Frederick M. (Frederick Madison) Allen.

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on Nov. 17, were normal for a child.

Blood Sugar. — The quick fall to normal is characteristic of an early case.
Normal values were still present on Sept. 12 and 13, after a long period of ade-
quate nutrition; but increase of the carbohydrate allowance from 82 to 100 gm.
on Sept. 23 without change in the total calories resulted in a rise of blood sugar
to 0.26 per cent on Oct. 7. There was hyperglycemia of 0.25 per cent on Oct.
22 during the carbohydrate test. Thereafter the general tendency of the curve
was downward. Notwithstanding the increase of carbohydrate on Nov. 30,
which subsequently resulted in glycosuria, the analysis before breakfast on Dec.
4 showed normal sugar in the whole blood and only slight elevation in the plasma.
At the close of the following week, on Dec. 11, there was definite hyperglycemia,
giving advance warning of the glycosuria which appeared on Dec. IS.

Weight and Nutrition. — Though the patient was a growing child, undernu-
trition was employed to obtain control of the threatening condition present when
admitted. The degree of undernutrition thus enforced for 2 months can be
shown as follows. The quantity of bread obtained surreptitiously was so small
as to be negligible in this calculation.



58 days.



Total calories in diet 37,132

" protein" " 1,769. 9gni.

Animal " " " 850.3 "

Vegetable" " " 919.6 "

Carbohydrate" " 3,190.0 "



Per day

(average)


Per day

per kg.


640.0


24.0


30 . 5 gm.


1.13 gm


14.6 "


0.54 "


15.8 "


0.58 "


55.0 "


2.03 "



The child was cross and rebellious at first because of having been spoiled at
home, so that trouble resulted not merely from hunger but from any matters in
which her will was thwarted. The greatest loss of weight was 3 kg. The in-
crease of weight during the carbohydrate test in June represented the usual
slight edema. By reason of the subsequent diets, the weight at dismissal was the
same as at entrance. It was not learned whether any growth in stature occurred



350 CHAPTER III

in hospital. At discharge, with weight of 27 kg. and height of 129.8 cm., the child
appeared splendidly developed and nourished and her strength and spirits were
of the highest.

The diet at discharge represented approximately 2.8 gm. protein and 56 cal-
ories per kg., reduced by the weekly fast-days to 2.4 gm. protein and 48 calories
average per kg. Along with this, heavy exercise had been employed and was
evidently one reason for the failure to gain weight. The child had certainly
gained in muscle, for her muscles were large and hard at discharge, and presum-
ably she had lost some fat. Exercise was in the form of strenuous sports, and
because of her strength and boisterous disposition she enjoyed these thoroughly.

Subsequent History. — This was an instance in which more reliance had to be
placed on the child than on the parents, for they would not control her effectively.
Though spoiled and rebellious at first, she had become obedient and convinced of
the necessity of remaining free from glycosuria. Though in tenement environ-
ment, she was able to obtain the required food, and remained free from glycosuria,
except for 1 day in Jan. with a bad cold. She continued exercise and also at-
tended school, leading a thoroughly normal child's life except for diet. On
Mar. 2, 1916, the height was 130.6 cm. On Apr. 18, the blood sugar was 0.156
per cent, plasma sugar 0.164 per cent, CO2 capacity 52.6 per cent. As the urine
was consistently normal, 150 cc. milk were added to the diet. On June 13, the
blood sugar was 0.123 per cent, plasma sugar 0.130 per cent, CO2 capacity 52.1
per cent. On July 17, the health and urine remained as before. The blood sugar
was 0.192 per cent, plasma sugar 0.227 per cent, CO2 capacity 50.5 per cent.
Weight 26.8 kg. Height 131 cm. The diet was diminished to 1400 calories
with only 50 gm. carbohydrate, and the patient was allowed to go to the country
until fall. In Nov. traces of glycosuria began to appear frequently, the urine and
subjective condition having been normal up to this time. The patient was there-
fore readmitted Nov. 17, 1916.

