Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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tion became consistently negative in the period Jan. IS to 28. Many of the
traces indicated elsewhere were only tinges of color in individual fractions of the
24 hour specimens. For the sake of improvement ia strength, the above men-
tioned high diets of Mar. and Apr. were continued in spite of the well marked
ferric chloride reactions which they produced, with the idea that as long as the
tolerance was rising and the urine kept sugar-free, the mUd acidosis could be left
for disposal in the future. The curve of the blood bicarbonate, beginning Jan. 24,
also reveals the slight chronic acidosis. Alkali was seldom used. 15 gm. sodium
bicarbonate were given on the day of admission; also, toward the close of the initial
fast, 15 gm. on Dec. 2 and 3, and 5 gm. on Dec. 4, all as precautionary measures.
On Feb. 19, 10 gm. bicarbonate left the urine slightly acid. On Feb. 20, 20 gm.
turned the urine alkaline. Likewise the carbon dioxide capacity of the plasma
rose within the lower normal limit on Feb. 20 for the first time. It was still
approximately at this level on Feb. 22, following the fast-day of Feb. 21. But
then, because of the high fat diet or merely loss of the administered alkali, it fell
steeply to the lowest value yet observed; namely, 40 per cent on Feb. 24. It
promptly rose agaui on Feb. 25 without the use of alkali, and the tendency now
to remain closer to the normal level may be interpreted as one indication of the
general improvement. The fasting and minimal diets Apr. 3 to 11 brought
another sharp fall, but thereafter on Apr. 15 it rose still higher than before.
Again the fasting of Apr. 29 to May 2 brought another sharp drop below normal,
followed by a rising tendency; so that on a moderate total diet containing a small
quantity of carbohydrate the blood alkalinity at the last determination on June



270 CHAPTER in

24 was fully normal and higher than at any point in the entire previous record.
Correspondingly the ammonia output was within normal limits, and the ferric
chloride reaction in the urine had become consistently negative.

Alcohol. — ^Whisky was given in moderate quantities for the sake of keeping up
strength. It seemed clearly beneficial for this purpose. The patient felt less
well with larger doses, and it was never pushed to any high quantity. There is no
evidence of any effect ia clearing up acidosis. After Apr. 7 alcohol was (as in
all cases when possible) discontinued altogether. The clearing up of the acidosis
progressed uniaterruptedly, so that the impression is created that the alcohol
was without influence in this regard.

Blood Sugar. — A solitary determination on Jan. 25 showed a strictly normal
value of 0.1 per cent. No fiulher analyses were made until Apr. 1, when the
level was 0.145 per cent. The diets had been high, and at this time were raised
to the maximum; namely, almost 3000 calories on Apr. 2. The result was glyco-
suria, with hjrperglycemia of 0.27 per cent on Apr. 3. The subsequent 3 days
of fasting and alcohol brought the blood sugar down to 0.1 per cent on Apr. 6.
On Apr. 8, with carbohydrate feeding, it rose promptly to 0.182 per cent without
glycosuria. On the ensuing carbohydrate-free diet of 2200 to 2S00 calories it
rose steadily higher, up to 0.312 per cent on Apr. 28. 4 days of fasting restored
a normal value of 0.118 per cent in the plasma on May 3. It will be noticed
that in these periods of feeding and fasting the rise and fall of the blood sugar
and body weight were parallel. A small amoimt of carbohydrate in the diet
from May 11 onward was in excess of the true tolerance, as indicated by the rising
blood sugar, which reached 0.20 per cent on May 18; and though it still rose to
0.232 per cent on May 22, the omission of carbohydrate and a fast-day on May
23 brought a fall to 0.138 per cent on May 24. With restoration of carbohydrate
in the diet the blood sugar again rose, reaching 0.2 per cent on Jime IS. In gen-
eral, it is seen that the hyperglycemia is a more delicate index of the tolerance
than the glycosuria. On the other hand, it is by no means a sole criterion of the
condition or progress. The normal blood sugar of Jan. 25 was the result of 2
months of semistarvation. At later periods the blood sugar was higher, though
the patient's diabetes was definitely improved, in the sense that he could tolerate
more of all classes of food and more easily remain free from both glycosuria and
ketonuria. In other words, an identical diet would doubtless have caused greater
hyperglycemia in Jan. than in June. The hyperglycemia at the time of discharge
was the one noticeably abnormal feature in the condition, but, as the subsequent
experience showed, it could be borne by such a patient without preventing the
general tendency to improvement under treatment.

