Type 1 Diabetes

https://wellcomecollection.org/works/hhqkczzb

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As I wish only in this part of the work to enumerate facts, with the intention of applying them in support of any arguments which I may in the conclusion employ for maintaining any particular opinions, I will not here anticipate any thing that I may then judge right to advance concerning the method of cure; let me however just observe , that during the former period of this gentleman's disease, I enjoined him a strict animal diet, with as much milk as he chose; but in the latter part of it he eat and drank almost as his fancy directed him, since it was found that none of the vegetable decoctions had for several weeks affected his urine, nor any sweetness again arisen from the use of vegetable matters, or from fermented or vinous liquors.

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The next was the case of a gentleman with whom I was afterwards upon terms of very friendly intercourse, and whose urine yielded sugar upon evaporation, in the pro portion of one ounce in sixteen or twenty. A common attack of fever first made me acquainted with him , and which, with some difficulty, gave way to the usual methods of cure : his recovery I found retarded by a frequency of micturition, which interrupted his sleep, and which had very long distressed him : he attributed it, however, to some disease either of the bladder or of the prostate gland, which he said he knew to exist, for that his water was often loaded with large quantities of mucus, and that he had been in the habit of introducing bougies for several years, to overcome a stricture which he always found seated very high in the urethra. As he recovered his strength, and was again able to pursue his professional concerns, I did not then at all suspect that there might be any additional cause of his frequent calls to void his urine: nor in truth did I ever suppose, during two or three attendances which I had afterwards upon this gentleman, that any thing more than irritation at the neck of the bladder, increased by a little occasional intemperance, was the cause of the hectic which usually attacked him, accompanied by its common symptoms of thirst, and heat of body, and costiveness. It was nearly two years afterwards, when, from a continuance of these symptoms beyond their usual period; I first suspected that something Diabetic might be connected with them; and on examining the urine I found it sweet. As he was a man of a sound understanding, I explained to him such circumstances as might best induce him to persevere strictly in a proper plan of diet and of medicine; and although he had been accustomed, from a public situation which he held , to live well, I found no difficulty in shewing him the necessity of avoiding all vinous and spirituous liquors, and of entering upon a plan of complete abstinence from all vegetable matters. He took freely and largely of milk, both night and day, to which he latterly added mutton-suet; and his more substantial meals consisted of animal food, with a very small quantity of bread. He took the sulphurated hydrogenous medicines, in very large doses, without any manifest advantage: and afterwards, for many weeks, persevered in the common green mixture of sulphat of iron, with myrrh and tartrat of potash, in the quantity of half a pint in every twenty four hours, which I was induced to press upon him from the benefit I supposed to have arisen from its use in a case above related : this gentleman's strength very much increased under this plan, which, from the relief obtained, he pursued with astonishing perseverance: his urine became much less troublesome, having sometimes but very little sugar, and occasionally none at all: the organic mischief at the neck of the bladder, of course, still continued, and his nights were still disturbed, by his being frequently obliged to make water, but he recovered his usual countenance and his strength again. He did not afterwards indulge to any immoderate extent in company, but as to food, took his milk and suet during some years, pursuing to the time of his death, in 1803, a very active employment, and undergoing great exercise, both of body and mind.

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Hitherto I have detailed the cases that have occurred to me, more at length, per haps, than might be necessary; but if any apology may be required for it, I have only to observe, that what I have stated is almost literally written from notes which were taken when the cases were pässing under my observation : and the same apology must be offered for any imperfect statement, if such it should appear, in those which follow ; for having made up my mind with re spect to the method of treatment, from finding it in several instances successful, I was not so studious about noting all the particulars of any individual case, as I had been accustomed to be : but the truth of the matter is, that besides those which have been already, and those which are about to be mentioned, many others did occur, of which I took no note whatever, either be cause they yielded (although the symptoms were really Diabetic) in so short a time, that I had not a convenient opportunity of ascertaining the sweetness of the urine ; or because, from the very common versatility of mind attending this disease, the patients did not return to me after the first inter view : of these, therefore, as cases merely of conjecture or suspicion, I have not made any record ; considering those only as truly legitimate, whose names, with other circum stances, impossible from their notoriety to be misunderstood, I could fairly and honestly register.

