Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

. (page 46 of 76)
Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 46 of 76)
Font size
QR-code for this ebook


show downward progress, which may be called "spontaneous," but is sufficientlj
accounted for by inadequate treatment. The persistent marked hyperglycemia
not tending to improve, and the slight acidosis indicated by a slightly elevated
ammonia output, are plain evidence that overstrain of the weakened function has
been only diminished and not stopped, and unless there is an unexpectedly high
spontaneous recuperative power, the downward progress will be merely slowed, not
stopped. The high diets in this and other patients do not even serve the intended
purpose of keeping up weight, strength, and resistance, for these poorly treated
patients are the very ones who are most subject to infections and suffer most
harm from them.

The patient's ambition of resuming active work has not been achieved. He
would doubtless be far nearer to it, and in better condition in all respects, if he
had at the outset been brought down to a suitably low level of diet and weight.
A lower level of weight, efficiency, and comfort than required in such a plan will
probably result here, as it has in other cases, from the gradual downward prog-
ress, and this loss of weight will be attended not by benefit but serious injiu-y
of the assimilative function. Thorough treatment should still offer much hope.

CASE NO. 60.

Female, married, age 43 yrs. American; housewife. Admitted Jan. 1, 1916

Family History. — Parents lived to old age. Two brothers and one sister well.
Husband and one 6 year old child well. No other pregnancies. No diabetes or
other heritable disease known in family.

Past History. — Very healthy life. Whooping-cough, measles, and chicken-pox
in childhood. "Gastric fever" in 1896; in bed 3 or 4 weeks. Frequent attacks
of tonsillitis up to 10 years ago, none since. No other illnesses. Appetite, diges-
tion, bowels, menstruation, and sleep normal. Never nervous. No excesses of
any kind.

Present Illness. — About 9 months before admission, patient noticed that she
was losing weight and was imduly thirsty. After 2 months (June, 1915) a physi-
cian consulted for pruritus vulvae diagnosed diabetes. The patient was fasted
for a day or two, then placed on a diet of eggs and milk. She was said to be
"practically sugar-free," but continued to lose weight and strength. In Aug.



CASE RECORDS 407

1915, she came under the care of a speciah'st for 6 weeks, first in hospital and sub-
sequently at home. She was made sugar-free by fasting, and then kept on a mmi-
mal diet. She lost 60 pounds weight, and was referred to the Institute as a Case
of extremely severe diabetes. .

Physical Examination. — Height 153.8 cm. A very emaciated woman, with fair
strength and no acute symptoms. Slight hyperpnea and drowsiness are present,
but are probably accounted for largely by weakness and weariness after -her
railroad trip. Teeth in good condition. Tonsils hypertrophied. Breath has
acetone odor. Knee jerks not obtainable even with reinforcement. Wasser-
mann negative. Examination otherwise negative.

