COLUMBIA LIBRARIES OFFSITE HEALTHSCIENCESSTANDARD lillll i Hit ' HX00033014 Columbia ©ntoergttp intijeOtitpoOtogork THE LIBRARIES jHebtcal Hibvatp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diabeticmanualfoOOjosl a >> 03 10 2 la — 03 £ D 73 0^ Sh S O^e 3 O £ fa o £ > E y, % V, eq ca o Fel). 17 4000 8.4 336 19 1500 2.2 33 54 84 720 360 3 20 1500 1.8 27 54 84 7201 360, 3 21 1250 1.8 23 39 84 142 720 | 360 1 1J 22 1500 0.4 6 24 M 432 720 j 360 23 1250 0.2 3 21 84 432 720 ! 360 1 24 1500 Tr. 24 84 432 720 ' 360 1 25 1500 Tr. 21 84 15 567 i39 720 | 240 90 26 24 84 39 783 720 i 120 90 4 27 1250 24 82 57 937 720 1 120 90 2 60 Mar. 1 2-1 82 82 1162 720 t 120 j 90 2 (id 30 3 26 84 94 1286 i3S 720 120 90 2 60 30 60 32 85 106 1422 720 i 120 1 I 90 2 60 30 90 9 42 85 106 1462 i36 720! 120 ' H 90 2 1,(1 30 90 13 54 87 168 2076 With many thanks for your cheerful help in the care of my patients at the hospital, and for your faithfulness to treat- ment at all times, I remain, Your friend, Elliott P. Joslin. CHAPTER VI. EFFICIENCY IN VISITS TO A DOCTOR. Diabetic patients frequently fail to get the benefit they should derive from a visit to their physician because they do not furnish the facts upon which advice for further treatment can be based. The physical appearance of the patient is by nt » means a satisfactory guide. Information must be furnishe* 1 concerning the examination of the urine and concerning the diet. The efficient cooperation of the patient is necessary. 1. Information Obtained by Examination of the Urine. — The physician should know whether the urine of the patient is free from sugar, or, if present, how much it contains. This is essential in order to prescribe the diet for the following days. The patient should therefore take with him a specimen of the urine saved from the entire twenty-four-hour amount. To collect such a specimen of urine, discard that voided at 7 a.m., and then save all urine passed up to and including that •obtained at 7 the next morning. Take one-half pint of the thoroughly mixed twenty-four-hour quantity for examina- tion. Record the twenty-four-hour amount of urine and the name on the bottle. The bottle in which the urine is being collected should be kept in a cool place. It is best to procure a bottle 1 for this special purpose sufficiently large to hold the entire twenty-four-hour amount of urine. Select a bottle with a large mouth, that it may_be more easily cleansed. The bottle should be scalded out daily. It should have a tight-fitting cork. Urine so collected decomposes slowly. On account of the presence of sugar, diabetic urines are prone to ferment, and if fermentation occurs a portion of the sugar disappears and invalidates any subsequent test for the quan- tity of sugar which the urine contained when voided. 2. Information Obtained by Examination of the Diet. — The quality and quantity of the food eaten during the twenty-four hours of the collection of the urine should be recorded. If thirty minutes are allowed for a visit to the physician's office 1 Bottles, known to the druggists as percolator bottles, and graduated in 100 c.c. up to 2000 c.c. are most convenient. 46 INTRODUCTION TO DIABETIC TREATMENT it is no exaggeration to say that unless this recording of the diet is neatly done, one-third to one-half of the visit is spent by the physician in learning what the patient has eaten. For this reason my intelligent patients always bring a diet list arranged according to the plan shown in Table 7 (page 42). Even if the quantity of carbohydrate, protein, fat and calories are not worked out by the patient, the grouping together of 5 per cent, vegetables, the summary of the total quantity of butter, cream, meat, eggs, fish, oatmeal and fruit, rather than the hit-or-miss record of the amount taken at each meal, saves really an enormous amount of time, and time which can be used by the physician in helpful advice. In other words, the patient should go to the physician for treat- ment rather than for a lesson in grammar-school arithmetic. 3. Body Weight. — If the patient has scales, the weight fasting and preferably undressed on the morning of the visit should be taken. 4. Note Book. — The patient should have a note book, and all questions about symptoms and diet which have arisen since the former visit should be neatly set down, with space left for an answer to each question. It is a common error for patients to ask the same question many times, whereas if the answer is written down by the physician the question would thus be answered once for all time. Furthermore, it is a great advantage for a patient to keep a note book, because gradually it becomes valuable for reference, and his whole plan of treatment is systematized. The note book should contain a statement as to whether sugar has been present or absent in the urine since the last report to the physician. Such data can easily be gathered on one page and again thus save time. When a patient comes to my office with a single specimen of urine instead of a portion taken from the twenty-four-hour quantity, and without any record of the food eaten during the preceding day, and starts in to recount that he had nothing but eggs, meat and fish, then later remembers that he had a little cream and various vegetables, then with prompting recalls butter and an orange and a little oatmeal, I always pity him, and on very excep- tional occasions am able to recall with satisfaction after the interview Solomon's soliloquy in Proverbs xvi, verse 32. CHAPTER VII. HYGIENE FOR THE DIABETIC. Any agency which promotes physical or mental hygiene is a step toward the prevention of diabetes in the predisposed and the abatement of its severity when it has appeared. It is only justice to Hodgson to say that for years in dealing with his patients he has urged that they " should be kept mentally indolent and physically active." The experiments of Cannon, Folin and their associates upon the appearance of sugar in the urine of animals and of both normal and insane individuals following periods of great emotional excitement have demon- strated the truth of the former half of the motto. Therefore all individuals who have a tendency toward diabetes should be especially urged to take vacations, and the good effect of vacations should be generally pointed out. I have never forgotten the remark of Dr. Sabine, of Brookline, that in the course of his long practice he had observed that those of his patients who had taken active camping trips in the woods bore the stress of modern life best. By this means exercise was combined with mental relaxation. That the good effects of each last for months is not hard to believe. It is only natural to conclude that if the muscles, in which is stored one-half of the carbohydrate of the body, are kept in good condition by training, a favorable effect must be exercised upon the general metabolism of carbohydrate. Pedometers are to be encouraged. It is better to discuss how far you have walked than how little you have eaten. Stimulated by Dr. Allen I have gradually increased the exercise of all my patients, except those unduly weak or in a dangerous condition upon entrance to the hospital. The effect of this increase of exercise upon the well-being of fat diabetics has been pronounced, and it is striking how many miles a semi- 48 INTRODUCTION TO DIABETIC TREATMENT ill or obese diabetic patient can learn to walk during two weeks. The patients are encouraged to take their walks soon after meals and to go outdoors at least five times in the day. Not alone are the good effects of exercise shown by freedom of the urine from sugar with an increased carbohydrate tolerance, but by improved circulation and general well-being. Even fasting diabetics, as a rule, appear to do better when up and about the wards for a few hours a day than when abed. However, caution is necessary in sug- gesting this plan to severe cases of diabetes. No ease should be considered too far advanced for an attempt at muscular redevelopment. I have seen two patients so weak from lowered vitality that they could not stand, through the help of skilful massage and carefully planned dietetic treat- ment again begin to walk. If the patient, by means of exercise, can have 5 grams more of carbohydrate a day the added comfort will be enormous, for the addition of 5 grams of carbohydrate to a diet in a case of severe diabetes brings almost untold joy. It allows various alternatives, such as half a small orange, 50 grams of straw- berries, a small tablespoonful of cooked oatmeal or a potato half the size of a pullet's egg. Case No. 1024, a lady, aged seventy-eight years, I learned from Miss Walker, her nurse, not only takes exercise in the forenoon and afternoon, but goes out for her walk in the evening with a flash light. Case No. 804, a patient whose diabetes has changed from severe to moderate, and finally from moderate to mild under his own care at home, writes me that lie considers exercise of the greatest importance. He says that he has the best garden of anyone in his city. Case No. 352, a diabetic who has outlived his expectation of life, is now seventy years of age, having had diabetes twenty-three years, and throughout this time has led a most active life. He writes: "First, it is very hard to start the exercise, and the less one feels inclined to start the more one needs it. Second, it is neither necessary nor desirable that it should be violent. I found a quiet ride of an hour, walking or jogging after taking HYGIENE FOR THE DIABETIC 49 something on the stomach, started up my old metabolism for the whole day. If I rode hard I got tired out." Finally, it is astonishing how much exercise a diabetic in training can take. One of my severe cases, living on a strict diet, several years ago walked between twenty and thirty miles in one day. Inquiry elicited the following letter from Case No. 783, a Harvard student, who frequently shows a small trace of sugar, a case which borders upon the renal type of diabetes. The blood sugar one morning before break- fast was 0.07 per cent.: Cambridge, Mass., Dec. 1, 1915. "My Dear Doctor Joslin: "I first noticed the effect of exercise last spring. I was rowing for exercise at the time, and observed that if I went out on the river about a half-hour after lunch and rowed for an hour or less the test would not show any sugar in the urine at any time during the afternoon, even though I ate potatoes and a small amount of bread for lunch. But if I ate potatoes (no bread) without so exercising the test always showed sugar about two hours after the meal." Rest is essential. A tired child is put to bed and wakens refreshed; one of the most noted surgeons in our country is not ashamed to leave his guests at the table and lie down for fifteen minutes after his luncheon; the best treatment for a failing heart is to put its owner in bed for a week. Diabetic patients should rest often, should never get tired and should avoid athletic contests. The diet is designed to give a rest to the pancreas. Sleep nine hours and more if you can, and get another hour of rest by day. Short periods of complete relaxation yield maximal returns. Forget you have diabetes and do not talk about it with others. This is one reason for not using saccharin, and another is to avoid the perpetuation of a sweet taste, thus reviving the thought of the previously unrestricted diet. Mental diversion is desirable, but anxiety is harmful. Heavy responsibilities should be avoided as well as nervous upsets and emotional excitements. It is almost as dangerous for a diabetic to get angry as for a man with angina pectoris. 4 50 INTRODUCTION TO DIABETIC TREATMENT Case No. 1157 had been sugar-free for five days, but it came back when he had an important conference with one of his superintendents. Wear warm clothes instead of staying by the radiator or in an overheated room. The change in the mental attitude of patients during the course of treatment is a gratifying encouragement to the physician. Untreated diabetics after a moderate number of years usually show depression, and with women this often becomes pronounced. In the first ten years of my experience with diabetes I was much impressed with the tendency of such patients to cry, but even then, with the methods in vogue, it was interesting to see how depression disappeared with the decrease or disappearance of sugar in the urine. This could not be explained by the mental encouragement which a patient derived from his knowledge of the decrease in sugar excretion. Even when patients became sugar-free but developed acidosis, mental symptoms often improved, and to so great an extent that one could say that with treatment, even though it did end in coma, the patient enjoyed life far more thoroughly than when untreated. During the last two years and a half the mental attitude of the patients has improved still more. The enthusiasm about new methods of treatment has been so great as to account partially for this, but the actual improve- ment in health which the patients have felt has been of more importance. Greeley explained to my patients how diabetes has largely been robbed of its terrors. He urged the simple life as a great aid in treatment and told them not to try to be first in the Iberian village and be ill, but rather to be second in Rome and keep well. He told them to have a hobby, and not to make it a labor; to be cheerful and to keep their minds occupied, and, so far as possible, to continue the previous currents of their lives. PART II. THE DETAILS OF DIABETIC TREATMENT. CHAPTER I. THE DIET OF NORMAL INDIVIDUALS. The diet of the normal individual is made up chiefly of carbohydrate, and to a lesser extent of protein and fat. Carbohydrate in the Normal Diet. — The carbohydrate foods are divided into starches and sugars. Everyone is familiar with the conversion of starch into sugar, as in the ripening Of a banana. In the body this is the common event, and is brought about through the activity of the digestive glands. Carbohydrate is found chiefly in the vegetable kingdom, as in cereals, sugar-cane, vegetables and fruits. Milk contains 5 per cent, of sugar. Meat, fish and eggs are entirely free from carbohydrate save for an extremely small percentage of animal starch (glycogen) to be found in liver. By a carbo- hydrate-free diet, therefore, one usually means a diet consist- ing of meat, fish, eggs and pure fat (such as butter and oil), broths, coffee and tea. The quantity of carbohydrate in various foods is shown in Fig. 7 graphically, p. 52 and in Table 9. Under the heading 5 per cent, are placed foods which contain not over 5 per cent, carbohydrate; in the 10 per cent, group those which contain 5 to 10 per cent, carbohydrate; in the 15 per cent, and 20 per cent, groups those with about 15 and 20 per cent, carbo- hydrate respectively. The foods in each group are also arranged according to the amount of carbohydrate which 52 DETAILS OF DIABETIC TREATMENT they contain. Thus, lettuce, at the beginning of the list, contains about 2 per cent, carbohydrate, and string beans toward the end of the second column, about per cent. For 5 10 15 20 25 30 CALORIES OATMEAL CREAM 40# CREAM 205! MILK BRAZIL NUTS OvSTERS 6 MEAT UNCOOKED MEAT COOKED CHEESE BACON EGG-ONE VEGETABLES 551 VEGETABLES 10^4 POTATO BREAD BUTTER OIL COD, HADDOCK BROTH .„,, , (ORANGE OH SMALL {^GRAPEFR. - 120 120 GO 20 210 50 50 75 130 155 75 6 10 30 90 225 270 25 3 40 mm u i i mmmm ^\ 'mmmmmm r I i i r i .> , ! ; ■ i.l m^mmmmmmmm msmm%%mwz%m\ 1 i m A ' I ) \ 1 ! : ^ 1 1 ^ta - - I CARBOHYDRATE (SUGAR AND STARCH)} j VTZ-m PROTEIN (LEAN OF MEAT AND FISH, CURD OF MILK, EGG-WHITE ETC. '; gjjlll Fig. 7. — Diet table showing total calories and quantities in grams of carbohydrate, protein and fat in 30 grams (1 ounce) of various foods. Each lineal division represents 1 gram. this reason, and also because a portion of carbohydrate is often lost in the cooking or is present in the form of cellulose which is unassimilable, one may reckon the average per- DIET OF NORMAL INDIVIDUALS 53 centage of carbohydrate in a mixture of 5 per cent, vegetables as 3 per cent., and similarly a mixture of 10 per cent, vege- tables as 6 per cent. The carbohydrate in the 15 and 20 per cent, groups should be taken at its full value. Table 9. — Foods Arranged Approximately According to Content of Carbohydrates. Vegetables (fresh or canned). 