Frederick M. (Frederick Madison) Allen.

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by different observers several months apart, is now distinctly subnormal in size.
The superficial veins of the abdomen are becoming prominent. The diagnosis
of cirrhosis seems evident, progressing through the hypertrophic to the atrophic
stage. This has not suppressed the diabetes and dietary care should not be
remitted, but the most rigorous measures appear unnecessary. The frequency of
pancreatitis in connection with cirrhosis of the liver is worthy of investigation.

CASE NO. 6.

Female, married, age 48 yrs. Italian; housewife. Admitted July 23, 1914.

Family History. — Indefinite. Patient is ignorant of any special disease in
family. (Husband, short and obese, is said to have developed mild diabetes
siince this patient's discharge.)

Past History. — Very healthy life. Patient keeps house for her husband and
four children. Six children died young, perhaps because of tenement conditions.
One of those living is mentally defective. Menses regular up to 1 year ago,
absent since. She drinks four glasses of beer, one cup of coffee, and one cup of
tea a day. Other habits are those of an industrious poor Italian woman.

Present Illness. — Patient was admitted on the pneumonia service on July 23,
1914.

Physical Examination. — ^A short, slightly obese woman with sturdy peasant
appearance, and normal on physical examination except for consoHdation and
pther signs of pneumonia of right lower lobe. The urine showed heavy sugar and
ferric chloride reactions, though there had been no former complaints indicating
diabetes.



CASE RECORDS 213

Treatment was conducted first by the pneumonia service of the hospital. The
temperature fell by lysis on the 5th, 6th, and 7th days, and on July 31 the signs
in the right chest had cleared up and the patient was turned over to the diabetic
service.

During the period of pneumonia the diet consisted of oranges and egg-nogs
with whisky and cream, the caloric intake being about 1400 to 1600, as shown
in the graphic chart. Glycosuria and ketonuria remained heavy during this
time as indicated, but there were no symptoms threatening coma.

Diabetic treatment was begun on Aug. 1 with fasting, with addition of whisky
because of the convalescent condition. She thus received about 600 calories of
alcohol daUy until Aug. 7 to 8. She was a very unwilling patient during this
time, having been content to stay in the hospital during the pneumonia, but now
that she felt well, she was determined to go home to her babies. She had never
heard of diabetes and was accordingly unwilling to be treated. Her husband was
'of equally ignorant type, but fortunately he and certain relatives had seen a
few deaths from diabetes and comprehended the necessity of dietetic treatment.
Accordingly she consented to remain until completion of treatment. On Aug.
8, green vegetables were added to the whisky and gradually increased until on
Aug. 14 they represented 80 gm. carbohydrate. The next day one egg was
given, Aug. 17 two eggs, Aug. 18 three eggs, Aug. 19 four eggs, and the next
■day 100 gm. fish were added. A ration was thus gradually buUt up amount-
ing to some 1400 to 1700 calories, with 100 gm. carbohydrate and almost the
same quantity of protein. This seemed to be an adequate but not excessive
diet for her body weight of 54 kg., and it was tolerated without glycosuria
or ketonuria. She received several days' instruction in the diet kitchen in the
preparation of her food. She was not required to weigh it, but was ordered to
take the same kinds and quantities at home as she had been receiving in the
hospital.

Acidosis.— A small point is noteworthy regarding the effect of alcohol. On
fasting with whisky the ferric chloride reaction became absent on Aug. 3, and
the glycosuria the next day. With continuance of 600 calories of alcohol daily,
the ferric chloride reaction reappeared on Aug. 6. 600 calories of alcohol there-
fore did not suffice to keep it absent. It cleared up on Aug. 13 in consequence
of the addition of green vegetables to the whisky, about 50 gm. carbohydrate in
this form sufficing for this result.

