COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 49897 RC660 .St4 1 91 6 Fasting and undernut RECAP Columbia Snitjergitp .^ intl)eCitpofi9ett)19orfe ' ^'e gitbool o£ ©ental anii <©ral purser? iCveferente Hibrarp ,fo FASTING AND UNDERNUTRITION IN THE TREATMENT OF DIABETES BY HEINRICH STERN, M.D, LL.D. VISITING PHYSICIAN, ST. MARK'S HOSPITAL; CONSULTING PHYSICIAN, METHODIST- EPISCOPAL (SENEY) HOSPITAL; STATE HOSPITAL AT CENTRAL ISLIP; DEACONESSES' HOME; PORT CHESTER AND GLENS FALLS HOSPITALS; FOUNDER AND EDITOR OF THE ARCHIVES OF DIAGNOSIS; FORMERLY CHAIRMAN, SECTION ON PHARMACOLOGY AND MATERIA MEDICA, AMERICAN MEDICAL ASSOCIATION; PRESIDENT NEW YORK PHYSICIANS' ASSOCIATION; FELLOW OF THE AMERICAN CONGRESS ON INTERNAL MEDICINE; THE AMERICAN UROLOGICAL ASSOCIATION; THE AMERICAN THERA- PEUTIC society; THE NEW YORK ACADEMY OF MEDICINE. ETC.. ETC. MEDICAL A] (FORMERLY REB.N NEW YOWK 30 IRVING PLACE (cor. e. ,6th st.) TEL. CALEDONIA 3012 COPYHIGHT, 1916, BT REBMAN COMPANY New York PRINTED VS AMERICA PREFACE , Fasting {not starvation) has an assured place in diabetes therapy, a place, however, which is not by far as important as some modern en- thusiasts are wont to make us believe. Fasting without being followed by undernutrition is en- tirely valueless so far as the management of diabetes is concerned. In the preponderating majority of instances of diabetes a protracted fasting-undernutrition regi- men is, fortunately, not indicated. In all such cases we do more lasting good without incurring any risks by following the older approved meth- ods of dieting. Only the advanced and severest forms of dia- betes which are no longer or never were bene- ficially influenced by ordinary antidiabetic dieting are apt to be appreciably improved by continued fasting and undernutrition. This little book is based entirely upon personal observations and experiences. It mil be found that it differs, in certain essentials and in a num- ber of details, from the rules and regulations laid v vi Pkeface down by others in articles dealing with the same theme. The discussion of hypothetical subjects has been avoided in the main text (Part I). A few more or less theoretical points, particularly the question of the ketones, have been dwelled upon at greater length in Part II, the supple- mentary portion of the book. Heinrich Stern, New York. CONTENTS FACS I. Introductory Remarks 3 II. Technic of Therapeutic Fasting in Dia- betes 11 III. Breaking of the Fast and Undernutrition IN Diabetes 26 IV. Failures • 48 V. Physico-Therapeutic Measures in the Man- agement of Severe Forms of Diabetes 56 YI. Illustrative Cases 64 Supplementary Notes on the Topic of the Ketones in the Human Organism I. The Acetone Bodies in the Urine and the Ferric Chlorid Reaction 97 II. Are there Ketones of Intestinal Produc- tion! 101 III. Concerning the Suppression of the Ace- tone Bodies in Diabetics Ill IV. The ''Yolk Cure" in the Treatment of the Underfed 133 V. The Fat Question in Its Relation to the Production and Cure of Infantile Ma- rasmas 147 Assay of the Urine 1*71 Estimation of Sugar in the Blood *190 Nutritive Constituents of Food 195-213 Index 215 vii Digitized by the Internet Archive in 2010 with funding from Open Knowledge Gommons http://www.archive.org/details/fastingundernutrOOster PART I FASTING AND UNDERNUTRITION IN THE TREATMENT OF DIABETES Introductory Remarks There is no pathological condition in the clini- cal control of which dietary treatment plays such a paramount influence as in diabetes mellitus. There is no other agent except a proper regula- tion of the diet that has ever been of any real value in reducing the two cardinal symptoms of diabetes: weakness and glycosuria. This fact has been definitely recognized ever since the ad- vent of the physiological school of medicine. Diabetes is and remains a wasting disease. By a rational system of dieting adapted to the in- dividual case and to each period in the course of the affection, the painstaking clinician is often enabled to stem its progress — or rather its rapid progress — for the time being. This dietary indi- vidualization consists of the periodical diminu- tion or the temporary withdrawal of one or all the types of nutriments. The almost universal tonic for the confirmed 3 4 Fasting and Undernutrition in diabetic is the permanent, or almost permanent, complete withdrawal of all the sugar-containing aliments, and the greater or lesser temporary reduction of starchy foods. Upon this plan of withholding and decrease the management of the average case of diabetes has been based since the times of Pavy, Kiilz, Bouchardat, Ebsteiu and Naunyn. There are numerous modifications of the sugar- free and starch-poor regimen. In the end all pertaining restrictions and modifications amount to the same thing : to render the patient stronger and more resistant, and sugar-free. A logical outcome of Chittenden's ** Physiologi- cal Economy in Nutrition," published in 1904, was that about two or three years later the pro- teins, especially those derived from meats, were also to a certain extent withheld from the dia- betic. Finally a few clinicians decided that the reduction of all the types of nutriments was the sine qua non in the treatment of diabetes. While it was the accepted dictum before the investiga- tions of Chittenden that the diabetic should be maintained in a rather continuous state of over- nutrition, a doctrine has lately been promulgated according to which the life of the diabetic should be one of everlasting renunciation and undernu- trition. The first therapeutic conception is based on the assumption that diabetes is a wasting dis- ease; the latter conception on the observation that a few diabetics get along better and become The Treatment of Diabetes 5 more active after they have lost ten, twenty or more pounds. On the face of it, however, the treatment of. the average case of diabetes by a system of con- tinuous undernutrition bears the stamp of inex- perience, irrationality and harmfulness. Such a plan of treatment has its place in a small pro- portion of the cases of diabetes, in such cases in which besides a persistent glycosuria, a pro- nounced and obstinate ketonosis (acidosis) and rapid decline of body-weight and strength are present. Here, it is true, fasting and undernutrition may produce wonders; in the preponderating majority of instances of diabetes, however, the patient vrill get along much better, and is apt to remain a useful member of society for a number of years if he be not kept below par. On the other hand, forced feeding in diabetes is not always devoid of danger. Instead of as- sisting in the adjustment of the activity of the liver, continued overalimentation is bound to diminish and undermine, sooner or later, the function of this most important organ of the human body. Again, a liver that is not func- tionating perfectly can neither prevent the ali- mentary poisons from entering into the general blood stream, nor is it able to cause normal cleav- age of the intermediary products of metabolism. That total abstinence from food for from three to four successive days renders the urine of the 6 Fasting and Undernutrition in patient with severe diabetes sugar-free and **dis- intoxicates'' the diabetic organism, was the im- portant observation of G. Guelpa, of Paris. This clinical discovery has proved of great moment in the management of both (1) the grave types of diabetes, and (2) the overnonrished cases of diabetes in which the liver no longer affords the necessary protection against the various forms of autointoxication. "While it is true that the discoverer's own hypotheses respecting the ra- tionale of the fasting treatment of diabetes are to the greater part scientifically untenable, it is nevertheless Guelpa who has shown us a way out of the bewildering vagaries of diabetes ther- apy. We should never forget that it was this French clinician who first in all the world de- clared that all food may be withheld for a number of days from a human diabetic without inciting ketonosis (acidosis) and subsequent coma. By one leap the treatment of severe diabetes has suddenly made more progress than it has for the previous quarter of a century. Guelpa 's "cure by privation" (abstinence from food and purgation) consists of the fol- lowing :* First. The taking every day for two, three or •Guelpa: Starvation and Purgation in the Relief of Disease. Brit. Med. Ass., July, 1910. Published in Brit. Med. Jour., Oct. 8, 1910. Guelpa: Autointoxication and Disintoxication. Trans- lated by F. S. Arnold, B.A., M.B., B.Ch. (Oxon.), New York, Rebman Company. The Treatment of Diabetes 7 four days of a bottle of Himyadi Janos water, warmed if possible, or from 40 to 55 c.c. (mils) = one and one-quarter to one and three-quarters oimces of castor oil, followed by about 750 c.c. (mils) = one pint and a half — of water. Second. The abstinence during this period of all kinds of food. Third. The free imbibing of water (not car- bonated), weak tea without milk, toast and water, fruit infusion, etc. (Up to the time of the publi- cation of the translation of his book, Guelpa had avoided any drug treatment whatever, as he wished to prevent any self-deception concerning the therapeutic influence of the treatment.) Guelpa declares that it is only rarely that a patient has difficulty in completing his three or more days' fast. This he finds especially true if the purge and the other liquids that are im- bibed during the fasting period are taken warm. The method of treatment usually calls forth pro- nounced improvement in the patient's state of health. In no instance had any aggravation of the disease resulted on account of the fasting and purging. The benefits accruing from this plan of treat- ment are, according to Guelpa, the follomng: First. Total disappearance of the annoying and distressing sensation of hunger. Second. Marked decrease of the intestinal bacteria, and therefore a pretty perfect state of disinfection of the intestinal tract. Third, Pronounced reduction of thirst. 8 Fasting and Undernutrition in Fourth. Suppression or conspicuous decline of perspiration, even in the heat of summer. Fifth. Production of normal, periodic sleep, very refreshing though somewhat shortened in length. The patient, awakening passes through no stage of drowsiness; full mental activity en- suing immediately. Sixth. Firmness of the pulse and diminution of blood pressure, and increase in hemoglobin, red cells and leukocytes. Seventh. A decrease in the volume of certain visceral organs, particularly the heart and liver, with greater and easier lung expansion. Eighth. Continuous loss in body weight, at the average rate of two pounds a day. Concur- ring therewith the activity of the heart and other organs becomes less oppressed. Ninth. Disappearance of joint and muscular pains and the production of a feeling of agility, liveliness and well-being. Excepting a few loose statements concerning a low protein intake, Guelpa has not devoted much attention to the dietary treatment follotving the fasting periods. More or less he has concentrated his therapeutic endeavors upon that what is now understood as the * initial fast,'' and has given no or but scant rules how to proceed as regards the food-intake after the fasting period is broken. Yet the question how to go ahead after the fast- ing days without occasioning the reoccurrence of The Treatment of Diabetes 9 sugar and ketones is the only intricate one con- nected with the plan of treatment. The fasting period itself offers no difficulty whatever. Fasting and undernutrition in the treatment of diabetes must never assume a stereotyped character. Some patients do well on a one or two days' fast and a week of undernutrition; in others the fasting period should extend over five, six or more days, and the subsequent undernu- trition should be continued for one, two, three or more months. In some diabetics of the graver types a fast day weekly or fortnightly and a slight reduction of the diet may keep the disease in check, in others the duration of the periodical fasting term and a much more decided reduction of alimentation are necessary to accomplish the desired end. Fasting with subsequent undernutrition must go hand in hand in the treatment of the severe forms of diabetes. This fact was already recog- nized in some degree by Naunyn when he advo- cated the interpolation of ** green days" in the dietary of the patient affected with grave or ad- vanced diabetes. These ** green days," however, are to all intents and purposes fast days, as the patient obtains on them but a certain amount of green vegetables whose low starch content is not readily attacked by the digestive juices. Undernutrition in diabetes, as I understand and uphold it, is not the reduction of the intake of one class of foodstuffs, but of all of them. The 10 Fasting and Undernutrition in proportion in the diminution of the various arti- cles of food mnst, however, of necessity differ in the various phases after the fast. Fats, particu- larly those of high melting point, may practi- cally always be permitted, though they may on rare occasions give rise to a slight ketonosis (acidosis) or aggravate an already existing one. Proteins of animal origin, in more or less reduced amounts, must be resorted to soon after the fast. The patient simply cannot get along without them, despite the assertions of some clinicians to the contrary. Great care, however, must be exer- cised that the ingested proteins do not over- burden the liver. The starches should be added latest and then only in the form of vegetables containing at first not more than five per cent, of carbohydrate matter which is not readily elab- orated by intestinal activity. It is now almost six years since I started to make use of Guelpa's method in suitable cases. Naturally, I have modified and amplified it ac- cording to the needs of the manifold cases which have come under my observation since that time. The general plan of treatment by fasting and undernutrition, as evolved by me, differs in more than one respect from similar endeavors. This plan of treatment which is minutely dwelled upon in the following pages is designed as a guide, pure and simple, and as such it merely points to a course of procedure, but it is readily capable of modification and adaptation to individual demands. The Treatment of Diabetes 11 II Technic of Therapeutic Fasting in Diabetes Where to take the fasts AVhile the liospital, on account of its labora- tory and other facilities, may be the best place in which to let the patient take his initial fast, the home, for reasons presently to be explained, is after all to be preferred when the patient has to submit to frequently repeated fasting periods. The fasts in order to do any good should be undertaken at certain, preferably regular inter- vals. One fast is of little consequence, and it should be remembered that one swallow does not make a summer. The arguments in favor of home treatment are, (1) the simplicity of the management of the case itself; (2) the simplicity of the necessary tests which, if need be, may be performed at the bedside by the physician, a nurse or by the pa- tient himself; (3) the accustomed atmosphere which is much less apt to depress the patient than the hospital milieu, and (4) the inexpensive- ness as compared with the extravagant hospital charges. The patient should be resting in bed during the entire course of the fast. The room should have a southern exposure, if possible, but it must 12 Fasting and Undernutrition in not be artificially heated. The toilet, if conveni- ently located, may be used by the patient. If this be not the case a commode must be employed. The attending physician During the inaugural fasting period the at- tending physician should make daily calls and personally assure himself of the patient's physi- cal condition. He should perform or should have performed a blood examination for glucose be- fore the fast is started. In the beginning it is well to examine for blood-sugar every third or fourth day. This, however, is not imperative. The urine should be tested every day for grape- sugar and the ketone substances, especially ace- tone and diacetic acid. (The examination for beta-oxybutyric acid is difficult and time-consum- ing, and is by no means essential in the general run of cases.) During subsequent fasts — provided no compli- cations ensue — the physician need not pay any calls. He should, however, make a daily urinary assay. If there be any indication, an examina- tion for blood-sugar should be made at the be- ginning and conclusion of each subsequent fast. The physician should give his orders either to a nurse, a member of the family or to the patient himself. The nurse The initial fasting period should be under the direct and continued supervision of a nurse. The The Treatment of Diabetes 13 nurse, as a matter of course, receives her instruc- tions from the attending physician to whom he or she should report the patient's condition as often as the exigencies of the case demand. It is the nurse who has to minister to the wants of the patient and who has to keep him as comfort- able as possible. It is the nurse — and this should be particularly the case during the initial fast — who forms besides the physician the sole means of communication between the patient and the outside world. The nurse should keep a chart of the tempera- ture, pulse and respiration w^hich should be re- corded from three to five times during the twenty- four hours. The temperature should always be taken in the rectum unless a disease of the same precludes this. The condition of the skin should be recorded, whether it be warm or cold, dry or moist, etc. Besides an exact account, both as to the amount and the time of the intake of liquids and the output of urine and feces must be kept by the nurse. In subsequent fasts, when the dia- betic state of the patient is no longer an unknown factor to the medical observer, it is not essential that a detailed chart be kept in the average case. The nurse need not belong to the privileged ** registered" class. Any member of the family with a little common sense, possessing some tact and devotion, is able to nurse an uncomplicated case of the graver forms of diabetes during all but the initial fasts. Many servants who watch 14 Fasting and Undernutrition in the doings of the trained attendant during the initial fasting period will make excellent nurses for cases during the periods of fasting and under- nutrition. Indeed, my best nurses for patients suffering from nutritive disturbances I have re- cruited from the ranks of the ** unregistered," the common garden and field variety of attend- ants. Last but not least, they receive only from one-third to one-half the salary which the **E. N.'' exacts. The patient his own nurse I am often asked by the patient why he cannot act as his own nurse during the therapeutic fasts. Excepting, of course, the initial fast when valu- able data for the future guidance of his case are to be gained and when he is necessarily to be kept under close medical surveillance, the ques- tion is certainly justified as, roughly speaking, about half of the cases get along quite nicely without any special assistance. It is my experi- ence that male diabetics may be more trusted in this respect than their female fellow-suiferers. As a rule, the members of the stronger sex have a much better conception of their disease than those of the weaker one, and men have a much keener appreciation than women of the necessity that something be done for their infirmity. Of course, when entirely without the help of some- body the diabetic patient cannot keep his fast. Someone has to make his bed, prepare the per- The Treatment of Diabetes 15 mitted liquids for him, and do other chores. How- ever, as just stated, about one-half of the cases need no special attendance whatever. The patient himself It goes without saying that the patient must have full confidence in his physician. He should talk matters over with him, and not start fasting unless he feels assured that this therapeutic meas- ure is going to benefit his condition. The patient should become acquainted with the fact that the fast is to be immediately followed by a more or less protracted period of undernutrition. He must foster a certain degree of self-denial and as- sume a mental attitude of submission, good will and trust. He must be entirely free from mental unrest, and for this reason should put his house in order before he attempts the fasts. He must not question the orders of his physician once the fast has begun. Worry, exaltation and excite- ment are only too apt to aggravate a case of dia- betes and to increase the intensity of the sugar excretion. The patient mil note that when the ice is once broken, viz., after he has undergone the initial fast, that there are worse things than abstaining from food for a number of days. In subsequent fasts many patients are masters of the situation, indeed so much so that everything connected with the therapeutic fasts, even the slightest detail, may be left to their o^\m discretion and execution. 