When I present the following bill-of-fare, I do not contradict what has just been said as to the impossibility of its general application. It is given only as a sample of the diet for one day in a special case. Whoever would undertake the direction of such a course of treatment must study special works dealing with the composition of nutritive materials, must make special culinary studies, and, as far as lies in his power, undertake investigations himself in the line of food prep aration. In the way of explanation I would refer the reader to Diet Tables I. and IV., given below. The dishes there given and other similar ones must serve as the main reliance in providing for the nourishment of the patient. Only in case of necessity may some of the dishes given in Table II. be made use of. In general the " cure" is the more easily carried out, the fewer are the concessions made; once a point is yielded there is no end to the argument and to entrea ties for permission to indulge in one or the other special dish.
It is strongly to be recommended that the physician who would assure the success of a strict dietetic course should himself try living for a time under the same regimen. He will thereby learn much which he can later apply to the advantage of his patient.
A Sample Bill of Fare.
The aim is to provide nourishment to the value of 2,500 calories, with the least possible ingestion of carbohydrates.
This amount of nourishment for the day, containing about 150 gm. albumin, 785 gin, fat, and SO gm. alcohol, represents iu round numbers the very considerable value of 2,900 calories. It therefore makes allowance for the possibility that all the dishes will not be taken in the prescribed quantity. If we omit the alcohol there will still remain a nutritive value of about 2,375 calories. As to the rules for computing the calorie values, see page 87.
During the strict dietary course the patient had better lead a quiet life, avoiding society and any intellectual strain or exciting reading, and limiting his bodily exercise to a walk of an hour or an hour and a half duration. It is advisable also that be should be in the open air as much as possible, sitting on the veranda, taking his daily exercise in the garden, and sleeping with open windows. The use of Carlsbad or other similar mineral waters is to be discontinued. As a drink or to dilute the wine any indifferent carbonated water may be taken in desired amount. Any strict bath treatment is to be avoided. A warm bath twice a week and daily spongings with moderately cold water are advisable.
b. The Diet in the Intervals.—At the end of this period of "strict diet" bread should be given in gradually increasing quantities to de termine whether the patient's limit of tolerance is essentially raised.
If the tolerance is much greater (which it seldom is), carbohydrates may be given with a freer hand and a dietary established somewhat after the regulations applicable to the milder forms of glycosuria in young people. Ordinarily more restrictions are called for than in those cases, and these are to be effected in the following way : It is immaterial whether glycosuria returns or not under this diet or how intense it is, at least as much carbohydrate is to be allowed in the clay, in addition to the traces always present in meat and green vegetables, as is contained in 120 grams (4 ounces) of good wheat bread (66 gin. carbohydrate). This is the average amount permissi ble in most cases ; only exceptionally, when careful observation for several days shows that glycosuria is absent or that less than 10 gm. sugar is excreted in the twenty-four hours, may as much as 150 grams of wheat bread be allowed. In order to assure an average calorie value of 2,500 (see p. 134) the ingestion of a certain quantity of fat must be absolutely insisted upon (p. 153). As in these cases, in dis tinction to the milder forms, milk is not included in the fixed dietary rule (see the section on Milk-cure, below), and as the body derives little benefit from carbohydrate as a food, the fat must be prescribed iu greater quantity and under another form. There is no great diffi culty in providing a suitable quantity of fat in palatable form, if the physician will devote a little thought to the matter and if the patient can have his food specially prepared. Of course special directions must be given as to what dishes are allowable and what not, and in what amounts flour, sugar, starchy vegetables, etc., are to be per mitted (see below). If under these favorable circumstances the rule is adhered to that every dish must contain as much fat as it can, and yet be palatable, in the form of butter, cream, bacon, olive oil, yolk of egg, marrow, etc., the patient will receive in this way from 120 to 150 grams of fat, having a value of from 1,100 to 1,400 calories, a clay. In addition there is the butter which he puts on his bread and pota toes, amounting to at least 40 grams a day, and containing 35 grams of fat with a calorie value of 325. If the diabetic is further directed to drink at least a pint of light or moderately heavy wine and to take a small glass of cognac or old whiskey after any especially fatty food, he will easily reach an amount of 40 grams of alcohol a day, repre senting a further value of 280 calories. In this way we are assured of the daily ingestion of food to the value of 1,700 to 2,000 calories. The necessary remainder will be furnished by the proteids and in a small measure also by the carbohydrates.