Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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orable carbohydrate balance, but on the contrary rose and fell according to the
ingestion of fat. For about the last month in the hospital acidosis was entirely
absent on a diet moderate in protein, relatively abundant in carbohydrate, and
low in fat.

Weight and Nutrition. — Weight at admission 42.6 kg., at discharge 40 kg.;
i,e., a loss of 2.6 kg. The variations and excesses in diet were experimental.
The diet at discharge was approximately 56 gm. protein, 120 gm. carbohydrate.



188 CHAPTER in

and 1400 calories (1.4 gm. protein and 35 calories per kg., reduced slightly by
occasional fast-days). The patient's figure and strength at discharge appeared
normal. The diet was planned as one on which she could work. She was in-
structed not to gain weight, and it was proposed to give her instructions there-
after chiefly on the basis of her body weight.

Remarks. — ^Aside from the intentional experimental variations, the treatment
was fairly efficient and the result good. The reduction in weight and the arrange-
ment of the final diet, restricted in total calories, adequate "in protein and rather
liberal in carbohydrate, was about what was needed for a relatively mild case,
such as this one by this time had proved itself to be. By comparison of the
diets of Apr. 14, IS, 18, and 19 with those of Aug. 9 and 11, it will be seen that
the calories are about the same, while the carbohydrate, counting also that deriva-
ble from proteia, is higher in the latter period. Along with this, the sharp
contrast as respects glycosuria and ketonuria shows a decided upward progress
in this 17 year old girl during these 4 months.

Subseqtient History. — ^After discharge on Aug. 14, the patient followed diet and
remained sugar-free for about a month at home. Owing to poverty it was almost
impossible for her to obtain the necessary food, and she gradually began to take
the diet of the rest of the family. Sugar reappeared, followed by other symptoms.
She was readmitted Nov. 30, 1914, complaining of polydipsia, polsoiria, and for the
last few days loss of appetite and drowsiness.

Second Admission. — A 4 day fast was instituted, glAug., Oct., and Dec, 1915, was almost exactly the quantity
which could be included in her regular mixed diet in Aug., 1914, without any



190 CHAPTER III

appearance of glycosuria. It is thus clearly confirmed that a marked and last-
ing injury of assimilation can be produced by a few months of unregulated diet.
On the other hand, the former carbohydrate tolerance tests of Aug., Oct., and
Dec, 1915, covered a period of S months, and conclusively proved the absence of
any perceptible downward progress during that time. Also the weight remained
essentially the same, so that no disturbing factor was thus introduced. Moreover,
comparison of the tolerance at the beginning and end of the second hospital
period shows that glycosuria appeared on Dec. 14, 1914, on a diet of 60 gm. pro-
tein, 42 gm. carbohydrate, and 981 calories. If all these earlier occurrences of
slight glycosuria be ignored, it is still evident that on repeated occasions in Jan.,
Feb., and thereafter, glycosuria was present on carbohydrate-free diets of some
1700 calories. In contrast to this, it is seen that from Dec. 27, 1915, to Jan. 1,
1916, a diet of 1760 calories with 10 to 30 gm. carbohydrate was tolerated without
glycosuria, and the protein in this diet was fully as high as in the above men-
tioned carbohydrate-free periods. Glycosuria appeared only on Jan. 6, toward
the close of another week on the 30 gm. carbohydrate allowance. It was thus
present on Jan. 11, but cleared up on withdrawing carbohydrate from the diet.
A slight gain in food tolerance is thus evident during these 14 months in hospital,
and this upward tendency is the more remarkable in view of the improper treat-
ment, with its long periods of overfeeding and almost continuous marked hyper-
glycemia. The essential criticism of the treatment in this period is that by
pernicious protein-fat overfeeding (up to 60 calories per kg.) it held back the ten-
dency to improvement, and ultimately sacrificed 6| kg. weight for only the slight
gain of assimilation above mentioned. An excellent physical condition was main-
tained throughout, and the patient was discharged seemingly in splendid health.
The failure of the plan of feeding for immediate weight and strength is well dem-
onstrated by this prolonged trial. The transitory well-being is too dearly bought
at the price indicated by the laboratory findings. Proper management would
have imposed a rigid low diet from the outset and insisted upon continuously
normal urine and blood. A sharper initial fall of weight would have resulted.
A small quantity of carbohydrate could have been included in such a low calory
diet. Under such a program there is little doubt that the patient could have been
discharged in fully as good physical condition and on fully as high a total diet as
was actually the case; and the diet could have been balanced properly with car-
bohydrate, and the entire condition from the standpoint of the diabetes would
have been far more favorable.

