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tabolism is afforded by hyperglycemia or ketonuria.

Carbohydrate.— With. Benedict's method,*^ it is now as easy to de-
termine the sugar in blood as formerly the sugar in urine, and really
simpler and more satisfactory to make the analysis than to send the
blood to a laboratory. One hindrance to its use by practitioners has

" Lewis, R. C, and Benedict, S. R., /. Biol. Chem., 1915, xx, 61-72. Benedict,
S. R., ibid., 1918, xxxiv, 203-207. Bock, J. C, and Benedict, S. R., ibid., 1918,
XXXV, 227-230.



GENERAL PLAN OF TREATMENT 141

been the cost of a colorimeter, which has been met by the introduction
of the Bock and Benedict^' instrument. Epstein' s*^ modification of
the Benedict method, though not quite so accurate, is the sim-
plest and cheapest of all and requires only a few drops of blood, ob-
tainable from the ear or finger. A large number of physicians whose
tests must be made in their own offices and who would never under-
take a more elaborate method, will undoubtedly make use of this
device, and will have no excuse for being without blood sugar analyses.
Knowledge spreads rapidly among diabetic patients, and instead of
objecting to the drawing of blood many of them doubtless will soon
be demanding it.

If the blood sugar is kept normal, urine tests are almost superfluous.
The patient has the agreeable knowledge that glycosuria is always
absent, and his tests merely guard against errors in diet or any un-
foreseen change. The blood sugar is one of the most delicate indi-
cators not only of the carbohydrate but of the total metabolism.
Even though glycosuria be absent, a dangerous lack of control of the
diabetes is indicated in those instances where the blood sugar actu-
ally rises after one or several days of fasting. It is sometimes but not
necessarily associated with a correspondingly unfavorable change in
the acidosis. The h3^erglycemia after carbohydrate ingestion rises
and falls relatively quickly. There is a more gradual rise and fall
after protein. The absence of hyperglycemia after feeding pure fat,
and the slowness of the rise of blood sugar on adding fat to a diet,
are in accord with the accepted belief that fat is not converted directly
into sugar; but the h3^erglycemia is particulatly lasting and stubborn.
The limit of fat in a maintenance diet is reached when hj^erglycemia
results from its further addition to the ration of protein and carbo-
hydrate which has been fixed as necessary. The ideal is that the
blood sugar shall not be above 0.1 per cent fasting or above 0.15 per
cent during digestion.^

*^ Epstein, A. A., /. Am. Med. Assn., 1914, Ixiii, 1667-1668. Instrament with
instructions obtainable from Ernst Leitz, 30 East 18 Street, New York City.

■*'As this monograph goes to press, the first of a sferies of papers from the
laboratory of S. R. Benedict, who has already contributed so preeminently in the
field, are appearing in The Journal of Biological Chemistry, 1918, xxxiv, 195-262.
The application of a newly perfected method, which determines quantitatively



142 CHAPTER n

Fat. — The two direct evidences of disordered fat metabolism are
acidosis and lipemia, which will be considered separately.

Acidosis. — Quantitative tests are necessary precautions when
acidosis exists; but as far as now known, there is no danger from
diabetic acidosis if the nitroprusside test is negative in both urine
and blood plasma." It has proved possible to keep the reaction con-
sistently negative in some of the severest cases of diabetes. A ques-
tion is possible whether strictness to this degree is necessary: whether

the sugar even in normal urine, gives promise of results of the highest importance
in the study of sugar tolerance and carbohydrate metabolism. The prediction
may be ventured that such a refined method will reveal a pathological excretion
of urinary sugar by diabetics with the familiar marked hyperglycemia. In-
vestigation will have to show whether the urine becomes normal for sugar when
the above requirements of normal blood sugar are fulfilled. It is to be empha-
sized that the essential progress and improvement of clinical results must lie in
this direction of finer methods, earlier diagnosis, and stricter control of incipient
abnormalities. Only by such means can the principle of treatment by sparing
a weakened function be carried out successfully.

