Dltl~~~~~C~~ES-JOS LIN ~~~~~~JUN~- 2, 1921
1582DiA£EkS-fJOSLIN JOUR. A. .. A.
1582
bohydrat or a much below that quantity as was n The place at which insulin is given is most frequently
bohydrate- or as much below that quantity as wa. teas ,te h tighnn atytebtok
the patient's former diet, or, if that is unknown, with The arm, then the thigh,of insulin daitly thefor 127 of myck.
an equivalent of tise grams of sugar in the urine. For The average dose of insulin daily for 127 of my
use in the hospital, test and maintenance diets are use- ptwentyfour hol uitrs m or e than 45 units, but threeaking i
ful; but advances in dietetic treatment and insulin force tware taking a ors more thany as 30 45 units, butwhile a considerable
their constant modification, so that the one here shown aume r (eighteen) receive less than 5a units, while a cosiderabley.
must be regarded as tentative. It is a great advantage numer (eighteen) receive les than 5 uits a da.
not to have invented a formula for compuitig~ tiiets, ''The first of my patients chosen to receive insulin was
notto aveilvened fomua fr (omptllg les,selected because I knew of none more severe or more
lbecause one feels quite free to take the best of all sys- selected becau knew of noe more evere or more
tems. Having started the diet, one proceeds each (lday strictly faithul to every detail of treatment in the past:
to the next diet in sequence until the urine is sugar- Miss M, aged 42, who had had diabetes for five years
free. Fasting is practically never necessary for even whose weight had fallen from 157 to 72 pounds (from 72 to
one meal, since generally the patient becomes sua-fee 33 kg.); wo cod scarcey e kept sugar-free on any diet
o n Test Diet 3 or 4. Then one skips to that maintenalice aid who had heen down to the street but once in nine months,
liet whicb bas about the same quantity of carbohydrate, began insulin, Aug. 7, 1922. Since that date she has gained
andiadvances each day. If sugar returhs, for onstahicae, 20 pounds (9 kg.), has a normal blood sugar before and after
and advances each day. If sugar returns, for instanlehrcakfast, and is sugar-free while taking 10 units daily
on the carbohydrate and protein and fat for the sixth inosteal of the 35 units daily, which she at one time required.
day (C6- + PF6) and the patient is not receivilng Her diet has been, carbohydrate, 25 gmn.; protein, 43 gmn.;
enough calories, one lowers the diet to C5 or C4 anl1 fat, 105 gmi., and I have now raised it to carbohydrate, 30
advances the protein and fat (PF) to PF7 or PFS or gin.; protein, 50 gm., and fat. 110 gmn. I am content to have
mrore as oseeded, or even adds extra fat in the foron of had the weight in my severest case of diabetes increase in
creanm or butter. cight months by 28 per cent., and to have reduced the dosage
TABLE 1.-lInsulin Diabetic Diets
Total ODiet Carbohydrate (C) Protein and Fat (PF)
Carbo- 0% Shred- Cream
hy- Pro- Calo- Vege Oat- ded 2a
Diet drate tein Fat ries tables Orange meal Wheat Unceda Potato Egg Fat Bacon Butter Meat Diet
T. D. 1 1810. 4fi 4a 1,sito4 31300 30 3 4 240 3 120 . ...... 1
Tet T. D. 2 1Ot 35 43 931 3() 300 1 t20 3 120 . . 2
T. D. 3 i6 24 37 693 3(10 300 .. l 2 ... 2 120 .. .. ... 3
IT.D.4 34 15 30 466 300 200 .. .. . 1 120 . 4
C1+ PF1 14 15 30 386 300 ... .... .. ... 1 120 ..
