Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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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 June 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 hunger, 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 systoUc, 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. Neurasthenic symptoms still
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 stUl 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 saUent 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 abxmdant 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, immarried, 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 •f
other heritable disease.



CASE RECORDS 309

Past History. — ^Healthy life in fair environment. Measles in childhood, the
only sickness. Venereal denied. No excesses in alcohol or tobacco. Diet
moderate without much sweets, but has consisted largely of bread and meat; few
vegetables.

Present Illness. — In Nov., 1911, the patient consulted a physician for pains in
his arms. Local examination revealed nothing, and a liniment was prescribed
which accomplished nothing. An osteopath was then consulted and gave elec-
trical treatments without result. In the latter part of 1912 the patient returned
to the original physician, who this time discovered glycosuria. On carbohydrate-
free diet plus one slice of Graham bread daily, glycosuria diminished. The
physician sent the patient to a sanitarium, where he remained 5 weeks. Glyco-
suria was absent only on green days, but the patient returned home with sugar
diminished and strength improved. He resumed work as a clerk, but gradually
became worse, and in 1913 was again sent to the sanitarium. Glycosuria did not
cease and the result was less favorable. He attempted light work after return-
ing home, but becoming alarmed by the downward progress, with polyphagia and
polydipsia, he spent S weeks under the care of Carl von Noorden in the summer
of 1914. He was free from glycosuria only on 1 fast-day, but felt improved in
strength on leaving. He resumed light work on carbohydrate-free diet with addi-
tion of 250 to 300 calories carbohydrate.

Physical Examination. — ^A well developed young man, thin, but not seriously
emaciated. No acute symptoms or distress. Flush of cheeks and slight yellow-
ish color about nasolabial folds. Teeth in good repair; throat slightly congested;
tonsils not hypertrophied. No palpable lymph node enlargements. Blood
pressure 110 systolic, 90 diastolic. Knee jerks active. Examination otherwise
negative.

Treatment. — On admission, the patient had glycosuria of 6.61 per cent or
150 gm. in 17 hours, with an intense ferric chloride reaction. There were no
symptoms suggesting coma, and no hesitancy was felt in instituting carbohy-
drate-free diet. On Feb. 20 and 21 the diet was 75 to 80 gm. protein, 2 to 3 gm.
carbohydrate, and 1650 to 1750 calories. The glycosuria fell to 33.2 gm. on
Feb. 20, and 18.65 gm. on Feb. 21. Fasting was then begun with 500 to 600
calories of whisky daily. On Feb. 25 the urine was free from sugar and the
ferric chloride reaction was much diminished. On Feb. 27, green vegetables were
added to the whisky, and increased to 100 gm. carbohydrate on Mar. 7 to 8. A
trace of glycosuria then appeared, whUe a slight ferric chloride reaction still
persisted. After a fast-day with 600 calories whisky on Mar. 9, two eggs and 20
gm. bacon were added, and increased to a total of 1300 calories on Mar. 11.
Whisky was then dropped and carbohydrate introduced; but the diet of 91 gm.
protein, 25 gm. carbohydrate, and 1740 calories on Mar. 13 to IS proved de-
cidedly in excess of the tolerance. After a fast-day on Mar. 16, a low carbohy-
drate-free diet was again begun. On Mar. 24, it became possible to introduce
10 gm. carbohydrate. The diet was then progressively built up until before



310 CHAPTER ni

discharge on May 8, it represented 95 gm. protein, SO gm. carbohydrate, and
2900 calories. The diet prescribed at discharge was 80 gm. protein, 10 gm. car-
bohydrate, and 2500 calories (nearly 1.6 gm. protein and 50 calories per kg.,
reduced one-seventh by weekly fast-days). The patient looked entirely weU and
described himself as feeling better than at any time since the onset of diabetes
He was discharged to rest in the country during the summer.

Acidosis. — There were no threatening s)rmptoms, either on carbohydrate-free
diet, or during the initial fast. The carbon dioxide capacity of the plasma was
slightly below the lower normal level at admission, but rose spontaneously and
was normal toward the close of the stay in hospital. No alkali was employed at
any time. The chief signs of acidosis were the ammonia nitrogen of 3.1 gm. at
admission, and the intense ferric chloride reactions. The ammonia fell rapidly
to normal values. The beginning of a diet deficient in carbohydrate brought it
up to 1.4 gm. N on Mar. 12, but later the curve ran lower. The ferric chloride
reaction gradually diminished and was sometimes negative, but never remained
so during this hospital period.

