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This chapter, like the later ones, aims only to present the methods
and experience of the present investigation. A multitude of ques-
tions and details concerning the treatment of diabetes must neces-
sarily be left to general text-books on the subject. Discussion of the
observations and suggestions of others who have used this treatment
must also for the most part be omitted in the interests of brevity.
For details of the laboratory methods employed, reference may be
made to the original papers or to the excellent description in Joslin's

As emphasized from the outset, every case of diabetes must be
managed according to its own requirements, and the best results are
obtainable only when the treatment is intelhgently individualized.
At the same time, a basic plan is essential, inasmuch as one general
principle underhes the treatment of all cases, and organization and
routine conduce to both ease and efl&ciency. The system developed
in this hospital may be described under the following headings:

I. General measures.

II. Treatment up to cessation of glycosuria in simple cases.

III. Complications and emergencies (acidosis, infections).

IV. Treatment following cessation of glycosuria.
V. Ideals of diet and laboratory control.

VI Practical management of diets.


I. General Measures.

A. The Routine Care of Patients.

1. Hospital Observation.^AH. the cases treated have been under
direct hospital observation. Between February 24, 1914, and July
1, 1917, altogether 96 patients were received, for a total of 165 ad-
missions, an average of 1.72 admissions to each patient. The great-
est number of admissions for a single patient was five. The total
number of days of diabetic treatment was 11,308, giving an average
of nearly 69 days to each admission. The longest single admission
was 304 days, the shortest a few hours (acute death). Hospital ob-
servation has seemed advisable for the following reasons: (a) to obviate
possible danger from acidosis during the active treatment of the dis-
ease by the fasting method; (b) to govern with the greatest possible
accuracy the individual diet, while the preliminary tests of tblerance
are being made, a ration built up, and its suitability demonstrated;
(c) for the instruction of the patient, in order that he may carry out
his diet and tests properly after leaving the hospital.

2. Confinement to Bed. — ^Unless made advisable by some complica-
tion or by a dangerous degree of acidosis, the patients have not been
confined to bed. Even during the most trying period of treatment,
namely the initial fast, it has not been uncommon for patients to lessen
the tedium of treatment by going to theatres, concerts, etc.

J. Clothing. — ^As many patients show a decided susceptibility to
cold weather, they have been advised to dress wannly, but without
specific instructions. The use of exercise, as discussed in Chapter V,
has obviated this condition to some ^tent, especially for that great
majority of diabetic cases which rank as relatively mild. But the
extremely low diets required for the very severe cases provide so
little combustible material that body heat must be conserved as care-
fully as possible.

4. Baths. — It has not been attempted to gain effect through hydro-
therapy. Bath temperature has been left to individual inclination.
Patients with severe diabetes have naturally chosen warm water.



5. Catharsis. — Chronic and obstinate constipation has been a rule
with few exceptions in the past history of these as of other severely
diabetic patients. It was regulated by cathartics before bran was
incorporated into the dietary of the hospital. This and the bulky
vegetables have almost banished constipation. When something
more active has been needed, the usual cathartics (castor oil, salts,
cascara sagrada) have been employed.

6. Medication. — The principle has been followed of giving drugs
to diabetic patients only as they would be used for other persons. No
medicines have been employed with a view to influencing the dia-.
betes, and no effect upon the diabetes has been observed from any of
those employed for incidental purposes. The recommendations of
various drugs in the past have probably been based upon inadequate
control and study of the cases. Special mention may be made of the
dangerous possibilities of anesthetics, especially chloroform. It is well
known that drugs of the chloroform class most easily injure the liver
when it is poor in glycogen. The visceral disturbances set up by
general anesthesia readily explain the production of either glycosuria
or acidosis, as so frequently described. The dangers are greatest
where the treatment is poorest, and the majority of diabetics under
thorough treatment are able to undergo suitable anesthesia without
glycosuria and without dangerous acidosis.

