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acetone reactions, and gave a prognosis of only a few months of Ufe. The family
physician then prescribed an antidiabetic diet with some oatmeal, and 2 days
later the boy was brought to this hospital.

Physical Examination. — Height 106.6 cm. The child is an admirable physical
specimen, fully developed and still well nourished, handsome, but with a pale
waxen beauty and listless apathetic behavior which augur badly. Axillary and
epitrochlear glands palpable. Reflexes lively. Blood pressure 90 systolic, 70
diastolic. Wassermann reaction negative. Physical examination normal.

Treatment. — The urine at admission showed only sHght sugar and ferric chloride
reactions. Fasting was begun immediately. The sugar immediately fell too low
to titrate, and was absent after 24 hours. After 2 days of fasting a carbohydrate
tolerance test was begun. On Mar. 21, 82.5 gm. carbohydrate were taken with-



460 CHAPTER ni

out glycosuria, but 90 gm. on the next day resulted in glycosuria. A mixed
diet was then gradually bxiilt up, and the patient showed no more glycosuria
up to his discharge on May 8, 1917.

Acidosis. — This was limited to slight ferric chloride reactions, and ammonia
excretion of 1.16 gm. daily. There were no clinical symptoms or lowering of the
plasma bicarbonate. During the carbohydrate tolerance test the ammonia
output fell as low as 0.05 gm., and there was no further evidence of acidosis.

Blood Sugar. — The usual hyperglycemia was present at admission. In sub-
sequent treatment the blood sugar was made and kept normal throughout.

Weight and Nutrition. — ^Weight at admission 15 kg., at discharge 14.4 kg.;
i.e., undernutrition to the extent of 0.6 kg. altogether. The diet was gradually
built up to SO gm. protein, 65 gm. carbohydrate (25 gm. in milk, 30 gm. in bread,
the rest in vegetables), and 900 calories. This represented nearly 3.5 gm. pro-
tein and 63 calories per kg., diminished by the weekly fast-days to about 3 gm.
protein and 54 calories per kg. The child still appeared normal and well nour-
ished but remained somewhat depressed.

Subseqiient History. — The patient lived his regular normal life with the other
children at home, spending most of every day in lively outdoor exercise. With
this his strength and spirits improved while the luine tests, in four periods every
day, remained continuously negative for sugar. Perhaps on account of the
exercise the weight remained stationary. He seemed to be in favorable condition
and steadily improving, and was readmitted to hospital on Sept. 12, 1917, solely
for observation. One noteworthy feature of both earlier and later stages of the
history has been the occurrence of occasional digestive upsets from slight or
imknown causes. The question of pancreatitis is open.

Second Admission. — Height 107.5 cm. j i.e., a growth of 0.9 cm. since first
admission. Weight 14.7 kg.; i.e., a gain of 0.3 kg. since discharge. On his pre-
scribed diet the blood sugar was normal (0.067 to 0.099 per cent) in repeated tests,
both fasting and at different periods of digestion. A carbohydrate tolerance
test by the usual method resulted in a trace of glycosuria only with 250 gm.
carbohydrate. It is not fully certain that improvement to this degree had actu-
ally occurred, for it is possible that the 90 gm. taken in the former test may
not have represented the true limit of tolerance at that time. The patient was
discharged Oct. 16, 1917, weighing 14.4 kg. (the same as at the former discharge)
with both urine and blood normal in all respects. The prescribed diet was 55
gm. protein, 80 gm. carbohydrate, and 980 calories, representing 3.8 gm. pro-
tein and 68 calories per kg., diminished by weekly fast-days to about 3.3 gm. pro-
tein and 58 calories average. This diet is permitted with the idea of permitting
the boy to grow if possible. A close watch is being kept, and any appearance of
slight hyperglycemia will be the signal for a reduction of diet. The carbohydrate
has since been increased to 100 gm., and the child is growing steadily, the blood
sugar remaining normal.

Remarks. — The case was received at a favorably early stage, and the treatment
has been followed with the utmost fidelity. The result in this 4 year old patient
is favorable to date.



CHAPTER IV.
PANCREAS FEEDING.

Since so many factors, dietary, psychic, and others, influence the
glycosuria in most cases of diabetes, the only valid material for testing
the specific influence of any therapeutic agent must consist of cases in
which the food tolerance is accurately known under exact dietetic
management for considerable periods of time. The use of drugs and
other agencies credited with power to influence diabetes has never
been supported by reliable tests of this character. Since diabetes is
accepted as a deficiency of the internal secretion of the pancreas, and
since a few other internal secretory deficiencies can be more or less
compensated by administering preparations of the organ in question,
the attempt to supply the internal pancreatic secretion in this manner
has appealed to investigators since the time of von Mering and Min-
kowski. Such attempts have uniformly failed in both animals and
patients. It seemed worth while, if only for the sake of negative
results, to make a few tests with the administration of fresh pancreas
to patients whose assimilative power was accurately known. As pan-
creas preparations are toxic when admim'stered parenterally, the fresh
gland was given by feeding.