5 per cent. 10 per cent. 15 per cent. 20 per cent. Lettuce Tomatoes Pumpkin Green peas Potatoes Cucumbers Brussels Turnip Artichokes Shell beans Spinach sprouts Kohl-rabi Parsnips Baked beans Asparagus Water cress Squash Canned Green corn Rhubarb Sea kale Beets lima beans Boiled lire Endive Okra Carrots Boiled Marrow Cauliflower Onions macaroni Sorrel Egg plant Mushrooms Sauerkraut Cabbage Beet greens Radishes Dandelion Leeks greens String beans Swiss chard Broccoli Celery Fruits. Ripe olives (20 per cent, fat) Oranges Apples Plums Grape fruit Cranberries Pears Bananas Lemons Strawberries Blackberries Gooseberries Peaches Pineapples Watermelon Apricots Blueberries Cherries Currants Raspberries Huckleberries Prunes Nuts. Butternuts Brazil nuts Almonds Peanuts Pignolias Black Walnuts walnuts (English) Hickory Beechnuts 40 per cent. Pecans Pistachios Chestnuts Filberts Pine nuts Miscellaneous. Unsweetened and unspiced pickle, clams , oysters, scal- lops, liver, fish roe. Protein in the Normal Diet. — Protein is an essential constit- uent of the diet, for out of protein the cells and tissues of 54 DETAILS OF DIABETIC TREATMENT the body are formed. Examples of protein are the white of egg, lean of meat or fish and curd of milk. White of egg is pure protein and water. In the white of one egg are 3 grams protein, and the yolk contains an equivalent quantity, combined, however, with 6 grams of fat. Table 10. — The Quantity of Carbohydrate, Protein and Fat and the Caloric Value of Thirty Grams (One Ounce) of Foods in Common Use. 30 grams (1 ounce) Carbohydrates, Protein, Fat, Contain approximately. grams. grams. grams. Calories. Oatmeal, dry weight ... 20.0 5.0 2 120 Cream, 40 per cent 1.0 1.0 12 120 Cream, 20 per cent 1.0 1.0 6 60 Milk 1.5 1.0 1 20 Brazil nuts 2.0 5.0 20 210 Oysters, six 4.0 6.0 1 50 Meat (uncooked, lean) ...0.0 6.0. 3 50 Meat (cooked, lean) . ... 0.0 8.0 5 75 Bacon ' . . 0.0 5.0 15 155 Cheese 0.0 8.0 11 130 Egg (one) . 0.0 6.0 6 75 Vegetables 5 per cent, group .1.0 0.5 6 Vegetables 10 per cent, group .2.0 0.5 10 Potato 6.0 1.0 30 Bread 18.0 3.0 90 Butter 0.0 0.0 25 225 Oil 0.0 0.0 30 270 Fish, cod, haddock (cooked) .0.0 6.0 25 Broth 0.0 0.7 3 Small orange or half of grape fruit 10.0 0.0 40 Table 10 contains a list of foods which I have found most commonly eaten by diabetic patients and, indeed, by normal individuals. Anyone who masters this table will know the essentials of the diabetic diet. It is well worth while to study carefully both Fig. 7 and Table 10 here numerically compiled. Fat in the Normal Diet. — Fat and carbohydrate are to a large extent interchangeable. In northern climates fat forms a large part of the diet while in the tropics it is replaced by an excess of carbohydrate. Examples of fat in its pure form are oil and lard. Butter and the substitutes for it contain 85 per cent, or more fat. Common cheese is one- third fat. The fat in meat varies from that in fat bacon, in which the percentage occasionally rises to 80, to chicken, DIET OF NORMAL INDIVIDUALS 55 in which the percentage of fat is 3 or less. In codfish and haddock the amount of fat is negligible, but in salmon it reaches 13 per cent. Nuts are rich in fat. Food Values and Food Requirements. — The quantity of food which an individual requires has been estimated in various ways. One method has been to weigh the amount of food eaten by a large number of individuals and then calculate the amount consumed by each individual. I imagine that it is upon this basis to a considerable extent that soldiers are assigned their rations. The rations now furnished the soldiers in various armies are reported to be as follows: Table 11. — Soldiers' Rations. Carbo- hydrate, grams. United States garrison ration . . 651 Russian ration in Manchurian war 487 British ration 524 Italian ration 1 560 French ration (normal) .... 402 The rations allowed for prisoners in the German prisoner- of-war camps in the period prior to the stringency in food- stuffs and in a later period of stringency are given below. 2 In general, one can be quite sure that the prisoners were not allowed more than the civil population. Table 12. — Rations Allowed in German Prisoner-of-war Camps. Protein, Fat, grams. grams. Calories, 185 141 4751 215 90 3717 224 195 4962 145 93 3745 130 117 3478 Carbo- hydrate, grams. Protein, grams. Fat, grams. Calories, 510~ 89 30 2740 310 57 21 1720 Daily diet prior to stringency Daily diet during stringency Another method allows the food required by a given indi- vidual to be calculated far more accurately. By this method the heat given off by a man at rest or at work has been determined. The quantity of food is then estimated which is required in the course of its oxidation in the body to produce an equivalent amount of heat. The heat liberated in the oxidation of the various foodstuffs has been determined and 1 From unofficial sources. 2 Taylor, A. E.: Jour. Am. Med. Assn., 1917, lxix, p. 1575. 56 DETAILS OF DIABETIC TREATMENT is measured in heat units known as calories. A calorie represents the heat which is necessary to raise 1 kilogram of water 1° Centigrade, or 4 pounds of water 1° Fahrenheit. For each kilogram (2.2 pounds) body weight per twenty- four hours it has been found that an individual requires at rest 25 calories and at light work 30 calories. Experiments have demonstrated that the heat which is liberated in the body from the combustion of 1 gram of protein or of carbo- hydrate produces 4 calories, from 1 gram of fat 9 calories, and from 1 gram of alcohol 7 calories. Fat is, as we would expect, more than twice as nourishing as carbohydrate or protein. With these figures in mind, it is easy to estimate with suffi- cient exactness from dietetic tables the calories in the diet, and to compare the result with the number of calories required. For scientific accuracy frequent analyses must be made of samples of the food eaten. It will be noted in the above paragraph that the metric system of weights and measures is given preference. This is done because it is far easier in diabetic work to deal with grams and cubic centimeters than with ounces, pounds and quarts. The only figures in the metric system necessary to remember are those shown in Table 13. Table 13. — Weights and Measures Employed in the Estimation of the Diet. 30 grams = 1 ounce. 1 30 cubic centimeters = 1 fluidounce. 2 1 000 grams = 1 kilogram — kilo or kg. (2.2 pounds). 1000 cubic centimeters = 1 liter. 16 ounces = 1 pound (454 grams). 32 ounces = 1 quart (946 c.c). 1 gram carbohydrate = 4 calories. 1 gram protein = 4 calories. 1 gram fat = 9 calories. In estimating carbohydrate, protein and fat in the diet or sugar in the urine, enough accuracy is obtained in clinical work by considering that 30 grams (g.) or 30 cubic centi- meters (c.c.) equal an ounce, dry or fluid measure. 1 Actually 28.4 g. 2 Actually 29.6 c.c. DIET OF NORMAL INDIVIDUALS 57 Individuals with sedentary occupations require approxi- mately 30 calories per kilogram body weight. Thus a man weighing 70 kilograms (70 kilograms X 2.2 pounds = 154 pounds) would need (70 X 30) 2100 calories. The caloric needs of the body, however, vary not only from day to day but from moment to moment. Thus an individual lying down requires not far from 25 calories per kilogram body weight, but at moderate work 30 or more. So much of the twenty-four hours is spent sleeping that the individual saves then what he uses at other periods. To walk one hour on a level road at the rate of 2.7 miles an hour requires 100 calories above that of keeping quiet, according to Lusk. For a man to ascend a flight of stairs ten feet high about 3 calories are necessary. Table 14 shows the calories needed according to the amount of work done. Table 14. — Calories Required during Twenty-four Hours by an Adult Weighing Seventy Kilograms (One Hundred and Fifty-four Pounds). Condition. Calories per kilogram, body weight. Calories per pound, body weight. Total calories. At rest At light work At moderate work At hard work . 25 to 30 . 35 to 40 . 40 to 45 . 45 to GO 11 to 14 16 to 18 18 to 20 20 to 27 1750 to 2100 2450 to 2800 2800 to 3150 3150 to 4200 Children require far more food than adults because of growth and increased activity. This is shown in Table 15. Table 15. — -Caloric Needs of Children during Twenty-four Hours. ~ Age in years. kg. Weight pounds. Calories per Calories per kilogram, pound, body weight, body weight. Total calories. 2 12 26 80 36 960 6 20 44 70 31 1400 12 36 80 50 23 1800 Composition of the Normal Diet. — The ordinary diet for a man at moderate physical work would contain about 400 grams of carbohydrate, 100 grams of protein and 100 grams of fat. This would amount to 2900 calories in the twenty- four hours, or about 40 calories per kilo for an individual Calories, Total per gram. calories. 4 1600 4 400 9 900 58 DETAILS OF DIABETIC TREATMENT weighing 70 kilograms. These figures would be proportion- ately reduced both for those of lower body weight and for those with lighter occupations who would require nearer 30 calories per kilo. As age advances the metabolic require- ments are lessened ; thus if 2000 calories are required at thirty years, 1800 calories will suffice at seventy and 1600 at eighty years of age. Table 16. — The Proportion of Carbohydrate, Protein and Fat in the Normal Diet. Quantity, Food. grams. Carbohydrate .... 400 Protein 100 Fat 100 2900 Chittenden, in his painstaking and scientific manner, accomplished an immense amount of good when he showed that people ordinarily consumed much more food than physiological needs demand. He suggests that it is more than probable that this excess of food is in the long run detrimental to health, weakening rather than strengthening the body and defeating the very object of nutrition. From the preceding statements it will be seen that 55 per cent, of the -energy of the diet of the normal individual con- sists of carbohydrate. These figures are only approximate, but they leave no doubt as to how large a place sugar and starch occupy in the daily ration. Fig. 8 shows graphically the relative caloric value of the different foodstuffs in the total diet. The quantity of protein in the normal diet is probably decidedly less, than 100 grams. From Cannon's investi- gations at the Harvard Medical School it would appear that these active, hard-working students, with their regular activities, ate about 90 grams each day. There is compara- tively little doubt but that it is safe for an individual to get along on 1 gram protein for each kilogram body weight, and I have no worries if my patients secure 60 grams protein, DIET OF NORMAL INDIVIDUALS 59 though the students ate rather more. Protein is animal food to a large degree ; hence its cost. This is an added reason for being sparing in the use of protein. There is also still another reason, for when an excess of protein is burned the other foods are also consumed more rapidly, and there is more chance for the heat produced to go to waste. The quantity of fat in the normal diet varies, partly from choice and partly from economic reasons. In general, in those cases in which the carbohydrate in the diet is high, the fat is low, and vice versa. The Voit standard placed the fat at 55 grams, but in a series of 1300 dietary studies of families, carried out among different races and in different countries, it was shown that the average quantity of fat eaten was about 135 grams (4.5 ounces) per person per day, the varia- tion recorded being from 45 to 390 grams per person per day. 400 G. CAflB. 1600 C.MS. 100 Q. FAT 900 CALS. Fig. 8. — The relative caloric value of protein, carbohydrate and fat in a normal diet. The more agreeable varieties of fat, such as butter, cream and oil, are expensive foods. Fat-js also a concentrated food, not only because it has twice the caloric value of either carbohydrate or protein, but because it occurs more fre- quently in pure form. Oil, butter and lard contain little water, whereas except for pure sugar and stanch most carbo- hydrates and proteins are diluted five to ten times with water. The chief source of error in calculating "the total caloric value of the diet, and especially of the diabetic diet, is in the estimation of fat. Anyone can realize this upon examining a piece of meat with its fringe of fat. The fat in bacon is 60 DETAILS OF DIABETIC TREATMENT most variable, and in amount its value can only be approxi- mately estimated. Portions of bacon lose varying quantities of weight in the cooking, as shown in Table 17. (See the column for percentage loss.) Table 17.- -Loss OP Weight op Bacon DURING COOKI Uncooked, Cooked, Lost, grams. grams. per cent. 80 4G 43 200 100 50 50 17 66 60 23 62 30 10 67 Eggs in some cities by law must weigh a pound and a half a dozen, an average of GO grams (2 ounces) apiece. Such eggs contain approximately 6 grams of protein and 6 grams of fat. How gross our caloric reckonings are is obvious if a collection of eggs is weighed and the minimum and maximum weights noted. The weight of the heaviest egg in such a collection was 72 per cent, more than that of the lightest. (See Table 18.) Table 18. — Variations in Weights of Eggs with the Shells. Number of eggs Minimum, Maximum, Variation, weighed. grams. grams. per cent. 9 52 63 21 12 40 62 55 11 56 63 12 12 51 69 35 12 48 66 38 The weight of one egg shell is usually about 7 grams. Milk may be employed in the treatment of diabetes, but it must be prescribed and taken with care, because of the large quantity of carbohydrate, protein and fat which it contains. A glass of milk is drunk so easily that one is apt to forget that it contains 12 grams carbohydrate, 8 grams protein and 8 grams fat. The graphic table given below (Fig. 9) will make this clear. Skimmed milk and buttermilk contain the same quantity of carbohydrate and protein as whole milk, but differ from it in the absence of fat. Thirty DIET OF NORMAL INDIVIDUALS 61 c.c. (one ounce) of skimmed milk, whole milk or buttermilk contain 1.5 grams of carbohydrate and 1 gram of protein, and 1 quart of milk contains approximately 48 grams carbo- hydrate and 32 grams protein. Skimmed milk and buttermilk therefore are carbohydrate-protein food. Whey contains carbohydrate, but practically no protein or fat. Diabetic patients seldom become sugar-free on a milk diet. They may become sugar-free if so little milk is taken that the patient is partially fasting. QUANTITY (30 GRAMS OR 1 OUNCE) |::i;]=CARB. HH||]=PROTEIN ^ = FAT 5 10 15 20 25 30 CALORIES SKIMMED MILK MILK CREAM 205( CREAM 40% BUTTERMILK BUTTER WHEY CHEESE ir 10 20 r 1 60 m p**= 10 i w r 225 T i N i -j- 130 Fig. 9. — Milk and milk products. Carbohydrate, protein and fat in 30 grams or 1 ounce. Each lineal division represents 1 gram. The high nutritive value of cream, butter and cheese is evident from Fig. 9. This makes these special milk products desirable, but if carelessly taken* danger of acid poisoning arises from the large amount of fat which they contain. The high protein value of milk — 1 gram to the ounce, 32 grams to the quart — is important to consider, not alone because of the protein itself, but also because from protein sugar is often formed. Cheese contains about half again as much protein as fish. Caloric Values which Every Doctor Should Know by Heart. — The quantity of carbohydrate, protein and fat in the diet must be known by physician and patient if a case of diabetes is to be treated in modern fashion. The value of the different 62 DETAILS OF DIABETIC TREATMENT foods in the diet can easily be calculated from Table 10. This is a sufficiently accurate arrangement, because except in the most exact experiments the errors in the preparation of the food are too great to warrant closer reckoning. Repeatedly physicians and patients have requested me to arrange the common articles of the diabetic diet men- tioned in Table 10 in terms of household measure. To a considerable extent this is impracticable, because the diabetic- diet deals with so small a quantity of carbohydrate. For this reason the only safe way for diabetic patients at the commencement of their training is to weigh their food. After a few days of weighing, patients can select utensils which conform to the size of the portions of their own special diets and use these exclusively. Two such utensils are shown in Fig. 10. a b Fig. 10. — a, a ramekin this size holds 45 c.c. of water, or 3 tablespoonfuls; b, a pitcher graduated to 15 c.c.; capacity, 60 c.c. The ramekin level full of Quaker Oats holds 30 grams. When packed tightly with 5 per cent, vegetables or potato it holds 90 grams, but when filled loosely in the ordinary manner, 75 grams. The pitcher holds 00 c.c, or 2 ounces, and is graduated to 15 c.c. (Ramekin and pitcher were arranged for me by Jones, McDuffee & Stratton Company, of Boston, Mass.) DIET OF NORMAL INDIVIDUALS 63 Patients and physicians often err in thinking their com- putations of the diet are extremely accurate. In order to demonstrate the errors which easily arise from general statements about foods. Fig. 11 is inserted. Fig. 11. — Variations in the sizes of common foods. 64 DETAILS OF DIABETIC TREATMENT Fig. 11 shows: 1. How readily errors may occur in estimating the food values of the diet unless definite quantities of foodstuffs arc prescribed. 2. The absurdity of reckoning food values to the fraction of a gram unless actual analyses of each food as served are made. Errors in eggs may compensate themselves, because the eggs average about 60 grams (and must so average in some communities); errors in potatoes, oranges and grape fruit must necessarily be very great. The largest of the three potatoes is actually a small potato; the potato weighing 60 grams is about the size of an egg; the oranges from left to right are sold under the trade names of 120, 170 and 250 (to the box) and the grape fruit under the trade names of 28, 64 and 96 (to the box). Three Eggs. Grams. Grams. Grams. Weight of one egg Protein in one egg Fat in one egg . .... 