Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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was still as high as 105.2° on Apr. 29, and fell by crisis to normal the next day.
Liquid diet was given, largely milk, containing as high as 40 gm. carbohydrate. ^

The course of the pneumonia was uneventful, and neither glycosuria nor acidosis
appeared. The patient was transferred from the pneiunonia to the diabetic serv-
ice on May 5. He convalesced uneventfully, and was discharged May 28 on a
diet of 100 gm. protein, 80 gm. carbohydrate, and 2250 calories. Weight 59.2 kg.

Subsequent History.— On June 19, the patient caught cold and also lost his
temper in a dispute. Rather heavy glycosuria appeared promptly, but disap-
peared on omitting four meals. On resinning full diet glycosxu-ia returned, and
ceased with another fast-day. The patient then reduced h s diet and reported
on July 2, having been sugar-free s'nce the attack. The diet was ordered di-
minished to 80 gm. protein, 60 gm. carbohydrate, and 2000 calories. On this he
has since remained shghtly himgry but free from symptoms and feeling strong
and well. In July, 1917, the weight was 61.9 kg., the blood sugar during digestion
0.112 per cent, CO2 capacity 60.2 per cent.

Remarks. — ^The diabetes was essentially mild, and it is hoped that it may be
kept so. The most noteworthy feature is the wholly uneventful manner in which
the patient passed through an attack of pneumonia of moderate severity. The
absence of diabetic symptoms during this time may be attributed chiefly to the
very low diet given during the period of active infection. Permanent injury
of the tolerance was thus apparently prevented. Notwithstanding the excellent
condition and the normal blood sugar, the outbreak in June shows that the latent
diabetes must stiU be guarded against, doubtless throughout the patient's life,
though improvement may perhaps continue with advancing years. On the
other hand, the age is such as to threaten serious consequences if the condition is
not held in check. The patient is now on a well balanced diet, which may be ex-
pected at least to delay any downward progress if it does not prevent it altogether.



CASE NO. 45.

Male, age 6 yrs. American Jew. Admitted Sept. 1, 1915.

Family History.— Pa.Tents and two brothers of patient (aged 9 and 11) are en-
tirely well and free from glycosuria, though shghtly obese. No diabetes in
mother's family, but her mother died of cancer at 53. The father's family his-
tory is negative on his mother's side, but diabetic on his father's side; i.e., a
great grandmother died at 76 of diabetes, and the father and an uncle of the
present patient's father are living and have diabetes. No tuberculosis, syphilis,
Bright's disease, goiter, etc., known.



CASE RECORDS 359

Past History. — Normal delivery. No childhood diseases; never sick a day.
Always big and plump, but not obese. Never nervous. Has never gone to
school but received a little instruction from a governess. He has been bright
and quick to learn, and has spent nearly all his time playing, automobUing, or in
other active recreations. Appetite always large, and he has eaten much cake,
candy, ice cream, and other sweets.

Present Illness. — ^About Nov. 20, 1914, polyuria and loss of weight were no-
ticed. A physician prescribed medicine without examining the urine. Another
physician a few days later discovered glycosuria, and two eminent consultants
were called. A repetition of oatmeal and green days was employed according
to the von Noorden plan, and the patient with difficulty was made free from
glycosuria, but acetonuria persisted. Last Mar. there was an attack of grippe,
with otitis media requiring paracentesis, which was performed without anesthesia.
The patient is said to have become completely comatose; he was treated with
fasting and rectal drip, recovered from this attack, and became sugar-free on a
diet of Whiting's milk and thrice cooked vegetables. A little carbohydrate was
later added, but traces of acetone continued. During the past summer, at the
parents' summer home, the control was too lax to prevent violations of diet, with
the result that on July 10 the patient suddenly fell out of his chair at table. He
was then brought to New York and placed imder the care of one of the advocates
of treatment with lactic acid bacilli. A fuU caloric diet was given with restricted
carbohydrate during this treatment, and also sodium bicarbonate, from one to
six heaping teaspoonfuls daily. There was steady loss of weight and strength.
For 7 weeks past the patient has been confined to bed or chair, unable to stand
because of weakness; for past several days he has been too weak to sit up. Dur-
ing this time apathy and stupor have been increasing, but he is not quite in
coma. Greater edema than that now present is said to have occurred from bi-
carbonate in the past. The weight before onset of diabetes was 47 pounds; be-
fore the present bicarbonate edema, it was 36 pounds. Meantime a long series of
urinalysis reports from a commercial laboratory, exhibited by the father, showed
steady improvement under the lactic acid treatment, the glycosuria being dimin-
ished from heavy to slight and the acidosis having disappeared. The practi-
tioner in charge blamed the laboratory for the mistake, but had been administer-
ing sodium bicarbonate in maximum doses rectaUy as well as orally. An incon-
sistency on the part of the laboratory was that their reports showed acid reac-
tions of the urine with alleged negative ferric chloride reactions imder this
treatment.

