Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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Only shght glycosuria was present, and only a moderate ferric chloride reaction.
She was admitted in the afternoon and received supper consisting of soup, 100 gm.
steak, and 100 gm. raw and 100 gm. thrice cooked vegetables. She was men-
struating, and had slight diarrhea. A phenolphthalein tablet and 15 gm. mag-



CASE RECORDS 295

nesium sulfate produced small liquid or soft movements which continued undSr
small doses of cascara on the following days. On the first full day in hospital
(Jan. 31) the diet consisted of 81 gm. protein, 5 gm. carbohydrate, and 1650 cal-
ories. Glycosuria was entirely absent, the ferric chloride reaction still only
moderate, and the condition apparently satisfactory. The next day, Feb. 1,
the diet consisted of SO gm. protein, 12 gm. carbohydrate, and 1250 calories. The
patient showed slight nausea. On Feb. 2, the diet consisted of coffee, soup, one
egg, and 600 cc. milk, representing 27 gm. protein, 30 gm. carbohydrate, and 500
calories. Nausea had increased, and on this day the patient vomited once a
little undigested food. She said she had often had such attacks with her indi-
gestion in the past. With small doses of chloretoUe, also a Seidlitz powder fol-
lowed by a saline enema which removed considerable feces, the nausea seemed
greatly diminished. Meanwhile a trace of glycosuria had appeared from the
carbohydrate, and the ferric chloride reaction had become intense, but the highest
ammonia nitrogen output (Feb. 2) was 1.9 gm. On Feb. 3, the diet was limited
to 300 cc. clear soup, 300 cc. milk, and 90 cc. whisky. The patient also received
3 cc. aromatic cascara, 30 cc. Pluto water, and 10 gm. sodium bicarbonate. On
Feb. 4, as glycosuria and ketonuria were well marked and the patient was slightly
nauseated, a fast-day was given, the entire intake being 150 cc. coffee, 130 cc.
whisky, 15 gm. sodium bicarbonate, 3 cc. aromatic cascara, and 30 cc. Pluto
water. Though the urine remained acid, the glycosuria diminished to a trace,
ammonia fell to 0.87 gm. N, and the CO2 capacity of the plasma, which had been
only 35.8 per cent on Feb. 2, rose to 57.7 vol. per cent on Feb. 4. Feb. 5 was also a
fast-day, the intake being 140 cc. whisky and 15 gm. sodium bicarbonate. The
urine remained acid. In the morning the patient felt well; toward evening she
was slightly dizzy and nauseated. Feb. 6 was also a fast-day with 125 cc. whisky
and 25 gm. sodium bicarbonate. The symptoms were more alarming; the tem-
perature was 99.2°F., the pulse 90, the respiration 20; the pulse was weak, and the
patient complained of dizziness and vomited several times. Two doses of 0.5
gm. chloretone were given for the vomiting, and 2 gm. compound jalap powder
to empty the bowels further, though there had been one or more defecations
every day.

On Feb. 7 only 25 cc. whisky could be taken because of nausea. Vomiting
continued notwithstanding the use of a variety of routine measures, and weakness
was becoming serious. The temperature first was as high as 99.8°, but fell by
the close of the day to 96°. The pulse ranged 100 to 130, the respiration 28 to
44. Caffeine was administered at intervals subcutaneously, and later camphorated
oil. An attempt also was made to feed, and milk, eggs, and beef juice were
given and partly vomited. 1 liter of 4 per cent sodium bicarbonate solution was
successfully given by the rectal drip method. The patient had become very
drowsy, almost unconscious.

