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made at a time when the digestion of the last meal is not finished.
The segregation in four periods has a decided value. Patients are
not free from glycosuria unless the test is absolutely negative in every
period. Even when the reaction seems negative in the mixed 24
hour urine, tests of the separate specimens may show not only the
presence of faint traces but also after which meal they appeared.
Also a transgression of diet is sometimes revealed by a marked reac-
tion occurring suddenly in some period and clearing up thereafter,
whereas a slight reaction in the mixed 24 hour urine might be of doubt-
ful interpretation.

5. Meals. — Food has generally been served in three meals, with
sometimes an additional lunch at bedtime. In the past, minor pecu-
liarities in the relation between meals and glycosuria have been de-
scribed, generally glycosuria after carbohydrate ingestion and clear-
ing up during the night, more rarely glycosuria only at night, absent
during the day perhaps because of exercise. Also, it seems a promis-
ing plan to give carbohydrate distributed in nmnerous small fractions
at intervals, or in slowly digestible form, so as to avoid flooding



88 CHAPTER II

the system suddenly; and from such work as that of Thomas,'
it might appear that the best assimilation of protein would be ob-
tainable by the same scheme. Undoubtedly it is possible to flood the
system, especially with a quickly absorbable carbohydrate such as
sugar, when the same quantity in divided doses would be assimilated
without glycosuria. But under the ordinary conditions of diabetic
treatment, the essential cause back of either regular or irregular
glycosuria is a diet in excess of the tolerance or a persistently high
blood sugar. As for distribution of foods between meals, a mild case
of diabetes on a proper diet should be independent of such variations
within limits of reason. With severe cases, the difficulty lies in the
persistence of the hyperglycemia set up by either carbohydrate or
protein, so that before the effect of one ingestion has subsided the next
is superimposed upon it. In general, the total diet is the important
thing, and httle is to be hoped from unusual fractionation. A ration
so close to the verge of tolerance as to require such aid will not be
permanently tolerated. On the other hand, when the blood sugar
is kept normal by a total diet truly within the assimilative power,
glycosuria or other trouble does not result from any arrangement of
meals that is likely to be made.

6. Regulation of Habits. — Precision regarding diet has been the
chief essential. In other matters, it seems advisable, in brief, that
patients should do whatever is necessary to maintain the best possible
general health, while restraining their activities within the limits set
by their diet and tolerance. With a more hopeful general prognosis,
it becomes highly important to guard patients against alcohol and
drug habits; and especially as opium and other drugs are worthless
or harmful, and alcohol as a means of adding calories is also inadvis-
able, it is important that their widespread use in diabetic treatment
be stopped. With other indulgences, such as tobacco, tea, and coffee,
there are two opposite considerations. On the one hand, these articles
in excess probably injure all persons, and even in moderation appar-
ently injure some persons. On the other hand, the diabetic is denied
so many enjoyments in diet that it is a pity to deprive him of any
pleasures unnecessarily. Accordingly, the patients have been enjoined

* Thomas, K., Arch. Physiol, 1910, 249-285.



GENERAL PLAN OF TREATMENT 89

to use such moderation in these respects as is advisable for normal
persons. Smoking within careful limits has seemed very enjoyjtble
to men long addicted to it. All habitual users of coffee have derived
the utmost comfort from it, especially during fasting. From one to
three cups a day has been the allowance, and decaffeinized coffee has
been used if there was any suspicion of harm. In all other matters,
the usual life of the patient should be altered just as little and just as
much as demanded by the particular case. It will be seen that fre-
quently in this series men have continued business, children have at-
tended school, and everything possible has been done to keep patients
contented and useful. Especially those with milder diabetes are able
to pursue practically a normal existence with care only in diet, and
this fact is one of the most hopeful elements in the prognosis and one
of the greatest encouragements to fidelity in diet. Either mental or
physical overstrain is injurious to such a degree as to be out of the
question for the severest cases and inadvisable even for the milder
ones. Healthful rest, short of ennui, is important. Exercise is dis-
cussed in Chapter V. While reduction of weight and diet to a cer-
tain point is known to be compatible with physical and mental
efl&ciency, with more extreme diminution these are progressively im-
paired, until in the severest cases emaciation and invahdism are
chronic. Even in these worst cases, much depends on the individual
disposition, and light emplojonent or amusement aids in keeping the
mind off the subject of food. If it comes to a choice, neurasthenia is
preferable to overfeeding. Finally, one of the most important points
in the hygiene of diabetics is the avoidance of infections, either great
or small. This need not contraindicate outdoor exercise in cold
weather, which may be one means of building up resistance for pa-
tients who can stand it. For some, however, it means avoiding
crowds or any places where colds or influenza may be caught. For
others, it means the removal of foci of chronic or recurrent infection,
even at the risk involved in surgery. The best possible care of the
teeth, skin, and body in general is advisable at all times, though the
extreme susceptibility of diabetics to troubles from these sources is
greatly diminished under proper diet.



