Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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Remarks. — The low resistance suspected at admission was confirmed by the
outcome. Diabetes probably contributed to increase susceptibility, but it is
believed that the treatment, by improving strength and permitting outdoor
exercise, tended to raise rather than lower resistance in such a case.



366 CHAPTER m



CASE NO. 47.



Female, married, age 31 yrs. American; houseworker and canvasser. Ad-
mitted Oct. 6, 1915.

Family History. — Parents alive; Bright's disease suspected in father. Two
sisters are well. Maternal grandmother died of tuberculosis. Husband healthy.
Patient pregnant only once; the child is well, aged 8. History otherwise negative.

Past History.— Liie was spent in Wisconsm until 11 years ago, then in Porto
Rico until 1 year ago, since then she has lived near New York. Always strong and
healthy. Has had only some mild childhood diseases. Never nervous. Habits
and diet normal.

Present Illness. — This began 4 years ago with pruritus vulvae, not relieved by
local treatments, but increasing during a year. By the end of the year poly-
phagia, polydipsia, and polyuria were present, and the normal weight of 185
poimds had fallen to 145. A physician then diagnosed diabetes and merely for-
bade sugar and starch. The pruritus has remained continuously present, and
glycosuria was never reduced below 2 per cent. The patient applied to the In-
stitute because she had been informed that she could not live more than 3 months.

Physical Examination. — Height 170.1 cm. A tall, large boned woman without
marked emaciation but with flabby skin and muscles. She appears strong and
phlegmatic by nature, but worried and upset at present. Cheeks, high color;
no dyspnea or other acute symptoms. Teeth in fair condition. Tonsils slightly
enlarged. Lymph nodes palpable only in axillse. Reflexes normal. Superficial
genital infection from scratching. Blood pressure 90 systolic, 60 diastolic. Ex-
amination otherwise negative.

Treatment. — The patient was placed on an observation diet of 100 gm. pro-
tein, 100 gm. carbohydrate, and 3000 calories. Heavy glycosuria continued and
acidosis increased. After 3 days of this diet a high ammonia and low plasma
bicarbonate indicated danger. Accordingly 2 days of plain fasting were given
(coffee and soup, each 300 cc.) followed by 4 days with alcohol up to 600 calories.
Glycosuria was absent after Oct. 12, but the fasting was continued for 3 days
longer, because it was acting favorably upon the acidosis and the patient was
of a type requiring sharp undernutrition. With the cessation of glycosuria, the
distressing vaginal pruritus of 4 years duration promptly cleared up. A carbo-
hydrate test was then instituted. The ferric chloride reaction thus disappeared,
and the limit of tolerance was foimd to be 240 gm. carbohydrate. After a fast-
day on Nov. 14, the diet on Nov. 15 and 16 was 100 gm. protein and 2000 calories
without carbohydrate. In order to test the effect of fat, this diet was built up
by addition of fat. The first trace of ferric chloride reaction appeared with
2500 calories on Nov. 20. This reaction increased, the blood sugar rose, and
glycosuria appeared on Nov. 27 with 4000 calories. It showed the characteris-
tics of fat glycosuria in being slight and stubborn, not increased by the rise to
4500 calories on Nov. 29 and 30. Protein and fat were then stopped and nothing



CASE RECORDS 367

but green vegetables given, increasing from 10 gm. carbohydrate on Dec 1 to
70 gm. carbohydrate on Dec. 4 The ferric chloride reaction promptly cleared up,
but traces of glycosuria persisted. After the fast-day of Dec. 5, a diet of 100 gm.
protein and 2000 calories was begun, as on Nov. IS and 16, but with the addi-
tion of first 10 and then 20 gm. carbohydrate. After Dec. 9 both glycosuria and
ketonuria were absent on this diet, and on Dec. 18 it was possible to increase the
carbohydrate to 70 gm. without glycosuria. The effect of the fat in lowering toler-
ance is thus eVident. The patient was discharged Dec. 22 on a diet of 100 gm.
protein, SO gm. carbohydrate, and 2000 calories, (1.6 gm. protein and 31.8 cal-
ories per kg., reduced by the weekly fast-days to 1.4 gm. protein and 27.3 calories
per kg.).

