Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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to overfeeding. The milder diabetes of later Hfe seems often or gen-
erally different in origin, perhaps from chronic rather than acute
pancreatitis; at any rate, it generally is less rapidly and seriously
affected by excesses of diet. The inherently milder form sometimes
occurs in children, and there is a possible hope that recovery from
both the pancreatitis and the diabetes may then be more complete
than in adults. It is useful to distinguish diabetes which is in a
mild incipient stage but is inherently and potentially severe. For
this reason every case of diabetes in a child calls for the most careful
treatmept from the earliest possible moment, preferably .under a



534 CHAPTER VII

specialist; and such juvenile diabetes, even in the early stage with high
tolerance, may be classified among severe cases, unless later experi-
ence proves it clearly to be of the rarer mild form. On the other
hand, no patient is so old that diabetes is harmless to him. No
senile diabetes is so free from progressive tendency as not to be ag-
gravated by prolonged diet keeping up active symptoms, or so mild
as not to carry the threat of gangrene, bhndness, or other form of
death or disability at any time. When, after experience with severe
cases ill young persons in this series, some older patients with long
standing diabetes were taken, the supposition that treatment would
be quick and easy proved to be a mistake. Not only are an appre-
ciable proportion of such patients subject to the danger of acidosis on
fasting, but their glycosuria may be very stubborn and hypergly-
cemia and acidosis still more so, the apparent food tolerance maybe
almost nothing, and months of rigorous undernutrition may be re-
quired if the condition is to be controlled. The patient and friends
may feel that a relatively harmless glycosuria has been exchanged
for a state of weakness and discomfort, for a merely theoretical bene-
fit expressed in the laboratory findings; but with perseverance in right
management, the reward is obtained in an evident improvement of
health, as well as in relief from lurking dangers. Notwithstanding
the necessity and the frequent difl&culty of rational treatment, the in-
fluence of age can generally be trusted to assist; laxness of methods
can often be tolerated to an extent which would be fatal in the
young. For example, when glycosuria is effectually controlled, the
stubborn hyperglycemia and slight ketonuria generally do not de-
mand the infliction of further acute privations upon the old person,
but will gradually diminish and disappear in the course of months,
provided always that the plan of diet is fundamentally correct. The
ultimate results as respects preservation of Kfe and the recovery of
strength and ability to take a satisfying diet are also, other things
being equal, generally more favorable in the old.

3. The clinical course of diabetes has always been an important
criterion of its severity. Until recently, the very acute cases in young
persons, terminating fatally within a few weeks, have stood as the
extreme type of severity defying all treatment. Fasting has proved
surprisingly successful in checking the progress of such cases, and it is



RESULTS — ^PROGNOSIS 535

established that they are often not the most severe as measured by the
food tolerance, and do not necessarily run the most rapid or unfavor-
able course. Nevertheless, the rapidity and degree of the break-
down of fat, carbohydrate, and protein metabolism, as shown by
acidosis, carbohydrate intolerance, high or "total" dextrose-nitrogen
ratios, and exaggerated protein catabohsm and aminosuria, must be
regarded as important evidence of the inherently dangerous and
progressive character of the case. Some allowance is necessary for
dietary, infectious, and other modifpng influences. For example,
an unwise protein-fat diet may bring on early coma. Likewise, in
cases Nos. 37 and 66, previously compared, the cold which marked
the onset of acute sjmaptoms in the former, and the larger appetite
of an athletic boy as compared with a delicate girl, might well be re-
sponsible for different rates of initial progress, without relation to
any differences in the specific diabetic condition. Sufficiently long
subsequent observation may prove that an occasional case, alarming
because of intensity of symptoms or its occurrence in a child or young
person, is actually mild or transitory in character. Diabetes dis-
covered with an acute infection is notably subject to this rule. For
example, among the pneumonia cases in the present series. No. 6
was presumably a mild diabetes rendered temporarily more severe by
the infection and resuming its chronic course thereafter; in No. 40,
either transitory diabetes was produced by the infection, or latent dia-
betes was made active and afterward became again latent. In aU
cases, the results of treatment are instructive. Patient No. 24 wa .2



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Improvement on
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Condition imper-
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None.

Spasmodic for 3
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part of time for
2 yrs.

Various diets from
outset.




Buration of

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7 yrs.
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RESULTS — ^PROGNOSIS



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EESXTLTS — ^PROGNOSIS



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554



CHAPTER Vn



TABLE IX.
Mortality,





Total
number

of
patients.




Dead.






Living.




Decade of
life.


No.


Per cent.


Average duration.


No.


Per
cent.


Average duration.




Under
treat-
ment.


From first
symp-
toms.


Under
treat-
ment.


From first
symptoms.


