Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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ample testimony that the long program is actually a greater tax on
the patient's endurance than is the brief fast. With regard to the
subsequent diet, it should be understood that the ideal is the best



576 CHAPTER VII

possible nutrition compatible with freedom from active S3miptoms.
Opponents must then support one of two theses : either that they can
bring about a higher assimilation without active symptoms by some
other method than by this method; or that patients wiU live either
longer or more comfortably when allowed to suffer the usual symptoms
of glycosuria, acidosis, and complications either in full force or in some
mitigated degree. It is believed that facts contradict both these
propositions. The latter is the one more likely to be defended by
those who seek to justify lax or careless methods; but it may be
pointed out that in this case they stand opposed to the best authori-
ties on diabetes from Naunyn to the present, who have held that
glycosuria and acidosis should be kept absent if possible.

A second question pertains to the possible danger or harm of re-
ducing the weight and nutrition of diabetic patients. The observed
facts have already been stated concerning subjective health and com-
fort, longevity, and the chance of infection when the patient is faithful
to diet. With regard to breaking diet, the conclusion was drawn
that this is less rather than more frequent under the new treatment.
The remaining question then is what is the effect of the treatment
when it is begun and later not followed out properly. A physician
clearly should not impose fasting if he is not competent to maintain
the benefit subsequently. When glycosuria is aboHshed by fasting,
then brought back by improper diet, then stopped by fasting again,
and so forth, the nutrition is lowered with no corresponding gain in
assimilation, and this harmful process may be continued even to
death from starvation. This is wrong management. When a pa-
tient abandons trealtment, there is a risk of arbitrary judgment
without tangible support. If he dies quickly, it may be claimed
either that the treatment injured him, or that it was the means of
prolonging life in a case demonstrated as severe by the outcome. If
he lives long, this result may be regarded as an after-benefit from
the treatment, or as proof that the stringent measures were unneces-
sary and that a longer and happier life was made possible by dis-
carding them. Confusion is largely obviated by considering facts as
follows. Nmnerous patients in the present series have been received
in critical condition, have been kept alive for long periods under
treatment, and have died in coma soon after breaking treatment, thus



EESTJLTS — ^PROGNOSIS 577

demonstrating the severity of the diabetes. When they have es-
caped early coma, they have lived surprisingly long for patients of
such a type; e.g., patients Nos. 1 and 60. As already mentioned, the
vast majority of deaths are due to acidosis and not to undernutri-
tion. To show an injury from the treatment, it would be necessary
to prove that patients are made more susceptible to coma by having
their acidosis completely cleared up. It is believed, therefore, that
careful treatment represents clear gain, even if it is later abandoned.

Prognosis.

The expression, by word or act, of opinion concerning the probable
course and termination in diabetes is more than prognosis ; it is a part
of the therapy. It is important that patients should be told the
actual truth, without favorable or unfavorable bias or concealment.
Great harm is frequently done by careless judgment of the earliest
and mildest cases and by an unwarrantably gloomy forecast in the
severe ones.

According to Naunyn,* "der Verlauf der Krankheit ist so verschie-
den wie denkbar." The statement is correct in the sense intended by
that author, signifying the wide extremes of mild and severe, acute
and chronic forms. It is not true in the sense of any bizarre hetero-
geneity of the disease, indicative of multiple organic origins or for-
bidding prognosis in individual cases. With allowance for the rare
exceptions encountered with every ailment, with consideration of the
principal factors of severity previously mentioned, and with cogni-
zance of the influence of aU three classes of foods, it is possible to out-
line fairly definitely the prospects in the great majority of diabetic
cases. Predictions can be hazarded to some extent at the outset,
but are more certain after a period of observation under treatment.
The prognosis of possible accomplishment under the present method
pertains to comfort and longevity.

If a patient can be kept alive, it is generally desired to know at
what level of comfort, strength, and efl&ciency this is possible. As no
cure exists, it should be stated plainly that this level is lowered in
proportion to the severity of the case. Tables I to VIII show the

^Naunyn, B., Der Diabetes melitus, Vienna, 2nd edition, 1906.