7. Complications. — The experience with these has not been large.
It is discussed in Chapter VII and in the individual case histories.
The treatment of the acute forms is described under Section III of
the present chapter. Metabolic complications in general do not in-
terfere with the treatment of the diabetes; the present diabetic diet
does not conflict, for example, with the usual treatment of nephritis.
In regard to infectious complications, it may be said that the ideal of
treatment is to make the patient as nearly like a normal person as
possible by means of diet, and then to use as nearly as possible the
measures considered best for normal persons. The recently debated
question of the relation of infections, sometimes focal and minor in
degree, to the etiology of diabetes is discussed in Chapter VIII.
Certainly bad tonsils, teeth, and other foci are sources of injury for
diabetic patients, which in acute attacks often give rise to glycosuria
and acidosis, and which may interfere seriously with the success of


dietetic treatment. It has been the policy with this series of cases to
have teeth or tonsils removed or other operations performed on the
same basis as advised for normal persons by conservative specialists.
Experience has indicated that such measures are beneficial from the
standpoint of the general health and also of the diabetes, in obviating
chronic and acute disturbances and the downward progress associated
with them. No patient has died or suffered harm from such opera-
tions performed while on the dietetic treatment, and it appears that
there is less danger from performing needed surgery than from
omitting it. On the other hand, if toxic absorption causes diabetes,
evidently the damage has mostly been done before the case has come
under treatment, for in no instance has the removal of a focus of in-
fection been followed by cure of the diabetes or by improvement
beyond that seen in other patients.

B. Ward Regulations and Clhstical Remarks.

1. Respiration, pulse, and temperature have been recorded at 4
hour intervals when fever was present or when acidosis or other
crisis threatened. Otherwise they have been taken every 12 hours.
Sohie of the information which may be gleaned from these signs in
diabetic patients follows.

Respiration. — Increased breathing is one of the classical indications
of acidosis, the increase generally applying to both volume and fre-
quency. Ordinarily it is a fairly constant and rehable index of danger,
unless obscured by the use of alkali; but in the type of acidosis pro-
duced by fasting, it may, like the drowsiness and other symptoms,
be far less prominent than in typical diabetic coma.

Pulse. — It may some day be possible to analyze the records of
these cases with respect to the pulse rate. F. G. Benedict has noticed
a relation between pulse and metabolism, and he and Joshn reported
acceleration of the pulse in proportion to increased metabolism in
severe cases of diabetes with active symptoms present. Patients in
the present series entering the hospital with intense diabetes and
threatening acidosis have regularly shown rapid pulse, which has
become slower under treatment. A few examples appear in tables in
certain of the case histories. Marked bradycardia has been observed


in some of the patients subjected to extreme undernutrition and the
corresponding reduction of metabolism, but this has not been con-
stant. The conditions are evidently not simple. On the one hand,
the tachycardia out of proportion to any possible exaggeration of
metabolism in impending coma is clearly an effect of intoxication upon
the circulation. On the other hand, Dr. Alfred Cohn has observed
in radiograms of some of these emaciated patients a diminution of the
cardiac shadow even out of proportion to the thinning of the chest.
This wasting of the heart muscle, like other states of general or circu-
latory weakness, might of itself alter the rate, especially in the di-
rection of tachycardia. With the uncertainty concerning the re-
spective influence of metabohc and other factors, a uniform inter-
pretation may be difficult.

