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DIABETIC COMA WITHOUT ACETONURIA.
750 I found death with cardiac failure to occur in from 40 to 50 per cent. But both series contained a good many examples of the old rheumatic type of case. Yet in the groups which chiefly include ex-soldiers, death has been due to heart failure in much the same proportion as this ; Cotton gives 47 per cent., and Starling gives 60 per cent., in their two series
A
STUDY
OF
MINERS’ BY G. H.
SOME
ASPECTS
OF
NYSTAGMUS.
POOLEY, B.A. CAMB., F.R.C.S. ENG.,
OPHTHALMIC SURGEON TO THE ROYAL
INFIRMARY, SHEFFIELD.
respectively.
IN 1920 I was invited to become a member of the Miners’ Nystagmus Research Committee of the Renal failure is admittedly the most frequent Medical Research Council, and found it necessary cause of death next to heart failure. After this, the whole of the existing evidence. examine to in probable order of frequency, come cerebral causes There was a great deal of information, varying much (and especially coma following embolus), exhaustion in its value. Numerous papers had been published, from the prolonged toxicity, and pneumonia. and their contents accumulated without any very critical examination of the evidence contained in them. To get an insight into the conditions that DIABETIC COMA WITHOUT prevailed it was necessary to read as much as possible of the writings of previous workers, to weigh the ACETONURIA. evidence as carefully and as dispassionately as BY T. H. OLIVER, M.D. MANCH., M.R.C.P. LOND., possible, and to reinvestigate all the material which seemed of any real value. HONORARY ASSISTANT PHYSICIAN, MANCHESTER ROYAL INFIRMARY. Two different periods may be studied. The first ranges from 1870-1907, and the second from 1907 In the epoch 1870-1907, THE following case of diabetic coma possesses some until the present time. Simeon Snell and Sir Josiah Court were the two prinunusual features. A youth, aged 21, who had been on insulin treatment since cipal writers in this country. In the evidence he gave May, 1923, and whose symptoms were so severe as to before the Departmental Committee of 1907, Snell deals necessitate three injections of 15 units daily in order to with the question of incapacity, his views being founded keep the blood-sugar approximately normal and the urine on over a thousand cases. He recognises a large free from sugar and acetone, developed a severe gastro- incidence, but gives no statistics. In " Miners’ enteritis on Oct. 1st, 1926. As a result of this he was unable he deals with the result of examinaNystagmus," 1892, to take food and, owing to a misunderstanding, insulin was tion of 134 cases, and dwells almost -entirely on the also withheld. On Oct. 4th he had very severe abdominal causation. The evidence which Simeon Snell gave to his attendant onset of which medical the pain suggested in the year 1907 may be epitomised as follows :He was sent from the to peritonitis. Manchester, country " Errors of refraction have no effect on miners’ nystagmus. It is difficult to define which men of those who have marked oscillation are incapacitated ; many are affected but not suffering. If miners’ nystagmus is scheduled, a very large number of miners will seek compensation for slight amounts of miners’ nystagmus, not severe enough to prevent them from working. It is very difficult to separate the genuine from the other cases. Probably a large proportion of miners will continue their work as they do now, and experience no pain or difficulty from the nystagmus ; on the other hand, a large number of men who are able to do their work may seek compensation. Compensation will not be good from the men’s point of view nor from the employers ; it may throw so many men out of work and add enormously to the cost of coal-getting. A typical severe case of miners’ nystagmus is fit for surface work in a few weeks, and fit for pit work eventually. I cannot remember ever meeting a miner who had given up work for nystagmus five or six years before and who had not resumed work below ground. I do not think a very great proportion of men are incapacitated by miners’ nystagmus, only a small proportion ; nor that it is a very great evil, but it may be considered so under
distance of 80 miles, where I examined him about 5 o’clock the same evening. During the journey he became unconscious, and when I saw him he was in typical diabetic coma with a feeble pulse of 128 and a temperature of 98° F. The heart sounds were very feeble, and he appeared to be dying. A specimen of urine was loaded with sugar, but no acetone bodies were present. There was also a faint cloud of albumin. 40 units of insulin were given immediately, and afterwards 20 units every three hours throughout the night. Lemonade containing glucose was given in unlimited amount. By next morning the patient had partially recovered consciousness, but the pulse was still 120 and very feeble. During that day 80 oz. of urine were passed, sugar being present in all specimens, but no acetone bodies. From that time 20 units of insulin four-hourly were given, this being reduced gradually to 15 units t.i.d. as the patient improved. The trace of albumin persisted for three or four days and then disappeared. At the end of four days the glucose lemonade was discontinued and a solid diet gradually substituted. Except for one day, throughout the illness there were no acetone bodies present in the urine and, on that one occasion, only the slightest trace could be detected by ferric chloride a
.solution.
compensation."
