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DIABETIC MANUAL

FOR THE

MUTUAL USE OF DOCTOR AND PATIENT

ELLIOTT P. pSLIN, M.D.

ASSISTANT PRpFESSOR OF MEDICINE, HARVARD MEDICAL SCHOOL; CONSULTING

PHYSICIAN, BOSTON CITY HOSPITAL; COLLABORATOR TO THE NUTRITION

LABORATORY OF THE CARNEGIE INSTITUTION OF WASHINGTON,

IN boston; MAJOR, M. R. C.

fllusttatcD

LEA & FEBIGER

PHILADELPHIA AND NEW YORK

1918

• f

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• : •

• • • .'

• • •

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• * .

• * . V • •

LEA & FEBIGER

1918

R, BJL R,

THE DIABETIC PATIENTS

THE UNITED STATES OF AMERICA

UPON EACH ONE OF YOU
REST RESPONSIBILITIES OF SAVING FOOD

BOTH BY

YOUR OWN EXAMPLE, SHOWN IN THE CAREFUL TREATMENT

OF YOURSELF, AND BY YOUR INSTRUCTION OF

THOSE ABOUT YOU IN FOOD VALUES

PREFACE.

For one diabetic patient who knows too much about his
disease there are unquestionably ninety-nine who know too
little. That is the reason for this little book, in which I have
tried to give in schematic form the modern conception of
diabetes and its treatment. The presentation is radically
elementary, in the hope that a book of this nature, written
in the light of recent discoveries in laboratory and clinic,
will be a help to the general practitioner and useful as a
text-book for his patients, thereby securing their intelligent
cooperation, and thus enabling him to raise the standard of
diabetic treatment. These pages emphatically cannot take
the place of a competent physician, but I trust that they will
supply sound instruction in combating a disease which is
statistically four times as prevalent in Boston today as in
1890, and twice as prevalent in the registration area of the
United States as in 1900.

The manual is arranged in four parts. Part I might be
called a diabetic primer. It gives in untechnical language
a rapid survey of the whole subject, sketching fundamental
conceptions and emphasizing their most important applica-
tions. Part II retraces with more detail and in more technical
language the general field, and contains an outline of the
treatment of the severer diabetic, already elsewhere described
for physicians in The Treatment of Diabetes Mellitus, recently
published for the author by Messrs. Lea & Febiger. The

778688

VI PREFACE

technic of becoming sugar-free and remaining so is described
in detail. Part III contains diet tables and recipes which
the author has found valuable in his daily practice. In
Part IV are described the simplest tests which a physician
can employ for the estimation of sugar and acid bodies in the
urine, the sugar in the blood and the carbon dioxide in the
alveolar air. These tests can be readily acquired. I have
been teaching them for several months to my most experi-
enced nurses, and if druggists should master them I am sure
they would be of great service to their respective localities.

Tables and, to a lesser extent, the text show repetition.
This is with design, and I trust will prove to be with profit.

In the preparation of the following pages I am indebted
directly or indirectly to nearly all who helped me in the
compilation of The Treatment of Diabetes Mellitus, but more
than ever I am under obligation to Professor Walter R. Miles
for his valuable counsel and continuous aid.

I am especially grateful to my publishers because of their

continued courtesies, and to my secretary, Miss Helen

Leonard, upon whom has devolved the final revision of

the proof.

E. P. J.

Boston, 1918.

CONTENTS.

PART I

INTRODUCTION TO DIABETIC TREATMENT.

CHAPTER 1.
General Considerations 17

CHAPTER II.
The Treatment of Mild Cases 22

CHAPTER III.
The Improvement in the Treatment 26

CHAPTER IV.
Questions and Answers for Diabetic Patients .... 29

CHAPTER V.
Diabetic Arithmetic 34

CHAPTER VI.
Efficiency in Visits to a Doctor 45

CHAPTER VII.
Htgiene for the Diabetic 47

viii ' CONTENTS

PART 11.
THE DETAILS OF DIABETIC TREATMENT.

CHAPTER I.

The Diet op Normal Individuals.

Carbohydrate — Protein — Fat — Food Values and Require-
ments — Composition op Normal Diet — Caloric Values 51

CHAPTER II.

The Diet op Diabetic Individuals.

Normal and Diabetic Diets Compared — Carbohydrate —

Protein — Fat — Liquids — Salt 65

CHAPTER III.

The Treatment op Moderately Severe and Severe Cases of

Diabetes.

Fasting — Intermittent Fasting — Carbohydrate, Protein
AND Fat Tolerance — Reappearance of Sugar — Weekly
Fast Days — Caloric Needs 80

CHAPTER IV.
Acid Intoxication; Acidosis; Diabetic Coma 103

CHAPTER V.
Weight Peculiarities 106

CHAPTER VI.
The Diet op the Untreated Diabetic is Expensive . . 110

CHAPTER VII.
Care op the Teeth 113

CONTENTS \it

CHAPTER VIII.
Cabe of the Skin 116

CHAPTER IX.
Treatment op Constipation 118

CHAPTER X.
Drugs in the Treatment of Diabetes ....... 120

PART III.
THE DIABETIC MENU AND POOD VALUES.

CHAPTER I.
Dietetic Suggestions, Recipes and Menus 121

CHAPTER II.
Diet Tables 14S

PART IV.

SELECTED LABORATORY TESTS USEFUL IN
MODERN DIABETIC TREATMENT.

CHAPTER I.
The Examination of the Urine, Blood and Expired Air . 165

PART I.
INTRODUCTION TO DIABETIC TREATMENT.

CHAPTER I.

GENERAL CONSIDERATIONS.

It is perfectly true that diabetes is a chronic disease, but,
unlike rheumatism and cancer, it is painless; unlike tuber-
culosis, ' it is clean and not contagious, and in contrast to
many diseases of the skin it is not unsightly. Moreover, it
is susceptible to treatment, and the downward course of a
patient can usually be promptly checked. Treatment, how-
, ever, is by diet and not by drugs, and the patients who know
the most, conditions being equal, can live the longest. There
is no disease in which an understanding by the patient of
the methods of treatment avails as much. Brains count.
But knowledge alone will not save the diabetic. This is a
disease which tests the character of the patient, and for
success in withstanding it, in addition to wisdom, he must
possess honesty, self-control and courage. Already 33 of my
patients have lived longer than would have been expected of
them had they been normal, healthy people. For the diabetic
this is a demonstration and a challenge.

The underlying cause for diabetes is usually considered
to be a derangement in one of the functions of the pancreas.
This is a gland, in animals known as the sweetbread, which
lies behind the stomach near the liver. It discharges into the
bowel the most important digestive juice of any gland in

the body, and this juice is capable of digesting all kinds of
2

18 INTRODUCTION TO DIABETIC TREATMENT

food. Strangely enough this digestive action of the pancreas
remains undisturbed in diabetes. The fault with the pan-
creas in diabetes concerns that function of the gland which
regulates the body's use of the sugar formed from the food.
This function appears to reside in groups of cells distributed
throughout the pancreas and called the "islands of Langer-
hans." When these cells have been found to be diseased a
history of diabetes has been usually demonstrable. These
groups of cells probably manufacture a special internal
secretion which is discharged into the blood. Experimentally,
with animals, it is easy to produce diabetes by simply
removing a large portion of the pancreas, and the severity
of the diabetes so produced is proportional to the amount of
the gland removed. If the diabetic patient could secure a new
pancreatic gland he would be cured. As yet all attempts to
successfully treat diabetes by feeding patients the healthy
pancreatic glands of animals, by the use of extracts made from
the gland or by grafting portions of a healthy gland under the
skin have failed. Nevertheless, I expect some measure of
success will be eventually achieved along these lines, and I
hope within the next decade.

Granted that there is a natural tendency to diabetes in
certain individuals, this develops into the actual disease
most commonly when the body has been overfed. More
than 40 per cent, of my diabetic cases have been too fat, and
in a recent series of 100 diabetic cases I found obesity to have
existed in 57 of them. The average number of poimds over-
weight for a series of 457 diabetic patients for different ages
is shown in Table 1.

Table 1. — Overweight Usually Precedes Diabetes.

Age in years.

Number of cases.

Average number of
pounds overweight.

12 to 24

25 to 29

30 to 39

39 and over

320

Lack of exercise is of course a factor in producing the con-
dition of overweight, and thus an indirect cause of diabetes.

QENERAL CONSIDERATIONS 19

Disuse of the muscles, however, is itself a direct factor, for
it is largely in these that the sugar formed from the food is
consumed. That man who gives up an active outdoor life
and is promoted to an office chair by this change becomes a
promising candidate for diabetes. If the overfeeding has been
in the form of sugar, predisposition to diabetes is greater.
There is real danger in the candy habit. It is possible that
the recent increase in the quantity of sugar consumed per
capita in the United States has increased our number of
diabetics. Between 1800 and 1810 the average consumption
of sugar by each individual in the United States was 11
pounds a year, but between 1910 and 1917 it was 73 pounds,
and Mr. Hoover is credited in the daily papers for September,
1917, with showing this figure for 1916 to be 90 pounds.

No other condition rivals obesity in importance as a fore-
runner of diabetes, but the strenuous life is probably of some
significance. This appears reasonable, for it has been shown
that medical students, after three-hour written examinations
upon which their promotion for a year depends, often show
sugar in the urine immediately thereafter, and it may not be
a chance coincidence that within the last year I had at one
time under active treatment for diabetes three children who
had recently led their respective classes at school. My most
recent illustration of this is another child, Case No. 1380, who
came to the office showing 6.2 per cent, of sugar. She had
skipped two classes at school, and the following summer had
eaten even more than her habitually large amount of sweets
and candy.

In the presence of an infectious disease, for example ton-
sillitis, an existing diabetes grows worse; but it is yet to be
demonstrated that diabetes frequently occurs as the result
of an infection.

Of my cases, only 21 per cent, show a history of diabetes in
their families, i. e,, that the disease has been present in parents,
brothers or sisters. Hereditary cases in my experience are
usually mild, and I am in hopes that with the avoidance of
obesity and with moderation in the use of sweet food the
children of diabetics may be no more liable to the disease
than other children. Particularly should the urines of such

20 INTRODUCTION TO DIABETIC TREATMENT

individuals be carefully examined when conditions arise
which would favor the development of diabetes. It would
be a great mistake to consider the diet alone of importance.
Mental relaxatfon and physical exercise should be promoted.
If we are to bring about a decrease of diabetes in the com-
munity it will be with measures such as these. Every agency
which promotes health and physical development tends to
prevent an outbreak of the diabetic tendency. " It is .easier
to keep well than to get well." (Greeley.)

The disease sugar diabetes, usually known by its Latin
name, "diabetes mellitusj" is revealed when sugar is found
in the urine. The development of the disease may be gradual
or acute, and with or without symptoms. It is fortunate
that the disease can be so readily discovered, for unlike many
diseases whose beginnings can be only detected by specialists
or disclosed by the help of elaborate and expensive methods
such as the Roentgen rays, diabetes can be easily and promptly
recognized by any physician who will be on the watch for it
and will examine the urine of his patient for sugar. The
subsequent behavior of the disease and the effect of treat-
ment are also easily followed by simple examinations, and
herein the diabetic has a great advantage over many another
patient.

The sugar in the urine of diabetic patients is derived from
the food, and chiefly from that consumed within the pre-
ceding twenty-four hours. The effects of a meal begin to
show by an increase of the sugar in the blood or by the
appearance of sugar in the urine within ten minutes. Most
of the sugar in the urine comes from carbohydrate (sugar
and starch), but in extremely severe cases as much as 60
per cent, of the protein (examples of which are lean of meat
and fish, white of egg and curd of milk) in the diet may change
to sugar. No sugar is formed from fat, but if a diabetic eats
too much fat he utilizes the carbohydrate and protein of the
diet less well.

Improvement in diabetes takes place when the urine is
kept free from sugar. The annoying symptoms of the un-
treated diabetic then vanish. Under such conditions the
power of the pancreas to assimilate carbohydrate is increased.

GENERAL CONSIDERATIONS 21

Conversely, if the urine is not free from sugar the patient is
generally only holding his own, or more likely is growing
worse. Professor Naunyn, who for a generation was perhaps
the leading specialist in diabetes, observed that even severe
eases if treated early did well, whereas mild cases if neglected
usually did poorly.

In what follows an attempt will be made to show how to
treat the disease, and since success of treatment is most easily
attained by the selection of a diet which will keep the urine
sugar-free, detailed advice along dietetic lines will be given.
The responsibility for maintaining this favorable state must
rest in large measure upon the patient himself. He must
learn what diet is best for him and must constantly control
his condition by the examination of his urine. He is his own
nurse, doctor's assistant and chemist. If he tries to be his
own doctor he will come to grief. To acquire the requisite
knowledge for this triple vocation requires diligent study,
but the prize offered is worth while, for it is nothing less than
life itself.

CHAPTER II.

THE TREATMENT OF MILD CASES.

The present treatment of mild cases of diabetes in many
respects resembles the form of treatment generally employed
for all cases of whatever severity prior to 1913. It is simple
and can be made successful. Patients who faithfully follow
the advice given seldom suffer any material annoyance from
the disease. Even after a decade the disease makes little or
no progress. How readily symptoms of thirst, frequent
urination and loss of weight yield to treatment is evidenced

by the useful careers of several of my genial, fat, doctor-
patients. Such a one is Case No. 653, who came to me at
the age of fifty-three years, having found 5.8 per cent, of
sugar in the urine. The volume of urine in the entire twenty-
four hours was 3000 c.e. (100 ounces or a little over 3 quarts).
The total quantity of sugar therefore which he lost and thus
wasted in the urine each day was (3000 c.c. X 0.058) 174
grams or (^gnj*) 5.8 ounces. Fig. 1 is an illustration of this
quantity of sugar, shown as lumps of sugar, and is inserted
here to make it plain why any untreated diabetic will eat more
than a normal individual and yet not be satisfied and will

TREATMENT OF MILD CASES 23

easily lose weight. It also makes it evident why the untreated
diabetic is a food spendthrift.

According to his own story this doctor had always eaten
freely; candy was the rule rather than the exception in his
house, and die hospitable home was renowned for its cooks.
At the age of fifty-three years his weight was 254 pounds,
which for his height represented 88 pounds overweight.
Contrary to the usual rule he engaged in athletics, but only
for a part of the year. Despite the high percentage of sugar
I could remove worries at once and declare the outlook
favorable because of the early detection of the disease and the
obviously exciting but remediable causes.

Treatment was simple. First of all daily instead of inter-
mittent exercise was encouraged and temporarily less exact-
ing work. The diet was likewise rearranged. Like all dia-
betics of whatever severity he was allowed as much as desired,
but controlled by common-sense, of the following articles:
Water; clear, thin broths; coffee; tea; cocoa shells; cracked
cocoa. These liquids contain practically no nourishment,
and no allowance need be made for the food content. The
balance of the diet was made out for him in rather more
definite terms. Thus he was given for breakfast two eggs and
four strips of bacon, and at the other two meals a single por-
tion of meat or fish of moderate size. Here again the diet
resembles in quantity that prescribed for severer cases, for
all excesses are avoided. The remainder of the menu was
made up of articles selected from the following lists without
limitations as to quantity or quality, though he was restricted
to the use of a single vegetable from the 20 per cent, group
at a meal. (See Table 2; also p. 25.)

It will be seen that the choice of diet was liberal. It con-
tained nearly everything except sugar, bread, bread products
and cereals, desserts, milk and milk products. Even potato,
in the 20 per cent, group, and fruits were allowed freely.

What was the result of this treatment upon our fat doctor.
Case No. 653? The next specimen of urine contained 1 per
cent, of sugar, and as the quantity of urine was 2040 c.c,
the total excretion was 20 grams, or two-thirds of an ounce.
Nine days later the percentage of sugar was 0.4 and the

24 INTRODUCTION TO DIABETIC TREATMENT

amount 5 grams, and a week later the urine was sugar-free.
It has remained so since. The weight of the patient is now
213 pounds, a reduction of 41 pounds. Except for the addition
of cream and butter to the above diet no change in it was
made for some months; later it was gradually increased, and

Table 2.-

-FooDs Classified According to the Percentage
CoNTteNT OF Carbohydrate.

Vegetables (fresh or canned).

6 per cent.

10 per cent.

16 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 rice

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

Apricots
Blueberries

Prunes

Gooseberries

Peaches

Pineapple

Cherries

Currants

Raspberries

Watermelon

Huckleberries

Nuts.

Butternuts

Brazil nuts

Almonds

Peanuts

Piguolias

Black

Walnuts

walnuts

(English)

Hickory

Beechnuts

40 per cent.

Pecans

Pistachios

Chestnuts

Filberts

Pine nuts

AlisceUaneoas.

Unsweetened

and unspiced

pickle, dams, oysters, scal-

lops, livier.

fish roe.

TREATMENT OF MILD CASES 25

in September, 1917, in answer to my inquiry, the patient
summarized for me his diet, and wrote as follows:

Breakfast. — Oatmeal with cream, 2 eggs, hash (alter-
native, fish or fish balls), fruit.of any kind and potatoes.

Lunch. — Cold meat (alternative, hash, creamed salt fish,
sometimes meat pie made with pastry or macaroni), potatoes
and fruit.

Dinner. — ^Any kind of soup except baked-bean soup, any
kind of meat or fish, all kinds of vegetables and salads. For
dessert generally fruit, now and then a custard made with salt
and no sugar or an apple pie made without sugar.

"When at home I very rarely eat any bread of any kind.
If out to dinner will eat bread, occasionally a couple of
griddle cakes without syrup or sugar, and now and then a
doughnut. If at a dinner party I drink whisky or wines.
Have not tasted a cocktail or any kind of malt liquor for four
years. Average consumption of alcoholic drinks would be
about one ounce a week. Have not wilfully eaten anything
prepared with sugar for four years. Have used 100 sacdharine
pills in thirty-two months. I cannot say just how many days
I haye been forced to stay away from business, but my
trouble has not interfered with my daily life."

The treatment which this patient has undergone has been
the treatment of most casea of diabetes of whatever type in
the past, but with this notable difference in result: That
upon it this patient, a mild case, has been able to keep sugar-
free. By means of such a diet even severe cases often live for
a year or two and moderately severe cases for more than half
a decade. This still remains the diet best adapted to those
moderately severe and severe diabetics who are ignorant or
unwilling to make an effort to improve. But for the intelli-
gent patient with moderately severe or severe diabetes who
is honest, energetic and has self-control, later pages will show
how his span of life can be lengthened, his comfort main-
tained and his efficiency in large part preserved.

CHAPTER III.

THE IMPROVEMENT IN THE TREATMENT.

One often hears the remark that patients with diabetes
live for years with little inconvenience to themselves, even
though strict rules of diet are neglected. This may be a
consoling thought to some weak-willed patient, but if the
average diabetic yields to such seductive advice the proba-
bility is overwhelming that he will later pay the penalty.
Furthermore, such statements are not true. Their origin
lies in the favorable course of the large number of mild cases
of diabetes, but just as it is a serious blunder in war to
disparage the strength of the enemy, so it is in diabetes.
How serious in the past diabetes has really been, and at the
same time how much the methods of treatment have improved
during the recent years, is better shown by the statistics for
diabetes of the Massachusetts General Hospital than in any
other way I know. These statistics are incorporated in
Table 3. No student of medicine, practitioner, patient or
investigator can fail to be impressed by them or to gather
hope for the future from this progressive improvement. It
is gratifying that this advance has come through hard work
and not by chance, and that multitudes of scientific men
and women have shared in it. I believe everyone will agree
that Dr. Frederick M. Allen, of the Rockefeller Institute for
Medical Research, has contributed most of all toward bring-
ing this improvement about.

Table 3. — ^The Recent Improvement in Diabetic Treatment as
Shown by the Statistics of the Massachusetts

General Hospital.

Number of

Mortality during hospital stay

Period.

cases.

Number of deaths.

Per cent.

1824 to 1898

172

1898 to 1914

284

1914

1915

1916

103

1917

105

IMPROVEMENT IN THR TREATMENT 27

During the first seventy-four years subsequent to the
opening of the hospital, of every 100 diabetic patients who
entered the hospital 27 died within its walls. Even in the
succeeding period of sixteen years, which closed with the year
1913, the mortality remained as high. Examination of the
next few years ending with the present shows a constant
lowering of the mortality, so that in 1917 it was less than
one-fourth of what it was a few years ago. A reduction in
mortality from 28 per cent, to 6 per cent, is no mean achieve-
ment.

I consider these figures far more valuable than my own,
which follow, in showing the improvement in diabetic treat-
ment, because in a large hospital the cases cannot be selected,
and the treatment is carried out by many rather than by a
single physician. Confirmatory of the Massachusetts General
Hospital statistics, however, are those of my own cases
treated at the Corey Hill Hospital and the New England
Deaconess Hospital beginning with January, 1913, as shown
in Table 4.

I attribute the improvement in my own series of cases to
(1) the introduction of the newer methods of treatment
inaugurated by Dr. Allen; (2) improved methods for the
estimation of acid poisoning — ^that arch enemy of the dia-
betic; (3) the preliminary omission of fat prior to any change
in diet; (4) the omission of alkalis.

Table 4. — Mortality Among Author^s Cases Treated at The

Corey Hill and New England Deaconess Hospitals,

January, 1913 to January, 1918.

Number of

Mortality during hospital stay.

Year.

cases.

Number of deaths. Per cent

1913

4 9

1914

3 5

1915

109

6 6

1916

164

8 5

1917

181

4 2

No disease is known to me whose statistics during the
last three years show an advance in treatment comparable
to that demonstrated in Tables 3 and 4. The chief explana-
tion for the lessening of hospital diabetic mortality is undoub-

28 INTRODUCTION TO DIABETIC TREATMENT

tedly the improved methods of recognition and of treatment
of diabetic acid intoxication, which formerly used so often
to culminate in diabetic coma and death. This has been one
of the outgrowths of the introduction of newer methods of
treatment, of which fasting is the most important.

The need of further improvement in the treatment of severe
diabetes still exists. This fact must be courageously faced.
The prevention of acid intoxication is an important victory
yet to be won. This will be borne in mind in all that follows
about treatment, but a summary of the nature of acid poison-
ing, its cause and the measures now available to combat
it will be found beginning on page 103.

