DIABETES MELLITUS:

By: Joseph Jacobs, Maurice Fishberg

A Disease of Civilization.

A constitutional disorder of nutrition, characterized by the persistent elimination of grape-sugar in the urine. It is considered to be a disease of the wealthier classes, and is more common in cities than in the country. Dr. Bertillon has demonstrated that the mortality from diabetes is higher in all the wealthy districts. Persons of a nervous temperament are very often affected, and it is not uncommon to find a history of insanity, consumption, and gout among the relatives of diabetics. Sudden emotional excitement, grief, terror, worry, and anxietymay each and all be followed so closely by diabetes that there is no room for doubt as to their having occasioned it. It is well known as a result of commercial disaster. "When stocks fall, diabetes rises in Wall Street," says Dr. Kleen. It has also been noticed that engine-drivers are especially subject to this disease; this fact is presumably due to the excessively anxious nature of their occupation.

Diabetes is met with, in varying degrees of frequency, in every country. It is stated to be extremely common among the educated classes of natives in India and Ceylon. The disease is almost unknown among the Chinese, the Japanese, and the negroes of Africa; but many cases have been observed among negroes in the United States. Many competent and reliable observers show that diabetes is more common among the Jews than among any other European races; and statistics prove conclusively that the disease occurs among Jews from two to six times as frequently as it does among nonJews, as can be seen from an examination of the following tables:

Locality.	Period.	Percentage of Deaths Due to Diabetes.		Authority.
		_____________
		Jews.	Gentiles.
Frankfort-on- the-Main.	1876-90	1.9	0.4	Wallach, in "Med. Wochenschrift," 1893, p. 779.

Observer.	No. of Cases.	No. and Percentage of Jewish Patients.		Authority.
F. T. Frerich.	400	103	25	"Ueber den Diabetes," p. 185, Berlin, 1884.
Külz	692	123	17.8	"Klinische Erfahrungen über Diabetes Mellitus," pp. 2, 3, Jena, 1899.
Carl v. Noorden	650 328	252 119	38.8 36.3	"Die Zuckerkrankheit und Ihre Behandlung," p. 44, Berlin, 1901.

Other observers have given statistics showing that the German Jews are more liable to diabetes than non-Jews. On the other hand, these statistics have been objected to as valueless, because most of them relate to German bathing-resorts and sanitariums, where well-to-do patients from every country are apt to flock for relief. It is further shown that Jews are attracted to these resorts in relatively greater numbers than other races, because they more often seek relief of celebrated physicians and specialists. Thus, Dr. Arnold Pollatschek ("Zur Aetiologie des Diabetes Mellitus," in "Zeitschrift für Klinische Medizin," xxxii. 478-482, Berlin, 1901) shows that in the course of ten years (1891-1900) he treated 4,719 persons, of whom 2,381 were Christians, 2,333 Jews, and 5 Mohammedans. Of these patients 653 suffered from diabetes—289 Christians and 364 Jews. Of his entire clientele 13.8 per cent were diabetics, and there were 124 diabetic Christians per 1,000, as against 155 per 1,000 of Jewish origin. The slight relative excess of the Jewish diabetics is, according to Pollatschek, only apparent. He believes that the circumstance that Jews apply oftener than Christians to the sanitariums for treatment is due to their greater wealth, and that, consequently, as a bath physician in Carlsbad, he saw more patients of Jewish origin. He finally draws attention to the fact that the mortality from diabetes in England is quite high, although there are comparatively few Jews there, and claims that it is questionable whether Thomas, Willis, Dobson, and Rollo, who first observed and described diabetes, had Jewish material for their researches.