Physical Examination. — Patient stiU shows signs of having been a splendidly
developed, handsome child. He is now stuporous, and questions must be re-
peated several times before a response is obtained. Complexion pasty. High
degree of general anasarca; deep pitting of extremities on pressure, and fingers or
bed clothing leave marks all over the body. EyeUds are swelled nearly shut.
Intraocular pressure very low. Mucous membranes very red; tongue coated;



360 CHAPTER in

gums swollen and spongy and bleed easily. Throat not examined because of
mental condition and edema. No gland enlargements made out. Left chest
hjrperresonant. Right side shows everywhere flatness and other signs of a
large pleural effusion. Systolic blood pressure approximately 62. Marked
tympanites in abdomen, and movable dulness in flanks. Both testicles in
scrotum, partly obscured by fluid which swells scrotum to about the size of a
large apple. Knee and Achilles jerks not obtainable. Over the sacrum an area
of dusky redness, as large as a man's hand, seems almost ready to slough. Tem-
perature 97.4; pulse 66; respiration 16, without dyspnea.

Treatment. — (No graphic chart.) The patient was too weak to move himself
in bed, and the nurses were instructed to turn him at intervals with a view to
avoiding pressure sores and h)rpostatic pneumonia. Fasting was begun with
very small doses of whisky. Notwithstanding the huge bicarbonate edema, the
previous reports of acid urine were confirmed, and in the presence of incipient
coma, fear was entertained of stopping bicarbonate suddenly, or using any strong
diuretic which might alter the water balance in imknown manner. Accord-
ingly, on the 1st day 10 gm. sodium bicarbonate, 16 gm. calcium carbonate, and
4 gm. magnesium oxide were given, and on the next day 20 gm. each of sodium
bicarbonate and calcium carbonate, also 1 cc. aromatic cascara. Satisfactory
laxative action was obtained, and there was neither nausea nor diarrhea. The
tympanites was reheved. The attempt was made to force fluids, and 3850 cc.
water were given on Sept. 2, but the total urinary output was only 1425 cc. It
was evident that the child was unable to dispose of his fluid, and this fact was
further evidenced by the gain of 2.6 kg. weight, with evident increase of edema.
Strength did not improve, as it frequently does on fasting. On the contrary,
there was a perceptible increase of weakness, though the mental condition decid-
edly improved. Both glycosuria and ketonuria were rapidly diminishing. Be-
ginning Sept. 3, no alkali was used, and water was suppUed only for thirst. By
Sept. 5 glycosuria was absent, and on the next day the ferric chloride reaction
was entirely negative. The child was mentally bright, and seemed in no imme-
diate danger in regard to strength. Green vegetables representing 3.3 gm. car-
bohydrate were eaten with reUsh, and it was planned to begin protein feeding the
following day, with encouraging prospects. Edema was beginnmg to subside, as
shown by the falling weight; but albuminuria, which had been absent on admis-
sion, seemed to develop as the urine turned alkaline; casts were not foxmd. Dur-
ing the night of Sept. 6-7, the strength suddenly collapsed altogether. The resi-
dent physician, immediately called, gave a saline hypodermoclysis, which was
absorbed but had no perceptible effect. When seen at 4:30 a.m., the child was
cold in spite of being surrounded with hot water bottles; temperature down to
95.8°; pulse 60, barely perceptible; respiration 16 to 20; completely unconscious,
without eye reflex; rectal sphincter completely relaxed. 10 gm. levulose m 100 cc.
water were immediately given by stomach tube, and another 10 gm. in 100 cc.
saline subcutaneously. The condition seemed to improve sHghtly, but con-



