Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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he ate 166 gm. protein, 30 to 40 gm. carbohydrate, and 4000 calories daily, and
excreted 16.7, 31.6, and 14.5 gm. sugar, with only slight ferric chloride reactions
and low normal plasma bicarbonate. 4 days of fasting were then imposed, a
trace of glycosuria remaining in the early hours of the last day. Without waiting
for full 24 hours of sugar-freedom, feeding with green vegetables was begun on
Nov. 24 and increased to 100 gm. carbohydrate on Nov. 26, when a trace of gly-
cosuria appeared. After a fast-day on Nov. 28, carbohydrate was begun in the
form of oatmeal, for comparison with the green vegetables. Glycosuria ap-
peared with 250 gm. carbohydrate on Dec. 5, and remained no more than a trace
with increase to 300 gm. carbohydrate on Dec. 6. The oatmeal being eaten
plain after 3 hours boiling, with no flavoring but salt, and nothing else being



398 CHAPTER m

permitted but 300 cc. coffee and 300 cc. clear soup, the caloric intake was thus
kept down to undernutrition level. After a fast-day on Dec. 7, another test was
begun with potato under the same conditions. 500 gm. carbohydrate were toler-
ated in this form, causing only a trace of glycosuria on Dec. 15, which cleared
up with the same intake on Dec. 16. The patient had been longing for potatoes
for many years, but the test was stopped because he could not eat a larger
quantity.

After a fast-day on Dec. 17, an attempt was made to compare the different
proteins in their effect upon the carbohydrate tolerance, potatoes being used
because the patient enjoyed them so much. On Dec. 18, glidine was given with
potato, but the test had to be broken off because the taste of glidine caused
nausea. Begioniag Dec. 19 the protein used was in the form of meat (beef,
veal, pork, every day). A trace of glycosuria thus appeared on Dec. 19 with
136 gm. meat-protein and 300 gm. potato-carbohydrate, and increased only
slightly with the increased intake of 150 gm. protein and 400 gm. carbohydrate
on Dec. 20 and 21. Instead of a fast-day on Dec. 22, 927 calories of fat were
given in the form of butter. The glycosuria cleared up in practically the same
manner as on plain fasting, a trace being present only in the early hours. The
ferric chloride reaction remained negative, notwithstanding the fears once enter-
tained concerning lower fatty acids in butter. , On Dec. 23, this same quantity of
butter fat was given with 100 gm. potato-carbohydrate, and glycosuria resulted,
in contrast to the far higher tolerance shown for potato without fat. On Dec. 24,
three eggs were added and the carbohydrate simultaneously increased to 200 gm.
On Dec. 25, 300 gm. potato-carbohydrate with 100 gm. butter iat without eggs
resulted in still heavier glycosuria. Protein starvation was continued on Dec.
26 and 27, 400 gm. potato-carbohydrate being given daily with 100 gm. butter
fat. Moderately heavy glycosuria was continuous, showing a well marked re-
duction of tolerance by fat as compared with the former period of potato alone.
A fast-day on Dec. 28 stopped the glycosuria.

Beginning Dec. 29, the desired test with vegetable protein was made by the
use of Barker's gluten flour. Glycosuria appeared on the first day with 124 gm.
protein and 204 gm. potato-carbohydrate. It became constantly heavier as the
intake was raised to 148 gm. protein and 404 gm. carbohydrate. No appreci-
able advantage of vegetable protein, therefore, was perceptible in comparison
with the previous period of potato and meat. After stopping the glycosuria by
the fast-day of Jan. 2, green vegetables were resumed. On accoimt of the quan-
tities of carbohydrate, it was necessary to include the higher classes up to green
peas, green lima beans, beets, tunups, etc. Faint or doubtful traces of glycosuria
were present on each day, but did not increase as the intake was increased from
200 to 400 gm. carbohydrate in this form. Therefore, no special superiority of the
form or kind of carbohydrate was definitely demonstrable between oatmeal, pota-
toes, and green vegetables, variations of the patient's tolerance being sufficient to
account for the facts observed.



CASE RECORDS 399

This patient was one of several diabetics discharged rather hastily because of
an epidemic of grippe in the hospital. Jan. 8 to 10 his diet was rapidly built up
to 150 gm. protein, SO gm. carbohydrate, and 3000 calories. The reduction of
copper shown amounted to only doubtful traces in a single voiding each day, and
was judged to be due to a concentrated urine, not true glycosuria. The patient
had recovered complete health, such as he had never enjoyed during the time of
his diabetes, and left to undertake active medical work. Hyperidrosis had ceased,
along with the other symptoms.