AH too often in recent years it has been felt that if the urine
of a patient were rendered sugar-free by fasting the treatment
of the diabetic ended; in reality it is hardly begun. The
problem of diabetic treatment varies so much that it is
impracticable to give dogmatic rules, though I often do so
(1) to make precise in my own mind my ideas upon treatment
and (2) to learn by experience how these rules can be ad-
vantageously altered. The disease covers so long a period
of time that it is really necessary for the moderately severe
and severe diabetic patient to be familiar with the reasons
for treatment and the methods involved. He must recognize
the three varieties of food — carbohydrate, protein and fat —
and he must have a clear knowledge of the nutritive (caloric)
values of these foods. Upon his acquaintance with the
composition and quantities of the foods he eats depends his
ability to successfully combat his disease. Before under-
taking such a study, and indeed as an introduction to it, I
have inserted the following four chapters because the material
which they contain applies to all types of diabetes.

CHAPTER IV.

QUESTIONS AND ANSWERS FOR DIABETIC

PATIENTS.

Knowledge Essential for a Diabetic. — ^The treatment of
a patient with diabetes lasts through life. Treatment must
therefore be adjusted to his condition, and should be so
arranged that it can be continued for years without harm
and with as little annoyance or interference with the daily
routine as is possible. Consequently the patient must be
taught the nature of his disease and how to conquer it. In
the following questions and answers an attempt is made to
indicate essential features of the knowledge desirable for a
diabetic patient.

Question 1. Why does the human body need food?

Ans. To furnish heat, repair waste, permit growth and
exercise.

Question 2. How may the many varieties of food be
simply classifed?

Ans. Carbohydrate, protein and fat, also water and salts.
(Fig. 7, page 52.)

Question (a) What is carbohydrate?
Ans. It octurs in many forms, but examples of it are
sugar and starch (pages 40 and 51).

Question (6) What is protein?

Ans. It also occurs in many forms, but examples of it are
lean of meat and fish, curd of milk, white of egg. It is
present to a lesser extent in grains and vegetables (pages 40
and 53).

Question (c) What is fat?

Ans. Oil, butter, lard, the fat on meat and fish (pages 40
and 54) .

30 INTRODUCTION TO DIABETIC TREATMENT

Question 3. Should the diabetic patient know about foods
and their relative values?

Ans. It is of the utmost importance for him to know these
things, since (a) diabetes is a condition in which the normal
utilization of carbohydrate is impaired, and (b) the disease is
usually due to overeating (pages 18 and 19).

Question 4. What is the proof that the diabetic does not
make normal use of the carbohydrate eaten?
Ans. The appearance of sugar in the urine.

Question 5. How much sugar is lost in the urine?

Ans. From a mere trace to two pounds in the twenty-four
hours (Frontispiece; Fig. 15, page 111). The percentage of
sugar in the urine may reach 10 per cent., but rarely exceeds
this figure.

Question 6. How is the urine tested for sugar?
Ans. In many ways. The Benedict test is one of the most
reliable (page 168; also Fig. 6, page 37).

Question 7. Why are diabetics unusually hungry?

Ans. Because they must eat enough to sustain life and in
addition enough to make up for the sugar lost in the urine
(page 22).

Question 8. Why are diabetics abnormally thirsty?
Ans. Because they must produce enough urine to dissolve
the sugar and thus remove it from the body.

Question 9. What is the aim of treatment?
Ans. The improvement of the condition of the patient,
which is best indicated by urine which is sugar-free.

Question 10. What is the nature of the treatment?

Ans. Restriction of the variety and quantity of the food
to such an extent as will remove the sugar from the urine;
the cultivation of the simple life and moderate, regular
exercise.

QUESTIONS AND ANSWERS FOR DIABETICS 31

Question 11. Is treatment beneficial ?

Ans. Yes. In the large majority of instances it cures
disagreeable symptoms; it prevents dangerous and painful
complications; it prolongs life and enables one to lead an
almost normal existence. If treatment is not followed the
diabetes grows worse.

Question 12. How does the diabetic diet differ from the
normal diet?

Ans. Usually by the smaller quantity of carbohydrate
and the greater quantity of fat (Fig. 12, page 65).

Question 13. How can sugar be removed from the urine
(or, in other words, the patient become sugar-free)?

Ans. In mild cases by eating less and exercising more.
In moderate cases by great care in not eating a particle of
unnecessary food and by reducing the quantity of carbo-
hydrate and protein. In severe cases by omitting the fat
from the diet, by which the danger of acid poisoning is pre-
vented, and then reducing the carbohydrate and protein, or
in a few cases by fasting.

Question 14. When the urine of the patient is sugar-free
what is done next?

Ans. a little carbohydrate and protein are first given the
patient and then fat, meanwhile testing the urine daily to
determine whether the total quantity of food and the differ-
ent varieties of it can be increased without the return of sugar.

Question 15. What can a diabetic patient do for himself
besides keeping the urine sugar-free?

Ans. Be cheerful and be thankful that his disease is not
cancer, tuberculosis or Bright's disease, but a disease which
his brains will help him to conquer. Keep his skin and teeth
scrupulously clean. Avoid people with head colds and sore
throats. Secure a daily action of the bowels. Sleep nine or
more hours at night and invariably take at least half an hour
off during the day. Exercise moderately in the forenoon,
afternoon and evening.

32 INTRODUCTION TO DIABETIC TREATMENT

Question 16. What is the commonest enemy of the
diabetic?

Ans. Acid poisoning, often termed acid intoxication or
acidosis.

Question 17. How can acid poisoning be prevented?

Ans. Practically always by keeping sugar-free. If the
patient feels "sick^tand is in doubt about acid poisoning he
need not worry if he (1) goes to bed; (2) drinks a glass of hot
water, tea or coffee or clear, thin broth slowly every hour or
hour and a half, or if nauseated takes the same quantity of
liquid by enema, but in the form of salt solution (a level
teaspoonful of salt to the pint of water) ; (3) fasts; (4) moves
the bowels by injection; (5) procures a nurse or has someone
to act as nurse so that he is relieved of all responsibility; and
finally (6) avoids soda or other alkali.

Question 18. What should a diabetic weigh?

Ans. From 10 to 20 per cent, below the average weight for
his height and age. (Table 28, p. 106). Why? Because if the
body is under weight it will not be necessary to eat as much to
maintain weight, and thus there will be less of a burden of
food for the body to assimilate.

Question 19. What is a calorie?

Ans. a calorie is a measure of heat, just as a gram or an
ounce is a measure of weight. It represents the quantity of
heat which is necessary to raise 1 kilogram of water 1° Centi-
grade or 1 pound of water 4° Fahrenheit.

Question 20. (a) How many calories are produced in the
body by the utilization of 1 gram of ^carbohydrate, protein
and fat?

1 gram carbohydrate produces 4 calories.

1 gram protein produces 4 calories.

1 gram fat produces 9^calories.

QUESTIONS AND ANSWERS FOR DIABETICS 33

Question (6) How much food does a diabetic patient
need?

Ans. About 25 to 30 calories per kilogram body weight or
12 to 14 calories per pound; This is a little less than for the
ordinary individual.

A diabetic patient at the beginning of treatment should be
made to understand that he is taking a course in diabetes.
For successful graduation in the course he should be able:

1. To demonstrate how to test the urine for sugar (page
168).

2. To serve himself with approximate accuracy, without
scales, 75 grams of a 5 per cent, vegetable (page 39).

3. To record a summary of his diet for the previous day
(page 42). ^

4. To explain the quantity of carbohydrate which it con-
tains (page 43).

5. To state his diet on his weekly fast day (page 99).

6. To describe what he is to do if sugar returns in the
urine (page 97).

7. To describe what he is to do if he has reason to believe
that he is threatened with acid poisoning (pages 32 and 104).

CHAPTER V.
DIABETIC ARITHMETIC.

A Letter to a Grammar-school Girl.

Dear Freda:

Diabetic patients often get discouraged about the arith-
metic of their diet, and it has occurred to me that if I
could explain it to you, a little girl, the same explanation
should be simple enough for grown-ups. The chief diflSctrlty
arises from the fact that when the doctors talk about the
diabetic diet they speak of grams and kilograms, cubic centi-
meters and liters, instead of ounces and pounds, pints and
quarts. The reason for thi3 is that it is a great deal more
convenient to reckon food values by the metric system. I
do not know of a doctor who uses the avoirdupois system
in the treatment of his patients and in his reports about them
whose plan of treatment of his patients is adopted by any
other doctor. First of all therefore let me explain the metric
system.

The unit of weight in the metric system is the gram. This
is a small weight, and if you will remember that a nickel,
five cent, coin weighs exactly 5 grams you will always have a
correct idea of it. Six nickels (30 grams) would weigh an
ounce, and 1000 grams (200 nickels) make a kilogram, which
is the weight conm[ionly used in all European countries instead
of our pound. A kilogram is 2.2 pounds. It is better to
use decimals — ^2.2 pounds — ^than fractions — 2^ pounds — ^for
the decimal system, when you are thoroughly familiar with
it, is much easier to employ. That you may better under-
stand what a kilogram really means, divide your own weight
in pounds by 2.2 and the result is your weight in kilograms.
A shredded wheat biscuit weighs 30 grams (1 ounce) and so
do three large portions of butter or six lumps of sugar.

DIABETIC ARITHMETIC

15
1(1

Fjq. 2. — o, teaspoon, capacity 5 e.c; b, tablespoon, capacity 15 c

36 INTRODUCTION TO DIABETIC TREATMENT

The average egg weighs 60 grams (2 ounces) and a banana
(peeled) 100 grams.

•i

H^P i

The liquid measures used are cubic centimeters and liters,
and these are employed instead of ounces, gills, pints and

DIABETIC ARITHMETIC 37

quarts. Thirty' cubic centimeters make a fluidounce, and
you know in your cooking that it takes 2 tablespoonfuls of
water for each ounce, and that ordinarily 3 teaspoonfuls

Fio. 6. — 1 tcaspoonful (S c.c.) ol Benedict aolutic

make a tablespoonful. One thousand cubic centimeters make
one Hter, and this is a little more than a quart.

30 cubic centimeters (c.c.) = 1 (fluid) ounce.
4 ounces - 1 giU.
4 gills = 1 pint.
949 " " 2 pints = 1 quart

1000 " " _ 1 liter.

The foods upon which diabetic patients live are nearly
all printed m the lists below (Tables 5 and 6) and shown
in Fig. 7 as well. Most of the foods in Table 5 come under
the head of 5 per cent, vegetables. By this is meant that not

1 Actudly 29.6,

38 INTRODUCTION TO DIABETIC TREATMENT

over 5 per cent, (or 5 grams in each 100 grams) of these vege-
tables may be counted as carbohydrate. As a matter of fact,

Table 5. — Foods Arranged Approximately According to Content

OF Carbohydrate.

Vegetables (fresh or <

canned) .

5 per cent.i

10 per cent.i

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 rice

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

Pineapple

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.

1 Reckon available carbohydrates in vegetables of 5 per cent, group as
3 per cent.; of 10 per cent., group as 6 per cent.

Water, clear broths, coffee, tea, cocoa shells and cracked cocoa can be
taken without allowance for food content.

DIABETIC ARITHMETIC 39

lettuce, at the beginning of the first column, contains 2.2 per
cent., and string beans, toward the bottom of the second
column, occasionally contain as much as 6 per cent, carbohy-
drate. The average percentage of carbohydrate for the entire
group would be about 3 per cent., or 1 gram carbohydrate for
each ounce (30 grams) of vegetables. A large saucerful of
a 5 per cent, vegetable weighs about 150 grams and contains
about 5 grams of carbohydrate. Another reason for reckoning
these vegetables at 3 per cent, available carbohydrate is that
when they are cooked considerable carbohydrate is lost in
the water used in the cooking. The same thing applies to
the vegetables in the 10 per cent, column, and I reckon these
vegetables as containing 6 per cent, carbohydrate or 2 grams
to the ounce. In the 15 per cent, and the 20 per cent, vege-
tables about their full value is available. Fruit, also, must be
reckoned as containing the full quantity of carbohydrate
assigned to it in the column in which it occurs.

Table 6. — Diet Table Showing Total Calories and Quantities

IN Grams op Carbohydrate, Protein and Fat in

30 Grams (1 Ounce) of Various Foods.

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

Cheese 0.0 8.0 11 130

Bacon 0.0 5.0 15 155

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 26 226

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

You will be glad that patieDts seldom need to know the
food values of more than the 20 foods mentioned in Table 6.

40 INTRODUCTION TO DIABETIC TREATMENT

I advise patients to buy gram scales, but as many house-
holds already have ounce scales, I have arranged Table 6 so
that the quantity of carbohydrate, protein and fat in an
ounce, or 30 grams, of food are placed opposite that food.
There are a few exceptions. You will see that the values for
six oysters, one egg, a small orange or half a small grape fruit
are given instead of 30 grams. For another reason I have
given, in the first line, the food value of oatmeal weighed
dry, because when oatmeal is cooked the quantity of water
which it takes up is so variable that the weight of cooked
oatmeal would neither be uniform from day to day nor
the same with different kinds of oatmeal, whereas the food
values for the dry weights of all kinds of oatmeal remain
approximately the same. (See Fig. 7, p. 52.)

THE THREE FOODSTUFFS.

The value of a food depends upon the quantity of the
three food materials — carbohydrate, protein and fat — ^which
it contains.

Carbohydrate Foods. — By carbohydrate one means sugar
and starch. With sugar you are acquainted, and a pure
starch is cornstarch. Fruits are almost wholly water and
sugar and vegetables largely water and starch. Bananas,
when green, contain nearly 20 per cent, starch, but when
ripened this changes to sugar. Potatoes are 20 per cent,
starch. Bread is about 60 per cent, starch, and the flour
out of which it is made, being drier than bread, contains
about 70 per cent. Two-thirds of oatmeal is starch.

Protein Foods. — ^Protein is the food from which our muscles
and tissues are made. Examples of protein are the lean of
meat and fish, the curd of milk and the white of egg. The
yolk contains just as much protein as the white, but it is
mixed with fat. Protein is also found in grains, and there
is considerable in beans and peas, but very little in other
vegetables and almost none in fruits.

Fat Foods. — ^Fat is found mostly in the form of butter,
oil, lard, cream and the fat on meat and fish. Rich cream
contains 40 per cent, fat, and milk may contain only about
3 per cent.

DIABETIC ARITHMETIC 41

FOOD AND FUEL.

Foods are fuel for the body, just as gasoline is fuel (food)
for an automobile. Man and automobile depend upon fuel
as a source of energy. / In case the gasoline gives out the
automobile will stop, but if the food gives out the man will
not immediately die, because he carries a good deal of the
fuel stored up in his body, first and chiefly as fat, second, a
lesser amount in the form of protein in the muscles and
various tissues, and third, a little in the form of carbohydrate
as animal starch (glycogen) and sugar in the liver, muscles
and blood. Living upon this reserve supply of food you
will remember that Prof. Benedict's man at the Carnegie
Laboratory in Boston fasted for thirty-one days.

Just as one can measure how much gasoline is required for
an automobile to run 100 miles, so one can measure how
much food is necessary for a man to live for twenty-four
hours and do a given amount of work. Small automobiles
require less gasoline than large automobiles, and this is
pretty much true of individuals, for the food which they need
depends upon their weight. There are exceptions. Children
require proportionately more food because they are growing,
and old people require less because they are quieter. We can-
not measure the quantity of food which we use in as simple
a way as we can measure the fuel gasoline which the auto-
mobile requires because we depend upon three kinds of food.
However, you can easily see that if we know the food value
for 1 gram each of the foods, carbohydrate, protein and fat,
and if we know how much of each food is eaten, we can then
determine the total food value of the diet for the patient.

THE FOOD MEASURE.

A food measure or unit of food value has been determined
for eacli of the three foodstuffs, and it is known as the cahrie.
By a calorie is meant the quantity of heat which is necessary
to raise 1 kilogram of water 1° Centigrade, or in the English
system V pound of water 4° Fahrenheit. Experiments have
shown that 1 gram of carbohydrate or of protein will produce,

INTRODUCTION TO DIABETIC TREATMENT

when used up, that is, when burned in the body, 4 calories,
and 1 gram of fat, 9 calories. A gram of alcohol produces 7
calories. If you read over again what I have just written
and also Table 6 it is not very difficult to reckon the values
of the food in a patient's diet, and I will give you an example
of this in the following table:

Table 7. — ^The Computation op the Diet.

Food.

Break-
fast.
Grams

Dinner.
Grams.

•

Supper. Total
Grams, grams.

Carbo-

lurdrate

Grams.

Prot^.in.
Grams.

Fat.
Grams.

Five per cent. veg.
Eggs (2) .
Meat, cooked
Fish ....
Bacon

Butter . . .
Cream, 20 per cent.
Oatmeal .

100
2

• • •

15
10
30
15

+ 200
60

+ 10

+ 30

• •

+ 150 = 450

... = 2

... = 60

60 = 60

15 = 30

+ 10 = 30

+ 30 = 90

... = 15

"3
10

8
12
16
12

• • •

3
3

12
10

• • •

15
25

18
1

Totals =
Calories per gram =

28
4

59
4

81
9

Total calories

= 112 + 236 + 729 = 1077

In the first column is recorded a list of the different foods
taken during the day. Of 5 per cent, vegetables you will see
that 100 grams were given for breakfast, 200 for dinner and
150 for supper, making a total for the day of 450 grams.
Two eggs were given at breakfast; meat was given at dinner
and fish at supper, but a little bacon appears on the list for
both breakfast and supper. Cream containing 20 per cent,
fat was given at each meal; oatmeal only at breakfast.
Knowing the total quantity of each kind of food given
during the day, by using the table of food values (Table 6)
one can determine the amount of carbohydrate, protein and
fat for each given food. Thus, 450 grams of 5 per cent,
vegetables were used. Table 6 shows that for each 30 grams
(1 ounce) of 5 per cent, vegetables, there is 1 gram^ carbo-
hydrate and 0.5 gram protein, and therefore in 450 grams
(15 ounces) there would be 15 grams carbohydrate and half
as many grams protein, or 8 (actually 7.5).

Two eggs were given at breakfast. Table 6 shows that the
eggs contain no carbohydrate, but that each egg contains

* Arithmetically, 1.5 grams, but on account of variation in vegetables
and in cooking, as well as for convenience, reckoned as 1 gram.

DIABETIC ARITHMETIC 43

6 grams protein and 6 grams fat— in other words, 2 eggs
contain 12 grams protein and 12 grams fat. In the same
way you can reckon the amount of carbohydrate, protein
and fat in 60 grams of meat (cooked), 60 grams of fish, 30
grams of bacon, 30 grams of butter, 90 grams of 20 per cent,
cream {L e,, cream containing 20 per cent, butter fat), and
15 grams of oatmeal. In Table 6 the quantity of carbo-
hydrate in 30 grams of oatmeal is given as 20 grams — conse-
quently, in 15 grams of oatmeal there would be half as
much, or 10 grams carbohydrate and 3 (actually 2.5) grams
of protein and 1 gram of fat.

The actual percentages of carbohydrate, protein and fat
in various other foods are given in the large tables on pages
144 to 164. From these it is easy to calculate the quantity of
carbohydrate, protein and fat in any food which a patient eats
when the total quantity of eaten food is known. Patients
and nurses somehow are repeatedly confused by such tables,
forgetting that if the quantity of carbohydrate in milk is
5 per cent., that 100 grams of milk (or in this case cubic
centimeters) would contain 5 grams of carbohydrate, just as
5 per cent, interest on $100 for a year would be $5. Lobster,
for instance, contains 16 per cent, protein, and therefore
100 grams of lobster contain (100 X 0.16) 16 grams protein.

One should be familiar with percentages, because in this
way one can often find the values of various foods which are
not contained in the 30-gram (1-ounce) table. Should a
patient, for example, wish to substitute his 8 grams of
protein m the form of 30 grains of meat for 8 grams protein
in the form of lobster, this could be done by his taking
(ooe) 50 grams of lobster.

The use of percentages, however, is employed far more in
determining the quantity of sugar voided in the urine by
diabetic patients in the twenty-four hours. If an individual
voids 2000 c.c. (cubic centimeters) of urine and the per-
centage of sugar is 5 per cent., it is plain that the quantity
of sugar lost in the urine during the twenty-four hours would
be 2000 X 0.05 = 100 grams. As a lump of sugar amounts
to about 5 grams, this would mean that the equivalent of
20 lumps of sugar were lost in the urine in one day.

44 INTRODUCTION TO DIABETIC TREATMENT

It is interesting to compare the decrease of sugar in the
urine with the reduction of carbohydrate in the diet.

In Table 8 it is to be seen how this took place. It is true
that each day required quite a little arithmetic on the part
of doctor and nurse, but now you could construct such a
table by yourself, and I am sure would do it far better than
most patients twice your age.

Table 8. — ^Illustration of Ambulatory Treatment without

Fasting or Omission of Protein. Case No. 1237. Age

at Onset in September, 1915, Thirty-nine Years

AND Five Months.

Urine.

Diet]

in grams.

ght, pounds,
ressed.

Dietary prescriptions in grams.

•
•

Sugar.

•

etables,
per cent.

•
OB

•

C8 a>

Date,
1917.

Per

cent.

Total
gms.

-3

• IM

•a

tf-o

«8

Plh

:?:;«

Feb. 17

4000

8.4

336

1500

2.2

• • • •

720

360

1600

1.8

• • • •

720

360

1250

1.8

• • • •

i42

720

360

1500

0.4

432

720

360

1250

0.2

432

• • •

720

360

1500

Tr.

432

720

360

1500

Tr.

567

i39

720

240

• • •

783

• • •

720

120

1250

937

• • •

720

120

Mar. 1

1162

• • •

720

120

1286

138

720

120

106

1422

• • •

720

120

106

1462

136

720

120

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
no means a satisfactory guide. Information must be furnished
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^ for this special purpose suflSciently 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 oflSce

^ Bottles, known to the druggists as percolator bottles, and graduated in
100 o.c. up to 2000 o.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 nieans 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 leam 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 case 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 tt 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 he 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 tiie 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.

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

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 6 per cent. For

5 10 15 20

CALORIES

C'ATMEAL
CREAM A0%
CREAM 2Q%
MILK

BRAZIL NUTS
OYSTERS 6
MEAT UNCOOKED
MEAT COOKED
CHEESE
BACON
EGO-ONE
VEGETABLES H
VEGETABLES 10)(
POTATO
BREAD

'^^

^^^

^^^^^

^^^

120

210

130

155

225

270

25
3

—

^^^^^^^^^^^^^^^^^^^^^^^^1

"^^^■■^^L

mtL

^^^^

■■■■I

III 1

Ml !