Blood Sugar. — On Mar. 24, without glycosuria, there was nevertheless a fasting
blood sugar of 0.23 per cent. On Mar. 29, following the preceding fast-day, the
morning blood sugar was 0.17 per cent. Thereafter the findings were all below
0.2 per cent. The normal blood sugar on Mar. 3, after the preceding fast-day,
indicated a downward tendency, and showed that more rigorous treatment could
easily have maintained a normal level.

Body Weight. — ^This was 51.6 kg. at admission. The lowest figure, on Mar. 29
and Apr. 5, was 48.2 kg., representing a loss of 3.4 kg. There was occasional
slight edema, and particularly during the initial fasting and carbohydrate period
up to Mar. 8 there was pronounced edema with gain of 0.5 kg. in weight. The
weight rose on the higher diets in Apr. and May, and at discharge was 51.2 kg.;
«. e., 0.4 kg. less than at admission.

Subsequent History. — ^Intelligence and financial circumstances were in the pa-
tient's favor. He adhered to diet while resting in the country, but on May 18
showed glycosuria, and as the traces did not clear up he fasted 48 hours. On
May 25, his urine showed positive sugar and negative ferric chloride reactions.
The diet was quantitatively reduced, and thereafter glycosuria remained absent
except for traces appearing at the close of each week and cleared up by the
routine fast-days. He was therefore readmitted to the hospital on July 28.

Second Admission. — ^Almost 1 kg. had been gained since the former discharge,
so that the patient now weighed 0.4 kg. more than at the previous admission.
The urine was sugar-free but showed a well marked ferric chloride reaction. A
carbohydrate tolerance test was first instituted. Beginning with a fast-day on
July 28, 20 gm. carbohydrate in the form of green vegetables were given on July
29 and increased 20 gm. daily until well marked glycosuria occurred with an in-
take of 120 gm. After a fast-day on Aug. 5, the diet on Aug. 6 and 7 con-
sisted of 100 gm. protein, 30 gm. carbohydrate, and 2580 calories. Glycosuria



CASE RECORDS 311

resulted; also the ferric chloride reaction, which had become negative during the
carbohydrate test, returned. A lower diet was then begun, of SO gm. protein, 10
gm. carbohydrate, and 1300 calories. It became possible to increase the carbohy-
drate to 20 gm., and the ferric chloride reaction became negative. Sept. 9 to 11
the patient was at home on this same diet. Sept. 12 was a fast-day. A diet of SO
gm. protein, 70 gm. carbohydrate, and 1200 to 1400 calories then caused well
marked glycosuria. The fast-day of Sept. 18 was spent at home. The same
carbohydrate was given for the following week and strenuous exercise begun.
Glycosuria remained absent during this week, though the protein was increased
to 80 gm. and the calories to 2030. Sept. 27 to Oct. 9, a diet of 80 gm. protein,
100 gm. carbohydrate, and 2130 calories was tolerated without glycosuria. (For
details of the exercise experiments, see Chapter V.) After the fast-day of Oct.
10 another carbohydrate test was instituted with heavy exercise. Potatoes and
other high carbohydrate vegetables had to be used this time to avoid excessive
bulk. Glycosuria appeared with 210 to 220 gm. carbohydrate on Oct. 28 and 29.
Exercise was then increased, and glycosuria cleared up and did not return until
an intake of 270 gm. was reached.

On Nov. 14, the patient was discharged in apparently excellent health, free
from glycosuria and ketonuria, on a diet somewhat better balanced than before,
namely 7S gm. protein, 75 gm. carbohydrate, and 2400 calories (over 1.5 gm. pro-
tein and 50 calories per kg., reduced by weekly fast-days to 1.3 gm. protein and
43 calories per kg.).

Acidosis. — ^The fluctuations shown in the blood bicarbonate were mostly con-
nected with the exercise, experiments. The ferric chloride reaction cleared up as
stated when the carbohydrate intake reached 60 gm. on Aug. 1 without other food.
It remained absent on the fast-day of Aug. 5, but reappeared promptly with the
subsequent diet. During Aug. it became entirely negative, doubtless on account
of the low calory diet rather than the introduction of the small quantities of
carbohydrate. The subsequent occasional traces were perhaps associated with
the heavy exercise, but continued exercise produced no continuance of this reac-
tion. Alkali was not used.