16 Fastifg and Undernutrition in The cooperation of such patients with their phy- sicians spells success — if a favorable issue can be obtained by this plan of treatment. Duration of the fast The average ketonemic diabetic voids a sugar and acetone-free urine in from three to five days after starting the initial fast. A majority of these patients cease to excrete sugar within forty-eight or sixty hours. In some patients the glycosuric symptom already terminates after the omission of two or three meals ; in others it per- sists for six days or even longer. Again, there are cases of the severest type of diabetes which no amount of fasting will render sugar-free. Generally speaking, the initial fast should not come to an end when sugar ceases to be excreted, but should be continued for another twenty-four or forty-eight hours. It always takes longer to render the patient ^s urine free from ketones (diacetic acid, acetone, beta-oxybutyric acid, etc.) than from sugar. In a rather considerable number of instances — twenty-five per cent, approximately — ^no amount of fasting will accomplish this feat. In these cases prolonged starvation treatment is out of place ; the accustomed diet should be taken up as soon as possible. Subsequent fasts need hardly ever be pro- tracted unless the intervening period has been an exceptionally long one. The intercalation of a The Treatment of Diabetes 17 hunger-day, as advocated by former authors, will often suffice. Frequency of the fast No iron-clad rules concerning the frequency of the therapeutic fasts can be propounded. Once the inaugural fast is over and the severity of the case determined {i.e., the readiness of the disap- pearance and reappearance of the urinary sugar and ketones),. it is a simple matter to decide when and how often subsequent fasts should be under- taken. The decision resolves itself in the an- swering of the following two questions: Firstly, has the inaugural fast been of benefit to the pa- tient; secondly, is the patient to be kept entirely sugar- and acetone-free during the interval. It should be the physician's endeavor not only to prolong life, but also to prolong the usefulness of his patient. For years I have advocated that the diabetic with low carbohydrate tolerance and a tendency to acetonuria should make a fast-day of that which is euphoniously called ^^the day of rest." If possible, I let him also add the Satur- day half-holiday. By cutting out the Saturday mid-day meal and permitting a very moderate supper on Sunday, a fasting period of about thirty hours is obtained without interfering ^^dth the patient's business. I am in the habit of al- lowing a small amount of food on Sunday evening in order that the patient is able to resume work the next morning, which he does after taking his 18 Fasting and Undernutrition in regular breakfast. These weekly fasts are a great boon to the average patient affected with a severe type of diabetes, and often enable him to- gether with the restricted diet during the week to keep above water in a physical, financial and social sense. In many cases a one-day fast every second or third week may suffice, in others of the sev- erer and severest types more protracted fasting periods — for from two to four days — should be instituted every two weeks. Thus it may be necessary that four days out of every fourteen must be spent fasting. It should not be forgot- ten, however, that a certain proportion of these cases are not only not benefited but actually harmed by this treatment. The initial fast en- ables the clinician to recognize the cases not suited for the fasting-undernutrition treatment. The indications for instituting protracted fast- ing periods other than the initial one, are: pro- gressive weakness of the patient, certain com- plications like gangrene and infection, very low or negative carbohydrate tolerance, pronounced ketonosis (acetonuria, acidosis, etc.), heart dis- ease (fat heart), marked obesity and disease of the liver (hepatic inefficiency) and kidneys (renal insufficiency). All subsequent protracted fasting must occur while the patient is resting in bed and under the same general conditions as the inaugural fast. A single weekly fast-day, however, does not call for The Treatment of Diabetes 19 bed-rest, especially not in summer time. The pa- tient may spend the day in the open air, reclining in a steamer chair or other comfortable piece of furniture, but away from the hustle and bustle of every-day life. Other essentials in therapeutic fasting A. Purging. — Inasmuch as fasting in the graver forms of diabetes is considered by Guelpa to be a method of disintoxication, he combines the treatment for the sake of greater efficacy mth purgation. The natural Hungarian bitter waters, Carlsbad water and the less concentrated solu- tions of sodium or magnesium sulphate are best suited for the purpose provided there be no kid- ney disease. Of the natural mineral waters not less than two tumblerfuls, heated to about 130 deg. F., should be taken at one time, preferably in the morning. If the bowels have moved less than twice during the day, the dose should be repeated in the late afternoon. If a solution of sodium or magnesium sulphate should be prepared extemporaneously not more than one and one-half teaspoonful should be added to each glass of warm water. Two glasses of the solutions are a dose. The purge is to be taken in the morning and, if neces- sary, also in the early evening. In instances wth impaired kidney efficiency castor oil should be substituted for the solutions of Epsom and Glauber's salts. It should be administered once 20 Fasting and Undernutrition in a day in doses from 30 to 60 c.c. (mils)=l to 2 ounces. Care must be taken that it be not ad- mixed with any sweetening material. In the average case these purgatives must be exhibited every day as long as the fast lasts. They should not be replaced by any other laxa- tives, especially not by drugs containing sugar, such as elixirs of cascara sagrada, magnesium citrate, compound powder of licorice, etc. B. Drinking, — The continuance of the normal physico-chemical processes in the organism de- mands that a certain amount of liquids be im- bibed. At the same time fluids are the carriers of a great number of excretory substances. Water may practically be partaken of at pleasure by the fasting diabetic provided there is no con- traindication offered by advanced cardio-vas- cular disease and a general hydremic condition. The patient may drink from 20 to 40 c.c. of water for each kilogram (from a little more than % ounce to somewhat more than 1 ounce for each pound) of body weight in the twenty-four hours. A man weighing 60 kilograms (132 pounds) may therefore take daily from about 1200 to 2400 c.c. (35 to 50 ounces) of water. Only still water should be permitted, as carbonated waters are apt to produce gastro-intestinal and vesical dis- comfort. Some of the necessary liquid may be given in the form of a weak infusion of tea. Of course, this must be taken without milk or sugar, but The Treatment of Diabetes 21 some lemon juice is permissible. Three, four or even five cups of weak tea may be drunk during the twenty-four hours, but the liquid thus im- bibed should be deducted from the total amount that is allowed. The tea (as well as other fluids) ma}^ be taken as warm as desired unless there be a gastric or duodenal disease, ulcer for instance. Then, of necessity, the liquids must be taken luke- warm or cold. Occasionally tea is not well-borne ; it may occasion headache or a slight gastric dis- turbance, an undue diuresis, or it may agitate the patient, preventing sleep. In such cases I am in the habit of ordering a very weak infusion of chamomile which is a wholesome and satisfactory drink. In rare cases I permit coffee. However, it usually overstimulates the patient and the re- action never fails to make itself kno^vn. This reaction manifests itself by a pathological de- pression. Not more than tw^o cups of rather weak coffee should be allowed for each day of the fast. If the fast is to be continued for longer than two days some hot beef broth, a cupful at midday and the same amount five hours later, ^vi^ act as a mild stimulant. The quantity of the broth should also be deducted from the total amount of per- mitted liquid. Sparers of body tissue There are certain substances the ingestion of which may prevent too rapid and too pronounced a decline of body weight when the organism is in 22 Fasting and Undernutrition in a state of therapeutic fasting. The best known substances of this class are alcohol and gelatine. A. Alcohol. — Alcohol is by no means as valu- able a saver of body structures as gelatine. Positive proof that it saves the tissues in healthy man is absolutely wanting. However, alcohol is a time-honored adjuvant in the treatment of a number of wasting diseases, and its stimulating action is certainly of benefit to many patients. Small doses of alcohol, that is about 0.5 c.c. per day for each kilogram of body weight (about one drachm per pound) may be permitted. A person weighing sixty kilograms (132 pounds) could therefore consume in the neighborhood of 30 c.c. (one ounce) of alcohol per day. As the distilled liquors contain on the average about fifty per cent, of alcohol, a patient of above weight may take 60 c.c. (two ounces) of whiskey or brandy in the twenty-four hours. In exceptional cases twice the amount even may be permitted. These alcoholic beverages should be well-diluted with plain water, and given in small doses every two, three or four hours. B. Gelatine. — Gelatine does not appear to be a builder of body-albumin, but it spares circula- tory proteid. Hence, it prevents or limits the loss of body-albumin. The albumin-saving property of gelatine is at least twice as large as that of the fats and carbohydrates, as 100 grams of it can replace 36 grams albumin, that is about 175 grams of meat. Of course, the gelatinous substances can- The Treatment of Diabetes 23 not entirely prevent loss of tissue albumin, and, for this reason, a certain amount of albumins proper must ordinarily form a constituent of the nourishment. In the gravest forms of diabetes when glucose and ketones are being excreted in considerable quantities, the ingested gelatine still produces bodily energy, and averts rapid body waste without increasing the sugar output in any marked degree. Gelatine may also be a sparer of body-fat. However, its influence in this respect is more limited than in regard to the body-protein. Still, 100 grams gelatin prevent disintegration of 25 grams body-fat, a fact which may be made use of in the suppression of the ketone substances (ace- tone bodies). In the latter respect it is, indeed, a much more valuable substance than alcohol. The tissue-sparing properties of gelatine are only limited by the comparatively small amount of the substance which the organism will tolerate without aversion. It is always best to have on hand two or more differently flavored gelatines when treating a diabetic. Gelatines to which is added some lemon juice or some beef extract, beef juice and their like are especially cherished by the fasting pa- tient. Such preparations may be given alter- nately, from a teaspoonful to a tablespoonful at a time. The diurnal intake should not exceed 10 or 15 grams (one-third to one-half ounce) of gela- tine (in the raw). 24 Fasting and Undernutrition in Drugs Medicines have little or no influence upon the excretion of sugar or the ketones and are cer- tainly out of place during the therapeutic fast of the diabetic. The much vaunted, but in the sup- pression of acidosis entirely useless sodium bi- carbonate, is included in this pronunciamento. Even if there were any proof of the antigly- cemic or antiketonotic properties of certain drugs, their employ would still be contraindicated in the fasting diabetic for the reason that the therapeutic influence of the fast alone be recog- nized. This is especially true in the inaugural fast. Again, the fact must not be lost sight of that in the fasting person most medicines exert their physiological effects much more readily than in the individual that is properly nourished. If, therefore, the attending physician, for one or the other reason, does not think he is able to get along without a certain drug, he should, if it be a potent one, prescribe it in smaller than the ac- customed doses. Under all circumstances, how- ever, he should rid himself of the superstition that any medicine which he may order is able to control or modify the sugar or acetone output of his patient. The average diabetic on a fast sleeps on and off from twelve to eighteen hours per day. So long as his mental condition does not prevent it he falls asleep for similar reasons as the hibernating The Treatment of Diabetes 25 animal does. Should a hypnotic be necessary, morphine in doses from 0.0075 to 0.005 gram (V12 to Vs gr.) is not alone the safest and promptest, bnt withal the most valuable of this class of reme- dies, as it retards the processes of general meta- bolism, thereby acting as a tissue sparer. Medication for local pathological states, as gangrene and infection, is, of course, necessary, A remedy thus employed differs entirely from a drug that is supposed to ameliorate the diabetic condition as such. 26 Fasting and Undernutrition in III Breaking of the Fast and Undernutritio2S[ IN Diabetes "While the technic of therapeutic fasting in dia- betes is a rather simple matter, this is by no means the ease with the breaking of the fast, for this entails a variety of precautions which I may be allowed to embrace in the principle ^* Individ- ualization" of the patient. Individualization of the patient There are few measures demanding a stricter individualization of the patient than the re-start- ing of eating without occasioning sugar and ace- tone after a therapeutic fast of the diabetic. It is not sufficient to render the patient sugar-free or, in favorable cases, free from acetone sub- stances. This freedom from sugar, and of ke- tones, should be maintained for as long a period as possible, provided the patient becomes not un- duly emaciated and feeble and a burden to him- self and his family. The moment the patient rapidly fails — sugar or no sugar — ^ketones or no ketones — , he has to be supported by a diet that does not keep him in a state of undernutrition. It is surprising to note how some diabetics thrive The Treatment of Diabetes 27 on a diet that is none too strict soon after a therapeutic fast. Of course, the sugar may and most ahvays does return, but the patient may in- crease in body weight, strength and endurance. The great majority of the diabetic patients, however, are not benefited at all by the fast unless this be immediately followed by a more or less prolonged state of undernutrition; and furthermore, there is a small group of diabetics which is actually worse off after than before the fast. This is the case when the sugar and acetone excretions become quickly re-established on ac- count of a wrong diet. Fasting therapy is indicated in about twenty per cent, of all the cases of diabetes. These cases recruit themselves from among the severer types, as a rule. In these cases the course of the dia- betic affection has either been a rapid one right from the start or the patient has had the disease for a long period. In either eventuality he has lost a good deal in weight, and his bodily force, efficiency and resistance have markedly dimin- ished. In patients of this class the ordinary methods of antidiabetic dieting usually no longer avail much, and the fasting treatment must and should be given a fair trial. It stands to reason, however, that the management of these cases must be strictly individualized. Neither should the fast cause a too rapid or too great a decline of body weight nor should it cause diminution of strength beyond reasonable limits. 28 Fastiintg and Undernutrition in Some medical enthusiasts have declared that the loss of weight per se exerts a salutary in- fluence upon the diabetic constitution and in- creases tolerance by allowing the diminished function of the pancreas to recuperate. Such an assumption can only have been dictated by purely academic experiments and clinical inexperience. In the grave forms of diabetes in which a system of fasting periods is to be instituted, the motto, **To have and to hold" must be paramount, and be adhered to as closely as possible. On the other hand in the general run of cases of diabetes, furnishing approximately eighty per cent, of the affection, fasting treatment, though not invariably contraindicated, seems out of place as a measure of routine. To this great category belongs the so-called diabetes of the obese, usu- ally one of the mildest types of diabetes. Dieting or no dieting, obese diabetics lose from ten to thirty pounds on the average during the first year of the affection. If they are subjected to an anti- diabetic regimen (which in sum and substance is identical mth an antiobesity diet) they decline in body weight on account of the ingesta, changed quantitatively and qualitatively. If on the con- trary they continue to subsist on their habitual food, they lose just the same because the diabetic deterioration is not being curbed and counter- worked. Diabetics of this class unquestionably fare better if they lose some weight; this, how- ever, will ensue at all events. The Treatment of Diabetes 29 As already stated, four-fifths of all diabetics need not ordinarily submit to any fasting periods. To be sure, fasting may not necessarily do any harm in these cases, but a strenuous treatment of this sort is comparable to shooting at sparrows with cannon balls. The diet after the inaugural fast — undernutrition First and second days. — When the urine has been sugar-free for about two days the tea, beef broth and alcohol, which were allowed during the fasting period, should be continued, the gelatine preparations may be withdra\\Ti, and from three to four yolks of eggs are to be added during the subsequent twenty-four hours. The yolks are best given by incorporating them with the per- mitted liquids. One-half of one yolk may be mixed with the tea at breakfast time, another half with the whiskey around ten or eleven o 'clock in the morning, a whole yolk with the broth at the luncheon hour; half a yolk with tea at about four P.M., and a half or whole yolk with whiskey in the evening. (Concerning the rationale of the yolk ingestion in the graver forms of diabetes see page 111.) If a mixture of the urine voided between six P.M. of that day and seven o'clock the following morning is still free from sugar, the amount of broth and yolks may be doubled while that of tea and alcohol should remain unchanged. If the urine derived from the period between six P.M. 30 Fasting and Undernutrition in and seven A.M. does not show clinically demon- strable amounts of sugar, the following dietary for the third and fourth days after breaking the fast may be ordered. Third and fourth days. — Breakfast: Cup of tea or coifee, without milk or sugar. Two soft-boiled eggs with two extra yolks. 