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"I have had no experience myself of the Hepatised Ammonia, nor did I know whether it could be procured here or not ; and as the gentleman's stay was likely to be so short in Oxfordshire, I was not very anxious about it : but as I have seen the best effects by limiting the use of vegetables, and if possible preventing it entirely, I urged this point as much as I could, but I am afraid I was but imperfectly obeyed. Indeed, I fear we shall have but very few patients who will so perfectly comply with that part of Dr. Rollo's plan, as the patient he has described.

The three next cases may be said to be still my patients, as they continue under the regimen prescribed for them ; or if they are deviating from it, they remain as examples not merely of the efficacy of the plan, but of the durability of the cure: The first was a gentleman from Kent, who consulted me more than a year ago, for indigestion and a bilious irregularity. In March, 1809, he called upon me with every symptom of Diabetes ; and in addition to the large quantity of water, and the usual thirst and voracious appetite, he complained of a wasting of his pudenda, and of absolute impotency; circumstances which I believe to happen not unfrequently in Diabetes, notwithstanding I have not hitherto made such the subject of particular enquiry: I ordered him upon the chalybeate plan, and enjoined him the usual strict regimen with respect to diet: I was to see him again, or hear from him in case of necessity : but not hearing from him I wrote to him, expressing my anxiety about him, which brought him to London : -He then candidly acknowledged, that he had not tried the plan, for that he had taken it into his head that nothing could be of any service to him. I remonstrated with him most strongly, and shewed him his danger ; and on his return to Rochester, he commenced his plan, for his apothecary some time afterwards informed me, in a letter dated Oct. 27, 1809— “Our patient, Mr. S—, is perfectly recovered, from the plan you recommended.” 

A gentleman who resides in Surrey, up wards of sixty years of age, was also, a year ago, relieved by a similar plan; for, in about three weeks, his urine, and thirst and appetite, became natural, and his emaciation was succeeded by flesh and strength : In the following year, 1809, the symptoms returned , and the same treatment was pursued with the same fortunate result ; for his urine, which had again become sweet, soon was found, upon evaporation, to .contain not a particle of sugar, and his health, in proportion, improved. It may not be improper to mention, that I found it necessary to secure rest at night by means of ten grains of the compound powder of ipecacuanha. 

The next case is that of a gentleman's housekeeper in Portland Place, who states her complaint to have arisen six years ago. About ten years since, one of her breasts was removed, from an apprehension of cancer. Her age is above sixty. Her urine was very sweet, and in large quantity, and very frothy, and when spilled upon the ground, left an incrustation like chalk, in appearance, but which was, in reality, a saccharine crystallization. —The peculiar odour from her body and her lungs was here remarkably, characteristic of her complaint : but this, as well as the other symptoms of the disorder, admitted of a change in less than two days : She had complained of an uneasiness and weight at the stomach, which was removed by a bolus of the hydragyrus cum cretà , given for a few successive nights, and then the strict animal diet, with forbearance from all sorts of vegetables, and from fermented liquors, together with the common steel ' draught, with myrrh, three times a day, was perse vered in most accurately ; the change al most immediately took place for the better, and her health, more than could have been expected at her time of life, is manifestly improving: 

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--After persevering about three weeks, rigidly, in the plan prescribed, I indulged her with beer at her meals, and with potatoes, and had the satisfaction of finding no sugar reproduced in her urine : In a few days she used stale bread, (for she had fancied that new bread had a tendency to bring back the disease) with the same happy result : and was then directed to eat any sort of vegetables she pleased, adapting the quantity to her usual portion of animal food ; and, after a trial of ten days, she experienced no renewal of her disorder. After the expiration of two months, I saw her again, without any symptom of the complaint whatever; and again, after an absence of several more months, still continuing in a perfect state of health.

Whilst these pages were preparing for the press, I was consulted for a young lady in the neighbourhood of Liverpool, who was labouring under the worst description of saccharine Diabetes :-She certainly experienced considerable relief during several weeks from the full plan of animal diet, chalybeates, and the phosphoric acid, but: ultimately she fell a victim to her disorder: In the last stage of the disease I visited her at her father's house, and I think I never saw emaciation so extreme, nor patience so constant, nor attention to the plan of regimen so scrupulously exact; as in this amiable, and exemplary young lady. 

