PRACTICAL THERAPY 95 



The following is another typical example of this group : 



A bookbinder, seventeen years old. No family history of diabetes. For five weeks, 

 without apparent cause, he was continually hungry, he lost weight, was extremely weak, 

 and had a non-gonorrheal urethritis. Organs sound; knee-jerk normal; weight 45 kilo- 

 grams. On a diet of 220 to 300 grams of meat, green vegetables, 250 grams of milk and 

 300 grams of bread, there was a glycosuria of 6 per cent. = 150 to 200 grams of sugar 

 a day. Only upon complete withdrawal of bread while still taking 25 grams of milk, 

 did he become free from sugar. After a sugar-free period of one month, he could take 

 more milk and a small quantity of bread without excreting sugar. He gradually became 

 accustomed to a larger allowance of bread and milk, being careful never to take enough 

 to produce glycosuria. This tolerance gradually increased imtil he could ingest 170 

 grams of bread and 100 grams of milk without sugar appearing in the urine. 



The patient remained in this condition, outside the hospital, for two years. After 

 this (probably because he did not adhere to the same diet) sugar was again excreted, 

 and did not disappear on very strict diet — so that the case became severe. 



The object in quoting these examples is to show clearly the existence of 

 a moderately severe form of the disease. At the outset, eases like those just 

 quoted may readily be looked upon as extreme, and thus great harm may 

 result. Among the points on which the recognition of medium severe cases 

 rests the most important is this, that after partial withdrawal of carbohydrates 

 (for example, 200 grams of milk and 50 grams of bread), no matter how 

 marked the glycosuria has previously been, it immediately and decidedly 

 decreases, usually falling below 100 grams. Besides, in these cases of medium 

 severity, the amount of acidosis as determined by the ferric-chlorid and ace- 

 tone reaction is slight, and the amount of urine is not great (4 and, at most, 

 5 liters per day). All these conditions may also exist in severe cases. 



After determining to which group a given case belongs, the physician must 

 outline the method of treatment as follows : 



1. Mild eases are to be made aglycosuric, and maintained in this condition 

 until continuous observation for at least six months has demonstrated that 

 the disease shows no tendency to progress. Later, a permanent increase of 

 glycosuria above 0.5 per cent, should not be permitted. Such a transitory 

 increase need cause no anxiety, but as soon as it becomes greater the case is 

 to be treated as at first by strict limitation of the diet. 



2. Cases of the medium severe form are to be made aglycosuric by strict 

 treatment if this is necessary. Then, in case they do not prove to be mild 

 cases, they are to be permanently maintained in this condition. Even a mild 

 glycosuria is not to be permitted, and anything causing a transitory increase 

 of glycosuria is to be absolutely avoided, as it threatens the already greatly 

 endangered tolerance. It is possible that there are individual cases which 

 at the onset belong to the medium severe group, but which may be rendered 

 mild, and then the indulgences possible for cases of the mild forms may be 

 permitted ; but such cases are certainly not frequent. 



3. The nature of the severe and very severe cases becomes manifest when 

 on the first attempt to produce aglyeosuria the feebleness of their tolerance 

 appears. In these cases, our primary object is to bring the patient to the 

 point at which life can be maintained without a deficit; but this can rarely 

 be brought about, unless we can limit, and that decidedly, the loss of sugar in 