Subsequent History. — After discharge on Feb. 2, 1916, diet was followed until
Mar. 8, when the patient began to take two slices of bread daily in addition to the
weighed diet, because of a strong craving for carbohydrate. Sugar had been ab-
sent before, but then reappeared and continued. She was doing 5 hours work
on the sewing machine at home and 2 hours housework daily, and in addition
walked two miles two or three times a week. A fast-day was taken once a week
up to the 1st of Mar.



CASE RECORDS 191

Third Admission. — Mar. 20, 1916. Weight 39.4 kg. Nutrition and strength
still appeared very good. Fasting was imposed Mar. 21 to 23 inclusive, then low
protein-fat diet, gradually increasing from 1000 to 1200 up to 1800 calories, with
protein ranging from 40 or 50 up to 60 or 70 gm. daily. The patient was again
discharged on July 12 at her own request, still appearing in excellent condition.
Headaches had been somewhat relieved after prescription of glasses by an
oculist.

Acidosis. — It is of interest that heavy acidosis was brought on by the addition
of two slices of bread to the weighed diet on which both glycosuria and acidosis
had been absent. Fasting was begun on the day following admission (Mar. 21).
The patient was depressed, dizzy, and significantly unwell. The finding of 33.4
per cent plasma bicarbonate showed the reason. Sodium bicarbonate was then
given in 3 doses of 10 gm. each. Within half an hour after the first dose the clini
cal effect was striking. The headache, dizziness, depression, and malaise van-
ished, and were replaced by comfort and cheerfulness. It is possible that fasting
alone would have been badly borne, as the tendency to a fall in blood alkalinity
on fasting was previously noted in this patient. No more alkali was given. The
CO2 capacity was found normal on the day after the bicarbonate dosage, but fell
to 46 per cent on the succeeding day (Mar. 23). On this day also glycosuria
ceased. Mar. 24 to 27, a trial was made of carbohydrate-free diet, which fre-
quently relieves fasting acidosis. On Mar. 24 nothing but 21 gm. protein was
fed, the diet being coffee, soup, and veal. The blood bicarbonate rose a trifle.
On Mar. 25 the diet contained 40 gm. protein and 800 calories. Thereafter pro-
tein was increased and fat diminished, so that on Mar. 27 the diet was 70 gm.
protein and 600 calories. The net result of these low protein-fat rations was
that by the morning of Mar. 26 the blood bicarbonate had risen to 52.8 per cent.
On Mar. 28, the diet was sharply reduced to 16 gm. protein and 10 gm. carbohy-
drate. The blood alkalinity fell sharply as on a fast-day; i.e., to 40 per cent on the
morning of Mar. 29. Beginning Mar. 29, the diet was limited to green vegetables.
On this, by the morning of Mar. 31, the CO2 capacity had risen to 44 per cent,
though the carbohydrate intake had amounted to only 30 gm. on Mar. 30. By
Apr. 7, the plasma alkalinity had risen to within normal limits on low protein-fat
diet. Thereafter it remained generally at a low normal level. No reason is
known for the low reading of 45.6 per cent on June 27, unless it were the in-
creased fat intake. By July 7, it had returned to normal without the aid of
alkali, possibly with the aid of the small allowance of carbohydrate. The other
tests were not parallel with the plasma bicarbonate. The ammonia nitrogen
at first fell from 3.4 gm. on Mar. 20 to 1.94 gm. on Mar. 22, then remained nearly
stationary to Mar. 27, thus corresponding to the plasma bicarbonate. But
when the plasma bicarbonate fell at the beginning of the vegetable period, the
ammonia fell also. Later, on protein-fat diet, the ammonia was a more sensitive
indicator of acidosis than the plasma bicarbonate, being unduly high (Apr. 14,
June 6 to 8) at times when the plasma bicarbonate was approximately normal.



