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).
De la glycosurie ou Diabète sucré son traitement hygiénique, Paris, (1875, second edition 1883) – On glycosuria or diabetes mellitus and its hygienic treatment.
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.
November 22, 1883
On the Treatment of Diabetes - A Clinical Lecture by Professor Dojardin-Beaumetz
In a clinical lecture in Paris in 1883, Professor Dojardin-Beaumetz explains how Rollo, Bouchardat, Cantani, and Seegen figured out how to remove starch and carbohydrates from the diet to help diabetics.
ON THE TREATMENT OF DIABETES. A CLINICAL LECTURE DY PROFESSOR DOJARDIN-BEAUMETZ, Member of the Academy of Medicine Physician to the Hôspital St. Antoine, Paris, France
The dietetic treatment of diabetes deserves the first place. Ever since John Rollo at the end of the last century first called attention to the influence of foods in the production of glycosuria, all authorties have felt the obligation to regulate rigorously the diet of diabetic patients. At their head is Bouchardat; after him I will mention especially Seegen, a German writer, and Cantani, an Italian, and what I have now to offer respecting the hygienic regime of this affection will be based on a careful study of the contributions of these three men. The hygienic treatment is founded on the endeavor, far as possible, to exclude from the food all substances capable of forming glucose. This glucose may be derived from sugar in the ingesta, or from starch which has undergone conversion in the alimentary canal. These glycogenous principles, then, should bo suppressed. All this, however, though simple in theory, is difficult in practice.
March 30, 1889
Treatment of glycosuria
Dr Purdy has caustic words for medicine when it comes to treating diabetes. "It remains, to speak of the medicinal treatment of glycosuria, and I may as well state frankly at the beginning that I have little faith in the curative power of medication over the disease, while on the contrary I am satisfied that the use of drugs in these cases is often productive of harm."
[This is the second half of the paper.]
In accustoming the patient to the more strict form of diet, care should be exercised not to permit the stomach to be overloaded. The beneficial effects of temperate eating in glycosuria were very prominently illustrated during the siege of Paris, as Bouchard observed that sugar entirely disappeared from the urine of diabetics in whom up to that time it had persisted, even though they had been living on a carefully regulated diet. The diminution in the quantity of food, occasioned by its great scarcity during the siege, effected that which alteration in quality had failed to accomplish.
The more slowly food is submitted to the digestive forces, the more completely is it likely to become assimilated. Tight meals frequently repeated is the better rule to follow, at least until the patient becomes accustomed to the change. It is important also that the diet be varied as greatly from day to day as the range of food in the list will permit.
I have repeatedly placed diabetic patients that were considerably under 20 years of age upon the strict lines of diet herein indicated, with the result of completely eliminating the sugar from the urine for weeks and months together, and without resort to medication. Thus it may be seen how much may be expected from proper dieting, even in cases that we are forced to consider as ultimately hopeless ones.
By way of illustration—a year ago this month a lad of 18 years came to me from a distant State with a history of diabetes of over a year’s standing. His symptoms, as is usual in such cases, were great thirst, morbid appetite, polyuria, and advancing emaciation, with a very considerable amount of sugar in his urine. His physician at home had put him upon a diet scarcely so limited as the ‘ ‘ first step ’ ’ laid down in this paper, and but a slight check was put upon the disease. I gradually restricted his food allowance until it conformed to the strict diabetic diet already laid down. His thirst gradually subsided, the quantity of urine diminished, and at the end of six weeks no trace of sugar was to be found in his urine, and he began to regain his lost weight. •Under a continuance of this course the urine remained normal in quantity and free from sugar for about three months, when he returned to his home with directions to follow as closely as possible the course that had so greatly benefited him. This case may be fairly ranked among the most unpromising ones, chiefly on account of the patient’s age; for it is a rare exception to meet with a case under 20 years of age in which the disease does not rapidly prove fatal unless the patient be very strictly dieted.
