Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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enlarged. Liver edge 3 cm. below costal margin. Examination otherwise
negative.

Treatment. — ^The patient was kept for a week on an observation diet of 95 to
120 gm. protein, 10 to 20 gm. carbohydrate, and 1800 to 2400 calories. The
highest anunonia nitrogen excretion was 2.31 gm. There were no symptoms of
danger or even discomfort. Fasting was begun on Dec. 5, first absolute, then (Dec.
6 and 7) with alcohol up to 52.5 gm. This was followed by a low carbohydrate-
free diet, but glycosuria promptly returned (Dec. 10 to 11) on about 50 gm.
protein and 1600 calories. Ferric chloride reactions persisted, and the ammonia



262 CHAPTER III

excretion was practically as high as at the beginning. The case had been taken as
a mild one. These signs indicated that notwithstanding the absence of striking
symptoms, the real condition was by no means trivial and nothing but radical
undernutrition could bring a satisfactory result. The patient was absolutely
obedient and gave his full confidence, and a rigid program was therefore insti-
tuted. With a view to combating acidosis, food was given chiefly in the form of
alcohol, the highest intake being about 260 cc. whisky on certain days in Feb.
The general plan of treatment is best seen from the graphic chart. Protein-fat
diets were given on a few days, for example, Jan. IS to 17, but for the most part
the diet consisted only of whisky with addition of carbohydrate from time to
time up to the limit of tolerance. This hmit was very low. The giving of 40 to
70 gm. carbohydrate in the form of green vegetables with no other food but
whisky was sufficient to cause glycosuria on repeated occasions in Dec, Jan.,
and Feb. The maximum alcohol doses above mentioned, with the addition of
these quantities of carbohydrate, failed to abolish the persistent, fairly heavy
ferric chloride reactions. Also it was not possible to allow an adequate diet and
await a later recovery of tolerance for clearing up acidosis, because the total food
tolerance remained persistently low. For example, on Jan. 17 a carbohydrate-
free diet of 89 gm. protein and 1790 calories gave rise to glycosuria lasting 2 days.
Under such conditions it is generally necessary to master both the glycosuria and
the acidosis before much real improvement of assimilation can be expected. At
the end of Mar. and first of Apr. the patient's weight touched its lowest point,
51.4 kg.; i.e., a loss of 19.2 kg. during 4 months of severe continuous under-
nutrition. The patient had come to the hospital looking strong and robust.
By this time he appeared thin and weak. His strength was definitely dimin-
ished, and his general decline seemed so evident that only fuU confidence on his
part and on the part of those conducting the treatment permitted the completion
of the necessary program. But about this time the ferric chloride reactions grew
steadily paler, until they were negative in certain urine specimens of each day and
not more than traces in the other periods. Also a recovery of assimilation was
evident, such that on Apr. S to 7 a diet of approximately 100 gm. protein, 20 gm.
carbohydrate, 100 gm. alcohol, and 2200 calories was tolerated without glycosuria.
Exercise had not been employed in the earUer treatment, because of uncertainty as
to its effects in the presence of marked undernutrition and a persistent tendency
to acidosis. It was now begun and rapidly increased up to the hmit of strength.
The high calories in the later diets were permitted in proportion to the amount of
physical labor performed. On Apr. 8 it appeared feasible to discontinue alcohol,
and except for the fast-day on Apr. 11 it was never resumed. On Apr. 9 and 10 the
diet was made approximately 100 gm. protein, 30 gm. carbohydrate, and 1500 cal-
ories. This was increased rapidly to 2700 to 3000 calpries with the same protein
and carbohydrate. A regular fast-day each week diminished the average intake
to about 86 gm. protein and 2300 calories daily, or about 43 calories per kg. for
the weight of approximately 54 kg. at that time.



CASE RECORDS 263

The patient, though thinner, now both felt and looked far better than at ad-
mission. He was up to full strength in every way and able to carry on his regu-
lar business and in addition take much exercise and recreation daily. He was
discharged in this condition on May 8 to spend the summer in the country. He
was instructed to report in 6 weeks and not to gain more than 2 pounds in this
time.

Subsequent History. — In the country he spent his days in walking, riding, swim-
ming, tennis, and other exercise, buUding up strength while keeping weight
within prescribed limits. In Aug. ferric chloride reactions ceased to appear.
The urine never showed sugar except traces on rare occasions when he made
unintentional mistakes in diet. He returned to resume his regular business in the
city in Sept.