192 CHAPTER m

The ferric chloride reaction became negative early in the vegetable period, at
the very time when the plasma bicarbonate fell. It remained negative thereafter.

Blood Sugar. — ^The fall during the initial period of fasting and undernutrition
is evident from the graphic record. Subsequently it rose, and remained much
of the time in the neighborhood of 0.2 per cent. The decline to a nearly nor-
mal value shortly before discharge is in conformity with the other improvement.

Weight and Nutrition.— Weight at admission 39.3 kg.; i.e., the same as at the
previous discharge. Weight at discharge 35.2 kg. Nearly 4 months of treat-
ment thus represented undernutrition to the extent of 4.1 kg. This under-
nutrition was imposed especially at the beginning of this hospital period. -From
Apr. 18 to discharge there was an actual gain of 1 kg. During most of the time
one egg was allowed on fast-days, but beginning with July the fast-days were
made absolute. The daily allowance of 70 gm. protein, 10 to 15 gm. carbohydrate,
and 1800 calories was thus reduced to an average of 60 gm. protein and 1540
calories (1.7 gm. protein and 44 calories per kg.).

Remarks. — The carbohydrate tolerance test Mar. 28 to Apr. 4 showed an assimi-
lation not above 60 gm. carbohydrate. Glycosuria also appeared subsequently on
protein-fat diets lower than those previously tolerated. Very decided downward
progress was thus clearly demonstrated in consequence of violations of diet,
during less than 2 months at home, the violations being said to have been limited
to less than 1 month. Susceptibihty of this case to rapid downward progress
on dietary overstrain is thus proved. On the other hand, in nearly 4 months
of hospital sojourn this time, the progress was demonstrably upward. From
Apr. 18 onward, as mentioned, there was a gain of 1 kg. weight, and at the same
time the patient became able to remain free from glycosuria and ketonuria on
diets decidedly higher in protein, fat, and carbohydrate than those on which
glycosuria repeatedly occurred earUer in the period. The tendency of the blood
sugar likewise was downward. Furthermore this improvement occurred in spite
of grossly excessive diets, the tendency to spontaneous upward progress being
thus all the more remarkable. In extenuation of the diet only two excuses can
be offered. One is that the patient was taking heavy exercise, and it had not
yet been learned that this does not atone for excessive diet. The other is that
it was known that the patient at home would not adhere to any diet which kept
her at all hungry or uncomfortable. Accordingly she was allowed this diet, on
which her progress seemed at least temporarily favorable, in preference to a
more beneficial diet which would be more Uable to be violated.

Fourth Admission. — Sept. 11, 1916. (No graphic chart.) Patient returned to
hospital with the usual history of having broken diet. Heavy sugar and ferric
chloride reactions were now present on her former diet. A 4 day fast was neces-
sary. A carbohydrate test with green vegetables in the usual manner showed a
tolerance of 50 gm. A carbohydrate-free diet was then begun, with 40 gm. pro-
tein and 600 calories. The experiment was then performed of keeping this pro-
tern the same while gradually increasing fat to make a totalof 1300 calories (see



CASE ItECOEDS 193

Chapter VI). The result was glycosuria, while the ferric chloride reaction re-
mained negative. Thereafter with less fat (900 to 1200 total calories) and the
same protein, glycosuria was absent, but returned when the protein was in-
creased to SO to 65 gm. She was discharged on Dec. 4, 1916, stiU in fair subjective
health.

