M. C. Mackin, Superintendent, Mount Pleasant State Hos- A. E. Kepford, Superintendent, State Juvenile Home, Charlotta Goff, State Agent, Soldiers' Orphans' Home. Grace B. Paddack, State Agent, Training School for Girls. M. N. Voldeng, Superintendent, Hospital for Epileptics and School for Feebleminded, Woodward. ACUTE NEPHRITIS. Chairman Strief: The first paper this morning will be read by George B. Crow, M. D., of Burlington, Iowa, on the subject "Acute Nephritis." This paper will be found on page 162. Superintendent Mackin: I would like to request that Dr. Crow discuss diabetes. Doctor Crow: I told Dr. Mackin that I had a diabetic in the hospital under the insulin treatment, and for that reason I wished to return to Burlington as soon as possible. I cannot give you a great deal from personal experience, for though I have been using insulin some, my experience has been limited. For the benefit of those who are not medical men, I will make just a few remarks about diabetes in general, which will be very brief. Diabetes is a condition in which there is an inability on the part of the body to burn sugar. You know we are taught that food is burned in the same way chemically that wood and coal are burned in the furnace, except that there is no flame. It is the burning of the food which creates the energy to run our engines. Diabetes is a disease in which there is an inability of the body to burn sugar. We mean starches and sugar, because in the body starches are all changed to sugar. We know also that there is a certain gland in the body known as the pancreas, one of the functions of which is to create a certain substance which enables the body to burn sugar. The part of the pancreas which does this is made up of a group of little islands, known as the islands of Langerhans. They secrete a substance which is poured into the blood and this element is the essential element in the burning of sugar in the body. If for any reason the amount of secretion of these islands is lessened-the body is unable to burn sugar properly- the sugar then accumulates in the blood stream and after it reaches a certain point overflows into the kidneys and then into the urine. Several years ago Dr. Allen of New York, as a result of experiments on dogs, said that diabetes in most cases is essentially a fatigue of the islands of Langerhans in the pancreas, they have been overworked and therefore the logical treatment is to give them a rest. One way that they can be given a rest is to take only that amount of sugar into the body which the body can handle, or slightly below that amount. If you keep below that amount, the glands may have a chance to rest up and be able to handle the sugar and the ability to handle sugar would therefore be increased.. Allen's idea therefore was to get these people sugar free, and keep them sugar free-keep them then where they shall have no sugar in the urine and where the blood sugar shall remain normal. That was a great advance in the treatment of diabetes. A large number can be carried along by that method. There are individuals however whose ability to handle sugar is so low that if you put them on a diet which keeps them sugar free, they will starve to death-so they are between the devil and the deep sea. Quite recently, within the last year or so, some men working at the University of Toronto-Dr. Banting and Dr. Best, under Dr. McLeod of the University of Toronto, have worked out an additional change in the treatment of diabetes. They have succeeded with the aid of their chemists there, in extracting a substance from the pancreas in animals-beef pancreas containing this essential secretion of these islands of Langerhans. They have been able to extract it in such pure form that it can be injected into men with no serious results. This has appropriately been named "insulin", the product of an island. This substance is not yet released for free distribution. Dr. McLeod and his workers, Drs. Banting and Best, have found that by taking an individual whose tolerance is so low that he is almost hopeless, and injecting hypodermically this extract of insulin, that individual can take care of much more sugar. If sufficient insulin can be injected to increase the tolerance of the individual health may be restored. It has also been found that even after the diabetic coma has set in, which is the usual ending of a case of diabetes of long standing, the injection of insulin will very frequently bring a patient out of coma. Also any diabetic individual needing an acute surgical operation-and a surgical operation on a diabetic has always been accompanied by a great deal of fear-can be tided over and has a good chance of going through the operation. And the same may be said of any common infection. The ability to handle sugar may tide over some trivial infection by the injection of insulin. The use of insulin has certain elements of danger. It reduces the sugar in the blood very promptly, and reducing the blood sugar below a certain point results in death. Its use should be surrounded by laboratory proceeding. Insulin is not a cure but it is a very great help in certain of the crises we have always heretofore feared very much in diabetics. Chairman Strief: We will stop here to introduce some distinguished