On Feb. 8, eggs and beef juice were continued, as also the caffeine and cam-
phorated oil. Levulose was also given in small doses totahng 140 gm.; it was



CASE RECORDS 295

nesium sulfate produced small liquid or soft movements which continued under
small doses of cascara on the following days. On the first full day in hospital
(Jan. 31) the diet consisted of 81 gm. protein, 5 gm. carbohydrate, and 1650 cal-
ories. Glycosuria was entirely absent, the ferric chloride reaction still only
moderate, and the condition apparently satisfactory. The next day, Feb. 1,
the diet consisted of SO gm. protein, 12 gm. carbohydrate, and 1250 calories. The
patient showed slight nausea. On Feb. 2, the diet consisted of coffee, soup, one
egg, and 600 cc. milk, representing 27 gm. protein, 30 gm. carbohydrate, and 500
calories. Nausea had increased, and on this day the patient vomited once a
little undigested food. She said she had often had such attacks with her indi-
gestion in the past. With small doses of chloretotxe, also a Seidlitz powder fol-
lowed by a saline enema which removed considerable feces, the nausea seemed
greatly diminished. Meanwhile a trace of glycosuria had appeared from the
carbohydrate, and the ferric chloride reaction had become intense, but the highest
ammonia nitrogen output (Feb. 2) was 1.9 gm. On Feb. 3, the diet was limited
to 300 cc. clear soup, 300 cc. milk, and 90 cc. whisky. The patient also received
3 cc. aromatic cascara, 30 cc. Pluto water, and 10 gm. sodium bicarbonate. On
Feb. 4, as glycosuria and ketonuria were well marked and the patient was slightly
nauseated, a fast-day was given, the entire intake being 150 cc. coffee, 130 cc.
whisky, 15 gm. sodium bicarbonate, 3 cc. aromatic cascara, and 30 cc. Pluto
water. Though the urine remained acid, the glycosuria diminished to a trace,
ammonia fell to 0.87 gm. N, and the CO2 capacity of the plasma, which had been
only 35.8 per cent on Feb. 2, rose to 57.7 vol. per cent on Feb. 4. Feb. S was also a
fast-day, the intake being 140 cc. whisky and 15 gm. sodium bicarbonate. The
urine remained acid. In the morning the patient felt well; toward evening she
was slightly dizzy and nauseated. Feb. 6 was also a fast-day with 125 cc. whisky
and 25 gm. sodium bicarbonate. The symptoms were more alarming; the tem-
perature was 99.2°F., the pulse 90, the respiration 20; the pulse was weak, and the
patient complained of dizziness and vomited several times. Two doses of 0.5
gm. chloretone were given for the vomiting, and 2 gm. compound jalap powder
to empty the bowels further, though there had been one or more defecations
every day.

On Feb. 7 only 25 cc. whisky could be taken because of nausea. Vomiting
continued notwithstanding the use of a variety of routine measures, and weakness
was becoming serious. The temperature first was as high as 99.8°, but fell by
the close of the day to 96°. The pulse ranged 100 to 130, the respiration 28 to
44. Caffeine was administered at intervals subcutaneously, and later camphorated
oil. An attempt also was made to feed, and milk, eggs, and beef juice were
given and partly vomited. 1 liter of 4 per cent sodium bicarbonate solution was
successfully given by the rectal drip method. The patient had become very
drowsy, almost unconscious.

On Feb. 8, eggs and beef juice were continued, as also the caffeine and cam-
phorated oU. Levulose was also given in small doses totaling 140 gm.; it was



296 CHAPTER m

retained but had no evident effect. At 4 p.m., 700 cc. 4 per cent sodium bicar-
bonate were given intravenously. At 10 p.m. 100 cc. were likewise given. The
temperature had slowly risen, and continued to rise, reaching 101° F. at 7 p.m.
on Feb. 8, 101.8° at 1 a.m. on Feb. 9, and 104° at 5 a.m. The pulse remained
about 140, the respiration 40 to 48. Toward the close the picture was that of
fully developed diabetic coma. Death occurred at 6:45 a.m. on Feb. 9.

Remarks. — ^This was the first case seen at this Institute showing development
of fatal acidosis on fasting, and the treatment was mistaken because the condi-
tion was unexpected. The very rapid loss of weight, from 56.8 kg. on Jan. 31,
down to 52.2 kg. on Feb. 7, is a significant feature apparently present in all such
cases. One error in treatment is the low fluid intake and correspondingly low
output as shown in the graphic chart. Salts should also have been more liberally
suppUed. But the chief lesson for such cases is to break off fasting when the
first warning symptoms appear, and after a period of some days of feeding to
repeat the fast, which then is well borne. Suitable preparatory feeding preceding
the initial fast will doubtless also prevent all or nearly all such mishaps.

