Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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weeks he began to notice polyuria and polydipsia. A physician then diagnosed
diabetes. A list of carbohydrate-free foods, also " Metchnikoff 's tablets" were
prescribed. For the past 9 months he has been under treatment at one of the
best New York clinics on practically carbohydrate-free diet. The severer symp-
toms date back 4 or S months, during which time he has lost 25 pounds in weight,
has grown much weaker, and his cough has become worse. Constipation and
abdominal cramps have been jnarked, with nausea and sometimes vomiting.
There is a chronic cough, mostly at night, with expectoration of white mucus
without blood. There was blood in the sputum on one occasion. He now
drinks 20 to 30 glasses of water daily and passes as much as 8 quarts of urine.
Polyphagia present. "••

Physical Examination. — ^Young man with nervous look, moderate emaciation,
and general appearance of weakness. Eyes unduly bright, face flushed, skin in
good condition. Some pyorrhea, and a few decayed teeth. Throat red, tonsils
not visibly enlarged, cervical glands not palpable. A few subcrepitant riles in
both apices posteriorly, and expiratory murmur slightly prolonged; lung sounds
otherwise normal. Organs otherwise negative. Knee jerks absent. Blood
pressure 80 systolic, 60 diastolic.

Treatment. — The patient was placed upon an observation diet of protein, fat,
and green vegetables for 4 days, as shown in the graphic chart. Glycosuria was
as high as 98 gm. on Oct. 11, but the excretion of acetone bodies was not above
1.4 gm. of /3-oxybutyric acid. Fasting with whisky was begun on Oct. 12, and
the urine became sugar-free on Oct. 15. Nevertheless, as the patient was well
able to endure fasting, green vegetables were not begun untU Oct. 18, when 6
gm. carbohydrate were given in this form, increased to 15 gm. on the next day,
30 gm. on the next, and 54 gm. on the next. Sugar was present in traces on the
last 2 days (Oct. 20 and 21), therefore 1 more fast-day with alcohol was given on
Oct. 22. On Oct. 23 the diet consisted of one egg, 30 gm. alcohol, and 600 gm.
thrice cooked vegetables. The next day was similar, with two eggs and substi-
tution of 20 gm. butter for the alcohol. Three eggs were given on Oct. 25, and
four on Oct. 26, and then fat was gradually introduced in the form of butter and
bacon. A little steak was added on Oct. 30. The highest diets of this period,
Oct. 29 to Nov. 1, were only 40 to 60 gm. protein and some 1200 to 1400 calories.
But the traces of sugar and ferric chloride reactions made a fast-day with alcohol
advisable on Nov. 2. A higher diet was then attempted, up to 2700 calories on
Nov. 12, with 17 gm. carbohydrate and 99 gm. protein. The rise in glycosuria
was controlled by 1 fast-day with whisky on Nov. 16 and 2 complete fast-days
on Nov. 30 and Dec. 1. Protein-fat diets were then employed during most of



222 CHAPTER ni

Dec. and Jan., the short high calory periods being atoned for by other days of
fasting or very low diet. The carbohydrate feeding shown in the graphic chart
for the latter part of Jan. represents caramel, which was tolerated with very little
glycosuria. It was evident from experience that the patient's carbohydrate
tolerance was practically nil, and symptoms returned with any attempt at protein-
fat overfeedmg. Therefore, in Feb. he was placed on a diet of about SO gm. pro-
tein and ISOO calories, which, if the body weight be set at SO kg., would be 1 gm.
protein and 30 calories per kg. A fast-day once a week served to reduce this by
i, making it equivalent to ? gm. protein and 26 calories per kg. Exercise had
not been adopted for such cases at that time, and this patient was kept mostly
at rest. He pronounced this diet adequate for his appetite, and was dismissed
on Feb. 17, free from glycosuria and acidosis and, in condition for taking up some
light occupation.

Subsequent History. — After several weeks experience with the diet prescribed
at discharge, the patient had professed his full ability and willingness to live
on it, and was expected to go to some nearby place in the country and report
frequently concerning his progress. No reports were received. It was learned
that he had told another patient in the ward that he was not satisfied to be re-
lieved by diet. He showed an advertisement of a proprietary remedy for diabetes
and announced his purpose to seek a complete cure. Instead of keeping his
promise to the hospital, he went immediately upon departure to a southern
state. He died in Mississippi on Apr. 17, exactly 2 months after discharge.
This information was received from a life insurance official, who was unable to
give any particulars concerning the death.