Subsequent History. — ^After dismissal on July 31, nothing more was heard from
the patient until Nov. 25, 1914, when she called at the hospital by request, bring-
ing a specimen of normal urine and reporting that she had followed her diet faith-
fully and that daily urine tests had been uniformly negative. Circumstances pre-
vented testing the carbohydrate tolerance at that time.

Nothing more was heard from her until she was finally located by the
visiting nurse and called at the hospital by request on July 5, 1917. The urine
:showed heavy sugar and negative ferric chloride reactions. The patient claimed



214 CHAPTER in

to feel entirely weU but looked pale and run down. She admitted that she had
abandoned diet shortly after her previous report and since then had eaten starches^
sugars, and the regular family diet without restriction. She was advised to
reenter the hospital and resume treatment, but refused on the ground that her
children required her presence at home.

Remarks. — ^The case is chiefly noteworthy from having been first discovered
during an acute infection. Presumably diabetes had been present without notice-
able symptoms before this time. It was evidently aggravated as usual by the
infection. The case is essentially mild and readily controllable by treatment, but
the patient's ignorance and neglect are responsible for continuance of active
symptoms, which may be expected to bring serious trouble within a few years.

CASE NO. 7.

Female, married, age 36 yxs. American; clothing saleswoman. Admitted
July 23, 1914.

Family History. — Father died at 52 of heart trouble. Mother alive and
healthy. All grandparents lived to old age. Five brothers and two sisters of
patient alive and well. No diabetes or other family disease known.

Past History. — ^Healthy life, but obesity from childhood. Only sickness scar-
let fever. At the age of 15 patient weighed 135 pounds; before onset of present
trouble, her weight was 168 pounds. At 18 she began work as a clothing sales-
woman; married at 33 but continued work. No children; one miscarriage. Un-
happy married life ending in separation. Habits said to be regular, alcohol de-
nied. Patient was a light eater all her life and also indulged very little in candy
or sweet dishes. Since onset of diabetes, for thirst and to stimulate strength,
she has taken coffee to excess, at least 20 cups a day, 1 pound of cofiee every 2
days. Nervous since onset of diabetes but not before.

Present Illness. — Symptoms began last Dec. with pruritus vulvae. A physician
made an examination and prescribed a local application without testing urine.
She and her friends noticed rapid loss of weight, and she applied at the Board of
Health for examination for tuberculosis, which was found absent. She then
went to a medical school clinic, where the physician in charge diagnosed diabetes
and merely gave her a list of things to eat and to avoid. During 4 months' at-
tendance at the clinic no benefit was received, and pruritus vulvae and loss of
weight continued. Since Mar. there has been constant pain in calves of legs,
described as like toothache. Within the past few weeks she has had six styes
on the left eye, which healed uneventfully. Much of her hair has fallen out.
There is polydipsia and polyTiria but no pol3T)hagia.

Physical Examination. — ^Nutrition still medium, though superficial tissues
show flabbiness and wasting. Nervous facies and behavior. Posterior cervical
glands slightly enlarged. Vagina and surroimding parts show superficial in-
flammation. Uterus retroflexed retroverted. Examination otherwise negative.
Wassermann reaction negative.



