The Treatment of Diabetes Mellitus: With Observations Upon the Disease Based Upon One Thousand Cases

In the treatment of diabetes the diet plays tho most important part. We cannot attack the real cause of the disease because we do not know it. Our task, then, is to prevent, so far as is possible, sugar-production. This can bo done only in the mild form of diabetes. The diet should be regulated as follows: 

There should be absolute avoidance of carbohydrates, and accordingly a diet composed exclusively of fat and meat. Cantani and other physicians have wished to embody this principle in its entirety in their practice, and Cantani believes that he has seen a cure following a long-continued diet composed exclusively of meat. The reader has never seen so fortunate a result. Absolute meat diet, if it be long continued, has undoubtedly the advantage that it permits a certain tolerance for starch; but this tolerance is a very limited one, and a diabetic who, after a long-continued life of meat diet, allowed himself to live like a healthy person, would pay heavily for it. 

Aside from its great difficulty of accomplishment, a diet composed entirely of meat has this great drawback: cases so treated quickly acquire a catarrhal gastritis and enteritis. Besides this, the less-determined patients generally break through their diet regulations and eat injurious food without stint, because the treatment is so very unpleasant and of such long duration. 

The theory that diabetes can be cured has another great disadvantage connected with it. Patients from whose urine the sugar has all disappeared except a trace, consider themselves cured, and think their diet may be varied. In this way relapses occur. 

The idea which Seegen follows out in treating his diabetes cases is as follows: there should be ordered for the patient such a diet as can be continued throughout a life-time, with the aid of a strong determination. A diet of meat and fat should prevail. Seegen warns you that the patient must not be allowed to eat meat and eggs in too great quantities for the purpose of building himself up. A diabetic patient does not need more meat than any healthy person who lives chiefly on a meat diet. But with this diet the patient should be ordered green vegetables in any quantity desired, and sour (not sweet) fruit in moderate amount. Bread is indispensable for a time, and Seegen orders 40-60 grs. per diem, but speaks most decidedly against fresh bread, because this always contains starch, and if allowed, the control of the diet (over the disease) will be lost. An exclusive meat diet is strenuously to be recommended :

 (1.) If it is necessary to decide whether the disease is of the first or second form. 

(2.) When wounds do not heal and when gangrene sets in, or a surgical operation is necessary. 

Sour (not sweet) red or white wine is allowed in any quantity, and yet it is an error to allow a diabetic patient to drink large quantities of wine with the idea of strengthening him. Beer may be allowed in moderate quantity, (that is, about half a litre). In diabetes of the severe form abstinence from carbohydrates is important only because, as a result of such abstinence, the excretion of sugar is markedly lessened. To restrict cases of this kind to a meat diet is not indicated, for it makes little difference whether 20-30 grs. (sugar), more or less, are excreted ; and the advantage gained is not equivalent to the privation endured.

THE TREATMENT OF DIABETES MELLITUS 

BY ELLIOTT P. JOSLIN, M.D. 

Boston 

RATHER more success is achieved by surgeons in the treatment of general peritonitis than is attained by physicians in the treatment of diabetic coma. In neither condition are the statistics flattering to the profession; but the successes obtained by our surgical colleagues in the prevention of general peritonitis make the failure to prevent coma as a cause of two out of every three diabetic deaths mortifying to say the least. We physicians should begin to regard diabetic coma in the same light as your British brother, Mr. Moynihan, has taught the medical fraternity to look upon the late stages of a neglected gastric ulcer-namely, as an emergency which should not have been allowed to arise. With this issue of the prevention of diabetic coma plainly to the fore as the cardinal point in the treatment of diabetes, it is pertinent to inquire what diabetic patients are most susceptible to coma? And your own experience will enable you to anticipate that the answer, which an analysis of my own fatal cases shows, will be children. Of the sixty-two diabetic children under the age of fifteen who have died under my care, coma was the cause of death in all, and the significance of this melancholy fact is this: that where diabetes appears in its most severe type, as in children, coma is its expression. The propositions are simpler to state than to execute -first, that the best way to avoid coma is to prevent the progress of a case of diabetes from the mild into the severe type, and second, to protect the patient from all those agencies such as infections, anesthetics like chloroform and ether, undue exertion (mental or physical), which tend toward intensifying the severity of the disease. For if the diabetes is kept mild or moderate the coma need not be feared. Next to the children in the frequency of death from coma, strange as it may appear, were those of my cases who succumbed during the first year of the disease. The cause of death in 87 per cent. of these was coma. But diabetes is a chronic disease and the first year of its course should be mild rather than severe, and in mild diabetes coma should find no place.

Diabetes should be sought in the families of diabetic patients and in order to allay anxiety from urinary examinations, it is a good plan to have these made with such frequency that they will become simply a matter of routine. Such individuals should be taught to regulate the quantity of food eaten by the body weight, and never to indulge in unusual quantities of carbohydrate.

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

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

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.)

"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."