Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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cosuria appeared on June 14 with 90 gm. carbohydrate, but this did not represent
the true limit of tolerance, because glycosuria ceased, and the true limit was
reached only with about 150 gm. carbohydrate on June 23. Further increase
up to 170 gm. on the following days caused only slight but continuous glyco-
suria. Under this program the ferric chloride reaction became negative and the
ammonia excretion held a low level. After a fast-day on June 28, a regular
diet was gradually built up with one fast-day every week. Even with 37 to 45
gm. carbohydrate in the diet the ferric chloride reaction reappeared, but dimin-
ished, and on July 13 became negative with 67 to 75 gm. carbohydrate in a diet
otherwise composed of 75 to 100 gm. protein and 1600 to 2100 calories. The
weight on July 24 was 41.8 kg.; i.e., a loss of 2 kg. during this period in hospital,
or a loss of 11.2 kg. since her first admission. She was discharged to continue
this diet at home.

Subsequent History. — The patient continued to follow treatment faithfully,
and improvement continued with constantly normal urine. She passed through
an attack of grippe in Nov., 1915, without return of glycosuria. She has led a
fully normal life except for attention to diet, does her work easily, has lost all ner-
vousness, and feels well in every respect. In addition to her reports, she came
for personal examination on July 18, 1916. Her weight was then 45.2 kg.; i.e.,
a gain of 3.4 kg. since discharge. Her general appearance was excellent, with pig-
mentation unchanged. The urine was normal, the CO2 capacity of the plasma
50.3 per cent, the plasma sugar 0.189 per cent. This hyperglycemia received no
special treatment, for since there had been such obvious improvement before, it
was considered probable that it would continue, with ultimate reduction of blood
sugar, without more radical measures in a case of this type.

Remarks. — ^Aside from points abready noted, the case again illustrates the
benefit resulting from general therapeutic undernutrition in a patient who had
already suffered considerable loss of weight and strength from diabetes. Both
the treatment and the improvement were gradual in character. Results could
have been achieved more quickly by following up the alcohol-carbohydrate period
of Dec, 1914, with undernutrition sufficient to keep the ferric chloride reac-
tion negative, at the same time buUding up carbohydrate tolerance more rapidly.
As usual in such cases, however, the simple continuance of freedom from gly-
cosuria brought steady improvement, so that at the second admission there was
a considerable carbohydrate tolerance and acidosis was easily abolished without
interruption of the steady gain in well-being. The patient now weighs enough
for fully satisfactory looks, comfort, and strength. There is a complete con-
trast in these respects with her former condition at a higher weight. An at-
tempt to return to the former weight would doubtless bring a return of the
previous troubles. There has probably been little or no absolute improvement



CASE RECOEDS 255

in the power of assimilation, neither is there any evidence of any progressive
•decline. The patient is merely living within her assimilative power. As far as
-can be judged from the experience of nearly 3 years, she can continue to do so
without difficulty, and the general trend seems to be upward rather than
•downward.

CASE NO. 21.

Female, married, age 46 yrs. Scotch,* housewife. Admitted Nov. 20, 1914.

Family History. — Father died in accident. Mother died of heart trouble at
42. Patient was the only chUd. Diabetes, tuberculosis, cancer, syphilis, or ner-
vous disorders in any relatives denied. Patient married twice. Has had only
one child, who is alive and well; no miscarriages.

Past History. — Measles, mumps, and whooping-cough in childhood. Came
from Scotland to United States at age of 17. Scarlet fever 15 years ago. Op-
eration for ventral hernia 1 year ago. Subject to occasional headaches ever since
she can remember. Also has shortness of breath on exertion. Occasional sore
throats. No use of alcohol. Drinks six or eight small cups of tea daily. Up to
15 years ago weight was 146 pounds; since then it increased, so that at the time
of her operation a year ago it was 266 pounds. During this year she has lost
36 pounds.

Present Illness. — ^About 6 months ago patient began to notice polyuria, poly-
•dipsia, polyphagia, and increasing nervousness, with rapid loss of weight. These
have been the only symptoms. No treatment by diet.

Physical Examination. — ^Height 155 cm. A large framed, plethoric, obese
woman with dry skin, a nervous expression, and bilateral arcus senilis. Teeth
neglected, some missing; those remaining show caries and pyorrhea. Tonsils a
trifle hypertrophied. Slightly large thyroid palpable. No lymph node enlarge-
ment. Heart slightly enlarged. Slight emphysema. Knee jerks active. Leg
veins markedly varicosed. Blood pressure 175 systolic, 120 diastolic. Trace of
albumin in urine, but no casts.

