CHAPTER XX

Chapter 207,585 wordsPublic domain

DIABETES MELLITUS

~Definition.~--Diabetes is a disease which is characterized by an inability on the part of the body to utilize the carbohydrates, in consequence of which there is abnormal excretion of glucose in the urine.

~Sugar in the Urine.~--The appearance of sugar in the urine may not necessarily signify diabetes, it may be merely a temporary glycosuria due to certain pathological conditions, such as infectious diseases, diseases or trauma which affect the pancreas, and which disappear upon the recovery from the disease. But any appearance of sugar in the urine should be looked upon with suspicion, since the future welfare of the patient depends largely upon an early diagnosis in any form of diabetes.

~True Diabetes.~--Allen claims that true diabetes may always be distinguished from nervous glycosuria by the application of the laws governing these conditions (Allen's Paradoxical Law[137]), which is "whereas in normal individuals the more sugar given the more is utilized, the reverse is true in diabetes."

~Manufacture of Sugar from Other Foods.~--If the carbohydrate foods alone caused all the trouble in diabetes, the disease might be more easily controlled. This, we found, however, not to be true, since in certain conditions the body utilizes the protein foods for the manufacture of glucose also. Consequently in diabetes if the absolute sugar output of the body is to be controlled, the intake of nitrogenous foods must be likewise adjusted.

~Functions of Carbohydrates.~--In the chapter describing the functions of the carbohydrates in the human body it was demonstrated that their energy-producing properties did not cover the extent of their usefulness. It has been proved that this food constituent normally acts as neutralizing agent for the toxic acids produced within the organism as a result of the breaking down of the _fats_. Hence, when this function of the carbohydrates becomes impaired, these acids, Oxybutyric acid, Diacetic acid and Acetone, fail to be neutralized and are consequently absorbed into the blood stream, giving rise to a form of intoxication known as acidosis. When acidosis becomes extreme, the diabetic patient is apt at any time to succumb to the dreaded diabetic coma.

~Keeping Urine Sugar Free.~--Thus it is seen that the treatment of diabetes mellitus consists not alone of freeing the urine from sugar and keeping it free, but of controlling the acidosis which may at any time develop.

~Diabetic Cures.~--Numberless so-called diabetic cures have been brought forward and more or less tested for years, but whether they have really accomplished cures has not been satisfactorily proved. Not until Dr. Allen instituted what is known as the Allen's Starvation Treatment has the disease been so universally treated, at least by one method or modification of one method. Dr. Joslin, who has used this treatment most successfully, does not claim to have accomplished a cure, but states that he is watching the results of the treatment in his patients with interest.

~Starvation Treatment.~--The Allen Starvation Treatment consists of first a period of about forty-eight hours in which the patient is given an ordinary diet, during which time the daily weight is taken and the urine examined and recorded.

~Acidosis.~--It has been found in some cases, such as with elderly patients or those in whom there is an evident acidosis, advisable to precede the period of starvation by a preliminary treatment.

~Method of Treatment.~--Joslin[138] suggests the following method of procedure:

"Without otherwise changing the diet omit fat. After two days, omit protein, then halve the carbohydrates daily until the patient is taking only ten grams, then fast."

In the Michael Reese Hospital, the following series of test diets are given to determine the severity of the diabetes:

DIABETIC TEST DIETS[139]

BREAKFAST

Grapefruit 1/2 Eggs 2 Bacon 20 grams Bread 25 grams Butter 10 grams Cream 15 c.c. Coffee 1 cup

DINNER

Cream soup 3 oz. Roast beef 75 grams Spinach 100 grams Kohl-rabi 100 grams Lettuce salad 50 grams Ripe olives 15 grams Bread 25 grams Butter 20 grams Wine gelatin 4 oz. Coffee Cream 15 c.c.

SUPPER

Lamb chop 1 Asparagus tips 50 grams Eggplant 50 grams Tomato salad 50 grams Custard (diabetic) Coffee Cream 15 c.c. Butter 20 grams Bread 25 grams

~Diet in Mild Cases.~--This diet contains approximately 70 grams of protein, 100 grams of fat, and 70 grams of carbohydrates, and the patient is kept on it for at least two days; then the carbohydrates are cut down by taking away 25 grams of bread every day.

DIABETIC DIETS[140]

KEY A Carbohydrate B Protein C Fat D Calories E 5% Vegetable F Orange G Oatmeal H Shredded Wheat I Uneeda J Potato K Bread L Egg M Cream 20% Fat N Bacon O Butter P Meat Q Fish R Skimmed Milk S _Name of Diet_ T _Maintenance Diets_

========+==============+===============================================+== Diets | _Diet in_ | | with | _Grams_ | _Test Diets_ | which to+---+--+--+----+---+---+--+---+-+---+--+-+---+--+--+---+---+---+ become | | | | | | | | | | | | | | | | | | | Sugar | | | | | | | | | | | | | | | | | | | free | A |B |C | D | E | F |G | H |I| J |K |L| M |N |O | P | Q | R |S --------+---+--+--+----+---+---+--+---+-+---+--+-+---+--+--+---+---+---+-- T. D.1 |189|89|15|1247|300|300| | 1 | |240|90| | | | | 90|120|480| 1 T. D.2 |102|58| 0| 640|300|300| | 1 | |120| | | | | | |180|300| 2 T. D.3 | 64|33| 0| 388|300|300| | | | 60| | | | | | | 90|240| 3 T. D.4 | 36|27| 0| 252|300|200| | | | | | | | | | | 90|120| 4 T. D.5 | 15| 5| 0| 80|300| 50| | | | | | | | | | | | | 5 --------+---+--+--+----+---+---+--+---+-+---+--+-+---+--+--+---+---+---+-- | | _Carbohydrate_ | _Protein and Fat_ | T | | (_C_) | (_PF_) | --------+---+--+--+----+---+---+--+---+-+---+--+-+---+--+--+---+---+---+-- C1 +PF1 | 10|11| 6| 138|300| | | | | | |1| | | | | | | 1 C2 +PF2 | 22|13|18| 302|300|100| | | | | |1| 60| | | | | | 2 C3 +PF3 | 32|24|24| 440|600|100| | | | | |2| 60| | | | | | 3 C4 +PF4 | 42|29|39| 635|600|200| | | | | |2| 60|30| | | | | 4 C5 +PF5 | 52|32|53| 813|600|200|15| | | | |2| 60|30|15| | | | 5 C6 +PF6 | 63|43|65|1009|600|200|30| | | | |2| 90|30|15| 30| | | 6 C7 +PF7 | 73|51|70|1126|600|300|30| | | | |2| 90|30|15| 60| | | 7 C8 +PF8 | 83|59|87|1351|600|300|30| |2| | |2| 90|30|30| 90| | | 8 C9 +PF9 | 96|62|93|1469|600|300|30|1/2|2| | |2|120|30|30| 90| | | 9 C10+PF10|107|63|93|1517|600|300|30| 1 |2| | |2|120|30|30| 90| | |10 C11+PF11|131|75|98|1706|600|300|30| 1 |2|120| |2|120|30|30|120| | |11 C12+PF12|155|79|98|1818|600|300|30| 1 |2|240| |2|120|30|30|120| | |12 ========+===+==+==+====+===+===+==+===+=+===+==+=+===+==+==+===+===+===+== _Weight in_ _Approximate_ _Food_ _grams_ _equivalent_ Orange 300 One and one-half (large size) 5 per cent vegetables 300 Three moderate portions Skimmed milk 480 One pint (16 ounces) Fish 120 Two small portions Potato 240 Two medium sized potatoes Meat 90 One moderate portion Bread 90 Three small slices Oatmeal (dry wgt.) 30 One large saucerful Cream 60 Four tablespoonfuls Bacon 30 Four crisp strips Butter 30 Three medium portions

