Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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observation. The fasting blood sugar on 3 days was 0.13 per cent. Otherwise
everything was normal, except for persistence of slight anemia. The diet was
reduced to 1500 calories, with 80 gm. protein and 45 gm. carbohydrate.

Third Admission.— Apr. 4, 1917. The patient suddenly developed heavy gly-
cosuria and was immediately brought to the hospital. On the regular prescribed
diet the glycosuria immediately disappeared, and had apparently been due to
error in diet. The weight was 50 kg., the fasting blood sugar 0.10 per cent.
After 4 days of observation on this diet a test with green vegetables was begun,
and only a trace of glycosuria appeared with 145 gm. carbohydrate on Apr. 18.
The test was not continued to learn whether this was the actual limit of tol-



CASE RECORDS 435

erance. It was demonstrated that the tolerance was at least as high as 1 year
previously. The blood sugar on the morning of Apr. 19 was 0.1 per cent, the
CO2 capacity 74 per cent. The 1500 calory diet was continued, keeping the pro-
tein at 80 gm. and raising carbohydrate to 60 gm. by substitution for a little fat.
Six eggs were allowed on fast-days. The weight at discharge on May 2 was 48.2
kg. The diet thus represented 1.66 gm. protein and 31 calories per kg., dimin-
ished by the partial fast-days to 1.55 gm. protein and 28 calories per kg.

Subsequent History. — On moving to the country for the summer the patient was
allowed to substitute thick coimtry cream for the poorer city cream, and when the
mother reported traces of glycosuria the carbohydrate was diminished from 60
to 45 gm. The reports of marked increase of weight then aroused suspicion, and
notwithstanding the record of vigorous health and continuous absence of glyco-
suria, the patient was ordered to return immediately to the hospital, where
these facts were ascertained.

Fourth Admission. — Sept. 10, 1917. Weight 55.4 kg.; a gain of 7.2 kg. since
last discharge, and 5.4 kg. more than at the first admission. The plasma sugar
on the afternoon of Sept. 10 was 0.159 per cent; and though glycosuria was ab-
sent, a heavy reaction developed as soon as the regular diet with 60 gm. carbo-
hydrate was given. The ferric chloride reaction was negative, but there was a
strong nitroprusside reaction. A 2 day fast was necessary to aboUsh the glyco-
suria, and the acetone reaction became still heavier. A carbohydrate test was
then carried out in the usual manner, and glycosuria appeared with 140 gm. car-
bohydrate. The tolerance was thus approximately the same as before. If any-
thing there was improvement, because the weight was so much higher at the time
of this test. The patient was discharged on Oct. 4 to resume her vacation in the
country.

Acidosis. — The plasma bicarbonate was continuously at a high normal level
(67.2 to 78.6 per cent) without the use of alkaU. Though the ferric chloride test
was always negative, the nitroprusside reaction was strongly positive all through
the carbohydrate test and also on the diet at discharge. In other words, as
much as 140 gm. carbohydrate without other food failed to abolish acetonuria
at this time.

Blood Sugar. — ^This was not only dangerously high in consequence of the over-
nutrition at admission, but was also stubborn, being 0.156 per cent on the first
fast-day (Sept. 12) and 0.154 per cent on the second fast-day (Sept. 13). On
Sept. 14, it was found to have fallen abruptly to 0.09 per cent. The subsequent
values were normal when taken fasting. A sample taken after eating lunch on
Oct. 2 showed plasma sugar of 0.123 per cent; i.e., distinctly higher than a normal
person would show after the same kind of a meal.

Weight and Nutrition. — The undernutrition in hospital brought the weight
down to 52.7 kg. For the purpose of further reducing weight, an undernutrition
diet was prescribed at discharge, representing 80 gm. protein, 50 gm. carbohy-
drate, and 1100 calories.



436 CHAPTER III

Subsequent History. — The patient continued to feel well and the urine re-
mained negative for sugar. Nitroprusside reaction was negative after Oct. 18.
She was slightly hungry on this diet. She returned by request for a brief obser-
vation in hospital.

Fifth Admission. — Oct. 23, 1917. Weight 51.7 kg. Blood and urine normal
in all respects. The blood sugar before breakfast on Oct. 26 was 0.098 per cent.
At various periods of digestion, Oct. 23 to 25, it ranged from 0.109 per cent to
0.119 per cent. The patient was discharged on the 3rd day (Oct. 26) oh a diet
of 70 gm. protein, 60 gm. carbohydrate, and 1275 calories, the plan being to
reduce weight somewhat further while giving a balanced ration and protecting
body protein.

