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Von Noorden's designation of fast-days as "metabolic Sundays" is
suggestive. There is no evidence whether the same number of calories
weekly will be borne any differently if distributed over 7 or 6 days.
But as the body in other respects seems to function more efficiently
by working 6 days and resting 1, it is possible that a similar prin-
ciple may apply to metabolism; also, the patient may perhaps feel
and work better if he takes the larger ration on 6 days and relaxes
as completely as necessary on the 7th. The occasional relief from the
metabolic burden may also be beneficial in even the mildest cases, in
guarding against downward progress and in atoning for any chance
indiscretions. Such days of special restriction are also a strong re-
minder of the existence of diabetes and the need of continuous precau-
tion, so that they aid instead of hindering discipline. Regular fast-
days are intended for prevention of symptoms. When fasting is
compelled by the actual occurrence of glycosuria or hyperglycemia,
the diet is wrong and must be changed. ,



152 CHAPTER n

2. Water. — There is no objection to mineral waters, but they are
without special virtues and are unnecessary when good plain drink-
ing water is available. Mineral springs and resorts should be rated
solely according to the efficiency of their dietetic treatment, and in as
far as curative influence is attributed to the water they constitute an
unfavorable environment.

3. Alcoholic Beverages. — As stated, all alcohol habits are best dis-
couraged, and as the calories of alcohol must strictly be counted in a
limited diet, the patient will generally prefer more wholesome food.
Light wines, as low as possible in both carbohydrate and calories, are
probably best for those with whom alcoholic beverages are a habit
too firmly fixed to be broken.

4. Coffee or Tea.— The use of weak tea or coffee, or Kaffee Hag, not
more than three cups daily, has already been mentioned as permis-
sible with fasting or any diet, except that a coffee habit has not been
cultivated in persons not addicted to it. Joslin often substitutes a
drink made of cocoa hulls.

5. Milk. — Sugar-free milk of satisfactory taste is prepared by
D. Whiting and Sons, 570 Rutherford Avenue, Boston, Mass., and its
keeping qualities are such that it can be shipped long distances.
Little use has been made either of it or of home-made preparations of
casein and washed cream (i.e. cream mixed with large volumes of
water to remove lactose, and skimmed off after rising or centrifuga-
tion). Milk is important for children, but it is considered the best
policy to regulate their total diet so as to create sufficient carbohy-
drate tolerance to enable them to take natural milk. Sugar-free
milk would thus be needed only temporarily, or as part of the diet of
diabetic infants.

6. Soup. — Thin soup made from bones or stock contains very little
nutrition, but its warmth and flavor are highly gratifying, and it also
supplies salts, and aids in serving bran biscuits, thrice cooked vege-
tables, and other articles having httle taste. It has been allowed in
quantities of 300 to 600 cc. daily, during fasting, carbohydrate tests,
and all other diets. Sometimes beef tea, made from beef extract,
has been used as a means of avoiding even the small quantities of
protein of ordinary soup.



GENERAL PLAN OF TEEATAIENT 153

7 . Salt. — Probably because of the rather monotonous and unsatis-
ifying diet,' patients with severe diabetes often crave surprising quan-
tities of salt. Many of them develop edema on unrestricted salt
intake. The susceptibility of individuals differs. Though no real
harm has been seen from the edema, salt-free diet has sometimes
temporarily been necessary to remove it, and for all severe cases
sodium chloride is given in a weighed daily allowance like other
items in the diet. The limit has commonly been 5 gm. daily; some-
times only 3 gm., occasionally as much as 8 gm. Numerous glass
tubes containing such weighed quantities of salt are kept on hand
in the diet kitchen. The nurse uses a part of the day's allowance for
seasoning, and the rest is placed in a small salt shaker on the pa-
tient's tray, to be used at his discretion with one day's meals. The
craving is generally not noticed when limitation of the supply pre-
vents forming the abnormal habit.

8. Meats. — Meats are included in the diet according to their food
value and the tastes and digestion of the patient. Eggs and vegetable
proteins are available on the same basis. No indications of specific
differences between proteins and no advantages in vegetarianism have
been observed. For a low protein vegetarian diet, it would be neces-
sary to use care in selecting the kinds of protein, to assure an adequate
supply of all indispensable amino-acids.

P. Fats. — These are chosen on a similar basis of suitability; There
is no need to pay attention to the content of higher or lower fatty
acids from the standpoint of ketonuria. If anything, butter is pref-
erable to olive oil.