CASE RECORDS 215

Treatment. — For the first 3 days, the patient was allowed an observation diet
Tunning as high as 115 gm. protein, 80 gm. carbohydrate, and 2000 calories. On
this her highest sugar excretion was 63 gm. The ferric chloride reaction, whicL
was slight on admission, became heavy on this diet, indicating that the former
diet had included more carbohydrate. 2 days of absolute fasting were then im-
posed. The glycosuria ceased but the ferric chloride reaction remained heavy.
The next day 100 gm. lettuce and 100 gm. cucumber were allowed. Green vege-
tables were increased daUy without other food untU 33 gm. carbohydrate were
;given in this form on July 30. The ferric chloride diminished to a shght reac-
tion, but glycosuria appeared. A fast-day with 35 gm. alcohol was then given,
and as glycosuria immediately ceased, 27 gm. carbohydrate in the form of green
vegetables were given the next day for the sake of acidosis. Glycosuria ap-
peared, but the carbohydrate was continued for 2 days. Then Aug. 3 was a fast-
•day with 70 gm. alcohol. On Aug. 4, 12 gm. carbohydrate were given as green
vegetables, and on Aug. 5, 17 gm. The ferric chloride reaction had been di-
minishing and was now absent. Although glycosuria remained absent, Aug. 6
and 7 were fast-days with respectively 65 and 87 gm. alcohol. A slight ferric
•chloride reaction returned. On Aug. 8, 90 gm. alcohol and 5.8 gm. carbohydrate
(in green vegetables) were given. On Aug. 9, the alcohol was increased to 120
gm. and the carbohydrate to 16 gm.; Aug. 10, alcohol 105 gm., carbohydrate 17
gm.; Aug. 11, alcohol 90 gm., carbohydrate 22 gm. The alcohol was then dimin-
ished to, 75 gm. and this program was continued to Aug. 16. The ferric chloride
reaction had been well marked under the large doses of alcohol at the beginning
of this period, but gradually diminished with the introduction of carbohydrate
untU it became negative. On Aug. 17 one egg was added, on Aug. 20 a second egg.
A slow increase of diet was continued, until on Aug. 27 it included four eggs, 200
gm. meat, and green vegetables representing 41 gm. carbohydrate. Both glyco-
suria and ketonuria were now continuously absent, the exclusion of fat having
been the principal means by which this end was attained. Fat was then gradu-
ally introduced, finally making a diet of about 100 gm. protein, 60 gm. carbohy-
drate, and 2100 calories. Slight glycosuria resulted and the diet was therefore
•diminished to 80 gm. protein and 1700 calories.

The patient began to keep irregular hours on visits outside the hospital and
was absent one whole night, returning with glycosuria. On Sept. 28 she went
out and failed to return. She reappeared on Dec. 7 showing 3.3 per cent glyco-
suria, which easily cleared up. She visited friends on Christmas and did not
■return for 2 days. Therefore on Dec. 27 she was dismissed for this conduct, and
no further tracing of her case was attempted. ' The impression was received that
the patient was a drug addict or an occasional alcoholic, and that her behavior
was thus explained, but no real proof of this supposition was obtained.

Acidosis. — ^The only noteworthy feature is the fact that doses of alcohol from
75 to 120 gm. failed to clear up the ferric chloride reaction or prevent its reap-
pearance. The efficient means of stopping the persistent acidosis was found in



216 CHAPTER III

continued undernutrition and carbohydrate up to the limit of tolerance, with-
abstinence from fat.

Remarks. — The initial treatment consisted in continuous undernutrition with
as much carbohydrate as possible. After both glycosuria and ketonuria were
thoroughly controlled, the diet was built up by the gradual addition of first pro-
tein and then fat. The weight at entrance was 52.8 kg. The lowest weight re-
sulting from the undernutrition was 47.9 kg. on Aug. 19. Thereafter it gradu-
ally rose, and at the time of her first leaving on Sept. 28 the patient weighed 50
kg., which was a satisfactory state of nutrition for both comfort and strength.
The case illustrates the treatment of diabetes of moderate intensity with the aid of
only the simplest laboratory tests. The outcome was satisfactory except that
the psychic instability of the patient precluded continuing treatment.

CASE NO. 8.

Male, married, age 29 yrs. American; printer. Admitted July 28, 1914.

Family History. — Father and mother are alive and well. Mother had a goiter
removed at age of 40 for cosmetic reasons; there were no symptoms. Grand-
parents all healthy. Patient is the oldest of six children. No diabetes or other
family diseases.

Past History. — Healthy life. Measles, mumps, and chicken-pox in childhood.
Always took cold easily; never had sore throat. Slight pleurisy 4 years ago; irk
bed only 1 day. Regular life; no excesses Never nervous. Married 1 year ago;
wife well, never pregnant.

