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authorities, that it is not safe to disregard diabetes even in advanced
life. By the use of repeated fast-days, vegetable days, and restricted
diet he achieves freedom from glycosuria in cases of the type given up
as hopeless by many writers. The procedure in such cases is slow,
and the control transitory (p. 216). "By the enforcement of rest in
bed and a stringent diet the urine can be freed of sugar in the vast
majority of cases. With early cases the result is often effected within
a few days; when the disease is advanced and there is a complicating

severe acidosis, months may be necessary These are the

most discouraging cases, as they never approach a semblance of health.
. . . . At once on beiiig released from incessant control, there is
an inevitable transgression beyond the path of safety in diet and exer-
cise. . . . . With severe cases of diabetes coma develops finally
in spite of the best endeavors."

Mosenthal applied the hospital class system to the care of diabetics.**
The method is particularly adapted to a disease in which instruction
of patients is so essential as in diabetes, and it is the most effective
practical measure in the organization of a clinic, both for the care of

^' Cf . Joslin ( (4), pp. 327 and 409) .


ambulant cases and for guarding against relapse in patients after dis-
charge from hospital. More widespread and effective social service
along these lines offers one of the most important means of diminishing
the death rate from diabetes.

Woodyatt (1) was one of the very few who in 1909 held clearly to
the conception of diabetes as a deficiency of the internal function of the
pancreas.'** Woodyatt (3) has recently suggested that the weakness
of the pancreatic function here concerned may not always be an in-
herited or constitutional defect in the Naunyn sense, but may some-
times be acquired, especially through infections which selectively
injure either the pancreas or the nervous mechanism cohtroUing it.

^ "Diabetes mellitus is a disease in which the body has in part lost its ability
to utilize sugars. Sugar arrives at the point where it should burn, but fails to do
so, and accumulating in the blood creates an hyperglycemia. Disregarding acces-
sory factors, which may play a part, we can say that ultimately the failure of sugar
combustion in diabetes mellitus depends upon lack of 'a something derived from
the pancreas.' The pancreas, like other glands, is capable of being stimulated intO'
a state of fatigue. It may be conceived that excess of sugar in the blood of healthy
individuals acts directly or indirectly (e.g. through nerves) as a stimulus to the
pancreas, as a result of which more internal secretion is set free and the excess of
sugar thereby automatically taken care of. This removed, the stimulating in-
fluence ceases and the pancreas rests. In diabetes it may be assumed that the
pancreas is functionally weak. A small excess of sugar in the blood, let us say,.
calls for a response from the pancreas, and as in health the excess may be removed.
Sooner or later, perhaps as a result of some dietary excess, or of some shock to the
nervous system which results in an outgush of sugar from the glycogen depots of
the liver, an unusual hyperglycemia occurs. This calls for a strong pancreatic
response, more than the functionally weak gland can give, and some excess of
sugar remains unutihzed in the blood. If hyperglycemia persists for any appreci-
able time the continuous pancreatic stimulation thereby engendered results in
glandular fatigue. Less and less secretion is elaborated, less and less sugar utilized,
the hyperglycemia grows progressively worse and a vicious circle becomes es-
tablished. The condition of the pancreas then corresponds to that of a heart with
broken compensation, and as the treatment for such a cardiac condition is rest, so
in diabetes rest is needed for the pancreas. To secure this we must control the
stimulating hyperglycemia, which means primarily the withdrawal of carbohy-
drates from the diet, secondarily reduction in the amount of protein, until absence
of glycosuria tells us that the blood sugar percentage is approximately normal.
After prolonged rest of this sort a return of the pancreatic function to its previous-
state is frequently spoken of as an increased body 'tolerance for sugar.'

Such restoration of sugar-burning capacity, such increase in 'tolerance' is the-


Raulston and Woodyatt in 1914 described a case of diabetes, for which
fasting had been used.^* Woodyatt (2) said at a symposium on dia-
betes before the Association of American Physicians in 1915: "For
eight years at the Presbyterian Hospital we have regularly used starva-
tion in the treatment of diabetes, following principles with which I
became acquainted in the clinic of Muller in Munich. We have fasted
patients for the purpose of desugarization for periods of one, two,
three, and in one case five days, and have kept patients for prolonged
' periods in semistarvation. There can be no doubt of its value in cer-
tain phases of treatment. As to its safety, I have seen two deaths
apparently from spread of infection immediately following a period
of fasting."

