General Observations

When prescribing any dietetic regimen for diabetic patients, the general condition of bodily nutrition must be carefully considered. Obese, naturally robust, and sometimes gouty patients will be benefited by very strictly limited and carefully regulated diet, but emaciated and feeble patients cannot always endure the severity of a strict diabetic diet without too great loss of vitality, and it becomes necessary to maintain their strength even at the cost of sometimes increasing the amount of sugar in the urine. Obese persons make their fat largely out of carbohydrates, and hence a nitrogenous diet is particularly well suited to their condition, whereas emaciated, weak patients gain no flesh upon an exclusive nitrogenous diet, and it may barely support life for them.

Some persons with diabetes have been said to excrete more sugar on a diet of animal food than on the hydrocarbons, but it will generally be found that such patients have eaten some farinaceous food, bread, etc., with their meat, and the combination seems particularly favourable to the maintenance of a secretion of saccharine urine once established. Such patients may be temporarily given a diet in which fat in great part replaces meat, the fat being eaten with those vegetables which contain a minimum of starch and sugar (see p. 135).

Regulation of the diet should be faithfully tried before any medication is resorted to, for the latter frequently becomes superfluous, but a placebo may be given if necessary. During the siege of Paris in 1871 it was observed that a number of diabetics improved considerably owing to the enforced restriction in their diet (Bouchardat).

Cantani advises a preliminary fast of twenty-four hours before commencing dietetic treatment, but the value of this expedient is questionable.

Phenomenal improvement follows in many cases upon a diet which excludes starches and sugars almost completely, but this is a difficult regimen to enforce, for the craving for carbohydrates, especially for bread, becomes so fierce that patients whose veracity is otherwise unimpeachable will resort to lying or any form of deception to obtain this coveted food.

It is a matter of common experience that the most difficult of all food for a man to be deprived of, when once accustomed to it, is bread. This has always been found to be the case in arctic expeditions in which men have been reduced to a starvation dietary, and it is usually observed in any form of largely restricted diet, although patients who are living upon an exclusive diet of milk appear to have somewhat less craving for it than diabetics, who are allowed a greater variety of food, especially meat. This is due in part to lifelong association of certain kinds of food with one another at meals and the habit of eating this one article of food with more constancy than any other, but it is also undoubtedly referable to a positive craving of the system, which is particularly marked in diabetes, for a kind of food which the tissues need but cannot assimilate. For this reason it is generally advisable to allow patients from two to four or even six ounces of bread a day in divided portions; otherwise the craving for it does them positive harm, and a loathing for all food results, or they break all restraints and injure themselves more by overeating.

It should be remembered that diabetic patients are very susceptible to the influence of the nervous system, and that worry and anxiety about themselves, with too close an observation of their own diet, will often react unfavourably. Moreover, it is undoubtedly much harder for these patients to restrain themselves from eating varieties of food which are not wholesome for them if they sit at a general table where others are indulging in various luxuries of the season. It is sometimes possible for them, as has been proved by Cantani, to maintain good health for many years upon a strictly nitrogenous diet, but in attempting to enforce any rigid dietetic system one is compelled to have some regard for the environment and general habits of life of the patient, and it is easy to make the individual so miserable by too harsh rules as to defeat the very object in view, and the adoption of a too restricted system of diet may result in disastrous failure. For these reasons it is now customary to allow patients a more liberal dietary in diabetes than was at first permitted after the discovery of the real nature of the disease and the influence of carbohydrates upon it, but they should always be given carefully written directions as to what articles they may eat and what must be avoided.

While it is necessary to secure the intelligent co-operation of the patient in regard to carrying out his treatment, it is highly undesirable that he should devote too much time and attention to it, and, when possible, it is better to have some one else select and provide food for him in order that his mind may not be constantly occupied with questions of dietetics which tend to restrict the appetite, and sometimes to materially interfere with the beneficial effects of the diet. There is the more need for supervision of the diet by a second person, because the craving of diabetic patients often attains an ascendency over their will power and habits of truthfulness; in fact, a lack of mental force and even imbecility are quite characteristic of the advanced disease.

Deception should be suspected in those cases in which there is more urine passed than is to be accounted for by the quantity of fluid allowed in the diet, and in those cases which apparently ought to improve upon dietetic treatment, but in which after repeated trials no headway is made in regard to controlling the amount of sugar in the urine. I have known hospital patients to steal bread and potatoes and consume them surreptitiously in spite of repeated warnings, and also to acquire such a craving for fluid as induced them to drink their own urine.