Temperature. — It being understood that the temperature of diabetic
patients typically is normal, notice should be taken of variations in
two directions. Elevation of temperature often accompanies severe
acidosis, as illustrated in a few of the case records in this series.
Otherwise, fever of any grade generally points to infection, and ceases
with the finding and removal of the cause. Subnormal temperature
■^is common in proportion to malnutrition, whether the latter is due
to failure of assimilation of food with active diabetes, or to thera-
peutic restriction of diet. In the most severe cases of this series under
treatment, the rectal temperature has commonly been below 98° and
above 96°F. An important practical point is to watch the tem-
perature when children must be subjected to extreme xmdernutrition.
Even though the weakness is not visibly graver than before, a fall of
temperature to the neighborhood of 96-95°F. is a signal of danger,
which generally comes in time to permit warding off death by giving
food. If acidosis or stubborn glycosuria makes a full diet inad-
visable, even protein alone may support strength to the point where
fasting can be continued. More careful attention to this point
might possibly have prevented the fatal collapse which occurred in
several children of this series. The low temperatures in severely
diabetic patients are readily explained by the failure to receive or to
assimilate (according to the treatment) enough combustible material.
The same circxunstance may wholly or partly explain another im-
portant clinical phenomenon, namely the absence or diminished grade


of the febrile reaction to infection in some cases. Joslin called atten-
tion to the possibility of an almost complete lack of symptoms with
tuberculosis, even in an advanced stage. Something similar may be
witnessed occasionally with other infections. Either the weakened
individual is deficient in reactive power, or possibly the resultant of a
subnormal temperature and a febrile tendency may be something like
a normal temperature. This possible fallacy regarding fever should
be borne in'mind, and if a patient under rigid dietary control begins
to do badly without apparent cause, careful search should be made
for the infection which is often responsible.

2. Blood Pressure. — ^Aside from extraneous causes of hypertension,
the blood pressure of diabetic patients is generally normal or below
normal. Not only weakness, but also the intoxication of acidosis, is
responsible for the depression. Several patients received in extreme
stages have had a systolic blood pressure below 80, and in certain
others the circulation was so feeble that it was not possible to deter-
mine the pressure accurately. In such cases the question always arises
whether the patient can endure the week or more of absolute fasting
required to control his diabetes. In actual fact, every adult has
passed successfully through such fasting, not only without collapse,
but generally with more or less gain in strength, as indicated for one
thing by a rise in blood pressure. It thus appeared that intoxication
was the most dangerous factor in the depression, and relief from it
even at the price of fasting was necessary to save life. Therefore a
dangerously low blood pressure is not necessarily any contraindication
to fasting. On the other hand, it is possible that a fall in blood pres-
sure during fasting or extreme imdemutrition may be a signal of
danger, but the clinical observations have not been sufl&cient to show
whether this is a reliable warning or whether it comes in time to per-
mit of averting the danger.

3. Body Weight. — AU patients have been weighed naked each morn-
ing after voiding urine and before breakfast. The weight has been
recorded in kilograms. The weight is very valuable among the cri-
teria of treatment, though it is well known to be only a crude measure
of the true body mass. Patients with intense active diabetes some-
times seem to be dried out by diuresis; they may hold or gain weight
by water retention during fasting and for days or weeks on inadequate


diet thereafter. Fall in weight is sometimes sudden, to the extent of a
kilogram or two on a fast-day, without evident significance. Fat diet
following carbohydrate diet gives rise to such a water loss. The
commonest cause of precipitous fall in weight for a series of days is
acidosis. This melting away of weight and strength is seen in its
most alarming degree in the occasional cases combining intense acido-
sis, maximal D:N ratio, exaggerated nitrogen loss, and, with these,
rapid water loss. The opposite condition of sudden gain in weight
represents water retention, sometimes associated with relief from
glycosuria or acidosis, or with carbohydrate feeding, but frequently
from obscure cause. Even without nephritis, it is commonly con-
nected with salt retention and removed by salt-free diet. It may
differ in degree at different times and especially in different patients,
from invisible storage to extensive edema. Edema, sometimes huge,
has been well known in connection with the large salt intake in "oat-
meal cures," and especially with high dosage of sodium bicarbonate.
In Joslin's experience, water loss is one of the most dangerous, and
water retention or edema one of the most favorable conditions when
combating a dangerous acidosis. On the other hand, the more severe
cases have the greatest tendency to edema. This edema may there-
fore be classed among the indications of severity, though not aU
severe cases show the tendency equally. Apart from any mere
changes in the function of the kidney for salt, it is likely that there
is some unknown metabolic cause affecting the general tissues, either
belonging in some measure to diabetes itself, or perhaps largely or
wholly a phenomenon of undernutrition. It may possibly belong in
a series of dropsical conditions due to malnutrition, a related member
being the "hunger swelling" ^ of the wretchedly poor classes in Poland
on an almost exclusive potato diet in the present war, another re-
presentative being the "epidemic dropsy"^ of famine times in India,
another being the edema of cachectic children, while at the farther
extreme is beri-beri.

