The Journal of the
American Medical Association
Published Under the Auspices of the Board of Trustees
VOL. 80, No. 22 CHIcAGO, ILLINOIS JUNE 2, 1923
physicians. There is no reason why any physician
THE ROUTINE TREATMENT OF DIA- should not treat other patients, provided he spends one
BETES WITH INSULIN hour learning the diabetic diet, or makes certain that
the patient knows it. This knowledge of diabetic arith-
ELLIOTT P. JOSLIN, M.D. metic is a pivotal point in order to balance diet wxvith
BOSTON drug with enough accuracy to justify the trouble of tlle
treatment. If the diet much overbalances the drug,
Successful treatment of diabetes with insulin there will be free glycosuria, and the expense and pains
dlepends on the utilization of all those measures that are practically wasted. If the drug overbalances the
have proved of the greatest value in the treatment of diet, there is likely to be a reaction, always fraught with
diabetes without insulin. These are: adherence to a alarm;-and, finally, if the physician does not know the
diet which will keep the urine sugar-free; avoidance of diet he may lose the confidence of his patient
over nutrition or extreme undernutrition, and a method For example: Five weeks of dietetic treatment
of life compatible with the strength such a diet affords. failed to control the severe diabetes of Alie S., last
. . , . . ...............................failed to control the severe diabetes o f Alice S ................... last
A knowledge of the fundamental principles of the diet summer. ith insulin she improved, ad when it was
andof hlLfoo vauesofa f w ood , s es t lsummer. ¥Vilth insulin she improved, and when it was
and of the food values of a few foods is essential; time to go bore, fot ber parents, but ber old, over-
otherwise the insulin will be squandered and the patient worked, country phyician traveled nearly 200 mile to
placed in jeopardy. ~~~~worked, country physician traveled nearly 200 miles to
placed in jeopardy.
Insulin does not cure diabetes. Insulin does not get her, to see for himself how she and other patients
Insulin does not cure diabetes. Insulin' does not
allow a diabetic to eat anything he desires. It is cruel were treated, to observe for himself what they ate, an
to hear them recite their lessons on food and insulini
for prominent individuals to make such statements to hear tem recite their lessons on fod and insli
and arouse false hopes. It is true that heretofore there and sugar tests. Alice learned the diet for the doctor-
and Dr. B. learned about insulin for Alice. The part-
has never been anything discovered as valuable for the and Dr B. learned about insulin for Alice. The part-
diabetic as insulin; but diabetes, though subdued, is not nership has already earned a 40 per cent. dividend iii
yet conquered. weight for the child, and I fancy far more than that
Insulin is no more dangerous than morphin, and it in joy for that faithful practitioner.
~~~~~~~~~~~~~~insjyfrthtfihulprcitiner
has these advantages: Whereas an excess of morphin Intelligent patients can be taught the use of the diet
leads directly to sleep, coma and death, an overdose of and insulin in a week, and in two weeks the average
insulin causes a warning train of symptoms, beginning patient can become free of acid and sugar, learn what
with nervousness and extreme hunger as the blood is requisite either in hospital or in boarding house, or
ugar drops below 0.07 per cent.; progressing to sweat- with a diabetically trained nurse in his own home.
sugar drops belo0.7prcnt;porsigoswet
subconscious or evident, and endingThus, with education they accomiplish with 5 units
ing and tremor, subconscious or evident, and ending
ing and tremor, ~~~~~what would otherwise require 10 units. Blond sugar
with unconsciousness, as the blood sugar reaches 0.03 what would otherwise require 10 units. Blood sugar
tests are very desirable, but I doubt whether one in teni
per cent.; and death is possible. Again, unlike the of my patients as such a test once a month in is ow
coure inmorhin oisoing recveryfolows lleof my patients has such a test once a month in his ownl
course in morphin poisoninig, recovery follows tile
home. The cost of one such test would probably sup-
simplest of measures--the juice of an orange or from hoeTecsofneuhtstwldpbal u-
simplest of measures-the juice of an orange or f rom ply them with insulin for a week, and they prefer the
1 to 3 teaspoonfuls of sugar--and takes place promptlyplthmwh nunfoawekadteyrerte
1 to 3 teaspoonfuis of sugar-and takes place promptiy insulin. Instead of blood sugar tests, they depend on
within five or ten minutes. Recovery may be further frequent Benedict tests of each single specimen of
expedited by 1 c.c. (15 minims) of a 1:1,000 solution eenBnditessoeahiglspcmnf
~~~~.expedited by 1 c.c. (15 minime,) of a 1:1000 soluton f which the cost of one test is 1 cent. By test-
of epinephrin subcutaneously administered, though this ing the urine before and after meals they learn whether
also is to be followed by the orange or sugar. the relation between carbohydrate and insulin should be
It is a mercy that at present insulin becomes inert changed. If glycosuria is present and yet the patient
when given by mouth, and that its use is restricted to is receiving sufficient calories, carbohydrate is reduced
a syringe. The medical profession cannot be too until all specimens throughout the day are sugar-free;
grateful to the Insulin Committee of Toronto for limit- or, if the carbohydrate is below 30 gm. in the diet,
ing the supply and the distribution for a few months. insulin may be increased. After a few weeks of pre-
Consider for a moment what would happen if morphin liminary treatment, "single specimen" days are only
was the drug discovered and then was at once sold over occasionally necessary, and the patienlt is safe wvith a
the counter. The useless pancreatic preparations of the test of all that portion of the twenty-four hour quantity
past required no supervision; insulin does, because it is of the urine that is voided at home.
potent. The first diet given a diabetic patient showing glyco-
Insulin, nevertheless, should be and can be used by suria should approximate that which he has been tak-
the general practitioner. This I have proved, because ing, with these modifications: The calories should be
already 127 patients have been sent home from the reduced by a marked restriction in fat, and the protein
hospital or boarding house across the street and are limited to 1 gm. or less per kilogram of body weight;
taking insulin under the supervision of their own and it is desirable to begin with about 200 gm. of car-