. > UNIVERSITY of CALIFORira AT LOS ANGELES UBRARY / ,- 0CT28 2921 li'i' ' PRACTICAL DIETETICS IVITH SPECIAL REFERENCE TO DIET IN DISEASE BY W. OILMAN THOMPSON, M. D. PROFESSOR OF MEDICINE IN THE CORNELL UNIVERSITY MEDICAL COLLEGE, NEW YORK VISITING PHYSICIAN TO THE PRESBYTERIAN AND BELLEVUE HOSPITALS 0711 " Good diet with wisdom best comforteth men " TUSSER (1520) NEW YORK D. APPLETON AND COMPANY 1900 I0TI\ Copyright, 1895, By D. APPLETON AND COMPANY. T 5^ ? INTRODUCTION. The subject of the dietetic treatment of disease has not received the attention in medical literature which it deserves, and it is to be regretted that in the curriculum of medical colleges it is either wholly neglected or is disposed of in one or two brief lectures at the end of a course in general therapeutics. Upon examining the stand- ard treatises upon the Theory and Practice of Medicine, as well as monographs upon important diseases, such as those of the circula- tion, nervous system, and skin, one cannot fail to be impressed with the meagre notice given to the necessity of feeding patients prop- erly, and the subject is usually dismissed with such brief and in- definite phrases as "The value of nutritious diet requires mere mention," " A proper but restricted diet is recommended," and favourite, if not convincing, expressions are, " The patient should be carefully fed," and " General dietetic treatment is of primary im- portance." With such vague directions the dieting must indeed be very "general." In many excellent works upon food and dietetics the space de- voted to the practical application of dietetics to disease is compara- tively insignificant, and much less emphasis is given to this matter in hospitals and in the training of nurses than is demanded in the interests of medical science. A writer of wide experience in practical dietetics, Mrs. E. H. Richards, says : " At present there are comparatively few persons who are called upon to feed the sick to whom a glass of milk or a pound of beef represent any definite amount of food materials. Still fewer who can tell how much food value a glass of lemon jelly or wine whey represents, and yet the adult patient is dependent upon the attendant even more than the week-old infant for the requisite nutrition." The present volume has been prepared with the view of in some iv INTRODUCTION. measure making good these deficiencies by furnishing a text-book in which the practitioner of medicine may find detailed the appro- priate diet for each disease which is at all influenced by right feeding. Quite as much depends upon the suitable preparation of food as upon the selection and limitation of the food itself, and it has there- fore been thought advisable to include a general account of the composition and uses of foods, and the changes which may be pro- duced in them by cooking and other processes. In this first portion of the work, however, the practical application of such knowledge to the feeding of the sick has been constantly emphasised rather than unnecessary scientific detail. The reader will also find a discussion of representative hospital dietaries, the official dietaries of Government institutions, and sec- tions upon the proper feeding of infants and children. Numerous cross references and a complete index have been added to avoid un- due repetition. Bennett wrote, as long ago as 1858: "Of all the means of cure at our disposal, attention to the quantity and quality of the ingesta is by far the most powerful." While fully concurring in this view, that appropriate dieting is often more needed than medication, I distinctly disclaim the advocacy of any special dietetic system as a cure-all, as well as the specific influence of any one food in the gen- eral treatment of disease. It cannot be expected that the experience of a single individual should cover so extensive a ground as that which embraces the uses or application of all foods, and I have therefore impartially introduced the views of others, especially where, as in such diseases as gout, diabetes, and obesity, opposing dietetic theories are held by clinicians of extensive experience and authority. Due acknowledgment of these references is made in the text, but the admirable researches upon foods of our own Govern- ment, found in the published reports of the Bureau of Agriculture and of the Commission to the Paris Universal Exposition of 1889, and at the Columbian Exposition of 1893, are especially to be com- W. Oilman Thompson. May a8, tSgS- CONTENTS Introduction PART I. FOODS AND FOOD PREPARATIONS. Elementary composition of foods I Food classification ............. 4 Force production. Energy from food 7 Force-producing value of the different classes of foods 15 I. Water 15 II. Salts 16 III. Proteids, carbohydrates, and fats 16 Stimulating foods 18 Economic value of foods 19 Nutrition .............. 22 Animal and vegetable foods compared . . . ' . . . . .22 Vegetarianism 28 The classes of foods . . . . , 30 I. Water 30 Uses of water in the body 31 Purity of water 31 Varieties of drinking water .......... 32 Hard and soft water 32 Rain water 32 River water ............. 33 Distilled water ............ 33 Filtered water 33 Boiled water 33 Special dietetic uses of water 34 Excess of water 34 Deprivation of water. Water starvation 35 Thirst 36 Temperature of drinking water 37 II. Salts 37 Varieties of salts 37 Uses of salts in foods 38 Excess of salt 38 Deprivation of salt 38 Sodium salts 39 Potassium salts 40 Calcium salts 40 V yi CONTENTS. PAGE Phosphorus 40 Sulphur 41 Iron 41 Vegetable acids -4^ III. Animal foods. Milk 41 Exclusive milk diet 42 " Milk cure " 44 Chemical composition of milk 44 Fat 45 Lactose 45 Casein and albumin 45 Varieties of milk 46 Cow's milk . . . . . . . . . . . .46 Human milk 46 Drugs in human milk 48 Goat's milk . .49 Ass's milk 49 Mare's milk . . . . .49 Milk analysis 49 Reaction, colour, taste, odour . . 49 Estimation of solids 49 Estimation of fat 50 Estimation of lactose . -SO Estimation of albuminoids 50 Milk adulteration and impurities 51 Addition of water . . 52 Addition of colouring matter 52 Addition of preservatives 53 Addition of thickening substances 53 Milk contamination by the cow's food ........ 53 Contamination by the cow's condition .53 Contamination by the cow's disease germs 54 Contamination by extraneous disease germs . . . . . -55 Souring and decomposition v. 56 Absorption of bad odours 57 Prophylaxis against milk infection 57 Uses of milk 58 Milk digestion 60 Normal (Rennin) 60 Abnormal 61 Adaptation of milk for the sick 62 Methods of altering the taste of milk 63 Methods of improving the digestibility of milk 64 Skimming 64 Boiling 64 Dilution with water 65 Dilution with alkaline and aerated waters 65 Dilution with amylaceous foods 66 Addition of alkalies, acid, and other substances 66 Methods of predigestion of milk 67 Peptonised milk 67 CONTENTS. vii PAGB Pancreatinised milk . . . 68 Koumiss ............. 69 " Koumiss cure "........... 71 Kefir 72 Matzoon 73 Methods of sterilisation and preservation of milk ..... 73 Sterilised milk ........... 73 Pasteurised milk ........... 75 " Humanised milk " .......... 77 Modified milk. Milk laboratories 78 Milk derivatives ............ 81 Condensed milk 81 Cream 82 Butter 84 Buttermilk 85 Cheese 86 Whey 88 Eggs 89 Raw eggs. Eggnog. Egg albumin 90 The cooking of eggs ........... 90 Preservation of eggs 92 Meats 92 Consumption of meat 92 Composition of meats ........... 93 Raw meats . 94 Digestibility of meats ........... 95 Beef 96 Beef preparations for the sick 96 Solid meat preparations .......... 97 Scraped meat 97 Beef meal 98 Beef jelly 98 Beef extracts 98 Beef blood 99 Beef peptonoids -99 Fluid meat preparations. Beef juice 100 Beef tea loi Bouillon ............ 102 Beef broth 103 Beef extracts ........... 103 Summary 104 Various meats 105 Beef tongue 105 Veal 105 Mutton 105 Lamb . 106 Venison 106 Pork 106 Ham and Bacon 106 Fowl 107 Came , 107 Viii CONTENTS. PAGE Animal viscera 107 Sweetbread ............. 107 Tripe, liver, kidneys, brains, blood 108 Isinglass, gelatin . . . . .108 Jellies .............. 109 Fish no Crustaceans ............. 112 Shellfish oysters, clams, mussels . , .112 Vegetable foods , . . . .113 Sugars 113 Sugars and the urine 114 Cane sugar, saccharose 114 Caramel 115 Molasses and treacle 116 Grape sugar, glucose .116 Milk sugar, lactose . 117 Mannite and levulose 117 Honey 117 Saccharin 117 Cereals and other starchy foods 1 18 Starchy foods in general 118 Bread making. Structure of the wheat kernel l2o Bran 120 Gluten . 121 Composition of bread . . . . . . . . . .121 Bread baking . 121 Development of carbonic-acid gas ........ 121 Yeast, leaven 122 Baking powders 123 Aerated bread 124 Varieties of bread stuffs 125 Wheaten flour and bread 126 Whole-meal bread ........... 127 Gluten bread 128 Rye bread 120 Biscuits, pastry, puddings, etc. . . . . . . . . 129 Prepared farinaceous foods " . . . 130 Buckwheat 135 Rye 136 Com 136 Rice 137 Barley 138 Oatmeal 139 Arrowroot 140 Tapioca, cassava 140 Sago 141 Iceland moss 141 Starchy foods for children , 141 Diastase, malt extracts, etc. . 142 Vegetable food 143 Legumes, peas, beans, lentils 145 CONTENTS. ix PAGE Roots and tubers 147 Potatoes 147 Beets 149 Succulent tubers 150 Green vegetables 151 Cabbages, etc. 151 Tomatoes, etc. 153 Fruits 156 Composition of fruits ........... 156 Uses and properties of fruits 158 Fruit ripening. . . . . . . . . . . .159 Fruit poisoning 159 When to eat fruit ..... ...... 159 Fruit soups 160 Dried fruits 160 Digestibility of fruits 160 Varieties of fruits 161 Lemons, limes, shaddocks 161 Oranges H 162 Apples 162 Pears, peaches, etc. .......... 163 Bananas ........ 163 Banana flour for invalids . . . . . . . . .164 Grapes ............. 166 Plums, prunes. ........... 167 Berries, strawberries, etc 168 Melons ............. 169 Figs and dates 169 Fungi 169 Poisonous fungi ............ 171 Lichen 171 Nuts 171 Fats and oils 172 Uses of fats 173 Digestibility of fats . . . 174 Animal fats 176 Bone marrow ............. 177 Vegetable fats and oils 178 Olive oil 178 Dietetic uses of fats and oils 179 Diseases in which fats are beneficial 179 Diseases in which fats are forbidden 179 Glycerin 180 Cod-liver oil 180 Chemical and physical properties 180 Dosage 181 Methods of administration 182 Substitutes 184 Uses ... 184 X CONTENTS. PART II. STIMULANTS, BEVERAGES, CONDIMENTS. p^^^ Stimulants and beverages uses 187 Alkaline and mineral waters, efTervescing waters 188 Tannin 191 Tea 192 Physiological and therapeutic action of tea . 193 Adulteration of tea . . . . > 196 Coffee 196 Physiological action of coffee . . . . 198 Adulteration of coffee 200 Relative value of coffee and tea 201 Cocoa 201 Cacao butter 202 Chocolate 204 Kola 205 Alcohol 205 General discussion of the value of alcohol 206 Physiological action 208 I. As a food 209 II. As a stimulant 209 III. Action upon the muscles . 210 IV. Action upon the temperature 210 V. Action as a diuretic 211 VI. Action on mucous membranes 211 VII. Action upon gastric digestion 211 VIII. Alcohol absorption 212 IX. Alcohol elimination 213 X. Alcohol poisoning 213 XI. Alcohol and climate 213 Clinical uses of alcohol 214 I. As a tonic 214 2. . As a vascular and cardiac stimulant 214 3. Use in nervous diseases . . . .215 4. Use in fevers 216 Proper time for giving alcohol . . . .217 Selection of proper alcoholic beverage 218 Malt liquors 219 Beer 219 Beer brewing . 220 Ale 220 Porter, stout . 221 Wine 221 Composition ............. 221 General properties ............ 222 White wines . 223 Red wines 223 Varieties of wines 224 I. Strong dry wines . . . . . . . . . . . 224 II. Strong sweet wines 225 III. Aromatic wines 226 CONTENTS. xi / PAGE IV. Acid wines 226 V. Sparkling wines 226 VI. " Perfect " wines 227 VII. Rough wines 229 Liquors 229 Brandy, whisky, gin, rum 230 Therapeutic uses of liquors 231 Adulteration of liquors and wines ......... 231 Liqueurs .............. 232 Cider 232 Condiments and spices . 233 Properties, uses, harmful effects 233 Varieties 234 PART III. COOKING. FOOD PREPARATION AND PRESERVATION. THE QUANTITY OF FOOD REQUIRED. Cooking 238 Object of cooking food 238 Varieties of cooking ............ 239 1. Boiling 240 2. Stewing 242 3. Roasting ............. 243 4. Grilling 243 5. Frying 246 6. Braising 247 7. Baking 247 8. Steaming 247 Soups 248 Cooking of fish 248 Cooking of vegetables 248 Food concentration, Condensed food ......... 249 Drying, desiccation, extracts 249 Diet of concentrated foods . . . . . . . , . . .251 Food preservation 253 I. Drying 253 II. Smoking ............. 254 III. Salting 254 IV. Freezing 255 V. Refrigeration 256 VI. Sterilisation , . . . . ,..,.,. 256 VII. Exclusion of air. Canning 257 VIII. Antiseptic and preservative substances 259 Substitutes for food 260 Quantity of food required ,.......,,, 261 Starvation and inanition 274 Voluntary fasting 275 Symptoms of starvation 277 Treatment after starvation 281 Famine .,......,.,,,, 281 Improperly balanced ingredients of diet 281 Xii CONTENTS. PART IV. FOODS REQUIRED FOR SPECIAL CONDITIONS. PAGE Age and food 283 Food in childhood . . . . 283 Food in adult life 284 Food in old age . . . . . . 285 Individual size and food 289 Body weight and food 289 Sex and food 290 Diet and heredity 291 Diet and race 291 Climate and season and food 296 PART V. FOOD DIGESTION. CONDITIONS WHICH ESPECIALLY AFFECT DIGESTION. Hours for meals and order of taking food 299 Appetite 303 Abnormal cravings 304 Variety in diet 305 The nervous system and digestion . 307 Circulation and digestion 308 Temperature and digestion 308 Exercise and digestion 312 Rest and sleep and digestion 313 Sleep in relation to meals 314 Mental emotion and digestion .316 Food in the mouth 316 Food in the stomach 317 Quantity of gastric juice 318 Secretion of the gastric juice . ' . . . 319 Hydrochloric acid 320 Pepsin, albumoses, peptones 321 Peristalsis 322 Duration of gastric digestion of different foods 322 Digestion of proteids in the stomach 325 Abnormalities of gastric digestion 326 Hypersecretion 326 Hyperacidity 326 Absence of hydrochloric acid 326 Pyrosis 326 Food in the intestine . 326 Pancreatic juice 327 Bile 327 Digestion of fats 328 Intestinal gases 329 Artificial digestion 329 Predigestion of starches 330 Predigestion of proteids . . . . ....... 331 Food absorption . . 334 Elimination of food waste 335 CONTENTS. xiii PAGE The urine and food 336 Tobacco and food 337 Food equivalents 337 PART VI. THE GENERAL RELATION OF FOOD TO SPECIAL DISEASES. DISEASES WHICH ARE CAUSED BY DIETETIC ERRORS. The general relations of food to special diseases ....... 339 Diseases caused by dietetic errors. ......... 341 I. Insufficient food 342 II. Overeating and overdrinking . . . . . . . . . 342 III. Food in itself wholesome, but which is injurious because the ingredients are not properly balanced 344 IV. Food containing parasites or their embryos 344 Intestinal worms ............ 345 Trichiniasis 346 V. Food containing ptomaines . 350 Poisoning by meat or game . 351 Poisoning by milk, cream, ice cream, and cheese ...... 353 Poisoning by shellfish and fish 353 VI. Food containing other poisons than ptomaines . . . . . . 354 Grain poisoning ............ 355 Ergotism 355 Lathyrism . 355 Pellagra 356 VII. Food adulteration ........... 356 Pigments 357 Salicylic acid 358 Tin and lead poisoning ........... 358 VIII. Food containing micro-organisms ........ 360 Milk infection 360 Tubercular infection through milk and meat 360 Typhoid and cholera infection 361 Infection through oysters 362 Diphtheria and scarlatina .......... 363 Foot-and-mouth disease .......... 363 Food infection through flies 363 IX. Idiosyncrasies in regard to food. ........ 364 X. Alcohol poisoning. Alcoholism ......... 364 Delirium tremens 367 PART VII. ADMINISTRATION OF FOOD FOR THE SICK. Methods of feeding the sick 369 General rules ............. 369 The appetite 369 Regularity in feeding ........... 370 Quantity of food ..." 370 Details of serving food 370 Feeding helpless patients 372 Xiv CONTENTS. PAGE Sleep and feeding 373 Cleansing the mouth . 373 Disinfection of utensils 374 Feeding unconscious patients 374 Nutrient enemata 375 Conditions necessitating rectal feeding . . 375 Hunger and thirst during rectal feeding 376 Method of injection 377 Aids to retention 378 Temperature of injections .......... 378 Number of injections 378 Care of the rectum 379 Opium in enemata ............ 379 Substances available for rectal feeding 3S0 Prescriptions for food enemata ......... 382 Food suppositories , . . 382 Inunction foods , . . . . 382 Intravascular feeding 383 Hypodermic feeding ............ 383 Medicines and food , . . 383 Diet-kitchen outfit 386 Trained purveyors of food 386 PART VIII. DIET IN DISEASE. DIET IN INFECTIOUS DISEASES. Diet in fever in general 387 Pathological physiology of fever . 387 Dietetic treatment 389 Beverages in fevers 392 Alcohol as a food in fevers 393 Diet in convalescence from fevers ......... 395 Typhoid fever 397 Pathological physiology 397 Dietetic treatment 398 Milk diet 398 Substitutes for milk diet 400 Thirst 402 Alcohol 403 Relation of intestinal antisepsis to diet 404 Care of the mouth 405 Convalescence 406 Rules for feeding atypical cases 408 Typhoid fever in children 409 Typhus fever 410 Smallpox 410 Scarlet fever 411 Measles . 412 Mumps . 412 Whooping cough 413 Influenza 413 Diphtheria 414 CONTENTS. XV PAGE Intubation 416 Tracheotomy 417 Post-diphtheritic paralysis 418 Cerebro-spinal meningitis 418 Erysipelas 419 Cholera 420 Yellow fever 422 Pyaemia and septicaemia . 426 Malarial fevers 426 Tetanus 427 Rabies 428 Tuberculosis 428 General considerations 429 Diet in mild cases 434 Foods allowed in non-active cases without gastric catarrh .... 435 Diet in advanced cases 436 Milk diet 437 Suralimentation 438 Diet for forced feeding . 439 Aids to dietetic treatment 440 Diet " cures " for phthisis 440 DIET IN DISEASES OF THE RESPIRATORY SYSTEM. Laryngismus stridulus 441 Tubercular laryngitis 441 Haemorrhage of the lungs 442 Acute capillary bronchitis 443 Chronic bronchitis 443 Asthma 444 Emphysema " 445 Pneumonia 445 Broncho-pneumonia 447 Broncho-pneumonia in children . 448 Pleurisy 44^ Empyema 449 DIET IN DISEASES OF THE CIRCULATORY SYSTEM AND BLOOD. Diseases of the heart 45 Pathological physiology 450 Use of fluids 451 Dietetic treatment 45' Cardiac valvular disease in children 452 Dietetic treatment of the senile heart 453 Angina pectoris .......... 45^ Cardiac palpitation 45^ Arterial sclerosis 45^ Aneurism 45^ Tufnell's diet 457 Anaemia. Chlorosis .458 Pernicious anaemia 4^3 xvi CONTENTS. DIET IN DISEASES OF THE URINARY SYSTEM. PACK Modifications in the urine caused by food 463 Acute nephritis 464 Acute nephritis in children 466 Albuminuria. Functional albuminuria . 466 Chronic Bright's disease . 470 Milk diet . .471 Pyelitis 475 Oxaluria 475 Calculi, renal and vesical 476 Lithsemia. Uric-acid diathesis. Gravel 478 Gonorrhoea .............. 481 DIET IN DISEASES OF THE ALIMENTARY CANAL. Abnormal dentition 481 Catarrhal stomatitis 482 Tonsilitis and quinsy 482 Dysphagia 483 Stricture and carcinoma of the oesophagus ........ 484 Feeding through a gastric fistula 484 Foreign bodies swallowed 484 Indigestion and dyspepsia 485 Symptoms 485 Etiology. Idiosyncrasies 487 Examination of the stomach contents ........ 489 Test meals 490 Tests for hydrochloric acid 491 Hypersecretion . 493 Tests for pepsin and rennin 494 Test for motor power of stomach . . . 494 Test for absorptive power of stomach 495 Dietetic treatment of dyspepsia 496 Desirable foods 497 Beverages 498 Special systems of treatment 49S General rules for dyspeptics 499 Rules for special varieties of dyspepsia 500 Dyspepsia in children " . 501 Acute gastric catarrh 502 Gastric fever in children . 504 Chronic gastric catarrh 505 Pathological physiology ........... 505 Dietetic treatment . 506 Milk diet 506 Other diet 507 Convalescence 509 Hydrochloric acid 509 Chronic gastric catarrh in children .510 Dilatation of the stomach. Gastrectasia 511 Lavage 513 Massage 516 Electricity 517 CONTENTS. xvii PAGE Vomiting 518 Pathological physiology . .51S Dietetic treatment 519 Seasickness 5ig Vomiting of pregnancy 521 Ulcer of the stomach 522 Cancer of the stomach . 525 DIET IN DISEASES OF THE INTESTINES. Diarrhoea 529 Pathological physiology 529 Dietetic treatment 529 Diarrhoea in infants and young children 530 Dietetic causes 530 Examination of stools 532 Dietetic treatment 533 Entero-colitis in infants and children. Summer diarrhoea . , . . . 534 Cholera infantum or acute milk infection 535 Cholera morbus. Acute catarrhal enteritis in adults 536 Chronic enteritis in adults. Chronic intestinal catarrh. Chronic colitis . . 537 Chronic intestinal indigestion in children 538 Chronic gastro-intestinal catarrh. Chronic entero-colitis. Chronic diarrhoea in children 539 Simple atrophy. Marasmus 540 Mucous disease. Chronic pseudo-membranous gastro-enteritis. Membranous enteritis 541 Dysentery 543 Chronic dysentery 544 Acute intestinal obstruction . . 544 Chronic constipation 545 Physiology . . . -545 Pathological physiology 546 Dietetic treatment 548 Summary of the most useful articles of diet 550 Foods to be avoided 550 Aids to dietetic treatment 550 Constipation in infants and children 553 Foods recommended ............ 554 Foods forbidden 554 Hemorrhoids . . . 555 Appendicitis 55 Causation 555 Dietetic treatment . 55^ Acute j)eritonitis 55^ Chronic peritonitis 557 DIET IN DISEASES OF THE LIVER. Diet in liver diseases in general 557 "Biliousness" 557 Causation 557 Dietetic treatment 558 Directions for eating 5^ Xviii CONTENTS. PAGE Acute catarrhal inflammation of the gall ducts. Angiocholitis. Catarrhal jaundice 561 Cirrhosis 561 Dietetic treatment of cirrhosis without ascites 562 Ascites 562 Dietetic treatment of cirrhosis with ascites 563 Fatty liver 564 Amyloid liver 564 Syphilis of the liver 565 Abscess of the liver 565 Gallstones 565 Pathological physiolc^ 565 Dietetic treatment 567 Diet in pancreatic diseases 568 DIET IN DISEASES OF THE NERVOUS SYSTEM. Neuralgia 569 Causation 569 Dietetic treatment . . . . . . 569 Visceral neuralgia 571 Gastralgia 571 Enteralgia . 572 Hepatalgia 572 Migraine . . . . . 573 Neurasthenia . . . 574 Causation 5^4 General treatment 575 The " rest cure " 578 Weir Mitchell's diet 579 Playfair's diet 580 Leyden's diet 580 Keating's diet 581 Insomnia and disordered sleep 582 Vertigo 583 Chorea 583 Epilepsy 583 Beri-beri 585 Locomotor ataxia. 586 Apoplexy 586 Acute insanity. Melancholia. Primary dementia. Mania .... 587 Forced feeding 588 DIET IN SKIN DISEASES. Skin diseases which are caused by improper diet 591 General principles of dietetic treatment 592 Erythema. Urticaria 502 Acne Eczema . 593 594 Cases due to overeating 594 Typical diet for eczema 594 Cases due to insufficient food 595 Cases due to improper food 595 Eczema in nursing infants 596 CONTENTS. xix PAGE Eczema in children 5g7 Exfoliative dermatitis 597 Rosacea jgy Psoriasis 598 Pruritus 598 Furunculosis 598 DISEASES ESPECIALLY INFLUENCED BY DIET. Obesity (Polysarcia) 599 Causation 599 Dietetic treatment 601 Systems of Banting 603 Ebstein 604 Oertel 605 Schweninger ............. 6og Schleicher . 610 Germain S6e . 610 Weir Mitchell 610 Yeo 611 Dujardin-Beaumetz 612 Meat and hot-water treatment 612 System of Bouchard 613 System of Chambers 613 " Anti-fat " remedies 615 Diet for leanness 615 Rheumatism, acute 617 Chronic 618 Rheumatoid arthritis 6i3 Gout 619 Causation 619 Preventive treatment 621 Theory of dietetic treatment 622 Diet for the gouty diathesis and chronic gout 624 Beverages 628 Diabetes mellitus . 631 Causation 633 Relation to gout and other diseases 634 Physiological experiments . . . -635 The nervous system and diabetes ......... 638 The circulation and diabetes 639 Various theories ....... 639 Symptoms ^40 Course .......... ^44 Dietetic treatment 646 Foods allowed ^5 1 Foods forbidden "53 Substitutes for bread ^53 Substitutes for sugar "57 Beverages ^5^ Special diets ^59 Skimmed milk ^59 Ebstein's diet . . . . ' 660 xz CONTENTS. PAGE Diiring's diet 66i Naunyn's diet 6Ci Scrofula 662 Rhachitis (rickets) 664 Aids to dietetic treatment 667 Diet in scurvy 668 Causation .............. 668 Haemorrhagic purpura . . . . . 671 DIET IN MISCELLANEOUS DISEASES. Addison's disease 671 Osteomalacia. 672 Exophthalmic goitre . 672 Chronic lead poisoning ............ 672 Drug habits. Morphinism, etc 673 Dietetic complications arising from associated diseases 673 DIET FOR SURGICAL PATIENTS. Food and anaesthetics . . ... 674 Diet after anaesthesia , . . . 675 Surgical operations and injuries . 676 Laparotomy. Ovariotomy .......... 677 Surgical inflammation. Sepsis 678 PART IX. RATIONS. DIETARIES. Army and navy diets 680 The U. S. army rations 680 U. S. army ration in the field .......... 6S2 U. S. army travel ration ........... 683 Garrison ration for ten days 683 Foreign army rations 684 Navy rations 686 Diet in prisons ............. 688 U. S. army prison diet ........... 688 New York State Reformatory diet 690 Dietetic cures .......... Milk cure 694 Whey cure 697 Various ' ' cures " 698 Kneipp system 699 Fruit cures 690 Grape cure 699 Meat and hot-water cure 701 Dry cure 702 Schroth's method ............ 702 Athletic training 703 Dietary of the Yale boat crew 705 Dietary of the Yale football team 707 CONTENTS. xxi PAGE Diet and occupation 707 Brain workers ............. 708 Commercial life . . . 711 Travel .............. 712 Diet in pregnancy . . . . . . . . . . . .713 Diet for puerperal women 714 Selection of a wet nurse 716 Diet of a nursing mother or wet nurse . 717 Drugs in human milk 718 Food of infants 718 Size of the infant stomach 718 Overfeeding 719 Methods of feeding 719 Feeding by the mother or wet nurse ......... 719 Feeding by the bottle ........... 720 Mixed feeding ............. 724 Weaning 724 Artificial infant foods 729 Infant stools 730 Nursing bottles ............. 730 Care of infant's mouth 731 Weighing of infants * 731 Premature infants ............ 732 Food for young children ........... 732 Rules for feeding young children ......... 734 Dietaries for young children .......... 735 Teething and food ............ 739 Sleep and food 739 Diet for school children ........... 740 Hours for meals ............ 741 Hospital dietaries ............. 747 The New York Hospital 750 Presbyterian Hospital 751 Bellevue, Gouvemeur, Fordham, and Harlem Hospitals 755 Roosevelt Hospital 757 Johns Hopkins Hospital 758 Cook County Hospital 758 Liverpool Infirmary 758 New York Infirmary 758 New York State Hospital 759 Utica State Hospital for Insane 760 Dietaries of army hospitals 763 United States 763 British, Prussian 764 French 765 APPENDIX. Receipts for invalid food and beverages suitable for fevers and convalescence from acute illness 767 Beverages 767 Demulcent and nutritive 767 Diuretic and refrigerant 76S xxii CONTENTS. PACB Fluid beef preparations 769 Broths and soups 771 Solid meat preparations 772 Milk preparations ............. 773 Egg preparations 775 Farinaceous foods 777 Gelatin preparations 780 LIST OF ILLUSTRATIONS. Plate I. Milk laboratory Facing 78 " II. Animal fats (butter and butterine) Facing 84 " III. Starch granules (wheat, barley, rye, oats, corn, and rice) , Facing 118 " IV. Maize starch and wheat starch . . . . . . Facing 120 Section through wheat kernel . . . . . . . .120 Microscopic characters of wheat 120 " V. Rice starch . . ' Facing 138 " VI. Starch granules (marunta, potato, ginger, sago, peas, and beans) Facing 141 " VII. Bean starch and pea starch . . . . . . . Facing 146 " VIII. Potato starch Facing 148 " IX. Animal fats (beef fat and oleomargarine) .... Facing 172 Comparison of daily dietaries 692 Diet sheet . 754 PRACTICAL DIETETICS. PART I. FOODS AND FOOD PREPARATIONS. l Olli . ELEMENTARY COMPOSITION OF FOODS. Of the seventy-three chemical elements, thirteen enter uniformly into the composition of the body and ten more are occasionally found. Of all these, several exist in very small proportion and their uses are unknown, several are found more abundantly but are not indispensable to life, and certain elements namely, carbon, hydrogen, oxygen, and nitrogen are necessary ingredients of the tissues of the body. These elements form compounds which, as they occur in the structure of the various tissues, have the following characteristics : First, although the elements are but few in number, their molecu- lar arrangement is very complex. Second, their compounds are comparatively unstable and are readily converted in the body or by chemical analysis into other forms. All food is composed of combinations of these simpler chemi- cal elements which, for the most part, must be subjected to altera- tion in the body itself to prepare it for assimilation by the tis- sues. The nutrition of the body, therefore, involves several distinct processes, viz. : 1. The secretion of digestive fluids and their action upon food in the alimentary canal. 2. The absorption of the ingredients of the food when digested into the blood and lymphatic vessels. 3. The assimilation of the absorbed nutritious products by the tissues. 4. The elimination of the waste material. The analysis given below exhibits admirably the relative predom- inance of the elements of which the human body is composed. 3 1 2 FOODS AND FOOD PREPARATIONS. Approximate Analysis of a Man (Moss). (Height, 5 feet 8 inches ; weight, 148 pounds.) Oxygen 92-4 pounds. Hydrogen 14.6 Carbon 31 -6 Nitrogen 4-6 Phosphorus 1-4 Calcium 2.8 Sulphur 0.24 " Chlorine 0.12 " Sodium 0.12 " Iron 0.02 " Potassium 0.34 " Magnesium 0.04 " Silica ? Fluorine 0.02 " Total 148.00 pounds. All these elements are necessarily derived from food plus the oxygen of the air which is breathed. The three predominating elements oxygen, hydrogen, and carbon are the great force producers of the body, although they are tissue formers as well, and to them must be added nitrogen, as serving in this double capacity, although its relation to tissue formation and re- newal is greater than its capacity for supplying energy. The common elements which enter into tissue formation chiefly and which bear no direct relation to the main sources of the force production in the body are chlorine, sulphur, phosphorus, iron, sodium, potassium, calcium, and magnesium in different combinations. Bone tissue, for example, contains about 50 per cent, of lime phosphate. If this substance is deficient in the food of the young growing infant, the bones are poorly developed and so soft that they yield to the strain of the weight of the body and become bent and out of shape. This constitutes one of the principal symptoms of rickets. Lack of iron salts in the food impoverishes the colouring matter of the red blood-corpuscles on which they depend for their power of carrying oxygen to the tissues, and anaemia and other disorders of deficient oxidation result. The lack of sufficient potash salts, especially potassium carbonate and chloride, is a factor in producing scurvy, and the condition is ag- gravated by the use of common salt (Nace). A diet of salt meat and starches may cause it with absence of potatoes and fresh fruit and vegetables. The lack of sodium chloride interferes with many of the functions of the body immediately concerned with nutrition, such as absorption (osmosis), secretion, etc., and alters the density and reactions of the different fluids. ELEMENTARY COMPOSITION OF FOODS. 3 These few illustrations suggest the diversity of roles exhibited by the elements and the need for a correctly balanced diet. In-order to determine what such a diet should consist of it is ne- cessary to study the value of the principal classes of foods in force production and in nutrient power or tissue building, but before pro- ceeding further with this discussion it will be advisable to adopt a sim- ple comprehensive classification of the foods in general use by man. The following table of analyses made by Dujardin-Beaumetz is quoted by Yeo to show the proportion of nitrogen present in differ- ent foods, and also the combustible carbon and hydrogen. " The hydrogen existing in the compound in excess of what is re- quired to form water with the oxygen present is calculated as carbon. It is only necessary to multiply the nitrogen by 6.5 to obtain the amount of dry proteids in 100 grammes of the fresh food substance : " Beef (uncooked) Roast beef. Calf's liver Foie-gras Sheep's kidneys Skate Cod, salted Herring, salted Herring, fresh Whiting Mackerel Sole Salmon Carp Oysters Lobster .(uncooked) Eggs Milk (cow's) Cheese (Brie) Cheese (Gruyfere) Cheese (Roquefort) Chocolate Wheat (hard southern, variable average).. Wheat (soft southern, variable average) . . Flour, white (Paris) Rye flour Winter barley Maize Buckwheat Rice Oatmeal Bread, white (Paris, thirty per cent water) Bread, brown (soldiers' rations formerly). Bread, brown (soldiers' rations at present) Bread from flour of hard wheat Potatoes Beans Haricots (dry) Lentils (dry) Peas (dry) C + H. Nitrogen. Combustibles cal- culated as carbon. 3-00 11.00 3.53 17.76 3 09 15.68 2.12 65-58 2.66 12.13 3-S3 12.25 5.02 16.00 311 23.00 1.83 21.00 2.41 9.00 3-74 19.26 1. 91 12.25 2.09 16.00 3-49 12.10 2.13 7.18 2.93 10.96 1.90 13-50 0.66 8.00 2.93 35.00 5.00 38.00 4.21 44-44 1.52 58.00 3.00 41.00 1. 81 39-00 1.64 38.50 1-75 41.00 1.90 40.00 1.70 44.00 2.20 42.50 1.80 41.00 1-95 44.00 1.08 29-50 1.07 28.00 1.20 30.00 2.20 31. CO 0.33 II 00 4.50 42 00 3.92 43-00 3-87 43- 00 3.66 44-00 FOODS AND FOOD PREPARATIONS. Carrots Mushrooms Figs (fresh) Figs (dry) Plums Coffee (infusion of ico grammes) Tea (infusion of lOO grammes). . Bacon Butter (fresh) Olive oil Beer, strong Wine Nitrogen. C + H. Combustibles cal- culated as carbon. 0.31 0.60 5-50 4-52 0.41 0.92 0.75 15-50 34-00 28.00 1. 10 9.00 1. 00 10.50 1.29 0.64 Trace 71.14 83.00 98.00 0.05 0.15 4-50 4.00 To estimate the equivalent chemical elements in the different classes of foods Parkes gives the following simple rules : 1. To obtain the amount of nitrogen in proteid foods, divide the quantity of food by 6.30. 2. To obtain the carbon in fat, multiply by 0.79. 3. To obtain the carbon in carbohydrate food, multiply by 0.444. 4. To obtain the carbon in proteid food, multiply by 0.535. Estimates vary somewhat as to the average quantity of the ele- ments carbon and nitrogen consumed per diem. In a general way it may be said that the consumption of carbon is 320 grammes, and that of nitrogen about 20 grammes. (See Quantity of Food.) FOOD CLASSIFICATION. Foods may be classified in various ways, according to 1. Their physical properties. 2. Their source. 3. Their composition. 4. The role which they perform in the animal body. Foods are classed in accordance with their general physical properties : First, into solid, semisolid, and liquid foods ; secondly, into fibrous, gelatinous, starchy, oleaginous, and albuminous foods. A subdivision sometimes used is that of the " complete " foods, such as eggs and milk which in a single article comprise all the necessary ingredients and elements to support life, and "incom- plete " foods, which are capable of maintaining life but a compara- tively short time. Foods may be classed as to> their source primarily into animal and vegetable foods. Animal foods consist of meats, fowl, fish, shell fish, and crusta- ceans, eggs, milk and its products, animal fats, gelatin. The vege- table foods are subdivided into cereals, vegetables proper, fruits, sugars, vegetable oils. FOOD CLASSIFICATION, .5 The simplest chemical classification possible is that advocated by- Baron von Liebig, who was the first to suggest a really scientific division of foods. He grouped all foods into two classes a. Nitrogenous, b. Non-nitrogenous. Each of these classes contains food materials derived from both the animal and vegetable kingdoms, although the majority of the animal substances belong to the nitrogenous, and the majority of vegetable substances to the non-nitrogenous group. a. The nitrogenous group von Liebig regarded as containing *' plastic " elements i. e., they are essentially " tissue builders " or "flesh formers." Nitrogenous foods are sometimes called " azotised foods " or " albuminoids " that is, substances resembling albumin. They con- sist chiefly of the four elements carbon, oxygen, hydrogen, and nitrogen, to which a small proportion of sulphur and phosphorus are usually joined. These elements for the most part are combined as some form of albumin. Nitrogenous or proteid foods are non-crystallisable, but coagula- ble, principally fluid or semisolid substances. They are fermenta- ble, and under some conditions will putrefy. The nitrogenous group comprises all forms of animal food, ex- cepting fats and glycogen. It includes, therefore, albumins and gela- tins. Its chief representatives are milk, eggs, crustaceans, fish, shell fish, flesh, and fowl. It also contains such nitrogenous substances as occur in the vegetable kingdom or ** vegetable albuminoids." b. The second or non-nitrogenous group von Liebig called " respiratory or calorifacient foods," because their function in the body is to furnish fuel or maintain animal heat. Since this original classification was suggested it has been established that the non- nitrogenous aliments supply energy as force, manifested through muscular action, hence they are also called " force producers," in distinction from the nitrogenous " tissue formers." This is a convenient distinction to adopt, but it must not be held too absolutely, for in emergencies the tissue builders are used as force producers and heat givers as well. The non-nitrogenous group contains strictly only the three ele- ments carbon, hydrogen, and oxygen, although various salts are mixed with both vegetable and animal foods. It includes all forms of vegetables and fruits, cereals, starches, sugars, gums, fats and oils, which are both animal and vegetable, and organic acids. Many vegetables, besides some fruits, contain considerable nitrogen. Many of the vegetables, and, in fact, all the starch granules, contain a certain proportion of nitrogenous material which is chiefly used in the formation of outside coverings for the purpose of giving protec- tion and affording firmness of resistance to a softer pulp within. 6 FOODS AND FOOD PREPARATIONS. Neither is animal food strictly nitrogenous, on account of its fat and glycogen, nor is vegetable food strictly non-nitrogenous, owing to its albuminoids and other forms of proteids, yet this classification is a very convenient and simple one which has met with general acceptance. It will be used in this book whenever a further degree of subdivision is not needed, but always with the understanding that it has only a general and not too literal application, and, unless otherwise distinctly specified, " nitrogenous food " will be understood to include animal food, and "non-nitrogenous food" to include vegetable food of all kinds, and vice versa. The following analyses by Hofmann and Parkes of several com- mon foods illustrate the mixed character of animal and vegetable foods and the difficulties of a purely chemical basis of classification : Table of Composition of Some Common Foods. (Hofmann.) Nitrogenous constituents. Fat. Carbo- hydrates. Salts. Total. Fat beef 51-4 89.4 27-3 16.6 7-7 45.6 5-5 0.8 0.9 0.4 68^9 81.9 91.2 3-0 5-1 30 0.6 0.7 100 100 Pea flour ICO Wheat 100 Rice 100 Table of Composition of Common Foods. (Abridged from Parkes.) Articles. Beefsteak Fat pork Smoked ham Whitefish Poultry White wheat in bread. . . . . Biscuit Oat meal Maize Macaroni Arrowroot Peas (dry) Potatoes Carrots Cabbages Butter Egg (i-io for shell) Cheese Milk (specific gravity, 1032), Cream Skimmed milk Sugar Water. Proteids. Fats. Carbo- hydrates. 74-4 20.5 3-5 39-0 9.8 48.9 27.8 24.0 36.5 78.0 18. 1 2.9 74.0 21.0 3-8. 40.0 8.0 1-5 49.2 8.0 15.6 1-3 73.4 I5-0 12.6 5-6 63.0 13-5 10. 6.7 64-5 I3-I 9.0 0.3 76.8 15-4 0.8 83.3 I5-0 22.0 2.0 53-0 74.0 2.0 0.16 21.0 85.0 1.6 0.25 8.4 91.0 1.8 5-0 5-8 6.0 0.3 91.0 73-5 13-5 II. 6 36.8 33-5 24-3 86.8 4.0 3-7 4.8 66.0 2.7 26.7 2.8 88.0 4.0 1.8 5-4 3-0 96- 5 Salts. FORCE PRODUCTION. ENERGY FROM FOOD. y Another classification is that of Prout, who grouped foods as follows : I. Aqueous. 2. Saccharine. 3. Oleaginous. 4. Albuminous. This arrangement fails to provide separate groups for salines, starches, and gelatinous substances. For the purpose of the present work, it is found convenient to subdivide foods more accurately, and the following classification is adopted : I. Water. II. Salts. III. Proteids (chiefly albumins and the allied gelatin). IV. Starches. V. Sugars. VI. Fats and oils. Some writers class oxygen in a separate division among foods. This seems hardly necessary, unless one is to make a separate divi- sion for hydrogen, and in fact for each element. The primary object of food classification is to obtain a practical working basis of subdivision, and the less complex this is made, the bet- ter. Further details of grouping belong to the refinements of physio- logical or organic chemistry, and are out of place in the present work. FORCE PRODUCTION. ENERGY FROM FOOD. The two ultimate uses of all food are to supply the body with materials for growth or renewal, and with energy or the capacity for_ doing work. The energy received in a latent form, stored in the various chemical combinations of foods, is liberated as kinetic or active energy in two chief forms : first, as heat ; second, as motion. Force is the manifestation of energy. The force developed by a healthy adult man at ordinary labour averages 3,400 foot tons per diem, a foot ton being the amount of force required to raise a weight of one ton through the height of one foot. Of this, somewhat less than one fifth is expended in motion, and somewhat more than four fifths, or 2,840 foot tons, in heat, which maintains the body tempera- ture at its normal average. A man weighing one hundred and fifty pounds or over one thirteenth of a ton obviously expends considerable energy in merely moving his own body about from place to place, aside from carrying any additional burden. The original force developed in the various functions of animal life which result in heat production and motion is chiefly obtained from the radiant heat of the sun stored by plants in the latent form of certain chemical compounds chiefly starches and sugars which, on being consumed as food by animals, furnish energy. 8 FOODS AND FOOD PREPARATIONS. A useful comparison may be made between the processes of nu- trition and development of energy from food in the human body and the energy derived from a steam engine and boiler. In both cases the main source of energy is oxidation, and principally of car- bon. In both cases the latent energy of the carbon liberated by oxidation processes is converted into heat and motion, forms of energy which bear a definite relation to one another. If a large part of the original latent energy is converted into heat, less will yield motion, and conversely. The proportion of these two forces to each other is in the case of the most perfectly constructed en- gine about one of motion to eight of heat ; whereas in the human body it was calculated by Helmholtz that the motion obtainable from a given amount of food may stand in relation to the heat in the proportion of one to five. Hence, as regards the production of work through motion, the human body is a more perfectly con- structed machine than the engine. Furthermore, after combustion of the carbon by the fires of the boiler a certain amount of waste matter or ash is produced. If this is allowed to accumulate, it obstructs the draught and interferes with active oxidation. In the human body, in like manner, the fuel or food consumed produces ashes, such as urea and other forms of waste material, which, if not removed, accumulate in the system and embarrass or retard the normal oxidation processes. The body possesses the additional power of sorting and modifying the fuel food which it receives so as to develop its energy to the best advantage in different organs. Whether elementary substances are burned outside of the body or oxidised within the body, the resulting products are the same. There can be no loss of matter, and there can be no loss of energy. The matter is simply changed in form by molecular rearrangement, the energy is converted from one type into another. The following simple experiment will illustrate this point : In a large covered glass jar place an ounce of alcohol in a small metal vessel. Also place in the jar a little lime water in a tumbler, and a thermometer. On Igniting the alcohol and allowing it to burn away completely, a film of aqueous vapour will accumulate on the surface of the jar, and a film of calcium carbonattf'Will form on the surface of the lime water pro- duced by the union of carbonic-acid gas with the lime water. The thermometer will indicate a rise in temperature of the air in the jar. An ounce of alcohol consumed as food will be similarly converted into carbonic-acid gas and water, and in this process the body heat will be increased, l^o substance is a good food unless it fulfils two conditions viz., easy assimilation and complete combustion.- The relative importance of the different food fuels should be considered. This is well summarised by Woodruff : " For instance, cut off the supply of oxygen, and death ensues in FORCE PRODUCTION. ENERGY FROM FOOD. o from one to ten minutes. If water is withheld, preventing the trans- portation of the fuel and oxygen to various parts of the body, death follows in about two to seven days or more, according to climate, exposure, and exercise. If the fuel itself is taken away, death follows in from seven to forty days or more, according to the amount of exposure that would abstract heat and the amount of work that would use up the energy already stored up in the body. If materials for the repair of tissues be excluded, death follows in a variable time, dependent upon the importance of the tissue that is being starved a time varying from a week if all nitrogen is excluded, to several months if the vegetable acids are excluded, or even to several years " if certain more obscure substances are withheld. / It still remains extremely difficult in the case of all foods to trace their final uses in the body and determine with any approach to accuracy what proportions of each furnish respectively energy, repair of tissue, and heat, for there are no more complex chemical processes known than those of tissue metabolism. In order to study the quantity of energy which may be derived from different varieties of food, a man or an animal may be placed in an apparatus known as a calorimeter. This apparatus is con- structed as follows: It consists of a large dpuble box surrounded by one or more jackets of non-conducting material, such as asbestos. The space between the double layers of the box is filled with water, and an animal is placed inside of the box and supplied with air at a uniform temperature. A measured quantity of food is given. All the excretions of the animal are then collected, carefully weighed, measured, and compared with the bulk of ingested food. The tem- perature of the water in the walls of the calorimeter will be found to have risen after some time, and the amount of heat developed in order to raise the temperature of this water through a certain num- ber of degrees is quickly calculated. In this manner may be estab- lished the relations of different diets to heat production. The unit of measurement used is the calorie, which is the amount of heat re- quired to raise i kilogramme of water from o to i C, which equals 1.53 foot tons. ' "" It is a more complex problem to establish the same relation in regard to motion, but it may be ascertained in a general way by feeding men or animals upon a known and measured quantity of food, and requiring them to perform muscular work. Elaborate investigations have been made with all the principal classes of foods in order to estimate their nutrient, their heat-pro- ducing, and their force-producing value, and many tables have been issued furnishing statistics of this character. It should be remem- bered that all this work is merely approximate, and that the liability to error in the various factors is considerable, but in a general way lO FOODS AND FOOD PREPARATIONS. the results are instructive, and they are certainly interesting and not altogether without practical application. The mere calculation of the nitrogen and carbon in a food does not at all show its force value in the body, unless it can at the same time be demonstrated that it is assimilable. Many substances appear to contain abundant food energy which in reality are not economical foods at all from the point of view of supplying all the needs of the body; thus beef fat is wholesome, but it contains no nitrogen for tissue building, and peas contain a large proportion of flesh formers as compared with heat givers. Wood pulp can be made to furnish cellulose and yield much energy, but it is worse than useless in the stomach of man, although some of the lower animals, like rodents, can digest it and make it available for nutrition. Sugar can be made from old rags in the laboratory, yet no stomach can deal with such material. Tables are now available for the calculation of the force value of rations for large bodies of men under different conditions, as, for example, soldiers in barracks or on the march, which are based upon- the principle of careful comparisons between the income and output of energy of the body. That is to say, a study of the force-producing value of different classes of foods, as obtained by chemical research in the laboratory, is carefully compared with the amount of waste matter which is eliminated by the system while a man is being fed upon a measured quantity of food and kept under uniform conditions as regards the amount of work performed. In this manner a check is established upon the theoretical calculations of food values as com- pared with their practical uses in maintaining the equilibrium of the body. Obviously these experiments require great care and system, and if they are to be made of intrinsic value they can only be con- ducted by expert physiological chemists upon persons who are willing to subject themselves from periods varying from several days to several weeks to conditions involving monotony of diet and ex- istence. For this reason the number of. actual experiments of this kind which have been made is comparatively small, and the conclusions drawn from them must be accepted with considerable allowance for possible error. A diet system to which a man may be willing to submit for a few weeks is by no means always that which w^ill prove best for him through a longer period, and a too rigid ap- plication of the rules established for the computation of the force value of foods yields much less practical results than the experience derived by those who actually control the commissary department with due regard to proper economy and variation in food, but entire- ly without resort to calculations of grammes of carbon, nitrogen, etc. A criticism has lately reached me from the inmates of a large girls' college, where the diet has for some time been experimentally FORCE PRODUCTION. ENERGY FROM FOOD. II regulated by an expert in such matters, that " if one half the time were bestowed upon properly serving and selecting the food that is given to computation of its force-producing value, the girls would have very much better appetites and digestion." On the other hand, it is easy to err if the dictates of hunger and capriciousness of appe- tite are allowed to wholly control diet. In the lower animals the instincts which these factors develop are very much safer guides than in the case of man. Nevertheless, the knowledge derived from experiments of the kind under discussion is certainly useful and instructive, when allow- ance is made for its relative value by taking into consideration the wide range of circumstances that will modify its application which occur in the organisation of different individuals, in their varying capacity for work, and in the condition of their external surroundings. With this word of explanation the following tables from different au- thors are reproduced. It will be observed that there are some few discrepancies among them, but the cause has been explained above. The following table of analyses, given by Captain C. E. Woodruff, M. D., Assistant Surgeon, United States Army, differs in some details from the preceding table by Parkes, (p. 6), and adds several in- gredients together with the calories. Percentage Composition of Edible Portions of Garrison Ration. Bacon, fat Beans Pork, salt and fat Sugar, ground Sugar, brown issue Flour Beef Potatoes Onions Oatmeal Cornmeal Canned apples Dried apples Tapioca or cornstarch . . . Butter Syrup Lard Rice Canned corn Canned tomatoes Macaroni and vermicelli. Milk, fresh Milk, condensed Peas Raisins Cheese . , Prunes Cabbage Water. 20 12 12 2 3 12 55-0 78.9 87.6 7.6 15-0 83.2 25.0 2.0 10.5 43-7 12.0 12.4 81.3 96.0 13. 1 14. 1 25.0 12.3 40.0 350 30.0 92.0 Protein. 8.00 23.10 0.90 11.00 17.10 2.10 1.4 15-10 9.20 0.20 0.90 1. 00 0.60 7-4 2.80 0.80 9.00 0.843 17.00 26.70 0.40 33.00 2.50 2.10 Fats. 69-5 2.0 82.8 I.O 27.0 O.I 0.3 7-1 3-8 0.4 1.8 85.0 83-4 0.4 I.I 0.4 0.3 0.802 II. o 1-7 22.0 *o!6 Carbo- hydrates. Salts. 2.5 59-2 3-1 4.2 97.8 0.2 96.5 0-5 74-9 0-5 .... 0.9 17.9 1.0 10. 1 0.6 68.2 2.0 70.6 1.4 15-9 0.3 71-5 1.4 97.8 0.2 0.5 3-0 55-0 2-3 4.0 79-4 0.4 13.2 0.6 2.5 0.3 76.8 0.8 1.069 0.164 44.00 3-0 56.40 2.9 24.00 0.6 5.00 50 12.0 0.6 5-5 I.I Energy, calones per lb. 3.080 I.615 3,510' 1,820 1.795 1,644 1,460 375 225 1,850 1,645 315 1,418 1,820 3-615 1,023 3,570 1,630 345 80 1,406 418 1,595 1,565 440 1,600 140 155 12 FOODS AND FOOD PREPARATIONS. Ham Apricots, canned. Barley Chocolate Sausage Oysters Salmon, canned.. Crabs Crackers Water. 41-5 50.0 12.0 41.2 87.1 63.6 Protein. 16.7 2.00 13-00 20.00 13-80 6.00 21.60 15-0 10.3 Fats. 39-1 2.7 50.0 42.8 1.2 13-4 I.O 9.4 Carbo- hydrates. 30.0 76.0 10. 3-7 70.5 Salts. 2.7 0.6 3-0 4.0 2.2 2.0 1.4 Enerf^, calories per lb. 1,960 460 1,800 2,650 2,065 230 965 526 1,900 Church furnishes the following table showing the number of tons which it is calculated could be raised through the height of one foot by the complete combustion of a single pound of each kind of food. In the body only about a fifth of this energy would develop work, the rest going into heat production : I pound beef fat raises 5,649 tons i foot high. oatmeal " 2,439 " gelatin ' 2,270 " " lean beef 885 " potatoes 618 " milk 390 " ground rice ' 2,330 " Standards for Daily Dietaries. (Compiled by Atwater.) Weights of nutrients and calories of energy (heat units) in nutrients required in food per day. I. Children to a year and a half. 2. Children of two to six years , 3. Children of six to fifteen years. 10. ir. 12. 13- 14. 15- 16. 17- Aged women Aged man Women at moderate work (Voit). . Man at moderate work (Voit) Man at hard work (Voit) Man with moderate exercise (Play- fair) Active labor (Playfair) Hard labor (Playfair) Women with light exercise (At- water) Man with light exercise (Atwater). Man at moderate work (Atwater). . Man at hard work (Atwater) Man at moderate work (Moleschott) Man at moderate work (Wolff).. . . NUTRIENTS. Protein. Fats. Carbo- hydrates. Total. Grammes. Grammes. Grammes. Grtns. 28 37 75 140 (20-36) (30-45) (60-90) 55 40 200 295 (36-70) (35-48) (100-250) 75 43 325 443 (70-80) (37-50) (250-400) 80 50 260 390 100 68 350 518 92 44 400 536 118 56 500 674 145 100 450 695 119 51 531 701 156 71 568 795 185 71 568 824 80 80 3C0 460 100 100 360 460 125 125 450 700 150 150 500 800 130 40 550 720 . 120 35 540 695 Potential energy. Calories. 767 1,418 2,041 1.859 2,477 2,426 3,055 3,370 3,139 3,629 3,748 2,300 2,820 3,520 4,060 3,160 3,032 FORCE PRODUCTION. ENERGY FROM FOOD, 13 Landois and Stirling give the following table, which differs some- what from the foregoing in the relative proportion of fats and starches. An adult doing a moderate amount of work takes in as food per diem C. H. N. 0. 120 grammes albumin, containing. . . . 90 " fats, containing 330 " starches, containing 64.18 70.20 146.82 8.60 10.26 20.33 18.88 28.34 9-54 162.85 281.20 39-19 18.88 200.73 Add 744.11 grammes O. from the air by respiration. " 2,818.00 " H0. " 32.00 " inorganic compounds (salts). The whole is equal to three kilogrammes and a half (seven pounds), i. e., about a twentieth of the body weight, so that about six per cent of the water, about six per cent of the fat, about one per cent of the albumin, and about 0.4 per cent of the salts of the body are daily transformed within the organism. An adult doing a moderate amount of work gives off in grammes : o. By respiration . , By perspiration By urine By faeces , Water. C. H. N. 660 1,700 128 248.8 2.6 9.8 20.0 3-3 3-0 ? 15^8 3-0 2,818 281.2 6.3 18.8 651-15 7.2 II. I 12.0 681.45 The following table is a fair average work ration in round num- bers, based on such data as those in the foregoing tables : Estimated Work Ration, Maximum and Minimum. (Mrs. E. H. Richards.) For one day. Proteid, grammes \ ^ c * \ 125 r at, grammes -j /t Carbohydrates, grammes ] ^lo Calories I 3.500 I 3.000 About thirty grammes of salts should be added to this (Landois). The bare subsistence ration is much less, as follows : Estimated Life Ration. (Mrs. E. H. Richards.) For one day, Proteid, grammes 75 Fat, grammes 40 Carbohydrates, grammes 325 Calories 2,000 14 FOODS AND FOOD PREPARATIONS. Prof. Egleston's standard of nutrition is high. He places the daily allowance of nutritive material at 700 grammes, divided as fol- lows: Carbohydrates, 400 grammes; fats, 150 grammes; proteid, 150 grammes; yielding in all, 3,650 calories. The average percentage of the different food classes needed to sustain a man in perfect health is thus given in the Kensington Mu- seum Handbook on Food : Percentage. Water 81.5 Albuminoids or flesh formers 3.9 Starches and sugars 10.6 Fat 3.0 Salt (NaCl) 0.7 Phosphates, potash salts, etc 0.3 An Ideal Ration with Solid Food. (Mrs. E. H. Richards.) AMOUNT. PROTEID. FAT. CARBOHYDRATES. Material. Grms. Oz. Grms. Oz. Grms. Oz. Grms. Oz. Calories. Bread 453-6 226.8 226.8 28.3 "3-4 453-6 28.3 14.17 16 8 8 I 4 16 I 31.75 34.02 12.52 6 60 3-63 18 14 0.14 1. 12 1.20 0.44 0.23 0.13 0.64 2.26 11-34 2.04 7-50 4.42 18.14 12.27 0.08 0.40 07 0.26 0.16 0.64 257.28 9.60 4.88 90.72 27.36 9.04 0-34 0.17 3-20 0.96 1,206.82 Meat 243 72 Oysters Breakfast cocoa. Milk 70.01 135-42 75-55 613.21 112. 17 118.62 Broth Sufifar Butter Total 106.80 57-97 .... 389.84 2,575-52 It will be observed that the totals are somewhat less in this diet than those of the preceding table, which was designed for a working man, who is developing more calories. 'Table of Energy estimated in Foot Tons instead of Calories (Yeo). Energy developed by one ounce of the following foods when oxidised in the body. Food Stuff. Beef (best quality), uncooked Meat (served to soldiers), uncooked Beef (fattened), uncooked Meat, cooked Corned beef (Chicago) Salt beef Salt pork Fat pork Dried bacon Smoked ham Whitefish Poultry Bread Wheat flour With usual per- One ounce centage of water. water-free. Foot tons. Foot tons. 48-5 199 57-8 243 96.0 280 102.6 240 124.0 217 52.0 138 71.6 166 202.0 336 292.3 346 179-6 267 44-3 209 50.7 204 87.5 147 123.6 146 FORCE-PRODUCING VALUE OF FOODS. 15 Food Stuff. Biscuit , Rice Oatmeal Maize , Macaroni Millet Arrowroot Peas (dried) Potatoes Carrots Cabbage Butter Eggs Cheese Milk (cow's), new . . Cream Skimmed milk Sugar Pemmican Ale (Bass's bottled) Stout (Guinness) . . . With usual per- One ounce centage of water. water-free. Foot tons. Foot tons. 173-3 189 126.5 141 130.0 154 132.0 160 122.7 146 125-9 149 116. 4 138 118. 9 151 33-0 141 14-3 137 13.0 158 344-5 367 67-3 265 149.9 245 26.9 225 109.2 365 20.4 181 126.4 128 270.1 293 30.0 260 41-5 360 FORCE-PRODUCING VALUE OF THE DIFFERENT CLASSES OF FOODS. I. Water. Estimated as a force producer within the body, water may be said to have comparatively little value. Much of the water which is either drunk or ingested in combination with foods passes through the body unchanged, and is eliminated from one or more of the excreting surfaces ; but some of it is undoubtedly altered or split up into elements which unite with other compounds. The nature of these processes is obscure, and as yet very little understood. It is believed also that a certain quantity of water is produced in the body by the union of oxygen and hydrogen which occurs incident to other chemical change, or by the liberation of water from more complex molecules. Water is entitled to rank as a food because it enters into the structural composition of all the tissues of the body, and, in fact, constitutes rather more than two thirds (70 per cent) of the entire body weight. Its importance is readily appreciated after it has been withheld from the diet for a short time, when striking physical and physiological alterations in the functions of the body occur. Yeo says that, " assuming the water-free food to be 23 ounces, and a man's weight to be 150 pounds, each pound weight of the body receives in twenty-four hours 0.15 ounce, or the whole body receives nearly a hundredth part of its own weight. But ordi- nary solid food contains usually between 50 and 60 per cent of water; and if we add this to the water-free solids, the total daily l6 FOODS AND FOOD PREPARATIONS. amount of so-called dry food (exclusive of liquids) is about 48 to 60 ounces. But from 50 to 80 ounces of water in the liquid form is usually taken in addition, and this would make the total supply of water equal 70 to 90 ounces, or half an ounce for each pound of body weight." II. Salts. The salts have practically no force producing power, but they are concerned in tissue formation to some extent, especially in the bones and teeth, where the lime and magnesium compounds are the most fixed of any in the body. Some of the compounds of sulphur and phosphorus which occur in meat and bran are undoubt- edly associated with the development of energy in the body, but the salts are already saturated and stable, and, although their functions as laboratory agents within the body are numerous, they may be left out of calculations of force-producing foods. III. Proteids, Carbohydrates, and Fats. It is easy to de- termine with accuracy the force value of a pound of albumin by chemical analysis, but it does not follow from this that the energy contained in it will all be developed in the body at exactly the right time or even within a sufficiently short period to enable the system to utilise it completely. Von Pettenkofer and Voit have shown that during the performance of hard labour the consumption of albumin remains practically the same as during rest, whereas fully three and a half times as much fat is consumed and the amount of carbohy- drates remains unaltered, the diet being abundant when due allow- ance is made for the influence of varying external conditions. Hence for hard labour, beef should not be increased so much as fats, pork, butter, oil, etc. The latter are good heat producers, and good foods for both nerves and muscles. The daily quantity of solid food con- sumed by an adult male at ordinary work will range between 50 and 60 ounces, and that of water drunk is about the same. The require- ments of severe labour, if continued, exceed this range, so that as much as 75 ounces of solid food may become necessary, and this should be mainly in the form of albuminates and fats. The standard diet for twenty-four hours for a healthy adult male at ordinary work should contain, in round numbers, 20 grammes of nitrogen (con- tained in 120 grammes of proteid) and 320 grammes of carbon, a proportion of i to 16, but, because the food is best taken in the form of a mixed diet, the proportion may be stated as one part of nitro- genous or animal food to three or three and one half of non-nitro- genous or vegetable food. Ordinary albuminous food yields, on the average, about 16 per cent of nitrogen. For an adult male the average consumption of nitrogen being 20 grammes per diem, the ordinary allowance for daily variation does not exceed 3 grammes on either side of this standard. For a man of average weight that is, 67 kilogrammes the daily allowance of FORCE-PRODUCING VALUE OF FOODS. 17 food ranges from 6 to 9 grains of carbon, and 0.25 to 0.36 grain of nitrogen per kilogramme of body weight. Those elementary foods which approach most nearly in composition the economical propor- tion of nitrogenous to non-nitrogenous material are cow's milk and wheat flour. In the former this proportion is one to three, in the latter one to four and a half. The question of the nutritive value of any fixed diet cannot be solely estimated from variations in the body weight, for the loss of water or of albumin may increase while fat is stored up. Neither can the quantity of food eaten be relied upon for this purpose, for from habit one man may eat more than another while doing the same work, and may eat more than he needs. Nor is it possible to deter- mine from the various excreta alone whether the body has had a suitable quantity of nourishment, for they are too constantly chang- ing, and "life will soon become extinct if the nutriment given be measured by the metabolism of starvation " (Bauer). A man in perfect health might easily lose weight upon the iden- tical diet which would enable an emaciated and feeble invalid to gain flesh. In convalescence from typhoid fever, for example, one often sees evidence of a daily gain in weight while the quantity of food is still far below that necessary to support a healthy man in vigour. The needs of the organism at any particular time must, therefore, be taken into account as well as the strength of the digestive organs in prescribing the quantity of food consumed. In making calculations for the quantity of food required by large numbers of persons under any conditions, somewhat more than the averages above stated should be always included in order to make allowance for variations in absorption and assimilation of the food by different individuals. (See Quantity of Food Required.) The carbohydrates are not as available for the repair and growth of the tissues as the fats, but by their oxidation they save tissue waste, and furnish both heat and muscle force. Bauer says: " The easy metabolism of the carbohydrates in the body must not be regarded as depending on their great affinity for oxygen ; its cause is to be sought far more in the properties of the animal tissues. . . . The action of the carbohydrates agrees in many respects with that of fat, since they are in like manner capa- ble of protecting from metabolism a certain amount of the cir- culating albumin and of assisting its transformation into organic albumin." But the destruction of carbohydrates in the body is very com- plete, even when eaten in excess, and herein they differ from the fats, "an excess of which in the food invariably produces an acces- sion of fat." From these and other statements made by Bauer he argues that probably the carbohydrates do not directly form fat in 4 1 8 FOODS AND FOOD PREPARATIONS, the body, but their well-known fattening action is, when eaten with albumin and fat, to spare the consumption of these latter substances, which are then converted into tissue fat. When a muscle contracts it is not the muscle tissue itself which is consumed, but its supply of glycogen. The candle wick is but very slowly burned so long as its supply of tallow does not fail, and so the muscle is spared while the carbohydrates furnish force. When a muscle is much used it increases in size, and needs more nitrogen to build new substance. Albumin burned in oxygen outside of the body is very completely oxidised, but after oxidation in the body, about one third of its sub- stance is excreted, imperfectly consumed, as urea. On the other hand, the consumption of some carbohydrates, such as alcohol and sugar, appears as complete within the body as it may be outside of it, and the amount of energy actually developed is identical with that which may be theoretically calculated. The statement is sometimes made that the compounds of carbon and hydrogen are slowly oxidised, and give a more continuous yield of energy than nitrogenous compounds, but with less powerful indi- vidual discharges. In other words, they are said to be good " main- tainers of energy." There are, however, many exceptions to this, like naphtha and benzine, and even the food alcohol. The proportion of nitrogenous or proteid compounds required is greatest where growth is active. Nitrogenous substances possess high potential and explosive energy, as illustrated by nitroglycerin and fulminating powder. Proteids are always present where the phenomena of life are exhibited, and bear a direct relation to their activity. STIMULATING FOODS. In the broadest sense all food is stimulating to the functional ac- tivities of the body ; but when the digestive and assimilative powers are lowered, less variety and less quantity of food can be tolerated, and foods that in health are never needed may become necessities; such foods, for example, are cod-liver oil and the various prepara- tions of meat, such as albumoses or peptones, meat juice, etc. Certain food substances have a distinctly stimulating action at all times. The various condiments possess a local action of this kind upon the alimentary organs, but not a general or systemic ac- tion. The latter stimulation, manifested especially upon the nerve- muscular apparatus, is derived from such substances as strong beef extracts, coffee, tea, and alcohol, all of which at times are of great service in the dietetic treatment of disease. ECONOMIC VALUE OF FOOD. lO ECONOMIC VALUE OF FOOD. It is not within the scope of this work to discuss the details of the economic value of foods, but brief reference to one or two facts will emphasize the importance of this topic. It is estimated that the actual annual cost of food production in the United States is at least three billion dollars, and the cost of production must be doubled in estimating the price paid by the con- sumer. Naturally, many attempts have been made to tabulate the cost of feeding large bodies of men employed by contract, or patients in hospitals and institutions. Some of these studies have been con- ducted with great care, but on a comparatively small scale, as in the case of the economic diets of the French factory operatives in Mas- sachusetts, the penny dinners furnished to London school children, and the researches made by Mrs. Richards and Miss Talbot upon pupils at the University of Chicago. Calculations upon a much larger scale are available as a basis for the supply of armies and navies. Further consideration of this topic will be found in the section upon Diet for the Army and Navy (page 680). The economic value of food is by no means to be estimated ex- clusively from its weight, and, as suggested by Williams, a pound of biscuit may contain more actual force-producing material than a pound of beefsteak, and yet the body may be able to assimilate more of the beefsteak and derive more energy therefrom ; and it is the chemical processes of Nature which convert such substances as grass, which are not assimilable by the human organism, into the flesh of the ox, which is readily digested by man. It is economical for contractors employing large bodies of men in manual labour to see that they are well fed, for much more work proportionately will then be got from them. Carbohydrates check albuminous waste, and, like fats, yield both heat and mechanical work ; hence good bread, sugar, and vegetables are all economical foods for the labourer. Unlike the other classes of foods, however, they do not produce brawn, and do not enter into the actual structure of the tissues to any great extent, although the carbohydrates may be found existing as glycogen in some of the tissues, like the muscles and liver. In general, they seem to be more easily metabolised than fats or proteids. The following tables give a fair conception of the economical value of common foods in relation to their waste residue and ca- pacity for producing work : Note. An admirable Digest of Metabolism Experiments has lately been pre- pared by W. O. Atwater and C. F. Langworthy, under the supervision of A. C. True, Director of the Office of Experiment Stations, and issued as Bulletin No. 45 of the United States Department of Agriculture, 1897. 20 FOODS AND FOOD PREPARATIONS, The Relative Value of Foods (Scammell). (The figures represent percentages.) Articles. Wheat Barley , Oats Northern com . Southern com.. Buckwheat . . . , Rye Beans Peas Lentils Rice Potatoes Sweet potatoes. Parsnips Turnips Carrots. Cabbage Cauliflower . . . , Cucumbers . . . . Milk of cow. . . . Milk, human.. . Veal Beef Lamb , Mutton Pork Chicken Codfish Trout Smelt Salmon Eels Herring Halibut Oysters Clam Lobster Eggs (white of), Eggs (yolk of). . Butter Artichoke Asparagus Bacon Carp Cheese Cherries Chocolate Cream Currants Dates (fresh) . . . Figs Ham Horseradish . . . Kidney Lard Liver As mate- rial for the muscles. As heat givers. 14.6 12.8 17.0 12.3 34-6 8.6 6.5 24 23 26 5 I 1.2 3.6 0.1 50 3.0 17-7 19.0 19.6 21.0 17-5 21.6 16.5 16.9 17.0 20.0 17.0 18.0 18.0 12.6 12.0 14.0 13.0 1.9 0.6 8.4 18.0 30.8 0.6 8.8 3-5 0.9 5-0 35-0 0.1 21.2 26.3 66.4 52.1 50.8 67.5 39-2 53-0 75-2 40.0 41.0 39-0 82.0 15.8 21.8 14-5 4.0 12.2 6.2 4,6 1-7 8.0 7.0 14.3 14.0 14-3 14.0 16.0 1.9 i.o 0.8 Very little Some fat Very little 29.8 100. o 19.0 5-4 62.5 0.8 28.0 21.0 88.0 4.5 6.8 73-7 57-9 32.0 4.8 0.9 100. o 3-9 As food for the brain and nerv- ous system. 1.6 4.2 3-0 I.I 4-1 1.8 2.5 1-5 0.5 0.9 2.9 1.0 0.5 1.0 0.8 1.0 0.5 1.0 0.5 2.3 2.0 2.2 2.0 2.2 2.8 2.5 4-3 5 or 6 6 or 7 3 or 4 4 or 5 3 or 4 0.2 2 or 3 5 or 6 2.8 2.0 "I'.k 0.4 0.5 2.9 4-7 1.0 1.8 0.3 Water. 14.0 3- 14.0 16. 13.6 16. 14.0 5- 14.0 8. 14.2 22. 13.5 4- 14.8 17- 14. 1 19. 14.0 19. 9.0 3- 74.8 7. 67.5 6. 79.4 3- 90.4 3- 82.5 3. 91-3 0. 90. 0. 97.1 0. 86.0 89-5 65.7 65.0 63-9 63.0 64-3 73-7 80.0 78.0 750 74.0 75-0 75.0 74.0 87.2 79.0 84.2 51-3 76.6 0.' 93-6 28.6 78.3 36.5 76.3 I. i..^ 92.0 81.3 10. 24.0 2.' 18.7 I5-C 28.6 78.2 16. c 76.5 68!6 . ECONOMIC VALUE OF FOOD. 21 Articles. Onions Pearl barley Pears Pigeon Prunes Radishes . . . Suet Venison. . . . Vermicelli . . Whey As mate rial for the muscles. 0.5 4-7 o, 23. 3. 20.4 47-5 As heat givers. 5-2 78.0 9.6 1.9 78.6 7-4 100. o 8.0 38.0 4.6 As food for the brain and nerv- ous system. 0.5 0.2 2-7 4-5 i.o 2!8 1-7 0.7 Water. 93- 9- 86. 72. 13- 68. 12. 94. Waste. 8 "5 7 4 3 4 o I I 8 '.'. 8 7 Atkinson's Table of Digestibility of Nutrients of Food Materials. In the Food Materials Below Meat and fish . . . . Eggs Milk Butter Oleomargarine. . . . Wheat bread Com (maize) meal Rice Peas Potatoes Beets OF THE TOTAL AMOUNTS OF PROTEIN, FATS, AND CARBOHYDRATES THE FOLLOWING PERCENTAGES WERE DIGESTED. Protein. Fats. Carbohydrates. Practically all 79 to 92 96 88 to 100 93 to 98 98 96 ? 81 to 100 ? 99 89 ? 97 84 ? 99 86 ? 96 74 ? 92 72 ? 82 Percentage of Nutrition in Various Articles of Food (Moss). Raw cucumbers 2 Raw melons 3 Boiled turnips 4-J Milk 7 Cabbage 7^ Currants 10 Whipped eggs 13 Beets 14 Apples 16 Peaches 20 Boiled codfish 21 Broiled venison 22 Potatoes 22^ Fried veal 24 Roast poultry 26 Raw beef. 26 Raw grapes 27 Raw prunes 29 Boiled mutton ^ . . 30 Oatmeal porridge 75 Rye bread 79 Boiled beans 87 Boiled rice 88 Barley bread 88 Wheat bread 90 Baked corn bread 91 Boiled barley 92 Butter 93 Boiled peas 93 Raw oil 96 22 FOODS AND FOOD PREPARATIONS. Atkinson s Table for Nutrients and Potential Energy in Dietaries of Different People. European and Japanese dietaries : Sewing girl, London wages 93 cents (3J. 9 KICHARDHON. ANIMAL FOODS. 85 by melting and shaking it in boiling water which is several times re- newed and then pouring it into ice-cold water. It is then called "smalt." The addition of salt to butter in the strength of twenty to twenty-five grammes per kilogramme postpones or prevents the fer- mentation, and sugars or syrups in which the butter mjiy be immersed have the same effect. So also does protecting it from atmospheric air in hermetically sealed jars set in cold water, or simply keeping it under fresh water which is renewed two or three times a day. Sometimes weak solutions of tartaric or acetic acid, three grammes to the litre (Hayem), are employed for this purpose. Pure fresh-butter fat is not crystalline, but old or rancid butter becomes so. An ingenious process for making rancid butter sweet again has been employed in California. The butter is melted in a tub in which the electrodes of an electric battery, encased in flannel, are placed so that a current of electricity, when passed through the butter from one pole to the other, determines a collection of the acids causing the rancidity at one or the other pole. In striving to reach the pole the acids soak into the flannel, and may be then removed. Strong-tasting butter is not necessarily unwholesome, for the flavour may have been derived from the cow having fed upon dead leaves or turnips, and butter is even more sensitive than milk in transmitting unpleasant flavours. Butter will not support life for any length of time when taken alone. Carnivora fed upon an exclusive diet of meat and fat do not grow fat, therefore the original Banting treatment for obesity (see Obesity) has been modified by Ebstein and others by the free addi- tion of butter to the diet. Taken in connection with other foods, however, butter is a highly digestible and nutritious food, and is often fattening, and it has been wittily said that " if bread is the staff of life, butter is its golden head." In weak stomachs the digestion of butter is improved by spread- ing it thoroughly in thin layers upon bread, or allowing it to soak into hot toast. It is thus prevented from floating about in the man- ner which coats the food and walls of the stomach and retards gastric secretion (Brunton). Most persons eat about an ounce a day of but- ter, but many eat double that quantity. Its annual production in the United States exceeds one billion pounds. The use of oleomargarine and butterine as substitutes for butter are described under the heading Fats and Oils (see pages 176, 177). 4. Buttermilk. Buttermilk is the residual milk left after churn- ing and removing the fat. It is usually fed to pigs, but it is whole- some and diuretic, and makes a capital beverage for those patients who fancy its peculiar sour taste. It contains albumin and finely coagulated casein, salts, water, and sugar, which is largely converted 86 FOODS AND FOOD PREPARATIONS. into lactic acid. It should be drunk fresh, for it soon decomposes. Some patients can digest it who are unable to take ordinary milk.' In those disorders in which the digestion of peptones and fats is poor it is often well borne, and it contains less fat than skimmed milk, over which it jjossesses but little advantage, although some persons are very fond of it. It is of especial value in chronic gastric catarrh with atrophy of the gastric glands (Eulenburg). A "buttermilk cure" is sometimes practised after the manner of the "whey cure" (see pages 697, 698), but buttermilk cannot long be depended upon as an exclusive diet. 5. Cheese. Cheese is the separated casein of milk, which in- cludes some of the fat and salts. There are many varieties, pre- pared in different ways, but the two chief classes are hard cheeses and soft cheeses, the former being pressed and salted. Cheese forms a highly nutritious food and an important article of commerce. In countries where meat is scarce and dear the peasantry consume large quantities to supply the nitrogenous element of their diet. Weight- for-weight cheese contains about twice as much proteid as meat (Parkes). They use for this purpose the heavier, less highly fla- voured cheeses. The wealthier classes eat cheese more as a condi- ment, taken after meals, and therefore they require higher flavoured varieties, which please the palate and excite the secretion of gastric juice. Eaten in moderation, such cheeses are an aid to digestion. Taken with milk, cheese tends to reduce the size of the coagulae in the stomach. About 250,000,000 pounds of cheese are annually produced in the United States alone. The kinds of cheese differ somewhat in composition, but in gen- eral they may be said to contain from 35 to 55 percent of water and from 10 to 20 per cent of fats, 20 to 30 per cent of casein, and about 6 per cent of salts. Cheese is rich in fat or in flavour according as it is made from whole or skimmed milk. Cream cheese contains about 77 per cent of fat, and the highly flavoured Roquefort, Edamer, Cheshire, and Emmenthaler, or Schweizer cheeses have a similar quantity, and are nutritive when they can be digested. Bauer's analysis of cream cheese places the fats much lower, and the casein is also at a minimum. Bauer s Analysis of Cream Cheese Water. Nitrogenous matter. Fat. Extractives. Ash. Cream cheese Whole milk 35-75 46.82 48. 02 7.16 27.62 32.65 30.43 20.54 8.41 2.53 2.97 6.80 4-13 3-05 4.12 Skimmed milk ANIMAL FOODS. 8^7 Cheese is usually prepared from sweet milk. The coagulation is accomplished in a few minutes by the addition of the ferment rennin with gentle heat (120 F.). The heat secures firmer coagulation. Casein may also be coagulated by acids. A little salt is added ; the curd is strongly pressed m a mould, and the expressed, fluid is called "whey." The curd is then salted and dried on the surface by fre- quent turning in the air. The harder cheeses are made under higher temperature and pressure. Cheese is kept for a time to " ripen," by fermentation or decomposition. If the decomposition goes too far, it develops leucin and tyrosin. The casein may become soluble in water, producing soda albuminate and peptones. The " riper " a cheese the greater is its value as a condiment. During the ripening volatile fatty acids are evolved from the fatty matter present, which occasion the odour and flavour. The casein also undergoes change, and is partially converted into fat (Foster). It may putrefy and evolve ammonia, or even become poisonous. Ripening, when not carried too far, makes cheese more friable, and hence more digestible. Cream cheese is fresh, and usually not ripened, but Neuchatel is ripened. Pot cheese is eaten fresh after the whey has been expressed. It contains : Water, 60.27 per cent ; casein, 24.84 per cent ; fat, 7.33 per cent ; ash, 4.02 per cent ; milk sugar and lactic acid, 3.54 per cent. The quality of cheese depends upon the richness of the milk in fat. In the richest cheeses made of whole milk, such as Stilton, double Gloucester, Gorgonzola, and Roquefort, cream is added. Single Gloucester, American, and similar cheeses are made from milk from which the cream has been removed. Dutch, Suffolk, and Parmesan cheeses are also made from skimmed milk, and are "poor." Being nearly pure casein, they are hard to digest in bulk. These latter varieties keep well, and become hard enough to be grated. Fatty matter separates the flocculi of casein and makes cheeses soft, friable, and rich, but they sooner decay. The two soft cheeses most used in this country are Camembert and Brie. Camembert is a cheese made of whole milk, which is very care- fully dried under regulated temperature It requires three or four weeks to ripen. Brie cheeses are manufactured in three grades of richness, accord- ing to whether the milk is whole, partly skimmed, or skimmed. Roquefort is a hard cheese made in the department of Aveyron from goat's milk, partly skimmed and coagulated with rennin. The curd is then pressed for half a day, dried for ten or twelve days, and ripened in caves. This cheese is streaked with bluish lines, which are formed by the addition of a mould which grows on stale rye bread. 88 FOODS AND FOOD PREPARATIONS. Gruy^re was originally a hard Swiss cheese, but is now made also in France and elsewhere. It is dry, aerated with large holes, and it can be crumbled. It is manufactured in three grades, according to the degree of skimming of the milk, and the curd is cooked a short time before it is pressed. It has a somewhat saltish taste. Gorgonzola {stracchino) is a Piedmontese cheese made with hot and cold curds from two milkings, which do not perfectly unite, but which form minute interstices in which a green mould called " pars- ley " grows and imparts a high flavour (Clark). The curd is hung in hempen cloths to ferment. It is well salted. In the United States most of the cheese manufactured is of the common sort called ''American cheddar," but Neuchatel, Stilton, pineapple, and other more highly flavoured varieties are also pro- duced. An imitation cheese is also prepared from a mixture of one part lard and two or three parts milk, mixed or emulsionised at 140 F. This emulsion is then added with buttermilk to skimmed milk, so that the finished product contains about 14 per cent of lard (Cald- well). Toasted cheese is one of the most indigestible articles of diet, unless the cheese is new, " poor," and cut thin. " Welch rarebits " are notoriously difficult of digestion, although highly nutritious when absorbed. It is an old saying of such cheese that it is "gold in the morning but lead at night." Certain low organisms, ifioulds, fungi, etc., flourish in cheese and make it very irritant to the stomach. Such are Iht Aspergillus glaucus and Sporendonetim casei, both of which give a red colour, the cheese mite {Acanis domesticus) and the maggots of a fly [Piop/iilia casei). Bad cheese has been known to develop poisonous symptoms (see Ptomaine Poisoning) resembling those of poisoning by sausage meat. 6. Whey. Whey is the residuum of milk from which the casein and fat have been removed as cheese by the action of rennin or other- wise. It contains, in addition to water, salts, especially of potassium, a little lactalbumin, and lactose. It is apt to turn sour, but is fairly digestible even then, and its taste may be disguised by the addition of nutmeg and sugar. It makes a palatable, mildly diuretic drink, which is enjoyed by some invalids. In Europe several "whey cures " have been estab- lished for the treatment of renal disease, dropsical affections, etc., but whey is not in any sense a specific, and its dietetic value is greatly overrated. Yeo gives the following simple directions for the preparation of whey for invalids: Boil a pint of milk with one to two teaspoonfuls of lemon juice; strain in muslin, and express all fluid from the curd. Break the curd up first, and much fat and some finely divided casein ANIMAL FOODS. 89 will go into whey. Add beef tea or milk juice, or egg yolk in hot water. Eggs. About nine billion eggs are produced annually in the United States (Clark). Eggs contain all the ingredients necessary to support life and develop the organism. Like milk, they constitute a complete food, for out of an egg the entire structure of the bird its bones, nerves, muscles, viscera, and sometimes even feathers are devel- oped previous to hatching. The inner portion of the shell is dis- solved by phosphoric acid to furnish phosphates for the bones. The average weight of a hen's egg, according to Bauer, is 50 grammes, divided as follows: Shell, 7; white, 27; yolk, 16 grammes. Composition of a Hens Egg (Lawes and Gilbert). Fresh weight 1.8 ounce. Dry weight 0.45 " Fat 0.198 " Mineral matter 0.025 " Nitrogen o . 036 " Carbon 0-275 " Or in percentage : Water 70. 00 per cent. Dry matter 30.00 " 100 . 00 per cent. Nitrogen 2 .00 per cent. Carbon 17-52 " The shell of the egg weighs about one hundred grains. An egg consists approximately of Shell 10 parts Carbonate of lime. Yolk 30 parts : Proteid 16.00 per cent. Fats 30-70 " Salines 1.30 Water 5200 100.00 per cent. White 60 parts : Proteid 20.40 per cent. Salines i-, is of little more value as an ali- ment or heat producer than beef tea or extractum carnis. It is a good vehicle for giving beaten or dropped eggs, flour, etc. It stim- ulates the nerves, but in a much less degree than alcohol. It has the advantage over the latter and over condiments that it is never poi- sonous. A good meat puree may be made by adding a tablespoon- ful of scraped beef to three or four tablespoonfuls of bouillon, warm- ANIMAL FOODS. 103 ing over a brisk fire until the meat turns of a faint drab colour, and seasoning with pepper and salt or a little butter. Beef broth is agreeable to invalids, but on the whole it is less nu- tritive than that made from chicken, veal, or mutton. Ltebig's extract of meat, or extractum carnis, consists of the fla- vouring extractive matters such as kreatin, isolin, decomposable ha^matin, and salts. Some of these substances are excrementitious, and on this account Masterman compares it to urine, although it contains less urea. A pound of mutton is represented by two fifths of an ounce of the extract. It contains no albumin or fibrin, and has in all but 2 per cent of solids, hence its nutritive power is practically nil, but when regarded as a stimulant and so used, it removes fatigue, strengthens the action of the heart and nervous system, and improves the func- tional activity of the stomach, and in this manner aids the digestion of foods. There is no occasion for taking it in large quantities, and when this has been done, symptoms of slight ptomaine poisoning have been observed, such as heaviness and stupor (Yeo). The ex- tract has the advantage of keeping for years without decomposition, and it has been found that sometimes in cases of shock, especially after wounds received on the battlefield, its stimulant action has been considered almost equal to that of alcohol, and bulk for bulk, it is certainly much greater. Johnson s fluid beef is a digestible preparation, somewhat less dis- agreeable in taste than many extracts of meat. Valentine's meat juice is a much-used preparation which resembles Liebig's somewhat in its properties. Valentine's meat juice is a clear fluid of a deep claret-colour, hav- ing a meaty odour and strong meaty taste. It is prescribed in doses of one half to two teaspoonfuls, diluted in eight times its bulk of cold water, or it may be mixed with cracked ice. Its taste, which is disagreeable to many patients, is easily disguised by the addition of half a tumblerful of milk, or it may be mixed with light, farinaceous gruels (after they have cooled to 130 F.), or used to re-enforce soups and broths or cod-liver oil. Like Liebig's extract, it may be given by the. rectum. An ounce of this preparation is said to represent the concentrated pure juice of two pounds of the best lean beef or the condensed essence of three fourths of a pint of natural expressed beef juice. Among other ingredients it contains haemoglobin and some albumin. It keeps well in all climates when tightly corked. It should not be diluted with hot water, strong liquors, or acid medi- cines, as these substances alter it and lessen its value. It may be given in champagne and in tea which is not too hot. Bovinine is the concentrated expressed juice of raw lean beef ob- tained without use of heat or acid. It is claimed that each ounce 104 FOODS AND FOOD PREPARATIONS. represents nearly one pound of beef, that it contains 26 per cent of coagulable albumin, and that it keeps well without decomposition owing to the addition of glycerin and alcohol. It is said to contain egg albumen also. It may be given />er os in doses of a teaspoonful or more, or in ounce doses with pancreatin for rectal injection. Not being predigested, it may be pancreatinised like milk just before its administration in cases where it is desirable to give absolute rest to an irritable or ulcerated stomach. Bovinine has been used topically for injection around indolent ulcers with the idea of improving local nutrition, but it is doubtful whether this procedure is of any value. Beef Peptones. There are innumerable fluid preparations of pep- tonised beef which are recommended for invalid consumption ; but, as a rule, they are not so good as those which are freshly made by the addition of pancreatin powder, although their use saves time and trouble. They may be sometimes employed to tide over an emer- gency after a severe operation or collapse from hsemorrhage, un- controllable emesis, etc. The use of peptones for invalid foods is open to the objection that after a short time they excite disgust, and may cause vomiting and diarrhoea. The more complete the conversion of albumin into peptone the more bitter it becomes. Voit, Politzer, Gerlach, and others maintain that true peptone possesses little if any nutritive power, and that the albumoses can be directly absorbed from the alimentary canal without further fer- mentation into peptones. Of the numerous commercial preparations sold under the general names of peptones, peptonoids, predigested meat extracts, etc., those have proved the most nutritious which, in reality, contain the least peptone, and the most albumose. Bread and beef peptone, or panopeptone, is a preparation in which wheat starch and beef are both predigested and preserved in sound sherry. It may be taken cold in doses of one to four teaspoonfuls iced, or with carbonic acid, water, or wines, but it should not be mixed with milk or other foods. Beef peptonoids are also mixed with predigested milk and gluten. Summary. Most of these preparations are given in doses of one or two tablespoonfuls once in four hours. Usually they are tired of soon, and do not support life long, for, beyond the means employed of condensation of food by evaporation of water and com- pression, it is not possible to "concentrate" nourishment very much. Making food assimilable and more useful is another matter from concentrating it in the sense that it can be made to support an able- bodied man and supply him with energy for a day's work, for ex- ample, of mountain climbing. Neither does such predigested aliment represent concentration ANIMAL FOODS. 105 for an invalid ; the bulk of food given is certainly reduced, and its assimilation may be improved, but it does not convey into the body any phenomenal quantity of latent force units or of heat units. It is important to understand this fact ; otherwise serious misconcep- tions arise as to the actual amount of nutrition which a patient fed exclusively on peptonoids and similar food preparations is receiving. The following analyses illustrate the comparative composition of some of the preceding preparations as given by Chester : Composition of Meat Extracts. (Albert H. Chester.) Water. Organic matter. Ash. Soluble albumin. Alcoholic extract. Liebig's extract 18.27 40.65 37.00 41.20 54-40 58-48 39-85 55-65 50.40 31.84 23.25 19.50 7-35 8.40 13-75 0.05 I. II I.IO 1. 17 0.44 44.11 13-18 10.13 15-93 26.32 Benger's extract of beef Starr's extract of beef Tohnston's fluid beef Valentine's meat juice Various Meats. Beef tongue is a tender form of meat, but it contains rather too much fat to agree well with delicate stomachs. Veal. Veal, especially when obtained from animals killed too young, is apt to be tough, pale, dry, and indigestible; but when the animals are slaughtered at the right age the meat is sometimes tender, and is regarded by many as nutritious. It differs consider- ably from beef in flavour, and contains more gelatin. Veal broth is nutritious, and affords a wholesome variety in the dietary for the sick. When too much is given it may excite diarrhoea. Veal is much more used for invalids in Germany than elsewhere, although it figures less conspicuously in hospital dietaries there now than for- merly. Bauer declares it to be more digestible than beef, but Pavy says, referring to both veal and lamb, " they are meats that it is desirable to avoid, generally speaking, in case of dyspepsia," and this opinion is prevalent in America as well as in England. Veal contains more water and less fat and proteid than ox flesh. Mutton. Mutton is rated as more digestible than beef by Eng- lish writers upon dietetics. That can hardly be said to be the case in this country, where the quality of beef has been so much im- proved of late years, and where average mutton is not so tender as in England. For example, Balfour writes in his late work upon the Senile Heart (1894): "We also recommend meat with short fibre, such as chicken, rabbit, game, mutton, or well-grown lamb, in prefer- ,06 . FOODS AND FOOD PREPARATIONS. ence to such meats as beef, whose fibres are long and tough." Fat mutton is richer in fat than beef, and is certainly less digestible than lean beef. Undoubtedly tough mutton is quite as difficult of digestion as tough beef, and it is harder to obtain it tender. Mutton fat contains a larger percentage of stearic acid, which makes it firmer and less digestible than beef fat. Fat mutton is more apt to disagree with those whose digestion is enfeebled. When properly assimilated after digestion, mutton possesses equal nutrient value with beef. Mutton should not be eaten until the sheep is at least three years old, and the best English mutton is derived from animals which are six years of age. Mutton broth is wholesome and suitable for the sick. It may be given in typhoid and other fevers. It is somewhat constipating. Lamb. Lamb, when very tender and of just the right age, is quite as digestible as beef or mutton, but the flesh contains too large a proportion of fat more than is present in veal. Good lamb is ex- pensive, and, on account of the uncertainty of the character of the meat, it is not usually to be recommended for invalids. Venison. Venison is a tender meat with short fibres, which is very digestible when obtained from young deer, but it is regarded as somewhat stimulatmg to the stomach, and it is often eaten when aged to a degree which, while some think it improves the flavour, unfits it for dyspeptics. The meat corresponds very closely in chemical composition to lean beef. Pork is a tender-fibred meat, but it is notoriously indigestible on account of the high percentage of fat present, which may exceed 37 per cent, or considerably more than the quantity of its nitro- genous material. Pork ribs may have as much as 42 per cent of fat. The fat is composed chiefly of palmitic and oleic glycerides. Ham and Bacon. Bacon is much more digestible than pork, and ham occupies an intermediate position. " On an average, 100 grammes of ham give 30 of albuminates and 32 of fat; the salt ranges between 7 and 10 per cent " (Bauer). In Germany, and especially at Carlsbad and other mineral springs, ham i,s much prescribed in invalid dietaries. It is often given scraped or " rasped." Bauer says (Dietary of the Sick, p. 91) : *' The flesh of the hog seems to be better adapted for smoking than that of other animals, and long experience compels us to recognise smoked ham as one of the wholesomest forms of meat. Whether boiled or eaten raw, it seems as a rule to be more easily digested by weak organs than almost any other." An opposite view is preva- lent in England and America, where it is less used for the sick. So distinguished a dietician as Pavy omits mention of it in his book upon Food and Dietetics. Ham is much more digestible when thor- ANIMAL FOODS. 107 oughly boiled, cut thin, and eaten cold. It should not be fried for invalids. Hot ham fat is very indigestible. If cut thin and cooked crisp, fat bacon is friable and easily broken into small particles during digestion. It can often be eaten by dyspeptics, and forms an excellent variety of fatty food for con- sumptives. According to Letheby, prime bacon should not lose over one tenth of its weight by boiling, and ham should lose even less. Rabbit has white meat, but it is not a proper invalid food. Fowl. Chicken is among the most digestible of meats for inva- lids, whether cooked by broiling, roasting or boiling. The white meat is more easily digested than the dark, and a little of the breast of chicken may be given to a typhoid convalescent or a patient recovering from any severe illness before beef and mutton are allowed. Chicken broth is almost universally liked, and when thickened with rice, and sometimes with an tgg, it forms a highly desirable invalid food. Turkey and capon are somewhat less digestible than chicken, the meat being of tougher fibre. Young pigeons are quite digestible, and the breast of a squab may be given to a convalescent from fever before other meat is allowed. Tame ducks and geese are indigestible unless quite young and tender, on account of containing too much fat. Goose meat may sometimes hold over 40 per cent of fat, with which it is thoroughly infiltrated. Game, such as the flesh of partridge, grouse, woodcock, snipe, prairie chicken, etc., is by many persons preferred when it is " high " that is, when it has been kept long enough for putrefactive changes to occur. These may originate in the meat itself or in the viscera which have not been removed and from which the odour and flavour of commencing putrefaction are derived, and penetrate the meat. When the meat itself is not perfectly fresh it may produce violent gastro-intestinal disorder, but many persons with good digestive organs are not disturbed by the consumption of such . food in moderation, provided it is well cooked. The process of cooking disinfects it by heat. The fat of old birds is apt to be too strongly flavoured, and their meat is tough. Animal Viscera. Animal viscera are eaten to some extent in this country, and some of them are digestible, although none are as nutritious as good meat, and they contain but little nitrogen. With the exception of sweetbread, and in some cases the thyroid gland, they should not be given to the sick. Sweetbread is most useful in the invalid dietary. This should consist of the thymus gland of the calf, which is tender and has an I08 FOODS AND FOOD PREPARATIONS. agreeable flavour ; but butchers substitute the pancreas or " stomach bread " for it whenever they can, which is larger. The latter can be recognised by its coarser blood vessels, and it is less digestible than true sweetbread. The thyroid gland has been lately shown to possess remarkable power in regulating disordered nutrition in cases of myxcedema, chronic skin diseases, etc. It is usually given as a powdered extract in five-grain doses, but it is sometimes cooked fresh and eaten as a food. TriJ>e, made from the third stomach of the cow, when tender and well cooked, is easy to digest, although somewhat too fat. It con- tains about i6 per cent of fat and 13 per cent of albummoids rather more than most viscera. The heart is sometimes eaten, but the meat is tough and unde- sirable. Liver and kidneys are eaten more than any other viscera. If cooked too long they become very hard and tough. Calf's liver is always better flavoured and more tender if the animal has had fresh milk for food and not boiled skimmed milk and slops. Tender liver is more easily digested than kidney, and is fairly nutritious. It should not be allowed to diabetics. These foods are apt to be fried or stewed in rich sauces or " devilled," all of which are indigestible modes of cooking. Brains are fairly digestible, but not nutritious; they contain too much fat and cholesterin for invalids. Blood has sometimes been used as a fluid food. At one time there was a fashion among consumptives of going to the abattoirs to drink it warm, in the belief that it had somfe specific curative value for tuberculosis. This, however, is not the case, and it nauseates most persons to taste it, if not to look at it. Isinglass. Gelatin. Isinglass is derived from the membrane of the swimming blad- der of the sturgeon, but that of other fishes is occasionally used. It is not very soluble in the crude state, but is hygroscopic and swells very much in cold water. It dissolves in boiling water, and when the water is evaporated again hardens. Gelatin. Gelatin is a substance the potential energy of which is calculated as being even more than that of some fats and albu- minates, yet in the body it is very inferior in the production of force. It is obtained from bones, ligaments, and other connective tissues. It is a curious and interesting property of gelatin that used alone it fails to have much nutritive power, but in proper combina- tion with other foods it is a useful aliment. "By the addition of ANIMAL FOODS. 109 gelatin very large quantities of albumin can be spared in the body or devoted to increase of bulk, just as by the supply of fats and carbohydrates " (Bauer). Gelatin itself takes no part in repair and growth of tissues it must be regarded solely as an " albumin-sparer." It cannot, there- fore, replace albumin, the loss of which still goes on to some ex- tent even when gelatin is eaten in large quantity. It also slightly spares the consumption of non-nitrogenous materials. This is a question of considerable importance in the feeding of invalids, be- cause, while many jellies are easily digested and are agreeable to the palate, it is useless to burden the stomach with them if they do not possess nutritive properties in proportion to other foods, and the matter must therefore be discussed somewhat in detail. The " Bone Soup Commission " of the French Academy of Sciences was consti- tuted to determine the nutritive value of prolonged boiling of bones in order to obtain, if possible, an inexpensive form of aliment for hospital patients. The commission made elaborate researches, the result of which showed that animals which were fed exclusively upon gelatin rapidly deteriorated in strength and weight, and finally suc- cumbed to starvation. Subsequent experiments upon gelatin have been conducted by many physiologists with these conclusions : i. Gelatin is innocuous, and its exclusive use will not support life. 2. Mixed with other foods, it promotes nutrition and is easily digested and absorbed. 