On account of persistent hyperglycemia, exercise was increased, the patient
preferring this to a reduction in diet. Daily exercise was taken in the form of
horseback riding, athletic exercises under an instructor, swimming, and boxing.
He also walks to business, an average of about 8 mUes daily, frequently walks
20 or 30 miles on Sundays, and also plays tennis and squash three or four times a
week. His business duties occupy about 5 hours a day, and in the remaining
hours he has made a trained athlete of himself. Because hyperglycemia stiU
persisted, on Dec. 17 the diet was made 130 gm. protein, SO gm. carbohydrate,
and 2500 calories, this change representing particularly an increasd in carbo-
hydrate and a diminution in total calories. At the same time he was allowed to
increase his office work by 1 hour. On New Years day, 1916, the patient added
a large baked potato to his diet without glycosuria, but was warned against a
repetition. Traces of glycosuria appeared in subsequent months on rare occa-
sions, and accordingly on July 10, 1916, the diet was diminished to 130 gm.
protein, 40 gm. carbohydrate, and 2200 calories. In the entire time since then
there was a trace of sugar in the urine only on 2 days. The weight at last report
was 68.4 kg., in comparison with the 70.6 kg. at the time of first beginning treat-
ment in hospital. The general strength and subjective condition are the best
the patient ever enjoyed.

Acidosis. — Though mostly shght, this was notably stubborn, and the mastery
of it was one of the most difficult features of the treatment. The prolonged pro-
gram of undernutrition, with alcohol short of intoxication and carbohydrate to the
point of glycosuria, resulted in a slow decline of the ammonia to a normal level
about the middle of Feb. There was a prompt rise with the addition of small
quantities of protein and fat to the diet late in Feb. and early in Mar., followed
by another slow decline. Also, in addition to the tenaciously persistent ferric
chloride reaction, the CO2 capacity of the plasma indicated the same chronic ten-
dency to acidosis. From the graphic curve it can be seen that the values were
generally near the lower normal limit and frequently fell considerably below this.
Sodium bicarbonate was used twice; namely, SO gm. on 1 day to check the par-
ticularly marked fall of the plasma alkalinity at the close of Feb., and 30 gm.



264 CHAPTER m

daUy on Mar. 8 and 9. These doses gave immediate relief from slight symptoms
of malaise of which the patient complained at this time. But obviously his fun-
damental trouble was not lack of alkali, and the treatment had to be directed
to the causes imderlying the state of acidosis.

At the time of discharge from hospital the ammonia nitrogen excretion was stiU
0.8 to 1.2 gm.; and some color was shown with ferric chloride in certain urine
specimens every day, while specimens in other portions of the day were negative.
As mentioned, the ferric chloride reactions became fully negative in Aug. and
have remained so since. Acidosis has also remained absent by other tests. On
July 25, 1916, the CO2 capacity of the plasma was 60.6 per cent, and it has since
remained high.

Exercise and Blood Sugar. — It seems probable from other experience that no
harm would have been done and progress might have been hastened by using ex-
ercise in this case from the outset. The improved assimilation of carbohydrate
and other food might have aided in a quicker clearing up of acidosis. Exercise
was carried to a higher point in this patient than in any other of the series. As
stated, he has made a trained athlete of himself and has enjoyed the highest
vigor and subjective health. In a general way it seemed evident that exercise
improved his assimilation. Precise experiments concerning the effect of exercise
upon his blood sugar were not performed.

It will be noted in the graphic chart that the blood sugar in the latter part of
Mar. was below 0.15 per cent and fell to normal. With the higher carbohydrate
and higher total diet in Apr. it rose as high as 0.17 per cent, but came down,
apparently as a result of exercise, to a nearly normal level at discharge. After
leaving hospital the patient's weight gradually rose and the blood sugar likewise
increased. On Oct. 6, with weight up to 60.9 kg., the sugar in whole blood was
0.185 per cent, in plasma 0.208 per cent. It was at this point that a maximum of
exercise was begun, the patient preferring this to a reduction of diet. Nevertheless
on Oct. 18 the sugar in the whole blood was 0.192 per cent, in the plasma 0.208
per cent, whUe the patient was feeling in splendid condition. On Oct. 25 the
blood sugar was again 0.192 per cent and the plasma sugar 0.208 per cent; on Oct.
28 the plasma sugar was 0.222 per cent; on Nov. 15 the blood sugar was 0.161 per
cent, plasma sugar 0.222 per cent. Traces of glycosuria had formerly been cleared
up on repeated occasions by exercise, but it seemed evident that the diet was too
high, so that exercise could not lower the hjrperglycemia or entirely prevent re-
currences of these traces of sugar. Accordingly the diet was modified on Dec.
27 as above noted. On July 10, 1916, the blood sugar was 0.156 per cent, the
plasma sugar 0.217 per cent. The weight as above mentioned was higher than
before; namely, 68.4 kg. On July 25 the blood sugar was 0.143 per cent, the
plasma sugar 0.169 per cent. On Aug. 2, 1916, the blood sugar was 0.167 per
cent, the plasma" sugar 0.178 per cent. A reduction of body weight is the one
means which may be expected to control the hyperglycemia. The chief value of
exercise from the standpoint of permanent results probably consists in buming



CASE RECORDS



265



up surplus calories and keeping down excess weight. Exercise has doubtless been
somewhat overdone in this case.