first aim of diabetic therapy. There are cases in which the ability of the
body to utilize carbohydrate has sunk so low that as a result certain secondary
changes in the fat metabolism have supervened. These changes are mainly re-
sponsible for the condition spoken of as acidosis. In health and in diabetes with-
drawal of carbohydrate from the diet frequently causes the appearance of a pre-
viously absent acidosis or an increase in the severity of an already existing one.
These aggravations are temporary. Still in such cases as already have a danger-
ously large amount of the acetone bodies in the blood no increase at all is per-
missible. In these cases, and only in these cases, should one refrain from an at-
tempt to improve tolerance. Just where to draw the line is a matter for individ-
ual judgment. Where means are at hand for accurate quantitative measurements
of the daily excretion of acetone bodies one may be justified in closely approaching
the danger point. When these means are not available a more respectful margin
of safety must be maintained."

*^ "We made a transfusion of blood into the veins of a patient suflfering from
diabetes mellitus, one for whom all known expedients had been exhausted and who

was approaching the end The patient, a man, aged thirty-four, had

first shownsymptomsofdiabetessixyearspreviously For two years the

symptoms had been severe, and for eighteen months prior to the transfusion he
had been constantly under observation in the Presbyterian Hospital, Chicago,
where on numerous occasions his metabolism had been studied for prolonged
periods. Prior to entering he had twice become unconscious with what had been
diagnosed as diabetic coma, and on several occasions afterward coma was
averted only by the enforcement of complete bodily rest and the use of maximum
doses of alkali and wine. He became fully educated with regard to the require-
ments of a metabolism study and voluntarily cooperated in a highly intelligent
way. He knew that the expectancy of life was very limited and solicited the
trying of any new line that might even temporarily mitigate his condition or


In the same discussion, Billings (1) spoke to similar effect.*^ Re-
cently Billings (2) has written, "In the service of the Editor in the
Presbyterian Hospital, Chicago, in collaboration with Dr. R. T.
Woodyatt, the treatment of diabetes by a preliminary absolute fasting
period, until the urine is sugar-free, has been followed for nine years.
We have fasted patients for as long as eight days. The patient is
encouraged to drink water freely. Acidosis usually diminishes
rapidly. One may give whisky or sour wine during the fasting period.
Soda bicarbonate may also be used in persistent acidosis. All that is '
said by Allen and Joslin concerning the treatment we can afSrm."

I^o clear up possible misunderstandings, the following may be

(1) Friedrich Miiller has published nothing in regard to the principles attributed
to him. On the contrary, Staubli published (1908) the records of one clinic patient
and two private patients of Friedrich Miiller, showing that they were treated by
the Naunyn method, and though the treatment continued for a number
of months and the cases were not extremely severe, they continually showed marked
glycosuria and ketonuria and were dismissed with these still present. Further-
delay the end. On several occasions his glucose to nitrogen ratio closely approx-
imated 3.65 : 1 on a diet aggregating 2,500 calories (due allowance having been
made for ingested carbohydrate). Nevertheless his urine coiild always be
rendered sugar-free by fasting, and on semistaryation (the Falta-Lusk quotient)
could be reduced from 100 or thereabouts to the neighborhood of 50, as it was on
the diet used at the time of transfusion. During the time of observation the
patient remaiaed quietly in bed. Diet. — For two weeks prior to the transfusion
and for five days afterward the diet consisted of 800 cc. of 16 per cent cream, three
eggs (150 gm.), and water, clear tea or coffee to make the total volume of fluid two
liters daily." The patient died shortly after this time.

** "I am surprised to hear it said that the method of starvation of diabeticpatients
is new. We have used that method in Chicago for a number of years and patients
have been fasted for as long as eight days. The adoption of the method there was
due to the work of Woodyatt. A point to be remembered is that the study of
patients at rest in a hospital is only part of the problem; it is necessary to study
them after exercise, after return to ordinary mode of life. For years, I have taught
patients how to examine their own urine. While it may be harmful to give fats in
general in diabetes, butter fat is not harmful. Diabetics may take butter fat or
bacon fat and may do so for years. Whatever may be said, it is impossible ever
really to control diabetic patients; they will do as they please as soon as they get
beyond the observation of the doctor."


more, personal letters recently received show that Friedrich Miiller has no knowl-
edge of the proposed treatment, and considers it theoretically inadvisable because
of the supposed danger of acidosis.*' Such an attitude on the part of one so
widely informed concerning diabetes and so familiar with the Naunyn method,
affords some evidence of the newness of the proposed treatment and the principles
underlying it.

