Ketogenic Diet

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.

Main Works:

• 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.[2]

CHAPTER VII.
ON THE SELECTION OF ALIMENTARY SUBSTANCES FAVOURABLE TO THE REDUCTION OF CORPULENCE.

It is to be borne in mind, that in dividing alimentary matter into two kinds—one fitted to develop fat, and the other having an opposite tendency—my object is merely to suit the indispensable requirements of my plan of treatment. Nor is the conclusion to be drawn, that in order to diminish corpulence, an exclusive meat diet is absolutely necessary. Man is omnivorous; that is to say, he partakes of everything entering into the composition of ordinary alimentation; but, for the purposes of my system, azotized substances should constitute, though not exclusively, his principal food.

Large quantities both of animal and vegetable substances compose the ordinary diet of man. According to some philosophers, man should live on flesh only; while others maintain that man is by nature a vegetable feeder. Most naturalists, however, are agreed that the human species is omnivorous; that is to say, can live both upon vegetable and animal matter. A certain proof, in my opinion, that such is the case, is to be found in the fact that man is provided with the two kinds of teeth, the one appertaining especially to carnivorous, and the other to herbivorous animals.

It is remarkable that man, in his present state of civilization, does not instinctively recognize the kind of food which is beneficial or prejudicial to his well-being. Experience alone teaches him what is good or bad. With the lower animals it is otherwise; they have the power to discern that which is suitable for food. The colt and the kid know how to select, among the varied herbage, the particular grasses which are suitable to their organization. Domesticated animals, having but an insufficiency of food, do sometimes partake of noxious plants. It may be that man, in consequence of his civilization, has lost that instinct possessed by the lower animals, and in blind confidence partakes of everything which is served to him in the shape of food; and this view derives support from the fact, that savages, and people but partially civilized, refuse to eat anything they are unacquainted with, no matter how temptingly it may be prepared.

The uneducated peasantry of France, at this day, will not taste food to which they are unaccustomed, or if they do, it is only with great mistrust.

It is matter of daily experience, that man can simultaneously feed upon both vegetable and animal matter, and can also live when restricted to one of these alone; such restriction, however, being better borne under the varied conditions of age, season and climate.

From these considerations it follows that, for the accomplishment of a given purpose, man has the privilege of selecting certain alimentary substances, and of refusing many others; the health of the individual, who may thus submit to the diet of his choice, being in no wise affected thereby.

Bearing in mind the well established principles of physiology and chemistry, together with the precepts set forth in the preceding pages, we may be safely guided in the selection of such alimentary substances as will conduce to the fixity of a certain condition of embonpoint, although having a tendency to redundancy; or which, on the other hand, will insure a diminution of obesity. 

Such results can be obtained by paying attention to the following remarks:

• That kind of meat known as game is very nutritious, occupies but small space, and consequently only moderately distends the alimentary canal. It contains but a small amount of carbon, relatively to the other compounds, and therefore should be used as much as possible: such as venison, hare, the warren rabbit, woodcock, snipe, partridge, quail, plover, wild duck, &c.

• The fluid portion of all ragouts should be avoided by those who dread corpulence, and game should therefore be roasted rather than stewed. The same may be said of butcher's meat, such as surloin of beef, beefsteak, veal cutlet, mutton chop, fresh pork, leg of mutton, &c. Gelatinous dishes, such as calves' feet and tripe, should be avoided. Poultry, when roasted, is not contra-indicated.

• It is a matter of observation, that those races which live chiefly upon fish are gross and dull, pale and lymphatic, and less courageous than such as live upon flesh. A fish diet is consequently favourable to the development of fat, and the usual accompaniment of butter sauce is also productive of a like result.

• The anti-obesic treatment, therefore, requires that fish should be partaken of sparingly; still it has been remarked that patients, while undergoing treatment, who eat principally of meat, with a very small amount of fish, do nevertheless succeed in the accomplishment of the object they have in view. The most nutritious fish are turbot, trout, sole, salmon, perch, pike, tench and carp. On the other hand, shell fish, such as oysters, lobsters, crabs and shrimps, have a tendency to impede the formation of fat.