3. To some extent it saves waste of albuminous tissues. Since bones consist of nearly two thirds of their weight of gela- tin, the latter may be advantageously used as an inexpensive means for furnishing variety in the diet by addition to meat broths and jellies, pea and bean soups, etc. M. Edwards says that the proper proportion for such mixtures should be at least one fourth of meat soup to three fourths of gelatin soup. The bones them- selves may be broken and made to yield fat and gelatin for soup "stock." The amount of nourishment which they afford is ex- tremely little, and they are mainly of service for economic reasons to save waste. Edible birds' nests are not true gelatin, but a Chinese food product allied to mucin. Gelatinous substance may be obtained from boiling for several consecutive hours such material as calves' feet, sheep's trotters, ox tails, etc., and after clarifying, straining, and concentrating very palatable jellies may be made, to which chicken or mutton is added for invalid use. Calfs-foot jelly and calf s-head jelly, if not made too rich by added ingredients, makes a suitable invalid dish, especially when flavoured with sherry or Rhine wine. Ox-tail soup is too rich for the sick. no FOODS AND FOOD PREPARATIONS. Pure white gelatin is insipid, and is almost impossible to eat in considerable quantity unless it is well seasoned. If free from all gluey taste and odour, and prepared with coffee or lemon juice, or other fruit flavours, it makes an easily digested invalid food. Or it may be combined with eggs or milk as blancmange, or with soup. The addition of meat extracts to it improves the taste, and the ad- mixture of wine, like good sherry, alters the taste rather by the in- troduction of its aromatic principles than by the alcohol itself, which is largely evaporated from the jelly. "Well-prepared jellies, not containing too much acid or pungent spices, are very useful foods for invalids, and may be administered with advantage in febrile states " (Bauer). Dry gelatin contains 17.3 per cent of nitrogen, which is even a larger proportion than is contained in albumin ; consequently urea excretion is decidedly increased by gelatin feeding. Diuresis is also produced, and the desire for liquid is intensified, so that a large proportion of gelatin in the diet causes decided physiological effects. Fish. Fish vary both in digestibility and nutritive qualities. The chief differences are in regard to coarseness of fibre and the quantity of fat present. Fish meat is less stimulating, sustaining, and satisfying than that of birds or mammals. Eels contain the largest proportion of fat, which amounts to 28 per cent. Herring have 7, salmon about 6.5, while sole has but 0.25 per cent (Konig). Mackerel, trout, and shad have considerable fat. Fish which, like the salmon, are rich in flavour and in fat, while they may be very nutritious, are much less easy of digestion than are the simpler varieties, such as sole or flounders and codfish. Dried codfish can be eaten on long sea voyages day after day without the repulsion which is soon excited by the continuous diet of the more highly flavoured fatty fish. The flesh of many fish contains a large percentage of water, be- sides gelatin. The following fish, in the order named by Walker, have the largest percentage of albuminoids: Red snapper, whitefish, brook trout, sal- mon, bluefish, shad, eels, mackerel, halibut, haddock, lake trout, striped bass, cod, flounder. All fish are best in their proper season, for out of season they deteriorate from change in food or other causes, and are less nutri- tious, besides possessing inferior flavour, and sometimes disagreeable odour. They should be eaten as fresh as possible, for there are few alimentary substances capable of exciting so violent gastro-intestinal disturbance as decomposing fish. The practice of preserving fish frozen or packed in ice is open to the objection that the cold pre- ANIMAL FOODS. Ut vents malodours from revealing commencing putrefaction. Vivid red gills and fulness and brightness of the eye are a good test of freshness. It is a popular fallacy that fish constitute a good " brain food " on account of their containing a large percentage of phosphorus, a prominent ingredient of nerve tissue; but in reality many fish con- tain less of this element than meat, and neither Eskimos nor other aboriginal tribes who live largely upon fish are noted for intellec- tuality. Some fish contain different species of tapeworm, but they are seldom if ever transmitted to man. Fish having white meat constitute an excellent food for invalid diet, and when cooked by boiling or broiling (not frying) they may be given to convalescents and to those with feeble gastric powers. The most digestible fish are fresh sole, whiting, bluefish, whitefish, bass, red snapper, fresh codfish, halibut, shad, and smelt. Pavy says : " Of all fish, the whiting may be regarded as the most delicate, tender, easy of digestion, and least likely to disagree with a weak stomach. The haddock is somewhat closely allied, but has a firmer texture and is inferior in flavour and digestibility." Crimping is a process sometimes applied to fresh fish, like the cod, by which the firmness of the flesh, as well as its flavour, is increased. As soon as caught, the fish is incised transversely by numerous deep cuts. On being plunged into ice cold water, the muscle fibres con- tract firmly and so remain. As a rule, dried, smoked, or pickled fish should not be given to invalids, although thoroughly boned and desiccated or "shredded" codfish is quite tender. The latter process is now conducted by ma- chinery, and thus prepared the fish requires less prolonged soaking and cooking. Fish roe is not very nutritious, and it serves mainly as a relish. Shad roe, thoroughly cooked, is not objectionable, but sturgeon's roe or caviare, which is sometimes used as an " appetiser," is capable of arresting digestion, especially when old, black, or rancid. Caviare contains, according to analyses by Konig and Brimmer, water, 45.05 ; proteids, 31.90; fat, 14.14; salts, 8.91 per cent. It must not be forgotten that some persons cannot digest fish of any kind, or at most can take but one or two varieties without pro- voking an attack of dyspepsia or biliousness. A few tropical fish are poisonous, and constitute the only exception to the general edibility of vertebrate animals. There are no diseases in which a fish diet possesses specific value, but often in chronic Bright's disease, lithaemia, gout, or other condi- tions in which it is undesirable to give much meat, it is very service- able as a compromise. xo 112 foods and food preparations. Crustaceans. Lobsters, crabs, and shrimps, although they constitute a whole- some food, when absolutely fresh, for those in health, should never be admitted to an invalid dietary. They are all scavengers of the sea, and crabs not thoroughly cleaned or imperfectly cooked may be poisonous from contamination with putrid matter, although their own flesh is good. Soft-shell crabs are by no means always " soft " when eaten, and their shells furnish a large bulk of indigestible res- idue, which may prove irritating. I recall one fatal case of appendi- citis caused by them. Lobsters are highly poisonous to some persons even when fresh, and especially if eaten with other food they may excite nausea, vomiting, and even gastro-enteritis. In others they may cause urti- caria or aggravate existing skin eruptions. Persons who live at a distance from the seashore are apt, in making occasional visits to seaside resorts, to gratify a fondness for crustaceans, fish, and shellfish food by an excessive indulgence in " shore dinners," which result disastrously with stomachs unaccus- tomed to such diet ; but the evil effects are fortunately temporary. Shellfish. Oysters, clams, and mussels are very nutritious food, and the for- mer at least, when fresh and when eaten raw or properly cooked, are an excellent invalid aliment. Oysters can often be digested earlier than meat in convalescence from fevers, and in many forms of gastric disorder. The " soft part " of shell fish is formed chiefly by the bulkier liver, while the tough harder portion is mainly the muscle which attaches the animal to its shells. This muscle is coagulated and rendered tougher by all forms of cooking ; hence raw oysters are more tender and digestible than if stewed or broiled. In oysters the liver is relatively larger and more nutritious than in clams. In rec- ommending oysters to invalids it is always best to allow only the soft parts to be eaten, and when this rule is observed they may be cooked in a variety of ways by stewing, broiling, roasting or "pan- ning," and steaming but they should never be fried for the sick. Both oysters and clams have the advantage that they are very generally liked, and they make a pleasant variety of food to relieve restricted diets. They impart an agreeable flavour to milk and broths. It is customary to forbid their use by diabetics, on the ground that their livers contain glycogen. Clam juice or plain clam broth is almost specific for some forms of vomiting, especially sea- sickness. It may be tried in the vomiting of pregnancy, and may be retained when beef juice and milk are not. It is mildly stimulating VEGETABLE FOODS. 113 to the gastric mucous membrane, and slightly nutritious and laxative. It is best obtained fresh, but very good canned or bottled prepara- tions of it are made which keep pure indefinitely. It may be taken either hot or cold with a little Cayenne pepper half an hour before a meal. It seems to have an invigorating effect upon the stomach, and promotes the appetite. Mussels are less commonly eaten in this country than in England and some parts of Europe. They belong in the same category with oysters and clams, and the remarks just made in regard to the latter apply to them as well. There is a form of poisoning by mussels which is exceedingly dangerous and sometimes fatal (see Poisoning by Shellfish, page 353). In some persons shellfish, like crustaceans, produce skin erup- tions, such as urticaria, or aggravate existing eczema. IV. VEGETABLE FOODS. Sugars. Sugars are crystallisable carbohydrates in which oxygen and hydrogen exist in proportion to form water. There are many vari- eties, of which the commoner contained in food or used as an adjunct to diet are cane sugar, saccharose or sucrose, grape sugar or glu- cose, and sugar of milk or lactose. Inosite, mannite, dextrin, sugar of malt or maltose, honey, a sweet nitrogenous substance called sac- charin, and fruit sugar or levulose (diabetin) are also used. Sugar may be derived from the stems of plants, as in the case of the sugar cane, or the palm, from tubers like the beet, from maple-tree sap, and from other vegetable growths. The sugars present slight differences in their physical properties, such as specific gravity, solubility, and effect upon polarised light. They also differ in sweetness of taste and in digestibility. As foods, sugars have essentially the same uses as starches (see Farinaceous Foods, p. 119), for all starch must be converted into dextrin or sugar before it can be assimilated. For this very reason, sugars, although they form an excellent class of food, producing force and heat and fattening the body, are not absolutely necessary for the maintenance of health if starches or fats are eaten. They possess additional properties, in that they have a more agreeable flavour than starches, are more satisfying to the palate, and they have antiseptic and preservative power. Hence sugars and syrups are extensively employed to preserve fruits either in solution or in dried form, like "candied" cherries, ginger, etc. When taken for food, sugar is quickly soluble, and on this account taxes the digestive organs but little. Cane sugar, however, needs to 114 FOODS. AND FOOD PREPARATIONS. be converted into grape sugar before it can be absorbed and assimi- lated, and grape sugar, which needs no change, is therefore sometimes spoken of as a predigested carbohydrate. Many persons acquire an inordinate fondness for sugar, and con- tinued overindulgence in this food is very sure to give rise to, flatu- lent dyspepsia, constipation, and disorders of assimilation and nutri- tion. It may even cause functional glycosuria (see Diabetes). Sugar is very fattening. In the West Indies the negfoes always grow fat in the sugar season, when they chew the cane in the fields. Sugars are emphatically force producers. Chauveau and Kauf- mann have demonstrated that during muscular activity the consump- tion of sugar in the body is increased fourfold. Harley found experimentally that the muscle energy producing effect of sugar is so great that two hundred grammes (seven ounces) added to a small meal increased the total amount of work done from 6 to 30 per cent, and that when sugar was added to a large meal it increased this total from 8 to 16 per cent. Sugars and the Urine. Grape sugar and fruit sugar or levu- lose, when eaten in large quantity in health, reappear unaltered m the urine, but the latter sugar in diabetes is said by Moritz to be consumed within the body. Saccharose, eaten in excess, may reappear in the urine unaltered, or more commonly as glucose. Lactose is converted into glucose, and it produces functional gly- cosuria more easily than the latter if eaten in bulk. Alimentary glycosuria usually ceases in a few hours after discon- tinuance of the food which has caused it. There are some diseases in which sugar in all forms should be strictly avoided, such as flatulent dyspepsia, acute and chronic gas- tritis, gastric dilatation, gout, rheumatism, obesity, and the uric- acid diathesis, and it should be absolutely forbidden in diabetes. Temporary disturbances of digestion from eating too much sweet food are very common, and can usually be rectified by simple reme- dies, and by withholding or diminishing the customary allowance of sugar. Sugar eaten constantly in excess spoils the teeth and de- stroys the appetite for other food. Cane Sugar. Cane sugar, saccharose, or sucrose, as used in the United States, is usually derived from the clarified and crys- tallised juices of the sugar cane, but it is a'lso made from beet root. The latter form is somewhat less sweet than are the better grades of cane sugar. Nearly half the world's commercial sugar is derived from sugar cane, and nearly half from beets. The maple tree also yields from 2 to 10 per cent of sucrose. Maple sugar is eaten chiefly as a luxury, on account of its unique and agreeable flavour. It also makes an excellent syrup which is in great demand. VEGETABLE FOODS. IIS Cane sugar can be obtained from' the sugar pea, from the flower buds of the coca palm, andfrom other substances. The sap which is drawn from the sugar cane as well as the juice of compressed beet root is not a pure aqueous solution of sugar, but is mingled with other materials, chiefly of a mucilaginous character. An elaborate process of refining is applied in order to produce the commercial white sugars of various grades. The principal steps in this process areas follows: " i, Melting of the sugar; 2, straining through bag filters ; 3, filtering through charcoal ; 4, boiling or evaporating the decolourised liquid in vacuum pans; 5, separation of crystallised sugar by centrifugals " (Clark). Cane sugar was formerly sold more extensively than at present in the form of coarse brown sugar. This variety is somewhat im- pure, and on this account has a slightly laxative action ; but the great improvements made of late years in the processes of refining sugar, and the extreme cheapness of this commodity, place the clarified forms of it within the reach of all, and even reduce to a minimum the temptation for sophistication which was originally much more extensively practised, especially in the adulteration of confectionery, with chalk, plaster of Paris, etc. The most highly refined cane sugars contain about 0.25 per cent only of impurities and ash, but poorer grades hold i to 2.3 per cent, with as much water (Konig). Cane sugar is about two and a half times sweeter than glucose. " Grocer'^ itch " is a form of irritation of the skin of the hands sometimes acquired from contact with moist brown sugar, adulterated with dirt or sand and mites. Caramel. By the application of heat, at 400 F., refined cane sugar is melted, browned, and converted into a non-crystallisable fluid substance called caramel, having a slightly bitter but agreea- ble taste. Comparatively insipid farinaceous food, such as corn- starch and farina, may be flavoured with it for invalid diet. Burned flour may be used in the same manner, but its flavour is less agreea- ble. Caramel is also useful for flavouring milk, custards, etc. Sugar differs from starch by containing another molecule of water, or the elements which form it. Starch, which forms fully three fourths by weight of the solid ingredients of wheat flour, is altered into sugar by heating with a little sulphuric acid, or even by prolonged heating alone or " torrification." The latter pro- cess converts it into dextrin, sometimes called ** British gum," on account of its substitution in commerce for gum arable. With pro- longed heat there is a further change in the starch, which becomes of a brownish and finally black hue, passing through a stage analo- gous to the formation of caramel from sugar, and with extreme heat forming a residue of black carbon, all the water having been driven off. A hard, dried, thoroughly browned bread crust or toast is I 1 5 FOODS AND FOOD PREPARATIONS. therefore similar to caramel, and every one is familiar with its gain in flavour. Sugar candy is made by extremely slow crystallisation. Sorghum is a variety of grass or cane from which sugar can be extracted, but in this country it is used more for the manufacture of molasses. Molasses and Treacle. Molasses and treacle are products that are incidentally formed in the process of crystallising and purifying cane sugar. Treacle is the waste drained from moulds used in the refining process, and it contains, besides sugar, acids, extractives, salts, and more or less dirt. Like cane sugar, molasses constitutes a very desirable food, and is highly nutritious. Its use, both for cook- ing and to add to farinaceous food and enhance its flavour, is too well known to require description. Molasses, according to Konig, contains acetic and formic acids, which impart their reaction to it. Both treacle and molasses, owing to impurities, are somewhat laxative, and the effect, as an aperient, of plain gingerbread made with good brown molasses is due to this property. For young chil- dren from six to ten years of age molasses sometimes operates very well in keeping the bowels open. Plain molasses candy is a wholesome form in which to give sugar to growing <:hildren, if they are not allowed to eat too much and spoil their appetite for other foods. Walker says that " good candy is good food." Candies are apt to be made too rich with butter, choco- late, and other ingredients when they disagree. Molasses, like syrup, is a good preservative. It has been used to preserve potatoes in layers. Glucose. Grape sugar is present in almost all fruits, in the sweeter varieties of which it exists in large quantity. In peaches, pineapples, and strawberries it is found with cane sugar, and in grapes, cherries, and honey it occurs in connection with other varie- ties of sugars. In dried fruits, such as raisins or figs, glucose is present in a gummy form. It is commonly manufactured from starch. Although prepared for immediate absorption from the stomach and intestine and assimilation, glucose is of little service for fla- vouring other articles of food, for when so used it is apt to produce flatulent dyspepsia with acid eructations. Moreover, it has less strength of sweetness than cane sugar, and, as it is more difficult to crystallise, it is much less convenient and desirable for gen- eral use. Sucrose and maltose can only be absorbed by alteration into glucose. If glucose be eaten as a food, in form of candy or otherwise, it over- loads the system by being too promptly absorbed. Malt extracts, syrups, and preserves adulterated with glucose easily ferment, for VEGETABLE FOODS. 117 nothing ferments more promptly than such combinations with the bacteria present in the stomach. Lactose. Lactose, or sugar of milk, is taken as a food in some quantity with ordinary milk, and forms a very important ingredient of the diet of the growing infant, who is unable to digest much starch during the first year of life, and yet requires an easily assimilable form of carbohydrate. Cow's as compared with human milk is deficient in lactose, and the latter should therefore be added in proper proportion to the milk of bottle-fed infants (see Milk Com- position, p. 44). It might be used for sweetening various articles of food, but it possesses no advantages over ordinary cane sugar, and is m fact more expensive and less sweet. Mannite. Mannite is obtained from the sweet juice of the stems of the ash tree. It is also contained in beet roots and some other vegetables. Like sucrose, it crystallises, and is white and free from odour. It does not ferment with yeast. It is laxative, and it may be used in diabetes, for it is not secreted in the urine as glucose. Levulose. Fruit sugar, or levulose, is now sold under the name of diabetin, in crystalline form, for use in diabetes, on the ground that it is not known to reappear in the urine. It can be taken freely and in considerable quantity without disordering digestion, as sac- charin often does after continued use. Diabetin is sweeter than cane sugar, and has a somewhat fruity taste. Honey. Honey is a form of sugar prepared from the nectar of various flowering plants gathered by bees, and stored by them in cells. It is really a vegetable product, although manufactured by an insect. In addition to sugar, it holds several other ingredients, prin- cipally wax, gum, pigment, and odorous materials. The sugar exists in two forms crystallisable and non-crystallisable. The former is somewhat similar to glucose. Honey contains, according to Konig: Water, 16.13; ^r^i^ sugar, 78.74; cane sugar, 2.69 ; nitrogenous matter, 1.29; ash, 0.12 per cent, besides traces of other ingredients. Honey was more in demand for sweetening before the discovery of a method of making sugar from the sugar cane. It is a whole- some food, and is fattening when eaten with bread. In some coun- tries as, for example, in the Black Forest of Baden the peasants consume it as a staple article of diet. Artificial honey-combs are now made from paraffin, stamped into cells to imitate the original, which enable the bees to devote more energy to the manufacture of honey and bestow less on the combs. Saccharin. Saccharin is a crystallisable organic acid substance, containing, in addition to the elements carbon, hydrogen, and oxygen, a little sulphur and nitrogen. It was introduced a few years ago as a substitute for sugar, and it is especially useful in cases of obesity, Il8 FOODS AND FOOD PREPARATIONS. rheumatism, gout, and diabetes, when the withdrawal of sugar is followed by intense craving for it, or a refusal to eat those foods which are customarily flavoured with it. It is antiseptic, and has the property of acidifying the urine, being eliminated unaltered by the kidneys, hence it can be used medicinally in cases of pyelitis or cystitis. It may be given for months at a time without danger, if the quantity prescribed does not exceed more than two or three grains, three times a day. More than this dose may cause gastric derangement. It may be added to food in cooking, or a one-half grain tablet may be used to sweeten a cup of coffee. Cereals and other Starchy Foods. Starchy Foods in General. The cereals in commonest use as food products are wheat, corn, rice, rye, barley, oats, buckwheat. From these are manufactured a variety of flours and meals. About 30 per cent of all cereals produced in the world are grown in the United States, and at least one fourth of the total wheat pro- duction is from this country ; on the other hand, 98 per cent of the rye and 75 per cent of the barley and oats are grown in Europe. The United States produces about 75 per cent of the corn of the world. These estimates give a general idea of the relative use of these cereals, and illustrate the great preponderance of wheat bread and corn meal and other preparations of corn eaten in the United States. Besides the cereals and vegetables which, like the potato, are composed chiefly of starch, there is a large miscellaneous group of starchy foods used as flours, which are therefore conveniently con- sidered with the cereals. Such are arrowroot, tapioca, cassava, sago, and peas. Peanuts, chestnuts, and plantains are also sometimes used to furnish flour. Starch is the term applied to the fecula or granular material found in fruits, roots, and tubers and in the cellular tissue of plants. The structure and form of the starch granules vary, and those from different plants may be distinguished by microscopic examination. Patients, as a rule, are ignorant as to the nature and limitations of " starchy foods," and their conception of them is based upon such foods as resemble powdered laundry starch in appearance, like ar- rowroot, cornstarch, etc. After being told to eat no starchy foods, they not infrequently will say they suppose that potatoes are not starchy. The expression at best is not an accurate one; for many starch-holding foods contain a large proportion of other ingredients, especially proteids, as will be seen from the following table furnished by Riibner : PLATE III. f S; RYE OATS 4 CORN STARCH GRANULES, MAGNIFIED. {Prmn Bulletin Mo. IS, Divimm of ChemiMry, United HUUen Agrimltuml Bureau). DRAWN KV (;F. biscuits are so dry and firm that they are much less bulky than bread, and it is estimated that three fourths of a pound of such biscuits is equivalent to one pound of bread in actual nutritive value (Yeo). All biscuits, if kept long exposed to the air, become exceedingly dry and tasteless, although they do not readily mould. Owing to their hardness and unpalatableness when long kept, it is found in- expedient to give them to soldiers or sailors to the exclusion of fresh bread whenever the latter can be obtained. The biscuits known as " hard-tack " are usually made five inches square and are perforated with small holes. They have the advantage of keeping well for a very long time and remaining edible, although they are not very palatable even when fresh. They are extremely tough, and require soaking in milk or water before they can be eaten. Semolino is a name having two applications. In France it de- notes the hard central substance of the wheat grains which are retained in the bolting machine after separation of the finer por- tion which has passed through ; but in Italy the word is used to denote the finer portion itself, consisting of fine hard granules rounded by grinding. The larger sizes contain more gluten than flour, and may be used to thicken soups. The granules swell in water. When the grinding and sifting process is carried still further the starch granules are obtained in the fine powder which constitutes flour. Semolino is used extensively in the manufacture of what are called " alimentary pastes," such as macaroni. Macaroni is made by mixing semolino made from hard flinty wheat into a paste which is kneaded and put into a cylinder, the bottom of which is pierced with holes. A piston descends in the cylinder, and the paste issues from the perforations in the form of long thin tubes, which are cooled by a ventilator, cut in lengths, and VEGETABLE FOODS. 135 dried on screens. As much as twenty million pounds of macaroni are manufactured annually in Lyons alone. It contains 16 to 18 per cent of gluten, whereas bread holds 10 to 11 per cent. Sir Henry Thompson says, in speaking of macaroni, which is rather a form of gluten than of starch, that, " weight for weight, it may be regarded as not less valuable for flesh-making purposes in the animal economy than beef or mutton. Most people can digest it more easily and rapidly than meat; it offers, therefore, an admi- rable substitute for meat, particularly for lunch or midday meals." After thorough soaking and when well cOoked by boiling or stewing in milk or stock it is very nutritious, and it is often agree- ably combined with cheese, although this is not advised for persons with feeble digestive power. Cooked alone with boiling water, maca- roni is by many regarded as tasteless; and as the art of cooking it properly is less understood in this country than in Italy, it is not so favourite an article of diet as it might be. The use of Italian pastes macaroni, spaghetti, and vermicelli in this country is extensive, but by no means as much so as their intrinsic value deserves. They are manufactured from flour from which the starch has been in part removed, and hence contain a relatively larger proportion of nitrogenous matter. While being very wholesome they are tough, and require prolonged cooking. The vermicelli which is sold in the form of letters, to use in soups, cannot be boiled sufficiently to be thoroughly digestible unless the letters lose their shape. Buckwheat. Buckwheat, or blackwheat as it is sometimes called, is indigenous to temperate climates, and in some parts of the world, notably in Russia, Siberia, and Brittany, it constitutes a staple of diet, but in the United States it is the least important of the cereals, and is used rather as a luxury for making griddle cakes. The buckwheat produced in the United States is mainly raised in New York, Pennsylvania, and some of the New England States. Buckwheat bread is nutritious, but it crumbles and does not keep well. Soya bread is made from an oily pea which grows in China and Japan, and is used sometimes by diabetics, for it contains over one-third part of gluten and but 1.17 per cent of glucose. Millet and sorghum are grown in the warmest parts of Asia and Africa, and to some extent in southern Europe. In Russia millet is sold as a white meal. White sorghum, which is a grass or cane, is converted into flour called doura, and in Africa, mingled with barley, it is distilled into beer. A fine quality of alcohol may be made from it. In the United States it is mainly grown for molasses and sirup; sugar is also made from it. Bread made from either millet or sor- ghum meal is fairly palatable and nutritious when warm, but when Ij^ FOODS AND FOOD PREPARATIONS. it becomes cold it grows dark and crumbles. The grains are hulled like barley and are ground into flour, which is either eaten pure or mixed with bread. Millet is a grass raised largely in India, China, Egypt, along the west coast of Africa, in Italy, Spain, and Portugal. There are many sub-varieties. It contains, on an average, over 7 per cent of fat, nearly 10 per cent each of proteid and dextrin, 60 per cent of starch, and 2 of sugar (Parkes). Rye. Rye may be said to stand very close to wheat in impor- tance as a food. In Europe it is more in use for bread making than in this country, where it is mainly eaten by the Germans. In Ger- many the rye production is double that of wheat, and in Russia it is three times greater. Former generations lived almost entirely upon rye in France, as they did upon oats in Scotland and parts of England, wheat being an almost unobtainable luxury. Rye yields a coarser, darker bread than wheat, but is about equally nutritious, although not always so digestible, and it is somewhat laxative. In general, the statements made in the preced- ing pages (pp. 119-121) in regard to bread making, etc., with wheaten flour, may be applied to rye flour. Rye bread contains less gluten than wheaten bread, and it takes less time to raise and bake it, provided the oven is very hot. If properly made it is easily assimilated, and many like its taste. Rye is often combined with wheat in France, under the name of meteil, and in Spain and Greece a mixture of the same name is made with barley instead of wheat. Corn.T Maize, or Indian corn, is very extensively grown in tem- perate and warm climates all over the world. It may be dried, parched, and roasted whole, or ground into meal of various degrees of fineness. According to Clark (Tenth United States Census Reports, volume on Agriculture), the average annual crop of corn in the United States alone is over one and a half billion bushels, and 72,000,000 cans of corn are prepared, the latter representing the harvest of 40,000 acres. There are some 300 varieties of corn, but the common kinds are known simply as white, yellow, and red. The chief preparations of corn are hominy, samp, corn meal, cracked corn, cerealine, and maizena (a South American corn meal, used in the manufacture of a drink called " chicca "). Aside from its use as a food, corn furnishes alcohol and liquor, as well as glucose and starch. Chittenden and Osborn have made an elaborate research into the chemical composition of the " proteids of the corn or maize kernel " (American Chemical Journal, vol. xiii, Nos. 7 and 8, and vol. xiv, No. i). These consist of " three globulins, one or more VEGETABLE FOODS. 137 albumins, and an alcohol-soluble proteid " called maize fibrin or zein. Corn is a wholesome cereal, for it contains considerable fat and proteid as well as starch, and it furnishes abundant energy, produc- ing heat. It is very fattening for both the lower animals and man. In the Southern States and in France it is largely fed to horses. As a vegetable, corn is less used in Europe than in America, perhaps on account of the prevalent Tdea that it is a hog's food, although corn meal is employed for baking into cakes and to mix with flour in bread making. Eaten as a vegetable, unless very young and tender, corn is one of the least digestible foods, and canned corn is notoriously so. This is chiefly on account of the toughness of the husk of the kernel, which often is found in the faeces practically unaltered by its transit through the body. Hence it may cause flatulency, indigestion, and diarrhoea. Corn tneal, on the other hand, is quite digestible, and, like oat- meal, is somewhat laxative. As compared with wheaten flour, it contains more fat, having about 9 per cent, but it is deficient in salts. It makes a dry, friable bread. Samp is a very digestible form of corn when well boiled. When maize becomes mouldy it causes the disease known as pellagra (see Diet in Pellagra). Polenta is a maize meal extensively used in Italy. The finest variety of corn meal, or rather of cornstarch, is very white and soft, and consists almost wholly of starch. Indian corn-starch contains 53 per cent of starch. The best grades are used as a substitute for arrowroot, and make a wholesome invalid food. The coarser meal, called Indian meal, is yellow and granular. Corn is also used for the manufacture of commercial starch. Mush is made of well-ground corn meal. The cereal is boiled in salted water, and when cooked is not pasty, but mixes well with cream, and is very digestible and nutritious. Rice. Although less eaten in this country than wheat, corn, and rye, except in the Southern States, rice constitutes the staple food of a majority of the world's inhabitants. Asia produces most of the rice consumed, but a little is grown in Spain, Italy, and Portugal. According to Clark (Tenth United States Census Re- port on Agriculture), " in Asia a large part of the population con- sume two hundred and seventy-five pounds per head a year," and nearly two billion pounds are used per year in Europe, In the United States, where rice was first introduced in 1694, it is chiefly grown in South Carolina. There are several hundred varieties of rice, the two principal classes being the dry or mountain rice, and the wet rice, which grows in flat marshland, periodically inundated. 138 FOODS AND FOOD PREPARATIONS. Both the Chinese and Japanese make a wine from rice, and a vinegar can also be obtained. The native Oriental method of treating rice is to beat the ker- nels of grain out of their husks in wooden mortars, and for European markets they are glazed by shaking in a sheepskin-lined drum (Clark). They are also bleached, and may be broken after de- cortication and ground into a flour. Rice contains more starch than any other cereal from 75 to 85 per cent and is an exceedingly digestible form of starch for in- valids when properly cooked, so that the individual grains are swollen or softened. This object is best attained by the process of steaming. The digestibility of plain boiled rice is improved by eating it with a little fresh butter, which coats the kernels and pre- vents their agglutination into a pasty mass. If the rice tastes in- sipid it may be spiced or flavoured with raisins. Rice pudding, milk and rice, and rice with beefsteak juice constitute excellent foods for young, growing children, and for use in convalescence from typhoid fever, diarrhoeas, and many other diseases. It is also advantageous to eat rice with fruit, such as apples or prunes. Rice should not be depended upon without some form of animal food, for it contains too little nitrogen to satisfy to the needs of the system. Bread cannot be made economically from rice, on account of the small amount of nitrogen which this cereal contains, and the con- sequent lack of stability in the shape of the loaf, and unless wheat be added in large proportions, such bread is indigestible and watery. Barley. Barley ranks very close to wheat in nutritive power, and cooked barley meal, like wheaten flour, contains gum, albu- minoids, starch, and dextrin. As compared with wheat, barley con- tains more fat, salts, and indigestible cellulose, less proteid, and less digestible carbohydrates. The employment of barley bread for food is of very ancient date, reaching back to the early days of the Greeks and Hebrews, but with the spread of the use of potatoes and the cheapening of wheaten flour, it has fallen into comparative disuse, and in the United States barley is mainly used to thicken soups and in the manufacture of beer. In some of the Pacific States it is fed to horses. Pearl barley is made by depriving barley corn of their outer shells or covering, and then subjecting them to rubbing be- tween a single millstone and a sheet of rasped iron or wire cloth, a process which polishes the kernels and rounds them off. Barley water makes an excellent diluent and demulcent drink for infants and invalids. For the latter it may be flavoured with lemon juice. It may be made as follows: Grind half an ounce of pearl barley in a coffee mill, add six ounces of water, boil twenty PLATE V. Rice Starch x 150 Rice Starch x 450 (fVom Bulletin No. 13, Diinnion of Chemistry, (hiUed fiUUeK AgricultunU HureAiu). i'llOTO BY I l.irKiiKK Kl< HAKIiSON. VEGETABLE FOODS. 139 minutes, add salt, and strain. It should be made fresh daily and kept in a cool place. It is better than oatmeal water whenever the bowels are loose. The latter, made in a similar manner, is to be preferred when constipation exists. Oatmeal. Oats contain considerable fat, proteid salts, and indi- gestible cellulose, in addition to a large percentage of starch. They have been eaten in Germany for over a thousand years, and consti- tuted the original grain food for all Europe. Oatmeal is much less used than other cereals for bread be- cause it lacks gluten, although it is still so employed to a limited extent among the poorer classes in France. It makes a dark, bitter bread, but forms a better porridge than can be obtained from rice or barley. The use of oatmeal porridge by all classes is very exten- sive throughout the United States. This is largely attributable to the improved methods of its preparation by high milling, rolling, etc. Scotch groats are prepared by removing the outer husk, leav- ing the grain almost whole. The grain is then reground between closer-set millstones. It forms two grades of meal, the coarser of which is used for porridge and the finer to make bannocks or oat- meal cakes. A good deal of the oatmeal sold in America is identical with Scotch groats. True Scotch groats are heated by the miller over perforated iron plates and slightly parched for three or four hours before being ground. For those who can digest oatmeal well, it ranks among the cheapest and most satisfying of foods. The nutritious value of oatmeal is great, but it depends very largely upon the skill with which it is cooked. It is not infre- quently cooked in such a manner that the individual grains are left whole, but in this form the flavour is less well developed than it is by prolonged cooking; the oatmeal granules are much more diffi- cult of digestion, and are capable of exciting gastro-intestinal irritation in feeble persons. But for many people oatmeal thus cooked possesses a decided advantage from the fact that it is less completely absorbed, leaving a considerable residue which adds to the bulk of fiecal matter, excites peristaltic action, and reduces the liability to constipation. For most persons, however, and especially for all those with limited digestive power, oatmeal should be so thoroughly cooked as to acquire the consistence which enables it to be easily poured, and on cooling it should form a tender, gelat- inous mass. Oatmeal is a very hearty food, and those who eat much of it should live a vigorous outdoor life. If ill-cooked and if given to very young children, it occasions colic, flatulence, and rashes. It is best when of recent crop and freshly ground. If it is kept long it absorbs moisture, and, losing its delicate flavour, becomes mouldy and sour (Clark). 140 FOODS AND FOOD PREPARATIONS. The following analysis of oatmeal is given by Letheby. Nitrogenous matter 12.6 per cent. Carbohydrates, starch, etc 63 . 8 " " Fatty matter 5.6 " " Mineral matter 3.0 " " Water 15 o " " Total 100. o " " Oatmeal, like cornmeal, has more proteid and fat than the flours and meals derived from other cerealia, and hence, like bread, it may be eaten daily without impairing the appetite. Revalenta, or revalenta arabica, is a farinaceous food much eaten in some parts of Europe, which is a mixture of several meals, princi- pally ground peas, beans, corn, and lentils, but barley and oatmeal may be included. Arrowroot. Arrowroot is derived from the rhizomata or root stocks of several kinds of tropical plants grown in both the East and West Indies. The roots are washed, reduced to a pulp, strained, dried, and pulverised into a very fine starchy flour. The best flour is made from the Maranta arundmacea. It is obtainable in market in the form of a fine white powder, and consists of exceptionally pure starch, the granules of which are small and friable. It has a very bland, insipid taste, and it is as digestible or more so when cooked than any other starch which is used in making gruel or jellies for invalids. In the form of a jelly it keeps longer without souring than do many other forms of starchy food, such as the potato; and in bad cases of dyspepsia, when much gastric irritation exists, it often con- stitutes a serviceable article of diet. Arrowroot is sometimes fed to young infants, but it is unwholesome for them, and sours the stomach. Tous-les-mois. Tous-les-mois is a starch derived from a West Indian tuber by maceration, straining, washing, and drying. It is used for the same purpose as arrowroot. Its granules are the larg- est of any of the food starches, but they are quite digestible and nutritious for invalids. They are soluble in boiling water. Salep. Salep is a starchy food which is obtained from the tuber- cles of certain Oriental orchids. It is a mixture of starch and mu- cilage which makes a useful demulcent drink. Tapioca, Cassava. Tapioca and cassava are made from the rhizomata of the Manioc utilissitna (spelled also manihot), a common plant in temperate and tropical regions. It is extensively grown in South and Central America, Africa, and the West Indies. Manioc flour forms the basis of food of the natives, and when made into bread and cakes it replaces the wheaten bread of Europe and North America. Cassava contains a poisonous juice that must be first drained off. PLATE VT. ## \ MARUNTA i^ # SAGO PEAS BEANS STARCH GRANULES, MAGNIFIED. {From Bulletin No. IS, Division of Chmiidry, JMte(tlSldier:AjricuUund Bureau). DRAWN BY IJEO. MARX. VEGETABLE FOODS. 141 Tapioca, which is purified cassava, is made, like sago, by drying on hot plates, the clarified starch being first heated into a paste in large metal pans. It is an almost pure starch. The granules are not tough, and are very easily digested, so that they form one of the most useful of the amylaceous foods for persons with feeble digestions. Tapioca may be eaten alone in the form of puddings with cream or flavoured with lemon juice, wine, nutmeg or other spice or aromatic, or may be used to thicken broths or soups. " Pearl tapioca " is a spurious article made from potato starch. Sag^O. Sago is an easily digestible form of starch derived from the pith found in the stem of different varieties of palm from Sumatra, Java, and Borneo. It is commonly sold in market in a granular form, and is known as "pearl sago." This is prepared by adding water to sago flour so as to form a paste which is run through sieves to granulate it. The spherical form of the granules is ac- quired by allowing them to fall into a shallow iron pan held over a fire. Sago is made with milk, cream, and eggs into nutritious pud- dings, and it may be used to thicken broths and soups of various kinds. It has an agreeable flavour, somewhat more delicate than tapioca, and is an invaluable adjunct to the invalid dietary. Iceland moss {Cetraria) is a lichen sometimes employed as foo^ after purifying it by washing. It contains at first various bitter' principles, which must be eliminated. It can be made into bread or used as an ingredient of blancmange, etc. It has been recom- mended by Senator and others for use by diabetics to replace ordi- nary bread, and it makes a convenient vehicle for the administration of fats, such as bone marrow (Walker). It also forms a good demul- cent decoction. Several forms of seaweeds are used as food by the Japanese, Siamese, and Polynesians. Starchy Foods for Children. The best cereals and other starches for children are rice, hominy, Indian meal, barley, oatmeal, cracked wheat or wheaten grits, farina, cornstarch, and sago. When the cereal grains are used instead of flour, they should be soaked in cold water for five or six hours and then cooked for two or three hours in a double boiler. If fed to infants less than two years of age or to children with any gastro-intestinal disorder, they must be thoroughly strained. They should be salted and served with cream, but without much sugar. The steamed preparations of oats, wheat, etc., which are sold in market, may be boiled one hour, and otherwise treated as the grains. Bread and crackers may be allowed to infants after the first eighteen months, but only with their meals. 142 FOODS AND FOOD PREPARATIONS. The bread should always be porous, well baked, and stale. It may be toasted, or given dry in milk, or moderately buttered. Zwie- back and plain rusk is also good food for young children. Crackers are made in great variety for children. They should not be too dry or hard. They may be eaten in milk or with beef juice, or separately, with meals only. The best are those made of wheaten or Graham flour, oatmeal, or gluten. The latter are the least palatable. A large variety of prepared cereal foods are sold and recom- mended especially for children's use. These foods have been con- verted by heat or malt to dextrin and glucose or maltose, but they often contain a deficiency of flesh formers, and should never be long relied upon for feeding young infants to the exclusion of more natu- ral food (see Prepared Farinaceous Foods). Diastase, Malt Extracts, etc. Diastase is a vegetable ferment which has the property of con- verting starchy foods into a soluble material called maltose. It is soluble in water and weak alcohol, insoluble in stronger alcohol. Its advantage, as compared with similar ferments in the saliva and pan- creatic juice, is considerable, and its strength enables it to dissolve starches when present in the proportion of only i to 2,000. Like the above-named ferments, it acts in alkaline solution, but, unlike them, it continues to operate in acid media ; hence its action is not dis- turbed by the gastric juice. Diastase is the peculiar substance which causes the ripening during germination of fruits and vegetables by converting their starches into dextrins and sugars. Hence fruit becomes more and more digestible as it ripens. In prescribing diastase or malt extract it should be remembered that the ferment is precipitated and destroyed by alcohol of even mod- erate strength, and also by salicylic acid, which is antagonistic to it. When malt is added to a pease pudding or other mashed vege- table, it separates the mass into a paste of cellulose and vegetable casein, with a supernatant solution of dextrin. Williams recommends the use of malt flour with cereal foods to render them more digestible. Malt flour alone is too sweet, but, added in the proportion of one part to four or eight of oatmeal, it makes an excellent light, thin porridge for invalids. A variety of malt extracts and malted foods are prepared for in- valids, and many of them possess intrinsic value for nutrition and tonic action. They are especially useful in chronic and subacute ail- ments and convalescence from protracted fevers. They are benefi- cial in tuberculosis, caries, chronic abscess, neurasthenia, the scrofu- lous diathesis, typhoid fever, and to some extent they can be used as beverages to replace the stronger malt liquors, ale, beer, etc. VEGETABLE FOODS. 143 All fnalted foods are deficient in fats and proteids. Farinaceous meal of any kind mixed with one eighth of its weight of ground malt forms a highly digestible combination. Even 20 per cent of meal can be used, and the preparation still keeps fluid (Roberts). Kepler s Extract of Malt is given in the dose of a teaspoonful after meals in milk or soda water, or it may be spread upon any form of starchy food. Loeflund's Malt Extract is given in doses of a dessertspoonful after meals in a gobletful of milk. Maltine is made from three cereals barley, wheat, and oats. It is'rich in diastase. It may be added in the proportion of one half to wheat or barley flour which has been previously boiled in water, and the mixture may be used as a diluent of milk. Maltine may be taken after meals, either plain or added to cod-liver oil, coca wine, pancreatin, hypophosphites, etc., for use in tuberculosis and other diseases. Hoff's Malt Extract is given in doses of a wineglassful or more with meals for adults, and one or two tablespoonfuls for children. It contains considerable diastase, a minimum of alcohol (about 2 per cent), and is said to be free from noxious ingredients. It may be drunk warmed, with a lump of sugar added, as a soothing draught to allay cough. If desirable for feeble stomachs, it may be diluted with water or soda water. Trommer's Diastatic Extract of Malt is composed of the soluble ingredients of Canada barley malt. It is of a sirupy consistence and has a sweetish taste, which some patients object to, while many prefer it. The sweetness may be lessened or disguised by dilution with water, hot milk, brandy, whisky, or rum. It is advisable, if the stomach is feeble, to give teaspoonful doses at first, to be increased to a tablespoonful three times a day after meals. Pancreatic extract or three to five grains of pancreatin with five grains of sodium bicarbonate may be added to a cupful of thick, well- boiled farinaceous gruel of any sort oatmeal, cornstarch, etc. and if kept at 100 F_for a few minutes, the mass is soon liquefied and, made digestibje. The hydrated starch has been converted into dextrin and sugar. There is little or no alteration produced in taste, and if starch is to be given to an infant under a year old for any purpose, it may be prepared in this manner. Vegetable Food. Nearly all the great divisions of the vegetable kingdom afford wholesome food for man. Vegetable food eaten in large quantity increases the elimination of carbon dioxide from the lungs. It also makes the urine alkaline and intensifies the alkalinity of other secretions. The urine of her- 13 144 FOODS AND FOOD PREPARATIONS. bivorous animals is normally alkaline when they are well fed, but during prolonged fasting it becomes acid. The nursing calf when taking only animal food from the mother passes acid urine, but after weaning, when the animal changes to a vegetable diet, the reaction becomes alkaline. The chief vegetable proteids are vegetable albumin, vegetable casein or legumin, and gluten. The latter predominates in the cerea- lia, and the legumin is principally found in pulses. These ptoteids are less rich in nitrogen than the corresponding animal albumi- nates. Many vegetables contain tough cellulose, and at best not over 50 per cent of this material is digested and assimilated in man, although the lower animals derive much more nutriment from it. Cellulose added to meat interferes with its complete digestion (Hoffmann). A purely vegetable diet is not economical for a labouring man, for the reason that to derive sufficient nitrogenous substance from it he must either obtain the very best and most expensive cereals or legumes, or he must eat a very large quantity of vegetables. By the addition of albuminous food or fat to his diet he saves both expense and wear and tear of his digestive organs. If unable to obtain fresh meat, he may employ for this purpose milk, bacon, lard, dried fish, such as herring or cod. Apiong vegetable foods oatmeal and beans will furnish him with the largest available proportion of nitrogenous material. Vegetables, except those which are really seeds, such as those of the leguminosae or pulse tribe, contain but little fat. A strict classification of vegetables is impossible in these pages. Green corn is certainly a vegetable, but it is more conveniently described in connection with corn meal, samp, etc., among the cereals (see Maize). Certain vegetables are classed as "green vegetables," meaning the lighter kinds of vegetables which contain considerable earthy salts and comparatively little starch, like spinach and lettuce, in dis- tinction from heavy vegetables which contain much starch, like pota- toes, beans, etc. The former term is used to describe fresh garden vegetables of all kinds in distinction from those which, like potatoes or onions, may be kept for some days or weeks without spoiling. The name is, however, too vague for accurate description. " Greens " is the common name given to such vegetables as spinach, lettuce, beet tops, etc., which contain much chlorophyll and little starch or sugar, and which are eaten soon after being taken from the garden. A very simple division of vegetables to give to some patients is (a) those which grow above ground and {l>) those which grow below ground. With but few exceptions, like the legumes, corn, and cab- bage, the heavier vegetables i. e., those which require more digestive VEGETABLE FOODS. 145 power, and whicli contain abundant starch or sugar grow below ground, or are tubers. Those which grow above ground are more digestible when fresh and young. Celery, however, is not a tuber, is not especially " starchy," and yet grows, in part at least, beneath the earth ; so it is best in all im- portant cases to specify by name the individual vegetables which can be partaken of rather than to describe them in general classes. Many vegetables, in themselves difficult of digestion, may be made less so by conversion into well-cooked purees, or their extracts can be used for flavouring broths and soups for invalid use. Gener- ally speaking, dried vegetables are much less digestible than when fresh. They become hard, stringy, and tasteless. The following-named vegetables are those in common use which contain the largest percentage of both starches and sugars : Pota- toes (both white and sweet), yams, beans, lentils, corn, peas, carrots, parsnips, beets, turnips. Vegetable foods which are somewhat stimulant or pungent in their action are leeks, onions, garlic, herbs in general, mustard, cresses, mints, asparagus, and radishes. They increase the secretion of the saliva and gastric juice, and several are somewhat diuretic. Some vegetables are laxative on account of their special chemical composition. Such, for example, are spinach, tomatoes, and most green vegetables when fresh and well cooked. Some, like cucumbers, are laxative from the seeds, or, like old corn, from the indigestible residue which they contain. The heavier vegetables, such as peas, beans, turnips, potatoes, etc., are more apt to be constipating, al- though they aid normal peristalsis in that class of cases in which the .diet has been previously mainly nitrogenous (see Dietetic Treatment of Constipation). Vegetables which have a special antiscorbutic reputation are cab- bage, tomatoes, and all those used for fresh salads. These also fur- nish calcium oxalate in the urine. All vegetables which are eaten raw should be thoroughly washed beforehand ; otherwise they may be contaminated with manure and other impurities, or the excrement of domestic animals which have been roaming in the garden. The larvae of both tapeworms and roundworms have been transmitted to man in this manner. Water from foul wells is sometimes used for sprinkling gardens, and it is possible for typhoid, cholera, or other noxious germs to be spread by this means when the vegetables are eaten raw. Legumes. Peas, Beans, Lentils. Owing to the exceedingly leathery ex- ternal envelope which they possess when old, legumes are very indi- gestible unless cooked for a long time, and if dried they require pre- 146 FOODS AND FOOD PREPARATIONS. vious prolonged soaking in cold water, for drying diminishes their size and makes them extremely tough. Dried or " split " peas have had this envelope removed, and they may be made into nutritious purees. The tough external coats of old peas may often be found wholly unaltered in the faeces. According to Parkes, a pound of peas contains 168 grains of starch, and about 6.5 per cent of this food is wasted in the alimentary canal. Fresh very young green peas, petit pois, are easily digested, and may occasionally be allowed in a convalescent dietary, but old and tough legumes require more mastication even than meat. The legumes are often cooked with pork, which raises the per- centage of fat in this form of food and adds to their nutritive value. Baked beans are cooked in this way, and also pea soup ; the swelling starch granules mingle with the melting fat of the pork and make the dish more palatable as well as much more digestible than when this fat is added to meat in the form of croquettes or mince, when it merely smears the outside of the larger particles of food. Erbswurst, or pea sausage, was introduced some years ago in the German army. It was invented in 1870 by a cook named Griinberg, and the German Government bought the secret of its preparation. It is a cooked food composed of pea meal mixed with fat pork and salt, so treated as to prevent the decay of legumin. It is highly nu- tritious, for the peas contain a large proportion of nitrogenous as well as starchy material, and the fat furnishes energy, but as a diet it soon becomes monotonous and not infrequently produces flatu- lence and diarrhoea effects, for which the legumes are noted. The flatulence is caused by liberation of sulphuretted hydrogen from a substance called legumin. Erbswurst may be quickly made into soups. It figured largely in the Franco-Prussian War, and was known as the "iron ration." A powdered "pea soup " may now be obtained which is composed of powdered peas and extracts of bpef with salts and herb extracts for flavouring. A three-and-a-half-ounce package contains in grammes : proteids, 21 ; fats, 17.25 ; carbohydrates, 46.5. It is excellent for army service in the field. Composition of some Prepared Military Pea Foods (Woodruff). Water. Protein. Fat. Carbo- hydrates. Wood fibre. Ash. Authority. Erbswurst 12.09 31-18 16.00 15-70 16.93 15-81 21.09 3-08 35-00 23.00 8.98 24.41 17-25 47-50 27.00 53-44 36.78 46-45 1-34 1.69 4.40 6.15 11-73 13-53 6.03 Blythe, Parkes. " as first used. 1887 Dried pea soup (i).. . . " " " (2).... Kopfs " " (used by the English army). 7-58 8.08 4.78 Konig. S. P. Sharpless PLATE VIT. > | *v?s'8 .irOrs Bean Starch x 145 Pea Starch x 145 (f^om Bulletin No. 13, Divmxm of Chemitiry, United StaU: AgricuUunU Bureau). IIOTO BY I'LlrroHll KIIHARIISON. VEGETABLE FOODS. 147 Penzoldt has succeeded in obtaining predigested vegetable albu- min by the following receipt: Finest pea meal 250.0 grammes. Pepsin V 0.5 gramme. Salicylic acid i . o " Mix and let stand at 100 F. for twenty-four hours ; strain. The fluid retains the taste of pea soup, and is quite free from starch. It may be added to meat extracts or eggs, and may be fla- voured with salt, pepper, and spices. Haricot or kidney beans constitute a very serviceable article of diet, being one of the cheapest and best of all the pulses. These beans must be thoroughly soaked until swollen and soft before boiling, and should be only eaten when wholly tender. Their flavour is height- ened by the addition of a little onion, parsley, or other aromatic vegetable, and their nutritive value is increased by cooking them with pork. Fresh, young, and tender string beans are very digestible. Young fresh Lima beans are wholesome and very nutritious, but if old they are quite indigestible. Lentils. Lentils grow in the south of France, and also near Paris. They are usually dried and split, in which condition they make an excellent and nutritious soup. They are used more on the Continent of Europe than in this country, and to some extent they are eaten in England, usually in the form oi pur^e. They are sold under the name of " ravelenta arabica " of which they form an ingredient (p. 140). Their taste is somewhat bitter, and on that account, unless disguised by some other vegetable fla- vour, they ^e disliked by many persons. Like the other legumes, they contain proteid material and fat, and are quite nutritious. Roots and Tubers. Roots and tubers constitute a very important class of vegetable foods. They contain both starch and sugar as well as a little pectin and potash salts. They have much less albuminous material than is to be found in any other forms of starchy food, and they also hold a large percentage of water. Many of them are very nutritious and even fattening, but in proportion to their bulk they afford less actual nutriment than either the legumes or cereals. Potatoes. The potato ranks first in importance among the class of tubers which serve man for food, both on account of its easy cul- tivation in a great variety of soils and on account of its easy digesti- bility, when properly cooked. As an exclusive article of diet the potato is too largely composed of starch to be of much nutritive 1^8 FOODS AND FOOD PREPARATIONS. value, and enormous quantities have to be eaten (several pounds a day) in order to supply enough nitrogen for the energy of the body. In Ireland this form of vegetable constitutes a greater proportion of the daily food than in almost any other country, and in periods of famine has been known to form four fifths of the entire food for a time, but of late years it has been largely supplemented by the cul- tivation of Indian corn and other products. The flavour and quality of the potato is influenced very much by the soil and climate in which it grows, a sandy soil being best. Konig gives the percentage composition of the potato as water, 75.77; nitrogenous materials, 1.79 (others give 2.10); fat, 1.60; starch, 20.56 ; cellulose, 0.75 ; ash, 0.97. It is thus seen to contain about one fourth solid matter. The potato becomes a much more strengthening food when eaten, as it usually is, with meat gravy, fat, or butter and salt. Potato juice has a faintly acid reaction, and its vegetable acids are mainly combined with salts of potassium, but also with sodium and calcium. It also contains traces of iron, phosphoric and sul- phuric acids, chlorine, silica, and magnesia. Owing to the large proportion from 12 to 24 per cent of nearly pure starch which is found in the potato, it is very extensively used in this country and elsewhere for the manufacture of laundry starch. Old potatoes, and those which have been long kept, show some alteration in the quan- tity of their starch, and a part is converted into sugar and gum. Potato starch, as compared with other starches, is thoroughly digestible, but much depends upon the cooking. The starchy gran- ules are tough and absorb water from the acid juices which surround them and from water added in cooking, and when properly prepared the potato becomes soft and mealy. When this is not the case, how- ever, it remains hard and soggy, and is thoroughly indigestible. The following statement in regard to the potato is made in a re- cent report of the British Commissioners of Prisons: "Within and surrounding the cells is a fluid or juice the albumi- nous constituents of which are coagulated during the process of cook- ing. The watery part of this juice is absorbed by the starch gran- ules, which swell up and distend the cells in which they are con- tained, so that they no longer adhere together, and the result is the loose flocculent mass which is described as a floury or mealy potato. Unless the potato be properly cooked, the fluid referred to is only partially absorbed, the cells do not become sufficiently distended and separated, and the potato is then described as 'waxy' and 'dense.' In this condition it is not digested, and consequently does not fur- nish to the system the antiscorbutic principle in which resides its chief value as an article of diet." When potatoes are cooked in water, it is desirable not to remove PLATE VIII. POTATO Starch x 43 Potato Starch {Fom HulUtin So. 13, LHvwion of ChemiMry, Unik'd SUiU: AgricuUunU Bureau). I'IKiTO BY > I.ItKi'KI) RIiHARrmilN. VEGETABLE FOODS. 149 their skins, for the latter prevent to a great extent the passage of the salts out into the fluid. The fact that potatoes will not decay if kept dry for a length of time makes them very useful vegetables upon sea voyages, when their antiscorbutic properties are especially serviceable. Potatoes are more digestible when cooked by baking in their skins than by any other process. They then become mealy and their starch is digested with comparative ease by invalids. They are also quite digestible if steamed, or if boiled and mashed through a colander. Potatoes must be avoided in all cases of feeble digestion unless they are perfectly mealy and crumble readily, and this quality de- pends not alone upon the method of cooking, but upon the nature of the potato itself, which varies according to the soil or the season of the year in which it has been grown. Very young potatoes are not mealy. They require more cooking and are less digestible than those of medium age. If too old, on the other hand, potatoes become waxy and equally undesirable. If they have been exposed to frost or have been cultivated in a damp, boggy soil, their digestibility is much impaired. Sweet Potatoes. The variety known as the sweet potato contains somewhat less starch than the white potato, having but 16 per cent, but it has more water, and a larger proportion of sugar 10 per cent. It forms a valuable and decidedly nutritious food which is eaten ex- tensively throughout the United States, but it is not so digestible as the white potato, for it cannot always be obtained in a mealy form, and is sometimes stringy and sodden. A flour or meal can be pre- pared from it by drying. Its use in Europe antedates that of the white potato, which has to a great extent superseded it. These po- tatoes vary much more in flavour than do the white. In general, they should not be given to invalids. The yam^ another form of tuber, is eaten in the tropics and in some parts of Europe. It is mealy, but not very sweet, and it con- stitutes a wholesome and thoroughly digestible food. The Jerusalem artichoke, or ground pear, is a tuber belonging to the sunflower family, which was originally introduced from Brazil. It is used more commonly in England than elsewhere, but is also sometimes cultivated in the United States. It is sweet and watery, for it contains but little starch, and it does not cook "mealy." It contains more sugar than the sweet potato, having 14 per cent of sugar, 3 per cent of nitrogenous material, and 2 per cent of inulin (Yeo). Its nutritive value is comparatively slight, but it is easily digested. The Beet contains among its solid ingredients between 85 and 90 per cent of starches and sugars, a trace of salts, and somewhat over I per cent of proteid matter. It is a common source of sugar, 150 FOODS AND FOOD PREPARATIONS. which when refined is sometimes less sweet than cane sugar, but is otherwise as good. On account of the sugar which they contain, beets have the reputation of contributing to the formation of fat in the body. Young, tender beets are very nourishing, and they are often eaten in the form of salads or with vinegar and oil, and thus contribute a useful variety to the diet. Succulent Tubers. There is a group of succulent roots which contain considerable watery juice and on this account are usually eaten fresh, for if kept long they become dry and less palatable, or are apt to decay; with care, however, they may be preserved in their natural state for a considerable period. They are very digestible, and when thoroughly boiled are nutritious. They are carrot^, pars- nips, turnips, and salsify. To these may be added the radish as be- longing to the same type, although it is too pungent to be eaten otherwise than as a relish, and on account of its flavour it is pre- ferred raw. Carrots consist of upward of 85 per cent of water, with a small proportion of salts, 8 per cent of carbohydrates with some sugar, and about I per cent of proteid. The outer layers of the carrot contain a material called pectin that can be obtamed as a jelly and mixed with fruit or meat jelly for flavouring invalid diet. Young carrots, when soft and friable, if boiled are very tender and highly flavoured, and constitute a nutritious food. In France and Germany they are more popular than in this country and are cooked with other vegetables, although somewhat at the expense of the flavour of the latter. At the baths of Vichy they form a part of the daily breakfast. Parsnips contain the sugar of starch with a large percentage of water, and they are sometimes fermented into an alcoholic beverage. They are a wholesome although less used food than carrots. The parsnip contains over 90 per cent of water and only 6 per cent of starch and sugar, with i per cent of proteid, besides other materials. It is a rather strongly flavoured vegetable, and bulky in proportion to its nutritive value. It is extensively used for feeding cattle, and when young and properly cooked by prolonged boiling and season- ing it is a good food. It should be particularly avoided by those persons in whom there is any tendency to flatulency, which, like the legumes, it is apt to produce. Turnips are less nutritive than either carrots or parsnips. They should never be eaten by the sick. Kohl rabi, or turnip-root cabbage, yields an overground turnip, which is somewhat astringent. Salsify, or oyster plant, is a root which has a mild sweet flavour somewhat similar to the parsnip, and is an excellent food of easy digestibility. VEGETABLE FOODS. 151 Radishes, which are not unlike turnips in composition, contain a large percentage of water and a comparatively small amount of starch. This vegetable is of no special value for nutrition, and serves merely as a relish. Being eaten raw, it is difficult of digestion, and is apt to produce eructations. It has some reputation as an anti- scorbutic. Green Vegetables. Composition. Green vegetables do not contain much nutriment in comparison with the cereals and tubers, and they are mainly useful for furnishing a pleasing variety in diet and for supplying a large proportion of salts and some acids which are believed to be service- able in the prevention of scurvy. The various uses of the salts have been elsewhere described (see p. 38). These vegetables often con- tain 90 per cent or more of water, which in itself is useful to the system in many ways. They furnish but a small quantity of nitro- genous material, which varies from 1.5 up to 4 per cent. In addition, they contain cellulose, chlorophyll, sugars, gum, pectin, and some- times a little fat. Their variety of taste depends upon the presence of flavouring materials, chiefly essential oils. As a rule, they have a better flavour, and are more digestible when young than old, when they become tough and " stringy " from a relatively large percentage of cellulose or woody fibre. Since the green vegetables afford so little nutriment in proportion to their bulk, they are not of much service for persons with feeble digestion, and, unless they are young and tender, they are positively harmful by overtaxing the digestive system and irritating the alimentary canal. On the other hand, they are very useful in overcoming constipation by their bulky waste matter, which acts as a mechanical stimulus to peristaltic action and promotes movement of the bowels. The digestibility of these vegetables is rendered much greater by careful cultivation in suitable soils. Owing to the large quantity o water which they hold (which readily evaporates), they soon wilt or become dry in market. For the most part they should be eaten when quite fresh, although winter cabbage is an exception to this, as it may be kept for weeks. Fresh green vegetables as well as roots or tubers are always made more digestible by cooking, which softens them. Their most diges- tible form for invalids is that oi purees. Cabbagfes. The cabbage family, which belongs to the natural order Cruci/ene, furnishes many examples of green vegetables, some of which are of value for their leaves, and others for their modified flowers. There are about seventy varieties of cabbages. They con- tain considerable sulphur, which, if malfermentation exists in the alimentary canal, produces sulphuretted hydrogen, causing flatulence and unpleasant odour. They also give rise to calcium oxalate in the 152 FOODS AND FOOD PREPARATIONS. urine, and they should be avoided by the rheumatic or gouty, and, in fact, by all classes of invalids. Cabbages and other vegetables of this order impart a strong taste and odour to the water used for boiling them. When soft and crisp, cabbage is a wholesome food for those with strong digestion, and it has decided antiscorbutic proper- ties when fresh, which are lessened by fermentation. The principal edible representatives and preparations of the cab- bage family are the following : 1. Sauerkraut is made by placing salt between layers of cabbage leaves and subjecting them to pressure, which bruises them and squeezes out their juices. The mass then ferments with the forma- tion of acids. 2. Cauliflower and broccoli are the flowers of the plants which are grown large and tender by cultivation. When boiled and served with a milk sauce they are much esteemed for their flavour and easy digestibility in healthy stomachs, but they cause flatulence if eaten by dyspeptics. These vegetables may be dressed with olive oil and eaten as a salad. 3. Coleslaw is sliced cabbage served as a salad. 4. Seakale is grown in the dark so that it has no chlorophyll. It is equally digestible with the cauliflower if well bleached. It is more often cultivated in England than in this country. Spinach, beet tops or greens, dandelion tops, and turnip tops are all useful green vegetables, and of these spinach, which is slightly acid, is the most common and desirable. These substances afford almost no nutriment, and are valuable chiefly for their laxative action. If the leaves are young and tender, and if they are cooked until they become quite soft and are then chopped into a fine pulp, they are very wholesome articles of food for the relief of chronic constipation. The dandelion leaves have a less delicate flavour than spinach, and are said to possess a slight diuretic action. Unless bleached they are apt to be bitter. The dandelion root is laxative, like the leaves, and it forms an ingredient of root-beer. Lettuce, etc. There is a group of vegetables of which lettuce is the chief type, the leaves of which are eaten raw. They are useful for their flavour and for the variety which they furnish in the course of a meal. They cannot be said to possess any nutrient value, but they are usually taken with vinegar and oil, and the latter is very nourishing. Since they contain but little starch and practically no sugar, they may be allowed in the diabetic regimen. Sorrel and cress, or peppergrass, are used in the making of salads, but less in this country than in Europe. Sorrel has a somewhat pun- gent or acid flavour, which is due to acid oxalates, and this fact ren- ders it unfit for use by patients who are subject to attacks of gout and rheumatism or who have the uric-acid diathesis. VEGETABLE FOODS. 153 Many other substances are mentioned in works on dietetics which are used in the making of salads or pickles and as relishes. They are antiscorbutic and serve to stimulate the digestive secretions and give a fillip to the appetite. Such are green peppers, capers, mint, tarragon (an aromatic Siberian plant), parsley, chervil, endive, chicory, okra. Celery is a wholesome vegetable when cooked in milk until it is quite soft ; but eaten raw it is stringy, and, as it has but little nutri- tive value, its use in that form should be discarded by invalids. Its aromatic flavour makes it very popular, and it furnishes a useful addition to a light luncheon with bread and cheese. It has acquired an undeserved reputation for use in rheumatism. " Celery salt " is an agreeable flavouring substance for soups and salads. Various preparations are made from the plant, which are sold by druggists as hypnotics. They are of no value. Artichokes are a variety of thistle. They contain tannin and mu- cilaginous materials, but nothing of true nutrient power, although, according to Moleschott, they hold 17.75 P^^ cent of organic matter. Green artichokes when tender and thoroughly cooked are easily digested, but their cost in this country prevents them from being consumed except as an article of luxury. They may be given to some diabetic patients among the few vegetables which they can eat with impunity. Eaten raw, as they sometimes are ir^ France, they are very indigestible. Tomatoes. The tomato is a vegetable which was introduced into this country about fifty years ago, the value of which is becoming more and more appreciated. In Germany it is still sold as a fruit of luxury rather than as a common vegetable. It is wholesome when eaten raw as a salad with vinegar and oil, and it forms a popular in- gredient of strong condiments, such as tomato catsup. It is refresh- ing, slightly acid, and easily digested. The oxalic acid which it con- tains makes it injurious in cases of gout or the uric-acid diathesis. The tomato is much prized as a canned vegetable on account of the fact that it retains more of its original flavour than do most vege- tables preserved by this process. The eggplant is related to the tomato, and like it contains many seeds when full grown, but it is much less digestible, especially when fried, and is not a suitable food for invalids. Cucumbers are mainly eaten raw, and they should be young. Like celery, they contain too much woody fibre to be consumed in bulk. They are valuable for pickling in vinegar or in the making of chow- chow, but they are always indigestible; this is due in great part ^o the large size of the seeds which the vegetable contains, and it should never be eaten by any one excepting those having vigorous 154 FOODS AND FOOD PREPARATIONS. Stomachs. Eaten raw, even in small quantities, it may pioduce vio- lent colic and diarrhoea. Asparagus is a vegetable possessing a very deiicate flavour, and from the fact that it is among the first of the fresh vegetables to ap- pear in the early spring it is highly esteemed. When young and tender it is very digestible, even for invalids. The greener asparagus contains more bitter and resinous principles* than the white. It has been claimed that it possesses some influence as a cardiac sedative as well as aphrodisiac action, but these properties are imaginary. It is, however, slightly diuretic, and it owes this influence to a substance called asparagin, which may be obtained in crystalline form. Aspara- gus imparts a very strong and disagreeable odour to the urine which I have known to appear within an hour after it has been eaten, and which persists from twelve to twenty hours. It is caused by a vola- tile sulphur product, a methyl mercaptan, which has been proved to originate in the intestine during digestion, from whence it is ab- sorbed. Rhubarb, or " pieplant," the stems of the leaves of which are eaten stewed, is an excellent vegetable. The flavour is quite tart, and the fibre is stringy, but thorough cooking renders it soft and digestible. It is laxative, and is therefore useful in cases of chronic constipation. This wholesome vegetable has not received the atten- tion it deserves. In Germany, for instance, it is still grown merely as an ornamental garden plant on account of its large showy leaves. It produces calcium oxalate in the urine if eaten in excess, and must therefore be avoided in oxaluria, gout, and rheumatism. Pumpkins and squash contain much water and a good deal of coarse fibre. Tender and young summer squash is fairly digestible, but presents no special dietetic advantages. The pumpkin is one of the oldest vegetables on this continent, and it was grown extensively together with maize by the early Indian tribes. Onions, garlic, shallots, and leeks, which are edible both as fresh vegetables, and after long keeping, are useful as condiments for fla- vouring salads, meat stews, and other foods. They are also eaten independently for their nutritive properties, which are somewhat greater than those of the four or five vegetables last considered. Tender young leeks and white onions boiled and served with milk or cream are very wholesome and of delicate flavour. They possess, in common with the other green vegetables, a moderate laxative action, and are antiscorbutic. They impart a strong typical odour to the breath, which appears within two or three hours, and if the individual is constipated, persists for twenty-four hours or more. This is due to volatile substances which are absorbed by the blood from the ali- mentary canal and carried to the lungs, where they are liberated. Vegetable marrow is a highly succulent vegetable, somewhat re-. VEGETABLE FOODS. J.W sembling the pumpkin. It possesses an agreeable flavour, but con- sists so largely of water that it is of scarcely any use as food. Cranberries are really more of a fruit than a vegetable, but they are usually eaten with meat as a vegetable. They are serviceable for their agreeable acidity and flavour, but unless very thoroughly cooked and made into a jelly with much sugar, they are indigestible, for their outer coatings are extremely tough. They should never be given to invalids. The composition of some common vegetables is thus tabulated by Moss : Composition of Vegetables. Constituents. Potato vPayen). Potato (Lethe- by). Sweet potato (Payen). Jerusa- lem ar- tichoke. Carrots (Lethe- by). Parsnips (Lethe- by). Turnips (Lethe- by). Cab- , bage. Nitrogenous matter Starch, etc 2.50 20.00 1.04 1.09 O.II 1.26 2.1 18.8 3-2 0.2 0.7 75-0 1.50 16.05 0.45 10.20 0.30 2.60 1. 10 67. 50 3-1 1-5 14.7 0.2 1-3 0.9 0.4 1.9 76.0 1-3 8.4 0.2 I.O 83.0 I.I 9.6 5-8 0.5 1.0 82.0 1.2 5-1 2.1 o!6 91.0 2.0 Cellulose 0.5 0.7 Sugar and gummy matter Fatty matter Saline matter Other organic matter.. . . Pectic acid Pectin Inulin Water 74. CO 91.0 Total 100.00 100. 100.00 100. 100. 100. 100. 100. The following analyses of common vegetables have been made by Konig : Water Nitrogenous matters.. . Fat Sugar Other non-nitrogenous ex- tractives Cellulose , Ash Carrots. Turnips. j Beet root. 88.32 91.24 87.07 1.04 0.96 1-37 0.21 0.16 0.03 1.90 4.08 0.54 7-17 . 1.90 9.02 0.95 0.91 1.05 0.71 0.75 0.92 Celery. 84.09 1.43 0.39 0.77 11.03 1.40 0.84 Onions. 85-99 1.86 o.io 2.78 8.04 0.71 0.70 Cabbage. 89.97 1.89 0.20 2.29 2.58 1.84 1.23 Water Nitrogenous matters Fat Sugar Other non-nitrogenous ex tractives Cellulose Ash Cauli- flower. Brussels sprouts. Spinach. Lettuce. Asparagus. 90- 39 85.63 90.26 94-33 93-32 2-53 4.83 3.15 1. 41 1.98 0.38 0.46 0.54 0.31 0.28 1.27 0.08 0.40 3-74 6.22 3.26 2.19 2.34 0.87 1.57 0.77 0.73 1. 14 0.82 1.29 1.94 1.03 0.54 French beans. 88.36 2.77 0.14 1.20 6.82 1. 14 0.57 1^6 FOODS AND FOOD PREPARATIONS. The two preceding tables differ slightly in detail, but no rtiore than the average variation in percentage composition of the vege- tables when not grown under identical conditions. They agree as nearly as can be expected. Fruits. Composition. The varieties of fruits which are consumed in all countries are innumerable, and their uses are various. Sweet fruits no doubt largely composed the diet of primordial man, as they do of every savage tribe to-day living outside .of the Arctic Zone. Speaking generally, fruits are composed largely of water with starches, sugars, a vegetable jelly called pectin, cellulose, and organic acids. Pectin is a carbohydrate substance found in ripe pulpy fruits. It enables fruits to gelatinise when boiled. Its properties and com- position are not thoroughly understood. The organic acids exist mainly in union with alkalies, forming compounds which are readily split up in the system, leaving the al- kalies free to combine as carbonates or phosphates. The most important acids are citric, malic, and tartaric, which exist in various quantities and combinations. Citric acid predominates in lemons, limes, and oranges; tartaric acid in grapes ; malic acid in apples, pears, peaches, apricots, goose- berries, and currants. Among the least acid of the common fruits are peaches, sweet pears, sweet apples, bananas, and prunes ; moderately acid are straw- berries. The most acid of all are currants and lemons. Fruits contain a smaller proportion of earthy salts than other foods. Certain fruits also hold a little nitrogenous material, chiefly as albumins, but, as a rule, the starches and sugars predominate, and the nutritive value of any fruit depends upon them chiefly. Most fruits contain too much water to constitute an economic diet if eaten alone. Some also contain a small quantity of fat and waxy matter, and most of them have more or less pigment. Fruits which are especially rich in flavour, and which exhale a pleasant aroma, owe these conditions to the various essential oils and compound ethers which they possess in considerable amount. Many fruits are only partially edible owing to the fact that they are composed of a pulp contained within an indigestible structure of cellulose or woody fibre. Fruits are commonly classified into stone-bearing fruits, pomes, berries, capsules, and pepos. Some, such as the date, the plantain and its variety, the banana, afford sufficient nutriment to amply sup- port life for a long time ; others, like the apple, are wholesome, but VEGETABLE FOODS. 157 slightly nutritious; while others again are of little value for nutri- tive purposes, and are mainly serviceable for their agreeable flavour to furnish variety in the diet. Composition of Fruits (Bauer). Orange, pulp cnly. Water Nitrogenous matters, Free acids Sugar , Other non - nitrogenous matters Cellulose and kernel Ash Apple. Pear. Peach. Grape. Straw- berry. Currant. 83.58 0.39 0.84 7-73 83.03 0.36 0.20 8.26 83.03 0.65 0.92 4.48 78.18 0.59 0.79 24.36 87.66 1.07 . 0.93 6.28 84.77 0.51 2.15 6.38 5-17 1.98 0.31 3-54 4-30 0.31 7-17 6.06 0.69 1.96 3.60 0.53 0.48 2.32 0.81 O.QO 4-57 0.72 89.01 0.73 2.44 4-59 0.95 1.79 0.49 Composition of Fruits (Yeo). Apple. Cherry. Raisin. Fig. Water 27-95 1.28 0.82 3.60 42.83 17.00 4-95 1-57 49.88 2.07 0.30 32.22 14.29 0.61 1.63 32.02 2.42 0.49 54.26 7-4S 1.72 1. 21 31.20 4.01 1.44 I. 21 Nitrogenous matters Fat Free acid Sugar 49-79 4.51 4.98 2.86 Other non-nitrogenous matters Cellulose and seeds : Ash Fruits arranged According to the Proportions between Acid, Sugar, Pectin, Gum, etc. (^Average). (Fresenius.) Fruits. Plums Apricots Peaches Raspberries.. . . Currants Blackberries . . . Whortleberries. Strawberries . . . Gooseberries. .. Prunes Apples Sweet cherries.. Grapes Red pears Acid. Sugar. Pectin, gum, etc. 1.6 3-1 1-7 6.4 2.3 II. 9 2-7 I.O 3-0 0.1 3-7 1.2 4-3 0.4 4.4 0.1 4-9 0.8 7.0 4-4 II. 2 5-6 17-3 2.8 20.2 2.0 94.6 44.4 Fruits arranged in the Order of their Content of Sugar (^Average). (Moss.) Peaches 1.6 per cent. Apricots 1.8 " " Plums 2.1 " " Reineclaudes 3.1 '* " 1 53 FOODS AND FOOD PREPARATIONS. Mirabelles 3-6 percent. Raspberries 4-0 Blackberries 4-4 " Strawberries 5-7 " " Whortleberries 5-8 " " Currants 6.1 Prunes 6.3 " " Gooseberries 7-2 " " Red pears 7-5 " " Apples 8.4 Sour cherries 8.8 " " Mulberries 9.2 " " Sweet cherries 10.8 " " Grapes 14-9 " " Uses and Properties. The uses of the different fruits may be summed up as follows: 1. To furnish nutriment. 2. To convey water to the system and relieve thirst. 3. To introduce various salts and organic acids which improve the quality of the blood and react favourably upon the secretions. 4. As antiscorbutics. 5. As diuretics, and to lessen the acidity of the urine. 6. As laxatives and cathartics. 7. To stimulate the appetite, improve digestion, and give variety in the diet. 8. As special " cures " for certain diseases, like the grape cure, although their specific action is very doubtful. Fruits which afford the most nutriment are the banana, date, fig, prune, and grape. This is due to the large proportion of sugar which they contain. Fruits which contain the most water are muskmelons, water- melons, oranges, lemons, shaddocks, and grapes. The antiscorbutic value of fruits is illustrated particularly by cer- tain varieties which furnish abundant potash salts, as well as lime and magnesia. Among these are to be mentioned apples, lemons, limes, and oranges. The diuretic influence of fruits is in part due to their water, but chiefly to their organic acids and salts, which stimulate the circula- tion and probably, also, the activity of the renal epithelium. Fruit eating lessens the acid of the urine or even makes it alka- line owing to decomposition of various alkaline salts in the blood or tissues, which are reformed into alkaline carbonate and, as such, are excreted. For this reason fruit is generally believed to be bene- ficial in lithsemia, gout, and allied conditions to prevent accumula- tion of acid urates. The laxative action of fruits is partially derived from indigestible VEGETABLE FOODS. 159 substances, cellulose, seeds, etc., and also, no doubt, from the special influence of their organic ingredients, which in some instances is very striking. The best fruits to offset constipation are fresh apples, figs, prunes, peaches, and berries. Dyspeptics must be careful to avoid eating all hard skins, seeds, or coarse-fibred fruits. Fruit Ripening. As fruit ripens it absorbs more and more oxygen, and the tannin and vegetable acids which it originally contained are altered, so that it becomes less astringent and acid. The starch i| more or less completely turned into levu- lose or glucose, and soluble pectin is formed. The aroma and taste of ripe fruits depend upon the relative quantity of these different substances, together with various volatile ethers and oils. The sour fruits have either more acid or less sugar, and in the sweet fruits there is a preponderance of sugar which masks the acid taste. The more luscious the fruit, the more soluble sugars and special flavour- ing substances does it contain. The employment of fruits as a common article of daily diet is highly beneficial, and the improvements which have been made of late years in methods of culture and means of rapid transportation make some varieties of fresh ripe fruits, such as the orange and the banana, available in almost every climate in all seasons, while their mcreasing cheapness places them within reach of the poor. Fruit Poisoning. While fruits eaten daily and in proper mod- eration are very wholesome, if they are eaten too freely, or if they are either insufficiently ripe or overripe, soft, and decomposing, they undergo malfermentation in the alimentary canal, and are al- most certain to cause diarrhoea with colicky pains, cramps, and some- times nausea and vomiting. Severe attacks of gastritis may, espe- cially in children, be produced by indulgence in unripe apples, pears, cherries, berries, etc., and even fatal choleraic diarrhoea has been occasioned by the indiscriminate consumption of fruits which have strongly laxative action. After such fruit poisoning, emesis should be excited if the patient is seen in time, and otherwise, if free purga- tion has not occurred, it is advisable to give a dose of castor oil or other cathartic, to remove the irritating substances as soon as pos- sible from the alimentary canal. In bad cases, prolonged gastric fever may ensue. When to Eat Fruit. Cooked fruits may be eaten with any meal, but usually when fruit is eaten for special dietetic purposes its effect is always more pronounced if taken alone, either at the commencement of meals or, better, between them. One often observes patients who can obtain no laxative effect from apples, figs, and other fruit eaten as dessert, but which taken at night into an empty stomach or an hour before breakfast, with a glass or two 13 l6o FOODS AND FOOD PREPARATIONS. of cold water, has a very pronounced favourable influence upon the bowels. The poorest time for eating fruit is at the conclusion of a very- hearty dinner at which considerable variety of food has already been consumed. Fruit in general is less wholesome when eaten out of its natural season. All fruits, such as berries, the seeds of which are eaten, are much less liable to produce intestinal irrita- tion if taken with bread or other bulky starchy food. Fruit Soups. In Germany fruit soups are more in vogue for general use than in this country, and they are often prescribed in fevers when diarrhoea does not exist. Uffelmann directs that for making a fruit soup one part of fruit to four or five of water may be used, and Bauer recommends soups "made by boiling fresh or dried fruits with water, with or without the addition of sugar, lemon peel, etc., and freed from the solid residue by pressure." Dried Fruits can be eaten less abundantly than fresh fruits. Some of the dried fruits are wholly indigestible; such are currants and citrons. Others, like figs or prunes, are wholesome, and raisins, sultanas, dates, etc., contain considerable nourishment. All these dried fruits are preserved in their own sugar (glucose), which forms a sticky, gummy, non-crystallised mass, Dried apples, peaches, prunelles, etc., are preserved simply by the evaporation of the excess of water which they contain. Dried "currants" are the berries of a vine cultivated in the Ionian Islands. According to Pavy, the word currant is a cor- ruption of Corinth. The fruit in its dried state is wholly indi- gestible. When dried fruits, such as figs or dates, have become too hard they may be softened and made more palatable by pouring boiling water over them and allowing them to soak for a few hours, or the fruit may be put into cold milk and brought to the boiling point over the fire. This method will soften them in a quarter of an hour. A simple fruit diet which has been advocated for the cure of obesity and other ailments is the following: Three meals a day are eaten, consisting of half a pint to a pint of milk, with from two to six ounces of whole-meal bread and a similar quantity of figs or dates, prepared in milk as above described. Obviously this diet is not sufficiently sustaining to be long endured. Digestibility. Among the commoner fruits of easy digestion are grapes, oranges, lemons, cooked apples, figs, peaches, strawber- ries, and raspberries. Somewhat less digestible are melons, prunes, raw apples, pears, apricots, bananas, and fresh currants. Of course the digestibility depends very much upon ripeness and VEGETABLE FOODS. l6l freshness of the fruit as well as personal idiosyncrasy, and any classi- fication can only be approximate. Fruits most Useful for Invalids. The most useful fruits for the sick are lemons, oranges, baked apples, stewed prunes, grapes, banana meal (not the fruit pulp). Varieties of Fruits. Lemons, limes, and shaddocks may be con- sidered together as possessing the same general properties. Owing to the potash and other salts and abundant vegetable acids which they contain, they are the most serviceable of the antiscorbutic fruits, and also afford an agreeable acid and pungent flavour to articles of diet which might become monotonous in taste. For many persons the addition of a little lemon juice to some articles of food, such as cooked cereals and porridge or broiled fish, renders them more im- mediately digestible, and it can be regarded as having almost a specific action in promoting gastric digestion, although it is difficult to say in just what manner this comes about. Lemons are therefore a most desirable addition to the diet kitchen. Lemon juice is a well-known mild remedy for seasickness, and holding a thin slice of freshly cut lemon in the mouth often removes the disagreeable taste from a coated tongue, cleanses the mouth, and may even counteract nausea. Sour lemonade taken in moderation, and made quite strong by squeezing the juice of one or two lemons in a small tumblerful of water, with the addition of only one or two lumps of sugar, is a cooling and refreshing drink in fevers, and does more to diminish the craving of thirst than almost any other form of beverage. For those who fancy effervescing drinks, the lemonade may be improved by using one of the aerated waters such as Apollinaris, Vichy, or carbonic-acid water instead of plain water, or efferves- cence may be produced by the addition of five or ten grains of sodi- um bicarbonate. In many cases this mild remedy is beneficial to the stomach. Henry claims that pure lemon juice poured into the nose will often control epistaxis. Limes. The lime is a thin-skinned acid fruit, but there is also a sweet variety. Although less extensively eaten throughout this country than the lemon, which it resembles in effect, it is equally serviceable, and nearly ten thousand gallons of condensed lime juice are imported annually into this country, from Jamaica. To make this juice the fresh limes are pressed by machinery, and the seeds and pulp are removed by straining and filtering. The juice is then boiled down to a high degree of concentration. It is carried to prevent scurvy on sailing vessels, and used in almshouses and pris- ons, where the diet is monotonous. The shaddock, pomelo, or citrus pomelanus, is a very large, globular, l62 FOODS AND FOOD PREPARATIONS, pulpy fruit, which grows in clusters on pendant branches. The rind is thick and acid, and the very juicy pulp is bitter. The fruit keeps fresh for a long time. It is coming into general use of late, owing to improved methods of cultivation, although it is still a relatively expensive fruit in most parts of the country. Many per- sons find that half a shaddock taken at the commencement of break- fast has both a laxative and diuretic action, and it is always cool- ing and agreeable to those who do not dislike a bitter taste. The objection to its use is that it requires a large quantity of sugar to make it really palatable and diminish its astringency. This is dis- advantageous in cases of flatulent dyspepsia, but for invalids who are convalescing from prolonged fevers, suppurating disease, etc., an excellent tonic may be given by cutting a shaddock in two and pouring half an ounce or more of good rum into the fruit, with the addition of a little sugar. The bitterness is entirely disguised and the combination is agreeable and appetising. Oranges. Oranges are an exceedingly useful article of invalid diet. The juice of ripe oranges allays thirst, and it is well borne in cases where there is considerable gastric irritation and tendency to vomiting. It is only in the worst forms of gastric disorder that orange juice disagrees, and there is no fruit which is so generally available in the sick-room, for it is agreeable to almost every one, and is soothing and refreshing in mild fevers. Orange juice is laxa- tive, particularly for infants, and it is a good antiscorbutic. It may be given undiluted or made into orangeade with one of the efferves- cing waters. In renal and other diseases in which it is desirable to induce the patient to drink large quantities of fluid for its diluent and diuretic effect, the addition of orange juice to beverages will often encourage their consumption. Orange marmalade is a wholesome relish, having an appetising bitter flavour. Orange water ice, as well as lemon ice, well frozen, if not made too sweet, may be allowed in the milder forms of fever, inflammations of the throat, etc., especially in children. It is soothing, refreshing, and cooling, and is less apt to disagree than the richer ice cream. Apples, when ripe and properly selected, are extremely wholesome and very digestible. They contain abundant potassium and sodium salts, as well as those of lime, magnesium, and a trace of iron. Their nutritive value is not high, depending mainly upon a little sugar, for they are largely composed of water, having over 83.5 per cent (Bauer). In dried apples the percentage of water is reduced to one third, while that of sugar is proportionately increased. Apples contain free organic acids as well as salts, such as malates, citrates, and tartrates. They are good antiscorbutic remedies, and are quite laxative, especially when taken into an empty stomach. VEGETABLE FOODS. 163 There are many dyspeptics who thrive upon apples, even if eaten raw, and who can regulate the action of the bowels with them effec- tually. They should be given to most invalids only when cooked. They are most digestible when baked and eaten with cream, or they may be beaten with white of egg to add to their nutritive power. They are both palatable and very digestible for convalescents if stewed as apple sauce, when there is no objection to the addition of the greater quantity of sugar which is required in this method of cooking. They should be avoided in all cases of diarrhoea, gastro- intestinal irritation, and diabetes. Pears are similar to apples in their effect, but are less laxative. If fully ripe and soft they are even more digestible raw than apples. They have the advantage of keeping their flavour when well preserved in sirups, but they possess no special food value, and are mainly used for their choice flavour, aroma, and appearance, which stimulate the appetite. Quinces are indigestible unless very thoroughly cooked. Peaches, nectarines, and apricots are of comparatively little nutrient value, but their flavour and appearance make them tempting articles for the table. They do not contain as much sugar as apples and other fruits. When thoroughly ripe they are wholesome if not eaten in excess. They agree well with some gouty persons, and are even allowed to diabetics in cases of moderate severity. Peach and apricot juices are laxative unless the fruits are very ripe. Pineapples, as usually obtained in this country, have been picked green in Cuba, and if eaten raw are indigestible. Their juice is, however, very wholesome, and they contain a ferment capable of digesting proteid material, which is used to some extent in the pre- paration of predigested invalid foods. Tamarinds are cooling and laxative. When added to milk they cause curdling and form a whey which may be used as a beverage in fevers when constipation is to be overcome. The mango is a sweet and somewhat acid fruit, with moderately laxative action. The pomegranate is a pulpy fruit, wholesome when fresh, but it is expensive and little used in this country. It has a thick, tough rind, which is astringent, with a bitter-sweetish taste. A taeniacide for the tapeworm is made from an infusion of the rind, but it is so nauseous and disgusting to the taste that patients can seldom retain it unless it is put into the stomach with a tube. Bananas. The banana is really a variety of the plantain, or Plan- tago musa, but the fruit is not so large or so hard as that commonly called plantain, and the flavour is far more delicate. The botanical name of the banana, Musa sapientum, was given because it constituted the principal food of the Brahmin caste of India. There are 164 FOODS AND FOOD PREPARATIONS. many score of varieties of the banana, ranging from the most delicate examples of the Miisa sapientum family to the heaviest of the plantains, and they vary in digestibility as they do in flavour. Casati (Equatorial Province, 1891) names some fourteen varieties, having different characteristics and occurring in the Equatorial Province of Africa alone. He noted that, curiously, only the women and children ate the natural fruit, the warriors feeding on the fruits dried and prepared in oil probably from an intuition that they were more highly nourished by the concentrated food. In the West Indies, in the islands of the Pacific, along the Congo, and throughout Central Africa many natives eat bananas as their staple article of food, and maintain good physical development. The fact that a diet consisting solely of this fruit will sustain life for long periods is owing to the relatively high percentage of nitrogen which it contains compared with sago, arrowroot, and similar carbohydrates. This percentage amounts to nearly five parts per hundred of the en- tire fruit, or one fifth of the total solids (Corenwinder). Grown on a given acreage, bananas will support a larger number of persons than wheat. The banana has of late years assumed a very important position among fruits sold in this country. Improvements in cultivation and means of transportation, and the length of time through which the ifruit will keep without spoiling, are accountable for this, and up- wards of one hundred thousand bunches of bananas are sold per :month for distribution in New York city and vicinity alone. It .ranks equally with the orange in extent of consumption, and during the winter months it is often the only fresh fruit which is universally obtainable in remote country districts, while its cheapness places it within the reach of almost every one. In British Guiana the banana is employed especially as a nourish- ing food for young children and invalids. Many persons find that they cannot easily digest bananas as we obtain them in this country ; but this no doubt depends upon the fact that the fruit shipped to the United States is picked very green, and is often quite immature and irregularly ripened when eaten. Imper- fectly ripened bananas are composed chiefly of starch, but, as the natural ripening proceeds, the saccharine material is converted into a mucilaginous substance, which in turn forms dextrin and glucose. The flour, which is made by drying carefully selected and well- ripened bananas, is, however, remarkably easy to digest, and highly nutritious. Surgeon Parke (My Personal Experience in Equatorial Africa, p. 416), in an instructive and interesting account of his experience with the sick of the Emin Pasha Relief Expedition, refers to Mr. Stanley, who was in the midst of a severe attack of acute gastritis, VEGETABLE FOODS. 165 as follows: " He eats porridge made with banana flour and milk. It is very light and digestible, and has more flavour than arrowroot; it is also very nutritious. We whites have very good reason to know this fact now, as we have mostly lived on banana flour for the past two years." During most of this period, it should be observed, the members of the expedition were taking very long marches and were suffering from frequent attacks of malarial fever, which were a severe test of the nutritive qualities of any dietary. Farinaceous food is so prone to undergo malfermentation in the stomach when the normal digestion is disordered that it becomes very important to seek some variety of starchy food which can be easily assimilated without the production of acid eructations, flatu- lence, or heartburn. The starchy foods which have heretofore been obtainable in this country for this purpose have been all derived from tubers or cereals which have been rendered more assimilable by predigestion or "malting." It is difficult to make a good fruit flour, for many fruits, when dried, form a mucilaginous mass like the fig, or a sticky material like the raisin, or shrivel to a stringy substance like the apple and the apricot. But the banana, in some varieties and conditions, consti- tutes an important exception, and when carefully selected and thor- oughly dried it can be ground into a meal or even into a flour, making as fine a powder as arrowroot, having a white or pale greyish or yellowish colour, and an agreeable faintly aromatic odour and taste. This meal possesses decided intrinsic advantages as an invalid food. I have tested these preparations, both experimentally in the laboratory and clinically, and found that an unboiled saturated aqueous solution of banana flour contains a very large percentage of sugar from one half to three fourths as much as certain of the best known prepared saccharine foods for infants to which sugar had been artificially added. The finest banana flour, called "bananose," at the end of one and a half hour of pancreatic digestion was capable of developing twice as much sugar as the same quantity of oatmeal or farina, and approximately one and a half time as much sugar as cornstarch. Saliva, when substituted for pancreatic ex- tract, produces a similar effect. The banana flour, when prepared from the best quality of bananas, is made into a thin gruel or porridge by the addition of either water or milk, and eaten with cream it constitutes a delicious and highly nutritious article of diet suitable in cases of gastric irritability and acute gastritis, etc. It is particularly serviceable for children be- tween five and ten years of age. For those craving an acid flavour, lemon juice with powdered sugar upon the banana porridge is found 1 66 FOODS AND FOOD PREPARATIONS. to be very acceptable. The records of some fifty cases in the New York and Presbyterian Hospitals to which I gave gruel or porridge made with banana flour show that it was exceptionally well borne by irritable stomachs, almost never vomited, having no tendency to pro- duce acidity from flatulence, nor did it cause diarrhoea or any ap- parent laxative effect. It proved very useful in several cases of sim- ple gastritis and acute gastritis complicating chronic indigestion and in the early convalescent stage of typhoid fever. It was used with advantage even during the fever itself whenever a change from an exclusive milk diet seemed indicated either by the patient's dislike for milk or by its causing dyspepsia. The taste of banana flour is peculiar, and is not always agreeable at first ; but it may be so modified by different processes of cooking that the majority of patients find it much more palatable than the conventional arrowroot, cornstarch, or farina. It is a decided gain to be able to enlarge the list of starchy foods adapted to feeble digestions by a fruit flour which presents the following advantages : An agreeable variety of taste ; a high percentage of nitrogen, dex- trin, and glucose; ready digestibility; high nutritive value; the prop- erty of keeping definitely in a concentrated dry state, ready for im- mediate use. Grapes. Grapes are universally grown and enjoyed on account of their delicious flavour and aroma as well as their general whole- someness, and they constitute an important article of diet. Per- fectly ripe and seedless grapes, such as the Black Hamburg and other varieties, have long been recognised as an excellent food for invalids. Grapes contain so large a proportion of water that they possess but little nutrient property, although they hold considerable sugar, but the salts which they furnish to the system are useful. The habit which some people have of swallowing the pulp whole with the seeds, however small the latter may be, cannot be too strongly condemned. The seeds under no circumstances are digested, being too hard and tough to be affected by any of the juices of the digestive tract, and they therefore act as irritants or foreign bodies. It was originally believed that inflammation of the appendix vermi- formis was often caused by the entrance of one or two sharp-pointed grape seeds into this small division of the alimentary canal, and in exceptional cases no doubt this may occur; but the disease is far too common among those who have not eaten grapes to assign much importance to such a theory. The main disadvantage of swal- lowing seeds consists in their interference with normal digestive processes, while they are liable at any time to cause more serious disturbance of the nature of diarrhoea, enteritis, or intestinal obstruc- tion. Swallowing the skins of grapes is equally harmful. Grapes, on account of their sugar, must be forbidden in cases of VEGETABLE FOODS. 