Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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68



60



54



57



418



CHAPTER m



TABLE XVII — Continued.





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Diet.


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Urine.


Blood
plasma.


Date.


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1917


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gm.


gm.


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per
cent


vol.
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cent


Jan. 26





98.6
97.8


30.0


40.5





10


569


3250


2526


+





0.88


"


~


" 27





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97.6


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5


534


3550


3016


+





0.86


0.118





" 28





98.4
97.4


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40.2





20


637


3672


2913


+





0.72








" 29





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98.2


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40.2





7


532


3405


2758


+





0.84








" 30





98.6
97.0


30.0


40.6





10


60S


3415


3278








0.68








" 31





98.6
96,8


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20


640


3470


3043








0.57









was raised to 50 gm., and Feb. 17 to 60 gm., and the total calories were gradu-
ally raised to 1300. Also 15 gm. carbohydrate daily were introduced with no
glycosuria or ketonuria at any time. The ammonia nitrogen was 0.48 to 0.68
gm. The blood sugar was 0.12 per cent, the lowest yet attained in this patient.
The plasma bicarbonate was 66 per cent. The patient was discharged on this
diet Mar. 9, 1917, weighing 31 kg. The diet thus represented nearly 2 gm. pro-
tein and 42 calories per kg., diminished by weekly fast-days to an average of 1.7
gm. protein and 36 calories per kg. Absolutely, the diet was low. In view of
the emaciation and the attendant lowered metabolism, it was relatively liberal.

Subsequent History. — The condition was excellent up to Apr. 11, then glycosuria
began to recur and the patient lost control of it. She was readmitted May 23
on this account.

Fourth Admission. — Weight 32 kg. There was heavy glycosuria, with only
fault traces of ferric chloride reaction. Blood sugar 0.326 per cent, CO2 capacity
63.4 per cent. Fasting was begun immediately, with 300 cc. coflEee, 300 cc. soup,
and 3 gm. salt daily. The ferric chloride reaction immediately disappeared.
Glycosuria fell to traces within 24 hours, and was negative in less than 48 hours.
Nevertheless, fasting was continued imtil May 27, when a tolerance test with



CASE RECORDS 419

green vegetables was begun, with 10 gm. carbohydrate and increasing 10 gm.
daily, as usual. Glycosuria appeared only with 60 gm. carbohydrate, June 1 and
2. The tolerance of SO gm. would thus indicate an increased assimilation to the
extent of 20 gm. as compared with the earlier test in Mar., 1916. A mixed diet
was then built up, until a trace of glycosuria appeared on June 7 with 60 gm. pro-
tein, IS gm. carbohydrate, and' 1300 calories. The ration was then fixed at 46
gm. protein, 10 gm. carbohydrate, and 1100 calories, and the patient discharged
on this in good condition, June IS, 1917, weighing 31.1 kg. The diet thus repre-
sented almost 1.5 gm. protein and about 35 calories per kg., diminished by weekly
fast-days to 1.3 gm. protein and 30 calories average. The CO2 capacity of the
plasma remained between 62.5 and 66.8 per cent throughout, the ammonia nitro-
gen between 0.37 and 0.77 gm. The blood sugar gave the only unfavorable indica-
tion, for with sugar-free urine it was found as high as 0.220 per cent and never
below 0.166 per cent.

Subsequent History. — The patient has remained in good condition, free from
symptoms.

Remarks. — The diabetes seemed to run a less rapid course in this patient than
in most of her age, but without radical measures the end must have been fairly
close when she was first received. The opportunity for restoring anything ap-
proximating normal condition was past, ,and the tolerance had been brought per-
manently and irretrievably low. The patient has been kept alive IJ years since
then, at a sacrifice of 8 kg. weight. It is to be emphasized that except for occa-
sional periods of greatest rigor, she has been stronger and more comfortable and
has actually looked better, according to her friends' judgment, than at the higher
weight. She remains continually cheerful, fairly well satisfied, faithful to the diet,
and strong enough for light labor and amusements, spending much of her time
outdoors and evidently taking pleasure in Mfe.

The usual recrudescence of diabetic symptoms with infection, and the smooth
and uneventful recovery of a severely diabetic patient from typical lobar pneu-
monia on the undernutrition which was requisite to ward ofi acidosis, are also
features of interest.

