DIABETES DIABETES 
A HANDBOOK FOR PHYSICIANS 
AND THEIR PATIENTS 
BY 
PHILIP HOROWITZ', M.D. 
WITH THIRTY'FOUR TEXT ILLUSTRATIONS 
AND TWO COLORED PLATES Z 
SECOND EDITION 
REVISED AND ENLARGED 
PAUL B. HOEBER, Inc. 
NEW YORK < MCMXXIV Copyright, 1924 
By PAUL B. HOEBER, Inc? 
Published May, 1924 
Printed in the United States of America PREFACE TO THE SECOND EDITION 
The author's aim in offering the second edition 
is primarily the same as in the first-"to bring 
about more intelligent cooperation between 
doctor and patient," and also to incorporate 
the latest ideas and methods regarding the use 
of insulin and the calculation of maintenance 
diets. 
Except for the revision of the chapter on 
mild diabetes, the book has been entirely rewrit- 
ten. The insulin treatment of severe and juve- 
nile cases has been thoroughly discussed; meth- 
ods for working out proper maintenance diets 
have been formulated; seventeen new formulas 
and recipes have been added; the Van Slyke 
test for CO2 combining power of the plasma has 
been inserted and the Folin and Wu method of 
sugar estimation substituted for that of Benedict 
Lewis. With the use of insulin it is essential 
to be able to estimate the blood-sugar level and 
to elicit the CO2 combining power of the plasma. 
V VI 
PREFACE TO THE SECOND EDITION 
For upon the blood-sugar level depends the 
amount of insulin to be administered in a given 
case, and upon the CO2 combining power 
depends the amount of insulin required in a 
case of severe acidosis and in coma. More 
cases are cited to show how the various phases 
of the disease are handled and what results 
can be obtained in cases with complications. 
Although the use of insulin gives the physician 
considerably more latitude in prescribing diets, 
a thorough knowledge of food values is more 
necessary than heretofore. The physician must 
know what to give in order to balance the diet 
and insulin. Dietary restriction cannot be 
dispensed with, nor is it possible with our present 
knowledge of the use of insulin to state whether 
patients treated with it will be able to dis- 
continue its use. In a few cases the author was 
able to reduce the dose, and in one, to discon- 
tinue its use entirely. 
The author does not advise insulin treatment 
in mild cases, for he has found it possible to 
bring these cases up to a better than maintenance 
diet by ordinary dietetic treatment. The relief 
from strain and irritation afforded the pancreas PREFACE TO THE SECOND EDITION 
VII 
by eliminating the glycosuria and reducing the 
blood-sugar level to within normal limits brings 
about a resumption of its function to such a 
degree that patients are able to handle these 
diets satisfactorily. 
The author has gone into the history of 
diabetes from the time of Hippocrates, a sum- 
mary of which is given in the appendix. 
In spite of additions to the book, its size has 
been but slightly increased, because of the omis- 
sion of various tables and charts made unneces- 
sary by the use of insulin. 
The author wishes to thank his publishers, 
Paul B. Hoeber, Inc., for the courtesies extended 
to him and for kind suggestions. 
He also wishes to express his appreciation to 
his secretary, Miss Abbie M. Warnock, and to 
his technician, Miss Hilda Prussin, for their 
help in preparing copy and reading proof. 
Philip Horowitz. 
New York, N. Y. 
April, 1924. CONTENTS 
Chapter Page 
I. General Considerations 1 
IL Insulin 20 
III. Mild Diabetes 23 
IV. Moderately Severe Diabetes 70 
V. Severe Diabetes 80 
VI. Acidosis and Coma 107 
VII. Complications 115 
VIII. Hypoglycemia 125 
IX. Hygiene and Exercise 129 
X. Menus, Recipes and Tables 139 
XI. Tests 180 
Appendix-History-Tables and Weights .... 200 
Index 211 
IX LIST OF ILLUSTRATIONS 
Figure Page 
1. Record Chart Showing Daily Food Consumption In- 
cluding the Exact Quantities and Caloric Values of 
Each Meal 16 
2. Reverse Side of Chart Shown in Figure 1 16 
3. Diet No. 1 30 
4. Diet No. 2 31 
5. Diet No. 3 33 
6. Diet No. 4A 34 
7. Diet No. 5A 35 
8. Diet No. 6A 37 
9. Diet No. 7 39 
10. Diet No. 8 40 
11. Diet Prescribed for Case 350-1 46 
12. Diet Prescribed for Case 350-2 46 
13. Diet Prescribed for Case 350-3 48 
14. Diet Prescribed for Case 350-4 49 
15. Diet Prescribed for Case 350-5 50 
16. Diet Prescribed for Case 350-6 51 
17. Diet Prescribed for Case 350-7 52 
18. Diet Prescribed for Case 350-8 53 
19. Diet Prescribed for Case 350-9 55 
20. Diet Prescribed for Case 350-10 56 
21. Total Diet Prescribed for Case 350 59 
22 and 23. Case 461. March, 1923 Facing 104 
24 and 25. Case 461. July, 1923 Facing 105 
26. Irrigating Apparatus 133 
27 and 28. Abdominal Muscle Exercises 135 
29 and 30. Knee and Trunk Exercises 136 
31. Folin Blood-Sugar Tube 192 
32. Van Slyke Separatory Funnel with Bottle 194 
XI XII 
LIST OF ILLUSTRATIONS 
Figure Page 
33. Van Slyke Apparatus 196 
34. Epstein Apparatus Facing 198 
Plate 
I. Benedict's Test for Sugar in the Urine {Colored) Facing 180 
II. Tests for Acetone and Diacetic Acid in the Urine 
{Colored)................................. Facing 186 DIABETES 
Chapter I 
GENERAL CONSIDERATIONS 
The term diabetes merely implies a condition 
which renders the individual incapable of utiliz- 
ing normally the carbohydrates ingested without 
their appearing in the urine as dextrose or glucose. 
Not every condition, however, in which sugar 
appears in the urine can be taken as an indication 
of diabetes. For example, glycosuria may appear 
temporarily after the ingestion of extremely 
large quantities of sugar or candy (alimentary 
glycosuria) and it is often found as an accom- 
paniment of injuries, apoplectic attacks, epileptic 
seizures, gout, Graves' disease, the ingestion of 
mineral poisons or other conditions. In such 
cases glycosuria usually disappears with the 
elimination of the conditions which induced 
it. These cases should be considered potential 
diabetes, and should be closely watched, since 
true diabetes often begins with a transitory 
1 2 
DIABETES 
glycosuria which comes and goes before finally 
establishing itself. Only when the glycosuria 
has been fixed is the case to be classed as true 
diabetes. 
Practically all investigators report a statistical 
increase in deaths from diabetes between 1880 
and 1900-a condition which is especially evi- 
dent in centers where vital statistics have been 
carefully kept. In 1910 the mortality from this 
cause was between three and four times as great 
as in 1880. Joslin1 has given a very complete 
and exhaustive resume of the statistics relating 
to the mortality from diabetes in various centers 
-New York, Boston, Paris etc.; his figures 
show a four-fold increase between 1860 and 1910. 
The United States Census Bureau2 has com- 
piled figures showing that in thirty-four states 
of the health registration area, comprising 82 
per cent of the country's population, New York 
had the highest death rate from diabetes in 1921, 
this being 21.8 per 100,000 of population. The 
average death rate in the registration area was 
16.6 per 100,000 of population. 
1 Joslin, E. P. Treatment of Diabetes Mellitus. Philadelphia, 
1917, p. 19-27. 
2N. Y. Times, Dec. 23, 1922. GENERAL CONSIDERATIONS 
3 
Heredity. In about 13 per cent of Joslin's 
own cases the patient's father or mother, or 
both, had also been affected; while in 7 per 
cent some other relative was known to have 
had diabetes. This makes a total of 20 per cent 
in which an hereditary tendency could be traced. 
Barker1 likewise gives 20 per cent of the average 
number of cases which show a history of diabetes 
in the family, as also does Elsner.2 In a series 
of 560 cases, the author finds that 13 per 
cent had one or both parents affected, while 
in 11 per cent some distant relative was reported 
as having had the disease; making 24 per 
cent of the total cases showing an hereditary 
tendency. 
Improved methods of treatment have been 
instrumental in lowering the mortality of dia- 
betes since 1910. The advent of insulin has made 
possible the reduction of this mortality to a 
very low figure. By its use practically all patients 
can, with comparatively little trouble, be made 
sugar-free and be given a prolongation of life. 
1 Barker, L. F. Monographic Medicine. New York, 1916, 
Vol. iv, 822. 
2 Elsner, H. L., Monographic Medicine. New York, 1916, 
Vol. vi, 1110. 4 
DIABETES 
Banting and his co-workers have proved 
conclusively that in diabetes there is a lack of, 
or interference with, the internal secretion or 
hormone furnished by the islands of Langerhans 
which brings about a failure of the normal 
utilization of the carbohydrate intake and its 
conversion into glycogen. But the cause of 
this interference with the internal secretion 
or the hydropic degeneration of the beta cells 
(Allen) has not yet been determined. 
Research has led the author to conclude 
that diabetes and other forms of metabolic 
disturbance, such as nephritis, arteriosclerosis, 
gout etc., are in the main the result of an auto- 
intoxication, infection or mineral poison, causing 
an interference with the function of the ductless 
glands, or irritation of these and other organs. 
The organs most affected will show the train 
of symptoms peculiar to their perverted 
functions. 
In diabetes there is an interference with the 
proper functioning of the pancreas, which results 
in the creation of glycosuria. If this irritation 
is permitted to continue for a long time 
actual tissue destruction results, such as the hy- GENERAL CONSIDERATIONS 
5 
dropic degeneration (Allen) of the islands of 
Langerhans. 
In the mild cases, only an irritation of the 
organ exists; with this condition removed, 
the patient is able to return to an almost normal 
diet. If the toxemia has been very severe or of 
long standing, and the organ has been severely 
injured, the most serious form of the disease 
is found to obtain. 
The same holds true for the other forms of 
metabolic disturbance. In nephritis there is 
irritation and destruction of different parts of 
the kidney. The severity and rapidity, or the 
mildness of the irritation, determine whether 
the secreting cells (parenchyma) are affected, 
or whether there is a deposition of connective 
tissue between them. 
In arteriosclerosis the toxin or toxins cause an 
irritation or destruction of parts of the intima 
(the innermost coat of the blood-vessels) and 
the deposition of lime salts serves to strengthen 
the vessel wall. 
In a severe autointoxication, the liver is 
usually found enlarged and swollen; its functions, 
in consequence, are interfered with, owing to 6 
DIABETES 
the swelling of the secreting cells. The liver has 
numerous functions, the most prominent of 
which are: First, the conversion of sugar into 
glycogen and the storing of it for the use of the 
body; second, the secretion of bile; and third, by 
its biochemic action, the conversion of toxins 
into inert and harmless substances-for instance 
the conversion of indol, a highly putrefactive 
gas, into indoxyl-sulphate or indican. In cases of 
severe autointoxication, the liver has to bear 
the brunt of the toxemia, for the blood which 
carries the toxins from the abdominal viscera 
passes through the liver by way of the portal 
vein before reaching the right side of the heart 
through the inferior vena cava. When very 
potent toxins are present the secreting cells 
of the liver become irritated and swollen, thereby 
causing an enlargement of the entire organ. 
As a result, this function of the liver is inter- 
fered with, and many toxins are permitted to 
get into the general circulation. The presence 
of these toxins in the blood causes an irritation 
of the entire body, including the ductless glands. 
If the irritation is of short duration, general 
symptoms of toxemia prevail, such as general GENERAL CONSIDERATIONS 
7 
malaise, headache, anorexia etc. When the irrita- 
tion and toxemia are removed the symptoms 
disappear. If this condition is very severe or 
prolonged, the result is a destruction of those 
organs which are unable to withstand the irritant 
effect of the poisons or toxins, and a definite 
morbid state is induced. The development of 
diabetes in one case, and nephritis, or circulatory 
disturbance in another, depends upon the partic- 
ular organs or set of organs which are affected. 
As stated previously, the pancreas, kidney, 
liver and other endocrine organs may also 
become diseased by the specific action of mineral 
or bacterial poisons. This is seen after the inges- 
tion of mercury, phosphorous, arsenic or alcohol, 
or as an accompaniment of erysipelas, typhoid, 
scarlatina and other febrile diseases. The pathol- 
ogy under these conditions is similar to that 
described above. However, in these instances 
the irritation and destruction of the tissue are 
caused by a mineral and bacterial instead of an 
organic toxin, formed from the putrefaction of 
the partially digested food or the amino-acids. 
The average patient, with the advice of his 
physician, can follow out the treatment for 8 
DIABETES 
diabetes comprehensively and thoroughly. After 
the determination of his tolerance by the physi- 
cian, both for diet and insulin, the patient can be 
taught how to proceed with his diet and how 
to administer his own injections of insulin. 
He can also be instructed how to avoid overdosage 
of the latter with its resulting shock, and also 
what course to follow should such a condition 
arise. 
The tests for sugar, acetone and diacetic 
acid in the urine are so simple as to be easily 
carried out. It is necessary that they should be 
carried out, for the patient must know whether 
he is eliminating sugar and acetone on a given 
diet, that he may judge as to the proper dose 
of insulin. Details of the tests are given in 
Chapter X. 
To simplify the consideration of its treatment, 
true diabetes may be divided into the following 
groups: 
Group A. Simple cases, in which the glycosuria 
disappears on eliminating sugar from the food 
and cutting down the starches. (Usually these 
cases are accidentally discovered by insurance 
companies.) GENERAL CONSIDERATIONS 
9 
Group B. Moderately severe cases, in which 
acetone may or may not be present in the urine. 
The condition is accompanied by loss of flesh, 
thirst and polyuria. 
Group C. Severe and very serious cases, 
including juvenile cases, in which the tolerance 
is poor, and there is an accompanying acidosis. 
The complications are serious and dangerous- 
threatened coma, severe nephritis, arteriosclerosis 
with gangrenous involvement of the extremi- 
ties, and retinal hemorrhage with marked diminu- 
tion of vision. 
Psychology of Patients. The necessity of 
studying the psychology of the patient cannot 
be too strongly emphasized. Treatment must 
be administered for the 11 state of mind" as well 
as for the diabetic condition. Above all, the 
physician should obtain the full confidence of 
his patient. 
Patients often tell of being treated by a 
physician who lost their confidence by giving 
orders in a hesitating, uncertain manner. Instead 
of telling his patients: "Here is your diet; you 
must eat only what is written on this list; 10 
DIABETES 
nothing lias been omitted that you may eat or 
can tolerate"; he would say: "I think you might 
try this diet," and subsequently weaken his 
position by adding: "You might also try some- 
thing else." In this case the patient is left in an 
uncertain state of mind. 
Most patients are eager to learn all there is to 
know about the etiology, prognosis and treat- 
ment of diabetes. The more intelligent ones have 
read newspaper reports on its modern treatment 
and the advances made, and perhaps have 
read one or more books on the subject, so that 
they are able to appraise the physician at the 
first visit. 
Some physicians are unable to keep their 
patients sugar-free on certain diets, while others 
find no difficulty in eliminating the glycosuria. 
The failure in the first case is usually due to lack 
of proper attention to accuracy and detail in 
prescribing the diet. When a patient is given a 
diet calling for 120 gms. of chicken, or 900 gms. 
of vegetables, that amount only, and no more, 
should be eaten. Patients will often stop weigh- 
ing and measuring their food, because of the 
trouble it entails, trusting to their supposed GENERAL CONSIDERATIONS 
11 
ability to estimate the proper amounts by sight 
alone. Disastrous results usually follow any 
deviation from the rule laid down. Another point 
not to be overlooked is that the instructions 
apply to the weight of cooked and not raw foods. 
An appreciable source of error is the misinter- 
pretation of terms employed. 
In the diet table given in this book the term 
"level tablespoonful" is used. Patients must be 
warned that this instruction must be followed 
literally; a "heaping tablespoonful" taken under 
such conditions may cause a recurrence of 
glycosuria. 
Those patients who abstain from sugars and 
carbohydrates only when glycosuria reappears 
should be seriously impressed with the fact 
that chronic diabetes may eventually lead to 
nephritis, neuritis, arteriosclerosis, blindness and 
gangrenous involvement, and that serious results 
may follow even the slightest deviation from 
the hard and fast rules laid down. 
The same applies to the insulin cases. They 
must be made to realize that although insulin 
reduces the sugar concentration of the blood 
and will do away with an existing ketosis, 12 
DIABETES 
indiscriminate disregard of diet will positively 
give them a high blood sugar, marked glycosuria, 
and even a recurrence of acetone and diacetic 
acid, with its attending danger of complications. 
The following insulin case exemplifies the 
recurrence of sugar and acetone, although the 
patient took as much as 70 to 75 units of insulin 
per day: 
Case 474. Female, aged twenty-three, a 
native of the United States. Family history 
negative to diabetes. She had typhoid fever 
at the age of eight. The present condition dates 
back to 1918, when sugar was discovered during 
a urine analysis, made to elicit the cause of 
polyuria. At that time she weighed over 103 lbs. 
and was otherwise normal. She was put on a 
marked undernutritional diet and lost over 
42 lbs. When insulin was first given her in Octo- 
ber, 1922, she was markedly emaciated, weighing 
less than 61 lbs., and had practically no toler- 
ance. On a diet of 610 calories, the urine showed 
2 plus sugar, and the blood 230 mgm. of sugar. 
She was given insulin and responded wonder- 
fully well, but would occasionally overstep her 
diet, with a recurrence of glycosuria. Now, on a GENERAL CONSIDERATIONS 
13 
diet of 70 gms. carbohydrate, 80 gms. protein, 
and 160 gms. fat, or 2040 calories, and an avail- 
able glucose intake of 130 gms., and using 
between 70 and 75 units of insulin, she shows 
122 gms. of glucose in twenty-four hours, 3 
to 4 plus acetone and diacetic acid, and 320 
mgm. of sugar in the blood. 
The girl presents a picture of health, and is 
very stout, having gained 80 lbs. in weight. 
It is doubtful, however, whether she will be 
able to continue in her present condition for 
any length of time, because of the marked 
hyperglycemia, and the presence of much ace- 
tone and diacetic acid. 
The idiosyncrasies of each patient must be 
carefully studied. Articles of food that disagree 
with a patient at one time may agree with him 
at another. If glycosuria should reappear, how- 
ever, under a certain diet, the patient should not 
be permitted to become discouraged. 
To obtain proper cooperation it is advisable 
to tell the patient his exact condition. A patient 
who understands his case will obey orders more 
strictly and intelligently than one who does not. 
It is therefore necessary: 14 
DIABETES 
1. To inspire the patient with confidence. 
2. To insist upon the fact that diabetes is 
not a hopeless condition; that while the patient 
may be obliged to remain on a restricted diet 
for the balance of his life, nevertheless, his life 
will be prolonged, and he will live easily with 
comparatively slight discomfort. 
3. To see that the patient exercises care and 
accuracy in weighing and measuring his food. 
4. To insist that the patient should under no 
condition break this diet without consulting his 
physician. 
5. To impress upon the patient that if he 
wishes to avoid blindness, neuritis, kidney 
complications, gangrene and coma, he must 
persevere and adhere to his treatment. 
Each patient should keep a daily record of the 
food permitted with the quantities and caloric 
values. In this way he will become acquainted 
with the method of treatment, and will learn what 
food and combinations of food he can tolerate. 
If he should develop a glycosuria, he will be 
able to recognize what food or foods have dis- 
turbed the equilibrium, and can readily tell 
whether the disturbance is due to an increase in GENERAL CONSIDERATIONS 
15 
proteins, carbohydrates or fats. In this manner 
lie will be able to compare a new diet with 
one which he has taken before and tolerated. 
He will also be able to adjust any increase in 
diet so that the offending substance (whether it 
be carbohydrate, protein or fat) will be kept at 
a low level, or at least increased very slowly. 
The following charts, which are self-explana- 
tory, were designed by a diabetic. By means of 
these charts a patient can keep a record of his 
daily intake, and can estimate the caloric value 
of each meal. On the back of the card a record of 
the urine analysis, blood sugar, blood pressure 
etc., is to be kept. 
The choice of foods that enter into the formu- 
lation of diets of certain caloric values should not 
be left to the discretion of either nurse or patient. 
The nurse may not be able to detect the idiosyn- 
crasy of the patient; the patient may choose 
the food he likes best as long as it has the 
definite number of grams of carbohydrates, 
proteins and fats, irrespective of whether he 
can tolerate it or not. Not all patients can toler- 
ate everything that appears in the various tables 
and menus. 16 
DIABETES 
NAM 
K 
__D 
ATE 
. C 
)AY 
Days Treat 
ED. 
- 
NO._. 
FOOD 
OKT IN O»AMl 
HRKAKFAS 
r 
LUNCH 
6 U 
R 
CaA 
FWC 
FAT 
3H 
C AA 
fat 
C ACS 
GMT 
FAT 
GALA 
M 
CAR 
FAO 
lUi 
CAI A 
TOTAL GRAM? 
MULTIPLY FOR CALORIES 
4 
4 
9 
4 
4 
9 
4 
4 
9 
4 
4 | 
9 
TOTAL CALORIES 
Fig. 1. Record chart showing daily food consumption including 
THE EXACT QUANTITIES AND CALORIC VALUES OF EACH MEAL. 
DAILY AND WEEKLY SUMMARY 
OATS 
OAT 
OUT GPAM9 
I 
WT 
LBS. 
URINE AJA. SAMPLE 
URINE P.M. SAMPLE 
H 
■«s 
2 
II 
J 
1 
1 *SSt 
LABORATORY ANALYSIS 
- 
Fig. 2. Reverse side of chart shown in Figure 1. GENERAL CONSIDERATIONS 
17 
Many diabetics cannot tolerate grapefruit, a 
5 per cent fruit with an available carbodydrate 
content of 3 per cent; whereas they can tolerate 
heavy gluten bread with the same carbohydrate 
content, and with an even higher carbohydrate 
content than has grapefruit. Others have an 
intolerance for cream cheese, and such small 
quantities as to 1 oz. have caused a recurrence 
of the glycosuria. These same patients often 
cannot tolerate bread made of casein flour. 
Quite often it is found that a patient can toler- 
ate a certain diet when it is made up of the 5 per 
cent vegetables, but cannot tolerate the 
same amount of carbohydrates when the 
diet consists of a mixture of the 5 and 10 per 
cent vegetables. A patient sometimes presents 
himself with diet prescriptions calling for a 
definite number of grams of carbohydrates, pro- 
teins and fats, which he cannot tolerate, although 
they seem correct for his condition. The cause 
of this intolerance may be either improper food 
with the correct amounts of proteins, carbo- 
hydrates and fats, or proper food for which the 
patient has an idiosyncrasy. 18 
DIABETES 
It is therefore not enough to give the patient 
a diet of a definite caloric value; the articles 
of food that enter into it must be tested to 
see whether or not the patient can tolerate 
them. 
All prescriptions calling for definite amounts of 
carbohydrate, protein and fat of definite caloric 
values should also specify the various articles 
of food that go to make up the amount, and the 
choice of food should not be left to the discretion 
of nurse or patient. 
Many intelligent patients are difficult to 
handle after they have grasped the fundamentals 
of treatment. The impression will be found to 
have taken root that all that is necessary for 
continued relief is a set of rules and a desire and 
ability to follow them. The value of the rules 
depends entirely upon their adjustment to the 
individual case, and it is only under the con- 
tinued direction of a physician that good results 
can be maintained. 
Differential Diagnosis 
The first essential of successful treatment is, of 
course, correct diagnosis. It cannot be too GENERAL CONSIDERATIONS 
19 
strongly emphasized that sugar in the urine does 
not always signify diabetes. We often find pa- 
tients who are undergoing treatment for diabetes 
mellitus based upon insufficient findings, with 
discouraging results. A sufficiently careful exami- 
nation would have revealed that these cases 
were probably of renal origin. In all instances 
of suspected diabetes a complete physical and 
clinical examination must be made. The omission 
of any one test may throw the physician off the 
scent. It is as important to examine the blood as 
it is to examine the urine. The height of the 
blood-sugar level in a particular case will deter- 
mine whether insulin should be administered and 
what the initial dose should be. Chapter II 
INSULIN 
The fact that there seemed to be a close 
relation between diabetes and disease of the 
pancreas was known to many observers, among 
whom was Bonchardat (1835) who reported 
necropsy findings in diabetic cases showing an 
atrophied condition of this organ. He believed 
that lesions of the pancreas could produce 
diabetes. Popper, however, at the same time, did 
not believe that the lesions alone, but a 
lack of pancreatic juice, prevented glycogen 
from combining with the fatty acids which were 
transformed into sugar, resulting in glycosuria 
and hyperglycemia. Physiologists and observers 
from that time on came to the conclusion that 
the removal of the pancreas would produce 
diabetes, and this was finally definitely proved 
as a result of the classic experiment of Von 
Mering and Minkowski (1889). Lepine,1 however, 
was the first to mention that the pancreas 
1 Lepine. Arch, de mtd. exp&r. et d'anat. path., 1891, iii, 222. 
20 INSULIN 
21 
contributed an internal secretion which led to 
the destruction of glucose. 
In 1900, Opie demonstrated the connection 
between the disease and the islands of Langer- 
hans. 
W. G. MacCallum (1909) found that if a 
portion of the pancreas were separated from 
the rest of the gland, and its duct tied, it 
atrophied and left tissue containing enlarged 
islands of Langerhans. 
Zuelzer, in 1901, stated that the tying of the 
veins of the adrenals prevented glycosuria in 
depancreatized animals, and in 19081 he prepared 
an alcoholic extract of the pancreas which had 
the veins tied off. This extract, when injected 
into the blood, prevented the rise in the blood 
sugar and the glycosuria which usually follows 
the injection of epinephrin. Zuelzer was followed 
by many other observers who attempted to 
make potent pancreatic extracts, but no therapeu- 
tic agent was evolved until Banting and Best 
isolated the alcoholic extract from the pancreas 
of dogs in which the ducts were ligated. After 
much experimentation, a purified, sterile, aqueous 
solution was prepared. This is called "insulin." 
1 Zuelzer. Berl. klin. Wchnschr., 1907, xliv, 474. 22 
DIABETES 
In various reports published in the past year 
on the use of insulin in the treatment of diabetic 
cases, there is a concurrence of opinion that 
by its use the important symptoms of diabetes 
mellitus are ameliorated, if not entirely removed. 
Patients show a very marked improvement in 
physical condition and appearance; their tem- 
peraments are changed. They acquire a different 
outlook on life, and show a marked increase in 
hopefulness and activity. They become interest- 
ed in every-day things, instead of food and drink. 
Up to the present time, however, insulin cannot 
be considered a cure for diabetes in the usual 
sense of the word; but it enables the diabetic 
patient to utilize carbohydrates and fats nor- 
mally, so long as the use of the extract is con- 
tinued. The blood sugar can be maintained at a 
normal level; glycosuria disappears and ketosis is 
abolished; the respiratory quotient rises and the 
CO2 and alkali reserve in the plasma of patients 
suffering from acidosis and coma become normal. 
The diet used in the treatment of diabetes with 
insulin is based on the caloric requirements, and 
will be taken up in the chapter on Severe 
Diabetes. Chapter III 
MILD DIABETES 
Very often sugar is discovered accidentally by 
life-insurance examiners or in the course of a 
routine urine analysis; the patients have pre- 
viously shown no symptoms indicating diabetes 
and have considered themselves in perfect 
health. These patients have no thirst or polyuria 
and are usually normal in weight, or may even 
have gained weight for a year or two prior to 
the discovery of sugar. 
Such persons are usually those who have been 
very busy or overworked and were inclined 
to overeat while not taking sufficient exercise. 
The sugar output may vary from a fraction 
of 1 per cent to 2 or 3 per cent. Usually there is 
no acidosis or albuminuria. 
Most cases of this type have a fairly marked 
indicanuria and only a slight hyperglycemia- 
rarely 0.20 per cent or higher; in most cases, if 
the fact of the glycemia had not been called to 
23 24 
DIABETES 
their attention, they would have considered 
themselves in perfect health. 
The following cases exemplify this type of 
diabetes: 
Case 304. Male, a native of the United 
States. Family history negative. Present trouble 
dates back three years, when sugar in the 
urine was found by the life-insurance examiner. 
When first seen by the writer, in February, 
1918, the patient had lost neither strength nor 
flesh and had no headache. Sight perfect; bowels 
in good condition. The only complaint-a dizzi- 
ness-always occurred on getting up suddenly 
or lying down. Examination showed the patient 
apparently in good health; weight 206 lbs.; 
blood pressure 170; liver enlarged, the anterior 
edge being 5 cm. below the free border of the 
ribs. Urine examination showed a trace of 
sugar, and 2 plus indican, otherwise it was 
negative. Blood sugar, 0.17 per cent. 
Case 355. Male, aged fifty-one, a Spaniard. 
Family history negative as to diabetes. One 
brother died of tuberculosis. Patient never very 
ill, except for frequent colds. Had been perfectly 
well up to about three weeks before he consulted MILD DIABETES 
25 
his physician with reference to a severe cold 
and laryngitis. In the course of the routine 
urine examination 0.63 per cent of sugar and 
a trace of acetone were found. A small amount 
of indican was also present in the urine, but no 
albumin. The blood examination showed 0.15 
per cent sugar. 
Case 328. Male, aged seventeen, a Canadian. 
Family history, also personal history, negative. 
When first seen, in November, 1918, he was 
perfectly well. He had applied for a life-insurance 
policy, but had been refused on account of 
sugar in the urine. The patient had not been 
losing strength or flesh, did not tire easily, was 
not thirsty, and did not report polyuria. On 
inspection he looked perfectly well. The physical 
examination of the body disclosed nothing 
unusual. Weight 126K lbs. Urine examination 
showed a trace of sugar and 3 plus indican. 
Blood sugar, 0.20 per cent. 
Case 439. Male, aged forty-three, a native 
of Russia. Family and personal history negative. 
Present history dates back to May 1, 1921. 
At that time he had a tooth extracted and the 
gum did not heal well. He also began to lose 26 
DIABETES 
flesh and strength. His dentist advised him to 
have his urine analyzed, and 3.7 per cent sugar 
was found. He never complained of thirst or 
polyuria. His general appearance is good; skin 
of good color, blood pressure 120, height 5 ft. 
5 in. and weight 198 lbs. Urine examination 
showed 1 per cent sugar, 2 plus acetone and a 
trace of albumin. Blood sugar, 150 mgm. per 
100 c.c. of blood. 
Case 518. Female, aged thirty-eight, a native 
of the United States. Family history negative 
to diabetes; nor was she ever ill. In September, 
1922, she began to have severe pains in the back 
which were thought to come from either flat 
feet or a fibroid, or both. She had no polyuria or 
thirst. General examination elicited no abnor- 
mality. Urine analysis disclosed the presence of 
1 per cent sugar and 4 plus acetone, and the 
blood sugar was 186.41 mgm. to 100 c.c. of 
blood. 
Case 538. Female, aged forty-seven, a native 
of Russia. Father died of diabetes at sixty-nine; 
history otherwise negative. Excepting for an 
otitis media in December, 1922, she was never 
ill. About March 14, 1923, she noticed that MILD DIABETES 
27 
she began to tire easily; had no ambition or 
energy; could not sleep very well on account of 
an itch of the genitals. Examination of the urine 
disclosed WA per cent sugar. General examina- 
tion showed an apparently normal woman of 
good healthy appearance. Blood sugar, 196.47 
mgm. to 100 c.c. of blood. 
Not only must something be done for the 
glycosuria, but considerable influence must be 
brought to bear upon the mental state. Usually 
marked physical depression exists, and it is 
essential to restore such patients to a proper 
equilibrium before much can be accomplished. 
With our present knowledge the use of insulin 
is not indicated in mild cases. Practically all 
these patients can be made aglycosuric on diet 
alone, and with very few exceptions they can have 
their tolerance improved and brought up to a 
very good diet. If experience shows that insulin 
can be discontinued in these cases after a certain 
definite period, the mild cases will be justified 
in undergoing the inconvenience of taking one 
or two injections daily. But until that is proved 
to be a fact, there is no reason why they should 
be burdened with the use of a hypodermic 28 
DIABETES 
Table I 
Table of foods with their carbohydrate content 
(Joslin) 
Water, clear broths, coSee, tea, cocoa shells and cracked cocoa can be taken 
without allowance for food content. 
