Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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never a heavy one, and in a feeble woman of this age it was not considered ad-
visable imder the circumstances to impose the rigorous measures which wovdd
have been necessary to make the urine quickly normal. Theoretically, this con-
tinued slight acidosis and the diet keeping her barely on the verge of glycosuria
all the time were wrong, and under ideal conditions actually better results could
have been achieved by more rigid measures, cutting her diet and weight still
lower and bringing about a normal state of the urine and at least some slight
carbohydrate tolerance. Practically, there was a strong likelihood that she
would not be able to foUow the necessary diet outside the hospital, and it seemed
therefore unwise to attempt an ideal result. Under the plan pursued, her condi-
tion at discharge was a good one for her years, and by persisting in the same
program she would almost certainly have gained gradually some carbohydrate
tolerance and lost her trace of acidosis; but her mental and social state interfered
with this result.

Remarks. — This patient was admitted as presenting early diabetic gangrene
with seniUty and arteriosclerosis, the idea being to test the effect of therapy in
such a case. Simple protection and occasiohal hot air baths were the only local
measures employed, but healing proceeded uninterruptedly and apparently as
rapidly as possible at this age. It was striking that pain in the foot could at
first be produced at wiU by food. Excessive diet which brought return of glyco-
suria was found to bring complaint of pain the same day, although the patient
was kept ignorant of the laboratory tests. On discharge the foot appeared
entirely normal, except for coldness to touch and some loss of tissue in the for-
merly discolored areas. Pain, tenderness, and disability had disappeared. The
loss of weight under treatment, amounting to about one-seventh of her entrance
weight, did not serve to weaken her. On the contrary, she went out with improved

The case well illustrates a familiar therapeutic situation. In numerous cases
of diabetes in advanced senility, in one sense the diabetes is mild, the glycosuria


is not excessive, the acidosis does not threaten coma, and the patient seems to
go along for years "with little injury. Some form or degree of harm ordinarily
results sooner or later, frequently, as in this case, gangrene. On treatment, the
apparently mild diabetes proves by no means easy to control. The tolerance
from the standpoint of complete sugar-freedom is surprisingly low, and months
of privation and reduction of weight and sometimes also of strength are neces-
dary to atone for the harm caused by years of lack of care. Only three courses
are open. One is rigorous and conscientious treatment, just as in a younger
patient. This is diflScult and tedious for both physician and patient; but when
circumstances permit it to be carefully carried out, the ultimate results are more
favorable than in younger persons, and the improvement of health and appar-
ently of longevity prove that the previous glycosuria was not harmless but was
largely responsible for symptoms attributed to senility or other causes. The
other extreme is complete disregard of diet. This course may be expected to
bring death from gangrene or other accident, sometimes even coma, in a large
proportion of patients. Here again due weight may not be given to diabetes as
the predisposing cause back of the infection or other terminal condition. The
middle course is one frequently adopted; namely, a moderate regulation of diet
with the aim of preserving strength and comfort and not paying too much attention
to laboratory findings. In the case of this patient, the alleged comfort of such a
course consists actually in continuous pain in the right foot and the danger of
gangrene at any time. It is also scarcely reasonable to suppose that the foot is
the only part of the body injured by the diabetes.

CASE NO. 18.

Male, unmarried, age 16 yrs. American; errand boy. Admitted Nov. 18,

Family History. — Grandparents' history not certain. Father died at, 42 of
cirrhosis of liver. Mother and two sisters of patient alive and well.

Past History. — Healthy life. Chicken-pox at 6. Tonsillitis in 1912. No
other iUnesses. Habits regular. No alcohol, very little tobacco. No exces-
sive sweets or carbohydrate. Never nervous. Ordinary weight 133 pounds.

Present Illness. — Only 3 weeks ago, during the last week of Oct., first symptoms
were noticed in the form of thirst, polyuria, polyphagia, weariness, and sleepiness.
During present month he has been unable to read by artificial light because of
blurring. Nov. 1, he stopped work and consulted a physician, who found 5 per
cent glycosuria. Patient claims to have followed restricted diet since then, in-
cluding gluten bread. He has never become sugar-free.

Physical Examination. — ^Normal in appearance though rather thin and nervous.
Teeth in good condition. Tonsils slightly enlarged. A few small palpable
glands in neck. Knee and AchiUes jerks exaggerated. Blood pressure 135
systolic, 60 diastolic. Examination otherwise negative.


