Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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curred on Aug. 7 with 500 gm. carbohydrate and 118 gm. vegetable protein.
The glycosuria ceased with a green day on Aug. 8, representing 24 gm. protein
and 103 gm. carbohydrate. The patient was disniissed Aug. 11 on a diet of 100
gm. protein, 100 gm. carbohydrate, and 2450 calories. He looked and felt
entirely well and was permitted to resume school work. The only special inci-
dent in hospital was the necessary dental work to bring his mouth into good con-
dition, including the extraction of three molar teeth, which was done without
ill effects.

Acidosis.— The clearing up of the various signs of impending coma on fasting
was noted above. The carbon dioxide capacity of; the plasma fell slightly fol-
lowing the discontinuance of soda on Mar. 22, also following discontinuance of
wliisky on Mar. 24. In each case it readily rose again, and it is probable that
neither alkali nor alcohol played an essential role. The ferric chloride reactions
and the ammonia showed no such influence, On the carbohydrate test (Apr. 3
to 15) the ferric chloride reaction became entirely negative. On beginning
mixed diet, nothing was definitely altered in the CO2 capacity, and the ammonia
was only slightly higher, but ferric chloride reactions began to recur as the caloric
intake was raised, notwithstanding the fact that carbohydrate was similarly
increased. Such reactions persisted up to May 22, with 50 gm. carbohydrate in



324



CHAPTER m



the diet. Further increase to 65 gm. carbohydrate abolished them, and they
remained -absent with further increase of carbohydrate, even though fat was
also increased.

Blood Sugar. — The curve shows the characteristics of an early case, still in
the mild stage. It returned quickly to normal, rose only slightly as the diet was
built up, then became and remained continuously normal, notwithstanding the
high diet.

Weight and Nutrition. — For nearly the first month in hospital there was under-
nutrition. The practical abstinence from protein for 29 days is noteworthy,
and there must have been a large loss of body nitrogen. The weight fell during
the first part of the fast to Mar. 25, then began to rise on fasting with only 600
cc. soup and 300 cc. coffee daily, and continued to rise on green vegetables, until
on Apr. 3 it was 1.2 kg. higher than at admission and there was visible edema
of face and ankles. The weight then diminished spontaneously, but water reten-
tion evidently persisted, for the lowest point was gradually reached on May 10,
when the diet was theoretically adequate. A slow continuous gain followed,
and at discharge the weight was approximately the same as at admission.

The diet prescribed at discharge represented over 2 gm. protein and 50 cal-
ories per kg. of weight, diminished one-seventh by the weekly fast-days. Con-
sideration was taken of the fact that the patient was a growing boy; also activity
had been gradually increased, so that by July he was walking 7 miles daily in
addition to other exercise. He was encouraged to develop his muscles, avoid
mental strain, and plan a vocation in line with these purposes. In view of the
normal results of all clinical and laboratory tests, the attempt was made to let
him develop as nearly normally as possible, and the liberal diet was permitted to
this end.

Subsequent History. — The urine remained normal, and the patient kept up
with his school work and exercised by bicycling and skating. On Oct. 9, the
weight was 50 kg., it having been kept down by exercise as ordered. The physi-
cal and subjective condition was excellent, but sugar was found to be 0.232 per
cent in whole blood, 0.270 per cent in plasma. Increase of exercise was ad-
vised instead of reduction of diet. Competitive sports had been strictly for-
bidden for fear of excitement and strain. This was the only point in "which the
patient was disobedient, for he resumed basket-baU and participated in inter-
scholastic matches. More dental work was necessary, and three trips to the den-
tist were followed by slight glycosuria each time. The carbohydrate was dimin-
ished to 40 gm., and the dental operations thereafter produced no glycosuria,
illustrating the usual dietary factor. The blood sugar continued to rise, being
0.263 and 0.285 per cent in whole blood and 0.344 per cent in plasma on succes-
sive examinations. Undoubtedly exercise, by consuming surplus calories and
keeping down weight, delayed the progress of the diabetes far beyond the period
at which active symptoms would have developed at rest; but it was not able en-
tirely to take the place of caloric restriction. By request, the patient returned
to the hospital during his school holidays, after Christmas, for observation.



