Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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a diet, including 200 gm. cane sugar distributed throughout the day. On July
23, the carbohydrate allowance included this same quantity of sugar, but it was
given all at once, and a trace of glycosuria was present for a few hours. The
patient was therefore sent out on fuU mixed diet, on the presumption that the
diabetes had been transitory.

Acidosis. — ^The case is an illustration of threatened coma under the influence
of infection in a patient never known to have been diabetic, kept on very low
diet because of the inability to take more, and with only slight sugar and ferric
chloride reactions in the urine. The actual acidosis was revealed by the quanti-
ties of alkali required to turn the reaction of the urine, and by the intense ferric
chloride reactions which resulted. Relatively few analyses had been made at the
outset while the infectious features predominated. On Apr. 21, the first am-
monia determination showed the low value of 0.59 gm. N under the influence of
alkali. With omission of alkali, the ferric chloride reaction cleared up quickly
but temporarily, and the ammonia nitrogen on Apr. 24 shot up suddenly to nearly
2.5 gm. By Apr. 26, adjustment had occurred under the influence of continued
undernutrition and a little carbohydrate, and ammonia values thereafter never
reached an alarming level. More or less ferric chloride reactions recurred until
June 16, especially by reason of the high fat intake, but thereafter 75 gm. or more
of carbohydrate in the diet sufficed to abolish ketonuria even with abundance
of fat.

Weight and Nutrition. — The 1st month in hospital represented marked under-
nutrition, particularly in view of the fever. The body weight was kept up by
edema. Beginning May 7, there was a sharp decline in weight with subsidence
of edema, and after June 4 the weight rose rather rapidly under the liberal diets.



342 CHAPTER III

Remarks. — The case is an example of diabetes occurring with an acute infection
under circumstances which make it appear that the infection had given rise to
the diabetes. It is open to speculation whether the diabetes would have
passed off if heavy glycosuria had been maintained by excessive carbohy-
drate feeding from the outset, especially as this might actually have been em-
ployed under former methods of treatment for the purpose of controlling acidosis.
It was also important to determine whether the diabetes was actually transitory,
presumably the result of direct or indirect involvement of the pancreas, or whether
the infection merely brought into prominence a latent diabetes. The normal
sugar tolerance at discharge would point to a genuinely transitory diabetes.
On the other hand, the only decisive test would lie in following such a patient for
many years. If diabetes ultimately became manifest, it might then mean either
a latent diabetes, antedating an infection and temporarily made active by it, or it
might represent injury of a previously normal pancreas by the infection, with tem-
porary recovery to a considerable degree, with impairment and later breakdown of
the internal function. None of these questions could be answered because the
patient was lost sight of in spite of attempts to foUow him up. •

Among the features of the treatment, the most striking seems to be a defi-
nitely beneficial effect of alkali which cleared up symptoms threatening coma,
when fasting and low diet were accompanied by dangerous acidosis and when the
patient was in no condition to take much food. It is also worth noting that
coma may threaten under such conditions with only sUght sugar and ferric
chloride reactions and with diabetes apparently of mild degree.

CASE NO. 41.

Male, married, age 52 yrs. Irish; poKtician. Admitted Apr. 23, 1915.

Family History. — Parents died in old age. One brother well; two died in in-
fancy. One sister well; one died in infancy; one died of tuberculosis at 33. There
was mental disorder running through several generations on the mother's side.
Two of the patient's aunts died in insane asylums. No diabetes or other diseases
in family.

Past History.— Healthy and checkered life. Measles, mumps, chicken-pox,
scarlet fever, diphtheria in childhood; no sequelae. Bom in Ireland, ran awaly
to sea at age of 20, and worked mostly as a stoker in the tropics for 7 years, but
continued to enjoy good health. He then came to New York, worked at manual
labor for a number of years, then gained influence in labor organizations and poU-
tics, and has since been occupied in ofiicial positions. There was cough and
loss of weight shortly after his arrival in New York; tuberculosis was diagnosed, .
but there was apparently complete recovery. He also had pleurisy and "shingles"
20 years ago, but recovered rapidly, and has never been iU since. Venereal his-
tory consists in Neisser infection in 1883, followed by inguinal buboes treated by
incision in hospital. Chancre in 1885, followed by slight rash 3 weeks later.



CASE RECOIIDS 343

Habits have generally been good in view of hard life. Not mbre than 2 or 3
drinks a day, generally beer. Has never used tobacco. The diet on shipboard
left him with more or less indigestion. Bowels usually regular. He has eaten
rather liberally of sweet foods.