1 67 diabetes and gout. A special " grape cure " has been established for some diseases. It is discussed under that heading. Unfermented California grape juice constitutes an agreeable, wholesome, and slightly laxative, non-alcoholic beverage, which may be prescribed during mild fevers and in convalescence. Raisins, prepared by sun drying from certain species of grapes which are particularly rich in sugar, form a useful food, chiefly oh account of the agreeable flavour which they impart to more insipid substances (see also Raisin Wine). * Raisins are usually made from white grapes, but they turn dark purple or brown from oxidation of the tannic acid of their skins (Leoser). Muscatel raisins are dried on the vine by incising the stems to cause withering of the grapes. Raisins cannot be eaten very abundantly without disordering digestion unless they have been cooked. Added to some forms of farinaceous food such as rice pudding, sweetened breads, buns, cakes, pemmican, and the like they increase the appetite. If given to children, as they too often are, they should be stoned carefully beforehand, and the tough skins must not be swallowed. The latter contain a whitish waxy material which keeps the grapes waterproof. Plums. Plums and green gages are wholesome fruits when they are wholly ripe; but they remain fresh for only a short time, and are often on that account picked and sent to market in an unripe condi- tion, in which they are very indigestible, and are particularly apt to excite diarrhoea and intestinal colic. Prunes. Prunes or dried plums are obtainable in various forms and sold in large masses like dates, or preserved individually in jars, in which form they have the advantage of keeping well for a long period. They contain a large percentage of sugar. They have a dis- tinctly laxative effect, eaten raw or, preferably, stewed, and they are very wholesome and useful in cases of chronic constipation. They are comparatively inexpensive, and by some patients may be taken two or three times a day. They have a good effect in regulating the bowels in children, and three or four prunes given once or twice a day between meals will sometimes prove quite sufficient for this purpose. Ptunelles are sold in masses dried like dates. They have a pleas- ant acid flavour, but are not very digestible. Olives are eaten for their agreeable flavour and their nutrient value, which is due to the oil they contain (see Olive Oil). They may be eaten fresh in the warm countries where they grow, but they are too bitter for most palates, and are usually preserved by soaking respectively in {a) strong lye, {b) fresh water, and {c) salt solution, and are left in the latter for preservation. The lye neutralises their bitter taste. 1 68 FOODS AND FOOD PREPARATIONS. Berries. The straiuberry, on account of its exceptional!}' agree- able flavour, and also from the fact that it is one of the first fruits of the spring season in the eastern part of this country, is enjoyed by almost every one. There are, however, a few persons who have a striking idiosyncrasy against it, and in whom urticaria or more or less violent gastro-enteritis with sore throat (Osier) is promptly developed by taking even a few berries. The reason for this is not fully explained, for analysis of the strawberry fails to show any product which is peculiar to itself. There must consequently be some combination of organic acids or other materials existing in this berry which is exceptionally irritating to some persons. The strawberry is usually a very wholesome food. It contains abundant salts of potash, lime, and soda, which give it a moderate diuretic action ; it is also slightly laxative, partly from the seeds which it contains. There are many modes of eating, cooking, and preserving the strawberry which are too familiar to require comment here. Some persons learn that eating the berry with pepper or lemon juice enables them to digest it better, and those who suffer from flatulent dyspepsia, if they can digest the berry at all, do well to take it without sugar. Currants, bilberries, mulberries, blueberries, huckleberries, raspberries, blackberries, and gooseberries all contain considerable free acid, and are moderately laxative, partly on account of their seeds, but their expressed juices sometimes have the same effect. Not all berries are laxative, however. Huckleberries and blueberries may be laxa- tive when eaten with their seeds and skins, but Winternitz has re- cently shown that a decoction made from these berries is a good astringent for use in chronic diarrhoea. Blackberries have a similar action. The expressed juice of red currants, raspberries, or blackberries makes a cooling and refreshing beverage or " shrub " when added to some effervescing water, such as Apollinaris or carbonic-acid water, and may sometimes be used in fevers, although lemon juice is usually preferable. Currants are preserved in various ways, the chief one being in the form of jelly. Prepared in this manner, they constitute an appe- tising and wholesome flavouring material, which may be taken with meats and other foods to excite the appetite of invalids and con- valescents whose chief difficulty is lack of desire for sufficient food. Currants, raspberries, blackberries, etc., are frequently made into jams. These, on account of the large quantity of sugar which is added in their preparation, are quite nutritious, and their numerous seeds have a laxative action. For this purpose they are sometimes beneficially given to children to be eaten with bread and butter. They aid in satisfying the natural craving of children for sweets. VEGETABLE FOODS. 169 and, if taken in moderation, they are very wholesome, and their taste may encourage the eating of more nutritious but less agreeably flavoured food, such as rice, cornstarch, or farina. The gooseberry is much more popular in England than in the United States. It contains citric and malic acids as well as sugar. It is rendered more wholesome by cooking, and is sometimes made into wine. The elderberry furnishes an astringent wine, which is also some- what diuretic and sudorific. Melons. Melons are of little service for nutrition, but they are so agreeable to the palate that they are in very general use. The varieties commonly obtainable in this country are the cantaloupe, or muskmelon, and watermelon, and of these, the former is less apt to produce gastro-intestinal disorder when not eaten too freely. These fruits contain so large a proportion of water upward of 95 per cent that they are not satisfying to the appetite ; and since in hot weather they are cool and refreshing, overindulgence in them is a common fault, and most of the ill repute of watermelons has arisen in this way rather than from any specific injurious effect which they produce. If eaten with other food, they dilute the gastric juice. Well-ripened muskmelons may often be eaten by invalids in moderation to promote the appetite, served at the commencement of a meal, at which time it is best that most fruit should be eaten when taken with other food. Citrons are very indigestible. Figs and Dates. Figs and dates are chiefly eaten in the United States in the dry form, although in California and elsewhere they may be obtained fresh. These fruits hold large quantities of sugar, especially in their dry state, in which this ingredient is not only concentrated, but changed in the drying process. They also contain a little nitrogenous material, so that they have more nutri- tive value than many fruits; in fact, in some countries they consti- tute a staple article of diet. This applies to the use of the date in Arabia. Figs have a decided aperient action, which is chiefly, but not solely, owing to their seeds. Three or four dried figs taken with a glassful of water at night before retiring, and again half an hour be- fore breakfast, will sometimes cure mild constipation. The dried figs, like prunes, may be stewed if preferred. They contain a large percentage of glucose. The best figs, called Turkey figs, are raised in Smyrna, and when dried will keep for a long time. Fungi. There are many species of fungi, some of which are available for food, while others are irritating, and still others produce violent i/o FOODS AND FOOD PREPARATIONS. gastro-intestinal disorder, and by their absorption give rise tO symp- toms of collapse, and may cause death. Konig gives the following percentage composition : Water Non-nitrogenous substances Fat Grape sugar, mannite Other non-nitrogenous substances. Woody fibre Ash Fresh mushroom. 91. II 2.57 0.13 1.05 3-71 0.67 0.76 Fresh truffle. 72.08 8.91 ,0.62 7-54 7.92 2.21 Fresh common morel. 90.00 3-48 0.24 0.72 3-95 0.67 0.94 Mushrooms. Mushrooms, on account of their nitrogenous matter, are of some slight use as food ; but if eaten in sufficient quantity to yield much nutriment, they always disagree. Bauer says : " Judg- ing from their chemical composition, they ought to have no small value as foods, but it is doubtful how far they are really utilised in the alimentary canal." Mushrooms have a tempting flavour, which is developed on cook- ing, and while they agree with most persons in health and form an acceptable article of diet, there are some persons who can never eat even the simplest varieties without suffering more or less from acute gastro-intestinal irritation. They should never be eaten raw. They are usually served alone, broiled upon toast or as a dressing for beef, fillet, steak, etc., or they may be preserved in olive oil or by drying. Truffles. The truffle is a subterranean vegetable of the order of Thecapore. It is an expensive luxury, and is used to add flavour in cooking and as an ingredient of rich meat sauces, /i/'/.y, etc. It con- tains no sugar. Eaten in quantity by itself it is a highly indigestible substance. It easily decomposes with a very offensive nauseous odour. There are several varieties, of which the black is the chief, and it is obtained from beneath the trees of oak forests of Perigord in Southern France, where it is hunted by trained Spanish poodles or sows, whose sense of smell enables them to detect the fungus beneath the ground. There is a special hereditary race of trufiling swine, broken for the purpose. The morel is a friable, greyish-black, cone-shaped mushroom, which grows extensively in a variety of dry soils, but, like the cepe, is obtained principally in France. It may be cultivated artificially. It is used for flavouring, like the truffle. Clpe is a name given to several mushrooms belonging to the Boletus family, which are globular in shape, and coloured orange or white. VEGETABLE FOODS. 171 Poisonous Fungi. Most poisonous fungi are distinguished from the non-poisonous by a warty cap. They are acrid or astrin- gent, and have a pungent, disagreeable odour (Christison). Muscarin is a substance isolated from poisonous fungi, which is a violent cardiac poison and constrictor of the pulmonary blood vessels, producing dyspnoea, prostration, and death. Its effects are opposed to those of belladonna. Lichen. Iceland moss is used extensively as a food by dwellers in the arctic regions. Konig gives the percentage composition of the dried moss as fol- lows: Water, 15.96; nitrogenous matter, 2.19; fat, 1.41 ; non-nitro- genous matter, 76.12. A bread is made from it after carefully washing out two bitter organic acids which it contains. Senator has recommended this bread for use by diabetics. Nuts. Nuts contain proteids, with some starch and more or less fat. With the exception of the cocoanut, chestnut, almond, and English walnut, the varieties eaten in this country furnish but little nutri- ment. Their chief value is to stimulate the appetite and afford variety in the diet. As a rule, they are to be proscribed from in- valid dietaries, but, with-'the exception of chestnuts and peanuts, they may be allowed to diabetics, and there are some few patients with dyspepsia whose sluggish stomachs are stimulated into greater activity by eating a few parched or salted almonds or walnuts after a meal. Almonds contain a ferment called emulsin and much fat, and sweet almonds have 3 to 5 per cent of sugar, but no starch (Bauer). This low percentage of sugar makes them of service in the treatment of diabetes, in which disease they are sometimes used as a substitute for bread after being ground into meal (see Diabetic Breads, p. 653). Macaroons are a digestible form of cake for convalescents and children composed chiefly of almonds and sugar. Almonds are quite wholesome and nutritious. They should not be eaten in cases of gastric irritability, but occasoinally dyspeptics in whom gastric digestion is slow derive benefit from eating a few salted almonds with meals. They should be soaked and peeled or "blanched," otherwise their skins may set up gastric irritation. The bitter almond contains hydrocyanic acid, sugar, and oil, and is not used except for flavouring cough mixtures. English walnuts eaten liberally between meals may assist in over- coming constipation through the bulk of insoluble residue which they leave. 172 FOODS AND FOOD PREPARATIONS. Cocoanuts are very indigestible even when thoroughly desiccated and grated. The cocoanut contains a proteolytic ferment which con- verts meat into albumoses with considerable activity. Brazil nuts, pecan nuts, butternuts, filberts, etc., all hold much oil, and are difficult of digestion. Chestnuts contain 15 per cent of sugar with so much starch that they are very nutritious, and in some parts of Italy they are made into cakes and eaten by the peasants as a substitute for potatoes. Raw chestnuts are wholly indigestible, but if thoroughly roasted or, better still, if long boiled, they become much less so. They should, however, not be given to invalids. Peanuts are nutritious, but indigestible when roasted whole. Pea- nut flour is made from the ground and bolted nuts, and it is claimed that a pound of it contains as much nutritive material as three pounds of beef or two of peas. The peanut grits may be boiled like oatmeal or made into biscuits. Experiments have lately been made with the view of possible introduction of this food into the German army to be used like the *^ Erbswurst" of fame in the Franco-Prussian War. Peanuts contain considerable oil, which is extracted and sold largely as spurious olive oil. It is also sometimes used in the preparation of oleomargarine, and the roasted nuts themselves make a sort of imita- tion coffee. A form of peanut meal is now prepared for diabetics which is said to contain little or no carbohydrate. V. FATS AND OILS. Fats and oils contain but three elements namely, carbon, oxy- gen, and hydrogen. In the starches and sugars the proportion of oxygen and hydrogen is such as to form water, HgO, when their molecules are split up; but in the group of fats oxygen is not present in sufficient quantity to form water with all the hydrogen atoms, and in their combustion with oxygen considerable heat is evolved. In some fats, like butter, but very little oxygen is pres- ent, and carbon and hydrogen compose the bulk of the substance. The amount of fat which from time to time is stored in the body is regulated to a greater degree than any other substance by muscular exercise, which, if active, always tends to prevent its accumulation. The storage of fat is favoured by sleep as well as inactivity (see Obesity and Leanness, pages 599 and 615). About one fifth of the entire body weight is composed of fat, but only about a quarter of an ounce is contained in the blood. Before death results from starvation 90 per cent of the body fat is consumed. The chief sources of this fat in the human body are undoubtedly starches and sugars, but it is probable that under cer- tain conditions it may also be derived from fatty food. PLATE IX. Beef Fat x 40. Oleomargarine x 40. ANIMAL FATS, MAGNIFIED. f<}-om liulUim No. IS, IHmmm of Chemislrif, Vmled SUiU-k AgrimUurdl Jiamiu). P'riOTO B^ I I,IKKciKl> UK IIAItllSliN. FATS AND OILS. 173 Fat is required to promote the earlier stages of growth and de- velopment of the organism, and there are also many forms of disease and degenerative changes which are accompanied by increased accu- mulation or production of fat in and between the tissues and cells. It is impossible to live in perfect health without fatty food, and it is equally impossible to live long upon fat alone, for it soon disorders the digestion and causes absolute disgust. Fat constitutes one of the ingredients of pus, and is found in the normal living white blood-corpuscles, and after the ingestion of fat in excess as food, a sufficient quantity of it may be absorbed into the serum of the blood to give rise to a thin film upon its surface when shed. In hot climates where fat meats are scarce, or their use is pro- hibited by the religion of the inhabitants, they employ the oils of fish, vegetables, or fruits instead. Uses of Fats. The chief uses of fatty food are : 1. To furnish energy for the development of heat. 2. To supply force. 3. To serve as covering and protection in the body. 4. To lubricate and make more plastic various structures of the body and give rotundity to the form. 5. To spare the tissues from disintegration, for, although their combustion in the body results largely in the production of heat, they also take part to some extent in tissue formation. 6. To serve for storage of energy. The various forms of energy manifested in the different nitro- genous tissues as muscular action, secretion, nerve force, etc are more or less intimately dependent upon fat combustion. It was originally believed that the force of the body was supplied by the oxidation of nitrogenous materials. Fat eaten with the food was supposed to be deposited again as fat in the tissues of the body without material change, but of recent years this theory has been very largely recast, and the primary value of fatty food exists un- doubtedly in its contribution to force production and its power of saving other tissues, especially the albuminous, from destruction by oxidation, whereas its secondary use is in connection with tissue formation. Fats do, however, enter into the composition of many different tissues, even those of the nervous system. The fats and oils which are employed as food all serve essen- tially the same purpose, and may therefore be grouped together as a distinct class. There is a general resemblance in their physical properties, although they differ considerably in the melting point. The several food fats and oils are of various chemical composition, but after being absorbed they are recognised mainly in one or two simple forms, chiefly as stearin and olein. J74 FOODS AND FOOD PREPARATIONS. The use of animal oils, such as lanolin, and of the petroleum products, like purified vaseline, has very largely superseded the ex' ternal application of other fatty substances lard, etc. to the skin for the purpose of lubrication. It is not possible to get very much nourishment into the body by osmosis through the integument, but some improvement seems to follow the rubbing of fats and oils, such as cacao butter, olive oil, or cod-liver oil through the skin of marasmic children and other pa- tients (see Marasmus). One or two teaspoonfuls of the oil may be rubbed in twice a day on the thighs, abdomen, and chest. The state- ment that the application of fats to the surface of the body by inunction reduces the body temperature is not substantiated by experience. The treatment of biliary calculi by the administration of large doses of olive oil two or three ounces at a time given upoi;i an empty stomach, has been suggested, apparently with the idea that it might have some local lubricating action. Cases have been reported in which gallstones have been said to appear in the f?eces as a result of this treatment, but it has been shown that the oil itself may become mixed with inspissated intestinal mucus and form small, hardened masses, which have been mistaken for gallstones. There is no foundation for the belief that oil is of any value for cholelithia- sis, and it is not rational to suppose that it enters the bile ducts to " lubricate " them. Fats and oils are useful preservatives of many foods by prevent- ing access of air, drying, and decomposition. A layer of oil floating on top of a flask of wine is capable of preserving its delicacy of flavour for a long time (Chambers). Oil preserves fish, like sardines, and layers of lard are used to protect jars of potted meats, /i//-^^- fois-gras, etc. Oils and butter protect eggs from decomposition. Digestibility of Fats. There is some difi'erence of opinion as to what extent fat may aid or retard the process of digestion, but it is a matter of very common experience that those persons whose digestive organs are feeble do not tolerate fats or oils well when eaten with other forms of food. This is no doubt owing to the fact' that fats are practically unaltered in the mouth and stomach, and in the latter, when melted, they coat the mucous membrane and surround the particles of food with a thin film which materially interferes with the normal action of the gastric juice. For this reason fats are to be avoided by dyspeptics, and the fats selected for special nutritive processes should be in the form of good butter, cream, or cod-liver oil. On the other hand, fats may sometimes aid the digestibility of starchy foods by preventing them from forming lumpy masses in the mouth and stomach. For example, a well- roasted mealy potato may be made all the more digestible for an FATS AND OILS. 175 invalid by being mashed with a little butter or cream. There is no practical method by which the digestibility of fats may be improved in the sense that the digestibility of meat is improved by converting it into peptones. Artificial emulsions make oils somewhat more palatable, but the simple oil is sometimes better borne than such preparations. It is stated by Ringer that fats taken fasting lessen the secretion of bile, whereas if taken with or after food they increase it, but, as many kinds of food promote the secretion independently of fat, it is doubtful whether the latter possesses any very decided action in relation to bile formation. Most of the fat used as food melts at the temperature of the body, which facilitates its digestion. Children often eat butter more readily than any other form of fat. As a rule, the stomach is less disturbed by animal than by vege- table fats taken in excess, and the former may be tolerated for a longer time. The limit of digestibility of increasing quantities of food is much sooner reached with fats than with other articles of diet, and they produce satiety early in a meal, but, as in the case of many foods, toleration may be acquired for the ingestion of fat, which is exemplified in the fact that many persons who cannot digest cod-liver oil completely at first may do so after two or three weeks' trial. This is, in part, due also to the general improvement in health which follows in some cases the administration of easily digested fat. Overdoses of fat at any time are apt to give rise to the forma- tion of irritating acids which cause nausea and vomiting, with pos- sibly abdominal cramps and loose evacuations. Fat taken too liber- ally with other food ceases to be economical for the system and becomes positively harmful. Since fat is exclusively digested in the small intestine, diseases of any part of the alimentary canal are contraindications for its use. Liquefied fats and oils are usually administered as a matter of routine when corrosive poisons have been swallowed, with the idea that they coat over the mucous membrane of the stomach and oesophagus and protect them from the action of the irritant. This protective action is overestimated, for it is difficult to coat to a sufficient degree a mucous membrane which is already moistened with watery mucus. The digestibility of all fat depends somewhat upon its cooked state. Many persons are nauseated or made dyspeptic by eating hot mutton fat who can eat the same with impunity when it is cold. In the latter condition it becomes more friable and, if thoroughly mixed in chewing with starchy food, or used as suet in the form of a farinaceous pudding, it becomes very much more digestible. Chil- 14 176 FOODS AND FOOD PREPARATIONS. dren usually dislike fat meat, but they are quite willing to take suet puddings, which, if light and well cooked, are wholesome. While the various fats and oils, in general, have the same bene- ficial effect upon nutrition, there is considerable difference in their force value and in the facility with which one variety or another may be assimilated in individual cases. The animal fats have a higher nutritive power than those derived from vegetables, and liver fat, butter and cream, art! the most serviceable of all. Animal Fats. The principal animal fats and fatty foods are butter, cream, suet, lard, oleomargarine, the fat of beef, mutton, pork and bacon, bone marrow, pemmican, fish, and cod-liver oil. Oil is also made from the yolk of eggs. Butter and cream hafe been discussed under the heading Milk Derivatives (pp. 82-84). Lard is hog fat separated by melting from the areolar connective tissue. Considerably over half a billion pounds are annually pro- duced in the United States. Crude lard contains glycerides of oleic, stearic, and palmitic acids, besides a little gelatin and other substances. " Cuisine " is a preparation of cotton-seed oil designed to replace lard and cheap cooking butter. " Cottolene " is another such substitute for cooking purposes. Stearins are the solid residue of animal fats remaining after pres- sure has separated the fiuid fats. They are used in making com- pound lard, butterine, and similar foods. Tallow is a general term originally applied to all fat tried from the different tissues of cattle. Suet is the fat which surrounds the kidney. Oleomargarine. Oleomargarine was invented in 1870 by a French chemist, Mege-Mourier, who discovered that beef fat from particular portions of the bullock would melt at the same temperature with butter, and would keep longer without becoming rancid. The fresh fat is mashed in a grinding machine to free it from membrane. " The fragments fall into a tank heated with steam, which for every thou- sand parts of fat contains three hundred parts of water and one part of carbonate of potash and two stomachs of sheep or pigs. The temperature of the mixture is raised to 45 C." (Clark). After two hours the fat is withdrawn from the membranes, which have been digested away, and is heated still more with the addition of 2 per cent of salt. It is then cooled, pressed, and packed for market. Much discussion has arisen in regard to the wholesomeness of oleomargarine, and its sale has been regulated by act of Congress since 1886 and by many State laws. It has been declared perfectly FATS AND OILS. 177 innocuous, and the object of the legal control of its sale is mainly intended to prevent it from being fraudulently offered as butter. It certainly tastes better than poor butter. According to Clark, forty- five billion pounds of oleomargarine were sold throughout the United States in 1883 (Report of United States Commissioners to the Paris Exposition, 1889) ; therefore it takes high rank as a food product. Butterine, which has now largely replaced oleomargarine in this country, is made in a similar manner, but with a somewhat different proportion of ingredients, and some of the leaf fat of the hog is added during the manufacture. The United States law, however, still requires all products of this general class to be branded "oleo- margarine." Beef Fat, Pork, etc. Beef, mutton, and pork fat consist prin- cipally of the glycerides of such common fatty acids as stearic, palmitic, and oleic. The fat of good roast beef is nutritoius, and a very digestible variety of fat is good bacon thinly sliced and thoroughly cooked. This form of fat is crisp and dry, and it is often digested by invalids who cannot tolerate other kinds. Ham fat and pork fat, on the other hand, are usually very indigestible the more so when hot. Bone Marrow. Bone marrow is an easily digestible and whole- some fat which has long been used as a food. The long bones of the ox are cut crosswise in pieces about two inches in length and cooked with the marrow within them. It has quite lately been sug- gested that red marrow might prove a useful food in cases of anaemia and chlorosis, because the red blood-corpuscles are, in part at least, made from the cells contained in it. But few cases treated with this food have as yet been reported, and it is doubtful whether the mar- row acts otherwise than in furnishing an assimilable fat to patients who are much in need of such food, and also a very digestible form of iron, which exists in it in considerable quantity. The marrow of young animals, such as the calf or lamb, is preferred for this pur- pose, because their tissue-building power is so active. Fraser re- ported the first case of anaemia treated by means of marrow, and he prefers a glycerin extract. Mann reports a case of haemophilia and pronounced anaemia which yielded to teaspoonful doses given twice a day on bread, and this after other remedies had failed. He cites several other favourable cases (Lancet, December, 1893). J. S. Billings, Jr. (Johns Hopkins Hospital Bulletin, November, 1894, p. 115), has used a similar preparation made as follows: "Twelve sheep's ribs, carefully scraped, were chopped into small fragments and rubbed in a mortar with one pound of glycerin. This was allowed to macerate for three or four days, being kept in a re- frigerator during that time. It was then strained through gauze, and the resultant liquid administered in teaspoonful doses three 178 FOODS AND FOOD PREPARATIONS. times a day. No complaint was made by the patients with regard to its taste." Walker, of New York, uses a sort of emulsion made by mixing thoroughly the red marrow of the long bones of the ox with Cetraria (Iceland moss). This makes an exceedingly agreeable preparation, a whitish paste pleasant to the eye, and tasting not unlike good but- ter. It may be spread upon bread and eaten three or four times a day. Pemmican is made of meat cut into slices and thoroughly dried in the sun ; to this are added fat, sugar, and dried fruit, such as raisins and currants. It is used on long voyages, especially to the Arctic circle, where a fatty diet is essential to furnish heat and force to en- able the body to withstand the rigour of the climate. It is easily masticated, and the sweet fruit promotes the flow of saliva. Brains and liver contain considerable fat. The common fish which contain most fat are eels, salmon, herring, and mackerel. Sardines contain some fat, but derive most of it from the oil in which they are immersed for preservation. Many fish oils have special uses. The Eskimos eat whale and seal oil and blubber, and dugong oil is eaten to some extent in Aus- tralia. The oil of the sturgeon is employed for preserving caviare. Turtle oil and butter is made extensively in Brazil from both the eggs and fat of the reptile (Clark). Cod-liver oil will be separately considered. ggs contain considerable fat in their yolks. Some eggs, like the plover's, are very rich in this ingredient. They have already been described in detail (see Eggs, p. 89). Vegetable Fats and Oils. The principal vegetable fats or oils and fatty foods are derived from seeds. Such foods are olives, olive oil, cotton-seed oil, and nuts. Traces of fat are found in the legumes. Olive Oil. Olives and olive oil constitute a very digestible form of fatty food, and may sometimes be eaten by consumptives in lieu of cod-liver oil. French olives gathered while young and tender are very wholesome. Olive oil is made by crushing the fruit with stones, after which the pulp is pressed in bags. The first oil thus obtained is the best. A second oil is got by adding boiling water to the pulp residue, and pressing it again. This oil is more apt to become rancid than the first (Clark). The best oil generally obtamable is from France and Italy, but an excellent quality is manufactured in Southern Califor- nia. The paler variety is the best, but, unfortunately, it is constantly adulterated or imitated (see also Olives). Cotton-seed oil, and to some extent poppy-seed oil, are now fre- FATS AND OILS. 179 quently substituted for olive oil in the preparation of various foods, and the sardines which were formerly preserved in pure olive oil are, for the most part, immersed in cotton-seed oil. This oil is not ran- cid, but its flavour and odour, which resemble linseed oil, are not agreeable when it is eaten raw with salads or fish, and, unless ex- tremely pure, it leaves an unpleasant after-taste in the mouth. It is composed principally of palmitin and olein. It is a harmless food. Linseed oil is sometimes substituted for olive oil, but it is not very digestible. Cacao butter^ oil of theobroma, is a firm oil obtained from ca- cao seeds during the manufacture of chocolate. It easily melts at the body temperature. It is used for inunctions and for making suppositories, and sometimes as an ingredient of infant foods, such as lactopreparata. Nuts, especially English walnuts, cocoanuts, hickory, pecan, and Brazil nuts, all contain a good deal of vegetable oil (see Nuts). The oil of nuts which have been too long kept sometimes becomes rancid and unwholesome. Cocoanut oil \% principally used in Oriental countries. Peanut oil is used to some extent in this country, like cotton-seed oil, mainly to adulterate or imitate olive oil, which is much more ex- pensive. Java almond oil may also be used for cooking. Dietetic Uses of Fats and Oils. Since fats are essential for growth and nutrition as well as force production, fatty food is indi- cated for convalescence from severe acute diseases, and for patients suffering from chronic wasting diseases, in both of which classes there has been considerable waste of the tissues. Persons whose general health has been impaired by bad hygienic surroundings, chil- dren who have been wrongly fed by ignorant or poor parents who could not obtain proper food for them, and aged persons in whom the nutritive processes are becoming less and less vigorous, may all be benefited by supplying a sufficient amount of fatty food in the dietary. For scrofulous and tuberculous patients fats are especially indicated. There is, therefore, a very large variety of diatheses and of actual diseases, both local and general, which may be benefited by improving the nutrition of the body and increasing force produc- tion through the agency of easily digestible forms of fatty foods. Diseases in which Fats are Particularly Beneficial. Tu- berculosis, pulmonary as well as other forms; scrofulous conditions; chronic wasting diseases with secretion of pus, as empyema, chronic abscesses, etc. ; marasmus ; rickets ; chronic bronchitis ; many chronic diseases of the skin and nervous system. Diseases in which the Use of Fats should be forbidden or restricted. All forms of acute gastro-intestinal disease; chronic l80 FOODS AND FOOD PREPARATIONS. gastritis ; dilatation of the stomach ; chronic diarrhoea ; obesity ; fatty and waxy liver ; gallstones; acne; urticaria. Generally speaking, fats are laxative, and oils should not be given in cases of diarrhoea or intestinal disorder. By most persons fat cannot be eaten continuously in large quan- tity without producing indigestion. The stools become offensive and diarrhoeal, there is apt to be nausea and gastric indigestion, and dis- gust for such a diet very soon arises. There are some individuals who are unable to digest fats in any amount, however small, and they must derive all their energy from carbohydrates. Glycerin. Glycerin plays an inconspicuous role as a food. It is mainly useful for its sweetish taste as a substitute for sugar in the diet of diabetics, but to many persons the taste of glycerin itself is nauseous. It is now largely superseded by saccharin. It is highly hygroscopic, and if taken in the mouth undiluted makes the mucous membrane sticky and unpleasant, but it is often used as a mouth wash in a diluted form in the proportion of a drachm to the ounc.e. The mouth may be rinsed or swabbed with it in cases of acute fever, such as typhoid, where the mucous surface has become dried or the tongue is glazed or fissured. It acts by protecting the mucous mem- brane from evaporation, making the mouth a little more comfortable. In such cases it sometimes diminishes thirst, although its effect in this respect is very uncertain. Glycerin is also quite laxative, and it may be given either/er se the cause of the decomposition of food, but it is now known that the great num- ber of germs contained in even comparatively "pure " atmospheric air are the agents of putrefaction rather than the air itself, but the exclusion of the one implies the exclusion of the other. The different methods of preserving foods are therefore all de- pendent upon the principle of preventing fermentative changes which are liable to occur when germs, derived either from the atmospheric air or contamination with unclean substances, come in contact with foods under favourable conditions of warmth and moisture. The conditions which are inimical to the development of bacteria are those which may be successfully adopted for the preservation of food. . Ferments and putrefactive germs require for their activity a fair degree of moiature, a moderately warm temperature, which for many putrefactive germs ranges between 60 and 100 F., while certain germs must, in addition, have free oxygen derived from the atmos- pheric air. The principal means employed for preserving food are included under the following headings: I. Drying. II. Smoking. III. Salting. IV. Freezing. V. Re- frigeration. VI, Sterilisation. VII. Exclusion of Air Canning. VIII. Addition of Antiseptic and Preservative Substances. I. Drying. Drying in the sun or before a fire is probably the oldest of methods of preserving food. At present it is used mainly 254 FOOD PREPARATION AND PRESERVATION. for fruits and vegetables, although in some excessively dry and clear atmospheres, comparatively free from putrefactive bacteria, meat also may be preserved in this way. " Jerked " meat is kept by cut- ting it into thin slices and drying in the sun for several days. Fa-_ miliar instances of preservation by drying are found in raisins, figs, dates, prunes, dried apples, peaches, desiccated cocoanut, etc. Some vegetables are also preserved in this manner, such as Lima beans, okra, corn, etc. Others are cut into slices and then dried, but the latter are apt to become tough and tasteless. Fish, such as the cod, is desiccated and preserved by drying, but with the addition of salt. The desiccated meats and vegetables which are used for making soups have the advantages of portability and permanency. They are nutritious, and may be added to strong beef tea to increase its flavour and make it more palatable. This subject has been further discussed under the heading Food Concentration (page 249). II. Smoking. Smoking is the preservation of meat or fish by means of volatilised creosote and other substances developed from wood or peat smoke, which have an antiseptic action. It is chiefly applied to beef, tongue, ham, bacon, and fish. The meat or fish is hung in a confined chamber and saturated with wood smoke for a long time, so that it absorbs a small percentage of antiseptic materi- als, the fat is prevented from becoming rancid and the albumin from putrefying. The smoking is commonly employed after salting and in connection with drying. Painting the surface of meat with a solu- tion of wood creosote in vinegar has the same preservative action. The outer surface of meat, such as ham or bacon, preserved by smoking becomes considerably drier and tougher than the interior, but the latter is not made especially tough by the smoking if it was originally tender. Well-smoked bacon cut thin and thoroughly cooked is a digestible form of fatty food for tubercular patients, and smoked beef may sometimes be eaten for the sake of variety by patients who are placed upon a meat diet. The digestibility of hams is enhanced by the smoking process to which they are subjected. The process of smoking is applied to fish upon a very large scale, and their digestibility and flavour cannot be said to be destroyed by it in many cases ; in fact, in some instances, as in those of smoked mack- erel, herring, and salmon, while the flavour is very different from that of the fresh fish, it is agreeable to many persons, and these articles aff'ord an important and appetising variety of food. III. Salting. The process of salting is a primitive but still de- sirable method of preserving meat and fish. Salted meat usually becomes pale from the action of the salt upon the haemoglobin con- tained in the blood vessels of the muscle fibre. The addition of a little saltpetre helps to preserve the original reddish colour of salted FOOD CONCENTRATION. CONDENSED FOODS. 255 meat. Salt also absorbs moisture from the food, and thus dries it while preserving it. Brine, a strong solution of common salt, may be used to tempo- rarily preserve meat and other substances. The Chinese have long practised the art of preserving fruits, roots, and flowers in it. Corned beef is made by soaking the meat for some days in such a solution. The brine acts upon the muscular tissues and toughens it. Brine, concentrated by long-continued use, has been known to acquire poisonous properties from changes in the organic matter which has passed into it from the meat. The process of soaking in brine causes much of the extractives and natural salts of the meat to osmose out from it, and the loss of organic material and salts occurring in this way has been estimated by Liebig and Parkes as equal to fully one third, for myosin itself is soluble in strong salt solution. For these reasons salted meats, such as corned beef, require prolonged cooking. Salt meat of all kinds is drier, less digestible, and slightly less nutri- tious than fresh meat. IV. Freezing. Food may be kept in a frozen condition almost indefinitely. On being thawed, it must be cooked immediately, other- wise decomposition is apt to set in at once, and, omitting milk and cream, food is not easily eaten in an actual frozen state, excepting by the northern Eskimos, who take their meat in that form by pref- erence. Meat and fish may be kept for many days frozen in blocks of ice without losing much in flavour, but vegetables are not as good when cooked after freezing. In 1867 Dr. Carl von Baer reported to the Royal Society of Lon- don the discovery in arctic Siberia of the body of a frozen mam- moth, the meat of which was preserved. As this animal has been extinct since the days of prehistoric man, it afforded an illustration of the marvellous preservative power of intense cold. Another such animal was found, in 1799, being eaten by wolves in' Siberia. In-i86i the entire bodies of three Swiss guides were found in a state of excellent preservation which forty-one years before had been buried by an avalanche over the Glacier de Boissons. With these examples of the influence of cold, it is little wonder that meat may be preserved for a few months in ice and yet be quite fit to eat. Meat actually frozen should be cooked as soon as it is thawed, and meat thus preserved is better cooked by roasting than boiling, unless it has been imperfectly thawed, in which case the central por- tion may remain frozen after the external layers have begun to cook, and when the latter are thoroughly roasted, the inside may still be found almost raw. Frozen meat loses 10 per cent of its nutritive value in cooking. 10 ^ FOOD PREPARATION AND PRESERVATION. V. Refrigeration. The process of refrigeration does not in- volve the actual freezing of meat or vegetables, but implies their preservation in chambers at a temperature which is maintained but a few degrees above the freezing point. This causes less alteration in flavour than freezing. The cold is artificially generated, and" beef, fish, fruits, and vegetables are now successfully transported for thousands of miles in refrigerator cars and rooms fitted for the purpose on steamboats. The refrigerating processes applied to the preservation of meat, etc., are several. In most of them the actual reduction of tempera- ture of the meat is maintained by cold air and not by contact with ice. One method consists in the adaptation of the principle that com- pressed air on expanding derives the energy for its expansion from heat, which it abstracts from all surrounding bodies. The liberation of strongly compressed air, therefore, produces intense local cold in its immediate vicinity. The air is originally compressed by a force pump, and the heat which is developed by the compression is re- moved by a circulating stream of cold water. The cooled com- pressed air is then liberated with the effect described. Other apparatus is constructed on the principle of ice machines, which are operated by evaporating ammonia, which produces extreme cold. The keeping of meat by refrigeration is rapidly superseding the canning process for this kind of food, over which it has many decided advantages. Between 15 and 20 per cent of all the mutton eaten in Great Britain is brought from New Zealand and the River Plate in a refrigerated condition. Captain Woodruff, U. S. Army, writes : *' The French Govern- ment is taking the initial step towards applying this new industry to the purposes of war. They have succeeded in keeping dressed beef in a perfect condition for three or four months with the present appliances. "A moment's thought will show what a revolution this matter of cold storage can make in military practices. It will obviate all necessity of keeping live cattle near the army, a system that so often results in diseased animals and fatal epidemics among the soldiers. It will help to wipe out of existence all the salt meats formerly supplied, and will thus avoid that large list of diseases of stomach, bowels, and nutrition that salt meats have been accused of causing." VI. Sterilisation. By sterilisation of food is meant the process of rendering it germ-free by heat, and it includes the preservation of such food in sterilised vessels. Practically all thoroughly cooked food is for the time being "sterilised," and overdone meat keeps longer than underdone meat, for if the outer layers are firmly FOOD CONCENTRATION.- CONDENSED FOODS. 257 coagulated and dried by the heat of boiling or roasting, they form an envelope which is less pervious to the atmospheric air and germs (see Cooking, pages 240, 243). Canned food (see below) is also sterilised, but the latter term is applied chiefly to milk which has been treated by the method de- scribed on page 73. VII. Exclusion of Air. Exclusion of air from contact with food is accomplished not only in the process of canning, but by such means as varnishing or covering it with substances which are com- paratively impermeable, as in the case of varnishing eggs, covering fish with oil, or /i/"/ with lard, etc. Eggs undergo decomposition from the entrance of the atmos- pheric air and germs through their shells, and this process may be prevented, sometimes for several years, by covering fresh eggs with almost any substance which is more impermeable than their shells, such as gum, fat, butter, oil, beeswax, or fresh milk of lime. The sawdust or salt in which eggs are commonly packed serves the double purpose of insuring safety in transportation and excluding to some degree the air. Similarly meat may be preserved by coating it with paraffin, gelatin, collodion, or layers of powdered charcoal or of lard after the manner of potted meats. Beef has been sent in good condition from Australia to England by merely dipping it into hogsheads of melted fat, in which it was allowed to remain after the fat cooled and solidified. The preservation of meats in air-tight skins, like sausages, has long been practised. When food is preserved by any of these methods care must be exercised to have it perfectly fresh at the start and to drive off by heat or otherwise any air which may be present in the food itself or in its containing vessel. Canning. The original idea of the preservation of foods by can- ning was that the exclusion of air was the sole object necessary of accomplishment. It is now known, however, that many putrefactive bacteria are anaerobic, and that the food must be thoroughly steril- ised before the can is closed. This should be done by heat, but since it can also be accomplished by the addition of antiseptics, the introduction of the latter is practised by some unscrupulous manu- facturers to the detriment of the public health. The process of canning meat or vegetables is conducted as fol- lows: The food is placed in clean new tin cans, filling them as com- pletely as possible. Lids are then tightly soldered on the cans, leaving a minute pinhole opening only for the escape of air and steam. The cans are then immersed in a bath of boiling fluid, such as zinc-chloride solution, having a higher boiling point than the water within the cans. The latter boils, expels at first air, then steam, and thoroughly cooks the food, making it aseptic by killing 2c8^- FOOD PREPARATION AND PRESERVATION. all germs. Before the cans cool, their minute openings are soldered,^ and they are then ready for storage. The long boiling of meat in this manner toughens its fibres by hardening the syntonin. Such meat is apparently tender, but in reality it is not very digestible (Williams). To avoid the necessity of cooking food at a high temperature in order to exclude the air, various modifications in the process of canning are employed. One of these McCall's is based on the disinfection of the air by sodium sulphite. In another process sul- phurous acid and nitrogen are used to replace the air. H. W. Wiley, who has made an exhaustive study of canned foods, says, in an instructive report on Foods and Food Adulter- ants, made by him in 1893 for the United States Department of Agriculture (Bull. No. 13, Part VIII) : " All manner of food is canned, and that at prices which place it within the reach of the humblest pockets. Preserved food has been a great democratic factor, and has nearly obliterated one of the old lines of demarcation between the poor and the wealthy. Vege- tables out of season are no longer a luxury of the rich. ... In the American grocery pineapples from Singapore, salmon from British Columbia, fruit from California, peas from France, okra from Lousi- ana, sweet corn from New York, string beans from Scotland, mut- ton from Australia, sardines from Italy, stand side by side -on the shelves." Much light is thrown by Wiley upon the economic value of the substances under consideration in the following important state- ments from the report above quoted : " The quantity of dry food material in canned goods varies within wide limits. It is very low in such vegetables as string beans, asparagas, etc., and quite high in such materials as canned corn, succotash, and other bodies of that description. The lowest percentage of dry matter in string beans of American origin was 4.17. In other words, in buying one hundred pounds of such ma- terial the consumer purchases 95.83 pounds of water. '' The price of the packages of string beans [bought in open market] varied within wide limits, depending both upon the size of the packages and the labels they bore. The highest price paid was "thirty-five cents, and the weight of the contents of the package was a little over three pounds. The lowest price paid was ten cents, and this was paid in many instances. The highest price paid, according to the percentage of dry matter, was in sample 10,928, costing thirty cents and containing only two hundred and fifty-four grammes of string beans, 31. i grammes of dry matter, and 94.37 per cent of water. The price of the dry matter in this package was nearly one cent per gramme, which would be almost five dollars per pound. FOOD CONCENTRATION. CONDENSED FOODS. 259 The enormous cost of food in canned goods is illustrated to the fullest extent by this sample, showing in a striking way that such food materials must be regarded in the light of luxuries or condi- ments rather than as nutrients to support a healthy organism. An expenditure of ten or fifteen cents for a good article of flour or meal will procure as much nutriment for a family as the investment of three or four dollars in canned goods would. "A general view of the digestive experiments must lead to the conviction that the process of canning, especially when preservatives are employed, such as salicylic acid and sulphites, tends to diminish the digestibility of the albuminoid and other bodies. The low per- centage of digestible albuminoids will be remarked with some degree of astonishment in all the analytical tables." Of the dangers of poisoning from canned foods Wiley says : " Veg- etables are usually canned in the fresh state, and if they are in any degree spoiled at the time the fact is usually conspicuously evident to the taste, so that the canner cannot afford to use them. Bacterial action seldom occurs in the can without bursting it or rendering it unsalable. Ptomaines may, however, develop where the canned food is allowed to stand for some time after opening, though even then this is unlikely in the case of preserved vegetables. " It may be said, therefore, that the principal risks to health which may arise from the use of canned goods are those due to the use of preservatives, or to the presence of the heavy metals copper, tin, lead, and zinc. ... In this country there is no restriction whatever in regard to the character of the tin employed, and as a result of this the tin of some of the cans has been found to contain as high as 12 per cent of lead. . . . The analyses of numerous samples of solder employed show that it contains fully 50 per cent of lead. In addi- tion to this there is no care taken to prevent the solder from coming in contact with the contents of the can. It is a rare thing to care- fully examine the contents of a can without finding pe?llets of solder somewhere therein. "Another great source of danger from lead has been disclosed by the analytical work, viz., in the use of glass vessels closed with lead tops or with rubber pads, in which sulphate of lead is found to exist." The frequency of poisoning by eating canned lobster, crabs, or shellfish is due mainly to the rapidity with which they decompose and develop ptomaines after the can has been opened. The contents of such a can partially used should not be kept until the next day. VIII. Antiseptic and Preservative Substances. A long list of chemical substances have been used from time to time in the pres- ervation of food, but most of them have been supplanted by the safer process of canning, refrigeration, etc. The use of various antiseptic or preservative fluids is designed to 26o FOOD PREPARATION AND PRESERVATION. prevent the activity of germs and fermentation. Sugar, like salt, in strong solution possesses decided antiseptic powers, and hence the employment of strong sirups for the preservation of fruits, and of sugar itself in making candied fruits. Other harmless preservative materials which are added are oils, chiefly serviceable for keeping fish, and vinegar and spirits of wine for pickling such products as chilies, tarragon, and shallot. Vinegar is used to preserve oysters, lobsters, and other sea food, as well as cucumbers, cauliflower, and other vegetables, as "pickles." Spices, mustard, and similar condiments are usually added. " Soused " fish, such as mackerel, are "immersed in mixtures of cider vinegar flavoured with cloves, nutmeg, parsley, bay, onions, etc. After being " soused " once or twice the food is heated in the fluid to 140 F., flavouring substances are added, such as Worcestershire sauce, extract of anchovy, and lemons, and the whole is put in air- tight jars (Clark). Among the materials sometimes employed for preserving foods may be mentioned the fumes of burning sulphur (sulphurous acid), acetic acid, weak carbolic acid, bisulphite of calcium, and the injec- tion into the blood vessels of meat of alum, chloride of aluminum, etc. Borax, boric and salicylic acids, and other materials have been ex- tensively used in the preservation of milk, beer, meats, etc. A new method of meat preservation has been introduced by Mr. Jones in England. It consists of injecting the animal the moment after it is killed with a solution of borax, which is so uniformly dis- tributed through the circulation to all the fibres of the meat that but a very small quantity of the antiseptic need be employed. Glycerin has been used as a preservative, but it cannot be em- ployed in any quantity on account of its aperient action. Carbonate of soda and sugar added to milk will preserve it for ten or twelve days (Yeo). It is true of practically all of these latter substances that food preserved by them if used in excess or for any length of time is apt to endanger the normal digestive functions, besides being somewhat less nutritious and more tasteless than other preparations. The use of many of them has been suppressed by law on account of their injurious properties, and the addition of salicylic acid to beer, milk, and other forms of animal food is everywhere condemned. Substitutes for Food. Men are often placed under conditions in which, from poverty or exposure, sufficient quantities of food cannot be obtained. Under these circumstances, the craving of hunger may be diminished and the actual tissue waste may be retarded by the substitution of cer- tain mild stimulants and beverages. Tea, coffee, and tobacco all FOOD CONCENTRATION. CONDENSED FOODS. 261 possess moderate action in this respect, and alcohol, under such conditions, is both a stimulant and a food. The natives of various barbarous or semicivilised countries, while performing long feats of marching, being often unable to obtain sufficient food with regu- larity, make use of a variety of different substances for the purpose above indicated. Among these may be mentioned betel nut, kola nut, Siberian fungus, the cocoa leaf, and pepperwort, which are chewed from time to time ; hasheesh and opium, which are both eaten and smoked ; mate, and various forms of alcoholic fermented drinks. All these substances are used to enable men to prolong periods of fasting. Quantity of Food Required. The quantity of food required to maintain the body in vigour de- pends upon the following conditions : I. External temperature. 2. Climate and season. 3. Clothing. 4. Occupation, work, and exercise. 5. The state of individual health. 6. Age. 7. Sex. In civilised communities, where cooking is a fine art, the number and variety of food preparations is so great that the appetite is often stimulated beyond the requirements of the system, and conse- quently more food is eaten than is necessary or desirable to maintain the best standard of bodily health and vigour. Persons in this country who live in comfortable circumstances often eat a dozen or fifteen ounces of solid food at breakfast, and again at luncheon, and perhaps thirty ounces more at dinner, making a total of, say, fifty-five or sixty ounces, to which are added only fifty or fifty-five ounces of fluids. This is about a third more than the amount of solids actually needed, forty ounces of solid food (which equals twenty-three ounces of water-free food) being a fair average for the daily necessities of most persons, one fourth of which should be animal and three fourths vegetable food. They eat. too much and drink too little fluid in proportion (see Water, page 15). Gluttony results in overdevelopment and overwork of the digest- ive apparatus. The stomach and bowels become enlarged, the liver is engorged, and a predisposition is established to degenerative changes, fatty heart, etc. (see Overeating), The most northern Eskimos, for example, who often eat but one meal a day and then gorge themselves with tough meat, develop big jaws and distended abdomens (Cooke). Hayes described Eskimos who ate daily from twelve to fifteen pounds of food, about one third of which was fat, and the rest mostly meat; and Captain Hall, when on his arctic expedition, declares that he saw a native consume twenty pounds of raw meat and drink a quart of train oil within twenty-four hours. 263 FOOD PREPARATION* AND PRESERVATION. It is stated by competent students of dietetics that more disease arises from abuse of food in regard to both quantity and quality than from abuse of drink. Sir H. Thompson says (Diet in Relation to Age and Activity): '* More mischief in the form of actual disease, of impaired vigour/ and of shortened life accrues to civilised man, so far as I have ob- served in our own country and throughout western and central Eu- rope, from erroneous habits in eating than from the habitual use of alcoholic drink, considerable as I know the evil of that to be." 1. The external temperature increases the rate of oxidation pro- cesses in the body as it becomes colder by stimulating the respira- tion and circulation, and there is a consequent increased demand for food. 2. Climate and season influence the quantity of food eaten. Cold, bracing atmosphere stimulates the appetite, tempts one to exercise vigorously, and hence demands a larger consumption of fuel or food. A hot climate or season, with enervating, moist air, disposes man to languor and inactivity, and diminishes the appetite as well as the need for food. 3. Abundant clothing in a cold climate conserves the body heat, and less food is therefore required to maintain life than if the body is but scantily clad. 4. Exercise and muscular work also promote oxidation in the tissues and augment waste production from the muscles. This waste must be replaced, and energy must be supplied for work by additional consumption of food. Outdoor work demands more food than indoor work, and mental labour less than physical. Where men are fed upon a carefully regulated diet as in prisons it is found that those who are performing hard labour require about one fifth more solid food than the others. The hard-labour prison diet- ary in England comprises fifty ounces of solid food, chiefly bread and vegetables (see Diet in Prisons, page 688). 5. The state of health of the individual greatly modifies the amount of food required both indirectly, through influencing exer- cise and work, and directly, by the local condition of the digestive system. Feeble and inactive persons may live on a third or less of the ordinary ration. Patients having chronic, purulent discharges, such as come from old sinuses, empyema, and tubercular abscesses, need large quantities of food if they can digest it lo maintain their strength against the. constant drain on their systems. The nursing mother should have abundant food, for she must eat for two. 6. The age of the individual not only modifies the absolute amount of food required, but also the relative quantity in proportion FOOD CONCENTRATION. CONDENSED FOODS. 263 to body weight. In the first year of life the infant grows six or eight inches, and at the end of a twelvemonth it should weigh two or three times as much again as at birth. This rapid growth necessitates a relatively larger consumption of food than at any other period of life, and hence the child is fed at first once every two hours, and later every three hours. During the second year the proportionate growth is half that of the first year, and during the third year it is one third that of the first. After the third year the weight and growth mcrease more uniformly, but the child must still have a large relative quantity of food, a great proportion of which must be tissue-forming i. e., nitrogenous. In infant feeding in the earlier months of life it is advisable to weigh the child frequently and measure all its nourishment*, in order that a definite ratio may be maintained between growth and food consumption. A child of ten years requires half as much food, and one of four- teen years about as much as a grown woman. The rapidly growing, active boy often eats more animal food than the adult, and the middle-aged man eats more than the aged. A man of seventy years may preserve good health on a quantity of food which would soon starve his grandson. 7. Sex influences to a considerable extent the quantity of food consumed, but allowance must be made for totally different habits of life. There are many women who eat as much as men, but the majority require less food, even when doing the same work. Under equal c'onditions in penal institutions men require about one fifth more solid food than women. Female factory operatives eat from one tenth to one fifth less food than men. Mrs. E. H. Richards, as the result of observations (Food as a Factor in Student Life) upon 130 young women students at the Uni- versity of Chicago, whose average weight was 120 pounds, gives the following table of food consumption in grammes/^/- diem : Proteid 120 Fat 161 Carbohydrates 402 Total ' 659 Potential energy in calories 3.383 Women, on the average, weigh less than men, take less exercise, work less, and live less in the open air, and hence require less food. As a consequence of their habits of life they are more liable to dys- pepsia and constipation, which are also factors in reducing the quan- tity of their food below the standards for men. There are naturally many exceptions to all these general statements. It is ordinarily impossible or impracticable to definitely weigh the food for individual consumption, but where large numbers of men 264 FOOD PREPARATION AND PRESERVATION. are being fed by contract in institutions, or as sailors or soldiers, or on exploring expeditions, it becomes necessary to estimate carefully the quantity of food required / \ / \ / / <)5 p.' "^ ^ L. , / L^ f*tS ^-^ ^ -^ ,^ k ^ ^ "^ ^> "~^ ^ The following table from Landois and Stirling is arranged to show the total quantity of each single food which it would be neces- sary to eat in order to obtain the requisite proteids on the one hand (column A) and the requisite carbohydrates on the other (column B), For the purpose of comparison these authors estimate the necessary daily amount of carbohydrates at 448 grammes and the necessary proteids at 130 grammes : B. Rice Wheat bread Lentils Peas Eggs Rye bread . . , Cheese Potatoes Beef 2,562 grammes. 572 grammes 1.444 625 " 491 806 582 " 819 968 902 " 2,875 " 930 388 2,01 r " 10,000 2,039 " 614 " 2,261 268 FOOD PREPARATION AND PRESERVATION. If a man doing hard labour were to attempt to live upon milk alone he would require fully ten pints a day to obtain the carbon necessary. Either of these quantities of food constitutes an exces- sive bulk and greatly overtaxes the digestive system. In fact, it would be wholly impossible for most people to eat meals of this' character. The food would be too heavy ; it would take too long a time to consume it, and it would be too monotonous. It becomes absolutely essential, therefore, for man to so regulate the composi- tion of his diet as to properly balance its essential chemical ele- ments. This balance is best secured by a diet in which nitrogen bears the relation to carbon of i to 3.5 or 4. In bread the propor- tion of carbon to nitrogen is 3.0 to i, and in meat it is reversed, and stands i to 3.5. It is also more economical for the workingman to have fats and sugar in his diet and not to live exclusively on meat. The con- tractor soon learns that ill-fed men do poor and insufficient work. The force must be developed out of the latent energy of matter whether bricks are to be carried to the top of a building by a man or a hoisting machine. The carbon of coial is oxidised to develop force for lifting through the engine. The carbon in all the forms of fats, starches, and sugars is utilised in the body of man to enable him to do the same work. The labourer does right therefore when he eats bacon with his cabbage and treacle with his oatmeal. There is one fallacy in the above comparison that must not be overlooked, which is that the more fuel the machine consumes, the more work it doe4; this applies to man only within narrow limits, and too large a quan- tity of food promptly brings him into trouble with his digestive organs (see Overeating, page 342). The amount of nutrient material required per diem by a healthy adult male doing moderate manual labour is summed up as follows: Atwater. Protein 118 grammes. 125 grammes. Fat 56 " 125 " Carbohydrates 500 " 450 " This proportion is repres.ented by Billings as follows : Lean meat 20 ounces. Bread 22 " Potatoes 10 " Three or four cups of coffee. According to Chambers, the average adult at ordinary labour obtains enough food in a day if he eats one pound of meat and two pounds of bread or its equivalent, provided no peculiarities of size, health, or climate are to be accounted for. FOOD CONCENTRATION. CONDENSED FOODS. 269 Moleschott estimates the daily quantity of food required exclu- sive of water i. e., "dry food "at 23 ounces, one fifth of which should be protein. The average amount of water contained in the food of a mixed diet may be estimated at about 45 or 50 per cent, although it may reach 60 per cent. Therefore the 23 ounces of dry food is the equivalent of 46 or 48 ounces of food as ordinarily eaten. The average percentage of water in bread is 37 per cent ; in cooked meat, 54 per cent ; in vegetables, 70 per cent or more (Letheby). "Assuming the average to be 23 water-free ounces daily and the mean weight to be 150 pounds, the body receives %<^ of its own weight in water-free solids. The range in different persons is 'j^ to y,^ of the body weight " (Parkes). This problem may be differently stated, reckoning in the water with the solid food as follows: A robust man weighing 144 pounds may consume '/^ of his body weight, or 6 pounds, in nourishment per diem, divided as follows: Inorganic food, water, and salts, 3.5 pounds. Organic food (animal food, i pound ; vegetable food, 1.5 pound), 2.5 pounds. It is usually better, unless active exercise is being taken, to eat a little less meat and more vegetable food, as previously stated, and to drink a little more fluid. The average amount of dry food by weight required for breakfast may be put at 8 ounces, for luncheon 6 ounces, for dinner 9 ounces. The "middle diet" at Guy's Hospital, which is supplied to the ma- jority of the patients, furnishes 29.5 ounces of solid food per diem in addition to liquids. Of course such persons are taking no active exercise. This is equivalent to 17 ounces of dry or water-free food. It consists of 4 ounces of meat (cooked), 12 ounces of bread, 8 ounces of potatoes, i ounce of butter, 0.75 ounce of sugar, 0.25 ounce of tea, and 2.5 ounces of milk. Nitrogenous material should constitute "one fifth of the water- free food, or from 4 to 5 ounces for active life. The ordinary meat ration for soldiers is 12 ounces per diem, of which 20 per cent, or 2.4 ounces, is deducted for waste of bone, tendon, etc. For inactive life, from 3 to 3.5 ounces " (Pavy). This diet will completely replace the nitrogen eliminated from the body. " Two pounds of bread and three fourths of a pound of uncooked beef contain as nearly as possible the right proportion of carbon and nitrogen." This makes 44 ounces of solid food. Water-free meat contains about 0.20 per cent nitrogen. Fat added to the daily diet in the proportion of about one ounce of butter not only supplies necessary force and tissue elements, but acts favourably in promoting the proper assimilation of the other classes of food and diminishing to a great extent the wear and tear of the tissues. The scrofulous diathesis has been attributed in great 270 FOOD PREPARATION AND PRESERVATION. part to an insufficient quantity of fatty food. With active work, es- pecially in a cold atmosphere, more than double this amount is con- sumed with advantage, and even 2.5 ounces form an average allow- ance for many classes of workmen. The carbohydrates are required in quantities between 14 and 22 ounces, their main use being to convey energy for heat and mechan- ical v/ork. The quantity of mineral matter for daily use varies from 0.5 to i ounce. This quantity is less affected by conditions of temperature and exercise than are other food constituents. Chaumont estimates that a man of 150 pounds can do an average day's work upon a diet of albuminoids, 4.5 ounces; fats, 3.75 ounces; carbohydrates, 18 ounces; and salts, !'/ ounce. These estimates are of water-free constituents. Water. The amount of water drunk /^r diem is usually less than should be taken. Many persons believe that it is injurious to drink much fluid with their meals and forget to take any between, and as a result not enough water is consumed to thoroughly dissolve and eliminate the waste matter of the system. The average quantity of urine voided is 52 ounces, 10 ounces more are lost from the surface of the lungs, and 18 ounces from the skin. This total of 80 ounces must be daily replaced to maintain the equilibrium of the body. The solid food of a mixed diet has been shown above to contain on the average 50 or 60 per cent of water, so that about 25 ounces of water are taken into the system daily as an integral part of the food. In addition, at least 55 ounces or more should be drunk either as plain water or in various beverages. Another way of stating the above facts is that the average quan- tity of solid food (not water-free) which is required by adults is be- tween 40 and 45 ounces per diem, and the total amount of food, in- cluding all fluids, should be from 95 to 120 ounces, of which three fifths or four fifths is composed of water, and the remaining one or two fifths of water-free substance. These estimates are only intended for general application, and there are necessarily many exceptions. The ratio of solid to liquid food varies in health with the greater or less preponderance of fluids, the solid being more constant. It is commonly nearly i to 2, but many persons reduce it to i to 1.5, or even i to i. Muscular exertion demands an increase in both solid and fluid food, but the former is more essential than the latter, if the exertion be prolonged. When a man does increasing work, unless his food be proportion- ately increased, he begins to consume his own tissues until their loss so weakens him that he is obliged to desist from a part, at least, of his labour. Should the disproportion between output and income FOOD CONCENTRATION.-CONDENSED FOODS. 271 continue, he becomes so enfeebled as to be liable to the inroads of disease in various forms especially to the influences of cold and of zymotic diseases. It is estimated that in each twenty-four hours a man of normal health and physique absorbs, including the respiratory oxygen and water, about 7.25 pounds of material, which he eliminates in a corre- sponding quantity of waste, about three fifths of which is water. One of the best means of determining the proper amount of food to sustain a man in good health is derived from a study of the ex- periences of arctic explorers. Their men are subjected to great hardships and feats of endurance, as well as to intense cold. From the nature of the expeditions no superfluous food can be carried, and yet the chief factor in success is the maintenance of good bodily vigour. For these reasons the rations for arctic travellers have been most carefully established, and a brief review of them will throw much light upon this interesting subject. The Peary expedition to the north pole in 1887 used 19 ounces of solid food as the ration for the sledging expedition, but this soon proved to be inadequate in the cold of the arctic regions. Dr. Ray used 29 ounces, which also proved insufficient, and later 34 ounces of solid food. Various other expeditions have used 32 ounces of solid food, consisting wholly of pemmican, which has been sufficient. Molintock, another arctic sledge traveller, used 40 to 48 ounces of food daily. Captain Neary's expedition used 38 ounces of solid food, proportioned as follows: Meat, 20 ounces; biscuits, 14 ounces; potatoes, 2 ounces ; sugar, 2 ounces. To this were added chocolate, I ounce; rum, 2 ounces; and 1.5 ounce each of tea and tobacco with condiments, making in all 44 ounces of supplies. De Long quotes from the physician to his arctic expedition that "alcohol proves a great advantage, keeps off the craving for food, preventing gnawing at the stomach, and has kept up the strength of the men as given 3 ounces per day." (This was during starvation.) While performing active exercise in the cold a diet of 1.5 pound of stewed deer's meat was found wholly inadequate to prevent severe hunger, but 1.5 pound of pemmican per diem, with one half ounce of tea and one half .ounce of Liebig's extract of meat, supported life comfortably for some time. On leaving the ship behind and starting on their long sledge expedition, the following daily ration was al- lowed each man by Lieutenant De Long : Breakfast. Pemmican 4 ounces. Ham I ounce. Bread 3 " pieces." Coffee 2 ounces. Sugar I ounce. 20 272 FOOD PREPARATION AND PRESERVATION. Dinner. Pemmican 8 ounces. Liebig's extract i ounce. Tea i " Sugar f " Supper. Pemmican 4 ounces. Tongue i ounce. Tea i " Sugar 1^ " Lime juice i " Bread 4 ounces. While held fast in the ice, and still on the steamer, the average al- lowance of food per day was about four pounds, but some complained of being hungry on this ration. Several men suffered s.everely from lead poisoning from the solder used in canning tomatoes, traces of lead being found on examining the contents of the can. The acid of the tomato acts upon the solder, forming a soluble lead salt. The cans, however, had been kept for a period of two years before their contents were eaten (De Long). (See Canning, page 257.) In the voyage of the Jeannette to the arctic zone in the polar expedition of iS/p-'Si a very liberal diet was allowed the sailors on entering the arctic regions, the average quantity of food allotted per man />er diem being a ration of 5.5 pounds. Meat was furnished three times a day. Fat was supplied in the form of pork and butter, and bread and potatoes made the bulk of the starchy diet, constitut- ing about two thirds of the whole amount of food. The diet at first included large quantities of condensed milk, butter, eggs, oatmeal, cheese, and macaroni, together with a great variety of canned fruits and vegetables and dried fruits, such as apples, peaches, dates, figs, prunes, and raisins. In Lieutenant A. W. Greely's account of the expedition (Three Years of Arctic Service) he says : " The amount of food per man each day actually eaten in over two years at Fort Conger was as follows: Meat 26.8 ounces. Canned vegetables 10. o " Sugar and sirup 5.3 " Farinaceous articles 13.6 " Canned fruits 4.7 " Dried fruits, preserves, fruit, butter, and pickles 2.9 " "This aggregate of 64.3 ounces would doubtless be increased by coffee, chocolate, tea, spices, condiments, etc., to nearly seventy ounces. This amount may reasonably be assumed as the quantity of food necessary for the maintenance of a man's health in a lati- tude such as Conger (81 44' N.), where the actual temperature is 4 F. (20 C.)." He adds that tomatoes proved to be the most serv- FOOD CONCENTRATION. CONDENSED FOODS. 273 iceable vegetable, and apples and peaches the best fruits. The bev- erages consisted of coffee, tea, chocolate, cider, and a small quantity of rum, the latter averaging two gills weekly for each man, which he regarded as beneficial from the effect it had upon the cheerfulness and good humour of the men. Meat in the above table included fat, in the shape of pemmican (four ounces), butter, lard, pork, and bacon. The hours for meals were as follows: Breakfast, 7 a. m. Dinner, 4 p. M., and two lunches. The latter consisted of hard bread and butter, tea and coffee. The typical vienu was as follows: Breakfast. Corned beef, oatmeal, fresh bread, chocolate, or coffee. Dinner. Vegetable soup, baked pork and beans, corned bread, stewed peaches, and coffee. On sledging expeditions it was important to reduce the weight and bulk of the food to a minimum; accordingly in the Greely ex- pedition of 1882 the daily allowance for sledging expeditions was thirty-nine ounces, to which was added an ounce of lime juice. The lime juice was carried frozen in small squares, in which form it proved refreshing and invigorating to the exhausted men. This constituted the ration of the first year, 1882, Greely writes: "On the above ration of 1882 parties kept the field for forty days in a mean temperature below zero 17.8 C, and returned in health and strength." In 1883 the experience of the previous year led him to modify the ration by replacing part of the bread with butter and meat. This modified ration consisted of Meat .' 22 ounces. Butter 2 " Vegetables 4 Bread lo " Sugar 2 Milk i ounce. Tea or chocolate i Salt \ " Pepper sff with an allowance of six ounces of alcohol for cooking the food of a party of three or four people; therefore the ration contained 40.5 ounces besides beverages. Greely says again : " Three fourths of the ration were about equal quantities of pemmican, bacon, and frozen musk meat, while the balance was made up of canned sau- sages and corned beef in about equal quantities " (Three Years of Arctic Servicer, vol. i, pp. 202, 203). He suggests as a still further improvement that the vegetable ration should consist of three ounces of preserved potatoes, the remaining ounce being replaced by half an ounce each of milk and extract of beef tea, which is the best drink for the arctic regions. It should be chiefly used in the field in 274 FOOD PREPARATION AND PRESERVATION. the form of an extract. A little coffee is preferable to chocolate. The latter was found to induce thirst during the day. Tea should be compressed or used as an extract. Curry paste and other power- ful condiments were also found serviceable. Alcohol was not con- sidered necessary as a food. During the third winter of his arctic expedition, from November I, 1883, to June 23, 1884, Greely's per capita ration for his entire party was : Butter 0.5 ounce. Lard o. 26 " Rice 0.1 " Raisins o. 16 Tea, compressed 0.3 Extract of coffee 0.44 Extract of chocolate 0.3 Milk 0.2 Mulberries 0.2 Meat 4.0 ounces. Beef extract 0.26 ounce, Evaporated potato 0.4 " Soup 0.6 " Tomatoes 0.3 " Peas 0.2 " Corn 0.2 " Carrots o. i " Bread 6.0 ounces. Dog biscuit 0.8 ounce. The usual estimate for the total quantity of all food material, in- cluding solids, water, and respiratory oxygen as well, which is con- sumed by a healthy adult male per annum is one and a half ton. Men eat about two thirds of all the meat, and women one third. Men consume about four fifths of all the alcoholic beverages, and women one fifth. The latter consume much more tea than men. Soyer has computed some curious tables of the total quantity of different foods consumed by a single individual during his lifetime. He estimates that a man during sixty years of life after early child- hood eats Z2>^ln tons of meat, vegetables, and farinaceous food, and that an ordinary man by the time he has attained to seventy years has consumed 30 oxen, 200 sheep, 100 calves, 200 lambs, 50 pigs, 1,200 fowls, 300 turkeys, 24,000 eggs, 4.5 tons of bread, and 3,000 gallons of tea and coffee. Starvation and Inanition. Starvation is a term which technically applies rather to the lack of sufficient food for the maintenance of the body, while inanition means the lack of assimilation of food by the tissues. Where there is defective absorption, food may be furnished to the system in abundant quantity, but inanition results from lack of ability to ab- sorb and develop force and nutriment from it. The interval through which different individuals can subsist without food depends upon : I, External conditions of temperature and moisture ; 2, the amount of work being performed; and 3, the existing condition of the body. I. The maintenance of a uniform warm external temperature prolongs the period through which man can endure abstinence from food. Exposure to cold accelerates starvation symptoms by reduc- FOOD CONCENTRATION. CONDENSED FOODS. 275 ing the vitality of the body and the resistance of the system. Moisture in the air, by preventing evaporation from the surface of the body, prolongs the period of starvation which can be endured. 2. Persons who refrain completely from exercise can live far longer without food than when undergoing active work. Self-for- getfulness in times of famine, by diverting the mind from the suf- ferings of the body, tends to prolong life. 3. Well-nourishjed persons can endure longer intervals of absti- nence from food than the weak or diseased. The distress of deliri- ous or apparently insensible persons may be augmented by lack of sufficient food. Sex has no influence with the effects of starvation, but they are most keenly felt at the extremes of age, by young chil- dren, and senile subjects. Those who have the most fat stored in their tissues call upon this supply to maintain the energy of the body in the absence of food, and, having a larger supply than thin or emaciated persons, they can en- dure starvation much longer, although they may complain more bit- terly of the pangs of hunger than invalids, who are accustomed to a low diet. Chossat's experiments with starving animals proved that while they lost 40 per cent of body weight, the loss of fat alone reached 90 per cent, being greatly in excess of that of any other .substance. Anselmier fed starved dogs upon their own blood, and succeeded in thus prolonging their lives for three or four days be- yond the usual limit, and life lasted until 60 instead of 40 per cent of their body weight had been lost. When food is wholly withheld, life cannot be prolonged beyond six to ten days in the majority of instances. During the winter of i876-'77 an accident occurred in a colliery in South Wales by which four men and a boy became imprisoned for ten days without food. At the expiration of this period they were found alive, and, although very feeble, they were able to walk when released. They had had a supply of water, and the atmosphere in which they were confined was moist. At a second recent colliery accident in Wales a number of men were confined in a mine for six days without food, and, although their sufferings were extreme, nearly all were able to walk out on being rescued. The lack of food may be endured with far less torture if water is applied in abundance to the system. When water is withheld in addition the body loses weight much more rapidly, the tissues be- come dry, the thirst excessive, the secretions are suppressed, and the suffering is greatly intensified. VOLUNTARY FASTING. Of late years several persons have attempted prolonged feats of starvation, tempted by love of notoriety or desire of gain, by ex- 276 FOOD PREPARATION AND PRESERVATION. " hibiting themselves for the gratification of public curiosity. In sev- eral instances they have been carefully watched by medical experts and there is every reason to believe that the fast has been conducted with honesty. In at least two of these authenticated instances,, those of Tanner and Succi, the complete starvation period has been prolonged for over forty days. In both cases fluids were allowed, and one of the men relieved intense epigastric pain and food craving by condensed medication. % Succi was an Italian who, in 1890, undertook an absolute fast of forty-five days, during which period he lost 42'/^ pounds and drank 1,154 ounces of water, or an average of about 2^^!^ ounces per diem. This he took in the forms of plain water, mineral water, and ice. He became alarmingly reduced during the fast, but even on the last day had strength to walk about the room. He resumed eat- ing by first taking cocoa, and subsequently bouillon and other light articles, and made a complete recovery. His mind remained clear throughout. He took occasional doses of a few drops of an elixir supposed to contain opium. There have been a number of cases from time to time recorded of " fasting girls." They are usually of nervous hysterical tempera- ment. On reaching the age of puberty they become dyspeptic and grow shy and disinclined to eat what is good for them, although they may gratify abnormal cravings surreptitiously. They are very apt to be at the same time strongly impressed by religious beliefs, and in their disordered mental condition to acquire the delusion that it is sinful to eat. This delusion becomes fixed, and they then are regarded as " freaks " and achieve much newspaper advertising. They should be treated as ordinary cases of hysteria simply, and be removed from oversympathetic friends and dealt with kindly but firmly. Hydrotherapy yields excellent results, and even a good spanking may not be amiss in awaking the patient to a realising sense of her errors. The claim sometimes made in such cases as those just described, that they lose no weight, is nonsensical, for the body must diminish in weight continually by evaporation of water from the lungs and skin and its passage from the kidneys and by the exhalation of carbon. Edward Smith estimates that the quantity of carbon exhaled in one day of fasting is equivalent to that contained in twenty ounces of bread. When either voluntary or forced starvation takes place very gradually, especially in elderly people, their systems become slowly accustomed to very small quantities of food. Luigi Cornaro was a Venetian gentleman who advocated a very abstemious diet, and whose own case is often cited in illustration of the smallest quantity of food which may support life. He was born in 1463 ; after a reckless and intemperate youth he reformed, and FOOD CONCENTRATION. CONDENSED FOODS. 277 by careful dieting prolonged his life to one hundred and three years. He published a Treatise on a Temperate Life, and for the last forty-eight years of his own existence he subsisted on a daily allow- ance of twelve ounces of vegetable food with fourteen ounces of light wine. He occasionally ate eggs, but rarely took any other form of animal food. There is much wisdom in some of his doctrines, but, unfortu- nately, no one else who has attempted to practise his rules has met with similar success in prolonging life. The majority of mankind would undoubtedly prefer to live fewer years for the pleasure of being less abstemious. Periods of voluntary fasting of greater or less duration are rec- ommended and practised by devotees of many religious sects. Such fasting was formerly carried to a greater extent by ascetics than at the present time. As a means of mental discipline or culti- vation of will power, fasting may in some instances be defended, but fasting "to be useful must be voluntary " (Chambers), otherwise it is apt to cause irritability of temper, and it may even lead to de- ception to obtain food. Such fasting may be carried to an excessive and injurious degree unless it be definitely limited and supervised. It is more powerful in its effect, moreover, if it is but seldom under- taken. If a man so reduces himself by fasting that he cannot use his intellectual faculties with accustomed vigour he may be sure that he is doing himself injury. Better than complete fasting for pur- poses of mental discipline or religious motives is the temporary elimination from the diet of accustomed luxuries, or giving up such articles of daily use as butter, sugar, salt, wine, tobacco, etc. This, in fact, is a custom practised by many persons during the Lenten season. The day has long since passed when fasting can be regarded as favouring either clearness of intellect, muscular strength, or en- durance, and, as Gerland has said, " the ethnologist can trace the physical and mental decay of whole nations to a long course of insuf- ficient food." Dr. Denis, of Brussels University, presented an interesting report at the International Congress of Anthropology for 1892, showing striking parallelism in the curves of famine and crime, and of mar- riages as inversely related to the price of wheat. Symptoms. The symptoms which result from complete star- vation are characteristic. If food is suddenly withheld, the sensation of hunger gradually increases at first, becomes extreme, lasts for two or three days, and slowly disappears. It is accompanied by a gnaw- ing pain in the epigastrium, which is relieved on pressure. The pain may disappear with the hunger, but it is followed by a sensation of extreme weakness or faintness, which is both local in the stomach and general throughout the body. 27? FOOD PREPARATION AND PRESERVATION. When food is gradually withheld, urgent hunger may not be felt at all, but the longer and more severe the fast, the more difficult does digestion become. The circulation grows feeble, the heart ac- tion rapid, the respiration shallow and possibly slow and irregular^ There is apt to be some thirst, even though water be supplied. If it be withheld, the torture becomes unbearable. Constipation may be succeeded by diarrhoea, but it more often remains complete. The facies are typical, the expression is anxious and staring, the orbital fat disappears, and the eyes are greatly sunken and finally become glassy. Corneal ulceration may be present. General bodily ema- ciation ensues, the muscles are reduced in size and soft, the skin becomes pale, loose, and, from change in the secretion of perspiration, emits a peculiar foetor and acquires a clay-like colour. The feet and ankles may swell, owing to the enfeebled circulation. The victims become so ravenous that all sense of taste gives place to the intense hunger. Upon one of the recent unfortunate arctic expeditions, on one occasion, the tea being accidentally omitted from the kettle, dirty water was drunk by the starving men without rec- ognising the difference. The secretions are altered, and become inactive. The total volume of blood is diminished, and it becomes ansemic. The body temperature begins to fall in the first day of the period of starvation, and continues falling, so that a loss of ten or more degrees below the normal of 98. 6*^ F. may occur. In extreme cases muscular action is no longer possible; there are vertigo and faintness on raising the head, the voice is lost, and grad- ually the nervous system succumbs to languor and general pros- tration ; the mind becomes more and more dull, listless, and even idiotic, the victim being unable to describe his condition or express his wants. He may have hallucinations, insomnia, and dreams, in which are often pictured scenes of plenty. The sufferings produced by slow starvation distract the mind and render connected thought difficult. If long continued, the mind becomes unbalanced, and men who have been shipwrecked and left to wander in the open sea in rowboats for a long time without food usually become delirious, or even maniacal, within four or five days. In 1874 three men and two boys were starved for twenty-two days in an open boat. They had at first ten days' provisions, and subsequently nothing but old boots and jellyfish, and they fought violently with each other in the delirium which ensued (Chambers). During prolonged starvation the most important organs of the body are nourished at the expense of others, especially of the skeletal muscles. For example, in an animal starved for thirteen consecutive days it was found that while the muscles lost 30 per cent in weight, the brain lost but 3 per cent and the heart but 2.5 per cent. FOOD CONCENTRATION. CONDENSED FOODS. 279 The ultimate effects of starvation are identical whether the pro- cess be gradual or rapid, occupying days or years, and death results when the body has lost six tenths of its weight. It may occur while the victim is in stupor or coma from cardiac failure or, possibly, in convulsion. The actual cause of death has by many been attributed to the loss of body heat. While this is undoubtedly a contributing factor, it is more reasonable to suppose that it is due to the general inanition of the muscles and nerves and the progressive enfeeble- ment of the heart action. The heart muscle not infrequently will be found to have undergone fatty degeneration. It is, however, true that in animals kept warm by artificial means the advent of death from starvation may be considerably postponed. While undergoing starvation the blood is reduced in volume pro- portionately with the loss in body weight, but it nevertheless main- tains the balance of its normal average composition (Panum and Voit.) Hunger is not always a reliable guide as to the need of the sys- tem for food. Some dyspeptics are always hungry and eat moje than they can digest. Hunger begets a habit of too rapid eating, and more food may be taken than is necessary, because it has not had time to be absorbed and reach the tissues before the meal is over. Moreover, hunger may be temporarily appeased by eating other substances than food, like bits of old leather, for example, which appear to act mechanically in the stomach. For this pur- pose men rendered insane by hunger will sometimes swallow all manner of useless and harmful substances, such as buttons, pieces of metal, pebbles, etc. No more graphic and pathetic account of the miseries of star- vation exists than is found in the journal of Lieutenant De Long, commanding the expedition of the Jeannette, which visited the arctic regions in i879-'8i (The Voyage of the Jeannette, Journals of George W. De Long, 1883). After leaving their sinking vessel the members of the expedition were exposed, at first in open boats, and later in their long sledge journey, to the most exhausting work and to intense suffering from cold and wet. They frequently dragged their sleds in severe storms for ten or twelve miles a day, while subsisting solely upon half a pound of stewed deer meat, with a little tea three times a day. This food being exhausted, they were obliged to consume the meat of their last remaining dog, which they ate fried. They subsisted upon this food exclusively for four days longer, having an allowance of but half a pound a day, and finally their last journey of twenty-five miles was performed with no other nourishment than a few ounces of alcohol and an infusion made from some old tea leaves. During this time their intense suffering from hunger was partially alleviated by chewing scraps of deer 2^0 FOOD PREPARATION AND PRESERVATION. skin, which, from its bulk in the stomach, seemed to afford slight relief. The alcohol being exhausted, they lived for another day upon a teaspoonful of olive oil, with a breakfast composed of an infusion . made from the arctic willow (containing really no nourishment) and "two old boots." After this the men, becoming weaker and weaker, were unable to proceed farther on their journey, being driven back by intense cold and the difificulty of crossing the par- tially unfrozen rivers. Their feebleness gradually overcame them, until one by one they died of inanition. Four men survived for six- teen days upon absolutely no food whatever, and possibly their sufferings were even further prolonged, but the journal of their gallant and heroic commander ceased at this point, for he, too, died. In the starvation which overtook the members of the Greely party on the Lady Franklin Bay Expedition, and caused the death of a large number of the company, attempts were made, as in the case of the Jeannette expedition, to relieve the agonies of hunger by filling the stomach with indigestible material of various kinds. The skin sleeping bags were roasted or boiled and eaten, and even oil- tanned skin was consumed, while the sufferings of the men were aggravated by the presence of game in sight but out of reach. A few shrimp and lichens were obtained and stewed with seal skin. At this time, although it was summer, the temperature was occasionally below the freezing point, but during part of the two years spent in the vicinity of Fort Conger it was sometimes 40 or even 60 F. During the siege of Paris in 187 1, when thousands of the inhabit- ants were reduced to starvation, it was found that a diet which was barely sufficient to support life consisted of ten ounces of bread with one ounce of meat. In prisons the diet limit has often been reduced too low. It may be sufficient to maintain life, but if hard labour be inflicted, weakness, sickness, and death will inevitably follow. In an over- crowded prison a daily ration of twenty-eight ounces of unbolted meal and five ounces of bacon has been known to cause death by slow starvation. As a means of discipline a starvation diet is some- times enforced in penal institutions for a few days, and it is usually quite as efficacious as corporal punishment. A diet which is de- signed to effect its aim by monotony as well as reduction in quan- tity, but without reaching the limit of cruelty, is the following, which has been used at the United States military prison at Fort Leavenworth : Breakfast. Hash or stew, 8 ounces; bread, 7.5 ounces. Dinner. Soup, 8 ounces; bread, 7.5 ounces. After twenty continuous days of this diet eight ounces of bread FOOD CONCENTRATION. CONDENSED FOODS. 28 1 are allowed for supper. This diet has been found to make the most refractory men soon manageable (See Diet in Prisons). Treatment. The treatment of persons rescued from starvation must be conducted with the utmost care. The digestive system is so enfeebled that to allow them to yield to the cravings of returning appetite is to insure immediate death by overburdening the stomach and circulation. The body should be kept warm and in absolute rest, and warm fluid nourishment in minute quantities half tea- spoonful doses of beef peptones or meat juice may be given at intervals of fifteen minutes or half an hour. If no vomiting or evil symptom results, small quantities of peptonised milk may be tried at half-hour intervals. Alcoholic stimulants in any quantity are to be avoided, but a few drops of brandy or whisky may be given from time to time in water. If the stomach is irritable, nutrient enemata should be employed. The following day the quantity of food may be slightly increased, but if emaciation is extreme and enfeeblement is pronounced, the patient must be kept upon a fluid diet for ten days or more. Easily digested forms of starchy food may then be added, such as dry bread, arrowroot, gruel, and the like. FAMINE. When starvation occurs upon a large scale, affecting a community with famine, pestilence is sure to accompany it. Disease has always been rampant in Ireland when the potato crops have failed, and in India when the grain supply has given out. Much of the illness which occurred in the early history of the Crimea was due to insuffi- cient food, and in the Middle Ages the ravages of pestilential dis- eases, such as typhus, blackpox, the plague, etc., were always worst in times of general starvation. The history of epochs of famine in siege or otherwise is always accompanied by outbreaks of violence, for hunger begets ill-temper, vice, and crime. This has occurred of late years, notably in Athens, Florence, and London, and in Paris during the Commune. Nothing predisposes man so much to all forms of infectious dis- ease as starvation and inanition. This is so v/ell known that phy- sicians and nurses in charge of contagious cases are particularly cautioned to eat well and not expose themselves to infection while suffering from fatigue and lack of food. Improperly Balanced Ingredients of Diet. Improper diet is often quite as injurious as slov/ starvation, for a person who eats a large bulk of food of one class, to the exclusion of other classes, may delude himself by thinking that he is taking nourishment enough on account of the degree of satiety which he 282 FOOD PREPARATION AND PRESERVATION. derives from his diet. " The outward appearance of such persons is to a certain extent characteristic, marked generally by a pale and puffy aspect, due partly to a general excess of water in the tissues and partly to an abnormal deposition of fat " (Bauer). The evil result of such diet is very apparent among infants and growing children who have been fed upon a large bulk of farinaceous food to the exclusion of milk, meat juice, etc., and in them the foundation may be laid for the development of scurvy, or scrofula, or tuberculo- sis, and sometimes also the stomach and bowels become permanently distended (see Diet for Infants and Children, pages 718 and 732). The effects above described are commonly produced by excessive ingestion of starchy and saccharine foods to the exclusion of proteids, and, on account of the cheaper cost, the children of the poor are more apt to be injured in this manner than the rich, among whom the opposite diet an excess of nitrogenous aliments is more com- mon. The latter sometimes gives rise to circulatory disturbances, overworks the kidnfeys, and produces nervous irritability. It has often been observed by dietists that proportionately more fat is consumed in the United States than in Europe, and some are inclined to attribute to this form of food some influence upon the greater activity which characterises Americans. It is extremely doubtful whether this has as much to do with it as climatic and other conditions of environment. Taken by themselves, carbohydrates have little or no effect in deferring death from starvation, but with albuminates they act as tissue sparers (see Force-producing Value of Foods, page 16). Mrs. Richards gives the following useful comparisons of food composition, showing particularly the inefficiency of fluid diets other than milk to support life : Three quarts of milk Three quarts of beef broth or consommi . ... Soup of Munich Hospital Rations recommended in certain invalid re ceipt books Rations recommended in another receipt book Prausnitz's estimate of normal ration for man Prausnitz's estimate of normal ration for woman Estimated life ration Maximum work ration Minimum work ration Common invalid ration too low in proteids : I pint beef juice, containing 7 per cent.. . . I pint whole milk 1 quart flour gruel, made with whole milk. 2 quarts of liquid. Total Proteid. Fat. 102.0 108.0 123.0 3-0 21.6 21.6 24-5 28.5 66.5 23.5 IIO.O 50.0 100. 50.0 75-0 40.0 125.0 125.0 IIO.O 90.0 31.5 17.0 18.0 18.2 18.2 66.7 36.2 Carbo- hydrate. 132.0 108.0 65.6 83.5 350-400 300-350 325-0 450.0 420.0 22.0 38.0 60.0 Calories. I.953-0 532.0 730.0 631.0 831.0 2,350.0 2,100.0 2,COO.O 3,500.0 3,000.0 129.0 325.5 397-9 852.4 PART IV. FOODS REQUIRED FOR SPECIAL CONDITIONS. AGE AND FOOD. INDIVIDUAL SIZE AND FOOD. BODY WEIGHT AND FOOD. SEX AND FOOD. DIET AND HEREDITY. DIET AND RACE. CLIMATE AND SEASON FOOD. AND AGE AND FOOD. Food in Childhood. A CHILD at three or four years of age actually consumes nearly one fourth as much food as it requires at adult life, for during this process tissue growth is very rapid, and if the child be in health, the bodily activity is relatively very great. An active child at twelve or fifteen years of age who is growing fast and who is freely exercising may require and assimilate as much food as a man past middle age, and insufficient food and food of defective quality and composition work proportionately far more harm during the grow- ing age. Inquiries made in this country in regard to the diet of older children and young adults demonstrate that it contains a proportion- ately large quantity of fatty food much more than is customarily consumed in European countries. This is in great part owing to the habit of eating considerable butter, which, generally speaking, the better circumstances of Americans enable them to obtain. The following table from the investigations of the Munich School gives: The Minimum Amount of Food Necessary for Different Ages. Age. Infant unlil one and a half year. Child from six to fifteen years. . Man (moderate work) Woman Aged man Aged woman Nitrogenous substances. Fat. Carbohydrates. Grammes, Grammes, Grammes. 