The Project Gutenberg EBook of The Starvation Treatment of Diabetes, by Lewis Webb Hill and Rena S. Eckman This eBook is for the use of anyone anywhere at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.org Title: The Starvation Treatment of Diabetes Author: Lewis Webb Hill Rena S. Eckman Release Date: July 14, 2008 [EBook #26058] Language: English Character set encoding: ISO-8859-1 *** START OF THIS PROJECT GUTENBERG EBOOK STARVATION TREATMENT OF DIABETES *** Produced by Stacy Brown, Bryan Ness and the Online Distributed Proofreading Team at https://www.pgdp.net (This book was produced from scanned images of public domain material from the Google Print project.) THE STARVATION TREATMENT OF DIABETES WITH A SERIES OF GRADUATED DIETS USED AT THE MASSACHUSETTS GENERAL HOSPITAL by LEWIS WEBB HILL, M.D. Children's Hospital, Boston and RENA S. ECKMAN Dietitian, Massachusetts General Hospital, Boston WITH AN INTRODUCTION BY RICHARD C. CABOT, M.D. Second Edition BOSTON, MASS. W. M. LEONARD 1916 Copyrighted 1915 by W. M. Leonard Second Edition First Edition Printed August, 1915 Second Edition Printed January, 1916 Second Edition Reprinted April, 1916 INTRODUCTION. Although Dr. Allen's modifications of the classical treatment of saccharine diabetes have been in use only for about two years in the hands of their author, and for a much shorter time in those of other physicians, it seems to me already clearly proven that Dr. Allen has notably advanced our ability to combat the disease. One of the difficulties which is likely to prevent the wide adoption of his treatment is the detailed knowledge of food composition and calorie value which it requires. Dr. Hill's and Miss Eckman's little book should afford substantial aid to all who have not had opportunity of working out in detail the progressive series of diets which should be used after the starvation period. These diets, worked out by Miss Eckman, head of the diet kitchen at the Massachusetts General Hospital, have seemed to me to work admirably with the patients who have taken them, both in hospital and private practice. The use of thrice boiled vegetables, as recommended by Dr. Allen, seems to be a substantial step in advance, giving, as it does, a considerable bulk of food without any considerable carbohydrate portion, and with the semblance of some of the forbidden vegetables. It is, of course, too early to say how far reaching and how permanent the effects of such a diet will be in the severe and in the milder cases of diabetes. All we can say is that thus far it appears to work admirably well. To all who wish to give their patients the benefit of this treatment I can heartily recommend this book. Richard C. Cabot. PREFACE TO FIRST EDITION. The purpose of this little book is to furnish to the general practitioner in compact form the details of the latest and most successful treatment of diabetes mellitus. The "starvation treatment" of diabetes, as advanced by Dr. Frederick M. Allen of the Rockefeller Institute Hospital, is undoubtedly a most valuable treatment. At the Massachusetts General Hospital it has been used for several months with great success, and it is thought worth while to publish some of the diets, and details of treatment that have been used there, as a very careful control of the proteid and carbohydrate intake is of the utmost importance if the treatment is to be successful. In carrying out the Allen treatment the physician must think in grams of carbohydrate and proteid—it is not enough simply to cut down the supply of starchy foods; he must know approximately how much carbohydrate and proteid his patient is getting each day. It is not easy for a busy practitioner to figure out these dietary values, and for this reason the calculated series of diets given here may be of service. The various tests for sugar, acetone, etc., can, of course, be found in any good text-book of chemistry, but it is thought worth while to include them here for the sake of completeness and ready reference. The food table covers most of the ordinary foods. We wish to thank Dr. Roger I. Lee and Dr. William H. Smith, visiting physicians, for many helpful suggestions. PREFACE TO SECOND EDITION. The Authors beg to thank the Profession for the cordial reception given the first edition of this book. The present edition has been revised and enlarged, with the addition of considerable new material which we hope will be of use. January, 1916. DETAILS OF TREATMENT. For forty-eight hours after admission to the hospital the patient is kept on ordinary diet, to determine the severity of his diabetes. Then he is starved, and no food allowed save whiskey and black coffee. The whiskey is given in the coffee: 1 ounce of whiskey every two hours, from 7 a.m. until 7 p.m. This furnishes roughly about 800 calories. The whiskey is not an essential part of the treatment; it merely furnishes a few calories and keeps the patient more comfortable while he is being starved. If it is not desired to give whiskey, bouillon or any clear soup may be given instead. The water intake need not be restricted. Soda bicarbonate may be given, two drachms every three hours, if there