Blood Sugar. — ^There is little to remark except the tendency to slight continuous
hyperglycemia. Some of the fluctuations stand in connection with the exercise
experiments. On the high diets allowed it is evident that exercise failed to
keep the blood sugar below about 0.15 per cent. This accords with other ex-
perience that it cannot be used as a substitute for caloric restriction.

Body Weight. — From 52 kg. at entrance, this was reduced to 49 kg. on Aug. 30.
Thereafter it rose as high as 52.6 kg. on Oct. 10, partly by reason of slight edema.
The carbohydrate tolerance test in Oct. produced first a sharp fall in weight due
to undernutrition, followed by a rise to 51.6 kg. due to edema. With subsidence
of the edema, the long undernutrition (29 days) of this carbohydrate test made
itself felt by a sharp drop in weight. The patient was discharged weighing 47.4
kg.; i.e., 4.2 kg. less than at the first admission.



312 CHAPTER m

Subsequent History. — ^The patient adhered to diet and exercise, and the urine
remained normal. The health seemed perfect. On Feb. 10, 1916, sugar in blood
was 0.141 per cent, in plasma 0.145 per cent, CO2 capacity 65 per cent. Weight
51 kg. On Feb. 20, the patient slightly overstepped his diet at his brother's
wedding, and brought on glycosuria which was checked by a fast-day. In Mar.
he passed through an attack of grippe and bronchitis, and showed traces of
glycosuria which required temporary reduction of diet.

Death occurred June 10, 1916. Inquiry elicited the information that there
had been an attack of acute appendicitis. On account of the diabetes the family
physician had attempted to avoid operation. Symptoms of perforation appeared
on June 5, and glycosuria had also developed. On that day the patient was rushed
to a hospital for an emergency operation. Anesthesia was given with nitrous
oxide and oxygen. Perforation of the appendix and free peritonitis were found.
Following operation he seemed to do well and became free from glycosuria. The
diet during this time was not stated. On June 9, coma was said to have devel-
oped in spite of alkali treatment and resulted in death the next day.

Remarks. — Undernutrition had the usual effect in raising tolerance, relieving
symptoms, and improving strength. The diet toward the close of the first period
in hospital was unduly high. The condition then, with sugar-free urine, rising
weight, and only a trace of ferric chloride reaction and slight hjrperglycemia, was
one ordinarily considered highly favorable in a case of this type and was clearly
superior to the results achieved by specialists who had treated this patient at
earlier and milder stages of his condition. But the return of glycosuria whUe the
patient was under favorable environment at home and adhering faithfully to
treatment was not accidental nor an indication of spontaneous downward prog-
ress, but was the inevitable result of the high diet which was producing the gain
in weight. A stUl more favorable condition was achieved during the period of
undernutrition in the first half of the second stay in hospital. The diet was then
increased to a less degree than before, and at the same time heavy exercise was
employed to use up the surplus calories and if possible buUd up the assimilation.
The effect upon both the tolerance and the general health was clearly beneficial
and no ill results were observed. Nevertheless, exercise could not entirely re-
place caloric restriction, for hyperglycemia was persistent, whereas with exercise
and a lower diet the blood sugar might have been normal. The ultimate outcome
in this type of case probably could not have been favorable on a diet as high as
that allowed. The observation upon this patient was interrupted by the im-
timely death from a cause bearing no definite relation to the diabetes. A note-
worthy point is that the patient was on liberal diet, so that he was steadUy gain-
ing weight; otherwise critics might allege that susceptibility to such an accident
was due to undernutrition. It so happens that the majority of serious infec-
tions and accidents in this series have happened to patients on high rather than to
those on low nutrition. It is possible that suitable dietetic care before and after
operation might have prevented the fatal result.



CASE RECORDS 313

CASE NO. 35.

Male, married, age 61 yrs. American; lawyer. Admitted Feb. 20, 1915.

