keep it reduced._

We have not found that the acetone and diacetic acid output behaves in
any constant manner during starvation; in some cases we have seen the
acetone bodies disappear, in others we have seen them appear when they
were not present before.

Their appearance is not necessarily a cause for alarm. The estimation
of the ammonia in the urine is of some value in determining the amount
of acidosis present, and this can readily be done by the simple
chemical method given below. If the 24-hourly ammonia output reaches
over 3 or 4 grams, it means that there is a good deal of
acidosis--anything below this is not remarkable. More exact methods of
determining the amount of acidosis are the determination of the ratio
between the total urinary nitrogen and the ammonia, the quantitation
of the acetone, diacetic acid and oxy-butyric acid excreted, and the
carbon dioxide tension of the alveolar air. These are rather
complicated for average clinical use, however.

When the patient is sugar-free he is put upon a diet of so-called "5%
vegetables," _i.e._ vegetables containing approximately 5%
carbohydrate. It is best to boil these vegetables three times, with
changes of water. In this way their carbohydrate content is reduced,
probably about one-half. A moderate amount of fat, in the form of
butter, can be given with this vegetable diet if desired. The amount
of carbohydrate in these green vegetables is not at all
inconsiderable, and if the patient eats as much as he desires, it is
possible for him to have an intake of 25 or 30 grams, which is
altogether too much; the first day after starvation the carbohydrate
intake should not be over 15 grams. Tables No. 1 and No. 2 represent
these vegetable diets. The patient is usually kept on diet 1 or 2 for
one day, or if the case is a particularly severe one, for two days.
The day after the vegetable day, the protein and fat are raised, the
carbohydrate being left at the same figure (diets 2, 3 and 4). No
absolute rule can be laid down for the length of time for a patient to
remain on one diet, but in general we do not give the very low diets
such as 2, 3 and 4, for more than a day or two at a time. _The diet
should be raised very gradually_, and it is not well to raise the
protein and carbohydrate at the same time, for it is important to know
which of the two is causing the more trouble. The protein intake may
perhaps be raised more rapidly than the carbohydrate, but an excess o