Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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data are shown in Table XIX.

The diet was built up in Mar. to 35 gm. protein and 600 calories, which caused
occasional traces of glycosuria. Toward the close of Mar. this diet was tolerated,
and was later increased to 45 gm. protein and 850 calories. The attempt to in-
troduce 10 gm. carbohydrate in Apr. caused only temporary glycosuria, but was
given up after Apr. 28 in order to increase protein to 55 gm. The patient was
discharged May 5, 1917. Height 142.4 cm. Weight 25.9 kg. Diet 55 gm. pro-
tein and 750 calories (2.1 gm. protein and 29 calories per kg., diminished by the
weekly fast-days to 1.8 gm. protein and 25 calories per kg.). He was definitely
weaker and worse off than before, but even on this low diet was able to be about
and was cheerful and courageous.

Subseqiunt History. — The patient was seen on June 8, weighing 24.8 kg., and
feehng brighter and stronger than on leaving hospital. He had shown shght
glycosuria ui the first week at home, but thereafter had been sugar-free. He
spent his time about the house and garden, raismg vegetables and chickens,
weighing and cooking his own diet, and keeping a complete record of diet and
urine tests. The ferric chloride reaction was negative. Plasma sugar (during
digestion) 0.264 per cent, CO2 capacity 49.1 per cent.

• Fourth Admission. — ^July 20, a telephone message was received from one of the
family that the boy had broken diet by eating bread and fruit, that he had heavy
glycosuria and seemed sleepy. Upon bringmg him to the hospital, heavy sugar
and ferric chloride reactions were found in the urine, but there were no cUnical
symptoms of acidosis. Weight 23.6 kg. The urinary conditions cleared up very
easily and the boy was discharged Aug. 10, 1917, on the same diet as before.
Hyperglycemia was persistent as before.

Suhsequeni HMtory.— Another relapse occurred and the boy was taken to a public
hospital, where he died Oct. 11, 1917.



TABLE XIX.



Diet.



Date.



1917
Feb. 12



i



n



kg

24.8



13



14



15



16



17



18



19



20



21



22



23



24



25



23.8



22.6



23.1



23.0



22.



23.0



23.4



23.7



23.8



24.0



24.0



°P.

97.2

97.6

98.2
99.6

99.6
97.2

95.6
97.6

96.4
98.2

!97.4
98.1

97.4
99.4

96.2
98.0

96.4
97.6

96.4
97.6

96.4
96.0

96.4
98.0



24.0



24.0



96.0
98.0

95.8



76
84

86
68

76
70

46
70

60
40

80
50

48
76

50
98

68
52

54
70

44
60

76
50

68
50

64



97,8 40



20
20

20

24

24
20

60
16

16
16

16

22

17
20

18
18

18
16

18
20

16

18

16

18

20
15

16
16



gm.





gm, gm, gm.
Fasting; 200 cc. soup.



400 " coffee.

600 " soup.

400 " coffee.

600 " soup.

400 " coffee.

600 " soup.

400 " coffee.

600 " soup.



22.3


15.9





22.3


15.9





22.3


15.9





22.3


15.9





22.3


15.9





22.3


15.9





22.3


15.9





22.3


15.9





7.4


5.3






240



240



cc,
1502



5000



5000



2500



2500



2500



2500



Urine.



