December 3, 1798
Dr Rollo summarizes the cases of diabetes. He finds a difference between a chronic form(likely Type 2) and an acute form(likely Type 1), and notes the powerful effect of an animal-based diet on both. He also talks about the difficulty of convincing patients to stick with the diet, and how they complain of wanting a pill or drug to take instead. He concludes with vegetables that do not increase the sugar in the urine, such as broccoli, spinach, cauliflower, cabbage, and lettuce, setting the grounds for ketogenic diets.
Of the appropriate Treatment of the Diabetes Mellitus.
Of the appropriate Treatment of the Diabetes Mellitus.
THE principles of the treatment, as established by our cases of the disease, by the view we have given of the proximate cause, and we may further add, by the general success, consist;
In the prevention of the formation or evolution of the saccharine matter in the stomach.
In the removal of the morbidly increased action of the stomach and in its restoration to a healthful condition.
Whatever may be the cause of the formation of the saccharine matter, it is necessary to prevent it, as on its general stimulus in the system, and particularly on the kidneys, very general affections are maintained. Besides, the means employed to prevent such formation may tend to the removal of the morbid action of the stomach and lacteal absorbents, and the increased and altered state of the gastric fluid, on which its production probably depends. Animal food, and confinement, with an entire abstinence from every kind of vegetable matter, afford the general means ; but which may be facilitated by the daily use of alkalines, calcareous and testaceous substances. The quantity of animal food should be restricted, and given in as small quantities as possible to satisfy the stomach : see page 54.
When the urine points out the absence of the saccharine matter, and at the same time its quantity continues more than natural, containing likewise more of the extractive matter in a viscid, or tenacious form, while the appetite remains keen, it may be presumed that the increased morbid action of the stomach is not removed. It becomes then necessary to exhibit the hepatifed ammonia, with an opiate and antimonial at night, and to continue them until the morbid condition of the stomach is removed; the marks of which are, a scarcity and high coloured state of the urine, with turbidness, furnishing on evaporation an offensively smelling and saltish tasted residuum, without tenacity, accompanied with a want of appetite and loathing of food. At this time the tongue and gums will be found to have lost their florid colour, and to have become pallid.
When such a state occurs, exercise is to be enjoined, a gradual return to the use of bread, and those vegetables and drinks which are the least likely to furnish saccharine matter, or to become acid in the stomach, with the occasional use of bitters, &c. Should this period of the disease be overlooked, and the confinement and animal food rigidly persevered in, scurvy, or something akin to it, might be produced. That such might be the termination of Diabetes, the appearances which arose, more especially in Captain Meredith's case, render extremely probable. The gripings, and offensive stools; the oiliness on the surface, and the high colour of the urine; the foetid breath and saltish taste; the great latitude and heaviness, with indifference to either eating, drinking, or moving; were strong marks of a state approaching to scurvy.
When the disease has continued long, it may leave local effects, which may prevent the entire restoration of health ; the most ample form of which might be supposed to consist in mere dilatation, or enlarged capacity of vessels, as those of the kidneys; or in a habit acquired by long continued action. Our first case shows, that these, when the disease has not been of very long duration, may be soon removed. They may, however, prove one of the circumstances retarding recovery in such a length of disease as that of our second case ; but even in this, the kidneys very early partook of apparently their ordinary action. Dissection has shown some morbid condition or derangement of the mesenteric or lacteal absorbent glands, and some altered appearance of the kidneys. There may also arise some derangement of stomach structure, of pancreas, spleen, liver, and possibly of lungs. Such sequelae would probably be sooner and more certainly formed in scrofulous habits. Whenever they occur, recovery must be retarded, if not finally prevented. They, however, will not interfere with the actual removal of the diabetic disease. We suspected some affection of the mesenteric glands, and of the stomach, in our second case; but we are warranted in alleging, that want of steadiness in the patient solely prevented the complete removal of the complaint. The nature of its sequelae, or whether they will remain, so as to maintain a state of chronic disease depending on them for its cause, requires still to be determined. Of this determination we must now continue entirely ignorant, as the patient from unsteadiness died, and was not examined after death.
These are the general means of treatment, and they will be found adequate to the most common circumstances of the disease. We think it, however, necessary to particularise certain cases and states of the complaint. The former, are those of short, or long continuance, acute or chronic in degree; the latter comprehend the progress and fleps of recovery. It is necessary to attend to these distinctions, as they must direct the remedies and regimen to be employed.
When the disease has been of short duration, an entire use of the animal diet may be immediately pursued, with an abstraction of all vegetable food and fermented drink which may have been formerly taken. In this state of the disease it may be acute arid then the diet should be spare; blood-letting and blistering may be necessary, with the use of opening and diaphoretic medicines. But when the disease has been of long continuance, especially in persons advanced in years, and whose habits have been luxurious in point of living, it may be proper to regulate the plan of cure by gradually adopting the animal diet: see the case of the Gentleman of 77 Page 179 and Dr. Stoker's continuation, page 253.
On the removal of the general symptoms, and the return of the urine to a natural condition, which may be ascertained by a comparative examination with the healthy standard of it, as described by Mr. Cruickshank, vegetable substances may be cautiously tried. In the selection of which, the preference should be given to those least likely to furnish sugar, or excite disturbance in the stomach. The urine should now be very frequently examined, and on any appearance of a return of the diabetic state of it, the animal diet must be again strictly renewed. In this way the diet must be varied, until we are certain not only of the removal of the disease, but of the disposition to it. In the prosecution of the plan much steadiness and perseverance are required. We have to lament, that our mode of cure is so contrary to the inclinations of the sick. Though perfectly aware of the efficacy of the regimen, and the impropriety of deviations, yet they commonly trespass, concealing what they feel as a transgression on themselves. They express a regret, that a medicine could not be discovered, however nauseous, or distasteful, which would superfede the necessity of any restriction in diet.
The vegetable substances we have hitherto found the safest, in the change from the animal diet, are, broccoli, spinach, cauliflower, cabbage, and lettuce. These do not seem to furnish sugar when prudently used in the diabetic stomach, after a proper adoption of the animal diet ; but under certain circumstances they have been supposed to produce an acid urine : see the Cases of Mess. Houston and Thomas. When these vegetables have been safely taken, a return to a very small quantity of bread has reproduced the saccharine matter in the urine, and the general symptoms of distress, as thirst, &c. It becomes, therefore, a principal object in the treatment, to vary the articles of diet, so as to gratify the earned desire of the patient, without bringing on a return of the complaint.