IC2 + PF2 22 19 37 497 300 100 . ... 2 fi . 15 2
C3 + PF3 32 24 37 557 600 100 .. .... ...3
C4 + PF4 42 29 52 752 200.. .. . 2 60 3) 15 ... 4
C5 + PF5 52 32 i6 930 fOO 2() I52 60 30 30 ... 5
Mainte- C63+PFf 64 44 83 1,179 fi)0 2Ot 30 ..2.. ... 120 30 30 30 6
nance C7 + PF7 74 52 88 1,296 6 30 30 3.. 2 120 30 30 60 7
CS + PFS 84 61 94 1,426 600 300 30 2 ... 2 120 30 30 90 8
C9 + PF9 98 65 106 1606 0 300 30 2 ... 2 180 30 30 80
C10 + P100 109 66 119 1,771 600 300 30 1 2 ... 2 180 30 45 90 10
C11 + PF11 135 80 135 2,075 60o 300 30 1 2 120 2 240 30 45 120 11
C12 + PF12 159 84 135 2,187 600 300 30 1 2 240 2 240 30 45 120 12
The first dose of insulin should be 1 unit. This is of itnsulin from 35 units to 10 units. With the extra food
the amount necessary to lower the blood sugar of a 1 allowed, she requires at least 5 units more of insulin. Her
kilogram rabbit, fasting twenty hours, to 0.045 per cenlt. weight has again increased to 96 pounds (43.5 kg.). With
it is safer to begin with one unit, because I have known tle restricted diet, will she not again be able to reduce her
tis to rig dow te blood ugar of a diaetic patient sulin when her further gain in weight makes her once
tbis to bring downo t1he blood sugar of a dialetic patient tir ueîd
with a tolerance for and while taking 91 gm. of carbo-
hydrate to 0.03 per cent. Insulin is more often given Patients omitting insulin through lack of supply
than withheld at the hospital as soon as the diagnosis must go to bed and restrict the diet one-third:
is dlefinitely madte, in order to meet the patient's
wisll to curtail hospital stay. Before tlle secolld meal Thomas D., my faithful little patient, went home and,
2vii) ra isptat.Before 21e secoo meal, i ! h i dunfortunately, in the absence of his home physician, thought
2 units are given, 3 before the third, and so os ip to he could get along without insulin. After five days he
5 units, and then this quantity is given three tilles ta becamrne ill, an intercurrent respiratory infection occurred,
dlay anti increased or decreased as insdicated. Some- cotila developcd, and he returned to the hospital to die in
tiO3es thue extract îiroves to be Ounoecessary asfter a sevmn bhours, Oct. 20, 1922. No other patient with coma has
coupole of dlays. Durinig this period the diet also is dtcd at the New England Deaconess Hospital since Aug. 7,
1922.
being changed. ()nce the patient is sugar-free, the
attemlpt is 03t(le to get rid of the noon dose by shiftiiîg Tlle treatment of coma with insulin is spectacular, but
the carbolbydlratc as far as feasible to breakfast amii comia is a diabetic accident, and, like all accidents, to be
supper, and (decreasing the noon0 insulin by a unit each avoided. At tie New England Deaconeos Hospital, the
day. If unsparabhlc, the omitted in sulin is< takien pte h augh,ph
day. If iinusparab>le, the on3itted i03 2 s takeni np> Ilack of coma is to be attributed partly to the training
again, but this time is divided between the doses before giveî patients. Tbey are taugbt, wbenever iii from
~breakfa~st sud supper. any cause to (1) go to bed; (2) keep warm; (3) take
The time~ aI wbicb mçulin is given varies f rom une- a glass of hot water, tea, broth, orange juice, or oatmeal
quarte~~~r hou to on Cad onehl hor befr meals,
quarter our to oie ad oe-alf our befre niei, wter gruel every hour; (4) empty the bowels with an
depending on the rapidity of absorption of carbo- enema, sud (5) rail a physician, wbu, if he findo
hydrate from the stomach and insulin from the sub- acidosis, probsbiy will give tbem moulin, digitalis sud
cutaneous tissue, as estimated after observation of each caffein, and may wash out their stomachs. This free-
individtoal natient. dom from coma is perhaps stili more to be attri,nted to