The Starvation Treatment of Diabetes, Lewis Webb Hill [iphone ebook reader .TXT] 📗
- Author: Lewis Webb Hill
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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:
Whiskey, 1-1/2 ounces.
Protein, 5 grams.
Carbohydrate, 12 grams.
Fat, 7 grams. No glycosuria.
Calories, 213.
Whiskey, 1-1/2 ounces.
Protein, 26 grams.
Carbohydrate, 18 grams.
Fat, 46 grams. No glycosuria.
Calories, 768.
Whiskey, 1-1/2 ounces.
Protein, 45 grams.
Carbohydrate, 22 grams.
Fat, 72 grams. No glycosuria.
Calories, 1050.
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:
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,
Carbohydrate, 63 grams.
Fat, 113 grams.
Calories, 1546.
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:
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
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:
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:
Protein, 9 grams.
Carbohydrate, 20 grams.
Fat, 9 grams. No glycosuria.
Calories, 200.
Protein, 7 grams.
Carbohydrate, 15 grams.
Fat, 35 grams. No glycosuria.
Calories, 415.
Protein, 17 grams.
Carbohydrate, 15 grams.
Fat, 55 grams. No glycosuria.
Calories, 625.
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
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