On the other hand, the gain of 20 gm. carbohydrate tolerance is too little
return for the loss of 8 kg. weight. If by any means the weight could be built
up by several kg., the tolerance would undoubtedly be less than at the first ad-
mission, and according to this standard there has been downward progress.
Such progress is fully accounted for by the general policy of feeding too close to
the limit of tolerance and thus keeping up slight overstrain of the assimilative
function as shown by the persistent hyperglycemia. If in Apr. and May, 1916,
the low blood sugar had been kept continuously normal, by fixing the body
weight at 33 or 34 kg. and the diet at its present figure of about 1100 calories, with
inclusion of a little carbohydrate, it is believed that the condition would today
be more favorable as respects weight, strength, and laboratory findings. It is the
old story of refraining from bringing the patient down to the necessary level of
undernutrition for therapeutic benefit, and later being forced to accept a still lower



420 CHAPTER ni

level of nutrition by reason of the downward progress resulting from the over-
strain. The progress has been so slow even with the overstrain that it is hard to
see how any "spontaneous" factor can be assumed. Notwithstanding the pro-
longed periods of comfortable existence and freedom from symptoms, it is prob-
able that the slow aggravation will contmue to ultimate death from coma or
inanition unless the patient is radically taken in hand and undernourished far
more rigorously than would have been necessary at the first admission. It is
even doubtful if such an attempt can now atone for the lost opportunities of the
past, or if the assimilative function may not have fallen too low to support life
permanently at any feasible level of nutrition.

CASE NO. 63.

Male, age 13 yrs. Polish American; schoolboy. Admitted Feb. 22, 1916.

Family History. — Father and one brother are well. Mother dead, cause vin-
known. No diabetes or other heritable disease known in family.

Past History. — Measles, chicken-pox, scarlet fever. Otherwise healthy life.
No sore throats or other minor infections. No abnormalities of diet. Never
nervous or obese. Apparently a thoroughly healthy, active boy.

Present Illness. — Polydipsia and polyuria with loss of weight and strength began
1 year ago. He has spent most of the year in hospitals. On one occasion he
had to be taken to a hospital because he "became sleepy" after eating a large
quantity of cakes. About 6 weeks ago he was in an institution where he was
given bread and other starches and made to take long walks "to buUd him up."
He realized that the treatment was making him worse, and having heard of the
Institute came here of his own accord on Feb. 21. The CO2 capacity of the
plasma was then 37.2 per cent, but dyspnea and other clinical symptoms were
absent, so the patient was told to return in 3 days, when there would be room for
him. On Feb. 21, he ate | pound of pork, half a loaf of gluten bread, some fat,
and some cofiee and soup. That evening he is said to have appeared a little tired
and cold. At 4 o'clock the next morning he woke up with extreme dyspnea. A
physician pronounced him dying, and the father considered treatment scarcely
worth attempting, and it was due to the patient's own request that he was brought
to the hospital.

Physical Examination. — ^Height 142.4 cm. A well developed, moderately emaci-
ated boy with intense air-hvmger. Skin dry, cold, very white, and lips grayish-
blue. He is nevertheless intelligent when roused. Tongue red, dry, brown-
coated. Teeth and tonsils normal. No superficial glandular enlargement. Pulse
rapid and thready. Abdomen much distended, but not rigid or tender. Knee
jerks present but sluggish. Wassermann negative. Examination otherwise
negative.

Treatment. — ^Death seemed imminent durmg the ambulance trip, and stunulants
were used. On arrival at hospital the rectal temperature was too low to register
on the ordmary cUnical thermometer. Pulse 92; respiration 31, air-hunger type.



CASE RECORDS 421

The CO2 capacity of 12.3 per cent was the lowest witnessed in this series of cases.
Sodium bicarbonate was immediately begun in 5 gm. doses by mouth, and hot
water and soup were also given as freely as possible. The patient was surroimded
with hot-water bottles, and rectal tube, turpentine stupes, and enemas were used
to reduce meteorism. After 4 hours the rectal temperature was 94.2°, pulse 96,
respiration 34. There was a gradual steady rise thereafter, until by 7 o'clock the
next morning the temperature was 101°, the pulse 100, the respiration 44. Up to
this time (12 hours) 45 gm. sodium bicarbonate and 4200 cc. fluids had been taken
and 2180 cc. acid vurine passed, with the usual intense ferric chloride reaction
and 3.6 gm. ammonia nitrogen. By this time (Feb. 23) the CO2 capacity of the
plasma had risen to 26.8 per cent. Additional clinical details are shown in
Table XVni.

The parallel slowing of pulse and respiration with relief of acidosis is note-
worthy; also the strikingly rapid loss of weight, notwithstanding fluid, salt, and
alkali intake during the period of highest acidosis (Feb. 22 to 26).

