Ketogenic Diet

I do not wish to speak here of the patients whom I am treating at present, although in all these cases there are a great number in the process of perfect recovery, and several patients have already returned for some time to the use of carbohydrates: but enough time has not yet elapsed, and I cannot regard them as fully healed. In addition, there are many cases of diabetes cured by my method, by other doctors: so that today we can count diabetes among the most curable diseases. To pretend that a man cured of diabetes could not get it back, even under the conditions in which he contracted it the first time, would be nonsense: just like to claim that one can no longer contract pneumonia, acute catarrh or rheumatism, when you are cured of a first attack, or several. Just as it would be unwise to claim that it is the same disease which recurs after several years, it would be incorrect to maintain that a man, cured of diabetes for one, two or three years and eating everything, experiences a "Relapse" if they contract the disease again after further abuse of mealy or sweets, and under the influence of debilitating conditions. Should it therefore be that the treatment procured future immunity, and that the patient had acquired impunity with regard to the abuse of starchy foods and fruits? It would really be asking too much of a treatment to require such immunity before declaring it effective. Quinine and mercury are not required as much as they are said to be specific, and which do not always even prevent recurrence of morbid manifestations. I cannot cite here the names of all those of my colleagues from Italy or abroad who have obtained success with my treatment: but it would be necessary to add to the 73 cases published above, 52 other cases cured by others than by me, which would make 125 successes obtained in 4 years (1), a figure not to be despised in (1) I asked Professor Primavera for notes on the cases of diabetes treated by him alone . He replied to me by the following letter, which I publish without comment: 

Naples, January 25, 1874. 

Very honored Professor Cantani, 

You ask me for notes on diabetics which you have not seen, but which I have analyzed urine and disease monitoring. Strictly, I don't and which do a disease previously regarded as incurable. Moreover, this cure has become popular in our southern provinces, where everyone orders it, even pharmacists, priests and former patients. Success is assured provided that the treatment is not started too late, provided that it is followed with all the necessary rigor and for a sufficient time. The high frequency of diabetes in these countries means that its beginnings do not escape attention as easily as it once did, and still happens in countries where diabetes is rarer, and therefore is often recognized too late, if the patient does not watch himself, or if he comes across a doctor who does not pay attention then say the exact number, but I can assure that they are roughly twenty in number: some from outside were treated according to your method by foreign doctors, others treated in the same way by Neapolitan doctors, some finally absolutely wanted to be treated by me, always according to your method, henceforth known to all. 

The first piece of information I must give you is this: I have never seen a single one of these patients not being cured, and if four of them seemed to resist the treatment, it is because they were not following it, not with enough rigor; but warned by me, they did it, and also came to a complete recovery. This fact is certainly very consoling, I do not explain it by the practice of other doctors who have also administered to their patient several therapeutic agents unrelated to your medication, such as a decoction of quina, strychnine, opium and the like; but, on reflection, let me explain it to myself because the diabetics of the civilian clientele, that is to say rich or at least well-off, do not allow their disease to age: on the contrary, the poor diabetics who resort to hospitals when they really cannot take it any longer, must necessarily provide a contingent of incomplete healings. My second piece of information, which I guarantee to be correct, relates to this fact: patients who do not strictly follow the meat diet often emit in their urine, along with a little sugar, lime oxalate; so that the presence of this salt is very useful for me to deny those who claim to adhere strictly to your treatment, and transgress it more or less, by eating a little bread or fruit (often out of ignorance). 

As for the return of diabetes, I have observed several cases of it after eight months and more, up to two years; but I have always seen the sick recovering again with the same treatment. So much so that it can be said, with great probability, if not complete certainty, that any diabetic, once cured by your method, could secure lifelong cure, if he had the patience to repeat the rigorous treatment for two months every semester, and this for a number of years. If I were diabetic this is how I would act, with the firm conviction that I would never die from it. Finally I noted in all these patients, as a constant cause, the usual abuse of flour (bread, pasta in general): only once was this abuse lacking, but there was, on the other hand, abuse of cane sugar (sweets, sorbets, jellies, sweet coffee, etc.). 

