Glycosuria, in a strict sense, is only a symptom, and, as a rule, when we use the term, we mean only the transient elimination of sugar in the urine, the result of excessive ingestion of sugar or other carbohydrates. In such cases, the liver must be considered a glycogen storer, but crippled in this function, or overloaded. In some cases where this transient glycosuria appears frequently, we often find that the liver is cirrhotic. This condition may also involve the head of the pancreas, but, of course, then the glycosuria is apt to be persistent, and then we have, as a rule, a mild form of diabetes. In the treatment of these cases, the liver must receive special attention rather than the diabetes.

In true diabetes, the diet is, after all, the most important part of our therapy, and will always remain so unless a specific remedy is discovered to restore the disturbed equilibrium of the internal secretions and metabolism. In the dietetic management of diabetes, we must remember that sufficient food must be given to supply energy, not only for the tissue needs, but also for the waste in the urine. Every gram of sugar excreted means 4.1 calories, and each gram of oxybutyric acid a loss of 4.4 calories, so that a patient eliminating 150 grams of sugar and 20 grams of oxybutyric acid is losing over 700 calories. There are, in addition, other sources of loss, such as the heating of the large quantities of urine excreted. In view of all this loss of energy, it is well to conserve energy as much as possible, by protecting from undue exposure to cold. The severe cases should be warned against against too much exercise, and the very weak patients should be kept in bed so as to diminish metabolism as much as possible.

The object of treatment is to increase the tolerance for carbohydrates and thus lessen the waste in the urine. Before

prescribing a diet, the tolerance should be carefully determined, and also at frequent intervals during treatment. This must be done carefully so that, from time to time, we may know exactly how much carbohydrate is utilized and, by comparison, know if there is any progress. If the patient eliminates more sugar than ingested, then we know that some sugar is produced from the complex proteid molecule and we have a severe form with which to deal. At the same time the tolerance is determined, we should also estimate the degree of acidosis, When these factors have been determined. then one of two plans may be adopted. In the one, prescribe a regular allowance of carbohydrate and, at intervals, estimate the tolerance and vary the prescription accordingly, which I find works very well in patients with no acidosis and over 45 years of age; the other plan is to follow the regimen worked out by Von Noorden, consisting of frequent variation in diet by the introduction of vegetable, or fasting days, and oatmeal days. During the past two years, I have been using this plan in nearly all my cases with decidedly more satisfactory results. The green or vegetable diet, as outlined by Van Noorden, consists of broth or bouillon several times a day as desired, any of the green vegetables, such as spinach, lettuce, asparagus, cabbage, artichokes, string beans, cauliflower, etc., in form of salads, or boiled and prepared with an abundance of good butter. Of the proteids, only 3 to 5 eggs and 3 to 5 yolks and bacon are permitted. The object is to give, as nearly as possible, a carbohydrate free and low proteid diet, in order to free the tissues, as nearly as possible, from glycogen. The patient should keep in bed on this diet if weak, and, in any event, cautioned against exercise of any kind, and, in case acidosis is marked, the use of alcohol may be of value.

crease, then the green diet may be used. After one or two days on the green or vegetable diet, the oatmeal cure should follow. On the basis that carbohydrate is the best thing to stimulate toleration for the same, a liberal quantity of oatmeal is given. I usually give from 200 to 250 grams of oatmeal a day, equalling 800 to 1000 calories. The oatmeal is prepared in the form of strained gruel or porridge, with an abundance of butter. In addition to the oatmeal and butter, 3 to 5 eggs may

Von Noorden gives the following precautions in the use of the oatmeal cure:

1. No other form of starch should be given with the oatmeal, otherwise, without exception, the result is unsatisfactory, the glycosuria often showing enormous increase.

2. No meat should be permitted on the oatmeal days. If proteid is given, it should be in the form of vegetable albumin or eggs, and, in some cases, eggs seem to 8. Zuckerkrank, 1910. Von Noorden, p. 316.

9

inhibit the favorable action of the oatmeal. Bluin of Strassburg, has recently reported a series of cases where he has used wheat starch instead of oatmeal with similar results. He used the same variations as outlined by Von Noorden.

In the moderate cases of diabetes, the tolerance is decidedly increased by this regimen in a comparatively short time, and, even in the severe cases, satisfactory improvement is often made, but, of course, the treatment must be carried on for some months, as a rule. My experience convinces me that this method of managing the diet gives the most satisfactory results in the shortest time. In the cases of marked acidosis, extreme care must be used in withdrawing the carbohydrate too suddenly as this greatly increases the danger of fatal coma. We are also apt to be misled if we depend too much on the amount of sugar in the urine as quite frequently this drops suddenly, just before coma develops. If symptoms of coma are present, it is advisable to give carbohydrates freely, preferably oatmeal gruel, or levulose in form of lemonade. Balint10 recommends sugar solution by enema in the treatment of extreme acidosis. Bicarbonate of soda or sodium

9. Munch. Med. Woch., July 4, 1911. 10. Berlin Klinisch, Woch., No. 34, 1911.

citrate

should be given in liberal doses three or four times a day in such cases.

