Frederick M. (Frederick Madison) Allen.

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readiness. At the same time liquids were forced to 6 or 7 liters per day, and alkali
was given as stated under acidosis below. As coma was imminent, there was no
choice but to take the chance of beginning the proposed treatment. Therefore
Feb. 27 was a vegetable day with 45 gm. carbohydrate and 530 calories. Feb. 28
was a fast-day with nothing but 200 calories of whisky. Marked improvement was
evident in the urine, which became alkaline, but there was a large bicarbonate
edema as illustrated by the weight curve, and weakness and drowsiness con-
tinued. Then, in order to guard against any supposed dangers of fasting, 20 gm.
oatmeal were permitted on Mar. 1, increased to 52.5 gm. on Mar. 2. By this
time glycosuria and coma symptoms were entirely cleared up, and alkali was di-
minished. On Mar. 3 the diet consisted of soy beans and green vegetables. On
Mar. 4 the diet was greatly reduced, consisting only of 90 gm. banana, 20 gm. oat-
meal, 10 gm. potato, and 10 gm. cream. The patient was extremely weak, there-
fore the attempt was made to build her up by a routine diabetic diet, in the hope
that she might be strengthened for later undernutrition treatment. No gain of
weight or strength was achieved, but glycosuria returned and the persisting acido-
sis was greatly increased, as shown in the graphic record. It was again reduced
by undernutrition, and brought to a minimum by a fast-day on Mar. 23. A
carbohydrate period was then instituted to clear up the tendency to acidosis if
possible, and the opportunity was taken to compare the assimilation of oatmeal



CASE RECORDS 179

and pure starch. On Mar. 24, 40 gm. Kahlbaum's soluble starch were the only
nourishment given, and 80 gm. on each of the succeeding days, in ten doses of 8
gm. each. On Mar. 29 a change was made to oatmeal, reducing the quantity of
carbohydrate slightly as an allowance for the oat protein. Nevertheless a gly-
cosuria of 1.39 gm. appeared on Mar. 31, proving the absence of any superiority
of assimilation of the oatmeal over the soluble starch. The resulting traces of
glycosuria were cleared up by a fast -day on Apr. 1 . Acidosis now being entirely
absent, another attempt was made to overcome the persistent weakness by as
high a diet as possible without glycosuria. Though the attempt was made to
balance protein, fat, and carbohydrate to this end, the graphic record shows that
acidosis returned promptly, and glycosuria resulted on Apr. 12. This was cleared
up by a fast-day on Apr. 14. The attempt was then made to build up strength by
still higher diet and to diminish acidosis by increasing carbohydrate, even at the
cost of glycosuria, with the idea that glycosuria could later be checked by brief
fasting. Acidosis was not controlled, and weight and strength were not gained,
and on Apr. 25 this attempt was abandoned. From this date to May 1, pure pro-
teici-fat diet was attempted, but both glycosuria and acidosis were present. At
this time a more rigid program of undernutrition was begun. It will be seen
chat the calories during May averaged less than 1000 daily, a maximum of car-
bohydrate was introduced, and frequent fast-days were employed. The weight
diminished very slightly. The complaints of weakness were about the same.
Most of this period from May 1 to the end of July was vegetarian, chiefly nuts
and green vegetables, of which the patient was fond. On June 30 an enormous fat
intake was permitted experimentally, as mentioned under acidosis. No special
virtue of the vegetarian regime was perceptible. Glycosuria and acidosis were
practically absent during the undernutrition of the month of May; both returned
with the higher caloric diet of June and July. This period was terminated be-
cause of the increasing weakness of the patient, due particularly to the low pro-
tein. In the period July 10 to 14 a test was made with raw pancreas feeding as
described in Chapter IV.