806



5090



3611



2388



1918



2366



2126



240


2500


240


2500


240


2500


240


2500


240


2500


240


2500


80


2500



++++

++++

+++

++

++

+++

++

++

2346 + +



2397



2468



2643



3413



2488



+



+



+






+ + + +

+■+ +

+

+

+





427



428 CHAPTER III

Remarks. — ^The case is characterized by continuous downward progress, for
which two causes are known. One is extreme youth. Though the boy did not
gain in weight, nor to any significant extent in height, yet the growth impulse or
general metabolic strain of youth may be held responsible for the unfortunate
prognosis for diabetes of this grade of severity at this age. Nevertheless, it must
be recognized that a defiiute improvement in the power of assimilating food is
demonstrated by the record of the first period in hospital, so that the power to
recuperate was not wholly lacking, even in this chUd. The second known factor
is the excessive diet, which brought back hyperglycemia after the blood sugar
had fallen to normal, and would have been responsible for downward progress
even in an adult imder the same conditions. The low diet was not used at first
by choice, and therefore had to be used later by compulsion, after the real oppor-
tunity had been lost. Irrespective of the ultimate prognosis in such a case, the
duration of life and comfort may vary as much as several years, according to the
eflSciency of treatment and the earliness with which it is begun. In this instance
the boy was ready to die after 1 year of indifferent treatment, which had brought
the tolerance almost to zero, and was thereafter kept alive a year and a half,
most of the time in greater strength and comfort than during the earlier period
under other treatment.

CASE NO. 64.

Male, age 12 yrs. American Jew; schoolboy. Admitted Feb. 24, 1916.

Family History. — Father, mother, and one sister are well. No diabetes or
other heritable disease known in family.

Past History. — Fully healthy life except for measles and mimips. No sore
throats, toothaches, or minor infections known. Appetite, digestion, bowels
normal. Never nervous or under strain; always ranking well in school, and pro-
ficient in outdoor sports.

On Dec. 1, 1915, he fell down a flight of 10 stairs, landing on the front of his
head. There was no cut in the skin, no imconsdousness, no bleeding from ear or
nose, no paralysis or any perceptible symptoms beyond the slight bruise. The
patient did not associate the accident at all with his present iUness.

Present Illness. — ^About 3 weeks before admission there was acute onset of poly-
dipsia and polyuria, but not polyphagia. There has since been very rapid loss of
weight. Patient nevertheless continued at school until 1 week before admission.
He then saw a physician, who diagnosed diabetes and prescribed only a moderate
reduction of carbohydrate. During the present week the boy became increas-
ingly sleepy, and has spent ahnost his entire time for several days past sleeping
on a couch.

Physical Examination.— Hei^t 142.5 cm. Normal development, moderate
emaciation. Patient sleepy but easily roused. Moderate dyspnea of air-hunger
type. Face is that of a mouth breather and suggests adenoids. Cheeks flushed.
Skin dry and cracked. Mouth and Ups dry; teeth poorly kept, several carious;
some pyorrhea. Tongue and pharynx red and dry; tonsils do not protrude, but



CASE RECORDS 429

show pus on pressure. Few small palpable lymph nodes in neck, axillae, and
groins. Knee jerks obtamable by reinforcement. Exammation otherwise nega-
tive. Later examination by a rhinologist showed nose and ears normal, no ade-
noids, tonsils moderate in size, yielding considerable creamy pus on pressure.

Treatment. — On the day of admission the bowels were moved with calomel and
magnesium sulfate. Fasting was begun immediately because of the imminent
coma, 300 cc. clear soup and 3 to 5 liters total fluid being given daily. Within
24 hours, the CO2 capacity of the plasma rose from 16.6 to 27.7 per cent. The
D:N ratio had apparently been high, for on the first fast-day it was 2.65: 1, and
on the second day 1.43 : 1. On the second fast-day (Feb. 25) 25 gm. sodium bicar-
bonate were given. It was unnecessary, since the progress was favorable without
it, but seemed to produce an effect quickly in making the patient brighter and less
drowsy. Thereafter no alkali was given. Both glycosuria and acidosis rapidly
diminished, and on Feb. 29, after more than 24 hours of sugar-freedom, 2.4 gm.
carbohydrate were given. Green vegetables were increased progressively and
it became necessary to add potatoes, green peas, and lima beans before the limit
of tolerance was reached with 330 gm. carbohydrate on April 2 to 3. Mixed diet
was then begun without difficulty, and the patient was soon taking 2 or 3 nule
walks and other exercise daily. Four decayed teeth were extracted unevent-
fully and the mouth brought into good condition. The tonsils were not re-
moved. The patient was discharged May 5, 1916, feeling and appearing per-
fectly well and strong.

