SUMMARY

Key:AWeight Gm.BProtein Gm.CFat Gm.DCarbohydrate Gm.ECalories

30-35 Proteins25-30 Carbohydrates1600-2000 caloriesFoodABCDEDinner:Beef tenderloins8013.019.5227with butter10.18.577Asparagus1001.5.12.818with butter10.18.577Squash1001.4.59.046with butter10.18.577Broth—TeaSupper:String bean salad—Lettuce10.1.32String beans501.1.13.726Pimento10.2.42Onion10.21.05Mayonnaise30.523.3228Tomatoes1201.4.24.828with butter20.217.0154Chocolate pudding—Cream1002.240.03.0381Cocoa, ½ tsp1.2.3.45Broth—TeaBreakfast:Bacon303.219.4187with 1 egg6.75.374Coffee with cream30.712.0.911432.9163.226.31728

Diabetic Diet No. 4

Key:AWeight Gm.BProtein Gm.CFat Gm.DCarbohydrate Gm.ECalories

50-60 Proteins30-40 Carbohydrates2000-2500 caloriesFoodABCDEDinner:Veal steak (roast)10019.910.8177Onions1261.9.411.949with cream501.120.01.5190Tomatoes1501.8.36.035with butter30.325.5231Fruit salad—Lettuce10.1.32Celery50.61.69Grapefruit80.6.28.137Whipped cream30.712.0.9114Tea—BrothSupper:Cream of celery soup—Celery50.61.69Cream751.630.02.2285Broth to fill bowlBoiled ham306.16.785Custard—2 egg yolks4.710.0109Cream902.036.02.7343TeaBreakfast:Eggs (2)13.410.5148with butter30.325.5231Coffee with cream20.48.0.676Broth56.1195.937.42130

Nurse’s Directions for Collecting and Testing the Urine in Diabetes Mellitus.—The first urine voided in the morning at 7A.M.should be thrown away, after which the entire quantity during the ensuing twenty-four hours, including that at 7A.M.the following morning, should be collected in a thoroughly clean, wide-mouth bottle sufficiently large to contain the entire quantity. This should be kept in a cool place to prevent decomposition. After the urine has been measured, four or five ounces are removed for testing purposes. There is no necessity for having an elaborately equipped laboratory for making the simple tests of the diabetic urine. The nurse is only required to make the simple tests, leaving the more elaborate one for the physician. The articles necessary for these tests must be kept perfectly clean in order to make the tests accurate. The bottle in which the urine is collected must be washed and sterilized daily before the collection begins. One small three-inch white enameled or porcelain dish, one 10 c.c. graduated pipette, 6 test tubes, 1 small alcohol lamp or Bunsen burner, 1 box of sodium carbonate, 1 box talcum, and the reagents necessary for making the test, namely, Benedict’s solution, Fehling’s solution, and Haines’s solution.

Diabetes Mellitusis a disease in which the body becomes more or less unable to utilize the sugars and starches, consequently there is an abnormal amount of glucose in the urine.

Manufacture of Sugarin the body from other food constituents besides carbohydrates has been proved with regard to proteins, hence the intake of nitrogenous substances must be restricted in diabetes—to a less extent, however, than the sugars and starches.

Acetone Bodies.—Diacetic acid, oxybutyric acid, andacetone develop in diabetes as a result of the breaking down of the fats and the lack of certain neutralizing agents found chiefly in carbohydrate foods.

Acidosisis a form of intoxication due to the retention of these toxic acids in the body. If not combated and overcome, it will result in the diabetic coma which is fatal in so many cases.

Diet Treatments.—The best known treatments are those devised and used by Drs. Allen and Joslin “The Starvation Treatment for Diabetes Mellitus,” and the “High Fat Diet” formulated by Drs. Newburg and Marsh. All cases cannot be handled alike and it is for the physician to determine the treatment calculated to give the best results in the definite case.

Training for Diabetic Nursing.—So much depends upon the administration of the treatment in this pathological condition that in many hospitals special training is being given to the nurses in the care of diabetic patients that they may be able intelligently to carry out the necessary régime, both in the hospital and in private practice.

Symptoms.—She must be able to recognize symptoms both from the findings resulting from the urinalysis and from those manifested otherwise by the patient.

The Record.—She must keep an absolute record of all that occurs during the course of treatment and instantly report any unusual happening.

Urine Tests.—It is advisable to make the tests in the morning; those for sugar and diacetic acid should be made every day or, in some cases, every other day, as directed by the physician, and those for ammonia and albumen about once a week.

