Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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often happens, so that the weight on Mar. 2, after practically continuous fasting,
was 1 kg. higher than at admission. This slight but visible edema cleared up
spontaneously and did not return. It wUl be noted that the initial fasting
treatment, which cleared up the impending coma, consisted in 18 days of total
abstinence from food, except the moderate quantities of alcohol and trifle of
green vegetables. The weight fell from 53.2 kg. on Feb. 18 to 49 kg. on Mar.
9, a loss of 4.2 kg. Later with higher diets it tended to rise slightly, but was
only 50 kg. at discharge; i.e., 2.3 kg. less than at admission. It was hoped that
the case was mild enough to permit a moderate gain in weight, and as the patient
had to work, a liberal diet was allowed as described.

Subsequent History. — ^This patient, though poor and uneducated, adhered
strictly to dietary instructions. The urine was continuously free from sugar
and the ferric chloride reaction had disappeared, therefore lO gm. carbohydrate
were added to the diet on May 26. On June 4, the blood sugar was 0.105 per
cent; on June 11, 0.122 per cent in the whole blood, 0.143 per cent in the plasma.
The weight had risen to 56.3 kg. By Oct. 12, it had risen to 62.3 kg. The blood
sugar then was 0.130 per cent and the CO2 capacity of the plasma 66.2 vol. per
cent. The diet was then increased by 200 cc. milk, as the patient reported her-
self not yet quite up to full workiiig strength. On Nov. 3, the sugar in the
blood was 0.149 per cent, in the plasma 0.175 per cent, and the CO2 capacity was
56.3 per cent.

On Nov. 22, the sugar in the blood was 0.130 per cent, in the plasma 0.143



302 CHAPTER III

per cent, and CO2 capacity 42.5 per cent. The first trace of sugar was reported
in the urine.

On Dec. 6, the patient reported having had cold and cough for 10 days. The
urine remained normal, and she probably ate less than usual, for the sugar was
found to be 0.100 per cent in the blood, 0.105 per cent in the plasma; the CO2
capacity 65.5 per cent.

On Dec. 23, the patient reported at the hospital with fever of 100°, com-
plaining of pains in joints and chest. She continued to feel badly and lost a
few pounds in weight. The urine remained normal. Her menstruation, which
had returned in the autumn, had again ceased.

On Dec. 27, she was readmitted because of her cold or grippe, though diabetic
symptoms were absent.

Second Admission. — Coryza was present, but the general appearance was good.
Temperature was never above 99.8°F. The body weight was now 58.3 kg., as
compared with 53.2 kg. at the first admission. Glycosuria was present Dec.
29 to 31, on a diet of 90 gm. protein, 50 gm. carbohydrate, and 2075 calories (1.54
gm. protein and 35.6 calories per kg.). The low blood sugars recorded mornings
before breakfast show the absence of any continuous hyperglycemia. The am-
monia nitrogen was 0.73 gm., and the total acidity (Henderson) 205. A carbo-
hydrate tolerance test was instituted in the usual manner, beginning with a fast-
day on Jan. 2. The increase in carbohydrate was made more rapidly than usual
because of the high tolerance, which was found to be approximately 180 gm.
carbohydrate. The patient was discharged on Jan. 16, 1916, weighing 57.8 kg.,
with a prescribed diet of 100 gm. protein, 50 gm. carbohydrate, and 2000 calories
(1.7 gm. protein and 35 calories per kg., reduced one-seventh by the weekly
fast-days). She was advised this time to take as much open air exercise as pos-
sible in order to buUd up her strength and relieve her chronic neurasthenia. The
blood sugar had now come down to normal, so that all tests were normal in all
respects, and the physical condition was entirely favorable.

Subsequent History. — The patient remained free from glycosuria and acidosis,
notwithstanding an attack of tonsillitis in Mar. Normal menstruation returned
in Apr. In July she again had fever and a grippe-Uke iUness.

