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Neumann, R. O., Vrtljschr. gerichll. Med., 3rd edition, li, pt. ii, (unfavorable).



162 CHAPTER II

with composite recipes, carbohydrate-free puddings, saccharine sweet-
ening, imitation milk, and a host of similar artifices. The most con-
venient way to manage such a diet accurately is to weigh out the
day's allowance of eggs, fat, etc., in the morning and use for cooking
the different meals as required. It may be urged that habits of food
are hard to break, and that a diabetic should not be deprived of
gustatory pleasure xmnecessarily. It may be objected on the other
hand that such diets tantalize and tempt more than they satisfy;
that saccharine keeps aUve the taste for sugar, that the liabiUty to
carelessness is increased, and that a patient does best to face squarely
the fact of his diabetes and the necessary restrictions, and to resolve
to eat to hve rather than Uve to eat, especially since care in diet is the
means whereby all the other pleasures and advantages of the world
are opened to him in fullest measure.

It is generally beheved that the plainest and simplest diets are the
most wholesome for mankind in general. It has therefore been consid-
ered inadvisable to take such great pains to depart from such a diet
for diabetics. Not only is simpHcity highly important for accuracy,
fidehty, convenience, economy, and healthful habits, but in the long
run the simple diet has proved the most satisfying and the least irk-
some. The patient begins such a Spartan regime immediately after
his initial fast in the hospital, when anything tastes good, and by the
time he leaves the hospital his new habit of diet is estabhshed. With
simple menus and a balanced ration, diabetics are free from abnormal
cravings, and natural himger on reduced diets is also easier to appease.

Simplicity does not mean unpleasantness to sight or taste. Here the
skill of the diet nurse or cook comes into play. The refinement of
the table service, even though not expensive, has its esthetic value.
Salads and other simple dishes can be made attractive in appearance.
A single egg can loom surprisingly large to the eye if beaten into a
fluffy omelette or souffle. Variety in cooking and combining the
same foods varies them to the taste. Vegetables offer variety in soups,
and the different ways of serving meat are well known. Eggs, bacon
grease, meat, or the juice from meat give variety and taste to thrice
cooked vegetables, and even to bran muffins. There is no inherent
objection to condiments or spices, but these, except salt, have been
little used, since the diabetic appetite generally needs no stimulation,



GENERAL PLAN OF TEEATMENT 163

and the simple taste of plain foods is sufl&ciently appreciated. Coffee
lovers generally learn readily to like their drink black, without sac-
charine. A little fruit is a sufficient dessert in most cases. The de-
sire for cake, puddings, and other luxuries is discouraged by disuse.
Exceptions have been made only in some extremely severe cases on
minimal diets, since small treats mean so much to these patients.
Agar jelly, ices, sherbets, etc., can be flavored with saccharine, coffee,
wine, brandy, fruit juices, or sugar-free caramel (the quantities re-
quired being very small). Likewise agar with soup or beef extract
makes an agreeable meat jelly. Such tricks often eke out a low diet
or reheve a hard fast-day in the worst cases; but the better fed class
of patients do not need them.

The physician who cannot calculate diets to suit his individual cases,
but is dependent upon text-book menus, will not be able to substi-
tute celery or spinach when one or the other is disliked, and will oc-
casionally meet patients who know more about diets than he. Any-
body who has a list of food values and can use the decimal system can
easily make up the simple diets required by diabetics. The unwise
complexity of dishes in the past has doubtless been largely respon-
sible for the unfortunate helplessness of so many physicians in this
regard. The use of the metric system is not a difficulty but a great
convenience, and it can be learned in a few minutes by those un-
accustomed to it. Though the energy value of carbohydrate and pro-
tein is 4.1 calories per gm., and of fat 9.3 calories per gm., it is suffi-
ciently accurate for ordinary purposes to reckon them as 4 and 9
calories respectively.^^ One elementary example should make the
method clear. .