Treatment. — On Jan. 1, the day of admission, the patient received 54 gm. pro-
tein, 5 gm. carbohydrate, and 1247 calories, and excreted 20.4 gm. glucose, 1.6
gm. amnjonia nitrogen, and 495 cc. 0.1 n acid, with an intense ferric chloride re-
action. 3 days fasting was then imposed, with resulting glycosuria of 11 gm. on
Jan. 2, 9.2 gm. on Jan. 3, 12.1 gm. on Jan. 4. As the weakness seemed to be of
dangerous degree, the tempting experiment was tried of feeding a liberal diet in
the hope of getting a fresh start for subsequent fasting. Accordingly, on Jan. S,
2 eggs were given, with coffee and clear soup each 300 cc. as during fasting.
The diet was rapidly built up (Jan. 6 to 11) as high as 75 gm. protein and 2150
calories on Jan. 10. Glycosuria increased only to 24.1 gm., but hyperpnea,
drowsiness, and nausea developed. The plasma bicarbonate fell sharply to 24.6
per cent, while the ammonia nitrogen rose to 3.19 gm., with urinary acidity of
335 cc. 0.1 N. Fasting had to be resumed to ward off coma, with the patient
worse instead of better than before. Under fasting without alkali, the above
mentioned low CO2 on the morning of Jan. 12 rose to 27.6 per cent by evening of
the same day. Thereafter it cUmbed steadily, and the patient was out of danger
within 24 horns. On Jan. 14, 2 and on Jan. 15, 3 eggs were allowed in addition
to soup and coffee. After a plain fast-day on Jan. 16, 420 calories of whisky
daily were begun, 1 egg also being allowed on Jan. 17. Glycosuria had been
diminishing, and cleared up on Jan. 19. After about 40 hours of sugar-freedom,
10 gm. carbohydrate in the form of green vegetables were given on Jan. 21, and
20 gm. on Jan. 22. Slight glycosuria resulted, and persisted as the carbohydrate
intake was increased as high as 35 gm. on the following days. After a fast-day
with 150 cc. whisky, 400 gm. thrice boiled vegetables, and 60 gm. bran biscuit
on Jan. 28, a very low carbohydrate-free diet was attempted. On Feb. 5, when
this had been built up to 50 gm. protein, 850 calories (245 being alcohol), and 300
gm. thrice boiled vegetables, a trace of glycosuria appeared, requiring a fast-day
on Feb. 6. With the same number of calories, and diminution of protein to 40
to 35 gm., glycosuria continued. It still persisted with 12.5 gm. protem and 450
calories (315 being alcohol) on Feb. 10, and a fast-day on Feb. 11 was necessary
to abolish it. Beginning Feb. 12, the diet was again cautiously built up to 42
gm. protein and 650 calories (315 being alcohol). Glycosuria on Feb. 17 and 19
required a fast-day on Feb. 20. With the same calories and reduction of protein
to 35 gm., glycosuria still recurred, requiring another fast-day on Feb. 27. A



410



CHAPTER III



in whole blood and 0.333 per cent in plasma on Jan. IS. A faU then began, and
on Jan. 25, on alcohol and green vegetables, the sugar was down to 0.143 per
cent in whole blood and 0.167 per cent in plasma. The values then began to
approach normal, and from Mar. 7 to 29 it can be said that vmdemutrition had
brought about normal blood sugar as judged by morning samples before breakfast.
The subsequent higher diets brought back hyperglycemia, which was reduced by
the lower diet beginning Jxme 3. Increased diet again brought a rise on June
23, but on Jime 28, on the diet proposed for discharge, the blood sugar was be-
low 0.15 per cent, which seemed rather satisfactory in such a case at this stage.
Weight and Nutrition. — For 5 months before admission the patient had been
extremely undernourished, green vegetables up to or slightly past the Umit of toler-
ance, and a few eggs, having been almost the only nourishment in this time.
This had repressed the dangerous acidosis to the greatest possible degree, but
both body fat and body protein had necessarily been sacrificed heavily in the
process. The process had been persisted in, though the patient felt fairly well
and strong at the outset in Aug., and on admission in Jan. was emaciated and
seriously exhausted. Accordingly, the experiment was tried of feeding more
liberally for a short time in the attempt to restore some strength, so as to get a
fresh start for further fasting. Though the diets on Jan. 5 to 11 averaged only
33 calories per kg. of body weight, the attempt caused only harm ipstead of bene-
fit, as always in genuinely severe cases. The question thereafter was whether the
glycosuria could be controlled without starving the patient to death. The method
used consisted in alcohol short of any perceptible symptoms, protein generally
on feeding days above 1 gm. per kg. of weight, and close restriction of fat, so
as to maintain almost continuous undernutrition. It would doubtless have been
better if alcohol had been omitted and the fat had been excluded stDl further,
and the condition thus controlled earlier and more radically. The weight at ad-
mission was 36.6 kg. The gain in weight about Feb. was due to edema, which
was controlled by regulation of the salt intake, sodium chloride being given,
weighed Uke the rest of the diet, first 10 gm. and later 8 gm. daily. The weight
at discharge was 33 kg.; i.e., a loss of 3.6 kg. The low level of metabolism caused
by undernutrition is thus illustrated, for a patient starting well nourished at the
outset would have lost much more weight on such a diet. The degree of imder-
nutrition is shown in the following calculation.*



183 days.



