Reprintedfrom THE CANADIAN MEDICAL ASSOCIATION JOURNAL, August, 1923
OBSERVATIONS WITH INSULIN ON DEPARTMENT OF SOLDIERS'
CIVIL RE-ESTABLISHMENT DIABETICS*
JOSEPII A. GILCHRIST, B.A., M.B., C. H. BEST, M.A., AND F. G. BANTING, M.C., M.D.
Toronto
THE object of this paper is to give a brief tract infection, constipation and chronic appendi-
report of the recent work on diabetes citis. If any source of septic absorption is lo-
mellitus in the Soldiers' Civil Re-Establishment, cated it is appropriately treated, since such
and to present to the physician an outline of conditions may lower carbohydrate tolerance.
insulin treatment of diabetes, which may assist The eye grounds are examined for a possible
him in the management of cases, when insulin diabetic retinitis or neuro-retinitis.
is available for general distribution. The report, At first the patient continues on the same diet
therefore, will not give in great detail the labora- as that previous to his admission to hospital in
tory findings obtained by methods which are not' order to obtain some idea of the severity of his
available to the general practitioner. The dia- case, and to avoid complications from sudden
betic cases receiving insulin at the Christie changes of diet. Coma will be discussed sepa-
Street Hospital of the Department of Soldiers' rately. On the second or third day he is placed
Civil Re-Establishment are men who acquired upon a diet the caloric value of which is calcu-
this disease during, or shortly after, the Great lated on his basal requirement. This is deter-
War. The patients, whose ages range from mined from Dubois' chart and Aub-Dubois
twenty-five to fifty-three years, are practically table. It has been estimated by Marsh, New-
all severe diabetics. There are, however, two burg, and Holly' that the body requires two-
moderately severe cases and one mild case. thirds of a gram of protein per kilogram,
Previous to their admission to hospital, all of (1 kilo=2.2 pounds), of body weight per day,
the patients were glycosuric and were progress- in order to maintain nitrogenous equilibrium.
ing unfavourably under dietetic treatment and, The remaining calories must be supplied by carbo-
with one exception, they all showed ketosis. hydrate and fats in a ratio that will prevent the
The daily routine urinalysis includes the volume production of ketone bodies.
of the twenty-four hour specimen, the specific The patient remains on this basal requirement
gravity, the reaction, and tests for albumen by diet at least a week. During this time, blood
heat or nitric acid. The acetone bodies are es- sugar is estimated before, and three hours after,
timated by means of the Rothera and ferric breakfast, in order to determine the fasting level
chloride tests. The sugar determinations are and the effect of food. The quantity of sugar
done by means of the Benedict qualitative and excreted is estimated daily, and this amount sub-
quantitative solutions. In addition to the above, tracted from the available carbohydrate ingested
the blood sugars are estimated by means of the gives approximatelytheutilization. The available
Schaffer-Hartman method and the respiratory carbohydrate includes fifty-eight per cent. of the
quotients with the Douglas bag and Haldane protein, ten per cent. of the fat, and the total
gas analysis apparatus. carbohydrate in the diet. It may be noted that
After a careful history has been taken, the when a patient is placed upon a diet in which
patient is given a complete physical examina- the protein, fat and carbohydrates are balanced,
tion. Special attention is directed to the find- that the amount of sugar excreted soon ap-
ing of foci of possible infection. The teeth, proaches a fairly constant amount, whereas, if
tonsils, accessory sinuses, chest and digestive the diet is not well adjusted to the patient's re-
system are examined clinically, as well as by quirements, there is wide variation in the amounts
X-ray. Special consideration is given to biliary of sugar excreted.
-~~~~~~~ ~~If a patient becomes sugar-free and blood
*The insulin used in this study has been prepared sugar normal on a basal requirement diet the
bv the Connaught Laboratories, University of Toronto
r by the Eli Lilly Company, Indianapolis. caloric intake is gradually increased until sugar