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Diabetes Mellitus and Pulmonary Tuberculosis
DIABETES MELLITUS AND PULMONARY TUBERCULOSI,S
JOHN A. FOLEY, M.D., F.A.C.P.AND JOHN B. ANDOSCA, IVl.D., F.C.C.P.t INCIDENCE OF TUBERCULOSIS IN DIABETES
THE frequent combination of diabetes mellitus and pulmonary tuberculosis is an accepted fact· of clinical medicine. In 1883 Windle9 reported that out of 333 diabetic cases which came to autopsy 50 per cent had active tuberculous lesions; in 1906 Nannyn5 found the two' diseases associated in 41 per cent of cases at postmortem examination. In 1931 Banzai! concluded from a study of the available literature that tuberculous disease was three times as common among diabetics as among the general population. Root6 in 1934, after investigating the incidence of tuberculosis morbidity among 1651 diabetic patients, also confirmed Banzai's conclusions that the incidence of tuberculosis was three times as common among diabetic as among the general populace. REASONS FOR THIS FREQUENCY
The exact cause of the high incidence of tuberculosis among diabetics has not been entirely explained. Steinback7 and his co-workers have furnished some experimental evidence. They found that pancreatomized diabetic dogs were less resistant to a known dose of tubercle bacilli than a control group of healthy animals. This suggests that the increased susceptibility to tuberculosis of the diabetic dogs may be due to faulty carbohydrate metabolism. Authorities maintain that, in spite. of the decline in mortality rates from tuberculosis, the mortality from tuberculosis among diabetics is steadily increasing. It has been "definitely shown that patients with poorly controlled diabetes are much more prone to develop pulmonary tuberculosis than those whose disease is well controlled. Himsworth3 showed that, in a series of 300 diabetics whose disease was well controlled, only two developed pulmonary tuberculosis. From the Boston Sanatorium and the Department of Medicine, Boston University School of Medicine. This work was aided by the W. P. A. Hospital Research Project No. 22206. • Chief-of-Staff, Boston Sanatorium; Clinical Professor of Medicine, Boston University School of Medicine; Director, Fifth and Sixth Medical Services Boston City Hospital. ' t Chief Resident Physician, Boston Sanatorium; Instructor in Medicine, Boston University School of Medicine.
499
500
JOHN A. FOLEY, JOHN B. ANDOSCA
CLINICAL FEATURES
It is generally agreed that pulmonary tuberculosis in the diabetic usually appears suddenly and progresses quite rapidly. Such a sudden appearance of the tuberculous lesion can only be explained in one of two ways. Either the diabetic is unusually vulnerable to tuberculous infection, or the tuberculous lesion lies deep-seated in the lung and ~ernains undetected until it rises to the surface and produces its physical signs. It is our opinion that the latter explanation, namely, the deep-seatedness of the tuberculous lesion in the diabetic, ,accounts for the sudden appearance of the disease as soon as it reaches the surface of the lung. Consequently we recommend radiological examination of every diabetic's chest every six months. Clinicians report quite a discrepancy between radiological and clinical examination in diagnosing tuberculosis in the diabetic. Himsworth3 states that in his clinic, out of a series of 230 consecutive diabetic patients, pulmonary tuberculosis was detected by clinical means in two and suspected on clinical grounds in. two others. In this same series radiological examination revealed a lesion in the lung in fifteen cases. Thus by clinical methods tuberculosis would have' been detected in only 1.4 per cent of the