70 . . . . 7 . . . . 7 00 6 6 50 5 5 Three Potatoes. Weight of one potato .... 120 Carbohydrate in potato ... 24 90 18 60 12 Three Oranges. Weight of one orange Carbohydrate in one . . . . 350 orange . . 20 Three Grape Fruit. 225 15 150 10 Weight of one grape fruit . . . 900 Carbohydrate in one grape fruit . 40 600 30 300 20 It is partly on account of the ease with which large errors in the carbohydrate content of food may occur that it is desirable to give to patients with a low carbohydrate toler- ance their carbohydrate in the form of 5 per cent, vegetables exclusively, for an error in weighing, reaching 120 grams (4 ounces), would amount to but a few grams of carbohydrate. The weights and food values given for the various foods in the illustration are not absolutely but they are approximately correct. CHAPTER II. THE DIET OF DIABETIC INDIVIDUALS. The Normal and Diabetic Diets Compared.— Four-sevenths of the calories of the diet in health are made up of carbo- hydrate, two-sevenths of fat and one-seventh protein; but in diabetes the diet is composed almost exclusively of the latter two foods. This is not discouraging, for until recently the Eskimo's diet contained only about one-seventh carbo- hydrate. It takes time and experience to learn to live suc- cessfully upon a diabetic diet, and it is only with time that the body adjusts itself to a diet with so marked a reduction of carbohydrate and so marked an increase in fat. It is indeed wonderful that it is possible for the body to do so at all. CARBOHYDRATE PROTEIN NORMAL DIABETIC i^^^^ |250 .. : ]5oci. : , [ wmm 75 G. 1 FAT H 6b cj H c. Foods arranged in grams. Fig. 12.— The diet of a normal and of a diabetic individual compared. Weight of each patient 60 kilograms (60 X 2.2 = 132 pounds) . Foods arranged in calories. Fig. 13.— Same as Fig. 12. In Figs. 12 and 13 the carbohydrate, protein and fat in the normal and diabetic diets are graphically compared by weight and by calories. It is assumed in this comparison that a 5, 66 DETAILS OF DIABETIC TREATMENT diabetic patient has a tolerance for 50 grams carbohydrate. It will be noted that the total caloric value of the diabetic diet is slightly less than the normal diet. This is so arranged with design, partly because the diabetic patient is usually less active and partly because, by a slight restriction of diet, the opportunity for improvement of the diabetes is favored. Caloric Needs of the Diabetic. — The diet of the diabetic patient should contain, except for brief intervals, the mini- mum number of calories which the normal individual would require under similar conditions. I am convinced that many normal individuals actually live upon less than 30 calories per kilo, and repeatedly one sees diabetic patients over fifty years of age who comfortably live upon less for long periods. This is true for the untreated diabetic. If the patient is allowed more than the minimum amount of food there is far more likelihood that a portion will be unassimilated and appear as sugar in the urine. One of the first rules for the diabetic patient to learn is never to overeat. He should be a model in food conservation for his household. As a matter of fact, during scientific treatment he always returns a clean plate because his appetite is always equal to the food allowed. Carbohydrate in the Diabetic Diet. — The total carbohydrate in the diet of diabetic patients is almost invariably restricted, and seldom exceeds 100 grams. This is a decrease to approxi- mately 25 per cent, of the normal carbohydrate ration, and so radically changes the composition of the normal diet as to make it self-evident that rapid changes from a normal to a diabetic diet containing even 100 grams carbohydrate might easily cause indigestion in normal as well as in diabetic individuals. The decrease in carbohydrate must be com- pensated by an increase in fat. The Estimation of the Carbohydrate in the Diabetic Diet. — The quantity of carbohydrate in various foods is easily calculated and far more simply than is usually thought. (See Table 10, p. 54, and Fig. 7, p. 52, with accompanying text.) Carbohydrate in Vegetables. — It would appear perplexing to determine the amount of carbohydrate in the various vege- DIET OF DIABETIC INDIVIDUALS 67 tables which the patient eats in twenty-four hours, but this is really not the case. It is true that there is considerable variation in each group in Table 5, but the average content is not far from that represented, the error being on the lower side. This does not hold for string beans, for often trouble occurs from the beans having developed into maturity, thus greatly increasing their content in carbohydrate. Many an unexplained trace of sugar in the urine has undoubtedly occurred in this way. One will not be very wrong if he considers the total carbo- hydrate of the 5 per cent, vegetables which a diabetic patient will eat in the twenty-four hours as 10 to 20 grams. This is why in mild cases of diabetes it is unnecessary to weigh the vegetables, for it is improbable that a patient will eat too much of these. Loss of Carbohydrate in Cooking Vegetables. — Vegetables lose carbohydrate in the cooking, and this loss is favored (1) by changing the water in which they are prepared two or three times, and (2) by preparing the vegetables in finely divided form so that the water can have easy access to the whole mass. Von Xoorden 1 pointed out that 100 grams of raw spinach contained 2.97 grams carbohydrate, but cooked spinach only 0.85 gram. Similarly, 100 grams of ripe peaches contained 9.5 grams carbohydrate, but when boiled and the water changed, only 1.8 grams. Allen 2 has utilized this method of removing carbohydrate from vegetables and thus allows patients to have bulk in their diet. He terms vege- tables so prepared "thrice-cooked vegetables," though at the present moment it seems more appropriate to term them "camouflage vegetables." "Under these conditions the vegetables may be boiled through three waters, throwing away all the water. Nearly all starch is thus removed. The most severe cases generally take these thrice-cooked vegetables gladly and without glycosuria." Patients often say that it makes little difference to them whether the vege- tables are thrice washed or not. It is easy and useful to add 1 Von Noorden: Die Zuckerkrankheit, Berlin, 1912, p. 306. 2 Allen: Boston Med. and Surg. Jour., 1915, clxxii, p. 241. 68 DETAILS OF DIABETIC TREATMENT a little salt, and if desired the vegetables can be flavored with meat juices or meat extracts. Even when vegetables are cooked in the ordinary way, considerable carbohydrate, protein and, what is quite unfor- tunate, salts, are lost. Few analyses of cooked vegetables are available, but some of those which I have found are recorded in the following table: Table 19. — The Influence of Cooking upon the Content of Carbohydrate in Vegetables. Food. Asparagus . Spinach Beans (string) Beets Carrots . Cabbage Greens (beet) Onions . Beets (boiled) Parsnips Peas Potatoes Potato chips Sweet potatoes Carbohydrate: Fresh, per cent. 3.3 3.2 7.4 9.7 9.2 5.6 9.9 16.9 18.4 27.4 Cooked, per cent. 2.2 2.6 1.6 7.4 6.8 3.7 3.2 4 . 9 10.0 13.2 14.6 20.9 46.7 42.1 Through the kindness of Professor Ruth A. Wardall, of the Department of Home Economics of the State University of Iowa, working in Professor Mendel's laboratory in Yale University, I am able to insert Table 20, which shows the carbohydrate in washed vegetables. The results shown in this table are simply preliminary experiments, but they are of so much value that they deserve attention. Professor Wardall finds it no disadvantage to use the boiling temperature for each of the extractions. In the data recorded below the extractions were made by start- ing the vegetables in cold water and then bringing this to the boiling-point and maintaining it at this temperature for one minute. Hot water was added for each of the other extractions, and all were boiled one minute. If the first extraction is kept at 150° F., as has sometimes been recom- DIET OF DIABETIC INDIVIDUALS 69 .5 a Q.J3 CC ° o ^ o si 3 CO O > a IN <-< IN "5 O o Cauli- flower. CD Mush- rooms, Agaricus pestris. iO o o o ^ o oi so C3 -a a O CM >> o CO of Celery A, soaked 2 hours in cold water. CO of 43 '3. CO co" O) Vegetable. | °>*£ |§§J| ?i S 2 "£ ° «3 -^ a c c M a £ ;= o * 2 ts o £ -22 a*-0"g w cu £ ;£ -^ ,c ~ «« ® § •=. M <£ OAST'S? ex £ o> t> ,2 2 a a tf cj ■- p a> g^v^a ^s-iOcoo 70 DETAILS OF DIABETIC TREATMENT mended, the second extraction leads the list in removing carbohydrate, the first extraction ranking after the third or fourth. In general, 100 grams of the fresh, clean, dry vege- table, weighed from the edible portion, were used for each analysis, and all calculations were made on this basis. With the exception of canned asparagus the four or five extractions necessary to remove all reducing substances left the vege- tables still attractive in flavor and appearance. Professor Wardall has further reported 1 that repeated washings with water will remove the carbohydrate from beets and parsnips; 3 in the case of the beets and 7 in the case of the parsnips. For practical purposes three extractions will probably be found sufficient. For the first, place the vegetables in cold water and bring the same to the boiling-point, maintaining the temperature for three to five minutes, but for the others begin with hot water. The Carbohydrate in Various Foods. — 1. Potatoes. — The variation in the percentage of carbohydrate in potatoes before and after cooking is negligible, save with potato chips, in which it more than doubles. The loss of protein is slight, but if soaked in cold water before boiling the loss of protein is 25 per cent, and of mineral matter 38 per cent. If the potatoes are not soaked but dropped at once into boiling water the loss is much decreased, and if the potatoes are boiled with the skins on the loss is very slight. Emphasis should be laid upon the comparatively small amount of carbohydrate in potato in comparison with its bulk and in comparison with the percentage of carbohydrate in bread. A considerable number of my milder cases of diabetes, by giving up bread and bread preparations entirely, have been able to eat potatoes freely. In prescribing potatoes for diabetic patients it is desirable to designate baked potatoes, for these can be eaten with the skins if pains are taken to have them carefully cleaned with a scrubbing brush in the kitchen. This is advantageous in two ways: the skins are quite an addition to the meager diet of the diabetic, and furthermore, they counteract constipation. 1 Am. Med. Assn., 1917, lxix, p. 1859. DIET OF DIABETIC INDIVIDUALS 71 2. Nuts. — Xuts containing 15 and 20 per cent, carbo- hydrate are probably far less objectionable than most other foods with a similar carbohydrate content. This is due to the fact that in such nuts as almonds and peanuts a larger part of the carbohydrate is in the form of pentosan, galactan or other hemicelluloses which probably do not readily form sugar. 3. Fruit. — Fruit is most desirable for a diabetic patient if his tolerance will allow him to take it. The taste is agree- able, it serves instead of a dessert, and so relieves the patient of the embarrassment of sitting idly at the table when others are eating. The best varieties of fruit for diabetic patients are grape fruit (5 per cent.), strawberries (7 per cent.) and oranges (11 per cent.). These fruits are safer for the patient than apples (15 per cent.), because they contain 5 to 10 per cent, less carbohydrate and are more satisfying. Furthermore, it is less easy thoughtlessly to eat an orange than an apple and thus break dietetic restrictions. 4. Oranges. — The quantity of carbohydrate in a small orange is about 10 grams. The same statement will apply to one-half a small-sized grape fruit. One will not be far wrong to consider that one compartment of a small orange contains 1 gram carbohydrate. The illustration on p. 63 shows that larger oranges and larger grape fruit easily con- tain twice as much carbohydrate as do the smaller varieties. 5. Bananas. — Bananas can seldom be taken by diabetic patients because the content of carbohydrate is so high, being equivalent to that in potato. In general, the riper a banana, and for that matter any vegetable or fruit, the more the starch in it has changed to sugar, and also the more carbohydrate it contains. Since unripened fruits with their lower carbohydrate content can be made palatable by cooking, a way is afforded for diabetic patients to use them. 6. Ripe Olives. — Ripe olives make a pleasing change in the diet. They contain 4 per cent, carbohydrate in contrast to green olives, which contain 1.8 per cent. Furthermore, ripe olives are more easily digested. Five ripe or ten green olives contain 1 gram carbohydrate and 5 grams of fat. The quantity of protein in ten olives is about 1 gram. 72 DETAILS OF DIABETIC TREATMENT 7. Milk.— The carbohydrate in milk is in the form of lactose and can be reckoned at 5 per cent., or 1.5 grams per 30 c.c. or 1 ounce. It is the same in skimmed milk, buttermilk and whey; but cream and koumiss contain about 3 per cent., or 1 gram carbohydrate to the ounce. Butter- milk contains essentially the same quantity of carbohydrate and protein as milk, but only a trifling amount of fat. I cannot understand why doctors so frequently give it to their patients. 8. Oatmeal. — Oatmeal is two-thirds carbohydrate. In calculations one should always be guided by the dry weight, because the different preparations vary greatly in bulk and weight when cooked. It is a simple matter for a few days to weigh out 30 grams (1 ounce) of dry oatmeal containing 20 grams carbohydrate, have it cooked and note the bulk. By dividing the oatmeal thus cooked into four portions each would contain 5 grams carbohydrate. In weighing foods one should never attempt to weigh out quantities as small as 5 grams with the usual variety of scales. A more reliable result is obtained by weighing out multiples of 5 grams and then dividing into enough portions to make each portion 5 grams. 9. Bread. — The carbohydrate in white wheat bread amounts to about 53 per cent. If the bread is toasted, enough water is lost to raise the percentage of carbohydrate in the toast to about 60 per cent. If the bread is made without sugar and with water instead of milk the carbo- hydrate content is lowered and may amount to only 45 per cent. Coarse breads if made without sweetening or milk would contain slightly less carbohydrate. It is undesir- able to give bread to diabetic patients unless their tolerance is very high, because they can take so little without causing glycosuria that the bread is simply an aggravation. An error in weight of 1 ounce of a 5 per cent, vegetable amounts to 1 gram carbohydrate, of potato to 6 grams, but of bread to 18 grams. Crackers and zweiback contain still less water than toast, and in consequence the percentage of car- bohydrate is raised to the neighborhood of 70 per cent. Many gluten breads upon the market contain as much as 30 per cent, carbohydrate. DIET OF DIABETIC INDIVIDUALS <3 Protein in the Diabetic Diet. — The quantity of protein required by diabetic patients varies with the age, weight and activity of the case as well as with the condition of the kidneys. It is a safe rule at the beginning of treatment to attempt to increase the protein gradually up to the same quantity as that required by a normal individual. Chittenden points out that 60 grams (one-half the old standard protein) are quite sufficient to meet all the real physiological needs of the body under ordinary conditions of life and with most individuals not leading an active out- of-door life even smaller amounts will suffice. Chittenden, weighing 57 kilograms, and Mendel weighing 70 kilograms, lived respectively on 34 and 41 grams protein daily, the former for nine and the latter for seven months. Until the Chittenden low-protein diet is proved to be entirely satis- factory for healthy individuals over a long period of years it is best not to have recourse to it for long periods in the treatment of diabetes. Temporarily small quantities may be given, but safety lies not far from 1 gram protein to each kilogram body weight. It has been claimed that vegetable proteins give rise to less carbohydrate than do animal proteins. As a matter of fact, carbohydrate may be formed out of any protein. Meat and Fish. — The study of the chemical composition of meat and fish is simplified for the diabetic patient by the fact that except in liver and shell-fish, carbohydrate is absent. Even in liver the quantity of carbohydrate is almost negli- gible when we consider the amount and frequency with which this article of food is eaten. The analyses of liver and shell-fish will be found in the tables on pages 150 and 151. The chief difficulty in computations of the nutritive value of meat and fish is due to the varying content of fat. Thus, the edible portion of chicken may contain on the average only 2.5 per cent, of fat, whereas lean ham may contain 14 per cent, of fat, fat ham as much as 50 per cent., and smoked bacon 65 per cent., though lean