ST. JOSEPH, MO., SEPTEMBER, 1907.

Contributed Articles

DIABETES MELLITUS.*

T. N. Bogart, M. D., Excelsior Springs, Mo.

Ex-Vice-President Missouri State Medical Association; Surgeon C., M. & St. P. and Wabash R. R. President, First Alumni Association Barnes Medical College, St. Louis, Mo., 1893.

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HIS subject has been so thoroughly thrashed over by the medical profession of the entire world, that it has become a joke among medical men for one of the profession to attempt to give his views on diabetes mellitus. But we all meet and have to treat the patients suffering with this disease, and our treatment and opinions are in keeping with text-book rule, along the line of advice and diet. The diet is always the same, and has been handed down to us from generation to generation for the last hundred years, with practically no change whatever, viz., leave starch and sugar alone. This idea has been given out so often and so long that the laity are now about as well prepared to treat the disease and carry out the analysis of the urine, as the practitioner. But I believe, in fact I know, it is one of the most easily managed and controlled of all the ma. lignant diseases; and am prepared to say that there are as many different phases in this ailment as you will find in the acute diseases; we all realize that acute ailments must be treated according to the symptoms manifested at different times during its progress; yet every text-book on the subject of diabetes mellitus has practically the same treatment from the inception of the disease until the termination. This is a form of treatment, and advice that, if you will pardon the expression, I shall call "machine made," for it only consists of a list of articles which you may, and may not eat; and this diet list is handed to the patient by every physi cian whom he consults.

The diagnosis of this disease is easy if the proper precaution is observed in making the examination; for nearly all diabetics will give a history of gradual onset; persistent presence of glucose in the urine, acetonuria, polyuria, dry skin, and if the case has progressed very long there will be stickiness of the lips and tongue, with intense thirst. One important symptom which always calls for an analysis of the urine is a rapid loss of weight for which there can be no cause assigned; if in such a case sugar is found to exist it is positive proof of diabetes mellitus.

Pathology. The true pathology, as regards the cause of the disease, is very uncertain, for so many different lesions have been found at the post-mortem table of diabetic patients, that various theories have been advanced as a result of these findings. In fact many of the findings are of

Read before the Clay County Medical Society, June, 1997.

such a character that we really do not know whether the pathological condition was caused by diabetes, or diabetes caused by the pathological condition. I am inclined to attach more significance to the pancreas and liver, also to heavy mental strain and worry, than anything else. Often the liver is engorged and is the seat of degenerative changes, and for this reason alone intestinal glycosuria is sure to show itself in the form of disturbed nutrition. As regards mental strain and worry, I certainly believe it to be one of the causes of diabetes; in fact four-fifths of my cases attribute their trouble to some continued mental strain on the nervous system, either mental worry or nerve shock; and as this disease is a disorder of nutrition, the liver, pancreas, and mental worry, are responsible for its existence. It seems reasonable that mental worry plays an important part in its production, for this nervous phenomenon is certainly enough to upset the functioning powers of these important organs whose disturbance is felt immediately, and a structural change soon takes place; and as we can find nothing but these pathological conditions on post-mortem examination, we say this is responsible, when it is only secondary.

The question is often asked the physician: What is diabetes mellitus? And they, as well as myself, cannot answer on account of its pathology and the idiopathic way in which it makes its appearance in different individuals; hence, I submit this definition: "Diabetes mellitus is a disease in which the capacity of the organism for burning up grape sugar is mor bidly depressed, and is caused by a deranged nervous system that has charge of the liver, which is the store-house for sugar, and thereby fails to give the proper orders for its normal output; hence it is thrown into the circulation, and has to be excreted by the kidneys; which in due time produces a kidney disease as a result of handling urine that is loaded with sugar.

I divide the disease into two classes: first, mild glycosuria, or cases which we can manage and relieve of the glycosuria by putting them on the ordinary treatment or dietary, where their toleration for white bread will reach as much as three ounces without creating a sugar output; second, severe glycosuria. It is necessary to make this separation (although it is not always easy) in order that we may be able to separate the curable, or those whose lives may be prolonged from the incurable; for in hopeless case a rigorous diet is useless. It serves only to make matters worse, and a marked restriction of carbohydrates should not be allowed; but instead, I allow them a wide latitude in diet and give them an abundance of fats, alcohol, and sugar free wines (old wines, see diet list). It is absolutely necessary to do this in order that their nutrition may be maintained (weight increased).

Here another problem comes up, viz., those cases which come under the head of severe glycosuria, yet by the proper medical and dietary treatment, they derive great benefit; these are the cases which we find impossible to rid of glucose, and they will carry from two to four per cent of sugar. all the time. Here our aim should be to arrive at what might be called a toleration, i.e., that amount of white bread or its equivalent that will maintain this amount of sugar, but not increase it; and if this amount should be increased, a rigid diet should be maintained for at least one to five days every month. In maintaining this diet, weight

should never be lost, but acetone should be reduced, and the urine should be analyzed daily for the appearance of acetic acid. If diacetic acid should appear, it is always considered a bad symptom, yet it is not always fatal, for many have diacetic acid and coma does not follow, yet every case which develops coma is preceded by the appearance of diacetic acid in the urine; and for this reason I always make and keep a careful daily record of the urinary output while they are in the sanitarium taking the cure; noting the per cent of sugar, total amount of sugar in grammes, amount of acetone passed, with the total estimation of urea. If this is done during the course of treatment you can often avert the dread coma, which carries off all diabetics if not properly treated, and especially if their death is caused by diabetes.