Present Illness. — In June, 1913, immediately upon return from honeymoon^
patient noticed abnormal thirst and dryness in mouth. Physician immediately
diagnosed diabetes but merely prescribed a diet list, and condition rapidly grew
worse. Patient was then referred to a New York physician who ordered a diet of
nothing but ham and lettuce. He lived strictly on this diet for 6 weeks, eating
as much as 5 or 6 pounds of ham a day. Sugar diminished but did not disappear.
Other treatments were tried with a steady downward progress. He then con-
sulted a New York specialist, who placed him on strict diet with one " green day""
each week, and three or four teaspoonfuls of sodium bicarbonate daily. The-
urine was never sugar-free, and the loss of weight and strength became worse^
On July 25, 1914, patient entered a New York hospital, where a D : N ratio of
3 : 1 was demonstrated on carbohydrate-free diet. Coma threatened on this diet^
but the addition of a slice of bread seemed to make him worse. He was then-
transferred to this hospital in critical condition.

Physical Examination. — An emaciated man appearing very weak. Face thin,
and nervous. Skin dry. Acetone odor. Drowsiness and increased respiration
very evident. Knee jerks absent. Physical examination otherwise negative.

Treatment. — For the first 4 and a fraction days in hospital, the patient was
placed on an observation diet as nearly carbohydrate-free as convenient, thrice
cooking of vegetables having not yet been adopted. This diet, which represented



CASE RECORDS 217

77 to 135 gm. protein, 6 to 12 gm. carbohydrate, and 2800 to 3300 calories, was
all the patient could eat. He showed the usual inability to gain weight or strength
on full feeding, and clinical evidences of acidosis increased. 20 gm. sodium bicar-
bonate and 20 gm. calcium carbonate were given daily. By Aug. 2 there was in-
cipient coma with nausea, continuous dozing which was promptly resumed when-
ever patient was roused, hyperpnea, malaise, and weakness. Fasting was there-
fore begun from necessity. Whisky was given in 10 cc. doses hourly, amounting
to about 100 gm. alcohol on the various fast-days. Calcium carbonate 20 gm.
and sodium bicarbonate 30 gm. were given on Aug. 2. On Aug. 3 the bicarbon-
ate was increased to 40 gm., on Aug. 4 it was diminished to 20 gm., and on Aug. 5
all alkali was stopped. Clinically, meanwhile, the condition seemed to grow worse
during the first 24 hours of fasting; the sleep was noticeably deeper. Improve-
ment on the following day was marked and all the threatening symptoms cleared
up rather suddenly. Sugar-freedom resulted on Aug. S, the 4th day of fasting,
although the D : N ratio had been 3 : 1 on the feeding days. Because of the
marked weakness, whisky was continued in doses just short of producing intoxi-
cation, and green vegetables were gradually added, beginning Aug. 7 with 100 gm.
each of lettuce and cucumbers. On Aug. 10 the quantity of carbohydrate in this,
form amounted to 38. S gm., and by reason of 240 cc. whisky, the total calories for
this day were 1073. TherewasadayofwhiskyaloneonAug.il. The program
of alcohol and green vegetables was continued to clear up acidosis thoroughly,
and 40 to 50 gm. carbohydrate were now assimilated daily without glycosuria.
The ferric chloride reaction was abolished, but the patient was ravenously hungry
and seriously weak. Accordingly, on Aug. 23 the carbohydrate was stopped, and
the diet consisted of 4 eggs, 100 gm. butter, and 135 gm. alcohol. The eggs were
then increased and the alcohol diminished daily, until on Aug. 27 the diet was 60
gm. protein, 37.5 gm. alcohol, and 1660 calories. Aug. 28 was a "green day" of
nothing but alcohol and green vegetables with 55 gm. carbohydrate. This sort of
program continued until Sept. 11. As usual, no benefit to weight or strength re-
sulted from the attempt to feed to the limit. Accordingly, on Sept. 12 a lower
diet was begun, carbohydrate-free, with 80 gm. protein and 1300 calories, the alco-
hol being at the time diminished to 20 gm. daily. For the weight of about 35
kg. this meant less than 30 calories per kg. daily, and this was diminished still
further by the fast-days every 1 or 2 weeks. Exercise would presumably have
been beneficial, but the tradition was followed of keeping a patient with severe
diabetes as quiet as possible. Therefore he was weak and cold and spent most
of his time in a chair close to the radiator, clad in heavy clothing and double
underwear. Nevertheless, the condition at certain times began to appear rather
promising, since the sugar and ferric chloride reactions were frequently both nega-
tive. A difference from the average case soon began to be noted, in that sugar
kept unaccountably reappearing and the tolerance seemed to be perceptibly fall-
ing under conditions when it should have risen or at least remained stationary.
With the progress of time it became more evident that something unusual was