Acidosis. — The attending physician sent this patient to the Institute because
confronted with the dilemma formerly feared; i.e., continuous glycosuria not-
withstanding restriction of carbohydrate, and acidosis present even with carbo-
hydrate in the diet. The rise of ammonia nitrogen from 1.62 gm. on Oct. 7 to
3.63 gm. on Oct. 10 probably indicates that 10 gm. carbohydrate represented
greater restriction than this patient had been accustomed to. The CO2 capacity
of the plasma, 41 per cent on Oct. 10, also gave evidence of well marked acidosis
on this diet. There was the usual improvement on fasting, the CO2 capacity
rising promptly without the use of alkali, but not attaining the normal hmit
until near the close of the carbohydrate test on Nov. 12. Protein-fat diet there-
after brought a fall, and particularly with the increase in fat it is seen that well
marked acidosis developed, the CO2 capacity of 39 per cent on Nov. 27 being
lower than recorded even in the first days after admission. Coma would almost
certainly have resulted from continuance of such an experiment. The fast-day
of Nov. 28 gave a prompt respite, so that the CO2 capacity on the morning of
Nov. 29 had risen steeply to almost S3 per cent. On the morning of Nov. 1,
after 2 more days of higher fat intake, it showed a drop, but the small quantities
of carbohydrate and omission of fat brought it up promptly within normal limits
by Dec. 2. Thereafter, with reduced fat and introduction of a little carbohy-
drate, fully normal values of blood bicarbonate were obtained.

Ammonia determinations had been discontinued on Oct. 12, after it was evi-
dent that the course was downward. It may be assumed that the curve fell to
normal during the carbohydrate test. Following the fat experiment it was up
to 2.24 gm. N on Nov. 1. There was a prompt drop with carbohydrate, followed
by a rise to 1.92 gm. N on the lower fat intake, and another fall after the fast-
day of Dec. 12. The ferric chloride reaction roughly corresponded to the other
evidences of acidosis.

Blood Sugar. — Though the restriction of carbohydrate caused acidosis, the
high values of 0.38 per cent sugar in whole blood and 0.S24 per cent in plasma
on Oct. 9 indicated how far the diet stUl exceeded the tolerance. With fasting
there was a prompt fall in blood sugar, but not to normal. H}rperglycemia
gradually increased during the carbohydrate test, and persisted after it to Nov.



368 CHAPTER ni

17. The abstinence from carbohydrate showed its effect in a fall on Nov. 20; but
an increase of blood sugar due to an increase of fat in the diet was then clearly
demonstrable, leading to glycosuria as mentioned. After the undernutrition
period (Dec. 1 to 5), the first normal plasma sugar was obtained on Dec. 6.
Thereafter the restriction of fat, though protein was kept the same and carbohy-
drate was added, resulted in a fall of blood sugar so that the patient was dis-
missed with a normal plasma sugar of 0.12 per cent.

Weight and Nutrition. — The weight at admission was 67.3 kg!, at discharge
62.9 kg. The treatment thus represented undernutrition to the extent of 4.4 kg.
At the same time vigorous exercise was employed. The patient was naturally
strong, and after her immediate distress was relieved she was soon able to walk
4 miles, climb 40 flights of stairs, and practice roller skating and other exer-
cises daily. Her weight at discharge was satisfactory for both strength and
looks. Her muscles were firm, and she was in splendid health subjectively and
objectively.