Alcohol calories 55,496

Food " 81,878

Total " 137,374

Protein 5,162 .3 gm.

Fat 6,109.9 "




0.83 gm.
0.98 "



The diet prescribed at discharge was 50 gm. protein and 1000 calories, more
than a third being in the form of alcohol as shown, (1.5 gm. protein and 33



CASE RECORDS 411

calories per kg., reduced by partial fast-days to about 1.4 gm. protein and 31
calories per kg.).

Subsequent History. — The patient was discharged with the idea that she might
be able by great care to remain 2 or 3 weeks at home. She was actually at home
4 months and 1 week, remaining free from glycosuria, except for traces on a very
few days, on account of which the diet was ordered on Aug. 16 to be reduced to
40 gm. protein and 800 calories. She was readmitted for further treatment Nov.
8,1916.

Second Admission.— Weight 29.9 kg.; i.e., a loss of 3.1 kg. since discharge.
In addition to glycosuria, a slight ferric chloride reaction was present. Instead
of fasting immediately, the diet was limited to green vegetables representing 20
gm. carbohydrate, and diminishing to 5 gm. carbohydrate on Nov. 12. 2 fast-
days, Nov. 13 and 14, left the urine normal. On Nov. 15, 5 gm. carbohydrate in
the form of green vegetables were assimilated, but 10 gm. on Nov. 16 brought a
trace of glycosuria. Carbohydrate-free diet was then built up, beginning with
1 egg and 360 calories on Nov. 17, and increasing to 6 eggs and 1200 calories on
Nov. 22. Continuance of this diet brought glycosuria beginning Nov. 25, re-
quiring a fast-day on Nov. 27. Thereafter similar diets (40 to 50 gm. protein and
1150 to 1300 calories) were continued, with routine weekly fast-days. The effect
of these in checking acidosis is shown by the ammonia curve. No more than the
faintest traces of glycosuria appeared, but these were unduly frequent. Though
the food was thus pushed to the utmost limit of tolerance, it was not possible to
prevent gradual loss of weight.

Lipemia was not noticed at the first admission. It was heavy at the second
admission, and gradually disappeared during the first week of treatment. The
difference may be attributed to the fact that the patient was eating little but
green vegetables when first received, but preceding the second admission had been
on protein-fat diet. No quantitative estimations were made.

The patient was dismissed Apr. 6, 1917, weighing 27.6 kg. The prescribed
diet represented 1.45 gm. protein and 45 calories per kg., reduced by the weekly
fast-days to 1.25 gm. protein and 39 calories average. The diet therefore was
absolutely very low. It appeared relatively high on account of the emaciation,
but either because of the relative increase in body surface, or the lack of carbo-
hydrate, or a specific diabetic disorder, it did not produce gain in weight.

Subsequent History. — The patient has since remained at home on the same
program as in hospital. She adheres rigidly to her diet and clears up traces of
glycosuria promptly by fast-days. There is little perceptible change up to the
present in weight, strength, or assimilative power.

Remarks. — By extreme undernutrition it has been possible to keep this patient
alive over 2 years from her first fasting treatment. Though always hungry,
excessively emaciated, and lacking strength for any real exertion, some of the
noteworthy feature? are her constant cheerfulness, freedom from infection, and
comfort in all other respects. She is able to be up and about, carries on light
household duties, and — the point of most importance to her — attends to the



414 CHAPTER III

sponse to slight dietary restrictions indicates no special difficulty in bringing
down the blood sugar. Nevertheless, the renal impairment served as a block to
the ordinary glycosuria, and the finding of as much as 0.73 per cent blood sugar
with only slight glycosuria shows the necessity of blood examinations in such
circumstances. The treatment was not so rigid as would be advisable if the
duration of hfe from other causes were less limited. On the other hand, to ignore
the diabetes would probably lead to aggravation of the entire condition and
materially shorten life.

CASE NO. 62.

Female, unmarried, age 19 yrs. American; houseworker. Admitted Feb.
19, 1916.

