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 {497} 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.{498}

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 {499} 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 {500} 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.