Third Admission. — On account of this she was readmitted on July 13, 1916,
with definite tonsillitis and temperature of 100.5° F. This cleared up in a few
days. The general condition was good, and the weight 54.5 kg. A carbohydrate
test at this time showed a tolerance of 190 gm.; i.e., practically identical with the
180 gm. half a year before. The patient was discharged on Aug. 15, 1916, weigh-
ing 52.2 kg., with a prescribed diet of 90 gm. protein, 60 gm. carbohydrate, and
2300 calories.

Subsequent History. — ^The urine remained normal. On Aug. 29, the blood sugar
was 0.2 per cent, the plasma sugar 0.204 per cent, CO2 capacity 65.1 per cent.
On Sept. 6, the blood sugar was 0.167 per cent, the plasma sugar 0.181 per cent,
the COa capacity 65.8.



CASE RECORDS 303

Fourth Admission.— On Oct. 24, 1916, the patient was again admitted to hos-
pital because of cold and sore throat. The urine was normal, but a carbohy-
drate test showed a tolerance of only 130, as compared with the former 190 gm.
She was again discharged on Dec. 5, 1916, in good physical condition, on a diet of
75 gm. protein, 30 gm. carbohydrate, and 1750 calories. Her weight was 51.6
kg. The blood sugar was 0.164 per cent.

Fifth Admission. — Feb. 20, 1917. The trouble again was tonsillitis with fever.
There had been increasing tendency to glycosuria following repeated attacks of
sore throat, and the patient had recently carried out a carbohydrate test in the
regular manner at home, which showed a tolerance of only 90 gm. carbohydrate.
A test prior to this had shown a tolerance of only 70 gm. carbohydrate. The
general condition was still good, but the patient was kept in hospital for some
time in order to prepare her for tonsillectomy under the most favorable conditions.
Tonsillectomy was performed under local anesthesia on Mar. 19, 1917, and
was followed by no glycosuria, acidosis, or complication of any kind.

The patient was discharged Apr. 6, 1917, on a diet of 50 gm. protein, 10 gm.
carbohydrate, and 1200 calories, weighing 46.5 kg.

Subsequent History. — On a low diet, made still lower by weekly fast-days, the
urine remained normal and the patient felt well except for weakness. There were
no more sore throats, bm occasional joint pains returned as in the previous
attacks.

By May 22, the diet was increased to 55 gm. protein, 10 gm. carbohydrate,
and 1500 calories. On June 5, it was further increased to 60 gm» protein, 10
gm. carbohydrate, and 1600 calories. The weight was 46.5 kg.

On June 19 the blood sugar was 0.161 per cent and the CO2 capacity 61.7 per
cent. On account of complaints of persistent weakness and recurrent attacks of
so called rheumatism, the diet was further increased to 75 gm. protein and 1800
calories (1.6 gm. protein and 38.5 calories per kg.). On July 3, the weight was
47.3 kg., the blood sugar 0.172 per cent, the CO2 capacity 58.4 per cent. The
general condition seemed slowly but steadily improving.

Remarks. — ^This result, 2^ years after the patient was first received on the
verge of coma, is not bad under the circumstances. Downward progress, though
not rapid, has been perceptible in the presence of two distinct causes.

The first to be considered is diet. In the light of later experience a severely
diabetic patient, aged 21 years, ought not to receive an average ration of 43 cal-
ories per kg. as prescribed for this patient at the first discharge. One of the
hopeful features of the earher stage of diabetes is the abiUty to react energetically
and to carry even unduly high diets with apparent safety for a considerable
length of time. The most discouraging feature of the later stage resulting from
these high diets is the apparent breakdown of recuperative power, so that lower
diets may then spare the weakened assimilation, but can no longer raise it. This
patient at her first discharge had good flesh and color, but was hindered in earn-
ing her living by slight neurasthenia and subjective weakness. The familiar



