Elliott P. Joslin

"Caloric Values which Every Doctor Should Know by Heart. 

The quantity of carbohydrate, protein and fat found in an ordinary diet must be known by a physician if he wishes to treat a case of diabetes successfully. If he cannot calculate the diet he will lose the respect of his patient. The value of the different foods in the diet can be calculated easily from the diet Table 165. This is purposely simple, because a diet chart, to be useful, must be easily remembered . With these food values as a basis it is possible to give a rough estimate of the value and composition of almost any food . Various foods are also classified according to the content of carbohydrate (see p.435) in 5, 10, 15 and 20 per cent groups, and the lists are so arranged that those first in each group contain the least, those at the end the most . This is a practical and sufficiently accurate arrangement , because except in the most exact experiments the errors in the preparation of the food are too great to warrant closer reckoning. It is practically impossible , except when accurate analyses of the diet are made , to reckon the car bohydrate for the twenty - four hours closer than within 5 to 10 grams , and we had best acknowledge that fact . It is really surprising , however , how reliable the figures are if we do not push the matter to extremes . For example, the protein was analyzed in 10 portions of cooked lean meat, similar to 10 other portions served the same day at the New England Deaconess Hospital. In these analyses it was found that the protein content was 30 per cent . 

Repeatedly physicians have requested me to arrange the above table in terms of household measures. To a considerable extent this is impracticable because the diabetic diet deals with so small a quantity of carbohydrate."

Protein . The protein burned in the metabolism of a healthy individual from day to day depends chiefly on the protein supplied by the diet . Muscular exercise has little effect upon it , since that is dependent upon carbohydrate or fat, with a preference for the former. Even in the early days of fasting the protein metabolism changes but little from that in health. With a diet rich in carbohydrate and fat and low in protein the protein metabolism is easily brought to less than 50 grams per day, but with an excess of protein in the diet it may rise to 150 or 200 grams. A liver well stored with glycogen protects the body protein of a fasting man for a day just as carbohydrate in the diet , but on a second day fails because the glycogen is nearly exhausted. “The influence of the available supply of body fat upon the protein metabolism of fasting,” as cited by Sherman, "is shown by the following observations of Falck, on the protein metabolism of two fasting dogs -- the one lean, the other fat ." ( See Table 160. ) The fat dog was healthy thirty - five days after the lean dog died .

Carbohydrate.- 

From the preceding statements it will be seen that 55 per cent of the energy of the diet of the normal individual consists of carbohydrate . These figures are only approximate , but they leave no doubt as to how large a place sugar and starch occupy in the daily ration. (See p.415.) What percentage of carbohydrate is furnished by sugar is problematical . We do know, however, that the average individual was supposed to consume 84 pounds of cane sugar during the year 1921. This would amount to 105 grams, or 0.2 pounds, per day, which would amount to about one - fourth of the carbohydrate calories. 

The proportion of carbohydrate in the normal diet varies in different countries, reaching its maximum in the tropics and its minimum in the arctic zones. The people in India take 484 grams carbohydrate daily , while the Eskimos get along very comfortably upon 52 grams . Table 159 is arranged by modifying somewhat a similar table of Lusk's. It shows well the adaptability of different races to different diets . That the Eskimos live upon 52 grams of carbohydrate daily should greatly encourage diabetic patients . All who treat diabetics should be very thankful that there is a race of Eskimos through which proof is afforded that it is perfectly possible to maintain life on a diet in which carbohydrate is largely replaced by fat. The composition of the diet also varies in the same race from time to time and this has been interestingly described by Mendel.

Attention has already been called to the increase in the consumption of sugar in the United States during the last century. Rübner noted that the consumption of meat per capita in Germany had risen three and one - half times during a hundred years prior to the war. The effects of undernutrition during the war were manifest generally in Europe and America, but the total dietary restriction obscures the results of qualitative changes. (See p115.)

On this day in 1893, a student at Harvard Medical School made the first entry in a ledger he would keep for the rest of his long career. Elliott Joslin examined a frail young Irish girl, who was suffering from diabetes. Long before he became one of the world's leading authorities on diabetes, he understood the importance of careful documentation. Keen observation of his patients helped him develop a novel approach to the treatment of diabetes. He prescribed a strict diet that regulated blood sugar levels and helped patients manage their own care. The introduction of insulin in 1921 confirmed the effectiveness of Joslin's approach. Elliott Joslin saw 15 patients a day until a week before his death in 1962, at age 93.

Unlike many other men who made Boston a center of medical innovation, Elliott Joslin was born in Massachusetts — in the town of Oxford, 40 miles west of Boston. The son of a wealthy shoe manufacturer, Elliott was an unusually focused, driven young man. He attended Yale College, graduated at the top of his Harvard Medical School class, and served an internship at Massachusetts General Hospital. After additional study in Europe, he returned to Boston in 1898 and opened a private office in the house his father had bought in the Back Bay.