1
2
3
4
5
6
7
8


8
14
14
16
13

8'

2

1


5
9
9
5
3
2


62.5
64.3
64.3
31.2
23.0
25.0


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8

16.5
13*

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2
3


vtos.
22

30.9
35*
24t
9
63


3
5
5
11
10
6
2
1


37.5

35.7

35.7

69

77

75

100

100


mos.

11

31.2

33t

28§

31

27

27

20


mos.
16
41.2
39t
81§
8611
63 f
142
Above 74.


Total or aver-
age


76


33


43.4


10.2


30.8


43


56.6


27.3


67.8



* Case No. 48 estimated.

f Cases Nos. 29 and 40 omitted.

I Case No. 38 omitted.
§ Case No. 7 omitted.

II Case No. 6 omitted.

\ Case No. 65 estimated.

At the same time, no hesitation is felt in discussing the results
from the therapeutic standpoint, even on the basis of the 43 per
cent mortality of the table.

First, if any defense of the principle of treatment is called for, it
sufi&ces to mention that the harmful effect of an increase of fat and
total calories has been proved upon a fair number of the cases and is
capable of proof in all the rest. None of these patients could be
treated successfully by former methods, and if 56 per cent have been
kept alive for the period in question, the figure represents ahnost
clear gain. Many of them would not even drag along for months if
overfed, but would die very quickly, as indicated by some obser-
vations in the preceding chapter.

Second, a critic may claim that this record at any rate justifies the
traditional pessimistic attitude toward diabetes, irrespective of tem-



RESULTS — PROGNOSIS 555

porary benefit by improvement in dietetic treatment. It may be
recalled that in the above tables, some cases formerly considered to
represent the extreme limit of severity have been ranked as mild or
moderate, and those classed as severe not only possess an actually
low assimilative power, but have also reached the stage of hopeless
inability to recover the lost power. A few milder, senile, obese, or
other cases had to be included as examples of their type. Otherwise,
broadly speaking (apart from rare cases with extraordinary sugar and
nitrogen excretion and acidosis, not always proving excessively severe
in the long run) the present series of cases is believed to be represen-
tative of the most severe diabetes that exists. The proportion of
examples of acutely threatening acidosis or complications, as tabu-
lated below, should also be borne in mind. The critic of the mor-
tality is invited to make comparison with the results in similarly
selected cases of any acute or chronic disease with any therapeutic
method whatsoever. It may be contended that in these other dis-
eases the patient who does not die is cured. But if sufficiently bad
cases be chosen for comparison, there are paralyses and other troubles
after diphtheria; there are recrudescences of syphilis, especially if the
choice includes a proper proportion of syphihtics too ignorant or too
careless to pursue treatment faithfully; and the worst cases of hyper-
and hypothyroidism are by no means all cured. The general medical
attitude toward these other diseases is not pessimistic, and a pessi-
mistic position toward diabetes cannot be founded upon the results
in the most severe cases.

Third, a glance at the mortahty table shows that the majprity
of the patients below 30 years die and the majority of those above 30
live. It may therefore be claimed that these figures at least confirm
' the inevitably bad prognosis of the severe form of diabetes in young
persons. The question to what extent there is such an inherently
hopeless severity in youthful diabetes, and to what extent merely a
greater sensitiveness to injurious influences, is discussed later in
this chapter.

In Table X, "under treatment" includes patients in the hospital
or following diet faithftilly at home; "without treatment" designates
those who have broken diet and died without returning to the hos-
pital. All the deaths can be classified under coma, compUcations, and
inanition.



556 CHAPTER vn

Under inanition are placed patient No. 1, who abandoned treatment
at home and gradually wasted away on a carbohydrate-rich diet which
apparently prevented coma; No. 4, a boy who was unduly undernour-
ished by mistake arising from his stealing food; No. 13, a child who
gradually progressed downward under inadequate treatment; No. 45,
a child received with incipient coma and extreme weakness and im-
possible to save on the latter account; and No. 54, a woman showing
continuous downward progress not checked by prolonged undernu-
trition. This last case was atjrpical, as was also case No. 8, in
which the necessity of gradual starvation was due to tuberculosis.
Under the usual conditions of treatment, even in the severest cases,
a necessary choice between death from diabetes and death from
starvation has not yet been encountered in this series, though it
may later have to be faced in a patient such as No. 73 and prob-
ably ultimately in some others.

Among the deaths from complications, those of patients Nos. 11
and 25 were clearly independent of the diabetes. The infectious
complications are discussed in connection with Table XII below.

