The only objection that remains against a fat-and-meat diet in severe cases of diabetes is the theoretical one that it favors the occur rence of coma. I can only say that in the case of a thing upon which so little calculation can be made as the occurrence of diabetic coma, and in view of the fact that coma has been observed under all forms of diet, we should be very careful how we use the word "favor." Only an extensive critical comparison of statistics, which has never yet been made, could give objective support to this opinion, and put to one side the subjective judgment of the physician theoretically dis posed to one or the other view. Single cases prove absolutely noth ing here. Furthermore it must be noted that the opposition, which the fear of coma has aroused, to a diet containing no carbohydrates relates properly to a purely flesh diet and not to the improved fat-and flesh regimen. I have already shown that the former weakens the body and thereby predisposes to coma, but this cannot be asserted of a generous fat-and-flesh diet. From what I have been able to glean from the literature, from what I myself have seen, and from what has been related to me by other judicious partisans of the fat-and-flesh diet (one often learns more of therapeutics by verbal exchange than by the most exhaustive study of the literature), it appears to me that the dread of coma so produced is wholly unfounded. I believe, there fore, that for every really grave case of diabetic glycosuria, the fat and-flesh diet to the exclusion of carbohydrates is to be regarded as the ideal regimen, against which no serious objection can be raised.
The actual carrying-out of this regimen is another thing. The practical difficulties demand certain concessions which must be granted if one would be certain of the continued trustworthiness and obedi ence of his patients. It cannot be doubted that' a patient in hospital or in a private sanitarium may now and then be nourished for weeks and mouths without carbohydrates ; the strict military discipline of the institution often keeps the bread-hunger of diabetics in check, even without the confinement which has been advised by some over zealous physicians. But in private practice, except in the case of the occasional strong-willed individual, and such a one is rarely en countered among diabetics, the patient will not obey the command to abstain from carbohydrates. He will always say that he does, but unfortunately diabetes is one of the diseases that ruin character. Just as the victim of morphine is constrained to deceive his physi cian and himself, so is the sufferer from diabetes.
The tooth of man in civilized regions is not set for meat and fat with no admixture of carbohydrates. The indispensable fat espe cially becomes repugnant to him when taken continuously for a long time. Just in proportion as it is easy to take large quantities of fat in connection with carbohydrates, is it difficult to ingest them with out the latter. The conscientious patient would soon be led through disgust to reduce the amount of fat and thereby be driven on the rocks of an objectionable exclusively meat diet with its dangers of under-nourishment. All the variety which the richest and finest
cuisine can offer in the choice and preparation of carbohydrate-free food becomes insufficient in the long run, for the diabetic even more than the healthy person has a genuine longing for carbohydrates —not sugar and sweets, but bread and potatoes. In this respect, it seems to me, there is an essential difference between obesity and diabetes. The corpulent, especially those in the well-to-do classes, submit to a deprivation of carbohydrates, even the most minute quan tities, for months at a time without complaint. I know corpulent in dividuals who year in and year out never take more than about 30 grains of carbohydrates a day and have no longing to increase this amount. But with the diabetic the case is different; he cries for bread. This craving is doubtless inherent in the nature of the disease.
For this reason all sorts of substitutes for bread have been devised (gluten bread, almond bread, etc.), but all of these answer for a short time only, and a disgust for them soon arises. The only one of value is aleuronat bread, not indeed because it is free from carbohydrates, but because, while containing only a comparatively small proportion of the latter, it preserves the genuine bread taste, and because, as I can testify, it is taken readily for months at a time by some, but by no means all, diabetic patients. What therefore is theoretically undesirable is practically urgently demanded. How this demand can be best and least injuriously -met will be discussed in the section on the special treatment of the severe forms of diabetes.
c. Coil•ideiatirms. cowerniny Alco1v,l in have already spoken above (ef. p. 82) of the influence of alcohol upon glycosuria, the conclusion being reached that moderate amounts do not at any rate increase the glycosuria. Nevertheless many physicians avoid alcohol. I cannot agree with them in this course.
Alcohol may be useful in various ways in diabetes and may also under certain circumstances be injurious.
(1) Alcohol is very important in the carrying out of the fat-and flash diet, which is poor in carbohydrates, for the ingestion of con siderable quantities of fat is greatly facilitated if alcohol is allowed at the same time. Even the healthy individual often feels the need after eating very greasy dishes of a swallow of brandy to remove an un pleasant sensation. It is important in the case of the diabetic not to allow these disagreeable sensations to arise after the taking of fatty food, otherwise a disgust for the latter would soon be excited. Therefore the patient should take from the start a small quantity of alcohol with or after fatty food. The form of alcohol best suited to this purpose is cognac, cherry brandy, whiskey, rum, or the like, either clear or with soda water ; a good Burgundy is also very use ful in such cases.