Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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never yet been known to develop under thorough treatment by this method; and
anyone making use of high diets for the sake of supposed comfort must be pre-
•pared to assume responsibihty for occasional blindness and similar troubles.

CASE NO. 5.

Male, married, age 34 yrs. American; customs inspector. Admitted July
15, 1914.

Family History. — Entirely negative for heritable or metabolic disease.

Past History. — Generally healthy life. Measles, tonsiUitis, and adenoids in
childhood. Neisser infection at 22. No history or indications of syphiUs. Ner-
vous and easily excitable since boyhood. Indigestion and constipation began at
about 22 and have grown worse up to the present, probably aggravated by irregu-
lar eating since entering customs service at 23. There is a feeUng of hunger with
nausea between meals, temporarily relieved by eating; no pain, no vomiting, little
• eructation. No alcohol up to 25, then began to drink beer and other liquors,
occasionally to sUght excess; during the past 4 months has lost all appetite for
liquor. Smokes two or three cigars a day.

Present Illness.— In July, 1913, while at work, patient experienced a sudden
-feeling of dizziness, then compression about chest, followed by vomiting, colic,



CASE RECORDS 205'

and diarrhea. After a doctor had given him calomel and salts at home, on diag-
nosis of "autointoxication," he had hot fever during that night, but felt well the
next day and returned to work. Urine was not examined. From that time on
he felt constantly thirsty and steadily lost weight and strength. About Sept. 1
the same doctor was consulted again and found 4 per cent glycosuria. Patient
followed the routine restricted diet prescribed, but was sugar-free only twice for
about a week; this sugar-freedom was obtained by rigid exclusion of carbohydrate.
Acetone appeared, so a small quantity of carbohydrate was allowed, with result-
ing glycosuria. Occasional vegetable days have been employed. Lately a quart
of mUk daily has been added, and diet has been unrestricted on 1 day each week..
On vacation in the country, July of this year, he took ordinary mixed diet for 1
week, and experienced an acute attack similar to the initial seizure 1 year pre-
viously. At present he follows the diet with restricted carbohydrate; feels ner-
vous and weary, no polyphagia, slight polydipsia and polyuria; no dryness of skin,
but on the contrary troublesome sweats. Normal weight has been 175 to 18&
pounds; recently it has fallen to 144 pounds.

Physical Examination. — Height 1 73.8 cm. Weight 60.4 kg. Body well formed,
but lean. Neurasthenic manner, expression indicating weakness and weariness.
Skin very moist, noticeable pallor. Slight enlargement of tonsils. Knee jerks-
entirely absent. Other reflexes normal. Examination otherwise negative.

Treatment. — On the day of admission and the 2 following days, patient was
allowed to choose a diet resembling his habitual one. Then 2 plain fast-days were
given, followed by 3 alcohol days. The result, as shown in the graphic chart,
was a clearing up of glycosuria but persistence of the ferric chloride reaction.
Green vegetables were then added (July 23 to 27) and the latter reaction thus
cleared up. After a single fast-day with alcohol on July 28, the patient proved
able to tolerate a diet as high as 1100 calories with about 50 gm. protein and 70
to 75 gm. carbohydrate. This was undernutrition, representing, for a body weight
of about 60 kg., about 0.9 gm. protein and less than 20 calories per kg. Alcohol'
was discontinued on Aug. 5, as it was unnecessary and the formation of a habit
was undesirable. Beginning Aug. 11, an experimental period was begun to show
the effect of increasing calories, particularly in the form of fat (see below) . There-
after, it was intended to place the patient upon a proper hving ration preparatory
to dismissal; but on Nov. 9 he suddenly requested discharge to accept a particu-
larly favorable business opportunity. He was therefore allowed to go with
approximate instructions regarding diet, following the plan of not weighing his-
food but judging portions by the eye, and guiding himself by his urinary tests and
particularly by his weight. The diet ordered consisted of protein, fat, and about
100 gm. carbohydrate in green vegetables. The entire treatment was not one of
undernutrition, because he left weighing approximately 1 kg. more than on adibis-
sion to hospital. The relative mildness of the diabetes had not called for the-
most rigorous measures, and the patient was already far under normal weight..
He was instructed never to allow himself to gain weight above 160 pounds.



206



CHAPTER lU



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CASE RECORDS



207



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TABLE VII.





Diet.




Urine.


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Date.






