Chapter 2

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?

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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.

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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:

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.