Most of the month of Aug. was occupied with pure protein-fat diet of between
1000 and 1100 calories, and about 30 gm. protein. The patient was relieved
of the fast-days, of which she had been complaining bitterly. Glycosuria was
mostly absent, but acidosis was persistent. In Sept. the calories were increased,
partly by use of alcohol, and a few fast-days mitigated by vegetables or alcohol
were employed. Weight and strength were not thereby improved, and both
glycosuria and acidosis were troublesome. Oct. was a period of marked undernu-
trition, the calories being mostly about 900 daily, carbohydrate-free, except for
two tests in which respectively 60 and 58. 8 gm. carbohydrate resulted in glycosuria,
when added to this caloric intake. In Nov. and Dec. the carbohydrate-free diet
was pushed to the upper limit of tolerance, so that traces of glycosuria and keto-
nuria kept recurring and were checked by occasional fast-days. The attempt
thus to build up weight and strength failed as usual. The patient was dismissed



180 CHAPTER m

on Dec. 20 with instructions to continue diet as during Dec. and to take a fast-
day once each week.

Acidosis. — ^The excretion of acetone bodies in the first few days was evidently
very high, but the analyses were lost. Notwithstanding the alkali dosage, the
urine was strongly acid, and the ammonia nitrogen was 1.7 gm. on Feb. 25 and
1.93 gm. on Feb. 26. Each day the patient took 2.4 gm. potassium citrate, small
quantities of light magnesia, and calcium carbonate in quantities equal to the so-
diurii bicarbonate. It was thus hoped to provide a balance of salts, and perhaps
also to neutralize some acid with a non-irritating substance such as chalk. The
sodium bicarbonate dosage was as follows: Feb. 25, 20 gm.; Feb. 26, 32 gm.; Feb.
27, 72 gm.; Feb. 28, 48 gm.; Mar. 1 to 7, 40 gm. daily; Mar. 8 to 20, 20 gm. daily.
All alkali was stopped at this time. No efiect upon the carbohydrate tolerance
was evident.

As mentioned, acidosis was brought under control by the initial undernutri-
tion period. With the high diets (Mar. 10 to 15) it returned very markedly, the
ammonia nitrogen rising slightly above 1 gm. notwithstanding the alkali dosage,
and the ketonuria reaching 28.7 gm. (as j8-oxybutyric) on Mar. 15. With a single
fast-day (Mar. 16) the ammonia nitrogen fell to 0.63 gm. and the acetone bodies
to 9.57 gm. With reduced diet the acidosis diminished further, and, was entirely
abolished by the carbohydrate period, Mar. 24 to 31, the ammonia and acetone
figures falling to normal, and the ferric chloride reaction turning entirely negative.
MildCT acidosis returned with the beginning of mixed diet after Apr. 2, and it was
proved that carbohydrate, even to the point of causing glycosuria, could not keep
acidosis absent. Especially in the period Apr. 19 to 24 the carbohydrate was
gradually increased to 90 gm., with a total diet as high as 2800 calories (over 75
calories per kg. on 37 kg. weight). The highest glycosuria resulting was 7.26
gm. on Apr. 24. This program was adopted on the principle frequently stated
in the literature, that 90 gm. carbohydrate intake is worth a glycosuria of 7 gm.
The attempt was to build up weight and strength with the high diet, while keep-
ing acidosis in check by a favorable carbohydrate balance. Acidosis, however,
remained present as stated, and the peculiar weakness and malaise characteristic
of severely diabetic patients with even moderate acidosis persisted likewise.
Carbohydrate had to be discontinued in order to check the steady increase of gly-
cosuria. Thus the diets of Apr. 29 to 30 consisted of 61 gm. protein and 200 gm.
fat. Both protein and fat were then diminished, until on May 1 the diet was 53
gm. protein and 177 gm. fat. This would correspond to an orthodox diabetic diet
of about 1.5 gm. protein and 37 calories per kg. Nevertheless slight glycosuria
and heavy ferric chloride reactions persisted, and the ammonia nitrogen by May
1 was up to 1.2 gm. May 2 was a fast-day with 34 gm. butter, this quantity of
fat being abnost negligible for either good or ill. The glycosuria ceased before the
close of the 24 hours, the ferric chloride reaction diminished to a trace, and the
ammonia nitrogen fell to 0.6 gm. Thus 1 day of undernutrition accomplished
' what had been impossible on full diets either rich or poor in carbohydrate.