Second Admission. — The weight was 27.8 kg. There was slight edema of feet,
but the apparent physical condition was still very good, though the child was
obviously not so strong as before. Only a trace of glycosuria was present, but
this persisted on a diet of 60 gm. protein, 15 gm. carbohydrate, and 800 calories.
It cleared up with 1 fast-day. A carbohydrate tolerance test was then insti-
tuted in the usual manner, and the tolerance was found to be only 90 gm. There-
after a diet was given consisting of '40 gm. protein, 10 gm. carbohydrate, and
800 calories. Any attempt at an increase above this diet caused glycosuria.
She was discharged on this diet Dec. 18, 1916, weighing 25.5 kg. On the basis of
this weight, with allowance for the weekly fast-days, the prescribed diet repre-
sented 1.3 gm. protein and 27 calories per kg.

Subsequent History. — Traces of glycosuria still recurred, and on this account
the patient was out of the hospital only a little over 2 weeks.

Third Admission. — Jan. 4, 1917. Weight 27.5 kg., evidently explainable by
edema, as the diet had not been high enough for gain in weight. Only a trace



CASE RECORDS 351

of glycosuria was present, and the prescribed diet was continued for 3 days in hos-
pital to determine whether it resulted from violation of diet at home. The
sugar, however, slightly increased instead of decreasing, and 2 fast-days were then
necessary to stop it. The trace of ferric chloride reaction present at admission
persisted on fasting, but the ammonia nitrogen, which had been 1 gm., fellto
0.36 gm. A carbohydrate test was then given in the usual manner, and the toler-
ance was found to be only SO gm., indicating steady downward progress. The
blood sugar on admission was 0.332 per cent, and at the end of a fast-day following
the carbohydrate test it was 0.176 per cent. Frequent traces of glycosuria and
acidosis persisted on a diet of 36gm. protein, 10 gm. carbohydrate, and 750 calories.
In Feb. the condition changed for the worse. There were gastric upsets, edema
of face and legs', mental depression, and loss of weight and strength. The diet
was gradually diminished to 25 gm. protein and 350 calories without carbohy-
drate, but traces of glycosuria continued, while acidosis was absent or slight by all
tests. There was no cough, but pain particularly with breathing appeared over
the precordia. The temperature did not go above 98.9° F. Physical and x-ray
examinations gave only suspicious and not positive signs in lungs. The continu-
ance of pain made tuberculous pleurisy probable. On Feb. 27, the CO2 capacity
of the plasma was down to 44 per cent. A trace of ferric chloride reaction re-
turned on Mar. 5. At the beginning of Mar. the attempt to maintain sugar-
freedom was abandoned, and heavy glycosuria was thenceforth present on a
carbohydrate-free diet of 30 gm. protein and 450 calories. By Mar. 8, the am-
monia nitrogen was up to 1.1 gm. The ferric chloride reaction gradually became
heavy. By Mar. 14 the ammonia nitrogen was 1.5 gm. The CO2 capacity of
the plasma was 18.9 per cent on that day. IS gm. sodium bicarbonate were
given, and the CO2 capacity fell to 16.9 per cent. The patient died in diabetic
coma on Mar. 15, 1917.

Remarks. — The patient was received with diabetes acute and severe in type,
but yet early and mild in degree. She was treated for 2 months with rigorous
undernutrition, and all threatening symptoms cleared up and a high carbohydrate
tolerance was developed. Undernutrition was then abandoned and the attempt
was made to feed a high calory diet suitable for a normal child, while at the same
time gain in weight was prevented by means of heavy exercise. A splendid physi-
cal condition was attained.