10.30 A.M.: Egg-nog (20 c.c. (V3 ounce) whiskey, 75 c.c. (2% ounces) water, one egg yolk). Midday: One or two plates of beef broth (pre- pared with green vegetables, such as parsley, leak or onion, celery tops, strained) with one yolk per plate stirred in. Spinach, dessert-plateful (75 grams=2% ounces) with one whole egg, 4 P.M.: Whiskey (20 c.c.^Vs ounce) with one yolk. Supper: One plate of beef broth (as above), with one yolk stirred in. String beans, dessert-plateful (75 grams = 2% ounces). Lettuce with French dressing and one or two yolks. It is not necessary that the urine of the third day after breaking the fast be examined. The urine of the fourth day, which is to be accumu- lated for the same period six P.M. to seven A.M. The Treatment of Diabetes 31 (the fifth day) will tell the story much better. If it contains no sugar, the following diet for the fifth day may be proceeded with. Fifth day. — Breakfast: Cup of tea or coffee, without milk or sugar. Two soft boiled eggs ^\\t\\ two extra yolks. Two slices of bacon. 10.30 A.M.: Egg-nog as on previous day. Midday: One or two plates of beef broth (pre- pared as on pre^dous days), mth one yolk stirred in for each plate. Spinach, soup plateful (125 grams=4J ounces) with two whole eggs. Four oil sardines. String bean salad (French dressing). 4 P.M.: "Whiskey (20 c.c.^Vs ounce) wdth one yolk. Supper: One plate of chicken broth, with three tablespoonfuls of cut giblets. Brussels sprouts or kohlrabi, seasoned, but without butter or flour, dessert-plateful (75 grams=2i/2 ounces). Salad of canned asparagus (eight to twelve whole asparagus). American cheese (30 grams=one ounce). If after this diet there occurs no urinary sugar, a larger amount of protein in the form of meat may be added to the food of the sixth day. 32 Fasting and Undeknutrition in Sixth day. — Breakfast: Cup of tea or coffee, without milk or sugar. Ham (or bacon) and eggs (two eggs, 30 grams =one ounce ham or bacon). 10.30 A.M.: Egg-nog (as on previous days). Midday: One or two plates of green vegetable soup (parsley, celery, onion, cabbage, cauli- flower). Breast of chicken (40 grams^lVs ounce). String beans, dessert-plateful. Lettuce or watercress, French dressing. 4 P.M.: Whiskey (20 c.c— Vg ounce), or tea, with one yolk. Supper: One or two plates of green vegetable soup (as above). Cabbage, dessert-plateful. Dandelions or field salad, dessert-plateful. American cheese (30 grams=one ounce). If the urine continues to be free from sugar, the following sample of a diet may serve for the seventh day of undernutrition following the fast. Seventh day. — Breakfast: Cup of tea or coffee, without milk or sugar. Ham (or bacon) and eggs (two eggs, 40 grams =1V3 ounce ham or bacon). 10.30 A.M.: Egg-nog (as on previous days). The Treatment of Diabetes 3 o Midday: One plate of chicken broth with half tablespoonful of rice (cooked) ; some chicken giblets. One lamb chop, or a slice of any meat (50 grams =1V3 ounce). Spinach, string beans, or Brussels sprouts (one even soup-plateful). Lettuce, French dressing, as much as de- sired. 4 P.M.: Whiskey (20 c.c), or tea, ^^dth one yolk. Supper: One plate of chicken broth, \vithout rice, but with some chicken giblets (three table- spoonfuls). Any green vegetable (one even soup-plate- ful). Eomaine or endive, French dressing, as much as desired. Brazil nuts (30 grams==one ounce). After a week, then, the patient obtains a daily ration yielding betw^een 1000 and 1100 of avail- able calories. This is approximately one-third less than he should receive at the end of the fol- lowing week, and about half of the caloric food value he should be allowed at the end of the third week after the fast, provided his urine be still free from sugar. During the period of undernutrition, that is, so long as the diabetic patient ingests food less than will yield about thirty-five calories per kilo- gram of body w^eight, he cannot, of course, pursue his usual occupation. It is not quite necessary 34 Fasting and Undernutrition in that he be resting all the time, but he shonld take only very moderate exercise and be in bed for not less than from fourteen to eighteen out of the twenty-four hours. Second week of undernutrition The bulk of the increase in calories during the second week after the inaugural fast should de- rive from the fats of high melting point. For reasons set forth elsewhere (pages 111, 133) the yolk of the hen's Qgg contains the fatty substances best suited for this purpose. For the very same reasons cream and butter should be withheld strictly. The daily ingestion of from ten to fif- teen yolks, properly incorporated with the other food, almost every diabetic will submit to for a few weeks. This number of yolks yields approxi- mately from 500 to 750 calories. The addition of but even ten yolks to the diet of the seventh day (see before) would almost make up for the daily caloric deficit during the second week. However, an increased amount of green vege- tables and some more protein (egg-white, meat, fish) may be allowed to help in overcoming the caloric inadequacy. In this connection I wish to state that the deter- mination of the fat-tolerance is hardly necessary as far as the production of urinary sugar is con- cerned. The fat-tolerance should be ascertained because the low fatty acids may be possible progenitors of the ketone substances (acetone The Treatment of Diabetes 35 bodies). In many hundreds of cases of diabetes in which I have employed the **yolk cure," I have seen a heightened intensity degree of the glyco- suric SATiiptom in less than half a dozen instances, while an increased ketonuria ensued in not more than three or four per cent, of the patients. An ordinary yolk contains over five grams of fat. Ten yolks embody therefore somewhat more than fifty grams of fatty material. This is less than one gram per kilogram of body weight of the average patient. x\s a matter of fact, the gen- eral case of diabetes undergoing the undernutri- tion treatment may have in the second week after the fast as much as two or three grams of fat of high melting point per kilogram of body weight. Method of adding food The food-increase should occur slowly and in the manner that not more than one and a half calories per day and kilogram of body weight be added. A man weighing 60 kilograms (132 pounds) should therefore receive a daily addition of ninety calories from day to day. This means more than six hundred additional calories on the last day of the week. Together wdth the food of the seventh day of undernutrition (after the fast) when the number of calories available from the food amounted to from one thousand to eleven hundred, this patient hence partakes at the end of the second week (after the fast) of an amount of nutriment almost maintaining him in a state 36 Fasting and Undernutrition in of metabolic equilibrium. His decline in body weight should not surpass one to two kilograms (two to four pounds) during the second week of undernutrition. Here follows a sample dietary for the first three days of the second week (eighth, ninth and tenth days) after the fasting period. The figures in brackets are for the ninth and tenth days, re- spectively. First three days of second week Breakfast: Cup of tea or coffee, without milk, cream or sugar. Bacon and eggs (3 eggs), 1st day 50 grams, 2nd day 60, 3rd day 70 grams bacon. 10.30 A.M.: Egg-nog (whiskey 20 c.c, two yolks). Midday: One plate (2nd and 3rd days 2 plates) vegetable soup (parsley, celery, onion, cab- bage, cauliflower, tomatoes, unstrained if desired). Fish, mackerel or shad, boiled or broiled, ^gg sauce, 30 grams (40, 50 grams 2nd and 3rd days resp.). Beef in any form, one small slice, medium fat, 70 grams. Cauliflower, 60 grams (70, 80 grams 2nd and 3rd days resp.). String beans, 60 grams (70, 80 grams 2nd and 3rd days resp.). Cold slaw, French dressing, as much as de- sired. The Treatment of Diabetes 37 4 P.M.: Whiskey, 20 c.c, or tea, with one yolk (2 yolks 2n(i and 3rd days resp.). Supper: Four oysters (5, 6 oysters 2nd and 3rd days resp.). One plate of beef or mutton broth. Omelette, two eggs. Spinach, 100 grams. Any green salad, French dressing, as much as desired. The available calories of this diet vary from about 1150 on the eighth to about 1325 on the tenth day. By the end of the second week the patient should take approximately the following dietary in case the urine has remained free from sugar. End of second week after fast Breakfast: Cup of tea or coffee, with one yolk, but without milk, cream or sugar. Bacon and eggs (3 eggs, 80 grams bacon). 10.30 A.M.: Egg-gelatine (one whole ^gg, one ex- tra yolk). Midday: One plate of okra soup (some green vegetables, tomatoes, teaspoonful of oat- meal). Salmon, smoked, 40 grams. Bean salad, 150 grams. Beef in any form, medium fat, 100 grams. Spinach, 100 grams. Egg-salad (2 eggs), lettuce, French dressing. Brazil nuts (30 grams without shells). 38 Fasting and Undernutrition in 4 P.M.: CofPee-gelatine (half teaspoonful pow- dered gelatine, two table spoonfuls water, three quarter's cup boiling coffee). Supper: Anchovies or sardines in .oil (3). Chicken broth with half a tablespoonful of fine noodles. Asparagus omelet (three eggs, eight stalks asparagus). Cauliflower, 100 grams, with yolk sauce (two yolks). Eipe olives (40 grams). The foodstuffs in the last diet list yield no less than from 1750 to 1800 calories, an amount on which a patient weighing sixty kilograms (132 pounds) can very well get along for some time if he be at rest the greater part of the twenty-four hours. Third week after the fast By the end of the third week after the fast, the patient — in successful cases— will be able to in- gest food yielding about 40 calories per day and kilogram of body weight without giving rise to either glycosuria or ketonuria. At the same time he should not have lost more than from six to eight kilograms (13 to 17% pounds) in weight, and be rather more vigorous (resistant) than be- fore he started to fast. If this be not the case the method of treatment here outlined is a failure in this particular instance. Eecalling to mind that only in the severest forms of diabetes the The Treatment of Diabetes 39 fasting-underniitrition method should find em- ployment, it will at once be seen that the differ- ence between 1800 calories at the end of the second, and 2400 calories at the end of the third week, cannot be made np by carbohydrates alone. Moreover, experience has shown that the inges- tion of vegetables containing five or ten per cent, carbohydrate in amounts larger than 400 grams, is practically useless for the human economy in- asmuch as the intestinal juices in a severe case of diabetes are insufficient to elaborate the starchy material from the mass of cellulose tex- tures. The additional carbohydrate must, there- fore, be derived from vegetables containing a higher percentage of starchy material. At the same time it should be easier of elaboration. The tolerance for carbohydrate as such in the severer forms of diabetes is always below fifty grams per day ; often it is nil. These fifty grams carbohydrate yield, at the best, 200 calories. Vegetables with a low carbohydrate content (five per cent, or less), for reasons just mentioned, hardly furnish any starchy material to the dia- betic organism. They fill the gastro-intestinal tract, giving thereby a certain feeling of satia- tion; they also supply a certain amount of vari- ous salts, but they do not contribute to any extent to the combustion processes within the body. In planning the food intake up to the end of the third week after fasting, it wdll be found that, as far as their nutritive-calorific value is con- 40 Fasting and Undernutrition in cerned, the green vegetables by themselves have not been taken by me into any account whatever. They are solely added to the dietaries in order to meet physical and mental satisfaction. Favorable cases, those which have hitherto re- mained sugar and ketone-free, should receive about ten grams more fatty material (no cream or cheese) and the same amount of protein every other day during the ensuing week. Further- more, these patients should be tested for their carbohydrate tolerance. For this purpose I pre- fer the small, hard potato (new, if possible) which contains approximately twenty per cent, starch. I order the potatoes in any of the fol- lowing forms: Boiled in their jackets; French fried, or Saratoga chips. Determination of carbohydrate tolerance^ The patient receives the diet of the end of the second week after the fast (or its equivalent) and the fat and protein addition just pointed out. To this is added five grains potato in the form of Saratoga chips at the midday meal. If the urine for the ten hours following the potato intake be sugar-free, five grams of the Saratoga chips may be again added to the midday meal of the following day ; in addition five grams of the same may also be incorporated with the supper of this day. In case the urine voided between 1 P.M. and 7 A.M. the next day is sugar-free, seven one-half The Treatment of Diabetes 41 grams of the chips should be added to the mid- day repast and the same amount to the supper. If the afternoon-evening-night urine shows no sugar, the patient may have twenty grams chips, ten* grams respectively for the midday and even- ing meals. If sugar cannot be demonstrated in the urine twenty-five grams chips, half at noon and half in the evening, should be allowed on the following day. In case the urine continues to be sugar-free the twenty-five grams of potato chips should be con- tinued for a week or ten days as part of the daily ration of the patient. After this period the tolerance determination for carbohydrate may be continued, but in the manner that only very small amounts of the carbohydrate, say two or three grams, be added every day or, what is still better, every other day. However, it will be found that but few of the severe cases of diabetes will toler- ate more than thirty or thirty-five grams avail- able carbohydrate from day to day. In exceptional cases the carbohydrate toler- ance increases for a certain period or from time to time. With the essentially identical intake of food the carbohydrate tolerance becomes sud- denly greater so that no glycosuria supervenes after thirty or even forty grams of carbohydrate, whereas on the previous day fifteen and more grams of glucose were excreted with the urine. This phenomenon generally disappears as rap- idly as it has ensued and, in my opinion, has 42 Fasting and Undernutrition in nothing to do with sparing of the function that presides over the carbohydrate metabolism. Subsequent diet The subsequent diet-question in severe cases of diabetes resolves itself in particular in the de- crease or occasional re-increase of the carbohy- drate intake and the periodical interspersing of fast days. In this respect the dietary manage- ment of severe cases of diabetes following an in- augural fast and the graded system of under- nutrition does not differ essentially from that championed by the writers of half a generation ago. This management of the patient is nothing else but a continuous piloting between the devil and the deep sea. On the one side the greater intensity degree of the sugar output, on the other side the re-appearance or augmentation of the ketonosis. However, I am certain that a mild ketonuria is much less of a danger signal than we are wont to believe. Many of my patients exhibited this phenomenon for months and months, without noticeable injury to their general well-being. If I have to choose between the production or the continuation of a mild ketonuria and the sup- pression of a high-degree glycosuria, I never hesi- tate to counterwork the latter. It is true enough that the inaugural fast will often work wonders, but even in the successful cases this influence will not endure for a protracted period. Other fast- The Treatment oi* Diabetes 43 ing periods should be intercalated ; in some cases when called for, in others as a routine practice. Taking it all in all, the food intake at the end of the third week following the completion of the inaugural fast (when the provisional determina- tion of the carbohydrate tolerance has been ac- complished) is a fair example of the subsequent dieting in the severe forms of diabetes. Subsequent fasting periods Cases under observation from the beginning of the inaugural fast until the end of the third week of graded undernutrition, having shown no uri- nary sugar since the second or third day of the fast, need not be submitted to any subsequent fast during this period. At the end of the fourth week, however, w^hen the patient is receiving in the neighborhood of forty calories per day and kilogram of body weight, a fasting period of about thirty-four hours should be interpolated. Weekly thereafter, so long as he receives from thirty-five to forty calories per day and kilogram, the patient should undergo a fast of the same length. The fast should be taken under this con- dition even in case the urine of the past week should have proved sugar-free. I generally let the patient start his thirty-four hours' fast in the afternoon of Saturday (half- holiday) and let him continue it until Sunday evening. He omits the midday and evening meals on Saturday and the breakfast and midday meals 44 Fasting and Undernutrition in on Sunday. At about five or six o'clock on Sun- day evening I let the patient have a light meal composed of oysters or broth, two or three eggs, some green salad, spinach and asparagus. On Monday morning, after having had his usual breakfast, he is ready to attend to his business affairs until the following Saturday afternoon, when the same routine is going to be repeated. In some cases a two-days' fast is necessary to regulate the metabolic unbalance. These two- days' fasts may also be submitted to in periodic intervals, and it may be necessary to intercalate two-days ' fasts every week. However, more than three or four times in succession fasts of that duration should not be ordered as the patients will lose weight and strength too rapidly. Every fast day, of course, lowers the patient's weight. With from thirty to forty calories per day and kilogram of body weight the diabetic in- dividual may just maintain his own. The inter- calated thirty-four hours fasting will invariably reduce his weight for not less than one to one and a half kilograms (two to three pounds). As a matter of fact a loss of from three to four kilo- grams (six and one-half to almost nine pounds) is not rare. Patients holding their own will make up this loss almost entirely before the next weekly fast. However, there must be a limit in the decline in body weight, and hence also in the number of fast days. Some recent writers have made a virtue of The Treatment of Diabetes 45 necessity, maintaining that the loss of weight is a boon for the diabetic patient. This, as has al- ready been shown, is true to a certain extent so far as the mild cases of diabetes, especially those occurring in association with obesity, are con- cerned. Severe cases of diabetes, on the other hand, should undergo fasting and undernutrition out of dire necessity only. They must live, for the time being, in conformity with the restricted intake, but they should lose as little as possible in body weight. In severe diabetes, decline of body weight goes in nearly every instance hand in hand with decline in body strength and sys- temic resistance. It will be found that in the course of time com- plete fasting periods cannot be intercalated any longer in any of the cases. They will debilitate the patient more than they vnll detoxicate him, and they cannot be continued sufficiently long so that in advanced instances the urinary sugar can be any longer materially reduced. As every therapeutic measure so fasting in diabetes has its natural limits. However, while fasting as such may no longer be applicable (and for obvious reasons this will occur sooner in private than in institutional prac- tice), undernutrition may be resorted to in those stages of severe diabetes in which fasting is no longer of demonstrable value. Here the food in- take of the second or the first week after the inaugural fast may be of service. 