CASE RECORDS



181



For the next 3 months a vegetarian r6gime was tried, as described under "weight
and nutrition" below. Because of the low protein and fat, a relatively high car-
bohydrate tolerance was exhibited, which was also assisted by the very frequent
fast-days. In this way both glycosuria and acidosis were almost continuously
absent for a month. The hope of a gain in tolerance was disappointed, however,
as demonstrated by the prompt return of both glycosuria and ketonuria when a
moderate increase of diet was attempted in June and July.

On June 30 an enormous fat intake was allowed experimentally for a single
day, followed by a series of lower diets, as shown in Table II.

TABLE n.





Diet.


Urine.


Date.


Protein.


Fat.


Carbo-
hydrate.


Calories.


Volume.


Sugar.


Total
nitrogen.


NH.-N


Acetone

bodies (as

l8-oxy-

butyric).


IHM


gm-


gm.


im.




cc.


gm.


gm.


gm.


gm.


June 27


43.1


104.7


87.0


1403


2320


+


4.02


0.35


0.78


" 28


40.0


104.8


85.9


1415


3188


3.31


4.38


0.41


1.66


" 29


0.5


123.9


3.4


1270*


1858





2.17


0.35


0.62


" 30


83.6


448.6


72.4


4456


2128


+


4.55


0.92


4.67


July 1


74.7


292.8


51.0


2707


2629


4.12


11.38


1.34


8.57


" 2


57.4


185.7


64.0


2013


1422


7.11


4.54


0.91


3.21


« 3


57.6


202.0


68.3


2107


1852


14.63


6.22


2.00


5.64


" 4


41.0


112.0


39.0


1295


1411


4.06


6.28


1.50


. 2.73


" S


0.2


0.2


1.8


290t


1506





4.14


0.80


0.47


" 6


36.3


109.8


72.6


1315


1528





6.17


0.38


1.11


" 7


55.1


101.2


68.2


1420


1630





7.02


0.43


0.48



* Butter 150 gm., strawberties 50 gm., alcohol 25 gm.
t Alcohol 40 gm.



The relation between combustion of food fat and body fat is here illustrated.
The huge ration of June 30 did not produce any explosive increase of acidosis. The
acetone bodies showed a rise on the same day, but a more marked one the follow-
ing day, while the ammonia nitrogen did not reach its summit until July 3. It is
evident that what happened was not the conversion of any large proportion of the
fat on June 30 into acetone bodies, but rather an injury of fat assimilation pro-
duced by this excess and continued by reason of the fat rations (lower but still
excessive) of July 1 to 3. On the fast-day of July 5, storage or depot fat was
necessarily burned, yet the ammonia nitrogen was approximately the same as On
June 30. On July 6, with a limited fat intake, the effect of carbohydrate was
evident in producing a lower ammonia nitrogen excretion than on the fast-day.
The entire observation is against the idea of a difference between food fat and



182 CHAPTER in

body fat in combustion, and indicates rather an overtaxing of fat metabolism by
excessive intake and improvement of assimilation by relief from the strain.

On the carbohydrate-free diet beginning in Aug., strong ferric chloride reactions
and unduly high ammonia excretion were the rule. Temporary control of both
glycosuria and acidosis was achieved with the low diets (about 900 calories) in early
Oct. Thereafter it will be noted that the ferric chloride reactions were some-
times negative and never more than slight, even on carbohydrate-free diet, the gen-
eral diabetic condition being now under better control. The continuance of slight
acidosis, however, throughout so much of the period of treatment represents one
of the serious mistakes in the management of this case.