Weighing the Patient.—Patient should be weighed each day before breakfast, and the weight of the clothes also carefully recorded separately.

The Bowelsmust move daily, even if it is necessary to resort to mild laxatives or an enema.

Formulating and Calculating the Dietary.—The menus of the day must be formulated and the chemical composition and nutrient value of the foods calculated. The vegetables belonging to the five per cent. group should be in readiness and the amount to be used weighed after they have been boiled in clean, separate water to reduce their carbohydrate content still further.

Commercial Diabetic Foods.—It may be well to mention the danger of putting faith in the so-called diabetic foods so widely advertised. Some of these foods are of undoubted worth, but it is never safe for the nurse or the patient to judge of the merits of the various diabetic foods without first knowing their chemical composition, and not even then without the definite directions from the physician.

Diabetic Flours.—The diabetic flours used in the recipes included in this text have been approved by some of the leading specialists in diabetes in this country, but the nurse should not include them in the diet for her patient unless they are prescribed by the physician in charge.

(a) Outline test diets for determining the severity of the disturbance.(b) Give examples of diets used in testing for tolerance of carbohydrates, fats, proteins.(c) Give an example of a diet order showing the use of the high fat method of feeding. Why is it used?

(a) Outline test diets for determining the severity of the disturbance.

(b) Give examples of diets used in testing for tolerance of carbohydrates, fats, proteins.

FOOTNOTES:[137]Allen’s Paradoxical Law, quoted from “Treatment of Diabetes Mellitus,” p. 18, by Joslin.[138]“Treatment of Diabetes Mellitus,” p. 305, Joslin.[139]“Food for the Sick,” by Strouse and Perry.[140]Courtesy of Dr. Joslin and Thomas Groom & Co., Boston.[141]The giving of coffee or clear broth, with or without whisky, does not materially affect the starvation and serves to make the patient more comfortable during this trying period.[142]Dr. Joslin has given a very complete schedule in his “Treatment of Diabetes Mellitus,” from which the above schedule is taken.[143]Hill and Eckman’s “Starvation (Allen) Treatment of Diabetes.”[144]See 5% vegetable, p.383.[145]Table used by Dr. Joslin in his treatment of diabetes mellitus. It is convenient, and many changes in the diet may be made by substituting one food for another of like carbohydrate content. This table can be purchased on cards from Thomas Groom & Co., Boston, Mass.[146]Table devised by H. O. Mosenthal showing accessory diets rich in carbohydrates. “Medical Clinics of North America,” July, 1917.[147]“h” represents household measure.[148]Mosenthal: “Medical Clinics of North America,” July, 1917.[149]“Starvation Treatment of Diabetes,” by Hill and Eckman.[150]“Practical Dietetics,” by Alidia Pattee.[151]“Food for the Sick,” p. 62, by Strouse and Perry.[152]Sweetened with saccharin.[153]“Starvation Treatment of Diabetes,” by Hill and Eckman.[154]Courtesy of R. Eckman and D. M. Stewart, University of Michigan Hospital, Ann Arbor, Michigan.

[137]Allen’s Paradoxical Law, quoted from “Treatment of Diabetes Mellitus,” p. 18, by Joslin.

[138]“Treatment of Diabetes Mellitus,” p. 305, Joslin.

[139]“Food for the Sick,” by Strouse and Perry.

[140]Courtesy of Dr. Joslin and Thomas Groom & Co., Boston.

[141]The giving of coffee or clear broth, with or without whisky, does not materially affect the starvation and serves to make the patient more comfortable during this trying period.

[142]Dr. Joslin has given a very complete schedule in his “Treatment of Diabetes Mellitus,” from which the above schedule is taken.

[143]Hill and Eckman’s “Starvation (Allen) Treatment of Diabetes.”

[144]See 5% vegetable, p.383.

[145]Table used by Dr. Joslin in his treatment of diabetes mellitus. It is convenient, and many changes in the diet may be made by substituting one food for another of like carbohydrate content. This table can be purchased on cards from Thomas Groom & Co., Boston, Mass.

[146]Table devised by H. O. Mosenthal showing accessory diets rich in carbohydrates. “Medical Clinics of North America,” July, 1917.

[147]“h” represents household measure.

[148]Mosenthal: “Medical Clinics of North America,” July, 1917.

[149]“Starvation Treatment of Diabetes,” by Hill and Eckman.

[150]“Practical Dietetics,” by Alidia Pattee.

