Type 2 Diabetes

Although advocating the employment of vegetable diet in cases of diabetes of the second class, I do not wish it for a moment to be supposed that I agree with Piorry in thinking that the cause of death, even in this form of diabetes, arises from the loss of sugar; for, on the contrary, I think it springs from the inability of the body to assimilate the sugar it possesses. In such cases, therefore, I give vegetable food, not because it contains sugar, but because it possesses many of the other substances necessary for the purposes of nutrition, which neither exist in the same quantity nor in so easily an assimilated form in animal diet. 

It is well known from the reports of travellers among savage nations, that men restricted solely to animal diet must consume an almost fabulous amount in order to obtain sufficient of all the ingredients requisite in the processes of life. "We know, too, that an animal can be most effectually starved by limiting him to one particular element of food, although that element be even albumen. The benefits derivable from Piorry's plan of treatment, therefore, in my opinion, arise from the fact that when he gives sugar he at the same time ceases to restrict the patient to animal diet, and that in the mixed food they find many of the materials essential to life much more abundantly and in a more easily assimilated form than in animal diet. I shall now give a few typical cases illustrative of the two principal forms of diabetes. 

Diabetes from Excessive Formation. 

In the beginning of 1860 a young gentleman, aged 19, suffering from diabetes, was brought to me by his brother, a Medical Practitioner, who had detected the disease two year previously. This patient had already been under various systems of treatment. What appeared to agree with him best was animal diet, coupled with. small doses of chlorodyne. 

To look at the patient one would have thought that he was a perfectly healthy individual. His weight was 135 lbs. ; the appetite was moderate ; and the amount of urine passed was not at that time excessive. The object of bringing the patient to me, it appeared, was in order that I might, if possible, suggest some remedy to replace the chlorodyne, the constipating effects of which were anything but agreeable. On carefully inquiring into the history of the patient, the case appeared to be one of diabetes by excess, and the origin of the mischief could in some measure be traced to some irritation in the liver, which was painful at its lower margin, the pain being much increased on pressure. Having an intelligent Practitioner to deal with, I at once gave my view of the case, and explained how, as scarcely any two cases of diabetes are precisely alike, it would be necessary to try the effects of different forms of treatment in order to discover what would be best for this particular case. The following table is an abstract of the results : 

TABLE 

The average amount of sugar passed by this patient during the next six months being from fifty to sixty grammes (775 to 930 grains) and his -weight 156 pounds, a quantitative analysis of the sugar -was no longer thought necessary. I may add that-when I last saw the gentleman in August, 1864 (on the occasion of his bringing to me a poor lad, -whose case I shall presently relate), he looked in excellent health, being, as he said, -without any feelings of discomfort, although he had still to continue his medicine, for as soon as he neglected it, the sugar again increased.

https://www.google.com/books/edition/Researches_on_the_Nature_and_Treatment_o/DBQDAAAAQAAJ?hl=en&gbpv=1

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Dietary for the diabetic:

May Eat:

Butcher's meat of all kinds, except liver.

Ham, bacon.

Poultry.

Game.

Fish.

Animal soups.

Eggs, cheese, cream, butter.

Greens, spinach, lettuce, nuts sparingly.

Must avoid Eating:

Sugar, bread, Rice, Potatoes, Cauliflower, peas, broccoli, and many more.

The next case is that of a lady who also suffers from diabetes by excess. Before coining to me she had been under a gentleman connected with one of the City Hospitals, who treated her according to what has been hitherto considered the orthodox principles of restricted diet, upon which treatment she had thriven so well that when she walked into my consulting-room I never dreamt that she came to talk about herself, but imagined she came about the health of another patient with whom she had been to see me a short time previously. She looked, in fact, the very picture of health ; being plump, hale, and rosy. Like many patients in her position of life, she thoroughly understood the nature of her disease, and criticised the opinions of our first authorities on the subject in a manner which somewhat surprised me — especially when she finished by saying she had come to put herself under my care, not for the purpose of being dieted, but for the purpose of being able to live without being dieted. She was tired, she said, of gluten bread, etc., and wanted to live like other people. She had brains enough to see that dieting kept down the sugar, not by cujing the disease, but merely by stopping the supply, and that as soon as she gave up the restricted diet, back came all the disagreeable symptoms. On analysing the urine I found she was in as good a condition as restricted diet could make her; the quantity of urine passed was moderate, of a specific gravity of 1030, and the amount of sugar comparatively trifling, — 310 grains. 

