January 1, 1841
Total dietary regulation in the treatment of diabetes
"Bouchardat's treatment": Treatment of diabetes mellitus by use of a low-carbohydrate diet. He added green low carb vegetables to the all meat Rollo diet. Bouchardat also used fasting and exercise and even invented gluten bread.
Though Bouchardat (1806-1886) read his first memoir to the Academy of Sciences in 1838, and the final edition of his book appeared in 1875, he came into prominence through important contributions in the decade 1840 to 1850. Like Rollo and all other founders of the dietetic treatment, he considered diabetes a disease of digestion. According to his theory, normal gastric juice has no action upon starch, which is digested in the intestine; but in diabetes, an abnormal ferment digests starch in the stomach, and glycosuria, polyuria, and other symptoms result. He claimed to demonstrate the presence of diastase in the vomitus of diabetics and its absence in that of normal persons. Hypertrophy of the stomach and atrophy of the pancreas in diabetic necropsies were also held to support his theory; and he was thus the first to suggest an influence of the pancreas in the causation of diabetes, and the originator of the attempt to produce it by pancreatectomy in dogs. For sugar determination in urine, he used fermentation, the polariscope, and the Frommherz copper reagent. By the fermentation method he showed the presence of sugar in diabetic blood, but found none in normal blood. At how low an ebb was the Rollo treatment at this time is shown by the pleading and arguments of Bouchardat. He begs all friends of truth to hear him; whatever be the original cause of glycosuria, diabetics, who otherwise all die, are actually saved when his dietetic treatment is used.
Bouchardat in the clinical field ranks with Claude Bernard in the experimental field. He is easily the most brilliant clinician in the history of diabetes. He resurrected and transformed the Rollo treatment, and almost all the modern details in diabetic therapy date back to Bouchardat. He was first to insist on the need of individualizing the treatment for each patient. He disapproved the rancid character of the fats in the Rollo diet, but followed an intelligent principle of substituting fat and alcohol for carbohydrate in the diet. He forbade milk because of its carbohydrate content. He urged that patients eat as little as possible, and masticate carefully; also (1841) he inaugurated the use of occasional fast-days to control glycosuria. Subsequently he noted the disappearance of glycosuria in some of his patients during the privations of the siege of Paris.
Though the introduction of green vegetables is credited by Prout to Dr. B. H. Babington, the honor of thus successfully breaking the monotony of the Rollo diet, properly belongs to Bouchardat. He recommended them as furnishing little sugar, a little protein and fat, but especially potassium, organic acids, and various salts. He also devised the practice of boiling vegetables and throwing away the water, to reduce the quantity of starch when necessary. As a similar trick he "torrefied" (i.e., charred and caramelized) bread to improve its assimilation; possibly this is the origin of the widespread medical superstition that diabetics may have toast when other bread must be forbidden. He invented gluten bread; this started the idea of bread substitutes, from which sprang the bran bread of Prout and Camplin, Pavy's almond bread, Seegen's aleuronat bread, and the numerous later products.
Bouchardat also first introduced the intelligent use of exercise in the treatment of diabetes, and reported the first clinical experiments proving its value. He showed that carbohydrate tolerance is raised by outdoor exercise; and to a patient requesting bread, he replied: "You shall earn your bread by the sweat of your brow."
There is a modern sound to his complaints of the difficulties of having treatment efficiently carried out in hospitals, of the lack of adequate variety of suitable foods, of deception by patients, and of how, even when improved in hospital, they break diet and relapse after returning home. He advocated daily testing of the urine, to keep track of the tolerance and to guard against a return of sugar without the patient's knowledge.
He followed Mialhe in giving alkalies, viz. sodium bicarbonate up to 12 to IS gm. per day, also chalk, magnesia, citrates, tartrates, soaps, etc., also ammonium and potassium salts; he found them often beneficial to the patients but not curative of the glycosuria. He told a patient: "You have no organic disease; there is merely a functional weakness of certain parts of your apparatus of nutrition. Restore physiological harmony and you will attain perfect health."
He used glycerol for sweetening purposes, and introduced both levulose and inulin as forms of carbohydrate assimilable by diabetics, for reasons which well illustrate his intellectual keenness. On giving cane sugar to diabetics, he had found only glucose excreted. Was the levulose utilized or changed into glucose? Levulose proved under certain conditions to be more easily destroyed in vitro than glucose. Accordingly he gave levulose and inulin to diabetics, and found no sugar in the urine. Therefore he recommended levulose for sweetening purposes, and inulin-rich vegetables for the diabetic diet.
Manuel de matière médicale de thérapeutique et de pharmacie, (1838, fifth edition 1873) – Materia medica manual of therapeutics and pharmacy.
