Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

. (page 2 of 76)
Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 2 of 76)
Font size
QR-code for this ebook


' "Quasi melle aut saccharo imbutam, mire dulcescere."

8



HISTORY 9

treatment which is very difl&cult to break even at the present time.
Superficially, the sweet taste of the urine appears such a primitive and
fortuitous observation as might have fallen to the credit of anybody
in the 2000 years of European medicine from Hippocrates to Willis.
But, with due allowance for the inevitable element of chance, the above
record makes it clear that this, like most discoveries, fell to the lot of
the man whose point of view and whose methods were capable of yield-
ing discoveries. It marked a triumph of modern independent thought
and objective clinical study over subservience to authority and dogma.
It was of epoch-making importance in the history of diabetes; first,
because it established a radically new and decidedly more accurate
basis for diagnosis, which had previously depended upon polyuria and
other uncertain symptoms; and second, because it led first to the
dietary treatment of RoUo and his successors and later to the experi-
mental work of Claude Bernard and all subsequent investigators of the
normal and abnormal metaboHsm of carbohydrates. It may in some
measure be due to the stimulus given by Willis that for nearly two
centuries (viz., until Bernard and Bouchardat transferred the leader-
ship to France) the important progress in the subject of diabetes was
practically confined to Great Britain.

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 h3^otheses of free versus combined sugar are here anticipated.
In treatment, Sydenham prescribed narcotics and theriak; also, "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.

Richard Morton (died 1698) likewise regarded diabetes as "a con-
tinual flow of nutritive juice pouring out through the kidneys, which

' "Sued sanguini illati per vias urinarias crudi, et inconcocti, exitum sibi
quaerunt; tuide sensim labefactantur vires, colliquescit corpus, et quasi substantia
ejus per banc cloacam exinanitur, cum siti, ardore viscerura, lunxborum coxarum-
que intumescentia, et salivae spumosae exspuitione crebra."



10 CHAPTER I

frequently befalls intellectual persons, and drinkers of brandy and
diuretic liquors."" He was the first to note its hereditary character.
Milk, diet was a feature of his treatment. He opposed the bleeding
and purging in use among some physicians.

Richard Mead (died 1754) was the first to consider diabetes a dis-
ease of the liver, and brought supposed necropsy evidence in support
of this view. On the Continent also began a careful postmortem
search for lesions causing diabetes, but nothing of significance was
found.

Matthew Dobson (1775) completed the discovery of Willis, and
with his paper in English, the history of diabetes emerges froni Latin
into the modern languages. He first grasped the fact that the sweet
substance in diabetic urine is sugar, proving this experimentally by show-
ing that such urine was subject to alcoholic and acetic fermentation,
did not coagulate on heating or addition of a mineral acid, but on
evaporation four pounds of a patient's jirine yielded a whitish cake
weighing four ounces, two drams, and two scruples. This cake
"smelt sweet, like brown sugar, and could not be distinguished from
sugar, except that the sweetness left a slight sense of coolness on the
palate." The urine of the same patient in convalescence yielded a
less abundant dark residue which was not sweet. Dobson also was the
first to discover a sweet taste in diabetic blood serum. He therefore
concluded that the sugar contained in normal chyle is assimilated by
the body, so that the trace in normal blood is so slight that its taste is
overcome by that of the salts. In diabetes this transformation is
slowed, so that sugar accumulates in the blood. Also, the quantity
of sugar in some cases is too great to be derived entirely from the chyle,
therefore sugar must be formed by some abnormal fermentation in the
body. The diabetic loses flesh and strength because of the loss of
nutritive material in the urine, therefore he should eat as much as
possible to make up for this loss."

^^ "Continuus succi nutritii fliixus per renes decurrens, qui cogitandibus, et
vini Gallici liquorumque diureticorum potatoribus plerumque accidit."

" A prototype of the modern fallacy of replacing through the diet the calories
lost in the urine.



HISTORY 11

Thomas Cawley*^ (1788) by a careful account of a single case, earned
credit for the first example of diabetes decipiens, the first diagnosis
of diabetes by demonstration of sugar alone, and the first description
of a pancreatic lesion in a diabetic necropsy. He, however, regarded
diabetes as a disease of the kidneys.

