Cream: From four to six tablespoonfuls daily. Cheese: Ementhal, Romadur, 60 grams; Gervais, Stilton, Brie, Holland. Gruyere, 50 grams; Edam, Cheddar, Gloucester, Roquefort, Parmesan, 30 grams; Cheshire, 25 grams. Vegetables: (Prepared without flour or sugar); 5 Teltower turnips; salsify, turnip-rooted celery, turnip cabbage, pumpkin, two tablespoonfuls; green peas, beans, carrots, Brussels sprouts, one tablespoonful; 11⁄2 artichoke; 1 truffle; 5 medium-sized champign1 tablespoonful of mordels and other edible mushrooms. Raw vegetables: 8 radishes, 2 sticks of celery, 2 medium-sized ons; tomatoes. Nuts: 2 walnuts, 6 hazelnuts, 3 almonds, a thin slice of cocoanut, S Brazil nuts. Fresh fruits: 1 thin slice of melon, I small tart apple, 11⁄2 peach, I spoonful of raspberries or strawberries, 4 spoonfuls of currants, 6 green gages, 12 cherries, 1⁄2 a medium-sized pear; corresponding amounts of other fresh fruits. TABLE III.—CONDITIONALLY ALLOWABLE FOODS. The condition under which dishes from the following table are permitted is that an equivalent shall be deducted from the allowance of bread. Each amount given below is the equivalent of 50 grams of white bread, and that must be given up in return. 1 litre of milk. 11⁄2 litre of kumyss. I litre of cream. 60 grams of rye bread, graham bread or Hamburg pumpernickel. 100 grams of Aleuronat bread. 30 grams of English cakes of all sorts. 55 grams of zwieback and simple coffee cakes (made without sugar). 40 grams of chocolate. 40 grams of chestnuts, shelled, or 60 grams unshelled. 35 grams of cane sugar, brown sugar or rock candy. 35 grams of sweet preserves. 40 grams of fruit sugar. 40 grams of milk sugar. 50 grams of fruit jam. 40 grams of honey. 40 grams of flour, wheat, rye, barley, buckwheat, millet, or oat or corn meal. 45 grams of bean, pea or lentil flour. 35 grams of starch preparations, potato, wheat, or rice starch, tapioca, sago, maizene, etc. 35 grams of rice. 35 grams of farinaceous preparations, noodel, maccaroni, oatmeal, grits, barley. 50 grams of lentils, peas, beans, weighed dry. 100 grams of green peas. 160 grams of new potatoes. 140 grams of winter potatoes. 120 grams of apples, pears, green gages, plums, damsons, mirabelles, apricots, cherries, grapes. 200 grams of strawberries, raspberries, gooseberries, mulberries, currants, blackberries, whortleberries, blueberries. 3 peaches. 40 grams of raisins or dried dates. 50 grams of figs. 3 bananas. A handful of walnuts, hazelnuts, almonds or Brazil nuts. 18 litre of beer of any sort. Jg litre of sweet wine. This, then, is the basis of our treatment: to find the limit of a patient's ability to warehouse carbohydrates; and then, by providing him with a complete set of diet lists, to enable him to continue permanently his dietetic regime. In a certain proportion of cases, however, the patient does not become aglycosuric even after two or three weeks on the standard diet. These are the severe cases, often in younger subjects, and tend usually toward a fatal issue. It is necessary, nevertheless, that these patients be allowed some carbohydrate food, and it is customary to permit them to take from 80 to 100 grams (or 3 or 4 ounces) of white bread, or its equivalent, daily. It is advisable, however, to follow von Noorden's suggestion, and insist that at least three times a year, and if possible quarterly, such patients be subjected to four weeks of strict dietary treatment. During this period work should be abandoned, the patient should enter a hospital or sanitarium, and should spend the greater portion of his time at rest in the open air, with occasional short walks or drives. It is in these cases that remain persistently glycosuric that Naunyn has advised the institution of a "hunger day," a period of twenty-four hours' fasting, at intervals of a month or less. In a certain percentage of cases this is quite successful, reducing the quantity of sugar in the blood to within normal limits and causing its disappearance from the urine; and by giving the tissues a rest it raises the subse quent tolerance for carbohydrates. Withal, however, the dietetic. limitations bear heavily upon many diabetics, and in particular their desire for bread demands some satisfaction. Of most of the gluten breads, to speak is only to condemn; for they contain starch in scarcely lower proportions than does white bread. If gluten is to be used at all, the physician should test it himself by fermenting a definite quantity in the saccharometer; this will determine quite accurately its starch content. Much less objectionable is "torrified" bread, i. e., bread toasted thoroughly until it is charred black, this process consuming much of the starch. The favorite German substitute is Aleuronat bread a wheaten preparation said to contain but 7 per cent. of starch and over 90 per cent. of albumen. It is made by Dr. Hamm, of Hundhausen, in Westphalia, and is highly praised by von Noorden and Williamson; but I have had great difficulty in securing it in this country. A recipe for its preparation into bread will be found in Williamson's well-known work on diabetes. Almond meal I have not found serviceable. Within the past year or two the potato, formerly relegated to the lists of foods not allowed, has been readmitted to favor. This is largely the result of Mosse's experiments, by which he demonstrated that the fresh potato, weighed raw, contained only about one-third as much starch as a corresponding weight of white bread. Moreover, experiments on diabetics show that practically all of them warehouse the potato better than bread. In my own cases, fully three times as much potato, weighed raw and then baked, can be taken. In addition to this, by using the potato for a time and then returning to bread, it is found that the power to assimilate the latter has been increased much as it is by Naunyn's hunger day. It may be that the potato produces a form of sugar more easily burned up in the system, or else its value may be due to the accompanying bases, the potash which is present in the potato in large amount favoring glycolysis. The question of sweetening materials, so often raised by diabetics, is usually met by the use of small amounts of saccharin, which is, as you