(2) Though Woodyatt states (1915) that an initial fast has been used for eight
years, and Billings (1916) that it has been used for nine years, the above quoted
therapeutic program of Woodyatt (1) makes no mention of the use of such a
method in 1909; on the contrary, it is there advised, in harmony with Naunyn,
that in cases with very dangerous acidosis one should "refrain from an attempt to
improve tolerance." No description of the new method has since been pubHshed
by either of these authors.

(3) The paper of Raulston and Woodyatt makes incidental reference to fasting
and semistarvation. It seems evident that the plan of fasting used and referred to
by these authors resembled that of von Noorden, the only difference being that the
periods were sometimes longer; the effect is a temporary cessation of glycosuria

*' One letter was addressed to Professor Graham Lusk, and another to one of the
present authors. Liberty is taken to quote from the latter, under date of August

"Die Frage einer kalorisch armen Ernahrung bei Diabetes ist vor einigen Jahren
in der deutschen Literatur durch Schlesinger erortert worden, und er hat gezeigt,
dass Diabetiker haufig bei einer an kalorieri auffallend armen Nahrung sich erhal-
ten. Ein Nutzen fiir die Kranken wird aus dieser Arbeit nicht erkenntlich. Dann
hat Weintraud vor Jahren in seinen aus der Naunynschen Klinik kommenden in
der Bibliotheka medica erschienenen Arbeit auf die Bedeutung einer zeitweiligen
Unteremahrung hingewiesen, und Sie finden diese Gesichtspunkte in dem Buch von
Naunyn iiber Diabetes ausfiihrlich dargelegt. Wir verwenden in Deutschland
zeitweiUge Unteremahrung, sogenannte Hungertage, ganz gewohnHch zur Re-
duktion des Zuckers, und scheuen uns nicht das Korpergewicht dadiirch zu re-
duzieren. Freilich gelingt es nur selten durch solche Hungertage die Acidosis zu
vermindern, da ja der Hunger an sich auch bei gesunden Menschen ausgesprochene
Acidosis zu erzeugen pflegt. Jeder Hungerzustand fiihrt zu Verbrennung von
Korperfett imd erzeugt daher bei Mangel an Glykogen eine Acidosis. Bei Dia-
betes, wo der Glykogenvorrat ohnedies reduziert ist, und wo die Zuckerverbren-
nung haufig schwer geschadigt ist, tritt die Hungeracidosis gewohnlich noch
starker hervor, und erschwert die Behandlung durch Unteremahrung. Eine
generelle Verordnung der Unterernahrang bei Diabetes dtirfte schon aus dem
Grunde nicht ganz ohne Bedenken sein, well die Diabetiker unter einander so un-
geheuere Verschiedenheiten zeigen, dass man sich hiiten muss alle Falle nach der-
selben Regel zu behandeln. Das letzte Wort in dieser Frage hat jedenfalls nur die
Erfahrung, nicht aber die Theorie."


and diminution of ketonuria at the price of a certain amount of weiglit and nutri-
tion, but the diet after the fast permits a quick return of the symptoms. It is
expressly stated that in the semistarvation periods the Falta-Lusk quotient^* was
still about 50, which means serious glycosuria; and it is obvious that marked
ketonuria was constantly present. Billings' opinion concerning fat, and the high
fat diet used by Raulston and Woodyatt, suffice to explain such a result, for without
fat restriction these patients cannot be kept free from such symptoms.

Misunderstanding of the incomplete description of the method in the brief pre-
liminary communications was evidently responsible for the early criticisms of this
character. Aside from the fundamentally new principle of total caloric regulation,
it has been necessary to develop many practical details. The discussion of the
resulting system has in general remained free from questions of priority.

Joslin has had the largest experience in the treatment of severe dia-
betes in this country, and has published the latest as well as the most
advanced and authoritative text-book. No other American clinician
has followed the scientific study of diabetes so long and intensely.
His careful records cover approximately 1000 diabetic patients treated
during the past eighteen years, and are particularly valuable because
the great majority of the cases have been accurately followed up to
death or to the present time. His definition is one which when gener-
ally adopted will tend to lower the death rate from diabetes and its
complications. "My rule in the treatment of diabetes is to consider
any patient to have diabetes mellitus and treat him as such, until the
contrary is proven, who has sugar in the urine demonstrable by any of
the common tests. This method of procedure is safer for the patient
than to make use of the term glycosuria, which begets indifference."
He has laid emphasis upon the necessity of keeping patients supplied
with sufficient quantities of fluid and salts. He has been closely in
touch with the development of the fasting treatment from the outset.
He was informed in advance concerning the first clinical results, and
has treated a greater number of severe cases of diabetes by this method
than any other individual. The rapid general adoption of the method
has been largely due to his example and influence, and in his various
publications he has formulated a detailed program which many prac-
titioners have followed. The reversal of conditions is shown by the
fact that whereas fat was formerly the only food not restricted,



Joslin now begins treatment by withdrawing only fat. His statistics
-support the belief that the life of diabetic patients is lengthened by the
new method, and in his judgment they enjoy also better strength and
'Comfort. References to and comparison with Joslin's results afford
valuable information on the questions discussed in the ensuing chap-
ters, and certain topics can be here omitted altogether because of the
manner in which he has handled them on the basis of a wider experience.