Nitrogen Loss. — In the prolonged period of almost protein-free diet, it is evi-
dent that much protein must have been lost from the body. The nitrogen analy-
ses of the urine are very incomplete. If the known points of the nitrogen output
are joined to make a curve as shown in the graphic chart, a reckoning from such a
curve win give a rough idea of the depletion of body nitrogen. The general
undernutrition is evident from the following table:



Total nitrogen output

Protein intake

Nitrogen "

" deficit (output — intake)

Alcohol calories in diet

Food " " "

Total " " "



77 days.




Per day

(average) .




511.32


gm.


6.61


gm.


1236.20


It


16.10


{{


197.80


tt


2.50


u


313.52


tt


4.14


tt


28979




376




24284




316




53263




692





Alcohol. — Prolonged high dosage of alcohol in this patient was for the purpose
of kpeping up strength by supplying calories and if possible aiding to diminish
acidosis. According to clinical indications it was of value for the first purpose.
There is no evidence that it had any value for the second purpose. If the thing
were to be done over, less alcohol or none would be used. Better and quicker
results could doubtless be obtained by a low protein diet, without fat, with vege-
table periods interspersed. Body nitrogen and strength would be better con-
served by the protein. Alcohol is probably injurious rather than beneficial as
regards acidosis.

Remarks. — ^The outstanding feature of this case is that a patient in seemingly
good physical condition was subjected to over 3 months of continuous under-
nutrition and brought into a thinner and seemingly worse condition as a thera-
peutic measure on the basis of laboratory findings alone. The case was not
mUd as imagined when the patient was admitted. It is believed, on the con-
trary, that trouble was shortly impending. The condition confronted was an
assimilation of carbohydrate or protein so low that glycosuria resulted from a
very low intake, and a mild but very stubborn acidosis. An attempt to give any
considerable quantities of protein and carbohydrate would have resulted in con-
tinuous glycosuria. The use of any considerable quantities of fat would have in-
creased or prolonged the acidosis. Accordingly the only escape lay in undernutri-
tion until this dilemma could be broken. The undernutrition was therefore pushed
to the necessary point without hesitation because of any clinical appearances.
The result was successful as stated, and it is believed that a successful result
could not have been attained on any program overtaxing the patient's tolerance



266 CHAPTER ni

on the side of either carbohydrate or fat. The ultimate outcome has been good
from both the clinical and the laboratory standpoints. The persistent hyper-
glycemia is the one unfavorable feature. Unless it diminishes in the natural
course of improvement under present treatment, a reduction of body weight will
have to be ordered; otherwise there may be downward progress and somebody
may call it spontaneous. With simple precautions now, the situation promises
a favorable outcome of an unexpectedly difficult case.

CASE NO. 24.

Male, married, age 44 yrs. American; manufacturer. Admitted Nov. 28,
1914.

Family History. — Father and mother still ahve. The former has glycosuria,
discovered 4 years ago, but no other symptoms.' A paternal aunt died of cancer.
A brother and a sister of the patient are well. Patient has been married 30 years.
Wife had two miscarriages, then one chUd, who is ahve, aged 19.

Past History.— Healthy hfe, spent in small town in Indiana. Measles and
mumps in childhood. Neisser infection at 19. SyphUis denied. Rheumatism
10 years ago; joints involved successively and very painful; night sweats; illness
lasted about 6 weeks but was not severe enough to confine to bed. Occasional
sore throats before and since this time. 8 years ago patient had indigestion,
with pain after eating, pale feces, and yellowness of skin. This continued about
a year and he lost 25 pounds weight, but finally recovered under forced feeding.
No fever or sharp pain at any time. There is a discharge from the left ear
dating from boyhood. Hearing is much impaired in this ear. No excesses in
alcohol or food. For many years he smoked 6 to 10 cigars daily. Last Mar.
he diminished his smoking to a minimum; has noticed no benefit. Normal
weight is 165 pounds.