304 CHAPTER in

attempt was therefore made to build her up by liberal feeding. For a time she
displayed the ability, characteristic of this incipient stage, to carry the increase of
both diet and weight; but the neurasthenia was not cured, nor the recurrent in-
fections prevented. It is apparent that the high diet had the usual eflfect of low-
ering the assimilation and weakening the power of recovery. Evidence is seen
in the marked hyperglycemia on certain occasions between the first and second
admissions, and in the persistent traces of glycosuria, Dec. 29 to 31, 1915, on diets
lower than had been tolerated at the close of the first admission. At the second
admission the blood sugar was kept normal. In contrast to the former 2500
calories, she was discharged this time on the wiser diet of 2000 calories (30 cal-
ories per kg. daily average). The third admission was 7 months later, and the
carbohydrate tolerance test proved that no loss of assimilation had occurred dur-
ing this interval. The diet -was then raised to 2300 calories. Marked hyper-
glycemia was found within 2 weeks; and in the interval of only 2 months between
the third and fourth admissions there was a demonstrated loss of 60 gm. carbo-
hydrate tolerance. The hyperglycemia at the fourth admission was not over-
come, and though the diet at discharge was only 1750 calories, traces of glycosuria
recurred and downward progress accordingly became more rapid. It is the fa-
miliar story that high diet first fails to accompUsh the intended purpose, and
subsequently forces the employment of lower diets than would have been proper
in the first place.

A second and highly important factor was that of infection. The attacks
recurred at all periods. The history shows, first, that high feeding did not pre-
vent the infectious attacks; second, that glycosuria and lowering of tolerance
from these attacks were most marked when the diet was unsuitable. Even if the
diet, however, had been perfectly planned, downward progress might still be
expected from the repeated infections. The comparative safety with which
operations can be performed with suitable preparation renders them advisable
in preference to a continuance of the infectious injury.

CASE NO. 33.

Female, married, age 51 yrs. Russian Jew; housewife. Admitted Feb. 18'
1915.

Family History. — ^Not much known. One sister died of consumption. Pa-
tient has been married 32 years; had eight children; one died after tonsillectomy;
others are well.

Past History. — Patient was bom in Russia. For past 9 years has lived in New
Jersey in good environment. Healthy life. Measles and typhus in childhood.
Had nervous breakdown at time of her son's death, and about that time all her
teeth became loose and were pulled out. During her first pregnancy she appears
to have had an acute nephritis following a cold; another such attack occurred last
year. Occasional indigestion and constipation. No alcoholism. Much starch
and sweets in diet. She has been obese throughout her adult life.



CASE RECORDS 305

Present Illness. — Over 2 years ago, because of nervousness, weariness, cold feet,
headache, and pains in limbs, she consulted a physician and diabetes was diag-
nosed. Glycosuria cleared up on carbohydrate-free diet; she did not reUsh it and
lost 25 pounds. Toast was then added to the diet, and later she was allowed even
cake. She regained 7 pounds weight and glycosuria returned. She was then re-
stricted to three slices of bread at each meal, but as glycosuria continued, the
suffering from the above symptoms was so great and continuous that she was
eager to submit to the most radical treatment if relief were obtainable.

Physical Examination. — ^Height 130 cm. A short, obese woman without acute
symptoms. General sensitiveness to touch. Skin of face pits slightly on pres-
sure. Teeth all false. Throat normal. No lymph node enlargement. Slight
emphysema. Systolic murmur at heart apex, transmitted to axilla. Blood
pressure 190 systolic, 100 diastolic. Knee jerks exaggerated. Ankles pit slightly
on pressure. Faint albuminuria without casts.