** Legal (Z. and. Chem., 1883, xxii, 464) first observed that the nitroprusside
reaction (originated by Weyl as a creatinine test) might serve as a test for acetone
and acetoacetic acid. V. Arnold {Centr. inn. Med., 1900, xxi, 417), by fine
quahtative tests showed that acetone is excreted only in the severest grades of
acidosis, while the substance present in ordinary so called acetonuria is aceto-
acetic acid. Embden and Schliep {Centr. ges. Physiol, u. Path. Stqffwecks.,
1907, ii, 289) found quantitatively no preformed acetone in the fresh urine in
some cases of ketonuria, and in other cases it ranged about 1/10 to 1/4 of the total
acetone bodies. Folin and Denis (/. Biol. Chem., 1914, xviii, 267) stated that
"acetone urines contain from two or three to nine or ten times as much aceto-
acetic acid as acetone." Rothera (/. Physiol., 1908, xxxvii, 491) regarded his
improvement of the nitroprusside test as a test for acetone; but W. H. Hurtley
{Lancet, 1913 (1), 1160) proved that with pure materials the Rothera reaction is
sensitive to acetoacetic acid in 1 to 400,000 dilution, but to acetone only in 1 to
20,000 solution. Kennaway {Guy's Hasp. Rep., 1913, Ixvii, 161) confirmed the
fact that the Rothera test is essentially an acetoacetic test which is at least 25
times as deUcate as the Gerhardt ferric chloride reaction; and he suggested that
the greater opportunity and ease of diffusion through the lungs as compared
with the kidneys is the reason why most of the preformed acetone leaves the
body through the former. There is no simple qualitative test for /3-oxybutyric
acid. To some extent the intensity of the acetoacetic reactions serves as a rough
index of the quantity of both acids present, but there are wide departures from
this rule in both directions.



GENERAL PLAN OF TREATMENT 143

normal persons with identical nutrition would not show slight keto-
nuria, and whether it may not be harmless. There is an opposite
speculation whether a diet or metabolic state productive of keto-
nuria is not more or less harmful even to normal persons, and whether
a diabetic may not be more susceptible to injury. The presence of
|3-oxybutyric acid out of proportion to the small acetone-acetoacetic
"fraction seems to characterize some of the long standing severe cases.
Any considerable ketonuria in severe cases is associated sooner or later
-with hyperglycemia. When the blood sugar is low, faint nitroprusside
reactions have been allowed to exist in some patients, without empiric
evidence of harm. While ketonuria is most closely associated with the
fat ration, it can result directly or indirectly from unwise addition of
•any kind of food to the diet. When acidosis in the strictest clinical
•definition is kept absent as described, the plasma bicarbonate is regu-
larly high, generally above rather than below 65 per cent.

Lipemia. — ^The investigation of this subject is apparently of rapidly
;growing importance. It has long been known that some cases of dia-
betes are characterized by lipemia far in excess of anything found in
any other condition. Some of the facts recently established^ are
that the blood fat may be several times the normal without notice-
able turbidity; that the lipoid relations, especially the high cholesterol,
-are in contrast to normal alimentary Hpemia; that in severe diabetes
the hyperlipemia is apparently as constant and characteristic as the
Tiyperglycemia, and that it is largely associated with the fat intake
and with other active diabetic sjonptoms. At present, the findings
•seem to support the conception of diabetes as a disorder of the
total metabolism, and to furnish further evidence against the mis-
leading practice of labelling phloridzin, adrenalin, or other forms of
-sugar excretion as "diabetes." The question immediately arises
whether excess of fat in the blood is not as truly indicative of over-
^strain and injury as excess of sugar. It is also essential to know
whether the rigid program above outUned brings the lipoids as well as
other blood constituents to normal. The work of Gray^^ shows actu-
.ally low levels of blood fat in some severe cases under strict treat-
ment. Many analyses are also under way in this hospital. It is

"Allen, Am. J. Med. Sc, 1917, cb'ii, 313-371. Gray, Boston Med. and Surg.
J., 1918, clxxviii (references to Bloor and Joslin).



144 CHAPTER II

not yet certain whether fat determinations are necessary for guid-
ing treatment at this stage. The blood sugar and nitroprusside tests
may perhaps suffice.