The Test Diets are designed for the period during which the patient becomes gradually sugar free. On successive days advances can be made from Test Diet 1 to Test Diet 5, and if on the fifth day the patient is not sugar free, fasting can be employed for one or more days.

The Maintenance Diets are for use so soon as the urine of the patient is free from sugar. If this occurs as a result of Test Diet 5 the patient begins with Maintenance Diet C1PF1. The actual articles of food representing the carbohydrate in the diet for the first day are given under the heading of carbohydrate, for convenience described C1, 2, 3, etc. The articles referred to under protein and fat are under that heading, which for the same reason is described as PF1, 2, 3, etc. Certain cases of diabetes can proceed steadily day by day from C1PF1 to C12PF12, without showing sugar. If sugar does appear in the urine, drop back two days in the carbohydrate group, wait till sugar free, then advance in the protein and fat group until sufficient calories are obtained. Thus, if sugar shows on C7PF7 the diet prescribed would be that included in C5PF7 and thereafter progression could be made in the PF group until twenty-five to thirty calories per kilogram body weight were furnished the patient.

Occasionally the patient becomes sugar free on Test Diet 2, 3, or 4. It is then unnecessary to begin with Maintenance Diet C1PF1, but instead with a maintenance diet which contains a value for carbohydrate similar to that of the test diet upon which the patient became sugar free.

If the protein and fat are too high for the individual on a given day it is easy to advance the carbohydrate and decrease to an earlier day on protein and fat.

The plan is arbitrary and the majority of cases will demand some modification. It is arranged to enable patient or nurse to see in advance the general plan of treatment.

(Courtesy of Dr. Joslin and Thomas Groom & Co., Boston.)

If the case is a mild one, this may be sufficient to free the urine from sugar, but the diet is given primarily to enable the physician to find out by means of urinalysis just how great is the functional impairment.

In some cases, which are mild in character, the urine is made free of both sugar and acetone without further dietetic measures. However, when a severe diabetes is manifested and a high percentage of glucose and in some cases acetone bodies are found in the urine a more rigid treatment will be found necessary.

~Preliminary Diet.~--Many physicians find it advisable, as has already been stated, to cut down the food allowance before stopping it entirely. In the Michael Reese Hospital this is done by first giving a practically fat-free diet, followed by one or two days in which three or four eggs, 250 to 300 grams (8 or 10 ounces) of 5% vegetables are given, after which it is found safe to institute the starvation treatment.

~Sample Menus.~--The following menus are given to illustrate the dietetic treatment which it is deemed advisable to institute in cases where the starvation treatment cannot be given at once:

After the test diet of forty-eight hours, the following regime is instituted:

THIRD DAY =============================+=========+=======+==============+========== |_Protein_| _Fat_ |_Carbohydrate_| | _Gm._ | _Gm._ | _Gm._ |_Calories_ -----------------------------+---------+-------+--------------+---------- Breakfast: | | | | 1/2 grapefruit | | | 5 | 20 1 egg | 5.3 | 4.1 | | 59 1 slice bread 30 gm. | 2.6 | .3 | 15 | 73 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 7.9 | 4.4 | 20 | 152 Dinner: | | | | Broth 180 c.c. | 3.7 | .17 | .34 | 18 Chicken (breast) 90 gm. | 18.2 | 2.1 | | 92 Spinach 100 gm. | 2.0 | | 3.0 | 20 Potato (1 medium) 90 gm. | 1.8 | .09 | 15.6 | 70 Lemon jelly 90 gm. | 4.2 | | 2.7 | 27 +---------+-------+--------------+---------- Total for meal | 29.9 | 2.3 | 21.6 | 227 Supper: | | | | Lamb chop 50 gm. | 9.3 | 14.1 | | 126 Asparagus 100 gm. | 1.5 | | 3 | 18 Bread 20 gm. | 1.6 | .2 | 10 | 48 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 12.4 | 14.3 | 13 | 192 Total for day | 40.2 | 21 | 54.6 | 571 =============================+=========+=======+==============+==========

FOURTH DAY =============================+=========+=======+==============+========== |_Protein_| _Fat_ |_Carbohydrate_| | _Gm._ | _Gm._ | _Gm._ |_Calories_ -----------------------------+---------+-------+--------------+---------- Breakfast: | | | | 1/2 grapefruit | | | 5 | 20 1 egg | 5.3 | 4.1 | | 59 1 slice bread 20 gm. | 1.6 | .2 | 10 | 48 Coffee or tea | | | | +---------+-------+--------------+---------- Total for meal | 6.9 | 4.3 | 15 | 107 Dinner: | | | | Tomato bouillon 180 gm. | 2.2 | .23 | 2.5 | 15 Whitefish 90 gm. | 2 | | 5 | 28 Boiled onions 100 gm. | 1.5 | .3 | 7.5 | 40 Bran muffin (1) | 5 | 7 | 4.5 | 101 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 25.7 | 16.2 | 20.5 | 322 Supper: | | | | 1 egg | 5.2 | 4.1 | | 59 Tomato (baked) 100 gm. | .6 | | 2 | 10 Bran muffin (1) | 1 | 5 | 7 | 101 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 6.8 | 9.1 | 9 | 170 Total for day | 38.4 | 29.6 | 44 | 513 =============================+=========+=======+==============+==========