Present Illness. — 4 years ago he was troubled with dry throat following a
cold. Physician in routine examination found 2 per cent glycosuria. Shortly
after this polyphagia, polydipsia, and polyuria set in, but disappeared on mod-
erate restrictions of diet. There has been no attempt to make him sugar-free.
6 months age he barked his shins; these were very slow in healing, and collections
of pus required opening. Since Mar. 17, he has had a grippe infection and con-
siderable impairment of general health, and his physician advised him to come
to the Institute for diabetic treatment. The loss of weight has amounted to 15
pounds in the past 3 years.

Physical Examination. — Height 172 cm. Awell developed, strong looking, some-
what obese man, showing no distress, but with cyanosis of face. Temperature 1 02°
F., pulse 120, respiration in bed 36. Breathing not of air-hunger type. Teeth all
false. Throat slightly congested; tonsUs show slight hypertrophy without exu-
date. Lungs, slight bronchitis and emphysema. Slight generalized enlargement
of lymph nodes. Blood pressure 125 systolic, 70 diastolic. Reflexes normal.
Pigmented scars on shins; sHght edema of ankles. Wassermann -j - |- in blood,
negative in spinal fluid. Physical examination otherwise negative.

Treatment. ^-On admission there was a rnoderate sugar and slight ferric chloride
reaction, and a heavy trace of albuminuria with large mmibers of hyaline and
finely granular casts. On Apr. 24, the first full day in hospital, the diet was 84
gm. protein, 3 gm. carbohydrate, and 2375 calories. Glycosuria entirely cleared
up during the day, and the ferric chloride reaction was also negative. Fasting
was begun, nevertheless, as the quickest means of undernutrition, and was con-
tinued for 8 days. The temperature and cough cleared up during this time, also
the albuminuria gradually diminished to a trace. The patient was fully com-
fortable, and on 450 cc. soup daily had no special complaint of himger. Green
vegetables were the first food given, in the form of a tolerance test. The gly-
cosuria with 20 gm. carbohydrate on May 4 was an accidental trace, not repre-
senting the true limit, which was reached with 100 gm. carbohydrate on May
8 and 9. This glycosuria ceased on cutting down the carbohydrate to 21 gm.
on May 10. Beginning May 11, two eggs and 50 gm. bacon were given as the
first substantial food in the 18 days since admission. 10 to 20 gm. carbohydrate
were retained in the diet, which was gradually built up to 65 gm. protein and 1330
calories on May 16 and 17. That this diet was too high was indicated by the
sharp rise in ammonia, and the high blood sugar on the morning of May 18.
The fact that glycosuria was absent then, but traces were present on certain
subsequent days, is possibly a phenomenon of renal permeability. Albumin
and casts were absent from the urine after May 9, and renal function tests by
Dr. McLean showed no abnormality throughout. It became possible to increase



344 CHAPTER III

all three classes of food rather rapidly. There was more feelipg of hunger toward
the close of May than on the fasting and lower diets previously. On May 13,
0.2 gm. salvarsan, and 0.5 gm. doses on May 24, and June 7 and 21, were injected
intravenously. There were 30 mercury inunctions about this time. At dis-
charge on July 7 the prescribed diet was 100 gm. protein, 95 gm. carbohydrate
(including 20 gm. bread), and 2400 calories (approximately 1.4 gm. protein and
33 calories per kg., reduced one-seventh by the weekly fast-days). The re-
covery of subjective health was complete, in such manner that there was no
question of the patient's future fidelity.

Acidosis. Ferric Chloride Reaction. — First may be noted the fact that a
slight ferric chloride reaction was present along with glycosuria on the lax diet
at admission, and on the carbohydrate-poor diet of Apr. 24 this cleared up com-
pletely. It then reappeared on the second day of fasting and became heavy,
but this was no reason for discontinuing the fast. The reaction diminished to
traces on May 8 and 9, but the ingestion of 100 gm. carbohydrate without other
food was unable to abolish it completely on these days. With the diminished
carbohydrate intake and the gradual addition of fat on the succeeding days, it
again became heavy, but showed the usual tendency to fade out, irrespective of
diet, as the general condition improved. After becoming negative, it stiU showed
the same tendency to reappear with fasting, being present on June 21 after a fast-
day (but not on the fast-day itself), absent with the fast-day of June 27, and
present on the fast-day of July 4. The trace of glycosuria which appeared on
Jime 23 was supposedly the result of slight excitement, and, as frequently hap-
pens, a trace of ferric chloride reaction appeared with the sugar.