Acidosis. — The slightness of ketonuria at admission is presumably to the
credit of the treatment given the patient at the clinic in the previous months.
It was easily cleared up by the routine measures. The acetone body excretion
remained low notwithstanding the high diets in Nov., but the ammonia rose
to apfftoximately 1 gm. on two occasions. It fell after the fast-day with whisky
on Nov. 16, but the fall was particularly sharp in the 2 days of plain fasting,
Nov. 30 to Dec. 1. Acidosis was easily controlled during the hospital stay.
There was no doubt of the inherent severity of the case, however, and the prob-
able cause for death 2 months after leaving hospital symptom-free would
undoubtedly be coma.

Blood Sugar. Renal Function. — The few analyses from Oct. 11 to Nov. 2 indi-
cated that the blood sugar was rather easily brought to normal. Traces of gly-
cosuria appeared with a lower blood sugar level than usual for diabetic patients,
and the findings suggested that the kidney was rather easily permeable. This
is the more interesting in view of the fact that small quantities of albumin and
casts were present in the urine at some times. This patient was also one of
those who, from renal deficiency or unknown cause, are subject to marked
edema under treatment. The sharp rise in weight on fasting and low diet, up
to 56.2 kg. on Nov. 1, was an example of marked edema. Other peaks in the



CASE EECORBS 223

weight curve likewise are explainable as edema, sometimes not visible, but in the
marked instances plainly evident in face and extremities, with pitting about the
ankles. The rapid clearing up of edema with sharp fall in weight as shown at
various points on the chart was regularly accomplished by salt-free diet.

Remarks. — This patient was neurotic and secretive. Most of his difficulties
in the hospital were neurasthenic, and the attempts to please him were responsible
for most of the irregularities and excesses of the diet. He was admitted with
a particular view to the suspicion of tuberculosis. The cough gradually cleared
up during the diabetic treatment. In Jan. he had a 10 day attack of bron-
chitis. Examinations for tubercle bacilli on 6 days of this attack as well as on
other occasions during his hospital stay were uniformly negative. He was kept
in the fresh air most of the time and at dismissal was continuously free from
cough or any perceptible signs in the chest. The diagnosis of the pulmonary
condition is therefore uncertain.

The entire lack of ability to take carbohydrate without glycosuria on a diet
of less than 30 calories per kg. is one index of the severity of the case. Theoreti-
cally, some degree of tolerance should have been built up by more radical under-
nutrition, but the patient was not psychically suitable for thorough measures.

The treatment cannot be considered ideal in view of the dietary irregularities
and excesses. It represents undernutrition to the extent of reducing the body
weight from 53.6 kg. on admission to 47.6 kg. on discharge; i.e., a loss of 6 kg.
As a result the patient felt stronger and more comfortable, and was free not only
from the urinary signs of diabetes but also from his former subjective symptoms.
The marked neurasthenia remained. The outcome is satisfactory to the extent
that the patient was kept in a tolerable condition for S| months in hospital and
was symptom-free at the close, while the actual severity of his condition was
demonstrated by death after 2 months of unregulated diet following discharge.

CASE NO. 10.

Male, unmarried, age 17 yrs. Irish American; plumber. Admitted Nov. 7,
1914.

Family History. — Grandparents lived to old age. Parents living and well.
One brother died in infancy; one brother and three sisters living and well. No
diabetes or other disease known in family.

Past History. — Healthy, vigorous life. Measles and whooping-cough in child-
hood. No other infections; no venereal disease, alcohol, or tobacco. Has
worked hard as plumber's helper since stopping school at 14, but he was strong
and the work was no strain on him. Always a heavy eater; partiailarly candy,
ice cream, pastry, and everything sweet taken in large quantities. Normal
weight 133 pounds.

Present Illness. — Last Jan. or Feb. the patient began to drink two gallons of
water per day and pass urine correspondingly. He felt well at this time and was



CASE RECORDS 225

1000 calories was made on Dec. 29. Jan. 5 was a complete fast-day, Jan. 26 an-
other. Generally reduced diet was used instead of fast-days because of the pa-
tient's weakness. He gained strength very markedly during the course of treat-
ment and began to look and act almost like a well boy. Exercise was employed
with apparently great benefit, especially as he was naturally strong and muscular.
He walked many miles daily, went skating on the ice, and undertook other
activities.

