Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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454 CHAPTER III

Subsequent History.— Tht patient felt fairly well, played about with her friends,
and led an approximately normal life. Sugar and ferric chloride reactions
gradually returned about Mar. Particularly on Mar. 9, it is suspected that
candy was obtained surreptitiously, and later in that day shortness of breath
and drowsiness developed. On the morning of Mar. 10, these had increased and
nausea had come on, which prevented eating, but water was stiU taken in large
quantities on account of thirst.

Second Admission. — 11 :20 p.m.. Mar. 10, 1917. Child pale, with flushed cheeks,
semiconscious and delirious, in tjrpical diabetic coma. Temperature 96.8°,
pulse 97, respiration 36. Otherwise appearance and examination as before.

In addition to the usual urinary reactions, it was found that the CO2 capacity
of the plasma was 14 per cent, and the total acetone of the plasma 54.5 mg. per
100 cc. The stomach was washed out, and 20 cc. castor oil and 5 gm. sodium bi-
carbonate were given through the tube. A saline enema had Httle result. Sodium
bicarbonate was continued in 5 gm. doses, so that 25 gm. had been taken by 6
a.m. The coma gradually became deeper. The temperature gradually rose to
100°, the pulse to 138, the respiration rate remained 36 to 38. Death occurred
at 6:50 a.m. A blood sample taken shortly before death showed plasma bicar-
bonate 17 per cent and total plasma acetone 97.8 mg. per 100 cc.

Remarks. — ^With diabetes of this severity only imperfectly controlled by treat-
ment, downward progress is inevitable. The case illustrates the necessity of
prolonged and thorough hospital treatment if any results worth while are to be
achieved in the severest diabetes, though it is possible that any dietetic method
would have been inadequate to save this patient.

In connection with the rapid premortal rise of acetone bodies in the blood, the
question may be raised whether this was due to the administration of alkaU, and
whether sodium bicarbonate was harmful in this case. Similar premortal increase
of circulating acetone has been observed in patients receiving no alkali.

CASE NO. 73.

Female, age 3 jrrs. American. Admitted Dec. 18, 1916.

Family History. — Negative except for glycosuria in a paternal grandfather.

Past History. — Entirely healthy life; no known infection. Habits normal.

Present Illness. — ^About 1 year ago, thirst and loss of weight attracted notice,
and the patient then received fasting treatment for 3 weeks in a hospital under
the best care (Dec, 1915). Glycosuria was abolished and the tolerance was high,
so that she was finally able to take 46 gm. protein, 24 gm. carbohydrate, and 1000
calories. Only occasional traces of glycosuria appeared on this diet at home
until Oct., 1916. Since then glycosuria has occurred every 3 or 4 days, despite
increasing strictness of diet. The diet before entry contained 25 gm. protein,
5 gm. carbohydrate, and 430 calories.

Physical Examination.'^— Titi^t 88.6 cm. A poorly developed, emaciated, pale
and pinched looking child, without acute symptoms. Mouth and throat normal.



CASE RECORDS 455

Abdomen slightly distended, but soft. No lymph node enlargements. Exami-
nation otherwise negative.

Treatment. — Glycosuria was very slight and the ferric chloride reaction negative.
The traces of sugar persisted, however, not only on 25 gm. protein and 420 calories
but even on 20 gm. protein and as little as 250 calories. In a tolerance test with
green vegetables, increasing by 5 gm. carbohydrate daily, glycosuria was absent
with 20 gm., but appeared with 25 gm. carbohydrate. With gradual undernu-
trition the food tolerance rose slightly, and the patient was disch^fged on Apr. 7,
1917, free from diabetic symptoms but not otherwise improved.

Acidosis. — By reason of the former treatment, this was never present. The
plasma bicarbonate was normal, and the ammonia nitrogen on carbohydrate-free
diet was about 0.084 to 0.42 gm. daily, with total nitrogen output of some 3 to
5gm.

Blood Sugar. — This was 0.245 per cent at admission, and was not appreciably
affected by treatment, even though freedom from glycosuria was achieved.