Acidosis. — The COj capacity of the plasma at first was 35.5 per cent. Weak-
ness and malaise, making her imfit for work, were the only clinical symptoms of
acidosis. With 4 days of fasting, the CO2 capacity rose to 53.3 per cent. After 2
days respectively of 10 and 20 gm. carbohydrate, it was 59.5 per cent, and at the
close of the carbohydrate test (Sept. 22) 58 per cent. This reaction to fasting is
noteworthy ia a patient who on previous admissions had shown such decided
falls in blood bicarbonate on fasting. Likewise the heavy ferric chloride reaction
diminished on fasting and cleared up during the vegetable period. The am-
monia nitrogen, which was 3.3 gm. on the prescribed diet, dropped to 2 gm.
at the close of fasting, and to 0.43 gm. on the fast-day (Sept. 23) following the
vegetable period. Thereafter on protein-fat diets the plasma bicarbonate re-
mained at a high normal level (59.8 to 68.8 per cent) and the ferric chloride reac-
tion continued negative. The ammonia nitrogen ranged from 0.8 to 1.5 gm.,
and was thus the most delicate index of acidosis.

Blood Sugar. — This was 0.218 per cent in whole blood and 0.238 per cent in
plasma on the first day of fasting (Sept. 13), 0.192 per cent in plasma on the last
day of fasting (Sept. 16). It was never brought lower than 0.122 per cent in
whole blood and 0.147 per cent in plasma. The last analysis, with sugar-free
urine, showed 0.202 per cent plasma sugar.

Weight and Nutrition. — ^Weight at admission 41 kg., part of which was edema.
Weight at discharge 34.3 kg. The final weight was thus only about 1 kg. less
than at the previous discharge, but otherwise the condition was much worse.
The carbohydrate test above mentioned indicated a loss of only 10 gm. tolerance.
A truer index is afforded by the fact that traces of glycosuria now tended to ap-
pear on relatively low carbohydrate-free diet. In contrast to the 70 gm. protein,
10 to 15 gm. carbohydrate, and 1800 calories tolerated at the former discharge,
the diet at discharge this time had to be limited to 45 gm. protein and 1200 calories
(1.3 gm. protein and 35 calories per kg., reduced by the weekly fast-days to 1.1
gm. protein and 30 calories average). Moreover, marked hyperglycemia was con-
tinuous on this diet as stated, and glycosuria appeared upon very slight increase
of either protein or fat. The patient had again demonstrated how rapidly she
could progress downward with improper diet in the short period of 2 months at
home. At this discharge she was distinctly weaker than ever before, though still
comfortable and able to do housework. The treatment had not been radical, but
she had been fed during the whole of this hospital period to the limit of her
tolerance in order to keep up her weight and strength.

Subsequent History. — A note received from the family Mar. 14, 1917, stated that
the patient died at 2:30 a.m. that day. She had again broken diet because of the



194 CHAPTER III

unfavorable environment, and the diabetes took its natural rapid course. She
refused the petitions of her family that she return to the hospital.

Remarks. — ^The patient had been kept alive and almost uninterruptedly com-
fortable for 3 years under treatment. In view of her state of intelligence, will
power, and environment, this was probably as much as could have been accom-
plished unless she had been kept continuously in an institution. The chief
scientific interest in the case lies in its demonstration of rapid downward progress
with dietary indiscretions, and complete absence of downward progress and
distinct tendency to upward progress even under treatment which never was
radical enough to remove the continuous evidences of slight metabolic overstrain.

CASE NO. 3.

.Female, unmarried, age 26 yrs. American; no occupation. Admitted May
23, 1914.