smoked bacon 42 per cent. In general, a mixture of cooked lean meats probably contains not far from 10 to 15 per cent, of fat. Fish differs from meat chiefly in the small quantity of fat. 74 DETAILS OF DIABETIC TREATMENT Even salmon, which contains more fat than most other fish, showed in its analysis only 12.8 per cent, fat, shad 9.5 per cent, and herring and mackerel 7.1 per cent. In general, other kinds of fish show 6 per cent, or less of fat. Halibut steak, for example, contains 5.2 per cent, and cod 0.4 per cent. Preserved fish, however, is quite rich in fat; thus sardines contain 19.7 per cent. In substituting fish for meat, my patients are taught to add from \ to 1 teaspoonful of olive oil to the diet for each 30 grams of fish. The quantity of protein in meat also varies considerably and usually falls as the percentage of fat rises. A value of 20 per cent, for protein in uncooked lean meat represents about the average and this is increased to 25 per cent, or more when the meat is cooked. The quantity of protein in fish is very slightly less than that in meat. Fish is especially desirable in the early days of protein feeding following the preliminary carbohydrate-feeding days, because in fish the quantity of fat is so low. Shell-fish make agreeable additions to the diet: (1) they are desirable because they are pala- table; (2) they are bulky foods and so are satisfying; (3) they furnish a separate course at a meal. Half a dozen oysters or clams are quite sufficient. The edible portion of a medium-sized oyster on the shell weighs on the average half an ounce, and half a dozen oysters would amount to 90 to 100 grams. The six would contain about 4 grams carbohydrate, 6 grams protein and 1 gram fat, the equivalent of 50 calories. Half a dozen clams on the shell (edible por- tion) weigh 35 grams and contain 0.7 gram carbohydrate, 3 grams protein, and a negligible quantity of fat. Broths. — Broths are so extensively used on fasting days and for lunches for diabetic patients that their composition deserves notice. As a rule the nutritive value of a broth made for diabetic patients should be negligible. That this may be the case the broth should be skimmed free of fat, and obviously should be clear so as to be free from particles of meat fiber. The broths should be thin, because a jelly- like broth would contain a large quantity of protein in the form of gelatin, and I have known such broths to prevent diabetic patients from rapidly becoming sugar-free when DIET OF DIABETIC INDIVIDUALS 75 they were allowed broths freely on otherwise fasting days. Canned meat extracts contain very little nourishment. The danger in broths lies in the amount of salt which they contain. Frequently this is very great, whereas the amount of salt should be moderate. Patients often desire to drink several cups of broth a day, and if the broth is heavily salted all the salt is not excreted, but remains in the body and retains with it so much liquid that weight is increased, and swelling of the legs or even of the face may develop. (See pages 79 and 108.) Fat in the Diabetic Diet. — Fat forms the bulk of the diabetic patients' diet. Even with the most modern ideas upon treatment this statement holds. Figs. 7 (p. 52), 12 and 13 (p. 05), and Table 16 give the proportions which the different foodstuffs take in the diet and show the extent to which diabetic patients must depend upon fat to offset the loss of carbohydrate. Remember that the diet of a healthy individual of 70 kg. at office work contains approxi- mately 300 grams carbohydrate, yielding (300 X 4) 1200 calories, and if nearly all this quantity is unutilized by the .diabetic patient, it can be calculated how many calories in the form of fat must be given to replace it. Theoretie.illy, these 133 grams -^— ^ — fat should be taken in addition to the usual 100 grams of fat in the normal ration; but practi- cally this is seldom necessary, partly because the diabetic patient is usually less active than the ordinary individual. Furthermore, most diabetic patients have a tolerance for quite a considerable quantity of carbohydrate. Finally, these calculations are made for a patient weighing 70 kilo- grams. In reality most diabetic patients weigh far less and therefore require less food. The Eskimos live largely upon fat. Diabetic patients should be very thankful that there is a race of Eskimos through which proof is afforded that it is perfectly possible to maintain life on a diet in which carbohydrate is largely replaced by fat. How much fat should a diabetic patient eat? This does not depend upon the capacity of the digestion. The safest 7G DETAILS OF DIABETIC TREATMENT answer would be: as little as possible in order to maintain body weight. Unquestionably the quantity will vary from time to time, and it may increase with years without detriment to the patient. Nevertheless I am always glad to see a diet which contains as much or half as much carbo- hydrate as fat; in other words, a carbohydrate-fat ratio of 1 : 1 or 1 : 2, respectively, and dread to see one with a car- bohydrate-fat ratio of 1 : 5 or above. Fat is most agreeably taken as cream, and cream which contains 20 per cent, butter fat is usually easier to bear than a richer cream. It is seldon advisable to allow more than half a pint (240 c.c.) of cream, although patients prefer to increase the quantity of cream at the expense of other forms of fat in the diet. There is no other form of food from which a diabetic patient can derive more pleasure for its caloric value and yet with less harm to himself than from cream. Half a pint of 20 per cent, cream contains 48 grams of fat, and yet the quantity of carbohydrate or of protein in cream of this richness is but little over 8 grams, and may be esti- mated in clinical work as 8 grams, or 1 gram to the ounce. Occasionally patients tolerate butter more readily than cream, and, as a rule, fresh unsalted butter is preferred. Obviously, when cream is increased in the diet, the butter must be decreased, and vice versa. Thirty grams of butter contain 25 grams of fat, and this is a welcome addition to the diet. Oleo, butterine and nut margarine contain no sugar and have about the same percentage of fat as butter and the cost is very much less. Lard being nearly 100 per cent, fat can be used to advantage more than it now is in the diabetic's diet. Crisco, also nearly 100 per cent, fat, is often more wel- come than lard, because of its lack of flavor. Oil is an ideal diabetic food, because it is a pure fat. Oil is so desirable for a diabetic that I hesitate to have a patient take more than 15 grams (1 tablespoonful), lest he weary of the same. If oil is disliked upon vegetables it can be taken in small quantities after meals as a medicine. Italian patients naturally bear olive oil unusually well. Olive oil forms an excellent lunch for diabetic patients. I frequently advise its use upon retiring. It is the diabetic patient's cough DIET OF DIABETIC INDIVIDUALS 77 medicine; it relieves the symptoms of his hyperacid stomach. Peanut, corn or cotton-seed oil may be substituted if expense is a factor. The Danger of Fat to the Diabetic. — Fat is the chief source of the dreaded acidosis, though to this in lesser degree the amino-acids of the protein molecule with even numbers of carbon atoms contribute as well. Fat, therefore, at one time may save the life of the diabetic, but at another period may destroy it. The close dependence of acidosis upon a fat diet is beautifullv shown in Table 21. Table 21. -The Dependence of Acidosis upon the Fat in the Diet (Williams and Dresbach.) U rine. Diet. Date. Diaoetio acid. Total • XH:, (Folin), grams. Total sugar (polar), grams. Carbo- hydrate, grams. Protein, grams. Fat, grams. 1912 July 5 + + , 1.9 48 20 100 200 6 + + 2.1 27 65 100 200 27 + 0.6 30 90 33 74 Aug. 8 + + 2.7 86 190 75 200 Oct. 20 + 0.6 45 64 75 30 31 0.3 38 45 75 30 Nov. 12 0.5 56 56 75 30 1913 Jan. 28 + + + 2.6 122 35 100 21 11 1 Feb. 2 + + + 3.0 152 66 90 200 June 12 + + + + 4.1 IDS '.)() 100 21 i( ) July 27 + + + + 4.4 12.5 200 150 180 f 31 + + + + 3.3 172 200 150 180 + There is no more potent agency in the prevention of acidosis than the withdrawal of fat from the diet. Allen has made us all his debtors by a series of experiments upon diabetic dogs which show the insidious way in which fat is harmful in the manner in which it has been customarily employed in the treatment of diabetes. " Fat unbalanced by adequate quantities of other foods is a poison." Alcohol. — The use of alcohol in diabetes would seem to be indicated, but, as a matter of fact, there is but a small per- 78 DETAILS OF DIABETIC TREATMENT centage of my patients who employ it at all. Theoretically, 1 c.c. of pure alcohol yields 7 calories in its combustion. Thus, 15 c.c. (1 tablespoonful) of alcohol or its equivalent — 30 c.c. (2 tablespoonfuls) of whisky, brandy, rum, or gin — would yield 105 calories to the body. Seldom, however, do I prescribe it for patients, and this rule holds even for patients during days of fasting, Most of the physicians with whom I am acquainted treat a large majority of their patients without alcohol in any form. Liquids. — It is rarely necessary to restrict the liquids in diabetes. The diminution of the carbohydrate in the diet with the resulting fall in the excretion of sugar usually leads to a corresponding diminution in the thirst and quantity of urine. I hesitate to restrict liquids in severe diabetes for fear too little liquid will be available for the body with which to eliminate the acids which may have been formed. On the other hand, patients often upset the digestion by drinking large quantities of liquids rapidly. This is avoided by allow- ing only half a glass of liquid at a time, though the patient is instructed to take that as frequently as desired. Case No. 1196 continually voided large quantities of urine, but usually I could find a cause such as the ingestion of 20 or more grams of salt, bouillon cubes in variable number or 21 half-grain saccharin tablets a day. Ice-water should be discouraged. Sodium Chloride. — Salt is of great service to the diabetic patient. If it is withdrawn from the diet the weight falls, due to the simultaneous excretion of water, and the skin and tissues of the patient are obviously dry. In the early days of fasting treatment, patients often lost much weight because water alone was allowed. For example, I learned of one case who lost thirteen pounds in four days in this manner. When broths are freely given during fasting it is not uncommon, particularly in the presence of acidosis, to see a patient gain weight, and invariably such patients feel better than those who lose. Salt is very freely used by diabetic patients. I do not remember to have ever seen a diabetic patient who took too little salt. One of my fasting cases was accustomed to DIET OF DIABETIC INDIVIDUALS 79 shake it into his hand to eat. Patients will often salt their broths, although they contain considerable salt. The fact that it is harmful for a diabetic patient to take large quantities of salt is frequently shown by the excessive quatities of urine which they are obliged to void, though sugar-free, and by the swelling which may appear in legs and ankles. However, it should be stated that I have never known a patient with dropsy to develop diabetic coma, and I recall but one instance of a patient in diabetic coma in whom dropsy appeared. The withdrawal of salt from the diet of Case No. 137S wrought surprising changes in her weight and her dropsy entirely disappeared. From 98 pounds it fell to 70 pounds in twenty-five days and this was due almost exclusively to the disappearance of the dropsy. CHAPTER III. THE TREATMENT OF MODERATELY SEVERE AND SEVERE CASES OF DIABETES. The object of diabetic treatment is to enable the patient, by rearrangement of his diet and habits of life, to live in a maimer similar to that of the healthy individual. This object is best attained by preventing the loss of sugar in the urine — in other words, by keeping the urine sugar-free. Cases Nos. 804, 1024, 894, 564 and 632 illustrate successful treatment. Case No. 804 contracted diabetes at the age of forty-two years, and first consulted me four years later, December 17, 1914, at the age of forty-six. His weight at that time was 139. The quantity of sugar amounted to 5.6 per cent., and acid poisoning was present. With restriction of diet and fasting he became sugar-free on December 30, and the acid poisoning disappeared on January 7. He left the hos- pital sugar-free, having gained one pound by January 11, and a year later his weight was 150. Difficulty occurred in keeping sugar-free, and he returned for hospital treatment on April 22, 1917, showing in a twelve-hour specimen 2.5 per cent. (66 grams) of sugar and severe acid poisoning. In Table 22 it will be seen that even four days of fasting did not suffice to rid the urine of sugar. This was followed by three days of restricted diet, when the institution of one fast day made the urine sugar-free. On May 18 he left the hos- pital free from acid poisoning and sugar, and weighing 134 pounds. His diet then contained carbohydrate 15 grams, protein 71 grams, fat 122 grams, and alcohol 12 grams, making a total of 1526 calories. By August 17 he had been able to increase the diet to 50 grains carbohydrate, about 110 grams protein, and 110 grams fat, making 1600 to 1800 MODERATELY SEVERE AND SEVERE DIABETES 81 ■ ^ oS C Ol lO lO O >-i O M o CN —1 ^H i-H rt 2 3 £ O O O O O a •O -w «j Nake weigh n C * O -^ M M ?1 ?] K S -t -f -f lO -t i9 M C S 3 i3 3 -f ■* ^ U5 xx^ircrc^c^xrorororc^fccoco^wxrcx^rccorcrcro i o"» . x a a a t, ^ ?J 2 ifl^NN WM ;c: 01 h o 3 3 0!05010»HMiOiOiOO iiro^H^H o O O " t) O _, ,_, ^ ^_ ,_ uO -7" E 1 1 1 1 1 1 1 1 + + + + + + + + + + + + + + ies. NO'HOMfflOOOTtiOlN^XW'S'OOMNOtSO g 1 I OOOOW(0iMHffi(i0!0hNiflt.H00H01PlHfli!0SNMM 1 ' fl •* O N O X h X * - - M CSlHHNHM^iOiOC o ■ o o 1 1 00©©0>) O i.) o to O O O O O O !' 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(C ~ Am- moni; tota gram 01 CO iC • Ol Ol i-H ~ 'S + ,-i-oo-roo-r . . . .oooooooooooooo "E (fi K !/! !C C3 + s -H01CO'tLOcSN»010H(NW'*iOtONXfflOH(NCO'*iO!ON»N 7* 1 1 I 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 £'-' O 1 1 1 1 1 1 1 1 1 1 1 1 a HN«io 'jBSns poojg © © 'ingnui !!.;:;; «^ ja^siq •;usD © p J8d 0^ 'UJB8J3 © 03 M .s •ja^ng © CO a a a CO o ft •uooBg >o >. •s33a CO a Q "H S U o © ■^uaa jad 9 o o o o o o o o © © sajqB^aSa^ i iO o CO o CO © © o CO "lyBiBM. i © 1 CM © 1 1 1 © © © ai CO Oil •S8UO[BQ i o o o o © CM CO o CO o CM © 00 H 43 o 00 • CM -o a •^d i o o o o o o o o © a a o "^ •uia^ojg i o o o o o CO iO o iO n el 03 •satcjpXijoqj'Ba i o o o o o »o o o CM © CO 44 CO CI •SU1BJ3 t~ 00 CO CO o o o o © o © '[B^OX © rt -*^> H 03 U 3 OQ ■* CM N. CM o •^uaa jag o o o o © © "tf T— t o o t> + + + + + + + •piOB OI^aOBIQ + + + + + + o © + + + 03 VI m ■* Eb © t^ CO © © ^ CM CO © a»co CM cm CM CM ^T 1 *s P. CO I 1 1 CO 1 I CO 1 © 1 © 1 1 CM £© -t--" CM CM cm MODERATELY SEVERE AND SEVERE DIABETES 87 Preparation for Fasting. — In severe, long-standing, complicated, obese, and elderly cases, as well as in all cases with acidosis, or in any case if desired, without otherwise changing habits or diet, omit fat, offer two days omit protein, and then halve the carbohydrates daily until the patient is taking only 10 grams; then fast. In other cases begin fasting at once. Fasting. — Fast four days, unless earlier sugar-free. Allow water freely, tea, coffee, and thin, clear meat broths as desired. It is important for the patient to observe how his physician frees the urine from sugar in his particular case, because later, if sugar should return, he should follow the same plan by himself. An example of fasting treatment is shown in Table 23. This patient was twenty-two years of age and had previously been accustomed to a low diet, but had neglected treatment, and returned for hospital care with 4.4 per cent, of sugar and in a serious condition with much acid poisoning. This is shown by the diacetic acid in the urine being recorded -f- + +, four + signs (+ + + +) being the maximum according to my scale. It will be observed that during one day of fasting the quantity of sugar dropped from 97 to 13 grams, and the percentage of sugar to 1.2 per cent. During the second day of fasting, 8 grams of sugar were excreted, merely a trace on the fourth da}', and the fifth day of fasting made the patient sugar-free. Table 24 shows how Case No. 938, a child, aged two years and four months, became sugar-free in two days with a moderately restricted diet for the first day, and with fasting for the second day. Table 24, -Case No. 93S. Aged Two Years, Four Months. Onset September, 1915. Date. Urine. Diet. Diacetic acid. Sugar, per cent. 1915. October 25 October 25-26 October 26-27 + 7.6 3.2 Diet unrestricted. Diet moderately restricted. Fasting. 