20-36 30-45 60-90 70-SO 37-50 250-400 118 56 500 92 44 400 100 63 350 80 50 260 283 284 FOODS REQUIRED FOR SPECIAL CONDITIONS. The special diet regulations for infancy and childhood are de- scribed at length under the headings Diet in Infancy and Diet in Childhood. Food in Adult Life. The nature and quality of the diet appropriate for adults must depend somewhat upon individual constitution, occupation, habits of life, and to some extent upon the climate in which they live. The full adult weight is not usually attained before the twenty- fifth year, although in some cases it is reached earlier. In many in- stances adults after the age of forty or forty-five years increase con- siderably in weight. In men the bones continue to solidify until about the thirtieth year; in women this condition is usually reached a few years earlier. When the final growth of the body and develop- ment of the vital organs is completed the use of food consists simply in maintaining the proper equilibrium of the tissues by replacing waste with new material and in furnishing fuel for the development of force, the food being no longer required for growth. Many per- sons eat more than is required for these purposes. As men advance in life, become prosperous, and acquire more and more luxurious habits of living or become absorbed in various occupations, they are apt to take less exercise, while the number of luxuries of the table which their means enable them to command constantly tempt them to indulge in food which is not needed and which is imperfectly consumed in the body. Sir H. Thompson writes (Diet in Relation to Age and Activity) : " More than one half of the disease which embitters the middle and latter part of life among the middle and upper classes of the population is due to avoidable errors in diet." It is often difficult for a man between the ages of twenty and thirty years who has led an exceptionally active and vigorous or perhaps even an athletic life to realise, as he grows older and passes on towards forty-five or fifty years of age, that he requires less food to maintain his organic equilibrium than formerly, and his habits of eating acquired at a more impressionable period of life cling with great pertinacity. It may prove an advantage sometimes in such cases to lessen the appetite for dinner by a late lunch, or to try other simple means of restriction. These observations fail of application to the poor, whose means do not allow them to gratify their appetites, and in the case of those whose diet is established for them. There is quite as much, if not more, ill arising from deficient feeding as from overfeeding; in either case the difficulty is only made serious by long continuance, and occasional great indulgence in overeating as in overdrinking is much less productive of harm than habitual indiscretions of a less AGE AND FOOD. ,28j; degree. So much is due to habit in the different organs of the body in relation to food that the stomach and intestine will usually reject undigested the contents of an occasional excessive meal, whereas with habitual overeating they become accustomed to appropriating very large quantities of food, which are absorbed, but which are not eliminated without straining the excretory organs, or which may be stored in the body in the form of incompletely oxidised material, which accumulates until the system rebels and a violent bilious attack by vomiting and purging relieves the overburdened body. There are persons who have so little restraint over their appetites that they persistently indulge themselves in this way. Food in Old Age. In old age there are inevitable changes which slowly occur in the circulatory and digestive organs of the body. Although the general health may .still be unimpaired, the circulation is less vigor- ous, and the nervous system less active to external stimulation. There are degenerations in the secreting organs with a tendency to deposition in the tissues of phosphate and carbonate of lime, derived from the food. Absorption is less active, and there is diminished adaptability of the whole system to alterations in environment, and much less ability to meet the requirements of emergencies, such as sudden calls for the use of muscles or mental strain. The muscular tone of the intestine is apt to deteriorate and produce constipation and a relaxed condition resulting in its dilatation. The circulation through the mesenteric vessels and those of the portal system be- comes inactive, with a consequent reduction in the rate of absorp- tion, and a diminished and altered gland secretion in the liver, pan- creas, etc. For these reasons the digestive powers are less vigorous, but, on the other hand, there is not so much demand for fuel in the body as in earlier years. The vital processes conducted by the circula- tion, respiration, and metabolic changes in the tissues are very inac- tive, and there is a correspondingly restricted expenditure of energy. Persons of very advanced age those who are past eighty years or more can sometimes live comfortably on an astonishingly small quantity of food. J. Forster examined the food of the inmates of an institution for elderly widows and, found that many of the old women subsisted very comfortably upon a diet containing, in grammes, al- bumin, 67 ; fat, 38; and carbohydrates, 266. Much depends, however, upon the rapidity with which the changes above described have developed, and dietetic rules for such cases are not to be based upon a definite period of years so much as upon the degree of senility which is present in individual instances. 286 FOODS REQUIRED FOR SPECIAL CONDITIONS. Sir H. Thompson (Diet in Relation to Age and Activity), in com- menting upon the progressing diminution with advancing years of physical energy and of the power to eliminate waste material from the body, and the consequent harm of overeating, says that if a man past his half century of life " continues to consume the same abun-- dant breakfasts, substantial lunches, and heavy dinners which at the summit of his power he could dispose of almost with impunity, he will in time either certainly accumulate fat or become acquainted with gout or rheumatism, or show signs of unhealthy deposit of some kind in some part of the body processes which must inevitably empoison, undermine, or shorten his remaining term of life. . . . The typical man of eighty or ninety years is lean and spare, and lives on slender rations." In the dietetic treatment of cases of advanced old age the rules which are naturally suggested are : 1. To diminish the total quantity of food ingested. 2. To give food at frequent intervals in small amount. 3. To give only easily digestible food, which does not produce too large a residue of waste matter, either in the intestinal canal or in the form of excrementitious material in the blood. It is an undoubted fact that, having reached an advanced age, a man may often prolong his life and greatly add to the comfort of his remaining years by adhering to these rules. Yet there are many instances of those whose constitutional vigour is so great and whose appetite for the good things of the table remains so keen that they are unable or unwilling to listen to the dictates of reason. I recol- lect an instance of a gentleman who, in the enjoyment of almost per- fect health at the advanced age of ninety-four suddenly terminated his life by an uncontrollable indulgence in lobster salad. The idea is prevalent with some people that the quantity of food and stimulants should be xncr tdiSed pari passu with age, but this is as wrong in theory as it is pernicious in practice, and the simple fact that an article of particularly rich or hearty food has been enjoyed with impunity for many years is no argument that it can be indefinitely taken in the same degree, although this reasoning is very often encountered. In commenting upon Prof. Humphrey's report upon centenarians, made for the British Medical Association, in 1887, Dr. Yeo observes: " Their habits in eating and drinking tended, as a rule, to great mod- eration in both. ... Of animal food the majority took but little. , . . The exact quantity is mentioned in nine instances : One took 12 ounces, one 6, one 5, and six 4 ounces daily. In the use of alco- holic drinks we also find evidence of great moderation." Some more recent investigations of the dietetic habits of men over one hundred years of age show considerable diversity ; thus, for example, some were found who ate but one meal a day, while others AGE AND FOOD. 287 ate four or five ; some drank but little fluid, others took a great deal ; some were total abstainers from alcohol, and others were not. Persons who attain to very advanced age are almost invariably of spare habit, and the universal testimony in regard to centenarians is that they have never abused food or drink, and that in the latter years of life, at least, they have been very abstemious in the use of meat. In fact, Nature usually furnishes a hint in this direction by depriving them of their teeth, making it practically impossible to eat animal food, which requires mastication, and, as Yeo suggests, " if ar- tificial teeth are used for the purpose of continuing a diet composed of animal flesh, they will not prove an unqualified advantage." Next in importance to diminishing the quantity of food in the diet of the aged (especially the proportion of fats and proteid ma- terial) should be considered the necessity of regularity in "diet, both in regard to the general character of the food taken and the times of eating. If the teeth are absent, tough vegetables and meats must be avoided, yet the food should not be wholly fluid, for some mastica- tion should be performed in order to maintain the salivary flow. Plenty of time should be allowed for this purpose. Any sudden changes in diet should be avoided, and the intervals between the ingestion of food should not exceed six or eight hours. It is very common for elderly people to awaken early in the morn- ing at three or four o'clock and to be unable to drop off to sleep again, but if they have some light form of nourishment at the bedside, such as a glass of milk or a little gruel, which they can take at that time, they will often continue their sleep. Malt liquors are very good for the aged, and a moderate amount of alcohol acts as a tonic and supplies them with needed energy for digestion and other functions. Yeo gives the following suggestions in regard to the diet of the aged, which are so useful that they will be quoted in full : " Of animal foods best suited for this time of life the following may be mentioned. When the organs of mastication are altogether inefficient these foods should be minced or pounded into a paste or otherwise finely subdivided : "Young and tender chicken and game and other tender meats. *' Potted chicken, game, and other meats, sweetbread. "White fish, as soles, whiting, smelts, flounders, etc. Best when boiled. "Bacon, grilled; eggs lightly cooked or beaten up with milk, etc. " Nutritious soups, such as chicken purees or fish purur/es of all kinds may b*e taken in moderation e. g., potatoes, carrots, spinach, and other succulent vegetables. " It is important that the use of potatoes and fresh vegetables should not be neglected ; otherwise a scorbutic state of the body may be engendered. " Stewed celery and stewed Spanish or Portugal onions. " Stewed or baked fruits and fruit jellies and the pulp of per- fectly ripe raw fruits in small quantity. " The acidity of certain stewed fruits may be advantageously neutralised by the addition of a little bicarbonate of soda so as to avoid the use of a large quantity of cane sugar to sweeten it, as this is apt to cause gastric fermentation and acidity. In stewing fruit, about as much soda as will cover a shilling should be added to each pound of fruit. " Aged persons often require their foods to be accompanied with some kind of condiment, which promotes their digestion and prevents flatulence. " Caviare and the roes of smoked and salted herrings are of this nature. " For sweetening food, milk sugar is much less prone to excite acid fermentation than cane sugar. " A very digestible form of fat when it is needed is cream, mixed with an equal quantity of hot water and about ten drops of sal volatile to each fluid ounce." BODY WEIGHT AND FOOD. 289 INDIVIDUAL SIZE AND FOOD. The size of the body has more influence than its weight upon the quantity of food consumed. In infant feeding the relationship is made the subject of careful study (see Infant Feeding), but in adults there is more variation. As a general rule, persons of large frame eat in proportion to their size, and vice versa, but there are many exceptions familiar to all, and some very corpulent persons are very abstemious at the table. Because most persons eat more than they really need, a man of large frame can often eat less than one of small size, and yet have plenty. Attempts have been made to demonstrate that a preponderance of animal or vegetable food respectively, or of some particular sys- tem of diet, influences the stature of men. Of course, children who receive insufificient food or food poor in quality may be half grown, but beyond that fact theories as to the specific influence of different classes of food upon the development of the body are founded upon ignorance of the natural history of the different races of man. The diet of bushmen, Australians, and Fuegians presents instructive ex- amples of tribes with large or small bodies, demonstrating that "it is not quality or monotony of food, but its quantity that affects devel- opment " (Gerland). BODY WEIGHT AND FOOD. The question as to how far gain or loss in the body weight may be taken as an indication of the appropriateness of diet is important. In prescribing systems of diet for many diseases, such as dyspepsia, obesity, diabetes, phthisis, etc., it is very important to have the pa- tient weighed systematically at least once a week, and good scales are very useful in the physician's office. Care should, of course, be observed that changes in clothing are not allowed to interfere with the accuracy of the observations. Loss of weight, under some con- ditions, may be much more rapid than gain ever is. The latter at best does not usually proceed at a rate of more than two or three pounds in a week, even during convalescence from such an illness as typhoid fever ; but in diseases like cholera, for example, in which emaciation is extremely rapid, the loss of weight may amount to two or three pounds a day, or possibly more. In some diseases a fallacy arises in comparing food consumption with body weight. In fevers there is usually loss of weight, but this is not always the case. Sometimes in aseptic fevers the weight may remain uniform; and in phthisis there is sometimes uninterrupted gain during a moderate hectic. Leyden has found that in fever, while the albuminous ingredients of the body are diminishing, there 2QO FOODS REQUIRED FOR SPECIAL CONDITIONS. may be more water stored in the tissues, and in cases of anasarca and dropsical accumulations of rapid development it is quite possible for the weight to increase, while in reality the body is rapidly wasting away, and it would be a very grave mistake to deduce any conclu- sions for feeding the patient from the weight alone. Another impor- tant consideration is the rapidity of loss of waste food products from the body. The normal weight of feeces which should be voided each day is five or six ounces about one fourth of which is solid matter, the rest water. Many persons do not pass over half this quantity for days together, and thus go on accumulating waste material, which adds to their weight. The same disproportion between food ingestion and the elimination of urea and different salts in the urine may exist. Moreover, the loss of weight by excessive perspiration may reach a pound or two a day. Athletes subjected to violent physical strain and stokers working in great heat sometimes of 120 F. may lose two pounds in an hour in this manner. The night sweats of phthisis cause considerable actual loss in weight, besides the exhaustion which they occasion. The loss of weight through the aqueous vapour and carbon dioxide in the lungs may vary somewhat, although it is less changeable than might be supposed. For all these reasons it is necessary to be somewhat cautious in accepting conclusions from the scales for application in ordering more or less food, or altering its character. The weighing of infants immediately before and after nursing at the breast is an excellent and fairly accurate method of determining how much food they are getting, and infants whose nutrition gives any cause for anxiety should be frequently weighed, for in them, for obvious reasons, the record of slight variations in weight can be much more accurately utilised in regulating feeding. SEX AND FOOD. The relation of sex in regard to food affects the quantity rather than the quality, excepting among a few rude tribes where supersti- tion is allowed full sway. The northern Eskimos, for instance, have a belief that if women eat eggs they cannot become pregnant, which is in curious contrast to the reputation for aphrodisiac effects which this food has among civilised people ! (See Eggs, page 90.) Women eat less food than men relatively because their average size is smaller, and also absolutely because they do less work and lead a more indoor life. The difference is slight, and when other conditions are equalised the question of sex has very little influence upon the quantity of food consumed. Generally speaking, women's bodies are smaller than men's, their DIET AND RACE. 291 digestive processes are somewhat less active, and they have greater tendency to constipation. About the only way in which sex affects the quality of food con- sumed is in the somewhat greater fondness for sweets and confec- tionery exhibited by females, but this can be shown to be due more to other considerations of habit and custom than to sex. The use of tobacco by many men, for instance, makes them care less for such foods. DIET AND HEREDITY. The influence of heredity upon diet is not very striking. Children are sometimes supposed to inherit likes and dislikes for particular foods, whereas they are merely acquired tastes from the circumstance that they have certain foods offered them at home to the exclusion of others. The functions of the stomach and intestines appear to be somewhat hereditary. Violent seasickness and a tendency to bilious- ness and constipation in some persons and the prompt vomiting of the contents of an overloaded stomach in others is sometimes a family trait, running through three or four generations. So is occa- sionally the inability to digest special foods, such as crustaceans, strawberries, etc., but such instances are rare. Unfortunately, the abuse of alcohol is very strongly hereditary so much so that the children of inebriate parents should be protected as long as possible from learning the taste of either beer, wine, or spirits. Heredity has some influence in disorders of food assimilation, like gout and diabetes, and in such cases improper diet and careless habits of eating may develop latent disease. DIET AND RACE. The food of prehistoric man necessarily consisted of the simplest elements, represented by fruits, berries, nuts, insects, and an occa- sional piece of raw fish or meat. Such food is, in fact, the diet of primitive tribes to-day. The Fuegian lives chiefly upon shellfish and seaweeds, and the Central African dwarf upon plantains and in- sects (see page 29). The name " Eskimo " was first applied by natives of eastern Canada in opprobrium, to signify "raw-fish eater." The history of the development of diets and of food cultivation and preparation is practically a history of the progress of culture, and most of our present foods were quite unknown to our earliest progenitors. The discovery of the uses of fire greatly increased the variety of available foods for man, for all the cereals which are cul- tivated require its use to fit them for digestion. As Gerland has said, men obtain their food from natural products, by cultivation, or by barter and commercial exchange, according as nomadic or fixed 2Q2 FOODS REQUIRED FOR SPECIAL CONDITIONS. habits predominate, and " no mere hunting or fishing tribe can be large and remain in one place," for it is estimated that in the tem- perate zone to support one man by these means at least sixteen square miles of territory are necessary. Many a tribal, and even national war has been the more or less direct outcome of the necessities of obtaining food supply from distant sources, and the economic, commercial, and social development of all matters pertaining to food among civilised people to-day far ex- ceeds in importance all other practical questions. As man advanced in culture and began to live in communities where division of labour became an important factor in development, preference to some ex- tent superseded necessity in the selection of diet, and as food acquired a commercial value, more and more labour was bestowed upon its preparation and preservation, until at the present time the rich are able to select their diet with almost total disregard of season or climate, and even the common labourer finds it economical to eat some foods which, like sugar or tea, may have been transported many thousands of miles. Following is a synopsis of an exceedingly interesting report kindly written for me by Dr. Frederick A. Cook, the physician to the Peary expedition to northwestern Greenland in 1891-92, which is appended to illustrate the dietetic habits of a race which, for nearly a thousand years, are believed to have been practically isolated from commercial or social relations with any of their neighbours. There is so little scientific information existing in regard to the di- etetic habits of the tribe of Eskimos which he studied, who live the farthest north of any people in the world, that his statements will be found of exceptional interest. One cannot peruse the account without being impressed with the fact that generalisations in regard to the influences of diet upon the system should be made with great caution when applied to different races of man. For example, both scurvy and rheumatism are sometimes attributed to an excessive meat diet, yet the Eskimo has no starchy food at all and does not suffer from these diseases, and, moreover, his bodily vigour and power of endurance compare favourably with that of any other race or class of men, and in some respects it is greater than that possessed by others. Dr. Cook says in regard to the Eskimos of northwestern Green- land : "They usually eat but one meal a day, which they take at irregular times, being people without restrictions of any kind. They can be seen eating and drinking whenever able to procure sustenance. Their diet consists almost exclusively of meat, com- posed principally of the muscular tissues of the following animals, in the order of their importance to the natives: Seal, walrus, nor- whale, white whale, polar bear, reindeer, arctic hare, and sea fowls, DIET AND RACE. 293 such as guillemots, gulls, eider ducks, etc. When food is scarce they eat every part of the animal, including the stomach and intes- tines ; indeed, the only vegetable food that the most northern Es- kimo can obtain consists of the contents of the stomach of the reindeer (lichens), which he is only occasionally able to secure. The women and children sometimes eat flowers of the arctic poppies and the so-called scurvy grass, but never to any great extent. In times of famine, in order to prevent wholesale starvation, the aged are turned out to starve to death, and their bodies are then devoured by the more vigorous members of the tribe. Occasionally, when the old people are shrewd and active, the younger children are sac^ rificed for this purpose. As a rule, the Eskimo will not eat dogs, but when food is scarce dogs are first added to their larder, and when the last dog has been eaten, human beings come next in order. " One of the greatest delicacies is old seal. A native never wastes the carcass of an animal ; if he should kill the seal fifty or a hundred miles from home he will bring it to shore and cache it in such a way that the foxes, bears, and birds cannot attack it. He then leaves it, and may not return for two or three years, when he comes back in anticipation of a great feast, for the old seal seems to him like old cheese to us, and he enjoys it immensely, although a white man could not endure the odour. I have known twenty indi- viduals to eat a seal of this character in less than two hours, leaving only shreds of the skin after them. I have never been able to verify the statement, so commonly quoted, ' that Eskimos can eat twenty pounds of meat or blubber.' " Fully two thirds of the Eskimo food is eaten raw, and one half is consumed while in the frozen state. When an Eskimo woman starts her blubber lamp and places over it a conlipsie (the name applied to their primitive stew pot), she does so principally to obtain the warm drink which the cooked meat affords. It cannot be said that Eskimos cook their meat because they prefer it cooked, but because when the meat is heated slowly, as it can only be heated by their primitive method, the blood and fat ooze from the mus- cular tissues and form a thick soup, which, aside from water, is almost their only drink, and a cupful of this beverage is offered to every guest. The natives may consume three or four hours in cat- ting one meal, and when they have thoroughly gorged themselves they will lie down and sleep; as they do this, however, they place before themselves a dish full of cooked meat, and those who awake from their sleep will finish their meal, but on rising no breakfast is served, for the Eskimo who has a day's journey before him would not think of eating before starting. He claims that this would prevent his ability to travel, and this rule the Eskimos apply to their dogs as well, who are often only fed every two days. These Eski- 2Q4 FOODS REQUIRED FOR SPECIAL CONDITIONS. mos are as irregular in their habits of sleep as they are in regard to their meals. During the four months of constant sunshine they usually arise when the sun is in the south, but the Eskimo never thinks of going to bed until he is sleepy, so that in time of excite- ment, when there is a new arrival or in the pursuit of game, he will often remain awake for forty-eight or seventy-two hours, and then he will sleep ' until the spirit of sleep has left him,' as he ex- presses it. " The Eskimos endure fasting very well, and after a good, full meal they can fast for two or three days, apparently without seri- ous inconvenience. Indeed, when food is scarce which usually happens during the period of darkness some thrive on about one meal a week, but they appreciate the fact that he who is not well fed cannot encounter fierce storms, and no one who has not had full rations would think of venturing out in severe weather. During the tedious night of four months these Eskimos appear to undergo a state of hibernation, eating very little and sleeping a great deal ; their otherwise lively spirits are more or less subdued, and while they try to keep cheerful they are apt to become depressed and debilitated, and they are not capable of great muscular exercise during this time. When the sun returns their skins are somewhat jaundiced, and they are very anaemic. This peculiar effect was also produced in the members of our party in a more exaggerated form, although we tried many methods of overcoming the depression, and though we had no trace of scurvy our will powers were lessened, and our ambition was, to some extent, lost, and our muscular power as well was much reduced, so, that a walk of a mile produced exhaus- tion. All of the secretions were diminished, particularly those of the digestive tract, and to stimulate these taxed my mental skill for the greater part of the winter of i89i-'92, but with us, as with the Eskimo, as soon as the sun returned our strength and ambition came back, and we felt as if we had gained a new lease of life and were ready to encounter any hardship. " The Eskimo drinks very little while eating. He usually defers that for some time afterwards, or perhaps until he arises next morn- ing, when he drinks a great deal, and while I have not measured the quantity of water consumed by any definite number of inches in twenty-four hours, I have often given Eskimo men three pints of water at one time, and nursing women two quarts. Before starting upon a journey a native will fill up with water. It should be re- membered that these people use no free salt or condiments. " I am not prepared to say that the food of these people bears any relation to their stature, as other factors may influence their height, but their large abdominal development is undoubtedly due to the immense quantity of food and drink which they consume at DIET AND RACE, 295 one time. "Variation in diet does not seem to be a necessity to the Eskimo unless he is feeling ill, when he recognises the importance of a change of food and surroundings. He will always hail with pleasure the first bird, deer, or walrus of the season. " The Eskimo's clothing is such a perfect non-conductor that the temperature does not vary much around his body, and in summer it is practically the same as in the coldest day of winter. For this reason, the extreme cold of winter does not call for a large quantity of food, but a native knows that his food is fuel for his body, and that he must take it in sufficient quantity to develop muscular power and animal heat. " The Eskimo mother nurses her child until the next is born or shortly before it, a period which varies in from one to eight or nine years, but the average time is four years. Long before the mother weans her child she masticates the food, opens the baby's mouth, and transfers the food from her own mouth to the baby's, very much as a pigeon does, and the child thus brought up would not think of taking up pieces of meat or toys or anything else to put into its mouth, for it will take nothing except from its mother. " The members of our expedition took very few forced marches in low temperatures. The one over the interior of Greenland was undertaken at the time of year when the thermometer ranges from 5 F. below zero to 40 above. *' The quantity of food consumed per man every twenty-four hours upon this expedition was as follows : " Pemmican i^ pound. Bacon, fat 6 ounces. Powdered pea soup 2 " Dry ship biscuits 12 " Condensed milk 3 " " A quart of tea with perhaps a pint of water was our only drink, but we had no drink through the day while on the march, and often were unable to secure more fluid than two cups each morning and night. The pemmican was composed of dried beef and beef tal- low, half and half, a few currants, and a little sugar, but no salt. On several expeditions during the spring of 1892, while the ther- mometer ranged from 20 to 40 F. below zero, the members of the party always consumed large quantities of food. This was not, however, until they had been out two or three days, when the amount of food which they could devour seemed almost un- limited. There was no time that we craved for fat. We enjoyed the pemmican immensely, but that was because we had nothing else. During the extreme cold weather, while in the field, we took more kindly to fats, but never in preference to other foods. Canned meats, for some unexplained reason, were soon in disfavour, for the 2q6 foods required for special conditions. variety and character of the food seemed to be of very little con- sequence ; indeed, our appetites were such that we were ready to eat anything and everything placed before us. We were, however, always liberally supplied with hydrocarbons, and I believe had this not been the case, a demand for them would soon have arisen, for the most valuable food for a polar expedition is composed largely of hydrocarbons. " The most important articles of diet for a polar expedition we found to be pemmican, cranberry sauce, tea, coffee, chocolate, pre- served milk, sugar, ham, cheese, bacon, oleomargarine, lard, pickles, lime juice, dried fish, beef-soup tablets, wheat, corn, rye flour, rice, hominy, oatmeal, dried vegetables, and a liberal supply of all kinds of canned vegetables, particularly canned tomatoes, peas, beans, corn, canned soups, and dried fruits. Lime juice was not served regularly to the members of the expedition, and I think nothing is to be gained by so doing. For some of the members of the party it was decidedly injurious, but others called for it occasionally as a refreshing drink. '' The average weight of these northern Eskimo men is one hun- dred and thirty-five pounds, but that of the women one hundred and eighty-eight pounds. Obesity is foreign to the Eskimo, and leanness is equally rare." CLIMATE AND SEASON AND FOOD. Much has been written about the need of man changing his diet when he removes from one climate to another, in the belief that the natives always eat the kind of food best adapted to the climate in which they live. This is superficial reasoning, and too much im- portance is attached to the relations of climate to diet/>er se. As a matter of fact, the natives of a country eat what they can obtain easiest, or what their habits and mode of life have accustomed them to in the struggle for the survival of the fittest. " Climate affects diet mainly by the supply it affords " (Chambers). "The national dietary is determined largely by the climate and nature of the available soil, and among civilised communities it is largely modified as facilities for commerce and interchange of food products are increased. " Maritime people naturally derive much nitrogenous food from the sea, as fish, molluscs, crustaceans, etc. Among the residents of the far North albuminous and fatty diet predominates, and the coarser cereals barley, rye, oats, etc. being more hardy, predomi- nate in their food. Barley grows the farthest north of all the cere- als " (Clark). The Hindu subsists mainly upon rice, one of the simplest types of farinaceous food, and he derives his nitrogen from corn. He CLIMATE AND SEASON AND FOOD. 207 must consequently eat a large bulk of food in order to obtain suffi- cient nitrogen for the needs of the system; his digestive organs enlarge, and he finds the means of stimulating them by the free use of condiments of various sorts. Bulky and fibrous vegetable food distends the alimentary canal. The natives of very hot coun- tries live mainly upon vegetable and starchy foods, eating cereals, green vegetables, and pulpy fruits which contain water, salts, and acids in abundance, which are cooling and refreshing. As a rule, they eat less animal food than do the natives of temperate and arc- tic regions, nor do they require fats in excess, although they take some fats and oils. While these statements apply to a majority of mankind, they are by no means without exception, and it must not be argued that because a tribe eats the only food which Nature has provided, they could not live equally well in their own climate upon other food, if they could obtain it. Far from depending solely upon vege- table food, most savage tribes living in the torrid zone eat meat rav- enously when they can get it, and often prefer it in an advanced stage of decomposition. The New Zealander and South Sea Islander choose a varied diet of fish, eggs, roots, seeds, berries, seaweeds, and meat if obtainable (see page 29). As pointed out by Chambers, the Pampas, who eat flesh and drink water only, thrive on hot arid plains, and so do the Nubian Arabs, while the peasants of northern Norway and southern Spain live alike almost wholly on breadstuff's without meat. He says that "the im- mediate transition from a purely animal to a purely vegetable diet, though borne by the individual, is fatal to the race," and "the best diet in the abstract is a mixed diet, and mixed in the proportion se- lected by the experience of most civilised nations, and it is also best for the individual who is accustomed to it to adhere to under what- ever sky he may be wandering." In changing residence from one extreme of climate to another it is not advisable to alter the diet too suddenly, and more must depend upon the previous habits and occupation of the individual than upon external temperature. Meat eaters find it easier to adopt quickly another form of diet than vege- tarians. The English soldiers transported to India or Africa are not re- quired to become exclusive vegetarians; and the French in .Africa or Panama have done best upon a mixed diet. "Well-clad and sheltered sftldiers require less rations than poorly clad men exposed to the weather a good thing to know in times of great privation " (Woodruff). Men often become involuntary vegetarians while travelling in hot climates from inability to procure meat, and may partially starve 2q8 foods required for special conditions. themselves from lack of appetite for monotonous food, variety being unobtainable. This leads them to resort to strong condiments, spices, curry, etc., to stimulate the appetite. Many persons, especially those past middle life and people with a tendency to corpulency, find that during the heat of the summer sea- son, and especially during the prevalence of "heat waves," they are in much better health when they abstain from hot soups, fat, and meat, and take but little animal food of any kind. The total quan- tity of food eaten may advantageously be reduced at this time of the year as much as one sixth, or even one fourth. Most persons find this out as a matter of individual experience; but there are others who should be especially directed in the matter, and the rule applies to infants as well as adults. The diet in winter should com- prise both more nitrogen and more carbon than in summer. The breakfast hour is often made half an hour or an hour earlier in summer than in winter to advantage. The thirst engendered by living in hot climates is conducive to excessive drinking, and as the water is often bad, an additional ex- cuse is often made for drinking too much liquor. By these means the foundations for hepatic and renal troubles, cirrhosis, and Bright's disease are often laid. On this account, in very hot climates strong alcoholic drinks ought especially to be avoided. In India they uni- formly disagree, and lighter beverages, such as beer and wines, must be taken very sparingly; but there is no objection to tea, coffee, and chocolate. PART V. FOOD DIGESTION. CONDITIONS WHICH ESPE- ' CIALLY AFFECT DIGESTION. HOURS FOR MEALS AND ORDER OF TAKING FOOD. The hours for taking meals which are commonly selected are those which are best adapted to the varying needs of the system at different times in the day, and experience teaches that they must be varied considerably with occupation. In the larger American cities where commerce is active, and many men are subjected during the day to excitement, hurry, and strain, an evening dinner hour often better meets the needs of the system as well as the requirements of personal c6nvenience. In the rural districts, however, and in many countries where life is less hurried and active than under the condi- tions of the extraordinarily rapid growth and development of the United States, it is found that taking the heaviest meal at noon agrees better with the wants of most persons. The hours for infant feeding are described under the heading Infant Feeding. Children should always dine early in the day. There are in gen- eral three systems for adults in regard to the number of meals and hours for taking them which are in common use, in which two, three, and four meals, respectively, are eaten in the twenty-four hours. The first system, which is in vogue in France and, to a less extent, elsewhere, is that of eating but two substantial meals a day. On first rising in the morning, a cup of hot coffee or chocolate is taken with a roll or some other simple form of bread. This enables two or three hours of moderate work to be accomplished before the first real meal, which is a breakfast eaten in the late morning, usually at or before twelve o'clock. This meal is substantial, consisting of sev- eral courses of solid food. The second meal, which is the dinner, is usually eaten between six and seven o'clock. This system is in use among workingmen as well as with the leisure classes, and is found well adapted to their habits of life. Americans travelling abroad, who are accustomed to eat a heavier meal for breakfast, often find some difficulty in adapting themselves to the French custom, but many learn to like it, and as the travelling public are commonly, for 299 30O FOOD DIGESTION. the time being, a leisure class, it is less difficult to adapt themselves to new customs abroad than to introduce them at home. The Germans also usually take a cup of coffee or other light beverage and a roll of Butter-brod soon after rising, but they dine very early, often at half past twelve, taking a heavy, de- liberate meal at this hour, which they are apt to follow with beer and tobacco. Their offices and banks open early, and are often closed from noon until three o'clock, when they are reopened until five, whereas in most cities in this country the most active business hours are in the middle of the day, and it would be practically impossible for many men to give up two or three hours at this time to eating and social converse. The Germans usually take a supper with meat at a somewhat late hour between half past seven and eight o'clock. In many German towns it is customary to open the theatres as early as six o'clock, so that the performance is closed in time for a supper at nine. The habit of eating between meals and of tak- ing occasional light lunches in the afternoon seems to be more prevalent there than elsewhere. In England it is a very common custom for the better classes to breakfast at eight or nine o'clock, lunch or dine between one and two, take a cup of tea and perhaps a biscuit at four or five, and dine or sup at seven or eight o'clock. In the United States, where there are theoretically no class dis- tinctions, they practically do exist very strikingly in regard to the hours for taking meals, and the hard-working labouring class, whether employed in the city or country, almost universally dine at noon. It is mainly the mercantile and professional classes in large cities who dine between 6 and 7 p. m., while the more fashionable or leisure classes dine even later sometimes at eight o'clock. Most of the latter, however, on going to the country for a summer holiday, are accustomed to reverse their habits and dine at the usual country hour at one o'clock, taking supper at half past six or seven. In the Southern cities it is quite common to dine in the neighbourhood of half past two or three o'clock. Many persons in cities who habit- ually dine late on week days from long-continued custom, on Sun- days dine shortly after noon, taking supper in the evening. This is an old custom handed down from days in which less exacting oc- cupations favoured noon dining throughout the week, but due in part also to economical reasons, and a desire to make the work for servants as light as possible on Sunday afternoon. While those in good health with active digestion suffer no inconvenience from thus changing the hour for meals on one day in the week, there are others who find that it disagrees with them and disturbs their digestion. A hearty meal at noon following a very light breakfast, consisting of a roll and cup of coffee or tea, may be perfectly digested for years. HOURS FOR MEALS AND ORDER OF TAKING FOOD. 301 yet reversing the order of the meals may entirely disorder the digestion. For professional and other classes of men in the United States who are not occupied in physical labour or outdoor pursuits the fol- lowing system is found to possess decided advantages : A breakfast is taken soon after rising, at half past seven to half past eight, which consists of fresh fruit, porridge or oatmeal, or other varieties of cereals, poached eggs or omelet, and a little bacon or fresh or salt fish, bread and butter, tea or coffee. The lunch, eaten between one and two o'clock, may consist of a lean chop, or a piece of cold ham, or a slice of rare beef with some stewed or baked potatoes, with a simple lettuce salad, or perhaps a little cheese for dessert. If a heavy meal is taken at this hour by persons unaccustomed to it, and who have had a breakfast of solid food, they often feel dull and sleepy for an hour or two thereafter, and are consequently inca- pacitated from active mental exercise. The dinner should be from half past six to half past seven, after the principal labours of the day are over, and at an hour early enough to allow of the complete diges- tion of the heaviest meal of the day before retiring. This may con- sist of several courses, which are conventionally arranged in the order which appears to be most rational and physiological namely, soup, fish or an entree, a steak or joint with potatoes and one or two fresh vegetables, a salad, and a light pudding or cooked fruit. A clear soup at the commencement of a meal does not interfere with digestion, but favours it. The fluid, if taken in a quantity not exceeding eight or ten ounces, is, for the greater part, promptly absorbed in the stomach, and its warmth and the sustenance it con- tains act favourably upon the circulation, stimulate the secretion of gastric juice, and satisfy temporarily the cravings of hunger which are not met by the taking of solid food until after it has been digested for some time. The fish or entree is then eaten in the earlier stage of gastric secretion when the gastric juice has not yet attained its full strength and quantity. This is followed by the eating of meat, which is destined to remain in the stomach for several hours, and requires all the energies of its digestive processes. The saccharine or farinaceous food, which does not undergo digestion in the stomach, is taken towards the end of the meal, when it remains a less time in the stomach than animal food. The discussion of more elaborate dinners, consisting, as they do very often, of a dozen or more separate courses, would be out of place in this volume. Such dinners can only be indulged in for any length of time by those whose digestion is robust and whose leisure and comparative freedom from care and anxiety allow them to devote abundant time and physical energy to their meals and to secure sulificient holidays and trips to noted spas to enable them to OQ2 FOOD DIGESTION. periodically relieve the digestive system of the strain put upon it. Persons who rise late and dine early should eat but a small break- fast and a hearty supper. If the noon dinner is replaced by a light luncheon, a substantial breakfast should be eaten. Undoubtedly it is usually best to so order one's occupation that neither severe mental nor physical labour need be undertaken imme- diately after eating. Yet much depends upon the age and strength of the individual. At one of the largest colleges for girls in New England the pupils dine at one o'clock, and many of them commence to study imme- diately thereafter, or at 2 p. m. ; yet cases of indigestion are compar- atively infrequent among them ; and the ordinary day labourer begins his work again without detriment almost immediately after a hearty noon meal, and continues it while gastric and intestinal digestion are still necessarily incompleted. Invalids often require modification in the accustomed hours for meals, and Balfour says that "all invalids should have their impor- tant meal in the middle of the day." Between four and five hours, on the average, must be regarded as necessary for complete digestion of a mixed meal. The intervals between meals should be regulated with reference to individual peculiarities. As a general rule, convalescents or per- sons with feeble digestive powers and poor appetites, who are unable to eat a sufficient quantity of food at any one meal, should be fed more frequently, perhaps four or five times that is, in addition to three ordinary meals, they should have light lunches in the middle of the forenoon and afternoon, or possibly just before retiring. The latter is particularly to be recommended, for if the food be light and nutritious, such as a bowl of gruel and a glass of hot milk, or a cup of cocoa with a biscuit, and possibly a glass of beer, sleep is not interfered with, but is promoted, and the system is saved from too long an interval of starvation between the hours of dinner or sup- per and breakfast. On the other hand, dyspeptics and patients with gastric catarrh may find it desirable to allow an interval of fully seven hours between their meals, in order to give abundant time for the digestion of one meal before that of the next is undertaken, and they should stop eating short of repletion. There are others whose digestion is good, but constitutionally slow, and they are better with intervals of at least six hours between their meals ; and there are some people who keep in better health on only two meals a day, and occasionally, although it must be re- garded as an eccentricity, except in the case of some savages and the Eskimos (see page 292), there are persons who thrive upon but one meal a day. The monks of La Trappe eat but one meal daily, as a religious APPETITE. 203 custom, at which they consume so much food that they become dull and lethargic for several hours afterwards (Combe). Many savages, like the Hottentots, have no regular times for eat- ing, but, like the carnivores, take their food whenever and however they can best obtain it. The business or professional man when overworked sometimes forms the habit of omitting his noon luncheon; but this custom, although it may benefit some forms of dyspepsia, is a pernicious one in the majority of instances if long continued. APPETITE. The term " appetite " in relation to dietetics usually means a pleasurable desire for food or drink, whereas hunger and thirst im- ply a craving for food and drink respectively, which has become disagreeable or positively painful. There is, however, no distinct Ime of demarcation to be drawn between these terms. The appetite for food is a most capricious sensation, subject to all manner of disturbing influences. It is to some extent appar- ently under control of the will, in that it can be trained to recur at certain intervals before taking food. In a normal state it is, there- fore, rhythmical, and it may then be taken as an index of the need of food, but when it becomes abnormal it is a very unreliable guide. "As a general rule, though by no means without exception, sub- stances pleasing to the palate are useful and not injurious to the organism " (Brunton). The appetite often appears with great suddenness, either inde- pendently or as the result of directing the attention to matters of food and eating. It may depart as suddenly, even without gratifi- cation, or it may vanish after the first few mouthfuls of food are eaten, although it was apparently vigorous a moment before. The appetite is aroused by a variety of circumstances and con- ditions, both physical and mental. Such are the smell, taste, and sight of food, good hygienic surroundings, exercise, bathing, cold or stimulating air, agreeable companionship, pleasurable mental emo- tions, and the proper preparation and serving of food. It may be stimulated by bitters, condiments, and in some cases by alcohol. Wine drunk between meals is apt to spoil the appetite, but taken in moderation with meals it may increase it. To obtain the most complete satisfaction from the sense of taste one should swallow the food, and not merely take it into the mouth. The appetite is usually somewhat more keen in winter than in summer, but many persons observe no difference. It is depressed or destroyed by mental emotion, especially grief, anxiety, and worry ; by the sight, smell, or taste of ill-prepared or improperly 22 204 FOOD DIGESTION. cooked or badly served food ; foul air and poor hygienic surround- ings; fatigue and exhaustion; many diseases, more particularly febrile diseases and most gastric disorders; nausea; the use and abuse of strong condiments, and many drugs, notably opium and those which, like potassium iodide, produce a continual offensive taste in the mouth; the abuse of alcohol; eating irregularly and at too short intervals. In old age the appetite, especially for meats, usually becomes less keen, and the absence of teeth contributes to the loss of desire for this kind of food. There is often a dislike for cold fluids. A voracious appetite sometimes occurs in children and youth. Bulimia is the name given to this condition, which is by no means an indication of vigour, and is often due, according to Beale, to an irritable condition of the nerves of the stomach, and may be brought about by eating at irregular intervals, which results in dis- turbance of the gastric secretion. Such children are usually thin, and are encouraged by ill-advised parents or attendants to gorge themselves with food which they do not digest. It is a popular belief that the presence of intestinal worms excites a ravenous appe- tite. In some cases this may be true, especially of round worms {^Ascaris lumbricoides), which are very active, and which may even throw a child into convulsions by local irritation of the intestine. On the contrary, worms of any sort may be present in considerable num- ber without giving rise to symptoms. Persons whose appetites exceed their digestive strength do well to eat very slowly. By so doing, the food eaten at the first part of a meal may become par- tially absorbed and lessen the desire for more before the meal is over. The appetite is very dependent upon habit and upon the usual order and arrangement of the meal. An attempt to eat a lump of butter alone usually fails, but it is easily consumed if spread upon bread. Reversing the customary order of the different foods served at a dinner usually produces disgust, and may even excite nausea. Abnormal Cravings. Instances of abnormal cravings for food are familiar to every one. They sometimes take the form merely of an inordinate desire for food which is in itself wholesome but which is poorly adapted to an existing diseased condition. Such desire is apt to come in the course of any protracted illness in which a very restricted diet has been maintained for weeks. It is largely psychic, and does not necessarily indicate an increased appetite. The dysenteric patient may long for ham or pickles or vegetables, or the very obese will beg for sweets, preserves, or farinaceous food. In other cases the .craving may be an indication of a positive VARIETY IN DIET. 305 want in the system, as when a scorbutic patient hungers for fresh fruit and vegetable acids. In no disease is the craving for food of every kind more pro- nounced than in convalescence from typhoid fever. In this case the hunger can hardly be considered abnormal, for it is an expres- sion of the need of wasted and exhausted tissue throughout the body for nutriment. Patients usually find it most difficult to give up the class of foods which they well know does them most harm. The subject of flatu- lent dyspepsia longs for saccharine, and perhaps amylaceous or fatty foods confectionery, pastry, and the like and the diabetic some- times has an inordinate craving for bread, which so far possesses him as to cause a resort to any subterfuge to obtain it. In disordered mental conditions, hysteria, hypochondriasis, mel- ancholia, and in the peculiar periods of puberty, pregnancy, and the menopause, cravings for wholly injurious articles may occur. Such patients have been known to eat chalk, or sour food, or consume large quantities of salt, sodium bicarbonate, etc. With the exception of chronic alcoholism if alcohol be regarded as a food as well as stimulant there is no distinct food " habit," in the sense that any particular food is apt to be long eaten to an in- jurious excess. Those articles of diet which are oftenest abused are condiments and confectionery. VARIETY IN DIET. Monotony of diet is not incompatible with maintenance of life, and even of health, when the food is restricted to two or three arti- cles only, but for the reasons given in discussing the force value of different foods (page 7) there is no single food, not even milk, which will support man in ordinary health and vigour for long. There are many primitive races and tribes of man who live comfortably upon a diet so restricted that it would soon prove unbearable for a European or an American. Much, therefore, depends upon custom, and no doubt upon heredity. The Hindu eats boiled rice and ghee, or melted butter, and the low-caste Chinese eats rice to the almost, but not complete, exclusion of other food; the Eskimo lives upon one or two kinds of meat or fish, and a little fat ; and the Congo native sub- sists chiefly upon the plantain. The Central American Indian lives almost entirely upon maize, and some of the Polynesians eat bread- fruit alone for two thirds of the year. The roving Indian of the North American plains originally subsisted all winter upon a diet of salt meat, and the Scotch peasants formerly lived for six days in the week upon oatmeal porridge. Such a monotony of diet is, however, usually a question of en- 3o6 FOOD DIGESTIOlSf. vironment and not of choice. The carnivorous Eskimo enjoys canned vegetables when they are offered to him, and the vegetarian African native gorges himself with meat when he can obtain it. As a rule, the more civilised the tribe of man the greater is the variety of his diet, and once accustomed to variety, it is very difficult to sub- sist upon a too restricted regimen. It is the ability to subsist upon a variety of foods which makes it possible for man to adapt himself so well to his environment when he migrates from one extreme of cli- mate to another. This adaptation is also possible because the elementary foods possess general nutritive properties for all the organs of the body, rather than special value for individual structures; for example, there is no " brain food " in distinction from food which nourishes other organs as well. An ideally perfect food combination if made upon purely theo' retical considerations of the needs of the body for just so much al- bumin, fat, starch, sugar, salts, and water would be a compound which in a very short time would become too monotonous and wea- risome to be eaten. Even the domestic animals are kept in better condition by occasional slight changes in diet such, for instance, as are afforded by change of pasturage or the variety which the season of the year produces in their natural food ; and it is well known that the flavour of the meat of fish and wild animals depends upon the nature of their diet. For example, canvasback and redhead ducks are much more palatable while feeding upon the wild celery plant than when eating other food, domestic turkeys and capons improve when fed upon grain, swine flesh is made better by feeding the ani- mal with corn than with skimmed milk, and salmon and shad acquire a more delicate flavour when feeding in fresh-water rivers. Among some peoples the variety of food is considerably restricted by religious observances, custom, and associations. For instance, there is the Buddhist prohibition of meat and the Jewish prohibi- tion of swine flesh. When a variety in food cannot be secured the desired effect in stimulating the appetite and digestive secretions may be obtained by altering the methods of cooking and by modi- fying the taste and odour of food. On the other hand, too great variety, as well as too elaborate cooking, becomes equally tiresome. Those who eat constantly at restaurants and large hotels, where the table is greatly diversified, often find that a change to a simpler home table agrees with them better. Woodruff attributes the decrease in drunkenness in the past few years in the United States army to the advantages accruing from a much greater variety in diet since fresh vegetables were made a part of the ration, and since by a system of exchange the soldier has been enabled to barter an excess of common ration food for a few articles- THE NERVOUS SYSTEM AND DIGESTION. 307 of luxury. He also says: "Variety is necessary in the army for another reason : When the diet is very simple there is apt to be constipation, and in the field this condition is sometimes quite marked. It is recognised by physicians that chronic constipation cannot be properly treated with drugs, and it must be rectified by diet. The field ration, if possible, should overcome this tendency to constipa- tion. Sluggishness of the bowels quite commonly goes along with discontent, homesickness among soldiers, and in such conditions the soldier is not a reliable fighter he is easily beaten." THE NERVOUS SYSTEM AND DIGESTION. The influence of the nervous system on digestion is very com- plex. In a general way, the peripheral nerves may affect the digest- ive process (a) through the circulation, {/>) through motion, (c) through glandular action. The nerves chiefly concerned in these processes are the branches of the sympathetic system and the vagus. The latter, through its association with the cardiac, vasomotor, and respiratory centres in the medulla oblongata, places the vital func- tions of the body in very intimate connection with food stimulation acting through the branches of the nerve in the alimentary canal. (a) Action through the Circulation. The nerves influence digestion through the circulation by their vasomotor control, regu- lating the calibre of the vessels and quantity of blood supplied to the walls of the alimentary canal, the local blood pressure, and the consequent rate of absorption. {^) Action through Motion. The nerves influence the move- ments of the entire alimentary canal, either accelerating or inhibit- ing them, thus controlling the propulsion of the food, its admixture with, secretions, and its contact with absorbing surfaces. (c) Action through the Glands. The nerve supply of the digestive glands is distributed to their blood vessels, and also prob- ably to some extent to the cells of the gland parenchyma. This latter distribution is not always demonstrable histologically in man, but the influence is unquestionable. Under normal conditions, the nerves act mainly in connection with the digestion through reflex stimulation produced by mechan- cal irritation of food and by the chemical irritation of its different ingredients as they undergo absorption. But, in addition, nerve cur- rents from the central nervous system or from a remote peripheral origin may interfere with the normal nerve functions. Every one is familiar with examples of acute indigestion produced by fatigue of the nervous system, undue mental excitement, emotion, etc. For any given phase of digestion, disturbance of normal nerve function will retard the process more in its earlier stages by checking or alter- ^q3 food digestion. ing gland secretion. In its later stages the effect of the nervous system will be more pronounced in controlling or inhibiting absorp- tion. Overstimulation of the local nerves of the alimentary tract may excite an increased watery secretion and exaggerate peristaltic movement of the intestines, thereby hastening the passage of the food through them before there is time for digestion or absorption, and giving rise to diarrhoea. CIRCULATION AND DIGESTION. The influence of the circulatory system upon digestion appears in the composition of the blood and in i^s rate of supply to the diges- tive glands. Vigorous active circulation accompanies good diges- tion and maintains a normal local reaction and temperature, and feeble, sluggish circulation produces local congestion of the viscera and interferes with gland secretion and absorption. When the nerves of the salivary glands are experimentally stimulated in ani- mals by an electric current the blood vessels are altered in calibre. If the chorda-tympani nerve is stimulated the vessels are dilated and the rapidity of the blood flow is accelerated so that the venous blood issuing from the gland is of a red arterial hue, it not having lin- gered long enough to undergo the ordinary changes in regard to its gases. The salivary secretion becomes watery and contains a smaller percentage of solids. On the other hand, when the sympathetic nerves are stimulated exactly the reverse occurs. Hence the blood supply is shown to alter the digestive power of a secretion by modifying its compo- sition. Blood which is impoverished in composition, watery, anaemic, or deficient in albuminous ingredients, will furnish poor materials for the manufacture of the digestive secretions, and, further, the muscu- lar walls of the alimentary canal will suffer from malnutrition and peristaltic action will be diminished. TEMPERATURE AND DIGESTION. Both the external temperature and the internal body heat in- fluence digestive processes. The effect upon the system of the temperature of food and drink is also a matter of important consid- eration. Hot food and drinks in cold weather, cold food and beverages in hot weather, are instinctively resorted to by almost every one, although this is, no doubt, as much due to mental association and, perhaps, a temporary agreeable sensation of the temperature in swallowing as it is to any decided influence exerted over the body temperature. TEMPERATURE AND DIGESTION. 309 Sudden modifications in the external temperature of either exces- sive heat or cold react upon the circulation, respiration, and the nervous system in a variety of ways and indirectly affect the digest- ive apparatus. The shock of sudden or, more particularly, of con- tinued exposure to cold over the entire surface of the body tends to constrict the peripheral blood vessels and produce congestion of the visceral vessels, modifying secretion and absorption in consequence. A local application of heat and of cold over the abdominal wall dur- ing activity of the digestive organs has but limited influence. Pa- tients wearing a Leiter coil over the abdomen through which ice water is continually passed for many hours do not necessarily suffer from retarded digestion, nor ao those who are having poultices con- tinuously applied to the abdomen. In a series of experiments which I have recently made to determine the extent of heat penetration through the abdominal wall it has been shown that the application of heat or of cold of such extremes as can be borne without discom- fort has little or no influence on the circulation in the stomach or the intestines or upon the temperature of those organs so long as the subcutaneous circulation is vigorous. This is owing to the rapid neutralisation of the heat or cold applied externally by the constantly changing layer of blood flowing beneath the surface. In dogs, a poultice of 140 F. or an ice coil with water at 34 F. placed over one side of the abdominal wall does not raise the temperature of a long-stemmed thermometer more than a quarter of a degree when slipped beneath the abdominal wall through a perforation or held immediately below the poultice or coil. If, however, the ani- mal be killed, circulation ceases, and the temperature of the ther- mometer will immediately be affected to the extent of fifteen or twenty degrees. It is doubtful, therefore, whether enfeebled diges- tion can be much influenced by the local application of warmth over the abdominal wall. Many persons, however, who have a tendency to intestinal indigestion find it both agreeable and salutary to wear continuously a broad flannel bandage about the abdomen to favour uniformity in temperature and prevent the liability of taking cold. It is incompatible with life that the variations of body tempera- ture between the highest fever and the lowest depression should exceed the limits of temperature at which digestion is known to pro- ceed when artificially conducted, so that these alterations do not of themselves alone destroy digestive power in the stomach. The lat- ter is usually diminished or lost during fever, but this may be owing more to disturbances of the circulatory and nervous systems than to increased warmth of the stomach. Efforts to raise or lower the local temperature in the stomach during digestion by swallowing, respectively, hot watftr or pounded ice are not productive of very striking results. ^jQ ;FOOD DIGESTICWSr. It is customary, and no doubt best, to administer stimulants -hot in collapse from any cause. Wunderlich, Fotkergill, and others have laid considerable stress upon the antipyretic value of giving all fluids very cold in fevers, but I have yet to see any effect upon genuine pyrexia, as, for example, in typhoid fever, depending upon whether milk or other fluids were administered very hot or iced. I often prescribe hot boiled milk in such cases if patients prefer it, and have taken it so myself without any appreciable influence upon the natural course of the fever. It is a popular belief that rich wines and oils are " heating " foods, and, conversely, " cooling drinks " have long been used in fevers, but the use of iced fluids and of cracked ice itself for relief of thirst in fevers is of comparatively recent date. It followed the extended introduction of the clinical thermometer, and to this day one oc- casionally meets with opposition from mothers to giving a child with high fever anything really cold. Hot fluids drunk also favour perspiration, and sometimes aid ex- pectoration, but this is because they are promptly absorbed and added to the volume of the blood, not because they contribute many heat units to the body. Winternitz endeavoured to show by sphyg- mograms that the imbibition of cold fluids increases arterial tension, and that of hot fluids lessens it. This may be true, but the sphyg- mograph is not at all a reliable instrument, and certainly the clinical application of this rule is not capable of substantiation, although in giving hot-air baths to promote perspiration in Bright's disease hot drinks are of undoubted service. With practice one may learn to swallow water which is uncom^ fortably hot to the touch at a temperature of 115 or 120 F. It has been swallowed at even 132 F. The drinking of very hot water before meals aids in cleansing the mucous membrane in cases of gastric catarrh and acts as a diuretic. The rate of local digestion in the stomach is comparatively little influenced by swallowing either hot fluids, such as soups or broths, or hot solid foods, and similarly it is not much retarded by taking such substances very cold, provided in each case they are swallowed very slowly. Some food is more digestible when eaten hot than cold, but with other food the reverse is true. In either case it is not so much because of the warming or cooling of the stomach, but because of the physical condition of the food. For example, some persons who cannot digest hot mutton fat can take it cold because it becomes friable and mixes better with other food. Some persons with very sensitive stomachs cannot take the fat of cold butter spread upon bread, but can digest it if melted thoroughly into hot toast, which subdivides the fat particles and keeps them from fusion. Hot boiled ham is more indigestible than cold ham for many persons. Hot milk may be more digestible TEMPERATURE AND DIGESTION. 3II for invalids than iced milk, yet the latter may be better borne if vomiting be present. Much must depend upon habit and individual peculiarities. One may begin a dinner with iced raw oysters, then take hot soup, and later conclude the meal with ice cream, followed by hot coffee, and yet throughout, the temperature of the stomach contents does not vary so much as half a degree, because the warm blood circulating so rapidly and abundantly within its walls and those of the oesophagus maintains the necessary normal average most favour- able to digestion. Hot food is cooled and cold food is warmed in swallowing, and it may be said the hotter or the colder it is, the less likely it is to modify the rate of gastric digestion, for these extremes of temperature necessitate slow swallowing. Swallowing several tumblerfuls of iced water in quick succession does cool the stomach and inhibit digestion by local reduction of temperature, and also by shock to the gastric nerves; but even this effect is less than is com- monly supposed. There are about fourteen pounds of blood in the body, having an average temperature of very nearly 100 F., all of which in turn keeps circulating through the digestive organs, and a single tumblerful of iced water poured into such a volume of warm fluid would not lower the temperature of the whole very much. This is why swallowing pounded ice is of so little avail to control gastric haemorrhage, and much less pulmonary haemorrhage, although it may relieve nausea somewhat. In support of these statements are the results of many experiments which I have made upon patients un- dergoing treatment by lavage, to whom I have given fluids at dif- ferent temperatures, which were immediately siphoned out of the stomach, and tested for heat loss or gain. Two tumblers of ice water may be slowly swallowed, and if promptly siphoned out again the temperature of the fluid will be found to have risen in five min- utes to fully 95 F. The question has often been raised as to whether the body tem- perature can be permanently affected by alterations in the quality of the diet. It may be definitely stated that so long as the diet is abundant and nutritious it makes no difference whether man is carnivorous, a vegetarian, or lives upon mixed diet. Insufficient food and starvation or inanition from improper food, it is well known, reduce the body temperature to from one to three or more degrees below normal. Excess of alcohol also reduces it. Improper and indigestible food may cause temporary rise in tem- perature, but this is usually caused by more or less gastritis or gastro-enteritis, and is therefore independent of normal considera- tions. The total daily variation in body temperature normally pro- duced by the ingestion of food does not commonly exceed '/, ., but it may reach 1 F. The vegetarian rabbit has as high a tem- perature as a dog fed upon animal food alone. The grass-eating 32 FOOD DIGESTION. COW has a temperature two or three degrees above man's and quite equal to that of many strictly carnivorous animals. The graminiv- orous pigeon has a temperature as high as that of the fish-eating gull. No deductions can therefore be made in regard to any per- manent influence of diet upon normal body temperature in healthy animals or in man. The loss of body heat consequent upon starvation and inanition will be discussed under those headings. EXERCISE AND DIGESTION. The influence of muscular exercise upon digestion is practically exemplified by every one's personal experience. Violent exercise, even by those of robust constitution, taken immediately after the ingestion of food almost invariably retards the process if it does not produce acute dyspeptic symptoms, and even vomiting. This is due mainly to the modification in the distribution of the blood, which during active exercise passes in large amount to the periphery of the body, and in much less quantity to the abdominal organs. There are also increased products of waste matter formed during muscular activity which circulate in the blood, and it is possible, though it cannot be definitely asserted, that they may temporarily interfere with the digestive secretions. Young children between the ages of four or five and ten or twelve suffer much less from the influence upon digestion of violent exercise than do adults. It is a common experience to see children romping and playing violent games immediately after eating without necessarily provoking in- digestion a procedure which would be very disastrous to adults. On the other hand, exercise has a very important relation to diges- tion when taken at proper times and in right amount. This influence is to be attributed rather to the combined effect upon the circulation and respiration and general functional activity of the tissues which promotes their nutrition than to any special local action on the stomach or intestines. Exercise of a certain kind compresses or shakes the liver in such a manner as to favour the elimination of bile from it and increase its functional activity. For this reason horseback ridmg is unquestionably the most useful form of exercise for many varieties of dyspepsia and so-called " biliousness." Mus- cular fatigue following activity retards digestion very much, prob- ably for the reason above suggested in regard to accumulation of waste matter as a result of exercise. Moderate exercise may often be advantageously taken in the morning on rising for ten or fifteen minutes in order to get into a good perspiration before taking a cold bath. Such exercise with dumb bells, Indian clubs, or weights with pulleys does not harm the REST AND SLEEP AND DIGESTION. 313 appetite, and for some persons it is invigorating and beneficial. Stronger exercise, such as bicycle riding or taking long walks before breakfast, is not to be recommended unless the individual has been greatly overfed the night before. In the early morning hours, with an empty stomach, exposure to the influence of cold and damp, or possibly to infectious diseases, is believed to be greater than at other hours in the day. Physicians visiting cases of infectious diseases do well to go only at a time of day when they have recently taken a full meal and when they are not suffering from extreme fatigue. Men differ greatly in the amount of exercise which they find necessary to keep them in good health and maintain a normal ap- petite. To keep a really vigorous man in the best bodily condition he should take daily exercise amounting to one hundred and fifty foot tons of work, or an equivalent of a walk on a level of about nine miles ; but very few are able to accomplish this excepting day labourers. The influence of food upon muscular activity has been lately studied by Hodge, who reported some preliminary results at a meet- ing of the American Physiological Society, December 28, 1894. He has constructed a movable cage so arranged that any movements of the animal which it contains are communicated to the cage itself, and through it to a recording tambour and kymographion. In this manner the restless activity of the hungry animal seeking for food about its cage is recorded, as well as the indolence produced by a satisfying fatty diet and the stimulating effect of nitrogenous food. For example, he demonstrated that a mouse well fed on corn meal alone may be active but a few minutes in the day, whereas the same animal fed upon meat and cream alone will exercise for ten hours out of the twenty-four. This is no doubt due to combined effects of the influence of the feeling of satiety, exhilaration, varying func- tional activity of different organs of digestion, and of the circulation and nervous system. It is to be hoped that future investigations will differentiate more clearly between these factors. REST AND SLEEP AND DIGESTION. The custom of spending half an hour in making a leisurely toilet for dinner is beneficial in giving the rest to mind and body which puts the latter into the most favourable conditions. Dyspeptics and persons suffering from an irritable or feeble digestive system can often derive much benefit by observing the rule of not eating when suffering from bodily or mental fatigue. They should lie down from half an hour to one hour and quietly rest before each meal, which may then be digested in comfort. Muscular fatigue and over- exertion demand food for the replenishment of waste material, but 314 FOOD DIGESTION. the immediate digestive process is much facilitated by an intervening period of rest. It is often advisable for them to rest (but not sleep) for a similar time after meals. The practice of sipping hot coffee after dinner and of smoking a cigar is conducive to the rest which should be taken, whenever possible, after the ingestion of a heavy meal. Sleep is often affected by the amount of food taken. Overeating, with lack of physical exercise combined with sedentary habits and brain work, is very apt to produce sleepiness. Sleep in Relation to Meals. During profound sleep the differ- ent functions of the body are all more or less reduced in activity. The rate of circulation and respiration becomes slower, and gland secretion and digestive processes are retarded. For this reason, after eating a heavy meal at night, it is unwise to retire for two or three hours until the stage of gastric digestion is in part completed. It is true that many of the lower animals, particularly the carnivo- rous, who eat very frequently, are accustomed to lie down and sleep immediately after taking their food, but their conditions in so many ways differ from those of man that but little is to be gained by a com- parison with them, and their sleep is usually light until digestion is accomplished. On the other hand, in man, if profound sleep follows the eating of a heavy meal, it is very apt to be disturbed. A large volume of blood is kept in the abdominal vessels during digestion, and the cerebral circulation must be modified in consequence. It is possible also that the various products of nutrition which are being absorbed into the blood may act in stimulating the central nervous system in peculiar ways. Such sleep is restless, and is disturbed by dreams and nightmares, and even feverishness. On the other hand, a light doze, in cases of exhaustion and for the aged, taken for half an hour after dinner, does certainly no harm, and may promote digestion by allowing more blood to be diverted to the digestive organs, none being required for other activities. Persons whose health is below the average on account of disor- ders of digestion and assimilation not infrequently find that they be- come very sleepy after eating, more particularly after eating a heavy meal at noon; this condition is sometimes very annoying, and al- ways indicates a lack of balance between the income and output of energy, which must be regulated by proper attention to diet and ex- ercise. Usually in such cases the difficulty consists in habitually eat- ing more food than the system can appropriate, and cleansing the body through the emunctories, with a temporary reduction in the quantity of food eaten, will remove it. In other cases the trouble arises from the exhaustion of the nervous system, which is unable to properly conduct two functions at once that is, to regulate diges- tion and at the same time exercise the mind. Obviously, in such REST AND SLEEP AND DIGESTION. 315 cases, rest and tonic treatment are indicated. The food should be given more often, but in small amount. In England the custom is very prevalent among some classes of people outside of the larger cities of taking four meals a day. A breakfast at about eight o'clock and dinner from one to two, and a heavy tea that is, a lunch with tea and some solid food be- tween five and six, which is followed by supper from eight to nine. This practice is well adapted for some individuals, especially young, growing children at school (see Diet in Schools), but older children are apt to overeat if they follow such a custom. An interval of from one and a half to two hours should elapse between eating supper and retiring, and from two to three hours between dinner and bed- time if the alimentary canal is too empty ; sleep will be retarded on this account, and the earlier stages of hunger before great exhaus- tion has occurred may be accompanied by restlessness and insomnia. A very little food taken into the stomach under these conditions will often produce sleep promptly. The aged, whose systems are sus- ceptible to slight changes in their condition or environment, are very apt to become sleepy after their meals, and they find it to their advantage to take a brief nap after dinner : but this sleep is not usually profound, and if it is too prolonged it indicates ex- haustion, which should be met by more careful attention to the diet and stimulation. Hunger produces wakefulness and restlessness, and starvation may cause persistent insomnia. Going to bed late without dinner or supper results in restlessness and insomnia, which may often be cured by taking a glass of hot milk, or a cup of chocolate and some light farinaceous article, or a light sandwich and a bottle of beer. In all ordinary cases of insomnia it is well to see what help can be got from diet and regular habits before resorting to hypnotics (see Insomnia, page 582). In some diseases, notably diphtheria, it becomes a grave question between nourishment and sleep as to which is the more important. Vigorous local measures may be needed to control the spread of the membrane in the throat, necessitating half-hourly applications day and night, which of course interrupt sleep; and yet the patient may need to be wakened for such applications, and the giving of nourish- ment and stimulants as well. Sleep is often more needful than food, and it is the duty of the physician to see that there is a proper balance between them. In general, in exhausting disease, protracted typhoid or other fevers, etc., nourishment must be given once in two hours day and night ; but if the patient does not fall asleep readily at night after being aroused for food, the intervals may be made three-hourly, and as strength returns, four-hourly. In such cases it is sometimes well to relax the rule, and give the patient one good -jg FOOD DIGESTION. night's rest of five hours without awakening him for food; but the degree of exhaustion and need of cardiac stimulants must be the guide in each separate case. MENTAL EMOTION AND DIGESTION. Strong mental emotion, such as fright, terror, or excessive excite- ment of almost any kind, inhibits the digestive functions, especially in the stomach, but also in the intestines. Such emotion may be accompanied by vascular disturbances which will react upon the digestive organs, and in addition there seems to be a diversion of nerve currents from their proper course. Pleasurable emotions, however, affect digestion favourably, and the expression " laugh and grow fat " is certainly not without physiological basis. Hufeland wrote that " laughter is one of the greatest helps to digestion with which I am acquainted, and the custom prevalent among our forefathers of exciting it at table by jesters and buffoons was founded upon true medical principles." Prolonged anxiety and worry, in almost every instance, result in more or less gastric indigestion and malassimilation, so that, al- though the appetite may remain good, nervous dyspepsia, constipa- tion, and loss of weight result. FOOD IN THE MOUTH. The proper care of the mouth in relation to diet is an important subject which is frequently overlooked. In patients who are unable, from weakness or the prostration of fever, to use solid food or to cleanse the mouth themselves, lack of movement in the tongue and buccal muscles prevents proper cleansing of the teeth, and particles of food accumulate about the gums. In extreme weakness of the facial muscles the jaw drops and mouth breathing results. The air passing through the mouth evaporates the moisture present and gives rise to dryness of the tongue, which may become so extreme as to interfere with deglutition and articulation. In such cases the mouth should be frequently moistened by the nurse and swabbed out by some antiseptic, such as a saturated solu- tion of boric acid or diluted Listerine. This topic will be more fully treated under the heading Dietetic Treatment of Typhoid Fever. Food which is allowed to collect in the cavities of decayed teeth favours the development of bacteria, which on being swallowed may become a cause of dyspepsia by exciting malfermentation in the stomach, especially of milk. Much bacterial filth accumulates be- neath artificial teeth which are not frequently cleansed.- Imperfect or painful teeth, or swollen gums, interfere with the FOOD IN THE STOMACH. 317 proper mastication of food, and when such conditions are present care should be exercised that all food eaten be soft and bland. This applies particularly to young children, very old persons, and the in- sane, who are incompetent to take care of their own mouths. The digestion of non-nitrogenous food begins in the mouth, and depends upon the activity of the salivary ferment ptyalin, which con- verts starches into dextrin and maltose. In health this action is prompt and vigorous, and much of the starchy food is digested in the mouth, in its transit along the oesophagus, and also in the stom- ach, until the gastric juice becomes so acid as to check the process, for ptyalin is most active upon the alkaline side of the neutral point, and strong acidity inhibits its power. Chittenden has demonstrated that after neutralising saliva, ptyalin fermentation proceeds well in the presence of 0.005 P^r cent of hydrochloric acid, but stops with 0.025 P^'' cent. Dufresne is responsible for the statement that ptyalin recovers its activity in the alkaline intestine, but that dias- tase is completely destroyed by the gastric juice. In feeble and ill-nourished persons the salivary digestion becomes much impaired, and consequently their farinaceous food should be partially dextrinised artificially by diastase or by prolonged cooking. An acid reaction in the mouth may be present because of fer- mentation, not because the saliva itself is acid. In rheumatism the saliva is very often acid. This reaction causes a sensation of dry- ness, lessens the taste for food, and gives rise to thirst. Saliva which is rich in cells and mucus is too viscid, and does not moisten the food properly during mastication. When salivation is present, the ptyalin becomes too dilute to have any digestive action upon starchy foods. If swallowed, the too abundant saliva carries much air into the stomach; and if it is alkaline, it neutralises the gastric juice. A dry diet (see Dry Diet) will sometimes improve this unde- sirable condition. FOOD IN THE STOMACH. Much controversy has arisen over the question as to how far the stomach performs the essential work of digestion, and how far the intestine is responsible for it. Some writers argue that the stomach is a comparatively useless organ except as a receptacle, and that the small intestine, with the different juices which are poured into it, is abundantly capable of doing alone the digestive work for the entire body. Several experimenters have successfully excised the stomachs of dogs, and after the oesophagus had been united to the intestine the animals digested their food apparently as well as before. They were even able to digest decomposing meat without the aid of the antiseptic action of the gastric juice. .jg FOOD dig;e>stion. Of recent years more careful analysis has shown that the digest- ive products formed from the food in the stomach are by no means as complete in all cases as was at first supposed. The only really important action of this organ consists in digesting a single class of foods namely, proteids and this process is not always finished,' whereas the intestine digests not only proteids, but fats, starches, and sugars. The stomach serves to warm and macerate all the food, so that it relieves the small intestine of much preliminary work of this kind. Gastric digestion is hindered by either acids or alkalies used in excess, by metallic salts, strong alcohol, and by regurgitation of bile from the intestine. Quantity of Gastric Juice and other Digestive Fluids. No reliable estimates of the exact quantity of gastric juice, or, in fact, of any of the digestive fluids, are obtainable. At best, such estimates vary greatly according to different authorities. An abun- dant secretion is not necessarily an active one in ferment or acid, and the constant reabsorption of the water makes it quite impossible to say how much fluid has been secreted, for if the digestive juices be drained off and measured, the natural conditions are disturbed by the process. Bile or pancreatic fluid allowed to drain off constantly through a fistula is found to soon become altered in quality and weakened in digestive power. The estimates which have been made of the total quantity of the digestive fluids secreted per diem extend all the way from three or four quarts to three gallons ! The quantity of gastric juice is sometimes estimated by the amount of pepsin and acid which outside of the body are re- quired to digest a measured bulk of food. As an illustration of an extreme estimate, that of Letheby as to the relative quantity of secretion of the gastric and pancreatic juices may be given. It is : Gastric juice, 14. ii pounds; pancreatic juice, 0.44 pound. Such an estimate is wholly fallacious, for the pancreatic juice is far more active than the gastric juice it has ten times the work to do and the pancreatic gland cells outnumber the gastric cells. Moreover, there are but fourteen pounds of blood in the entire body, and it does not seem probable that a quantity of secretion equal to the whole volume of blood should be formed by a single organ like the stomach. It would require very rapid reabsorption from the stomach not to have it remain full all the time. FOOD IN THE STOMACH. Secretion of the Gastric Juice. 319 When food enters the stomach it immediately excites the secre- tion of the gastric juice. This it does at first through mechanical action, either upon the nerves or the cells of the gastric tubules themselves. The purely physical character of the food which is taken into the stomach will therefore, to some extent, affect the rate of secretion as well as the composition of the gastric juice, and foods are often spoken of as being either bland or irritating. The former are those which are soft or in a fine state of subdivision, such as well-cooked farinaceous articles. The latter are the coarser forms of food and condiments, especially pepper, mustard, curry, pickles, etc., which have a more specific influence in increasing the flow of juice. This is probably due to reflex action through the nerves of the gastric mucous membrane. The gastric juice is secreted more abundantly in response to the chemical stimulus of some foods than others, as, for example, sodium chloride and carbonate and alcohol when taken in moderate dilution. If, however, they are taken to excess they cause derangement of the gastric function, and congestion ensues with secretion of a neutral or alkaline mucoid juice instead of the true acid secretion. Haidenhain has observed that the mechanical pressure of food against the stomach wall may be comparatively local and circum- scribed, whereas the chemical stimulation of the food as soon as it begins to be felt, causes abundant secretion from the whole surface of the stomach, which becomes red and turgescent from increased vascularity. The flow of juice commences almost immediately after the food has entered the stomach, and it continues to be secreted in varying quan- tity for two or three hours. After this period the secretion gradu- ally diminishes. If the food has not been properly digested within a limit of three and a half hours, it may fail to pass on into the intes- tine, and while remaining in the stomach it undergoes various pro- cesses of malfermentation which are wholly different from the normal. These processes will be more fully discussed under the headings of the several forms of dyspepsia. By examining the interior of the human stomach when a fistula has been made, it appears that if the organ is empty, merely irritating the mucous membrane by rubbing its surface gently with a glass rod provokes the secretion of juice, which first appears in little clear drops at the site of irritation. These gradually coalesce and form tiny rivulets which run over the mucous surface to the most dependent portion of the stomach. At the same time the mucous membrane becomes somewhat congested and of a pinkish hue, owing to the greater quantity of blood which circulates through it. 23 S20 FOOD DIGESTION. Hydrochloric Acid. Hydrochloric acid exists in the human gastric juice in the aver- age proportion of 0.2 per cent. Experimentally it is found that the best proteolytic digestion results with hydrochloric acid in strength between o.i and 0.2 per cent. The acidity is reduced upon a vege- table diet. The acid is secreted during active digestion but not at other times. It is often diminished in quantity, and much less often it may be abnormally increased. Its action upon proteid foods like egg albumen, blood fibrin, and meat, is to cause them to swell and become somewhat translucent. It contributes the necessary acid reaction in which the ferment pepsin causes solution of these and other proteids and converts them into albumoses. The quantity of free acid obtainable from the stomach is not great when much proteid food has been eaten, although its secretion may have been considerable. The secretion of the acid begins shortly after the ingestion of food, and reaches a maximum within about an hour. After an hour or two longer, according to the nature and quantity of the food present, it gradually lessens and finally ceases. According to the views of some writers,'the first acid formed m the stomach is lactic acid, which joins the alkali of chlorides in the blood, and liberates chlorine to form hydrochloric acid. Maly has advocated the theory that the hydrochloric acid was formed from the action of phosphates in the blood serum, splitting up the chlo- rides so that the highly diffusible hydrochloric acid passes readily out upon the free surface. Roberts furnishes the following table illustrating the effect of varying quantities of hydrochloric acid on the speed of peptic di- gestion : 2 grammes beef-fibre ; i c. c. glycerin extract of pepsin ; varying proportions of hydrochloric acid ; water to 100 c. c Proportion of dry HCI in the Time in which digestion digesting mixture. was completed. 0.05 per cent 500 minutes, almost no digestion. o . 08 " " 200 " 0.1 " " 130 " 0.15 " " 115 0.2 " " 100 " 03 " " 115 " 0.4 " " 160 0.6 " " 350 minutes, embarrassed. The acid has an antiseptic influence, preventing the decomposi- tion of food, and even checking it if already begun. It is also be- lieved to possess. an influence over the formation of pepsin. Briicke claims, contrary to many observers, that the acid of the stomach FOOD IN THE STOMACH. 32 1 makes starch more soluble, and that much of it is also converted by lactic-acid fermentation in the stomach into erythrodextrin. Pepsin. According to Chittenden, pepsin is a hydrolytic ferment which is found in the cells of the tubules of the gastric mucous membrane, chiefly near the cardiac portion. It exists in these cells in an antecedent form, or as a granular ''proenzyme," which is called pepsinogen or propepsin, and the agent which is believed to convert the propepsin into true pepsin, the active ferment, is hydrochloric acid. This theory assigns a new function to this acid. Lactic and acetic acids derived from food possess the same power in lesser degree. Like the other digestive ferments, pepsin belongs to the class of colloid or non-crystallisable, indiffusible substances. Pepsin digests coagulated egg albumen even better than fibrin, gluten, casein, myosin, and gelatin, and hence this substance is com- monly employed in making quantitative tests of the relative digestive power of different preparations of the ferment. The standard of the United States Pharmacopoeia requires that pepsin shall dissolve three thousand times its own weight of coagulated disintegrated egg albumen. "The rapidity of digestion is augmented only up to a certain point by increase in the quantity of pepsin, but beyond this limit it has no accelerating influence no influence at all, in fact. Pepsin reaches its maximum activity at a temperature considerably higher than that of the body namely, 130 F. Its action is sus- pended below 40 F., and destroyed between 160 and 170" F, The secretion of both pepsin and the rennet ferment or rennin which is often associated with it seems to rise and fall with that of hydrochloric acid, but this is not always the case. Rennin has been described on page 61. Aibumo^es, Peptones. The final product of food digestion as accomplished by pepsin with the hydrochloric acid of the gastric juice is peptone. Kiihne showed that peptone is seldom, if ever, pure in the stomach, but the substance produced is a mixture of true peptone with proteoses or albumoses, which have reactions that in many respects are similar. The albumoses are more highly diffusible than peptones. Undoubtedly both peptones and albumoses are formed during digestion, and both may be absorbed. Albumoses, like peptone, give a violet colour when added to a dilute Fehling solution of copper sulphate, and on boiling with nitric acid they exhibit a yellow colour and a precipitate which alternately falls on cooling and disappears upon warming. The albumoses may be separated from peptones by complete precipitation by saturation in aqueous solution with sulphate of ammonium. Bauer states it as his belief (Dietary of the Sick) " that the peptones do fulfil in the organism all the functions of the albuminous bodies, since they are 222 FOOD DIGESTION. again turned into coagulable albumin " ; but dissolved albuminates are not necessarily converted into peptones before they are capable of absorption (Voit and Bauer). Politzer, Gerlach, and others have demonstrated experimentally that albumoses can support nutrition and even cause gain in weight when given alone and free from peptones, and Hildebrandt found that the nitrogen of albumoses artificially fed to animals was utilised in the nutrition of the body to an even greater degree than the pep- tones of meat. An excess of peptones overworks the liver and produces, on reaching the general vascular system, various nervous disorders lithaemia, gout, etc. Peristalsis. In addition to exciting secretion upon entering the stomach, the food, at first by mechanical action and subsequently possibly through chemical stimulation, excites more or less rhythmical peristaltic movement in the muscular coat of the stomach. The ob- ject of this movement is fourfold : i. To mingle the contents of the food thoroughly with the gastric juice. 2. To cause moderate tritu- ration of the particles of food which are made to move in currents which proceed along the greater curvature and pass back to the cardiac end along the lesser curvature. 3. To bring the food in contact successively with different portions of the mucous membrane, and to thus stimulate it and favour the absorption of such ingredients as this division of the alimentary canal is capable of taking up. 4. To favour the occasional emptying of a portion of the contents of the stomach into the duodenum, the movement at this time being accompanied by a relaxation of the pyloric orifice. Peristaltic action is influenced by the nature and composition of the food ingested, and it may be also stimulated in other ways, which will be more fully described in connection with intestinal peristalsis (see Diarrhoea and Constipation),, for it may be said in general that those stimuli which effect intestinal peristalsis also influence this peculiar movement in the stomach. DURATION OF GASTRIC DIGESTION OF DIFFERENT FOODS. Bauer says: "By the digestibility of a food one can obviously understand nothing more or less than the sum of the resistances that it offers to the action of the gastric juice." The time required for gastric digestion cannot be stated with ab- solute accuracy. In general, the period for the full digestion of a mixed meal consisting of bread, meat, and vegetables is three and a half hours, but because some kinds of food are thoroughly digested in the stomach, while others are acted upon but little if at all, the DURATION OF GASTRIC DIGESTION OF DIFFERENT FOODS. 323 preponderance of one or other article of food in a mixed diet may affect somewhat the whole period of digestion. Tables are sometimes given in text-books upon physiology in which the time required for digestion of various kinds of meat are stated in a very definite and arbitrary manner, and we are told perhaps that it requires fifteen or twenty-five minutes longer to digest mutton than beef (see Digesti- bility of Meats, page 95). All such statements, however, should be received with ample allowance for ordinary variations. If one con- siders for a moment the different elements concerned in the process of gastric digestion, it is obvious that the normal time required for complete digestion will vary constantly, even in the same individual in a state of health, for it depends upon the kind of food eaten as well as the following conditions : i. Its state of subdivision, its solu- bility, complexity, and the process of its cooking. 2. The rapidity with which it is swallowed. 3. The thoroughness with which it is masticated. 4. The activity of the stomach at the time. 5. The interval which has elapsed since the previous meal. 6. The condi- tion of the blood and nerve supply of the gastric glands. 7. The activity of peristaltic movement, which may either retard or hurry the rate of emptying the stomach. 8. The amount of fluid drunk with which the gastric juice is diluted. 9. The strength of the im- portant ingredients of this juice, its volume, and the effect upon it of food itself, neutralising it or not. 10. The rate of absorption. II. Habit. 12. Idiosyncrasy. 13. The presence of excess of fat or other materials incapable of digestion in the stomach. 14. The diversion of the nervous energy required for digestion to other functions, such as mental or muscular work. Such statements are often definitely made in articles upon die- tetics as that boiled mutton requires three hours for stomach diges- tion, while roasted mutton requires three hours and eighteen minutes ; that raw oysters require two hours and fifty-five minutes and roasted oysters three hours and eleven minutes; that boiled carrots require three hours and sixteen minutes, and the like. These figures may impress the lay mind as being of interest and accuracy, but when the above considerations have been taken into account, it must be seen that they are far from reliable. It is impor- tant, however, to state, if possible, the approximate time required for the digestion of certain general classes of food, and the following estimates are probably as nearly correct as possible in view of the statements above made. The time required for the complete digestion of meats cooked by broiling, roasting, or boiling, is fully three hours or three hours and a half. Gigglberger found, as a result of feeding patients with test meals and withdrawing the stomach contents through a tube, that meat re- 224 FOOD DIGESTION. quires from two and a half to five and a half hours for digestion, according to its quality, method of cooking, etc. Stewed meats require less time than roasts. Pork and very fat meat may require four or five or more hours for digestion, and veal is generally of slow digestion, requiring at least four hours. Fresh lamb may be digested in two and a half to three hours. Chicken, capon, and turkey may be digested in from two to two and a half hours, but the meat of many of the forms of wild birds, such as ducks, may require four hours. Some of the viscera of animals which are eaten as food, such as brains, tripe, liver, and kidneys, are digested in less time approxi- mately two hours. Fish and shellfish require from two and a half to three hours for their digestion. Raw eggs are usually digested in less time than cooked ones, and they may be ready for absorption in two hours, whereas hard-boiled eggs require at least three and a half hours. Milk is usually digested somewhat sooner when boiled than if raw. Milk whey is absorbed from the stomach, but the curds often pass on into the duodenum. The majority of the heavier vegetables, such as peas, beans, corn, beets, turnips, etc., remain in the stomach for between three and three and a half hours, but potatoes, if baked and mealy, may remain but two and a half hours. Raw vegetables, such as coleslaw or raw cabbage and lettuce, etc., may remain two and half hours or more in the stomach, and the same IS true of most raw fruits, such as berries, apples, pears, peaches, etc. The more digestible cereals rice, sago, tapioca, etc. should pass on from the stomach within two hours. Fats and oils taken alone may not remain in the stomach but a few moments. Sugars may, to some extent at least, be absorbed from the stomach wall in the course of the first hour of digestion. Since gastric juice is fairly constant in composition, its effect in health upon the duration of digestion of the same kind of food may not vary in the same individual ; but persons differ from one another very much in the rapidity of their digestive processes. In some individuals, even in health, stomach digestion may be uni- formly an hour or more slower than it is in others. Variations from the usual period of digestion are almost always upon the side of its retardation. The quality, composition, and quantity of the food all affect the rate of gastric digestion. Coarse food, badly cooked starchy food, excess of fats, tough- fibred meats, unripe fruits or vegetables, all retard digestion, and" may prove very irritant. Among articles of diet, substances are sometimes eaten which DIGESTION OF PROTEIDS IN THE STOMACH. 