CASE NO. 31.

Male, unmarried, age 35 yrs. American; real estate agent. Admitted Feb.
12, 1915.

Family History. — Mother is well except for occasional rheumatism. Father
died of sarcoma at 62. One brother and two sisters are well; two died in in-
fancy. No knowledge of any family disease.

Fast History. — Patient has lived all his life in New York City in good health
and hygienic surroundings. Measles and whooping-cough in childhood. Gonor-
rhea 10 years ago. SyphiUs denied; two Wassermann tests in the past have
been negative. In 1889, after ^exposure to a great blizzard in winter, the patient
suffered from inflammatory rheumatism in the spring. This returned almost
yearly until 1895, when he received treatment by medicine, which ended the
rheumatism permanently but left him with persistent bad digestion. 12 years
ago he had St. Vitus' dance, which was cured in a German sanitariimi b}'- rest
and arsenic. He has sore throats every year. No excesses in food, drink, or
tobacco. Since becoming diabetic he has lost about 35 pounds weight. For
about a week past he has had pain in the great toe of the right foot.

Present Illness. — 3 years ago debility without other sjrmptoms began. The
urine was found to contain 5 per cent sugar. This gradually cleared up on
carbohydrate-free diet with addition of one sUce of bread at each meal. In 1913
he became worse and was placed in a hospital, where 3 green days cleared up gly-
cosuria. Since leaving the hospital he has constantly had 3 to 5 per cent sugar
in the urine. He continued work up to 4 months ago; since then he has been
physically and mentally incapacitated.

Physical Examination. — Sallow color; only moderate emaciation; acetone odor
present. Teeth in good repair. TonsUs and throat normal. Axillary glands



CASE RECORDS 297

palpable, but not cervical, epitrochlear, or inguinal. Arteries are palpably scler-
otic. Blood pressure 90 systolic, 75 diastolic. Knee jerks sluggish; Achilles jerks
active. The great toe of the right foot shows a slight abrasion. The toe is
bluish in color, cold to the touch, and the skin between it and the next toe is
lifted up by exudate. Examination otherwise negative.

Treatment.— There were 2 days of observation diet. On Feb. 13, the first full
day in hospital, this consisted of 84 gm. protein, 6 gm. carbohydrate, and 1830
calories. The glycosuria on this day was 31.3 gm., and the ferric chloride reac-
tion was strong. Fasting was then begun, particularly with a view to the in-
cipient gangrene. Whisky was permitted in quantities up to 500 calories of
alcohol. On Feb. 17, whisky was diminished to 30 cc, and 9 gm. carbohydrate
were added. Glycosuria, which had been absent, returned in traces and con-
tinued for 2 days longer, though the carbohydrate on Feb. 18 was diminished to
4 gm., and on Feb. 19 only whisky and 350 gm. thrice cooked vegetables were
given. These traces of glycosuria were accidental, or else continued undernutri-
tion brought rapid improvement; for beginning Feb. 20, 40 to 50 gm. carbo-
hydrate in the form of green vegetables were given daily without glycosuria,
vmtil Feb. 25. On Feb. 26, the carbohydrate was diminished to 10 gm. The
whisky was now 170 cc. Glycosuria ceased, but reappeared Mar. 3 on a diet
of 70 gm. protein and 1700 calories without carbohydrate. It became heavier
as the calories were increased to 2300, stopped with the fast-day of Mar. 7, re-
appeared with the carbohydrate-free diet of 2300 calories on Mar. 8, and ceased
when the diet was cut down to 1200 calories Mar. 9 to 11. There were no
vegetables of any kind in these later diets, so the glycosuria was evidently due
to the protein-fat intake. Thrice cooked vegetables were then added and were
at first tolerated, but glycosuria reappeared on Mar. 13, 14, and 15, on diets lower
in protein and calories than those formerly assimilated. Though the vegetables
on these days consisted only of 150 gm. string beans and 100 gm. celery, both
thrice boiled, the glycosuria was evidently due to this trifle of carbohydrate.
This very low tolerance improved with continued undernutrition and the dim-
inution of other elements in the diet. Thus, beginning Mar. 17, the same
thrice boiled vegetables were tolerated, the protein now being 30 gm. and the
total calories 400. This diet was gradually built up and on Apr. 3 a trace of
glycosuria appeared with 75 gm. protein, 200 gm. thrice boUed vegetables (string
beans and asparagus), and 1700 calories. This stopped on the fast-day of Apr.
4; and on Apr. 5, 5 gm. carbohydrate in the form of asparagus, celery, and lettuce,
without other food, were tolerated without glycosuria. Beginning Apr. 6 the
protein was diminished to 40 gm. and the calories to 1400. With this reduction
in protein, not only did the same quantity of thrice cooked vegetables cause no
glycosuria, but also on Apr. 9 and 10 the addition of 10 gm. carbohydrate was tol-
erated. The attempt during the ensuing week (Apr. 12 to 17) to raise the carbo-
hydrate to 20 to 30 gm. and the calories to 1800 resulted in slight glycosuria.
The tendency to glycosuria gradually diminished, and by July 7 the patient had