patients, although it was actually present in 6.5 per cent. The pulmonary tuberculosis found in the diabetic does not show any remarkable characteristic clinical symptoms or physical signs. Errors of course, are often made in ascribing these symptoms to the patient's diabetes rather than to his tuberculosis. A striking feature that was noted in the course of the diabetes in the adult was rapid loss of weigh!t preceding the development of tuberculosis. Some patients had lost as much as 75 pounds in several months. , As regards the roentgenographic examination we have sometimes noticed the so-called tubercular-diabetic or the butterfly type of lesion. The salient features of this type may be described as a soft exudative process spreading from the region of the hilum toward the periphery most commonly in the midzone of the lung, leaving the apex and at times the extreme base free from disease. It is the consensus that in the great majority of cases diabetes does not follow the tuberculous infection but rather tuberculosis afflicts the diabetic. In our series of twenty-eight cases, diabetes definitely preceded the tuberculous infection in twenty-two; tuberculosis preceded the diabetes in two cases;' in three cases the diagnosis of pulmonary tuberculosis and diabetes was made at the same time and we were in no position to say which condition came first. The age distribution of the tuberculous diabetic patient parallels that,. of4l, diabetes rather than that of tuberculosis in the general popu-
DIABETES MELLITUS AND PULMONARY TUBERCULOSIS
501
lation (Table 1). The average age in our series was forty-seven years. The oldest patient was sixty-seven and the youngest was twenty-one. The group comprised'sixteen male and twelve female patients; all were of the white race except three, two of whom were colored and one Chinese. TABLE 1.-ANALYSIS OF DATA ON 28 CASES OF DIABETES AND PULMONARY TUBERCULOSIS
Results and Comments
H
lU
en
- _ . -.------.-. ---1-----1-------1--1---------1 2 4
41 47 60 24
9 10 11 12 13 14
58 51 41 59 57 58 24 21 48
16 17 18 19
56 43 44 67
3
5 6 7 8
'15
20 21 22 23 24 25 26 27 28
5R
59
37 48 51 23
59
31 44 56 37
M. F.
M. M.
M. M. F. F.
F. M. F
M.
M.
M. M. M.
M. F. M. F.
F. F. F.
M. F.
F. M. M.
W. W. W. W.
W. N. W. W. W.
W. W.
W.
W.
W. W. Y.
W. W. W. N.
W. W. W. W.
W. W. W.
W.
1/34 8/46 1/33 . 9/40 5/41 5/42 2/43 2/35 2/23 2/31 4/28 10/32 6/42 1/43 3/41 10/42 4/41 6/40 2/30 4/42 9/42 8/32 5/42 4/30 10/36 8/39 4/43 4/43 7/31 7/41 4/40 2/42 8/40 9/41 10/40 9/41 4/42 9/41 6/38 6/40 1/41 10/30 3/41 1/39 1/35
5/15 1/17
8/41 10/41 1/41 10/42 3/41 1/49 12/36 5/10 3/42
Mod. adv. Far adv. Mod. adv. ~~r a1,v.
" " " " Mod. Far Mod. Mod. ~~r
" " "
" " "
" " " " adv. adv. adv. adv. a1,v.
" "
.
"
"
Mod. adv.
" "
" "
" " " "
"
363 645 197 167 230 166 312 276 260 294 170
266
154 170 140 220 210 185 197
166
298 245 151 190 143 225 165
211
150 170
128 180 130 200 200 150 175 150 200 135 140 130 135 140
183 160 158 137 137 160 129 100 105 109 104 138 120 105 115 125 120
115
119
115
110
100 190 115 90 100
110
200
110 130
110 162 125
100
102 88 90 165 120 129
191 184 185 145 140 184
115
105 1St 130
116
154 136 124 130 120 119 112
110
130 129 100
110
115 113 194 130 138
1 Pneumothorax.
In sanatorium. Pnx. 1 L. In sanatorium In sanatorium In sanatorium In sanatorium. Pnx. L. In sanatorium In sanatorium In sanatorium In sanatorium In sanatorium In sanatorium. Phrenic R. In sanatorium In sanatorium. Pnx. R. In san{(torium Dead Dead Dead Dead Dead. Autopsy also showed bronchogemc carcinoma Dead. Pulmonary hemorrhage Dead Dead Discharged Pnx. R. and Lysis 2 Discharged Discharged. Pnx. R. Discharged. Pnx. L and Lysis Discharged Discharged. Pnx. L. and Lysis 2
Pneumonolysis.