• Vegetables, such as lettuce, chicory, sorel, artichokes, spinach, green pease, beans, cabbage, celery, and all such as are used by way of salad, are not very nutritive, but contain much watery and mucilaginous matter, favourable to the development of corpulency: the same may be said of carrots, turnips, potatoes, rice, beet-root, maccaroni and vermicelli bread; all kinds of cakes, pastry and biscuits, which are made of wheaten flour, are decidedly contra-indicated, as are also eggs, cream, cheese and butter.

• In reference to chocolate, much difference of opinion has hitherto existed as to its nutritious properties; but we know by experience that it is easy of digestion, and eminently suited to such as are subject to great mental exertion. Some dietists have held that chocolate has a tendency to prevent any augmentation of corpulency. When made with water, it is decidedly preferable to coffee made with milk, the latter being productive of fat. Milk, by virtue of its composition, combines all the elements which are fitted for the development and nutrition of the body; casein containing nitrogen, a fatty matter (butter), and a saccharine substance (sugar of milk).

• Chemistry reveals the remarkable fact, that the composition of casein or the cheesy portion of milk, is identical with that of the fibrin and albumen of the blood. Under this aspect, therefore, milk is very nutritious.

• The sugar and butter which exist in milk, have no analogy with flesh; according to analysis, they are composed of carbon and the elements of water. When, therefore, we partake of milk, we obtain in one and the same substance all the elements which are necessary for the growth and nutrition of the body, and such is the case in infant life. Since, however, both carbon and hydrogen, in very large proportion, enter into the composition of milk, it is advisable, whenever there is a manifest tendency to corpulence, that the use of it as an article of diet should be avoided. Infants are usually fat, owing to the elements of adipose matter forming so large a proportion of their food, whether that consist of milk alone, or in combination with starchy or farinaceous and saccharine substances.

▽Jean-Francois Dancel (a French physician) presented his thoughts on obesity in 1844 to the French Academy of Sciences and then published a book, Obesity, or Excessive Corpulence: The Various Causes and the Rational Means of a Cure.
“All food which is not flesh ―all food rich in carbon and hydrogen [i.e., carbohydrates] ―must have a tendency to produce fat,” wrote Dancel.

Dancel also noted that carnivorous animals are never fat, whereas herbivores, living exclusively on plants, often are.

Dancel claimed that he could cure obesity “without a single exception” if he could induce his patients to live “chiefly upon meat," and partake “only of a small quantity of other food."

Dancel argued that physicians of his era believed obesity to be incurable because the diets they prescribed to cure it were precisely those that happened to cause it. (pp.151-152)

CHAPTER VI.
CASES OF REDUCTION OF CORPULENCE.