It should be emphasized that comparison and clinical judgment are
necessary in interpreting the significance of all laboratory tests. It is
wholly erroneous to consider that hyperglycemia, ketonuria, or any
other laboratory finding is in itself proof of a breaking strain upon
metabolism, or that absence of such indications gives assurance that
all is well. As in dogs, so in patients, hyperglycemia may gradually
subside on right diet or may gradually develop on wrong diet. The
same is true of ketonuria, and doubtless also of lipemia. Some pa-
tients in this series have been discharged with marked hyperglycemia
and ferric chloride reactions present. These persisted for months,
but yet the policy was safe, because it was recognized clinically that
the cases were essentially mild diabetes, and that these symptoms
would gradually clear up, without requiring that an elderly or weak
person be subjected to more serious privations. Such liberties with
a severe case, even though tlie remaining symptoms be slight, are
risky; and they are disastrous with any case unless the diet is within
the actual tolerance. It is highly important not to treat an incipient
case of potentially great severity as if it were a genuinely mild case.
Also, in some severe cases in this series, the blood sugar was sometimes
brought to normal by withdrawal of carbohydrate, with a diet too
high in fat and calories. More or less ketonuria was present, and
doubtless the blood fat was high. Notwithstanding absence of hyper-
glycemia for weeks or months on carbohydrate-poor diet, such a case
can be expected to go steadily downhill. The character of the case,
comparisons of different tests, and the direction of progress are there-
fore important guides in treatment and prognosis. Too much em-
phasis upon any single test may be as misleading as the lack of tests;
and though laboratory work should never be slighted, the experienced
man with very simple means will administer far better and safer
treatment than the tyro with a great laboratory at his disposal.
The ideal treatment therefore begins with rather extensive laboratory
study, but in the end comes down to a very few simple tests.

While discussing ideals, the fact should be plainly faced that the
program above suggested is for very severe cases an excessively rig-



GENERAL PLAN OF TREATMENT 145

orous one. The patients of this extreme type are weakened by it;
sometimes they must be temporarily kept in bed; and their physical
and psychic depression becomes greatest at about the time the blood
sugar becomes normal. No disaster has occurred under the method,
and none of these patients has refused it. Strength returns when a
maintenance diet is resimied; sometimes it seems as great as before,
but more often the fall in both flesh and strength is noticeable. In
view of the questionable prognosis in such extreme cases at best,
the conservative physician will ask himself whether it is advisable to
impose such privation, especially as inanition and the dangers of
chance infections are obviously brought closer. In a few cases, mod-
erate hyperglycemia and shght nitroprusside reactions without other
symptoms have been permitted in the interests of strength and
efficiency. Similar ideals have suggested themselves to a number of
the best workers in this subject, on account of their similar mishaps
with the less careful methods. As far as known, however, both the
plan and execution of the above program are new. It has been appHed
because the patients wished to live, and because it was certain that
they would die soon unless saved by radical measures. Their sub-
jective comfort after the rigid treatment has been about the same as
before. The downward progress formerly evident has in every in-
stance been either arrested or delayed — the few months of experience
do not permit answering which. It is not certain whether such a
method is to be generally recommended in practice, and in any event
there is no desire to urge it upon either physicians or patients. It is
fairly certain that the rigid plan will prolong life and also maintain
a fixed level of nutrition, if not indefinitely, at least considerably
longer than laxer methods. If hyperglycemia, ketonuria, and other
symptoms are allowed to persist, a definitely gloomy prognosis must
be accepted, and the choice is essentially either death in coma or pro-
gressively more severe undernutrition, which becomes more extreme
than required under the rigid plan and increases to death in starva-
tion. The above quaUfications apply, however, only to these cachetic
patients with excessively severe diabetes. The greatest importance
of the plan lies in its application to earlier cases, and for these it is
strongly and unreservedly recommended. In the early stage it is
shorter and easier to carry out, involves no extreme privation or



146 CHAPTER II

physical deterioration, and fulfills the purpose of relieving metabolic
strain as far as present analytic methods can determine. It has
thus far demonstrably prevented downward progress in several cases
of the type which ordinarily progress downward, and it offers at least
a chance of continued subjective health, whereas looser methods prom^
ise nothing but death.