The tuberculosis which IS associated with diabetes IS In the great majority of cases of the far advanced type. The stage of the pulmonary disease In the entire group of twenty-eight cases classified according to the criteria adopted by the National Tuberculosis Association was as follows: minimal stage, none; moderately advanced, 11, or 39 per cent; far advanced, 17, or 61 per cent (Table 2). It IS InTABLE 2.-STAGE OF PULMONARY TUBERCULOSIS
Number Minimal . Moderately advanced . Far advanced .......................•.
o
11 17
Per Cent.
o
39 61
502
JOHN A. FOLEY, JOHN B. ANDOSCA
teresting to note that no case in the series could be classified as minimal. All the patients in the series had a positive sputum. We recommend sanatorium care for all diabetics with a tuberculous lesion until both conditions are stabilized and controlled. TREATMENT OF THE COMBINED DISEASES
For the past two years it has been our policy to treat our tuberculous diabetics on a high caloric house diet of at least 3000 calories. The three main component foodstuffs are roughly in the proportion of c,arbohydrate 3, protein 1 and fat 1, in addition to sufficient minerals and vitamins. An example of an ordinary daily diet consists of 345 gm. of carbohydrates, 120 gm. of protein and 130 gm. of fat, totalling about 3030 calories. This procedure has been successfully employed by Kutschera-Aichbergen4 (1931) and by Vrhovae 8 (1937). Fishberg 2 (1932) stated that patients submitted to a low caloric diet certainly lose their glycosuria but at the same time a rapid PFogress of the pulmonary tuberculosis occurs. Again, if the limitation of calories in a diabetic helps to decrease the patient's resistance to pulmonary tuberculosis, we believe that the opposite, namely, a high caloric intake, should be beneficial to a diabetic patient with tuberculosis. It was special attention to these points which led us to stress the importance of a high caloric diet supplemente4 by ample minerals. and vitamins. We do not advocate a high caloric diet for the tuberculous diabetic patient without strict control of his diabetes through the use of insulin. The diabetes should be brought under control as soon as possible so as to retard any further spread of the tuberculous lesion. To this end no attempt is made to build up the patient's diet from one of low to one of high caloric value, nor is any attempt made to spare the amount of insulin required to bring about control. The full high caloric diet is given as soon as the patient is admitted to the sanatorium. Fasting blood sugars in the beginning are taken weekly and later every two weeks. Our patients are given their required dose of protamine zinc insulin and a small dose of regular insulin every morning before breakfast. The practical advantage of protamine zinc insulin in treating tuberculous diabetics is its reduction of the frequency of injections. Furthermore, by its use it is possible to have a steady and constant formation of glycogen and in addition the danger of severe insulin reactions is definitely reduced. Examinations of the urine are made on the wards daily before each meal and depending on the color reactions the following dosages of regular insulin are given: (a) green reaction, 5. units; (b) yellow reactj.on, ..t10 units; (c) olive reaction, 15 units; (d) orange reaction, 20 lfnits. In addition, every morning urine specimen is examined for
DIABETES MELLITUS AND PULMONARY TUBERCULOSIS
503
sugar and ketone bodies by the laboratory technicians. The criteria of satisfactory control should be a urine consistently free from ketone bodies and either free of sugar or containing the smallest amount of sugar that the patient can tolerate without experiencing symptoms. We find that in the older cases a moderate hyperglycemia is harmless and excessive means to lower it are not employed. Occasionally we find that in cases with much toxemia the patient may be unable to ingest a high caloric diet made up of so much solid food. In that case a fluid or semifluid diet is devised containing the full amount of carbohydrate, protein and fat. Later, as the condition improves, this diet can be slowly changed to contain the more solid foods. The same general principles that are followed in the. treatment of the nondiabetic tuberculous patient are advocated for the tuberculous diabetic patient. Fresh air, rest and lack of worry are all essential. Some form of collapse therapy such as pneumothorax, phrenic nerve surgery, or thoracoplasty where indicated should be carried out. Of course, due to the age and coexisting cardiovascular changes in many of the patients, collapse therapy is definitely limited. The entire group was submitted to basal metabolic rate and electrocardiographic studies' but no remarkable conclusions were derived except that patients with very active tuberculosis tended to have higher basal metabolic rate readings. RESULTS OF TREATMENT
The results after two years of nutritional studies have for the most part been very encouraging. Practically every patient showed a weight gain and a definite improvement in his sugar tolerance. It was noted that the average weight gain in the eleven cases classed as moderately advanced was 26 pounds, while the average weight gain in the seventeen far advanced cases was 5 pounds. The sputum became negative for tubercle bacilli in thirteen cases (47 per cent). Out of the group of twenty-eight patients, fourteen are still in the sanatorium and doing well, eight are dead and six have been discharged (Table 3). It is interesting to observe that all the patients TABLE 3.-PRESENT STATUS OF PATIENTS
In Sanatorium Dead Discharged
. . .