Foods Arranged Approximately According to Content of Carbohydrates. 
5% 1 10 % 
15% 
20% 
Reckon average carbohydrate in 5 % veg. as 3 %-of 10 % veg. as 6 % 
£ 1 %-3 % 3 %-5 % 
g Lettuce Tomatoes 
a Cucumbers Brussels 
Spinach sprouts 
Asparagus Water cress 
o Rhubarb Sea kale 
x Endive Okra 
3 Marrow Cauliflower 
£ Sorrel Egg plant 
Sauerkraut Cabbage 
h Beet greens Radishes 
J Dandelion Leeks 
® greens String beans 
g Swiss chard canned 
e Celery Broccoli 
h Mushrooms Artichokes 
canned 
10% 
String beans 
Pumpkin 
Turnips 
Kohl-rabi 
Squash 
Beets 
Carrots 
Onions 
Green peas 
canned 
15% 
Green peas 
Artichoikes 
Parsnips 
Lima beans 
canned 
20% 
Potatoes 
Shell beans 
Baked beans 
Green corn 
Boiled rice 
Boiled 
macaroni 
Watermelon 
Strawberries 
Lemons 
Cranberries 
Peaches 
Pineapple 
Blackberries 
■ Gooseberries 
Oranges 
Raspberries 
Currants 
Apricots 
Pears 
Apples 
Huckleberries 
Blueberries 
Cherries 
Plums 
Bananas 
Prunes 
g Ripe olives (20 % fat) 
g Grapefruit 
I 
1 gm. protein, 4 calories 1 kilogram = 2.2 lbs. 
1 gm. carbohydrate, 4 calories 30 grams (gms.) or cubic centi- 
1 gm. fat, 9 calories meters (c.c.) = 1 ounce. 
A patient "at rest" requires 
6.25 gms. protein contain 1 gm. nitrogen. 25 calories per kilogram. 
(30 gms. 1 OZ.) CARBOHYDRATES PROTEIN FAT CALORIES 
CONTAIN approximately Gms. Gms. Gms. 
Oatmeal, dry wgt 20 5 2 118 
Shredded wheat 23 3 0 104 
Cream, 40 % 1 1 12 116 
Cream, 20% 1 1 6 62 
Milk 1.5 1 1 19 
Brazil nuts 2 5 20 208 
Oysters, six 4 6 1 49 
Meat (uncooked, lean) 0 6 3 51 
Meat (cooked, lean) 0 8 5 77 
Chicken (cooked, lean) 0 8 3 59 
Bacon 0 5 15 155 
Cheese 0 8 11 131 
Egg (one) 0 6 6 78 
Vegetables, 5 % group 1 0.5 0 6 
Vegetables, 10 % group 2 0.5 0 10 
Potato 6 1 0 28 
Bread 18 3 0 84 
Oil 0 0 30 270 
Fish, cod, haddock (cooked) 0 6 0 24 
Broth 0 0.7 0 3 
Fruit, 110% 3 0 0 12 MILD DIABETES 
29 
syringe, since with very little trouble they can 
acquire an almost normal diet. 
The author has found that much can be accom- 
plished in the mild cases by reducing the diet to a 
point lower than that which the patient can 
readily tolerate. I usually prescribe the following 
diet, which, of course, is schematic, and must be 
varied to suit the individual: 
600 gms. (20 oz.) 5 per cent green vegetables 
3 hard-boiled eggs (20 min.) 
540 c.c. (3 cups, 6 oz. each) black coffee 
540-720 c.c. (3-4 cups, 6 oz. each) chicken broth 
60-120 gms. (2-4 oz.) white meat of chicken 
Plenty of clear water. 
(I usually leave the apportionment of meals 
to the patient, merely suggesting the arrange- 
ment which follows.) 
Diet No. 1 (24-hour content) 
Breakfast 
1 hard-boiled egg 
About 240 gms. (8 oz.) 5 per cent green 
vegetables, such as spinach, string beans or 
cauliflower 
180 c.c. (6 oz. or 1 cup) black coffee 
180 c.c. (6 oz. or 1 cup) chicken broth 30 
DIABETES 
Mid-day Meal 
1 hard-boiled egg (20 min.) 
60-120 gms. (2-4 oz.) white meat of chicken 
180 c.c. (6 oz. or 1 cup) black coffee 
180 c.c. (6 oz. or 1 cup) chicken broth 
240 gms. (8 oz.) 5 per cent green vegetables 
FOOD 
CAR MORA! 
4 EA K FAS 
clui 
wti 
1MT 
LU NCH _ 
CALI 
WtlOHT 
CAR! MO 1 FAT fCAli 
So 
1 J 
I J 
3 
4 
3% ifatnatfs 
f6<ii 
elicit Coffee 
StorH 
Chkhih (Mtv.r} 
2o 
0 
o 
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0 
to 
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0 
o 
32 
o 
/a 
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0 
Zo 
tZo 
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o 
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3o6 
7 
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QI 
% 
7 
0 
0 
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3' 
6 
o 
0 
o 
6 
0 
Q 
42 
76 
P 
0 
7 
/ 
/ 
1 
4 
91 
V 
01 
7 
0 
o 
Q 
0 
3' 
6 
a 
3Z 
0 
6 
0 
0 
20 
42 
76 
0 
0 
306 
7 
1 
1 
1 
01 
7 
O 
O 
3/ 
6 
0 
0 
6 
0 
F 
76 
0 
0 
MULT 
TOTAL GRAMS 
to 6o 36 
66g 
7 
3f 
6 
/so 
7 
4,9 
166,154 
4i6 
«a| 
r_ 
26 
9' 
6 
ieo 
IPLY FOR CALORIES 
TOTAL CALORIES 
60 810|3« 
662 
4 
80 
4 
Jfi 
9 
54 
ISLO 
- 
4 
£5 
4 1 9 
~Zo 
Lunch (At 3 p. m. or 10 p. m.) 
180 c.c. (6 oz. or 1 cup) chicken broth or 
black coffee. 
Fig. 3. Diet No. 1. 
Supper 
Same as breakfast. 
The accompanying charts show the distribu- 
tion of these diets for the various meals, with 
the equivalent caloric values. MILD DIABETES 
31 
With this diet the patient will usually become 
sugar-free in forty-eight hours and the blood 
sugar will drop down to 0.12 or 0.13 per cent 
and even lower. After the urine has become sugar 
free I allow: 
Name ..... JJ/CI..M-®- 
_ DATE . 
. Day * 
_...Days Treated.-.., 
NO _ 
rjitT 
N GRAM* 
B R E 
K F 
A G 
LUNCH 
ffe r 
MT 
27 
oz 
SH Vtcernitfi 
27 
is" 
O 
zee 
9 
01 
9 
4f 
o 
54 
9 
or 
9 
4J 
o 
54 
9 
Cl 
3 
4' 
o 
J 
£6C$- 
o 
/a 
/a 
234 
2 
0 
<2 
•t 
>56 
o 
a 
o 
o 
o 
1 
6 
6 
76 
5 
s 
Slack CoKrtC. 
Q 
o 
o 
o 
/ 
0 
Q 
a 
0 
1 
o 
e 
o 
0 
t 
° 
o 
O 
0 
3 
.. 
340TH 
Q 
o 
0 
0 
/ 
o 
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0 
O 
I 
o 
o 
Q 
o 
t 
o 
o 
0 
6 
4 
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CHlcKtN(»ACAtr) 
O 
3£ 
20 
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4 
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o 
3e 
2o 
Jo© 
o 
o 
Q 
o 
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4 
CLMN BtxUb fi$Jf 
0 
£4 
0 
96 
4 
oz 
o 
96 
TOTAL GRAMS 
27 
sd 
36 
600 
9 
16' 
a 
£/o 
0 
36" 
to 
362 
9 
6 
228 
MULTIPLY FOR CAL DRIES 
4 
4 
9 
4 
4 
9 
4 
4 
9 
4 
4 
9 
TOTAL CALORIES 
IOQ 
5g> 
>2 
SOO 
56 
66 
lod 
2/o 
36 
746 
/6o 
362 
36 
fja 
54 
228 
Fig. 4. Diet No. 2. 
Diet No. 2 
800-900 gms. (27-30 oz.) 5 per cent green 
vegetables 
540 c.c. (3 cups, 6 oz. each) black coffee 
540-720 c.c. (3-4 cups, 6 oz. each) broth 
120 gms. (4 oz.) white meat of chicken 
120 gms. (4 oz.) plain boiled fish. 32 
DIABETES 
Should the patient feel somewhat weak, I 
allow 30-45 c.c. oz.) of whiskey per day. 
I prefer, however, not to give any alcohol at all. 
This diet should be kept up for two or three 
days, depending upon whether the patient has a 
high or low sugar index and hyperglycemia at 
the beginning. 
During this period attention must be paid 
to general hygiene. The bowels must move or 
be made to move. After the first forty-eight 
hours the patient should be instructed as to 
exercise. Walking is best. Details regarding 
exercise are given in Chapter IX. 
After two or three days the diet may be in- 
creased to the following schedule: 
Diet No. 3 
900 gms. (30 oz.) 5 per cent green vegetables 
4 eggs 
540-720 c.c. (3-4 cups, 6 oz. each) broth 
180 gms. (6 oz.) white meat of chicken 
3 gms. (i^0 oz.) aerated gluten (Luft) bread 
(1 in.) 
Alcohol, if necessary. MILD DIABETES 
33 
When the patient is under treatment and the 
diet reduced, the urine, though free from acetone 
and diacetic acid at the beginning, may at times 
show marked reaction to both. Usually this con- 
dition will adjust itself as the diet is increased 
and rarely, if ever, is recourse to other means 
Name D: ST. N'.J. 
Date 
Day 
Days Treated. 
NO 
TOT 
FOOD 
Dili 
- 
■ 
R E A K F A S 
LUNCH 
9 U 
p p 
ER 
37 
01 
3% ttecrAsLes 
37 
/6C 
/o 
OZ 
/0 
y 
0 
60 
lo 
Ok 
Io 
jr 
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6 o 
~io 
02 
~io 
6o 
♦ 
tits 
«* 
£# 
Hi 
z 
0 
/c 
•* 
f£6 
/ 
o 
6 
6 
76 
/ 
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6 
6 
re> 
3 
s 
slack, earns 
0 
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0 
1 
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o 
o 
0 
/ 
s 
O 
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o 
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/ 
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0 
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Q 
a 
3 
Morn 
o 
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t 
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o 
o 
o 
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/ 
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o 
o 
o 
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o 
0 
c 
/ 
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0 
to 
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to 
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0 
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o 
0 
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t 
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0 
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462 
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43 
o 
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9 
36 
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TOTAL ORAM* 
31 
gf1 
uoa 
u 
It/ 
It 
in 
lo 
S3 
36 
6oo 
lo 
6 
eee 
MULTIPLY FOR CALORIE* 
4 
4 
e 
4 
4 
4 
0 
4 
4 
9 
TOTAL CALOMICS 
/€♦ 
0®M6 
1106 
44 
T4 
106 
£Z6 
40 
□5 
«4 
Boo 
<0 
tee 
u 
gag 
Fig.|5. Diet No. 3. 
necessary to eliminate it. The urine is examined 
daily. In mild cases, I do not give bicarbonate of 
soda to neutralize the acidosis, as it may upset 
the stomach, cause nausea, and sometimes 
prolong the condition (page 112). 
If for another forty-eight hours a sugar and 
acetone-free specimen is obtained, the diet is 
replaced by the following: (If acidosis exists, 34 
DIABETES 
add 2 level tablespoonfuls of oatmeal, which has 
been cooked for two hours, without cream.) 
Diet No. 4a 
900 gms. (30 oz.) 5 per cent green vegetables 
540 c.c. (3 cups, 6 oz. each) coffee, with a 
teaspoonful of cream in each cup 
240 gms. (8 oz.) chicken or lamb chop 
240 gms. (8 oz.) fish 
2-4 eggs, hard-boiled, soft-boiled or poached 
6 gms. oz.) aerated gluten (Luft) bread 
(about 2 in.) 
name 2>/«r.A'+4 
Date 
Day 
Days Treated No_ 
FOOD 
O.CT 
l»Yt " 
R 
K 
A S 
H 
PR 
R 
3% KuntUt 
Jo 
/<T 
o 
/SO 
1 49 
0/ 
TO 
J" 
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01 
to 
o 
6o 
/o 
0£ 
io 
o 
6q 
£t<SS 
o 
f4 
14 
3/2 
2 
o 
'£ 
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736 
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o 
6 
6 
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0 
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0 
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. 
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6 
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47- 
(.Ho CHCHn) 
- 
TOTAL GRAMS 
St* 
3+ 
6 7 
/V/1 
III 
/3 
23' 
/<* 
7& 
o 
76<| 
ni 
7 
SSI 
MULTIPLY FOR CALORIES 
4 
4 
9 
4 
4 
9 
4 
4 
9 
4 
9 
TOTAL CALORICS 
jo 
5/a| 
6oj 
'J5/| 
td 
111 
?J6 
(o& 
4U 
764 
«1 
A 
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Fig. 6. Diet No. 4a. 
If the patient is without acidosis and continues 
to do well, the diet is increased every twenty-four 
hours as per the following lists: MILD DIABETES 
35 
900 gms. (30 oz.) 5 per cent green vegetables 
540 c.c. (3 cups, 6 oz. each) coffee and cream 
540-720 c.c. (3-4 cups, 6 oz. each) broth 
240 gms. (8 oz.) fish 
240 gms. (8 oz.) chicken, steak or chop 
2-4 eggs 
30 gms. (1 oz.) bacon 
9 gms. (3 in.) aerated gluten (Luft) bread 
30 gms. (1 oz.) cream cheese 
Diet No. 5a 
NAME J Date Dav days Treated No _ 
3o 
Z 
3 
3 
3 
6 
6 
/ 
/ 
7> 
or 
02 
oz 
FOOD 
£«> 
(Moth 
ti£'AT 
PtSH 
Bacon 
Pail. CltfAHCMftSf 
P'tt se> 
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MST«4» Of W* 
3o 
O 
0 
3 
o 
o 
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3 
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2% 
o 
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0 
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to 
4-2. 
TOTAL GRAMS 
MULTIPLY FOR CALORIES 
Total calories 
54 i/5 
4 4J_9_ 
(jajew, 7so 
'4661 
'*5«| 
46 
Jit 
9 
f33 
Tw] 
uf 
46 
7 Jfl 
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9 
59 
JU 
Fig. 7. Diet No. 5a. 
If acidosis is present, omit bacon, cheese and 
cream and allow instead grapefruit (Diet 
No. 5b). 36 
DIABETES 
If it is found that these diets can be tolerated, 
patients without acidosis may add grapefruit, 
lean ham, bacon, butter, olives and aerated 
gluten (Luft) bread to their diet as follows: 
Diet No. 6a 
grapefruit 
900 gms. (30 oz.) 5 per cent green vegetables 
540-720 c.c. (3-4 cups, 6 oz. each) coffee, 
with a teaspoonful of cream in each cup 
540-720 c.c. (3-4 cups, 6 oz. each) broth 
240 gms. (8 oz.) fish, boiled, broiled or baked 
240 gms. (8 oz.) chicken, chop or steak 
2-4 eggs 
60 gms. (2 oz.) bacon 
12-18 gms. (4-6 in.) aerated gluten (Luft) 
bread 
45 gms. oz.) Philadelphia cream cheese 
or Swiss cheese 
From this point on, a slice or two of Lister 
bread may be substituted at each meal for 
the aerated gluten (Luft) bread. This bread is 
made of Lister's casein flour according to the 
directions given on page 142. MILD DIABETES 
37 
Patients who have tolerated Diet No. 5b after 
a three-day trial, and in whom acetone and dia- 
cetic acid have been eliminated, may now have 
Diet No. 6b. 
1 ■' ■■■■■■■ ' -- ■"■■Il ■■»■■■■ , . ■ '■■■ 
Name DtfXl HL&A. -Date Day , days Treated- No 
3 
2 
' 3 
2 
a 
& 
4 
6 
2 
AL 
HT 
'x 
>, 
al 
01 
\ 
T 
FOOD 
Vttarattai 
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nt kt. 
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L*P1 8*1 An 
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f 
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0 
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6 
8 
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4 
to 
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5 
£ 
AS* 
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3 
Jo 
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to 
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5/ 
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I&9 
be 
47! 
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/ 
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02 
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to 
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o 
o 
£ 
£ 
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to 
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i 
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30 
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o 
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40 
6o 
to 
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63 
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fo 
t 
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4 
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6/6 
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63 
2o 
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ps 
s 
cz 
\ 
s u 
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to 
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FRO 
o 
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4<5 
4 
3 
o 
o 
/ 
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o 
o 
o 
6o 
'O 
o 
o 
o 
63 
£o 
TOTAL GRAMS 
i mulVirly for CALORICS 
TOTAL CALORIES 
4$ 7°' ioo 
4-j* 
i>z iaz *<> 
'J* 
izTj 
nXH4, /a 
4 l_4 1 9 
653 
6?S 
4 
761,4 b 
4 9 
3o?+<4 
769 
76j 
ZH 
SoXWtf 
6_ 
9 
343* 
3?5 
Fig. 8. Diet No. 6a. 
Diet No. 6b 
y2 grapefruit 
2 level teaspoonfuls oatmeal (cooked for 
two hours) without cream, and the foregoing 
diet without the bacon, cream or cheese. 
For all cases, whether free from acetone or not, 
I now institute what for want of a better name 
is called a "Green Day." The milder the case, 
the more the diet is modified to meet the condi- 38 
DIABETES 
tion. In mild cases like those already described, 
the patient may at first be allowed on his weekly 
"Green Day": 
Diet No. 7 
900 gms. (30 oz.) 5 per cent green vegetables 
540 c.c. (3 cups, 6 oz. each) black coffee 
540-720 c.c. (3-4 cups, 6 oz. each) chicken 
broth 
3 hard-boiled eggs 
1 quart of Kalak water, or a quart of lemon- 
ade made from the juice of 1 lemon added to 1 
quart of water 
The "Green Day" should fall on the same day 
each week. Although the arrangement is dis- 
agreeable to most patients, we can by this means 
bring the tolerance up to a much higher point 
than before, thereby compensating for any 
annoyance entailed by the "Green Day." 
It is necessary to examine the blood from time 
to time for the sugar content, as the diet must 
be determined by the quantity of the blood 
sugar. The longer a normal blood sugar is main- 
tained in a patient, the sooner can his diet be 
increased to within almost normal limits. (Un- MILD DIABETES 
39 
fortunately time is an uncertain factor in all 
diabetic cases, and the physician's judgment 
must be the sole guide for each specific case.) 
The average blood sugar is about 0.12 per cent 
or 120 mgs. per 100 c.c. of blood, and ranges 
from 0.075 per cent to 0.14 per cent. 
name Th e r (V° 7 
Date 
SK££H OKI 
DlfT 
Days Treated No 
TOTAL 
DIET IN GRAMS 
BRE 
KKF 
T 
1" 
WEIGHT 
PRO 
FAT 
GA LS 
AtlOH 
CAR 
PRO PAT 
CALS 
WEIGHT 
PRO 
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WEIGH 
4 
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60 
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£645 
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6 
6 
76 
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76 
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6 
6 
73 
3 
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0 
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TOTAL GRAMS 
io\33'a 
4141 
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6 
136 
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6 
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MULTIPLY FOR CALORIES 
4 1 4 1 9 
4 
4 
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4 
4 
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9 
TOTAL CALORIES 
<14 
4 0,44 
54 
<58 
4o 
44 
34 
/36 1 
4t|'-'J4. 
Fig. 9. Diet No. 7. 
In a diabetic patient, a high threshold, such 
as 0.17 per cent blood sugar, with an absence of 
glycosuria, shows an impermeability of the kid- 
neys or an arteriosclerosis, a condition which 
is taken up in Chapter IV. 
The diet may in this way be increased, pro- 
vided the tested specimens are found to be 40 
DIABETES 
sugar-free. The following diet furnishes a fur- 
ther increase in food intake: 
Diet No. 8 
Vi grapefruit, or about 10-15 strawberries 
or raspberries 
900 gms. (30 oz.) 5 per cent green vegetables 
or 600 gms. (20 oz.) 5 per cent and 
150 gms. (5 oz.) 10 per cent green vegetables 
TOTA 
DICT IN <I»*MS 
BREAKFAST 
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SUPPER 
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TOTAL GRAMS 
MULTIPLY FOR CALORIES 
TOTAL CALORICS 
sa* 
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ml 
2?1 
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Fig. 10. Diet No. 8. 
540 c.c. (3 cups, 6 oz. each) coffee, with a 
teaspoonful of cream in each cup 
540-720 c.c. (3-4 cups, 6 oz. each) chicken 
broth (this is optional) MILD DIABETES 
41 
240 gms. (8 oz.) chicken, steak, chops or 
roast beef 
240 gms. (8 oz.) fish, boiled or broiled 
2-4 eggs in any form 
30 gms. (1 oz.) or 1 loaf of aerated gluten 
(Luft) bread or 
6 slices Lister bread 
60 gms. (2 oz.) bacon 
30 gms. (1 oz.) sweet butter 
60-75 gms. oz.) Philadelphia cream 
cheese 
This diet is prescribed especially for acetone- 
free cases. It should be remembered, however, 
that when treatment has progressed to this 
point, cases which have had acetone and diacetic 
acid in the urine are usually found to be free 
from these. The same diet, therefore, can be 
given to patients who originally showed acetone 
in the urine, as to those who were free from 
acetone at first. Oatmeal (2-3 level tablespoon- 
fuls) can be given to both classes of patients. 
Some of the 10 per cent vegetables, as kohl-rabi, 
onions, squash, mushrooms etc., may also be 
added. These have an available carbohydrate 
content of 6 per cent (Table I). It is usual to start 42 
DIABETES 
with 6 oz. (or 180 gms.) of these vegetables 
and gradually increase this amount to about 
10 oz. (or 300 gms.). This quantity is to be 
figured with the 900 gms. of green: vegetables 
permitted in Diets Nos. 7 and 8. 
As the diet is increased, the quantity becomes 
too great for the average patient to digest. The 
amount prescribed must, therefore, be adjusted 
to the individual needs. Instead of 900 gms. 
of greens, which makes about 300 gms. to each 
meal, the allotment of green vegetables for 
breakfast is omitted. Most patients will be 
satisfied with a breakfast consisting of 2 eggs, 
60 gms. (2 oz.) of bacon, a cup of coffee (180 
c.c.) with cream, some cheese and butter, and 
one of the following: 
3 in. aerated gluten (Luft) bread 
2 slices Lister's bread 
1 to 2 muffins made of Lister's flour 
1 to 2 muffins or biscuits made of soy-bean 
flour 
The broth may be discontinued, since it has 
practically no food value (about 3 calories to 
the ounce, or 30 c.c.). It is used at first merely 
as a "filler" and afterward is employed as such MILD DIABETES 
43 
on the "Green Days." Patients often attempt 
to eat all the food allotted to them, no matter 
how voluminous the diet becomes, a practice 
which results in marked indigestion. It must 
be understood that the diet as here given indi- 
cates what is allowed; not everything on the list 
is mandatory. 
In this way the diet is increased slowly and 
gradually. Fruit is given as indicated, and if 
no sugar appears on examination, oranges, 
peaches, berries and nuts are added. It is also 
advisable at this time to change the bread diet. 
Two kinds of muffins have already been men- 
tioned in the diets above; cookies, cheese pan- 
cakes, and as dessert, spice cakes and crullers, 
as set forth in the chapter on menus, may also 
be included. 
In some of the mild cases another step may be 
taken at this point by replacing the aerated 
gluten (Luft) bread or the Lister bread with an 
ordinary rye or white bread. In the majority 
of cases, however, this should not be done. The 
change can be accomplished in the following 
way: After the patient has had ordinary gluten 
or Lister bread for at least two weeks, one slice 44 
DIABETES 
of white, or preferably rye bread, 3 by 3 by y2 in. 
(weighing approximately 30 gms.) is substituted 
for the gluten or Lister bread at one meal. 
If, after a few days, sugar does not appear in 
the urine and the blood sugar remains within 
normal limits, the bread of another meal is 
replaced by a slice of rye bread. This substitu- 
tion is carried on until the gluten bread is en- 
tirely replaced.1 It must be emphasized, however, 
that this can be done only in a small percentage 
of cases. Case 350, although belonging to the 
severe type, shows this. 
Case 350. Female, aged fifty-one, an American. 
Family history negative regarding diabetes and 
Bright's disease. The patient had not had a 
serious illness up to eight years ago, when sugar 
was discovered in the urine. Since that time 
treatment has been followed indifferently. One 
year ago she had an abscess of the left lung, 
which ruptured into a bronchus. On May 2, 
1 The advantage or necessity of returning to ordinary 
breads as quickly as possible is one of utility entirely. Gluten 
breads are disliked by most patients and (especially in the case 
of patients who are not living at their own homes) cannot 
be obtained at all times and places without considerable 
inconvenience. MILD DIABETES 
45 
1919, the author was called by her physician to 
see her. At that time she reported that some 
teeth had been extracted about three weeks 
previously. Since that date she had had severe 
pains in the mouth and throat; temperature 
ranged between 103° and 104°F.; pulse, 120; 
blood pressure, 120. The patient was very rest- 
less. Locally the gums of the right lower jaw 
looked edematous. This area and the throat 
w'ere covered with greenish membrane and were 
quite sore. The glands at the angles of the jaw 
were much enlarged. The urine examination 
showed 5.4 per cent sugar; 4 plus acetone, and 
diacetic acid. The patient was placed on the 
following diet: 
720 gms. (24 oz.) 5 per cent green vegetables 
540 c.c. (3 cups, 6 oz. each) black coffee 
3 hard-boiled eggs (20 min.) 
540-720 c.c. (3 to 4 cups, 6 oz. each) chicken 
broth 
1 qt. bottle Kalak water 
16 c.c. Bacillus Bulgaricus, t.i.d., hour a.c. 
The chart shows this diet properly pro- 
portioned for the three meals. 
The patient was not seen again until May 16, 
1919, although the diet was increased under the 46 
DIABETES 
name CAit-iSo Date. Day_. Days Treated _No._ i 
3 
3 
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FOOD 
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TOTAL GRAMS 
| MULTIPLY FOR CALORICS 
TOTAL CALORICS 
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Name .. Date . Day ... . Days Treated No_!§ < 
Jo 
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TOTAL CALORIES 
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Fig. 12. Diet prescribed a few days later. MILD DIABETES 
47 
direction of the physician in charge, who was in 
constant touch with the writer during the in- 
terim. At this examination the patient weighed 
145 lbs.; the blood pressure was 120. The 
diet had been increased to: 
900 gms. (30 oz.) 5 per cent green vegetables 
540 c.c. (3 cups, 6 oz. each) black coffee 
540-720 c.c. (3 to 4 cups, 6 oz. each) chicken 
broth 
120 gms. white meat of chicken 
3 hard-boiled eggs (20 min.) 
1 qt. bottle Kalak water 
The patient looked very well; her pulse and 
temperature were normal; the condition of the 
throat appeared greatly improved. The gums 
had healed and the patient was advised to 
order the dental plate needed. The urine 
examination showed no sugar present; 3 plus 
acetone; no diacetic acid. The patient's diet 
was increased to the following: 
900 gms. (30 oz.) 5 per cent green vegetables 
540 c.c. (3 cups, 6 oz. each) black coffee 
540 c.c. (3 cups, 6 oz. each) chicken broth 
180 gms. (6 oz.) white meat of chicken 
60 gms. (2 oz.) plain boiled fish 
4 hard-boiled eggs (20 min.) 
1 qt. bottle Kalak water 48 
DIABETES 
On May 18th the patient's condition was not 
so encouraging. She had a severe headache, her 
eyes ached and were heavy. The bowels were 
constipated. The temperature and pulse were 
rnT A : 
FOOD 
niFT IH GRAMS 
BREAKFAST 
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4 
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HO 336 fgt 
40 b&IOQ 
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Fig. 13. Diet prescribed on May 16th. 
normal. Urine examination showed a trace 
of sugar, 2 plus acetone, but no diacetic acid. 
Blood examination showed a sugar content of 
0.18 per cent. The same diet was continued. 
Two days later, on May 20th, the patient was 
somewhat improved; she felt stronger and more 
cheerful. The urine examination still showed a 
trace of sugar and 2 plus acetone. The tem- 
perature and pulse, however, were normal. The MILD DIABETES 
49 
patient was placed on the following "Green 
Day" diet for twenty-four hours, after which she 
resumed the diet prescribed on May 16th. 
900 gms. (30 oz.) 5 per cent vegetables 
540 c.c. (3 cups, 6 oz. each) black coffee 
540 c.c. (3 cups, 6 oz. each) chicken broth 
3 hard-boiled eggs (20 min.) 
nam 
K. - 
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TOTAL CALORIES 
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44 
54 
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Fig. 14. "Green Day'' diet. 
The "Green Day" weakened the patient 
slightly, but the blood pressure remained at 120 
and the temperature and pulse were normal. 
The blood-sugar content came down to 0.10 
per cent. On May 22nd the diet was changed to 
the following: 50 
DIABETES 
900 gms. (30 oz.) 5 per cent green vegetables 
540 c.c. (3 cups, 6 oz. each) black coffee 
540-720 c.c. (3 to 4 cups, 6 oz. each) chicken 
broth 
240 gms. (8 oz.) chicken or lamb chops 
120 gms. (4 oz.) fish 
3 gms. (1 in.) aerated gluten bread 
4 hard-boiled eggs (20 min.) 
1 qt. bottle Kalak water 
name . - Date . Dav _ days treated NO-.A 
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TOTAL CALORICS 
3l 
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Fig. 15. Diet prescribed on May 21st. 
The patient continued this diet until May 
25th. She still felt weak and her weight was now 
only 143 lbs. Blood pressure remained at 120; 
the urine showed no sugar, and the acetone 
reaction indicated only a trace. The diet was 
changed to the following: 
900 gms. (30 oz.) 5 per cent green vegetables 
540 c.c. (3 cups, 6 oz. each) black coffee MILD DIABETES 
51 
540-720 c.c. (3 to 4 cups, 6 oz. each) chicken 
broth 
240 gms. (8 oz.) white meat of chicken 
180 gms. (6 oz.) fish 
3 eggs 
9 gms. (3 in.) aerated gluten (Luft) bread 
1 qt. bottle Kalak water 
' name - date . Day Davs treated.- jmo....G. 
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TOTAL CALORIES 
33 
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Fig. 16. Diet prescribed on May 22nd. 
On May 27th, the patient reported that she 
felt fairly well, but still somewhat weak. On 
examination the urine showed no sugar, but a 
trace of acetone. The blood, pressure remained 
at 120. The diet was further increased as follows: 
900 gms. (30 oz.) 5 per cent green vegetables 
540 c.c. (3 cups, 6 oz. each) black coffee 
540-720 c.c. (3 to 4 cups, 6 oz. each) chicken 
broth 
4 hard-boiled eggs (20 min.) 52 
DIABETES 
240 gms. (8 oz.) chicken, lamb chops or steak 
240 gms. (8 oz.) fish 
15 gms. (5 in.) aerated gluten (Luft) bread 
1 qt. bottle Kalak water 
, NaIae 
. Day 
Days Treated No ? 
FOOD 
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Fig. 17. Diet prescribed on May 27th. 
On the following day the patient was given a 
"Green Day" diet, and on one day each week, 
thereafter, this diet was prescribed. In each 
case, however, 4 eggs were given instead of the 
3 as outlined in the diet of May 20th. Twto days 
later (May 30th) when the patient reported for 
further observation and treatment, she com- 
plained of being depressed and tired. The urine 
examination showed no sugar, and the acetone 
content was much less, only a faint trace being MILD DIABETES 
53 
present. The blood pressure was 118; the weight 
144 lbs. The diet was again increased as follows: 
grapefruit 
900 gms. (30 oz.) 5 per cent vegetables 
540 c.c. (3 cups, 6 oz. each) black coffee 
540-720 c.c. (3 to 4 cups, 6 oz. each) chicken 
broth 
4 hard-boiled eggs (20 min.) 