Weight and Nutrition. — Weight at admission 9.8 kg., at discharge 8.9 kg. With
gradual undernutrition the patient became able in Jan. to take a diet of 22 gm.
protein and 350 calories. It gradually became possible to increase this and also
to introduce carbohydrate, so that she was discharged on a prescribed diet of 28
gm. protein, 7.5 gm. carbohydrate, and 550 calories (3.2 gm. protein and 62
calories per kg., reduced by weekly fast-days to 2.7 gm. protein and 53 calories
average). The carbohydrate was in the form of milk, and no reckoning was made
of the 300 gm. thrice cooked vegetables. The child showed no injury from the
0.9 kjg. loss of weight whUe in hospital, but on the other hand was no stronger,
and remaitted pale and puny, fairly comfortable, yet with her mind fixed on her
diet, Uke a severely diabetic adult.

Subsequent History. — Only rare traces of glycosuria have occurred at home.
There has been no sign of downward progress; neither has there been improvement
in tolerance, or anything resembling normal development. The small patient
merely leads an existence of semi-invalidism. She has recently been readmitted,
and the blood sugar brought to normal by the method described in Chapter II.
It is of interest that this was possible in a case of such extreme severity, but the
ultimate result is still doubtful.

Remarks. — The case is one of the severest and most hopeless examples of juve-
nile diabetes. There has been no improvement in assimilation. The ability to
remain free from glycosuria on a higher diet than at admission has merely been
purchased at the price of the sUghtly reduced weight. With regard to the ques-
tion of "spontaneous downward progress" in children, it is instructive to note
what a great loss of tolerance took place within 10 months on high caloric diet,
while no downward progress has been perceptible in the past 10 months on low
diet, even though the diabetes in the latter period is at a much more severe stage
than before.



456 CHAPTER rn

CASE NO. 74.

Male, unmarried, age 23 yrs. American; plumber. Admitted Feb. 1, 1917.

Family History. — Mother died from an operation of unknown character.
Father and two brothers are well. No diabetes or other heritable disease known
in family.

Past History. — Thoroughly healthy hfe. Never ill to his knowledge, even
with childhood diseases. Appetite, diet, digestion, and bowels normal. No
alcohol; moderate tobacco. Never had a medical examination before.

Present Illness. — 1 year ago began weakness and excessive thirst. He con-
sulted a physician within a month but received only a very lax diet sUp. 7 months
age he was forced to give up work and has continued to grow weaker. He has
lost about 45 poimds in aU.

Physical Examination. — Height 173.8 cm. A rather poorly developed, emaci-
ated yoimg man. Skin dry and pale. Perceptibly but not seriously drowsy.
Mouth and throat normal. Knee jerks absent. Wassermaim reaction nega-
tive. General examination negative.

Treatment. — Fasting was begun immediately and continued Feb. 1 to 4 in
elusive. 10 and 20 gm. carbohydrate were tolerated on Feb. 5 and 6, but 30
gm. caused glycosuria on Feb. 7, which increased with 40 gm. on Feb. 8. There-
after the diet was rather rapidly buUt up, and on 60 gm. protein and 1100 calories
there was decided improvement in general condition. In another green vegetable
period beginning Mar. 19, 100 gm. carbohydrate were tolerated without glyco-
suria. The weight at this time was down to 40 kg. The improvement continued
on an increased diet of 65 gm. protein, 10 gm. carbohydrate, and 1450 calories.
The patient was discharged on Apr. 27, 1917, much improved, though stiU not
strong enough to return to his regular work.

Acidosis. — The plasma bicarbonate of 36 per cent at admission rose steadily
without the aid of alkali to 55 per cent on Feb. 3, 57 per cent on Feb. 5, and 73
per cent on Feb. 8. Thereafter it remained at a high normal level. Ammonia
determinations were not made at first, so the highest ammonia nitrogen observed
was that of 2 gm. on Feb. 5. The ferric chloride reaction of the urine was only
slight at admission, diminished to traces on the first fast-day, and thereafter was
negative. Nevertheless, the anunonia nitrogen remained stubbornly elevated,
frequently as high as 1.5 gm. daily, except for a fall as low as 0.45 gm. during
the second carbohydrate test. At discharge it was still 0.8 to 1.4 gm. daily.
The ammonia excretion was therefore the most delicate index of acidosis and at
the same time evidence of an unduly high fat ration.