88 DETAILS OF DIABETIC TREATMENT It will be observed that diacetic acid appeared October 26 and 27. In 1915 I did not appreciate the necessity of completely omitting fat prior to fasting. I doubt if this appearance of diacetic acid would occur at present, because during the last two years measures taken for the safety of the patient at the beginning of treatment have increased enormously. One of the most satisfactory cases which I have treated was a man, Case No. 1237, aged thirty-nine years, who looked like a severe diabetic, but proved to be a moderate one, with whom the following simple schedule of diet worked admirably. It will be seen that the patient did not fast at all, main- tained a high quantity of protein in his diet, and yet he became sugar-free on the seventh day of treatment without the development of acid poisoning. Although he did not enter the hospital, he came to the office each day until the urine was sugar-free. The case is all the more remarkable because the duration of the disease before treatment was a year and a half. In consequence of his lack of treatment, his weight had fallen from 210 pounds to 142 pounds. (Com- pare this case with Case No. 653, described in Part I, Chapter 2, p. 22, for whom treatment was begun early.) When first seen the sugar in the twenty-four-hour quantity of urine of ( ase No. 1237 was 336 grams. The directions given the patient may be summarized as follows: 1. Take \ pound (240 grams) 5 per cent, vegetables, \ pound (120 grams) fish, and one small orange at each meal for two days. 2. On the third day omit half and on the fourth day all the orange. 3. When sugar-free, exchange \ pound (4 oz. = 120 g.) fish for 3 ounces (90 g.) meat and next replace another \ pound fish by 4 eggs. 4. Then replace 2 eggs with 2 ounces (60 g.) bacon and subsequently add \ ounce (15 g.) butter a day for two days, to be followed every other clay by the addition of 1 ounce (30 c.c.) of 20 per cent, cream until 3 ounces are taken. MODERATELY SEVERE AND SEVERE DIABETES 89 o & H m < U fc r» a w H F-> O ?; « n P* § N O w > Jn 0! O £ a ■< O rfl « « o P >H fc H W < £ s* H H P « O - - H -I IS i^T Eh -- A 3 En < K H - >< - a En z hJ P H m H J. o In C H <" £ o a - < <1 « H M t^ PCO »J. u - 5 •^uao CM COCO jawing ~~~~ uooug CNtNcNCNCN •s83a •* CN CM •* -tf •juao jad c •sa]qiu>r:-i \ CNCNCNCNCNCNCNCNCNCNCNCNCN •}U30 a B oj bO a CO B » % a E >. u 03 a (5 jaa Oo ui«<«;j •jjung oooo • II • > . > l : 5. [ ■S333 H^K •aitui:j( > CO CO — i C O OC C O OO rH il s !i ooooooooooooo •- cc: cr cc ci cc -r cm m cm cm cm cm MMKMCCCC!N«rHr-^.-rH ■joao j.mI g 'sa[qi:;,>7>.) \ OOOOOOOCOO'OCO "i cm ci:ici:i:i m ?j m m cm m spunod '-MIDWAY • -CM • ■ -O - • -00 -tO . -^cf • • -co ■ ■ *co -co oi 1 _B 1 P s,)UO[EJ ■ • • CM CN CM 1^ CO t*- CN ~ CM CM EC • • • co co co .: x. ro \z a cm ccr~ . . . T^ -^ tJH lC I> Cyi ^ CN -^ ^ O . . . r-» --< r-i »— 1 CN ■ V*& OOOOOOCONOli'.i* _ ,>-i«i>oooe300o 'o s e3 o j ■ -£ Date, 1916. _C5 +j si >> ft -Si c 2 t 03 v M a '3 03 a ~ O a '3 O j5 03 oi a 03 6 "5 03 oj ft ? - 7. ,fi o> z OS « "c3 £ i Q fa H O £ fa O > o fa W < O fa Jan. 25 7.4 25-26 6.2 54 130 26-27 5.6 Ml 142 48 16 944 128 300 1 1.0 90 100 1 90 6 27-28 4.0 70 112 43 16 764 128 300 1 1.0 90 50 1 90 6 28-29 (1 2.2 26 72 38 16 5S4 1 28 300 1 2.0 90 90 6 29-30 II 1.0 14 50 28 11 411 127 300 1 1.0 30 60 6 30-31 0.6 8 40 28 1 1 371 127 300 1 0.0 30 (10 6 Feb. 31- 1 1) 0.2 2 25 26 5 249 126 300 0.5 30 20 6 40 1- 2 II 0.0 25 27 8 280 126 300 0.5 30 40 6 20 1917 Feb. 16 Trace Fasting. — Fasting is never so rigorous as doctors or patients expect. Patients are more ready to undergo it than physi- cians to prescribe it. Quite as often it is as much a relief to the patient as it is discomfort. This is in part due to the gradual decrease in thirst and frequent urination. Headache occurs less frequently than would be expected, and is usually dispelled by a cup of coffee. Nausea almost never occurs unless a patient is given alkali or alcohol. Children bear MODERATELY SEVERE AND SEVERE DIABETES 91 fasting more easily than adults. Case No. 799 with onset at eighty-three, shunned it and rightly, but she became sugar-free and now, two years later, is vigorous, remains sugar-free and is actually able to eat apple pie and put sugar in her coffee without sugar occurring in the urine. It is always desirable to avoid fasting in the old, and this can be accomplished usually by the help of preparatory treat- ment. Fasting does not seem like fasting to the patients when they receive coffee, tea, cracked cocoa, cocoa shells and broths, and are given an unlimited supply of water. Warm drinks are preferable. If the quantity of urine, as it often does, falls to less than normal, the patients are urged to drink water freely. Clear meat broths are a great satis- faction. An analysis of the 1220 c.c. of broths taken by Case No. 765 during three days, showed the total amount of calories therein contained to be negligible. Contrary to my experience with digestive cases, broths do not stimulate the appetite in fasting diabetics; they relieve it. The advan- tage of broths is probably due in part to this, but to a con- siderable extent to the patient receiving salt by which he •may maintain the equilibrium of body fluid. Patients need not be kept abed during fasting, neither should they be forced to be up all day. Reclining in a steamer chair requires no more exertion than rest in bed. Remember what happens to an old man who is suddenly confined to bed, and the discomfort which follows confinement after a fracture. Do not force a temperate man to drink against his will. Patients should be afforded diversion by brief visits from friends, walking short distances, easy handiwork, playing games, letter writing, and reading. In general, they are glad to rest for the greater part of the first day of the fast, but upon each succeeding day I have noticed that they are desirous to increase the amount of exercise. An advantage which the omission of fat from the diet affords is the rest which is given to the digestive tract. Former treatment, which increased the fat in the diet, was the converse of this, and frequently led to vomiting, with the result that patients on the verge of coma fell into it. In every way seek to prevent worry on the patient's part, and 02 DETAILS OF DIABETIC TREATMENT from the start give them to understand that they are at school rather than at hospital. Patients upon a low diet should be guarded from infections. If a nurse has a cold she should be relieved from duty, cer- tainly from duty near diabetics. For this reason, when on a low diet, patients should keep out of street cars and shim congregations of people. It is surprising how variable is the period required to render the urine sugar-free. Frequently a urine which con- tains 7 per cent, of sugar becomes free from sugar after fast- ing for four meals, and, conversely, a urine with only .3 per cent, of sugar may still retain traces after the patient has been deprived of food for three or four days. Cases present- ing acidosis I believe invariably require longer to become free from sugar. In general, cases seen soon after onset become sugar-free promptly, whereas the reverse is true for those of long duration. However, Case No. 733, age at onset seventeen years, was fasted twenty-six months later, when he showed 6.6 per cent, of sugar and became sugar-free in two days. The explanation in this instance was apparently the fact that the case was remarkably mild, being of the obesity type; in fact, the patient's highest weight — 196 pounds — was reached when he first came under observation, and during the preceding twenty-six months he had gained twenty-six pounds. Children showing large amounts of sugar have also become sugar-free very promptly when the duration has been only a few weeks. Cases of long standing appear to become sugar-free more quickly with preparatory treatment than with an immediate fast. This is probably due to the avoidance of acidosis. Rarely is it necessary for a patient to fast more than a few days, and I usually prefer, after four days of fasting, if the urine still contains sugar, to feed the patient for two days and then fast again. The general rule which I have as a guide is as follows: Intermittent Fasting. — If glycosuria persists at the end of four days, give 1 gram protein or 0.5 gram carbohydrate per kilogram body weight for two days and then fast again for three days unless earlier sugar-free. If glycosuria remains, repeat and then fast for one or two days as necessary. If there is still MODERATELY SEVERE AND SEVERE DIABETES 93 sugar, give protein as before for four days, then fast one, and then gradually increase the periods of feeding, one day each time, until fas-ting one day each week. I have seen no uncom- plicated ease fail to get sugar-free by this method. Carbohydrate Tolerance. — Inspection of the various charts above cited will show that when the twenty-four-hour quantity of urine has been free from sugar it is the custom to increase the carbohydrate, and this is usually done to the point at which sugar returns. In this way the tolerance of the patient for carbohydrate is determined. My rule is: When the twenty-four-hour urine is free from sugar, give 5 to 10 grams carbohydrate (150 to 300 grams of 5 per cent, vege- tables) and continue to add 5 to 10 grams carbohydrate daily up to 50 grams or more until sugar appears. The carbohydrate is generally given in the form of 5 per cent, vegetables, choosing those which are especially bulky. A plateful of lettuce appeals much more to the patient than a small saucer of string beans. When a mixture of 5 per cent, vegetables is given, one can be quite sure that the average content of carbohydrate is not more than 3 per cent., or •approximately 5 grams for the 150 grams prescribed, and for convenience this is reckoned as 1 gram of carbohydrate for each 30 grams (1 ounce). This small amount of food, of course, has little nutritive value, but is enough to break the fast. Upon succeeding days, 5, 10 or even more grams of carbohydrate, varying with the severity of the case, are added daily until sugar returns or the approximate quantity is reached which it appears probable the patient will tolerate. It should be borne in mind that a patient fasting or on a very low diet often shows an apparent tolerance for carbohydrate far in excess of that which he would have shown if the neces- sary protein and fat in his diet were simultaneously ingested. Following the trial with 5 per cent, vegetables, one can proceed to the 10 per cent, group and these can be empir- ically reckoned as containing 6 per cent, carbohydrate or approximately twice that of the 5 per cent, group, or 5 grams carbohydrate for 75 grams vegetables. From this point onward the addition of carbohydrate can be made according to the desire of the patient. The foods commonly employed 94 DETAILS OF DIABETIC TREATMENT in determining the tolerance for carbohydrate are : 5 per cent, vegetables, oranges, oatmeal and potato. With children one often makes the mistake of increasing the carbohydrate too rapidly, forgetting the fact that 5 grams of carbohydrate to a child weighing 20 kilograms is in the same proportion as 15 grams of carbohydrate to an individual of 60 kilograms. The increase in carbohydrate is also illustrated by Case No. 1209, Table 27, whose chart, however, shows how sugar sometimes appears in the urine when if the doctor's advice had been followed it would have remained absent. This little boy ate candy, and though the quantity of sugar in his urine had fallen to 1 gram on January 3-4, it re- quired two days of fasting following his use of candy for it to disappear. Once again he broke rules and fasting was necessary. Gradually he learned his lesson, at least tem- porarily, and left the hospital with a tolerance for 37 grams of carbohydrate and 50 calories per kilogram body weight. Protein Tolerance. — When the urine has been sugar-free for three days, add about 20 grams protein and thereafter 15 grains protein daily in the form of egg-white, fish or lean meat (chicken) until the patient is receiving 1 gram protein per kilogram body weight or less if the carbohydrate tolerance is zero. Thirty grams of fish or an egg of average size contain approximately 6 grams of protein and 30 grams of lean meat contain approximately 8 grams. The white of an egg con- tains 3 grams of protein. By this arrangement a patient weighing 60 kilograms would be taking, within six days from the time he became sugar-free, 1 gram of protein per kilo- gram body weight. This quantity is quite satisfying to all except children — in fact, it is astonishing to me to find how few patients care to take as much as 1.5 grams of protein per kilogram body weight. Children, however, crave and need considerably more, and indeed take with avidity as much as 2 to 3 grams protein per kilogram body weight. Fish is especially desirable in the early days of protein feeding because it contains so little fat. Cod, haddock and flounder, for example, contain less than 1 per cent. MODERATELY SEVERE AND SEVERE DIABETES 95 o w o o w X * r H Q Q fa g O fa <;h OS DO c CI fl rH Q fa « fa Ed «1 o o o J w o -.o '-^uao jad of 1 mrcajQ •ja^ng •uojbjj aajj-Jt'Sng •33 3 •^ajM ■naspiqQ "4«!jI qcaui^O •!}U9D jad 2 a[quia3aA OOiOOO ■-< (N i-i CO CO a> a o> s 2; hnon cm 01 --i ** **< ooooo 00:0:00 ooooo ooooo ?oooooooo ooooo TfOOOOOOOOOO ooooo ooo -ooooooo QOOOO oo • o om >o oooo>o coco • co CO 1 * ■* oocociit- sq[ '}q3ia.\i paqra]^ •sauopjQ qoqooiy •w& •uia'jojfj aj'CjpXqoqjBQ •suiiuS piioj. •}uao ja,j •pioB arjaoBiQ •ZT6T>^a O ■"* • -l CO CI CO i-c >-l CM CO CO t- OS O 01 CI 'OOOOOOOOOOO OOOOO IOOOOMOMG0OC0 (N t» t~ ->5 a a s £ do c J3 o — & C3'C M tions. 'v t- u n" ■§ t. "5°o ■w i. & o C3© O ft s a &» os a •3 OH Ph fe Q «3 O Flours and Meals. — Continue* I. Jireh Diabetic Food Co., Nev 7 York: 1906 Diabetic Flour .... 12.1 1.8 72.7 355 1913 Flour 14.4 2.3 72.9 60.9 370 1913 Patent Barley 11.4 1.6 80.2 67.8 381 1913 Patent Cotton Seed Flour 49.4 12.7 21.3 6.0 396 1913 Patent Lentils Flour 27.3 1.2 59.8 42.6 359 1913 Protein Flour 31.4 2.0 56.7 48.5 370 1913 Soja Bean Flour . 42.3 18.2 25.8 0.0 435 1913 Wheat and Barley Flour 11.8 1.9 73.5 66. 2 l 358 1911 Johnson Educator Food Co. Boston, Mass.: Educator Standard Gluten Flou r 40.1 1.4 50.2 40.9 374 1912 The Kellogg Food Co., Battlt Creek, Mich.: 20 per cent. Gluten Meal . 27.5 0.5 71.7 49.6 357 1913 40 per cent. Gluten Flour . 43.7 0.9 47.3 40.5 367 1912 80 per cent. Gluten . 81.3 0.9 6.2 365 1913 Eugene Loeb, New York: Gluten Cracker Meal 27.8 7.7 53.5 40.2 394 1913 Imported Gluten Flour . 76.3 0.9 11.8 4.4 361 1913 Pure Gluten Flour . 40.3 2.4 46.3 39.6 368 1913 Whole Wheat Flour . . . 14.6 2.2 70.5 54.6 360 1913 Gluten Flour 43.9 1.1 44.4 39.8 363 1915 Lister Bros., New York: Diabetic Flour .... 84.5 3.6 372 1913 Thos. Martindale & Co., Phila.: Special Gluten Flour 40.3 1.5 49.1 41.4 371 1913 Mayflower Mills, Ft. Wayne, Ind. Bond's Diabetic Flour . 40.2 1.3 48.3 40.6 366 1913 Theo. Metcalf Co., Boston, Mass. Soja Bean Meal, 18 per cent starch 41.0 20.0 25.0 444 1913 Vegetable Gluten, 8.1 per cent starch 80.4 1.5 9.8 5.9 374 1913 Pieser Livingston Co., Chicago: 1.3 46.2 38.4 370 1911 Pure Gluten Food Co., New York 1.6 50.8 42.4 371 1906 Gum Gluten Ground 50.1 1.9 39.6 38. 6 2 376 1906 Hoyt's Gum Gluten 31.8 1.6 52. 2 358 1914 Hoyt's Gum GJuten Biscui t Crisps 52.7 0.5 38.0 31.2 368 1 Possibly in part due to the copper-reducing power of the agar agar present. 2 Determined by the diastase, etc. (see preceding page). DIET TABLES 157 So-called Diabetic Prepara- tions. a .5 ° O ft e o <0 "3 . ° u .n © O a o3 ft 02 &> en o> g c3 "3.2o o SO O Flours and Meals. — Continued. Pure Gluten Food Co., New York: 1914 Breakfast Food . 45.4 0.9 46.4 39.2 375 1914 Flour, 50 per cent. 49.7 1.2 41.5 37.1 375 1914 Flour, Ground 41.9 0.9 48.1 42.6 369 1914 Granules . 42.7 0.7 48.8 41.9 372 1914 Noodles 40.5 1.2 49.1 41.8 369 1914 Self-raising Flour 42.7 0.8 45.0 39.0 357 1914 Special Flour 90.7 0.7 1.7 2.2 376 1914 No. 1 Dainty Fluffs 79.9 0.5 11.3 10.7 370 1914 No. 2 Dainty Fluffs 66.3 0.5 24.9 21.9 369 1913 Sprague, Warner & Co., Chicago: Richelieu Gluten Flour . 47.7 1.2 39.7 31.6 368 1913 G. Van Abbott & Sons, London: Almond Flour 24.6 58.6 7.9 0.0 657 1913 Gluten Flour 75.1 0.9 12.6 12.4 359 1913 Wilson Bros., Rochester, N. Y. : Gluten Flour, f Standard . -20.8 2.1 64.6 54.6 361 1913 Self-raising, f Standard 17.4 2.0 63.5 51.8 342 1913 Waukesha Health Products Co., Waukesha, Wise. : Hepco Flour 42. 9 1 20.8 22. 3 2 trace 448 Breakfast Foods. 1913 Brusson Jeune, Villemur, France: Farine au Gluten .... 33.9 0.6 53.8 48.8 356 1910 Gluten Semolina .... 17.2 0.5 71.6 64.9 360 1913 Farwell & Rhines, Watertown, N. Y.: Barley Crystals 11.5 1.3 75.2 62.7 359 1913 Cresco Grits 17.8 1.4 68.6 54.1 358 1908 Hazard's Wheat Protein Break- 40 1 1.0 49.7 368 1913 Health Food Co., New York: Manana 37.6 1.9 46.8 31.0 355 1913 Jireh Diabetic Food Co., New York: Whole Wheat Farina 12.9 2.3 74.6 59.5 371 1913 Frumenty 12.3 1.7 77.3 65.4 374 1911 The Kellogg Food Co., Battle Creek, Mich.: Granola . 13.9 0.8 76.3 45.2 368 1 Determined by the diastase method, without previous washing with water, and calculated as starch. 2 Chiefly derived from Soy bean and therefore non-assimilable, and for patients can be considered carbohydrate-free. 158 DIABETW MENU AND FOOD VALUES o a So-called Diabetic Prepara- a "5 %£ "2 2™ g tions. a a ° — o 8 " *z 3°o — &> i. oj O (SO o a. i a s» a O, - o-. ftn fn O m o Breakfast Foods. — Continued. 