218 CHAPTER ni

breaking the patient down. Dr. Joslin chanced to see the patient on a visit and
suggested the presence of tuberculosis, but physical signs and sputum examina-
tions remained negative. Dec. 6 to Jan. 1, pancreas and duodenal feeding were
attempted without benefit, as described elsewhere (Chapter IV). Thereafter
the attempt at radical treatment of the diabetes was abandoned, and the patient
was allowed at times to eat his fill of a selected diet. Although this diet amounted
sometimes to 60 or 70 calories per kg., there was the usual absence of benefit
to weight or strength, and the attempt to overfeed was doubtless a mistake.
Certain days of lower diet and occasional fast-days were necessarily inserted be-
cause the increasing acidosis sometimes threatened coma. On Jan. 9 he was
transferred to the metabolism ward of the Russell Sage Institute of Pathology at
BeUevue Hospital for calorimetric studies by Dr. Eugene DuBois.' He returned
to this hospital on Jan. 15. The diet of 2000 calories or over during most of
Jan. failed to prevent further loss of both strength and weight . Both the weakness
and the rapidly falling weight were probably associated with the seriously increas-
ing acidosis. The steep elevations in weight shown in the graphic chart at times
in this same period represented marked edema due to sodium bicarbonate in doses
up to 80 gm. daily. Nevertheless on Feb. 1 the point had been reached where a
choice was necessary between fasting and immediate death in coma. A 6 day
fast with whisky was accordingly imposed, which stopped the glycosuria and
cleared up the threatening symptoms, though the ferric chloride reaction was not
made negative. A lower diet was then employed, mostly about 30 calories per
kg., on which glycosuria remained almost continuously absent and greater comfort
was enjoyed by reason of the absence of acidosis symptoms, though the patient
was very weak. On Mar. 16 the patient had the symptoms of catching cold
with fever and pain in the chest. Some dulness and crepitant rMes were now de-
tected. On account of the aggravation of the diabetes, fasting with alcohol was
employed on Mar. 16 and 17, but the glycosuria increased. The D : N quotient
on Mir. 16 was 2.3, on Mar. 18 it was 4.6. As death was imminent, the attempt
at dietary restriction was abandoned and a liberal protein-fat diet with alcohol
was permitted. By Mar. 22 the weakness had become extreme. Though there
was chemical evidence of intense acidosis, the patient never went into typical
coma. Death occurred at noon on Mar. 22, 1915; the patient recognized his
wife shortly before this, though too weak to speak.

