Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

. (page 57 of 76)
Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 57 of 76)
Font size
QR-code for this ebook


216


10


2495


39.6


++











" 24


104


223





2496


39.7


++


+


0.383


48.6


" 25


104


223





2496


40.3














" 26


104


223





2496


40.0


+


+








" 27


104


223





2496


40.5


++


+


0.278


56.4


" 28


Fast-day.




40.6














Nov. 29


104


223





2501


40.3








0.213


58.9


" 30


104


223





2501


40.4














Dec. 1


104


223





2501


40.5


+


+








" 2


104


223





2501


40.4


+


+


0.270


48.4


" 3


104


223





2501


40.7


+4-


+








" 4


104


223





2501


40.7


++


+


0.244


52.8


"5


Fast-day.




40.3














Dec. 6


104


169





1995


39.7








0.344


55.2


" 7


104


169





1995


41.3














" 8


104


169





1995


42.0














" 9


104


169





1995


41.0








0.250


58.8


" 10


104


169





1995


40.8














" 11


104


169





1995


41.4








0.227


56.6


" 12


Fast-day.




41.3















514



INFLUENCE OF FAT IN THE DIET



515



TABLE VI.
Patient No. 47.





Diet.


Weight.


Urine.


Blood plasma.


Date.


Protein.


Fat.


Carbo-
hydrate.


Total
calories.


Sugar.


FeCIs
reac-
tion.


Sugar.


CO!


1915


gm.


em.


em.




he.






Per cent


vol.
per cent


Nov. IS


100


170





1992


60.2








0.20


50.8


" 16


100


170





1992


61.1














" 17


100


224





2492


61.6








0.23





" 18


100


224





2492


61.9














" 19


100


278





2994


62.0














" 20


100


278





2994


62.5





+


0.18


55.1


" 21


Fast-day.




62.4





+








Total for week.


600


1344





18440












Nov. 22


100


331





3492


61.1





-1-








" 23


100


332





3498


62.0





+








" 24


100


386





3995


62.6





++


0.22


51.9


" 25


100


385





3991


62.6





++








" 26


100


386





3995


62.7





++








" 27


100


386





3995


62.6


+


+++


0.20


39.0


" 28


Fast-day.




62.6


+


+++





— .


Total for week.


600


2204





22966












Dec. 6


100


167


10


2001


61.8


+


++


0.11


60.0


" 7


100


166


10


2001


62.8


+











" 8


100


162


20


1997


62.8














« 9


100


1S8


20


1961


63.2








0.18


59.4


" 10


100


163


20


2005


63.3














" 11


100


163


20


2005


63.1














" 12


Fast-day.




63.2












Total for week.


600


978


100


11972












Dec. 13


100


163


20


2005


62.3








0.13


66.9


" 14


100


159


30


2007


63.0














" IS


100


154.


40


2002


63.7














" 16


100


148


50


1993


63.6














" 17


JOO


143


60


1999


63.8








. —





" 18


100


140


70


1998


63.7














" 19


Fast-day.




64.3










Total for week.


600


909


270


12004












Dec. 20


100


148


50


1990


61.9














" 21


100


148


SO


1990


62.7








0.11






516



CHAPTER VI



decided fall in plasma bicarbonate, which evidently would have been
serious except for being checked by fasting. After the injury from the
fat had been corrected by an undernutrition period, December 1 to
5, the patient within 2 weeks demonstrated the ability to tolerate as
much as 70 gm. carbohydrate with the same protein as before, with

TABLE VII.
Patient No. 74.





Diet.


Urine.


Date.


Protein.


Fat.


Calor-
ies.


Vol-
ume.


Nitro-
gen.


NHs-N


100 NHs-N


Total
acetone
bodies.


Sugar.




N


1917


gm.


em.


em.


cc.


em.


gm.




gm.




Feb. 13


50


43


600


141S


9.66


0.93


9.6


0.82


Negative.


" 14


SO


43


600


1160


9.08


0.90


9.9


0.64


it


" IS


SO


43


600


1470


10.14


1.00


9.9


0.43


tt


" 16


50


43


600


1770


.11.35


1.10


9.7


0.58


ft


" 17


50


43


600


1440


9.76


0.99


10.1


0.45


11


" 18


]


^ast-day.


1145


6.25


0.84


13.4


0.45


(t


" 19


50


150


1600


1875


8.77


1.46


16.6


4.61


t(


" 20


so


43


600


1480


6.64


1.14


17.2


0.70


It





Blood Findings February


19 to 21.