Diabetes is considered to be mild when the sugar disappears as result of the withdrawal of carbohydrates, and at the same time does not require the withdrawal of albuminous foods below the quantity usually partaken of by diabetics, and not reduce the nitrogenous output to any great extent.

Glycosuria is severe when it is entirely or only partially relieved by the withdrawal of carbohydrates, and marked reduction of albuminous substances; and as a result only 150 grains of nitrogen is excreted in the twenty-four hour specimen of urine.

I estimate the severity of the glycosuria before I begin to treat, or even advance an opinion on a case, and I do not consider a high per cent of glucose as being the index to go by. Many cases will show from three to eight per cent of sugar and not be in a serious condition. I arrive at this conclusion by a test diet, or a series of test diets; and at the same time preserve the precaution in regard to urinary findings, as outlined above; i.e., reduction of sugar, acetone and nitrogen, as result of the test diets given, without reducing weight and power of endurance.

The per cent of sugar, without the quantity in twenty-four hours, is worth but little more to the physician than it would be to know only the presence of sugar; for a patient may pass four pints of urine one day with eight per cent of sugar, and the next day eight pints with four per cent. Often the patient is led to believe, by this reduction in the per cent that they are improving, when if the total output were given, they would show no impovement whatever; for during those two days it is exactly the same. To prove this, you multiply the number of cubic centimeters passed by the per cent, which gives the amount of glucose in grammes.

Many cases of diabetes of the severe type, with the prognosis bad, can by following a close regime of diet, be converted into the mild form, and as result live many years of useful life, even though they may be carrying a good per cent of sugar.

Treatment.-There has been no improvement on the principles of the treatment of diabetes, but we certainly have made progress in the application of the different foods in the dietary treatment to such an extent that we now handle them much better than we once did; and by knowing the chemistry foodstuff we can now relieve, and even cure patients, whom we once considered to be beyond the reach of any treatment whatever. The application of the dietary and what medical means needed, should always

be associated with hydrotherapy, consisting of the various Excelsior Springs mineral waters and baths of different temperatures, which I consider as one of the most valuable adjuvants in the treatment of this disease, as well as various other diseases.

Such a course cannot be taken outside of a well-regulated sanitarium, as the toleration for carbohydrates must be reached by weighing all foods each time it is served, and when arrived at, this must be maintained by the patient for the purpose of being able to increase the toleration. In this point lies the secret of being able to produce a cure. This diet should be regulated to suit the individual needs of every patient instead of following the text-book rules of treating every case alike.

In all cases of diabetes, whether it be severe or mild, it should be the aim of the physician to test his patient, and see first how much carbobydrates can be taken without excreting sugar; yet we must not be satisfied with only a reduction of sugar, for if we find it necessary to withhold the carbohydrates too low, it is certain that the toleration of this patient will be interfered with, and lowered instead of raised, as it should be.

According to the theories of Noorden, the permanent absence of sugar from the urine cannot be reached until the toleration reaches or exceeds 2.3 ounces to 2.5 ounces of white bread in twenty-four hours. If taking less than this amount of bread is followed by the excretion of sugar, the diet is considered to be too rigid to follow for a long period of time. While the treatment of diabetes is regulated wholly by the diet, yet this diet should be regulated more carefully to suit the individual needs than was formerly done, and, than is even now generally appreciated by the medical profession at large.

Now, a few words as regards the medical treatment of this disease. I do not condemn medicine if properly given, when needed to meet a grave symptom, which comes often in diabetes, such as acidosis; and I even resort to the transfusion of a solution of sodium bicarbonate on the approach of diabetic coma. I have met with some very brilliant results in my private practice along this line, and have seen good results in the hands of Noorden, while taking my post-graduate course in Vienna, Austria, during the winter of 1907; although if coma is deep there is but little use to resort to this at any time, for there is nothing that will relieve the condition; and as I stated above, this condition of acidosis is responsible for diabetic coma, and is always preceded by the appearance of diacetic acid in the urine; hence it is negligence on the part of the physician to wait until coma approaches before he begins to combat it.

There are many remedies used and recommended in the treatment of diabetes mellitus, but unless the proper dietary rules are followed they all fall into disrepute. Most all the advertised proprietary and patent medicines that are heralded over the country and flaunted into the face of the medical profession as cures for diabetes, owe their reputation to the printed diet table around the container, and not to the remedy itself. I believe the diet tables, as outlined by Noorden, are the most systematic of any, after a cure is taken. There are four of them: Diet Table No. 1, which contains a list of all foods that may be taken by any diabetic; Diet Table No. 2, this is a tabulated list of articles of food which are of a high nutritive value, and are of special value to diabetics.

Diet Table No 3, this table contains a list of articles of food which, if they are not forbidden, may taken in the proportion indicated; but if the diet is rigid they should not be given. Diet Table No. 4, the white bread equivalent table, from this the various food substances are reckoned. I here submit to you the table of white bread equivalent, as I have had it printed, and go by it in the management of my cases after they have taken the cure, and their toleration for carbohydrates has been reached: