5Jem ^ork ^tate OfnUcgB of Ulnmc f cottomirH At aiDrnell UttiacraltH Stliata. K. f , ffiibrarg Cornell University Library RC 662.H64 1917 Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31 92400351 3870 A MANUAL OF PRACTICAL LABORATORY DIAGNOSIS By Lewis "Wbbb Hill, M.D. " It has seemed to the Author for a long time that all the worth-while laboratory tests that a practical med* ical man needs could be put t-ogether in tt small and compact volume." — From the Author's Preface. " There must be many physicians who have been waiting for just such a book as this." — New '£or1c MediccU Journals Price postpaid: ONE DOLLAR AN0 A HALF THE STARVATION TREATMENT OF DIABETES WITH A SERIES OF GRADUATED DIETS BY LEWIS WEBB HILL M.D. Junior Assistant Visiting Physician, Children's Hospital, Boston; Alumni Assistant in Pediatrics, Harvard Medical School AND RENA S. ECKMAN Dietitian, Massachusetts General Hospital, Boston, 1911-1916 WITH AN INTRODUCTION BY RICHARD C. CABOT, M.D. THIRD EDITION BOSTON W. M. LEONARD, Publisher 1917 Copyright 1916 BT W. M. Leonard First Edition Printed August, 191S Second Edition Printed January, 1916 Second Edition Reprinted April, 1916 Tliird Edition Copyrighted 1917 INTRODUCTION Although Dr. Allen's modifications of the classical treatment of saccharine diabetes have been ia 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 knowl- edge of food compositions 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 starva- tion period. These diets, worked out by Miss Eck- man, head of the diet kitchen at the Massachusetts General Hospital, have seemed to me to work admir- ably 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 con- siderable bulk of food without any considerable carbo- hydrate 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 Hi INTRODUCTION we can say is that thus far it appears to work admir- ably well. To all who wish to give their patients the benefit of this treatment I can heartily recommend this book. RiOHABD C, Cabot. August, 1915. iv PEEPACB 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 melli- tus. The "starvation treatment" of diabetes, as advanced by Dr. Frederick M. Allen of the Rockefeller Insti- tute Hospital, is undoubtedly a most valuable treat- ment. 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 protein 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 protein — ^it is not enough simply to cut down the supply of starchy foods; he must know approximately how much carbohydrate and pro- tein, 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 in- clude them here for the sake of completeness and ready reference. The food table covers most of the ordinary foods. PREFACE TO FIRST EDITION We wish to thank Dr. Roger I. Lee and Dr. Wil- liam H. Smith, visiting physicians, for many helpful suggestions. August, 1915. PREFACE TO THIRD EDITION In preparing the third edition we have tried to in- clude such additional data as will make the book of more value to the physician and patient. The analy- ses of diabetic foods done by the Connecticut Agri- cultural Experiment Station are of interest to every diabetic, and as we have had inquiries from many diabetics about these various analyses, we have in- cluded some of the more important in our food tables. The series of graduated diets has been completely re- vised, and an index made for it so that any given diet may be easily found. It will be noted that there is less fat in most of these new diets than there was in our old series: more and more emphasis is being laid on the role that a high fat intake plays in pro- ducing acidosis. Maech, 1917. STARVATION TREATMENT OF DIABETES STARVATION TREATMENT OF DIABETES DETAILS OF TEEATMBNT FOR forty-eight hours after admission to the hos- pital the patient is kept on ordinary diet, to deter- mine the severity of his diabetes. Then he is starved, and no food allowed save whiskey and black coffee, 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 in- stead. 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 indi- cated by strong acetone and diacetic acid reactions ia 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 starva- tion. This is indeed the most important point that Dr. AUen has brought out in his treatment. The immedi- ate fasting applies to ordinary cases of diabetes.^ In dealing with cases of long standing, as well as in obese 9 10 STARVATION TREATMENT cases, and cases with, acidosis, it is best, as Dr. Joslin has pointed out, not to start the fast abruptly, but to prepare for it more slowly, by gradually omitting cer- tain articles of food from the diet. He first omits the fat, after two days the protein, and then halves the carbohydrate intake daily until the patient is taking only 10 grams. After this fasting may be started, the same as in any other case. The reason for this preparation before fasting is to prevent acidosis. 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 tbe 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 obsti- nate cases that have been starved for as long as ten or eleven days without bad results. The patients toler- ate 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 moder- ate 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 OF DIABETES 11 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 am- monia 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 determin- ing 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 per cent, vegetables," i.e. vege- tables containing approximately 5 per cent, carbohy- drate. It is best to boil these vegetables three times, with changes of water. In this way their carbo- hydrate content is reduced, probably about one-half. The amount of carbohydrate in these green vegetables 12 STARVATION TREATMENT is not at all ineonsiderable, 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. 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 he 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 carbo- hydrate, but an excess of protein is very important in causing glycosuria, and for this reason the protein intake must be watched as carefuUy as the carbo- hydrate. 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 wiU 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 wcmt 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 OF DIABETES 13 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 glyco- suria, 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 be- coming sugar-free. 2. The stage of gradually working up the diet to the limit of tolerance. During the first two stages a daily weight record should be kept, and the urine should be examined every day. The patient should, of course, be under the immediate supervision of the physician during these two stages. It is always weU to discharge a patient on a diet somewhat under his tolerance, if possible. 3. The stationary stage, when the diet is kept 14 STAEVATION TEEATMBNT at a constant level. The patient is at home and going about his business. Most patients may be taught to test their own urine, and they should do this every other day. If there is sugar in the urine, the patient should go back to a lower diet, and if he cannot be made sugar-free this way, he should be starved again. A semi-starvation day of 150 grams of vegetables, once a week, whether or no the urine contains sugar, is of value for the purpose of keeping well within the margin of safety and of reminding the patient that he is on a strict diet. It is very important for a diabetic to take a consider- dble amownt of exercise: he ccm utilize his carbo- hydrate better, if he does. If this treatment is to be successful, it is absolutely necessary for the patient to adhere very strictly to the diets, and to measure out everything very care- fully; the meat especially should be weighed. The essential points brought out by Allen's treat- ment are as follows : 1. It is not dangerous to starve a diabetic, and two or three days of starvation almost always make a patient sugar-free, thus saving a good deal of time, as contrasted with the old treatment of gradually cut- ting down the carbohydrate. 2. It is not desirable for all diabetics to hold their weight. Some cases may do much better if their weight is reduced ten, fifteen, or even twenty pounds. 3. After starvation, the diet must be raised very slowly, to prevent recurrence of glycosuria. 4. An excess of protein must be regarded as pro- ducing glycosuria and an excess of fat ketonuria, and OP DIABETES 15 the protein and fat intake must be restricted a good deal more than has usually been the custom in treat- ing diabetes. CASE REPORTS It is thought worth while, for the sake of illustra- tion, to include a few case reports. The adults were treated at the Massachusetts General Hospital, the children at the Children's Hospital. Two charts are kept for each case : one a food chart, with the amounts of the different articles of food taken each day, and the protein, carbohydrate, fat and caloric value figured out for each foodstuff; the second (see below) a more general chart, which shows graphically the progress of the case. The first three are cases which were treated first with the old method of gradually reduciog the carbo- hydrate intake and could never be made sugar-free, running from 0.1 per cent, to 0.2 per cent, of sugar. On the new treatment they responded promptly and were discharged sugar-free. Case 1. A woman of 64, diabetic for two years. She was sent in from the out-patient department, where she had been receiving a diet of 50 grams of carbohydrate and 50 grams of protein. On this diet she was putting out 8 grams of sugar a day with moderately strong acetone and diacetie acid reactions in her urine. When the carbohydrate was cut in the ward to 30 grams, she put out 3 grams of sugar a day. She complained of severe pruritus vulvae. After sixteen days of this treatment she continued 16 STARVATION TREATMENT to put out from 0.1 per cent, to 0.2 per cent, of sugar a day. Allen's treatment was then started, and after one day of starvation she was sugar-free and remained so for four days on a diet of carbohydrate, 20 grams ; protein, 30 grams; fat, 150 grams. The itching had gone. Then the protein was raised to 80 grams, with the carbohydrate at 20 grams, and she immediately showed 1.5 per cent, of sugar. This is very impor- tant; the protein should not be raised too quicMy. This we did not realize in our earlier cases. A second starvation day, followed by two vege- table days, and a more careful raising of the diet — as follows — ^kept her sugar-free, and she was dis- charged so. Her diets were : Dec. 12, Carbohydrate, 20 grams. Protein, 30 grams. Fat, 150 grams — 1500 calories. No glycosuria. Dec. 15, Carbohydrate, 30 grams. Protein, 30 grams. Fat, 200 grams — ^2000 calories. No glycosuria. Dec. 20. Carbohydrate, 30 grams. Protein, 40 grams. Fat, 180 grams— 2000 calories. No glycosuria, Dec, 26. Carbohydrate, 40 grams. Protein, 40 grams. Fat, 180 grams — ^2000 calories. No glycosuria. Dec. 30, Carbohydrates, 50 grams. OF DIABETES 17 Protein, 50 grams. Fat, 180 grains — 2000 calories. No glycosuria. Weight on entrance, 119 pounds. Weight at discharge, 116 pounds. Case 2. A Jew of 49, at entrance had 175 grams of sugar (5.5 per cent.), acetone slight, diacetic acid absent. Treated for three weeks with the old method, he got down to a diet containing carbohydrate, 15 grams; protein, 50 grams, — ^but still put out from 3 to 8 grams of sugar a day. By the old method we could not do away with the last traces of sugar. The Allen treatment was started with two starva- tion days. On the second he was sugar-free — ^but showed 2.6 grams of sugar the following day on 12 grams of carbohydrate and 40 grams of protein. (This was one of the earlier cases when the diet was raised too quickly after starvation.) After one more starvation day and two vegetable days he stayed sugar-free while the diet was raised slowly to 30 grams of carbohydrate and 45 grams of protein, calories about 2000. Discharged sugar-free on this diet. Weight at entrance, 109 pounds. Weight at discharge, 110 pounds. Case 3. A man of 35, a severe diabetic, entered Dec. 28, 1914. He had been in the hospital the previous July for a month and could never be made sugar-free with the old method of treatment. At en- trance he was putting out 2.5 per cent of sugar (135 grams) per day with strongly positive acetone and 18 STARVATION TREATMENT diacetic acid tests. Two starvation days made him sugar-free, but we made the mistake of not using twice boiled vegetables for his vegetable day after starva- tion. So on this day he got about 30 grams of carbo- hydrates, and for a few days he showed from 0.2 per cent to 1 per cent, of sugar. Another starvation day was given him and he became sugar-free. This time his vegetables were closely restricted and he was given only enough twice-boiled vegetables to provide about 15 grams of carbohydrates. After this the diet was raised very slowly. He remained sugar-free for three weeks and was discharged so on, Carbohydrate, 20 grams. Protein, 40 grams. Fat, 200 grams. At no time did he receive more than 2200 calories. Weight at entrance, 139 pounds. Weight at discharge, 138 pounds. These three cases were the first ones we tried, and in each one of them we made the mistake of raising the diet too quickly — either allowing too many vege- tables on the vegetable day, or raising the protein too quickly afterwards. With the later cases, after we had more experience, there was no more trouble. Case 4. A Greek (male) of 48, diabetic for two months, entered Jan. 14, 1915, with 3.8 per cent. (65 grams) of sugar and moderate acetone reaction. There was no diacetic reaction present at entrance. After one starvation day he became sugar-free, but was kept on starvation one day longer and then started OF DIABETES 19 on vegetables in the usual way. After the third day a moderate amount of diacetic acid appeared in the urine and continued. The ammonia rose from 0.7 grams per day to 2.6 grams per day, and then varied from 0.3 to 1.5 grams per day. No symptoms of aci- dosis. Jan. 18. Carbohydrate, 15 grams. Protein, 25 grams. Fat, 150 grams — 1360 calories. No glycosuria. Jan. 20. Carbohydrate, 15 grams. Protein, 25 grams. Fat, 200 grams — 1571 calories. No glycosuria. Jan. 24. Carbohydrate, 25 grams. Protein, 35 grams. Fat, 200 grams — 1760 calories. No glycosuria. Jan. 26. Carbohydrate, 35 grams. Protein, 40 grams. Fat, 200 grams — 1838 calories. No glycosuria. Jan. 29. Carbohydrate, 45 grams. Protein, 50 grams. Fat, 200 grams — 2194 calories. No glycosuria, Jan. 31. Carbohydrate, 50 grams. Protein^ 60 grams. Fat, 200 grams — 2347 calories. No glycosuria. Discharged Feb. 1 sugar-free on this diet. Weight at entrance, 160 pounds. 