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Sept. 29


26.4


7.3


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511


8.7


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1375


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" 30


26.3


7.2


82.2


511


8.5


60.0


1975





+++


10.51


-6.69


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Oct. 1


26.2


5.9


75.6


471


7.7


60.8


3035





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6.80


-2.89


+75.6


" 2


25.7


7.3


80.9


513


8.4


60.6


2900


+


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5.92


-2.10


+80.9


" 3


26.1


7.4


80.4


504


8.3


60.6


2995





+++


8.69


-8.98


+80.4


" 4


24.4


6.6


82.5


499


8.3


60.0


2715





+


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-3.43


+82. S


" 5


32.5


13.0


80.0


582


9.6


60.2


3380





+


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" 6


40.1


16.8


73.2


620


10.3


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8.56


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57.8


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983


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" 8


45.5


51.6


84.3


1010


16.5


61.0


2590








8.38


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" 9


46.1


51.7


82.3


1006


14.7


61.4


3205








8.46


-1.58


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" 10


45.5


51.6


84.3


1010


16.4


61.6


2615





+


7.95


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+84.3


" 11


51.5


56.3


82.6


1072


17.3


62 jO


2795













+82.6


" 12


S8.7


61.8


77.0


1129


18.1


62.4


2960








8.88


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+77.0


" 13


65.2


96.0


82.0


1495


23.6


62.2


2822





+


8.81


+0.98


+82.0


" 14


69.1


128.5


82.1


1814


29.1


62.4


3150








9.45


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+82.1


" 15


75.2


163.2


82.1


2161


34.4


62.8


3145








9.12


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75. 5


187.3


82.4


2392


38.1


62.8


2895








7.30


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" 17


81


189


105


2518


39.9


63.0


4280








9.93


+2.11


+ 105.0


" 18


92


196


104


2621


41.6


63.0


3380








8.92


+4.76


+ 104.0


" 19


104


195


99


2643


41.9


63.0


3270








10.20


+5.27


+99.0


" 20


103


194


103


2647


41.7


63.4


3960








11.56


+3.78


+ 103.0


" 21


104


195


103


2661


42.0


63.4


3160








10.49


+4.99


+ 103.0


" 22


110


203


124


2851


45.0


63.4


4070





+





+5.38
(calc.)


+ 124.0


" 23


114


197


121


2646


41.7


63.4


3680








11.48


+s:49


+ 121.0


" 24


114


220


118


2999


47.0


63.8


4254








15.31


+ 1.64


+ 118.0


" 25


114


228


120


3073


48.4


63.4


4085








15.36


+ 1.61


+ 120.0


" 26


113


219


119


2829


44.7


63.2


4487








14.36


+2.47


+ 119.0


" 27


115


221


123


3128


50.0


62.8


3590





+


_





+ 123.0


" 28


112


227


118


3053


48.3


63.2


3810








_





+ 118.0


" 29


114


228


120


3074


48.8


63.0


3554





+


_





+ 120.0


" 30


81


222


39


2556








1605








_





+39.0


" 31


78


368


51


3950








930





+++


_





+51.0


Nov. 1


108


193


92


2610


39.4


62.2


3770














+92.0


" 2


148


292


92


3676


59.8


61.4


3205





+


_





+92.0


" 3


165


483


104


5595


90.8


61.6


2865


+


++


_





+104.


" , 4


165


482


99


5563


89.4


62.2


2600


+


+





,


+99.0


" S


112


351


93


4099


65.9


62.2


3090





+





_


+93.0


" 6


Alcohol 2C


'gm.


140




61.6


2690















" 7


155


221


119


3177


53.6


59.2


2240











_


+ 119.0


" 8


114


220


120


3002


48.8


61.4


3880











_


+120.0


" 9


114


220


120


3002


49.0


61.2


1710








-


-


+ 120.0



208



CASE RECORDS 209

Overfeeding Experiments. — The patient was peculiarly adapted to experiments
with excessive diets, for though he had never suffered from true diabetic poly-
phagia, he was habitually a very heavy eater. Also his constipation was invinci-
ble, notwithstanding the most enormous fat diets. He took these diets with
relish and without increase of his slight dyspeptic complaints. As indicated in the
laboratory chart, the stools were small, hard, and infrequent, and carmine for de-
marcation was always retained for several days. With the return of diabetic
symptoms in each instance the patient felt so much worse that he was glad to re-
sume a rational diet even at the price of slight continual hunger. The experi-
ments were of practical usefulness in convincing him of the inadvisability of try-
ing to satisfy his appetite, and with this object lesson he has remained faithful to
treatment from that time to the present.

