Type 2 Diabetes

OBSERVATION VM Francesco Maria R., 60 years old, from Aversa. He was little fond of meat, and hardly ever ate it: no cause but the abuse of flour and sweets: no moral emotions, no sorrows. Fading and losing weight for a long time, for three or four years, he had experienced a great dryness of the mouth: for a year very great polyuria, extraordinary thirst, and still more rapid emaciation. For six months, glycosuria had been known, and treated with alkalis, without any advantage: the polyuria itself had increased. 

In the first quantitative analysis, on September 20, 1870, Professor Primavera noted 4 liters of very pale urine, with a specific gravity of 1034, with 100 g. of sugar per liter. In the second analysis, 5 liters of urine were found with 550 gr. sugar. On October 2, Professor Buonomo submitted him to my meat cure, with ö gr. lactic acid. After four days, the urine again examined was completely free of sugar: one liter in twenty-four hours: specific gravity 1018; normal color: abundant uric acid. It was at this time, October 2, 1870, that I saw the patient, in consultation with Professors Buonomo and Ramaglia, and Doctors Ruffo and Grimaldi d'Aversa. It was decided to continue the cure, which was done very scrupulously by the patient, although it was a great sacrifice. Every eight or ten days, we redo the examination of the urine, which remained examples of sugar, with a weight of 1017 to 1020, and rich in urea and urates. The cure was thus followed very rigorously until the end of December. The patient then began to eat green vegetables, then fruit: in February a little bread and pasta; and little by little he increased their quantity, preferring beans, peas and lentils to cereals, but eating above all meat and eggs. In June, he began to eat sweets. The glycosuria did not reappear. Even today this gentleman, whom you saw here because he wanted to hear one of my lessons on diabetes, enjoys the best health. His weight has increased by several kilograms, he is strong and healthy. In September 1874, the healing persisted, complements.

OBSERVATION VI. - Mgr B., Patriarch Archbishop of Antioch, born in Candia, 64 years old, diabetic for four years, had previously had intermittent fevers in Syria; great previous sorrows, great moral and physical fatigue, and finally, four years ago, great fear from an assault in which he was threatened with death; as a treatment he was bled until he became bloodless, and fell into a faint. Note that this patient ate almost exclusively flour and sweets. In 1867, Mgr began to experience ardor in the mouth and lips, with ardent thirst and polyuria, especially at night; He observed that the flies were throwing themselves in great numbers on his urine, the drops of which stained his clothes. Little to

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The hunger increased, and however the patient grew thinner, the polyuria still increased. In November 1870, he was seen by two of my colleagues who ordered my treatment: the urine which initially weighed 1042 quickly went down to 1020: the sugar disappeared; but after eight days he ate bread, and immediately relapsed: three times he resumed the rigorous cure, but each time he returned too quickly to bread, and relapsed. However, there was a noticeable improvement in that thirst and polyuria were greatly reduced. When he came to Naples in the spring of 1871 he was emitting three liters of urine per day, according to Professor Primavera's analysis: specific weight 1035, sugar 240 gr. every twenty-four hours. After only five days of rigorous treatment, the specific gravity of the urine went down to 1018 and the sugar disappeared. Fifteen days later, the patient having taken a slightly sweet lemonade, again had a little sugar: then he did the cure very rigorously for two months, and from then on, completely cured, he was able to return first for the use of fruits and vegetables, the following month for the use of bread: the healing still persists today, according to the news I have received. He knows how to analyze his urine himself and thus monitor the results of his diet. All diabetics should learn to do it too: relapses would be much rarer.

OBSERVATION XII. Mr. Adamo A., famous artist of the Italian theater, suffering for a long time from thirst, polyuria and general weakness, recognized diabetic for a few months: unknown causes apart from the habitual abuse of flour. He presented 65 gr. of sugar per liter of urine, and the specific gravity of 1030, when, Submitted to my cure by Primavera himself, from November 22, the urine had come down to 1 liter in. about, specific gravity 1022, no trace of sugar. The patient weighed 66 kilog., On January 31 he weighed 71 kilog. This soft man. rut more than a year after being cured of diabetes, stroke: although he had resumed mixed feeding for a long time, his urine had remained free of sugar: their weight at 1016-1018. On April 22, 1872, he was submitted to my treatment by M. Finizio, pharmacist of Naples. On May 25, the urine weighed 1013: they were free of sugar, and have remained such until this day (September 1874): MA is doing very well, and will continue thus, if he no longer abuses the flour: we hope for the sake of Italian art.