Subsequent History. — The patient reported on Jan. 4 free from glycosuria, but
weighing 64.9 kg., a gain indicating that she had not been faithful to the prescribed
exercise and quantity of diet. She was instructed to bring the weight down to that
at discharge. Notwithstanding warnings, she gradually became more careless in
regard to diet, and ceased weighing food. Glycosuria returned first in occa-
sional traces which were cleared up, and then during Apr. continuously. On
May 24, she was still looking perfectly well, but complained of weakness and
weariness along with glycosuria. The sugar in both whole blood and plasma
was 0.201 per cent, CO2 capacity 52.1 per cent. When seen again on July 22,
the findings were heavy glycosviria, moderate ferric chloride reaction, blood sugar
0.370 per cent, plasma sugar 0.385 per cent, CO2 capacity 56 per cent, weight
68.3 kg. She was not seen again imtU Jime 7, 1917, when her weight was 70
kg., due in considerable part to edema. She was still looking and feeling fairly
well, but the urine showed a heavy sugar and slight ferric chloride reaction. The
carelessness ia diet was continuous. Downward progress clinically, which seemed
to be slow in appearing, was very rapid at the close, and reports in July, 1917
indicated that the patient was close to death from weakness and acidosis.

Remarks. — The case would have been a diflncult one to manage under former
treatment, but with the present methods showed itself as only moderately severe.
The complete clearing up of the condition both chertiicaUy and clinically served
to prolong comfort, strength, and Ufe, even though diet was violated afterwards.
The patient lacked the necessary wiU power to adhere to diet, and downward
progress was therefore inevitable. She gained strength as she lost weight in hos-
pital, and lost strength as she gained weight outside the hospital. At no time
could it be said that she was stronger or better ofiE on a diet in excess of the
tolerance.



CASE RECORDS 369

CASE NO. 48.

Male, unmarried, age 20 yrs. American; shipping clerk. Admitted Oct. 7,
1915.

Family History. — Partly unknown. Two uncles died of tuberculosis. Family
said to be free of diabetes, cancer, syphilis, and nervous troubles.

Past History. — ^Healthy life in rather poor surroundings. Childhood diseases
unknown. Occasional mild sore throats. Considerable trouble with teeth. No
venereal disease. Reached graduating class in grammar school at 15, then began
work as delivery boy, and 6 months ago was promoted to shipping clerk. No
alcoholism. Cigarettes smoked to excess. Has had more than the average
appetite for candy, pastry, and sweet things.

Present Illness. — Polyphagia, polydipsia, and polyuria began 1 year ago. Diag-
nosis was made within a month, and the physician forbade sugar and starch and
ordered a teaspoonfid of sodium bicarbonate three times a day. Patient did not
adhere to the diet and became worse. Later he was treated by another physician
and at a hospital clinic, and at the latter place was advised to come to this
Institute.

Physical Examination. — A round shouldered, narrow chested, underdeveloped,
imdernourished boy. Teeth in fair repair; tonsils normal. General examination
negative.

Treatment. — (No graphic chart.) The usual heavy glycosuria and ketonuria
were present, but no signs of immediate danger. After 3 days of observation
diet, a S day fast cleared up the glycosuria. Green vegetables were begun on
Oct. 15, and 10 gm. carbohydrate added daily, until persistent traces of glycosuria
appeared with 130 gm., Oct. 27 to 30. Meanwhile the ferric chloride reaction
became negative. A mixed diet was then rather rapidly built up, but though this
was adequate in amount, the patient proved himself entirely imtrustworthy.
He was kept in the hospital vmtil July 28, 1916, but always showed the undepend-
able character and degeneracy of the excessive cigarette smoker, and continually
broke rules in regard to both diet and smoking. He insisted that he must have
sugar on occasions, and 40 to SO cigarettes daily. Under hospital management
he had been kept free from glycosuria nearly the entire time. He was discharged
with the certainty that he would go rapidly downhill.

CASE NO. 49.

Female, divorced, age 30 yrs. American; seamstress. Admitted Oct. 9,
1915.

Family History. — Father died of peritonitis, following gall stones. Mother
living, aged 55, also has gall stones. Four brothers died in infancy; one brother
and one sister are well. No diabetes or other heritable disease in family.

