This is reducing the combustible material with a vengeance, and although the diet becomes more generous as the treatment of the case progresses, in a typical case it is always one of low caloric value. In these circumstances it is quite fair to question the existence of hyperpyraemia as it is conceived by Hare, i.e., as an excess of carbonaceous material in the blood. The only available evidence would be in the detection of large quantities of glucose or carbohydrate in solution in the blood, apart from its appearance in the urine. We know that even in health the blood contains quantities of sugar not sufficiently great to be detected by ordinary clinical tests, just as the urine also always contains a certain amount of glucose in similar circumstances. We also know that in diabetes very large quantities of sugar - amounting to as much as close upon 8 per cent. - may be found in the blood, but this so-called hyperglycemia, even when infinitely smaller quantities are present, is always accompanied by glycosuria.

We recognise that large numbers of people must eat an excessive quantity of carbohydrates without increasing their deposit of fat, without being afflicted with paroxysmal neuroses, and without suffering in any appreciable degree thereby. What constitutes the difference between those who can, and those who cannot metabolise the extra quantity of combustible material, and what becomes of it in those who dispose of it with impunity? We know that carbohydrates are the most important source of muscular power, and fat the principal source of heat, although we are equally aware, in accordance with the Law of Isodynamics, that the different organic nutrients can replace one another in amounts as nearly as possible in proportion to their relative heat values. Buhner states the following as the quantities of the different foodstuffs which are isodynamic: Fat, 100 grams; starch, 232 grams; cane sugar, 234 grams; dried meat, 243 grams. We are absolutely certain in the animal organisms that fats are able to be manufactured from carbohydrates, and although not definitely proved, it is fairly certain that they also can be formed from albumin, while clinically we have no hesitation in saying that sugar is derived from albumin. We know that plants must synthesise albumins from carbohydrates and nitrogen, either extracted from the soil or, as in the leguminosae, from the air; but we are equally certain that such transformations are impossible in the animal organisms. But the close relationship between lactic acid and alanine and other amino-acids, and the fact that synthetic changes which used to be considered a prerogative of plants are now known to take place at least in the kidneys, give us warrant for assuming that complicated synthetic processes of which we are as yet ignorant do take place in the animal cell. There may, therefore, be methods for the disposal of carbohydrates yet unknown to scientists, and this presupposition is at least as probable as the existence of hyperpyraemia.

Now Hare quite frankly recognises that the manifestations of hyperpyraemia are not associated with glycosuria, but that, on the contrary, the supervention of the latter is attended by a cessation of them, and hence hyperglycemia excludes hyperpyraemia. He therefore relies upon Pavy's theory rather than that of Bernard, and declares that hyperpyraemia implies the existence in the protein molecules of the power to take on side chains of carbohydrate material, whereas when this power is lost we are in the presence of hyperglycaemia. The one condition, therefore, necessarily excludes the other. Hare confesses himself quite unable to reconcile these facts, but is content with the statement that hyperpyraemia and hyperglycaemia are antagonistic for the most part in their clinical relationships.

It is rather unfortunate that there is as yet no clinical evidence of the existence of hyperpyrsemia, and I note that there is an entire absence of any appeal to chemistry in Hare's book. One is quite unable to refute the clinical evidence or the valuable therapeutical influence of Hare's dietetic suggestions, but it is quite possible on some other hypothesis than that of his theory. He expressly excludes the possibility of auto-intoxication, solely on the ground that there is no evidence of the existence of excessive intestinal fermentation. This, however, is by no means necessary, for toxins derived from proteins exist in the alimentary canal and are satisfactorily dealt with by the liver and kidneys, in a degree quite within the limits of health. There is no reason at all why a similar process associated with the carbohydrates might not be proceeding in such a manner as to disturb hepatic metabolism. The reduction of carbohydrates and fats in the foods simplifies the digestion in a very remarkable degree, and I have pointed out that Folin believes that some people have as much difficulty in metabolising carbohydrates as others have with proteins.

Besides, as Ryffel has pointed out, there can be no question that excess of carbohydrates is sometimes responsible for an accumulation of lactic acid in the blood, and there is no inherent possibility why some of the other acids associated with the decomposition of carbohydrates might not also be present, and set up inflammation or irritation in susceptible parts, or of some mucous membrane, perchance, during the process of excretion. I have recently had a case of severe asthma which derived no benefit from the purin-free diet, nor that associated with Hare's name, and yet was completely relieved by an exclusive diet of Revalenta Arabica. The assimilable protein in such a diet was not more than 14 per cent., and the daily calories never exceeded 1,000, so that ample opportunity was given for the body to rid itself of its toxins in the fortnight before the gradual resumption of an ordinary diet.