■^^^^^^1

w^^^^.

^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^B

OIL

COD, HADDOCK

BROTH

euAi 1 S ORANGE OR
SMALL ^j^Q^^pgPP^

CARBOHYDRATE (SUGAR AND STARCH}|

»RC
■AT

>TE

'AN

- M

EA-

FI8

RDOF

. E

GG-

<IT

E E

TC.

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

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

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 rice

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 j

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 cm'd of milk. White of egg is
pure protein and water. In the white of one ^gg 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 60

Meat (cooked, lean) ....0.0 8.0 6 75

Bacon 0.0 6.0 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.

Pat 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^ 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.^
In general, one can be quite sure that the prisoners were not
allowed more than the civil population.

Table 12. — ^Rations Allowed in German Prisonbr-op-war Camps.

Protein,

Fat,

grams.

Calories.

185

141

4761

215

3717

224

195

4962

145

3745

130

117

3478

Carbo-

lydrate,

grams.

Protein,
grams.

Fat,
grams.

Calories.

510

2740

310

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.

* Taylor, A. E.: Jour. Am. Med. Assn., 1917, Iziz, 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.'

30 cubic centimeters = 1 fluidounce.^

1000 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 160
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).

Br
Iv

Total calories.

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.

Condition.

Calories per

kilogram, body

weight.

Calories per

pound, body

weight.

At rest
At light work
At moderate work
At hard work

. 25 to 30
. 35 to 40
. 40 to 45
. 45 to 60

11 to 14
16 to 18
18 to 20
20 to 27

Age in years.

Weight:
kg. pounds.

Calories per Calories per

kilogram, pound,
body weight, body weight.

Total
calories.

12 26

80 36

960

20 44

70 31

1400

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

1600

400

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 suflSce at seventy and 1600 at eighty
years of age.

Table 16. — ^The Proportion of Carbohydrate, Protein and

Fat in the Normal Diet.

Quantity,
Food. grama.

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

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 a GARB.
1600 CAL8.

\r:

100 G. FAT
900 CAL8.

100 Q. PMOTEIN
400 CAL8.

Fig. 8. — ^The relative caloriq. 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 is 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 starch 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 of Weight of Bacon during Cooking.

ncooked,

Cooked,

Lost,

grams.

per cent.

200

100

Eggs in some cities by law must weigh a pound and a half
a dozen, an average of 60 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.

per cent.

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

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.

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 modem fashion. The value of the different

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.

}OF^f^'

^[^^

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 60 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.

Fia. 11. — Vsriatioiia in the

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 are
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 126, 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 70 60 50

Protein in one egg .... 7 6 5

Fat in one egg 7 6 5

Three Potatoes.

Weight of one potato .... 120 90 60

Carbohydrate in potato ... 24 18 12

Three Oranges.

Weight of one orange .... 350 225 150

Carbohydrate in one orange . . 20 15 10

Three Grape Fruit.

Weight of one grape fruit ... 900 600 300

Carbohydrate in one grape fruit . 40 30 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.

Foods arranged in grams.

F:g; 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, — lit 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 ip 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 Noorden^ 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. AUen^ 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.

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

4.9
10.0
13.2
14.6
20.9
46.7
42.1

.6
,6
,4

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

O
m
m

O
OS
QQ

o
<

Spinach,
canned.

o ^ o

CO 1 CD

5
o

r* 1 t>

Cauli-
flower,

Mush-
rooms,
Agaricus
Cam-
pestris.

lO O O

Aspara-
gus,
canned.

o 9 o

Celery A,
soaked 2
hours in

cold
water.

03
GQ

co"

•

« «*-iirt>, jaoi»-"'
« § §2-2 £-5 « o $^ 2 $

at? I^sll sisg'^

30 §^^4^-00 3^H«wO

/O DKTAILS. OF DIABETIC TREATMENT

lu. uvl\ il, Uic Hc'OJiul extraction leads the list in removing
V uliv»U,\Unau, th^^ ftvst extraction ranking after the third or
U'ui ill. lu gciuual, UK) grams of the fresh, clean, dry vege-
UiliK", \Ml>;licil ixoin the edible portion, were used for each
.uial.N .^is, uiul all calculations were made on this basis. With
llu' r\ci'pticui of canned asparagus the four or five extractions
lu i I .sNury to remove all reducing substances left the vege-
tulilcM btill attractive in flavor and appearance. Professor
WunluU has further reported^ that repeated washings with
water will remove the carbohydrate from beets and parsnips;
'^ iu the case of the beets and 7 in the case of the parsnips.

VuY practical purposes three extractions will probably be
foiuul sutficieut. For the first, place the vegetables in cold
wutcv and bring the same to the boiling-point, maintaining
the tcn\peratu?e for three to five minutes, but for the others
bcKiu with hot water.

The Carbohydrate in Various Foods. — 1. Potatoes. — The
^uriation 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 carefuUy 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.

» Am. Med. Assn., 1917, Ixix, p. 1859.

DIET OF DIABETIC INDIVIDUALS 71

2. Nuts, — ^Nuts 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, thfe
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 6 per cent., or 1.5 grams
per 30 c.c. or 1 ounce. It is the same in skinuned 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. Oa^mea/.—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 73

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 suflSce. Chittenden,
weighing 67 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 i 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 abouir 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. 65), 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. Theoretically,

(1200)
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

76 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 : 6 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 16 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

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 beautifully shown in Table 21.

Table 21. — The Dependence of Acidosis upon the Fat in the

Diet (Williams and Dresbach.)

Urine.

Diet.

Date.

Diacetic

Total
NHs

Total
sugar

Carbo-
hydrate,
grams.

Protein,

Fat.

acid.

(FoUn).

(polar),

grams.

1912

July 5

+ +

1.9

100

200

+ +

2.1

100

200

0.6

Aug. 8

+ +

2.7

190

200

Oct. 20

0.6

0.3

Nov. 12

0.5

•56

1913

Jan. 28

+ + +

2.6

122

100

200

Feb. 2

+ + +

3.0

152

200

June 12

+ + + +

4.1

108

100

200

July 27

+ + + +

4.4

123

200

150

180 +

+ + + +

3.3

172

200

150

180 4-

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 CO. 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 sifnultaneous 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. 1378 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
manner 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 160. 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 grams carbohydrate, about
110 grams protein, and 110 grams fat, making 1600 to 1800

MODERATELY SEVERE AND SEVERE DIABETES 81

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82 DETAILS OF DIABETIC TREATMENT

calories in a day, and the weight had risen^to 148 pounds.
From the above it can be seen that the diabetes changed
from the severe to the moderate tyi)e, and finally became
mild.i

Case No. 1024 consulted me at the age of seventy-seven
years with a history of diabetes of eight years' duration.
She was annoyed by symptoms referable to the circulation,
digestion and skin, and her age and discomfort suggested
that it might not be worth while to attempt any treatment.
Treatment, however, was attempted, and rewarded by the
urine becoming sugar-free and remaining so at the end of
three weeks, but only upon a rigid diet containing 1 gram
carbohydrate, 32 grams protein, 72 grams fat, and alcohol
12 grams. Even upon this stern regime the urine remained
sugar-free for only a few weeks, when sugar reappeared in
varying quantities. But no one even thought of giving up
the fight for health. Under the careful supervision of skilled
nurses, sugar disappeared again, and the weight, which had
fallen from 122 pounds to 106 pounds in August, 1916,
steadily increased to 119 pounds the following summer and
the patient remained sugar-free over a period of months,
with a diet containing carbohydrate about 40 grams, protein
75 grams and fat about 140 grams. The blood-pressure,

which was 160, is now 125; Mrs. now looks well and

is more active than any woman I know of her age. This
patient, apparently a severe case of diabetes, with distressing
symptoms, under careful treatment has changed to a case of
almost mild type.

Occurring at the other extreme of life is Case No. 894, a
little girl, who developed diabetes at the age of one year and
five months, although it was not discovered until a year
later. In March, 1915, the urine showed 5.3 per cent, of
sugar, although when I first saw her (July 30, 1915) she was
upon a restricted diet, and but 0.2 per cent, was found.
Under careful treatment she has remained sugar-free except
during a brief period in midsummer of 1917, when confusion

^ I consider the diabetes to be severe when sugar appears in the urine if
the diet of the patient contains not over 10 grams carbohydrate, moderate
if between 10 and 50 grams carbohydrate, and mild if more than 50 grams.

MODERATELY SEVERE AND SEVERE DIABETES 83

existed as to the solution used for testing the urine, and the
diet had been unfortunately increased. With little trouble,
however, she again became sugar-free. The weight on August
3, 1915, was 33i pounds, and on August 12, 38^ pounds.

One of the most satisfactory cases. Case No. 664, whom I
have had under observation was a boy of sixteen, who came
to my then assistant. Dr. F. Gorham Brigham, in November,
1912.. Sugar had appeared in the urine without previous
symptoms following a football game between two large
preparatory schools. The patient entered the New England
Deaconess Hospital, where, under the methods of treatment
adopted in 1912 and 1913, he remained from December 15^
1912, to January 14, 1913, without becoming sugar-free, the
quantity of sugar varying between 3.4 per cent. (187 grams
in the twenty-four hours) to 0.8 per cent. (43 grams in the
twenty-four hours) at discharge. However, with the methods
adopted at that time, under the supervision of Dr. R. J.
Thompson, of Fall River, and a nurse thoroughly versed
in diabetic treatment, the acid poisoning, which had been
severe and later amounted to as much as is represented by
5.7 grams ammonia in twenty-four hours, disappeared, and
at his home he became sugar-free in April, 1913. He has
now passed a considerable portion of his examinations for
college, and should enter this coming year. On September
23, 1916, the urine was sugar-free and the blood sugar
amounted to 0.13 per cent. His weight naked was 129f
pounds in contrast to 97^ pounds on December 17, 1912. On
December 26, 1916, the dressed weight was 134 pounds. On
December 27-28, 1917, the urine showed 0.3 per cent., or
6 grams sugar. The blood sugar was 0.23 per cent, and the
blood fat 0.704 per cent. It is interesting to record this case,
because persistent treatment faithfully followed by doctor,
nurse and patient's family has given remarkable results.

Case No. 632, a young oflScer, aged thuty-five years, with
diabetes of one and a half years' duration, came to me first
in 1913. At the hospital diacetic acid showed repeatedly,
and the anmionia was 1.7 grams, but the tolerance for carbo-
hydrate lay between 15 and 30 grams. Nevertheless, he was
discharged with 0.5 per cent, of sugar in the urine, and diacetic

84 DETAILS OF DIABETIC TREATMENT

acid was present, with a diet of 30 grams carbohydrate and a
limited quantity of protein, though with an unlimited amount
of fat. He returned in February, 1916, and it required twelve
days to rid the urine of sugar and twenty-one days to rid
it of acid, but he left the hospital April 13, having been
sugar-free the preceding week with a tolerance for 28 grams
carbohydrate, 79 protein, 133 fat and 9 alcohol. The blood
sugar was 0.21 per cent. While at the hospital exercise was
utilized to the limit, and, as to be expected of an army man
with a Victoria Cross, obedience was implicit, cooperation
ever present and system exact. I have permission to publish
this letter received eleven months after leaving the hospital.

March 8, 1917.

"I have really been wonderfully well, feel splendid and
everyone remarks how well I am looking. Tests have shown
a slight trace of sugar on three mornings since October 8
last; all other times absolutely sugar-free. My weight
doesn't change at all— if anything I have gotten very slightly
lighter. I weigh from 124| to 125^ pounds. I still stick
absolutely rigidly to my routine, but I have gotten up to
30 grams carbohydrate per diem — ^that is, on the last five
day^ of the week I take 30 — ^rest of diet the same. The last
three weeks I have been taking 15 grams oatmeal for break-
fast on Monday, Tuesday, Thursday, Friday and Saturday
mornings, Wednesday all carbohydrate in 5 per cent, vege-
tables and cream, Sunday (fast day) all carbohydrate in
5 per cent, vegetables.^'

That this improvement continues is evident from another
letter of October 12, 1917.

"We had a patriotic golf match here last Saturday and
Monday against the rival golf club here. I was chosen to

play 2d for the and my opponent and I came out

even in both our matches, one over our course and the other

over the . I am sending you a newspaper clipping

of the last game at , just to let you see that there is

some life in the old dog yet. Since our game Mr.

won the club championship of the .

MODERATELY SEVERE AND SEVERE DIABETES 85

"I keep very well, as you may surmise from the above,
sugar-free all the tune. I stick to the same old routine —
30 to 31 grams carbohydrate per diem. I gave up the orange,
as I really prefer the 5 per cent, vegetables, and I thought
that I took the vegetables better. I had a fine five days
the end of September, up in the woods, trout fishing, had
good weather and very good fishing. I managed to keep
sugar-free all the time, although I had a good appetite and
took lots to eat.''

February, 1918, the patient continued in good condition,
sugar-free with tolerance as before.

In what follows the general principles underlying the
treatment of moderately severe and severe cases of diabetes
are explained. It will be seen that there are many means
by which the urine of a diabetic patient may be freed from
sugar, but that the simplest of all is by fasting, and to this
all other methods converge. If fasting for a day or two
appears inadvisable, the simple omission of fat, which mate-
rially reduces the nutritive value of the diet, may render
the patient sugar-free. Formerly, physicians endeavored
to get their patients sugar-free by the reduction of carbo-
hydrate in the diet, at the same time immediately increasing
the fat and protein to make up for the calories thus lost.
Various dangers attended this practice, and at present it is
generally abandoned. The method now adopted to free the
urine of sugar is designed to accomplish this end without
any risk to the patient. It is brought about either by com-
plete fasting or by the withdrawal of fat from the diet, and
the subsequent reduction of carbohydrate and protein to a
point at which the patient no longer voids sugar in the urine.
Frequently I am in the habit of combining both methods,
for it so often happens that by the adoption of the plan about
to be described under "Preparation for Fasting" that a
patient becomes sugar-free within a few days, and free from
acid poisoning if that were present. By methods like the
above alkalis are unnecessary, and, indeed, I believe if they
are given that they do harm. In the following paragraphs
in italics the plan is summarized:

DETAILS OF DIABETIC TREATMENT

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MODERATELY SEVERE AND SEVERE DIABETES 87

Preparation for Fasting. — In severe, long-standing,
complicated, obese, and elderly cases, as well cw in all cases
with acidosis, or in any ca^e if desired, wUhout otherwise
changing habits or diet, omit fat, after 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
+ + +> 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 day, 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. 938. Aged Two Years, Fou^ 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
Case No. 1237 was 336 grams. The directions given the
patient may be summarized as follows:

1. Take J 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 J
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 day by the addition of 1 ounce
(SO c.c.) of 20 per cent, cream until 3 ounces are taken.

MODERATELY SEVERE AND SEVERE DIABETES 89

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DETAILS OF DIABETIC TREATMENT

5. Similarly, thereafter every other day add one-half an
orange until one-half is taken at a meal and from then on
every other day 1 ounce potato until as much as desired is
taken, or sugar appears.

Case No. 979, a woman, aged forty-nine years, developed
diabetes at the age of thirty-two. When I first saw her
seventeen years later, January 26, 1916, she showed 7.4
per cent, of sugar and no diacetic acid. It will be seen from
Table 26 how she became sugar-free without the develop-
ment of acidosis by the elimination of fat and the restriction
of protein, followed by the gradual diminution of carbo-
hydrate.

Table 26. — Case No. 979, or Seventeen Years' Duration, Illus-
trates (1) How Preparatory Treatment Makes Fasting'
Unnecessary and (2) Renders the Urine Sugar-free

WITHOUT THE APPEARANCE OF AciD PoiSONING.

Urine.

Diet in grains.

Dietary prescriptionR in grams.

Sugar.

•

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Date. 1916.

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0.

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cent.

•
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per

Jan. 25

7.4

25-26

6.2

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130

26-27

5.6

142

944

128

300

1.0

100

27-28

4.0

112

764

128

300

1.0

28-29

2.2

584

128

300

2.0

29-30

1.0

411

127

300

1.0

30-31

0.6

371

127

300

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Feb. 31- 1

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126

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1917

Feb. 16

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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 drink^ 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

92 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 shun
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 inunediate 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 fasting one day each week. I haw seen no uncom-
plicated case fail to get stigar-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 (160 to 300 grams of 6 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 (rf 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 toleranoe 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 3 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
Xo. 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
grams protein daily in the form of egg-^hite, 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 da^'s 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

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96 DETAILS OF DIABETIC TREATMENT

The advantage of giving and increasing protein simul-
taneously with the determination of the carbohydrate
tolerance is that one approaches more nearly normal condi-
tions. What the physician is after is to determine the carbo-
hydrate tolerance while the patient is on a full diet and not
the tolerance for carbohydrate alone. On the other hand, I
freely admit that a higher carbohydrate tolerance can be
attained when the addition of protein following the prelimi-
nary fasting is deferred until the actual carbohydrate toler-
ance is learned in the absence of protein and fat. Naturally
the method adopted will vary somewhat with each patient.

There are very few patients who will not bear at the outset
as much as 1 gram of protein per kilogram body weight, and
I am very loath to allow the protein to remain permanently
below this figure. This can be avoided by still further
restricting the carbohydrate; either temporarily or per-
manently. It is always necessary to remember that one
food which the diabetic patient cannot do without is protein,
and to it everything else must be subordinated. More and
more I believe we shall strive to spare body protein.

Fat Tolerance. — The work of Professor Bloor and
Dr. Gray in Boston and that of workers at various other
laboratories has provided us with a reliable indicator
for the tolerance of the patient for fat by means of the
estimation of fat in the blood. As yet the test is too com-
plicated for general use, but for those who have access to a
laboratory it is perfectly practical. For those not in a posi-
tion to employ Bloor's fat method there are two indirect
methods of determining fat tolerance, namely, signs of
acidosis and the appearance of sugar in the urine (glycosuria).
So long as these exist the fat must be kept low. While testing
the protein tolerance a small quantity of fat is included if,
in addition to whites of eggs and lean fish, meat is given.
Formerly I thought this advantageous, and such small
quantities of fat certainly do no harm in the milder cases.
In fact the same rule holds for the testing of the carbohydrate
and protein tolerance in the presence of fat as has been said
for protein alone. There are, on the other hand, two impor-
tant reasons why fat should not be given to the diabetic

MODERATELY SEVERE AND SEVERE DIABETES 97

patient immediately upon his becoming sugar-free: (1) by the
omission of fat, partial fasting is continued and thereby
the patient is gaining a tolerance for carbohydrate, and (2)
the continued omission of fat is beneficial in counteracting the
last vestige of acid poisoning, or preventing the appear-
ance of acid poisoning, which might easily occur in a diabetic
patient whose metabolism has not become accustomed to so
low a quantity of carbohydrate. But as soon as the patient
has received the essential gram of protein per kilogram
body weight the fat in the diet should be increased. If the
patient is one in whom acidosis has been an essential factor,
or if the patient is obese, the fat should be increased slowly,
and for such a patient an increase of 5 to 10 grams a day
may be all that he can take without the recurrence of a posi-
tive ferric chloride reaction in the urine. Cases which have
shown little acidosis may easily be allowed an increase of
25 grams fat daily, and for such cases this is desirable,
because it rapidly brings the total caloric value of the diet
up to a normal figure. Naturally, patients in whose treat-
ment a loss of weight is desired would be given smaller
quantities of fat.

The rule which I have for myself is as follows:

Add no fat until the protein reaches 1 gram per kilogram
body weight {unless, the protein tolerance is below this figure)
and the carbohydrate tolerance has been determined, but then
add 5 to 25 grams daily, according to previous acidosis until
the patient ceases to lose weight or receives in the total diet
about 30 calories per kilogram body weight

Reappearance of Sugar. — The return of sugar demands
fasting for twenty-four hours or until sugar-free. Resume the
former diet gradually , adding fat last in order to maintain as
high a carbohydrate tolerance as possible, sacrificing body
weight for this purpose. This rule should be inflexibly fol-
lowed, especially with children.

In hospitals it simplifies the treatment enormously.
As soon as it is understood that the reappearance of sugar
means a fast until sugar disappears from the twenty-four-
hour quantity of urine there is little tendency to break over
the diet. Furthermore, most patients are thrifty enough
7

98 DETAILS OF DIABETIC TREATMENT

to see the disadvantage of pacing their board with no return.
The rule must be rigidly enforced with children, because
with them disobedience means death. When a patient has
been made sugar-free by a preliminary fast, absence of food
for twenty-four hours will almost invariably be sufficient
to free the urine at once if the sugar returns. This will not
be the case unless the presence of glucose is promptly detected,
and hence the necessity for the patient to examine his twenty-
four-hour urine daily. Following this accessory fasting day,
the previous diet of the patient may be gradually resumed,
making ever>' endeavor to regain the former tolerance for
carbohydrate by slowly increasing the quantity of fat.
Great care should be exercised, more indeed than I have
often taken, not to break down the tolerance a second time.

Months rather than weeks should intervene before the
final amounts of carbohydrate, protein and fat, reached the
second time, equal the quantity of carbohydrate taken when
sugar reappeared. , I have always been much impressed by
the success of Drs. Janeway and Mosenthal in the treatment
of one of their patients, because the patient had been taught
to keep the carbohydrate so low that sugar did not reappear
though he was away from their supervision for a period of
months.

Patients often get into trouble by their failure to energetic-
ally grapple w'th the reappearance of sugar. One day of
fasting will accomplish far more than many days of a moder-
ately low diet. It is a mistake for any, save the most highly
trained patients, to attempt to meet such a s'tuation without
medical advice. ,

Case No. 804, described on page 80 illustrates this well,
for it is perfectly evident that he was an intelligent patient,
and yet grew steadily worse until he returned for the second
period of treatment at the hospital.

Another instance is Case No. 1279, who reached a toler-
ance in April, 1917, at the hospital, for 78 grams carbohydrate,
63 grams protein and 109 grams fat, with a blood sugar at
this time of 0.12 per cent. In the autumn of the same year
sugar repeatedly recurred, and he was unable to become
sugar-free at home. After a stay of a few weeks at the hos-

MODERATELY SEVERE AND SEVERE DIABETES 99

pital he was discharged with a tolerance for 65 grams carbo-
hydrate, 74 grams protein, 98 grams fat and blood sugar of
0.14 per cent.