Acidosis. — The slight degree of acidosis after so many years of heavy glycosuria
was one of the indications that this was essentially a mild case, though the patient
and all who had treated him regarded it as severe and intractable. The specific
difference as respects acidosis seems to be illustrated by comparison of this patient
with others in the series. Not only was this patient rather obese, but also on Nov.
18, for example, he ingested only 37.7 gm. carbohydrate in the form of green
vegetables (presumably not all absorbed) and excreted 31.6 gm. sugar. The rest
of the diet consisted of 166 gm. protein and 344 gm. fat. Yet this large quantity
of fat was disposed of with such slight traces of ketonuria that quantitative esti-
mation was considered not worth while. The plasma bicarbonate likewise remained
within normal limits. There was a slight fall in CO2 capacity in the initial fast,
but no serious acidosis was shown either by this or the clinical symptoms, though
the ferric chloride test became heavy. It is noteworthy that distinct ketonuria
continued during the period up to Dec. 7, when the patient was receiving absolutely
no food but oatmeal, in quantities increasing from 25 up to 300 gm. carbohydrate.
Even large quantities of assimilated carbohydrate therefore did not necessarily
clear up ketonuria promptly and completely.

Blood Sugar. — This gave another indication of the inherent mildness of the
case. Hjrperglycemia between 0.25 and 0.3 per cent, as shown at admission, had
presumably been present for a number of years. It was remarkable that it should
have fallen to normal so quickly. The marked hyperglycemia with sUght glyco-
suria dming the subsequent carbohydrate tests indicated a high renal threshold.
Fast-days brought the sugar promptly to normal.

Carbohydrate "Cures." — The diabetes here was so stubborn that it had for
years resisted oatmeal "cures," "green days," and restricted diet, under the
care of consultants experienced in the management of diabetes. The case was
a typical example of so called "protein sensitiveness," "fat sensitiveness," and
"paradoxical tolerance." The first two terms have been used to denote suscepti-
bility to glycosuria from the addition of protein or fat to a standard diet. The
last is NaunjTi's expression for cases with glycosuria continuously present, but
showing little diminution of glycosmia on diminishing carbohydrate and little
increase upon addition of even considerable quantities. These peculiarities were
all illustrated in the above tests. The actual condition was a mild diabetes with
obesity. Under the prevalent misconception that obesity in itself is a favorable
feature, this patient had been restricted in carbohydrate, but continuously
"built up" with protein and fat, and the intractable glycosuria was due to this



CASE RECORDS 401

War Demonstration Hospital of this Institute on Jan. 21, 1918, for Carrel-Dakin
treatment or amputation if necessary. Immediate fasting changed the condition
so promptly that surgery was unnecessary, and rapid healing without deformity
resulted. On Feb. 2, the patient was able to leave, free from hyperglycemia as
well as glycosuria and acidosis, to finish convalescence at home. The lesson has
been effective, and he has returned to the condition stated after his first discharge.
Remarks.— The record illustrates what can be hoped for in a large proportion
of cases not of such maximal severity as those comprising the majority of this
series; it further illustrates the dangers of excessive diet and weight even in
patients of this type.

CASE NO. 58.

Female, married, age 72 yrs. American. Admitted Dec. 3, 1915.

Family History. — No heritable disease.

Past History. — Very healthy life under excellent hygienic conditions. Whoop-
ing-cough in childhood the only infection remembered. "Never sick a day."
Never any throat or tonsil trouble. Eyes have always been weak. Teeth all
removed within the past decade. Married 55 years. One still-birth; one child
died in infancy; five children are well. Habits regular, appetite moderate. No
excesses of any description.

Present Illness. — 4i years ago patient consulted an oculist for failing vision.
Diabetic retinitis was diagnosed, and the oculist advised that efficient treatment
■ of the diabetes was necessary in order to save her eyes. Physicians have em-
. ployed half-hearted measures, and she has never been free from glycosuria. There
has been polydipsia and pol3ruria, but no polyphagia. Vision has grown pro-
gressively worse, and the patient came to the Institute on this account.

Physical Examination. — Height 155 cm. Normal development, slight obesity.
Skin very dry. Blood pressure 185 systolic, 120 diastolic. Teeth false. Slight
emphysema. Liver edge palpable 4 cm. beneath costal margin. Examination
by oculist showed double senile unripe cataract preventing retinal examina-
tion; amblyopia with inability to count fingers at 2 meters. Over internal mal-
leolus of left foot is an encrusted, red and angry-looking, but painless sore about 2
cm. in diameter. Scabs showing less inflammation are present over the meta-
tarsal joint of the great toe and on the dorsum of the third toe of the same foot.
Examination otherwise negative.