I was ałşo, about the same time, consulted by a gentleman near Somerset House, in the Strand : He was about sixty years of age : His skin was cold and harsh ; and his pulse small and freqüent: He made · water very often , but it was not at all sweet; and on evaporation it yielded plenty of crystallized salts , leaving a bitter and offensive residuum . His appetite was moderate, and so was his thirst, but his debility and emaciation were excessive ; and his nervous irritability, which seldom suffered him to sleep, had terminated in a slight paralysis, affecting the organs of speech, and the whole of his right side. His case seemed to me to want nothing .but the saccharine Characteristic to constitute it a true Diabetes, and I accordingly ordered him eggs instead of bread, milk and broth instead of tea, and animal food under any form he pleased, and the exclusion of all vegetable and fermented matters; and his medicine was the myrrh draught, with the sulphat of iron. Although I had not much expectation of doing him good, I had the satisfaction of finding him better in a few days; and, after visiting him, perhaps twice a week, for about a month, I requested him to remove to Hampstead, --for the benefit of the chalybeate water, and where he might have the opportunity of exercise in a fine air. This, however, he neglected to do ; and, during my absence from London at my house in the country, I found that he had deviated altogether from the plan advised for him, and that a fresh attack of palsy had terminated his existence.: A clergyman, also , from the neighbour hood of Harrow , consulted me for a dropsy. He was advancing in years, his debility was great, and his legs were much swollen : I found, however, that his appetite was very good, and his complexion clear; and that, independent of his extreme weakness. and the tumefied legs, he was apparently in health: On examination, too, it was discovered that his urine was in greater quantity than is usual, but that it neither to the taste, nor on evaporation, yielded any sugar: Still I was not convinced that his dropsy could arise from any other cause.

Case VI.

George Barratt, Mt 43. Husbandman

In-Patient, December 23rd, 1805.

Was admitted as a case of Diabetes Mellitus, under the care of my late worthy colleague. Dr. Jackson, only a few days after William O'Brien (whose case follows) entered under mine. As Dr. Jackson was acquainted with the circumstance of my having enjoyed frequent opportunities of treating this disease, he consulted me on the plan to be pursued. We accordingly determined that this patient should live upon the ordinary diet of the house, without any particular restraint from vegetable food; and that his medical treatment should be confined to the exhibition of the nitric acid, to the amount of about two drachms in twenty-four hours. This quantity to be increased or diminished, according to its effects on the system. On examining the patient, I collected the following particulars :

He has been many years married, and for the most part enjoyed good health, but was liable to profuse sweating upon any ordinary exertion; and at such times, was accustomed to quench his thirst by drinking immoderately of cold whey, sour butter-milk, &c.

His diabetic symptoms commenced two years ago ; and he remarked, that since the great thirst, and flow of urine came on, his propensity to sweating had been diminished. He discovered, twelve months since, his urine to be sweet; from being persuaded, by a neighbour, to drink it, as a cure for his disorder.

The quantity of his water he estimates to be nearly twenty quarts every twenty-four hours, but he never exactly measured it. His appetite is extremely ravenous, and may be said to be omnivorous. He was accustomed to devour raw vegetables, when boiled ones were not in the way ; and he believes that he has consumed, in one day, five or six pounds of animal food.

He gets little sleep from the interruption every half hour, during the night, to make water; and he conjectures that the quantity far exceeds the amount of his drink. For six months past he has never experienced any venereal desires, and the semen is involuntarily discharged, but there is no phymosis : pulse 86, The emaciation is very great, and the debility proportionable. He is above the middle size, And was formerly a stout and muscular man ; but he is now so much reduced, that he only weighed nine stone, twelve pounds ; three days previous to his leaving home. He was capable, and very desirous, of keeping a register of the ingesta and egesta; and the better to secure the faithful discharge of this task, he was put into the same ward with my patient, O'Brien, (in whom I deservedly placed the greatest confidence) who was instructed to watch privately over his conduct. I shall select from this register, ( which I have every reason to believe correct) and my own notes, such particulars as are most deserving of notice.

On the 25th of December, the urine he passed within the last twenty-four hours, measured thirty-two pints, and his drink of nitric acid, diluted with water, twenty-five pints; exclusive of three pints of beer porridge.