Acidosis. — Even with the low CO2 capacity of 16.6 per cent, it was evident
that treatment coxdd have been easily and safely conducted without alkali. The
use of sodium bicarbonate on 1 day, however, seemed to hasten results. The
ammonia nitrogen of 1.88 gm. on the day of admission covered ISJ hours.
The ammonia on Feb. 25 (2.36 gm. N) showed little perceptible effect from the
bicarbonate. On Feb. 26, it was 2.42 gm., on Feb. 27, 2.34 gm.; and only then,
with the CO2 capacity almost normal and the ferric chloride reaction down to
traces, did the ammonia show a real fall. Seemingly it was the active neutraliz-
ing agent which permitted the spontaneous rise in blood alkalinity. Subse-
quently acidosis was entirely absent by all tests.

Blood Sugar. — The hyperglycemia of 0.25 per cent showed a prompt fall to
normal, characteristic of an early case even though severe in symptoms. The
thoroughly normal course of the blood sugar as estimated mornings before break-
fast is one of the striking features of this case.

Weight and Nutrition. — The weight at admission was 25.2 kg., at discharge
25.6 kg.; i.e., a gain of 0.4 kg. There was visible edema only with the sharp
rise of weight up to Mar. 5, as so often happens on vegetable diet after fasting.
It is to be supposed that there was loss of body substance during treatment, with
retention of water due especially to the carbohydrate supply"; in contrast to the
dried tissues at admission. The evidence lies in the fact that on Apr. 3 the
weight was 1.8 kg. more than at admission, though the fasting and vegetable
period for 5 weeks had represented prolonged undernutrition, especially in pro-



430



CHAPTER III



tein. After Apr. 3 there was presumably some rebuilding of tissue, but the
weight diminished by 1.4 kg. The diet at discharge was 65 gm. protein, 50 gm.
carbohydrate, and 1750 calories. It thus represented about 2.5 gm. protein and
64 calories per kg., reduced by weekly fast-days to 2.25 gm. protein and 55
calories average. The diet was thus abundant for growth. Such a caloric
burden would produce downward progress in almost any adult diabetic.

Subsequent ffis^oj-j).— Progress seemed favorable tmtil on Mar. 20, 1917, the
boy had to be readmitted because of the development of persistent glycosuria.

Second Admission— Utight 142.4 cm. Weight 28 kg. Appearance hke that
of a normal boy. The very slight ferric chloride reactions were deceptive, for the
true grade of the acidosis was shown by the high ammonia and low CO2. The
data for the early stage of treatment are shown in Table XX.



TABLE XX.





Diet.


1

a .
'^


i


Urine.


Plasma.


Date.


i


p2


ll


1

1750
1750
1757
910
834
766
766
462
307
307
307


1


H




s

3.1


1




1917

Mar. 21
" 22
" 23
" 24
" 25
" 26
" 27
" 28
" 29
" 30
" 31

Apr. 1


gm.

65.0
65.0
65.0
65.0
65.0
65.0
65.0
31.4
18.5
18.5
18.5


em.

137.6

137.6

138.3

47.3

39.1

31.7

31.7

13.9

2.9

2.9

2.9

Fast


gm.

50
50
50
50
SO
50
50
50
SO
SO
SO
day.


gm.

30
30
30

30

24


kg.

28.0

27.4
28.4
28.7
28.5
28.5
28.8
29.0
29.0
28.8
28.7
28.6


cc.

1460
1530
1980
1410
1828
1270
2032
2094
1885
1976
1855
840


++++

++++

++++

+++

+++

+++

+++

+++

+++

++

++




++
++
+
+
+
+
+
+
+
+
+
+


gm.

10.16
10.70
11.25
6.56
8.56
7.70
8.84
6.01
4.82
5.62
4.49
3.13


gm.

2.13
1,88
1.23
0.94
1.33
0.73
0.67
0.34
0.38
0.38
0.28
0.26


ml.
per cent

38
41
60

56

so

70
67



In this case it is seen that diminution first of fat and then of protein, without
changing carbohydrate, reduced glycosuria so that it was abolished by a single
fast-day instead of several. On the other hand the high ammonia, notwith-
standing the large alkaU dosage, indicates persistence of acidosis. There was no
such rapid clearing of acidosis as is usually seen with fasting.