Blood Bicarbonate. — No CO2 estimations were made during the first few days.
The low level of 45 per cent on Apr. 30 was probably the result of fasting. No
alkali was given, and the curve tended to rise rather than fall. Particularly the
allowance of a little carbohydrate brought it well up to normal limits on May 6.
With undernutrition and predominantly fat diet on May 12, the CO2 was again
down to 46.4 per cent. On the morning of May 18, following the increased diets
of May 16 and 17, it was again within normal limits. It may be noted that this
rise was not prevented by the febrile attacks mentioned below. On May 24,
following the preceding fast-day, it was again barely above 45 per cent. With
the higher diets and higher carbohydrate ration prior to discharge, the CO2
capacity was at a high normal level.

Ammonia.— In conformity with the absence of other signs of acidosis, the
ammonia nitrogen on carbohydrate-poor diet on Apr. 24 was only 0.63 gm. It
steadily rose on fasting, showing the development of acidosis, and on Apr. 30 had
reached 2.27 gm. The 100 gm. carbohydrate on May 8 and 9 brought the ammonia
down to a low normal level. Thereupon, with little carbohydrate, and under-
nutrition with a predommance of fat, the ammonia rose slightly. On May 13,
0.2 gm. salvarsan in 150 cc. saline was injected intravenously. On May 14,
there was temperature of 100.8°F., with slight albuminuria and a few casts!



CASE RECORDS 345

Toward evening there was a chill with temperature of 104°, leucocyte count
14,000, polynuclear 75 per cent; no malaria parasites; blood culture sterile;
influenza bacillus and Pneumococcus IV in sputum. On the following days
there was pain and swelling of the left leg from knee to ankle. By May 18, the
temperature was down to 99.2°, and thereafter was normal. Aside from the
hyperglycemia shown, this infectious attack made itself felt strikingly in the
ammonia output. This climbed steeply to the astonishing figure of 5 gm. am-
monia nitrogen on May 17, then fell abruptly as the temperature fell. Rela-
tively low values were present with the undernutrition and fasting of May 19
and 20. In consequence of protein-fat feeding, the ammonia rose as feeding was
continued to nearly 3.36 gm. N on May 26 and 30. Thereafter, with increasing
carbohydrate intake and improved general condition, the ammonia proceeded to
fall to a permanently normal level.

Blood Sugar. — The hyperglycemia doubtless present at admission was re-
placed by the normal figure of 0.120 per cent as early as Apr. 27. The rise to
0.167 per cent on Apr. 30 is one of the curious fluctuations which occur some-
times in fasting. Hyperglycemia of 0.168 per cent was present with the febrile
attack on May 18. Subsequent determinations showed fully normal values
(mornings before breakfast).

Weight and Nutrition. — The patient was obviously overnourished, and treat-
ment consisted primarily in reducing weight and relieving the overburdened
metabolism. The sharp fall in the weight curve during the early undernutrition
is shown in the graphic chart. It was noted above that only benefit was felt
subjectively, and the existing grippe infection and albuminuria both cleared up
promptly. Even during the period of low diets the patient said he felt as if 10
years had been subtracted from his age. He lost 10.2 kg. in hospital, but the
weight of 72 kg. at discharge was abundant for his stature, and he stated that he
had never felt better in his life. It is obviously bad practice to allow a diabetic
patient to carry abnormal weight. The good prognosis of fat diabetes belongs
to the mildness of the diabetes and not to the obesity, and the prognosis is better
when the obesity is properly reduced.

Subsequent History. — ^The patient took long vacation trips to Michigan and
California, exercised heavily in walking, swimming, etc., and remained free from
glycosuria. On Oct. 8 the diet was increased by two eggs and 20 gm. bread. The
weight was 72.6 kg. On Jan. 1, 1916, it was the same. On Apr. 8, 1916, 25
gm. glucose were given at 11 a.m., and specimens of urine at 12, 1, 2, and 3 p. m.
were negative for sugar. Weight 80 kg. On Apr. 24, the patient came to the
hospital fasting for the purpose of a glucose test. 100 gm. Merck anhydrous
dextrose were ingested at 9:55 a.m. The record was as follows:



346



CHAPTER III



Hr.


Blood Sugar.


Plasma Sugar.


Urine Sugar.




fer cent


fer cent




9:50 a.m.


0.125


0.135





10:50 "


0.179








11:50 "


0.156


0.164


Faint.


12:50 p.m.


