Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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better condition in aU respects than at the former discharge. The diet pre-
scribed to be followed at home was carbohydrate-free, containing 100 gm. pro-
tern (1.5 gm. per kg.) and 1500 to 1750 calories (23 to 26 calories per kg.). It
was considered probable that she could remain free from glycosuria on this diet,
and if so the shght persisting ketonuria would gradually take care of itself.

Subsequent History. — Reports showed that the patient remained sugar-free
and continued to gain in strength and well-being at home. On May 21, her son
telephoned that she had had some sort of stroke during the night and an ambu-
lance surgeon had diagnosed pulmonary edema. Her death occurred the same
day, and the certificate of the coroner's physician assigned chronic nephritis as
the cause. There was no sugar in the urine at any time.

Acidosis. — The acidosis was never quantitatively high, and the coma was
atypical in character. There was the familiar history of onset shortly after
exclusion of carbohydrate from the diet, but constipation seemed to be a more
important factor. More complete analyses of blood and urine would have been
valuable had they been possible at this time. Along with the general food in-
tolerance, the ammonia nitrogen was slow in reaching normal limits, but at the
first discharge was down to about 0.56 gm. At the second admission the figure
0.28 gm. ammonia nitrogen was obtained after 3 days of fasting; there might weU
have been a much higher ammonia earlier in the attack. Such a possibility is
strengthened by the rise to almost 2 gm. ammonia nitrogen with the diet of only
1100 calories on Feb. 26. The ferric chloride reaction became pale toward the
close of each stay in hospital, and accordingly no further attention was paid to
it, since with continuance of undernutrition and freedom from glycosuria it was
certain to become negative.

Estimations of the carbon dioxide capacity of the plasma were made begin-
ning Feb. 23, and confirmed the tendency to chronic acidosis. Inasmuch as so-
dium bicarbonate had been used rather liberally in the opening days of each
hospital period and had presiamably raised the blood alkalinity, there is some
ground for supposing that such analyses if made during the stuporous attacks
would have indicated a true acidosis coma. Subsequently, in the absence of
bicarbonate, the carbon dioxide capacity of the plasma in Feb. and Mar. ranged
between 45 and 53 per cent. There is no evidence that alkali dosage would
have altered the subjective condition, which was good; and the fundamental acido-
sis process could be influenced only by continuance of the undernutrition pro-
gram as adopted, whereas the giving of alkaU would only have masked the lab-
oratory indications.



CASE RECORDS



279



Blood Sugar. — Only one determination was made. This was 0.118 per cent
before breakfast on Mar. 22. There is no evidence of a renal glycosuria, but on
the other hand a continuous h)Tperglycemia seems excluded, notwithstanding
both diabetes and nephritis.

Undernutrition. — During the initial fast, Nov. 29 to Dec. 7, inclusive, the
patient lost 94.3 gm. nitrogen in the urine. Dec. 8 to 11 the ingestion of 7.5 to
15 gm. protein daily left the nitrogen output at its minimal fasting level of about
8 gm. daily. The degree of undernutrition in the first period in hospital is shown
by the following calculations:



Total nitrogen output

Protein intake

Nitrogen " (protein -^ 6.25).
" deficit (output— intake)



13 days.



127.19 gm.
46.70 "
10.35 "
116.84 "



Per day
(average).



9,78
2.60
0.79
8.99





70 days.


Per day
(average).


Alcohol calories . ....


18518
25701
54219


264.5


Food "


495 7


Total "


760 2







Owing to the clinical condition it was not feasible to weigh the patient uritU
Dec. 6, when the weight was 76 kg. The obesity was diminished as rapidly as
feasible by undernutrition, while the body nitrogen was protected as far as pos-
sible by allowing protein in quantities just short of producing any considerable
glycosuria. Fat was the element which was mainly eliminated from the diet,
and general undernutrition and the burning off of body fat was regarded as the
most important therapeutic measure. At the first discharge the weight was 68.4
kg., and at the second admission and discharge respectively it was approximately
66 kg.; i.e., 10 kg. below the first weight. Strength, well-being, and food toler-
ance had risen in proportion to the fall in weight.