Next to the control of the carbohydrate, comes the judicious use of albumins. This is especially important where, on a carbohydrate free diet or fasting day, there is still considerable sugar in the urine. I have already called attention to the exclusion of meat from the oatmeal days, and, in the severe cases, it is well to remember that all forms of albumins are not equally well tolerated. Von Noorden has found that casein and meat from cattle and fowl are least tolerated, next fish albumin, then egg, and, best of all, vegetable albumins. Of course, the average case of diabetes tolerates a liberal allowance of all forms of proteids, but, in the severe cases, the quantity should be limited, and the more easily tolerated forms should be chosen.

With reference to the fats, little need be said, as they are well tolerated, as a rule. It is probable that acetone is derived from the fatty acids, hence, with increasing acetonuria, the amount of fat should be reduced. It is also well to examine the stools for excess of free fat and fatty acids, and, of course, if large amounts of free fat are found, then the fat allowance should be decreased.

DOCTOR WILLIAMS:* During the course of this afternoon's work on the consideration of carbohydrates in the digestion of infancy, and the question of diet in diabetes and glycosuria, there seems to be a distinct relationship, and I think many of the same things can be said of one as of the other. For instance, I think that anyone who has carefully observed the causes of carbohydrate intoxication in infancy, and cases of diabetes, will agree that there are questions of relationship. I think too many of our patients have been too extremely treated; that the term "carbohydrate" and the term "pro*Address and initials not obtained. [Editor).

teid" does not mean that all proteids and carbohydrates are equivalent as far as their digestibility and use in the body are concerned. I certainly think that the oatmeal is, and that the proper use of carbohydrates in the feeding of diabetes, is of great importance in keeping up the body weight which is a matter of the utmost importance in diabetes.

A VOICE: I have had some practical experience with a very serious question, that has been productive of good results, particularly so far as acidosis is concerned. In regard to the oatmeal therapy, where there is a condition of acidity, I would suggest the addition of wine or

alcohol in some form with the oatmeai diet. The presence of wine, whiskey or alcohol, in some form, makes the food much more palatable; and, in addition to this consideration, the alcohol itself has a different value-it serves as a food. In one case which I have at the present time, I give from a half pint to a pint of Rhein wine. obtain three hundred calories per day from this wine; and the wine serves the purpose of somewhat lessening the production of the acetone bodies.

I

DOCTOR MERRILL: I would like to ask what the prognosis is in a case that constantly excretes sugar from a period of six or eight months.

MARY WILLIAMS, Bay City: I have been very much interested in this disease; and several cases that I have known, I think have been caused by an over-taxation of the nervous system. Probably the nerves were so attacked that it produced a disturbance of metabolism and a disturbance of the pancreatic glands; and then too, in regard to the matter of diet, I have for several years prescribed it myself, and have known of several physicians that have been using the mixed diet. Of course, we used to use an exclusive diet, and I have known some, physicians that have used a mixed diet and have not put them on the meat diet at any time, but gave just a little meat each day in order to get a mixed diet, and it has been a very successful treatment.

J. E. DAVIS, Detroit: I want to express my appreciation of this excellent paper. I think it sums up the very best treatment for this trouble. The most important clinical point to be taken in mind is to treat the patient, regarding the general condition rather than the amount of sugar that is being excreted, or the amount of acetone. Von Noorden has shown that some patients are doing very badly when the excretion of sugar is very low. This point has already been brought out in the paper. The whole question, it seems to me, is one of keeping up the nutrition of the patient for a sufficient length of time until the carbohydrate metabolic process can be properly raised. we are going to have a recovery, it will come after they are properly raised; and the playing from one diet to another, as is the plan on the table here before us, enables the patient to keep up the highest state of nutrition, and that accomplishes the purpose that we are after, keeping the patient going as long as possible, so that the greatest of rest can be secured.

If

M. A. MORTENSON, closing: I feel that I have not given you anything new this afternoon; but from my experience with this class of cases, I find that a great many of them have been treated with attempts at using something along this line, but that the physician has failed to observe the important points, and, of course, has failed to get the results. Now, I was asked with reference to the preparation of the oatmeal. This is very important. It is not, as a rule, siniply what you speak of, as oatmeal mush, that is given to the patient; but the oatmeal is thoroughly boiled and strained, and you get then practically all the carbohydrate from the oatmeal, and in a very smooth, bland condition. With this oatmeal, then, almost an equal amount of good butter is mixed, and it makes a very palatable dish, and it can be given to the patient every two or three hours during the days that they are on this diet.