Toward the close of Jan. he and his parents considered that a cure had been
achieved and that he was ready to go to work. As long as he felt ill he was an
ideal patient. At this time, feeling well, he began to rebel at diet and all other
hospital rules. The glycosuria and ketonuria during and just preceding the
month of Feb. are attributable not to the prescribed diet, but to violations on the
part of the patient. It became necessary to discharge him on Feb. 8, and he was
informed that in view of his conduct this hospital could have no further connec-
tion with his case. It was learned that he followed no regular diet thereafter, and
died Mar. 9 with the usual acidosis symptoms.

Acidosis. — The only alkali given was 10 gm. sodium bicarbonate on Nov. 11.
In the absence of alkali treatment the excretion of acetone bodies was relatively
low, reaching only 13.2 gm. of /S-oxybutyric acid on Nov. 10. For the same
reason the ammonia excretion was high in comparison, being 3.4 gm. on Nov.
10, 4.75 on Nov. 11, and 4.46 on Nov. 12. It is evident that fasting with alcohol
did not immediately bring about a low ammonia, but beginning Nov. 12 the
steepest fall occurred, down to 1 .5 gm. on Nov. IS, and 0.42 gm. on Nov. 20. The
clinical symptoms cleared up much more strikingly than the ammonia.

On the too abundant carbohydrate-free diet of Dec, the ammonia never fell to
a normal level. It seemed to rise quite markedly after stopping alcohol on Dec.
16, so that on Dec. 22 and 26 it was slightly above the level of Nov. 14 (2.18 gm.).
Dec. 27, with a diet solely of whisky representing 85 gm. alcohol, brought a strik-
ing drop in the ammonia, and on the lower diet following this date the ammonia
never returned to the height of this peak, but also did not fall to normal. It
could presumably have been brought down to normal by the use of alkali, but the
advisability of alkali for this purpose under the circumstances is open to question.
In this same period the ferric chloride reaction was entirely negative. Alkali
would presumably have made it positive and increased the excretion of total
acetone bodies. The desirability of this change is also an unknown matter. The
real trouble was an unsuitable diet.

Blood Sugar. — The accuracy of the single determination showing an unexpect-
edly low blood sugar on Nov. 13 is doubtful. While irregularities are possible, it
seems more probable that the blood sugar remained close to 0.25 per cent until
about the close of the fast and then it fell to below 0.15 per cent. The occasional
analyses up to Dec. 15 showed a tendency to remain within normal limits. Fur-
ther analyses were not possible at the time. More attention should have been
paid to this point. In correspondence with the improvement otherwise, it would



226 CHAPTER in

seem that the case was still at a stage when normal blood sugar values were rather
easily attainable, and such should have been insisted upon.

Remarks. — The earlier part of the treatment was well carried out, and the
patient, threatened with coma, was rapidly freed from ketonuria, glycosuria, and
hyperglycemia. This was still at an early period of experience with this method;
it had not yet been learned that apparent restoration of tolerance is not to be
trusted too far, and that weakened function does not so rapidly recover to this
extent, but that it must be continuously spared by prolonged undernutrition.
Therefore, a carbohydrate-free diet was built up too fast and too high. Even in
the absence of laboratory danger signs, it is now known that such a procedure
inevitably brings disaster later. The lower diet of early Jan. was more rational.
But in general, instead of trying to make the patient feel too well and build him
up too rapidly, a more stringent limitation of both diet and weight should have
been insisted upon. The patient was received weighing 41.6 kg. After a sharp
initial drop to 39 kg. in the early days of fasting, the weight remained stationary,
then rose sharply as a result of water retention. Even with the weight of 45.6
kg. on Nov. 28 he did not appear edematous. His tissues had evidently been
dried before and retained water subsequently, so that he looked and felt better.
The water thus stored on undernutrition was then driven out by increase of the
carbohydrate-free diet, probably especially by the increase of fat, so that by
Dec. 15 weight had fallen to the same level as at entrance. Nevertheless, the
period from Nov. 28 to Dec. 15 must be regarded as one of actual gain of body
substance. There was some perceptible edema when the weight rose above 47
or 48 kg., as on Dec. 22 and Jan. 4. The patient was discharged weighing 45 kg.,
and at least part of the gain over the entrance weight may be regarded as actual
increase of body tissue. This gain should be considered as harmful not only in-
directly, owing to the fact that the patient became too confident from feeling too
well, but also directly, inasmuch as tolerance ought to have been built up in-
stead of weight. Trouble would have resulted later from this condition even if
the patient had remained faithful, and it would have been necessary to make a
radical restriction of his diet. Also the therapeutic possibilities are never so good
after several months of imperfect treatment as at the outset. The cause of the
final disaster was, however, the deep ignorance and lack of education of the
patient and his entire family, who had no conception of the nature of the disease
and were deaf to all advice as soon as the patient felt fairly well. Under such
circumstances a successful outcome was precluded. The favorable side of the
case is that such a degree of well-being and freedom from symptoms was attained
during the 3 months in hospital, while the severity of the case was demonstrated
by the death in comal month after breaking diet.