578 CHAPTER vn

existing condition of the patients of this series, which in the ma-
jority of those living is decidedly, and in many of them extremely
below normal. A point not to be overlooked is that, except for some
bad results due to transgressions by the patients or mistakes in treat-
ment, this state of invalidism had been present before and was bene-
fited by treatment, and the way to avoid such a state is to adopt
the most efl&cient treatment possible at the earliest possible stage. To
generalize the actual results, it may be said that the patients as a
whole have been relieved of the tormenting complications of dia-
betes. Therapeutic reduction of weight has ordinarily been attended
by increase, not by diminution of strength. ' The notions of " starved"
patients entertained by those having no experience with the method
are widely erroneous. Of 18 living patients above the age of
30 who have been faithful to diet, (excluding the cardiorenal case
No. 61), all but 2 are carrying on their regular duties more or less
satisfactorily, and 13 of these are almost or entirely free from
impairment of strength,, working power, appearance, or subjective
health referable to diabetes. The most extremely undernourished
man (No. 24) has carried on his business continuously. The most
radically undernourished woman (No. 60) has continued light house-
hold tasks and supervised the bringing up of her daughter. There is
frequently a tendency to progressive gain in health in this older
group. Of the 5 in the third decade counted as living, one was
an exceptional case resulting in apparent cure, one is emaciated by
reason of transgressions of diet, one looked and felt well at departure
to Finland, and two are leading their usual lives in such condition
that a stranger would notice nothing wrong, over 3 years from the
onset of their diabetes. The younger patients are discussed more in
detail below. The best accomplished in them has been to preserve
such strength and well-being as they possessed at the time of begin-
ning treatment.

A familiar defense of overfeeding is that the patient must die any-
way and should be kept as comfortable as possible in the meantime.
Very often this is a mere excuse for mismanagement, and it is not
justified by the present experience. No patient of this, series has
broken diet with impunity. The penalty of eating much or little in
excess of the tolerance has been corresponding reduction not only



RESULTS — ^PROGNOSIS 579

of length of life but also of strength and comfort. Cases mild enough
to drag along for months or years on improper diet are also mild
enough for a reasonably satisfactory diet and bodily condition under
proper treatment. The more severe cases face a correspondingly
worse dilemma. Moderate overeating does not satisfy; diabetic
polyphagia is harder to endure than simple hunger, and the malaise
of chronic acidosis and the troubles of various complications are super-
added. Excessive overeating of carbohydrate increases polyphagia
and emaciation; excessive overeating of fat brings quick coma. The
only argument against thorough treatment must therefore be that
it is cruel to prolong the state of impaired health. But euthanasia
is no more justified in diabetes than in numerous other conditions.
The strongest reason for the earliest and most efl&cient treatment
possible is not the relief of the immediately threatening or trouble-
some symptoms, but is rather the fact that such treatment acts to
preserve strength, comfort, and assimilative power, and either saves
from the condition of extreme privation altogether or holds it off
to the farthest possible time. Diabetics who overeat for the de-
liberate purpose of killing themselves are uncommon. In this re-
spect the experience shown in Table XIII probably holds for diabetics
in general. The patients who died from breaking diet were not
driven to desperation by hunger or suffering. They were generally
not the ones who had to endure the greatest privations. , They were
rather the ignorant, the careless, the weak-willed, the neuropathic,- and
others who would not have been faithful to any restrictions no
matter how mild. Under such circumstances it is the physician's
duty to strengthen, encourage, and aid. The condition of the living
patients of the present group, young and old, ranges from perfect
subjective health to very serious privation, according to the severity
of their diabetes. The lesson from the standpoint of comfort is
wholly in favor of efficient treatment at the earliest possible stage,
not in favor of bad treatment at any stage. The only apology for
reciting these obvious facts is the frequency with which the fallacy
in question is encountered.