Remarks. — The importance of emptying the bowels when there is impending
coma, especially in certain cases, has been pointed out by former writers. In
this instance it seemed the most important therapeutic measure. Though there
were chemical indications of acidosis as above noted, the urine was easily
made alkaline and the actual quantity of acid formed was evidently not great.
A feature of therapeutic interest is the fact that a very obese patient already
suffering from acidosis with nausea and vomiting came through safely with
simple fasting. There is no evidence of any specific value of the alcohol used.
The danger of increased acidosis from fasting in patients of this type is obviously
to be borne in mind; but a coma which comes on with feeding can generally be
treated by fasting. The reduction of the excessive body weight was beneficial



280 CHAPTER ni

from every standpoint. Judging by the threatened coma and subsequent almost
complete intolerance of food, the case might be called extremely severe, but with
mere continuance of undernutrition sufficient to bring the excessive weight
down to normal or slightly below the average normal, the condition would almost
certainly have stood revealed in its true light as one of fairly mUd diabetes. For
this reason, with falling body weight and rising general health, the traces of
glycosuria and ketonuria were ignored to an extent never ventured in younger
patients. Also this patient's nephritis was far more dangerous to her than her
diabetes. The existence of nephritis in no way interfered with the treatment of
the diabetes. Though the blood pressure diminished as the ordinary conse-
quence of hospital care, there is no indication that the nephritis was improved
by the diabetic treatment. It so happened that death came early from some
embolic or other accident, but the case nevertheless Ulustrates the benefit of
proper treatment of diabetes even in the presence of complicating conditions.

CASE NO. 26.

Female, age 14 yrs. American; schoolgirl. Admitted Dec. 7, 1914.

Family History. — No diabetes in family. Mother's mother died of cancer,
and mother's grandmother of "dropsy." Several more remote relatives died of
tuberculosis. Patient's father is healthy, the mother nervous but fairly strong.
There have been no other children and no miscarriages.

Fast History. — Girl has been healthy though rather nervous. Measles at 3,
chicken-pox at 4, mild whooping-cough at 5. She began school at 6th year, was
bright and studious but not overworked. Ate large quantities of candy. Al-
ways constipated. Fairly normal menstruation began at 12. For about 2 years
before the present illness there was frequent twitching of face, limbs, and trunk
during sleep. No such movements when awake.

Present Illness. — In Feb., 1913, the patient had an attack of vomiting after
eating heavily, and for a few days was nervous and without appetite. During
the following 3 weeks polyphagia, polydipsia, and polyuria were noted, also
weariness and sleepiness. Strength then failed progressively until she became
too weak to dress herself. A physician consulted in Mar. diagnosed diabetes and
prescribed carbohydrate-free diet. On this the patient remained sugar-free until
June, but lost weight even though bread and potatoes were gradually added to
diet. Glycosuria then reappeared, but remained absent from June to Dec. on
carbohydrate-free diet. It then became persistent, and a trip was made to
consult a specialist, who placed the patient in a hospital for 2 weeks and allowed
only small quantities of carbohydrate-free food. Glycosuria ceased but keto-
nuria persisted, and all symptoms recurred promptly on returning home. The
family physician then allowed an abundance of carbohydrate. The subsequent
symptoms have been the usual loss of weight and strength, and falling out of much
of the hair. Menstruation ceased with the first period after the onset of diabetes.



CASE RECORDS 281

Physkal Examination. — A tall, emaciated, nervous appearing girl, without
acute distress. Teeth in good condition. Tonsils not enlarged. No lymph
node enlargements. Skin dry. General physical examination negative. Right
knee jerk present, left not obtained. Achilles jerks lively. Blood pressure 105
systolic, 70 diastolic.