Apr. 2, a test with green vegetables was begun, with daily addition of 10 gm.
carbohydrate in the usual manner. Faint glycosuria occurred with 100 gm. car-
bohydrate on Apr. 11. The test was not carried further to learn whether this
was the true limit, but it seems strongly probable that a marked fall in tolerance
had occurred since the previous admission. A mixed diet was then begun, of



CASE EECOSDS 431

60 gm. protein, 30 gm. carbohydrate, and 1000 calories, including 200 cc. milk.
The blood sugar before breakfast on Apr. 13 was 0.110 per cent. Carbohydrate
was gradually increased up to 55 gm. on Apr. 27, with no glycosuria. The patient
was discharged again in apparently excellent health on May 2, 1917. The pre-
scribed diet was 60 gm. protein, 50 gm. carbohydrate, and 1250 calories, repre-
senting, for the body weight of 26 kg., 2.3 gm. protein and 48 calories per kg.,
reduced by weekly fast-days to 2 gm. protein and 41 calories per kg.

Subseqiient History. — The patient spent his time reading and playing at home.
On Jime 2, 1917, he weighed 26.2 kg., but a trace of glycosuria was found. The
diet was diminished to 45 gm. protein, 25 gm. carbohydrate, and 1000 calories.
There was a suspicion that the trouble had been due to overstepping diet. On
June 27, he reported again, weighing 25.8 kg., with normal urine, blood sugar
0.138 per cent, CO2 capacity 55.2 per cent. The same condition has continued
since. The patient is contented on his diet, attends school regularly, and ex-
pects to graduate from grammar school this year. He behaves and appears like a
normal boy, except for being noticeably thin.

Remarks. — This was one of the most rapidly progressive cases of juvenile dia-
betes, coma being imminent within 3 weeks of the first known symptoms. In one
respect such symptoms are advantageous, in that they call prompt attention to the
condition and afford the opportunity for early treatment. As usual, a high car-
bohydrate tolerance was quickly recovered in this case. The blood sugar also
became normal as tested mornings before breakfast, though the existence of ab-
normal digestive hyperglycemia must be assumed. As usual, a luxus diet re-
sulted in downward progress. It then became necessary, as usual, to reduce the
diet even lower than would have been required for proper treatment in the first
place.

Measures may soon be taken to reduce the persisting hyperglycemia. Owing
to the mistreatment during the most hopeful stage, the patient can never appear
like a normal boy again, but with suitable care it may be possible to preserve
the present condition of fair strength and comfort for a long, perhaps indefinite
time.

CASE NO. 65.

Male, married, age 53 yrs. American; business man. Admitted Mar. 6,
1916.

Family History. — Father died in old age, with diabetes for some years pre-
viously, though it was not the direct cause of death. A brother died of Hodgkin's
disease. History otherwise negative.

Past History.— MesLsles in childhood. Diphtheria at 14. Two attacks of
"gravel" 14 and 16 years ago; no trouble since. 6 or 7 years ago began to notice
cramp-like pains in calves of legs after long walking. On the whole, he has been
a healthy, hard working, prosperous man of rather large business affairs, but
without special strain. Appetite good, but not excessive. Acid stomach com-
plained of for past 5 or 6 years. Slight constipation; little exercise. No special



432 CHAPTER in

indulgence in alcohol, tea, or coffee, but the smoking of 8 or 10 strong cigars
daily is a fixed habit. Sleep normal. No nervousness.

Present Illness. — Onset not known. In 1914, life insurance was obtained, with-
out abnormal urinary findings. Patient has continued to feel well and work
efSciently. No polyphagia, polydipsia, or polyiiria. Eyesight may have failed
to undue extent. Occasional headaches. Persistent cough for 3 months before
admission. No hemoptysis, fever, chills, or sweats. The one symptom noted has
been gradual loss of about 15 pounds weight. On this accoimt he consulted a
physician, who found blood pressure 170-150, a trace of albxmiiniuia, and 3
per cent glycosuria. The patient was badly frightened at the word diabetes.
His physician slightly restricted starches and referred him to the Institute.