298 CHAPTER m

become able to tolerate 80 gm. protein, 25 gm. carbohydrate, and 2150 calories
(over 1.5 gm. protein and 40 calories per kg. for a weight of SO kg., but dimin-
ished one-seventh by the weekly fast-days). He was dismissed on this diet in
good condition.

Acidosis. — This was never acutely threatening. The ferric chloride reaction
was fairly persistent. It cleared up with the undernutrition at the close of Mar.,
and returned with the higher diets in Apr., even though carbohydrate was soon
added to these diets. Then, without special change in the diet, the ferric chloride
reaction gradually disappeared and was absent at discharge. 20 gm. sodium bi-
carbonate were given daily Feb. IS to 22. On Feb. 23, it was diminished to 5
gm., and then stopped. The carbon dioxide capacity of the plasma, as far as
observed after Mar. 18, was within or near normal Umits, and was high at
discharge.

Blood Sugar. — ^This fluctuated, but hyperglycemia was the rule. The last
analysis on June 24 still showed 0.165 per cent. It is evident that hyperglycemia
did not prevent continued improvement in tolerance and sjonptoms. Neverthe-
less, this hjrperglycemia is an unfavorable feature. It could doubtless have been
brought lower, but the patient was unintelligent and untrustworthy. For this
reason an ideal result was not considered possible in his case, and a fairly satis-
fying diet was therefore permitted, with some hope that improvement might stiU
be possible, if he remained continuously free from glycosuria.

Weight and Nutrition. — The rise of 5 kg. in weight from Feb. 15 to 23 was
due to edema resulting from the sodium bicarbonate. The weight fell rapidly on
stopping the bicarbonate. Beginning May 31 there was another onset of edema
independent of bicarbonate or other known cause. Albumin and casts were
absent from the urine. The entire gain in weight from May 31 to June 16 was 6
kg. That this was wholly due to fluid retention, apparently from renal cause,
is shown by the prompt fall following June 16, when salt-free diet was instituted.
The entire period in hospital represented undernutrition such that the weight was
diminished by 4 kg. There was clinical benefit instead of injury. Under the
fasting and subsequent treatment the threatened gangrene cleared up smoothly.
Strength was regained, the appearance and color improved, and at discharge the
patient was able to resume his work, in contrast to the state of incapacity at the
time of admission with higher weight and active diabetes present.

