That alterations in adrenal cortical structure and function may accompany diabetes mellitus is indicated by a number of observations. Untreated alloxan-diabetic rats, for example, exhibit both gross (1) and microscopic (2) evidence of adrenal cortical hypertrophy, suggesting that adrenal cortical hyperfunction may accompany diabetes, at least in the absence of insulin therapy. Diabetic patients, on the other hand, tend to excrete 17-ketosteroids (3) and perhaps corticosteroids (4) at a lowered rate, and to react to surgical trauma with abnormally transient eosinopenia (5), suggesting that under certain circumstances there may be hypofunction, and possibly partial exhaustion, of the adrenal cortex.Of the various metabolic abnormalities which might produce hyperfunction and ultimate attrition of the adrenal cortex in diabetic patients, instability in the control of the blood sugar level appeared to us to merit primary consideration inasmuch as hypoglycemia and hyperglycemia, states between which the diabetic patient oscillates continuously, are both capable of stimulating the adrenal cortex (6-16). The present study was designed to determine whether there was any relation between the degree of control of blood sugar and the level of adrenal cortical activity. Serial measurements of the level of the blood sugar, the eosinophil count, the rate of urinary excretion of corticosteroids, and of certain other variables, have been made on a diabetic patient over 15-day periods during which crystalline insulin in dosage levels ranging from 25 to 80 units per day was administered.
EXPERIMENTAL PROCEDUREThe subject of these studies was a physically vigorous 19-year-old male in whom mongolism had been recognized for 18 years and diabetes mellitus for 12 years. For at least three years prior to these studies asymptomatic pyelonephritis had been present. White cells were continuously present in the urine, from which B. pyocyaneus could be cultured, despite repeated courses of sulfadiazine, streptomycin and aureomycin. However, no obstruction could be demonstrated in the urinary tract and the urea clearance test was normal. The renal threshold for glucose was elevated. Adrenal responsiveness was normal, as judged by the ACTH-eosinophil test.At the time that these observations were made, the patient was 57.75 inches (144.4 cm.) tall and weighed 110 pounds (50 Kg.). Except for the short stature and mental retardation, positive physical findings consisted only of mongoloid features and hypertrophied tonsils. While he was at home, the patient's diabetes was reasonably well controlled on a 2,000 calorie diet by the administration of 40 units of protamine zinc insulin and 16 units of regular insulin in separate sites before breakfast. Insulin reactions had been rare and although he had become mildly acidotic on a few occasions, he had never been in diabetic coma.These studies were conducted on a metabolic ward at intervals over a period of 12 months. The diet, which was maintained constant throughout, consisted of carbohydrate 193, pr...