is much evidence of acidosis, as indicated by strong acetone and diacetic acid reactions in the urine, or a strong acetone odor to the breath. In most cases, however, this is not at all necessary, and there is no danger of producing coma by the starvation. This is indeed the most important point that Dr. Allen has brought out in his treatment. At first it was thought best to keep patients in bed during the fast, but it is undoubtedly true that most patients do better and become sugar-free more quickly if they are up and around, taking a moderate amount of exercise for at least a part of the day. Starvation is continued until the urine shows no sugar. (The daily weight and daily urine examinations are, of course, recorded.) The disappearance of the sugar is rapid: if there has been 5 or 6 per cent., after the first starvation day it goes down to perhaps 2 per cent., and the next day the patient may be entirely sugar-free or perhaps have .2 or .3 per cent. of sugar. Occasionally it may take longer; the longest we have starved any patient is four days, but we know of obstinate cases that have been starved for as long as ten or eleven days without bad results. The patients tolerate starvation remarkably well; in no cases have we seen any ill effects from it. There may be a slight loss of weight, perhaps three or four pounds, but this is of no moment, and indeed, Allen says that a moderate loss of weight in most diabetics is to be desired. A moderately obese patient, weighing say 180 pounds, may continue to excrete a small amount of sugar for a considerable period if he holds this weight, even if he is taking very little carbohydrate; whereas, if his weight can be reduced to 170 or 160, he can be kept sugar-free, with ease, on the same diet. This is very important: reduce the weight of a fat diabetic, and keep it reduced. We have not found that the acetone and diacetic acid output behaves in any constant manner during starvation; in some cases we have seen the acetone bodies disappear, in others we have seen them appear when they were not present before. Their appearance is not necessarily a cause for alarm. The estimation of the ammonia in the urine is of some value in determining the amount of acidosis present, and this can readily be done by the simple chemical method given below. If the 24-hourly ammonia output reaches over 3 or 4 grams, it means that there is a good deal of acidosis—anything below this is not remarkable. More exact methods of determining the amount of acidosis are the determination of the ratio between the total urinary nitrogen and the ammonia, the quantitation of the acetone, diacetic acid and oxy-butyric acid excreted, and the carbon dioxide tension of the alveolar air. These are rather complicated for average clinical use, however. When the patient is sugar-free he is put upon a diet of so-called "5% vegetables," i.e. vegetables containing approximately 5% carbohydrate. It is best to boil these vegetables three times, with changes of water. In this way their carbohydrate content is reduced, probably about one-half. A moderate amount of fat, in the form of butter, can be given with this vegetable diet if desired. The amount of carbohydrate in these green vegetables is not at all inconsiderable, and if the patient eats as much as he desires, it is possible for him to have an intake of 25 or 30 grams, which is altogether too much; the first day after starvation the carbohydrate intake should not be over 15 grams. Tables No. 1 and No. 2 represent these vegetable diets. The patient is usually kept on diet 1 or 2 for one day, or if the case is a particularly severe one, for two days. The day after the vegetable day, the protein and fat are raised, the carbohydrate being left at the same figure (diets 2, 3 and 4). No absolute rule can be laid down for the length of time for a patient to remain on one diet, but in general we do not give the very low diets such as 2, 3 and 4, for more than a day or two at a time. The diet should be raised very gradually, and it is not well to raise the protein and carbohydrate at the same time, for it is important to know which of the two is causing the more trouble. The protein intake may perhaps be raised more rapidly than the carbohydrate, but an excess of protein is very important in causing glycosuria, and for this reason the protein intake must be watched as carefully as the carbohydrate. With adults, it is advisable to give about 1 gram of protein per kilogram of body weight, if possible; with children 1.5 to 2 grams. It will be noticed that the diets which follow contain rather small amounts of fat, a good deal less than is usually given to diabetics. There are two reasons for this: In the first place, we do not want our diabetics, our adults, at any rate, to gain weight; and in the second place acidosis is much easier to get rid of if the fat intake is kept low. If the fat values given in the diets are found too low for any individual case, fat can very easily be added in the form of butter, cream or bacon. Most adults do well on about 30 calories per kilogram of body weight; children of four years need 75 calories per kilogram, children