The best means of determining the amount of carbohydrate that may be allowed is by the addition of milk to the daily bill of fare. The standard diet (see p. 76) is first increased by the addition of one litre of milk a day, and then it is ascertained how much starch (in the form of bread) can be added to the food without giving rise to glycosuria. If the case is really a "mild" one, the amount of per missible starch ought to be from 60 to 100 grams. The regulations concerning the ingestion of carbohydrates and the general institution of the dietary will vary in different cases. We will first consider the matter of carbohydrates.
In many cases, especially young people who are obliged to eat in restaurants, it is advisable for the sake of simplicity to forbid the use of all articles containing carbohydrate except bread and potatoes; these are sugar, sweetmeats, pastry, sweet stewed fruits, preserves, sweet jellies, thick soups, farinaceous dishes, maccaroni, rice, beans, peas, and the like, and sweet wines. On the other hand, fresh vege tables and fresh fruits in moderate quantities may be allowed. In this respect the dietary is much the same as that prescribed in mild forms of glycosuria occurring in elderly persons. But it differs from the latter in that there must be a limit in the consumption of bread and potatoes, to be determined by the ascertained tolerance and by individual peculiarities, beyond which the patient cannot go; say, on an average, 100 gm. bread and 150 gm. potatoes. The patients soon learn, after having weighed the portions once or twice, to estimate by the eye the amount allowed them.
Other patients are not content with bread in all varieties, potatoes, vegetables and fruit; they want to vary the form of carbohydrate, and especially they long for farinaceous foods and sweets. There is nothing in the way of yielding to this desire, but the patients must be instructed how to order the change ; they must be shown how to omit a portion of the bread or potatoes allowed them and to substitute therefor an equivalent from the dishes given in Diet Table III. (see below). This is somewhat circumstantial, and demands a certain amount of intelligence on the part of the patient and careful watch fulness on the part of the family.
The prescriptions thus far have been essentially of a negative nature. But the question of the dietetic management of these cases is not exhausted in simple negation. This is a point that is often
forgotten to the patient's detriment. In view of the restriction as to carbohydrates it is 'much more important here than in the case of elderly patients to maintain the calorie values of the food. We have to do with individuals who have no fat to consume or at any rate cannot afford to lose much fat, and also with persons in whom the metabolic changes are much more active than they are in the elderly. The reduction of carbohydrates leads only too readily to an involun tary reduction in the ingestion of fat. It is seldom sufficient to rest content with generalizing to the patient concerning the great nutritive significance of fat; the physician must have a certain guarantee that there is a sufficient amount of nourishment, and especially of fat, taken. I therefore make it an iron rule that a certain fixed quantity of fatty food is to be included in the daily dietary. This necessary daily amount may be taken as desired in divided portions with the different meals.
Only in the case of milk, which I always prescribe for this class of patients, do I lay down the definite rule of which experience has of ten proved the value, that one-half litre (one pint) is to be taken in the morning before rising and another half litre in the evening at bed time; this amount should not be swallowed at once but rather sipped slowly, at least twenty minutes being taken in its consumption. Many prefer sour milk, kephyr, or kumyss to fresh milk, and there is no objection to it. I consider the drinking of a litre of milk a clay of great value in these cases. Patients often say that they can not take milk, but that is purely imagination; except in the case of those sufferin gfrom certain diseases of the stomach, intestines, or peritoneum, in which diseases a temporary abstinence from all food is demanded, there are almost no people who do not bear milk well or who cannot accustom themselves to its use.
The amount of fat which is to be taken under this "iron rule" varies in the individual cases from 80 to 100 grams. Alcoholic bever ages, to the daily amount of at least 30 grams of alcohol, may be added in order to economize in fat. I would recommend the follow ing as the definite quantity of fat-containing foods which must abso lutely be taken in the twenty-four hours.