10. Raw and Steamed Vegetables. — Since carbohydrate is desirable
in the diet, it is obviously preferable to use vegetables without ex-
traction when possible. Even ordinary boihng is a partial extraction.
Therefore, for accurately retaining the food value, vegetables have
been served either raw or steamed in the steamer above described.
Additional mention may be made of canned vegetables, which are
used either in this way or after thrice cooking if necessary. Canned
or dried vegetables are important aids to the winter diet.
Patients sometimes prepare their own supply in summer. The ad-
vantage of giving carbohydrate in the pleasant, varied, bulky, and
satisfying form of vegetables, rather than in smaller quantities of



154 CHAPTER II

bread or cereals, is obvious. With green vegetables, eggs, butter,
etc., there should be no fear of a lack of vitamines or other accessory
substances in the diabetic diet.

11. Thrice Cooked Vegetables. — ^Whatever time a vegetable requires
to cook is divided into three approximately equal periods, and the
boiling water changed so as to make three extractions of carbohy-
drate. Each patient's portion is made ready for cooking as usual,
weighed raw, and tied loosely in a single layer of cheese-cloth, and
the portions for different patients thus boiled together in one large
pot. The thrice cooked vegetables have been used to contribute
bulk with negligible food value. They are so important for this
purpose that the treatment would in some cases be almost impossible
without them, and they -add much comfort in other cases not quite
so severe. The different kinds of vegetables vary in the degree to
which they retain their flavor, but most are palatable and some are
practically as appetizing as with ordinary cooking.

Their empirical use without analyses has entailed some uncertainty
and inaccuracy in the present series. Such analyses before and after
boiling or extraction have been made by Wardall.*' There is always
a question in interpreting such figures. The cellulose of which
vegetables are largely composed is a carbohydrate, but indigestible.
On the other hand, if starch and soluble carbohydrates are alone
considered, there is a question whether other substances present may
not become potential sugar-formers upon digestion. Furthermore it
is possible that more or less starch inclosed within cellulose may not
be utilizable. Phloridzinized animals could scarcely furnish fully
conclusive results. Accordingly an empirical element remains, and
numerous patients in the present series have had sufficiently severe
diabetes that extracted vegetables could not be taken without limit.
The empirical observations have closely agreed with Wardall's chemi-
cal proof that spinach, celery, and asparagus are the safest for this
purpose. Cabbage, cauliflower, Brussels sprouts, and onions retain
enough carbohydrate to cause glycosuria much more readily than the
three first named. If only 1 per cent absorbable carbohydrate
should remain, and if a kilogram of the vegetables should be given in a

" WardaU, R. A., J. Am. Med. Assn.. 1917. box, 1859-1862. See also Joslin's
text, 2nd edition, p. 261.



GENERAL PLAN OF TREATMENT 155

day, it is clear that such carbohydrate content is important for a
patient whose actual tolerance may be 5 gm. or less. As previously
mentioned, this state of excessively low tolerance ought not to be
allowed to persist; but nevertheless carbohydrate should always be
reckoned as accurately as possible. There is no reason why patients
whose tolerance is a little greater should not, at least for occasional
variety, receive higher class vegetables which have been extracted
to reduce their carbohydrate content; but analyses such as those of
Wardall will be necessary before they can be used with accuracy.
What can be done with fruits in this direction will also bear further
investigation.

Besides a little carbohydrate, thrice cooked vegetables convey more
or less salts, and may have some real importance in this respect.
Blunt and Otis*' found that spinach loses 50 per cent, string beans
43 per cent, navy beans 39 per cent, peas 36 per cent, and potatoes
22 per cent, respectively, of their iron in cooking. Salts of potassium
and heavy metals are also furnished in utilizable form by such vege-
tables. Courtney, Fales, and Bartlett*' investigated the salt content
of vegetables boiled so thoroughly as to be comparable to the thrice
cooked kind. Tables IV and V are reproductions of two of their
tables.

This large loss of salts occurred in the first few minutes of boiling;
for example, spinach boiled only 10 minutes had already lost 42.2
per cent of its ash; the very prolonged further boiling had relatively
little effect. These authors confirm the well known marked predomi-
nance of bases over mineral acids in vegetables, and the assimilable
character of these bases, which are probably in combination with or-
ganic acids. It is possible that the very high plasma bicarbonate
(above rather than below 65 per cent) so often, found in severe cases
under rigid treatment may be attributable to the vegetable diet.
With the customary liberal use of vegetables, diabetics should certainly
suffer no lack as respects quantity, variety, or assimilability of the
supply of mineral bases.