of eight years need 60, and children of twelve years need 50. If sugar appears in the urine during the process of raising the diet, we drop back to a lower diet, and if this is unavailing, start another starvation day, and raise the diet more slowly. But it will be found, if the diet is raised very slowly, sugar will not appear. It is not well to push the average case; if the patient is taking a fair diet, say protein 50, carbohydrate 50 and fat 150, and is doing well, without any glycosuria, it is not desirable to raise the diet any further. The caloric intake may seem rather low in some of these diets, but it is surprising to see how well most patients do on 1500 or 2000 calories. It will be seen that the treatment can be divided into three stages: (1) The stage of starvation, when the patient is becoming sugar-free. (2) The stage of gradually working up the diet to the limit of tolerance. During the first two stages a daily weight record should be kept, and the urine should be examined every day. The patient should, of course, be under the immediate supervision of the physician during these two stages. It is always well to discharge a patient on a diet somewhat under his tolerance, if possible. (3) The stationary stage, when the diet is kept at a constant level. The patient is at home and going about his business. Most patients may be taught to test their own urine, and they should do this every other day. If there is sugar in the urine, the patient should go back to a lower diet, and if he cannot be made sugar-free this way, he should be starved again. A semi-starvation day of 150 grams of vegetables, once a week, whether or no the urine contains sugar, is of value for the purpose of keeping well within the margin of safety and of reminding the patient that he is on a strict diet. It is very important for a diabetic to take a considerable amount of exercise: he can utilize his carbohydrate better, if he does. If this treatment is to be successful, it is absolutely necessary for the patient to adhere very strictly to the diets, and to measure out everything very carefully; the meat especially should be weighed. It will be noticed that in some cases the calories in the diets do not tally exactly with the protein, fat and carbohydrate values. The reason for this is that for the sake of convenience the calories have been given in round numbers—5 or ten calories one way or the other makes no difference. The essential points brought out by Allen's treatment are as follows: (1) It is not dangerous to starve a diabetic, and two or three days of starvation almost always make a patient sugar-free, thus saving a good deal of time, as contrasted with the old treatment of gradually cutting down the carbohydrate. (2) It is not desirable for all diabetics to hold their weight. Some cases may do much better if their weight is reduced ten, fifteen, or even twenty pounds. (3) After starvation, the diet must be raised very slowly, to prevent recurrence of glycosuria. (4) An excess of protein must be regarded as producing glycosuria and an excess of fat ketonuria, and the protein and fat intake must be restricted a good deal more than has usually been the custom in treating diabetes. Case Reports. It is thought worth while, for the sake of illustration, to include a few case reports. The adults were treated at the Massachusetts General Hospital, the children at the Children's Hospital. Two charts are kept for each case: one a food chart, with the amounts of the different articles of food taken each day, and the protein, carbohydrate, fat and caloric value figured out for each foodstuff; the second (see below) a more general chart, which shows graphically the progress of the case. The first three are cases which were treated first with the old method of gradually reducing the carbohydrate intake and could never be made sugar-free, running from 0.1% to 0.2% of sugar. On the new treatment they responded promptly and were discharged sugar-free. Case 1. A woman of 64, diabetic for two years. She was sent in from the out-patient department, where she had been receiving a diet of 50 grams of carbohydrate and 50 grams of protein. On this diet she was putting out 8 grams of sugar a day with moderately strong acetone and diacetic acid reactions in her urine. When the carbohydrate was cut in the ward to 30 grams, she put out 3 grams of sugar a day. She complained of severe pruritus vulvae. After sixteen days of this treatment she continued to put out from 0.1% to 0.2% of sugar a day. Allen's treatment was then started, and after one day of starvation she was sugar-free and remained so for four days on a diet of carbohydrate, 20 grams; protein, 30 grams; fat, 150 grams. The itching had gone. Then the protein was raised to 80 grams, with the carbohydrate at 20 grams, and she immediately showed 1.5% of sugar. This is very important; the protein should not be raised too quickly. This we did not realize in our earlier cases. A second starvation day, followed by two vegetable days, and a more careful raising of the diet—as follows—kept her sugar-free, and she was discharged so. Her diets were: Dec. 12. Carbohydrate, 