CASE RECORDS 325

Second Admission. — ^The weight was now 53.8 kg.; i.e., a gain of 6.2 kg. since
the first admission. There were barely perceptible sugar and ferric chloride
reactions. After 2 days of fasting a carbohydrate tolerance test was begun
on Dec. 29. Glycosuria resulted with only 175 gm. carbohydrate on Jan. 2, 1916,
and persisted when this intake was continued for 3 days. It ceased following the
green day of Jan. 5, when only 41 gm. carbohydrate were taken. Also the blood
sugar, which on Dec. 30 was 0.35 per cent, fell to 0.164 per cent on the morning
of Jan. 6. The patient was discharged on Jan. 9 and allowed to return to school,
on a diet of 100 gm. protein, 5 gm. carbohydrate, and 2100 calories (approximately
2 gm. protein and 40 calories per kg. on 52 kg. weight, diminished by the weekly
fast-days). Clinically the condition was perfect, and laboratory findings were
normal except for the hyperglycemia.

Subsequent History. — The patient did not do so well this time, showed traces of
sugar frequently and lost weight by reason of the consequent fasting. Instructions
were sent for him to return to the hospital, but he was unwilling to give up his
school work. Early in Feb. there was constipation and an attack of colicky
abdominal pain without fever or nausea, but with glycosuria. The patient hoped
to fast himself sugar-free without stopping school. He fasted 8 days, attending
school during the first 6. Glycosuria increased instead of diminishing. On Feb.
17 he was too weak to fast, and spent that and the following day lying down
at home without nausea or vomiting, with increasing dyspnea and drowsiness.
The only food eaten during the 8 days was four eggs and some bacon on Feb.
18. This seemed to give a little strength.

Third Admission. — The patient was readmitted at 3:15 p. m., Feb. 19, stupor-
ous, but intelligent when roused, with deep noisy respirations, 25 per minute;
typical odor; temperature 97.6°F., pulse. 114, small and thready; cheeks unnatur-
ally flushed and pinched; tongue dry and red; urine showing intense sugar and
ferric chloride reactions, containing enormous numbers of casts, and turning to a
solid curd of albumin with the heat-acetic test.

At admission, the CO2 capacity of the plasma was 26.4 vol. per cent. In the ab-
sence of nausea, the bowels were moved by calomel in divided doses followed by
30 cc. 50 per cent magnesium sulfate solution and a colon irrigation. Plain
fasting was imposed, with 150 cc. clear soup, and the patient was urged to drink
as much water as possible, the fluid intake on this fast-day thus amounting to
1680 cc. By the next morning the cKnical appearance was practically unchanged,
but the CO2 capacity of the plasma had fallen slightly, to 24.2 per cent. Because
of this fact, and because the acidosis symptoms were said to have come on as a
result of prolonged fasting, it was decided to feed as nearly a pure protein diet as
possible, and to give moderate doses of sodium bicarbonate such as would prob-
•ably not derange the stomach. The diet consisted of 600 cc. clear soup, 600 cc.
coffee, 300 gm. thrice boiled vegetables, steak, and white of egg, with addition of
10 gm. sodium chloride daily. The record is summarized in Table X.