Suppose that a patient's weight is 50 kilograms, that his tolerance
in the carbohydrate test was 180 gm., and that he is to be given a
mixed diet containing one-sixth of this maximal carbohydrate toler-
ance, together with 1.5 gm. protein and 30 calories per kilogram.

^^Food chemists are well aware of the technical considerations which make
absolute exactness impossible in the ordinary reckoning of a diet. A practical
point is that the number of calories obtained by multiplying the total grams of
protein, carbohydrate, and fat by the proper factors, and the number found by
adding up the calories given in food tables for the individual meats, vegetables,
and other foods served, are seldom identical. Either method is permissible.



164



CHAPTER n



One-sixth of the carbohydrate tolerance of 180 gm. is 30 gm. Any
desired vegetables are selected from food tables to make up this total
of 30 gm. for the day, and divided between the meals at will. The
protein, fat, and calories in the vegetables chosen must be reckoned,
which will give a result such as shown in Table VI.



TABLE VI.










Food.


Carbohy-
drate.


Protein.


Fat.




Breakfast.

Canned asparagus


gm.
150

50

37
148
142

50

150

86


gm.

4.2

1.7
1.1

5.0

5.5

1.7
5.9
5.0


gm.
2.3

0.7
0.5

2.2

1.1

0.7
1.2
1.4


gm.

0.2

0.2

0.1
0.5

0.2
0.6
0.6




Dinner.

Lettuce




Celery




Canned Brussels sprouts




Raw tomato




Supper.

Lettuce




Raw tomato




Cauliflower








Gm


30.0
120.0


10.0
41.0


2.4
22.3




Calories


18"?







TABLE VII.



Food.


Protein.


Fat.




Breakfast.

Eggs


gm.

100
50

57
25

100
50


gm.

14.8
5.0

18.3
6.5

14.8
5.0


gm.

10.6
33.6

2.5
7.9

10.6
33.6




Bacon




Dinner.

Roast chicken




Cream cheese




Supper.

Eggs




Bacon








Gm


64.6
258.0


98.8
899.0




Calories


1157.0





GENERAL PLAN OF TREATMENT



165



Taking up next the protein allowance, this, at l.S gm. per kilogram
for a weight of SO kilograms, will amount to 75 gm. of protein. Since
10.4 gm. of protein is contained in the vegetables already chosen,
this leaves 64.6 gm. yet to be supplied for the day (Table VII).



TABLE


VIII.














Food.


Carbo-
hydrate.


Protein.


Fat.




Bueakfast.

Eess


gm,

100

50

ISO

5

57
10
50
37
148
142
25

100

50

9

50

150
86


cc.

150
150

150
150

150
150


4.2

1.7

1.1

5.0

5.5

1.7
5.9
5.0


gm.

14.8
5.0
2.3

18.3

0.7
0.5
2.2
1.1
6.5

14.8
5.0

0.7
1.2
1.4


gm.

10.6

33.6

0.2

4.1

2.5
8.2
0.2

0.1

0.5
7.9

10.6
33.6
7.4
0.2
0.6
0.6




Bacon




Canned asparagus




Butter




Bran biscuits (2)




Coffee




Clear soup




Dinner.

Roast chicken




Butter .




Lettuce




Celery




Canned Brussels sprouts




Raw tomato




Cream cheese




Bran biscuits (2)




Kaffee Hag.




Clear soup




Supper.

Eggs




Bacon




Butter . .




Letituce




Raw tomato




Cauliflower




Bran biscuits (2)




Kaffee Hag




Clear soup








Gm


30.0
120.0


75.0
300.0


120.6
1085.0






1505







A ration of 30 calories per kilogram for a weight of 50 kilograms
means 1500 calories for the day. Since the foods chosen for carbo-
hydrate and those chosen for protein together represent 180+1157 =



166



CHAPTER n



1337 calories, this leaves 163 calories yet to be supplied in the fonn of
fat. It is now necessary to divide the 163 calories by 9, thus showing
18 gm. as the quantity of fat needed. This could be supplied by 18
gm. of olive oil, or 24 gm. of butter, or the equivalent in any other
fat. The total diet for the day is shown in Table VIII.