20 STARVATION TREATMENT Weight at discharge, 156 pounds. This was not a severe case and responded very easily to treatment. Case 5. A female of 59, a diabetic of two years' standing, excreted 2.6 per cent, of sugar on Jan. 16, 1915, with no acetone or diacetic acid reactions in the urine. Severe pruritus vulvae. Starved two days; sugar-free on the second starvation day, with disappearance of the pruritus. Jan. 21. Carbohydrate, 15 grams. Protein, 25 grams. Fat, 150 grams — 1595 calories. No glycosuria. From this time the diet was slowly raised until on Jan. 30 she was getting Carbohydrate, 35 grams. Protein, 45 grams. Fat, 200 grams — 2156 calories. She was sugar-free on this and was discharged to the out-patient department after a two weeks' stay in the wards. Weight at entrance, 135 pounds. Weight at discharge, 133 pounds. Case 6. A man of 52, entered Jan. 10, 1915, with 1 per cent, of sugar. He entered for arterio- sclerosis and hypertension, and the sugar was found in the routine examination of the urine. He was kept on house diet for a few days and his sugar rose to 3.5 per cent. No acetone or diacetic acid. After two days of starvation he became sugar-free and continued so as OF DIABETES 21 the diet was slowly raised. He was kept sugar-free in ward eighteen days and was sugar-free on Feb. 6 with a diet of Carbohydrate, 60 grams. Protein, 60 grams. Fat, 200 grams— 2280 calories. On Feb. 7 the protein was raised to 80 grams and 0.2 per cent, of sugar appeared in the urine. The protein was then reduced to 60 grams and he remained sugar-free on this diet and was discharged so. In this case, after starvation, a moderate amount of acetone appeared and continued. No symptoms of acidosis. The ammonia ran from 0.3 to 1.0 grams per day. Weight at entrance, 160 pounds. Weight after three weeks' treatment, 156. Maximum caloric intake, 2525. Case 7. A young man of 25, diabetic for eight months, entered Jan. 20, 1915, with 6.6 per cent. (112 grams) of sugar and strongly positive tests for acetone and diacetic acid. After a period of two starvation days he was sugar-free and actually gained three pounds in the process of starvation (probably due to water retention) . His diet was then raised as follows : — Jan. 24. Carbohydrate, 15 grams. Protein, 25 grams. Fat, 150 grams. No glycosuria. Jan. 26. Carbohydrate, 20 grams. 22 STAEVATION TREATMENT Protein, 35 grams. Fat, 175 grams. No glycosuria. Jan. 29. Carbohydrate, 20 grams. Protein, 45 grams. Fat, 200 grams. No glycosuria. Jan. 31. Carbohydrate, 30 grams. Protein, 45 grams. Fat, 200 grams. No glycosuria. At entrance his ammonia was 1.7 grams per day; after the starvation days it ran from 0.9 grams to 0.3 grams per day. The acetone was a little stronger than at entrance; the diacetic absent except on three days. On Feb. 5 he was still sugar-free (having been so since his starvation days two weeks previously), and weighed 127 pounds, a gain of seven pounds since entrance. At no time did he receive over 2150 calo- ries. This was a very satisfactory case; no doubt the carbohydrate could have been raised to SO 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. StiU, in the few cases that have been treated with the starvation treatment at the Children's Hospital, the results have been very satis- factory, 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 OP DIABETES 23 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 chil- dren 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 render- ing them sugar-free. Case 8. M. M., female, 12 years, entered the Chil- dren'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 the ordinary diet of the ward she showed 8.7 per cent, sugar, no acetone or diacetie acid. Weight, 521/4 pounds, — a very thin, frail girl. She was starved two days, taMng about li/^ oz. of whiskey in black coffee each day. The first day of starvation the sugar dropped to 2.3 per cent., 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, lYz ounces. Protein, 5 grams. Carbohydrate, 12 grams. Fat, 7 grams. No glycosuria. Calories, 213. 24 STARVATION TREATMENT April 6. "Whiskey, 1% ounces. Protein, 26 grains. Carbohydrate, 18 grams. Fat, 46 grams. No glycosuria. Calories, 768. April 8. Whiskey, li^ ounces. Proteia, 45 grams. Carbohydrate, 22 grams. Fat, 72 grams. No glycosuria. Calories, 1050. April 9. "Whiskey, 1^^ 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. OP DIABETES 25 Fat, 113 grams. Calories, 1546. On this diet she excreted .40 per cent, sugar. The next day the bread was cut down to one slice, and her sugar disappeared. On April 20 she was tak- ing 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 per cent, sugar. The next day her oatmeal was cut to 2 tablespoonfuls, giving her about 10 grams less carbo- hydrate. 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 uidne, 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 re- porting to the Out-patient Department every two weeks, and has never had any sugar, acetone or dia- cetic 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. 26 STARVATION TREATMENT 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% 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 gen- eral 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 dis- covered 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 per cent, of sugar, with a moderate amount of acetone, and a very slight trace of diacetic acid. May 2 he was starved, taking 1% ounces of whiskey. One day of starvation was enough to make him sugar- OP DIABETES 27 free. His diet was gradually raised, until on May 7 he was taking 32 grams protein, 33 grams carbo- hydrate, and 75 grams fat, and was sugar-free, with absent diacetie acid and acetone. May 9 his carbo- hydrate intake was raised to 45 grams and he excreted .40 per cent, sugar. May 10 it was cut to 40 grams, and he excreted 2.2 per cent, 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, % 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 diacetie acid in the urine; for the rest of his stay in the hospital these were absent. His weight at en- trance was 31% pounds; he lost no weight during starvation, and weighed 32i^ 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). 28 STARVATION TREATMENT 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 re- fused 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 ex- tremely careful and intelligent woman, and it is cer- tain that all directions as to diet were carried out faithfully. He had never shown any evidence of a severe acido- sis, 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 ex- creted 6.9 per cent, 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 per cent., the second day to 1.1 per cent., and third day she was sugar-free with a little more acetone in the urine than had been present before, but not quite so much dia- cetic acid. From then her diet was raised as follows : Nov. 8. Protein, 9 grams. Carbohydrate, 20 grams. OF DIABETES 29 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 per cent, 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, carbhohydrate 25, fat 140, calories 1538, and on this diet she showed .5 per cent sugar. The carbohydrate was cut to 15 grams, and kept at this level for 3 days, but she still eointinued 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, carbo- 30 STARVATION TREATMENT hydrate 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 ordi- narily be the case. OP DIABETES 31 Following, in two parts, is a graphic chart such as we use in recording our cases. It is here reproduced at three-fourths actual size. APRIL Ii±lZz£i ■ ■ n!j ^ i^ *» «-iiiiiiiESi_ :: i_ __ ^..-pifiTT^Ifl «_ _ ___i__ .1 Kftft — «if .. _ 7L . ._ # ., . 4l__ I~it«l" I JJ-III IIlhjS I J f ^ ff .. »* A, to ll- = SI _ - ff ■ L* '*» -. » ilT- r-aes: _ __ 32 STARVATION TEEATMENT 10 ' " ~ "■ — m ■ •'7'P-9f^ « « " \ L «> 1, ? o ft mt »• n ^ » ft # aW^I * • 9-HHtK 4(0 1 to h If ^ n 10 f 5" — 1_ ^ ft 1 \ 8 O - nr«r.-!'^nnnT?n'^ A ^ ^ i ( } Jt f.i il /ii/eH S Q /<»pouT« ■ 1 Ift" • B Cj^ sumr : t2. ^ s tl ft ■^ ^ ^ ■ _ ^ A ■ '^^r^mr^imnw^r^K^r^mw^mm^mmi. ?"r'^| •• ■ ' ei. • « ■ ft a IP « ■ # « # » * *| «' ■ •i » ' " _ _ ^ _ _ _ Although it is not necessary to keep such a chart as this for every case of diabetes it makes the progress of the case somewhat clearer in noting in this graphic way the presence of sugar (or its absence), and the amount. EXAMINATION OP 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 » solution in a test tube, and add to the hot Fehling's an equal amount of urine, a few drops at a time, boil- ing after each addition. A yellow or red precipitate indicates sugar. For practical purposes in the following of a dia- betic '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 « re- 1 Fehling's solution is prepared as follows : (a) Copper sulphate solution: 34.65 gm. of copper sulphate dissolved in water and made up to SOO c.c. (b) Alkaline tartrate solution: 125 gm. of potassium hydroxide and 173 gm. of Rochelle salt dissolved in water and made up to 500 c.c. These solutions are kept in separate hottles and mixed in equal volumes when ready for use. 2 Benedict's solution has the following composition : Copper sulphate, 17.3 gm. Sodium citrate, 173.0 gm. Sodium carbonate (anhydrous), 100 gm. Distilled water to 1000 c.c. 33 34 STARVATION TREATMENT agent 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. 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 per- formed as follows: The specific gravity of the 24° 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 multi- plied 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 Bene- dict'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 car- OF DIAteETES 35 bonate, heat to boiling, aijid while boiling, run in the urine until a white precipitate forms. Then add the urine more slowly until the last trace of blue disappears. T^ie 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 fol- lows: Dissolve 9.0 gm. of copper sulphate in 100 c.c. distilled water. (The copper sulphate must be weighed very accurately.) Dissolve 50 gm. anhy- drous sodic carbonate, 100 gm. sodic citrate, and 65 gm. of potassium sulpho cyanate in 250 c.c. of dis- tilled water. Pour the copper solution slowly into the alkaline citrate solution. Then pour the mixed solutioli 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. 1(3) Acetone Test : — To 5 c.c. of urine in a test tube add a crystal of sodium nitro pruside. Acidify with glacial acetic acid, shake a moment, and then make alka^ne with ammonium hydrate. A purple color in- dicates acetone. (4) Diacetic Acid Test: — To 5 c.c. of urine in a test tube add an excess of a 10 per cent, solution of Ferric chloride. A Burgundy red color indicates dia- cetic acid. iThis 18 the I test which is ordinarily used for acetone, but in reality it is a very delicate test for diacetic a«id. The 36 STAEVATION TKEATMBNT Quantitative Test for Ammonia. To 25 c.c. of urine add 5 c.c. of a saturated solu- tion of potassium oxalate an*! 2 to 3 drops of phe- nolphthalein. Run in from a burette decinormal sodic hydrate, to a faint pink color. Then add 5 c.c. of formalin (40 per cent, commercial) and again titrate to the same color. Bach 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 an^d the formalin must both be neutral to phenolphthalein. best test to use for the dotection of acid bodies in the urine is the diacetic acid test with ferric chloride.