[151]“Food for the Sick,” p. 62, by Strouse and Perry.

[152]Sweetened with saccharin.

[153]“Starvation Treatment of Diabetes,” by Hill and Eckman.

[154]Courtesy of R. Eckman and D. M. Stewart, University of Michigan Hospital, Ann Arbor, Michigan.

Much of the so-called biliousness from which the human family is so prone to suffer is nothing more or less than one of Nature’s danger signals by means of which man may understand that some part of the delicate organism called the human body is being overworked. Close investigation of these conditions has proved that it is the liver which has been overtaxed, in many cases to such an extent that in a measure it slows down, as any overtaxed machine will do, and has become clogged with material which, owing to its condition, it is not able to prepare properly and send out on time.

Work of the Liver.—When one considers the vast amount of work performed by this organ, one marvels that so little trouble is manifested. In another part of this text the functions of the liver were defined. It was found to be the largest secretory organ in the body, producing a constant supply of bile by means of which the fats were dissolved and the digestion and absorption of the other food materials facilitated. We likewise found that the greater part of the fuel foods was transformed within this organ into available energy, either for immediate or future use.

As a Detoxifying Agent.—To the liver must also be credited the detoxifying of the various poisons produced within the body during the process of metabolism or brought in by way of food. Too much cannot be said as to the value of the liver in this respect, the importance of which is made known as soon as anything happens to the organ to put it even temporarily out of commission.

Causes of Liver Disorders.—Is it any wonder, then, that with such abuses as overeating and drinking, especially of those foods rich in fats and carbohydrates which depend upon the liver for their availability in the body, Nature cries aloud for help and for the comparative rest of this, her largest organ?

The taking of alcohol in excess has been found to bring about tissue changes in the liver. Hence it must be avoided by individuals with a tendency to biliousness or to any disease in which the liver is involved.

The Bowels.—The bowels are as a rule constipated, and one of the first means of relief is the overcoming of this condition. The method of doing this depends upon the individual, and the treatment must be decided on by the physician.

Dietetic Treatment.—The dietetic treatment consists in abstaining from food or reducing the amount to a minimum while the attack lasts and while the intestines are being thoroughly emptied. All stagnant material which has clogged the bowels and which has been subjected to the activities of putrefactive bacteria must be gotten rid of. The diet must be especially low in fat. Oyster or clam broth, soft-cooked eggs, toast, cereal, or rice, with a little milk instead of cream and very little sugar, tea, and baked apple or stewed prunes are given.

Convalescent Diet.—After the attack the diet may be gradually increased until it is again normal. Moderation must be observed in the amount of food eaten; no highly seasoned or spiced foods, pickles, or condiments, such as peppers, mustard, or horseradish, should be taken. Salads should be dressed without oil. Lean beef, lamb chops, fish, chicken, sweetbreads, quail, squab, eggs (except fried or hard cooked), green vegetables (except radishes, onions, water-cress, and celery) in abundance, a small amount of potato, rice, or tapioca, fresh and cooked fruit with little, ifany sugar, junket, custards, fruit jellies, weak tea and coffee should constitute the diet. Certain individuals find that milk increases the tendency to constipation; this is probably due to the small amount taken; large quantities do not as a rule produce this effect. Buttermilk, koumiss, and modified milk are advised in severe cases.

Diet for Constipation.—Individuals inclined to biliousness should endeavor to overcome the constipation which is one of the most prominent features. This is done by proper diet more successfully than by drugs (cathartics): bran bread, vegetable soup, fresh fruit, stewed fruit, fruit beverages, plenty of water. The following menus are suggested:

Advice to Patient.—The above menus are merely suggested. The diet may be selected from the list of foods already mentioned. The patient must be warned against overeating and drinking. Pastry, rich cakes and puddings, confectionery, gravies, etc., must be avoided. In certain individuals beer will induce a bilious attack. By them it should be avoided.

The cause of this disease and the stage in which it exists must determine the treatment necessary. However, it matters not what produced the disease, whether it is the result of alcoholism, syphilis, etc., the diet plays an important rôle in its cure.

The Diet.—The diet in this disease, as in any other, must be determined by the condition of the patient. Unfortunately, many patients do not know of their condition until the disease is well advanced and symptoms of obstruction are prominent. A study of these must be made before the diet can be formulated. When the symptoms are mainly those arising from disturbed digestion of the stomach and intestines, without kidney or heart complication, the diet for chronic gastritis is used.