The specimen diets in Tables IX to XV are given as suggestions.
In them, the factors 4.1 and 9.3 are used, as customary in this
hospital.



TABLE rx.

Carbohydrate Tolerance Test.

A Day's Diet with 30 Gm. Carbohydrate.



Food.



Breakfast.

Canned asparagus

Coffee

Clear soup

Dinner.

Lettuce

Celery

Canned Brussels sprouts.

Canned okra

Clear soup

Kaffee Hag.

Supper.

Lettuce

Raw tomato

Spinach

Canned okra

Clear soup

Kaffee Hag.



m

Calories.



ISO



25

75

150

65



25
ISO
200

66



150
150



150
150



150
150



FFotein.



2.3



0.4
1.0
2.2
0.4



0.4
1.2
4.2
0.5



12.5
51.0



Fat.



0.2



0.1
0.1

o:o5



0.1
0.6
1.0
0.05



2.2
20.0



Carbo-
hydrate.



4.2



0.9
2.2
5.1
2.3



0.9
5.9
6.2
2.4



30.0
123.0



194



GENERAL PLAN OF TREATMENT



167



TABLE X.

Carbohydrate Tolerance Test.
A Day's Diet with 100 Gm. Carbohydrate.



Food.



Breakfast.

Canned asparagus..

Beets

Celery

Clear soup

Coffee

Dinner.

Lettuce

Raw tomato

Carrots

Cabbage

Clear soup

Canned okra

Celery

Kaffee Hag

Supper.

Lettuce

Celery.

Turnips

Clear soup

Canned okra

Raw tomato

KaSee Hag



gm.

ISO

208

SO



100
203
218
172

90
SO



SO
100
230

90

S4



ISO
ISO



150



ISO



ISO



150



Gm

Calories.



Protein.



gm.

2.3
3.2
0.7



1.3

1.6

2.3
3.5

0.7
0.6



1.5
1.4
3.2

0.6
0.4



23.3
95.5



Fat.



Carbo-
hydrate.



gm.

0.2
0.2
0.05



0.4
0.8
0.8
0.6

0.1
0.05



0.2
0.1
0.4

0.1
0.2



4.3
45.6



gm.

4.2

20.0

1.5



3.3

7.9

20.0

10.0

3.2
1.5



1.7

3.0

20.0

3.2
2.1



101.6
416.6



557.7



168



CHAPTER n



TABLE XI.

Carbohydrate Tolerance Test.
A Day's Diet with 250 Gm. Carbohydrate.



Food.



Breakfast.

Orange

Canned peas

Carrots

Rice

Coffee

Clear soup

Dinner.

Grapefruit

Lettuce

Canned asparagus..

Potato

Canned lima beans.

Turnips

Kaffee Hag

Clear soup

Supper.

Apple

Lettuce

Raw tomato

Parsnips

Onions

Kaffee Hag

Clear soup



104

204

218

39



200
100
ISO
168
205
230



120
100
64
122
303



150
150



150
150



150
150



Gm

Calories .



Protein,



gm.

0.8

7.2
2.3
3.0



1.3
2.3
2.0
8.2
3.2



0.6i
1.3
0.5
2.0
5.1



Fat.



39.8
159.1



gm.

0.6
0.4
0.8
0.1



0.4
0.2
0.1
0.6
0.4



0.6
0.4
0.2
0.6
1.2



6.6
61.4



Carbo-
hydrate.



gm.

10.0
20.0
20.0
30.0



10.0
3.3
4.2
30.0
30.0
20.0



20.0

3.3

2.5

19.6

30.0



252.9
1025.0



1246



GENERAL PLAN OF TREATMENT



169



TABLE XII.
Exclusive Protein Diet, as Sometimes Used for Bringing Down Blood Sugar.