OBSERVATION IX. - Mr. Leopoldo Lam ... of fat constitution, 60 years old, owner in Naples; constant abuse of mealy crops. Patient for more than two years, cataract for a month, eliminating 6 liters of urine, containing 730 gr. of sugar, and of the specific weight of 1037, with some traces of albumin, according to the analysis of Primavera of December 9, 1870. Subjected to the rigorous treatment, meat diet and lactic acid, he experienced from the first twenty-four hours , an extraordinary improvement: after three days, the polyuria and glycosuria had disappeared. On January 4, the patient noticed an improvement in his eyesight: he resumed eating bread and even sweets, without relapse. On January 18, 1871, the urine weight was 1011: the healing was maintained complete. The patient remained in good health for a few months, then died from acute intercurrent lobar pneumonia.

Bouchardat and the evolution of the diabetes diet 

Towards the end of the 1850’s, Pierre Adolphe Piorry (1794-1879), Professor of Internal Medicine in Paris, recommended that diabetics consume large amounts of sugar. However, one of his colleagues, a diabetic, was unfortunate enough to follow his advice and died as a consequence. Nevertheless, at the beginning of the 20th century, a considerable number of physicians still believed in the need to increase the consumption of sugar as a means of treating this disease. Even the most seemingly knowledgeable specialists tended to urge their diabetic patients to gain weight. 

In 1910, the American physician Frederick Madison Allen (1879-1964) developed his famous “Allen starvation treatment”. Considered the best therapy for diabetics before the introduction of insulin, it comprised severely restricted calorie intake (1000 calories per day) and was rich in fat and protein accompanied by 10g of carbohydrate daily.6 

An important first step in the right direction was made when physicians began to adopt a position contrary to that of overeating, realizing that the surplus of food absorbed by diabetics required an extra effort of the organism, this aggravating their condition. Noting that carbohydrates appeared on the whole to be particularly harmful, they additionally recognized that, since the absorptive capacity of the diabetic organism is severely compromised, a diet poor in carbohydrates would likely be appropriate.7 

Bouchardat refuted the disastrous method of Piorry, establishing his own diet specifically adapted to the needs of his diabetic patients. He experimented with periodic fasting, having noted that, during the 4-month siege of Paris in the 1870 Franco-Prussian war, those patients of his who suffered from starvation presented diminished glucose in their urine. He had also observed that exercise seemed to increase the tolerance of diabetics to carbohydrate. “You should earn your bread through the sweat of your brow”, declared Bouchardat to one of his patients who had asked him to increase his food ration.8  Moreover, Bouchardat sought to demonstrate the merits of his principles via their practical clinical application. He was the first to put his patients on a specific diet, thus inaugurating the clinical knowledge of diabetes and its dietary treatment. 

His clinical mind and common sense impelled him to stress the importance the importance of the diabetes diet since he wrote: “...it is difficult to refrain, and to continue thus, when man so much hungers after bread. Despite the most careful monitoring, despite the assurances of these unfortunates, it is true that this food will become fatal for them, since nothing averts them from it. A little later, tired of this treatment that does not end and exhausted, more morally than physically, the diabetics resume their starchy meals; the accidents reappear.....and death arrives”.8  Bouchardat’s work on diabetes, begun in 1830, continued for half a century. All his articles on this disease are summarized in his book De la glycosurie ou diabète sucré; son traitement hygiénique, published in 1875 in Paris and considered as the best approach to dietary treatment of diabetes. 

Although a supporter of Rollo’s gastric theory concerning diabetes, Bouchardat would modify it, adding the hypothesis of the presence in the gastric juice of a “diastase”, an enzyme that promotes the transformation of amide into glucose. Normally carried out in the intestine, this chemical reaction was thought to occur in the stomach under certain pathological conditions; the gastric mucosa would allow a more rapid passage of sugar in the blood, hence the hyperglycemia and glycosuria.8  This constituted an approach similar to that of the German physician Wilhelm Griesinger (1817-1868). 