Diagnosing the case to be one of diabetes by excess, I honestly told her that although her case was one of the most favourable as far as longevity was concerned, it was one of the least satisfactory kind to put on ordinary diet. At the same time adding, that the treatment must, in the first place, be entirely experimental, it being impossible to say what remedy would most successfully allow her to dispense with dieting. The case so closely resembled the preceding in its general characters, that I ventured on the same line of treatment, and, as will be seen by the subjoined table, with a favourable result. The sugar gradually diminished, until at length, after seven months' treatment, the saccharine matter had entirely disappeared from the urine. Being too sanguine as to the result, in an unlucky moment I consented to the patient's throwing aside the restricted diet, and whether this was done too suddenly or not I cannot say, but certain it is, that before a month was over, the urine con- tained as much, and even more sugar than when iirst I took the case in hand. One very remarkable peculiarity of this case is the very Large amount of urea passed by the patient. A large quantity  of urea is common to all diabetic cases, and especially to those on animal diet. Regarding the cause of the high percentage of urea in diabetes, the Rev. S. Ilaughton (a) remarks that it comes from the excessive decomposition of protein substance which takes place in this disease, quite independent of the amount of bodily work done. In a series of observations on two cases in XJniversity College Hospital, Ringer(b) arrived at the following conclusions : — 1st. That after the influence of food on the urine has entirely disappeared, a constant ratio is maintained between the sugar and urea. 2nd. That after a purely non-amylaceous and non-saccharine meal both the sugar and urea are increased, but that during this increase the same ratio between them is observed. This ratio being 1 of urea to 2-2 of sugar. 3rd. That under both these circumstances the sugar could only be derived from the nitrogeneous elements of the body, and, therefore, that some such ratio might, on a priori grounds, have been expected.

Bernard's study of the pancreas would be discovered by Banting's doctor.

Bernard’s contribution in the study of metabolism and diabetes remains leading. In 19th century, scientists hypothesized on the role of pancreas in the physiopathology of diabetes as they found in the post-mortem examination of the diseased, atrophic or stone filled pancreases. However, as they believed that pancreas was an exocrine organ, they interpreted these post-mortem findings as a chance phenomenon. During that period the French experimental physiologist, Claude Bernard decided to test this hypothesis[1,12].

At the beginning, he falsely believed that “diabetes was a nervous affection of the lungs”. However, during an experiment, he injected grape sugar into the jugular vein of a dog, extracting at the same time blood from the carotid artery. This blood contained a large amount of sugar and he realized that glucose was not destroyed in the lungs, because blood must pass by these organs in order to move from the jugular vein to the carotid artery. He was then fed dogs on a carbohydrate-rich diet, the blood from the hepatic veins and vena cava contained sugar which was not destroyed in the liver and was also present in heart ventricles, so the theory of lungs’ role in diabetes was rejected. In further experiments, Bernard proved that animal blood contains sugar even if it is not supplied by food. Testing the theory that sugar absorbed from food was destroyed when it was passing through tissues, Bernard put dogs in carbohydrate diet and killed them immediately after feeding. To his surprise he observed large amounts of sugar in hepatic veins. The same observation was done in the control group, animals that were fed only by meat. He then moved to the analysis of liver tissue samples and in every liver he examined he found large quantities of glucose which was missing from other organs. He concluded that liver was storing a water insoluble starchy substance that he named glycogen which was converted into sugar or glucose and secreted into the blood. He assumed that it was an excess of this secretion that caused diabetes[13,14].

Moving toward, Bernard demonstrated the connection between the central nervous system and diabetes. Using a needle, he stimulated the floor of the fourth brain ventricle and produced temporary “artificial diabetes” which lasted less than one day. He named this procedure piqûre diabétique and linked for the first time glucose homeostasis and the brain to the pathogenesis of diabetes[15].