Treatment. — The diet on Nov. 19 consisted of 105 gm. protein, 17 gm. carbo-
hydrate, and nearly 2000 calories. The glycosuria diminished to traces, and sugar-
freedom could doubtless have been readily attained without fasting. Neverthe-
less, for the sake of more rapid and radical improvement, 4 days of fasting were
imposed (Nov. 20 to 23). To make the fast easier, thrice cooked vegetables in
quantities increasing up to 1500 gm. daily were permitted. The trace of ferric
. chloride reaction which developed cleared up spontaneously.

On Nov. 24 two eggs and 20 gm. butter were added, increased on the next
day to four eggs and 40 gm. butter. Meat and bacon were subsequently added.
The negative ferric chloride reactions, Dec. 1 to 4, on diets of 2200 to 2300 calories
without carbohydrate and composed chiefly of fat, stand in strong contrast
with what other patients often show when sugar-free on the same sort
of diet. Thereafter the patient proved able to tolerate as much as 2900
calories with 60 to 80 gm. carbohydrate and 107 to 130 gm. protein. He was
dismissed on approximately this diet but with calories diminished to about 2500.
. General instructions were given, but the food was not required to be weighed.
The liberal diet (over 2 gm. protein and 50 calories per kg.) was permitted with
the idea of satisfying the patient and allowing him to work hard, and in the hope
that it might be tolerated in view of the early and mild stage of the diabetes.
The average was reduced slightly by the fast-day ordered ev^ry 2 weeks. Also
instead of weighing food, the patient was instructed to keep careful account of
his own weight and never let it go above 120 pounds {i.e. 13 pounds below his full
normal weight). Any gain over this was to be checked by fasting and reduced

Subsequent History. — Reports indicated that the patient adhered to his diet
until cherries became ripe in summer, when he started glycosuria by eating cher-
ries. As he then broke diet in other respects, he was instructed to return to the
bospital on July IS.

Second Admission. — In addition to glycosuria, decided ketonuria was present
this time, notwithstanding 125 gm. carbohydrate in the diet on July 16. 3 days
of fasting with nothing but cofiee and soup were imposed Quly 18 to 20), followed
by a carbohydrate tolerance test, starting with 20 gm. carbohydrate in the form
of green vegetables. The quantity was increased by 20 gm. carbohydrate daily,
until on Aug. 4, 350 gm. carbohydrate were taken without glycosuria. Without
attempting to push the carbohydrate higher, a fast-day was given on Aug. 5, with
only coffee and soup. A diet was then instituted of 100 gm. protein, 100 gm. car-
bohydrate, and 2600 calories. Later the carbohydrate was raised as high as 200
gm. Traces of glycosuria occurred on this diet. It is noteworthy that even with-
out glycosuria and with this high carbohydrate intake, some distinct ferric
chloride reactions were present. On Aug. 21, the carbohydrate was diminished
to 5 gm., the protein remaining about 100 gm., and the total diet about 2500
calories. On Aug. 28, 100 gm. carbohydrate were resumed, and the protein and
total diet diminished to 84 gm. and 2400 calories respectively. The patient was


discharged on this diet. His weight was 56 kg. at this admission, {i.e. a return
to his full normal weight which had been forbidden) and 51.8 kg. at discharge
(still about 1 kg. higher than at his first admission) .

Subsequent History. — Nothing further was heard from the patient until a letter
from his sister.reported his death on Nov. 11, 1915. Inquiries revealed that the
mother had no control over the boy, who refused to foUow diet or allow his urine
to be tested. The physician who referred the boy to this hospital was out of
town. After the usual polyuria, polydipsia, and loss of weight and strength, the
patient late in Oct. began complaining of indigestion, and a few days before death
showed a high degree of nervousness and excitement. A local physician treated
these symptoms of acidosis with tablets for the indigestion, sedatives for the
nervousness, and tonics for the weakness. Heavy breathing was noted at the end,
but actual coma was only a few hours in duration.

Remarks. — ^The condition was at a very early and favorable stage when treat-
ment was begun. The well marked ferric chloride reactions without glycosuria
on the high carbohydrate diets of Aug. 16 to 20 possibly indicate the intrinsic
severity of the case. Undoubtedly the violations of diet and the gain in weight
between the two admissions constituted a serious setback. Nevertheless, the
carbohydrate test up to Aug. 4 showed that the tolerance was still high, and the
blood sugar later in Aug. was found to be easily brought to normal. The later
course was the t3rpical uninterrupted downward progress of severe untreated dia-
betes, owing entirely to the fault of the patient and of the local practitioner who
then treated him. No dietetic treatment could accomplish anything in a patient
so irresponsible as this.