Body Weight. — ^The patient, whose normal weight was 75 kg., entered weighing
44.2 kg., i.e., 59 per cent of his normal weight, or a loss of 30.4 kg. During
fasting his weight rose by water retention, the sodium bicarbonate of Dec. 2 and
3 probably being responsible for the summit of the weight curve on Dec. 3. The
rise of weight was accompanied by well marked edema of the ankles. The patient



CASE EECOEDS



271



stated it had been present at former times to a still greater extent. With the
continuous undernutrition there was a sUght progressive fall in weight, the lowest
point being 39.8 kg. on Feb. S. Thereafter with the increased diets the weight
steadily rose, so that the patient was discharged on June 28 at precisely his
entrance weight of 44.2 kg.

Nutrition. — ^The salient feature is the degree of undernutrition imposed upon a
patient already extremely emaciated and weak. The patient himself had not
expected to hve. Notwithstanding this state of weakness, he not only with-
stood a 6 day fast successfully, but also bore 2 months of radical undernutrition
thereafter.

From Nov. 30 to Feb. 2 the following calculation can be made.





65 days.


Per day
(average).


Per day
per kg.*




1655.8 gm.
264.9 "
23362
28249
51611


25.40 gm.
4.07 "
359.4
434.6
794.0


5.80 gm.
0.09 "
8.00


Total nitrogen in diet

Alcohol calories


Food "


10.00


Total "


18.00







* On 44 kg. weight.

The case at first seemed hopeless, with the combination of emaciation and
weakness on the one hand and inabUity to tolerate a living diet on the
other. The extreme restrictions necessary for controlling the diabetes were
rigidly carried out, and the unmistakable gain in strength along with loss of
weight under these conditions was the most surprising feature. At dismissal,
with the identical body weight as at entrance, the physical condition was trans-
formed. The man had come as a helpless bedridden invahd supposedly at the
point of death. At discharge he was stiU very thin, and strangers regarded him
as having tuberculosis or cancer, but he was able to make the trip to his home
unattended and carry his two heavy suitcases without assistance.

Subsequent History. — ^The patient resumed his business duties and also took con-
siderable daily exercise as instructed, chiefly in the form of walking. He remained
free from glycosuria and other symptoms, with continuous improvement in
strength and health, untU he committed a few minor indiscretions in diet, con-
sisting only in the addition of a few eggs and vegetables beyond the prescribed
quantity. Persistent glycosuria resulted, which did not stop on omitting aU
carbohydrate or on the routuie fast-days. He reported his condition promptly
and was advised to return to the hospital.

Second Admission. — ^The patient returned Oct. 17, 1915, weighing 45.2 kg.;
i.e., a gain of 1 kg. The glycosuria and ketonuria on his regular diet were both
rather heavy. The ammonia nitrogen was up to 1.54 gm. The carbon dioxide
capacity of the plasma was as low as 46 per cent, and the plasma sugar was 0.35
per cent. But the physical strength was still as good as at discharge, and the



272 CHAPTER in

task of treatment was far easier than before. Blood pressure 102 systolic, 82
diastolic.

After 1 week of observation on the diet which had been tolerated at the former
discharge, fasting was imposed Oct. 24 to 31. The urine was sugar-free on Oct.
30. On Nov. 1, 10 gm. carbohydrate were given in the form of green vegetables,
followed by the usual increase of 10 gm. daily, and definite glycosuria appeared
with 40 gm. carbohydrate. This may be compared with the 100 gm. tolerance
in the previous May and with the zero tolerance at the outset of treatment.

Beguming Nov. 8, a diet of 75 gm. protein, 5 gm. carbohydrate, and 1800
calories caused glycosuria. Therefore carbohydrate was omitted, and the protein
diminished to 50 gm., and total calories to 1300. This diet represented approxi-
mately 1.1 gm. protein and 30 calories per kg., but the weekly fast-days brought
the average down to approximately 0.9 gm. protein and 26 calories per kg. — a
low diet especially in view of the rather vigorous exercise which the patient was
encouraged to take. Nevertheless, the blood sugar remained unduly high and
traces of glycosuria were frequent.

Beginning Nov. 25, an attempt was made to mcrease protein while keeping
the total calories the same by subtracting an equivalent of fat. The protein was
thus gradually raised to 110 gm. on Nov. 30, the calories remaining 1300. The
blood sugar rose markedly, and glycosuria appeared with 100 gm. protein on
Nov. 29.

