Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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that absence of fasting hyperglycemia is not proof that the diet given is suita;ble.
Irrespective of any laboratory findings, downward progress cbutd'be eq)ected" with
certainty from such a strain upon a weakened metabolism. As usual^ithe^diet
which is not restricted at the outset from choice, is later restricted from neces-
sity. The child does not grow or thrive, and the only -result «f excessive-feed-
ing is the permanent injury produced. Whether downward progress is inevit-
able in an infant (as it probably often may be) or not, there Ts little doubt
that it can be delayed and both life and comfort longer maintained with a more
rational hmitation of food. J ' ~. '~~~~'. ; J

The failure to make the limitation, even on the appearance of warning hyper-
glycemia, long before the onset of glycosiuria, is anottefseHous' fault In the man-
agement, which either caused or hastened disaster. It leaves the question of
inevitable downward progress of infantile (Habetes undecided, and" merely proves
that such a patient does not possess any remarkable recuperative power on
account of his years. ~ ] ~ ~7



1" Coma death occurred early in Dec, 1917.



CASE EECOEDS 443

CASE NO. 69. '

Female, married, age 39 yrs. German Jew; housewife. Admitted Aug. 23,
1916.

Family History. — Father died of Bright's disease at 69. Mother died of cancer
of liver at 79. Patient has had five brothers and two sisters. Three brothers
are well; one has right-sided hemiplegia; one died of "creeping paralysis" at 49.
Both her sisters died in infancy of unknown cause. No known diabetes, gout,
obesity, tuberculosis, syphilis, or cancer elsewhere in family.

Past History. — A few ordinary childhood diseases. The only other illnesses
were two attacks of "vaginal cellulitis" in 1912 and 1914. The local swelling was
such that catheterization was necessary. The inguinal glands were tender and
there was temperature as high as 104.5° F. She has had a healthy hfe, always in or
near New York, but has been overwrought and neurotic and has tended to become
obese. She was married 14 years ago and has been separated from husband
for the past 4 years. She has been vmder strain as a housewife, directing a large
estabhshment. Menstruation normal, except for some hemorrhages in recent
years, said to be due to fibroids. No children; five miscarriages, all self -induced.
Venereal denied. No tobacco. Only a little wine occasionally. Food taken
very sparingly for a number of years in order to check the tendency to obesity.
Bowels regular until onset of diabetes.

Present Illness. — On Dec. 28, 1915, there was a distinct acute onset of marked
polyphagia, polydipsia, and polyuria. 2 weeks later, because of these and rapid
loss of weight and strength, a physician was consulted, who immediately diag-
nosed diabetes and referred her to an experienced internist. She spent most of
Feb. in a hospital under his care, and by fasting and very low diet became sugar-
free 5 days before leaving hospital. A nurse was with her for 10 days after dis-
charge, and freedom from glycosuria continued diuring'this time. Glycosuria
returned soon after the nurse discontinued supervision. Since then on several
occasions doctors are said to have given her up because of threatening coma. There
has been a tormenting pruritus vulvae. Much of her hair has fallen out. There
has been loss of weight as follows: Sept., 1915, weight 138 pounds; Dec, 129
pounds; Jime, 1916, 89 pounds; Aug., 1916, 82.5 pounds; i.e., a total loss of 55.5
pounds.

Physical Examination. — An emaciated, neurotic looking woman with sallow,
dry skin and anemic appearance, but no acute symptoms. She claims to be so
weak that she can scarcely move a limb, but tests show that she is not quite so
feeble. Eyes, mouth, and throat negative aside from pallor of mucous mem-
branes. Liver edge palpable 2 cm. below costal margin. Blood pressure 70
systolic, 50 diastohc. General lymph gland enlargement. Slight edema of legs
withvpittjing about ankles. Knee and Achilles jerks normal. Wassermann
reaction negative.

Treat^^nt.—The Ratient fasted Aug. 25 to Sept. 1 inclusive. In the subsequent
test with green vegetables, 10 to 20 gm. carbohydrate were tolerated on Sept. 2



444 CHAPTER III

and 3, but glycosuria appeared with 30 gm. on Sept. 4. Corresponding to this
low tolerance, it was necessary to employ very low carbohydrate-free diets there-
after. Apart from the severity of the diabetes, the greatest difficulty in hospital
resulted from her excessively neurotic nature. She was subject to fits of crying or
screaming and other irresponsible conduct, and though the condition improved
somewhat with relief from the diabetic symptoms, it was never satisfactory.
She was discharged on Nov. 27 with a view to continuing imdernutrition treatment
under her private physician.