G. PRIMAVERA.

OBSERVATION LI. MRG, 47 years old, from Terra di Lavoro, a habitual amylivore, with an adipose constitution, himself noticed polyuria in 1871, and a few months later progress in weight loss and weakness: for that, and for unquenchable thirst, with continual dryness and ar- teness of the mouth, and above all for sexual debilitation, he had recourse to his doctor, the distinguished doctor Leonardo Bian- (1) In Barth, Gazzetta di medicina e di scienze naturali, di Malta, di GAVINO Gulía, Anno II, Nov, 15 and 16. Malta 22 luglio 1873. (2) In Barth, loc. cit. and all the diabetic symptoms were gone; since then he has been doing well. This observation has already been published by Dr. P. Sammut (2). chi. In April 1873 the urine, about 7 liters per day, had the specific weight of 1035, with 130 gr. of sugar per liter, about 900 gr. per day. After a cure almost exclusively meat, with tolerance of a few berberages, a little butter, a little red wine, which was prescribed to him by Doctor Bianchi, the patient improved extraordinarily quickly, so that ' after eight days, he emitted only 2 liters of urine, with 70 g. of sugar per liter, 140 gr. about sugar per day; after five more days, he emitted only a liter and a half of urine, with 49 g. of sugar per liter. Consulted on May 4, I insisted that the cure became rigorous, I prohibited butter, vegetables and wine, granted by the transaction of Doctor Bianchi: after fifteen days, the sugar completely disappeared from the urine, the volume of which fell to 700 cc, the patient regained his strength and has been doing well until this day (September 1874), where I have received news from him: for more than a year, he returned to mixed feeding. 

OBSERVATION LII. - M. Guiseppe Durini, 47 years old, from Bolognana (Chieti) (1) very fat in 1866, usually eating large quantities of flour, fruits and sweets, began little by little, without any known cause, and especially without having experienced any moral emotion, to lose weight; in the last seven months he became extraordinarily emaciated: at first, this symptom was attributed to diarrhea which had occurred in the meantime. Finally he showed himself to Doctor Colombo de Nicola, who noticed polyphagia, polyuria, polydipsia, vision impairment and impotence, suspected diabetes and confirmed this suspicion by urine analysis. On January 2, 1874, the patient emitted 5 liters of urine in twenty-four hours, with 65 gr. of sugar per liter, which makes 325 gr. of sugar per day; after eight days of rigorous treatment, Primavera observed the complete disappearance of sugar. The patient continued to be perfectly well; he returned to see me on April 7, 1874, comforted, flourishing in appearance, perfectly healthy, ruddy in color, with greatly improved eyesight. I allowed her the pastures, the wine, the coffee (without sugar), some unsweetened fruits. I saw him again in the best state of health on May 17, 1874: his urine was completely free of sugar, weighed 1022, because it was rich in urea by the fact of (1) He himself wanted to be named here, meat diet; I then allowed him the starchy foods: at the last I heard he was still doing very well, and feeling stronger than ever. 

OBSERVATION LIII. - Doctor G., a very distinguished doctor and director of a hospital in one of the most important towns of Campania, about 50 years old, of fat constitution, lover of starches, contracted diabetes mellitus in 1871, presenting the usual symptoms, with weight loss and considerable weakness. Having learned of the happy results that I had since obtained at my Clinic, which a young student of his parents attended, he submitted to my treatment, and followed it with great rigor. He recovered completely, and used a mixed diet for a long time: today he has gained weight again, he is flourishing in health, and a few weeks ago (August 1874), I saw him in consultation for one of his patients (1). 

OBSERVATION LIV. Doctor Pasquale M., distinguished doctor from Salerno, about 60 years old, of normal constitution, extremely amylivorous, suffering from diabetes for two years, with all the ordinary symptoms; so emaciated and weakened that it was difficult for him to continue his visits, and a little frightened also by the sight of the progress of the diabetes in the dean and the most renowned of the doctors of Salerno, Doctor Centola (who never did the treatment of rigorous meat diet, wasting his time taking arsenic, strychnine, and following the Bouchardat diet), Doctor PM submitted to my treatment, followed it rigorously, and recovered completely; therefore, fully recovered in possession of his strength and with normal urine, although he had returned to mixed food for about a year, I saw him again a few months ago (in March 1874 ), in a consultation in Salerno, which he attended as an attending physician. 