Number
Per Cent
14 8 6
50 28
22
who died had far advanced tuberculosis while those who were discharged had moderately advanced disease. In one case which came to
504
JOHN A. FOLEY, JOHN B. ANDOSCA
autopsy the patient was found to have a bronchogenic carcinoma in addition to diabetes and pulmonary tuberculosis. CONCLUSIONS
At one time the combination of diabetes and pulmonary tuberculosis was considered fatal. The advent of insulin has certainly altered this prognosis. It is interesting to note that the tuberculosis death rate among diabetics per 1000 fell from 11 prior to the use of insulin to 4 after the use of insulin. It is' safe to say that in the sanatorium a well-controlled diabetic with tuberculosis is no more difficult to treat than a person suffering from tuberculosis alone. Early diagnosis of the tuberculous infection is the all-important factor, for, once tuberculosis has reached an advanced stage, the prognosis is poor even when the. diabetes is controlled. The surest and quickest method of detecting pulmonary tuberculosis in the diabetic is by routine radiological examination of the chest every six months. At the present time, earlier diagnosis, proper use of the high caloric diet, insulin administration and collapse therapy have all contributed in prolonging the life of the tubercular diabetic. SUMMARY
1. A two-year nutritional study of twenty-eight patients with coexisting diabetes and pulmonary tuberculosis was made. 2. The composition of the average diet for the entire group yielded at least 3000 calories. The three main foods were roughly in the proportion of carbohydrate 3, protein 1 and fat 1. 3. The diabetes was controlled as soon as possible by the use of protamine zinc insulin and regular insulin. 4. Frequent blood sugar estimation and urine examinations are essential. 5. The pulmonary tuberculosis was classified as moderately advanced in eleven and as far advanced in seventeen patients. No case' could be classified as minimal. 6. The ayerage age in the twenty-eight cases being forty-seven years, collapse therapy was somewhat limited. 7. A weight gain and improvement in sugar tolerance were observed in a great number of the patients. 8. Of the twenty-eight patients, fourteen are still in the sanatorium and doing well, eight are dead and· six have been discharged. 9. A poor prognosis is invariably given in the case of a diabetic with far advanced tuberculosis even if the diabetes is~ controlled. 10. The importance of early diagnosis of the tuberculous lesion, a high caloric diet and careful control of the diabetes cannot be over. "\ emphaSIzed.