Both of these views—(1) that the Jews suffer more frequently from diabetes than other races, and (2) that they are not more often affected—are probably well founded. It is only a question of the nativity of the Jews: the Jews in Germany, for example, are decidedly more diabetic than those in Russia, England, and France; and the difference of opinion among physicians of experience is simply due to the fact that they usually neglect to consider the question of the nativity of the Jews under consideration. In the United States, where Jews arrive from various countries, diabetes is found to be extremely frequent among the German and Hungarian Jews; while among the Russian Jews it is certainly no more—perhaps it is even less—frequent than among other races.

Dr. Heinrich Stern ("The Mortality from Diabetes Mellitus in the City of New York During 1899," in "The Medical Record," lviii. 766-774), who has carefully analyzed the death-certificates of diabetics in New York, has found that of 202 deaths due to diabetes 54 were those of Jews, or over 25 per cent; of these, 21 were males and 33 females. New York city (Manhattan and the Bronx) in 1900 had a population of over 2,050,000, of which the Jews constituted 20 per cent. This would indicate that in these boroughs there were over 400,000 Jews, and 1,650,000 non-Jews. The following table shows the relative death-rate from diabetes in New York (Manhattan and Bronx) in 1899:

Race.	Population (Census of 1900).	Number of Deaths Due to Diabetes (1899).	Death-Rate of Diabetes per 100,000 Population.
All races	2,050,000	202	9.85
Non-Jews (80 per cent)	1,650,000	148	8.95
Jews (20 per cent).	400,000	54	13.50

From this table it is evident that the mortality from diabetes of the Jews in New York is relatively more than double that of the rest of the population of the city.

The morbidity of New York Jews from this disease has been investigated by Dr. Julius Rudisch ("Mount Sinai Hospital Report," 1898-99, pp. 26-29); and the following table gives his statistics of the cases of diabetes which were treated in MountSinai Hospital during the years 1890-1900, compared with those of four other New York hospitals for the same period:

Hospital.	Total Number of Hospital Cases.	Percentage of Diabeties.	No. of Diabeties.	Race.		Sex.
				_____________		_______________
				Jews.	Gentiles.	Males.	Females.
Mt. Sinai	29,166	.0021	62	52	10	43	19
Lebanon	3,953	.0027	11	10	1	4	7
German	24,811	.0023	59	19	40	45	14
New York.	50,429	.0005	28	3	25	20	8
Roosevelt	28,402	.0014	36	2	34	25	11
Total	136,761		196	86	110	137	59

It will be seen that the total number of cases treated in the five hospitals in question during the ten years mentioned amounted to 136,767, of which 196 were diabetics, or 1 diabetic to 697 general cases. "If we assume," says Rudisch, "that upon the basis of population [of New York city] 15 per cent of the total number of patients were Jews, we find that 20,500 were treated. The whole number of diabetics was 196, and of these 86 were Hebrews—a matter of 43 per cent. If we now assume 20,500 as the total number of Jewish patients, we find that diabetes is nearly three times as prevalent among Hebrews as among any other race or creed."

Jews Endure Diabetes Better than Others.

It has been observed by many clinicians that the Jews bear diabetes better than other races; thus, Van Noorden (l.c. p. 176) states that it is remarkable how some patients will endure glycosuria for years without much discomfort, succumbing at last—perhaps after decades—to what is supposed to be heart-failure. This peculiar type of diabetes, and this remarkable endurance by the human body of the anomalous metabolism of diabetes, are more frequently met with among women than among men, and almost exclusively among Jews.

Dr. Stern has pointed out another peculiarity; viz., that Jews dying of diabetes succumb through coma more frequently than non-Jews. Thus, while the ratio of fatal coma cases occurring in New York city in 1899 to the total mortality from diabetes was as 60 to 202, or 29 per cent, coma occurred in 43 per cent of the cases of diabetes among Jews.

Not a Racial Disease.

