Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

. (page 37 of 76)
Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 37 of 76)
Font size
QR-code for this ebook


23 and 24, when nothing but water was given. The persistent glycosuria and
elevated blood sugar strongly suggest surreptitious eating during this time.
The usual diet was begun on Apr. 26 and rapidly increased, until for a short time
after May 24, 90 to 100 gm. protein, 40 gm. carbohydrate, and 2300 calories
were tolerated. On account of persistent slight glycosuria (June 3 to 7) fasting
was imposed. No other interpretation seems possible than that this was due to
forbidden food obtained in some manner not discovered; but the policy of fast-
ing until glycosuria ceased was a salutary check to such practices. Thereafter a
slightly lower diet was tolerated with occasional traces of glycosuria, some of
which were confessedly, and others probably, due to candy or other prohibited
foods. After fast-days on July 24 and 25, a carbohydrate test was instituted, and
showed a tolerance of approximately 300 gm. carbohydrate ip the form of green
vegetables. The hospital discipline had benefited the patient, and this indica-
tion of improvement was a great encouragement to her.

She was discharged Aug. 13 on a diet of 100 gm. protein, 30 gm. carbohydrate,
and 1900 calories (about 1.8 gm. protein and 34 calories per kg.), the weekly
fast-days reducing the average to about 1.4 gm. protein and 30 calories per kg.
She promised faithfully to adhere to this diet. There was unmistakable psychic
as well as physical change in the patient, and though still nervous she was clearly
more dependable and better fitted to take care of herself.

Acidosis. — At entrance the ammonia nitrogen was only 0.56 gm. and the
ferric chloride reaction mostly no more than moderate; but the plasma bicarbonate
showed the rather low level of 47 per cent on Apr. 5 and 45 per cent on Apr. 7. It
thus fell slightly during the days of very low carbohydrate, which were almost equiv-
alent to fast-days (10 gm. carbohydrate and 300 cc. soup daily). With continu-
ance of undernutrition and slight increase of carbohydrate, it rose sharply within
normal limits by Apr. 9, without the use of alkali. Thereafter the curve ran a
normal course but seemed to tend to fall with fasting, being found slightly below
normal on May 3, following the preceding fast-day, and again after fasting on
July 26. The consistent course of the ammonia curve was low. A slight ferric



334 CHAPTER in

chloride reaction tended to persist. It gradually faded out and became negative
in periods, and after the carbohydrate test in July and Aug. it became consistently
negative.

Blood Sugar.— On Apr. 7, just as the glycosuria was clearing, the blood sugar
was just below 0.2 per cent, indicating a normal renal threshold. With further
days of low carbohydrate, it had fallen to normal on Apr. 9. The carbohydrate
tolerance test led to hyperglycemia of 0.22 per cent with glycosuria on Apr. 16.
The excessively high figure shown on Apr. 22 was not checked and therefore
might have been a mistake. Thereafter the values tended to fall below 0.15
per cent. Other work made it necessary to stop the analyses; on this case after
May 18. >

, Weight and. Nutrition. — The patient entered in a very well nourished condition
weighing 59.2 kg. She was still well nourished at discharge, weighing 55.8 kg.
The net result of treatment was thus undernutrition to the extent of a loss of 3.4
kg. With the clearing of diabetic symptoms there W9,s the usual gain in strength
and well-being, and the patient felt entirely well at discharge.

Subsequent History.— The: patient resumed her regular work at home and fol-
lowed diet surprisingly well. On three occasions she went' on what she termed
"sprees" of carbohydrate, but experienced symptoms of weakness and.mp,laise
within a limited number of hours after the onset of the heavy glycosuria, and
cleared up her condition, generally after some delay, by fasting, on one or two
occasions as long as 5 days. Against external as well as internal difficulties she
kept up a continuous effort to remain sugar-free, and notwithstanding the lapses
from diet, continued to gain in weight and subjective health. On account pf
sugar and ferric chloride reactions in urine specimens received, it became advis-
able to readmit the patient on Jan. 12, 1916, 5 months after discharge.