Beginning Dec. 12, radical undernutrition was maintained imtil Jan. 7 in
the most favorable manner possible, namely by restriction or almost complete
exclusion of fat. The protein was at first kept unchanged at SO gm. On Christ-
mas day as a special indulgence, 85 gm. protein were granted to allow the patient
to enjoy turkey. After Jan. 28 the regular protein allowance was 60 gm. Owing
to exclusion of fat, the total calories were only 300 daily up to Dec. 17. For the
week of Dec. 20 they were increased to 600 by addition of alcohol. By increase
of protein and fat they were brought up to 1000 on Jan. 3 to 6. The most strik-
ing effect of the exclusion of fat was not upon the ammonia but upon the blood
sugar, which was brought well within the normal limits. Also the tolerance was
improved, so that beginning Jan. 8 the patient was able to tolerate a diet of 70
gm. protein, IS gm. carbohydrate, and 1900 calories. The body weight was
down to 43.2 kg., or 1 kg. less than at the former discharge, but the strength
and general condition were better than at any former time. The patient was
discharged on Jan. 18 to resume his business in his home town.

Acidosis.— As mentioned, the ammonia output and carbon dioxide capacity of
the plasma indicated a slight acidosis on admission. The high point of the am-
monia nitrogen at 2.5 gm. on Oct. 26 does not necessarily mean that the ammonia
rose on fastmg. The only previous determinations had been on Oct. 17 to 18,
and it is possible that toward the close of the week of feeding the ammonia was
higher than on Oct. 26. After this date the ammonia fell sharply, and reached
a still lower point with the carbohydrate tolerance test on Nov. 3. With protein-



CASE RECORDS 273

fat diet it again shot up to 2.5 gm. N on Nov. 11. On Nov. 15, following a
fast-day, it was again found at the lower level of 0.7 gm., rising again with pro-
tein-fat diet. But as this diet was only 1300 calories, the ammonia remained de-
cidedly lower than it had been with 1800 calories. Thereafter the curve slopes
gradually down to the normal output of 0.35 gm. at discharge. The ferric chlo-
ride reactions were easily cleared up and remained negative. The carbon dioxide
capacity rose with fasting to the lower normal limit on Oct. 30. With a slight
fluctuation it came safely up within normal values with the carbohydrate tol-
erance test on Nov. 5. With the 1800 calory diet composed chiefly of fat, it fell
steeply below the lower normal level on Nov. 10. Thereafter it fluctuated above
and below the lower normal limit. The highest value, namely 71.6 per cent,
was shown on the fast-day of Dec. 12. At discharge it was exactly at the lower
normal limit of 55 per cent.

Blood Sugar. — ^At admission the plasma sugar was 0.35 per cent, and with con-
tinuance of observation diet reached 0.43 per cent on Oct. 21, and 0.44 per cent
on Oct. 22. It fell sharply on fasting, so that on the second fast-day (Oct. 25)
it was down to 0.17 per cent. The succeeding fluctuations are not explained.
The behavior for several days is so bizarre that the accuracy of some analyses is
called into question. But on Oct. 29, the day when glycosuria ceased, the
plasma sugar had fallen to 0.23 per cent. With the carbohydrate tolerance test
it rose to 0.325 per cent on Nov. 4. On Nov. 8, following the fast-day of Nov. 7,
it was down to 0.2 per cent. The diiet of 1800 calories caused a rise to 0.44 per
cent on Nov. 11. Thereafter, with the diet of 1300 calories, it wiU be seen that
the sugar tended to be up during the week and down on the morning after the
weekly fast-day, but hyperglycemia was continuous. The rigorous undernu-
trition beginning Dec. 12 was what definitely brought the blood sugar down
within normal limits. On the hberal diet with 15 gm. carbohydrate at discharge, '
hyperglycemia again resulted to the extent of 0.16 per cent plasma sugar. This
was the one unfavorable feature at discharge.

Exercise. — Beginning Nov. 11, the patient was exercised daily to the point of
exhaustion, being required to walk up and down 8 flights of stairs 6 times daily,
walk 3 or 4 miles, and toss a 6 pound medicine ball for half an hour daily. With
this amount of labor the diet of 1300 calories was definite undernutrition, yet
neither the body weight nor the blood sugar diminished very perceptibly. The
clinical condition was rather unfavorably affected, however, and the patient was
tired and exhausted from the prolonged exertions. Therefore, beginning Dec. 12,
he was kept in bed during the period of marked undernutrition, and gained in
well-being by reason of the rest. With the higher diets which began in Jan.
he was allowed to take moderate exercise, and was advised to continue this at
home. -

Subsequent History. — ^The patient remained at home from Jan. 18, 1916, to
June 25, 1917, and during this time missed only 6 days from his regular busi-
ness, in consequence of slight additions to the diet, or on two occasions because



274 CHAPTER m

of colds. The weight was up to 48.1 kg. One of the colds mentioned then caused
a setback requiring slight reduction of diet, so that during the summer the
weight was approximately 46 kg. On Jan. 13, 1917, at the patient's request,
he was allowed to diminish his diet from 1900 to 1500 calories, which he said
satisfied him, and on this basis he omitted the weekly fast-days. On May 31,
1917, a telegram was received from the patient stating that he had yielded to a
holiday temptation to eat strawberry shortcake and pie, and was showing heavy
glycosuria in consequence. He was instructed to fast himself sugar-free, and
did so successfully. On June 13, he accidentally increased his diet by 300 calories,
and showed a trace of sugar in consequence.

