Rena Sarah Eckman

“ 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. ”

“ 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. ”

“ 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 ”

“ Patients who are instructed how to feed themselves on leaving the hospital are cautioned carefully to take about the quantity of an article of food they have been served while in the hospital when the diet is weighed. Any written advice is always given in quantities known to be under the carbohydrate or protein tolerance of the patient. However, if they will boil the vegetables and change the water at least twice, so much carbohydrate is removed that it is quite possible for them to obtain a comfortable bulk and still take in very small quantities of carbohydrate. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ Remove yolk, mash, moisten with cream, French or mayonnaise dressing, shape in balls, refill whites, and serve on lettuce leaves. Garnish with thin slices of radish, and a radish so cut as to represent a tulip.
EGG SALAD.
Prepare egg same as for Egg Salad I, adding to yolk an equal amount of chopped cooked chicken or veal.
EGG AND CHEESE SALAD.
Prepare egg same as for Egg Salad I, adding to yolk three-fourths tablespoon grated cheese; season with salt, cayenne and a few grains of mustard; then moisten with vinegar and melted butter. Serve with or without salad dressing. ”

“ Cucumber Sauce.—Pare one-fourth cucumber; chop, drain, and add French dressing to taste.
ASPARAGUS SALAD.
Drain and rinse four stalks of canned asparagus. Cut a ring one-third inch wide from a red pepper. Put asparagus stalks through ring, arrange on lettuce leaves, and pour over French dressing. ”

“ Beat one egg slightly, add one-fourth cup cold water, two tablespoons heavy cream, one tablespoon melted butter, one tablespoon grated cheese and a few grains salt. Turn into an individual mould, set in pan of hot water, and bake until firm. ”

“ Fill basket with cold cooked string beans cut in small pieces and two halves of English walnut meats cut in pieces, moistened with French dressing. Serve on lettuce leaf.
TOMATO AND CHIVE SALAD.
Remove skin from small tomato. Chill and cut in halves crosswise. Spread with mayonnaise, sprinkle with finely chopped chives, and serve on lettuce leaf.
CANARY SALAD.
Cut a slice from the stem end of a bright red apple and scoop out pulp, leaving enough to keep shell in shape. Fill shell thus made with grapefruit pulp and finely chopped celery, using twice as much grapefruit as celery. ”

“ Fill basket thus made with one tablespoon cold cooked chicken or sweet bread cut in small dice, mixed with one-half tablespoon small cucumber dice, and one teaspoon finely chopped celery moistened with cream or mayonnaise dressing. Spread top with dressing and sprinkle with thin parings cut from round red radishes finely chopped. Insert a small piece of parsley on top of handle. ”

“ It is not true that all the vegetables weigh the same, but for the sake of simplicity in most of the diets it has been reckoned that two heaping tablespoons of any one of the "5%" vegetables weighs 100 gms. ”

“ 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. ”

“ Fractions of per cents. have been left off in order to make the use of the table more simple, and the values given will be found quite accurate enough for clinical purposes.
The values for all the vegetables are calculated from the raw vegetables.
ADDITIONAL DATA.
All of these values are approximate. ”

“ 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. ”