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 pan reatic 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.