Physical Examination. — ^A well developed, well nourished man, shghtly over
weight. Rales without consoUdation, especially in lower lobe, left limg. Blood
pressure 160 systoUc, 80 diastolic. Examination otherwise negative.

Treatment. — With only a trace of glycosuria, there was nevertheless hyper-
glycemia (fasting) of 0.212 per cent in whole blood and 0.244 per cent in plasma.
Acidosis was absent by aU signs. Glycosuria ceased quickly on a diet of 100
gm. protein, 50 to 75 gm. carbohydrate, and 1800 calories. A green vegetable
period was begun with 25 gm. carbohydrate on Mar. 12 and 50 gm. on March 13.
Glycosuria appeared only with 220 gm. carbohydrate on March 28 to 29. The
patient was placed upon a diet of 90 gm. protein, 75 gm. carbohydrate, and 2200
calories, on which he was discharged Apr. 6. The weight had been reduced by 1
kg. The blood sugar had been brought to normal by the imdemutrition of the
carbohydrate period (Mar. 25) and had subsequently risen, especially on mixed
diet, to 0.147 per cent in whole blood and 0.131 per cent in plasma. In view of
the age and the mildness of the case, the hyperglycemia could be trusted to take
care of itself if the patient followed diet and reduced his weight as instructed.

Remarks. — The question is often asked whether fasting is necessary for patients
who readily become sugar-free without it and whose diabetes is mild. The general
principle is undernutrition. This patient had no fast-days. A carbohydrate
period is an agreeable means of undernutrition, and is furthermore useful as af-
fording a standard of tolerance for comparison with some later time. By June
the patient's weight was down to 59 kg., and by Aug. to 58 kg. He now esti-
mates his diet instead of weighing it. There has been no return of symptoms.
It is probably more important for such a patient to weigh himself than his food.

CASE NO. 66.

Female, age 15 yrs. American; schoolgirl. Admitted Mar. 6, 1916.

Family History. — Healthy, except that a paternal grandfather had diabetes at
time of death.

Past History. — ^Adenoids and tonsils removed in infancy. No illnesses, except
measles 4 years ago. Life and habits normal. Not neurotic. No excessive
appetite or indulgence in sweets. Menstruation began at 12 years, was regular
and normal up to Dec, 1915, when it stopped.



CASE RECORDS 433

Present Illness. — 5 months ago (Oct., 1915) patient had an attack of urticaria
from unknown cause. She was instructed to drink much water, and when unusual
thirst began thereafter she supposed it to be due to the habit of drinking. 1
month before admission she was seen by a physician, who did not examine the
urine and pronounced her in good health. On accoimt of the continuance of
excessive thirst she was taken to another physician 1 week ago, who made the
diagnosis from the lurine.

Physical Examination. — Height 158.1 cm. A well developed and normally
nourished girl with healthy color and no visible abnormahty. Blood pressure 90
systolic, 60 diastolic. Examination normal throughout.

