For the estimation of these severe forms of glycosuria the above described carbohydrate-free standard diet is also suitable; the more sugar that remains in the urine after the institution of this diet the more grave is the glycosuria. If such trials are repeated from time to time it will be found that, in these severe forms as well as in the milder ones, the sugar-destroying power varies in energy in individ ual cases. Cases will frequently be encountered in which sugar dis appears from the urine immediately upon the institution of the stan dard diet, which respond at once to any addition of carbohydrates although they bear very well an increase in the amount of albumin (transition forms; see below). These cases are more favorable than those in which sugar continues even with the standard diet, but are less favorable than those which can bear a slight addition of carbo hydrates to this standard diet.
c. Critical lien?arks ormceinimi the Diviioo 2oto Severe (rod 21111(1 1011118 n f authors believe that the difference be tween severe and mild forms of glycosuria is merely a quantitative one. I am also of this opinion, but there are those who hold the contrary. Among the most prominent of the latter may be mentioned I. Seegeu, who has endeavored in numerous writings to prove that these two forms constitute distinct diseases. The mild form is re ferred to disease of the liver, the severe form to a functional distur bance of all the cells of the body. In the mild form, says Seeger, only the nutritive sugar, but in severe forms that also which is pro duced in the liver from albumin (" liver sugar") is excreted in the urine. The first is only fat forming, the second is fuel for consump tion in the body.
The following may be said against this division and the theoreti cal grounds upon which it is made : 1. We know of no physiological fact upon the strength of which it may be assumed that the sugar ingested with the food finds auy application essentially different from that of the sugar formed within the body itself. But, on the contrary, we know of many facts which prove the opposite, especially the facts of the mutual interchange ability of nutrient material according to the laws of isoclynamia.
2. Between the mild and severe forms of glycosuria we meet with transitional forms. A glycosuria which is at first mild may often
become severe, although the reverse is rare. Neither pathologically nor etiologically, nor in respect to complications and final outcome, can any essential difference be justly maintained. On the contrary, experiment has shown that, after a lesion of the pancreas, at first a mild form of diabetes occurs, and later, as the panCreatic affection continues and passes into atrophy of the organ, the diabetes merges into the severe form (Sandmeyer ; this speaks in the strongest manner in favor of the unity of the cause and of the merely quantita tive difference in degree of the two forms. As regards prognosis there is, it is true, a difference. This is comparable to the difference existing between a very chronic pulmonary tuberculosis accompanied with marked new connective-tissue formation and an acute caseous pulmonary phthisis. Both are essentially the same disease, yet how different in course and prognosis ! 3. We must indeed admit the fact, adduced by Seegen, that the carbohydrates of the food are much more likely to cause glycosuria than those formed in the body from albuminates. It is very clearly seen in the transitional forms. Still it is not permissible to conclude from this that there is any qualitative difference in the uses to which the carbohydrates derived from these two sources are put. The difference remains always a quantitative one and can be explained in the following way : a. The rapidity with which the sugar introduced through the mouth enters the blood is much greater than that with which sugar is formed from the slowly absorbed and slowly decomposed albumin. The cells are able to take care of the sugar coming to them gradually, but not of that suddenly poured upon them.
b. The sugar derived from the food reaches the cells as a ready formed molecule (grape sugar) and approaches them from without; the sugar derived from albumin originates in the cells themselves and presents itself to their uses in the nascent state. It is easy to understand that the cells may be fully capable of disposing of the nascent molecule while unable to cope with one already formed.