Diabetes In The Medical Casebook

 

This Week

I’m just going to go with a sample disease chapter – and we’ll have the first chapter of the book. This is on diabetes, which just gets a single mention in the Sherlock Holmes’ stories. It is a fascinating disease – potentially extremely very serious in Victorian times, and still a hugely important medical condition today.

 

Diabetes

Diabetes + Sherlock 

We will start the book with a chapter on diabetes. This is one of the most important diseases in modern general practice, and like many of the diseases we will encounter, was a terrifying disease in Victorian times. 

However, despite its importance in both eras, diabetes only makes an appearance in one of the Sherlock Holmes stories - “The Boscombe Valley Mystery”. This is one of the earliest short stories, appearing in Conan Doyle’s first collection, “The Adventures Of Sherlock Holmes.”

The chief suspect in the murder of Charles McCarthy is his son James. Holmes proves James’s innocence, and demonstrates that the murderer is John Turner, the victim’s landlord. Turner was previously a highwayman in Australia, and is being blackmailed by McCarthy senior, who is aware of his secret. Turner’s daughter Alice engages Holmes on the case, as she is in love with James.

Holmes proves the case using some marvellous forensic detective work.

“And the murderer?”

“Is a tall man, left-handed, limps with the right leg, wears thick-soled shooting-boots and a grey cloak, smokes Indian cigars, uses a cigar-holder, and carries a blunt pen-knife in his pocket.”

We then get a long and detailed break-down of how Sherlock deduced all the above facts from a close examination of the crime-scene. With fine dramatic timing, as he is about to give the identity of the murderer, the man himself appears.

“Holmes,” I said, “you have drawn a net round this man from which he cannot escape, and you have saved an innocent human life as truly as if you had cut the cord which was hanging him. I see the direction in which all this points. The culprit is—”

“Mr. John Turner,” cried the hotel waiter, opening the door of our sitting-room, and ushering in a visitor.   

The man who entered was a strange and impressive figure. His slow, limping step and bowed shoulders gave the appearance of decrepitude, and yet his hard, deep-lined, craggy features, and his enormous limbs showed that he was possessed of unusual strength of body and of character. His tangled beard, grizzled hair, and outstanding, drooping eyebrows combined to give an air of dignity and power to his appearance, but his face was of an ashen white, while his lips and the corners of his nostrils were tinged with a shade of blue. It was clear to me that he was in the grip of some deadly and chronic disease. 

We then learn why Turner looks so unwell.

“I am a dying man,” said old Turner. “I have had diabetes for years. My doctor says it is a question whether I shall live a month. Yet I would rather die under my own roof than in a jail.” 

Holmes decides not to let Inspector Lestrade know the identity of the murderer, so as not to ruin Alice Turner, and instead clears James on the basis of other technical objections. Turner outlives the doctor’s prognosis, but not for long.

James McCarthy was acquitted at the Assizes on the strength of a number of objections which had been drawn out by Holmes and submitted to the defending counsel. Old Turner lived for seven months after our interview, but he is now dead; and there is every prospect that the son and daughter may come to live happily together in ignorance of the black cloud which rests upon their past.

Conan Doyle is using diabetes here as a terminal illness – we will see in our Victorian medicine section below that this was often the case. He needed to give the murderer a serious disease, and a subsequent short life-expectancy, to enable Holmes to not expose Turner to the police. We will encounter this plot device again in our chapter on Aortic Aneurysms.

The other area I would like to discuss here is Conan Doyle’s brilliance at character descriptions. His portrayal of the appearance of John Turner is wonderful, and I think reflects a writer who is very comfortable at observing people, which is part of the job of a doctor.

  

Diabetes In Victorian Times 

As explained in my introduction, most of our Victorian medicine sections will follow a set pattern. For this first chapter, and the next, I’m going to provide headings, but will then dispense with them. For each section we will have a collection of interesting quotes from the Victorian medical texts, often followed by some commentary from myself.

Background [general information on the disease]

Diabetes mellitus or mellituria may be a slight affair, as in old fat people, or may be very serious, as is more commonly the case in young adults and children; in the latter, however, a rare disease. [5]

The presence of sugar in the urine is always an alarming symptom, and the prospect is, as a general rule, unfavourable. The younger the patient the more unfavourable is the prospect of recovery. The disease is usually of slow progress, but, in the young, life is seldom protracted beyond three or four years, and most die within a year or eighteen months. A form of diabetes occurs in old people, especially in the stout, that often lasts for very many years, without apparent detriment to the general health. [6]

Thus in Victorian times there was an understanding of diabetes having two forms. We still divide diabetes into type 1 [generally starting in childhood, and needing insulin] and type 2 [starting as an adult, and potentially manageable by lifestyle change].

As you might expect, prior to the discovery of insulin, type 1 diabetes was a horrendously serious disease. Insulin was first used as a treatment in 1922 – on a 14 year old Canadian boy called Leonard Thompson, who lived for another 13 years, rather than the expected couple of years prior to the use of insulin.

Aetiology [understanding of the causes of a disease]

Unfortunately, we are not certain as to the organ affected, and we have no real remedy for diabetes. [6]

Glycosuria is only a prominent symptom of the sugar in the blood, and this is doubtless obtained by a too free conversion of the glycogen of the liver and perhaps other tissues; probably a ferment which exists in arterial blood is the cause of the conversion. At least this chain of events is highly probable, but the physiology and pathology is a complicated matter. [5]

Whence comes the sugar? Is it from the food, the blood, the kidneys, the stomach, the liver? These are questions that cannot be satisfactorily answered. Again, diabetes in a number of cases has been found to be linked to a lesion of the pancreas. It also often follows mental emotion. In some instances it is hereditary. [3]

It is interesting that they had some case studies linking diabetes to pancreatic disease, but there were no theories at the time that the pancreas controlled blood glucose.