Third Admission. — On June 25, he appeared unexpectedly at the hospital,
stating that he had decided to travel for a change, and had dropped in to report,
and to stay for examination if desired, especially as he was now finding trouble in
remaining sugar-free after his recent indiscretions. The weight was 45.5 kg.
Although slight glycosuria and ketonuria were found present, the condition was
now very simple from the therapeutic standpoint, and the opportunity was em-
ployed to carry out a test of the effect of fat feeding, as described in Chapter VI.

Remarks. — The heavy Upemia which was such a striking feature of this case at
the outset would have been an interesting feature to study chemically if
circumstances had permitted. Presumably it was responsible for the remark-
able yellow color of the patient, but this color persisted with Uttle diminution
long after the blood plasma had become entirely clear. This color of the skin
was very well marked at the second admission. By the third admission it had
almost entirely disappeared and the complexion had begun to look normal.

Also, though the weight was only 1.3 kg. more than at the original admis-
sion, the face and bearing were different. The patient was stiU excessively
thin, but with the change in facial expression, complexion, and energy of move-
ment, strangers no longer looked upon him as a sick man, and he behaved in all
respects like a normal person. The outcome is therefore a satisfactory one un-
der the circumstances. The diabetes seems to be under control, and any mani-
festations appearing can in each instance be cleared up more easily and quickly
than on former occasions — one indication of favorable progress. The diabetes
was genuinely severe, as demonstrated by the prolonged mtolerance of food and
by the enture history. The heavy hpemia may probably be included among the
symptoms of severity. Death must have resulted within a brief period in the
absence of radical treatment. The ultunate prognosis in a case at this age is
generally better than in younger persons, and the tendency to improvement
seems more permanent and genuine.

This patient furnishes another example of the absence of any perceptible
spontaneous aggravation in a very severe case of diabetes under observation for
2i years; but the possibility of downward progress due .to chronic pancreatitis may
yet have to be considered. The patient describes himself as feeling better than
for many years past. He carries on his work successfully and enjoys life. Fur-



CASE RECORDS 275

thermore, he has had no more attacks of cold and grippe than at periods before
his diabetes, and no greater difficulty in recovering from them. Notwithstanding
the still low tolerance, the outlook at the present time appears favorable for some
time to come.

CASE NO. 25.

Female, married, age SO yrs. Austrian Jew; housewife. Admitted Nov. 28,
1914.

Family History. — Parents lived to old age. Four brothers and two sisters are
well. No heritable disease in family. Patient has been married 28 years. Had
six children and later three miscarriages. One child died of diphtheria, another
in an accident; the other four are well, aged 13 to 26 years.

Past History. — ^Healthy life. Patient came to United States from Austria at
age of 28 and has lived in fairly hygienic surroundings. Erysipelas, in 1912
and again in Jan., 1914, was practically the only infection. Venereal disease
denied, although 3 years ago a general eruption is said to have appeared over the
whole body and disappeared after a few days. 8 or 9 years ago, left-sided hemi-
plegia occurred suddenly and improved gradually within 6 months. A second
stroke occurred in Jan., 1914. Edema of ankles has been noticed during past 2
years. Habits have been regular. No alcohol or other special indulgence.

Present Illness. — 3 years ago a routine urine examination revealed sugar.
Since then one test every month has always shown sugar but never acetone. For
2 years past there has been dyspnea and palpitation on slight exertion, so that
she has been practically confined to her house. Dyspnea also has frequently
made her unable to sleep lying down at night, so that she has had to stay in a
chair. No polyphagia, polydipsia, or polyuria. She has been on a lax anti-
diabetic diet of protein, fat, and green vegetables unrestricted in quantity, and
two roUs and a slice of bread daily. Weight 3 years ago 211 poimds, now 186
pounds. 1 week ago the patient went to a hospital clinic, and was ordered to
stop carbohydrate. Thereafter she began steadily to feel worse and has shown
a progressively increasing stupor during the past few days, with nausea which
has led to vomiting during the past 2 days.

