60 gin. butter (with bread, bread and cheese, and potatoes)-480 calories.
2 eggs-150 calories.
10 gm. olive oil (with salad, cucumbers, etc.)-90 calories. 30 gm. fatty cheese-115 calories.
1 litre of milk (fresh or sour)-590 calories.
30 gm. alcohol-210 calories.
This amount of nourishment assures to the organism an energy equivalent of about 1,600 calories. If the patient, while obeying the above-given directions as to carbohydrates, consults his own taste as to the rest of his food, the amount will always be sufficient, unless there is an extraordinary degree of anorexia, to bring the total value of available food to the required 2,500 calories or more.
As before mentioned the diet in this form of the disease must be so ordered that the excretion of sugar is either nil or very insignifi cant in amount. To obtain this result and at the same time to main tain the nutritive value of the food to the desired height is most difficult in practice in these forms of diabetes—often more difficult, indeed, than in the severer forms. For most of these patients do not feel sick at all; they scarcely credit the physician when he says that they need a special diet; they are greatly inclined to excesses in eating and drinking, and are often prevented by their social position and their calling, as well as their desire for companionship at home and elsewhere, from giving the necessary attention to their diet as regards quantity and quality. It is often a difficult task for the physician to keep the patient's will-power firm and to hold him in the middle path as far removed from careless neglect of necessary precautions as from discouragement and hypochondriasis.
b. General Directions.—As regards the management of the case in other respects enough has already been said in the appropriate sections (especially in that on Neurogenous Diabetes, pp. 126 and 142). But I desire to give prominence to the following points meet ing the special indications present in the cases under consideration : Care that there shall be regular mental employment as well as regular muscular exercise (as regards the use of the latter for in creasing the tolerance for carbohydrates, see p. 143). Caution against excess in both these directions.
Caution against excess in the use of alcohol, tobacco, tea, and coffee.
As regards mineral-water cures, the alkaline muriatic waters fre quently answer better than those containing sulphur. The first are to be avoided in proportion as nervous irritability and a neurasthenic condition form a prominent feature in the morbid picture. Although
the alkaline muriatic springs are not so distinctly prejudicial to pa tients of this kind as are the waters of Carlsbad, Marienbad, and the like, still the sufferers are often much more markedly benefited by being sent for the warm summer months to some subalpine resort with an elevation of 800 to 1600 metres (2,500 to 5,000 feet). The stay in such a resort may be taken advantage of by patients with a slight degree of glycosuria for the institution of a milk-cure. Experience has shown that milk is taken in large quantities much more readily in the mountains than at home. Three litres of milk may without difficulty be added each day to the diet with no fear that not enough other food will be taken. During the milk-cure the patient should avoid all starchy and saccharine food, including bread and potatoes, and eat only so much farinaceous matter as may be needed in the preparation of the meats and vegetables to make them palatable. Three litres of milk yield about 1,800 calories ; 40 grams of alcohol, which is best taken in the form of cognac, cherry brandy, or the like, added to the milk or drunk after it, yield 280 calories more. With a normal appetite, which is seldom wanting in the mountains, the meat, fish, eggs, well-buttered vegetables, etc., easily bring the total calorie value of the food up to 3,000 or more. The three litres of milk contain about 135 gm. milk sugar. In mild forms of glyco suria, which we are now considering, there will be no sugar, or at most only 15 or 20 grams a day, excreted in the urine during the continuance of the "cure." Even when in the first few days of the treatment a somewhat larger amount is excreted, it is not necessary to discontinue the cure, for the glycosuria almost invariably sinks in a short time, a result to which the favorable hygienic conditions and the mountain air doubtless contribute not a little. Should the gly cosuria not diminish, the milk sugar evidently exerting an unfavor able influence upon it, we may still resort to kephyr, which is com paratively poor in milk sugar, a part of which (from one-third to one-half of the entire amount) is destroyed in the process of alcoholic fermentation. Kephyr shOuld not, however, be recommended except in those cases in which experience proves that milk is injurious. The organ of taste does not recommend kephyr to civilized people as a permanent beverage; it is a drink that cannot hide its barbaric origin.