CASE RECORDS 361

sciousness did not return. At 6:50 a.m. another hypodermoclysis was given of
250 cc. saline containing 20 gm. levulose. Half an hour after this, when asked if
he was hungry, the child answered yes. He swallowed 50 cc. bouillon containing
2 gm. ereptone. During the day six eggs, SO gm. butter, and 700 cc. soup were
taken with relish, also 20 cc. whisky. A similar diet was given on Sept. 8.
The child seemed to be rapidly gaining strength; but diarrhea was present, sup-
posedly due to the levulose and ereptone, and bismuth was given for this. By
Sept. 9, the stools had become frequent, badly digested, and very putrid in odor.
Tympanites had returned. In place of the former subnormal temperature there
was now fever of 101.8°. The blood pressure could now be definitely determined
at 85 systolic and 68 diastolic. The patient now moved his arms and legs volun-
tarily, but had not become able to turn his body. On account of the apparent
putrefactive intestinal condition, and the impossibility of employing fasting in
view of the former collapse, it was decided to try oatmeal. Therefore, the former
egg diet was stopped after breakfast. A dose of 10 cc. castor oil was given; 16
cc. whisky, 60 gm. oatmeal, and 200 cc. clear soup constituted the diet for this
day. The tympanites and diarrhea were not relieved; stools became frothy as
well as foul smelling. Heavy glycosuria appeared immediately, as shown in Table
XII, and with it a moderate ferric chloride reaction. Stupor and Kussmaul
dyspnea came on rapidly. As the oatmeal had failed so completely, it was or-
dered stopped at evening, and 10 cc. more castor oU were given. Between 9
and 10 p.m., a 250 cc. cylinder containing 25 cc. 3 per cent sodium citrate solu-
tion was filled with blood from the patient's father. A vein was exposed in the
patient's arm, the operation eliciting no sign of consciousness, and the blood was
■allowed to flow in. It was hoped by means of the transfusion to contribute a little
strength to tide over the fasting necessary as the only hope for clearing up the
coma. No inmiediate change was perceptible except a slight improvement in
pulse. On Sept. 10, the temperature had become normal and the patient could
be roused. Toward evening he wakened spontaneously and began to cry for
food. 75 cc. clear soup were given. Edema of both face and feet became more
marked. On Sept. 11, the child became unconscious in a different manner,
with weak pulse and feeble Cheyne-Stokes breathing. Another transfusion of
150 cc. citrated blood from the father was given; a hypodermoclysis of 200 cc.
saline containing 10 gm. levulose; and by stomach tube 6 cc. whisky, 10 gm.
levulose, and 140 cc. Whiting's milk, from which the cream had been removed
by centrifugation. The temperature was normal, and the picture was one of
intoxication, different from the previous hunger collapse or diabetic coma. Eggs
and whisky were given by stomach tube during the day, making a total diet of
40 gm. protein and 500 calories. The putrid smelling diarrhea returned, and
death occurred with weakness, imconsciousness, and Cheyne-Stokes breathing at
5:30 p.m.

Acidosis. — ^The excessive use of bicarbonate, guided only by the urinary reac-
tions, had produced not only extreme anasarca but a decided alkalosis. Prob-



362 CHAPTER in

ably this and the renal impermeability formed a vicious circle, each making the
other worse. The lack of paralleUsm between urine and blood is illustrated by
the acid urine of Sept. 9, with the highest plasma alkalinity of the series. The
value of the direct determination of the plasma bicarbonate is thus illustrated.
The only other indication that no more alkali was needed was given by the low
ammonia values. These are of interest as evidence that the ammonia forma-
tion of diabetic acidosis is due entirely to acid and not to any toxic perversion of
protein metabolism. On the other hand, the strict independence of coma and
acid intoxication is shown by the beginning of dialaetic coma, typical in every-
thing except hyperpnea, observed on two occasions (at admission and Sept. 9)
even with abnormally high plasma alkalinity. The effect of oatmeal on Sept. 9
is also remarkable, for it increased the ketonuria, raised the plasma bicarbonate
from 67.8 to 84.9 vol. per cent, and brought on prompt coma. Clinically,
therefore, it aggravated both the diabetes and the intoxication, irrespective of
chemical findings. It is interesting that such administration of carbohydrate
with reduction of fat should have had this effect, illustrating the fact that coma
is generally treated more safely and effectively with fasting than with carbo-
hydrate. The acidosis caused by oatmeal cleared up on fasting, and the urine
at death was free from both sugar and ferric chloride reactions. The relatively
low output of acetone bodies may be explained by the renal impermeability,
which doubtless favored retention. Neither qualitative nor quantitative tests
for acetone bodies in the blood were made, but the clinical picture indicated
that death was not due to acidosis.

Lipemia. — The blood at admission showed one of the most intense grades of
lipemia observed in this series. Analyses were not possible, and judgment is-
based on the thick, creamy appearance of the plasma. The lipemia showed no
perceptible diminution up to Sept. 9, but on Sept. 11, after transfusion on Sept.
10, the. plasma was perfectly clear. It was unfortunate that the effect of the
transfusion was not observed in this connection.

