Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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cluded in the diet, but this was on a lower ration than during the first admission.
Real improvement in assimilation would have meant that the child could grow in
weight and stature; on the contrary, the third and fourth admissions represented
further loss of weight. The carbohydrate tolerance in July, 1916, was the same
as in Oct., 1915, but as the latter test was at a lower body weight, the result may
be interpreted as actual downward progress.

On the other hand, the record furnishes evidence against the "spontaneous"
character of such downward progress. Hyperglycemia was almost continuous,,
and glycosuria and ketonuria recurred rather frequently throughout the entire 3
years. A partially depancreatized dog under similar conditions would have gone
into hopeless diabetes much sooner. Any inherent downward tendency should
have been perceptible in this type of case in this length of time. The slow change
observed is abundantly explainable by the prolonged slight overstrain of the
weakened function.

CASE NO. 14.

Male, married, age 51 yrs. American; optician. Admitted Nov. 16, 1914.

Family History.— Fkthei died of typhoid at 28, mother of heart trouble and'
dropsy at 55. Two sisters living and well. Patient has been married 23 years;
one child dead, one living and well. Tuberculosis, cancer, syphilis, diabetes, and
other family diseases denied.

Past History.— Kenlthy life. Scarlet fever in childhood. Occasional sore
throats. Gonorrhea twice. Syphilis denied by name and symptoms. In Apr.,
1914, he was confined to bed with so called dry pleurisy and had cough and
slightly blood-tinged expectoration for 3 or 4 weeks. Constipation, slight indi-
gestion, moderate or poor appetite. Alcohol used rather freely but not to-
drunkenness. Moderate tobacco.



CASE RECORDS 239

Present Illness. — 7 years ago patient states that he strained himself lifting a
trunk. He had pain in the back for several months, therefore had his urine
examined and sugar was found. He claims never to have had any of the typical
diabetic symptoms. He now complains of indefinite neuritic pains in back and
legs. His best weight was 140 pounds 6 years ago; now 112. A few days after
• admission the patient's wife volunteered the information that he had undertaken
a number of different treatments for his diabetes at different times, but had never
adhered to any prescribed diet for even a brief time.

Physical Examination. — ^A fairly developed, poorly nourished man. Teeth
mostly absent, little decay in those remaining, slight pyorrhea. Throat con-
gested but tonsils not visibly enlarged. Cervical, axiUary, epitrochlear, and in-
guinal glands slightly enlarged. Reflexes very active. Blood pressure 100 sys-
tolic, 70 diastolic.

Treatment. — ^After 2 days of observation on a low protein-fat diet, fasting was
begun on Nov. 18. On Nov. 20 to 22 he received 27 to 35 gm. alcohol. This
S day fast greatly diminished but did not quite abolish glycosuria. The ferric
chloride reaction, which was negative on the day of admission, became strongly
positive on the carbohydrate-free diet and on fasting. The weight fell sharply
from 50.6 to 47.6 kg. On Nov. 23, 300 gm. thrice cooked vegetables were given
to appease the patient, who was discontented. This program continued up to
and including Dec. 1. As such vegetables are reckoned as having too little food
value to count, the treatment represents 2 weeks of practically continuous fasting
except for the alcohol mentioned. The continuance of glycosuria aroused sus-
picion. Accordingly the patient was removed from the ward to a private room,
and glycosuria abruptly ceased (Nov. 26). He was then returned to the ward,
and was sufficiently impressed by his sugar-freedom that he followed diet with
some degree of fidelity thereafter, though some of the traces of glycosuria are
doubtless to be attributed to slight violations. A low diet was begun, and it was
found that the tolerance was actually very low, the smallest quantity of carbo-
hydrate bringing on glycosuria, while even on protein-fat diet traces of sugar were
frequent, apart from any steaUng of food. The patient was discontented and
unreliable, and the irregular shifts of diet resulted largely from attempts to please
him. The general outcome of the treatment was to reduce his weight from the
original 50.6 kg. to 44.8 kg., with the result that glycosuria was absent on a car-
bohydrate-free diet of 53 gm. protein and over 2200 calories, but a well marked
ferric chloride reaction persisted. Thorough treatment was not carried out
because the patient had never been seriously iU and would not have endured
rigorous measures. Accordingly he was allowed to go on Mar. 2, with his con-
dition improved but by no means satisfactory, on a prescribed diet of about 50
gm. protein and 1500 to 1750 calories.