Present Illness.— 7 years ago, on account of loss of weight, extra food was
taken and considerable candy eaten. There was no special appetite, and no
thirst or other symptoms, and the food and candy were taken merely with the
idea of putting on weight. His eyesight then began to fail, and he consulted an
ocuUst who examined the urine and diagnosed diabetes. A diet was later pre-
scribed, and on this he regained some weight. Within a year, however, there
was further loss of weight, and polyphagia, polydipsia, and polyuria were pres-
ent. He then spent 10 days in a diabetic sanitarium, and became sugar-free for
the first time in 10 months on carbohydrate-free diet with whisky and sodium
bicarbonate. For the past 5 years he has made annual trips to this sanitarium,
remaining for 10 days to 10 weeks at a time. During the past 3 or 4 years he
has not become sugar-free on these trips. During the past year he was worn out
by nerve strain attendant upon a defalcation and a lawsuit. On the last day
of the trial he had to be carried to court on a cot to testify, and has been bed-fast

'The father refused all dietary restrictions, and died of diabetes in Jan., 1919.



CASE RECORDS 267

for the 2 months since that time. He was brought to this Institute from Indiana
with his physician in attendance, and had to be wheeled or carried.

Physical Examination. — Height 173 cm. A well developed, extremely emaci-
ated man, showing evidence of profound weakness but no acute distress. Teeth
in good condition. Throat congested. Slight enlargement of lymph nodes in
left axilla and groins. Knee jerks sluggish. Routine examination otherwise nega-
tive. The most striking feature aside from the emaciation is a lemon yellow color
of the skin, most pronounced on the face, but noticeable also over most of the
body; the conjunctivae are bluish white and not jaundiced, and the urine is
free from bile. The color suggests pernicious anemia. Blood examination
showed hemoglobin 80 per cent, red cells 4,000,000, leucocytes 6,000, with normal
differential count. Lipemia of heaviest degree present; plasma hke cream. Was-
sermann negative. Urine free from albumin and casts. Blood pressure only 70
systolic, diastolic doubtful at about SS.

Treatment. — Because of the extreme weakness and the absence of threatening
acidosis, the patient was given for 2 days a diet Hke that to which he had been
accustomed; i.e., on Nov. 28 and 29 about 100 gm. protein, 20 to 30 gm. carbohy-
drate, and 2000 to 2100 calories. On Nov. 29 he excreted 45 gm. sugar and 2.5
gm. ammonia nitrogen; on Nov. 30 (the first fast-day), 20.5 gm. sugar and 2.78
gm. ammonia nitrogen. Fasting was begun on Nov. 30, with some misgivings on
account of weakness. Because of tendency to nausea only 30 gm. alcohol were
given the first day, increased to 70 gm. by Dec. 5. Glycosuria was absent by
Dec. 5, and the ammonia nitrogen had diminished to 0.88 gm. (total N output
3.83 gm.). The ferric chloride reaction was much diminished but still well
marked, and the blood plasma was still intensely lipemic. The patient's strength
showed no dechne whatever on account of the fasting, and possibly a slight im-
provement. He was able to sit up in bed to read, and could walk to the bath-
room with assistance. The fasting was therefore prolonged through Dec. 6,
making 6 days. On Dec. 7, one egg, 10 gm. butter, and 500 gm. thrice cooked
vegetables were added to the whisky. This was increased daily, so that on Dec.
10 the intake was 52 gm. protein and 1450 calories. On this diet a glycosuria
of 9.9 gm. appeared. A fast-day with 100 cc. whisky on Dec. 12 failed to clear
up the glycosuria. Only one egg and 20 gm. butter were added to the whisky
on Dec. 13, yet glycosuria persisted. On Dec. 14, another fast-day with 140
cc. whisky cleared up the sugar and the ferric chloride reactions. On Dec. 15, a
diet of only 17 gm. protein and 600 calories (450 of which were alcohol) caused
glycosuria of 2.61 gm., this sugar being doubtless partly attributable to the 1000
gm. thrice cooked vegetables allowed for the sake of bulk. This glycosuria per-
sisted under similar conditions on Dec. 16, so that a fast-day with 140 cc. whisky
became necessary on Dec. 17. . Beginning Dec. 18, all vegetables were omitted
in the attempt to build up strength. A diet was given on Dec. 18 and 19 of 52
gm. protein in the form of eggs, 420 calories of alcohol, and olive oil to bring the
total calories up to 2600. The ammonia excretion rose, and persistent traces of
glycosuria appeared. The diet was sharply reduced, so that on Dec. 21 it con-



268 CHAPTER III

sisted of only two eggs and 130 cc. whisky. The eggs were increased until on
Dec. 26 seven were given. Though such diets were frequently below 1000 cal-
ories and composed largely of alcohol, traces of glycosuria remained persistent.
It became established during this time that the patient could not tolerate even
the carbohydrate of 200 gm. thrice boiled vegetables such as celery or Brussels
sprouts, and the protein of six or seven eggs also sufficed to cause glycosuria.
Under such circumstances the prospects for nourishing a patient already seri-
ously weak seemed hopeless. But the notable feature was that the patient's
strength and spirits continually improved during the time when he should theo-
retically have been starving. He became able to sit up in a chair, but was con-
fined to bed almost continuously under orders.