Date.


Time.


Sugar.


Total
acetone
bodies

per
100 cc.


Com-
bining
power
for CO2.


Macroscopic appearance
of plasma.


1917




per cent


mg.


vol.
per cent




Feb. 19


7:00 a.m. (fasting).


0.14


31.8


62


Clear.




11:30 " (after first fat meal).


0.14


28.0


60


Slightly cloudy.




4:30 p.m. (3 hrs. after second fat












meal).


0.15


38.9


47


Milky.




11:30 p.m.


0.17


50.0


48


Cloudy.


Feb. 20


7:00 a.m. (fasting).


0.16


35.9


57


Slightly cloudy.


" 21


7:00 "


0.15


29.0


62


Clear.



fat diminished so as to limit the total diet to 2000 calories. Not only
was the urine normal, but it is seen that the blood sugar also fell to
normal. Fat was therefore clearly responsible for glycosuria, hyper-
glycemia, and acidosis in this case.

The immediate effect of a single large addition of fat to an other-
wise fixed diet was studied in greater detail in patient No. 74. The



INFLUENCE OF FAT IN THE DIET 517

diet was one of undernutrition, with a negative nitrogen balance,
though the deficit appears unduly large in the table because no
allowance is made for the nitrogen of the soup which was taken in
fixed quantities daily. On February 19, 107 gm. fat were added,
divided between the morning and noon meals. Though the blood
was not analyzed for fat, a tendency to pathological lipemia seemed
indicated, for the plasma was unusually opaque during digestion
and some cloudiness persisted in that obtained at 7 a.m. the next
day. During the earUest period the total acetone in the plasma
was not increased. Only at 4:30 pi.m., 3 hours after the second fat
meal and 9 hours after the first one, was such an increase demon-
strated. At 11 :30 p.m., when the lipemia had markedly diminished,
the maximum ketonemia was encountered. By the following morn-
ing it had fallen to nearly the same level as before the fat addition.
The plasma bicarbonate ran strikingly parallel, falling as the acetone
bodies rose, and rising thereafter, as they fell. There was also a
well marked increase of acetone bodies, of ammonia nitrogen, and
of the ratio of ammonia to total nitrogen in the urine. Also, instead
of a sparing of protein, there was an increase of nitrogen excretion on
this day. No glycosuria occurred, and though the slight increase in
blood sugar may be significant here as elsewhere, there is no indi-
cation that sugar was actually formed from the fat.

The effect of a smaller and more gradual addition of fat was tested
as shown in Table VIII. Glycosuria being absent on an under-
nutrition diet of 40 gm. protein and 500 calories, the fat tolerance was
tested by the addition of 5 gm. fat daily to this diet. Under the low
diet it is seen that the blood sugar diminished up to October 18,
whereas the fall in the acetone bodies was maintained only to Octo-
ber 16. Both then progressively increased, and excretion of both
sugar and acetone bodies in the urine developed correspondingly.
The rise of weight must be attributed chiefly to water retention, since
even with the low metabolism of this emaciated condition, genuine
gain in tissue is scarcely possible on the diets shown. The test indi-
cated a very low total food tolerance in this patient and the necessity
for extreme undernutrition if active symptoms were to be prevented.

A test of the sudden giving and withdrawal of a considerable
quantity of fat was made upon patient No. 75, as shown in



518



CHAPTER VI



Table IX and in the graphic chart (Chapter III) . By consulting the
graphic chart it can be seen that this patient had been kept in the
hospital from February 21, 1917, on diets up to 60 gm. protein and
1850 calories, with urine very comnaonly showing the faintest detec-
table traces of sugar and ferric chloride reactions, but never titra-
table quantities of sugar in the two month period. In correspond-
ence with the urine, the blood showed continuous hyperglycemia

TABLE vm.
Patient No. 69.





Diet.


Weight.


Urine.


Blood.


Date.


Protein.


Fat.


Alcohol.


Calor-
ies.


Volume.


Sugar.


Total
acetone
bodies
(as ace-
tone).


Sugar.


Total
acetone
bodies

in
plasma
(as ace-
tone)
peiiOO

cc.


19i6


gm.


em.


gm.




kg.


cc.


gm.


gm.


per cent


««.