In his first treatise on diabetes (1830), Bouchardat proposed the presence of a “diastase” in the stomach of diabetic patients. Later, he carried out numerous experiments to study in depth the digestion of starches in both physiological and pathological conditions. The results of these investigations were recorded in various publications dealing with “la fermentation glucosique”, presented at the Academy on January 13, 1845, “la digestion des aliments sucrés et féculents” and “les fonctions du pancréas”, presented to the Academy of Sciences on January 20, 1845.3 

The following question occurred to him: “Does there exist in the gastric juice a specific substance that plays an important role in the disease?” Italian and German medical authors of the same period who had written on diabetes reported the existence of the diastase in normal gastric juice. However, though Bouchardat experimented on the action of normal gastric juice on intact starch, on jelly starch and on bread, he could never discern the least specific debilitating action. He thus concludes: “To my mind, the existence in the gastric juice of a substance that transforms the starch into glucose in the stomach of diabetics concerns a “pathological” fact and not a “physiological” one, and it is none other than the diastase”. This was Bouchardat’s theory, inspired by that of Rollo. He summarized his ideas saying, “... abundant glycogenic food, production of an overly energetic diastatic ferment, excess of glucose in the blood: these are the main conditions defining diabetes mellitus pathogenesis”8  (Figure 2). 

Bouchardat, promoter of the first diet for diabetes in the contemporary age 

Despite some unresolved questions and the unsoundness of his “diastase” theory, the fact remains that Bouchardat was the first physician to formulate a dietary treatment and should therefore be viewed as the originator in the present age of a diet tailored to diabetes. He recommended the substitute of carbohydrate fats and advocated alcohol which, according to him, was a valuable source for diabetics of considerable amounts of calories. He was opposed to milk consumption because of its richness in lactose, while he recommended green vegetables and gluten bread. He also demonstrated the importance for diabetics of a moderate degree of undernutrition combined with physical exercise.9 

In his book, De la glycosurie ou diabète sucré, Bouchardat devotes seventeen pages to enumerating both forbidden and permitted foods. He begins by offering general advice on the alimentation of diabetics such as the following: “Eat moderately and slowly, chewing the food thoroughly; the amount of urine in 24 hours needs to be over one liter and a half; drink the least possible; two meals a day are advised: one at 10 o’clock, the other at 6 o’clock; avoid resting, and especially sleeping, after meals; a good walk out of doors is recommended; sleep only four to five hours after the last meal; refrain from smoking”.8 

In the list of forbidden foods he includes starches and sugars and anything which contains “all fruits” and “jams of all kinds”. Also prohibited are bread, regardless of the cereal, carrots, turnips, rape and other farinaceous roots, or sweet onions, radishes, beans, peas, lentils, beans and chestnuts. This list additionally incorporates honey, milk, beer, cider, wines sparkling or sweetened, carbonated water, soft drinks and other beverages, especially when they are sweet, and also sorrel soup. All these foods are prohibited because they are not used by the body and, moreover, will produce sugar in the urine.9 The list of permitted foods is very long, including gluten bread and many others. Providing more specific advice about meals, he writes: “...you can add egg yolks and cream in the last soups and in chocolate”. Concerning meat, he said: “...all the meats and deli meats, smoked or salted, are acceptable; they can be served dry in slices or with olive oil and herbs on them”. Concerning pastry entries: “...all these dishes should be prepared with gluten flour instead of regular flour”. Regarding wines: “...during the 24-hour day, a liter of wine suffices for a man and 0.5 liter for a woman”. He advocates old wine (white or red) and adds: “...wine is very useful to animate the body’s forces, but when these are diminished by the design of the regime and moderate exercise, it is appropriate to eliminate them from the diet”.8 

In general, the recommended foods were meat (beef, lamb, veal), fish fried or with sauce, cheese, eggs, cream. Preference was given to animal and vegetable fats, in order to replace banned carbohydrates, and alcohols. He suggests that “you can add to coffee and tea infusions either a dash of rum or brandy, kirsch, pure glycerin or a dollop coffee instead of sugar cream”.8  Bouchardat believed that the diabetic’s sugar in the urine was “grape sugar” (glucose). To detect glycosuria, he used the fermentation test, the polariscope and solutions of copper.