Second Admission. — The weight had now risen to 64.1 kg.; i.e., 4.9 kg. more
than at the former admission, and both the physical and mental condition ap-
peared excellent. On the diet prescribed at discharge, the plasma sugar was
0.264 per cent and the CO2 capacity 49 per cent. There was a heavy ferric
chloride reaction, and 2.18 gm. ammonia nitrogen in the > urine. Fast-days on
Jan. 19 to 20 sufficed to clear up the glycosuria, but the tolerance on the ensuing
days with green vegetables proved to be now only 50 gm. carbohydrate. Though
diets lower in both carbohydrate and total calories were employed, it was diffi-
cult to obtain freedom from traces of glycosuria. During late Mar. and early .
Apr. there was decided intolerance for a diet of 65 gm. protein, 15 gm. carbohy-
drate, and 1500, calories. After Apr. 16, carlaohydrate was excluded. Even on
diets as low as 60 gm. protein and 1000 calories, traces of glycosuria recurred.
But with continuance of this undernutrition they remained absent after May
2, and by May 12, 70 gm. protein and 1400 calories were tolerated. With redu,Cj-
tion of one-seventh by weekly fast-days, this represented approximately 1 gm.
protein and 20 calories per kg. of weight. The patient was discharged on this
diet May 13, 1916. , ,



CASE RECORDS 335

Acidosis. — The CO2 capacity of the plasma rose easily within normal limits
without the aid of alkali, and remained so except for a single low reading on
May 9. The ammonia excretion at the outset was much higher than before,
i. e. 2.18 gm. N; also the ferric chloride reaction was heavier. Thus these signs
indicated a higher acidosis than at the former admission, though the plasma
bicarbonate was 2 per cent higher than then. Isolated determinations on Feb.
7 and 21 indicated about the same subsequent level of ammonia as at the pre-
vious period in hospital. The ferric chloride reaction cleared up much more
easily and promptly than before, although the diets were so much poorer in
carbohydrate than before and frequently carbohydrate-free. This result is ex-
plained by two causes, first, the previous treatment, and, second, the lower total
caloric i value of the diets at this admission. The ferric chloride reaction was
thus negative on carbohydrate-free diet at discharge.

Blood Sugar. — An aggravation of the condition was indicated by the fact that
even on low diets the blood sugar never became normal, but remained above,
rather than below 0.15 per cent. More rigorous treatment could presumably
have reduced the hyperglycemia even at this stage.

Weight and Nutrition. — The patient's gain in weight during her absence from
hospital would once have been regarded as an improvement. Its real meaning
is that the diabetes was sufficiently mild to permit a gain in weight even in the
presence of glycosuria, and in this mUd stage injury was wrought by exceeding
the true functional power with respect to both diet and weight. After readmis-
sion to hospital, the weight at first fell from undernutrition, then fluctuated,
and on two occasions, namely Mar. 7 and 8, and Apr. 28, rose higher than at ad-
mission, because of marked edema. This edema was not associated with any alkali
administration, but may have been due to sodium chloride. The weight at dis-
charge was 61.2 kg., being 2 kg. higher than at the first admission and 2.9 kg.
lower than at the second admission. A portion of this weight may stUl have
been abnormally retained water, which however was not apparent on examina-
tion. The diets in general represented undernutrition, and the diet at discharge
meant further undernutrition and reduction of weight.