Oct. 13


40


17


25


500


37.0


3850





0.51


0.20


26.6


" 14


40


22


25


546


37.4


2790














" IS


40


28


25


602


37.2


3170





0.49








" 16


40


33


25


649


37.1


2335





0.32


0.15


19.7


" 17


40


40


25


704


38.2


2370





0.36








" 18


40


45


25


750


38.0


2950





0.39


0.13


24.3


" 19 .


40


50


25


800


37.9


2515





0.41








" 20


40


55


25


855


38.0


2220





0.36








" 21


40


60


25


902


38.2


2755





0.61


0.14


33.4


" 22


40


65


25


958


38.9


2900





0.95








" 23


40


70


25


1005


38.0


3390





1.09








" 24


40


75


25


1051


38.0


3090





0.99


0.16


35.6


" 25


40


80


25


1107


38.6


2760


-t-


1.27








" 26


40


85


25


1153


39.0


2230


++


0.98








" 27


40


90


25


1205


40.8


6180


9.84


2.53


0.27


42.3



and a moderate increase of total acetone (31 mg. per 100 cc.) at the
time the test was made. A week before this (April 30) the protein
had been increased by 10 gm., and the diet at the beginning of the
test consisted of 70 gm. protein and 1500 calories. In addition
there was an allowance of 600 cc. clear soup and 800 gm. thrice
cooked vegetables daily, which were ignored in reckoning food values.
With the increase in protein, sugar reactions became slightly more pro-



TABLE IX.

Patient No. 75.





Diet.




Urine.


Blood Plasma.










(U










1.


,




la




Date.






H












-1






-i


Remarks.




4




-1


■3


■S


i,


i




S8






ill






o

1^




em.


8
cc.


o

3


•g
^


1


to


1^


w


8


|..




1917


em.


em.




kg.


cc.


gm.


em.


per
cent


vol.
per
cent


me.




May 7


70


131








1500


36.2


2615





+













" 8


70


131








1500


37.6


2370





+













" 9


70


131








1500


37.2


3080





+













" 10


70


131








1500


37.1


3440


+


+













" 11


70


131








1500


37.3


2860



















" 12


70


131








1500


36,6


2440





+













" 13


Fa


ist-day.




37.2


3100



















" 14


70


131








1500


36.2


2000


+


2.62













" IS


70


131








1500


37.4


2582





5.73


0.208


72.0


31.0




" 16


70


131








1500


37.5


2770


+


12.41





-^







" 17


70


131








1500


37.8


3142


++


17.58













" 18


70


131








1500


38.0


3340


++


5.98













" 19


70


131








1500


37.9


3152


++


3.18













" 20


Fe


ist-day.




37.2


2800


+


1.08


0.179


71.1


31.0




" 21


70


231








2430


35.8


2413


+


5.70


0.246





34.7




" 22


70


281








2895


37.4


2800


5.88


18.54













" 23


70


281








2895


38.0


3480


10.26


17.32













" 24


70


281








2895


37.6


3340


13.86


13.70


. —










« 25


70


281








2895


37.6


3630


16.29


18.65













" 26


70


281








2895


37.2


3435


18.87


15.98


0.200


47.1


83.0


5:00 p.m.


" 27





100








930


37.2


3377


18.54


7.61


0.238


57.6


63.5


10:00 a.m.


" 28*


70


281








2895


36.4


1955


7.40


18.10


0.263
0.208


69.1
63.5


71.3
89.2


9:00 "
6:00 p.m.


" 29*


70


281





-^—


2895


37.5


3483


26.13


25.01













" 30*


70


281








2895


38.0


3448


22.87


49.73


0.216


57.8


108.0


5:00 "


" 31


70


11





__


391


38.2


3105


21.56


17.68


0.286


59.7


57.2


9:00 a.m.


June 1


70


11








391


37.9


•2520


22.32


4.24













" 2


70


11








391


38.3


2728


18.83


1.85













" 3


Fe


ist-day.




38.5


2155


8.36


0.67


0.303


69.2


12,6


10:00 "


" 4




ti




38.2


2810


+


0.90


0.204


63.6


35.8


10:00 "


" 5


70










391


38.4


1760


+


0.81













" 6


70










391


39.2


3052


+


0.81













" 7


70










391


38.7


3030


+


0.33













" 8


70










391


38.8


3000


+


0.18













" 9


70










391


38.5


2790


+


0.50













" 10


Fast-


day.





38.6


3260





0.19


0.170 56.0


12.2


10:30 a.m.



* 20 gm. sodium bicarbonate on this day.