CASE RECORDS 227

CASE NO. 11.

Female, married, age 55 yrs. Austrian; housewife. Admitted Nov. 9, 1914.

Family History. — Father died at 55, cause unknown. Mother died at 70.
Three brothers and three sisters of patient were healthy; one of them died at 65.
Family are obese. No diabetes or other family disease known.

Past History. — Patient has been strong and weU, though obese. As a young
woman she weighed over 200 pounds, more recently she has considered 183 pounds
her regular weight. No infections, except measles at 16. No sore throats.
She was married at 21 ; four miscarriages; nine children born alive, four of whom
died in infancy. All of those alive are more or less obese.

Present Illness. — 10 years ago she began to notice a bitter taste after eating,
also constipation. 7 years ago a doctor found 7 per cent sugar in the urine, and
by dieting reduced it to 2 per cent. She had followed prescribed diets during
these 7 years, but sugar was never below 2 or 3 per cent. She thinks she has lost
weight chiefly in the last few weeks. She continued to do housework until last
week, when she went into collapse, pale, exhausted, and vomiting blood. Her
physician reported 7 per cent sugar in the urine. He prescribed a diet of noth-
ing but green vegetables for 3 days. Vomiting then made eating impossible.
Patient entered hospital in this condition with extreme weakness, anorexia and
nausea, pain in chest and abdomen, hemoptysis, headache, and dyspnea. The
blood brought up at first is described as being brighter and more abundant than
now.

Physical Examination. — An obese woman with appearance of prostration, face
pale, also extremely cyanosed, cyanosis extending into neck. Moderate constant
dyspnea, a weak frequent cough bringing up sputum either bloody throughout or
streaked with dark blood. Slight jaundice. Lungs: resonance, passing into
dulness at bases, especially posteriorly; breath sounds become bronchial in
character over dull areas and are everywhere rough. Coarse, loud riles every-
where. Heart is enlarged to 16 cm. to left of midsternal line and other signs are
those of mitral regurgitation. Liver is easily palpable, lower border extending
from 2 cm. below umbilicus obliquely into right flank barely above iliac crest.
Pain and tenderness complained of over liver, also pain down left arm. Leg
veins badly varicosed. Examination otherwise negative.

Treatment. — The patient necessarily remained in bed and was treated by the
cardiac service of the hospital with digipuratum for her evident heart failure. The
temperature ranged from 37 to 37.6°, the pulse from 92 to 112. The urine was
strongly acid, with specific gravity 1020 to 1025 and considerable albumin. The
general clinical record is given in Table VHI.

The patient was both weak and drowsy, and the symptoms were evidently due
to a combination of acidosis and heart failure. She took no food on Nov. 9 and
10, nevertheless glycosuria was heavy and weakness seemed to be critical. The
condition had arisen on a diet limited to green vegetables, and the consequences



CASE RECORDS 229

Present Illness. — About 3 years ago abnormal weakness, thirst, and polyuria
appeared. A physician found glycosuria of 7 J per cent. He ordered abstinence
from sugar and pastry. The glycosuria thus diminished to 2 per cent and the
patient felt fairly well, but after 8 months on the same diet the sugar rose to 5i
per cent and weakness returned. He has been unable to work for the past 2
years. For the past week he has been confined to bed because of weakness and
pains in chest and back. There has been cough, especially at night for 2 months
past. No fever and no hemoptysis now, but there was spitting of blood on three
occasions last winter. 18 months ago small ulcers appeared on both feet and
have slowly extended instead of healing; they are painful only when he walks.
He is now nervous and constipated, and teeth have decayed rapidly. He has
continued to lose weight.

