Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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Alternate Feeding and Fasting. — -The last mentioned case was one
which apparently did not respond well to fasting. An example of
relief of fasting acidosis by protein diet was afforded by patient No.
37 at his third admission. The result of failing to recognize the con-
dition in time was shown by the death of patient No. 30. Protein-
carbohydrate diet is used for this puropse under the well known plan
of Joslin. Even protein-fat diet may sometimes serve, as illustrated
by case No. 35 (not in Table XI).

Alkali. — Patient No. 10 received 10 gm. sodium bicarbonate on
one day. Patient No. 64 received 25 gm. on one day only. Patient
No. 72 (first admission) was an example of treatment of threatening
acidosis without alkali. The high dosage of alkali given to patient
No. 1 was unnecessary in her case and in most cases. In certain in-
stances (Nos. 38, 40, 63) high bicarbonate dosage by mouth (40 to
125 gm. daily) has seemed both necessary and life-saving. In the
majority of the cases it appeared that fasting was the essential treat-



562 CHAPTER vn

ment and would have sufficed by itself, but that sodium bicarbonate
in moderate dosage (IS to 30 gm. daily, in doses of 5 gm. each) has-
tened the restoration of blood alkaUnity and the clearing of cHnical
symptoms. Joslin has rendered service in emphasizing the harm and
possible danger in the prevalent abuse of soda, and has demonstrated
the successful routine treatment of acidosis cases without alkali.
Patient No. 45 illustrated such injury from bicarbonate by mouth;
even with all the other factors against him, he might possibly have
recovered if he had not been thus dosed with alkali. Sodium bicar-
■ bonate intravenously failed to save any patients in this series (e.g.
No. 30). There was suspicion that a Uter of 4 per cent solution in-
travenously was responsible for the death of patient No. 1^, who
otherwise might have had a chance for recovery. It also seemed
likely that a somewhat smaller injection hastened death in patient
No. 39, who would have died anyway, and in whom the infusion was
tried only as a last resort. It is plain from the literature that some
patients have survived such measures in the past, but the danger of
large intravenous doses of alkaU should be more generally recog-
nized. There is also some evidence in recent literature that when
not enough alkali can be absorbed from the intestine because of
nausea, diarrhea, or other difficulty, smaller doses, perhaps 200 cc.
4 per cent sodium bicarbonate, may be given intravenously with
benefit and repeated at intervals of several hours. Most of the
truth about the real effect of alkali in treatment is yet to be learned.
It is certain that its wholesale use is pernicious. Also, it is probably
bad policy to try to force a low blood alkaUnity suddenly up to or
above normal by large alkali dosage, especially intravenously. Prog-
ress is favorable if the level of the plasma bicarbonate tends distinctly
even though gradually upward. A basic element of success in the
newer treatment of acidosis consists in allowing the organism time
and opportunity to adjust its disordered relations under the meta-
boUc reUef afforded by abstinence from food.

Infections.

One of the fears expressed concerning the undernutrition treat-
ment has been that the traditionally low resistance of these patients
would be reduced still lower, and that the favorable initial results



RESULTS — ^PROGNOSIS 563

respecting diabetes would in prolonged experience give way to a high
mortality from infections. The reverse has proved true. Table XII
includes all the important infectious complications encountered in the
entire series of 100 patients, except the 3 cases (Nos. 16, 41, 67) of
latent syphilis. The Ust includes 27 infections with 7 deaths and 20
recoveries. Noteworthy among the recoveries are 4 cases (Nos. 6,
40, 44, 62) of typical lobar pneimionia. Among the deaths, it may
be noted that normal persons sometimes develop conditions like those
in Nos. 34 and 38, and die from them, so that these results are not
necessarily attributable to diabetes. Patient No. 46 seemed to be an
individual of naturally low resistance, who might have succumbed to
pulmonary gangrene independently of diabetes. Also tuberculosis is a
leading cause of death among the general population, and it must not
be expected that diabetics shall be immune. Patients Nos. 9 and 12
were taken because of the suspicion of incipient tuberculosis, which
could not be definitely confirmed. It was possible by undernutrition
treatment of their diabetes, together with fresh air and light exercise,
to bring them into good physical condition, and pulmonary signs and
symptoms cleared up completely. The weak and emaciated condition
may be held chiefly responsible for 4 deaths, those of patients
Nos. 8, 42, and 74 from tuberculosis, and of No. 70 from influenza,
but this condition had resulted from the severity of the diabetes and
was not attributable to the therapeutic undernutrition.
The general experience may be summarized as follows:
First, efficient treatment of the diabetes, even though this involved
the most radical undernutrition, has seemed in every instance the
best treatment for the infectious complications. The results of abso-
lute fasting with carbuncle in case No. 27, with incipient gangrene in
case No. 17, with influenza in case No. 41, and with some of. the
pneumonia cases, are examples in point.^

