spinach, sorrel, beet-tops, cauliflower, cabbage, brussels-sprouts,
dandelions, tomatoes, radishes, oyster-plant, celery, onions,
string-beans, water-cresses, asparagus, artichoke, Jerusalem
artichokes, parsley, mushrooms, all kinds of herbs.
Substitutes for Sweets.--Peaches preserved in brandy without sugar;
wine-jelly without sugar, gelée au kirsch without sugar, omelette au
rhum without sugar; omelette à la vanille without sugar; gelée au rhum
without sugar; gelée au café without sugar.
Miscellaneous.--Butter, cheese of all kinds, eggs cooked in all ways
except with flour or sugar, sauces without sugar or flour. Almonds,
hazel-nuts, walnuts, cocoanuts. Tea or coffee with a little cream and
without sugar. (Glycerin may be used instead of sugar if desired.)
Moderately palatable ice-creams and wine-jellies may be made, sweetened
with pure glycerin; but although these may be quite satisfactory for a
time, they soon become distasteful.
Alcoholic Beverages.--Claret, burgundy, dry sherry, Bass's ale or
bitter beer. (No sweet wines.)
Prohibited.--Ordinary bread; cake, etc. made with flour or sugar;
desserts made with flour or sugar; vegetables, except those mentioned
above; sweet fruits.
[Footnote 49: "On the Treatment of Diabetes Mellitus," a paper read
before the American Medical Association at its meeting in Washington,
May, 1884, and published in the _Journal_ of the association July 12,
1884. I have so far modified the bill of fare as to permit the use of
milk, which Flint excludes.]
One of the foods the omission of which is most illy borne by the
diabetic, however great his previous indifference to it, is wheaten
bread, while the substitutes which have been at different times
suggested for it very imperfectly supply its place. Perhaps the best
known of these is the bread made of gluten flour. It was suggested by
Bouchardat in 1841, and is made by washing the ordinary wheat flour to
free it from starch.[50]
[Footnote 50: The Health Food Company, of 74 Fourth Avenue, N.Y.,
prepare a gluten flour by first removing the five bran-coats,
pulverizing the cleaned berry by the cold-blast process, stirring the
powder into iced water, and precipitating the gluten, cellulose, and
mineral matters, siphoning off the water holding in suspension the
starch, and drying out the precipitate. In this manner the salts of the
wheat are retained. A purified gluten made by the Health Food Company
is deprived of the cellulose walls of the cells in which the gluten
granules are held. Directions for making gluten bread and cakes of
various kinds are furnished by the company on application.]
Gluten flour, however prepared, contains some starch, as indeed it must
if bread is to be made out of it; and I confess to having been a good
deal disappointed in its use. I have known the sugar absent in a {223}
selected diet to return when gluten bread was permitted, and again
disappear on its withdrawal. Of course gluten flour contains less
starch than the ordinary wheat flour, and there may be cases where the
starch in the former can be assimilated when the quantity in the latter
cannot be. The gluten may be made into porridge.[51]
[Footnote 51: Gluten porridge is made by stirring the gluten into
boiling water until thick enough, and then keeping up the boiling
process for fifteen minutes. A little salt and butter are added at the
close to improve the flavor, and it may be eaten with milk or cream.]
A method of getting rid of the starch and sugar in bread, suggested by
Liebig and tried by Vogel, consists in converting the starch into sugar
by the action of diastase and dissolving out the sugar thus produced.
This is accomplished by treating thin slices of bread with an infusion
of malt. The bread is then washed, dried, and slightly toasted.
Another substitute for wheaten flour is the bran flour whence the
starch is removed by washing.[52] The bran itself, according to
Parkes,[53] sometimes contains as much as 15 per cent. of nitrogenous
matter, 3.5 per cent. of fats, and 5.7 per cent. of salts. It is
therefore not wholly innutritious, although the salts are washed out in
removing the starch. It is considered especially useful when there is
constipation, the slightly irritant properties of the bran aiding in
maintaining a proper peristalsis and action of the bowels. These
irritant properties are, however, inversely as the degree of
comminution. The bran flour may be made with milk and eggs into a
variety of cakes, of which the best known are those made according to
Camplin's directions.[54]
[Footnote 52: A very carefully prepared bran flour, as well as a
wheat-gluten flour, is prepared by John W. Sheddon, pharmacist, corner
of Broadway and Thirty-fourth street, New York City.]