FIFTH DAY =============================+=========+=======+==============+========== |_Protein_| _Fat_ |_Carbohydrate_| | _Gm._ | _Gm._ | _Gm._ |_Calories_ -----------------------------+---------+-------+--------------+---------- Breakfast: | | | | 1/2 grapefruit | | | 5 | 20 Broiled tomato 100 gm. | 1.5 | | 3 | 18 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 1.5 | | 8 | 38 Dinner: | | | | Broth 120 c.c. | 3 | | | 12 Lettuce 50 gm. | .5 | | 1.5 | 8 Cauliflower 90 gm. | 1.5 | .4 | 3.9 | 25 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 5 | .4 | 5.4 | 45 Supper: | | | | 1 egg | 5.35 | 4.16 | | 59 String beans 100 gm. | 2 | | 5 | 28 Celery 50 gm. | .5 | | 1.5 | 8 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 7.85 | 4.16 | 6.5 | 85 Total for day | 14.3 | 12.5 | 19.9 | 168 =============================+=========+=======+==============+==========

SIXTH DAY =============================+=========+=======+==============+========== |_Protein_| _Fat_ |_Carbohydrate_| | _Gm._ | _Gm._ | _Gm._ |_Calories_ -----------------------------+---------+-------+--------------+---------- Breakfast: | | | | Asparagus tips 60 gm. | 1.5 | | 3 | 18 Spinach 60 gm. | 1.1 | 1.8 | 1.8 | 32 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 2.68 | 1.8 | 5.8 | 50 Dinner: | | | | Stewed celery 100 gm. | 1 | .10 | 2.1 | 15 String beans 50 gm. | 1.5 | | 2.5 | 16 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 2.5 | .1 | 5.6 | 31 Supper: | | | | Beet tops 75 gm. | 1.5 | | 2.5 | 16 Onions (boiled) 75 gm. | 1.5 | .3 | 7.5 | 44 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 3 | .3 | 10 | 60 Total for day | 11.2 | 2.2 | 21.4 | 141 =============================+=========+=======+==============+==========

FAST

~Method of Administering Treatment.~--In many cases the patient is first put to bed during the starvation treatment, but recently Dr. Allen has emphasized the value of exercise, claiming that it assists in utilizing the sugar. In any case, the starvation regime remains the same. The patient is given only coffee or clear broth with or without whisky (one ounce every two hours) and the treatment continued from one to four days, or until the urine becomes sugar free.[141]

It has rarely been found necessary to continue the fast longer than four days, since in most cases the sugar decreases rapidly upon the discontinuance of food.

~Loss of Weight.~--The slight loss of weight, which may be noticeable as the result of starvation, is not undesirable, especially in those cases where obesity is a prominent feature. In fact care must be exercised in the follow-up treatment to prevent the taking on of weight by the diabetic individual, since, according to Allen, it is often found that even moderately obese patients (180 lb.) continue to excrete a small amount of sugar so long as they hold this weight, even upon a low carbohydrate diet, whereas those same patients show no difficulty in becoming sugar free if the weight is reduced by ten or fifteen pounds.

SCHEDULE FOR TREATMENT AND METHODS OF DETERMINING FOOD TOLERANCES

A number of schedules have been devised to enable the nurse successfully to carry out the Allen Treatment. In following out this treatment and reeducating the organs afterward to tolerate foods which they have been unable to handle on account of the impairment of the sugar-making organs, it is necessary to make a series of tests whereby the diet is gradually increased in its various constituents until the diabetic patient is able to handle a reasonable amount of carbohydrates as well as other foods which have given more or less trouble in the past.

The following schedule, after Joslin,[142] is included, and a careful study of it is advised in order that the nurse may intelligently carry out the Allen Treatment.

~Schedule.~--Fasting in many cases begins at once and the patient experiences no ill effects from it. However, in severe, long-standing cases many patients do better if the fats are omitted at once and the rest of the diet left unchanged for two days. Then the proteins in the diet are omitted and the carbohydrates cut in half. This halving of the carbohydrates is continued daily until only 10 grams remain, after which they too are omitted. The fast is thus made complete and remains so until the urine is entirely free from sugar.

~Carbohydrate Tolerance~ is determined by giving, as soon as the urine has been sugar-free for twenty-four hours, 150 grams of 5% vegetables. This is equivalent to from 8 to 10 grams of carbohydrates. After this 5 grams of carbohydrates, or 75 grams of 5% vegetables, are added daily to the diet until the patient is taking 20 grams. Then the addition of 5 grams of carbohydrates is made every other day, using the fruits and vegetables belonging to the 10% and 15% carbohydrate group, until potatoes and oatmeal and finally bread can be tolerated unless sugar appears in the urine before this or the tolerance reaches 3 grams to each kilogram of body weight or, in other words, until a man weighing 150 pounds is consuming 225 grams of carbohydrates per day.

~Protein Tolerance.~--In making the test for the protein tolerance it is necessary to wait until the urine has been sugar free for forty-eight hours; 20 grams of protein is then given. This is equivalent to 3 eggs, and daily additions of 5 grams protein are made, usually in the form of meat, until the patient is receiving 1 gram of protein to every kilogram of his body weight per day unless his carbohydrate tolerance is zero, in which case it is wise to add only three-fourths of a gram of protein per day.

~Fat Tolerance.~--A determination of the fat tolerance is made coincidently with that of the protein. No additional fat is allowed until the protein tolerance reaches 1 gram per kilogram of body weight, unless the patient's tolerance for protein is less than that. After which 25 grams of fat per day are added until there is no further loss of weight, taking care never to allow more than 40 calories per kilogram of body weight.

~Reappearance of Sugar.~--Should the urine again show the presence of sugar, another period of fasting lasting for twenty-four hours, or until the urine is again sugar free, must be instituted. After the second fast the increase in the diet may be twice as rapid as used after the first fast. However, it is not advisable to increase the amount of carbohydrates to more than half of that determined by the former tolerance for a period of two weeks, during which time the urine has been entirely sugar free, then the increase is made more slowly and the amount given should not exceed 5 grams a week.