240 gms. (8 oz.) fish 
240 gms. (8 oz.) chicken, lamb chop, steak or 
roast beef 
21 gms. (7 in.) aerated gluten (Luft) bread 
Name .. - 
DATE 
Day . . 
Days Treated No._fl_ _ 
TOT 
FOOD 
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fJ9O 
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£66 j 
4ft 
28636fl 
696 
tie 
106 
4E6 
Fig. 18. Diet prescribed on May 30th. 
This diet was continued until June 3rd. When 
the patient was interviewed on this day, she 
felt greatly improved and was not tired or 
depressed. Blood pressure, 115; weight 
lbs., slightly less than on May 30th. The urine 54 
DIABETES 
examination showed an absence of sugar; the 
acetone reaction was doubtful. The diet was 
increased by grapefruit; otherwise the quanti- 
ties allowed were the same as those noted above. 
Examination on June 6th showed the patient 
slightly weaker as the result of a "Green Day" 
on June 4th. The reduced diet of the "Green 
Day" seemed to disturb her greatly. She had 
also been having considerable annoyance in 
having the dental plate properly fitted. The 
pressure of the plate on the gums caused certain 
ulcerated areas; as a result, the patient could 
not employ the plate in mastication. The urine 
examination showed a reappearance of the 
acetone; the sugar was still absent. The blood 
pressure on this day was 120; weight 142 lbs. 
The following diet was prescribed: 
grapefruit 
900 gms. (30 oz.) 5 per cent green vegetables 
540 c.c. (3 cups, 6 oz. each) coffee with 4 
c.c. cream to each cup 
540-720 c.c. (3 to 4 cups, 6 oz. each) chicken 
broth 
4 hard-boiled eggs 
240 gms. (8 oz.) chicken, lamb chop, steak or 
roast beef 
240 gms. (8 oz.) fish 
15 gms. Philadelphia cream cheese 
21 gms. (7 in.) aerated gluten (Luft) bread MILD DIABETES 
55 
Four days later, on June 10th, the patient 
felt very well; she had improved greatly in 
appearance, having lost the waxy pallor; the 
eyes also were clearer. The urine examination 
showed neither sugar nor acetone. Blood pres- 
name , . Date Day Days Treated No. ? 
"■ p* <J> ® «•* Cm -ft ? p*|i8 
% 
OX 
r 
FOOD 
57o WrMttt 
£045 
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+6 
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Fig. 19. Diet prescribed on June 6th. 
sure was 125. The portion of aerated gluten 
bread permitted was increased to 30 gms. (9 to 
10 in., or 100 calories), and the allowance of 
cream cheese to 30 gms. (1 oz., or 126 calories). 
Veal (240 gms., or 8 oz.) was substituted for the 
other forms of meat permitted in the diet of 
June 6th, and 60 gms. (2 oz.) of smoked tongue 
was also added. 56 
DIABETES 
On June 13th the patient reported disturbance 
after the "Green Day" June 12th; she seemed 
tired and weak. Urine examination showed 
absence of sugar; 2 plus acetone was present. 
The following diet was prescribed: 
grapefruit 
900 gms. (30 oz.) 5 per cent green vegetables 
540 c.c. (3 cups, 6 oz. each) coffee with 4 c.c. 
cream to each cup 
540-720 c.c. (3 to 4 cups, 6 oz. each) chicken 
broth 
4 hard-boiled eggs (20 min.) 
2 level tablespoonfuls (60 gms. by weight) of 
well-cooked oatmeal 
240 gms. (8 oz.) chicken, chop, steak, roast 
beef or veal 
240 gms. (8 oz.) fish 
30 gms. (9 to 10 in.) aerated gluten (Luft) bread 
45 gms. oz.) Philadelphia cream cheese 
60 gms. (2 oz.) smoked tongue 
name ... Date Day. Days Treated No.JD_._ 
1 
Jo 
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bo 
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Fig. 20. Diet prescribed on June 13th. MILD DIABETES 
57 
Three days later, on June 16th, the patient 
reported that she felt much better. She did not 
feel as tired as previously. The urine examination 
showed only a faint trace of acetone; no sugar 
was present. Blood pressure was 110. The 
patient had eaten the amount of oatmeal 
prescribed and had tolerated it. The oatmeal 
allowance was increased to 3 level tablespoonfuls 
(90 gms., or 71 calories). The increase in the 
amount of cheese in the diet had caused 
the acetone excretion to increase to 3 plus. 
Accordingly, the cheese and Kalak water were 
omitted from the diet prescribed on June 13th; 
otherwise the diet was as noted above. 
On June 24th the patient reported feeling well. 
The urine examination showed no sugar and 
only a faint trace of acetone. The blood pressure 
was 110. To the diet prescribed on June 13th, 
60 gms. of corned beef (2 oz.) were added at this 
time, a few green olives, tomatoes (these, how- 
ever, to be included in the 900 gms. of 5 per 
cent green vegetables allowed) and a dill 
pickle. During the four days which followed 
(up to June 28th) the patient felt less comfort- 
able on account of further annoyance in adjust- 58 
DIABETES 
ing the plate to the gums. She had to make 
several trips from the country to the city for 
this purpose. These trips, in conjunction with 
the pain incident to the inflamed gums, were 
weakening and depressing. She lost 4 lbs. during 
this period.. The urine examination, however, 
showed no sugar present and only the faintest 
trace of acetone. The following articles were 
added to the diet: 
2 Brazil nuts 
2 almond cookies1 (33 calories. Formula appears in the 
chapter on menus and recipes 
1 small peach 
6 stalks of asparagus 
On July 1st the patient reported that the 
condition of the teeth and gums still caused her 
distress and pain. The plate did not yet fit prop- 
erly; hence it could not be used. The examina- 
tion of the urine showed sugar absent and only a 
very faint trace of acetone present. The bread 
allowance was changed to 1 slice (20 gms., or 
26 calories) of heavy gluten bread, and 6 in. 
(18 gms., or 60 calories) of aerated gluten bread. 
1 Almond cookies have: carbohydrate, 17 per cent; protein, 
21 per cent; fat, 55 per cent. In 100 gms. there are 660 calories. 
Each cookie weighs gms. MILD DIABETES 
59 
Olive oil (15 c.c.) with 4 c.c. of lemon-juice was 
permitted as dressing for lettuce. 
The patient was not seen again until July 17th. 
During the interim (July 1st to July 17th) noth- 
ing unusual developed in the case. She had con- 
Name 
DATE 
Day'- 
Daye treated- 
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Fig. 21. Total diet prescribed on June 28th. 
tracted a slight cold, which caused a recurrence 
of the acetone in the urine. She had become 
accustomed to using the dental plate, and 
consequently was able to eat her food with 
less discomfort. The diet now prescribed was as 
follows: 
grapefruit 
900 gms. (30 oz.) 5 per cent vegetables 60 
DIABETES 
540 c.c. (3 cups, 6 oz. each) coffee with 4 c.c. 
cream to each cup 
540-720 c.c. (3 to 4 cups, 6 oz. each) chicken 
broth 
2 to 4 hard-boiled eggs (20 min.) 
240 gms. (8 oz.) chicken, chops, steak, roast 
beef or veal 
240 gms. (8 oz.) fish 
60 gms. smoked tongue 
2 Brazil nuts 
2 almond cookies 
1 small peach 
2 slices rye bread (3 by 3 by in. or 
60 gms.) and 6 in. (18 gms.) aerated gluten (Luft) 
bread 
One week later (July 24th) the patient reported 
that she felt well, but feared the 11 Green Day" 
which was to follow, since she always felt weak 
after the special diet. The blood pressure was 
110. An extra slice of rye bread (3 slices in all, or 
84 calories) was now permitted-one for each 
meal. Butter, 30 gms. (1 oz., or 225 calories) and 
the same amount of cream cheese (126 calories) 
were also permitted. This addition to the diet 
caused no disturbance. Four days later, examina- 
tion showed the urine free from sugar and ace- 
tone. The blood pressure, however, was 105, 
due to the general exhausted condition of the 
patient as the result of the extremely warm 
weather then prevailing. The diet of cheese MILD DIABETES 
61 
(89 calories) and butter (337 calories) was 
increased to 45 gms. oz.); cantaloupe 
and an omelet were also added to the diet. 
On examination, three days later, the urine 
showed no change. Spice cakes and crullers 
(according to the recipes given in the chapter 
on menus and recipes) were added to the pre- 
scribed diet. 
During the next week this diet was continued 
without change. The patient complained of 
intercostal neuralgia and pain in the right 
shoulder, for which atophan was prescribed. 
The blood pressure was 110, the urine examina- 
tion negative. At this point the red meats 
were omitted from the diet, the white meat of 
chicken only being permitted. On August 7th, 
the blood sugar was 0.11 per cent. The following 
articles were added to the diet: 
(30 gms., 1 oz.) small baked potato (30 calories) 
1 teaspoonful freshly grated unsweetened chocolate.1 
During the following week the patient felt less 
comfortable on account of the pain in the 
shoulder and back. The dental plate again caused 
1 Maillard's unsweetened chocolate (chocolat) was used in 
this instance. 62 
DIABETES 
a slight ulceration of the gums as a result of 
pressure. In spite of the potato and chocolate 
eaten, the urine examination showed absence of 
sugar and acetone. The blood pressure remained 
at 110. Five gr. of duotonal and gr. of strych- 
nia were given as a tonic. In addition to the 
foregoing diet, 60 gms. (2 oz.) of ice cream 
(made of cream, eggs and glycerine) and a 
custard (made of cream and eggs) were permitted. 
The cultures of Bacillus Bulgaricus, which had 
been taken since the treatment was begun, were 
now eliminated. 
On August 21st the patient was greatly dis- 
turbed and excited by a collision between the 
automobile in which she was riding and another 
machine. As a consequence she felt weak and 
depressed. The blood pressure, however, was 
115; the urine examination showed absence of 
sugar and acetone. The following articles were 
added to the diet: 
60 gms. (2 oz.) mushrooms 
30 gms. (1 oz.) mashed turnip 
Gelatin flavored with coffee, lemon or strawberries 
On August 28th, the patient reported great 
improvement; she had completely recovered MILD DIABETES 
63 
from the shock of the collision. The ulceration in 
the mouth, caused by the pressure of the dental 
plate, was now healed. Although she had eaten 
potato and rye bread daily, examination showed 
the urine free from sugar and acetone. The 
blood pressure was now 115. One bottle, 180 
gms. (6 oz.) of fermillac was now added to the 
daily diet. 
On September 12th, the patient again reported 
for observation. The additions to the diet had 
been well tolerated. Aside from a slight annoy- 
ance from the dental plate she felt very comfort- 
able. During the interim (August 28th to 
September 12th) the diet had been varied; 
turkey, squab and lamb's tongue had been 
substituted for the other meats and had been 
well tolerated. The following articles were 
added to the diet at this time: 
240 gms. (8 oz.) herring or mackerel 
1 peach 
60 gms. (2 oz.) Swiss, cottage or pot cheese 
mixed with 60 gms. (2 oz.) cream 
1 small (greening) apple 
With all these additions the diet had now 
become very liberal and varied, so that the 
patient could take short trips away from home 64 
DIABETES 
and still be able to obtain the proper food with- 
out inconvenience. The urine continued to re- 
main free from sugar and acetone. On October 
28th, she reported that since the previous visit 
on September 12th, she had eaten and tolerated 
salt mackerel, corned beef, a Cassaba melon, 
34 a small cantaloupe, 120 gms. (4 oz.) smoked 
salmon, and pickled herring. Her "Green Day" 
diet was the same as the regular diet except that 
the bread, cereal and potato were omitted on 
these days. She had lost about 12 lbs. since 
the treatment was begun, her weight being 120 
lbs., 12 oz. The greater part of this loss in weight 
was, however, the result of suffering caused 
by the defective dental plate. The blood pressure 
fluctuated between 110 and 120. 
The complete diet allowance from which 
sufficient food could be selected was as follows: 
Fruits 
y grapefruit (40 calories) or 
y orange or 
1 peach or 
34 Cassaba melon or 
y cantaloupe or 
Dish of strawberries or raspberries 
Vegetables 
900 gms. from the following list: spinach, string 
beans, celery, lettuce, cauliflower, cabbage, water cress, MILD DIABETES 
65 
kale, okra, cucumber, mushrooms, kohl-rabi, turnip, 
potato, asparagus (180 calories) 
Meats 
240 gms. from the following list: chicken, squab, 
turkey, steak, lamb chop, roast beef, lamb's tongue, 
corned beef, sweetbreads (616 calories) 
Fish 
240 gms. from the following list: perch, cod, mack- 
erel, flounder, sea bass, sea trout, smoked salmon, her- 
ring, pickled herring (192 calories) 
Soups 
540-720 c.c. from the following list: beef, mutton, 
lamb or chicken broth or vegetable soup from the vege- 
tables in the list given above 
Bread 
4 to 5 slices rye bread (3 by 3 by y in., or 336-420 
calories) 
Butter 
120 gms. (2 oz., or 450 calories) 
Cereals 
3 level tablespoonfuls oatmeal or wheatena with 
30 gms. of sweet cream (168 calories) 
Desserts 
180 gms. custard (made with cream and egg) or 
120 gms. ice cream (made with cream, egg sweetened 
with glycerine or saccharin) or 
2-4 sponge cookies1 or 
30 gms. (1 oz.) chocolate almond bar or 
1 cup chocolate (made from 1 teaspoonful of freshly 
grated unsweetened chocolate and 30 gms., or 
1 oz., of sweetened cream) or 
y dozen walnuts, pecans or filberts 
During the month of November the patient 
began to gain weight. On November 18th she 
weighed 135 lbs. The blood pressure was 110. 
'Made at Loeb's Diabetic Food Bakery, New York. They 
contain 0.91 per cent starch. 66 
DIABETES 
She seemed well and happy. The urine examina- 
tion showed absence of sugar and acetone. At 
this time one slice of white bread (3 by 3 by % in.) 
was substituted for a slice of rye bread. During 
the two weeks following, the patient continued 
to improve. On December 2nd she weighed 
135% lbs. The blood pressure was 110, the 
urine examination negative. Another slice of rye 
bread was withdrawn from the diet and white 
bread substituted. On December 9th the 
patient's weight had increased to 137 lbs. The 
urine continued to be negative regarding both 
sugar and acetone. Sixty gms. of green peas 
(2 oz.) were added to the diet. 
On December 16th, the patient complained of 
a severe headache due to constipation. The 
urine, on examination, was free from sugar 
and acetone but showed a 2 plus indican reac- 
tion. The weight was 137% lbs. At this point 
another slice of white bread was substituted 
for the rye, making 3 slices of white bread in 
all. From December 20th to 23rd the patient had 
a severe cold, and coughed considerably. The 
headache and dizziness complained of the 
previous week had disappeared after a dose of MILD DIABETES 
67 
calcined magnesia. The urine, on examination, 
was negative in regard to sugar, acetone and 
indican. Two oz. of lima beans were added to 
the tomato. The cold cleared up in a few days 
and the cough was checked after indicated 
treatment. The patient continued to gain in 
weight. On December 30th, she weighed 139 lbs., 
a gain of 1>4 lbs. in two weeks. On examination 
the urine continued to be free from sugar, acetone 
and indican. The patient at this time was 
allowed 4 to 5 slices of white bread instead of 
the rye. Rice was substituted for the oatmeal 
and was well tolerated. 
Referring again to general treatment: consider- 
able misunderstanding prevails regarding the 
value of cultures of Bacillus Bulgaricus in the 
treatment of diabetes, due to a faulty conception 
of the causative factors involved. 
While many successes have been attained 
by the use of cultures, almost as many failures 
have resulted because the pathologic condition 
involved has been overlooked. In the majority of 
cases where lack of success has attended the use 
of the culture, the failure has resulted from want 
of a proper restriction in diet. 68 
DIABETES 
Granting that the etiology of diabetes mellitus 
as given on page 4 is correct, then the use of 
the previously mentioned cultures, with little or 
no attention to proper diet, can be of value only 
in the initial or irritative stage. The only cases 
which have been treated successfully, when no 
dietary restrictions have been observed, are 
those in which the condition was in the initial, 
irritative stage. Where failure attended the use 
of cultures, this failure was due to the lack of 
proper dietary restrictions. 
It is true that the Bacillus Bulgaricus will aid 
in reducing and eliminating the intestinal tox- 
emia, but it cannot bring the organically changed 
pancreas back to its normal condition. For this 
reason, dietary changes must be instituted in 
order that the organ may be given an oppor- 
tunity to regain its power to function. 
Neither in the original report1 on the use 
of the Bacillus Bulgaricus nor in any subsequent 
paper has it been claimed that the culture is a 
cure. It is merely claimed that it accomplishes 
two things: (a) it helps to take care of and neu- 
1 Paper read before the Section of Medicine of the New York 
Academy of Medicine, May 19, 1914. MILD DIABETES 
69 
tralize an existing (auto) toxemia; (&) it increases 
the time necessary for starch to be converted 
into dextrose or glucose, so that smaller quan- 
tities of glucose are formed in a given time.1 
When the cultures are used, a considerably 
higher tolerance is obtained in a much shorter 
time than without their use. Large doses have 
been found to produce the best results. 
I prescribe from 16 to 64 c.c. of an almost 
sugar-free bouillon culture three times a day, 
half an hour before meals. It is frequently found 
that although very large doses are given, the 
toxemia persists, as shown by the large amount 
of indican present or the high percentage of 
ethereal sulphates excreted. This is due to the 
fact that the toxemia is in many cases so severe 
that the bacilli are destroyed before they can set 
up a proper colonization in the colon. In these 
cases a retention enema of 128-192 c.c. of the 
culture is given after the bowel has been thor- 
oughly cleansed in the manner described in 
Chapter IX. In this way we obtain a coloniza- 
tion from below and the toxemia is usually 
quickly subdued. 
1 Bacillus Acidophilus may be substituted for the Bacillus 
Bulgaricus, and in many cases is found to be more efficacious. Chapter IV 
MODERATELY SEVERE DIABETES 
Cases of moderately severe diabetes usually 
give the classic symptoms. These patients are 
either mild cases that have been neglected, or 
those who have been in perfect health and, for 
no apparent reason, have begun to lose flesh 
and strength, and exhibit polydipsia and poly- 
uria. Very often they ascribe their trouble to 
a severe shock or to a sudden misfortune which 
has visited the family. Some time after the 
supposed shock, the patient begins to feel ill 
and gradually grows weaker, tires easily and 
loses from 20 to 30 lbs. Some patients sleep fairly 
well;others complain of lack of sleep; all generally 
lack energy and ambition. They are nervous 
and irritable, and their power of concentration 
is slightly below par. 
On examination, soon after the onset, we find 
that they have lost flesh; the tongue is dry and 
coated; the great majority wet their lips, making 
70 MODERATELY SEVERE DIABETES 
71 
a peculiar smacking sound as though the mouth 
were very dry. The urine is usually of high 
specific gravity-betweeen 1.030 and 1.035 
-and shows from to 6 per cent sugar. 
A few of the cases show acidosis and occasion- 
ally some have a trace of albumin, with or 
without casts (usually of the hyaline type). 
Acetone may be present-from 2 to 3 plus- 
and there may be a faint trace of diacetic acid. 
The blood sugar is usually between 0.17 and 0.24 
per cent. Women may complain of pruritus 
vulvae (itching of the genitals) and may have 
an eczematous rash. 
Case 518. Female, aged fifty-five, a native 
of Russia. Family history negative. Previous 
history gives ordinary diseases of childhood, 
but is otherwise negative. Present history dates 
back five years (to 1917), the time of onset which 
she thinks was the result of shock when her 
three boys were drafted for war. She became 
listless and morose, began to have headaches 
and dizziness, and a rash appeared on her body. 
She tired easily, and had severe polydipsia and 
polyuria. When she presented herself for treat- 
ment, in April, 1922, she was pale, weighed 150 72 
DIABETES 
(previous weight 185) and showed 2 plus sugar 
in the urine and 192 mgm. of sugar in the blood. 
She was placed on dietetic treatment and im- 
proved to such an extent that she is now on a 
diet of 2000 calories, and remains sugar-free. 
A history of constipation is usual, accompanied 
by headache and dizziness. Any exertion renders 
these patients extremely weak. A very few in 
this class complain of eye symptoms, such as 
diminished vision, and a sensation as if there 
w'ere a mist before the eyes. Some have pains of 
neuralgic character, in the arms or the legs. 
Case 494. Female, aged seventy, a native of 
France. Family history negative to diabetes. 
She had no illness until fifteen years ago when 
she began to have trouble with her right eye, 
and except for a sense of fatigue and weakness 
accompanied by polyuria, has had no other 
diabetic symptoms. Bowels were badly consti- 
pated. Examination disclosed no physical defects. 
Urine showed a sugar index of 1.2 per cent, 
acetone 1 plus and blood sugar 212 mgm. to 
100 c.c. of blood. There was no evidence of 
arteriosclerosis, and blood pressure was 140 
systolic, and 90 diastolic. She responded well MODERATELY SEVERE DIABETES 
73 
to dietetic treatment for diabetes, but eye 
symptoms became progressively worse; the other 
eye became affected and she can barely distin- 
guish strong light. 
Others complain only of the neuralgic symp- 
toms and ascribe all their trouble-reduction in 
weight and other symptoms-to the fact that 
they have pain. The unsuspected glycosuria 
is revealed by the urinalysis. When their rations 
are reduced, they invariably show an acidosis, 
even if they had none before treatment. It is 
advisable with the reduction in diet to relieve the 
constipation and endeavor to ameliorate the 
pains and weakness. These patients should be 
put to bed and kept there from four to seven 
days. 
Case 490. Female, aged fifty-six, a native of 
the United States. Family and personal history 
are negative. Present trouble began seven years 
ago with marked pain in left arm and leg. This 
pain was so intense that she could not sleep, and 
as a result lost considerable weight. She com- 
plained of severe constipation and headaches, 
and was very nervous. Examination disclosed the 
presence of 1 per cent sugar and no acetone. 74 
DIABETES 
Blood pressure was 210, liver enlarged 4 cm. 
below costal margin, and tongue coated and 
dry. Under treatment she improved somewhat, 
but was unfaithful to diet and regime. When the 
sugar was reduced and she became aglycosuric, 
the pains disappeared. 
Case 495. Male, aged forty-eight, a native 
of Italy. Father died of diabetes at fifty-two. 
Had the ordinary diseases of childhood; had 
typhoid at fifteen and malaria at twenty-two. 
Present illness began in June 1920, with boils 
and carbuncles; and urinalysis showed the 
presence of sugar. Tires very easily and is only 
intermittently thirsty. Has lost between 35 and 
40 lbs. On examination, no physical defect was 
discovered and he looked fairly well. His blood 
pressure was 130 systolic and 70 diastolic, tongue 
badly coated and eyes icteroid. Urine showed 
sugar 2 per cent, acetone 3 plus and blood sugar 
240 mgm. This case made an uneventful recov- 
ery, and was discharged with a diet of about 1800 
calories. 
These cases may be treated either by diet alone 
or with insulin. Cases that show a loss of 30 lbs. 
or more, with a progressive downward trend, MODERATELY SEVERE DIABETES 
75 
should receive insulin, for unless the downward 
grade is stopped, they will, in a short time, be 
unable to carry on their work; and although they 
may, by dietary treatment, acquire the power 
to utilize considerable amounts of glucose, 
their tenure of life will be brief. It is necessary 
that these moderately severe diabetics be in- 
structed as to the value of insulin. A good many, 
so long as they are able to carry on their work, 
rebel at the idea of taking two injections daily, 
and prefer to try dietetic treatment first. They 
should be made to understand that although they 
may improve to some extent, it is doubtful 
whether they can ever be brought up to a diet 
large enough to enable them to keep on with 
their work, and that their scope of usefulness 
will be short-lived. In the milder cases of this 
type, where the loss of weight does not exceed 
10 to 15 lbs. and there are no complications, 
dietetic treatment may be instituted. 
The first diet is: 
600 gms. 5 per cent green vegetables 
540 c.c. (3 cups, 6 oz. each) black coffee 
720 c.c. (4 cups, 6 oz. each) chicken broth 
1000 c.c. lemonade made from the juice of 76 
DIABETES 
1 lemon sweetened with either saxin, saccharin 
or crystallose.1 
This diet is maintained for at least twenty-four 
hours after the urine has become sugar-free. 
In stubborn cases of constipation, the patient 
is given an irrigation night and morning with 
four quarts of plain warm water or warm saline 
solution, depending upon whether or not the 
kidneys are involved. 
It is an open question whether the use of 
sodium chloride is advisable for a severe diabetic. 
Some claim salt to be necessary, since without 
it, the patient becomes very thin. Others claim 
that sodium chloride, when taken in large quan- 
tities, may increase the sugar output. If no kid- 
ney complication exists, I permit the use of salt 
in fair amounts and allow the cooking of vege- 
tables in salted water. However, I have seen 
a marked edema present in diabetics who were 
consuming large quantities of salt-especially 
in cases complicated by acidosis. 
Severe purging is to be avoided, as it increases 
an already existing weakness. A purgative of 
1 It is important that too much saccharin should not 'be 
used, as it is cumulative in action. MODERATELY SEVERE DIABETES 
77 
some preparation of calcined magnesia gives the 
best results with the least disturbance of the 
general system. Its mild cholagogic action rids 
the liver of considerable toxin. 
When the urine has been sugar-free for twenty- 
four hours the diet is increased by: 
3 hard-boiled eggs (20 min.) 
1000 c.c. of lemonade (1 liter of water and the 
juice of 1 lemon) or a drink made of cracked 
cocoa and hot water. 
At the end of forty-eight hours, 60 gms. (2 oz.) 
of white meat of chicken may be added to the 
above. 
At this stage, symptoms of acidosis frequently 
appear; the urine may be loaded with acetone 
and diacetic acid, and the patient may also have 
an acetone breath. Severe headache and nausea 
and much weakness or languor are present. 
Occasionally there will be sudden bloating, a 
condition which, while rare in this form of dia- 
betes, is quite common in the very severe form. 
This is a grave symptom and requires immediate 
attention, as it is the forerunner of coma. 
The treatment of marked acidosis with threat- 
ened coma is considered in the following chapter. 78 
DIABETES 
Beginning with Diet No. 2 the menu is now 
increased as in the mild cases, the increase, 
however, being more gradual. The eye symptoms 
and the neuritis usually clear up with the disap- 
pearance of the glycosuria and acidosis. A 
severe case of neuritis will seldom persist when 
the patient is otherwise doing well. If, however, 
the neuritis still is present, treatment will depend 
upon the conditions found. Often the galvanic 
current, applied with the positive pole (anode) 
on the affected limb, and the negative pole 
(cathode) at some other part (for example, the 
back) will relieve the symptoms. 
Inasmuch as the diet is increased gradually 
in the moderate form of diabetes, we must often 
resort to articles of diet which have little or no 
food value. "Jell agar" may be prescribed, a 
jelly made of agar-agar1 and Indian gum flavored 
Water (1 qt.) 910 gms. 
Agar-agar1 20 gms. 
Indian gum 10 gms. 
Benzoate of soda 1 gm. 
Saccharin gm. 
Citric acid X teaspoonful 
Glycerin (1 oz.) 30 gms. 
Extract raspberry (sugarless) (1>£ pts.).... 700 gms. 
1 Method. The agar-agar and the Indian gum should first 
be dissolved in hot water; the other ingredients should then be 
added. MODERATELY SEVERE DIABETES 
79 
with saccharin or glycerin and a fruit extract, or 
a special marmalade1 made of agar-agar. The 
marmalade, however, contains about 1.5 per cent 
fruit sugar and must be used with caution. 
Gelatine flavored with coffee, chocolate, lemon, 
or small amounts of fruit juice may also be 
prescribed. 
1 These articles are made by Lister Brothers. Chapter V 
SEVERE DIABETES 
Severe cases of diabetes, whether in the old or 
the young, tax the patience of both doctor and 
patient. All severe cases show some form of 
complication, ranging from acidosis in the young 
to the marked arterial changes, nephritis, retini- 
tis, arteriosclerosis and gangrene in the old. 
Whereas the moderate cases may only occasion- 
ally exhibit eye symptoms, patients having 
severe diabetes show these symptoms very 
frequently, as well as the symptoms peculiar to 
the other complicating condition. These cases are 
frequently of the chronic type, though occasion- 
ally they are of short duration but fulminating 
in character. Often the glycosuria is slight- 
only a fraction of 1 per cent-but of long 
standing, treatment having been begun, not on 
account of the glycosuria, but for loss of vision, 
edema of the legs, or incipient gangrenous in- 
80 SEVERE DIABETES 
81 
volvement of the extremities. These patients 
almost always exhibit arterial changes and have 
a relatively high blood pressure. One of the 
reasons why these cases have a very low sugar 
index in the urine is because of an accompanying 
nephritis which raises the threshold. The blood 
sugar is always fairly high. The following cases 
illustrate these points: 
Case 343. Female, Russian. Family his- 
tory negative. Never ill until about eighteen 
years ago when, on examination, sugar was 
discovered in the urine. The patient had never 
had much sugar and thought she was doing well. 
The sight of the right eye was destroyed, and 
that of the left eye was so badly impaired that 
she could hardly observe objects. On examina- 
tion, the urine was found to contain over 5 per 
cent sugar, a pronounced trace of albumin and 
granular casts. Blood pressure 150. Under treat- 
ment the diabetic condition cleared up, but the 
eye symptoms and kidney condition remained 
unchanged. 
The following case, in which eye symptoms 
were present but less severe in form, was referred 
to me by Dr. Charles H. May. In this instance, 82 
DIABETES 
after the clearing up of the diabetic condition, 
the sight returned. 
Case 335. Female, American. Family history 
negative. The patient had had diabetes for 
thirty years and during this period had lost over 
80 lbs. in weight. In the last few years she experi- 
enced impaired vision with neuritis in the fingers 
and toes. When she came under my treatment 
the urine examination showed 3.12 per cent 
sugar content, but this percentage was high, 
as the average had been 0.6 per cent, the acetone 
2 plus, the blood sugar 0.20 per cent and the 
urea nitrogen 31 mgm. per 100 c.c. of blood. There 
was also a trace of albumin in the urine. The 
sugar cleared up under treatment and the eye- 
sight returned to almost normal. 
The following is a case of the fulminating 
type as far as the eyesight is concerned. 
Case 320. Female, aged thirty-three, Russian. 
Family history negative. Condition began two 
years ago with marked thirst and hunger, itch, 
loss of flesh and strength and diminution of 
vision. Examination showed the urine to con- 
tain over 4 per cent sugar, 4 plus acetone, and 
4 plus diacetic acid. The blood sugar was SEVERE DIABETES 
83 
0.30 per cent. At the beginning of the treatment 
she was markedly edematous, but the swollen 
condition cleared up and the blood sugar came 
down to 0.12 per cent. However, she did not 
follow up the treatment, often breaking dietetic 
rules; and finally, the writer's oversight of the 
patient was discontinued. When last heard from 
she was absolutely blind. 
The following case, seen in consultation, ex- 
emplifies gangrenous involvement: 
Case 223. Male, Russian. Family history 
revealed diabetes and Bright's disease among 
brothersand sisters. The patient had had diabetes 
for years, but showed only occasional traces of 
sugar, had not been under a physician's care, 
but had regularly sent urine specimens to labora- 
tories. He suffered from impaired circulation in 
both extremities; on examination gave a history 
of varicose ulcer of the right leg which had come 
on five weeks previously. This ulcer would not 
heal, and on June 15, 1919, showed a definite 
gangrenous condition involving the leg to a 
point above the knee. The urine showed only 
a trace of sugar, but contained 0.45 per cent 
of albumin with hyalin and granular casts and 84 
DIABETES 
occasional red blood cells. The blood sugar 
was 0.25 per cent despite the fact that only a 
trace appeared in the urine. The creatinine 
was 3 mgm. per 100 c.c. of blood. This patient 
collapsed suddenly before amputation could be 
performed, and died in coma. 