\ The so-called "acetone test" may be discarded entirely. \ DIET TABLES THE diet tables may be used as a graduated series by following them in the order given below. It is not always either necessary or advisable to increase the food allowance each day. The physician must de- cide whether the patient should be advanced rapidly or cautiously, and must direct when he shall take regular days of abstinence, when to go back to the be- ginning and rebuild anew, and at what point to stop the carbohydrate increase or maintain a constant level of each food element. It is at the stage of constant level that the patient is discharged from the hospital and then is the time to study the use of the recipes hereinafter given. The quantity of material to be used in the recipes must be learned from the diet tables. When the tolerance for carbohydrate is greater than 35 grams, substitute the "15 per cent." and "20 per cent." vegetables and fruits for an equivalent weight of a 5 per cent, and 10 per cent, vegetables. Do not add more than one high carbohydrate food per day and give this carbohydrate in divided portions, never an over supply in any one meal. A good way of using oranges or grape fruit is to take half of the portion at 10:30 a, m. and the re- mainder at 2 :30 p. M. thus sparing the tissues an over- influx of sugar at any one time. 37 38 STARVATION TEEATMENT Fruit drinks sweetened with, saccharine may be used. Coffee shakes will be an aid in using cream. "When the patient misses the taste of bread, bran cakes may be used. Remember the food value if the patient shows a desire to take many of them Vse ordi- nary stable bran, and not "hra/n, flour." Bran and Lyster muffins must be counted as having definite food value as has been stated elsewhere. Broths contain practically no nourishment and may be used in moderation as often as the patient wishes. It has been estimated that four tenths of the carbo- hydrate will go into solution when such vegetables as carrots and parsnips et cetera are cut into pieces and boiled. With changes of water and smaller pieces, even more of the sugar content will be lost. OF DIABETES 39 GRADUATED SERIES OF DIET TABLES Series i — ^Weight of patient 40 kilograms (88 lbs.). Use diet tables I to XVI inclusive. Series n — ^Weight of patient 50 kilograms (110 lbs.). Use tables I to V inclusive and tables XVII to XXIII inclusive. Series hi — ^Weight of patient 60 kilograms (132 lbs.). Use tables I to V inclusive, table XVII and tables XXIV to XXXI inclusive. Series iv — ^Weight of patient 70 kilograms (154 lbs.). Use tables I to V inclusive, table XVII, table XXIV and tables XXXI to XLII inclusive. Series v — ^Weight of patient 80 kilograms (176 lbs.). Use tables I to V inclusive, table XVII, table XXIV, table XXXI, and tables XLIII to XLVIII in- clusive. The weights given above are intended as a general guide to the use of the tables and do not need to be followed slavishly. 40 STARVATION TREATMENT DIETARY TABLES m.1,1. Grams Grams Grams Total ^""^ Protein Pat Carbohydrate Calories 1 3 2 4 47 2 6 + 11 70 3 24 22 8 336 4 31 17 19 363 5 39 22 16 430 6 37 31 13 493 7 37 36 16 552 8 42 37 15 578 9 40 42 20 636 10 40 40 20 614 11 40 40 25 638 12 40 38 30 640 13 40 40 35 687 14 41 63 36 901 15 42 91 35 1148 16 42 114 36 1379 17 50 40 20 659 18 50 43 25 707 19 51 41 32 721 20 51 43 36 756 21 50 64 36 948 22 51 90 37 1197 23 51 101 35 1301 24 61 42 25 743 25 62 41 31 763 26 60 41 35 770 27 60 68 36 1026 28 62 90 36 1238 29 60 115 38 1471 30 62 139 36 1693 31 71 41 30 795 32 71 40 36 810 33 70 65 35 1031 34 69 90 36 1267 OF DIABETES 41 m_vi_ Gramg GramB GramB Total ■^''°'* Protein Fat Carbohydrate Calories 35 70 m ii 1514 36 72 139 35 1732 37 71 151 36 1843 38 71 148 40 1832 39 72 152 47 1900 40 71 146 50 1853 41 71 152 55 1926 42 69 153 61 1955 43 80 53 35 964 44 81 75 36 1177 45 80 101 35 1410 46 80 127 38 1661 47 80 154 35 1903 48 80 171 35 2062 42 STARVATION TREATMENT TABLE I Thrice Cooked Vegetables Breakfast. Asparagus 50 grams . . 1 h. tbsp. Broth. Tea or Coffee. DlNNEE. Spinach 50 grams . . 1 h. tbsp. Broth Tea or Coffee SUPPEE. Stewed celery 50 grams . . 1 h. tbsp. Broth. Tea or coffee. OF DIABETES 43 TABLE II Thrice Cooked Vegetables Breakfast. String beans 150 grams . . 3 h. tbsp. Broth Tea or coffee. Dinner. Cabbage 150 grams . . 3 h. tbsp. Broth Tea or coffee. Supper. Asparagus 150 grams . . 3 h. tbsp. Broth Tea or coffee. 44 STARVATION TREATMENT TABLE III Protein, 24 grams Fat, 22 grams Carbohydrate, 8 grams Calories, 336 Breakfast. String beans 100 grams . . 2 h. tbsp. Egg 1 Coffee. Dinner. Egg 1 Turnips 100 grams . . 2 h. tbsp. Cabbage 100 grams . . 2 h. tbsp. Tea. Supper. Egg 1 Turnips 100 grams . . 2 h. tbsp. Spinach 100 grams . . 2 h. tbsp. Tea. OP DIABETES 45 TABLE IV Protein, 31 grams Carbohydrate, 19 grains Pat, 17 grams Calories, 363 Breakfast. Egg 1 Asparagus 100 grams Tomatoes 100 grams Coffee. 2 h. tbsp. 2 h. tbsp. Dinner. Chicken (minced) .... 35 grams . . 1 sm. serv. String beans 200 grams . . 4 h. tbsp. Cabbage (cooked) 100 grams . . 2 h. tbsp. Tea or coffee. SUPPEB. Egg 240 grams . . 4 h. tbsp. Cauliflower 100 grams . . 2 h. tbsp. Tea or coffee. 46 STARVATION TREATMENT TABLE V Protein, 39 grams Carbohydrate, 16 grams Fat, 22 grams Calories, 430 Beeakfast. Egg 1 Asparagus 200 grams Coffee 4 h. tbsp. DlNNEE. CMcken 70 grams . . 1 med. serv. Cauliflower 120 grams . . 2 h. tbsp. Cabbage (cooked) 100 grams . . 2 h. tbsp. Tea. Supper. Egg 1 String beans 100 grams Spinach 200 grams Tea.' 2 h. tbsp. 4 h. tbsp. OF DIABETES 47 TABLE VI Protein, 37 grams Fat, 31 grams Carbohydrate, 13 grams Calories, 493 Breakfast. Egg 1 Asparagus 100 grams . . 2 h. tbsp. Coffee. Dinner. Steak 100 grams . . 1 sm. serv. Celery (cooked) 100 grams .. 2 h.tbsp. Tea. Supper. Egg 1 Lettuce 20 grams . . 2 medium leaves. Cucumbers 100 grams . . 2 h. tbsp. String beans 50 grams . . 1 h. tbsp. Tea. 48 STAEVATION TREATMENT TABLE VII Protein, 37 grams Fat; 36 grams Carbohydrate, 16 grams Calories, 552 Breakfast. Egg 1 Asparagus 100 grams . . 2 h. tbsp. or 9 stalks 4 iQ. long. Spinach 100 grams . . 2 h. tbsp. Coffee. Dinner. Steak 100 grams . . 1 sm. serv. Turnips 140 grams . . 2 h. tbsp. Spinach 100 grams . . 2 h. tbsp. Cabbage 100 grams . . 2 h. tbsp. Tea. Supper. Spinach 100 grams . . 2 h. tbsp. String beans 100 grams . . 2 h. tbsp. Cauliflower 120 grams . . 2 h. tbsp. Tea. OF DIABETES 49 TABLE VIII Protein, 42 grams Fat, 37 grams Carbohydrate, 15 grams Calories, 578 Breakfast. Egg 1 Asparagus 100 grams . . 2 h. tbsp. Spinach 100 grams . . 2 h. tbsp. Coflfee. Cream (heavy) 1 tbsp.^ DnSTNEB. Steak 100 grams . . 1 sm. serv. Turnips 140 grams . . 2 h. tbsp. Celery 100 grams . . 2 h. tbsp. Cabbage 100 grams . . 2 h. tbsp. Tea. SUPPEE. Egg 1 Egg white 1 Spinach 100 grams . . 2 h. tbsp. String beans 100 grams . . 2 h. tbsp. Cauliflower 100 grams . . 2 h. tbsp. Tea. 1 Cream should contain 40 per cent, fat both in this table and in all others. This means very heavy cream. 50 STARVATION TREATMENT TABLE IX Protein, 40 grams Fat, 42 grains Carbohydrate, 20 grams Calories, 636 Breakfast. Orange 50 grams . . Yz sm. serv. Egg 1 2 h. tbsp. Spinach 100 grams . . Cream 1 tbsp. Coffee. DnSTNEB. Egg 1 Steak 50 grams . . 1 very small serving Cabbage 100 grams . . 2 h. tbsp. Onions 100 grams . . 2 h. tbsp. Cream 1 tbsp. Tea. Supper. Scraped beef balls 40 grams . . V/s ounces mixed with 1 egg white Chopped celery salad ..100 grams . . 2 h. tbsp. Tomatoes 100 grams . . 2 h. tbsp. Tea. OF DIABETES 51 TABLE X Protein, 40 grams Fat, 40 grams Carbohydrate, 20 grams Calories, 614 Breakfast. Orange 50 grams . . ^ small Egg 1 Cauliflower 120 grams . . 2 h. tbsp. Butter Cream 1 tbsp. Coffee. Dinner. Cod or Haddock 100 grams . . 1 med. serv. Tomatoes 100 grams . . 2 h. tbsp. Turnips 140 grams . . 2 h. tbsp. Butter Tea. Three p. m. Orange 50 grams . . ^ small Supper. Egg 1 Egg white 1 Celery 100 grams . . 6 stalks 43^ in. long. Asparagus 100 grams . . 2 h. tbsp. Butter. Tea. Allow during day: Butter 25 grams . . 2i^ small squares. 52 STARVATION TREATMENT TABLE XI Protedn, 40 grams Fat, 40 grams Carbohydrate, 25 grams Calories, 638 Breakfast. Orange 100 grams . . 1 small. Egg 1 Egg whites 2 Tomatoes 100 grams . . 2 h. tbsp. Cream 1 tbsp. Coffee. Dinner. Steak 50 grams . . 1 very small serving. Cabbage 100 grains . . 2 h. tbsp. Spinach 200 grams . . 4 h. tbsp. Butter 5 grams . . % small sq. Tea. SUPPEE. Scraped beef balls 40 grams . . 1% ounces. Celery 100 grams . . 6 stalks 4^^ in. long. Onions 100 grams . . 2 h. tbsp. Tea. OF DIABETES 53 TABLE XII Protein, 40 grains Fat, 38 grams Carbohydrate, 30 grams Calories, 640 Beeakpast. Orange 100 grams . . 1 small Egg 1 Asparagus 100 grams . . 2 h. tbsp. Cream 1 tbsp. Coffee. Dinner. Chicken 80 grams . . 1 sm. serv. Cabbage 100 grams . . 2 h. tbsp. Cauliflower 120 grams . . 2 h. tbsp.4- Cueumbers 100 grams . . 2 h. tbsp. Tea. SUPPEK. Egg 1 String beans 100 grams . . 2 h. tbsp. Peas 100 grams . . 2 h. tbsp. Turnips 140 grams . . 2 h. tbsp. Butter 10 grams . . 1 small sq. Cream 1 tbsp. Tea. 54 STARVATION TREATMENT TABLE XIII Protein, 40 grams Pat, 40 grams Carbohydrate, 35 grams Calories, 687 Breakfast. Orange 100 grams . . 1 small. Egg 1 Spinach 100 grams . . 2 h. tbsp. Cream 1 tbsp. Coffee. Dinner. Broth with vegetables: Cabbage 25 grams Tomatoes 25 grams Turnips 25 grams Celery 50 grams Steak 100 grams Squash 50 grams Tomatoes 75 grams Tea. Supper. Egg 1 Turnips 175 grams Celery 100 grams Peas (canned) 75 grams Tea. 1 level tbsp. 1 level tbsp. 1 level tbsp. 3 pieces 4% in. long. 1 sm. serv. 1 h. tbsp. 1% h. tbsp. 334 h. tbsp. 6 stalks 4% in. long. 1% h. tbsp. OF DIABETES 55 TABLE XIV Protein, 41 grams Fat, 63 grains Carbohydrate, 36 grams Calories, 901 Breakfast. Egg 1 Peas 75 grams . . 1% h. tbsp Tomatoes 100 grams . . 2 h. tbsp. Butter Cream 1 tbsp. Coffee. Dinner. Broth Halibut 100 grams . . 1 sm. serv. Turnips 200 grams . . 4 h. tbsp. Squash 70 grams . . li/^ h. tbsp. Butter Cream 1 tbsp. Tea. Supper. Oysters 75 grams . . 4 oysters. Celery 100 grams . . 6 stalks 4% in. long. Beets 100 grams . . 2 h. tbsp. Cabbage (raw) 25 grams . . 1 h. tbsp. Butter Cream 1 tbsp. Tea. Allow during day^: 40 grams buttert=4 small sqs. 56 STARVATION TREATMENT TABLE XV. Protein, 42 grams Fat, 91 grams Carbohydrate, 35 grams Calories, 1148 Breakfast. Grapefruit 75 grams . . ^4 small size Bacon 50 grams . . 3 slices 6 in. long. Parsnips 100 grams . . 2 h. tbsp. Cream 1 tbsp. Coffee. Destneb. Broth Lamb chop 100 grams Cabbage 100 grams Celery 100 grams Grapefruit 75 grams Cream 1 tbsp. Tea. Supper. Egg 1 String beans 200 grams Cucumbers 100 grams Parsnips 100 grams Cauliflower 120 grams Butter 10 grams Cream 2 tbsp. Tea. 1 chop. 2 h. tbsp. 6 stalks 4y2 in. long. 14 medium h. tbsp. h. tbsp. h. tbsp. h. tbsp.+ small sqs. OP DIABETES 57 TABLE XVI Protein, 42 grams Fat, 114 grams Carbohydrate, 36 grams Calories, 1379 Bbeakfast. Orange 50 grams . . y^ small Bacon 50 grams . . 2 slices 6 in. long. Asparagus 100 grams . . 2 h. tbsp. String beans 100 grams . . 2 h. tbsp. Butter Cream 2 tbsp. Coffee. Dinner. Eoast Beef 75 grams . . 1 sm. serv. Beets 100 grams . . 2 h. tbsp. Cauliflower 120 grams . . 2 h. tbsp. Butter Tea. StrpPEB. Bacon 50 grams . . 2 slices 6 in. long. Peas 100 grams . . 2 h. tbsp. Celery 100 grams . . 6 pieces 4^ in. long. Brussels sprouts 100 grams . . 2 h. tbsp. Butter Cream 1 tbsp. Tea. Allow during da/y: Butter 35 grams . . 3^^ sqs. 58 STARVATION TREATMENT TABLE XVII Protein, 50 grams Carbohydrate, 20 grains Fat, 40 grams Calories, 659 Breakfast. Egg 1 String beans 125 grams Cream 1 tbsp. Coffee. Ten a. m. Orange 50 grams Dinner. Broth Fish (cod) 125 grams Brussels sprouts 100 grams Olives 20 grams Butter 5 grams Tea. Supper. Egg 1 Egg white 1 Spinach 100 grams Butter 5 grams Cream 1 tbsp. Tea. 2l^ h. tbsp. Yz small. 1 med. serv. 2 h. tbsp. 5 small Yz small sq. 2 h. tbsp. Yz small sq. OF DIABETES 59 TABLE XVIII Protein, 50 grams Pat, 43 grams Carbohydrate, 25 grams Calories, 707 Breakfast. Grapefruit 75 grams . . % small sized. Eggs 2 Asparagus 100 grams . . 2 h. tbsp. Cream 1 tbsp. Coffee. DiNNEE. Broth Chicken 80 grams Cauliflower 120 grams Grapefruit 75 grams Butter 5 grams Cream 1 tbsp. Tea. Supper. Cold roast veal 50 grams Tomatoes 150 grams Butter 5 grams Cream 1 tbsp. Tea. 1 sm. serv. 2 h. tbsp. % medium. y^, small sq. 1 medium thin slice. 3 h. tbsp. y^ small sq. 60 STARVATION TREATMENT TABLE XIX Protein, 51 grams Carbohydrate, 32 grams Fat, 41 grams Calories, 721 Beeaktast. Egg 1 Egg white 1 Peas 100 grams Cream 1 tbsp. Coffee. Ten a. m. Orange 100 grams Dinner. Broth Lean steak 75 grams Onions 100 grams Butter 5 grams Cream 1 tbsp. Tea. SUPPEE. Egg 1 Egg white 1 Celery (stewed) 100 grams String beans 100 grams Cream 1 tbsp. Tea. . 2 h. tbsp. 1 small. 1 sm. serv. 2 h. tbsp. y2 small sq. 2 h. tbsp. 2 h. tbsp. OF DIABETES 61 TABLE XX Protein, 51 grams Carbohydrate, 36 grams Fat, 43 grams Calories, 756 Breakfast. Grapefruit 75 grams Egg 1 Egg white 1 Asparagus 100 grams Cream 1 tbsp. Coffee. DlNNBR. Broth Roast beef (very lean) . . 75 grams Beets 100 grams Lettuce 50 grams Cucumbers ' 100 grams Cream 1 tbsp. Tea. Supper. Egg 1 Egg white 1 Spinach 100 grams Asparagus 100 grams Grapefruit 75 grams Butter 10 grams Cream 1 tbsp, Tea. J4 small. 2 h. tbsp. 1 sm. serv. 2 h. tbsp. 5 medium leaves. 2 h. tbsp. 2 h. 2 h. tbsp. tbsp. 14 small 1 small sq. 62 STARVATION TREATMENT TABLE XXI Protein, 50 grams Fat, 64 grams Carbohydrate, 36 grams Calories, 948 Bebakfast. Orange 100 grams . . 