Frederick M. (Frederick Madison) Allen.

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which the downward progress later brought her, the opinion may be ventured
that she not only would have lived longer, but also this same period between
Oct., 1915, and Apr., 1916, would have been characterized by a higher average of
strength, comfort, and usefulness.

CASE NO. S3.

Female, age 9 yrs. American; schoolgirl. Admitted Oct. 15, 1915.

Family History. — Parents well, except that mother is nervous. One sister well.
No diabetes or heritable disease known in family.

Past History. — Healthy life in good hygienic surroundings in a small town in
the middle west. Measles, mumps, chicken-pox in early years. No tonsillitis for
2 years past; 4 or 5 attacks before that. Stiffness and pain in various joints at
times, but no definite rheumatism. Child has made average record at school.
Nervous disposition. Development normal; not obese.

Present Illness. — Polyphagia, polydipsia, and polyuria began 2 years ago. Un-
der a specialist's care in a Chicago hospital, glycosuria was cleared up on restricted
diet without fasting. Sugar-freedom was maintained until last Feb.; since then
glycosuria has been continuous. Pruritus vulvae for past 4 months.

Physical Examination. — Height 125.2 cm. A fairly developed but emaciated
child, pale and weak. Mouth and throat negative. No notable lymph gland
enlargement. Reflexes normal. General examination negative.

Treatment. — A 5 day fast was necessary to clear up glycosuria. On the usual
green vegetable period, glycosuria appeared on Oct. 30 with 80 gm. carbohydrate.
Thereafter a diet of 1000 calories with small quantities of carbohydrate was badly
assimilated from the standpoint of hyperglycemia and occasional traces of glyco-
suria. Carbohydrate was omitted beginning Dec. 10, the usual diet being 40



382 CHAPTER in

gm. protein and 600 to 800 calories, with routine weekly fast-days. A second
carbohydrate test beginning Jan. 24 showed increased tolerance; glycosuria ap-
peared with 120 gm. carbohydrate on Feb. 5. By Feb. 21, the patient was able
to assimilate a diet of 40 gm. protein, IS to 20 gm. carbohydrate, and 750 calories.
She was discharged Feb. 24 on this diet, except that only 10 gm. carbohydrate
were permitted.

Acidosis. — No threatening symptoms were present at any time, but the heavy
ferric chloride reaction and the CO2 capacity of 37 per cent at admission were
significant. Both these signs changed rapidly for the better on fasting, and on
carbohydrate and mixed diet thereafter. With normal CO2 and negative ferric
chloride, the ammonia excretion still showed a slight acidosis in Dec. and Jan.
This gradually diminished to a normal level by the time of discharge.

Blood Sugar. — There was evidently a far greater excess of plasma sugar over
corpuscle sugar on Oct. 26 than at later periods. The salient feature is the steady
decline of the blood sugar curve toward normal. The reason for the occurrence
of h)rperglycemia in the last analysis on Feb. 24 is not known.

Weight and Nutrition. — The weight was 20 kg. on admission, 16.9 kg. at dis-
charge; i. e., a loss of 3.1 kg. The child was emaciated at admission, and never
showed improvement of appearance in consequence of treatment. Exercise was
employed dvuing most of the period in hospital. It afiEorded the child a more
normal and enjoyable life, but did not build up tolerance appreciably or confer
real strength. It may have been one factor along with the low diet in bringing
down the blood sugar. There was one cold while in hospital; glycosuria did not
result, and recovery imder the low diet was normal. The diet prescribed at dis-
charge represented about 2.4 gm. protein and 44 calories per kg., diminished to
about 2.1 gm. protein and 38 calories average by the weekly fast-days. The diet
therefore was absolutely low, but adequate as reckoned on the greatly reduced
weight. The child was regularly up and about all day long, and amused herself
with active play and other occupations, but always kept the appearance of a
little invalid.

Subsequent History. — The patient remained free from glycosuria, except for rare
traces due to accidents of diet and one attack of grippe. By Sept. 9, she had im-
proved sufficiently to begin school, but weighed only 17.7 kg. Toward the end
of Sept. she had a severe cold, and another in Oct. with temperature of 101.5°.
Both caused glycosuria, and thereafter permanent sugar-freedom was difficult
to maintain. She was advised to return to the hospital, but the parents delayed,
and death occurred in coma on Jan. 25, 1917.

Remarks. — ^This was one of the worst cases among the children in this series,
not only because of the low food tolerance, but also because of the frailness of the
patient, whose whole appearance indicated exhaustion and low resistance. The
diets were never excessively low, even those in the forepart of Jan. representing
about 2.2 gm. protein and 36 calories per kg. for 18 kg. weight. The general
result of treatment, by reason of the fasting and carbohydrate periods and
exercise, was the above mentioned loss of 3.1 kg. during more than 4 months



CASE RECORDS 383

in hospital. Durmg 7 months thereafter at home, the weight showed a slight
increase.