Restricting the Fluids.—When the heart is involved, itis sometimes found necessary to restrict the fluids (dry diet) to 1 quart (about 1000 c.c.) per day. The Karell Cure has been used advantageously in many of these cases. In cases where the kidneys are involved, the diet will depend upon the condition of these organs.

Restricting the Diet.—The diet in any case must be restricted. Individuals with a tendency to cirrhosis and those coming of a family in which liver diseases are frequent should be especially warned about the dangers of overeating and drinking. Alcohol should be avoided especially by such individuals. They should keep their diet simple in character and moderate in amounts.

Avoidable Foods.—All foods, such as condiments and spices, meat extracts, the outside browned portions of roasted meat, alcoholic beverages, which exert a stimulating or irritating effect upon the liver, should be studiously avoided and the fats and carbohydrates restricted, since, as it has already been demonstrated, it is upon the liver that the body depends for the preparation of these substances for their utilization. When, for example, the flow of bile is lessened, an incomplete emulsification of the fats exists and the fatty acids which are highly acid in character cannot be efficiently dissolved or neutralized, or when the liver is diseased and for this reason the conversion of glycogen into glucose is interfered with, the utilization of the carbohydrate foods is thus impaired.

Factors Influencing Their Formation.—According to Friedenwald and Ruhräh[155]the two factors that in all probability exert the most influence on the formation of gallstones are the stasis of bile and the inflammation of the bile passages and gall bladder.

Dietary Rules.—There are certain dietary rules whichshould be observed by all persons who have had gallstone attacks. These are (1) to prevent stasis of bile, (2) to avoid fats. Everything should be done to prevent the formation of the stones, and this can only be accomplished by observing these rules. The flow of bile must be free; this is encouraged by keeping the intestinal tract in good condition.

Stimulating Peristalsis.—Peristalsis must not be allowed to become sluggish, for it is only during the process of digestion when the food mass passes along the intestinal canal that there is an ejection of bile into the intestines. When the passage is abnormally slow the bile is in a measure dammed back with a formation of gallstones as a result. The restriction of the fats has already been discussed in another part of the chapter. It has been demonstrated that these substances have a chemical influence upon the formation of gallstones as well as upon the intestinal stasis which leads to their formation.

Dietetic Treatment.—Hence the diet should be so directed as to (1) increase the flow of bile, and (2) to avoid all foods that are liable to cause indigestion which may bring about putrefaction in the intestinal tract and a consequent irritation and inflammation of the bile passages and gall bladder.

The meals should be regular and an abundant diet advised to increase the flow of bile and stimulate peristalsis in the intestines.

Exercise.—Exercise is especially recommended. Horseback riding, swimming, rowing, golf, and tennis are especially valuable in forcing the bile from the gall bladder and liver.

The Clothing.—The clothing should be loose enough to be perfectly comfortable. Certain cases of gallstone attacks in women have been said to have been traced to tight lacing, which interfered with the normal flow of the bile.

The Bowels.—Constipation should be avoided, and the diet should be directed with this point in view. The meals must be frequent, ranging from four to six a day. In this way only is the flow of bile encouraged. The breakfast should be ample in order to utilize the bile secreted in the night season. With all this, care must be observed not to give more food than can be adequately handled by the digestive apparatus, since food which is not digested becomes a prey to the actions of the putrefactive bacteria which infest it, and the toxic substance thus formed produces the very result which all of our efforts are directed to prevent.

Available Foods.—The following foods low in fats may be used in formulating the diet:

Soups: Meat broth (made from lean meat) from which all the fat has been removed.

Meats: Lean beef, lamb, chicken, squab, quail, lean fish (in small quantities and not too frequently).

Green vegetables: Except peas and carrots; beets and turnips may be taken sparingly.

Fruits: Oranges, lemons, grapefruit, and unsweetened stewed fruit.

Cereals: Wheat cereals, oatmeal, rice, and tapioca in moderation.

Bread: Whole wheat, white, rye, and graham bread, toast, and crackers.

Fluids: Weak tea and coffee (without cream, and a little sugar), orange and lemonade, mineral waters, water, skimmed milk, whey.

Eggs: (except hard-cooked or fried).

Desserts: Fruit gelatin, fruit whips, raw or stewed fruit.

Avoid the following foods: Fats, oils, mutton, liver, brains, sardines, and caviar, oily fish, rich gravies and sauces, sweet fruit, peas, carrots, condiments and spices, pastry and confectionery, pickles, alcoholic beverages. Restrictcarbohydrates, yolks of eggs, milk (cream must be skimmed off if too rich).