In the month of August, 1849, M. Guénaud, a master baker, still residing in the Rue St. Martin, Paris, presented the following appearance:—Age, twenty-eight years; height, four feet eleven inches. His obesity was such that he was scarcely able to walk, and whenever he attempted to do so, suffered from difficulty of breathing. When standing for a short time, he experienced great pain in the region of the kidneys. He was incapable of superintending the workshop and attending the flour market, duties which devolved upon him as manager of an extensive bakery. An unconquerable drowsiness overcame him the moment he sat down, and rendered him unable to attend to his numerous accounts. When in bed he was obliged to be propped up by a number of pillows, in a semi-recumbent position; for if his head happened to be too low, he suffered from vertigo, dizziness, &c. His countenance was suffused, and the veins of the head, especially the temporal, were more than usually distended. The slightest exercise was attended with excessive perspiration. The cerebral circulation was so much impeded, that he could not bear even the pressure of a hat; and asserted that he would not dare to stoop, even were it to insure him a fortune. In this distressing condition he sought the advice of a physician, under whose directions he was repeatedly bled, and freely purged. He was recommended to live upon the smallest quantity of food that nature would permit, and to diet chiefly upon watery vegetables, such as cabbage, turnips, salad, spinach, sorrel, &c., and only occasionally to partake of a very small quantity of meat. He was also directed to use active exercise, to work in the bake-house, and to take long walks. But he found it impossible to follow the latter part of this advice, on account of a feeling of impending suffocation, and severe pains in the region of the kidneys. He was therefore recommended to take exercise on horseback; but this even could not be borne, and in spite of every effort his obesity was constantly on the increase. At last he could not walk a quarter of a mile, and was obliged to confine himself to the house, passing his time in a listless, somnolent condition, entirely deprived of all mental and bodily energy. His mother, who lived in the neighbourhood of Paris, having seen the advertisement of my book upon Obesity, and thinking of the melancholy condition of her son, procured a copy and read it. She thereupon brought her son in a carriage to my office. Guénaud was quite out of breath from having to ascend one pair of stairs; he seated himself upon a sofa in my room, and soon fell asleep. Occasionally he would wake up, and take some part in the conversation. The mother and her son went home, and on the following day Guénaud began to carry out the directions he had received from me; and at the end of thirteen days he was able to walk from the Porte St. Martin to La Chapelle, where his mother resided, delighted at having recovered the use of his legs. What astonished him most was that he had been able to perform the journey on foot, without once taking his hat off. The latter remark may appear trivial; it shows, however, the great inconvenience he had been wont to suffer from the violent perspiration hitherto induced by the slightest exercise. By the end of the month Guénaud had reduced his weight from one hundred and ninety to one hundred and seventy-four pounds, and his circumference round the belly from fifty to forty-three inches. He was recovering his activity, both of mind and body, and his respiration was already considerably improved. The treatment was continued two months longer, and at the end of the three months his circumference was reduced fourteen inches, having lost forty pounds of fat. His muscular powers were now much increased. Guénaud had a very short neck; the two masses of fat, which made his cheeks appear continuous with his chest, have disappeared. The line of the lower jaw is now perfectly distinct, and without the slightest wrinkle. Instead of his former aged appearance, induced by obesity, his figure is now youthful, his countenance intelligent and sparkling. Before commencing my system of treatment, the patient was in continual danger from threatening head symptoms. It was generally said, even by the medical men under whose care he had placed himself, that he suffered from excess of blood; yet he has not lost a single drop during the whole course of treatment, and is now free from somnolency, giddiness and headache. The veins of the head are no longer turgid, nor does he suffer from excessive perspiration of the head.

I am satisfied that this man, at the present time, has more blood in his system than he had when labouring under obesity; but the circulation being now free, all inconvenience has disappeared.

It is unnecessary to add that, owing to the lungs being no longer oppressed on all sides by a superabundance of fat, their movement is unimpeded, air finds easy access, and the difficulty of breathing, with sense of impending suffocation, no longer exist. Guénaud can now sleep in the ordinary recumbent position. Men of great corpulence, when walking, experience severe pain in the kidneys, and this arises from the enormous mass of fat which surrounds these organs, inducing by its weight a dragging sensation. Guénaud, having lost his big belly, is no longer troubled with this uneasiness when walking.

With respect to this patient, and in all the other cases which have come under my care, it may be well to remark that the muscular system has recovered its tone, and that the muscles are harder than they were before treatment; and I can safely say, without fear of contradiction, that every person who has been submitted to my system for the cure of obesity, is convinced that his flesh, his muscle, has increased both in firmness and in size.

I have had men under my care weighing two hundred and fifty pounds. Upon the occasion of their first visit, having felt their limbs, I have said, "I can diminish your weight by fifty pounds; but these enormous muscles will be increased rather than diminished in size. You must not expect a reduction of more than fifty pounds; but fifty pounds less of fat, distributed among organs overloaded with it, will be highly beneficial to health."