Family History. — Mother died of typhoid at 32, father of some paralytic con-
dition at 57. Three sisters and two brothers are well; one other brother has
arthritis. A first cousin died of cancer. No other heritable disease known.
Patient has been married 34 years; wife healthy but never pregnant.

Past History. — Healthy life under excellent hygienic conditions. Grippe,
measles, whooping-cough, and mumps in childhood. Probably mild typhoid at
13. A few attacks of grippe since. No sore throats or other minor infections.
No venereal disease. Habits very regular and simple. No alcohol used until
prescribed for diabetes. No excesses in diet or indulgence in sweets. Bowels
regular. No nerve strain. Patient has been a prosperous lawyer and official in
a small New York cityunder seemingly ideal conditions of health.

Present Illness. — 11 years ago persistent backache was the first symptom.
Within a year thereafter more or less polyuria was noticed. Glycosuria was then
found, but ceased with simple abstinence from bread and potatoes. During the
ensuing year, however, glycosuria became more stubborn and 20 pounds weight
were lost. 9 years ago, on his physician's advice, the patient spent 30 days under
the care of Carl von Noorden. He received the usual treatment with green days,
oatmeal days, etc. , and was told that it was impossible for him to be free from
glycosuria. He returned with glycosuria diminished and strength increased,
with a gain of 5 pounds in weight. He adhered for 1| years to the diet pre-
scribed in Vienna, which contained liberal amounts of carbohydrate. 10 pounds
weight were lost. He then returned to Vienna for 33 days of treatment. He
again gained 5 pounds and felt better. The glycosuria was stUl present on
leaving. He again followed the prescribed diet until 1909, when he returned to
von Noorden for 31 days. This time the trouble was more persistent and there
was little improvement. The patient still carried on his regular work. In 1911
he was treated by von Noorden for 33 days with more stringent measures than
before, 2 fast-days being employed. He continued in sKghtly reduced health
until Apr., 1914, when a buU knocked him down and broke four ribs. Dangerous
acidosis came on. His medical advisor knew of the fasting treatment, and
withheld aU food for 4 days. The symptoms of impending coma passed off.
Since then he has remained subjectively in tolerable health, and came for treat-
ment only because his physician advised that the persistent glycosuria and acidosis
should be cleared up if possible.

Physical Examination. — Height 170 cm. A well developed, adequately nour-
ished, unusually rugged looking man for his age. No aCute symptoms, but a
marked odor of acetone. Mouth and throat normal. Only insignificant lymph
node enlargements. Blood pressure 120 systolic, 80 diastolic. Liver edge pal-
pable 4 cm. below costal margin in mammary Hne. Knee jerks obtained only
slightly with reinforcement. Ankle jerks sluggish. General examination is that
of an unusually healthy man.