~Weekly Fast Days.~--One day in seven should be set aside by the diabetic patient for fasting, when the carbohydrate tolerance is less than 20 grams. When, however, the tolerance is between 20 and 50 grams of carbohydrates, the patient may take one-half of his daily allowance of protein and fat and a certain amount of 5% vegetables as well upon the weekly fast day. When the tolerance reaches between 50 and 100 grams per day, vegetables of a higher carbohydrate content may also be included. If the carbohydrate tolerance should exceed 100 grams per day, the carbohydrates upon the fast day may be simply half of the amount allowed upon other days.

~The Giving of Alkalies.~--If acidosis is evident, as may be indicated by an excretion of diacetic acid, oxybutyric acid, or acetone in the urine, alkalies may be given. Bicarbonate of soda may be given in doses of 2 grams every 3 hours, as suggested by Hill and Eckman,[143] but this is not as a rule necessary, for, as Jacobi aptly remarks: "Prevention is the treatment of acidosis in children, and those susceptible to acidosis should not have fat." What he has said for children holds good for adults. However, it is likewise true that fat must constitute a large part of a diabetic diet and the only way to prevent it poisoning, is to raise the fat in the diet gradually until the tolerance is determined.

~Determining the Extent of Acidosis.~--It will be remembered that in an earlier chapter it was found that the excretion of ammonia in the urine to a certain extent indicated the extent of the acidosis in the body, that is, if the ammonia output exceeds three or four grams a day (twenty-four hours), the extent of the acidosis is considerable, while if it falls below that amount it is not alarming. More exact methods, however, for the determining of the severity of the acidosis will be found in another part of this text, where the test for sugar and the acetone bodies will be explained in detail.

~Dietetic Treatment.~--The patient is placed upon a vegetable diet consisting of vegetables containing not more than five per cent. carbohydrate.[144] These vegetables have their carbohydrate content still further reduced by changing the water in which they are cooked three times. In many cases this will reduce their content as much as one-half.

A small amount of fat usually in the form of butter is allowed with these vegetables. The amount of 5% vegetables given must be carefully adjusted since the patient might readily take too much if allowed to follow the dictates of his appetite.

The carbohydrate intake during the first one or two days must be limited to 15 grams. This allows about 10 grams of protein, 7 grams of fat, and 15 grams of carbohydrates. Tea or coffee, without sugar or cream, may be given at each of the three meals.

The following table is included, showing the various foods arranged according to their carbohydrate content:

TABLE[145]

STRICT DIET

Meats, fish, broths, gelatin, eggs, butter, olive oil, coffee, tea, and cracked cocoa.

Foods arranged approximately according to per cent of carbohydrates

======================+==============+================+=============== 5% | 10% | 15% | 20% ----+-----------------+--------------+----------------+--------------- |Lettuce |Pumpkin |Greens |Potatoes |Cucumbers |Turnip |Peas |Shell beans |Spinach |Kohl-rabi |Artichokes |Baked beans |Asparagus |Squash |Parsnips |Green corn |Rhubarb |Beets |Lima beans |Boiled rice F |Endive |Carrots | (canned) |Boiled macaroni r |Marrow |Onions | |Prunes V e |Sorrel |Mushrooms | | e s |Sauerkraut | | | g h |Beet greens | | | e |Dandelion | | | t o |Swiss chard | | | a r |Celery | | | b |Brussels sprouts | | | l C |Water cress | | | e a |Sea kale | | | s n |Okra | | | , n |Cauliflower | | | e |Eggplant | | | d |Cabbage | | | |Radishes | | | |Leeks | | | |String beans | | | |Broccoli | | | |Tomatoes | | | ----+-----------------+--------------+----------------+--------------- |Ripe olives |Lemons |Apples |Plums F | (20% fat) |Oranges |Pears |Bananas r |Grapefruit |Cranberries |Apricots | u | |Blackberries |Blueberries | i | |Gooseberries |Cherries | t | |Peaches |Currants | s | |Pineapple |Raspberries | | |Watermelon |Huckleberries | ----+-----------------+--------------+----------------+--------------- |Butternuts |Brazil nuts |Almonds |Peanuts 40% N |Pignolias |Black walnuts |English walnuts |Chestnuts u | |Hickory |Beechnuts | t | |Pecans |Pistachios | s | |Filberts |Pine nuts | ====+=================+==============+================+=============== M | Unsweetened and unspiced Reckon available carbohydrates i | pickle, clams, oysters, in vegetables of 5% group as 3%, s | scallops, liver, fish of 10% group as 6%. c | roe. . | ====+=================================================================

30 grams (1 oz.) contains approximately:

==============================+=========+=====+==============+========== |_Protein_|_Fat_|_Carbohydrate_| | _Gm._ |_Gm._| _Gm._ |_Calories_ ------------------------------+---------+-----+--------------+---------- Oatmeal, dry weight | 5 | 2 | 20 | 110 Meat (uncooked ham) | 6 | 3 | 0 | 50 Meat (cooked ham) | 8 | 5 | 0 | 75 Broth | 0.7 | 0 | 0 | 3 Potato | 1 | 0 | 6 | 25 Bacon | 5 | 15 | 0 | 155 Cream, 40% | 1 | 12 | 1 | 120 Cream, 20% | 1 | 6 | 1 | 60 Milk | 1 | 1 | 1.5 | 20 Bread | 3 | 0 | 18 | 90 Butter | 0 | 25 | 0 | 240 Egg (one) | 6 | 6 | 0 | 75 Brazil nuts | 5 | 20 | 2 | 210 Orange or grapefruit (one) | 0 | 0 | 10 | 40 Vegetables, 5% and 10% groups | 0.5 | 0 | 1 or 2 | 6 or 10 Oysters | 6 | 1 | 4 | 50 ------------------------------+---------+-----+--------------+----------

TABLE[146]

Carbohydrate equivalent of 1 slice of white bread (1 oz. or 30 gm.) containing approximately 15 gm. of starch

TABLE[148]