Past History. — Measles, mumps, chicken-pox, scarlet fever, before 10. Mem-
branous croup at 6 years requiring intubation. Many sore throats, espyecially



370 CHAPTER ni

tonsillitis previous winter. Married 8 years ago. Two children 13 months
apart; both high forceps and died of weakness or convulsions within 6 months.
Patient always nervous and overexcitable. 6 years ago nervous breakdown
confined her to bed for 12 weeks. No excesses in diet or otherwise.

Present Illness.— Shortly before Christmas, 1914, began polyphagia, polydipsia,
and polyuria. She found she had lost 25 pounds weight smce the previous sum-
mer. She was given the usual diet but did not adhere closely to it. Last win-
ter vision became blurred; glasses have helped somewhat, but at present she can-
not read and has difficulty walking about because of blurring of sight. Has
been tired and weak for 6 months past, and sleeps a couple of extra hours in the
afternoon.

Physical Examination. — Patient fairly developed, only slightly emaciated.
Mouth and throat normal. No lymph node enlargements. Reflexes normal.
General examination negative.

Treatment. — The patient was admitted at 11 a.m., and up to 6 a.m. the next
morning excreted 118 gm. glucose, with a heavy ferric chloride reaction and 2.93 gm.
ammonia nitrogen. The first CO2 determination on Oct. 9 was 34.4 per cent.
The diet on Oct. 9 was 100 gm. protein, 100 gm. carbohydrate, and 2200 calories.
The ammonia nitrogen rose to 3.36 gm., and the CO2 capacity on the morning of
Oct. 10 was down to 27.8 per cent. The patient was drowsy, with face flushed,
and spent most of her time in seemingly normal sleep. There was no marked
dyspnea, but the coryza present at admission persisted, with temperature up to
100.5° F. On Oct. 10 fasting was begun, with 120 cc. whisky and 60 gm. sodium
bicarbonate. Whisky was continued, but no more alkali was given. The CO2
capacity rose and the ammonia fell, and acidosis symptoms cleared up. Glyco-
suria ceased after 5 days of fasting. 10 gm. carbohydrate in green vegetables
were added to the whisky on Oct. 15. Whisky was then discontinued and carbo-
hydrate continued at 30 gm. daily. This caused glycosuria, which cleared up
under exercise as noted below. It was then possible to make the usual increase
of 10 gm. carbohydrate daily. A trace of glycosuria appeared with 150 gm.
carbohydrate on Nov. 2, then disappeared, and reappeared with 170 gm. carbo-
hydrate on Nov. 5. Meanwhile the ferric chloride reaction cleared up. A diet
of 2000 calories with 75 gm. protein and 15 gm. carbohydrate was then begun
with the usual weekly fast-days. The attempt to increase carbohydrate to 40
gm. on Nov. 23 resulted in glycosuria. The patient was dismissed on Dec. 3
feeling strong and well, having recovered her vision perfectly. An oculist found
vision normal and considered that the blurring had been a functional weakness
of accommodation.

Acidosis. — Even though the diet on Oct. 9 contained 100 gm. carbohydrate,
restriction to this extent brought on symptoms of impending coma. There was
the usual clearing up on fasting, and the recovery of a considerable carbohydrate
tolerance. It is noteworthy that mixed diet tended to bring back the ferric
chloride reaction. In the last analyses on Dec. 1, preceding discharge, the CO2



CASE RECORDS 371

capacity of the plasma was normal and the ferric chloride reaction negative, but
a slight acidosis was indicated by the ammonia nitrogen of 1.24 gm. The sugar
in both whole blood and plasma at admission was 0.333 per cent. On Oct. 15,
after 2 days freedom from glycosuria, the sugar was still 0.217 per cent m whole
blood and 0.244 per cent in plasma. Notwithstanding the high carbohydrate in-
take, the blood sugar on Nov. 4 was down to 0.169 per cent, plasma sugar 0.164
per cent, in consequence of continued undernutrition and exercise. After a rise
to 0.204 per cent on Nov. 11 with mixed diet, the tendency of the blood sugar was
downward, and on Dec. 1 it was 0.133 per cent in whole blood, 0.167 per cent
in plasma.