1 small. Egg 1 Egg white 1 Tomatoes 100 grams . . 2 h. tbsp. Butter 5 grams . . ^ small sq. Cream 2 tbsp. Coffee. Dinner. Broth Roast veal 75 grams 1 sm. serv. Squash 50 grams . . 1 h. tbsp. Parsnips 100 drams . . 2 h. tbsp. Cabbage 100 drams . . 2 h. tbsp. Butter 10 grams . . 1 smaU sq. Cream 2 tbsp. Tea. Supper. Egg 1 Egg white 1 Squash 50 grams . . 1 h. tbsp. Carrots 200 grams . . 4 h. tbsp. Butter 5 grams , , % small sq. Cream 3 tbsp, Tea. OF DIABETES 63 TABLE XXII Protein, 51 grams Carbohydrate, 37 grams Fat, 90 grams Calories, 1197 Beeakfast. Egg 1 Peas 100 grams Butter 5 grams Cream 1 ounce Coffee Dinner. Broth Lamb chop 100 grams Asparagus 100 grams Beet greens 100 grams Butter 5 grams Cream 1 ounce Tea. Supper. Egg 1 Cauliflower 120 grams Lima beans 50 grams Radishes 50 grams Butter 5 grams Cream 1 ounce Tea. 2 h. tbsp. % small s 2 tbsp. 1 chop 2 h. tbsp. 2 h. tbsp. y2 small sq. 2 tbsp. 2 h. tbsp. 1 h. tbsp. 5 radishes. Yz small sq. 2 tbsp. 64 STARVATION TREATMENT TABLE XXIII Protein, 51 grams Fat, 101 grams Carbohydrate, 35 grams Calories, 1301 Bebakpast. Orange 100 grams . . 1 small Bacon 100 grams . . 4 slices 6 in. long. Carrots 100 grams . . 2 h. tbsp. Butter 10 grams . . 1 small sq. Cream 1 tbsp. Coffee. Dinner. Broth Halibut 100 grams . Lettuce 50 grams . Cucumbers 100 grams Cabbage 100 grams Tomatoes 100 grams Butter 10 grams Tea. Supper. Eggs 2 Onions 100 grams Orange 100 grams Butter 10 grams Cream 1 tbsp. Tea. 1 sm. serv. 5 medium leaves. 2 h. tbsp. 2 h. tbsp. 2 h. tbsp. 1 small sq. 2 h. tbsp. 1 small. 1 small sq. OF DIABETES 65 TABLE XXIV Protein, 61 grams Fat, 42 grams Carbohydrate, 25 grams Calories, 743 Breakfast. Grapefruit 75 grams . . ^ small. Eggs 2 Celery 100 grams . . 6 stalks about 41^ in. long. Coffee (black). 10 A. M. Grapefruit 75 grams . . % small. DmNEE. Broth. Cod or Haddock 100 grams . . 1 sm. serv. Tomatoes 100 grams . . 2 h. tbsp. Tea. SUPPEE. Lamb chop 100 grams . . 1 chop. Cauliflower 120 grams . . 2 h. tbsp. Tea. 66 STARVATION TREATMENT TABLE XXV Protein, 62 grains Fat, 41 grams Carbohydrate, 31 grams Calories, 763 Beeakpast. Orange 75 grams . . l^ medium. Eggs 2 Carrots 100 grams . . 2 h. tbsp. Cream Vz oz 1 tbsp. Cofifee. Dinner. Pork chop 75 grams . . 1 small lean chop. Brussels sprouts 100 grams . . 2 h. tbsp. Peas 75 grams . . li^ tbsp. Butter 5 grains . % small sq. Tea. SUPPBB. Boast chicken 100 grains . . 1 med. serv. Lettuce 50 grams . . 5 medium leaves. Cucumbers 100 grains . . 2 h. tbsp. Orange 75 grams . . % medium sized. Cream 1 tbsp. Tea. OF DlABEf^S 67 TABLE XXVI Protein, 60 grams Fat, 41 grains Carbohydrate, 35 grams Calories, 770 Breakfast. Grapefruit 75 grams . . ^ sm. sized. Eggs 2 Parsnips 100 grams . . 2 h. tbsp. Butter 5 grams . . 14 small sq. Cream 1 tbsp. Coffee. Dinner. Broth. Roast veal 100 grams . . 1 medium serving. Onions 100 grams . . 2 h. tbsp. Beets 100 grams . . 2 h. tbsp. Cabbage 100 grams . . 2 h. tbsp. Cream 1 tbsp. Tea. Supper. Broiled chicken 50 grams . . 1 very small portion. Peas ; 50 grams . . 1 h, tbsp. Grapefruit 75 grams . . % medium sized. Butter 5 grams . . V^ small sq. Cream 1 tbsp. Tea. 68 STARVATION TREATMENT TABLE XXVII Protein, 60 grams Fat, 68 grains Carbohydrate, 36 grams Calories, 1026 Breakfast. Orange 75 grams . . V^ medium sized. Broiled cod 70 grams . . 1 sm. serv. Bacon 50 grams . . 2 slices, 6 in. long. Spinach 100 grams . . 2 h. tbsp. Cream 1 tbsp. CofEee. 10 A. M. Orange 75 grams . . y2 medium sized. Dinner. Broth. Steak 100 grams . . 1 sm. serv. Squash 50 grams . . 1 h. tbsp. Turnips 140 grams . . 2 h. tbsp. Tea. Supper. Eggs 2 Peas 100 grams . . 2 h. tbsp. Cream 1 tbsp. Tea. OF DIABETES 69 TABLE XXVIII Protein, 62 grams Fat, 90 grams Carbohydrate, 36 grams Calories, 1238 Beeakpast. Grapefruit 75 grams . . ^ small. Bacon 50 grams . . 2 slices, 6 in. long. Egg 1 Egg white 1 Lettuce 50 grams 5 medium leaves. Cream 2 tbsp. Coffee. DiNNEK. Broth. Lamb Chop 100 grams . . 1 chop. Lima beans 50 grams . . 1 h. tbsp. Celery 100 grams . . 6 stalks 4% in. long. Cream 1 tbsp. Tea. SUPPEE. Egg 1 Egg whites 2 Lima beans 50 grams . . 1 h. tbsp. Cauliflower 120 grams . . 2 h. tbsp. Grapefruit 75 grams . . % medium sized. Cream 1 tbsp. Tea. 70 STARVATION TEEATMENT TABLE XXIX Protein, 60 grains Fat, 115 grams Carbohydrate, 38 grams Calories, 1471 Breakfast. Orange 75 grams . . 14 medium sized. Bacon 50 grams . . 2 slices, 6 Egg 1 in. long. Egg white 1 Asparagus 100 grams . . 2 h. tbsp. Butter. Cream. Coffee. DiNNEE. Roast beef 100 grams . . 1 med. serv. Beets 100 grams . . 2 h. tbsp. Carrots 100 grams . . 2 h. tbsp. Butter. Cream. Tea. Supper. Egg 1 Egg whites 2 Com 50 grams . . 1 h. tbsp. Orange 75 grams . . i/^ medium Butter sized. Cream. Tea. Allow dMrmg day: Butter 20 grams . . 2 small sq. Cream 3 ounces . 6 tbsp. OP DIABETES 71 TABLE XXX Protein, 62 grams Fat, 139 grams Carbohydrate, 36 grams Calories, 1693 Breakfast. Orange 75 grams . . % medium sized. Bacon 100 grams . . 4 slices, 6 in. long. Egg 1 Asparagus 100 grams . . 2 h. tbsp. Butter. Cream. Coffee. Dinner. Steak 100 grams . . 1 sm. serv. Peas 100 grams . . 2 h. tbsp. Cucumbers 100 grams . . 2 h. tbsp. Butter. Cream. Tea. Supper. Egg 1 Canned salmon 50 grams . . % can. Parsnips 100 grams . . 2 h. tbsp. Tomatoes 100 grams . . 2 h. tbsp. Orange 75 grams . . % medium Butter. sized. Cream. Tea. Allow during day: Butter 40 grams . . 4 small sq. Cream 2 ounces . 4 tbsp. 72 STARVATION TREATMENT TABLE XXXI Protein, 71 grams Fat, 41 grams Carbohydrate, 30 grams Calories, 795 Breakfast. Grapefruit 75 grams . . i/4 small. Eggs 2 Cauliflower 120 grams . . 2 h. tbsp. Black GoflEee. Dinner. Roast lamb 100 grams . . 1 med. serv. Onions 100 grams . . 2 h. tbsp. Celery 100 grams . . 6 stalks 41,4 in. long. Deviled eggs 2 Tea. Supper. Cold roast beef 60 grams . . 1 small serv- ing. Oysters 100 grams . . 6 oysters. Tomatoes 100 grams . . 2 h. tbsp. Grapefruit 75 grams . . %, sm. sized. Tea. OF DIABETES 73 TABLE XXXII Protein, 71 grams Fat, 40 grams Carbohydrate, 36 grams Calories, 810 Breakfast. Orange 100 grams . . 1 small. Eggs 2 Lettuce 50 grams . . 5 medium leaves. Cream 1 tbsp. Coffee. Dinner. Cod or haddock 150 grams . . 1 large serr. Cabbage 100 grams . . 2 h. tbsp. Peas 50 grams . . 1 h. tbsp. Tea. Supper. Eggs 2 Beets 100 grams . . 2 h. tbsp. American cheese 10 grams . . small, piece lxlx% in. Orange 100 grams . . 1 small. Cream 1 tbsp. Tea. 74 STARVATION TREATMENT TABLE XXXIII Protein, 70 grams Fat, 65 grams Carbohydrate, 35 grams Calories, 1031 Beeakfast. Grapefruit 75 grams . . ^ smaU. Eggs 2 Spinach 100 grams . . 2 h. tbsp. Cream 1 tbsp. Coffee. DiNNBE. Roast lamb 100 grams . . 1 med. serv. Cauliflower 120 grams . . 2 h. tbsp. Squash 50 grams . . 1 h. tbsp. Butter 5 grams . . 1 small sq. Cream 1 tbsp. Tea. SUPPEE. Cold chicken (young) . . 75 grams . . 1 small serv- Eggs 2 ing. Onions 100 grams . . 2 h. tbsp. Celery 100 grams . . 6 stalks 4^^ in. long. Grapefruit 75 grams . . 14 medium Cream 1 tbsp. Tea. OF DIABETES 75 TABLE XXXIV Protein, 69 grams Pat, 90 grams Carbohydrate, 36 grams Calories, 1267 Breakfast. Apple 50 grams . . ^ small. Eggs 2 Egg white 1 Tomato 100 grams . . 2 h. tbsp. Butter. Cream. Coffee. Dinner. Lean roast beef 100 grams . . 1 med. serv. Brussels sprouts 100 grams . . 2 h. tbsp. Lettuce 50 grams . . 5 medium Snow pudding made of: leaves. 1 egg white. 2 tablespoons orange 1 level teaspoon gelatine. juice 1 tablespoon lemon juice. 5 tablespoons water. 1/^ grain saccharine. Butter. Cream. Tea. Supper. Eggs Bacon 100 grams . . 4 slices 6 in. long. Asparagus 100 grams . . 2 h. tbsp. Onions 100 grams . . 2 h. tbsp. Apple 50 grams . . % small. Butter. Cream. Tea. Allow during day: Butter 20 grams . . 2 small sq. Cream 2 ounces , 4 tbsp. 76 STAEVATION TREATMENT TABLE XXXV Protein, 70 grams Fat, 117 grams Carbohydrate, 34 grams Calories, 1514 Breakfast. Orange 150 grams . . 1 med. sized. Bacon 100 grams . . 4 slices 6 in. long. Eggs 2 Turnips 140 grams . . 2 h. tbsp. Cream 1 tbsp. Butter 5 grams . . % small sq. Coffee. Dinner. Steak 100 grams . . 1 sm. serv. Carrots 100 grams . . 2 h. tbsp. String beans 100 grjims . . 2 h. tbsp. Butter 5 grams . . % small sq. Cream 1 tbsp. Tea, Supper. Eggs 2 Dried beef 25 grams . . % oz. Cucumbers 100 grams . . 2 h. tbsp. Lettuce 50 grams . . 5 medium , leaves. Orange 100 grams . . 1 small. Cream 1 tbsp. Tea. OF DIABETES 77 TABLE XXXVI Protein, 72 grams Fat, 139 grams Carbohydrate, 35 grams Calories, 1732 Breakfast. Apple 50 grams . . % small. Bacon 50 grams . . 2 slices 6 in. Eggs 2 long. Asparagus 100 grams . . 2 h. tbsp. Cream 2 tbsp. Butter 5 grams . . % small sq. Coffee. Dinner. Lamb ebop 100 grams . . 1 chop. Peas 100 grams . . 2 h. tbsp. Kadishes 50 grams . . 5 radishes. Coffee jelly made with : 1 level teaspoon gelatine 8 tablespoons coffee % grain saccharine Cream 1 tbsp. Butter 5 grams . . % small sq. Tea. Supper. Bacon 50 grams . . 2 slices 6 in. Eggs 2 long. Beet greens 100 grams . . 2 h. tbsp. Apple 50 grams . . % small ap- Cream 1 tbsp. pie. Butter 10 grams . . 1 small sq. Tea. 78 STARVATION TREATMENT TABLE XXXVII Protein, 71 grams Carbohydrate, 36 grams Fat, 151 grams Calories, 1843 Bbeakfast. Orange 100 grams . . 1 small Bacon 50 grams . . 2 slices 6 in. Eggs 2 long. Celery (cooked) .100 grams . . 2 h. tbsp. Butter. Cream. Coffee. Dinner. Boiled ham 100 grams . . 1 med. serv. Cabbage 100 grams . . 2 h. tbsp. Beets 100 grams . . 2 h. tbsp. Lemon sponge made of : 1 level teaspoon gelatine. 6 tbsp. water. 2 tablespoons lemon juice. 2 egg whites. % grain saccharine Butter. Cream. Tea. SXJPPEB. Eggs 2 Tomatoes 100 grams . . 2 h. tbsp. Parsnips 100 grams . . 2 h. tbsp. Orange 100 grams . . 1 small. Butter. Cream. Tea. Allow during day' Cream 4 oz 8 tbsp. Butter 40 grams . . 4 small sqs. OP DIABETES 79 TABLE XXXVIII Protein, 71 grams Carbohydrate, 40 grams Fat, 48 grams Calories, 1832 Breakfast. Grapefruit 75 grams Eggs 2 Bacon 75 grams Spinach 100 grams Butter Cream Coffee. DiNNEB. Boast chicken 100 grams Cucumbers 100 grams Peas 100 grams Butter Cream Tea. Supper. Cold tongue 25 grams Eggs 2 Tomatoes 100 grams Olives 25 grams Grapefruit 75 grams Butter Cream Tea. Allow during day: Butter ^ 40 grams Cream 3 oz ^ small 3 slices 6 in. long. 2 h. tbsp. 1 med. serv. 2 h. tbsp. 2 h. tbsp. 1 thin slice. 2 h. tbsp. 5 small. 14 small. 4 small sqs. 6 tbsp. 80 STARVATION TEEATMENT TABLE XXXIX Protein, 72 grains Fat, 152 grams Carbohydrate, 47 grams Calories, 1900 Breakfast. Apple 100 grams . . 1 small Steak 100 grams . . 1 small serv. String beans 100 grams . . 2 h. tbsp. Butter "Cream Coffee. Dinner. Lean Roast beef 100 grams . . 1 med. serv. Corn 50 grams . . 1 h. tbsp. Beet greens 100 grams . . 2 h. tbsp. Lettuce 50 grams . . 5 medium Oil 1/2 tbsp. leaves. Butter Cream Tea. Supper. Bacon 100 grams . . 4 slices 6 in. long. Cold chicken 50 grams . . small serv. Cabbage 50 grams . . 2 h. tbsp. (raw, chopped fine) Com 50 grams . . 1 h. tbsp. Butter Cream Tea. Allow during day: Butter 40 grams . . 4 sm. sqs. Cream 3 oz 6 tbsp. OF DIABETES 81 TABLE XL Protein, 71 grams Fat, 146 grams Carbohydrate, 50 grams Calories, 1853 Beeaktast. Orange 100 grams . . 1 small Bacon 50 grams . . 2 slices 6 in. Eggs 2 long. Carrots 100 grams . . 2 h. tbsp. Butter Cream Coffee. Dinner. Steak 100 grams . . 1 small serv. Cauliflower 120 grams . . 2 h. tbsp. Potatoes 100 grams . . 1 potato size of large Butter Cream Tea. egg. Supper. Eggs 3 Onions 100 grams Coffee jelly made with 1 tsp. gelatine, 8 tbsp. coffee, % grain saccha- rine, 3 whole walnut meats Orange 100 grams Butter Cream Tea. Allow during dwy: Butter 40 grams Cream 3 oz. . . . 2 h. tbsp. 1 small. 4 small sqs. 6 tbsp. 82 STARVATION TREATMENT TABLE XLI Protein, 71 grams Fat, 152 grams Carbohydrate, 55 grams Calories, 1926 Beeakpast. Grapefruit 150 grams . . ^ small size. Bacon 100 grams . . 4 slices 6 in. Egg 1 long. Spinach 100 grams . . 2 h. tbsp. Butter Cream Coffee. Dinner. Lamb chop 100 grams . . 1 chop size Potato 100 grams . . of large Cabbage 100 grams . . 2 h. tbsp. Lettuce 50 grams . . 5 medium Butter leaves. Cream Tea. Supper. Eggs 2 Asparagus 100 grams . . 2 h. tbsp. Milk 7 oz 12 tbsp. Butter Cream Tea. Allow during day: Butter 15 grama . . 1^ small squares. Cream 3 oz 6 tbsp. OP DIABETES 83 TABLE XLII Protein, 69 grams Fat, 153 grains Carbohydrate, 61 grams Calories, 1955 Breakfast. Strawberries 100 grams . . 2 h. tbsp. Eggs 2 String beans 100 grams . . 2 h. tbsp. Potato 50 grams . . % size large Butter Cream CofEee. egg. Dinner. Broiled ham 100 grams . . 1 med. help. (medium fat) Potato 50 grams . . % size large egg. Cucumbers 100 grams . . 2 h. tbsp. Lettuce 50 grams . . 5 medium Butter Cream Tea. leaves. SXJPPER. Eggs 2 Canned salmon 50 grams . . % can. Cauliflower 120 grams . . 2 h. tbsp. Rhubarb 100 grams . . 2 h. tbsp. (sweetened with saccharine) Butter Cream Tea. Allow during day: Butter 40 grams . . 4 small sqs. Cream 6 oz 12 tbsp. Lemon juice 3% oz 7 tbsp. 84 STARVATION TREATMENT TABLE XLIII Protein, 80 grams Fat, 53 grams Carbohydrate, 35 grams Calories, 964 Breakfast. Orange 100 grams . . 1 small. Eggs 2 Tomatoes 100 grams . . 2 h. tbsp. Cream 1 tbsp. Coffee. Dinner. Lean roast beef 125 grams . . 1 generous serving. Celery (chopped) 100 grams . . 