Food.



Breakfast.

Egg white

Celery T.C.*

Spinach "

Coffee

Clear soup

Bran biscuits (2)

Dinner.

Flounder

Sauerkraut T. C

Brussels sprouts T. C.

Bran biscuits (2)

Coffee.

Soup

Supper.

Roast chicken

CauHflowerT. C

Asparagus "

Bran biscuits (2)

Kaffee Hag

Soup



Gm

Calories.



gm.

162
200
100



216
200
200



78
200
100



150
ISO



150
150



150
150



Protein.



20.0



30.0



25.



75.0
307.0



Fat



0.3



1.2



3.4



4.9
45.0



352



' T. C. indicates thrice cooked.



170



CHAPTER n



TABLE Xni.

Example of a Low Maintetiance Diet for a Case of Extreme Severity; Body Weight

30 to 40 Kilograms.



Food.



Bieakfast.

Eggs

Bacon

Butter.

Celery T.C

Bran biscuits (2).. ,

Coffee

Clear soup

Dinner.

Flounder.

Butter

Lettuce

Raw tomato

Cauliflower T. C. .

Asparagus " . .

Bran biscuits (2)...

KaffeeHag

Clear soup

Sup per.

Eggs

Cream cheese

Butter.

Lettuce

Canned asparagus..

Spinach T.C

Cabbage "

Bran biscuits (2) . .

Kaffee Hag

Clear soup



Gm

Calories.



gm.

100

50

7

200



72

7

25

34

200

200



100

13

7

25

71

200

200



150
150



Protein.



150
150



150
150



14.9
5.0



10.0

0.4
0.2



14.9
3.3

0.4
1.0



50.1
205.0



Fat.



gm.

10.6

33.6

5.8



0.4
5.8
0.1
0.1



Carbo-
hydrate.



10.6
4.1
5.8
0.1



77.0
716.1



gm.



0.9

1.3



0.9
2.0



5.1
21.0



942



GENERAL PLAN OF TREATMENT



171



TABLE XIV.

Specimen Diet of a Child Aged 3 or 4 Years {Patient No. 73), with Extremely Severe
Diabetes; Weight 9 Kilograms.



Food.



Protein,



Fat.



Carbo-
hydrate,



7:30 a.m.

Egg

Milk

Butter.

Asparagus T. C...

Clear soup.

Bran biscuit (1)

11:00 a.m.

Egg.

Milk

Canned asparagus..

Butter.

Clear soup.

1:00 p.m.

Milk

Butter.

Raw tomato

Clear soup

Bran biscuit (1).. . .
3:00 p.m.

Milk

Clear soup

5:30 p.m.

Egg.

Milk

Butter.

Celery.

Bran biscuit (1)....

Clear soup



SO
25

7
75



50

25

107

6



50

6

60



25



50
25

7
75



100



100



100



100



100



Gm

Calories.



(m.

7.4
0.8



7.4
0.8
1.6



1.6
0.5

0.8



7.4
0.8

1.0



30.1
125.0



gm.

5.3
1.0
5.8



5.3
1.0
0.1
4.9



2.0
4.9
0.2



1.0



5.3
1.0

5.8



43.6
405.0



1.3



1.3
3.0



2.5
2.3

1.3

1.3

2.2



15.2
62.3



591



172



CHAPTER n



TABLE XV.

Example of a Maintenance Diet, Showing the Substitutions Indicated for Patients Who

Cannot Perform Calculations for Themselves.

Protein 90 gm. Carbohydrate 50 gm. Calories 2000.



Food.


1


i


V

1




Substitutes.




gm.


cc.


gm.


gm.


gm.