Physical Examination. — Patient stiU appears comfortably nourished, with good
color in face. Tonsils slightly enlarged; part of left one is missing. Viscera
no^al to examination. Blood pressure 150 systolic, 95 diastolic. A few patches
of lichen planus on arms. Legs show small varicose veins threatening to ulcerate
at some points. The skin is pigmented and scaly, somewhat eczematous. Sev-
eral small superficial ulcers are present on ankles and feet. No gangrene. Strong
pulse in dorsalis pedis arteries.

Treatment. — Supper was given on the day of admission and then fasting imme-
diately begun. Though glycosuria cleared up in 2 days, the patient being over
weight was given 4 days of absolute fasting followed by 2 alcohol days, then 4
days of green vegetables, then 3 fast-days, and then a diet of moderate undernu-
trition. The superficial infections cleared up promptly. It is a question whether
the trace of glycosuria on Nov. 16 on taking 220 cc. whisky was attributable to
the alcohol. As frequently found at the outset in cases of this type, the food toler-
ance was rather low. Early in Dec. a diet with only 10 gm. or less of carbohy-
drate caused occasional traces of glycosuria, and in the period Dec. 17 to 25 the
attempt to give IS to 40 gm. carbohydrate had to be abandoned because of per-
sistent glycosuria. At the same time the total diet, if the mean body weight be
taken as 80 kg., represented approximately 1 gm. protein and only 25 calories per kg.
On strictly carbohydrate-free diet the patient proved able by Jan. 7 to 8 to take
116 gm. protein and 2600 calories without glycosuria. As he had now been re-
duced by about 11 kg., it was considered advisable in view of his age to allow a
diet of this sort and let him have the benefit of improved living conditions in the
Country and such exercise as he might be able to take. He was therefore dis-
charged on Jan. 9 with this purpose in view.

Subsequent History. — The patient reported at intervals that he was free from
glycosuria, and occasional examinations at the hospital showed absence of sugar,
very slight ferric chloride reaction, and a tendency to gain weight on the pre-
scribed diet. Though he looked well he complained of continual weakness which
made him unable to work. He was very faithful to all instructions, and when
unable because of poverty to obtain the prescribed food he fasted altogether.
He was readmitted to the hospital May 5 for further treatment.



230 CHAPTER m

Second Admission. — The weight at this admission was 82.6 kg.; i.e., about 4
kg. less than at his former admission and about 7 kg. more than at his former
discharge. His food tolerance appeared perceptibly higher, as he was now able
to take a diet of some 120 gm. protein, 50 gm. carbohydrate, and 3000 calories
without glycosuria. On account of the weekly fast-days these figures must be
reduced by ^ to give the actual average intake. Undernutrition was shown by
the fall in weight during stay in hospital. The weight gained outside of hospital
was evidently due to unintentional overstepping of the prescribed quantities. Two
determinations of the blood sugar gave values below 0.15 per cent. A fairly lib-
eral diet was permitted with a view to overcoming the marked weakness, and
exercise within the patient's limited capacity was also encouraged for this pur-
pose. Shortly before his second dismissal he was made accustomed to a diet of
about 100 gm. protein, 50 gm. carbohydrate, and 2500 calories, which repre-
sented a reduction below his known tolerance to allow for unintentional errors.
He was dismissed on June 29 greatly improved in all respects, and was advised
again to take a rest in the country for general hygienic reasons.

Subsequent History. — He reported in person on Sept. 7 with normal urine, feel-
ing able to do moderate work. On Nov. 29 he was seen again; sugar and ferric
chloride reactions were regularly negative and he was making his living at his
usual work. He had gained about 2 kg. since discharge. The same condition
has continued with steady improvement up to the present. He now feels well
constantly and carries on his work without difficulty. His diet satisfies him and
urine remains normal.

Remarks. — This case is a good illustration of a numerous type — diabetes rela-
tively mild but finally bringing the patient to a state of disability. The clearing
up of such a condition generally proves to be neither quick nor easy. The most
important therapeutic measure is the reduction of weight, which, however, may
not have to be carried to the point of emaciation. The patient is benefited
slowly. Unless he has full confidence in the physician, he is likely to abandon
treatment because of the tedious privations of diet and the apparent lack of
benefit. At first he sometimes even looks and feels worse than before.

For the sake of strength, liberties were taken here in the direction of high
feeding which would have meant disaster to a younger patient. More protein
and less fat would doubtless have been better. With a weak patient at such an
age, it was considered that the slight persistent ferric chloride reactions could be
temporarily ignored. The outcome justified the procedure, since the continued



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 23 of 76)