Subsequent , History. — The patient undertook to support herself by visiting
and other duties in connection with diabetic patients of a physician in New
York, and one stay at a country place was also arranged. She remained free
from glycosuria through the summer, but her diet became uncertain by reason of
her preparing her own meals under irregular conditions and making trials of
various modifications to suit herself. She finally undertook too heavy a load of
work and took too high diets in the attempt to keep up with her ambitions.
She managed to remain in fair condition as respects, diabetes, and in good con-
dition as respects general health, until readmitted Dec. 30, 1916.
■ Third Admission.— The weight was still 62.7 kg., partly due to edema. The
general appearance, strength, and behavior showed no perceptible change.
Downward progress was indicated by the fact that a 7 day fast was neces-



336 CHAPTER in

sary this time to bring the glycosuria under control. The subsequent history in
hospital was uneventful. The patient broke diet on a few occasions, otherwise
she was maintained sugar-free, and was dismissed Apr. 10, 1917, weighting 57.2
kg. on a diet of 60 gm. protein, 2.5 gm. carbohydrate, and 1300 calories. The
patient's intentions in regard to work were now the principal difSculty. She
was determined to carry a heavy load of work, and was not willing to undergo
undernutrition to a point which would diminish her working capacity. As
inevitable in such cases, the long abuse of the weakened assimilative power had
now brought the point where maintenance of full weight and working power was
impossible. The tolerance could be benefited only by undernutrition diets such
as prescribed. Such reduction must continue for several months before any gain
could be expected, and the damage already wrought -was such that a full return
to the former tolerance was undoubtedly impossible. The patient, though intelli-
gent and grateful, was unwilling to accept life on these terms, and proposed from
her knowledge of diets to nourish herself with a view to temporary working
capacity as long as possible.

Subsequent History. — The patient took mixed diet with restriction of all three
classes of food, but the period of ability to work was very brief. All her former
symptoms quickly returned except the neuralgia. The mental abnormality
again showed itself markedly. Though appearing bright and merely nervous in
public, in private she tore her clothing, bit and otherwise injured herself, and
made several attempts at suicide. She recognized symptoms of acidosis,
and accordingly excluded fat almost completely from her diet. It was learned
indirectly that she was in serious condition, and she was accordingly sent for
and brought back to the hospital by a nurse on June 18, 1917.

Fourth Admission. — There was a history of edema a week before. The pa-
tient took two capsules of 8 grains diuretin, and edema is said to have disap-
peared rapidly, and epigastric pain began. Smce then weakness and dyspnea
have rapidly increased, so that she has remained lying down for the past 2 days.
On the day before admission there was nausea and vomiting, and she took two
teaspoonfuls of sodium bicarbonate; otherwise she has had no alkali. Also dur-
ing these 2 days she claims to have fasted, partly from lack of appetite and
partly in the attempt to treat herself for acidosis. Weight was 58.1 kg.; i.e.,
1.1 kg. less than at first admission. The patient lay in bed, evidently extremely
weak. The general appearance was about as before. Neither emaciation nor
edema was present, also the tissues were not perceptibly dry or flabby. There
was a deep dusky flush of cheeks, involving lower eyelids. Air-hunger was in-
tense; deep pauseless respirations 22 to 23 per minute as the patient lay
in bed; so extreme on the slightest exertion that drinking and speaking were
difficult. The patient dozed continually when undisturbed, but roused easily and
rather nervously. Intelligence was fully clear, and she was entirely cheerful,
while convinced that death was imminent. Physical examination was negative
except for a row of herpes vesicles beginning to dry up under the left breast.



CASE RECORDS 337

These and associated tenderness explained the epigastric pain still complained
of, as due to intercostal neuralgia.