Still another patient, Case No. 1265, shows the improve-
ment of medical supervision. This patient, a woman, aged
fifty-seven years, left the Corey Hill Hospital on May 5,
1917, with a tolerance for 30 grams carbohydrate, 58 grams
protein and 119 grams fat, and a blood sugar under 0.1
per cent. Until the sunmier she did well, but in the
early autumn apparently finding the urine normal, steadily
increased her diet, yet her condition was not satisfactory
to herself or her friends. Upon the return of her doctor he
discovered that the Benedict solution she had been using
was inaccurately made up and for over a month sugar had
undoubtedly been present in the urine. Under hospital
treatment she was discharged in two weeks with a tolerance
for 33 grams carbohydrate, 61 grams protein and 81 grams
fat, with a blood sugar of 0.14 per cent.

Weekly Fast Days. — Whether sugar reappears in the
urine or not it is desirable upon one day each week to rest that
'junction of the body which controls the assimilation of sugar
by either a complete fast day or a diet of low caloric value. My
plan is patterned on the follqwing rule: Whenever the tolerance
is less than 20 grams carbohydrate^ fasting should be practised
one day in seven; when the tolerance is over 20 grams carbo-
hydrate, cut the diet in half on one day each week (*' half-day'').

This is a revival of an old practice used, I understand,
many years ago by Dr. Austin Flint, of New York, who
fasted and kept abed his diabetic patients on Simdays, and
in fact I believe von Noorden terms such weekly fast days
" Diabetic Sundays.''

The benefit which the older clinicians derived from the
use of one day's fast in seven in the treatment of their
diabetic patients should ever be borne in mind. Case No.
1062, now under observation, who contracted diabetes
twenty-six years ago, possibly in connection with gall-
stones, tells me that at that period her physician. Dr.
Randall, of Topsfield, Mass., often told her to go without
food, save broths, for several days in succession, and that

100 DETAILS OF DIABETIC TREATMENT

she would follow this advice. Her severe symptoms of
diabetes subsided at the end of four years. Recently the
quantity of sugar has been slight. Her tolerance on June 1,
1916, reached 116 grams carbohydrate. The advantage
of this restricted diet day each week is partly inherent in
the fast or restricted diet, but to a considerable extent it is
due to the attention of the patient being sharply called to
his disease one day in seven, and the recollection which it
awakens in his mind of his condition before treatment began
and the difficulties which may have originally accompanied
becoming sugar-free. Some exceptions to the above rules
may be mentioned: for example, elderly patients bear fasting
poorly, and when they remain sugar-free upon a rigid diet
containing only 10 grams of carbohydrate it is my impression
that it is better to simply restrict the calories of the diet
one-half on one day each Week rather than to institute an
absolute fast. With such treatment these patients almost
invariably gain in tolerance for carbohydrate. Children
become fretful upon a fast day, though physically they
endure it well. If they are allowed a few green vegetables in
addition to broths they get along very comfortably. Von
Noorden pointed out that the good effects of a fast day
continued many days beyond the actual fast.

The Caloric Needs of the Patient. — ^The total number of
calories which a diabetic requires varies not only with each
case, but varies with each case each day. Schematic rules
do not hold. One must remember that an individual trained
to be quiet and while lying down can get along with only
20 calories per kilogram body weight reckoned per twenty-
four hours, whereas the average of a large group of normal
men and women at the Nutrition Laboratory, not especially
trained for the test, consumed 25 calories per kilogram body
weight reckoned also per twenty-four hours. If this varia-
tion exists while at rest, how much more it must exist during
the various activities of different individuals. Furthermore,
one must remember that the number of calories consumed
per hour varies enormously. An individual weighing 60
kilos walking at the rate of four miles per hour would require
an additional 193 calories for that hour over the resting

MODERATELY SEVERE AND SEVERE DIABETES 101

■> • ' ■• ■• ' ■>

metabolism. Habits of individuals vary vWely. Som:(e are
quiet and some are active. All th^se oensidei^ation^.^Jroiiicl-}
be clearly borne in mind by doctors d-nd' patients in order
not to allow themselves to be held too rigidly by any caloric
fetish.

Special Dietetic Rules and Hints. — ^The responsibility for
the management of the diet of a diabetic patient should
always rest upon one individual. As a rule that individual
is the patient, but at times another member of the house-
hold. Children who are above the age of ten years should
be taught to plan their own diet. They readily learn to do
this and in so doing make their elders blush. In fact, it is
more important for diabetic children to learn what and how
much to eat than all the knowledge which their schools
afford, for upon this informatioli their life depends. Perhaps
it is because this personal responsibility is so deeply felt in
the management of little children that the treatment of
diabetes in them proceeds so uniformly and always produces
results so much better than are expected. Eat too little
rather than too much. With a return to normal weight
sugar may appear.

All food must be eaten slowly, and the coarser the food
the more thoroughly it should be masticated.

If in doubt about a food, let it alone until you have found
out whether it is allowed. Do not yield to the temptation
of friends to break the diet, for if this is done the plan of
treatment is upset, a week's time may be lost and several
pounds of weight sacrificed. So-called diabetic foods often
contain considerable quantities of carbohydrate, and usually
contain so much protein and fat that they should not be
taken by the patient without due allowance for the same.
They should not be taken under any circumstances unless
their composition is known. Be especially careful to note
the effect of any increase in carbohydrate. The same rules
hold for protein. The quantity of fat is generally regulated
by the patient's weight.

The carbohydrate in the diet should be divided between
the three meals. Even if the 10 per cent., 15 per cent, and
20 per cent, vegetables are allowed, vegetables from the 5

102 DETAILS OF DIABETIC TREATMENT

» • • *
• • • '

j)er cent.^ group' should be taken as well. Usually it is allow-
/^ble/'to^.substiHteifpV a given quantity of 5 per cent, vege-
tables 'one-half 'as* much from the 10 per cent, group, one-
quarter as much from the 15 per cent., or one-sixth as much
from the 20 per cent. Exchange vegetables for fruit only
under advice. Remember it is always possible to get articles
of food which are included in a strict diabetic diet for a few
meals, such as eggs, meat, butter, oil and even 5 per cent,
vegetables, fresh or canned. One of my cases who has done
exceptionally well has a diabetic garden and thus provides
liberally for his table both summer and winter. Quiet out-
door work agrees with diabetic patients.

In case of illness curtail the fat in the diet, and if acid
poisoning is shown by the ferric chloride reaction, omit fat
entirely.

CHAPTER IV.

ACID INTOXICATION— ACIDOSIS— DIABETIC

COMA.

Acid intoxication is the bugbear of doctor and patient.
Formerly more than six of every ten diabetic patients
succumbed to it, but now it is much less frequent. The acid
intoxication (acid poisoning, or technically termed acidosis)
of diabetic patients differs in no respect from the acidosis
of normal individuals, easily to be produced within three
days by the omission of carbohydrate from the diet. The
ferric chloride (diacetic acid) reaction will then appeal^ just
as in a severe diabetic, and if at the same time the quantity
of fat is increased, a type of acidosis will be caused, so severe
as to threaten the life of the individual. When, however,
the healthy body is gradually accustomed to live upon a
diet low in carbohydrate, acidosis is avoided. The same
course of events takes place in diabetes. In severe cases
when all the carbohydrate of the diet appears in the urine
a^ sugar, the diabetic patient, although eating carbohydrate,
is exactly like the normal individual deprived of his customary
carbohydrate. If fat in undue quantities is given to a severe
case of diabetes, under these circumstances diabetic coma
may result. This did result when years ago we physicians,
doing the best we knew, deprived patients of their carbo-
hydrates in order to make thena sugar-free, and at the same
time, in order to enable them to maintain their weight, we
markedly increased fat and protein to make up the calories
omitted as carbohydrate. From what has been already
written, it can be seen that now we know better.

Patients are first of all deprived of fat, without other
change in their dietary habits, in order to take away the
great danger of acid intoxication, and they subsequently are

104 DETAILS OF DIABETIC TREATMENT

either made sugar-free by gradual reduction of carbohydrate
and protein or by simply fasting. When sugar-free and one
begins to increase the diet, the fat is the food element to
be given last of all.

Even when patients already showing acidosis come for
treatment, it usually disappears under the above plan.
Should the acidosis be severe the following rules, now in
force for my cases at the New England Deaconess and Corey
Hill Hospitals, are suggested. I recommend that all patients
become familiar with these rules, and thus anxiety over acid
poisoning will disappear. This plan of treatment seldom
fails. Indeed, since I have established it as a routine method
of procedure, worry about acid poisoning in my patients has
largely decreased^ and evening visits to the hospitals are
eliminated.

Rules for the Treatment of Severe Acid Poisoning.

1. Nursing, — Provide a special nurse for the patient for
both day and night, and preferably one trained in diabetic
work.

2. Bed, — Keep the patient in bed and warm. Avoid loss
of calories through exertion or exposure; if restless, protect
from becoming chilled by flannel nightclothes. Every effort
should be made to allay nervousness and discomfort.

3. Care of the Bowels, — ^Move the bowels by one or more
enemata. Cathartics should usually be avoided for fear of
causing diarrhea.

4. Administration of Liquids, — Give 1000 c.c. (1 quart) of
liquids within each six hours. The liquids are to be given
slowly, and hot. Use coffee, tea, thin broths, water; see
also 5. If the prospect is dubious of giving so much liquid
by mouth, salt solution or tap water is to be given by rectum;
if this resource fails, the nurse should call the doctor to give
intravenously, or if that is impossible, subcutaneously, the
balance of the liter which remains not given for the period.
(It will seldom be found necessary to give more than 1000 c.c.
liquids, thanks to the avoidance of alkalis.) In order to
secure the introduction of sufficient liquid in the first six

ACID INTOXICATION— ACIDOSIS— DIABETIC COMA 105

hours, the cleansing enema at the beginning of treatment
should be followed after half an hour by an enema of 500 c.c.
salt solution (one teaspoonful salt in one pint of water) in
all cases as a matter of precaution.

5. Diet — If the patient has been accustomed to the fasting
method of treatment, begin or continue the fast, but if he
has been upon a full diet omit the fat which it contained,
but continue the same quantity carbohydrate and protein
of the preceding days, giving at least a gram of carbohydrate
per kilogram body weight in the form of strained orange
juice or gruel (oatmeal) made with water, during the twenty-
four hours. Of late I have given each six hours an amount
of carbohydrate equal to or slightly in excess of that voided
in the urine during the preceding twenty-four hours. Which-
ever course is adopted, it is to be followed until danger is
over. The carbohydrate should be given in a form easily
tolerated by the stomach, such as carefully made gruels,
orange juice, skimmed milk or bread. Avoid an excess of
coarse vegetables.

6. Stomach. — If there is evidence of retained food in the
stomach or of a dilated stomach, the stomach should be
emptied at once. The prompt recognition of such a state
and its relief I believe will save many lives. With adults
when in doubt, but with children in all cases, begin treat-
ment with gastric lavage.

7. Heart. — ^Sustain the circulation with the help of digi-
talis. Caffein may be given subcutaneously or as black
coffee by the rectum. ' , .

8. Alkalis. — ^Avoid alkalis. If such have been previously
given, omit at the rate of 30 grams a day.

CHAPTER V.
WEIGHT PECULIARITIES.

Most diabetic patients are obese prior to the onset of
diabetes. As soon, however, as sugar begins to be lost in the
urine, the weight usually falls because too little food is eaten
to make up for that lost. It is not uncommon for a patient
to lose 50 pounds before treatment begins, and occasionally
a patient will lose as much as 100 pounds during the course
of years. A diabetic patient in reality is probably in safer
condition if he is 10 to 20 per cent, below weight, because
thus he can be assured that he is not overeating. In this
respect it is better to emulate the Indian than the Eskimo.
The individual 10 per cent, and even 20 per cent, below weight
may not be a delight to our eyes, but if over thirty-five years
of age and in this condition he is much more acceptable to
the Insurance Company. It is often desirable for a patient
to lose weight, but this should be undertaken only under

Table 28. — ^The Weight of Normal Individuals.^

Height.

Age 15 to 24.

Age 25 to 29.

Age 30 to 39.

Age 40 and over.

Ft.

In.

Cm.

Lbs.

Kg.

Lbs.

Kg.

Lbs.

Kg.

Lbs.

Kg.

152.4

120

54.5

125

56.7

129

58.5

133

60.4

154.9

122

55.4

126

57.2

130

59.0

135

61.3

157.5

124

55.8

128

58.1

132

59.9

138

62.6

160.0

127

57.6

131

59.5

135

61.3

141

64.0

162.6

131

59.5

135

61.3

139

63.1

144

65.4

165.1

134

60.8

138

62.6

142

64.4

148

67.2

167.7

138

62.6

142

64.4

146

66.3

152

69.0

170.2

142

64.4

147

66.7

151

68.5

156

70.8

172.7

146

66.3

151

68.5

155

70.3

161

73.1

175.3

150

68.1

155

70.3

160

72.8

166

75.3

177.8

154

69.9

159

72.2

165

74.9

171

77.6

180.3

159

72.2

164

74.4

171

77.6

177

80.3

182.9

165

74.9

170

77.1

177

80.3

183

83.0

185.4

170

77.1

177

80.3

183

83.0

190

86.2

188.0

176

79.9

184

83.5

190

86.2

196

88.9

190.5

181

82.1

190

86.2

197

89.4

201

91.2

* Average for men and women with clothes. Clothes weigh 8 to 10 pounds,
or about 4 kilograms.

WEIGHT PECULIARITIES

107

Table 29. — ^Heights and Weights of Children.

HBight.

Weight.

Age.

Boys.

Girls.

Boys.

Girls.

Inches.

Cm.

Inches.

Cm.

Pounds.

Kg.

Pounds.

Kg.

Birthi

1 year

2 years

3 years

4 years

20.6
29.0
32.5
35.0
38.0

52.5
73.8
82.8
89.1
96.7

20.5
28.7
32.5
35.0
38.0

52.2
73.2

82.8
89.1
96.7

7.55
21.0
27.0
32.0
36.0

3.43

9.54

12.27

14.55

16.36

7.16
20.5
26.0
31.0
35.0

3.26

9.31

11.81

14.09

15.90

The heights and weights in the above table are net, i. e., without shoes

or clothes.

Age at

last

birthday.

5 years

6 years

7 years

8 years

9 years

10 years

11 years

12 years

13 years

14 years

15 years

16 years

41.7

105.9

41.3

104.9

41.0

18.6

39.6

43.9

111.5

43.3

110.1

45.2

20.5

43.4

46.0

116.8

45.7

116.0

49.5

22.5

47.7

48.8

123.9

47.7

121.1

54.5

24.7

52.5

50.0

127.0

49.7

126.2

59.6

27.0

57.4

51.9

131.8

51.7

131.3

65.4

29.5

62.9

53.6

136.1

53.8

136.6

70.7

32.1

69.5

55.4

140.7

56.1

142.4

76.9

34.9

78.7

57.5

146.0

58.5

148.5

84.8

38.5

88.7

60.0

152.4

60.4

153.4

95.2

43.2

98.3

62.9

159.7

61.6

156.4

107.4

48.8

106.7

64.9

164.8

62.2

157.9

121.0

55.0

112.3

18.0
19.7
21.7
23.8
26.0
28.5
31.5
35.7
40.3
44.6
48.5
51.0

The heights in the above table are without shoes.

The weights are with indoor clothes. These make up for boys approxi-
mately 8 per cent., and for girls 7 per cent., of the gross weight.

The term, *'age at last birthday," is liable to give a wrong impression,
because the figures given are really average figures taken from all the
children from that birthday to the next. A more accurate term is the
succeeding half-year; age approximately for succeeding half-year; i. e., five
and a half years instead of five years, the age at the last birthday.

the doctor's direction. Frequently it is only by losing weight
that a patient regains the power to tolerate carbohydrate,
but as yet I have not reached the point of purposely beginning
treatment by reducing the weight of a diabetic to below
normal, though perhaps this would be the best way. As a
guide to the proper weight for a diabetic, the average weights
of individuals for given heights and weights when dressed,
according to Shepherd's statistics, are given in Table 28.
Along with these I include weights for normal children
selected by Dr. John Lovett Morse, Table 29.

108

DETAILS OF DIABETIC TREATMENT

Changes in Weight during Treatment. — Diabetic patients
are often surprised at the sudden change in weight which
they undergo during a two weeks' course of treatment.
Occasionally the weight goes up, but more often it falls.
It may remain the same or even increase during several
days of fasting. The reason for these changes is to be
explained by the retention or discharge of water from the
tissues. The following experiment conducted by me many
years ago illustrates this well. A student was given a diet
sufficient to maintain his body weight so far as nutritive
value was concerned, but from his food salt was entirely
removed. As a result, in the course of thirteen days the
weight fell 11.66 pounds. Upon the resumption of his former
diet with salt as desired, 9 pounds of those lost were regained
in three days. Diabetic patients often gain weight from
exactly the same cause — ^namely, the ingestion of too much
salt. Such gain in weight, however, should be looked upon
at its real value, in other words, simply as a retention of
fluid in the body.

Case No. 1378, showing considerable dropsy, lost weight as
shown in Table 30. When the equivalent of the weight lost
was weighed out in water it half-filled a pail, and when we
realized that this had been carried about all day in the
tissues of the patient, all of us were far more sympathetic
toward the patient's disinclination to go up and down stairs.

Soon after entrance the salt in the diet was partially
restricted, but evidently not enough to prevent increase in
weight, as the chart shows (see September 23-24). From

Table 30. — Chart of Case No. 1378. Illustration of Disappear-
ance OF Dropsy Coexistent with Loss of Weight
Due to a Salt-free Diet.

Urine.

Diet in grams.

Date,
1917.

Di-
acetic
acid.

NaCl,
grams.

Sugar
Total
grams

Carbo-
hydrate

Pro-
tein.

Fat.

Alcohol.

Calories.

Weight,
lbs.

Sept. 13-14

23-24

Oct. 21-22

4.9

• •

17
12

20
50
53

6
42
52

• • • •

50
30

146
996
938

891
98!
69^

WEIGHT PECULIARITIES 109

this point onward the salt was excluded with the greatest
care from the diet, and the weight uniformly fell. It is note-
worthy that this patient a year previously, some thousands
of miles from Boston, had been given during a period of six
months enemata of 8 quarts of salt and soda daily. Further-
more, she was then in the habit of taking beef tea loaded
with salt, and each week consumed one and a half pounds
of salted almonds, as well as using salt freely in her food.

It is also interesting that although the carbohydrate in
an individual's diet is replaced by an equivalent number of
calories in the fonn of fat, the weight promptly falls, and if
the reverse procedure is adopted the weight will rise. The
loss or gain of weight which occurs under such conditions
may amount to 2 pounds in a day for several days. Finally,
there is a real reason for a loss of weight during the treat-
ment of diabetes, due to the fact that the diet is often defi-
cient in calories. Against this loss we must fight!

CHAPTER VI.

THE DIET OF THE UNTREATED DIABETIC IS

EXPENSIVE.

Case No. 1171, before treatment was begun, told me that
he ate 13 eggs for breakfast, not by any means as a stunt,
but because he wanted them. Case No. 1147, a lady of
thirty-five years of age, ate a dozen eggs a day, and in
response to my request gave me a report of her daily diet
before she began treatment. ' This is shown in Table 31. It
will be observed, however, that the carbohydrate was below
normal — ^good evidence, therefore, that her diet had already
been somewhat altered from the normal before the time
at which she reported; in fact, I think her diet was origi-
nally considerably in excess of that recorded.

Table 31. — Estimated Diet of a Woman of Thirty-five Years,
Case No. 1147, Prior to Treatment. Weight Seventy-
two Kilograms.

Food for twenty-four Carbohydrate, Protein, Fat,

hours. Quantity. grama. grams. grams.

Eggs 12 7S 72

Five per cent, vegetables 450 grams. 15 8

Milk 2000 c.c. 96 64 64

Forty per cent, cream . 240 c.c. 8 8 96

Butter 90 grams. 75

Meat 120 grams. 32 20

Bread 100 grams. 60 10

Totals . . 179 194 327

4 4 9

Total calories 716 776 2943

Total calories 4436 -5- 72 kilograms =« approximately 60 calories per

kilogram body weight.

Although the diet contained 60 calories per kilogram body
weight instead of the normal 30 calories the patient, while

DIET OF UNTREATED DIABETIC IS EXPENSIVE 111

upon it, lost 66 pounds in a little over two and a half years.
The reason for this was apparent, for on October 6, 1916,
the volume of the urine was estimated at 6000 e.c. (6 quarts)
and the sugar was found to be 5 per cent, or 300 grains

{10 ounces), the equivalent of a loss of 1200 calories in the
urine in twenty-four hours. In one year this would amount
to 240 pounds of sugarl After a two weeks' stay in the hos-
pital she felt more content with a diet of 1600 calories — a
trifle less than her body needs — than when upon that at
entrance.

It is obvious that the saving of food which results from
becoming sugar-free under modern treatment must be con-
siderable. It is the diet of the untreated diabetic which is
expensive, since the large excess is far worse than wasted.

112 DETAILS OF DIABETIC TREATMENT

Case No. 295 voided in twenty-four hours on October
23-24, 1909, approximately 10 liters of urine (nearly 20
pounds) containing 680 grams of sugar, the equivalent of
2720 calories! The weight of this patient was 50 kilos. In
other words, he lost in the urine 54 calories per kilo, an
amount sufficient in calories to supply almost double his
own needs if taken in the form of food which he could
assimilate.

Diabetic patients with acid poisoning lose calories in the
urine not only in the form of sugar but as acid bodies as well.
The quantity of acid bodies thus lost is quite considerable.
These acid bodies represent wasted food just as much as
does the sugar in the urine. Case No. 344 is a good illustra-
tion of this. On December 25-26, 1911, he excreted 188
grams sugar, the equivalent of (188 X 4) 752 calories, and
in addition 55 grams acid bodies, equivalent to (55 X 5)
275 calories. Acid intoxication is really a dreadful robber,
for besides stealing the food of a patient, it frequently steals
his life !

CHAPTER VII.
CARE OF THE TEETH.

Many diabetics have sound teeth, thus showing that
diabetes is not necessarily productive of bad teeth. On the
other hand, the teeth should always be kept in good condi-
tion, for it is common to have the diabetes grow worse in the
presence of inflammatory conditions about the teeth and
gums. The teeth should be cleaned after each meal and it
is desirable to have them cleaned by a dentist at least every
three months. If the teeth are to be extracted, novocain
injected cautiously acts admirably. If necessary, gas or
gas and oxygen may be employed, but ether should be used
only when the carbohydrate tolerance is high and after careful
consideration.