DIABETES MELLITUS AND PULMONARY TUBERCULOSIS
50S
BIBLIOGRAPHY
1. Banzai, A. L.: Am. Rev. Tubere., 24:650, 1931. 2. Fishberg, A. M.: Pulmonary Tuberculosis, 4th ed. Philadelphia, Lea & Febiger, 1932, Vol. II, p. 210. ' 3. Himsworth, H. P.: Quart. J. Med., 31:373, 1938. 4. Kutschera-Aichbergen, H.: Wien. kline Kchnschr., 44:1217, 1931. 5. Nannyn, B.: Diabetes Mellitus. Vienna, 1906, p. 249. 6. Root, H. F.: New England J. Med., 210:1, 1934. 7. Steinbeck, M. M., Klein, S. J. and Deskowitz, M.: Am. Rev. Tubere., 32:665, 1935. 8. Vrhovae, V.: Lyecnicki Vjesnik, Zagreb., 4:5, 1937. 9. Windle, B. C.: Dublin ]. Med. Se., 76:112, 1883.
JOHN A. FOLEY, M.D., F.A.C.P.AND JOHN B. ANDOSCA, IVl.D., F.C.C.P.t INCIDENCE OF TUBERCULOSIS IN DIABETES
THE frequent combination of diabetes mellitus and pulmonary tuberculosis is an accepted fact· of clinical medicine. In 1883 Windle9 reported that out of 333 diabetic cases which came to autopsy 50 per cent had active tuberculous lesions; in 1906 Nannyn5 found the two' diseases associated in 41 per cent of cases at postmortem examination. In 1931 Banzai! concluded from a study of the available literature that tuberculous disease was three times as common among diabetics as among the general population. Root6 in 1934, after investigating the incidence of tuberculosis morbidity among 1651 diabetic patients, also confirmed Banzai's conclusions that the incidence of tuberculosis was three times as common among diabetic as among the general populace. REASONS FOR THIS FREQUENCY
The exact cause of the high incidence of tuberculosis among diabetics has not been entirely explained. Steinback7 and his co-workers have furnished some experimental evidence. They found that pancreatomized diabetic dogs were less resistant to a known dose of tubercle bacilli than a control group of healthy animals. This suggests that the increased susceptibility to tuberculosis of the diabetic dogs may be due to faulty carbohydrate metabolism. Authorities maintain that, in spite. of the decline in mortality rates from tuberculosis, the mortality from tuberculosis among diabetics is steadily increasing. It has been "definitely shown that patients with poorly controlled diabetes are much more prone to develop pulmonary tuberculosis than those whose disease is well controlled. Himsworth3 showed that, in a series of 300 diabetics whose disease was well controlled, only two developed pulmonary tuberculosis. From the Boston Sanatorium and the Department of Medicine, Boston University School of Medicine. This work was aided by the W. P. A. Hospital Research Project No. 22206. • Chief-of-Staff, Boston Sanatorium; Clinical Professor of Medicine, Boston University School of Medicine; Director, Fifth and Sixth Medical Services Boston City Hospital. ' t Chief Resident Physician, Boston Sanatorium; Instructor in Medicine, Boston University School of Medicine.
499
500
JOHN A. FOLEY, JOHN B. ANDOSCA
CLINICAL FEATURES
It is generally agreed that pulmonary tuberculosis in the diabetic usually appears suddenly and progresses quite rapidly. Such a sudden appearance of the tuberculous lesion can only be explained in one of two ways. Either the diabetic is unusually vulnerable to tuberculous infection, or the tuberculous lesion lies deep-seated in the lung and ~ernains undetected until it rises to the surface and produces its physical signs. It is our opinion that the latter explanation, namely, the deep-seatedness of the tuberculous lesion in the diabetic, ,accounts for the sudden appearance of the disease as soon as it reaches the surface of the lung. Consequently we recommend radiological examination of every diabetic's chest every six months. Clinicians report quite a discrepancy between radiological and clinical examination in diagnosing tuberculosis in the diabetic. Himsworth3 states that in his clinic, out of a series of 230 consecutive diabetic patients, pulmonary tuberculosis was detected by clinical means in