Blood Sugar. — The sugar in the plasma was 0.377 per cent at admission, 0.290
per cent on the morning of the second fast-day, and thereafter gradually dimin-
ished to its lowest level of 0.137 per cent at the last analysis on Apr. 14. These
values obtained mornings before breakfast showed that the hyperglycemia was
inadequately controlled, though the tendency was in the right direction.



CASE RECORDS 457

Weight and Nutrition. — Weight at admission 43.6 kg. Lowest weight 40 kg.
The diet of 65 gm. protein, 10 gm. carbohydrate, and 1450 calories at discharge
thus represented 1.5 gm. protein and 33 calories per kg., diminished by the
weekly fast-days to 1.3 gm. protein and 28 calories average.

Subsequent History. — The patient contracted a cold with heavy cough 3 days
after leaving hospital. He adhered to his diet and remained free from glycosuria,
but cough and weakness increased. He returned to report on May 29, 1917, and
was immediately readmitted.

Second Admission. — The patient was more emaciated and much weaker than
before. Weight 38.6 kg. Sugar and ferric chloride reactions negative; COj
capacity of plasma 64 per cent. He was kept in hospital until June 13, and on
carbohydrate-free diet of 75 gm. protein and 1500 calories showed neither gly-
cosuria nor dangerous acidosis. The ammonia excretion was about 1 gm. daily.
The temperature during the first 4 days in hospital was 102 to 103° F., there-
after 101°. Cough persisted. Physical examinations revealed nothing in the
right lung beyond fine moist rales at the base. Over the left lung there was
dulness from the apex to the fourth rib in front, to the fifth interspace in the
axilla, and to the middle part of the infraspinous region behind, with bronchial
breathing and coarse and fine moist rales. X-ray plates and the finding of tubercle
bacilli confirmed the diagnosis. As such a patient could not be kept long, he
had to be mioved on June 13 to a public hospital, and died on July 3.

Remarks. — ^The susceptibility of diabetic patients to tuberculosis is well known,
and this patient's weakened condition doubtless impaired his resistance to the
disease. The slight or absent influence of the infection and fever in producing
glycosuria or acidosis is noteworthy. With tuberculosis of this grade and such
severity of diabetes, the prognosis was necessarily hopeless.

CASE NO. 75.

Male, vmmarried, age 33 yrs. Irish Canadian; teamster. Admitted Feb. 21,
1917.

Family History. — Father died at 65, cause imknown. Mother alive, aged 60.
Three brothers and two sisters are well. As far as known, a perfectly healthy
family of laboring class.

Past History. — Measles and mumps in childhood. Never ill since. Venereal
denied. Patient is slight in build, but tough and wiry. Has lived rough out-
door life with heavy work as a teamster in Hudson Bay district. Thus had a
very high caloric diet, but well balanced. He has taken 5 or 6 drinks of whisky
or beer daily.

Present Illness.— In June, 1914, patient noticed polydipsia and polyuria with-
out polyphagia. Principal trouble was that all his teeth loosened and fell out.
Smce then he has been most of the time under fasting treatment at the Victoria
General Hospital at Halifax. He has been kept alive for this time, but the normal
weight of 130 pounds has fallen to 89 pounds. He was referred to this Insti-



458 CHAPTER ni

tute because of the great severity of his case, making it almost impossible to
keep him sugar-free on any living diet.

Physical Examination.— Kei^t 162.4 cm. A short, slight, small-boned young
man, extremely emaciated, but still cheerful, alert, and with a look of strong
constitution and unlimited resisting power. He still shows indications of his
former weather beaten life and sinewy musculature. There is a peculiar icteric
tinge to the skin of the face and thorax, while conjunctiva are clear. Hair thin
and dry. Teeth missing. Throat normal. Blood pressure 110 systolic, 80
diastolic. Knee jerks not obtainable even with reinforcement. Examination
otherwise negative.

