GENUINE DIABETES MELLITUS 545 



the proteids and carbohydrates. Also this individual may, as Weintraud 

 has already shown, be maintained at body weight for a long time, on this 

 just adequate diet, indeed it seems as though through the chronic under- 

 feeding he may become established on a lower requirement for calories, as 

 we can observe also in chronically underfed nondiabetic individuals. In 

 still further advanced .stages of the disease, the adequate diet does not serve 

 any longer to maintain freedom from sugar in the urine; indeed in very severe 

 cases it is no longer possible to limit the glycosuria to a low figure, as now 

 on account of the strong formation of ketone bodies, carbohydrates must be 

 administered unconditionally. That in such cases the carbohydrates are 

 in a position to limit the formation of ketone bodies, at least to some degree, 

 indicates that a part of the carbohydrates goes over the glycogen stage, 

 although on account of the rapid re-combination this cannot be demon- 

 strated with certainty in respiration experiments. The most marked effects 

 are in such cases produced by the exclusive administration of carbohydrates, 

 especially of oat-meal (v. Noorden), perhaps because other simultaneous 

 administration of protein favors the re-combination of the formed glycogen. 

 In such cases, too, we then see the body weight rapidly increase, a phenom- 

 enon that is certainly not explained by the inhibition of water alone. In 

 the very highly advanced cases these carbohydrate treatments are, as is 

 known, also of no use. The severe diabetic loses weight and uses up 

 his protein constituent, because he can be maintained sugar-free and 

 ke tone-body-free only on an extremely just adequate diet; as soon, how- 

 ever, as the diet becqmes more abundant, the elimination of sugar and ketone 

 bodies is increased, by which the value of the diet is detracted from. That 

 the fattening of severe diabetics presents great difficulties is intelligible as it 

 is known that a fattening is only possible when abundant assimilation of 

 carbohydrates goes on at the same time. 



To me it seems that very much seems to speak for the fact that the 

 metabolic disturbance that is present in genuine diabetes mellitus is made 

 up of two different factors. The one factor consists of a disturbance in 

 anabolism. This disturbance in the building up of glycogen is usually first 

 to appear. The alimentary influence is here predominant. In the initial 

 stages a disturbance becomes manifest only on overstraining of the carbo- 

 hydrate assimilation. If we adopt the viewpoint that the disturbance of 

 glycogenesis affects both liver and muscle and that combustion of the carbo- 

 hydrates in the muscles is only possible after preceding assimilation, we may 

 in this sense speak also of a disturbance in sugar-combustion. On account 

 of the lessened formation of glycogen, there gradually develops a deficient 

 splitting up of protein and fat, and the formation of ketone bodies. 



The other factor consists in a disturbance of catabolism. This is most 

 evident, when in spite of the ruling out of alimentary influences sugar is 

 continually formed from albuminous and fatty substances and eliminated 



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