I consider the care of the teeth of enough importance to
insert the following abstract of a dentist's leaflet, which
supplies speciflc instruction on this subject.

Clean Teeth Will Not Decay.

How can all the food be removed from all the surfaces of
all the teeth after each meal?

1. By brushing.

2. By using floss silk between the teeth.

3. By thoroughly rinsing the mouth with lime water.
Rules for Brushing the Teeth. — 1. Brush four times a day:

Before breakfast, with clear water.

After each meal, with a tooth paste or powder.

The teeth must be clean and free from food before

going to bed, as most of the decay takes place while

sleeping.

2. Brush two minutes each time (two minutes by the

clock).
8

114 DETAILS OF DIABETIC TREATMENT

It takes two minutes of brushing to properly stimulate
the gums and thoroughly cleanse the teeth. Be sure
and brush the gums.

3. Do not use pressure with the brush. A fast, light

stroke is the best. A brush should never be worn
out by having its bristles flattened and spread out.

4. Candies, sugar, crackers, cake, pastries, bread will all

decay the teeth if allowed to remain on their surfaces.

Floss Silk. — ^Four-fifths of the decay of teeth takes place
on the surfaces between the teeth and one-fifth on the sur-
faces on which one chews. There is but one way which is
effective in removing the food from between the teeth, and
that is with a piece of floss silk.

Use a section of floss about twelve inches long. Hold
one end between the thumb and first finger of the left hand
and wrap the floss twice around the end of the first finger.
Do the same with the thumb and first finger of the right
hand. Now by using combinations of the ends of the thumbs
and second fingers the floss may be carried into the mouth
and forced carefully between all the teeth. Rub it back and
forth against the surfaces of each tooth to loosen and remove
the food and to clean these surfaces. After a little practice
one can floss all the surfaces between the teeth in a minute's
time.

There still remains on the surfaces of the teeth, especially
between them, a glue-like deposit known as mucin. This
mucin must be removed, as it allows the bacteria to cling to
these surfaces. The most effective and harmless solvent
to use as a mouth wash is lime water. In fact if but one
thing could be used to prevent decay of the teeth, lime water
used three times daily would prove to be the most valuable.

Preparation of Lime Water, — ^Secure coarse, unslaked lime
and crush it into a fine powder. Place a half-cupful in an
empty quart bottle and fill nearly full with cold water.
Thoroughly shake and then allow the lime to settle to the
bottom of the bottle, which will take several hours. Avoid
injury to furniture from heat generated in the bottle. After
the lime has settled pour off as much of the clear water as
possible without losing anj of the lime, as this first mixing

CARE OF THE TEETH 115

contains the washing of the lime. Again fill with cold water,
shake well and allow it again to settle.

Into an empty twelve-ounce bottle pom* the clear lime
water, taking care not to stir up the lime in the bottom of the
bottle. Again fill the quart bottle with cold water, shake
thoroughly and set it aside to use when the smaller bottle
becomes empty. This process may be repeated until the
half-cup of lime has made five or six quarts of mouth wash.

The twelve-ounce bottle is used as it is more easily handled
at the wash bowl. After brushing and flossing the teeth,
pour out a little of the lime water in a glass and taking it in
the mouth force it back and forth between the teeth with
the tongue and cheeks until it foams. If you rinse it long
enough to make it foam it has then been in the mouth
long enough to have a beneficial action on the teeth. After
spitting it out rinse the mouth with clear water to take away
the taste of the lime. If the lime water is a little strong at
first, dilute it with clear water in the small bottle, half and
half. It should be used clear and full strength as soon as the
gums become hard and healthy from brushing.

CHAPTER VIII.
CARE OF THE SKIN.

The skin must be kept unusually clean. Take a tub bath
daily, but avoid prolonged cold baths. Short cold baths are
often desirable. One boy I know took his cold morning bath
in four seconds; adults often go to the other extreme in point
of time and thus lose the good effect.

Protect the Skin from Injuries. — If any infection occurs,
see a physician at once. Infections of the skin are apparently
less common now than formerly and this may be attributed
to cleanliness. Such infections are and should be rare in
diabetic patients under treatment. They demand immediate,
thorough, yet gentle, treatment. One of the first duties of
the physician is to tell diabetic patients to keep the skin
clean and to report the beginning of an infection at once.
Patients should be warned of the danger from slight wounds,
should specifically be advised not to allow manicurists or
chiropodists to draw a drop of blood, and cautioned to
promptly report any injury to the skin. Absolute cleanliness
of the body is essential. Subcutaneous injections, whether
of water, salt solution or drugs may be harmful, but with
modern asepsis I hope can be safely employed. It is common
for salt solution or solutions of sodium bicarbonate, when
injected subpectorally, to result in abscess. If there is the
slightest tendency to furunculosis, I at once adopt simple
measures analogous to those described by Bowen.^ The
patient is advised to wash the whole body twice a day with
soap and water, using a wash cloth or piece of flannel, and
to dry the skin without rubbing, so as to avoid breaking open
any pustule; the whole body is then bathed with a saturated
solution of boracic acid in water, with the addition of a small

1 Bowen: Jour. Am. Med. Assn., 1910, Iv, p. 209; Boston Med. and Surg.
Jour., 1917, clxxvi, p. 96.

CARE OF THE SKIN 117

proportion camphor water and glycerin. I have often used a
solution of two parts alcohol and one part water to advantage,
but I notice that Bowen in his second paper still prefers the
boracic acid. Individual furuncles may be treated with the
following ointment ; according to Bowen :

Boracic acid 4

Precipitated sulphur 4

Carbolated petrolatum 30

One should be careful, however, not to overtreat the skin.
Harm may result from frequent dressings. The simplest
lotions should always be employed. In severe cases the
patient should be put to bed, all linen changed twice daily,
and the patient treated in as aseptic a way as possible. In
a few cases vaccines have appeared to be of marked benefit.
"This procedure, thorough bathing and soaping, the applica-
tion of the borated solution, and the dressing of the individual
furuncles, is repeated, as has been said, morning and niight.
A further point of vital importance relates to the clothing
that is worn next the skin. Every stitch of linen worn next
to the skin should be changed daily, and in the case of
extensive furunculosis all the bedclothing that touches the
individual, as well as the nightclothing, should be subjected
to a daily change. Naturally, this treatment must be con-
tinued for several weeks after the la^t evidence of pyogenic
infection has appeared, and this fact must be emphasized
to the patient at the outset.'' (Bowen.)

CHAPTER IX.
TREATMENT OF CONSTIPATION.

The bowels should move daily. The coarse vegetables
and fruit of the diet may prove quite sufficient, but if neces-
sary, bran muffins made with agar agar (see page 130) may
be employed. Never purge the bowels but depend upon an
enema or upon simple laxatives, such as aloin, grain ^; fluid-
extract of cascara sagrada, 10 to 30 drops; extract cascara
sagrada, 5 grains, or compound rhubarb pills.

If diarrhea occurs, go to bed, keep warm and drink hot
water.

If the patient has not had a movement for several days,
at the beginning of treatment give an enema followed by
some simple cathartic or mild aperient, and another enema
twelve to twenty-four hours later; but do not piu*ge the
patient. Gain enough is obtained if a movement is produced
once in twenty-four hours when it has only been taking place
once in seventy-two. In other words, do not upset any patient
who is in a tolerable state.

The following exercises for constipation were recommended
to me by Mr. Gustaf Sundelius:

Home Exercises for Constipation.

1. Abdominal Kneading and Stroking. — Kneading. — Lying
down, with knees slightly drawn up. Place hands one on
top of the other on the abdomen at the right groin; with
small circular movements and deep pressure work upward
until the ribs are met, then across toward left, following the
boundary-line of the chest, then downward to the left groin.
Repeat twenty to fifty times. Stroking. With hands simi-
larly placed, make long, steady and deep strokes following
the same route. Repeat twenty-five to one hundred times.

TREATMENT OF CONSTIPATION 119

2. Leg-rolling. — ^Lying down, take hold of both legs just
below the knees, press the knees up close to the abdomen,
then carry them apart, then down and inward until they
meet again, thus letting the knees describe two circles.
Repeat ten to twenty times.

3. Abdominal Compression. — Standing against the wall
with hands clasped behind neck, draw the abdomen forcibly
in, using the abdominal muscles, hold a second, then let go.
Repeat ten to forty times.

4. Trunk-rolling. — ^Standing with hands on hips, feet
apart and legs well stretched, roll the upper body in a circle
on the hips by bending forward, to the left, backward and
to the right. Then reverse, and repeat six to twelve times
each way.

Case No. 559 warded oflF constipation by sawing wopd,
and Case No. 265 regulated his bowels by eating a slice of
raw cabbage for breakfast.

CHAPTER X.
DRUGS IN THE TREATMENT OF DIABETES.

Drugs are not recommended by physicians like Professor
Naunyn, the Nestor of diabetic treatment, or by those
concerned in the recent advance in diabetic treatment in
this country.

Drugs are not prescribed with the purpose of lowering the
sugar in the urine in the most famous of our large hospitals.

On the other hand, drugs are frequently recommended,
I have observed, (1) by physicians who do not determine
the quantity of carbohydrate in their patients' diets or the
quantity of sugar in the lU'ine, (2) by those who are not con-
nected with large hospitals, and (3) by those who do not have
access to well-equipped laboratories.

I wish I knew of a good drug for diabetic patients. It
would save me so much time and talk.

PART III.
THE DIABETIC MENU AND FOOD VALUES.

CHAPTER I.
DIETETIC SUGGESTIONS, RECIPES AND MENUS.

The narrow confines of the diabetic diet have greatly
stimulated the manufacture of so-called diabetic foods.
These are often serviceable, but are to be employed with
discretion. Their use should be discouraged at the beginning
of treatment. The patient should never become dependent
upon special diabetic foods, for they are often unobtainable,
always make him conspicuous, and when he acquires a
disgust for foods of this class it is all the harder to abide by
the original diet. When the patient buys one of these foods,
unfortunately he is often given a list of other diabetic foods
and a new diabetic diet list, and confusion in the diet often
results. The patients under my care who have done best
either never use special diabetic foods or only a few varieties,
such as Akoll Biscuits, Barker's Gluten Flour, Casoid Flour,
Hepco Flour, Lister Flour, No. 1 Proto Puffs and Sugar-free
Milk.

Substitutes for Bread. — Many of the preparations upon the
market contain as great or even a greater quantity of car-
bohydrate than ordinary bread; a few contain less; but the
percentage of carbohydrate may vary from time to time.
Patients, and sometimes physicians, forget that substitutes
for bread must be prescribed only in definite amounts. A
diabetic bread should never be prescribed without a knowl-
edge of its content of carbohydrate, protein and fat.

122 DIABETIC MENU AND FOOD VALUES

The bread of one of the largest bakeries in Boston, upon
analysis, showed 55 per cent, carbohydrate. Bread made
without milk or sugar, but with water and butter, con-
tains 45 to 50 per cent, carbohydrate. Such a bread is
undoubtedly superior to many different bread substitutes
upon the market. The percentage of carbohydrate in toast
is greater than in plain bread because it contains less water.
Some of the coarser kinds of bread, such as rye bread, graham
bread, black bread and pumpernickel, contain somewhat less
carbohydrate. Never give bread substitutes early in treat-
ment. Teach patients to live without them.

Bran Bread. — ^Bran is being more and more employed in
the diet of diabetic patients. This is neither more nor less
than the use of cellulose, and this is supposed to have no
effect upon the metabolism. Unfortunately, the availability
of the protein, fat and carbohydrate of wheat bran to the
diabetic patient has not been determined, although there are
plenty of data upon its digestibility by ruminant animals.
Bread made of bran alone is not very palatable, though with
the fat of bacon or butter it is liked better. It furnishes
bulk and acts favorably upon constipation. If made with
eggs and butter the flavor is improved. It should be
remembered that bran often contains a considerable quantity
of starch. For this reason bran biscuits often prove to be a
delusion and a snare, and I dread to see them on a patient's
tray. In large hospitals where diabetic patients are con-
stantly being treated the danger is less, for the bran is bought
by the same person and at the same place; but in private
practice this is different. In purchasing bran go to a feed
store and ask for coarse bran for cattle and not for bran for the
table. The various preparations of bran, bran breads and
cookies sold under trade names often contain carbohydrate
other than bran, hence the reason for their palatable taste;
beware of them! They may contain over 60 per cent,
carbohydrate, of which less than 10 per cent, is real bran.
Mild diabetics get into little trouble with bran, but the
serious ones often suffer. The starch may be washed out
with water by tying the bran in a cheesecloth and fastening
the same on a faucet. It should be thoroughly mixed and

DIETETIC SUGGESTIONS, RECIPES AND MENUS 123

kneaded from time to time to be sure the water reaches all
portions, and should be washed until the water comes away
clear. This may require an hour.^

Gluten Breads. — ^These breads are made by removing the
sugar-forming material from the flour. It is surprising how
thoroughly this can be done. I have often found the per-
centage of carbohydrate in one such flour to be negligible.
The large quantity of protein in small bulk which they con-
tain is objectionable.

light Breads. — French bread cut in thin slices is often
useful, because it is bulky, gives the appearance of a large
quantity and carries much butter. Manufacturers have
taken advantage of this idea, and many light breads are on
the market. These breads often contain about the same
quantity of carbohydrate as ordinary bread, though a few
contain considerably less. Their virtue often consists solely
in their bulk, which allows a surface on which to spread
butter. I seldom advise breads. It is better for the patient
to forget the taste. »

Various other substances have been used for flour in the
manufacture of bread. Thus, aleuronat meal has been
employed, and with it have been mixed various vegetable
products. A group of casein breads is upon the market in
the form of casoid flour and Lister's Diabetic Flour, and to
some diabetics these are valuable.

Soy bean is also extensively used, and probably deserves a
still wider introduction into the diabetic diet. The carbo-
hydrate in it is unassimilable. It is used in the manufacture
of Hepco Flour. Agar agar may be used to dilute the flour
or to add to bran and also to relieve the constipation of the
diabetic, which is frequently troublesome.

Substitutes for Milk. — ^A few tablespoonfuls of cream are a
great comfort to a diabetic patient. Except in cases with a
very low tolerance a gill (120 c.c.) of 20 per cent, cream can

* Four preliminary analyses of washed bran showed the following per-
centages of starch: 0.6, 1.8, 2.7. 6.2 per cent. Two preliminary analyses
showed pentosan 29.8, 33.5. The wide variations in the percentages of
starch will account for the occasional occurrence of sugar in the urine fol-
lowing the use of bran cakes. I hope these investigations will be continued
in the laboratory from which I obtained these analyses.

124 DIABETIC MENU AND FOOD VALUES

generally be allowed, and if it is desirable to give more fat
without increasing carbohydrate and protein, a gill of 40
per cent, cream is also well borne. Formerly patients took
half a pint of 40 per cent, cream readily. With severe cases
it is seldom possible to allow more than 60 to 90 c.c. of 20
per cent, cream, for the balance of the fat which can be
safely employed can more advantageously be taken in meat,
butter, oil and cheese. On the other hand, fat having been
removed, the chief value of the milk to the diabetic patient
is lost. The percentage of sugar in sour milk is not much
less than in fresh milk. Recently, sugar-free milks^ have
been put upon the market on a large scale, .and many of my
patients, particularly children, have found them of distinct
advantage. These preparations of diabetic milk will keep
from one to three weeks, and are consequently of great
value to patients when travelling. As a rule they are con-
centrated one-half. Consequently they should be diluted
before being used. They are so valuable for diabetic patients
that I always enccjurage their use in small quantities at first,
so that the patient can become accustomed to the artificial
taste and can determine the form in which the milk is most
agreeable to him. This is often as equal parts of milk and
Vichy C^lestins.

Williamson^ suggested the following rule for the manu-
facture of artificial milk: "To about a pint of water, placed
in a large drinking pot or tall vessel, three or four tablespoon-
fuls of fresh cream are added and well mixed. The mixture
is allowed to stand from twelve to twenty-four hours, when
most of the fatty matter of the cream floats to the top; it
can be skimmed ofiF with a teaspoon easily, and upon examina-
tion it will be found practically free from sugar. This fatty
matter thus separated is placed in a glass." The white of an
egg is added to it and the mixture well stirred. Then dilute
with water until a liquid is obtained which has the exact
color and consistency of ordinary milk. ** If a little salt and a
trace of saccharin be added, a palatable drink, practically

1 D. Whiting & Sons, Boston.

* Williamson: Diabetes Mellitus and its Treatment, Macmillan Company,
1898, p. 334.

DIETETIC SUGGESTIONS, RECIPES AND MENUS 125

free from milk-sugar, is produced,^ which has almost the same
taste as milk, and which contains a large amomit of fatty
material. With very little practice the right proportions
can be easily guessed, and of course much larger quantities
can be employed (in order to prepare a considerable amount
of the drink at one time) than those mentioned above/'

Rennet may be made from milk, but unless the curd is
carefully washed it will contain 2 to 2.5 per cent, lactose.
When the rennet is made from cream the lactose is materially
diminished. Kefir contains approximately 2.4 per cent,
milk-sugar. Von Noorden says this milk has also been of
great help in the treatment of diabetes in children.

Lawrence Litchfield, of Pittsburgh, gives whipped cream .
to his patients made according to the following rule: Add
two ounces of 40 per cent, cream to a pint of cold water in
a Mason jar and have it shaken vigorously until the cream
is thoroughly "whipped.'' Sometimes a trace of saccharin
is added, usually not. "My patients like to eat this with
a spoon, but, of course, it can be used in any way that is
desired. It contains only a trace of sugar."

The fermented milks contain about half as much carbo-
hydrate as ordinary milk.

RECIPES.

Many books have been written containing recipes for dia-
betic patients. With modern methods of treatment, however,
most of these rules are worthless for severe diabetic patients
because of their high content of protein and fat. In general
such patients prefer and should be encouraged to take simple
natural foods rather than artificial ones.

The mild cases of diabetes need no special recipes. Des-
serts can often be made with gelatin, and this may be flavored
with coffee, lemon, rhubarb or cracked cocoa. In preparing
such desserts if saccharin is used it should be added as late
as possible during the cooking, for it is apt to become bitter
with heat. It is always a safe rule to add too little rather
than too much saccharin. Usually one need pay little
attention to the quantity of protein in the gelatin, because

126 DIABETIC MENU AND FOOD VALUES

the ordinary portion of jelly contains ooly about 2.5 grams.
One of my patients on a very rigid diet so enjoyed the bulk
of the gelatin as to take 10 grams daily. She accomplished
this by having the gelatin made very thick.

DIABETIC BREAD.

' 1 Box Lister's Diabetic Flour^
3 Eggs

Method. — Separate whites and yokes of eggs. Add to
whites salt to taste. Beat whites until very thick. Beat
yolks until thick and lemon colored. Combine and beat
with egg-beater. Fold in gradually one box of Lister's
Diabetic Flour. Bake in tin 5 inches long, 3 inches wide
and 3 inches high (straight sides). Have oven hot. If baked
in gas-stove oven, bake for fifteen mnutes, full heat, then
reduce heat one-half for ten minutes longer. If baked in
coal or wood oven, bake from fifteen to thirty minutes. Do
not opeii oven door until bread is done. Do not remove
from tin until partly cooled. Each loaf contains protein, 58
grams; fat, 18.6 grams; calories, 397.

USTER'S UTTLE CAKES.

10 Eg^^ / ^*^®^ ^^^ ^*^®^

Each cake contains protein, 0.66 gram; fat, 0.40 gram;
calories, 6.

1 The foUowing analysis of Lister's Diabetic Flour is given out by the
manufacturers. This is used in the preparations of a- number of the
recipes which follow:

ANALYSIS OF LISTEb'S DIABETIC FLOUB.

Grams in each
Per cent. 2-ounce box.

Moisture 10.66 6.06

Ash 1.63 0.93

Fat 0.67 0.38

Protein 69.95 39.66

Starch 0.00 0.00

Sugar 0.00 0.00

Leavening 17.09 9.69

DIETETIC SUGGESTIONS, RECIPES AND MENUS 127

Method. — ^Beat eggs until very stiff. Stir in one box of
Lister's Diabetic Flour without further beating. Use flat
baking pan that has been slightly greased, deposit the dough
or batter in small amounts about the size of a 50-cent piece.
Bake in moderately hot oven for about ten minutes.

DIABETIC NOODLES.

Method. — ^To the well-beaten yolks of two eggs, add two
tablespoonfuls of warm water and a little salt. Slowly
stir in one box of Lister's Diabetic Flour. Knead and roll
on pie-board. When almost dry, roll and cut fine. Dry
thoroughly.

DIABETIC MUFFINS.

1 Box Lister's Diabetic Flour

1 Egg

3 Tablespoonfuls of sweet heavy cream (40 per cent, cream)

2 Tablespoonfuls of bacon fat

Same quantity of butter, melted lard or Crisco may be used
in place of bacon fat. This will make eight muffins, each
miifin having food value equivalent to one egg (or protein,
6 grams; fat, 6 grams; calories, 78).

Method. — ^Beat white of egg very stiff; beat yolk
separately from white; to the beaten yolk add the cream
and beat; then add bacon fat (butter, melted lard, or melted
Crisco); beat again, then add the beaten white of egg; lastly
the flour, beating the mixture all the while the flour is slowly
added. Put in buttered, hot muffin irons and bake for ten
to twenty minutes. If coal range is used, bake for fifteen
minutes and have the oven hot. Oven door should not be
opened for ten minutes. Use old-fashioned cast-iron muffin
iron.

USTER'S FLOUR AND BRAN MUFFINS USEFUL IN

DIABETIC CONSTIPATION.

1 Level tablespoonful lard, bacon fat, butter or crisco

1 Egg

2 Tablespoonfuls heavy cream
1 Cupful washed bran

1 Package Lister's Blour
i Cupful water or less

128 DIABETIC MENU AND FOOD VALUES

Tie dry bran in cheesecloth and soak one hour. Wash by
squeezing water through and through. Change water sev-
eral times; wring dry. Separate egg and beat thoroughly.
Add to the egg yolk the melted lard, cream and beaten egg
white. Add Lister's Flour, washed bran and water. Make
nine muffins.

DIABETIC COOKIES.