Family History. — Father, mother, one brother and two sisters are well. One
brother died in infancy of "spinal meningitis." A maternal grandmother died
of tuberculosis. No diabetes or other heritable disease known in family.

Past History. — Whooping-cough, measles, and chicken-pox in infancy. No
throat trouble. Grippe once. There is a hazy description of what the doctors
are said to have called diabetes at the age of 7. The symptoms are described as
puffiness of the face in the mornings, whiteness of the skin, and urine which
looked bloody and contained a heavy sediment. There was also skin eruption
over the back and legs described as "poison water blisters," which were small,
not hemorrhagic, and healed without scars. Treatment is said to have been by
diet with prohibition of starches. This trouble passed off after about a year.
The habits, appetite, digestion, bowels, and menstruation have been normal.
No alcohol. Moderation in tea, coffee, and carbohydrates. Not neurotic.
Always slept well and was imder no strain.

Present Illness. — Polydipsia and polyuria began in the summer of 1911. Dia-
betes was promptly diagnosed, and the diet was limited to proteins and fats with
vegetables. Glycosuria has been continuous since the beginning. Menstrua-
tion stopped 1 year after onset of diabetes, and bowels have become irregular.
There have been no infections or distressing symptoms. The patient has felt
reasonably comfortable while losing 30 pounds weight and corresponding strength.
Recently she noticed sKght edema of ankles and dyspnea on exertion. She applied
for treatment merely on account of knowledge that her condition was serious,
and not for any special urgent symptoms.

Physical Examination. — Height 157.5 cm. Mediimi development, rather
marked emadation. Skin dry. Cheeks flushed. Tongue red, teeth poorly
kept, two carious. Examination by specialist showed nose and ears normal;
no adenoids; tonsils sUghtly enlarged, showing a little thick yellow material on
pressure. Very sUght glandidar enlargement. Reflexes normal. Moderate
edema below knees. Examination otherwise negative. Wassermann negative.

Treatment. — On an observation diet of 75 gm. protein, 100 gm. carbohydrate,
and 2000 calories, there was excretion of 145.5 to 131 gm. glucose and 5.3 to 4.5
gm. ammonia nitrogen with intense ferric chloride reaction. On Feb. 25 and 26



416 CHAPTER m

Weight and Nutritiofi.— Weight at admission 39.4 kg., at discharge 36 kg.;
i.e., a loss of 3.4 kg. The lowest weight was 34 kg. on Mar. 20, following the
most extensive undernutrition. Some fluctuations in the weight cwrve were caused
by slight edema. The diet prescribed at discharge represented nearly 1.4 gm.
protem and 42 calories per kg., reduced by the weekly fast-days to 1.2 gm. pro-
tein and 36 calories average. Notwithstanding the loss of weight there had been
improvement in strength and comfort, and the patient was now walking 3 miles
daily and otherwise exercising without weariness.

Subsequent History. — On June 19, the plasma sugar was 0.161 per cent, CO2
capacity 52 per cent. June 30, sugar 0.156 per cent in whole blood, 0.172 per cent
in plasma, CO2 capacity 63.6 per cent. The weight was still 36 kg. Strength
had greatly increased, and the only complaint was of hunger. The urine had
remained consistently normal. The diet was increased to 60 gm. protein and
1550 calories. Glycosuria remained absent imtU Nov., and the general condi-
tion was excellent. Readmission was necessary Dec. 8, 1916, because glycosuria
was then persistent.