46 Fasting and Undernutrition ii?" Water during undernutrition Besides the liquids pointed out in the various dietaries the patient during the period of under- nutrition may take as much water as is consistent with a good gastric digestion and general com- fort. As soon as the sugar output has materially diminished, it will be found that the patient has little inclination to drink more than small amounts of water. When this is the case the patient must be made to drink water, that is to say he should imbibe not less than one liter during the twenty- four hours. Aerated waters are apt to cause gastro-intestinal and even vesical distress for which reasons they should not be permitted in the general run of the eases. When the patient is in a state of undernutri- tion he should take but small quantities of water at any one time. Each drink should not exceed one hundred cubic centimeters (three ounces). Before the night's rest especially, the water should be taken sparingly. Chopped ice is a very good form in which to carry water into the system. Evacuation of the bowels The movements of the bowels during the periods of undernutrition are nearly always sluggish. Assistance has to be rendered by some artificial means. An enema is often all that is needed; one of soap-suds and oil is to be pre- ferred. It must be administered daily, as a rule. The Treatment of Diabetes 47 Epsom salts may render good service in instances where kidney disease can positively be excluded. Its dose must presumably be increased every few days. It should be administered daily. In the long run phenolphthalein or aloin in combination with some carminative should be prescribed. These preparations are best given at bedtime. Castor oil in sufficiently large doses should be ordered to be taken once or twice each week if the intestinal evacuations are not as copious as they ought to be after the exhibition of afore- mentioned expedients. Rest during undernutrition It is imperative that the diabetic patient in the state of undernutrition has a good deal of rest. Eest in bed is, of course, the best. Some diabetics need considerably more rest than others. How- ever, twelve hours in bed during the twenty-four hours should be the minimum. Many diabetics get along vdth. very little sleep; they hate the bed. Sedatives and h^^notics should not be ad- ministered to such patients, but they must learn to rest their bodies and brains without sleeping. Mild exercise like walking is permissible if the patient's strength allows it. 48 Fasting and Undernutrition in IV Failures Thus far detailed descriptions were given of the technic of the fast in severe forms of dia- betes, of the breaking of the fast, and of the sub- sequent graded system of undernutrition. Occa- sionally only allusion has been made that the sailing is not always an easy one, and that there are cases unsuccessfully treated by this combina- tion method. It has already been stated that the overwhelm- ing majority of diabetics need not submit to a dietetic juggling that has neither any raison d^etre in the ordinary diabetic economy, nor will or can or is even expected to do more good than is accomplished by the approved methods of dia- betes therapy. The advanced and severer forms of diabetes alone — forming about twenty per cent, of all the cases of the affection — are those that should be submitted to the prolonged fast- ing-undernutrition method. Of these consider- ably more than half are markedly benefited by this plan of treatment, about one-fifth of the pa- tients are not influenced by it one way or the other, and the general condition (and sometimes also the glycosuria and ketonuria) becomes un- questionably aggravated in about five per cent, of the instances. The Treatment of Diabetes 49 Peremptory failures For the present it may suffice to know that many of the ultimate successful cases may prove failures for a time on account of a wrong technic or for some other reason. However, there are always some patients — a comparatively small number, it is true — who are and remain peremp- tory failures. Now, what is a peremptory failure! Among the peremptory failures I count those cases in which an existing glycosuria on prolonged fast- ing does not decrease or disappear altogether, and in which the ketonuria does not diminish in the ratio in which body weight and vigor* decline. Cases in which the glycosuria disappears while the ketonuria persists I do not classify as peremp- tory failures, as the majority of the diabetic cases with ketonosis treated by prolonged fasting still show evidence of acetonuria. (As a matter of fact, however, the ketone content is, as a rule, more or less diminished after a fast of from four to six days.) Moreover, there are cases which are free from ketonuria on a certain day of the fast and which again exhibit acetone during the following twenty-four hours. And again, there are cases in which a prolonged fast has caused the disappearance of ketonuria, while in the same patient, a fast of even greater length a month later failed to accomplish this feat. It stands to reason that cases can only be counted among the peremptory failures after 50 Fasting and Undernutrition in varions attempts at protracted therapeutic fast- ing have been made. The cases do not bear the imprint of peremptory failures upon their fore- heads. If they would, some useless treatment, not to say suffering, could be avoided. A num- ber of writers following the lead of v. Noorden assert that in the really severe forms of diabetes the loss of weight sustained on a fast day is rap- idly made up or considerable increase even is ob- tained, on the addition of one hundred grams carbohydrate to the food. Every clinician with some experience in the treatment of diabetes knows that this is by no means the case in the general run of the severe cases, that it is nearly always an impossible task to make the diabetic affected with a grave type of the disease regain what he has lost through restricted diet in gen- eral and fasting in particular ; and that the clini- cian can consider himself rather lucky if he is able to avert any further decline of his patient's physical condition. Cases proving peremptory failures not only belong to this category on account of the unim- proved urinary condition, but also — and this is the crux of the entire question — on account of the aggravation of the peculiar physical circum- stances of the patient. While autotoxic phenom- ena play a certain role in advanced or severe forms of diabetes, they, by no means, dominate the entire clinical picture. The peculiar mus- cular weakness of the diabetic, the grave lassi- The Treatment of Diabetes 51 tude culminating in listlessness, the entire want of emotion and the absence of *Hhe will to live'' are symptoms of undernutrition and not of auto- intoxication. In grave diabetes danger from starvation is just as much a possibility as is danger from autointoxication, and, under exist- ing circumstances, one cannot readily differen- tiate between the beginning of the one and the termination of the other. Cases of this sort should, of course, not be subjected to prolonged fasting or undernutrition. The occasional omission of a few meals in order to at least reduce the degree of the glycosuria may be tried. The reduction of the starch intake to a minimum must never be carried out for longer than a day or a day and a half. In some of my cases I have succeeded tolerably well for a time by withdramng the more substantial starch carriers every third day, that is by placing the patients on a diet consisting of yolks, bacon, whiskey, spinach and lettuce, and keeping them in bed during this time. In a very few cases I could even intercalate one of these restricted diet days every other day. In other instances, how- ever, it is not permissible to intercalate one of these restricted days oftener than every fifth, sixth or seventh day without doing some real harm to the patient. At any rate, many of these cases which are out-and-out failures at fasting and continued starvation may get along in com- parative comfort if less treatment is applied to 52 Fasting and Undernuteition in the urinary features and more attention given to the physical individuality and idiosyncrasies of the patient. Eule-of-the-thumb measures should certainly not hold sway in the treatment of the severe forms of diabetes. They should be tried, to be sure, but must not be adhered to if they have proved useless or harmful in the particular instances. Apparent failures Apparent failures are not real failures. Many of the finally successful cases are failures in one way or the other at the first attempts of the fastr ing-undernutrition treatment. Blame for this must mainly be given to two causes, viz.: first, the lax manner in which the fasting-purging- rest program is prescribed and performed, and, second, the too firm adherence to the graded dietaries during the period of undernutrition. Ad 1. — In order to adjudge the severe cases of diabetes properly and to treat the suitable in- stances of the malady successfully, it is abso- lutely necessary that the attending physician delineate minutely every phase and every step of the fasting period before the treatment is insti- tuted. He must have full confidence in the com- petence and integrity of the nurse in charge of the case during the inaugural fast. The program must be strictly adhered to (if necessary ten days and longer), so long as the patient does not alarmingly fail in body weight, resistance and The Treatment of Diabetes 53 strength. If this be the case, fasting should be discontinued immediately. Another attempt at it may be made two or three weeks later. If the patient exhibits then the same alarming symp- toms, fasting must again be stopped. Some months later another trial may be given. If again unsuccessful the case belongs to the per- emptory failures and should not be treated by this method. Ad 2. — ^The graded plan of undernutrition as outlined in the foregoing, is of course, only a tentative one. It is designed for the average case after the fasting period. It cannot in the nature of things be a close fit in every case. It is just here where individualization must set in. For one case the first week of the period of under- nutrition is too strenuous, for another the graded dietaries follow each other too quickly, for a third the period of undernutrition is too ex- tended, and for a fourth and a fifth this or that is not especially suitable. The various untoward phenomena have to be met as they arise. If in a case the daily intake of food appears to be 'too small to keep body and mind together — a not very rare occurrence in the first week after the fast — a somewhat greater amount may be given. In many cases the skip- ping of three or four days of the scheduled diet- ary of the first week makes no difference in the urinary condition and is of distinct advantage to the general well-being of the patient. In other 54 Fasting and Undernutrition in words, the first week of undernutrition may often be contracted to three or four days. However, if sugar reappears, a fast day should at once re- place the third, fourth, etc., day, as the case may be, after which one has to start again with the dietary of the first day following the inaugural fast. In case the diet of the second week of under- nutrition should be productive of urinary sugar, the food intake of the previous week should be ordered and the patient kept on it until the urine has again been sugar-free for three or four days. If this cannot be accomplished in this manner a few fast days should be intercalated, after which the diet of the first week is again ordered. Hoav- ever, instead of giving this diet for one week only it may be necessary to continue it for two weeks or longer. During the time this low diet is taken the patient must rest in bed for from fourteen to eighteen hours every day. In case a glycosuria should supervene in the third week after the fasting period, a fast day should at once be intercalated and the patient be maintained on the diet of the second week of undernutrition. If this should not render the urine sugar-free, another fast day should be in- tercalated and the diet of the first week of under- nutrition given thereafter. Following this the food of the second week of undernutrition is given for two weeks or longer. When the urine is then free from sugar, the diet of the third The Treatment of Diabetes 55 week of undernutrition may be permitted. In short, whenever sugar reappears in the urine, the patient may be rendered sugar-free by fast- ing and kept sugar-free by the prolonged pursu- ing of the diet of the week of undernutrition pre- ceding the week during which the sugar had again been excreted. None of the apparent failures are real failures. In nearly every pertaining case it is only a ques- tion of time that the desired object will be at- tained. True, in some of these cases the car- bohydrate tolerance will always remain extremely low. In such cases fats, proteins and vegetables with low carbohydrate content— the diet of the second week of undernutrition with additional fats and proteins — must be given for long-con- tinued periods. 56 Fasting and Undernutrition in Physico-Therapeutic Measures in the Manage- ment OF Severe Forms of Diabetes With Especial Reference to the Fasting and Undernutrition Periods Some of the physical methods of treatment are of essential value in instances of grave or ad- vanced diabetes. This is especially the case dur- ing the periods of fasting and undernutrition. Rest Attention has repeatedly been drawn in pre- vious paragraphs to the fact that the diabetic; pa- tient undergoing fasting or undernutrition needs rest and much of it at that. Eest, in fact, is the sine qua non in the management of the severe forms of diabetes. It is the most important of all physico-therapeutic measures during the fast- ing and undernutrition periods. Appertaining details will be found in Chapters II and III of this little book. The exact amount of rest needed in the indi- vidual case must be left to the common sense of the attendant. External temperature A high surrounding temperature is conducive to the physical comfort and the decline of the The Treatment of Diabetes 57 glycosuria in severe forms of diabetes. Further- more, fasting and undernutrition are easier exe- cuted in a warm than in a cold surrounding at- mosphere. One is less hungry in a warm than in a cold climate. The conclusions are that the fasting-undernu- trition plan of treatment promises considerable success if undertaken during the w^arm seasons of the year, that in winter time the room tempera- ture should be kept at summer heat, and that the bed temperature should be at or near 100 deg. F. for as long a time as the patient can tolerate it. To obtain the necessary bed-warmth, the hot- water bag or the electric heating pad must oc- casionally be resorted to. Superheated air or the so-called leukodescent lamp, applied for the usual brief periods, cannot replace the continuously warm surrounding atmosphere, and have no spe- cial value as far as the treatment of the severe types of diabetes is concerned. Profuse per- spiration, as induced by the sweat or electric bath is, of course, out of the question, as it virtually counterworks the physiological objects which are attained by a moderate surrounding temperature. During the cold season patients with severe diabetes should wear flannels, at least when out of the house. They may be allowed to be in a very mild perspiration for one or two hours after the midday repast. In winter they should live in well-ventilated rooms heated to from 75 to 85 deg. F. While in bed, these patients should be 58 FaSTIKG and UlsTDERNUTRITIOl? llT well-covered with blankets, and the temperature of the room be lowered to about 65 deg. F. The utilization of an increased surrounding temperature in the fasting-undernutrition system of diabetes treatment is based upon the following facts and observations: In a paper read at the Kongress fiir innere Medizin, in April, 1905, Liithje brought out the interesting fact that in the grave diabetes of pan- creatomized dogs the surrounding temperature had a decided influence upon the intensity of the glycosuria. This was found to be markedly de- pressed when the external temperature was high (30 deg. C.~86 deg. F.). He ascribes the in- fluence of the surrounding temperature upon the fluctuation of the sugar excretion to regulatory processes in connection mth the body heat, be- cause the experiment animal, exposed to the cold, in the endeavor to maintain its momentary most important function, the retention of its body heat, suddenly excretes large amounts of sugar. The same author also tried to employ high external temperatures for the treatment of human dia- betes. He had four diabetics under his observa- tion for from one to one and a half months. Of these, two cases were severe, one mild, and the last one moderately severe. In temperatures varying between 15 deg. and 30 deg. C. (43 to 86 deg. F.) he also noted fluctuation in the sugar excretion, but not as marked as in the dogs. Under the influence of a high external tempera- The Treatment of Diabetes 59 tnre tolerance (for what is* not stated), body- weiglit and general vigor rapidly increased. In the discussion of this paper Klemperer pointed out that the experiments of Liithje tended to clear up some hitherto unexplainable facts of 'Clinical experience. It was kno^\ii to him for a long time, he said, that a cure at Carlsbad in winter did not agree as well with diabetics as one in summer, and that the beneficial influence of bed-warmth and alcohol upon grave cases of diabetes could now also be accounted for. In the same discussion Kiihn mentioned the case of a patient living in Java whom he found affected with a severe type of the disease, and which he had already unfavorably prognosticated years ago. In spite of the ingestion of large amounts of carbohydrates (rice, etc.), the patient was still alive, and Kuhn concludes that the patient's pro- longed life may be attributable to the relatively high temperature of his abode. Busquet studied the influence of the external temperature on the intensity of the glycosuria in three cases of diabetes. His tests demonstrated conclusively that the glycosuria constantly de- creased when the temperature surrounding the patients was warm, while it increased when it was cold. He never placed his diabetics in tempera- tures above 20 deg. C. {68 deg. F.), but his clini- cal findings tallied with those of Liithje in every respect. At a discussion at the meeting of the British 60 Fasting and Undernutrition in Medical Association in 1908, on diabetes in the tropics, attention was drawn to the frequent oc- currence of glycosuria and diabetes in the natives of India, and to the fact that acute cases are rather infrequently met with in the tropics, where the diabetic is not emaciated and his appetite less abnormal. Sir Havelock Charles made the inter- esting statement that the progress of the diabetic process in the East Indian is often slower than in the European, and that the disease may last twenty-five years. The foregoing are practically all the references in regard to the influence of the external tem- perature on the degree of the glycosuria and the course of diabetes which I could gather from a brief search of the literature. I have known from personal experience for a number of years that diabetes occurring in certain districts of Central and South America, irrespective of a diet very abundant in carbohydrates, often runs a pro- tracted and very mild course. This is also the case to some extent with the diabetic affection in certain localities of our own