II. Treatment up to Cessation of Glycosuria in Simple Cases.



Any fixedly prescribed routine is opposed by the necessity of indi-
vidualizing treatment to suit the special needs of every case, and by
the desirability of free play for the physician's individuality and ad-
justment to environment. The basic principle of undernutrition
being grasped, the application can be made in various ways. This
period is occupied by the observation diet (if used) and the initial
fast.

A. The Observation Diet.

All sorts of possibilities are of course open in the choice of an ob-
servation diet. One conservative plan is to leave the patient for a
short time on as nearly as possible the same diet he has been taking,
to guard against the danger of any sudden change, especially in the
form of carbohydrate reduction. In order to establish data for com-
paring cases with one another and also with cases in the literature
treated by older methods, the majority of patients in this series have
been placed for a few days (2 to 5) on a diet somewhat as follows:



Protein per 24 hrs.


Carbohydrate per 24 hrs.


Fat per 24 hrs.


1.5 gm. per kilo.


10 to 25 gm.


Sufficient to bring total calories to 35 per
kilo body weight.



This is essentially the traditional "carbohydrate-free diet," for the
low carbohydrate allowance is given only in the form of green vege-
tables, such as have usually been included in diets of this description
in the past. With close laboratory and clinical observation, no hesi-
tation has been felt in placing patients abruptly on this diet; and
even though this was done in some very severe cases, such as No. 8,
the ability to control acidosis when necessary by fasting prevented any
mishap. This plan was necessary for the accurate study of the earlier
cases. Also, it frequently shortened the requisite period of fasting,

90



GENERAL PLAN OF TREATMENT 91

when the previous diet had been grossly improper. In general, it is
not therapeutically advisable, and was seldom used when the pa-
tient's condition at entrance seemed dangerous. More recently, this
observation period has been omitted, treatment has been begun im-
mediately, and the severity of the diabetes has been judged by the
subsequent progress and food tolerance.

B. The Initial Fast.

If diabetes is deficiency of the function of food assimilation, logi-
cally the most effective method of relieving strain upon this function
should consist in withholding food. The benefit of such relief should
apply not only to glycosuria but also to acidosis, irrespective of
whether the latter is wholly secondary to glycosuria or is partly a
specific diabetic phenomenon; and the slight ketonuria developed by
normal persons on fasting should not serve to confuse this expectation.

With regard to the initial tests on dogs, it may be mentioned that
irregularities in the glycosuria following total pancreatectomy are
well known, and in particular the urine may become free from sugar
just befort death from starvation or weakness; but the fatal diabetic
cachexia is always present and freedom from glycosuria never avails
to save the lives of such animals. Also, partially depancreatized dogs,
of the type best suited for therapeutic experiments, in the severest
stage continue to show glycosuria through the most prolonged fast-
ing, up to death or the hopeless exhaustion just preceding death. It
was a serious question whether the severest clinical cases are in a
similarly hopeless state, or whether they still correspond to the type
of dogs which can be freed from glycosuria by fasting and then kept
symptom-free at a more or less reduced weight by suitable regulation
of the total diet. Some encouragement was found in the results of
the shorter therapeutic fasts employed by former writers, but there
was nowhere in the literature any description of such a procedure as
contemplated, or any information as to what might happen if a pa-
tient with the worst type of diabetes were suddenly subjected to abso-
lute fasting until sugar-free. Accordingly, as noted in the history
of patient No. 1, the first attempt was made with considerable caution.
It so happened that this patient, although of the type in which glyco-