One of the present writers*' previously published work which seemed
to promise the possibility of investigating diabetic therapy by animal
experiments. The conception underlying the subsequent research at
this Institute had a threefold origin. One lay in considerations from
the literature as above mentioned, and also the reports of cessation of
'diabetes in various forms of cachexia {loc. cit., p. 800 ff.). The second
was found in certain of the preceding observations; viz., that in dogs
with severe diabetes not too far advanced, glycosuria ceased and tiie
diabetes seemed more or less improved on fasting alone {loc. cit., p. 480,
Dog 64), or together with ligation of the pancreatic duct (Chapter
XXII). The latter experiments were repeated and the role of im-
paired food absorption and undernutrition demonstrated by Homans.
The third suggestion was furnished by Joslin,^" who in a conversation
-called attention to his observations that though infections are gener-
;ally so serious in diabetes, tuberculosis with rapid emaciation had
•seemed sometimes, notably in one very carefully studied case, to be
.accompanied by diminution of both glycosuria and acidosis.

On these various grounds, animal experiments were begun with a
view to the possibility that diabetes is a disorder of the total metabo-
lism and not of carbohydrate utihzation alone, that the entire diet and
maintenance of the entire body mass constitute a load upon the inter-
nal function of the pancreas, and that accordingly in the treatment of
•diabetes increase of diet and of body weight increases the strain upon
this function, and reduction of the total diet and weight relieves this
;;strain more effectively and permanently than restriction of carbo-
hydrate alone. A series of animal experiments seemed to support this

« Allen (1).

^ Cf. Benedict and Joslin, p. 55, Case R; also Joslin, Treatment of Diabetes
:Mellitus, 2nd edition, 1917, p. 409.


conception, which was then applied to the treatment of diabetic
patients. Some of the results have been outlined in preliminary
communications, which, however, have not been sufficient to convey
an accurate knowledge of the details, and results have varied somewhat
with the different appHcations of the method in different hands.

Among authors who have reported favorable experiences are: in
America, Barker, Bookman, Christian, Friedenwald and Limbaugh,
Greeley, Halsey, Hamburger, Heffron, Heyn and Hawley, Hill and
Eckman, Hill and Sherrick, Jeans, Jones, Lemann, Levy, Lovewell,
Marshall, Martin and Mason, McNabb, Moses, Paley, Potter, Rob-
bins, Stengel and collaborators, Strouse, and Wilhams; in England,
Cammidge, Fenwick, Leyton, Spriggs, and speakers discussing their
papers; in Ireland, Nesbitt; in India, Waters. Its adoption by
speciahsts and institutions, and by a still greater number of general
practitioners, has furnished gratifying evidence not only of its theo-
retical soundness but also of its feasibihty for successful practical
application under the many varied conditions of medical work and
environment. Geyelin and DuBois, and Jonas and Pepper, have
demonstrated the possibility of beneficial results in the most intense
uncomplicated cases ever described in the literature of diabetes.

Aside from any benefits inherent in the treatment itself, it has
apparently served to stimulate interest in diabetes among members of
the medical profession, and to promote the understanding and employ-
ment of rational dietetic management of this disorder, than which
none has been more poorly understood or treated. Such knowledge
and confidence concerning the rational therapy will diminish the use
of the worthless or harmful remedies which appeal to ignorance or
despair. The history of the development of the scientific treatment,
and of some among the many contributors to it, may;fittingly be closed
with a quotation from Naunyn ( (5) , p. 452) . "The interest in novelty
may be granted also to physicians, and the lack of prejudice with
which we accept for trial all things, even the strangest and from the
worst source, may — so far as one may believe in it — ^be praised; but
every physician must beware of undertaking such special treatments
or of recommending them, without ascertaining their relation to what
science has estabHshed and teaches concerning the therapy of our
disease. If this is not possible for him, then the employment of them


is not permissible. The therapy of diabetes has been well founded by
painstaking labor highly fruitful in all directions; we may be proud of
that which has been achieved and attained here. The physician who
here frivolously abandons the scientific basis must, if he wishes to be
deemed honorable, submit to the accusation of ignorance."