20 grams. Protein, 30 grams. Fat, 150 grams—1500 calories. No glycosuria. Dec. 15. Carbohydrate, 30 grams. Protein, 30 grams. Fat, 200 grams—2000 calories. No glycosuria. Dec. 20. Carbohydrate, 30 grams. Protein, 40 grams. Fat, 180 grams—2000 calories. No glycosuria. Dec. 26. Carbohydrate, 40 grams. Protein, 40 grams. Fat, 180 grams—2000 calories. No glycosuria. Dec. 30. Carbohydrates, 50 grams. Protein, 50 grams. Fat, 180 grams—2000 calories. No glycosuria. Weight on entrance, 119 pounds. Weight at discharge, 116 pounds. Case 2. A Jew of 49, at entrance had 175 grams of sugar (5.5%), acetone slight, diacetic acid absent. Treated for three weeks with the old method, he got down to a diet containing carbohydrate, 15 grams; protein, 50 grams,—but still put out from 3 to 8 grams of sugar a day. By the old method we could not do away with the last traces of sugar. The Allen treatment was started with two starvation days. On the second he was sugar-free—but showed 2.6 grams of sugar the following day on 12 grams of carbohydrate and 40 grams of protein. (This was one of the earlier cases when the diet was raised too quickly after starvation.) After one more starvation day and two vegetable days he stayed sugar- free while the diet was raised slowly to 30 grams of carbohydrate and 45 grams of protein, calories about 2000. Discharged sugar-free on this diet. Weight at entrance, 109 pounds. Weight at discharge, 110 pounds. Case 3. A man of 35, a severe diabetic, entered Dec. 28, 1914. He had been in the hospital the previous July for a month and could never be made sugar-free with the old method of treatment. At entrance he was putting out 2.5% of sugar (135 grams) per day with strongly positive acetone and diacetic acid tests. Two starvation days made him sugar- free, but we made the mistake of not using twice boiled vegetables for his vegetable day after starvation. So on this day he got about 30 grams of carbohydrates, and for a few days he showed from 0.2% to 1% of sugar. Another starvation day was given him and he became sugar-free. This time his vegetables were closely restricted and he was given only enough twice-boiled vegetables to provide about 15 grams of carbohydrates. After this the diet was raised very slowly. He remained sugar-free for three weeks and was discharged so on, Carbohydrate, 20 grams. Protein, 40 grams. Fat, 200 grams. At no time did he receive more than 2200 calories. Weight at entrance, 139 pounds. Weight at discharge, 138 pounds. These three cases were the first ones we tried, and in each one of them we made the mistake of raising the diet too quickly—either allowing too many vegetables on the vegetable day, or raising the protein too quickly afterwards. With the later cases, after we had more experience, there was no more trouble. Case 4. A Greek (male) of 48, diabetic for two months, entered Jan. 14, 1915, with 3.8% (65 grams) of sugar and moderate acetone reaction. There was no diacetic reaction present at entrance. After one starvation day he became sugar-free, but was kept on starvation one day longer and then started on vegetables in the usual way. After the third day a moderate amount of diacetic acid appeared in the urine and continued. The ammonia rose from 0.7 grams per day to 2.6 grams per day, and then varied from 0.3 to 1.5 grams per day. No symptoms of acidosis. Jan. 18. Carbohydrate, 15 grams. Protein, 25 grams. Fat, 150 grams—1360 calories. No glycosuria. Jan. 20. Carbohydrate, 15 grams. Protein, 25 grams. Fat, 200 grams—1571 calories. No glycosuria. Jan. 24. Carbohydrate, 25 grams. Protein, 35 grams. Fat, 200 grams—1760 calories. No glycosuria. Jan. 26. Carbohydrate, 35 grams. Protein, 40 grams. Fat, 200 grams—1838 calories. No glycosuria. Jan. 29. Carbohydrate, 45 grams. Protein, 50 grams. Fat, 200 grams—2194 calories. No glycosuria. Jan. 31. Carbohydrate, 50 grams. Protein, 60 grams. Fat, 200 grams—2347 calories. No glycosuria. Discharged Feb. 1 sugar-free on this diet. Weight at entrance, 160 pounds. Weight at discharge, 156 pounds. This was not a severe case and responded very easily to treatment. Case 5. A female of 59, a diabetic of two years' standing, excreted 2.6% of sugar on Jan. 16, 1915, with no acetone or diacetic acid reactions in the urine. Severe pruritus vulvae. Starved two days; sugar-free on the second starvation day, with disappearance of the pruritus. Jan. 21. Carbohydrate, 15 grams. Protein, 25 grams. Fat, 150 grams—1595 calories. No glycosuria. From this time the diet was slowly raised until on Jan. 30 she was getting Carbohydrate, 35 grams. Protein, 45 grams. Fat, 200 grams—2156 calories. She was sugar-free on this and was discharged to the out-patient department after a two weeks' stay in the wards. Weight at entrance, 135 pounds. Weight at discharge, 133 pounds. Case 6. A man of 52, entered Jan. 10, 1915, with 1% of sugar. He entered for arteriosclerosis and hypertension, and the sugar was found in the routine examination of the urine. He was kept on house diet for a few days and his sugar rose to 3.5%. No acetone or diacetic acid. After two days of starvation he became sugar-free and continued so as the diet was slowly