Caloric equivalent of 10 gm. steak in carbohydrate-free meat or fish

=================+============+============+============+=========== _Food_ | _Gm._ | _Fat_ | _Protein_ | _Calories_ | | _Gm._ | _Gm._ | -----------------+------------+------------+------------+----------- Steak | 10 | 1.0 | 2.4 | 19 Roast beef | 5 | 1.4 | 1.1 | 18 Tongue | 7 | 1.4 | 1.6 | 20 Lamb chop | 5 | 1.5 | 1.1 | 18 Roast lamb | 8 | 1.3 | 1.6 | 20 Sweetbreads | 11 | 0.1 | 4.4 | 19 Boiled ham | 7 | 1.4 | 1.5 | 19 Fried ham | 5 | 1.7 | 1.1 | 20 Roast pork | 9 | 0.9 | 2.6 | 19 Bacon | 9 | 1.7 | 0.9 | 20 Chicken | 10 | 1.0 | 2.4 | 19 Duck | 9 | 1.3 | 1.8 | 19 Guinea hen | 12 | 0.8 | 2.8 | 19 Squab | 9 | 1.1 | 2.1 | 19 Turkey | 7 | 1.3 | 2.0 | 20 Bluefish | 13 | 0.6 | 3.5 | 20 Halibut | 16 | 0.7 | 3.3 | 20 Mackerel | 15 | 1.0 | 2.5 | 20 Sardines in oil | 7 | 1.4 | 1.6 | 20 =================+============+============+============+===========

Approximate equivalent in 30 c.c. (1 oz.) of whisky in liquors containing 2 per cent or less of carbohydrates

==============================+==============+=============== | | _Household_ | _C.C._ | _Measure_ ------------------------------+--------------+--------------- Gin, rum, brandy | 30 | 2 tbs. Claret, Burgundy Hock, Rhine | | and Moselle wines | 130-160 | 3/4 tumbler ==============================+==============+===============

CARBOHYDRATE-FREE MENUS

The following menus are suggested as meeting the carbohydrate-free diet requirements with a nutrient value of from 200 to 500 calories:

Breakfast--Black coffee (cream, 20 c.c.) } Bacon, 2 slices (1 oz.) } 30 grams Egg--1

Dinner--Broth, 6 ounces 180 grams Steak, 1 small piece, 1-1/3 oz. 40 grams Stewed tomatoes, 3-1/3 oz. 100 grams Lettuce (lemon juice and olive oil) 25 grams

Supper--Broth 180 grams Whitefish 40 grams Spinach 100 grams Cabbage salad 100 grams Coffee

Breakfast--1/2 grapefruit 1 egg Bacon 40 grams Coffee 50 grams Cream 20 c.c.

Dinner--Broth 180 c.c. Kohl-rabi 100 grams Lettuce 25 grams Cheese salad 50 grams Roast beef 40 grams Coffee Butter 5 grams

Supper--Cold chicken 25 grams Baked tomatoes 100 grams Water cress 50 grams Coffee Cream 20 c.c. Butter 5 grams

TABLE

KEY: A _Protein Gm._ B _Fat Gm._ C _Carbohydrate Gm._ D _Calories_

===================+========================+=====+======+=====+======== | | | | | _Material_ | _Measure_ | A | B | C | D -------------------+------------------------+-----+------+-----+-------- Apple | 1 medium (150 gm.) | .5| .5 | 16 | 70 Almonds[149] | 10 small (10 gm.) | 2 | 5 | 2 | 63 Apricots (dried) | 1 oz. (30 gm.) | 1.5| .28| 17.5| 78 Asparagus | 6 large stalks | 1.3| .14| 2.5| 16 | (74 gm.) | | | | Bacon (raw)[149] | 4 slices, 6 in. long, | 10 | 64 | | 636 | 2 in. wide | | | | Bacon (cooked)[149]| 4 slices, 6 in. long, | 10 | 32 to| | 388 to | 2 in. wide | | 46 | | 468 Beef juice[150] | 100 gm. | 4.9| .6 | | 25 Beef roast[149] | 1-1/2 in. x 1/8 in. | 6 | 7 | | 89 Cheese[149] | | | | | (Neufchatel) | 1 cheese 2-1/4 in. x | 16 | 23 | 1 | 284 | 1-1/2 in. x 1-1/4 in. | | | | Cream, gravity 16% | 1 glass (7 oz.) | 5 | 32 | 10 | 359 Cream, 40% | 30 c.c. (2 tbs.) | .6| 12 | 1 | 114 Cracker (Uneeda | 1 biscuit | 1 | .5 | 1 | 16 biscuit) | | | | | Dry peptonoids[150]| 1 tbs. | 6 | | 8 | 57 Egg | 1 medium (45 to | 54 | 4.2 | | 60 | 50 gm.) | | | | Fowl | 3-1/2 oz. (100 gm.) | 19.3| 16.3 | | 224 Grapefruit | 1/2 | | | 5 | 20 Ham (lean) | 50 gm. | 12.4| 7.1 | | 113 Lemon juice[151] | 3 tbs. (43 gm.) | | | 4.2| 19 Lemon Jelly[152] | 3 oz. (90 gm.) | 2.6 | | 1.4| 16 Milk (whole) | 1 glass (8 oz.) | 7.9 | 9.6 | 10 | 158 | 240 c.c. | | | | Oatmeal[153] | 1 tbs. (50 gm.) | 1 | | 6 | 33 Oatmeal | 1/2 cup (3.6 oz.) | 2.1| .1 | 8.2| 50 Potato[153] (size | | | | | large egg) | 1 (100 gm.) | 2 | | .8| 83 5% vegetable[153] | | | | | uncooked | 1 tbs. | | | 2.5| 10 5% vegetable | | | | | (boiled once) | 1 tbs. | | | 1.7| 7 5% vegetable | | | | | (boiled thrice) | 1 tbs. | | | 1 | 4 Orange | 1 large | 1.7| .2 | 22.7| 100 Orange[153] | 1 medium | 1 | | 13 | 57 -------------------+------------------------+-----+------+-----+--------

~Increasing the Diet.~--The following menus show the manner in which the diet is increased after the starvation treatment:

~First Day~

Approximately 150 grams of vegetables with tea or coffee; value: protein 2, fat trace, carbohydrate 4.

Breakfast--String beans 20 grams Celery hearts 20 grams

Lunch--Spinach 25 grams Lettuce 25 grams

Supper--Tomatoes 25 grams Cucumbers 25 grams

~Second Day~

Three eggs, 150 grams of 5% vegetables, tea or coffee; value approximately: protein 18, fat 12, carbohydrate, 4, calories 198.

Breakfast--1 poached egg Spinach or beet tops 50 grams Coffee or tea

Dinner--1 hard-cooked egg String beans 25 grams Lettuce 25 grams Tea

Supper--1 soft-cooked egg Asparagus tips 25 grams Tomatoes 25 grams

~Third Day~

Approximately 19 grams protein, 15 grams fat, 5 grams carbohydrate, 230 calories.