£«ercMe.^Glycosuria had appeared with green vegetables representing 30
gm. carbohydrate on Oct. 17, and persisted with this intake on the following
days. Beginning Oct. 19, exercise was ordered. The patient skipped rope for
IS mmutes daily, and on Oct. 19 climbed 32 flights of stairs, on the 20th 48 flights,
on the 21st 96 flights. On this day glycosuria ceased. Exercise to the point of
exhaustion was continued as carbohydrate was increased on the following days.
The effect in raising tolerance was demonstrated by the cessation of glycosuria
as described, and the exercise doubtless contributed toward the high tolerance
then displayed. Nevertheless simple continuance of undernutrition represented
in the carbohydrate period must be given credit as the most beneficial factor.

Weight and Nutrition. — ^The weight at entrance was 52.4 kg., at discharge 49.8
kg., the treatment thus representing undernutrition to the extent of 2.4 kg. The
diet at discharge was 75 gm. protein, 25 gm. carbohydrate, and 2000 calories,
representing approximately 1.5 gm. protein and 40 calories, reduced by the weekly
fast-days to an average of about 1.3 gm. protein and 34 calories per kg. This
was considered a low diet in view of the amount of exercise which the patient was
ordered to continue at home. She was some 36 pounds below her normal weight
and was not expected to gain weight on this ration. Faith was largely reposed in
exercise to bring down the blood sugar further and raise the tolerance. Later
knowledge makes it evident that a lower diet with less strenuous exercise would
have been better treatment, and reduction of the too large fat intake would
have been the best means of bringing down both the ammonia and the blood
sugar.

Subsequent History. — In Jan., 1916, the patient showed traces of glycosuria dur-
ing a short attack of grippe. Thereafter she was free from sugar and ferric
chloride reactions up to the last report in Feb. The next word received was
notice of her death on May 19, 1916. Inquiry elicited the fact that she had
broken diet about 1 month before death, and died with symptoms of diabetic
coma.

Remarks. — The progress to a fatal end in 1 month indicates the severity of the
case, and this result of breaking diet is in contrast to the excellent condition at
the time of discharge.



372 CHAPTER m



CASE NO. 50.



Widow, age 54 yrs. American; teacher. Admitted Oct. 8, 1915.

Family History. — Negative for diabetes or other heritable disease.

Past History. — Very healthy life. No illnesses beyond those of childhood.
Never pregnant. Regular habits. No excesses. Appetite, digestion, bowels,
and menstruation normal until present illness; no menstruation since.

Present Illness. — In 1907, the patient entered a sanitarium on account of a
"nervous breakdown." This had begim so gradually that the exact onset was
unknown. She complained of general weakness and loss of energy, memory, and
mental powers, also her teeth and hair were falling out, speech was slow, tongue
thick, and face swollen. The diagnosis of myxedema was made, and thyroid ex-
tract restored apparently normal health. In 1912 she returned to the sanitarium,
having taken thyroid extract throughout the interval. This time she had poly-
phagia, polydipsia, and pol)airia. The diagnosis of diabetes was made, and
thyroid extract was ordered discontinued for fear it might aggravate the dia-
betes. She has been unable to get along without thyroid, and has therefore con-
tinued to take it at intervals as the myxedema S3Tnptoms returned. Loss of
weight has been only moderate, and the chief symptoms are a general breakdown,
with weakness and nervousness, along with marked myxedema S)rmptoms as
above mentioned, coryza, headache, and complaint of pains all over the body.

Physical Examination. — Height 152.2 cm. A well developed, well nourished
woman; hair turning gray, slightly coarse, abundant; broad puflEy face; dry skin;
pasty color; eyebrows and lashes scanty. A number of teeth missing; the others
show some caries and pyorrhea. Throat normal. Lobes but not isthmus of
thyroid palpable, apparently normal in size and consistency. Heart and Ivmgs
negative. Liver edge palpable O.S cm. below costal margin. Blood pressure 90
systolic, 75 diastolic. Fingers short, thick, not clubbed. Reflexes normal. The
patient appeared as if intoxicated, and speech was difficult, almost incoherent.
The diagnosis of myxedema was confirmed by several observers, and it was con-
sidered possible that intoxication of acidosis character was also present, not-
withstanding the low ammonia and high CO2.

