The prognosis is almost without exception unfavorable if the diag nosis of a true diabetes is certain. As already stated transitory glyco sitrias occur especially among children and these completely recover. R. Schmitz and Cr. Klemperer have mentioned such cases and I have seen several. Such diabetic glycosurias dependent upon transitory disorders of the pancreas inns! entirely disappear within a few weeks, if the seri ousness of the prognosis is to be disregarded. There are also patients through whose entire life from early childhood to advanced age, a definite intolerance exists to large quantities of carbohydrates which is not pro gressive in character. These are benign cases.
I know a family, the father of whom showed from his sixth year glycosuria as soon as the quantity of carbohydrates exceeded 200 grams. This idiosyncrasy has continued without change up to the present time. In the daughter, glycosuria has never been detected. One of two sons had even in his fourth year the same idiosyncrasy as his father and continues to manifest it. although now over thirty years of age. Father and son, with this exception, are perfectly healthy. The process has possibly been influenced by the fact that in both since the day of discovery of this condition, there has been a rigid reduction in carbohydrates.
With few exceptions the statement is true that true diabetes in childhood knows no cure, no matter how mild it may appear in the beginning nor how gradual its development in the first months or even has no effect in preventing this sad result but may influence the duration of the disease. This has usually been given in the writings of others as one to one and a half years. The aver age duration of my cases, which were detected after their development into a severe type, was not much higher; one and a half to two years. Patients who came under observation in the stage of mild glycosuria lived three to six years. Only those are considered in whom the disease developed before the seventh year of life.
In spite of the hopeless prognosis, it is our duty to prolong life as much as possible. The treatment will vary with the stage of the disease.
As soon as the tolerance for carbohydrates has been reduced to noth ing, or has gone beyond that, strict dietary rules need no longer be considered. Their value no longer equals the distress which the com plete prohibition of the carbohydrates or the limitation of the proteid diet gives to the child. Carbohydrates, with the exception of sugar, are permitted and it is a matter of indifference whether emphasis is placed upon milk or upon cereals. Experience however teach that the carbohydrates of oatmeal are by far best assimilated in the diabetes of children. It has been possible for me several times to reproduce for a time a marked tolerance for carbohydrates by an oatmeal cure. Lang stein also noted favorable results from its use in children. In the oat meal cure children receive nothing except a gruel made of 150 grams (5 oz.) of oatmeal, 1:50-200 grams (5 to 61 oz.) of butter, 60-70 grams
(2-2:1 oz.) of Roborat or 1-5 eggs as a daily allowance arid in addition some wine. This diet is continued 1-2 weeks and then gradually replaced by other food. The result is often marvellous in increasing the toler ance, which unfortunately does not continue. Alkalies are the only drugs to be considered unless there are distinct indications for other medication; 10-15 grams of bicarbonate of soda are adminis tered daily to neutralize the acid products of metabolism and to prevent acid intoxication. When there is a marked tolerance for carbohydrates at least to the extent of about 40-50 grains (11-2 oz.) with a diet other wise strictly free from carbohydrates (meats, eggs, green vegetables, fats), this favorable condition with complete physical and mental vigor of the child may be prolonged for a. considerable period. To accomplish this. au exact knowledge of the limits of tolerance is necessary. The quantity of the carbohydrates allowed must then be kept within these limits and this should be alternated from time to time for several days with a strict carbohydrate-free diet. It is unfortunately impossible to arrange distinct schemata for such a diet since the excessive capricious ness of the taste in childhood makes each patient an object of special study. Schematic regulations are from their nature worthless. • It is a difficult matter for the child and still more for the relatives who are responsible to continuously administer carbohydrates and pro teids below the limit which produces glycosuria and at the same time to satisfy the demands of the infantile digestion and the taste of the child. But it must be done if the child is to be brought through. This attempt has so rarely been scrupulously made, that little can be said of the gen eral results of such treatment. It would be of great importance in many cases to carry through the dietetic treatment of the child in a sanitarium. with the mother or another member of the family. It might then be feasible to restrain as long as possible the advances of the morbid pro cesses and thereby to give opportunity to the organism to overcome the disease in case it is not of a hopelessly malignant nature.
It is naturally senseless to recommend for diabetic children the cure at Carlsbad, Neuenahr or Vichy. Of drugs, none can be recom mended. Many home remedies are praised for diabetes in infants as well as for that disease in adults but such praise is almost. criminal. Alkalies should not be administered before the condition of the urine (acetone, acetic acid and oxybutyric acid) indicates the proximity of an acid intoxication. It is not wise to begin earlier as children do not bear alkalies well for a long time and frequently digestive disturbances result from their use.
When diabetic coma occurs the attempt can be made to overcome it by intravenous infusions of a 3 per cent. solution of soda. It has been possible in some cases to get a good result, the fatal termination how ever is only postponed.