^Budzynski, B., and Chelkowski, K., abstracted in /. Trop. Med., 1916, xix,

^Megaw, J. W. D., Indian Med. Gaz., 1910, xlv, 121; /. Am. Med. Assn.,
1911, Ivii. 826.


4. Measurement of Fluids. — It is well known and has lately been
emphasized by DuBois that an accurate water balance is one of the
hardest of all things to determine. In our cases the fluid intake and
output have been measured daily, and occasionally gross retention
or loss of water has been thus demonstrated. The information
afforded is necessarily vague and inaccurate. No allowance was made
for the water content of foods, and especially the large quantities of
vegetables generally given made this unknown factor a considerable
one. Most of the apparent discrepancies of intake and output
shown in the graphic charts are thus explained.

(a) Intake. — Thirst is not of abnormal degree in ordinary
diabetic patients under proper treatment, one of the advantages of
which is the relief from the discomfort of polydipsia and the incon-
venience of polyuria and nycturia. Severely diabetic patients on
very low diets generally drink rather freely, merely for the sake of
something to fill the stomach. There has been no need to restrict
fluids, except temporarily in a single patient (No. 1) who had formed
the habit of excessive drinking, and in a few others during periods of
marked edema. There is also no need to urge drinking of mineral
waters or anything else under the conditions of proper diet, there
being no poisons to wash out of the system. This may be an im-
portant advantage in cases with a complicating nephritis, with lim-
ited ability to excrete fluid. The one emergency which demands the
forcing of fluids to capacity is dangerous acidosis, as mentioned later
in this chapter.

(b) Output. — If an occasional patient drinks so little that the urine
is unduly concentrated, a troublesome turbidity may cloud the sugar
reactions; and instead of using chemical reagents for clearing, the best
plan all around may be to urge the patient to drink a normal quantity
of water. Usually in the severe cases the urine is very pale and clear,
both because of the excessive drinking stimulated by hunger and be-
cause of the small total content of solids. It thus resembles in appear-
ance the traditional diabetic urine, but a sharp difference is found in
the very low specific gravity. Delicate sugar reactions are easily
seen. The total 24 hour urine is saved in four separate portions each
day, the divisions coming at mealtimes. During all the earlier and
greater part of the investigation, days were counted from 7 a.m. of


one day to the same hour the next day. More recently, for general
hospital convenience, a change has been made to the less commenda-
ble method of counting from midnight to midnight. Accordingly
at present the order of periods is as follows:

Period I. Midnight to 7 a.m.
Period U. 7 a.m. to 11:30 a.m.
Period III. 11:30 a.m. to 5:30 p.m.
Period IV. 5:30 p.m. to midnight.

Two considerations favor this latter plan, namely that all urine is re-
corded under the date on which it was voided instead of being dis-
tributed over two dates, and second that the separation of days is
made at a time when there is little work in the hospital instead of at
the busy hour of 7 a.m. The arguments against this plan and in
favor of the former plan are more weighty, first that patients are sub-
jected to the inconvenience of being wakened at midnight to void
urine, and second that the urine of a day does not correspond cor-
rectly to the diet of the day, inasmuch as the break between days is

Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 9 of 76)