519



520



CHAPTER VI



TABLE IX — Concluded.





te.


Diet.


^


Urine.


Blood plasma.




Da


d




1


1


1

o

•3
u


■o

>


i


1

Is




8




Remarks.


1917


sm.


em.


gm.


cc.




kg.


CC.


em.


gm.


per
cent


wl.
per
cent


me.




June


11


70


11








391


38.1


2215


+


0.48


0.161


61.7


18.6


9:00 a.m.


cc


12


70


11








391


38.8


2050


+


0.18













a


13


70


11








391


39.9


3640


+


0.11













a


14


70


11








391


39.7


3830





0.11





— ■







u


15


70


11







391


39.3


3470





0.52













it


16


70


11








391


39.0


3435








0.164





8.3


5:00 p.m.


ti


17


Fast-c


ay.




39.0


4110








0.182


67.3





11:00 a.m.


((


18


70







70


881


38.5


1728





0.13


0.141


61.7


13.0


9:00 "


tt


19


70







70


881


39.9


3630





0.18













ti


20


70







70


881


39.8


3585





0.32













ti


21


70







70


881


39.4


3690





0.33








__




tt


22


70







70


881


39.0


2210



















It


23


70







70


881


38.6


3060



















tt


24


Fast-da


y


100


700


39.0


4166








0.098


57.0


7.2


10:00 a.m.


tt


25


70


11





100


1091


38.4


2104





0.23


0.066


72.1


19.1


9:00 "


tt


26


70


11





100


1091


39.2


3340





0.23













it


27


70


11





100


1091


38.4


3555



















It


28


70


11





100


1091


38.4


2975



















tt


29


70


11





100


1091


38.6


3468



















tt


30


70


11





100


1091


38.6


3685








0.12


55.1


11.1


5:00 p.m.


July


1


HI





3.6


100


721


39.0


4030








0.11








10:00 a.m.


(t


2


77


16.5





100


1170


37.6


1620








0.13


64.5





9:00 "


It


3


77


16.5





100


1170


39.4


3535



















u


4


85


22





100


1250


39.0


3640



















ti


5


85


22




100


1250


38.2


3230



















tt


6


85


22




100


1250


38.2


2882



















It


7


85


22





100


1250


38.0


3990











^'







it


8


111





3.6


100


721


37.8


3505



















ti


9


85


22





100


1250


37.4


2678



















ti


10


85


22





100


1250


37.2


4807



















ti


11


95


22





100


1297


36.5


4225



















ti


12


95


22





100


1297


36.3


2430



















tt


13


95


22





100


1297


37.8


3015



















tt


14


95


22





100


1297


37.5


2998



















tt


15











100


700


38.0


3350




















INFLUENCE OF FAT IN THE DIET 521

nounced in the urine, but no titratable quantity was excreted. Under
these conditions 100 gm. fat were added to the diet on May 21 and
another 50 gm. on May 22, so that the diet May 22 to 30 consisted
of 70 gm. protein, 281 gm. fat, and 2895 calories. Also 100 gm.
olive oil were given on the fast-day of May 27. The result, as seen
in the table and the graphic chart, was a prompt glycosuria and keto-
nuria of considerable degree, also a rise of sugar and still more marked
rise of acetone bodies in the blood, with a tendency to a lowering of the
bicarbonate reserve. Notwithstanding the giving of 100 gm. olive
oil on May 27, this fast-day accomplished part of the usual purpose.
There was no reduction of blood sugar. The blood taken at 10 a.m.
on May 27, before the oil had been given, showed benefit of absti-
nence up to that point in a lowering of total acetone and a rise in the
CO2 capacity. The 100 gm. oil were then given, and as this was so
much less than the fat of the regular diet, this day of undernutrition
apparently accomplished part of the benefit of a fast-day in checking
the rise of acetone and fall of CO2 capacity. The giving of 20 gm.
sodium bicarbonate on May 28, 29, and 30 lowered the blood sugar
only transiently if at all. It evidently safeguarded the plasma bicar-
bonate, but either failed to prevent the marked increase in plasma ace-
tone, or possibly contributed directly to this increase. On May 30
the total acetone had reached the dangerous level of 108 mg. per 100
cc, and the patient's clinical condition was so unfavorable that
prudence demanded a change in the diet. There was none of the
dyspnea characteristic of acid poisoning, but intoxication was mani-
fested by dizziness, malaise, weakness, and drowsiness. Beginning
May 31, fat was excluded from the diet as far as convenient, keeping
the protein ration unchanged. The table shows how in the remaining
3 days of that week all symptoms except the hyperglycemia strikingly
improved. The clinical transformation was equally plain. Traces of
glycosuria persisted up to June 13. Beginning June 18, the very
low ration was augmented by first 70 gm. and then 100 gm. alcohol,
but the total calories never exceeded 1300. Under this program,
not only was there cessation of glycosuria and of ketonuria (aside
from the trace indicated by a slight nitroprusside reaction), but also
by July 1 the blood was normal in sugar, acetone, and alkali reserve.
As an additional test of the relative importance of protein in produc-