South. A patient from Mississippi, since dead from old age (he died in the North), assured me that he has had diabetes for over thirty years. From a number of diabetics, who have repeatedly come from the South to consult me, I know that they lost weight and excreted large amounts of sugar when they were in New York for a few weeks, but that their body weight increased and the glycosuria de- The Treatment of Diabetes 61 creased soon after they liad left the flesh pots of the North for the hot corn and sweet potatoes of their Southern homes. Furthermore, it is a well- known fact that rest in bed is of beneficial in- fluence in many instances of grave diabetes; the good effect thus obtained is, however, universally and solely credited to the rest and not to the bed- warmth. Without intending to enter into statistical de- tails as regards my own observations concerning the question of surrounding temperature and the course of glycosuria, I wish to offer my conclu- sion on this occasion: (1) The external tempera- ture exerts a distinct influence upon the intensity of the diabetic glycosuria, inasmuch as this is de- pressed by warmth and raised by cold. (2) A temperature of from 80 to 90 deg. F. of the sur- rounding dry air may be employed therapeuti- cally to reduce the degree of a diabetic glycosuria. (3) A surrounding temperature of from 80 to 90 deg. F. may 'per se reduce the sugar output by from one-fourth to one-third. (4) A warm ex- ternal temperature does not materially influence the ketonuria concomitant with grave cases of diabetes. (5) A warm external temperature has no noticeable influence on mild cases of diabetes, but exerts a salutary effect on moderately severe and severe instances of the malady. (6) The salutary effects of a w^arm surrounding tempera- ture on the diabetic organism, besides the reduc- tion of the glycosuria, consist of the production 62 Fasting and Undernutrition in of an increased tolerance for carbohydrates and proteids ; tlie increase of body-weiglit, resistance, and vigor; the lessening of gastro-intestinal dis- orders, and the subduing of neuritic and angio- sclerotic pain. Massage A mild massage of the limbs — five minutes for each limb — may be daily practised in almost every diabetic undergoing the fasting-undernu- trition treatment. In many cases the procedure may be repeated on the same day. In cases after the fasting period in which there occurs much flatulence or in which there is a persistent non-inflammatory gastro-intestinal disturbance such as a paretic condition of the intestine, visceral ptosis (especially gastroptosis or coloptosis), congestive states, etc., general ab- dominal massage for from fifteen to twenty min- utes every day is usually of marked benefit. While massage is but an accessory measure in the treatment of the severer types of diabetes, it should be employed whenever the patient's con- dition permits. Among the physiological effects of massage the mechanical and thermal results occupy first place. The mechanical effects supervene rapidly. Cellular activity becomes increased and there en- sues an acceleration in the movement of blood and lymph vessel contents. Massage causes an in- crease of the temperature of the manipulated The Treatment of Diabetes 63 limb. The temperature of the whole body may also be elevated which is especially the case after abdominal massage. Increased body heat causes diminution of the glycosuria intensity in nearly every instance. This is also noticeable in many febrile states. Walking As soon as the patient receives food yielding about thirty calories per day and kilogram of body weight, provided there be no impediment of the lower extremities, he should be instructed to take short walks on level ground. The length of the walk and its rapidity of necessity depends upon the patient's strength and endurance. He should, however, not exceed one-eighth of a mile at the first attempt, but he may slowly increase his walk to half a mile. As soon as the patient ingests a somewhat larger amount of food so that about thirty-five calories per day and kilogram body weight be furnished, he may take longer walks, that is up to about one mile. It will be found that most diabetics not obtaining a full caloric supply are able to walk from one to two miles every day without any apparent effort. The daily walks may be taken in * 'broken doses.'' It should be remembered that in ordinary walk- ing the work performed by the muscles of the leg is much less than it appears to be, since the sway- ing motion of the leg, like the swinging of a pen- dulum, is a passive operation to the greater part. 64 Fasting and Undernutrition in VI Illustrative Cases In the following lines some instances illus- trative of the fasting-undernutrition plan of treatment and its results are given. In these case-histories only the data pertaining to the fasting-undernutrition period which are of the most general clinical interest are related. Case L — March 20, 1913. Woman, forty-one years old; widow; has had two children, both dead. Diabetes had supervened about two years ago ; had then weighed 189 pounds. Present weight 145 pounds. Complains of sleeplessness; head- aches; extreme weakness and pains in thighs. The physical examination showed very flabby muscles ; rather small liver ; blood pressure, sys- tolic, 105 mm. Hg. The urine showed the follow- ing features : Twenty-four hours' amount 2200 c.c; specific gravity 1030; glucose 12 per cent.; acetone medium amount; diacetic acid present; ammonia increased; albumin absent; no evidence of renal disease. The patient was immediately ordered to go to bed and to fast for four days. During this time nothing but weak tea (without milk or sugar) and The Treatment of Diabetes 65 water were allowed. The patient was instructed to take a tablespoonful to a tablespoonful and a half of Epsom salts in the evening. March 24. Patient feels comfortable. Urinary features: twenty-four hours' amomit 1350 c.c. ; specific gravity 1019; glucose absent , acetone in- creased; annnonia stationary. March 25. Still fasting. Feels well. Urinary features: twenty-four hours' amount 1400 c.c. ; specific gravity 1019.5; glucose absent; acetone much increased; ammonia increased. March 31. At my office. Feels stronger ; slept very well during past w^eek; has only occasional headaches; pains in thighs much improved. Has been on yolk-protein-green vegetable diet since breaking the fast. Average daily intake twenty calories for each kilogram body weight. Present weight 139 pounds. Urinary features: Twenty-four hours' amount 1320 c.c; specific gravity 1016; glucose 1 per cent.; acetone de- creased, April 7. At my office. Feels decidedly better ; has uninterrupted night rest ; no more headaches ; no longer pains in thighs. Has been on about the same diet, but some- what enlarged quantities. Average daily intake twenty-five calories for each kilogram body weight. Present weight 143% pounds. Urinary features: Twenty-four hours' amount 1560 c.c; specific gravity 1020; glucose 1 per cent.; acetone medium amount; ammonia decreased. 6Q Fasting and Undernutrition in April 14. At my office. Feels strong and well ; slight pain in thighs. The same diet as last week, but had in addition half slice of toast in the morn- ing, half a slice in the evening. Present weight 143% pounds. Urinary features: Twenty-four hours' amount 2800 c.c. ; specific gravity 1009; glucose absent; acetone absent; diacetic acid ab- sent ; ammonia normal amount. April 21. At my office. States that she **feels grand"; no pain in thighs; uninterrupted night rest ; looks very well. Has been on the same diet, but instead of half a slice had whole slice of toast in the morning and evening. Present weight 1431/2 pounds. Urinary features: Twenty-four hours' amount 2000 c.c; specific gravity 1017; glucose absent; acetone trace; no diacetic acid; ammonia normal and stationary. • April 28. At my office. Looks and feels well ; entirely free from pain; sleeps through entire night. Has been on the same yolk-protein-green vege- table regimen plus three slices of toast per day. Present weight 143% pounds. Urinary features: Twenty-four hours' amount 1800 c.c; specific gravity 1014; glucose absent; acetone absent; diacetic acid absent; albumin absent; ammonia decreased. May 5. At my office. *^ Feels fine." Free from pain. Uninterrupted sleep at night. The same diet as last week. Present weight The Treatment of Diabetes 67 1451/^ pounds. Urinary features: Twenty-four hours' amount 1600 c.c. ; specific gravity 1010; glucose 0.1 ^per cent,; acetone absent; diacetic acid absent. May 12. At my office. ''Feels as well as ever.'' Has had the same diet, but only two slices of toast per day. Present weight 1441/^ pounds. Urinary features: Twenty-four hours' amount 1750 c.c. ; specific gravity 1016 ; glucose absent; acetone absent; diacetic acid absent; no ammonia increase. May 26. 'At my office. Feels and looks well. Patient thinks she is cured. The same diet; only two slices of toast daily. Present weight 147l^ pounds. Urinary features: Twenty-four hours' amount 1750 c.c; specific gravity 1015; glucose absent; acetone absent; diacetic acid absent ; ammonia in normal amounts. June 9. At my office. Feels and looks well. The same diet ; three slices of toast daily. Pres- ent weight 146% pounds. Urinary features: Twenty-four hours' amount 1750 c.c; specific gravity 1002 ; glucose absent; acetone and diacetic acid absent; albumin absent; no microscopic evi- dence of any renal lesion. June 23. At my office. Looks and feels well. The same diet ; three slices of toast daily. Pres- ent "weight 151% pounds. Urinary features: Twenty-four hours' amount 1750 c.c; specific gravity 1011 ; glucose absent; acetone and diacetic 68 Fasting and Undernutrition in acid absent; no albumin; no microscopic evidence of any renal lesion. Remarks: This case is remarkable inasmuch as there ensued a continuous increase in weight despite a diet which was not only restricted, but the fuel value of which never exceeded thirty calories per day and kilogram of body weight for any length of time. Case II. — December 28, 1912. Man, fifty-one years old, single. Theatrical manager. Princi- pal complaint: Weakness. Diabetes was recognized about eighteen months ago. Was since under treatment; also was in two sanitaria. During this period has had as much as seven per cent, glucose and much ace- tone. At times the urine was sugar and ketone free. Has lost about twenty-five pounds in weight. The physical examination revealed be- sides a much emaciated body and flabby muscles nothing that was truly abnormal. The heart was not diseased; systolic blood pressure 140 mm. Hg. ; liver not enlarged; no abdominal pressure sensitiveness. Hemoglobin 64 per cent. Urinary features: Twenty-four hours' amount 1860 c.c; specific gravity 1032; glucose 8.6 per cent.; ace- tone very large amounts; diacetic acid very large amounts; ammonia excessive amounts; indican absent; no microscopic evidence of renal disease. Diet: The patient was ordered to take a pro- longed fast under the supervision of an experi- enced nurse. Water, tea and Hunyadi water were The Treatment or Diabetes 69 to be taken during the fast. After the third fast day 40 c.c. alcohol (80 c.c. whiskey) was permitted during the twenty-four hours. Dec. 29. Feels well. Not very hungry. Uri- nary features: Twenty-four hours' amount 1580 c.c; specific gravity 1020; glucose absent; ace- tone and diacetic acid very large amounts. Dec. 30. Does not feel hungry. Urinary fea- tures: Twenty-four hours' amount 1300 c.c; specific gravity 1017; glucose absent; acetone and diacetic acid very large amounts. The purgative upset the patient considerably. Dec. 31. Feels more comfortable. Urinary eatures: Twenty-four hours' amount 1220 c.c; specific gravity 1014 ; glucose absent; acetone and diacetic acid large amounts. Jan. 1, 1913. Feels comfortable. Urinary fea- tures : Twenty-four hours ' amount 900 c.c. ; speci- fic gravity 1008; glucose absent; acetone and dia- cetic acid large amounts. Patient was permitted to take whiskey and in addition 60 grams green vegetables with low carbohydrate content. Jan. 2. Feels comfortable. Urinary features: Twenty-four hours' amount 980 c.c; specific gravity 1018; glucose 0.83 per cent.; acetone and diacetic acid large amounts. Jan. 3. Fasting. Jan. 4. Fasting. Jan. 5. Fasting. Feels comfortable, but hun- gry. Urinary features: Tw^enty-four hours' amount 1200 c.c; specific gravity 1013; glucose ''TO Fasting and Undernutrition in absent; acetone and diacetic acid large amounts. The patient was advised to remain in bed most of the time. Diet: Exclusion of all starches; limited quantity of proteins. Jan. 7. Feels hungry. Urinary features: Twenty-four hours amount 2000 c.c; specific gravity 1017; glucose ahsejit; acetone and dia- cetic acid large amounts. Apenta water in large doses was ordered to be taken. Diet: Green vegetables; fifteen yolks; albumin of seven eggs. Jan. 8. Hunger is appeased. Urinary fea- tures: Twenty-four hours' amount 1650 c.c; specific gravity 1022; glucose absent; acetone and diacetic acid unchanged in amount. Jan. 9. Feels well. Same diet. Present weight 117% pounds. Urinary features: Twenty-four hours' amount 2350 c.c; specific gravity 1018; glucose absent; acetone large amounts. Jan. 10. Patient was out of the house all day yesterday. Urinary features: Twenty-four hours' amount 2300 c.c; specific gravity 1014; glucose absent; acetone very small amount; diacetic acid absent. Jan. 11. Feels well. Urinary features : Twenty- four hours' amount 2000 c.c; specific gravity 1015; glucose absent; acetone small amount; dia- cetic acid absent. Diet: Eighteen yolks and eight egg whites daily in addition to green vegetables. The Treatmext of Diabetes 71 Jan. 12. Feels well. Urinary features: T^venty- four lioiirs' amount 2200 c.c. ; specific gravity 1016; glucose absent; acetone a trace. Jan. 13. Feels well. Present weight 118 pounds. Urinary features. Twenty-four hours' amount 2130 c.c; specific gravity 1020; glucose absent; acetone and diacetic acid traces. Diet: The same; in addition 180 c.c. whiskey. Jan. 14. Feels somewhat depressed; pro- nounced phosphaturia. Urinary features: Twenty-four hours' amount 2100 c.c; specific gravity 1024; very turbid; large amounts of earthy phosphates; reaction alkaline; glucose absent; acetone mere trace. Jan. 15. Depressed. Mouth temperature 98 deg. F. Present weight 119% pounds. Urinary features: Twenty-four hours' amount 2100 c.c; specific gravity 1020; glucose absent; acetone trace. Patient was ordered to discontinue Apenta water for two days. Diet: Green vegetables; twenty-one yolks; ten ^gg whites. Jan. 16. Feels better. Mouth temperature 98.2 deg. F. ; pulse 76. Urinary features: Twenty- four hours' amount 1830 c.c; specific gravity 1020; glucose absent; acetone and diacetic acid absent. Since this time the patient has not only held his o^^Ti, but has gained about three pounds. His urine is sugar-free most of the time; in case he 72 Fasting and Undernutrition in excretes sugar this does not exceed twenty or thirty grams in the twenty-four hours. Ketones appear but rarely in his urine. In other respects the patient has his ups and downs, but fasting at proper intervals and long-continued periods of undernutrition have enabled him to devote all of his time to business which is a very extensive and exacting one. On Sundays he remains in bed and fasts or has but one meal during the twenty-four hours. Case III. — August 31, 1910. Man, forty-nine years old. Has had diabetes for about one year. Complaint: Shortness of breath, especially upon walking. No nocturnal urination. No particular weakness. Decline of sexual desire. Little loss of body weight. Urinary features: Twenty-four hours' amount 1800 c.c. ; specific gravity 1022.5; glucose 2.5 per cent.; acetone and diacetic acid absent; albumin absent; indican absent; no mi- croscopic evidence of renal disease. The case was considered to be of a mild type and was suc- cessfully treated by the usual dietary means. August 7, 1912. Patient feels and looks well, but the diabetic condition has become aggravated to some degree. He has lost about ten pounds in body weight during the last four months, uri- nates once or twice during the night, and the twenty-four hours' urine has increased to about 2500 c.c. Patient is sexually entirely impotent. He is living in the South and states that he had a good deal of business worry during the last few The Treatment of Diabetes 73 months. The urine, voided at my office, showed a specific gravity of 1024; glucose 8 per cent.; medium amounts of acetone and diacetic acid and increased ammonia output. The urine contained no other abnormal substances or normal sub- stances in abnormal quantity, and there was no evidence of any kidney lesion. The patient was advised to undergo a thera- peutic fast of three or four days ' duration. Dur- ing this period water and tea were allowed. Castor oil was to be taken before starting the fast, and Epsom salt, in purging doses, every day thereafter during the fasting period. Rest in bed was made compulsory. August 8. Feels well. Urinary features: Twenty-four hours' amount 1800 c.c. ; specific gravity 1020; glucose 2.5 per cent.; acetone and diacetic acid medium amounts. August 9. Feels well. Urinary features: Twenty-four hours' amount 1680 c.c; specific gravity 1015; glucose 0.2 per cent.; acetone trace; diacetic acid absent. August 10. Feels well; is not particularly hungry. Urinary features: Twenty-four hours' amount 1400 c.c; specific gravity 1013; glucose absent; acetone trace; diacetic acid absent, August 11. Feels comfortable. Urinary fea- tures: Twenty-four hours' amount 1460 c.c; spe- cific gravity 1012.5; glucose ahsent; acetone and diacetic acid absent. The patient was kept on the graded plan of 74 Fasting and Undernutrition in undernutrition for three weeks. Starcli in the form of toast was permitted thereafter, at first tentatively, i,e., half a slice twice a day. Later on two and three slices a day were tolerated. He can take now four or five slices of bread a day. For one week each month he pursues a fat-pro- tein-vegetable diet (excluding cream, butter, cheese and vegetables containing more than five per cent, available starch). Case IV. October 16, 1913. Man, 52 years old ; Member of Congress. Has diabetes for about ten years. Complains of extreme weakness. A physical examination shows a very dry skin ; fat heart; enlarged liver and stomach. The lat- ter is also ptotic. There is no pressure point sensitiveness. The urine exhibits a specific grav- ity of 1030; glucose 12.5 per cent.; some acetone and diacetic acid; no albumin; no indican. It shows no microscopic evidence of renal disease. As the patient had much declined in body weight and vigor since he was last seen by me, a three or four days' fast w^as proposed. The pa- tient readily consented. October 21. First fast day. Feels very well. Urinary features: Twenty-four hours' amount 2150 CO.; specific gravity 1027; glucose 2.5 per cent.; acetone trace. October 22. Feels comfortable. Not hungry. Urinary features: Twenty-four hours' amount 1460 e.c; specific gravity 1020; glucose 0.25 per cent.; acetone somewhat increased. The Treatment of Diabetes 75 October 23. Feels well. Not particularly hun- gry. Urinary features: Twenty-four hours' amount 1320 c.c. ; specific gravity 1014; glucose absent; acetone considerably increased; diacetic acid present; albumin trace. October 24. Feels well, but rather weak. Uri- nary features: Twenty-four hours' amount 1550 c.c. ; specific gravity 1014 ; glucose absent; ace- tone stationary in amount. October 25. Has lost over nine pounds during the fast. Feels a little weak, but very well other- wise. Institution of undernutrition. October 27. Feels stronger. Urinary features: Glucose absent; acetone very small amount. October 31. Feels very well. Urinary fea- tures: Glucose absent; acetone trace. November 5. Feels well. Urinary features: Twenty-four hours' amount 1700 c.c; specific gravity 1015; glucose