Family History. — Father was never strong, and died when patient was 5 years
old. Autopsy is said to have revealed numerous intestinal ulcers. His parents
lived to healthy old age. Patient's mother is alive and well; her father died at age
of 28 of tuberculosis said to have resulted from a career of dissipation; also her
brother died of tuberculosis, and her sister with acute melancholia. Patient
has one brother aged 32 who suffers from nervousness and indigestion. No
diabetes or other family diseases known.

; Past History. — ^Healthy life in excellent hygienic conditions, but numerous in-
fections. Measles, mumps, chicken-pox in early childhood. Typhoid at 8.
Tonsillitis at 16 with recurrent attacks in following years until right tonsil was re- '
moved 3 years ago. Only a little sore throat since then. S years ago " colitis"
for 10 days; fever, vomiting, and dull aching pain in upper abdomen, consider-
able bloody diarrhea, no jaundice. Several slight attacks of grippe, the last
about 3 years ago. 4 years ago, "intercostal rheumatism;" in bed about a
week, no herpes. Quiet life; no overstudy, but considerable social activities in
recent years, and some exhaustion after attending several dances in the same week.
Not nervous. Worry and loss of sleep for some time following unhappy love
affair 4 years ago, but this has entirely passed off. Moderate appetite, but she
has eaten even more candy than the average girl.

Present Illness.— Jan. 12, 1914, after having been in apparently perfect health,
patient woke up with malaise and slight abdominal pain. The attack subsided
with fasting and bed- rest, but on account of slight tenderness and rigidity,
laparotomy was performed on Jan. 14, revealing obliterative appendicitis and
blood clots about right ovary, treated by removal of appendix and one ovary.
Incision healed per primam, but IS days after operation phlebitis occurred, first in
left leg, then in right. Left leg has required bandaging until recently. Urine was
reported normal in hospital, but it is doubtful if tests for sugar were made.
Weakness and weariness felt at this time were attributed to convalescence and
the patient went to summer resorts to recuperate. Polyphagia, polydipsia and



CASE RECORDS



195



polyuria began, and most of her luxuriant hair fell out. The normal weight of
120 pounds diminished to 109 pounds. 2 weeks before admission, diabetes was
diagnosed. The laboratory reports showed 8.3 per cent sugar and heavy ferric
chloride reaction. A diet was prescribed containing considerable starch. Since
then, rapid dimming of vision has been noticed. Menstruation has continued.



TABLE IV.





Diet.


Urine.


Date.


Protein.


Fat.


Carbo-
hydrate.


Alcohol.


Calories.


Volume.


Sugar.


NHj-N


Acetone

3odies (as

fl-oxy-

butync).


IDM


gm.


gm.


gm.


gm.




cc.


gm.


gm.


gm.


May 24


82.8


127.5


127.7


7.5


1854


2010


47.2


1.39


2.27


" 25


126.5


175.0


272


4.0


3259


2470


68.0


1.06


2.31


" 26


:


Fast-day.


35.0


245


910


4.2


0.88


0.88


" 27




tc




25.0


175


644





1.00


1.63


" 28


4.2


0.8


25





122


825





1.15


1.93


" 29


10.9


2.5


60





302


934





1.23


0.64


" 30


37.0


9.5


162





8*8


1700


7.99


1.31


2.08


" 31


11.6


2.7


52





421


1362


4.22


0.34


1.05


June 1


7.0


1.2


22





125


1106





0.38


0.21


" 2


6.2


1.4


16




99


957





0.46


0.45


" 3


10.8


3.7


37





222


866





0.54


0.41


" 4


24.7


10.1


98





568


1008





0.53


0.37


" 5




Fast-day.


30.0


210


1758





0.35


0.74


" 6


14.0


1.8 1 98





474


774





0.55


0.80


" 7




Fast-day.