325 are purely refuse material, such as the skin of potatoes and of coarse fruits, grape seeds, shells, soft-shell crabs, etc. They may pass on unaltered into the intestine and cause diar- rhoea, or they may sometimes linger for several days and excite reflex irritation. I have known undigested capsules of cod-liver oil to be retained in the stomach for three or four days before being vomited (see Cod-liver Oil, page 180). The temperature of food and drink affecting gastric digestion is discussed under the heading Temperature and Digestion. DIGESTION OF PROTElt^S IN THE STOMACH. The various albuminous foods are digested best, each with a different degree of acidity, and it is probable that throughout a meal the intensity of reaction of the gastric juice varies consider- ably, becoming stronger as more food is absorbed or more juice is formed, or weaker as more of it passes with the chyme into the pylorus or as it is more diluted with additional food or drink. In this manner the different proteids are all certain of a fair oppor- tunity for timely digestion. The products of albuminoid digestion in the stomach have been carefully analysed by Kiihne and Chittenden, and are found to suc- ceed each other in the following order : 1. Albuminoids or proteio^. 2. Syntonin or acid albumin. 3. Albumoses or proteoses proto-albumose, hetero-albumose, deutero-albumose. The three latter form 4. Peptones. Raw meat in the stomach turns grey-brown and swells. It takes longer to digest meat raw th^n when cooked, for the fibres are pene- trated less easily by the gastric juice. An exception to this is found when the raw meat is first scraped or made into a pulp. In the di- gestion of meats Frerichs found that the connective tissue is first broken down by the gastric juice, then the sarcolemma, and finally the substance between the striae of the muscle fibres. Vegetable albumin is digested in the stomach in a manner quite similar to the digestion of animal proteids. Gluten and vegetable casein are also dissolved by the gastric juice when strongly acid. Gelatin is one of the substances most easily dissolved in and absorbed from the stomach. It is altered by the hydrochloric acid of the gastric juice, so that it can no longer be solidified by cold. If is finally converted into diffusible substances somewhat resembling peptones, but not identical with them. 326 FOOD DIGESTION. ABNORMALITIES OF GASTRIC DIGESTION. (The clinical examination of the stomach contents will be found elsewhere described under that heading. See page 489.) Hypersecretion. -Hypersecretion of gastric juice gives rise to thirst, sour eructations, more or less epigastric distress, and it often accompanies dilatation of the stomach. The secretion may digest proteids well, but carbohydrates are ill borne in this condition, which is believed to be chiefly caused by some form of neurosis. An excess of acid gastric juice passes on with the chyme into the small in- testine, and causes an acid reaction therein, requiring more of the intestinal digestive fluids bile, pancreatic juice, etc. to neutralise it. The saliva is often increased at the same time, and Roberts suggests that this may be a provision of Nature to neutralise the acid in the stomach. Hyperacidity. Hyperacidity, or increase in the hydrochloric acid of the gastric juice, does not necessarily imply hypersecretion of juice. Hypersecretion may be abundant, watery, and weak in acid, or more concentrated with stronger acid, or normal in quantity but with increased hydrochloric acid. Hyperacidity is not very common, and is more apt to be present in connection with gastric ulcer than other diseases. Absence of Hydrochloric Acid. The persistent absence of hydrochloric acid from the gastric contents does not absolutely indicate the presence of any one disease, but rather that a consider- able extent of the gastric mucosa is involved, and, indeed, according to Ewald, it may be absent in nervous dyspepsia without organic lesion. Pyrosis. Pyrosis, or eructation of gas from the stomach, if it occurs very soon after ingestion of food, is usually due to lactic- acid fermentation. Occurring later, (Mring active digestion, it may be due to the same cause or to hyperacidity from excess of hydro- chloric acid. The latter condition is less common when due to lactic acid ; the giving of hydrochloric acid stops further fermenta- tion, whereas sodium bicarbonate, although it momentarily neutral- ises the lactic acid, soon produces an alkaline reaction in which the further development of the acid rapidly proceeds. On the other hand, pyrosis due to hydrochloric acid must be checked by alkalies. FOOD IN THE INTESTINE. After preliminary maceration under the conditions of the moisture, warmth, and motion in the stomach, and after partial digestion there, the food, mixed with gastric juice, passes in a pultaceous mass, known as chyme, into the duodenum. Here the physical conditions FOOD IN THE INTESTINE. 327 are almost identical with those found in the stomach, but the chem- ical composition of the new digestive fluids namely, the bile and pancreatic and intestinal juices is alkaline, and a number of new ferments complete the solution and digestion of the food. The starches which were but partially digested by the saliva are converted into dextrin, maltose, and glucose by a diastatic ferment amylopsin contained in the pancreatic juice. Cane sugar is con- verted by the intestinal juice into glucose, any proteids which have been but partially digested in the stomach are completely converted into proteoses and peptones by the proteolytic ferment trypsin of the pancreatic juice, and the fats are emulsified and saponified by the combined action of the bile and a pancreatic ferment. Pancreatic juice is the most active and comprehensive digesting fluid of the body. It is not only much stronger than the gastric juice in its action upon proteids, being able to form peptones with fewer intermediate products, but it possesses the distinct advantage that it also digests fats and carbohydrates by a ferment, called steap- sin, which acts in either acid or alkaline media. Its amylolytic power is stronger than that of the saliva, for it digests the raw starch and cellulose which is eaten in such vegetables as celery, lettuce, or radishes, and in fruits like the apple. The ultimate products of trypsin digestion are antipeptones and hemipeptones. The ferment acts best in a fluid medium rendered alkaline by from 0-5 to i per cent sodium carbonate. It also digests proteids energetically in a neutral medium, but free acid soon de- stroys it. Chittenden has shown that combined acids do not neces- sarily put a stop to trypsin proteolysis. The bile plays several roles in intestinal digestion, but its chief action is in aiding the emulsion of fats, described below. It can accomplish the absorption of fats even in the absence of pancreatic juice. When bile is absent tfce fatty food may decompose in the in- testine and develop gases and foul odours. Voit says that the white colour of icteroid stools is dependent rather upon the presence of undigested fat than the absence of bile, for with a meat instead of a milk diet they may still be of a dark colour. When a biliary fistula is made in dogs and the bile is drained away, they emaciate and have a ravenous appetite if fed upon meats and fats, but not if fed upon carbohydrates (Voit). The quantity of bile secreted is increased by a nitrogenous diet, and diminished uponan exclusive fat diet (Uffelmann). Vegetable foods colour the bile green ; animal foods make it yel- low or orange. Bile is often said to prevent putrefactive changes in the food in the intestine. It is not, however, an antiseptic substance, for, unlike 328 FOOD DIGESTION. the gastric juice, it easily undergoes decomposition, and the influence attributed to it is due rather to its promotion of peristalsis, thereby- keeping the intestinal contents moving and preventing stagnation and putrefaction. The Digestion of Fats. When fat is cooked in the food, a good deal of it is converted into rancid fat i. e., fat containing free fatty acids. In the mouth the fatty food is unaltered, unless it be in the form of adipose tissue, when the process of mastication breaks it down and liberates some of the fat globules, which are melted by the natural warmth. If eaten in the form of oil or butter, with starchy or vegetable food, the fat coats the particles of food in the mouth. Bread thus mingled with butter is less apt to form a large and too tenacious bolus. In the stomach the fat remains unaltered, and when the semifluid chyme begins to flow into the intestine it passes in with it. The connective-tissue elements of fatty meats, etc., are dissolved away and digested like other proteids by the gastric juice. In the intestine the fat is subjected to a double process of emul- sification and saponification, which is accomplished by the combined action of the bile and pancreatic juice. The latter splits fats into glycerin and fatty acid, and this action is favoured by the admix- ture with bile, which simultaneously occurs in the duodenum. Ac- cording to Rachford, the fat-splitting power of pancreatic juice is more than trebled by bile, although the latter has no fat-splitting influence of its own. He also declares that the presence of hydro- chloric acid which has just entered the upper duodenum with the chyle, like the bile, still further aids the pancreatic action upon fats, as four to one. It is held by the majority of authorities that pancreatic juice also contains an emulsifying ferment, steapsin, and that the free fatty acid above described splits up the sedium bile salts and liberates their sodium, which unites with a portion of the free fatty acid, form- ing a soap. The soap coats the droplets of emulsified fat with a thin film (like a soap bubble) and prevents them from coalescing again. The emulsion is then absorbed by the lacteals. Opposed to this theory is the one ably advocated by Rachford namely, that the hydrochloric acid and bile in the duodenum not only can prevent the formation of emulsions, but can destroy those already formed by redissolving their coatings. Hence he argues that in the duodenum fats are split, but not emulsified, and that they pass further on and enter the jejunum, where they encounter the intesti- nal juice, containing about 0.25 per cent of sodium carbonate. This salt prevents further fat-splitting, and at the same time emulsifies the fats. It is, however, not a necessary part of the theory of digestion of ARTIFICIAL DIGESTION. 329 fatty food that the fat must all be emulsified. No doubt a large part of it is absorbed more directly or as a soap without emulsification. Extracts of both the liver and spleen have been said to favour the absorption of fats by emulsification. Undigested food reaches the intestines under the following con- ditions : (a) When too much food is eaten, (d) when gastric digestion is imperfect, (c) when the food is bad. Intestinal Gases. During the digestion of certain foods in the intestine more or less gas is evolved. The gas, by distending the walls of the gut, serves the purpose of keeping them from agglutinat- ing, and thereby facilitates the free movement and intermingling of the digestive fluids and food, and the absorption of the latter. Ruge has published the following table of the percentage of gas evolved by several different kinds of foods : MILK. MEAT. PEAS OK BEANS. Food. I. 2. I. 2. 3- I. 2. 3- CO,.... H CH.... N, 16.8 43-3 0.9 38.3 9.9 54-2 36.7 13-6 30 37-4 45-9 12.4 2.1 27.5 57-8 8.4 0.7 26.4 64.4 34.0 2.3 44.5 19. I 38.4 49-3 10.6 21.0 4.0 55.9 18.9 ARTIFICIAL DIGESTION. To physiologists we are indebted for the discovery and develop- ment of the scientific preparation of digestive ferments or enzymes and the predigestion of food outside of the body. The composition of the various digestive ferments and their action in general have been understood for a long time, but it is only withirf the last two or three decades that the use of these organic bodies has been made practicable on a large scale for rendering food more digestible or assimilable by invalids, and the whole question of artificial digestion of foods is one which is absorbing more and more careful attention and thorough study. The subject may be said to be yet in its in- fancy, and it is highly probable that the extensive researches which are being conducted by so many investigators at the present day will yield even more practical and important results than those al- ready attained. The use of predigested food at present forms an indispensable adjunct to the treatment of a large number of serious diseases, both acute and chronic, especially those which concern the alimentary canal, and the methods of infant feeding have been prac- tically reorganised by it. The different ferments which can be used for increasing the ac- tivity of digestion within the body or for partially digested foods outside of the body are principally diastase, pepsin, and extracts of pancreatic juice, which are usually called pancreatin, and which are 230 FOOD DIGESTION. compounds of several substances. Besides these there are several vegetable ferments, such as papain from the American papaw, and ferments are present in the juice of the pineapple, and the century plant or agave. Predigestion of Starches. There are a variety of ferments and other materials which have the power of converting starch into dextrin and sugar. They are ptyalin in the saliva, amylopsin in the pancreatic juice, diastase, a ferment in the intestinal juice, and the substances inulin and lichen- in. The latter is obtainable from various lichens, such as Iceland moss. Mucin and certain gums are also amylolytic. Of these different ferments, the one which is found to be of most practical service for predigestion is diastase. The action of the diastase of malt resembles that of the ptyalin of the saliva and the amylopsin of the pancreatic juice, which alter starches into dextrin and maltose. It is prepared in several ways, as, for example, in meal of malt, which may be added to farinaceous foods, and in the form of malt extracts, and various malted foods (malted milk, etc.) are sold for invalid use or for infant feeding. In such preparations the predigestion of amylaceous foods is carried to the extent of more or less complete conversion of the starch into dextrin and maltose. The diastase has no action in the stomach provided the acid gastric juice is being secreted, for it only causes fermentation in a neutral or alkaline medium ; in fact, the ferment is probably destroyed before reaching the intestine. The presence of alkaline carbonates retards the action of diastase. In early infancy the amylolytic ferments of the salivary and pancreatic fluids are not well developed and are very meagre in quantity. If a young child is unable to digest milk for any reason, malted food may be temporarily supplied in some cases, because in it the starch is already more or less completely digested and is ready for absorp- tion. In general, the value of malted foods and malt extracts de- pends upon the predigested starch which they contain, which fur- nishes nutrition, rather than upon the action of the diastatic ferment within the alimentary canal. Ground malt itself possesses even stronger digestive action upon starches than malt extracts. The latter contain the ferment dias- tase, dextrin, maltose, and a portion of the salt aild some nitroge- nous ingredients of barley. Both ground malt and malt extracts digest starches at a moderate heat, not exceeding 150 F. There are many varieties of malted foods, but Liebig's Infant Food is a good illustration of this type of food. It is prepared as follows (see also page 131) : Mix a half ounce each of ground malt and wheat flour, seven ARTIFICIAL DIGESTION. 331 and one fourth grains of potassium bicarbonate with one ounce of water and five ounces of sweet cow's milk. Warm slowly and stir until thick. Remove from fire, stirring for five minutes, replace over fire, and remove when quite thick. As the diastase continues to act the mass will become thin and sweet. Boil and strain. It contains gluten and albumin of flour and barley, besides dex- trin and maltose. The food thus prepared is very nutritious, for it not only con- tains the proteid materials of the milk, but those also of the wheat flour and malted barley (gluten and albumin), as well as the predi- gested starch. The malted foods which are made with desiccated milk and malted flour are deficient in fats, salt, and proteid material, but the lack of these substances can be supplied by the addition to the food, when used, of cream and beef juice. For manufacturing malted foods the wheat or barley flour should be baked in order to rupture the starch granules and make them more soluble. Predigestion of Proteids. The digestion of proteids may be accomplished either within the body by prescribing pepsin and hydrochloric acid, or without the body by use of the same agents, or, as it is more often done at pres- ent, by pancreatinisation. Pepsin was the first among the digestive ferments to be isolated and employed for artificial fermentation. This ferment diff'ers from diastase in the fact that it is capable of continuing its digestive functional activity within the body, and it is therefore frequently prescribed in cases of deficient gastric secretion, to be taken with the meals, or immediately after, as a powder or in solution. The action of pepsin is confined to the conversion of albuminous food, and it requires an acid reaction. It is sometimes claimed that the continual administration of pepsin and dilute hydro- chloric acid may weaken the stomach by doing the work of that organ while it rests ; but it is difficult to see any true ground for the statement, for this action in no wise concerns the stomach wall or its secretion, but is limited to the conversion of food into more easily soluble material, which increases the general bodily nutrition, and and therefore indirectly improves the stomach digestion. Pepsin is destroyed by dilute solutions of sodium carbonate as well as by the alkaline pancreatic intestinal fluids and the bile. It is obtained in a number of forms for use in aiding gastric digestion, such as scales, dry powder, pills, and solution. There is considerable variation in the strength of the preparations, depending upon the care taken in their manufacture and differences in the processes of extracting the ferment; but all of them have some digestive action, 332 FOOD DIGESTION. and they are very serviceable remedies for gastric indigestion. A comparative analysis of the relative digestive power of several of the more important ones was made by Prof. Chittenden and reported in the Philadelphia Medical News (February i6, 1889) as follows: (i) Parke, Davis & Co.'s Pepsinum Purum in Lamellis 100 (2) Fairchild's Pepsin in Scales 52 (3) Scheffer's Dry Pepsin Concentrated 48 (4) Jensen's Crystal Pepsin 35 (5) Boudault's Pepsin 14 (6) Royal Chemical Company's Pure Pepsin 9 Pepsin should never be given in combination with an alkali, such as sodium bicarbonate, excepting in cases of hypersecretion of hydrochloric acid with scanty pepsin formation, a decidedly rare form of gastric disorder. The pepsin-secreting cells predominate over the acid-forming cells in the stomach so largely that they are seldom destroyed to the same degree as the latter, and hence pepsin is of much less im- portance than hydrochloric acid in the treatment of both functional and organic disease of the stomach. It is a very common practice to prescribe it in tablet form without acid, but as a rule, to which there are almost no exceptions other than that of hyperacidity, in those cases in which the exhibition of pepsin is indicated hydro- chloric acid is equally if not more important, and they should be prescribed together. The pepsin is given in doses of three to five or ten grains imme- diately after meals when proteid food of any kind has been eaten. Ten grains may be added to a pint of milk, but if long continued in excess of twenty grains /^r diem, it may excite purgation. Pancreatin is the name given to a complex fermentative body derived from extracting the pancreatic gland. It is obtained in the form of a dry powder, and also as a solution or liquor. Its intro- duction is mainly due to the researches of Dr. William Roberts, of- England. The extract made from the pancreatic gland is a powerful digest- ive agent and, on the whole, is more serviceable for the predigestion of food than any of the other ferments. It contains both trypsin and amylopsin. This extract also emulsifies fats, and it is quite as easy, if not easier, to obtain the pancreatic extract than pepsin, and since its action is so powerful and varied, the majority of the predigested food preparations the so-called " peptonised foods " are made with pancreatin instead of pepsin. Pancreatin is sometimes prescribed by physicians for internal use, but unless protected in a keratin-coated capsule the ferments are entirely destroyed in the stomach by the action of the gastric juice. Keratin is a horny sub- stance derived from feathers which is not soluble in acid fluid, but ARTIFICIAL DIGESTION. 333 is quite soluble in alkaline media. Hence a capsule containing five grains of pancreatin coated over with keratin may remain undis- solved in the stomach until gastric digestion is completed, when it will pass into the intestine," where the coating is dissolved and the ferments act upon the chyle. It is customary to add some alkali, such as sodium bicarbonate, to the pancreatin in the process of arti- ficial digestion, although it will also operate on proteid matter in the presence of a neutral reaction. All the products of pancreatin di- gestion, as well as the ferment derived from the juice itself, decom- pose if exposed for any length of time to the air. Pure meat pep- tones, prepared either by pepsin and hydrochloric acid or by trypsin in alkaline solution, are ready for immediate absorption and are nutritive, but a very general objection to their use exists in the ex- ceedingly disagreeable odour and taste which they possess, which to many persons are nauseating and disgusting. This difficulty is over- come when peptones are used for rectal injection, for which purpose they are most valuable. Efforts are often made to disguise the disa- greeable taste and odour of beef peptones in various ways. When obtained in solution, wines and aromatic substances are added to them or they are sometimes evaporated to dryness, pulverised, and redissolved in sherry, but the taste is exceedingly persistent and it is often difficult or impossible to disguise it in any manner, so that patients will not sooner or later object to it. Among the principal peptones which are used are Koch's, Kemmerich's, Catillon's and Carnrick's, Savory and Moore's, and Benger's. Some of the pan- creatinised foods are strengthened by the addition of predigested starches and sugars. Some of them constitute very good foods for cases of enfeebled digestion or diminished absorptive power. Among them may be mentioned Benger's Food, which is made with cooked wheat meal and pancreatic extract. The latter par- tially converts the starches into malt and diastase, and when added to milk at the proper temperature for fermentation, it acts upon the casein and converts it into a soluble peptone. Oat flour and lentil flour are similarly prepared. Carnrick's Infant Food is made on the same principle with Benger's Food, with wheat flour, pancreatin, and milk, to which is added a certain percentage of lactose. Savory and Moore prepare a concentrated predigested milk and milk with cocoa, which have an agreeable taste and considerable nutrient value. Another preparation is Loeflund's Peptonised Kindermilch. All peptonised or pancreatinised foods are open to the objection that they are much more expensive if used for a long time than the preparations which can be easily made at the bedside by any intel- ligent person by the use of the simple pancreatin extracts. Among these extracts are Benger's Liquor Pancreaticus and Peptonising Powders and Fairchild's Zymine, which act upon lean meat as well 224 FOOD DIGESTION. as milk. If complete peptonisation is required, large quantities of the ferment must be used, and the process should be continued longer than for a lesser degree of peptonisation. One or two drachms of Benger's Liquor Pancreaticus with fifteen grains of sodium bicar- bonate will completely peptonise half a pint of milk in a few min- utes if the bottle be immersed in water which is heated, but which is not too hot for the hand to bear. Roberts's rule for pancreatinised milk gruel is quoted by Yeo as follows: "A good thick gruel made with oatmeal or other meal while still boiling hot is added to an equal quantity of cold milk. The temperature of the mixture will then be about 140 F. To a pint of this mixture two or three tea- spoonfuls of Liquor Pancreaticus and twenty grains of bicarbonate of soda are added ; it is kept at the same temperature for about two or three hours, and then boiled for a few minutes and strained. This mixture contains not only the casein of the milk peptonised, but the starch of the material is converted into sugar and its albuminates are peptonised. The bitterness of the peptonised milk is scarcely perceptible in this gruel." Papoid is a vegetable ferment which is thus described by Prof. Chittenden, of Yale University : " Extended study of the reactions of the vegetable ferment papoid shows that it is composed essentially of a mixture of vege- table globulin, albumoses and peptone, with which is associated the ferments characteristic of the preparation. " Papoid, so far as my observations extend, has the power of digesting to a greater or less extent all forms of proteid or albu- minous matter, both coagulated and uncoagulated. Furthermore, papoid is peculiar in that its digestive power is exercised in a neu- tral, acid, and alkaline medium. " Papoid will act in dilute solutions, but the best and character- istic action is seen only when a small volume of fluid is present. In this respect it differs very markedly from the animal ferment pepsin, and for this reason any direct comparison of the two fer- ments is practically impossible, but blank experiments without papoid [with acid and alkali as used in these experiments] showed that these reagents have in themselves only a comparatively light solvent action on raw fibrin." After taking the ferment it is found in the stools, showing that it is not wholly destroyed in the alimentary canal. It is prescribed in doses of from one to three grains after each meal. FOOD ABSORPTION. The absorption of food takes place from the stomach to a limited extent, to a great degree from the small intestine, and to a lesser ELIMINATION OF FOOD WASTE. 335 degree from the larger intestine. The rectum is capable of absorb- ing enough predigested food to sustain life for several weeks (see Food Enemata). The entire digestive process does not have to be completed before absorption begins. Usually those foods which are first digested, or which are administered in predigested form, are first absorbed. The rate of absorption depends upon the degree of digestibility of the food, the extent of absorbing surface with which it is brought into contact by the peristaltic movement, the composition of the blood, the relative pressure in the intestine, blood vessels, and lymphatics, and, probably more than anything else, upon the functional activity of the cells covering the intestinal villi. The accompanying table shows the percentage of food swallowed which is actually absorbed : Weight of Food. Absorbed. Residue. Of lOO parts of solids of mixed diet 89.9 81.2 96.9 II. I " " albumin 18.8 " " fats or carbohydrates 31 ELIMINATION OF FOOD WASTE. The following data are quoted by Yeo : " According to Dujardin-Beaumetz, a man loses, in connection with the processes of nutrition, nitrogen, carbon, water, and salts. In twenty-four hours these losses [for an adult man at moderate labor], on an average, amount to 20 grammes (300 grains) of nitrogen, 310 grammes (4,650 grains) of carbon, 30 grammes (450 grains) of salts, and 3 litres (about 6 pints) of water. The chief part of the nitrogen (14.5 grammes) passes away in the urine in the form of urea and uric acid, and the remainder (5.5 grammes) in the faeces, perspiration, and mucous discharges. Of the carbon, 350 grammes are consumed in the lungs, 45 grammes are eliminated by the kid- neys, and 15 grammes in the other secretions. The water passes off by the skin, lungs, kidneys, and bowels. A man's food must con- tain the elements necessary to repair these incessant losses. "The 20 grammes of nitrogen represent 124 grammes of dry proteid matters, and as these contain 64 grammes of carbon, on sub- tracting the 64 grammes from the 300 grammes necessary for nutri- tion there remain 236 of carbon to be derived from starch sub- stances or from fats." When waste matter has accumulated in the system its elmina- tion may be assisted in various ways, as follows: I. Through active exercise, which produces more complete 24 336 FOOD DIGESTION. oxidation and the formation of a larger proportion of water and carbon dioxide. 2, By diuretics, large draughts of saline waters, and occasional doses of saline cathartics. 3. By Turkish baths, which increase the elimination from the skin. The data given below, which are derived from Bauer, exhibit the balance of income of food and output of waste of the body under different conditions of rest and activity. Income of Food and Output of Waste (Bauer). Small, ill-nour- Rest and Work and ished man ; abundant diet. abundant diet. rest and abundant diet. Grammes. Grammes. Gramtnes. 139-7 I5I-3 I5I-I 41-5 48.1 61.8 450.0 450.0 450.0 500.0 500.0 509.6 1,025.0 1,065.9 1,012.7 70.0 60.2 58.8 30.0 30.0 30.0 70.0 70.0 70.0 17.0 17.0 17.0 4.2 4.9 4-3 286.3 489.1 41.4 709.0 1,006.1 600.7 3,342.7 3,892.6 3,007.4 1.343- 1 1,261.1 1,069.6 II4-5 129.0 137-1 1,739-7 2,545-5 1,597-8 3,197-3 3-935-6 2,804.5 + 145-4 -43 -o -1- 202 . 9 Income. Meat White of egg Bread Milk Beer Suet Butter Starch Sugar Salt Water Oxygen from air Total Output, Urine Faeces Breath Total Balance THE URINE AND FOOD. The relation of the composition of the urine to the quality and quantity of the food is highly important. Independently of renal disease and of excessive perspiration, the occurrence of a scanty urine means that too little fluid is being in- gested, and that the nitrogenous waste is accumulating faster than it is being removed. The urine secretion is normally increased in quantity after meals, and is diminished during fasting and in sleep. The increased rate of secretion lasts for two or three hours, and then lessens. The in- crease usually begins within an hour after breakfast, but not for two or three hours after dinner. This may be owing to the slower ab- FOOD EQUIVALENTS. 337 sorption of fluid which occurs with the heavier meal i. e., while solid food is retained in the alimentary canal, it holds back the fluid like a sponge. The maximum rate of secretion is also reached somewhat later after dinner, sometimes not for four hours. After mi.ved meals the quantity of urea is more than doubled, and the phosphates and urates are increased in nearly the same ratio. Proteid foods always increase the output of urea, urates, or uric acid, while vegetable foods increase the phosphates and sul- phates. Klemperer has stated that in diseases characterised by nitrog- enous tissue waste the latter is reduced by giving carbohydrates. In other words, the carbohydrates save the consumption of tissue and consequent production of urates or urea. Meat and albuminous foods in general tend to make the urine more acid, whereas milk and vegetables make it more alkaline. TOBACCO AND FOOD. The use of tobacco in its relation to digestion is a subject very closely allied to dietetics, but a brief mention of it only can be made here. Like alcohol, undoubtedly most persons are better without it, and its abuse is well known to disorder digestion through the action of nicotine upon the circulation, and especially upon the vagus nerve. No definite rules can be formulated for the use of tobacco in relation to meals beyond those suggested by the fact that the action of tobacco is always less likely to prove irritating if it is smoked while there is abundant food in the stomach. The after-dinner cigar in many persons promotes the secretion of gastric juice, and there are those in whom a mild cigar after breakfast favours peristalsis and the evacuation of the bowels. If there is any tendency to indigestion of starchy or saccharine foods, it is usually aggravated by the use of tobacco in any form. As observed elsewhere, when food cannot be obtained after fatiguing exercise or a forced march, the moderate use of tobacco is often found to temporarily replace it, at least to the extent of lessen- ing the feeling of weariness (see Substitutes for Food, page 260). Smoking immediately before meals may destroy the appetite and interfere with the digestion of the food. FOOD EQUIVALENTS. It is easy to compute the chemical equivalents of foods as analysed outside of the body. It is quite another matter to com- pute them with accuracy within the body. Most writers upon die- tetics, however, make some attempt to do this, and the following 338 FOOD DIGESTION. data may be accepted as approximately correct : One pound of lean beef equals in nutrient value three eggs or two pints of milk. One pound of wheat equals 3.5 pounds of potatoes. Of common cheese, Parkes estimated that " about half a pound contains as much nitrogenous substance as one pound of meat, and one third of a pound as much fat." Van Noorden estimates that as a fat former seven grammes of fat equal 9.3 grammes of alcohol. Oertel says that " one part of fat is iso-dynamic with 2.4 parts of carbohydrates, on an average," and one part of fat develops as much heat and force as 2. 11 parts of albumin (Voit). Church gives the following table of the estimated equivalents of foods which would yield the necessary daily supply of nitrogen if eaten alone : Pounds. Ounces. Oatmeal I 2 2 3 24 54 6 3 10 Eecs Lean beef I Wheat bread 13 Potatoes White turnips 4 8 Cow's milk Rice 7 To obtain the necessary daily supply of carbon Bacon Cow's milk . . Wheat bread Eggs Rice Turnips Lean beef. . . Potatoes . . . . PART VI. THE GENERAL RELATIONS OF FOOD TO SPECIAL DISEASES. DISEASES WHICH ARE CAUSED BY DIETETIC ERRORS. i THE GENERAL RELATIONS OF FOOD TO SPECIAL DISEASES. There are two methods of adapting diet for the sick : First, by- giving one half, one third, or one fourth of the ordinary quantity of food for health; second, by altering the quality of the different classes of foods, and reducing the total amount simultaneously or not, as required. The former method is simpler and less trouble- some, and for some few cases it may prove sufficient. It is to be regretted that it is a routine method adopted in many hospitals, for it is unscientific, besides being often wasteful and radically wrong. The second method presupposes a knowledge of the relations of diet to disease, and requires careful supervision. In speaking of this subject Parkes wrote : " It is certain that the physician can in this way wield a great power, which, if less striking than that ob- tained more rapidly by drugs, is yet of immense moment." The same aliments which in health produce definite results in furnishing energy and repairing tissue loss may fail completely in disease. Such is the case in diabetes when starches become not only a useless but a harmful food, and in severe albuminuria, when meats only aggravate the albuminuric waste. In the majority of severe diseases, and especially of acute and febrile diseases, the proteids and fats, aside from those of milk, be- come less assimilable than the carbohydrates. Beneke attributes this to the fact that carbohydrates are respiratory foods i. e., their consumption results in the production of carbon-dioxide gas and water, and the elimination of carbon dioxide proceeds in disease very much as in health. If carbohydrates are not therefore fur- nished, inanition ensues, for the tissues begin to consume their own substance. There are, on the other hand, some few diseases, such as tubercu- 839 340 GENERAL RELATIONS OF FOOD TO SPECIAL DISEASES. losis, the scrofulous diathesis, or anaemia, in which proteids and fats may be distinctly required, and others again may temporarily de- mand a purely nitrogenous diet. Food improper in quality or deficient in quantity is sure to be not only a direct source of disease, but indirectly, by lowering the vitality of the body, it leaves it an easy prey to epidemic and con- tagious diseases of every sort. This was strikingly shown during the ravages of the plague in the Middle Ages, and it has been ap- parent in the history of all recent famines. (See Starvation, page 274, and Famine, page 281.) The important relation of food to disease in regard to its quantity and composition, as well as the frequency and method of its admin- istration, are becoming more and more thoroughly appreciated. This is owing in great part to improved methods of diagnosis and to modern means of clinically discriminating between different kinds of gastric and intestinal indigestion. It is also due to an increasing knowledge of the chemistry of food, of food preparation by cooking, and of "artificial digestion." There is still much difference of opinion in regard to the best dietaries for certain diseases, such, for example, as gout and obesity, but the general principles of dietetics are to-day well established and more widely understood and practised than ever before, and starva- tion in fevers, like excessive venesection and similar depleting meas- ures, is no longer carried to the former injurious extreme. There remains much to be learned in regard to dietetics ; and the great variations in digestive power which are encountered in individual cases of disease and in personal idiosyncrasy, together with the in- creasing varieties of foods and food preparations, make the rela- tion of diet to disease a constantly broadening subject, the impor- tance of which cannot be overrated. It is to be regretted that the study of dietetics is not more thoroughly taught as a necessary part of medical education, and that thorough systematic instruction in this practical branch of science is omitted from the curriculum of our medical schools. For many physicians it seems far easier to write a brief prescription for a " nerve tonic " or cathartic pill than to take the time and pains to state in writing for their patients a definite dietary which in very many cases will prove an invaluable adjunct to medicinal treatment, if not in itself a curative measure. Sometimes indeed they appear possessed with the idea that the minutiae of dietetics are beneath consideration, whereas in reality, like the details of good nursing, they are most important, and a care- ful attention to them and a close interrogation into the ordinary habits of the patient in regard to his daily regimen is sure of appre- ciation and of beneficial results. In all acute febrile diseases and in all so-called "wasting " dis- DISEASES CAUSED BY DIETETIC ERRORS. 341 eases in which there is faulty assimilation of the food, the digestive functions are impaired, while the rapid tissue waste increases the need for nutriment to replace it. In such cases enfeebled digestive powers must be taken into account, and while endeavouring to sup- ply the increased demand for food, every effort should be made to relieve the alimentary canal of unnecessary labour by supplying those preparations which will yield the necessary amount of nutri- tion and force with a minimum expenditure of energy. Moreover, the conditions of elimination of waste materials from the tissues must be studied in relation to the composition of different foods in order to prevent the overworking of the excretory organs. It may be asserted that there is almost no disease of long dura- tion and severity, and certainly no disease accompanied by grave constitutional disturbances, the course of which cannot in a measure be controlled or benefited by thorough study of the nature and uses of foods. There are many acute aliments in which undoubted bene- fit is derived from greatly diminishing or altogether withholding temporarily the consumption of food, while there are others in which forced feeding that is, increasing the quantity of food to the utmost capacity of the digestive organs is a necessity. The general relations of food to the organism, as well as the na- ture of foods and the processes involved in their digestion, absorp- tion, and assimilation, have received full consideration in the preced- ing pages. In the following chapters the principles briefly outlined above will be considered in their application to individual diseases. At the risk of some repetition, it has been thought best to make the dietetic treatment of each disease as comprehensive as possible under the different headings considered, and to emphasise its value by a brief synopsis of the more important symptoms which arise, and a discussion of the indications to be met by appropriate dieting. DISEASES CAUSED BY DIETETIC ERRORS. While the course of the majority of all diseases is obviously influ- enced by the quantity and quality of the food eaten, there are par- ticular diseases which are directly caused by improper diet. This causative relation concerns: I. Insufficient food. II. Overeating and overdrinking. III. Food in itself wholesome, but which is injurious because the ingredients are not properly balanced. IV. Food containing parasites or their embryos. V. Food containing ptomaines. VI. Food containing other poisons, grain poisoning, etc. VII. Food conuining adulter- ants. VIII. Food containing micro-organisms. IX. Food which is in itself wholesome, but against which personal idiosyncrasy exists. X. Alcohol as a food and poison. 342 DISEASES CAUSED BY DIETETIC ERRORS. I. Insufficient Food. The general effects of starvation have been described in the study of the proper quantity of food (page 274). The effects of the depriva-^ tion of water are discussed on page 35. Insufficient food may cause the condition of marasmus, and is an important agent in producing some forms of anaemia (see Marasmus). II. Overeating and Overdrinking. Both overeating and overdrinking may be (i) temporary that is, the result of an occasional debauch; or (2) chronic. 1. Temporary overeating may apply to the excessive consump- tion (a) of a mixed diet, or (d) of particular articles of food. The former (a) causes dyspepsia, or, in extreme cases, acute gastro-enter- itis. The latter (d) may also cause dyspepsia and diarrhoea, or such affections may be produced as glycosuria, from excessive indulgence in candy and sweets ; acne and other skin diseases, from the too lib- eral consumption of fats. Temporary overeating at one or two meals may not produce any serious effect, but if the excess in feeding be long continued a variety of ills result, attributable directly to overloading of the alimentary canal and to the accumulation of waste matter in the tissues, and consequent imperfect oxidation processes. The excess of food may be injurious in one of two ways : First, if it is not absorbed, it ferments abnormally in the alimen- tary canal. There is a limit to the quantity of every food which can be digested in a given time ; beyond this the food, whether starches, fats, sugars, or proteids, may decompose, or pass away unaltered. Second, if the excess be absorbed the blood is overwhelmed, and the excretory organs are overworked. The most northern Eskimos and Yakuts often eat but one meal a day, and, owing to the uncertainty of their supplies, they occasionally have to make the interval longer. As a result, when they do find food in abundance, they gorge themselves, and they are noted for the relatively large size of their abdomens and stomachs which is, how- ever, the only inconvenience which they seem to suffer from such irregular habits (see Gluttony, page 261). 2. Chronic overeating may cause such diseases or diatheses as obesity, gout, lithaemia, oxaluria, and the formation of renal, vesi- cal, and hepatic calculi. It is very certain to cause congestion of the liver and the condition known as " biliousness," in which the stomach and intestines are engorged, constipation results, the tongue is heavily coated, the bodily secretions are altered in composition, the urine especially becoming overloaded with salts, the liver be- comes congested, and finally the nervous and muscular systems are OVEREATING AND OVERDRINKING. 343 affected, with the result of the production of headache and feelings of fatigue, lassitude, drowsiness, and mental stupor. For persons leading sedentary lives, excessive consumption of animal food is more injurious than vegetable food, for the reasons given above, although obesity is more favoured by excess in vegetable diet and sweets. The nitrogenous foods, requiring, as they do, a large consumption of oxygen for their complete combustion and reduction to urea and allied products, produce forms of waste mat- ter in the system which are more deleterious than the carbohydrates that are converted into water and carbonic acid, and are more easily eliminated. It is for this reason that defective nitrogenous metab- olism alters the composition of the blood and paves the way for disorders of nutrition, such as lithiasis. Patients suffering from severe epilepsy and from certain forms of insanity, chiefly manias, and sometimes hypochondriacs, at times gorge themselves with food and drink. The presence of intestinal roundworms and tapeworms may give rise to overeating, though this by no means always follows. Overeating is apt to be carried to an injurious extent by the half-starved poor if they have sudden access to plenty, and by convalescents from typhoid fever. Bulimia is a form of perverted sensation, causing inordinate craving for food (see page 304). Overeating not only taxes the digestivesystem, but, what is often more serious, it throws too great a strain upon the glandular and excretory organs, especially the liver and kidneys, and if the habit is long continued, disease of the nature above described inevitably results. In like manner the overfed boiler becomes sooner burned out, and its fires choked with ashes which accumulate faster than they can be removed. Overeating, especially among the well-to-do, is the commonest dietetic error, and looking at the question in its broadest aspects, it is quite certain that the foundation for more disease is laid by this habit than by overdrinking (see Alcohol, page 206). The former, indeed, sometimes conduces to the latter, and there are some examples of alcoholism in which the desire for drink is only aroused and fostered by previous excesses in eating. Overdrinking, except of alcohol (which is considered under the heading of Alcoholism, page 364), is not common, and is mainly confined to the excessive consumption of tea and coffee, which re- sults in insomnia, cardiac palpitations, and various neuroses. Dila- tation of the stomach has been attributed in some cases to over- indulgence in mineral waters, but such instances are very unusual. Polyuria and diabetes insipidus have also been ascribed to the ab- normal consumption of fluids, but without strong proof. Excessive use of milk as a beverage usually results in "biliousness" and 344 DISEASES CAUSED BY DIETETIC ERRORS. constipation, but for the reason that it is really a solid food that is, it becomes such immediately on entering the stomach. Thirst is often extreme in fevers, diabetes, and other conditions, but the drink- ing of exceptionally large quantities of water is by no means always harmful, and it is often desirable to recommend it as a diluent and diuretic. The propriety of restricting its use in dropsies, gastric disorders, etc., will be considered under the appropriate headings (see Gastric Catarrh, Ascites, Diabetes). III. Food in itself Wholesome, but which is Injurious BECAUSE the INGREDIENTS ARE NOT PROPERLY BALANCED. Such diet may produce anaemia, from lack of meat or other animal food ; scurvy, from preponderance of salt meat and fish and lack of fresh fruits and vegetables ; rickets and scrofula, from errors in infant feeding, such as excess of amylaceous and lack of animal food, necessary salts, etc. ; acne, or eczema, from food too rich in fats; constipation, from a too nutritious and concentrated diet; pos- sibly rheumatism, from various dietetic errors. The belief is held by some authorities that a diet of coarse cereals and vegetables favours the development of chronic endarteritis (see Vegetarianism, page 28). IV. Food containing Parasites or their Embryos. Food sometimes serves as the medium for the introduction of parasites or their embryos, such as the tapeworm, roundworm, echi- nococcus, and trichina. In many cases the source of infection is found in the consumption of raw or very imperfectly cooked swineflesh and other meats used in the manufacture of sausages and similar preparations which are carelessly handled and come in contact with the viscera of the ani- mals in which the parasites or embryos reside in some intermediate stage of development. Another possible source of infection, espe- cially of intestinal worm larvae, is in the excrement of animals, which is permitted to pollute raw vegetables growing upon the ground. Manure is freely spread about, and dogs infested with worms, or a casual pig allowed at large in a vegetable garden, may contaminate by their faeces such vegetables as grow low upon the ground and are usually eaten raw, as lettuce, celery, cabbage (coleslaw), etc. Fortunately, this is by no means a common source of infection, but it is well to remember that several cases have been definitely traced to such a source, and this explains the occasional presence of tape- worms in people who never eat raw meats, ham, or sausage, or the flesh of swine in any form. No animal should ever be allowed to roam in a vegetable garden. Other varieties of parasites or their INTESTINAL WORMS. 345 larvae may occasionally be introduced with the food or water, such, for example, as the Dracunculus tnedinensis, which produces the Guinea-worrn disease, or Dracontiasis, the larvae of which are some- times swallowed in drinking water by the natives of parts of Africa and the East Indies. INTESTINAL WORMS. The presence of intestinal worms, such as the roundworm, Ascaris lumbricoides, and various species of cestodes or tapeworms, requires no special dietetic care beyond the preventive treatment of avoiding raw or imperfectly cooked flesh and submitting to a period of starvation for twenty-four hours, in order that the intestine may be completely emptied of food before an anthelmintic is given, so that it may more certainly reach the worms. There are two principal varieties of tapeworm in man, besides four or five others, which are very rarely present in the intestine, being derived from the lower animals through habits of filth or carelessness in preparing food. Of these two varieties, the commonest in this country is the beef tapeworm, Tcenta saginata, or mediocanellata ; the other, the pork tapeworm, or Tcenia solium, is more often found in Europe and Asia. The Tcenta mediocanellata is a segmented worm, having a large square head presenting four suckers, by which it maintains its hold upon the intestinal mucosa without the aid of booklets. The seg- ments increase very slowly in size behind the head, and finally attain a breadth of eight to ten millimetres and a length of seventeen to eighteen millimetres, while the whole animal may reach a length of twenty feet, or even become longer than the intestine. Fragments of the worm are constantly breaking off, compressed bythe waste matter of the food, and with it are swept out of the gut. The Tcenia solium is not so long as the mediocanellata, measuring usually from six to twelve feet. The head, which is quite small, presents four suckers and several minute hooks, which enable the animal to secure a firm hold upon the mucous membrane. Behind the head are the series of segments, many hundred in number, con- stituting the body. They gradually increase in size, and the larger ones contain male and female organs of generation, each segment being supplied with both varieties. The larger segments attain a 'size of seven to eight millimetres by ten millimetres. Each mature segment contains an enormous number of ova often several thou- sandand in about three months, when the worm has reached its full size, the segments, which are narrower and smaller than those of mediocanellata, are continually breaking off and passing out with the faeces. Pigs eat the ova, and digest them. The ova consist of 346 DISEASES CAUSED BY DIETETIC ERRORS. shells which contain minute embryos with six hooklets. The em- bryos make their way into the viscera or muscles of the animal, where they lodge and develop to form the larvae or cysticerci, called also ** measles." If the measled hog meat is eaten by man, and imperfectly cooked, the cysticerci develop with the intestinal worms above described. The worms infest man at all ages, from early childhood up. They may cause no symptoms, but sometimes give rise to a raven- ous appetite, as they interfere with intestinal digestion and absorp- tion. They occasionally excite reflex nervous disturbances. Their presence is easily made certain by the finding of either the ova or the complete segments in various lengths in the stools. Treatment. The patient should be put upon very short rations for two days, during which time the bowels must be well emptied. The evening before giving the vermifuge the patient should take a light supper of bread and milk or a sandwich, and that night a brisk cathartic. It is best to give the medicine the next morning fasting. By this means the intestines become almost empty, and the head of the worm is left unprotected, so that whatever remedy is used to kill it will make it loosen its hold. Another laxative may be given a few hours later, and if the patient eats bulky food, such as bread and potatoes, for a day or two, and keeps the bowels active, the worm may be completely dislodged and crowded out. The stools must be floated in water and closely examined for the head, for if this is not obtained the worm is sure to grow again in three or four months. There are many tseniacides. One of the least disagree- able and most efficient when properly administered is pumpkin seed. The seeds should be husked, and three ounces may be pounded in a mortar, macerated, mixed with honey into a paste, and eaten spread like jam upon a thin slice of bread. TRICHINIASIS. iEtiology. Trichiniasis is a parasitic disease produced by the embryos of a worm, the Trichina spiralis, which work their way into the voluntary muscles and there become embedded. Among the parasites liable to be eaten with raw meats this one is by far the worst and most fatal in its effects. The habitat of the adult worm is the small intestine. During the emigration of the embryos into the voluntary muscles a' group of characteristic symptoms is pro-^ duced. The parasites have the following appearance: The adult male measures 1.5 millimetre in length ; the female is from two to two and a half times as long. The embryo is 0.6 to i.o millimetre in length, and when at rest, encapsulated in the muscle, is coiled in a spiral. It has a blunt tail and a sharp head. The adult male has two small projections from the caudal end. The ovoid capsule first TRICHINIASIS. 347 appears translucent, but later, from the deposition of salts of lime, it becomes opaque. Infection in man is caused by the eating of ham and pork from hogs whose bodies contain the parasite. Among these animals it is of quite frequent occurrence. It is also spread through the agency of rats, which are eaten by hogs (Dock). Salmon reports that in American hogs the ratio affected is slightly over 2 per cent, but this is doubtless far too high an estimate. In Germany the proportion is I in 1,852. Natural History of the Parasite. After eating flesh which contains the embryos the process of digestion dissolves their cap- sules, and they are liberated, passing into the small intestine, where, with the presence of the favourable conditions of warmth, moisture, and food, they reach their adult growth in from three to six days. Rapid reproduction takes place in the intestine, and the number of young produced by a single female worm varies up to at least a thousand. In a week or more after the ingestion of the parasites the newly developed embryos pass out through the intestinal wall and mesentery, seeking the muscles which they enter ; they then work their way through the connective tissue between the fasciculi or the separate muscle fibres, and finally enter the latter, where a fortnight's further development produces the complete muscle form. Recent observations of Askanazy point to the conclusion that the adult female deposits the embryos within the walls of the in- testinal villi, not setting them free in the intestine, as heretofore supposed. From the villi they penetrate the muscles, as above mentioned. Thornbury recently reported at the Buffalo Academy of Medicine the results of analysis of 500 cases of infected swine. In these ani- mals the parasite was found in the diaphragm 400 times, in the loin 290 times, and in the neck 170 times. "The point of predilection therefore appears to be the diaphragm. This is explained by its close proximity to the digestive tract, from which the trichinae pri- marily bore." In three cases in man which he examined the trichinae were found principally in the extremities, "one microscope slide from the biceps of an arm containing fifty of the parasites." They were also present in the diaphragm, intercostal and abdominal muscles. The embryos, when lodged in the muscle fibres, act as foreign bodies or irritants and excite an interstitial myositis with the forma- tion of a capsule around each embryo. But one embryo may be lodged in a single capsule. Once within the muscle fibres, embryos remain without change until the capsule, the completion of which requires about six weeks, is in some way destroyed. After forma- tion of the capsule a precipitation of lime salts occurs slowly within 348 DISEASES CAUSED BY DIETETIC ERRORS. it for four or five months. The embryos, thus securely protected in a strong envelope, may retain their vitality for many years, and it is claimed that they have survived for at least two decades, but the worms themselves not infrequently become calcified. Other animals besides hogs may harbour this parasite, among which are the rat, cat, mouse, and fox, and it can be artificially inoculated. Prophylaxis. The prevention of trichiniasis should consist in the more careful feeding of swine upon grain instead of offal, and for man the only absolute prevention is the extremely thorough cooking of all swine flesh, for a temperature of 140 F. is fatal to the embryos. Smoking and pickling is also preventive. " In the usual curing solutions trichinae are killed within six weeks in thin pieces of meat, but in thick pieces they can exist as long as four months" (Dock). The presence of the parasites in countless numbers in the flesh of the hog may give rise to no symptoms of any kind in the animal, and it is this fact which makes the eating of raw ham, pork, and sausages particularly dangerous unless the meat of the animals killed has been subjected to a searching microscopic examination. It is the safest rule never to eat such meats. The difficulty of detecting the parasite in the hog is considerably increased by the fact that the calcification is very much slower than it is in man, so that the worms are more readily overlooked. The parasites fortunately are com- pletely killed by boiling for some time the meat which contains them, but pickling or corning meat or smoking ham and bacon are not necessarily fatal to them. Frequency. Cases of trichiniasis are occasionally reported in this country chiefly among the Germans, whose fondness for raw ham and a variety of sausages is well known. Osier reports the finding of 456 cases, including 122 deaths recorded in America. Many persons are often simultaneously affected from eating the meat of the same animal, thus giving the disease the false character of an epidemic. Symptoms. The symptoms vary with the number of parasites which have been eaten. If very few are ingested, the embryos are not reproduced in sufficient number to give rise to any symptoms. Usually, however, they are well marked, and embrace a stage of gastro-intestinal irritation followed by systemic infection. The pa- tient, three or four days after eating raw pork or ham, suffers from more or less severe abdominal cramps, with anorexia, vomiting, and diarrhoea. The latter occasionally becomes severe. General mus- cular prostration is also present, and there may be chills. In a number of cases the gastro-intestinal symptoms may not be severe enough to attract attention, and the first symptoms are those of gen- eral infection, which develop at the commencement of the second TRICHINIASIS. 349 week. There is an increase of temperature, amounting to 103 or 104 F,, of an intermittent or remittent character. As soon as the embryos have extensively penetrated the muscles they give rise to great local pain and tenderness, accompanied by swelling and tension of all the muscles affected. The patient naturally assumes the posi- tion in which there will be the least strain upon the muscles. These symptoms increase in intensity, and general oedema is apt to follow, which may appear first in the face (Osier). When certain muscles are implicated more serious symptoms may result. If the diaphragm is invaded or other muscles of respiration, there may be extreme or even fatal dyspnoea. If the parasites reach the muscles of the face, jaw, and pharynx, mastication and deglutition become difficult or impossible. There is more or less itching and burning of the skin and perspiration. Urticaria has been observed ; anaemia and a marasmic condition eventually develop in a majority of cases. There is comparatively little disturbance of the nervous system, and patients are usually conscious until the time of death, but in some instances a typhoid state supervenes with delirium. The other symp- toms which have been reported as occasionally present are loss of tendon reflex, bronchitis, pneumonia, pleurisy, albuminuria, and polyuria. Prognosis. Mild cases may recover within a fortnight. In severe cases in which there has been great prostration and emacia- tion convalescence is retarded for many weeks. Children are more apt to recover than adults, but the outlook depends chiefly upon the number of parasites ingested. Cases pre- senting severe diarrhoea are more likely to recover, probably because some of the parasites are eliminated in this way. Mortality. The greatest mortality is reported between the fourth and sixth week. The causes of death may be exhaustion from choleraic discharges, dyspnoea, and inability to swallow. In protracted cases inanition results. Autopsies show that but few organs aside from the muscles are affected by anatomical lesions. Cohnheim observed fatty degenera- tion of the liver and enlargement of the mesenteric glands. The muscles present the appearances of lesions of acute interstitial myo- sitis around the capsules of the embryos. Diagnosis. The affection differs from acute rheumatism in the absence of swelling in the joints and the much greater local tender- ness along the surface of the muscles. The latter are exceedingly painful both to pressure and voluntary movement. The disease m its protracted form has been mistaken for enteric fever, and un- doubtedly it has many times escaped detection. The most valuable features in determining the diagnosis are the extreme tenderness to pressure of the muscles, their swollen condition, and the general 350 DISEASES CAUSED BY DIETETIC ERRORS. oedema and dyspnoea. Under cocaine anaesthesia a small piece of muscle may be excised from the arm or thigh for microscopic exam- ination. Osier advises searching the stools for the parasites, which may be found with a low-power lens as glistening threads. Treatment. The basis of treatment is to at once evacuate the alimentary canal, providing the fact of eating the infected meat is known within a day or two. Diarrhoea should not be checked. If constipation exists, a strong purgative of calomel and jalap or castor oil should be administered. When systemic symptoms develop, the treatment must be purely symptomatic, because there is no known remedy which will reach and destroy the trichinae. Every effort must be made to support the strength of the patient until the em- bryos have become encysted, after which the acute symptoms will subside of themselves. V. Food containing Ptomaines. Ptomaines are substances resembling alkaloids which are formed in the alimentary canal by the decomposition or putrefaction of ni- trogenous foods. They may also form in such food outside of the body. This decomposition is the result of the action of certain micro-organisms simultaneously first described by Gautier in France and Selim in Bologna. It is at present believed that the constitu- tional symptoms observed in many infectious diseases are caused by similar poisons called leucomaines, which originate in the blood and other tissues of the body through the action of specific germs. The artificial cultivation of micro-organisms has proved that they are capable of forming substances which have distinct physiological actions, that are sometimes highly poisonous. The poisonous pto- maines Brieger calls toxines. Many of these micro-organisms flour- ish in beef juice, milk, and various solutions of nitrogenous material ; and in the alimentary canal, when such food is taken, all the most favourable conditions are present for the development of toxines. When the proper germs are ingested for this purpose, the toxines are readily absorbed by the intestinal mucous membrane, and it is prob- able that ptomaine poisoning would occur very much oftener were it not that the liver, acting as it does as a gateway for the admission of nutritive matter for the body, is capable of destroying many poisons which enter it from the intestines through the branches of the portal vein. Corroboration of this statement is found in the fact that snake bites of the surface of the body may prove highly poi- sonous by immediate absorption of toxic material into the circu- lation, whereas snake poison may be swallowed with impunity, for if it is absorbed from the alimentary canal it is destroyed in the liver before reaching the nervous system. The same is true of the action of putrefying meat, which in very POISONING BY MEAT OR GAME. 351 small quantities may not produce severe gastro-intestinal symptoms or constitutional disturbances, and yet if inoculated through a cut in the finger may cause symptoms of a violent septic character. Richard (Diseases of Modern Life) reports a fatal case of poison- ing from eating tainted hare. The victim had had a small ulcer beneath the tongue for some time, which became gangrenous after eating the meat, and which was the undoubted source of inocula- tion. Ptomaines may be developed from a variety of foods, but the principal ones from which poisoning from time to time occurs are spoiled meat, milk, shellfish, and fish. POISONING BY MEAT OR GAME. When meat has been kept too long exposed to the air, or when it has become contaminated in any manner with putrefactive bac- teria, it is wholly unfit for food, yet if thoroughly cooked it may not be necessarily poisonous. This is the case with " high " game. Dangerous and even fatal cases of systemic poisoning by meat ptomaines have resulted from eating sausages, pork pie, ham, meat juice, beef, head-cheese, mutton, or veal. The putrefactive change may have already begun in the meat although it may not be appar- ent by an altered taste. Sausage poisoning is called botulism or allantiasis. It is a curious fact that certain persons have great toleration for tainted meats. Among civilised races, and especially in England, the use of " high " game and mutton is much less in vogue at pres- ent than formerly, but the Eskimos and many savage tribes in Africa eat with relish, and digest well, decomposing meat the mere odour of which turns the stomach of a white man. Bishop Colenso stated that among the Zulus of Natal the synonym for heaven is ^^ ubomi," which means "maggoty meat." The natives of Siam and Cambodia prefer to keep their fish until it has begun to putrefy. In some parts of China foul eggs several months old are enjoyed as a delicacy. Measly swine flesh rapidly decomposes, and the various processes of drying, smoking, and salting still leave it wholly unfit for food. The meat of very young animals should never be eaten, and the sale of young or "bob " veal two or three weeks old is usually pro- hibited by law. It is indigestible, innutritious, and it easily decom- poses. Symptoms. The symptoms of meat poisoning from these vari- ous substances are substantially the saipe in each case, being those of severe gastro-intestinal irritation, but in bad cases they are accompanied by dangerous collapse. The symptoms may follow almost immediately or after an interval of several days. The for- 25 352 DISEASES CAUSED BY DIETETIC ERRORS. mer is much better for the patient, for the sooner vomiting and diar- rhoea relieve the alimentary canal of the toxicogenic material, the greater the chance of recovery. In the majority of cases there is a latent period of twelve to thirty-six hours between the ingestion of the spoiled food and development of symptoms. The symptoms usually begin with suddenness and violence, but they may be pre- ceded by malaise, nausea, lassitude, and mild abdominal cramps. The sudden onset is ushered in by rigours with vertigo or faintness, or violent headache. Exceptionally there is dyspnoea, and there may be cold perspiration and sudden severe pains in the epigastrium or in the thorax, especially between the shoulders. Intense thirst has also been observed. Soon after one or more of these symptoms have appeared there is violent colicky pain in the bowels, accom- panied by nausea, retching and vomiting, and profuse watery diar- rhoea. There is an extreme degree of muscular prostration which comes on suddenly and prevents the patient from standing. It may be due to the abdominal pain, but it also occurs independently. The tongue is dry and coated with a thick brownish-yellow fur on the dorsum, but the margins are of a bright red with distinct papillae. Fever is usually present, and the temperature may rise to 103.5 or i4 F., although the skin may feel cold and moist. The pulse is somewhat accelerated and the rate may reach 130 or 140. Occasional symptoms which have been noted by Ballard are severe cramps in the legs and arms, convulsive twitching of the mus- cles of the face and hands, stiffness in the joints, and various abnor- malities of sensation, such as numbness, tingling, and flashes of heat and cold in the extremities. There may also be drowsiness, photo- phobia, and, in the worst cases, insomnia, nervous excitement, or mild delirium. If the poison results fatally, the prostration in- creases, the pulse grows rapid and feeble, the watery evacuations are uncontrollable, and rapid emaciation ensues. The patient be- comes cyanotic and passes into a state of collapse resembling that of the last stage of cholera. The poisoning presents all degrees of severity depending on the amount of the tainted food which has been taken, the nature of the putrefactive process, and the condition of the alimentary canal at the time. In mild cases, more or less abdominal pain, vomiting, diarrhoea, and headache, with slight prostration, are the only symp- toms. In the more severe cases, if convalescence follows the attack, it is prolonged, and the weakness of the patient may be fully as great as after some of the severe infectious fevers affecting the ali- mentary canal, such as cholera or yellow fever. In cases in which the symptoms develop very slowly, after an interval of a day or more the nervous symptoms are apt to predominate over those of the gastro-enteric system. There are painful muscular cramps, POISONING BY SHELLFISH AND FISH. 353 dyspnoea, aphonia, delirium, and palpitation. This variety of poi- soning is extremely dangerous. Diag^nosis. The diagnosis is almost always obtainable from the history of the case in connection with the symptoms above de- scribed, and when canned food has been eaten, the only difficulty consists in determining whether the poisoning is the result of eating tainted meat or of acute metallic poisoning from chloride of zinc, tin, or lead used in the process of tinning and soldering the cans (see page 257). POISONING BY MILK, CREAM, ICE CREAM, AND CHEESE. Poisoning by plain milk is less common than from certain vari- eties of cheese and from cream. When ice cream is made in large quantities, the cream is allowed to accumulate, and if a portion of it becomes infected with pathogenic organisms it will soon convert the whole mass into highly poisonous material. Vaughan and Novy in this country have thoroughly studied the whole subject of pto- maine poisoning, and Vaughan has isolated from cheese and ice cream a toxine to which he has given the name of " tyrotoxicon," and in Michigan in i883-'84 nearly three hundred instances of cheese poisoning were collected by him. In 1890 he isolated three proteid substances from germ cultures from the intestines of infants having milk infection. The symptoms of tyrotoxicon poisoning are sub- stantially the same with those of meat poisoning, consisting of se- vere gastro-intestinal disturbance with collapse. This toxine produces almost immediately after ingestion by a previously healthy infant violent symptoms of cholera morbus, which prove fatal in a few hours unless the poison can be eliminated (see Cholera Morbus Treatment). Of this poison Vaughan says: "Post- mortem examination shows but little change. [There is time for but little in fatal cases.] The mucous membrane of the small intes- tine is bleached and softened, and possibly deprived here and there of its superficial epithelium." The poison apparently acts somewhat as the toxine of Asiatic cholera, by absorption from the intestinal wall, and by violently de- ranging the nervous and vascular systems, producing sudden and extreme loss of fluid from the body through osmosis into the in- testine. POISONING BY SHELLFISH AND FISH. Poisoning by shellfish and fish results from infection with pto- maines developed by micro-organisms, as in cases of milk and meat poisoning. In addition, it must be remembered that there are a number of persons who, from idiosyncrasy, possess an extreme degree of sensitiveness to the action of shellfish of all kinds. To 354 DISEASES CAUSED BY DIETETIC ERRORS. such persons the eating of clam broth or raw oysters, crabs or lob- sters, may give rise to violent outbreaks of urticaria or eczema, or produce severe headache, nausea, and vomiting. It is scarcely probable that these cases are due to the same source as those of true ptomaine poisoning, for they occur when the shellfish have been eaten in perfectly fresh condition ; the symptoms, moreover, are usually less violent than those caused by ptomaines, and similar effects are produced in some people by certain vegetables and fruits, like the strawberry. Among shellfish the mussel furnishes the most violent poison. This substance Brieger has isolated under the name of " mytilotoxine." It develops particularly in the liver of the animal. The intensity of the poison depends somewhat upon the locality in which the animal has lived and fed. The same mus- sels may become non-toxic in different waters. The name ichthys- mus is applied to fish poisoning in general. Symptoms. The symptoms of poisoning from eating raw fish or cooked mussels in which ptomaines have developed are somewhat different from those of meat and milk poisoning in that they con- cern the nervous system with less gastro-intestinal disorder. For this reason the poison is very much more dangerous, and fatal cases have been known to result two hours after eating mussels. In such instances there may be no nausea, vomiting, or fever, but there is sudden and extreme prostration, with numbness, faintness, coldness of surface, dilatation of the pupils, restlessness, nervousness, anxiety, and a feeble and very rapid pulse. Decomposing oysters and fish may also produce symptoms of gastro-intestinal poisoning resem- bling those from the use of bad meat. The salted sturgeon which is eaten extensively as a food in parts of Russia, has caused death from its decomposition, and a variety of fishes both in European and Eastern waters are capable of developing very active toxines. VI. Food containing other Poisons than Ptomaines. Grain Poisoning, etc. It sometimes happens that flesh becomes poisonous from the ani- mal having fed upon some noxious substance shortly before it was killed. The flesh of pigs fed on garbage may cause diarrhoea (Parkes). It is a well-known fact that the flavour and digestibility of game, and even fish, varies much with "the season of the year and the consequent nature of the food which the animal has had. Oys- ters are not wholesome food from May to September, or in " the months without an R." Cow's milk becomes unhealthful for infants when the animal eats improper food, and instances have been re- ported although, fortunately, they are very exceptional of illness of adults caused by eating meat which had been poisoned during the animal's life, as in the case of a sick ox to which a large dose of GRAIN POISONING. 355 tartar emetic was given. The animal died, and the meat subse- quently was found to contain enough of the substance to severely poison those who ate it. Game sometimes disagrees on account of the nature of the food upon which the animal has previously been living. This is said to be particularly true of the grouse in various parts of the country at some seasons of the year. The laurel buds act in this manner. Hares fed upon rhododendron are poisonous (Letheby). A curious instance of poisoning from eating turkey meat was lately reported by Seelye, of Amherst, Mass. Several young women at a boarding school showed symptoms of atropine poisoning after eating a bird which had fed upon the deadly nightshade berries. GRAIN POISONING. Old unripe grain and mouldy flour develop poisons from decom- position of their gluten. Ergotism. The fungus known as ergot, or Claviceps purpurea, grows upon rye, and in Europe the careless admixture of this sub- stance with grain in the preparation of flour has several times re- sulted in violent symptoms of poisoning. Collectively the symp- toms are described as " ergotism," and they are commonly divided into two varieties, the gangrenous and the convulsive. The ergot- containing flour or meal must have been eaten for a considerable time, as a rule, in order to develop the symptoms. Ergot is sometimes employed too freely in medicine. In appro- priate cases it may be given in considerable quantity for a brief period without exciting toxic symptoms. When, however, its use is prolonged beyond a few days, serious poisoning results. In the gangrenous form of ergotism the early symptoms are referable to local vasomotor disturbances, affecting principally the extremities. These symptoms are anaesthesia, numbness, prickling pain, and spasmodic twitching of the muscles, with an impeded blood flow due to vasoconstriction. In the convulsive variety the nerv- ous system is profoundly disturbed. After a period of indefinite symptoms, such as lassitude, headache, and prickling sensations, spasms of the muscles with contractures begin. The spasms may be intermittent, or may assume a tetanic character, lasting sometimes through many days; the arms are strongly flexed and the legs and toes are extended. Spasmodic rigidity of the muscles may give place to violent convulsions, which become general and fatal. There is sometimes slight fever, and in the chronic cases melancholia or dementia results. Delirium also is sometimes present. In cases re- ported by Siemens and Tuzzek the posterior columns of the spinal cord were found sclerosed. Lathyrism. A grain called the chick-pea vetch is sometimes used 356 DISEASES CAUSED BY DIETETIC ERRORS. for the adulteration of flour from various cereals. Several varieties are used which have a similar effect to ergot in producing a condi- tion of spastic rigidity in the lower extremities. This form of poi- soning has been observed in India by James Irving, and by others in- Italy and France. It is, however, rare, and but little is known as to the exact nature of the lesions. Pellagra. Pellagra is a functional disturbance caused by eating fermented unripe maize or Indian corn, made into polenta. It is un- known in this country, but prevails in the south of Europe, in por- tions of Spain, France, and Italy. The first symptoms noticed are those of dyspepsia with more or less nervousness, insomnia, and debility. These symptoms are followed by an eruption, the pella- gral erythema, which develops in the spring. After the eruption has lasted for some time, the skin becomes very dry and extensive des- quamation ensues accompanied by burning pains, or, if neglected, the surface may become incrusted with areas of suppuration. With the appearance of the eruption the dyspeptic symptoms are increased, and there may be salivation and severe diarrhoea. The disease lasts in greater or less severity for several months and ends in slow con- valescence, or else, in the worst forms, the nervous system is in- volved and emaciation, headache, convulsions, delirium, and paraly- sis of the legs may appear. The peasants who eat this spoiled food sometimes have severe attacks in successive years, and melancholia and suicidal mania have been observed among them. There are no definite lesions other than those of malnutrition, such as fatty de- generation of various organs (Arnold). The disease is not contagious, and it is said to be preventable by adding salt to the corn meal ; but salt is a Government monopoly in Italy. The peasants resist the tax upon it, and, through prejudice as much as through ignorance and poverty, they fail to make use of it. VII. Food Adulteration. Food adulteration consists of: i. The addition of deleterious substances. 2. Fraudulent substitution of cheaper articles of food or the sale of food not as fresh or good as it is represented. A. J. Wedderburn, in a recent report to the United States Depart- ment of Agriculture, makes the statement that of all food products sold in this country, 15 per cent is adulterated, but only 2 per cent is deleterious. With the exception of milk and alcoholic beverages, the adultera- tion of foods in the United States is of comparatively little impor- tance from any harmful influence it may have upon health. Its moral are often worse than its physical aspects. In this country almost all food products are so abundant and FOOD ADULTERATION. 357 cheap that adulteration would be too expensive, and it offers small temptation to unscrupulous dealers. The object of adulteration of food namel)', to cheapen cost of production is attained by (a) increasing the bulk, {i>) altering the appearance, and (c) giving false strength. In many States stringent laws have been enacted against all adul- teration of food products, beverages, and drugs, but the ingenuity of manufacturers and dealers in evading them necessitates the constant vigilance of the experts of health boards. Among the common adulterations may be mentioned the follow- ing : Isinglass adulterated with gelatin ; powdered sugar with barium sulphate; mustard with flour and turmeric ; distilled coloured vinegar sold as cider vinegar ; pickles adulterated with iron and copper (Mas- sachusetts State Board of Health Reports) ; oleomargarine sold as butter; ground spices are adulterated with cocoanut shells, rice, flour, and ashes (Ohio Dairy and Food Commission) ; water, sugar, and tartaric acid are sold as lemonade. Wines and liquors are sometimes adulterated with alum, baryta, caustic lime, salts of lead, salicylic acid, and pigments, especially haematoxylon. Candies are adulterated with terra alba, kaolin, and various pig- ments, and the different chewing gums, gum drops, etc., are largely made with petroleum-paraffin products. Most of the maple sugar sold is made from glucose, and maple sirup is also derived from other sugars and artificially flavoured with extract of hickory bark (Wiley). Cotton-seed oil is often sold as olive oil. Nearly half the liquid honey sold is adulterated with glucose. Cocoa and chocolate are adulterated with both starch and sugar. Coffee is very extensively adulterated with sugar, caramel, pea meal, chicory, and saccharine extracts. Even coffee berries are artificially made in moulds out of mixtures of starch, molasses, or caramel, chicory, etc. Prof. Chittenden, as a result of elaborate investigations made with a view to determine the effect upon digestion of borax and boric acid when added, as they often are to preserve foods, con- cludes that "borax and boric acid, when present in moderate quan- tities, can have little or no deleterious effect upon the more impor- tant chemical processes of digestion. On the contrary, it would appear that the presence of these agents may, in some cases at least, even accelerate the normal digestive processes of the alimen- tary tract." Pigments. Artificial colouring matters are added to foods, both to intentionally deceive and also merely to make different sub- stances, such as preserved green vegetables, candies, or confections, appear more attractive to the eye. 358 DISEASES CAUSED BY DIETETIC ERRORS. Formerly highly injurious copper or zinc salts were much used- to colour canned peas and beans, and not infrequently they were found in poisonous quantities, but the green plant pigment chloro- phyll is so much cheaper, and is so abundant and harmless, that it^ has superseded them almost entirely since its introduction for this purpose in 1877. Ultramarine is much used to colour sirups ; eosin and many other anilines are employed in the manufacture of candies, as is also cochineal. The pigments most in vogue to colour butter and cream are tur- meric, saffron, an orange pigment from the stigmas of a flower, and annotto, a yellow pigment derived from the fruit of a South Ameri- can tree. Annotto as used by dairymen to colour milk and cream is not harmful. To detect it, add a teaspoonful of baking soda to a quart of the milk, and immerse in it a strip of unglazed paper. In a few hours the latter becomes orange-coloured if annotto is present (Leffmann). Salicylic Acid. The French Commission of Public Hygiene made a few years ago an exhaustive investigation of the subject of adulteration of beer, milk, and other aliments with salicylic acid, which is mainly added to prevent decomposition. They reported that its daily use in the quantities employed for preservation is not harmful to healthy persons, but if renal or hepatic disease exists it may become so, for under these conditions it is not promptly elimi- nated. Used in any considerable quantity, it in time produces anaemia, as.it does in rheumatism. Wiley found salicylic acid in seven out of ten samples of canned tomatoes bought in markets. Vaseline is sometimes used to adulterate butter for making pas- try and cakes. It does not become rancid, and is therefore difficult of detection. Fortunately, it is not especially harmful. TIN AND LEAD POISONING. Both tin and lead poisoning may occur from the prolonged use of preserved meats, vegetables, or fruits. In tin cans the lead is de- rived from the action of various organic acids upon the solder (which in this country is usually 50 per cent lead), and the tin used for coating the inside of the can eventually is dissolved in a similar manner (see also Canning, p. 257). Of late years attention has been directed to this subject by chemists, and a number of cases are reported from time to time of serious metallic poisoning. As a general rule, if the canning is properly conducted and the meats or vegetables have not decom- posed, there is no danger in their use provided they are thoroughly cooked, and provided also that the cans have not been kept too TIN AND LEAD POISONING. 359 long. The amount of tin dissolved is directly proportionate to the age of the contents of the cans. The food in cans that have been unopened for two or three years is very apt to produce poisonous effects (Dr. van Hamel Roos, Rev. Intern, des Falsifications, 4, 10, 179). Prof. Bettink declares that malic acid is the solvent of the tin when fruits and vegetables are canned. In 1880 Hehner examined many canned foods, and found tin pres- ent, in most of them as a stannous hydrate, which existed in sufficient quantity to be fatal when given to Guinea pigs. Ungar and Bodlander in 1883 reported a number of cases of poi- son from canned asparagus. Tin present in such food in an insoluble form may be dissolved and absorbed during digestion. Professor Beckurts reported at the Congress of German Physi- cians in Heidelberg, September 25, 1889, that a sulphate of tin is formed by the action of vegetable albuminoids or of meat albumin on the can. This is very liable to take place with canned asparagus, and two recent cases of severe poisoning of this nature have come under my personal notice. Violent gastro-intestinal symptoms oc- curred, such as severe vomiting and diarrhoea, accompanied by faint- ness and vertigo. The symptoms came on two or three hours after eating the asparagus from cans which had been kept for a long time. Johnson (in The Medico-Legal Journal, vol. iii, p. 53) reports cases of dangerous poisoning from eating tinned tomatoes which were accompanied by symptoms of violent gastritis, stupor,, and coma. Winckel reported to the Congress of Industrial Hygiene at Am- sterdam in September, 1890, that 270 soldiers had been made ill from eating lettuce and meat preserved in tins. In their cases it was estimated that the quantity of tin in solution was from 19 to 72 mil- ligrammes per kilogramme. Dr. Roos advises the coating of such cans on the inside with insoluble varnish, which prevents the albu- minoids or vegetable acids from coming in contact with the tinned surface and dissolving the metal. He found upon opening a can of asparagus preserved for thirty-one years that the inside tin coating was wholly dissolved in the liquid. A can of beef preserved for eight years, weighing 976 grammes, contained 77 milligrammes of oxide of tin, and a can of asparagus preserved only four months contained 11 milligrammes of oxide of tin and 6 of copper. Preserved apples, corn, apricots, meats, and soups have also all been found to possess the same solvent action upon tin cans. This is almost entirely pre- vented in those instances in which a coating of varnish has been put over the tinned surface. Pears cooked in a tin stewpan have been known to cause severe poisoning. 360 DISEASES CAUSED BY DIETETIC ERRORS. In 1883, 150 cases of severe metallic poisoning occurred among the soldiers of a Tyrolese regiment who ate food from a tin-lined copper kettle. In general, food cooked or allowed to stand for any length of time in either brass or copper vessels not kept absolutely clean is dangerous to life. VIII. Food containing Micro-organisms. Recent developments in the study of micro-organisms conducted within the past decade have demonstrated very clearly the dangers of infection upon a large scale from consumption of meat, milk, and other foods contaminated by the germs of infectious diseases. MILK INFECTION. Milk is an admirable culture medium for a great variety of germs, and some bacilli, like those of typhoid fever and tuberculosis, thrive particularly well in it. Moreover, its abundant and varied proteid material furnishes substance out of which to develop powerful toxines for absorption. The following are the chief diseases whose germs are capable of being sometimes conveyed by milk : Tuberculosis, typhoid fever, cholera, diphtheria, scarlet fever. Milk, and food in general, should never be kept standing in an ice box or cellar near an open or defective drain, as it becomes rapidly tainted in noxious air. TUBERCULAR INFECTION THROUGH MILK AND MEAT. Tubercular Milk Infection. This matter is of special impor- tance in regard to the danger of conveying tuberculosis to infants through raw milk. That this often happens is abundantly proved, and State boards of health in this country are everywhere endeavour- ing to secure proper legislative authority to inspect and condemn tuberculous cattle. Milk infected with tubercle bacilli when fed to animals has been shown to produce primary intestinal and mesenteric tuberculosis, and this is equally true of infants. Cow's milk may contain tubercle bacilli even when the disease is located in the lungs of the animal (Ernst). It is possible that this is the dase with the milk of tubercu- lar mothers, although it is not yet an established fact. The danger to the infant is less in such cases, for the disease in the mother is usually recognised in time to discontinue breast nursing. It has been estimated in regard to the Eastern States that 15 per cent of the common dairy stock is tubercular, and the " virulence is retained in cream and butter " (Osier). Stall-fed animals who live TYPHOID AND CHOLERA INFECTION. 361 in filthy barns and get but little exercise show the largest percentage of infection. In healthy adults the gastric juice may succeed in de- stroying tubercle bacilli swallowed with such food, and no doubt it often does so. Fortunately the milk of all tuberculous cows does not contain the bacilli, but it is almost certain to do so when the udders become involved in the disease. In infants who live largely upon raw milk, and whose gastric digestion is less vigorous than that of adults, mesenteric tubercu- losis is relatively more common. Tubercular Meat Infection. Tubercular meat usually proves less virulent than raw milk, probably because it is subjected to thorough heat in cooking, but all the bacilli are not invariably killed by imperfect cooking, and infected meat or milk should on no account be eaten. This fact is being gradually appreciated by the public, and meat inspection at abattoirs is now much better regulated j?y law and supervised by local health boards than formerly ; but Billings says that " probably one half of one per cent of the beef sold in market comes from animals in whom tubercle existed at the time of death." All slaughtering should be done in public abattoirs under compe- tent inspection, and not only should the animals be examined before killing, but the meat should be inspected afterwards. The Bacillus tuberculosis has been found not only in the meat or muscle of the animal butchered, but in the liver, kidneys, and other viscera. It has also been seen in peripheral caseous nodules grow- ing upon fowls (Sibley), and barnyard fowls have been known to eat tuberculous sputum carelessly expectorated within their reach. Other Infections. Meat from animals dead of various acute diseases is sometimes eaten, and if well cooked it is usually harmless, but it is not good food, and no part of any animal suffering from the foot-and-mouth disease (or cattle plague), rabies, glanders, actinomy- cosis, anthrax, septicaemia, swine plague, sheep or cow pox, pneumo- nia, trichiniasis, or tuberculosis should ever be eaten. TYPHOID AND CHOLERA INFECTION. Typhoid infection is undoubtedly conveyed through milk which has been diluted with water infected from a barnyard well or cess- pool, or which has been placed in cans rinsed in such water. Mr. Hankin (Indian Medical Gazette, 1894) describes cases of this fever derived from eating dahi, a curdled milk made by Indian confec- tioners. Over two hundred cases from milk infection occurred at Stam- ford, Conn., in May, 1895. Typhoid infection through contaminated drinking water has been already mentioned (page 31). Even brushing the teeth with such water or using it as ice may convey the bacilli into the body. 362 DISEASES CAUSED BY DIETETIC ERRORS. INFECTION WITH TYPHOID-FEVER GERMS THROUGH EATING OYSTERS. An epidemic of typhoid fever occurred at Wesleyan University in the latter part of November, 1894, which affected only certain stu- dents to the number of thirty, who had attended college-society sup- pers and ate raw oysters. A very thorough investigation was made by Prof. H. W. Conn (Medical Record, December 15, 1894) into the aetiology of the epidemic, and the following account of it was pub- lished in the New York Times on November 20, 1894: " The investigators at first ascertained that neither the water of the college well nor the milk supply had been the agent of infection. Six college societies had given initiation suppers. All of the oysters eaten at these suppers had come from one dealer, who had obtained them from one oyster grower. At three of these suppers raw oysters were served, and all of the thirty victims had partaken of the oysters in this condition ; no one of those present at the other three sup- pers, where only cooked oysters were served, was attacked by the disease. These facts indicated that the germs of typhoid had been conveyed in the water and other matter which accompanied the raw oysters. How had that water and other matter become infected ? "The oyster grower, who lives on the shore of the Quinnipiac River, a stream which flows into New Haven harbour, had been in the habit of laying down his oysters for a day or two in the river, after taking them from the deep salt waters of the Sound and before putting them on the market. At about the time when the first cases appeared at the university his wife died of typhoid fever. His daughter had been ill with the same disease. The oysters which were sold to the students had been bedded temporarily in the river at a point near the place where a short drain from his house dis- charges into the stream. The water became infected by the flow from the drain, and when the qysters were taken up the liquid and other matter which accompanies oysters so dislodged, either on the outside of the shell or inside of it, contained the germs of typhoid. Cooking killed these germs, but the raw oysters carried to those who ate them a dose of typhoid poison. It is reported that several recent cases of typhoid in New Haven have been traced to infection thus conveyed by oysters from the same river." It has generally been believed heretofore that typhoid bacilli do not develop in salt water, but the circumstantial evidence points, strongly to their having existed in the brackish water above de- scribed. Two fatal cases of typhoid fever have lately been reported in Berlin as due to infection from raw oysters. Sir William Broad- FOOD INFECTION THROUGH FLIES. 363 bent reported in the British Medical Journal ten cases which he saw during November and December, 1894, and attributed to the same origin. It is possible, although it is not definitely proved, that typhoid bacilli may be conveyed upon raw vegetables and fruits which have been washed in contaminated water. It is known that cholera germs are conveyed in all of these ways. From this reason, as well as from the necessity of avoiding diarrhoea, it is customary to advise against the use of all raw fruits and vegetables during the preva- lence of a cholera epidemic. DIPHTHERIA AND SCARLATINA. Diphtheria germs, and even those of scarlatina, can be conveyed in milk should they have access to it. Several epidemics of both diseases have been traced among families employing in common a milkman whose children at home had one or other disease. FOOT-AND-MOUTH DISEASE. The foot-and-mouth disease may be propagated from the use of milk from an infected cow. Sometimes this milk is of a bad taste and odour, or it may even be mixed with blood or pus if the nipples are excoriated or if the udders are inflamed. In other cases the milk appears normal, but when boiled coagulates readily into small flocculi in a bluish whey. Such milk is rendered innocuous by the process of boiling. Children are more apt to contract the disease in this way than are adults, owing to their greater con- sumption of cow's milk. FOOD INFECTION THROUGH FLIES. . The importance of preventing food infection through the agency of common house flies is just beginning to be appreciated. These insects are admirably adapted to convey infection from their great numbers and incessant activity, as well as their numerous feet, capacious intestines, their frequent evacuations, and disgusting habits of alighting and feeding upon sputum, manure heaps, and all animal discharges. When fed on tubercular sputum the bacilli have been discovered alive in their intestines, and cholera germs have been found adhering to their feet by which they are easily transported from a choleraic stool to a piece of bread or a raw fruit or vegetable, destined in turn to infect the first person who is unlucky enough to eat it. During the recent cholera epidemic in Hamburg Dr. Sim- monds found comma bacilli in the intestines of flies in the post- mortem room where dead cholera patients were examined. The bacilli remained one and a half hour in the flies time enough to be carried a long distance or to be widely distributed. When the matter 364 DISEASES CAUSED BY DIETETIC ERRORS. is further investigated it will doubtless be shown that other kinds of infection are often spread by the medium of these vulgar pests. Ordinary pus infection is readily carried by flies. IDIOSYNCRASIES IN REGARD TO FOOD. Idiosyncrasies are found to exist with some persons in regard to special articles of food, and these cannot be readil)^ explained. As a rule, if marked, they extend throughout life, but it is not seldom the case that some people pass through periods when a particular article of food disagrees with them which they have been previously able to eat with impunity. Some are unable to digest milk and are immediately nauseated or made "bilious" by it, while others cannot eat eggs, and yet can drink milk, while some cannot take either. Some can eat the white and not the yolk of eggs. Others, again, cannot eat fat in any form or are unable to digest some one variety of fat, especially hot mutton fat. Some few persons acquire a head- ache whenever they eat butcher's meat in excess. Among the com- moner idiosyncrasies of diet are the revolt of the system which occurs from the use of shellfish of all kinds, but especially lobsters, and from strawberries. Fothergill reported the case of a lady who all her life was unable to drink coffee, of which she was very fond, without having diarrhoea from it within an hour or two. Such idiosyncrasies are not infrequently hereditary, and may affect several members of one family. They are wholly independ- ent of ordinary dyspeptic conditions, and may be present in those whose digestive organs are exceptionally robust. X, Alcohol Poisoning. Alcoholism. Delirium Tremens. The position of alcohol as both a food and a stimulant has al- ready been fully discussed in connection with its physiological and dietetic action (page 209). alcohol poisoning. The effects of poisoning by alcohol differ according as they are acute or chronic, and according to the previous alcoholic habits of the patients. Habitual drinkers easily consume quantities of raw spirits which might prove fatal if drunk by one not inured to their use. Men have been known to drop dead a few moments after quickly drinking a pint or more of whisky on a wager. Alcohol when used to excess as a stimulant differs somewhat from ether and chloroform in the fact that its effects come on more slowly, as manifested by the increased mental excitement of intoxi- cation. The stage of insensibility and final stupor or coma develops later after slowly taking large quantities of alcohol, and is of longer ALCOHOL POISONING. 365 duration. Patients suffering from alcoholic coma are always in danger of heart failure from paralysis of that organ, which forms no excep- tion to the general rule that overstimulation of any muscle produces exhaustion and paresis. When in this condition, however, they are fortunately incapacitated from making any sudden or violent exer- tion, and in acute cases alcohol is eliminated with considerable rapidity from the various excretory organs of the body, especially the kidneys, in the form of waste matter, which it produces. The continued use of strong spirits, as well as the occasional use of alcohol in excess, almost invariably results after some time in the establishment of chronic gastric catarrh, which is characterised by the formation of thick, ropy mucus, thickening and hardening of the gastric mucous membrane, with atrophy of the gastric glands. There is always malfermentation with more or less acidity and heartburn and considerable nausea, especially in the morning, when the mucus or products of indigestion have accumulated overnight. There is also an increased production of connective tissue in the stomach wall. The effects of chronic alcoholism upon the alimen- tary canal are chiefly manifested in the stomach, although the intes- tine may share in the pathological changes. This is due to the fact that the alcohol reaches the stomach in a more concentrated form, and that being very diffusible it is absorbed in great part without entering the intestine. In addition to the local gastric catarrh and inflammation which it may produce, alcohol gradually alters various viscera, causing cir- rhosis of the liver, nephritis, chronic endarteritis, etc. In chronic alcoholism the intense craving for alcohol in any form tends to weaken and overcome the will power and debase the moral nature of the individual, and those who are afflicted by this habit very often drink periodically that is, the intervals between their excesses may be prolonged for one or several months, during which time they touch no alcohol in any form, and, indeed, in some cases they may have a positive loathing for it. The very sight of it nauseates them. The craving then returns and becomes so irresisti- ble that if they cannot obtain liquor they have been known to drink raw alcohol from spirit lamps or in any shape in which they can ob- tain it. The craving consists partly of a special appetite for liquor in the stomach, and in part of the general irresistible desire of the system, which is somewhat akin in its effect to intense hunger, al- though the effect on the will power is more disastrous. The evil results of excessive indulgence in alcohol are strikingly shown by its effect upon liquor dealers, the mortality among whom, from various diseases, as compared with that of other men, bears the ratio 3 to 2. When a similar comparison is made in regard to the mortality of liquor dealers from special diseases, the result is still 366 DISEASES CAUSED BY DIETETIC ERRORS. more striking; thus for liver diseases the ratio is 6 to i, for nervous diseases nearly 2 to i, and for alcoholism 5.5 to i. Dietetic Treatment of Mild Cases. In the milder cases characterised by nervousness, muscular tremors, indigestion, dys- pepsia, a foul breath, coated tongue, and urine loaded with urates or crystalline deposits, if the patient can be induced to stop all alcoholic drink and take abundant water or alkaline effervescing waters (Vichy, Seltzer, Apollinaris, etc.), together with a proper diet, much can be done to ward off an acute attack. A very good example of the appropriate diet is the following from Foods and Diet- aries : '^Breakfast. A lightly boiled Q.g%, or a little bit of whitefish or of bacon, or a light savoury omelet; toast, or bread and butter; a cup of weak tea or of coffee and milk. ''Early Dinner, i o'clock. A slice of roast mutton, or the wing of a chicken, or a plain cutlet, with a spoonful of mashed potato and some well-boiled green vegetable. A few spoonfuls of any plain milk or bread pudding, with occasionally some stewed fruit. Bever- age. A glass of plain or aerated water, to be taken slowly towards the close of the meal. ^'Afternoon. A cup of tea with milk may be allowed, with toast or rusk. ^^ Supper, 7.30. A light meal of fresh fish, or of bird, or of calf's head, or of tripe, with dry boiled rice or bread. Beverage. Small glass of milk and soda water.." In cases of periodic alcoholism, in which the patient has no crav- ing for drink between his attacks, it is best to recommend for the intervals a non-stimulating diet, avoiding condiments and richly cooked or highly seasoned food of all sorts. Fruits, plainly cooked cereals, and vegetables should constitute the staple diet, and animal food should be eaten only in moderation. In some of these cases overindulgence in food excites the crav- ing for alcohol. Dietetic Treatment of Severe Cases. The treatment of the severer cases, in which dyspeptic or gastro-intestinal symptoms pre- dominate, but in which delirium tremens is not necessarily present, is mainly that of gastric catarrh, described elsewhere. It must be adapted to the degree of inflammatory or cirrhotic changes which have already taken place in the different organs. The patients usu- ally feel much worse in the mornings, having nausea and vomit- ing or loathing for food, but later in the day they may recover considerable appetite and power of digestion. Advantage should be taken of this fact in feeding them. The following menu from Foods and Dietaries is very well adapted to this stage of chronic alco- holism : DELIRIUM TREMENS. 