OBSERVATION LV. - Dr. Guiseppe B., from Randazzo, who usually ate a lot of starchy foods, ill, according to what he wrote to me, for three and a half years, is now fully recovered: his urine are normal in specific weight, free from sugar, although, for several months, (1) Special considerations, and the wishes of this distinguished colleague himself, require me to suppress the other details: it is the same for the following cases. he returned to a mixed diet about a year ago. I saw him again a few months ago (in March 1874), in a consultation in Salerno, which he attended as an attending physician, he returned to mixed feeding. On February 26, 1874, this distinguished colleague wrote to me that having interrupted the rigorous treatment too early, he relapsed four times, so much so that he began to regard my treatment as a palliative which suppressed, but did not cure diabetes; but after having followed it for a sufficient time, he was able to return to a mixed diet without seeing the sugar reappear in the urine: he then reconsidered his previous opinion. 

OBSERVATION LVI. MF Saverio M., from Borgia (Cantanzaro), 53 years old. At the age of 40 he experienced, as a result of serious sorrows, sufferings in his stomach and intestines, with diarrhea: but he recovered completely, got married at 14, had children and did well until the age of 49. At this age, and with no known cause (apart from the daily abuse of mealy seeds), he began to present the first symptoms of diabetes, which he recognized in him a year later by Doctor Cirillo, who prescribed him a treatment which was followed for two and a half months , and which consisted of a diet composed mainly of meat, eggs and milk, with limitation for the use of flour, all accompanied by a prescription of cinchona, strychnine, rhubarb and baking soda. A great improvement followed, but hardly the cure ceased, the patient relapsed and more seriously than the first time. So Doctor Cirillo prescribed a more rigorous treatment, ours, forbidding the use of fruits, milk, vegetables and flour, and adding lactic acid to the previous drugs. The patient got better again, but as he was not sufficiently rigorous in his diet, he presented on January 27, 1874, when I was consulted, 30 gr. of sugar per liter, with a polyuria of 2 to 3 liters per day, and the specific weight of 1023. Subject to my rigorous treatment, the urine, examined on February 15 by Professor Primavera, had the specific weight of 1015 and was completely free of sugar; they were still similar on April 27, 1874. The patient continues to be well, although he has resumed the moderate use of flour. 

OBSERVATION LVII. - Mr. Giacamo F., 33 years old, from Tunis (Africa), client of Doctor Quintilio Mugnaini. He had two brothers who died of diabetes, the second from phthisis after consulting the best doctors in the largest cities in Italy, the rigor of my cure. The patient himself, as his brothers had done, ate almost exclusively on flour and very fond of sweets; he never had moral emotions. In September 1873, he noticed that he had a slight polyuria, that he got up three times at night to urinate, while before that he always slept through the night. The example of his brothers made him seek advice from his doctor, Doctor Quintilio Mugnaini, who analyzed the urine with the help of the pharmacist Sinigaglia, and finding them sweet, diagnosed diabetes, and submitted the patient to my cure. After three days, the urine was free of sugar; after ten days, he ate a little bread, and the urine picked up a little sugar, but with a much less clear reaction than the first time: this sugar disappeared again after a more careful treatment of two months. After forty-five days the patient returned to a varied diet, for he was feeling quite well, and his nutrition was good. On February 25, 1874, he came to Naples, and wanted to consult me: his urine, examined by Professor Primavera, was free of sugar. This case is very interesting because it demonstrates, not only that diabetes is often a family disease, thus affirming its constitutional character, but also, by the sad antecedents of the two brothers, neither long enough nor rigorously enough. treated, that the third brother followed the same route and succumbed, if he had not been saved by coming in time to be treated and to follow the treatment exactly. He also demonstrates that there are not two kinds of diabetes, one curable, the other incurable: curability depends on the degree reached by the disease, on the period at which the disease is recognized, and the patient subjected to rigorous treatment. 