1911 Pure Gluten Food Co., New York: Gum Gluten Breakfast Food . 37 . 8 1.3 51.8 37.9 370 1911 Gum Gluten Granules . 45.5 1.6 43.6 32.3 371 1901 Pure Gluten Breakfast Cereal . Waukesha Health Products Co., Waukesha, Wis. : Hepco Grits 1 Macaroni, Noodles, etc. 43.7 1.6 44.4 367 1906 Pure Gluten Food Co., New York: Gum Gluten Macaroni . 41.4 1.0 46.3 46.22 360 1911 Gum Gluten Noodles 36.6 2.4 51.4 42.0 374 1910 Brusson Jeune, Villemur, France: Pates aux Ocufs Macaroni . 13.9 0.4 76.2 69.2 364 1910 Pates aux Oeufs Nouillettes 14.4 0.5 75.7 68.9 365 1913 Petitcs Pates au Gluten 18.6 1.0 70.4 61.2 365 1910 Vermicelle au Gluten 18.4 0.4 72.4 65.8 367 1913 Jireh Diabetic Food Co., New York: Macaroni 16.9 0.9 71.4 58.8 361 1913 Eugene Loeb, New York: Home- made Noodles 41.8 5.5 41.7 36.7 384 1913 Gustav Muller & Co., New York: Dr. Bouma Sugar-free Fat-milk 3 2.4 5.3 57 1913 D. Whiting & Sons, Boston: Sugar-free Milk (ave. 3 5 7 7.2 trace 88 Soft Breads. 1913 Ferguson Bakery, Boston, Mass. : Gluten Bread 24.2 3.1 33.6 25.2 259 1906 Health Food Co., New York: Glutosac Bread 27.4 2.7 36.1 29.91 278 1914 2.1 31.1 22.2 1906 Health Food Co.: Protosac Bread 32.5 37.0 1.6 292 1914 1914 Protosac Bread J. Heinbockel & Co., Baltimore, Md.: 29.8 1.8 35.2 27.7 276 Diabetic Bread for Diabetes 8.6 1.5 52.1 40.4 256 1906 Jireh Diabetic Food Co., New York: Whole Wheat Bread . . . 9.4 48.6 0.4 236 1 Said to be identical with Waukesha Hepco Dodgers. 2 Determined by the diastase, etc. (see preceding page). 3 Water 91.8 per cent. DIET TABLES 159 So-called Diabetic Prepara- tions. a .5 ° a u go. o ■fig ° u Si a O C3 O. a> m "3.2o O Soft Breads. — Continued. 1913 Eugene Loeb, New York: P. & L. Genuine Gluten Bread 10.4 2.6 53.7 44.2 280 1914 P. & L. Genuine Glubetic Bread 38.8 4.1 25.7 19.2 294 1915 Lister Bros., New York: Casein Bread 36.6 18.4 322 Hard Breads and Bakery Products. 1907 Bischof & Co., London: Diabetic Gluten Bread . 73.1 0.5 14.3 •• 354 1907 Essential Bread for Super-Ali- mentation 26.6 1.6 59.6 359 1912 Brusson Jeune, Villemue, France: Gluten Bread 37.3 1.8 47.1 40.1 354 1909 Callard, Stewart & Watt, London: Almond Biscuit, plain . 28.3 28.0 36.8 512 1909 Almond Shortbreads 19.5 52.1 27.0 630 1913 Casoid Biscuits, No. 1 . . . 66.8 18.8 5.8 4.0 460 1909 Casoid Biscuits, No. 2 . . . 57.8 25.5 5.6 0.0 483 1909 Casoid Biscuits, No. 3 . . . 54.3 25.0 7.8 trace 473 1909 Casoid Dinner Rolls 78.0 11.1 2.1 420 1909 Casoid Lunch Biscuit 25.5 44.9 21.6 593 1909 Casoid Rusks 37.0 32.3 20.8 522 1909 Cocoanut Biscuit + Saccharin 16.6 61.3 16.4 684 1909 Ginger Biscuit 4- Saccharin 17.1 58.6 18.1 668 1913 Kalari Batons 43.2 39.0 7.4 553 1909 Kalari Biscuits 56.9 31.4 1.7 517 1909 Prolactic Biscuit .... 42.9 27.5 19.3 496 1913 Charrasse Biscuits Croquettes au Gluten _34.3 5.4 52.3 30.6 395 1913 Biscottes Lucullus .... 11.4 5.7 73.4 59.2 391 1913 Gluten Exquis Biscuits aux Amandes 18.1 23.8 15.6 25.5 489 1913 Gluten Fleur de Neige Pain 35.9 12.5 42.8 25.1 427 1913 Mignonettes au Gluten . 40.1 5.7 43.6 27.3 386 1913 Pain de Gluten 40.8 5.3 43.5 27.2 385 1913 Tranches Grillees pour Potage 40.6 3.6 45.5 28.8 377 1913 Health Food Co., New York: Alpha Best Diabetic Wafer 66.1 13.6 11.3 trace 432 1914 Alpha Best Diabetic Wafer 67.1 8.4 11.7 1.3 391 1913 Diabetic Biscuit 25.0 9.2 54.2 46.5 400 1914 Diabetic Biscuit 35.9 8.8 46.5 39.8 409 1913 Gluten Nuggets 30.2 12.8 48.3 38.6 429 160 DIABETIC MENU AND FOOD VALUES So-called Diabetic Prepara- tions. a . 0J .5 ° '53 u 2 & Ph a oj - oj oj J3 o ° h O a 03 P. w s.2o 530 a Hard Breads, etc. — Continued. Health Food Co., New York: 1906 Glutona 22.1 11.8 58.5 54. 9 1 429 1906 Glutosac Butter Wafers 27.6 12.9 49.4 41.2i 424 1906 Glutosac Rusks 36.5 3.8 51.6 42. 5> 387 1906 Wafers, Plain 29.4 9.6 49.9 41. 6 1 404 1906 Zwieback 32.5 6.9 49.3 40. 9 1 389 1913 No. 1 Proto Puffs .... 76.3 2.9 10.7 4.3 374 1913 No. 2 Proto Puffs .... 56.6 2.1 30.7 19.0 368 1906 Protosac Rusks 40.9 2.0 48.7 43. 9 1 376 1913 Protosoy Diabetic Wafers . 43.1 24.9 21.2 4.7 481 1906 Salvia Sticks 39.2 20.8 2.4 18. 7 1 440 1914 Gluten Nuggets . . . - . 31.7 14.3 45.7 34.9 438 1914 Gluten Butter Wafers . 31.1 13.9 47.0 38.9 438 1914 Gluten Rusks 39.3 3.4 47.0 33.6 376 1914 Gluten Wafers, Plain 42.6 1.7 44.3 29.6 363 Gluten Zwieback .... 36.4 7.7 46.6 32.5 401 1914 Manana Gluten Breakfast Food 42.6 2.0 43.6 29.9 363 1914 No. 1 Proto Puffs .... 72.3 2.8 13.0 9.2 366 1914 No. 2 Proto Puffs .... 58.8 2.1 27.0 20.7 362 1914 Protosac Rusks 39.7 3.0 46.7 35.9 373 1914 Protosoy Diabetic Wafers . 37.1 23.5 29.3 14.4 477 1914 Salvia Almond Sticks 22.3 29.9 41.0 28.3 523 1913 Heinz Food Co., Chicago: Gluten Biscuits 12.8 18.3 57.7 21.4 447 1914 Heudebert, Paris: Pain d'Aleurone pour Diabet- iques 76.1 1.5 9.2 4.2 354 1914 Pain de Gluten pour Diabetiques 80.7 0.8 6.5 3.4 356 1914 Pain de "Essential" en Bis- cottes 26.4 1.2 62.2 49.9 365 1906 Jireh Diabetic Food Co., New York: Diabetic Biscuits .... 14.8 3.7 72.3 65. 4 1 382 1906 Diabetic Rusks 14.6 5.0 67.7 374 1913 Diatetic Biscuits .... 13.2 7.4 70.8 49.6 403 1913 Diatetic Rusks 14.9 8.7 68.0 47.0 410 1906 Wheat Nuts 19.0 15.6 54.5 50. I 1 434 1906 Johnson Educator Food Co., Boston: Almond Biscuits 29.0 8.8 54.3 50. 1 412 1906 Diabetic Biscuits .... 25.3 7.5 59.0 54. 9 l 405 1906 Educator Crackers, Greseni Gluten 23.0 4.6 63.1 57.91 386 1 Determined by the diastase method, without previous washing water, and calculated as starch. with DIET TABLES 161 So-called Diabetic Prepara- tions. a a a O O. o - ffl fa o 1.1 O CD m T3 ft C 3.2© « °~ O Hard Breads, etc. — Continued. Johnson Educator Food Co., Boston: 1913 Educator Gluten Bread Sticks 35.9 7.2 45.8 37.5 392 1911 Gluten Cookies 26.4 16.0 49.8 37.8 449 1906 Gluten Rusk, Greseni Gluten . 22.1 0.3 68.1 63. 3 1 364 1906 Gluten Wafers 30.3 0.4 61.2 57. 1 370 1906 Glutine, Greseni Gluten 21.9 0.8 67.7 63. I 1 366 1912 The Kellogg Food Co., Battle Creek, Mich.: Avena-Gluten Biscuit 21.4 12.7 55.5 41.1 422 1913 Potato Gluten Biscuit . . . 41.5 0.5 48.0 39.5 363 1909 Pure Gluten Biscuit .... 48.3 3.3 39.1 379 1913 Taro-Gluten Biscuit- 31.3 0.5 57.7 48.2 361 1913 40 per cent. Gluten Biscuit 37.2 0.8 53.2 45.0 369 1912 SO per cent. Gluten Biscuit 82.4 0.9 4.4 4.7 355 1913 Eugene Loeb, New York: Gluten Luft Bread .... 27.9 9.2 54.2 44.1 411 1914 Gluten Luft Bread .... 52.4 13.2 26.0 22.9 433 1914 Chocolate Almond Bars 16.3 41.0 31.8 5.7 561 1914 Diabetic Almond Macaroons . 46.5 37.7 8.0 0.6 558 1914 Diabetic Bread Sticks . 50.4 3.4 34.5 24.6 371 1914 Diabetic Chocolates 14.9 51.4 23.0 6.9 614 1914 Diabetic Lady Fingers . 56.6 28.3 6.0 1.8 505 1914 Diabetic Sponge Cookies 54.7 30.1 5.0 1.2 510 1913 Pure Gluten Food Co., New York: Gum Gluten Biscuit Crisps 42.9 0.7 48.5 39.3 372 1913 G. Van Abbott & Sons, London: Caraway Biscuits for Diabetics 35 . 6 37.5 15.9 8.6 544 1913 Diabetic Rusks for Diabetics 70.9 0.8 16.0 12.6 355 1913 Euthenia Biscuits ... _35.8 40.7 13.2 6.9 562 1913 Gluten Biscottes or Rolls 51.6 2.3 33.0 29.8 359 1913 Gluten Bread or Slices . 54.1 2.2 30.9 27.4 361 1913 Gluten Butter Biscuits for Dia- betics 44.1 33.2 12.7 9.0 526 1913 Ginger Biscuits for Diabetics 34.6 39.4 16.7 10.9 560 1913 Midolia Biscuits 17.6 36.4 31.6 13.4 524 1913 Walnut Biscuits for Diabetics 20.9 57.2 12.3 trace 648 1913 Waukesha Health Products Co., Waukesha, Wis. : Hepco Dodgers 41.6 21.3 20.7 trace 441 1913 Callard, Stewart & Watt, London Casoid Chocolate Almonds 22.3 51.8 16.1 trace 620 1 Determined by the diastase method, without previous washing with water, and calculated as starch. 11 162 DIABETIC MENU AND FOOD VALUES Wines: 1 Dry. Grams reduc- ing sugars, per 100 c.c. California, red, Bordeaux or Claret . (range 0.04- 0.63) 0.16 " Burgundy .... (range 0.03- 0.42) 0.15 " Zinfandel .... (range 0.03- 0.35) 0.15 " white, Rhine .... (range . 06- . 63) . 15 " Burgundy . . . (range 0.10- 0.45) 0.23 " Sauterne . . . (range 0.07- 3.57) 0.64 French, red (range 0.11-0.84) 0.23 white (range 0.65- 1.02) 0.84 German, white (range 0.09-1.96) 0.20 Hungarian, white (range 0.04-0. 86) 0.25 Italian, red (range 0.02-2.70) 0.16 " white (range 0.02- 2.15) 0.19 North Carolina (range 0.08-1.75) 0.49 Ohio (range 0.07- 1.54) 0.31 Portuguese, red (range 0.01- 1.21) 0.16 white (range 0.10- 1.19) 0.32 Rhine, red (range 0.06-0.27) 0.13 " white (range 0.02- 1.02) 0.18 Spanish, red (range 0.19-0.54) 0.35 white (range 0.27- 0.62) 0.42 Sparking, French and German . . (range 0.13- 1.95) 0.53 Swiss, red (range 0.10-0.27) 0.13 " white (range 0.08- 0.38) 0.10 Virginia (range 0.06- 1.23) 0.16 Wines: Sweet. California Port (range 0.23-13.56) 4.76 Madeira and Sherry . . (range 0.12-17.21) 5.38 French (range 0.73-12.40) 5.38 German (range 0.64-12.13) 4.60 Madeira (range 2.48- 3.88) 2.95 Malaga (range 12.50-25.20) 18.32 Marsala (range 2.67- 8.24) 3.25 Port (range 3.76- 8.17) 6.04 Rhine (range 1.82-10.69) 6.35 Sherry (range 0.52- 4.80) 2.54 Sparkling, American '(range 6.51-12.02) 8.28 French and German . . (range 8.00-18.50) 10.92 Tokay, true (range 1.86-20.50) 12.62 " commercial (range 2.70-40.70) 19.80 Vermouth (range 3.47-14.39) 9.46 1 Wines contain approximately 10 per cent, alcohol. DIET TABLES 163 Wines: Especially Low in Carbohydrate. Alcohol by Carbo- volume hydrate, Manufacturer or Agent and Brand. percent. percent. 1 Alfonso & Hipolito: Sancho Vinos de Jerez Amontillado Don Quixote (Wm. J. Sheehan Co., New Haven, Agents) 20.60 1.23 Brotherhood Wine Co., New York City: Sunnyside Claret 11.87 0.10 Riesling 12.37 0.34 Vin-Crest Brut ... 12.24 1.66 California Wine Association, New York City: Riesling 11.31 0.10 Zinfandel .... 11.62 0.16 Calwa Distributing Co., New York City: 2 "Calwa" Brand Greystone (Light Hock Type) 3 11.81 0.19 "Calwa" Brand La Loma (Burgundy Type) 2 . 11.27 0.14 "Calwa" Brand Vine Cliff (Riesling) 2 . . . 10.90 0.17 ' ' Calwa ' ' Brand Winehaven (Table Claret) 2 . 1 1 . 46 0.14 H. T. Dewey & Sons Co., New York City: Ives Claret 12.53 0.24 Moselle Type ..." 8.37 0.14 Old Burgundy Type 11.14 0.27 Ruby Claret . . : 13.03 0.27 Pedro Domecq's Manzanilla Sherry 3 . . . . 20.86 0.32 Empire State Wine Co., Penn Yan, N. Y. : Dry Catawba 12.80 0.15 State Seal Champagne 12.39 1.51 Los Angeles Co., Boston, Mass: California Chasselas 12.12 2.97 California Chasselas 11.68 2.99 California Gutedel 11.87 0.79 California Gutedel 11.56 0.19 Monticello Wine Co., Charlottesville, Va.: Extra V. Claret 12.80 0.25 Norton's Virginia 12.57 0.37 Virginia Claret 12.54 0.20 Virginia Hock _ . . . 12.60 0.22 A. Pierlot & Co., Bouzy, Rheims: Champagne Vin Nature sans Sucre . . . . 11.97 0.36 Pleasant Valley Wine Co., Rheims, N. Y.: Claret 11.22 0.29 Dry Catawba 12.02 0.18 Great Western Extra Dry 12.33 4.36 William J. Sheehan Co., New Haven, Agents: California Cabernet 11.49 0.31 California Hock 11.21 0.14 California Riesling 11.15 0.14 California Zinfandel 11.32 0.16 Urbana Wine Co., TJrbana, N. Y. : Gold Seal Brut 12.14 2.30 Gold Seal Absolutely Dry 12.65 0.54 Gold Sparkling Red, Special Dry . . . . 11.26 2.86 Gold Sparkling Red, Absolutely Dry . . . 11.98 0.29 1 Grams reducing sugars per 100 c.c. 2 Sold by M. Zunder & Sons, New Haven, Conn. » Sold by Chris. Xander, Washington, D. C. 164 DIABETIC MENU AND FOOD VALUES Other Alcoholic Beverages. Brandy, gin, rum, whisky 1 Absinth Trace Angostura 4.2 Beer 4.5 Weiss bier 4.6 Ale 5.1 Porter or Stout 7.0 Malt extract, commercial . . . 10.6 Curacao 25.5 Creme de men the 27.7 Kummel 31.2 Benedictine 32.6 Anisette 34.4 Chartreuse 34.4 Maraschino 52.3 Malt extract, true 71.3 1 Grams reducing sugars per 100 c.c. PART IV. SELECTED LABORATORY TESTS USEFUL IN MODERN DIABETIC TREATMENT. CHAPTER I. THE EXAMINATION OF THE URINE, BLOOD AND EXPIRED AIR. An early diagnosis in diabetes is as important as in tuber- culosis. The disease usually begins insidiously, and its prompt detection depends upon the routine examination of the urine of all patients rather than upon the examination of the urines of patients who present symptoms of the disease. General practitioners should teach their patients, as a matter of routine, to have their own urines and those in their families examined each birthday. This is not fantastic. It is simply a part of the movement to have each member of the com- munity undergo a physical examination each year. EXAMINATION OF THE URINE Examination of the urine should cost the patient little. Formerly I deprecated the routine examinations made in drug stores, but now I welcome them. The druggist is a trained chemist. He is constantly doing quantitative work, and it is far easier and cheaper for him to examine a urine than for a doctor. Druggists will undoubtedly undertake such work with satisfaction. It will be an agreeable relief from the many activities in a drug store which have nothing to do with the profession of a pharmacologist. 1GG SELECTED LABORATORY TESTS The examination of the urine of the diabetic patient is usually a simple matter. It comprises a statement indicating the volume in twenty-four hours, specific gravity, reaction, presence or absence of albumin, sugar and diacetic acid. Frequently the ammonia, salt (sodium chloride), acetone and nitrogen are determined and the urinary sediment submitted to microscope study. Although diabetic patients can test their own urines for sugar and almost invariably arc warranted in relying upon the result of their examination, they should not feel that they are expert analysts. More than once patients have arrived at erroneous conclusions, in part due to the preparation of chemical reagents employed. I believe it is therefore safer for all diabetic patients to send their urines once a month to their physician, for the simple tests for volume, color, reaction, specific gravity, albumin and sugar. Such an examination can be made by a physician within fifteen minutes. A quanti- tative examination for sugar would require an individual, not daily accustomed to it, not far from half an hour or more. The Collection of the Twenty-four-hour Quantity of Urine.— To collect the twenty-four-hour quantity of urine, discard that voided at 7 a.m. and then save in a cool place all urine passed thereafter up to and including that obtained at 7 a.m. the next morning. Reaction. — The normal urine is acid. Urine voided after a meal rich in vegetables and fruits is frequently alkaline, due to the alkaline salts which they contain. Therefore the report that the urine is acid does not imply in the slightest degree that a patient has acid poisoning. (For detection of acid poisoning, see Tests for Diacetic Acid and Ammonia, pp. 17G and 177.) Specific Gravity. — The specific gravity of the urine will be best understood if it is recalled that the specific gravity of water is considered to be 1000. Normal urine has a specific gravity, on account of the solids contained in it, of about 1015 to 1020. Normal urine if concentrated would have a higher specific gravity, and if dilute it would be lower. The specific gravity of the urine in diabetes varies chiefly with the percentage of sugar which it contains. It frequently is EXAMINATION OF URINE, BLOOD, EXPIRED AIR 167 above 1020 and may be above 1040, but I have known sugar to be present in the urine when the specific gravity was as low as 1007. Albumin. — Two tests are usually employed, the one in confirmation of the other. 1. Nitric Acid Test. — To 5 c.c. of filtered urine add one- third the quantity of nitric acid by pouring it down the side of the glass so that it underlies the urine. A white precipitate forms in the urine at the junction of the two fluids. A pre- cipitate higher in the urine may be due to urates. Bile or urinary coloring matters may give a color to the urine or precipitate at the junction of the fluids. 