Treatment. — The patient was first placed on a low diet of approximately 52
gm. protein, 5 gm. carbohydrate, and 750 to 800 calories. With this intake the
glycosuria on Feb. 18 was 6.1 gm., and on Feb. 19, 5.95 gm. On the first day
of fasting (Feb. 20) it fell to 1 gm. and after a trace on Feb. 21, cleared up en-
tirely. For the purpose of reducing the excessive weight, plain fasting was con-
tinued for 1 week, with only 150 cc. cofifee and 150 cc. soup daily (Feb. 20 to 26).
On Feb. 27 and 28, nothing but whisky was given (250 to 400 calories), and then
green vegetables added, containing 12.5 gm. carbohydrate on Mar. 1 and in-
creasing to 50 gm. carbohydrate on Mar. 6. A fast-day with 300 calories of whisky
on Mar. 7 cleared up the resultant trace of glycosuria. Eggs and a trifle of crisp
bacon were then added to the whisky, but the total intake was not above 850
calories (Mar. 9). The trace of glycosuria which appeared on this day was prob-
ably attributable to 100 gm. string beans and 150 gm. cabbage, both thrice
boiled. This glycosuria cleared up on the following day on practically the identi-
cal diet. After Mar. 12 no more whisky was used, except on the fast-day of
Mar. 21. On Mar. 12 to 13, a diet of 25 to 40 gm. protein and approximately
300 calories was tolerated. But on Mar. 14, 68 gm. protein, 9 gm. carbohydrate,
and 1200 calories caused glycosuria, which continued on the subsequent days with
reduced caloric intake; the glycosuria was, however, very faint and ceased spon-
taneously on Mar. 20. The plan was pursued of giving a diet adequate in protein,
with carbohydrate to the limit of tolerance, but poor in fat and calories. Thus,
toward the early part of Apr. this diet contained about 120 gm. protein, 20 to 45
gm. carbohydrate, and 1000 to 1100 calories. Fast-days, sometimes doubled,
were given almost every week for reducing weight. Toward the close of Apr.
the patient had become able to assimilate as much as 118 gm. protein, 30 to 50
gm. carbohydrate, and 2000 calories. She never complained much of hunger
and was well satisfied on the later diets.

There was a general gain in clinical condition, but still many complaints of
headache and pains in abdomen and various parts of body. Weakness and ner-



306 CHAPTER m

vousness were also persistent. About the middle of Mar. occurred the first
menstruation since 8 months before admission to hospital. In Apr. there was
another menstruation, with undue hemorrhage. Gynecological examination
failed to reveal fibroids or other cause of hemorrhage, but some abnormality was
suspected because of the history of a similar trouble in the past. The patient was
discharged May 8, with the idea of having her reduce her weight further at
home and find something to divert her attention from her symptoms, which
were of the sort called neurasthenic. She was well pleased with the improvement
and could be trusted to continue treatment.

Acidosis. — ^A salient point is the absence of any threatening symptoms in this
obese woman during a week of complete fasting without special preparation. The
ferric chloride reaction, which had been negative, became positive on the low diet
of Feb. 19 and grew heavy during the fast. Alkali was not employed. The ferric
chloride reaction subsequently diminished, but was not permanently negative
during this period in hospital. In the latter part of the stay in hospital the
ammonia followed a fairly low curve, and the plasma bicarbonate held a low
normal level.

Blood Sugar. — There is little to remark except the downward tendency. Evi-
dently radical measures might have brought it within normal limits rather quickly,
but in view of the general condition it was deemed preferable to allow the hyper-
glycemia to be taken care of in the course of long improvement.