Insulin is produced in the islets of Langerhans of the pancreas, and these structures were discovered in 1869 [by Paul Langerhans, who impressively was only a medical student in Berlin at the time]. Yet it took until 1901 for Eugene Opie [an American pathologist] to work out that type 1 diabetes was caused by destruction of the islets of Langerhans. 

Diagnosis [symptoms, clinical signs and investigations]

In severe essential diabetes, sometimes hereditary, the early indications are not generally well marked, some feeling of malaise or a sense of feverishness being the first sign. Soon the frequent passage of a clear watery urine, having the faint odour of sweet apples, attracts the attention, the stools become dry and infrequent, thirst troublesome, and the skin dry and harsh. Loss of sexual power and of the knee-jerk with severe pains thought to be rheumatic, probably announce the arrival of a diabetic multiple neuritis. The pains are often felt in the loins, and the palms and soles have a burning feeling to the patient. Excessive eating [bulimia or polyphagia] disturbs the digestion, and the patient thinks of worms. He may become mentally depressed, not unnaturally hypochondriacal, and at times suspicious. Soft cataract, retinitis, boils, eczema and other skin lesions are possible manifestations. [5]

Diabetic urine is of pale colour and of high specific gravity, ranging generally from 1030 to 1050. The quantity passed is enormous: seventy pints and upwards have been known to be discharged daily. The symptoms attending the drain of fluid from the system are, as may be supposed, great thirst, constipation, and generally a dry, harsh skin, and a feeling of constant emptiness and of hunger. To these are added a steadily-progressing waste of the body, muscular feebleness, chills, a somewhat hurried breathing, and a peculiar mawkish odour of the breath, peevishness of temper, a tendency to boils and carbuncles, and in women pruritus of the vulva. [3]

These are some great descriptions of the potential symptoms of diabetes. Classically the disease presents with tiredness, polydipsia [drinking a lot] and polyuria [peeing a lot]. I think I would have “peevishness of temper” if I had that list of medical problems. Potentially passing 70 pints of urine in a day is staggering.

These days most patients with diabetes are completely well, as we are able to manage the disease very effectively. We make the diagnosis, in most cases, by screening for the disease, rather than waiting for patients to have a very high blood sugar causing symptoms.

The Victorian physicians had some understanding of diabetic complications – retinopathy [eye damage] and neuropathy [nerve damage] both make an appearance in the lists of features above.

Treatment [how Victorian doctors managed the disease]

Every article in the Pharmacopoeia has at one time or another been supposed capable of curing it, but there is none on which we can place confidence. Tonics of all kinds, such as quinine, strychnia, arsenic, have been used unavailingly. They are, however, of use in the diabetes of old people, when the appetite begins to fail or the strength is much reduced. Dilute nitric acid was formerly a favourite remedy. In the young, iron and cod-liver oil are of service in supporting the strength, but they have no effect in lessening the amount of sugar. [6]

Warm clothing, exercise short of fatigue, plenty of fresh air and bathing, with avoidance of excitement of hard work, a diet, free as possible from sugar and starch, are essentials in the treatment of diabetes. The diet should be changed gradually: oil, cream, butter, green vegetables, meat, fish, poultry, game, eggs, tea, coffee, almond biscuits, bran cakes, gluten bread may be taken; potatoes, rice, bread, sago, tapioca, beetroot, carrots, turnips, livers, oysters, jams, pastry, cakes should be avoided. Broths, soups and jellies prepared without meal or sugar, but flavoured to taste, may be allowed. Milk is physiologically, owing to its sugar, not permissible, but is often given and with advantage to diabetics. Spirits, wine and beers are allowed by some, it is best to avoid all sweet wines and malt liquors. Glycerin and saccharine for sugar. [5]

The treatment of diabetes mainly consists in confining the patient to a diet which contains very little starch or sugar. For example, bran bread, almond bread, or gluten bread must be substituted for the ordinary bread, and potatoes and farinaceous food should be avoided. The following is, perhaps, one of the most useful dietaries you can prescribe:

Breakfast. Milk, whey, coffee, tea, bran bread, butter, bacon, eggs, animal food of any kind.

Dinner. Beef, mutton, pork, veal, fish of any kind, birds of any kind, soups, if made with the vegetables afterwards named, and without flour, rice, sago etc; beef-tea, cabbage, cauliflower, broccoli, sprouts, sea-kale, spinach, celery, lettuce, onion, watercress, cheese, curds, crabs, lobsters, oysters, claret wine, brandy, rum.

Tea and Supper. May be made with any of the above kinds of foods. [6]

I found this section fascinating. They were aware that this was a disease that they simply couldn’t treat, and as in many of my chapters, experimented with a frightening range of poisons. But they had a pretty good understanding of the role of sugars and carbohydrates in worsening diabetes. Of note, however, is that they had no understanding of the roles of fats.

I decided to include two detailed lists of the foods recommended for diabetic patients, as I think they provide a very interesting picture of the range of foods a typical Victorian was eating.

 

Pancreas anatomy:-

“Illustration of pancreas anatomy from Gray’s Anatomy – one of the most famous medical texts [first published in 1858, and still in print].” [7]

 

Next Week

We will have a look at another very common modern disease – asthma. Like diabetes a disease that is generally well-controlled with modern medicine, but was a very scary medical condition in the Victorian Age.

 

My Kickstarter Project

A reminder that I have a Kickstarter project in progress. This can be found at:-

https://www.kickstarter.com/projects/1263265994/the-medical-casebook-of-sherlock-holmes-and-doctor-watson