OBSERVATION LVIII. Mr. Carlo de S., 44 years old, military employee on the island of San Stefano. As a result of a great abuse of starchy substances, for he seldom ate meat, and without any other known cause, he suffered from diabetes; for some time he kept his illness concealed, although he suffered from polyuria, with thirst, impotence, great emaciation and extreme weakness. In June 1873, the presence of sugar was found in the urine, and he followed a treatment, but not with sufficient rigor: he ate almost exclusively meat, bis. The sugar gradually disappeared from the urine, and the treatment continued for five months. The urine remained free of sugar, and the patient recovered, assumed a flourishing appearance, and felt robust and strong. Having returned then to abuse flour and to abandon the meat almost completely, after a month we found sugar in the urine, but in small quantities. Professor Primavera, on March 1, 1874, found only 5 gr. of sugar per liter in urine emitted on an empty stomach at 11 am; the urine presented this interesting thing, that it was rare in the morning, but very abundant after the meal, during which he consumed so much flour. The urine, after the meal, contained up to 50 gr. of sugar per thousand. It is a kind of intermittent diabetes depend on the diet, such as starting diabetes. On March 23 began my rigorous cure, and shortly after the urine was completely free of sugar. In June 1874 he was still doing perfectly well, although he returned to a mixed diet after only a month of rigorous treatment. 

OBSERVATION LIX. Mr. Nicolangelo S., 53 years old, from Forino (Avellino). Diabetic since August 1873, by abuse of flour and without other known cause, he also presented a symptom of beginning diabetes, that of the intermittence of diabetic phenomena (polyuria, thirst and sugar in the urine, only after meals, usually rich in starch; in the morning urine is normal and completely free of sugar). - Come to Naples to consult me, he presented me, on January 3, 1874, urine emitted after meals, and whose specific weight was 1034, with 60 gr. of sugar per liter: he immediately submitted to my rigorous cure; from January 22 the urine was sugar free, and weighed 1018: the same on February 23. The severe cure was only continued for a short time: nevertheless, according to the news received, he is still doing perfectly today, although he makes moderate use of the mixed diet. 

OBSERVATION LX. Mr. Aniello S., lawyer, 47 years old, from Carbonara de Nola. Recognized diabetic by Doctor Mele in Ayril 1872; after 2 days of rigorous treatment, his urine no longer contained sugar; he continued thus for a month only, and then was very well, although he ate everything; however relying too much on his regained health, then he abused for a long time flour, sweets and wine, so that again contained sugar; however, the patient was subjectively well. He resumed the cure in January 1873, for 40 days; his urine got rid of the sugar, and he was well, although he ate everything. But in the carnival of 1874, returning to the abuse of sweets, he began to urinate more, and felt his virile power go away: the urine examined contained sugar: here is therefore a relapse after 13 months of well- be and mixed diet, brought about by the abuse of sugary foods. On March 7, 1874, the urine examined by Professor Primavera showed the weight of 1035 with 70 gr. of sugar per liter: but there was no polyuria yet. The cure resumed, the sugar soon disappeared, and the patient regained virile power. - He continues to do well, to what Dr Mele assured me in September 1874. - What is remarkable in this case is that it shows that an individual, who has once contracted diabetes, should not never again abuse the sweets, which are even more perilous and harmful than the mealy ones themselves. This case also teaches that there is no need for trauma or moral suffering to reproduce diabetes: the abuse of hydrocarbons is enough.

Cantani’s dietary regime involved periods of energy restriction, however the German physiologist Wilhelm Ebstein cites Cantani as an authority for the use of pure fat in diabetic diets. In 1892 Ebstein published his comprehensive review of the literature on diet, lifestyle, and diabetes, Über die Lebensweise der Zuckerkranken, which includes the statement that “up to about 200 grams of fat is well tolerated by the majority of diabetics” [7]. Also in 1892, Ebstein’s book on Corpulence and its Treatment on Physiological Principles, which contained brief summaries of his findings on fat and diabetes, was translated into English [8]. In this book and his subsequent work On the Regimen to be Adopted in Cases of Gout Ebstein discussed experimental evidence on the metabolism of protein and the desirability of limiting both protein and carbohydrate, and increasing fat, in the treatment of metabolic diseases [9].

