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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
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:
[Illustration: Case 8. A chart tracking Urine and Calorie Intake for
the month of April.]
[Illustration: A chart tracking Carbohydrate and Protein Intake for
the month of April.]
[Illustration: A chart tracking per cent. of sugar for the month of
April.]
[Illustration: A chart tracking sugar output for the month of April.]
[Illustration: A chart tracking ammonia for the month of April.]
[Illustration: A chart tracking acetone and diacetic acid for the month
of April.]
[Illustration: A chart tracking weight in pounds for the month of
April.]
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.
[1] 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.
[2] 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 deg.
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 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.
[3] 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.
[4] 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.
Carbohydrate, 1 gram. Calories, 300.
One muffin = Protein, 3 grams. Fat, 4 grams.
Carbohydrate + Calories, 50.
[5] Casoid Diabetic Flour. Thos. Leeming & Co., Importers,
New York City.
LYSTER FLOUR AND BRAN MUFFINS[6]
1 ounce (30 grams) Lyster 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
1/8 teaspoon salt
1 teaspoon baking powder
1 cup washed bran
Method as in previous recipe. Bake in six muffin tins.
Total food value:
Protein, 18 grams. Fat, 25 grams.
Carbohydrate, 1 gram. Calories, 310.
One muffin = Protein, 3 grams. Fat, 4 grams.
Carbohydrate, trace. Calories, 50.
In order to guard against a monotonous diet, some recipes for special
dishes suitable for diabetics are given, most of which can be used in
the diets of moderate caloric value. They are taken from "Food and
Cookery for the Sick and Convalescent" by Fannie Merritt Farmer.
[6] Lyster's Diabetic Flour prepared by Lyster Brothers. Andover,
Mass. Barker's Gluten Flour, Herman Barker, Somerville, Mass.
Note.--In the three preceding recipes one whole egg may be
substituted for one egg white. The food value will be slightly
increased but the texture of the finished article is improved.
RECIPES.
BUTTERED EGG.
Put one teaspoon butter into a small omelet pan. As soon as the butter
is melted break one egg into a cup and slip into the pan. Sprinkle
with salt and pepper and cook until white is firm, turning once
during the cooking. Care must be taken not to break the yolk.
EGGS AU BEURRE NOIR.
Put one teaspoon butter into a small omelet pan. As soon as butter is
melted, break one egg into a cup and slip into the pan. Sprinkle with
salt and pepper and cook until white is firm, turning once during the
cooking. Care must be taken not to break the yolk. Remove to hot
serving dish. In same pan melt one-half tablespoon butter and cook
until brown, then add one-fourth teaspoon vinegar. Pour over egg.
EGG A LA SUISSE.
Heat a small omelet pan and place in it a buttered muffin ring. Put in
one-fourth teaspoon butter, and when melted add one tablespoon cream.
Break an egg into a cup, slip it into muffin ring, and cook until
white is set, then remove ring and put cream by teaspoonfuls over the
egg until the cooking is accomplished. When nearly done sprinkle with
salt, pepper, and one-half tablespoon grated cheese. Remove egg to hot
serving dish and pour over cream remaining in pan.
DROPPED EGG.
Butter a muffin ring, and put it in an iron frying-pan of hot water to
which one-half tablespoon salt has been added. Break egg into saucer,
then slip into ring allowing water to cover egg. Cover and set on back
of range. Let stand until egg white is of jelly-like consistency. Take
up ring and egg, using a buttered griddle-cake turner, place on
serving dish. Remove ring and garnish egg with parsley.
DROPPED EGG WITH TOMATO PUREE.
Serve a dropped egg with one tablespoon tomato puree. For tomato
puree, stew and strain tomatoes, then let simmer until reduced to a
thick consistency, and season with salt and pepper and a few drops
vinegar. A grating of horseradish root may be added.
EGG FARCI I.
Cut one "hard boiled" egg into halves crosswise. Remove yolk and rub
through a sieve. Clean one-half of a chicken's liver, finely chop and
saute in just enough butter to prevent burning. While cooking add a
few drops of onion juice. Add to egg yolk, season with salt, pepper,
and one-fourth teaspoon finely chopped parsley. Refill whites with
mixture, cover with grated cheese, bake until cheese melts. Serve with
one tablespoon tomato puree.
EGG FARCI II.
Prepare one egg as for Egg Farci I. Add to yolk one-half tablespoon
grated cheese, one-fourth teaspoon vinegar, few grains mustard, and
salt and cayenne to taste; then add enough melted butter to make of
right consistency to shape. Make into balls the size of the original
yolks and refill whites. Arrange on serving-dish, place in a pan of
hot water, cover, and let stand until thoroughly heated. Insert a
small piece of parsley in each yolk.
BAKED EGG IN TOMATO.
Cut a slice from stem end of a medium-sized tomato, and scoop out
pulp. Slip an egg into cavity thus made, sprinkle with salt and
pepper, replace cover, put in a small baking pan, and bake until egg
is firm.
STEAMED EGG.
Spread an individual earthen mould generously with butter. Season two
tablespoons chopped cooked chicken, veal, or lamb, with one-fourth
teaspoon salt and a few grains pepper. Line buttered mould with meat
and slip in one egg. Cook in a moderate oven until egg is firm. Turn
from mould and garnish with parsley.
CHICKEN SOUP WITH BEEF EXTRACT.
1/2 cup chicken stock
1/2 teaspoon Sauterne
1/8 teaspoon beef extract
1-1/2 tablespoons cream
Salt and pepper
Heat stock to boiling point and add remaining ingredients.
CHICKEN SOUP WITH EGG CUSTARD.
Serve Chicken Soup with Egg Custard.
Egg Custard.--Beat yolk of one egg slightly, add one-half tablespoon,
each, cream and water, and season with salt. Pour into a small
buttered tin mould, place in pan of hot water, and bake until firm;
cool, remove from mould, cut into fancy shapes.
CHICKEN SOUP WITH EGG BALLS I OR II.
Egg Balls I.--Rub yolk of one hard boiled egg through a sieve, season
with salt and pepper, and add enough raw egg yolk to make of right
consistency to shape. Form into small balls, and poach in soup.
Egg Balls II.--Rub one-half yolk of hard boiled egg through a sieve,
add one-half of a hard boiled egg white finely chopped. Season with
salt and moisten with yolk of raw egg until of right consistency to
shape. Form and poach same as Egg Balls I.
CHICKEN SOUP WITH ROYAL CUSTARD.
Serve Chicken Soup with Royal Custard.
Royal Custard.--Beat yolk of one egg slightly, add two tablespoons
chicken stock, season with salt and pepper, turn into a small buttered
mould, and bake in a pan of hot water until firm. Cool, remove from
mould, and cut into small cubes or fancy shapes.
ONION SOUP.
Cook one-half large onion, thinly sliced, in one tablespoon butter
eight minutes. Add three-fourths cup chicken stock, and let simmer
twenty minutes. Rub through a sieve, add two tablespoons cream, and
yolk one-half egg beaten slightly. Season with salt and pepper.
ASPARAGUS SOUP.
12 stalks asparagus, or
1/3 cup canned asparagus tips
2/3 cup chicken stock
1/4 slice onion.
Yolk one egg
1 tablespoon heavy cream
1/8 teaspoon salt
Few grains pepper
Cover asparagus with cold water, bring to boiling point, drain, and
add stock and onion; let simmer eight minutes, rub through a sieve,
reheat, add cream, egg and seasonings. Strain and serve.
TOMATO BISQUE.