Treatment. — The patient had been on practically unrestricted diet except for
abstinence from sugar. With the heavy glycosuria there was a trace of ferric
chloride reaction. Instead of the usual fasting, limitation of the diet, especially
in fat, was employed. On Mar. 7 the diet contained 51 gm. protein, 45 gm.
carbohydrate, and only 17 gm. fat. Carbohydrate was then diminished while the
calories were kept at approximately 800. Mar. 14 and 15 were almost fast-days, the
latter being a green day with only 10 gm. carbohydrate. Glycosuria and keto-
nuria being absent, the usual test with green vegetables was instituted. Traces of
glycosuria appeared on Mar. 22 to 23 with 80 gm. carbohydrate, but did not indi-
cate the true limit of tolerance, which was only reached with 140 gm. carbohy-
drate on Mar. 29 to 30. Mixed diet was then begun, and allowances of 70 to 90
gm. protein, 25 to 65 gm. carbohydrate, and 1750 to 2200 calories were tolerated.
Instead of fast-days, the patient took each week a day of six eggs, 450 cc. soup,
and 60 gm. bran. Anemia was foimd to be present, with hemoglobin 75 per cent,
and no ceU changes to characterize the condition. Examination by rhinologist
showed ears and nose normal, but cheesy deposits in crypts of the tonsillar rem-
nants. The anemia was treated with fresh air, exercise, and iron. The only
special event while in hospital was an attack of supposed appendicitis at the end
of May. Without any other symptoms, a trace of glycosuria appeared on May
29 on a diet within the demonstrated former tolerance. It cleared up spontane-
ously, but on May 31 the patient woke up with abdominal pain and nausea with-
out vomiting. There was some rigidity, slight tenderness, polymorphonuclear leu-
kocytosis, and temperature of 99.8° and 100.8°. From the double standpoint of
appendicitis and diabetes very little food was given from May 31 to June 2. With
rest in bed the abdominal symptoms quickly subsided, and beginning June 3 the
diet was cautiously btiilt up to the former level. The patient was discharged
June 29, feeling and appearing entirely well and exercising freely though not
strenuously.

Acidosis. — Owing to the mixed diet, acidosis was absent at admission, aside
from the trace of ferric chloride reaction. The CO2 capacity was normal, and
the ammonia nitrogen only 0.52 gm. Although, as stated, the diet on Mar. 7
was as nearly fat-free as convenient, the simple limitation of carbohydrate was
followed by a moderate ferric chloride reaction, a rise of ammonia to 0.89 gm. N,
and a fall in CO2 capacity from 56 to 48 per cent. On Mar. 8, with a diet of 59



434 CHAPTER m

gm. protein, 69 gm. carbohydrate, and 36 gm. fat, the ammonia rose to 1.6 gm. N,
and the COa fell to 44 per cent. Carbohydrate was then diminished ahnost to
Zero, keeping protein the same, while fat was gradually increased to S3 gm. On
this arrangement the ferric chloride reaction became negative, the ammonia fell
to 0.85 gm. N, and the CO2 capacity rose to normal without the use of alkali.
The explanation of this effect of diminished carbohydrate and increased fat Ijes
in the undernutrition, which amounted to a partial fast. Also the relief of the
overtaxed metabolism, by stopping glycosuria, tends to stop acidosis, even though
accomplished by dimim'shing carbohydrate. It must be added that this last sen-
tence does not contradict the first in this paragraph. The tendency to acidosis
accompanying diabetes can for some time be overcome by sufficient carbohydrate
in the diet.

With the abdominal attack on June 2, a trace of ferric chloride reaction ap-
peared. This and the slight irregularities in the CO2 curve may have been due
entirely to greatly reduced diet.

Blood Sugar. — The high percentage of 0.61 per cent in whole blood and 0.73S
per cent in plasma at admission were merely the accompaniments of an acute case
on carbohydrate-rich diet. With the simple restriction of diet stated, there was
an abrupt faU within 24 hours to 0.277 per cent in whole blood and 0.294 per cent
in plasma. Thereafter, with a more gradual decline, a fuUy normal value was
reached on Mar. 16. Subsequently the fasting blood sugar was always found
normal.

.■ Weight and Nutrition. — Weight at admission 50 kg., at discharge 45 kg. The
diet at discharge was 80 gm. protein, 40 gm. carbohydrate, and 1900 calories
and included milk and a little bread. Three eggs were allowed on weekly fast-days.
The diet thus represented about 1.8 gm. protein and 42 calories per kg., dimim'shed
by the partial fast-days to 1.6 gm. protein and 36 calories average. With the
moderate exercise prescribed, this may be considered a fairly low diet for a girl
of 15, though not so low as advisable under the circumstances.

Subsequent History. — The patient was next seen on Nov. 8 and reports of nor-
mal urine confirmed. The blood sugar was 0.110 per cent; total acetone in the
blood less than 10 mg. per 100 cc. 2 kg. weight had been gained. The appearance
was that of perfect health.

i Second Admission. — Dec. 6 to 10 the patient was in the hospital solely for



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 48 of 76)