Treatment. — The 1st full day in hospital, a diet was given of 99 gni. protein,
15 gm. carbohydrate, and 1900 calories. The urine showed 26.65 gm. sugar,
and the ferric chloride reaction, which had been negative, became sUght during
this day. It then became apparent why physicians had failed to check the gly-
cosuria, notwithstanding the ocular damage; for when carbohydrate was entirely
withdrawn and the total diet reduced to 75 gm. protein and 1600 calories, glyco-
suria diminished slightly but remained rather heavy, and the ferric chloride reac-
tion became moderately heavy. Accordingly, after a week of such diet, 2 days
of fasting (Dec. 11 and 12) were given. Glycosuria ceased, but a moderate ferric



402 CHAPTER in

chloride reaction continued. The usual green vegetables were then begun with
10 gm. carbohydrate on Dec. 13 and increased rapidly, until glycosuria appeared
with 100 gm. on Dec. 16. The ferric chloride reaction consequently became
negative. The diet was then rapidly built up to 70 gm. protein and 1500 calories,
the urine remaining normal. The patient was discharged Dec. 24. The dry skin,
patches of threatened gangrene, and other minor conditions had cleared up, and
the patient stated she felt better than for years past.

Acidosis. — There was never any clinical symptom of acidosis. The develop-
ment of rather marked ferric chloride reactions in a mild case of diabetes when
the diet is restricted, has frequently, as in this instance, frightened physicians so
that they refrained from taking the measures imperatively demanded to control
such a genuinely serious compUcation as diabetic retinitis. On the other hand,
if this warning sign were entirely ignored and a high protein-fat ration kept up,
it might readily bring on coma even in some patients with mild diabetes.

Blood Sugar. — On the day of discharge with normal urine, the sugar was still
0.147 per cent in whole blood and 0.175 per cent in plasma. In view of the pa-
tient's age, the mildness of the case, and the expectation of improvement with
time, this hyperglycemia required no more rigorous measures for the immediate
present.

Weight and Nutrition. — ^The weight at admission was 68 kg., at discharge 67.2
kg. The diet prescribed at discharge was 70 gm. protein, 15 gm. carbohydrate,
and 1500 calories (a little over 1 gm. protein and 22 calories per kg.). Mild
exercise suitable to her age was advised, and a continuance of sb'ght undernu-
trition was desired, while the cataracts were ripening.

Subsequent History. — The patient remained sugar-free, aside from a few traces
due to slight laxity in the care of an indulgent daughter. The diet was sufficiently
bulky and entirely satisfied the patient, except that she still entertained some
longing for the desserts of the past. She was readmitted to the hospital June 8,
1916 for cataract operation.

Second Admission. — The weight was now down to 62.6 kg., the urine normal,
and the strength at its best. The prescribed diet was continued. On June 10,
sugar was 0.145 per cent in both whole blood and plasma. By June 26 it had
further diminished to 0.111 per cent in whole blood and 0.128 per cent in plasma,
although the carbohydrate meanwhile had been increased to 30 gm. Tests showed
that 50 gm. carbohydrate could be tolerated, but instead of maintaining this in-
take, 30 gm. carbohydrate were resxmied and the protein increased to 90 gm. Cata-
ract operation was performed on July 11 without glycosuria, acidosis, or any
untoward incident. Diabetic retinitis was diagnosed thereafter. The patient
was discharged July 28. The weight was now down to 59 kg., which was suffi-
cient for her figure, and the health was stiU further improved-.

Subsequent History. — ^After several months of sugar-freedom and favorable
progress, she began to steal sweet and starchy foods, and reached a chronically
weak condition with continuous glycosuria. Gangrene of the foot then necessi-
tated fasting, which was conducted at home, and sugar-freedom has since been



CASE RECORDS 403

maintained on restricted diet. At last report (1918) glycosuria was absent, but
owing to two apoplectic strokes and an intestinal obstruction diagnosed as car-
cinomatous, death was expected within a few weeks or months.

Remarks. — Diabetes at such an age is usually easy to control. The very high
proportion of senile patients who sooner or later lose comfort and even life by
reason of gangrene or ocular or other complications indicates the error and danger
of the widespread belief that glycosuria at this age is harmless enough to be
neglected. Efficient treatment is indicated, for relief, if complications are present,
and for prophylaxis if they are not present. The general health as a rule is
improved, and it becomes evident that part of the trouble attributed to senility
was due to diabetes. Surgical operations should then be performed if required.

CASE NO. 59.