William Cullen (1709-1790) was the first to regard diabetes as a
disease of the nervous system, comparing the polyuria with that seen
in spastic states. He also wrote: "I think I have met with one in-
stance of diabetes, in which the urine was perfectly insipid; and it
would Seem that a like observation had occurred to Dr. Martin Lister.
I am persuaded, however, that such instances are very rare, and that
the other is by much the more common and perhaps the almost uni-
versal occurrence, I judge, therefore, that the presence of such a
saccharine matter may be considered as the principal circumstance in
idiopathic diabetes." Thus, Cullen and Lister called the attention

'^ This name often appears in the literature incorrectly as Cowley. The essen-
tials of his concise report are interesting to quote verbatim.

"Allen Holford, Esq., aged thirty-four years, strong, healthy, and corpulent, ac-
customed to free living and strong corporeal exertions in the pursuit of country
amusements, in December, 1787, was seized with diabetes; but the cause of the
great degree of emaciation and debiUty which gradually came on was not dis-
covered until March 20, 1788; at which time his urine was found to be sweet,
fermentable with yeast, and two pounds, on evaporation, jdelded about five or six
ounces of sweet black extract, exactly resembling that preparation of melasses
made by confectioners for children, and vulgarly called coverlid.

"Within the above mentioned period the quantity of urine evacuated was never
observed to exceed what is usual in health, or to be disproportioned to the ingesta,
though the state of it had been frequently inquired into, and even the quantity of
liquids drank and voided measured. For these reasons the quality of it was not
suspected until it became inconceivable, considering the quantity of aliment taken
in, how such a degree of exhaustion could ensue, unless the body was drained by
the quality of what was rejected as apparently excrementitious.

"Variety of medicine, the usual consequence of inefficacy and despair, were suc-
cessively administered. Decoction of bark with vitriolic acid and alum, with
astringents and aromatics, with chalybeates, with sacc. saturni and opium, and with
cantharides, together with cold bathing in salt water, were theprincipalmeans used,
and at first had a very good effect; but soon afterwards every medicine disagreed
with the stomach, and the patient gradually sunk and died on the 18th of June."

"The pancreas was full of calculi, which were firmly impacted in its substance.
They were of various sizes, not exceeding that of a pica, white, and made up of a



12 CHAPTER I

of the medical profession to the possible existence of diabetes insipi-
dus.i' GuUen first added the adjective "mellitus" to the name of the
disease. Cullen's theory of diabetes was that of Dobson, with whom
he had discussed it. "I formerly communicated this idea to Dr.
Dobson, who adopted it, and published it; but I must confess that
the theory is beset with difficulties, which cannot at present be solved."
He gave a wholly pessimistic view of the treatment and prognosis;
he had tried the known methods on twenty diabetic patients and failed
to save any of them.

John Brown (1735-1788) conceived life as motion. Diabetes, as a
disease of weakness, should be treated by exercise, which should be
neither too slight nor too severe. But Brown's treatment was inferior
to that of his predecessor Celsus, in that abundance of food and drink
was also prescribed for strengthening.

Johann Peter Frank (1745-1821), the most renowned German phy-
sician of his time, gave the name of diabetes decipiens, or deceptive
diabetes, to the condition of glycosuria without polyuria described by

number of lesser ones, which made their surface rough, like mulberry stones; and
in all respects they appeared analogous to the calculi which we sometimes meet
with in the salivary ducts. The right extremity of the pancreas was very hard,
and appeared to be scirrhous."

"Experiment I. — A small quantity of urine, set by in a phial, spontaneously
entered into the viaous, and then into the acetous fermentation, discharging a
great quantity of mephitic gas. A white cloud formed in the center, which gradu-
ally fell to the bottom in the form of a white precipitate. In short, the whole of
this experiment corresponded with Dr. Dobson's."

"Experiment IV. — ^A small quantity of the extract put into spirit of wine neither
dissolved nor communicated any colour to it, but immediately became very hard
and brittle.

"It appears, by the last experiments, that the extract consists of sugar united
with gummous or coagulable matter, all of which ought to remain in the body for
its support, and that little of what is excrementitious passed through the kidneys
but superabimdant water, the vehicle of this nutritious matter."