two and suspected on clinical grounds in. two others. In this same series radiological examination revealed a lesion in the lung in fifteen cases. Thus by clinical methods tuberculosis would have' been detected in only 1.4 per cent of the patients, although it was actually present in 6.5 per cent. The pulmonary tuberculosis found in the diabetic does not show any remarkable characteristic clinical symptoms or physical signs. Errors of course, are often made in ascribing these symptoms to the patient's diabetes rather than to his tuberculosis. A striking feature that was noted in the course of the diabetes in the adult was rapid loss of weigh!t preceding the development of tuberculosis. Some patients had lost as much as 75 pounds in several months. , As regards the roentgenographic examination we have sometimes noticed the so-called tubercular-diabetic or the butterfly type of lesion. The salient features of this type may be described as a soft exudative process spreading from the region of the hilum toward the periphery most commonly in the midzone of the lung, leaving the apex and at times the extreme base free from disease. It is the consensus that in the great majority of cases diabetes does not follow the tuberculous infection but rather tuberculosis afflicts the diabetic. In our series of twenty-eight cases, diabetes definitely preceded the tuberculous infection in twenty-two; tuberculosis preceded the diabetes in two cases;' in three cases the diagnosis of pulmonary tuberculosis and diabetes was made at the same time and we were in no position to say which condition came first. The age distribution of the tuberculous diabetic patient parallels that,. of4l, diabetes rather than that of tuberculosis in the general popu-
DIABETES MELLITUS AND PULMONARY TUBERCULOSIS
501
lation (Table 1). The average age in our series was forty-seven years. The oldest patient was sixty-seven and the youngest was twenty-one. The group comprised'sixteen male and twelve female patients; all were of the white race except three, two of whom were colored and one Chinese. TABLE 1.-ANALYSIS OF DATA ON 28 CASES OF DIABETES AND PULMONARY TUBERCULOSIS
Results and Comments
H
lU
en
- _ . -.------.-. ---1-----1-------1--1---------1 2 4
41 47 60 24
9 10 11 12 13 14
58 51 41 59 57 58 24 21 48
16 17 18 19
56 43 44 67
3
5 6 7 8
'15
20 21 22 23 24 25 26 27 28
5R
59
37 48 51 23
59
31 44 56 37
M. F.
M. M.
M. M. F. F.
F. M. F
M.
M.
M. M. M.
M. F. M. F.
F. F. F.
M. F.
F. M. M.
W. W. W. W.
W. N. W. W. W.
W. W.
W.
W.
W. W. Y.
W. W. W. N.
W. W. W. W.
W. W. W.
W.
1/34 8/46 1/33 . 9/40 5/41 5/42 2/43 2/35 2/23 2/31 4/28 10/32 6/42 1/43 3/41 10/42 4/41 6/40 2/30 4/42 9/42 8/32 5/42 4/30 10/36 8/39 4/43 4/43 7/31 7/41 4/40 2/42 8/40 9/41 10/40 9/41 4/42 9/41 6/38 6/40 1/41 10/30 3/41 1/39 1/35
5/15 1/17
8/41 10/41 1/41 10/42 3/41 1/49 12/36 5/10 3/42
Mod. adv. Far adv. Mod. adv. ~~r a1,v.
" " " " Mod. Far Mod. Mod. ~~r
" " "
" " "
" " " " adv. adv. adv. adv. a1,v.
" "
.
"
"
Mod. adv.
" "
" "
" " " "
"
363 645 197 167 230 166 312 276 260 294 170
266
154 170 140 220 210 185 197
166
298 245 151 190 143 225 165
211
150 170
128 180 130 200 200 150 175 150 200 135 140 130 135 140
183 160 158 137 137 160 129 100 105 109 104 138 120 105 115 125 120
115
119
115
110
100 190 115 90 100
110
200
110 130
110 162 125
100
102 88 90 165 120 129
191 184 185 145 140 184
115
105 1St 130
116
154 136 124 130 120 119 112
110
130 129 100
110
115 113 194 130 138
1 Pneumothorax.
In sanatorium. Pnx. 1 L. In sanatorium In sanatorium In sanatorium In sanatorium. Pnx. L. In sanatorium In sanatorium In sanatorium In sanatorium In sanatorium In sanatorium. Phrenic R. In sanatorium In sanatorium. Pnx. R. In san{(torium Dead Dead Dead Dead Dead. Autopsy also showed bronchogemc carcinoma Dead. Pulmonary hemorrhage Dead Dead Discharged Pnx. R. and Lysis 2 Discharged Discharged. Pnx. R. Discharged. Pnx. L and Lysis Discharged Discharged. Pnx. L. and Lysis 2
Pneumonolysis.