Concerning the diets prescribed in the hospital the following may be re-
marked. The change to practically carbohydrate-free diet on Aug. 21 is the
typical old-fashioned method. It is observed that in spite of the high caloric
intake (nearly SO calories per kg.) the blood sugar promptly fell to normal and
the results might be called favorable. The fact is that the ferric chloride reaction
persisted, and continuance of such a high intake would inevitably have brought
disaster later, no matter how favorable the laboratory findings for the time being.
The diets allowed this patient were unduly high, for the following reasons. First,
it had not yet been established whether the patient at such an early stage might
recover sufficient tolerance to carry the fuU load of diet and weight. Second, this
patient was given exercise involving considerable labor (see Chapter V), and it
was anticipated that he would perform considerable muscular work at home.
Third, it was evident from his general character that he would not endure any
real privations, and he was therefore placed on a diet which left no excuse for
violations, being fuUy satisfactory in protein, carbohydrate, and total quantity,
and calling only for abstinence from sugar and reasonable limitation of starch.
As stated, later experience has made it evident that such treatment is bad, and
always results in the downward progress which was formerly regarded as spon-
taneous and inevitable. The attempt to try this method in this case failed on
account of the patient's disobedience.

250 CHAPTER ni

CASE NO. 19.

Female, married, age 39 yrs. Russian Jew; housewife. Admitted Nov. 18,

Family History.— Pa.ients lived to old age. Patient had four brothers and nine
sisters; all are living or died of typhus or accidental causes in Russia. No dia-»
betes, cancer, tuberculosis, syphilis, or nervous diseases known in family.

Past History.— Born in Russia; came to United States 26 years ago. Hy-
gienic surroundings poor. Measles and whooping-cough in childhood. Typhus,
at 12. 16 years ago a so called abscess in throat, said to have been cured by
lancing. 7 years ago patient had a convulsion after a confinement; had to be in
hospital 3 weeks and was sick for 3 months. Some shortness of breath on exer-
tion for 2 years past. She was married 18 years ago. Husband Uving and well.
Four children living and well; one born dead, full term; one miscarriage. Habits
regular, no excesses. Frugal diet, poor in sweets but also in vegetables.

Present Illness. — ^Began with pruritus vulvae li years ago. A doctor pre-
scribed a salve which was ineffective. 1 year ago polydipsia commenced. She
drank 60 glasses of water a day. Polyphagia began 6 months ago. She has lost
38 pounds during the past year, falling from her normal weight of 146 pounds
to 108 pounds. Sleeplessness, weakness, pains in back also complained of. She
consulted two different physicians who, notwithstanding these typical symptoms,
told her she was "run-down" and prescribed tonics without examining urine.
4 weeks ago she came to New York for further medical advice. Diagnosis of
diabetes was made and she was in a hospital for 2 weeks on a diet limited abso-
lutely to meat, eggs, fish, cream, cheese, and string beans. Her condition failed
to improve, and on her physician's advice she made apphcation at this Institute.
Her chief complaints are extreme weakness and persistent headaches.

Physical Examination. — A well developed woman without evident discomfort
or dyspnea, appearing only sUghtly undernourished, but with flabbiness of skin
indicating considerable loss of weight. Nephritic countenance, with slight edema
about eyes and general pallor. Ocular examination negative. Teeth show
neglect; many missing; those remaining show caries and pyorrhea. Throat ap-
pears normal. Heart normal. Slight empyema. Reflexes normal. Examina-
tion otherwise negative. Blood pressure 90 systolic, 70 diastolic. Wassermann

Treatment. — (No graphic chart.) On her first day in hospital (Nov. 18) the
patient received a carbohydrate-free diet of 12 gm. protein and 411 calories, and
excreted 8.3 gm. sugar. Notwithstanding the great weakness complained of and
the presence of nausea and colic, fasting was begun the next day and continued
for 5 days. Alcohol was permitted because of weakness, but not more than 80
cc. whisky per day could be taken because of nausea. The ferric chloride reaction
was negative on admission, positive on the first fast-day and diminished so that
it was fully negative like the sugar reaction on the 3rd day of fasting. 180 gm.