absent; acetone small amount. Diet: Undernutrition regimen of end of second week; in addition one slice of toast in the morn- ing and evening. November 7. Urinary features: Twenty-four hours' amount 1750 c.c; specific gravity 1020; glucose absent; acetone trace. Diet: The same, excepting two slices of toast in the morning and one slice in the evening. November 10. Feels very well. Physical ex- amination reveals nothing abnormal of import. Urinary features: Twenty-four hours' amount 76 Fasting and Undernutrition in 1900 c.c. ; specific gravity 1018; glucose absent; acetone absent. Diet: Undernutrition, end of second week; in addition two slices of toast in the morning and evening. November 12. Urinary features : Specific grav- ity 1018; glucose absent; acetone absent. The patient attends to his arduous duties as a member of Congress and at home. He abstains entirely from food for about thirty-six hours every month. For one week every month, follow- ing the fast, he adheres to the diet, prescribed for the last days of the second week of the period of undernutrition. At this time he transacts most of his business while he is resting in bed. De- spite the frequent fasting and periods of under- nutrition the patient has lost not more than about sixteen pounds in thirty-four months. Case V. — October 9, 1913. Woman, fifty-two years old ; one child. Has had diabetes for fifteen years. States that she was operated upon seven- teen times (fourteen times by one of the most renowned American gynecologists) for genito- urinary diseases. Present weight 161% pounds. The physical examination reveals a distinct murmur (presystolic), and a distinct accentua- tion of the second aortic sound. Abdomen is pendulous; liver somewhat enlarged and ptotic. There is an umbilical hernia. No pressure point sensitiveness. The skin is full of * 'liver spots" The Treatment of Diabetes 77 of rather recent production. The urine is voided in daily amounts of about 2000 c.c. October 10. Urinary features: Twenty-four hours' amount 1900 c.c; specific gravity 1024; glucose 7.14 per cent.; acetone medium amount; diacetic acid present; very turbid; microscopi- cally there were distinguished epithelia of lower genito-urinary tract and from renal pelvis; pus corpuscles; ammonium urate crystals; colon bacilli. The case was considered to be one of an ad- vanced, though not of a serious type of diabetes, and a fast of three days' duration was ordered. October 14. After the fast. Feels well, but is very recalcitrant. Present weight 158 pounds. Urinary features: Twenty-four hours' amount 1200; specific gravity 1019; glucose 0.416 per cent.; acetone a trace; diacetic acid absent. Diet: Undernutrition, first, second and third weeks (yolks, proteins, green vegetables). November 4. Feels very well. Present weight 159 pounds. Urinary features: Twenty-four hours' amount not stated; specific gravity 1024; glucose absent; acetone a trace. The treatment was continued by the family physician. Despite a rather large excretion of sugar this case is not of grave character. It is of long duration — fifteen years — at the start of the f asting-undernutrition plan of treatment. The urinary anomalies yielded readily, but the pa- 78 Fasting and Undernutrition in tient liad to be watched very carefully as she had no self-control whatever. Case VI.— September 15, 1914. Man, fifty-five years old; attorney-at-law. Diabetes was first recognized in May, 1914. Has lost about thirty pounds in body weight since the onset of the affection. Present weight 112% pounds. Complains of weakness, rhinitis and extreme dryness of the mouth (it could be demonstrated later on that this dryness was part and parcel of a very pronounced ketonosis). The physical examination revealed a dry skin and dry mucous membranes, a slightly dilated heart, but no other cardiac irregularity of any kind. The liver was somewhat enlarged, more so toward the median line. It presented no abnormality in hardness, etc. The stomach was crowded to- ward the left; the cecum was somewhat inflated. No pressure point sensitiveness anywhere. Urinary features: Twenty-four hours' amount 2200 c.c. ; specific gravity 1026; glucose 12.5 per cent.; acetone and diacetic acid very large amounts; albumin medium amount; microscopic evidence of sclerotic kidney. Treatment: Prolonged fasting; allowed during the fast water, tea and whiskey (60 c.c. per day) ; castor oil. September 17. Feels about the same as before starting the fast. Urinary features: Twenty-four hours' amount 2000 c.c; specific gravity 1022; The Treatment of Diabetes 79 glucose 8.33 per cent.; acetone and diacetic acid very large amounts ; albumin medium amount. September 18. Feels weak, but comfortable. Urinary features: Twenty-four hours' amount 1750 c.c. ; specific gravity 1015; glucose 3.57 per cent. (64.68 grams) ; acetone unchanged in amount ; diacetic acid very large quantity. September 19. General condition unchanged. Urinary features: Twenty-four hours' amount 2000 c.c; specific gravity 1010; glucose 1.25 per cent.; acetone and diacetic acid unchanged in amount. September 20. Feels comfortable. Urinary features: Twenty-four hours' amount 1750 c.c; specific gravity 1008; glucose 0.9 per cent.; ace- tone unchanged ; diacetic acid large amount. September 21. Feels stronger. Urinary fea- tures: Twenty-four hours' amount 1500 c.c; spe- cific gravity 1007; glucose absent; acetone de- cidedly decreased; diacetic acid traces. Patient refused to fast longer. Undernutrition (yolks-green vegetables), about 800 calories per day, called forth a glucose output of from 15.65 grams to 85 grams per day during the follomng week. The ketone excretion was increased, but did not reach then the values which obtained be- fore the fast. Despite the continued excretion of glucose and ketones the patient had reached about 120 pounds in weight on November 4. Patient could not again be persuaded to submit to another fast of the same duration. He would 80 Fasting and Undernutrition ik execnte any other dietary stunt. This, however, proved without avail. Some time ago he wrote me that his urine was free from sugar and ace- tone. This, I doubt, unless he has submitted to the fasting-undernutrition treatment since I last saw him. Case VII.— May 24, 1906. Woman, fifty-three years old; two children. Diabetes was diagnosed some years ago. Prin- cipal complaint when first seen by me was pruri- tus vulvae. Former weight 190 pounds; present weight 160^/2 pounds. The case was a rather mild one, belonging to the type of diabetes of the obese. For more than eight years the diet of the patient was not rigid, the daily amount of permitted carbohydrate vary- ing between 100 and 150 grams. Slowly the car- bohydrate tolerance declined and ketonuria, at first more or less intermittent, ensued. In mean- time an ulcus malum on the right foot and some minor gangrenous processes, due no doubt to obliterating, atherosclerotic changes, had formed. For these various reasons the patient was in- structed to undergo a fasting-undernutrition treatment in November, 1914. November 4. (Before fast) Urinary features: Twenty- four hours' amount 2200 c.c. ; specific gravity 1028; glucose 3.5 per cent. (77 grams); acetone and diacetic acid medium amounts; am- monia much increased. The patient utilizied a servant as a nurse dur- The Treatment of Diabetes 81 ing the fast. Tea, water and Epsom salts were taken in the usual amounts. Alcohol was refused by the patient. November 8. After three days' fast. Patient feels well; is not particularly hungry. Urinary features: Twenty-four hours' amount 1200 c.c. ; specific gravity 1020; glucose one per cent. (12 grams). Acetone and diacetic acid small amounts. Slough of gangrenous processes decidedly less (proper local treatment was applied all the time). November 11. After six and one-half days' fast. Feels very comfortable ; not hungry and not ** really weak." Urinary features: Twenty-four hours' amount 1000 c.c; specific gravity 1020; glucose absent; acetone and diacetic acid absent. The patient was thereafter kept on the afore- described graded plan of undernutrition. The urine remained sugar and ketone-free for a num- ber of months. Weekly fast days were inter- calated for some time. During the summer of 1915 the patient relaxed somewhat in her regime with the result that the pathological urinary fea- tures became aggravated. The patient has since been subjected to a series of fasting periods ; the outcome proved always beneficial. The various gangrenous processes have entirely healed. (The patient has received for the latter not alone the proper antiseptic applications and surgical treat- ment, but also footbaths of sodium salicylate, superheated air, etc.) The healing of these gan- 82 Fasting and Undernutrition in grenons mortifications must be, in part at least, ascribed to the dietary inflnences. Case VIII. — March 24, 1915. Woman, forty years old; two children. Diabetic symptoms are present for abont two years. Former weight 145 pounds; present weight 115 pounds. Is lean, but quite energetic. Attends to her affairs, but is often very tired and exhausted. Has noted decline of sexual appetite. Complains especially of interstitial gingivitis. The physical examination revealed an emaciated body with extremely dry external integument. No cardiac lesion. Blood pressure, systolic, 120 mm. Hg. Liver somewhat enlarged. No pressure point sensitiveness anywhere. Deep reflexes slightly exaggerated. Wassermann negative. The urine showed the following features : Twenty- four hours' amount 2100 c.c; specific gravity 1034; glucose 20 per cent. (420 grams); acetone and diacetic acid large amounts; ammonia in- creased ; albumin absent ; no microscopic evidence of renal disease. Patient is under a very liberal diet which has been prescribed by the family physician. Partakes of plenty of milk, cream, bread and fruit, I ordered a fat-protein-green vegetable diet plus two slices of toast per day. March 29. Patient feels somewhat stronger. Present weight 109 pounds. Urinary features: Twenty-four hours' amount 2000 c.c; specific gravity 1030; glucose 5 per cent (100 grams); The Treatment of Diabetes 83 acetone much reduced; diacetic acid unchanged; ammonia stationary; no indican; no albumin. Diet: The same, but three instead of two slices of toast per day. April 1. Is somewhat stronger. Urinary fea- tures: Twenty-four hours' amount 1920 c.c. ; specific gravity 1040; glucose 10 per cent. (192 grams); acetone increased; diacetic acid un- changed; ammonia slightly increased; albumin and indican absent. Diet: The same, excepting toast. As only car- bohydrate rice, 30 grams, boiled, in morning, 30 grams in evening. April 8. Feels very weak. Urinary features: Twenty-four hours* amount 2000 c.c; specific gravity 1030; glucose 5 per cent. (100 grams); acetone decreased ; diacetic acid absent ; ammonia much decreased; albumin and indican absent. Diet: The same; increased amount of yolks. To add sodium bicarbonate in large doses. April 14. Looks and feels better. Has passed large amounts of earthy phosphates during last few days. Urinary features : Twenty-four hours ' amount 2100 c.c; specific gravity 1030; glucose 5 per cent. ; acetone much increased ; diacetic acid present; ammonia increased; indican and albu- min absent. Yolks and sodium bicarbonate with- out avail in reducing ketone substances. Diet: The same, however, instead of rice oat- meal in the same quantity. 84 Fasting and Undernutrition in April 21. Feels better and much stronger. Present weight 107% pounds. Urinary features: Twenty-four hours' amount 1850 c.c. ; specific gravity 1030; glucose 5 per cent. (92.5 grams); acetone large amount; diacetic acid medium amount; ammonia increased; indican and albu- min absent. Diet: The same ; 30 grams oatmeal in the morn- ing; 30 grams in the evening. April 28. Feels better and stronger. Has taken much water and perspired profusely (hot weather) ; has ingested from seventeen to twenty yolks (six whole eggs) per day. Present weight 110% pounds. Urinary features: Twenty-four hours' amount 3000 c.c; specific gravity 1034; glucose 7 per cent. (210 grams) ; acetone large amounts; diacetic acid unchanged; ammonia in- creased; albumin and indican absent. Diet: The same, including the large amount of yolks. Under this plan of treatment the patient held her own until the beginning of October, when her weight had declined to 107 pounds. The urine during this period always contained be- tween three and eight per cent, of sugar, and was not ketone-free on a single occasion. After oat- meal as '^sole carbohydrate" had been taken for some months it was replaced by potatoes. When potatoes as the sole carbohydrate were ingested (three per day) the glucose output never ex- ceeded 5 per cent., and the twenty-four hours' urine did not exceed 1800 c.c. Hence never mor^ The Treatment of Diabetes 85 than 90 grams glucose were excreted on any of the potato days. In order to render the patient sugar-free and, if possible, also ketone-free, a fasting period under the supervision of an experienced attend- ant was ordered on October 10. The patient was instructed to go to bed and stay there during the entire period of fasting, to take medium doses of Epsom salts every day, and water or tea when desired. "Whiskey not to exceed 60 c.c. per day was allowed to be taken in broken doses. It was advised to take resort to the electric pad in case the patient felt slightly chilled. October 11. Patient is comfortable and does not complain of hunger. Has slept three hours in the afternoon and nearly through the night. Had two copious movements after taking mag- nesium sulphate. Eectal temperature at 8 A.M. 99 deg. F. ; pulse 90 ; respiration 20 ; rectal tem- perature at 4 P.M. 98.6 deg. F. ; pulse 92 ; respira- tion 20. Intake of liquids during twenty-four hours 1200 c.c. Urinary/ features: Twenty-four hours' amount 630 c.c; specific gravity 1018; glucose 1.86 per cent. (11.71 grams); acetone, diacetic acid and ammonia diminished. October 12. Patient is comfortable and does not complain of hunger. Has slept well. Eectal temperature at 8 A.M. 99.2 deg. F.; pulse 100; respiration 20 ; rectal temperature at 4 P.M. 98.4 deg. F.; pulse 88; respiration 20. Intake of liquids during last twenty-four hours 900 c.c; 86 Fasting and Undernutrition in urine twenty-four hours amount 630 c.c. Other urinary features: Specific gravity 1015; glucose absent; acetone and diacetic acid absent; ammonia diminished. The fast was continued for four days longer, during which time the urine remained free from sugar and ketones. The plan of undernutrition treatment was started on October 17. The urine on this date showed neither sugar nor ketones. On October 24, when the urine was still free from sugar and ketones, the second week of under- nutrition was started. The food w^hich the pa- tient then obtained yielded from about 1000 to 1100 available calories per day. October 27. The patient feels well, but has slightly lost in weight. The urine is free from sugar and ketones. November 24. After a two-weeks' stay at At- lantic City, during which time the patient had more or less overstepped the undernutrition boundaries, she feels and looks well. Urinary features: Twenty-four hours' amount 1600 c.c; specific gravity 1029 ; glucose 2.86 per cent. (45.76 grams) ; acetone and diacetic acid medium amounts; albumin absent. Fasting period ordered. Tea and water al- lowed; alcohol permitted in amounts of from 40 to 60 c.c. (from 80 to 120 c.c. whiskey) per day. Epsom salts. No attending nurse. November 28. After fasting three and one- half days. Feels well and not hungry. Urinary The Treatment of Diabetes 87 features: Twenty-four hours' amount 850 c.c. ; specific gravity 1015; glucose absent; acetone trace; diacetic acid absent, December 1. After six days of fasting. Feels well. Urinary features: Twenty-four hours' amount 800 c.c; specific gravity 1015; glucose absent; acetone small amount; diacetic acid small amount. December 3. After eight days of fasting. Pa- tient feels well. Urinary features: Twenty- four hours' amount 800 c.c; specific gravity 1012; glucose absent; acetone slightly increased; dia- cetic acid slightly increased ; ammonia increased ; albumin and indican absent. The following diet (undernutrition) was or- dered: Breakfast — two soft boiled eggs, cup of tea without" milk or sugar ; 10 A.M. — 15 c.c whis- key; luncheon — two cups of bouillon, soup-plate- ful of spinach or string beans, green salad; 2 P.M. 15 c.c. whiskey; 4 P.M. cup of tea without milk or sugar; supper — bouillon, one egg, soup- plateful of green vegetables, green salad ; 8 P.M. 15 c.c whiskey. December 10. Has strictly complied with diet. Feels well. Urinary features: Twenty-four hours' amount 1100 c.c; specific gravity 1025; glucose 1 per cent. (11 grams) ; acetone and dia- cetic acid small amount. Diet: The same; in addition six more yolks to the daily ration. To walk one-half mile daily if weather permits. 88 Fasting and Undernutrition in December 17. Looks well. States that slie feels very hungry. Present weight 102 pounds. Uri- nary features: Twenty-four hours' amount 1000 c.c. ; specific gravity 1020; glucose absent; ace- tone and diacetic acid absent. The patient weighs now in the neighborhood of 111 pounds. She feels very well and energetic and attends to most of her household duties. She is sugar-free most of the time. The few times she excreted sugar during the last eight months the daily amount never exceeded five or six grams. On no occasion has the patient excreted acetone or diacetic acid since her improvement last December. The patient is now very well able to manage her own case. As a rule she fasts one day every week; occasionally she only fasts for one day every second week. She obtains about thirty calories per day and kilogram. The food is al- most entirely absorbable. She never ingests less than ten yolks per day. Besides the starches yielded by green vegetables she also obtains about 30 grams of starch a day in the form of toast. A small amount of water or muskmelon was permitted of late. This case is one of the most interesting ones which I had the good fortune to observe. For this reason I have reported it somewhat in detail. It clearly demonstrates the great value of fasting and undernutrition in suitable cases. This case was, and probably still is, a very grave instance The Treatment of Diabetes 89 of diabetic deterioration. The patient was treated on *^ new-fashioned/' liberal lines by her family physician, which aggravated the disease without any doubt. For nearly seven months I tried to render the patient sugar- and ketone-free by the older methods of dieting without any assured success. Within a few weeks from the start of the inaugural fast the entire type of the affection of this patient seemed to have changed. Case IX.