Weight and Nutrition. — The most important therapeutic purpose was to di-
minish the excessive body weight. The abdomen was very pendulous, and the
question- arose whether there might not be benefit from a surgical operation which
should correct the diastasis of the recti and tighten up the abdominal wall, per-
haps thereby relieving some neurasthenic complaints, and at the same time am-
putate some 10 or 15 pounds of fat which were sufficiently in the patient's way
that she would have welcomed surgical relief. It was decided not to venture this,
but to depend entirely on dietary measures. The weight fell rapidly on fasting,
and continued to fall on the subsequent diet which conformed to the above men-
tioned standard of adequate protein, carbohydrate to the limit of tolerance, and
restriction of fat. The weight at admission was 83 kg., at discharge 70.6 kg.;
i.e., a loss of 12.4 kg. in 2| months. The discharge diet represented 92 gm. pro-
tein, 30 gm. carbohydrate, and 1800 calories (approximately 1.3 gm. protein and
25 calories per kg., reduced one-seventh by the weekly fast-days). As usual, the
clearing up of diabetic symptoms by reduction of weight had resulted in actual
gain of strength. In this instance the reduction of the obesity was in itself a reUef
to the patient.

Subsequent History. — The presence of a somewhat elevated blood pressure and
the occasional uterine hemorrhages raised a question in regard to exercise in this
patient. She was advised to practice walking and to work 3 or 4 hours every day
in her garden. The urine continued to show negative sugar and slight ferric
chloride reactions. On June 11, the diet was increased by 50 gm. meat, 2 eggs,



CASE RECORDS 307

and 10 gm. carbohydrate. The weight was 70 kg. On July 21, the carbohy-
drate intake was increased to 50 gm., and at the same time the fat was dimin-
ished by omitting 25 gm. olive oil. Though the condition in respect to diabetes
remained uniformly good, the patient's neurasthenia made her a nuisance to a
devoted family, and she was therefore readmitted to the hospital on Aug. 25 for
observation.

Second Admission. — ^The sugar was down to 0.112 per cent in the blood, 0.118
per cent in the plasma. A slight ferric chloride reaction still persisted. None
of the organic disorders suggested by the patient's numerous complaints could be
found. She was again kept on very low diet, the fat being particularly low, the
protein low but adequate as before, and in this instance the carbohydrate was
also made low with the idea of maintaining a normal blood sugar. This was
also the diet prescribed at discharge; namely, 100 gm. protein, 10 gm. carbohy-
drate, and 1000 to 1100 calories. The patient was now some 7 kg. below the
weight at her former discharge, and the loss was expected to continue.

Subsequent History. — The progress was as before. Glycosuria remained absent,
and on Oct. 6 the ferric chloride reaction was also found negative. Hyperglycemia
was, however, found to be present after eating, the sugar being 0.156 per cent in
the whole blood and 0.182 per cent in the plasma. The varied neurasthenic com-
plaints had diminished but were stiU upsetting the patient herself and her entire
household. There had been no recurrence of the former uterine hemorrhages,
and the patient was readmitted to hospital on Oct. U to try more vigorous exercise
under supervision.

Third Admission. — The weight was down to 59.2 kg.; i.e., a loss of 24 kg.
since the first admission. The patient was far stronger and more cheerful.
Both sugar and ferric chloride reactions were negative. A carbohydrate test
was now begun in routine manner with a fast-day on Oct. 11, then green vege-
tables with increase of carbohydrate by 10 gm. daily. A slight ferric chloride
reaction quickly reappeared and persisted until abolished by increase of carbo-
hydrate; i.e., with the ingestion of 80 gm. carbohydrate on Oct. 21. The trace
of glycosuria appearing with the 150 gm. carbohydrate on Oct. 29 was evidently
accidental, for it disappeared with further increase of the ingestion, and the true
limit seemed to be reached with 250 gm. carbohydrate Nov. 7 to 13. This assimi-
lation is in striking contrast to the almost complete absence of tolerance shortly
after the first admission. One contributing factor in it seemed to be exercise
(see Chapter V) . The slight glycosuria was cleared up by a fast-day on Nov. 14,
which promptly brought the high blood sugar of the carbohydrate test down to
0.119 per cent in the whole blood and 0.125 per cent in the plasma. Thereafter
a trial was made of a diet of 75 gm. protein, 150 gm. carbohydrate, and 2500
calories. Persistent traces of glycosuria resulted, evidently from the carbohy-
drate, inasmuch as the blood sugar curve shows normal values in the morning
before breakfast. The carbohydrate was therefore diminished to 100 gm., and
the intake of 2500 calories maintained by substituting fat. The patient was dis-
charged on Nov. 26, 1915, weighing 55.6 kg., a total loss of 27.4 kg. since her first



