Fast until sugar free. Drink water freely and tea, coffee, and clear meat broth as desired. In very severe, long-standing and complicated cases, without otherwise changing habits or diet, omit fat, after two days omit protein, and halve carbohydrate daily to 10 grams, then fast.

Carbohydrate Tolerance

When the twenty-four-hour urine is sugar free, add 150 grams of vegetables containing 5 per cent, of carbohydrate and continue to add 5 grams carbohydrates daily up to 20, and then 5 grams every other day, passing successively upward through vegetables containing 5, 10, and 15 per cent, of carbodydrate, fruits containing 5 and 10 per cent, of carbohydrate, potato and oatmeal to bread, unless sugar appears or the tolerance reaches 3 grams carbohydrate per kilogram body weight.

Protein Tolerance

When the urine has been sugar free for two days, add 20 grams protein (3 eggs) and thereafter 15 grams protein daily in the form of meat until the patient is receiving 1 gram protein per kilogram body weight, or if the carbohydrate tolerance is zero, only ¾ gram per kilogram body weight.

Fat Tolerance

While testing the protein tolerance, a small quantity of fat is included in the eggs and meat given. Add no more fat until the protein reaches 1 gram per kilogram (unless the protein tolerance is below this figure), but then add 25 grams daily until the patient ceases to lose weight or receives not over 40 calories per kilogram body weight.

Reappearance Of Sugar

The return of sugar demands fasting for twenty-four hours or until sugar free. The diet is then increased twice as rapidly as before, but the carbohydrate should exceed half the former tolerance until the urine has been sugar free for two weeks, and it should not then be increased more than 5 grams per week.

Weekly Fast Days

Whenever the tolerance is less than 20 grams carbohydrate, fasting should be practised one day in seven; when the tolerance is between 20 and 50 grams carbohydrate upon the weekly fast day, vegetables containing 5 per cent, carbohydrate and one-half the usual quantity of protein and fat are allowed; when the tolerance is between 50 and 100 grams carbohydrate the 10 and 15 per cent, vegetables are added as well. If the tolerance is more than 100 grams carbohydrate, upon weekly fast days the carbohydrate should be halved.

Joslin1 writes, "The advantages of the new treatment are many. It has made attainable the ideals of treatment, namely, a sugar-free and acid-free urine. The standards of the success of treatment are so simple that they are within the reach of the patient. At one stroke the patient is delivered from medicines, patent or otherwise, sham kinds of treatment, gluten breads, and in ninety-nine cases out of a hundred, of alkalies." With his increased knowledge Joslin2 does not hesitate to carry pregnancy in the diabetic to term.

Joslin found that the ingestion of fructose by a diabetic did not increase the respiratory quotient (see p. 296).

Von Noorden's oatmeal cure has occupied a prominent place in diabetic therapy. Blum3 denied its specific efficacy and attributed the results to the low protein dietary. Roily,4 on the basis of respiratory experiments, concluded that there was no difference in the value of the various forms of starch ingested by the diabetic, and Joslin5 showed the failure of either oatmeal or potato starch to raise the respiratory quotient in severe diabetes. Allen believes that the significance of the oatmeal treatment lies in the fact that it is usually administered after interpolation of days of green vegetable diets, which constitute virtual starvation, while Joslin states that in the salt content of the oatmeal lies its only benefit. Baumgarten and Grund6 have separated the starch and other constituents of oatmeal and have administered them separately to diabetics without improving their condition.

1 Joslin: "American Journal of the Medical Sciences," 1915, cl, 489.

2 Joslin: "Boston Medical and Surgical Journal," 1915, clxxiii, 841.

3 Blum: "Munchener med. Wochenschrift," 1911, lviii, 1433.

4 Roily: "Deutsches Archiv fur klin. Med.," 1912, cv, 494. 5 Joslin: "Archives of Internal Medicine," 1915, xvi, 693.

6 Baumgarten and Grund: "Deutsches Archiv fur klin. Med.," 1911, civ, 168.

The elimination of β-oxybutyric acid from the system is furthered by the administration of alkalies. Staubli reports a diabetic who eliminated 34 grams of β-oxybutyric acid daily when the diet contained 60 grams of sodium bicarbonate. This excretion fell to 17 grams on a diet which was free from alkali, and then rose to 45.2 grams on return to 60 grams of bicarbonate. Such treatment with alkali is sometimes highly beneficial, for, as Magnus-Levy observes, the diabetic does not die in coma because of the neutralized acid which is eliminated in the urine, but rather on account of that which is retained in the body which neutralizes the alkalies of tissue and of body fluids. .

Von Noorden1 reports cases of diabetics who have excreted 5 to 6 grams of aceton and 30 to 40 grams of β-oxy-butyric acid in a day, and yet have lived comfortably for years.

Alkali therapy has long been considered important in the treatment of diabetes. Bicarbonate of soda up to 200 grams daily has been given. Weiland2 cites a case in which green vegetables, 200 grams of meat, and 120 grams of sodium bicarbonate were given daily, under which circumstances the urine contained the following ingredients:

It is evident that, despite the high acidosis, the ammonia is kept at a low level on account of the large amount of alkali administered.

1 von Noorden: von Leyden's "Handbuch der Emahrungstherapie," 1904, ii, 253.

2 Weiland: "Zeitschrift fur ex. Path, und Ther.," 1912-13, xii, 116.

Murlin1 has obtained results which indicate that if de-pancreatized dogs be given alkali they are able to oxidize some glucose. This accords with the idea that diabetes is the result of acidosis (see p. 261). Whether alkali therapy, if applied still more rigorously than heretofore practised, will enable the diabetic patient to oxidize glucose is a question raised by these experiments.2