Treatment. — ^The most obvious requirement was to reduce weight. The most
noteworthy initial observation was that in 4 days of absolute fasting this very
•obese woman failed to develop any ferric chloride reaction and showed abso-
lutely no symptoms of acidosis. On the following 4 days she received only mod-
erate quantities of whisky (not above SO gm. alcohol) . It is evident that they did
not prevent the appearance of a slight ferric chloride reaction. This reaction was
(negative on Nov. 28, when only 10 gm. alcohol were given, as if the larger quan-
tities of alcohol had tended to produce rather than prevent it. On Nov. 29, a
•carbohydrate-free diet of 93 gm. protein and 2260 calories caused a trace of
glycosiuia. The subsequent diets represent very marked undernutrition. It is
obvious from the graphic record that the patient not only had practically no car-
bohydrate tolerance but also tended to show traces of glycosuria even on very
low carbohydrate-free diets. She was of the type spoken of in older text-books



256 CHAPTER in

as relatively independent of diet ("paradoxical tolerance"). That is, her glyco-
suria had never been excessive, and if tested she would doubtless have proved her
abihty to assimilate most of the carbohydrate of any diet. Yet complete sugar-
freedom was difficult to achieve even with the most radical restrictions. Blood
sugar analyses were not made. It is probable that a continuous marked hyper-
glycemia was responsible for the frequent traces of glycosuria, and that this
varied Uttle with diet. The principal result of treatment was to bring the body
weight down from 108 kg. to 90 kg. No special attempt was made to conserve
the body protein. Nitrogen balances would undoubtedly have turned out strongly
negative. Nevertheless, there was a gain in well-being, and at discharge there were
no symptoms except those referable to arteriosclerosis, the former migraine attacks,
and other conditions apparently independent of the diabetes. The diet pre-
scribed at dismissal was approximately 75 gm. protein, 60 gm. carbohydrate, and
1300 calories, representing, for a weight of 90 kg., only about 0.8 gm. protein and
IS calories per kg. The trace of glycosuria on Jan. 24 may be regarded as of
the accidental type sometimes resulting from a sudden increase of carbohydrate.
It appeared that the patient could carry this diet without glycosuria and with a
bare trace of ferric chloride reaction. She stated that her appetite was reasonably
well satisfied, and she felt better when eating and weighing less. The trace of
albumin present in the urine at admission remained unchanged, but casts could
very seldom be found. The treatment was not considered complete at dismissal,
but undernutrition was to be continued at home.

Subsequent History. — The patient continued free from glycosuria at home,
with a persisting trace of ferric chloride reaction. She was not required to weigh
her food, and her estimates were probably enlarged with increase of appetite, for
her weight at first held practically even, being 90.6 kg. in Aug., 1915. By Oct.
there was an increase of 2.6 kg. The sugar in the whole blood was then 0.128 per
cent, in the plasma 0.161 per cent. Sugar remained absent from the urine; the
ferric chloride reaction continued present. She was instructed to fast 1 day every
2 weeks."

On Nov. 29, the weight was found to be 101.4 kg., plasma sugar 0.143 per cent,
CO2 capacity of plasma 43.2 per cent. The blood pressure was 240 systolic, 140
diastolic, and there had been symptoms referable to hj^jertension. She was
instructed to fast IJ days every week.

On Jan. 11, 1916, the blood pressure was 220 systoUc, 120 diastolic. The weight
was 101.5 kg. with clothing, 99 kg. stripped. She was instructed to remain in bed
for a week on a diet of nothing but low percentage green vegetables. The urine
was entirely negative for both sugar and ferric chloride reactions.

On July 13, 1916, the blood sugar was 0.128 per cent, plasma sugar 0.156 per
cent, CO2 capacity 56.9 per cent. Sugar and ferric chloride reactions in urine
remained negative. Though recent dietary instructions theoretically estab-
lished an intake of only 1000 calories, the patient's estimates were evidently too
high and the weight continued to rise, being now 103.2 kg. stripped. The patient



CASE EECORDS 257

has remained so well that she has not been closely supervised. She still con-
tinues to lead a normal life, and suffers only from headaches and occasional attacks
referable to hypertension.