Subsequent History. — On Apr. 1, patient returned to the hospital reporting that
he had followed diet, had remained permanently sugar-free, had gained 6 pounds,
and was enjoying greatly improved health. His appearance conformed to the



240 CHAPTER m

statement, but a sample of urine showed a trace of sugar. Information from other
quarters indicated that he had not adhered strictly to his diet. On Apr. 9, he
again reported and his urine was found sugar-free. On May 20, he reported
showing a slight glycosuria, and information was given by his family that he had
departed somewhat from his diet. Since then nothing has been heard of him.

Remarks. — ^The case illustrates diabetes of long standing, apparently doing the-
individual little harm but bringing progressive injury in the course of years,
and undoubtedly destined not only to impair comfort and usefulness, but also
to shorten life. As frequently found in such cases, a normal state of the urine is
very diflBicult to establish and maintain, and rigorous restriction of food and re-
duction of weight for a number of months are necessary for a satisfactory re-
sult. Such patients are often not convinced that these measures are necessary,
especially since they feel decidedly worse during the period of rigorous restric-
tion. FideUty brings ultimate reward in comfort and longevity. On the other
hand, the penalty of carelessness is often slow in appearing, and accordingly the
lesson is often learned too late.

CASE NO. 15.

Male, married, age 42 yrs. Scotch; bookkeeper. Admitted Nov. 16, 1914.

Family History. — ^Entirely negative as far as can be learned from wife.

Past History. — Healthy life.

Present Illness. — Patient is known to have had diabetes for about 2 y^ars past,
with practically no symptoms except some loss of weight and strength. He has
continued at his work until the present week. He was not supposed to be seri-
ously unwell until last evening, when a doctor was sent for hurriedly and found
him in coma to such a degree that he could not be roused enough to recognize
persons. The physician cleared out considerable feces by the use of cathartics
and enemas and gave a few small doses of sodium bicarbonate by mouth. This
morning the patient was stiU in coma, but was apparently a little more easily
roused.

Physical Examination. — Fairly good muscular development along with moderate
emaciation. Routine physical examination negative. Kjiee jerks absent. The
usual picture of coma, except that h3Tjerpnea is not striking. Respiration is
fuU, but quiet. When forcibly roused the patient regains consciousness suffi-
ciently to utter words in drunken meaningless fashion, but not to recognize his -
wife or doctor. With some difficulty he can be induced to swallow medicine and
to pass urine.

Treatment. — ^This was the first case of actual coma received, and the orthodox
treatment was attempted, with an intravenous infusion of 1 liter of 4 per cent
sodium bicarbonate solution prepared without heat and sterilized by filtration
through porcelain. The injection was apparently well borne; pulse, respiration,
and consciousness showed no appreciable, change during the period of injection,
which lasted about an hour. IS cc. whisky were given hourly. The patient



CASE RECORDS 241

was received at 5 :30 p.m. The infusion was finished at 7 p. m., and death occurred
suddenly and without warning at 7:50 p.m.

The following laboratory data may be noted. Heavy glycosuria and ketonuria
both before and after bicarbonate infusion, not determined quantitatively because
of loss of considerable urine. Blood sugar 0.316 per cent. Sodium chloride in
serum 6.11 gm. per liter. Sodium chloride in urine 0.2 gm. per hter before in-
fusion. The urine passed after bicarbonate infusion was pale and abundant as
before, but contained no chlorides.

Remarks. — Though few patients ever come out of actual coma, this man was
one who appeared to have a fighting chance. At that time it was hoped that
the alkali in the customary dosage would reinforce whatever benefit he might
derive from fasting. Without the intravenous alkali he might have had a chance.
Later experience makes it seem probable that when a patient in this condition
receives an injection of alkali in this manner and quantity, no immediate harm
and sometimes an apparent benefit is perceptible, but sudden death is likely to
occur within a few hours.

CASE NO. 16.

Female, married, age 47 yrs. American; housewife. Admitted Nov. 17,
1914.

Family History. — Father died of cancer at 61. Mother had diabetes; died of
sepsis from varicose veins in legs at 74. Brother aged 61 has mild diabetes.
Patient's husband died 20 years ago, aged 34, of some condition resulting from
alcoholic excess. Three chUdren; the two older living and weU; the youngest
was mentally deficient and died last July at the age of 20, after having been
treated from childhood for syphilis.

Past History.— Healthy childhood. Measles and mumps when very young.
Chlorosis before marriage. Married at 20; two children within a year of each
other; no miscarriages. Third child, born 4 years after second, showed syphilis,
and patient after its birth had sore on tongue and hair fell out. There was also
a genital chancre. Symptoms cleared up after 1 month of treatment with blue
ointment. No further symptoms or treatment. Regular habits. No excess in
alcohol, tea, coffee, or sweets. Never nervous until recent years. Ordinary
weight 180 pounds.