III

Functions of Liver.—To transform fuel foods into available energy; to detoxify those poisonous substances produced as the result of metabolism of body tissue or brought in in food, and to select those available for use; to secrete bile.

Factors Influencing Disorder of Liver.—Errors in diet: (a) overeating; (b) excessive drinking; and (c) unbalanced diet, especially as regards the amount of fats and carbohydrates in the diet.

The Bowels, in most of the disturbances affecting the liver, become constipated, thus causing much additional work on the part of the liver in handling the products produced as the result of putrefactive bacteria upon the accumulated mass in the colon.

Tissue Changesin the liver have been caused by the taking of alcohol, which should therefore be avoided by all individuals having any disease involving the liver and by those with a predisposition to liver disturbances.

Exercise and Lack of Exerciseare potent factors in the treatment of conditions involving the liver. First, because the liver requires exercise to enable it to empty itself more completely and assure a free flow of bile; second, because exercise directly affects the energy output of the body, causing an increased rate of metabolism and a better utilization of the food ingested. Lack of exercise acts in exactly the opposite direction, and it has been found that with the majority of patients suffering from diseases of the liver too little exercise and too much food are at the bottom of the trouble.

Dietetic Treatmentin the majority of diseases affecting the liver is much the same. The keynote in each is a balanced diet. Constant overeating and excessive drinking have proved the foundation of the majority of such diseases, especially of the bilious type, while an excess of fat and carbohydrates in the diet lead to the more serious disorders.

Biliousnessrequires abstinence from food for a short period and a cleansing of the entire gastro-intestinal tract, the measures being directed by the physician. After the bilious symptoms have subsided, a simple, well-regulated diet should be established, in which no rich foods of any sort are allowed. All condiments and spices which have an astringent effect upon the bowels are strictly prohibited, and alcoholic beverages had best be eliminated from the diet.

Cirrhosisof the liver is apt to be insidious in its development, taking a firm hold before the character of the disorder is discovered. Dietetic treatment of this disturbance is most important and should be directed toward overcoming not only the liver symptoms but other symptoms as well.

Gastro-intestinal Disturbances, manifested in cirrhosis of the liver, are treated by the diet used in chronic gastritis (see p.250).

Heart Symptomssometimes occur during the course ofthe disease and require especial attention to the diet. The fluids at times must be restricted, in which case a modification of the Karell Cure will prove valuable (see p.342).

Kidney Complicationsdevelop in a certain percentage of cases, and it then becomes necessary to institute one of the various diets devised to meet the needs of those special conditions (see ChapterXVIII).

Restricting the Dietwill be found to be necessary for those individuals showing a tendency to cirrhosis, also for those in whose family diseases of the liver are of frequent occurrence. Such individuals should be warned of the dangers arising from overindulgence in food or alcoholic beverages.

Prohibited Foodsare those which by reason of their astringent qualities favor the development of constipation, such as condiments and spices; those foods which exert a stimulating and irritating effect upon the liver and bile passages, such as alcohol, malt extractives, etc.; and fats and carbohydrates in excessive quantities, on account of the extra amount of work required of the liver in order to make them available in the body.

Gallstonesdevelop as the result of inflammation or clogging of the bile passages.

Treatmentis dietetic in character and is directed toward relieving or preventing inflammation in the bile passages, also in stimulating the flow of bile in order that it may not become sluggish and thus give rise to the development of the gallstones.

The Fats, therefore must be restricted in the diet, as they, more than any of the other food constituents, favor the above conditions.

Peristalsisin the intestinal tract must be stimulated to facilitate a free flow of bile, which will not occur where the movements are sluggish. Stasis of the bile must be prevented or stones will be apt to form.

Dietetic Treatmentfor gallstones is therefore directed to increase the flow of bile and to avoid the inflammation of the gall bladder and bile passages which may result from the product of intestinal putrefaction.

The Dietconsists of foods simple in character, low in fats, but abundant in quantity, in order to prevent constipation. It must be selected carefully that digestional disturbances may not develop.

The Mealsshould be frequent, from four to six a day, in order to encourage a free flow of bile.

Breakfastshould be ample in order that the bile secreted and accumulated during the night may be utilized as soon as possible.

Constipationmust be avoided, and the foods particularly adapted to prevent or overcome this condition should have a prominent place in the diet. Any accumulation of unabsorbed food in the lower intestines becomes a breeding ground for putrefactive bacteria, the product of whose activity imposes a serious tax upon an already overworked organ.

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