Inasmuch as symptoms of serious acidosis had begun and persisted while fat
was diminished or even excluded from the diet, and signs of coma had appeared
after 2 days of supposedly complete fasting, it was difficult to decide upon a line
of treatment for the threatening crisis. It was feared that the existing nausea
would be increased by alkali. An attempt was therefore made first with plain
fasting with soup and coffee and water forced to the limit of capacity. The
plasma bicarbonate was 30.5 per cent, the heart and kidneys were keeping up well,
and there was no sign of immediate death. It therefore seemed most conserva-
tive to wait a few hours to learn the behavior under fasting alone. The actual
progress was rapidly downward, perhaps partly on account of exhaustion from
the trip to the hospital. Unmistakable progress into coma was evident. The
patient was received at 4:30 p.m. By evening moderate doses of alkali by
mouth were begun; by midnight there had been given 10 gm. sodium bicarbonate,
30 cc. whisky, and 2105 cc. total fluids. By 9 a.m. June 19, an additional 15 gm.
sodium bicarbonate and 30 cc. whisky had been taken, yet the plasma CO2 had
fallen to 20.7 per cent, and the sugar and total acetone of the plasma were de-
cidedly increased. During June 19, 1 gm. doses of sodium bicarbonate were
given hourly with 5 gm. doses of calcium carbonate, in the hope that the latter
would help settle the stomach and possibly have some acid-neutralizing power.
Whisky was given in 15 cc. doses every 4 hours, 1800 cc. soup during the day,
and 15 gm. sodium bicarbonate. The total fluid intake was 9805 cc. By 10:30
p.m. improvement seemed to have been obtained. The breathing seemed
quieter, the consciousness clearer, and the CO2 capacity had risen to 27.7 per
cent. By the next morning the patient had begun to refuse bicarbonate because
of nausea, and the coma sjonptoms showed increase. An attempt was therefore
made to supply fluid and a moderate quantity of alkali intravenously. Accord-
ingly, 500 cc. physiological saline solution, containing 13 gm. sodium bicarbonate
were given slowly through a needle. The breathing became quieter, but an
attack of vomiting resulted and consciousness did not improve. It was then
attempted to feed protein in the form of white of egg mixed in the soup. The
small quantities thus given were retained several hours, then vomited. Com-
plete unconsciousness came on, with continuance of the intense dyspnea, and
nothing seemed left but to attempt to raise the blood alkalinity by larger doses of
soda intravenously, notwithstanding the known danger. Accordingly 1 hter of
saline solution containing 38 gm. sodium bicarbonate was given in an injection
into the arm vein in half an hour. Dyspnea diminished. The pulse, which was
strong, was unchanged. The flush of the cheeks became paler. Consciousness
was not restored, and an attack of vomiting was excited. Unconsciousness with
slight restlessness continued until 5 p.m., when there occurred the sudden death
without warning which is rather characteristic following large intravenous doses
of alkali. The principal data are contained in Table XII.



n






a

d
o
p


9:00 a.m.
12:00 n.
10:30 p.m.


9:00 a.m.
2:00 p.m.
Autopsy:


•ODOOI
«d3nO}3Dl!I^OX


i


1^


105.0

116.0

93.0


112.5
146.5
176.4


■M 001
Bd (3no;33B
s^) 3ii^nqXxo-g/


s


1


M 1 ■


91.0
108.0


•DD GOT "<! 3B"


t


1


1 1 1


55.5
68.4


■SOD BoisrBId


1^1




t^ ■f-H t^

O T-H !>■
CS <N CS


CO ro 00
1^ 00 lO

^ ^ cs


•jB3ns BoiffBU


11


o

IN

d


VO -^ - ^H

Tt< O ON

ro rri CS

odd


ID t^ O

m in o\

^ CO uo

d <=> a


6


•snojsOT p;ox


i


d


VO
CO

in

VO


CS


•(anataje
SB) 3uX}nqjCxo-gl


i


00


1— 1
CO

9


VO


•DH3D

-3ip ptre snojsov


E


IN




vd


N^N




1-1


o\


s


■ORW M : a




^

lO


o

CO




•aaSoJira [ejox


E




On
NO

CN


ID

On


•j^Sns


i


VO


2


NO


•aninioA


s


00


as


§
s


■a^B^mpraij


u


o

<N


1


1-4


4>

(3


■331101^3






1 "^

1 ^


1-1


■loqoaiv




lo


^


t^


•3]BjpjCqoq]E3


III 1


■'^^


a


1


1


d


•UI3J0JJ


i


1


1


CS


■dnog


S


i


1—1


8

cs

^— 1


•9pU0[qD lunipog


1


>o


1-1.