0.123


0.110





2:05 "


0.083


0.084






Up to this time the patient had received a total of 9 intravenous injections of
0.5 gm. salvarsan and 30 mercury inimctions. The Wassermann reaction re-
mained consistently + + + +. With the idea that the diabetes might have
been of luetic origin and might have been cured by the specific treatment, per-
mission was given on the basis of this glucose test for the patient to relax his
diet to the extent of ceasing to weigh food, and merely take the same general
type of diet as before so as to avoid much carbohydrate. Up to June 1, 1916,
three more doses of salvarsan had been given, also three mercurial injections
outside this Institute. He was seen at the Institute July 14, weighing 86.2 kg.;
i. e., a greater obesity than at the time of the first admission. He looked tired
and overstrained. Glycosuria was present. He had not been performing urine
tests, and showed blood sugar 0.270 per cent, plasma sugar 0.294 per cent, CO2
capacity of plasma 62 per cent. He was instructed to resume a weighed diet of
93 gm. protein, 75 gm. carbohdyrate, and 2300 calories, and to take measures to
reduce his excessive weight. With swimming and other heavy exercise he lost
2 kg. in the following week, and became free from glycosuria and ketomu^ia on
July 20. On Jidy 21 the sugar in whole blood was 0.182 per cent, in plasma
0.204 per cent, COz capacity 54.7 per cent. The urine has since remained nor-
mal and the patient has retained subjective health. The management of the
diet at home is probably not accurate, for with continuous exercise he has never
brought his weight below 80 kg. Vigorous treatment with salvarsan and mer-
cury has been continued under the care of a competent private practitioner, but
the Wassermann reaction is stiU -f- -f- -|- in the serum.

Remarks. — The case is of special interest in connection with the possible
luetic origin of the diabetes. There has been no tendency to progress down-
ward even though the Wassermann reaction remained strongly positive. The
state of health was transformed by diet alone, before any antisyphUitic treatment
was employed. If specific treatment checked the syphilitic damage, it did not
repair it. The combined treatment did not cure the diabetes, notwithstanding
the excellent result of the glucose test of Apr. 24. It could then have been no-
ticed that the patient at his elevated weight showed hyperglycemia even on
fasting, and the blood sugar curve following the dose of glucose was unduly
high. This warning was not heeded; and with further gain of weight, without
carbohydrate excess, the inevitable glycosuria returned in due season.

The case was a t3rpical example of so called "spontaneous downward progress"
when the treatment was wrong; but progress was upward when the treat-



CASE RECORDS 347

ment was right. The patient's treatment of himself at home is evidently not
sufficiently stringent. He keeps his weight too high, and although he is in
excellent subjective health and carries on his work without difficulty and the
urine remains normal, more rigid treatment is necessary or there may ultimately
be trouble.'

CASE NO. 42.

Female, age 11 yrs. American; schoolgirl. Admitted Apr. 30, 1915.

Family History. — Patient is the only child of apparently healthy parents, with
no heritable disease anywhere in family as far as known.

Past History. — Measles and whooping-cough in infancy. Scarlet fever at 7
and again at 9. No sequelae. Has been a strong, healthy, well grown child,
though living in tenement environment. She has attended school in the usual
grades. During the past 2 years she has been nervous, the mother stating that
"the higher she gets in school the more nervous she gets." About the average
indulgence in candy. A curious feature of diet is that she has never eaten vege-
tables, not even potatoes. The food has been mostly eggs, bread, and milk.
Appetite has been notably small and she has had to be coaxed to eat.

Present Illness. — 3 weeks before admission polyphagia, polydipsia, and poly-
uria began acutely. After 2 weeks she was taken to a physician who first pre-
scribed carbohydrate-free diet with addition of milk, then as glycosuria continued
he advised bringing her to this Institute.

Physical Examination. — ^A thoroughly well developed and nourished, normal
appearing girl. Tonsils protrude and show deep crypts, with pus on pressure.
Very few small lymph nodes palpable. Reflexes normal. General examination
fully normal. The child is a splendid physical specimen, brimming over with hfe
and spirits.

Treatment. — Patient was admitted at 11:45 a.m. Apr. 30, and received no
food on that day. Castor oil was given as a laxative. The blood sugar was
0.286 per cent at 3:30 p.m., but probably diminished rapidly, for the glycosuria
in the mixed urine up to the next morning was only 0.3 per cent. On May 1,
nothing was given but two eggs and 450 cc. clear soup. May 2 and 3 were fast-
days. The glycosuria was only slight on May 1, and immediatelly cleared up,
the whole picture being characteristic of an early, still mild stage in which glyco-
suria and hyperglycemia had been kept up essentially by carbohydrate. On the
other hand, the ferric chloride reaction was well marked at admission and became
heavy on fasting. The child also vomited on the ist fast-day and was weak on

' Continued specific treatment finally reduced the Wassermann reaction to ± . .
At the same time continuous glycosuria gradually developed, followed within a
few weeks (Feb., 1918) by a rather threatening infection of the right foot. This
cleared up promptly with fasting and rest, and a more rigid dietetic regime has
since been pursued.