raised. He was kept sugar-free in the ward eighteen days and was sugar-free on Feb. 6 with a diet of Carbohydrate, 60 grams. Protein, 60 grams. Fat, 200 grams—2280 calories. On Feb. 7 the protein was raised to 80 grams and 0.2% of sugar appeared in the urine. The protein was then reduced to 60 grams and he remained sugar-free on this diet and was discharged so. In this case, after starvation, a moderate amount of acetone appeared and continued. No symptoms of acidosis. The ammonia ran from 0.3 to 1.0 grams per day. Weight at entrance, 160 pounds. Weight after three weeks' treatment, 156. Maximum caloric intake, 2525. Case 7. A young man of 25, diabetic for eight months, entered Jan. 20, 1915, with 6.6% (112 grams) of sugar and strongly positive tests for acetone and diacetic acid. After a period of two starvation days he was sugar-free and actually gained three pounds in the process of starvation (probably due to water retention). His diet was then raised as follows:— Jan. 24. Carbohydrate, 15 grams. Protein, 25 grams. Fat, 150 grams. No glycosuria. Jan. 26. Carbohydrate, 20 grams. Protein, 35 grams. Fat, 175 grams. No glycosuria. Jan. 29. Carbohydrate, 20 grams. Protein, 45 grams. Fat, 200 grams. No glycosuria. Jan. 31. Carbohydrate, 30 grams. Protein, 45 grams. Fat, 200 grams. No glycosuria. At entrance his ammonia was 1.7 grams per day; after the starvation days it ran from 0.9 grams to 0.3 grams per day. The acetone was a little stronger than at entrance; the diacetic absent except on three days. On Feb. 5 he was still sugar-free having been so since his starvation days two weeks previously, and weighed 127 pounds, a gain of seven pounds since entrance. At no time did he receive over 2150 calories. This was a very satisfactory case; no doubt the carbohydrate could have been raised to 50 or 60 grams, but he was doing so well that we felt it unwise to go any further. Diabetes in children is likely to be a good deal more severe than it is in adults. Still, in the few cases that have been treated with the starvation treatment at the Children's Hospital, the results have been very satisfactory, as far as rendering the patient sugar-free is concerned. Most diabetic children, however, are thin and frail, and they have no extra weight to lose, so it does not seem so desirable to bring about any very great loss of weight, which is quite an essential part of the treatment for most adults. The few children that have been treated have borne starvation remarkably well. It is too early, and we have seen too few children treated by this method, to say what influence it may have on the course of the disease, but it can certainly be said that it is very efficacious in rendering them sugar-free. Case 8. M. M., female, 12 years, entered the Children's Hospital April 1, 1915. She had probably had diabetes for about 6 months, and had been on a general diet at home. (See charts on pp. 31-36.) On the ordinary diet of the ward she showed 8.7% sugar, no acetone or diacetic acid. Weight, 52-1/4 pounds,—a very thin, frail girl. She was starved two days, taking about 1-1/2 oz. of whiskey in black coffee each day. The first day of starvation the sugar dropped to 2.3%, and a slight trace of acetone appeared in the urine. The second day of starvation she was sugar-free, with a moderate acetone reaction. No soda bicarbonate was given. She lost 2 pounds during starvation. After she became sugar-free, her diets were as follows: April 5. Whiskey, 1-1/2 ounces. Protein, 5 grams. Carbohydrate, 12 grams. Fat, 7 grams. No glycosuria. Calories, 213. April 6. Whiskey, 1-1/2 ounces. Protein, 26 grams. Carbohydrate, 18 grams. Fat, 46 grams. No glycosuria. Calories, 768. April 8. Whiskey, 1-1/2 ounces. Protein, 45 grams. Carbohydrate, 22 grams. Fat, 72 grams. No glycosuria. Calories, 1050. April 9. Whiskey, 1-1/2 ounces. Protein, 58 grams. Carbohydrate, 36 grams. Fat, 86 grams. No glycosuria. Calories, 1309. From this her diet was raised gradually until on April 16 she took the following: Bacon, 4 slices. Oatmeal, 2 tablespoonfuls. Bread, 2 slices. Meat, 1 ounce. Cabbage, 5 tablespoonfuls. Spinach, 5 tablespoonfuls. String beans, 5 tablespoonfuls. Butter, 2 ounces. This calculated to, Protein, 64 grams. Carbohydrate, 63 grams. Fat, 113 grams. Calories, 1546. On this diet she excreted .40% sugar. The next day the bread was cut down to one slice, and her sugar disappeared. On April 20 she was taking 4 tablespoonfuls of oatmeal and one slice of bread with her meat and vegetables, and was sugar-free. This diet contained: Protein, 63 grams. Carbohydrate, 59 grams. Fat, 112 grams. Calories, 1521. On April 21, on the same diet, she excreted 1.1% sugar. The next day her oatmeal was cut to 2 tablespoons, giving her about 10 grams less carbohydrate. No glycosuria. She was discharged April 24, sugar-free on Protein, 63 grams. Carbohydrate, 50 grams. Fat, 112 grams. Calories, 1510. There had never been any diacetic acid in her urine, and only a trace of acetone. She lost about 2 pounds during starvation, but gained part of it back again, so that at the discharge she weighed just a pound less than when she entered the hospital. She has