326



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CASE RECORDS 327

By Feb. 21, clinical improvement was perceptible and the albumin and casts
had almost disappeared. Thereafter clinica;l betterment was rapid. The patient
was kept in bed on account of weakness until Mar. 2, after which, notwithstanding
the fasting, his strength permitted being up. The diet as shown represents first a
high and subsequently diminished protein ration, with continuous undernutrition
from the total energy standpoint. Glycosuria diminished but did not cease, and
there was a still more marked subsidence of signs of acidosis. Beginning Mar. 1
fasting was instituted, with 300 cc. clear soup, 300 cc. coffee, and 10 gm. sodium
chloride daily. The glycosuria cleared up uneventfully, also the ferric chloride
reaction became entirely negative even during the fast. The diet was subse-
quently built up gradually in the usual way, and the patient was dischargted July
29, 1916, weighing 39.6 kg., on a carbohydrate-free diet of 80 gm. protein and
1550 calories, without fast-days unless demanded by glycosuria (approximately 2
gm. protein and 39 Calories per kg.). Not only was the carbohydrate tolerance
practically nil, but the patient was now a thin semi-invalid, cheerful and able
to be about, but contrasting strongly with the fully healthy appearing lad that he
was at the former discharge. Though the urine was free from sugar and ferric
chloride reactions, and the ammonia excretion and plasma bicarbonate were within
normal limits, hyperglycemia was persistent. A bad prognosis was given.

Acidosis. — ^An example is afforded of the treatment of coma coming on during
fasting, by means of protein feeding and moderate doses of alkali. Fat would
presumably be harmful, both as furnishing acetone bodies directly and as de-
tracting from the desired undernutrition. The value of carbohydrate is question-
able with such high glycosuria, hyperglycemia, and D : N ratios. Protein presum-
ably serves to protect body nitrogen, maintain strength, and supply material for
ammonia formation, in addition to serving as a source of carbohydrate and to
promote diuresis. In this instance such treatment was successful when pro-
longed fasting, aided only with alkali, probably would have ended fatally.

Subseqiient History. — The patient remained free from glycosuria at home
except for occasional traces cleared up promptly by fast-days. At the beginning
of Sept. he developed a cold and simultaneous glycosuria. He was accordingly
readmitted to hospital Sept. 5, 1916.

Fourth Admission. — The weight was 38.2 kg. The patient was not so strong as
before, and had lost hope. No alarming symptoms were present, but a fast of
8 days was required to clear up the heavy glycosuria and ketonuria. A carbohy-
drate tolerance test with green vegetables alone showed a tolerance of 60 gm.
carbohydrate under these conditions; but no carbohydrate was tolerated with
mixed diet, and an intake of 60 gm. protein and 1200 calories was the maximum
possible without glycosuria. The patient's appearance suggested tuberculosis, but
the cold passed off readily with the clearing up of other symptoms by fasting,
and there were no later symptoms or findings on examination suggesting tuber-
culosis. The patient was discharged on Oct. 4, 1916, weighing only 35.2 kg.,
on a diet of 50 gm. protein and 1000 calories (1.4 gm. protein and 28 calories
per kg.). From the laboratory standpoint the condition was as before; i.e.,
nearly normal urine with persistent hyperglycemia.



328 CHAPTER in

Subsequent History. — The patient passed through another cold late in Nov.,
for which he was treated by a private physician who did not attempt to abolish
glycosuria and ketonuria. The cold passed ofiE, but when seen Dec. 13 the pa-
tient was in very bad condition, with edema of face and legs, and too weak to
rise from a chair without help. He was on a diet of 38 gm. protein, 10 gm. car-
bohydrate, and 1000 calories, with continuous glycosuria and ketonuria. By
Feb. 2 the strength had slightly improved, and edema was absent. He was on
a diet of 40 gm. protein, 10 gm. carbohydrate, and 1200 calories, with sodium
bicarbonate. Death occurred suddenly and without special symptoms. Mar.
29, 1917.