[Footnote 53: _Practical Hygiene_, 5th ed., Philadelphia, 1878, p.
222.]
[Footnote 54: The following are Camplin's directions for making biscuit
of bran flour: To one quarter of a pound of flour add three or four
fresh eggs, one and a half ounces of butter, and half a pint of milk;
mix the eggs with a little of the milk, and warm the butter with the
other portion; then stir the whole together well; add a little nutmeg
or ginger or other agreeable flavoring, and bake in small forms or
patterns. The cake, when baked, should be about the thickness of an
ordinary captain's biscuit. The pans must be well buttered. Bake in
rather a quick oven for half an hour. These cakes or biscuits may be
eaten by the diabetic with meat or cheese for breakfast, dinner, or
supper; at tea they require rather a free allowance of butter, or they
may be eaten with curd or any soft cheese.]
Where extreme restriction of diet is not required the ordinary bran
bread of the bakers may be used. The unbolted flour of which this is
made of course contains the starchy principles, but in consequence of
the retention of the bran the proportion of starch is less. The
cold-blast flour of the Health Food Company is said to contain the
nutritious, but not the innutritious, parts of the bran.[55]
[Footnote 55: It is made by pulverizing the carefully cleaned wheat by
a compressed, cold air blast, which strikes the wheat and dashes it to
atoms.]
The almond food suggested by Pavy is another substitute for bread. The
almond is composed of 54 per cent. of oil, 24 per cent. of nitrogenized
matter known as emulsin, 6 per cent. of sugar, and 3 per cent. of gum,
but no starch enters into its composition. Theoretically, therefore,
the food should be everything that can be desired if the gum and sugar
can be removed. The latter is done by treating the powdered almonds
with boiling water slightly acidulated with tartaric acid, or soaking
the almonds in a boiling acidulated liquid which may form a part of the
process for blanching. The boiling and acid are necessary to
precipitate {224} the emulsin, which would otherwise emulsify the oil
of the almond. Pavy speaks well of biscuit made of almond flour and
eggs, which he says go very well with a little sherry or other wine,
although he admits they are found too rich by some for ordinary
consumption. One person only under my observation has used the almond
food, and found it unpalatable.
Seegen recommends an almond food made as follows: Beat a quarter of a
pound of blanched sweet almonds in a stone mortar for about
three-quarters of an hour, making the flour as fine as possible; put
the flour thus obtained into a linen bag, which is then immersed for an
hour and a quarter in boiling water acidulated with a few drops of
vinegar. The mass is thoroughly mixed with three ounces of butter and
two eggs; the yolks of three eggs and a little salt are added, and the
whole is to be stirred briskly for a long time. A fine froth made by
beating the white of the three eggs is added. The whole paste is now
put into a form smeared with melted butter and baked by a gentle fire.
Biscuits made of inulin, the starchy principle largely contained in
Iceland moss, were suggested by Kuelz. Although a starch, it is one of
the assimilable ones alluded to, of which small quantities at least may
be taken as food without appearing in the urine as sugar. The biscuits
are made with the addition of milk, eggs, and salt, and are
inexpensive.
To some persons sugar is almost as imperative a necessity as bread,
although to many it is not a very great sacrifice to omit it from
ordinary cooking, if not from tea and coffee. For the latter it is just
as well to dispense with sugar altogether. But where patients feel that
they must have some substitute for sugar, glycerin has been suggested
for this purpose, at least for sweetening tea and coffee. But Pavy has
noted[56] that under the use of glycerin the urine increased from three
and three and three-fourth pints to between five and six pints, and the
sugar from 1100 grains to 3000 grains per diem, in the course of three
days. Its withdrawal was followed by a prompt fall in both the urine
and sugar, a return to it by a second increase, and subsequent
withdrawal by another decline. Along with the increase of urine and
sugar came also more thirst and discomfort. An examination of the
chemical composition of glycerin would seem to confirm these results of
experience. Glycerin is represented by C_{3}H_{8}O_{3}, sugar by
C_{6}H_{12}O_{3}, and glycogen by C_{6}H_{10}O_{5}; whence it is
evident that a conversion of glycerin into sugar may take place in the
liver. These facts seem to show conclusively that glycerin is no
suitable substitute for sugar. I therefore do not use it.