Treatment. — He made the trip from Halifax to New York in this condition unat-
tended, and had the misfortune to be detained for a week by the immigration
officials. As he could not during this time receive suitable treatment, it was ad-
vised that he be fed protein and carbohydrate with as little fat as possible. Con-
sequently, he finally arrived at the hospital with heavy glycosuria; but with no
acidosis beyond a trace of ferric chloride reaction. On an observation diet of SO
gm. protein, 10 gm. carbohydrate, and 600 calories, glycosuria remained heavy.
Fasting was therefore begun on Feb. 23. Glycosuria ceased in 3 days, but the
fast was continued for 5 days. The tolerance was evidently too low to make an
attempt at a carbohydrate test worth while. Accordingly, the first food (Feb.
28) consisted of two eggs, with coffee, soup, bran, and 300 gm. thrice boiled vege-
tables. This diet was increased until on Mar. 8 glycosuria appeared on 60 gm.
protein and 800 calories. The patient is still in the hospital, and the tolerance
has gradually improved under treatment, so that he has sometimes for brief
periods taken diets as high as 95 gm. protein and 32O0 calories (fat and alcohol)
with little or no glycosuria. The opportunity has been taken of shifting the
diet in various ways for experimental purposes. The data are partly given in
Chapter VI.

Acidosis. — This has remained absent, except as slight ketonuria has been
deliberately produced and abolished at times in the course of experiments.

Blood Sugar. — Hyperglycemia, though not excessive (0.2 to 0.3 per cent)
proved stubborn, as usual in such a case. It has been more marked when the
true tolerance was experimentally exceeded. Nevertheless, it has since been
shown that the plasma sugar even in this case can be brought fully to normal
(0.066 to 0.11 per cent). Whether it can be made to remain so and whether the
cHnical result wiE be beneficial is an important question.

Weight and Nutrition. — The weight at entrance was 37.6 kg. Under treatment,
it touched a minimum of 33.4 kg. on Mar. 20. It has since been possible to
increase the weight to 38.8 kg. with no more than faint glycosuria (Aug. 14, 1917),
but it will again be reduced therapeutically. There has been no perceptible
edema. The diet has varied widely for experimental reasons, but has never
included more than 20 gm. carbohydrate. The above mentioned high diets must
be understood as only brief and experimental, and clearly injurious if continued.
In general the diet is a low maintenance ration in proportion to the emaciated
condition.



CASE RECORDS 459

Remarks. — The absence of knee jerks is supposedly attributable to neuritis or
some other nervous disorder, for, in contrast to the rule with most emaciated
diabetics, the muscles are not relaxed in this patient. He has remaiued clmicaUy
the same as at admission, always cheerful and alert, always feeling a Uttle hungry
and sometimes decidedly so, and as active as the fuel value of his diet permits.
He is thus up and about all day long, occupied with reading or other recreation,
and able to go on walks and visits outside the hospital when desired. He can-
not Hve outside an institution, partly on account of lack of education. The
diabetes is in the extreme stage where true recovery of assimilation has never
been known to occur. But during 9 months in hospital there has been not the
slightest indication of "spontaneous downward progress."

CASE NO. 76.

Male, age 4 yrs. American. Admitted Mar. 9, 1917.

Family History. — ^A maternal grandaunt and cousin had diabetes at the
time of their deaths, aged 55 and 60 years respectively. The famUy history is
otherwise negative for heritable disease. Parents and three older brothers of
patient are well.

Past History. — ^Normal birth. Breast fed for 9 months; always perfectly
healthy, mild whooping-cough being the only disease ever suspected. He took
a prize as a most perfect baby a year or so before onset of diabetes.

Present Illness. — ^An earache occurred on Feb. 17, 1917. A physician found
the temperature 103° F. With simple warm applications the pain promptly
subsided, and the ear has been normal since. On Feb. 22 the boy, still appearing
and feeling entirely well, was target shooting with his father, and intense polyuria
was noticed, the father saying that the boy urinated every 15 minutes. He
was immediately taken to the family physician, who made no diagnosis, but the
father is convinced that the urine was tested only for albumin. In addition to
intense polydipsia and polyuria, rapid loss of flesh was noticed, though the
amount was not determined by weight. As the family physician continued to
make Ught of the trouble, the father insisted on taking the boy on Mar. 6 to a
New York pathologist, who found glycosuria of about 8 per cent and positive



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