Subsequent History. — ^The patient followed diet and showed normal urine for
several months. In Aug. he passed through a severe bronchitis without show-
ing sugar. Toward Oct. he had much business worry, and analysis showed 0.204
per cent sugar in the whole blood and 0.278 per cent in the plasma (probably
more dietetic than psychic in origin, however). The patient rejected the advice
to return to the hospital at this time because of business emergencies which he
must meet. He again reported at the hospital on Nov. 29. Meantime he had
been traveling through other states under conditions which prevented following
diet. The blood sugar was 0.227 per cent, plasma sugar 0.244 per cent. He was



CASE EECOBDS 299

instructed as to becoming sugar-free at home, and on Dec. 5 reported that glyco-
suria had stopped with 1 day of fasting and had remained absent on his regular
diet. The urine on this date was normal, the blood sugar 0.208 per cent,^ the
plasma sugar 0.2S0 per cent. On Dec. 12 a trace of glycosuria appeared, and
the patient therefore fasted on Dec. 13. The urine was normal, the blood sugar
0.178 per cent, the plasma sugar 0.213 per cent. The patient was continually
inclined to carelessness, but felt worse when showing sugar and therefore made
some attempts at following diet. On Dec. 28 he returned to the hospital.

Second Admission. — ^The urine showed slight sugar and ferric chloride reac-
tions. On the observation diet of Dec. 29, comprising 77 gm. protein, 15 gm.
carbohydrate, and 2000 calories, a trace of glycosuria persisted in the early hours
but cleared up before the close of the day. A fast-day was nevertheless imposed
on Dec. 30, followed by a routine carbohydrate test, which fixed the tolerance at
70 gm. carbohydrate. On the subsequent diets entirely unaccountable traces of
glycosuria occurred, and the patient finally proved to be repeatedly violating
diet. On account of his persistent carelessness and disobedience, he was dis-
missed and was referred to a local speciahst, with the idea that he might appre-
ciate treatment more if he had to pay for it.

Remarks. — On the fast-day of Dec. 30 the blood sugar was 0.111 per cent and
the plasma sugar 0.122 per cent. It is seen that the body weight at the second
admission was identical with that at the former discharge. Notwithstanding
repeated indiscretions in carbohydrate, the patient had kept down his total diet
approximately as directed, and the tendency to a lowering of the hyperglycemia,
as hoped for at the previous discharge, had actually shown itself. The case had
been characterized by very low tolerance in the initial period of the first admission,
but, in consequence of the undernutrition then imposed, had become easy to man-
age. The only difficulty was the light-mindedness of the patient. He was dis-
charged in favorable clinical condition, with prognosis governed by behavior.

CASE NO. 32.

Female, married, age 21 yrs. Russian Jew; housewife. Admitted Feb. 18,
1915.

Family History. — Father died when patient was an infant. Mother well at
51. One brother and one sister well. No heritable disease known.

Past History. — Considerable sickness in infancy. Diphtheria complicated by
measles at 2i years. Pneumonia at 3 years. Healthy life since then. Habits
regular. Diet largely carbohydrate, but no sugar. Married 3 years, has a
healthy 2 year old child. The only recent illness was a 2 day attack of tonsil-
litis 2 years ago.

Present Illness.— Last June began polyphagia, polydipsia, polyuria, weakness,
headache, and pains in legs. Recently pruritus vulvae. Menstruation stopped
last Oct. Patient supposed all the symptoms due to pregnancy, and was sur-
prised when a physician found pregnancy absent and diagnosed diabetes. She
was sent to this hospital for impending coma.



300 CHAPTER ni

Physical Examination. — Height 168.5 cm. A well developed and nourished
young woman, with flushed face and drowsy expression. Dyspnea is present;
respiration about 30 per minute. Teeth in fair condition; some pyorrhea. Ton-
sils moderately hypertropMed; the left axillary and epitrochlear glands pal-
pable; cervical and inguinal not palpable. Knee jerks not obtainable; Achilles
jerks present. Blood pressure 100 systolic, 65 diastolic. Faint albuminuria.