January 6th — 16th

The patient threw up a large quantity of acid contents from his stomach, in consequence of the emetic.

Since the alteration in his diet an important and decisive improvement has taken place. His thirst is much abated. His mouth and tongue are moister and cleaner, and he sleeps longer and sounder. His strength is remarkably increased, and he feels every way more comfortable and alert.

His craving for food is entirely gone : and the sense of internal heat, especially in the palms of the hands, and soles of the feet, greatly moderated. His finger ends, which before felt benumbed, and looked almost livid, are now of a natural warmth and appearance; and the skin which was before hardened into scales, is become quite renewed, and feels soft and moist.

On the 9th, the solid ingesta were one pound and ten ounces, liquids eleven pints and a half, urine fourteen pints; and upon the average the egesta have exceeded the ingesta.

The urine is neither so sweet nor so whey colored and turbid, it has indeed a bitterish taste which resembles new small beer: one pint of this fluid yielded only nine drachms and a half of a dark coloured extract, which yet differed but little in its sensible and chemical properties from the last.

January 16th — February 1st.

There has been a considerable fluctuation in the quantity of the urine discharged within this period.

On the 19th, the solids were nineteen ounces, liquids twelve pints, and the urine sixteen pints ; while on the 23d the solids amounted to one pound and twelve ounces, and the liquids to Only six pints and a half, and the urine seven pints and a half.

It is, however, proper to notice, that on this day he had been troubled with a griping and purging, though not in a very considerable degree.

The urine is very slightly sweet, and has a more natural appearance ; indeed the general change for the better, is strongly marked in the patient's person and countenance.

February 1st — March 1st. There has been, upon the whole, a considerable amendment in the patient's disorder, within this period. He was allowed four ounces of toasted bread daily, and eggs and beef tea, occasionally.

This addition of vegetable food did not increase either the quantity, or saccharine quality of the urine ; but on the contrary, its quantity has been decreased, his appetite improved, and his strength recruited.

It appears, on the 13th, (four days after the use of bread) that he ate with great relish four ounces of this article, along with two pounds, three ounces of animal food; while his drink measured only five pints and a half, and the urine seven pints.

Whereas for seven days previously to the admixture of vegetable with the animal diet, the average daily quantity of his animal food did not exceed one pound six ounces ; yet the urine, during the same period averaged about nine pints, and the drink seven pints, and a half.

The urinary residuum on the 9th, weighed ten drachms, and was of the same colour and consistence as the last ; but its smell and taste were partly saccharine, and partly urinous. Indeed the urine, when tasted, seemed to partake of the same mixed properties.

In addition to these favorable changes, some other important ones were very conspicuous.

The patient had gained flesh, was more alert in his motions, and his countenance had become cheerful and animated. I saw him weighed on the 19th, and had the pleasure to find that he had gained not less than seventeen pounds and a half, since his entrance into the Infirmary.

The venereal appetite had returned, and the involuntary flow of the semen had entirely disappeared.

March 1st — April 1st

Nothing remarkable has occurred within this period. The highest quantity of urine has reached to nine pints, and the lowest has fallen to five pints ; but the average may be estimated at six pints, each twenty-four hours. There is still a slight excess of this discharge, when compared with the drink. One pint of urine left upon evaporation nearly eleven drachms of a thick extract, which differed, a little in its sensible properties from the last, as it was rather bitter, than either salt or sweet to the taste.

The patient is so far improved in general health and strength, as to be able to carry all the coals into the different wards upon the same floor, and to assist in various employments about the infirmary. He never feels thirsty but at meals. His appetite is regular and moderate, and he can sleep eight or nine hours without any interruption.

He was desirous of being discharged, as he fancied himself quite cured, and capable of undertaking his usual employments. As the urine, however, was not entirely free from saccharine impregnation, and consequently the assimilating powers of the system not completely restored ; it was thought advisable, both on the patient's account and for the sake of making a fair trial of the efficacy of the method of the cure, to detain him in the house for some time longer.

April 1st – 20th. He has remained nearly stationary during this interval. The average quantity of urine does not exceed six pints, it has no perceptible sweetness, but has very little of a urinous flavor. One pint of it on the 6th afforded ten drachms of a thick dark coloured extract, which certainly was both salt and sweet to the taste. The patient was weighed on the 15th, and was found to have gained four pounds since February the 29th. He observes that his old habit of sweating upon slight exertions has returned ; but he does not find himself weaker on this account.