No one who has had any experience in treating 
severe diabetics with insulin can dispute the 
fact that insulin alone offers hope to these un- 
fortunates. It is true that prior to the advent 
of insulin, a great number of cases did well on 
ordinary dietetic treatment. But while the 
majority were made aglycosuric for a time, all 
showed a progressive downward trend-con- 
tinued loss of flesh and strength, loss of activity 
and usefulness, which terminated finally with 
death either in coma or from complications. 
Insulin1 works equally well in the young and 
in the older cases. By its use the important 
symptoms of diabetes are ameliorated if not 
entirely removed. As has been stated before, 
patients show a very marked improvement in 
their physical condition and appearance; their 
1 Banting, F. G., Campbell, W. R., and Fletcher, A. A., J. 
Metab. Research, Nov. and Dec., 1922, ii, Nos. 5 and 6, p. 547. SEVERE DIABETES 
85 
temperaments and dispositions are changed; 
they acquire a different outlook on life; they 
regain their lost activities, and are able to resume 
their work; they can put on weight and acquire a 
sense of well-being which causes them to be 
interested in everyday things, instead of food 
and drink alone. 
It is not the aim of the author to go into detail 
regarding all the experimental work carried on 
under his supervision with insulin. He will 
confine himself to the application of conclusions 
reached as a result of experiments in treating 
severe diabetes, both in the old and in the 
juvenile cases. 
Insulin is administered hypodermically, either 
one, two or three times daily, depending upon 
the severity of the case and the height of the 
blood sugar. It should be given subcutaneously, 
and not intramuscularly or within the skin itself. 
The several doses are best given one-half hour 
before meals, but the time will vary with the 
individual, and the physican must work out the 
best time to administer the insulin in each case. 
It is best to begin with a small dose of one to two 
units, and increase gradually, thereby preventing 86 
DIABETES 
the danger of hypoglycemia in cases sensitive 
to insulin. This is especially true in children 
and weak, emaciated individuals, in whom a 
dangerous hypoglycemia may occur without 
any warning symptoms. The lowering of the 
blood-sugar level may begin within one-half 
hour after the administration of insulin, and may 
last from four to six hours or even longer. There- 
fore all new insulin cases should have frequent 
blood tests made to see how they respond to it. 
Quite often a new batch of insulin is more potent 
than the last, and for the sake of safety when 
beginning treatment with new insulin, a blood- 
sugar estimation is necessary. In Cases 461 (p. 
104) and 543 (p. 100), symptoms of hypogly- 
cemia1 occurred several times, because, instead 
of the prescribed half hour after injection, their 
meals were delayed from three quarters of an 
hour to an hour. 
They both complained of some interference 
with sight, nervousness and marked perspiration, 
and Case 461 experienced a severe hysterical 
attack. 
1 Campbell, W. R. J. Metab. Research, Nov. and Dec., 1922, 
ii, Nos. 5 and 6, p. 606. SEVERE DIABETES 
87 
The dose of insulin is increased with a 
corresponding increase in diet. Various experi- 
menters have reported that 1 unit of insulin 
can utilize from 1 to 2 gms. of glucose in severe 
cases, and even more in milder cases. 
Very often large doses of insulin may be 
reduced and the patient remain aglycosuric or 
show a faint reaction with the same intake of 
carbohydrates. This is because at the beginning 
the blood sugar may have been high and the 
tissues may have contained considerable sugar; 
therefore the larger amount of insulin was 
necessary. Also in ketosis some of the insulin 
is used up by the acetone bodies. But when the 
acidosis disappears and the blood sugar is 
reduced, less insulin is required to utilize the 
given amount of glucose (carbohydrates). 
The author's experience has been that the 
dose of insulin had to be increased, and, in Cases 
543, 541 and 542 (pp. 100, 102 and 121), practi- 
cally doubled; but Case 542, the last-mentioned, 
showed a remarkable improvement. The dose 
of insulin was reduced from 55 units daily to 
35, and he remained aglycosuric and the blood- 
sugar level was kept within normal limits. The 88 
DIABETES 
author will not venture to state whether the rest 
to the pancreas, afforded by the use of the in- 
sulin, brought about some regeneration of the 
patient's own function, or whether the improve- 
ment was due to the dietary readjustments and 
the resulting increased tolerance. It is interesting 
to note, however, that this condition may occur 
in some cases, and further study will be neces- 
sary before a definite conclusion can be reached. 
It is more imperative than ever that there 
should be a proper knowledge of diet in the 
treatment of diabetes with insulin. Dietary 
restrictions cannot be dispensed with and the 
patient must receive a thorough training with 
regard to w'hat is expected of him. 
If the rules for diet are transgressed and not 
enough insulin is given, there will be a return 
of all the classic symptoms of diabetes, such as 
thirst, polyuria, etc. If too large a dose of insulin 
is given to care for this increase in glucose, there 
is the danger of hypoglycemia. Therefore the 
patient cannot afford to take any chances. 
The author has adopted two methods of 
handling the diet in severe diabetes. If the 
patient has lost but little weight, though he may SEVERE DIABETES 
89 
have a marked glycosuria and hyperglycemia, 
time and insulin may be saved by putting him 
on a slightly undernutritional diet. In this way 
the glycosuria will become reduced and the 
ketosis diminished, and smaller doses of insulin 
will be required to make the patient aglycosuric 
and free from acidosis. The diet is then gradually 
increased, as described in the chapter on mild dia- 
betes, and the insulin increased proportionately 
to the dietary increase. 
The markedly emaciated and weakened patient, 
however, cannot afford to be further depleted. 
He is put to bed and kept there from three days 
to a week, so as not to dissipate further strength 
and energy. A patient at rest needs a certain 
minimum amount of food for energy and for 
repairing the nitrogenous waste of the cells and 
body tissue. This required amount is expressed 
in terms of calories, varies with the age, sex, 
height and weight of the individual, and is called 
the basal caloric requirement. The patient is 
placed on a diet based on his normal basal caloric 
requirement, which can be determined with a 
fair amount of accuracy from the Aub-Dubois 
charts and tables. These necessary calories must 90 
DIABETES 
come from the carbohydrates, proteins and fats, 
or from the body tissue itself. The necessary 
repair of the cells and body tissue must come, to 
a certain extent, from the proteins ingested, the 
amount of which is estimated to be from 0.6 
to 1.0 gm. per kilo of body weight in the adult, 
and from 1.0 to 2.0 gms. per kilo in the child, who 
also must have some protein for growth. The 
remainder of the energy must be supplied by the 
carbohydrates and fats. In diabetes there is a 
subnormal fat as well as a carbohydrate com- 
bustion, resulting in the accumulation in the 
body of certain incompletely burned fatty 
acids known as ketones, giving rise to ketosis 
or acidosis.1 Complete fat combustion can take 
place only when there is a complete carbohydrate 
combustion at the same time. It requires 1 
gm. of glucose to affect the complete combustion 
of 1.5 to 2 gms. of fat in order to prevent the 
formation of diacetic acid, B-oxybutyric acid 
and acetone. It is therefore necessary that the 
ketogenic products of the fat should be balanced 
by the antiketogenic glucose. The available 
Chaffer, P. A. J. Biol. Chem., 1921, xlvii, 433, also 439; 
ibid., 1921, xlix, 143. SEVERE DIABETES 
91 
glucose in any diet is derived not only from the 
carbohydrates, but from 58 per cent of the pro- 
teins and 10 per cent of the fats; so that in 
estimating the glucose in any diet the available 
glucose of the protein and fat must be added to 
that of the carbohydrates. 
Now since 1 gm. of glucose will oxidize or 
bum to 2 gms. of fat, and 0.7 gms. of protein 
are necessary to replace the tissue waste, the 
greatest number of calories required in a given 
case can be derived from these two sources and 
the balance made up by the carbohydrate. 
Let us cite a concrete example and see how it 
works out. It is commonly estimated that an 
adult with average nutrition requires between 
30 and 33 calories per kilo of body weight in 
twenty-four hours. Therefore an individual weigh- 
ing 132 lbs. or 60 kilos will require between 1800 
and 1980 calories. We have stated before that 
from 0.7 to 1 gm. of protein per kilo is necessary 
for repair. Therefore the protein (using 1 gm. 
per kilo) will furnish 1 X 60 X 4, or 240 calories. 
It is also commonly estimated that the average 
severe diabetic, who is almost always under- 
nourished, may safely take from 2 to 2.5 gms. 92 
DIABETES 
of fat per kilo. Therefore the fat (using 2.5 gms. 
per kilo) will furnish (2.5 X 60 X 9) 1350 calories 
and the balance, 210 to 390 calories, will have 
to be made up by the carbohydrates, which 
will be 52 to 97 gms. This gives a well-balanced 
diet of 52 C., 60 P. and 150 F., or 1800 calories; 
or 97 C., 60 P. and 150 F., or 1980 calories; but 
would give a ratio of 1.6:1 when worked out 
according to Woodyatt's formula:1 
FA .46P- .9F- 
G C .58P- .1F- 
If we use 0.7 gms. of protein per kilo we will 
have, based on the above calculations, 71 C., 
42 P. and 150 F., or a fat-to-glucose ratio of 1.5 
to 1. 
On the other hand, we may work out a well- 
balanced basal caloric diet in another way. We 
might choose 50 gms. of carbohydrates as an 
"initial" amount. As before mentioned, the 
fat-glucose ratio is 1.5 to 1. Calculating on that 
basis, and using 1 gm. of protein per kilo, the 
total available glucose would be 50 gms. from 
the carbohydrate and 35 gms. (being 58 per cent 
of the available glucose) from the protein. We 
1 Woodyatt, R. T. Arch. Int. Med., 1921, xxviii, 125. SEVERE DIABETES 
93 
can therefore figure that 127 gms. of fat are 
required in order to balance the diet properly. 
This will make a good initial diet with which 
to start insulin. 
Since the severe diabetic has a very poor toler- 
ance he will no doubt show a marked glycosuria 
on the above diet, which will be partially con- 
trolled by the initial dose of insulin. The author 
has found it advisable to keep the patient on 
the same dose of insulin for a few days and cal- 
culate his glucose tolerance before increasing 
the dose. This is done in the following manner: 
If the patient voids 2000 c.c. in twenty-four 
hours and shows a glycosuria of 3 per cent, 
then he is eliminating 60 gms. in twenty-four 
hours. The total available glucose intake of 
the above diet was 97 gms.; therefore the patient 
has a glucose tolerance of 37 gms. The insulin 
is then increased gradually by one or two units 
per day until the patient is aglycosuric or shows 
only 4 to 5 gms. in twenty-four hours. The 
carbohydrate is then increased by 5 gms. at a 
time. But an increase of carbohydrate will 
permit an increase of 8 gms. of fat as: 
C. 50 P. 60 F. 127 1483 Calories 
C. 55 P. 60 F. 135 1675 Calories 94 
DIABETES 
and a further increase of 5 gms. of carbohydrate 
will give us a diet of: 
C. 60 P. 60 F. 142.5 1762 Calories. 
It is advisable not to use a twenty-four-hour 
specimen, but single specimens; for it is possible 
that, after a given dose of insulin, succeeding 
specimens may be sugar-free and a like dose of 
insulin may give rise to symptoms of hypogly- 
cemia. As soon as the urine is sugar-free, the 
diet is either increased or the insulin diminished 
or omitted entirely for one dose. Frequent 
blood tests are likewise made in the beginning so 
as to avoid the danger of hypoglycemia. 
In this manner the diet is gradually increased 
until the patient receives a final maintenance 
diet which usually contains 50 per cent more 
calories than the initial diet. On a diet such as 
this the patient should be able to carry on moder- 
ate work and exercise. 
Kellogg1 has evolved a table which gives a 
rapid method of estimating a proper basal 
caloric diet based on the carbohydrate tolerance 
1 Kellogg, J. H. A simple method of approximating the proper 
ration for a diabetic patient. J. Am. M. Ass., 1923, Ixxxi, No. 
10, p. 825. SEVERE DIABETES 
95 
and the protein intake without the necessity of 
resorting to the formulas as specified above. 
The patient's sugar tolerance must first be 
found. A diet is selected from the table which will 
supply the number of calories required by the 
basal metabolism of the patient. A patient weigh- 
ing 132 lbs. or 60 kilos will require 1500 calories. 
The protein requirement will be 40 gms. (% of 
his weight in kilos). We locate on the chart 
ration 40 to 90 as furnishing the requisite number 
of calories. This diet supplies: 
P. 40 F. 130 C. 53 1542 Calories. 
It is only necessary to put the patient on this 
diet for twenty-four hours, determine the urinary 
sugar and subtract this from the known carbo- 
hydrate content of the diet. Supposing the 
urinary sugar for twenty-four hours to be 60 
gms.; subtracting this from 90, we have 30 
gms. as the patient's sugar tolerance. 
Referring again to the table, we find in the 
column under 30, diet 40 to 30; protein40 gms.; 
calories 446. On this diet the patient should be 
sugar-free. Having found the diet on which 
the patient is sugar-free, one has to raise the DIABETES 
96 
Carbohydrate Tolerance.... 
10 
20 
30 
40 
50 
60 
70 
80 
90 
100 
110 
120 
130 
140 
150 
160 
170 
180 
190 
200 
Fats 
60 
77 
94 
110 
127 
144 
160 
177 
194 
210 
227 
244 
260 
277 
293 
Protein 80 
Carbohydrates. 
8 
16 
25 
33 
41 
50 
58 
66 
75 
83 
91 
100 
108 
116 
125 
Calories 
... 
892 
1,077 
1,266 
1,442 
1,627 
1,816 
1,992 
2,177 
2,366 
2,542 
2,727 
2,916 
3,092 
3,277 
3,457 
Fats 
47 
63 
80 
97 
113 
130 
147 
163 
180 
197 
213 
230 
247 
263 
280 
296 
Protein 75 
Carbohydrates. 
2 
10 
18 
27 
35 
43 
52 
60 
68 
77 
85 
93 
102 
110 
118 
127 
Calories 
... 
731 
907 
1,092 
1,281 
1,457 
1,642 
1,831 
2,007 
2,192 
2,381 
2,557 
2,742 
2,931 
3,107 
3,292 
3,472 
Fats 
49 
65 
82 
99 
115 
132 
149 
165 
182 
199 
215 
232 
249 
265 
282 
298 
Protein 70 
Carbohydrates. 
4 
12 
20 
29 
37 
45 
54 
62 
70 
79 
87 
95 
104 
112 
120 
129 
Calories 
... 
737 
913 
1,098 
1,287 
1,463 
1,648 
1,837 
2,013 
2,198 
2,387 
2,563 
2,748 
2,937 
3,113 
3,298 
3,478 
Fats 
52 
68 
85 
102 
118 
135 
152 
168 
185 
201 
217 
234 
251 
268 
285 
301 
Protein 65 
Carbohydrates. 
7 
15 
23 
32 
40 
48 
57 
65 
73 
82 
90 
98 
107 
115 
123 
132 
Calories 
... 
756 
932 
1,117 
1,306 
1,482 
1,667 
1,852 
2,028 
2,213 
2,393 
2,569 
2,754 
2,943 
3,132 
3,317 
3,497 
Fats 
37 
54 
70 
87 
104 
120 
136 
154 
170 
187 
203 
219 
236 
253 
270 
287 
Protein 60 
Carbohydrates. 
1 
10 
18 
26 
35 
43 
51 
60 
68 
76 
85 
93 
101 
109 
118 
126 
Calories 
... 
577 
758 
938 
1,123 
1,312 
1,488 
1,668 
1,866 
2,042 
2,227 
2,407 
2,583 
2,768 
2,953 
3,142 
3,327 
Fats 
39 
56 
73 
90 
106 
123 
139 
156 
172 
189 
205 
221 
238 
255 
272 
Protein 55 
Carbohydrates. 
4 
12 
21 
29 
37 
45 
53 
62 
70 
79 
88 
96 
104 
112 
121 
Calories 
... 
587 
772 
961 
1,146 
1,322 
1,507 
1,683 
1,872 
2,048 
2,237 
2,417 
2,593 
2,778 
2,963 
3,152 
Fate 
42 
59 
76 
92 
108 
124 
141 
158 
175 
192 
208 
224 
241 
258 
Protein 50 
Carbohydrates. 
7 
15 
23 
31 
40 
48 
56 
64 
73 
81 
90 
98 
107 
115 
Calories 
.... 
606 
791 
976 
1,152 
1,332 
1,508 
1,689 
1,878 
2,067 
2,252 
2,432 
2,608 
2,797 
2,982 
Table II SEVERE DIABETES 
97 
Fats 
28 
44 
61 
78 
94 
111 
127 
144 
160 
177 
193 
210 
226 
243 
Protein 45 
Carbohydrates. 
1 
10 
18 
26 
34 
42 
50 
58 
66 
75 
84 
93 
101 
110 
Calories 
... 
430 
616 
801 
996 
1,162 
1,347 
1,523 
1,708 
1,884 
2,073 
2,253 
2,442 
2,618 
2,807 
Fats 
30 
47 
63 
81 
97 
113 
130 
146 
163 
180 
196 
213 
229 
Protein 40 
Carbohydrates. 
4 
12 
21 
28 
36 
45 
53 
61 
69 
78 
86 
96 
104 
Calories 
... 
446 
631 
811 
1,001 
1,177 
1,357 
1,542 
1,718 
1,903 
2,092 
2,268 
2,461 
2,637 
Fats 
33 
49 
66 
83 
99 
116 
133 
149 
166 
183 
199 
215 
Protein 35 
Carbohydrates. 
7 
15 
23 
31 
39 
48 
56 
64 
72 
81 
89 
99 
Calories 
... 
465 
641 
826 
1,011 
1,187 
1,372 
1,557 
1,733 
1,922 
2,111 
2,287 
2,471 
Fats 
18 
35 
52 
69 
85 
101 
118 
135 
152 
168 
185 
202 
Protein 30 
Carbohydrates. 
1 
9 
18 
26 
34 
42 
51 
59 
67 
75 
84 
92 
Calories 
280 
471 
660 
845 
1,021 
1,197 
1,386 
1,571 
1,756 
1,932 
2,121 
2,306 
Fats 
20 
37 
54 
71 
87 
103 
120 
137 
154 
171 
187 
Protein 25 
Carbohydrates. 
4 
12 
21 
29 
37 
45 
53 
61 
70 
78 
86 
Calories 
296 
481 
670 
855 
1,031 
1,207 
1,392 
1,577 
1,766 
1,951 
2,127 
Fats 
23 
40 
57 
73 
90 
106 
123 
140 
156 
174 
Protein 20 
Carbohydrates. 
6 
14 
23 
31 
39 
47 
56 
64 
73 
81 
Calories 
311 
496 
685 
861 
1,046 
1,222 
1,411 
1,596 
1,776 
1,970 
Fats 
8 
25 
42 
59 
76 
92 
108 
125 
142 
159 
Protein 15 
Carbohydrates. 
0 
8 
16 
25 
33 
41 
49 
58 
66 
75 
Calories 
132 
317 
502 
691 
876 
1,052 
1,228 
1,417 
1,602 
1,791 
Fats 
11 
28 
45 
62 
79 
95 
111 
128 
145 
Protein 10 
Carbohydrates. 
3 
11 
19 
28 
36 
44 
52 
61 
69 
Calories 
151 
336 
521 
710 
895 
1,071 
1,247 
1,436 
1,621 
Rations for diabetic patients balanced for sugar tolerance and acidosis. Courtesy of the Journal of the American Medical Association. 
Table II-Continued 98 
DIABETES 
caloric value of the diet to the actual body re- 
quirement as rapidly as possible. Here is where 
insulin comes in. If the patient is given 5 units 
of insulin, his sugar tolerance will be increased 
10 gms. Following the table, we shall find the 
approximate diet in the 40 column on the 40 
protein line, diet 40 to 40. This raises the caloric 
intake to 631, an increase of 185 calories. The 
addition of another 5 units of insulin raises the 
diet to 40 to 50 with 811 calories. Thus, within 
a few days the diet may be brought up to the 
patient's full basal requirement of 1500 calories 
which is provided by diet 40 to 90 with 30 units 
of insulin. 
Case 546. Male, aged sixty, a native of the 
United States. Family history: Father died of 
cardiac condition at seventy-three, mother at 
sixty-five, of nephritis; otherwise negative. Pre- 
vious history: Was never ill until the present 
illness, which began April, 1922. Present history 
began with classic symptoms of thirst, polyuria 
and loss of flesh and strength (lost about 30 
lbs. in all) otherwise complained of no head- 
ache or dizziness, and was but slightly con- 
stipated. On examination nothing abnormal SEVERE DIABETES 
99 
was found. Blood pressure 150 to 90. Urine analy- 
sis showed 0.77 per cent sugar, 1 to 2 plus acetone, 
trace of albumin, hyaline and granular casts, 2 
plus red blood cells. Blood sugar test taken while 
fasting showed 163 mgm. He at first refused 
insulin treatment, as he lived quite a distance 
from New York and could not remain here long 
enough for a tolerance of insulin to be worked 
out. He was placed on dietetic treatment; and 
although on the diet of 1400 calories he was sugar- 
free, as soon as he returned home sugar and 
acetone would reappear and he became weaker 
and weaker, and in four weeks lost 10 lbs. He 
finally agreed to take insulin, and in four to five 
weeks was able to tolerate a diet of 2400 calories 
on 26 units per day and gained 17 lbs. in weight. 
He discontinued the use of insulin for three 
weeks and remained sugar-free. 
Case 547. Male, aged fifty-two, a native of 
Russia. Family history: One aunt died of dia- 
betes. Previous history: Excepting for the ordi- 
nary diseases of childhood and influenza three 
years ago, was never ill. Present history dates 
back two and a half years when symptoms began 
with polyuria, polydipsia and polyphagia. He 100 
DIABETES 
lost over 20 lbs. He tires easily and is quite 
drowsy, has some dizziness, and sight has been 
poor for the past two or three weeks. Exami- 
nation disclosed no abnormal conditions, blood 
pressure 150 to 90; urine showed per cent 
sugar, 4 plus acetone and no diacetic acid. 
Blood sugar 230 mgm. per 100 c.c. of blood, 
weight 149>£ lbs. He was placed on a diet of 
950 calories per day and was given 10 units of 
insulin twice daily. His diet and insulin were 
gradually increased until he was taking over 
2000 calories and 33 units per day. At first he 
lost 6 lbs. in weight, but in a week regained 2 
lbs., and the insulin was reduced to 26 units. 
In the next two weeks he took about 15 gms. 
of Intarvin1 daily. He felt and looked very 
well, had a different outlook on life, and claimed 
that he could think much better than before. 
Case 543. Male, aged fifty-seven, a native 
of Scotland. Family history: Father and mother 
died of senility; one sister and one uncle died 
of diabetes. Previous history: Had the ordinary 
1 The author has used Intarvin in many cases and has ob- 
tained uniformly successful results in rapidly increasing the 
weight of markedly emaciated patients. SEVERE DIABETES 
101 
diseases of childhood, and pleurisy as a young 
man. Present history dates back four years. 
Had marked weakness, polyuria and polydipsia; 
never followed out any diet, has no headaches, 
but some dizziness. He tires easily and is short 
of breath; he does not sleep well, being obliged 
to get up two or three times during the night; 
is drowsy and sleepy; has lost 30 lbs. His chief 
complaint is that he cannot read, and his sight is 
becoming poorer every day. Examination: 
Looks thin but fair; face very red; drowsy. 
General physical examination discloses nothing; 
blood pressure 120 to 70. Urine analysis shows 
sp. gr. 1.032, urea 0.8, faint trace of albumin, 
sugar 6.25 per cent, 5 plus acetone and diacetic 
acid, small number of hyaline and granular 
casts. Blood sugar 380 mgm. per 100 c.c. He 
was put on an undemutritional diet with 
daily irrigations, and given 10 units of insulin 
twice daily. In three days he was sugar-free, 
and had 2 plus acetone and 1 plus diacetic acid. 
The insulin was reduced from 20 to 15 units 
daily and diet was increased from 450 to 1100 
calories. His sight improved somewhat from the 
very beginning. The diet and insulin were grad- 102 
DIABETES 
ually increased until at the end of four weeks 
he had a diet of 2055 calories on 46% units. 
Occasionally he would eat more, and sugar and 
acetone would reappear in all specimens; on 
two or three occasions he could not reach home 
within the alloted half-hour, and he showed 
symptoms of hypoglycemia, such as marked 
hunger, some interference with vision, nervous- 
ness and marked perspiration. At the end of 
three more weeks he was receiving 2400 calories, 
but inasmuch as he was not very careful with 
his diet and would take a fourth meal before 
retiring, he needed 70 units per day to keep him 
aglycosuric and free from acetone and diacetic 
acid. At the end of six weeks from the beginning 
of treatment his sight was so far improved that 
he was able to give himself one to two injections 
daily. At the beginning of treatment he also had 
edema of the ankles, which disappeared under 
the treatment, and he therefore lost some weight, 
which he later regained. 
Case 541. Female, aged forty-two, a native 
of the United States. Family history and pre- 
vious personal history are negative. Present 
history dates back one year, when she noticed SEVERE DIABETES 
103 
a loss of weight and strength. An examination 
at that time showed over 5 per cent sugar. 
Since then she has had treatment on and off. She 
was on a marked undernutritional diet for 
awhile and lost 58 lbs. She tires easily, sleeps 
poorly, is very drowsy, has pain in left arm and 
chest, feels cold, bowels are badly constipated; 
no headaches. Examination disclosed a thin, 
partially emaciated woman with bad color; 
weight 1 lbs.; hands and arms had a peculiar 
mottled cyanotic appearance. Liver was 5 cm. 
below costal margin; heart normal, but pulse 120; 
blood pressure 150 to 90; urine showed 5.55 per 
cent sugar, 4 plus acetone and 4 plus diacetic 
acid; large number finely granular casts; blood 
sugar 268.41. She was given a diet of 1200 
calories, and 6 units of insulin the first day, 16 
the second day and 20 the third day. The sugar 
promptly came down to a trace, but the acetone 
and diacetic acid still persisted to 4 to 5 plus. 
A few days later she was sugar-free and the 
acetone and diacetic acid began to diminish. 
At the end of five weeks she was sugar-free and 
free from acidosis on a diet of 2300 calories, 
on 46 units of insulin per day. Three weeks later 104 
DIABETES 
she was taking 2660 calories on 55 units, which 
she continued. When she was last seen the 
symptoms had entirely disappeared. 
While insulin has proved excellent in severe 
diabetes in adults, its results are almost miracu- 
lous in juvenile cases. Children that looked like 
living skeletons are not only brought back to a 
very good maintenance diet sufficient for repair 
and growth, but they put on from 20 to 50 
lbs. or more, so that they are normal in every 
way. The diet and insulin treatment for them 
is practically the same as for adults, with the 
exception that from 1 to 2M gms. of protein per 
kilo is given, since in children provision must 
be made for growth as well as for repair of 
waste and the destruction of body tissues. The 
following case exemplifies results obtained in 
children: 
Case 461. Male, aged twelve years. One of 
eight children. Family history negative. Had 
whooping-cough when an infant. In April, 1921, 
his mother noticed that he began to lose flesh, 
showed a marked polyuria and polydipsia, 
became irritable and cranky and lost all desire 
to play with other children. On examination Figs. 22 and 23. Case 461. March, 1923. Figs. 24 and 25. Case 461. July, 1923. SEVERE DIABETES 
105 
at that time, he excreted over 6 per cent sugar; 
4 plus acetone and diacetic acid; blood sugar 
270 mgm. He then weighed lbs. He was 
kept on ordinary dietetic treatment with various 
changes from time to time. But only on the 
most rigid diet of 650 calories could he be kept 
sugar-free and free from acidosis. In the last 
week of March, 1923, his diet was adjusted 
previous to the administration of insulin. He 
was then given 33 gms. carbohydrate, 50 gms. 
protein and 100 gms. fat, which gave him 1232 
calories; and he remained on that diet for a week. 
His sugar output on this diet in twenty-four 
hours was about 45 gms. glucose, 1 plus acetone 
and 224 mgm. blood sugar. His weight was 
about 60 lbs. He was markedly thin, practically 
emaciated, irritable, with the peculiar appear- 
ance which is characteristic of the severe diabetic. 
He was given 4 units of insulin twice daily, and 
kept on the above diet. The glycosuria gradually 
became less and finally disappeared, as well as 
the acetone and the diacetic acid; the blood sugar 
was reduced to 170 mgm. His weight, however, 
dropped to 58 lbs., due to the disappearance of 
the edema and bloat of face and ankles, which 106 
DIABETES 
were formerly present. His diet was gradually 
increased until he received over 2400 calories. 
With this increase in diet, he was given a corre- 
sponding increase in insulin, until he was getting 
32 units per day. He was free from sugar and 
acetone for months, with an occasional trace 
at times in the morning specimen. Lately, his 
insulin intake was reduced to 20 units per day. 
His last weight was 82 lbs. He has lost his 
irritability, plays ball, and takes an interest in 
life like that of any normal healthy child. Chapter VI 
ACIDOSIS AND COMA 
Acidosis is the most formidable of all complica- 
tions in diabetes, and has been responsible for 
the greatest number of deaths. This condition 
is most to be feared, even with the use of insulin. 
Good judgment and rapid treatment are neces- 
sary. Symptoms which should not be over- 
looked are headache, marked weakness, nausea, 
vomiting and great restlessness, drowsiness and 
dyspepsia. A patient who shows the presence of 
large quantities of ketone bodies in the urine, 
and who begins to complain of the symptoms 
just listed, should be put to bed, and treatment 
should be instituted at once. 
Insulin has brought about marvelous results 
in severe acidosis and coma; but sometimes coma 
cases will improve under treatment, with a 
return to consciousness, and subsequently die, 
owing to the fact that the condition was not 
recognized and treatment instituted in time. 
107 108 
DIABETES 
A great number of very severe acidosis cases 
have been adequately treated by dietetic 
measures,1 but occasionally a case progresses 
steadily into a state of coma in spite of all 
methods of treatment. The following case exem- 
plifies such a condition: 
Case 267. Female. Family history negative. 
The patient never had an illness until about 
seven years ago, when the present condition 
was discovered during pregnancy. She then 
displayed the usual symptoms of polyuria and 
polydipsia and had a sugar index of 8 per cent. 
The condition cleared up after the birth of the 
child and she remained sugar-free for about a 
year. Sugar reappeared during a second preg- 
nancy, and for about a year before coming to 
me she had sugar in the urine almost constantly. 
She had been losing flesh progressively, had 
slight headache, tired easily, and complained 
of drowsiness in the afternoon. She was slightly 
constipated, had no eye symptoms, and looked 
fairly well. Weight 124 lbs.; blood pressure 140; 
liver enlarged; colon thickened; heart normal. 
1 Campbell, W. R. J. Metab. Research, 1922, ii, Nos. 5 and 
6, p. 605. ACIDOSIS AND COMA 
109 
Urine examination showed sugar, 3 plus acetone 
and 3 plus diacetic acid. Blood sugar 0.24 per 
cent. 
The patient was placed under treatment and 
responded well; blood sugar went down to 
0.112 per cent and then to 0.100 per cent. The 
urine became normal and remained so for nearly 
a year. She was practically well. However, in 
the course of a pleasure trip she broke her diet, 
eating large amounts of fats in the hope of 
regaining weight. On returning to town, she 
suddenly felt very ill and began to bloat. She 
died shortly afterwards in coma. 
When the diagnosis of severe acidosis has been 
verified and the patient complains of headache, 
nausea and some shortness of breath and is very 
restless and drowsy, it is advisable that 20 to 
30 units of insulin be injected at once. The 
blood-sugar level and CO2 combining power 
should be elicited. If there is marked hyper- 
glycemia and glycosuria no glucose or carbohy- 
drates need be given with this initial dose of 
insulin. Every subsequent injection, however, 
should be followed by either orange-juice or 
glucose solution, or, if that is not obtainable, 110 
DIABETES 
by carbohydrates in proportion of 1 gm. of 
carbohydrate to each unit of insulin injected. 
If the patient cannot retain the orange-juice 
or glucose solution, then 5 per cent glucose 
solution may be given by rectum, either alone 
or with a 5 per cent bicarbonate of soda solution. 
Very often this solution given in the form of 
Murphy drip is efficacious, as it is easily retained. 