Levulose. — The patient had tolerated 3.3 gm. carbohydrate on Sept. 4. The
glucose tolerance in such a case must necessarily be close to zero. Nevertheless,
40 gm. levulose on Sept. 7 were assimilated without a trace of glycosuria. The
most remarkable feature was the clinical transformation wrought by the levu-
lose — a patient apparently dying restored in strength and consciousness within a
few hours. As saline h5T5odermoclysis had previously failed, this effect must be
attributed to the levulose and not to the fluid given with it. It is of interest
that the quantity of carbohydrate in the form of levulose was almost identical with
that given in oatmeal on Sept. 9. The contrast between the excellent assimi-
lation of levulose and the prompt glycosuria and ketonuria from oatmeal is
striking.

Transfusion. — This was performed for the purpose of improving strength, and
not with the idea of conveying any special substances curative of either the dia-
betes or the acidosis. The facts pertaining to this, as also other special features
of the case are given in Table XIII.



CASE RECORDS 363

The analyses of the father's blood immediately preceding the two transfusions
were as follows:

On Sept. 9, blood sugar 0.1 per cent, plasma sugar 0.091 per cent, corpuscle
sugar analyzed 0.125 per cent, calculated 0.114 per cent. Hemoglobin (Fleischl-
Miescher) 104 per cent. Corpuscles (hematocrit) 42 per cent. CO2 capacity of
plasma 56.4 per cent.

On Sept. 11, blood sugar 0.115 per cent, plasma sugar 0.137 per cent, corpuscle
sugar analyzed 0.097 per cent, calculated 0.083 per cent. Hemoglobin 95 per
cent. Corpuscles (hematocrit) 40 per cent. CO2 capacity of plasma 52.8 per
cent. The high sugar and low CO2 are explainable by the anxiety and haste of
the father when called to the hospital.

The purpose of improving strength was accomplished. No specific benefit to
the diabetic condition was perceptible from the transfusion, also there was no
indication of harm.

Sugar Permeability of Corpuscles. — As the abnormalities were so marked in
several respects, observations upon the sugar content of the corpuscles were made
in the same manner as with the exercise experiments in Chapter V; viz., by direct
analysis of the corpuscles after hard centrifugation, and by calculation from the
values for whole blood and plasma. The agreement between the two results is
generally as good here as can be expected. Deficient centrifugation, leaving
some plasma with the corpuscles, is probably responsible for the imduly high
figure from direct analysis on Sept. 1. No special abnormality in the permea-
bility of the corpuscles to sugar was shown under the conditions in question.

Remarks. — Obviously there was little real hope for such a patient under any
circumstances, and the relatives were surprised that life was continued for 10
days and that impirovement seemed to be evident at certain periods.

CASE NO. 46.

Male, married, age 48 yrs. Russian Jew; dry goods storekeeper. Admitted
Sept. 1, 1915.

Family History. — Mother died at 65 of supposed cardiac trouble. Father well
at age of 72. Only brother is well. Patient's wife and five children well, but
one daughter died of diabetes at age of 16, 9 years ago. No other heritable dis-
ease known in family.

Past History. — Healthy, rather sedentary Ufe without special strain or worry.
Pnemnonia at 10 years the only infection remembered. Diet has been the con-
centrated, monotonous type characteristic of his class. No special excesses.

Present Illness. — Patient distinctly remembers a day in Oct., 1914, when he
became acutely thirsty and drank much water. He immediately consulted a
physician, who reported 5.5 per cent sugar in the urine. On a diet of protein, fat,
and vegetables, glycosuria ceased in 2 days, and remained absent until Mar.,
1915, when rapid loss of weight also came on. From the normal 150 pounds he



364 CHAPTER ni

was now down to 130 pounds. He entered a hospital on May 5, 1915, where the
sugar and diacetic acid cleared up on fasting with brandy. These returned
within 2 days of his discharge from the hospital on May 17. His private physi-
cian, on account of fear of the diacetic acid present, then kept him on a liberal
carbohydrate diet. In July the condition was again cleared up in the hospital.
It returned promptly and was again treated with carbohydrate by the same
physician. Loss of weight and strength has proceeded rapidly. There is chronic
pain in back and legs.

Physical Examination. — Medium sized, thin, very exhausted appearing
patient. Skin dry. Eczema in axillas. Teeth in bad condition. Phar3Tix
reddened; tonsils not enlarged. Scattered lymph nodes palpable. Heart slightly
enlarged; systolic murmur heard all over precordia, loudest at apex. Slight
arteriosclerosis. Double inguinal hernia retained by truss. Knee jerks not
obtainable, even with reinforcement. Examination otherwise negative.