The child was kept alive for 2 years, during the greater part of which she
enjoyed a high degree of health and led an approximately normal existence. The
outcome shows that exercise cannot wholly replace restriction of total calories.
While downward progress may be unavoidable with severe diabetes under the
metabolic strain of youth and growth in children, a longer and better course in
other children more rigidly treated is an indication that at least part of the down-
ward progress in this case was attributable to the unduly high diet. It is better
to make a less severe reduction in the earliest stage when so much greater benefit
is attainable, than a more extreme reduction after downward progress has



352 CHAPTER in

resulted. As usual, the attempt to maintain the highest possiblelevel of vigor
did not prevent and probably predisposed to infection. With the onset of
tuberculosis, a quickly fatal termination in such a case was assured.

CASE NO. 43.

Female, xmmarried, age 27 yrs. American; nurse. Admitted May 31, 1915.

Family History.— Fa.theT died at 70 of Bright's disease. Mother died of un-
known cause during menopause at 45. Possible diabetes in a maternal aunt.
Maternal grandmother died of tuberculosis. No other heritable disease known.

Past History. — Patient has spent her life under favorable conditions in two
southern states. In childhood, measles, mumps, whooping-cough, chicken-pox,
diphtheria. Pneumonia at 7 and again at 17; both light. In the spring of each
year she has had so called malarial attacks with slight fever and malaise, but
without chills. Menstruation has been irregular. General health good. Habits
and diet normal. 3 years ago she accidentally plunged a hj^odermic needle
into her hand and broke off the point, which was not extracted for 24 hours.
Severe sepsis resulted. The whole arm was swollen and blackened, and three
incisions were made for drainage. There was delirium, and at one time her
recovery was not expected. The hand has only partially recovered function.
There was also albuminuria durilig the attack, and treatment with diet and
other measures for nephritis was followed for many months. Albuminuria finally
cleared up.

Present Illness. — In Jan., 1915, marked polyphagia, polydipsia, and polyuria
were noticed, and the weight fell from the usual 118 to 97 pounds. About the
first of Mar. she concluded she had diabetes, and this was confirmed by a medical
examination. Beginning late in Mar. she was imder treatment in hospital for
several weeks on the von Noorden plan with green days, oatmeal days, and
occasional fast-days. She was sugar-free during the last week, but relapsed on
leaving hospital. Since the middle of Apr. she has been on protein-fat diet with
addition of green vegetables, a little potato, and two slices of bread at each meal.
Pruritus vulvae troublesome.

Physical Examination. — ^Poorly developed, thin young woman. Pale com-
plexion. Skin dry. Considerable loss of hair. Mouth and throat normal. A
few barely palpable lymph nodes. Reflexes normal. Trace albuminuria. Ex-
amination otherwise negative.

Treatment. — On June 1, the first day in hospital, the diet was 83 gm. protein,
5 gm. carbohydrate, and 2530 calories. The sugar excretion was 14.88 gm. On
the next day 2071 calories were taken. June 3 and 4 were fast-days with no food
of any kind. On June 5 and 6, 300 cc. clear soup, 150 cc. coffee, and 3550 cc.
whisky were permitted. Glycosuria cleared up, but signs of acidosis became
marked. On June 7, green vegetables containing 10 gm. carbohydrate produced
prompt glycosuria. This carbohydrate was continued, and eggs, butter, and