92 CHAPTER II

suria and acidosis had formerly been viewed as hopeless, and though
chosen as one in whom at least no great harm could be done, re-
sponded with rather exceptional ease to this treatment, and both
glycosuria and sjonptoms of impending coma quickly disappeared.
If this first experience had concerned a case, such as frequently en-
countered later in the series, requiring from a week to 10 days for
sugar-freedom, it is a question whether courage would have held out;
and if by any chance this first case had been one of the rare ones which
develop fatal acidosis on fasting, the proposed treatment might have
ended there. The first fact demonstrated was that even the severest
cases of human diabetes almost invariably become free from glycosuria
and as a rule also improve markedly as respects acidosis upon fasting.

Regarding the practical carrying out of the initial fast in ordinary
cases, the following details may be noted.

Water. — It is advantageous on general principles that the total
daily intake of fluids be at least 1500 to 2000 cc, and patients have
therefore been encouraged to drink tap water or any kind of mineral
or table water rather freely. In hot weather, cracked ice has some-
times been rehshed. No limit is placed on the fluid intake if patients
desire more than the above quantity.

Alcohol. — The use of alcohol was one of the early precautions
adopted to support strength during fasting. According to some earlier
literature, it not only produced no glycosuria but also might diminish
acidosis. In a number of cases, 50 to 350 cc. whisky or brandy
were given daily, in small divided doses every hour or two, the limit
for any individual being always short of producing subjective or ob-
jective symptoms. A rather general misapprehension was created
by the first papers pubhshed, as it was not clearly understood that
the use of alcohol was not new but was adopted entirely from pre-
vious writers, that it was used for cases with extreme weakness or for
other special purposes, and that it was never a primary or essential
feature of the treatment. Experience has tended to discredit it even
for the purposes for which it was first employed. It is a decided com-
fort during fasting to persons already habituated to its use. In other
persons, especially women and children, it often excites discomfort
or even nausea, and is therefore detrimental. It has an unmistakably
bracing action in weak patients, but its real effect is probably more



GENERAL PLAN OF TREATMENT 93

harmful than beneficial. Soup and coffee are preferable in almost
every case.

Soup. — In the great majority of cases, clear meat soup has been
allowed in quantities up to 600 cc. daily during fasting. The trivial
quantities of protein contained are harmless, but even such can be
avoided if desired by substituting beef extract. Soup is very com-
forting, and the fluid and salts may be valuable.

Coffee. — One to three cups of coffee or Kaffee Hag daily are pleasing
and supporting to most fasting patients. It is not advisable to
cultivate the coffee habit in children or other persons not addicted
to it.

Solids. — Three to six of the bran muffins described subsequently in
this chapter have generally been allowed daily during fasting. They
are of some use in diminishing the feeling of emptiness. Theoreti-
cally, small quantities of thrice cooked vegetables might be permissi-
ble in the milder cases, but have very seldom been used, because there
is no use in trying to trick the appetite too far, and it is better for
patients to learn to bear rigorous fast-days.

Purgation. — The habitual constipation of most diabetics renders a
cathartic advisable at the outset. With the use of bran, there is
generally more natural tendency to defecation. On a prolonged fast
with only fluid intake, the patient may safely go for a week or more
with no bowel movement. There is no specific virtue in purgation.

Edema. — ^As mentioned, water retention even to the point of visible
edema is sometimes observed in fasting, especially in the more severe
cases. It seems never to have been reported in normal persons on
simple fasting, but only in connection with prolonged malnutrition
and abnormal living. Diabetics vary in susceptibiUty, but the imme-
diate cause of edema is usually the salt of the above ingesta, especially
the soup. No harm has ever been observed from the fluid retention.
The prevention or remedy consists in the restriction or exclusion of
salt.