o


•sjOTOqjTO ranpi^o


E


1


VO


o

CO


•3}Bnoq«Diq innipog


a


o


^


3


•uoijBiidsa^




cs o

(N CS


s?g


"i" 00
CM (N


•3Sina




^§8


ss


O NO
CO On


■3jn}«3(ilH3X


&;


On On


O 00
O 0\


On no
ON 0\






5


OO

3
1—1


2


O



338



CASE RECORDS 339

Remarks.— This was one of the cases with exaggerated protein catabolism, as
indicated by the nitrogen excretion of 23.7 gm. on June 19. On June 20, an equal
or higher quantity must have been eliminated, but large quantities of urine passed
involuntarily were lost, and also death occurred at the end of 17 hours of this
day. Any error of diet as an explanation of the high D : N ratios is excluded,
as the patient was stuporous and isolated in a room with a special nurse. Only 2
days of fasting, according to the patient's report, had intervened since her period
of liberal diet, including carbohydrate. The nutrition was well maintained as
stated, and it must be assumed that with the rapid and intense change for the
worse, body glycogen was being swept out.

Several lines of treatment are open in such a case, but death occurs in a great
majority under these circumstances no matter what is done. Treatment without
alkali and -vjithout food, but supplying fluid and salt, was first tried with ominous
results. Another possibility would have been fasting with alkali from the outset.
Dosage by mouth could have accomplished nothing more by reason of nausea.
There might have been some real helpfulness in small intravenous doses of bicar-
bonate at intervals of a few hours, perhaps alternating with doses by mouth.
It appeared, however, that considerable quantities of alkali were necessary to
affect the blood alkalinity, and this excited nausea even when given intravenously.
Another possibility lay in feeding with or without alkali. It is highly question-
able if carbohydrate is of any benefit in the presence of a maximal D : N ratio.
Fat would seem to promise nothing but harm. Protein might have been bene-
ficial; but again it may be that an attempt to feed anything wiU sometimes aggra-
vate a condition of impending coma. A noteworthy feature is the fact that the
renal function was weU maintained to the end, and large quantities of urine were
passed involuntarily in the closing hours of life. It is now less common for pa-
tients received with impending coma to go into coma under treatment, but with
the exaggerated protein catabolism and continued maximal D : N ratios, such a
result is still often unavoidable.

In its general aspects the case illustrates the interrelation of diabetes and
nervous disorder, and the actual symptomatic improvement of the latter under
careful treatment of the former. Had either the psychic state or the environ-
ment been more favorable, something might have been accomplished; but with
both adverse, the patient made a brave effort but lost in the end.

CASE NO. 40.

Male, unmarried, age 29 yrs. American; doorman. Admitted Apr. 12,
1915.

Family History. — Little known; no history of disease obtainable.

Past History. — Measles, whooping-cough, scarlet fever in childhood. Right-
sided pneumonia 15 years ago. Neisser infection, also chancre some years ago;
no secondary symptoins and no treatment. Frequent colds, but rarely sore



340 CHAPTER III

throat. Formerly used whisky to excess, but recent alcoholism denied. He
smokes pipe and cigars in moderation, and takes two cups of coffee and three
of tea a day. He sleeps well, has poor appetite, and regular bowels. No known
loss of weight or other diabetic sjrmptoms.

Present Illness. — Patient entered on the pneumonia service 24 hours after
initial chill. He had a severe Type I pneumonia involving lower lobes on both
sides, with positive blood culture. Leucocytes 24,800, polymorphonuclear 90
per cent. Highest temperature 104°. Blood pressure 125 systolic, 70 diastolic.
Physical examination otherwise negative.

