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DIABETIC CLINIC: ST. PETER'S HOSPITAL.
Report for the year ending 31st December, 1934.
By B. A. Young, M.D., M.R.C.P., Senior Assistant Medical Officer, St. Peter's
Hospital.
During the last year there has been a considerable increase in the number of
patients receiving treatment at the clinic and in the wards. In December, 1934,
67 diabetics were attending as out-patients and, during 1934, 62 were admitted to
the wards. For the same periods in 1933 the numbers were 38 and 49, respectively.
The cause of the high incidence of diabetes in the hospital district is suggested in
Joslyn's statements that the obese individual is at least twice, and at some ages
forty times, as liable to diabetes as is the normal individual, and that over-weight
is most common among females and Jews, two groups most prone to the disease.
Of our cases 72 per cent. are females, the large majority Jewish, and, in spite of their
poor financial circumstances, obese.
Poverty and
diabetes
When poverty and diabetes are associated the treatment is difficult, prognosis
poor, and the disablement produced considerable. This fact has been emphasised
by continental writers with wide experience of diabetes among the poor, whose
opinions have recently been summarised by Wislicki.15 Pryll,9 in a reference in this
paper, states that the progress of the diabetic is inversely proportional to his
income. Gottschalk2 rates intelligence and perseverance first and social conditions
second in controlling the fate of the diabetic. In my experience these three factors
unfortunately vary directly with one another. The only diabetic fatalities among
children in Joslyn's clinic in 1931 were dependent on aid from town, city or state.6
Principles of
treatment.
The majority of patients at present attending the clinic fall into the group with
poor social conditions and low intelligence. The adaptation of modern lines of
diabetic treatment to their modest capabilities has been the object of the work
during the last year. The principles of treatment which were suggested in the last
report as most suitable for this type of patient have been followed and developed,
and are in short (1) frequent attendance and constant supervision at the clinic;
(2) diets of the inexpensive high-carbohydrate, low-fat, low-calorie type, made as
simple as possible; and (3) all new patients and re-admissions to the wards are
instructed in the visual method of quantitative measurement of food by means of
models. The results have been encouraging. In December, 1934, 87 per cent. of
the patients were constantly without glycosuria, 4 per cent. showed occasional and
9 per cent. constant glycosuria. There have been no cases of gangrene or diabetic
coma requiring admission from the regular attendants at the clinic.
The diet.
Subjoined is a short description of the type of diet in use, and the method
employed for its quantitative measurement.
It is now generally accepted that the high-carbohydrate, low-fat and low-tomoderate
calorie diet is superior to diets with low-carbohydrate, high-fat and highcalorie
content of the past. Lawrence7 has defined the carbohydrate content of a
diabetic diet as low when it contains below 80 grammes; as moderate between 100
and 150 grammes; as high when more than this is given. Rabinowitch11,12,13
advocates as much as 250 grammes of carbohydrate, with very low fat and low
caloric values. Easton and Lyon1 give moderately high amounts of 150 grammes,
and Lawrence7 considers such quantities advisable. Leyton8 states that in all but
very severe cases 200 grammes may be given. The carbohydrate content of the
diets in use in the clinic vary from 150 to 190 grammes.
With increase in carbohydrate there has been reduction in the fat and total
caloric value of the diabetic diet. Rabinowitch11 gives as little as 50 grammes, finds
no deleterious effect on the patient's health and a considerable increase in his sugar
tolerance. Other authorities1,3 consider such a low fat content unnecessary and
advise average amounts of 120 grammes. As a large number of the clinic patients
are over-weight, I find 85 to 100 grammes of fat usually sufficient. The total
calories used rarely exceed 2,000, or 27 to 30 calories per kilogramme of body weight,
except in children, heavy manual labourers, or where diabetes is complicated by
pulmonary tuberculosis. A woman with a sedentary occupation receives 1,500 to
(80)