The tuberculosis which IS associated with diabetes IS In the great majority of cases of the far advanced type. The stage of the pulmonary disease In the entire group of twenty-eight cases classified according to the criteria adopted by the National Tuberculosis Association was as follows: minimal stage, none; moderately advanced, 11, or 39 per cent; far advanced, 17, or 61 per cent (Table 2). It IS InTABLE 2.-STAGE OF PULMONARY TUBERCULOSIS
Number Minimal . Moderately advanced . Far advanced .......................•.
o
11 17
Per Cent.
o
39 61
502
JOHN A. FOLEY, JOHN B. ANDOSCA
teresting to note that no case in the series could be classified as minimal. All the patients in the series had a positive sputum. We recommend sanatorium care for all diabetics with a tuberculous lesion until both conditions are stabilized and controlled. TREATMENT OF THE COMBINED DISEASES
For the past two years it has been our policy to treat our tuberculous diabetics on a high caloric house diet of at least 3000 calories. The three main component foodstuffs are roughly in the proportion of c,arbohydrate 3, protein 1 and fat 1, in addition to sufficient minerals and vitamins. An example of an ordinary daily diet consists of 345 gm. of carbohydrates, 120 gm. of protein and 130 gm. of fat, totalling about 3030 calories. This procedure has been successfully employed by Kutschera-Aichbergen4 (1931) and by Vrhovae 8 (1937). Fishberg 2 (1932) stated that patients submitted to a low caloric diet certainly lose their glycosuria but at the same time a rapid PFogress of the pulmonary tuberculosis occurs. Again, if the limitation of calories in a diabetic helps to decrease the patient's resistance to pulmonary tuberculosis, we believe that the opposite, namely, a high caloric intake, should be beneficial to a diabetic patient with tuberculosis. It was special attention to these points which led us to stress the importance of a high caloric diet supplemente4 by ample minerals. and vitamins. We do not advocate a high caloric diet for the tuberculous diabetic patient without strict control of his diabetes through the use of insulin. The diabetes should be brought under control as soon as possible so as to retard any further spread of the tuberculous lesion. To this end no attempt is made to build up the patient's diet from one of low to one of high caloric value, nor is any attempt made to spare the amount of insulin required to bring about control. The full high caloric diet is given as soon as the patient is admitted to the sanatorium. Fasting blood sugars in the beginning are taken weekly and later every two weeks. Our patients are given their required dose of protamine zinc insulin and a small dose of regular insulin every morning before breakfast. The practical advantage of protamine zinc insulin in treating tuberculous diabetics is its reduction of the frequency of injections. Furthermore, by its use it is possible to have a steady and constant formation of glycogen and in addition the danger of severe insulin reactions is definitely reduced. Examinations of the urine are made on the wards daily before each meal and depending on the color reactions the following dosages of regular insulin are given: (a) green reaction, 5. units; (b) yellow reactj.on, ..t10 units; (c) olive reaction, 15 units; (d) orange reaction, 20 lfnits. In addition, every morning urine specimen is examined for
DIABETES MELLITUS AND PULMONARY TUBERCULOSIS
503
sugar and ketone bodies by the laboratory technicians. The criteria of satisfactory control should be a urine consistently free from ketone bodies and either free of sugar or containing the smallest amount of sugar that the patient can tolerate without experiencing symptoms. We find that in the older cases a moderate hyperglycemia is harmless and excessive means to lower it are not employed. Occasionally we find that in cases with much toxemia the patient may be unable to ingest a high caloric diet made up of so much solid food. In that case a fluid or semifluid diet is devised containing the full amount of carbohydrate, protein and fat. Later, as the condition improves, this diet can be slowly changed to contain the more solid