30.0


210


1325





0.32


0.35


" 8


14.0


1.7


85





419


727





0.67


0.88


" 9


31.7


6.4


144





779


2009


4.31


0.74


0.69


" 10


40.1


13.6


147





893


2278


4.57


0.43


0.48


" 11


43.7


15.1


150





932


2728


4.19


0.55


0.5S


" 12


1.6





7.8


25.0


220


2054





0.35


0.41


" 13


43.2


10.4


113





735


1969





0.41


0.23


" 14


40.1


11.7


124





778


2060





0.27


0.33


" 15


38.5


7.8


136





787


1878





0.26


0.31



Physical Examination. — Height 161.3 cm. Patient appears rather juvenile for
her age; stiU well nourished, and with look of perfect health. Mouth and teeth
in good condition. Right tonsil missing, left appears normal. No enlarged
lymph nodes. Reflexes normal. Examination otherwise negative.

Treatment. — (No graphic chart.) An observation diet was first permitted simi-
lar to what the patient had been taking. The initial treatment is shown in
Table IV.



196



CHAPTER in



The most disturbing symptom was the blurred vision. The patient compared
it to the efiEect of atropine. In the early days in hospital she became unable to
read even with glasses. An oculist found no organic change, and vision rap-
idly cleared in parallel with the urine. After an uneventful period of hospital
observation without return of any symptoms, the patient was discharged on
July 24.

Acidosis. — This was never heavy, and was easily controlled by reason of the
high carbohydrate tolerance. The only alkali used was 20 and IS gm. sodium
bicarbonate respectively on the &st 2 days in hospital.

Weight and Nutrition. — Weight at admission 46.5 kg., at discharge 43.4 kg.
The apparent reduction of weight was thus 3.1 kg., but actually must have been
somewhat more, as the dried tissues recovered their normal water content during
undernutrition after cessation of glycosuria. The treatment was characterized
by low protein, low calory diets, as liberal as possible in carbohydrate. At
first such diets were exclusively vegetable. Glycosuria at first resulted from
140 gm. carbohydrate, but by June 16, 171 gm. carbohydrate were taken without
glycosuria. One egg was then added to the diet; and after June 22, 200 to 225
gm. carbohydrate could be taken daily without glycosuria. As a precaution,
however, the allowance was diminished to 150 gm. The diet prescribed at dis-
charge represented approximately 70 to 80 gm. protein (largely vegetable), 150
gm. carbohydrate, and 1200 to 1500 calories (1.5 to 1.75 gm. protein and 26 to 33
calories per kg., without fast-days). As the patient was about 9 kg. below nor-
mal weight, this allowance was considered prudent; and she was permitted to
estimate her diet instead of weighing it, on condition that she be guided by her
body weight and not allow herself to gain much flesh. She was stiU sufiiciently
well nourished to look and feel entirely healthy. The degree of undernutrition
in hospital, and the extent to which fat was excluded and carbohydrate empha-
sized in the diet, can be shown by the following table.





Total.


Average per day.


Calories in diet for 61 days


61,287
2,788.7 gm.
2,073.1 "
7,121.0 "


1005


Protein " " "61 "


45.7 gm.
34 "


Fat " " " 61 "


Carbohydrate " " "61 "


117 "






Nitrogen in diet for 61 days (Protein -f- 6.25)


446.0 gm.
278.6 "
266.5 "


7 ^ CTTYl


" " " " 49 " ( " ■^6.25)


5.68 "
5 44 "


" in urine "49 "


" " " per kg. per day (average 44 kg.)


0.125"



It should be borne in mind that the diet was strictly vegetarian, chiefly green
vegetables, except for a single egg daily after June 16. A considerable propor-
tion of the protein was therefore non-absorbable, so that the close correspondence



CASE RECORDS 197

between food and urine nitrogen must be attributed not to unusually good utili-
zation of food, but rather to loss of body nitrogen. Protein restriction to this
degree was doubtless unnecessary, but the rigid undernutrition was a commendable
feature.

Subsequent History. — The patient led a thoroughly normal and comfortable life,
but managed her diet so as to permit a gradual gain in weight. Occasional traces



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 19 of 76)