Treatment. — ^The glycosuria for 16 hours following admission was 44.5 gm.
On Dec. 8 to 10, under an observation diet of 30 to 65 gm. protein, 3 to 10 gm.
carbohydrate, and 900 to 1300 calories, the urine contained 6.8 to 14.3 gm. sugar
and showed heavy ferric chloride reactions. Fasting was begun Dec. 11, with
200 calories of alcohol daily. Glycosuria was absent in 24 hours. 140 gm. thrice
cooked vegetables were allowed on Dec. 13, 5 gm. carbohydrate in the form of
green vegetables on Dec. 14, and 9 gm. carbohydrate on Dec. 15. A trace of
glycosuria appeared. Nevertheless the vegetables were increased, up to 44 gm.
carbohydrate on Dec. 17, then diminished while two or three eggs were added.
With this continuance of undernutrition the trace of sugar cleared up. On Dec.
26 a diet of 51 gm. protein, 9 gm. fat, and 1200 calories caused another trace of
glycosuria, which cleared up with the fast-day of Dec. 27. Alcohol was discon-
tinued on Jan. 9. It was still given on fast-days to the extent of 200 calories,
up to Feb. 21. In early Jan., diets of approximately 40 gm. protein, 6 gm. car-
bohydrate, and 1000 calories twice caused slight glycosuria, which later cleared
up, and at the end of the month a diet as high as -80 gm. protein, 16 gm.
carbohydrate, and 1700 calories was borne without glycosuria. An attempt
on Jan. 30 and 31 to raise the carbohydrate to 25 gm. resulted in gly-
cosuria, checked by the routine fast-day of Feb. 1. In the succeeding week the
diet was further increased until on Feb. 5 to 6 glycosuria resulted from 90 gm.
protein, 30 to 40 gm. carbohydrate, and 2400 calories. Thereafter still higher
diets were tolerated, but on Feb. 27 glycosuria was produced by 84 gm. pro-
tein, 50 gm. carbohydrate, and 3000 calories. Not only the laboratory findings
but also the weakness and nervousness which were the essential complaints were
improved. Also, on admission there had been a marked albuminuria with
casts, but albumin gradually diminished to a trace and casts were absent. The
patient was discharged on Mar. 6, 1915, on a diet of 25 gm. carbohydrate, 75
to 80 gm. protein (2.5 gm. per kg.), and 2400 calories (almost 80 per kg.). The
regular weekly fast-days reduced the average to approximately 64 gm. protein
and 2100 calories. The prescribed diet was thus below what she had proved
able to tolerate.

Acidosis. — This was at no time threatening. The ferric chloride reaction
diminished as usual and became negative with the low diets of mid- January.
It will then be noted that increase of the total diet brought back well marked
ferric chloride reactions, even though carbohydrate was decidedly increased at
the same time.

Body Weight. — ^This was 31.2 kg. at admission. The undernutrition treat-
ment brought it down to its lowest point of 27.2 kg. on Jan. 26. Thereafter the



282 CHAPTER rn

higher diets produced a rise in weight, so that at discharge it was 30.7 kg.; i.e.,
0.5 kg. less than at admission.

Subsequent History.— The diet was faithfully followed. A few traces of glyco-
suria required a slight diminution of the carbohydrate allowance. On one occa-
sion a trace of glycosuria followed excitement due to having seen a woman run
over by a street car. The physical and psychic conditions remained good and
the patient enjoyed hfe and kept herself interested in various occupations not
involving exertion. Nevertheless, she tended to lose slightly in weight instead of
gaining. Menstruation did not return, but none of the former symptoms of
diabetes was present.

Second Admission. — Oct. 4, 1915, the patient returned to the hospital by
arrangement, for purposes of observation and for testing the effect of exercise.
Height 156.2 cm. Weight 28.8 kg.

The urine was stiU sugar-free, but showed a trace of ferric chloride which
disappeared with a single fast-day on Oct. 5. A tolerance test was then be-
gun in routine manner with 10 gm. carbohydrate in the form of green vege-
tables on Oct. 6. A trace of glycosuria appeared with 130 gm. carbohydrate on
Oct. 19, and persisted with the same intake the next day and with increased in-
take on the following days, notwithstanding the introduction of exercise at this
point in the attempt to raise tolerance. After the clearing up of glycosuria by a
sharp reduction of food on Oct. 24 to 25, a diet was gradually buUt up, with the
usual weekly fast-days. In the week of Nov. 22, a ration of 55 gm. protein, 15
gm. carbohydrate, and 2200 calories was tolerated without glycosuria, but with
ketonuria. With the same protein and carbohydrate, an increase of fat to 2400
calories in the following week brought on well marked continuous glycosuria,
and the damage thus done resulted in a continuance of glycosuria and ketonuria,
notwithstanding a sharp reduction of diet in the succeeding week (Dec. 6 to 11).
Low nutrition beginning Dec. 12 was continued throughout the remainder of the
stay in hospital. From Dec. 15 to Jan. 22, the protein was kept at 60 gm. daily.
The calories at first were 1200, but beginning Jan. 3 were diminished to 850.
Though all carbohydrate was omitted at the same time, this diminution in total
calories brought a complete clearing up of the ferric chloride reaction. Begin-
ning Jan. 24 another carbohydrate tolerance test was made. The assimilation
was found to be 140 gm., a gain of 20 gm. over the previous test. The patient
was discharged Feb. 26 on a diet of 30 gm. carbohydrate, 60 gm. protein (2.26
gm. per kg.), and 1000 calories (nearly 36 calories per kg.). This was reduced
one-seventh as usual by the regular fast-days, making the average daily intake
approximately 1.9 gm. protein and 33 calories per kg.