1 Box Lister's Diabetic Flour

1 Egg

3 Tablespoonfuls of cream

3 Tablespoonfuls of butter or bacon fat

Method. — Beat egg until light. Add cream and beat
again. Add butter and beat again. Then add Lister's
Flour slowly. A little caraway seed, ginger or vanilla may
be added to suit the taste. Roll very thin and only a small
amount at a time. Bake in hot oven about ten minutes.

Makes thirty cookies of about 23 calories each.

DIABETIC BISCUITS.

1 Box Lister's Diabetic Flour)

3 Eggs /

Makes six Biscuits

Each biscuit contains protein, 9.70 grams; fat, 3.05 grams;
calories, 66.

Method. — Separate whites and yolks of eggs. Add to
whites salt to taste. Beat whites until very thick. Beat
yolks until thick and lemon colored. Combine and beat
with egg-beater. Fold in gradually one box of Lister's
Diabetic Flour. Divide into six parts if Lister's Baking
Biscuit Tins are used. Have oven moderately hot. If
baked in gas-stove oven, bake from fifteen to twenty minutes.
If baked in coal or wood oven, bake from fifteen to thirty
minutes. Do not open oven door until biscuits are done.
Do not remove from tin until partly cooled. If desired

DIETETIC SUGGESTIONS, RECIPES AND MENUS 129

these biscuits may be flavored to taste with nutmeg, cin-
namon, ginger or cloves. If the biscuits are to be kept for
several hours, wrap them in a cloth.

FRENCH TOAST.

1 Egg

2 or 3 tablespoonfuls cream
Lister's Muffins, Biscuits or Bread

Beat the egg and cream together. Slice Lister's MuflSns,
Biscuits or Bread. Soak the slices in the egg and cream and
fry in a little hot butter until light brown.

Follow all directions exactly as given. The batter may
appear to be too thick or heavy but no more moisture should
be added than is called for in these directions.

BAKED SOT BEANS.

Yellow Soy beans, 120 grams, are soaked for forty-eight
hours, then boiled for about half an hour and finally baked
with 30 grams pork for twelve hours. The food value is
approximately as follows:

Carbo-
hydrate, Protein, Fat,
grams. grams. grams.

Soy beans, 120 grams 48 24

Pork, 30 grams 4 12

Baked Soy Beans and Pork .... 52 36

SEA MOSS.

Sea moss farina and Irish moss are usually allowable for
diabetic patients. Mosl^'of the carbohydrate in these mate-
rials is in the form of pentosans and galactans, which Swartz^
has shown to be quite inert in the body. Unfortunately
these products are sometimes adulterated with other carbo-
hydrates. This emphasizes the fact that no matter how
useful a food may be in itself, one must always be on the
lookout for adulteration.

I Swartz: Tr. Conn. Acad. Arts and Sc, 1911, zvi, p. 247.
9

130 DIABETIC MENU AND FOOD VALUES

HEPCO CAKES.

So arranged that one cake is equivalent to an egg.

Protem. Fat.

Hepco flour, 140 grams 60 29

EggB(2) 12 12

Cream, 40 per cent., 60 c.c 2 24

Butter, 10 grams 9

74 74

Make twelve cakes. Each cake contains 6 grams protein,
6 grams fat, and approximately 75 calories.

BRAN BISCUITS FOR CONSTIPATION.

The following rule was given me by Dr. F. M. Allen:

Bran 60 grams

Salt { teaspoonful

Agar agar, powdered 6 grams

Cold water 100 c.c. (^ glass)

Tie bran (for character of bran to purchase see p. 122) in
cheesecloth and wash under cold water tap until water is
clear. Bring agar agar and water (100 c.c.) to the boiling-
point. Add to washed bran the salt and agar agar solution
(hot). Mold into two cakes. Place in pan on oiled paper,
and let stand half an hour; then, when firm and cool, bake in
moderate oven thirty to forty minutes.

The bran muffins naturally will be far more palatable if
butter and eggs are added. This may be done providing
the patient allows for this in the diet. If the patient is not
upon a measured diet, then considerable latitude can be
employed in making the bran cakes.

BRAN CAKES FOR DIABETICS.

Carbo-
Protein, Fat, hydrate,
Food. Amount. grams. grams. grams. Calories.

Bran ... 2 cupfuls

Melted butter . 30 grams 25 225

Eggs (whole) 2 12 12 156

Egg white (1) . 25 grains 3 12

Salt .... 1 teaspoonful
Water.

15 37 393

DIETETIC SUGGESTIONS, RECIPES AND MENUS 131

Tie bran in cheesecloth and wash thoroughly by fastening
on to the water tap, until the water conies away clear. The
bran should be frequently kneaded so that all parts come in
contact with the water. Wring dry. Mix bran, well-beaten
whole eggs, butter and salt. Beat the egg white very stiff
and fold in at the last. Shape with knife and tablespoon into
three dozen small cakes. If desired one-half gram of cinna-
mon or other flavoring may be added. Each cake contains:
protein, 0.5 gram; fat, 1 gram; calories, 11.

CRACKED COCOA.

Cracked cocoa (cocoa nibs) makes a most useful drink
for diabetic patients. This is not generally appreciated by
the profession.

The sample of cracked cocoa (cocoa nibs) used has been
purchased of the S. S. Pierce Co., Boston. It was analyzed
by Professor Street, with the following result:

Moisture 2.83

Protein . 14.69

Fat 61.42

Fiber 4.32

Ash 3.88

Starch ' . 7,48

Reducing sugar, as dextrose, direct ' none

Reducing sugar, as dextrose, after inversion . . . 0.94

The cocoa is prepared for the table by adding a cupful of
the cracked cocoa to a quart of water and letting it simmer
on the back of the stove all day, adding water from time to
time.

Professor Street was good enough to analyze the infusion,
and wrote me: "The cocoa prepared according to directions
contained 0.032 per cent, of reducing sugar as dextrose
direct and 0.138 per cent, of total reducing sugars."

LEMON JELLT (DIABETIC).

Carbo-
Protein, Fat, hydrate,

Food. Amount. grams. grams. grams. Calories.

Lemon juice . . 30 c.c. . . . . 3 12

Water .... 60 c.c.
' Gelatin .... 4 grams 4 . . . . 16

Saccharin (to sweeten)
Cream, 40 per cent. 30 c.c. 1 12 1 116

5 12 4 144

132 DIABETIC MENU AND FOOD VALUES

Soften gelatin in a part of the cold water. Heat the remain-
ing water and lemon juice and pour over the gelatin. Stir
until dissolved. Add saccharin, strain into cups. Serve with
cream.

BAVARIAN CREAM (DIABETIC).

Carbo-
Protein, Fat, hydrate.
Food. Amount. grams. grams. grams. Calories.

Cream, 40 per cent. 90 o.c. 3 36 3 348

Water .... 10 c.c.

Egg (1) . . . .60 grains 6 6 78

Gelatin .... 2 grams 2 . . 8

Saccharin (to sweeten)

Flavoring (to taste)

11 42 3 434

Soften the gelatin in cold water, then add to the cream,
which has been heated. Stir until dissolved, pour on the
beaten egg, cook like soft custard, turn into mold and chill.

ICE CREAM (DIABETIC).

Food. Amount.

Protein,
grams.

Fat,
grams.

Carbo-
hydrate,
grams.

Calories.

Cream, 40 per cent. 90 c.c.

348

Water . . . . 10 c.c.

Egg (1) . . . .50 grams
Saccharin (to sweeten)
Flavoring (to taste)

• •

9 42 3 426

Make a soft custard of the egg, 50 c.c. of the cream, and
the water. Whip the remaining 40 c.c. of cream and fold into
custard. The saccharin may be added to the egg. The
flavoring should be added last.

AGAR AGAR JELLT.

One-quarter of an ounce sufficient to make one quart of
jelly. Agar agar may also be added to broths.

Miss E. Grace McCullough, Dietitian at the Peter Bent
Brigham Hospital, has given me several practical suggestions
about the preparation of hospital diabetic diets. Many of
these have been incorporated in what follows.

DIETETIC SUGGESTIONS, RECIPES AND MENUS 133

THRICE-COOKED VEGETABLES.

The vegetables are cleaned, cut up fine, soaked in cold
water and then strained. The vegetables are then tied up
loosely in a large square of double cheesecloth — ^large enough
so that the corners of the cloth, after it has been tied up
with a string, make conveniently long ends, and also large
enough to allow the vegetables to swell without sticking
together. They are then transferred to fresh cold water,
placed on the fire, and brought to the boiling-point, at which
temperature they are maintained for from three to five min-
utes. This water is then poured off and replaced by fresh,
and the vegetables again boiled a similar length of time.
Three changes of water are usually sufiicient to remove the
carbohydrate, as has been proved by Professor Wardall's
preliminary experiments. The pots for the vegetables should
be of sufiicient size to hold a large quantity of water, and
in a hospital, vegetables enough for the daily supply of six
patients. Vegetables thus cooked will keep in cold storage
two or more days, and the reheating of the same in a steamer
is a simple affair.

If the vegetables are cooked with the cover left off the pot
they will be lighter in color and the fiavor not so strong.

Miss McCullough has adopted several expedients by which
variety in the 5 per cent, vegetables is obtained, and thus the
monotony of the diet avoided. She suggests that the large
outer stalk — slightly green covering — of cauliflower be care-
fully cleaned, cut into half-inch pieces and boiled until tender,
and frequently this is transferred from four waters. Similarly •
the green outside leaves and any small pieces of lettuce may
be shredded and served like spinach. Chard in season can be
purchased by the bushel, cut, and then chopped up. Rhu-
barb retains its acid flavor and has proved so acceptable an
addition to the diet that in the future it should be canned by
the cold-water method for subsequent use. The flat, large,
celery stalks with any or all the leaves, whether yellow or
green, chopped fine, serve excellently well. White, green, and
red cabbage is cut fine and served as cold slaw.

Diabetic patients should be urged, whenever possible, to

134 DIABETIC MENU AND FOOD VALUES

have a garden and to raise suitable vegetables for themselves
for the ensuing winter. One of my patients does this and
thus provides himself with the best of celery, cabbage, lettuce,
etc. This patient eats a slice of cabbage, cut as one buys
cheese in a grocery store, for breakfast each morning, and
by this means keeps the bowels perfectly regular.

Canned vegetables which have been of the most service
at the Peter Bent Brigham Hospital are of four varieties:
soup asparagus, broad, flat, cut string beans, the tender,
green, stringless bean, and the white wax beans. The pods
are separated from the beans, the latter being used for the
benefit of other patients. Soup asparagus proved to be
excellent for hospital use. It is a by-product of the factory
and consists of the broken-off tips and the shorter thin stalks
which are unfit for the standard size. The pieces are about
one inch long and are all edible.

SQUAB.

A squab when carefully boned yields 50 grams of meat.
This is broiled in an oiled paper case to prevent evaporation,
and when served with the escaped juices proves a favorite
dish for patients. It contains about 12 grams protein and
5 grams fat.

BOILED DINNER.

Corned beef, with cabbage and one other vegetable, served
together as a boiled dinner, is most acceptable to male
patients. A portion containing 50 to 75 grams of meat and
100 grams of each vegetable makes an excellent meal.
Corned-beef hash made of meat and vegetables in the same
proportion could also be served for variety.

The proper seasoning of the food is a great help to the
diabetic patient. So many articles are excluded from the
diet that the great variety which is possible in the prepara-
tion of the food by the help of seasoning is overlooked.
Horseradish, to be sure, contains 10 per cent, of carbohydrate,
but it would take at least two teaspoonf uls to contain a
gram, and probably far more. Sour pickles are allowable.

DIETETIC SUGGESTIONS, RECIPES AND MENUS 135

and other pickles made from the group of 5 per cent, vege-
tables, provided one is assured that they have been prepared
without sweetening. Mint, capers, curry, tarragon vinegar,
onion, bay leaf and cloves may all be used as seasoning, and
tomato and onion stewed, to which bay leaf and cloves may
be added and then thickened with Irish moss, serves as a
sauce.

SEVEN MENUS FOR A SEVERE DIABETIC.

For the menus and the recipes which make them possible
I am greatly indebted to Miss Alice Dike, Instructor in
Household Economics at Simmons College, and to Case
No. 765. The directions given were as follows:

Carbo-
hydrate, Protein, Fat,
Daily dietetic prescription.^ grams. grams. grams.

Five per cent, vegetables, 300 grains . . 10 5

Eggs, 2 12 12

Bacon, 30 grams 5 15

Butter, 30 grams 25

Cream, 60 grams, 40 per cent 2 2 24

Meat, 120 grams 32 20

Lister roll (2) 12 12

12 68 108

The calories furnished amount to about 1200 — a main-
tenance diet for a patient weighing 40 kilograms and a
sufficient diet for a patient of 50 kilograms when in bed.

FIRST DAT.
Breakfast.

Soft-bojled egg, 1.
Fried bacon, 30 grams.
Lister roll and butter, 8 grams.
Coffee and cream, 30 grams.

Lunch.

Roast beef, 60 grams; grated horseradish.

String beans, 75 grams, and butter, 7 grams.

Lettuce and cucumber salad, 50 grams. ^

Rhubarb jelly and meringue (rhubarb, 25 grams, and i white of egg).

^ These represented the dietetic orders for one week^ and from the foods
mentioned in the list the menus which follow were prepared.

136 DIABETIC MENU AND FOOD VALUES

Dinner.

Chicken, 60 grams.

Cauliflower, 75 grams, and butter, 7 grams.

Celery and olives, 75 grams.

Lister roll and butter, 8 grams.

Coffee. Spanish cream (egg 1 and cream 30 grams).

SECOND DAT.
Breakfast.

Shirred egg, 1.

Fried bacon, 20 grams.

Lister roll and butter, 8 grams.

Coffee and cream, 30 grams.

Lunch.

Boiled haddock, 60 grams.

Cucumber sauce, 25 grams.

Butter, 6 grams.

Spinach, 75 grams, and butter, 8 grams, and i egg.

Lettuce, 30 grams.

Coffee jelly whip.

Dinner.

Lamb chops, 60 grams; tomato sauce, 45 grams.
Asparagus, 75 grams and butter, 8 grams.
Dandelion greens, 50 grams, and bacon, 10 grams.
Lister cream puff and custard.

THIRD DAT.
Breakfast.

Egg, 1 ; scrambled with tomato, 50 grams.

Bacon, 20 grams.

Lister roll and butter, 8 grams.

Coffee and cream, 30 grams.

Lunch.

Vegetable hash (corned beef, 40 grams; cabbage, 80 grams; onions, 10 grams;

beet, 10 grams; bacon, 10 grams).
Lettuce, 30 grams.
Lister roll and butter, 8 grams.
Tea.

Dinner.

Steak, 80 grams, and butter, 7 grams.

Broiled pepper, 25 grams.

Cauliflower, 75 grams, and butter, 7 grams.

Wine jelly and egg and cream sauce (egg, 1, and cream, 30 grams).

DIETETIC SUGGESTIONS, RECIPES AND MENUS 137

FOITRTH DAT.
Breakfast.

Liver, 40 grams, and bacon, 15 grams.
Lister roll and butter, 10 grams.
Coffee and cream, 15 grams.

Lunch.

Ham omelet (egg, 1, and meat, 20 grams).

Bacon, 15 grams.

Salad, 150 grams (celery, cabbage, lettuce).

Lister roll, butter, 10 grams.

Cracked cocoa and cream, 15 grams.

Dinner.

Boast lamb, 60 grams, and mint sauce.
Sliced tomatoes, 75 grams.
String beans, 75 grams, and butter, 10 grams.
Vanilla ice-cream (egg, 1, and cream, 30 grams).

FIFTH DAY.

Breakfast.

Scrambled egg, 1, and dried beef, 20 grams.
Lister roll and butter, 6 grams.
Coffee and cream, 20 grams.

Lunch.

Spinach soup (spinach, 25 grams; cream, 15 grams; yolk 1 egg, stock).

Bacon, 30 grams; fried with egg plant, 125 grams.

Coffee.

Dinner.

Steak, 100 grams, and water cress, 25 grams; "Maitre d'Hdtel" butter, 10

grams.
Vegetable marrow, 125 grams, and butter, 8 grams.
Lister roll and butter, 6 grams.
Cracked cocoa whip (white 1 egg and cream, 25 grams).

SIXTH DAT.

Breakfast.

Fried fish cakes and butter, 6 grams (fish, 40 grams; egg, 1 ; cream, 15 grams).
Sliced cucumbers on lettuce, 75 grams.
Coffee and cream, 15 grams.

138 DIABETIC MENU AND FOOD VALUES

Lunch.

Fried egg, 1, and bacon, 30 grams.
Lister roll and butter, 10 grams.
Cold slaw, 75 grams.
Tea.

Dinner.

Broiled swordfish, 80 grams (drawn butter sauce, 7 grams, and parsley) .

Brussels sprouts, 100 grams, and butter, 7 grams.

Tomato jelly salad, 50 grams.

Lister roll and whipped cream, 30 grams (flavored with coffee) .

SEVENTH DAT.
Fasting.

RECIPES USED IN PREPARING THE PRECEDING MENUS.

Grated Horseradish Sauce.

1^ teaspoonfuls grated horseradish.

i teaspoonful vinegar.

i teaspoonful salt.
Cayenne.

2 teaspoonfuls cream or water.
Mix first four ingredients and add cream beaten stiff.

Cucumber Sauce.

Grate 25 grams cucumber and season with salt, pepper and vinegar.

Tomato Sauce.

Stew 45 grams tomato, season with salt, pepper, clove and bay leaf.
Irish or sea moss may be used for thickening.

Parsley Sauce.

7 grams butter.
1 teaspoonful chopped parsley.
Salt and pepper.
Add parsley to melted butter just before serving.

Mint Sauce.

\ cup finely chopped mint leaves,
i cup vinegar.
1 grain saccharin.
Add saccharin to vinegar and dissolve, pour over mint and let stand thirty
minutes on back of range. Let cool before serving.

DIETETIC SUGGESTIONS, RECIPES AND MENUS 139

Maitre d 'Hotel Butter.

10 grams butter.
Salt and pepper.
1 teaspoonful chopped parsley.
h teaspoonful lemon juice.
Put butter in bowl and with wooden spoon work until creamy. Add season-
ing and lemon juice slowly.

Coffee Spanish Cream.

1 scant teaspoonful gelatin soaked in 1 tablespoonful cold water and

dissolved in 5 tablespoonfuls hot coffee.
Add 30 grams cream and pour on slightly beaten yolk of egg.
Cook like soft custard and pour while hot on stiffly beaten white of egg.
Saccharin.

Rhubarb Jelly with Meringue.

1 teaspoonful gelatin soaked in 1 tablespoonful cold water and dissolved
in sauce made by cooking rhubarb in enough water to make 7 table-
spoonfuls.

Serve garnished with beaten white of egg flavored with vanilla.
Saccharin.

Coffee Jelly Whip.

Make the same as plain coffee jelly, but just before it hardens beat in an

egg beaten until fluffy.
Saccharin.

Lister Cream Puff.

Lister biscuit with soft custard poured over it. The soft custard is made

as follows:
30 grams cream,
^egg.

2 tablespoonfuls water.
Saccharin and flavoring as desired.

Wine Jelly with Custard Sauce.

1 scant teaspoonful gelatin soaked in 1 teaspoonful cold water and
dissolved in 4 tablespoonfuls boiling water and flavored with 3 table-
spoonfuls wine and saccharin.
Serve with sauce used above for Lister cream puff.

Cracked Cocoa Whip.

1 scant teaspoonful gelatin, soaked in 1 tablespoonful water, dissolved

in 5 tablespoonfuls strong hot cocoa.
When cooled to the consistency of thick cream, pour slowly on the beaten

white of an egg, beating all the time. Mold and chill.

140 DIABETIC MENU AND FOOD VALUES

Spinach Soup.

25 grams spinach.

15 grains cream.

Yolk of 1 egg.

} cup beef or chicken stock.
Add stock to cooked spinach and cook five minutes. Then rub through sieve.
Beat yolk of egg with cream. Add spinach and stock and return to
double boiler. Cook one minute and serve at once.

INEXPENSIVE MENUS.
Diet for Day.

Carbo-
hydrate,
grams.

Five per cent, vegetables, three times

washed, 300 grams

Eggs, 2

Bacon, 30 grams

Oleo or butter, 60 grams \ «
Lard or crisco, 45 grams /

Meat, 120 grams

Hepco cakes, 2

61 100

FIRST DAT.

Breakfast.

Fried egg, 1, and bacon, 30 grams.
Hepco cake, 1, and oleo, 15 grams.
Coffee.

Dinner.

Boiled dinner:

Corned beef » 80 grams.

Cabbage, 150 grams.

Oleo, 10 grams.

Pickle.

Hepco cake, 1, and oleo, 15 grams.

Tea and cofifee.

Supper.

Vegetable and corned beef hash with fried egg:
Corned beef, 40 grams.
Cabbage, 150 grams.
Oleo, 10 grams.
Tea or coffee.

Protein,

Fat,

grams.

DIETETIC SUGGESTIONS, RECIPES AND MENUS 141

SECOND DAT.

Breakfast.

Egg, 1 ; scrambled with tomato, 50 grams.
Bacon, 15 grams.

Hepco cake, 1, and oleo, 15 grams.
Tea or coffee.

Dinner.

Hamburg steak, 80 grams.

Onions (30 grams) fried in 10 grams oleo, 60 grams.

Greens, 90 grams, with egg, 1, and oleo, 10 grams.

Hepco cake, 1, and oleo, 15 grams.

Tea or coffee.

Supper.

Meat (liver), 40 grams, with bacon, 15 grams.

Cold slaw, 100 grams (cabbage, vinegar, salt, pepper).

THIRD DAT.

Breakfast.

Boiled egg, 1.

Bacon, 30 grams.

Hepco cake, 1, and oleo, 15 grams.

Coffee.

Dinner.

Boiled cod, 80 grams, with oleo, 10 grams, and vinegar.
String beans, 150 grams, and oleo, 10 grams.
Hepco cake, 1, and oleo, 15 grams.

Supper.

Sardines, 40 grams, with hard-boiled egg, 1.
Sauerkraut, 150 grams.
Tea or coffee.

PICNIC LUNCHES.

FIRST DAT.

Dinner.

Lister sandwich: 1 Lister roll, chicken, 60 grams, cucumber, 75 grams.

Hard-boiled egg.

Olives.

Tea or coffee.

142 DIABETIC MENU AND FOOD VALUES

Supper.

Sardines, 60 grams.

Lister roll and butter.

Lettuce, radish, and celery, 75 grams.