Treatment. — On Oct. 8 the diet contained 64 gm. protein, 28 gm. carbohydrate,
and 1500 calories. The next day, with diminishing appetite, it was 35.5 gm. pro-
tein, 38 gm. carbohydrate, and 1375 calories. On this day there was nausea and
one attack of vomiting. The symptoms at admission were still present. The
highest temperature was 100.2° F. Fasting was begun on Oct. 10, with 300 cc.
clear soup daily. 30 cc. castor oil and several high colon irrigations removed
large quantities of feces. Glycosuria cleared up after 48 hours. On Oct. 10, 6
gm., and on Oct. 11, 22 gm. sodium bicarbonate were given. The urine re-
mained acid or neutral, and the ferric chloride reaction, which had been slight,
was increased to only moderate degree. On Oct. 13, 10 gm. carbohydrate in the
form of green vegetables were given, and increased on subsequent days until on



CASE RECORDS 373

Oct. 26, 110 gm. were taken without glycosuria, and a fast-day was necessary the
next day because of indigestion due to the quantity of vegetables. The ferric
chloride reaction had cleared up, and weakness and other symptoms had greatly
improved. After the fast-day exercise was begun, particularly with a view to
improving digestion, and by Nov. 1 the patient was on a regular program of
walking 10 blocks and 24 flights of stairs daily. The bulk of vegetables was
diminished by giving potato. On Nov. 2, the patient, feeling well and cheerful,
experienced the sensation that the left foot was asleep. She stamped it and fell,
fracturing the tip of the fibula. The leg was put up in plaster and exercise neces-
sarily stopped. From Nov. 5 to 13, 200 gnl. carbohydrate daily were tolerated
without glycosuria and with diminishing blood sugar. Beginning Nov. IS, a
mixed diet of 2000 calories and 65 gm. protein was begun with high carbohydrate,
for purposes of a test with thyroid extract as described below. The subsequent
glycosuria was cleared up by the fast-days of Dec. 19 and 20, after which a diet
was bmlt up of 75 gm. protein and 1500 calories, with carbohydrate graduaUy
increasing up to 90 gm. on Jan. 14. The cast was removed from the fractured
leg on Dec. 8, repair having been uneventful and perfect. She was discharged
Jan. 14, 1916, with the feeling and appearance of complete health, to resume her
duties as teacher.

Acidosis. — On the chemical side this never amounted to more than a slight
ferric chloride reaction, but there was prompt and striking improvement in the
intoxication symptoms under the usual treatment for acidosis. One subsequent
feature is the steady rise of the CO2 curve with increasing carbohydrate intake
up to the very high value of 74.6 per cent on Dec. 17, then, with carbohydrate
almost excluded, the steep fall to 53.8 per cent on Dec. 30. By Jan. 5, it had
risen within low normal limits, without the aid of alkali, perhaps with the aid of
the small quantity of carbohydrate.

Blood Sugar. — At admission, sugar was 0.375 per cent in whole blood and 0.371
per cent in plasma. By Oct. 16, it was found normal (0.113 per cent). With
the subsequent high carbohydrate intake it tended to rise, but was brought
promptly to normal on the morning after the single fast-day of Oct. 27. Values
0.3 to 0.32 per cent were obtained on Nov. 1 and 3 durmg digestion without gly-
cosuria, but those taken mornings before breakfast tended to fall, so that toward
the close of the period in hospital normal figures were the rule.

Weight and Nutrition. — The weight at entrance was 49.6 kg., at discharge 46.2
kg., the period of treatment thus representing imdernutrition to the extent of
3.4 kg. The long period of relative protein abstinence is noteworthy, inamuch



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 41 of 76)