died on the journey the responsibility would be my own. Thus, my polar expedition came to an end." page 211

In 1923 the Nobel Prize in Medicine was awarded to Frederick Banting and John MacLeod for the discovery of insulin. It was actually a story of success that provoked a great scientific conflict.

Frederick Banting was a young Canadian surgeon, who was admitted into the laboratory of the eminent biochemist, interested in diabetes, Professor John Macleod, at the University of Toronto[13]. In 1920, Moses Barron, physician in Minnesota, published an article on “The relation of the islets of Langerhans to diabetes, with special reference to cases of pancreatic lithiasis[17] which was mentioning that the continuation of experiments of Minkowski and von Mering could lead to the discovery of a substance capable to control diabetes. Influenced by this article, Banting focused on the study of diabetes[13]. During that period the distinguished English physiologist Ernest Starling (1886-1927) was mentioning: “We don’t know yet how the pancreas affects sugar production or utilization in the same animal. It is generally assumed that it secretes into the bloodstream a hormone which may pass to the tissues and enable them to utilize sugar or pass to the liver and inhibit the sugar production of this organ… but we have been unable to imitate the action of the pancreas still in vascular connection with the body, by injection or administration of the extracts of this organ”[18].

On 16 May 1921, Banting started to collaborate with Charles Best, a young medical student. Experimenting in dogs they initially ligate the pancreatic ducts, achieving atrophy of the exocrine region and almost ten weeks later they removed dog’s degenerated pancreas. They crushed the atrophied pancreatic glands in a cool mortar and froze it in salt water. Then the mass was ground down and added to 100 mL of physiological salt. Afterwards, they administrated 5 mL of this extract intravenously to a depangreatized dog. Within 2 h its blood sugar had considerably dropped. They repeated several times the experiment with other diabetic dogs, gaining similar results and they experimented also with fetal calf pancreas using different ways of administration such as subcutaneous and rectal[19,20] (Figure ​(Figure44).

At the end of 1921 the skilled chemist James Collip joined the team and developed a better extraction and purification technique. Obtained substance was initially named by the team insletin and later on by MacLeod insulin[13].

The dietetic observations and experiences of Vilhjalmur Stefansson during his career as an arctic explorer are worthy of careful scrutiny by students of nutrition. Because of his contributions, he is entitled to prominence in many departments of science, among them anthropology, geography, geology, oceanography, languages and comparative religions. Whether reading Stefansson's books, attending his lectures, or in private conversation with him, one is impressed not only by his broad knowledge of biology but also by the keenness of his observations and deductions in the domain of metabolism, particularly as applied to the science of practical dietetics. An anthropologist by training, an arctic explorer by choice, he became a student of nutrition by necessity. Perhaps there is no other man living today whose experimental studies have been so well controlled and done on so large a scale. His laboratory was the arctic circle, his experimental subjects human beings, and his experimental material, meat.

 

This paper reviews the medical history of this unique man. It is hoped that the facts gleaned from the study of his arctic dietetic regimen and body physiology may throw additional light on a subject about which our knowledge is still somewhat vague and controversial ; namely, protein metabolism.

 

During the month of September, 1922, I made a medical survey of Mr. Stefansson. He suggested at that time that the facts elicited from the studies might be of sufficient scientific interest to warrant publication. The present paper represents the work done on him at that time, amplified by a clinical survey of his condition some two years later.

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The following facts regarding Stefansson's life in the Far North are noteworthy:

 

1. He spent altogether eleven and one-half years within the arctic circle.

2. He lived for a number of days, totaling nine years, on an exclusive meat diet.

3. He lived for nine successive months on an exclusive meat diet.

4. He reached his maximum weight while subsisting on meat (fish).

5. His sense of physical and mental well being was at its best during that period of his life. 6. He found that the exclusive meat diet worked as well when he was inactive as when active, and as well in hot weather as in cold.

7. Constipation was never present. One month's entire absence from exercise produced neither constipation nor muscular weakness.

8. His hair thickened, and his scalp became healthier.

9. Teeth decay was apparently much less rapid. Stefansson avers that not a single case of constipation was observed in 600 exclusively meat-eating Eskimos for a period of three years

​

Neither Stefansson nor any of his men, so far as we could determine, suffered any ill effects from long continued meat diet.