foods. The same general principles that are followed in the. treatment of the nondiabetic tuberculous patient are advocated for the tuberculous diabetic patient. Fresh air, rest and lack of worry are all essential. Some form of collapse therapy such as pneumothorax, phrenic nerve surgery, or thoracoplasty where indicated should be carried out. Of course, due to the age and coexisting cardiovascular changes in many of the patients, collapse therapy is definitely limited. The entire group was submitted to basal metabolic rate and electrocardiographic studies' but no remarkable conclusions were derived except that patients with very active tuberculosis tended to have higher basal metabolic rate readings. RESULTS OF TREATMENT
The results after two years of nutritional studies have for the most part been very encouraging. Practically every patient showed a weight gain and a definite improvement in his sugar tolerance. It was noted that the average weight gain in the eleven cases classed as moderately advanced was 26 pounds, while the average weight gain in the seventeen far advanced cases was 5 pounds. The sputum became negative for tubercle bacilli in thirteen cases (47 per cent). Out of the group of twenty-eight patients, fourteen are still in the sanatorium and doing well, eight are dead and six have been discharged (Table 3). It is interesting to observe that all the patients TABLE 3.-PRESENT STATUS OF PATIENTS
In Sanatorium Dead Discharged
. . .
Number
Per Cent
14 8 6
50 28
22
who died had far advanced tuberculosis while those who were discharged had moderately advanced disease. In one case which came to
504
JOHN A. FOLEY, JOHN B. ANDOSCA
autopsy the patient was found to have a bronchogenic carcinoma in addition to diabetes and pulmonary tuberculosis. CONCLUSIONS
At one time the combination of diabetes and pulmonary tuberculosis was considered fatal. The advent of insulin has certainly altered this prognosis. It is interesting to note that the tuberculosis death rate among diabetics per 1000 fell from 11 prior to the use of insulin to 4 after the use of insulin. It is' safe to say that in the sanatorium a well-controlled diabetic with tuberculosis is no more difficult to treat than a person suffering from tuberculosis alone. Early diagnosis of the tuberculous infection is the all-important factor, for, once tuberculosis has reached an advanced stage, the prognosis is poor even when the. diabetes is controlled. The surest and quickest method of detecting pulmonary tuberculosis in the diabetic is by routine radiological examination of the chest every six months. At the present time, earlier diagnosis, proper use of the high caloric diet, insulin administration and collapse therapy have all contributed in prolonging the life of the tubercular diabetic. SUMMARY
1. A two-year nutritional study of twenty-eight patients with coexisting diabetes and pulmonary tuberculosis was made. 2. The composition of the average diet for the entire group yielded at least 3000 calories. The three main foods were roughly in the proportion of carbohydrate 3, protein 1 and fat 1. 3. The diabetes was controlled as soon as possible by the use of protamine zinc insulin and regular insulin. 4. Frequent blood sugar estimation and urine examinations are essential. 5. The pulmonary tuberculosis was classified as moderately advanced in eleven and as far advanced in seventeen patients. No case' could be classified as minimal. 6. The ayerage age in the twenty-eight cases being forty-seven years, collapse therapy was somewhat limited. 7. A weight gain and improvement in sugar tolerance were observed in a great number of the patients. 8. Of the twenty-eight patients, fourteen are still in the sanatorium and doing well, eight are dead and· six have been discharged. 9. A poor prognosis is invariably given in the case of a diabetic with far advanced tuberculosis even if the diabetes is~ controlled. 10. The importance of early diagnosis of the tuberculous lesion, a high caloric diet and careful control of the diabetes cannot be over. "\ emphaSIzed.
DIABETES MELLITUS AND PULMONARY TUBERCULOSIS
50S
BIBLIOGRAPHY
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