2. Heat Test. — Pour 10 c.c. of filtered urine into a test-tube and boil the upper half of the fluid. Add one or two drops (not more) of ordinary (36 per cent.) acetic acid and boil again. A precipitate appearing on boiling which persists after the addition of the acid, or appearing on the second boiling, is albumin; one disappearing with the acid is phos- phates. The test may fail with an excess of acid. Sugar. — Sugar is absent from the urine of carefully treated diabetics. If present it can be readily demonstrated if it amounts to as little as 0.05 per cent., and it may rise to as high as 9 or 10 per cent, when the diabetic diet is not followed. Most untreated cases show between 2 and 6 per cent, of sugar. The total quantity of sugar in the urine in the twenty- four hours is easily estimated by multiplying the percentage of sugar which the urine contains by the total amount of urine voided. Thus, if the total -quantity of urine is 3 liters (3000 c.c, a little more than 3 quarts, which would equal 2838 c.c), and the percentage of sugar is 4, the amount of sugar in the urine would be (3000 X 0.04) 120 grams, that is, about 4 ounces or \ pound. It is not very often that one finds more than 1 pound of sugar excreted in the urine during twenty-four hours. The food value of the sugar lost, if only 120 grams, is considerable. Each gram of sugar is the equivalent of 4 calories, and the total would amount to 480 calories in a day, w T hich is approximately one-fourth of the total food value required by an individual, with a quiet occupation, who weighs 60 kilograms (132 pounds) . Thus it is 168 SELECTED LABORATORY TESTS evident that 4 untreated diabetics, even though the disease is of very moderate severity, provided they eat enough to make up the loss, will waste in a day enough food to supply the needs of a normal individual of equal weight for the same space of time. Tests for Sugar. — Qualitative Tests. — Many tests for sugar in the urine are employed. At present I use the Benedict test 1 most. The Benedict solution employed has the advan- tage of not decomposing even after months. Druggists occa- sionally find difficulty in making it, and on three occasions my patients have been sold unreliable solutions. The quali- tative Benedict solution is made as follows: Grams or c.c. Copper sulphate (pure crystallized) 17.3 Sodium or potassium citrate 173.0 Sodium carbonate (crystallized) (one-half the weight of the anhydrous salt may be used) 200 . Distilled water to make 1000 . The citrate and carbonate are dissolved together (with the aid of heat) in about 700 c.c. of water. The mixture is then poured (through a filter if necessary) into a larger beaker or casserole. The copper sulphate (which should be dissolved separately in about 100 c.c. of water) is then poured slowly into the first solution, with constant stirring. The mixture is then cooled and diluted to one liter. This solution keeps indefinitely. Case No. 632 has written out the rules for the test, with his customary military directness and precision: Benedict's solution is used for testing the urine for sugar as follows: To about 5 c.c. (one large teaspoonful) of the solution add 8 drops of urine; the test may then be continued in either of the two following ways: 1. Boil the mixture of the solution and urine for three minutes and set aside to cool to the temperature of the room. 2. Place the. tube containing the mixture of the solution and urine in bubbling, boiling water, where it must remain, with the water actually boiling, for five minutes. In either case if the solution remains clear the urine being tested is sugar-free; if a heavy greenish precipitate forms it 1 Benedict, S. R.: Jour. Am. Med. Assn., 1911, lvii, p. 1193. EXAMINATION OF URINE, BLOOD, EXPIRED AIR 169 usually means there is a trace of sugar; the appearance of a yellow sediment indicates the presence of a few tenths per cent, of sugar in the urine, and a red sediment more. Benedict's original description of the test is as follows: Five cubic centimeters, a trifle over one teaspoonful, of the Benedict solution, are placed in a test-tube and 8 to 10 drops (not more) of the urine to be examined are added. The mix- ture is then heated to vigorous boiling, kept at this tempera- ture for three minutes, and allowed to cool spontaneously. In the presence of glucose the entire body of the solution will be filled with a precipitate, w r hich may be greenish, yellow or red in tinge according to whether the amount of sugar is slight or considerable. If the quantity of glucose be low r (under 0.3 per cent.) the precipitate forms only on cooling. If no sugar be present, the solution either remains perfectly clear, or shows a faint turbidity that is blue in color, and consists of precipitated urates. The chief points to be remem- bered in the use of the reagent are (1) the addition of a small quantity of urine (8 to 10 drops) to 5 c.c. of the reagent, this being desired not because larger amounts of normal urine would cause reduction of the reagent, but because more delicate results are obtained by this procedure; (2) vigorous boiling of the solution after addition of the urine, and then allowing the mixture to cool spontaneously, and (3) if sugar be present the solution (either before or after cooling) will be filled from top to bottom with a ^precipitate, so that the mixture becomes opaque. Benedict (personal communication) states that the test as performed above will detect glucose in as low concentration as 0.01 to 0.02 per cent, provided the urine is of low dilution. Fehling's Test. — The solutions required are made up as follows: Dissolve 34.64 gm. pure CuS0 4 in water and make up to 500 c.c. Dissolve 173 gm. Rochelle salt and 60 gm. sodium hydrate each in 200 c.c. water and mix, and then make up also to 500 c.c. ; 5 c.c. of each solution are used for the test. In performing the test, 3 to 5 c.c. of equal quantities of the copper solution and the alkaline solution are mixed in a test- tube and thoroughly boiled. If no reduction takes place one-half as much urine as the reagent employed is then added 170 SELECTED LABORATORY TESTS and the whole boiled vigorously again. A yellow or red precipitate indicates the presence of sugar; a greenish pre- cipitate may or may not indicate sugar. Occasionally sub- stances in the urine other than sugar reduce the copper upon prolonged boiling, but this is so exceptional that I consider it far safer to boil the solution a second time, and when in doubt, to repeat the test without boiling. Quantitative Tests. — All quantitative tests for glucose in the urine are as unsatisfactory as the qualitative tests are satisfactory. It is one of the chief advantages of modern treatment that the need for these tests is nearly abolished. It will be one of the disadvantages of modern treatment if we introduce a multiplicity of new tests in diabetes. The simplification of the treatment of diabetes means everything to the practitioner and patient. The simplest quantitative test for sugar for physicians who do not devote unusual attention to diabetes is the fermentation test. Fermentation Test. — To 100 c.c. of urine of known specific gravity, one-fourth of a fresh yeast cake, thoroughly broken up, is added and the whole is set away at a temperature of 85° to 95° F. Twenty-four hours later the urine is tested with Fehling's or Benedict's solutions. If a reduction is obtained it is set aside for further fermentation. Complete fermentation having been proved, the specific gravity is taken after the urine has acquired its original (room) tem- perature. The difference in specific gravity multiplied by 0.23 gives the percentage. In the performance of the fermen- tation test for sugar a few crystals of tartaric acid should be added whenever the urine is alkaline. If the temperature of the urine (room) is 76° F. when the specific gravity is taken at the beginning and end of the test the result will be still more accurate. Benedict's Test. — The easiest method with which I am ac- quainted for performing the quantitative Benedict test is that employed by Miss Evelyn Warren, my laboratory assistant. Quantitative Benedict Solution. The quantitative Benedict solution is different from the qualitative. Mistakes often occur from this solution being EXAMINATION OF URINE, BLOOD, EXPIRED AIR 171 used for the qualitative test for sugar, for which purpose it is valueless. The quantitative Benedict solution is given on page 173. Fig. 16.— Apparatus required for a simplified, quantitative Benedict test. 172 SELECTED LABORATORY TESTS Articles Required. Ten cubic centimeter graduated pipette; small white enamelware dish, 3 inches across, 2 inches deep; sodium carbonate; talcum. The test can be performed by the aid of a kitchen gas burner. If the gas burner is not a small one and so flares up around the edges of the dish, put an asbestos plate or simply an iron cover over it. Performance of Test. 1. Place 5 c.c. of the quantitative Benedict solution in the dish. 2. Add less than one-fourth teaspoonful of sodium car- bonate. 3. Add one-half as much talcum. 4. Add about 10 c.c. water. 5. Dilute 1 part urine with 9 parts of water unless the quantity of sugar is low. (A low per cent, of sugar is shown by the qualitative Benedict test turning green instead of yellow. With small quantities of sugar, it is unnecessary to dilute the urine.) G. Bring the contents of the dish to boiling, maintain in this condition and then add, drop by drop, the urine from the graduated pipette until the blue color has entirely disap- peared. Upon the first trial too much may be added, and therefore, having noted the approximate quantity of urine required to reach the end-point, invariably repeat the test as a control. Calculation. Five cubic centimeters of the Benedict quantitative copper solution are reduced by 0.01 gram glucose. Consequently, the quantity of undiluted urine required to reduce the 5 c.c. Benedict solution contains 0.01 gram glucose. o.oi — X 100 = per cent. x = c.c. of undiluted urine. x EXAMINATION OF URINE, BLOOD, EXPIRED AIR 173 Example. — Fifteen hundred cubic centimeters urine in twenty-four hours. Five cubic centimeters used to reduce (decolorize) the Benedict solution. — : — X 100 = . 2 per cent. 5 1500 X 0.002 (0.2 per cent.) = 3 grams sugar in twenty-four hours. Example. — If the urine had been diluted with 9 parts water —in other words, 10 times — the calculation would be: 5 c.c. diluted urine = 0.5 c.c. actual urine. - 1 — - X 100 = 2 per cent. 0.5 1500 X 0.02 (2 per cent.) = 30 grams sugar in twenty-four hours. For convenience in the laboratory, instead of working out the percentages of sugar in the urine by the above formula, we use the accompanying scale, shown in Table 32. The method as originally described by Benedict 1 is as follows: "Like Fehling's quantitative process the method is based on the fact that in alkaline solution a given quantity of glucose reduces a definite amount of copper, thus decoloriz- ing a certain amount of copper solution. The copper is, however, precipitated as cuprous sulphocyanate, a snow- white compound, which is an aid to accurate observation of the disappearance of the last trace of color. The solu- tion for quantitative work, which keeps indefinitely, has the following composition : Pure crystallized copper sulphate, 18 grams. Crystallized sodium carbonate, 200 grams (or 100 grams of the anhydrous salt) . Sodium or potassium citrate, 200 grams. Potassium sulphocyanide, 125 grams. Five per cent, potassium ferrocyanide solution, 5 c.c. Distilled water to make a total volume of 1000 c.c." i Benedict, S. R.: Loc. cit., p. 168. 174 SELECTED LABORATORY TESTS Table 32. — Per Cent, of Sugar by Benedict Method. Urine, c.c. used. Sugar, per cent. Urine, c.c. used. Sugar, per c 0.1 10.0 3.6 0.28 0.2 5.0 :;.7 0.27 0.3 3.3 3.8 0.26 0.4 2.5 :;.!i 0.26 0.5 2.0 4.0 0.25 0.6 1.7 4.1 0.24 0.7 1.4 4.2 0.24 0.8 1.3 4.3 . 23 0.9 1.1 4.4 0.23 1.0 1.0 4.5 0.22 1.1 0.91 4.6 0.22 1.2 0.83 4.7 0.21 1.3 0.77 4.S 0.21 1.4 0.71 4.9 0.20 1.5 0.67 5.0 0.20 1.6 0.63 5.1 0.20 1.7 0.58 1.8 0.55 5.2 0.19 1.9 0.53 5.3 0.19 2.0 0.50 5.4 0.19 2.1 0.48 5.5 0.18 2.2 0.45 5.6 0.18 2.3 0.43 5.7 0.18 2.4 0.42 5.8 0.17 2.5 0.40 5.9 0.17 2.6 0.38 6.0 0.17 2.7 0.37 6.1- 6 .4 0.16 2.8 0.36 6.5- 6 .9 0.15 2.9 0.34 7.0- 7 .4 0.14 3.0 0.33 7.5- 7 ,9 0.13 3.1 0.32 8.0- 8 .7 0.12 3.2 0.31 8.8- 9 .5 0.11 3.3 0.30 9.0-10 .0 0.10 3.4 0.29 3.5 0.29 " With the aid of heat dissolve the carbonate, citrate, and sulphocyanide in enough water to make about 800 c.c. of the mixture and filter if necessary. Dissolve the copper sulphate separately in about 100 c.c. of water and pour the solution into the other liquid, with constant stirring. Add the ferro- cyanide solution, cool and dilute to exactly one liter. Of the various constituents the copper salt only need be weighed with exactness. Twenty-five cubic centimeters of the reagent are reduced by 50 mg. (0.050 gram) of glucose." The procedure for the estimation is as follows: "The EXAMINATION OF URINE, BLOOD, EXPIRED AIR 175 urine, 10 c.c. of which should be diluted with water to 100 c.c. (unless the sugar content is believed to be low), is poured into a 50 c.c. burette up to the zero mark. Twenty-five cubic centimeters of the reagent are measured with a pipette into a porcelain evaporating dish (10 to 15 cm. in diameter), 10 to 20 grams of crystallized sodium carbonate (or one-half the weight of the anhydrous salt) are added together with a small quantity of powdered pumice stone or talcum, and the mixture heated to boiling over a free flame until the car- bonate has entirely dissolved. The diluted urine is now run in from the burette, rather rapidly, until a chalk-white pre- cipitate forms and the blue color of the mixture begins to lessen perceptibly, after which the solution from the burette must be run in, a few drops at a time, until the disappearance of the last trace of blue color which marks the end-point. The solution must be kept vigorously boiling throughout the entire titration." If the mixture becomes too concentrated during the process, water may be added from time to time to replace the volume lost by evaporation; however, too much emphasis cannot be placed upon the fact that the solution should never be diluted before or during the process to more than the original 25 c.c. Moreover, it will be found that in titrating concentrated urines, or urines with small amounts of sugar, a muddy brown or greenish color appears and obscures the end-point entirely. Should this be the case the addition of about 10 grams of calcium carbonate does away with this difficulty. The calculation of the percentage of sugar in the original sample of urine is very simple. The 25 c.c. of copper solution are reduced by exactly 0.050 gram of glucose. Therefore the volume of diluted urine drawn out of the burette to effect the reduction contains 50 mg. of sugar. When the urine is diluted 1 to 10, as in the usual titration of diabetic urines, the formula for calculating the percentage of sugar is the following: - X 1000 = percentage in the original sample, wherein x is the number of cubic centimeters of the diluted urine required to reduce 25 c.c. of the copper solution. 176 SELECTED LABORATORY TESTS " In the use of this method chloroform must not be present during the titration. If used as a preservative in the urine it may be removed by boiling a sample for a few minutes, and then diluting to the original volume." Methods for the Determination of the Urinary Acids. — Qualitative Tests.— (1) Diacetic Acid (CH 3 COCH 2 COOH).— The simplest method for the detection of acidosis by urinary examination is Gerhardt's ferric chloride reaction for diacetic acid. The test may be performed as follows : To about 10 c.c. of the fresh urine carefully add a few drops of an undiluted aqueous solution of ferric chloride, Liquor Ferri Chloridi, U. S. P. A precipitate of ferric phosphate first forms, but upon the addition of a few more drops is dissolved. The depth of the Burgundy red color obtained is an index to the quantity of diacetic acid present. I record the intensity of the reaction as follows: +,++,+ + +, or + + + +. _ Confusion as to the significance of the test arises if the patient is taking sodium salicylate, aspirin or allied products. This is to a considerable extent avoided by vigorously boiling the urine after the addition of the ferric chloride, when the deep color markedly decreases or disappears if caused by diacetic acid, but remains the same if caused by the above drugs. Acetone (CH 3 COCH 3 ) .- — The different tests for acetone are in reality tests for diacetic acid. Legal's test is as follows: A few crystals of sodium nitroprusside are dissolved in 5 c.c. of urine, which is then rendered alkaline with sodium hydrate. A few drops of glacial acetic acid are then slowly added and a distinct purple color appears, which, if the test-tube is shaken, is best seen in the foam. Quantitative Tests. — Ammonia. — The quantity of the alkali — ammonia — in the urine is a measure of the effort of the body to counteract the acid poisoning which may be present. To this extent its estimation gives a more accurate idea of the acid production of the. body than any other of the urinary tests at our disposal, which simply show the quantity of acid leaving the body. The test, however, becomes of less value as soon as extraneous alkali is administered, because under such conditions the ingested alkali is used by the body in EXAMINATION OF URINE, BLOOD, EXPIRED AIR 111 preference to ammonia. The normal amount of ammonia in the urine varies between 0.5 to 1 gram, and the ratio between the ammonia-nitrogen to the total nitrogen in the urine is fairly constant at 1 to 25 (4 per cent.). In severe diabetes the ammonia may gradually increase, and in Case No. 344 it amounted to 8 grams in one day. Ronchese-Malfatti Method for the Determination of Ammonia. — (a) To 25 c.c. of urine in a 200 c.c. Erlenmeyer flask, add about 25 c.c. of distilled water, about 10 grams (1 to 2 teaspoonfuls) of powdered potassium oxalate, and a few drops of indicator (phenolphthalein). Shake a few times to dissolve the oxalate, then titrate with one-tenth normal sodium hydroxide until the first faint pink color is permanent. (b) Take 5 c.c. of commercial formalin solution in a test- tube, add a few drops of phenolphthalein indicator, and then titrate with one-tenth normal sodium hydroxide until a faint pink is obtained. (c) Add this neutralized formalin to the urine, which has just been titrated, and titrate again with one-tenth normal sodium hydroxide until the previous pink is again obtained. (Calculation: The number of cubic centimeters of one- tenth normal alkali used in titration (c) multiplied by 0.0017 gives the number of grams of ammonia in 25 c.c. of urine.) No account need be taken of the amount of sodium hydroxide used in titrations (a) and (b). The method depends upon the fact that formalin combines with free NH 3 and forms hexamethylenetetramin. The ammonia is liberated from its salts by means of NaOH. Nitrogen. — The Kjeldahl method is that usually employed for determining the nitrogen, and a modification of it has served me best. 1 However, improvements in the method are constantly taking place, and time will always be saved by adopting the most recent methods. Sodium Chloride. — The method which I employ for deter- mining the sodium chloride is Volhard's quantitative method. 