[Footnote 56: _On Diabetes_, London, 1869, p. 259.]
From what has been said it may be inferred that sugar of milk, mannite,
and lævulose, or fruit-sugar, are admissible where sugar is demanded.
They may be tried, but the urine should be carefully examined under
their use, and if glycosuria occur or be increased they should be
promptly omitted.
Almost every purpose of sugar in the cooking of acid vegetables is
served by bicarbonate of sodium or potassium. As much bicarbonate of
potassium to the pound as will lie upon a quarter of a dollar will
neutralize the acidity of most fruits which require a large amount of
sugar to mask this property. In this manner cranberries, plums,
cherries, gooseberries, red currants, strawberries, apples, peaches,
and indeed {225} all fruits to which sugar is usually added in the
cooking, become available to the diabetic.
In the matter of drinks, where the patient is not on a skim-milk diet,
which usually affords as much liquid as is required by the economy,
little restraint need be placed upon the consumption of water, which is
demanded to replace that secreted with the sugar. Instead of water,
Apollinaris water, Vichy, or the ordinary carbonated water may be used
if preferred, and to many they are much more refreshing by reason of
the carbonic acid they hold in suspension. Apollinaris water is
particularly so, and one of my patients, who recovered completely under
a suitable selected diet with which this mineral water was permitted,
insists that it was that which cured her.
Where a simple selected diet is adopted, tea and coffee without sugar
are usually permitted. The propriety of the substitutes for sugar
already referred to must be determined by circumstances.
Of distilled and fermented liquors, moderate quantities of whiskey and
brandy, dry sherry and madeira, the acid German and French wines--in
fact, any non-saccharine wines--may be permitted. A medical friend who
reports himself about cured of diabetes writes me that he has consumed
eighty gallons of Rhine wine since he began to adhere closely to a
diabetic diet. On the other hand, the free use of the stronger
alcoholic drinks has been charged with causing diabetes, and I have
known such use to produce a recurrence of sugar. No malt liquors,
except those in which the sugar has been completely converted into
carbonic acid and alcohol, should be used. Bass's ale may be allowed
where no especial stringency is required.
HYGIENIC TREATMENT.--The patient should be surrounded by the most
favorable hygienic influences. He should sleep in well-ventilated
rooms; pass much time in the open air; bathe regularly, but not in
water that is very cold, and especially the body should not be long
submerged in cold water, as the liver must share the general internal
hyperæmia incident to prolonged cooling of the skin, and increased
glycosuria may result. I have known sugar to reappear after a prolonged
drenching of the skin of patients overtaken by a rainstorm. Perhaps the
most suitable time for the hot or tepid bath is on retiring in winter,
but in summer it may be taken on rising. Thorough friction of the
entire body should be practised after the bath or independently of it.
An ounce or two of sodium carbonate may be added to it with advantage,
as it softens the skin and facilitates the removal of the effete
epithelium. The bowels should be kept regularly open, as the effect of
their confinement is to produce torpor and congestion of the liver.
Certain natural mineral waters have always enjoyed a reputation for the
cure of diabetes, and notably those of Vichy and Carlsbad. The former
is an alkaline water with a slight laxative tendency, and the latter a
decided aperient alkaline-saline water; and it is not unlikely that
they owe a part of their good effects to an action upon the liver and
upper bowel. This seems the more likely because Carlsbad, which enjoys
the highest reputation, contains a far larger proportion of chlorides
and sulphates, which are purgative. Vichy water contains 35 grains of
carbonates to the pint, and Carlsbad 11, but the latter contains twice
the proportion of chlorides, or 8 grains to the pint, and ten times as
much sodium {226} sulphate, or 19 grains to the pint. They may be used
as adjuvants to the treatment, a pint of Vichy or half as much Carlsbad
in the morning. Being imported waters, they are comparatively
expensive, and I know of no American waters which closely approach them
in composition.
Of American waters, the Saratoga Vichy contains twice as much chlorides
as the Carlsbad, 17.7 grains to the pint, but no sulphates. It contains
about the same amount of carbonates as Vichy. It is therefore a
saline-alkaline water, and may be expected to serve the purposes of
Vichy and some of those of Carlsbad, for which it may be substituted.