Second, the susceptibility to either major or minor infections has in
no way run parallel to the degree of therapeutic undernutrition. The
great majority of the complications included in Table XII have been
present at admission or have developed on rather liberal diets. The
most radically undernourished patients of the series are not repre-
sented in this table. Also it might be shown by similar analysis of the

^ Benefit in cutaneous lesions has been reported by Grau, R., Cronica Medico-
Quirurgica de la Hahana, January, 1918.



564



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566 CHAPTER VII

cases that common colds and other minor troubles have been most
numerous in the overfed patients. Presumably resistance is best in
the mildest diabetes permitting assimilation of a fairly liberal diet.
The patients who are worst off in susceptibility to and injury from in-
fections are those with severe diabetes on low diets which neverthe-
less slightly overtax their assimilative power. The experience indi-
cates that the resistance of these patients is increased by reducing
their nutrition within the limits of their assimilation. Also both
glycosuria and acidosis, which are the common accompaniments of
infection in inadequately treated cases, are frequently avoided when
the dietetic management has been thorough, as exempHfied by various
cases in this series. The vicious circle of aggravation of infection by
diabetes and of diabetes by infection is important to avoid. Patient
No. 42. might never have acquired tuberculosis had not tolerance and
resistance been broken down by unduly high diets, and the infection
in turn made the diabetes hopeless. Similar illustrations might be
pointed out in regard to less serious infections. The benefit of thor-
ough dietetic treatment consists not only in raising the existing toler-
ance and resistance, but in preventing them from falling lower.

Third, apart from the one case of pulmonary gangrene and three
cases of tuberculosis, none of the traditional complications of diabetes
has occurred in any of the 100 cases under treatment. The freedom
from pruritus may be mentioned as affording prophylaxis against in-
fection from scratching. Wounds have healed normally, and slight
accidents have never had serious consequences. It will probably
be conceded that under inadequate treatment the numerous troubles
hsted in older text-books are constantly overhanging every patient.
The relief from them is one of the greatest advantages of the present
treatment for both comfort and safety.

In conclusion it may be said that patients undernourished so as
thoroughly to control diabetic symptoms may be expected to display
a lowering of resistance corresponding to that of equally undernour-
ished normal persons. The large proportion of extremely under-
nourished patients enjoying complete freedom from infection, or re-
covering from occasional colds and other accidents like normal per-
sons, proves the safety and benefit of the undernutrition treatment
from this standpoint. Food in excess of the assimilation apparently
lowers resistance by poisoning the organism. Resistance is raised by



RESULTS — ^PROGNOSIS 567

increasing the assimilative power rather than the food supply. The
widespread contrary practice based on preconceived ideas is erroneous.

Reasons for Failure in Treatment.

At the outset of the present work, it was proposed' to take patients
solely on the basis of their diabetes, without regard to intelligence,
social position, or reliability of character. It was understood that the
statistics would suffer thereby, but it was deemed of interest to learn
what might be accompKshed with the average run of severely diabetic
patients. This policy has not been followed throughout, for especially
in view of the large number of applicants, there was an inevitable drift
toward choosing those who were most dependable and deserving.
The character qualification has been given a high place during the
last year or more. On the whole, however, the group has been fairly
representative; the patients have ranged from the ignorant shiftless
poor to the pampered willful rich; and some judgment is afforded
concerning the two influences discussed in the preliminary com-
munication mentioned; viz., the "human factor," representing all the
weaknesses of human nature, and the "scientific factor," representing
all the faults of treatment.

Table XIII classifies the failures of the present series, to the num-
ber of 52. On this basis, only 24 of the 76 cases rank as successes.
The failures may be divided into total and partial. The former are
reckoned at 40, viz. the 2>S deaths, and cases Nos. 6, 7, 14, 17, 22, 47,
and 56, in which abandonment of treatment makes a bad prognosis.
Partial failure is understood as downward progress or failure to
maintain the initial improvement. There are twelve examples. The
classification under fault of treatment does not always mean that the
treatment was mistaken. For example, a number of patients died of
coma or comphcations when no known methods could have saved
them, and in some instances diabetic treatment was not blame-
worthy because death was not caused by diabetes. But it is not
possible to distinguish sharply between deaths due to diabetes and
deaths independent of diabetes; also, when there is failure with no
fault on the part of the patient, it can only be said that the treatment

' Allen, F. M., Boston Med. and Surg. J., 1915, clxxii, 241-247.