Treatment. — Fasting with whisky and 30 gm. sodium bicarbonate and 30 gm.
calcium carbonate daily was begim immediately. After Sept. S, both glycosuria
and ketonuria ceased. Alkali was stopped and whisky continued. Green
vegetables were then begun, and increased imtil glycosuria appeared with 140
gm. carbohydrate on Sept. 12. After a few days of low mixed ration, on Sept.
19 a diet was started containing 100 gm. protein and SO gm. carbohydrate.
Keeping this constant, the total calories were rapidly increased by addition of
fat, with the result that sugar and ferric chloride reactions returned in the period
Sept. 21 to 25. Exercise experiments were performed during this time as de-
scribed elsewhere (Chapter V). Exercise was then continued in the period Sept.
27 to Oct. 9. The result showed that the discontinuance of alcohol, combined
with muscular work to the point of exhaustion, did not cause acidosis as evi-
denced by either ferric chloride reactions or lowered plasma bicarbonate. Also,
though the total caloric ration was much higher than that which had brought
glycosuria on Sept. 21, sugar now remained absent until Oct. 6. A carbohydrate
tolerance test was next instituted in the usual manner. Glycosuria appeared
with an intake of 230 gm. on Oct. 30, but was not quite" continuous when the
intake was raised to 240 gm., or even to 300 gm. on Nov. 6. The heavy exercise
probably contributed somewhat to this tolerance. The patient was discharged
on Nov. 16 and resumed business, feeling well.

Acidosis. — Moderate acidosis was indicated by the heavy ferric chloride reac-
tion, 1.1 gm. ammonia nitrogen, and plasma bicarbonate of 41.9 vol. per cent at
admission. Under fasting and alkali the ammonia quickly fell to normal, and
the CO2 capacity rose to the high level of 73 per cent. The ferric chloride reac-
tion diminished even during alkali administration, and became negative the day
after alkali was stopped. But within 2 days thereafter (Sept. 7), the CO2 ca-
pacity had fallen to 50.4 per cent. The lower figure of 39 per cent on Sept. 8
was obtained after hard exercise. Other tests in exercise experiments are omitted
from the graphic chart. The last determination, on Oct. 27, during the carbo-



CASE RECORDS 365

hydrate period, showed a low normal figure of 55.8 per cent. The ferric chloride
reactions behaved as frequently noted, coming and going about the same time
with small traces of glycosuria.

Blood Sugar. — On the first day in hospital the sugar in whole blood was 0.555
per cent, in plasma 0.606 per cent. Fasting brought a very quick fall, but not
to normal, and marked hyperglycemia returned on feeding. The renal threshold
was probably high. On Sept. 25, the percentage in plasma was 0.371 per cent
as against 0.244 per cent in whole blood, indicating a very low sugar content in
the corpuscles. The low plasma sugar of 0.123 per cent on Sept. 29 was obtained
immediately upon finishing noon lunch, the patient having spent the morning
at heavy exercise. The tendency of the blood sugar was continuously downward,
the last analyses, on the morning of Nov. 13, showing 0.113 per cent in whole
blood and 0.145 per cent in plasma.

Weight and Nutrition. — Weight at admission 51 kg.; at discharge 47.4 kg., a
reduction of 3.6 kg. The patient had been pale and badly exhausted at admis-
sion. He was accepted because he appeared to represent a very pronounced
degree of lowered resistance and susceptibility to infectious and other accidents.
On imdernutrition treatment he gained strength decidedly with the combination
. of loss of weight and heavy exercise, and though thin, pronounced himself feeling
well. The diet prescribed at discharge was 100 gm. protein, 50 gm. carbohydrate,
and 2000 calories (about 2.1 gm. protein and 42 calories per kg., reduced by the
weekly fast-days to 1.8 gm. protein and 36 calories per kg.). Three factors were
considered here: first, the low weight upon which this reckoning is based (47.4
kg. as against 65 kg. normal); second, the hard exercise prescribed; and third, the
steady improvement, justifying some slight liberality of diet, which also seemed
desirable for the purpose of building up weight and strength.

Lipemia. — The plasma at admission was heavily lipemic. This Upemia was
present in marked degree up to Sept. 3, then ceased rather abruptly, for the plasma
on Sept. 4 was clear. No analyses were done.

Subsequent History. — The condition remained favorable, and glycosuria was
absent except for a trace on Feb. 1. About Feb. 20, he contracted a severe cold,
and shortly thereafter began to raise large amounts of foul smeUing sputum.
When seen on Mar. 4 he was a very sick man. Necrotic tissue but no tubercle
bacilli were found in the sputum. Glycosuria and acidosis had returned with
this infection. The patient was referred to another hospital, and died of pul-
monary gangrene on Mar. 15, 1916.



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 40 of 76)