By reference to the graphic chart of patient No. 1 (Chapter III) it
will be seen that diets of 75 to 100 gm. carbohydrate and 40 to 60 gm.
protein had been tolerated in May and June without glycosuria, or
with only small quantities of glycosuria toward the close of June as the
calories were increased by addition of fat. Pancreas feeding was
tried for a week, following the fast-day of July 9. The diet was the
same as during the previous 2 months; viz., nothing but vegetables
with the addition of a little cream, butter, or bacon on certain days.
The calories were thus kept very low and the only protein, aside from
that of the green vegetables, was in the form of pancreas. This con-
sisted of 100 gm. pancreas on July 10, 150 gm. daily on July 11-12,
and 200 gm. daily on July 13-14. The pancreas was obtained fresh

461



462 CHAPTER IV

from the slaughter house each day, so that the first portions were
eaten only a few hours after kiUing, and that taken at supper was still
less than 12 hours old. The pancreas was kept on ice except during
the messenger's trip, and was served raw with vegetables in the form
of a salad. It can be seen from the graphic chart that glycosuria was
absent with 80 gm. carbohydrate on July 10 and with 117 gm. carbo-
hydrate on July 11. On July 12, with 143 gm. carbohydrate, there
was glycosuria of 9.59 gm.; on July 13 with 92 gm. carbohydrate a
glycosuria of 5.54 gm.; on July 14 with 83 gm. carbohydrate, a glyco-
suria of 7.39 gm. This record may be compared with that of the pre-
ceding 2 months. For example, on May 23, 140 gm. carbohydrate
had been taken without glycosuria, and the total calories on that day
were higher than on any day during the pancreas period. There was
also no subsequent improvement of tolerance, owing to the week of
pancreas feeding, because, beginning July 16, diets somewhat lower in
carbohydrate, but with the addition of considerable fat, soon brought
on continuous glycosuria.

Patient No. 4, a 12 year old boy, developed a liking for raw pancreas,
and the opportunity was taken to carry out several feeding tests.
One series is described in detail in his history (Chapter III), and the
conclusion was there drawn that the pancreas did not improve the
carbohydrate tolerance to the extent of a trivial quantity of sugar,
and did not improve the protein tolerance to the extent of one egg.
Another test was undertaken in August and September. It will be
seen in the graphic chart (Chapter III) that there was a gradual in-
crease of carbohydrate-free diet beginning August 26. This diet
consisted of eggs, steak, olive oil, butter, and whisky, with no vege-
tables or other food. It will be noted that sugar and ferric chloride
reactions remained negative until the diet reached 58 gm. protein and
1300 calories on August 30. Ferric chloride reactions then developed,
followed by glycosuria of 0.75 gm. on September 1. The glycosuria
and ketonuria were continuous on the following days, until checked by
the alcohol days of September 5 and 6. Beginning September 7 a
similar carbohydrate-free diet was resumed, which on Septeniber 8
and 9 amounted to 60 gm. protein and 1600-f calories. On Septem-
ber 10, 100 gm. pancreas were substituted for the former 100 gm.
beefsteak. This happened to be the day on which a glycosuria of



PANCREAS FEEDING 463

0.32 gm. appeared. The pancreas was continued in the same quantity
on the subsequent days, and it is seen that glycosuria was continuous.
Also the ferric chloride reactions were actually heavier than before,
due doubtless to the gradual impairment of tolerance. It was neces-
sary on September 16 to stop this diet, and then two alcohol days were
inadequate to clear up this glycosuria and ketonuria which had de-
veloped on pancreas feeding. B eginning September 18, very low diets,
generally below 500 calories daily, were employed, and the attempt
was made to compare successive days of pancreas and steak feeding.
The results were interfered with because during this time the patient
obtained small quantities of food surreptitiously. All that can be said
is that these tests, which continued up to September 27, showed no
perceptible advantage of the pancreas. What is certain is that even
on these very low diets the pancreas feeding did not avail to prevent
glycosuria from even a few grams of bird-seed eaten by stealth.