Eléments de matière médicale et de pharmacie (Paris 1839) – Elements of materia medica and pharmacy.
Nouveau formulaire magistral, etc. (1840, 19th edition 1874).
Traité d'hygiène publique et privée basée sur l'etiology, 1881 – Treatise on public and private hygiene, based on etiology.
January 1, 1856
Mr. Harvey's Remarks
Dr. Harvey knew that a diet of purely animal foods helped cure diabetes and would likely help obesity as well.
“My patient, Mr. Banting having published for the benefit of his fellow sufferers, some account of the diet which I recommended him to adopt with a view to relieve himself of a distressing degree of hypertrophy of the adipose tissue. I have been frequently urged by him to explain the principles upon which I was enable to treat with success the inconvenient and in some instances distressing condition of the system.
“The simple history of my finding occasion to investigate the subject is as follows: when in Paris in the year 1856, I took the opportunity of attending a discussion on the views of M. Bernard who was at that time propounding his now generally admitted theory of the liver functions. After he had discovered by chemical processes and physiological experiments, which it is unnecessary for me to recapitulate here, that the liver not only secreted bile, but also a peculiar amyloid or starch-like product which he called glucose, and which in its chemical and physical properties appeared to be nearly allied to saccharine matter, he further found that this glucose could be directly produced in the liver by the ingestion of sugar and its ally starch and that in diabetes it existed there in considerable excess.
It had long been well known that a purely animal diet greatly assisted in checking die secretion of diabetic urine; and it seemed to follow, as a matter of course, that the total abstinence from saccharine and farinaceous matter must drain the liver of this excessive amount of glucose, aid thus arrest in a similar proportion the diabetic tendency. Reflecting on this chain of argument and knowing too that a saccharine and farinaceous diet is used to fatten certain animals and that in diabetes, the whole of the fat in the body rapidly disappears, it occurred to me that excessive obesity might be allied to diabetes as to its cause, although widely diverse in its development: and that if a purely animal diet was useful in the latter disease, a combination of animal food with such vegetable matter as contained neither sugar nor starch, might serve to arrest the undue formation of fat.
I soon afterwards had an opportunity of testing this idea. A dispensary patient who consulted me for deafness, and who was enourmously corpulent, I found to have no distinguishable disease of the ear. I therefore suspected that his deafness arose from the great development of adipose matter in the throat, pressing upon and stopping up the eustachian tubes. I subjected him to a strict non-farinaceous and non-saccharine diet, and treated him with the volatile alkali alluded to in his Pamphlet, and occasional aperients and in about seven months he was reduced to almost normal proportions, his hearing restored and his general health immensely improved. The case seemed to give substance and reality to my conjectures, which further experience has confirmed.
“When we consider that fat is what is termed hydrocarbon, and deposits itself so insidiously and yet so gradually amongst the tissues of the body it is at once manifest that we require such substances as contain a superfluity of oxygen and nitrogen to arrest its formation and to vitalize the system. That is the principle upon which the diet suggested in his pamphlet works, and explains on the one hand the necessity of abstaining from all vegetable roots which hold a large quantity of saccharine matter, and on the other beneficial effects derivable from those vegetables, the fruits of which are on the exterior of the earth, as they lose, probably by means of the sun’s action a large proportion of their sugar.
“With regard to the tables of Dr. Hutchinson, referred to in his Pamphlet, it is no doubt difficult, as he says, to determine what is a man’s proper weight, which must be influenced by various cases. Those tables, however, were formed by him on the principle of considering the amount of air which the lungs in their healthy state can receive and apply to the oxidation of the blood. I gave them to Mr. Banting as an indication only of what the approximate weight of persons in proportion to their stature should be, and with the view of proving to them the importance of keeping down the tendency to grow fat; for, as that tendency increases, the capacity of the lungs, and consequently the vitality and power of the whole system must diminish. In conclusion, I would suggest the propriety of advising a dietary such as this in diseases that are in any way influenced by a disordered condition of the hepatic functions as they cannot fail to yield in some degree to this simple method of treatment if fairly and properly carried out; it remains for me to watch its progress in a more limited sphere.
WILLIAM HARVEY, F.R.C.S.
Surgeon to the Royal Dispensary for Diseases of the Ear 2, Soho Square
May 10, 1862
Researches on the Nature and Treatment of Diabetes
The leading British diabetologist of the day - Dr Frederick Pavy, publishes a dietary for the diabetic full of animal meats, eggs, cheese, greens and nuts. "Must avoid eating: Sugar in any form, Bread, Potatoes. Peas. Cabbage. Pastry. Fruit of all kinds."
Dietary for the diabetic:
Butcher's meat of all kinds, except liver.
Eggs, cheese, cream, butter.
Greens, spinach, lettuce, nuts sparingly.
