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Moderately Severe Forms of Glycosuria

carbohydrates, diet, patient, amount, food, periods, day and physician

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Under this heading are classed the cases in which the excretion of sugar is arrested or reduced to small amounts (from 10 to 20 grams) only by total abstinence from carbohydrates, that is to say, in which but an insignificant amount of carbohydrates can be borne. Any increase in the quantity of these substances will excite such a degree of glycosuria that the available value (the difference between the amount of carbohydrate of the food and that of the sugar in the urine) is very minute. The limit of tolerance varies also in these cases, but unfortunately the variation is more often in the direction of a de crease than in that of an increase; this is especially the case in young persons, for the moderately severe and severe forms of diabetes in childhood and early life give no quarter.

This form occurs usually in the young and middle-aged, seldom in those of later years, An hereditary influence is frequently evident, and there seems often to be a neuropathic basis for the disease; a gouty diathesis is more rarely present; obesity is uncommon, ema ciation frequent.

In prescribing a suitable diet it must be remembered that the car bohydrates are not to be counted on as a nutritive material, although they cannot be permanently excluded as an accessory food, and that the calorie values lost by the abstraction of carbohydrates must be made up by an increased supply of fat and albumin.

The limits of tolerance must be determined at the beginning of the treatment and frequently thereafter at intervals of several months. If this is not done a slight tendency to improvement or deterioration may be overlooked and thus no advantage be taken of it to institute the necessary changes in diet.

I would recommend that these patients be subjected to a three-weeks' course of complete abstinence from carbohydrates at least twice, and if possible three times, in the year, while in the intervals a certain amount of carbohydrates may be allowed.

We may take this opportunity to state, however, that there is actually no absolute carbohydrate-free food that man can eat. Even meat, eggs, and the lightest kinds of vegetables always contain minute quantities, and under the most carefully ordered diet at least 10 to 20 grains of carbohydrate will be taken in the clay.

The intercalation of these periods of a strictly regulated diet has the advantage that it reminds the patient of the need of great watch fulness over his food and constantly renews, as it were, his moral sup port; it has the advantage that these periods can be employed to determine the oscillations of tolerance; and, above all, it has the ad vantage that during these periods opportunity is given for a strength ening of the sugar-consuming function so that it may be better prepared to deal with new accessions of carbohydrates page 130). Every diabetic also, whose will-power is even half-way pre

served and who earnestly desires the improvement, or at least the maintenance, of his strength and the prolongation of his life, is ready and willing to undergo a course of strict dieting of such short dura tion; and the more so as by these short periods of deprivation he gains the permission to indulge again during the longer intervals in his wished-for carbohydrates.

a. The Diet in the Perias of Strict Abstinence.—The difficulty consists in providing for the necessary amount of fat without the foundation of carbohydrates. There is no lack of tasty dishes for au allmminous diet. The distribution of the nourishment through five meals is very necessary, otherwise the required amount will not be taken. As there mast be the greatest variety from day to day and individual tastes must be most carefully catered to, it is impossible to lay down any satisfactory special directions applicable to all cases. The physician must consult with the patient and pay attention to his special preference and antipathies. The patient will derive no assist ance from short general rules laid down during his visit in the physi cian's office; they only confuse and discourage him. The dietetic treatment of such an individual demands the sacrifice of time, patience, and thought. But it is only in the beginning, during the preliminary consultations, that the patient should be allowed to give expression to his wishes as to the daily bill-of-fare; this responsibility should then be taken from him, for it would only annoy and worry him and might readily excite a disgust for many articles of food. As it is only in rare cases that the domestic kitchen will suffice for the needs of the patient and of the physician, it is advisable that, while following out the strict dietary course, the patient enter a hospital or some private institution under the physician's direct control, at least for the first course. During this period the physician must give a definite pre scription for the diet, as to both quality and quantity, from day to day. The patients themselves will learn how they should live dur ing the subsequent courses. The educational side of such a course of treatment in an institution and under the direct supervision of the physician is not sufficiently appreciated. It is as beneficial to the diabetic—nndatis to the sufferer from gastric troubles, pulmonary phthisis, neurasthenia, etc.

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