Subsequent History. — The patient remains weU and is pronounced by her
mother the strongest and most energetic member of the family.

Remarks. — The diet prescribed at the first discharge was somewhat too high.
The functional overstrain was detected from the slight hyperglycemia, and the
diet accordingly reduced in fat and calories. The carbohydrate was actually
increased by 5 gm. With this well advised change, normal blood sugar was again
restored and the entire condition remained favorable. After the third admission,
a more dangerous situation developed from the neglect regarding the fat intake,
and this danger was masked by the reduction of carbohydrate. Serious damage
would certainly have resulted had not suspicion been aroused by the increase in
weight while the patient was seemingly in splendid condition. It is thus proved
by two experiences that the appearance of "spontaneous downward progress" can
quickly be produced in this patient by ovemutrition. With rational regulation
of the total diet, the subjective and objective appearance of perfect health has
been maintained to date with no sign of downward progress. The only danger
in sight at present lies in the patient's tendency to overstep her diet, particu-
larly by taking fat. Though the ultimate outcome cannot be predicted, it is
believed that if the mistakes committed in other cases are avoided, and early
and ef&cient treatment be employed, the progress in the great majority of cases
of juvenile diabetes can be at least as favorable as in this one.

CASE NO. 67.

Male, married, age 46 yrs. Spanish; lumber merchant. Admitted Apr. 20,
1916.

Family History.— A maternal aunt died of diabetes. A cousin on the father's
side had diabetes. No other heritable disease known in family.

Past History. — Healthy life with considerable business strain, but also consid-
erable recreation and outdoor exercise. No illnesses remembered except mild
childhood infections. Luetic infection at age of 18 with secondary eruption.
Has been treated with short courses of mercury for many years, but never con-
tinuously or with salvarsan. Tendency to nervousness and insomnia. Consid-
erable but not excessive indulgence in brandy, wme, beer, and cigarettes. The
appetite has also been rather large. Normal weight 85 kg.



CASE RECORDS 437

Present Illness.—In Dec, 1913, patient consulted a physician for a sensation
of heat Uke fever. Polyuria and other usual diabetic symptoms were absent.
The temperature was found normal, and 4.1 per cent sugar was found in the
lurine. Patient states that he lived on " broths" for 15 days and glycosuria ceased,
but a "blood test" still revealed diabetes. He soon afterward disregarded
diet, and after 3 months, thirst and loss of weight were noticed and the glycosuria
was found to be 7 per cent. Since then he has received treatment at a number
of watering places and under specialists on the European continent and in England.
In Spain he once underwent the Guelpa treatment with benefit. Glycosuria has
become more persistent with time, and acidosis, as evidenced by both ketonuria
and lowering of the alveolar CO2, has been present at least since 1914. He has
gradually lost 30 kg. weight.

Physical Examination. — A fairly developed, moderately emaciated man, with
intellectual and rather nervous face. Teeth poorly kept, marked pyorrhea.
Tonsils normal. No lymph node enlargement except a few palpable glands in
groins. Arteries not perceptibly sclerotic. Knee jerks absent. Repeated Was-
sermann reactions strongly positive.

Treatment. — Fasting was begun immediately, and carbohydrate was used as
liberally as possible with the idea of clearing up acidosis promptly. Notwith-
standing the mild clinical character of the diabetes, the tolerance in a carbohydrate
test was not above 150 gm. carbohydrate in the form of vegetables. Mixed diet
was then begun and increased rapidly to 110 gm. protein, 30 gm. carbohydrate,
and 2000 calorifes. A few sUght sugar and ferric chloride reactions recurred, but
on the whole this diet was apparently well tolerated, and the patient was greatly
improved subjectively. He was discharged on the above diet on Jiuie 16, 1916.

Acidosis. — The slightly subnormal blood bicarbonate quickly rose, and the
ammonia correspondingly fell to normal.

Blood Sugar. — This was 0.27 per cent on admission, but fell to normal with the
rapidity characteristic of an early or mild case. The later values were normal or
on the upper limit.

Weight and Nutrition. — Weight at admission 54.2 kg., at discharge 55.7 kg.;
i.e., a gain of 1.5 kg. Part of this was evidently water retention, for there was
no appreciable loss of weight during more than a month of fasting and under-
nutrition at the outset. The diet at discharge represented almost 2 gm. protein
and 36 calories per kg., reduced by the weekly fast-days to 1.7 gm. protein and
31 calories average.