German Txt (Very hard to read)

https://archive.org/stream/diefettleibigkei00ebst/diefettleibigkei00ebst_djvu.txt

English Translation Scanned PDF:

https://dlcs.io/pdf/wellcome/pdf-item/b21050533/0

Ebstein describes Rabbit Starvation:

Page 37:

Notwithstanding the vastly important part played by nitrogenous food in human dietetics, those substances that contain no nutritive ingredients except albumen, as for instance flesh destitute of fat, are not proper food for man. As flesh satisfies his demand for carbon only when it is consumed four times in excess of the quantity required to yield the nitrogen needed for his nourishment, such a course would in the first place be far from economical, seeing that meat is one of the dearest articles of food. And then we should very soon find it impossible to consume every day the 90 oz. of pure flesh required for this purpose.

The dietetic systems of treatment now in vogue are based on an almost exclusively albuminous diet. In 1850 Chambers had already pronounced in favour of this regimen, his system excluding all fat substances such as fat, oil, butter, milk, cream, as well as sugar. Of starch-flour in the form of potatoes and even of bread he remarked, that they should be looked on with the greatest suspicion. He also insisted on a diminished consumption of liquids. 

We thus perceive that strictly speaking Chambers' cure differs in no respect from that, by which Banting grew lean in the hands of his physician Harvey, and which has received the name of the Banting cure from the patient, who has written an account of his malady and curative process. From it's specially operative factor Kisch has named it the "Anti-Fat Cure".

Cantani has gone still more vigourously to work. He bars not only all fats - fat meat, fat fish, cheese (owing to its sebacic acid), but all farinaceous preparations, all saccharine foods, sweet and aromatic fruits. Only when the patient is unable to continue this diet long enough, either through excessive repugnance to meat, or nausea of the stomach, or muscular debility, he combines it with the Harvey-Banting system, which also no doubt anathematises the fats, but allows a certain quantity of carbohydrates. 

    Hence these cures have this in common that both alike to the very utmost exclude fats, which they regard as the chief source of the accumulation of fat in the body.

    Now I will by no means deny that a series of cures does result from the Harvey-Banting and Cantani methods, that is to say, by these means corpulent persons become thin. But on the other hand it must be allowed that: 

Page 44:

Ebstein strongly supports fat for satiety.

"I would now specially insist that the suitable quantity of alimentary fat must not forsooth remove hunger in such a way as to produce dyspeptic symptoms or injure the digestion; and this I dwell upon because the question has already been more than once placed before me by competent colleagues. It is of course a tacit assumption that the fat like all other human aliments, be of unexceptionable quality. The experiments made on persons suffering from fistula in the stomach, have already shown that fat substances disturb the digestion only when they are consumed too abundantly, and I have myself often enough administered with surprising succcess alimentary fat to dyspeptics of the worst type, while limitng their allowance of carbohydrates. But my own numerous experiences have also convinced me, that in the treatment of corpulency fat agrees perfectly well even with those, who had previously regarded it with nausea. I have even noticed a total disappearance of the dyspeptic affections, which the corpulent had hitherto brought upon themselves by an improper diet. The patients preserve a good appetite, which they must learn to moderate by yielding only the actual feeling of hunger. 

The reason of this alleviation of the feeling of hunger with a proper allowance of fat in the diet is due to the circumstance, that fat checks the decomposition of albumen, and that consequently the craving to make good the waste makes itself felt more slowly and less urgently. Precisely because fewer albuminates have been decomposed, fewer require to be replaced. As by the addition of fat to the diet in the same proportion as the decomposition of albumen is diminished, the quantity of nitrogenous refuse from the assimilated substances is also limined, a smaller amount of drink is needed for its removal. Hence in this way thirst as well as hunger becomes appeased. That fats reduce the craving for food was already known to Hippocrates, who remarks in the section dealing with those that wish to become fat or lean: "the dishes must be succelent, for in this way we are easiest sated." Very interesting to me was a communication from Loew, bearing on the point that the use of fat is also effective in checking the craving for liquids. After the consumption of fat in hot climates he always noticed a diminished demand for water; thirst became decidely less irksome.