Ripe tomato, 50 grams.

SECOND DAT.

Dinner.

Sliced veal loaf sandwiches (1 Lister roll).
Dressed cabbage, 75 grams.
Custard (^ egg).
Coffee.

Supper.

Salad (cold halibut, egg, i, cucumber, 75 grams).
Lemon or rhubarb jelly.
Brazil nuts.

THIRD DAT.
Dinner.

Cold lamb chop.
Tomato.

Olives and pickles.
Lister cream puff.

Supper.

Salad: egg.

Lister sandwich: Lister roll, cold bacon, lettuce.

Coffee Bavarian cream.

FOURTH DAT.
Dinner.

Egg baked in tomato with cheese on top.
Ham sandwich: 1 Lister roll.
Swiss chard.
Coffee jelly.

Supper.

Sandwich: cold roast beef, 1 Lister roll, lettuce and horseradish.
Rhubarb sauce.

CHAPTER 11.
DIET TABLES.

The improvement in the treatment of diabetes owes much
to the recent dissemination of knowledge regarding the com-
position of foods. To the United States Government we
are indebted for an excellent monograph by Atwater and
Bryant entitled "The Chemical Composition of American
Food Materials, Bulletin No. 28, revised edition,*' which was
first issued in 1906. This can be purchased by sending ten
cents in coin to the Superintendent of Documents, Wash-
ington, D. C. From this I have abstracted such analyses as
are especially useful in computing the diets of both normal
and diabetic individuals and have computed the calories
per 100 grams instead of recording the same per pound.

Analyses are also inserted published by the Connecticut
Agricultural Experiment Station. Most of these analyses
are concerned with the so-called diabetic foods, but in some
cases other analyses are included as well. To these latter
lists the values of protein and fat have been added. Whereas
the analyses of many so-called diabetic foods are recorded,
no special food is reconmiended. In general the cost of these
special foods is greater than that of the common foods
selected from the ordinary diet; in fact, the patient pays for
the taste. Each physician must decide the merits of any
particular food for himself.

The arrangement of the analyses is as follows:

Foods. Page.

Vegetables 144

Fresh 144

Canned 145

Fruits and Berries 146

Fresh 146

Canned 147

Dried 147

Pickles and Condiments 147

144 DIABETIC MENU AND FOOD VALUES

Foods. Page.

Nuts 148

Dairy Products 149

Milk 149

Butter 149

Peanut butter 149

Fats and oils 149

Cheese 149

Meat 150

Fish 150

Fresh 160

Preserved and canned 160

Shell-fish 151

Gelatin 151

Eggs 151

Soups . . . . • 151

Home-made 151

Canned 151

Flours, Meals, Bread, Pastry, etc 152

Pastes 154

Miscellaneous 154

Non-alcoholic Beverages 154

So-called Diabetic Preparations 155

Flours and meals 156

Breakfast foods, macaroni, noodles, etc 157

Milk, sugar-free 158

Soft breads 158

Hard breads and bakery products 169

Wines 162

Dry 162

Sweet 162

Especially low in carbohydrate 163

Other alcoholic beverages 164

Vegi^tables: Fresh.

Protein, Fat,

per cent, per cent.

Rhubarb 0.6 0.7

Endive 1.0 0.0

Vegetable marrow 0.1 0.2

Sorrel

Sauerkraut 1.7 0.5

Beet greens, cooked 2.2 3.4

Celery 0.9 0.1

Tomatoes 0.9 0.4

Brussels sprouts 1.6 0.1

Watercress 0.7 0.5

Sea-kale 1.4 0.0

Okra 1.6 0.2

Cauliflower 1.8 0.6

Carbo-
hydrates,
per cent.

Caloric

value

per 100

grams.

2.6

3.0

3.2

3.3

3.4

3.7

3.8

4.0

4.3

DIET TABLES

145

Caloric

Carbo- value

Protein, Fat, hydrate, per 100

j>er cent, per cent, per cent, grams.

Eggplant 1.2 0.3 4.3 25

Cabbage . . . (range 3.0- 6.5) 1.6 0.3 4.7 29

Radishes . . . (range 2.7- 7.5) 1.3 0.1 5.0 27

Leeks 1.0 0.4 6.0 32

Mushrooms! . . (range 2.0-18.0) 3.5 0.4 6.0 43

Pumpkins . . . (range 3.0-14.0) 1.0 0.1 6.0 30

String beans . . (range 3.9-10.0) 2.3 0.3 6.0 37

Turnips . . . (range 2.3-18.0) 1.3 0.2 6.0 32

Celery root .. 6.3 26

Kohl-rabi . . . (range 3.5-14.0) 2.0 0.1 7.0 38

Oyster plant 1.2 0.1 7.0 35

Rutabagas . . . (range 3.0-12.0) 1.3 0.2 7.0 36

Truffles 9.1 0.5 7.0 71

Squash .... (range 3.0-15.0) 1.4 0.5 8.0 43

Beets .... (range 6.0-10.0) 1.6 0.1 9.0 44

Carrots .... (range 5.9-11.5) 1.1 0.4 9.0 45

Onions .... (range 4.0-14.0) 1.6 0.3 9.0 46

Parsnips . . . (range 6.0-14.0) 1.6 0.5 11.0 56

Chicory .. 15.0 62

Peas 7.0 0.5 15.0 95

Artichokes' 2.6 0.2 16.0 78

Yams .. 16.0 66

Corn 3.1 1,1 19.0 101

Potatoes . . . (range 13.0-27.0) 2.2 1.1 20.0 101

Lima beans 7.1 0.7 22.0 126

Sweet potatoes . (range 16 . 5-44 .5) 1.8 0.7 26 . 1 20

Soybeans^. . . (range 19.3-39.0) 20.0 43.0 28.0 467

Lettuce 1.2 0.3 2.2 17

Cucumbers 0.8 0.2 2.3 15

Spinach 2.1 0.3 2.3 21

Asparagus 1.8 0.2 2.4 19

Vegetables: Canned.

Beans, haricot-verts 1.1 0.1 2.0 14

Asparagus . . . (range 1.6- 3.3) 1.5 1.1 2.3 26

Brussels sprouts 1.5 0.1 2.9 19

Okra 0.7 0.1 2.9 16

Tomatoes . . . (range 1.0- 4.5) 1.2 0.2 3.0 19

Stringbeans . . (range 1.5-4.5) 1.1 0.1 3.3 19
Macedoine, mixed

vegetables . . (range 1.9- 5.0) 1.4 0.0 3.9 22

! The carbohydrate which these contain is to a considerable extent

unassimilable, and patients often eat these with impunity, as I have found
since my attention was called to this fact by Professor Wardall.

' French artichokes. According to Konig, canned artichokes contain
92.46 per cent, water, 0.79 per cent, protein, 0.02 per cent, fat, 4.43 per cent,
carbohydrates.

' The carbohydrate is non-assimilable.

146

DIABETIC MENU AND FOOD VALUES

Caloric

Carbo- value

Protein, Fat, hydrates, per 100

per cent, per cent, per cent, grams.

Artichokes . . . (range 3.2- 6.1) 0.8 0.0 4.4 21
Pumpkins . . . (range 3.6- 7.3) 0.8 0.2 6.0 30
Peas .... (range 4.3-17.2) 3.6 0.2 10.0 58
Squash .... (range 3.6-12.8) 0.9 0.5 10.0 49
Beans, haricot-
flageolets . . (range 9.8-12.4) 4.6 0.1 11.0 65
Lima beans . . (range 9.6-16.5) 4.0 0.3 13.0 72

Baked beans 6.9 2.5 17.0 121

Red kidney beans 7.0 0.2 17.0 100

Corn .... (range 11.7-25.1) 2.8 1.2 18.0 97

Succotash . . . (range 13.9-21.3) 3.6 1.0 18.0 98

Beans 22.5 1.8 55.0 334

Cow peas 21.4 1.4 65.0 326

Peas 24.6 1.0 58.0 348

Lentils 25.7 1.0 69.0 357

Lima beans 18.1 1.5 66.0 359

Fruits and Berries: Fresh.

Strawberries 1.0 0.6 5.0 30

Grapefruit .. 6.0 25

Alligator pear .. 7.0 29

Lemons 1.0 0.9 7.0 31

Watermelons 0.3 0.1 7.0 32

Blackberries 0.9 2.1 8.0 56

Cranberries 0.5 0.7 8.0 41

Peaches 0.5 0.2 9.0 41

Muskmelons 0.7 0.3 10.0 47

Raspberries 1.0 ? 10.0 45

Whortleberries 0.7 3.0 10.0 72

Apples 0.4 0.5 11.0 71

Pears 0.4 0.6 11.0 72

Apricots 1.1 ? 12.0 54

Gooseberries 0.4 .. 12.0 51

Mulberries 0.3 12.0 48

Pineapples 0.4 0.3 12.0 54

Currants 0.4 ^. 13.0 55

Oranges 0.9 0.6 13.0 63

Mangoes .. 13.0 53

Grapes 1.0 1.0 15.0 75

Nectarines 0.6 ? 15.0 64

Cherries 0.8 0.8 17.0 80

Figs 1.5 .. 17.0 76

Huckleberries 0.6 0.6 17.0 78

Plums 1.0 .. 17.0 74

Pomegranates 1.5 1.6 17.0 91

Prunes 0.8 ? 19.0 81

Bananas 1.5 0.7 20.0 96

Persimmons 0.8 0.7 32.0 141

Dates 1.9 Trace 64.0 229

DIET TABLES 147

Oranges.^

Caloric

Carbo- value

Protein, Fat, hydrates, per 100

per cent, per cent, per cent, grams.

Florida, average of seven analyses (soluble portion) . . 8.0 33

California, average of eight analyses (soluble portion) . 8.3 34

Bananas.

Yellow 1.3 0.6 22.0 101

Grape Fruit.

Porto Rico, average of two analyses (soluble portion) 8.2 34

California, average of four analyses (soluble portion) 6.9 28

Florida, average of four analyses (soluble portion) . . 6.6 27

Fruits: Canned.

Peaches 0.7 0.1 11.0 49

Blueberries 0.6 0.6 13.0 61

Pineapples . . . (range 6.0-25.0) 0.4 0.7 15.0 70

Apricots 0.9 ? 17.0 73

Pears 0.3 0.3 18.0 78

Cherries 1.1 0.1 21.0 92

Crab apples 0.3 2.4 54.0 245

Blackberries 0.8 2.1 56.0 252

Jams, jellies, preserves and marmalade contain 47 per cent, or more carbo-
hydrate.

Fruits: Dried.
Contain 63 per cent, or more of carbohydrate.

Pickles and Condiments.

Distilled vinegar

Cider vinegar* 0.25 1

Cucumber pickles 0.5 0.3 2.7 16

OUves, ripe 1.7 25.9 4.3 265

Capers 3.2 0.5 5.0 41

Prepared mustard 4.7 4.1 5.0 78

Prepared mustard

plus cereal . . (range 4.0-15.0) 3.5 1.9 7.0 61

Ketchup . . . (range 3.0-26.0) 1.8 0.2 10.0 50

Spiced salad vinegar 10.0 41

Horseradish 1.4 0.2 11.0 53

Chili sauce. . . (range 14.0-28.0) 20.0 82

Spiced pickles 0.4 0.1 21.0 89

Olives, green' 2.1 12.9 1.8 137

Olives, 'ripe 2.0 21.0 4.0 220

Peppers (paprica), green, dried . . . 15.5 8.5 63.0 400

* If carbohydrate in oranges is reckoned at 10 per cent., comparatively
little error will result.

* Professor Street writes (November 27, 1916), '*In our last examination
of 27 brands we found the reducing sugars to range from 0.27 to 1.52 per
cent."

* Univ. Calif. College Agriculture, 1916. Personal communication:

148

DIABETIC MENU AND FOOD VALUES

Nuts.

Caloric

Carbo- value

Protein, Fat, hydrates, per 100

per cent, per cent, per cent, grams.

FUberts 15.6 65.3 13.0 724

Hickory nuts 15.4 67.4 11.4 736

Peanuts 25.8 38.6 24.4 563

Pecans 11.0 71.2 13.3 760

Pine nuts; pignolias 33.9 49.4 6.9 626

Pistachios, first quality, shelled . . . 22.3 54.0 16.3 659

Walnuts, California 18.4 64.4 13.0 726

Walnuts, California, black . . . . 27.6 66.3 11.7 683

Walnuts, California, soft shell . . . 16.6 63.4 16.1 723

Almonds 21.0 54.9 17.3 667

Brazil 17.0 66.8 7.0 , 364

Butternuts 27.9 61.2 3.5 95

Chestnuts, fresh 6.2 5.4 42.1 248

Cocoanuts 5.7 50.6 27.9 607

Calcu-

Nut Preparations.

Protein,
per cent.

Fat,
per cent.

Carbo-
hydrate
per cent.

Starch,
per cent.

lated
calories
per 100
grams.

The Kellogg Food Co.,

Battle Creek, Mich.:

1913

Nut Bromose (Meltose

and Nuts) ....

17.1

26.8

39.4

3.2

467

1906

Nut Butter (Sanitas) '.

28.8

50.5

13.9

9.11

625

1906

Nut Meal (Sanitas) .

29.0

51.7

12.1

8.91

630

1906

Nuttolene (Sanitas) .

12.7

21.8

6.3

• •

272

1906

Protose (Sanitas)

22.6

9.2

3.6

• •

188

1913

Nashville Sanitarium Food
Co., Nashville, Tenn.:

Nut Butter ....

28.0

52.6

13.0

3.8

637

1913

Nutcysa

12.9

21.0

6.3

trace

266

1913

Nutfoda

Malted Nuts.

20.8

8.0

6.8

trace

182

1901

The Kellogg Food Co.,
Battle Creek, Mich.:

Malted Nuts ....

23.7

27.6

43.9

• •

519

1913

Nashville Sanitarium Food
Co., Nashville, Tenn.:

Malted Nut Food . .

24.7

42.7

27.5

3.4

593

1 Determined by the diastase method, without previous washing with
water, and calciilated as starch.

DIET TABLES

149

Dairy Products, etc.

Protein, Fat,

per cent, per cent.

Milk, whole 3.3 4.0

Milk, condeDsed, sweetened . 8.8 8.3
Milk, condensed, unsweetened, "evapo-
rated cream" 9.6 9.3

Milk, skimmed 3.4 0.3

Cream, approximately 20 per cent, fat . 2.3^ 18.5

Cream, 40 per cent, fat 1.5^ 40.0

Buttermilk 3.0 0.6

Whey 1.0 0.3

Kephir 3.1 2.0

Koumiss . . .* 2.8 2.0

Caloric
Carbo- value
hydrates, per 100
per cent, grams.

5.0 72
54.1 334

11.2
6.1
4.5
3.0
4.8
5.0
1.6
5.4

172
37
194
378
36
27
38
53

1913

Protein, Fat,
percent, percent.

Butter 1.0 85.0

S. S. Pierce Co., Boston:
Acharis Brand peanut
butter 28.7 48.3

Carbo-
hydrate
per cent.

Starch,
per cent.

14.6 5.1

Caloric

value

per 100

grams.

793

608

Oils and Fats.

Lard, tallow, oleomar-

garine, cod-liver oil, olive

oil and other edible oils

(crisco, oleo. E. P. J.) .

85 to
100

• •

Carbo-

900

Caloric
value

Protein,

Fat,

hydrates,

per 100

per cent.

grams.

8, American, pale .

. . 28.8

35.9

0.3

452

red ...

. . 29.6

38.3

476

Camembert ....

. . 21.0

21.7

• •

290

Cottage

. . 20.9

1.0

4.3

112

Dutch

• • • •

17.7

• •

316

Full cream ....

. . 25.9

33.7

2.4

429

Limburger ....

. . 23.0

29.4

0.4

369

Neufchatel ....

. . 18.7

27.4

1.5

337

Pineapple

. . 29.9

38.9

2.6

494

Roquefort ....

. . 22.6

29.5

1.8

374

Skimmed milk

. . 31.5

16.4

2.2

290

Swiss

. . 27.6

34.9

1.3

442

1 Estimated. E. P. J.

150

DIABETIC MENU AND FOOD VALUES

Meat.

Protein,
j>er cent.

Beef, cooked:

Roast 22.3

Round steak, fat removed . 27 . 6

Calfs foot jelly 4.3

Beef, canned:

Dried beef 39.2

Beef, corned and pickled:

Corned beef, all analyses . . . . 15 . 6

Mutton, cooked: /

Mutton, leg roast 25.0

Pork, pickled, salted and smoked:

Ham, smoked, lean 19.8

Bacon, smoked, aU analyses . . 10.5

Sausage, A:

Bologna sausage (range 0.2-3.1) 18.7

Frankfort . . (range 0.0- 6.6) 19.6

Pork (range carbohydrate 0.0-8.6) 13.0
Deerfoot Farm, cooked, analysis fur-
nished by the manufacturers

Poultry and game, fresh:

Chicken, broilers 21.5

Fowls 19.3

Goose, young 16.3

Turkey •. 21.1

Liver:

Beef 21.0

Chicken, as purchased 22.4

Goose, as purchased 16 . 6

Mutton, as purchased 23.1

Pork, as purchased 21.3

Turkey, as purchased 22 . 9

Veal, as purchased 19.0

Caloric
Carbo- value
Fat, hydrates, per 100
per cent, per cent, grams.

28.6

7.7
0.0

6.4

26.2

22.6

20.8
64.8

17.6
18.6
44.2

2.5
16.3
36.2
22.9

4.5
4.2
15.9
9.0
4.5
5.2
5.3

17.0

0.6
1.1
1.1

1
2
3
5
1

.7
.4
,7
.0
.4

356
185

211

307

312

274
645

243
258
468

19.93 54.21 0.34 587

0.6

111
230
403
299

133
141
231
199
135
144
127

Fish: Fresh.

Cod sections 16.7 0.3

Flounder, whole . 14.2 0.6

Haddock, entrails removed 17.2 0.3

Halibut, steaks or sections 18.6 5.2

Mackerel, whole 18.7 7.1

Salmon, whole 22.0 12.8

Shad, whole 18.8 9.5

Trout (brook), whole 19.2 2.1

'124

142

209

165

Fish: Preserved and Canned.

Cod, salt, "boneless" 27.3 0.3

Herring, smoked 36.9 15.8

Sardines, canned 23.0 19.7

Shad roe 20.9 3.8

Sturgeon caviare 30.0 19.7

2.6
8.0

108
298
277
121
198

DIET TABLES

151

Shell-fish. '

Protein, Fat,

per cent, per cent.

Clams, long, in shell 8.6 1.0

Crabs, hardshell, whole 16.6 2.0

Lobster, whole 16.4 1.8

Mussels, in shell 8.7 1.1

Oysters, in shell 6.2 1.2

Scallops, as purchased 14 . 8 0.1

Terrapin . 21.2 3.5

Turtle, green, whole 19.8 0.5

Gelatin.

Gelatin! • . . 91.4 0.1

Eggb.
Eggs, edible portion:*

Hens', uncooked 13.4 10.5

Hens', boiled . 13.2 12.0

Hens', boiled whites 12.3 0.2

Hens', boiled yolks 15.7 33.3

Soupb: Home-made

Beef 4.4 0.4

Bean 3.2 1.4

Chicken 10.5 0.8

Clam chowder 1.8 0.8

Meat stew 4.6 4.3

Soups: Canned.

BouiUon 2.2 0.1

Chicken gumbo 3.8 0.9

Chicken soup 3.6 0.1

Consomme 2.5

Julienne 2.7

Mock turtle 5.2 0.9

Mulligatawny 3.7 0.1

Oxtail 4.0 1.3

Pea soup 3.6 0.7

Tomato soup 1.8 1.1

Vegetable 2.9

Carbo-
hydrates,
per cent.

Caloric

value

per 100

grams.

2.0

1.2

0.4

4.1

3.7

3.4

^ ^

120

• •

375

158

168

376

1.1

9.4

2.4

6.7

5.5

0.2

4.7

1.5

0.4

0.5

2.8

5.7

4.3

7.6

5.6

0.5

1 1 understand that many of the brands of commercial gelatin contain
from 83 to 87 per cent, gelatin, 11 to 14 per cent, of moisture and 1 to 2
per cent, of ash. E. P. J.

* One egg contains approximately protein 6 grams and fat 6 grams, of
which one-half the protein and all the fat are in the yolk. E. P. J.

152

DIABETIC MENU AND FOOD VALUES

Flour, Meals, Bread, Pastry, etc.

Caloric

Carbo- value

Protein, Fat, hydrate, per 100

per cent, per cent, per cent, grams.

Flours, meals, etc. :

Barley meal and flour 10.5 2.2 72.8 361

Buckwheat flour 6.4 1.2 77.9 356

Cornmeal, unbolted 8.4 4.7 74.0 381

Hominy 8.3 0.6 79.0 363

Oatmeal 16.1 7.2 67.5 409

RoUedoats 16.7 7.3 66.2 407

Rice 8.0 0.3 79.0 359

Rice, boiled 2.8 0.1 24.4 112

Rye flour . » 6.8 0.9 78.7 359

Wheat flour, CaUfornia fine ... 7.9 1.4 76.4 358
Wheat flour, entire wheat . . . . 13.8 1.9 71.9 369
Wheat flour, patent roller process, high
grade (average of all analyses of high
medium grades and grade not indi-
cated) 11.4 1.0 75.1 363

Wheat preparations:

Macaroni 13.4 0.9 74.1 366

Macaroni, cooked 3.0 1.5 15 . 8 91

Soy bean meal 42.5 19.9 34. 0» 499

Pea flour 25.7 1.8 57.0 354

Acorn meal 7.3 4.9 64.0 338

Graham flour 13.3 2.2 70.0 362

Pop corn, popped 10.7 5.0 77.0 586

Cassava meal 1.3 1.2 81.0 348

Potato starch 0.9 0.1 81.0 337

Sago starch 2.2 0.0 81.0 341

Tapioca (Arrow-root) 0.1 0.1 84.0 346

Banana flour 3.9 1.0 85.0 375

Cornstarch 1.2 0.0 85.0 353

Rye 10.2 1.7 72.0 353

Buckwheat 10.1 2.5 61.0 315

"Ralston Health Food" 11.9 1.7 72.0 360

"Quaker Wheat Berries" .... 13.8 1.9 72.0 370

"Wheatlet" 12.8 1.6 74.0 371

"Force" 10.6 1.1 74.0 358

Cracked wheat 11.1 1.7 74.0 365

"Pettijohn's Breakfast Food" ... 9.1 2.0 74.0 359

" Malt Breakfast Food " 13.8 1.5 75.0 378

"Cream of Wheat" 11.5 0.9 75.0 353

"Triscuit" 11.0 1.4 75.0 365

"Grape Nuts" 11.5 0.6 75.0 360

Farina 11.0 1.4 75.0 367

"Wheatena" 11.3 2.8 76.0 384

"Mapl-Flake" 11.0 1.4 76.0 369

"Shredded Wheat Biscuit "2 .... 8.3 0.6 76.0 351

Hominy 7.6 0.2 78.0 353

Pufifedrice 6.7 0.4 80.0 359

Toasted corn flakes .. 81.0 332

1 The assimilable carbohydrate in soy beans is 3 per cent, or less.

2 Weight of 1 biscuit 30 grams, and it contains approximately, carbohy-
drate 23 grams and protein 3 grams.

DIET TABLES

153

Caloric
Carbo- value

Protein, Fat, hydrate Starch, per 100
percent, percent, percent, percent, grams.

