Dinner: 200 c.c. clear bouillon; 250 gm. beef (weighed raw) basted with 10 gm. butter; 80 gm. green salad, with 10 gm. vinegar and 20 gin. olive oil, or 3 tablespoonfuls of some well-cooked green vegetable; 3 sardines iL l'huile; 20 c.c. cognac with 400 c.c. Apolli naris water.
Supper : 2 eggs (raw or cooked) ; 400 c.c. seltzer water.
This standard diet is free from carbohydrates; it contains very nearly 200 gm. albumin (with 32 gm. nitrogen) and about 135 gm. fat. As soon as the urine has been free from sugar for two or three days nuclei. this diet, gradually increasing amounts of starch up to 20, 50 and 100 gm. are added. I sometimes give for this purpose white bread, containing 55 per cent. of starch, and sometimes Albert biscuit which contains 75 per cent. of starch. As soon as, under these increasing additions of starch, sugar reappears in the urine, we get the formula : Tolerance = standard diet + x gm. starch.
In patients with mild glycosuria a careful observer can convince himself most positively that the diabetic disturbance is not con stantly the same in a given case, but that it oscillates in a remarka ble and wholly unaccountable manner, and indeed—a fact which I wish especially to emphasize—independently of any therapeutic in terference. As an example of this I recall the case of a corpulent patient with diabetes whom I had under observation for a number of years; at first he could take 5 gm. of starch daily without excreting sugar in the urine; a few months later the tolerance had risen to 80 gin., then fell back to 20 gm., and afterward rose again to 100 and even 150 gm. of starch. Frequently the oscillations are even much more marked. There are patients who for a long time can bear al most no carbohydrates; then the glycosuria entirely subsides, some times gradually, at other times tolerably quickly, and the individuals may go to the family table and eat the ordinary diet there offered without showing a trace of sugar in the urine; and then at a later period, months or years afterward, the glycosuria reappears. Ob servations of this kind are especially frequent in corpulent or gouty persons.
In cases of this kind it often seems as though the therapeutic measures instituted, for example, a course of the waters at Kissingen, Carlsbad or Neuenahr, had had a very positively favorable influence. In other instances a much less marked interference with the patient's mode of living appears to effect a change for the better; such may be increased muscular exercise, the disuse of alcohol or tobacco, insistance upon a regular action of the bowels, and the like. We
shall speak of this again in the section on the Treatment of Diabetes, and only refer to it here as a warning against an overestimation of the value of such measures. It is indeed often very difficult for the physician, who has a modest appreciation of his own powers and of his success in therapeutics, to decide, in this disease, whether he. is in the presence of a spontaneous improvement or of one brought about by medical art.
b. Severe Glycosuria.—This is characterized by the fact that the excretion of sugar continues in spite of the total withholding for days of carbohydrates from the diet. It signifies that even the car bohydrates gradually and slowly formed from the albumin, and ad mitted a little at a time into the circulation, are not wholly consumed. The functions of glycogen storage, of the splitting up of the sugar molecule in the tissues and of its compression into fat must be very seriously affected.
Here also there are many degrees of gravity, the tolerance of car bohydrates varying greatly in different cases. Some diabetics, for example, with a daily ingestion of 1,000 gin. of meat will still con tinue to excrete sugar, but if the amount is reduced to 500 gm. the glycosuria ceases. What is the significance of this phenomenon? In 1,000 gm. of flesh-meat there are about 212 gm. of albumin, in 500 gm. about 100 gm. of albumin. Now it is known that the decompo sition of albumin in man keeps pace nearly with its ingestion; and this holds true in the main even iu diabetics. Therefore, after the ingestion of 1,000 gm. very nearly, although not exactly, a double quantity of albumin is decomposed in the body, and therefore also approximately double the amount of carbohydrate is formed by the division of the albumin molecule. In our supposed case the quantity of sugar formed from 500 gin. of meat was disposed of in the body, but that formed from 1,000 gm. of meat could not be entirely con sumed. In the severest, but very rare, cases, the urine does not be come sugar-free even when the decomposition of albumin is reduced to its lowest possible figure, that is, during an absolute fast.