Physical Examination. — A large framed, obese woman lying in bed in a stu-
porous condition and irrational when roused. The odor of the breath is partly
sweetish, partly foul. Some dyspnea is present, but seems of a panting and ner-
vous type rather than Kussmaul air-hunger. The face is sHghtly edematous and
pits on pressure. Exophthalmos and apparent photophobia. Pupils react to
light and accommodation. No jaundice. Pyorrhea and receding gums. Tonsils
slightly enlarged. Signs of slight left-sided paresis. Thyroid lobes hard and
definitely palpable; isthmus not felt. Lymph nodes not enlarged. Some bron-
chitis and emphysema. Cardiac dulness extends 4 cm. to right of midstemal
line and 13 cm. to left in fifth interspace. Soft systoHc blowing murmur at apex.
Aortic second sound markedly accentuated. Walls of radial arteries not pal-
pable. Abdomen obese and flaccid, negative to examination. Knee and Achilles



CASE RECORDS 277

On Dec. 9, this was increased to two eggs and 20 gm. butter; and though no
vegetables or other sources of carbohydrate were given, a trace of glycosuria
appeared, and continued when one egg was given on Dec. 10 and two eggs on
the subsequent days. The protein intake ranged from 15 to 46 gm. and the
total calories averaged well below 1000, even including alcohol, until on Dec.
17 and 18 a diet of eggs and olive oil was given, without vegetables or whisky, rep-
resenting 44 to SO gm. protein and 1900 to 2000 calories. Such diets sufficed to
maintain a continuous glycosuria. This cleared up when nothing but two eggs
was given on Dec. 20. But on Dec. 21, the feeding of only 80 gm. asparagus,
containing 2.2 gm. carbohydrate, caused a trace of glycosuria. To clear this up
3 fast-days with whisky were necessary, on Dec. 24 to 26. Then, on Dec. 27,
the feeding of two eggs and 500 gm. thrice boiled vegetables brought back a
decided trace of glycosuria. After omission of all vegetables, the frequent traces
of glycosuria still continued on low diets Umited to eggs, olive oU, soup, and
coffee, none of these diets containing more than 52 gm. protein and 1300 to 1950
calories. The subsequent treatment represented a continuance of such under-
nutrition. The principle was adopted of giving protein to conserve body nitro-
gen and alcohol to assist weakness, while keeping fat and calories at a very low
figure and compelling the patient to burn off her body fat.

She remained almost without appetite, and on Feb. 4 mentioned being hungry
for the first time. The ferric chloride reaction was much diminished and the
occasional traces of sugar were only very faint reactions in fractional specimens
on certain days. The patient was desirous of continuing treatment at home, and
as all immediate danger was over and the one necessity was merely a continuance
of undernutrition, she was allowed to go out on a diet of 1250 calories, 350 of which
were alcohol. She was instructed to take a fast-day whenever sugar appeared and
once every 2 weeks if it did not appear. She was also warned against constipa-
tion and was encouraged to take exercise. At the time of discharge she was be-
ginning to take short walks, which tired her considerably. Aside from the
weakness, symptoms were absent and she felt well.

Second Admission. — Feb. 11, 1915. The patient was readmitted 5 days after
discharge. She had followed her diet but had had no bowel movement during
this time. The former symptoms recurred in milder form, and she was drowsy and
vomiting occasionally when received. The glycosuria was 0.6 per cent, and the
ferric chloride reaction was heavier than at discharge. A low ammonia value
was found on Feb. 13 after 3 days of fasting. There was no albuminuria, but the
face and ankles were again puffy and pitted on pressure. Blood pressure 170
systolic, 110 diastolic. 30 gm. sodium bicarbonate may have played a part in
the edema. The treatment was carried out on the same lines as before, the
most important feature being the purgation with 2 gm. compound jalap powder
daUy, which yielded the same enormous stools as before. The first 12 days in
hospital, up to Feb. 23, represented almost continuous fasting. 200 calories of
alcohol were given almost daily during this entire period in hospital. The acute



278 CHAPTER ni

sj^nptoms passed off easUy. The food tolerance was obviously higher than be-
fore, and a more liberal diet was gradually built up, finally reaching 83 gm. pro-
tein and 2000 calories at the time of discharge on Mar. 25. Traces of glycosuria
were frequent but easily controDed. Albuminuria was constantly present after
the initial days. The blood pressure on Feb. 16 was 205 systolic, 130 diastolic;
on Feb. 20, 185 systoKc, 140 diastolic. The patient was feeling stronger and in



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 29 of 76)