Frederick Allen—one of the first to appreciate that diabetes involves total metabolism rather than carbohydrate metabolism alone—developed this model to show that complete removal of the organ resulted in uncontrolled diabetes and death, whereas dogs who retained more than 20% of their pancreas never developed diabetes. The fate of those with 80–90% pancreatectomy depended upon what they ate. ‘On an Eskimo diet they may be found to live in health’, said Allen, but ‘on a Hindu diet they soon go down to fatal diabetes’ [8]. Carbohydrate loading produced progressive glycosuria and hydropic degeneration of the islets, leading Allen to conclude that the as yet unknown pancreatic factor that prevented diabetes had been exhausted. Glucose toxicity had found its first advocate. Physiology also has its cycles, and investigators discovered in 1988 that glucose infusion precipitated pancreatic islet failure in dogs with subtotal pancreatectomy, little suspecting that they had reproduced one of the classic experiments in diabetes 75 years later [9].

Allen concluded that people with diabetes should be given just enough food to keep body and soul together, with as little carbohydrate as possible, and the starvation regimen was born [8]. The physician in charge of this diet has been described as a yachtsman sailing as close as possible to the wind [10]. Too many calories, and symptomatic hyperglycaemia would result; too few, and the patient would die of starvation (as some did). Naunyn had taught that ‘fat burns in the fire of the carbohydrates’, and carbohydrate was needed for the proper combustion of dietary fat, which might otherwise precipitate ketoacidosis. One risk having thus been balanced against another, a man weighing 60 kg and able to tolerate 100 g of carbohydrate might end up on 60 g of protein, 130 g of fat and 25 g of carbohydrate. His daily ration of the latter might consist of 7 oz (198 g) of thrice boiled cabbage, or 5 oz (142 g) of similarly treated spinach or two and a half bran biscuits [10]. The bran was needed to counteract the constipation induced by the rest of the diet.

Adults did relatively well on this regimen, but children hovered miserably between death from diabetes and death from starvation. One 12-year-old boy, already blind from diabetes, was reduced to eating toothpaste mixed with birdseed stolen from his pet canary. ‘These facts were obtained by confession after long and plausible denials’, remarked the pitiless Allen. The unfortunate child died of starvation. A few physicians hailed the treatment as a means of prolonging life, but Carl von Noorden shuddered and turned away when Joslin showed him one of his cases. The controversy concerning the value of extra months or years purchased at the cost of so much misery was very bitter, and Allen was banned from the diabetic clinic at the Rockefeller Institute in 1918 [11].