Although Joslin had been interested in diabetes since medical school, he began his career as a general practitioner. Physicians who specialized in one particular disease were still rare in American medicine, and it would be almost 20 years before Elliott Joslin emerged as one of the most influential people in the study and treatment of diabetes.

Mary Higgins's case sparked his interest and convinced him of the need to chart in detail the course of a patient's illness. Joslin began keeping a diabetic ledger in 1893; Mary Higgins was the first entry in the first volume. He documented every patient he treated for the next 70 years. Eventually, his ledgers filled 80 volumes and became the central registry for diabetes in the United States, the first system for recording patient diabetes data outside of Europe.

- Case #8: 

Dr. Joslin's Mother 

The first was 73 years old and was Dr. Joslin's mother. The second was 16 years old and the youngest daughter of Dr. James Jackson Putnam, who had been Dr. Joslin's principal mentor in the first year of his practice and his teacher in the medical school. Dr. Putnam was the austere, brilliant and path-finding neurologist whose name is now inscribed on the chair in Neurology at the Harvard Medical School. 

It is said that Dr. Joslin specialized in diabetes to help his mother with her disease. While this is not correct, he certainly remained highly interested in her progress as well as in her type of diabetes, hee proudly noted in his later writing that a remission or two occurred in her diabetes when she carefully followed the restraints of a good meal plan. In the first edition of his textbook on diabetes, published in 1916, EPJ described his mother's case, thinly disguised under the topic "Is the tendency of the diabetic glycosuria to increase?" 

A woman showed the first symptoms of diabetes in the spring of 1899 at 60 years of age and 5% of sugar was found in June. She had gradually lost during the preceding fifteen years, twenty pounds and weighed 165 pounds when the diagnosis was made. Under rigid diet, the urine promptly became sugar-free, the tolerance rose to 130 grams and safe for very brief intervals and remained so for nine years until 1908. In 1909, a carbuncle appeared. With prompt surgical care, vaccines, the restriction of carbohydrates and the temporary utilization of an oatmeal diet, the sugar disappeared and the carbuncle healed promptly, but the urine did not remain permanently sugar-free, although only about 30 grams of sugar was excreted. Residence in the hospital for a few days in September of 1912, in order to have a few teeth removed, lowered the sugar to 0.8%. 

Except for brief periods of illness due to the carbuncle and pneumonia, the patient remained well during all these years and was unusually strong and vigorous for a woman of 73 until she finally succumbed to a lingering illness subsequent to a hemiplegia and death finally occurred due to a terminal pneumonia in 1913. 

With his mother's case. Dr. Joslin described the most common presentation of diabetes. When she was diagnosed with diabetes, she was overweight and probably inactive. Had she been born a decade later, Mrs. Joslin might have enjoyed a life lengthened by the use of insulin in the 1920s and antibiotics in the 1930s. 

As an aside: Dr. Joslin's inheritance from his mother, Sara Proctor Joslin, left Dr. Joslin a millionaire several times over by today's standards. Sara Proctor, her sisters and one brother were the heirs to a very large fortune derived from their father Abel's leather tanning trade. Sara Proctor became the second wife of Dr. Joslin's father Allen, who was a shoe manufacturer in the town of Oxford. This connection with the Proctor leather tanning business guaranteed the success of the Joslin shoe factory. EPJ was fond of noting that he was a direct descendant of John Proctor of Salem, who had been hanged for defending his principles in the witch trials of 1692.

EPJ's lifestyle, in line with his upbringing and religion, always understated his affluence. However, it afforded him the means to aid family and associates with education and travel, as well as the ability to acquire the property needed to gradually expand his clinic. He underwrote Priscilla White's training in 1928 at the leading pediatric center in Vienna, a typical act of generosity to his co-workers.

On Dec. 1916, Boston pathologist Elliott Joslin compiles 1,000 of his own cases and creates the textbook The Treatment of Diabetes Mellitus. In it he reports that ‘the mortality of patients was approximately 20 per cent lower than for the previous year’, due to ‘the introduction of fasting and the emphasis on regular exercise.’ This book and Joslin’s subsequent research over the next five decades establishes his reputation as one of the world’s leading expert in diabetes.

https://www.youtube.com/watch?v=qTYjR1H-SqM

"Alternate feeding and fasting are adopted when it is found that the glycosuria persists after a preliminary four days' fast. The method which I have found most successful has been to allow, following the first fasting period, 20 to 40 grams carbohydrate not far from half a gram per kilogram body weight-and about one gram of protein per kilogram for two days.This can be avoided by still further restricting the carbohydrate, either temporarily or permanently. It is always necessary to bear in mind that one food which the diabetic patient cannot do without is protein, and to it everything else must be subservient. While testing the protein tolerance, a small quantity of fat is included in the eggs and meat given."