Remarks. — ^This was an early case of diabetes in the best type of patient, with
hereditary taint excluded as thoroughly as possible, and with the utmost intelli-
gence and fidelity in respect to everything pertaining to the treatment. The
early course was rapidly downward, threatening coma within 3 weeks, and the
case was then of the type generally described in text-books heretofore as un-
controllable. These symptoms were promptly and easily cleared up, and a
result was achieved which, according to former standards, was ideal. All cliiu-
cal and urinary symptoms were abolished and a high carbohydrate tolerance was
restored. Weight and strength were built up, and the blood sugar also was nor-
mal. The attempt was niade to let the patient return to normal activities on a
liberal caloric ration. The activity may have been permissible. The diet was
calamitous. It is not to be supposed that the carbohydrate allowance was too
high. There is not necessarily any harm in the fact that the protein at the
first discharge was up to the Voit standard (1.7 gm. per kg.; one-sixth of total
calories). But the average energy intake was 43 calories per kg. Vigorous
exercise and moderate restriction of weight did not atone for this overload im-
posed upon a weakened metaboUsm. Efl&ciency and health are known to be pos-
sible on a far lower intake. With some reduction of weight, Ufe could have been
well maintained on half to two-thirds this number of total calories. As usual,
the time actually arrived later when the boy was compelled to live on less than half
this number of calories. The fatal mistake lay in imposing this strain upon his
weakened function at the outset, so that it later broke down and was incap-
able of carrying adequately half this burden. The proper treatment would clearly
have consisted in limiting the burden in the first place, so as to avoid such a break-
down. The case is a perfect example of what was formerly called "spontaneous
downward progress" in diabetes.

By comparison with other cases taken under far worse conditions and treated
on a different principle, it can be concluded that the downward progress in this
case was due chiefly or solely to the treatment employed. Even in the later stages
the diets permitted were such as taxed the weakened tolerance to the utmost.
But the essential harm was done at the most favorable period, and the fatal out-
come was assured by the methods employed at the very time when the prognosis
seemed brightest.



CASE RECORDS 329

CASE NO. 38.

Female, married, age 39 yrs. Russian Jew; housewife. Admitted Mar. 20,
1915.

Family History.— FaXhex died at 65. Mother, one brother and sister are well;
one brother died of phthisis. No other diseases known.

Past History.— No illnesses known. Said to have been treated at a hospital
2 years ago for "large liver and abdomen," cured by wearing a support. Habits,
appetite, and bowel action normal. No excesses. Last menstruation was S
months and 3 weeks before admission.

Present Illness. — Began with chilly sensations and malaise 1 week ago,
followed by cough, fever, and pain, particularly in left lower chest.

Physical Examination.— A well developed and nourished woman, 5 or 6 months
pregnant; flushed cheeks, slightly bluish lips; lymg in bed breathing about 40
times per minute and groaning frequently. Tongue coated and dry; teeth false;
tonsils and lymph nodes not enlarged. Pulse 110, temperature 102.8°. Blood
pressure 150 systolic, 90 diastolic. Signs of pneumonia of left lower lobe. Liver
edge 3 cm. below costal margin. Knee jerks not obtainable. Examination
otherwise negative. Sputum was mucopurulent, yellowish gray, containing
Gram-positive diplococci, not agglutinated by Pneumonia Serum I or II. Blood
culture was sterile. Leucocytes 22,000, polymorphonuclears 91 per cent, lympho-
cytes 5 per cent, large mononuclears 4 per cent. Urine contained some albumin
and casts and showed heavy sugar and ferric chloride reactions.

Treatment. — The patient was received on the pneumonia service, and the finding
of diabetes was unexpected. The temperature feU to normal within 24 hours,
but the pulse and respiration continued elevated.

After death a needle inserted in the third intercostal space close to the ster-
num, with the idea of obtaining blood from the heart, yielded an abundance of
very turbid gray fluid, which clotted quickly on standing, showed leucocytes
but no bacteria in films, and was sterUe on culture — apparently a large peri-
cardial effusion. Necropsy was not permitted.

Remarks. — ^This is another example of diabetes discovered during the course
of an acute infection. Whether the infection produced it, or (more probably)
made active a latent or mild diabetes, is undetermined. The severity of the
acidosis is indicated by the low blood bicarbonate with large doses of alkali.
In expectation of the use of such doses, cathartics were omitted, and, as antici-
pated, moderate persistent diarrhea was kept up by the bicarbonate, the dis-
crepancy between fluid intake and output being thus accounted for. The impres-
sion was created that the alkali in such doses was definitely beneficial, and that
smaller doses would not have sufficed. Notwithstanding the combination of in-
fection and existing coma on Mar. 26, the acidosis symptoms passed off, and the
blood bicarbonate on the day of death was nearly normal. It is possible that
death was partly due to the diabetic intoxication, which may exist in the absence
of some of the signs of acidosis, but there is entirely sufficient cause for death



