408 PROCESSES INFERRED FROM DIRECT OBSERVATION 



In this dilemma the only feasible procedure is to take advantage of 

 the long-recognized fact that the tissues may be educated by habitude 

 to the proper utilization of carbohydrates, but the slightest overstrain 

 upon the carbohydrate-utilizing mechanism produces a directly con- 

 trary result and accelerates the downward course of the diabetic. This 

 is the foundation of "Allen's Paradoxical Law," namely, that "whereas 

 in normal individuals the more sugar is given the more is utilized, the 

 reverse is true in diabetes." The treatment suggested by Allen con- 

 sists essentially in freeing the urine from glucose by starvation, bearing 

 in mind, however, the fact that starvation increases acidosis and that 

 if the preceding acidosis was high the additional acidosis of too severe 

 or too prolonged starvation may precipitate Diabetic Coma. The 

 starvation-period is succeeded by a period in which proteins are 

 admitted to the diet. Carbohydrates are now admitted, at first in 

 very small, and then in gradually increasing amounts, until a tolerance 

 is built up. Fats are admitted last of all, and with great caution, the 

 allowance never being a large one. Patients treated in this way cannot 

 commit dietary indiscretions, but they may maintain a tolerably 

 normal and healthy existence for a number of years. Whether the 

 "expectation of life" of a diabetic may, by a systematic regimen of this 

 kind, be rendered equal to that of a normal individual of like age and 

 antecedents, cannot as yet be stated, for the treatment of diabetes 

 based upon a full realization of the part played by fats in the genesis 

 of fatal symptoms has only recently come into being, and statistics 

 are therefore not available. Furthermore the number of psychological 

 factors which enter into the successful treatment of any chronic 

 disease must be carefully borne in mind in adjudging the statistics 

 when they do become available. The physician may know very well 

 what ought to be done, but in practice he may rarely achieve it. The 

 fluctuating cooperation of attendants, and the fragmentary attention 

 of the busy practitioner to any individual case; the thousand personal 

 details of means, circumstances, behavior, temperament, and metabo- 

 lism, which render every individual case a separate problem which 

 differs from any other, these factors combine to detract from the 

 success of any method of treatment of a chronic disease-condition, 

 however theoretically perfect the method may chance to be. It is 

 probable, indeed, that to correctly evaluate any method of treatment of 

 a chronic condition we should look to the successful cases rather than 

 to the failures. The ideal means of attaining success would be, of course, 

 to educate the patient to become his own doctor. Unfortunately, 

 however, many patients are unteachable, and most physicians are bad 

 pedagogues. 



To revert to the questions of intermediate metabolism which render 

 the phenomenon of diabetes of such exceptional interest to the bio- 

 logical chemist; it appears very probable that /3-Hydroxybutyric Acid 

 is one of the normal intermediate steps in the oxidation of fats, just 

 as lactic acid is an intermediate step in the oxidation of carbohydrates, 