This property of fat to produce satiety more rapidly, to diminish the craving for food and abate the feeling of thirst, facilitates to an extraordinary degree the introduction of the modified diet. For to the sacrifices which after all must in any case be required of the corpulent, nothing further need be superadded at least in this direction. On the contrary, the permission to enjoy certain succulent things, always of course in moderation, as for instance salmon, pate de foie gras and such like delicacies, reconciles the corpulent gourmet to his sacrifices. These consist in the exclusion of the carbohydrates. Sugar, sweets of all kinds, potatoes in every form I forbid unconditionally. The quantity of bread is limited at most to from 3 to 3.5 oz a day, and of vegetables I allow asparagus, spinach, the various kinds of cabbage and especially the leguminous, whose value as conveyors of albumen, as Voit rightly observes, is known to few. Of meats I exclude none, and the fat in the flesh I do not wish to be avoided, but on the contrary sought after. I permit bacon fat, fat roast pork and mutton, kidney fat, and when no other fat is at hand I recommend marrow to be added to soups. I allow the sauces as well as the vegetables to be made juicy, as did Hippocrates, only for his sesam-oil I substitute butter. 

In spite of all this it would be little to the point to say that I treat the corpulent with fat, whereas I simply vindicate the full claims to which fat is entitled as an article of food. I do not suppose that the corpulent, with who we are practically concerned, will have to consume anything like the quantity of fat that Voit concedes to the working man, or that is allowed to the rank and file of the German imperial army in time of war, say from 7 to 9 oz. daily. I reduce this daily allowance of fat to from 2 to 3.5 oz on an average. The quantity of course changes with the individual relations, nor is it the same for every day. Under the influence of this diet it becomes possible to do with a less quantity of meat. This again I reduce to fully one half or three-fifths of the quantity required in the Banting system, which varies from 13 to 16 oz. a day.

ON THE TREATMENT OF DIABETES. A CLINICAL LECTURE DY PROFESSOR DOJARDIN-BEAUMETZ, Member of the Academy of Medicine Physician to the Hôspital St. Antoine, Paris, France 

GENTLEMEN, 

The dietetic treatment of diabetes deserves the first place. Ever since John Rollo at the end of the last century first called attention to the influence of foods in the production of glycosuria, all authorties have felt the obligation to regulate rigorously the diet of diabetic patients. At their head is Bouchardat; after him I will mention especially Seegen, a German writer, and Cantani, an Italian, and what I have now to offer respecting the hygienic regime of this affection will be based on a careful study of the contributions of these three men. The hygienic treatment is founded on the endeavor, far as possible, to exclude from the food all substances capable of forming glucose. This glucose may be derived from sugar in the ingesta, or from starch which has undergone conversion in the alimentary canal. These glycogenous principles, then, should bo suppressed. All this, however, though simple in theory, is difficult in practice.

GOUT.

BY W. H. DRAPER, M.D.

DIET.—The prevention of the accumulation of azotized matters in the [p. 128]blood involves, first, a consideration of the question of the diet appropriate to the gouty dyscrasia. The almost uniform counsel upon this point of all the authorities from Sydenham to the present time is, that albuminous foods should be sparingly allowed in the diet of the gouty patient, and that vegetable foods, especially the farinaceous, should constitute the principal aliment. This counsel is based upon the theory that uric acid is the offending substance, and, this being the outcome of a nitrogenous diet, the nitrogenous element in diet must be reduced. My own observation has led me to believe that while this may be a legitimate deduction from the uric-acid theory of gout, it is not supported by the results of clinical experience. If there is one signal peculiarity in the digestive derangements of gouty persons, it is their limited power to digest the carbohydrates, the sugars and starches. In whatever form these foods are used, they are more commonly the source of the dyspeptic troubles of sufferers from gout than the albuminous foods. They provoke the acid and flatulent dyspepsia which so generally precedes the explosion of the gouty paroxysm; and it must have attracted the attention of every observer who has studied the dyspeptic disorders of sufferers from inherited gout, who have sought to control their unhappy heritage by abstemious habits, that these disorders are especially provoked by over-indulgence in saccharine and amylaceous foods.