been reporting to the Out-patient Department every two weeks, and has never had any sugar, acetone or diacetic acid in the urine, and appears to be in splendid condition. She is taking just about the same diet as when she left the hospital. A rather mild case, which responded readily to treatment. The question is, can she grow and develop on a diet which will keep her sugar-free? Case 9. M. D., female, age 3-1/2 years, entered April 7, 1915, with a history of having progressively lost weight for a month past, and of having had a tremendous thirst and polyuria. Had been on a general diet at home. At entrance the child was in semi-coma, with very strong sugar, diacetic acid and acetone reactions in the urine. For the first 12 hours she was put on a milk diet, with soda bicarbonate gr. xxx every two hours, and the next day was starved, with whiskey 1 drachm every 2 hours, and soda bicarbonate, both by mouth and rectum. She died after one day of starvation. This is hardly a fair test case of the starvation treatment, as the child was already in coma and almost moribund when she entered the hospital. When a diabetic, old or young, goes into coma, he rarely comes out of it, no matter what the treatment is. Case 10. H. S., male, 6 years, entered April 29, 1915. Duration of his diabetes uncertain; not discovered until day of entrance. An emaciated, frail looking boy. He would eat very little at first, and on ward diet, containing 31 grams of protein, 73 grams of carbohydrate, and 20 grams of fat, he excreted 5.7% of sugar, with a moderate amount of acetone, and a very slight trace of diacetic acid. May 2 he was starved, taking 1-1/2 ounces of whiskey. One day of starvation was enough to make him sugar-free. His diet was gradually raised, until on May 7 he was taking 32 grams protein, 33 grams carbohydrate, and 75 grams fat, and was sugar-free, with absent diacetic acid and acetone. May 9 his carbohydrate intake was raised to 45 grams and he excreted .40% sugar. May 10 it was cut to 40 grams, and he excreted 2.2% sugar. May 11 it was cut to 20 grams, and he became sugar-free and remained so until June 8, when he was discharged, taking the following diet: String beans, 3 tablespoonfuls. Spinach, 4 tablespoonfuls. Bacon, 4 slices. Butter, 2 ounces. Eggs, 3. Bread, 1/2 slice. Cereal, 2 tablespoonfuls. Meat, 3 ounces. Protein, 63 grams. Carbohydrate, 31 grams. Fat, 113 grams. Calories, 1402. For the first few days after entrance he showed a moderate amount of acetone and a slight amount of diacetic acid in the urine; for the rest of his stay in the hospital these were absent. His weight at entrance was 31-1/2 pounds; he lost no weight during starvation, and weighed 32-1/2 pounds on discharge. He was kept on approximately the same diet, and was followed in the Out-patient Department, and on two occasions only did his urine contain a small trace of sugar and of acetone (July 31 and Oct. 16, 1915). Nov. 9 his mother brought him in, saying he had lost his appetite, which had previously been good. The appearance of the boy was not greatly different than it had been all along, but his mother was advised to have him enter the wards immediately, so that he could be watched carefully for a few days. She refused to leave him, but said she would bring him in to stay the next day. She took him home, and he suddenly went into coma and died that night. This was a most unfortunate ending to what seemed to be a very satisfactory case. The boy's mother was an extremely careful and intelligent woman, and it is certain that all directions as to diet were carried out faithfully. He had never shown any evidence of a severe acidosis, but he must have developed one very suddenly. Case 11. V. D., 11 years, female, was admitted to the Children's Hospital Nov. 3, 1915. She had had diabetes for at least a year. On house diet, containing about 90 grams of carbohydrate, she excreted 6.9% of sugar, with moderate acetone and diacetic acid reactions in the urine. Starting Nov. 5, she was starved 3 days. The first day of starvation the sugar dropped to 3.5%, the second day to 1.1%, and the third day she was sugar-free with a little more acetone in the urine than had been present before, but not quite so much diacetic acid. From then her diet was raised as follows: Nov. 8. Protein, 9 grams. Carbohydrate, 20 grams. Fat, 9 grams. No glycosuria. Calories, 200. Nov. 9. Protein, 7 grams. Carbohydrate, 15 grams. Fat, 35 grams. No glycosuria. Calories, 415. Nov. 10. Protein, 17 grams. Carbohydrate, 15 grams. Fat, 55 grams. No glycosuria. Calories, 625. Nov. 11. Protein, 38 grams. Carbohydrate, 20 grams. No glycosuria. Fat, 88 grams. Calories, 1055. Nov. 13 two tablespoonfuls of oatmeal were added to her diet, making the carbohydrate intake about 30 grams. This day she showed .6% sugar. She was starved for half a day and became sugar-free again. On Nov. 16 she was taking protein 40, carbohydrate 20, fat 90, calories 1080, and had no glycosuria. Nov. 17 her diet was protein 43, carbohydrate 25, fat 140, calories 1538, and on this diet she showed .5% sugar. The carbohydrate was cut to 15 grams, and kept at this level for 3 days, but she still