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.