Type 1 Diabetes

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

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

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

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

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

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

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

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

Diet. — Our injunctions to-day aro thoso of Sydenham : " Let the patient est food of easy digestion, eiich aa voal, mutton, and the like, and abstain from all sorts of fruit and garden stuff." The carbohydrates in tho food should be reduced to a minimum. Under a strict hydrocarbonaceous and nitrogenous regimen all casc«are benefited and some arc cured. The most minute and specific instructions should be given in each case, and the dietary arranged with scrupulous care^

 It is of the first importance to give the patient variety in the food, otherwise the loathing of certain essential articles becomes intolerable, and too oft«u tho patient gives up in diegiiet or despair. It is wcl), perhaps, not to attempt the absolute exclusion of the carbohydrates, but to allow a small proportion of ordinary bread, or, belter still, as containing less starch, potatoes. It is beat gradually to cnforoe a rigid system, cutting oH one article after another. Tho following is a list of articles which diabetic patients may take :

1.  Liquids; Soups — ox-tail, turtle, bouillon, and other clear soops 

2. Lemonade, coffee, tea, chocolate, and cocoa; these to be taken without sugar, but they may bo sweetened with saccharin. 

3. Potash or soda water, and the Apoltinatis, or the Saratoga Vichy, and milk in moderation, may be used. 

4. Of animal food : 

• Fish of all sorts, salt and fresh, 

• butcher's meat (with the exception of liver), 

• poultry, 

• and game. 

• Eggs, 

• butter, 

• buttermilk,

•  curds,

•  and cream cheese. 

• Of bread : gluten and bran bread, and almond and coconut biscuits. 

• Of vegetables: Lettuce, tomatoes, spinach, chiccory, sorrel, radishes, water-cress, mustard and cress, cucumbers, celery, and endives. Pickles of various sorts. 

5. Fruits : Lemons, oranges, and currants. Nuts are, as a rule, allowable 

Among prohibited articles are the following : 

1. Thick soups, liver, crabs, lobsters, and oysters; though, if the livers are cut out, oysters may be used. 

2. Ordinary bread of all sorts (in quantity): rye, wheaten, brown, or white. 

3. All farinaceous preparations, such as hominy, rice, tapioca, semolina, arrowroot, sago, and vermicelli. 

4. Of vegetables : Potatoes, turnips, parsnips, sqimslies, vegetable marrow of all hinds, beets, corn, artichokes, and asparagus. 

5. Of liquids: Beer, sparkling wine of all sorts, and the sweet aerated drinks. 

The chief difficulty in arranging the daily menu of a diabetic patient is the bread, and for it various substitutes have been advised — ^bran bread, gluten bread, and almond biscuits. Most of these are unpalatable, and the patients weary of them rapidly. Too many of them are gross frauds, and contain a very much greater proportion of starch than represented. A friend, a distinguished physician, who has, unfortunately, had to make trial of a great many of them, writes : 'That made from almond flour is usually so heavy and indigestible that it can only be used to a limited extent. Gluten flour obtained in Paris or London contains about 15 per cent of the ordinary amount of starch and can be well used. The gluten flour obtained in this country has from 35 to 45 per cent of starch, and can be used successfully in mild but not in severe forms of diabetes." ' Unless a satisfactory and palatable gluten bread can be obtained, it is better to allow the patient a few ounces of ordinary bread daily. The " Soya " bread is not any better than that made from the best gluten flour. As a substitute for sugar, saccharin is very useful, and is perfectly harm- less. Glycerin may also be used for this purpose. It is well to begin the treatment by cutting off article after article until the sugar disappears from the urine. Within a month or two the patient may gradually be allowed a more liberal regimen. An exclusively milk diet, either skimmed milk, buttermilk, or koumyss, has been recommended by Donkin and others. Certain cases seem to improve on it, but it is not, on the whole, to be recommended.

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

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

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

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

Recent studies of the dietetics of diabetes have clearly demonstrated the great danger involved in the use of an exclusive meat diet. The rapid tissue disintegration taking place in severe cases of diabetes results in flooding the system with waste matters, which are, of course, toxic in character. When to these are added the toxic substances contained in the flesh of animals under the best conditions, together with the ptomains resulting from the decomposition which always takes place to a greater or less extent in flesh food before it is eaten, and still further by the urea and other excrementitious products resulting from the excess of nitrogenous material contained in the system when meat is largely used, it becomes apparent that the diabetic who makes use of an exclusive meat diet or a diet consisting largely of flesh foods, is in a state of chronic auto-intoxication. Such a person is constantly on the verge of diabetic coma; if he escapes, it is simply because his liver and kidneys are still able to do a sufficient amount of work in the destruction and elimination of poisons to save his life ; but sooner or later he will certainly reach a point at which a failure of these important organs to do the excessive amount of work demanded of them will result in the accumulation of toxic substances to such a degree as to produce the universal poisoning which is so graphically pictured in diabetic eoma.

- Case #8: 

Dr. Joslin's Mother 

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

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

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

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

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

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

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