It is noteworthy that in a case of this very unpromising type a demonstrable
increase of carbohydrate tolerance was produced in hospital, and also all symptoms,
including hyperglycemia, were brought under control. No upward progress or
actual recovery of assimilation was demonstrated; the improved tolerance was
merely purchased at the price of diminished weight. But even with the neces-
sarily unfavorable conditions, downward progress came only with an infection
approximately 1 year from the time the patient was first received. The record is
satisfactory to the extent that both life and comfort were evidently prolonged by
treatment in an unpromising type of case.

CASE NO. 54.

Female, married, age 29 yrs. American; telephone operator. Admitted Oct.
16, 1915.

Family History. — Mother died with a "severe cold" in 1891. Father is well.
One brother died of meningitis in childhood; eight brothers and sisters are well.
Husband well. No diabetes or other heritable disease in family.

Past History. — Measles and whooping-cough in childhood. No other illnesses;
no sore throats. Healthy life. No nervousness. Appetite, diet, and digestion
normal. Menstruation normal. One miscarriage 3 years ago; no other pregnancy.

Present Illness. — June 1, 4| months before admission, patient weighed 144
pounds and felt so well and free from strain that she went on with work instead
of taking summer vacation at the usual time. Within 2 weeks from that time
and with no illness or other disturbance of any kind, polydipsia and polyuria
began, and there has since been progressive loss of strength and 30 pounds weight.
Patient was first seen by a doctor and diabetes diagnosed on July 4. Under
gradual withdrawal of carbohydrate she became free from glycosuria on Aug. 13
and remained so until Sept. 12, since when glycosuria has been present except on
fast-days.

Physical Examination. — Height 169 cm. A well developed and fairly nourished
woman, with no striking symptom except dyspnea and acetone odor. Mouth and
throat normal. Abdomen slightly distended and tympanitic. Kjiee jerks sluggish .
Blood pressure 110-80. General examination negative. Wassermann negative.

Treatment. — Impending coma was indicated by the dyspnea, heavy ferric chlo-
ride reaction, ammonia nitrogen of 2.52 gm., and CO2 capacity of 29 per cent. A
light observation diet was given, with SO gm. sodium bicarbonate in the evening.
The next day fasting was begun, with 300 cc. each of coffee and clear soup and 286
calories of alcohol daily. 30 gm. sodium bicarbonate were given on Oct. 17 and
19, 20 gm. on Oct. 20, and 15 gm. on Oct. 21. Glycosuria was absent after the
21st. On Oct. 22, 10 gm. carbohydrate were given in the form of lettuce, celery,
and tomatoes; 20 gm. on the 2 succeeding days, and 14 gm. on Oct. 25. Glyco-
suria was continuous on this low intake, but was checked by the fast-day of



384 CHAPTER m

Oct. 26. On Oct. 27, 10 gm. carbohydrate were given, and increased by 10 gm.
daily, glycosuria appearing with 40 gm. carbohydrate on Oct. 30, and continuing
with diets of SO to 30 gm. protein, 10 gm. carbohydrate, and 1000 to 800 calories
on the following day. At first the patient had given the impression of a mod-
erately severe diabetes with threatened coma, but now the case looked more
serious when it appeared that the food tolerance was ahnost zero. Ketonuria,
though diminished, persisted. Hyperglycemia was stubborn, and between Nov.
10 and 20 it was found that carbohydrate-free diets of 40 gm. protein and 800
calories sufficed to keep up almost continuous glycosuria. Nov. 21 was a fast-
day with only 70 calories alcohol. On the following 3 days, 10 to 20 gm. car-
bohydrate in green vegetables were the only food. On Nov. 25 and 26, 40 gm.
protein, S gm. carbohydrate, and 800 calories were given. Still glycosuria and
ferric chloride reactions persisted. The former was stopped and the latter
diminished by 3 fast-days, Nov. 28 to 30. Then, beginning with 5 gm. carbo-
hydrate on Dec. 1 , green vegetables were increased daily, until glycosuria appeared
with 40 gm. carbohydrate on Dec. 5. On Dec. 8 to 11, carbohydrate-free diets of
60 to 25 gm. protein and 800 to 325 calories kept up marked glycosuria and keto-
nuria which did not cease even with 3 fast-days (Dec. 12 to 14). On Dec. 15
and 16, 30 to SO gm. protein and 170 to 305 calories were given, with continued
glycosuria and ketonuria. Dec. 17 and 18 were fast-days with cofifee, soup, and
315 calories alcohol, and both sugar and ferric chloride reactions became nega-
tive. With continuance of the same liquids, one egg was allowed on Dec. 19 and
two eggs the next day, and glycosuria and ketonuria remained absent on an increase
up to five eggs on Dec. 25 (714 calories, 315 of which were alcohol). A pre-
cautionary fast-day with whisky was given on Dec. 26, then the diet again in-
creased until continuous glycosuria appeared on 45 gm. protein and 1025 calories
(315 alcohol, 710 food) following Dec. 30. The fast-day on Jan. 2 checked the
glycosuria, but it reappeared on a diet of 45 gm. protein and 888 calories (alco-
hol 315, food 573). The menu for such a day, characteristic of the diets on which
it was necessary to keep this patient, was as follows:

60 gm. bran. 6 eggs.