Breakfast.
Eggs


100
50
13

ISO

96

20
•25
150

295

100

19

100
SO
20
25
75
323
172
19


ISO
LSO

150
150

ISO
150


14.8
5.0

2.3

22.3

0.4
1.2

4.4
1.6
4.9

14.8
5.0

0.4
1.0
6.7
3.5
4.9


10.6

33.6

10.7

0.2

1.5

16.5
0.1
0.6

0.3
0.8
6.0

10.6

33.6

16.5

0.1

1.6
0.6
6.0


4.2

0.8
5.9

10.0
6.0

0.8

2.2

10.0

10.0






Bacon




Butter




Canned asparagus.
Bran biscuit (2)...
Coffee


Fresh asparagus 124 gm. (in place of canned).


Clear soup

Dinner.

Roast beef

Butter.


Roast chicken 69 gm.less butter 2 gm.

Flounder 160 gm.

Veal 79 gm.

Roast Lamb 113 gm. less butter IS gm.


(in

place of

roast

beef).




Radishes 25 gm. (in place of lettuce).


Raw tomato

Canned Brussels

sprouts

Cauliflower

Cream cheese

Bran biscuits (2) . .

Kaffee Hag

Clear soup

Supper.


Beets 61 gm. (in place of tomato).

Carrots 109 gm. (in place of Brussels sprouts).

Celery 200 gm. (in place of cauliflower).


Bacon




Butter




Lettuce




Celery


Dill pickle 82 gm. (in place of celery).


Spinach


String beans 107 gm. (in place of spinach).


Cabbage


Turnips 115 gm. (in place of cabbage).


Cream cheese

Bran biscuits (2)..

Kaffee Hag

Clear soup


Sauerkraut 228 gm. (in place of cabbage).


Gm


93.2
369.0


149.9
1394.1


50.0
205.0






Calories


1968







ClSRBiGHTDRATE




GENERAL PLAN OF TREATMENT 173

E. Food Tables.

The accompanying graphic charts illustrate a short method for
approximating food values, which can be made both more convenient
and more accurate if enlarged and used for wall charts. The abscissa
represent grams of foodstuffs; the ordinates show both grams and cal-
ories of carbohydrate, protein, and fat respectively. Thus, taking
the number 50 at the bottom of the carbohydrate chart, and follow-
ing the line up to where it cuts the line for sauerkraut, it is seen at a
glance that 50 gm. of sauerkraut contain 2 gm. or 8.2 calories of car-
bohydrate. Conversely, if it is desired to select food containing 5 gm.,
of carbohydrate, one may start at the number 5 on the left of the chart
and by following it across may see that this quantity is represented
in about 51 gm. of onions, about 67 gm. of blackberries, about 100
gm. of either grapefruit or milk, etc. The same method is used in
finding protein and fat values in the other charts.

The food values in Tables XVI to XIX are taken almost entirely
from the tables of Bryant and Atwater, Bulletin 28, Department of
Agriculture, Bureau of Experiment Stations, Washington, D. C. Simi-
lar tables, along with analyses of cooked foods, etc., are given in the
book on "Food Values," by Edwin A. Locke, Appleton and Company,
1914.

Abundant data for diabetic needs are contained in Joslin's text-
book. The list given in Chart 1 and Tables XVI to XIX is not
extensive, but yet contains nearly everything found necessary for
the diets in this hospital. Copies are supplied to patients for
reckoning their diets at home.



174



CHAPTER n



TABLE XVI.

Meat and Fish*



Edible portion.


Protein.


Fat.


Carbohy-
drate.


Meats.


fer cent

10.0
20.5
20.8
22.8
20.2
19.5
19.7
19.1
21.0

18.8
19.0
15.8
13.9
18.3
20.6
20.9
18.6


per cent

67.2

6.4

5.8

1.8

20.8

14.4

19.0

12.4

3.6

0.5
1.2
0.4
0.6
5.2
12.8
3.8
9.5


per cent



Beef sirloin verv lea,ii





" round " "




















" loin . ...





Lamb





Veal





Fresh fish.

Sea bass





Blue fish





Cod, fresh





FlouiMier





Halibut










Shad roe


2.6


" whole :










*Uncooked values.