Present Illness. — 5 years ago patient began to feel weak and lost 20 pounds in
weight. Physician found glycosuria of 4§ per cent. She has dieted more or less
since then, but has been sugar-free only occasionally, never more than a few
months. Lowest weight 143 pounds last August. Menstruation stopped 6
months ago. Especially for the past 3 weeks she has felt weak and miserable and
been troubled with thirst, headache, pains in knees, cold feet, pruritus vulvae,
failing vision, and loosening and falling out of teeth.

Physical Examination. — Height 158 cm. A rather obese woman, looking
strong but nervous. Several teeth missing; others loose. Throat normal. No



242 CHAPTER m

palpable lymph node enlargement. Murmur of mitral regurgitation. Area of
cardiac dulness slightly enlarged. Arteries hardened. Blood pressure 225
systolic, 110 diastolic. Albumin and casts in urine. Knee and Achilles jerks
slight. . A few small copper colored scars on legs. Uterus sUghtly retroverted.
Right Fallopian tube slightly tender. Blood shows strong Wassermann reac-
tion. In addition to diabetes, there was a diagnosis of chronic mitral insuffi-
ciency, chronic interstitial nephritis, latent syphilis, arteriosclerosis, and cystitis.
Twice during hospital sojourn the patient complained of dizziness and fainted,
and was treated for short periods with digipuratum. Syphilis was not treated
at this time, and the effect of dietetic treatment of the diabetes was tested alone.

Treatment. — ^As shown in graphic chart, the patient fasted Nov. 18 to 20 inclu-
sive, receiving respectively 45 and 75 cc. whisky on the last 2 days. On Nov.
21 she received cauliflower, celery, and asparagus to the amount of 17.5 gm. car-
bohydrate. As the primary object was to reduce weight, 3 more days of practi-
cal fasting (Nov. 22 to 24) followed, the only food being 800 gm. thrice cooked
vegetables daily. On Nov. 25, one egg was added. This diet was rapidly in-
creased to about 1100 calories on Dec. 6 and 2300 calories on Dec. 19. AU at-
tempts to introduce even small quantities of carbohydrate led to glycosuria, and,
as shown in graphic chart, numerous periods of low diet or fasting were employed
to diminish the weight further. She was finally (Jan. 27 to 29) placed on a car-
bohydrate-free diet of 66 gm. protein and 1400 calories. This, for her weight of
54.5 kg. at that time, was about 1.2 gm. protein and 26 calories per kg. The pa-
tient insisted that this diet with addition of 500 gm. thrice boiled vegetables satis-
fied her appetite perfectly, and as she was very eager to be home and had received
the necessary instruction, she was allowed to leave in this condition. All sub-
jective symptoms had disappeared and she felt fuUy strong and well.

^Subsequent History. — The progress continued to be favorable at home, and in
Feb. the diet was increased by 400 calories of bacon. Sugar remained constantly
absent and the ferric chloride diminished to a trace. It became entirely negative
about June 1. The plasma sugar on June 1 was 0.114 per cent. The weight
was 54.5 kg. By Oct. 5, the patient had gradually increased the quantity of food,
the weight had risen to 59.8 kg., and the plasma sugar to 0.196 per cent, with nega-
tive sugar and ferric chloride reactions in urine. Blood pressure 250 systolic, 160
diastolic. She was advised to avoid gaining weight. Excellent subjective
health and normal urine continued, and 1 year after discharge she reentered the
hospital by request for examination and advice.

Second Admission. — ^Jan. 31, 1916. The weight at this time was 63 kg.; namely,
8.6 kg. above that on dismissal and 2 kg. below that at former admission. The
urine showed negative sugar but a trace of ferric chloride reaction. Feb. 2 a fast-
day was given, and then a carbohydrate tolerance test, begiiming with 10 gm.
carbohydrate and increasing by 10 gm. daily vmtil by Feb. 23 to 25 the limit of
tolerance was reached with 220 gm. carbohydrate. After a fast-day on Feb. 27
to clear up the slight glycosuria, a diet was instituted of 90 gm. protein, 20 gm.



CASE RECORDS 243

carbohydrate, and 2000 calories (1.5 gm. protein and 34 calories per kg., reduced
by weekly fast-days to about 1.3 gm. protein and 30 calories average). On this
diet the patient was dismissed, weighing 59.5 kg.