thrice cooked vegetables were given on the 4th and 5th days. A very low diet
was then begun, consisting of two eggs and 500 gm. thrice boiled vegetables.
The weight, which was 47.2 kg. on admission, diminished to 44.6 kg. on Nov. 24.
The patient complained of great hunger. The diet was rapidly increased until on
Dec. 5 it consisted of 60 gm. protein, 2 gm. carbohydrate, and 3600 calories.
This was tolerated without glycosuria or ketonuria, but the carbohydrate toler-
ance was very low. On Dec. 7 the addition of 200 gm. green vegetables con-
taining 9.8 gm. carbohydrate resulted in shght glycosuria. The weight by this
time was up to 48.8 kg. and the patient was much improved subjectively. The
glycosuria was checked by a fast-day with 45 cc. whisky, then carbohydrate-free
diet resumed, at first very low (25 gm. protein and 250 calories), but again rapidly
increasing until on Dec. 19 it contained 138 gm. protein and 3330 calories. The
attempt to include 7 to 12 gm. carbohydrate in the form of green vegetables
again resulted in slight glycosuria. Without a fast-day, the carbohydrate was
stopped and the total diet diminished to 600 calories, followed by an increase as
before. On Dec. 28 the weight was 47.4 kg., and a diet of 100 gm. protein and
22 gm. carbohydrate were tolerated without glycosuria. The same was true of
the diet of 91 gm." protein and 27 carbohydrate on Dec. 29. The assimilation of
carbohydrate here is explainable by the lower weight and the lower total diet;
namely, 2200 calories on each of these days. Likewise 103 gm. protein, 24 gm.
carbohydrate, and 2400 calories were tolerated on Dec. 30. The patient was
discharged on Jan. 3, 1915, on a carbohydrate-free diet of 110 gm. protein and
2500 calories, with 600 to 800 gm. thrice cooked vegetables daily. She felt well
and fit for work and was continuously free from both glycosuria and ketonuria.
Her weight at discharge was 47.6 kg., or practically identical with the weight at

Subsequent History. — The patient followed her diet faithfully, and on Apr. 20
the addition of 10 gm. carbohydrate was permitted. Her weight tended to in-
crease, and was 50.4 kg. on Aug. 2, 1915, and 55.8 kg. on Jan. 11, 1916. She was
then instructed to take a fast-day once every 2 weeks. One feature of her his-
tory is that 7 weeks after discharge (Feb., 1915) and again in Nov., 1915, she had
severe colds or grippe with fever, which confined her to bed 1 or 2 weeks, while
no more than traces of glycosuria appeared. Her progress continued steadily
favorable, and in Jan., 1916 she was referred to another clinic for further guidance
and observation. She was seen again in Apr., 1918, still following diet and doing
her housework without complaint.

Remarks. — The case gives the usual illustration that the way for a weak and
undernourished diabetic to gain strength and well-being is by therapeutic under-
nutrition. Abrupt initial fasting is sometimes dangerous in patients showing the
condition here described at the outset, but was well borne in this instance. With
sugar-freedom and loss of weight, the patient felt distinctly better; and in view
of her age and the relative mildness of the case it was considered safe to augment
her diet rather rapidly. As is frequent in such cases, with an adequate ration of

252 CHAPTER ni

protein and calories, the carbohydrate tolerance was practically nil. With the
weakened condition and the apparent absence of tolerance, this might have been
classed in standard text-books as a severe case. The relative mildness was
shown by the steady improvement when the urine was merely kept sugar-free.
It is also of interest that occasionally patients of this sort, handicapped by ignor-
ance and poverty combined, prove able to follow diet with fidelity, test their urine
conscientiously, and achieve satisfactory results.

CASE NO. 20.

Female, married, age 38 yrs. American; housewife. Admitted Nov. 19,

Family History. — One brother died of tuberculosis at 29 years of age. Family
otherwise healthy.

Past History. — Scarlet fever, measles, chicken-pox, whooping-cough, and
diphtheria all before 7th year. Also at age of 2 patient had a fall injuring left
knee so that she was unable to walk until 13, and the leg is stiU stiff. Has had
headaches all her life. Lately they are limited to the menstrual period, and are
localized in migraine fashion on the left side of the face. Numerous sore throats
during the past year. Habits regular. No excesses, no special fondness for
sweets or starches. Married 13 years ago. One child born 12 years ago died of
heart trouble a few hours after birth. A second living and well. Venereal dis-
eases and symptoms denied.