522 CHAPTER VI

ing the former glycosuria, a gradual increase of protein was then
made, and it was found that with as much as 95 gm. protein and
1300 calories glycosuria was still absent on July 14.

Tests with both gradual and sudden addition of fat were performed
upon patient No. 43, as shown in Tables X and XI and in the
graphic chart (Chapter III) . This young woman entered the hospital
for her fourth admission on December 2, 1916, with heavy glyco-
suria and ketonuria. The condition was controlled by fasting and
low carbohydrate-free diet as shown in the graphic chart. Traces
of sugar at first persisted, but with continuance of undernutrition
sugar and ferric chloride reactions were negative after December 17,
on a diet of 50 gm. protein and 500 calories. Also 300 cc. clear
soup and 300 gm. thrice boiled vegetables were given daily and not
reckoned in the tables. At this point the test began with a
gradual regular addition of fat to the diet through successive weeks.
The diet in these earher weeks remained one of undernutrition.
H3^erglycemia was still present at the beginning of the test,
but with continued low diet up to January 7 a progressive fall can
be seen. Although the small additions of fat had little definite in-
fluence upon the acetone bodies in the blood, there was nevertheless a
distinct increase of the excretion in the urine. In general the im-
pression gained from this period up to January 7 is that fat gives
rise directly to acetone bodies, but does not directly give rise to sugar
in the body. As the diet continued to increase, the blood sugar rose
after January 7, not to an excessive height at any time, but enough
to make continuous hyperglycemia and thus to sacrifice the benefit
of the previous undernutrition. Also traces of glycosuria appeared
and became continuous. The acetone bodies reached their highest
point in the blood plasma with 76 mg. per 100 cc. on January 13
and 19. The rise in the blood was not progressive, apparently be-
cause the kidneys acted efficiently in removing the excess, so that the
urine showed a steady increase of acetone bodies in parallel with the
increased fat ration. The ammonia nitrogen showed a correspond-
ing gradual increase. The lowering of the plasma bicarbonate to 56
per cent on February 20 may or may not be significant. Though the
diet finally reached a high level for a patient of this size at rest,
weight was not gained, though there was probably a gam in body fat.



TABLE X.
Patient No. 43.





Diet.


Weight.


Urine.


Blood.


Date.


Pro-
tein.

gm.


Fat.


Calo
ries.


Volume.


Su-
gar.


NHs-N


Total
acetone

bodies

as

acetone.


Sugar.


Total
acetone
bodies

in
plasma
fas ace-
tone)
per 100
cc.


Plasma
COa.


191(


gm.




kg.


cc.


gm.


gm.


gm.


per cent


mg.


ml.
per cent


Dec. 18


50


32


500


34.0


2435





0.55











" 19


SO


42


595


34.0


2249





0.66











" 20


SO


S3


700


33.9


2485





0.95


0.49


0.27


25.2


59.0


" 21


SO


64


800


33.8


3080





0.92


0.46








" 22


50


64


800


33.6


2783





0.66


0.44








" 23


50


64


800'


33.7


3085





0.59


0.55








« 24




Fast-day.


33.8


1780





0.46


0.39








" 25


SO


64


800


33.4


2660





0.S9


0.72








" 26


SO


70


850


34.2


2770





0.65


0.80


0.21


26.2


60.0


" 27


SO


70


850


34.2


3350





0.78


0.62








« 28


SO


70


850


34.0


2820





0.62


0.48








" 29


SO


70


850


34.0


3235





0.67


0.55








" 30


SO


75


900


34.1


3980





0.80


0.48








" 31




Fast-day.


34.2


2350





0.61


0.31








1917
























Jan. 1


SO


75


900


33.6


2515





0.63


0.70


0.2S


30.8


72.0


" 2



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 57 of 76)