367 ^'Breakfast, say 8 o clock. A cup of weak tea with an t%g beaten up in it, and a slice of toast. " Second Meal, 10.30. A cupful of good meat soup, thickened, or a cup of peptonised milk, warmed, with toast or rusk. " Early Dinner, i clock. A tablespoonful of pounded meat on toast, or a small teacupful of fresh meat juice, with fingers of toast. A couple of spoonfuls of sago, custard, or tapioca pudding. Bever- age. WaXi a tumblerful of milk and soda water (equal parts). ''Afternoon Tea, 4.30. A cup of weak tea or of cocoa nibs, with rusk or a plain biscuit. ''Evening Meal, 7 o'clock. K cup of soup or of mutton broth, as at the forenoon meal. " 9.30 or 10. A cup of peptonised milk and a slice of thin bread and butter. " Eood During the Night. In case of wakefulness there should be within reach, and arranged so as to be readily warmed, peptonised milk." DELIRIUM TREMENS. Delirium tremens is a condition of active maniacal excitement which in its worst form is accompanied by intense general nervous excitement, muscular weakness, and hallucinations, chiefly of sight and hearing, of a terrifying or disgusting nature. Delirium tremens is sometimes excited by a temporary debauch, but as a rule this results in a condition of coma rather than maniacal excitement. Delirium tremens is much more characteristic of habitual alcoholism. In the earlier stages the heart action may be apparently vigor- ous and the pulse full and bounding, but the heart is very apt to be- come suddenly exhausted and cardiac failure is the chief danger to be feared. Dietetic Treatment. The indications for dietetic treatment are to make sure that the alimentary canal, which has been previ- ously disordered and congested, if not inflamed by the excessive irritation of strong alcoholic drink, is emptied of any accumulation of abnormally fermenting food. In the earlier stages brisk purga- tion or an evacuant enema should be given. If the stomach is over- loaded with improper food, free vomiting should be produced by ipecac, provided the condition of the patient is sufficiently vigorous to warrant this procedure. Large draughts of water, aerated and saline waters, should be taken to promote the activity of the kidneys and to dilute the poison in the system. The alimentary canal having thus been emptied of fermentation products, it becomes necessary to support the patient's strength with abundant nourishment. The appetite for food is usually entirely absent, being replaced by that 26 368 DISEASES CAUSED BY DIETETIC ERRORS. for drink, but the patient must be urged to take all the nourishment possible, and to this end it may be given in fluid form in smaH, fre- quent doses. The food should be stimulating and predigested. If there is much gastro-intestinal irritation, pancreatinised milk, strong meat soups, beef tea with dropped eggs added to it, and egg albumen may all be given. The mucous surface of the stomach has been long accustomed to the stimulating effect of strong alcohol, and if this be suddenly and completely removed, gastric discomfort and craving for drink become intolerable. This condition is often re- lieved by using strong spices or condiments, such as ginger or Cay- enne pepper, in quantities which would be injurious to a normal stomach, and might possibly produce gastritis. These substances may be added to food and non-alcoholic drink, although the stom- ach may be actually inflamed. Experience proves that highly sea- soned food is sometimes borne with the effect of diminishing the suffering of the patient. This applies, of course, only to very robust cases, in which an otherwise vigorous constitution has been abused by excessive indulgence in drink, and the gastric stimulant should not be long continued. In this variety of cases the quantity of food which the patient is encouraged to take need only be limited by the ability to digest it, for the digestive organs can be kept fairly active without being overloaded to the extent of exciting abnormal fermen- tation. The nervous system is always strengthened and soothed by abundant nourishment. Ginger ale constitutes a very serviceable non-alcoholic beverage, which in part relieves the craving for stronger drink. It may be drunk in considerable quantity, and it possesses the advantage of being somewhat laxative, diuretic, and mildly stimulating to the stomach. Care should be taken to obtain a pure article, as there is much inferior ale in market. It is well known that persons who for many years have indulged excessively in spirituous drinks are very apt to develop delirium tremens if taken suddenly ill, or if they sustain an injury such as a fracture, although they may have drunk no liquor for many weeks. In such cases the patient's life is in serious danger and it may be necessary to give more alcohol to maintain the accustomed influence. The conditions here to be met are very different from those resulting from an ordinary debauch, when liquor should be entirely with- held. PART VII. ADMINISTRATION OF FOOD FOR THE SICK. METHODS OF FEEDING THE SICK. General Rules. In no branch of her work can the nurse be of more service than in her ability to feed a very sick patient properly. There are many details which can only be mastered by extensive bedside experience and close observation, and so much depends upon tact and discretion, which can never be learned from text-books or lectures, that it is impossible to formulate rules for feeding which shall cover all cases; but the following suggestions will be found applicable in many instances. Miss Nightingale wrote that *' to watch for the opinions which the patient's stomach gives, rather than to read ' analyses of foods,' is the business of all those who have to settle what the patient is to eat perhaps the most important thing to be provided for him after the air he is to breathe." The Appetite. In judging of the patient's appetite it must be remembered that what is supposed to be a lack of desire for food is possibly due merely to defective cooking, to serving meals at inop- portune moments, or to selecting food which is not to his liking. There may be appetite enough for food, but not for the particular food offered, and it is the province of the nurse to differentiate such matters. She should not only save the patient from physical exer- tion, but from the effort of thinking as well. It is the function of the nurse to observe and record all the con- ditions of the patient's appetite, digestion, and likes and dislikes for different foods, and when her instructions have not been specific, or have not provided for emergencies, she should make it a point to have them understood at the next visit of the physician. A thorough practical knowledge of dietetics should be the foundation of the nurse's education, and this subject should receive much more attention in the curriculum of training schools than is at present bestowed upon it. The nurse has a far better opportunity than the physician to judge of the patient's appetite and study his whims and fancies in 869 370 ADMINISTRATION OF FOOD FOR THE SICK. regard to food, and she should not fail to report them and under- stand very positively from the physician in charge to what extent she is to be permitted to humour them and substitute one form of food or drink for another. Directions are apt to be given too ia- definitely to the nurse, and with the best intentions, from lack of instruction, she may neutralise the effects of medicines by overfeed- ing, or by irregularities in feeding which disorder digestion and in- terfere with the action of drugs, besides making the patient worse. She is often merely told to give " soft diet " or " fluid food," and she promptly resorts to milk and eggs, which may or may not agree and nourish. Or instead of such vague orders she may be directed to give only some one form of food, which she conscientiously does, offering it in spite of the patient's accumulating nausea and disgust, with the result of half starving him, because the physician has for- gotten to allow the nurse any latitude or discretion. Regularity in Feeding. The hospital nurse should be taught that it is as important to give food as medicines at regularly appointed intervals. Punctuality should be carefully observed in serving all meals to the sick. There is much unconscious habit in regard to eating, and an appetite which was ready at the accustomed hour of receiving food may vanish if the meal is delayed. It is well, when possible, to bathe the patient's face and hands before offering a meal. It is best always for the same nurse to have the charge of feeding a definite number of patients. If they are served by a different nurse at each meal it is much more difficult to report those whose appetites are defective or capricious. Quantity of Food. Among the first considerations is the proper quantity of food to offer the sick, and the extent of its dilution. Miss Nightingale has said that " an almost universal error among nurses is the bulk of the food, and especially of the drinks, they offer to their patients," and " it requires very nice observation and care (and meets with hardly any) to determine what will not be too thick or strong for the patient to take, while giving him no more than the bulk that he is able to swallow." By diluting milk, stimulants, and gruels too much, or making beef tea too weak, the quantity of the fluid is so great that the patient soon tires of swallowing, and stops before enough nourishment has been obtained. Predigested milk possesses the decided advantage that it aids the assimilation of the milk without adding to its bulk, as lime water and other substances do. When the appetite flags it is unwise to ask the patient each time beforehand what he would like to eat. It is often the unexpected which pleases. The smell of cooking and the noise of the prepara- tion of food should be kept from the sick-room. The nurse should never eat her own meals in the presence of the patienc. METHODS OF FEEDING THE SICK. 371 Details of serving Food. Hot food should be served very hot and cold articles very cold, for lukewarm food is unpalatable. In serving hot beverages or foods the cups or plates should be first well heated. Milk and butter should be kept cold and well covered. A simple refrigerator is easily improvised by placing a few large lumps of ice in a dish pan or pail kept by an open shaded window, and wrapping them in flannel to prevent evaporation. Patients may appear too ill to notice details, whereas they are often only too ill to speak of them, and a refined, fastidious, or nervous patient may have the appetite wholly destroyed by the carelessness of a nurse who tastes the food in the patient's presence or with his spoon, or who serves food with unclean hands. Untasted food, dishes after use, or half-emptied cups or glasses should never be left standing about the sick-room. Nothing is more uninviting than to have to drink from a glass to the sides of which stale milk is adhering. If there is any suspicion of the absolute freshness of milk, eggs, butter, or fish, they should never be served. It is equally important to make all food look inviting by offering it with the most attractive china which the house affords, and with only the cleanest of linen. Dishes should always be wiped dry on the outside, and pains should be exercised not to spill the con- tents of cups into their saucers. These may appear trivial details, but it must be remembered that the horizon of the sick-room is very limited, and a patient who has been long confined to bed with a serious illness thinks a great deal of his immediate surroundings. The taking of food is the chief event of the day for him, and too much care cannot be be- stowed upon the minutiae of service, while the natural stimulants to appetite such as fresh air, exercise, and enlivening companionship are necessarily wanting. When patients are able to partially sit up for their meals, the nurse should see that they have a comfortable position in the bed, and that the food tray does not cramp the arms or legs. The effort of sitting up may cause fatigue too soon and destroy the appetite before the meal is half done. As a rule, twice-cooked food should not be served to invalids. This applies especially to meat, fish, and vegetables. Whenever economy is an important consideration, it is better to cook but little food at a time, and serve it fresh and hot. Food is often made unpalatable by being too greasy, and this is one of the chief objec- tions to the use of meat broths, and mutton or chicken broth should always be several times skimmed before they are given, and blotting paper or a bit of bread can be passed over the surface to remove the last trace of oily substance. A chafing dish is invaluable for the convalescent from protracted illness. 372 ADMINISTRATION OF FOOD FOR THE SICK. When the dietary ordered is very limited in variety, the patient is often gratified by having his food served in "courses," and will eat more than if given everything at once. In other cases, when a patient is first allowed to sit up for half an hour or more beside the bed, it may be well to utilise this time for giving the principal meal of the day, which will be eaten with more relish, and perhaps better digested in consequence. Patients having nausea or other gastric disorder or diarrhoea should be given but little food at once. Small, oft-repeated feed- ings are best for them. As a rule, invalids need more salt, but less sugar, than those in health. When patients are being fed with fluids, wholly different recep- tacles should be used for holding their medicines, or the association of ideas may be strong enough to destroy what little appetite there is, and even to produce nausea. The nurse should always have a cheerful manner and a cleanly and tidy appearance, which contribute much towards the patient's appe- tite. She should never offer nourishment too soon after removing the vessels employed for the patient's discharges or evacuations, but should allow a proper interval to elapse, and let it be evident that she has thoroughly cleansed her hands. No form of perfumery should ever be used by the nurse. Bread crumbs should never be allowed to fall into the bed, especially of a helpless patient. When possible, it is well to divert the patient's mind from his ailments while feeding him by introducing some cheerful or inter- esting topic. Feeding Helpless Patients. In feeding helpless patients with fluids, if the head is to be raised, it should be done by placing the hand beneath the pillow and raising both together gently. This affords much better support, and is more comfortable for the patient, for the head is less likely to be bent so far forward as to interfere with swallowing. If a tumbler is used, it should always be small and not more than two thirds filled. An aver- age breakfast cup holds eight fluid ounces, and an average tea- cup six fluid ounces. A thirsty patient derives more satisfaction from draining a small glass than from sipping from a large one which he is not allowed to empty. The feeble patient should not be allowed to swallow during inspiration, and the nurse should be careful that each mouthful is swallowed before another is given, to prevent serious coughing. When a glass tube is used for feeding, it should have a flattened end to hold in the mouth, and should be bent near the centre at a slight angle, so that it is unnecessary to flex the patient's head. If feeding-cups with spouts are employed, they should be of glass, so that the nurse can see how much the patient is taking ; otherwise METHODS OF FEEDING THE SICK. 373 fluid is apt to be poured into the mouth in too large a quantity. As a rule, the bent tube is decidedly better to use when the patient has any power of suction at all. Even when he has not, the glass may be raised by the nurse, so that the fluid flows into the mouth with- out effort. The cup and tube should always be prevented from dripping. Sleep and Feeding. Patients need only be aroused from sleep to take nourishment in serious cases. Usually the ease with which a patient drops asleep should determine the necessity for awakening him. Sleep is often more beneficial even than food, but there are cases in which a patient awakens to take a sip of milk or a few mouthfuls of food, and will immediately drop off to sleep again. Such patients may be aroused for food every two hours if there is need, as there may be in typhoid fever. Some patients are annoyed by awakening at three or four o'clock in the morning, not being able to sleep again. Food of some sort should always be kept on hand during the night, and drinking a cup of hot bouillon or cocoa will often enable them to fall asleep again for two or three hours. Cleansing the Mouth. The patient's comfort is very depend- ent upon keeping a clean mouth, as indeed are his appetite and taste. A helpless patient whose mouth and lips are allowed to be- come parched and sour will refuse nourishment which he might otherwise gladly take. The mouth should be rinsed each time after eating with pure water, or diluted Listerine (two teaspoonfuls to the tumbler of water), or borax water of similar strength. It is much easier to keep the mouth clean in this manner than to disinfect it after it has been neglected. Milk especially lingers on the mucous surface, and, fermenting there, destroys the sense of taste and de- velops germs that interfere with digestion. When the patient can- not rinse his own mouth, it must be frequently cleansed by the nurse with a swab of fresh cotton fastened on a small flexible stick, such as a piece of splint, and moistened with the mouth wash. The best tongue scraper is made with a piece of whalebone, about nine inches long, bent into a loop. If this be applied before the patient's meals, the taste nerves of the tongue will be uncovered from the accumulated debris which coats them, and the appetite will be im- proved. Dry lips should be moistened with vaseline or cold cream, not glycerin. Cracked ice will keep much longer if not allowed to float in melt- ing water. The contact of a metal spoon or dish also melts it sooner, by virtue of the great conductivity of metal. A piece of cheese cloth, mosquito netting, or linen may be tied over a cup by an elastic band, and the fragments of ice split off with a pin may be laid upon the cloth, so that the melted fluid drains away beneath. 374 ADMINISTRATION OF FOOD FOR THE SICK. Disinfection of Utensils. All dishes or utensils used in serv- ing food to patients having syphilis, stomatitis, or diphtheria, or any infectious disease likely to be communicated through such means, should be boiled for at least an hour in water containing a few tea- spoonfuls of soda. Syphilitic patients, especially, should have their own set of food receptacles, spoons, forks, etc., properly labelled, to prevent any one else from using them. Feeding Unconscious Patients. The feeding of unconscious patients demands special care and skill. They should never be given anything but fluid nourishment, and this must be fed with a spoon or through a catheter. Sometimes, if the jaw is set, a medicine dropper may be utilised. Not over a teaspoonful should be given at once, and the nurse must make sure that it is swallowed before she repeats the experiment. It should be remembered that the mechanism of deglutition is not excited by one or two drops of fluid, but usually at least half a drachm is required to start this reflex. In feeding coma- tose infants or children with tubercular meningitis, apoplexy, etc., Fernete and Widerhofer advise pouring fluids into the nostril with a spoon rather than into the mouth. It disturbs the child less than does the effort to force open the mouth, and if the head is lying back the fluid trickles down the posterior pharyngeal wall. Any excess of fluid is returned through the other nostril. There is no greater dan- ger of choking when fed by this method than by the mouth. It is usually better, however, to use a soft catheter with a funnel attached to the free end. The catheter is oiled or dipped in vaseline or butter, and passed gently through the nostril down into the oesophagus, or, if desired, into the stomach. Before pouring any fluid into it through the funnel it must be made certain that the patient is breathing easily, and that the tube has not made a false passage into the larynx. Such an accident is very rare. This topic will receive further atten- tion in connection with Lavage. Gavage, or feeding with the stomach tube, is described under that heading. Nasal feeding is employed sometimes for gavage in young infants, in feeding children with diphtheria, or the insane, who may refuse food or resist the passage of a tube through the mouth by biting, and it may be used when the mouth is sore from ulceration or the effect of corrosive poisons. The process is described in connec- tion with Gavage. When patients are living upon "teacup diet," or broths and gruels, it is a common mistake to give them a diet which is either too low in carbohydrates or deficient in proteid. The proper proportions to be prescribed, unless there is some special indication for the con- trary, will be appreciated by a comparison of the following table, compiled by Mrs. E. H. Richards, and those previously given on page 265. METHODS OF FEEDING THE SICK. 375 A Common Invalid Ration too Low in Carbohydrates (Mrs. Richards). I pint of beef juice, containing 7 per cent . . I pint of whole milk 1 quart of flour gruel made with whole milk 2 quarts of liquid. Total Proteid. Grammes. 31-5 17.0 18.2 66.7 Fat. 18.0 18.2 36.2 Carbo- hydrates. Gramtnes. 22 38 60 Calories. 129.0 325-5 397-9 852.4 Nutrient Enemata. Rectal Absorption. That all mucous membranes are capable of absorbing certain materials from their surfaces and passing them into the blood vessels or lymphatics has long been recognised ; but it is only of comparatively recent years that this knowledge has been applied extensively to the purpose of nourishing patients by means of the rectum, and the fact is now established that sufficient aliment may be absorbed from the mucous membrane of the rectum or sig- moid flexure alone to sustain life for a considerable period, amount- ing in some cases to from four to seven weeks. Moreover, the rectum may be utilised for accessory feeding for many cases in which the stomach is able to digest some food, but not in sufficient quantity to prevent emaciation. Whenever rectal food enemata are employed certain principles should be observed : 1. The rectal surface must be cleansed from all mucus and faeces. 2. The irritation of the rectum should be allayed as far as pos- sible. 3. The quantity and quality of food thus administered should be so regulated as to avoid exciting peristalsis, and yet allow of the complete absorption of one injection before another is given. The minutest details which will secure the best conditions for absorption should never be regarded as too insignificant. Some patients find the idea of rectal feeding very repulsive, and dislike to submit to it ; but with a little tact and perseverance their objections can usually be overcome. conditions necessitating rectal feeding. The conditions which may require the use of rectal feeding are these : I. Temporary obstruction to the entrance of food into the ali- mentary canal. Rectal feeding must be resorted to until the ob- struction such as the presence of new growths and foreign bodies, or inflammatory conditions with swelling in the mouth, pharynx, or oesophagus can be overcome. 376 ADMINISTRATION OF FOOD FOR THE SICK. II. Inability to swallow food from coma, delirium, or paralysis affecting the mechanism of deglutition, as, for example, post-diphthe- ritic paralysis. III. Extreme irritability, pain, acute inflammation or ulceration of the upper portion of the alimentary canal, such as that excited by corrosive poisons like carbolic acid, ammonia, etc. IV. Stricture occurring in any part of the alimentary canal above the rectum. . V. Prolonged reflex vomiting, such as may occur in pregnancy and seasickness. VI. Gastric ulcer, for the purpose of resting the ulcerated surface and allowing it to heal. VII. Cancer of the stomach with inability to absorb or digest sufficient food, especially with obstruction to either the cardiac or pyloric end of the organ. VIII. Any form of severe gastric irritation, such as occurs in acute gastritis. IX. Exhausted conditions of the system which may be present during the course of severe fevers in which absorption of even pre- digested food is largely, suspended. X. For the insane who refuse food by the mouth. XI. To supplement the action of a feeble stomach, or when for any reason, such as total lack of appetite, emaciation is rapidly pro- gressive. Hunger and Thirst during Rectal Feeding. These symp- toms are not necessarily present after the first day or two of rectal feeding. In an obstinate case of gastric haemorrhage in which abso- lutely nothing not even water was given by the mouth for more than a week, I questioned the patient in regard to her sensations of hunger and thirst, and she told me that they were entirely relieved after the first twenty-four hours' use of nutrient enemata. The mouth and tongue were not dry, and she did not lose weight during this period. I have been told the same thing by other patients. An interesting case was reported by C. W. Brown, of Washing- ton (Food, vol. iv. No. 8, 1894, p. 337), in which a patient suffering from carcinoma with ulceration of the pyloric end of the stomach was supported for forty-three days upon exclusive rectal nourish- ment consisting of from four to six ounces of beef tea and milk, which were given on an average once in three hours, with the occa- sional addition of laudanum and a little whisky. During an interval of improvement which followed the exclusive use of injections, the patient was able to take some food by the stomach, though not enough to satisfy the cravings of hunger and prevent a feeling of faintness ; but these symptoms were overcome by giving four nutrient injec- tions day and night in addition to the milk taken by the stomach. METHODS OF FEEDING THE SICK. 377 Method of Injection. The common practice of giving nutrient enemata by a Davidson syringe with a short hard-rubber or steel nozzle is always to be condemned. In the hands of an unskilful nurse, irritation and sometimes haemorrhages are likely to be pro- duced in this way, sooner or later. In commencing the use of rectal alimentation, especially in cases which manifest much irritation of the lower bowel, it is important to employ a long, soft, flexible rubber catheter or rectal tube which can be passed well up, for eight inches or more, to the sigmoid flexure. In selecting the tube, one should be chosen which is not so flexible that it is liable to bend or double upon itself, but which is not so stiff as to give pain or damage the mucous membrane if it happens to catch in a fold of its surface. For children a No. 12 or No. 14 ordinary " velvet-eyed " flexible catheter may be used, and passed up as high as the sigmoid flexure. For adults the tube should be of moderate calibre, not exceeding the diameter of a stout pen handle. The tube or catheter should be dipped in sweet oil, melted butter, or vaseline; but glycerin must not be used, for it excites peristalsis. In adults the tube should be passed in for from ten to twelve inches, for the injection should be plaqed as high up as possible. When this is done there is less liability to its rejection, and it is brought in contact with an extensive mucous surface. There is a further physiological or anatomical reason for placing the injection as high up as may be, in the fact that the sigmoid veins and those returning the blood from the upper rectum communicate with the inferior mesenteric vein, while those from the lower third of the rectum communicate with the inferior vena cava. Consequently, whatever is absorbed by the wall of the inferior third of the rectum passes into the inferior vena cava without going to the liver, but that which is absorbed higher up is returned to veins whose contents reach the liver directly through branches of the vena porta. It is in the liver that the further digestion and assimilation of proteid material takes place in great part, and hence the desirability of ob- serving this rule for injection. It was found by Brown, in the case above cited (page 376), that the patient was able to discriminate between the taste of iodide of potassium and ergot, etc., in from a quarter to half an hour after these medicines had been given /^r rectum. The same phenomenon has been noticed from the injection of such substances directly into the stomach through a gastric fistula, and it is due to their ready absorption and conveyance in the blood to the taste bulbs in the tongue or to the saliva, in which fluid the iodide of potassium is promptly excreted. According to some observers, under the best conditions not over one fourth of the necessary nutriment can be absorbed from the 378 ADMINISTRATION OF FOOD FOR THE SICK. rectum (Bauer). Such a statement should be considerably modified, for, as a matter of practical experience, many patients may be kept alive and gain slightly in weight upon the use of nutrient enemata, when they are intelligently given. If injected but a short distance into the intestine, the absorbing surface is so limited that compara- tively little material is taken up ; but if given in the manner pre- scribed above, through a long catheter inserted high up, much more will be retained, and the benefit derived from such injections will be enhanced. The injection should be applied by means of a small hard-rub- ber syringe, which need not hold over two ounces. Very little force should be used, and the patient must be told not to strain. After the syringe is filled, by holding it vertically nozzle uppermost and pressing it until the fluid exudes from the nozzle, all air is excluded. When a Davidson syringe is used for the purpose of injecting small quantities of fluid, it very often happens that air is drawn into the syringe in addition to the materials of the enema, which, when in- jected, is very apt to excite peristalsis and evacuate the bowel. The use in unskilful hands of a funnel or fountain syringe for filling the tube is open to the same objection that air is likely to enter the rectum. In any case it is well to fill the tube with the injection fluid before it is inserted. When the enemata are given in gynaecological or obstetric cases, it should be remembered that tight tamponing of the vagina may interfere with absorption from the rectum. Aids to Retention. Upon withdrawing the tube, if there is danger that the injection will not be retained, a soft compress or folded towel should be pressed up firmly against the anus for twenty minutes or half an hour. The retention of the enema is aided by placing the patient in a proper position. He should lie, if possible, upon the left side, with the hips raised high upon a pillow, and the injection should be given very slowly and carefully. The "Sims" gynaecological position is the best, but with the hips more elevated. Temperature of Injections. All food enemata should be given moderately warm, at a temperature of 90 or 95 F. They are less apt to excite peristalsis than if administered very hot or very cold. Number of Injections. The question of how many injections can be given must depend upon the irritability of the rectum. It can never be used like the stomach, and it is advisable to begin by ordering an enema only once in six hours. If the rectum is in good condition the number may be increased to one every four, or even every three hours. In exceptional cases or for emergencies small injections, not exceeding one and a half ounce, may be given once METHODS OF FEEDING THE SICK, 379 in two hours ; but if repeated at such brieiifmervals, they are almost certain to excite irritation. CARE OF THE RECTUM. When it is important that nutrient enemata should be continued for some time, the exact condition of the rectum should be ascer- tained by the physician, and the most minute directions should be given to the nurse. The matter is not infrequently left to an attend- ant, who is wholly ignorant of the proper conditions to be observed, and failure is sometimes reported when a little intelligent attention bestowed upon details would overcome all difficulties. As already stated, many cases have been recorded in which patients have been nourished exclusively by nutrient enemata for several weeks, and it is an important fact that the rectum may acquire a certain degree of toleration for them. For the first few days they may be rejected, but when correctly prepared and adminis- tered they will soon be successfully retained. But it is only in the most favourable cases that rectal alimentation can be long continued without eventually producing irritation and diarrhoea, and in the majority of instances this is likely to occur after two or three weeks. The enemata must then be discontinued, but may, if necessary, be resumed again after a brief interval. The presence of haemorrhoids is a serious drawback when the use of rectal feeding becomes imperative, and care should be exercised not to irritate or inflame them by the passage of the catheter or nozzle of the syringe. In such cases it is necessary to use only a very soft and flexible catheter, and to allay irritation by the topical application of a 2-per-cent solution of cocaine. Whenever nutrient enemata are employed for a long time the rectum should be thoroughly evacuated and cleansed, at least once a day, by flushing with a copious injection of warm soapsuds and water, amounting to two or three pints, immediately after which a food enema should be given. The cleansing enemata may be given through a double or single catheter. If a double catheter is preferred, a larger quantity, two or three quarts, of water may be advantageously given, and a few grains of common salt should be added to each injection. If the rectum is irritable, and much mucus coats its inner surface, it may be well to add boric acid to the water. The injection washes out any particles of waste matter or remains of a previous nutrient in- jection, cleanses the mucous surface, stimulates its circulation, and prepares it for better absorption. Opium in Enemata. Opium, while it prevents peristaltic ac- tion and favours retention of the enema, may also tend to interfere with its absorption. It is consequently to be avoided, if possible, *80 ADMINISTRATION OF FOOD FOR THE SICK. but when irritation of the rectum exists it becomes necessary to in- ject a little laudanum. Ordinarily, three to four minims is sufificient, but ten, or even twenty, may be required in some cases. This dosage must not be often repeated. Its effect, of course, should be watched^ and it must not be given too freely. If nutrient enemata are con- stantly employed it is sometimes found that a larger dose injected by a small hard-rubber syringe half an hour or an hour before giv- ing an enema allays the irritation more completely than if the opium is given in one of its constituents. Injected by itself, the quantity of opium is so small that it does not excite peristalsis, but is absorbed, and its local action is obtained before the larger bulk of fluid in the enema is injected. In other cases it is sufficient to give the laudanum in very small quantity, five or six minims with each enema. Instead of laudanum, the deodorised tincture of opium or McMunn's elixir may be used. SUBSTANCES AVAILABLE FOR RECTAL FEEDING. Of the different classes of foodstuffs, there are some which are absorbed readily by the rectum, while others are scarcely taken up at all. To the latter class .belong starches and most of the fats. Those starches which are predigested and partially converted into sugar may be absorbed to a very limited extent, but not sufficiently to add to the nutrition of the body. Maltine may sometimes be ab- sorbed. Fats and oils not only remain unabsorbed by the rectum, but they prevent the absorption of other foods by coating either the mucous membrane or the food itself, and are therefore worse than useless. Attempts have been made to give them saponified or finely emulsified, prepared with pancreatin or otherwise, but it is doubtful if even under these circumstances enough of any form of fat or oil can be taken up to be of practical bene'fit in rectal feeding. It is exceedingly important to use -only materials which will be as completely absorbed as possible. Anything else acts as a foreign body, and in time proves more or less irritating. Moreover, it is- found that many albuminous materials which are absorbed from the surface of this portion of the intestine become irritating if given in too concentrated a form, such as pure peptone, and they must be diluted to two or three times their volume with water or some bland fluid. Some forms of albumin are undoubtedly absorbed from the mucous membrane of the rectum without predigestion, such as the albumin expressed from chopped meat or egg albumen, but it is much better to at least partially pancreatinise it. Pancreatinised Meat. In preparing proteid food for absorp- tion one of the forms of pancreatic extract or pancreatin may be used. Extracts of pancreas are open to the objection that they do not keep very long, and unless perfectly fresh they are apt to prove METHODS OF FEEDING THE SICK. 381 irritating, and glycerin extracts cannot be used in any quantity on account of the aperient action of the glycerin itself. To overcome these difficulties, Leube suggests using the fresh pancreas, which is to be added in the proportion of one part to three of beef. Both the meat and the pancreatic gland should be scraped or thoroughly minced and rubbed into a paste with a little warm water. Any fat should be carefully removed. The pulp thus obtained is to be injected by means of a suitable syringe with a rather wide nozzle. The idea of using this combination is that the digestion, which is begun out- side, is continued within the rectum, and the products are gradually absorbed. Leube claims that this form of nutrient enema may be retained for ten or twelve hours, and that it is very rarely irritating. He sometimes adds egg albumen and even fat to the mixture. It has been advised to inject hydrochloric acid into the rectum with beef solutions as well as with milk, but this process is too irri- tating, and all artificial digestion should be completed outside of the body. Blood. Dried beef blood has sometimes been used as a rectal food, but there is no evidence that it is absorbed. In those cases in which I have employed it it has usually caked within the rectum and prevented the absorption of other materials. Fresh defibrinated blood has also been used for the same purpose four ounces may be given every six hours but it possesses no advantage over predi- gested milk or peptones, and is not to be recommended. Milk. Pancreatinised milk in which the process of predigestion has not been carried too far is, on the whole, one of the most satis- factory foods which can be used by rectum. It should not be rich in cream. Eggs. Egg albumen is also one of the best ingredients of nutri- ent enemata. It is absorbed unaltered to some extent through the rectal mucous membrane, but it is better that it should always be predigested by the use of a peptogenic or pancreatinising power. The whites of two eggs may be added to peptonised milk, or, better, to peptone solution or one of the meat extracts. Ewald, who has experimented extensively with rectal alimentation, states that un- peptonised egg albumen is absorbed as promptly from the rectal surface as commercial peptone, while peptonised egg albumen is taken up even better. The absorption of the albumen is furthered by the addition of a little table salt to the injection about fifteen grains to each egg but this is sometimes irritating to the rectum. The yolk of egg is not recommended for rectal use, for although it contains albuminous material, so much fat is mixed with it, which is not absorbed excepting by the intestinal villi in the small intes- tine which are expressly constructed for the purpose, that it is practi- pally useless. 382 ADMINISTRATION OF FOOD FOR THE SICK. Alcohol. The alcohol used for rectal injection should be in the form of good liquor, somewhat diluted. If pure alcohol is given, it should be diluted in three or four parts of water, when it becomes less irritating to the mucous membrane and is more easily ab- sorbed. Very often a small injection of half an ounce of whisky in an ounce and a half of water, or even an injection of whisky, brandy, or sherry and water given alone, will be retained and com- pletely absorbed, when a larger volume of fluid or other ingredients added to the alcohol will not be retained, and the whole enema will pass out again. Rum may be used, or brandy, but, as a rule, good whisky is the most serviceable. When alcohol is given in connection with other rectal foods, it may be unnecessary to dilute it with water, but undiluted whisky sometimes causes precipitation in milk. If added too strong it coagulates casein which has not been pan- creatinised, and no solid matter, even in the form of a fine precipi- tate, is of much use in the rectum. Such an injection simply acts as an irritant. PRESCRIPTIONS FOR FOOD ENEMATA. Pwald recommends the following : Beat the whites of two eggs with a tablespoonful of cold water, add a teaspoonful or two of starch boiled in a half teacupful of a 20-per-cent glucose solution, a wineglassful of claret, and a teaspoonful of peptone solution. Mix at a temperature below the coagulation point of the albumen. Yeo prescribes expressed meat juice, egg albumen, and peptones. Leube prefers the mixture of scraped meat and fresh pancreas made into an emulsion, as prescribed above (page 381). Roberts gives milk gruel and beef tea, with two teaspoonfuls of liquor pancreaticus freshly mixed. He reports a case in which he sustained the patient's life for nine weeks upon this treatment alone. FOOD SUPPOSITORIES. Rectal food suppositories are sometimes made of predigested and evaporated or condensed forms of milk or meat juice, which are mixed with oil or cacao butter and pressed into an elongated bougie- or suppository. They sometimes prove useful, and are certainly con- venient, but they possess no real advantages over nutrient enemata, and if the use of rectal feeding is to be long continued, the latter are found more practical. Inunction Foods. Attempts are sometimes made to get nourishment into the body by means of inunction through the skin, and olive oil, cod-liver oil, and cacao butter are rubbed into the integument of the abdomen MEDICINES AND FOOD. 383 and thighs. This means is naturally only employed in cases of ex- treme emaciation from wasting diseases, such as carcinoma, maras- mus, and phthisis. It has proved mainly useful with marasmic infants, but it is doubtful whether it possesses any true value beyond the advantage of lubricating a dry and shrivelled skin, and retaining some of the body heat in case of great feebleness. Intravascular Feeding. In extreme cases of collapse, where death has seemed imminent, nutrient injections have sometimes been given directly into the veins. Of late years, however, it has been shown that in collapse from haemorrhage, or from loss of fluid in the evacuations of Asiatic cholera and cholera morbus in infants, salt-water injections answer as well, and have the advantage of being much safer and easier of application. Hodder was the first to practise the intravenous injection of milk in 1850 for collapse from Asiatic cholera, and T. G. Thomas was among the first to inject warm milk into one of the veins of the arm. He reported one case in which eight ounces of milk adminis- tered in this way saved life. Both goat's and cow's milk have been so used, but the milk must be rendered alkaline. Down reports similar success. Fowler tried intravenous injec- tion of peptone solution, and has given as much as six ounces of a digested beef solution in this manner. The peptone does not reap- pear in the urine, but the casein of milk does, as well as solutions of sugar or albumen when injected into a vein. Some of the oil cells in milk have greater diameter than the capillaries, which might prove a practical objection to the injection of unskimmed milk. Hypodermic Feeding. Feeding in cases of desperate exhaustion by hypodermic injec- tions of milk and of peptone solutions has been several times at- tempted, but the results, beyond the use of alcohol by this method, have not proved sufificiently satisfactory to warrant its continuance. MEDICINES AND FOOD. Too little attention has been bestowed upon the mutual relations of food and medicines. So little is really definitely known of the intricate chemistry of digestion and assimilation that it is difficult to formulate rules for the right time of giving every drug in rela- tion to fulness or emptiness of the stomach. The reaction of the stomach contents varies from alkaline to neutral and acid, and these several reactions will decompose medicines in various ways. Besides 27 384 ADMINISTRATION OF FOOD FOR THE SICK. this, the reactions themselves are dependent upon a large number of organic acids, salts, and other substances which may wholly alter the composition of a medicine at one time, and not be present to affect it at another. A drug given after a full meal may be decomposed by the strong hydrochloric acid of active digestion, which is unaltered in an empty stomach. Conversely, remedies which are not themselves influenced by the gastric and pancreatic juices may affect these secretions as synergists or the reverse. Chittenden says: "Take, for example, the influence of such substances as urethan, paraldehyde, and thallin sulphate on the proteolytic action of pepsin-hydrochloric acid, and we find that small quantities (o.i to 0.3 per cent) tend to increase the rate of pro- teolysis, while larger amounts, say one per cent, decidedly check proteolysis. Similarly, among inorganic compounds, arsenious oxide, arsenic oxide, boric acid, and potassium bromide in small amounts increase the proteolytic power of pepsin in hydrochloric-acid solu- tion, while larger quantities check the action of the ferment in proportion to the amounts added. Again, with the enzyme trypsin, similar results with such salts as potassium cyanide, sodium tetra- borate, potassium bromide and iodide may be quoted as showing not only the sensitiveness of the ferment towards foreign substances, but likewise its peculiar behaviour viz., stimulation in the presence of larger quantities. Furthermore, we have found that even gases, as carbOnic-acid and hydrogen-sulphide, exert a marked retarding in- fluence on the proteid-digesting power of trypsin." These gases, being a product of intestinal malfermentation, may thus interfere with digestion. Hydronaphthol and bismuth salicylate retard gastric digestion. Sodium bicarbonate and other alkalies check pyrosis in chronic gas- tritis, which is caused by diminished hydrochloric-acid secretion, but increase pyrosis subsequently, because of the greater alkalinity pro- duced, which favours the growth of lactic-acid organisms. Accord- ing to Leffmann and Beam, beta-naphthol stops the action of diastase, but not that of the amylolytic ferment of pancreatin, hence it is use- ful as an intestinal antiseptic without wholly stopping digestion. It, however, retards proteid digestion. They also state that salicylic acid and saccharin both prevent the amylolytic action of diastase and of pancreatin, but do not retard proteid digestion. These few examples are sufficient to illustrate the very diverse influence of some of the common drugs. The following rules are subject to many exceptions, but they will serve as a general guide : medicines and food. 385 Rules for administering Medicines in Relation to Food. 1. Alkalies are best given shortly before meals, unless designed to neutralise hypersecretion of hydrochloric acid. 2. Acids should be given within half an hour after meals, 3. Bitters should be given before meals. 4. Remedies such as iron and arsenic, which may prove somewhat irritant to mucous membranes, should be given either soon after the regular meals or after taking some simple article of food. Ammo- nium carbonate and potassium iodide, for example, may be pre- scribed in milk. This also modifies their disagreeable taste. 5. Most cough medicines, cardiac tonics, diuretics, and systemic remedies which are not especially irritating to the stomach should be taken between meals. They will be more promptly absorbed from an empty stomach, and are less liable to be altered in composition by digestive fluids or to inhibit digestion. 6. Remedies designed to act in the intestine and not in the stomach, such as salol, should be given at the end of gastric diges- tion, when the stomach contents are about to pass into the intes- tine. 7. Saline laxatives should always be taken at least half an hour or an hour before meals, preferably before breakfast ; but the stronger, more slowly acting cathartics should be given on an empty stomach at night. Cod-liver oil should be given an hour and a half after meals, or on an empty stomach before retiring. According to Whitehead, starchy food should be avoided while iodine preparations are being administered, because of the insoluble compound likely to be formed of iodine and starch. Syphilitics, he says, should therefore eat meat and light green vegetables only, in order to get a maximum effect from the remedy. If they are taking very large quantities, such as half an ounce or more a day, this may be advisable, but it is unnecessary for ordinary cases. Foods and beverages may be often used to disguise the taste of disagreeable or bitter medicines, especially for children. An un- pleasant dose may often be smuggled down in a teaspoonful of jam or a little molasses, and quinine is somewhat disguised by mixture in chocolate lozenges. It may be given in solution to adults in cof- fee. Castor oil is given floating on coffee or beer. Both milk and Vichy partially disguise the taste of potassium iodide. Milk is an excellent vehicle for powders, such as bismuth, mag- nesium carbonate, or sulphonal. Many bitter medicines may be fol- lowed by a lump of sugar or a strong peppermint lozenge, or the mouth may be rinsed with a little brandy and water. Chocolate is 386 ADMINISTRATION OF FOOD FOR THE SICK. also a good vehicle for the administration of bitter medicines, and it may be employed to emulsify cod-liver oil. DIET-KITCHEN OUTFIT. When a case of protracted severe illness occurs in a household it is very convenient to improvise a small diet kitchen in a room next the patient's bedroom. The outfit should consist of the following articles, in addition to the usual receptacles for containing the food : A spirit or gas lamp kept ready to heat a porcelain- lined sauce- pan at any time, day or night. A double porcelain-lined saucepan for a hot-water bath. A cooking thermometer for use in hot fluids. A measuring glass to hold six or eight ounces. Pancreatin powders. A bottle of rennet ferment. Sodium bicarbonate, two or three ounces. Borax, half a pound (to clean utensils). A glass funnel. A meat-mincing machine. A good chafing dish, although not necessary, is highly desirable. TRAINED PURVEYORS OF FOOD. The training of food purveyors for hospitals, asylums, and other institutions has only quite lately received the attention which it de- serves, and hospital managers are awakening to the fact that it is truly economical to employ a skilful trained buyer who understands something of food values, dietetically as well as pecuniarily, and who studies the conditions of the market at different seasons of the year in order to secure variety of food at a minimum cost. To meet the constantly increasing demand for such persons, the Pratt Institute, of Brooklyn, has this year opened a series of three-months' courses for both men and women, which are to cover the following topics: (i) The selection of food material as to quality, food value, and cost. Marketing and buying by sample. (2) Methods of prepara- tion in a large way and by appropriate apparatus. The care of food, cold storage, etc. (3) Serving, embodying general dining economy, labour-saving appliances, etc. Field work, visits to public kitchens, and manufactories of kitchens, and hotel furnishings. PART VIII. DIET IN DISEASE. DIET IN INFECTIOUS DISEASES. DIET IN FEVER IN GENERAL. The general principles of the dietetic treatment of the condition of fever which accompanies many different diseases are conveniently studied collectively, while the special modifications of diet required for certain infectious fevers will be considered under their several headings. The cardinal principles of feeding the sick involve, first, the avoid- ance of all articles that disagree with the condition present, and sec- ond, the giving of the food best adapted to relieve the digestive or- gans of unnecessary labour and to maintain nutrition. In addition, for certain special diseases there are classes of foods which have dis- tinctly curative value for example, the use of fresh fruits and vege- tables in scurvy, fats and oils in scrofula and tuberculosis. Although there is no curative food for fevers, it should be remembered that there is nothing so easily assimilated as water, and advantage must be taken of this fact to introduce other foods into the body with it, giving them therefore in fluid form. Pathological Physiolog^y of Fever. The former treatment of fevers by starvation and depletion, on the theory that the poison of the disease was soonest conquered by withholding all food and drink upon which it might thrive, and starving out "a devouring flame of inflammation," has long been superseded by more scientific methods. This early treatment culminated in France in the first part of this century, and was first combated in England by Graves and his successful followers. It is now known that in fevers by supplying the patient with abundant nitrogenous food the tissues of the body are spared from consumption in other words, that the proteid matter of the food is burned up or oxidised instead of the proteid matter of the patient's muscles and other structures. The animal food thus given does not add to the substance of the tissues, but saves them from wasting and combustion. 387 388 DIET IN DISEASE. Bauer believes that "the gravest possible injury to the organism of the fever patient may be brought about by a diet too rich in albu- minates," and to some extent carbohydrates and gelatin may be sub- stituted for them, yet he adds that while "an exclusive use of albu- minates is undesirable. ... In fever a larger relative proportion of albuminates is requisite than in health, and so much larger as the albuminous metabolism is greater." Fever patients commonly excrete much more nitrogen than they take in as food. In so doing it is believed that they first exhaust whatever reserve supply may be on hand in the food proteids pre- viously absorbed and circulating in the blood, and subsequently draw upon the tissues, just as is the case in starvation. The urea daily eliminated during fever may exceed by forty or fifty grammes the normal amount voided in the urine during health, and this may be the case even when no food is given ; hence the waste increase is mainly nitrogenous (Bauer). In chronic fevers with remissions, like tuberculosis, there is less rapid waste than in the continuous forms, such as typhoid. If the digestion remains fairly good in any fever, the loss of body weight is proportionately checked. Voit suggested the theory that the tissues act somewhat after the manner of gland cells, and normally attract such albuminous sub- stances as they need without themselves undergoing any serious change, and Bauer believes that this hypothesis may be applied to the consumption of proteids in fever, " that under those conditions which the febrile processes bring with them the tissues yield up to the circulation a larger proportion of their own albumin, and that an abnormal amount of materials for metabolism is thus presented to the cells." The organs meanwhile lose proteids faster than in ordinary starvation, but by the same processes. A single albumi- nous meal adds more proteid to the circulation, which in starvation would aid in restoring equilbrium ; but in fever it fails to do so, and the loss continues because the inflamed cells have for the time being lost their power of assimilation. Emaciation therefore proceeds. Another theory which has been strongly advocated, but which, on the whole, has less to recommend it, is that the inflamed cells consume and destroy proteid material from the blood at a much faster rate than in health, and supplying a purely proteid diet does not check the waste. The entire question is exceedingly intricate and difficult of solution. The experiments which have been made in febrile metabolism are somewhat contradictory, and it is undoubtedly better to be guided at present by the results of clinical experience in feeding fever patients than by theoretical formulae. This subject is physiologically very closely related to the paren- chymatous and fatty degenerations of organs which attend many dis- eases, but it is impossible within the practical limitations ot this DIET IN FEVER IN GENERAL. 389 work to enter into this discussion, and the reader is referred to a very able presentation of these theories in the chapter upon Con- sumption in Febrile Disease by Bauer in his Dietary of the Sick (Handbook of General Therapeutics, v. Ziemssen). Leyden and Frankel believe that in fever more fat as well as more albumin is consumed than in health, but other authorities think that fat destruction does not keep even with albuminous waste. In fever the secretion of hydrochloric acid is diminished or sus- pended in the stomach, and its peristaltic action is so lessened that the food Is apt to remain longer than it should and undergo mal- fermentation, causing oppression or pain, nausea, and vomiting. Absorption also is much reduced in fevers. The stomach may wholly give out, and, as Roberts observes, it becomes merely a con- duit, so that the intestine must carry out the work of digestion unaided. Dietetic Treatment. The conditions to be met in the dietetic treatment of fever are as follows : 1. To save tissue waste by supplying sufficient nourishment. 2. To give semisolid or fluid nourishment in a form which will not overtax the enfeebled digestive apparatus or leave a large residue for decomposition. 3. To give abundant fluid with the object of relieving thirst and to wash out through the kidneys the waste matter produced by the increased rate of metabolism. 4. In some cases, to give alcohol as a food as well as a stimulant. In all fevers presenting periods of remission it is desirable to give the greater portion of the food while the temperature is lowest, so that it will be better digested and absorbed, for at this time the tissues appear to temporarily recover their assimilative power to some extent. In mild cases, with remissions, if the appetite holds out, it may do no harm to allow some little variety in the diet; but if the fever is brief and the appetite fails, it is unnecessary to force the patient to take food. As a rule, in fevers which are protracted or severe, nourishment should be given in fluid form. To offer solid food in serious fevers is practically to place foreign bodies in the alimentary canal which merely ferment and putrefy, causing discomfort with flatus, fetor, and diarrhoea. There are some exceptions to this, notably the fever of phthisis, some forms of protracted sepsis, and ague. Milk being the first and " natural food " of man, it would seem most appropriate that it should constitute the staple article of diet in fevers in which the digestive powers are temporarily greatly en- feebled or wholly suspended. The danger from its continuous and exclusive ^se arises from its coagulating in lumpy masses, which act -QQ DIET IN DISEASE. practically as solid food, but the many means which are at the disposal of the physician and nurse make it possible to overcome this difficulty almost completely, and by processes of artificial diges- tion milk may be given ready for absorption, so that nutrition is rendered quite independent of stomach and intestinal digestion. In the majority of cases, therefore, milk is altogether the best food. The methods of giving it have been described in the section upon Adaptation of Milk for the Sick (page 62), and the reader is also re- ferred to the section upon the Treatment of Typhoid Fever (page 398). Next in importance to milk in the diet of fever are to be men- tioned the various preparations of meat infusions, extracts, juice, powder, broths, etc. (page 96). The fundamental idea of all such preparations is the solution of the nutritious myosin of the muscle fibres and its separation from the much less digestible sarcolemma and the connective tissue constituting the sheaths of the muscle fasciculi. These preparations may be made from tender veal, chicken, roast beef, and beefsteak. Clear soups or consommh are nu- tritious and mildly stimulating in fevers, but if given often or in large quantities patients are very apt to tire of them, and they may be considerably varied by flavouring with vegetable juices and extracts or aromatic herbs, which afford variety, and as a rule do no harm, unless exhausting diarrhcea be present. Buss gives the following mixture to fever patients : Peptone, 100 ; grape sugar, 300; rum or Cognac, 200; water, 600 grammes the quantity to be taken in twenty-four hours in addition to milk, yolk of egg, bouillon, etc. If this food is too sweet, tincture of gentian is added. Purees may be given, made by thickening clear soup with well- cooked arrowroot, or finely ground rice, or thoroughly baked wheat- en flour. Bauer recommends the use of " fruit soups," which are prepared by boiling fruit, either fresh or dried, with the addition, if desired, of grape sugar, lemon peel, etc. The mass is then com- pressed and strained, and the fluid obtained has an agreeable taste and somewhat laxative action. In cases of moderate severity and shore duration, when the di- gestive organs are not greatly disturbed, it is not necessary to con- fine the patient to fluids, although solid food, especially meats, should be withheld. Semisolid food may be given, such as milk toast, cream toast, soft-cooked eggs, beef jelly, or plain rice pudding. Thoroughly boiled oatmeal gruel sustains strength while undergoing severe physical toil, and fever has some resemblance to muscular effort in its temporary arrest of digestive activity, so that sometimes substances of this class prove useful from their supporting power. Many other varieties of farinaceous and other carbohydrate foods are suitable in febrile cases when carefully prepared in fluid form. DIET IN FEVER IN GENERAL. 391 Patients often object to these substances for the reason that they are tasteless and monotonous, whereas if prepared with a little care, by giving proper attention to their flavouring, they may be made very palatable. Thin gruels of rice, oatmeal, or barley, from which all solid matter has been very carefully removed by straining through a cheese-cloth bag, may be salted and flavoured with any desirable aromatic, such as cinnamon, clove, nutmeg, lemon or orange peel ; grape sugar may also be added. Such gruels may be prescribed either alone or combined with meat extracts, or beef tea, or beaten eggs. The addition of grape sugar has been recommended by See and others because of its ready absorption, and from the fact that it is the form of sugar which is produced from the digestive fermen- tation of starches, and is to be regarded, therefore, as an easily as- similable carbohydrate which, to some extent, may prevent tis- sue waste by furnishing fuel to the body. If a patient be fed upon clear farinaceous gruels alone during fever, he cannot thus obtain over eight or ten grammes of proteid material per diem, or one twelfth of the quantity required by a healthy man at rest, and obviously he will suffer within two or three days from tissue waste and inanition. Egg albumen, meat broths, or gelatin must therefore be added, or the soups must be thickened. Eggs may be eaten, but they should never be boiled, and in fact they require but little cooking. They may be beaten with boiling water and strained and dropped into consomm^ or light broth or gruel. The yolk and the white may be used either separately or together. The yolk may be beaten with hot milk and water, or with hot tea sweetened with grape sugar (Yeo), or it may be added to brandy. The brandy mixture of the British Pharmacopoeia (mistura spiritus vini gallic;, Br. Ph.), is made as follows: The yolks of two eggs with half an ounce of refined sugar are beaten and added to four ounces of Cognac and an equal amount of cinnamon water. The brandy in this mixture may be still further diluted or reduced to advantage. Some patients prefer to take eggs raw, while others prefer to have them very slightly cooked by immersing them in water which has been boiling thus cooking them very slowly at a temperature not exceeding 180 F. for ten or fifteen minutes. Eggs prepared in this way are uniformly and lightly cooked, and the al- bumen is coagulated in a soft gelatinous mass instead of the hard, white, tough coagulum which is produced by greater heat (see page 90). Cold meat jellies as well as simple sherry wine and lemon jellies may occasionally be given, but gelatin alone is not particularly nu- tritious, and, in proportion to the bulk occupied by this class of foods, comparatively little benefit is derived from them. .Q2 I>IET IN DISEASE. Gelatin given with other foods, especially those of proteid com- position, is assimilated much better, and makes a desirable addi- tion to the dietary in mild cases. When added to milk in the form of blancmange patients usually enjoy it. Beef tea and chicken jelly in equal parts make an excellent com- bination. Beverages in Fevers. The Value of Water and Other Beverages. In almost all febrile affections the liberal use of water, or some beverage com- posed chiefly of water, is to be recommended both for the relief of thirst and on account of its diluent effect and of its increasing the facility with which the waste matter resulting from the rapid metab- olism of the fever is eliminated through the kidneys. A dry mouth destroys the appetite. It is believed by many that the toxines pro- duced by the action of typhoid-fever germs or other micro-organisms are rendered less powerful and are in some degree " washed out " of the system by the imbibition of large draughts of water. Patients who are extremely feeble, or who are not wholly rational, may not ask for drink although their mouths are dry and parched, and it should always be the duty of the nurse to give water in proper amount at regular intervals. In long-continued fevers there is a tendency for an increased loss of water from the surface of the lungs, and sometimes from the skin, although the kidneys may be less active than normal, and if care is not taken to replace the fluid in the body the effects of this loss become much more pronounced. If there are profuse watery evacuations from the bowels the drain of fluid from the blood, and eventually from other body tissues, is considerable. Sour lemonade constitutes one of the most useful and refreshing beverages. It is not particularly apt to disorder the stomach, espe- cially if taken in the intervals between the ingestion of food, and to many persons it is exceedingly grateful. It may be made efferves- cing by the addition to a strong lemonade of Vichy, carbonic-acid water, soda water, or ten grains of sodium bicarbonate. Barley and rice water with a little lemon juice and sugar, or with cinnamon, wine, and sugar, afford refreshing drinks to many persons, especially children, but they contain very little nourishment. Either tea or coffee may be allowed once a day in many cases of fever, al- though this fact is often overlooked. Tea should be avoided if there is marked indigestion in the stomach, and coffee as well as tea should be avoided in cases where there is insomnia or excessive nervousness. If there is flatulency they should be given without sugar, and not with other food. Many persons who object to the taste of milk will often take it contentedly if a tablespoonful of good coffee be added to the tumblerful. Strong black coffee, moreover, is useful in controlling DIET IN FEVER IN GENERAL. 393 vomiting, and is mildly stimulating in cases-of heart failure. Its diu- retic action is also valuable in fever, but it should be remembered that persons who are not ordinarily disagreeably affected by the daily use of strong coffee may be made very nervous by even small quantities given when the system is reduced by the wasting processes of fever. Both tea and coffee should be used, therefore, with discretion, al- though they may at times prove valuable in relieving the monotony of a fluid diet. Other useful beverages are whey, or whey and beef tea, either hot or iced, and unfermented grape juice. For the immediate relief of thirst cracked ice may be given, but it sometimes parches the lips. Some patients prefer a glycerin mixture. A drachm or two of glycerin and half a drachm of borax or boric acid may be added to a tumbler of water and used to rinse the mouth. By sipping fluids, thirst is more relieved than if they are quickly drunk. There is more satisfaction in being allowed to drain a small glass than in merely taking a few mouthfuls from a large tum- blerful. The question of the temperature at which milk or any form of beverage should be given in fevers may safely be left, in most cases, to the liking of the patient. I have elsewhere shown (page 308) that the body temperature can be but little if any affected by that of in- gested fluids, and it is a matter of far more importance to give them in so agreeable a form that they will not be refused. An excess of cold drinks may embarrass digestion or cause stomach cramps, and should be avoided, but any cold fluid slowly sipped will do no harm. Alcohol as a Food in Fevers. The principal theory of the action of alcohol in all fevers is that it serves as a food; it is readily absorbed and carried in the blood to all parts of the body, and it is believed that its combustion saves in some degree the wear and tear of the tissues, as the alcohol burning in a spirit lamp furnishes energy in the form of heat, and itself be- comes oxidised to waste products, but spares the carbon of the wick. The latter is not itself burned up or oxidised until the alcohol has been exhausted. Another theory of the use of alcohol is that it possesses a positive antipyretic action by which it controls the body tempera- ture by restricting heat production. It is also believed that alcohol in fevers acts upon the nervous system, strengthening and support- ing it, in this manner indirectly controlling the nerve currents which preside over the activity of nutrition, chemical change, and heat pro- duction. The subject is a very broad one, and is obscured by the lack of definite knowledge as to the exact nature of the chemical processes concerned in heat production, which are probably very DIET IN DISEASE. complex. It is possible that in many instances alcohol may act si- multaneously in all the ways suggested, having the combined effect of a food, a nerve tonic, and an antipyretic. This view is ably advo- cated by Dujardin-Beaumetz, who gives an exhaustive discussion on the subject in his work on alimentation in fevers (Du Regime Alimentaire dans les Maladies Febriles, page 227). Light white wines, diluted claret, and even beer are recommended in fevers by some writers on dietetics, especially in those countries in which good water is unobtainable, or in which for other reasons wine drinking is in much more common daily use than it is in Amer- ica, where there is an abundant supply of pure water. In France and Germany light red wine is frequently allowed throughout the course of mild fevers, and from five to ten ounces are given daily. The fever diet in the Munich General Hospital includes 150 to 300 grammes of light red wine or white wine. Beer is also much used in Germany for fevers, and it contains some nourishment. If alcohol is not required for its stimulating effect upon the cir- culatory or nervous systems it is better to withhold it, for in con- tinued fevers emergencies may at any time arise in which it is impera- tively demanded to strengthen the failing powers or aid in controlling the exhaustion of delirium. Its influence will always be more de- cided and its action can be much better controlled if spirits have not previously been given, and when it is needed for any such reason it is best to prescribe it in the form of brandy or whisky. In general, it may be stated that alcohol is usually needed if the temperature remains for several days above 103 F., and is always required if it remains as high as 105 F. The typhoid condition supervening in the course of any fever always demands it i. e., the condition characterised by great prostration, low muttering delirium, subsultus, rapid feeble pulse, dry tongue, etc. In the convalescence following prolonged fever the daily use of liquors with meals, or in the form of toddy or punches between meals, two or three times a day, is often indicated. This is particu- larly the case among elderly people convalescing from pneumonia and other acute febrile diseases or who have been greatly weakened by some prolonged adynamic disease. In infancy also, and early childhood, the use of alcohol may be demanded in the course of acute fevers. Persons who have been habitual though moderate drinkers for many years, or throughout their lives, when attacked with any severe acute or infectious disease possess less vitality and resistance than those whose tissues have not been constantly bathed in alcohol. To withhold the long-accustomed stimulation in these cases is often to precipitate serious exhaustion, and the problem of properly adapting DIET IN FEVER IN GENERAL. 395 the quantity of alcohol to the patients' actual needs becomes a very serious one to the physician, to which he should give careful and thorough study. Caution should be given against the continued use of alcohol by patients in whom there is danger of inducing the alco- hol habit. It not infrequently occurs that* those who have been addicted to excessive drinking, but who have been temporarily cured of the habit, and who have taken no liquor for possibly several years, acquire some acute disease in which there is need of active stimulation. In such cases, having in view the possible recovery of the patient, with a renewal of his alcoholic habit, this stimulant should be withheld as long as possible while efforts are made to sus- tain the enfeebled heart power by strychnine, digitalis, or diffusible cardiac stimulants, such as ether, ammonium carbonate, aromatic spirits of ammonia, camphor, etc. From the above account it appears that the question of the use of alcohol in all febrile disorders should be considered from two chief standpoints, embracing, first, its value as a food, with its relation to other foods and to nutrition ; second, its value as a stimulant and the extent to which it may be replaced or re-enforced by drugs. The continued use of strong alcohol always disorders digestion, and since the stomach is weakened in fevers, it is more susceptible to such influences, and this is an additional argument for not employing alco- hol in a routine method, but for saving it for positive indications, such as asthenia. But in those cases in which the battle for life must be waged largely with stimulants as much as one ounce an hour (twenty-four ounces/^/- diem) of brandy or whisky must sometimes be given, and it is a curious fact that in the presence of high fever patients can often tolerate such dosage without the indications of alcoholic poisoning which in health would promptly follow the use of a smaller quantity. Diet in Convalescence from Fevers. Convalescents who have long subsisted wholly upon fluids must be careful in resuming solid diet, for the rapidity of recuperation of the digestive organs varies very much in different persons, and taking meats or other solid foods too soon may cause rise in temperature, rapid heart action, and possibly visceral congestion. The first meat given, therefore, should be in a finely subdivided state, such as scraped beef or minced chicken. During convalescence from protracted fevers the more easily di- gested forms of starchy foods are found to be very useful, especially if there has been much loss of weight. Sago and tapioca thoroughly cooked and served with cream are highly nutritious, and dried bread crumbs rolled through a fine sieve may be added to thicken clear meat broths. Crackers and Zwieback are useful. 396 DIET IN DISEASE. Other ingredients which may be added to thicken soups during convalescence are panada, semolina, tapioca, and macaroni. Cus- tard puddings, cooked fruit, wine and beef jellies, blancmange, or baked custard may be allowed. Mush, fine hominy, cornstarch, farina, and boiled rice, with beef juice, can be ordered. The following dietary will serve as a general guide for feeding convalescents from fevers of ordinary severity in which special lesions of the alimentary canal are not present. It is taken from a Handbook of Invalid Cooking: ' FIRST DAY. *^ Breakfast. Poached t%% on toast. Cocoa. ^^ Lunch. Milk punch. *^ Dinner. Raw oysters. Cream crackers. Light wine if desired. *^ Lunch. One cup of hot beef broth. " Supper. Milk toast. Wine jelly. Tea. "SECOND DAY. ^'Breakfast. Soft-cooked &g%. Milk punch. Coffee with sugar and cream. ''Lunch. One cup of soft custard. ^^ Dinner. Cream-of-celery soup. Sippets of toast. A little bar- ley pudding, with cream. Sherry wine if desired. ''Lunch. Milk punch. " Supper. Water toast, buttered. Wine jelly. Tea. "THIRD DAY. ^^ Breakfast. Scrambled ^gg. Cream toast. Cocoa. ''Lunch. One cup of hot chicken broth. "Dinner. Chicken panada. Bread. Light wine if desired. A little tapioca cream. " Lunch. An eggnog. ' Supper. Buttered dry toast. Baked sweet apples and cream. Tea. "FOURTH DAY. " Breakfast.~Kn orange. Oatmeal (H. O.), with cream and sugar. Poached egg on toast. Baked potato. Cocoa. " Lunch. One cup of hot soft custard. "Dinner. Potato soup. Croutons. A small piece of beefsteak. Creamed potatoes. Baked custard. Coffee. "Lunch. One cup of chicken broth, with rice. " Supper. ~^di^ oysters. Banquet crackers. Graham bread, toasted. Wine jelly. Tea. TYPHOID FEVER. 307 "FIFTH DAY. '^ Breakfast. hx^ orange. Coffee. Oatmeal, with cream and sugar. Broiled mutton chop. Toast. ^^ Lunch. One cup of mulled wine. "Z)/^r. Chicken soup. Bread. Creamed sweetbreads. Duch- ess potato. Snow pudding. Cocoa. " Lunch. Siphon soda, with coffee sirup and cream. " 6'//^r. Buttered dry toast. Orange jelly. Sponge cake and cream. Tea." A further discussion of this topic will be found in the section upon Convalescence in Typhoid Fever. While brandy and whisky constitute the best form in which to give alcohol in the acute stage of fevers, in convalescence it is often advisable to use some other alcoholic drink, and an occasional change from one variety to another renders the patient somewhat less liable to the danger of acquiring a permanent alcoholic habit. For convalescence, if the patient's purse can afford it, champagne, port wine, sherry, Madeira, or a good claret or Burgundy, may be taken with advantage in the class of cases above mentioned. TYPHOID FEVER. Pathological Physiolog^y. Careful nursing and diet regula- tion are the life-saving agents in typhoid fever. In few diseases does a closer relation exist between right feeding and symptoms. In average cases the fever lasts a month, no matter what the treatment, whether by cold bathing or otherwise, while in some it continues for five or even six weeks. There is then a convalescent period of at least two weeks, and often as many months, during all which time constant care in feeding must be exercised. At any time during the prevalence of the fever the slightest departure from the strict rules for diet laid down by the physician may determine a fatal issue, but it is during the period of ulceration that the greatest danger is met. The ulcers involve the Beyer's patches and solitary follicles in the lower end of the ileum, but they may extend into the jejunum, and even into the large intestine. They are deep and clean-cut, often including the whole thickness of the muscular layers, and some- times perforating through the serous layer. An overloaded intes- tine or a distended bowel may precipitate perforation at any mo- ment. It is therefore important to select a diet which will leave but small residue. More or less intestinal as well as gastric catarrh is often present, interfering with both digestion and absorption. 393 DIET IN DISEASE. The prolonged fever is itself a menace to life by the secondary changes which it induces in the alimentary system. The digestive secretions are altered in quality and lessened in quantity. En- feebled circulation retards or inhibits absorption, and the functional activity of the liver is in abeyance. Poisonous products suspended in the blood, as well as its ele- vated temperature, interfere with the normal rate of metabolism through the body, and finally the excretory organs are overworked. Dietetic Treatment. There are two chief factors which should influence the selection of a proper diet for typhoid fever. These are: i. The supposed danger of mechanically irritating the ulcerating surfaces in the intestine and the danger of overloading an intestine and stomach whose digestive functions are impaired by fever. 2. The relations of the chemical ingredients of the food to the increased tissue change that causes or accompanies the excessive production of heat. If the proper fuel can be furnished as food, the tissues are spared too great self-consumption in producing heat. Milk Diet. In regard to the first factor the danger of mechan- ical irritation of the intestinal wall is somewhat exaggerated. In prescribing a milk diet for typhoid fever in order to lessen this danger many overlook the fact that undiluted milk, on entering the stomach, becomes almost solid, and large firm milk curds are likely to prove quite as irritating to the ulcerating surfaces, or even more so, than are starchy foods. When patients are fond of milk and digest and absorb it thor- oughly, there is no better diet for typhoid fever, and it answers every requirement of a fever food. It contains all the essential elements of nutrition, is easily digested, furnishes fluid to the tis- sues, is a good diuretic, and, if properly administered, in many cases it is soothing to the stomach when a mild degree of gastric catarrh exists. Those who dislike milk at first may later grow accustomed to it and take it contentedly for a month or even six weeks. Due emphasis should be given to the fact that an exclusive milk diet need not and should not be prescribed in routine for all cases. Within the past few years a number of writers have advocated a departure from the strict milk diet which had come to be the rule for typhoid fever, and it is found beneficial to enlarge the dietary of some patients considerably. It is much easier to put all hospital cases of typhoid fever on a routine, milk diet, but it is often better to devote a little study to securing suitable variation in the food. In typhoid fever every effort should be made to maintain good stomach digestion. If all food is thoroughly disintegrated before it TYPHOID FEVER. 399 enters the intestine there need be little fear of a mechanical irrita- tion of the ulcerating surfaces. Far more danger may occur through malnutrition of the intestinal wall, which prevents absorp- tion of nutriment. An accumulation of undigested food in the intestine is therefore highly undesirable, and the stools should be periodically examined to see that undigested milk curds do not appear in them. Milk for some persons in health is really a poison. They com- pletely fail to digest it. It causes constipation with clay-coloured or white stools, and fills the bowels with products of malfermentation, ptomaines, and gases. They digest it even less when they acquire a prolonged fever. Others, with whom the milk agrees, become very tired of it after taking it exclusively for several weeks at a time. I have several times seen cases of typhoid fever with symptoms which resembled scurvy, with swollen and bleeding gums and great emaciation, occurring in patients who had been fed too long upon an exclusive milk diet which they failed to assimilate. Quantity of Milk required. If milk is the oply food, enough should be given, and the problem of what constitutes enough must be solved in each case separately. Much harm is done by overfeed- ing, which induces indigestion and restlessness, increases the pulse rate, and aggravates the abdominal symptoms such as tympanites, diarrhoea or constipation, haemorrhage, and abdominal pain. Inges- tion is very different from digestion. There are many writers upon dietetics who give a special cau- tion against the practice of overfeeding in cases of enteric fever on account of the fact that more or less gastric catarrh is usually pres- ent and that it is an undue tax upon the digestion of the patient to have to deal with a large bulk of food. On the other hand, underfeeding causes malnutrition, favours the occurrence of complications, and prolongs convalescence. For an exclusive milk diet the outside limits lie between one and three quarts /^r ^/V'w, depending somewhat upon the age and size of the individual, but more upon the condition of his digestion. A clean tongue, a soft abdomen, and natural milk stools, not too hard and without coagulae of casein or flakes of fat, indicate that the milk is being well digested. The reverse of these symptoms suggests that the milk is supplied in too large quantity, or that it is not being digested, and one or more of three things must be done: (a) The quantity must be re- duced; (/^) the mode of administration must be changed i. e., the milk must be " prepared " or " predigested " ; (c) other foods must be substituted, either wholly or in part. {a) When milk appears to be well digested, but the patient 28 .QQ DIET IN DISEASE. emaciates rapidly early in the disease, he is not getting nourishment enough, and the quantity must be increased or other food must be added. As a general rule, from one and three fourths to two quarts of milk per diem (or six ounces every two hours, day and night), however diluted, is sufficient during the height of the fever to sus- tain the patient properly. It is best to give as much as can be thoroughly assimilated according to the symptoms above noted. Johnston believes that from three to four ounces of milk given every two or three hours is sufficient. Moore states that very few patients digest over one and a half to two pints of milk, and " it is scarcely ever necessary to exceed the amount of one quart of milk in the twenty-four hours," or three ounces of milk in ten feedings at intervals of two and a half hours. This estimate, for uncomplicated cases at least, is too low. It may be necessary to reduce the allow- ance to .this figure if severe gastro-intestinal disturbance occurs, or, in fact, with violent vomiting to temporarily discontinue the milk entirely, and give only cracked ice or half-ounce doses of iced cham- pagne, but patients kept too long on as low a diet as that mentioned will emaciate, grow feeble to an alarming degree, and require exces- sive stimulation. {p) The milk may be given raw, boiled, diluted with plain water, barley water, lime water, Vichy, Seltzer, or ApoUinaris, or pancreatin- ised according to taste and need. Gelatin, as well as gum arable, is sometimes added to milk to dilute it and prevent tough curds from forming. The milk should never be skimmed. Its taste may be dis- guised by the addition of a little strong coffee or some of the extract of coffee, or a little caramel makes it agreeable to the taste where patients have refused it before, or it may occasionally be preferred with a cup of cocoa in which the milk predominates. If diarrhoea is present, a milk diet is especially useful, and the milk should be boiled. When vomiting occurs, it is better to use peptonised or pancre- atinised milk than soda or lime water, for the latter tend to neu- tralise the activity of an already enfeebled gastric juice. These fluids may be given either hot or cold, according to taste. If cold, the nausea is sometimes controlled, but digestion may be somewhat retarded. If the vomiting is very obstinate, koumiss, kefir, or mat- zopn may be given for a time with very good result in place of milk. Whey or buttermilk is also used sometimes for a change for a few days. Loomis recommended from four to six quarts of the latter/^/- diem. {c) Substitutes for Milk Diet. When milk is obviously dis- agreeing and producing flatulence, I have often seen improvement follow an entire change of diet for a day or two to animal broths. Similar results are familiar in the treatment of infantile diarrhoea. In cases like those above described in which, after fair trial, it is TYPHOID FEVER. 401 found impossible to urge upon the patient the taking of milk, there is no objection to giving strained broths of mutton, chicken, or beef a little clam broth for a relish, and light farinaceous articles, such as the prepared starchy foods, like Mellin's or Nestle's, barley water, farina, arrowroot, and other gruels, custards, eggnog, or a piece of Zwieback softened by soaking in milk, weak tea, or bouillon. I have recently used gruel made from banana meal, which is palatable, highly nutritious, and easily digested (see page 164). Junket and cream are very nutritious and agreeable to the palate. Egg albumen can be made very palatable by beating it with a little milk and sherry. In this manner considerable variety is secured for the patient; the appetite, and in many cases the digestion, are improved, and by alter- nating one or more of these articles with the milk, a much larger quantity of nourishment will in the end be taken and absorbed Layton estimates that typhoid patients may sometimes lose half a pound in weight per diem, and in that class of cases in which rapid emaciation is a most alarming feature of the disease these various adjuncts to the milk diet are especially useful. Moreover, patients fed in this manner are not apt to become ravenous during convales- cence. It is well expressed by Henry that "it is not so much solid as in- digestible food that should be eschewed, and it should never be for- gotten that all foods except such as are predigested are solid in the first stage of digestion." A pint of milk contains as much solid material as a mutton chop. The continued use of beef tea, beef juice, or meat extracts and peptonoids undoubtedly produces loosening of the bowels, and such substances must be avoided when diarrrhoea is present; but in cases where there is a tendency to constipation this may be a decided ad- vantage. Veal and chicken broth are much less apt to have a laxa- tive effect than beef and mutton broth, and calf's-foot jelly is allowed by some clinicians. When patients tire of the taste of beef tea or broth it may be flavoured with a little celery salt or, if there is no diarrhoea, with a very little tomato juice or other simple vege- table extract. Henry advocates the use of gelatin as an "albumin sparer," although it should not be given if diarrhoea is present. As much as a claret-glass full may be given on alternate days, and it can be in the form of simple blancmange or peptonised milk jelly, which is made by adding while hot gelatin dissolved in a little water to peptonised or pancreatinised milk, and flavouring with lemon or orange and sherry or rum. It is eaten cold. In the stomach it is quite as fluid as predigested milk. Farinaceous Gruels. I have alluded to the occasional advan- tage of giving farinaceous gruels, for, despite the fact that many writ- .Q2 DIET IN DISEASE. ers are opposed to them on the ground that they may excite tympany, I believe them to be at times of great service. Stromeyer feeds his patients largely upon oaten grits boiled for three hours without sugar. Da Costa recommends giving three pints of milk and one pint of broth every twenty-four hours, with a midday allowance of some gruel, such as arrowroot. There is a variety of enteric fever in which without any noticeable complications, and even without a very high temperature curve, emaciation is rapid and extreme. In such cases especially the use of farinaceous gruels is indicated. They must not be given too sweet, and a little cream or lemon juice may be added in lieu of sugar. It is often advisable to add a tablespoon- ful of malt extract, or one of the "prepared foods," such as Mellin's, Horlick's, Ridge's; or malted milk may be given in milk. Sleep and Food. In all cases of typhoid fever the question arises in regard to waking the patient at night for nourishment, or to take the temperature. Some patients awaken easily, are fed, and drop off to sleep again almost immediately. They may be fed every two hours day and night. Others, if awakened, do not readily fall asleep again, and lose half the night's rest or more, and this may considerably, retard their recovery. It is sometimes best to let them sleep for three, or even four, hours without being aroused, for the rest may be of more value to them than food. So much depends upon the temperature, pulse, and general condition of each case that no rigid rule should be formulated, but it is best never to let four hours pass while the fever lasts without giving food. If patients are told that they have a little longer interval than usual in which to rest undisturbed, they will sometimes go to sleep at once. Of course, if they sleep during the day there is less need of post- poning feeding by night. Constant drowsine'ss may indicate a need of more food. The nurse should always furnish a daily record of the exact amount of milk or broths actually given in twenty-four hours, making allowance for dilution, and this should be compared with the quantity of urine voided. Thirst. Thirst is a prominent symptom in enteric fever, and cool water should be given in abundance by the nurse, without wait- ing for the patient to ask for it. Water favours nutrition and the elimination of waste. If diarrhoea is absent it is well to acidulate the water with a little dilute phosphoric or hydrochloric acid, ten or fifteen drops to the tumblerful, or water flavoured with infusion of orange or serpentaria. Hoppe-Seyler has washed out the stomach in cases of typhoid fever, and shown that while the temperature re- mains high there is little or no acid contained in the gastric juice, and a mildly acidulated beverage may prove serviceable by aiding digestion as well as by relieving thirst. TYPHOID FEVER. 403 Relief of the latter symptom is sometimes sought by painting the tongue with glycerin, which is used to prevent evaporation from the surface and not because of any special virtue in the glycerin itself, which, in fact, is hygroscopic and tends to abstract water from the mucous surface unless it is already very much diluted, and it cannot protect it sufficiently from the evaporation which occurs in mouth breathing. The use of cracked ice in excess aggravates thirst rather than relieves it, and it is better to sip cool water at a temperature of 50 to 60 F. rather than ice. The juice of a sweet orange or a lemon is often very acceptable, and in the absence of serious com- plications it can do no harm. Iced tea may prove agreeable. As a rule, it is well to restrict the use of effervescent drinks for the con- trol of thirst on account of the danger of increasing flatulency, and stretching the ulcerated intestinal wall. In addition to the need of water for relieving thirst, it is of great service as a diluent for washing out the waste products of the febrile action from the system through the kidneys. Many clinicians, as Henry, Meigs, and Beverley Robinson, make it a special feature of their treatment to give large draughts of water. Henry advises giv- ing each patient eighty ounces of water (including that contained in fluid food) per diem, and Meigs has given as much as one hundred and thirty ounces with benefit, including from thirty to fifty ounces of free water. Debove gives six ounces every two hours. It should not be drunk too soon after the fluid food, but in the intervals, so as not to dilute the gastric juice too much. In mild cases a little coffee or a cup of cocoa may be drunk in the morning. Alcohol. The question of how far alcohol serves the purpose of a food and a " force regulator " in typhoid fever is very important. The employment of it in excess as a routine treatment is greatly to be deplored. It is seldom required at all in the first fortnight. Later the heart is enervated and its muscular tissue is enfeebled. In all complications which threaten life, such as severe haemorrhage, sudden cardiac dilatation, hyperpyrexia (107 F.), pneumonia, or un- controllable diarrhoea, alcohol must be given without stint. When the complication is passed the dosage should be gradually reduced. Patients above forty years of age usually require stimulation early. It was formerly customary to prescribe whisky in typhoid fever at the rate of twenty or twenty-four ounces per diem, and in some chronic alcoholic patients large quantities of alcohol may be needed to prevent collapse. Sometimes delirium will disappear when exces- sive dosage of alcohol is discontinued, and I am inclined to prescribe very much less alcohol than formerly, especially for young and ro- bust patients. Undoubtedly there are cases of greatly weakened circulation in which its use must be pushed rapidly, and in which it .Q. DIET IN DISEASE. quiets restlessness, insomnia, and delirium better than opium or other narcotics, but it is not to be forgotten that there are other valuable cardiac stimulants. By giving small doses of digitalis or strophanthus, or the two in combination, by the use of caffeine, cam- phor, small doses of morphine, and other remedies in combination with alcohol, much less of the latter will be required, and there is much less danger of inducing the alcohol habit. Strong whisky often intensifies the stomach catarrh and interferes with the natural absorption of food. One very noticeable feature of the Brand cold- bath treatment is that the patients do well with so little alcohol, many of them requiring none at all in the intervals between the baths. The kind of alcoholic stimulant prescribed must depend upon the circumstances of the case. Brandy and whisky possess the advan- tage that the dosage is more uniform and the bulk is not great. It is a matter of routine hospital practice, founded largely on econom- ical reasons, to give whisky or brandy as the only form of alcho- holic stimulation, but in private practice, especially among women, liquors may be distasteful, and equally good results can be ob- tained by ordering some good strong wine which is more agree- able to the taste, such as one of the Hungarian wines, Malaga, port, sherry, claret, etc. In Germany patients are often allowed beer, but this beverage is open to the same objection as the effervescent drinks, for there is more or less gastric catarrh usually present. It is not much prescribed in this country. It serves better during con- valescence than while the fever is present. Brandy in milk or soda or Seltzer water is best for diarrhoea, and dry champagne is good if there is vomiting. As the latter is used in small doses an ounce or less at a time it is economical to place a patent cork with a faucet in the bottle, so that a little may be drawn at a time without losing all the effervescence. In any case in which alcohol is given the best guides for the proper quantity are found, as in pneumonia, in the breath, delirium, tongue, and pulse. If the breath has no odour of alcohol an hour or two after the dose has been taken, if delir- ium has subsided, if the tongue becomes more moist, and the pulse becomes more full and slow, the alcohol is doing good. During convalescence a little alcohol three ounces of whisky or four or five of Burgundy a day, for example may be needed as a tonic, but should be given only with food. Relation of Intestinal Antisepsis to Diet. It is said that bacilli fed on beef juice produce ptomaines which act more strongly upon the nervous system than if they are fed upon milk (Rachford). The .starches do not make ptomaines. The typhoid germs certamly thrive in nitrogenous media, but TYPHOID FEVER. 40.5 not upon carbohydrates. Their development in the former is ac- companied by the production of toxic material in the intestine, which, on being absorbed into the system, produces the symptomatic phenomena of the disease. This theory, which is of comparatively recent adoption, has emphasised the possible value of antiseptic treatment of the alimentary canal. While there are as yet no reme- dies known to therapeutics which can be used in sufficient strength in the intestine to be completely antiseptic or germicidal to the typhoid bacilli, there is another aspect of antisepsis, or rather asep- sis, of the alimentary canal, which should not be overlooked that is, the prevention of those fermentative changes which accompany in- digestion in any fever. In typhoid fever the importance of main- taining as nearly as possible the normal digestion and absorption of the food is of special urgency on account of the length of the dis- ease. Moreover, it would appear that the overdistention of the in- testine by flatus must have a very injurious effect upon the ulcerat- ing surfaces by stretching them. At autopsies upon typhoid patients ulcers are often seen which might have been easily torn by slight distention, and the prognosis of typhoid fever is more grave when extreme and obstinate intestinal flatulency appears early in the dis- ease, before there has been time for either perforation or peritonitis. One can do much to prevent this condition by bestowing special care upon the whole alimentary canal. Care of the Mouth. The mouth should be washed very fre- quently at regular intervals, and always after taking a glass of milk, for nothing coats the tongue more than a milk diet, or forms a better field for the development of bacteria, which are constantly being carried down to the stomach to excite indigestion and flatu- lency there. Listerine in the proportion of a teaspoonful to a claret- glass full makes a most satisfactory and cleansing mouth wash. A whalebone bent in a loop forms a good " tongue scraper," and cleans its surface quite thoroughly. If patients are too feeble to rinse the mouth, the nurse should swab it out for them with a bit of cotton. Nurses should be made to understand the importance of this simple detail, for, if properly attended to, it adds greatly to the patient's comfort and appetite. When this is faithfully done, one seldom sees even in fatal cases a typical " typhoid tongue " brown, dry, hard, fissured, and so stiff that it is useless to the patient. Patients can often learn to use a tongue bath to advantage that is, to hold the mouth full of fluid for several minutes at a time, when such mois- ture is absorbed by the mucous membrane. The proper care of the mouth will greatly lessen the liability to parotiditis and catarrh of the middle ear. The Stomach. The dangers of overfeeding with milk have already been considered above (paje 399). Milk disagrees with many 4o6 DIET IN DISEASE. patients sooner or later, and the fermentation processes of which it is capable produce large quantities of gas and sometimes eleva- tion of temperature. Small doses of salicin or cerium oxalate with each tumbler of milk often prevent dyspepsia, and the milk, if steril- ised, may be retained and digested where vomiting has been ex- treme. If there is the least indication of ordinary milk disagreeing, it should be at once changed for some other form peptonised, or sterilised, or boiled. With a clean tongue, and with sterilised* milk in the stomach, much may be done to favour the further digestion of milk in the intestine. The Intestine. Many typhoid patients are severely consti- pated by an exclusive milk diet. Constipation favours abnormal fermentation, and begets the flatulency which is so injurious. Such cases should not, as a rule, be allowed to go more than forty-eight hours without encouraging a movement with an enema. While rt is not possible to render the alimentary canal in any sense truly aseptic throughout, a great deal may be done to favour the vital conditions of nutrition by preventing the opposite extreme of excessive inges- tion of bacteria of various kinds and the production of malfermenta- tion. This appears to be at present a more encouraging field for germicidal efforts than treatment directed against the seat of war in the Peyer's patches. The judicious daily use of rectal enemata never excites intestinal haemorrhage, but excessive constipation provokes meteorism, stretches the thin ulcerating surfaces to the point of rupture, and tends to keep the temperature elevated. If relapses are due to reinfection or to simple septic absorption through ulcerating intestinal surfaces, there is all the more reason for the prevention of accumulation of too much food in the intestine. The recent good results with salol as an intestinal antiseptic have led to its employ- ment in typhoid fever with much benefit to prevent meteorism. It should be given in capsules of two grains every three hours to check abnormal fermentation of milk. Convalescence. As the fever subsides, it becomes an impor- tant question how soon to allow a return to solid food. Relapses are very easily induced by indiscretion in this regard. The patient's appetite is always a dangerous guide to follow in this disease. After four or five weeks of an exclusive milk or milk and broth diet, when the temperature subsides, and often before it has become normal, he becomes ravenous. Like a long-starved man, he thinks of nothing but food, and demands something new to eat every day. A hospital ward containing a dozen convalescing ty- phoid-fever patients is difficult to manage, as a bread riot is con- stantly menaced. Ill-advised but sympathetic friends attempt to smuggle in all manner of forbidden fruits, and the patient just ar- rived at the hungry stage is tempted to steal solid food from his TYPHOID FEVER. 407 mere advanced neighbour. I have seen critical relapses brought on by surreptitiously eating ginger snaps, or a few grapes, or a raw apple, and in one instance a young girl who had cried in vain for solid food ate all the flowers which some member of the " Flower Mission " had kindly placed by her pillow ! But it is only fair to state that, strange as it may sefem, she escaped a relapse. Some authors advocate always postponing the return to solid food, especially butcher's meat, for two weeks after the temperature has reached and remained at the normal for a day or two. Fagge says : " No solid food should be given for a fortnight after fever and diarrhoea have ceased," and no doubt in very feeble and anaemic patients and those who have suffered from haemorrhage one cannot be too careful in withholding solids for ten days at least after the tem- perature has fallen to below 100 F. But in the milder cases it is undoubtedly both safe and wise to allow a more strengthening diet at an earlier date, and it will greatly prolong convalescence to forbid it. Peabody advocates giving carefully prepared scraped beef two or three days after subsidence of the temperature. Osier is opposed to giving meat in any form early, for he finds it apt to disagree or excite a " febris carnis." Additional light farinaceous diet tapioca, rice, vermicelli, cream toast, a cracker soaked in cream, etc. may next be given with impunity in cases which have run a mild course. Meat broths may be thickened with rice, sago, or vermicelli. In a day or two more the soft part of oysters or a chop are permissible. In cases which have presented no serious complications, if there is good stomach digestion there is no need of prolonging a fluid diet for fear of intestinal injury. The following is a list of foods suitable for the different days of convalescence, commencing a day or two after disappearance of all fever. Milk should still be given until gradually wholly replaced by solid food. First Day. Chicken broth thickened with thoroughly boiled rice. Milk toast or cream toast. Once only during the day. Second Day. Junket, mutton broth, and bread crumbs. Milk toast. A piece of tender steak may be chewed but not swallowed. Third Day. A small scraped-beef sandwich at noon. A soft- cooked egg or baked custard for supper. Fourth Day. The soft part of three or four oysters. Meat broth thickened with a beaten 0.