Present Illness. — Glycosuria was discovered 1 year ago when patient went to a
hospital for another cause. Since then there have been no symptoms except the
gradual loss of SO or 60 pounds of weight. She has noticed a darkening of the skin
about her eyes during this time. This began in the form of small dots which have
increased and fused until they form a very noticeable broad brown ring around
her eyes. She has been on a moderately restricted diet with continuous glycosuria,
and has been taking sodium bicarbonate and citrate for the past few weeks.
Nervousness has developed and she tires easily. She was referred to the Insti-
tute by her physician on suspicion of bronzed diabetes.

Physical Examination. — Height ISO cm. A nervous, frightened looking woman,
well nourished, with sweetish odor of breath. Shghtly elevated bronzed circle
1| to 2 cm. wide about both eyes is most striking characteristic of face. Teeth
neglected, three missing, one carious; no pyorrhea. Throat normal. Heart
shows signs of well compensated mitral regurgitation. Blood pressure 140-
110. No enlargement of lymph nodes except in axilla. Knee jerks present
on right, absent on left (injured side). Examination otherwise negative. No
pigmentation except that about eyes.

Treatment. — Patient was first kept on an observation diet without fasting.
No special pecuharities were noticed, and she was able to tolerate 75 to 80 gm.
protein, 30 to 40 gm. carbohydrate, and 1500 to 1800 calories with no glycosuria


or only traces. Ketonuria was stubbornly persistent but never dangerous in de-
gree. Slight albuminuria present on admission cleared up completely and did not
return. The observation diet as a whole represented undernutrition, inasmuch
as the weight fell from 53 kg. at entrance to 48.5 kg. on Dec. 18. The condition
about the eyes proved to be xanthelasma, and nothing was found to indicate a
true bronzed diabetes. Accordingly a more radical treatment was instituted in
the latter part of Dec, especially with a view to reducing weight. From Dec. 20
to Jan. 6 the diet contained nothing but whisky and green vegetables. Traces of
glycosuria appeared when the carbohydrate intake was approximately 60 gm.
By this means the urine was at last made free from both sugar and ferric chloride
reactions (Jan. 5 and 6). Carbohydrate was then excluded by thrice boiling the
vegetables, and two eggs were added. The diet was then built up, so that on
Jan. 13 to 14 it consisted of about 80 to 90 gm. protein, 30 gm. carbohydrate, 60
gm. alcohol, and 2200 to 2300 calories. The weight had thus been reduced to
46.6 kg.; i.e., a loss of 6.4 kg. since admission. Though the ferric chloride reac-
tion had reappeared, it was deemed safe to let the patient go home on this theo-
retically excessive diet, in order that she might carry on her housework comfort-
ably and continue to improve in strength and nervous control, the expectation
being that in such a case and under such conditions the gradual gain in tolerance
resulting from continued sugar-freedom would take care of the persisting ab-
normalities, notably the ketonuria.

Subsequent History. — The patient adhered faithfully to her diet at home, car-
ried on her housework, nursed her daughter through pneumonia, gradually lost
her nervousness, and remained continuously free from glycosuria but with a
slight ferric chloride reaction constantly present, even with addition of 10 gm.
carbohydrate to the diet on Apr. 20. On June 2 she was readmitted to the hos-
pital because of complaint that she was not feeling so well and that her nervousness
was returning.

Second Admission. — The weight at this admission was 43.8 kg.; i.e., 2.8 kg.
less than at discharge. The general condition was much better than at the former
admission. The pigmentation about the eyes appeared neither to have increased
nor diminished. The urine was entirely free from sugar, as the patient reported
it had been continuously, but the ferric chloride reaction had become heavy, and
the 24 hour urine contained 1.96 gm. ammonia nitrogen. The symptoms com-
plained of were presumably associated with this acidosis. It was therefore
deemed desirable to proceed radically to abolish acidosis. This could not be
done by simple addition of carbohydrate to the diet, for on June 3 the giving of
30 gm. carbohydrate with 84 gm. protein and 1700 calories caused well marked
glycosuria. On the other hand, the acidosis diminished by simple reduction of
diet, so that on June 5, on a carbohydrate-free diet of 66 gm. protein and 1300
calories, there was excretion of only 0.56 gm. ammonia nitrogen. Therefore on
June 6 and 7, fast-days were given, with an allowance of 300 cc. coffee, 300 cc.
clear soup, and 50 cc. whisky. On Jime 8, alcohol was discontinued and never


again used for this patient. Green vegetables representing 10 gm. carbohydrate
were added on this day, and the usual carbohydrate tolerance test was instituted,
with increase of 10 gm. carbohydrate in green vegetables daily. A trace of gly-

Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 26 of 76)