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of diabetes; but, though still nominally defending it, and assigning
great importance to the liver and the thyroid, his later writings con-


cede the essential contentions of his opponents ((2), p. 69): "But
really these differentiations do not shake the essential unity of the
metabolic disturbance in diabetes in the very least. I think I shall
be voicing the opinion of all pathologists when I say that every indi-
vidual who has a diminished tolerance for carbohydrate, either per-
manently, or extending at least over a considerable period) and thus-
exhibits the most important clinical symptom of diabetes, must be
considered as a subject of pancreatic insufficiency. We need not
always expect to find perceptible anatomical evidence, for there may be
functional impairment where no macroscopic or microscopic patho-
logical appearances can be discovered." Von Noorden has been un-
fortunate in his support of false theories, but he deserves credit as the
principal upholder against the Naunyn school of two doctrines which
now appear to be justified by facts : first, that diabetic acidosis repre-
sents something more than lack of carbohydrate; second, that the
symptoms of acidosis, including the fatal termination, are due to some-
thing more than simple acid intoxication. Von Noorden's clinical
work has consisted chiefly in systematizing and improving the Kiilz;
method in some details. He justifies the Kiilz treatment by the state-
ment that he has under his care some of Kiilz's patients who have re-
mained in good condition for seventeen years. The one distinctive
feature introduced by von Noorden, the oat cure, was previously-
discussed. Though he stands as the most prominent believer in the
formation of sugar from fat, this belief has not influenced his treat-
ment; for he "perhaps gives diabetics greater quantities of fat than-
anybody else;" he regards fat as the anchor of their salvation; he has.
almost never seen increase of glycosuria from it, except when digestive
upsets occur, in which many diabetics immediately excrete more
sugar ( (1), p. 96). Nevertheless he recognizes occasional "fat-sen-
sitive" cases. High fat intake, greatly in excess of the requirement,
is said to increase metabolism, like every overabxmdant diet, and'
therewith increases the sugar excretion. But in order to produce this^
increase of glycosuria, the quantities of fat required are so high as to-
be superfluous and of no practical importance in treatment. In the
presence of severe acidosis, it is held that butter should be avoided,
but that ordinary animal and vegetable fats cause no increase of
ketonuria in a patient accustomed to strict diet ( (1), p. 141), and even*


during the transition to strict diet the administration of alkali is an
adequate precaution (p. 293), so that fats are given freely even under
these circumstances. In addition to alkali, von Noorden formerly-
treated impending coma with carbohydrates, especially oatmeal, milk,
and levulose; but recently he has found that one or two fast-days are .
far more effective. On these days the only food is alcohol in large
doses, up to 200 to 250 cc. cognac. As soon as the glycosuria and aci- .
dosis are thus partially controlled, he hastens to inflict an oat cure
( (1), p. 388). Here also the fat intake is limited, thus contradicting
his previous contention. A large proportion of severe cases are con-
ceded to be hopeless ; here a liberal varied diet is allowed, the glyco-
suria being merely limited and the strength maintained ( (1), p. 371;
(2), p. 151) and 15 to 20 gm. sodium bicarbonate and about 6 gm.
calcium carbonate given daily for the acidosis ( (l), p. 389) . Not only
strict diet or vegetable days, but also actual fast-days, are interposed
in this program. ( (2), p. 93) : "There are but few diabetics who do not-
become sugar-free on these days,^' and you will at the same time notice
an enormous fall in the acetonuria. Fast-days, combined with bed
rest, are excellently borne. I never find that the patient's strength
is unduly diminished by them. An important result is regu-
larly attained in the immediate and well-marked rise of tolerance
which follows." Again ( (2), p. 152) : "We need have no fears that the :
hunger day will damage seriously the general nutrition. Of course the
body weight falls on the fast-day, but the loss is rapidly made up, and
by this combined method we often obtain considerable increases in
weight." Von Noorden refers to these fast-days as "metabolic Sun-
days." The metaphor is striking and accurate, but the insufficiency
of the metabolic rest and the attempt to build up weight in the pres-
ence of glycosuria and acidosis are fatal to the patients and to the

Weichselbaum and Stangl in 1901 first observed the specific "hy-
dropic" degeneration of the islands of Langerhans. It is remarkable
that one of the most important contributions to the morphologic

" Remarks of this sort show the actual mildness of many cases classified by
writers as severe.


pathology of diabetes should have met with such a complete lack of
confirmation or credence.