— July 28, 1915. Man, thirty-eight years old. Had indigestion for years; obtained life insurance policy two and a half years ago. In December, 1914, had colicky pains and was operated upon for appendicitis. Four days after the operation had a ^ ^ stroke of paralysis, ' ' viz. : face Vv^as dra^^ai to one side; had aphonia; could not write with right hand; had frontal headache for two weeks. He could speak in whispers after about two weeks and at about the same time there ensued a corresponding improvement in the right arm. Sugar was found in patient ^s urine shortly after the operation; acetone was also demon- strated on some occasions. Complains of noc- turnal urinations and absence of sexual desire. Speaks very deliberately. Intonation is very monotonous. The examination showed the follomng: Heart, weak impulse ; no valvular or myocardial disease ; , slight accentuation of pulmonic and aortic second sounds; blood pressure, systolic, 95 mm. Hg. Liver is somewhat enlarged; freely palpable on 90 Fasting and Undernutrition in deep inspiration; stomacli normal in size; pres- sure point sensitiveness in lower epigastric re- gion; intestines apparently not abnormal; cecnm somewhat enlarged. Deep reflexes normal; anes- thetic zones over portions of right arm; coordina- tion and accommodation fair; pupillary reflexes somewhat sluggish. Wassermann test negative; cerebrospinal fluid negative. Urinary features: Twenty-four hours' amount 2600 c.c. ; specific gravity 1034; glucose 16 per cent. (335.6 grams) ; acetone and diacetic acid large amounts. Diet: Fat-protein-green vegetables. July 31. Feels weak and tired out; nocturnal micturition. Urinary features: Twenty-four hours' amount 1800 c.c; specific gravity 1027; glucose 8.66 per cent. (155.85 grams) ; acetone and diacetic acid large amounts. Diet: Unchanged. August 2. Feels very weak. No nocturnal micturition. Urinary features: Twenty-four hours' amount 2000 c.c; specific gravity 1030; glucose 4 per cent. (80 grams) ; acetone un- changed in amount. August 4. Feels very weak; has lost seven pounds since dieting. Urinary features: Twenty- four hours' amount 1560 c.c; glucose 0.25 per cent. (3.19 grams); acetone very large amount; diacetic acid ditto. August 5. Still weak. Urinary features: Twenty-four hours' amount 1500 c.c; specific The Treatment of Diabetes 91 gravity 1016; glucose absent; acetone and dia- cetic acid medium amounts. August 6. Is stronger, but complains of cramps in epigastric region. Urinary features: Twenty-four hours' amount 1620 c.c. ; specific gravity 1023; glucose absent; acetone and dia- cetic acid medium amounts. Diet: Unchanged. August 7. Feels stronger. Complains of watery stools. Urinary features: Twenty-four hours' amount 900 c.c; specific gravity 1030; glucose 0.5 per cent. (4.5 grams) ; acetone and diacetic acid medium amounts. August 9. Feels very weak. Bowels were not evacuated for two days. Examination of the epi- gastrium and neighboring regions shows nothing abnormal. Liver is somewhat enlarged, espe- cially toward left. This may be due to the head of the pancreas. There is no pressure pain in pancreatic region or anywhere else in abdomen. Urinary features: Twenty-four hours' amount 1360 c.c; specific gravity 1029; glucose 1.25 per cent. (17 grams); acetone medium amount; dia- cetic acid small amount; albumin and indican absent; no microscopic evidence of renal irri- tation. Diet: Unchanged. August 10. Feels better. Urinary features: Twenty-four hours' amount not ascertained; spe- cific gravity 1025 ; glucose absent ; acetone medium amount. 92 Fasting and TJndernutkition in In order to detoxicate the patient and to ren- der him, if possible, ketone-free, a fasting period of four days and complete rest in bed were or- dered. During the fast Epsom salts in sufficient doses was to be taken every day. Tea and water were allowed as much as desired. August 14. After a fast of four entire days. Feels very comfortable; is not particularly hun- gry; has perspired during the entire time. Uri- nary features: Twenty-four hours' amount 900 c.c. ; specific gravity 1020; glucose absent; ace- tone and diacetic acid absent; ammonia normal amount. Diet: The same as prior to the fast (undernu- trition). August 16. Does not feel very strong. Uri- nary features: Twenty-four hours' amount 1350 and diacetic acid absent. Inasmuch as the patient is compelled to return to his home in Utah within the next forty-eight hours, some toast (half a slice at noon and half a slice in the evening) is added to his diet. August 17. Feels better. Urinary features: Twenty-four hours' amount 1300 c.c; specific gravity 1025; glucose absent; acetone and dia- cetic acid absent. Diet: The same, but instead of half a slice one whole slice of toast to be added to the midday and evening meals. August 18. Feels better. Has gained nearly two pounds in body weight. Urinary features: The Treatment of Diabetes 93 Twenty-four hours' amount 1320 c.c. ; specific gravity 1023; glucose absent; acetone and dia- cetic acid absent. This case is interesting for the fact that under- nutrition could not suppress ketonosis while fast- ing for a few days freed the system from acetone and its mother substance. The influence of un- dernutrition was not sufficiently strong and far- reaching. In other instances fasting is apt to aggravate an existing ketonuria. PART II SUPPLEMENTARY NOTES ON THE TOPIC OF THE KETONES IN THE HUMAN ORGANISM In the following the ketone (acetone) question is dealt with somewhat in detail. Particular stress is laid upon the mode of production of the acetone bodies in the human organism and the rationale of the ^*yolk cure'' in the suppression of these substances. Again, some material has been added that will facilitate the understanding of the mooted question in its broader bearings. Without a careful reading of these supplemen- tary notes much that has been said in the pre- vious chapters cannot be fully comprehended. The Acetone Bodies in the Urine and the Ferric Chlorid Reaction It has become a matter of routine with many to employ the ferric chlorid reaction when ex- amining diabetic urines and to depend upon it for the recognition of diabetic acidosis. Clinical reports nowadays found in American as well as in foreign literature, in which apparently sole reliance upon the ferric chlorid reaction for the 91 98 Fasting and Undernutrition in detection of diabetic acidosis has been placed, are becoming so numerous, that a word of caution as regards the insufficient mode of testing is cer- tainly in order. The acetone bodies — beta - oxybutyric acid, aceto-acetic acid (diacetic acid) and acetone — are interrelated, it is true, and are derived by suc- cessive processes of oxidation from their common progenitors: the caproic, valerianic and butyric acids. However, contrary to a general supposi- tion, the three acetone bodies do not always co- exist and never occur in a definite ratio to each other. Acetone is the least important substance of this group, while beta-oxybutyric acid repre- sents the most dangerous factor of acidosis. This at least is the opinion prevailing at the present day. As a matter of fact, only a small portion of the acetone occurs as such in the urine; the greater amount is yielded by the aceto-acetic acid (diacetic acid) on standing of the urine or when the reagents are added. In reality an acetonuria is therefore a diaceturia. Aceto-acetic acid (diacetic acid) is the only acetone body giving the ferric chlorid reaction. While the reaction is obtained in most instances of diabetic acidosis, there is a certain proportion of cases in which it does not ensue, at least not on all occasions. "When a diabetic urine is being accumulated for twenty-four hours for the glu- cose determination — a common and necessary practice — ^its diacetic acid may have become com- The Treatment of Diabetes 99 pletely oxidized to acetone at the time of examina- tion. To avoid this eventuality only freshly voided diabetic urines should be subjected to the ferric chlorid test. Diabetic urines which have been standing for a number of hours must be examined for acetone by one of the direct acetone tests, preferabl}^ by the sodium — nitroprussiate — potassium hydroxid — acetic acid — method (Le- gal's test). Beta-oxybutyric acid, one of the paramount acid factors in diabetic acidosis, is not always found in the urine associated with the other acetone bodies. This is especially the case in far advanced in- stances of acid intoxication when the oxidative qualities of the diabetic organism are interfered mth to such an extent that beta-oxybutyric acid virtually represents the last stage of the oxy- transformation of aforementioned fatty acids of low molecular weight. Of course, the ferric chlorid test w^ill not respond if beta-oxybutyric acid is the sole representative of the acetone group and the tests for acetone as such mil like- mse be negative. Inasmuch as we do not possess a simple reaction for the detection of beta-oxy- butyric acid this is never searched for by the practitioner, and many a case of acidosis occur- ring at the time of examination without the lower homologues of oxybutyric acid simply remains unrecognized, and this at a period when vigorous treatment is especially indicated. In pronounced instances of diabetic acidosis 100 Fasting and Undernutrition in when oxybutyric acid exists in large amounts in the urine, especially when it be associated with some butyric acid, its immediate progenitor — as is not infrequently the case — its presence can always be readily detected by its penetrating rancid odor. To summarize: 1. A positive ferric chlorid reaction is usually indicative of a state of acidosis, but the reaction is solely due to the presence of aceto-acetic acid (diacetic acid). 2. A negative ferric chlorid reaction does not preclude the presence of either oxybutyric acid or acetone. 3. The ferric chlorid test should be applied to the freshly voided urine only, as the entire aceto- acetic acid or a portion of it, by a loss of CO2, may be converted into acetone if the urine be standing for some time. 4. As a rule, no acetone at all, or only a small amount of it exists in a preformed state in the freshly voided native urine. Standing of the urine or reagents causes liberation of acetone from aceto-acetic acid. 5. The presence of aceto-acetic acid or of aceto-acetic acid and acetone does not of neces- sity point to the occurrence in clinical amounts of beta-oxybutyric acid. 6. Oxybutyric acid is one of the paramount acid factors of diabetic acidosis so far as we know at the present day. The Treatment of Diabetes 101 7. Oxybutyric acid which is not demonstrable by the simpler testing methods may be readily discerned by its rancid odor. 8. A direct search should invariably be made for acetone by one of the other acetone tests. II Ake There Ketones of Intestinal Production? This chapter simply deals with the almost for- gotten question: — Are some of the ketones of enterogenous formation? Acidosis, as such, is, therefore, only mentioned in a casual way. In many cases of acidosis beta-oxybutyric acid is found in excessive amounts. However, it is by no means the only low fatty acid that contributes toward the acid intoxication. The other members of this series — proprionic, valeric, capric, enan- thylic, caprylic, pelargonic and caproic acids are probably as important in the production of acidosis as are the members of the butyric acid group themselves. Furthermore, besides acetone (CsHgO), the ketone yielded by acetic or aceto- acetic acid, the ketones formed from the succes- sive members of the fatty acid series, differing from one another by t^\dce CH2, undoubtedly par- ticipate in the production, or are concomitants of the clinical pictures that are erroneously ascribed to the acetone bodies or their direct progenitors. Such ketones are proprione (C5H10O) >delded by 102 Fasting and Undernutkition in proprionic acid, butyrone (C7H14O) from butyric acid, and valerone (CgHigO), a product of valeric acid. The close chemical relationship of the suc- cessive members of the fatty acid series and that of their respective ketones, and the facts that they are, to the greater part, volatile liquids which are readily intermiscible and are subject to the same chemical reactions, give strength to the assumption that one member of the series of fatty acids or ketones may preponderate in a given case, but that it is hardly probable that these single members are present to the exclu- sion of all the others. Originating in the organ- ism from practically the same source or sources and being affected by the identical chemical in- fluences, it is obvious why more than one of the lower fatty acids and more than one of their ketones are apt to occur at a time, and why the phenomena of acidosis, which are by no means invariable and uniform, must of necessity be the result of the conjoint activity, or be the concomi- tants of various fatty acids and various ketones. It is probably true that there is no case of gen- eral acidosis in which acetone or its immediate forerunner, diacetic acid, cannot be demonstrated in the urine ; this, however, is no conclusive proof that other ketones or their corresponding fatty acids are not found associated with the former. It is simply the readiness with which acetone and diacetic acid are detected in the urine that has given them a clinical prominence which, in reality, The Treatment of Diabetes 103 they do not deserve. Were the other ketones and fatty acids as easy of demonstration, the acetone bodies and their direct progenitors would not almost exdusively be held responsible for the production of acidosis. While the occurrence of acetonuria may, there- fore, furnish convincing evidence of an imminent or already established acidosis, it is in itself no proof that other members of the low fatty acid series have not participated in establishing this abnormal state, or that a ketone or ketones other than acetone stands at the foundation of the anomaly. The question concerning us, however, is not that of acidosis but of the presence or production of ketones prior to absorption. Hilliger,^ and with him the modern clinical school, is of the opinion that the liver is the place of formation of the acetone bodies. They assume that here they are probably generated as inter- mediary metabolic products which, physiologi- cally, are almost entirely oxidized to CO2 and HO2. Borchardt ^ had eight years previously maintained the same standpoint, namely, that the acetone bodies are intermediary metabolic sub- stances, resulting when carbohydrates, glycosides and glycerine are withheld from oxidation. There is little doubt, if any, that the bulk of the ketones that are produced after the stage of absorption are due to a certain form of hepatic insufficiency. That some of the ketones,, however^ 104 Fasting and Undernutrition in may reach the intestinal tract in a preformed or nearly preformed state, or that they may be yielded and elaborated during pancreatic and in- testinal digestion will be evinced in the following lines. Some recent writers, particularly Howland and Marriott ^ maintain that hyperpnea virtually spells acidosis. This is undoubtedly true. When there is an intestinal ketone formation and the liver is functionating properly, a ketonemia will either not ensue at all or, it will be so transitory and insignificant an occurrence that a hyperpnea will not be produced. In other words, ketones in the intestinal tract may give rise to various intestinal affections without concomitant keto- nemia and hyperpnea. In fact, the confinement of ketones within the intestines is in almost every instance not followed by any evidence of intoxi- cation or, for that matter, may not even result in any local clinical symptoms. However, many diarrheal disorders, preemi- nently in childhood, are caused by the irritating activity of ketones upon the intestinal mucosa. To understand the untoward local influence of most of the ketones I wish to recall the abundant experimental and clinical work anent the fatty diarrheas, so-called. Accordingly, in intestinal ketone formation we have to deal with a vicious circle, i.e., a perverse disintegration of fatty sub- stances in the alimentary tract on account of pan- creatic or intestinal insufficiency, a local hyper- The Treatment of Diabetes 105 emia, catarrh, etc., and a continuous irritation of the local process for reason of the continued per- verse or increased elaboration of ketones from the volatile fatty acids. This vicious circle is only broken by withholding the foodstuffs that yield measurable quantities of ketones. A fatty diarrhea is to all intents and purposes a ketone diarrhea, that is to say, it is not pro- duced by the fatty acids of low molecular weight but, in some degree at least, by the ketones they have yielded. The ketone diarrhea, like the fatty diarrhea, may ensue without any systemic symp- toms whatever. If it continues for more than thirty-six hours it is usually accompanied by loss of strength and body weight. In case it prevails for a protracted period, either in a continuous or the more common intermittent form, it is liable to give rise to marasmus and general atrophy. Even in the gravest types of atrepsia it is un- likely that one has to primarily deal with an in- toxication. Hyperpnea never supervenes in un- complicated cases and is certainly not an evi- dence of enterogenously-f ormed ketones that have not penetrated the intestinal wall. In all these cases one is hardly justified in speaking either of a ketonemia or an acidosis. Ketonemia or acido- sis may undoubtedly concur with enterogenous ketones; however, the clinical picture of intes- tinal ketonosis as such is due to the local action of the enterogenous ketones contained within the bowel. 106 Fasting and Undernutbition in Ketones, on the other hand, find their way very readily into the general blood stream. This is rather the normal occurrence when the liver does not sufficiently functionate to cause their physio- logical cleavage after they have been carried to the portal circulation. While in cases of acid intoxication the liver is the organ in and by which the acetone bodies are produced as intermediary metabolic substances, and are not physiologically split up into simpler bodies in intestinal ketono- si.s, when the ketones enter the alimentary tract either in a preformed state or are elaborated therein, the normally functioning liver is the principal line of defense against qualitatively or quantitatively abnormal intestinal substances. Symptoms The symptoms of intestinal ketonosis are in a degree negative in character, but positive evi- dence is not missing. General Appearance. — The patient usually looks undernourished, weak and anemic. Diarrhea, — ^Loose or watery discharges from the bowels are the rule. The reaction of the stools is always acid. These possess usually a butyric- valeric odor. When recently passed, acet- one may be contained therein. (Acetone in the stools may be detected in the following manner: The fresh feces are first well diluted with water, acidified with acetic acid, and then distilled. The distillate (10 e.c.) is treated with a solution of iodin in ammonium iodid; this results in the The Treatment of Diabetes 107 formation of iodoform and a black precipitate of nitrogen iodin. The latter gradually disappears on standing, thus rendering visible the iodoform. This test is reliable, as it excludes disturbing factors and sources of error like alcohol and aldehyde). The stools may be macroscopically fatty, but this is not necessarily the case. Mucus is of rather frequent, blood of infrequent, occurrence. The diarrheal attacks may alternate mth more or less protracted periods of constipation. Ketonemia and Ketonuria. — Absorption of ke- tones may take place, but ketonemia and keto- nuria, when present at all, are most always of very brief duration. Hyperpnea. — The amount of ketones which may be present in the blood at any one time is never sufficient to give rise to a hyperpneic con- dition. Ketones in the Alveolar Air, — The alveolar air is free, or almost so, from ketones. The ketone odor emanates from the alimentary tract and not, as in ketonemia, from the lungs. Ketones in the Intestinal Gases. — Ketones may be expelled with the flatus. Their presence can be demonstrated clinically by the sense of smell only. Of course, they are admixed with the other gases of fermentation and putrefaction. Pro- prione, butyrone, valerone and acetone are likely to occur in the flatus when their respective pro- genitors are found in the feces. 