Acidosis. — The highest ammonia nitrogen excretion was 1.81 gm., the lowest
plasma bicarbonate 42.7 per cent. This acidosis cleared up imder fasting without
alkali. Thereafter the CO2 capacity remained fully normal and the ammonia
output was only slightly elevated.

Blood Sugar. — The hyperglycemia of 0.344 per cent on the morning of Aug. 25
remained imchanged 24 hours later, then gradually diminished to 0.178 per cent
on the morning of Sept. 4. Thereafter, even on the extremely low diet employed,
it remained persistently high, the value of 0.156 per cent in the plasma in the last
analysis on Oct. 24 representing the lowest level observed. As usual with such
a degree of h3rperglycemia, traces of glycosuria readily occurred on any attempt
to increase the diet.

D:N Ratio.— Omitting the initial ratio of 4.5, evidently due to carbohydrate
of theformer diet, the ratios on the fast-days Aug. 25 to 28 were 2.12, 1 .85, 2. 12, 1.03.

Weight and Nutrition. — Weight at admission 37 kg., at discharge 35.7 kg.
Extreme undernutrition was necessary to control the severe diabetes during
the entire period of 100 days in hospital. The total intake was 2864 gm. protein
and 48,317 calories, or an average of 28.6 gm. protein and 483 calories daily. The
urinary nitrogen record is not complete enough to permit calculating the nitrogen
balance. Some of the figures for daily nitrogen output are conspicuously low;
e.g., 2.72 gm. urinary nitrogen on Sept. 5, and 2.62 gm. on Sept. 13. Neverthe-
less, there must necessarily have been a negative nitrogen balance. Between
Oct. 5 and 28, an experiment was performed showing the production of both
glycosuria and acidosis by addition of fat to the diet, as described in Chapter VI.
The diet at discharge was only 50 gm. protein, 10 gm. carbohydrate, and 730
calories, i.e. 1.4 gm. protein and 20 calories per kg., diminished by weekly
fast-days to 1.2 gm. protein and 17 calories average. The treatment was there-
fore incomplete, since the patient had not been brought into equilibrium. Even
with the extreme undernutrition required, she showed slight increase rather than
decrease in strength, especially subjectively.

Subsequent History. — The patient continued treatment for a period not exactly
known, and then was subjected to various diets by other physicians. She died
Feb. 23, 1917, supposedly in coma.

Remarks. — The diabetes was of genuinely great severity, and the psychopathic
disposition largely precluded success. More might have been accomplished by
stiU more stringent undernutrition, to control the symptoms more completely
within a shorter time, but the ultimate result must have been failure without
greater reliability on the part of the patient.



CASE RECORDS 445

CASE NO. 70.

Male, married, age 34 yrs. American; physician. Admitted Sept. 3, 1916.

Family History. — Mother once had a tumor of face, which was removed by
operation, and did not return; riature not known. She died of cardiorenal dis-
ease. Father living and well, aged 74. Two brothers are well. One sister died
of diphtheria in infancy.

Past History. — Healthy life in good hygienic surroundings. Measles in child-
hood. No illnesses, operations, or injuries since. Venereal denied. No ex-
cesses in food, alcohol, or tobacco. Never nervous. Life easy and pleasant
without financial or other worries. Normal weight 60 kg.

Present Illness. — Began in Sept., 1914, with polydipsia and polyuria, but no
polyphagia. The onset was apparently sudden and glycosuria was immediately
found. For a year he was on almost carbohydrate-free diet under experienced
care, with the usual quantitative restriction also in protein; nevertheless glycosuria
was never absent at any time. He has since become discouraged and therefore
has occasionally broken diet with bread or cake. During the past year he has
lost about 8 kg. weight.

Physical Examination. — A tallj extremely emaciated young man. Skin very
dry. Hair thinning rapidly. Gums receding, though teeth are well kfept. Knee
jerks absent. Blood pressure 85 systolic, 65 diastohc. Examination otherwise
negative. Wassermann negative.