** Blunt, K., and Otis, F. A., J. Home Economics, 1917, ix, 213-218; Chem.
Abstr., 1917, xi, 2124.

*' Courtney, A. M., Fales, H. L., and Bartlett, F. H., Am. J. Dis. Child..
1917, xiv. 34-39.



156



CHAPTER n



For practical purposes, thrice cooked vegetables (generally spinach,
celery, and asparagus) have been used in limited quantities without
any food value being reckoned for them. The protein of green vege-



TABLE IV.
Content in Gm. of Solids of 100 Gm. of Vegetables Erepared by Boiling.



Vegetable.






Spinach. .
New-
Zealand
spinach.
Young. . .
carrots
Onions.. .
String

beans. .
Aspara-
gus. . . .
Potatoes.



90



30

30

45

ISO

30
30



Solids.



.30



4.26

6.31
6.82

5.31

4.59
20.51



Ash.



1.172

0.535

0.408
0.398

0.371

0.370



CaO



0.305

0.145

0.039
0.020

0.070

0.038



MgO



0.035

0.021

0.014
0.013

0.030

0.021



PjOb



0.123

0.052

0.043
0.067

0.063

0.101



CI



0.036

0.000

0.023
0.008

0.045

0.024



KsO



0.238

0.157

0.181
0.186

0.123

0.174



NaaO



0.068

0.040

0.038
0.010

0.011

0.001



HjSOi



0.034



0.016

0.022
0.056



0.025



FezOj



0.0090



0.0154

0.0070
0.0026



Tr.



0.497

0.236

0.108
0.189

0.190

0.283



i

3 1

3.10



1.48

0.67
1.18

1.19

1.77



TABLE v.
Percentage Lost in Water under Ordinary Boiling Conditions.



Vegetable.




3


JZ

^


9


61.5
81.0
41.6
10.6
54.1
40.1


2


o


<2


9

61.1
77.8
48.8

56.3
Tr.


57.2
78.7
49.9
31.6

52.1


6

28.2
50.8
Tr.

U

Tr.


a;


Sninacli . , ;


90
30
30
45
150
30
30


32.2
41.3
37.5
22.5
31.8
27.4
4.4


45.2
72.2
47.8
28.0
43.4
46.7


Tr.

3.6
28.4
26.1
21.4
26.6


48.2
70.2
34.6
24.6
42.7
34.6


71.1
100.0
57.1
31.4
46.8
46.4


64.8
81.9
47.3
29.2

55.2
49.2


?3 1


New Zealand spinach.. . .
Youner carrots


22.3

?? 7


Onions


19 8


Striner beans


?6 7


Asnaraffus


?4 1


Potatoes









tables is known to be poorly absorbable.^" Irrespective of any food
content, diabetics should not be allowed to gorge themselves on these
extracted vegetables. Those on reasonably liberal diets do not need
them at all. The allowance for any patient is generally not more



5" Rubner, M., Berl. klin. Woch., 1916, No. 15.



GENERAL PLAN OF TREATMENT 157

than a kilogram per day, and less in proportion as ordinary vegetables
can be used. Excessive quantities are a useless burden upon both
the purse and the digestion.

12. Fruits. — Fruits are the best diabetic desserts, when they can be
tolerated. Most patients can take at least grape-fruit. Within
reasonable limits, there is no prejudice against fruits because of their
carbohydrate being largely in the form of sugar. Neither is there a
favorable bias because so much of the sugar is levulose, for in the long
run the actual carbohydrate and total food values are probably the
determining factors of a diet. Reference must be made to text-books
for the proportions of different carbohydrates in fruits. The latest
article that has chanced to come to notice is that of Eofi," showing
that 52 to 75 per cent of the sugar in apple juice is levulose.

13. Nuts. — Some nuts resemble prepared diabetic foods in their low
carbohydrate and high protein and fat content. They must be used
with corresponding caution. No superior assimilation for nuts or
other less common foods has been observed.

14. Unusual Carbohydrates and Abnormal Modes of Administration. —
Notwithstanding more or less deceptive appearances of assimilation,
little or no practical value is to be expected from caramel, pentose,
7-carbon sugars (hediosit), or other unusual food elements. Like-
wise no hope should be entertained of any special assimilability of
glucose given by rectum or other abnormal way. It need only be
noticed that no patient was ever saved from either starvation or coma
by such means. Confusion will be avoided by recalling the faulty
theory underlying such attempts. In acidosis, the only lasting benefit
must come from relief of the metabolism which is breaking down, by
reducing the diet especially in fat, and not from the introduction of
strange compounds. In nutrition, the level of total diet and weight
determined by the actual assimilative power is a limitation which
cannot be cheated by artificial devices.