Remarks. — Complication of this case with obesity and arterial hypertension
called for no special alteration in the treatment of the diabetes. The entire
condition rendered a reduction of weight desirable. By this simple measure
the carbohydrate tolerance, which appeared so very low, was easily raised, and
the case stood revealed in its true light as one of intrinsically mild diabetes. It
must again be mentioned that the initial stage of treatment of such a case some-
times presents difficulties and dangers such that fasting may have to be em-
ployed cautiously and after special preparation; but in this instance the fasting
offered no difficulty and the obesity was no obstacle to the gradual disappearance
of the ferric chloride reaction. The case thus opposes the idea that the available
' fat supply is the sole determining factor in fasting acidosis. Under a mild thera-
peutic regime hj^perglycemia has been persistent. It need not be attributed in
any degree to the hypertension; on the contrary, the hyperglycemia sometimes
described in cases of hypertension is more probably an indication of pancreatitis
and mild diabetes. This being one of the earlier cases of the series, conservatism
seemed to favor leniency in the treatment. Fuller experience indicates that the
right plan would be to reduce the weight sufficiently to keep the blood sugar nor-
mal. Nevertheless, in view of the mUdness of the case, if the patient follows a
fairly reasonable diet without letting her weight rise too high, she can probably
go through life without further trouble from her diabetes.

CASE NO. 22.

Male, married, age 52 yrs. American Jew; cigar manufacturer. Admitted
Nov. 20, 1914.

Family History. — Father died of pneumonia at 74. Mother, now 74, has kid-
ney trouble. One brother living and well. Two sisters died in childhood, a
third of appendicitis at IS, a fourth is living but has carcinoma of breast. No
tuberculosis, syphilis, or nervous disorders in family. Patient has been married
31 years; wife living and well. Five children; one died of diphtheria in infancy,
four living and well.

Past History. — Practically never sick from childhood up. Neisser infection
twice. Syphilis denied. At age of 21 patient was rejected for life insurance
because of alleged B right's disease. He consulted eminent specialists, and the
slight albuminuria was classified among the earliest examples of orthostatic al-
bimiinuria. For many years he has never been without albumin and casts in
urine, but has had no symptoms other than these and has never had to miss a
single day from business. For part of his life patient drank considerable wine in
connection with business dealings, and smoked IS to 20 cigars a day. He started
as a poor boy and became a millionaire, and has lived at highest nervous tension.



258 CHAPTER III

In the past 10 or 12 years he has had 25 or 30 hysteric attacks in which he was
practically irresponsible. He is accustomed to rich Uving. Bowels constipated.

Present Illness. — 2 years before admission sjrmptoms began with extreme
himger and thirst, loss of weight, bad breath, and cramps in the legs. On ac-
count of failing vision he consulted an oculist, who immediately asked for a
specimen of urine and diagnosed diabetes. The diet since then has been sUghtly
restricted qualitatively, but quantitatively two or three times as much as re-
quired by a normal appetite. The loss of weight has continued nevertheless.

Physical Examination. — ^A shghtly buUt, somewhat emaciated man with pale
complexion and nervous, feeble appearance. Several teeth missing; those pres-
ent show sUght caries and pyorrhea. Throat somewhat congested; left tonsil not
visible, right protrudes slightly. Shght generalized lymph node enlargement.
Heart very shghtly enlarged to left. Arteries palpably sclerosed. Blood pres-
sure 135 systoUc, 110 diastohc. Liver edge 2 cm. below costal margin. Reflexes
normal. Examination otherwise negative. Urine shows shght albumin and
numerous hyahne casts.

Treatment. — The patient's extreme nervousness, as also headaches and ter-
rors at night, required the use of codeine during the early days in the hospital.
He was kept on an observation diet for the first 3 days, poor in carbohydrate, and
particularly with total calories limited to about 1600 on Nov. 21 and 900 on
Nov. 22. The glycosuria was thus greatly diminished. Nevertheless fasting was
instituted as soon as the general condition seemed to permit. Owing to weak-
ness, the patient was in bed during the fast. On Nov. 23 and 28 the fasting
was absolute. On the intervening days whisky was given, but never above 70
cc. Glycosuria ceased with the first day of fasting. With continuance of the
fast, the ferric chloride reaction diminished to traces. On Nov. 29 a carbohy-
drate-free diet of 45 gm. protein and 2080 calories was tolerated without glyco-
suria, but brought back a heavy ferric chloride reaction. On the next day the
diet was diminished to 23 gm. protein and 600 calories. The weakness and
nervousness stiU being salient features and the patient being very hungry, a lib-
eral diet was permitted on the subsequent days, rising by Dec. 19 to 97 gm. pro-
tein, 33 gm. carbohydrate, and 3000 calories. Traces of glycosuria were fre-
quent on this high diet, and well marked ferric chloride reactions continued. By
this time the general condition had improved and the patient had grown more
accustomed to hospital hfe and dietary restrictions. Accordingly, on Dec. 21 a
more rigid treatment of the diabetes was undertaken. On that day the only
food was 50 gm.. alcohol. Green vegetables were gradually added to the alcohol,
representing 7.5 gm. carbohydrate on Dec. 22 and increasing to 107 gm. on Dec.
28. The ferric chloride reaction was still stubborn notwithstanding this car-
bohydrate intake without glycosuria — an illustration that food is not the only
controlling factor. In view of the patient's weakness and irritability a more
Uberal diet was again resumed. He was dismissed on Jan. IS, 1915, on a diet of
approximately 100 gm. protein, 15 gm. carbohydrate, and 2400 calories. The body