As to the prognosis for preservation of life. Tables I to DC
show the high mortality of 43.4 per cent as what the physician
may expect if he limits his practice to cases like these. For dia-



580 CHAPTER VII

betic patients themselves, it is instructive to extend the inspection to
Table X. Two or three elderly patients have paid for breaking diet
only in loss of health and not by loss of hf e. Otherwise,- the record
stands that the patients who abandoned treatment died, all but
one of them in coma. This statement is unjust in a few instances
where patients only gave up because of discouragement after down-
ward progress; but it can still be answered that none of them had
been called upon to endure lower diets than others have successfully
endured. If the list be limited strictly to those who have faithfully
followed treatment throughout (and they are the majority) then only
fourteen deaths remain to be explained. Of these, three (Nos. IS,
30, 45) were acute deaths, due to coma immediately following admis-
sion to the hospital for commencing treatment. Nine were due to
complications (tuberculosis in Nos. 8, 52, 74; heart disease in No. 11;
nephritis in No. 25; appendicitis, pneumococcus infection, pulmo-
nary gangrene, and influenza in Nos. 34, 38, 46, and 70). No. 13 was
complicated with urinary calculi and the diabetic treatment also was
not thorough. No. 54 was an unusual case, with fatal course sus-
pected as due to some complication. If all these cases were set aside,
it would make an absolutely clean record without deaths in the en-
tire experience of 3| years. Of course it is not permissible to wipe
the slate clean in this manner. For example, the tuberculosis in case
No. 52 was clearly the result of bad progress of the diabetes under
wrong treatment; the influenza in case No. 70 was probably fatal
chiefly because the patient was weak from diabetes. On the other
hand, some deaths from complications were, as stated, apparently
independent of diabetes. The fact may further be noticed that
diabetic statistics are perhaps the only ones in which patients who
do not follow the treatment are included among the failures of the
treatment, even when, as with most of the disobedient ones here, the
fault was solely their own. This exception with respect to diabetes
is just, because one important test of the practical worth of a treat-
ment is its feasibility, not for some specially selected patients, but for
the general average of human nature. Nowhere more easily than in
diabetes is it possible to obtain that famihar form of therapeutic
data which in themselves are not false, but are so selected as to lead
to erroneous conclusions. It can be repeated that in the^choice of



RESULTS — PROGNOSIS 581

these cases, all pains were taken to invite the highest mortality pos-
sible. It is fair to claim that disobedience, coma, and complications
do represent special difficulties. From the medical standpoint all
the deaths and failures from all causes belong strictly in the series,
and they were given full weight in the foregoing account. From the
patient's standpoint, however, it is justifiable to point out that if he
is constantly faithful in treatment, if he has not died in coma at the
outset, and if he is not one of the small proportion (9 or 10 in 100
cases in this series) to succumb to complications, his chance of sur-
vival according to the above statistics to date would be close to 100
per cent. These figures apply to a group of cases of high average
severity, in which coma, complications, weakness, and other dangers
are most common; also it was noted that there was considerable in-
jury from mistakes in treatment. It is believed that the record
offers a hopeful outlook for the average diabetic patient under efficient
care. It wiU not be possible to keep patients with the severest dia-
betes alive indefinitely by this or any other dietetic treatment, but
the great prolongation of life in them shows how much may be
hoped when such treatment is applied in the earliest and mildest
stages, as it properly should be.

" Spontaneous Downward Progress."

The belief in an inherent progressive tendency in at least a large
proportion of diabetic cases is universal. The evidence in the litera-
ture is valueless. The belief rests largely upon the rapidly fatal
course of many severe, especially youthful, cases. Other instances
cited, as by Naunyn, are merely those in which glycosuria was sup-
pressed by carbohydrate restriction and returned on the usual high
caloric diet. This question of spontaneous downward progress may
rank as the most important one in the entire subject of diabetes,
from two viewpoints. The first is clinical. It is the question of the
possible prolongation of life; whether, with adequate regulation of all
classes of food and aboHtion of aU symptoms, the diabetic process is
brought to a standstill, or is merely slowed so that the fatal end comes
somewhat later but just as surely. The second pertains to the path-
ology and etiology of diabetes; whether the cause producing the
diabetes is a transitory or a continuous and progressive process.