300 cc. coffee. 10 gm. olive oil.

300 " soup. 100 " thrice cooked asparagus.

90 " whisky. 100 " " " spinach.

Again reUef from glycosuria was given by a fast-day on Jan. 9, and on the 11th
glycosuria reappeared on four eggs, 300 cc. coffee, 450 cc. soup, and 90 cc. whisky
(30 gm. protein and 634 calories) — no vegetables, bran, or any source of carbohy-
drate. On the following days, it became certain that the patient definitely could
not tolerate the protein of four eggs. The fast-day of Jan. 16 failed to stop the
glycosuria, therefore (Jan. 21 to 25) 5 successive days of fastmg and alcohol were
imposed. On Jan. 26 one egg was added, on Jan. 28 two eggs, on Feb. 3 three
eggs, m addition to 200 gm. thrice boiled vegetables and 525 calories of alcohol.
The chart shows the continuous slight glycosuria, not stopped by the fast-day of



CASE RECOEDS 385

Feb. 6. Reduction to one egg on Feb. 10 and fasting the next day stopped the
glycosuria, but it returned when the eggs were increased to three on Feb. 15.
The remainder of the long graphic record shows practically the same story of con-
tinuous inabihty to tolerate anythmg approaching a livmg diet. On some occa-
sions, the Umit of tolerance was only two eggs without other food, three eggs causing
glycosuria. On this account alcohol was pushed to a maximum of about 500
calories, to keep up nutrition as well as possible. Beginning with a fast-day
on June 13, another carbohydrate period was tried. By June 18, 25 gm. carbo-
hydrate were taken without glycosuria, but the patient's strength had collapsed
and a change to other food was imperative. Accordingly on Jvme 19, the 8 month
attempt to control the condition was abandoned. Glycosuria was present on the
carbohydrate-free diet of 36 gm. protein and 1000 calories (490 alcohol, 590 food).
It increased, and ferric chloride reactions promptly returned, when the diet was
raised to 45 gm. protem and 1490 calories (490 alcohol, 1000 foo'd). An alarming
fall in the blood bicarbonate promptly followed, down to 28.7 per cent on June
29. To meet the combination of extreme weakness and impending coma, alcohol
and protein were continued the same and the fat diminished to make a total
ration of only 900 calories. The threatening symptoms passed off, and without
the use of alkali the CO2 capacity had risen to 61 per cent by July 6. The fat
was increased to make the same 1490 calories as before. Meanwhile also car-
bohydrate had been introduced up to 17.5 gm. daily. With the increase in fat
came another sharp fall of the CO2 capacity, so that on July 12 it was 35.9 per cent.
40 gm. carbohydrate were given on that day without clinical benefit. Resort
was had to fasting to avert the imminent coma. On July 13, the only food was 7
gm. carbohydrate and 70 cc. whisky; on the 14th only whisky was given; on the
15th, 15 gm. protein were added. By this time the CO2 capacity was up to 62.5
per cent, again without the aid of alkali. July 16 was a fast-day, and on the
17th the diet was 30 gm. protein, 20 gm. fat, and 35 cc. whisky; 430 calories in
all. On the 18th, the patient awoke clearly conscious, but weak. She went into
collapse with loss of consciousness, and died from final exhaustion of strength at
2:40 p.m. Death occurred with insignificant ammonia, negative sugar and
ferric chloride reactions, and normal plasma bicarbonate as far as can be judged
by the last analysis on July IS. There were no symptoms suggesting diabetic
coma, and the unconsciousness was merely such as precedes death from starvation.
Acidosis.— This patient always responded to fasting with a quick clearing up of
acidosis. The ferric chloride reaction was stubborn for about 2 months, then
remained almost continuously negative until the final period of overfeeding in
June. The plasma bicarbonate maintained a normal level throughout most of the
time. A more dehcate index of the slight acidosis was frequently found in the
sUght elevation of the ammonia output. Aside from the bicarbonate dosage on the
first few days as mentioned, no alkaU was used. A sharp fall in the CO2 capacity
in Jan. (62 per cent on )the 15th, 56 per cent on the 17th, 44.2 per cent on the
19th, 43.2 per cent on the 25th) occurred without known cause or disturbance.
By Feb. 2, it had risen spontaneously to 56.6 per cent. The terminal record in