The patient made an uninterrupted recovery, and when seen recently had resumed the diet of approximately 2100 calories and had returned to the dose of insulin which he was taking before his illness. The urine was sugar-free and the fasting blood-sugar was 0-19 per cent.
Sir Josiah Court, whose work has proved so remarkdefinite statistical information as to the incidence (see " Miners’ Diseases "). In 1892 he examined the whole of the men, 735 in at two of the Stavely pits. Of these, 376 were number, The features of interest in this case are : (1) The actual of whom 454 per cent. had miners’ coal-getters, onset of coma heralded by acute abdominal pain simuOf stallmen in safety lamp pits generally nystagmus. lating peritonitis. (2) The treatment with large doses he found about 40 cent. had nystagmus, whereas of insulin, together with an unlimited supply of glucose of those in naked per light only about 3 per cent. solution. This prevented the onset of hypoglycaemia, Sir Josiah Court in the pits same book (pp. 49 and 50) and probably with the aid of insulin was helpful in makes the following remark on incapacity :— " repleting the glycogen stores and thus preventing An Act of Parliament should be passed restricting the complete cardiac muscle failure. As the sugar- time for which compensation should be paid for miners’ tolerance after the illness was the same as before, theI nystagmus to four months." large amount of sugar given did not appear to have A careful study of the evidence given in 1907 done any damage to the pancreas. (3) The almost brings many interesting details to light; for instance, entire absence of acetone bodies is an unusual feature it is interesting to read the evidence, medical and in a case of coma. Such cases have been recorded, but this absence has been attributed to renal failure. otherwise, given on behalf of the Lanarkshire Miners’ In this case, however, not only was there no inability Union, where, according to Dr. Freeland Fergus, a to excrete sugar-containing urine in large quantities miners’ nystagmus now causes lot of incapacity with loss of vision and untoward other results. Mr. R. during the first week, but even when recovery had occurred and the kidney function was then presum- Smillie, for the Lanarkshire Miners’ Union, said :have quite a number of miners’ nystagmus cases in ably normal there was no excretion of accumulated the We 50 districts of Lanarkshire. Ophthalmic specialists acetone bodies. Here at least it is difficult to believe 1 that the direct causation of coma could be attributed Stallmen are both the coal-getters, or hewers, and the fillers, to them. who fill tubs with coal in the working-place or stall.
ably accurate (1891), gives
I
"
A
STUDY
OF
MINERS’ BY G. H.
SOME
ASPECTS
OF
NYSTAGMUS.
POOLEY, B.A. CAMB., F.R.C.S. ENG.,
OPHTHALMIC SURGEON TO THE ROYAL
INFIRMARY, SHEFFIELD.
respectively.
IN 1920 I was invited to become a member of the Miners’ Nystagmus Research Committee of the Renal failure is admittedly the most frequent Medical Research Council, and found it necessary cause of death next to heart failure. After this, the whole of the existing evidence. examine to in probable order of frequency, come cerebral causes There was a great deal of information, varying much (and especially coma following embolus), exhaustion in its value. Numerous papers had been published, from the prolonged toxicity, and pneumonia. and their contents accumulated without any very critical examination of the evidence contained in them. To get an insight into the conditions that DIABETIC COMA WITHOUT prevailed it was necessary to read as much as possible of the writings of previous workers, to weigh the ACETONURIA. evidence as carefully and as dispassionately as BY T. H. OLIVER, M.D. MANCH., M.R.C.P. LOND., possible, and to reinvestigate all the material which seemed of any real value. HONORARY ASSISTANT PHYSICIAN, MANCHESTER ROYAL INFIRMARY. Two different periods may be studied. The first ranges from 1870-1907, and the second from 1907 In the epoch 1870-1907, THE following case of diabetic coma possesses some until the present time. Simeon Snell and Sir Josiah Court were the two prinunusual features. A youth, aged 21, who had been on insulin treatment since cipal writers in this country. In the evidence he gave May, 1923, and whose symptoms were so severe as to before the Departmental Committee of 1907, Snell deals necessitate three injections of 15 units daily in order to with the question of incapacity, his views being founded keep the blood-sugar approximately normal and the urine on over a thousand cases. He recognises a large free from sugar and acetone, developed a severe gastro- incidence, but gives no statistics. In " Miners’ enteritis on Oct. 1st, 1926. As a result of this he was unable he deals with the result of examinaNystagmus," 1892, to take food and, owing to a misunderstanding, insulin was tion of 134 cases, and dwells almost -entirely on the also withheld. On Oct. 4th he had very severe abdominal causation. The evidence which Simeon Snell gave to his attendant onset of which medical the pain suggested in the year 1907 may be epitomised as follows :He was sent from the to peritonitis. Manchester, country " Errors of refraction have no effect