Most of the American mineral waters vaunted as useful in diabetes will
be found, on comparison with these waters, to be chemically
indifferent, and therefore about as useful as so much ordinary
spring-water. Of the Crab Orchard Springs in Kentucky, the Sowder's
spring contains 25 grains of sulphate of sodium and magnesium and 7
grains of sodium chloride to the pint, therefore about the same
proportion of the two substances combined as Carlsbad; yet I am not
aware that these waters have any reputation in diabetes. The waters of
Bedford Springs, Pennsylvania, also approximate them in the proportion
of sulphates of sodium and magnesium.
Other Saratoga waters have an undoubted action on the liver through
their chlorides, and may be used in lieu of the European waters above
referred to, and of the Saratoga Vichy, when these cannot be obtained;
such are the Geyser spring, which contains 70 grains of chlorides to
the pint, and the Hathorn, containing 63 grains.
MEDICINAL TREATMENT.--While the dietetic treatment, and especially the
skim-milk treatment, of diabetes mellitus is much to be preferred for
its results over an exclusively medicinal treatment, and is of itself
sufficient to control, if not to cure, a large number of cases, yet
instances arise in which it is insufficient to complete the removal of
sugar from the urine, and there are others in which it is impossible
for various causes to carry out such treatment.
In my book on _Bright's Disease and Diabetes_, published three years
ago, I gave the preference of drugs to ergot; but since then extended
opportunities have convinced me that codeia is a far more efficient
remedy. Repeated comparative trials of this drug in the wards of the
Philadelphia Hospital and elsewhere have satisfied me of this. The
trials have been made while the patients were upon a mixed diet, which
I hold to be the only fair way of arriving at a knowledge of the true
value of a drug in the disease. Codeia was first suggested by Pavy in
lieu of opium and morphia, which had long been used, his reason being
that it did not produce the same narcotic effect. Favorable reports
upon its use have been made by Foster, Image, Brunton, R. Shingleton
Smith, Cavafy, Austin Flint, Sr., Harvey L. Byrd, and others. It may be
given in pill or solution. One should begin with ¼ of a grain three
times a day, increasing ¼ of a grain daily until the sugar disappears
or the remedy ceases to have any effect, or until drowsiness is
produced. Thus gradually increasing, I have reached as high as 47
grains in a day. Cavafy has given 15 grains three times daily.
Opium--which is said to have been used by Aetius for this disease--or
morphia might be used if codeia cannot be obtained, but they are less
efficient, more dangerous, and more apt to produce the troublesome
{227} symptom of constipation. MacGregor[57] gave in one case 60 grains
of opium, and in another 90 grains, in the twenty-four hours.
[Footnote 57: _London Medical Gazette_, 1837.]
While I have seen the most striking results upon the quantity both of
sugar and urine during the administration of codeia, and at the same
time have noted a gain in flesh and strength, I cannot say that I have
ever seen a case totally recover under its use. Such cases are,
however, reported by others. I have always used it in the very worst
cases, where dietetic measures had also failed to remove the sugar. As
to the mode of action of codeine, we can only speculate. It may be said
that it quiets the irritation of the vaso-motor centre, whence result
the glycosuria and other symptoms of diabetes.
Next to codeine in efficiency, of drugs, is ergot. The favorable
results of its use are more easily explained by its physiological
action--contraction upon the muscular walls of blood-vessels--than
those of codeine, but it is not so efficient a remedy. It may be used
by beginning with half a drachm, and increasing to a drachm, four times
a day. Larger doses than this, as much as half an ounce four times a
day, have been given, but the stomach rarely permits their continuation
for any length of time.
Bromide of potassium, an old remedy for diabetes, has recently been
revived and much lauded by the French physicians, but I have never
found any results from its use. I can understand, however, how in
certain cases of nervous origin it may be useful.
Comparatively recently, Clemens of Frankfort-on-the-Main has
recommended the use of what he terms brom-arsen or bromide of arsenic.