continued to excrete a trace of sugar, and so on Nov. 21 she was starved again, immediately becoming sugar-free. From this her diet was raised, until on discharge, Nov. 30, she was taking: protein 48, carbohydrate 15, fat 110, calories 1280, and was sugar-free, having been so for 9 days. At entrance she weighed 56 pounds, at discharge 54, and lost 4 pounds during starvation, part of which she gained back again. On the diet which she was taking at discharge, she was just about holding her weight. She never excreted much acetone or diacetic acid, and when she was discharged there was merely the faintest traces of these in the urine. It is not well to raise the diet quite so rapidly as was done in this case, but for special reasons she had to leave the hospital as soon as possible, and so her diets were pushed up a little faster than would ordinarily be the case. Below is a graphic chart, such as we use in recording our cases. It has been split up into several pieces here on account of its size: CASE 8. EXAMINATION OF THE URINE. Directions for Collecting Twenty-four Hour Urine. Pass the urine at 7 a.m. and throw it away. Save all the urine passed after this up to 7 a.m. the next day. Pass the urine exactly at 7 a.m., and add it to what has previously been passed. Qualitative Sugar Tests. (1) Fehling's Test:—Boil about 4 c.c. of Fehling's[1] solution in a test tube, and add to the hot Fehling's an equal amount of urine, a few drops at a time, boiling after each addition. A yellow or red precipitate indicates sugar. For practical purposes in the following of a diabetic's daily urine, this is a valuable test, and the one which we always use. (2) Benedict's Test:—To 5 c.c. of Benedict's[2] reagent add 8 drops of the urine to be examined. The fluid is boiled from 1 to 2 minutes and then allowed to cool of itself. If dextrose is present there results a red, yellow, or green precipitate, depending upon the amount of sugar present. If no sugar is present the solution may remain perfectly clear or be slightly turbid, due to precipitated urates. This is a more delicate test than Fehling's. Fehling's solution is prepared as follows: (a) Copper sulphate solution: 84.65 gm. of copper sulphate dissolved in water and made up to 500 c.c. (b) Alkaline tartrate solution: 125 gm. of potassium hydroxide and 178 gm. of Rochelle salt dissolved in water and made up to 500 c.c. These solutions are kept in separate bottles and mixed in equal volumes when ready for use. Benedict's solution has the following composition: Copper sulphate, 17.8 gm. Sodium citrate, 178.0 gm. Sodium carbonate (anhydrous), 100 gm. Distilled water to 1000 c.c. Quantitative Sugar Tests. (1) The Fermentation Test:—The fermentation test is the simplest quantitative test for sugar, and is quite accurate enough for clinical work. It is performed as follows: The specific gravity of the 24° urine is taken, and 100 c.c. of it put into a flask, and a quarter of a yeast cake crumbled up and added to it. The flask is then put in a warm place (at about body temperature) and allowed to remain over night. The next morning a sample of the fermented urine is tested for sugar. If no sugar is present the urine is made up to 100 c.c. (to allow for the water that has evaporated) and the specific gravity taken again. The number of points loss in specific gravity is multiplied by .23, and this gives the percentage of sugar in the urine. (2) Benedict's Test:—The best quantitative test for dextrose (excepting polariscopic examination, which is too complicated for ordinary work) is Benedict's test. It is performed as follows: Measure with a pipette 25 c.c. of Benedict's solution into a porcelain dish, add 5 or 10 gm. (approximately) of solid sodic carbonate, heat to boiling, and while boiling, run in the urine until a white precipitate forms. Then add the urine more slowly until the last trace of blue disappears. The urine should be diluted so that not less than 10 c.c. will be required to give the amount of sugar which the 25 c.c. of reagent is capable of oxidizing. Calculation: 5, divided by the number of c.c. of urine run in, equals the per cent. of sugar. Benedict's quantitative solution is prepared as follows: Dissolve 9.0 gm. of copper sulphate in 100 c.c. distilled water. (The copper sulphate must be weighed very accurately.) Dissolve 50 gm. anhydrous sodic carbonate, 100 gm. sodic [1] [2] citrate, and 65 gm. of potassium sulpho cyanate in 250 c.c. of distilled water. Pour the copper solution slowly into the alkaline citrate solution. Then pour the mixed solution into the flask without loss, and make up to 500 c.c.; 25 c.c. of this solution is reduced by 50 mgm. of dextrose, 52 mgm. of levulose or 67 mgm. of lactose. (3) Acetone Test:—To 5 c.c. of urine in a test tube add a crystal of sodium nitro prusside. Acidify with glacial acetic acid, shake a moment, and then make alkaline with ammonium hydrate. A purple color indicates acetone. (4) Diacetic Acid Test:—To 5 c.c. of urine in a test tube add an excess of a 10% solution of Ferric chloride. A Burgundy red color indicates diacetic acid. Quantitative Test for Ammonia. To 25 c.c. of urine add 5 c.c. of a saturated solution of potassium oxalate and 2 to 3 drops of phenolphthalein. Run in from a burette decinormal sodic hydrate, to a faint pink color. Then add 5 c.c. of formalin (40% commercial) and again titrate to the same color. Each c.c. of the decinormal alkali used in this last titration equals 1 c.c. of n/10 ammonia, or .0017 gm. of ammonia. Multiply this by the number of c.c. n/10 sodic hydrate used in the last titration; this gives the number of grams of ammonia in 25 c.c. urine. Note:—The potassium oxalate and the formalin must both be neutral to phenolphthalein. 