There are instances of patients with diabetes who have lived for twenty years or more without any effort at treatment. This consoling thought must not make unwary the patient with a moderately severe or severe form of the disease. It is safer to overrate the seriousness of the condition than to commit an irreparable blunder and neglect the careful management of a serious condition. Children and young adults, for instance, may seem well during the first year after the appearance of sugar, but with few exceptions they develop the severest form of the disease later unless they are very carefully treated from the first.

A good many older persons may be treated satisfactorily with much less dietary restriction than is necessary in the severe cases. When this is possible, insulin is not needed and should not be used, or, in other words, if a condition is serious enough to require insulin, it is serious enough to require an accurately weighed diet. Occasionally patients have so little intelligence that it is hopeless to expect them to carry on the weighed diet in their homes. For such, and also for patients with very mild diabetes, the following general advice is usually beneficial:

  1. Avoid sugar and all foods made with sugar, such as candy, jelly, marmalade, syrup and molasses, pies, cakes, puddings and pastries. Saccharin may be used if desired: one-fourth grain saccharin will equal one teaspoonful of sugar in sweetening value.
  2. Avoid cereals (breakfast foods) and cereal products, such as mush, macaroni, spaghetti and noodles.
  3. Use bread only in very small amounts, not over one ounce at a meal. Whole wheat or white breads are preferable to any so-called diabetic breads. Gluten bread, brown bread and corn bread vary widely in compositions and it is safer to avoid them.
  4. Potatoes, bananas, apples, peas, dried beans, carrots, beets, turnips and onions should be used in small quantities, and not oftener than once a day.
  5. Dried fruits should be avoided. Use fresh fruits whenever possible. Fruits canned without sugar are permissible. They may be purchased on the market or prepared at home. Fruits may be taken every day as substitutes for other desserts.
  6. Vegetables that grow above the ground, except peas and dried beans, should be eaten in quantities sufficient to avoid hunger. Three ordinary servings of these vegetables may be included in each meal. Canned vegetables are palatable and wholesome. Fresh vegetables are, however, preferable.
  7. Meat and eggs should be eaten sparingly. As much harm may result from excessive protein as from excessive carbohydrate. The diet for the day should never contain more than 60 grams (2 ounces) of lean meat, weighed cooked, and three eggs. Thirty grams (1 ounce) of bacon, weighed cooked, may be included. Meat includes chicken, game, and fish.
  8. Fats, including butter or oleomargarine, nut butter, bacon fat, olive oil, Wesson oil, or other salad oil may be eaten freely.
  9. Cream is a very useful food for diabetic patients, and may be taken freely. Milk is relatively high in carbohydrate and less nutritious.
  10. The amount of fat, such as butter or cream, should be adjusted so as to provide adequate, but not excessive, nutrition. A rising body-weight calls for less food and, under such circumstances, the amount of fat should be reduced.
  11. Coffee and tea should be used sparingly, not in excess of one cupful of either at each meal.
  12. Condiments, such as salt, pepper and vinegar, may be used in reasonable amount.

If sugar appears in the urine, bread should be omitted. If it persists after thus reducing the carbohydrate intake, the condition of the patient is severe enough to warrant instituting the more accurate management discussed herein.

THE TREATMENT OF FEVERS OCCURRING IN DIABETIC PATIENTS

Fevers increase the need for insulin.—Today, with insulin, a properly dieted patient is as robust and capable as his normal neighbor. His handicap is the continued necessity for keeping his enemy under control, but if this control is watchfully maintained, he should live as long and as useful a life as do his fellows. However, throughout his life he is exposed, as are his fellows, to diseases other than diabetes. Measles, mumps, scarlet fever, diphtheria, acute colds, influenza, pneumonia, and other germ diseases, the so-called infectious diseases, will attack him, and when they do they invariably aggravate his diabetes and, by preventing the utilization of his sugars, subject him to the danger of acid poisoning from smoldering fats. Therefore, when such complications occur, a patient must have insulin, whether he has been able to do without it before or not, and usually the doses necessary to control these critical emergencies must be large. For instance, a patient on a set diet, whose urine remains free from sugar with 20 units of insulin, may require 40 units daily whenever he takes cold. A serious infection like pneumonia may make it necessary to use 80 units of insulin daily. Under normal circumstances, a patient taking 20 or 30 units of insulin daily, does very well when this is divided into two doses of 15 units each, and one dose is injected before breakfast, and the second before the evening meal. During an attack of pneumonia or any other fever-producing complication, it may be necessary to resort to four injections, spaced at six-hour intervals. It is usually necessary to modify and reduce the diet when a patient is sick. It is always wise to eat less. In particular, the fat allowance of the diet should be reduced. It is wise not to reduce the carbohydrate. The patient with fever may be nauseated during the course of a fever and refuse all food. Under such circumstances, less insulin may be required; usually, however, large doses are still necessary. The reason for this is not clear, but apparently the poisons created in the course of germ diseases counteract the effect of insulin. During disease, the urine should be examined every six hours and the dose of insulin necessary may be judged from the amount of sugar found.

OPERATIONS ON DIABETIC PATIENTS

Special precautions necessary in operating on diabetic patients.—It is self-evident that a person with diabetes is no less likely to develop appendicitis, gallstones, or cancer than he would be without diabetes. Consequently, serious operations are occasionally necessary. The danger from such procedures is many times greater in diabetic patients than in others, unless the diabetes is closely controlled. Formerly one out of every three operations on diabetic patients terminated fatally. This was because the anesthetic, ether or chloroform, provoked acid poisoning, and because the enfeebled patient was little prepared to withstand the shock of loss of blood, and injury. The added danger of diabetes may be avoided if the patient is in good condition before he goes to operation, and if acidosis is promptly combated with insulin. It is wise for the diabetic patient to employ only a very skillful surgeon, and to make certain either that he is familiar with the treatment of diabetes, or that he has associated with him some physician who has had a considerable experience with diabetes.

MISCELLANEOUS COMPLICATIONS

Arteriosclerosis.—When we pass the age of thirty-eight, we are enjoying life which was denied our grandparents. The expectancy of life for a newborn baby in 1860 was thirty-eight years. Now it is nearly sixty years. This accounts, in a large measure, for the specially rapid increase in the amount of diabetes among people more than forty-five, and for the larger incidence today of other diseases of a chronic type. Hardening of the arteries, or arteriosclerosis, is a complication with which older diabetic patients are frequently afflicted. As has been said, arteriosclerosis may be a cause of diabetes in a predisposed person, but be that as it may, diabetes, once established, unless controlled, aggravates and intensifies disease of the arteries. It is, therefore, important for the older diabetic patient to make a serious effort to avoid arteriosclerosis by keeping his diabetes checked. Most of the complications which harass and endanger the older patient are due to hardening of the arteries. In this disease, the elastic contracting tissue in the hollow muscular tubes that carry blood is replaced, bit by bit, with scar tissue.