Weight and Nutrition. — ^Weight at admission 40.1 kg., at discharge 35.2 kg.;
i.e., a loss of 4.9 kg. The initial gain in weight, up to 43.5 kg. on Feb. 28, repre-
sented a marked bicarbonate edema, simultaneous with the turning alkahne of
the urine. Slighter edema was present on certain occasions later, notably Aug.
15 and Nov. 7, being due apparently to sodium chloride and removed by diminish-
ing the salt intake.

On Mar. 21 the large fluid intake began to be restricted. The patient had
been accustomed to large quantities of water for some months past and com-
plained of thirst when the allowance was diminished by order; within a few days
this complaint disappeared and the thirst remained normal thereafter.

Vegetarian diet was tried for a period of nearly 3 months, chiefly because of
the claims in some quarters concerning differences in the glycosuric effect of
different proteins, and the bare possibility that meat protein might at least
stimulate a greater flow of gastric juice and correspondingly of pancreatic juice,
and thus perhaps depress the internal function of the pancreas by stimulating
its external function. Undernutrition was employed at the same time to create
the most favorable conditions, and acidosis was kept absent by such quantities
of carbohydrate as seemed within the tolerance. Butter was regularly allowed,
eggs rather frequently, and a Uttle bacon and bacon fat sometimes, but for much
of the time the ration was vegetarian in the strictest sense, composed entirely of
vegetables, fruits, nuts, soy beans, and occasional gluten preparations. There
was no gain of tolerance, and no advantages of a vegetarian diet or evidence of
specific differences between proteins were observed.

Neither food nor feces was analyzed. The former was calculated as usual
from the Atwater-Benedict tables. On this basis the following reckoning can be
made for the period from Mar. 16 to Nov. 30, for which the records of both food
and urine are complete. Also, the total period of 260 days is divisible into two
nearly equal portions, namely, 136 days up to July 31, during which the diet was
largely and sometimes wholly vegetarian and contained considerable carbo-
hydrate, and 124 days after July 31, in which the protein was of animal origin
and the diet was almost continuously carbohydrate-free. The results for the
various periods may be compared as shown in Table III.



CASE RECORDS



183







^










ej .


g (^ 10 irj




3 !3


S CN ■^ll




o5


fe^ T-J 0\ ro










.■§ o










a g


gm.
2.63
0.21
2.40






H


T-4 ^

1 (M S .rt




_g


i^ 0\ 00




■3 fl 2


0\ O; o\




■SS-S


S 0;' CO d




Hss


5 10 ^H




^ o\ t>»




■3


i-H




Total
nitrogen

in diet
per day
per kg.


0. c^ vo

E d d d




2* fl-.. t^


. ■* ^ lO






g CN >0

"^ t^ 00 \o




A .S






nitr
n in
prote
5.25).


CN ■*
S IN 0\' «




" S^.i.


Si cio in CN




00 o_ 00




aj '






H ■■V


w ^


M


Average
protein
per day
per kg.


sm.
1.23
1.44
1.02


a


!•§&■


. <N rf OS




tH^TJ


E "3 ro t^'


f^


I^R


h3


Th 10 re









g


2


•<l; f)


H


3'a*.-


.000




o'S.S


S « tN rC




H^-o


^ *^ ^., ^




g


^" vo" i^




a


-'




Average
calories
per kg.

per day.


ce ro re




CO PO re










t|l


ro ■* T-i




^ !N






C>l^ CN_ CN




.5


<N SO vo




si^"


*^ to w

Ce_ (N VH




,|,


•W as 0" ■




^ -"^ so
CO « ^






en












>,










tS

-a


^ 1






"5 "C






so OJ






IN -a a






^ ^=«






• 2 n •— 4






tal per
nimal'
egetab






£<>






H


::


;;


1



184 CHAPTER ni

The patient lost 5 kg. weight in 9 months. If it be assumed that 90 per cent
of a weight change is ascribable to fat, in this instance the loss of nitrogenous
"tissue" would not exceed 500 gm. Using Voit's figure of 3.4 per cent N, the
possible loss of body nitrogen would then be 17 gm. If it be urged that in an
emaciated person the wasting of "tissue" in proportion to fat is higher, the
above comparison of intake and output shows that the patient must have been
nearly in equilibrium. At worst, the nitrogen deficit must have been small, and
it may be assumed that the diet fulfilled the purpose of protecting body protein
from any extreme loss while maintaining prolonged undernutrition.