Male, married, age 46 yrs. American; physician. Admitted Dec. 29, 1915.

Family History. — Father died supposedly of cancer of Uver at 64 years, but there
are indications that the condition may have been luetic. Mother is living, aged
83, and has rheumatism and gout. A maternal aunt died of diabetes. One
brother of patient is well. One sister died after an acute illness of 3 days in some
form of coma, apparently following tonsillitis; there was a history of increasing
attacks of so called "acidosis" preceding, partially relieved each time by alkali;
there was also the possibility of slight h3?perth3T:oidism. Patient has been mar-
ried 8 years; wife and one 6| year child are well; another child died a year ago
with lymphatic leucemia and Streptococcus hatmlyticus infection.

Past History. — Measles, whooping-cough, and probably scarlet fever before 10.
Tendency to biliousness, nausea, and vomiting throughout childhood. One severe
sunstroke in boyhood. Patient was always rather frail in physique, of nervous
type, addicted to overwork. He blames overwork in college, financial worries,
and subsequent professional strain for his condition. In 1899 he was refused life
insxurance because of albuminuria with casts. Subsequently, with some difficulty,
he obtained a policy. Little alcohol; 10 to 15 cigarettes daily. No excesses in
diet or carbohydrate. There was a period beginning in 1889 when diabetes may
have been present unknown. There was persistent sciatica for the year 1889 to
1890. He has suffered for many years from true t)rpical gout. There were numer-
ous attacks in 1900, but the gout has diminished since 1907. In 1894, he under-
went an operation for axiRary abscess following a finger infection. In 1896, he
had numerous boils and carbuncles, treated by incisions and vaccines.

Present Illness. — ^The diagnosis of diabetes was not made until 1910, when
poljfiuia began. Treatment has been interfered with by professional duties, and
owing to downward progress the patient visited a specialist 2 years ago. He was
made sugar-free and his weight reduced from 137 poimds to 120| pounds. Upon
returning to New York he resumed his attempt to carry heavy professional work
and keep his diabetes secret. This necessitated violations of diet when attend-
ing dinners in company, so that relapse resulted. He came to the Institute
because he had finally lost power to continue his work.



404 CHAPTER in

Physical Exammation.— Height 1 76 cm. Normal development, decided emacia-
tion, marked weakness, but no acute symptoms. Slight diarrhea. Lymph
glands generally palpable. Blood pressure 118 systolic, 88 diastolic. Knee jerks
just obtainable with reinforcement. Wassermann negative. Examination other-
wise negative.

Treatment. — For 3 days the patient was kept on an observation diet of 76 gm.
protein, 10 gm. carbohydrate, and 2100 calories, about 200 calories being whisky.
The glycosuria of 0.88 per cent on the first day diminished to a trace by the third
day, and then ceased with 1 day of fasting. The ferric chloride reaction cleared
up in parallel. A carbohydrate test in the usual form showed a tolerance of 90
gm. carbohydrate, glycosuria resulting from 100 gm. on Jan. 10 to 11. A mixed
diet was then built up, containing 20 gm. carbohydrate and 1900 to 2400 calories.
The patient contracted a mild but persistent grippe infection, which was largely
responsible for the frequent traces of glycosuria. Beginning Feb. 18, the calories
were diminished to 1900. The grippe passed off and the tolerance improved, so
that at the end 90 gm. protein, 50 gm. carbohydrate, and 2245 calories were
taken without glycosuria. He was discharged Mar. 16 feeling improved, but
still below normal strength.

Acidosis. — The ferric chloride reaction jpromptly became negative. The CO2
capacity was practically normal throughout. In the initial fast it fell from a
high to a low normal, and it at first tended to be down after fast-days. The
tendency to a slightly high ammonia excretion was the only evidence of acidosis.

Blood Sugar. — Marked hyperglycemia present at admission was rather promptly
brought to normal. Subsequently the figures were generally normal after fast-
days, but showed hjrperglycemia on other days. Grippe was partly responsible,
but the marked h3rperglycemia, particularly at the close, was clear evidence that
the diet was too high.

Weight and Nutrition. — The weight at admission was 52.6 kg., at discharge
50.4 kg.; i.e., a loss of 2.2 kg. The above mentioned diet at discharge thus rep-
resented 1.78 gm. protein and 44.6 calories per kg., reduced by the weeklyfast-
days to about 1.5 gm. protein and 38 calories per kg. The body weight in this
calculation was a very low one; nevertheless the condition was obviously not
under good control, and therefore such a liberal diet was a mistake.