582 CHAPTER vn

Knowledge on this point would decide the clinical prognosis. Con-
versely, observations of the progress of patients with relief from food
injury will throw much light on the nature of the diabetic process.

From one aspect, it might seem natural to anticipate that, since
diabetes is not actually caused by diet, the essential process should
not be halted by change of diet. This point could not be settled
except by an anatomic investigation, as described in the following
chapter. This pathologic study has shown that the downward prog-
ress due to food injury is an additional and separate process, inde-
pendent of the original cause of the diabetes. A standard object of
comparison is the partially depancreatized dog. Here a surgical
resection produces a definite degree of pancreatic deficiency, and the
absence of any inherent progressive tendency has been established by
prolonged experiments. More or less gain in assimilation maybe
observable, dependent in at least some cases on h)^ertrophy of the
pancreatic remnant. But when a fairly fixed limit of tolerance has
been determined for some time, this shows little further spontaneous
change in experiments extending over years. The behavior in this
respect is like that of many human diabetics. The most important
point is that in suitably prepared animals with rather severe dia-
betes, the. prevention of active symptoms and fatal result requires
restriction not only of carbohydrate and protein but also of total
calories and body weight. By addition of fat to a diet on which the
condition is demonstrably stationary, the "spontaneous downward
progress ' of clinical cases can be precisely imitated. Even with
milder diabetes, it is possible to prove the same relation between
weight and tolerance as exhibited by human patients There are
dogs now living whose tolerance can be varied at any time by manipu-
lating their body weight.

The pathologic evidence needs to be supplemented by clinical ob-
servation. It is obvious" from the former that pancreatitis is some-
times chronic and progressive; also, even an acute inflammation
starts up changes which continue to a variable time and degree.
Such a process is necessarily beyond the power of dietetic treatment.
Clinical experience must therefore decide what proportion of human
patients show indications of such an advancing lesion, or any other
progressive factor not present in dogs and independent of food injury.



RESULTS — PROGNOSIS 583

The present series of cases should have answered this question, and
the greatest disappointment of the clinical research has been the
inability to carry out the original plan to this end. The existing
observations are presented for the partial information which they
afford. As mentioned before, the aggravation resulting from infec-
tion was exhibited by patient No. 8 with tuberculosis, and by other
patients with various acute infections. Similarly, patient No. 54
was a typical example of downward progress according to the idea
which has been so prevalent. When freed from symptoms by radical
undernutrition, it was impossible for her to remain so on any living
diet; the sjonptoms kept recurring in spite of progressive reduction of
weight and metabolism ; there seemed to be nothing but a continuous
choice between inanition and coma, and the patient finally died
after a steadily losing fight of 9 months. This is the conception which
has existed in some quarters concerning the undernutrition treatment
of severe diabetes. It is possible that some progressive process was
at work in this case. It is certain that the other cases of the series
have not been of this sort. The experience with the others can
best be considered in the groups above the age of 30 and in the
decades below that.

In the patients above 30 years, it may not appear surprising that no
progressive downward tendency has as yet been observed. Yet the
older patients are the ones in whom the pathologic studies in the lit-
erature have shown chronic pancreatitis most frequently. If there
were a progressive decline clinically, it might be readily explained by
progress of the pancreatic lesion, and some cases must certainly
show such a decline ultimately. In view of the known pathologic
findings, the accepted favorable prognosis of diabetes in the elderly is
rather remarkable. Patient No. 24 is a man aged 44 years, with the
most severe diabetes of any man of this group, and with the typical
history of the disease beginning in mild form 7 years previously,
and gradually progressing to the extreme stage present on entering
this hospital. There was a history of indigestion, pale feces, and
jaundice in the year prior to the diagnosis of diabetes. The skin is
yellowish, there is a dyspeptic tendency, and especially fat easily
upsets the digestion. The prediction can be made that if autopsy is
obtained it will reveal chronic pancreatitis. The case has actually



