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Diabetes





Diabetes is an affection of metabolism definitely recognized as due to
serious organic changes, though existing in several forms. We are not
as yet absolutely sure whether there may not be quite different
organic diseases in the various forms. Of one thing clinical
experience has given us assurance, that the condition of the patient's
nervous system is extremely important. While certain forms of diabetes
are due to pancreatic changes and others perhaps to changes in the
liver or other abdominal organs, the nervous system itself can affect
the consumption and excretion of sugar within the body. Certain
injuries, especially, as pointed out by animal experiments, irritation
of the floor of the fourth ventricle may produce passing diabetes. The
symptom may also occur in connection with states of the nervous
system. Glycosuria, or the passage of sugar in the urine, may occur
simply as alimentary glycosuria; and while this is usually due to an
excess of sugar in the diet, the glycosuria itself is predisposed to
by neurotic conditions in the patient. Diabetic patients are made
worse by worry of any kind and particularly by solicitude about
themselves and their ailment. Hence, the place that psychotherapy has
in the treatment of the disease.


Unfavorable Suggestion.--In most cases of diabetes, however, probably
the most important factor in the production of symptoms is the serious
disturbance of mind. The patient has an incurable disease and is
frankly told so. For the physician the word "incurable" means only
that his remedies are as yet inefficient in preventing certain
nutritional or metabolic disturbances, and that these will be likely
to continue in spite of all he can do. For the patient "incurable"
means that he has a disease for which the doctor confesses that he can
do nothing--which is not true--and that it is almost surely
progressive, while the many reports of death from diabetes of which he
hears only confirm the impression that he has not long to live and
that most of the time remaining will have to be spent in irksome care
of himself and almost superhuman self-denial.

As a consequence of this train of unfavorable suggestions, the history
of practically every case of the milder form of diabetes in older
people contains a period in which, shortly after the discovery that
they had the disease, they suffered more severely from it than at any
other time. As a rule, the discovery was accidental. The occurrence of
a succession of boils, the development of a carbuncle,
occasionally an intractable eczema or a great itchiness of the skin,
or an irritation of the external urinary organs, the occurrence of
cramps at night, or neuralgia pains, have led to an examination of the
urine and the finding of a considerable quantity of sugar. As a rule,
the patients are at once put on a diet containing little starch and no
sugar, and after a short time most of the bothersome symptoms of the
diabetes have ceased. Their own worry, however, the strictness of the
regimen, the craving for starches, the decrease in weight from the
limitation of diet, have made them profoundly miserable. Their
feelings have been translated into the definite conclusion that the
disease must still be making progress since they feel so miserable,
and they have suffered more from their mental state than from their
diabetes.

This is as true of physicians themselves when they are sufferers from
diabetes as of ordinary patients. Indeed, it seems that physicians
make themselves more profoundly miserable because of their supposed
knowledge of the disease than other people do. I have had the
confidences of more than a dozen physicians who were sufferers from
diabetes, and all of them admitted that they had suffered more from
their scare over the disease and from trying to maintain a sugar-free
diet than from the effects of their ailment. The lowering of nutrition
reacts upon the nervous system, already laboring under the strain of
the persuasion that an incurable disease is present, and the
consequence is a whole series of nervous and often mental symptoms,
especially of the depressive kind, that still further disturbs
digestion, interferes with peristalsis, causes constipation or
alternate constipation and diarrhea, leads to wakefulness at night,
inability to concentrate attention and a constant state of worry. All
this reacts upon the system and further increases the diabetes, that
is, the inability to use sugar properly, and adds to its elimination
through the urine.


Favorable Suggestion.--Just as soon as these patients realize that
people have often had considerable quantities of sugar--two per cent.
or more--in their urine for years without serious consequences and
that most diabetics die, not from the affection itself, but from
intercurrent disease, the reassurance of mind which ensues makes their
nervous system cease to be a factor in the further disturbance of
metabolism and they are able to consume more starch and sugar without
increasing the amount of sugar in their urine. This is not true, of
course, for the severe diabetes that attacks young people. These run a
rather rapid course and usually end in from one to two years in
diabetic coma or some complication connected directly with the
diabetes.


Danger of Over-treatment.--To strive to keep the urine of diabetic
patients free or nearly free from sugar is practically always sure to
produce a serious effect upon general nutrition and to disturb the
patient's mind and nervous system. Very often, however, an attempt of
this kind is made. Doctors who suffer from diabetes are too prone to
watch their urine carefully from day to day and this only emphasizes
their solicitude about themselves, impairs their digestion, and
produces such preoccupation of mind that all their functions are sure
to be disturbed. After a time they learn that their general condition
is a more important question than the amount of sugar in their urine.
If they can maintain their weight with reasonable freedom from the
secondary symptoms of diabetes, then the primary symptom--the amount
of sugar in the urine--may be almost or quite neglected.



Interval Treatment.--Van Norden has pointed out that if diabetic
patients are occasionally made to observe for a couple of weeks at a
time an absolute diet, these intervals seem to form a new
starting-point for metabolism and enable the patient to increase his
power of utilizing sugar and consequently to diminish his pathological
elimination of it. Patients look forward with interest to these
periods, provided that in the intervals they are allowed a certain
amount of starch; and each one of them seems a landmark on the road to
recovery. There is a strong element of suggestion in this that acts
very favorably and greatly influences the actual power of such
intermissions to help nature recover her lost metabolic faculties.
This is certainly a better method of treatment than the attempt to
keep up an absolute diet which so easily produces the other evil of
nervousness that adds to the diabetes, so that there is question of
choosing between two evils, and the lesser evil includes particularly
the reassurance of the patient.