Occasionally it is found that oral and rectal 
administration of glucose are not successful, 
and one must resort to an intravenous injection 
of a 5 per cent sterile dextrose solution or one 
with a 3 per cent bicarbonate of soda. Quite 
often it is difficult even to give intravenous 
injection and the solution must be given by 
hy podermoclysis. 
The initial injection of insulin is followed by 
subsequent injections of from 10 to 15 units 
every two or three hours, the blood and the 
urine being examined after each injection. 
With a diminution of the symptoms and a 
gradual reduction of the ketone bodies and rising 
of the CO2 tension, the interval between injec- 
tions is increased from three to six or eight 
hours-until the symptoms have disappeared. ACIDOSIS AND COMA 
111 
The ordinary pre-insulin treatment for aci- 
dosis should likewise be instituted-all food 
excepting carbohydrates should be withdrawn. 
The bowels should be promptly emptied and 
irrigations of bicarbonate of soda given once 
or twice daily. The patient should be kept warm; 
if necessary, hot-water bottles should be placed 
around the body, and large quantities of fluid 
should be given. 
If the patient is conscious and can swallow, 
Vichy (Celestin) and Kalak1 water are given, 
1 Kalak water is an artificial preparation containing the 
following: 
Parts per Million 
Total solids (1100 c.c.) 
5730 
Total solids after ignition to 
red heat 
5595 
135 loss of carbon dioxide 
The solids are divided as follows: 
Sodium carbonate 
4049.00 
Sodium phosphate 
238.50 
Sodium chloride 
806.3 
Calcium carbonate 
578.2 
Magnesium carbonate 
48.9 
Potassium chloride 
47.9 
5768.8 112 
DIABETES 
as both contain bicarbonate of soda in a form 
not likely to disturb the stomach or cause vomit- 
ing, as does ordinary bicarbonate of soda, espe- 
cially if given in concentrated doses. Too much 
bicarbonate of soda should not be used, espe- 
cially where there is a low diuresis, as there is a 
danger of alkalosis following the disappearance 
of the acid. The following case of alkalosis was 
a result of the indiscriminate use of bicarbonate 
of soda, and might have proved fatal if the con- 
dition had not been recognized in time: 
Case 535. Male, aged sixty-one, a native 
of the United States, Family history negative 
to diabetes. Previous history: Had the ordinary 
diseases of childhood, also typhoid fever. Present 
history dates back twelve or thirteen years 
when sugar was discovered in a urine examina- 
tion, the patient at that time suffering from 
phlebitis, as a result of a varicose ulcer. He was 
always thirsty and had polyuria and poly- 
phagia, which he attributed to hard work. The 
diabetic condition received very little attention 
until about four months ago (December, 1922) 
when his legs began to swell badly. He complained 
of marked constipation, headaches, dizziness ACIDOSIS AND COMA 
113 
and shortness of breath. Under very strict diet 
the sugar index in the urine was reduced from 
3 to m per cent. He lost about 31 lbs. as a 
result of his condition. He had great difficulty in 
walking. On examination in March, 1923, he 
looked pale and was dyspneic; blood pressure 
140 to 80; definite aortic diastolic murmur; 
enlargement of liver; (4 to 5 cm. below costal 
margin) weight lbs.; edematous; urine 
examination disclosed a glycosuria of 3.58 
per cent; 1 plus acetone and a trace of albumin; 
blood chemistry showed a blood sugar of 258.6 
mgm. to 100 c.c. of blood; 3.41 mgm. of 
uric acid; 14.93 urea nitrogen; 1.36 mgm. of 
creatinine. He was sent to a hospital and placed 
on appropriate dietetic treatment, to which 
he responded well, tolerating over 2200 calories. 
The glycosuria disappeared, the blood sugar 
came down to normal, and, except for a slight 
edema of the legs and a continued 1-2 plus 
acetone, he got along very well. He complained, 
however, of some dyspnea, which occurred 
especially during the night, and an inability to 
get around. This was at first ascribed to his 
cardiac condition, as the x-ray showed a dilatation 114 
DIABETES 
of the arch and descending thoracic aorta. At 
the beginning of treatment his weight was 
reduced to 170 lbs., but as he began to walk 
more his weight began to increase and within 
three weeks he reached 186% lbs. His legs were 
markedly edematous, he was very short of breath, 
unable to sleep, face pale and pasty in color, 
and he found great difficulty in walking. On 
close questioning it was discovered that 4 to 
5 times during the day and a few times during 
the night, the patient was in the habit of taking 
a teaspoonful of bicarbonate of soda in half a 
glass of water. This was immediately stopped, 
and within three weeks his weight came down 
from 186% lbs. to 163% lbs. and the dyspnea 
disappeared. He was then able to walk consider- 
able distances; his color returned to his face, 
he was able to sleep very well, and the persistent 
acetone disappeared from the urine. Chapter VII 
COMPLICATIONS 
Tuberculosis often offers complications in 
severe diabetes. The percentage of deaths from 
this complication has recently been greatly 
reduced. There was a time when diabetes was 
accompanied by tuberculosis, in as many as 
45 to 50 per cent of the cases; now the range 
is between 14 and 15 per cent. The use of insulin 
will no doubt lower the mortality still more by 
improving the nutrition of those so affected. 
But with an active case it is doubtful if it can 
avail to stop the progress of the disease. The 
following are cases of diabetes, complicated by 
tuberculosis: 
Case 299. Male, aged fifty-four, a native of 
the United States. Family history negative 
as to diabetes and tuberculosis; the father died 
of Bright's disease. Personal history: The patient 
has had no illnesses except the ordinary diseases 
of childhood. The present trouble started three 
115 116 
DIABETES 
years ago with thirst, polyuria and loss of flesh. 
When he presented himself in November, 1917, 
he was very thin and debilitated; complained 
of shortness of breath, cough in the morning, 
drowsiness in the afternoon and loss of 
appetite. The bowels were in fairly good 
condition. Pulse 150; temperature 100.6; 
blood pressure 115; height 5 ft., 6 in.; weight 
lbs. Dullness and bronchial voice and 
breathing were detected in the middle of 
the lower lobe and anterior aspect of the 
right lung. 
The urine showed a large amount of sugar, but 
no acetone, diacetic acid or albumin. The patient 
was placed under treatment and improved 
slightly. The sugar disappeared entirely from 
the urine and the cough diminished a little. 
He felt better and was more cheerful. Examina- 
tion of the sputum showed the presence of 
tubercle bacilli. The patient eventually died of 
tuberculosis. 
Case 470. Male, aged forty-eight, a native 
of Russia. Family history: Father died of 
pneumonia; mother has tuberculosis, and one 
brother died of tuberculosis; negative to dia- COMPLICATIONS 
117 
betes. Previous history negative except for 
repeated attacks of grippe. Present history: 
He was told, fourteen years ago, that he had 
diabetes. When he showed a little sugar he would 
begin to diet; otherwise he followed out no par- 
ticular regime. In October, 1921, he contracted 
grippe and has been coughing since (January, 
1922); feels weak, cannot sleep well, and brings 
up a considerable amount of sputum. On 
examination looks fairly well; blood pressure 105 
to 60; lungs show involvement of both apices 
and right base. There are crepitant and sub- 
crepitant rales and increased vocal fremitus. 
Sputum examination shows the presence of 
tubercle bacilli; the urine shows 2 per cent sugar, 
but no acetone or diacetic acid; blood sugar 
212.7 mgm. He ran an afternoon temperature 
of 99.4 to 100°F. The diabetes responded to 
ordinary dietetic treatment, but the chest 
condition became progressively worse. The cough 
became more marked; temperature rose higher 
until it reached 103.5. Finally, after a severe 
hemorrhage, the patient died. 
In such cases, both diseases need care and 
treatment-treatment to eliminate the diabetic 118 
DIABETES 
condition and also to prevent the extension 
of the tubercular processes in the lungs and 
throat (larynx). 
Cancer, as a complication of diabetes, occurs 
in a small percentage of cases. Four cases of this 
type have been present in my series, one involving 
the vertebrae, one the shoulder-joint, one the 
uterus and one the throat. The last-mentioned 
is cited in the following case: 
Case 190. Male, aged fifty-eight. Family 
history negative. The patient had had no ill- 
nesses except typhoid fever at eighteen, and 
ague. The present trouble dated back thirteen 
years, beginning with thirst, polyuria and loss of 
flesh. The patient had had an infected toe am- 
putated. He had been under treatment pre- 
viously for diabetes and had become free of 
sugar and acetone. Lately the acetone had 
reappeared and had been persisting. About a 
year ago a white cauliflower formation appeared 
on the right side of the throat and spread 
gradually over the tonsil. Pathological examina- 
tion revealed epithelioma of the tonsils. The 
growth was arrested for a number of months; 
later it began to grow again and filled part of the COMPLICATIONS 
119 
mouth and cheek. The urine contained 5 per cent 
sugar, 3 plus acetone and 1 plus diacetic acid. 
Under treatment the diabetic trouble cleared up. 
The patient was referred to a prominent surgeon 
who considered the case inoperable. The radium 
treatment, which was suggested, failed to act 
on the cancer. The patient finally died of the 
cancerous growth. 
Arteriosclerosis develops in a great number of 
elderly patients whose cases are of long standing, 
especially when associated with Bright's disease. 
I have never found it where the diabetes was 
otherwise uncomplicated, except in the following 
patient who showed no symptoms of kidney 
involvement: 
Case 234. Female, aged twenty-four. Family 
history negative. The patient gave no history 
of illnesses except, possibly, malaria in childhood. 
The present trouble started, about eighteen 
months previous to the time when she appeared 
for examination, with pruritus, polydipsia and 
polyuria. 
At first she lost weight, and later gained it 
again. She had shown 6 per cent sugar; however, 
when she came under treatment, only 2.8 per 120 
DIABETES 
cent was present, with large amounts of acetone 
and diacetic acid. 
At this time the patient really looked and felt 
very well; was neither tired nor drowsy, had 
no headache, and did not complain of constipa- 
tion. Weight lbs. Abdomen and eyes 
normal. Pain over the gall-bladder, cecum and 
sigmoid on palpation; tongue coated; urine 
showed sugar and large amounts of acetone and 
diacetic acid. There was definite hardening 
of the arteries, and the blood pressure was 160 
to 170. Neither the urine nor the blood showed 
nephritic complications. The patient gradually 
grew worse, and died four years later in a 
state of coma. 
It is in these cases of diabetes complicated 
with arteriosclerosis that we get gangrenous 
involvement. I have seen 12 cases in all; 8 
male and 4 female. 
Surgical complications in severe diabetes prior 
to the introduction of insulin gave rise to a very 
high mortality. Not only was operative inter- 
ference exceedingly hazardous, but the additional 
danger of acidosis and coma from the anesthetic 
was very great. If insulin is given prior to surgi- COMPLICATIONS 
121 
cal intervention, the risk from acidosis is reduced 
to a minimum; and a low blood-sugar level, 
with proper drainage, helps to heal the wound 
readily, provided the circulation is not markedly 
interfered with. The following case is one with 
marked arteriosclerosis and gangrene of the 
right extremity which necessitated amputation 
above the knee: 
Case 542. Male, aged fifty-six, a native of 
the United States. Family history: Father 
died at eighty-four, of grippe; mother living 
and well; one aunt has diabetes. Previous history: 
Had ordinary diseases of childhood; otherwise 
negative. Present history dates back fifteen 
years; he followed an indifferent kind of diet 
and regime. In January, 1923, he injured the 
second toe of the right foot. He had terrific 
pain, could not sleep, and three months after 
injury, could not walk without experiencing 
severe pain. Examination, March, 1923: Is 
very thin, of pasty complexion. Second toe of 
right foot shows gangrenous involvement of 
terminal phalanx; slight edema extending up 
on dorsum of foot; no pulse could be detected, 
even as high as popliteal space; circulation in 122 
DIABETES 
left extremity was also bad and no pulse could 
be felt below mid-thigh; urine showed 2 per cent 
sugar, 2 plus acetone, hyaline and granular 
casts; blood sugar 225.56 mgm. He was put on 
an undernutritional diet and the sugar promptly 
disappeared, but reappeared when the diet was 
increased to 1000 calories. The acetone, however, 
did not diminish; in fact, it increased to 4 plus 
and the gangrenous progress extended to the 
dorsum of foot. On the 11th of April treatment 
was begun with insulin in 5-unit doses and the 
diet was increased to 1350 calories. The diet and 
insulin were gradually increased until, by the 
22nd of April, he was taking 1800 calories and 
26 units of insulin per day, on which he showed 
no sugar, but 1 plus acetone. On the 19th of 
April, he received 150 c.c. of buffer salts solution 
intravenously, with the hope of stopping the 
gangrenous progress. This was followed by two 
subsequent injections, without any good results. 
In fact, the condition was aggravated. On the 
24th of April the leg was amputated in mid-thigh, 
and he was given a glucose bicarbonate of soda 
solution by protoclysis. The urine after that was 
sugar-free and showed only a trace of acetone. COMPLICATIONS 
123 
His diet and insulin were increased until he was 
receiving 2400 calories and 55 units of insulin 
per day. He became sugar-free on an even larger 
diet, the stump healed and the insulin was 
reduced to 35 units per day. 
Cases of severe diabetes with severe infection, 
if treated early with insulin and proper surgical 
interference, have a fairly good chance of recov- 
ery. The following patient, however, had a 
severe carbuncle which received no surgical 
attention for over ten days, and although he 
received insulin before operative interference, 
he developed secondary abscesses and general 
sepsis, from which he subsequently died: 
Case 549. Male, aged forty-five, a native of 
Russia. Family history negative to diabetes. 
Previous history: Excepting for ordinary diseases 
of childhood, was never ill. Present history: 
Diabetes was discovered six years ago. It began 
with the classic symptoms of thirst, polyuria, loss 
of weight etc. He followed no regime and prac- 
tically was never sugar-free. He discovered a 
pimple on the back of his neck which promptly 
developed into a severe carbuncle. Examination: 
Patient looks very ill; bad color; drowsy and 124 
DIABETES 
dyspneic; urine showed 1.25 per cent sugar, 
5 plus acetone and diacetic acid; blood sugar 
210 mgm.; tongue coated and dry. He received 
an initial dose of 15 units of insulin and was given 
the juice of one orange. He was operated upon 
two hours later. His diet was gradually increased 
to: carbohydrate 60, protein 90, fat 120; or 
1680 calories, and 70 units of insulin. The sugar, 
acetone and diacetic acid disappeared, but the 
patient gradually became worse and finally died. Chapter VIII 
HYPOGLYCEMIA 
While the intelligent use of insulin is attended 
with gratifying results, the careless and indis- 
criminate use of it may be fraught with danger. 
Insulin causes a lowering of the blood-sugar 
level. The normal blood-sugar level ranges 
between 0.075 and 0.125. If, however, a large 
dose'of insulin is given, and it is not properly 
balanced by the diet, the blood-sugar level may 
fall below 0.075 (75 mgm. to 100 c.c. of blood) 
and produce a fatal condition known as hypo- 
glycemia.1 
The warning symptoms of hypoglycemia are: 
1. Sudden and pronounced hunger. 
2. Sudden sensation of weakness and fatigue. 
3. A peculiar restlessness or nervousness often 
described as an "inward* trembling." 
1 Fletcher A. A., and Campbell, W. R. The blood sugar 
following insulin administration and the symptom complex. 
J. Metab. Research, Nov. and Dec., 1922, ii, Nos. 5 and 6, p. 
637. 
125 126 
DIABETES 
4. Pallor or flushing of the face; dilated pupils. 
5. Increased pulse rate (of diagnostic value 
in children). The patient should be taught to 
recognize these symptoms, and upon their 
appearance to take immediately some form of 
carbohydrate, such as the juice of an orange, 
a few pieces of sugar or candy, a glass of milk, 
or a teaspoonful of karo or com syrup. This 
will cause a prompt disappearance of the symp- 
toms and further danger will be avoided. 
If the dose of insulin was very large, and the 
above corrective measures were not adopted, the 
following symptoms might supervene: 
6. Sweating (two of the cases reported com- 
plained of marked perspiration at various times). 
7. Anxiety and fear or apprehension. 
8. Vertigo and diplopia. 
9. Convulsions. 
10. Unconsciousness. 
11. Death. 
The treatment for this condition is as indicated 
above. If the patient is unconscious and is unable 
to swallow, glucose solution should be given 
either by protoclysis or intravenously. In the HYPOGLYCEMIA 
127 
latter case the solution must be sterilized. 
Epinephrin in 10 to 20 minim doses given hypo- 
dermically will often help to bring back con- 
sciousness, but this must be followed by 
glucose solution as soon as the patient is able 
to swallow. 
Hypoglycemia may be brought about in 
various ways, and the doctor must always be 
on guard so that serious results do not ensue. 
Very often it is found necessary to give large 
doses of insulin, as in cases of coma or marked 
infection; great care should be exercised that 
these large doses are not continued beyond the 
necessary period, on account of the danger of 
hypoglycemia. It is always advisable in giving 
large doses of insulin to give glucose or some 
other form of carbohydrate at the same time in 
the proportion of 1 gm. of glucose to e'ach unit 
of insulin used. The urine and blood sugar should 
be examined frequently. So long as there is a 
slight glycosuria there is no danger of a hypo- 
glycemia. 
Insulin should not be given too long before a 
meal, as that may lower the blood-sugar level 
too much. 128 
DIABETES 
Occasionally, after a patient has been under 
treatment for some time, he acquires a natural 
increase in tolerance, and for this reason the 
doses of insulin which were previously correct 
may prove too potent. 
If for any reason a patient may have to omit a 
meal, the dose of insulin before that meal should 
be omitted; or if two doses are given daily, both 
doses must be reduced. 
In cases of acute indigestion, vomiting or 
diarrhea, food absorption may be delayed, and 
the dose of insulin should be either omitted or 
very much reduced. Chapter IX 
HYGIENE AND EXERCISE 
Teeth. The importance of hygiene in the 
treatment of diabetes cannot be overestimated. 
Very few cases exist without some involvement 
of the teeth or gums. Pyorrhea seems to affect 
diabetics more than any other class of patients. 
To avoid this complication, the teeth and gums 
must be kept clean and in good condition. The 
teeth should be brushed after every meal 
and on rising and retiring. Any bland dentifrice 
or prepared chalk may be used. Any accumula- 
tion of food between the teeth should be removed 
by the use of dental floss. Patients should 
visit the dentist regularly for the removal of 
tartar and for general prophylactic treatment. 
All cavities should be promptly filled. 
Skin. The skin must be kept in good condi- 
tion, as furunculosis is a very common complica- 
tion. Frequent baths are a necessity except in the 
very severe forms of diabetes when nephritic 
complications are present, and great care must 
129 130 
DIABETES 
be exercised not to chill the skin. With proper 
precautions the skin can be kept in good condi- 
tion by sponging and massage. Care must be 
taken not to abrade the surface of the skin, since 
any injury may lead to infection and cause a 
general septicemia. Very frequently serious in- 
fections result from the cut of the manicurist 
or the chiropodist. 
If furuncles should develop, keep the sites 
very clean and do not injure the surrounding 
parts. Local applications may often be used. 
Boils can frequently be aborted, if, at the very 
beginning, they are painted with iodin. How- 
ever, when they have already developed, iodin 
is not very effective. The furuncle may be 
covered with carbolized vaseline or salicylic 
ointment. Boric acid dressings are also effective. 
Yeast may be taken internally. In a number of 
cases good results have been reported from 
yeast treatment. It is advised that from 
to y2 cake of yeast be eaten every day. If the 
skin is broken or scratched, paint the injured 
part with tincture of iodin and maintain asepsis. 
Bowels. Constipation is a troublesome symp- 
tom. More than 90 per cent of the cases I have HYGIENE AND EXERCISE 
131 
treated gave a history of it, and the severer 
the case, the more marked has been the consti- 
pation present. Marked purging in weak and 
asthenic patients is to be avoided, since it 
tends to increase the weakness and to create a 
susceptibility to intercurrent infections. The 
bowels must move daily, and, while the use of 
the coarse vegetables aids in securing natural 
evacuation to a certain extent, in the majority 
of cases no result is obtained from this diet 
alone. In mild cases, much may be accomplished 
with bland medicaments, such as 15 drops of 
fluid extract cascara sagrada taken before retir- 
ing. Some prefer the tablets; the plain non-sugar- 
coated tablets may be used. These should be 
taken before retiring, in amounts ranging from 
5 to 10 gr. In other cases the use of a little 
compound licorice powder or calcined magnesia 
works very well. Bran muffins eaten in connec- 
tion with the regular diet will help considerably, 
provided the bran used in their preparation 
contains no starch. (See the special formula in 
the chapter on recipes, menus, etc.) 
In severe cases I usually find some fecal con- 
cretion in the cecal region, or some thickening 132 
DIABETES 
of the ascending colon. In these cases, especially 
if complicated with Bright's disease, I secure 
good results by irrigating with from 4 to 6 qts. 
of plain water, followed, one hour later, by a 
retention enema of 6 to 8 oz. of lukewarm 
oil of sesame. 
The apparatus used is that indicated in Figure 
26, which consists of a 4-qt. irrigating can to 
which is fastened a large rubber tube; at the 
end of this tube is placed a Y-glass connection. 
To one of the ends of this glass tube is attached 
a rectal tube (No. 20 American or No. 28-30 
French) which is inserted in the rectum. To 
the other end is attached a rubber tube which 
leads to a vessel on the floor. 
The patient is placed on the left side in the 
Sims position. The rectal tube is inserted and 
the water turned on. Care must be taken to 
make sure that the tube leading to the vessel 
on the floor is shut off. When the patient cannot 
retain any more water, the tube leading from 
the container is shut off and the lower tube 
opened. In this way the bowels can be irrigated 
thoroughly with little discomfort to the patient. 
One hour later the patient is again placed on his HYGIENE AND EXERCISE 
133 
Fio. 26. Irrigating apparatus. 134 
DIABETES 
left side, or in the knee-chest position. Through 
a rectal tube and funnel 6 or 8 oz. of luke- 
warm oil of sesame1 are poured into the rectum. 
The tube is then withdrawn, and the patient 
placed on the right side; he remains in this 
position for twenty minutes. In the majority of 
cases the oil will be retained, and will usually 
be evacuated in the morning with excellent 
results. Occasionally it is necessary to give 
Pluto water or a Seidlitz powder in the morning 
to expel the oil. In cases of marked acidosis, I 
give bicarbonate of soda, 30 gms. to the quart, 
without the oil retention enema. 
Exercise 
Exercise sometimes helps to overcome con- 
stipation and to tone up the abdominal muscles. 
The following forms are advocated: 
Abdominal Muscle Exercise. Lie down, with 
the back flat on the floor and the arms folded on 
the chest. Sit up without touching the floor 
with the hands or lifting the legs. Raise the 
lower extremities without bending them at the 
1 Oil of sesame is employed in preference to cotton-seed or 
olive oil on account of its non-drying properties. HYGIENE AND EXERCISE 
135 
knees or moving the arms. Each of these exer- 
cises should be repeated about twenty times. 
Fig. 27. Abdominal muscle exercise. 
Exercise Kneading the Abdomen. Start at 
right groin and work up with a steady even 
Fig. 28. Another type of exercise to develop the abdominal 
MUSCLES. 
pressure of the hands to the right side under the 
ribs; then down to the left groin and over to the 
right groin again. Repeat these movements 136 
DIABETES 
about twenty or thirty times. This exercise is 
sometimes accomplished by rolling a cannon 
ball from right to left. 
Massage. Many other exercises are beneficial, 
such as swinging the trunk on the abdomen, also 
Fig. 29. Knee-bending 
exercise. 
Fig. 30. Trunk-twisting 
exercise.. 
massage and less strenuous treatment. The exer- 
cise should, of course, be adapted to the consti- 
tution of the patient. The purpose of the exercise 
is to utilize the carbohydrates and to give the 
patient the needed strength. In cases accom- 
panied by marked acidosis exercise is usually HYGIENE AND EXERCISE 
137 
absolutely interdicted; if prescribed at all it 
must be very mild. Fatigue must be avoided since 
it may produce coma. In cases in which the urine 
is free from acidosis and the patient is improving 
on the diet prescribed, exercise is to be encour- 
aged. Walking is the best form of exercise. I 
advise a walk of three to four miles each day. It 
helps digestion and utilizes the carbohydrates, 
thereby increasing the tolerance. It induces 
the patient to inhale good clear air. 
Golf is an excellent exercise for those pa- 
tients who do not care to walk. In the course 
of the game these patients usually unconsciously 
cover some three to five miles a day. The severe 
forms of exercise are to be avoided. Some of the 
younger patients may be allowed tennis, but this 
is usually not desirable. 
Sleep is as essential as proper diet for diabetics. 
I recommend between nine and ten hours of 
sleep a day. The use of drugs to induce sleep 
should be avoided as much as possible. If, how- 
ever, the insomnia is very persistent and all 
physical means for inducing sleep fail to give 
results, 5 gr. of veronal, medinal or adalin 
may be given. 138 
DIABETES 
An alcohol rub, after a cool sponge, is usually 
sufficient to induce sleep, especially if the patient 
has taken sufficient exercise during the day. A 
cup of warm broth before retiring is sometimes 
efficacious. Chapter X 
MENUS, RECIPES AND TABLES 
The great difficulty in the treatment of dia- 
betes is to provide a sufficient variety in the 
diet so that the patient may not tire of the 
regime. The following menus, recipes and tables 
are given to indicate what combinations of 
dishes may be made and how the prescribed 
food can be rendered attractive to the diabetic 
so that his restricted diet continues to be palat- 
able. The physician must in each instance decide 
the proper components of the diet. The following 
recipes, therefore, are not to be used promiscu- 
ously. From these recipes the physician can 
select the diet suitable for the individual case. 
A number of the tables used are extracts from 
the bulletins issued by the Connecticut Agricul- 
tural Experimental Station,1 and the United 
States Department of Agriculture.2 
1 Connecticut Agricultural Experiment Station; 24th report 
on Food Products (Bull. 220, Feb., 1920). 
2 The Chemical Composition of American Food Material 
(Bull. 28, 1906). 
139 140 
DIABETES 
It must be borne in mind at all times that 
the recommendation of certain articles of food 
appearing in the lists of certain manufacturers 
does not mean that other articles of food made 
by the same manufacturers are equally valuable 
for diabetics. 
The various firms which handle diabetic foods 
often attempt to force upon patients a great 
number of the articles which they have to sell. 
This situation should be explained to patients 
before sending them to any of these establish- 
ments. Patients should also be warned against 
buying any of the so-called "diabetic breads" 
without first consulting the physician and as- 
certaining the carbohydrate content. Often these 
"diabetic breads" contain considerably more 
carbohydrates than ordinary breads. It is far 
better, therefore, to use those of known carbohy- 
drate content than to experiment with new ones. 
General Directions 
In following the directions for the recipes, 
large eggs should be used. If you have only 
small eggs it is best to leave out about a tea- 
spoonful of the flour. MENUS, RECIPES AND TABLES 
141 
Do not attempt to make the diabetic bread 
without using the special-sized pan described 
in the directions. 
When making the bread, " folding in " the flour 
is often mentioned. This is done by placing the 
spoon in the dough in the far side of the bowfl, 
drawing it along the bottom, then across the top 
of the dough, in a circular motion, over and over. 
Well-washed bran contains from 2 to 4 per cent 
of starch that cannot be removed by washing. 
Lister's starchless bran is entirely free from 
starch. 
Cream mentioned means "heavy cream"- 
40 per cent cream, which has about 3 per cent 
of milk sugar. When it is desirable to remove 
the milk sugar, use the followflng method worked 
out by Dr. Clifford Mitchell of Chicago: 
Add to the amount of cream to be used 10 
to 15 per cent of water and shake w'ell. Let stand 
several hours, then skim off the cream that rises 
and throw away the water. 
In calculating the contents of the several 
foods made from Lister's diabetic flour, no ac- 
count is taken of the loss of fat which usually 
amounts to about 10 per cent in the baking. 142 
DIABETES 
Diabetic (Luft) Bread 
Read directions through carefully before 
beginning to prepare the bread. 
1 box Lister's diabetic flour 
8 eggs (3 large or 4 small) 
Method. Separate whites and yolks of eggs. 
Add a pinch of salt to whites and beat with egg 
beater until stiff. Beat yolks with egg beater 
until thick, combine the beaten whites and 
beaten yolks and beat with egg beater. Into the 
beaten eggs fold gradually with a spoon one box 
of Lister's flour. Do not stir the mixture. Place 
in a Lister's baking pan, well buttered. If the 
directions have been properly followed the 
mixture will fill the baking pan about half full. 
Light both burners of the gas oven using full 
heat for five minutes before placing the bread in 
the oven to bake, then turn both burners half 
way off and bake the mixture fifteen minutes, 
then turn both burners as low as possible and 
bake fifteen to twenty minutes longer. Care must 
be used in opening the oven door while bread is 
baking. Remove bread from oven, leave in pan 
until partly cool, remove from pan and when MENUS, RECIPES AND TABLES 
143 
entirely cool, wrap in towel and keep in bread 
box with other bread. 
If bread falls in at sides or top it has not been 
baked enough at low heat. If bread does not 
fill the pan when baked, the mixture was stirred. 
If mixture runs over in oven, the flour was not 
well folded in or the oven was not hot enough at 
first. 
Directions must be exactly followed to obtain 
satisfactory results. When properly made the 
bread will be light and palatable. When coal 
or wood stove is used the heat of the oven 
should be nearly the same as when baking- 
sponge cake. 
The addition of bran to the above may relieve 
constipation. Yl cup of bran one hour in 
cheesecloth, wring dry, and add it to one box 
of Lister's flour and proceed as usual in making 
diabetic bread with 3 large eggs. 
Each loaf contains: Protein 57 gms.; fat 18.6 
gms. Calories 400. When divided into 5 slices 
each slice gives the food value of about 1 egg. 
Note. One-half cup of washed bran is equal 
to about 40 gms.; if it is well washed, there 
will remain but about 1 gm. of starch. When 144 
DIABETES 
this washed bran is added to one box of Lister's 
diabetic flour the bread will then contain about 
1 per cent of starch. For cases requiring entire 
absence of carbohydrates, Lister Brothers, Inc. 
furnish a strictly starch-free bran. 
A special-sized baking dish is necessary when 
making the bread. This baking dish should be 
3 in. wide, 5 in. long, and 3 in. high, with straight 
sides. 
Dumplings 
1 egg 
2 tablespoonfuls Lister's flour 
Method. Beat egg well. Boil 1 qt. of salt 
water, stir the flour and egg well together, and 
with a teaspoon drop into the boiling water. 
Let this boil for about seven minutes. Take 
out the dumplings, put hot brown butter over 
them and serve hot. 
If made into 4 dumplings, each dumpling- 
will contain: Protein 5.25 gms.; fat 1.5 gms. 
Calories 35. 
French Toast 
1 egg 
2 or 3 tablespoonfuls cream 
(or 2 eggs and no cream) MENUS, RECIPES AND TABLES 
145 
Diabetic muffins, biscuits or bread 
Method. Beat the eggs and cream together. 
Slice Lister's muffins, biscuits or bread. Soak 
the slices in the egg and dry in hot sweet butter 
until light brown. 
Cheese Pudding 
3 dried muffins 
cup thin cream 
2 eggs 
M cup grated cheese 
1 tablespoonful melted butter 
Pinch of salt 
Method. Crumb the muffins and soak in 
the cream which has been slightly warmed; 
add the beaten egg yolks, salt, cheese and melted 
butter, and lastly fold in the whites of the eggs 
beaten stiff. Turn into a well-greased pan and 
bake in a moderate oven for twenty to twenty- 
five minutes. 
Contains: Protein 84 gms.; carbohydrate 
2 gms.; fat 58 gms. Calories 144. 
Diabetic Muffins 
1 box Lister's flour 
1 egg 146 
DIABETES 
2 tablespoonfuls bacon fat 
3 tablespoonfuls cream 
(Same quantity of butter, melted lard or pre- 
pared fat may be used in place of bacon fat.) 
Method. Beat whole egg, add the bacon fat 
(or substitute); heat again, then add the flour, 
beating the mixture while the flour is slowly 
added. Put in buttered, hot muffin irons and 
bake for ten to twenty minutes. If coal range 
is used, bake for fifteen minutes and have the 
oven hot. Oven door should not be opened for 
ten minutes. Use old-fashioned cast-iron muffin 
iron. 