1 kilogram = 2.2 pounds. 1 calorie = The amount of heat necessary to raise the temperature of 1 kilogram of water 1 degree Centigrade. 1 gram fat = 9.3 calories. 1 gram protein = 4.1 calories. 1 gram carbohydrate = 4.1 calories. DIETS. In the diet tables following, the vegetables listed, excepting lettuce, cucumbers, celery, and raw tomatoes, are boiled. In the very low carbohydrate diets they are thrice boiled. When possible to obtain the figures, the analyses for boiled vegetables have been used. It has been estimated that four-tenths of the carbohydrate will go into solution when such vegetables as carrots and cabbage are cut into small pieces, and thoroughly boiled, with changes of water. It must be remembered that bacon loses about half its fat content when moderately cooked. A number of more or less palatable breads may be made for diabetics, but the majority of the so-called "gluten" and "diabetic flours" are gross frauds, often containing as much as fifty or sixty per cent. carbohydrate. Gluten flour is made by washing away the starch from wheat flour, leaving a residue which is rich in the vegetable protein gluten, so it must be remembered that if it is desired to greatly restrict the protein intake, any gluten flour, even if it contains only a small percentage of carbohydrate, must be used with caution. The report of 1913, Connecticut Agricultural Experiment Station, Part I, Section 1, "Diabetic Foods", gives a most valuable compilation of analyses of food products for diabetics. We have found some use for soya meal, casoid flour and Lyster's flour, "akoll" biscuits, and "proto-puffs," but generally the high protein content of all of these foods interferes with giving any large quantity of them to a severe diabetic over a long period of time. The flours mentioned below we know to be reliable. Some recipes which we have found useful are given below. The use of bran is meant to dilute the protein, increase the bulk, and incidentally to aid in preventing or correcting constipation. BRAN AND LYSTER FLOUR MUFFINS.[3] 2 level tablespoons lard 2 eggs 4 tablespoons heavy cream, 40% fat 2 cups washed bran 1 package Lyster flour 1/2 cup water or less Tie dry bran in cheesecloth and soak 1 hour. Wash, by squeezing water through and through, change water several times. Wring dry. Separate eggs and beat thoroughly. Add to the egg yolks the melted lard, cream and 2 beaten egg whites. Add the Lyster flour, washed bran and water. Make eighteen muffins. Total food value: Protein 99 grams, fat 68 grams, carbohydrate 2 grams, calories 1049. One muffin = protein 5 grams, fat 4 grams, carbohydrate, trace, calories 58. Lyster's Diabetic Flour prepared by Lyster Brothers, Andover, Mass. BRAN CAKES. 2 cups wheat bran 2 tablespoons melted butter 2 whole eggs 1 egg white 1/2 teaspoon salt 1/2 grain saccharine Tie bran in a piece of cheesecloth and soak for one hour. Wash by squeezing water through and through. Change water several times. Wring dry. Dissolve saccharine in one-half teaspoon water. Beat the whole eggs. Mix the bran, beaten eggs, melted butter, and saccharine together. Whip the remaining egg white and fold in at the last. Form into small cakes, using a knife and a tablespoon. Bake on a greased baking sheet until golden brown. This mixture will make about 25 small cakes. One cake represents 16 calories. A sample cake made by this recipe was analyzed and found to contain neither starch nor sugar. SOYA MEAL AND BRAN MUFFINS.[4] 1 ounce (30 grams) soya meal 1 level tablespoon (15 grams) butter 1 ounce (30 c.c.) 40% cream 1 cup of washed bran (see method given elsewhere) 1 egg white 1 whole egg may be substituted for 1 egg white 1/4 teaspoon salt 1-1/2 teaspoons baking powder Mix soya meal, salt and baking powder. Add to the washed bran. Add melted butter and cream. Beat egg white and fold into mixture. Add enough water to make a very thick drop batter. Bake in six well-greased muffin tins until golden brown—from fifteen to twenty-five minutes. Total food value: Protein, 11 grams, Fat, 27 grams. Carbohydrate, 2 grams. Calories, 304. One muffin = protein, 2 grams; fat, 4.5 grams. Carbohydrate, trace. Calories, 50. Soya Bean Meal, Theodore Metcalf Co., Boston, Mass. CASOID FLOUR AND BRAN MUFFINS.[5] 1 ounce (30 grams) Casoid flour 1 level tablespoon (15 grams) butter 1 ounce (30 c.c.) 40% cream 1 egg white 1 whole egg may be substituted for 1 egg white 1/4 teaspoon salt 1-1/2 teaspoons baking powder 1 cup washed bran Method as in previous rule. Bake in six muffin tins. Total food value: Protein, 18 grams. Fat, 24 grams. [3] [4]