When the blood sugar is normal, glycosuria from trivial carbohy-
drate ingestion does not occur. Accurate reckoning of the diet is
just as essential; but yet if glycosuria results from slight fluctua-
tions in the carbohydrate content of vegetables, or from adding a few
hundred grams of thrice cooked vegetables, the patient is certainly
too close to the verge of his tolerance and trouble will follow unless
the condition is improved. There are the following reasons for giv-
ing carbohydrate as prominent a place in the diet as feasible. First,
it gives the quickest and most harmless danger signal. Second, at
least a small quantity is necessary to fulfill the ideal of freedom from
ketonuria. Third, it spares protein more effectively than fat, and
incidentally spares the total metabolism somewhat; and as shown by
Zeller,*^ if the carbohydrate of the ration is equivalent to one-tenth
of the fat calories, the sparing is as effective as though all the fat were
replaced by carbohydrate. Fourth, by permitting a supply of fresh
green vegetables, it makes a diet more agreeable and satisf3dng than a
higher carbohydrate-free ration. Fifth, on general principles and for
reasons partly unknown, a mixed diet is the only natural diet, and
no diabetic will ever live long on any other. Caution is needed
against the mistake conamitted by some, in giving so much carbo-
hydrate that a living ration of protein and fat is made impossible.
But as stated, the rule in this hospital recently has been to reduce
the total diet sufficiently to enable any patient to assimilate at least
5 gm. of carbohydrate, and correspondingly more in the less extreme
cases.

Various methods of treatment have been tried in the present
series. At one extreme there has been reversion to the old practice
of carbohydrate-poor diets of 40 calories per kilogram or more.
At the other extreme are a few cases treated according to the rigid

^"ZeUer, H., Arch. Physiol., 1914, 213-236.



GENERAL PLAN OF TREATMENT 147

program last outlined. The results shown are therefore not those of
any one method. The results of different methods should be compared
and the choice of treatment governed accordingly. The experience
is believed to support the original principle that treatment should
aim to spare a weakened total metabolism, and that in proportion as
carbohydrate must be restricted, the total diet should also be kept
low.



VI. Practical Management of Diets.
A. Organization.

Many physicians and hospitals have found it possible to conduct
diabetic treatment more or less successfully under adverse conditions.
Foods may by special arrangements be served from the general kit-
chen if necessary. Though some patients in the present series, es-
pecially in observations requiring accuracy, have been isolated in
individual rooms, others have been in open wards with patients suf-
fering from other diseases. Their own fidelity, and the knowledge
that glycosuria and fasting would follow an indiscretion, have main-
tained a high general average of good conduct.

The ideal arrangement, and the one which is being rapidly adopted
by the best hospitals, is to organize a special diabetic or metabolic
ward, with a separate diet kitchen in as convenient proximity to it
as possible. The kitchen organization here, and the cooperation of
Miss Emmeline Cleeland, the diet nurse, have contributed much to
the success of the work.

The head of the kitchen may be either a specially quahfied nurse
or a trained dietetian who is not a nurse. Her time is best left
free for duties of supervision. The physician has merely to order a
diet in terms of protein, carbohydrate, and calories. The nurse then
translates these figures into the actual foodstuffs, superintends the
cooking, and is responsible for the accurate recording of everything
pertaining to the diet. She maintains a sympathetic acquaintance
with all patients, takes care that the selection and preparation of food
suits their tastes as well as possible, and by smoothing small diffi-
culties contributes greatly to lighten the lot of the patient and the
labor of the physician. Under some circumstances it may be con-
venient for one nurse to have charge of both the kitchen and the
ward, and to supervise also the qualitative testing and recording of
the urine.

The assistant diet nurses vary in number with the number of
patients and the degree of detail required. Labor is saved at the

148



GENERAL PLAN OF TREATMENT 149

expense of some slight inaccuracy by weighing certain foods after
cooking, by estimating certain other foods, etc. Servants at lower
wages can save both the nurses' time and some of the more dis-
agreeable features of the work. In this hospital every kind of food
has been weighed accurately raw, and cooked separately for each
patient. With this arrangement, one assistant nurse for about eight
patients has been needed. If the service is rotating, an assistant
nurse should if possible spend at least three months in the kitchen con-
tinuously; otherwise both time and accuracy are sacrificed in teaching
new nurses. At the end of the three months she should be familiar
not only with the cooking but also with the duties of the head nurse.