Must avoid Eating:
Sugar, bread, Rice, Potatoes, Cauliflower, peas, broccoli, and many more.
January 1, 1899
Elliott P. Joslin
A Centennial Portrait
Dr Joslin describes how his mother's Type 2 Diabetes could be put into remission if she followed his low carb diet. She was able to live for 13 more years.
- Case #8:
Dr. Joslin's Mother
The first was 73 years old and was Dr. Joslin's mother. The second was 16 years old and the youngest daughter of Dr. James Jackson Putnam, who had been Dr. Joslin's principal mentor in the first year of his practice and his teacher in the medical school. Dr. Putnam was the austere, brilliant and path-finding neurologist whose name is now inscribed on the chair in Neurology at the Harvard Medical School.
It is said that Dr. Joslin specialized in diabetes to help his mother with her disease. While this is not correct, he certainly remained highly interested in her progress as well as in her type of diabetes, hee proudly noted in his later writing that a remission or two occurred in her diabetes when she carefully followed the restraints of a good meal plan. In the first edition of his textbook on diabetes, published in 1916, EPJ described his mother's case, thinly disguised under the topic "Is the tendency of the diabetic glycosuria to increase?"
A woman showed the first symptoms of diabetes in the spring of 1899 at 60 years of age and 5% of sugar was found in June. She had gradually lost during the preceding fifteen years, twenty pounds and weighed 165 pounds when the diagnosis was made. Under rigid diet, the urine promptly became sugar-free, the tolerance rose to 130 grams and safe for very brief intervals and remained so for nine years until 1908. In 1909, a carbuncle appeared. With prompt surgical care, vaccines, the restriction of carbohydrates and the temporary utilization of an oatmeal diet, the sugar disappeared and the carbuncle healed promptly, but the urine did not remain permanently sugar-free, although only about 30 grams of sugar was excreted. Residence in the hospital for a few days in September of 1912, in order to have a few teeth removed, lowered the sugar to 0.8%.
Except for brief periods of illness due to the carbuncle and pneumonia, the patient remained well during all these years and was unusually strong and vigorous for a woman of 73 until she finally succumbed to a lingering illness subsequent to a hemiplegia and death finally occurred due to a terminal pneumonia in 1913.
With his mother's case. Dr. Joslin described the most common presentation of diabetes. When she was diagnosed with diabetes, she was overweight and probably inactive. Had she been born a decade later, Mrs. Joslin might have enjoyed a life lengthened by the use of insulin in the 1920s and antibiotics in the 1930s.
As an aside: Dr. Joslin's inheritance from his mother, Sara Proctor Joslin, left Dr. Joslin a millionaire several times over by today's standards. Sara Proctor, her sisters and one brother were the heirs to a very large fortune derived from their father Abel's leather tanning trade. Sara Proctor became the second wife of Dr. Joslin's father Allen, who was a shoe manufacturer in the town of Oxford. This connection with the Proctor leather tanning business guaranteed the success of the Joslin shoe factory. EPJ was fond of noting that he was a direct descendant of John Proctor of Salem, who had been hanged for defending his principles in the witch trials of 1692.
EPJ's lifestyle, in line with his upbringing and religion, always understated his affluence. However, it afforded him the means to aid family and associates with education and travel, as well as the ability to acquire the property needed to gradually expand his clinic. He underwrote Priscilla White's training in 1928 at the leading pediatric center in Vienna, a typical act of generosity to his co-workers.
January 1, 1903
Social Culture; a Manual of Etiquette and Deportment
A book on etiquette says: "A perfectly safe way to get thin is to eat chopped meat without any potatoes, and if possible eat no bread, butter, or sweets. Thin people who wish to get stout should eat oatmeal, hominy, or any of the preparations of wheat now sold."
How to Reduce Flesh
A man or woman who feels that flesh accumulating too rapidly may lose it by drinking sassafras tea, either cold or hot, with or without sugar, as the taste demands. There might be conditions of the system when it might be injurious, however, and it would be better to consult a doctor before using it. A strong infusion may be made of one ounce of sassafras to a quart of water. Boil half an hour very slowly, let it cool, and keep from the air.
A perfectly safe way to get thin is to eat chopped meat without any potatoes. Drink as little as possible of any fluid. Exercise a great deal without drinking and if possible eat no bread, butter, or sweets. Lemonade, acid drinks of any kind, a little strong tea and saline mineral waters will assist you, but of thees take only as little as possible. Start the morning by drinking a glass of clear water.
How to Increase Flesh
Thin people who wish to get stout should eat oatmeal, hominy, or any of the preparations of wheat now sold. Wheat rolls, corn mush, cream, chocolate, milk, sugar, omelets, jams, eggs, potatoes, bacon, and all other fattening foods.