CASE RECORDS 353

bacon were added to build up a diet approximating 1600 calories. Glycosuria
diminished when the carbohydrate was halved, but did not cease until the fast-
day of June 13. Thereafter a similar diet was tolerated up to June 21. Begin-
ning June 22, a carbohydrate tolerance test was instituted, and ignoring insignifi-
cant traces of glycosuria on July 5 and 8, the tolerance was reached with 230 gm.
carbohydrate on July 17 and 18. Thereafter a mixed diet of 80 to 100 gm. pro-
tein, 100 gm. carbohydrate, and 2200 to 2500 calories was taken, with only occa-
sional traces of glycosuria. The weight having risen to equal that at entrance,
another carbohydrate test was begun on Oct. 11, and the limit of tolerance was
reached with 170 to 190 gm. carbohydrate. Mixed diet was then resumed, and
though 2500 calories were tolerated, the permanent level, beginning Nov. 5,
was fixed at 2000 calories. Green days with 25 gm. carbohydrate were substi-
tuted for the previous weekly fast-days. Though glycosuria was absent, the
carbohydrate allowance beginning Nov. 26 was diminished to 25 gm. Never-
theless, a decided glycosuria appeared in the middle of Dec. It was then learned
that this, and also the preceding appearances of glycosuria (Nov. 6 to 24) had been
due to the patient's buying and eating 10 cents worth of cheese when on walks
away from the hospital. After reduced diet and fasting (Dec. 17 to 20) the gly-
cosuria was cleared up, and the former diet resumed on Dec. 21 without glycosuria.
The patient was dismissed on a diet of 80 gm. protein, 25 gm. carbohydrate,
and 1800 calories (1.92 gm. protein and 43 calories per kg., reduced by weekly
fast-days to an average of 1.65 gm. protein and 37 calories per kg.). She felt
well at discharge, except on fast-days, which always left her temporarily weak
and depressed. She proposed to imdertake diabetic nursing, and was instructed
also to continue regular exercise.

Acidosis. — ^At admission there were no acidosis symptoms, the ferric chloride
reaction was slight, the ammonia output was low, and the first carbon dioxide
determinations only slightly subnormal. Acidosis was produced by fasting. The
ferric chloride reaction promptly became heavy. Before breakfast on the morning
of June 7 the CO2 capacity of the plasma was down to 35 per cent, and the am-
monia nitrogen by that day had risen to 2.35 gm. Alcohol up to 350 calories had
not prevented this acidosis. On June 8, 20 gm. sodium bicarbonate were given,
with the low calory diet and 10 gm. carbohydrate above mentioned. The result
was a prompt rise in CO2 and fall in ammonia. But with simple increase of pro-
tein-fat diet without any more alkali, the CO2 capacity rose still more sharply
to a fuUy normal level, and the ammonia output correspondingly fell. The
acidosis was also manifested by the usual clinical symptoms of nausea, vomiting,
and malaise; these also cleared up promptly on feeding. The CO2 capacity was
unaccountably low on July 8, probably in consequence of undernutrition and
exertion, while on the next day the usual high normal value was found present.
On mixed diet the curve had descended by Sept. 12 to the lower normal limit.
The tendency toward acidosis on fast-days persisted. Sept. 12 was a fast-day,
and the CO2 capacity that morning was 54.8 per cent, whereas the next morning,



354 CHAPTER III

after 24 hours with only 300 cc. soup and 300 cc. coffee, it was down to 46.6 per
cent; while after 3 days of feeding it was 57 per cent on the morning of Sept. 16.
It was also within normal Hmits on Oct. 29, at the close of a carbohydrate test;
but on the morning of Nov. 1, after the previous fast-day, it was down to 47.4 per
cent. On the other hand, on Dec. 19 the high normal value found after fasting
is perhaps one indication of the improved condition, notwithstanding the exist-
ence of a positive ferric chloride reaction in the urine at that time. It is also
worth noting that the ferric chloride reaction became negative on June 28 with
nothing in the diet but vegetables representing 70 gm. carbohydrate. But after
the carbohydrate test it reappeared on mixed diet in July and Aug., notwith-
standing 100 gm. carbohydrate in the diet. Thereafter it tended to reappear,
particularly with glycosuria. It seemingly was governed not so much by the
carbohydrate intake as by the fat in the diet and the specific diabetic condition.

Blood Sugar. — The hjrperglycemia found on the morning of Sept. 12 was
promptly reduced to normal by the single fast-day. It was again unduly high
with feeding, but showed a downward tendency. The excessive figure of 0.4
per cent in whole blood and 0.44S per cent in plasma at the close of the carbo-
hydrate test on Oct. 29, .with only slight glycosuria, probably indicates renal im-
permeability, perhaps associated with the old nephritis. At the same time it
must be borne in mind that the urine reactions are shown for the 24 hours, whereas
the blood sugar was for the hyperglycemia during carbohydrate digestion. On the
morning of Nov. 1, it was found that a single fast-day had again brought the
blood sugar fully to normal. On Nov. 13, it was 0.125 per cent in whole blood and
plasma, and was barely below 0.15 per cent on Dec. 19 in consequence of the
recent violation of diet.