2 h. tbsp. Spinach 100 grams . . 2 h. tbsp. Lemon snow pudding. . made of 1 egg white 1 tsp. gelatine, 3 tbsp. lemon juice, % grain saccharine, 5 tbsp. water. Tea. Supper. Cold tongue 50 grams . . 2 med. slices. Eggs 2 Beets 100 grams . . 2 h. tbsp. Cream 1 tbsp. Tea. Allow during day: Lemonade made with 3 tbsp. lemon juice, water and saccharine to taste. OF DIABETES 85 TABLE XLIV Protein, 81 grams Pat, 75 grams Carbohydrate, 36 grams Calories, 1177 Breakfast. Grapefruit 75 grams . . % small. Eggs.... 2 Carrots 100 grams . . Cream 2 tbsp. Coffee. DiNNEE. Cod or Haddock 150 grams . . 1 large help. Onions 100 grams . . 2 h. tbsp. Peas 75 grams . . 1% h. tbsp. Cream 1 tbsp. Tea. Supper. Cold roast pork 50 grams . . 1 thin slice. Eggs 2 Lettuce 50 grams . . 5 medium leaves. Grapefruit 75 grams . . % small. Cream 1 tbsp. Tea. Allow during day: Butter 25 grams . . 21^ sm. sqs. 86 STARVATION TREATMENT TABLE XLV Protein, 80 grams Fat, 101 grams Carbohydrate, 35 grams Calories, 1410 Breakfast. Apple 50 grams . . % small. Eggs 2 Egg white 1 String beans 100 grams . . 2 h. tbsp. Butter 10 grams . . 1 small sq. Cream 2 tbsp. Coffee. Dinner. Hamburg steak 100 grams . . 2 small sqs. (made of lean round steak) Brussels sprouts 100 grams . . 2 h. tbsp. Fresh tomatoes 100 grams . . 1 small tom- ato. Butter 10 grams . . 1 small sq. Cream 2 tbsp. Tea. Supper. Eggs 2 Egg white 1 Cold ham 50 grams . . 1 small thin slice. Cucumbers 100 grams . . 2 h. tbsp. Radishes 50 grams . . 5 radishes. Turnips 140 grams . . 2 h. tbsp. Apple 50 grams . . i^ small. Butter 10 grams . . 1 small sq. Cream 2 tbsp. Tea. OP DIABETES 87 TABLE XLVI Protein, 80 grains Fat, 127 grams Carbohydrate, 38 grams Calories, 1661 Breakfast. Orange 75 grams . . % medium. Eggs 2 Lettuce 50 grams . . 5 medium Butter leaves. Cream 2 tbsp. Coffee. 10 A.M. Orange 75 grams . . y2 medium. Dinner. Steak 100 grams . . 1 sm. serv. Beets 100 grams . . 2 h. tbsp. Cream cheese 50 grams . . l^ cheese (about.) Olives 25 grams . . 5 small Butter Cream 2 tbsp. Tea. Supper. Cold veal 50 grams . . 1 sm. serv. Celery 100 grams . . 6 pieces 4V^ Eggs 2 in. long. Fresh pineapple 75 grams . . 1% h. tbsp. Butter Cream 2 tbsp. Tea. Allow during day: Butter 40 grams . . 4 small sqs. STARVATION TREATMENT TABLE XLVII Protein, 80 grams s Fat, 154 grams Carbohydrate, 35 grams Calories, 1903 Breakfast. Grapefruit 75 grams . . 14 small. Eggs 2 Tomatoes 100 grams . . 2 h. tbsp. Butter 10 grams . . 1 small sq. Cream 2 tbsp. Coffe. Dinner. Lamb chop 100 grams . . 1 chop. Peas ., 50 grams . . 1 h. tbsp. Squash 50 grams . . 1 h. tbsp. Butter 20 grams . . 2 small sqs. Cream 2 tbsp. Tea. Supper. Cold boiled ham 100 grams . . 1 large thin Eggs 2 slice. Egg white 1 Lettuce 50 grams . . 5 medium leaves. Olive oil 1% tbsp. Grapefruit 75 grams . . 14 small. Cream 2 tbsp. Tea. OF DIABETES 89 TABLE XLVIII Protein, 80 grams Fat, 171 grams Carbohydrate, 35 grams Calories, 2062 Breakfast. Apple 50 grams . . % small. Eggs 2 Asparagus 100 grams . . 2 h. tbsp. Butter Cream Coffee. DiNNEE. Roast chicken 100 grams . . 1 med. serv. Cabbage 100 grams . . 2 h. tbsp. Spinach 100 grams . . 2 h. tbsp. Fresh peach 100 grams . . 1 med. serv. Butter Cream Tea. SUPPEE. Eggs 2 28 sardines Sardines 100 grams . . Celery 50 grams . . 3 stalks 4i^ in. long. Apple 50 grams . . % small. Butter Cream Tea. Allow during day: Butter 40 grams . . 4 small sqs. Cream 6 oz 12 tbsp. Olive oil 1 tbsp. 90 STARVATION TREATMENT Dr. Edwin A. Locke's book of food values has been of much value in making up these diets. The following shows the successive steps in building up a diet for a patient who starved six days before becoming sugar-free: Ortimg Qrams Grams Total Protein Fat Carbohydrate Calories Day 1 2 + 5 30 2 15 12 4 189 3 23 18 8 294 4 36 30 11 471 5 18 48 9 560 6 51 44 17 688 7 52 51 15 750 8 46 51 19 740 9 49 78 20 1008 10 50 101 21 1230 11 49 123 19 1422 12 Starved because sugar came through 13 15 12 3 185 14 34 32 10 478 15 53 100 15 1208 Patient discharged with advice as to diet. The corresponding menus for the above are as follows : FIRST DAY. BREAKFAST DINNER SUFFEB String beans 25 Lettuce 25 grama. Lettuce 25 grams. grams. Cucumbers 25 gms. Tomato 25 grams. Lettuce 25 gra;ms. Tea. Tea. Coffee. Protein 2 grams, Fat, trace, Carbohydrate 5 grams, Calories 30. OF DIABETES 91 BBBIAKFAST 1. SECOND DAY. DINNEB Egg 1. Lettuce 25 grams. String beans 26 grams. Tea. Protein 15 grams, Fat 12 grams, Carbohydrate 4 grams, Calories 189. Lettuce 25 grams. Cucumbers 25 gms, Coffee. Lettuce 25 grams. String beans 25 grams. Tea. THIRD DAY. SUPPER Bggl. String beans 75 gms. Celery 50 gms. Protein 23 grams, Fat 18 grams, Carbohydrate 8 grama, Calories 294. BBEAKFAST Egg 1. Asparagus 50 gms. Lettuce 25 gms. DINNEB Egg 1. Cauliflower 50 gms. Lettuce 50 gms. FOURTH DAY. DII7NEB Chicken broth 6 oz. Egg 1. Celery 100 gms. Tea. BBEAEIFAST Egg 1. String beans 100 gms. Coffee. Cream 1 oz. Protein 36 grams, Fat 30 grams. Carbohydrate 11 grams. Calories 471. SUPPEB Egg 1. Egg whites 2. Lettuce 75 gms. Cucumbers 50 gms. FIFTH DAY. BBEAKFAST DINNEB SUPPKB Egg 1. String beans 75 Eggl. Cauliflower 100 gms. Asparagus. gms. Lettuce 25 gms. Tea. Coffee. Tomatoes 50 gms. Cream 2 tbsp, Cream 2 tbsp. Butter 1 square. Butter % square. Tea. Cream 2 tbsp. Protein 18 grams, Fat 48 grams, Carbohydrate 10 grams. Calories 560. 92 STARVATION TREATMENT BEEAKFAST SIXTH DAY. DINNEB Egg 1. Spinach 75 gms. Butter % square. Coflfee. Cream 1 tbsp. Broth 6 oz. Chicken 50 gms. Lettuce 50 gms. Tomatoes 75 gms. Asparagus 75 gms. Tea. Cream 1 tbsp. Eggl. Egg whites 2. String beans 75 gms. Cucumbers 75 gms. Tea. Cream 1 tbsp. Butter % square. Protein 51 grams, Fat 44 grams, Carbohydrate 17 grams. Calories 688. BKEAKFAST SEVENTH DAY. DINNER SXIPPEB Eggs 2. Asparagus 100 gms Coffee. Cream 1 tbsp. Beef broth 6 oz. Scraped beef 50 gms. Cauliflower 100 gms. Spinach 100 gms. Lettuce 25 gms. Tea. Cream 1 tbsp. Protein 52 grams, Fat 51 grams. Carbohydrate 15 grams, Calories 750. Salmon 50 gms. Cabbage 100 gms. Tomatoes (raw) 75 gms. String beans 100 gms. Tea. Cream 1 tbsp. 100 EIGHTH DAY. DINNEB Chicken 75 gms. Cauliflower 100 gms. Olives 25 gms. Cucumbers 50 gms. Tea. Cream 1 tbsp. Protein 46 grams. Fat 51 grams. Carbohydrate 19 grams, Calories 740. BBEAKEAST Egg 1. String beans gms. Asparagus 100 gms Coffee. Cream 1 tbsp. STJPPEB Egg 1. Spinach 100 gms. Celery 50 gms. Lettuce 50 gms. Tea. Cream 1 tbsp. OF DIABETES 93 BKEAEFABT Eggl. Egg white 1. Spinach 100 gms. Celery 50 gms. Coffee. Cream 2 tbsp. Butter 1 square. Protein 49 grams, BREAKFAST Egg 1. Lettuce 50 gms. String beans 100 gms. Cucumbers 100 gms. Coffee. Cream 2 tbsp. Protein 50 grams, NINTH DAY. MNNBB Chicken 75 gms. String beans 100 gms. Asparagus 100 gms. Olives 25 gms. Tea. Cream 1 tbsp. Butter IJ^ square. Fat 77 grams, Carbohydrate 19 grams, Calories 1008. SUPPEB Eggl. Cauliflower 100 gms. Cucumbers 50 gms. Lettuce 50 gms. Tea. Cream 1 tbsp. Butter 1 square. TENTH DAY. DINNEB Lamb chop 75 gms. Spinach 100 gms. Celery 50 gms. Olives 25 gms. Tea. Cream 2 tbsp. STJPPBB Salmon 50 gms. Asparagus 100 gms. Cabbage 100 gms. Tea. Cream 2 tbsp. Fat 101 grams, Carbohydrate 21 grams. Calories 1230. ELEVENTH DAY. BREAKFAST Bacon 50 gms. Asparagus 100 gms Spinach 100 gms. Butter 2 squares. Cream 3 tbsp. DINlfEB Beef broth 8 oz. Chicken 75 gms. Cabbage 100 gms. Cucumbers 50 gms. Butter 3 squares. Cream (made into ice cream) 4 tbsp. Protein 49 grams, Fat 123 grams. Carbohydrate 19 grams, Calories 1422. SnPPEB Egg 1. Tomatoes 100 gms. Spinach 50 gms. Butter 2 squares. Cream 1 tbsp. 94 STARVATION TREATMENT TWELFTH DAY. DINNEB BUFFEB Chicken broth 8 oz. Beef broth 8 oz. Protein 12 grams, Calories 49. THIRTEENTH DAY. BBEAKPAST Black coffee. BBEAEFAST DINNEB SUFFEB String beans 60 Egg 1. Egg 1. gms. Asparagus 50 gms. Cabbage 50 gms. Black coffee. Tea. Tea. Protein 15 grams, Fat 12 grams. Carbohydrate 4 grams, Calories 185. FOURTEENTH DAY. BBEAKTAST DINNEB SUPPEE Egg 1. Roast chicken 50 Egg 1. String beans 100 gms. Cauliflower 100 gms. Asparagus 100 gms. gms. Coffee. Cabbage 100 gms. Tea, Cream 1 tbsp. Tea. Cream 1 tbsp. Cream 1 tbsp. Protein 34 grams, Fat 32 grams. Carbohydrate 10 grams. Calories 478. FIFTEENTH DAY. BBEAKPAST DINNEB SUPPER Egg 1. Squab 100 gms. Egg 1. Tomatoes 50 gma. String beans 100 Cold chicken 25 Coffee. gms. gms. Cream 2 tbsp. Cauliflower 150 Lettuce 50 gms. gms. Spinach 50 gms. Butter 1 square. Tea. Custard made with Cream 2 tbsp. 1 egg. 4 tbsp. cream and 2 tbsp. water sweetened with saccharine. Tea. Protein 53 gi-ams. Fat 100 grams. Carbohydrate 15 grams, Calories 1208. Patient discharged with advice as to diet. RECIPES 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 re- strict the protein intake, any gluten flour, even if it contains only a small percentage of carbohydrate, must be used with caution. The reports of 1913 and 1914, Connecticut Agricultural Experiment Station (See p. 129), "Diabetic Foods," gives a most valuable compil- ation of analyses of food products for diabetics. "We have found some use for soya meal, casoid flour and Lyster's flour, "akoU" biscuits, and "proto-puflfs," 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 prevent- ing or correcting constipation. BEAN CAKES. 2 cups bran — ^measured after washing 2 eggs 95 96 STARVATION TREATMENT ^ teaspoon salt % grain saccharine. ' Tie bran in cheesecloth, and soak for one hour. Wash by squeezing water through and through. Change water several times. "Wring dry. Dissolve saccharine in % teaspoon water. Beat the whole eggs and mix with the washed bran, salt and saccharine. Form into twenty-four small cakes, using knife and tablespoon to shape them, and slip onto a greased bak- ing sheet. Bake until golden brown. When measuring the washed bran pack the material slightly in order to have the required number of cakes. Twelve cakes are equivalent in food value to one egg- When fat is allowed in the diet, two level table- spoons of either butter, olive oil, lard, or crisco may be be added to the recipe: Melt the fat, pour into the mixture, and stir well. The food value of twelve bran cakes will then be : Protein, 7 grams, fat 19 grams, total calories, 200. SOYA MEAL AND BRAN MUFFINS.i 1 ounce (30 grams) soya meal 1 level tablespoon (15 grams) butter 1 ounce (30 c.c.) 40 per cent, cream 1 cup of washed bran (see method given else- where) 1 egg white 1 whole egg may be substituted for 1 egg white. 14 teaspoon salt lYz teaspoons baking powder ; &Qjtt "Pern Meal, Theodore Metcalf Co., Boston,. Ma^S- OP DIABETES 97 Mix soya meal, salt and baking powder. Add to the washed bran. Add melted butter an^ 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 — ^f rom fif- teen to twenty-five minutes. Total food value: Protein, 11 grams Fat, 27 grams Carbohydrate, 1 gram Calories, 300 One muffin:=protein, 2 grams ; fat, 4.5 grams Carbohydrate, trace Calories, 50 CASOID FLOUR AND BRAN MUFFINS i 1 ounce (30 grams) Casoid flour 1 level tablespoon (15 grams) butter 1 ounce (30 c.c.) 40 per cent, cream 1 egg white 1 whole egg may be substituted for 1 egg white. 14 teaspoon salt iy2 teaspoons baking powder 1 cup washed bran Method as in previous rule. Bake in six muffin tins. Total food value: Protein, 18 grams Pat, 24 grams Carbohydrate, 1 gram Calories, 300 One muffini=Protein, 3 grams Pat, 4 grams Carbohydrate-j-Calories, 50 1 Casoid Diabetic Flour, Thos. Leeming & Co., ImporteTa, New York City. 98 STARVATION TREATMENT BRAN AND LYSTBR MUFFINS 1 ounce (30 grains) Lyster flour 2 tablespoons (30 c.c.) heavy cream (40 per cent, fat) 2 eggs y^ teaspoon salt 1 teaspoon baking powder 1 cup washed bran, measured after washing, packed slightly. Wash bran as in preceding recipe and wring firmly to get rid of most of the water. Beat egg yolks, add washed bran salt and Lyster flour which has been mixed with baking powder; add cream and stir well. Whip the egg whites and fold in at the last. Bake in eight mufBn tins. Two mufiSns are equal in food value to one &g^. Bran and Lyster mufSns will be found of value in making up the diets containing a generous amount of protein and fat. In any diet they may be substituted for eggs, two mufOns, as has been stated, being equiva- lent to one egg. 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 Fan- nie Merritt Farmer. 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 im- proved. OF DIABETES 99 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 dur- ing 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 SraSSE 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 tea- spoonfuls over the egg until the cooking is accom- plished. When nearly done sprinkle with salt, pep- per, and one-half tablespoon grated cheese. Remove egg to hot serving dish and pour over cream remain- ing in pan. 100 STARVATION TREATMENT DROPPED EGG Butter a mufSn 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 pur6e, 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 horse-radish 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 OP DIABETES 101 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 pars- ley 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 y2 cup chicken stock % teaspoon Sauteme Ys teaspoon beef extract 1% tablespoons cream Salt and pepper Heat stock to boiling point and add remaining in- gredients. 