Finally, another difficulty that the dietitian always meets in diabetes is the tendency to constipation. It is a matter, however, of the greatest importance that the bowels be so regulated as to produce an evacuation each twenty-four hours.

Figs and prunes, mentioned above as effective in the control of constipation, are contraindicated in diabetes because of the large percentage of sugar which they contain. Recourse must, therefore, be had to another laxative food free from sugar. Rhubarb fills this requirement. Its intense acidity, however, will make it necessary to sweeten it, otherwise the patient may be unable to take it. Saccharin, which possesses a sweetening power about 300 times as intense as sugar, may be utilized in the place of sugar wherever it is desired to sweeten the food. Not over one and a half grains or one tenth of a gram should be used per day.

In arranging a course of diet for a diabetic case, the first thing to determine is the tolerance of the patient for carbohydrates. In order to make this determination it is necessary to reduce the patient to a diet absolutely free from carbohydrates for a period of about a week. In passing, it must be noted and emphasized that whenever recourse is had to a carbohydrate free diet, the transition from the usual diet to the diet free from carbohydrates should be a gradual one and should cover not less than a week's time. Begin the withdrawal of carbohydrates by a withdrawal of all sugars, as the cane sugar used in sweetening the fruits, cereals, etc. A day or two later drop out from the diet all fruits and vegetables which are rich in sugar. Follow this a couple of days later by dropping from the diet all vegetables and cereal products (except bread and potato) that contain starch. Finally, on the first day of the week in which the patient shall be on carbohydrate-free diet, cut out even the bread and potato. Van Noorden has devised a standard carbohydrate-free diet which has been very widely used, both in Europe and this country. This standard diet, as quoted from Osier, is as follows:

Breakfast

Tea or coffee, 6 ounces.

Lean meat (beefsteak, mutton chop, or ham), 4 ounces.

Eggs one or two.

Lunch

Cold roast beef, 6 ounces.

Celery, or cucumbers, or tomatoes with salad dressing.

Coffee, without milk or sugar, 2 ounces.

Whisky, 5 drams diluted with 13 ounces of water.

Dinner

Bouillon, 6 ounces.

Roast beef, 7 1/2 ounces.

Butter, 2 1/2 drams.

Green salad, 2 ounces.

Vinegar, 2 1/2 drams.

Olive oil, 5 drams, or spinach with mayonnaise, large portion.

Whisky, 5 drams diluted with 13 ounces water.

Supper, 9 P.M

Two eggs, raw or cooked.

In mild cases there will be a rapid diminution of sugar from the urine until it has completely disappeared. In severe cases there will still be a small amount of sugar, even after a week or two of this diet. After a week of the minimum appearance of sugar in the urine, which minimum, as stated above, should be only a trace, it is customary to begin to add starch to the diet. Sugar is kept strictly out of the diet, except such minute quantities as gain access through certain fruits and green vegetables. The first starch-containing foods reinstated in the diet are the last ones removed in preparing the patient for the carbohydrate-free diet - namely, bread and potato. A reasonable menu for a diabetic case would be the following:

Breakfast

Tea or coffee, 6 ounces.

Cream, 2 ounces.

Meat (beefsteak, mutton chops, or ham), 4 ounces.

Bread and butter, 2 slices.

Baked potato, with butter.

Lunch

Cold roast beef or cold boiled ham, 6 ounces. Bread and butter, two slices. Salad with mayonnaise dressing, egg garniture. Tea or coffee with cream.

Egg lemonade or egg orangeade.

Dinner

Clear soup of any kind.

Roast beef or mutton, or pork.

Potatoes, baked or boiled.

Olives, celery, or radishes.

Side dish of green vegetables.

Bread and butter.

Dessert, milk-egg custard sweetened with saccharin.

The reader will notice that no alcohol is introduced into this diet. Many prominent clinicians advise the use of alcohol in moderate quantities in this disease. Clinicians who do not use it in any other disease use it in diabetes because it seems to assist the patient in the digestion and absorption of the fats in such a diet, as these are given in considerable quantities. When alcohol is used it is best to use it in the form of whisky or brandy rather than in any of the light wines or beers. The sweet wines and beers contain dextrin or sugar, or both, while the sour wines contain acids which disturb the digestion. Experience shows that if alcohol is to be used at all it should be in the form of diluted brandy or whisky. While there can be no objection to the use of alcohol in the case of an elderly person who has been used to it, the advisability of introducing it with freedom into the dietary of young people not addicted to its use, and particularly in the milder cases, is strongly to be questioned. Fortunately the milder cases can partake rather freely of bread and potato and reduce the fats of their dietary to a quantity which can easily be taken by most people, particularly if presented to them in the form of butter, cream, and other generally relished fats.

Many attempts have been made to devise breads that contain as little starch as possible. And so gluten bread and various other similar foods have been devised, but experience shows that these patent substitutes for common wheat bread have no especial advantage and certainly have marked disadvantages in comparison with the common breads. The practice has, therefore, come to be: to revert to the use of common wheat bread and potatoes as a source of the small amount of carbohydrates that may be admitted into the diet, the carbohydrates in bread and potatoes being a form of starch which is much better borne than other carbohydrates. Furthermore, the substitutes for bread and potatoes, as, for example, the gluten bread, bran bread, Soya biscuits, almond cakes, etc., are usually very distasteful to the patient, and for that reason alone are contraindicated.