Acidosis. — The most striking feature is that well marked ferric chloride reac-
tions were produced by high calory diets in every instance, irrespective of whether
these diets contained carbohydrate. On lower diets suited to the patient's actual
tolerance there has been no difficulty in keeping this test continuously negative.
The ammonia excretion is also kept at a low level. The carbon dioxide capacity



CASE RECORDS 283

of the plasma tended to remain near or below the lower normal limit, but was
within normal limits at the time of discharge.

Blood Sugar. — Though this must have been high with the glycosuria resulting
from the carbohydrate test of Oct., yet, as usual when hyperglycemia is pro-
duced only by carbohydrate, it fell quickly, for on Oct. 25, after 2 days of low
diet, it was down to 0.13 per cent. It promptly rose to 0.26 per cent in the
plasma on the next day with continuance of a diet of 1200 calories and 15 gm.
carbohydrate. On the morning of Nov. 1, following the fast-day of Oct. 31, it
was down to the former approximately normal level. The curve ran similarly
through Nov., with hs^perglycemia on feeding and lower values following fast-
days, but with a general upward tendency. The diet up to 2400 calories, ending
Dec. 4, had produced such injury that the reduction to 1500 calories did not
prevent the occurrence of the highest blood sugars of the series; e.g., 0.32 on
Dec. 9 and 0.29 on Dec. 11, with glycosuria. This was one of the reasons for the
ensumg sharp reduction of diet. After 2 days of fasting on Dec. 12 and 13, the
sugar in the plasma on the morning of Dec. 14 was down to 0.155 per cent, and
in the whole blood down to 0.125 per cent. Thereafter the curve ran nearly
within normal limits, except for the sharp terminal rise on Feb. 25 to 0.224 per
cent. This occurred on 40 gm. carbohydrate, and the patient was sent home
with only 30 gm. carbohydrate in the diet. .

Body Weight. — At the second admission this was 2 kg. less than at the pre-
vious discharge, and at the second discharge it had been brought down still
lower. The net result of treatment from the first admission to the second dis-
charge was a reduction of weight by 4.9 kg. At home the patient's weight has
been constantly reported as approximately 60 pounds; i.e., about 27 kg., or 4
kg. less than at her first admission. There has been no appreciable growth in
height, but the patient was already almost as tall as her mother. She is notice-
ably emaciated, but the graphic chart well illustrates that every gain of weight
brought on glycosuria and acidosis. In order to Uve, the patient must keep her
weight down. It is not only inadvisable but impossible to force the weight up,
for any diet exceeding her tolerance as respects food and weight wiU quickly
bring on active diabetic symptoms, which of themselves would lead to loss of
weight.

Exercise. — The second period in hospital was devoted largely to a clinical test
of exercise in this patient. During the carbohydrate tolerance test in Oct. she
was kept at rest until the first trace of glycosuria appeared. She was then ex-
ercised to the limit of her strength, chiefly by climbing stairs and walking, also
by roller-skating and tossing the medicine ball. The glycosuria did not cease,
and no gain in tolerance could be demonstrated. Subsequently high diets were
given, as stated, from the latter part of Oct. to the forepart of Dec; and the
patient, who was moderately strong, was exercised regularly to her utmost ca-
pacity in the attempt to bum off the surplus calories. The low plasma bicarbon-
ate during this time is doubtless due in part to exercise. It proved impossible to



284 CHAPTER in

prevent hyperglycemia and finally glycosuria by this means, and the ferric
chloride reaction became positive when exercise was thus taken to bum up the
fat, though on lower fat intake it was negative even without exercise. Accord-
ingly in Dec. the diet was reduced as above mentioned. Exercise was still
continued.

From Dec. 12, 1915, to Jan. 23, 1916, three influences were present, namely,
carbohydrate abstinence, undernutrition, and hard muscular exercise. Never-
theless, the absence of any noteworthy acidosis is demonstrated by all tests.
The rise of 20 gm. in tolerance shown by the carbohydrate test in Feb. is merely
what might be expected from the undernutrition treatment, and there is no
indication that the 4 months of hard systematic exercise had served specifically to
increase tolerance.

Subsequent History. — ^At the time of discharge the patient was advised to dis-
continue severe exercise and take only as much as she could enjoy. She has
foimd pleasure in spending much of her time in walking, bicycling, and various
forms of active play. What has actually been accomplished by exercise is a
decided gain in strength, general health, and happiness. The change, as com-
pared with the first admission when she was kept nearly at rest, is evident at a
glance, and friends complimented her on her improved color and appearance.
Nervousness and worry are also controlled, and she is enabled to derive some real
enjoyment from life.