Breakfast--1 egg String beans 50 grams Tomatoes 25 grams Coffee

Dinner--Cauliflower 50 grams Celery 50 grams Tea

Supper--Asparagus 75 grams Lettuce 50 grams

~Fourth Day~

Approximately 26 grams protein, 15 grams fat, 10 grams carbohydrate, 279 calories.

Breakfast--1 egg String beans 75 grams Coffee with cream 15 c.c.

Dinner--Tomato bouillon 6 oz. (180 c.c.) 1 egg Asparagus 75 grams Lettuce 25 grams Tea

Supper--1 egg Celery 50 grams Cauliflower 100 grams

~Fifth Day~

Approximately 20 grams protein, 46 grams fat, 15 grams carbohydrate.

Breakfast--Egg omelet (1 egg) Butter 10 grams Vegetable hash 100 grams Coffee or tea Cream 15 grams

Dinner--Chicken broth 180 c.c. 1 poached egg Tomatoes 100 grams Tea

Supper--1 soft-cooked egg Spinach 100 grams Cucumbers 50 grams Tea or Coffee Cream 15 grams

~Sixth Day~

Approximately 33 grams protein, 35 grams fat, 12 grams carbohydrate, 495 calories.

Breakfast--1/2 grapefruit 1 egg Butter 5 grams Spinach 50 grams Coffee Cream 15 grams

Dinner--Broth 180 grams Fish 50 grams String beans 100 grams Lettuce 50 grams Asparagus 50 grams

Supper--2 eggs Tomato, baked (1 medium) 75 grams Cabbage salad 75 grams Tea Cream 15 grams

~Seventh Day~

Approximately 38 grams protein, 45 grams fat, 17 grams carbohydrate, 625 calories.

Breakfast--1/2 grapefruit 2 eggs Butter 10 grams Coffee Cream 15 grams

Dinner--Beef broth 180 grams 1 lamb chop 50 grams Cauliflower 100 grams Tomato 150 grams Lettuce 50 grams Butter 10 grams

Supper--1 egg Tuna salad 50 grams String beans 100 grams Butter 5 grams Tea

~Eighth Day~

Approximately 32 grams protein, 16 grams fat, 20 grams carbohydrate, 625 calories.

Breakfast--1 egg String beans 100 grams Raw tomatoes 100 grams Coffee Cream 15 grams

Dinner--Chicken 50 grams Cabbage 100 grams Asparagus 100 grams Water-cress salad 50 grams Tea

Supper--1 egg Greens 100 grams Celery salad 50 grams Tea Cream 15 grams

The following menus are used after the diet has been more or less increased:

~First Day~

Breakfast--1 soft-cooked egg 2 slices of bacon 1 bran muffin, 5 gm. butter Coffee with 15 c.c. of 40% cream

Lunch--6 oz. tomato bouillon 2 oz. (60 gm.) roast lamb 60 gm. string beans 50 gm. lettuce and celery salad 25 gm. lemon jelly with 15 gm. cream

Dinner--60 gm. chicken 75 gm. asparagus 4 olives 50 gm. cauliflower 30 gm. ice cream 1 Lister roll, 5 gm. butter Black coffee

~Second Day~

Breakfast--1/2 grapefruit 1 scrambled egg 1 Lister roll, 8 gm. butter Coffee with 15 gm. cream

Lunch--60 gm. baked halibut with 10 gm. parsley butter 70 gm. cauliflower 50 gm. lettuce 1 Lister roll, 8 gm. butter Tea

Dinner--6 oz. chicken broth 60 gm. roast beef 75 gm. cabbage 75 gm. string beans 30 gm. coffee jelly with 15 gm. cream Black coffee

~Third Day~

Breakfast--1 soft-cooked egg 2 slices bacon 1 Casoid flour and bran muffin with 5 gm. butter Coffee with 15 gm. cream

Lunch--100 gm. cabbage 40 gm. corned beef 50 gm. tomato salad 1 soya meal muffin, 8 gm. butter Tea

Dinner--60 gm. beefsteak 75 gm. asparagus 75 gm. spinach 30 gm. tomato aspic 30 gm. soft (diabetic) custard Black coffee

~Fourth Day~

Breakfast--1 scrambled egg with 20 gm. chipped beef 1 Casoid flour muffin with 8 gm. butter Coffee with 30 gm. or less cream

Lunch--6 oz. tomato bisque 60 gm. tuna fish salad 75 gm. vegetable hash 1 Lister roll, 8 gm butter Tea

Dinner--60 gm. broiled chicken 75 gm. string beans 75 gm. cauliflower 30 gm. tomato and celery salad 30 gm. wine jelly, with 15 gm. whipped cream Black coffee

~Fifth Day~

Breakfast--1/2 grapefruit 1 soft-cooked egg 1 bran muffin with 8 gm. butter Coffee, 15 gm. cream

Lunch--40 gm. broiled beefsteak 75 gm. spinach 75 gm. boiled onion 1 soya meal muffin with 8 gm. butter Tea

Dinner--6 oz. tomato bouillon 80 gm. baked fish with parsley sauce 75 gm. Brussels sprouts with 5 gm. butter 1 Lister roll with 5 gm. butter Coffee jelly, 30 gm., with 15 gm. whipped cream

~Sixth Day~

Breakfast--1 poached egg 2 slices bacon 1 bran and Casoid muffin with 5 gm. butter Coffee with 15 gm. cream

Lunch--Ham omelet (1 egg, 1 tbs. cream, 15 gm. minced ham) 75 gm. spinach 1 soya meal muffin with 8 gm. butter Tea

A departure from the now almost universally used "Allen-Joslin Starvation Diet," is seen in the "Newburg-Marsh High Fat Diet."

The use of a high fat diet in the treatment of diabetes is based primarily on one fact--namely, that if the food eaten is not sufficient for the needs of metabolism, the body itself supplies the deficiency. Fat is used as long as it lasts, body protein being drawn upon for fuel when this is exhausted. It is of distinct advantage to the patient to have a diet of sufficient fuel value to run his body machine and permit him a moderate degree of exercise. For by this means he is not obliged to use his own body substance to carry on metabolic processes. We thereby avoid the condition of extreme emaciation (though it is to be emphasized that gain in weight is to be carefully guarded against) with its constant lowering of the general health.