Treatment. — The severity of the case and the results of initial treatment are
shown in Table XXII.

In the subsequent period on green vegetables, traces of glycosuria appeared
when the intake reached 100 gm. carbohydrate. Mixed diet was then rather rap-
idly built up, and the patient was discharged on Oct. 16 feeling much improved
in strength and comfort.

Acidosis. — The rapid clearing of the rather threatening acidosis on fasting
without alkali is shown in the table. By Sept. 17, the plasma bicarbonate had
reached 61.4 per cent, and acidosis remained absent thereafter, the plasma bi-
carbonate at the last analysis on Oct. 13 being 70.6 per cent. Analyses for
acetone bodies in the plasma were made on 11 days at irregular intervals. The
highest finding was 39 mg. total acetone per 100 cc. plasma on Sept. 29. Dim-
inution followed, so that on Oct. 13 the total acetone was 11 mg. per 100 cc.
plasma. The ammonia excretion in the last analyses up to Oct. 11 was 0.51 to
0.88 gm. daily.

Blood Sugar.— Though glycosuria was kept absent, hyperglycemia was present
most of the tune. From 0.143 per cent in whole blood and plasma on Sept. 17,
the blood sugar rose during the carbohydrate test to 0.213 per cent in whole
blood and 0.217 per cent in plasma on Sept. 24. It then gradually fell to 0.111
per cent in whole blood and 0.135 per cent in plasma on Oct. 9 and 0.100 per cent
in whole blood and 0.135 per cent in plasma on Oct. IL This was with 10 gm.
carbohydrate in the diet. With increase to 20 gm. carbohydrate daily, the final



446



CHAPTER in



analysis on Oct. 13 showed 0.179 per cent sugar in whole blood and 0.189 per cent
in plasma. The allowance was therefore diminished to 10 gm.

Weight and Nutrition.— Weight at admission 42.2 kg., at discharge 40.3 kg.
Edema was present at certain times in hospital, raising the weight as high as
44.8 kg. ; this subsided on salt-free diet. There was the usual gain in strength and
comfort with imdemutrition and reduction of weight. The diet at discharge
consisted of 70 gm. protein, 10 gm. carbohydrate, and 1500 calories; i.e., 1.7
gm. protein and 37 calories per kg., diminished by weekly fast-days to 1.4 gm.
protein and 32 calories average.

Subsequent History. — The patient remained comfortable and resumed his former
work. Slight glycosuria developed on two or three occasions, but was immedi-

TABLE XXII.



Date.


1916


Sept


4




S




6




7




8




9




10




11




12




13




14



Diet.



3.9

7.9






gm.

127 10

127 10

127 10

Fast-day.



0.4
1.5



10
20



1495
1495
1495



60

127



kg.

41.8

41.6

42.2

42.4

42.0

41.1

41.0

40

40.6

40.0

40.8



Urine.



1990
1780
1800
1780
1810
3370
2445
2420
2340
3540
2150



42.8
31.2
33.3
16.2

5.8

+

+











4.82
5.20
4.78
6.86
4.12



1.41
1.76
0.93
1.11
1.04
1.32
0.58



M U

U 01



++++

+++
+++

++

+

+

+





Blood plasma.



per
cent

0.294
0.291
0.238

0.208
0.175



o
o



vol.
per cent

39.1
42.1
51.0

55.7
52.2



ately checked by a fast-day. There was a further sUght diminution in weight. On
Dec. 19, an apparently sUght attack of influenza began. He was still up and
attending to regular duties imtil Dec. 23, when severe cough developed, and fever
and weakness forced him to go to bed. The highest temperature was 100.5°. The
weakness increased, and on Jan. 1 the respiration was noticeably rapid, the pulse
rapid and weak; unconsciousness came on about 3 p.m., and death occurred on the
morniug of Jan. 2, 1917. The local physician who attended him attributed the
death to infection and not to diabetes, and no urine examinations were made
after Dec. 23.

