The difficulty is greater if the food cannot be specially prepared for the diabetic. The dishes then come to the table prepared with much less fat, and we must take greater pains to see that the "iron rule" as to fat is adhered to. I would recommend the following pre scription concerning the addition of fatty substances to the diet, it being of course understood that they are subject to alteration as to quantity and quality in order to provide for variety and to meet in dividual indications: Batter: 100 grams (3 ounces) of butter (containing 85 grams of fat having a value of 800 calories) must be weighed out every morning for consumption through the day. The patient eats it as he will on bread, potatoes, vegetables, meat, fish, etc., either in solid form or melted, according to the nature of the food with which it is to be taken.
Vice Oil : 20 grams, a tablespoonful (with a value of 186 calories), should be taken on salad (lettuce, chicory, cress, cucumber, tomato, red cabbage, etc.). With that used in the preparation of mayonnaise dressing for salad, cold meat, fish, lobster, etc., the total amount will easily reach 40 or 50 grams in the day. In that case it may be possible to omit a portion of the butter or bacon.
Bacon : 20 grams (containing 15 grains of fat with a value of 140 calories) of either smoked or salt bacon, should be used in frying eggs, in the cooking of omelets, or in the preparation of various meat and vegetable dishes.
Eggs : 5 eggs are to be taken prepared in various ways; five me dium-sized hen's eggs contain about 35 grams albumin and 27 grams fat, and have therefore a value of 390 calories.
Alcohol: About 40 grams (an equivalent of 4 tablespoonfuls of brandy a day) under various forms, with a value of 280 calories.
By means of these articles the body will receive nutriment to the value of about 1,900 calories, of which more than 1,600 calories will be yielded by the fat. The ingestion of these considerable quantities of fat may, as T. have often convinced myself, be easily effected, and is not seriously contended against by either women or men who appre ciate the necessities of their disease and are inclined to yield to them.
Up to the present we have considered only the permissible quan tity of bread. as being the chief and inost important representative of carbohydrate foods, and the amount of absolutely necessary fat that is to be taken. The other articles of diet may be grouped under the following headings, easily comprehensible by the diabetic and by those who have to prepare his food: (1) Unconditionally Allowable Foods.—These are free from carbo hydrates or contain them only in very minute quantities. See Table I., below.
(2) Foods Permissible in Moderate Quantities.—These contain car bohydrate, but so little in proportion to the mass of the food that it need not be taken into account and calls for no compensation by lim iting the amount of bread permitted. Some of the foods in this group are proportionally richer in carbohydrates, but the absolute amount in which they are ingested is small. Examples of dishes in this category are given in Table II. Three or four of these arti cles, in the amounts given in the table, are to be selected for the patient each day, but the physician must use his own judgment in individual cases as to whether to allow a larger amount of each dish or a greater number of dishes either temporarily or permanently.
(3) Conditionally Allowable Foods.—These for the most part con tain a large proportion of carbohydrates. They should be taken in measured quantities, compensation being secured by reducing the usual allowance of bread. The relative value of these dishes, as com
pared with bread, is given in Table III.
(4) Especially Valuable Foods.—These are serviceable because of their large proportion of albumin and fat and their correspondingly high calorie value. Some of them contain small amounts of carbo hydrates. A list of them will be found in Table TV.
The dietetic rules just given are undoubtedly applicable for the most part to the longer intervals between the periods of strict diet. Both patient and cook soon learn from them to pay attention to the quality as well as the quantity of food. The patient should have as little as possible to do with the weighing and measuring of his food, and for this the cook must be made responsible. This can easily be done in every well-regulated household, although it de mands increased work and presupposes the exercise of loving watchful ness. It will also be necessary, in all but the mildest cases of glyco suria, to prepare certain dishes expressly for the patient.
The question of a milk diet demands a few words. From the. data given in Table III. it follows that, if desired, a portion of the allowance of bread may be replaced by milk,—for example, a litre of milk may be substituted for 50 grams of bread. Many patients ar& glad of this permission and avail themselves of it for long periods or permanently. But to the majority the remaining allowance of bread seems too small, especially when the gratification of a desire for ca riety demands a further curtailment of the permissible quantity. These difficulties may be considerably lessened if the patient is con tent to use aleuronat bread, which contains much less starch. The allowance of carbohydrates may then be apportioned as follows : 1 litre of milk, equivalent to 50 grams of bread.
100 grams of aleuronat bread, equivalent to 50 grams of bread. Other dishes selected from Table III., as for example: 90 grams of new potatoes, equivalent to 25 grains of bread; giv ing a total amount equivalent to 125 grams of bread.
At other times it may be advisable to give the total amount of permissible carbohydrates in the form of milk; for example, instead of 150 grains of bread the patient may drink three litres of milk a day, in which case the dishes from Tables I., II., and IV. only are to be allowed. Those "milk-cures" to which we have referred before in considering the treatment of the mild forms of glycosuria in young persons, are especially to be recommended in greatly weakened indi viduals and those suffering from grave complications. They should not be continued in general longer than three or four weeks at a time, and are best instituted during the patient's stay in the country or in the mountains.
General Considerations.—As regards the management of the case in other respects, the general rules laid down in a previous section (p. 142) are to be followed. It is to be remarked especially that these patients, even more than those suffering from mild forms of glycosuria, are to be guarded against energetic " cures" and over taxing of the bodily or mental strength. Long rests and freedom from business cares are to be taken several times a year. A moderate course of some alkaline sulphur water (Carlsbad) is often of great ad vantage and is best taken after a course of strict dieting. It has already been said that it is better to discontinue the use of mineral waters of this sort during such a course. For other considerations applicable to this class of cases see page 154.