January 1, 1692
Diabetes Research and Care Through the Ages
Sydenham describes a treatment for diabetes "Let the patient eat food easy of digestion, such as veal, mutton, and the like, and abstain from all sorts of fruits and garden stuff."
Thomas Sydenham (1624-1689), hailed as a second Hippocrates in general medicine, contributed nothing of value in diabetes except a clearer definition as a disease of metabolism. Because the nutritive elements of the blood are not properly prepared for assimilation, they pour out through the kidneys, and the flesh and strength melt away. Later hypotheses of free versus combined sugar are here antipated.
Thomas Sydenham prescribed narcotics and theriak and said, “Let the patient eat food easy of digestion, such as veal, mutton, and the like, and abstain from all sorts of fruits and garden stuff” , but no effective dietetic treatment grew out of this advice. (6).
June 12, 1796
Diabetes It's Medical and Cultural History
Dr Rollo meets Captain Meredith and explains the meat diet to cure diabetes.
"From that period I had not met with a case of Diabetes, although I had observed an extensive range of disease in America, the West Indies, and in England, until 1796." "Captain Meredith, of the Royal Artillery, being an acquaintance. I had seen him very frequently, previous to his going on camp duty in 1794, but then he had no disease; however, he always had impressed me, from his being a large corpulent person, with the idea that he was not unlikely to fall into disease. (Editor: Another instance of Rollo's clinical acuteness.)" "On the 12th of June, 1796, he visited me, and though I was at once struck with the diminution of his size, yet, at the same time, the colour of his face being ruddy, I received no impression, otherwise than of his being in health: a moment's conversation, however, convinced me of the contrary ......
"He complained of great thirst and a keenness of appetite; his skin was hot, dry and parched; and his pulse small and quick. He told me his complaints had been attributed to an old disease, and a liver affection. The thirst, dry skin, and quick pulse, marking a febrile state, depending probably on some local circumstance, and connecting these with the keenness of appetite, Diabetes immediately suggested itself to me. I enquired into the state of his urine, which I found in quantity and colour to be characteristic of the disease; and was at the same time much surprised, that for the two or three months he had been under the care of a Physician and Surgeon, the circumstance of the increased urine had not been known to them. The patient told me, as he drank so much, the quantity of urine had appeared to him a necessary consequence; and of course never having been asked about it, he gave no information. I directed him to keep the urine he next passed, and, on examination, it was found to be sweet; in consequence of which the disease became sufficiently ascertained."
At another point in the case history, Rollo states that Captain Meredith was 34 years of age and was 71 3/4 inches tall. At the time of beginning of the special treatment, the symptoms of diabetes had been present seven months or more and his weight had fallen from 232 to 162 pounds. A view held by some at that time was that diabetes was a primary affection of the kidneys. However, Rollo developed the idea that the disease was "a primary and peculiar affection" of the stomach in which, due to some morbid changes in "the natural powers of digestion and assimilation," sugar or saccharine material was formed in that organ, chiefly from vegetable matter. It was on this basis that he advocated the use of an animal diet together with certain medication designed to quiet the overactive stomach and to diminish the appetite.
Following initial bloodlettings, Rollo's treatment of Captain Meredith was as follows:
"1st. The diet to consist of animal food principally, and to be thus regulated:
Breakfast. One and a half pint of milk and half a pint of lime-water, mixed together; and bread and butter.
Noon. Plain blood-puddings, made of blood and suet only.
Dinner. Game, or old meats, which have been long kept; and as far as the stomach may bear, fat and rancid old meats, as pork. To eat in moderation.
Supper. The same as breakfast."
"2dly. A drachm of kali sulphuratum to be dissolved in four quarts of water which has been boiled, and to be used for daily drink. No other article whatever, either eatable or drinkable, to be allowed, than what has been stated."
"3dly. The skin to be annointed with hog's lard every morning. Flannel to be worn next the skin. The gentlest exercise to be only permitted; but confinement to be preferred."
"4thly. A draught at bed-time of twenty drops of tartarized antimonial wine and twenty-five of tincture of opium; and the quantities to be gradually increased. In reserve, as substances diminishing action, tobacco and foxglove. "
"5thly. An ulceration, about the size of half a crown, to be produced and maintained externally, and immediately opposite to each kidney. And,
"6thly. A pill of equal parts aloes and soap, to keep the bowels regularly open."
A special diabetic diet was undoubtedly one of the foremost therapeutic measures, even before the age of insulin. Even before it was recognized that diabetes was a disorder of carbohydrate metabolism, various kinds of diet had been recommended. A change to a diet decided purely pragmatically, which was nevertheless very effective, did not come until JOHN ROLLO (d. 1809), a Scottish physician, who, in 1797, had achieved good results with a meat diet, made his recommendation (MARBLE; ANDERSON; BECKENDORF). He gave a particularly detailed account The History of Diabetes mellitus 85 of the case of Captain MEREDITH of the Royal Artillery, who became diabetic at the age of 34, and who was very obviously overweight. His diet consisted of a breakfast and supper of milk mixed with lime-water and bread and butter, while his dinner consisted of pudding made of fat and blood and mature, preferably rank pork. In this way he had - without being conscious of it - excluded carbohydrates almost entirely from the diet. The patient of course lost a great deal of weight and felt extremely well.
A second patient was less cooperative and therefore died at the age of 57, 19 months after treatment was begun, mainly - as ROLLO pointed out - because during his last three months he indulged in such things as apple pudding, sugar in his tea, and wine.