guests from Minnesota. Mr. Ralph W. Wheelock and Mr. John Coleman, members of the board of control of Minnesota, Mr. C. H. Johnson, state architect, and Mr. G. A. Hanna, superintendent of the Schoool for Feebleminded. Chairman Strief: The paper of Dr. Crow is open for dis cussion. Superintendent Stewart: I have enjoyed Dr. Crow's discussion of acute nephritis, and he has covered the subject so thoroughly there is not much I can add. The only thing I would like to impress, would be the fact that I think if acute nephritis could be discovered sooner in young people, the same as in diabetes, these cases would not be so hopeless. A large percentage of the diagnoses are made accidentally through making an ex amination of the urine for life insurance or some such condition as that. Very frequently we find a case of nephritis resembling acute auto-intoxication characterized by vomiting and diarrhoea due entirely to nephritis. This is a symptom that is not so often seen and it is well to remember that when you have a symptom of ptomaine poisoning, with possibly but one such case in the institution, you will usually find these symptoms due entirely to nephritis. Dr. Fussel, when he first became connected with the clinic of the University of Pennsylvania, thought he could make a diagnosis of nephritis by looking at a patient. One day a boy came to the clinic with eyelids puffy and face swollen and the doctor felt sure that he had a case of Bright's disease, but when the urine was examined, it was found to be normal. Superintendent Donohoe: Acute nephritis, as Dr. Crow has stated, is more frequently found in children. For that reason the doctor's experience has been very much broader than mine as we do not have very much to do with children in the Cherokee State Hospital. I am very glad to know that the doctor's experience has been so encouraging in acute nephritis in young people. No complication following the infectious diseases is so liable to be of serious importance as this kidney trouble. It is my belief that many cases of nephritis which are first dis covered in early adult life and late adolescence may be traced back to infectious diseases such as scarlet fever, measles, and diphtheria in childhood, the low grade inflammation having existed many years without causing any great trouble on account of the kidneys being young, fresh and able to adapt themselves to conditions much better than the adult kidney. But when the body became overwhelmed by some acute infection such as cold, pneumonia, or in a woman of pregnancy, this adjustment of the damaged kidney could not be made and we have an acute nephritis. There is one type of infection that causes nephritis but perhaps Dr. Crow did not classify it as an acute nephritis and that is the infection in children due to the colon bacillus. This colon bacillus infection is very prone to occur in children who are constipated and who have very poor tolerance for certain classes of carbohydrates. The nephritis goes farther than the simple albumen but continues until pus is found in the urine. Of course we know that acute nephritis neglected will turn into chronic nephritis sooner or later, making a sclerotic kidney which increases the blood pressure. Then we have complications of the heart and finally of the lungs so that the end picture is a chronic Bright's disease with kidney symptoms, heart symptoms, and lung symptoms. The paper was very interesting to me and it is always pleasant to listen to a distinctly medical paper when you are obliged by your duties to do mostly executive work. Dr. Crow's talk on diabetes and insulin is very timely and I wish to endorse partly what he has said about it, insofar as it is not a "Cure all". It supplies a deficiency which exists in the work that should be done by the pancreas and is only a makeshift-that is, it does not stimulate the pancreas to take care of carbohydrates but instead of the active element being furnished by the pancreas of the individual, the extract of the is lands of Langerhans is taken from various animals and added. to the food. Just now the popular press and semi-scientific-I would almost say "More-all Journals," hail insulin as a definite cure for diabetes and it is well for all of us to put the brakes on such a thought. We have made application for the use of insulin at the Cherokee State Hospital but unfortunately have not been able to obtain any from Toronto. Just a word about diabetes since Dr. Crow has raised this subject also. I would like to ask Dr. Crow what he would do under the following conditions: If you had a man from fifty-five to sixty-five years of age who was carrying sugar and who could carry about one per cent and still feel pretty well, would you think it advisable to reduce the amount? I have a case where if we try to get the sugar down below one per cent he falls down in strength, gets nervous, gets weak and depressed due to the necessary starvation, so I have been feeding him right along and letting him eat everything and anything and when the examination of the urine shows over one per cent, I caution him about a few articles of diet, but in the main I do not tell him how much sugar he is carrying. Now I would not do this if he were a younger man but my belief is that |