Acidosis. — The patient was admitted originally with chronic glycosuria and
negative ferric chloride reaction. The result of fasting, notwithstanding 75 cc.
whisky on Nov. 20 and 17.5 gm. carbohydrate on Nov. 21, was the development
of a ferric chloride reaction. This persisted during most of the first stay in hos-
pital. It could doubtless have been cleared up by repeated periods of carbohy-
drate (without other food) to the limit of tolerance. But the tolerance at that time
was low, and for a patient with such inherently mild diabetes at a fairly advanced
age, it was considered sufficient to pursue a treatment of progressive undernu-
trition, knowing that the trivial acidosis would disappear as soon as the tolerance
was built up. This expectation was fulfilled in the period after leaving hospital.
With rise of weight, traces of ketonuria had returned at the time of second admis-
sion; these were readily cleared up by the carbohydrate tolerance test, and by
increasing carbohydrate in the diet. Since then ketonuria has remained per-
manently absent. As shown in the second graphic chart, the plasma bicarbon-
ate was slightly below the lower normal limit; but the tendency was upward, and
no alkali was employed.

Blood Sugar. — ^This was easily kept at normal level by regulation of body weight.
On this point the patient might be brought into line with the type formerly called
"fat sensitive." It wiU be observed in the second graphic chart that hyper-
glycemia was present on Feb. 2 after a diet of 2350 calories made up chiefly of
fat with very little carbohydrate. This elevated blood sugar is seen to have fallen
to normal subsequently when the carbohydrate was decidedly increased and the
total calories diminished. Though nephritis and arteriosclerosis were present
with hypertension, there was no tendency to a stubbornly high blood sugar.

Subsequent History. — The patient has reported at intervals to date, feeling en-
tirely healthy and leading a fully normal life with faithful attention to diet.
Weight June 19, 1917, 63.6 kg. This increase of weight has been borne with&ut
any glycosuria. The high blood pressure remains, also the albumin and casts in
urine. Lately she has complied with advice given several times before and has
taken a few salvarsan injections, without alteration of clinical findings. The
cardiorenal symptoms are perceptibly increasing, and death from this cause is to
be expected.

Remarks. — Two possible etiologic factors are here present, one heredity, the
other syphilis. Notwithstanding these, and even in absence of syphilitic treat-
ment, the entire tendency under suitable dietetic treatment through nearly 3
years of observation has been upward and not downward. This success has been
attained by regulation of the total caloric ration and body weight. It is practi-
cally certain that a progressive downward tendency could have been observed if
the weight had been built up with high calory, carbohydrate-poor diet. Such a
tendency is distinctly indicated by the findings at several times when weight was



244 CHAPTER ni

gained. Another interesting feature is that in Apr., 3 months after the first
dismissal, the patient had an acute otitis media and underwent paracentesis under
ether, but showed no sugar throughout this illness. From present indications the
prognosis in such a case is satisfactory from the standpoint of diabetes, and life
and comfort are apparently limited only by the other diseased conditions present.

CASE NO. 17.

Female, married, age 69 yrs. Russian Jew; housewife. Admitted Nov. 17)
1914.

Family History. — Indefinite on account of ignorance. Most of family seemingly
lived to considerable age, and patient knows of no family diseases. Patient has
been married 43 years. Seven children; four died in infancy, cause unknown; one
is in a pubhc institution with diagnosis of dementia praecox; the other two are
middle-aged and well.

Past History. — Measles in childhood. Came to New York from Russia 26
years ago. Hygienic surroundings bad. No diseases of consequence, except em-
pyema with pneumonia 20 years ago. This was drained, and two subsequent
operations were necessary before the sinus was closed a year later. She has had
no s)rmptoms pointing to tuberculosis. She has long complained of indigestion,
gas, and constipation. 6 years ago she underwent an operation for uterine pro-
lapse; there was a laparotomy and removal of some sort of tumor, concerning
which she knows nothing except that it was not cancer.

Present Illness. — ^Time,of onset unknown, but during the past 7 years her weight
has steadily diminished from 180 down to 108 pounds. Polyphagia never marked,
and polydipsia noticed only in the past few days. 6 weeks ago pain began in
the right foot with some discoloration around the great toe and heel. Local
measures did not benefit it. A physician suspected gangrene immediately upon
seeing it and found heavy glycosuria present. This was the first diagnosis of
diabetes. She is now unable to walk because of pain in this foot, which is also
painful when she remains in bed.

