Part 3

An uncontrolled normal diet contains approximately 300 grams, or 10 ounces of carbohydrate, 150 grams, or 5 ounces of protein, and 90 grams, or 3 ounces of fat. In the course of assimilation, about 400 grams of sugar are derived therefrom, and, to metabolize such an amount of sugar, 150 to 300 units of insulin must be necessary. A normal person probably makes, in his pancreas, 200 or 300 units of insulin a day, which is sufficient for any normal demand, but this natural insulin is doled out to his tissues, a bit at a time, so that there is never an excess of insulin in the blood.

_Excessive insulin harmful._--In severe diabetes the pancreas manufactures very little insulin, not more than 20 or 30 units, and the balance necessary for the day’s work must be given by hypodermic syringe in two or three doses. If the total amount of extra insulin necessary daily were 150 units, each hypodermic injection would be 50 units, and it is difficult to give such large doses as this without causing a temporary excess of insulin in the blood. Unfortunately, excessive insulin is as disagreeable as inadequate insulin. When too much insulin is present in the blood, the blood sugar falls to very low levels and a reaction occurs with symptoms that may be alarming, and results that may be serious. Consequently, very large single doses of insulin must be avoided and the total amount of sugar entering the body daily must be measured and made to balance with the insulin doses. This means dieting.

Furthermore, it proves to be very difficult to keep the level of the blood sugar low with insulin when diets are very rich in carbohydrate. The normal sugar level, as I have said, is 0.1 per cent. In uncontrolled diabetic conditions, it may be found as high as 0.5 per cent, or higher. This can be reduced by an insulin injection, but as soon as food rich in carbohydrate is eaten, back comes the sugar to a high level. In order to rest the pancreas, the blood sugar must be kept low, which can only be accomplished when the diet contains relatively little carbohydrate.

THE DIET

_Calories and sugar should be low._--All of the principal authorities on diabetes are agreed that a diabetic patient must not overeat and become fat. In other words, the total amount of food energy, that is, calories, must be limited. All are agreed also that the diet must be kept low in sugar producing foods. This means little carbohydrate and little protein. The diet in health, as I have said, includes a great deal of carbohydrate, probably more than is wise even for perfectly normal persons. The diet in diabetes must get more of its calories from fat and less from the starches and meats. Authorities are furthermore agreed that an excessive restriction of carbohydrate (sugar and starch) may be dangerous, because with such very low carbohydrate diets the fats may fail to be properly assimilated, with resulting acid poisoning.

_The authorities agree on general principles._--The actual procedures in diet-planning employed by various authorities differ but little, and only as to details. Doctor Allen, for instance, believes in much greater restriction of total food than do others. Doctor Joslin also favors rather low total food amounts and disbelieves in allowing much fat unless rather large amounts of carbohydrate can be taken. Doctor Woodyat of Chicago, the doctors in the Toronto Clinic, and Doctor McCann at the University of Rochester, New York, plan their diets in such a way that approximately one part of carbohydrate will be taken for every two and one-half parts of fat. Professor Petren of Lund, Sweden, now the leading authority in Europe, and Doctor Newburgh and Doctor Marsh of the University of Michigan, believe that restricting protein is of extreme importance, and that if this is done acidosis can be avoided even when larger proportions of fat are fed. In the Mayo Clinic, the practice is to limit protein rigidly and to limit carbohydrate rather more strictly than is done elsewhere, making the diet consist to a greater extent of fat, but planning this so that the total energy of the daily food supply will meet quite closely actual energy requirements. The procedures for arriving at these several diets can be found in various manuals that have been written for patients.

_Books on diabetes for patients._--Doctor Joslin’s “Diabetic Manual,” Lea and Febiger, is one of these. Doctor Petty’s “Diabetes, Its Treatment by Insulin and Diet,” F. A. Davis Company, Philadelphia, is another. Wilder, Foley and Ellithorpe’s “A Primer for Diabetic Patients,” W. B. Saunders Company, Philadelphia, may be consulted for more complete descriptions of the methods employed in the Mayo Clinic than can be given here.

_Patients must be trained._--The results of accurate management are so encouraging that they are almost as good as cures. They are not cures, because the fundamental island weakness is rarely if ever completely corrected, and treatment must continue for month after month. Success, therefore, rests largely in the patient’s hands and the doctors’ most important task is teaching the patient all that he can be taught about his diet and about the use of insulin. The books mentioned were written to help in this training of patients. In various clinics over the country, patients attend classes and are instructed in the subject of dietetics until they can weigh food and plan meals accurately so that each will contain a set number of calories and yield to the metabolism a predetermined amount of sugar. The hospital management of a case of diabetes is not complete until the patient can live a healthy life in spite of his disease. He may arrive at the hospital in a state of coma and be dragged from the very jaws of death with insulin, but afterwards, when he goes home, unless he has learned how to continue the use of insulin and combine with it an accurate diet, he will slip again into the same dangerous predicament.

It is best always to start treatment in a hospital where a systematic course of instruction can be obtained. Unfortunately, we have no schools for diabetic patients other than the hospitals, and some persons dislike hospitals. Good results can be obtained at home, provided one has the good fortune to consult a physician who will take the time to give this training. What are the essentials?