Remarks. — It seems possible that the terminal condition was really diabetic
acidosis of the fasting type, since the patient was eating practically nothing on
the final days and the tendency to acidosis with even a slight infection is well



CASE RECORDS 447

known. If this were the case, there might have been a chance of preventing the
death by simple measures. The patient may have fallen a victim to a simple
influenza infection by reason of his somewhat weakened condition, but the de-
sirability of consultation with someone having experience with diabetes is indicated
in conditions of this sort.

CASE NO. 71.

Male, age 9 yrs. American. Admitted Oct. 30, 1916.

Family History. — ^No diabetic or other heritable disease.

Past History. — Normal and vigorous child, with no known infections or illness
of any kind.

Present Illness. — 2 years ago, mother began to notice poljfphagia and polyuria
with bed-wetting. He received early treatment from Dr. Joslin in Boston, and
subsequently came to New York. Under the treatment he was continuously well
and sugar-free, playing like a normal boy and going to parties, always taking his
own food with hun. About the 1st of Sept. he was detected in the practice of
going downstairs at night to take forbidden food from the pantry. Heavy gly-
cosuria thus came on, which was not controlled by his New York physician.
Progress was rapidly downward, and recently there has been marked and increas-
ing drowsiness.

Physical Examination. — ^A fairly developed, moderately emaciated boy, stupor-
ous but not unconscious, with deep rapid grunting respiration, 30 per minute.
Temperature 96° F, pulse 124. Mouth and throat normal. No lymph node
enlargements. Abdomen rounded with tympanites. Testicles undescended.
Knee and Achilles jerks absent. Examination otherwise negative.

Treatment. — The cUnical record can be summarized in Table XXIII.

The patient was admitted at 12:50 p.m., Oct. 30. He could still be roused,
but immediately went to sleep. The stomach was washed out to remove remains
of previous food, and 30 cc. castor oil, 5 gm. sodium bicarbonate, and 200 cc.
water were given through the tube. A high colon irrigation removed considerable
feces and relieved tympanites. The bowels subsequently moved several times as
the result of the castor oil. The temperature fell at first to 95.6°, but with appli-
cation of heat gradually rose to normal by midnight. Notwithstanding fasting
and 20 gm. sodimn bicarbonate, the CO2 capacity of the plasma on Oct. 31 was the
same as at admission, and the patient was in full coma. The same treatment of
fasting with liquids and bicarbonate by stomach tube was continued, and on
Nov. 1 the patient became able to imderstand what was said to him aind to drink
voluntarily. On the following days he was conscious but not fully rational, and
more or less hyperpnea persisted.

After 6 days of fasting, glycosuria was still present, sugar and ketones in the
blood were higher than before, and the strength was plainly becoming exhausted.
Accordingly, on Nov. 6, food was given to the extent of two eggs and 5 gm. carbo-
hydrate in green vegetables, and on Nov. 7 a slightly higher diet. Bed sores
began to develop at this time, and death from weakness threatened. Therefore





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449



450 CHAPTER in

on Nov. 7, 200 cc. blood were taken from the father into sodium citrate, and in-
fused into the patient. The only result was a temporary improvement of
strength. Unconsciousness gradually came on, and death occurred at 10 a.m.
Nov. 8 in coma.

Acidosis. — The tirine gave no adequate indication of the degree of acidosis.
On the other hand, acetone bodies accumulated in the blood to a remarkable
degree, as if the renal elimination were defective. This renal impermeability was
perhaps of decisive influence for the fatal result. Albuminuria and casts were
present, as usual in such a condition. Food, even though smaE in amount and
composed largely of protein and carbohydrate with Uttle fat, was followed by a
return of coma. Of course, it cannot be said positively that coma might not
have returned even with fasting.

There is no chemical explanation for the death. The blood bicarbonate on
Oct. 31, the child being in coma, was identical with that on Oct. 30, when coma
was still absent. It was comparatively high on the days when coma was partially
reUeved, but was also far above the ordinary danger level up to the last determi-
nation. On the other hand, the acetone bodies in the plasma on Oct. 31, with coma
present, showed only twice the concentration present on Oct. 30 before coma; but
they rose as coma subsided, so that on Nov. 4, with coma symptoms mostly
absent, the concentration was over twice that on Oct. 31; with coma present.
Diminution of the ketonemia then followed as the clinical condition became worse,
though the figures remained high to the end.

