March 16, 2003, Sunday
MAGAZINE DESK
THE WAY WE LIVE NOW: 3-16-03: BODY CHECK; The Bittersweet Science
By Austin Bunn NYT 2617 words
Eleven-year-old Elizabeth Hughes was, in retrospect, the ideal patient:
bright, obedient, uncomplaining and wholly unprepared to die Born in 1907
in the New York State governors mansion, Elizabeth was the daughter of
Charles Evans Hughes, who later became a justice on the Supreme Court, ran
against Woodrow Wilson in 1916 and served as secretary of state under
Harding
Elizabeth had a perfectly normal, aristocratic youth until she seemed to
become allergic to childhood She would come home from friends birthday
parties with an insatiable thirst, drinking almost two quarts of water at a
sitting By winter, she had become thin, constantly hungry and exhausted
Her body turned into a sieve: no matter how much water she drank, she was
always thirsty
In early 1919, Elizabeths parents took her to a mansion in Morristown,
NJ, recently christened the Physiatric Institute and run by Dr Frederick
Allen A severe, debt-ridden clinician with a pockmarked résumé, Allen had
written the authoritative account on treating her condition He prolonged
hundreds of lives
and was the girls best chance Allen examined Elizabeth
and diagnosed diabetes — her body was not properly processing her food
into fuel — and told her parents what they would never tell their
daughter: that her life expectancy was one year, three at the outside Even
that was a magnificent extension of previous fatality rates The
diagnosis was like knowing a death sentence had been passed, wrote one
historian Then Dr Allen did what many doctors at the time would have done
for Elizabeth, except that this doctor was exceptionally good, if not the
finest in the world, at it He began to starve her
The history of medicine is like the night sky, says the historian Roy
Porter in his book The Greatest Benefit to Mankind: A Medical History of
Humanity We see a few stars and group them into mythic constellations
What is chiefly visible is the darkness
Diabetes doesnt come from simply eating too much sugar; nor is it cured,
as was once thought, by a little horseback riding It is not the result of
a failing kidney, overactive liver or phlegmy disposition, though these
were the authoritative answers for centuries Diabetes happens when the
blood becomes saturated with glucose, the bodys main
energy source, which
is normally absorbed by the cells — which is to say that the pathology of
diabetes is subtle and invisible, so much so that a third of the people who
have it dont even know it Until the prohibition against autopsies was
gradually lifted by 1482, the pope had informally sanctioned it, what we
knew of human anatomy came through the tiny window of war wounds and
calamitous gashes — and even then it took centuries for doctors to decide
just what the long, lumpy organ called the pancreas actually did or, in the
case of diabetes, didnt do We like to think surgically about the history
of medicine, that it moved purposefully from insight to insight, angling
closer to cure But that is only the luxury of contemporary life Looked at
over time, medicine doesnt advance as much as grope forward, with remedies
– like bloodletting, quicksilver ointments and simple, unendurable hunger
– that blurred the line between treatment and torture
Diabetes was first diagnosed by the Greek physician Aretaeus of Cappadocia,
who deemed it a wonderful affection being a melting down of the
flesh and limbs into urine For the afflicted, life is disgusting and
painful; thirst unquenchable
and one cannot stop them from drinking
or making water Since the classical period forbade dissection, Porter
notes, hidden workings had to be deduced largely from what went in and
what came out An early diagnostic test was to swill urine, and to the
name diabetes, meaning siphon, was eventually added mellitus,
meaning sweetened with honey Healers could often diagnose diabetes
without the taste test Black ants were attracted to the urine of those
wasting away, drawn by the sugar content Generations later, doctors would
make a similar deduction by spotting dried white sugar spots on the shoes
or pants of diabetic men with bad aim
For the Greeks, to separate disease symptoms from individual pain while
isolating them from magical causes was itself an enormous intellectual
leap We should be really impressed with Aretaeus, says Dr Chris
Feudtner, author of the coming Bittersweet: Diabetes, Insulin and the
Transformation of Illness He was able to spot the pattern of diabetes
in a dense thicket of illness and suffering
But for centuries, this increasing precision in disease recognition was not
followed by any effective treatment — more details didnt make physicians
any less helpless At
the time, they were unknowingly confusing two kinds
of diabetes: Type 1, known until recently as juvenile diabetes, which