Among English writers, Williamson in 1898 published a text-Hook
possessing permanent value by reason of the author's great experience
and wide knowledge. Recently (2) he has made some use of a diet
consisting only of casein and cream given in small quantities every
two hours. He attributes the benefit to this latter device and to the
reduction in the total quantity of food, but says: "In the most severe
forms of diabetes with marked diacetic reaction in the urine, I do not
at present feel justified in recommending the casein treatment."

Cammidge ( (1), p. 297) held that with impaired fat metabolism in-
dicated by wasting, lipemia, and acetonuria, a limitation of fat in the
diet and its partial replacement by carbohydrate is advisable, even
though glycosuria be increased. More recently (2) he has advocated
a treatment resembling that of Lenne. He aptly remarks that fat
and protein metaboHsm should be considered as well as that of sugar,
and that the absence of any striking color reaction for protein disturb-
ance, comparable to those for detecting sugar or diacetic acid, goes far
to account for the neglect concerning the protein metabolism. The
treatment consists in reduction of protein, rest in bed, and opium when
nitrogenous equilibrium cannot be established by any other means.
In adopting recently the fasting treatment, he has emphasized the
study of the protein metabolism for judging the condition and progress.

Modern France has not lived up to Bernard and Bouchardat in this
field. Not only has it remained relatively barren of important origi-
nal contributions, but also, outside the practice of a few specialists,
the knowledge and management of diabetes seem to fall below the high
general standard of French medicine. A French physician on a
recent visit to America remarked that patients in France were less
willing than those in other countries to adhere to restricted diet, and
demanded a cure which would enable them to eat freely.

Lepine has published a very large number of studies especially
concerning blood sugar and glycolysis, but his comprehensive text-
book alters nothing in the accepted treatment of diabetes. The
same is true of his recent review of the therapy (2, 3).

Fasting has been employed in diabetes not only by specialists in


this subject, but also by enthusiasts who advocate it as a panacea.*'
Of these the most prominent is Guelpa of Paris. Starting from
an incorrect observation of Dujardin-Beaumetz in typhoid fever,
"that the more regular and rapid the patient's loss of weight, up
to the disappearance of the pyrexia, the quicker and more favor-
able was his course to recovery," Guelpa applied the principle first
to infections. "I have found it an invariable rule that, in febrile
affections, the more promptly emaciation sets in, and the more defi-
nitely it establishes itself, the more sure and rapid is the patient's
progress toward recovery. Conversely, when the patient fails to
exhibit an emaciation proportional to the intensity of his pyrexia, the
illness is always graver and of longer duration, and the convalescence
more prolonged and more interrupted. All this, it seemed to me,
proved, so to speak, mathematically, that disease is a state determined
and kept up by the presence within the body of a quantity of products
of fermentations-toxins and the debris of poisoned tissues — which the
organism must eliminate before it can return to a condition of health."
Having set up the theory of autointoxication as the dominant feature
in all disease, Guelpa proposed fasting — ^generally in three-day periods
— as the sovereign remedy. Symptoms of weakness, headache, and
malaise during fasting, and the sensation of hunger itself, were at-
tributed to autointoxication; food relieves the symptoms by com-
bining with the toxin, while purgation also relieves by sweeping out
the toxin; copious purgation — a bottle of hot Hunyadi-Jdnos water
daily — was accordingly added to the treatment. Among the condi-
tions for which the fasting-purgation treatment is recommended, with
confirmatory histories of grateful patients, are gout and rheumatic
troubles, anemia, bronchitis and asthma, herpes zoster, eczema and
other dermatoses, various ophthalmic conditions, some gynecological
conditions (including postpartum hemorrhage), digestive complaints,
nervous disorders, insanity, epilepsy, drug addictions, various infec-

'"' Some of these are outside the ranks of the medical profession. Hereward
Carrington, in his book, "VitaKty, Fasting and Nutrition," New York, 1908, p.
187, mentions a patient with incipient diabetes who fasted twenty days continu-
ously, becoming free from glycosuria and remaining so for two months thereafter,
when he was lost from observation. In the same place is a reference to a previous
example recorded by C. C. Haskell.