Allen, F. M., (1) Glycosuria and Diabetes, Harvard University Press, Cam-
bridge, 1913.

(2) Studies Concerning Diabetes, /. Am. Med. Assn., 1914, Ixiii, 939.

(3) The Treatment of Diabetes, Boston Med. and Surg. J., 1915, clxxii,


(4) Prolonged Fasting in. Diabetes, Tr. Assn. Am. Phys., 1915, xxx, 323-

329; Am. J. Med. Sc, 1915, cl, 480-485.

(5) Metabolic Studies in Diabetes, N. Y. State J. Med., 1915, xv, 330-333.

(6) Note Concerning Exercise in the Treatment of Severe Diabetes, Boston

Med. and Surg. J., 1915, clxxiii, 743-744.

(7) Investigative and Scientific Phases of the Diabetic Question, J. Am.

Med. Assn., 1916, kvi, 1525-1532.

(8) Some Clinical Phases of Diabetes, Tr. College Phys. Philadelphia, 1916,

xxxviii, 249-254.

(9) The R61e of Fat in Diabetes, The Hai-iiey Lectures, 1916-17, xii, 42-

n\;Am. J. Med. Sc, 1917, chii, 313-371.
(10) The Present Outlook of Diabetic Treatment, Tr, Assn. Am. Phys.,

1917, xxxii, 138-148.
Allen, F. M., and Du Bois, E. F., Metabolism and Treatment in Diabetes,

Arch. Int. Med., 1916, xvii, 1010-1059.
Baedet, G., Diete absolue et alimentation restreinte dans le diab^te. Bull. gin.

thSrap., 1909, clvii, 308-315.
Barker, L. F., Diabetes Mellitus, Monographic Medicine, 1916, iv, 816-839.
Batjmel, L. (1) Pancreas et diabete, Montpellier Mid., 1881, xlvii, 406-413;

1882, xlviii 31-40, 442-462.
(2) Nouvelle theorie pancreatique du diabete Sucre, Ihid., 1889, xiii, 314-

353. Ref. by Lepine and Sauerbeck.
Benedict, F. G., and Joslin, E. P., Metabolism in Diabetes Mellitus, Carnegie

Institution of Washington, 1910; A Study of Metabolism in Severe

Diabetes, Ihid., 1912.
Bernard, C, (1) De I'origine du sucre dans Teconomie animale. Arch. gin.

mid., 1848, xviii, 303-319.

(2) Lefons sur la physiologic et la pathologie du systSme nerveux, Paris


(3) Lefons sur la diabete et la glycogenese animale, Paris, 1877.
Billings, F., (1) Discussion, Tr. Assn. Am. Phys., 1915, sxx, 338.

(2) Diabetes Mellitus, The Practical Medicine Series, 1916, i, 328.


BiOT, (1) Sur un caractere optique k I'aide duquel on reconnatt immediatement
les sues vegetaux qui peuvent donner du sucre analogue au sucre
de Cannes, et ceux qui ne peuvent donner que du sucre semblable
au Sucre de raisin, Ann. chim. et phys., 1833, lii, 58-72.
(2) Ueber Bestimmung der BeschaSenheit und Quantitat des Zuckers in
Saften durch ein optisches Kennzeichen, Pharm. Centr., 1833, iv,

Blum, L., (1) Ueber Weizenmehlkuren bei Diabetes mellitus, MUnch. med.
Woch., 1911, Iviii, 1433-1439.

(2) Die Diat bei Diabetes gravis, Med. Klin., 1913, ix, 702-705.

(3) Les hydrates de carbone dans le traitement du diabete sucre, Semaine

mid., 1911, xxxi, 313-318.
Bookman, A., The Allen Treatment in Diabetes Mellitus, N. Y. Med. J., 1915,

cii, 1240-1242.
Bose, C. L., Discussion on Diabetes in the Tropics, Brit. Med. J., 1907, ii, 1053-

BoucHAKD, C, (1) Lefons sur les maladies par ralentissement de la nutrition,

Paris, 1890.
(2) Troubles prealables de la nutrition, traite de pathologic gen6rale,

Paris, 1900, iii, 179-415.
BoucHARDAT, A., (1) Du diabete sucre ou glucosurie; son traitement hygienique,

Paris, 1851.
(2) De la glycosurie ou diabete sucre, Paris, 1875.
Cammidge, p. J., (1) Glycosuria and Allied Conditions, London, 1913.

(2) The Nitrogen Balance in Diabetes MeUitus and Its Importance in

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