386



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Fat 58.7
^ Carbohy-
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Alcohol 70.0
Calories 1231

Protein 50.8
Fat 33.1
Carbohy-
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Alcohol 70.0
Calories 1026














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388



CHAPTER III



June and July is of interest as showing how a low fat allowance brought on prompt
severe acidosis, not prevented by alcohol, nor on the second occasion by carbohy-
drate, but yielding very easily to simple withdrawal of fat both times (Table
XIV). The fat allowance bringing on the dangerous acidosis in each instance
was rather high in proportion to the weight of the extremely emaciated patient,
but in absolute quantity was very low. It is evident that the production of acido-
sis cannot be attributed to protein, because it developed on 35 to 60 gm. protein
in the period June 14 to 28 and cleared up on 50 to 55 gm. protein in the period
June 29 to July 6. Diets predominantly protein, as those of July 13 to 17, acted
favorably in diminishing acidosis, but protein was not indispensable for the pur-
pose, as fast-days always acted favorably in this patient. Carbohydrate was
scarcely important in checking the acidosis, since the quantities in the period
June 29 to July 6 were so small, and acidosis similarly was controlled on July 15
without carbohydrate. The influence of alcohol was not perceptible; acidosis
was controlled as readily on 35 gm. alcohol as on 70 gm. It is clearly evident
that the giving or withholding of fat was the sole determining factor in producing
and abolishing acidosis, and the specially noteworthy point is the small absolute
quantity of fat which was effective for this purpose.

Blood Sugar. — The marked and stubborn h)rperglycemia, and the response of
both blood sugar and glycosuria to sHght changes in the diet, proved that actual
severity of diabetes was the sole cause of difficulty, and not altered renal per-
meability. Normal blood sugar was attained on only a few occasions. On Dec.
2, there was a practically normal reading for the whole blood, but hyperglycemia
in the plasma, as if the corpuscles were almost sugar-free. Both were normal on
Apr. 5. The low normal figure before breakfast on June 18 doubtless represented
extreme exhaustion rather than genuine improvement in the diabetes.

Weight and Nutrition. — This was the most extreme imdemutrition in the entire
series. The patient appeared well nourished at a weight of 49 kg. at admission,
and died of inanition 9 months later at a weight of 24 kg.; i. e., a loss of 25 kg.
since admission, and 41 kg. since the onset of diabetes.

The nitrogen analyses show a fairly uniform excretion of about 8 gm. daily.
The negative balance during this time was not so great as will appear from the
comparison of intake and output, because the nitrogen of the soup was not in-
cluded in the dietary record. As no fecal analyses were done, an exact reckoning
of the balance is impossible. Concerning the total energy intake, the following
calculation can be made.





276 days.


Per day
(average).


Per day
per kg.


Alcohol calories


90,348
96,692
187,040
7,305 gm.
6.881 "


315.6
362.1

677.7
26.4 gm.
24.8 «


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Food "


10 9


Total "


20 5


Protein in diet


0.80 gm.
75 "


Fat " "







CASE RECORDS 389

On Mar. 31, this patient was studied in the respiration calorimeter by DuBois
and collaborators, who determined the following.' "I. Her total metabolism is
the lowest recorded in the literature, being only 23.3 calories per square meter
per hour, which is 37 per cent below the average basal normal in women. Since
her original weight with clothes had been 66 kg., one may be permitted to assume
a weight of 62 kg. without clothes. Had her metaboUsm been normal for this
weight, it would have been 63.3 calories per hour instead of 29.4 calories, which
were actually measured when her weight had fallen to 32. S kg. The extreme
emaciation which had resulted m a reduction of body weight to nearly haU of
what it was originally, reduced the metabolism so low that only 40 per cent of
the origmal heat production was necessary for life. II. The nitrogen excretion
in the urine (0.39 gm. per hour) is the quantity commonly found in normal
people. The total metabolism, however, is so low that the percentage of calories
from protein is quite high, 35 per cent (IS per cent being the average normal).
III. The respiratory quotients average 0.82, a normal figure. From this, one
may calculate that fat gives 39 per cent of the calories of metabolism and car-
bohydrate 26 per cent. This corresponds to the utilization of 44 gm'. of carbo-
hydrate daily, and smce none was given in the food, these results are difficult to
interpret."

The patient's total heat production at this time was 29.5 calories per hour, or
708 per day. Presumably it was somewhat higher in the preceding months, and
probably by June 15 had fallen even lower. If this 708 calories be taken as an
average for comparison with the average intake of 677.7 calories above calcu-
lated, it is seen that the diet is deficient notwithstanding the great lowering of
metabohsm, and even without allowance for any loss through the feces. The



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 43 of 76)