108 Fasting and Undernutrition in Fever. — Temperature elevation may or may not be present. It may occur on one day, but may be absent on the next. In adults the eventual in- crease hardly ever surpasses two deg. F. In children below four or five years of age the rectal temperature may reach 104 to 105 deg. F. Pain, — Abdominal pain is not always present; it is hardly ever of a severe type. This pertains to children as well as to adults. A pressure point sensitiveness is often found about the cecal re- gion. In small children a scorching pain about the rectum and perineum is frequently met with. It is due to the irritating volatile acids and their ketones excreted in the feces. The Seat of Production of Intestinal Ketonosis Normally the ketones are readily absorbed on account of their great volatility. At the bot- tom of intestinal ketonosis there must therefore stand either (1), an insufficiency of the lacteal system or (2), the possibility that in intestinal ketonosis the ketones are not yielded until the residual ingesta, containing the lower fatty acids, have reached the large bowel. A number of clinical observations have convinced me that a structurally or functionally diseased cecum, hin- dering the free absorption of water, is the fre- quent seat of the formation and retention of enterogenous ketones. A few of the pertaining observations may here find mention. Observation I, — Patient of Dr. Lack of Brook- The Treatment of Diabetes 109 lyn. Married ^voman, twenty-seven years old, one child. Very frail. Undernourished and anemic. Penetrating valero-hntyric odor from mouth when holding breath. The odor is independent from intake of food. Feces contain acetone as well as fatty acids and soap needles for a long period (two months). Occasional ketonuria. Chief complaints : Extreme prostration ; diarrhea. Examination: Nothing was found of patho- logical import, except cecal regurgitation and evidence of Jacksonian bands. Treatment. — Operation by Dr. Lack. Kemoval of appendix and Jacksonian membranes; ceco- pexy. Complete recovery from intestinal ke- tonosis. Observation II. — Married woman, thirty-eight years old, one child. Eather thin, anemic. Ean- cid odor from mouth when holding breath. Feces contain valeric, butyric, aceto-acetic acid, acetone and large amounts of mucus. No ketonuria. Chief complaints : Eestlessness ; pain over course of transverse colon; diarrhea alternating with constipation; dr^oiess in throat. Examination : A cecum of great length and very movable was found. Treatment. — Operation by Dr. Fischer. Ee- moval of appendix. Cecopexy. Complete recov- ery from intestinal ketonosis. Observation III. — Man, thirty-six years old. Present weight 142 pounds, but has lost over thirty pounds in five months. Aceto-valero-buty- 110 Fasting and Undeenutrition in ric odor from mouth when holding breath. Odor is practically always present. No acetonuria. Feces contain fatty acids, soap needles and ace- tone. Chief complaints: Pain and soreness in left inguinal region; irritability; attacks of diarrhea. Examination: By colonoscope no sign of dis- ease of rectum and sigmoid discernible. Gurg- ling sounds in the cecum, pointing to atony of this part of the gut, are much in evidence. Treatment. — Operation by Dr. Fischer. Re- moval of appendix. Cecopexy. Complete recov- ery from intestinal ketonosis. I could recount a number of similar cases in which an intestinal ketonosis disappeared after the removal of the appendix, bands and adhesions about the cecal region and with or without ceco- pexy. In other cases, especially in nurslings and children, operative interference is not indicated. In these cases a rational change of diet is always followed by a suppression of the intestinal ke- tonosis. Sources of Intestln 13,06 9,27 2,60 35,32* 23,00* 15,50* 23,34 19,77 21,47 21,71 18,49 23,32 22,65 22,14 35,26 22,19 24,70 1,09 0,28 0,44 0,26 2.27 11,94 16,23 17,09 18,11 18,34 14,03 19,51 21,86 19,98 18,00 19,18 17,37 19,36 13,57 18,53 15,01 41,27 75,75 77,60 3,75 11,32 0,50 1,13 1,92 9,76 2,55 9,34 3,15 3,11 1,00 1,43 1,77 8.50 77,48 85,50 98,15 99,04 85,43 0,25 0,33 0,34 0,44 0,51 0,69 0,91 1,09 1,80 1,90 2,10 2,68 4,92 5,02 5,16 6.42 0,70 0,19 1,42 0,75 0,46 1,20 2,49 2,33 0.76 1.39 0,47t 0.69 1 0.45 0.01 0,63 0,39 2,85 *Chiefly gelatinous matter. tSugar of milk. Vegetable oils are pure fats. 198 Fasting and Undernutrition in Nitrogenous Matter Fat N-Free Extractive Matter (Carbohy- drates) Fish {Continued) Herring Mackerel Blay Shad River eel Salt herring Sardelles, salted Codfish, salted Mackerel, salted Bloater, smoked Sprats Lamprey Sardines, canned Caviar Haddock (dried) Codfish (dried) Oyster Clam Lobster, fresh " canned Crayfish, fresh " canned Crab, fresh " canned Milk and Dairy Products Cow's milk Goat's milk Sheep's milk Butter Whey Sour milk Cream Kefir Pot cheese Lean cheese Half fat cheese Fat cheese Cream " Dutch " Edam " Limburger Emmenthal 10,11 19,36 16,81 18,76 12,83 18,90 22,30 27,07 19,17 21,12 22,73 20,18 25,90 30,79 76,07 9,04 8,69 14,49 18,13 13,63 16,10 15,80 25,38 3,41 3,52 6,31 4,06 0,85 3,41 3,61 3,26 25,04 34,99 27,24 25,09 16,28 29,48 24,07 25,09 32,42 7,11 8,08 8,13 9,45 28,37 16,89 2,21 0,36 22,43 8,51 15,94 25,59 11,27 15,66 0,70 2,04 1,12 1,84 1,07 0,36 0,46 1,54 1,00 3,65 3,94 6,83 83,27 0,23 3,65 26,75 0,86 5,04 11,37 23,71 29,05 41,22 26,71 30,26 29,05 29,67 0,53 1,57 0,13 0,98 1,61 0,19 1.67 6,44 4,12 0,12 0,58 0,21 1,01 0,75 0,24 Sugar of milk 4,81 4,39 4,73 3,73 4,70 3,50 3,52 2,04 2,57 5,40 1,54 2,22 1,90 3,72 4,48 3,70 0,31 The Treatment of Diabetes 199 Nitrogenous Matter Fat N-Free Extractive Matter (Carbohy- drates) MUk and Dairy Products (Cont'd) Mayence hand cheese Hohenburg hand cheese Parmesan cheese Swiss cheese "SVestphalian cheese (half fat) " (fresh) Neufchatel cheese . . ■ .^, Cheshire cheese t Caraway seed cheese Eggs Hen's egg, white " " yolk " " whole egg (( (( a n 1 egg 50 grams Duck egg 36,33 26,90 41,19 23,90 27,49 29,85 17,44 27,68 31,61 12,87 16,12 12,55 14,49 6,30 g. 7,24 g. 12,24 5,55 29,13 19,52 22,54 26,06 11,76 40,80 27,46 7,36 0,25 31,39 12,11 15,82 6,05 g. 7.91 g. 15,49 Sugar of milk 1,00 V 1,18 5,04 1,15 7,98 5,21 5,89 10,43 0,77 0,48 0,55 0,62 0,27 g. 0,31 g. 200 Fasting and Undernutrition in 03 02 C4 P4 2 *^ ton 05 00 00 o O ■«»< W5 ■^'* 00 (W »o »c? OS •* ot «o »o -g o S 05 i> r^ r~i 13 « Oj o i> i-l •a l-H CO ^ H 00 i> 00 «5 OO © GO -"^ s C<5 ■«* i-t © GO <» CO J> i-T *0 iSi CO O Q< "-ft «i 00 r> i> © «o O «5^© i-H 0< F-l P 1X4 2 »- © © OJ 00 »o © ^ © © -^ o O* »0 © OO © '^ l> © r-T©' 8© r-H «3 ^ »o o<_ ©^ ©" CO*" ©" ^" CO f"" i-^ i-^ © 05 i-HoT The Tkeatment of DiabeIes 201 ^ OS <0 «5«0 «0 CO ^ 00 ^ 00 "* l> rH Ol ?D t» »» i-< W5W 1 CO CO o i> F-i O^' 1— ( O rH 1— 1 © .-1 O 1 1-H r-l of of O" o c4 a> OO M3 co't-" 00 co" O l> CO «o CO ;o^ r-Ti-Tof ;o CO <;o 05 CN 00 CO rH »J0 O CO Co" CO" CO" CO i-< CO CO rH »» *Jf5 CO <5* CO o CO -^ CO »o 00^»O 05 oo'^Toi' CO o C0t^l>W50*'Jt-rcdof'^of'*co''i>*oofo QO«5«3»ocoooooeociOooi>aOGOj> •* 00 «5 CO 0< O l> rH CO CO rH CO CO CO CO o rH lO O 00 CO >* iO 1 rH O 00 00 O r-> 9i r-l i-HlQ CO O CO »-l 1 of (VT rH oo" o" CO 3 2 ^ 1^ t^ liO 00 ^ W5 rH rH l> Oi U5 0< CO -^ CO 05 CO 00 O r-i t* rH CO 05 CC i> 00 C0050C00500COrHi>rHiOC00005 r-TcOMJiOWSrHrHOOOCOOOrH i (^ CO c^ N "^Q 202 Fasting and Undernutrition in o ^ »» >-< 00 Oi O «5 »0 «0 05 W5 »< a -^^ I CO «0 CO 00 O O l> rHi «5 »< CO >* o I o o o oo" -"aM" o" o o o o" o" o »0 05^ »> <» l> 6» r^ O" ^ »0 O <* CO to CO 05 CO l-H *0 rH O 00 >~* «50?OCOi> ^COJ>00i-i«O00(N»»O* ©Ot^-^^OOOCOOGOt-H -^ o? co" of co" r-T «r j>r ph i> CO r-< is o OSOOO^^COOOOrHO-i^ CO of I I «5 «5 »« Oi o>o O (N^ o o o<^ iW CO CO CO •*■ 00 -^ W5 O rH O ©"of eo-^wiOi-Hr-tt^oooooo "^"^P'^OO^OS'ifj^O^OSrH © O © rH ©" O" i> 05 O" Co" CO ©' «5 rH (» CO 00 0> ■ © o © © i-H © ©" *r ph © J> 00 00 oo"© ©«i»O©»«W5C000W5i-t ©r-tOW50©i- © 00 © © © rH 1> 00 CO OS © © 00 1> i> © 00 00 © 1 2- .J6 iti: ^&q J iS^ i ^ - ^ 0«5 The Treatment of Diabetes 203 i-H O 00 O rH rH 1> CO Oi t' M O »0 (V 00 f-i oo »C ©p-i rHO I— I o< Tft »< CO (N o ■^ o i> r-l ^ CO O >«?'*'' O* '* CO 9* S '*' 05 O J> o*^j> CO f-H CO l> 1 OS co' CO «0 CO 1— t '•J' CO CO ©* >J CO 2- J © t* 1-1 © oo 1> OS^OS^ t>r ©" of io CO CO © ■<^^ ©^ o«^ •*''x"os GO 1-1 CO CO CO U5 CO lO ©" ©" ©" rH CO »o © ©" ©" ©" © 1-1 © © 00 CO ^ i> 1— I o< »^ -* ©" © ©" ©" ©" © o © CO© C0©©i-<»0«5»-i r-i© I— tCO'O'X'^i-Hi— I O" © ©' ©" ©" ©" ©" ©" ©" CO i-i © •^© 05_ <»i'co''co CO 1-1 CO © © »» ^^ ^^ '^^ "^^ "^^ '*. «* CO r^" i-T CO »? © CO © t- 0*1-? © -"Jl os_<>*^ 1-H of O* 00 ■^ b- GO CO (N ■<*< © M5 GO © 0< OS^ »f ©" -Q Xi ^ -S .5 2 ^ ^ «^ o a.;S 204 Fasting and Undernutrition in C4 to 3 2 "^ Ol2 »fi-?rHO'»-?i-?i-r<>frHrH' «0 ""Jf 05 6- O i> GO -* Oi_ 00 rHO rH O p-T CO t- O* i> i-H CO «5 O U5 COt-iOOOCOi-lO*) oooco-^r-He^coi-HO 00 •«f< 05 CO?OC<5">^I>05"«?''^ l>a-? CO I-H «5 of CO CO CO »fl CO »OCSi0505lNCO»00'«*CO CO GO^ O CO I-H (X io rH O o© ©©©ooooo 00 CO 05 05 © «5 CO &» "^ O* ©" ©" ©" ©" ©" rH ^ CO CO M5 r-t ©'©'■© I-H 05 1> ■^ CO CO ©" ©" ©" GO i'^oo©©os-«?i(5 iC0r-O«5G0 OirHTftrHi— (j-Hf— li— iCOr-t 00 «5 CO I-H © *o 0^00 © © of »-? Oi I-H © © 00^«5 of of «5 s .s :::;::;;; ; : : : : : : : : : : : s ::::::::: : : : : : : : : : • ■ • §:::::::::: : : : : : : : : : : : 60 ... . . . •^ ... . . . -^ ::::::::: : : : : : : : : : : : : eg ::::::::: : : : : : : : : : : : : oT ... ... <» ... ... 1.0 ' ... ... e ... . . . .*o •••......, .••.. ... ... >» ... . . csj • I . . . . . . ! • • • ^ ....... . .... ... ... ^^ • ^_^ ... o** 0-^5 Si "a; 3 cx-s u

i S" tti m 05 M 0» O O © 00 o « ■* 00 »» 1-" « I— I 05 05 Tf^ "^ O crT o rH o o i-< »f i-T ^ CO •«* o o o o OrHO t»© pHOOOf-i CM © ;c « fh' (V go" (W © O © f-i ^ lO *0 rH CC o cT o »o w? CM ri ri CM , © CO O CO ^ O 'f «5 «?^ O »^ i> i-^ i-T (>r ^ r-T 1> o o_ CO ^ r-l > 1-1 t> CO C5 © pi CO CO 1-1 © ?c »o Tfl ■^ i> 1-1 »i »< ^ -^ -* © © 1-1 »o »0 1-1 J> i> © © X © CO GO © 00 X ■ X !> © X IN 1-1 © ""fl •># © © o •* © of<5*COS4 i-cCOf-i'n<^*'-i I-'©" CO coco COCOp^CMOO s s s o o CO e "w o o o 93 c« 8 £•- ?: p g Si K =0 S K ^ o 'E o «s 2 5-E ^ to 206 Fasting and Undernutrition in* J> OS >f< e005i-iCOCOt»0>i-<««f-iOi-"l>00 «Cr CO ■* CD •* »0 ;© i-T 40 »f kO of >* CO r-J •*" O" O" »? CO I-H CO 05 CD 05 CO -* cd" Levulose Alone 000©*0«000»0-^00»0©OOCOO O O^CO^«I5 :D_0S q_0^r-< CO O O »* O 00^«5 >-^^o 1 1 i-s (V (>f <»f (>r 1 1 88 ^•3 OOCOCOCOt-^COOCOO^iOGOQOGOOlOO-^OO «5rH»OcOC5-«*<'*»OCOOrH(>lcOOO*(>»^rHCrt»OCO i-T co" co" co" co" "^ -^ "* -^ »jo «o" CO co" l> i> QO" Oi o" ci -^ F— 1 1— 1 rH CO 00 oo ■* of oT Tj< Ot N-Free Extractive Matter = Pectin*) CDG0'3Hl>'«JiI>»0«5b-0*C0©Or-i-^C0C0©C0 1 -JJ^ CO^ ■* © ■* I-H 0> CO 00 05 ■* Oi^ ■* oo^ »o ©^ 1> Oi_ o 1 rH •^jT r-? © i-T t-^ ©"©"©"«*''©©'' T-H »0 CO" of rH ©*■ F-? rH I-H rH CD t- ©CD ©"©" rH 0< 12 ^»-H©0lC0O»l'«f©«0>0C0»i0rH'»fiCOCOCOt> 0> '-i-«*Tf(^C0»OCOi>">*iJ>J>©»Ol>C0C0C0CO 1 »o ©©©©"©'"©"©© ©©"©"rH ©©'©©"©"©" 1 ©" i-Tof i 1 if ft. i;;;;;;;;;;;;:;:::;:; r*" : : : ^ :::::::::::: I ::::: I : "^ : I ::::::::::::::: I I ! § I I I : I I I I : I I ! >£:::::::::::::::::::: I1iiil^i|iilliij|pii The Treatment of Diabetes 207 5 i'S. •3-2 SB 1*1 ^ *i © Q t^ 9J M5 O l> I I O « 00 5» 'O 'V o> o 21 I w 8 1-2 o o o o o_ o o o o" »" o -?<■ w <>» -^ rs o SB « 1-1 |>< Oi ^ CC 30 ■"1. '^ *^. *^. ^. ^ '** o o o '^f '*r o* 'si' as CO ■*_^ a< o X GO i> -"^^ Tf*^ it -f" Oi ^ o »^ Oi_ l> CO oq CO o '-<' l> '>r l> i;o «:> © m II «.:^ ^ c '—' © CO b- 00 Ci^ «>< ■<*<^ O^ ■* l> •>* 1> l-^ I-!" 00 «5 CO (X «5 © O GO l> CO »C "* o* ©" ©' i-T 50 W5 t' O CO ofoTaf 1 1 ^ 1 »fl-H s S I: S s ^ C3 ■2* 3 e ■^ f^^f^CQ?;?fe,C^feiCQ 3 cl bf 3 w O 4^ d -a d a o 4^ o d w ^ © M o n © Xi ^ -d (I) bl H ai -d • •> © -S on d u 3 ? B ^ o m u 4>> >> i! 1 > d a; J2 J^ © bO 35 i-^ (A u at II tm 3 d t» •4^ d 4> rt CUfCJ * • ■i— 208 Fasting and Undernutrition in o i-T CO CO O ■* lO c> CNO (N OS »J0 O I-? rH r-T rH i-^ l> HO Oi O l> W5 i-H CO t- 05 ©< TjJ" o i> co" l> s ■? s I S)) ■^ "^ ?» • g1| § § i o S) »« b- GO b- »-< »-^ »-i ai 00 OS -* co" eo' eo of »n OS »ft o"eo eo OS CO »iO O 00 CO OS »OOO^OG001>C^CO<*»_»-^ co'~i>os'i-Hodi»i>j><»r'* CO l> i> CO l> 00 o rH^00'«3J_G00S^OC0O»0O T-H CO CO «0 ■* CO »o o oi>i;>»coos«oooo ~ O CO "^i^^ i-J_ ■* -* i-H CO <« t^ cocr»ooo>oO'^''»o'«oo 05! 8 SS ©* ©} o O O >-' o" o" o* «5 y-l r-* 00 1-^ I— I 0*0 §» ft5 o 05'*OOt^Oi-iOOM»flOt~0-^TfiCOOOOC50>00 t- O t- O »« C» 00 C^ O 0<^ »0 O^ t-; lO t^ O^ X CD i> !W 10 x^ o ooorHOo©pHr-3~i-I"oo'c>'oo'oocroo o o o of i-T 0< oi (^f qX or<>fcOC^"»fofof'3^Q<'5f©foforofrHofof Ci Qi C^ 00 ^•' O 50 50 OC O Oi^ 1-^ Oi_ 00^ t> O . rH (^ J> "^ 00 CO "-^ l> 00" 00' t^ 1-1 GO* 05" »0 O 00 05" X" X" cT t> 05" O 00 l> t^ 00 oc o 210 Fasting and "Undernutrition in Q 80 <0 »« U5 5» »i 1-1 oi !-• o o" © o © «© ® 00 ^ CO »"l Ol 1-H »-< >— I ©©©"©"© •d >> 3 lOt-C0I>»C00r-lb- »C 05 © 05^ «0^ O t^ 1> O ©" T-J" ©" ©' ©" ©" © Ob CO»»©»-i«5t-*80 1-H ©' ©" ©" ©* ©*■ © ©' Si © I— I © © CO ©" •^3 i-ii-i©W5W5©l>00© o" ©" ©~ ©" ©" ©" ©" ©" ©" ©" ©" ©" ©" ©' ©"O i-T ©' ©" ©" ©" ©" © » cos<«0'«?'©t'eO'«f'80 l>©©»OrHoq_rHpMGO r-ToicOOOCOrHsicO©? »o ©^ cfeoo^ ©^ ©^ j-H_ © ®» 00 eo 00^ «5 »o of of w of so" of ©f si af (N of I-T of of O'^CSO'sftCNOO©'"^ CO © i-i©©© oo" oo" 00 © © ©" J> ©" l> «5 oo" oo' oo" ©* oo" l> )-H J— I I— ( pH pH r- 1 8 ^•1 Oj 03 H W OT ^ 2 ^ 3 CO ^^ a •si •ti c 3 -f § I § ^ -i :S ^ fc -g 2 ^ g The Treatment of Diabetes 211 •tJ "S I ■2-2 «« © a OS E- H c c •c 00 i> t* QC t' CD •c CO b- CO .^ ,-1 p-i 8 l> C^ 1 1 »« •* l> Tf* S 'toi^'Hc^.^.QO* 1 >. o*©' 1 1 oo'od >» fi © © © © © 1 o Li ♦C-^t'OCOOOOS i-> »»©'«J<©©iC"4*i-i'* iO ko CO^ l> Q^^ CO^ ■* e4 ■<*<^W1>0000000 b£ 3 OOOOOSOOrH a l> C0~ r-T ©" 00* r-T m" <>f t-T M w 1—1 I— 1 1—1 1— 1 tJ :§ ©«-*C0«OO>W5»O ©©OOLOt-OOCOSO ijrjosto-^Oi-Ht-os ©t'iJOOiOO'^iO© s 'JiJ ©©00i-ii-H©0 ^^ ©©©"©©"©' ©" © ©" rt s b^ ■b) «ocO(Wi>o>GCoo«"*}>G0}>G0©O© 8 »c co^ »o 1-1 o^ o» © a> 2 i> 0«^ 00^ rH r^^ C^^ 1> 05^ © ^ K »f W Q< m" of »f CO CO 4J ©" ©" co" 00" ©" 50" ©" •* ©" r-t f-i 1— 1 Q< I— 1 1-^ 1— < rH 1— ( "3 ©W5©,-I^r-I©ii-I "o ©©GO^'*©©COi-< ja ooo05©Oi© ^ rH i-H 1— 1 Q^ ^ 1-1 1-1 65 - S 1 ."*^ ?3i s R •<;* s '^, 4 6c 85 *# <*< »-i CO o to t- »o ■* r-T O" O" ©" © ©' M ■'^ »» eo eo o» <0 -^ rH 0< »0 00 O 05* »r CO CO «s 00 l> W5 CO 0> © «o »o ^ '^ ^ -^ c? ©" © © © © «0 CO CO 0» b- »« <><^ O^ O »0 0i©t> ©*■ © ©* ©*©©''©' T-T © 1-H T-^ Oi^ i> no »» OS »ft O ^ W5_ CO W5 00 O»»lC0Oi00T-i»^t- lO 'JJ* »iO © »« OJ © "*^ --aj^ -^ 00^ i» ®rori> »o »o © CQ ?^ ^8 ^1 e.g CQ i^^fts -^ ^ § § 5? ^ 3 eS^a §5- jn The Treatment of Diabetes 21 1 1 § -< ■* "f «c a. t>- ce CO ^ Tf" U^ «© 1 1 CO W5 s o o* o o o" o 1 1 o o* t^ Cui c .-I © '»! 1— ' l> 1 t 1 1 1 1 •^ 3 >< OS «^* 1 1 1 I 1 1 ^- Q u Ci CO » "* ■<*" <*» Oi O O sf ■*" •*" o «i "o ©•^---OiiC^St-M •s '^^ cs_ oo x^ « ©_ ;o ^^ j> 1 oo" « ^'' ■* tri af «*■ vi '5* %- « ^ "5: •«» ligh eavy '1 ^ h~ 1^ ?* >S ^ k s s cq ^ ^ c h J>-C >» S 5? .25 1 h 2 K -o ^ =^ ^ ;^ ^ 1 INDEX Aceto-acetic acid, see also Ke- tonosis. detection of, 188. Acetone, see also Ketonosis. detection of, 186. detection of in stools, 106. Acetonuria, 98, 103. Acid, butyric, 116. Acidosis, diabetic, see Ketonosis. Alcohol, 22, 29. Alkalies, 120. Aloin, 47. Ammonia, determination of, 189. Athrepsia infantum, 147, 160, 161, 167. Bacteria, decrease of intestinal, 7. Beef broth, 21, 29. Beers, constituents of, 212. Beta-oxybutyric acid, see Ke- tonosis. Beverages, 20. Blood, estimation of sugar m the, 190. pressure, diminution of, 8. Body weight, continuous loss in, 8. Borchardt, 103. Breads, nutritive constituents of, 201. Busquet, 59. Butyrone, 102. Carbohydrate tolerance, deter- mination of, 40, 41. increased, 62. low or negative, 18. Cardio-vaseular disease, 20. Carlsbad water, 19. Cecum, functionally diseased, 108, 109, 110. Chamomile, 21. Charles, 60. Children, periodical vomiting in, 156. Coffee, 21. Diabetes of the obese, 28. Diabetics, female, 14. male, 14. Diacetic acid, detection of, 188. Diaceturia, 98. Diarrhea, fatty, 105. ketone, 105. Diffusion, insufficient, 112. Disease, gastro -intestinal, 156. Diseases, wasting, 134, 135. Diuresis, 21. Drugs, 24. Duodenum, disease of, 21. Eggs, 145. idiosyncrasy for, 160. nutritive constituents of, 198. Enema, 46, 123. Failures, apparent, 52. peremptory, 49. Fast, inaugural, 17. weekly, 17, 18. Fasting, 9. a possible cause of harm, lo. periods, subsequent, 43. protracted, contraindicated, 28. protracted, indications for, 18, 27. Fat absorption, impaired, 143. 215 216 Index Fats, nutritive constituents of, 196. Feces, fat in, 153, 155. Feeding, forced, 134. Ferric chlorid reaction, 97. Fish, nutritive constituents of, 196, 197. Flannels, 57. Food, nutritive constituents of, 195. Fruit juices, sugar content of, 206, 207. Fruits, dried, nutritive constit- uents of, 205, 206. fresh, nutritive constitu- ents of, 205. Gangrene, 18, 25. Gastro-intestinal disease, les- sening of, 62. Gelatine, 22. Glucosometer, Stern's, 178. "Green days," 9. Guelpa, 6, 7, 8, 19. Headache, 21. Heart, decrease of volume of, 8. Hemoglobin, increase in, 8. Hilliger, 103. Home treatment, arguments in favor of, 11. Howland, 104, Hunger-day, intercalation of, 17. Hunger, disappearance of, 7. Hunyadi Janos water, 7, 19. Hydremia, 20. Hyperpnea, 104, 105, 107. Infection, 18, 25. Ionization, insufficient, 112. Jean, 163. Ketones, 16, 26, 97, U2i in alveolar air, 107. in intestinal gases, 107. of intestinal production, 101, 102, 103, 104. Ketonosis (acetonuria, acidosis, etc.), 18, 24, 26, 35, 49, 97, 98, 99, 102, 105, 112. intestinal, seat of produc- tion of, 108. intestinal, sources of, 116. intestinal, symptoms of, 106. Kidney, insufficiency, 18. Klemperer, 59. Konig, 195. Kiihn, 59. Lecithin, 116, 159. Leukocytes, increase in, 8. Liquors, constituents of, 211. Liver, 5, 10, 18, 103. decrease of, 8. Lung expansion, greater, 8. Liithje, 58. Magnesium sulphate, 19, 123. Marasmus, infantile, 147. See also Athrepsia infantum. Marriott, 104. Massage, 62. Masuyama, 117. Matter, nitrogenous, 195. nitrogenous, free extrac- tive, 195. Meals and flours, 199, 200. Meats, nutritive constituents of, 195, 196. Milk and dairy products, 197, 198. Milk, cow's, character and pro- portion of fatty acids in, 151. mother's, character and proportion of fatty acids in, 151. physical characters of the fat of cow's, 150. physical characters of the fat of mother's, 150. Moritz, 177. Morphine, 25. Moss6, 113. Mueller, 117. Index 21? Naunyn, 9. V. Noorden, 112, 114. Nurse, the, 12, 13, 14. Nuts, nutritive constituents of, 207. Oatmeal cure, 112, 113, 114. Obeserskv, 117. Obesity, 18. Oil. castor, 7, 19, 20, 47, 123. Oil, cod-liver, 161. Olein, lie. Overfeeding. 134. Pain, reduction of neuritie and angiosclerotic, 62. Pains, disappearance of joint and muscular, 8. Palmitin. 116. Pancreas, diminished activity, 28. Perspiration, decline of, 8. profuse, 57. Phenolphthalein, 47. Potatoes, 40, 41. Proprione. 101. Proteins, 10. Pulse, firmness of, 8. Purging, 19. Rest, 56. Red cells, increase in, 8. Schmidt, 153. Schwartz, 115. Sodium sulphate, 19, 123. Sparers of body tissue, 21. Ssoborovr, 117. Starches, 10. Stearin. 116. St«rn. 133, 155, 178. 182. Stimulants, alkaloidal. nutri- tive constituents of. 199. Stomach, disease of. 21. Strasburger, 153. Sugar in blood, 12. estimation of. 190. in urine, 12, 16, 26. 29, 54. 61. in urine, detection of, 171. Sugar in urine, determination of, 176. Tea, 7, 20, 21, 29. Temperature, external, and course of glycosuria, 56, 57, 58, 59. 60, 61, 62. Test, Epstein's microchemical, 190. Fehling's, 181. fermentation, 176. ferric chlorid, 188. formalin for ammonia, 189. Gerhardt's. 188. Lieben's, 188. Xylander's, 173. sodium nitroprusside, 186. sodium nitroprusside (Niece's improvement), 187. Thirst, reduction of, 7. IJffehaann, 153. Underfed, yolk cure in treat- ment of the, 133. Undernutrition, graded dieta- ries, 29, 30, 31, 32, 33. 34. 35, 36, 37, 3 , 39, 40. 41, 42, 43. immediately following fasting, 27.* movement of bowels dur- ing, 46, 47. in diabetes, 9, 29. rest during, 47. water during. 46. Urine, assay of, 171. sugar in, 12, 16, 26, 29, 54, 61. Valerone, 102. Vegetables, 10. and salads, nutritive con- stituents of, 202, 203, 204. Volhard, 155. Walking, 63. Waters, aerated, 46. Wines, fruit, constituents of, 210. 218 iNDElt Wines, red, constituents of, 209. Yolk, cure, 116, 133, 136, 143, sparkling, constituents of, 146. 210. diastatic ferment in, 117, sweet, constituents of, 211. 159. white, constituents of, 208, Yolks, 29, 116, 137, 138, 139, 209. 140, 142, 158, 160. THE COPYRIGHTS OF THIS BOOK, IN ALL ENGLISH-SPEAKING COUNTEIES, ARE OWNED BY EEBMAN COMPANY, NEW YORK. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE A 1 °« HI Anne X 1 1 1 1 1 1 V ^# m C28 n264) 50M stem HC660 St4 1916 Fasting and undernutrition in 1 OCT • . / 'imi