%^. Cream toast. Rice pudding or blanc- mange and whipped cream, or Bavarian cream. Fifth Day. Scraped-beef sandwich. A tender sweetbread. Bread and milk. A poached egg. Calf's-foot jelly. Sixth Day. Mush and milk, scrambled eggs, chicken jelly. Bread and butter. Seventh Day. A small piece of tenderloin steak or a little breast 408 DIET IN DISEASE. of broiled chicken. Bread and butter. Boiled rice. Wine jelly. Sponge cake and whipped cream. Eighth Day. A slice of tender rare roast beef, a thoroughly baked mealy potato served with butter or mashed with cream. Other foods as before. Ninth Day. A little broiled fresh fish for breakfast. Beefsteak at dinner. Rice, macaroni, eggs. Sago, rice, or milk pudding. A baked apple. Tenth Day. Mush and milk. A squab or breast of partridge or roast chicken. Other foods as before. For the next four or five days the patient may select articles from the menu of the previous days, so that three good meals a day are taken, besides three or four glasses of milk between meals. It is often desirable to give a little alcoholic stimulant, especially if there is much difference in the frequency of the pulse between lying and sitting or standing, or if the pulse rate is very slow, say 56, as it sometimes is. A glass of sherry or of good sound Bur- gundy or a tumbler of ale may be drunk, but with meals only. Von Ziemssen's daily diet for convalescent typhoid-fever patients is as follows : First Breakfast. Tea, biscuit, one soft-cooked ^ZZ- Second Breakfast. Three and a half ounces (one hundred grammes) of finely minced raw ham with wheat-bread crumbs. Noon. Five and a quarter ounces (one hundred and fifty grammes) of pigeon, young chicken, or partridge finely minced in soup. A few days later a mashed potato is added. Wine or beer is permitted, with tea biscuit or plain cakes. Supper. Mush and milk, two soft-cooked eggs, and raw ham. In a few days soup, beefsteak, mutton, cooked fruits, and beer may be given. Rules for Feeding in Atypical Cases. If at any time during convalescence after several days of a normal temperature it begins to rise above 100 or 100.5 F- it is safest to return at once to fluid diet. If the temperature falls again in a day or two, convalescent diet may be resumed. A sudden rise to 103 F., or even higher, last- ing but a day or two, may be caused only by constipation, and it is not to be considered as a genuine relapse, but until the cause is ascer- tained the above precaution must be observed. There is a class of patients in whom the thermometric record is likely to fail as a guide for feeding unless it is correctly interpreted. After a protracted fever lasting four or five weeks the temperature falls to about 100 F. and fluctuates daily up to 100.5 or 101.5 F. without reaching the normal, or it may become subnormal and fluc- tuate between 97.5 or 98 F. in the morning, and 101 F., in the afternoon. These patients, in the absence of any sequels to account TYPHOID FEVER. 409 for the temperature elevation, have a " starvation fever," and they are usually considerably emaciated. It is necessary to give them solid food cautiously to bring the temperature to normal. Some- times even then the fever lasts until they are allowed to sit up. In estimating the proper time for giving solid food, regard must always be paid to the general severity of the disease. Complications, such as an abscess or furunculosis, may protract the fever, although the intestinal ulcers are completely healed, and such patients should have solid food in spite of a slight elevation of tem- perature. Very mild cases, in which the fever curve subsides in ten days or a fortnight, are deceptive in that they are apt to relapse, and their fluid diet should be prolonged. Patients who have been very ill with repeated haemorrhage or hyperpyrexia should be fed with the greatest caution during convalescence. At the end of a fortnight of normal temperature, if the bowels are moving regularly and if there is no diarrhoea, the patient may usually be allowed to select his own menu, although he must be warned to avoid for a long time eating food likely to leave much insoluble residue, such as raw vegetables, raw apples, soft-shell crabs, berries, green corn, old peas, beans, cabbage, tough meats, dried fruits, etc. He must be instructed also not to excite diarrhoea by eating too much fresh fruit. With any attack of indigestion he must return for a few days to a very simple diet. I have seen a second distinct re- lapse occur on the twentieth day after the first, but such cases are fortunately quite exceptional. Typhoid Fever in Children. Typhoid fever in young children is rare. When it occurs in in- fants between two and five years of age they must be fed, if possible, exclusively upon milk in some form, predigested if necessary, but in each case sterilised or Pasteurised. Children usually lake koumiss well and thrive upon it. If milk is refused, and emaciation threatens in consequence, some concession should be made in the rigour of the diet, but of course no solid food can be allowed. Beef juice, beef, mutton, or chicken broths (not thickened), and beaten egg albumen sweetened and flavoured with a few drops of sherry, may be substituted for milk or alternated with it. Children take junket extremely well. When stimulants are required, from ten drops to a teaspoonful of brandy or whisky, well diluted, should be given. If they refuse this, a little Tokay, champagne or wine whey may be tried. As a rule they need no alcohol unless they are very feeble, or if complications arise. The nurse must offer water freely. Barley water with a little lemon juice is useful to relieve thirst. It must be remembered that the temperature curve of enteric .jQ DIET IN DISEASE. fever in children is often very irregular, and a fall to near the nor- mal must not be regarded as justifying an allowance of solid food at once, and no matter how clamoroua the child may be for it, exactly the same rigid rules must be enforced as in the case of adults, and for the same length of time during convalescence. TYPHUS FEVER. In general the dietetic treatment of typhus fever should be the same as that of typhoid fever, but as intestinal ulceration is absent in the former, the extreme care of the alimentary canal is less im- perative. The fever is high and the patient is usually delirious, hence an exclusive milk diet is best during the height of the fever, provided it is well digested. The duration of this fever is much shorter than that of typhoid fever, and some of the objections to a milk diet are therefore less apt to arise. From four to six ounces of milk may be given every two hours. If the milk is not well assimilated it may be alternated with or supplemented by broths, custard, raw eggs, farinaceous gruels, etc. Abundant water should be offered, and the prominent tendency to ataxic symptoms and stupor may be counteracted by strong black coffee, alcohol, etc. Convalescence. During convalescence the precautions ob- served in the treatment of typhoid fever are not necessary, and patients may return much sooner to a solid diet; but some alcoholic stimulant, such as ale or porter, will be needed with the meals. The directions given in the section on Diet in Fever in General (page 387) may be observed ; for, although any severe fever may leave the di- gestive organs somewhat enfeebled, there is no unusual danger of this kind in typhus fever, and relapses are not occasioned by dietetic errors. SMALLPOX. The invasion of smallpox is usually abrupt, and the tempera- ture may reach 104 F. on the first day. There are anorexia, thirst, vomiting, and prostration, in addition to other symptoms. The fever continues for three days, or until the eruption has fully devel- oped, after which it subsides. During the febrile stage a light fluid diet should be given, such as is recommended for fever in general- milk, broth, gruel, etc. (page 387). The thirst is usually consider- ably relieved by taking cool liquids in abundance, such as water, iced lemonade, Seltzer water, etc. If there is much eruption in the throat, there may be considerable dysphagia. Cracked ice or cocaine should be employed to relieve it. During the suppurative stage of the eruption the patient requires SCARLET FEVER. 411 an abundant supporting diet, and as much milk, eggs, whisky, and stimulating meat broths should be prescribed as can be digested. The patient should be fed at least once every two hours, and must be awakened three or four times at night for food. Vomiting is not to be dreaded after the onset of the disease. The combined effect of the irritation of so large a cutaneous eruption and of the secretion of so much pus from the pustules, which may amount to many ounces, is exhausting to the last degree, and earnest effort must be made to counteract it. This is especially true of all confluent cases. A dozen eggs, three quarts of milk, and ten or twelve or more ounces of whisky or brandy, is not too much to order for an adult. These materials may be given alone or in combination, as eggnog, milk punch, etc. If the stomach rebels against so much food, the rectum- must be utilised for part of the work. This supporting treatment should in all severe cases be com- menced early, even in the vesicular stage of extensive eruption, without waiting for signs of exhaustion which, are otherwise certain to follow. If strong liquor is not tolerated, champagne or other wine must be substituted. Convalescence occupies from one to four weeks, according to the severity of the attack. The diet should be slowly increased, and should comprise abundant animal food, meat, milk, and eggs, and alcoholic stimulants, such as ale, porter, or Burgundy. SCARLET FEVER. In mild cases of scarlet fever the temperature subsides in a few days, and after that time, during the period of desquamation, special care in the diet is unnecessary unless nephritis is present. While the fever lasts the diet should be of fluid character, and milk, koumiss, soups, broths, and farinaceous gruels of arrowroot, farina, etc., are to be given. In all cases there is liability to renal irritation, and desquamative nephritis may occur ; and in order to eliminate the scarlatinal poison and waste products of the fever from the system as rapidly as may be, it is advisable that the patient take as little nitrogenous food as possible, except milk, and drink large quantities of fluid. Dryness of the mouth and thirst are prominent symptoms, and there is often difficulty in swallowing, owing to the inflamed condition of the throat. Water, effervescing waters (Seltzer, Apol- linaris), barley water, orange juice in Vichy, and sour lemonade may be drunk in considerable quantities. In mild cases a little plain vanilla ice cream is much enjoyed by children. It is nutritious, cooling, and grateful to the parched throat. If the fever is high, four or five ounces of fluids must be given .j2 DIET IN DISEASE. every hour. In severe cases there is gastric derangement, and the diet must be restricted to milk in some form, as koumiss or pepto- nised milk. If nephritis is present, the milk diet should be continued, and all other nitrogenous food must be withheld (see Albuminuria). Jaccoud maintains that scarlatinal nephritis can be usually averted by keeping the child upon a strict milk diet from the commence- ment and continuing it for several weeks. Convalescent children who have had very mild attacks are often hungry, but it is best to control their diet carefully for two or three weeks, even if albuminuria is not detected. They may be given at first such articles as junket, rice pudding, crackers, farina, corn- starch or sago with cream, milk toast, cream toast, baked custard, blancmange, wine and beef jelly, mush, baked apples, stewed prunes, oranges. The resumption of animal fare should be very gradual in all cases, and fish, oysters, chicken, or eggs should be given before meat. MEASLES. The diet in ordinary cases of measles does not require special care beyond that described under the section on Diet in Fever in General. The appetite is usually wanting in the prodromal and eruptive stages, and milk with farinaceous gruels answers every requirement. Thirst is prominent, and cool water or lemonade may be offered, or orange juice or unfermented grape juice in Vichy. Alcoholic stimulation is only needed if the patient is very feeble, or if severe complications arise. The resumption of a solid diet must be gradual, but it may begin as soon as the fever and catarrhal symptoms disappear. When nursing or hand-fed infants have measles they should be fed somewhat oftener than usual, and must be given less food at each feeding. A child of eight or ten months of age should be fed on diluted milk like one two or three months younger. In this manner any existing catarrh of the stomach is less likely to cause serious indigestion and vomiting. It is particularly necessary to give water, and half an ounce should be offered at least every two hours, or oftener, while the infant is awake. If there is much gastric irritation or catarrh, it may prove best to suspend milk feeding for a day or two and substitute meat juice or beef or mutton broth. MUMPS. For mumps no special diet is required beyond the necessity of giving fluids or soft food while the swelling of the parotid glands and fever last. The suggestions for the dietetic treatment of ton- sillitis apply to this disease. Anaemia is apt to be extreme during INFLUENZA. 4,^ convalescence, and meats should therefore be plentifully supplied. Cod-liver oil is very appropriate in protracted convalescence. WHOOPING COUGH. In whooping cough the paroxysms of coughing are so severe as to give rise to vomiting, and in bad cases they are excited by taking food which does not have an opportunity to become assimilated, and nutrition may suffer very seriously in consequen'ce, adding to the general exhaustion which accompanies the disease. All food must be made easily assimilable. It is best to give food regularly in moderate quantity at each time, and it should be predigested if necessary. Pancreatinised milk, koumiss, the prepared amyla-- ceous foods, cream toast, eggs, junket, chicken broth, malted farina- ceous foods, custard, milk puddings, gruels thiokened with meat extracts, and stimulants in the form of egg albumen in sherry, egg- nog, or milk punch, are recommended for patients who vomit solid food. The worst cases require nutrient enemata, as exhaustion becomes critical. INFLUENZA. Symptoms. Influenza is an acute and moderately infectious fever of microbic origin which is recognised by catarrhal inflamma- tion of the mucous membranes of the upper air passages, and by symptoms referable to the nerve centres. In many cases the symp- toms are mild and of short duration, and no special dietetic treat- ment is required beyond that common to febricula, but a large number of cases are accompanied by a variety of serious complica- tions or they present sequelae. In the majority of instances the mucous membranes of the air passages are the principal seat of the inflammation, but in others the gastro-intestinal mucous membranes are similarly attacked, giving rise to pronounced digestive dis- orders, nausea, vomiting, and diarrhoea. The fever, commonly of moderate severity (103 to 103.5 F.), persists for three or four days or a week. There is usually great depression of spirits, with ex- treme malaise, muscular pains, enfeebled circulation, and almost total loss of appetite. As an adjunct to other treatment, absolute rest in bed is imperative in all severe cases, not only for the purpose of maintaining a uniform temperature and of protecting the body from draughts, but to guard against syncope from debilitated heart action. Dietetic Treatment. While the fever lasts, the stomach is usually irritable, and the diet must be fluid and restricted. Food should be given in very small quantities, according to the rules applicable in cases of extreme'debility. .,. DIET IN DISEASE. 414 In severe cases it is necessary to prescribe an exclusive milk diet for the first two or three days, and two and a half quarts should be drunk if possible. Later the patient may be given nourishing beef, mutton, or chicken broths, with beaten eggs added, milk toast, custards, eggnog, and milk punch. As soon as solid food can be eaten, scraped-beef sandwiches, oysters, tender breast of chicken, eggs poached or scrambled, and light farinaceous articles with which cream are appropriate. As a stimulant, champagne is particularly serviceable in relieving both the physical and mental depression which is so characteristic of nearly all phases of this disease. Convalescence is frequently prolonged, and debility, muscular weakness, irritability of the heart, and enfeeblement of digestion are often present to a degree which appears wholly disproportionate to the intensity and duration of the febrile attack. The diet must therefore still be carefully supervised, while every exertion of either body or mind must be prohibited. The food should be of a highly nutritious character and served in an appetising and palatable manner, and as abundant as the condition of the stomach will allow (see Convalescence from Typhoid Fever, page 406). Patients with whom milk usually agrees do well to take it in quantities amounting to a quart a day, in addition to abundant solid nitrogenous food, roast beef, beefsteak, chicken, eggs, etc. Alkaline waters should be drunk. If the appetite flags and return of strength is delayed, tonics and possibly change of air may be required. When convalescence is protracted it is advisable to continue alcoholic stimulation, and milk punches, plain whisky and water, or a glass of sound Burgundy may be given two or three times a day, as a tonic, with the meals. Malt liquors may also be indicated in some cases. DIPHTHERIA. Symptoms. Diphtheria is an acute, infectious, and inoculable disease characterised by croupous inflammation of mucous mem- branes which particularly affect the pharynx and upper air passages. Clinically the disease presents fever of an irregular* type, with great debility, and frequently albuminuria. Anaemia and rapid loss of flesh and strength are characteristic. The mortality is high, espe- cially among children, whom the disease chiefly attacks, and death may result from toxaemia, sudden heart failure, obstruction to the entrance of air caused by accumulation of the diphtheritic membrane, the extension of the inflammation down the air passages, or exhaustion from inability to swallow food. Recovery is uniformly slow, and may be still further retarded by paralysis or other sequelae. DIPHTHERIA. 415 Owing to the extent to which the throat is involved, with conse- quent difficulty in swallowing, and to the general weakness and prostration, there are few diseases in which greater care in regard to dietetic treatment becomes imperative. There is anorexia, and the sense of taste is lost ; nausea is frequently present as well as consti- pation. The cervical lymphatic glands are more or less swollen and give rise to pain or soreness on opening the mouth. Albumin may appear in the urine as early as the second day. Dietetic Treatment. " Alimentation occupies the first place in the general treatment " (Trousseau). Throughout the active stage of the disease while the fever lasts, there is difficulty in swal- lowing. All food must be given in fluid form, of which milk is the best, or if, as sometimes happens, semisolid material is more easily swallowed, the food must be thickened with cream, gelatin, eggs, or farinaceous articles ; or beef meal, Mellin's food, malted milk, etc., may be added for this purpose to other foods. The diet should consist chiefly of nutritious beef or chicken broth and beef tea, egg albumen, eggnog, milk, and milk punch. Plain vanilla ice cream is nutritious, and if not too sweet it is well borne, and is frequently very grateful to the inflamed throat. Simple fari- naceous foods, such as arrowroot, thoroughly cooked rice, soft cream toast, and gruels, may be taken. Continued disgust for food is a very bad prognostic sign, and every effort must be made to counteract it by offering variety. When the child is unable to swallow on account of pain or accumulation of membrane in the throat, forced feeding with a nasal or stomach tube may be better than reliance upon nutrient enemata. Alcoholic stimulation is usually required early in the disease, and it should be given without stint if the pulse is feeble and heart failure seems imminent. A child of three or four years should have as much as two or three ounces of brandy or whisky a day, and in bad cases even ten ounces or more can be given. It may make the child dull and stupid, but it is the only way to combat severe sepsis. If the liquor, well diluted, disagrees with the stomach, it should be administered by rectum, or claret, sherry, or champagne may be substituted. Nourishment must be given regularly at least every two hours by day and every three hours by night, in small quantities at a time. The digestive ferments papain, or papayotin, and trypsin have some solvent action upon diphtheritic membranes, for they act in the medium of alkaline saliva. They have been found of practical benefit in many cases when used in a spray, to dissolve away the membrane as fast as it reforms. 39 4i6 DIET IN DISEASE. Intubation and Tracheotomy. Intubation of the larynx is a method devised in 1880 by O'Dwyer, of New York, and consists of the insertion of a small gold-plated tube between the vocal cords, which is left in situ, so that air can pass freely in and out, the channel previously blocked by false membrane being kept open by the tube. The tube is adjusted to fit closely between the vocal cords, and is inserted by an ingenious holder, which releases it when in position. A similar instrument is employed for its removal for the purpose of cleansing, extracting plugs of membrane, feeding, etc. The advantage of using this tube as compared with the operation of tracheotomy lies in the fact that it can be very readily and quickly inserted without the formal- ity of an operation, which is so much dreaded by the patient or by the parents of the child. Moreover, when the necessity of its use has passed, it is easily removed, and there is no wound left to heal or to become infected by the diphtheritic inflammation. By those skilled in the use of the instrument it can be removed at any time and reinserted, and the tube is believed to irritate the throat less than a tracheotomy tube. There are, however, some disadvantages attending the use of this tube, in addition to the fact that it may sometimes push the diphtheritic membrane farther down into the trachea. It may be coughed out by the child, who suffocates, before it can be replaced. Several cases have been reported in which the tube has been coughed up and then swallowed, and in which it has been passed into the oesophagus through carelessness. The latter mistake is easily avoided by leaving a thread tied to the tube, by which it may be withdrawn if a false passage should be made. The thread is fastened about the ear and is protected from the child's grasp by adhesive plaster. The child sometimes experiences great trouble in swallowing without drawing food into the trachea. It is difficult to close the epiglottis with the tube in position, or to draw up the larynx beneath the root of the tongue to the extent which should occur in normal deglutition, and hence fluid food particu- larly is liable to trickle through the tube into the trachea, exciting violent dyspnoea and spasms of coughing. Semisolid food or solid food, such as junket, mush, or eggs, is more apt to glide over the instrument without being sucked in through it during inspi- ration. Patients usually require considerable nourishment to sup- port their strength, so that the difficulties of feeding may be serious. Very young infants, who are dependent upon a milk diet, can swallow best if laid upon the back across the nurse's lap with the head downward supported below her knees. While in this position the bottle is given (Wharton). Regurgitation through the nose may DIPHTHERIA. 417 occur, but that is of little moment compared with the accident of inhaling the milk through the tube into the lungs. In older children, when proper precautions are taken in regard to the position of the head in swallowing and the avoidance of inspira- tion at the same time, these dangers may be reduced to a minimum, or they may be overcome by the passage of an oesophageal tube, though this irritates the throat and may spread the diphtheritic membrane along the oesophagus. Intelligent children can learn to swallow well with a little practice and care while wearing the intuba- tion tube. Some even swallow easier than before its insertion by reason of the relief of dyspnoea, which always makes deglutition difficult. In other cases the tube may be temporarily removed, if the dyspnoea is not extreme, while the child takes nourishment ; but this requires skilled attendance, and, as the patient must be very fre- quently fed, it possesses great disadvantages. As a rule, the longer the tube remains in position, the better the patient acquires facility in swallowing. In some cases it may be well to resort to rectal alimentation for a day or two to obviate the necessity of swallowing while the tube is worn. O'Dwyer says: " Solids and semisolids, when there is an appetite for such food, and when the patients can be induced to take it, are swallowed much better than fluids, and do not enter the tube, as far as I am aware " ; and he adds that a bolus of food tends to press the epiglottis down over the tube, while fluid tends to raise it, or slip in under it, although he has modified the head of the tube by giving it a concave surface to fit the epiglottis. It should not be forgotten with very young children that a failure to take food may be due to loathing or nausea, and not to physical inability to swallow with the tube in situ. He adds : " I always in- struct children who are old enough to understand, to drink as rapidly as they can, and then cough to expel any fluid which may have en- tered the tube, instead of coughing after each deglutition, as they usually do." He discountenances the theory that food may enter the tube and excite pneumonia by reaching the deeper portions of the lungs, and says : " I do not believe and there is no evidence so far to prove that any of the fluid entering the tube ever reaches the bronchi, for it is promptly expelled by coughing." He cites cases in support of this statement, one being that of a woman who wore the laryngeal tube for over ten months continuously, and en- joyed good health. He says that vomited food enters the tube even less often than swallowed food. TRACHEOTOMY. The operation of tracheotomy is performed for obstructions of various kinds, such as accumulation of diphtheritic membrane in the 4i8 DIET IN DISEASE. larynx, oedema of the glottis, etc. The conditions which require this procedure are usually among those which interfere to a greater or less extent with swallowing, although the presence of the tracheoto- my tube in the trachea is well borne and does not necessarily conflict with deglutition in any manner. No special precautions in feeding are necessitated by the presence of the tube, as in the case of intu- bation. POST-DlPHTHERITIC PARALYSIS. In post-diphtheritic paralysis the soft palate is oftenest affected, but the muscles of the tongue and pharynx, or even the oesophagus, may also be involved, in which case deglutition is hindered and the patient must be fed through a catheter or stomach tube (see Gav- age) or by enemata (see Food Enemata). The recent phenomenal success of antitoxine inoculations in re- ducing the mortality of diphtheria to less than one third of its former degree offer the consolation that sequelae of this nature may soon belong only to the past, and that both intubation and tracheotomy may seldom if ever be required in the future for this disease. CEREBRO-SPINAL MENINGITIS. Symptoms. Cerebro-spinal meningitis is an infectious disease of microbic origin, in which the chief lesions are an inflammation of the meninges of the brain and spinal cord. This inflammation of the membranous coverings of the nervous system results in the pro- duction of a variety of symptoms, including fever, disturbances of the nervous and muscular systems, nausea, vomiting, and constipa- tion. The symptoms vary greatly in severity and duration, lasting from a few days to several months. In mild cases convalescence is established at the end of a week, but in severe and protracted cases the nervous symptoms increase in severity. The stage of excite- ment and irritation of the nerves with active delirium is succeeded by profound prostration and coma, with progressive emaciation, a variable temperature, and paralysis of the sphincters, with involun- tary evacuations. Such cases as a rule prove fatal, but they are not necessarily hopeless, and recovery may occur at any time. Much, therefore, depends upon the careful nourishment of the patient, and every effort should be directed towards maintaining strength and promoting nutrition. Dietetic Treatment. In mild cases a liquid diet of milk, broth, meat, and egg albumen, with, perhaps, a little toast or crackers, may be given while acute symptoms last. In protracted severe cases, and especially where. convulsions, delirium, and coma are present, the pa- tients must be fed with great care, and all nourishment must be given ERYSIPELAS. 419 in frequent small doses and in an easily assimilable form. Huebner sometimes employs forced feeding with the stomach tube. Pancre- atinised meat broth, pancreatinised milk, albumoses, and beef juice must be ordered, if necessary, every fifteen minutes. Brandy or whisky is required when hyperaemia is succeeded by exhaustion. If given too early, alcohol may increase the delirium. In extremely feeble patients such fluids must be administered in teaspoonful doses, or even in smaller quantities, with a medicine dropper, by which they are passed between the closed teeth. It will be also advisable to employ rectal alimentation. There is seldom any lesion of the ali- mentary canal present, and consequently in those cases in which larger quantities of fluid nourishment, or even solid food, can be taken there is no objection. If the patient is able to eat and swal- low properly, milk toast, scraped beef, eggs, custard, wine jelly, farina, Bavarian cream, blancmange, etc., are indicated. Water may be given ad libitum to relieve the thirst, which is often severe. Convalescence will be promoted by giving abundance of food. Five or six meals a day may be taken. The appetite is frequently good from the commencement of convalescence. Beefsteak, chops, roast beef, mutton, or chicken, bread and butter, oatmeal, porridge, hominy, and rice with cream, may be allowed as soon as the patient's digestion admits. A milk punch, or glass of claret should be or- dered three times a day. ERYSIPELAS. Symptoms. Erysipelas is an infectious disease caused by a specific micrococcus, and characterised by high fever and intense local inflammation of the skin and contiguous mucous membrane. There is usually more or less prostration and enfeeblement of the heart and circulation. Dietetic Treatment. The indications for dietetic treatment are to support the strength by stimulants and nutritious foods, which must be adapted for easy digestion. When the temperature is high, and nausea and vomiting exist, nourishment should be taken in small quantities an ounce or two at a time every hour. In ordinary cases, pancreatinised milk, beef peptonoids or albumoses and beef juice, eggnog, milk punch, and farinaceous gruels are recommended. Alcohol is needed and it is well tolerated, for it seems to be con- sumed in the system without intoxicating eff'ects. From eighteen to twenty ounces of brandy or whisky may be given in twenty-four hours. In extreme cases an ounce an hour may be taken, or if allow- ance is made for sleep the individual doses may be increased. The liquor should be diluted with plain water, or with Vichy or carbonic water, or soda water. Aged or debilitated persons and young chil- .20 I^IET IN DISEASE. dren especially need vigorous alcoholic stimulation. After the local inflammation subsides the period of convalescence requires a very nutritious diet, and fluids may gradually be replaced by beef, soft- cooked eggs, toast, bread and butter, and light farinaceous foods with cream. If the disease invades the pharynx, an exclusive milk diet is necessary, and alcoholic stimulants as well as medicines, except those designed for local treatment, should be given J>er rectum to avoid in- creasing the local irritation. Heuter favours the drinking of large quantities of hot tea to in- duce perspiration, but it is doubtful whether this in any way affects the cutaneous lesion. CHOLERA. Dietetic Prophylaxis. Cholera is a zymotic disease, the germs of which can only enter the system by the mouth, and they are spread chiefly through the agency of contaminated water used for drinking or washing purposes. All raw foods and cooking utensils washed in such water are liable to become infected. No raw food or drink of any kind whatsoever should be taken. In many cities it is customary for the local health boards to pro- hibit the sale of raw fruits while a cholera epidemic is in progress. It is a standard rule to boil everything. Tea, coffee, chocolate, and cocoa should be made only with water previously sterilised by boiling. Sterilised water only should be used for cleansing the teeth. Water should not be cooled by direct contact with ice, or the latter should be newly made from distilled water. No beer, ale, soda water, or artificial mineral waters should be used if there is any chance of contaminated river or well water having entered into their manufacture. Milk may become infected from washing the milk cans in impure water. Acid beverages should be freely drunk, for the cholera germs do not thrive in acid media, and if accidentally introduced into the stomach they may perish there if the gastric contents always have an acid reaction. Sour lemonade made with ten or fifteen drops of dilute sulphuric acid has an excellent reputation as a prophylactic against cholera. Vinegar, sour pickles, or lime juice may be taken for the same purpose. Indigestion, perhaps because it promotes alkaline fermentation in the stomach, favours infection, and hence during the prevalence of an epidemic it is desirable to eat only plainly cooked, wholesome food, and to avoid all excesses in eating and drinking. All foods, such as pastry, fried dishes, etc., having the reputation of easily dis- agreeing should be eschewed. During the prevalence of an epidemic of cholera it is highly im- CHOLERA. ^21 portant to avoid eating anything likely to produce diarrhoea, and all indigestible substances, such as meat, eggs, fish, or milk not strictly fresh, unripe or overripe fruit and vegetables, must be absolutely forbidden. Symptoms. The symptoms of cholera are usually divided into four typical periods, which are those of 1. The premonitory diarrhoea. 2. The period of profuse serous diarrhoea. 3. The algid stage, or that of collapse or asphy.xia. 4. The reactionary stage. The dietetic treatment varies with each of these stages of the disease. It is imperative that the patient be kept absolutely quiet in bed throughout all the active phase of the disease. First Period. There is alkaline watery diarrhoea with frequent profuse stools, nausea and, usually, vomiting. The stomach is too irritable to retain food, and broths and milk only furnish culture media for development of the cholera bacilli and production of toxines. During this period only light fluid food in very small quantity should be eaten. Nothing can be worse than overeating. Whey, gruels, bouillon, or pancreatinised milk only are permissible. The contents of the stomach should still be kept acid, and sour lemonade, lime juice, dilute acid phosphates, dilute vinegar, and dilute hydrochloric acid, twenty or thirty drops in a half tumblerful of water, or diluted aromatic sulphuric acid in similar dosage, are to be swallowed from time to time. The acids should be given through a glass tube to spare the teeth. Hyperacidity of the stomach artificially produced, favours the passage of a portion of the acid stomach contents into the small intestine, so that its normal alkalinity is, to some extent, neutralised. The duodenum indeed may temporarily acquire an acid reaction, which is inimical to the development of cholera germs. Second Period. The stools become more frequent and serous. They are almost continuous, and enormous quantities of fluid are rapidly drained from the system, in which whitish flakes of desqua- mated intestinal epithelium are suspended. Sometimes they contain blood. As much as two quarts of fluid may be discharged in a single evacuation. Nausea and epigastric distress occur with projectile vomiting of fluid, which exceeds in quantity that which is drunk. Intense abdominal cramps follow and extend down the legs. The patient rapidly emaciates, and the feebleness and prostration are extreme. There is a cold clammy perspiration, and in a few hours the victim passes into collapse. Active efforts must be made to stop the vomiting and diarrhoea. The abdomen must be incased in flannel, and turpentine stupes are of service if the cramps are severe. ^22 I>IET IN DISEASE. A mustard paste may be placed over the epigastrium, and a hypo- dermic injection of morphine is required ; cocaine may be given internally. Cracked ice, cold lime water, iced champagne and car- bonic-acid water, iced fresh lime juice in Vichy, weak cold brandy and Seltzer, or plain soda are all good remedies which should be offered in very small doses every five or ten minutes. Strong black coffee may be tried. The thirst may be assuaged by dilute hydro- chloric acid or lemon juice in water. A little fluid held in the mouth for a few minutes sometimes affords more relief of this symp- tom than larger quantities swallowed. It is worse than useless to attempt to give even predigested milk while the vomiting and diar- rhoea continue. Third Period. In both the second stage and in the third stage of collapse the best results are obtained by the new method of hypodermoclysis that is, of hypodermic injections into the thighs and sides of the abdominal wall of large quantities of normal salt solution made by dissolving 50 grains (a scant teaspoonful) of salt to the pint of boiled water. The injections are given at the tem- perature of the blood, and the entire quantity may be used in the course of half an hour. The salt solution replaces to some extent the fluid drained by the serous diarrhoea and emesis, restores the blood pressure and equilibrium of the circulation, and almost im- mediately relieves the thirst. Fourth Period. If vomiting ceases and the symptoms of col- lapse abate, a little fluid nourishment must be very slowly and cautiously tried. A teaspoonful or two of pancreatinised milk, koumiss, Liebig's or Valentine's meat extract, or fresh beef juice is first given. If this is retained, the dose is to be repeated and con- tinued by increasing the quantity and diminishing the frequency of administration as the patient improves. The stomach remains feeble and irritable for many days, and for a week or two it may be neces- sary to limit the diet to predigested milk, beef albumoses, nutritious broths, egg albumen in diluted brandy, and champagne. The further dietetic treatment may be conducted in the manner of that of the convalescence of typhoid fever (page 406). YELLOW FEVER. Symptoms. Yellow fever is an acute, infectious disease charac- terised by a sharp febrile paroxysm, gastric haemorrhage, jaundice and suppression of urine. The nature of the symptoms is exceed- ingly acute and intense. In those patients who die very soon after the invasion of the disease no definite lesions are found. In other cases hyperaemia, and extravasation, with visceral degeneration are noted. These important changes are found in the liver and gastro- YELLOW FEVER. ^23 intestinal mucous membrane, and during the active progress of the infection digestion becomes almost impossible. The liver presents the lesions of parenchymatous hepatitis. The hepatic cells here and there are filled with granular material and oil globules. Many of them are distended or fused with indistinct or absent nuclei. The small bile ducts are filled with degenerated epithelium, and the func- tional activity of the liver is therefore almost completely suspended. The whole alimentary canal presents the picture of acute catarrh, but the stomach particularly is softened, swollen, and ecchymotic, and it may be eroded. The disease presents three different stages, the dietetic treatment of each of which is important, and it will therefore be necessary to briefly describe them. These stages are : 1. The cold period, followed by febrile reaction. 2. Remission or " stage of calm." 3. Second exacerbation, a uraemic condition or else collapse. The first stage begins with almost immediate vomiting and great prostration. The ejecta consist first of mucus, then bile in increas- ing amount, and finally, if the retching continues and muscular straining is severe, the irritability of the stomach in this period be- comes greater than in almost any other disease. The slightest pres- sure over the epigastrium excites projectile vomiting. Constipation is present from the inability to retain fluids; the mouth becomes dry and the gums sore and swollen, and thirst is extreme. The urine is much diminished in volume as the changes in the liver progress, and the bile ducts are blocked with degenerated epithelium ; the bile enters the blood, and the skin and conjunctivae become decidedly jaundiced. After several days usually four or five these symptoms sub- side and the second period is reached. The duration of this period seldom exceeds two days, and it may continue but a few hours. It is a condition of calm, in which all symptoms are abated ; the fever, which may previously have existed, subsides and the gastric irrita- tion is lessened. The third period promptly succeeds the second, and in it the symptoms of the first period return with renewed severity, and in addition a condition of uraemia develops. Haemorrhage of the stom- ach, known as "black vomit," is present in about one third of the fatal cases. The vomited material ejected during the course of the disease consists, first, of whatever food the stomach may contain, then of bile-tinged mucus, and finally of a deep brown or black grumous acid semifluid substance resembling coffee grounds, which consists of red blood-corpuscles, pigment granules, degenerated mu- cus, epithelial cells, leucocytes, fatty matter, and serous fluid. The action of the gastric juice upon the extravasated blood pigment 424 I*IET IN DISEASE. turns it dark brown or black. The quantity of this fluid may reach several pints. It is acrid and irritating to the fauces and mouth. The blood from the passively congested surface oozes freely from the capillary walls of the gastric mucous membrane. The intestinal mucous membrane may be similarly affected, in which case the stools are black and diarrhoeal. The urine becomes very scanty, and may be entirely suppressed. There is hsematuria. Should recovery result, the jaundice continues for some days, but the other symptoms subside gradually and convalescence is always slow and may be retarded by various complications, among the most serious of which are an exceedingly irritable stomach and intestine. Errors in diet have been known to cause fatal haemorrhage from the stomach as long as a fortnight or three weeks after beginning con- valescence. The heart action after such a severe ordeal is always feeble, and reparative and nutritive processes advance slowly. Irri- tability of the stomach may even persist for several months after the subsidence of all other symptoms. This brief account of the more important features of the disease emphasises the necessity for most careful dietetic management. Treatment of the First Period. The patient must be im- mediately put to bed and kept absolutely free from excitement. Rest in a recumbent position must be carefully enjoined, and the patient must not be allowed to even raise the head to drink. Medicine and fluids must be given through a tube or with a tea- spoon. If the patient is seen promptly, and there is a probability of undigested food being present in the stomach, that organ should be unloaded by an emetic, and as little medicine as possible should be ordered. If constipation is present the bowels should be emptied by a purgative enema. It is generally considered that profuse perspira- tion is an advantage. This object can be accomplished by covering the patient with blankets and giving a hot lemonade or hot toddy, such as hot whisky and water. As the vomiting becomes more and more severe, efforts may be made to relieve it, but if all measures fail, it will be best to let the stomach have absolute rest, which is secured by hypodermic injec- tions of morphine, mustard paste over the epigastrum, and the use of the rectum for all medication. Among the various means at com- mand for the relief of the vomiting are cracked ice, light acidulated and effervescing draughts, such as acid lemonade, Vichy, Seltzer, or carbonic water, strong coffee, plain lime water in frequent half-ounce doses given cold, besides cocaine, diluted hydrocyanic acid, cerium oxalate, etc. Iced champagne, very dry Mumm or Pommery sec, or acid lemonade with bitartrate of potassium, will sometimes be re- tained. With the supervention of uraemic symptoms, or when there is suppression of urine, there is urgent need of getting more fluid YELLOW FEVER. 425 into the body. The lumbar region should be cupped or poulticed or Covered with a mustard paste. If aerated waters are not toler- ated by the stomach, three or four pints of salt water should be in- jected into the rectum every two hours, or it is suggested that hypo- dermoclysis might prove of service after the manner employed in cholera (page 422). While the fever lasts, or throughout the first period, it is usually best not to attempt to give food at all, for the stomach is almost certain to reject or fail to digest it. Cochran dissents somewhat from the prevalent practice of allow- ing no food during this stage, and believes that an attempt should be made to supply a little nourishment per os, to fortify the system against the future drain upon it which is certain to follow. He says: " I have seen infants at the breast pass through attacks of yellow fever to prompt recovery, throwing up black vomit frequently and freely, and nursing as regularly and heartily as if there was nothing the matter with them." Many cases of yellow fever occur among previously healthy people who can withstand the absence of food for a day or two without serious loss, provided exhausting symptoms can be held in check. In many instances, however, prostration and exhaustion occur with extraordinary rapidity, and in an hour the patient may be too feeble to articulate or move. Active stimulation by the rectum and hypodermically is then necessary. For this purpose whisky is best. It should be obtained pure and injected hypodermically with a sterilised syringe in quantities of one to three drachms. The injections may be made beneath the skin on the outer surface of the thigh and arms in four or five places. Two ounces of whisky diluted in an equal part of water may be injected /^r rectum. Treatment of the Second and Third Periods. During the interval of the second period abatement of the fever and of the gastric irritation may admit of a little nourishment being taken by the stomach. Some patients recover without passing into the third period, but because many do not, extreme caution must be observed and food, if taken at all, must be in very minute quantities. The same rules in regard to diet and stimulants apply to the third period which have been prescribed for the first, and the main reliance for nourishment should be through rectal alimentation. When the paroxysm is over and the symptoms have abated, the greatest care must still be exercised in regard to diet even if the patient is hungry, as sometimes happens. In the worst cases no solid food should be permitted for at least ten days or a fortnight, and it must be re- membered that fatal relapses have been precipitated by not observ- ing this rule. When the vomiting and epigastric pain have ceased, half-a-teaspoonful or teaspoonful doses may be given once in fifteen minutes of pancreatinised milk, koumiss, Liebig's or Valentine's ^g DIET IN DISEASE. meat extract, iced dry champagne, or good Rhine wine. If such foods are retained, they may be followed after some hours by a few spoonfuls of pressed beef juice, salted, and later still by warm, nourishing beef broths, chicken broths, gruels, or buttermilk. Stimu- lating or nutrient enemata should still be ordered, because in the early stages of convalescence the stomach will not tolerate all the food which the impoverished tissues require. Any epigastric ful- ness or distress, or tympanites, should be regarded as a warning, and food should be again withheld until the difficulty is corrected by antacids or antifermentatives. It is to be noted that children usually require rectal feeding and stimulation even earlier than adults. Large doses of opium given to aid the retention of nutrient or stimulating enemeta should be avoided on account of the tendency to suppression of urine. In mild cases, after four or five days, and in severe cases after a fort- night, solid food may be occasionally given, commencing with milk, toast, crackers, junket and "cream custard, farina and boiled or broiled chicken, soft-cooked eggs, wine jelly, boiled rice, scraped beef, and similar nourishment. Fruits and vegetables should not be allowed for several weeks. PYyEMIA AND SEPTIC>dVIIA. In all septic conditions the diet must be made as nutritious as possible, and alcoholic stimulation must be given with a free hand, brandy or whisky being the best forms. As a rule, the diet must be fluid, but in very chronic cases and those accompanied by prolonged local suppuration easily digestible solid food such as broiled fish or beefsteak or chicken, oysters, toast, light bread and butter, and light farinaceous articles with cream may be allowed. The general directions given in the article upon the diet of fevers and con- valescence are applicable here, and as the patient improves, the stimulating diet recommended for some cases of tuberculosis (see Dietetic Treatment of Tuberculosis, page 439) is recommended. MALARIAL FEVERS. Intermittent Fevers. The dietetic management of malarial fevers consists of the treatment during the paroxysms and of that between them. In intermittent fever the paroxysms although severe, are comparatively brief. Vomiting often accompanies the chill. If the patient is disinclined to take food there is nothing to be gained by urging it upon him, and the stomach may be allowed to rest for a day. Otherwise a glass of milk or a cup of broth may be given. When the paroxysm is over, if the appetite returns, solid TETANUS. 427 food may be given without much restriction. If a patient has had several attacks at brief intervals he is usually both anaemic and con- stipated, and the subsequent diet should contain a liberal proportion of animal food to counteract the former condition, and of fresh fruits and green vegetables for the latter. Beyond these general directions but little is usually necessary. Remittent Fevers. In the continued malarial fevers, indiges- tion or feeble digestion may be a prominent symptom, requiring a milk diet while the fever is at its height. The reader is referred to the article upon the Treatment of Fever in General (page 387), which will cover the ground for these cases, as they present no peculiarities. Patients with malarial fever are very apt to resort too freely to the whisky bottle, and overstimulation in the continued fevers is a common fault. Only the severer forms of Southern and tropical agues, bilious remittent fever, etc., require much alcohol. The die- tetic treatment of the latter corresponds with the directions given for that of yellow fever (page 424), TETANUS. Symptoms. Tetanus is an acute infection caused by a bacillus which enters the body through an abraded surface, develops toxines in the system, and causes greatly exaggerated irritability of the cen- tral nervous system. With the heightened reflexes, tetanic contrac- tion of the voluntary muscles occurs, especially of those of the jaw, face, and the extensors of the back. The ordinary reflex action from peripheral excitation is so far intensified that the slightest pressure on the surface of the body, or change in surrounding temperature, or even a loud sound, may throw the patient into violent convul- sions and painful tonic spasms. Efforts in swallowing may induce them. The muscles of the jaw are often set in a condition of rigid contraction, making it impossible for the patient to open the mouth to take food, and forcible efforts to separate the teeth excite convulsions. It is necessary to support the strength by every available means, for tetanus is not invariably a fatal disease, al- though, according to Gowers, death results in about 90 per cent of all cases. Recent successful inoculation experiments with immu- nised serum offer the hope that recovery may be possible in a larger number of cases provided the strength of the patient, which is rapidly exhausted by convulsions, can be maintained. Dietetic Treatment. Food can only be given in liquid form, but if a front or side tooth is absent a soft-rubber catheter may be passed in between the. teeth and fluid can be conveniently poured into the mouth through it. Milk, egg albumen, eggnog, nutritious beef, mutton, or chicken broths, malted gruels, wine, brandy, and 428 DIET IN DISEASE. whisky should be given as frequently as the condition of the patient will admit. If possible, from two to four ounces should be adminis- tered every hour. The spasm does not affect the involuntary muscles, so that food is swallowed if it can be placed far back in the pharynx. Alcoholic stimulation and nourishment can also be given by the rec- tum, but this method is as apt to excite convulsions as mouth feed- ing. If severe convulsions are induced by every attempt to feed the patient, it becomes necessary to put him under primary anaesthe- sia by the inhalation of chloroform, and then a tube may be passed into the stomach, through which twelve or sixteen ounces of soup or predigested milk, eggnog, and stimulants may be poured. By this means he is disturbed much less often and larger quantities of nour- ishment are taken at one time. In a recent case of tetanus which came under my observation, and in which tetanus bacilli were found, the muscular spasms were intense and almost continuous for over five weeks. The difficulty in feeding the patient was extreme, and emaciation was very pronounced. He complained incessantly of thirst, and often of hunger, but he was able to swallow milk broths and stimulants given between the closed teeth in very frequent doses, and his final recovery was attributable mainly to persistent efforts at careful feeding, anaesthesia having been several times suc- cessfully employed. RABIES. In feeding a patient with rabies, substantially the same plan is to be followed as that above described for tetanus. In some cases, however, even in the early stages, all efforts to swallow fluid food excite violent general convulsions. Osier suggests that this spasm may be lessened by application of cocaine to the throat, so that the patient can swallow. Failing this, nutrient enemata must be relied upon, but they also sometimes excite convulsions. In this case it is justifiable to produce primary anaesthesia with chloroform, and to seize the moment of temporary relaxation for feeding. TUBERCULOSIS. Causation. Tuberculosis is an infectious disease, due to the presence in some part of the body of the Bacillus tuberculosis. The disease may be either acute or chronic, but in all cases fever is pres- ent whenever there is an exacerbation of the symptoms. The latter are both local and general, and vary with the particular organ or organs affected, but the lungs constitute by far the most frequent site for the development of the germs. The- bacillus produces from the tissue or soil in which it grows a toxine or poisonous substance which enters the circulation by absorption and which modifies nutri- TUBERCULOSIS. 429 tion, causing pyrexia and an increased production of tissue waste, with more or less rapid emaciation. Several factors combine to disturb the digestive system. These are : 1. The fever itself. 2. The impoverished condition of the blood, which affects the quality and quantity of the digestive juices. 3. In pulmonary tuberculosis, after the expectoration becomes considerable it is often ropy and tenacious, and some of it is very apt to adhere to the surface of the mouth or pharynx, and be swal- lowed with the food or saliva, with the result of exciting gastric and intestinal catarrhs, or possibly of locally infecting the mucous mem- brane of the intestine with the bacilli, which produce ulceration with further impairment of the digestive functions and of absorption. The prognosis of a given case depends very largely upon the digestion. General Consideration of Dietetic Treatment. Proper diet- ing is unquestionably one of the most important factors in the pro- phylactic as well as the active treatment of pulmonary tuberculosis, and in prescribing a regimen many things must be taken into con- sideration besides the mere classification and selection of food. The disease may be exceedingly protracted, lasting for years, with in- tervals in which the patient enjoys a comparative degree of health and comfort, which temporarily emancipate him from dietetic re- strictions. But even then he should see to it that his food is ample for his bodily needs. Malnutrition at any time may excite a latent tubercular process to renewed activity, and, on the other hand, an increase in body weight is accompanied by marked improvement in the symptoms of the disease. Since the disease is so chronic the pecuniary circumstances of the patient must be considered. By ordering him to abandon his only means of livelihood or to undertake a long and expensive journey he may be so impoverished that he cannot afford to procure the best food, which is so essential both to repair the tissue waste, which sooner or later is a prominent feature of the disease, and to supply energy ; and good climate is of little use unless it helps him to acquire a better appetite and easier digestion. The appetite, too, must be consulted. It is sometimes better to humour whims than to seek to combat them, and inflexible rules can no more be enforced for dieting than for medication. The appetite is often very poor or capricious, and the physician's dietetic expe- dients will be severely taxed to devise suitable foods which meet all requirements. The patient should be given a list of foods which he can regularly eat, foods to be avoided, and foods which he may have as an occasional indulgence. .,Q DIET IN DISEASE. Young phthisical girls especially are apt to long for sweets and confectionery, and despise the more wholesome animal food; in fact, some writers regard this as a symptom of the disease in such cases. If they cannot have what they crave they will refuse what they are allowed, and much tact and persuasion is required to induce them to eat rationally. Since so much depends upon sustaining the nutrition and strength of tuberculous patients, it is of the utmost importance to keep the stomach and bowels in the best possible condition. Patients should be warned never to swallow their sputum, for this always excites dyspepsia, and sooner or later gastric catarrh. The occurrence of the latter is also favoured by the habit, which many patients acquire, of perpetually taking cough medicines and patent "sure cures," many of which contain potassium iodide and other gastric irritants. In advanced cases the catarrh may be a sequel to enfeebled circulation. All food should be fresh and carefully selected, and the cooking should be as simple as possible without monotony. Viands should be savoury, and served in a manner to tempt the palate. The most important articles of diet for the consumptive are the animal foods, and milk, beef, and fats and oils should form the essen- tials, rather than too much meat ; but in ordinary cases any variety of properly cooked animal food may be eaten. Starches and sugars are allowable in milder cases, but never to the exclusion of nitrogenous aliments, and not at all if gastric catarrh exists. In phthisis there often seems to be a failure to assimilate amyla- ceous and saccharine food, which is beyond that which is explainable by the presence of catarrhal conditions. These substances, which or- dinarily furnish a large proportion of the energy of the body, in tuberculosis appear to do so less readily than the fats and proteids. Growing children, however, require more carbohydrates than do adults. Malt is especially valuable as a tonic in tuberculosis, and the diastase aids assimilation of farinaceous foods. Great diversity exists among different phthisical patients in the power of assimilation of food, and even in individual cases during the progress of the disease. Bauer says : " One not infrequently sees phthisical patients who consume the full hospital diet without any visible ill effects, although their evening temperature oscillates between 39 and 40 C. (102 to 104 F.). With such patients one need feel no anxiety as to the choice of foods, provided their nutritive value be the same." Rest is important in its relations to digestion, and patients should not eat when fatigued. Great benefit is often derived by lying down and quietly resting, even without sleeping, for half or three quarters of an hour before dinner and supper. It is best to take the principal TUBERCULOSIS. 431 meal in the middle of the day unless there is fever at that time or soon after it, in which case a hearty breakfast and a light lunch will be better borne. If much hectic fever is present, it is desirable to employ the intervals when the temperature is low for feeding, and it often hap- pens that a hearty meal taken between 7 and 10 a. m. may be better digested than at any other time of day. Patients should avoid eating more food at any one time than they can comfortably digest, and it is often best to give food five or six times in twenty-four hours, to avoid overworking the stomach. If the digestion is feeble, it is best to give only one article of food at a time, or else only such varieties of food as require the same length of time for digestion (page 322), and patients often do better when they eat all their animal food at one meal and vegetable food at an- other, having regard to the separate action performed by the stomach and intestines upon these different food classes. If there is stomach catarrh or if the gastric juice is feeble the quantity of fluid taken with meals should be restricted to a minimum, excepting in very ad- vanced cases, in which the diet may be necessarily entirely fluid. But half a pint of very hot water may be taken with advantage half an hour before each meal, to cleanse and stimulate slightly the gastric mucous membrane. Loomis wrote: "When the pressure of food in the stomach ex- cites cough, or when paroxysms of coughing have induced vomiting, the ingestion of food must be delayed until the cough ceases, or an appropriate sedative may be employed. In those extreme cases where every attempt at eating excites nausea, vomiting, and spas- modic coughs, excellent results are attained by artificial feeding through the soft rubber stomach tube." Meats. Raw beef is extolled by many physicians, especially among the French, as possessing peculiar nutritive and even cura- tive value for tuberculosis, and in the popular mind its blood-red colour and scarlet juice seem to suggest an intimate connection with blood formation. It is true that blood and muscle have great simi- larity of composition. The red wines are regarded by laymen in the same light. It has yet to be demonstrated that raw meat possesses any advantage over rare steak or underdone roast beef beyond the fact that the scraping and mincing process to which it is usually subjected prepares it somewhat better for solution by the gastric juice. Patients will often take scraped raw-meat balls contentedly for several days, and then acquire a distaste for them. This may be overcome by seasoning with a little aromatic herb, such as thyme, parsley, or marjoram. Yeo suggests that when made into small balls the meat may be covered with pov/dered sugar or gum, and swallowed 30 DIET IN DISEASE. 43- with a sip of wine or brandy, or the mouth may be rinsed with claret to remove the after-taste. Both scraped beef and the various preparations of beef powder, beef meal, etc., are useful to re-enforce broths, hot milk, milk punch, or light soups of vermicelli, tapioca, etc. According to Prof. Chit- tenden (Trans. Philadelphia County Med. Soc, 1891), the nutritive value of lean beef being placed at 100, that of beef peptonoids is 140 and that of Mosquera's beef meal is 400. If preferred, from one to five ounces of beef meal may be eaten daily, spread like jam upon bread and butter. Insomnia may be often prevented by taking on retiring a cup of hot bouillon, clam broth, or gruel, with a cracker or two. Beef juice, extracted by a small meat press, may be ordered two or three times a day. It may be seasoned and drunk Hke bouillon, or eaten as a luncheon upon dry toast, crackers, or boiled rice. H. P. Loomis gives the following useful details in regard to the preparation of this important food : " To obtain from the meat the maximum amount of juice, a meat squeezer is absolutely essential. There are a number of good ones in the market, which range in price from one to three dollars. The best kind of meat from which to squeeze the juice is a thick round steak free from fat. This should be seasoned with pepper and salt, broiled over a brisk fire, then cut in pieces two inches square, and then put into the meat squeezer. About eight ounces of juice can be obtained from each pound of meat. No heat can be applied to the juice, as the albumin would be at once coagulated and the juice rendered worse than useless. If the juice becomes cold and it is advisable to heat it, this can be best accomplished by placing the cup in hot water. It is necessary to go fully into the preparation of the beef juice, because of its im- portance as one of the most essential items in the diet of phthisis. Freshly squeezed beef juice is the best of the artificial preparations of meat known, and the trouble of preparing it is well repaid by the marked improvement in the patient." It is often desirable to give dilute hydrochloric acid and a little pepsin after the ingestion of meat or other animal food unless it has been predigested. Eggs. Eggs are not well borne if there is dyspepsia or decided gastric catarrh. Otherwise they are nutritious and wholesome. They may be given raw, beaten, or very lightly cooked in hot water, but never hard boiled. They may also be eaten scrambled or as an omelet if lightly made. Egg albumen will often be well digested when the yolk proves too rich. " A raw egg sucked from the shell will often relieve an irritable condition of the larynx " (H. P. Loomis). TUBERCULOSIS. ^jj Cereals. Cereals may be used in the early stage of the disease, before the alimentary canal is much disturbed, and such foods as corn mush, farina, oatmeal, wheaten grits, or germea may be allowed with cream. If cream and sugar disagree, they may be eaten with lemon juice. Fruits. The succulent fruits are well borne in mild cases, and are very wholesome and nutritious. Baked and stewed apples may be given, with cream. Fats and Oils. Fats and oils are indicated in tubercular disease, and especially in pulmonary phthisis, in as large amounts as the pa- tient may be able to digest. Crisp fat bacon, butter, cream, whole milk, egg yolk, cod-liver oil, and olive oil all furnish desirable forms of fat when the intestine absorbs them. While fat is being taken it is well to occasionally observe the stools to see that none passes away undigested, and if any one fat disa- grees and causes dyspepsia its use must be restricted, or temporarily withheld while another is tried. As a rule, cream, butter, and cod- liver oil will prove the best. Fats, well digested, seem in some in- stances to have an almost curative power, so greatly do nutrition and body weight improve during their use. Cod-liver Oil. The use of cod-liver oil in phthisis should be determined by the condition of the digestive organs and the general nutrition of the patient. Wherever the digestion is fairly good, in the absence of gastric catarrh, the oil is of great nutritive value, and it is usually well borne when properly administered. If there is much gastric catarrh or if the stomach is irritable and nausea is easily ex- cited, persistence in the use of the oil will only make matters worse. It should be at least temporarily discontinued, though in the chronic forms of tuberculosis unaccompanied by fever, in which debility and emaciation predominate, cod-liver oil is often well tolerated. Cod-liver oil is on the whole more satisfactory for children than adults, particularly in cases of tuberculosis in which the bones or glands are enlarged. The presence of diarrhoea is to be regarded as a contraindication for the administration of cod-liver oil, but unless it is given in large quantities it has very little if any laxative effect upon adults, and it may usually be continued in doses of a drachm two or three times a day, with no ill effect, and, in fact, by improving the nutrition it may sometimes benefit diarrhoea. Ringer suggests that for this class of patients a teaspoonful or more of the oil given at night before sleep may be better borne than at any other time in the day. The state- ment is usually made that persons with phlegmatic temperaments, with dark, sallow complexions, derive more nutrition from cod-liver oil than do others, but it is doubtful whether it can be applied any more distinctly to cod-liver oil than to other classes of food. .^. DIET IN DISEASE. Commonly it is best to give the oil pure and uncombined if it can be tolerated. It may be given in capsules, although they are not always dissolved at the proper time in the stomach. Patients who require alcohol may take the oil in whisky. For the many dif- ferent methods of administering it and of disguising its taste the reader is referred to the section on Cod-liver Oil (page 182). The newly isolated active principle of the oil, called gaduin, has been employed with some degree of success (page 180). Alcohol. Alcohol is not believed to possess any specific action in phthisis, and in many cases it is positively harmful. As a rule, if patients have a fair appetite and are improving in strength its use is contraindicated. When alcohol is required as a food and tonic rather than as a stimulant, the best form in which to give it is that of malt liquor or light wine. One or two pints daily may be prescribed of beer, stout, or porter, or half a pint of claret or sound Burgundy is useful if anaemia is marked. The light Hungarian, Italian, or Greek wines may be used by those whose purse places them within reach. One of the Tokay wines, with cocoa, may be prescribed. Sweet wines, sherry, port, Madeira, and champagne are not as useful. They are more apt to disagree, and cause dyspepsia and headache. The promiscuous habit of daily drinking rum, whisky, or other strong liquors in tuberculosis is to be condemned, although nearly all cases at some time in their course demand alcoholic stimulation. No class of patients exhibits more painfully and rapidly the inroads of the disease than those who for a long time have been preserving their own tissues, like pathological specimens, in daily draughts of strong alcohol. The cirrhotic changes which occur in various or- gans are the best possible preparation for the advancement of tuber- cular processes. If the exhibition of alcohol increases the tempera- ture and the pulse rate, and is followed immediately by greater weakness, it is doing harm (Loomis). Advanced cases of tubercu- losis show great toleration for alcohol, but it does not follow that it is proportionately benefiting them. When in the course of an ordinary case the hectic fever becomes high and exhausting, the pulse feeble and rapid, and the digestion fails, it may be best to lessen the quantity of food and give more stimulation. Usually three or four, but seldom more than eight, ounces of whisky, brandy, or rum may be required daily for this purpose. Special pains should be taken to use only such liquors as are strictly pure and of the best quality. Diet in Mild Cases. The following liberal menu will furnish abundant variety from which to select the dietary for tubercular patients in whom the prog- gress of active lesions is in abeyance or completely arrested, and in whom there is little or no gastric catarrh : TUBERCULOSIS. 435 FOODS ALLOWED IN NON-ACTIVE CASES WITHOUT GASTRIC CATARRH. Soups and broths : Mutton, oyster, clam, barley, vermicelli, bou- illon, chicken with rice. Purees of peas, beans, tomatoes, celery. It is often well to add to them meat extracts, peptonoids, beef meal, etc. Milk or cream in any form, including buttermilk and koumiss, clotted or Devonshire cream, whipped cream, etc. Shellfish : Oysters or clams, either raw, roasted, or broiled (the livers or "soft parts" only). Fish of any kind if fresh, either boiled or broiled (never fried), sardines (if they " agree " ) for the sake of the oil. Eggs, preferably raw or very lightly cooked, or in eggnog or cus- tard, also poached, scrambled, or in plain omelet (never hard-boiled). ^[eats : Beefsteak, rare roast beef, scraped-beef sandwiches or meat balls, lamb or mutton, roasted or boiled ; chops ; chicken, capon, turkey, either roasted, boiled, or broiled. Game : Partridge, squab, woodcock, snipe, prairie chicken, quail, roasted or broiled. Meats, especially beef and mutton, should predominate. Gelatin may be used, but it is not very nutritious. It should be combined with meal or meat preparations. Entrees : Sweetbreads. Fats and oils (as much as can be digested) : Good fresh butter, olive oil on lettuce or raw tomatoes, cod-liver oil, the fat of beef or mutton (if it "agrees"), cream (on everything with which it can be appropriately eaten), a little fat bacon. Pancreatin or pancreatic emulsions will aid the digestibility of fats. Vegetables : Baked potatoes, tomatoes stewed or raw, very young green peas, string beans, spinach, celery (stewed), onions, boiled asparagus, lettuce, cauliflower. All vegetables to be eaten in moderation. Cereals: Whole-meal bread, wheaten or rye only if stale or toasted. Zwieback, rusk, milk toast, cream toast, crackers, malted bread and biscuit, rice in any form, mush, hominy, farina, cracked wheat, wheaten grits, oatmeal, macaroni, spaghetti. Some authors recommend lentil flour, on the ground that it con- tains both iron and phosphorus. Oatmeal contains considerable fatty matter, and maize has still more. All cereals are to be eaten spar- ingly. Fruits : Apples, baked or stewed, oranges, shaddock, grapes, pears, peaches, plums, strawberries, blackberries, olives. Desserts: Wine jelly, custard, blancmange, rice pudding, bread pudding, junket and cream, Bavarian cream. .-5 I>IET IN DISEASE. Avoid fried foods, rich sauces, pastry, cakes, hot breads, ragotits, beans, carrots, turnips, cabbage, confectionery, puddings, dried foods, salt fish or meats (except as specified above). Beverages Allowed. Water, tea, coffee, cocoa, milk, koumiss, mat- zoon, buttermilk, milk punch, lemonade or orangeade, Vichy or other aerated water, non-fermented grape juice, malt extracts. Alcohol : Beer, ale, porter, wines, liquors, are permissible only if needful for special symptoms that is, if desirable for food or to aid digestion and promote exercise. H. P. Loomis gives the following useful sample diet, with the ap- propriate intervals for taking food. A glass or two of milk may be added at night with advantage : " On Awakening. Eight ounces of equal parts of hot milk and Seltzer, taken slowly through half an hour. ^'Breakfast. Oatmeal or cracked wheat, with a little sugar and an abundance of cream, rare steak, or loin chops with fat ; soft- boiled or poached ^gg, cream toast, half pint of milk, small cup of coffee. '''Lunch, lo A. M. Half pint of milk or small teacup of squeezed beef juice, with stale bread. 12, noon : Rest or sleep. ^^ Midday Meal, 12.30. Fish, broiled or stewed chicken, scraped- meat ball, stale bread, and plenty of butter, baked apples and cream, two glasses of milk. ^^ Lunch, 4 p. M. Bottle koumiss, raw scraped-beef sandwich, or goblet of milk. 5.30 p. m. : Rest or sleep. "Dinner, 6 p. m. Substantial meat or fish soup, rare roast beef or mutton, game, slice stale bread, spinach, cauliflower, fresh vegetables in season (sparingly)." Diet in Advanced Cases. It not rarely happens that patients who have suffered much from indigestion in the earlier stages of phthisis finally reach a condition in which, although greatly emaciated and prostrated, they seem able to eat and digest a much larger variety and quantity of food than before. As these cases are utterly hopeless, it is often best to let such patients select their own diet, providing only that it is nutri- tious and of a quality which does not excite cough or diarrhoea. If the bowels are not too loose, fresh fruit, especially oranges, may be allowed, and proves very refreshing. In very advanced cases, and in all cases during acute exacerba- tions of severity, with marked prostration, the patient must have food every two or three hours, and the intervals of feeding should never be longer than the latter. A diet consisting very largely of milk or milk and cream is best, but broths and pancreatinised meat preparations, albumoses, and egg albumen may be added. TUBERCULOSIS. 437 Milk Diet. Milk is a food which is especially adapted for con- sumptives, many of whom do best when living upon it almost ex- clusively, while others should drink it freely in connection with other nourishment. It is fattening, is assimilated without over- taxing the digestive organs, and taken hot, either alone or with an equal part of Vichy, it is soothing to the throat and ameliorates the cough. Advanced cases of tuberculosis living upon full milk diet should take between two and a half and four quarts a day, but not over eight ounces at once. It should be sipped, or really eaten, and not drunk, for it then will coagulate by slow degrees in the stomach and not form large indigestible curds. This should be insisted upon and ten minutes should be occupied in drinking half a pint. If the milk (disagrees at first it may be modified in any one of the ways sug- gested on page 64, but it is best not to give it in connection with beef juice. In this country cow's milk is preferred, but elsewhere the milk of other animals serves equally well. Goat's milk, drunk largely in Switzerland, contains more salts of lime and is good for cases of tubercular diarrhoea, and sometimes ass's or mare's milk proves more digestible. The latter varieties are principally used in Russia. Lebert's Milk Cure (from Bauer). " Lebert directs the pa- tient to drink slowly three hundred to five hundred grammes of milk every morning and evening, between five and six o'clock, fasting. He prefers it freshly drawn from the cow, and if, in consequence of having stood for some time, a separation of the cream has already begun, recommends it to be skimmed off. " During the continuance of the milk treatment the patient is al- lowed a substantial dinner, at least of soup, roast meat, young vegetables, stewed fruit, etc., and a little beer or wine. At the dis- cretion of the physician a proper breakfast may be taken an hour after the morning's milk of a cup of tea with plenty of milk and bis- cuits and, perhaps, one or two light-boiled eggs, and again in the evening a good soup, as well as, when possible (i. e., in the case of non-febrile patients), some more roast meat. If milk is well borne, the regular breakfast and supper may be supplemented by further doses of one hundred to two hundred grammes of milk." Whey or koumiss may be drunk instead of milk. For those who can digest it, cream is an excellent food. With some patients cream diluted with an equal bulk of hot water agrees even better than milk. The taste, if complained of, may be modified by a very little tea or coffee, or salt or sugar. Yeo sometimes adds a teaspoonful of rum or brandy or aromatic spirits of ammonia. Some patients can take a quart of cream besides a quart and a half of mWk per diem with profit. 438 DIET IN DISEASE. SURALIMENTATION. Suralimentation, called also "superalimentation," or "forced feeding," is based upon the theory that the best method to combat the symptoms of phthisis is by " stuffing " the patient with all the food which he can possibly digest. More food is needed than in health to counterbalance rapid tissue waste. The appetite is not always a reliable indication of the strength of the digestive organs, and, acting upon this fact, Debove introduced the plan of feeding by means of the oesophageal tube. It is only necessary to use this method when a patient loses all appetite, or acquires a positive dis- gust for food, and rapidly emaciates in consequence. The tube is employed in the manner described for feeding cases of insanity, and any form of desirable fluid food is introduced through it. It is sometimes only necessary to pass the tube to the level of the oesoph- agus, and the first few times that it is used it may be well to brush the pharynx with a two-per-cent solution of cocaine. The meals may be given three or four times a day, or a patient whose appetite is not wholly lost, but is inadequate, may prefer to eat part of his food himself and have other meals furnished through the tube. The following are the foods most suitable for tube feeding: I. Milk and its preparations; cream. 2. Raw eggs, eggnog. 3. Meat extracts, beef meal or powder. 4. Leguminous purees and cereals, thoroughly cooked and made fluid by predigestion with malt extract. A quart may be given at a time. If gastric catarrh is present the gavage should be preceded by lavage. Debove, speaking of his method, says: "A patient who has no appetite, or who has a decided disgust for all food, will digest per- fectly a large meal introduced by the tube, and even at the end of a certain time will recover appetite." His method is first to wash out the stomach with cold water, and then pour in through the tube a litre of milk, one hundred grammes of fine meat powder, and an egg. He adds that with suralimentation night sweats, cough, and ex- pectoration are all reduced or disappear completely, while there is considerable gain in weight and strength and improvement in the physical signs in the chest. Suralimentation may also be conducted without the stomach tube in patients who are able and willing to eat. They maybe given five or six meals a day. This appHes to patients who are not having severe hectic fever, and in whom gastric catarrh is not a prominent symptom. Should vomiting occur during the treatment, it will be necessary to suspend it until the stomach is again in order. As a rule, in such instances it is better to discontinue medicines than food, if both are being taken. The presence of moderate fever TUBERCULOSIS. 439 one or two degrees is not in itself alone a contraindication for forced feeding, or for keeping the patient confined to bed. The gain of appetite which often accompanies removal to a favourable climate may be utilised to promote forced feeding. The following diet recommended by Solis-Cohen serves as a good illustration of the proper regimen in the cases under discussion : "Diet for Forced Feeding. "The patient is to take a pint of hot water in the early morning to stimulate the stomach and cleanse it of mucus accumulated over- night. " A half hour after the morning bath, milk punch and beef meal or peptonoids. " Breakfast, a half hour later, consisting of rare steak or chop, eggs, sliced tomatoes, bread with plenty of butter, or cracked wheat and cream. In two hours, koumiss or soup, milk, bread and butter, celery salad, broth, and peptonoids. "Dinner^ i p. M. Bouillon, rare beef, greens, Burgundy, beer, fruits. "3^r4P. M. Koumiss, cream, or milk punch, peptonoids, malt extract. , " 7 p. M. Supper, like breakfast. " 9 or ID p. M. Cream and cocoa or coca wine, milk, and pep- tonoids." The patient should keep milk, or peptonoids, or some nutritious beverage by the bedside to be drunk if he awakens in the middle of the night. Another diet well suited to some patients is thus outlined by Weber in his Croonian Lectures for 1885 : " 7 A. M. While still in bed, a cup of milk with a dessertspoonful of Cognac or lime water, or a cup of tea or cocoa, with bread and butter. " 8.30 to 9 A. M. After dressing, milk and tea or coffee, bread and butter, fish, ham, or bacon. "n A.M. Milk, koumiss, or broth, or a sandwich and glass of wine. "i to 1.30 P.M. A substantial meal of meat, poultry, fish or game, fresh vegetables, a light pudding, fruit, and a glass of wine. "4 P.M. Milk or koumiss, tea or coffee, with bread and but- ter or biscuit. <' 7 P. M. Another meal like that at i p. m. "9.30 /^ 10 P. M. A cup of milk, bread and milk, or milk or cream and farinaceous food, such as Hart's, Liebig's, Nestl^'s, or Mellin's. A glass of brandy if there are night sweats." The question may properly be asked whether it is not possible . .Q DIET IN DISEASE. to overfeed patients in this manner ? This will happen when the increase in body weight exceeds the breathing capacity of the lungs in other words, when the facilities for oxygen supply are dispropor. tionate to the bulk of tissue to be supplied. The symptoms will be a coated tongue with dyspepsia and biliousness, increased pulse frequence, and possibly increased dyspnoea on exertion, all occurring without aggravation of the local physical signs. The food must then be reduced in amount. Both fluids and solids are to be re- stricted, and fish may replace meat temporarily. Aids to Dietetic Treatment. It is not within the scope of this work to discuss the details of hygiene, but they should be at least mentioned as important ad- juncts to dietetic treatment. In those cases especially in which forced feeding is recommended it is desirable to promote oxidation in every way. Patients should live in the open air all they can, and, if possible, should go to a climate which enables them to be outdoors all day long. Habits of moderate exercise, instruction in proper methods of breathing, cold bathing, massage, and reasonable mental diversion and good cheer are all useful factors in improving the digestion and assimilation of food. Worry and nervous strain of every kind should be avoided. Of the long list of medicinal remedies which have from time to time won favour or notoriety for the treatment of tuberculosis, those which have best withstood the test of practical experience are the ones which, like creosote, act mainly by maintaining asepsis and preventing malfermentation in the alimentary canal. It is imma- terial whether cod-liver oil be considered as a medicine or as a food. It has already been discussed as a food. In a negative way it should be stated that one of the best aids to digestion consists in prevent- ing the patient from disordering the stomach and the appetite with all manner of cough mixtures and ill-advised tonics. Such medicines as may from time to time be required for emer- gencies will be much better absorbed if the stomach has not been long kept in a state of dyspeptic irritability. Diet "Cures" for Phthisis. Many special forms of dietetic treatment have been devised and extensively practised for the cure of pulmonary tuberculosis. The details of these " cures " are elsewhere described. The principal ones are the " Milk Cure " (page 44), the "Whey Cure," the "Kou- miss Cure" (page 71), practised chiefly in the steppes of south- eastern Russia, and the " Grape Cure " conducted at Meran, Mon- treux, and elsewhere in the months of September and October. Aside from climatic influences and the effects of good hygienic THE RESPIRATORY SYSTEM. 441 surroundings, their benefits are attributable only to the fact that the patient is encouraged to take a large quantity of easily di- gestible food and live constantly in the open air. Patients with chronic phthisis are notoriously sanguine as to the possibilities of their ultimate recovery, and it is also true that their mental state reacts to a greater degree upon their physical condition than in almost any other disease. All manner of absurd foods, such as fish roes in Germany and snails in the south of France, have achieved fame with credulous persons as possessing specific virtues in the cure of phthisis. It should be as much the duty of the physician to protect them from the chagrin, disappointments, and expense of following dietetic illu- sions as to encourage them in every reasonable effort for improve- ment. Beyond the requirements of a good, nourishing, easily diges- tible diet, there is no specific food "cure " for tuberculosis, as there is no medicinal cure. DIET IN DISEASES OF THE RESPIRATORY SYSTEM. Laryngismus Stridulus, In children who are subject to spasmodic croup the .ittacks are often precipitated by dyspepsia caused by overfeeding and nurs- ing, by improper food, or by constipation. The diet must therefore be regulated according to the rules laid down under the heading Infant Feeding. The habit of night feeding especially should be given up after the first month of life. This can usually be done after two or three trials. If the infant awakens crying at night it must be offered a little cool water, and it may presently drop asleep. Up to the fourth month six meals a day, three hours apart, are all that are allowed, and from that time on until the second year five meals must suffice. Between the attacks the milk should be lessened in amount, and so modified as to insure more perfect digestion. Children over six months of age should be given from one to three tablespoonfuls of pressed beef juice in a day. Older children had better be kept upon a fluid diet of meat broths, milk, and egg albumen, solid food being withheld until the seizures abate. Cod-liver oil should be given in most cases. Tubercular Laryngitis. In tubercular laryngitis intense pain is excited by the act of deglutition. Nutritious but non-irritating food is therefore required. Thick soups and gruels, purees, cream, beaten raw eggs, scraped rare beef, raw oysters, junket, can all be swallowed more readily .,^ ^ DIET IN DISEASE. 442 than very fluid or solid food. Strong condiments, vinegar, and salt must be avoided, for they increase the pain. The difficulty experienced in deglutition is considerably relieved by the method proposed by Wolfenden, which is to have the patiei\t lie prone on a lounge, and with his face protruding over the lower edge he is to suck through a glass tube semifluid food from a tumbler on the floor. Sajous advises the patient to lean over forward when eating, which, he says, " causes the food to pass down along the pyriform sinuses, thus avoiding the upper portion of the larynx, contact with which causes the severe pain experienced by advanced cases during the act of deglutition." HEMORRHAGE OF THE LUNGS. Haemorrhage of the lungs, or rather from the bronchial mucous membrane, when occurring suddenly and in considerable amount, greatly reduces the strength, and naturally alarms the patient and excites the nervous system. Absolute quiet must be immediately secured by rest in bed without a pillow, so that the body may lie flat, and the head and arms should on no account be raised. The room should be kept quiet and the patient must not be allowed to speak or to feed himself. A reliable and quiet nurse should be secured for him, and he should be fed upon a nutritious diet, which requires no effort in eating. Small quantities only of fluid should be given at one time through a glass tube or by a teaspoon, so that the head need not be raised. If nausea occurs, every effort must be made to control it, for the violent muscular action and the tem- porary circulatory and respiratory disturbances occasioned by the act of vomiting might excite further haemorrhage. It is desirable to reduce the blood pressure in the lungs as much as possible in order to allow coagulation of the blood to occur over the oozing sur- face of the bronchial mucous membrane, and therefore large quan- tities of fluid should not be given at first. The patient is usually thirsty from the loss of blood and temporary drying of secretions. The thirst may be relieved by crushed ice and small quantities of cold acidulated drinks, such as very dilute phosphoric acid or sour lemonade, and if the stomach is in normal condition, plain milk may be given or else pancreatinised milk and strong beef broth in quantities not exceeding two or three ounces in as many hours. It is customary to administer all fluids cold, but the advantage of this is overrated. Warm fluids have a somewhat more stimulat- ing effect upon the heart, and are more rapidly absorbed, but the idea sometimes advanced that the cold of iced fluids taken into the stomach is ever sufficient to constrict the bleeding bronchial ves- sels, even by supposed reflex action, does not appear rational. For THE RESPIRATORY SYSTEM. 443 a full discussion of this question the reader is referred to experi- ments reported upon page 311. If coincident gastric disorder is present with bronchial haemor- rhage, to forestall vomiting it may be better to resort to nutritious enemata. In cases where exceptionally large quantities of blood have been lost, the blood pressure may be greatly reduced and the danger of death from heart failure may appear imminent. It then becomes necessary to give a larger quantity of fluid, and the rules in regard to the dietetic treatment of severe and sudden hemorrhage taking place anywhere from the body must be observed. Salt and water, a teaspoonful to the pint, may be injected into the rectum, or even beneath the skin. Most cases, however, are more mild, and after a few hours of rest and quiet, furthered, perhaps, by the hypodermic injection of morphine, the patient will be able to retain a little sim- ple semisolid food, such as milk toast, a beaten egg, junket, etc. If there is no return of the haemorrhage in a day or two, the diet should be increased and anaemia consequent upon the bleeding must be treated by an abundant meat diet. As a rule, alcoholic stimulants should be avoided, on account of the relation of blood pressure to the bleeding, or they should be given in moderation, unless the danger of heart failure is imminent. Acute Capillary Bronchitis. In acute capillary bronchitis in infants and children a wholly fluid diet of the simplest but most nutritious kind must be enforced. In young infants milk alone, in older children milk, meat juice, meat broths, and beaten eggs or egg albumen, should be fed at least every two hours in such quantities as the stomach will bear. It may be best to pancreatinise all food. Very feeble children will require food oftener, and sometimes a teaspoonful only should be ordered once every fifteen or twenty minutes. If the child refuses food or vomits constantly, nutrient enemata (page 375) must be prescribed once in three or four hours. Brandy is the best stimulant for these cases; it is well borne, and should be given early and often. Chronic Bronchitis. The diet for chronic bronchitis is substantially the same as that recommended for the earlier stages of pulmonary phthisis, to which the reader is referred (page 434). The cough is often momentarily relieved by drinking hot lemon- ade, hot milk and Seltzer or Vichy, glycerin and whisky, and some- times by sucking a raw egg through the perforated shell. DIET IN DISEASE. 444 Asthma. Spasmodic bronchial asthma is believed to be occasioned by temporary spasm of the bronchial muscles which narrows the lumen of the tubules and obstructs the free entrance and exit of air. It is also attributed to hyperaemia and swelling of the bronchial mucous membrane, and possibly, in some cases, to a reflex spasm of the dia- phragm and other muscles of inspiration. Asthmatic patients soon find from experience that errors in diet are liable to precipitate an at- tack, and overloading the stomach or eating particular kinds of food, which are unwholesome or against which the individual possesses some idiosyncrasy, may excite dyspnoea. Aitkin showed a true ap- preciation of the importance of diet in this disease when he wrote: " More is to be done for asthmatic patients on the side of the stom- ach than in any other direction," and " the asthmatic can never with impunity eat and drink as other people." Accumulation of large quantities of undigested and fermenting food results in the production of gas in both the stomach and intes- tines, which become distended and by pressure interfere with the movements of the diaphragm and abdominal muscles in free respira- tion. The chemical irritation of undigested food may be a cause of re- flex spasm of various muscles, and may possibly affect those of respira- tion. It is therefore necessary for asthmatics to exercise care in the selection of their food and to keep the digestive organs in as nor- mal a condition as possible. All food which is constipating or which is liable through fermentation to evolve large quantities of gas should be shunned. In general, fats and sweets should be given up, and starchy food, if eaten at all, must be very thoroughly cooked and slowly masticated, in order that the salivary digestion of it may be as complete as possible. Pork, veal, and cheese must never be eaten, and elaborate cooking and desserts are forbidden. No water should be allowed with meals or until at least three hours thereafter. A cup of very hot water may be drunk an hour before each meal and again at night. In most persons the asthmatic attacks are worse at night, and in many they only occur at that time. It is consequently better for them to take the principal meal of the day at noon and to eat a light supper, so that gastric digestion may be finished before going to bed. The following diet may be offered as giving a general idea of the regimen for somewhat advanced cases : Breakfast. Bread and milk or well-cooked oatmeal porridge or wheaten grits without sugar (lemon juice may be added instead). A chop or a little broiled fresh fish, coffee without sugar. Dinner (not later than 2 p. m.). Beef or mutton, bread, one or THE RESPIRATORY SYSTEM. 445 two green or succulent vegetables, such as spinach, stewed celery, stewed or raw tomatoes. Blancmange or custard (not sweetened), or a little rice pudding. Fresh fruit in season, such as a peach or baked apple. Supper (6 p. m.). A soft-cooked t%g or a little cold fowl or game, stale bread, toast, or Zwieback, milk, stewed fruit (without sugar). Patients should eat very moderately, masticate thoroughly, and take their meals with punctuality. Among beverages, coffee without sugar is better borne than tea. Loomis believed that " not infrequently a paroxysm of asthma can be warded off by taking two or three cups of strong coffee immedi- ately upon the accession of the first asthmatic symptom." During an attack non-alcoholic patients may take a hot strong lemonade with whisky or a hot brandy and soda. Malt liquors are forbidden. Emphysema. Patients suffering from emphysema have more or less engorge- ment of the venous circulation, and hence are liable to catarrh of the stomach and intestines. The dyspnoea from which they suffer on exertion is considerably aggravated by flatulency, and their diet must be regulated to prevent this occurrence. In general, starchy and saccharine foods are to be avoided as constipation must be prevented. For a discussion of these principles, the reader is re- ferred to the articles upon Gastric Dyspepsia and Constipation, The patient must be particularly warned against too rapid eating and overeating. Condiments, sauces, fried and greasy food, and all obviously indigestible articles, must be shunned. Fluids should not be taken with solid food, and should be used in moderation. Water may be drunk an hour before meals, but not for three hours after. In the early stages a nourishing diet, consisting chiefly of animal food, meat, fish, milk, cream, eggs, and good butter, .should be taken. If dyspnoea predominates with frequent asthmatic at- tacks, it will be best to substitute milk largely for other foods, and in the later stages, with a feeble heart and increasing congestion of the abdominal viscera, the diet should consist wholly of milk and meat broths. Cod-liver oil is an excellent food in emphysema. Pneumonia. Symptoms. Pneumonia is an infectious inflammatory disease of the lungs, accompanied by grave constitutional disturbances, such as fever and rapid and enfeebled heart action. The mortality at some seasons of the year, and especially among debilitated or alco- holic patients, is very great, and since no known remedy can limit ^6 DIET IN DISEASE. the disease, it is exceedingly important to maintain the strength of the patient through the fev/ days during which the fever lasts, or until the crisis by which it terminates has been reached. All danger, however, is not then over, and convalescence in all cases, and espe- cially in aged persons, must be promoted by careful dietetic treat- ment. The onset of the disease is acute, and the fever is often high, reaching 104 or 105 or more on the first day. The duration of the fever varies from five to seven or nine days on the average, when it subsides by a sudden fall. The rate of respiration is greatly accelerated, with or without subjective dyspnoea. More or less cough accompanies the fever, and there is frequently delirium. Dietetic Treatment. The indications for treatment are to give a light diet, which will not excite the cough in swallowing or increase dyspnoea by distention of the stomach, or augment the en- feeblement of the heart action by overtaxing the digestive powers. Vomiting should be especially guarded against, and if nausea exists, efforts should be made at once to control it. It is not necessary to keep the patient upon a rigid milk diet, but if milk is well borne, it is advisable to give nothing else while the acute symptoms last; otherwise, milk, whey, meat juice, broths, and egg albumen may be allowed. Starchy and saccharine food must be withheld. Cold drinks are both acceptable and beneficial to the patient, and water, plain or aerated, such as ApoUinaris or soda water, may be drunk in considerable quantity. It is believed by some authorities that the activity of the kidneys may be thus promoted, and that the poison which occasions the constitutional symptoms of the disease may be better eliminated. There are cases, however, among persons with robust circulation in which the onset is very sudden and violent. The pulse is full and bounding, and the heart is greatly overworked by the effort to propel a large volume of imperfectly aerated blood. In such instances the addition of large quantities of fluid to the cir- culation, besides what is actually required for nutrition, may have the effect of still further straining the heart. It is stated that carbonated waters reduce the viscidity of the sputum, which is often very tenacious. The diet should be kept fluid until defervescence has occurred, with a normal temperature and commencing disappearance of the ex- udation in fact, it is well to prolong the fluid diet for three or four days after the temperature has become normal, in order to make sure that a relapse of the fever is not likely to follow. In those cases in which resolution is postponed and the patient becomes more and more feeble, although the temperature may be nearly or quite normal, it may be desirable to give a little properly prepared solid food somewhat earlier, and scraped beef, milk toast, or a soft cooked egg may be added to the milk diet. THE RESPIRATORY SYSTEM. 447 During the entire period of convalescence the diet must be very nourishing and of easy digestion ; milk may still be given, and after slowly returning to the regulation three meals a day (see Convales- cent Diet, page 395) patients do well to take milk punch, or egg- nog, or a glass of wine and a biscuit three or four times a day in the intervals. Aicoholis exceptionally well borne, and it undoubtedly serves both as a food and as a support to the overworked heart. The fact that it is thoroughly oxidised in the circulation or tissues is demonstrated by the large quantities which patients can often digest and absorb without toxic symptoms. Doses may be thus tolerated which in health would ordinarily produce drunkenness. In alcoholic subjects who have been drinking up to the time of the onset of the disease it is indispensable to continue the use of alcohol, for the sudden with- drawal of its stimulating effect on the organism may give rise to rapid collapse. In aged and constitutionally weak persons it is also important that its use should be begun early in considerable quan- tities. In extreme cases as much as an ounce an hour, or twenty-four ounces in the day, may be given with benefit, but ordinarily from eight to ten ounces will suffice. There are other cases found among robust subjects who do not need such stimulation, and possibly may not require alcohol at all. The custom now in vogue of prescribing other forms of cardiac stimulants, such as strychnine and aconite, and vaso-dilators, like nitroglycerin, makes the employment of ex- cessive doses of alcohol less imperative. It should always be re- membered that it is undesirable to produce toxic symptoms of alco- holism in pneumonia as well as in any other disease. So long as the pulse is slowed and its force strengthened the use of alcohol may be regarded as beneficial ; but if delirium is increased and the odour of whisky or brandy is strong in the breath an hour or two after it has been given, it is an indication that the patient is receiving more than is desirable, and the dosage should be reduced. From its serv- ing as a fuel, and thereby saving tissue waste in the muscles, the free use of alcohol in pneumonia undoubtedly saves many lives. Broncho-Pneumonia. Symptoms. Broncho-pneumonia is an inflammation of the cap- illary bronchi which extends to the lobular structures. It is common in the extremes of age, in the very old and very young. The mor- tality is greatest in children under two years of age. It is the se- quel to many of the acute diseases of childhood, and is also pro- duced by the tubercle bacillus and by the inspiration of particles of food or fluid which are drawn through the larynx to the bronchi by: inhalation during the act of swallowing. The latter variety may- Si 448 DIET IN DISEASE. occur as a result of drawing seeds or other hard substances into the bronchi; from operations about the mouth and upper air passages after tracheotomy ; and from the conditions which impair the nor- mal sensitiveness of the larynx and the reflex action of the epiglot- tis and vocal cords, such as profound uraemia or apoplectic or alco- holic coma, and post-diphtheritic or laryngeal paralysis. A few cases have been produced by carelessness in the passing of the oesophageal catheter into the larynx and pouring liquid food into it. Dietetic Treatment. Broncho-pneumonia is always a very critical disease and the utmost care is required in nursing and feed- ing. The diet should consist of such articles as meat juice, predi- gested milk, and egg albumen. Stimulation is early required and in considerable quantity. Brandy or whisky sweetened with a little sugar and cold water should be systematically given, especially to young children, who are unable to make their want of drink known. Hot milk and Vichy, in the proportion of one part of Vichy to two of milk for older children, or half-and-half for young infants, may have the effect of loosening the tenacious mucus and easing the cough. If there is any tendency to flatulency, aerated waters had better be avoided. BRONCHO-PNEUMONIA IN CHILDREN. The diet should be adapted to foster the strength and tax the digestive organs as little as possible. At first food should be given every two hours, and milk is usually all that is required. Later it may be alternated with or supplemented by egg albumen, expressed meat juice, plain beef or mutton broths, arrowroot, or other gruels. Brandy is the best alcoholic food and stimulant, and it may be ordered in doses of from ten drops to a teaspoonful well diluted with water, Vichy, milk, or egg-albumen solution. In very bad cases a child a year old should be given one to two ounces, and a child two or three years of age four to six ounces in twenty-four hours. Pleurisy. Of the various forms of pleurisy, those which are chiefly influ- enced by diet are pleurisy with effusion and empyema. In pleurisy with effusion the objects to be attained are to preserve the strength of the patient and promote the reabsorption of the fluid in the pleu- ral sac. A diet is therefore advised which shall consist of nutritious solids with a minimum amount of fluid, in order that the blood may become more dense and that favourable osmosis may occur from the pleuritic cavity into the blood vessels: at the same time free action of the kidneys should be promoted. To still further favour the absorption of fluid, a special dry diet has been recommended in which, as in case of aneurism, the patient is encouraged to take as THE RESPIRATORY SYSTEM. 