584 CHAPTER vn

shown the stationary tolerance characteristic of severe diabetes, and
has done well under the circumstances during ahnost 3 years of ob-
servation. The woman No. 60 had the severest diabetes repre-
sented in this group. The type was more like that of younger per-
sons. Within less than a year after onset, the condition had attained
such severity that only the most radical undernutrition was able to
control it. Even though her hyperglycemia was not thoroughly
controlled, the downward progress was apparently halted, and there
was no perceptible further loss of tolerance during nearly 2 years of
observation. The improvement manifested by other patients when
their weight was reduced has persisted with continuous regulation of
diet and weight. Particularly important are the observations with
patients such as Nos. 23 and 41, showing how assimilation rises and
falls inversely with the weight, just as in dogs. Though such cases
belong among the milder ones of the series, it is plain that "spon-
taneous downward progress" can be produced in them at any time by
the familiar "building up" in diet and weight. With reUef from
such an overload, they have shown generally an upward tendency
as far as the period of observation extends.

In the third decade (cf . Table III) a number of cases are of service
only as examples of the rapid downward progress resulting from
dietary errors. The cases with compUcations are excluded; none
showed downward progress prior to the fatal infection. Patient No.
40 apparently illustrated complete recovery from acute diabetes ac-
companying pneumonia. Patient No. 29 was lost from observation.
No. 54 was the atypical case above mentioned. This leaves Nos. 1,
3, 32, and 52 as suitable for the present discussion. All showed more
or less downward progress. No. 3, for example, had been a very rap-
idly progressive case, with active glycosuria and acidosis under the
previous treatment and with the prognosis of only a few months of
life. A consistent reduction of diet and weight was maintained during
the 3| years since. With the mistakes in diet known to have oc-
curred in hotel life, causing slight glycosuria at times, it is not sur-
prising that some decline of tolerance has occurred in such a case;
but this has been slow in proportion as the dietetic errors have been
sKght. The other three patients illustrate the effects of continually
feeding to the verge of tolerance, keeping up continuous hyperglycemia



31ESULTS — ^PROGNOSIS 585

and occasional glycosuria. In dogs, one of two things occurs under
these circumstances. One possibility is that the pancreas remnant
increases in size or function and hyperglycemia diminishes and dis-
appears. This is the result which is noticed frequently in the more
elderly patients, and which originally was hoped for in others. The
other possible outcome in dogs is a gradual breakdown of function
under the overstrain when the pancreas is unable to rally in this
manner. This breakdown is much slower than on a higher diet,
but the susceptibility to this injury is in proportion to the real severity
of the diabetes. Accordingly the youngest patients are generally the
most susceptible. There is nothing perceptible in this group of cases
that cannot be exactly imitated in dogs.

In the second decade (Table II), case No. 4 illustrates the fact
that not all patients can be classified together in prognosis merely
because of youthful age. This diabetes began at 5 years; the diet
was the conventional sort on which children ordinarily die quickly,
and there were frequent transgressions; yet the boy lived to the age
of 12. There is natural interest as to what might have been the
result with this child if all active symptoms had been kept absent by
eflBcient dietary regulation from the outset. Several of the other cases
illustrate the rapid downward progress caused at this age by disregard
of diet. One of these. No. 10,^ showed "total" diabetes, as demon-
strated by the D : N ratio and the respiratory quotient at the time of
his admission. The gradual marked gain in food tolerance represents
upward not downward progress, in contrast to what quickly hap-
pened when he abandoned restraint. In the history of case No. 2
(Chapter III) it was pointed out how rapidly aggravation was pro-
duced by each departure from diet, whUe in the long intervening
periods in the hospital the absence of any perceptible downward
tendency was demonstrated, even though the treatment was far
from ideal. The patients of this group who were fairly faithful to
diet can be divided into those received in the final severe stage of
diabetes, and those received in an earlier, mUd or moderate stage.

The former group consists of cases Nos. 13, 26, 62, and 63. The
faults in their treatment are pointed out in the histories. In par-



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 61 of 76)