^^ They did not clearly demonstrate the existence of such an entity, for Bard-
sley (mentioned by Watt, p. 14, who gives the above quotation) criticized their
findings by showing that a urine with no perceptible sweet taste might form
more or less oxalic acid when examined chemically. This formation of oxalic acid
on treatment with a mineral acid was the first chemical method for the demon-
stration of sugar in urine, and was used by RoUo and his immediate successors.



HISTORY 13

Cawley. He also established the definite division and nomenclature
of diabetes insipidus or spurius and diabetes mellitus or verus.

Francis Home diflCerentiated "watery" and "milky" diabetes." He
proved experimentally that the urine of a diabetic patient was not in
excess of the fluid in food and drink. He isolated sugar from the urine
of two patients, respectively an ounce and an ounce and a half of
sugar to the pound of urine. Addition of yeast to the urine was fol-
lowed by fermentation; the urine lost its sweetness and acquired the
taste of small beer. He failed to confirm Dobson's observation of the
sweetness of diabetic serum. He upheld Dobson and CuUen's theory
of diabetes as a defective assimilation of food. The sweet urine,
milky in some cases, was evidence to him that vegetable foods are not
properly assimilated in diabetes; the sweet chyle, which is the first
product of digestion, is not converted into ammonium salts as it nor-
mally should be. Therefore diabetes should be curable by strict meat
diet; but he was unable to make this theory succeed in practice, and
he went on to try a multitude of drugs without result. Given suffici-
ent courage or skill to build on this theory a successful practical
method, he might have been the founder of the new era of therapy.

^*The relatively frequent mention of milky urine among early writers is re-
markable. Perhaps the appearance was due to fermentation. Whether in the
absence of dietary regulation there may have been occasionally a true visible
lipuria is a possible question of interest.



III. The Third Period, or Period of Empiric Treatment
(1796-1840-50).

John Rollo, a surgeon-general of artillery in the English army,
ventured to try an entirely original method on the first case of dia-
betes that he had ever treated. "For the case I had seen at Edinburgh,
and Dobson's account, with Dr. CuUen's opinion, had prepossessed
me with the idea of the disease being a primary and pecuUar affection
of the stomach" ( (2), p. 5)." This first patient, a certain Captain
Meredith, treated in 1796, shares some of his physician's fame, not
unjustly, in view of what he went through. The treatment began
with bleeding, which is said to have made the patient feel better.
Confinement to the house was ordered, preferably to one room, with
the utmost possible quiet and avoidance of exercise. The bill of fare
was as follows: "Breakfast, I5 pints of milk and J pint of lime-water,
mixed together; and bread and butter. For noon, plain blood pud-
dings, 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." The skin was to be greased daily with hog's
lard, flannel worn next the skin, and an ulceration about the size of
half a crown to be maintained opposite each kidney. At first, kali
sulphuratum was ordered several times daily, but later this was ex-
changed for "hepatised ammonia" (ammonium sulphide), "a medicine
proposed by Mr. Cruikshank, who was of the opinion that it might
prove a more certain and active medicine than the other on the stom-
ach, in diminishing its action, as well as that of the system in general."
Wine of antimony and tincture of opium were to be taken at bedtime,
and "in reserve, as substances diminishing action, tobacco and fox-
glove." Captain Meredith's age was thirty-four, and his diabetes of
seven months' standing, apparently moderate in degree. He steadily

^' This rules out the statement by various authors that Rollo received his stimu-
lus from Home.

14



HISTORY 15

improved, in spite of occasional indulgence in apple pie or beer. Along
with the gain in strength and disappearance of symptoms, Rollo noted
diminution in the quantity and sweetness of the urine, in the amount
of sugar obtained on evaporation, and in the oxalic acid test. After
cessation of glycosuria, the strict diet was gradually relaxed, and it is
complimentary to RoUo's judgment that the first vegetables permitted
were cabbage, boiled onions, salad, mustard, common radish, and
horse-radish. The patient resumed his military duties. Rollo under-
took his second case, that of "a General Officer." Here the diabetes
was of three years' duration, and the patient, aged fifty-seven, re-
peatedly broke even the rather mild regimen imposed, so that he
ultimately died.