330



CHAPTER III



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332 CHAPTER III

without this assumption. It was not the intoxication sometimes attending upon
fasting, because the typical nausea was absent, and the food retained on Mar. 29
.brought no improvement. In summary, it may be said that pneumonia, middle
ear infection, death of fetus with subsequent artificial delivery, and either peri-
carditis or empyema, constituted a sufficient explanation of the fatal result,
and under these conditions 5 days of very low diet followed by 5 days of fasting
failed to control the diabetes.

CASE NO. 39.

Female, unmarried, age 27 yrs. American; teacher. Admitted Apr. 3,
1915.

Family History. — ^A maternal grandfather died of cancer with suspicion of
accompanying diabetes. A paternal aunt was insane 15 years ago, but has ap-
parently recovered. Patient's mother died of diabetes at 37. Father is well,
aged 70, but had nervous breakdown 25 years ago which kept him from work
for 3 years. Strong neurotic element in family. A brother of patient is a young
physician, of nervous temperament. A sister died of heart trouble within a
few months after birth. No syphilis, tuberculosis, or other diseases known.

Past History. — General healthy life under good hygienic conditions in small
New England towns. Several childhood diseases, including scarlet fever, said to
have been followed by ear trouble and nephritis. No other illnesses. Habits
regular; always nervous in disposition.

Present Illness. — ^About 4^ years ago headaches began and transitory poly-
dipsia and polyuria. The patient was first dieted by a local physician, then be-
ginning in the spring of 1913 she was under Dr. Jbslin's care several times. He
found her a model patient in hospital and the glycosuria was easy to stop, but
the patient appeared mentally incompetent whenever she returned home and
never had the will power to adhere to diet. On certain occasions she
wandered from home in lapses of consciousness, and she was regarded by Dr.
Joslin as definitely insane, though bright and active most of the time. In
the summer of 1914, after heavy mental and physical strain, she suddenly lost
consciousness for 1 day and was stuporous for 6 days thereafter. Her local
physician called the condition diabetic coma. She recovered on fasting and
bicarbonate. Thereafter she made some attempts to follow diet, but home con-
ditions were difficult and glycosuria and ketonuria were continuous.

She was admitted to a New York hospital in Mar., 1915, with facial neuralgia
of intense type. Here again glycosuria cleared up rather easily, but there was
the same difficulty regarding adherence to diet, and here also the patient was
considered mentally irresponsible to the point of insanity. The neuralgia, how-
ever, ceased with the improvement in the urinary symptoms. The patient was
financially unable to remain longer under hospital expense, and was admitted
to this Institute on Apr. 3, 1915, for the purpose of testing the effects of pro-
longed thorough treatment, not only upon the diabetes but also upon the nervous
and mental condition.



CASE RECORDS 333

Physical Examination.— Yiti^t 168.1 cm. A well developed and nourished,
nervous appearing young woman. Hair thin, short, and dry. Eyes slightly
prominent. Suspicion of slightly enlarged thyroid on palpation. Knee and
ankle jerks normal. Examination otherwise negative.

Treatment. — Glycosuria and ketonuria were present. After a single fast-day
on Apr. 4, notwithstanding faint traces of glycosuria, small quantities of green
vegetables were begun. Glycosuria stopped even while they were increased, and
remained absent until, on Apr. 15, the vegetable diet (including com and peas)
represented 42 gm. protein and 150 gm. carbohydrate. Although the fat in such
diets was only 40 gm., marked ferric chloride reactions steadily persisted with
this carbohydrate intake, and with 170 gm. carbohydrate on Apr. 16. Apr. 17
was a fast-day followed by diets of 800 and 450 calories on Apr. 18 and 19, and then
6 days of complete fasting, 150 cc. clear soup being permitted, except on Apr.



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 36 of 76)