Elliott Proctor Joslin.

A diabetic manual for the mutual use of doctor and patient online

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days to free 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. Permission has been obtained
to publish this letter, received ele\'en months after leaving

the hospital.

March 8, 1917.

"I have reall\' been wonderfully well, feel splendid and
everyone remarks how well I am looking. Tests have shown
a slight trace of sugar on tjiree 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
days 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 and 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 new^spaper 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 .

"I keep very well, as you may surmise from the above,
sugar-free all the time. 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.

Explanation of the General Peinciples Underlying
THE Treatment of Moderately Severe and Severe
Cases of Diabetes. — It has been shown that there are many
means by which the urine of a diabetic patient may be freed
from sugar, but 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 both methods are combined, for it frequently
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:

Preparation for Fasting. — In severe, long-standing,
complicated, obese and elderly cases, as icell as in all cases
with acidosis, or in any case if desired, icithout otherwise
changing habits or diet, omit fat, after two days decrease protein
and halve the carbohydrate daily until the patient is taking SO
grams or less; 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 could follow the same plan
by himself.

Table 29 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.

It will be observed that diacetic acid appeared October
26 and 27. In 1915 the necessity of completely omitting fat
prior to fasting was not appreciated. With present methods



of treatment this appearance of diacetic acid would not occur,
because during the last two years measures taken for the
safety of the patient at the beginning of treatment have
increased enormously.

Table 29.— Case No. 938. Aged Two Years, Four Months.
Onset September, 1915.




Diacetic acid.

Sugar, per cent.

October 25
October 25-26
October 26-27




Diet unrestricted.

Diet moderately restricted.


Case No. 979, a woman, aged forty-nine years, developed
diabetes at the age of thirty-two. When she was first seen
seventeen years later, January 26, 1916, she showed 7.4
per cent, of sugar and no diacetic acid. It is apparent from
Table 30 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-

Table 30. — Case No. 979, of 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.


Diet in grams.

Dietary prescriptions in grams.






Date, 1916.



- c






































Jan. 25



















1 90













1 90






16 584




2.0 90








111 411




1.0 30

601 6








300 ! 1

0.0 30

60 6

Feb. 31- 1









20 6 40

1- 2










40 6 , 20


' ^ 1

Feb. 16




Fastiiifi. — Fasting is never so rigorous as doctors or j^atients
ex})eet. 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 Avould be expected, and is usually
dispelled by a cup of coft'ee. Nausea almost never occurs
unless a patient is given alkali or alcohol. Children bear
fasting more easily than adults. Case No. 899, with onset
at eighty-three, shunned it and rightly, but she became
sugar-free, and two years later was \'igorous, remained
sugar-free and actually able to eat apple ])ie and ])ut 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 b\' the help of preparatory treat-
ment. Fasting does not seem like fasting to the patients
when they recei\'e coffee, tea, cracked cocoa, cocoa shells
and broths and are given an unlimited supply of water.
Warm drinks are preferable. If the quantity of urine, as it
often does, falls to less than normal the patients are urged
to drink water freely. Clear meat broths are a great satis-
faction. An analysis of the 1220 c.c. of broths taken by
Case No. 765 diu-ing 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 equilibriimi of body fluid.

Patients need not be kept in bed 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. Kemember
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 handi-
work, 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 they are usually
desirous to increase the amount of exercise. An a<lvantage
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 brink of coma fell into it. In every way
seek to prevent worry on the patients' part, and from the
start give them to understand that they are at a school
rather than at a 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. These are
cases with high percentages of sugar or fat in the blood and
cases of long duration who have been upon a diet with low
carbohydrate and excessive quantities of fat. Cases present-
ing acidosis 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, though the latter may do very well if they are
free from acid poisoning. 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.
During the preceding twenty-six months he had gained
twenty-six pounds. Children showing large amoimts of
sugar have also become sugar-free very prompth- when the
duration has been only a few weeks. Cases of long standing


appear to become sugar-free more quickly \\\t\\ preparatory
treatiiient than with an iimnediate 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 it is usually
preferable, after four days of fasting, if the lu-ine still contains
sugar to feed the patient for two days and then fast again.
The general rule which serves as a guide follows:

Intermittent P'asting. — 7/ 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
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 iceek.