Comfort and Strength. — Fasting, sometimes up to a month or more
in duration, has been a well known practice for purposes of metabolic
studies and sometimes for public exhibitions, and the subjects have
retained physical and mental powers through these long periods and
have denied any real suffering. Fasting has also been one of the com-



94 CHAPTER n

monest religious customs of numerous peoples and sects. On the other
hand, the omission of a single meal is often felt as a great privation,
and a few days' abstinence from food is viewed as something serious
and alarming, not only by people in general but even by numerous
physicians. The most profoundly emaciated and cachectic diabetic
patients undergo even a 10 day fast with ease and safety. The re-
fusal of a patient to undergo fasting is generally as much the fault
of his physician as of himself, provided he is of a type who
will faithfully carry out any kind of careful dietetic treatment. The
first fast generally dispels the dread, and furthermore is valuable for
discipline.

As described in the histories, the fasting treatment has been applied
to patients in all physical states, from those appearing in full health
and strength to those seeming at the point of death from weakness and
emaciation. The effect upon the immediate comfort has varied with
individuals. Some patients have entered with nausea or vomiting
which prevented eating; others rejoiced in quick relief from acidosis
symptoms; others had been overfed till fasting was agreeable in itself.
At the other extreme are the occasional patients who, whether in
good or poor health and flesh, feel weak, uncomfortable, and depressed
whenever they fast. In the intermediate position are the great ma-
jority of patients, who find fasting more or less inconvenient but no
serious hardship, and who carry on their usual activities or amuse
themselves in various ways during either long or short fasts. As
stated elsewhere, some very weak patients have unmistakably gained
strength on fasting. More or less decline in strength is the rule.
Even in the most extreme cases, no adults have died from weakness
either during or within any short time after fasting to sugar-freedom.
Two small children (cases Nos. 45 and 71) entered with such a com-
bination of extreme diabetes, acidosis, and weakness that the choice
between coma and starvation could not be avoided; and it is conceiv-
able that such a dilemma may be possible in very rare adult patients.
The use of levulose as a restorative in sudden collapse of strength is
illustrated in cases Nos. 4 and 45.

Laboratory Control. — ^Laboratory tests are qualitative and quanti-
tative. So much information is derivable from the former that it is
generally possible to carry through a fast successfully by their guid-



GENERAL PLAN OF TREATMENT 95

ance alone. The qualitative test for urinary sugar has been the key-
stone of the plan, since fasting is terminated on the day after it
becomes negative. Acidosis can also be judged fairly safely by the
increase or diminution of the ferric chloride test of the urine and of the
Rothera test applied to the blood plasma (Wishart),and by the acid or
alkaline reaction of the urine; by simply noting the dosage of alkali
required to turn the urine alkaline, the latter test acquires a quantita-
tive significance Also, in default of accurate measurements of blood
alkalinity, the test proposed by Yandell Henderson* should not be
overlooked; namely, that normal persons can hold the breath 30 or
40 seconds without specially deep preparatory inspiration, but that
this period diminishes somewhat in proportion to the reduction of
blood alkali.

Of quantitative tests, that for blood sugar is of minor practical im-
portance during the fast. Generally the blood sugar falls; sometimes
it rises at first even when glycosuria is diminishing and the general
condition improving; and in the rare cases where fasting results badly,
the persistence or increase of hyperglycemia may be one significant
feature; but other tests are more important danger signals. Also,
the quantity of sugar excreted in the urine is of little practical im-
portance in the great majority of cases, though persistence or increase
of glycosuria gives warning of the failure of fasting, and likewise of
the danger of coma even independently of direct acidosis tests.

Quantitauve nitrogen determinations are of significance for the ra-
pidity of protein destruction and the D : N ratio, which is an im-
portant index of severity. Increase of the quantity of amino-acids in
blood and urine also marks the severe cases.

Possibly some significant behavior of the blood fat may later be
found, but at present such analyses have no established value as a
guide for treatment at this stage. In dogs it seems probable that
fasting acidosis is sometimes accompanied by increased lipemia, but
in human patients fasting generally produces no increased turbidity
of the plasma.

The essential danger that threatens during fasting is acidosis, there-
fore the tests for it are preeminent. All analyses of the urine are un-

* Henderson, Y., /. Am. Med. Assn., 1914, Ixiii, 318.