GElsTERAL PLAN OF TREATMENT



175



TABLE XVII.
Vegetables, in Order of Their Carbohydrate Content from Lowest to Highest.



Edible portion.



*Mushrooms (range 2 to 18 per cent) .

Cucumbers, fresh

Asparagus, canned

Celery, fresh

Spinach "

Asparagus "

Lettuce " !

Brussels sprouts, canned

Rhubarb, fresh

Tomatoes "

" canned

Brussels sprouts, fresh

Sauerkraut

Artichokes, canned.

Leeks

Eggplant, fresh

Pumpkin "

Cucumber pickles

Kohlrabi, fresh

Cabbage

Cauliflower

Radishes

Turnips

Carrots

Beans, string, fresh

Beets, fresh

Peas, green, canned

Onions, fresh

Squash "

Lima beans, canned

Com, green, fresh

Peas " "

Parsnip, fresh

Artichoke "

Potatoes "

Lima beans "



Protein.


Fat.


Carbohy-
drate.


per cent


per cent


per cent


(3.5)


(0.4)


(6.0)


0.8


0.2


2.5


l.S


0.1


2.8


1.4


0.1


3.0


2.1


0.5


3.1


1.8


0.2


3.3


1.3


0.4


3.3


1.5


0.1


3.4


0.6


0.7


3.6


0.8


0.4


3.9


1.2


0.2


4.0


4.7


1.1


4.3


1.5


0.8


4:A


0.8


0.2


5.0


1.2


0.5


5.8


1.2


0.3


5.1


1.0


0.1


5.2


0.5


0.5


5.4


2.0


0.1


5.5


2.1


0.4


5.8


1.6


0.8


6.0


1.4


0.1


6.6


1.4


0.2


8.7


1.4


0.4


9.2


2.2


0.4


9.4


1.6


0.1


9.6


3.6


0.2


9.8


1.7


0.4


9.9


1.6


0.6


10.4


4.0


0.3


14.0


2.8


1.1


14.1


4.4


0.5


16.1


1.7


0.6


16.1


2.6


0.2


16.7


2.1


0.1


18.0


7.1


0.7


22.0



* Wardall, (/. Am. Med. Assn., 1917, kix, 1859-1862) pointed out that the
carbohydrate of ordinary mushrooms is in some non-extractable form, and the
nitrogen according to Mendel's analyses is likewise in non-protein, non-utilizable
compounds. The figures in the above table are therefore placed in parentheses
to indicate their misleading nature. It would appear that ordinary mushrooms
may be reckoned as having no appreciable food value, and that they therefore
mav be a welcome feature of the diabetic diet.



176



CHAPTER II



TABLE XVin.

Fruits, In Order of Their Carbohydrate Content, from Lowest to Highest.



Edible portion.


Protein.


Fat.


Carbohy-
drate.


Grapefruit


per cent

0.3
1.0
0.9
0.6
0.7
0.4
0.8

0.5
1.0
1.0
1.1
0.6
0.5


per cent

0.1
0.1
0.2

0.1
0.3
0.6

0.7
1.0
1.3

0.8
0.5


per cent
5.0


Watermelon.


6.5


Strawberries


6.8


Blackberries


7.5


Muskmelon


9.3


Peaches


9.4


Pineapple


9.7


Orange


9.7


Lemon juice


9.8


Cranberries


10.1


Raspberries


12.6


Grapes


13.3


Apricots


13.4


Pears


14.2


Apples


16.6







TABLE XIX.
Dairy Products.



Edible portion.


Protein.


Fat.


Carbohy-
drate.


Eggs.


per cent
14.9

3.3
3.0
5.97
2.5

37.1
28.2
26.9
25.9
28.8
29.6
23.0
15.4
27.6
15.9
18.7
22.6


per cent

10.6

82.4
4.0
O.S
7.36

18.5

17.7
32.0
31.6
31.7
36.2
38.3
29.4
21.7
34.9
21.0
27.4
29.5


per cent


Butter




Whole milk


5


Buttermilk


4 8


Whiting's milk*




Cream, average


4 5


Cheese.