is more extreme but less common than Type 2, or adult onset, which
seems to be related to obesity and overeating With Type 1 what Elizabeth
Hughes had, the pancreas stops secreting insulin, a hormone that instructs
the body to use the sugar in the blood for energy With Type 2, the
pancreas produces insulin at least initially, but the tissues of the body
stop responding appropriately By 1776, doctors were still just boiling the
urine of diabetics to conclusively determine that they were passing sugar,
only to watch their patients fall into hyperglycemic comas and die
If dangerous levels of glucose were pumping out of diabetics, one idea was
obvious: stop it from going in That demanded a more sophisticated
understanding of food itself In the long tradition of grotesque scientific
experimentation, an insight came through a lucky break: a gaping stomach
wound In 1822, William Beaumont, a surgeon in the US Army, went to the
Canadian border to treat a 19-year-old trapper hit by a shotgun The boy
recovered, but he was left with a hole in his abdomen According to
Porter,
Beaumont took advantage of his patients unique window and dropped food
in on a string The seasoned beef took the longest to digest Stale bread
broke down the quickest The digestion process clearly worked differently
depending on what was eaten Then during the 1871 siege of Paris by the
Germans, a French doctor named Apollinaire Bouchardat noticed that, though
hundreds were starving to death, his diabetic patients strangely improved
This became the basis for a new standard of treatment Mangez le moins
possible, he advised them Eat as little as possible
In the spring of 1919, when Elizabeth Hughes came under Dr Allens care,
she weighed 75 pounds and was nearly 5 feet tall For one week, he fasted
her Then he put her on an extremely low-calorie diet to eradicate sugar
from her urine If the normal caloric intake for a girl her age is between
2,200 and 2,400 calories daily, Elizabeth took in 400 to 600 calories a day
for several weeks, including one day of fasting each week Her weight, not
surprisingly, plummeted As Michael Bliss notes in his book The Discovery
of Insulin, the Hughes family brought in a nurse to help weigh and
supervise every gram of food that she ate Desserts
and bread were
verboten She lived on lean meat, eggs, lettuce, milk, a few fruits,
tasteless bran rusks and tasteless vegetables boiled three times to make
them almost totally carbohydrate-free, Bliss writes Instead of a
birthday cake, she had to settle for a hat box covered in pink and white
paper with candles on it On picnics in the summertime she had her own
little frying pan to cook her omelet in while the others had chops, fresh
fish, corn on the cob and watermelon
You could say that Elizabeth Hughes was on a twisted precursor of the Zone
diet: her menu relied on proteins and fats, with the abolishment of
carbohydrates like bread and pasta In fact, Allens maniacal scrutiny of
his patients nutrition — fasting them, weighing each meal, counting
calories — was one of the first diets in the modern sense At the time
Elizabeth entered the clinic, being well fed was a sign of good health But
the new science of nutrition fostered the idea of weight reduction as a
standard of health and not illness
Allens starvation diet was a particular cruelty Patients came to him
complaining of hunger and rapid weight loss, and Allen demanded further
restrictions, further weight loss Yes, the
method was severe; yes, many
patients could not or would not follow it, writes Bliss But what was
the alternative? Over the years, doctors recommended opium, even heaps of
sugar which only accelerated death, but since nothing else worked, why not
enjoy the moment? But nobody had a better way than Allen to extend lives
If the fasting wasnt working and symptoms got worse, Allen insisted on
more rigorous undernourishment In his campaigns to master their disease,
Allen took his patients right to the edge of death, but he justified this
by pointing out that patients faced a stark choice: die of diabetes or risk
inanition, which Allen explained as starvation due to inability to
acquire tolerance for any living diet The Physiatric Institute became a
famine ward
Some of Allens patients survived levels of inanition not thought possible,
Bliss writes One 12-year-old patient, blind from diabetes when he was
admitted, still occasionally showed sugar in his urine The clinic became
convinced that the kid — so weak he could barely get out of bed — was
somehow stealing food It turned out that his supposed helplessness was
the very thing that gave him opportunities which other persons
lacked,
Allen later wrote in his book, Total Dietary Regulation in the Treatment
of Diabetes Among unusual things eaten were toothpaste and birdseed,
the latter being obtained from the cage of a canary which he had asked