Exercise. — ^As soon as adequate mixed diet was begun in Aug., vigorous exercise
was inaugurated, including daily walks of 8 mUes. The strength and general
appearance thereby improved. Glycosuria was present on Sept. 11, just before
the routine fast-day. Exercise was then omitted, and it appeared earlier in the
following week; namely, on Sept. 14 and IS. Without change in diet, an increase
of exercise was ordered, and glycosuria immediately ceased and remained entirely
absent in the subsequent weeks up to Oct. 9. Other observations concerning
exercise, particularly the blood sugar, are given elsewhere (Chapter V).

Emotion. — The glycosuria of Aug. 10 and 11 was apparently associated with
crying spells.

Weight and Nutrition. — The weight at admission was 44 kg. Some of the fluc-
tuations in the curve, notably the rise during the carbohydrate test in July, were
due to edema. It is noteworthy that the toleratice in Oct., after recovery of the
original weight, was far different than at admission, but yet was lower than in
July. It seems clear that the high diets from July to Oct. had been injurious,
notwithstanding the use of exercise. At discharge the weight was 41.6 kg.;
i.e., a loss of 2.4 kg. This was 12 kg. below her normal weight, and she had
always been rather shght in figure. The above mentioned diet, prescribed at



356 CHAPTER in

patient never was guilty of any large violation of diet, but indulged herself in
little things beyond permission. Glycosuria occasionally returned, and finally
became continuous. When she began to feel rapidly worse, she returned for
readmission on Dec. 2, 1916.

Third Admission.— Tht weight was 39 kg., partly edema. No acute symp-
toms were present, but there had been a perceptible loss in strength. With 3
days of fasting, sugar and ferric chloride reactions became negative. The diet
was then built up in the usual maimer, and the tolerance was found very low.
The limit was approximately 1000 to 1100 calories with 50 gm. protem and no
carbohydrate, and with the usual weekly fast-days. A considerable part of
this long period in hospital was occupied with tests with fat feeding, some of
which are described elsewhere (Chapter VI). On the very low diet the weight
has fallen to about 33 kg. The strength also is diminished, so that the patient
is now a confirmed invahd, able to be up and about, but not fit for work or for an
independent existence. She has remained in the hospital iip to the present.

Remarks. — The record of this patient during and following the first hospital
period confirms the fact that exercise cannot atone for an unduly high diet
The essential reasons for her downward progress have been the almost per-
petual, slight overstepping of diet, and the frequent colds and grippe. She has
reached the point where nothing but a hard struggle for the bare maintenance of
Ufe is possible. With continuous hyperglycemia not tending to diminish, a slight
continuous overstrain of the pancreatic function may be assumed, and down-
ward progress may be expected imder such conditions even in the absence of in-
discretions or compHcations. The only hope Hes in treatment radical enough
to relieve the overstrain if possible. The later results wUl show whether down-
ward progress can thus be checked at such an extreme stage.

CASE NO. 44.

Male, married, age 33 yrs. American; electrician. Admitted July 3, 1915.

Family History. — Parents hved to old age. Wife and three children of patient
are well. One aunt died of cancer of the nose. History otherwise negative.

Past ffwtory.— Diphtheria at 4. Frequent colds m head but no cough or sore
throat. Gonorrhea 11 years ago. Syphihs denied. Has worked in electrical
power house for past 15 years, for past 3 years as switchboard attendant. Mod-
erately nervous and excitable. No alcohol except occasional glass of beer.
Smokes considerably. Four or five cups of tea or coffee daily. Not a heavy
eater in general, but a lover of sweets. Highest weight 170 pounds, average 165
pounds clothed.

