Course

The course of diabetes is so protracted that there is abundant opportunity and usually necessity for trying dietetic experiments, for it will be found impossible to establish rules for dietetic treatment to which exceptions may not arise from time to time in the course of any individual case. The disease is sometimes well established long before its symptoms become sufficiently urgent to attract the attention of the patient. Persons who believe themselves to be in perfect health and who apply for life-insurance examination may be informed for the first time of the presence of glycosuria, and many cases are now discovered through incidental examination of the urine in connection with some other disease, which would have been overlooked a few decades ago, when clinical urinalysis was very imperfect.

If treatment is begun before the symptoms are well advanced the lives of many patients may be prolonged - in "some cases for more than ten or twelve years - whereas, of seven hundred cases reported by Prout which occurred over thirty years ago, only two patients lived beyond ten years. Frerichs reported one case which extended through twenty years and several more in which the disease lasted between ten and eighteen years. Occasionally diabetes is extremely acute, and may prove fatal within three weeks, but in such instances it is probable that glycosuria has been present for a long time without discovery.

Prognosis

Between 50 and 60 per cent of all cases are fatal in less than three years; undoubtedly a few which are recognised sufficiently early may be completely cured, but glycosuria, like albuminuria, indicates a weakness of the system in a special direction, and, the disease having once occurred, the patient should be under reasonable supervision for many years. It has been aptly said that "the only chance that a diabetic has of being cured is to believe that he never is cured" - that is, to be constantly on the alert to avoid all indiscretions in hygienic and dietary matters. There seems to be a relation between the general bodily nutrition and the chance of recovery or improvement. Usually stout, middle-aged men yield best to treatment; thin persons withstand the disease less well, and rapid emaciation is always more to be dreaded than the presence of sugar. The prognosis is more favourable in those cases which are readily amenable to the influence of a strict dietetic regimen. The prognosis is more favourable if the sugar does not speedily return if the dietetic treatment be interrupted, and also if the amount of urea excreted is large and the quantity of uric acid small. Cases which occur in connection with gout are relatively light.

In emaciated cases the malnutrition is so great that the patients easily acquire other diseases, especially pulmonary tuberculosis, and many die from complications rather than from the immediate effect of the disease itself.

Diagnosis

To determine the presence of permanent glycosuria, the patient should be placed for two days upon a standard diet containing no other carbohydrate food than 100 grammes of wheat bread (von Noorden). The urine passecl during twenty-four hours is then 45 collected and analysed by polarisation and titration or fermentation. If sugar be present, the carbohydrate allowance should be varied for a day or two, in order to determine its effect upon the quantity of sugar eliminated, and serve as a guide for dietetic treatment. Temporary glycosuria may be caused by a variety of conditions, such as excessive indulgence in sweets, poisoning from amyl nitrite, mercury, chloroform, alcohol, etc. It has been observed during pregnancy and after anthrax, diphtheria, scarlatina, typhoid fever, etc. In the transient form of glycosuria the urine contains much less sugar than in diabetes mellitus, and all the severe symptoms of excessive thirst, emaciation, and extensive tissue waste, leading to local disease and usually death, are wanting.

In polyuria or diabetes insipidus there is no sugar in the urine, and the specific gravity is very low - 1.002 to 1.005.

Primary peptonuric diabetes is described by Quinquand as a disease presenting the clinical features of mellituria - thirst, marked cachexia, polyuria, etc. - but instead of sugar, the urine contains peptones; it polarises to the left, and is of low specific gravity.

Temporary lactosuria sometimes occurs as an accompaniment of the puerperal state, and is not of special dietetic significance.

Treatment

The treatment of diabetes to-day is much more successful than it was thirty or forty years ago, when every case was regarded as necessarily fatal. The treatment should be (1) prophylactic, (2) dietetic, (3) hygienic, and (4) medicinal.

Prophylaxis

Until more is known of the aetiology of diabetes definite prophylactic rules cannot be established; but in general, where there is distinct heredity to be feared, or when the lithic-acid diathesis exists, all excitement of the nervous system, mental or physical, as well as indulgence in alcohol and sweets, should be strenuously avoided.