Treatment. — Urine was smoky red and showed heavy albumin, slight Benedict,
and moderate ferric chloride reaction. He was treated on the pneumonia serv-
ice with Type I pneumococcus serum. The blood became promptly sterile;
the temperature, pulse, and respiration remained elevated. On Apr. 12, the diet
consisted of 370 cc. milk, 150 cc. broth, and 150 cc. albumin water. On Apr. 13,
300 cc. albumin water, ISO cc. soup, and ISO cc. cocoa were given, and there
was shght glycosuria and a slight ferric chloride reaction. On Apr. 14, 700 cc.
albumin water and ISO cc. soup were the diet, and both sugar and ferric chloride
reactions diminished to traces. Apr. 15 and 16, the diet was similar but included
also 200 to 400 cc. mUk. Traces of sugar and diacetic acid persisted. Meanwhile
the temperature ranged from 101. 2-103. 6°F. Beginning Apr. 17, the patient
was placed partly under the care of the diabetic service because of abnormal
drowsiness and hyperpnea. On that day 15 gm. sodium bicarbonate were given,
and the diet was changed to clear soup and whisky. On Apr. 18, 40 gm. sodium
bicarbonate were given, and the previously acid urine turned neutral for part
of the day. On Apr. 19 another 40 gm. sodium bicarbonate were given, and the
urine was neutral throughout the day. On Apr. 20, the urine again turned acid,
but another 40 gm. bicarbonate then turned it alkaline. Continuance of 40 gm.
sodium bicarbonate on Apr. 21 and 30 gm. on Apr. 22 kept the urine neutral
or alkaline. Meantime the ferric chloride reaction, from almost negative, had
became intense. Under the influence of the alkali dosage the drowsiness cleared
up. Apr. 23, 50 gm. carbohydrate in the form of. green peas were tolerated, but
100 gm. in the form of peas and potatoes on Apr. 24 caused slight glycosuria.
Beginning Apr. 25 a diet of soup, eggs, and vegetables was given, mostly about
1000 calories. Because of the stubborn ferric chloride reaction, fastmg was im-
posed on May 2 and 3, and then a diet of vegetables up to May 6, containing a
maximum of 75 gm. carbohdyrate. On May 7, a low carbohydrate-free diet of
less than 500 calories was given for the purpose of avoiding too long continued
abstinence from soUd food in a patient with infection. A mixed diet was then
gradually built up, glycosuria appearing on May 16 with an intake of 67 gm. pro-
tein, 75 gm. carbohydrate, and 1700 calories. The diet nevertheless was still
built up, and the tolerance rapidly improved with subsidence of the infection.
The signs in the lungs persisted unduly long. Sermn sickness with urticarial
eruption was present Apr. 20 to 26. On May 10, the left seventh rib was resected



CASE RECORDS 341

under local anesthesia for drainage of the empyema. It will be noted that gly-
cosuria and a trace of ferric chloride reaction appeared on May 11, seemingly in
consequence of this operation, and promptly cleared up without reduction in
diet. The temperature subsided somewhat, but persisted in the neighborhood
of 100°. Albuminuria had gradually diminished and was negative after May 10,
but edema of the ankles persisted. On June 12, there appeared a fusiform swell-
ing of three fingers of the right hand, and later also in joints elsewhere. The tem-
perature rose at this time, but there was no glycosuria, and the ketonuria was
only such as could be explained by the high fat of the diet. Thereafter the
temperature gradually diminished and was normal after July 1. From the
diabetic standpoint, the diet was built up to a high level, not only for the pur-
pose of strengthening the patient, but also for the purpose of testing his toler-
ance. The latter proved to be almost unlimited. Carbohydrate was increased
through the various classes of food, until the tolerance was found above 200
gm. in diets containing fruits, potatoes, cereals, and bread. _ Cane sugar was
then permitted, beginning with 50 gm. on July 19, and glycosuria remained
absent until a brief trace appeared on July 23 on an intake of 119 gm. protein,
380 gm. carbohydrate, and over 3900 calories. On July 22, he had tolerated such



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 37 of 76)