308 CHAPTER in

admission. Her diet now represented approximately 1.3 gm. protein and 45 calo-
ries per kg., reduced one-fourteenth by fortnightly fast-days. The exercise had
been strenuous during this period in hospital, and it proved wholly beneficial.
She had reached a point where she could walk 8 mUes and climb 40 flights of stairs
daily in addition to an hour or two of jumping rope and tossing the medicine
ball. A fairly liberal diet was therefore allowed at the close to maintain strength
and nutrition and furnish energy for exercise.

Subsequent History. — On Dec. 13, 1916, the weight was 60 kg., and the patient
was doing her full housework and walking 5 miles and using a 6 potmd medicine
ball half an hour daily, with almost complete relief from neurotic troubles. In
summer, gardening was largely substituted, and she spent 6 hours daily at this
work.

On Jime 15, 1916, sugar was 0.141 per cent in the whole blood, 0.185 per cent in
the plasma; CO2 capacity 63.5 per cent; weight 52 kg. The patient complained
somewhat of himger, and on July 22 the diet was changed to 100 gm. protein, 50
gm. carbohydrate, and 2750 calories. On this diet the sugar was 0.159 per cent
in whole blood, 0.192 per cent in plasma, CO2 capacity 57.9 per cent. Blood
pressure 130 systolic, 90 diastolic.

In Sept., the weight was 54 kg. Occasional doubtful traces of glycosuria were
reported, but on examination at the hospital such reactions were found to be
false, the slight sediment not representing a true copper reduction. Prog-
ress has continued in this manner to the present. Neiirasthenic symptoms stiU
persist to some extent, pain being complained of at different times in head, abdo-
men, legs, and fingers. The quantity of the diet is fuUy satisfactory. Monot-
ony is sometimes complained of. Active work is still continued with pleasure,
and in general the patient is entirely transformed in health and appearance as
compared with her first admission.

Remarks. — There are three salient points. First is the good toleration of fast-
ing by an obese woman without symptoms of acidosis, and the improvement in
strength with undernutrition. Second is the transformation produced in the
sugar tolerance by reduction of weight, an increase from practically zero to 250
gm. Third is the beneficial effect of exercise in a patient apparently showing some
contraindications. The dangers feared did not materialize, and even the blood
pressure came down to normal. There is still an abundant supply of body fat,
but undoubtedly a larger proportion of the weight is now muscle. The neuras-
thenia was benefited more than the carbohydrate tolerance, and without exercise
it is doubtful if permanently favorable results could have been achieved.

CASE NO. 34.

Male, unmarried, age 26 yrs. Jew; clerk. Admitted Feb. 19, 1915.

Family History. — Father well at 55. Mother died with diabetes and cardio-
renal disease at 51. Two brothers and three sisters are well; one brother died in
infancy; one sister died this year in diabetic coma, aged 19. No knowledge tf
other heritable disease.



308 CHAPTER III

admission. Her diet now represented approximately 1.3 gm. protein and 45 calo-
ries per kg., reduced one-fourteenth by fortnightly fast-days. The exercise had
been strenuous during this period in hospital, and it proved whoUy beneficial.
She had reached a point where she could walk 8 miles and climb 40 flights of stairs
daily in addition to an hour or two of jumping rope and tossing the medicine
ball. A fairly liberal diet was therefore allowed at the close to maintain strength
and nutrition and furnish energy for exercise.

Subsequent History.— On Dec. 13, 1916, the weight was 60 kg., and the patient
was doing her fuU housework and walking 5 nules and using a 6 pound medicine



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 33 of 76)