know, 280 times as sweet as cane sugar. While this is unobjectionable, it is often quite as well to persuade the patient to take his coffee and tea unsweetened. Saccharin may be used with lemon juice or dilute phosphoric acid in the preparation of lemonade for patients who suffer with tormenting thirst, or a drachm of cream of tartar may be dissolved in a quart of boiling water, to which the juice of half a lemon and a granule of saccharin have been added. The better treatment of thirst, however, lies in diminishing the hyperglycemia; so long as sugar persists in blood and urine, so long will thirst and polyuria remain uncontrolled. Passing over for the present the treatment of these single symtoms, which, after all, are due almost without exception to the abnormal constituents of blood and urine, let us inquire as to what we may hope to accomplish by medical therapeutics. A sad commentary on this phase of our treatment is seen in the multitude of remedies that have been recommended, tried and discarded because found wanting. Perhaps the greatest disappointment of all is the pancreatic extract, from which, reasoning by analogy, we had a right to expect an action similar to that of the thyroid in myxedema. As a matter of fact, drugs have little influence on the disease. Their sole value seems to lie in the fact that certain of them, probably through their influence on metabolic processes, tend to raise the patient's tolerance for carbohydrates. Such is the effect of the morphine and codeine, at present the favorite remedies of our old school confreres, and such, in all probability, are the effects of our own medicines. There is no specific remedy for diabetes, and I am more and more firmly persuaded, as my experience increases, that the best results are attained by first regulating the patient's diet. according to the system that I have outlined, and then proceeding to forget that he is a diabetic and to prescribe simply for the symtoms and other signs that we find present. To discuss so broad a subject as this, however, is impossible, and so, perforce, I must say a word or two as to the remedies traditionally used for the disease itself. It is a remarkable fact that the one drug that has survived criticism is arsenic. It matters not whether it is given as the once popular bromide of arsenic or the latest proprietary remedy, it is the arsenic which does the work. I have used arsenic in some twenty cases in the course of the past ten years, and careful urinary analyses have seemed to demonstrate conclusively that it does increase the patient's ability to burn up sugar. In practically every case I have used the preparation once known as Martineau's specific; of a solution of three grains of sodium arsenite in a pint of distilled water, the patient adds one tablespoonful, together with three grains of lithium carbonate, to a quart of water, and this constitutes the daily dose. It has proven a pleasant and effective method of administration. Another remedy, and one peculiarly our own, is uranium nitrate. In many cases its action has been a disappointment; but on the other hand, in a severe case in which all other measures had failed and in which uranium itself in small doses had produced no effect, an increase of the dose to thirty grains of the crude drug, daily, was followed within twenty-four hours by marked improvement, the quantity of urine dropping from The patient was 150 to 49 ounces and sugar disappearing. enabled subsequently to leave the hospital in comparative health, It is my impression that we will continue to have these contradictory results until we are in a position to discriminate more accurately as to the precise nature of our cases, and for this purpose extended pathologic and therapeutic investigations will be necessary. Phosphoric acid has proven a valuable aid in some weak, prostrated, neurotic cases; and aurum is an admirable remedy in those cases in which heart weakness is pronounced and alarming. When nephritis is associated with diabetes-and this is a common complication-aurum seems particularly effective. Plumbum, prescribed for the same condition, has proven very disappointing. Passing over the treatment of the pruritus and the other cutaneous symptoms, which can be palliated in various ways, but cured only by freeing the system from the excess of sugar, let me say a word in conclusion regarding diabetic coma. This, the most dreaded catastrophe which can befall our patients, bears a close relationship to uremia in that it represents a stage in which certain poisons accumulating within the body have finally become powerful enough to overwhelm the central nervous system. It differs, however, in that in diabetic coma we have been able apparently to detect the chemical body to whose presence the coma is due; and that is Beta-oxybutyric acid. A natural corollary is the treatment of this acid intoxication with an alkali, and this method has been carried out by many clinicians, the discovery of acetone or diacetic acid in the urine being made the signal for the administration of 20 or 30 grams of sodium bicarbonate daily until the urine becomes alkaline. There can be no doubt that in this way the onset of coma may be deferred, though not indefinitely. Unfortunately, in many cases we are unable thus accurately to predict the oncoming coma, as our first knowledge of the cause is obtained when we are called upon to attend a patient whose nausea, headache, air hunger, fruity breath, or perhaps absolute unconsciousness, together with a history suggesting diabetes, renders us immediately apprehensive. In such a case the adminisiration of 4 grams of sodium bicarbonate dissolved in water by the mouth every two hours, of 8 to 10 grams by rectum at similar intervals, and, if the patient is in deep coma, the introduction of a 1 per cent. solution of sodium bicarbonate in normal saline solution into the median basilic vein-one or all of these methods may, as happened in a case which came under my observation, result in the patient's return to consciousness. But the result is only temporary, perhaps only for a few hours, and unless some great interest, such as the making of a will, depends upon the temporary passing of the |