Various other matters of interest are contained in Rollo's book.
The diuretic action of sugar is clearly recognized. ((2), p. 24) : "The
serum of the blood apparently containing less saccharine matter than
the urine, may depend on the power of the kidneys in separating it
in common with the other saline matters of the blood; but proving a
new and peculiar stimulus, their action is increased, and the saccharine
matter consequently separated speedily and in proportion to its for-
mation in the stomach." (P. 37) : "A diet of animal food, as rancid as
possible, was proposed in our case, with the view of preventing the
formation of sugar in the stomach, and by that means to remove the
peculiar stimulus which supported the increased action of the kid-
neys." A number of other physicians wrote enthusiastically concern-
ing the benefits of the new method. Currie (pp. 147 and 184 of
Rollo's book, 1798) reported experiments of weighing ingesta and
egesta, weighing the patient before and after bathing, etc., to refute
the ancient error of excess of fluid output over intake. Marshall de-
scribed a necropsy showing lipemia, "chyle in the subclavian vein;"
and "there appeared to be no proper blood in the body, but instead of
it, a hquid nearly resembling well made thin chocolate. All the veins
were filled with this singular brown blood, which had a sickly, sweet-
ish, slightly sour smell (not tasted)." On page 331 is the first re-
corded observation of an important phenomenon, — a diabetic aged
twenty-five, "with the odor of decaying apples in his breath." The
letters from physicians show that diabetes was a rarity and a curiosity
to them. Dr. Monro is quoted (p. 364) in a statement of the nature of



16 CHAPTER I

diabetes, which may well bear comparison with present-day views:
"Were I to give a theory of this wonderful disease, I would say that it
arises from a defect of the animal or assimilatory process, by which the
aliment is converted into the nature of our body." RoUo's theory was
inferior to that of Dobson and Monro. He held that diabetes is a
disease of the stomach, with increase of its activity, secretion of an
abnormal gastric juice, and probably increased activity of the lac-
teals; that "the saccharine matter is formed in the stomach, and
chiefly from vegetable matter." The source of sugar was to be cut
oif by restricting the diet to animal food; but milk was provisionally
included under animal food, and, to indulge the patient, a little bread
was permitted. Also, the abnormal activity of the stomach should be
depressed, so as to check bulimia and restore the secretion of a normal
gastric juice. Therefore, drugs were chosen to produce anorexia and
nausea — ammonium sulphide, antimony, opium, digitalis, tobacco.
The use of rancid fats in the diet was for a similar purpose. Fat in-
deed was responsible for the first fasting treatment of diabetes (RoUo
(2), p. 36). "Thus Villanovanus relates that a certain man, affected
with this disease, eat pot-bread dipt in lees of oil; and that a woman in
the like case drank twice the melted fat of beef, with a like quantity
of hot oil; and that both these patients contracted so great a loathing
of food, that neither of them eat anything for five days, and so got rid
of their distempers." It so happened, therefore, that the very incor-
rectness of RoUo's theory aided in his therapeutic success. From the
results achieved with his method by himself and others, he drew the
conclusion (p. 141) that "diabetes mellitus is so far understood as to be
successfully cured."

Dupuytren and Th6nard reported good results from the RoUo diet
in France, considering it as specific for diabetes as quinine for malaria;
yet they recognized that the cure is never complete, as patients re-
lapse whenever they discontinue the diet. They investigated the
properties of diabetic urine, demonstrating that on fermentation it
yielded carbon dioxide and alcohol; this was considered to prove the
presence of sugar, but this sugar was thought to be of a peculiar kind
with little taste.

Nicolas and Gueudeville held a theory similar to that of RoUo.
They regarded diabetes as a disorder of intestinal digestion; the chyle



HISTORY 17

is normally composed of nitrogenous substances, but in diabetes it
contains imperfectly elaborated materials saccharine in character and
unsuited for the nutrition of the body.

Robert Watt (1808), a Scotchman, reported benefit from treating
diabetes with the Rollo diet, bleeding, bhstering, antimony powders,
and sometimes mercury. Both food and drink were severely restricted
in quantity. Watt's clinical ability, and the position properly belong-
ing to him in the history of this subject, may be indicated by quota-
tions from his remarkable little book." His admonitions may be
profitable to many even at the present time.

