102 DIABETES MELLITUS 



DISTURBANCES AND DANGERS OCCURRING IN THE DIETETIC 

 TREATMENT OF DIABETES 



That disturbances of digestion often occur during dietetic treatment has 

 been known ever since the disease has been treated by a restriction of food. 

 The more violent disturbances, such as used to occur when our knowledge 

 was less, for instance, diarrhea, sometimes combined with vomiting, should 

 now be prevented entirely. They may be avoided in trustworthy patients if 

 the whole amount of food ingested is quantitatively determined, if too large 

 a portion of meat is not allowed, and if we bear in mind the sensitiveness of 

 the patient as regards fat and fatty foods. Some patients lose their appetite 

 from the beginning, or as soon as carbohydrate food, especially bread, is re- 

 stricted. This anorexia may be avoided by giving them fruits. If the patient 

 likes the fruits prepared for diabetics he is very fortunate; otherwise cooked 

 or uncooked fruits that contain but little sugar may be used. I am loath to 

 forbid fruits altogether, and even in the severe cases I usually allow as much 

 as 100 to 200 grams. Milk, also, is very valuable; ^ to 1 liter of milk a day 

 with a restricted fat-albumin diet often helps the patient over the period of 

 anorexia without increasing the glycosuria to any extent, and without mak- 

 ing the patient lose weight. With these precautions, we are not compelled to 

 break off the dietetic treatment as soon as it is begun, but may go on with it 

 cautiously as soon as the appetite has improved. 



Every disturbance of appetite, however, must be seriously considered, for, 

 on the whole, cases with anorexia are the most difficult to deal with. In some 

 of these cases, psychic depression plays a certain part, and if their disease is 

 not too pronounced, they often get along much better at Carlsbad or ISTeuenahr 

 than if they stay at home, or go to a hospital. 



In acidosis we have an especially formidable hindrance to strict dietetic 

 treatment. In many of the moderately severe cases it appears as soon as the 

 diet is restricted, or, if already present, it becomes more marked when the 

 carbohydrates are limited. Then the patient is at once in danger, because 

 acidosis may lead to coma. Formerly, this often happened when the diet was 

 restricted too ^suddenly, and even to-day cases with acidosis are always in 

 danger if severe gastric disturbances occur. In the absence of gastric irritabil- 

 ity this danger may be averted by the administration of sodium bicarbonate. 

 'Enough should be given to male the urine feebly alkaline, and 50 or more 

 grams in twenty-four hours may be necessary. With this precaution we may 

 endeavor to reduce glycosuria by strict diet even where decided acidosis already 

 exists. Of course all food and its calory value must be determined with quan- 

 titative exactness, for, to repeat, it is the disproportion between the quantity 

 of the products prepared in metabolism for oxidation and the power of oxida- 

 tion itself which finds its expression in acidosis. In cases with acidosis we 

 must not think of withdrawing carbohydrates entirely, but should allow 60 to 

 80 grams of bread, -| a liter of milk, and as much as 200 grams of fruit. The 

 latter is here particularly important in order to prevent indigestion. 



We may count with certainty on the fact that if the acetone reaction be- 

 comes marked at the onset, the cause is simply the urinary sodium, that is, the 