With respect to the fatty acid in relation to the acetone, an important point is brought out in the use of butter. First, it is practically agreed that the acetone comes from the fatty acids, and especially, the lower acids. VonNoorden states and writes that whenever butter is used, that is made from sour cream, or if the butter has been kept for some time, then we should look out that it does not contain a large amount of butyric acid; and, if it does, this can be removed by washing the butter in cold water, because the acid is soluble. With respect to alcohol, I think it is very important in a case of marked acidosis, and also where the ability to digest fat seems to be limited. The caloric value of alcohol is estimated at about seven

calories per gram. I did not get Doctor Merrill's question in the first part of the discussion?

DOCTOR MERRILL: I wish to get your idea as to the prognosis where a case has persistently excreted sugar for six or eight months?

M. A. MORTENSON: That is a difficult question to answer, definitely, because there are so many things that must be taken into consideration, aside from the simple elimination of sugar. I now have a patient under my care who has eliminated sugar, and who has had acetone and diacetic acid in the urine for five or six years. That patient has twice been under Von Noorden's care; and when he went there he was almost in a state of coma, and he is getting better. At varying intervals, he goes on a strict diet for a short time using the green diet followed by a few days on the oatmeal diet, and that keeps

man,

him at a level where he is comfortable; and each year that goes by he is geting better. This is about thirty-five years of age; and I have told him that every year that goes by his prospects for a reasonable degree of health improve. Now, in regard to young children, that is, individuals under twenty years of age, who have excreted sugar in a large quantity from six to eight months, with marked acidosis, I would say the prognosis is probably very bad; but Von Noorden emphasizes the fact that we must not be discouraged. It requires persistence and patience to deal with these cases; but by a proper manipulation of the diet, it is surprising the results that are obtained.

With reference to the question of the nervous system in relation to diabetes, that is, of course, a matter that has been before us for a long time. But there is no question that some severe nervous shock may bring on diabetes. Now, I do not think that the nervous shock in itself is the cause, but, rather it is the medium of bringing out a condition almost ready to appear. I remember one case where a little boy about seven or eight

years of age had been under treatment for diabetes, and we had been successful in eliminating the sugar, but there was still an acidosis, and thinking there might be lipemia, a blood test was taken, that is, the child was bled, and that shock or that operation on the child brought back the sugar in increased quantities, and it took weeks to overcome that exacerbation. Now it is probable that the recurrence of the sugar was brought on by the effect of the shock on the nervous system of the child.

DOCTOR WILLIAMS: Now, in the treatment of diabetes, would you restrict the amount of liquids taken; water?

DOCTOR M. A. MORTENSON: My rule in that respect is, simply let the patients drink as often as they want to, but tell them to drink small quantities at a time, because the small quantity of water will quench the thirst just as well as drinking a large quantity, and as a rule, they get along very well with that restriction. I pay very little attention to the amount of water that a patient drinks.

A summary of the recent legislation in regard to the reporting of occupational diseases is published by J. B. Andrews, Journal A. M. A., December 16). In 1911 for the first time in America, six states-California, Connecticut, Illinois, Michigan, New York and Wisconsinenacted laws requiring physicians to report cases of occupational disease. These laws have much in common, and the diseases usually specified are anthrax, caisson disease, lead, phosphorus, arsenic and mercury poisoning. In Wisconsin, anthrax is omitted, and in Illinois the law is not quite clear in every respect, but seems to cover the usual disorders. In most cases the notification is to include the name, address, place of employment and disease of the patient. Michigan requires, in addition, the length of time of such employment, and in New York such other information as may be required by the Commissioner of Labor. In every state but Connecticut there is a penalty for failure to report, but only in California and Connecticut is a compensation given for reporting.

This pioneer legislation is the result of an attempt to excite interest among medical men, and for this purpose a tentative bill based on twelve years of English experience was introduced into eight state legislatures. In Minnesota action was postponed after it had been passed in one house, and in Pennsylvania it was vetoed on account of an amendment considered to be unconstitutional. Extracts are

also given from a leaflet distributed not only to legislators, but to others interested, pointing out the improvements that have been made by legislation on this subject in Great Britain and elsewhere. The state officials are encouraged to add as many facts as possible on the subjects, by special blanks sent out for the purpose or by special investigations. The educational work, it is understood, is only begun by the enacting of these laws, and already in several states much valuable information has been obtained and boards of health and physicians are taking up the study of the subject.