CASE RECORDS 259

weight was SO kg. at admission, 47.2 kg. at discharge, the period of treatment thus
representing undernutrition to the extent of a loss of 2.8 kg. weight. There had
been a notable gain in strength, so that the patient was now outdoors daily and
was becoming restless owing to a desire to return to work. The nervousness was
greatly lessened and he felt that hfe was again worth hving. Albuminuria and
casts persisted, but several functional tests during the stay in hospital had shown
a normal index of urea excretion. The patient, being stiU weak, was instructed
not to work more than half of each day and to pay attention to rest and general
hygienic measures.

Subsequent History. — ^The urine continued negative to sugar and ferric chloride
tests, with the usual albumin and casts present. By Feb. 10 the weight had
risen to 53.2 kg. The blood pressure was 153 systoUc. The patient at this time
was working 6 or 7 hours a day, was taking horseback rides and other exercise,
and reported himself free from nervousness, sleeping soundly at night, and en-
joying life. In appearance he was very greatly improved. By Apr. 12 there had
been a further increase of 2 kg. in weight. The blood pressure was 180 systolic,
135 diastohc. He was warned that the gain in weight was contrary to instruc-
tions, and the diet was ordered changed to 115 gra. protein, 20 gm. carbohydrate,
and 1600 calories; i.e., the protein and carbohydrate were slightly increased and
the fat decidedly diminished. This allowance of about 30 calories per kg. was
expected to maintain his nutrition without further increase of weight. On July 7
the patient reported that he had been f eeUng as well as in his earlier years be-
fore the onset of diabetes. Occasional headaches recurred but were reheved by
catharsis. There had been a further sHght increase of weight up to 54.4 kg.
The blood pressure was 195 systolic, 160 diastolic. The patient had departed
sUghtly from diet, particularly by adding bread occasionally, and the urine showed
a trace of glycosuria and a moderate ferric chloride reaction. This trace always
disappeared with a single fast-day, and he was warned to adhere to diet and keep
sugar absent.

Second Admission. — ^The patient made no further report until he reentered the
hospital Jan. 24, 1916, slightly more than a year after discharge. He had car-
ried on his large business continuously and efl&ciently during this time and also
had enjoyed much recreation. He returned with glycosuria again present, in con-
sequence of too many visits to restaurants in the course of his amusements. The
weight was 50.2 kg.; i.e., 0.2 kg. more than at previous admission. He had been
running down lately by reason of his indiscretions in diet, but nevertheless was far
stronger and in better condition in all respects than at his previous admission.
Physical examination practically as before. Blood pressure 200 systohc, 135 dias-
tolic. AU the conditions being more favorable, measures were now instituted for a
radical clearing up of both glycosuria and ketonuria. 4 days of absolute fasting
were imposed (Jan. 28 to 31). This was followed by a carbohydrate period in
the form of the usual tolerance test, i.e. on Feb. 1 green vegetables were given
containing 10 gm. carbohydrate, and this was increased by 10 gm. daily. The



260 CHAPTER rn

traces of glycosuria on Feb. 4 and 5 were accidental in character and disap-
peared with further increase of carbohydrate intake. A tolerance of 150 gm.
carbohydrate was thus demonstrated on Feb. 15. By this time the ferric chloride
was entirely negative, the blood pressure had gradually diminished to 160 sys-
tolic, 120 diastolic, and the patient was feeling well enough to have recovered
from the fears which had brought him back to the hospital. Accordingly at this
point he suddenly announced that urgent business matters required his attention
and that he must leave immediately. He was therefore discharged on the fol-
lowing day with instructions not to return.