It may be said of glycosuria in general that its severity is usually in inverse ratio to the age of the patient. The youngest diabetic I have seen came under my care a short time since, in the person of a little boy 3 years and 2 months old. In this case the polyuria was so pronounced that a nurse had to be provided to attend him at night, as he “ wet the bed’’ from six to eight or more times each night. It may be of interest to note that he was put upon an animal diet, including milk, which soon lessened his polyuria so that the patient did not urinate during the whole night. I believe milk is more easily assimilated by children than by adults ; at any rate it seems to agree better with them in these cases ; and this is very fortunate, since we are almost driven to its use in diabetics of tender age. As a rule, in patients under middle age, we shall be obliged to bring to bear against glycosuria all our resources of dieting in the more strict form. I have met with an exception to this rule in the case of a Jewess, 29 years of age, in whom moderate restrictions of diet have kept the urine practically free from sugar for the past year and a half, only exceptional traces having appeared occasionally. It has been remarked by several observers that diabetes is frequent among Hebrews, and that in them the disease is always of. mild form. My own experience tends to confirm the latter statement. I have, indeed, at the present time, three cases in Hebrew women under treatment, and they are all of mild form.
For the most part the milder forms of glycosuria are met with in people that have passed the age of 40 or 50 years. In this class of cases our resources against the disease are always more effective ; indeed, one or two years careful dieting not infrequently leads to permanent cure.
It remains, to speak of the medicinal treatment of glycosuria, and I may as well state frankly at the beginning that I have little faith in the curative power of medication over the disease, while on the contrary I am satisfied that the use of drugs in these cases is often productive of harm. My conclusions upon this point have been reached through separating the dietetic from the medicinal treatment, and then comparing the results of each. When a system of diet and medication are employed together from the beginning, the benefits accruing from diet may be attributed to the medicines, while the unfavorable influence of medication may be attributed to the disease. Our faith has become so supreme in the efficiency of medication in these days, that we are apt both to permit ourselves to be misled in its favor, and to overlook its possible injurious effects.
Of the various drugs that have been recommended in glycosuria, opium, perhaps, maintains its reputation best and has become the most popular. Opium undoubtedly tends to restrain the excretion of sugar in these cases, but the doses necessary to accomplish this result are so large that the drug is likely to induce constipation and impaired digestion, and thus any good accomplished through its use is more than counterbalanced by resulting evil. I have recently gone over this ground very carefully in a series of trials systematically conducted. Three cases were selected, in each of which the sugar excretion had been reduced by strict diet to about i per cent. They were all typical cases of true diabetes of central origin; and no little pains had been expended in reducing the sugar to so small a percentage, and maintaining a good general condition with excellent digestion and assimilation. Under gradually increasing doses of opium the sugar excretion was reduced Somewhat in all the cases, but sooner or later constipation, loss of appetite, or nervous disturbances compelled the dis- continuence of the drug without exception. This has always been my experience in the use of opium in glycosuria ; nor have I found any material advantage in the use of morphia, its bimeconate, or the use of codeine. They all comport themselves much the same as does opium when used in equal physiological doses.
Ergot is probably the next most popular drug employed in the treatment of glycosuria. In the necessarily large doses required to effect the disease it is unsuitable for lengthy periods of administration. Its controlling power over glycosuria is very feeble and uncertain, and on the whole it may be regarded as unworthy of much confidence.
Bromide of arsenic and syzygium jambolanum have recently been highly lauded in the treatment of glycosuria. I have known the former to be administered in the largest doses (25 drops Gilliford’s solution), during which time the patient continued to excrete urine that contained 30 grains of sugar to the ounce. Upon withdrawing the bromide of arsenic and placing the patient upon a restricted diet, I had the satisfaction of seeing the sugar speedily reduced to 2]/i grains to the ounce. I have administered jambul to a number of my patients, but without noticing any favorable change that I could fairly ascribe to its use. A number of other drugs have been more or less highly extolled for their alleged specific influence over glycosuria. Among these may be mentioned iodoform, bromide of potassium, iodide of potassium, arsenic, sodium phosphate, nitrate of uranium, salicylic acid, picric acid and Calabar bean. There does not, however, appear to be sufficient evidence in favor of any one of these to entitle it to any degree of confidence. Carefully discriminated from the benefits derivable from dieting, these drugs are probably nearly inert so far as their influence over glycosuria is concerned.