B. Equipment.

The equipment is mostly that of an ordinary kitchen. A few
special articles have been found useful, as follows:

Diet scales. — An accurate spring balance has been used for weighing
the individual food portions. In construction it is similar to the or-
dinary letter scales. This model is manufactured* by Chatillon and
Company, 85 Cliff Street, New York. The price, formerly $5.00, is
now $7.50. Each patient buys such a balance preparatory to return-
ing home. The dial is movable, so that it can be set at zero after
the dish for receiving food is placed on the weighing stage. The
weight of the food can then be read directly in grams. The quickness
and convenience of such an instrument is important for prolonged
fidelity in weighing food, for few patients will trouble themselves
through months and years with the tediousness of ordinary scales
and weights.

Steamer. — A well known form of steam cooker has been used for
cookirig vegetables without loss of carbohydrate. The reservoir at
the bottom contains water; the compartments above hold the vege-
tables. As the steamer is constructed on the unit system, few or
many of the compartments may be used at any time as needed. By
this means a number of different vegetables can be steamed simul-
taneously, and the more easily cooked ones can be removed before
the others.

Slide Rule. — Nurses who are to calculate many diets can save time



150 CHAPTER n

and trouble in multiplication by learning to use a simple slide rule.
A convenient one is the "Merchant's," obtainable from the Keuffel
and Esser Company, 127 Fulton Street, New York City.

Adding Machine. — ^Additions have been performed with the Golden
Gem Adding Machine, manufactured by the Automatic Adding
Machine Company, 148 Duane Street, New York City. A small and
inexpensive instrument of this sort aids not only in time-saving but
also in accuracy.

Records. — ^A twofold record of diets has been kept. A more de-
tailed separate diet chart shows each individual food item for each
meal, together with the totals, as illustrated in the specimen diets
hereafter. A statement of the totals for the day is also entered in
the laboratory chart, in order that the relation between diet and
laboratory findings may be evident at a glance.

One general form of laboratory chart has been used since the early
organization of the work, with slight modifications as needed from
time to time (Table III). It measures 30 by 90 cm., and folds so as
to conform to the clinical charts. In the table two figures are given
for carbohydrate, protein, and fat for each day. The upper figure (in
bold face type) denotes calories, the lower figure (in ordinary type)
grams. For convenience in entering on the chart, the two figures
are written in the form of a fraction; the figure above the line
(calories) is written in red ink, that below the line (grams) is
written in black ink. Formerly there was a column for alcohol,
but this has been dropped, and if alcohol is given on any rare occasion,
it is written into the total calory column. There also was formerly a
column for sodium bicarbonate, but as this is so seldom used, the
column has been discontinued and any occasional doses of alkali en-
tered in the "Remarks" colimin. Among foods, three colimms are
found under "Bacon," the abbreviations indicating the three forms
in which it is served; first whole bacon; second crisp bacon, fried so
as to reduce the fat content as low as possible; third the clear bacon
fat, practically free from protein. These three forms serve different
purposes, and yet the advantage of the bacon flavor is retained. The
two columns under vegetables show the total weight respectively of
carbohydrate-containing or thrice cooked kinds. The various "Re-
marks" columns give room for additional analyses or special notes,
explanations, time of day, etc.



GENERAL PLAN OF TREATMENT 151

C. Notes on Special Features of the Maintenance Diet.

1. Fast-Days. — Occasional single days of fasting or greatly reduced
diet have been prescribed in the after-treatment of all cases. They
are taken at regular fixed periods, the length of the interval and the
rigor of the program being proportioned to the severity of the diabetes.
In the typical severe cases, a fast-day is taken once each week, the
patients generally choosing Sunday for the purpose. In even the
mildest cases, such a day is ordered at least once a month, more
commonly once every 2 weeks. Individuals react differently. Some
go about their usual affairs; others are comfortable in bed; others
become weak and depressed. When discomfort persists even after
habituation, and in any mild case when desirable, the ordeal is miti-
gated if possible. The addition of a few hundred grams of thrice
cooked vegetables to the bran, soup, and coffee of an ordinary fast-
day may give relief. Especially in milder cases, vegetable days are
useful; not the old fashioned kind with fat and other additions, but
only vegetables containing such carbohydrate as will not raise the
blood sugar above 0.15 per cent and will leave it not above 0.1 per
cent on the following morning. Protein and other foods necessarily
diminish the benefit of a fast-day in proportion as they are allowed.



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