Second Admission. — Weight 37.2 kg., without perceptible edema. General
condition good. Acidosis was shown only by the heavy ferric chloride re-
actions and the ammonia nitrogen of 1 gm. Instead of immediate fasting.
Dr. Joshn's plan of a low fat-free diet was used. Thus, the diet on Dec. 9 con-
sisted of lean meat and green vegetables, representing 40 gm. protein, 20 gm.
carbohydrate, 10 gm. fat, and 336 calories. With gradual diminution of this diet
to 20 gm. carbohydrate and 9 gm. protein on Dec. 16, the ferric chloride reaction
became negative, the ammonia fell to 0.74 gm. N, and glycosuria diminished to
traces. It is noteworthy also that the total nitrogen excretion at first was 13
gm. daUy. This progressively diminished on the semifasting to the low figures
of 4.71 gm. on Dec. 14, 4.76 gm. on Dec. 15, and 4.37 gm. on Dec. 16. A single
fast-day on Dec. 17 cleared up the lingering traces of sugar. To protect body pro-
tein, 40 gm. protein daily were itmnediately given, without carbohydrate, and
with fat so strictly limited that the total calories amounted to only 600. The
patient was dismissed temporarily on this diet on Dec. 22, 1916, to be home for
the Christmas hohdays. Weight 34.4 kg.; strength and spirits good.

Third Admission. — ^Jan. 8, 1917. Patient returned according to arrangement, -
saying that she had enjoyed the holidays greatly. Weight 34.3 kg. Very slight
edema of legs. The diet remained at 40 gm. protein and 600 calories.

On Jan. 11, sore throat was complained of, but temperature was normal. On
Jan. 12, the temperature rose as high as 100.6°. On Jan. 13;'>it was not above
100°. On Jan. 14, the weight was 32.2 kg., and the temperature up to 103.4°.
There were signs of tj^jical pneumonia of right lower lobe; sputimi showed Type
IV pneumococcus; blood cidture negative.

The conditions during this attack of typical lobar pneumonia in a severely
diabetic patient are best shown m Table XVII. No alkali was employed.

Beginning Feb. 3, the protein was increased to 40 gm. daily. Thereafter the
total calories were gradually increased to 900. Beginnmg Feb. 10, the protein

















CASE


RECORDS










417




TABLE XVII.










ate.


S




Diet.


.a


Urine.


Blood
plasma.


r


1


1


It


"o


II




.


£i ^


iz;


1


8


1917
Jan. 13


is.
32.6


'F.

94.4
100. C


gm.
4.3


em.


gm.
10


gm


61


cc.
2100


cc.

2547








gm.
0.8C


ter
cent




vol.
ter
cent


a


14


32.2


102.0
103.4


8.6


0.9


20





125


3562


3017


+





0.57








It


15


32.3


104.2
103.5


18.3


10.9


8.2





209


3800


2265+


+





0.70


0.268


68


tt


16


32.1


103.8
101.6


22.3


15.9








240


3025


3238


+


+


0.83








it


17


31.7


104.0
102.0


22.3


15.9








240


3700


2943


+ .


+


1.26


0.227


60


ft


18


31.8


102.8
100.6


22.3


15.9








240


3900


2130


++


++


1.18








n


19





102.2
101.4


7.4


5.3








80


3100


3330


++


++


1.95


0.227


54


tt


20





100.8
99.2


Fast-day










3300


2420


+++


+++


2.02


0.256





tt


21





100.8
99.2


tt








3300


2225


+ +++


+++


2.16








tt


22





99.4
99.0


tt








3900


2780


+++


++


2.20








tt


23





99.0
97.0


tt


25


175


3525


3535


++


+


2.08








tt


24


■—


99.8
97.0


tt


35


245


3900


3520


+ +


+


1.49


3.260


57


tt


25


~


99.2
97.6


22.3


L5.9





30


447 >


5200


2232


+


+


3.80


"






416 CHAPTER ni

Weight and Nutrition— '^ tight at admission 39.4 kg., at discharge 36 kg.;
i.e., a loss of 3.4 kg. The lowest weight was 34 kg. on Mar. 20, following the
most extensive undernutrition. Some fluctuations in the weight curve were caused
by sUght edema. The diet prescribed at discharge represented nearly 1.4 gm.
protein and 42 calories per kg., reduced by the weekly fast-days to 1.2 gm. pro-
tein and 36 calories average. Notwithstanding the loss of weight there had been
improvement in strength and comfort, and the patient was now walking 3 miles
daily and otherwise exercising without weariness.