Thomas Christie (1811) first brought to European notice the fact
that diabetes was known to the ancient Hindus. He described the
frequency of diabetes in Ceylon, and his success with the Rollo treat-
ment there.

"Watt, preface: "The rapid restoration of health after venesection, blistering
and an abstemious diet in cases, where from the great prostration of strength and
excessive emaciation, a stimulating mode of treatment seemed indicated, dis-
closes views of the animal economy by no means favourable to some modern opin-
ions. It is to be feared that a dread of debility and an emaciated state of body,
from an inflammatory, not a hectic cause, have sometimes deterred practitioners
from employing depletion, and the patient has been quietly resigned to his fate.
As diabetes is so obviously aggravated by too much aliment or stimuU, and as
there is such an attendant buUmia, the first aim of the practitioner should be
to remove a portion of that food, which, since it does not nourish, must oppress
and injure the system. Animal diet accomplishes this object to a certain ex-
tent, for during its use, the quantity of ingesta is necessarily diminished, and a
partial abstinence is enforced. More might have been done if, instead of an
exclusive confinement to animal food, the quantity of ingesta were gradually
diminished, till no more were received than the digestive organs could easily
prepare, and the functions of assimilation successfully convert to the support
and nourishment of the system. Artificial depletion may, in some measure,
supersede the necessity of too strict adherence to an abstemious diet; but the end
will imdoubtedly be more easily, and effectually accomplished if the patient can
exert the requisite fortitude to resist the cravings of appetite, and to repress urgent
thirst. These indulgences increase the flame, which sooner or later consumes the
patient. We aid the cure by a diminution of the supply, and the same means pro-
tract the fatal period, or smooth the passage to the grave, when a cure is beyond
the reach of art."

Watt (p. 29 ff.) described the treatment of a laborer suffering from moderate
diabetes. The man was bled daily, the quantity of blood taken being generaUy



18 CHAPTER I

Chevreul in 1815 demonstrated that the sugar of diabetic urine is
identical with glucose.

Latham (1811) distinguished two forms of diabetes, the saccharine
and the seirous. Likewise Gregory (1825) described the differences
between diabetes mellitus and diabetes insipidus. Such observa-
tions were of importance in settling the existing doubts among the
medical profession as to the decisive import of glycosuria for the diag-
nosis of diabetes.

Pelham Warren (1813) may be mentioned as the leading English
opponent of the Rollo treatment. He regarded dietary restriction as
of merely secondary importance, and voiced the frequent objection
that patients would not adhere to such a diet. He placed chief de-
pendence on large doses of opium, by which, without dietary regula-
tion, he obtained diminution of glycosuria and polyuria. Some
authors have referred to him as the originator of opium therapy. He

fourteen or eighteen ounces, but on one day twenty-four ounces. The bleedings
were well borne, and after^ twelve days there was marked improvement. Anti-
mony powders were also used, and the patient in consequence "was very sick and
uneasy all day; had no appetite for food." Again (p. 35): "The antimonial
powders appeared to have a more decided effect. They produced very severe
sickness, vomiting, and commotion in the stomach and bowels. The night after
taking these, the urine was greatly reduced, and next day he found himseK un-
commonly weU. On repeating them, they had not such violent effects, nor was
the relief obtained so decisive. . . . Anything which produces sickness has
a temporaiy effect in relieving diabetes, by diminishing the quantity of ingesta.
The antimonial powders seemed to possess no other specific action. During the
two days he was under their influence, he vomited everything, and was not dis-
posed to take either meat or drink, hence when the supply is cut off, the excretion
must diminish of course." (P. 204) : "The loss of balance between the digestive
and assimilative organs may be produced in two ways" (underf unction of lungs or
overfunction of lacteals). (P. 205) : "In some diseases the receptive power is not
only continued but even increased, whUe the assimilative powers remain at or
below their normal level." Finally, (p. 212): "Diet. From the very nature of the
disease, abstinence becomes an indispensable part of the practice. This doctrine,
however, is often very contrary to the feelings of the patients, who are apt to urge
in their defence that nature is the best judge of what is necessary for their support.
They feel weak, they have a strong craving for food, and they can see no reason



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 2 of 76)