Indeed, with the exception of the peculiarity of his urine, he may he said to enjoy his ordinary state of health ; and he is now so importunate to return to his family and usual occupations, that upon his promise to adhere as closely to his plan of diet as circumstances would permit, he was discharged on the 20th instant.

Remarks.

It appears from this well marked instance of diabetes mellitus that the nitric acid is productive of considerable advantage, in mitigating the thirst and heat, and thereby lessening the quantity of urine; but it is proved to be incompetent to destroy the saccharine impregnation of this fluids or to arrest the other characteristic symptoms of the disease

The efficacy of animal diet is strongly exemplified by the reduction of the quantity of urine from twenty pints to nine pints, in twenty four hours; and by the nearer approach to equality between this fluid and the liquids drank; but especially by the disappearance of great part of the saccharine properties of the urine ; all which events speedily followed the use of this regimen. Perhaps there could not have occurred a more favorable opportunity to ascertain the real effects of abstinence from vegetable diet than what the present case afiords. For the disease had existed two years ; its symptoms were unequivocal, and had attained their height of virulence; and the patient's constitution seemed free from any other malady. Nor were the opportunities for a trial of the remedy less auspicious. The patient was docile, steady, and capable of attending to the directions which were given him ; and he was under the vigilant care of the House Apothecary, and also of an intelligent and well principled patient, who was similarly afflicted ; and the whole arrangement was submitted to my daily inspection and superintendence.

If then the evidence contained in the reports on this case be admitted as correct and satisfactory, it will place beyond all doubt the existence of a fact which has lately been much disputed, viz: That in Idiopathic Diabetes Mellitus, the quantity of liquid egesta does sometimes exceed that of both the solid and liquid ingesta, and that the excess of the former cannot be accounted for solely on the supposition of its being derived from a general wasting and diminution of the solid and fluid parts of the system. For in Barratt's case we find, that during the period in which the register clearly pointed out almost a regular daily excess in the amount of the urine, compared with that of the liquids and solids taken; the patient, notwithstanding had gained an accession to his weight of seventeen pounds.

This singular phenomenon was likewise noticed, though not in so striking a degree, in the reports of the two last cases. Both Wild and Whitehead gained strength, and apparently flesh ; while at the same time the balance between the liquid and solid ingesta and egesta, was rather in favor of the latter.

To what law or process of the animal economy is the supply of this superabundant quantity of urine to be attributed ? Is it derived from cuticular or pulmonary absorption; or from a colliquation of the humours of the body? Each of these modes of supply have been insisted upon, by different writers.

I shall not, however, enter into the controversy, but content myself with remarking, that what happened in Barratt's case, seems to set aside the latter hypothesis ; for ( as before observed) he gained weight, during the time that the urinary discharge-exceeded the quantity of his drink; but it is proper to remark, that during his acquisition of strength and flesh, the sweetness of the urine, as well as other of the characteristic Diabetic symptoms were on the decline. This alteration of the qualities of the urine denoted the restoration of the assimilating powers, whereby the saccharine portion of the chyle was duly applied to the purposes of nutrition. Hence arose, I should imagine, the increase of the patient's vigor and bulk; notwithstanding the superiority of the quantity of urine to the liquids taken, remained. When the patient entered upon a mixture of vegetable with animal food, his strength and bulk were still more evidently increased, although the disproportion of the urine to the drink, remained stationary.

But as he was enabled by this plan to get down more solid food, and the powers of the system were capable of converting the same into nutriment, it is not surprising that his strength and flesh were so manifestly recruited.

The quantity of extractive matter in this patient's urine did not diminish in the degree that might have been expected; considering the amendment, not only of the specific complaint, but also in his general health. Nor could it be said, that the saccharine impregnation of the urine, was ever completely subdued, although the disease was' brought into that mild state, which led me to hope that it might be ultimately cured.

That the existence of sugar in the urinary residuum, obtained only a few days previous to the patient's departure, was proved by submitting it to the proper tests; but these chemical experiments will be adverted to, when the result of others of a similar kind are noticed.