2 1 Joslin: The Treatment of Diabetes Mellitus, 2d edition, Lea & Febiger, 1917, p. 10s. 2 Loc. cit., p. 201. 12 178 SELECTED LABORATORY TESTS THE EXAMINATION OF THE BLOOD. Blood Sugar. — The Lewis-Benedict method is the one upon which I now depend, with the modification of Myers and Bailey. 1 Recently I have been much impressed with the blood-sugar method recommended by Epstein. 2 This is a method particularly adapted to the practising physician, for the apparatus necessary for its performance can be readily obtained and the technic easily learned. The directions for the test come with the apparatus. 3 I am glad to insert a series of ten consecutive determinations obtained with this method by Miss Harriet Amory, and place alongside them for com- parison the results obtained with the Lewis-Benedict method by Miss Evelyn Warren, who has had much experience w r ith it. Table 33. — Comparative Blood-sugar Determinations. (Performed by Evelyn Warren and Harriet Amory with the Lewis- Benedict and Epstein Methods.) Benedict-Lewis. Epstein. 0.23 0.25 0.19 0.24 0.10 0.15 0.34 0.34 0.20 0.23 0.22 0.22 0.23 0.26 0.09 0.12 0.21 0.24 0.10 0.10 Wishart Method for Detection of Acetone in the Blood. — The blood is drawn into a syringe or tube containing a few crystals of potassium oxalate, then centrifuged for five minutes at medium speed. The test is made on the plasma with as little delay as possible, as there is liable to be some loss of acetone on standing. For a small quantity of plasma (0.5 c.c. or more) add solid ammonium sulphate until plasma is thoroughly saturated and protein precipitated; then add two or three drops of a freshly made 5 per cent, solution of sodium nitroprusside and 1 Loc. cit , p. 203. 2 Epstein: Jour. Am. Med. Assn., 1914, lxiii, p. 1667. 3 Purchased from E. Leitz, New York. EXAMINATION OF URINE, BLOOD, EXPIRED AIR 179 a few drops of concentrated ammonium hydrate. If the test is positive, in from one to ten minutes a color develops which runs all the way from a pale lavender to that of a deep permanganate hue, in this way indicating whether much or little acetone is present. This is an adaptation to the plasma of the Rothera nitroprusside reaction as ordinarily used for urine. It is said to be sensitive to 1 part in 20,000. EXAMINATION OF THE EXPIRED AIR FOR CARBON DIOXIDE. A knowledge of the carbon dioxide in the alveolar air is of greatest assistance in determining the presence or absence of acid poisoning. Two methods are available, the Fridericia method 1 and Marriott's method. 2 Both methods are excel- lent, but the Marriott method is rather more practicable for the practising physician. The Fridericia apparatus can be obtained from Emil Greiner, 55 Fulton Street, New York, and the apparatus for the Marriott method, with the description of the technic for its use, from Hynson, Wescott & Company, Baltimore, Md. The alveolar air collected by the Fridericia method is of a carbon dioxide tension from 10 to 20 per cent, lower than that collected by the Marriott method. Normally, the carbon dioxide tension of the alveolar air varies between 38 and 45 mm. mercury, 5.3 to 6.3 per cent. If abnormal acids are present in the blood, these displace a proportionate amount of carbon-xlioxide, and as the carbon dioxide tension in the alveolar air bears a direct relation to that in the blood, it is evident that the carbon dioxide in the alveolar air will vary likewise. A low carbon dioxide tension of the alveolar air therefore indicates an acidosis. If the carbon dioxide tension lies between 38 and 32 mm. mercury a slight acidosis is present, between 32 and 28 a moderate acidosis, and if it falls below 25 mm. mercury the acidosis is extreme. The lowest value with recovery in my group of cases has been 14 and the lowest obtained in the series was 9, and that occurred in a patient in coma. 1 Loc. cit., p. 233. 2 Loc. cit., p. 237, INDEX. Acetone in blood, Wishart method for detection of, 178 in urine, test for, 176 Acidosis (acid intoxication, acid poisoning), 103 carbon dioxide in alveolar air as measure of, 179 commonest enemy of diabetic, 32 danger of, arising from fat, 61 dependence on fat, 77 prevention of, 32 by withdrawal of fat, 77 rules for treatment of, 104 tests for, qualitative, 176 quantitative, 176 Agar agar, for constipation, 118 jelly, 132 Albumin, tests for, heat test, 167 nitric acid test, 167 in urine, 167 Alcohol, caloric value of, 42 in diabetes, 77 Alveolar air, carbon dioxide ten- sion, 179 Fridericia method, 179 Marriott method, 179 Ammonia, Ronchese-Malfatti method for determination of, 177 in urine, 176 Anger dangerous for diabetic, 49 Arithmetic, diabetic, 34 Asparagus, soup variety, 134 Automobile, fuel (food) of, 41 Avoirdupois system, 34 B Bacon, loss of weight during cook- ing, 60 Bananas, analyses of, 147 carbohydrate in, 40, 51, 71 weight of, 36 Bavarian cream (diabetic), 132 Benedict's test, qualitative, 169 illustration, 37 solution for, 168 quantitative, 170 apparatus required for, 171 per cent, sugar, 174 solution for, 171 Berries, analyses of fresh, 146 Beverages, analyses of, alcoholic, 162, 164 non-alcoholic, 154 Blood, acetone in, 178 sugar in, 178 Boiled dinner, 134 Bottles, percolator, 45 Bran, 122 muffins for constipation, US, 130 for diabetics, 130 Brandy, 78 Bread, analyses of, 153 bran, 122 "rarbohydrate content, 40, 72, 122 casein, 123 coarse, carbohydrate in, 72 gluten, 123 carbohydrate in, 72 light (French), 123 substitutes for, 121 undesirability of giving, 72 Broths, calories negligible, 91 gelatin in, 74 nutritive value of, 74 Butter, 61 Maitre d'Hotel, 139 toleration for, 76 Butterine, content for, 76 Buttermilk, 60 1S2 INDEX Cabbage, raw, for constipation, 119 Caloric needs of advancing age, 58 by children, 57 in diabetes, 32, 66, 100 at hard work, 57 at light work, 57 at moderate work, 57 at rest, 57 in sedentary occupations, 57 in walking, additional calories required, 100 Calorie, definition of, 32, 56 the food measure, 41 Candy, danger in candy habit, 19 rules broken, fasting required, 95 Cannon, experiments of, 47 Carbohydrate, addition of 5 grams, 48 content of foods, 24, 38, 53 estimation of, in clinical work, 56 in normal diet, 51 tolerance for, apparent tolerance, 93 determination of, 93 remarkable increase in, 81 in vegetables, 51, 66 where found, 29, 40, 51 Carbon dioxide tension of alveolar air, 179 Cellulose, 52, 122 Cheese, 61 Children, food requirements of, 41 heights of, 107 school children and diabetes, 19 weights of, 107 Chittenden, low protein diet, 73 suggests excess of food detri- mental of health, 58 Chocolate, analyses of, 154 Clams, composition of, 74 Cocoa, cracked, 131 cocoa whip, 139 Coffee Spanish cream, 139 Coma, diabetic, 103 Condiments, analyses of, 147 Constipation, treatment of, 118 exercises for, 118 potato skins counteract, 70 raw cabbage, 119 sawing wood warded off, 119 Crackers, carbohydrate in, 72 Cream, 61 puff (Lister), 139 whipped, Litchfield's method, 125 Crisco, content of, 76 Dairy products, analyses of, 149 Diabetes, candidate for, 19 causes of, derangement of func- tions of pancreas, 17 lack of exercise, 18 overfeeding, 19 remediable, 23 strenuous life, 19 chronic, 17 definition of, 20, 30 discovery of, easily made, 20 experimentally produced, IS heredity and, 19 favorable influences of, 19 improvement in, 20 incidence of, in Boston, v increasing, 19 in United States, v infectious diseases and, 19 measures for decrease of, 20 mild, definition, 82 moderate, definition, 82 not contagious, 17 painless, 17 predisposition to, 19, 47 serious in past, 26 severe, definition, 82 symptoms, annoying vanish, 20 treatment of, description, 30 diet in, 17 drugs in, 17 early, 21 illustrations of cases success- fully treated, 80, 91 improvement in, 26, 27 attributed to, 27 author's series, 27 Massachusetts General Hos- pital, 26 mild cases, 22 moderately severe cases, 80 need of further improvement in, 28 neglected, 21 INDEX 183 Diabetes, treatment of, object of, SO severe cases, 80 susceptibility to, 17 untreated, makes food spend- thrift, 23 Diabetic, caloric needs of, 66 commonest enemy of, 32 hygiene for, 47 knowledge essential for, 29 questions and answers for, 29 rules for, 66 weight of, 32 why hungry, 30 why thirsty, 30 Diacetic acid, test for, 176 Diarrhea, 118 Diet, caloric value of, source of error in calculating, 59 carbohydrate-free, 51 computation of, 42 diabetic, carbohydrate iri, esti- mation of, 66 essentials of, 54 fat in, 75 protein in, 73 estimation of, weights and meas- ures employed, 34, 56 " examination of, information ob- tained by, 45 expensive with untreated dia- betic, 110 normal, 51, 57 and diabetic compared, 65 fat in, in northern climates, 54 in the tropics, 54 proportion of carbohydrate, protein and fat, 58 protein in, 53, 58 tables of, 143 Dietetic rules and hints, 101 suggestions, recipes and menus, 121 Diversion, desirable, 49 Doctor, visits to, efficiency in, 45 Drinking glass, capacity of, 35 Dropsy, diabetes and, 79, 108 Druggists, vi, 165 Drugs in treatment of diabetes, 17, 120 Eggs, analysis of, 151 by law weigh, 59 Eggs, thirteen for breakfast, 110 weight of, 36 maximum and minimum, 60 white of, content, 54 yolk of, content, 54 Eskimos, diet largely of fat, 75 Excitement, effect of, on urine, 47 Exercise, effect of, on fat diabetics, 47 examples, 48, 49 lack of, 18 Fast days, weekly, 99 thirty-one days, 41 Fasting, 87 avoidance in the old, 91 Dr. Randall's plan, 99 examples of, 87 intermittent, 92 preparation for, 87 relief to patients, 90 required because rules broken, 95 simplest means of freeing urine of sugar, 85 Fat, administration of, slow in- crease in presence of obesity, 97 a concentrated food, 59 danger to diabetic, 77 an expensive food, 59 how much should diabetics eat? 75 in normal diet, 59 tolerance for, determination of, ~ 96 by signs of acidosis, 96 where found, examples of, 29, 40, 54 Fehling's test, qualitative, 169 Fermentation test, 170 Fish, analyses of, fresh, 150 preserved and canned, 150 composition of, 73 preserved, composition of, 74 Flour, analyses of, 152 Food, carbohydrate, 29, 40 content of, 24, 53 total calories, 39 classification of, 29 conservation of, model in, 66 excess, detrimental to health, 58 184 INDEX Food, fat, 29 40 total calories, 39 measure, 41 needs of diabetic, 32 protein, 29, 40 total calories, 39 requirements, 29, 55 accurate calculation of, 55 of children, 41 of old people, 41 in sedentery occupations, 57 spendthrift of, 23 stored up in body, 41 values, 40, 55 absurdity of reckoning to fraction of gram, 64 errors in, 63, 64 weighing, method of, 34, 56, 72 Fruit, analyses of, canned, 147 dried, 147 fresh, 146 carbohydrate in, 38, 40, 71 Furunculosis in diabetes, 116 G Galactan, 71 Garden for diabetic patients, 134 Gelatin, analysis of, 151 in broths, 74 protein in, 126 Gin, 78 Glycogen, animal starch, 41, 51 Grape fruit, analyses of, 147 H Height of children, 107 Hemicelluloses, 71 Hepco cakes, 130 Horseradish, 134 sauce, 138 Ice cream (diabetic), 132 Indian, emulation of, by diabetic, 106 Infectious diseases, diabetes and, 19 Insurance, 106 Irish moss, 129 Islands of Langerhans, diabetes and, 18 Jelly, agar agar, 132 coffee whip, 139 cracked cocoa whip, 139 lemon, 131 rhubarb with meringue, 139 wine, 139 Koumiss, carbohydrate in, 72 Lard, content of, 76 Lemon jelly (diabetic), 131 Lettuce, carbohydrate in, 39 Lime water, preparation of, for teeth, 114 Liquids in diabetes, 78 Lister's diabetic flour, 126 Liver, animal starch in, 51 composition of, 73 Lobster, carbohydrate in, 43 M Margarine, nut, content of, 76 Meals, analyses of, 152 Meat, analyses of, 150 canned extracts of, 75 composition of, 73 protein in, percentage falls as fat rises, 74 Mental attitude, change in gratify- ing, 50 relaxation, 47 Menus, inexpensive, 140 picnic lunches, 141 severe diabetic, 135 Metric system, 34 Milk and milk products, analyses of, 149 graphic table, 61 carbohydrate in, 43, 72 fermented, 125 food value of glass of, 60 INDEX 185 Milk, protein in, 61 skimmed, 60 substitutes for, 123 sugar-free, 124 Miscellaneous analyses, 154 N Nitrogen in urine, determination of, 177 Note book, 46 for reference, 46 treatment systematized by, 46 Nut preparations, analyses of, 148 Nuts, analyses of, 148 carbohydrate in, 38, 71 Oatmeal, carbohydrate in, 72 food value for dry weight, 40 Oil, content of, 76 corn, 77 cotton-seed, 77 cough medicine for diabetics, 76 as lunch for diabetics, 76 peanut, 77 relieves symptoms of hyperacid stomach, 77 Oleo, content of, 76 Olives, green, carbohydrate in, 71 ripe, carbohydrate in, 71 Oranges, analyses of, 147 carbohydrate in, 71 Outlook, diabetes and, 23 early detection makes favor- able, 23 Overfeeding, 19 Oyster crackers, weight of, 36 Oysters, composition of, 74 food value, 40 Pancreas, diabetes and, 17 increase of power to assimilate carbohydrate, 20 internal secretion of, 18 Pastes, analyses of, 154 Pastry, analyses of, 153 Patients, intelligent, 46 Pedometers, 47 Pentosan, 71 Physician's office, visit to, 45 Pickles, analyses of, 147 sour, 134 Picnic lunches, 141 Potatoes, baked, desirability of, 70 carbohydrate in, 40, 70 Protein, advantage of, to the dia- betic, 96 Cannon's investigations con- cerning, 58 estimation of, in clinical work, 56 in gelatin, 126 quantity in normal diet, 58 sugar formed from, 61 tolerance for, determination of, 94 vegetable, 73 where found, examples of, 29, 40, 54 Questions and answers for dia- betic patients, 29 R Rations, furnished to soldiers, 55 in German prisoner-of-war camps, 55 Recipes, diabetic, 125 Responsibility, heavy, should be avoided, 49 rests upon patient, 21 Rest7 essential, 49 Rum, 78 Saccharin, 125 Salt (sodium chloride), 78 harmful effects of, 75, 79 in urine, determination of, 177 Sauce, custard, 139 grated horseradish, 138 Maitre d'Hotel butter, 139 mint, 138 parsley, 138 tomato, 138 Sea moss, 129 Seasoning, 134 186 INDEX Shell-fish, agreeable addition to diet, 74 analyses of, 151 Shredded wheat biscuit, weight of. 34,36 Skin, care of, 116 dry because of withdrawal of salt, 78 infections of, 1 16 Soldiers, rations of, 55 Solomon's soliloquy, 46 Soup, analyses of, canned, 151 home-made, 151 spinach, 140 Soy bean, 123 baked, recipe, 129 Squab, 134 Starch, 40 in normal diet, 51 in various foods, 40 String beans, carbohydrate in, 39, 67 Sugar, barrel of, lost in urine, 22, 111, also frontispiece, consumption of, in United States 19 formed from protein, 61 lost in urine, mild diabetic, 22 moderately severe diabetic, 111 severe diabetic, 111 lump of, weight, 34, 36 in normal diet, 51 overfeeding of, 19 reappearance of, 97 failure to grapple with, 98 examples of, 98, 99 in relation to sugar in urine, 20, 43, 167 removal from urine, 31 tests for, qualitative, 168 quantitative, 170 Sugar-free, variable period of time required to become so, 92 without fasting, 88 Sundays, diabetic, 99 Sweet taste, 49 Sweetbread, 17 Tablespoon, capacity of, 35 Teaspoon, capacity of, 35 Teeth, care of, 113 Toast, carbohydrate in, 72 Treatment, early, 21 of mild cases, 22 neglected, 21 U Uneeda biscuit, weight of, 36 Urine, appearance of sugar follow- ing football game, 83 collection of, 45, 166 examination of, 166 information obtained by, 45 to be made on each birthday, 165 fermentation of, 45 following emotional excitement, 47 not sugar-free, patient growing worse, 21 percentage of sugar in, 30 reaction of, 166 removal of sugar from, 31 specific gravity of, 166 Utensils essential for the diabetic, 62 Vegetables, analyses of canned, 145 fresh, 144 camouflage, 67 carbohydrate in, 38 5 per cent, group, 38, 42, 51 10 per cent, group, 38, 51 15 per cent, group, 38, 51 20 per cent, group, 38, 51 loss in cooking, 67, 68 5 per cent., computation in diet, 42 not necessary to weigh in mild cases, 67 saucerful of, 39 total carbohydrate content fc eaten in twenty-four hours, 67 thrice cooked, 67, 133 washed, analyses of, 69 Voit standard, 59 INDEX 187 w Weight, 106 body, how taken, 46 changes in, during treatment, 10S of children, 107 of diabetic patients, 32 loss by fasting, 78 of normal individuals, 106 Weights and measures, 34, 56 avoirdupois system, 34 metric system, 34 Whey, 61 Whisky, 78 Zwieback, carbohydrate in, 72 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED j DATE DUE MAY 2 2 197f C2B (747J MtOO Joslin Diabetic manual % RC660 J782 1910