90 DIABETES MELLITUS 



four hours in order that his urine may become free from sugar. Just so, 

 it is occasionally necessary to give for a few days so little food that some 

 of the patient's body substance is utilized. At the beginning of strict dietetic 

 cures, it is often very difficult to overcome this consumption of tissue in dia- 

 betics who have previously lived upon a mixed diet and have excreted much 

 sugar. 



Let me again illustrate. Imagine, for example, a man weighing 65 kilograms, who, 

 on a mixed diet, has been excreting 600 grams of sugar daily. He is put upon a diet 

 not absolutely free from carbohydrates. According to Rubner, a man requires for his 

 maintenance about 35 calories per kilogram, so that this man ought to have sufiScient 

 food to produce 35 X 65, or, in round numbers, 2,300 calories daily. 



80 grams wheat bread contain 50 grams starch = 200 calories. 



500 " boiled or fried meat, medium fat ( 5 per cent. ) = 750 " 



200 " cream (30 per cent, fat) =600 " 



200 " milk =120 " 



100 " fat, in butter, cheese, fat sausage, bacon, etc. = 900 " 



2,570 calories. 



Besides this we will add about 300 to 400 grams of green vegetables, whose calory 

 value, like that of the albumin partaken of in fat foods ( bacon, cheese, fat sausage, etc. ) , 

 may be disregarded. 



According to this our patient would be plentifully fed, if he were free from sugar, 

 for a diabetic who excretes no sugar does not emaciate, and consequently does not need 

 any more food than a healthy person. Unfortunately, our patient continues on this diet 

 to excrete his full 100 grams of sugar per day. The calory value of these 100 grams 

 (400 calories) must be subtracted from the total calory value of the food he is ingesting; 

 2,570 calories — 400 calories = 2,170 calories, which is 130 calories less than the patient 

 requires, according to Rubner. 



In some cases, under favorable circumstances, it is possible to supply these 

 missing 130 calories by the further addition of fat, but by no means always; 

 at least, under ordinary circumstances, it is often quite difficult to make the 

 patient take the 500 grams of meat, 200 grams of cream and 100 grams of 

 fat mentioned in the dietary above; and we must always avoid throwing too 

 great a burden upon the metabolism of the diabetic. In short, as a choice of 

 evils, we must often allow our patient to remain imderfed and lose weight, 

 until his excretion of sugar decreases appreciably. Only when the glycosuria 

 becomes so slight that the net calory value of the ingested food approaches the 

 gross calory value, can we expect to avoid the evil of under-nutrition. We 

 must risk under-nutrition quite often, in severe cases, e. g., when, in order to 

 abolish the glycosuria, we forbid all bread, and reduce the albuminous (meat) 

 food considerably. 



I know of no successful treatment of severe cases without temporary under- 

 nutrition, but the physician must he very careful during these periods. We 

 should be especially cautious in regard to long-continued hyponutrition, such 

 as entails a loss of weight of more than two kilograms in subjects who have 

 already reached the minimum weight of 130 pounds in men and 110 pounds 

 in women, for this loss is difficult to regain. 



In the consideration of the theory of treatment in diabetes, some mention 

 of diabetic acidosis will not be out of place. By this term I mean the forma- 



