2108 DIABETES MELLITUS-WALLACE OuR A. M. A.
DEC. 17, 1910
A relationship between the function of the pancreas out in accordance with most approved modern methods
and other glands furnishing an internal secretion, espe- has been reported by DuBois and Veeder.12 rThey
cially the adrenals, has recently been demonstrated, and show that the energy requirement in diabetes is approx-
Eppinger, Falta and Rudingers have assumed that the imately 34 calories pro kilogram of body weight per
secretions of the thyroid and adrenals are of mutual day, which is no greater than that in a healthy man.
aid in affecting metabolic processes, while each of these Diets are generally arranged quantitatively, therefore,
inhibits the pancreatic function and is in turn inhibited with the idea of supplying this amount of energy, due
by it. On the basis of this assumption, Bruck9 has allowance being made for the loss through non-utiliza-
suggested that the serum of an animal deprived of its tion of sugar. Over this point a controversy has arisen.
adrenals will have a beneficial effect in diabetes through Von Noordenl3 states explicitly that the food-supply of
lessening the adrenal action, which is excessive on a diabetic must at least be equal to that of a heaIthy
account of the removal or diminution of the pancreatic man of the same weight and under the same conditions.
secretion. Such a line of treatment seems absurd. If less is taken a loss in weight is sure to occur. On the
However interesting and important the knowledge of other hand, the opinion is often expressed that severe
the relationship between the various internal secretions cases of diabetes may show a lowered level of energy
may be, it offers at present no therapeutic application in requirement. Kolisch14 especially has stated that 23
diabetes. calories pro kilogram weight may lead to an actual
There has come a tendency in recent years to a less increase in ody weight, and that some cases as litte
frequent employment of druge in diabetes therapy. as 20 calories may be taken with no loss in weight. 11e
Alcohol is still used to a large extent in the von Noor- strongly advises the use of a tinimum quantity of fond,
den clinic and elsewhere, but von Noorden himself has
and claims that this offers the beet success in the treat-
pointed out that amounts larger than 50O c.c. a day are mnt of severe cases.
not to be used. Its food value is of no great importance nt o s cs.
when takenl in this quantity, and it is to be recom- practce t of course ot of the queston to
determine w·hat is the minimal energy requirement for
mended chiefly as an aid to digestion, especially of fat. determne what l the minimal eergy requirement for
It would seem here that it is as a rule unnecessary, and each case, and the work done in this direction serves
chiefly iu establishing a principle of treatmenut. The
while there mav be some disadvantage in withdrawing chiefly in establling a principle of treatment. The
whil thre av e sme isaivatag luwitdraingconclusions which may he safely drawn are that higb
it from those who are accustomed to its use, it must be onclusons hich ay be afely dran are that high
remembered that diabetics seem especially susceptible feeding is injurious, that in some cases of severe dia-
to its injurious effects on the various organs of the body. betes the minimal amount of food which will maintain
It has been shown too that in some cases, at least, the body weight brings about the best results, and that
the tolerance for sugar is distinctly lessened by a too an amount equal to that required for a healthy man is
free une of alcohol. Neubauer'5 has reentfly recom- generally to be recommended. Starvation days and pro-
mended alcohol as a means of warding off diabetic coma longed periods of low diet are not unattended with
and reports cases in which the administration of fairly danger and are to be prescribed only with due considera-
large doses, up to 135 c.c., has given good results. These tion of this.
doses are too large to be used for any length of time Auother subject of importance concerns the quality
wlith safety, and, in fact, some other obrvrs have class of food comprising the diet. In mild diabetes
failed to obtain any beneficial effects in this direction. certain general principles may be laid down for prac-
Considerable interest was aroused in this country by tically all cases. First, the limit of tolerance for sugar
I1udisch'sll paper on the use of atropin in diabetes. is deterined. This is done most easily by gradually
Rudisch finds that atropin, when given in fairly large increasing the daily amount of bread in the test15 diet
amounts and in conjunction with dietetic treatment, is of until glycosuria reappears. The patient is then placed
great aid in lessening or preventing glycosuria. In the on a carbohydrate-free diet for at least two weeks. Dur-
hands of others, however, it has not been so beneficial, ing this time the sugar tolerance will gradually increase
and in a series of experiments I have carried out on and the hyperglycemia, which very frequently persists
depancreatizued dogs it produced no effect whatever. for some time after the urine is free of sugar, disap-
Thus it may be seen that little has been aecomplished pears. It is very rarely that acidosis of any dangerous
toward an etiologic or specific therapy and to find any degree occurs duriug this period. A mixed diet is now
actual progress we must turn to dietetic treatment. given and the new degree of sugar tolerance determined
There may be first considered here the question of the as before. In many cases it will be found that thc
energy requirement in diabetes. With the great appe- tolerance approaches the normal; in others it mav show
tite and marked loss in weight and strength so fre- only a slight increase, if any. In all cases, however,
quently seen in severe cases it is hardly surprisiing that the subsequent diet should be such that the urinc
the taking of large quantities of food should have remains sugar-free and there should conme at least once
seemed a necessity. And in spite of the teaching of il fhree months a period of carbohydrate-free diet last-
those having the largest experience, the idea is still ing one or two weeks. This treatment may seem quite
somewhat prevalent that diabetics have a miuch greater unnecessary to a patient whose tolerance for sugar has
energy requirement and accordingly need a much greater become well-marked, but it should always be enforced.
supply of food than normal persons. The following out severe cases qualitative arrangement of l
of this idea has undoubtedly led to considerable injury. diet is of greater importance. It has long been recoo-
The experiments of several investigators have shown that 12. DuBois, E. F., and Veeder, B. S.: The Total Energy Re-
an increased energy requirement does not exist in diabet- qUirement in Diabetes Mellitus, Arch. Int. Md., 1910, v 37.
13. Von Noorden: Handbuch d. Path. d. Stoffwechs., 1907, il, 46.
ics. Quite recently a series of experiments carried 14. Iolisch: Ztschr. f. phys. u. diltet. Thertip., 1908, xii.
1 E. I employ the standard test diet used in the von Noorden
8. Eppinger, Falta and REdinger: Ztschr. f. kiln. Med., 1908, clhnie for the determination of the severity of the case. This diet
lxvi, 1. contains 75 grams of white bread. The detailed diet and the method
9. Bruck: Med. Klia., 1908, 1760. of classifying diabetes Into mild and severe forms are described by
15. Neubauer: Miinchen. med. Wchnschr. 1906, lvIii, 791. von Noorden in Clinical Treatises on the Pathology and Therapy
11. Rudisch, J.: The Treatment of Diabetes Mellitus, THE Joua- of Disorders of Metabolism and Nutrition, E. B. Treat & Co., N. ¥.,
NaL A. M. A., Oct. 29, 1909, p. 1366. 1901, part 7, p. 175.