On Mar. 2, when after 9 days of fasting the urine had been sugar-free for more
than 24 hours, feeding was begun with 10 gm. carbohydrate in green vegetables.
A trace of glycosuria immediately returned, but increased very little as the car-
bohydrate was raised to 35 gm. on Mar. 9. Meanwhile the ferric chloride re-
action had become negative. After a fast-day on Mar. 11, another test showed
a higher carbohydrate tolerance, glycosuria appearing only with 100 gm. carbo-
hydrate on Mar. 23. After a fast-day on Mar. 26, mixed diet was begun, in-
creasing up to 50 gm. protein, 15 gm. carbohydrate, and 1200 calories on Mar.
31 to Apr. 1, without glycosuria. Glycosuria appeared on the same caloric
intake with 50 gm. protein and 20 to 30 gm. carbohydrate the following week.
Also in the next week a diminution of protein to 40 gm. and carbohydrate to 5
gm., with increase of fat to make 1500 total calories, brought glycosuria on Apr. 15.
In the following week with the same protein, without carbohydrate, glycosuria was
absent with 1200 calories, but appeared when the fat was increased to make 1400
calories; it then continued with diminution to 1200 calories. As usual with the
effects of fat, the h5rperglycemia and glycosuria were stubborn, not ceasing with
the fast-day on Apr. 23, a trace of glycosuria recurring on Apr. 24, and the sugar
being still 0.232 per cent in whole blood and 0.250 per cent in plasma on Apr. 27.
Nevertheless, the condition was conquered by restriction of fat. With the same
40 gm. protein, Apr. 27 to May 4, glycosuria remained absent with caloric intake
up to 1000. An increase of protein to 60 gm. and of calories to 1200 brought a
trace of glycosuria on May 6. By this time the general condition was good and
considerable exercise was being taken. Perhaps on this accoimt the diet of 40
gm. protein and 1200 calories, which caused glycosuria up to May 21, was subse-
quently tolerated; and in Jime the increase to SO gm. and 1300 calories and fi-
nally Qune 29 to 30) to 70 gm. protein and 1500 calories brought no glycosuria.
In July the protein was diminished to 52 gm. and the calories to 1200, in order to
permit the introduction of carbohydrate. This proved successful, so that by
Aug., 30 gm. carbohydrate were tolerated with this diet. The course in hos-



422



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424 CHAPTER ni

pital was uneventful, except that dental examination revealed three carious
teeth, which were removed without ill effects. The patient was discharged
Aug. 3.

Acidosis. — The acutely threatening condition at admission was described above.
This patient was apparently the nearest to death of any of those who recovered in
this series. Also there appeared to be a real acute need for alkaU, and in this
instance sodium bicarbonate seemed to be hfe-saving. It seems improbable that
simple fasting and fluid would have proved sufficient to combat such an acute
deficiency of alkah and high acid production. Thereafter the plasma bicarbonate
ran a fully normal course without the aid of alkah, the ferric chloride reaction
rapidly diminished with fasting and became negative after Mar. 6, probably more
by reason of the continuous imdemutrition than the small quantities of carbo-
hydrate then given. It reappeared, as may be so often observed, on subsequent
occasions about the same time with traces of glycosuria, even though the quanti-
ties of sugar lost were trivial and there were no significant differences in diet as
compared with other times when the reaction was negative. The only evidence
of continued acidosis was the ammonia nitrogen of 0.85 gm. on July 1, but with
the aid of 20 to 30 gm. carbohydrate this had fallen to a normal level by the
end of July.

Blood Sugar. — With blood sugars of 0.35 and 0.4 per cent at admission, it is
conceivable that carbohydrate feeding would have been injurious from this
standpoint, and possibly would have increased the acidosis by aggravating the
diabetic condition. There was a fairly prompt fall in the blood sugar. The well
marked rise. Mar. 2 to 10, indicated the genuine intolerance for even the small
quantities of carbohydrate then allowed. The rapid change for the better with
continued imdemutrition was shown by the rapid fall to 0.123 per cent in whole
blood and 0.141 per cent in plasma on Mar. 15. Notwithstanding the increased
carbohydrate intake, the sugar on the morning of Mar. 21 was only 0.151 per cent
in blood and plasma. On the morning of Mar. 29, it had reached the nearly
normal level of 0.104 per cent in whole blood and 0.123 per cent in plasma.
Instead of maintaining this advantage, with the added benefits of mixed diet, the
fat intake was increased unduly, with the consequence of many traces of glyco-
suria and continuous hyperglycemia. With the improvement in tolerance the
curve tended shghtly downward, to 0.145 per cent in whole blood and 0.159 per
cent in plasma on July 15. Then the simple increase of carbohydrate without
change in total calories brought a further elevation to 0.179 per cent in whole
blood and 0.182 per cent in plasma on July 29. As samples were taken before
breakfast and hyperglycemia was presimiably greater during digestion, it is
evident that the renal threshold was high.