Syphilis. — The diet was purposely raised to the verge of tolerance, partly be-
cause of the mildness of the case, but chiefly with a view to testing the effect of
syphilitic treatment. In hospital the patient received SO mercury inunctions,
each consisting of half a Parke Davis "mercurette." He was also given 4 in-
travenous doses of O.S gm. salvarsan. There were no reactions to the first
treatments, slight reactions to the later ones. After discharge, he was treated
with 50 more merciury inimctions of the same kind and 4 more salvarsan injec-
tions, which continued to cause slight reactions. The former -f 4- -H Wassermann



438 CHAPTER III

in the blood had become negative by Sept. 2. After return to Spain the patient
received treatment with neosalvarsan.

Subsequent History. — The patient went immediately upon discharge to a
nearby summer resort and adhered to the weighed diet. Glycosuria remained
absent. On July 12, sugar in whole blood was 0.145 per cent, in plasma 0.154
per cent; on Aug. IS, 0.132 per cent in whole blood, 0.151 per cent in plasma. The
patient complained slightly of chronic himger and weakness. An increase of
diet to 40 gm. carbohydrate and 2500 calories on July 25 resulted in slight traces
of glycosuria. A reduction was therefore made to 35 gm. carbohydrate and
2250 calories. The weight tended to fall; i.e., on July 12, 55 kg.; on July 25,
54.8 kg. In Oct. the patient returned to Spam, having a rough voyage and
showing glycosuria several times because of starch in the diet on shipboard. He
has tried to continue diet, but has not been successful in remaining sugar-free,
chiefly because of too high caloric intake, including alcohol.

Remarks. — Though syphihs is a possible etiologic factor in this case, it re-
sponded to dietetic treatment in the usual manner of a case of this type, whereas
antiluetic treatment, sufficiently thorough to render the Wassermann negative,
showed no appreciable influence upon the tolerance.

CASE NO. 68.

Male, age 23 mos. American Jew. Admitted June 13, 1916.

Family History. — Parents and one older brother living and well. A maternal
great grandmother and grandmother died of "old age diabetes" developing at
about the age of 75.

Past History. — ^A normal baby with never any iUness except an occasional slight
cold. Was entirely well when examined by a physician 3 months ago at time of
vaccination. Weight 1 month ago 25 povmds.

Present Illness. — ^About 1 month ago the baby was noticed to be not quite so
well, and hunger, thirst, and urine were increased. The diet had consisted of
cereals, vegetables, milk, cream, butter, and occasionally eggs. During this
month he has gradually lost about 5 poimds, but seemed bright and playful and
not iU enough to cause worry. 4 days ago (June 9) it was noticed that the breath-
ing was abnormally deep. Thereafter he became fretful, imwell, and somnolent.'
The respiration by today became alarmingly deep and rapid, and a physician
diagnosed impending diabetic coma.

Physical Examination. — ^Height 86.4 cm. A normal child, still fairly well
nourished. Cheeks flushed. Marked air-himger. Mind clear. Tonsils enlarged,
but not acutely inflamed. A very few shot-like glands in neck and axillae. Re-
flexes normal. Wassermann negative. Examination otherwise negative. '

Treatment. — The child was admitted at 9:30 p.m., showing intense glycosxuia
and ketonuria, a trace of albimiin, and numerous casts. The data of the initial
period are shown in Table XXI.



CASE EECOEDS



'439



The child was restless and irritalilfi ..and refused to take liquid. jq£ any Kind.
The bowels were moved by enema. _. Food or liquids being violently resista^, soup
and water were given by stomach, tulie during the day, along with sodmnk (Siloride
and bicarbonate. The bicarbonate seemed to act rather promptly in ditnSi^ning
dyspnea." On the morning of Jime 14, the breathing and general cond^tionljhad
not changed appredably. By Jxme'15, the tondition seemed only slightly beiiter.
Probably Owing to thirst created by 'the salt, the child occasionally dra,idr"mter
voliiatarUy,; -but was still mostly treated by gavage. Albumin and casts dlfeap-
peared.'On" June 16,^ the condition was better, but food and drink" were jktiU
refused. On June 17, liquids were still given by tube, but the patient begaip to
ask for food. On June'W,"lDO gm: thrice cooked asparagus^were given." On June
20, vegetables representing 10 gm. carbohydrate brought a return of glycosuria.
On June"21, a"diet Of~eggs7;teavy cresm, thrice boiled vegetables,"and' «
beguUj but thetolerance was so low that 20 grn. protein caused glycosuria,
of about 300 calories were cbntinued, with occasional fast-days, and the as^mi
lation gradually improved, - -The-patient -was discharged on Oct. i^-th; paijints
having carefully learned the;method of diet. ■'' |