tions, postoperative complications, etc. Important in the list is dia-
betes, where alone the results have attracted widespread notice. A
diabetic is given the usual fasting and purgation for three to five days.
Other features of the treatment are best shown in Guelpa's own words
((5), p. 131):

"It is necessary to insist on the absolute necessity of repeating the cure from time
to time, and of imposing, during the intervals, which should be carefully lengthened,
a carefully restricted diet. As regards the latter, it is my custom to complete the
first period of the cure (three or four days) by a week of mUk diet, the amount of
milk taken daily not to exceed 2J pints. At the end of this week, however satis-
factory the condition of the patient, I prescribe a second period of cure (three or
four days) to be followed by a week or a fortnight of a regime mainly of vege-
tables, which satisfies the patient by fiUing his stomach, but, in reality, under-feeds
him, the object being to continue the process of forcing the organism to live par-
tially on its reserves and to bum off its debris. The following is a menu of the
diet I generally adopt: Breakfast, coffee or tea without milk; Lunch, clear soup,
salad, one or two apples or pears; Dinner, as lunch. As drink, tea or other non-
nutritive drinks ad lib. In certain special conditions I allow an ounce or so of
bread, or a diet of cooked vegetables. I increase the amount of food after each
repetition of the cure, taking as my guide an analysis of the urine. Since I adop-
ted this regime, I have obtained more rapid and stable cures, without discouraging
relapses. I wish also to draw attention to what I believe to be a deplorable error;
namely, the doctrine that milk is very harmful in the treatment of diabetes. This
is a mistaken view, based on a false interpretation of a single fact. It is quite true
that diabetics kept on milk diet almost always pass an increased quantity of sugar.
This increased excretion, is, however, only temporary. From the fact of the in-
creased glycosuria, the conclusion has been drawn that milk is harmful in diabetes.
The deduction is the result of a too superficial process of reasoning. It would be
as logical to conclude that rest and warmth were harmful in the treatment of rheu-
matic conditions, from the fact that they lead to an increased discharge of urates.
In the case we are considering, the milk merely hastens the expulsion of sugar,
which is injuring and impeding the tissues, relieves the hematopoietic fimction,
and contributes to a cure, if the mistake is not made of overwhelming the blood-
forming organs by administering a quantity of milk beyond the metabolic powers
of the liver to deal with."

Afterward, potatoes, bread, and other elements of a mixed ration
are gradually added, with general admonitions against overeating.
Acidosis is not mentioned in the records of Guelpa's early "cures."
About 1911, something seems to have called his attention to acidosis,
for he suddenly (7) added a new chapter to his theory of diabetes.


Here he announces that diabetes is the type disease of hyperacidity.
Glycosuria is merely one of the multiple forms of defense of the organ-
ism against acidosis caused by food pernicious in its quantity and es-
pecially in its quality. There are several stages of the process, first
increase of urea, later glycosuria, later acetonuria, etc., and the sixth
and final stage is coma. The body defends itself by breaking down its
less useful elements, notably fat; an indication is the acetonujria, which
like the glycosuria is helpful and not harmful in the process of acidosis.
He denounces the overfeeding in the usual treatment of diabetes, and
denies that his method is unsuited for diabite maigre. As evidence,
he cites the example of a patient aged sixty-five years. This man
underwent a "cure" of five days' fasting with 40 gm. sodium sulfate
daily. The subsequent diet of vegetables, fruits, and 60 gm. bread
daily caused return of glycosuria, whereupon the five-day "cure" was
repeated, followed by a similar diet. The duration of this "dis-
toxication cure" was a month, and the result was that the patient be-
came free from his former glycosuria, albuminuria, and joint infection.
For threatened coma, Guelpa (7 and 11) advises copious drinks and
enemas of sugar and weak alkaline solutions, oxygen inhalations,
bleeding, and intravenous injections of physiological saHne or weak

The Guelpa treatment has gained followers chiefly in France
and England. Cammidge ( (1), p. 343) mentions authors reporting
favorable results, but states that he has never been able to persuade
any patient to undergo it. A recent favorable report is by Hume.