Dutch




Cheddar




Cheshire




Cream




American, pale




" red




Limburger


4


Boudon


0.7
1 ^


Swiss


Brie


1 4


Neufchatel


1 5


Roquefort


1.8





' D. Whiting and Sons, 570 Rutherford Avenue, Boston. Mass.



CHAPTER III.
Case Records.

Seventy-six cases have been selected for publication, for reasons
stated in Chapter VII. Graphic charts have been chosen as the
clearest and most compact means of presenting the large mass of
clinical and chemical data. With a little attention to the key shown
on all the charts, it is beheved that they will be found simple and
self-explanatory. The curves of ammonia, total acetone, and total
acidity of the urine have been plotted as cubic centimeters of deci-
normal solution, for the sake of chemical calculations and comparisons.
This plan will doubtless prove somewhat confusing to many clinicians,
but the tables and summaries in the case histories express the results
in grams. The written history of each case is supposed to be followed
in conjunction with the graphic chart, and reference from one to the
other will be necessary to make both plain.

Table I is a general summary of the entire series. The data mostly
tell their own story. Further details, of the age incidence, complica-
tions, results of treatment, etc., are shown in Chapter VII. The
etiologic relations are discussed in Chapter VIII.

CASE NO. 1,

Female, unmarried, age 28 yrs. American; no occupation. Admitted Feb.
24, 1914.

Family History. — Grandparents lived to healthy old age. Father living, aged
58, has arterial hjT)ertension, neuralgia, and tendency to melancholia. Mother
died at birth of this patient. An uncle died of tuberculosis. One fuU brother of
patient died at 16 of appendicitis. One half-sister aged 22 has nephritis, conse-
quent upon scarlatina.

Past History. — No childhood diseases except measles and one dysenteric attack.
Normal menstruation began at 13. Patient graduated from university at 20.
She has had a nervous, overactive life with late hours and irregular eating. Was
considered remarkable among her family and friends for the amount of candy
and sweets she consumed. Normal weight 115 to 120 pounds. July, 1912, pa-
tient's fianc6 died of accidental poisoning. Patient became melancholic and kept

177



178 CHAPTER in

more to herself, while eating still more candy than usual. She and her parents
were inclined to attribute onset of diabetes to grief.

Present Illness.— In Jan., 1913, abnormal thirst was first noted. In Mar.,
pruritus vulvae. In May, menstruation stopped and remained absent. Hair
fell out and is still thin. July, 1913, diagnosis of diabetes was made and routine
diet prescribed, which was taken in huge quantities owing to polyphagia. Symp-
toms persisted and increased till Jan. 4, 1914, when she began treatment at a
well known diabetic sanitarium. Qualitative and quantitative restriction of the
diet, oat cures, vegetable days, etc., failed to clear up the condition. She was
then transferred to this hospital, and arrived tired but not dangerously exhausted
after a journey of 32 hours.

Physical Examination.— Height 165.6 cm. Weight 40.1 kg. Marked emacia-
tion, face flushed and slightly pufiEy, drowsy and slightly alcoholic expression.
No enlargement of tonsils or lymph glands. Blood pressure 103 systolic, 80 dias-
tolic. Examination otherwise negative.

Treatment: — This was the first patient for the proposed treatment, and she was
qloser to coma than was desired for a first trial. Accordingly the attempt was
made to be conservative. She was put to bed and a light supper ordered of two
eggs, a slice of toast, and a cup of milk-cocoa. Breakfast the next morning in-
cluded oatmeal; the rest of the diet was light and included vegetables and potato
in limited quantities. Notice should be taken that the blank food space in the
graphic chart for Feb. 24 to 25 does not represent fasting, but exact reckoning
of the diet was impossible because cooking and other arrangements were not in



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