It is not possible to explain satisfactorily why the lithæmic condition should be induced by the carbonaceous aliments, but we believe there can be no question as to the fact. If, as modern physiological investigations tend to show, the liver is the organ in which urea as well as glycogen is formed, it may be that the overtaxing of its functions manifests itself more readily in the conversion of the albuminous than in that of the carbonaceous foods; or it is possible that the carbonaceous foods are destined chiefly for the evolution of mechanical energy, and that when this destiny is not fulfilled through indolence and imperfect oxygen-supply, they escape complete combustion, and so vitiate the blood. But whatever may be the cause of this anomaly, the clinical fact remains that in gouty persons the conversion of the azotized foods is more complete with a minimum of carbohydrates than it is with an excess of them—in other words, that one of the best means of avoiding an accumulation of lithates in the blood is to diminish the carbohydrates rather than the azotized foods.

The diet which a considerable experience has led me to adopt in the treatment of the gouty dyscrasia is very similar to that which glycosuria requires. The exclusion of the carbohydrates is of course not so strict. Abstinence from all the fermented preparations of alcohol is perhaps the most important restriction, on account of the unfermented dextrin and sugar which they contain. This restriction accords with the common experience respecting the part which wine and beer play as predisposing causes of the gouty disease and as occasional exciting causes of gouty lesions.

Next to the fermented liquors, the use of saccharine food in the diet of gouty persons needs to be restricted. This limitation also is one which common experience confirms. Sweet foods cannot be said to be as provocative of the dyspeptic derangements of the lithæmic subjects as wine and beer, but they are certainly often responsible for the formation of [p. 129]the dyscrasia and for perpetuating many most distressing ailments. Their more or less strict prohibition may constitute the essential point of treatment not only in controlling the progress of the constitutional vice, but in subduing some of the most rebellious lesions. It is important to observe that this prohibition sometimes involves abstinence from sweet and subacid fruits, in the raw as well as in the preserved state. Paroxysms of articular gout have been known to follow indulgence in strawberries, apples, watermelons, and grapes, and the cutaneous and mucous irritations which follow even the most moderate use of these fruits in some gouty persons are certainly not uncommon.

Next in order to the saccharine foods as the source of indigestion in gouty persons come the amylaceous aliments. These constitute, necessarily, so large an element in ordinary diet that the limitation of them in the dietary of gouty persons applies, in the majority of cases, only to their excessive use. This excessive use, however, is often observed. There is a popular prejudice in favor of this class of foods, and a corresponding prejudice against the too free indulgence in animal foods. The purely starchy aliments, such as potatoes and the preparations of corn and rice, and even those which contain a considerable portion of gluten, like wheat, oatmeal, and barley, often provoke in gouty subjects a great deal of mischievous and painful indigestion. This feeble capacity for the digestion of farinaceous foods is most frequently observed in the children of gouty parents, and especially in persons inclined to obesity, and in those whose occupations are sedentary and whose lives are passed for the most part in-doors, and they are least common in those whom necessity or pleasure leads to much active muscular exercise in the open air.

The fats are as a rule easily digested by gouty dyspeptics. This is a fortunate circumstance, for the reason that in the anæmia which is frequently one of the consequences of chronic gout the fatty foods are of inestimable value. In cases of persistent and rebellious lithæmia an exclusively milk diet constitutes a precious resource.

The succulent vegetables, such as tomatoes, cucumbers, cauliflower, cabbage, and the different varieties of salads, constitute for the gouty as well as the diabetic subject agreeable and wholesome additions to a diet from which the starchy and saccharine vegetables have to be largely excluded.