Guénaud is far from being thin, but he is strong and muscular, and has the physical and moral energy of a robust young man. His enormous size had rendered him conspicuous in that part of the city where he carried on his business as a baker; but when he had become reduced to the normal size of other men, the change produced considerable sensation, and excited curiosity as to the cause. He has done justice to the treatment which has made him once more a man. I will also do him the justice to say that he has honestly carried out my instructions. A beefsteak or a couple of cutlets, with a very small allowance of vegetables, together with half a cup of coffee, constituted his breakfast. Dinner consisted of meat and a very small quantity of vegetables. From being a great water-drinker, he had come down to an allowance of a bottle or a bottle and a half of liquid in a day. When thirsty he drank but little at a time; and between meals, used to gargle his mouth with fresh cold water.

A lady, residing in the town of Montereau, wrote to me in the early part of September, 1849. She was twenty-six years of age, and weighed one hundred and seventy pounds. Her corpulence was increasing to such an extent that she would soon be unable to attend to her household duties. She wished to know if my system of treatment would interfere with her general health, and whether it would prevent her pursuing her usual and indispensable daily avocations. On receiving the necessary explanations, she immediately placed herself under my care, and upon the 23rd of the same month, she informed me that her weight was already considerably less, but that her size remained about the same. A letter of the 12th October following states that she has lost fifteen pounds weight, and that her size is materially diminished. The treatment was continued for some time longer, and never caused the least interference with the discharge of her domestic affairs.

Towards the latter end of 1850, the wife of Dr. Pecquet, of Paris, purchased my work on Obesity. Having read it, she spoke to her husband about it, who said that, like most medical men, he was persuaded that the only way to reduce corpulency, is to eat less than the system demands.

Madame Pecquet, then about sixty years of age, had long been troubled with excessive corpulency, and weighed two hundred and fifty pounds. She had, in consequence of this affliction, passed the greater part of the last eighteen years either in her arm-chair or in bed. According to some of the most celebrated physicians of Paris, and also of her husband, her disease at one time was said to be pulmonary catarrh—at another time, disease of the heart—and again, something else; till at length Madame Pecquet had no rest, day or night.

If she attempted to go to sleep in the horizontal position, she was immediately troubled with a rush of blood to the head, accompanied with the most distressing hallucinations, which utterly prevented her from sleeping. She was unable to take exercise on foot, even when her ailments allowed her any respite, owing to the excessive pain she experienced in the region of the kidneys, and the abundant perspiration of the head, which a walk of even a few steps was sure to induce. It was consequently impossible for her to go out, unless in a carriage. Those only who are unable to enjoy this pleasure, know how great a privation it is not to be able to take a walk on a fine day, and how wearisome it is to be compelled to make use of a carriage in order to enjoy the advantages of fresh air, or to move from place to place.

Madame Pecquet was so situated, and many a time she has said,—"Eighteen long years have I been in this condition! Eighteen years of suffering and misery, in spite of every medical aid which has been bestowed upon me!" Under these circumstances, we can readily understand how anxiously she must have sought a means of cure. One day, without the knowledge of her husband, she took a carriage, and called to consult me.

Those who believe as I do, that an excessive development of fat may induce and sustain a generally diseased condition of body, will readily admit that the diminution of excessive obesity is the only rational means of cure in such a case.

Impressed with this idea, Madame Pecquet called upon me, and placed herself under my care. I prescribed some medicine, which she took without the knowledge of her husband, who, although eating at the same table, did not perceive that she partook of less vegetables and ate a larger quantity of meat than usual. Having continued the treatment four months, Madame Pecquet said to her husband,—"I have been following the anti-obesic treatment, and weigh at the present time one hundred pounds less than I did before commencing it. Formerly I was confined to my arm-chair, in consequence of catarrh or something else. I could not walk fifty yards without stopping to take breath; and now I can go out every day if I please, when the weather is fine. Night, formerly so wearisome, is now a season of delightful and refreshing repose; and, in fine, I have recovered my health, after eighteen years of continued suffering."

I again met this lady last year, and found her in the enjoyment of perfect health. She had not regained her embonpoint, but was in all respects perfectly happy, and gratefully ascribed her recovery to my system of treatment.