Subsequent History. — On June 19, the plasma sugar was 0.161 per cent, CO2
capacity 52 per cent. June 30, sugar 0.156 per cent in whole blood, 0.172 per cent
in plasma, CO2 capacity 63.6 per cent. The weight was still 36 kg. Strength
had greatly increased, and the only complaint was of hunger. The urine had
remained consistently normal. The diet was increased to 60 gm. protein and
1550 calories. Glycosuria remained absent until Nov., and the general condi-
tion was excellent. Readmission was necessary Dec. 8, 1916, because glycosuria
was then persistent.

Second Admission. — Weight 37.2 kg., without perceptible edema. General
condition good. Acidosis was shown only by the heavy ferric chloride re-
actions and the ammonia nitrogen of 1 gm. Instead of immediate fasting,
Dr. Joslin's plan of a low fat-free diet was used. Thus, the diet on Dec. 9 con-
sisted of lean meat and green vegetables, representing 40 gm. protein, 20 gm.
carbohydrate, 10 gm. fat, and 336 calories. With gradual diminution of this diet
to 20 gm. carbohydrate and 9 gm. protein on Dec. 16, the ferric chloride reaction
became negative, the ammonia fell to 0.74 gm. N, and glycosuria diminished to
traces. It is noteworthy also that the total nitrogen excretion at first was 13
gm. daily. This progressively diminished on the semifasting to the low figures
of 4.71 gm. on Dec. 14, 4.76 gm. on Dec. 15, and 4.37 gm. on Dec. 16. A single
fast-day on Dec. 17 cleared up the lingering traces of sugar. To protect body pro-
tein, 40 gm. protein daily were immediately given, without carbohydrate, and
with fat so strictly limited that the total calories amounted to only 600. The
patient was dismissed temporarily on this diet on Dec. 22, 1916, to be home for
the Christmas holidays. Weight 34.4 kg.; strength and spirits good.

Third Admission. — Jan. 8, 1917. Patient returned according to arrangement, "■
saying that she had enjoyed the hohdays greatly. Weight 34.3 kg. Very slight
edema of legs. The diet remained at 40 gm. protein and 600 calories.

On Jan. 11, sore throat was complained of, but temperature was normal. On
Jan. 12, the temperature rose as high as 100.6°. On Jan. 13'; it was not above
100°. On Jan. 14, the weight was 32.2 kg., and the temperature up to 103.4°.
There were signs of typical pneumonia of right lower lobe; sputum showed Type
IV pneumococcus; blood culture negative.

The conditions during this attack of typical lobar pneumonia in a severely
diabetic patient are best shown in Table XVII. No alkali was employed.

Beginning Feb. 3, the protein was increased to 40 gm. daily. Thereafter the
total calories were gradually mcreased to 900. Beginning Feb. 10, the protein



CASE RECORDS



417



TABLE XVII.



Date.



1917
Jan. 13

" 14

" IS

" 16

" 17

" 18

" 19

" 20

" 21

" 22

". 23

" 24

" 25



kg.
32.6

32.2

32.3

32.1

31.7

31.8



94.4
100.0

102.0
103.4

104.2
103.5



103.822.3
101.6

104.022.3
102.0



102.8
100.6

102.2
101.4

100.8
99.2

100.8
99.2

99.4
99.0

99.0
97.0

99.8
97.0

99.2
97.6



Diet.



gm.

4.3

8.6
18.3



22.3



7.4



0.9



10.9



15.9



15.9



15.9



5.3



If



gm.
10

20

8.2



Fast-day.



22.3 15.9



25



35



30



Is



61



125



209



240



240



240



80



175



245



447



2100



3562



3800



3025



3700



3900



3100



3300



3300



3900



3525



3900



3200



Urine.



2547



3017



2265+



3238



2943



2130



3330



2420



2225



2780



3535



3520



2232



+



+



+



+



++



+ +



+ + +



+++ +



++ +



++



+ +



+



■a



+



+



++



++



+++



+++



++



+



+



0.80
0.57
0.70
0.83
1.260.227



0.268



1.18



1.95



2.02



2.16



2.20



2.08



1.49



+



0.80



Blood
plasma.



0.227



0.256



0.260



vol,
per
cent



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 46 of 76)