15. Bran Bread or Biscuits. — These are the only form of bread
substitute used for the type of cases treated in this hospital. In
milder cases bran can be used in various ways; for example, bread can
be made of eggs, fat, and bran, or bran can be mixed with ordinary

" Eoff, J. R., J. Ind. and Eng. Chem., 1917, ix, 587-588.



158 CHAPTER n

flour to lower the carbohydrate and food value of the latter. But
while severely diabetic patients crave some form of bread, they do not
wish to devote any of their scanty protein or fat to this use. Accord-
ingly the following recipe was developed for a bran-agar bread
having no appreciable food value.

Bran Biscuits.

Bran, weighed dry 60 gm.

Agar-agar, powdered 6 "

Cold water ; 100 cc.

The bran is tied in cheese-cloth and hung under the cold water tap
to wash (with stirring or kneading as required) until the water
runs through clear. The agar is mixed in 100 cc. water (cold) and
brought to the point of boiling. The agar solution (hot) is then
added to the washed bran. The mixture is molded into three cakes
and placed in a pan and when firm and cold baked until dry and crisp.
Salt may be included in the recipe if desired. The biscuit or muffin
shape may be chosen, but it has generally been preferred to make thin
flat pieces like well browned toast. The toasting helps the flavor a
little, and the dryness facilitates keeping.

The chief caution is necessary in the choice of bran. Ordinary bran
flours or breakfast foods are high in carbohydrates. Some kinds of
cheap bran contain middlings or other carbohydrate admixture. It is
possible to buy purified bran, such as Kellogg's. But the bran
ordinarily used for feeding cattle, which on inspection is seen to con-
sist of coarse flakes of the outermost hull of the wheat, is obtain-
able very cheaply at feed stores, and is perfectly satisfactory when
washed under the cold water tap for half an hour or more as above
described.

Some patients like these tasteless bran rusks at once; others either
accept or enjoy them after becoming used to them. They are best
served hot, like toast, with butter, bacon fat, a fried egg, or even
soup, to give them flavor. Besides contributing bulk, like the vege-
tables, the bran is stiU more active in favoring catharsis, and since its
introduction the traditional constipation of diabetic patients has
been almost unknown in this hospital. A few individuals cannot
take the bran; in others sometimes indigestion or diarrhea limits the



GENERAL PLAN OF TREATMENT 159

amount. On general principles, an inert substance should not be
taken to excess, and accordingly the allowance is generally no more
than one or two of the above cakes at each meal.

Bran has never been responsible for glycosuria in this hospital,
and is probably not digested to any important extent. The chemis-
try of bran, especially from the standpoint of digestion, is not thor-
oughly known. It is poor in cellulose (2 to 4 per cent in most analy-
ses), and from its richness in protein and amides, phytin and other
complex compounds, might supply the body with much nitrogen and
phosphorus if digestible. Guareschi^^ states that bran milled to an
impalpable powder is 91 to 92 per cent digestible, and emphasizes its
value for food and for vitamines. The fine milling therefore defeats
the purpose for which bran is used in diabetes.

16. Proprietary Foods. — So called "diabetic" and "gluten" prepa-
rations have largely fallen into disrepute because of the rankly fraudu-
lent character of so many of them. It is still very common for pa-
tients to announce that as soon as diabetes was discovered they be-
gan to eat gluten bread, with or without a doctor's orders; but knowl-
edge on the subject is increasing, and it is becoming generally known
that a physician should at least never order such a food without
specifying a reliable brand.

The medical profession is indebted to Professor John P. Street for
the most complete analyses of diabetic foods. The results are obtain-
able in the publications of the Connecticut Agricultural Experi-
ment Station, especially the report for 1913, Part 1, with added analy-
ses in the report for 1914, Part 5, and the report for 1915, Part 5.
These data are the best basis for the choice of a diabetic preparation.
With improved technical methods, the best brands have been brought
to a high state of perfection from the standpoint of carbohydrate-
ireedom and agreeable taste. Without invidious distinctions, men-
tion may be made of American made examples of the three principal
classes of such foods; viz., gluten flour, which is manufactured in high
purity by Hermann Barker, Somerville, Mass.; casein flour and
muflSns, as prepared by Lister Brothers, 110 West 40th Street, New

^^ Cf. Guareschi, I., Ind. ckim., min. e metal.; 1917, iv, 97-103; Chem. Abstr.,
1917, xi, 2124. Holmes (Holmes, A. D., U. S. Dept. Agric, Bull. 751, 1919) has
obtained a coeflScient of digestibility of only 45 per cent for finely milled bran.



