THE VARIOUS DEGREES OF GLYCOSURIA AND THEIR OSCILLATIONS.
The question that has always to be determined in judging of a given case is : To what extent is the individual able to consume carbo hydrates in his body? We have seen that the healthy man is fully prepared to deal with very large quantities of carbohydrates by (1) burning a part at once, thereby meeting the requirements of heat production and labor, (2) storing up a second portion in the form of glycogen, (3) slowly converting another portion into fat, and (4) ex creting a fourth, very small, part in the urine, in cases in which carbohydrates have been ingested in unduly large amounts and at short intervals. Now in a diabetic the first three of these modes of sugar disposal are in some way interfered with, and the extent of the fourth serves as a measure of the degree of this interference. The more of a given quantity of sugar, introduced into the organism for purposes of estimation, that appears again in the urine, the more pronounced will the interference with the consumption of sugar be regarded. Naturally, in order to find the degree in which the sugar excretion occurs, we must have a standard measure which we can use as a basis for our calculations.
A procedure which was suggested independently of each other by I. Seegen and M. Traube, and which has been found to answer the purpose admirably in practice, is the following : The condition of the urine, when the patient is on a diet absolutely free from carbo hydrates, is first ascertained. According as it is then free from sugar or not, a distinction is made between mild and severe cases. I prefer to use the term mild and severe glycosuria.
a. Mild Glycosuria. is characterized by the fact that the urine becomes sugar-free within a few days after all carbohydrates have been withdrawn from the diet, and only when the carbohydrates are again ingested does sugar reappear in the urine. Let us under stand clearly the conditions present. Even when carbohydrates are withdrawn from the diet the organism is by no means sugar-free.
Sugar is continually formed from the albumin and, as I believe, under certain circumstances from fat as well. But all these carbohydrates, set free in the body during regressive metamorphosis of highly con stituted molecules, are formed very slowly, and a sudden flooding of the organism with carbohydrates can never occur in this way. If the diabetic's power of consuming carbohydrates is only moderately restricted, the organism is well able to dispose of these slowly formed quanta of grape sugar and excretes none in the urine.
These "mild cases" present every form of gradation. Some pa tients are free from glycosuria only when the food contains absolutely no sugar; others again may take carbohydrates in small quantities, perhaps 40 to 60 grams in divided doses throughout the day, with out becoming glycosuric, but if they should take this amount at one dose, they would immediately pass a portion of it in the urine. The mechanism of this is easily understood : the organs are capable of attending to the carbohydrates passing into the circulation slowly a little at a time, but are unable to cope with them when suddenly in troduced in quantity. In other patients we can give with safety still larger amounts, 100 to 150 grains of carbohydrates being easily disposed of, sugar appearing in the urine only when this limit is exceeded.
In order to obtain comparable values I always start with the same fixed diet—a standard diet. Before the patient is finally put upon it I prescribe a gradual reduction of carbohydrates, not shut ting them off suddenly and entirely. My standard diet, in which in the case of the poor I substitute other cheaper articles but of the same nutritive values, is the following: Breakfast: 5 gm. of tea steeped in 200 c.c. of water; 150 gin, of ham; one egg.
Lunch: 200 gm. cold roast beef; 60 gm. fresh cucumber with 5 vinegar, 10 gm. olive oil, and salt and pepper to taste; 20 c.c. brandy with 400 c.c. Apollinaris water; 60 c.c. coffee without milk or sugar.