_What the patient must know._--First, a knowledge of how to read food tables and, with their aid, to plan accurate diets. Food tables are lists of foods showing the composition of each, in protein, carbohydrate and fat. The books mentioned here all contain such lists. The most complete table is that published by the United States Department of Agriculture, Bulletin No. 28, “The Chemical Composition of American Food Materials,” a pamphlet that may be had from the Superintendent of Documents, Government Printing Office, Washington, D. C., for the small sum of ten cents.

Second, instruction in the manner of injecting insulin, that is, in the use of the hypodermic syringe. Insulin, as has been stated, must be given hypodermically, under the skin. The technic is not difficult, but sterile precautions must be observed in order to avoid introducing disease germs with the insulin.

Third, instruction in how to test the urine for sugar. This is a simple task but of great importance. Sugar in the urine is the first signal of inadequate treatment. To postpone correcting the mistake until other signs appear such as thirst, excessive urination, and loss of strength, is to court disaster. The sugar test can be completed in three minutes, and should be made every day, preferably on a specimen of urine passed just before the patient retires for the night. This specimen should be sugar-free. If it is not, more insulin is needed or the diet requires readjustment.

Fourth, advice concerning how to meet certain complications which I shall discuss later.

TREATMENT IN CASES OF MILD DIABETES

There are instances of patients with diabetes who have lived for twenty years or more without any effort at treatment. This consoling thought must not make unwary the patient with a moderately severe or severe form of the disease. It is safer to overrate the seriousness of the condition than to commit an irreparable blunder and neglect the careful management of a serious condition. Children and young adults, for instance, may seem well during the first year after the appearance of sugar, but with few exceptions they develop the severest form of the disease later unless they are very carefully treated from the first.

A good many older persons may be treated satisfactorily with much less dietary restriction than is necessary in the severe cases. When this is possible, insulin is not needed and should not be used, or, in other words, if a condition is serious enough to require insulin, it is serious enough to require an accurately weighed diet. Occasionally patients have so little intelligence that it is hopeless to expect them to carry on the weighed diet in their homes. For such, and also for patients with very mild diabetes, the following general advice is usually beneficial:

1. Avoid sugar and all foods made with sugar, such as candy, jelly, marmalade, syrup and molasses, pies, cakes, puddings and pastries. Saccharin may be used if desired: one-fourth grain saccharin will equal one teaspoonful of sugar in sweetening value.

2. Avoid cereals (breakfast foods) and cereal products, such as mush, macaroni, spaghetti and noodles.

3. Use bread only in very small amounts, not over one ounce at a meal. Whole wheat or white breads are preferable to any so-called diabetic breads. Gluten bread, brown bread and corn bread vary widely in compositions and it is safer to avoid them.

4. Potatoes, bananas, apples, peas, dried beans, carrots, beets, turnips and onions should be used in small quantities, and not oftener than once a day.

5. Dried fruits should be avoided. Use fresh fruits whenever possible. Fruits canned without sugar are permissible. They may be purchased on the market or prepared at home. Fruits may be taken every day as substitutes for other desserts.

6. Vegetables that grow above the ground, except peas and dried beans, should be eaten in quantities sufficient to avoid hunger. Three ordinary servings of these vegetables may be included in each meal. Canned vegetables are palatable and wholesome. Fresh vegetables are, however, preferable.

7. Meat and eggs should be eaten sparingly. As much harm may result from excessive protein as from excessive carbohydrate. The diet for the day should never contain more than 60 grams (2 ounces) of lean meat, weighed cooked, and three eggs. Thirty grams (1 ounce) of bacon, weighed cooked, may be included. Meat includes chicken, game, and fish.

8. Fats, including butter or oleomargarine, nut butter, bacon fat, olive oil, Wesson oil, or other salad oil may be eaten freely.

9. Cream is a very useful food for diabetic patients, and may be taken freely. Milk is relatively high in carbohydrate and less nutritious.

10. The amount of fat, such as butter or cream, should be adjusted so as to provide adequate, but not excessive, nutrition. A rising body-weight calls for less food and, under such circumstances, the amount of fat should be reduced.

11. Coffee and tea should be used sparingly, not in excess of one cupful of either at each meal.

12. Condiments, such as salt, pepper and vinegar, may be used in reasonable amount.

If sugar appears in the urine, bread should be omitted. If it persists after thus reducing the carbohydrate intake, the condition of the patient is severe enough to warrant instituting the more accurate management discussed herein.