314 CHAPTER in

Treatment.— Oa the first full days in hospital, Feb. 21 and 22, the patient re-
ceived an observation diet of 95 to 130 gm. protein, 5 to 8 gm. carbohydrate, and
1900 to 2000 calories, and excreted 25 to 22 gm. sugar, with evidently consider-
able diacetic acid. Beginning Feb. 23 he was given an 8 day fast, with 150 to
200 cc. whisky, 300 cc. soup, and 300 cc. coffee daily; no alkaU. The glycosuria
diminished, but the ferric chloride reaction became intense; the carbon dioxide ca-
pacity of the plasma remained approximately normal. The patient began to com-
plain of malaise and nausea, and appeared drowsy. On Mar. 2 he vomited. 10 gm.
sodium bicarbonate on this day failed to alter the symptoms. Therefore on Mar.
3 the fast was broken off, and a diet of 48 gm. protein, 5 gm. carbohydrate, and
1300 calories was given. This was increased on the following days, so that on
Mar. 10 the intake was 90 gm. protein, 5 gm. carbohydrate, and 2450 calories.
30 gm. sodium bicarbonate were given on Mar. 3, and the. same on Mar. 4. The
ketonuria continued heavy and the glycosuria increased, but not to anything
hke the previous figure. Mar. 12 to 16 the diet was strictly carbohydrate-free.
The symptoms which had developed on fasting had disappeared immediately on
feeding, and the patient remained entirely comfortable on carbohydrate-free
diet. Mar. 17 fasting was resumed with whisky, soup, and coffee as before.
The glycosuria promptly fell to traces. Alkali was not given. On Mar. 17 the
patient was subjectively comfortable. On Mar. 18 he complained of slight
nausea. Therefore, without waiting for absolute freedom from glycosuria, on
Mar. 19 the 630 calories of alcohol were augmented with an egg, 25 gm. bacon,
and 250 gm. thrice boiled vegetables. The clinical symptoms were thus re-
lieved, and the glycosuria also cleared up on Mar. 20, while the ferric chloride
reaction was diminished. Traces of glycosuria returned on certain of the ensuing
days. Another single fast-day withwhisky, soup, and coffee was given on Mar. 28.
The protein-fat diet was gradually buUt up, until on Apr. 2 and 3 it represented
72 to 82 gm. protein and 1750 calories, nearly half of which was alcohol. As
symptoms of danger were apparently past, it became feasible to proceed to raise
the tolerance and attack the persisting acidosis. Therefore Apr. 4 was a fast-
day with 700 calories of whisky. On the following 2 days, 10 gm. carbohydrate
were added to the whisky. On Apr. 7 whisky was diminished, and thereafter
discontinued. A routine carbohydrate test (Apr. 8 to 17) established the toler-
ance as about 100 gm. carbohydrate. At the same time the ferric chloride reac-
tion became much paler. A diet was then begun with inclusion of 15 gm. carbo-
hydrate. Traces of glycosuria were too frequent, and on May 12 to 14 the
patient fasted 3 days; nothing but 300 cc. coffee and 300 cc. soup daily was given.
Undernutrition was then continued, with persistent low diet and a routine fast-
day every week. After the fast-day of May 23, glycosuria was permanently
absent, but shght ferric chloride reactions continued. The patient was dis-
charged June 22, on a diet of 78 gm. protein, 15 gm. carbohydrate, and 2120 cal-
ories (slightly less than 1.5 gm. protein and 40 calories per kg., diminished
one-seventh by the weekly fast-days). He had become accustomed to the simple



CASE RECORDS 315

low diet, and could be depended upon to continue it accurately at home. The
general appearance was distinctly not so good as at admission; but in addition to
the altered laboratory findings, the patient insisted that he felt better and his
mind was clearer than before.

Acidosis. — ^The case illustrates the difficulties and possible danger of fasting
sometimes in long standing diabetes, when the patient perhaps appears in very
favorable condition. This patient had previously undergone fasting with benefit
after the accident with the bull. His physician considered that at that tmie the
fasting saved him from dying in coma. On the present occasion in hospital he
showed no symptoms either on mixed diet or on the change to carbohydrate-free
diet. But toward the close of an 8 day fast the typical warning symptoms de-
veloped, and were not prevented by the rather hberal use of whisky, nor relieved
by 10 gm. sodium bicarbonate. The carbon dioxide capacity of the plasma at
this time was within normal Umits and gave no warning of the critical condition,
which was recognized by cUnical symptoms alone. As usual when this condition is
taken in time, feeding cleared up the symptoms immediately. Other experience
confirms the view that the use of soda was not essential, nor was it necessary to
give carbohydrate. The mere giving of food, even though this consisted chiefly of
fat, was sufficient to reUeve the intoxication of this fasting acidosis. Also as usual
in such cases, the sensitiveness disappeared later, so that modifications of diet
were made at will without clinical disturbance. Corresponding to the normal
blood alkalinity, the ammonia nitrogen was never above 2 gm. It diminished,
but did not reach normal limits until the carbohydrate tolerance test in Apr.
The intense ferric chloride reaction was the only laboratory index which corre-
sponded to the cUnical intoxication, yet this remained equally intense when
carbohydrate-free diet had cleared up the chnical symptoms completely. This
reaction gradually faded out, but did not become permanently negative during
this period in hospital.

Blood Sugar. — The only normal blood sugar was 0.108 per cent in both whole
blood and plasma on the morning of June 14, following the preceding fast-day.
The persistent hyperglycemia was the reason for the rigorous undernutrition
period (May 11 to IS) comprising 2 days of very low diet and 3 fast-days. This
entirely failed to reduce the hyperglycemia, which was 0.2 per cent on May 15.
The treatment had been rigorous, and it was deemed advisable not to push
undernutrition further in an attempt at a rapid reduction of such a stubborn hy-



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 34 of 76)