for The staff, thinking he was pilfering food, cut his diet back and
further back The boy weighed less than 40 pounds when he died from
starvation
No one explained to Elizabeth Hughes why the friends she made at Allens
clinic stopped writing her letters Death was kept hidden, though it must
have been obvious from the halls of the clinic, where rows of gaunt
children stared from their beds It would have been unendurable if only
there had not been so many others, one Allen nurse wrote Dutifully,
Elizabeth — strong enough just to read and sew — hardly ever showed
sugar Her attendant punished her severely the one time she caught her
stealing turkey skin from the kitchen after Thanksgiving Still, she was
wasting away By April 1921, 13 years old and two years into her treatment,
Elizabeth was down to 52 pounds and averaged 405 calories a day In letters
to her parents, she talked about getting married and what she would do on
her 21st birthday Reading the letters must
have been heartbreaking,
writes Bliss Elizabeth was a semi-invalid
In the history of illness, there are countless medicines, over time and
across cultures, with varying degrees of suffering and success There is
only one kind of cure — the one that invariably, irrefutably works
Insulin is not a cure It is a treatment, but it changed everything In the
summer of 1922, two young clinicians in Toronto named Frederick Banting and
Charles Best surgically removed the pancreases from dozens of dogs, causing
the dogs to get diabetes They found that by injecting the dogs with a
filtered solution of macerated pancreas either the dogs own or from calf
fetuses, the glucose level in the dogs blood dropped to normal The
researchers had discovered insulin
But in August 1922, Dr Frederick Allen had patients who could not wait,
like Elizabeth Allen left for Toronto to secure insulin While he was
gone, word leaked through his clinic about the breakthrough Patients who
had not been out of bed for weeks began to trail weakly about, clinging to
walls and furniture, wrote one nurse Big stomachs, skin-and-bone
necks, skull-like faces they looked like an old Flemish painters
depiction of a resurrection
after famine It was a resurrection, a crawling
stirring, as of some vague springtime
On the night Allen returned to the clinic, he found his patients –
silent as the bloated ghosts they looked like — waiting in the hallway
for him, wrote the nurse When he appeared through the open doorway, he
caught the full beseeching of a hundred pair of eyes It stopped him dead
Even now I am sure it was minutes before he spoke to them I think,
he said I think we have something for you
He did, but not nearly enough Though the results were striking — with the
insulin, sugar vanished from the urine of some of the most hopelessly
severe cases of diabetes I have ever seen, wrote Allen — he did not have
enough extract to treat all his patients, including Elizabeth So her
parents got her to Toronto When Banting saw Elizabeth, she was three days
away from her 15th birthday She weighed 45 pounds He wrote: Patient
extremely emaciated hair brittle and thin muscles extremely
wasted She was scarcely able to walk
He started her insulin treatment immediately The first injections cleared
the sugar from her urine, and by the end of the first week, she was up to
1,220 calories a day, still
without sugar By the next, she was at 2,200
calories Banting advised her to eat bread and potatoes, but she was
incredulous It had been three and a half years since she had them That
fall, she was one of several hundred North American diabetics pulled back
from the edge By November, she went home to her parents in Washington, and
by January, she weighed 105 pounds The same year, the 31-year-old Banting
won the Nobel Prize Meanwhile, Dr Allen, proprietor of an expensive
clinic whose patients no longer needed him, went broke Insulin was a
miracle drug, resurrecting diabetics from comas and putting flesh on
skeletons and, since it needed to be administered at least twice daily, it
was a miracle that would be performed over and over The era of chronic
medical care had begun
That may be the most poignant part of the history of Allens clinic The
end of the famine of Elizabeth Hughes is really the start of another
hunger: for the drugs that will keep us well for the rest of our lives
Elizabeth went to Barnard, reared three children, drank and smoked but kept
her diabetes a secret almost her entire life She died of a heart attack in
1981, more than 43,000 injections of insulin later But if
the discovery of
insulin took away the terror of diabetes, it replaced the miraculous with
the routine Healing lost one major ingredient: awe To think that Ill
be leading a normal, healthy existence is beyond all comprehension,
Elizabeth wrote to her mother, days after her first injection, in 1922
It is simply too wonderful for words
Copyright 2002 The New
Source:memhc.com