The patients of this series are mostly such as typically die in coma.
With the single exception of patient No. 1, who starved to death on
starches and candy, every patient who broke diet died in coma, some
very qmckly. Where question marks are placed after the num-
bers in the table, the positive diagnosis was not obtained, but the cir-
cumstances made coma reasonably certain. No patient has gone
into coma while under the dietetic treatment. Since the principle of
treatment is to keep acidosis entirely absent, this statement means
only that the application has been feasible and successful. The only
exceptions to the general statement are patient No. 42, whose diet
was relaxed because of tuberculosis, and five others (Table X, first
column) whose treatment was incomplete, either because of initial
acidosis uncontrollable by fasting, or subsequent departures from diet.
These results indicate a genuine advance in the control or preven-
tion of acidosis; and that this is not confined to the present series
of patients but has become fairly general, at least in hospitals, is
indicated by the fact that a supply of levorotatory /3-oxybutyric acid
for experimental purposes is now decidedly more difl&cult to obtain
than formerly. Better success in the treatment of actual or threat-
ened coma is also indicated by Table XI.



TABLE X.
Causes of Death.



Case Nos. of patients dying of.



Coma.


Complication.


Inanition.


Under
treatment.


Without
treatment.




Cliaracter of complication.


Under
treatment.


Without
treatment.












1




2


















4








8


. Tuberculosis.








9












10














11


Cardiac failure; perhaps em-
bolism.














13




15














18














25 .


Nephritis. Apoplexy (?).






30
















34


Appendicitis.








36












37














38


Pregnancy. Pneumonia.






39












42






Tuberculosis probable.














45








46


Pulmonary gangrene.








48(?)












49












51(?)












52(?)












53
















Some complication possible.


54






5S(?)












63(?)












69(?)














70


Influenza.






71












72
















74


Tuberculosis.






Total








20


8




5



557



558



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RESULTS — PROGNOSIS



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560 CHAPTER VII

The majority of all the patients had marked acidosis when re-
ceived. There is no fixed boundary for the beginning of coma, or
between threatened or incipient and complete coma. Patients ex-
hibiting merely slight hyperpnea, malaise, drowsiness, or other pro-
dromes have been excluded from the above list. Only those have
been included who presented these sjonptoms in a degree sufficient
to make it evident to any observer that coma was actually beginning.
The standard of complete coma was not deep unconsciousness with
absent reflexes, since in some patients dying of acidosis such a stage
is absent or very brief; but when the patient was unable to compre-
hend where he was or answer questions intelligently, the condition
was classed as full coma.

The total number of such cases treated was 21, the deaths 7, or
33| per cent, the recoveries 14, or 66| per cent. It would be possible
to improve these figures by considering the fact that patient No. 38
came out of deep coma and died of complicating infections which
would have sufficed to cause death in a non-diabetic. There were two
deaths due to weakness; i.e., patient No. 45 recovered from incipient
coma on fasting, went intofuU coma when fed on account of weakness,
then came out of coma on fasting and died free from acidosis; patient
No. 71 entered in incipient coma, went on into deep coma before
fasting could take effect, partially woke up on continued fasting,
lived 9 days without fully regaining consciousness, and died in coma
when feeding was compelled by failure of strength. A number of
patients have entered with extreme weakness and emaciation, and
these features have not prevented treatment of the acidosis in any
adults of this series, for strength has usually been gained rather than
lost by such patients on fasting. Patients Nos. 45 and 71 above men-
tioned were small children, and the excessive weakness was the more
dangerous on this account. Fasting was risked because it offered a
chance, whereas without it death from acidosis seemed inevitable.

Complete Coma. — The chances must be considered to be strongly
against a patient in full coma under any treatment, and the results
in this series were more favorable than can be claimed as a rule.
Mention was just made of the two children (Nos. 45 and 71) who
came out of complete coma temporarily, also of patient No. 38, who
revived temporarily even in the presence of severe infection. Of the



RESULTS — PROGNOSIS 561

five examples of full coma at the time of admission, No. 25 was atypi-
cal and probably less grave in character. Patients Nos. 15 and 72
died after respectively 2^ and 7 J hours in the hospital. Patient No. 63
showed the lowest plasma bicarbonate and the most extreme collapse
of the series, and lived. It is possible that children go into and come
out from coma more readily than adults. In cases Nos. 38 and 71
with temporary recovery, and in case No. 63, the coma was complete
in the sense of absolute unconsciousness and loss of corneal reflex.
In the fatal case No. 15 there was no such stage. Patient No. 30 was
clearly conscious almost to the end, as frequently happens in fasting
acidosis.

Incipient Coma. — Excluding the two cases (Nos. 45 and 71) with
excessive weakness and the one (No. 38) with fatal infection, there
were twelve instances of patients received with incipient coma, with
one death. The recoveries include case No. 40, with coma im-
pending in the presence of lobar pneumonia. The fatahty was pa-
tient No. 39, who violated diet and was readmitted with extreme
dyspnea but perfectly clear intelhgence. There was abundant time
for treatment, but the methods were vacillating and uncertain, and
the patient went on into deep coma and died. This single death
was of a sort which will probably be avoidable when the treatment
under these circumstances is worked out better in certain details.



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 59 of 76)