Nitrogen Balance. — The most surprising feature is the remarkable nitrogen
retention, comparable to that described in normal persons by Liithje and in dia-
betics by Falta and coworkers. It is to be recalled that the patient was moderately
emaciated from diabetes and had then been subjected to fasting and low diet,
which had reduced his nitrogen excretion to a low level. Also the diet ia this ex-
periment was liberal in protein, and starting at 64.5 calories per kg. increased to
109 calories per kg. — an extreme surplus for a man at rest in a hospital ward.
With the rapid gain in weight it is not surprising that considerable nitrogen was
stored, but it is remarkable that the low output of 6 to 8 gm. daily was main-
tained up to the sudden increase on Sept. 13, the day before the onset of glyco-
suria, and simultaneously with the appearance of the first decided ferric chloride
reaction. The retention then continued, but to a diminishing extent, notwith-
standing the steady increase in total calories. The diminution of storage may
probably be attributed to the active diabetic symptoms. Notwithstanding the
large quantity of nitrogen stored, the fasting and low diet following Sept. 27
quickly brought a return to the same low nitrogen output as before. Analyses
are not complete for the second period of overfeeding, but the data available
fuUy confirm the results in the first period.

Influence of Body Weight. — The weight was built up in two feeding periods on
different diets. Diabetic symptoms were present at the higher weight in each
instance. The attainment of a higher weight in the second as compared with
the first period of overfeeding may have been aided by the mildness of the symp-
toms on the second diet. This difference makes it clear that weight was not
the sole factor in bringing back symptoms, but the kind and quantity of the
different elements of the diet is necessarily an important factor.

Influence of the Diet. — Both glycosuria and acidosis were brought on by in-
crease of the diet, particularly in fat. The influence of the three elements may
be considered as follows.

1. Carbohydrate. — The glycosuria cannot be attributed merely to carbohy-
drate, because the increase of carbohydrate in the first overfeeding period was
not great, and the quantity on certain days, such as Sept. 23, 25, and 26 with



210 CHAPTER in

heavy glycosuria was actually less than on earlier days without glycosuria. Also
in the second overfeeding period the carbohydrate was regularly higher than in
the first one, yet glycosuria was trivial in comparison with the first period. On
the other hand, carbohydrate was not effectual in preventing acidosis, so that
it would have been impossible, even in this relatively mild case, to control acidosis
by feeding carbohydrate along with a high fat diet. A fallacy of the carbohydrate
balance plan is also illustrated; for in the period Sept. 11 to 19 this balance was
as high as before, yet the beginning ferric chloride reactions and the higher average
acetone excretion, though so slight as to be often ignored, were actually significant
of the damage already done by fat and soon to be more manifest.

2. Protein. — Protein was increased at the time of glycosuria and acidosis in
the overfeeding period. Such increase did not prevent acidosis. The gener-
ally higher protein may be regarded as one cause of the heavy glycosuria in the
first overfeeding period, as compared with the slight glycosuria in the second.
On the other hand, protein can scarcely be credited as the sole cause of the gly-
cosuria, since the latter was out of proportion to the increase of protein in the
first overfeeding period, and also on certain days of the second period {e.g. Nov.
3 and 4), with sUght glycosuria, both protein and carbohydrate were higher than
on certain days in the first period {e.g. Sept. 20, 23, 25, and 26) with very heavy
glycosuria.

3. Fat. — The principal increase in the diet was in the form of fat, and to this
may be attributed most of the gain in weight and return of all diabetic symp-
toms. The fat diet was much higher in the first than in the second overfeeding
period, and the excessive caloric intake in this form may be considered the most
important factor in the production of both glycosuria and acidosis. Periods of
fasting and lower diet quickly cleared up both the laboratory and the clinical
symptoms.

4. Calorimetry. — ^This patient was studied by Dr. Eugene DuBois in the
respiration calorimeter of the Russell Sage Institute of Pathology on Oct. 30 and 31
and Nov. S, with a view to observing any possible anomalies in the disposal of
the huge rations, particularly of fat. No departures from the normal were demon-
strated either in the basal metabolism or in that following a heavy fat meal.'