The possibiHty was also considered that some portion of the benefit
in the way of improved assimilative power from fasting might be due
to the digestive rest involved. For example, it might be supposed
that the internal secretory function of the pancreas is more or less in-
hibited during activity of the external secretory process, while per-
haps the nervous, secretory, or glandular condition during the resting
state of the acinar tissue might be most favorable for the internal
secretory function. Inasmuch as the special stimulus to the formation
of pancreatic juice is furnished by the hydrochloric acid of the stom-
ach, experimental or practical results might be hoped for by admin-
istering food in some way which would not call forth acid secretion in
the stomach. Since rectal or parenteral feeding did not appear
promising, a trial was made with a tube like an ordinary Einhorn
duodenal tube, but over one meter in length, so that food might be
deHvered through it to a point low enough in the intestine to avoid
regurgitation into the stomach if possible, yet high enough up to per-
mit favorable absorption. Patient No. 8 was chosen as a suitable
subject. The method of procedure consisted in his swallowing the
tube slowly in the morning; after 2 or 3 hours the tube was generally
found in proper position for the first feeding, and was retained until
bedtime. The patient was very Kttle inconvenienced by the presence
of the tube. The position of the tube was tested in various ways:



464



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466 CHAPTER IV

by fluoroscopic examination for the oKve or injected bismuth paste;
by the character of the fluids aspirated; by the absence of the feeding
mixture from the stomach when the tube was withdrawn after the
last feeding; by the fact that air injected with the oUve in the stom-
ach was soon belched up, whereas with the olive in the intestine it
was before long passed by rectum; and, to some extent, by the sensa-
tions of the patient.

The mixture used for feeding consisted of an emulsion of eggs, olive
oil, and small quantities of sodium bicarbonate. On other days the
patient drank these same foods in the raw condition for comparison
with the results of tube feeding. Whisky was never given through
the tube but was always drunk in 10 cc. doses at intervals during the
day. This allowance of whisky could not impair the results, since
whisky used during fasting does not spoil the benefit of fasting. Some
details are supphed by Table I and in the graphic chart (Chapter
III).

It was evident that the feedings by tube did not cause glycosuria
to such an extent as lower diets taken by mouth, but weight was lost,
the patient was markedly weaker, the urinary nitrogen did not cor-
respond to the protein administered, and the feces though formed,
were unduly bulky, so that it seemed probable that the results were
due to poor absorption of the food given by tube. Accordingly, on
December 18 similar emulsions were given freshly mixed with pow-
dered commercial pancreatin. Acidosis was manifested not only by
the ammonia nitrogen above 1 gm. (notwithstanding the alkali dos-
age) but still more by weakness and malaise on the part of the patient.
Accordingly on December 19, oatmeal gruel representing 44 gm. carbo-
hydrate was added to the feeding mixture, with a view to testing both the
assimilation of carbohydrate administered by tube and the possibiUty of
any special virtues of oatmeal. Heavy glycosuria promptly resulted,
the ammonia excretion slightly increased, and a period of imdernutrition
was necessary to clear up the symptoms. On December 30-31 the
tube was retained by the patient both day and night for the purpose of
maximal feeding. Only two eggs were given on December 30 and none
on December 31 ; otherwise the feedings consisted of olive oil emulsified
with 5 gm. pancreatin and large quantities of extract of fresh pancreas.
Over 2 kilograms of pancreas were used for this purpose. The glands



PANCREAS FEEDING 467

from cattle were obtained within a few hours after slaughtering,
minced in a meat grinder, and then subjected to a pressure of 4000
pounds per square inch in a hydraulic press. The thick, almost pulpy
extract thus obtained was diluted slightly with water, and partly used
fresh. The soUd residue of the glands was incubated with water,
olive oil, and a trifle of sodium bicarbonate, and pressed again after
digestion. The emulsion of this material was also administered by
tube. Glycosuria and acidosis persisted, though apparently absorp-
tion of the material was poor. This large feeding caused only diarrhea
without benefit, and the experiment was therefore discontinued.

The experiments with feeding fresh pancreas confirm the accepted
view that it possesses no value in diabetic treatment As far as a con-
clusion is possible from the experiments with tube feeding, they indi-
cate that there is no benefit in this method. There is no evidence that
simple avoidance of the production of hydrochloric acid in the stom-
ach, or of stimulation of- the external secretion of the pancreas, has
any influence upon either glycosuria or acidosis in diabetes.



CHAPTER V.
EXERCISE.

The existing literature may be summarized as having led to con-
clusions as foUows: that in normal persons, moderate exercise slightly
elevates the blood sugar while severe exercise lowers it, but in either
case the sugar tolerance is increased; that in mild diabetes, exercise
may elevate the blood sugar even more than normally, but neverthe-
less the carbohydrate tolerance is raised; while in severe diabetes,
exercise can no longer improve tolerance and must be avoided be-
cause of exhaustion of the patient and dangerous increase of acidosis.
The onset of coma after slight or severe exertion has especially been
known and drea4ed.