96 CHAPTER n

reliable. Very high excretion of acetone bodies is dangerous, but yet
the progress may be favorable; while lower excretion may indicate
either less acidosis or more dangerous retention. The urinary am-
monia is governed not only by the degree of acidosis but also by
other factors such as the total nitrogen output and the alkali dosage.
The recently developed blood tests are the most convenient as well
as the most trustworthy. The Van Slyke method' of determining
the C02-combining power of the blood plasma has been used in the
present series of cases, because of its combination of ease and accu-
racy. Methods showing the carbon dioxide tension of the alveolar air°
are simple and almost equally reliable. Those requiring the patient's
cooperation encounter difficulty in coma or similar states, and even
the bag or mask methods are subject to possible errors from circulatory
or other causes. The air analyses are specially useful to those de-
siring to avoid the taking of blood, but both physicians and patients
should learn that blood ought to be taken for various analyses as a
means of intelligent diabetic treatment. The hydrogen ion concen-
tration of the blood, determined by either the gas-chain method, the
oxyhemoglobin dissociation, or the more convenient procedure of Levy,
Rowntree, and Marriott,' has recently attracted attention clinically as
well as experimentally, but is not so early or delicate an indicator of
danger as the CO2 capacity. Quantitative analyses for acetone bodies*
in the blood may sometimes be of practical service. For example, if
high and increasing, they may give warning of impending coma, even if
this is not revealed by any of the above mentioned tests. On the
other hand, the danger in different diabetic cases by no means runs
parallel to the ketonemia, neither has any infallible index yet been
derived from the relative proportions of /3-oxybutyric and acetoacetic
acids.

In summary, therefore, all laboratory tests are open to more or less
fallacy. The more tests performed, the more easily and accurately
can the condition be judged and needful measures instituted. If it

6 Van Slyke, D. D., and CuUen, G. E., J. Biol. Chem., 1917, xxx, 289.
^ Fridericia, L. S., Bed. klin. Woch., 1914, li, 1268. Marriott, W. M., J. Am.
Med. Assn., 1916, Ixvi, 1594.

' Levy, Rowntree, and Marriott, Arch. Int. Med., 1915, xvi, 389.
* Van Slyke and Fitz, J. Biol. Chem., 1917, xxxii, 495.



GENERAL PLAN OE TREATMENT 97

comes to a question of the absolute minimum of laboratory work on
which fasting can justifiably be conducted, the methods of choice are
the Benedict qualitative sugar test for the urine and the Van Slyke
determination of the bicarbonate reserve of the blood plasma, together
with the nitroprusside reaction in the plasma.



III. Emergencies and Complications.

A long list of greater or lesser troubles associated with diabetes
might be enumerated here. As mentioned in Chapter VII, the pres-
ent experience indicates that these traditional complications, which
have been the cause of so much suffering and fatality in diabetes, are
for the most part avoidable under efficient treatment; and when al-
ready present, it is beUeved that the best and quickest means of
curing any of these or hindering their further advance lies in fasting
followed by restriction of the total diet as described. A physiological
condition which stands as a real complication in the management of
diabetes is pregnancy. It was encountered in only one instance in
this series, namely case No. 38, where it was associated with a hope-
less complex of infections. JosUn's experience has proved that the
formerly grave prognosis for both mother and child can now be much
brighter; and unless deterred by eugenic considerations, the possi-
bility exists for women with not too severe diabetes to go through
pregnancy successfully. The essential requirement is the same
thorough dietetic treatment as for other patients. By far the chief
emergencies or complications, however, which are liable to be en-
countered in undertaking the fasting treatment, are acidosis and
infection.

A. Acidosis.

1. Definition.

If the normal resting metabolism upon which calorimetric studies
are based be accepted as a standard, acidosis may be broadly defined
as any departure from this normal tending to turn the reaction of the
body to acid. It may thus include all possible states of increased
production or deficient destruction of acid, administration of acid,
retention of acid, or deficient supply or abnormal loss of bases. The
most important clinical type of acidosis is a ketosis; namely, the
occurrence of abnormal quantities of the so called acetone bodies —



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 10 of 76)