568



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Death.

Downward progress.

Death.

Downward progress.

Relapse; bad prognosis.
Dismissed; bad prognosis.

Death.
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Relapse; bad ultimate

prognosis.
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Badly planned and irregular
diets; lack of blood analyses.
Unduly high diets.

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Lack of self control; Christian

Science.
Poverty.
Too lax dietary regulations;

lack of blood analyses in

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Neurotic character.
Too lax dietary regulations;

lack of blood analyses in

early period.
Ignorance.
Un trustworthiness; perhaps

drug habit.
Tuberculosis.

Deficient will and judgment.
Ignorance.
Cardiac disease.
Unduly high diets; inadequate

control of hyperglycemia.
Unreliable character.

Failure to relieve coma; un-
wise use of bicarbonate.










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RESULTS — PROGNOSIS 569





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572 CHAPTER vn

was ineffectual to save him. The classification also does not mean
that treatment was perfect in the cases ranked as successful, or in
those where the patient is held solely responsible for failure. Also on
the patients' side it does not signify that those held guiltless never
took a piece of forbidden food, though some in the series can truth-
fully boast such a record. The serial numbers of the patients are set
down in columns according to the sole or primary fault on theix part
or on the part of the treatment. When contributing factors are
present they are set down similarly. The reason for the difficulty is
also epitomized as accurately as possible in the parallel columns.

Diabetes has been and is now probably the worst treated of all dis-
eases. The statement does not express so much the genuine difficulty
and mystery which have overhung the subject, as the failure to ac-
quire and apply existing and readily available knowledge. Space
does not permit enumerating all the faults on the part of the profession
at large. Mainly they are gross errors and carelessness in the kind
and quantity of diets prescribed, due largely to ignorance of the
underlying principles of metabolism and nutrition, and ignorance and
neglect of laboratory methods for early diagnosis and for control of
treatment. This history of the urine tests will doubtless be more or
less repeated with the newer blood analyses. Specialists cannot be
criticized for high caloric diets when these were considered proper.
But there is experimental proof that dogs cannot live on the ex-
tremely low protein, high fat diets such as specialists have considered
ideal in severe cases; yet they blamed patients for breaking these
diets. Also, how many specialists of the highest standing have sub-
jected patients to an intolerable regime in hospital and been thankful
to dismiss them as soon as glycosuria was absent or minimal, knowing
perfectly the immediate relapse that must follow, yet recording these
cases as "improved" and shifting responsibility for the subsequent
fate always upon the patient under one of two headings, either trans-
gression of the (impossible) diet, or "spontaneous downward prog-
ress"? The patient cannot begin to be blamed until he has been
made thoroughly symptom-free, on a diet which maintains him in
equilibrium in this condition and is otherwise feasible to follow, and
has been instructed adequately in the management of this diet and
in the routine urine tests. Such a program involves hardships in



RESULTS — PROGNOSIS 573

proportion to the severity of the diabetes, and a patient must have
the courage and will power to endure these hardships if he is to live.
He can be blamed if he breaks a diet which a fair proportion of other
patients have proved able and willing to follow.

Table XIII assigns the responsibility for accessory causes of failure
to patients and to the treatment in 9 cases each. The direct or
exclusive source of trouble is blamed upon the patients in 23 cases,
while in 29 cases the treatment was unable to avert disaster or there
were faults in its application. The commonest blunder was feeding
beyond the true tolerance and lack of thoroughness in controlling
h)^erglycemia and other symptoms. In less carefully treated cases,
it must hold in still greater degree that diabetics are more sinned
against than sinning.

One of the possible fears regarding an undernutrition treatment is
that patients wiU not consent to follow it. The actual experience
here and elsewhere has been that they adhere to these diets more
faithfuUy than to the former high caloric diets. Some temporary or
long continued (e.g. No. 57) successes have been achieved with indi-
viduals who had persistently broken orthodox diets. No patient
has been forced by hunger to transgress. The great majority of those
listed in the above table as disobedient have been on fairly liberal or
often high and varied diets, and were the sort of persons who would
not abide by any restrictions no matter how slight. On the other
hand, the most rigorously undernourished patients, like the majority
of the others in the whole series, have for the most part been faithful
and trustworthy; so that for every one who has transgressed it is pos-
sible to mention one or more who have cheerfully followed equal or
lower diets. Doubtless only a minority will bear permanently the
extreme restrictions requisite in the cases of maximal severity.