Acidosis. — The intense acidosis during the first days in hospital was mentioned
above. On Aug. 1 the excretion of ammonia was 3.5 gm. and that of acetone bodies
(expressed as ;8-oxybutyric acid) was 38.6 gm. A rapid fall was evident even in
the first 24 hours of fasting. On Aug. 8, with 16 gm. carbohydrate in the diet,
the excretion was still 1.1 gm. ammonia and 3.1 gm. /?-oxybutyric acid. It is
noteworthy that the period of 20 days up to Aug. 23, with a diet composed solely
of alcohol and green vegetables in the quantities shown, failed to clear up the
acidosis entirely, as indicated by the excretion of 0.76 gm. ammonia nitrogen and
0.48 gm. /S-oxybutyric acid on Aug. 22. If allowance be made for the effect of the



CASE RECORDS 219

40 to 50 gm. of carbohydrate, which was assimilated without glycosuria, it would
seem that no evident antiketogenic effect, was exerted by approximately 600
calories of alcohol in the diet daily. A specific character of the acidosis perhaps
is recognizable in such cases, by comparison with others in which acidosis is
absent on similar regimen. Neither carbohydrate nor alcohol, but undernutrition
was the essential factor in controlling the acidosis at all periods of the treatment.

With a rather high carbohydrate-free diet beginning Aug. 23 there was a
marked rise in ammonia excretion, showing the harmful effects of the attempt to
build up strength or weight above the tolerance. With the low diet which began
Sept. 11 there was a gradual improvement, so that even without carbohydrate in
the diet the ferric chloride reaction became entirely negative on Oct. 7, and no
more than traces reappeared during the time of radical treatment. Early in
Dec, when the attempt was begun to nourish liberally on account of the assumed
infection, there is another marked rise in the acidosis, going higher as the attempt
was prolonged, until on Jan. 20 the ammonia excretion reached 5.1 gm. In con-
sequence of 2 fast-days it fell sharply, then rose to 4.62 gm. on Jan. 28 in con-
sequence of further excessive feeding. Then on fasting and lower diet it fell
and remained at a much lower level until near the end, analyses in the last few
days of life being lacking because of loss of some urine.

Beginning Jan. 25, the carbon dioxide capacity of the plasma was also deter-
mined. It is seen that although the body weight at that time was rising in con-
sequence of edema from heavy bicarbonate dosage, the blood alkalinity fell
sharply to a dangerously low level. With the fasting and alcohol beginning
Feb. 1 it rose easily within normal limits, then ranged slightly below and slightly
above the lower normal level for most of the remaining time, but dropped sharply
almost to the coma level just before the fatal end.

A statement of the alkali dosage is necessary for proper interpretation of the
ammonia and COj curves. After the stopping of alkali on Aug. 5 as above men-
tioned, no more was given until Aug. 28. From Aug. 28 to Dec. 18 inclusive, the
patient received daily 2 gm. each of sodium bicarbonate, calcium carbonate, and
magnesium oxide, and 1 gm. potassium bicarbonate. These were given in the
attempt to assure against a deficit or improper balance of any or all of these
bases, as well as to neutralize acids. Similar mixtures have been used in a few
other cases. The points in mind have been the reported wasting of bones and ex-
cretion of bone salts in diabetes, and also the vague idea sometimes suggested that
a disturbance of the balance of salts or metals is at the bottom of diabetes. No
effect of such mixtures upon the tolerance or general condition, and no advantage
over the use of sodium bicarbonate alone, have been perceptible in any of the
cases.

On Dec. 19, 6 gm. sodium bicarbonate were given, and 2 gm. on Dec. 20.
The ammonia excretion following the huge diet of Dec. 30 was less than it other-
wise would-have been, because of the giving of 6 gm. sodium bicarbonate on Dec.
30, and 15 gm. sodium bicarbonate and 30 gm. calcium carbonate on Dec. 31.



CASE RECORDS 221

Present Illness. — 1 year ago patient consulted a physician for a severe cough
which had lasted about 2 weeks, and also for a slight injury to his right knee
due to a fall. He was told that he had "lung trouble" and was sent to the
country. Here he began taking a larger diet than that to which he was accus-
tomed, and especially a great deal of cereals and starchy foods. In about 2



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 22 of 76)