The Individual in Diabetes.--While diabetes is a question of
glycosuria and usually of hyperglykemia, and the consumption of any
form of cane sugar or of starch convertible into it, will usually
increase the diabetic tendency, not all the forms of starch which may
change into cane sugar have the same effect in all individuals or
undergo the same modifications. Some patients, for instance, stand
milk better than others and may take large quantities of it so that
there is less craving for starchy foods. Most patients can take
potatoes better than bread even when there is the same equivalent of
starch in each. Those who have been accustomed to potatoes from their
early years sometimes stand them well and may be able to take them
almost with impunity. I have noted in several cases that the Irish and
Scotch, accustomed to oatmeal from their early years, seem to be able
to take notable quantities of this food when suffering from diabetes
without having a marked increase of sugar in the urine.

There are forms of sugar that satisfy the craving of patients for
sweets and may be taken in considerable quantities without seriously
disturbing metabolism. Honey is one of these, its sugar occurring in
the form of mannite, and there are other substances related to it that
probably can be employed to advantage. It must not be forgotten that
what seems to be sugar in the urine of certain patients, that is,
grape sugar, has proved on more careful investigation to be one of the
other chemical forms of sugar. We have a number of cases of pentosuria
on record in which patients were excreting penatomic sugar, but had
not glycosuria, though their urine responded to the ordinary tests for
this. It seems well not only to be sure of the diagnosis in these
cases, but to use what we have learned to make patients feel that
their condition though not curable is by no means hopeless. Care must
be exercised to take advantage of every possible individual
peculiarity for reassurance, for the extension of the diet in any
possible way, and for the satisfaction of the cravings which are so
likely to come to these patients. Some of their craving is really due
to the suggestion that they cannot have a particular article of diet.
Whenever any human being knows that he cannot have a thing, the liking
for it grows by suggestion and then it may become an obsession. To be
allowed even small quantities of it is often enough to enable patients
to overcome this and at least put them in a better state of mind.


Physical Condition.--The most important element in the treatment of
the less severe cases of diabetes is exercise in the open air.
Whatever the ultimate solution of the mystery of diabetes may be,
there is no doubt but that the muscles are an important factor in our
disposal of sugar within the body. The material which is burned up in
the muscles during movement is a form of sugar derived directly from
the starch and sugar ingested. When diabetics exercise freely much
more of their sugar is consumed within the body and much less of it
eliminated through the kidneys than when very little or no exercise is
taken. It is interesting to note the difference in the amount of sugar
in the urine when patients are taking abundant exercise and when they
are taking practically none. Even on a much more liberal diet the
percentage of sugar is likely to be less in the exercising patient.
One of the results of the diabetic scare is likely to be almost a
cessation of muscular exercise. This is partly due to the fact that
one of the results of diabetes in many cases is a sense of fatigue in
the muscles on comparatively little exertion. Indeed, this is
sometimes the first symptom that is noted and that calls the attention
of the patient to the fact that there is something seriously wrong
with him.

This occurs when there is a serious disturbance of sugar metabolism so
that the patient who consumes large amounts of starch and sugar is
excreting most of it. Just as soon as the diet is made a little more
rigid and the sugar metabolism improves, then exercise can be taken
and will benefit the patient. This is particularly true of women
suffering from diabetes whose depression on being told that they are
suffering from an incurable disease tempts them to remain within
doors; the frequent tendency to urination further adds to their
disinclination to go out. Under these circumstances they lose their
appetites, do not sleep well, and become highly nervous, thus
increasing their diabetic tendency. If they are required to go out and
take exercise in the open air and rather long riding or walking
periods every day, their general health will at once improve and the
diabetes will become more manageable. I have seen this happen without
exception even in patients well beyond middle age, and I am convinced
that it is the diversion of mind as well as the salutary tiredness and
thorough oxidation consequent upon outdoor exercise that is the best
possible remedial measure for these cases.


Solicitude.--It is important that diabetic patients should not be
bothered by frequent reports upon their urine. Their improvement and
the reduction of the amount of sugar excreted is at best but slow, and
is subject to many variations. While improvements, especially at the
beginning, are sources of great encouragement, the deteriorations that
are likely to be rather more frequent are prone to overweigh the good
effects and eventual discouragement results. It is not from the urine
but from the general condition that the improvement in the diabetic
condition is to be judged. So long as the patient feels strong, gains
in weight (when they do not belong to the obesity type of diabetes),
the diabetes itself is almost sure to be improving, even though there
may be discouraging periods as regards the amount of sugar eliminated.


Dangers of Rigid Diet--There are more dangers in a rigid diet than in
a certain amount of liberty in the consumption of starches and sugars.
The craving for these becomes so strong as to make life intolerable to
many people unless a certain amount of these substances is allowed. It
is rather easy to manage limitation while it is almost impossible to
be sure that patients will practice absolute denial. Besides,
the almost complete absence of starches and sugars, even though their
place is supplied by the fats, always seems to predispose patients to
the development of the acid intoxication which results in the coma
often so serious an incident of diabetes. It is for this reason
particularly that mild diet regulations are clinically more judicious
than the absolute denial which on chemical and physiological grounds
seems to be the scientific ideal. A rather good therapeutic method is
to have the patients maintain a rigid diet for some ten, fifteen or
twenty days and then leave them practically without restrictions for
the rest of the month. Continuous restriction of diet becomes
appalling. Looking forward to a period when they can eat as other
people do relieves the tedium, and makes it much easier to keep the
restrictions. The mental influence of this moderate treatment is very
favorable and encourages the patients in the thought that after all
their disease is not so serious. This is the most important element in
psychotherapy.





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