U913 Glidine: Menley & James,

New York .... 91.4 0.8 1.0 377

1909 Plasmon: FlasmoD Co.,

London 78.7 2.7 0.0 .. 339

1915 Cotton-seed flour : Allison ,

Schulenburg Oil Mill,

Schulenburg, Texas . 50.4 11.2 1.1 348

Protein,
per cent.

Bread:

Bread, brown 5.4

Bread, corn (Johnnycake) . 7.9

Bread, rye 9.0

Graham bread 8.9

Rolls, French 8.5

Rolls, all analyses 8.9

Toasted bread 11.5

White bread, home-made . 9.1

White bread, miscellaneous 9.3

Whole wheat bread 9.7

Whole rye bread 11.9

Peanut bread 33 . 6

Acorn bread

Cassava bread

Alfalfa bread 10.6

Crackers:

Boston (split) crackers 11.0

Uneeda biscuit^ 10.1

Graham crackers 10.0

Pilot bread 11.1

Saltines * 10.6

Zwieback 9.8

Peanut zwieback 23 . 2

Doughnuts. . . (range 45.0-63.0) 6.7

Cake (except fruit

cake) . . . (range 53.0-78.0) 6.3

Jumbles . . . (range 52.0-71.0) 7.4

Fruit cake 5.0

Macaroons . . (range 57 . 0-70 .0) 6.5

Caloric
Carbo- value
Fat, hydrate, per 100
per cent, per cent, grams.

1.8

47.1

231

4.7

46.3

265

0.6

53.2

260

1.8

52.1

266

2.5

55.7

286

4.1

56.7

307

1.6

61.2

312

1.6

53.3

270

1.2

52.7

266

0.9

49.0

249

0.6

35.0

198

12.8

20.0

339

• «

27.0

111

27.0

111

1.3

64.0

318

8.5

71.1

415

8.8

70.0

399

9.4

73. §

430

5.0

74.2

396

12.7

68.5

441

9.9

73.5

433

8.0

28.0

284

21.0

52.0

436

9.0

63.0

368

13.5

63.0

418

10.9

64.0

384

15.2

64.0

430

^ Analysis of preparation manufactured at this date.

* Analysis from Conn. Exp. Sta. Report, 1914, p. 230. One biscuit weighs
7 grams and contains about 5 grams carbohydrate, 0.7 gram protein and
0.5 gram fat.

154

DIABETIC MENU AND FOOD VALUES

Protein, Fat,

Pie: percent, percent.

Apple 3.1 9.8

Custard 4.2 6.3

Squash 4.4 8.4

Mince . . . (range 30 . 0-44 . 0) 5.8 12'.3

Pastes.

Noodles 13.3 0.8

Vermicelli 10.9 2.0

Spaghetti 12.1 0.4

Carbo-
hydrate,
per cent.

42.8
26.1
21.7
38.0

72.0
72.0
74.0

Almond Paste. Protein,

per cent.

1902-3 Chapman, Chicago . . 13.1
1902-3 Henry Heide, New York 12 . 7
1902-3 Spencer, New York . . 13.5

Carbo-
Fat, hydrate Starch
percent, percent, percent.

25.5 36.3 11.3
20.0 43.7 small
26.2 31.6 very

small

Caloric
value
per 100
grama.

279
183
185
194

357
358
353

Calcu-
lated
calories
per 100
grama.

427
406
416

Carbo-
MlSCELLANEOUS. hydrate,

per cent.

Plain chocolate 25.0

Cocoa nibs, roasted 28.0

Baking powder (range 0-51.5) 32.0

Cocoa 38.0

Milk chocolate 51.0

Milk cocoa 52 .

Custard powders 59 .

Sweet chocolate 67.0

Carbo-
NoN-ALCOHOLic BEVERAGES. hydrate,

per cent.

Tea (0.5 oz. to 1 pt. water) , 0.6

Coffee (1 oz. to 1 pt. water) 0.7

Cocoa (0.5 oz. to 1 pt. water) 1.1

Cider (range 0-13 . 5) 4.5

Cocoa (0.5 oz. to 1 pt. milk) 6.0

Cream or lemon soda 7.0

Sarsaparilla 7.0

Birch beer 8.0

Ginger ale 8.0

Root beer 9.0

Caloric
Carbo- value
Protein, Fat, hydrate, per 100
, per cent, per cent, per cent, grams.

Chocolate 12.9 48.7 30.3 629

Cocoa 21.6 28.9 37.7 510

Cereal coffee infusion (1 part boiled in

20 parts water) 0.2 .. 1.4 7

DIET TABLES

155

So-called Diabetic Prepara-
tions.

rotein,
per cent.

It,

per cent.

Eurbohydrate,
per cent.

;arch,
percent.

alculated
calories per
100 grams.

Flours and Meals.

1910

Acme Mills Co., Portland, Ore. .
Amthor & Co., Halle: Weizen-

9.4

1.9

77.4

71.4

364

Protein

84.1

1.4

4.8

• •

368

1912

Herman Barker, Somerville, Mass. :

Barker's Gluten Food, "A" .

86.9

0.5

3.7

trace

370

1913

Barker's Gluten Food, " B " .

85.1

0.6

7.2

3.7

375

1913

Barker's Gluten Food, " C " .

84.1

0.6

8.6

3.4

377

1914

Battle Creek Sanitarium Co.,
Battle Creek, Mich., 80 per

cent. Gluten Meal

84.0

•

5.8

368

1907

Bischof & Co., London: Gluten

Flour

79.8

3.6

5.0

• •

372

1909

Callard, Stewart & Watt, London:

Casoid Flour

82.5

1.6

3.1

357

1913

Cereo Co., Tappan, N. Y.:

Soy Bean Gruel J^'lour . . .

43.1

21.4

24.9

trace

465

1913

Farwell & Bhines, Watertowu,

NY-

Gluten Flour

43.1

1.2

46.6

38.1

370

1913

Gluten Flour

46.3

1.1

42.9

32.8

367

1913

Cresco Flour

18.1

1.0

67.4

57.2

351

1913

Special Dietetic Food

27.5

2.8

56.6

40.0

362

1913

Golden Rod Milling Co., Portland,

Ore., Acme Special Flour

15.8

1.4

71.4

57.9

361

1913

O. B. Oilman, Boston, Mass.:

Gluten J^'lour

47.3

2.0

40.4

31.4

369

1908

Hazard's Wheat Protein .

41.8

1.2

49.1

• «

374

1913

Health Food Co., New York:

Almond Meal

50.3

14.8

17.9

trace

406

1914

Almond Meal

49.1

21.8

15.9

457

1911

C B X Cold Blast Flour, 25 per

cent, protein

10.1

0.9

79.6

68.9

367

1913

Proniren (Griddle-cake l<'lour) .

37.3

1.2

• •

37.7

349

1913

Glutoaac Gluten Flour .

39.9

2.3

47.5

36.9

370

1914

Gluten Flour No. 1 . . . .

75.7

0.9

12.8

7.1

362

1913

Protosac Gluten Flour .

42.7

1.7

46.4

36.3

372

1913

Protosoy Soy Flour .- . . .

42.3

19.8

24.5

trace

446

1913

Pure Washed Gluten Flour .

80.3

1.6

29.5

7.0

380

1914

Gluten Flour ......

45.9

2.0

42.3

31.5

370

1914

Protosoy Soy Flour ....

42.9

19.2

26.0

1.9

448

1914

Pure Washed Gluten

85.6

1.0

5.4

2.8

373

1906

Jireh Diabetic Food Co., New
York:

1906

Diabetic Flour

14.3

2.2

71.9

66.61

365

1 Determined by the diastase method, without previous washing with
water, and calculated as starch.

156

DIABETIC MENU AND FOOD VALUES

So-galled Diabetic Prepara-
tions.

rotein,
per cent.

at,

per cent.

arbohydrate,
per cent.

barch,
per cent.

alculated
calories per
100 grams.

Flours and Meals. — Continued

Jireh Diabetic Food Co., Nev

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 i^'lour

. 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

66.21

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., Batth
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 J^'lour ....

. 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:

Gluten Flour

43.3

1.3

46.2

38.4

370

1911

Pure Gluten Food Co., New York

•
•

Gum Gluten Flour .

38.3

1.6

50.8

42.4

371

1906

Gum Gluten Ground

50.1

1.9

39.6

38. 6«

376

1906

Hoyt's Gum Gluten

31.8

1.6

• •

52. 0«

358

1914

Hoyt's Gum Gluten Biscuii

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.
> Determined by the diastase, etc. (see preceding page).

DIET TABLES

157

08 .

So-called Diabetic Prepara-
tions.

Protein,
per cent.

at,

per cent.

arbohydi
per cent,

^ch,
per ceni,

alculated
calories ]
100 gran

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

76.1

0.9

12.6

12.4

359

1913

Wilson Bros., Rochester, N. Y.:

Gluten Flour, ^ 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

42.91

20.8

22.32

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-

fast Food

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.

' Chiefly derived from Soy bean and therefore non-assimilable, and for
patients can be considered carbohydrate-free.

158

DIABETIC MENU AND FOOD VALUES

So-called Diabetic Pbepara-

TIONS.

rotein,
per cent.

It,

per cent.

EU'bohydrate,
per cent.

;arch,
per cent.

alculated
calories per
100 grams.

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
Gritsi

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:

P&tes aux Oeufs Macaroni .

13.9

0.4

76.2

69.2

364

1910

P&tes aux Oeufs Nouillettes

14.4

0.5

75.7

68.9

365

1913

Petites P&tes 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'

2.4

5.3

• •

1913

D. Whiting & Sons, Boston:
Sugar-free Milk (ave. 3

analyses)

5.7

7.2

trace

• •

Soft Breads.

1913

Ferguson Bakery, Boston, ^ass. :

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

Glutosac BreEwi

27.2

2.1

31.1

22.2

1906

Health Food Co.: '

Protosac Bread

32.5

• •

37.0

1.6

292

1914

Protosac Bread

29.8

1.8

35.2

27.7

276

1914

J. Heinbockel & Co., Baltimore,
Md.:

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.

* Determined by the diastase, etc. (see preceding page).

• Water 91.8 per cent.

DIET TABLES

159

So-called Diabetic Prepara-

•

Carbohydrate,
per cent.

Starch,
per cent.

ted

iesper

rams.

tions. .

Protein
per c<

Fat,
per a

Calcula
calori
100 g

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

Prod u el's.

1907

Bischof & Co., London:

Diabetic Gluten BreEtd .

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

19.6

52.1

27.0

• •

630

1913

Casoid Biscuits, No. 1 . . .

66.8

18.8

5.8

4.0

460

1909

Casoid Biscuits, No. 2 . . .

67.8

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

25.6

44.9

21.6

• •

693

1909

Casoid Rusks

37.0

32.3

20.8

• •

522

1909

Cocoanut Biscuit + Saccharin

16.6

61.3

16.4

• •

684

1909

Ginger Biscuit + Saccharin

17.1

58.6

18.1

• •

668

1913

Kalari Batons

43.2

39.0

7.4

553

1909

Kalari Biscuits

66.9

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

16.6

25.5

489

1913

Gluten Fleur de Neige Pain

35.9

12.6

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

43.6

27.2

385 <

1913

Tranches Grill6es 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

64.2

46.5

400

1914

Diabetic Biscuit

36.9

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.

rotein,
per cent.

at.
per cent.

arbohydrate,
per cent.

harch,
per cent.

alculated
calories per
100 grams.

(z<

Hard Breads, ETC.-^Continued.

Health Food Co., New York:

1906

Glutona

22.1

11.8

58.5

54.91

429

1906

Glutosac Butter Wafers

27.6

12.9

49.4

41.21

424

1906

Glutosac Rusks

36.6

3.8

51.6

42.51

387

1906

Wafers, Plain

29.4

9.6

49.9

41.61

404

1906

Zwieback

32.5

6.9

49.3

40.91

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

43.91

376

1913

Protosoy Diabetic Wafers .

43.1

24.9

21.2

4.7

481

1906

Salvia Sticks

39.2

20.8

2.4

18. 71

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 Diab^t-

iques

76.1

1.5

9.2

4.2

354

1914

Pain de Gluten pour Diab6tiques

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

65.41

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

50.11

434

1906

Johnson Educator Food Co.,
Boston:

Almond Biscuits

29.0

8.8

54.3

50.01

412

1906

Diabetic Biscuits ....

25.3

7.5

59.0

54.91

405

1906

Educator Crackers, Greseni

Gluten

23.0

4.6

63.1

57.91

386

1 Determined by the diastase method', without previous washing with
water, and calculated as starch.

DIET TABLES

161

So-called Diabetic Prepara-
tions.

rotein
per cent.

at,
percent.

arbohydrate,
per cent.

tarch,
per cent.

'alculated
calories per
100 grams.

(z«

Hard Breads, etc. — Continued.

John8on 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

63.31

364

1906

Gluten Wafers

30.3

0.4

61.2

57.01

370

1906

Glutine, Greseni Gluten

21.9

0.8

67.7

63. 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

80 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

46.6

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.

162 DIABETIC MENU AND FOOD VALUES

Winbb:* Dbt.

u
it

Grams reduc-
ing Bugars, per
100 c.c.

CaUfornia, red, Bordeaux or Claret . (range . 04- . 63) 0.16

" Burgundy. . . . (range 0.03-0.42) 0.15

" Zinfandel .... (range 0.03-0.36) 0.15

" white, Rhine .... (range 0.0^-0.63) 0.15

" Burgundy . . . (range 0.10-0.46) 0.23

" Sauterne . . . (range 0.07-3.67) 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 0.02-2.16) 0.19

North Carolina (range 0.08-1.76) 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- 1.96) 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) 6.38

German (range 0.64-12.13) 4.60

Madeira (range 2.48-3.88) 2.95

Malaga (range 12.60-25.20) 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 1.86-20.60) 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,

Manufactursr or Agent and Brand. per cent. per cent.*

Alfonso &, Hipolito:

Sancho Vinos de Jerez AmontiUado Don Quixote

(Wm. J. Sheehan Co., New Haven, Agents) 20.60 1.23

Brotherhood Wine Co., New York City:

Sunnyside Claret 11.87 0.16

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:*

*'Calwa" Brand Greystone (Light Hock Type)* 11.81 0.19

Calwa" Brand La Loma (Burgundy Type)* . 11.27 0.14

Calwa " Brand Vine Clif! (Riesling)* . . . 10 . 90 0.17

"Calwa" Brand Winehaven (Table Claret)* . 11 .46 0. 14

H. T. Dewey A 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* 20.86 0.32

Empire State Wine CJo., Penn Yan, N. Y.:

Dry Catawba 12.80 0.16

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

CaUfornia 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

CaUfornia Hock 11.21 0.14

California Riesling 11.15 0.14

California Zinfandel 11.32 0.16

Urbana Wine Co., Urbana, 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.

* Sold by M. Zunder & Sons, New Haven, Conn.

* Sold by Chris. Xander, Washington, D. C.

164 DIABETIC MENU AND FOOD VALUES

Otheb Alcoholic Beverages.

Brandy, gin, rum, whisky 0^

Absinth Trace

Angostura 4.2

Beer 4.6

Weiss bier 4.6

Ale 5.1

Porter or Stout 7.0

Malt extract, commercial 10.6

Curasao 25.5

Cr6me de menthe 27 . 7

Ktimmel 31.2

Benedictine 32.6

Anisette 34.4

Chartreuse 34.4

Maraschino 52.3

Malt extract, true 71.3

* Grams reducing sugars per 100 c.c.

PART IV.

SELECTED LABORATORY TESTS USEFUL IN
MODERN DIABETIC TREATMENT.

CHAPTER L

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.

166 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 are 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. 176 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 Add 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 J 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, which 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^ 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 .

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, Ivii, p. 1193.

EXAMINATION OF URIJSfE, 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, which 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
(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 CuS04 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 difl^erence 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 bfe 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.

Quautitative 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 ^ven on
page 173.

, lO.^ApparatuB required (or

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.)

6. 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.

-^ — X 100 = per cent. x » c.c. of undiluted urine.

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.

-V- X 100 = 0.2 per cent.
6

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.

0.01

-— X 100 = 2 per cent.

0.6

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^ 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.''

^ Benedict, S. R.: Loc. cit., p. 168.

174 SELECTED LABORATORY TESTS

Table 32.-

—Pee Cent, of

Sugar by Benedict Method.

Urine, c.c. used.

Sugar, per cent.

Urine, c.c. used.

Sugar, per cent

0.1

10.0

3.6

0.28

0.2

5.0

3.7

0.27

0.3

3.3

3.8

0.26

0.4

2.5

3.9

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

0.23

0.9

1.1

4.4

0.23

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

4.8

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

9.6-10.0

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 stin'ing. 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 pimiice 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
entu-e 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 Detenxmiation of the TTrinary Acids. —
Qualitative Tests.— (1) Diacetic Acid (CH3COCH2COOH).—
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 sodimn 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 (CH3COCH3). — ^The different tests for acetone are
in reality tests for diacetic acid. LegaPs test is as follows:
A few crystals of sodimn nitroprusside are dissolved in 5 c.c.
of lU'ine, which is then rendered alkaline with sodiimi 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
— ^anunonia — 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 177

preference to ammonia. The normal amount of anunonia
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 sodiimi
hydroxide until the first faint pink color is permanent.

(6) Take 5' c.c. of conunercial 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 nimiber 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 tiiat formalin combines
with free NH3 and forms hexamethylenetetramin. The
ammonia is liberated from its salts by means of NaOH.

Nitrogen. — ^The Kjeldahl method is that usually employed
for determining tjie nitrogen, and a modification of it has
served me b^st.^ 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 sodimn chloride is Volhard's quantitative
method.^

^ Joslin: The Treatment of Diabetes Melb'tus, 2d edition, Lea &
Febiger, 1917, p. 198.
« Loc. cit., p. 201.

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.^ Recently I have been much impressed with the
blood-sugar method recommended by Epstein.^ 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.^ 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 with 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

0.26

0.19

0.24

0.10

0.15

0.34

0.20

0.23

0.22

0.23

0.26

0.09

0.12

0.21

0.24

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, Ixiii, p. 1667.
' Purchased from E. Leitz, New York.

EXAMINATION OF UHINE, 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^ and Marriott's method.^ 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 dioxide, 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 nrni. 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 fis

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, 17§
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

Bacon, loss of weight during cook-
ing, 60

Bananas, analyses of, 147
carbohydrate in, 40, 61, 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, 118, 130
for diabetics, 130
Brandy, 78

Bread, analyses of, 153
bran, 122
carbohydrate content, 40, 72,

122
casein, 123

coarse, carbohydrate in, 72
gluten, 123

carbohydrate in, 72
light (French), 123
substitutes for, 121
imdesirability of giving, 72
Broths, calories negligible, 91
gelatin in, 74
nutritive value of, 74
Butter, 61
Maltre d'H6tel, 139
toleration for, 76
Butterine, content for, 76
Buttermilk, 60

182

INDEX

Cabbage, raw, for constipation,

119
Caloric needs of advancing age, 58
by children, 57
in diabetes, 32, 66, 100
at hard work, 67
at Ught 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, 18
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, dennition, 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 ,80
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 in, esti-
mation of, 66
essentials of, 64
fat in, 76
protein in, 73
estimation of, weights and meas-

\xxes employed^ 34, 56
examination of, information ob-
tained by, 45
expensive with untreated dia-
betic, 110
normal, 61, 57
and diabetic compared, 65
fat in, in northern climates, 54

in the tropics, 54
proportion of carbohydrate,

protein and fat, 58
protein in, 63, 68
tables of, 143
Dietetic rules and hints, 101
suggestions, recipes and menus,
121
Diversion, desirable, 49
Doctor, visits to, eflficiency in, 45
Drinking ^lass, capacity of, 35
Dropsy, diabetes and, 79, 108
Druggists, vi, 166
Drugs in treatment of diabetes,
17, 120

Eggs, analysis of, 151
by law weigh, 69

Eggs, thirteen for breakfast, 110
weight of, 36

maximum and minimum, 60
white of, content, 64
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 plani 99
examples of, 87
intermittent, 92
preparation for, 87
rehef to patients, 90
required oecause rules broken, 95
simplest means of freeing urine
of su^ar, 86
Fat, administration of, slow in-
crease in presence of obesity,
97
a concentrated food, 69
danger to diabetic, 77
an expensive food, 69
how much should diabetics eat?

75
in normal diet, 69
tolerance for, determination of,
96
by signs of acidosis, 96
where foimd, examples of, 29, 40,
54
Fehling's test, qualitative, 169
Fermentation test, 170
Fish, analyses of, fresh, 160
preserved and canned, 160
composition of, 73
preserved, composition of, 74
Flour, analyses of, 162
Food, carbohydrate, 29, 40
content of, 24, 53
total calories^ 39
classification of: 29
conservation ot, 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

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

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

Jellt, 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

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

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

com, 77

cottouHseed, 77

cough medicine for diabetics, 76

as lunch for diabetics, 76

peanut, 77

relieves symptoms of h3rperacid
stomach, 77
Oleo, content of, 76
OUves, 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 m normal diet, 58

susar 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

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
Rest, 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

Mattre d'H6tel 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, 116
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
Sundajrs, 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

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
eaten in twenty-four
hours, 67
thrice cooked, 67, 133
washed, analyses of, 69
Voit standard, 59

INDEX

187'

Weight, 106
body, how taken, 46
changes in, during treatment, 108
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

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