The "meat diet" was used well into the 19th century, although gradually it was considered wiser not to cut out all carbohydrates, and patients had a certain amount of carbohydrate added to their diet, even though that caused some glycosuria. This kind of diet was initiated in the middle of the 19th century, mainly by ADOLF NIKOLAUS VON DURING (1820-1882) and RUDOLF EDUARD KULZ (1845-1895). The latter even distinguished between harmful and harmless carbohydrates and found that levulose, inulin, inosit, mannite, and lactose, as well as some root vegetables like celery, comfrey, etc. caused no deterioration of the metabolic condition. But it remains true that many specialists did recommend a carbohydrate-free diet with a lot of meat and fat (DICKINSON; PAVY; SEEGEN; R. SCHUMACHER, STEPP).
June 12, 1797
Cases of the diabetes mellitus : with the results of the trials of certain acids
The continuation of the John Walker Diabetes Case: an entire diet of animal food to be adopted, confining of the following articles; three eggs for breakfast, four oz of cheese for supper, two lbs of meat for dinner, with three lbs of beef-tea in the day.
SECT. II. - Cases and Communications
the first Edition of the Work. From Doctor Marcet. London, January 12, 1798
MY friend and countryman Doctor de la Rive, having informed me that Walker had been readmitted into the Infirmary at Edinburgh, and placed under the care of Doctor Gregory, I requested him to send me an account of the further progress and treatment of the case, which I now have the pleasure to transmit to you.
Continuation of the Case of Walker.
June 12th, 1797.
He had continued perfectly well till within this fortnight, though his urine, which amounted to 5.5 lb. when he left the Hospital, increased gradually to 16 lb. His thirst is at present urgent; his tongue is dry, as well as his skin, which is also hot; says that he sweats frequently ; pulse 108. He complains of a burning pain in the palms of his hands and soles of his feet; of confiderable weakness) and occasional sourness in his stomach, with pain and flatulence. His fleep is disturbed ; his ankles often swell at night.
June 14th. In the last 24 hours he has passed 17 lb. of urine, which is of the common diabetic appearance. Su.aj. pulv. alum. comp. jfs. 4. in die; libat aquae calcis 2 lb. in die. Full diet, with meat for dinner.
June 17th. Urine l6 lb. The dose of the compound powder of alum to be increafed to a drachm.
June 19th. Urine 14 lb. and rather more limpid. The alum powder to be omitted, the lime water continued, and an entire diet of animal food to be adopted, confining of the following articles ; three eggs for breakfaft, four ounces of cheese for fupper, two pounds of meat for dinner, with three pounds of beef-tea in the day.
June 21st. Urine 8 lb, ftill pale, though less so than before.
June 29th. Urine 5 lb. yellower than it has yet been and of a more natural smell.
July 7th. Urine 5 lb. To be allowed 4 ounces of bread daily, in addition to his diet.
July 9th. Urine 5.5 lb. He has drank two cups of tea with sugar
July 11th. Urine 5.5 lb.; a portion of yesterday's was evaporated, and the residuum evidently contained saccharine matter.
July l6th. The bread to be omitted, and the animal diet strictly adhered to.
July 27th. Urine 5 lb. Within these few days his strength has been recruited. He is to be discharged. This Patient was detected in following his habits of irregularity and intemperance; indeed he could not be depended upon.
May 15, 1798
Cases of the diabetes mellitus: with the results of the trials of certain acids
Elizabeth Francis has her diabetes treated with the exclusive meat diet by Dr Gerard - "She still keeps to the plan of eating animal food, and avoiding all vegetable matter, but lives a good deal upon milk; and when I called upon her yesterday, she said she had certainly gained strength lately."
My other Patient, Elizabeth Francis, aged 36, is a married woman. She miscarried near 12 years ago, but never had a live child. Eighteen months after that, she became dropfical, and had 17 quarts of water drawn off by the operation of paracentesis. She recovered of this, and enjoyed tolerable good health for near five years ; but she has been complaining these four years past, and became diabetic about June 1797.
She was admitted into the Infirmary on the 28th of September following, at which time Mary Jackfon was using the carbonated ammonia, and apparently with advantage. Francis was therefore ordered to take it in the same manner, and to pursue the animal diet; I believe she did so rigidly, and with so good an effect, that on the 12th of November she was discharged at her own request, in consequence of feeling herself better than she had been for four years before, and indeed, to her own thinking, well; her strength being much improved, her thirst and appetite very moderate, and her water reduced to four, and sometimes to three pints in the- 24 hours, and free from sweetness, though for a week before she left us, she had been allowed two ounces of bread per day, and for the week preceding that, one ounce per day. On her going home, however, she increased it to a penny loaf per day, and at the same time took less animal food, owing to her inability to procure it ; the consequence was, that in a few weeks she became somewhat weaker, her urine increased a little, and she was frightened. She was therefore re-admitted on the 1 3th of February, and put again upon the animal diet, which she adhered to strictly till the 29th of March, when she was discharged again, to all appearance cured of the disease, though not restored to the strength and vigour of full health.
She still keeps to the plan of eating animal food, and avoiding all vegetable matter, but lives a good deal upon milk; and when I called upon her yesterday, she said she had certainly gained strength lately. I then learned, for the first time, that she had also been affected two different times with an itching about the meatus urinarius, which was exceedingly troublesome to her; the water was increased in quantity each time, and was hot and acrimonious ; but she has had no return of it since she left the Infirmary.
I shall now conclude this account with remarking, that the effects of the animal diet have been so obvious in all the three cases under my care, notwithstanding two of them occasionally deviated very largely, that I perfectly agree with you, in suspecting a deviation from the plan, wherever they are wanting, though the patient should strenuously deny it; for I have experienced the same propensity to deviate, and the same reluctance to acknowledge it, that you have done; and so averse are the other patients to betray the secret, that I believe the truth will seldom be obtained in an Hospital, while the patient remains there.
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.