102 STARVATION TREATMENT CHICKEN SOUP WITH EGG CUSTABD Serve Chicken Soup with Egg Custard. Egg Custard. — Beat yolk of one egg slightly, add one-half tablespoon, each, cream and water, and season with salt. Pour into a small buttered tin mould, place in pan of hot water, and bake until firm ; cool, remove from mould, cut into fancy shapes. CHICKEN SOUP WITH EGG BALLS I OR II Egg Balls. — Rub yolk of one hard boiled egg through a sieve, season with salt and pepper, and add enough raw egg yolk to make of right consistency to shape. Form into small balls, and poach in soup. Egg Balls I. — Rub yolk of one hard boiled egg through a sieve, add one-half of a hard boiled egg white finely chopped. Season with salt and moisten with yolk of raw egg until of right consistency to shape. Form and poach same as Egg Balls I. CHICKEN SOUP WITH ROYAL CUSTARD Serve Chicken Soup with Royal Custard. Royal Custard. — ^Beat yolk of one egg slightly, add two tablespoons chicken stock, season with salt and pepper, turn into a small buttered mould, and bake in a pan of hot water until firm. Cool, remove from mold, and cut into small cubes or fancy shapes. ONION SOUP Cook one-half large onion, thinly sliced, in one table- spoon butter eight minutes. Add three-fourths cup chicken stock, and let simmer twenty minutes. Rub OP DIABETES 103 through a sieve, add two tablespoons cream, and yolk one-half egg beaten slightly. Season with salt and pepper. ASPARAGUS SOUP 12 stalks asparagus, or Ys cup canned asparagus tips % cup chicken stock 1/4 slice onion. Yolk one egg 1 tablespoon heavy cream Ys teaspoon salt Few grains pepper Cover asparagus with cold water, bring to boiling point, drain, and add stock and onion; let simmer eight minutes, rub through a sieve, reheat, add cream, egg and seasonings. Strain and serve. TOMATO BISQUE % cup canned tomatoes ^^ sliced onion Bit of bay leaf 2 cloves ^ cup boiling water Ys teaspoon soda Y2 tablespoon butter Y4 teaspoon salt Few grains pepper 2 tablespoons heavy cream Cook first five ingredients for eight minutes Rub through sieve, add soda, butter in small pieces, season- ing, and cream. Serve at once. 104 STARVATION TREATMENT CAULIFLOWER SOUP % cup cooked cauliflower % cup chicken stock Small stalk celery % slice onion 1 egg yolk 1 tablespoon heavy cream 2 teaspoons butter Salt and pepper Cook cauliflower stalk, celery and onion eight min- utes. Rub through puree strainer, reheat, add egg yolk slightly beaten, cream, butter, and seasoning. MUSHROOM SOUP 3 mushrooms % cup chicken stock ^ slice onion 2 teaspoons butter 1 egg yolk 1 tablespoon heavy cream 1 teaspoon sauteme Salt and pepper Clean mushrooms, chop, and cook in one teaspoon butter five minutes. Add stock arid let simmer eight minutes. Rub through a puree strainer, add egg yolk slightly beaten, cream, remaining butter, seasoning and wine. SPINACH SOUP 1 tablespoon cooked chopped spinach Ys cup chicken stock 1 egg yolk OP DIABETES 105 1 tablespoon heavy cream Salt and pepper Cook spinacli with stock eight minutes. Rub through a puree strainer, reheat, add egg yolk slightly beaten, cream, and seasoning. BROILED FISH, CUCUMBER SAUCE Serve a small piece of broiled halibut, salmon, or sword fish, with cucumber sauce. Cucumber Sauce. — ^Pare one-half cucumber, grate and drain. Season with salt, pepper and vinegar. BAKED FILLET OF HALIBUT, HOLLANDAISE SAUCE "Wipe a small fillet of halibut and fasten with a skewer. Sprinkle with salt and pepper, place in pan, cover with buttered paper and bake twelve minutes. Serve with, HoUandaise Sauce.-^Put yolk of one egg, one table- spoon butter, and one teaspoon lemon juice in a small sauce-pan. Put sauce-pan in a larger one containing water, and stir mixture constantly with wooden spoon until butter is melted. Then add one-half tablespoon butter, and as the mixture thickens another one-half tablespoon butter ; season with salt and cayenne. This sauce is almost thick enough to hold its shape. One- eighth teaspoon of beef extract, or one-third teaspoon grated horseradish added to the first mixture gives variety to this sauce. BAKED HALIBUT WITH TOMATO SAUCE Wipe a small piece of halibut, and sprinkle with salt and pepper. Put in a buttered pan, cover with a 106 STARVATION TREATMENT thin strip of fat salt pork gashed several times, and bake twelve to fifteen minutes. Remove fish to serv- ing dish, discarding pork. Cook eight minutes one- third eup of tomatoes, one-fourth slice onion, one clove, and a few grains salt and pepper. Remove onion and clove and run through a sieve. Add a few grains soda and cook until tomato is reduced to two teaspoons. Pour around fish and garnish with parsley. HALIBUT WITH CHEESE Sprinkle a small fillet of halibut with salt and pepper, brush over with melted butter, place in pan and bake twelve minutes. Remove to serving dish and pour over it the following sauce : Heat two tablespoons cream, add one-half egg yolk slightly beaten, and when well mixed one tablespoon grated cheese. Season with salt and paprika. FINNAN HADDIE A LA DELMONICO Cover a small piece of finnan haddie with cold water, place on back of range and allow water to heat gradually to boiling point, then keep below boiling point for twenty minutes. Drain, rinse thoroughly, and separate into flakes; there should be two table- spoons. Reheat over hot water with one hard boiled egg thinly sliced in two tablespoons heavy cream. Season with salt and paprika, add one teaspoon butter and sprinkle with finely chopped parsley. FILLET OF HADDOCK WITH WINE SAUCE Remove skin from a small piece of haddock, put in a buttered baking pan, pour over it one teaspoon melted butter, one tablespoon white wine, and a few OF DIABETES 107 drops, each, of lemon juice and onion juice. Cover and bake. Eemove to serving dish, and to liquor in pan add one tablespoon cream and one egg yolk slightly beaten. Season with salt and pepper. Strain over fish, and sprinkle with finely chopped parsley. SMELTS WITH CREAM SAUCE Clean two selected smelts and cut five diagonal gashes on sides of each. Season with salt, pepper, and lemon juice. Cover and let stand ten minutes. Roll in cream, dip in flour, and saute in butter. Remove to serving dish, and to fat in pan add two tablespoons cream. Cook three minutes, season with salt, pepper, and a few drops lemon juice. Strain sauce around smelts and sprinkle with finely chopped parsley. SMELTS A LA MAITRE D'HOTEL Prepare smelts same as for smelts with cream, and serve with maitre d 'hotel butter. SALT CODFISH WITH CREAM Pick salt codfish into flakes; there should be two tablespoons. Cover with lukewarm water and let stand on back of range until soft. Drain, and add three tablespoons cream; as soon as cream is heated add yolk one small egg slightly beaten. SALT CODFISH WITH CHEESE To salt codfish with cream, add one-half tablespoon grated cheese and a few graias paprika. BROILED BEEFSTEAK, SAUCE FIGARO Serve a portion of broiled beefsteak with Sauce Figaro. 108 STARVATION TREATMENT Sauce Figaro. — To HoUandaise sauce add one tea- spoon tomato puree. To prepare tomato puree stew tomatoes, force through a strainer and cook until reduced to a thick pulp. ROAST BEEF, HOESERADISH CREAM SAUCE Serve a slice of rare roast beef with Horseradish Cream Sauce. Horseradish Cream Sauce. — Beat one tablespoon heavy cream until stiff. As cream begins to thicken, add gradually three-fourths teaspoon vinegar. Season with salt and pepper, then fold in one-half tablespoon grated horseradish root. FILLET OF BEEF Wipe off a thick slice cut from tenderlbin. Put in hot frying pan with three tablespoons butter. Sear one side, turn and sear other side. Cook eight min- utes, turning frequently, taking care that the entire surface is seared, thus preventing the escape of the inner juices. Remove to hot serving dish, and pour over fat in pan, first strained through cheesecloth. Garnish with cooked cauliflower, canned string beans, reheated and seasoned, and sauted mushroom caps. LAMB CHOPS, SAUCE FINESTE Serve lamb chops with Sauce Fineste. Sauce Fineste. — Cook one-half tablespoon butter un- til browned. Add a few grains, each, mustard and cayenne, one-fourth teaspoon Worcestershire Sauce, and a few drops lemon juice, and two tablespoons stewed ajid strained tomatoes. OF DIABETES 109 SPINACH Chop one cup cooked spinach drained as dry as possible. Season with salt and pepper, press through a puree strainer, reheat in butter, using as much as desired or as much as the spinach will take up. Ar- range on serving dish and garnish with white of "hard boiled" egg cut in strips and yolk forced through strainer. BRUSSELS SPROUTS WITH CURRY SAUCE Pick over Brussels sprouts, remove wilted leaves, and soak in cold salt water fifteen minutes. Cook in boiling salted water twenty minutes, or until easily pierced with skewer. Drain, and pour over one-fourth cup curry sauce. Curry Sauce. — ^Mix one-fourth teaspoon mustard, one-fourth teaspoon salt, and a few grains paprika. Add yolk of one egg slightly beaten, one tablespoon olive oil, one and one-half tablespoons vinegar, and a few drops of onion juice. Cook over hot water, stir- ring constantly until mixture thickens. Add one- fourth teaspoon curry powder, one teaspoon melted butter, and one-eighth teaspoon chopped parsley. FRIED CAULIFLOWER Steam or boil a small cauliflower. Cool and sepa- rate into pieces. Saute enough for one serviQg in olive oil until thoroughly heated. Season with salt and pepper, arrange on serving-dish, and pour over one tablespoon melted butter. CAULIFLOWER A LA HUNTINGTON Separate hot steamed cauliflower into pieces and no STARVATION TREATMENT pour over sauce made same as sauce for Brussels sprouts with curry sauce. CAULIFLOWER WITH HOLLANDAISE SAUCE Serve boiled cauliflower with HoUandaise sauce, as given with baked fillet of halibut, HoUandaise sauce. MUSHROOMS m CREAM Clean, peel and break in pieces six medium-sized mushroom caps. Saute in one-half tablespoon butter three minutes. Add one and one-half tablespoons cream and cook until mushrooms are tender. Season with salt and pepper and a slight grating of nutmeg. BROILED MUSHROOMS Clean mushrooms, remove stems, and place caps on a buttered broiler. Broil five minutes, having gills nearest flame during first half of broiling. Arrange on serving dish, put a small piece of butter in each cap and sprinkle with salt and pepper. SUPREME OF CHICKEN Force breast of uncooked chicken through a meat chopper; there should be one-fourth cup. Add one egg beaten slightly and one-fourth cup heavy cream. Season with salt and pepper. Turn into slightly but- tered mould, set in pan of hot water and bake until firm. SARDINE RELISH Melt one tablespoon butter, and add two tablespoons cream. Heat to boiliog point, add three sardines freed from skin and bones, and separated in small pieces, and one hard-boiled egg finely chopped. Sea- son with salt and cayenne. OF DIABETES 111 DIABETIC RAREBIT Beat two eggs slightly and add one-fourth teaspoon salt, a few grains cayenne, and two tablespoons, each, cream and water. Cook same as scrambled eggs, and just before serving add one-fourth Neufchatel cheese mashed with fork. CHEESE SANDWICHES Cream one-third tablespoon butter and add one- half tablespoon, each, finely chopped cold boiled ham and cold boiled chicken; then season with salt and paprika. Spread between slices of Gruyere cheese cut as thin as possible. CHEESE CUSTARD Beat one egg slightly, add one-fourth cup cold water, two tablespoons heavy cream, one tablespoon melted butter, one tablespoon grated cheese and a few grains salt. Turn into an individual mould, set in pan of hot water, and bake until firm. COLD SLAW Select a small heavy cabbage, remove outside leaves, and cut cabbage in quarters; with a sharp knife slice very thinly. Soak in cold water until crisp; drain dry between towels, and mix with cream salad dress- ing. CABBAGE SALAD Finely shred one-fourth of a small firm cabbage. Let stand two hours in salted cold water, allowing one tablespoon of salt to a pint of water. Cook slowly thirty minutes one-fourth cup, each, vinegar and cold 112 STARVATION TREATMENT water, with a bit of bay leaf, one-fourth teaspoon peppercorns, one-eighth teaspoon mustard seed and three cloves. Strain and pour over cabbage drained from salted water. Let stand two hours, again drain, and serve with or without mayonnaise dressing. CABBAGE AND CELERY SALAD Wash and scrape two stalks of celery, add an equal quantity of shredded cabbage, and six walnut meats broken in pieces. Serve with cream dressing. CUCUMBER CUP Pare a cucumber and cut in quarters crosswise. Remove center from one piece and fill cup thus made with tartare sauce. Serve on lettuce leaf. CUCXJMBER AND LEEK SALAD Cut cucumber in small cubes and leeks in very thin slices. Mix, using equal parts, and serve with French dressing. CUCUMBER AND WATERCRESS SALAD Cut cucumbers in very thin slices, and with a three- tined fork make incisions around the edge of each slice. Arrange on a bed of watercress. EGG SALAD I Cut one hard-boiled egg in halves crosswise, in such a way that tops of halves may be left in points. Remove yolk, mash, moisten with cream, French or mayonnaise dressing, shape in balls, refill whites, and serve on lettuce leaves. Garnish with thin slices of radish, and a radish so cut as to represent a tulip. OF DIABETES 113 EGG SALAD Prepare egg same as for Egg Salad I, adding to yolk an equal amount of chopped cooked ehicken or veal. EGG AND CHEESE SALAD Prepare egg same as for Egg Salad I, adding to yolk three-fourths tablespoon grated cheese; season with salt, cayenne and a few grains of mustard ; then moisten with vinegar and melted butter. Serve with or without salad dressing. EGG AND CUCUMBER SALAD Cut one hard boiled egg in thin slices. Cut as many very thin slices from a chilled cucumber as there are slices of egg. Arrange in the form of a circle (alternating egg and cucumber), having slices overlap each other. Fill in center with chicory or watercress. Serve with salad dressing. CHEESE SALAD Mash one-sixth of a Neufchatel cheese and moisten with cream. Shape in forms the size of a robin's egg. Arrange on a lettuce leaf and sprinkle with finely chopped parsley which has been dried. Serve with salad dressing. CHEESE AND OLIVE SALAD Mash one-eighth of a cream cheese, and season with salt and cayenne. Add finely chopped olives, two let- tuce leaves, finely cut, and a small piece of canned pimento, to give color. Press in original shape of cheese and let stand two hours. Cut in slices and serve on lettuce leaves with mayonnaise dressing. 