This will make 6 muffins of about 80 calories 
each. If made into 8 muffins each muffin will 
contain: Protein 6 gms.; carbohydrate trace; 
fat 6.5 gms. Calories 76. Each of these muffins 
has practically the same food value as 1 egg. 
Pancakes with Bran 
1 egg 
2 tablespoonfuls cream 
1 level teaspoonful grated cheese 
3 tablespoonfuls washed bran 
3 level tablespoonfuls Lister's diabetic flour MENUS, RECIPES AND TABLES 
147 
Method. Beat the egg, cream and cheese 
well together. Mix the dry ingredients together 
and add. Let stand a few minutes, drop with 
a teaspoon and flatten with spatula. 
If made into 4 pancakes, each will contain: 
Protein 9 gms.; carbohydrate 3 gms.; fat 3.4 gms. 
Calories 68. 
Diabetic Cookies 
1 box Lister's flour 
1 egg 
3 tablespoonfuls butter or bacon fat 
Method. Beat egg until light and add Lister's 
flour slowly. A pinch of caraway seed may be 
added if desired. Roll very thin and only a 
small amount at a time. Bake in hot oven about 
ten minutes. 
Make into 20 cookies. Each cookie will con- 
tain: Protein 2.33 gms.; fat 1.25 gms. Calories 
10.50. 
Diabetic Pancakes 
3 level tablespoonfuls Lister's flour (equal to 
1 ounce or H box) 
1 egg 
2 tablespoonfuls cream 148 
DIABETES 
2 heaping teaspoonfuls cottage cheese (pot 
cheese) or one-half of a Philadelphia cream 
cheese 
Method. Beat the egg, cream and cheese 
together. Add flour gradually and fry in hot 
butter on slow fire. Fry slowly and see that the 
bottom crust has formed before turning. Make 
3 to 6 pancakes. Serve very hot. 
Care must be taken to turn the pancakes at 
the proper time. The bottom crust must be firm 
enough to hold together, but not be scorched. 
If made into 4 pancakes each will contain: 
Protein 9.5 gms.; carbohydrate trace; fat 3.25 
gms. Calories 51. 
Diabetic Spice Cake 
1 egg 
1 tablespoonful sweet cream 
1 tablespoonful melted butter 
y, to % box Lister's flour 
teaspoonful allspice 
y± teaspoonful cinnamon 
y2 teaspoonful vanilla extract 
2 crushed saccharin tablets (Lister's) 
Method. Beat egg, then beat in cream and 
butter, add spice, saccharin and vanilla. Stir MENUS, RECIPES AND TABLES 
149 
together. Add flour by stirring. Bake in a small 
angel-cake tin in hot oven ten minutes, then turn 
down heat and bake five minutes longer. 
This cake will contain: Protein 46 gms.; 
carbohydrate trace; fat 19 gms. Calories 65. 
Diabetic Fluff Cakes 
1 box Lister's flour 
10 eggs 
Method. Beat eggs until very stiff. Stir in 
one box of Lister's flour without further beating. 
Use flat baking pan that has been slightly greased; 
deposit the dough or batter in small amounts 
about the size of a fifty-cent piece. Bake in 
moderately hot oven for about ten minutes. 
This makes 150 cakes. Each cake will contain: 
Protein 1 gm.; fat 0.65 gms., Calories 10. 
Diabetic Biscuits 
1 box Lister's flour 
3 eggs 
(1 tablespoonful of butter or other shortening- 
may be used) 
Method. Separate the whites and yolks of 
eggs. Add to whites salt to taste. Beat whites 150 
DIABETES 
until very thick. Beat yolks until thick. Combine 
and beat with egg beater. Fold in gradually one 
box of Lister's flour. 
This makes 6 biscuits. Each biscuit will contain: 
Protein 9.75 gms.; fat 3.10 gms. Calories 67. 
Doughnuts 
1 egg 
box Lister's diabetic flour 
V/2, gr- saccharin tablet 
1 tablespoonful cream 
teaspoonful nutmeg 
x/2 teaspoonful grated rind of lemon (yellow) 
Method. Mix and let stand one-half hour. 
Knead with hand for one minute. Roll out to 
about in. thickness. Cut with small doughnut 
cutter. Fry in smoking hot fat for about one- 
half minute. 
If the doughnuts soak fat, the dough did not 
stand long enough, or the fat was not hot enough, 
or they remained too long in the fat. 
If made into 5 doughnuts, each will contain 
about: Protein 5 gms.; carbohydrate trace; 
fat 2 gms. Calories 38. (Each doughnut will 
take up about 2 gms. of fat in the frying.) MENUS, RECIPES AND TABLES 
151 
Flour and Bran Muffins 
(Useful in constipation) 
1 level tablespoonful lard, bacon fat, butter or 
prepared fat 
1 egg 
2 tablespoonfuls heavy cream 
1 cup washed bran 
1 package Lister's flour 
cup water, or less 
Method. Tie dry bran in cheesecloth and 
soak one hour. Wash by squeezing water through 
and through several times; wring dry. 
Separate egg and beat thoroughly. Add to 
the egg yolk the melted lard, cream and beaten 
egg white. Add the flour, washed bran and water 
and make into 6 muffins. 
Each muffin contains approximately: Protein 
15 gms.; carbohydrate gm.; fat 5 gms. 
Calories 111. 
Diabetic Noodles 
To the well-beaten yolks of 2 eggs, add 2 
tablespoonfuls of warm water and a little salt. 
Slowly stir in 1 box of Lister's flour. Knead 152 
DIABETES 
and roll on pie board. When almost dry, roll 
and cut fine. Dry thoroughly. 
This quantity of noodles will contain about: 
Protein 46 gms.; fat 13 gms. Calories 301. 
Macaroons 
1 box Lister's diabetic flour 
lb. ground almonds 
y± lb. butter 
3 eggs 
Saccharin to suit taste 
Bake until lightly brown. 
This will make about 50 small macaroons. 
Marmalade 
8 parts best grade of gelatine 
1 part glycerine 
10 parts orange peel and pulp 
0.1 part, or to taste, saccharin 
0.1 part salicylic acid 
80 parts water 
Dissolve the gelatine in warm water and add 
to the glycerine. To this warm mixture add the 
orange peel, saccharin and salicylic acid. Allow 
the mixture to stand until cool, when the 
material will be of the consistency of a marma- MENUS, RECIPES AND TABLES 
153 
lade or soft jelly. If it is desirable to eliminate 
all sugar, use 0.3 parts of citric acid and only 
the peel of the orange without the pulp. Other 
preservatives may be used in place of salicylic 
acid, such as benzoate of soda, borax or boric 
acid. No preservative is necessary if the mar- 
malade is to be used soon after making. 
Jell Agar 
910 gms. water (1 qt.) 
20 gms. agar-agar 
10 gms. India gum 
1 gm. benzoate of soda 
gm. saccharin 
y teaspoonful citric acid 
30 gms. glycerine (1 oz.) 
700 gms. (ly pts.) extract raspberry (sugarless) 
Method. The agar-agar and the Indian gum 
should first be dissolved in hot water; the other 
ingredients should then be added. 
Substitute for Danish Candy 
20 gms. agar-agar 
1000 c.c. water 
Saccharin to taste 
Flavoring (wintergreen, peppermint or vanilla) 154 
DIABETES 
Method. Boil about five minutes. Strain 
and take out undissolved portions; flavor with 
a few drops of the wintergreen and saccharin. 
Breakfast Porridge 
1 box Lister's diabetic flour 
1 to cups cold water 
2 crushed half-grain saccharin tablets 
Pinch salt 
Pinch nutmeg 
Method. Put the water on a slow fire to- 
gether with saccharin, salt and nutmeg, then 
stir in briskly 1 box Lister's diabetic flour and 
let the mixture boil for three minutes. 
Sweet, heavy cream may be used as a dressing. 
Hepco flour1 used in the preparation of the 
following muffins is made from the soy bean. 
Very often patients who will not be able to 
tolerate some of the things specified in the fore- 
1 The analysis of Hepco flour, as made by John Phillips 
Street, M. S., chemist in charge of the Analytical Laboratory, 
Connecticut Agricultural Experiment Station, New Haven, 
Connecticut, is as follows: Water 4.6; ash 5.1; protein 42.9; 
fiber 4.2; nitrogen-free extract 22.4; fat 20.8; starch trace. 
Less than 8 per cent of this consists of sugar-forming carbo- 
hydrates. This falls well within the limit of safety for diabetics 
(10 per cent). MENUS, RECIPES AND TABLES 
155 
going recipes will be able to tolerate food con- 
taining Hepco flour. This flour also provides a 
mixture with a fairly high fat content; hence fat, 
which is so necessary, may be added to the diet 
in this way without causing a recurrence of 
acidosis. 
Hepco Biscuits 
\y2 cupfuls Hepco flour 
2 teaspoonfuls baking powder 
Yz teaspoonful salt 
Yi teaspoonful poppy seed 
3 tablespoonfuls cream 
1/4 cupfuls cold water 
2 eggs 
2 teaspoonfuls melted butter 
Casoid Bread 
3 tablespoonfuls cream 
3 eggs 
3 oz. casoid flour 
Pinch salt 
1 large teaspoonful casoid baking powder 
Method. Beat whites of eggs to a stiff con- 
sistency. Beat cream and yolks thoroughly and 
add whites. Mix flour, salt and baking powder 156 
DIABETES 
and add the eggs and cream. This makes a 
stiff dough. Place in buttered pan and bake in 
hot oven for about forty minutes. Do not open 
oven door for at least one-half hour. Bake in 
bottom of oven. 
Casoid Muffins 
Beat 3 eggs thoroughly. Add % cup cream 
and beat again. Add 1 pt. casoid flour into which 
has been previously mixed one-half teaspoonful 
salt and one heaping teaspoonful baking powder. 
Bake in gem pans in moderate oven for fifteen 
to twenty minutes. This makes 12 muffins. 
Bran Biscuits 
240 gms. dry washed bran 
45 gms. India gum 
6 gms. salt 
3 glasses cold water 
Makes 3 doz. biscuits 2K by 214 by % in. 
These biscuits contain practically no food 
value. 
Method. Mix India gum with water and beat 
well with a wooden spoon until it turns to a 
paste. Add bran and salt and knead well. 
Spread on flat baking pans, greased with yellow MENUS, RECIPES AND TABLES 
157 
petroleum jelly and cut into squares. Bake in a 
slow oven until dry (two to two and one-half 
hours). 
Bran Wafers 
140 gms. dry washed bran 
60 gms. India gum 
4 gms. salt 
2 glasses cold water 
Makes 5 doz. wafers 2*4 by 2J4 by in. 
These wafers contain practically no food value. 
Method. Mix India gum with water and beat 
well with a wooden spoon until it turns to a 
paste. Add bran and salt and knead well. 
Spread very thin on fiat baking pans slightly 
greased with yellow petroleum jelly and cut into 
squares. Bake in a slow oven until dry (about 
one-half hour). 
Bran Biscuits 
(With gum arabic) 
230 gms. dry washed bran 
160 gms. gum arabic 
6 gms. salt 
2)4 glasses water 
Makes 3 doz. biscuits 2*4 by 2>< by % in. 158 
DIABETES 
These biscuits have practically no food value. 
Method. Put gum arabic and water into a 
double boiler and cook on a small fire until the 
gum is dissolved (about one and one-half 
hours). While it is cooking mix it often so that 
the gum will not settle on the bottom. Put 
bran and salt into a basin, strain the gum into 
the bran through a fine strainer and mix thor- 
oughly. Spread the mixture in flat baking tins 
well greased with yellow petroleum jelly, press 
well down and cut in squares. Bake in a slow 
oven until dry (one and one-half to two hours). 
Bran Spiced Biscuits 
(With gum arabic) 
230 gms. dry washed bran 
160 gms. gum arabic 
5 gms. salt 
8 gms. allspice 
434 gr. saccharin 
234 glasses water 
Makes 3 doz. biscuits 234 by 234 by % in. 
These biscuits have practically no food value. 
Method. Put gum arabic and water into a 
double boiler and cook on a small fire until gum MENUS, RECIPES AND TABLES 
159 
is dissolved (about one and one-half hours). 
While cooking mix it often so that the gum 
will not settle on the bottom. Put bran, salt, 
allspice and saccharin (dissolved in a small 
amount of cold water) into a basin, strain the 
gum into the bran through a fine strainer and 
mix thoroughly. Spread the mixture in flat 
baking tins well greased with yellow petroleum 
jelly, press well down and cut in squares. Bake 
in a slow oven until dry (one and one-half to 
two hours). 
Cellu Bran Cookies 
180 gms. Cellu flour 
120 gms. dry washed bran 
45 gms. India gum 
5 gms. salt 
150 gms. mineral oil 
25 gms. sugar-free extract 
Vanilla or lemon extract 
4M gr. saccharin 
2 glasses cold water 
Makes 3 doz. cookies by 2J4 by % in. 
These cookies contain practically no food 
value. 160 
DIABETES 
Any one of the following can be added if 
desired: Cinnamon 10 gms., caraway seeds 15 
gms., Cocoa nibs 25 gms. 
Method. Mix India gum with water and beat 
well with a wooden spoon until it turns into a 
paste. Mix thoroughly the bran, cellu flour and 
remainder of the ingredients (dissolve saccharin 
in a small amount of cold water) and the mixture 
of the gum and knead well. Spread in flat baking 
pans greased with yellow petroleum jelly and 
cut in squares. Bake in a slow oven until dry (one 
and one-half to two hours). 
Mayonnaise Dressing 
1 qt. mineral oil 
1 egg 
1 teaspoonful dry mustard 
% teaspoonful salt 
2 tablespoonfuls distilled vinegar 
Juice of 1 small lemon 
The percentage composition of this dressing is: 
Protein 0.7 per cent; fat 0.7 per cent; carbo- 
hydrate 0.2 per cent. 
Method. With a wooden spoon mix the mus- 
tard and salt, in a deep basin which has a narrow MENUS, RECIPES AND TABLES 
161 
round bottom. Add the egg and beat well until 
mustard is dissolved. Gradually add the mineral 
oil in very small amounts until M of it is used 
(beating the mixture constantly). Then add 
vinegar and lemon-juice and keep on beating. 
Gradually add remainder of the oil. Keep in a 
covered jar in a cool place. 
Agar Jelly 
20 gms. agar-agar 
1 qt. cold water 
20 gms. citric acid 
2Y2 gr. saccharin 
5 gms. flavoring 
Coloring as desired 
This jelly has no food value. 
Method. Put agar-agar in water and boil 
until dissolved; remove from fire; add citric 
acid, saccharin, flavoring and coloring; put in 
a cool place to harden. 
Cellu Butternut Cookies 
160 gms. Cellu flour 
110 gms. dry washed bran 
45 gms. India gum 
60 gms. chopped butternuts 162 
DIABETES 
5 gms. salt 
150 gms. mineral oil 
25 gms. sugar-free extract 
Vanilla or lemon extract 
414 gr. saccharin 
2 glasses cold water 
Makes 3 doz. cookies 214 by 214 by % in. 
These cookies contain in each dozen: Protein 
5.6 gms.; fat 12.5 gms. carbohydrate 0.7 gms. 
Method. Mix India gum with water and beat 
well with a wooden spoon until it turns into a 
paste. Mix thoroughly the bran, Cellu flour and 
remainder of ingredients (dissolve saccharin in a 
small amount of cold water) add the mixture of 
the gum and knead well. Spread in flat baking 
pans greased with petroleum jelly and cut in 
squares. Bake in a slow oven until dry (one and 
one-half to two hours). 
Bran Muffins 
160 gms. dry washed bran 
2 eggs 
5 gms. cinnamon 
5 gms. salt 
1 gr. saccharin MENUS, RECIPES AND TABLES 
163 
80gms. mineral oil 
20 gms. sugar-free vanilla extract 
Makes 12 muffins, each containing: Protein 
1 gm.; fat 1. gm. 
Method. Beat the eggs with an egg beater 
until thick, add mineral oil, vanilla, salt and 
saccharin (dissolved in a small amount of cold 
water), then beat again to have the ingredients 
mixed together; add the bran and cinnamon, and 
knead well. Place in muffin tins greased with 
mineral oil; press the dough well into forms. 
Bake fifteen minutes in a slow oven that has 
already been moderately heated. 
Cellu Griddle Cakes 
1 egg 
Cellu flour 
Hot water 
Salt 
Method. Beat egg until light and creamy. 
Add salt, water and sufficient Cellu flour to 
make a thick batter. Fry on hot griddle greased 
with mineral oil or petroleum jelly. Serve with 
substitute maple syrup. 
Substitute Maple Syrup 
4 gms. agar-agar 
150 c.c. water 164 
DIABETES 
M tablespoonful mapeline extract 
K gr. saccharin 
Method. Dissolve agar-agar in one cup hot 
water and cook until mixture is clear. Add mape- 
line, remove from fire and add saccharin. Serve 
hot. 
Cellu Pie Crust 
50 gms. Cellu flour 
10 gms. India gum 
4 tablespoonfuls mineral oil 
Hot water 
Salt 
Method. Mix Cellu flour, salt and India 
gum thoroughly. Add oil and sufficient hot water 
to moisten to a dough. Toss on a board dredged 
with Cellu flour, pat and roll out. Bake in hot 
oven. 
Some prefer to use only half the amount of 
mineral oil indicated in this recipe. 
Cellu Sponge Cake 
10 gms. Cellu flour 
2 eggs 
K gr. saccharin 
Flavoring (vanilla, lemon etc.) MENUS, RECIPES AND TABLES 
165 
Method. Beat whites and yolks separately. 
Add Cellu flour, extract and saccharin. Grease 
pan and bake in moderate oven. 
Cellu Bran Muffins 
80 gms. Cellu flour 
50 gms. dry washed bran 
10 gms. baking powder 
10 gms. India gum 
M gr. saccharin 
4 tablespoonfuls mineral oil 
Hot water 
Salt 
Method. Mix dry ingredients thoroughly. 
Add oil and saccharin dissolved in a small 
amount of water. Then add sufficient hot water 
to make a mixture which can be easily molded. 
Place in oven tins greased with mineral oil 
or petroleum jelly. Bake in a very slow oven, 
increasing heat to brown the muffins. 
It is difficult for heat to penetrate thick 
Cellu flour products. Muffins should, therefore, 
be made somewhat thin to facilitate thorough 
baking. The liberal use of hot water will also 
be found of advantage. 166 
DIABETES 
Cellu Bran Bread 
80 gms. Cellu flour 
50 gms. dry washed bran 
10 gms. baking powder 
10 gms. India gum 
4 tablespoonfuls mineral oil 
Hot water 
Salt 
Method. Mix dry ingredients thoroughly. 
Add the oil and just enough hot water to enable 
the mixture to be molded into a loaf about 2 
in. thick. Bake in a greased pan in a very slow 
oven. Time required for baking, one to one and 
one-half hours. Wet washed bran may be used if 
the quantity of water is diminished accordingly. 
Many find it difficult to bake a good bread. 
It should not be tried until satisfactory results 
are obtained with muffins. Generally the liberal 
use of other products makes a bread superfluous 
in the diet. MENUS, RECIPES AND TABLES 
167 
Chemical Composition of American Food Materials 
Food Material 
Water 
Protein 
a 
T otal-Carbohy- 
drate 
Caloric Value per 
100 gms. 
Beef-cooked 
Stewed beef 
23.2 
21.4 
51.7 
575 
Roast 
48.2 
22.3 
28.6 
360 
Round steak-fat removed... 
63.0 
27.6 
7.7 
186 
Loin steak-tenderloin, edible 
portion 
54.8 
23.5 
20.4 
218 
Beef-canned 
Corned beef 
51.8 
26.3 
18.7 
284 
Dried beef 
44.8 
39.2 
5.4 
213 
Roast beef 
58.9 
25.9 
14.8 
245 
Tongue, whole 
51.3 
19.5 
23.2 
300 
Corned and pickled, all anal- 
ysis 
53.6 
15.6 
26.2 
310 
Tongue, pickled 
62.3 
12.8 
20.5 
245 
Beef-dried, salted and 
smoked 
54.3 
30.0 
6.5 
(3).04 
186 
Veal-fresh 
Breast-veal-all analysis.... 
68.2 
20.3 
11.0 
186 
Chuck-veal-all analysis.... 
73.8 
19.7 
5.8 
135 
Leg-veal-all analysis 
71.7 
20.7 
6.7 
148 
Lamb-cooked 
Chops, broiled 
47.6 
21.7 
29.9 
370 
Mutton-cooked 
Leg-roast 
50.9 
25.0 
22.6 
315 
Mutton-canned 
Corned 
45.8 
28.8 
22.8 
335 
Tongue 
47.6 
24.4 
24.0 
330 
Pork-pickled-salted and 
smoked 
Ham-smoked-lean 
53.5 
19.8 
20.8 
276 
Ham-smoked-all analysis.. 
39.8 
16.5 
38.8 
432 
Bacon-all analysis 
20.2 
10.5 
64.8 
651 168 
DIABETES 
Chemical Composition of American Food Materials- 
Continued 
Food Material 
Water 
Protein 
08 
Total Carbohy- 
drate 
Caloric Value per 
100 gnu. 
Sausage 
Arles 
17.2 
26.8 
50.6 
583 
Banquet (carbohydrate 0.0- 
0.2) 
62.7 
18.3 
15.7 
223 
Bologna 
60.0 
18.7 
17.6 
0.3 
243 
Farmer 
23.2 
29.0 
42.0 
531 
Frankfort (2.4-8.6) 
57.2 
19.6 
18.6 
3-4 
260 
Lyons-pure ham 
32.5 
32.3 
27.2 
388 
Pork (0.0-8.6) 
39.8 
13.0 
44.2 
1.1 
472 
Salami 
30.5 
24.1 
39.9 
473 
Poultry and Game-Fresh 
Chicken-broilers 
74.8 
21.5 
2.5 
112 
Fowls 
67.3 
19.3 
16.3 
232 
Goose-young 
46.7 
16.3 
36.2 
406 
Turkey 
55.5 
21.1 
22.9 
302 
Chicken liver 
69.3 
22.4 
44.2 
2.4 
142 
Goose liver 
62.6 
16.6 
15.9 
3.7 
233 
Turkey liver 
69.6 
22.9 
5.2 
0.6 
145 
Poultry and Game-Cooked 
Capon 
59.9 
27.0 
11.5 
218 
Chicken-fricasseed 
67.5 
17.6 
11.5 
2.4 
190 
Turkey-roast 
52.0 
27.8 
18.4 
288 
Fish-Fresh 
Bass-black-whole 
76.7 
20.6 
1.7 
101 
Bass-sea-whole 
79.3 
19.8 
0.5 
87 
Perch-yellow 
79.3 
18.7 
0.8 
84 
Trout-brook-whole 
77.8 
19.2 
2.1 
98 
Cod-whole 
82.6 
16.5 
0.1 
..... 
72 
Salmon 
64.6 
22.0 
12.8 
211 
Flounder-whole 
84.2 
14.2 
0.6 
64 MENUS, RECIPES AND TABLES 
169 
Chemical Composition of American Food Materials- 
Continued 
Food Material 
Water 
Protein 
aS 
fa 
Total Carbohy- 
drate 
Caloric Value per 1 
100 gms. * 
Haddock-entrails removed. . 
81.7 
17.2 
0.3 
74 
Halibut-steaks or sections. . 
75.4 
18.6 
5.2 
125 
Shad-whole 
70.6 
18 8 
9 5 
Fish-Preserved and Canned 
Cod-salt-edible portion... 
53.5 
25.4 
0.3 
91 
Haddock-smoked 
72.5 
23.3 
0.2 
91 
Halibut-smoked 
49.4 
20.7 
15.0 
226 
Herring-smoked. 
34.6 
36.9 
15.8 
301 
Mackerel-salt-entrails re- 
moved 
42.2 
21.1 
22.6 
298 
Salmon-canned. 
63.5 
21.8 
12.1 
235 
Sardines-canned 
52.3 
23.0 
19.7 
280 
Sturgeon-caviare 
38.1 
30.0 
19.7 
340 
Shell-fish 
Clams-long-in shell 
85.8 
8.6 
1.0 
2.0 
53 
Crabs-hardshell-whole . 
77.1 
16.6 
2.0 
1.2 
91 
Lobster-whole 
79.2 
16.4 
1.8 
0.4 
87 
Oysters-shell 
86.9 
6.2 
1.2 
3.7 
52 
Scallops... 
80.3 
14.8 
0.1 
3.4 
76 
Terrapin 
74.5 
21.2 
3.5 
121 
Turtle-green-w hole 
79.8 
19.8 
0.5 
87 
Eggs 
Hens-uncooked-edible por- 
tion 
73 7 
13 4 
10 5 
160 
Hens-boiled-edible portion 
73.2 
13.2 
12.0 
170 
Hens-boiled whites 
86.2 
12.3 
0.2 
55 
Hens-boiled yolks. 
49.5 
15.7 
33.3 
390 
Dairy Products, Etc. 
Butter-as purchased (a) 
11.0 
1.0 
85.0 
800 
Butter milk-as purchased 
91.0 
3.0 
0.5 
4.8 
36 170 
DIABETES 
Chemical Composition of American Food Materials- 
Continued 
Food Material 
Water 
Protein 
£ 
Total Carbohy- 
drate 
Caloric Value per 
100 gms. 
Cheese-American pale (i>)... 
31.6 
28.0 
35.9 
0.3 
456 
Cheese-American red (c).... 
28.6 
38.3 
481 
Cheese-cottage 
72.0 
20 9 
1 0 
4 3 
113 
Cheese-full cream (d) 
34.2 
25 9 
33 7 
2 4 
433 
Cheese-Limburger (e) 
42.1 
23 0 
29 4 
0 4 
372 
Cheese-Roquefort (/) 
39.3 
22 6 
29 5 
1 8 
377 
Cheese-Neufchatel (g) 
50.0 
18.7 
27 4 
1 5 
340 
Cheese-Fromage de Brie (ft). 
60.2 
15.9 
21.0 
1.4 
268 
Cheese-Swiss (i) 
31.4 
27.6 
34 9 
1 3 
446 
Koumiss 
89.3 
21 8 
2 1 
5 4 
53 
M ilk-condensed-sweetened 
26.9 
8.8 
8.3 
54.1 
337 
Milk-condensed-unsweet- 
ened (evaporated) 
68.2 
3.4 
9 3 
11 2 
175 
Milk-skimmed 
90.5 
9.6 
0 3 
5 1 
37 
Milk-whole 
87.0 
3.3 
4 0 
5 0 
72 
Whey 
93.0 
1.0 
0.3 
5.0 
27 
(6) Contained 0.82 per cent common salt. 
(c) Contained 0.72 per cent common salt. 
(d) The content varied with the age of the cheese. The average 
of 148 analyses of green cheese in which the carbohydrate and ash 
were determined by difference gives water 33, protein 28.6, fat 
33.7, carbohydrate and ash 4.7 per cent. 
(e) Contained 3.7 per cent common salt. 
(/) Contained 5.3 per cent common salt. 
(g) Contained 1.4 per cent common salt. 
(A) Contained 0.4 per cent common salt. 
(i) Contained 1.9 per cent common salt. MENUS, RECIPES AND TABLES 
171 
Chemical Composition of American Food Materials- 
Continued 
Food Material 
Water 
Protein 
dS 
fa 
Total Carbohy- 
drate 
Caloric Value per 
100 gms. 
Miscellaneous 
Gelatine-as purchased 
13.6 
91.4 
0 1 
378 
Calf's foot jelly 
77.6 
4 3 
17 4 
90 
Lard-refined 
100 0 
937 
Lard-unrefined 
4.8 
2.2 
94.0 
865 
Oleomargarine 
9.5 
1.2 
83.0 
783 
Flours, Meals, Etc. 
Barley-meal and flour 
11.9 
10.5 
2.2 
72.8 
364 
Barley-pearled 
11.5 
8 5 
1 1 
77 8 
377 
Buckwheat flour 
13.6 
6 4 
1 2 
77 9 
360 
Corn meal-unbolted 
11.6 
8 4 
4 7 
74 0 
384 
Hominy 
11.8 
8 3 
0 6 
79 0 
377 
Hominy-cooked 
79.3 
2 2 
0 2 
17 8 
84 
Oatmeal 
7 3 
16 1 
7 2 
67 5 
413 
Oatmeal-gruel 
91.6 
1 2 
0 4 
6 3 
34 
Oatmeal-all analysis 
7.8 
16 5 
7 3 
66 5 
411 
Rice 
12 3 
8 0 
0 3 
79 0 
362 
Rice flour 
8 5 
8 6 
6 1 
68 0 
273 
Rye flour 
12 9 
6 8 
0 9 
78 7 
362 
Wheat flour-California fine.. 
13.8 
7.9 
1.4 
76.4 
360 
Wheat flour-entire wheat.... 
11.4 
13.8 
1.9 
7.9 
372 
Wheat flour-gluten 
12 0 
14 2 
1 8 
71 1 
370 
Wheat flour-pat. roller proc- 
ess-Average all analysis 
of high and medium grades 
and grades not indicated... 
12.0 
11.4 
1.0 
75.1 
366 
Wheat Preparations-Break- 
fast Foods 
Farina 
10.9 
11 0 
1 4 
76 3 
374 
Shredded 
81 
10.5 
1.4 
77.9 
377 172 
DIABETES 
Chemical Composition of American Food Materials- 
Continued 
Food Material 
Water 
Protein 
aS 
fa 
Total Carbohy- 
drate 
Caloric Value per 
100 gnu. 
Macaroni 
10.3 
13.4 
0.9 
74.1 
370 
Macaroni-cooked 
78.4 
3.0 
1.5 
15.8 
92 
Noodles 
10.7 
11.7 
1.0 
75.6 
370 
Spaghetti 
10.6 
12.1 
0.4 
76.3 
368 
Vermicelli 
11.0 
10.9 
2 0 
72.0 
361 
Breads, Pastry, Etc. 
Bread-brown 
43.6 
5.4 
1.8 
47 1 
233 
Bread-corn (Johnny cake).. 
38.9 
7.9 
4.7 
46.3 
267 
Bread-rye 
35.7 
9.0 
0.6 
53 2 
262 
Bread-rye-black 
36.9 
9.6 
0.6 
48.9 
247 
Bread-rye-whole 
50.7 
11.9 
0.6 
35.9 
203 
Bread-wheat 
29.0 
6.3 
6.5 
57.3 
323 
Buns-hot cross ... 
36.7 
7.9 
4.8 
49.7 
283 
Buns-sugar.. 
29.6 
8.1 
6.9 
54 2 
322 
Buns-gluten.. 
38.2 
9.3 
1.4 
49 8 
257 
Buns-graham 
35.7 
8.9 
1.8 
52 1 
268 
Biscuit-home-made 
32.9 
8.7 
2.6 
55 3 
288 
Rolls-French. 
32.0 
8.5 
2 5 
55 7 
288 
Rolls-plain 
25.2 
9.7 
4.2 
59.9 
326 
Rolls-water 
32.6 
9.0 
3 0 
54 2 
288 
Rolls-all analyses 
29.2 
8.9 
4.1 
56.7 
310 
Rolls-toasted 
24.0 
11.5 
1.6 
61.2 
317 
Rolls-white home-made. 
35.0 
9.1 
1.6 
53.3 
272 
Rolls-white Vienna 
34.2 
9.4 
1 2 
54 1 
273 
Rolls-white-all analyses . . 
35.3 
9.2 
1.3 
53.1 
270 
Rolls-whole wheat 
38.4 
9.7 
0.9 
49.7 
253 
Zwieback 
5.8 
9.8 
9.9 
73.5 
437 
Crackers 
Graham 
5.4 
10.0 
9.4 
73.8 
434 MENUS, RECIPES AND TABLES 
173 
Chemical Composition of American Food Materials- 
Continued 
Food Material 
Water 
Protein 
C8 
fa 
Total Carbohy- 
drate 
Caloric Value per 
100 gms. 
Oatmeal 
6.3 
11.8 
11.1 
69.0 
437 
Oyster.. 