The legitimate field of therapeutics in glycosuria becomes practically narrowed down to the treatment of its accompanying symptoms, and upon this point but few words will be here added. It has already been stated that disordered digestion is so frequent in glycosuria as to constitute it an accompanying rule. Indeed, many of the milder cases owe their origin without doubt to this cause. The digestive and assimilative functions should therefore receive especial support through such agents as experience has taught us prove the most efficient. Among these may be mentioned, pepsin and the vegetable bitters— and especially strychnia. The latter I have come to regard with increasing favor.
Constipation, so frequent an accompaniment of glycosuria, should be especially guarded against, as this condition reacts very markedly in enfeebling the digestive and assimilative powers. I have an especial preference for the natural alkaline purgative waters to meet such requirements, since they relieve the over-acid condition of the intestinal canal so common to the disease. Fried- richshall or Sprudel—or the salt made by the evaporation of the latter—given before breakfast,
in hot water, seem especially appropriate. In middle-aged people inclined to stoutness and overeating, a course of purgation by either of these agents often proves highly beneficial.
The various nervous disturbances accompatiy- ing glycosuria are, on the whole, perhaps best met by the use of bromides—especially that of sodium or lithium. It is not uncommon to meet cases of glycosuria complicated by anaemia. When pronounced, this condition is frequently attended by oedema of the extremities, and under such circumstances the liberal use of iron and arsenic is attended by excellent results. The appearance of multiple boils is not uncommon in glycosuric patients; a complication generally considered ominous of approaching danger. I have seen a disappearance of this complication in two weeks under the use of quinine—8 to io grs. daily— after having resisted other measures for nearly three months.
The most dangerous, and certainly the most rapidly fatal, of all the complications of glycosuria is that of Kussmaul’s coma—sometimes called acetonaemia. Since the treatment of this complication has thus far proved so unsatisfactory, a knowledge of the conditions commonly leading thereto should be borne in mind, in order to guard the patient against it. Constipation, mental emotion, and fatigue seem especially to predispose to this complication, while a highly acid state of the urine often precedes it. I have repeatedly, in these cases, observed sudden death by coma to constitute the penalty of a hunting expedition, or long railway journey entailing unusual fatigue. If the early indications of approaching coma are observed, stimulants and hot baths should l>e resorted to without delay. It is believed that diabetic coma is brought about by some toxic agent in the blood, perhaps derived from alcoholic fermentation of glucose. Whether this be acetone, or some other agent, we are warranted by certain f facts in believing that it is of an acid nature and, therefore, large doses of alkalies seem the most appropriate remedies to employ. An ounce of tartrate or citrate of soda dissolved in a pint of water may be given three or four times a day. The intravenous injection of sodium carbonate, with chloride of sodium, is strongly advised if coma has already become established. Under the latter circumstances, however, recovery is extremely rare under any form of treatment. On the whole, then, promising results are only to be expected by attempts at warding off the attack through such measures as have already been suggested.
In concluding what has been intended as a practical review of the management of glycosuria, it seems desirable to emphasize the immense importance of careful dieting as greatly outweighing all our other resources combined. This fact should be strongly impressed upon the patient from the beginning. He should be taught to rely little upon medication, and the most effective means of doing this is to show him how much can be accomplished by careful dieting alone. When he has once learned through experience that the amount of sugar in his urine always bears a direct ratio to the prohibited foods indulged in, he is less likely to overstep the proper limits imposed. With his thirst, polyuria, and other discomforts relieved—a sure sequence of careful conformance to the rules—unless he be greatly lacking in intelligence and gratitude, he will cheerfully submit to the conditions imposed, since he will see and feel how greatly he is indebted to them.
163 State St., Chicago.