On Jan. 5, 50 cc. whisky, 200 gm. thrice boiled celery, and 100 gm. thrice
boiled asparagus were taken without glycosuria. On Jan. 6, meat and bacon were
added, and the diet was 20 gm. protein, 600 gm. thrice boiled vegetables, and 480
calories. This was tolerated, but on the next day (Jan. 7) 36 gm. protein and
900 calories with only 400 gm. thrice boiled vegetables (celery, spinach, and Brus-
sels sprouts) caused glycosuria. Diets of this sort or lower were continued, with
almost continuous slight glycosuria. The carbohydrate intake shown by the
graphic chart Jan. 21 to 28 was in the form of caramel, which was tolerated in
quantities of IS to 30 gm. daily without glycosuria. Under these low diets the
body weight gradually fell, while the strength slightly increased and the ferric
chloride reactions became pale or negative. With the progressive improvement
it became possible early in Feb. to raise the diet to approximately 68 gm. pro-
tein and 1400 calories, 250 of these being alcohol calories. In the latter part of
Feb. the intake could be markedly increased, and in Mar. and Apr. the diet ran
as high as 80 to 90 gm. protein and 2500 calories (of which 250 were alcohol)
and 200 to 300 gm. thrice cooked vegetables. With this there was a fast-day
weekly. During Feb. the patient was allowed out of bed, and in Mar. he was
encouraged to make trips from the hospital for exercise. On Mar. 12, he was
able for the first time to walk a mile. Thereafter he took steadily increasing
exercise, and high diets were allowed not only to build up strength but also to
support muscular activity. Glycosuria was limited to bare traces demonstrable
only in certain fractional specimens of certain days and not in the mixed 24
hour urine. But at the beginning of Apr. a more definite glycosuria appeared,
also the blood sugar on Apr. 3 was 0.27 per cent. Accordingly food was stopped,
making the diet on this day less than 900 calories. On Apr. 4 only 130 cc. whisky
were given, and on the following days only whisky and soup. After these 3
days of practical fasting, the blood sugar was down to 0.1 per cent.

Then on Apr. 7, 5 gm. carbohydrate were given in the form of green vege-
tables, and these without other food were increased on the following days, until
50 gm. carbohydrate were taken without glycosuria (Apr. 10). On Apr. 12, the
high protein-fat diets with weekly fast-days were resumed, with resultant hyper-
glycemia, so that on Apr. 28 the blood sugar was 0.31 per cent. Accordingly 4



CASE RECORDS 269

days of absolute fasting were imposed, followed by a carbohydrate tolerance test
in regular form. The tolerance was found to be almost 100 gm. carbohydrate.
Up to May 20 diets were given below 1500 calories, containing 10 to 15 gm. car-
bohydrate. Then, because of glycosuria and hyperglycemia, carbohydrate was
omitted, but resumed again in June. By this time the patient could tolerate a
daily ration up to 80 gm. protein, 20 gm. carbohydrate, and 2000 calories, with
an absolute fast-day each Sunday. He was dismissed on such a diet, with the
carbohydrate diminished to 15 gm. The urine was normal, and the clinical
condition, aside from the emaciation, was good.

Acidosis. — The excretion of as much as 2.75 gm. ammonia nitrogen at first in-
dicated a rather marked acidosis, but dangerous symptoms were never present.
An intense ferric chloride reaction was present, and there was the usual odor of
the breath, but no dyspnea. As shown in the graphic chart, t|he ammonia rap-
idly fell during the initial fast. On Dec. 8 the ammonia nitrogen was 0.74 gm.
and the ferric chloride reaction was negative. Protein-fat diet, together with
the use of whisky, sent the ammonia nitrogen up to 1.68 gm. on Dec. 11. It
then fell promptly when the diet was reduced, and beginning Dec. 18 rose still
higher as the diet was made higher than before, reaching the summit on Dec. 21.
It again fell with reduction of diet, and even on the large carbohydrate-free diets
of Mar. and Apr. never returned to the former height. The ferric chloride reac-



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 28 of 76)