114 STARVATION TREATMENT CHEESE AND TOMATO SAhAD Peel and chill one medium-sized tomato, and scoop out a small portion of the pulp. Mix equal quantities of Roquefort and Neuf chatel cheese and mash, then moisten with French dressing. Fill cavity made in tomato with cheese. Serve on lettuce leaves with French dressing. FISH SALAD I Remove salmon from can, rinse thoroughly with hot water and separate in flakes ; there should be one- fourth cup. Mix one-eighth teaspoon salt, a few grains, each, mustard and paprika, one teaspoon melted butter, one-half tablespoon cream, one table- spoon water, one-half tablespoon vinegar and yolk of one egg ; cook over hot water until mixture thickens ; then add one-fourth teaspoon granulated gelatin soaked in one teaspoon cold water. Add to salmon, mould, chill, and serve with cucumber sauce. Cucumber Sauce. — ^Pare one-fourth cucumber; chop, drain, and add French dressing to taste. ASPAEAGUS SALAD Drain and rinse four stalks of canned asparagus. Cut a ring one-third inch wide from a red pepper. Put asparagus stalks through ring, arrange on lettuce leaves, and pour over French dressing. TOMATO JELLY SALAD Season one-fourth cup hot stewed and strained to- mato with salt, and add one-third teaspoon granu- lated gelatin soaked in a teaspoon cold water. Turn into an individual mould, chill, turn from mould, OF DIABETES 115 arrange on lettuce leaves, and garnish with, mayon- naise dressing. FROZEN TOMATO SALAD Season stewed and strained tomato with salt and cayenne. Fill a small tin box with mixture, cover with buttered paper, then tight-fitting cover, pack in salt and ice, equal parts, and let stand two hours. Remove from mould, place on lettuce leaf and serve with mayonnaise dressing. TOMATO JELLY SALAD WITH VEGETABLES Cook one-third cup tomatoes with bay leaf, sprig of parsley, one-sixth slice onion, four peppercorns, one clove, eight minutes. Bemove vegetables and rub tomato through a sieve; there should be one-fourth cup. Add one-eighth teaspoon granulated gelatin soaked in one teaspoon cold water, a few grains salt, and four drops vinegar. Line an individual mould with cucumber cut in fancy shapes, and string beans, then pour in mixture. Chill, remove from mould, ar- range on lettuce leaf, and garnish with mayonnaise dressing. TOMATO BASKET OF PLENTY Cut a medium-sized tomato in shape of a basket, leaving stem end on top of handle. Fill basket with cold cooked string beans cut in small pieces and two halves of English walnut meats cut in pieces, moist- ened with French dressing. Serve on lettuce leaf. TOMATO AND CHIVE SALAD Remove skin irom small tomato. Chill and cut in halves crosswise. Spread with mayonnaise, sprinkle with finely chopped chives, and serve on lettuce leaf. 116 STAEVATION TEEATMENT CANARY SALAD Cut a slice from the stem end of a bright red apple and scoop out pulp, leaving enough to keep shell in shape. Fill shell thus made with grapefruit pulp and finely chopped celery, using twice as much grape- fruit as celery. It will be necessary to drain some of the juice from the grapefruit. Mositen with mayon- naise dressing, replace the cover and arrange on let- tuce leaf, and garnish with a canary made from Neuf chatel cheese, coloring yellow and shaping, desig- nating eyes with paprika and putting a few grains on the body of the bird. Also garnish with three eggs made from cheese, colored green and speckled with paprika. Note. — Do not use apple pulp. HARVAED SALAD Cut a selected lemon in the form of a basket with handle, and scoop out all the pulp. Fill basket thus made with one tablespoon cold cooked chicken or sweetbread cut in small dice, mixed with one-half tablespoon small cucumber dice, and one teaspoon finely chopped celery moistened with cream or mayon- naise dressing. Spread top with dressing and sprin- kle with thin parings cut from round red radishes finely chopped. Insert a small piece of parsley on top of handle. Arrange on watercress. CUCUMBER BOATS Cut a small cucumber in halves lengthwise. Scoop out centres and cut boat-shaped. Cut cucumber cut from boats in small pieces and add one and one-half OF DIABETES 117 olives finely chopped. Moisten with French dressing, fill boats with mixture and serve on lettuce leaves. SPINACH SALAD Drain and finely chop one-fourth cup cooked spin- ach. Season with salt, pepper, lemon juice, and melted butter. Pack solidly in an individual mould, chill, remove from mould, and arrange on a thin slice of cooked tongue cut in circular shape. Garnish base of mould with wreath of parsley and top with sauce tartare. Sauce Tartare. — To one tablespoon mayonnaise dressing add three-fourths teaspoon finely chopped capers, pickles, olives, and parsley, having equal parts of each. SWEETBREAD AND CUCUMBER SALAD Mix two tablespoons cold cooked sweetbread cut in cubes, one tablespoon cucumber cubes, and one- half tablespoon finely chopped celery. Beat one and one-half tablespoons with heavy cream until stiff, then add one-eighth teaspoon granulated gelatin dissolved in one teaspoon boiling water and three-fourths tea- spoon vinegar. Set in a pan of ice water and as mix- ture begins to thicken, add sweetbreads and vegetables. Mould and chill. Remove from mould, arrange on let- tuce leaves, and garnish top with a slice of cucumbers and sprig of parsley. CHICKEN AND NUT SALAD Mix two tablespoons cold cooked chicken or fowl cut in cubes with one tablespoon finely chopped cel- ery and one-half tablespoon English wabiut meats 118 STARVATION TREATMENT browned in oven with one-eighth teaspoon butter and a few grains salt, then broken in pieces. Moisten with mayonnaise dressing. Mound and garnish with curled celery, tips of celery, and whole nut meats. PRINCESS PUBDING 1 egg yolk % teaspoon granulated gelatin dissolved in 1 tablespoon boiling water 2 teaspoons lemon juice % grain saccharine dissolved in Yi teaspoon cold water 1 egg white. Beat egg yolk until thick and lemon-colored, add gelatin, continue the beating. As mixture thickens add gradually the lemon juice and saccharine. Fold in white of egg beaten until stiff and dry. Turn into a mould and chill. COFFEE BAVAEIAN CREAM 2 tablespoons coffee infusion 1 tablespoon water 2 tablespoons heavy cream 1 egg yolk Few grains salt % teaspoon granulated gelatin soaked in 1 teaspoon cold water. 1 grain saccharine dissolved in y2 teaspoon cold water 1 egg white Yi teaspoon vanilla Scald coffee, water and one-half cream. Add egg yolk, slightly beaten, and cook until mixture thickens ; OF DIABETES 119 then add gelatin and salt. Eemove from fire, cool, add saccharine, remaining cream beaten stiff, egg white beaten until stiff, and teaspoon vanilla. Turn into mould and chill. LEMON CEEAM SHERBET J4 cup cream 2 tablespoons cold water % grain saccharine dissolved in y2 teaspoon cold water 4 drops lemon juice Few grains salt Mix ingredients in order given and freeze. ORANGE ICE Ys cup orange juice 1 teaspoon lemon juice 2 tablespoons cold water Yz grain saccharine dissolved in 14 teaspoon cold water Mix ingredients in order given, and freeze. GRAPEFRUIT ICE ^4 cup grapefruit juice 14 cup water ^ grain saccharine dissolved in Yz teaspoon cold water Remove juice from grapefruit, strain and add re- maining ingredients, and freeze to a mush. Serve in sections of grapefruit. FROZEN PUNCH Ya cup cream 2 tablespoons cold water 120 STARVATION TREATMENT lYz teaspoons rum 1 egg yolk Yz grain saceliarine dissolved in l^ teaspoon cold water Pew grains salt Scald one-half cream with water, add egg yolk slightly beaten and cook over hot water until mixture thickens. Cool, add remaining ingredients and freeze. FOOD VALUES / SOME estimates of the quantity or bulk of food have been given in addition to that stated in the diet tables. Patients should be encouraged to study their own diets and provide themselves with suitable scales for weighing food. In no other way can severe cases be successfully treated, and those of the milder type can be provided for more comfortably. The description of a portion of food by the terms, "small helping," "thin slice," "heaping tablespoon" is obviously in- definite. 100-Geam Portions. Asparagus — 8 or 9 stalks 4 inches long. Beans (string) (cut in small pieces) 2 heaping table- spoons. Bacon — 4 slices 6 inches long, 2 inches wide.^ Cabbage (cooked) — 2 heaping tablespoons. Cauliflower — 2 rounding tablespoons. Celery — 6 pieces 4i/^ inches long, medium thickness. Cheese — a piece 4 inches by li/^ inch by 1 inch. Cucumbers — 12 slices % inch thick, y^ inch in diam- eter. Greens (spinach, kale, etc.) — 2 heaping tablespoons. Lettuce — 10 to 12 medium-sized leaves. - Bacon loses about half of its fat content when cooked. 121 122 STARVATION TREATMENT Onions — 2 onions, size of an egg. Olives — 25 small olives. Peas — 2 heaping tablespoons. Potatoes (baked) — 1 small potato, size of an egg. Potatoes (mashed) — 2 rounding tablespoons. Sardines — ^28 sardines = 1 small box. Salmon — 14 can (almost). Tomatoes — 2 heaping tablespoons. Tomatoes — fresh, one medium sized tomato, 2 inches in diameter. Other Weights. 1 tablespoon olive oil = 13 grams 1 tablespoon mayonnaise = 21 1 thin slice of bread (baker's loaf) = 25 1 medium sized orange = 150 1 peach = 125 1 medium sized apple = 150 y^ small grapefruit = 150 1 medium sized lamb chop with bone = 100 1 medium sized slice cold tongue = 25 1 slice tenderloin steak 1 in. thick = 100 1 average helping of fish = 100 1 average helping of butter = 10 1 average sized egg = 50 1 average helping of cooked green vege- tables such as spinach, cabbage, cauliflower, asparagus, etc. (2 ta- blespoons) ^ = 100 " 1 It is not true that all the vegetables weigh the same, but for the sake of simplicity in most of the diets it has been reckoned that two heaping tablespoons of any one of the "5 per cent.'' vegetables weighs 100 gms. OF DIABETES 123 1 average helping boiled cereal = 100 ' ' 1 potato, size of large egg = 100 " The following food values are taken from Locke's Abstract of Atwater and Bryant's Bulletin No. 28, 1906, United States Department of Agriculture. Fractions of per cents, have been left off in order to make the use of the table more simple, and the values given will be found quite accurate enough for clinical purposes. Pood Stuffs. Quantity. Protein. Raw, Grams. Meat. Beef 100 gms. 22 Chicken " " 32 Bacon (raw) " " 10 Fish. Fish (average) " " 20 Oysters " " 6 Eggs. Eggs " " 13 Eggs 1 egg 7 Dairy Products. Butter 100 gms. 1 Cheese (American) . . " " 28 Cheese (Neufchatel) . " " 19 Milk (whole) " " 3 Milk (whole) 1 qt. 30 Milk (skim) 100 gms. 3 Milk (skim) 1 qt. 31 Cream (gravity) 100 gms. 3 Cream (gravity) 1 pt. 12 Pat. Orama. Carbo- hydrate. Grams. Total Calo- ries. 28 350 4 168 64 636 7 147 1 3 46 12 165 6 84 85 795 35 2 448 27 2 337 4 5 70 36 45 642 0.3 5 35 3 46 343 16 5 181 73 23 822 124 STARVATION TREATMENT Oarbo- Total Food Stuffs. Quantity. Protein. Pat. hydrate. Calo- Baw. Orama. Grams. QramB. ries. Cereal Products. Oatmeal (cooked) ...100 gms. 3 0.5 12 66 Rice (cooked) " " 3 0.1 24 112 Macaroni (cooked) .. " " 3 0.1 24 112 Bread " " 9 1 53 264 Soda crackers " " 10 9 73 424 Cake (average) . " " 6 9 63 367 Vegetables. Asparagus (canned) .100 gms. 2 1 3 30 Beans (dried) " " 22 2 59 350 Beans (string) fresh cooked " " 1 1.0 2 22 Beats (cooked) " " 2 0.1 7 37 Cabbage (raw) " " 2 0.3 6 35 Carrots (raw) " " 1 0.4 9 45 Cauliflower (raw) ... " " 2 0.5 5 33 Celery (raw) " " 1 0.1 3 17 Com (green) " " 3 1 20 103 Cucumbers (raw) ... " " 0.8 0.2 3 17 Lettuce (raw) " " 1 U.3 3 19 Mushrooms (raw) ... " " 3 0.4 7 45 Onions (raw) " " 1 0.3 10 48 Peas (dried) " " 24 1 62 362 Peas (green, raw) ... " " 7 0.5 16 99 Potatoes (white) " " 2 0.1 18 83 Potatoes (sweet) " " 2 0.7 27 125 Spinach " " 2 0.3 3 23 Squash " " 1 0.5 9 46 Tomatoes " " 0.9 