Clear recognition should be accorded to Guelpa for the following
points of merit. First: without being guided by knowledge of earlier
undernutrition cures, and entirely from his own original and independ-
ent thought, he devised the first plan of treating diabetes by a radical
initial fast, longer than any previously recommended for this purpose.
Second: these fasts were repeated a number of times, with intervening
periods of diet very low in calories and protein and relatively rich in
carbohydrate, and the increase toward a living ration was made
gradually. Third : he emphasized loss of weight as a potent factor in
the improvement, and carried the reduction of weight to a more ex-
treme point than ventured by anyone before him, and did this even
in patients complaining of weakness. Fourth : he was first to demon-
strate the beneficial effect of fasting upon certain compUcations,


notably diabetic gangrene. The dietotherapy of gangrene is familiar
in text-books, but the important observation of Guelpa was that fasting
benefited the gangrene, instead of making it worse by weakening the
patient. Fifth: fasting periods were employed not only whenever
glycosuria or other symptoms appeared but also as a prophylactic
against their return. Certain' contrary facts must also be given
proper weight. The Guelpa treatment, in spite of its ease and sim-
plicity, failed of acceptance at the hands of diabetic specialists and
the immense majority of medical practitioners in all countries. The
explanation of this fact necessarily casts discredit either upon the
medical profession or upon this mode of treatment, and the latter
alternative is the true one. It is frequently repeated that the cases
treated successfully by Guelpa's method were severe, and that "the
usual anti-diabetic regime had failed;" but the details of the unsuc-
cessful diets are not given and the assertion cannot be accepted as cor-
rect in a single instance. In age, the patients were almost without ex-
ception above forty and frequently above sixty; many were obese;
their complaints were largely the natural consequence of their mode of
life at their time of life; on cessation of overeating and a lively purge
they were astonished how much better they felt, and their diabetes
was so slight that it was controlled by these simple measures with
little or no subsequent restriction of carbohydrate. The two most
severe cases of the series, namely that of the man described by Arnold*'
and that of the woman described by Bardet,^ cannot be considered

*^ Introduction to translation of Guelpa's book.

*^ Bardet narrates that in the therapeutic clinic of Beaujon was a woman with
diabetes of several years' duration, excreting 800 gm. sugar daily. Emaciation
was not extreme and acutely threatening symptoms were absent. Nothing re-
sembling the Naunyn treatment was undertaken. "She was placed for several
weeks under the ordmary treatment of M. Albert Robin, namely alternate medi-
cation with antipyrine and arsenic, without its being possible to reduce the
quantity of sugar below 160 gm. After a series of this medication, the patient was
left free from all treatment, and followed the routine diet of the diabetics of the
service : meat 500 gm., potatoes 500 gm., green vegetables 500 gm. At the time of
beginnmg the experiment (i.e. absolute fasting), she was passing 12 liters of urine in
24 hours, and on the final day showed an eh'mination of 760 gm. sugar." Here is
seen a combmation still too frequent in all countries; absence of rational treat-
ment, dependence on drugs, the use of routine instead of individualized diets, and
the physician's ignorance that the alleged sugar excretion on the diet stated is