Physical Examination. — Patient fairly nourished, lying in bed with quiet respira-
tion, but with decided sweet odor of breath. Dirt and pedicuH noticeable. Nu-
merous teeth missing or carious. No gland enlargements except in groins. A
few bronchitic rales. Heart sKghtly enlarged. Blood pressure 215 systolic, 150
diastoUc. Depressed scars on left thigh, pigmented scars on right shin. Swell-
ing, reddish blue discoloration and tenderness of great toe and over and under
first and second tarsometatarsal joints of right foot. The heel of this foot is
painful, the skin is Hfted up and evidently has fluid under it.

Treatment. — Patient received supper on the day of admission, consisting of 25
gm. AkoU biscuit, 10 gm. butter, and a cup of coffee. The next day she fasted
with 35 cc. whisky, and became sugar-free in 24 hours. The ensuing days were
also fast-days, with whisky up to 90 cc. On Nov. 23, one egg and 300 gm. thrice



CASE RECORDS



245



boiled vegetables (cauliflower and asparagus) were added. The diet was then
rapidly increased, particularly in its fat component,, as shown in Table IX.

It is seen that the great increase of fat intake on Nov. 29 was accompanied by
sharp increase of both glycosuria and ferric chloride reactions. The simul-
taneous increase of protein in the diet did not serve to prevent this increase of
acidosis. Also it is difficult to attribute the glycosuria of 11 gm. to the increase of
only 5 gm. protein on Nov. 29, as compared with the preceding day. Further-
more, though this glycosuria was only 11 gm., because the high diet was composed
chiefly of fat, the injurious after-effect is likewise characteristic of fat. For the
entire first week in Dec. the diet was only once as high as 500 calories; Dec. 5, 6,
and 7 were fast-days with alcohol, yet the aglycosuric condition was difficult to
restore. Beginning Dec. 8 the attempt was made to build up a diet, beginning
with eggs, butter, and 'thrice cooked vegetables. Whisky was never entirely
discontinued, and in Jan. the intake represented about 65 gm. alcohol daily.
The protein was generally 40 to 60 gm.; i.e., a httle above or below 1 gm. per kg.

TABLE rx.



Date.


Diet.


Weight.


Urine.


















Protein.


Fat.


Alcohol.


Calories.




Volume.


Sugar.


FeCb
reaction.


1914


em.


em.


am.




ke.


cc.


em.




Nov. 27


47


135


43


1746


50.6


1540


+


-f-l-H-


" 28


57


179


15


2005


51.6


2005


+


++


" 29


62


509


15


5096


50.5


1115


11.15


-1-4- H-


" 30


37


259


10


2629


51.3


1190


+


+++


Dec. 1


37


259


15


2664


51.0


860


+


++



of weight. The calories were kept at approximately 1000 to 1200, or about 20
to 24 calories per kg. for SO kg. body weight. The traces of glycosuria indicated
in the graphic chart were very slight, and were mostly connected with the use of
thrice cooked vegetables. The tolerance for carbohydrate was so low that
300 to 500 gm. of vegetables of Joslin's 5 per cent class, boiled through three waters
in the usual way, brought on these traces of glycosuria. In Jan. these vegetables
were omitted. The patient being an old woman with small appetite, it was pos-
sible to place her on a ration made up of coffee, soup, whisky, eggs, meat, fish,
butter, and olive oil. She remained practically sugar-free on this regimen, since
the traces of glycosuria noted thereafter were mostly very faint reactions in the
urine of single periods during the day, undiscoverable if mixed with the 24 hour
urine. The undernutrition is indicated by the continuous fall in weight during 2|
months, from 53.5 kg. on admission to 45 kg. on discharge. She was discharged
on Feb. 1, very happy with her condition. The incipient gangrene had healed
early, and she had been restored to comfort and activity. She felt able to con-



246 CHAPTER in

tinue her diet amid the difficulties of her home conditions. Slight albuminuria
and casts present on admission still continued at discharge, and the systolic
blood pressure was 205 mm.

Subsequent History. — The patient was unable to continue her diet successfully
at home. As she evidently required continuous care, she was advised to enter
a semipublic institution, where she has since lived and is kept on a moderately
restricted diet, with 1 to 3 per cent sugar constantly in the urine and continual
pain in the right foot, which does not completely disable her and has not been
accompanied by any return of actual gangrene.

Acidosis. — ^As respects acidosis, it will be noted that she entered with a nega-
tive ferric chloride reaction, evidently because of the carbohydrate in her former
diet. The ferric chloride reaction appeared on the 4th day of fasting, about as
might be expected in a normal person, and it is again nonceable that 300 calories
of alcohol did not prevent the appearance of this reaction. The reaction was



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 25 of 76)