Third Admission. — ^Nothing more was heard from him until on Oct. 17, 1916,
his wife telephoned that he had had an attack of apoplexy and was in a critical
condition. He was found in an excessively excited state, with partial right sided
hemiplegia. The body weight was again 50.2 kg.; the blood pressure 190 systolic,
125 diastolic, the blood sugar 0.305 per cent, the CO: capacity of the plasma 81
per cent. Xhe urine showed moderate sugar and negative ferric chloride reac-
tions. He was placed on a diet of 65 gm. protein, 10 gm. carbohydrate, and 1000
calories. On this diet glycosuria diminished to only occasional traces, but the
blood sugar never fell below 0.2 per cent. Only slight glycosuria resulted from
an increase of diet to 65 gm. protein, 35 gm. carbohydrate, and 1600 calories.
Meanwhile, with rest, the paralysis was gradually clearing up. In Dec. and Jan.
it seemed feasible again to undertake thorough treatment of the diabetes. A
week of fasting (Jan. 7 to 13) was well borne. At the end of it the ferric chloride
reaction was negative, the ammonia nitrogen excretion only 0.12 gm., the plasma
bicarbonate 68 per cent, but the blood sugar was stiU 0.222 per cent. A car-
bohydrate test with the usual increase of 10 gm. daily showed a tolerance of
only 30 gm. carbohydrate in the form of green vegetables. Treatment was con-
ducted according to the usual principles, the protein being kept low (50 gm. or
less daily) partly on account of the renal condition. Rigorous imdernutrition
brought the usual results, so that in Feb. a tolerance of 120 gm. carbohydrate
was demonstrated, and the stubborn hyperglycemia was at last reduced, not to
normal, but well below the renal threshold. By Mar. the patient was able to
tolerate 65 gm. protein, 10 gm. carbohydrate, and 1400 calories. His weight had
been reduced to 41 kg.; i.e., a loss of 9.2 kg. The paralysis had gradually di-
minished so that he was able to be about again and to make some use of his
right arm. He was improved sufficiently that he was no longer trustworthy in
regard to diet. He was discharged with the feeling that life could not be greatly
prolonged.

Remarks. — ^The case represents the treatment of diabetes in the presence of
nephritis. It is evident that such a combination presents no obstacle to the
carrying out of the usual method. A diet low in both protein and calories is
beneficial from the standpoint of both the diabetes and the nephritis, and there
is no antagonism in any of the measures required. In this instance the patient
was saved from threatening weakness and nervous collapse connected with his



CASE RECORDS 261

diabetes, and it was possible, as shown especially in the second admission, to
make the urine normal and bring the blood sugar also to a normal level. Disaster
came from the side of the nephritis. The patient is failing but was alive at
last report.

CASE NO. 23.

Male, married, age 44 yrs. American; insurance agent. Admitted Nov. 27,
1914.

Family History. — Father and mother living and well. One sister died in in-
fancy, and a brother of pneumonia. No diabetes or other special disease in
family. Patient married 20 years. Two children, one living and well at 17
years; the other died in a difficult labor. An interesting addition to this history
at time of admission is that patient's mother has since developed diabetes at the
age of 74.

Fast History. — Measles, mumps, and chicken-pox in childhood. Healthy life.
Neisser infection at 19; syphilis denied. 14 years ago had "bloody dysentery"
for a week. Habits regular; moderate drinking and smoking. Appetite normal.

Present Illness. — 9 years ago, after much worry in business, glycosuria was
discovered when patient applied for life insurance. His family physician pre-
scribed diet and pronounced the condition only a transient glycosuria. Subse-
quently life insurance was granted. He has had constant medical supervision
and the tendency to glycosuria has steadily increased, so that during the past 2
years he has never been sugar-free, and the amount has varied from 3 to 7 per
cent. His weight has diminished from 195 to. 165 pounds. He can stUl do con-
siderable work, but 'feels a decided impairment of strength and endurance. No
polyphagia. Urine not more than 3 liters. He avoids sugar and most starches,
but his diet includes oatmeal, two sUces of fraudulent gluten bread, fruits, vege-
tables, and occasionally a potato. He was referred to the Institute by a com-
petent general practitioner because both glycosuria and ketonuria were heavy on
the diet stated. The physician was in the old-time dilemma of hesitating to
increase glycosuria by adding carbohydrate, and fearing to increase acidosis by
withdrawing carbohydrate.

Physical Examination. — Height 172.5 cm. A well developed, adequately
nourished, healthy appearing man. Teeth in good condition. Tonsils slightly



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 27 of 76)