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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