Weight and Nutrition.— Weight at entrance 27.8 kg., at discharge 25.4 kg.;
i.e., a loss of 2.4 kg. The strength rapidly returned, especially with the aid of
exercise, and except for thinness and a persistent pallor (the latter perhaps nat-
ural) the boy appeared and acted normal. The diet prescribed at discharge was •
52 gm. protein, 25 gm. carbohydrate, and 1200 calories, representing approxi-



CASE RECORDS 425

mately 2 gm. protein and 48 calories per kg., reduced by weekly fast-days to
1.7 gm. protein and 41 calories per kg. The diet was absolutely low in view of
the age and subnormal weight. The objection to it is that it was in excess of the
assimilative power as demonstrated by the blood sugar.

Subsequent History. — The patient began school in Sept., and was able to do
everything like other boys. He prepared, weighed, and cooked his own diet,
and remained free from glycosuria. On Sept. 11, sugar in blood and plasma was
0.278 per cent (after 2 meals), CO2 capacity 55.8 per cent; weight 27.4 kg. He
had to be readmitted Nov. 20, 1916, because of difficulty with glycosuria, which
began on catching cold and then became unmanageable.

Second Admission. — Weight 26 kg. SUght glycosuria, negative ferric chloride
reaction. Patient still strong and comfortable, and normal to physical examina-
tion. Because of the stubbornness of the sUght traces of glycosuria, a 4 day
fast was imposed, reducing the weight to 24.2 kg. A diet of 30 gm. protein and
320 calories then brought back traces of glycosuria. The ferric chloride reac-
tion remained negative; and the ammonia nitrogen, which was 1.2 gm. the first
day, diminished to 0.5 gm. On Nov. 24 to 25, a diet of 30 gm. protein and 320
calories brought back traces of glycosuria, requiring a single fast-day on Nov. 26.
This glycosuria was evidently due to the suddeimess of beginning diet; therefore
on Nov. 27, 7 gm. protein and 80 calories were permitted, with an increase of
about the same quantity daily, until a trace of glycosuria reappeared with 45
gm. protein and 480 calories on Dec. 2. Dec. 4 to 16, a diet of 40 gm. protein and
600 calories caused almost daily traces of glycosuria, notwithstanding the usual
weekly fast-days. These ceased on the simple withdrawal of 100 calories of fat
beginning Dec. 18, protein continuing at 40 gm. Thereafter it became possible
to increase the calories first to 600 and then to 700. Also, beginning Jan. 1,
2.5 gm. carbohydrate were introduced, and increased to 10 gm. by Jan. 4. The
only evidence of acidosis was found in the ammonia nitrogen of 0.97 to 0.48 gm.
This seemed to be perceptibly diminished by the carbohydrate, for after its
introduction the range was 0.58 to 0.29 gm. The patient was dismissed on Jan.
10, weighing 25.2 kg., still in good condition although not so strong as before.
The diet mentioned represented nearly 1.6 gm. protein and 28 calories per kg.,
diminished by weekly fast-days to 1.4 gm. protein and 24 calories average. This
period of 2 months in hospital therefore represented extreme undernutrition, the
aim being only to protect body nitrogen with as high a protein intake as per-
mitted by the limit of tolerance. It is imfortunate that nitrogen balances were
not carried out. During fasting, Nov. 21 to 23, the daily urinary nitrogen was
5.24, 4.74, and 4.41 gm. No analyses were made of the 450 cc. soup taken daily.
Numerous analyses at other times indicate that the possible nitrogen content of
this quantity might range from 0.6 to over 2.0 gm. Later, 4 widely separated
days during the period of 40 gm. protein intake showed figures in close agreement,
between 6.74 gm. and 7.48 gm. urinary nitrogen. With allowance for the above
mentioned nitrogen taken in soup, this probably indicated nitrogenous equilibriiun.



426 CHAPTER III

The body nitrogen was seemingly spared effectively, but no material was pro-
vided for growth. Also body fat must have been sacrificed continuously, and the
relatively small loss of weight must have been due in part to water retention
masking the actual loss of substance. The boy was discharged only temporarily
on account of homesickness, and was instructed to report in 2 weeks'.

Third Admission. — Nothing further was heard from the patient until he was
readmitted in incipient coma on Feb. 12. It might seem that diabetic coma is
not strictly a single or imiform condition, for at his first admission this boy
showed chiefly dyspnea and extremely low blood alkahnity, with intelligence
apparently as clear as the state of collapse permitted. This time the same boy,
with CO2 capacity of 26 per cent, showed moderate dyspnea and disproportionate
stupor. The treatment this time was conducted without alkaU. Owing to other
work the laboratory study for this period is incomplete. No blood examinations
were made, except the one at admission which showed CO2 capacity 26 per cent
and sugar 0.425 per cent. The case shows how treatment can be conducted essen-
tially on the basis of chnical sjrmptoms and qualitative reactions. The available



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 47 of 76)