The system of feeding consists of a series of four diets, examples and standards of which are given below. The diet is made up of protein on the basis of approximately 2/3 of a gram per kilogram of body weight at the time the patient leaves the hospital, a quantity of carbohydrate known to be well tolerated and the balance of the calories in fat.[154]

DIABETIC DIET NO. 1 ======================================================================= 18-22 Proteins 12-15 Carbohydrates 800-1000 calories -------------------------+--------+---------+-----+---------+---------- |_Weight_|_Protein_|_Fat_|_Carbo-_ | _Food_ | _Gm._ | _Gm._ |_Gm._|_hydrate_|_Calories_ | | | | _Gm._ | -------------------------+--------+---------+-----+---------+---------- Dinner: | | | | | Fish | 50 | 8.9 | 5.1| | 82 with Butter | 10 | .1 | 8.5| | 77 Cabbage | 50 | .8 | .1| 2.8 | 16 with mayonnaise | | .7 | 38.2| | 353 Tomatoes | 100 | 1.2 | .2| 4.0 | 23 Broth--Tea | | | | | | | | | | Supper: | | | | | String beans | 80 | 1.8 | .2| 5.9 | 33 with bacon | 10 | 1.0 | 6.5| | 62 Spinach soup-- | | | | | Spinach | 10 | .2 | | .3 | 2 Cream | 10 | .2 | 4.0| .3 | 38 Broth to fill bowl | | | | | Celery | 20 | .2 | | .7 | 4 Broth--Tea | | | | | | | | | | Breakfast: | | | | | Omelet-- | | | | | 1 egg | | 6.7 | 5.2| | 74 with butter | 10 | .1 | 8.5| | 77 Coffee | | | | | -------------------------+--------+---------+-----+---------+---------- | | 21.9 | 76.5| 14.0 | 842 =========================+========+=========+=====+=========+==========

DIABETIC DIET NO. 2 ======================================================================= 25-30 Proteins 18-22 Carbohydrates 1200-1600 calories -------------------------+--------+---------+-----+---------+---------- |_Weight_|_Protein_|_Fat_|_Carbo-_ | _Food_ | _Gm._ | _Gm._ |_Gm._|_hydrate_|_Calories_ | | | | _Gm._ | -------------------------+--------+---------+-----+---------+---------- Dinner: | | | | | Pork chops | 60 | 10.0 | 18.0| | 202 Cabbage | 100 | .2 | .3| 5.6 | 32 (Use pork drippings) | | | | | Spinach | 100 | 2.1 | .3| 3.2 | 24 with butter | 20 | .2 | 17.0| | 154 Broth--Tea | | | | | | | | | | Supper: | | | | | Asparagus salad-- | | | | | Lettuce | 10 | .1 | | .3 | 2 Asparagus | 80 | 1.2 | .1| 2.1 | 13 Mayonnaise | 50 | .7 | 38.8| | 338 Tomatoes | 100 | 1.2 | .2| 4.0 | 23 with butter | 10 | .1 | 8.5| | 77 Nut charlotte-- | | | | | Walnuts, chopped | 10 | 1.8 | 6.4| 1.3 | 70 Cream | 50 | 1.1 | 20.0| 1.5 | 190 Broth--Tea | | | | | | | | | | Breakfast: | | | | | Bacon | 20 | 2.1 | 13.0| | 125 with 1 egg | | 6.7 | 5.2| | 74 Coffee with cream | 30 | .7 | 12.0| .9 | 114 -------------------------+--------+---------+-----+---------+---------- | | 28.2 |139.8| 18.9 | 1438 =========================+========+=========+=====+=========+==========

DIABETIC DIET NO. 3 ======================================================================= 30-35 Proteins 25-30 Carbohydrates 1600-2000 calories -------------------------+--------+---------+-----+---------+---------- |_Weight_|_Protein_|_Fat_|_Carbo-_ | _Food_ | _Gm._ | _Gm._ |_Gm._|_hydrate_|_Calories_ | | | | _Gm._ | -------------------------+--------+---------+-----+---------+---------- Dinner: | | | | | Beef tenderloins | 80 | 13.0 | 19.5| | 227 with butter | 10 | .1 | 8.5| | 77 Asparagus | 100 | 1.5 | .1| 2.8 | 18 with butter | 10 | .1 | 8.5| | 77 Squash | 100 | 1.4 | .5| 9.0 | 46 with butter | 10 | .1 | 8.5| | 77 Broth--Tea | | | | | | | | | | Supper: | | | | | String bean salad-- | | | | | Lettuce | 10 | .1 | | .3 | 2 String beans | 50 | 1.1 | .1| 3.7 | 26 Pimento | 10 | .2 | | .4 | 2 Onion | 10 | .2 | | 1.0 | 5 Mayonnaise | 30 | .5 | 23.3| | 228 Tomatoes | 120 | 1.4 | .2| 4.8 | 28 with butter | 20 | .2 | 17.0| | 154 Chocolate pudding-- | | | | | Cream | 100 | 2.2 | 40.0| 3.0 | 381 Cocoa, 1/2 tsp | 1 | .2 | .3| .4 | 5 Broth--Tea | | | | | | | | | | Breakfast: | | | | | Bacon | 30 | 3.2 | 19.4| | 187 with 1 egg | | 6.7 | 5.3| | 74 Coffee with cream | 30 | .7 | 12.0| .9 | 114 -------------------------+--------+---------+-----+---------+---------- | | 32.9 |163.2| 26.3 | 1728 =========================+========+=========+=====+=========+==========

DIABETIC DIET NO. 4 ======================================================================= 50-60 Proteins 30-40 Carbohydrates 2000-2500 calories -------------------------+--------+---------+-----+---------+---------- |_Weight_|_Protein_|_Fat_|_Carbo-_ | _Food_ | _Gm._ | _Gm._ |_Gm._|_hydrate_|_Calories_ | | | | _Gm._ | -------------------------+--------+---------+-----+---------+---------- Dinner: | | | | | Veal steak (roast) | 100 | 19.9 | 10.8| | 177 Onions | 126 | 1.9 | .4| 11.9 | 49 with cream | 50 | 1.1 | 20.0| 1.5 | 190 Tomatoes | 150 | 1.8 | .3| 6.0 | 35 with butter | 30 | .3 | 25.5| | 231 Fruit salad-- | | | | | Lettuce | 10 | .1 | | .3 | 2 Celery | 50 | .6 | | 1.6 | 9 Grapefruit | 80 | .6 | .2| 8.1 | 37 Whipped cream | 30 | .7 | 12.0| .9 | 114 Tea--Broth | | | | | | | | | | Supper: | | | | | Cream of celery | | | | | soup-- | | | | | Celery | 50 | .6 | | 1.6 | 9 Cream | 75 | 1.6 | 30.0| 2.2 | 285 Broth to fill bowl | | | | | Boiled ham | 30 | 6.1 | 6.7| | 85 Custard-- | | | | | 2 egg yolks | | 4.7 | 10.0| | 109 Cream | 90 | 2.0 | 36.0| 2.7 | 343 Tea | | | | | | | | | | Breakfast: | | | | | Eggs (2) | | 13.4 | 10.5| | 148 with butter | 30 | .3 | 25.5| | 231 Coffee with cream | 20 | .4 | 8.0| .6 | 76 Broth | | | | | -------------------------+--------+---------+-----+---------+---------- | | 56.1 |195.9| 37.4 | 2130 =========================+========+=========+=====+=========+==========