160



CHAPTER n



York City; and soy bean flour, one brand of which is made by the
Cereo Company, Tappan, New York, while the most extensive use
of soy beans by diabetics at present is in the form of the "Hepco"
flour, dodgers, etc., made by the Waukesha Health Products Com-
pany, Waukesha, Wisconsin. For complete hsts and analyses of such
foods, reference must be made to Street's reports or Joslin's text-book.

The essential objection to all such bread substitutes is that in ab-
sence of carbohydrate, they have necessarily been composed of pro-
tein and fat, and thus have represented highly concentrated forms of
food. Both physicians and patients have often viewed these breads
as harmless, or even commendable by reason of their high protein and
food value. The great amount of protein and calories that can be sO'
easily and inadvertently consumed in this way is capable of tre-
mendous damage. Janney^' has pointed out that the potential car-
bohydrate represented in the protein often exceeds the total carbohy-
drate of ordinary bread. It is necessary to warn strongly against this-
indiscriminate misuse of even the best preparations, in which the
manufacturer is not to blame. There is no objection to making upi
as large a proportion of the diet as desired from these flours, provided
the total diet is accurately reckoned and restricted as usual. For cases,
of the grade of severity treated in this hospital, the use of such prepa-
rations has been abandoned, simply because the patients prefer to
take their protein and fat in meat, eggs, bacon, butter, etc., rather
than in flour or bread.

Because of the very limited quantity of these concentrated foods-
which can safely be included in any diet, and because of the danger-
ous ease with which patients can be tempted to overstep their real
tolerance by taking only a small quantity in excess, the manufacturers-
of some of the better brands are moving in the direction of reducing;
the undesirably high food value by the introduction of some indigesti-
ble substitute for carbohydrate. A non-utilizable flour might be
employed in three ways; first, to dilute ordinary flour for mild cases,
so as to reduce the carbohydrate and food value of wheat, corn, or
other bread; second, to dilute the special diabetic flours, so as to make
them permissible more often and in larger quantities, Fhile at the same-

" Janney, N. W., Arch. Int. Med., 1916, xviii, 584-605.



GENERAL PLAN OF TREATMENT 161

time probably reducing their cost; third, for making an entirely non-
nutritious bread substitute, perhaps finer and more agreeable than the
bran bread. An extreme illustration of the feasibility of the use of a
non-nutritious flour can be gained by making a batter with egg, spices,
and impalpable talcum powder, and frying it crisp. This will appear
more satisfying than the egg fried alone. While talcum is inert and
harmless, it is scarcely to be recommended for eating, and a non-
utilizable flour for practical use is most likely to be found in the
vegetable kingdom, probably in some form of cellulose or other
polysaccharide.^* Ridicule or opposition may be aroused by sug-
gestions of flour from cotton, peanut-shells, corn-pith, etc., and the
technical difficulties also have thus far baffled manufacturers. The
German experience in the recent war, that large quantities of wood
flour may cause intestinal disturbance, was confirmed in one short test
with diabetics; but the long experience with bran and shorter trials of
other indigestible substances have shown that the prudent use of these
is safe and practicable. Critics should bear in mind the following
facts: first, it is generally conceded that the food of civilized man is
overconcentrated, frequently excessive, and subject to improvement
by an admixture of indigestible material, as in coarse vegetables;
second, the diabetic flours which it is proposed to dilute are dry pro-
tein-fat powders representing an unnaturally concentrated form of
food; third, diabetics must be more closely limited in their total food
intake than normal persons, and yet they have the usual, even if not
an excessive craving both for bread and for bulk.

D. General Scheme and Specimen Diets.

Two general plans, are possible for diabetic diets. The one which
has been customary in the past has aimed to give the patient substi-
tutes as nearly as possible resembling the accustomed dishes which
he must forego. Accordingly, diabetic cook-books have been fflled

^* Concerning some indigestible carbohydrates, see Mendel, L. B., Ceniralbl.
ges. Physiol, u. Path. Stoffwechs., 1908, iii, 641-654. Mendel, L. B., and Swartz,
M. D., Am. J. Med. Sc, 1910, cxxxix, 422^26. Swartz, M. D., Tr. Connecticut
Acad. Arts, and Sci., 1911, xvi, 247. Concerning the German experience with
wood flour, see Salomon, H., Wien. med. Woch., Dec. 15, 1917 (favorable), and



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