The dose is one-forty-eighth of a grain three times a day, gradually
increased by this same amount until one-sixth or one-fifth of a grain
is given daily.[58] Clemens, however, unites with its use a dietetic
treatment. I have used it in connection with an unselected diet, and
have not found the results claimed by Clemens. It is, however, both
tonic and sedative, and as such is to be recommended in conjunction
with other measures.
[Footnote 58: The late Mr. R. F. Fairthorne, with Mr. James T. Shinn,
apothecary, cor. Broad and Spruce streets, Philadelphia, prepared for
me a solution of bromide of arsenic in the following manner: 77 grains
of metallic arsenic in powder are added in small portions to 240 grains
of bromine, the latter being placed in a long test-tube immersed in
ice-water to control the otherwise violent reaction. One hundred grains
of the tribromide thus obtained are dissolved in sufficient distilled
water to make ten fluidounces. One minim will then contain
one-forty-eighth of a grain.]
Arsenic itself has some reputation in the treatment of diabetes, based
upon the observation of Salkowsky that glycogen diminishes in the
livers of animals poisoned with arsenic. It is at least a good adjuvant
tonic. Leube gave it in diabetes in doses of one-third of a grain three
times a day.
Strychnia is also very useful as a tonic, and may be used either alone
or in the shape of the sulphate, or combined with arsenic and iron, or
it may be given, perhaps preferably, in solution in combination with an
acid. Given in combination with phosphoric acid, I believe it the most
valuable tonic available in this disease.
To supply the phosphates, in which gluten bread is deficient, as well
as for their tonic effect, the various preparations of phosphates are
useful. {228} The well-known compound syrup of the phosphates, or
Parrish's chemical food, may be considered a type of these
preparations. Every fluidrachm, which is a dose, contains 2½ grains of
calcium phosphate, 1 grain of ferric phosphate, with fractions of a
grain of sodium and potassium phosphate with free phosphoric acid.
Similar is the solution of phosphates and phosphoric acid[59] known in
this country as solution of phosphoric acid with iron, or the latter
may be omitted.
[Footnote 59: Rx. Calcii phosphat. gr. iij;
Magnesii " gr. ss;
Potassii " gr. iv;
Ferri " gr. ss;
Ac. phosphoric minim vj;
Aquæ q. s. ad. fluidrachm i, which is a dose.]
Iodide of potassium has been used in some cases with satisfactory
results, and may be expected to be useful where syphilitic disease of
the nervous system is suspected.
Seegen has seen sugar disappear from the urine under a dosage of 20 to
30 drops of tincture of iodine daily, but the sugar reappeared after
the remedy was discontinued.
Lactic acid was recommended by Cantani on theoretical grounds as a
substitute for sugar. He supposes that in health the sugar ingested is
converted by the liver into lactic acid, and he would furnish the
latter already formed, and thus spare the liver this function. Senator
also favors the use of this acid for a similar purpose, but reasons
that in health sugar is converted into lactic acid in the small
intestine, while in diabetes this conversion is interfered with. Hence,
too, it should be given fully formed. Patients under its use are said
to gain in weight and to become stronger, while it is not claimed that
it alone diminishes the glycosuria; this must be brought about by a
selected diet. The lactic acid is simply an important force-producer
not otherwise obtainable, because sugar fails to undergo its usual
conversion. Cantani recommends that from 75 to 150 grains of the acid
should be taken daily in from 8 to 10 fluidounces of water. Diarrhoea
and pains in the joints are said to follow the use of large quantities
of the drug, but these again disappear on its omission. My experience
is limited to a single case, which recovered while taking 30 drops
three times a day in conjunction with Carlsbad water and a pill of
iron, quinia, and arsenic.
Senator suggested that the fatty acids--oleic, palmitic, stearic, and
butyric--be used on the same principle that lactic acid is given, that
their force-producing power may be availed of. To this end he
prescribed, with partially satisfactory results, soap in pills
containing 2-1/3 grains each, of which four were taken daily.
Cod-liver oil is especially suitable as a food where debility is to be
combated. Even those who claim that fats are convertible into sugar in
the liver admit that it is only in the most advanced stages of diabetes
that such conversion takes place. Cod-liver oil, therefore, in common
with other fats, may form part of a diabetic diet, and is especially
indicated where phthisis is present, as it so often is, in the latter
stages of the disease, or indeed whenever a good tonic is indicated.