Glycosuria has remained absent except for rare traces due to unintentional
excesses; e.g., traces resulted from the use of cream cheese or sugar cured ham.
By June 19 she had lost three quarters of a poxmd in weight, but this was slightly
more than regained by Sept. In the fall she undertook light school work. In
Nov. and Dec. she had two colds and showed traces of sugar several times in
consequence, so that carbohydrate had to be entirely eliminated from the diet on
some occasions. In Apr., 1917, the patient reported having finished the first year
of high school and having easily obtained the highest mark in every subject.
Her diet has been modified to consist of 40 gm. protein, 10 gm. carbohydrate, and
1000 calories. She keeps herself sugar-free without difficulty and knows how to
treat herself if accidental causes bring on traces of glycosuria.

Remarks. — This patient, when received, presented a case of juvenile diabetes
of 2 years standing and considerable severity. The subsequent treatment illus-
trates especially two points. One is the effect of exercise. The case was of
such severity that the deficiency of the pancreas could not be balanced to any
appreciable extent by improved function and activity of the muscles. Accordingly
the carbohydrate tolerance was not perceptibly improved, but the general health
was greatly benefited. Second is the question of growth and nutrition. Here
the clinical experiment was performed of taking this patient, clearing up her
condition radically by undernutrition, so that about the middle of Jan., 1915,
she was entirely free from both glycosuria and acidosis, and then making the
attempt to have her grow and develop. The diets in the latter half of the first



CASE RECORDS 285

hospital period were plarmed to this end. The weight rose, but symptoms shnul-
taneously returned. The diet at this discharge represented approximately 2.25
gm. protein and 80 calories per kg. of body weight. Fasting and modifications of
diet required by the occasional traces of glycosuria absolutely prevented gain or
growth. It is not known whether a specific diabetic deficiency also may be con-
cerned. The net result of this attempt to put on weight was, as stated, that the
patient returned to the hospital 7 months later, weighing 2 kg. less than at
discharge.

After the undernutrition represented by the Oct. carbohydrate test, the diet
was gradually built up, the weight rose with it, and the maximum of weight and
the onset of urinary symptoms coincided (Dec, 1915). Subsequently undernu-
trition diminished the weight and removed all active symptoms. It is obvious
throughout that the total diet was the essential governing factor, and the relative
proportions of protein, carbohydrate, and fat were of minor influence. The net
result to date is that the patient is alive 3 years from the beginning of this treat-
ment, and 4| years from the onset of her diabetes. There is no evidence of any
spontaneous downward progress; neither has there been any fundamental'im-
provement. The cumulative effect of slight strains and accidents may bring
bad results sooner or later. Meantime, the patient is holding her own and is
actually deriving enjoyment from Kfe and carrying on limited activities. The one
requisite is close- control of her diet.*

CASE NO. 27.

Male, married, age 42 yrs. American; clerk. Admitted Jan. IS, 1915.

Family History. — One sister died of cardiorenal disease at 23. Family his-
tory otherwise negative. Patient has been married 18 years and has one healthy
son, aged 15. Wife healthy; one miscarriage about 13 years ago.

Past History. — Healthy life. Good hygienic surroundings. Measles and
chicken-pox in childhood; mild diphtheria at 8; mumps at 18, complicated by
unilateral orchitis. At about 20 there was an attack of jaundice with clay-
colored stools lasting 2 or 3 days. At 26 one attack like acute appendicitis,
which passed off under ice applications in a hospital. There have been indefi-
nite minor attacks since. At 27 patient had fever every night for 28 days, with
one hard chill at the end; then given medicine by family physician and has had
nothing like malaria since. Occasional sore throats; never tonsillitis. Vene-
real disease or exposure denied. Habits regular; no excesses in alcohol, tobacco,
or food. .

* Word has been received of the patient's death in Feb., 1918. The child her-
self was faithful and contented, but the parents concluded to try an independent
experiment to "build her up." The child was kept in ignorance of the glycosuria
which quickly followed the increased diet, and the fatal outcome was due solely
to this foUy of the parents.



286 CHAPTER III

Present Illness. — 8 years ago patient began to feel rather poorly, also had
serious trouble with his teeth. Numerous teeth had to be extracted, and he de-
veloped an infection of the mandible, some of which sloughed away. His physi-
cian diagnosed diabetes. The carbohydrate in his diet was diminished but
other foods were not restricted. Since that time he has had occasional attacks of



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 30 of 76)