Treatment. — Because of the imminent danger of coma, fasting was begun im-
mediately, with some 400 to 600 calories of whisky daily. Th^ patient was con-
scious though sleepy, and not nauseated. On Feb. 18 she received 10 gm.
sodium bicarbonate and 2 gm. compound jalap powder; 30 gm. sodium bicarbon-
ate on Feb. 20 and 21,10 gm. on Feb. 22. She was thirsty, and was able to drink
as much as 3 liters of water daily, but the main reliance was placed on fasting.
Both the glycosuria and the clinical symptoms rapidly cleared up. The urine
became neutral on Feb. 21. Glycosuria was absent on Feb. 23, but the first food
was allowed on Feb. 26. This consisted only of 12 gm. carbohydrate in the form
of green vegetables. By Mar. 6 it had been increased to 50 gm. carbohydrate
without glycosuria. The whisky meanwhile was continued at 500 calories daily.
It might have been well to have pushed the carbohydrate to the point of glycosuria,
with a view to clearing up the remaining slight ferric chloride reaction. But
after the fast-day with whisky on Mar. 7, protein-fat diet was begun. On Mar.
10 whisky was permanently stopped. The diet was gradually built up to 118
gm. protein, 25 to 27 gm. carbohydrate, and 2600 to 2800 calories (approximately

2.4 gm. protein and 52 to 56 calories per kg. on 50 kg. weight, reduced one-seventh
by the weekly fast-days), with only transient traces of glycosuria. She was
dismissed Apr. 7 on a diet of 85 gm. protein, 20 gm. carbohydrate, and 2500 cal-
ories (1.7 gm. protein and 50 calories per kg. reduced by weekly fast-days to

1.5 gm. protein and 43 calories average). This was weU below what she had
seemed able to tolerate. At discharge she was to all appearances entirely healthy.

Acidosis. — ^The carbon dioxide capacity of the plasma was only 26.4 vol. per
cent at admission. Fasting was evidently the most important factor in raising it,
for on Feb. 19, after only 10 gm. sodium bicarbonate, it had risen to 38.5 per
cent. Under the larger doses of bicarbonate it rose still more rapidly to the
high normal figure of 64.6 per cent on Feb. 22. This was an artificial elevation
resulting from the alkali dosage, for with discontinuance of alkali the COa ca-
pacity fell steeply to 45 per cent on Feb. 25. Under the influence of the small
quantities of carbohydrate it rose spontaneously within normal limits, reaching
62.2 per cent on Mar. 4, without the aid of alkali. It fell on the fast-day of Mar.
7, alcohol alone being apparently unable to hold it up. It continued to fall, on
addition of protein and fat, down to 46.5 per cent on Mar. 10. The steep rise to
56 per cent on Mar. ll and 60 per cent on Mar. 12 is perhaps explainable by the
introduction of 75 gm. protein in the diet. From this time the curve tends to
run near or slightly below the lower normal limit, and was barely at this limit
at discharge. The ferric chloride reaction was intense at the outset, diminished



CASE RECORDS 301

rapidly during the fast, and was down to traces during the ensuing carbohydrate
period. The later diet being a high one, this reaction did not become perma-
nently negative in hospital. Notwithstanding the use of alkali, the ammonia
nitrogen on Feb. 19 was up to 3.54 gm. It fell as steeply as the plasma bicar-
bonate rose. Its general course was still downward after discontinuance of
alkali, but with the beginning of protein-fat diet, as the CO2 capacity fell, the
ammonia again rose, up to 1.9 gm. N on Mar. 11, with a fall thereafter, perhaps
partly because of introduction of carbohydrate, perhaps partly because of the
improved condition. No clinical symptoms were associated with the persistent
traces of ferric chloride reaction and chronically low CO2, and the use of alkali
was not indicated.

Blood, Sugar. — ^This was down to 0.128 per cent on the morning of Mar. 22,
following the preceding fast-day. On Apr. 3, at the close of a week of high diet,
it was up to 0.192 per cent. Following the fast-day of Apr. 4, the blood sugar
on the morning of Apr. 5 was found to have returned promptly to the normal
level of 0.117 per cent. At discharge on Apr. 7 it was 0.133 per cent. It could
have been kept rigidly within normal limits, but a gradual fall was hoped for
with continued improvement under suitable diet.

Weight and Nutrition. — ^The initial fall in weight during fasting was moderate,
amounting to 2 kg. in 8 days. The bicarbonate did not produce edema, but
beginning Feb. 26 the green vegetables produced a definite water retention, as



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 32 of 76)