Present Illness. — ^Headaches and lassitude began about a year ago. 5 months
ago pleurisy with chills, cough, and bloody expectoration confined him to bed
for 10 days. Weight has been steadily lost, and there have been night sweats for
week preceding admission. Polydipsia and polyuria began shortly after the



CASE RECORDS 357

pleurisy. A physician then diagnosed diabetes. In addition to medicines, he was
given a diet restricted to protein-fat foods with gluten bread and such vege-
tables as grow above the ground. He continued to lose steadily; impaired hear-
ing, numbness of hands and feet, cramps in legs at night, nervousness, and
irritability have been present.

Physical Examination— Height 175 cm. A fairly developed, moderately
emaciated man without acute symptoms. Slight pyorrhea. Many teeth miss-
ing. Tonsils not enlarged. Slight lymph node enlargements. Reflexes normal.
Blood pressure 90 systolic, 62 diastolic. Wassermann negative. Examination
otherwise negative.

Treatment.— Jinmig the first few days in hospital, glycosuria and ketonuria
were heavy on a diet of 2100 to 2400 calories with S gm. carbohydrate. The in-
crease of carbohydrate to 40 gm. on July 7 made little difference. On July 8,
only breakfast was given, and glycosuria cleared up during the day. 3 fast-days
were then imposed nevertheless, followed by a carbohydrate period. An intake
of 340 gm. carbohydrate in the form of green vegetables was reached without
glycosuria. The ferric chloride reaction meanwhile became negative. After a
fast-day on Aug. 1, the diet for 3 days was limited to potato, and 200 gm. carbo-
hydrate were taken in this form without glycosuria. A mixed diet was then
given, consisting of 100 gm. protein, 100 gm. carbohydrate, and 2600 calories.
Ferric chloride reactions promptly appeared, and persisted notwithstanding in-
crease of catbohydrate to 285 gm. on Aug. 21. The diet on this day also con-
tained 130 gm. protein and 3100 calories. Of this carbohydrate, 40 gm. were in
the form of bread and 100 gm. in the form of potatoes. The patient was dis-
charged on Aug. 23, weighing 58.6 kg., on a prescribed diet of 115 gm. protein,
160 gm. carbohydrate, and 2700 calories (almost 2 gm. protein and 50 calories
per kg., reduced one-seventh by weekly fast-days).

Acidosis. — The CO2 capacity of the plasma was sUghtly below normal, and rose
steadUy under treatment without the aid of alkali. The most interesting feature
from the standpoint of acidosis pertained to the ferric chloride reaction, for al-
though this became negative on a solely vegetable diet, it reappeared on a liberal
mixed diet, notwithstanding an ingestion of carbohydrate theoretically abundant
to prevent all acidosis.

Subsequent History. — The patient resimied his regular work, and maintained
health and normal urine. On Oct. 5, both sugar and ferric chloride reactions
were absent from the urine, and the sugar in whole blood was 0.102 per cent, in
plasma 0.110 per cent, weight 61 kg. In addition to his regular work of 8 hoiurs
a day he was making extra money and at the same time obtaining exercise by
canvassing several hours daily. On Dec. 27, the patient reported at the Insti-
tute with temperature of 99.2° F., after having had grippe and precordial pain for
10 days. Acidosis remained absent and he had continued his regular work. The
excessive diet was reduced to 97 gm. protein and 2170 calories. The grippe
cleared up promptly, and later examinations showed lungs and urine normal.



358 CHAPTER m

Secoftd Admission.— On Apr. 26, 1917, the patient was readmitted on account
of lobar pneumonia (Pneumococcus Type IV). Physical signs and radiograms
indicated consoUdation of right middle lobe. The temperature on adm'ssion
was 101°F., rose the next day to 104°, on Apr. 28 reached the maximum of 105.6°,



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 39 of 76)