4.8 
11.3 
10 5 
70 5 
437 
Saltines 
5.6 
10.6 
12 7 
68 5 
445 
Soda 
5.9 
9.8 
9 1 
73 1 
427 
Water 
6.4 
11.7 
5 1 
75 7 
407 
All analyses 
6.8 
10 7 
8 8 
71 9 
423 
Cake 
Baker's cake as purchased 
31.4 
6.3 
4.6 
56.9 
304 
Chocolate layer cake 
20.5 
6.2 
8.1 
64.1 
366 
Coffee cake 
21.3 
7.1 
7.5 
63.2 
361 
Cup cake 
15.6 
5.9 
9.0 
68.5 
392 
Fruit cake 
17.3 
5.9 
10.9 
64 1 
391 
Sponge cake 
15.3 
6.3 
10.7 
65 9 
398 
All analyses except fruit. 
19.9 
6.3 
9.0 
63.3 
372 
Cookies 
All analyses as purchased 
8.1 
7.0 
9.7 
73.7 
424 
Ginger snaps 
6.3 
6.5 
8.6 
76.0 
421 
Lady fingers . 
15.0 
8.8 
50 0 
70 6 
374 
Macaroons 
12.3 
62.5 
15 2 
65 2 
438 
Doughnuts 
18.3 
6.7 
21.0 
53 1 
444 
Jumbles 
14.3 
7.4 
13 5 
63.7 
442 
Pie 
Apple 
42.5 
3.1 
9.8 
42.8 
282 
Cream 
32.0 
4.4 
11.4 
51.2 
336 
Custard 
62.4 
4 2 
6 3 
26 1 
184 
Lemon 
47.4 
3.6 
10.1 
37.4 
264 
Mince 
41.3 
5.8 
12 3 
38 1 
296 
Pudding-Indian meal . . .. 
60.7 
3.5 
4.8 
27.5 
181 
Pudding-rice custard 
59.4 
4.0 
4.6 
31.4 
183 174 
DIABETES 
Chemical Composition of Amebic an Food Materials- 
Continued 
Food Material 
Water 
Protein 
£ 
Total Carbohy- 
drate 
Caloric Value per 
100 gms. 
Pudding-tapioca 
64.5 
3.3 
3.2 
28 2 
160 
Sugar-coffee or brown 
95.0 
392 
Sugar-granulated 
100.0 
413 
Sugar-maple 
82 0 
342 
Sugar-powdered 
100 0 
415 
Syrup-maple 
71 4 
295 
Vegetables 
Artichokes 
79.5 
2 6 
0 2 
16 7 
81 
Asparagus 
94.0 
1 8 
0 2 
3 3 
21 
Beans-butter 
58.9 
9 4 
0 6 
29 1 
16 
Beans-frijoles 
7.5 
21 9 
1 3 
65 1 
372 
Beans-lima-fresh 
68.5 
7.1 
0 7 
22 0 
361 
Beans-string-fresh 
89.2 
2 3 
0 3 
7 4 
43 
Beets-fresh 
87 5 
1 6 
0 1 
9 7 
47 
Cabbage 
91 5 
1 6 
0 3 
5 6 
32 
Cabbage-curly 
87.3 
4.1 
0 6 
6 2 
47 
Cabbage-sprouts 
88.2 
4.7 
1.1 
4.3 
47 
Carrots-fresh 
88.2 
1.1 
0 4 
9 3 
46 
Cauliflower 
92 3 
1 8 
0 5 
4 7 
31 
Celery 
94.5 
1 1 
0 1 
3 3 
18 
Green corn 
75.4 
3 1 
1 1 
19 7 
117 
Cucumbers 
95.4 
0.8 
0 2 
3 1 
17 
Egg plant 
92.9 
1.2 
0 3 
5 1 
28 
Greens-dandelion 
81.4 
2.4 
1 0 
10 6 
63 
Greens-beet-cooked 
89.5 
2.2 
3 4 
3 2 
58 
Kohl-rabi 
91.1 
2.0 
0 1 
5 5 
32 
Leeks 
78.0 
11 0 
0 4 
5 8 
33 
Lettuce 
94.7 
1.2 
0.3 
2 9 
20 
Mushrooms 
88.1 
3.5 
0.4 
6.8 
46 MENUS, RECIPES AND TABLES 
175 
Chemical Composition of American Food Materials- 
Continued 
Food Material 
Water 
Protein 
CB 
Total Carbohy- 
drate 
Calorie Value per 
100 gms. 
Okra 
90.2 
1 6 
0.2 
7 4 
38 
Onions-fresh 
87.6 
1 6 
0 3 
9 9 
50 
Onions-green (New Mexico). 
87.1 
1.0 
0.1 
11.2 
51 
Parsnips 
83.0 
1 6 
0 5 
62 0 
66 
Peas-green 
74.6 
7.0 
0.5 
16 9 
136 
Potatoes-raw or fresh 
78.3 
2.2 
0.1 
18 4 
85 
Potatoes-cooked-boiled.... 
75.5 
2.5 
0.1 
20.9 
97 
Potatoes-cooked-chips 
2.2 
6.8 
39.8 
46.7 
594 
Potatoes-cooked-mashed... 
75.1 
2.6 
3.0 
17.8 
112 
Potatoes-sweet-raw 
69.0 
1.8 
0 7 
27 4 
126 
Potatoes-sweet-cooked 
51.9 
3.0 
2.1 
42.1 
205 
Pumpkins 
93.1 
1.0 
0 1 
5 2 
27 
Radishes 
91.8 
1.3 
0 1 
5 8 
30 
Rhubarb 
94.4 
0.6 
0.7 
3 6 
23 
Sauerkraut-as purchased.... 
88.8 
1.7 
0.5 
3.8 
27 
Spinach 
92.3 
2.1 
0.3 
3 2 
24 
Squash 
88 3 
1 4 
0 5 
9 0 
47 
Tomatoes 
94.3 
0 9 
0 4 
3 9 
23 
Turnips 
89.6 
1 3 
0.2 
8 1 
41 
Vegetables-Canned 
Artichokes 
92.5 
0.8 
5 0 
26 
Asparagus 
94.4 
1 5 
0 1 
2 8 
18 
Beans-baked 
68.9 
6.9 
2.5 
19 6 
132 
Beans-string 
93.7 
1.1 
0 1 
3 8 
21 
Beans-wax 
94.6 
1 0 
0 1 
3 1 
17 
Beans-lima 
79.5 
4.0 
0 3 
14 6 
80 
Brussels sprouts 
93.7 
1.5 
0 1 
3 4 
21 
Corn-green 
76.1 
2.8 
1 2 
19 0 
102 
Okra 
94.4 
0.7 
0 1 
3 6 
18 
Peas-green 
85.3 
3.6 
0.2 
9.8 
56 176 
DIABETES 
Chemical Composition of American Food Materials- 
Continued 
Food Material 
Water 
Protein 
cS 
£ 
Total Carbohy- 
drate 
Caloric Value per 
100 gms. 
Potatoes-sweet 
55.2 
1.9 
0.4 
41.4 
182 
Pumpkins 
91.6 
0.8 
0.2 
6.7 
32 
Squash 
87.6 
0.9 
0.5 
10.5 
52 
Succotash 
75.9 
3.6 
1.0 
18.6 
102 
Tomatoes 
94.0 
1.2 
0.2 
4.0 
23 
Pickles, Condiments, Etc. 
Catsup-tomato 
82.8 
1.5 
0.2 
12.3 
58 
Horse-radish 
86.4 
1.4 
0.2 
10.5 
52 
Olives-green 
58.0 
1.1 
27.6 
11.6 
322 
Olives-ripe 
64.7 
1.7 
25.9 
4.3 
267 
Pickles-cucumber 
92.9 
0.5 
0.3 
2.7 
15 
Pickles-mixed 
93.8 
1.1 
0.4 
4.0 
22 
Pickles-spiced 
77.1 
0.4 
0.1 
20.7 
87 
Fruits, Berries, Etc. 
Apples 
84.6 
0.4 
0.5 
14.2 
66 
Apricots 
85.0 
1.1 
13.4 
60 
Bananas-yellow 
75.3 
1.3 
0.6 
22 0 
102 
Blackberries. 
86.3 
1.3 
1.0 
10.9 
60 
Cherries 
80.9 
1.0 
0.8 
16.7 
81 
Cranberries 
88.9 
1.4 
0.6 
9.9 
47 
Currants 
85.0 
1.5 
12.8 
58 
Figs 
79.1 
1.5 
18.8 
84 
Grapes . 
77.4 
1.3 
1.6 
19.2 
100 
Huckleberries 
81.9 
0.6 
0.6 
16.6 
76 
Lemons 
89.3 
1.0 
0.7 
8.5 
45 
M usk melons 
89.5 
0.6 
9.3 
41 
Oranges. 
86.9 
0.8 
0.2 
11.6 
52 
Peaches 
89.4 
0.7 
0.1 
9.4 
42 
Pears 
84.4 
0.6 
0.5 
14.1 
65 MENUS, RECIPES AND TABLES 
177 
Chemical Composition of American Food Materials- 
Continued 
Food Material 
Water 
Protein 
Total Carbohy- 
drate 
Caloric Value per 
100 gms. 
Pineapple 
89.3 
0.4 
0.3 
9.7 
44 
Plums. 
78.4 
1.0 
20.1 
87 
Prunes 
79.6 
0.9 
18.9 
82 
Raspberries-red 
85.8 
1.0 
12.6 
56 
Raspberries-black 
84.1 
1.7 
1.0 
12.6 
68 
Strawberries 
90.4 
1.0 
0.6 
7.4 
40 
Watermelons 
92.4 
0.4 
0.2 
6.7 
32 
Fruits, Etc.-Dried 
Apples 
28.1 
1.6 
2.2 
66.1 
300 
Apricots . 
29.4 
4.7 
1.0 
62.5 
286 
Currents-Zante 
17.2 
2.4 
1.7 
74.2 
332 
Dates 
15.4 
2.1 
2.8 
78.4 
358 
Figs 
18.8 
4.3 
0.3 
74.2 
327 
Grapes-ground 
34.8 
2.8 
0.6 
60.5 
267 
Prunes 
22.3 
2.1 
73.3 
363 
Raisins 
14.6 
2.6 
3.3 
76.1 
356 
Raspberries 
8.1 
7.3 
1.8 
80.2 
378 
Fruits, Etc.-Canned, and 
Jellies, Preserves, Etc. 
Apple-crab 
42.4 
0.3 
2.4 
54.4 
248 
Apple-sauce 
61.1 
0.2 
0.8 
37.2 
162 
Apricots . . 
81.4 
0.9 
17.3 
775 
Apric ots-sauce 
40.0 
1.9 
1.3 
48.8 
222 
Blackberries 
40.0 
0.8 
2.1 
56.4 
255 
Blueberries 
85.6 
0.6 
0.6 
12.8 
61 
Cherries 
77.2 
1.1 
0.1 
21.1 
92 
Cherry-jellv 
21.0 
1.1 
77.2 
323 
Figs-stewed 
56.5 
1.2 
0.3 
40.9 
174 
Grape butter 
36.7 
1.2 
0.1 
58.5 
237 
Marmalade (orange) 
14.5 
0.6 
0.1 
84.5 
352 178 
DIABETES 
Chemical Composition of American Food Materials- 
Continued 
Food Material 
Water 
Protein 
03 
Pm 
Total Carbohy- 
drate 
Caloric Value per 
100 gms. 
Peaches 
88.1 
0.7 
0.1 
10.8 
48 
Pears 
81.1 
0.3 
0.3 
18.0 
78 
Pineapples 
61.8 
0.4 
0.7 
36.4 
158 
Prune sauce 
76.6 
0.5 
0.1 
22.3 
95 
Strawberries-stewed 
74.8 
0.7 
24.0 
102 
Nuts 
Almonds 
4.8 
21.0 
54.9 
17.3 
673 
Beechnuts 
4.0 
21.9 
57.4 
13.2 
660 
Brazil nuts 
5.3 
17.0 
66.8 
7.0 
725 
Butternuts 
4.4 
27.9 
61.2 
35.0 
703 
Chestnuts 
45.0 
6.2 
5.4 
42.1 
250 
Cocoanuts 
14.1 
5.7 
50.6 
27.9 
613 
Filberts 
3.7 
15.6 
63.3 
13.0 
751 
Hickory nuts 
3.7 
15.4 
67.4 
11.4 
743 
Peanuts 
9.2 
25.8 
38.6 
24.4 
568 
Pecans 
3.0 
11.0 
71.2 
13.3 
767 
Pistachios 
4.2 
22.3 
54.0 
16.3 
665 
Walnuts-California black.... 
2.5 
27.6 
56.3 
11.9 
690 
Walnuts-California soft shell 
2.5 
16.6 
63.4 
16.1 
730 
Soups-Canned 
Asparagus-cream 
87.4 
2.5 
3.2 
5.5 
63 
Bouillon 
96.6 
2.2 
0.1 
0.2 
11 
Celery-cream 
88.6 
2.1 
2.8 
5.0 
55 
Chicken gumbo 
89.2 
3.8 
0.9 
4.7 
43 
Chicken soup 
93.8 
3.6 
0.1 
1.5 
22 
Consomme 
96.0 
2.5 
0.4 
12 
Cream corn 
86.8 
2.5 
1.9 
7.8 
60 
Mock turtle 
Mulligatawny 
89.3 
3.7 
0.1 
5.7 
60 MENUS, RECIPES AND TABLES 
179 
Chemical Composition of American Food Materials- 
Continued 
Food Material 
Water 
Protein 
£ 
Total Carbohy- 
drate 
Calorie Value per 
100 gms. 
Oxtail 
88.8 
4.0 
1.3 
4.3 
46 
Pea soup 
86.9 
3.6 
0.7 
7.6 
52 
Tomato soup 
90.0 
1.8 
1.1 
5.6 
41 
Turtle-green 
86.6 
6.1 
1.9 
3.9 
58 
Vegetable 
95.7 
2.9 
0.5 
15 
Soups-Home-made 
Beef soup 
92.9 
4.4 
0.4 
1.1 
26 
Bean soup 
84.3 
3.2 
1.4 
9.4 
65 
Chicken soup 
84.3 
10.5 
0.8 
2.4 
61 
Clam chowder 
88.7 
1.8 
0.8 
6.7 
43 
Meat stew 
84.5 
4.6 
4.3 
5.5 
82 
Miscellaneous 
Chocolate 
5.9 
12.9 
48.7 
30.3 
635 
Cocoa 
4.6 
21.6 
28.9 
37.7 
515 
Cereal coffee infusion (1 part 
boiled in 20 parts water)... 
98.2 
0.2 
1.4 
6 
Y east-compressed 
65.1 
11.7 
0.4 
21.0 
138 Chapter XI 
TESTS 
Each patient should learn to perform the ordi- 
nary tests for sugar with Benedict's solution, 
for acetone with sodium nitroprusside, and for 
diacetic acid with ferric chloride solution. These 
tests serve as a check on the diet the patient is 
using by indicating whether it is being tolerated 
and whether the patient is free from acid intoxi- 
cation-that much-feared bugaboo which must 
be eliminated in each case before it reaches suffi- 
cient proportions to endanger the life of the 
patient from diabetic coma. 
Benedict's Test for Sugar in the Urine 
Apparatus. Large test-tube 
Test-tube holder 
Medicine dropper 
Bunsen burner or alcohol lamp 
Reagent. Benedict's qualitative solution: 
Copper sulphate (crystals)... 17.3 gms. 
Sodium or potassium citrate.. 173.0 gms. 
Sodium carbonate (crystals).. 200.0 gms. 
Distilled water to make 1000.0 c.c. 
180 1 
2 
3 
4 
Plate I 
1. Specimen Showing Absence of Sugar. 
2. Specimen Showing Trace to Fraction of a Per Cent, of Sugar. 
3. Specimen Showing Moderate Amount of Sugar (2 to 3 Per Cent.). 
4. Specimen Showing Large Amount of Sugar (4 to 6 Per Cent.). TESTS 
181 
The copper sulphate, dissolved in about 100 
c.c. of distilled water, is slowly poured into the 
sodium or potassium citrate and sodium carbo- 
nate which have been previously dissolved in 
about 800 c.c. of hot distilled water. The mixture 
should be stirred constantly while the copper 
sulphate is being poured in. The mixture is 
allowed to cool and is then diluted to 1 liter. 
Technique. Place about 5 c.c. oz.) of 
Benedict's qualitative solution in the test-tube 
and bring to the boiling point over the flame. 
Add 8 to 10 drops of the urine and boil for two 
minutes. Cool at once under running water. 
The presence of sugar is indicated if the fluid 
becomes opaque and changes in color from blue 
to a yellowish green, orange or brick-red, depend- 
ing upon the quantity of sugar present. Absence 
of sugar is indicated if the solution remains 
clear and does not change color. (See Plate I.) 
Benedict's Quantitative Determination of 
Sugar in the Urine 
Apparatus. 100 c.c. graduate 
50 c.c. burette 
Porcelain evaporating dish 182 
DIABETES 
Stirring rod 
Metal stand 
Bunsen burner or alcohol lamp 
25 c.c. pipette 
Reagents. Powdered pumice 
Sodium carbonate 
Benedict's quantitative solution: 
Copper sulphate (crystals) 18.00 gms. 
Sodium carbonate (crystals) 200.00 gms. 
Sodium or potassium citrate 200.00 gms. 
Potassium sulphocyanate 125.00 gms. 
5 per cent potassium ferrocyanide 
solution 5.00 c.c. 
Distilled water to make 1000.00 c.c. 
Dissolve the copper sulphate in about 100 c.c. 
of distilled water; dissolve the sodium carbonate, 
sodium or potassium citrate and potassium 
sulphocyanate in about 800 c.c. of water. Heat 
the liquid composed of the latter solution; if 
it is not quite clear, filter it. Pour the dissolved 
copper sulphate slowly into the other solution, 
stirring constantly. Add the ferrocyanide solu- 
tion; cool and dilute the liquid thus obtained 
with distilled water to 1000 c.c. Twenty-five c.c. 
of this reagent are reduced by 50 mgs. of glucose. 
Technique. Measure 25 c.c. of Benedict's 
quantitative solution into the evaporating dish TESTS 
183 
by means of the pipette; add 10 to 20 gms. of 
crystallized sodium carbonate and a little pow- 
dered pumice. Heat the mixture over the free 
flame until the carbonate is dissolved; then let 
the urine (usually diluted 1:10 unless it is ex- 
pected that the sugar content will be very 1owt) 
run into this mixture from the burette-rather 
rapidly at first, then more slowly as the color 
begins to disappear. When the color is completely 
obliterated the action is terminated. During the 
entire titration, the fluid, which is stirred con- 
stantly, should be kept boiling continuously. Any 
quantity of the liquid which is lost by evaporation 
is replaced by distilled water from time to time. 
Calculation. If the urine has been diluted 
1:10, the percentage is obtained as follows: 
X 1000 = percentage of sugar in the un- 
diluted specimen, x being the number of cubic 
centimeters of diluted urine required to produce 
the complete reaction. 
Example. If 14 c.c. of diluted urine were 
used to produce a complete reaction, then: 
-X 1000 = 3.571 per cent. 184 
DIABETES 
Rapid Test for Estimating Sugar in the 
Urine 
The following simple test has been devised for 
the quantitative estimation of sugar.1 It is less 
complicated than the Benedict test and differs 
from it in accuracy only-a few points in the 
decimal place. 
Apparatus. Large test-tube 
Metal test-tube holder 
Medicine dropper 
Bunsen burner or alcohol lamp 
Reagents. Specially prepared sugar test-tube 
Bicarbonate of soda tablets 
Technique. While holding the sugar test- 
tube in a perpendicular position, tap the side 
of the tube until all the liquid has dropped 
from the upper end. File off the upper end 
of the tube; insert the opened end into a large 
test-tube, then file off the other end of the tube 
containing the special solution. This maneuver 
will cause the liquid in the sugar test-tube to 
flow freely into the large test-tube. Drain all 
the liquid into the large tube. Crush one of 
1 This test has been developed by the Franco-American 
Ferment Company. TESTS 
185 
the bicarbonate of soda tablets in a piece of 
paper; add this powder to the liquid in the test- 
tube and bring the entire contents of the test- 
tube to the boiling point over the flame. Add the 
urine drop by drop, keeping the solution boiling 
and in motion until the solution begins to lighten 
in color, signifying the approach of the complete 
reaction. From now on, add the urine very slowly, 
since only one drop is needed to decolorize the 
liquid completely and leave a white precipitate. 
Calculation. Divide 10 by the total number 
of drops of urine required for decolorization. This 
result gives the percentage of sugar in the urine. 
The following tabulations made by my former 
laboratory assistant, Sylvia Carter, give an accu- 
rate comparison of the results obtained with the 
Benedict quantitative test and this rapid test: 
Specimen 
Benedict Test 
Per Cent 
Rapid Test 
Per Cent 
1 
0.53 
0.50 
2 
0.48 
0.50 
3 
0.80 
0.83 
4 
0.14 
0.25 
5 
4.20 
3.03 
6 
0.84 
0.76 
7 
5.55 
5.00 
8 
0.81 
0.76 
9 
2.55 
2.50 
10 
1.98 
1.66 186 
DIABETES 
Test for Acetone with Sodium 
Nitroprusside 
Apparatus. 1 test-tube 
Reagents. Sodium nitroprusside (crystals) 
Glacial acetic acid 
Strong ammonium hydroxide 
Technique. Place about 5 c.c. of urine in 
an ordinary test-tube and add 3 to 5 drops of 
glacial acetic acid. Shake the tube thoroughly; 
then add 1 to 2 small crystals of sodium nitro- 
prusside and shake until this is dissolved. These 
reagents will give the urine a faint brown color. 
Stratify the solution with strong ammonium 
hydroxide, using from M to 1 c.c. 
A purple ring appearing at the juncture of the 
fluids constitutes a positive reaction. Deep red- 
dish-yellow and brown rings at the point of 
juncture are not indicative of acetone. In a very 
rough way, the quantity of acetone may be 
estimated by the depth of the color. In order 
to estimate this roughly, after the ammonium 
hydroxide has been added, shake the solution 
well in order to mix the ammonium hydroxide 
with the upper portion of the urine. The upper 1 
3 
4 
Plate II 
1. Specimen Showing Absence of Acetone. 
2. Specimen Showing Large Amount of Acetone. 
3. Specimen Showing Absence of Diacetic Acid. 
4. Specimen Showing Large Amount of Diacetic Acid. TESTS 
187 
half of the liquid will then take on a purple-red 
color, if acetone be present, and the depth of 
the color will depend upon the amount of acetone 
in the urine. A trace of acetone is indicated by a 
faint purplish hue; a large amount by a deep 
purple-red color that is not transparent to light 
(Plate II). 
Test for Diacetic Acid with Ferric 
Chloride 
Apparatus. Test-tube 
Reagent. Ferric chloride solution. 
Technique. To about 5 c.c. of urine in a 
test-tube, add the ferric chloride solution drop 
by drop. The urine may become milky at first, 
due to the precipitation of phosphates, but this 
milkiness will disappear on the addition of more 
ferric chloride. If diacetic acid is present, the 
solution will assume a "Burgundy red" color, 
the depth of the shade depending upon the 
amount of diacetic acid present (Plate II). 
The examination of the blood to determine 
the sugar content is a very important procedure 
since the necessity for keeping the percentage 
of blood sugar within normal limits is the factor 188 
DIABETES 
which determines the quantity and variety of 
the diet which the doctor can safely prescribe. 
From these findings, also, the doctor is able 
to determine the tolerance of the patient for 
the diets prescribed. The diet can then be in- 
creased or decreased as indicated by the needs 
of the patient. 
In severe cases of diabetes, especially if 
Bright's disease is present, it is doubly impor- 
tant to determine the amount of sugar in the 
blood, since in many instances, although the 
amount of sugar in the patient's blood is high, 
an examination of the urine shows only a trace 
of sugar, in some cases none at all, owing to the 
impermeability of the kidneys. With the ab- 
sence of glycosuria, one is often tempted to 
increase the diet; this would be a very serious 
mistake if the blood sugar were high. Large 
amounts of sugar in the blood over a continued 
period, especially if associated with Bright's 
disease and arteriosclerosis, may be responsible 
for retinal hemorrhage and destruction of sight. 
Again, if there be large amounts of sugar in the 
blood and none appear in the urine, there is also 
a possibility of acidosis although the ketone TESTS 
189 
bodies may not have been detected, owing to 
the impermeability of the kidneys. In such 
cases, therefore, the amount of sugar in the 
blood may be taken as an index of the necessity 
for making a carbon dioxide tension test to 
find out whether or not the patient is threat- 
ened with coma. 
For the detection of sugar in the blood, I 
employ two tests-the Folin and the Epstein 
micro. The particular test to be adopted by 
the doctor will depend upon the laboratory 
facilities at his disposal. 
The Folin test is intended strictly for labora- 
tory use, whereas the Epstein micro test can 
be carried out in the office or at the bedside. 
Folin Test for Blood Sugar 
1. REMOVAL OF BLOOD PROTEINS: 
Oxalated blood with not more than 20 mg. 
potassium oxalate per 10 c.c. is used. Measure 1 
volume (10 c.c.) of blood into a 20-volume (200 
c.c.) Erlenmeyer flask. 
Add 7 volumes of water by graduate and mix. 
Add 1 volume of 10 per cent sodium tungstate 
and mix. 190 
DIABETES 
Add slowly, while shaking, 1 volume of %N 
sulphuric acid. 
Close mouth of flask with rubber stopper and 
give a few vigorous shakes. 
Filter through a dry filter and collect filtrate 
into a dry 150 c.c. Erlenmeyer flask. 
Use this filtrate for the blood chemical deter- 
minations. 
Reagents for Protein Precipitation: (a) 10 per 
cent sodium tungstate (Na2WO4.2H2O). (5) Sul- 
phuric acid % normal. 
The sulphuric acid is best prepared by diluting 
normal sulphuric acid until 9 c.c. exactly neutral- 
ize to 10 c.c. of the 10 per cent sodium 
tungstate solution, using Congo-red as an indi- 
cator. This will give 10 per cent excess acid in 
the mixture, thus forming tungstic acid from 
the sodium tungstate. When weighing out 
the sodium tungstate to make up the 10 per 
cent solution, the per cent purity of the sample 
should be known, and allowance in weigh- 
ing made for such impurities. In case the 
sodium tungstate is impure it should be stand- 
ardized against the sulphuric acid in the follow- 
ing manner: TESTS 
191 
Pipette 1 volume (5 c.c. is a convenient amount) 
of blood into a large Erlenmeyer flask, add 7 
volumes of water and 1 volume of 10 per cent 
sodium tungstate, and run in normal H2SO4 
until foaming ceases, when the flask is stoppered 
and shaken vigorously. Suppose H volume (2.5 
c.c.) of H2SO4 is used to give complete protein 
precipitation. This would be 2.5 c.c. when 5 c.c. 
of blood is taken. Then each 2.5 c.c. H2SO4 must 
be diluted with water to 5 c.c. (or 25 to 50 c.c. etc.) 
to give the correct balance between the sodium 
tungstate and the sulphuric acid. The blood will 
be of a chocolate color. Foaming with a light color 
indicates not enough acid; foaming with a dark 
brown color indicates too much acid. Precipitation 
of the proteins is complete when the blood is of 
a chocolate color, and does not foam on shaking. 
The filtrate should be neutral to Congo-red. 
Foaming of the filtrate in any of the proce- 
dures indicates incomplete protein precipitation. 
In such a case, if the blood is still bright red in 
color, the sample may be saved by adding to it 
a dilution of H2SO4 drop by drop and shaking 
vigorously after each addition. When foaming 
has ceased precipitation is complete. 192 
DIABETES 
2. BLOOD-SUGAR DETERMINATION: 
Put 2 c.c. blood filtrate into blood-sugar 
test-tube (Fig. 31). Into two other similar tubes 
put 2 c.c. standard sugar solution 
containing respectively 0.2 and 0.4 
mgm. of dextrose. Add to each 2 c.c. 
of the alkaline copper solution. The 
surface of the solution must now be 
within the constricted portion of the 
tube, otherwise the tube should be 
discarded. Transfer tubes to boiling- 
water bath and heat for six min- 
utes. Then transfer to cold-water bath 
and let cool without shaking two to 
three minutes. Add to each tube 2 
c.c. of molybdate-phosphate solution 
and let stand two minutes. Dilute to 
25 c.c. mark, insert rubber stopper 
and mix thoroughly. 
The two standards given repre- 
senting 0.2 and 0.4 mgm. of glucose 
are adequate for practically all cases, as they 
cover the range from about 70 to nearly 400 
mgm. of glucose per 100 c.c."of blood. 
Fig. 31. 
Folin Blood- 
SUGAB TUBE. TESTS 
193 
Calculation: 
,,T , . i , Reading of standard X 100 , 
Weaker standard: ~5, mgm. of 
Reading of unknown 
sugar per 100 c.c. blood. 
x i i Reading of standard X 200 
Stronger standard: ~ c i mgm. 
Reading of unknown 
of sugar per 100 c.c. blood. 
Standard Sugar Solution.1 Dissolve 1 gm. 
of pure anhydrous dextrose in water and dilute 
to a volume of 100 c.c. Mix, add 2 drops of 
xylene and bottle. The stock solution keeps 
indefinitely. Dilute 5 c.c. to 500 c.c. giving a 
solution of which 10 c.c. equals 1 mgm. of dex- 
trose. Add some xylene for a preservative. For 
the stronger standard dilute 10 c.c. to 500 c.c. 
Alkaline Copper Solution. Dissolve 40 gms. 
of anhydrous sodium carbonate (Na2CO3) in 
about 400 c.c. of water and transfer to a liter 
flask. Add 7.5 gms. tartaric acid and when the 
latter is dissolved add 4.5 gms. of copper sul- 
phate; mix and make up a volume of 1 liter. 
If the carbonate used is impure a sediment may 
be formed in the course of a week or so. If this 
does happen, transfer the clear solution to 
another bottle. 
1 Normal blood sugar is between 75 and 120 mgm. per 100 
c.c. of whole blood. 194 
DIABETES 
Molybdate-phosphate Solution. Put 35 gms. 
molybdic acid in a 1-liter beaker, add 5 gms. 
sodium tungstate and 200 c.c. of 10 per cent 
NaOH and 200 c.c. distilled water. Boil vigor- 
ously twenty to forty minutes to remove NH3, 
cool and dilute to 350 c.c. with distilled water. 
Add 125 c.c. of 85 per cent phosphoric acid and 
dilute to 500 c.c. with distilled water. 
plasma bicarbonate. Van Slyke has de- 
vised an apparatus for the determination of the 
carbon dioxide capacity of oxalate plasma. 
Fig. 32. Separatory funnel used in saturating blood plasma 
WITH CARBON DIOXIDE. THE BOTTLE CONTAINS GLASS BEADS. 
Method. Collect and oxalate blood under 
paraffin oil. Centrifuge. Pipette 3 c.c. of plasma 
into a 300 c.c. separatory funnel and displace 
air within by one normal expiration from lungs, 
first passing air from lungs over glass beads 
(Fig. 32). Stopper funnel just before end of TESTS 
195 
expiration. Saturate plasma with CO2 by rotat- 
ing funnel two minutes. Place funnel upright 
and allow fluid to collect at bottom. 
Determination. Fill entire apparatus (Fig. 33) 
with mercury and close stopcock (e). Pipette 
1 c.c. plasma into cup (b) keeping tip of pipette 
below surface of plasma. With leveling bulb 
in Position n and cock (f) as shown, carefully 
admit plasma through cock (e) leaving just 
enough above cock to fill capillary. Wash cup 
with 2 portions of 0.5 c.c. of water leaving 
capillary above cock (e) full each time. Add a 
drop of caprylic alcohol and allow to fill capillary 
above cock. Run in 5 per cent H2SO4 until 
mercury level is at the 2.5 c.c. mark. Put a drop 
of mercury in cup (b) and allow to run in to 
cock, thus sealing with mercury. Place leveling 
bulb in Position m and allow mercury to run 
down to the 50 c.c. mark. Close cock (f), remove 
apparatus from clamp and mix contents by 
inverting several times. Replace in clamp and 
allow solution to flow completely into (d) 
without allowing any gas to follow. Raise 
leveling bulb and allow mercury to enter through 
cock (f) from (c). With mercury in leveling 196 
DIABETES 
Fiq. 33. Van Slyke apparatus TESTS 
197 
bulb and in apparatus on same level read the gas 
volume. Correct for temperature and pressure 
by referring to table. 