~Nurse's Directions for Collecting and Testing the Urine in Diabetes Mellitus.~--The first urine voided in the morning at 7 A.M. should be thrown away, after which the entire quantity during the ensuing twenty-four hours, including that at 7 A.M. the following morning, should be collected in a thoroughly clean, wide-mouth bottle sufficiently large to contain the entire quantity. This should be kept in a cool place to prevent decomposition. After the urine has been measured, four or five ounces are removed for testing purposes. There is no necessity for having an elaborately equipped laboratory for making the simple tests of the diabetic urine. The nurse is only required to make the simple tests, leaving the more elaborate one for the physician. The articles necessary for these tests must be kept perfectly clean in order to make the tests accurate. The bottle in which the urine is collected must be washed and sterilized daily before the collection begins. One small three-inch white enameled or porcelain dish, one 10 c.c. graduated pipette, 6 test tubes, 1 small alcohol lamp or Bunsen burner, 1 box of sodium carbonate, 1 box talcum, and the reagents necessary for making the test, namely, Benedict's solution, Fehling's solution, and Haines's solution.

SUMMARY

~Diabetes Mellitus~ is a disease in which the body becomes more or less unable to utilize the sugars and starches, consequently there is an abnormal amount of glucose in the urine.

~Manufacture of Sugar~ in the body from other food constituents besides carbohydrates has been proved with regard to proteins, hence the intake of nitrogenous substances must be restricted in diabetes--to a less extent, however, than the sugars and starches.

~Acetone Bodies.~--Diacetic acid, oxybutyric acid, and acetone develop in diabetes as a result of the breaking down of the fats and the lack of certain neutralizing agents found chiefly in carbohydrate foods.

~Acidosis~ is a form of intoxication due to the retention of these toxic acids in the body. If not combated and overcome, it will result in the diabetic coma which is fatal in so many cases.

~Diet Treatments.~--The best known treatments are those devised and used by Drs. Allen and Joslin "The Starvation Treatment for Diabetes Mellitus," and the "High Fat Diet" formulated by Drs. Newburg and Marsh. All cases cannot be handled alike and it is for the physician to determine the treatment calculated to give the best results in the definite case.

~Training for Diabetic Nursing.~--So much depends upon the administration of the treatment in this pathological condition that in many hospitals special training is being given to the nurses in the care of diabetic patients that they may be able intelligently to carry out the necessary regime, both in the hospital and in private practice.

~Symptoms.~--She must be able to recognize symptoms both from the findings resulting from the urinalysis and from those manifested otherwise by the patient.

~The Record.~--She must keep an absolute record of all that occurs during the course of treatment and instantly report any unusual happening.

~Urine Tests.~--It is advisable to make the tests in the morning; those for sugar and diacetic acid should be made every day or, in some cases, every other day, as directed by the physician, and those for ammonia and albumen about once a week.

~Weighing the Patient.~--Patient should be weighed each day before breakfast, and the weight of the clothes also carefully recorded separately.

~The Bowels~ must move daily, even if it is necessary to resort to mild laxatives or an enema.

~Formulating and Calculating the Dietary.~--The menus of the day must be formulated and the chemical composition and nutrient value of the foods calculated. The vegetables belonging to the five per cent. group should be in readiness and the amount to be used weighed after they have been boiled in clean, separate water to reduce their carbohydrate content still further.

~Commercial Diabetic Foods.~--It may be well to mention the danger of putting faith in the so-called diabetic foods so widely advertised. Some of these foods are of undoubted worth, but it is never safe for the nurse or the patient to judge of the merits of the various diabetic foods without first knowing their chemical composition, and not even then without the definite directions from the physician.

~Diabetic Flours.~--The diabetic flours used in the recipes included in this text have been approved by some of the leading specialists in diabetes in this country, but the nurse should not include them in the diet for her patient unless they are prescribed by the physician in charge.

PROBLEMS

(a) Outline test diets for determining the severity of the disturbance.

(b) Give examples of diets used in testing for tolerance of carbohydrates, fats, proteins.

FOOTNOTES:

[137] Allen's Paradoxical Law, quoted from "Treatment of Diabetes Mellitus," p. 18, by Joslin.

[138] "Treatment of Diabetes Mellitus," p. 305, Joslin.

[139] "Food for the Sick," by Strouse and Perry.

[140] Courtesy of Dr. Joslin and Thomas Groom & Co., Boston.

[141] The giving of coffee or clear broth, with or without whisky, does not materially affect the starvation and serves to make the patient more comfortable during this trying period.

[142] Dr. Joslin has given a very complete schedule in his "Treatment of Diabetes Mellitus," from which the above schedule is taken.

[143] Hill and Eckman's "Starvation (Allen) Treatment of Diabetes."

[144] See 5% vegetable, p. 383.

[145] Table used by Dr. Joslin in his treatment of diabetes mellitus. It is convenient, and many changes in the diet may be made by substituting one food for another of like carbohydrate content. This table can be purchased on cards from Thomas Groom & Co., Boston, Mass.

[146] Table devised by H. O. Mosenthal showing accessory diets rich in carbohydrates. "Medical Clinics of North America," July, 1917.

[147] "h" represents household measure.

[148] Mosenthal: "Medical Clinics of North America," July, 1917.

[149] "Starvation Treatment of Diabetes," by Hill and Eckman.

[150] "Practical Dietetics," by Alidia Pattee.

[151] "Food for the Sick," p. 62, by Strouse and Perry.

[152] Sweetened with saccharin.

[153] "Starvation Treatment of Diabetes," by Hill and Eckman.

[154] Courtesy of R. Eckman and D. M. Stewart, University of Michigan Hospital, Ann Arbor, Michigan.