on miners’ nystagmus. It is difficult to define which men of those who have marked oscillation are incapacitated ; many are affected but not suffering. If miners’ nystagmus is scheduled, a very large number of miners will seek compensation for slight amounts of miners’ nystagmus, not severe enough to prevent them from working. It is very difficult to separate the genuine from the other cases. Probably a large proportion of miners will continue their work as they do now, and experience no pain or difficulty from the nystagmus ; on the other hand, a large number of men who are able to do their work may seek compensation. Compensation will not be good from the men’s point of view nor from the employers ; it may throw so many men out of work and add enormously to the cost of coal-getting. A typical severe case of miners’ nystagmus is fit for surface work in a few weeks, and fit for pit work eventually. I cannot remember ever meeting a miner who had given up work for nystagmus five or six years before and who had not resumed work below ground. I do not think a very great proportion of men are incapacitated by miners’ nystagmus, only a small proportion ; nor that it is a very great evil, but it may be considered so under
distance of 80 miles, where I examined him about 5 o’clock the same evening. During the journey he became unconscious, and when I saw him he was in typical diabetic coma with a feeble pulse of 128 and a temperature of 98° F. The heart sounds were very feeble, and he appeared to be dying. A specimen of urine was loaded with sugar, but no acetone bodies were present. There was also a faint cloud of albumin. 40 units of insulin were given immediately, and afterwards 20 units every three hours throughout the night. Lemonade containing glucose was given in unlimited amount. By next morning the patient had partially recovered consciousness, but the pulse was still 120 and very feeble. During that day 80 oz. of urine were passed, sugar being present in all specimens, but no acetone bodies. From that time 20 units of insulin four-hourly were given, this being reduced gradually to 15 units t.i.d. as the patient improved. The trace of albumin persisted for three or four days and then disappeared. At the end of four days the glucose lemonade was discontinued and a solid diet gradually substituted. Except for one day, throughout the illness there were no acetone bodies present in the urine and, on that one occasion, only the slightest trace could be detected by ferric chloride a
.solution.
compensation."
The patient made an uninterrupted recovery, and when seen recently had resumed the diet of approximately 2100 calories and had returned to the dose of insulin which he was taking before his illness. The urine was sugar-free and the fasting blood-sugar was 0-19 per cent.
Sir Josiah Court, whose work has proved so remarkdefinite statistical information as to the incidence (see " Miners’ Diseases "). In 1892 he examined the whole of the men, 735 in at two of the Stavely pits. Of these, 376 were number, The features of interest in this case are : (1) The actual of whom 454 per cent. had miners’ coal-getters, onset of coma heralded by acute abdominal pain simuOf stallmen in safety lamp pits generally nystagmus. lating peritonitis. (2) The treatment with large doses he found about 40 cent. had nystagmus, whereas of insulin, together with an unlimited supply of glucose of those in naked per light only about 3 per cent. solution. This prevented the onset of hypoglycaemia, Sir Josiah Court in the pits same book (pp. 49 and 50) and probably with the aid of insulin was helpful in makes the following remark on incapacity :— " repleting the glycogen stores and thus preventing An Act of Parliament should be passed restricting the complete cardiac muscle failure. As the sugar- time for which compensation should be paid for miners’ tolerance after the illness was the same as before, theI nystagmus to four months." large amount of sugar given did not appear to have A careful study of the evidence given in 1907 done any damage to the pancreas. (3) The almost brings many interesting details to light; for instance, entire absence of acetone bodies is an unusual feature it is interesting to read the evidence, medical and in a case of coma. Such cases have been recorded, but this absence has been attributed to renal failure. otherwise, given on behalf of the Lanarkshire Miners’ In this case, however, not only was there no inability Union, where, according to Dr. Freeland Fergus, a to excrete sugar-containing urine in large quantities miners’ nystagmus now causes lot of incapacity with loss of vision and untoward other results. Mr. R. during the first week, but even when recovery had occurred and the kidney function was then presum- Smillie, for the Lanarkshire Miners’ Union, said :have quite a number of miners’ nystagmus cases in ably normal there was no excretion of accumulated the We 50 districts of Lanarkshire. Ophthalmic specialists acetone bodies. Here at least it is difficult to believe 1 that the direct causation of coma could be attributed Stallmen are both the coal-getters, or hewers, and the fillers, to them. who fill tubs with coal in the working-place or stall.
ably accurate (1891), gives
I
"