There is one fact which I have omitted to mention, but as it serves, in some measure, to point out the Diabetic state of the urine, and was found to exist in this, as well as the other confirmed cases of Diabetes Mellitus, it may be proper to notice it. The urine not only stained the linen, but thickened it as if starch, or mucilage, had been applied. In proportion as the urine discovered less of saccharine and extractive matter, and the disease declined, it lost the properties both of stiffening and staining the linen. Barratt himself remarked with pleasure this change, which took place not long after he had entered upon animal diet.

Since writing the above, I received a letter from the patient's widow, in answer to some enquiries, informing me, that her husband died on the 12th of May, about three weeks from the date of his discharge. I then wrote to Mr. Wilson, Surgeon of Altrincham, who attended Barratt the day before his death, and he very obligingly communicated the following particulars ; and at the same time transmitted a register which the patient had very diligently attended to,, and preserved.

His diet had consisted of coffee, tea, and occasionally both, to breakfast; toasted oatcake and milk, to dinner and suppar; be made use of some opening pills when necessary; and lime water, to the amount of a pint daily.

He was capable of following his usual employment and his thirst was not more than natural to a person in health. From the register it appears, the average amount of his urine was nearly five pints and a half each twenty-four hours ; but it still exceeded the quantity of his drink. Its taste and colour remained nearly natural. His appetite and strength had not improved since he came home, and his bowels had been remarkably constipated.

On May 5th, at a public house, he ate very plentifully of bread and cheese, and drank two pints of porter. After this refreshment, he was seized on his return home, with an uneasy sensation in his bowels, which terminated in a violent fit of the colic. He continued in this state,  without any medical assistance, till the 11th, when Mr. Wilson first saw him. He found the patient evidently sinking under Enteritis. The bowels had never been emptied since his first seizure, and now resisted all attempts to procure an evacuation. On the same evening, the pain suddenly abating, the patient became faint, and soon after expired.

From the above narrative, it is highly probable, that the patient died of an inflammation df the intestines, which was brought on by over repletion, and suffered to terminate fatally, from the want of early medical assistance.

It is only of late that any consistent and rational attempts have been made to explain the phenomena of this singular and obstinate disease and to establish a proper mode of cure. To the ancients we are indebted for little more than a history of the disorder by Aretaeus; which has been faithfully transcribed by all subsequent systematic writers, without addition or improvement, till the time of Dr. Willis. This writer first pointed out the remarkable properties of sweetness to the taste, and honey-like smell, in diabetic urine; and thus, by establishing a more decided and specific character of the disease, subsequent practitioners were enabled to distinguish it from many others, with which it had formerly been confounded. Hence, since Dr. Willis's discovery, diabetes has been more frequently noticed; and this, I imagine, has given rise to the erroneous hypothesis, of its being a more common disease in modern, than in ancient times. No further improvement in its history or theory seems to have taken place until Dr. Dobson discovered, by chemical analysis;, the existence of sugar in diabetic urine; and also pointed out the sweet taste and wheyish appearance in the serum of the blood. From hints which he derived from Dr. Cullen and his own experiments, he was led to consider diabetes as a species of imperfect digestion and assimilation. This idea of the nature of the disease was adopted confirmed, and further extended by Dr. Home. He may be said to have first opened the mine which Dr. Rollo and Mr. Cruickshank have so successfully explored. Dr. Home seems indeed to have erred in not steadily adapting his practice to his theory and in too hastily considering both the one and the other as defective, if not nugatory, merely from his want of success in two cases of very long standing.

To the ingenuity and industry of Dr. Rollo and his coadjutor, Mr. Cruickshank, in the treatment of diabetes, every praise is certainly due. For Dr. Home had abandoned the field of enquiry to future practitioners ; but Dr. Rollo  judiciously pursued the tract of his predecessor which in the end led him to success* This success; may be attributed to the revival of the practice which Dr. Home justly takes credit to himself for having first adopted; viz. The employment of animal diet> and air kalies with a view to their specific operation as septics. Indeed this idea of preventing the formation of sugar by the abstraction of vegetable food and of establishing a more perfect assimilation throughout the whole system by the rigid use of animal diet and medicinal septics forms the principal part, if not the entire basis of Dr. Rollo's plan. To this author then, we owe the revival of a practice, which had fallen into disuse, and would probably have sunk into entire oblivion bad not he, by the publication, and extended circulation of Captain Meredith's case, (in which -Dr. Home's principles and practice are judiciously applied and improved) roused the attention of practitioners to the subject ; and enabled them to form more correct notions of the nature and treatment of diabetes.