examples of severe diabetes; at the utmost, they would fall in the class
of "medium severity" according to von Noorden or Naunyn; they are
of the type easily cleared up under the Naunyn plan of regulated diet,
restricted protein, and intercalated fast-days, and neither of them
remained clear Tender the Guelpa method. So far from this method
being an improvement over the known treatment, a physician con-
fronted with the choice of referring a patient to Guelpa or to Naunyn
could have no possible ground for hesitation in choosing the latter.
The Guelpa plan is applicable only to mild diabetes, and here (not-
withstanding the quick temporary clearing of glycosuria) a permanent
success is attained only in a longer, harder, and less certain manner
than under the usual treatment. For diabetes of even moderate
severity, the attempt to fast, purge, and undernourish a patient until
he is able to tolerate carbohydrate-rich diet is inevitably disastrous.
In undertaking to apply the mode of treatment described in the pres-
ent monograph, the most common difl&culty and mistake of inexperi-
enced physicians has been to fast the patient till free from glycosuria,
then to give a diet permitting its return, then to fast, then to proceed
with improper diet, so that weight and strength are lost while tolerance
is injured instead of improved, and the end in any severe case will be
fatal. In the one young patient of his series, a youth of sixteen years,
with actually severe diabetes, Guelpa ( (5), p. 112) achieved sugar-
freedom after fifteen days, but relapse followed because the patient
finally found the program unendurable. There may be justifiable
surprise that Guelpa describes only successes; in his half dozen or less
of partially successful cases the blame for mishaps is placed entirely
upon the patients. Inasmuch as common knowledge and Guelpa's own
experience ( (1), p. 506) make it clear that purgation does not prevent
acidosis during fasting, it would be remarkable if so many diabetics
should be treated without encountering some of those severe cases of
long standing who go into fatal acidosis on fasting. There is still more
noteworthy absence of a record of any young patient with impending
coma who was cleared up and kept clear of both glycosuria and aci-
dosis. It is improbable that Guelpa avoided such cases altogether;
it is certain that his treatment must fail in the vast majority of them;
and his record of success limited to mild cases constitutes sufficient
evidence of his failure in more severe cases, even of the grade that can


be managed successfully under the Naunyn plan. On the one hand,
Guelpa should receive due credit for boldness, enthusia,sm, originality,
and some new observations growing out of a new clinical procedure.
On the other hand, it cannot be maintained that Guelpa devised a
good treatment for diabetes. The lesson of his work cannot be over-
looked; but the information and encouragement derivable from his

'long fasts in mild cases are less than from the shorter fasts of Naunyn
and von Noorden in severe cases, so that the proposed treatment of
severe cases by fasting is a development of the Naunyn method rather
than of the Guelpa method.

America has not been prolific of diabetic text-books. A notable
early example is that of Tyson, the frontispiece of which shows the
intraocular picture by which diabetic lipemia can be diagnosed.
■ The &st great contribution of this country to this subject was
Opie's hypothesis that diabetes is due to alterations in the islands of
Langerhans, on the basis of findings of hyaline, fibrous, and other
destructive changes in the islands in a series of cases where the acinar

■ tissue was relatively little affected.

Mandel and Lusk demonstrated the dextrose-nitrogen ratio of the
phloridzinized dog in a human diabetic, and drew attention to the
prognostic value of this ratio. Lusk's "Science of Nutrition" treats
a subject of such dominant importance for intelligent dietotherapy
that it may be placed in the highest rank among text-books of diabetes.
The most extensive investigation of the respiratory metabolism in
diabetes is that of Benedict and Joslin.

Hodgson treated over 1100 patients in the twenty years preceding
1911. He worked out a plan of treatment without drugs, using a
mildly alkaline mineral water freely. He held that patients "should be

kept mentally indolent and physically active One other

essential must be made' plain to the diabetic, and that is the quantity of

food eaten is just as important as the kind of food It is a

fact that many mild cases of diabetes will show a diminution of sugar
almost to the vanishing point when the patient is merely compelled
to eat a very moderate ordinary diet. That is to say an antidiabetic
diet is not always necessary to reduce the glycosuria; a reduction in the
amount of ordinary food will sometimes accomplish the same end.

' . . . . Again it should be stated that the quantity of all food, even


if it is carbohydrate-free, must be greatly restricted. The number of
calories that the body ordinarily requires is no safe criterion for the
amount of food that should be given a diabetic. It is not the quantity
of food that should be metabolized, but the quantity that can be me-
taboUzed that should determine the amount given to the patient. All
in excess of the quantity that the patient can actually use burdens the
already overtaxed excretory organs and retards improvement." In cases
severe enough that sugar did not disappear after two weeks of strict
diet, the patient was put to bed and allowed one raw egg and two
ounces of olive oil three or four times a day. If diacetic acid appeared,
the oil was diminished and some carbohydrate added. Hodgson's
statistics show a high percentage of favorable results in cases not too
severe in t}T)e.

Foster's manual (1915) is not only an excellent brief presentation of
the Naunyn system, but distinctly goes beyond this in the more radical
employment of undernutrition, with correspondingly better results.
He lays down the wise rule (p. 165) in contradiction to some European

Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 6 of 76)