It has also been shown that diabetes is not a racial disease of the Jews. Sée has observed that it is no more frequent among the Jews in France than among the rest of the population of that country. Rudisch says that while the total number of patients admitted into the Mount Sinai Hospital in New York is three times as large as that of patients who are natives of Germany, the striking feature is that the diabetic patients among the latter outnumber in the proportion of 6 to 1 those among the patients who are Russians. He attributes this to the circumstance that the Russo-Jewish patients of the hospital belong to the poorer laboring classes and are insufficiently nourished, whereas the majority of the German Jews represent the better classes of workmen as well as persons engaged in mercantile and professional pursuits.

The same fact is evidenced in the "Report on Vital Statistics of New York City" of the Eleventh Census, wherein the deaths for the six years ending May 31, 1890, are recorded. During the period in question the average mortality from diabetes per 100,000 population is seen to be as follows:

Native Country of Mothers of Patients.	Average Mortality (per cent) from Diabetes per 100,000 Population.
France	12.91
England and Wales.	14.30
Germany	8.79
Scotland	8.45
Canada	7.70
United States	7.18
Ireland	4.58
Russia (mostly Jews) and Poland	3.28
Bohemia	3.01
Italy	1.28

The Russian and Polish Jews in New-York show a lower mortality from diabetes than many of their non-Jewish neighbors. Of the 54 Jewish diabetics who died in that city during 1899, as shown by Stern (l.c.), 17, or 31.48 per cent, were born in Russia; and it is well known that at least 65 per cent of the Jews in New York are natives of Russia or of Poland. These data tend to show that diabetes is most frequently met with among German Jews, and that Jews from other countries are not more liable to contract the disease than are the other inhabitants of the city.

Reasons Given.

Many reasons have been given for the excessive predisposition of Jews to diabetes. Consanguineous marriages, more frequent among the Jews than among most other races (see Anthropology and Consanguinity), have been thought by some (Van Noorden, Stern, Frerich, and many others) to be the cause. Van Noorden ("Ueber Diabetes Mellitus," in "Berliner Klinische Wochenschrift," 1900, p. 1117) even thinks that the frequent intermixture of Jewish with Indo-Germanic blood has a great deal to do with the frequency of diabetes among Jews. These views are, however, untenable, because most modern authorities deny that consanguineous marriages, provided they are contracted between healthy individuals, are in any way detrimental to the offspring; and it is not known that racial intermixtures, which are frequent in modern civilized countries, have any etiological relation to the disease.

The alleged sedentary habits of the Jews are assigned by some authors (Saundby, Kleen, and others) as a predisposing cause. Diabetes is a disease brought about by high living, overfeeding, lack of proper exercise, etc., and most of the rich Jews who apply to the sanitariums for treatment are precisely of the class among which these conditions are most prevalent. This is disproved by Stern's statistics of the mortality from diabetes in New York city during the year 1899, which conclusively show that nearly 70 per cent of the deaths from that diseaseoccurred in tenement-houses, 15 per cent in coroners' cases, and only 15 per cent in private houses, which would indicate that high living has practically little to do with diabetes (Stern, in "Jour. Am. Medical Assoc." Jan. 26, 1901).

With the present knowledge of the pathogenesis of diabetes, the only reasonable explanation of the frequency of the disease among Jews is their extreme nervousness, the Jews being known as the most nervous of civilized peoples.

It remains to be mentioned that throughout the world the Jews are principally town-dwellers, two-thirds of them living in large centers of population; and that diabetes seeks most of its victims among the people who live under the strain, hurry, and bustle of modern city life. "The Jews are the children and grandchildren of town-dwellers," says Bouchard. "In the long run the unfavorable hereditary influences are not rectified for them by the frequent intermarriage of the urban with the country people, as is the case with the rest of the population. The Jews marry exclusively among themselves; first cousins from the paternal or maternal side find no barrier to marriage, and immediately on being born the young Israelite receives the accumulated unfavorable (hereditary) influences, which he further develops during his lifetime, and which tend to the diseases that are generated by disturbed nutrition, particularly diabetes" ("Leç. sur les Maladies par Ralentissement de la Nutrition," Paris, 1892).

J. M. Fi.