This is by no means a common disease for I believe there are many practitioners who have the care of extensive public Hospitals, to whom cases of diabetes have never occurred *. It has been my lot to see several instances of the kind ; and I have endeavored to avail myself of the principles and practice laid down by Dr. Rollo and other writers on the treatment of this stubborn and too often fatal disease ; with what success will be seen in the sequel.

I shall now proceed to give an abstract from my Infirmary register and private notep, of the several diabetic cases which have fallen under my care. Two of them, which were lately admitted, at the same time, into the Infirmary have afforded me a favorable opportunity of comparing the result of different modes of practice, and establishing, very satisfactorily, some important conclusions. With these patients I took much pains and I feel myself justified in reporting their cases more at large.

https://dlcs.io/pdf/wellcome/pdf-item/b2106331x/0

https://www.longdom.org/open-access/court-of-last-appeal--the-early-history-of-the-highfat-diet-for-diabetes-2155-6156-1000696.pdf

In Two Cases of the Diabetes Mellitus, Rollo and Cruickshank described the treatment of two patients suوٴering from glycosuria, polyuria and polydipsia with a combination of organic and inorganic salts and a diet restricted in vegetable food, and made largely of meat and fat [1]. Нis was based on the observation that, while both animal foods and vegetable foods are nutritious and will support life, glucose, found in the urine of patients with diabetes and therefore obviously connected to the disease, can be found in large quantities in vegetable foods but only in trace amounts in meat and fat. Нe diet was eوٴective for one of Rollo’s patients, but not the other. Redfearn subsequently published a report of the successful application of Rollo’s method in his own patient [2] and Rollo’s supporter John Latham published many case studies of the diet in his 1811 book Facts and Opinions Concerning Diabetes [3]. Rollo’s method seems to have become widely disseminated; circa 1830 the American adventurer Josiah Harlan, who had taught himself medicine from a popular encyclopaedia, prescribed an animal matter diet to a client in the Punjab, with what results we do not know, according to Ben MacIntyre’s life of Harlan, Нe Man Who Would be King [4]. Нe inconsistent response to the diet seen in Rollo’s first two cases, and in the cases of Latham, can be explained by its high protein content. In the later researches of Woodyatt and others, protein has a glucose value of 58%, due to a high proportion of gluconeogenic amino acids. Hadden gives an analysis of Rollo’s diet for patient 1, Captain Meredith, as supplying 160 g carbohydrate, 136 g protein and 135 g fat [1]. Нus only 50% of the energy from this diet is in the form of the nutrient, fat, which has the lowest requirement for insulin; nor is the diet as low in carbohydrate (from bread and milk, and later, when Captain Meredith returned to Ireland, potatoes) or as permissive with regard to non-starchy vegetables as modern thought would recommend. Captain Meredith lived another 15 years aіer adopting Rollo’s diet, dying in Newfoundland at the age of 49 - according to Hadden, death was probably due to macrovascular complications

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"I have now brought the history of Diabetes down to that period when Dr. Rollo first published his celebrated Treatise, a work which ought to be in the hands of every practictioner who is anxious for the fullest information upon the subject.: a work which, like the discovery of sugar in Diabetic Urine, equally marks an important area in this disease: a work which teaches us to cure what Willis taught us only to know, and which will convey his name, with that of his learned predecessor, down with honor to the latest posterity. And let not any thing which may occur in the following pages be construed to detract from that honorable distinction to which he is so justifly entitled; for his observations on the absolute necessity of a pure animal diet will stand the test of experience, when speculations, with respect to medicine in this disease, by every physician who has hitherto existed, (and even those by Dr. Rollo himself) may probably be altogether neglected and forgotten: I must refer the reader to the work itself, which in its more enlarged form is, if possible, rendered much more important by the many communications therein made from a great number of very ingenious correspondents."

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"so that not only may it exist where little of vegetable nutriment has been taken, and consequently where but little sugar can be produced, but where animal matter has alone been eaten:"

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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]