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. One rule is:
When the twenty-four hour urine is free from sugar, give 5 to
10 grams carbohydrate {150 to 300 grams of 5 per cent, vege-
tables) and continue to add 5 to 10 grams carbohydrate daily
up) to 50 grams or more until sugar appears, then fast until sugar-
free. The carbohydrate is generally given in the form of 5 per
cent, vegetables, choosing those which are especially bulky. A
plateful of lettuce appeals much more to the patient than a
small saucer of string beans. When a mixture of 5 per cent,
vegetables is given, one can be quite sure that the average
content of carbohydrate is not mpre 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 oimce). 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, ^'a^3dng w'ith the severity of the case, are
added daily mitil 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 empiri-
cally 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
in determining the tolerance for carbohydrate are : 5 per
cent, vegetables, oranges, oatmeal, Shredded Wheat, milk or
skimmed milk and potato. With children one often makes
the mistake of increasing the carbohydrate too rapidly, for-
getting the fact that 5 grams of carbohydrate to a child weigh-
ing 20 kilograms is in the same proportion as 15 grams of
carbohydrate to an individual of 60 kilograms.

The increase in carbohydrate is also illustrated by Case
No. 1209, Table 31, page 101, whose chart 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 although 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. Later he broke rules again and fastmg was
necessary. Gradually he learned his lesson, at least tem-
porarily, and left the hospital with a tolerance for 37 grams
of carbohydrate and more calories than now would seem wise.

Protein Tolerance.— PFAe?i the urine is again sugar-free
decrease the carbohydrate hy two-thirds below the carbohydrate
tolerance, or at least 10 grams, and then add about 20 grams
-protein and thereafter 15 grams -protein daily in the form of
egg-white, fish or lean meat {chicken) until the patient is receiv-
ing from 1 gram protein to 1.5 grams protein per kilogram body

Thirty grams of fish or an eg^ of average size contain


apjiroxunately gr;uiis of protein and '.]0 i^rams of lean meat
contain approximately S grams. Tlie white of an egg con-
tains 3 grams of protein. By this arrangement a patient
weighing 00 kilograms wonld be taking, within fonr days from
the tijne he became sugar-free, 1 gram of ]:)rotein per kilo-
gram body weight. This quantity is ciuite 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, howe^■er, crave and
need considerably more, and indeed take with a\'idity as
much as 2 to 3 grams })rotein per kilogram body weight.

Fish is especially desirable in the early da\s of ])rotein
feeding because it contains so little fat. Cod, haddock, pike,
skate, pollock, flounder and bass, for example, contain less
than 1 i)cr cent. Blue-fish contains 1.2 per cent., smelts 1.8,
trout 2.1 and white fish and perch each 15 per cent.

The ad^■antage of gi^'ing 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 a
higher carbohydrate tolerance can be attained when the addi-
tion of protein following the preHminary fasting is deferred
until the actual carbohydrate tolerance is learned in the
absence of protein and fat. Naturally the method adopted
will vary somewhat with each patient. With patients who
exhibit acidosis it is often preferable to defer the addition
of protein imtil after the carbohydrate tolerance alone has
been determined. The carbohydrate dispels the acidosis.

There are very few patients who will not bear at the outset
as much as 1 gram of protein per kilogram body weight. It
is unfortunate to allow the protein to remain permanently
below this figm-e. This can be avoided by still further
restricting the carbohydrate, either temporarily or per-
manenth'. 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. ]\Iore and
more^^an effort should be made to spare body protein,






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Fat Tolerance. — The studies of Professor Bloor and
Dr. Gray in Boston and that of workers at \arioiis other
hiboratories has provided us with a rehable indicator for
the tolerance of the j^atient for fat by means of the esti-
mation of fat in the blood. As yet the test is too compli-
cated for general use, but for those who have access to a
laboratory it is perfectly practical. For those not in a
position to employ Bloor's fat method there are indirect
methods of determinhig fat tolerance, namely, signs of
acidosis and the appearance of sugar in the urine (glyco-
suria) or an increase of sugar in the blood. 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 this appeared 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
patient inmiediately upon his becoming sugar-free: (1) by the
omission of fat, partial fasting is continued and thereby
the patient is gainmg 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 and the blood sugar has reached normal 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 recm-rence of a posi-
tive ferric chloride reaction in the urine. Cases which have
shown little acidosis may easily be allowed an increase of
15 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. Natiu*ally, patients in whose treat-
ment a loss of weight is desired would be given smaller
quantities of fat.
A working rule is as follows:

Fat Tolerance. — It is usually desirable, especially in the
young, to add no fat until the jnotein reaches 1 fjram to 1.5
grams protein per kilogram body weight and the blood sugar is
normal. Then add 5 to 25 grams daily, according to previous
acidosis, until the patient ceases to lose weight or receives in the
total diet 20 to 30 calories per kilogram body loeight.

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

In hospitals the above rule simplifies the treatment enor-
mously. 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
to see the disadvantage of paying 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 every endeavor to regain the former tolerance for
carbohydrate by slowly increasing the quantity of fat.

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Online LibraryElliott Proctor JoslinA diabetic manual for the mutual use of doctor and patient → online text (page 7 of 14)