The use of exercise in the present work was based upon experiments
on dogs, which were carried out with the necessary completeness and
controls, and will be published in detail in the near future. Though
circumstances prevented carr3dng out corresponding comprehensive
tests upon patients, nevertheless exercise has been employed for the
past 2 years as part of the treatment of diabetic cases, most of them
severe beyond the degree formerly considered to contraindicate
exercise. A few definite experiments were conducted at the outset,
and some empirical experience has been gained since. The observa-
tions may be grouped under the following four heads :

A. Immediate effect of exercise on blood sugar.

B. The effect upon carbohydrate tolerance and glycosuria.

C. Its use in various classes of patients.

D. The more permanent effects upon assimilation and the diabetic
condition.

A. Tta; Immediate Effect of Exercise on the Blood Sugar.

Observations on Patient No. 18.

This patient represented the early mild stage of potentially severe
diabetes. By reference to the graphic chart (Chapter HI), it will be
noted that the test with vegetables alone, ending August 4, showed a

46S



EXERCISE



469



tolerance above 350 gm. carbohydrate. On August 6, a mixed diet
was begun of 100 gm. protein, 100 gm. carbohydrate, and 2600
calories. Beginning August 10, carbohydrate was gradually sub-
stituted for fat until 170 gm. carbohydrate were taken, which caused
no glycosuria on August 12 but a trace on August 13. After the fast-
day of August 14, the increase of carbohydrate was continued up to

TABLE I.
Patient No. 18.





Blood.


Urine.


1


Date.








i


to




g


i








Corpuscle sugar.'


SIS


"


13
1




^5


lOlS


ter
cent


ter

cent


ter cent


per

cent


ter
cent






°F.


Aug. 19 (rest) 2:20 p.m.


0.256


0.213


0.286








+ +


++




8:00 p.m.


0.250


0.250


0.250
(calc. 0.244)


100


37.0








Aug. 20 (exercise) 10:00 a.m.


0.150


0.156


0.133


100








+


98.2


10:50 a.m.


0.100


0.105


0.093
(calc. 0.094)


108


42.8






100.6


2:20 p.m.


0.099


0.116


0.100
(calc. 0.075)


105


41.2






100.4


8:00 «


0.222


0.238


0.182
(calc. 0.197)


110


39.7






98.8


Aug. 21 (exercise) 10:00 a.m.


0.111


0.111


0.109
(calc. 0.111)


100


41.5





+


98.6


10:50 a.m.


0.098


0.080


0.115


105


44.8






99.9








(calc. 0.120)











* The top figues for corpuscle sugar in all the tables are those obtained by direct
analysis. The figures in parentheses are those calculated from the relations of
whole blood and plasma.

200 gm. on August 18. With this, slight glycosuria appeared, and
continued on August 19. Keeping the diet unchanged, the following
observations were made.

No breakfast was taken. The two meals were eaten at fixed hours,
12:45 to 1:20 p.m. and 5:30 to 6 p.m. daily. It will be noticed in
Table I that the diet with 200 gm. carbohydrate had produced a



470 CHAPTER V

marked hyperglycemia, in blood samples taken 1 hour after lunch and
2 hours after supper on August 19, the patient having been up and
dressed but otherwise as quiet as convenient up to this time. Under
the dietary conditions stated, the hyperglycemia could safely be ex-
pected to continue or probably to increase. On August 20, without
food, the boy exercised between 10 and 10:50 a.m. to the Umit of
strength, running up and down 80 flights of stairs and walking briskly
between times. He then rested and took food as stated. During the
hour after lunch (1 :20 to 2 : 20 p.m.) he performed the hardest exercise
of the day, and continued with only short rests until supper time, the
afternoon's work amounting to 160 flights of stairs and almost continu-
ous brisk walking between. No exercise was performed after supper.
On August 21, exercise was performed between 10 and 10:50 a.m.,
comprising 88 flights of stairs and walking as usual.

Each flight of stairs counted includes both ascent and descent. A
flight was composed of 24 steps, each 16 cm. high. The boy ran rapidly
up and down, and by walking between times avoided stopping for
rest. He was strong and active, and though considerably tired by the
exertions, was never exhausted and always felt able to do more.

It is evident from the table that violent exercise stopped the exist-
ing glycosuria and markedly lowered the blood sugar.

Ketonuria, as far as could be judged by the ferric chloride reaction,
diminished rather than increased. This reaction alone is obviously
not a safe index. The possible alterations in blood bicarbonate
were not studied; but if there was a lowering it was evidently soon
restored by rest, for a single determination at 8 p.m. on August 20
showed 63.6 per cent.

Exercise concentrated the blood, as indicated by the higher hemo-
globin (Fleischl-Miescher) and hematocrit readings. Sugar analyses
were performed directly upon the corpuscles, after 15 to 20 minutes
centrifugation at 3000 revolutions per minute. These furnish inter-
esting controls, but are subject to errors, on the one side from ad-
herent plasma, on the other side from possible imperfect laking of
the corpuscle mass in analysis; so that the calculated values are to
be preferred. No special effect of exercise is apparent upon the
distribution of sugar between plasma and corpuscles. If there was,



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 52 of 76)