There is greater difficulty with half treated than with thoroughly
treated patients. The reasons are physical and psychical. The first
consists in the avoidance of true diabetic polyphagia, and of the in-
ordinate carbohydrate craving which comes from an overbalance of
fat in the ration. Simple hunger is much more easily and rationally
endured than either of these. Psychically there is the encouragement
and confi:dence of continuous sugar-freedom, along with absence or
diminution of the neurotic irresponsibihty which belongs more often



574 CHAPTER vn

to the active symptoms of diabetes than to the constitution of the
patient. One weak point of the dietetic treatment necessarily is its
dependence upon human nature. In general, diabetic patients have
proved agreeable and satisfactory to deal with. They have their
state of health in their own hands to a greater degree than any others.
Since diabetes affects the higher more than the lower grades of hu-
manity, wholesale charges against diabetics are the more improbable.
Many of them apply to their treatment the intelligence and resolution
that have brought them success in important fields of work. An unex-
pectedly high proportion of poor and uneducated patients have
shown the ability and willingness to carry out their diet efl&ciently.
The fidelity and cooperation on the part of a majority of children
with diabetes is remarkable. On the physician's side, success lies in
relieving patients of abnormal cravings and nervous states as far as
may be done by rational diet, and in estabhshing the necessary rela-
tions of personal confidence.

No hesitation is felt in acknowledging mistakes of treatment as the
cause of failure in a high proportion of cases. If anyone treating
such a condition as diabetes is not able in looking back over several
years' experience to see mistakes in his methods, it is a sign of lack of
progress. The errors in this series of cases have been chiefly of three
sorts. First, in the early cases, there were some mistakes carried
over from the older methods of treatment, and the uncertainty in-
evitable in beginning a new method. In particular, it was hoped
that the tolerance would rise if freedom from glycosuria and acidosis
were maintained for a prolonged period, and experience was required
to prove that in the genuinely severest cases such a rise is negHgible.
At this time, when both the clinical and animal investigations, and
especially the whole of the laboratory work, were carried by one per-
son without assistance, the necessary completeness of study was im-
possible. Second, there was some hope that exercise might permit
a higher level of diet and strength, especially if the blood sugar were
kept normal; and some injury was done before it was learned that
burning up calories by exercise is not fully equivalent to subtracting
them from the diet. Third, the independent basis of association of
the collaborators has given free scope to divergence of opinions and
methods. It has thus happened that the practice of feeding to the



RESULTS — ^PROGNOSIS 575

verge of tolerance, and the familiar attempt to "build up" patients,
especially children, have received a full and fair trial in a high propor-
tion of the cases, with consequences not profitable unless for their
instructiveness as experimental controls of the primary principle of
treatment. Readers looking for model histories will therefore find
few if any, but may profit Hke the authors from the record of blunders
and mismanagement, especially as most persoiis who have tried to
carry out the treatment have doubtless committed the same sort of
mistakes. Acknowledgment is always to be made of the shortcomings
of the treatment itself, inherent in its negative nature as a mere rest
for a weak function, without any positive element of cure. The feel-
ing is that the method has accomplished more benefit than could be
achieved by any former plan of treating diabetes, but that much
better results than those obtained in this series of cases are possible
in the future.

Severity of the Treatment.

The prompt effectiveness of fasting and undernutrition in controlling
diabetic symptoms has recommended the treatment in most quarters,
but has excited some misgivings in others. A requirement not always
fulfilled is that a critic should be able to furnish evidence that he has
carried out the treatment correctly in at least a few cases. Two fears
may be worth mentioning.

The first is the apprehension as to the suffering involved. This
may pertain to the initial fast or to the subsequent diet. The experi-
ence in this hospital has received abundant confirmation from
nimierous physicians and patients elsewhere, that the initial fast as a
rule is easily borne. In the severest cases the fast is an absolute
necessity, because less radical measures fail to control the symptoms.
In all other cases, dietary restrictions in proportion to the severity
are always necessary. Under former methods, weeks or even months
have been required to abolish symptoms in cases at all severe. Be-
sides the waste of time and money and the injury to the diabetic
condition by such prolongation of metabolic overstrain, there is



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 60 of 76)