0.4 4 24 Turnips " " 1 0.2 8 39 OF DIABETES 125 The values for all vegetables are calculated from the raw vegetables. OaTbo- Total Food Stuffs. Quantity. Piotein. Fat. hydrate. Gslo- Kaw. Grams. Grams. Grams, riea. Fexjits. Apples (edible por- tion) 100 gms. 0.4 0.5 14 64 Bananas (edible portion) " " 1 0.6 22 100 Blackberries " " 1 1 11 59 Cherries " " 0.1 1 15 71 Cranberries " " 0.4 0.6 10 48 Currants " " 1 13 57 Figs (dried) " " 4 0.3 74 323 Grapes " " 1 1 14 71 Huckleberries " " 0.6 0.6 16 74 Lemon juice " " 10 41 Muskmelons (edible portions) " " 0.6 9 39 Oranges (edible por- tion) " " 0.8 0.2 11 50 Peaches (edible por- tion) " " 0.7 0.1 9 41 Pears (edible por- tion) " " 0.6 0.5 14 65 Prunes (dried) " " 2 73 308 Raisins (dried) " " 2 3 76 348 Pineapples " " 0.4 0.3 10 45 Plums (edible por- tion) " " 1 20 86 Easpberries " " 1 12 53 Strawberries " " 1 0.6 7 38 126 STARVATION TREATMENT Oarbo- Total FoodStufEs. Quantity. Plrotein. Fat. hydrate. Oalo- Baw. Grams. Grams. Grams, ries. ■Watermelons " " 0.4 0.2 7 32 Nuts. Almonds 100 gms. 21 54 17 658 Chestnuts " " 6 5 42 243 Peanuts (edible por- tion) " " 25 38 24 554 Walnuts " " 18 64 13 722 MiSCELANEOUS. Chocolate 100 gms. 13 48 30 623 Whiskey 50 c.c. 43% alcohol 152 Larger beer 250 c.c. 4.5% alcohol 130 ADDITIONAL DATA Bacon (raw) 4 slices, 6 in. long 2 in. wide 10 64 636 Bacon (cooked) 4 slices, 6 in. long, 2 in. wide 10 32 338 to 46 to 468 Beef (roast), 1 slice, 4i/^x lygxi/s in 6 7 89 Egg, 1 medium size, 50 gms. 7 6 84 Oysters, 6 large 6 1 3 46 Butter, 11^ in. cube (25 gms.) 21 195 Cream (Neufchatel) 1 cheese 21/4 X 11/2 xli^ in 16 23 1 284 Cream ( gravity — " 16 % " ) , ■ 1 glass, 7 oz 5 32 10 359 Milk (whole), 1 glass, 7 oz... 6 8 9 136 OF DIABETES 127 Oarbo- Total Food Stuffs. Quat^tity. Protein. Fat. hrdrate. Calo- Raw. Grams. Qranu. Qrams. rie». Bread, 1 slice, 3 x 3i^ x i^ in- (30 gms.) 3 .5 16 81 Uneeda Biscuit (1) 1 .5 4 20 Rice (boiled), 1 tablespoon, (50 gms.) 1+ 12 56 Oatmeal (boiled), 1 table- spoon (50 gms.) 1+ + 6 33 Potato (size of large egg), 100 gms 2 + 18 83 "5% "vegetables (uncooked) 1 tablespoon 2.5 10 "5%" vegetables (boiled once) 1 tablespoon 1.7 7 "5%" vegetables (boiled thrive) 1 tablespoon 1 4 Grape fruit as purchased (1 small) 300 gms 2 30 131 Orange as purchased (1 me- dium) 150 gms 1 13 57 English walnuts (6 whole meats) 20 gms 4 12 3 140 Almonds (10 small) 10 gms. 2 5 2 63 Peanuts (as purchased) 15 nuts 6 9 6 33 AH of these values are approximate. The follow- ing vegetables may be considered as falling into the "5%" group: Lettuce, string beans, spinach, cab- bage, Brussels sprouts, egg plant, cauliflower, toma- toes, asparagus cucumbers beet greens, chard, celery, sauerkraut, ripe olives, kale, rhubarb, dandelions, en- 128 STARVATION TREATMENT dive, watercress, pumpkin, sorrel, and radishes. As these various vegetables contain from 3 to 7% carbo- hydrate, it will be seen that the value of 21/^ grams carbohydrate for 1 tablespoonful of these vegetables raw, and 1 gram for the same amount thrice boiled, is not accurate, but it is near enough for practical purposes. 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 grajn protein = 4.1 calories. 1 gram carbohydrate = 4.1 calories. PEOTEIN AND CAEBOHYDRATE PERCENT- AGES OF "DIABETIC FOODS" Tke following analyses are taken from the Reports of the Connecticut Agricultural Station, Part I, 1913, and Part V, 1914. For the sake of uniformity the protein has been cal- culated by means of the factor 6.25, and for this reason the protein values of the wheat preparations are some- what too high. As can be seen from the analyses, many of the so- called " diabetic foods" on the market contain a large amount of starch, and are a source of danger to the diabetic. Many of the better preparations are, how- ever, of great value in supplementiag the diet. We recommend no particular brands, but the reader can easily see for himself by a study of the starch per- centages, what products are, and which ones are not, suitable foods for diabetic patients. "We have not in- eluded in the table the "nitrogen-free extract" or total carbohydrate of the various flours and bread products of the Connecticut Agricultural Station's original report, as in these preparations a consider- able amount of the "nitrogen-free extract" is carbo- hydrate which is in an unassimilable form. FLOURS AND MEALS Date or Analysis Manufaotueeb and Beand Peotbin, PEE CENT. Staeoh, PEE CENT. 1910 Acme Mills Co., Portland, Ore. Acme Diabetic Flour ... 9.4 71.4 129 130 STARVATION TREATMENT Date or Pbotein, Stabch, Analysis Manufaoturbb and Brand per oknt. pee cent. Herman Barker, SomerviUe, Mass. 1912 Barker's Gluten Flour A 85.4 4.5 1913 Barker's Gluten Flour B 84.4 6.0 1913 Barker's Gluten Flour C 84.1 3.4 1913 Cereo Co., Tappan, N. Y. Soy Bean Gruel Flour 43.1 Trace Farwell & Mames, Watertown, N. T. 1913 Cresco Flour 18.1 57.2 1913 Gluten Flour 43.1 38.1 1913 Special Diabetic Food 27.5 40.0 Golden Rod Milling Co., Portland, Ore. 1913 Acme Special Flour 15.8 57.9 0. B. Oilman, Boston, Mass. 1913 Gluten Flour 47.3 31.4 Beaith Food Co., New York 1913 Almond Meal 50.3 Trace 1911 C B Cold Blast Flour 10.1 68.9 1913 Glutosac Gluten Flour 39.9 36.9 Pronireu (Gluten Griddle Cake Flour) 37.3 37.7 1913 Protosac Gluten Flour 42.7 36.3 1913 Protosoy Soy Flour 42.3 Trace 1913 Pure Washed Gluten Flour 80.3 7.0 Jireh Diabetic Food Co., New York 1913 Diabetic Flour 14.4 60.9 1913 Patent Barley 11.4 67.8 1913 Cotton Seed Flour 49.1 6.0 1913 Lentil's Flour 27.3 42.6 1913 Protein Flour 31.4 48.5 1913 Soja Bean Flour 42.3 0.0 Johnson, Educator Food Co., Boston, Mass. 1911 Educator Standard Gluten Flour 40.1 40.9 The Kellogg Food Co., Battle Creek, Mich. 1912 20 per cent. Gluten Meal 27.5 49.6 1913 40 per cent. Gluten Flour 46.0 40.5 1912 80 per cent. Gluten Flour 81.3 6.2 OP DIABETES 131 Date op Peotein, Staboh, AnaiiYsis Manufactxieeb and Beand peb cent, pee cent. Eugene Loeh, New York 1913 Gluten Cracfeer Meal 27.8 40.2 1913 Imported Gluten Flour 76.3 4.4 1913 Pure Gluten Flour 40.3 39.6 1913 Whole Wheat Flour 4.6 54.6 Thos. Martinddle d Co., Philadelphia 1913 Special Gluten Flour 43.9 39.8 Mayflower Mills, Fort Wayne, Ind. 1913 Bond's Diabetic Flour 40.2 40.6 1913 Theo. Metoalf Co., Boston, Mass. Vegetable Gluten 80.4 5.9 Pieser-Livingston Co., Chicago 1913 Gluten Flour 41.8 36.5 Pure Oluten Food Co., New York 1911 Gum. Gluten Flour 38.3 42.4 Sprague, Warner, £ Co., Chicago 1913 Richelieu Gluten Flour 49.7 31.6 Wilson Bros., Rochester, N. Y. 1913 Gluten Flour ^ Standard 20.8 54.6 PROTEIN PREPARATIONS The Bauer Chemical Co., Berlin 1912 Sanatogen 80.1 Plasmon Co., London 1909 Plasmon (average 9 analyses) . . . 70.3 SOFT BREADS Ferguson Bakery, Boston, Mass. 1913 Gluten Bread 24.2 25.2 Jireh Diabetic Food Co., New York 1913 Whole Wheat Bread 12.4 44.9 Eugene Loeb, New York 1913 Genuine Gluten Bread 10.4 44.2 132 Date oi' Pbotbin, Staboh, Analysis MANurAOTUEBB and Bband pek cent, pbb cent HARD BREADS AND BAKERY PRODUCTS Health Food Co., New York 1913 Alpha Best Diabetic Wafer 66.1 Trace 1913 Diabetic Biscuit 25.0 46.5 1913 Gluten Nuggets 30.2 38.6 1913 No. 1 Proto Puffs 72.25 9.23 1913 No. 2 Proto Puffs 58.75 20.70 1913 Protosoy Diabetic Wafers 43.1 4.7 Heintz Food Co., Chicago 1913 Gluten Biscuits 12.8 21.4 1913 Gluten Biscuits 14.5 45.5 1913 Huntley £ Palmer, London AkoU Biscuits 54.5 Trace Jireh Diabetic Food Co., New York 1913 Diabetic Biscuits 13.2 49.6 Johnson Educator Food Co., Boston 1913 Gluten Bread Sticks 23.0 57.9 1911 Gluten Cookies 35.9 37.5 The Kellogg Food Co., Battle Creek, Mich. 1912 Avena-Gluten Biscuit 21.4 41.1 1913 Potato Gluten Biscuit 41.5 39.5 1913 Taro-Gluten Biscuit 31.3 48.2 1913 40 per cent. Gluten Biscuit 37.2 45.0 1912 80 per cent. Gluten Biscuit 82.4 4.7 BREAKFAST FOODS Farwell & Bhines, Watertoum, N. T. 1913 Barley Crystals 17.2 48.8 1913 Cresco Grits 11.5 64.9 Jireh Diabetic Food Co., N. T. 1913 Whole Wheat Farina 37.6 31.0 1913 Frumenty 12.9 59.5 Kellogg Food Co., Battle Creek, Mich. 1911 Granola 13.9 45.2 Pure Gluten Food Co., New York 1911 Gum Gluten Breakfast Food 37.8 37.9 1911 Gum Gluten Granules 45.5 32.3 133 Date of Pbotbin, Staeoh. Analysis Mantjfaotubbb and Brand pbe cent, pbb cent. MACARONI, NOODLES, ETC. Jireh Diabetic Food Co., New York 1913 Macaroni 16.9 58.8 Eugene Loei, New York 1913 Home Made Noodles 41.8 36.7 Pure Gluten Food Co., New York Gum Gluten Noodles 41.4 46.2 MORE RECENT ANALYSES, FROM THE 1914 REPORT The Dieto Food Go., New York Dieto Bread, Pure Whole Wheat 13.19 17.72 " Cocoa 23.56 12.38 " Crackers 13.38 54.84 " Flour, Pure Whole Wheat 14.75 62.44 " Nut Cereal 21.63 39.54 " Pine Nuts 39.69 0.00 " Rusks 15.94 52.09 " Wheat and Barley Cereal 11.63 61.42 " Whole Wheat Brand Macaroni 13.88 58.72 Sealth Food Co., New York Almond Meal 49.13 0.00 Glutosac Bread 27.16 22.17 Butter Wafers 31.13 38.93 Rusks 39.31 33.64 Wafers (Plain) 42.63 29.55 Zwieback 36.38 32.46 Protosac Bread 29.82 27.66 Gluten Elour 45.94 31.50 Pure Washed Gluten 42.88 1.86 Protosoy Soy Flour 37.07 14.40 Loeh's Diabetic Food Bakery, New York Chocolate Almond Bars 16.25 6.74 134 STARVATION DIET ANALYSES FROM 1914 REPORT.— Comtiimed Diabetic Almond Macaroons 46.50 0.64 Bread Sticks 50.44 24.64 " Chocolates 14.88 6.92 " Lady Fingers 56.56 1.81 " Sponge Cookies 54.69 1.24 Gluten Luft Bread 52.38 22.89 P. & L. Genuine Glubetic Bread 38.77 19.15 NOW READY THIRD EDITION PRINCIPLES OF MEDICAL TREATMENT By GEORGE C. SHATTUCK, M. D. Assistant Physician to the Massachusetts General Hospital Besides thorough revision, the principal features of the third Edition are new sections upon Infectious Dis- eases, Diphtheria, Scarlet Fever, Measles, Varicella, Pertussis, Tuberculosis. The Preface of the First Edition stated : " This work offers clearly and concisely sound principles of treatment based on known pathology." The book has been well reviewed by all Journals, and used with satisfaction by thousands of physicians. mcnuto c CABtfT, w. dl I ttAtU-BOROUGH $tt *aT)eiits4eea dhlv- by APPOIHTUENT. .t£«pHo»fc«we,TW Sept.,30,;a915. Dear' Mr^J,eoaard!-r, • I 'thank you very much for Dr. iShatttick's little book. . I know of no book on thei'apeQtlos nhiclt containa so much that seeas to me true and 80 little that seams to' me error.£>I have steadily reoommended and shall -continue toreconimend the book. Yours sincerely. i^f- " The worth of this book is out of all pro- portion to its size." — Medical Record. This book has been printed five times in three edi- tions, and in each printing the number of the edition has been doubled. Price Postpaid : One Dollar and a Half W. M. LEONARD Publisher Boston JUST PUBLISHED PULMONARY TUBERCULOSIS By EDWARD O. OTIS, M. D. Professor of Pulmonary Diseases and Climatology, Tufts Medical School, Boston; Formerly Visiting and Consulting Physician to the Massachusetts State Sana- torium (Rutland) ; Fellow and Former President of the American Climatological and Clinical Association; Cor- responding Member of the International Tuberculosis Institute; Consulting Physician to the Boston Dispen- sary, Tuberculosis Department, etc. From the Preface The author has been engaged in teaching the subject of pulmonary tuberculosis for a considerable number of years, and this manual is largely the result of his expe- rience. . . . One of the difficulties in making an early diagnosis of pulmonary tuberculosis is inability to correlate the symptoms and physical signs, and ,to give to each its due proportionate weight. In this handbook an attempt has been made to aid in this respect. No teacher or consultant knows better what is needed, and none is better qualified to write this manual, than Doctor Otis. It will be. found to present all that is wanted in Diagnosis and Treatment and no more, and to be well written, well-arranged and complete, with a very thorough index. Octavo, 220 pages, with i6 full page inserted illustra- tions. Postpaid $1.75. W. M. LEONARD Publisher Boston The Case History Series Six years ago the_ plan of presenting in a book, by means of case histories and discussion, a post-graduate clinical course, was begun. The following named au- thors in succession have chosen this method to present in their special subjects such courses to the Profession. JOHN LOVETT MORSE, M.D. CASE HISTORIES IN PEDIATRICS Second Edition. Second Printing. Octavo, 640 pages. Illustrated. $5.50 JAMES G. MUMFORD, M.D. ONE HUNDRED SURGICAL PROBLEMS Second Printing. Octavo, 354 Pages. 12 Plates. $3.00. RICHARD C. CABOT, M.D. CASE HISTORIES IN MEDICINE Third Edition. Octavo, 298 Pages. 2 Plates. $3.00. E. W. TAYLOR, M.D. CASE HISTORIES IN NEUROLOGY Second Printing. Octavo. Illustrated. $3.00. ROBERT L. DeNORMANDIE. M.D. CASE HISTORIES IN OBSTETRICS Second Edition. Octavo, 516 Pages. $4.00. CHARLES M. GREEN, M.D. CASE HISTORIES IN GYNECOLOGY Octavo, 480 Pages. Illustrated. $400. On Press By ELMER E. SOUTHARD, M.D. Director of the Massachusetts Psychopathic Hospital Professor of Neuropathology, Harvard University NEURO-SYPHILIS Presented in Case Histories and Discussion By CHARLES F. PAINTER, M.D. Dean of Tufts Medical College and Professor of Orthopedic Surgery ORTHOPEDIC SURGERY AND DISEASES OF BONES AND JOINTS W. M. LEONARD Publisher Boston