Two deductions seem justified. (1) Digestion and absorption of protein
were, as would be expected, distinctly better during the "animal" period, but the
utilization of vegetable proteins, including the times when the diet was exclu-
sively vegetable, was reasonably satisfactory. (2) Though the nitrogen intake
was lower in the "vegetable" period, it must be called low also in the "animal"
period, and it is evident that there is no serious obstacle to maintaining equilib-
rium on strict carbohydrate-free diet with a low protein ration. It is to be borne
in mind that the energy intake is a question not of food ingested but of food ab-
sorbed. If it be permissible to assume that the same proportion of total calories
as of nitrogen was lost in the feces, viz. 11.29 per cent, subtraction of this num-
ber from the 33 calories ingested daily would leave an average of between 29 and
30 calories absorbed daily per kg. of body weight. Accordingly, it would appear
that this patient lived for 260 days on an average of 0.173 gm. N and 30 calories
per kg. Work and exposure to cold were both far less than in ordinary individuals.
On the other hand, the rather tall, very emaciated figure presented a dispropor-
tionate surface. Losses in sugar and acetone bodies were sKght. On the whole,
the figures obtained correspond satisfactorily to the known laws of metabolism
in normal persons.

Subsequent History. — On Jan. 14, 1915, the patient reported by telephone that
she was feeling well and had cleared up occasional traces of glycosuria by fast-
days. On Jan. 20 she reported increasing difficulty in remaining sugar-free, and
was instructed to return to the hospital if difficulty continued. Nothing more
was heard until Apr. 1, when a letter stated that she had returned to her home
in Indiana. On Apr. 26 a response to a letter of inquiry showed that the cause of
her silence and removal was her adoption of Christian Science. Occasional
later reports showed that she was eating everything at will, including much
candy,, and gradually losing strength. Death occurred from simple weakness
the first of Oct. 1915, the terminal collapse being brought on by taking a dose of
Epsom salts.

Remarks. — The patient, when received, was undoubtedly close to coma. She
appeared then as having diabetes of extreme severity. The results obtained
seemed highly favorable. In the light of later experience this treatment was
very bad.

Part of the fault lay with the patient, who had always eaten injudiciously



CASE RECORDS 185

and was the most unruly of the entire series for dietary control. The high
diets, the persistence of glycosuria and ketonuria through considerable periods,
and the changes in program from time to time were in some measure forced by the
necessity of appeasing the patient's demands and meeting her psychic needs.
She insisted not only upon nourishment but also taste and satiety, and slight pri-
vations brought on hysterical tears and melancholy which seemed serious as a
possible influence upon the diabetes, though, as a matter of fact, no particular
influence of psychic upsets upon the food tolerance was observed. She was given
unusual leeway as being the first patient.

The cause of the final disaster was also instructive. It is noteworthy that al-
though a very careful limitation of diet both quantitatively and qualitatively
had resulted in threatened coma at the time of admission, subsequently on abso-
lutely unrestricted diet no symptoms of acidosis were described, evidently be-
cause the patient lived so largely on carbohydrate, and the polyiiria aided in the
elimination of acetone bodies. Although the patient was young and the kind
that typically dies in coma, death occurred from simple wasting and asthenia.

The chief difficulty consisted in inexperience with the treatment. The cautious
manner of beginning treatment, and the partial, irregular, and inadequate charac-
ter of the measures employed belonged to this stage of uncertainty and orienta-
tion. It showed the viciousness of some of the accepted methods in the man-
agement of diabetes. The same patient admitted at a later time could have been
treated far better; and the case, though severe, was mild in comparison with
some of the later ones. A bold initial fast, followed by testing of the tolerance
for different classes of food and arrangement of a diet accordingly, would have
brought far quicker and better results.