"^<;SfoiMl - 'WKile it Ts possible ffiaf simple fasting with fluids and'"silt wbuld
have -averted the threatened coma, the small iioses of alkah seemed to be ystih:tly
ibenmcial. iEven with the alkali the blood -bicarbonate was rather slow in ris iS.
The child- subsequently reniamed-fTee-f-r-eJB,;aeidosisr - F-romrSept-lS-t-b Oct. %
the total acetone inrthe blqod plasma varied between 5'and'9'mg;-^er 100 cc.U

Bteod Sugar.— Ti^~c^iTtsKows Me normilT^^^
An abnormaL-degree.' of .digestive hyperglyeemia. is npjL.exduded, |

Weight aM Nutrition. — Weight at admission 8.5 kg., at discharge 8.1 kg.
the firsf2 months the diet- was approximately IS to- 20 gm. protein- iand
. |calortes^aily, about 2 gm. protein and 40 calories per kg. The t6leran()e gri
iaily;rose, so, that at the end, 42 gm. "protein, 22.5 gm. carbo!hydrate7 and
iGaloHes-Gould-be-given,-(including loo. cc. milk) jraih-the'blD.od. sugar, remaining
as above shown. The diet j prescribed at discharge was 42| gm. protein, 15 •[
jcarbohydrate, and S'SO c'alones-CaboTir S-gm. protein andr^S^calories -per4cg.->7 I

Subsequent History. — The patient remained cheerful aiid well at home iand |f ree
'frbm'IgrycQsTinarrThe followml", bro;od: record was-ottained: On Oct-. - 20- -Ijlpod
jsiigar 0.125 per centj'plasiha' bicarbonate 60.7 per cent; on Nov. 20, '-blood siigar
0.I2S;pefxent7plpmrslIgar0.t3:3-perT:enr. - This fasting^^ a

jWarning of the begiiming - oi trouble- from: tfie excessive diet, which was ignoted.
INevertheless tHe'clinical condition coHtttmed apparently-favorable -mrtilan-atikck
of jgfippe at" Christmas. -:With thislie had'cou^h, feve#, 4ii^ heavy -glycosulria.
Ttepaifems7prtiaI!y"contfpfled-fhe:gl5'rosuria^
hastened to return the child .to the hospital. '■ :'.'■>

~5ecoMr^awmm;=^Jaiirl7-^^ kg.- The ferric chloride-reac-

jtion'Vas negative. "The ^cosuria' was s%ht, and ceased promptly on are-
jduced diet ofr 15 gm.iprotein^^and 160 calories, without fasting. Thiftwas rapidly
increased, and after an uneventful stay in hospital,1he patient was dismissed on












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441



442 CHAPTER ni

Jan. 24, 1917, weighing 8.1 kg., on a diet of 35 gm. protein, 10 gm. carbohydrate,
and 415 calories (4.3 gm. protein and 51 calories per kg., reduced by weekly fast-
days to 3.7 gm. protein and 44 calories average). For extraneous reasons no blood
analyses were performed.

Subsequent History. — The patient remained free from glycosuria except for
occasional slight traces, for which minor changes in diet were advised. The
weight on July 3 was still 8.1 kg. The diet was increased with a little bacon, and
glycosuria gradually developed. It did not cease on withdrawal of the bacon,
and the parents hesitated to employ fasting. One feature in the case was the
nervous strain which the prolonged invahdism of the child imposed upon the
mother. The course adopted therefore was to allow glycosxiria to continue on a
carbohydrate-free diet of 320 calories. The glycosuria remained moderate.
There was no serious acidosis, and the child was comfortaHe 'except for the pro-
gressive weakness. Death must occur before long.!"; It js noteworthy that the
tendency to acidosis seems to be no greater than in an adult.

Remarks. — The attempt to force a diabetic child to grow and develop on high
diet failed as usual. As the diet at first prescribed included milk and carbohydrate,
and was adequate in calories and liberal in protein, the possibihty of a specific
inability of a diabetic child to grow and develop properly is suggested.. Com-
parison of such a child with a normal chUd on an identical diet would be an

interesting and valuable experiment.

A diet as excessive as this, woiild quickly. bring disaster in any adult patient
with severe diabetes. It is only surprising that the baby was able to withstand
the injury so long. The record of blood sugars in -hospital illustrates- the fact



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 49 of 76)