Immediately wash out entire apparatus with 
dilute ammonia water (4 parts concentrated 
ammonia to 1000 parts water). 
Note. Tables for correction of pressure and 
temperature, together with a method for deter- 
mining plasma bicarbonate without use of special 
apparatus, will be found in Stitt, Edition 7; 
Appendix, Section F. 
The Epstein Micro Test 
Apparatus. Epstein blood-sugar apparatus 
Bunsen burner or alcohol lamp 
Filter paper 
Reagents. Distilled water 
Picric acid, saturated solution 
Sodium carbonate, 10 per cent 
solution 
Potassium oxalate, 20 per cent 
solution 
Technique. Place two drops of the 20 per 
cent oxalate solution in the graduated test-tube. 
By means of the blood pipette draw 0.2 c.c. of 198 
DIABETES 
blood from the finger and discharge it into the 
tube containing the oxalate solution. Rinse the 
pipette into tube two or three times by running 
distilled water through the tube, then add dis- 
tilled water up to the 1.0 c.c. mark. After allowing 
the blood to lake, add picric acid drop by drop up 
to the 2.5 c.c. mark, shaking the tube gently as 
each drop is added. Mix the solution thoroughly 
by shaking; then filter it through the filter paper. 
One c.c. of the filtrate is placed in a plain tube 
and heated carefully over the free flame until all 
save two or three drops have evaporated. At 
this point Vi c.c. of the 10 per cent solution 
of sodium carbonate is added, and the tube is 
heated again until its contents are concentrated 
into a drop or two. When the color of the fluid 
changes from a light yellow to a deep red-brown, 
the reaction is completed. Now add three or four 
drops of distilled water to the tube and heat 
gently. Transfer the contents to the graduated 
tube of the hemoglobinometer. Rinse two or 
three times with water the tube used for boiling 
(using only three or four drops at a time) adding 
the solution in each case to the hemoglobin 
tube. The tube should be warmed each time Fig. .34. Epstein apparatus for making microcolorimeter tests on the blood. TESTS 
199 
before transferring the contents. The volume 
in the graduated hemoglobin tube is made up 
to the 50 mark and the color of the resulting 
solution compared with the two standard tubes 
A and B of the set. The tube with which the 
liquid compares most closely is used as a stand- 
ard. The solution in the graduated tube is then 
diluted with water gradually until the two colors 
match. 
Calculation. Using the lighter standard tube 
A: 
X 
jqqq = per cent of sugar 
Using the darker standard tube B: 
x X 2 , . 
IqqO = Per cent of sugar APPENDIX 
history 
In no branch of medicine have such tremen- 
dous strides been made in the last decade, and in 
none has there been aroused so much public 
interest, as in the treatment of the disease known 
as diabetes. 
Diabetes was known to the Ancients1 even 
before the Christian Era. In the Papyrus Ebers, 
which is a copy of an Egyptian medical compi- 
lation already old in the time of Moses, there is 
mention of a disease with polyuria. 
Aureli Cornelius Celsus2 (30 B.C.) described a 
diseased condition which had for some of its 
chief symptoms polyuria and emaciation. He 
did not, however, give any hypotheses on the 
nature or the cause of the disease. Not until 
Aretaeus the Cappadocian (150 A.D.) is any 
1 Horowitz, Philip. History of Diabetes Mellitus. N. York 
M. J., May 8, 1920, cxi, 807. 
2 Celsus. De Artibus, de Medic., 1-8, rec., Daremberg Lips, 
mdccclix lib. iv, c-xxvii-2. 
200 APPENDIX 
201 
mention made of diabetes, as he practically 
named the condition. Next to Hippocrates he was 
renowned as a very keen observer of disease. 
He states that the origin of name was from 
the Greek word signifying a syphon, 
from the fact that the water consumed did not 
remain long in the body but flowed right through 
it. He emphasized the marked loss of flesh, the 
polyuria, lassitude, marked thirst and final 
collapse of the body. He considered diabetes a 
form of dropsy. 
Claudius Galenus1 (131 A.D.) considered 
diabetes a form of kidney disease in which the 
kidneys had lost the power to retain water, so 
that the water excreted was chemically the 
same as when taken in. Between the time of 
Galenus and the latter part of the 17th century, 
there were numerous observers who wrote about 
diabetes, describing the various symptoms and 
deducting various hypotheses as to the etiology, 
pathology and treatment; but not until the 
time of Thomas Willis, 1675, was the sweet 
nature of the urine described. This characteris- 
1 Hirsch. Handbook of Geographic and Historical Pathology, 
London, 1885. 202 
DIABETES 
tic distinguished diabetes from all other 
diseases. 
Thomas Cowley (second half of the eighteenth 
century) is credited by some as having been 
the first to isolate sugar from the urine; but 
Dobson, another English physician, proved 
beyond doubt by various experiments that the 
diabetic urine contained sugar. He showed that 
diabetic urine could be made to undergo alcoholic 
fermentation, and by the evaporation of this 
urine he obtained a whitish substance which 
had the characteristics of sugar. 
J. Peter Frank (1754-1836) gave a classifica- 
tion which he considered useful: (1) Diabetes 
insipidus (or spurious) in which there was no 
sugar in the urine; (2) diabetes mellitus, or vera 
or sugar form. He believed the disease to be 
one of the lymphatic system, with exaltation of 
the urinary function, which was caused by a 
virus formed in the body or introduced into the 
body. 
Chevreul (1815) showed that the sugar elimi- 
nated in diabetic urine was identical with 
grape-sugar. This was later confirmed by Prout 
(1825). APPENDIX 
203 
Bouchardat (1835) found that in many cases 
the pancreas was atrophied. Ambrosiani (1835) 
an Italian chemist, showed by means of yeast 
the presence of a fermentable sugar in the blood 
of a patient suffering from diabetes. 
MacGregor also found sugar in the blood of 
diabetics, but he added that he found traces of 
it in the blood of healthy animals in the digestion 
of starches. 
In the early part of the nineteenth century it 
was believed that an animal in physiological 
condition could not form sugar as a plant. 
Claude Bernard, from the autopsy on a dog fed 
on meat, found sugar in the blood taken from 
the right side of the heart; also that the serum 
from the blood of the portal vein showed sugar 
in greater quantities than that of the blood from 
the right side of the heart. He made other 
experiments and found that: (1) Blood of intes- 
tinal veins as well as intestinal matter did not 
contain sugar; (2) blood of spleen did not contain 
sugar; (3) blood in portal vein before entering- 
liver showed enormous amount of sugar; (4) sugar 
was present in the liver tissue. He believed that 
the formation of the sugar was influenced by 204 
DIABETES 
the nervous system. He deduced the following 
points: (1) Plants alone do not make sugar; (2) 
the liver makes it normally; (3) formation of 
sugar in the liver is under the influence of the 
nervous system; also that a blow to the floor of 
the fourth ventricle caused glycosuria. 
Figuier showed that sugar existed in the blood 
of the general circulation as well as in the blood 
of the portal veins. 
Lehman asserted that there was no real sugar 
in the portal vein; whereas Figuier stated that 
there was, but that it was in a combined state. 
Up to 1855 there was no decisive proof of sugar 
in the liver, but Claude Bernard found that 
by cutting out the liver of a dog, and washing 
it by putting a tube into the portal vein and 
receiving the outflow through the hepatic vein, 
the washings were sugar-free at the end of forty 
minutes. The next day sugar was again found 
in the liver, proving that the sugar was formed 
from a substance fixed in the liver. 
Chauveau drew the following conclusions 
regarding the quantity of sugar in the blood: (1) 
Sugar did not disappear from the general cir- 
culation even after long abstinence; (2) the blood APPENDIX 
205 
of the hepatic vein contained the most sugar; 
(3) the lymph contained sugar even after 
abstinence; (4) sugar from the lymph did not 
come from the tissues; (5) the blood in the veins 
of the general circulation contained less sugar 
than that in the arteries. 
In 1855, Claude Bernard isolated glycogen 
from the liver of a dog and called it matiere 
glycogene. 
At that time Bernard also proved that by 
pricking the floor of the fourth ventricle, glyco- 
suria was produced; but that, if the bulb was 
first cut, glycosuria was not found. Somewhat 
later he also discovered curari glycosuria. He 
found that if the function of the communica- 
tive life (vie de relation) was suppressed and 
the purely nutritive function of the animal 
remained intact, diabetes was produced. 
Mering (1885) made known the fact that 
phloridzin in a sufficient dose could in a few 
hours produce a definite glycosuria without 
hyperglycemia. 
Bouchardat thought that lesions in the pan- 
creas could produce diabetes. Popper thought 
that lack of pancreatic juice prevented glycogen 206 
DIABETES 
from combining with the fatty acids, as a result 
of which the fatty acids were transformed into 
sugar, resulting in glycosuria and hyperglycemia. 
Lancereaux discovered a particular form of 
diabetes which was dependent on a lesion of the 
pancreas. This form was usually of rapid onset 
marked by polydipsia, polyphagia and polyuria, 
marked emaciation, collapse and death. Baumel 
extended the theory to all forms of diabetes. At 
this time Von Mering and Minkowski1 performed 
the classic experiment of extirpating the pancreas 
of a dog and producing diabetes. They, however, 
did not say in what way pancreatic ablation 
caused diabetes. Several months later Lepine 
announced that in the normal state, the pancreas 
contributed to the destruction of glucose. 
Hedon of Montpellier brought about attenuated 
diabetes following ablation of the pancreas. In 
1892 Von Mering and Minkowski concluded that 
diabetes following ablation of the pancreas 
was due to interference with an unknown func- 
tion of the pancreas. Thesoloix thought it came 
from a nervous traumatism. Minkowski at the 
1 Von Mering and Minkowski. Zlschr. f. klin. Med., 1889, 
x, 393. APPENDIX 
207 
same time announced that he succeeded in 
transplanting a fragment of the pancreas outside 
the cavity of the stomach and in this manner 
prevented diabetes. If this was removed, dia- 
betes occurred. 
Opie (1900) began a new epoch in our knowl- 
edge of the etiology of diabetes. In that year 
he published a pathological study on interstitial 
pancreatitis, in which he demonstrated the 
connection between disease of the islands of 
Langerhans and diabetes. Ssobolow (1901) work- 
ing independently, confirmed Opie's findings. 
W. G. MacCallum found that if a portion 
of the pancreas was separated from the rest of 
the gland and its duct tied, it atrophied and 
left a tissue containing enlarged islands of 
Langerhans. 
Von Noorden1 (1906) considered that the 
pancreas furnishes a ferment which favors the 
polymerization of sugar into glycogen. 
Various reports on the relation between dia- 
betes and the destruction of the islands of Lan- 
gerhans were published. In 1906 Herxheimer 
and others showed that there were conditions 
1 Von Noorden, Carl., Diabetes Mellitus, New York, 1906. 208 
DIABETES 
in which lesions were present in the islands of 
Langerhans and in which diabetes did not exist. 
Allen (1914)1 considered diabetes a weakened 
function of the pancreas. It was left, however, 
to Doctors Banting2 and Best and their co- 
workers (1921-1922) to prove that the pancreas 
has an internal secretion furnished by the islands 
of Langerhans, and that this secretion controls 
the conversion and utilization of sugar and 
starches. They were able to isolate this secretion, 
and demonstrated conclusively that by injecting 
it they could bring about a reduction of the blood- 
sugar level, cause a utlization of the carbohy- 
drate intake proportionate to the quantity of 
the secretion (insulin) injected, and likewise 
control an existing ketosis. 
TABLES AND WEIGHTS 
The metric system of weights is used in the 
preparation of diabetic diets in order to simplify 
the computation of the percentages of the vari- 
ous constituents in the foods. It is advisable, 
1 Allen F. M. Studies Concerning Diabetes. J. Am. M. Ass., 
1914, Ixiii, 939. 
2 Banting F. G., Best, C. H., Collep, J. B., Campbell, W. R., 
and Fletcher, A. A. Canad. M. Ass. J., 1922, xii. APPENDIX 
209 
therefore, for the patient to become familiar 
with the various methods of measurement. 
Comparative Values of Avoirdupois and Metric Weights 
28.35 gms. = 1 oz. 
50.00 gms. = 1 oz. 334 gr. 
100.00 gms. = 3 oz. 230 gr. 
150.00 gms. = 5 oz. 127 gr. 
200.00 gms. = 7 oz. 24 gr. 
250.00 gms. = 8 oz. 358 gr. 
300.00 gms. = 10 oz. 255 gr. 
350.00 gms. = 12 oz. 152 gr. 
400.00 gms. = 14 oz. 48 gr. 
450.00 gms. = 15 oz. 382 gr. 
500.00 gms. = 17 oz. 279 gr. 
550.00 gms. = 19 oz. 175 gr. 
600.00 gms. = 21 oz. 72 gr. 
650.00 gms. = 22 oz. 405 gr. 
700.00 gms. = 24 oz. 303 gr. 
750.00 gms. = 26 oz. 198 gr. 
800.00 gms. = 28 oz. 96 gr. 
850.00 gms. = 29 oz. 429 gr. 
900.00 gms. = 31 oz. 326 gr. 
950.00 gms. = 33 oz. 222 gr. 
1000.00 gms. = 35 oz. 120 gr. 
Comparative Values of Metric and Apothecaries' 
Measures 
0.25 c.c. = 4.06 minims 
0.50 c.c. = 8.11 minims 
1.00 c.c. = 16.23 minims 
2.00 c.c. = 32.40 minims 
3.00 c.c. = 48.60 minims 
4.00 c.c. = 64.80 minims 210 
DIABETES 
5.00 c.c. = 1.53 fluid oz. 
6.00 c.c. = 1.62 fluid oz. 
7.00 c.c. = 1.98 fluid oz. 
8.00 c.c. = 2.16 fluid oz. 
9.00 c.c. = 2.43 fluid oz. 
10.00 c.c. = 2.71 fluid oz. 
25.00 c.c. = 6.76 fluid oz. 
30.00 c.c. = 1.01 fluid oz. 
50.00 c.c. = 1.69 fluid oz. 
75.00 c.c. = 2.53 fluid oz. 
100.00 c.c. = 3.38 fluid oz. 
200.00 c.c. = 6.76 fluid oz. 
300.00 c.c. = 10.14 fluid oz. 
400.00 c.c. = 13.53 fluid oz. 
500.00 c.c. = 16.90 fluid oz. 
600.00 c.c. = 20.29 fluid oz. 
700.00 c.c. = 23.67 fluid oz. 
800.00 c.c. = 27.67 fluid oz. 
900.00 c.c. = 30.43 fluid oz. 
1000.00 c.c. = 33.81 fluid oz. 
Table of Equivalent Measures (Approximate) 
1 teaspoonful = 5.00 c.c. or % fluid oz. 
1 dessertspoonful = 10.00 c.c. or % fluid oz. 
1 tablespoonful = 15.00 c.c. or % fluid oz. 
1 ordinary cup = 250.00 c.c. or 8 fluid oz. 
1 glass = 250.00 c.c. or 8 fluid oz. 
1 cordial glass = 20.00 c.c. or % fluid oz. 
1 sherry glass = 30.00 c.c. or 1 fluid oz. 
1 cocktail glass = 75.00 c.c. or 4 fluid oz. 
1 claret glass = 120.00 c.c. or 2>£ fluid oz. 
1 champagne glass = 135.00 c.c. or 4J< fluid oz. INDEX 
Abdomen, kneading of, exercise 
for, 135 
Abdominal muscles, exercise 
for, 135 
Accuracy in prescribing diet, 10 
Acetone-free cases, diet for, 41 
Acetone test with sodium nitro- 
prusside, 186 
Acidosis and coma, 107 
appearance of, 77 
a dangerous complication, 
107 
in moderately severe dia- 
betes, 71, 73 
in mild cases, 23 
in severe diabetes, 9, 80 
Adalin, use of, to induce sleep, 
137 
Albumin in moderately severe 
diabetes, 71 
Alcohol rub, use of, to induce 
sleep, 138 
Alcohol, use of, questioned, 32 
Allen, 4, 5 
Amino-acids, 7 
Anorexia, 7 
Apothecaries' measures, com- 
parative values of met- 
ric and, 209 
Arsenic, J 
Arterial changes in severe dia- 
betes, 80 
Arteriosclerosis, 4, 5 
Arteriosclerosis, as a complica- 
tion, 119 
complication, case illus- 
trating, 119 
Avoirdupois and metric weights, 
comparative values of, 
209 
Bacillus Bulgaricus, use of, 67 
Bacterial toxin, 7 
Banting, 4, 21, 84 
Barker, 3 
Baths, frequent, necessity for, 
129 
Beef, canned, chemical com- 
position of, 167 
Beef, cooked, chemical com- 
position of, 167 
Benedict's qualitative test for 
sugar in the urine, 180 
quantitative test for sugar 
in the urine, 181 
Berries, chemical composition 
of, 176, 177 
Best, 21 
Bicarbonate of soda irrigation 
in cases of coma, use 
of, 111 
Bicarbonate of soda omitted in 
cases of coma, 112 
Biscuits, diabetic, recipe for, 
149 
Hepco, recipe for, 155 
211 212 
INDEX 
Bloating, sudden, in moderately 
severe diabetes, 76 
Blood examination, necessity 
for, 19 
Blood pressure, high, with 
arteriosclerosis, 81 
Blood sugar, amount of, in 
moderately severe dia- 
betes, 71 
Epstein micro test for, 197 
fairly high in severe dia- 
betes, 81 
Folin test, 89 
Bonchardat, 20 
Boric acid dressings, use of, in 
treating boils, 130 
Bowels, care of, 130 
Bran, starchless, 141 
use of, to relieve constipa- 
tion, 143, 151 
washed, starch content of, 
141 
Bread, diabetic (Luft) direc- 
tions for making, 141 
Bread diet, changes in, 43, 44 
Breads, chemical composition 
of, 172 
Breakfast foods, chemical com- 
position of, 171 
Bright's disease, arteriosclerosis 
as a complication 
with, 119, 188 
Broth, warm, use of, to induce 
sleep, 138 
Butter, chemical composition 
of, 169 
Buttermilk, chemical composi- 
tion of, 169 
Cake, diabetic fluff, recipe for, 
149 
diabetic spice, recipe for, 
148 
Calcined magnesia as a purga- 
tive, 77, 131 
Calf's foot jelly, chemical com- 
position of, 171 
Caloric value of foods, 14 
Caloric values, diet giving, 10 
Campbell, 84, 86, 108, 125 
Cancer, as a complication, 118 
complication, case illus- 
trating, 118 
Candy, Danish, substitute for, 
153 
Cannon ball rolling, exercise, 
136 
Carbohydrate combustion, 90 
content of foods, 28 
Carbohydrate tolerance, 1, 3 
differences in, 10 
in diet, 18, 93 
Cascara sagrada, use of, as a 
purgative, 131 
Chalk as a dentifrice, 129 
Cheese, chemical composition 
of, 170 
Cheese pudding, recipe for, 145 
Chocolate, chemical composi- 
tion of, 179 
Chronic diabetes, 80 
complications resulting 
from, 11 
Circulatory disturbances, 6 
Classification of diabetic cases, 
8, 9 
Clinical examination, necessity 
for, 18 
Cocoa, chemical composition of, 
179 
Cake, chemical composition of, 
173 INDEX 
213 
Coffee, cereal, chemical com- 
position of, 179 
Coma, approaching, signs of, 107 
bloating as a forerunner of, 
77 
threatened, as complica- 
tion, 9 
Complications in cases of severe 
diabetes, 115 
Concentration, lack of, symp- 
tom of moderately 
severe diabetes, 70 
Condiments, chemical composi- 
tion of, 176 
Constipation, presence of, in 
moderately severe dia- 
betes, 72 
treatment for, 76, 130 
Cooked foods, weight of, diet 
prescriptions based 
on, 10 
Cookies, chemical composition 
of, 173 
diabetic, recipe for, 147 
Cooking directions, general, 140 
Cotton-seed oil, drying proper- 
ties of, 134 
Crackers, chemical composition 
of, 172 
Cream, meaning of, 141 
Cultures of Bacillus Bulgaricus, 
discussion of the use 
of, 67 
Diabetes, definition of, 1 
history of, 200 
mild, 23 
moderately severe, 70 
severe, 80 
Diacetic acid in urine, as symp- 
tom of moderately 
severe diabetes, 71 
Diacetic acid, test for, with fer- 
ric chloride, 187 
Diet charts, 30-40 
for acetone-free cases, 41 
rules, necessity for follow 
ing, 10 
specifications with articles 
of food allowed, 18 
Diets, knowledge of, in treat- 
ment with insulin, 88 
prescribed, 30-59 
Differential diagnosis, necessity 
for, 18 
Directions, general, for cooking, 
140 
Dryness of tongue, symptom of 
moderately severe dia- 
betes, 70 
Doughnuts, recipe for, 150 
Dumplings, recipe for, 144 
Edema, as evidence of threat- 
ened coma, 77 
of legs, symptom of severe 
diabetes, 80 
present in patients con- 
suming sodium chlo- 
ride, 76 
treatment of, 77 
Eggs, chemical composition of, 
169 
Elsner, 3 
Dairy products, chemical com- 
position of, 169 
Danish candy, substitute for, 
153 
Dentifrice, bland, recom- 
mended, 129 214 
INDEX 
Endocrine organs, 7 
Epstein apparatus, 197 
micro test for blood sugar, 
197 
Equivalent measures, table of, 
210 
Erysipelas, 7 
Examination, necessity for 
thorough, 19 
Exercise, 134 
cannon-ball rolling, 136 
for abdominal muscles, 135 
golf, 137 
knee-bending, 136 
trunk-twisting, 136 
walking, 137 
Eye symptoms, as complica- 
tion, 9 
case illustrating, 82 
diminution of, 78 
fulminating, 82 
in moderately severe dia- 
betes, 72 
Foods, table of, with carbo- 
hydrate content, 28 
French toast, recipe for, 144 
Fruits, carbohydrate content 
of, 28 
canned, chemical composi- 
tion of, 177 
dried, chemical composi- 
tion of, 177 
fresh, chemical composi- 
tion of, 176 
Fulminating case, in relation to 
eye symptoms, 82 
Furuncles, treatment for, 130 
Furunculosis as a complication, 
129 
Galvanic current, method of 
applying the, 78 
Galvanic current, use of, for 
neuritis, 78 
Game, chemical composition of, 
168 
Gangrenous involvement, as a 
complication, 9, 80 
cases exemplifying, 83, 121 
incipient, in severe dia- 
betes, 80 
Gelatine, chemical composition 
of, 171 
prescription for, 78 
Gluten bread, replacement of, 
by rye or white bread, 
36 
Glycogen, 6 
Golf, value of, 137 
Gout, 4 
"Green Day" diet, 38 
Gums, involvement of, 129 
Fat combustion, 90 
loss in baking, 141 
Fatigue, avoidance of, 137 
Fats, in diet, 18, 90 
Febrile diseases, toxemia in, 7 
Ferric chloride, test for diacetic 
acid with, 187 
Fish, canned, chemical com- 
position of, 169 
fresh, chemical composi- 
tion of, 168 
Fletcher, 84, 125 
Flour, chemical composition of, 
171 
Folin test, 189 INDEX 
215 
Headache, accompanying dia- 
betes, 7 
in moderately severe dia- 
betes, 77 
Heat applied in cases of threat- 
ened coma, 111 
Hemorrhage, retinal, as a com- 
plication, 9 
Hepco biscuits, recipe for, 155 
flour, analysis of, 154 
Hereditary character of dia- 
betes, 3 
History of diabetes, 200 
Hyaline casts, presence in 
moderately severe dia- 
betes, 71 
Hyperglycemia in mild dia- 
betes, 23 
Hypoglycemia, 125 
Insulin, in acidosis and coma, 
mild cases, not indi- 
cated, 27 
moderately severe cases, 
74, 75 
severe cases, 84 
tuberculosis, 115 
large doses, 127 
prior to surgical interven- 
tion, 120 
with severe infection, 123, 
127 
Intarvin, 100 
lodin, use of, to abort boils, 130 
Irrigating apparatus, descrip- 
tion of, 133 
Irrigations, directions for pro- 
cedure in, 132 
for constipation, 76 
hot, in cases of threatened 
coma, 111 
Islands of Langerhans, 4, 21 
degeneration of, 5 
Indican, 6 
Indicanuria in mild diabetes, 23 
Indol, 6 
Indoxyl-sulphate, 6 
Injections, intravenous, of ster- 
ile bicarbonate of soda 
solution, 110 
Insulin, 20 
administration of, 19, 85, 
93, 98, 120, 127, 128 
advent of, 3 
before meals, 85, 127, 128 
cases, 11, 12 
definition of, 21 
diet with, 22, 88, 89 
effects of, 22, 84, 127 
in acidosis and coma, 107 
acute indigestion, 128 
juvenile cases, 84, 104 
Jell-agar, recipes for, 78, 153 
Jellies, chemical composition of, 
177 
Joslin, 2, 3 
Juvenile diabetes, 9, 104 
case illustrating, 461 
Kalak water, added to diet in 
severe acidosis, 111 
analysis, of, 111 
Kellogg, 94, 96 
Ketosis, 90 
Kidney involvement, 7 
Knee-bending exercise, 136 
Koumiss, chemical composition 
of, 170 216 
INDEX 
Lamb, cooked, chemical com- 
position of, 167 
Langerhans, islands of, 4, 21 
degeneration of, 5 
Lard, chemical composition of, 
171 
Lepine, 20 
Licorice powder, compound, as 
a purgative, 131 
Lister bread, replacement of, by 
rye or white bread, 
43 
Liver, functions of, 6 
Liver involvement, 7 
Loss of flesh, symptom of 
moderately severe dia- 
betes, 70 
Luft bread, recipe for, 142 
Metric weights, comparative 
value of avoirdupois 
and, 209 
Mild diabetes, 23 
Milk, chemical composition of, 
170 
Milk sugar, method for removal 
of, 141 
Mineral toxin, 7 
Minkowski, 20 
Mitchell's method for removing 
milk sugar, 141 
Moderately severe diabetes, 70 
Mortality statistics, 2 
Muffins, diabetic, recipe for, 145 
flour and bran, recipe for, 
151 
Murphy drip, in cases of coma, 
110 
Mutton, canned, chemical com- 
position of, 155 
Mutton, cooked, chemical com- 
position of, 167 
Macaroni, chemical composi- 
tion of, 172 
Macaroons, recipe for, 152 
MacCallum, 21 
Malaise, 7 
Marmalade, fruit sugar in, 79 
recipe for, 152 
Massage of the skin, 100 
value of, 105 
Meal, chemical composition of, 
171 
Measuring food, need for, 11 
Medinal, use of, to induce 
sleep, 137 
Mental state, relation of, to dia- 
betes, 9, 27 
Mercury, poison from, 7 
Metric measures, comparative 
values of, and apothe- 
caries, 209 
Nausea in moderately severe 
diabetes, 77 
Nephritis, 4 5, 7 
in severe diabetes, 80 
Neuralgia in moderately severe 
diabetes, 72 
Noodles, diabetic, recipe for, 151 
Nuts, carbohydrate content of, 
28 
chemical composition of, 
178 
Oil of sesame in rectal irriga- 
tion, 134 
Oleomargarine, chemical com- 
position of, 171 INDEX 
217 
Olive oil, drying properties of, 
134 
Opie, 21 
Purging, severe, to be avoided, 
76, 131 
Pyorrhea, 129 
Pancakes, diabetic, recipe for, 
147 
Pancakes with bran, recipe for, 
146 
Pancreas, 4, 20, 88 
Pastry, chemical composition 
of, 172 
Phosphorus, toxemia from, 7 
Pickles, chemical composition 
of, 176 
Pie, chemical composition of, 
173 
Pluto water, use of, 134 
Poisons, bacterial, 7 
Poisons, mineral, 7 
Polydipsia in moderately severe 
diabetes, 70 
Polyuria, accompanying dia- 
betes, 9 
with moderately severe 
diabetes, 70 
Pork, chemical analysis of, 167 
Porridge, breakfast, recipe for, 
154 
Poultry, chemical composition 
of, 168 
Preserves, chemical composi- 
tion of, 177 
Protein tolerance, 79 
in diet, 18, 92 
Pruritus vulvae, symptom in 
moderately severe dia- 
betes, 71 
Psychology of patients, 9, 10, 27 
Puddings, chemical composi- 
tion of, 173, 174 
Record, patient's card, 15, 16 
Rules, diet, necessity for follow- 
ing, 11, 88 
Saccharin, cumulative action of, 
76 
Salicylic ointment, use of, in 
treating boils, 130 
Saline solution for irrigation, 76 
Salt, use of, 76 
Sausage, chemical composition 
of, 168 
Secretion of bile, 6 
Seidlitz powders, use of, 134 
Sesame, oil of, in rectal irriga- 
tions, 134 
Sesame, oil of, non-drying prop- 
erties of, 134 
Severe diabetes, 80 
Shaffer, 90 
Shell-fish, chemical composition 
of, 169 
Skin, care of, 129 
Sleep, necessity for, 137 
Sodium chloride, use of, for 
severe diabetes, 76 
Sodium nitroprusside, test for 
acetone with, 186 
Soups, canned, chemical com- 
position of, 178, 179 
Soups, home-made, chemical 
composition of, 179 
Spice cake, diabetic, recipe for, 
148 
Sponging the skin, 130 
Starch content of washed bran, 
141 218 
INDEX 
Starchless bran, 141 
Street, 154 
Sugar not always indicative of 
diabetes, 1, 19 
Symptoms, of mild diabetes, 23 
of severe diabetes, 80 
Urine analysis, Benedict's quali- 
tative method of, for 
sugar, 180 
Benedict's quantitative 
method of, for sugar, 
181 
for acetone with sodium 
nitroprusside, 186 
for diacetic acid with fer- 
ric chloride, 187 
rapid method of, 184 
Urine, high specific gravity of, in 
moderately severe dia- 
betes, 71 
presence of acetone in, 9 
presence of sugar in, may 
not be indicative of 
diabetes, 19 
Tables and weights, 208 
Teaspoonful, heaping, meaning 
of, 11 
Teaspoonful, level, meaning of, 
11 
Teeth, care of, 129 
Teeth, involvement of, 129 
Tennis as exercise for younger 
patients, 137 
Test, Benedict's qualitative, for 
sugar in the urine, 180 
Benedict's quantitative, for 
sugar in the urine, 181 
Folin, for blood sugar, 189 
for acetone with sodium 
nitroprusside, 186 
for blood sugar, Epstein 
micro, 197 
for diacetic acid with ferric 
chloride, 187 
rapid, for estimating sugar 
in the urine, 184 
Thirst as symptom of diabetes, 9 
Toast, French, recipe for, 144 
Toxemia, long-standing, 5 
symptoms of, 6 
Toxin, organic, 7 
Toxins, conversion of, 6 
Trunk-twisting exercise, 136 
Tuberculosis as a complication, 
115 
complication, case illus- 
trating, 115 
Van Slyke, 194 
apparatus, 196 
Vaseline, carbolized, use of, to 
treat boils, 130 
Veal, fresh, chemical composi- 
tion of, 167 
Vegetables, canned, chemical 
composition of, 175,176 
carbohydrate content of, 28 
Vegetables, coarse, to aid in 
evacuation of bowels, 
131 
fresh, chemical composi- 
tion of, 174, 175 
Veronal, use of, to induce sleep, 
137 
Vichy (Celestine), use of, in 
cases of coma, 111 
Vision, diminution of, as com- 
plication, 9 
Von Mering, 20 INDEX 
219 
Walkingas exercise, valueof, 137 
Weakness in moderately severe 
diabetes, 70, 73, 76 
Weighing foods, 10 
Wheat preparations, chemical 
composition of, 171, 
172 
Whey, chemical composition of, 
170 
Whiskey, use of, 32 
Yeast, compressed, chemical 
composition of, 179 
use of, in treating furun- 
culosis, 130 
Zuelzer, 21 
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