[* Read before the 68th Convention of the Southern Homoeopathic Medical Association, Miami Beach, Florida, October 21, 22, 1952]
Journal of The American Institute of Homoeopathy-April, 1953.
Diabetes is a disease that is particularly challenging to the conscientious physician because in no other chronic disease does he see greater dividends paid to the patient when every meticulous detail has been faithfully followed through. As he watches his patient remain healthy and happy and leading a useful productive life, he can rightfully feel grateful and humble in being able to bring to this diabetic a new lease of life. But, as you know, it was not always so. Prior to the great discovery of insulin by Banting and Best in 1921, the mere diagnosis of diabetes in patient was often the death knell for countless thousands who would probably still be living.
The modern era of diabetic therapy probably dates back to 1936 when Dr. Hans Christian Hagedorn of Denmark had the daring and imagination to try injecting semi-soluble particles containing insulin under the skin of experimental animals. His intention was to spread the effectiveness of natural insulin over a long period by letting it dissolve gradually out of particles into the blood stream. The technique worked, and now people can control their diabetes with a single injection only once in 24 hours.
This product, protamine insulin, later improved by adding zinc, is slowly absorbed following sub-cutaneous injection and exerts a correspondingly retarded insulin effect, prolonged even to 24 to 36 hours following injection. Regular insulin, you will recall has a blood-sugar-lowering effect, which is perceptible within one hour, with its greatest effect between three and six hours, after which the effect wears off, usually about seven to ten hours after the injection is given.
Globin insulin, which was introduced, which was introduced in 1942, has a blood-sugar- lowering action is intermediate between regular insulin and that of protamine zinc insulin, reducing the blood sugar more slowly but for a longer time, than does regular insulin. Its effect is more rapid but not as prolonged as protamine zinc insulin. It causes a reduction of blood sugar within two hours with the effect subsiding from sixteen to twenty-four hours.
N P H, which stands for Neutral Protamine Hagedorn Insulin, is our newest weapon in the diabetic armamentarium. This is an intermediate insulin in that it acts more slowly than a regular insulin, more rapidly than protamine, and has the added advantage that its effect can be hastened by mixing regular insulin in the same syringe without loss of potency from either type.
This results in the diabetic getting both a rapid and prolonged effect from the same dose. The initial influence on the blood sugar is almost identical with that of globin insulin, but the duration of the blood-sugar-lowering effect of N P H Insulin is somewhat shorter than that of protamine zinc insulin.
The treatment then, of our diabetic patient first starts with guidance and reassurance in making adjustments in his life, with instruction about the diabetes, and that he will not be starved, that he will be relieved of his symptoms, and that he can look for a nearly normal life expectancy. He will not usually have to change his occupation or give up customary activities. He can even now, since 1940, and for an extra premium, obtain life insurance, providing he follows the rules set up by most of the major companies.
Ideally, treatment is most effective and impressive on the patient when it is started in a hospital for four or five days, with the patient on an ambulatory basis. Here his individual characteristics can be studied, the dietitian can acquaint him with diet management, he can be taught by the nurse in insulin technique and testing of the urine and special hygiene.
Every diabetic patient should be diet-conscious. He should be aware of the degree of flexibility of the diet permitted in his case and he should understand why there should be quantitative uniformity in diet and regularity of meal time from day to day. Seventy per cent of new meal time from day to day. Seventy per cent of new diabetic patients seen months after month by general practitioners are overweight. The most satisfactory effective means of controlling diabetes in overweight patients is to reduce their weight by means of a reduced caloric intake. It is surprising how few of these people will ever have to take insulin, unless an acute complication develops.
All who are familiar with the effects of obesity on life expectancy agree that overweight should be corrected. In the diabetic, this result, accompanied by appropriate dietary measures, carries a double benefit. It cures the obesity and controls the diabetes.
Give your new overweight diabetic a trial on diet alone for several weeks. If, on the other hand, your patient is a child; or is underweight with glycosuria and hyper-glycemia; or has an acute complication, whether the underlying diabetes is mild or not; if a woman is pregnant, or has a sudden onset of symptoms within the three months prior to the consultation, insulin therapy is indicated at once.
Having adequately studied your patient by fasting and post-cibal blood sugars two hours after meals, and by urine examinations to determine where maximum glycosuria occurs, made having rules out false transitory glycosuria and hyperglycemia reactions from head injuries, intracranial infections of vascular accidents, thyrotoxicosis, hyperpituitarism, emotional disturbances, certain diseases of the liver from anesthetic, asphyxia and poisoning from chemicals, you next must individualize your choice of the proper insulin, by determining when his maximum hyperglycemia and glycosuria is present and choosing a modified insulin that is most effective at the times when his needs are greatest.
If we choose protamine zinc insulin, remember that, because of its slow action, the diabetes may get out of hand in the forenoon, and there is an increased risk of hypoglycemic reactions in the early morning. These can be corrected by the addition of a dose of regular insulin in the morning which acts promptly and tends to prevent the hyperglycemia and glycosuria in the forenoon, and you may have to reduce your dose of the protamine zinc insulin, and, thirdly, you may have to give a bed-time nourishment. When you use protamine zinc insulin remember that fasting blood sugars alone may be misleading. It is safer also to include a blood sugar test two hours after lunch.
Globin insulin, in a single daily dose given one hour before breakfast, will control a considerably higher percentage of the case of diabetes than is possible to do with a single daily dose of protamine zinc insulin, due to its shorter sphere of action. You may prefer it because there is practically no danger of a hypoglycemic reaction occurring during the night, and you will choose it when you find that the patients needs are greatest in the afternoon and evening.
Insulin combinations, or mixtures should be mentioned for the treatment of patients not well controlled by the previously mentioned insulins. The one most commonly used, as stated before, is an injection each of protamine zinc insulin and regular insulin, when the rapid action of regular insulin and the prolonged action of protamine zinc insulin are needed. Rarely a 2 to 1, very rarely a 3 to 1 mixture of regular insulin and protamine zinc may be called for in the hard-to-manage patient. Sometimes a dose of regular insulin before the evening meal may also have to be added to control late afternoon or evening rise of blood sugar.
N P H Insulin seems to be the best preparation of all, and has more flexibility than the three other insulins in general use. We have seen a great many cases do well in clinic practice, and regular insulin can be added to it at the time of injection if there is a high forenoon hyperglycemia and glycosuria.
The modern physician, after his patient has been well controlled, either by diet or by a combination of diet and insulin, then continues his constant observation of the patient by regular check-ups at his office when three urine samples are brought from the previous 24 hour periods, namely, the urine collected before luncheon the day before, which is labeled No. 1; the urine from just before the evening meal, which is labeled No. 2, and the fasting urine just before coming to the office, which is labeled No. 3.
He then does either a blood sugar test or a micro-sugar test. The physician also advises his patient to subscribe to The Forecast, a fine lay publication issued bi- monthly, that tells in plain English all recent developments that the patient should know about. If he lives in a large city the patient should be urged to attend the yearly lectures that are usually given diabetics by either a metabolic association or by a dietitian from the American Dietetic Society. A yearly chest x- ray and a consultation with a competent ophthalmologist should never be neglected, as well as a complete physical examination, with additional tests, such as an electrocardiogram, done when indicated.