348 CHAPTER III

the 2nd. On May 4, she received 16 gm. carbohydrate without glycosuria.
With 40 gm. carbohydrate on May 5 in the form of green vegetables and 150 gm.
strawberries, a trace of glycosuria appeared, increased with 60 gm. carbohydrate
on May 6, and disappeared with a reduction of carbohydrate to 12 gm. on May 7.
By this time the ferric chloride reaction was diminished, and a diet of eggs and
sugar-free milk (Whiting's) was begun, with S gm. carbohydrate in the form of
celery and asparagus. The caloric intake was below 650, and with this under-
nutrition the ferric chloride reaction and all other signs of acidosis were cleared
up by May 13. Traces of glycosuria were frequent, and accordingly, without
further trouble from acidosis, the diet from May 16 to 21 was kept so low as to
represent almost continuous fasting. Beginning May 22, the attempt was made
to feed approximately 1200 calories daily; but glycosuria promptly appeared, and
continued notwithstanding withdrawal of carbohydrate and a partial fast-day on
May 27 and a complete fast-day on May 30. This being an impossible state of
affairs, the child was brought to confess that the glycosuria was due to her stealing
small quantities of bread. Though always a rather unmanageable patient,
she was tractable after learning that glycosuria meant fasting, and soon became
contented imder hospital discipline.

On Jime 2 partial, and on June 3 complete fasting was given. Beginning
June 4, a carbohydrate tolerance test was continued until June 26. A deceptive
trace of glycosuria appeared with 180 gm. carbohydrate on June 17, but the
true tolerance proved to be 260 gm. carbohydrate on June 25 and 26, in contrast
to the 40 to 60 gm. carbohydrate which had caused glycosuria on May 5 and 6.
The benefits of the 2 months of imdernutrition and liberal carbohydrate supply
were now apparent in a greatly increased tolerance for mixed diets. This was
rapidly built up, with routine weekly fast-days, and glycosuria was absent until
the increase reached 84 gm. protein, 110 gm. carbohydrate, and 2250 calories on
July 21. The ration was immediately reduced to a lower figure than had been
tolerated before, nevertheless glycosuria continued for 3 days. The child was
now clinically and subjectively entirely well, and the urine remained normal ex-
cept for the traces of glycosuria on Aug. 19 and 20, due to stealing food. Oct. 11
to Nov. 3, another carbohydrate test showed a tolerance of 240 gm., as compared
with 260 gm. in June. In Nov. a diet of 75 gm. protein, 75 gm. carbohydrate,
and 1500 calories was assimilated without glycosuria. In Dec. the attempt to
replace part of the fat with carbohydrate, making the diet 75 gm. protein, 100
gm. carbohydrate, and 1500 calories, was endured for about 2 weeks, then caused
glycosuria on Dec. 15 and 16, so that the former diet with 75 gm. carbohydrate
was resumed. She was discharged on this, after having been 232 days in
hospital.

Acidosis. — This was an instance of the production of acidosis by fasting.
The tendency was already present, as shown by the ferric chloride reaction and
slightly subnormal blood alkalinity at admission; but the nausea and weakness
developing early in fasting were characteristic, and on the morning of May 4



CASE RECORDS



349



the CO2 capacity of the plasma was found to have fallen to the ominous level of
27 per cent. No alkali was given, but only the 16 gm. carbohydrate in green
vegetables as mentioned. With small carbohydrate intake the CO2 capacity
rose quickly to 44 per cent on May 6; then on a protein-fat diet of 600 calories
with only 5 gm. carbohydrate it rose still further. On May 18, which was a
green day with 20 gm. carbohydrate in the form of celery, asparagus, tomato,
and cucumber, the CO2 was as high as at admission. With the carbohydrate
tolerance test in June it reached a high normal level. It tended to fall below
normal on the ensuing mixed diet. The tendency toward acidosis on fasting was
displayed in the tests made on the morning of the fast-day of Sept. 12 and the fol-
lowing morning, but the steep drop in plasma bicarbonate as a result of this
fast was partly explainable by the lively exercise which the patient was now
taking. The later values, with the exception of the low figure of 48.8 per cent



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 38 of 76)