Subseqiient History. — ^The patient remained at work in excellent condition, until
he reported at the hospital on Dec. 28 weighing 160 pounds, glycosuria having
come on with the increase in weight without change in the prescribed diet. Fast-
ing and reduced diet at home brought him down to 157 pounds, but a trace of
sugar returned on Jan. 10. He was therefore instructed to keep his weight there-
after below 155 pounds. He then remained continuously sugar-free until he re-
ported at the hospital on Mar. 21 with the following history. On account of
his slight indigestion he had consulted a well known stomach specialist of New
York, who told him that he must omit most of his vegetables and take two white

1 Cf. Allen, F. M., and Du Bois, E. F., Arch. Int. Med., 1916, xvii, 1010-1059.



CASE RECORDS 211

rolls daily. The patient objected that this would bring back his glycosuria,
but the physician responded that he had better have glycosuria and feel better.
The patient therefore took the white rolls for a short time, and promptly showed
heavy glycosuria. He then on his own judgment stopped the rolls, cleared up the
glycosuria by fasting, and reported at the hospital because his tolerance had
been lowered and he now showed traces of sugar on the diet on which he was for-
merly sugar-free. A reduction of his green vegetables was therefore ordered, and
he was instructed not to exceed his existing weight, which was then ISO pounds.
At this weight he was reasonably weU nourished and fully able to work, and his
troubles were all classified as neurasthenic.

On Apr. 2 and again on Apr. 9, the patient reported, showing both sugar and
ferric chloride reactions and weighing 149 pounds. The vegetables were ordered
thrice boiled so as almost entirely to exclude carbohydrate from the diet, and the
quantities of food were now more strictly regulated so as to make a ration of
approximately 2500 calories.

On June 19, the ferric chloride reaction was negative, but there had been traces
of glycosuria from time to time.

On July 13, he returned with a similar report, but had recently caught cold,
and this had brought a return of glycosuria, concerning which he was very nerv-
ous. He was therefore readmitted to the hospital for the week July 13 to 19
for purposes of instruction. Physical examination was as before, except for en-
largement of the hver to 5 cm. below costal margin. He was placed on a diet
of approximately 2100 calories, with 90 gm. protein and 30 gm. carbohydrate
(see graphic chart). He was discharged with instructions to weigh all food,
adhere rigidly to this diet, and take a fast-day once every week.

On Aug. 8, he weighed only 58.8 kg., and complained of weakness, weariness,
and hunger, but had shown no sugar since leaving hospital. Bran muffins were
added to relieve both his feeling of emptiness and his constipation.

On Feb. 28, 1916, the report was similar. He was walking 6 mUes daily for
exercise. On this basis his diet was increased to 108 gm. protein, 30 gm. carbohy-
drate, and 2400 calories. Thereafter he continued at work with favorable re-
ports until June 5, when the carbohydrate was increased to 40 gm. and the cal-
ories to 2500. Traces of glycosuria gradually came on, so that on July 17 the
carbohydrate was again reduced to 30 gm.

The urine subsequently remained free from both sugar and ferric chloride
reactions, and the patient gradually increased his exercise to 8 miles of walkiag
daUy.

On May 23, 1917, the weight was 56 kg., the blood sugar 0.116, and the car-
bon dioxide capacity of the plasma 59.9 per cent.

On June 13, 1917, the weight was still 56 kg. and diet was 20G0 calories, with
50 gm. carbohydrate and 70 gm. protein. The blood sugar was 0.155 per cent,
and the carbon dioxide capacity of the plasma 64 per cent. The urine remained
negative for sugar and ferric chloride reactions.



212 CHAPTER III

Remarks.— This was one of the early cases, and the treatment contained errors
accordingly. The diabetes was of moderate severity, and the attempt was made
to treat it with as little inconvenience to the patient as possible, insisting upon
a normal urine and a moderately reduced body weight, and hoping for a recovery of
assimilation under these conditions. The result shows that such loose methods
are not advisable even in a case of this type, and that tolerance is lost rather than
gained under such a plan. The patient had felt unable to work at the time of his
first admission to hospital. He has been kept in working condition during most
of the time for 3 years. His tolerance has fallen sUghtly, so that now about
80 gm. carbohydrate is tolerated with a diet of 2200 calories. The blood sugar was
never reduced to normal, as might easily have been done, and the slight downward
progress seems to be nothing inherent in the nature of the condition, but rather
due to the inadequacy of the treatment and the continuous shght overtaxing of the
assimilation. On the whole, a prolonged and conscientious attempt was made to
treat this case from the standpoint of immediate comfort and efficiency, and the
record is now believed to show that this treatment is unjustifiable even for a case
apparently as well suited for it as this one.

Recent examinations have shown that the liver, which was normal in out-
line at the first examination, and afterward was obviously enlarged in examinations



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