The actual accomplishment was that the patient was kept alive in the hospital
from Feb. 24 to Dec. 20, with a loss of 5 kg. (one-eighth of her weight at en-
trance), and about a corresponding diminution of strength. Glycosuria and
acidosis were kept entirely absent at certain times, and were controlled within
small quantities at all times. Actual food tolerance was slightly less at the end
than in the earlier part of treatment, and the progress was slowly but distinctly
downward. The bungling and inadequate treatment furnished abundant reason
for this slight downward progress in 10 months, and no "spontaneous" cause
need be assumed. Methods and results of this sort have been common with a
large proportion of practitioners who have undertaken to apply the fasting
therapy. The record of this patient stands as a useful example of how a case
should not be treated.

CASE NO. 2.

Female, unmarried, age 17 yrs. Italian, sewing machine operator. Ad-
mitted Apr. 13, 1914.

Family History. — Grandparents healthy as far as known. Father a day laborer
and short of stature; weight about 200 pounds. Mother short, normal figure,



CASE RECORDS 187

was agreeable to this Italian patient. In other words, the fast was not broken
(as usual) by carbohydrate alone, but fat was introduced to make a total of 2000
calories. Also on the following days, diets low and relatively high in fat were
comparfed, and on Apr. 30 a day of 100 gm. olive oil was given instead of a regu-
lar fast-day, according to the practice of some authorities. The results are dis-
cussed elsewhere (Chapter VI). They illustrate the harmfulness of attempts to
use fat in this manner. In the first few days of May a rather low diet was given,
with absence of glycosuria. The succeeding period represents a low calory diet,
with as much carbohydrate as possible and frequently repeated fast-days for the
purpose of overcoming the persistent ferric chloride reaction. On June 11 an
enormous fat diet was given (137 gm. protein, 34 gm. carbohydrate, 6672 calories
= 167 calories per kg.) . A slight rise in the ammonia followed, but the patient's
appetite was spoiled so she could take only a low diet for several days. On June
17 a less extreme fat diet was begun, which nevertheless represented not far from
100 calories per kg. of body weight. The results are discussed in Chapter VI.
The onset of glycosuria and the marked rise of acidosis are the striking features.
July S was a fast-day with alcohol. Thereafter a low diet was given, relatively
rich in carbohydrate. Under this program both glycosuria and acidosis cleared
up and were kept absent.

The patient was discharged Aug. 14, symptom-free and feeling well and strong.
The hospital stay was uneventful except for occasional headaches for which no
cause was found.

Acidosis. — Although there were no signs of coma, the analyses in the first few
days indicated that trouble would have resulted before long on the restricted
diet. On Apr. 14 to IS no alkali was given, and the urine contained 2.4 to 2.7
gm. ammonia nitrogen and 4.2 to 7.0 gm. acetone bodies (as |S-oxybutyric) .
Apr. 16 to 20, 20 gm. sodium bicarbonate were given daily, and 10 gm. on Apr. 21,
after which alkali was stopped. The rise of ketonuria, up to 12.1 gm. /3-oxybutyric
acid on Apr. 18, was to be expected, but at the same time the ammonia, instead of
falling, remained little changed, and actually rose to 3.1 gm. ammonia nitrogen
on Apr. 18. With diminished fat and increased carbohydrate intake on Apr. 19
there was a drop in both ammonia and total nitrogen, but the steepest fall of the
ammonia occurred on fasting. Thereafter the three principal peaks of the
ammonia curve (Apr. 23, May 2, and June 19 to July 3) are clearly associated
with the fat content of the diet. It is evident from the graphic chart that acidosis
was not checked by hberal quantities of carbohydrate and protein, nor by a fav-



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 18 of 76)