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707300/

The two great types of diabetes, that due to excessive formation, the other to diminished assimilation of saccharine matter, require, of course, as far as animal dieting is concerned, opposite modes of treatment ; for while in the former class of cases it is a most important — I might almost say an essential — adjunct to the other treatment, in the latter it is either detrimental, or, at best, of no use at all. 

Even in the most favourable cases for restricted diet, we must never allow ourselves to be deluded into the idea that, because we are mitigating the symptoms, and reducing the amount of sugar in the urine, we are necessarily curing the disease, or we shall frequently be doomed to sad disappointment. In keeping a patient on restricted diet, we are merely with-holding from him the straw and mortar out of which the bricks are made — not removing the makers — so that, as soon as the straw and mortar is refurnished to them, they will again be found at work as actively as ever. It is true that it occasionally happens during the withdrawal of the straw and mortar the makers disappear; but this, unfortunately, is by no means invariably or even frequently the case; it is rather, indeed, the exception than therule. We must therefore rely on other means for the removal of the makers. Of these other means I shall presently speak. 

Meanwhile, let me explain that by the term restricted diet we mean not only the avoidance of all sugars, and substances containing saccharine matter, but also of all kinds of food convertible during the process of digestion into sugar. The foods convertible into sugar in the digestive canal are those containing starch (not gums), such as arrowroot, tapioca, sago, flours of all the different kinds of cereals (wheat, barley, oats, peas, beans, etc.), potatoes, carrots, beetroot, parsnips, turnips, and other edible roots. 

Green vegetables, on the other hand, such as spinach, cabbage, turnip tops, Brussels sprouts, and lettuce need not be forbidden, as they contain too small an amount of starch to do much injury. 

As for animal foods, on the other hand, every imaginable kind of fish, fllesh, and fowl may be indulged in, so that even on the most restricted diet the patient has still a large margin for selection — beef, mutton, pork, venison, poultry, game, and wild fowl, oysters, lobster, crabs, prawns, salmon, cod, turbot, etc., Iceland and Irish moss, calf's foot or gelatine jellies, butter sauces, and salad oils. 

The only true hardship, in fact, the patient suffers is the deprivation of ordinary bread, and that appears to be a more severe one than most people imagine. I have known patients in whom the craving became at last almost intolerable, as if nature were crying out for some indispensable element of food. In order to mitigate this hardship, a great number of plans of depriving bread of the forbidden element, starch, have been suggested, and many of them have been in a great measure successful. Thus, we have bran, gluten, almond, and glycerine breads and biscuits constantly kept in stock by many of our London bakers, (a) After a time patients get very tired of these substitutes, so it is as well to know that we may occasionally indulge them with well done toast, or very crisp pulled bread, the extra heat having destroyed a considerable portion of the starch normally contained in the article. 

As regards drinks, all such as contain saccharine matter are to be avoided ; such, for example, as sweet sparkling wines, whether they be champagnes, moselles, or hocks. An embargo is also to be put on all liqueurs and fruity wines, such as young port, RoussUlon, etc. ; sweet ales, stout, and porter are also to be shimned. If the patient is to be indulged in wines at all, let him have dry Lisbon, old Madeira, Manzanilla, or Amontillado sherries, Chablis, Niersteiner, or old Sauteme ; sound clarets may also be indulged in. "When stimilants are deemed requisite, brandy, whisky, rum, or Hollands may be used ; but these ought always to be employed with caution for the reasons previously given, when speaking of the artificial production of diabetes by means of stimulants introduced into the portal circulation. All that has now been said regarding regimen has of course only had reference to that form of diabetes arising from excessive formation. There are no restrictions either as regards food or drink requisite in cases springing from defective assimilation. On the contrary, the duty of the Practitioner is to select for his patient not only that which is most nourishing, but also that most easy of assimilation. He will often find, too, that such cases not only tolerate but even demand the free use of stimulants, in order to support the flagging vital energies, and enable the weakened organs to perform their work. I think if I were asked what is the best remedy for diabetes, I might venture to answer, in the language of Opie, when the student inquired what he mixed his colours with, "Brains, Sir." For to say that any one remedy or particular line of treatment is suitable to all cases of diabetes would be simply charlatanism of the worst sort.