Devonshire cream, which is liked by many, contains less than 2 per cent, of lactose and 65 per cent, of fat. It is made by keeping the milk in large pans at a gentle heat for many hours. The temperature should be much below boiling. Under the influence of prolonged heat the fat coalesces and rises more rapidly than otherwise. Buttermilk contains about 3.3 per cent, of lactose. Kumiss contains from 1.6 to 2.8 per cent, of lactose, and kephyr, 1.5 per cent. Milk may be permitted to diabetics, except when a very strict diet is prescribed. It usually contains 4 per cent, of fat, 4.5 per cent, of lactose, and 4 per cent, of protein. To some patients, however, it can be allowed only in small quantities, for a pint should contain an ounce and a half of milk-sugar, and certain individuals exhibit marked intolerance of this substance.

Several substitutes for milk have been devised. I suggest the following as much the easiest to prepare: gravity cream contains 16 per cent, of fat, approximately 3 per cent, of sugar, and the same of protein. If it be diluted four-fifths with water, it will contain approximately 3 per cent, of fat and 0.5 per cent, of sugar and protein. To the water with which it is diluted sufficient egg-albumen can be added to make the total amount of protein approximate that of normal milk. The mixture can be sweetened with saccharin or levulose. This will make an agreeable drink, rich in fat, containing also a small amount of albumin, and about one dram of milk-sugar to the pint of beverage.

All sugars do not seem to be equally harmful. The same can be said of starches. When glucose is eaten, it is most certain to appear at once in the urine of diabetics. Milk- and cane-sugar are somewhat better assimilated, and by most diabetics levulose can be taken in considerable quantity without harm. The latter, however, is too expensive to be used as a general substitute for cane-sugar. Saccharin is the most available sweetening agent, but must not be given in sufficient quantity to interfere with digestion. Honey must be forbidden, as must be cane- and grape-sugar.

Starch, although converted into sugar during digestion, is less certain than sugar to aggravate a glycosuria. Still, starch and foods containing it must be forbidden when a rigorous diabetic diet is prescribed, and it should always be limited when not forbidden. This makes it necessary to exclude from the diet of the diabetic, flour products (bread, cake, pastry, etc.), cereal foods, rice, cornstarch, potato starch, arrow-root, sago, tapioca, hominy, macaroni, vermicelli, and farina. The following tables will show the percentage of starch in many of the common flour products:

Numerous substitutes for flour products have been recommended. As bread is the most difficult of all articles of food for diabetics to abstain from, these substitutes are a comfort to them. But such articles must not be eaten freely, since most of them contain too much fat, nor are they long relished when taken steadily. They are also for the most part expensive. The following table shows the relative percentage of important ingredients in some of the breads:

Of these, the cocoanut flour, and the almond flour make the best substitutes for wheat bread, inasmuch as from them the carbohydrate present - sugar - can be almost entirely removed by raising bread with yeast, and from the last nearly as well by washing it with acidulated water. Commercial gluten bread contains half as much carbohydrate as wheat bread and sometimes more. It is less palatable and less safe to give than a limited amount of ordinary wheat breads. The bread made of nut flours should be used very moderately, for it contains so much fat that it is not readily digested. Moreover, patients tire of such breads after a few weeks. It is therefore well to shift from one nut flour to another, and to make a variety of bread, so that weariness of these preparations may be as long delayed as possible. The following receipt is recommended by O'Donnell as a substitute for home-made bread. It contains no starch or sugar, and will help to give variety to the diet: Beat six eggs thoroughly; add a teaspoonful of baking powder and a quarter as much of salt; again beat the eggs. Pour the mixture into hot waffle irons smeared with butter. Bake in a hot oven. Eat hot with butter or flavor with cheese or nuts.

Substitutes for home-made wheat bread should be used only while patients are upon a strict diet.

It has been shown repeatedly that many with mild diabetes can take one kind of starch in moderate quantities without detriment and often others of a more severe type can be habituated to one kind, so that it will be tolerated without aggravating the disease or even will permit the reduction of the sugar in the urine. Real improvement has been effected upon a diet of potatoes with plenty of butter and two or three eggs daily or meat broth. Von Noorden's oatmeal diet is a favorite, when a restricted protein-fat diet palls upon a patient or diacetic acid is demonstrated in the urine. It consists in taking a porridge made of oatmeal (about 200 to 250 grams), 100 grams of butter, and two or three eggs or equivalent of vegetable protein.1

1 Von Noorden prepares oatmeal for diabetics as follows; 250 grams of oatmeal are cooked for several hours in water, to which a little salt is added: 100 grams of butter are added while the porridge is cooking: 100 grams of egg albumen is added when the porridge is cool or the same amount of vegetable albumen while it is cooking. The whole of this is eaten in divided portions about every two hours during a day.