Lipemia. — The high Hpemia at the outset was one of the striking features. It
diminished imder fasting, and though later analyses were not performed, the
plasma in the closing days was clear.

Blood Sugar. — This also was very high in proportion to the glycosuria. Such
an apparent renal impermeability for sugar may perhaps be a disturbing influence
in the attempt to reckon dextrose-nitrogen ratios. Except for such impermea-
biUty, high and perhaps maximal ratios might have been found. Also, the child
might have been better off if he could have excreted both sugar and acids freely.
The relatively low blood sugar of Nov. 1 is remarkable in comparison with all the
other figures. Otherwise the blood sugar changed Kttle or even incraesed sUghtly
on fasting.

Body Weight. — There was not the precipitous fall in weight characteristic of
fasting coma and desiccation. On the other hand, bicarbonate did not cause
edema. The total loss of 2.1 kg. weight is adequately accounted for by the pro-
longed fasting and rather free purgation, without the assumption of any abnor-
mahty of the water balance.

Remarks. — The child went into complete coma before fasting had time to exert
much influence. He then came out of coma and apparently might have been
saved if the strength had held out.

The treatment has not been satisfactorily worked out for patients with either
dangerous weakness or extreme intensity of intoxication. With regard to alkali,
some would employ larger dosage, while Joslin suspects an injurious effect and



CASE RECORDS 451

would perhaps suggest that the great increase of acetone bodies in the blood repre-
sented such a harmful influence of the alkali. With regard to diet, there are the
possibilities of simple fasting, carbohydrate feeding, and protein feeding. Fasting
alone often fails in this extreme condition. Carbohydrate perhaps could not be
burned at all, and the possible hyperglycemia consequent upon any large dosage
of carbohydrate, with the blood sugar aheady 0.5 per cent and poor excretory
power, presents a serious question. Pure protein diet might maintain strength
and furnish ammonia to neutralize acids. At the same time it might aggravate
the diabetes and nulhfy the possible benefit derivable from fasting. Various
persons will hold various opinions, but the fact remains that while impending coma
of ordinary type is generally readily cleared up, the patients presenting this excep-
tionally severe condition generally die.

With regard to the cause of death, the evidence in this case excludes the sup-
position of simple acid intoxication or deficit of alkali. Some may seek the ex-
planation in the toxicity of certain substances of the acetone group. Others may
see the cause in possible precursors of acetone bodies in the tissues. The, expla-
nation is wholly undecided. It is possible that no one substance is responsible,
but that death results from a more general alteration of cellular metabolism and
protoplasm.

CASE NO. 72.

Female, age 12 yrs. American; schoolgirl. Admitted Nov. 16, 1916.

Family History. — Parents hving; mother rather sickly, cause unknown. One
brother died in infancy. Two brothers and one sister are well. No diabetes
or other hereditary diseases known.

Past History. — Measles, mumps, and possibly chicken-pox. No infections re-
cently. Normal development, health, and habits.

Present Illness. — Patient began to feel unwell about a year ago, and a physician
diagnosed diabetes. She has since been on starch-poor, fat-rich diet, and applied
at the Institute on account of progressive weakness especially during the last 2
months.

Physical Examination. — ^A well developed, fairly well nourished child; high
color in cheeks; sUght edema of eyeUds and ankles. Deep rapid respiration sug-
gesting air-htmger. Tongue red and dry. Teeth poorly kept, two decayed;
pyorrhea present. Enlarged lymph nodes on both sides of neck. Knee jerks
very feeble. Examination otherwise negative.

Treatment. — At admission temperature was 100.2°, pulse 120, respiration 24.
After the first 24 hours the temperature remained between 98 and 99, pulse about
80, respiration 18 to 20. The data of this period in hospital are shown in Table
XXIV. No alkaU was used.

The case was rather unusual-in its slowness in clearing up. The only special
incident in hospital was the uneventful removal of the two carious teeth. Com-
plete control of the diabetes was never achieved, as shown especially by the
persistent hyperglycemia. The patient was discharged Dec. 23, 1916, on a diet
of SO gm. protein, 10 gm. carbohydrate, and 600 calories.



452



CHAPTER ni





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Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 50 of 76)