THE TREATMENT OF FEVERS OCCURRING IN DIABETIC PATIENTS

_Fevers increase the need for insulin._--Today, with insulin, a properly dieted patient is as robust and capable as his normal neighbor. His handicap is the continued necessity for keeping his enemy under control, but if this control is watchfully maintained, he should live as long and as useful a life as do his fellows. However, throughout his life he is exposed, as are his fellows, to diseases other than diabetes. Measles, mumps, scarlet fever, diphtheria, acute colds, influenza, pneumonia, and other germ diseases, the so-called infectious diseases, will attack him, and when they do they invariably aggravate his diabetes and, by preventing the utilization of his sugars, subject him to the danger of acid poisoning from smoldering fats. Therefore, when such complications occur, a patient must have insulin, whether he has been able to do without it before or not, and usually the doses necessary to control these critical emergencies must be large. For instance, a patient on a set diet, whose urine remains free from sugar with 20 units of insulin, may require 40 units daily whenever he takes cold. A serious infection like pneumonia may make it necessary to use 80 units of insulin daily. Under normal circumstances, a patient taking 20 or 30 units of insulin daily, does very well when this is divided into two doses of 15 units each, and one dose is injected before breakfast, and the second before the evening meal. During an attack of pneumonia or any other fever-producing complication, it may be necessary to resort to four injections, spaced at six-hour intervals. It is usually necessary to modify and reduce the diet when a patient is sick. It is always wise to eat less. In particular, the fat allowance of the diet should be reduced. It is wise not to reduce the carbohydrate. The patient with fever may be nauseated during the course of a fever and refuse all food. Under such circumstances, less insulin may be required; usually, however, large doses are still necessary. The reason for this is not clear, but apparently the poisons created in the course of germ diseases counteract the effect of insulin. During disease, the urine should be examined every six hours and the dose of insulin necessary may be judged from the amount of sugar found.

OPERATIONS ON DIABETIC PATIENTS

_Special precautions necessary in operating on diabetic patients._--It is self-evident that a person with diabetes is no less likely to develop appendicitis, gallstones, or cancer than he would be without diabetes. Consequently, serious operations are occasionally necessary. The danger from such procedures is many times greater in diabetic patients than in others, unless the diabetes is closely controlled. Formerly one out of every three operations on diabetic patients terminated fatally. This was because the anesthetic, ether or chloroform, provoked acid poisoning, and because the enfeebled patient was little prepared to withstand the shock of loss of blood, and injury. The added danger of diabetes may be avoided if the patient is in good condition before he goes to operation, and if acidosis is promptly combated with insulin. It is wise for the diabetic patient to employ only a very skillful surgeon, and to make certain either that he is familiar with the treatment of diabetes, or that he has associated with him some physician who has had a considerable experience with diabetes.

MISCELLANEOUS COMPLICATIONS

_Arteriosclerosis._--When we pass the age of thirty-eight, we are enjoying life which was denied our grandparents. The expectancy of life for a newborn baby in 1860 was thirty-eight years. Now it is nearly sixty years. This accounts, in a large measure, for the specially rapid increase in the amount of diabetes among people more than forty-five, and for the larger incidence today of other diseases of a chronic type. Hardening of the arteries, or arteriosclerosis, is a complication with which older diabetic patients are frequently afflicted. As has been said, arteriosclerosis may be a cause of diabetes in a predisposed person, but be that as it may, diabetes, once established, unless controlled, aggravates and intensifies disease of the arteries. It is, therefore, important for the older diabetic patient to make a serious effort to avoid arteriosclerosis by keeping his diabetes checked. Most of the complications which harass and endanger the older patient are due to hardening of the arteries. In this disease, the elastic contracting tissue in the hollow muscular tubes that carry blood is replaced, bit by bit, with scar tissue.

_Apoplexy, heart trouble, gangrene._--The walls of the tubes thicken, become brittle, and what results? A vessel in the brain breaks, and hemorrhage in the brain may cause apoplexy. A vessel may also break in the eye. The amount of blood that can pass through the narrowed tubes is too little to supply the beating heart, and pain results, called angina, or irregular heart action or even heart failure. The circulation in the legs is restricted, and pains result, and sometimes gangrene. Coma, it will be remembered, is the chief cause of death among younger diabetic patients. Coma can now be prevented and no one should die from coma. Gangrene is the chief cause of death among older patients. In gangrene, usually of the legs, the tissues lose their vitality because of lack of blood; infection follows and blood poisoning results.

_Prevent gangrene._--We must prevent these deaths from gangrene. It can be done by watchfulness and attention. Keeping the urine sugar-free is the first requisite. Gangrenous ulcers of the feet can be made to heal by vigorous treatment with insulin, and diet. It is of great importance to encourage the circulation in the feet by massage and proper exercises. Finally, care in avoiding bruises and cuts of the skin of the feet will prevent much trouble. Every old diabetic patient should wash his feet daily, wear clean stockings, and very comfortable shoes. Watch and guard the feet. Achilles, the Greek hero, must have been a diabetic. The only vulnerable spot on his body was his heel. When before the walls of Troy the spear of Paris touched him on the heel, he died. Watch and guard the feet.

Transcriber’s Notes

Page 18: “fairly stabile” changed to “fairly stable”

Page 25: “like coloroform” changed to “like chloroform”

Page 39: “Overeating of carboydrates” changed to “Overeating of carbohydrates”

Page 52: “excessive carhobydrate” changed to “excessive carbohydrate”

Page 55: “one out of overy” changed to “one out of every” “with a diabetes” changed to “with diabetes”

Page 56: “be that is it may” changed to “be that as it may”

Page 57: “my cause apoplexy” changed to “may cause apoplexy”