Subsequent History. — The patient went to the seashore to rest under favorable
conditions. In the 2 weeks between discharge and Apr., he gained 4J pounds
and showed glycosuria 9 times, a slight cold being blamed for part of the trouble.
The diet was then changed to 127 gm. protein, 35 gm. carbohydrate, and 1950
calories. On this, glycosuria was almost continuously absent. He tried to
build himself up with exercise in the form of goU, but in the middle of Apr. devel-
oped a slight infection and herpes zoster. He then rettmied to New York, where
his diet could be more closely supervised, and the ration was reduced to 75 gm.
protein, 10 gm. carbohydrate, and 1900 calories. On this, glycosuria was almost
continuously absent; but in Jime another cold occurred with sinus infection, so
that traces of glycosuria were present almost continuously June 5 to 20. Twelve



CASE RECORDS 405

blood analyses between Apr. 28 and June 12 showed continuous hyperglycemia
and normal CO2 capacity, the lowest plasma sugar being 0.135 per cent, the
highest 0.218 per cent, and the average 0.177 per cent. Because of the unfavor-
able progress, the patient was readmitted June 20, 1916.

Second Admission. — The weight was 52.2 kg., as against 50.4 kg. at discharge
and 52.6 kg. at the first admission. The strength and spirits were decidedly
improved as compared with the first admission. On June 21, the glycosuria was
6.7 gm., the CO2 capacity 56.1 per cent, the sugar in whole blood 0.228 per cent
and in plasma 0.244 per cent. The diet was kept up to the maximmn prescribed
outside the hospital, and no fast-days were imposed. Traces of glycosuria were
present frequently on 2100 to 2250 calories, but for 3 days at the close (July 10
to 12), 90 gm. protein, 15 gm. carbohydrate, and 2000 calories were taken without
glycosuria. The patient's strength had improved so that he was able to go on with
moderate professional work. The weight was tmchanged during this period in
hospital. The hyperglycemia also showed practically no change. The renal
threshold for sugar was evidently high, but the urea index on June 28 was deter-
mined by Dr. Palmer as 200; also (the patient frequently worrying over his gouty
history) the uric acid in the blood was 2.8 mg. per 100 cc.

Subsequent History. — The patient went to a country place and attempted to
build up his physical condition by exercise and general care, but never succeeded
in regaining strength or working capacity. He had trouble with nausea, edema,
and mental irritability and depression, partly due to trouble with a tooth. Gly-
cosuria was almost continuously absent.

Third Admission. — July 31 the patient was readmitted to undertake a some-
what more thorough treatment. His intense desire to go on with active profes-
sional work had been a hindrance to radical measures. With glycosuria and keto-
nuria absent, the sugar was 0.200 per cent in whole blood, 0.208 per cent in plasma,
CO2 capacity 52.8 per cent. The output of ammonia nitrogen was 0.76 gm.jof
acid (Folin) 468 cc. 0.1 n. The weight was 52.5 kg.; i.e., practically the same as
at first admission. After 3 days on the prescribed diet, a fast-day was given on
Aug. 4, followed by a carbohydrate tolerance test. A trace of glycosuria appeared
Aug. 17 to 18 with 130 gm. carbohydrate. The tolerance of 120 gm. thus seems
to indicate an increase of 25 per cent over the first test in Jan. He was then
put back on a mixed diet of 90 gm. protein, 15 gm. carbohydrate, and 2000 cal-
ories, and was discharged on this Aug. 24. The weight had been reduced to 50
kg., and the blood sugar to 0.143-0.185 per cent. There had been another slight
gain in general health and spirits.

Subsequent History. — The patient went to the Catskills for the summer and to
California for the winter. On accoimt of recurrence of glycosuria, his diet has
had to be again reduced to 75 gm. protein, 10 gm. carbohydrate, and 1900 calories.
He remains a fairly comfortable semi-invalid, stronger and better in all respects
than at first admission, and hoping to return to work if he can improve a little
more.



406 CHAPTER III

Remarks.— A number of these patients have been tried on what could be callec
a modified Naunyn treatment; that is, using more or less prolonged fasting anc
perhaps transitory reduction of weight to suppress glycosuria, and then giving thi
maximal diet possible in order to keep up a maximum of weight and strength. I:
the diabetes has any claim to be called severe, the results of such a method an
imiformly and necessarily bad. In view of this patient's age, some power o;
recuperation may be expected. There is a possibility that slight improvement
may occur, as indicated by the higher tolerance in the carbohydrate test in spit(
of the excessive diet, the case somewhat resembling the milder ones in oldei
persons. It is more probable that a case of this severity will sooner or latei



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 45 of 76)