449 little fluid as possible and to eat quantities of table salt by the tea- spoonful, the idea being to increase the density of the blood both by withholding fluid and adding salt, and that the latter may also promote osmosis. This treatment has been attempted in several of the New York hospitals and elsewhere, but has not met with suc- cess, mainly, no doubt, on account of the difficulty of overcoming the thirst of the patient, which is doubly aggravated by the lack of fluid and the supply of salt. An extreme dry diet known in Germany as " Schroth's Method " has been indorsed by Niemeyer, Pimser, and others. The patient is fed upon lean roast veal and stale rolls {Butterbrod) without fluid of any kind but a little water until the third day, when half a pint of red wine is given. At the end of a week a pint is allowed. Very few patients will submit to such treatment in this country, and it certainly is severe. A reasonable abstinence from fluids, especially water, is all that can be expected. Practically, many patients are found to go on reabsorbing pleuritic exudation while continuing a milk or other fluid diet which is necessitated by some complication in the digestive system. Several French writers, as Serre and Eloy, advocate an exclusive milk diet, giving from three pints to three quarts daily, to be sipped in small quantities every hour or two. They rely upon the diuretic effect of the milk, and give it in any form most agreeable to the patient. The treatment is continued for a week or more after the exudation has been absorbed, and return to a solid diet must be gradual. This method is obviously directly opposed to the dry diet, and possesses no advantages over it, excepting sometimes in cases com- plicated by chronic valvular heart disease, gastric catarrh, or ad- vanced anaemia. In England and Europe thoracentesis appears to be much less practised than in this country, where it is performed with but little hesitation. If the pleuritic exudation accumulates in sufficient quantity to severely embarrass respiration or the action of the heart, it is so easy to absolutely withdraw it by the aspiration needle when anti- septic precautions are taken that annoying the patient by experi- mental dietetics is hardly justifiable, and I have found solid diet with reasonable restriction to be, on the whole, the most satisfac- tory. Patients who are fairly robust will naturally endure privation of food and drink better than the feeble and anaemic. Empyema. The dietetic treatment of empyema is based upon the need for nutrition to supply the drain on the system of the constant excretioh of pus, and fatty food, such as butter, cod-Kver oil, and cream should i-Q DIET IN DISEASE. therefore fill a large portion of the dietary. The general supporting treatment prescribed for the early stages of pulmonary tubercu- losis is recommended (page 434). DIET IN DISEASES OF THE CIRCULATORY SYSTEM AND BLOOD. Diseases of the Heart. The proper dietetic treatment of advanced heart disease deserves careful consideration, for on it to a great extent depends the pa- tient's comfort, if not the prolongation of his life. It cannot be said that the several conditions of cardiac enlargement, valvular disease, fatty degeneration, etc., demand different forms of treatment per se, but there are certain general principles which should be observed in any case when particular symptoms arise. The dietetics of cardiac diseases may, accordingly, be conveniently reviewed together. Pathological Physiology. The general conditions involved are largely physical, or rather mechanical perhaps more so than in any other form of disease. 1. We have to deal with a pump whose action is impaired by more or less weakness of its walls, or leakage or obstruction of its valves, or which is overworked by the imposition of increased re- isistance. 2. The balance of food pressure in the vessels is usually disturbed and the rate of blood flow is altered. 3. As the disproportion increases between the driving force or the resistance of the vessels and the volume of the fluid to be pro- pelled, there is apt to be leakage of serum in various situations, producing dropsies or general anasarca. Or these conditions may result from a diminution in the vitality of the peripheral blood ves- sels or changes in the composition of the blood itself. 4. The rate of absorption of the materia alimentaria by osmosis depends as much upon the activity of the circulation i. e., upon the rapidity of renewal of the layer of blood in the capillaries of the ab- sorbing surface as upon the density and composition of the blood, the action of individual cells, or any other factor. A feebly beating heart or an obstructed vascular system promptly checks absorption. Moreover, the reabsorption of transudated serum will depend upon the reversal of the conditions which originally caused it. 5. The elimination of waste and the various processes of secre- tion depend upon almost identical conditions with absorption, and while not due merely to filtration, they are nevertheless controlled very promptly by alterations in blood pressure and in the velocity of the current. THE CIRCUL'ATORY SYSTEM AND BLOOD. 451 Bearing in mind these elementary principles, the first question which arises in the dietetic treatment of advanced cardiac disease must concern the administration of Fluids. An additional pint of fluid beyond the needs of the system may be just sufficient to overtax the heart, alter the balance of blood pressure, disturb a temporary compensation, and precipi- tate anasarca, renal congestion, pulmonary oedema, or other symp- toms. On the other hand, with too little fluid the blood pressure may fall to a dangerous degree or there may not be water enough in the vascular system to maintain the free diuretic action which is so de- sirable. It is a well-known physiological fact that the heart, like any other muscle, does better work if it has reasonable resistance to overcome. Such are the problems, briefly stated, which must be met, not by the enforcing of text-book rules, but by the frequent examination of the peculiarities of each case, by the comparison from day to day of the amount and quality of the urine, the degree of arterial tension, the force of the heart beat, and the possible pres- ence of oedema. Dietetic Treatment. It is difficult to formulate any but the most general rules for the dietetic treatment of chronic valvular disease of the heart. These cases often extend through a period of many years, and the variety of secondary symptoms which may ap- pear is very great. The forms of valvular disease which are most apt to result in disturbances of digestion are those in which ob- structed venous circulation results in local engorgement of the ab- dominal viscera, producing nausea, vomiting, and great distaste for food. Constipation and more or less chronic gastric and intestinal catarrh may be among the symptoms. The hypostatic congestion of the liver retards the activity of that organ, and the ingredients of the food which ar-e brought to it by the portal system are no longer properly elaborated, so that general nutrition and assimilation suffer in consequence. A depleting diet is, therefore, sometimes to be rec- ommended, and concentrated food is required to prevent over- burdening the circulation. If gastric catarrh necessitates the use of fluid food, the quantity of beverages taken in addition should be considerably restricted. When acute attacks of indigestion super- vene in the course of chronic valvular disease, the bowels should be kept thoroughly open, and a diet of milk, beaten eggs, and broths, taken once in three hours, mus^-be prescribed for a few days, after which boiled fish, broiled chicken, scraped beef, beefsteak, or rare roast beef may be added. Fats, farinaceous foods, and sugars should not be allowed, owing to their tendency to produce flatu- lency and aggravate existing symptoms. The use of alcoholic stimu- lation may at times become necessary, and whisky diluted in some j^ DIET IN DISEASE. non-effervescing water is perhaps the best. Beer should be particu- larly avoided, and recommendation of the regular use of stimulants, in this as in other forms of chronic disease, should be made with great caution lest the alcoholic habit be acquired and become per- manent. Patients with sudden cardiac dilatation, such as sometimes occurs during convalescence from typhoid fever, need to return to a milk diet. When acute symptoms of palpitation, dyspnoea, etc., develop, the patient should never eat very much food at one time. It is better to take four or five meals a day, if necessary, and eat only small quan- tities. A large meal always distends the stomach considerably for several hours, causing this organ to elevate the diaphragm and dis- place somewhat the heart, which lies upon it, and diminishing the vertical diameter of the chest. The heart may become irritated by the mechanical pressure to which it is subjected by a moderate de- gree of displacement, and it is indirectly affected by the greater dif- ficulty of breathing, as well as by reflex irritation from the disor- dered stomach. All food which is liable to ferment in the stom- ach, such as sugar and indigestible starches and fats, must be par- ticularly avoided. Gastric catarrh is readily excited and aggravated by coarse or fermenting food. On this account also the use of strong alcohol should be forbidden except in the case of aged and feeble persons, to whom light wine or diluted spirits may be given. The regular use of tobacco should be prohibited, and tea and coffee, if permissible, are to be taken only in very dilute form. The tendency to constipation can be overcome by attention to diet and a moderate amount of fruit such as baked or stewed apples, stewed prunes, and grape fruit may be allowed between meals. CARDIAC VALVULAR DISEASE IN CHILDREN. Children who have chronic valvular disease or enlargement of the heart, but who are not strictly confined to bed, should be closely supervised in regard to their habits of eating. They should eat slowly and moderately, and have their meals at regular intervals, taking the principal meal at noon, and a light supper two hours be- fore bedtime. In general, animal food is better for them than vege- tables, but they may eat the lighter fresh vegetables, such as spinach, tomatoes, or stewed celery in season, and sometimes a little roast or mashed potato. Rice and macaroni may be given. Bread should be only eaten dry or toasted. Sweets should not be allowed, except very rarely, when a taste of jam or preserves may be given. Such substances are apt to cause flatulency and palpitation, if not more serious disturbances, and everything depends upon saving the heart from excitation or strain. All food should be very simply cooked, and too great variety is harmful. . THE CIRCULATORY SYSTEM AND BLOOD. 453 In acute disease of the valves such, for instance, as that pro- ducing mitral regurgitation it is very important to avoid all food likely to cause dyspepsia. Raw eggs with brandy, broths, and chiefly milk must be prescribed, and if the stomach is weak and irri- table, a part of the nutriment may be given /^r rectum (page 380). DIETETIC TREATMENT OF THE SENILE HEART. In persons past middle life the heart may become enfeebled from a variety of causes independent of inflammatory conditions or val- vular lesions. Fatty degeneration is a very common cause of such weakness, and in other cases the hearty muscle may gradually lose its normal strength and " tone " from strain, or a disturbance of bal- ance between its power and the peripheral resistance to be overcome. In the aged the arterial walls become less and less resilient, if not actually rigid, from calcareous deposit, and, moreover, the heart suffers no less than other organs from impaired nutrition. In such cases the prolongation of the patient's life as well as the mainte- nance of his comfort may be fostered by attention to dietetics. A weak heart implies impaired circulation in the gastric vessels, and hence the gastric juice becomes poor in quality and lessened in quantity. Digestion is consequently retarded, and absorption of food products is less active than it should be. The heart and the stomach being both supplied by branches of the vagus nerve, it is' easy to understand how gastric irritation, caused by products of mal- fermentation, organic acids, accumulated undigested food, or gaseous distention, may affect the heart through reflex action. Mechanically, too, a stomach distended by gas presses upon and irritates the heart. Balfour (The Senile Heart, 1894) says: "If the heart is weak the discomfort induced by such irregularities is after middle life more apt to be felt in connection with that organ than in the stomach itself." The result is intermission in the pulse rate, un- evenness in force and frequency of the heart beat, its " fluttering" action, and sensations of palpitation, praecordial distress, fulness or constriction, and dyspnoea. In order to avoid these symptoms as far as possible, the patient must have his diet carefully supervised. A sufficient interval fully five hours must always elapse for the complete digestion of one meal before a second is taken, and because the gastric juice is feeble it is best not to allow more than four or five ounces of fluid of any kind to be taken with the meals. While sufficient variety of food may be allowed to maintain a fair appetite, it should never be so great as to entice the patient to eat too freely. Balfour summarises excellent rules for dieting to be followed by patients whose cardiac action is enfeebled by any cause, but espe- cially for the condition described as "the senile heart." .^ .DIET IN DISEASE. Balfour's Rules for dieting for Weak Hearts. ' I. There must never be less than five-hour intervals between meals. " 2. No solid food is ever to be taken between meals. " 3. All those with weak hearts should have their principal meal in the middle of the day. "4. All those with weak hearts should have their food as dry as possible." " A good typical ttienu is given by the writer above quoted : Balfour s Diet for the Senile Heart. ^^ Breakfast, S.^o A. y[. Dry toast, one small piece one or one and a half ounce with butter; one soft, boiled egg, a small piece of whitefish ; three to five ounces of tea or coffee with cream and sugar, or an infusion of cocoa nibs, or milk and hot water, or cream and Seltzer. Sometimes oatmeal porridge is permissible, but not over three or four ounces should be taken. ^' Principal Meal, 1.30 or 2 p. m. Fish, such as haddock or sole, or meat and pudding. Two courses only are allowed. No soups, pickles, pastry, or cheese. Whitefish and short-fibred meat only are allowable. The fish may be boiled in milk. A little spinach or one potato may sometimes be eaten, or a half pound of fruit, such as pears, apples, or grapes. Four to five ounces of hot water may be drunk with each meal, but no more. " $ to 6 p. M. Three to four ounces of tea (one teacupful) infused for four minutes may be drunk, but absolutely no solid food is to be taken with it. If desirable, a teaspoonful of Liebig's extract of meat may be stirred in with the tea. " Supper, 7 p. M. Whitefish and a potato or toast and pudding, or milk pudding, or bread and milk, or revalenta made with milk or Liebig's extract. " Bedtime. Four to five ounces of very hot water, sipped, helps;" the patient to fall asleep." Upon this very Hmited regimen the patient, if heavy and water-., logged, at first loses weight by absorption of " oedematous soakage,"- or if much wasted he may gain in weight. In this manner the natu- ral equilibrium of the body is re-established. In not too critical cases a little more latitude is permitted, and such vegetables may be occasionally eaten as asparagus, onions, leeks, tomatoes, lettuce, cress. The heavier, coarser vegetables (like cabbage, sprouts, turnips, parsnips, carrots, beets, legumes), pastry, nuts, dried fruits, and sweets of all kinds are forbidden. Equal care must be given to the selection of proper beverages. - If there is much palpitation, tea, coffee, and chocolate must be pro-; scribed. In many cases Balfour allows a little weak tea, made by. , THE CIRCULATORY SYSTEM AND BLOOD. 455 infusing a teaspoonful (about one hundred grains) in four or five ounces of water for only three or four minutes. Alcathrepta may be drunk. The two latter beverages may be taken at 5 p. m. or on retiring, when the stomach is empty. They must not be made too sweet. No champagne or effervescing drinks are allowed, and all alco- holic beverages should be given only in moderation. If more than two ounces (a claret-glass full) of one of the stronger wines is taken, it excites acid dyspepsia, and claret. Burgundy, or hock should not be allowed in greater measure. A small glass of port or sherry may be drunk twice a day ; but, as Balfour observes, there is so much idiosyncrasy in the digestibility of wines that in general plain liquor is better for these cases and in the small quantity recommended in the menu given above. Alcohol is by no means a necessity, ^nd many patients are better without any. He has great faith in the stimulating properties of hot water, slowly sipped, and says : " This will be found to have quite as good an immediate effect upon the heart as alcohol." It has been elsewhere shown that the frequent acts of degluti- tion performed in sipping any fluid tend to increase the pulse rate slightly through reflex stimulation of the vagus branches which are concerned in the act. As the heart becomes more and more feeble, the inactive circula- tion, perhaps aided by alteration in the composition of the blood or by albuminuria, results in the production of localised oedema or gen- eral anasarca. In referring to the use of dry diet for these conditions as occur- ring in connection with the senile heart, Balfour says: "When there is anasarca, or any evidence of soakage in any dependent part of the body, it is of the greatest importance to place the patient, for a time at least, on the driest possible diet, and not too much of it. ... I have seen a considerable amount of oedema of the lower limbs disappear within twenty-four hours before there had been time for any change in the heart, which was feeble and dilated." His dry diet is as follows: Breakfast. ^. single slice of dry toast, without butter. A cup of tea (infused only four minutes). Dinner. The lean of two chops, or their equivalent in chicken or fish. No vegetables. Dry toast adlibitum. Half an ounce of brandy, whisky, or Hollands in three ounces of water. Supper. As much dry toast as desired. Half an ounce of liquor, as at dinner. Nothing else is allowed ; but if the patient is thirsty, very hot water may be sipped between meals. This, Balfour maintains, is an excellent cardiac tonic. 456 DIET IN DISEASE.- ANGINA PECTORIS. The only indication to be met in the dietetic treatment of angina pectoris is to reduce the arterial tension. A vegetable diet with re- stricted fluids, and no alcohol, is to be recommended. These patients often are subjects of the gouty diathesis, and the directions for diet in that condition are to be observed (see Gout). CARDIAC PALPITATION. The dietetic treatment of cardiac palpitation is sufficiently indi- cated under the heading of Flatulent Dyspepsia. Overeating should be avoided, as well as all stimulating foods and beverages. Tea, coffee, and tobacco should be forbidden at least temporarily. Effervescing drinks of all kinds, from their tende.ncy to produce flatulency, should also be proscribed, as well as all sweets and much starchy food. Laxative foods, especially fruits, will be found useful. ARTERIAL SCLEROSIS. In those cases in which renal inadequacy is a pronounced feature it will be well to put the patient upon a milk diet for several weeks. In general a non-stimulating diet is requisite, with a minimum of butcher's meat, and no strong condiments, richly cooked dishes, or alcohol should be allowed. ANEURISM. In aneurism of the larger arteries the vessel wall is dilated and thinned, and rupture is liable to occur at any time from increase of the blood pressure or obstruction to the circulation produced by sudden movement, or otherwise. The most favourable result of treatment which can be anticipated is thickening of the diseased vessel by the deposit of coagulated fibrin from the blood. The co- agulability of the blood varies with its composition, and is favoured by increased density of the blood and by structural changes in. its albuminous ingredients. To a limited extent this process can be aided by diet. The object to be attained in the dietetic treatment of aneurism is to reduce the volume, and consequently increase the density of the blood. The latter does not necessarily increase its coagulability, however. This method of treatment was originally^ formulated by Bellingham and Joliffe Tufnell, of Dublin, and it is now described by the latter's name. It is only less rigid than the very old method of Valsalva, who gave half a pound of pudding morning and evening, and nothing else practical starvation ! In conjunction with the dietetic treatment absolute rest of the patient is enjoined; he should lie horizontally in his bed, and not be per- mitted to make exertion of any kind, and mental strain and emotion- should be carefully guarded against. He should be fed by a nurse, THE CIRCULATORY SYSTEM "AND BLOOD. 457 and not allowed to sit up at any time. By rest alone the rate of the heart beat is materially slowed, and this is favoured also by the re- duced diet. The artery, in consequence, is distended less and less often and is submitted to less pressure. The exact treatment recom- mended by Tufnell is as follows : TufnelVs Diet. Breakfast. Two ounces of bread with a little butter and two ounces of milk. Dinner. From two to three ounces of meat without salt and four ounces of milk ; for a portion of the milk an ounce or two of claret may be substituted. Supper. The same as the breakfast. This extremely rigid diet is apt to be rebelled against by most pa- tients, but it serves as a basis for the commencement of other treat- ment, and if it be found impracticable to adhere to it, the quantity of food will have to be slightly increased. It may be necessary to double the quantity of milk and increase the amount of bread or vary it with crackers or some light form of starchy diet. The fluid, however, is in all cases to be restricted as much as possible. Pa- tients usually complain bitterly of thirst, and while it is more desir- able to restrict the fluids than the solids in the dietary, the thirst may be alleviated somewhat by the use of acidulated drinks, such as sour lemonade, dilute phosphoric acid in cinnamon water, etc. The danger which menaces the patient and the object of his treatment should be clearly explamed to him and his co-operation secured in the effort for his relief. It is customary to employ iodide of potas- sium and morphine in moderation for their sedative action upon the circulation and the system generally. Many cases are of syphilitic origin, and they are particularly benefited by the potassium iodide. Upon this reduced diet improvement in physical signs of the aneu- rism such as diminished pulsation and intensity of bruit and less- ened pain is occasionally quite decided. In favourable cases im- provement may be looked for at the end of a week, and if the dietetic treatment is persisted in for six weeks, the benefit may be considerable. Tufnell himself reports several cases in which the aneurismal sac became lined with a thick coating of fibrin. There are many cases of aneurism outside the province of surgi- cal treatment which are incapable of relief from any diet, but the method above described is decidedly worth a trial in an otherwise hopeless condition. I have several times known it to produce con- siderable lessening of pain, dyspnoea, and other symptoms, but it requires firmness and perseverance to carry it out successfully. The curative results have, unforturyately, not verified Tufnell's original claims, and as pointed out by Loomis, if the method is too rigidly 458 DIET IN DISEASE. and too long enforced for six or eight weeks an extreme degree of anaemia is apt to occur and leave the patient worse off than before. If the Tufnell diet is not prescribed, non-stimulating food only should be allowed, consisting chiefly of simply cooked fresh vege- tables and fruits, with but little meat. Anything likely to produce flatulency or gastric dyspepsia should be carefully avoided, and strong alcohol must be forbidden. Anemia. Chlorosis. Pathological Physiology. The proper nutrition of all the tis- sues of the body is directly dependent upon the quality of the blood plasma and of the amount of oxygen conveyed by the corpuscles. A very slight departure from the average composition of these ele- ments will sooner or later result in diminishing the nutrition and functional activity of all the organs in the body, notably those of the digestive system. Anaemia, whether acute and due to haemorrhage or some acute dis- ease, or chronic from any cause, by depleting the cellular elements of the blood, interferes with the proper oxidation of food after absorp- tion. On the other hand, a diet which is insufficient in amount or inappropriate in quality, if long continued, is certain to produce an impoverished condition of the blood with a diminution in the nam- ber of corpuscles; hence there is a double relation existing between the power of the blood to insure complete absorption and metab- olism, and of the food itself to maintain the normal balance of the ingredients of the blood. Anaemia, therefore, demands special feed- ing, the basis of which should be an effort to restore as soon as pos- sible the proper number of red corpuscles and the normal quantity of other ingredients of the blood by a diet which is nutritious and abundantly rich in nitrogenous food given in some easily assimilable form. When proteid food is excluded from the diet for some weeks the haemoglobin of the red blood-corpuscles is considerably reduced in amount and hydraemia ensues, but the pigment is always in- creased by an excess of nitrogenous food. Anaemia and chlorosis are most common at the age of puberty, and immediately thereafter, among young girls who are growing or who are overworked at school or in factories while beginning men- struation, and who are improperly fed. The diversion of consider- able nervous energy for other functions than those of the circulation at this time may interfere somewhat with the nervous mechanism of digestion and absorption. In other cases there is a constitutional or hereditary weakness of the digestive system, which is aggravated by an exceptional strain or overwork of the nervous system. The phe- nomena of growth and development of the different organs necessi- tates the consumption of a relatively larger quantity of good food THE CIRCULATORY SYSTEM AND BLOOD. 459 than is needed later in life for merely maintaining the equilibrium of the tissues and restoring the balance of material used in the production of energy. Growth implies the building up of new mate- rial and a renewal of the old as well. At the period of growth, there- fore, there are always unusual demands upon the nervous system, and overstrain at this time is to be especially guarded against. Symptoms. Among the many symptoms referable to the nerv- ous system which occur in the course of protracted anaemia are languor, vertigo, various forms of neuralgia and megrim, with in- definite muscular pains, which to some extent are produced by en- feebled circulation, which allows waste material produced by muscular action to accumulate in the tissues. Depression of spirits and drow- siness are also observed, and palpitation is easily excited. The poor circulation may result in the production of fainting, or of oedema in. the lower extremities. In advanced anaemia it is found that not only, is the normal rate of tissue metabolism impaired, but there may be modifications in the relative consumption of certain foods by the tis- sues. A large excess of urea is commonly observed, which indicates an active combustion of nitrogenous substances. The view is widely held that owing to the small number of the red disks, or oxygen car- riers, the final oxidation of fatty matter is retarded, and it is for this reason that anaemic subjects very often appear plump or even cor- pulent from the deposition of a large amount of fat derived from imcomplete combustion of fats and starches, whereas their muscles, from the increased nitrogenous waste, are reduced in size and are weak. Van Noorden, Kraus, Bohland, and others dissent from this argument and believe that chlorotic patients feel tired, sleep long, and are disinclined to expend energy in muscular exertion, and less energy than usual goes into heat production, and as they sometimes eat abundantly of sugars and starches, they necessarily store up fat, Rest, Exercise, and Air. In many cases of extreme anaemia, found especially among young chlorotic girls, the dietetic treatment must be accompanied by careful regulation of all hygienic conditions. Sufficient rest for the tissues, and especially for the digestive organs, must be secured. These patients, who appear so well nourished, may in reality be quite feeble, and it is a great mistake to compel them to rise early and perform tasks and indulge in exercises of the same char- acter and degree with those of healthy children. For many patients it is well to insist on prolonged and continuous rest in bed. For others it will suffice to restrict the activities of the day by permitting the patient to rise shortly before noon, and to insist upon rest being taken on a lounge both before and after meals in order to secure more perfect digestion. These patients must be cautioned against allowing themselves to become unduly fatigued. They are often able, under the influence of stimulants and excitement of various 46q DIET IN DISEASE. sorts, to perform f^ats of exercise or endurance which are equal to those of healthy persons, but a strong reaction is certain to follow, and a steady but slow progress will often be checked for several weeks by infringement of necessary regulations. In such cases, how- ever, as soon as decided improvement is evident, and in all the milder cases, it is desirable to enforce rules for gentle exercise in the open ait, and the patient should be outdoors nearly all the time whenever the weather permits. The exercise should be supervised and slowly increased in stout subjects, so that they gradually consume their superfluous fat. If the climate is unfavourable the cure will be much more rapid if the patient can be moved to a more salubrious locality. Fresh air is more important than exercise, for an abundant oxygen supply increases the appetite and distinctly favours the assimilation of the food. Dietetic Treatment. The dietetic treatment of anaemia requires, in the first place, that the most nutritious food should be supplied; secondly, care must be taken to insure its complete digestion and absorption. In all cases of ahgemia the impoverished and watery condition of the blood reacts unfavourably upon the character of the digestive secretions and diminishes their organic elements. The se- cretions are therefore unable to digest the food with the necessary vigour, and it is often desirable to re-enforce them by the use of arti- ficially prepared ferments or to give predigested food, making use of pancreatin, in the preparation of animal food, and diastase or malt extracts for the predigestion of amylaceous food (see pages 330, 331). At the commencement of treatment rest and a small amount of food may be required, but with improvement of the digestive organs the quantity of food must be rapidly increased, and four or five meals a day may be given. At first, if milk is well borne by the enfeebled digestive system, and if it is not distasteful to the patient, it should be the principal food. It may be drunk between meals, and especially at night on going to bed. Some of these patients who cannot digest milk with facility are able to take a mixture of equal parts of cream and hot water with ten grains of bicarbonate of soda and a teaspoon- ful of brandy to the tumbler (Yeo). Eggs in all forms which are of fairly easy digestion are an excellent food for anaemic subjects, and rare meat should be given in considerable quantities two or three times a day. Sandwiches made with pounded meat or beefsteak almost raw, which is placed between thin slices of bread and butter, may be taken with meals, or as a light lunch in the middle of the morning and afternoon. Inserting a crisp lettuce leaf in each sand- wich makes it still more palatable and wholesome. Patients of this class often object very strongly to eating meat, and prefer pastry and sweets, but with tact and persuasion they can usually be induced to take it in some form. Meat broths and consommes may be thick- THE CIRCULATORY SYSTEM AND BLOOD. 461 ened with scraped meat, or raw scraped beef may be added to choco- late or Burgundy, or may be eaten in any manner agreeable to the patient. In this way large quantities of meat in an easily digestible form may be taken without tiring of it, as fat anaemic women are very apt to do. Young chlorotic girls should receive at least five or six ounces of albumin /^r diem. See gives, as much as fourteen ounces of raw meat daily in some cases of chlorosis, and finds it especially serviceable for those pa- tients whose weak stomachs rebel against the use of the different preparations of iron. Anaemic patients often feel worse during the first half of the day. They then complain most of headache, languor, and anorexia, but they should be encouraged to begin the day early with nourishing albuminous food to counteract this condition. Van Noorden's sys- tem at the Berlin Charite is excellent, and he describes it as follows (International Medical Mag3,zine, May, 1894): " I recommend chlorotic girls to drink slowly half a litre of milk of the best quality while they are yet in bed in the morning. They must take time, and occupy at least a quarter of an hour in consum- ing this quantity. They ought to rise half an hour later, and they should be rubbed briefly with a dry rough woollen towel. This is to be followed by the breakfast, consisting of a small cup of tea, one or two slices of buttered toast, and plenty of meat. I consider it extremely desirable the physiological reasons for this are easy to defend that these patients should take in at breakfast, before the daily work commences, as much albumin as possible. Two and a half hours later some bread and butter and two eggs are to be eaten, followed immediately afterwards by drinking a quarter of a litre of milk. If considered advisable for special reasons, a small glass of sherry is now permissible." If the large quantities of meat recommended are not perfectly digested and absorbed, it is well to prescribe some preparation of pepsin with dilute hydrochloric acid. A concentrated meat diet almost always produces constipation if this condition does not already exist as a result of the anaemic and atonic condition of the intestinal wall, or the giving of iron. It is well to counteract this tendency by the use of draughts of hot water and oi purees of fresh vegetables, whole-meal bread, oatmeal, and such fruits as stewed prunes, apples, and the juice of oranges and grape fruit (see Con- stipation. The various Italian pastes, such as macaroni, vermicelli, and polenta, with meat gravies, are suggested by Yeo. But with those patients in whom there is a tendency to overproduction of fat, with- holding of hydrocarbons from the diet is highly desirable. 462 DIET IN DISEASE. For others who, besides being anaemic, are thin and poorly nourished, it is well to add some simple forms of starchy food and a good deal of fat with the meals. Van Noorden says : "For a well-nourished, moderately fat, chlorotic girl, weighing sixty kilos, I would consider the following diet as eminently suitable : " 1 20 grammes albumin = 492 calories. 60 " fat = 558 270 " carbohydrates = 1,110 " Total 2,160 " (I. e., 36 calories per kilo of body weight.)" The eating of fats is to be encouraged to the limit of toleration. Cream and large quantities of butter are recommended when easily digested, and they can be made to replace cod-liver oil when the patient is unable to take this form of fat. Many patients can digest broiled fat bacon with ease. Two or three eggs beaten with boiling water or milk, with the addition of sugar and spices and a table- spoonful of brandy or sherry, make a useful form of eggnog, which can be given two or three times during the day between meals. The use of glycerin extracts and of emulsions of bone marrow has been advocated within the past year for anaemia. The method of preparation of the marrow is described on page 177. The cases thus far reported by Fraser, Bigger, Danforth, J. S. Billings, Jr., Hamilton, and Walker of the use of bone marrow in different forms of anaemia have shown considerable benefit from this treatment. The condition most improved is chlorosis, but it is claimed that some cases of pernicious anaemia have been helped by it. The number and quality of the red corpuscles is improved. In Danforth's case the percentage of haemoglobin rose from 35 to 80. Billings (Johns Hopkins Hospital Bulletin, November, 1894, page 119) denies the value of marrow in pernicious anaemia, and thinks its good effect in the cases of chlorosis reported by him is attributable to the large proportion of iron which the marrow contains. Most anaemic patients have no appetite, or lose it, during the early part of the day, and careful attention should therefore be given to making all their food as agreeable to them as possible in taste and manner of serving. Meat should be prepared so as to re- quire the least possible effort in mastication, and much more food can easily be consumed in a fluid and semisolid form. Condiments are serviceable, for they render simple food more agreeable and stimulate the enfeebled gastric secretion. Moleschott insists on the free use of salt by chlorotic patients on account of its supposed favourable action in restoring the blood corpuscles and plasma. Vinegar, pickles, gravies, and sauces should be avoided. Alcohol is not indicated for all, but there are some patients who THE URINARY SYSTEM. 463 are benefited by its use, and the best form of alcoholic tonic for an anaemic patient isa good rich claret, Burgundy, or Madeira. Some of the milder cases, especially women in whom the digestive organs are not particularly disturbed, do very well on porter or stout, or one of the various malt preparations, which may be taken with the noonday meal or at bedtime with a few crackers or a raw-beef sand- wich. The latter is a prescription very serviceable in those cases in which insomnia is a harassing symptom. There is no apparent con- nection whatever between the absorption of alcohol and the forma- tion of new blood cells, although there is a popular idea to the effect that red wine produces red blood. Alcohol, however, often does promote the accumulation of fat, and this is most undesirable in anaemic subjects who already possess that tendency. PERNICIOUS ANEMIA. Hunter (British Medical Journal, July 5 and 12, 1890) argues for the use of an exclusively farinaceous diet for pernicious anaemia, on the ground that in health a proteid diet causes more extensive destruction of the corpuscular elements of the blood than a fari- naceous one, and in this disease, on account of putrefaction in the intestine, the blood destruction is increased by nitrogenous diet. This theory is in opposition to all others, and the most satisfactory and rational treatment consists in giving predigested milk, eggs, beef broth and juice, etc., in as large quantities as both stomach and rectum will absorb. There is defective assimilation of proteid foods, and hence they should be thoroughly predigested (see pages 331). DIET IN DISEASES OF THE URINARY SYSTEM. Modifications in the Urine caused by Food. The quantity as well as the composition of the food eaten exercises an important influence over the composition of the urine. Animal food naturally increases the nitrogenous elements of the urine, urea, uric acid, and urates, and vegetable food increases the carbonates and earthy salts. A concentrated diet restricted in fluids as well as solids reduces the water of the urine, and 'makes it relatively more acid, although the absolute quantity of acid may not be increased. Conversely, watery foods, milk, succulent fruits and vegetables, and all bever- ages increase the quantity of urinary fluid and tend thereby to lessen its acidity and density. Cantani dissents from the common view that the organic acids, such as fruit acids, form carbonates which promote alkalinity of the 33 464 DIET IN DISEASE. urine, and says that this is true of small quantities, but that larger amounts or the continued administration of these acids makes the urine strongly acid, A diet rich in fatty food, or an excess of cod-liver oil, may some- times give rise to fat in the urine, or lipuria. The volatile fatty acids may similarly be present. The presence of the fat makes the urine somewhat turbid, and oil globules and fat crystals may sometimes be seen under the microscope. A milk diet tends to make the urine somewhat alkaline, and it may increase the quantity of indican. Foods which may produce oxaluria are described under Oxa- luria. The peculiar odour which asparagus produces in the urine is ex- plained on page 154. Acute Nephritis. Symptoms. Acute diffused nephritis is an inflammation of the kidneys, which is principally caused by exposure to cold and wet, by certain medicinal poisons, or by the toxines developed in the course of acute infectious fevers, especially the exanthemata and diphtheria. It is unnecessary to discuss its varieties here, as the dietetic treat- ment is the same for all. Among the important symptoms are anaemia and a scanty secre- tion of urine containing abundant albumin with casts and blood. Anasarca and effusion into various serous cavities, such as those of the pleura and peritonaeum, may occur. The arterial tension is increased. The patient must be kept in bed to insure a uniform temperature of the body, and facilitate the use of measures to pro- mote perspiration. Dietetic Treatment. The dietetic treatment must be adapted to prevent overloading the digestive organs, which are easily de- ranged, and to prevent overworking the kidneys. A light diet is therefore necessary. The patient will do best to live exclusively upon milk for some days, until the functional activity of the kidneys is restored. The importance of this should be explained to him and insisted upon. Between four and seven pints are to be taken daily, diluted with Vichy or carbonic-acid water. If the bowels are loose, hme water may be added instead ; or if constipated, magnesia solution. If the liver seems inactive, skimmed milk or buttermilk may agree better. Milk sometimes causes gastric oppression. If sipped slowly, or taken with a teaspoon, this may be overcome, for it is then diluted with the saliva. If milk is strenuously objected to or actually disagrees with the patient, other simple foods may be allowed, such as koumiss, butter- milk, and gruels of oatmeal, groats, rice, barley flour, or arrowroot. THE URINARY SYSTEM. 465 These forms of starchy food should be prepared without much sugar, but a little cream may be added or, if preferred, the juice of a lemon, but no vegetables are permitted. If the patient is feeble, strong beef tea or beef or chicken broth are sometimes to be recom- mended, but, in general, so long as the symptoms are at all acute it is necessary to withhold all meat preparations from the diet. This is especially true in the case of young children. Animal broths dissolve substances from meat which easily develop into toxines and irritate the kidneys. When the kidneys become more active and the character of the urine improves, the diet may be increased by such articles as bread and butter, plain puddings, lettuce, or water cress with plain French dressing, stewed apples, grapes, oranges, etc., but whenever possible the food should consist largely of milk for a long period. Later, eggs and even meat broths may be allowed, and finally a little white meat of poultry. Any return of the albuminuria should be immediately met by a reduction in the diet to its original simplicity chiefly milk. A patient may lose thirty or forty grains of albumin in twenty- four hours without serious harm, but if three hundred to four hun- dred grains are lost the condition is in itself alarming, for he is losing from one fifth to one fourth of his total albuminous food through leakage of the kidneys i. e., he is passing daily in the urine one twelfth of the nutrient matter of his blood (Granger Stewart). A pint of milk supplies about an ounce of albumin and casein, thus replenishing the waste. The lactose of milk is sometimes given separately for its diuretic action, S^e gives it up to three ounces in twenty-four hours, to be drunk in two quarts of water, and he believes it acts best when car- diac dropsy is also present and the quantity of albumin is not large. I have found it difficult to push its use to such a degree without causing dyspepsia and a decided- dislike for it. Milk is undoubt- edly a good mild excitant of renal activity, but this is due to its water as much as to any other ingredient, and the diuretic effect of lactose is much overrated. Should vomiting occur at any time, the diet must be again re- duced, or it may be advisable to give the stomach complete rest for ten or twelve hours. To increase the activity of the skin and wash the casts and debris of granular matter and blood corpuscles from the renal tubules, the blood volume must be raised by the ingestion of abundant fluid, provided the tendency to dropsical effusions is not great. Water, alkaline, mineral, or effervescing waters, soda lemonade, or cream-of-tartar lemonade should be drunk freely, the latter especially if there is constipation (Dickinson). Osier rec- ommends the following: A drachm of cream of tartar in a pint of 466 DIET IN DISEASE. boiling water with the addition of the juice of half a lemon and a little sugar. To be drunk cold. It is a general rule to exclude all foods and drinks which may in any way irritate the kidneys, and the following are especially for- bidden : Grills, roasts, sauces, pastry, spices, very acid foods, strong alcoholic drinks, tea and coffee. Strong wines, sweet wines, and all sorts of liquors are absolutely prohibited. If alcohol seems neces- sary for the stimulation of the heart, a little weak claret, white wine, or diluted whisky and some effervescing water may be given. ACUTE NEPHRITIS IN CHILDREN. When the disease occurs in children, as often happens during or after acute infectious diseases, such as scarlatina and diphtheria, the diet must consist wholly of milk. During the most acute stage of nephritis the milk may be diluted one half with Vichy or water for its diuretic influence. It should be given in moderation, but often say at least once in two hours. As the acute symptoms subside milk is to be ordered in full strength. Gradually other articles may be added, such as crackers, toast, porridge, rice pudding, cornstarch, junket, and blancmange. Orange juice may be taken freely, and an occasional baked apple with cream or a few stewed prunes will act favourably upon the bowels. It is best, as in the case of adults, to forbid meat broths, and eggs and meat in any form must be withheld for three or four weeks after the urine has regained its normal composition. Subsequently a menu may be composed from such articles as a chop, the breast of a chicken or partridge, a little broiled whitefish, a poached egg, oysters, custard, a baked mealy potato with fresh butter, stale bread, wine jelly, and fresh ripe fruits. Albuminuria. Functional Albuminuria. Pathological Physiology. ^Albuminuria may be produced by alterations in the composition of the blood and by structural or functional changes in the kidney itself, or by both. The albumin is derived from the blood serum, which in turn comes from the proteid material of the food. Under ordinary circumstances proteid mat- ter in passing through the body undergoes several transformations which affect its degree of solubility and its ability to osmose or go through animal membranes such as line the alimentary canal, the blood vessels, and the tubules of the kidney. Most proteid matter taken into the body as food is not readily absorbed until converted into some form of peptone or albumose. These substances diffuse very easily, and their presence in the blood would render them liable to constant osmosis from the vessels into the lymph spaces or tis- sues almost immediately after absorption, but in their transit THE URINARY SYSTEM. 467 through the intestinal villi they are reconverted into serum albumin, which does not osmose easily, and which therefore remains in the vascular system. A certain amount of albuminous material, how- ever, must pass by osmosis from the blood vessels into the lym- phatic channels, and thence into the tissues which surround them or which they penetrate. For serum albumin to pass into the urine it must osmose through two layers of cells namely, the capillary wall of the blood vessel and the epithelial lining of the tubules of the kidney. Variations in the density of these walls, and probably also alterations in the functional activiy of the epithelial cells which compose them, will modify the rate of osmosis so that it may be completely checked, or it may be allowed to take place unhindered. The conditions of osmosis also depend upon the relative density of the fluids on either side of the membrane, hence alterations in the composition of the blood plasma may allow of the osmosis of serum albumin into the tubules of the kidney. It is important to observe that the presence of serum albumin in the urine in excess not only indicates a functional or structural weakness in the kidneys them- selves, or in the composition of the blood, but it represents actual loss of substance from the body i. e., of material which is not yet converted into waste matter, but which is capable of furnishing nu- trition to the tissues in other words, there is a leak of nutrient matter from the kidneys. From the foregoing statements it might seem feasible to disre- gard the leakage and increase the amount of nitrogenous food sufficiently to counterbalance the loss sustained. The same plan might theoretically be thought to be of benefit in cases of diabetes, where it would seem quite possible to counterbalance the loss of saccharine material from the kidneys by ingestion of much larger quantities of starches and sugars; but this is a fallacious compar- ison, for excess of sugar is really a foreign body in the blood, while albumin is not (Granger Stewart). Clinically, however, it has been found that when either of these conditions of loss of substance from the blood exists in the kidneys it is better to withhold as much as possible the particular variety of food which is leaking through them and reduce the work of these organs, hoping by rest, combined with other appropriate means of relief, to cure the faulty condition. Functional Albuminuria. Temporary functional albuminuria is now recognised as occurring in many individuals without the significance of any structural or organic lesion of the kidney. This subject has been exhaustively investigated by the medical ex- aminers of life-insurance companies, for it is of great importance not only to discover the presence of albuminuria early, but to as- sign the proper significance, to its presence. It is not many years 468 DIET IN DISEASE. since the detection of albumin in the urine was regarded as an in- fallible indication of some form of renal disease, but the fact is now established that errors in diet and faulty assimilation produced by mental and nervous strain, overwork, and worry, and more paF- ticularly by the exhaustion of very rapid growth of the body in the later years of childhood and early youth, may occasion albuminuria. A solution of meat albumin experimentally transfused into the venous circulation of a dog, injected either subcutaneously or into the rectum, reappears unaltered in the urine, but serum albumin similarly injected is retained by the blood and does not cause albuminuria, although the percentage of albumin in the blood plasma has been considerably raised above the normal. Moreover, if a man in health eats eight or ten raw eggs in the course of five or six hours, unaltered egg albumen may appear in the urine. Albumi- nuria thus produced is purely temporary, and is directly dependent on the nature of the food. So much of this proteid has been eaten that a portion of it is absorbed directly into the blood without the formation of intermediate products of digestion. Similarly this albumin will osmose through the kidney. But if the digestive activity in the stomach is very great, a large number of raw eggs may be eaten, and as many as nineteen have been taken in thirty-six hours (Dolradin) without the appearance of albuminuria. It is no doubt true in such an instance, as suggested by Yeo, that the vigour of the digestion converts egg albumen into peptones, which finally form serum albumin, whereas with a slower digestion more of the egg albumen is absorbed unaltered. According to the experiments of Stokvis, coagulated egg albu- men cannot be made to reappear in the urine of healthy animals, but raw egg albumen can. Oertel (Therapeutics of Circulatory Derangements, in von Ziem- ssen's Handbook of General Therapeutics), as a result of numerous experiments upon man and animals in opposition to the above view, declares that " egg albumen, given in whatever quantity, is not nor- mally excreted as such by the kidneys, and does not cause albumi- nuria." The albumin absorbed is all destroyed in the blood or tissues and excreted as urea from the kidneys. He further says that "a great increase of albumin supplied to the blood causes no increased excretion of albumin by the kidneys, and, in particular, that egg al- bumen gives rise to no irritation of the renal vessels and no albu- minuria (nor does it increase an existing albuminuria)." This statement, if corroborated by further observation, would considerably alter the prevailing notions in regard to the advisa- bility of giving eggs to patients with chronic Bright's disease. Of all the varieties of albuminuria, those which are most amen- able to dietetic treatment are the functional form and that which THE URINARY SYSTEM. 469 accompanies chronic Bright's disease. The functional albuminuria which is produced by eating an excess of proteid material or by mus- cular fatigue, which results in the accumulation of large quantities of nitrogenous waste matter and interference with normal oxidation processes, is usually curable by ascertaining and removing the cause. It seems to be almost impossible to produce functional albumi- nuria in the lower animals, such as dogs, by overfeeding them with a very large excess of albuminous food. Voit caused a dog to absorb within twenty-four hours six times the amount of albumin contained in the blood plasma without exciting albuminuria. In the instance given above of albuminuria caused by eating large numbers of eggs, it was emphasised that the proteid in the urine is egg albumen and not serum albumin. It is stated, however, that occasionally serum albuminuria may be produced in man by eating large quantities of meat. If true, this is certainly very un- usual, and this form of albuminuria is by no means as readily in- duced as the glycosuria caused by an excess of starches in the food. But if albuminuria already exists, certain forms of nitrogenous food will greatly increase the amount eliminated by the kidneys. It is probable that some persons inherit a special weakness of the kidney structure or an abnormal irritability of the renal cells which favours the occurrence of albuminuria from slight provocation. Granger Stewart (Lectures on Important Symptoms of Albumi- nuria, page 145) states that he has observed in certain persons that cheese, pastry, and eggs are substances capable of producing tem- porary albuminuria. In one case this symptom was accompanied by oedema of the eyelids. In regard to the production of functional albuminuria from diet- etic errors Yeo argues, and I think correctly, as follows : " May not the true explanation be that the ingestion of so large an excess of albuminous material may throw upon the kidneys such an excess of nitrogenous waste (to be secreted) that a temporary functional hy- peremia of the kidneys is excited, and that this leads to a slight escape of albumin from the blood ? It appears to us that this is a sound physiological explanation of what is observed to occur, and accounts for its occurrence in fever or disordered constitution, and not in the perfectly sound and vigorous." Albuminuria also results from passive hyperaemia of the vessels of the kidney, as well as from active congestion and inflammation. In functional albuminuria, when traces of serum albumin appear from time to time in the urine, it is found that the amount is pro- portionately increased by any special fatigue or exhaustion. It is possible, although it is by no means proved, that nerve currents supplying the epithelial cells of the renal tubules or the walls of the ^70 ^lET IN DISEASE. renal capillaries may cause a functional alteration in the activity of. these cells, which compels them to exercise a selective action upon the albumin of the blood serum, and favours its osmosis. The theory is advanced by Mills, of Montreal, that the epithelium of the capillaries possesses some at least of the functions of glandular epithelium, and that it is capable of controlling and varying the quality as well as the quantity of such substances as may pass through the minute capillary walls. Albuminuria is very common as a result of elimination of irritant poisons from the kidneys, and it is believed that the albuminuria usually present in diphtheria and the exanthemata is produced by the irritant effect upon the kidneys of toxines developed in these diseases which are being eliminated in the urine. Dietetic Treatment. The frequent return of functional albu- minuria should be regarded as an, indication of special weakness of the kidneys in the same way that frequent glycosuria invites suspi-. cion of the strength of the digestive power of the liver, and it de- mands a careful regulation in the diet. Meat should be reduced in quantity, or temporarily forbidden, as well as all forms of alcoholic drinks or other substances liable to produce renal irritation, and the diet should consist chiefly of fruits, vegetables, and milk. Careful attention must be paid to increasing the activity of the bowels. When functional albuminuria is observed in children and adoles- cents, it is not necessary, nor is it advisible in ordinary cases, to wholly exclude nitrogenous food, but it should be restricted, espe- cially in regard to eating butcher's meat and eggs, and the evening meal should be made very simple, consisting of food such as bread,, crackers, rice or porridge, and milk. Chronic Bright's Disease. Causation. Chronic interstitial nephritis may be of primary origin, or it may occur as a result of arterio-fibrosis and other con- ditions. It is usually a very slow process, and is believed to be pro- voked by chronic alcoholism and errors in diet, such as a too great proportion of meat in the food, which results in the overproduction of uric acid or lithaemia from functional derangement of the liver. Urine of a low specific gravity is passed in greater amount than normal, and thirst is increased. The arterial walls are thickened and their tension is high. That an exclusive meat diet is not alone the cause of chronfc Bright's disease is proved by the fact that Eskimos and other races, who subsist altogether upon it, are not especially liable to the dis- ease, although in the long sunless winter they live under very bad hygienic conditions (see the relation of proteid food to albumi- nuria, page 468). It is nevertheless a fact that the disease is very THE URINARY SYSTEM. 471 prevalent in this country among men past forty years of age who for years have been overworked with business cares, and who have neglected to take sufficient exercise and care in eating. In the early stages of the disease much may be accomplished by dietetic treat- ment. Osier says that " care in food and drink is probably the most important element in the treatment of these early cases." Whatever views may be entertained in regard to the causation of albuminuria, it is agreed by all that cooked meats, eggs, and highly seasoned food in general are injurious in all cases of existing albu- minuria. One should be cautioned against regarding the amount of albumin present in the urine from time to time in the course of chronic albuminuria as an exact indication of the extent of the renal disease. The fluctuations observed are often due to diet merely, and the albumin may occasionally be considerably reduced in quantity, or actually absent temporarily from the urine, although the lesion of the kidneys is making uninterrupted progress. The volume of al- bumin in the urine must not, therefore, be estimated alone as an indication for dietetic treatment ; it is merely one of many symp- toms incident to the course of chronic Bright's disease which are benefited by a strict regimen. Extensive disease of the excretory surface of the kidneys always interferes with the normal elimination of nitrogenous waste matter which accumulates in the system until it finally produces toxic or uraemic symptoms of a most serious character. If the alimentary canal is overloaded with food above the actual requirements of nu- trition, or beyond the capabilities of the system for oxidising food products, toxic symptoms are sure to follow. For these reasons the diet in chronic Bright's disease must be definitely regulated, and a mean must be maintained between overburdening the digestive ap- paratus and withholding food which is needed to support the bodily strength. This applies especially to the waste of nitrogenous food, which passes off through the kidneys, whereas the waste of farina- ceous food is eliminated largely from the lungs and skin in the form of water and carbonic acid. Milk Diet. In many cases of chronic Bright's disease the effect of feeding the patient for six weeks, or even two or three months, upon an exclusive milk diet is remarkably gratifying. The quantity of urine, urea, and extractives increases, while the albumin dimin- ishes, iand oedema and general anasarca disappear. The patient's strength and general condition improve, the pulse is strengthened, and if dyspnoea pre-existed it subsides. The quantity of milk to be prescribed for an exclusive milk diet in Bright's disease must depend on the age and size of the patient, as well as upon his ability to take exercise and use up force in mus- cular energy. If the patient is invalided so as to be confined to his .-2 I^IET IN DISEASE. room or the house, from five to seven pints of milk daily are quite sufficient. Seven pints of milk contain 216 grammes of albumin and casein, 172 grammes of butter, and 161 grammes of lactose; whereas, according to Pettenkofer and Voit, a healthy adult requires 137 grammes of dry albumin, 117 grammes of fat, and 352 grammes of carbohydrates (see page 264). The milk diet is therefore deficient in carbohydrates, but the latter are estimated in Volt's table for a person taking active exercise, and requiring the development of more muscu- lar energy and heat than the invalid. If the patient loses weight on a milk diet, although it otherwise agrees with him, it may be well to add farinaceous food in the shape of rice or bread. Many patients will live contentedly with no other food than a bowl of bread and milk four or five times a day. In some cases it is inadvisable to commence the milk diet immediately, and a good result can be best attained by cutting off one article of solid food after another and replacing the loss by an additional tumbler of milk. Where it is ex- pected to employ a milk diet for many months, as in an advanced case of Bright's disease, it is usually found that the milk is better borne if taken fresh at a natural temperature and without flavouring of any kind. Although the treatment may seem severe at first, if the patient understands the gravity of the situation he is usually willing to accept it, and after a few days seldom complains of the monotony of this most restricted form of feeding. In the worst cases it is desirable to give the milk at brief intervals, in quantities of six ounces, once an hour during the daytime, with an extra tum- blerful at night, and on awakening in the morning. Ordinarily, however, it is tiresome to have to drink milk so often, and the quan- tity may be so regulated as to give the requisite amount once every three hours. The quantity of milk necessary to support life for any length of time and maintain good nutrition, especially if the patient is exercising at all, is considerable, and he must* take from fourteen to eighteen, or even twenty-two six-ounce tumblerfuls of milk in the twenty-four hours. It is usually impossible to commence at this rate without producing gastric disturbance from souring of the milk in the stomach, and possibly diarrhoea. The latter symptom is an al- most certain indication that the milk is being imperfectly digested, and a temporary reduction in its quantity is advised. It is very important to thoroughly cleanse the mouth after drink- ing the milk, in order to avoid coating of the tongue and the dis- agreeable taste which destroys the appetite and interferes with the efficacy of the treatment. For a full discussion of this subject the reader is referred to the article on milk diet in typhoid fever (page 398). Obstinate constipation, which almost invariably results from a long-continued milk diet, must be met by medicinal treatment, or the use of glycerin suppositories or enemata. As a rule, the milder THE URINARY SYSTEM. 473 laxatives are the only remedies necessary ; a glass of citrate-of-mag- nesia solution, a half tumblerful of bitter water taken on rising in the morning, a drachm of the compound-licorice powder, or a two- grain pill of extract of cascara sagrada at night, will prove sufficient. There is, however, no objection in most cases to allowing the use of a few stewed prunes or the soft part of two or three baked. apples. It will be observed that whereas the normal average quantity of urine for an adult male is fifty-two ounces for the twenty-four hours, the milk diet under discussion requires the ingestion of upward of one hundred ounces of fluid. This necessitates greatly increased activity of the kidneys, but the polyuria usually results in the re- moval of the anasarca which frequently exists. The body weight may remain normal, or even be slightly increased on this treatment. It is not infrequently diminished, however, but much depends upon the condition of the patient at the time when the milk diet was inau- gurated. The abundant urine is of a pale-yellowish hue, which is somewhat typical of the milk diet. The specific gravity is low, and the reaction may be neutral or faintly acid on account of the great dilution of the fluid. The albumin, which at first may be present in considerable bulk sufficient when coagulated to almost solidify the contents of the test tube gradually diminishes, and the urea and salts increase. In mild cases this milk diet should be continued from four to eight weeks, after which a slight variation may be al- lowed in the shape of farinaceous food, fresh vegetables, and fruit, such as oranges and lemons. In other cases it may be necessary to prolong the treatment for half a year or more, because it will be found that any attempt to materially alter the diet is followed by an increase in the albumin and dropsy, with return of other symptoms. In such patients the lesion of the kidney is far advanced and in- curable, and the most that can be hoped for from any treatment is an amelioration of the worst symptoms, and it is found that in many cases this can be best secured by milk diet. For the class of cases in which this treatment is found for any reason to be impracticable, either from the persistent refusal of the patient to take milk or from any other cause, before giving up its use efforts should be made to modify its preparation in various ways, tempting the patient with different flavours and with light farinaceous foods, of which milk forms an important basis, such as bread and rice puddings. A good deal of milk may be taken in very weak coffee or tea, or in the form of soups and purees made with celery or potatoes, or gruels may be given, or milk thickened with tapioca, vermicelli, sago, or rice, and flavoured with a little lemon or orange peel, cloves, or all- spice. It is not desirable to use much high seasoning for fear of irritating the diseased kidneys. As the patient improves, the milk diet may be given up, but* it ._, DIET IN DISEASE-.. 474 should never be too suddenly abandoned. A sudden restriction of fluids in chronic nephritis is always injurious. In adopting any other diet it is a good rule never to let the nitrogenous food bear a greater proportion to the non-nitrogenous than one to four. The former increases the proportion of urea in the urine; the latter reduces it, A purely vegetable diet has often been tried for albuminuriacs, but it causes too pronounced ansemia if its use is persisted in, and a minimum of animal food must therefore be prescribed. Granger Stewart says, in speaking of the very chronic albuminuria of Bright's disease, "In the more advanced stages the diet should be as nutri- tious as possible, and then certainly fresh meat is by no means injurious." Vegetarianism should never be persisted in if the patient continues to lose weight and strength. When, after a milk diet, the change is to be made to a more liberal menu, the hours of taking the milk may be reduced in fre- quency, and some of the milk may be replaced by boiled fish, chicken, or game, and fresh green vegetables, cream, butter, and bacon. The urine should still be periodically examined, and if it is- found that the eating of meat is followed by an increase in the al- buminuria the patient must return to the milk diet. It not rarely happens that strict adherence to a milk diet for- several months produces more lasting improvement in the action of the kidneys, so that a diet to which steak, roast beef, chops, and eggs are admitted may not only be well borne, but may increase the strength of the patient. This is a matter which obviously cannot be regulated by fixed rules. If the general principles of the treatment' are understood, it is within the province of any intelligent physician to apply them to individuals. In cases in which it is found after trying all methods that milk cannot be assimilated in any form, the patient must live upon a carbohydrate diet, consisting of fresh vege- tables and fruits, with butter, cream, and olive oil. Dujardin-Beau- metz allows pork and ham to be eaten by those who refuse to relin- quish meat entirely. Cheese is to be avoided. Senator believes that whenever serious albuminuria is present egg albumen and meat should be withheld, although a little fish or flesh poor in albumin, like that of chicken or veal, may be given if necessary, but he prefers to prescribe only vegetables, salads, and fruits, or ati exclusive milk diet of two litres /^r diem. Semmola recommends the use of the following drink, which may be mixed with milk, and which possesses a decided diuretic action : Sodium iodide ic grains. Sodium phosphate 30 " Sodium chloride , go " Drinking water 36 ounces. THE URINARY SYSTEM. 475 In general, the patient had better leave alcohol alone, especially in the form of malt liquors. If habituated to its use, a feeling of dulness and drowsiness after a glass of wine is a strong reason for giving it up. An. occasional "spree" may do the patient less harm than continued drinking in smaller quantity. For a non-alcoholic subject, if weak and anaemic, as he improves, a little light wine or claret diluted with Seltzer water or Apollinaris may be ordered as a beverage. Tea, coffee, and cocoa are permissible. The effect of dietetic treatment will be much enhanced by secur- ing systematic outdoor exercise and freedom from worry and anxiety, and particular attention must be paid to keeping the bowels open^ for which laxative fruits may be taken freely. The patient must be cautioned against overeating, and all food must be thoroughly masticated. PYELITIS. Most cases require abundant fluid, such as alkaline mineral waters, for the purpose of washing out the pelvis of the kidney, and if there is much irritation or painful micturition, it- is well for the patient to be put on an exclusive milk diet for. a month or six weeks after the manner described above for treatment of nephritis in the preceding section. Many patients are benefited by attending such baths as Carlsbad, Vichy, or Neuenahr. OXALURIA. The condition of oxaluria may be unsuspected by the patient, or it may attract his attention by a sensation of burning in the urethra^ desire for frequent micturition, headache, "nervousness," etc. . Causation. The occasional presence of a trace of calcium oxa-r late in the urine need not be considered as abnormal, but the con- tinued presence of excess of oxalate-of-lime crystals in the urine is mainly caused by eating certain kinds of food and by dyspepsia and perverted nutrition, involving incomplete oxidation in the system of starchy, saccharine, and fatty foods. Ellis says that " oxalic acid is very readily prepared in the chemical laboratory by the action of reagents upon sugar, .starch, and cellulose. This fact would seem to render probable the possi- bility of its formation from the imperfect oxidation of these sub- stances in the body," especially from bacterial fermentation in the alimentary canal. FlOgge has shown that bacteria can form this acid, and its crys- tals occur in the intestine and are often found in the faeces. Oxa- luria is common in connection with dyspepsia, and it is not altogether improbable that some of it may be derived from imperfect digestion of food in the intestine, and be absorbed into the blood just as ptomaines are. 476 DIET IN DISEASE. Cantani finds that oxaluria is frequently present among those who indulge too freely in saccharine and amylaceous foods. Beneke holds quite an opposite theory, and attributes the condition to im- perfect metabolism of proteid foods. Even fasting animals may still show traces of calcic oxalate in their urine, and both in- creased and diminished oxidation have .been held accountable for oxaluria. Vegetables and fruits which may cause it when eaten in excess are rhubarb, tomatoes, turnips, onions, sorrel, apples, pears. Raw fruits and vegetables which contain citric, malic, and other organic acids seem to bear close relation to the formation of oxalic acid. The latter is not necessarily ingested with the food, but is produced in the body from a variety of substances. Dietetic Treatment. The diet should consist of animal food fish, poultry, game, and meat with stale bread or toast with a minimum of butter. Tea, coffee, carbonic-acid water, and alcohol should be temporarily forbidden. Hot water (three quarters of a pint) should be sipped half an hour before each meal, and before breakfast a drachm or more of Carlsbad salts may be taken in con- stipated cases. Dilute mineral acids, hydrochloric or nitro-hydro- chloric, are beneficial ordered immediately after meals in doses of fifteen or twenty minims in water. CALCULI, RENAL AND VESICAL. Beverages. When the presence of vesical calculus has been demonstrated it becomes important to regulate the diet so as to prevent, if possible, aggravation of the trouble. Not much is to be hoped from the action of any solvents, such as the alkaline waters or lithia salts, upon a large stone already formed, but diuretics may certainly do much to prevent recurrence of the formation by con- trolling vesical catarrh, and the production of mucus which forms the nucleus, and sometimes a considerable part of many stones. As White observes : " Our object should then be to make the urine as bland and abundant as possible, and for this purpose there is nothing better than milk and the free use of water between meals. The particular kind of water to be used is of minor importance, as the most noted waters in the treatment of stone seem to have purity as their chief recommendation." The still spring waters, such as Poland, Londonderry, or Bedford, may be prescribed, or the waters of Vichy, Saratoga, or Ems, on the principle that many patients will drink more fluid which bears the name of some reputed " Spring " than they will if it be plain water. Paget was fond of trying the effect of an exclusive milk diet before advising lithotomy. The milk is soothing, and while it is a THE URINARY SYSTEM. 477 good diuretic, it lessens the desire for frequent micturition which is often such an annoying symptom of vesical stone. The occurrence of vesical calculus in children is believed by Cadge, White, and others to be directly proportional to the difficulty of getting abundant milk. It is therefore much commoner among the children of the poor. White believes that " diet and regimen, at least in cities, have much more to do with the production of stone than heredity, climate, water, soil, etc." Young infants should not be given lime water indefinitely with their milk. It is best for adults to relinquish the use of alcoholic stimu- lants, but if this is not feasible light Rhine wine or still Moselle is admissible, especially if neutralised by some alkaline table water (Yeo). Lager beer is not harmful, and a little dry champagne or a light hock or white wine may be taken. All the heavier clarets. Burgundy and sweet wines of every sort, port, sherry, strong beer, ale, porter, and stout are forbidden. Weak tea and coffee may be drunk. Only such beverages should be allowed as contain no free acids and no sugar, and those having the greatest diuretic effect are the best. Foods. All highly seasoned and irritating articles, like vine- gar, pickles, strong condiments, such as mustard, should be rigidly forbidden, as well as anything prone to excite acid dyspepsia. Among patients who have calculi of various kinds a consider- able number are at the same time afflicted with obesity. Such per- sons must be especially abstemious in regard to the use of fats and sugars. Less corpulent persons may be allowed a little more laxity in this regard. Other substances to be avoided are puddings made with eggs and sugar and containing rice, sago, or other farinaceous foods, suet puddings, pastry of all kinds, meat fat, and fat pork. Bread, oatmeal, hominy, cracked wheat, corn-meal bread, custards, blancmange, boiled fish, and eggs are all admissible. In many cases total abstinence from animal food for a week or ten days is followed by marked improvement, the patient living meanwhile on green vegetables, salads, and cooked fruits which are not too acid, such as apples, not sweetened, but flavoured with some bland aromatic, like cinnamon, nutmeg, or cloves. In other cases it may not be necessary to withhold meat completely, but it should always be taken in moderation, not more than once a day, and it should be rare, lean, and thoroughly masticated. White meat of chicken may be eaten. The Carlsbad dietary, in which butter and sugar in all forms are rigidly proscribed, is found. to benefit calculus cases even more than the total withdrawal of meat. 478 DIET IN DISEASE. The above directions apply to the treatment of most varieties of calculi, and not to any one kind alone. In elderly people, in whom such disorders are relatively common, the functional elimination of waste from the body is considerably impaired. For such persons, as well as for those who live sedentary lives, it is important to abstain from overeating, and especially from the use of animal food in excess. LITH^MIA. URIC-ACID DIATHESIS. GRAVEL. Symptoms. Lithaemia is a condition in which the blood con- tains an excess of uric acid or its salts, and is usually productive of such symptoms as insomnia, vertigo, tinnitus aurium, disagreeable fulness of the head, and general " nervousness." The urine becomes loaded with nitrogenous waste. When uric acid appears in excess as a sediment in the urine it is very desirable that its formation should be checked, if possible, and that any crystals already deposited in the kidneys and bladder should be dissolved and eliminated. If the accumulation continues, the presence of crystals (" gravel ") gives rise to attacks of renal or vesi- cal colic, causing intense agonising pain, and often haematuria. A majority of the different forms of calculi are composed wholly or in part of uric acid, and they may be formed in any part of the genito- urinary canal, which, in addition to the other symptoms, may possibly cause ulceration and inflammation of the mucous membrane or seri- ous obstruction to the outflow of the urine. The exact mode of production of uric acid in the body is still a matter of uncertainty, but it is undoubtedly associated with nitrogenous metabolism, and the acid represents an imperfectly oxidised form of nitrogenous material. The final destination of uric acid is its conversion into urea, but from lack of perfect oxidation in the tissues this process is checked. Dietetic Treatment. The indications for dietetic treatment are clearly, therefore, to reduce the animal foods in amount or temporarily withhold them altogether, while giving large quantities of plain water and of waters containing potassium or lithium salts to aid in dissolving the uric acid already existing in the kidneys or bladder, and promote its conversion into urea and hippuric acid. The same rules apply to renal inadequacy from any cause, especially to lessen the quantity of nitrogen consumed. Although the acidity of the urine is not caused by uric acid, but by acid sodium phosphate (Na^POJ, the deposition of uric acid is accomplished in an acid menstruum, and it is well to reduce the urine temporarily to a neutral or even somewhat alkaline reaction. This can be done by adapting both food and drink. Animal food, except milk, tends to make the urine acid, whereas THE URINARY SYSTEM. 479 milk and vegetable food favour alkalinity. In speaking of the lithic- acid diathesis in children, Fothergill wrote that " lean meat, raw meat minced, and beef tea are so much poison." Lithaemic head- aches will often cease when the patient stops eating butcher's meat, cheese, etc., if excessive indulgence in animal food has been the previous habit. Peptonising such food makes matters even worse, for the dyspepsia which often accompanies lithaemia is in a way a conservative process, checking the digestion of animal foods, whereas the predigested foods are more promptly and easily carried to the overburdened liver. Some lithaemic patients cannot take meat well in hot weather, but can do so at other seasons. But an excessive meat diet cannot be regarded as the sole cause of lithsemia. Other important factors are concerned, such as overeating and the abuse of saccharine food, which causes malfermentation, deranges the functions of the liver, and alters the composition of both blood and urine. Murchison declares that " habitual lithaemia often results from the patient taking more food than can be converted into tissue or disintegrated in the liver," and Sir Henry Thompson expressed his views in regard to sweets thus forcibly : " Sugar, in all its forms, at every meal, and wherever met with, forbid it altogether, ... let fatty matters, butter, cream, and the fat of meat, whether simply cooked or in combination to form pastry, be taken very sparingly." This is the practice at Carlsbad also, and it considerably reduces the work of the liver and kidneys. For some patients especially the obese it is more important than wholly eliminating meat from the regimen. Murchison, who was among the first to advocate a rational dietetic treatment of habitual lithaemia, forbade all saccharine and oleaginous food, especially " made dishes," and highly-seasoned foods, sauces, rich gravies, etc. In severe cases he insisted upon giving up simple amylaceous foods as well, and forbade the eating of potatoes, rice, sago, fruits, etc., and bread was allowed only in moderation. In most cases, however, vegetables were given sparingly, and whitefish, poultry, game (if not too rich), and eggs were included. The total quantity of food was reduced considerably. Many acids contained in fresh fruits, such as benzoic or quinic acid, have a favourable solvent action. These acids are found in the external cuticle of fresh fruits and vegetables, which may be eaten in cases of gravel. According to Lyman, eating raw, unpeeled apples in considerable quantities supplies potassium salts, which tend to in- crease the alkalinity of the blood, but sweet fruits, pears, grapes, plums, strawberries, etc., must not be indulged in. Patients may eat abundantly of oatmeal, wheaten and Graham bread toasted, macaroni, fresh young peas, string beans, Lima beans, 33 gQ DIET IN DISEASE. rice, spinach, asparagus, celery, lettuce, and other salads, except tomato (without oil). Meat should not be eaten oftener than once a day. Fresh fish, sweetbread, poultry, and game may be taken spar- ingly in ordinary cases. No diet can be rigidly enforced in every case alike. If lithaemia is present in young strumous children after three or five years of age, they require a larger proportion of fat. They may have bread and butter with a little fat bacon, or a baked potato with butter, and puddings of bread, crackers, rice, or sago, but not of raw flour. They must not be tempted with sweets. They often have poor appetites, and some variety must be prescribed, or they will lose weight and strength. Some writers are disposed to attach less importance to dietetic errors as influencing lithaemia and L. C. Gray is of the opinion that the cooking is far more important than the composition of the food. Reasonable variety, including proteid food, should be allowed, for " lithsemics do best on plenty of well-prepared food in the greatest variety according to the seasons." He makes much use of milk, and says he has " never been able to trace a single case to overfeeding." Beverages. Various alkaline mineral waters are constantly prescribed for adults, and patients who can afford to take the course are benefited by the baths of Carlsbad, Vichy, Neuenahr, Ems, etc., but for those to whom travel is an impossibility and whose means do not allow them to purchase artificial mineral waters, very good substitutes are to be made by dissolving sodium carbonate or sodium phosphate in soda water or sour lemonade, or in plain water, in the proportion of from one to two drachms in three or four pints, to be taken in the course of the twenty-four hours, or two to five grains of the carbonate of lithium may be employed in the same way. Eflfer- vescent lithium tablets are now sold which may be added to a tum- bler of water at the table and taken with meals. Solution of the deposits, or at least the prevention of their in- crease, is aided by the free drinking of Londonderry, Buffalo, or other lithia waters, Vichy, Waukesha, etc., although it must be said of most so-called lithia waters that their use is chiefly that of pure water, for a barrelful would have to be drunk to obtain an ordinary medicinal dose of lithium. Most patients do better without alcohol in any form. They may feel the loss of accustomed stimulation for a few months, but they should make a strong effort to give it up completely. Malt liquors and sweet wines, champagne, and spirits had better be absolutely for- bidden, but if necessary, a little good sound claret or Scotch whisky in water may be drunk. Gravel is much less common among habitual beer drinkers than among those whose daily beverage is wine. This is attributed by THE ALIMENTARY CANAL. 481 Moleschott to the greater acidity and larger proportion of alcohol in the latter.* On the contrary, Ebstein holds that beer is not injurious in lithiasis, and tea also has some reputation in checking the deposi- tion of uric acid. Coffee does no harm. GONORRHCEA. The dietetic treatment of gonorrhoea consists in avoiding all stim- ulating food and drinking bland diluents. In severe cases, and in cases among young children who have in some manner been infected, a skimmed-milk diet should be ordered at first. Later, light farinaceous articles, stale bread and butter, milk, and rice puddings should be added. Patients, for fear of attracting attention to their ailment, are often unwilling to restrict their meals, but they must avoid acid fruits, all highly seasoned and fried food, con- diments, and pastry. Alcoholic drinks in all forms are absolutely pro- hibited. Malt liquors are especially bad, as they are in all diseases of the urethra, bladder, or prostate. No late meals should be taken. By observing these directions troublesome chordee and ardor uringe, so apt to appear in the first fortnight, may be prevented. Large quantities of such waters as soda. Seltzer, Apollinaris, and two or three quarts of plain water should be drunk. The fluid dilutes the urine, diminishes the danger of cystitis, and has the additional ad- vantage of decreasing the appetite. DIET IN DISEASES OF THE ALIMENTARY CANAL. Diet in Abnormal Dentition. In abnormal dentition in children the food is imperfectly masti- cated, and gastric dyspepsia or gastric catarrh may follow. If den- tition is delayed and the teeth are imperfect, as in the case of rickets, scrofula, tuberculosis, or any protracted disease involving nutrition, the diet should be made as nourishing as possible, and meat, eggs, milk, cream, and broths should be given in addition to cereals. Cod- liver oil is usually prescribed with benefit. There is no one food of special value for retarded dentition on account of its containing the lime salts of the teeth, and the chief reliance for this purpose must be placed in building up general nutrition. In all cases of dyspepsia, gastric catarrh, rickets, or syphilis the teeth must be carefully examined before prescribing special dietetic treatment. If the teeth are broken or irregular all solid food should be care- fully prepared by mincing or otherwise reducing it to a form requir- ing but little mastication. In a young child a sore mouth from swollen gums is often overlooked as a cause of anorexia. 482 DIET IN DISEASE. The perfection with which false teeth are now fitted has done much to improve the digestion of adults and to add to the comfort and, no doubt in some instances, prolong the life of the aged. Catarrhal Stomatitis. Catarrhal stomatitis is a simple inflammation of the mucous mem- brane of the mouth which, among other causes, may be excited by taking food or drink at either extreme of temperature. Food which is very acid or too highly seasoned with condiments may cause it, so also may excessive drinking and smoking. No special diet is required beyond giving food which is easily swallowed and which is free from the above objections. When the disease occurs in infants their diet must be regulated according to the directions for feeding detailed under the heading Infant Feeding. In gangrenous stomatitis the mouth may become too sore to ad- mit of swallowing, in which case food must be given by the rectum (see Nutrient Enemata, page 375). Otherwise small quantities of fluid food must be ordered at frequent intervals. Concentrated meat broths, egg albumen, meat juice, and milk are to be taken at hourly intervals. If the stomach is irritable this food should all be predi- gested with pancreatin. Alcohol, preferably in the form of brandy, should be frequently given to the limit of toleration. The above directions apply also to cases of inflammation of the mouth and pharynx caused by corrosive poisons, such as carbolic acid, ammonia, etc. TONSILITIS AND QuiNSY. These diseases require no special care in the acute stage beyond giving food in such fluid form as can be most easily swallowed. The pain caused by this act is often so extreme that it is advisable to con- centrate all food, to save the number of necessary acts of degluti- tion. Meat juice, peptonoids, beaten eggs, and brandy may be added to good milk. Plain vanilla ice cream may be given. Its coldness is sometimes soothing to the pharynx. Holding cracked ice in the mouth before swallowing will some- times annul the pain momentarily, or in extreme cases the pharynx and tonsils may be sprayed with cocaine, and the period of tempo- rary anaesthesia may be utilised for swallowing considerable nour- ishment. This is rarely necessary, for unless the patient is emaciated by previous serious illness, he is not apt to be in need of much food for a day or two. In bad cases of suppurative tonsilitis the strength suffers more, and stimulants may be given by the rectum if degluti- tion is impossible. After all forms of tonsilitis there is apt to be considerable anaemia, THE ALIMENTARY CANAL. 483 and the patient for a week or two should eat abundantly of animal food. Eggnog and milk punches are often needed for the first few days of (convalescence. Dysphagia. When the normal mechanism of swallowing the food is disturbed the condition is called dysphagia. It is commonly due to one of the following causes : Spasm of the muscles of mastication (trismus) ; inflammations of the mouth, tongue, pharynx, or tonsils; diphtheria; tubercular, cancerous, or syphilitic pharyngeal disease; retropha- ryngeal abscess ; stricture or carcinoma of the oesophagus ; paralyses (sometimes of central origin) ; operations upon or near the pharynx ; or the wearing of an O'Dwyer tube in the larynx. The devices employed to enable the patient to overcome pain or difficulty in swallowing his food should include reduction of the efforts at swallowing to a minimum. A raw egg or oyster may some- times be gulped down by a single act when the dread of pain from more repeated effort deters the patient from taking other food. Whatever is given should therefore consist of concentrated nutriment in a smooth, semisolid or gelatinous form. Wine jelly may be re-en- forced with beef peptonoids or egg albumen, and custards may be thickened with farinaceous material to a consistence which will enable them to be quickly swallowed. When patients are unable to swallow, an oesophageal tube is in- serted for feeding, which, however, should be a catheter of small calibre (English 8 to 18), and which need not be passed very far down into the cesophagus. If necessary, a 2- or 4-per-cent solu- tion of cocaine may be first applied to the pharynx to relieve pain and irritation. The fluid food eggnog, broths, thick gruels, milk, etc. is poured into the tube through a funnel. When the tube feeding connot be practised, it becomes necessary to resort to rectal enemata, or both methods may be employed in order to reduce the number of feedings through the painful throat. Delavan calls attention to the important fact that the point of greatest irritation is often the palatine arches, and by passing the tube through the nose into the pharynx behind them this difficulty is neatly avoided. In hopeless cases of cancer or of tubercular ulceration of the epiglottis, tonsils, etc., which are so intensely painful, it may be justifiable to perform gastrotomy in order to place food directly in the stomach. This is certainly preferable to letting the patient starve to death because he finds the agony of swallowing is even worse than the pangs of hunger. 484 DIET IN DISEASE. Stricture and Carcinoma of the CEsophagus. In diseases of the oesophagus which render swallowing difficult all food must be given in semisolid or fluid form. Many vegetable substances can be made mio purees, which can be strengthened by meat extracts, peptonoids, or beef meal. Milk, in its various forms, is always soothing, and it may be the only food which the patient can take. Richardson states that in oesophageal stricture cold food relaxes the circular fibres of the oesophagus and dilates its lumen, whereas hot food has an opposite effect. In some hysterical patients this may prove true, but in most cases of genuine stricture or occlusion the temperature of the ingested food makes but little difference. When the occlusion or the difficulty or pain in deglutition becomes so great that the patient suffers from inanition as, for example, after corrosive poisons have been swallowed he must be fed by nutrient enemata. Should the trouble not be overcome, a gastric fistula must be made, and the patient is to be fed by this means. Feeding through a Gastric Fistula. When a gastric fistula is made the wound may be left open with a drainage tube, or, what is better, a permanent hard-rubber or metallic tube is inserted, hav- ing a double flange, like a spool. The tube is nickei-plated to pre- vent erosion by the acid gastric juice. The lumen may be a third of an inch in diameter, and when not in use it is kept closed by a cork. When the patient is to be fed he must lie upon his back. The cork is removed, the tube cleansed with a syringeful of warm water, and through a glass funnel, to which is attached an inch or two of rubber tubing, fluid food is poured directly through the fistulous open- ing into the stomach. If desirable, lavage may be performed in a similar manner. Any kind of food may be given which the patient is able to digest. Even small pieces of chopped meat can be pushed into the stomach with a glass rod or forceps. Medicines are conve- niently given through the same opening. When the fistula has been made for other cause than malignant disease the spool may be worn indefinitely with no other inconvenience than that attending the pe- culiar process of feeding. I have recently seen a patient who has worn such a one for several years, and who goes about like other men, excepting that he takes his meals in private and feeds himself while lying on his back. FOREIGN BODIES SWALLOWED. When foreign bodies have been accidentally swallowed, such as coins, buttons, safety or other pins, large cherry, plum, or other fruit stones, fish bones, chicken bones, or pieces of clam or oyster shells, if the patient is seen within two or three hours, the object THE ALIMENTARY CANAL. 485 having passed beyond the reach of the finger or oesophageal pro- bang, an emetic may be given. If this fails to return the foreign body from the stomach, the patient should eat large quantities of bread, oatmeal, or potatoes. The plan of this treatment is to fur- nish a bulk of faecal matter, which in the intestines may envelop the pin or bone, and prevent its sharp or roughened ends from injuring the mucous membrane. Six or eight hours later a dose of castor oil should be given. By this means many dangerous objects may be safely voided. If the foreign body does not appear after the oil has acted, the treatment should be repeated next day, and the stools must be carefully watched until it is recovered. Experience has shown that the search should not be abandoned for at least eight or ten days. Men who earn a precarious livelihood by publicly exhib- iting themselves as possessing " iron stomachs," and who swallow broken glass, coins, nails, etc., take considerable risk from exciting grave injury or peritonitis, but by eating the foreign bodies only when the stomach is nearly full, and by following the treatment out- lined above, they manage to escape death. Indigestion and Dyspepsia. Symptoms. Indigestion and dyspepsia are terms which refer essentially to functional slight and often temporary derangement of the digestive system, although these conditions may result from many varieties of disease, especially from fever due to almost any cause. The terms are used somewhat vaguely to include a number of minor symptoms, such as weight and oppression at the epigas- trium and praecordium, eructations, "water brash," palpitations, ver- tigo, headache, modified taste and thirst sensations, loss of appetite or morbid craving for certain indigestible articles of food, flatulency, hiccough, and sometimes nausea, heartburn, pain referred to the cardiac end of the stomach, lassitude, irritability, drowsiness or rest- lessness, and despondency. As Sir H. Thompson says: "The word indigestion denotes not a disease, but an admonition." Fothergill wrote: " If it were not for the protection of indiges- tion, of which many so bitterly and ungratefully complain, the lives of a large number of individuals would not attain their furthest po- tential expansion." Many of these symptoms, especially those referable to the nerv- ous and vascular systems, are explained by the belief that morbid products which closely resemble poisonous alkaloids in their action (as indeed in their composition), and which are called ptomaines or leucomaines, are easily absorbed, and produce effects varying in in- tensity from slight headache to the collapse of violent ptomaine poisoning (page 350). Other symptoms are doubtless due to imper- fect elimination of waste matter of food or "ashes " from the system. 486 DIET IN DISEASE. Bauer says: "It is beyond doubt that insufficient secretion is the essential cause of most dyspeptic symptoms as they appear in vari- ous disorders of the stomach." In severe fevers and conditions of advanced anaemia or gastric catarrh the stomach secretes chiefly a ropy alkaline mucous fluid, with little or no true gastric juice. As a rule, the acid gives out before the pepsin, and a deficiency of acid is a very common condition, especially in anaemia. Anaemia produced experimentally by repeated bleeding of animals will cause it. Chronic hyperaemia and inflammation of the stomach excited by coarse irritating food have the same result, and the free acid, if se- creted, is neutralised by abundant mucus. Deficiency of hydrochloric acid in the gastric juice has a three- fold effect: i. Failure to digest proteids ; 2, failure to arrest mal- fermentation or putrefactive changes in the food ; 3, failure to ex- cite gastric peristalsis, so that the food lingers too long in the stom- ach. Other causes of delay may be found in too large a bulk of food, lack of peristalsis, and obstruction through stenosis of the pylorus without corresponding increase in contractile power of the stomach. Gases. The normal gases of the stomach are those of atmos- pheric air; but food which is improperly fermenting is capable of evolving others, and those which have been determined by analysis of eructations are CO^jH^tO^N^jCH^ (marsh gas) C^H^ (olefiant gas). Ewald reports a case in which sufficient marsh gas was evolved from the stomach to burn with a pale-yellow flame. Some degree of lactic-acid fermentation may be a normal accom- paniment of gastric digestion, but the process is easily carried too far; butyric acid develops, and gases are evolved. This action re- sembles that produced outside the body when decomposing albumin comes in contact with saccharine substances. Distention of the stomach and intestine with gas interferes with the free play of the diaphragm in the respiratory movements, and since the heart lies upon its side, separated from the stomach only by the diaphragm, an inflated stomach compresses and displaces the heart, interfering with its rhythm and force and causing palpitations. The latter, in connection with impeded extent of movement of the diaphragm, produces dyspnoea, especially on exertion. Pain is a very frequent accompaniment of dyspepsia. It is usu- ally of a dull aching variety, but is sometimes sharp and acute. It is often erroneously referred to the heart, but it is due rather to hyperaesthesia of the stomach wall, excited by products of imperfect digestion. In all diseases of the stomach the retention of any particles of undigested food gives rise to irritation and malfermentation, which still further complicates the diseased condition of the organ itself THE ALIMENTARY CANAL. 487 and interferes with its proper action upon fresh quantities of food. This may be occasionally relieved by vomiting or by the ingestion of some simple fluid which will aid in washing the stomach contents onward into the intestine. iEtiology, Idiosyncrasies. Personal idiosyncrasy is a very potent factor in dyspepsia. Not only do individuals vary from one another in this regard, but the same individual varies at different periods, in different stages of health, or at different ages. One not uncommonly observes persons who are most confirmed dyspeptics at home, but who when at sea are able to eat and digest all manner of richly cooked and thoroughly indigestible food without either nausea or discomfort, only to return to their dyspepsia on shore. On the other hand, many persons whose digestion is normal at home are made constipated and dyspeptic by the lack of exercise and by other conditions at sea, even though they be never " seasick." How often do dyspeptics who have been long kept upon a rigid regimen break away from all restraint and give astonishing accounts of the for- bidden articles which they have suddenly discovered they can eat for a time with impunity ! One who cannot digest the most tender mouthful of prepared meat or a crust of dry bread will thrive upon enormous quantities of nuts and oranges, another requires a prepos- terous quantity of pickles or of Cayenne pepper to stimulate the sluggish digestion into any sort of activity, and another lives largely upon raw apples ! Many people cannot eat strawberries without attacks of heart- burn and dyspepsia, while for others they are very wholesome food. Some persons cannot eat cauliflower without exciting dyspepsia, and for others the use of melted butter invariably brings on such an attack, while butter spread upon bread does not. Others exhibit in- tolerance for twice-cooked meats, new bread, potatoes, sweet jams of any kind, etc. (see Idiosyncrasies in Regard to Food, page 364). Other Causes. Fats and greasy foods set up butyric-acid fer- mentation which causes heartburn, regurgitation, and a rancid dis- agreeable taste. Sweets and raw or insufficiently cooked starches cause lactic-acid and other fermentations, with flatulence. Combinations of certain foods almost always disagree, as, for example, sweets and acids, fruits and beer, ice cream and beer, milk and cherries, milk and crabs. Dyspepsia is often caused by the continued abuse of irritants, such as alcohol and highly seasoned food, pickles, mustard, Cayenne. Tobacco and strong tea and coffee have a depressing action upon the nervous force of the stomach. To enumerate all the various substances which may at some time or other cause indigestion would be to include practically the entire 488 DIET IN DISEASE. list of foods. Each new case must be separately studied, and gen- eral rules admit of many exceptions. Balfour concisely sums up the relations of food to enfeebled stomach digestion by saying : " Three things greatly disturb gastric comfort too large a meal, too short an interval between the meals, and, lastly, the ingestion of food into a stomach still digesting." Examination of the Patient. It is important at the outset to understand all the patient's habits of daily life, the amount of sleep and exercise taken, the hours of meals and quantity and quality of food eaten, habits of drinking or smoking, the habit of the bowels, condition of the stools, and the nature of any irregularity the habit of eating too fast or taking too much or too little fluid with the meals. The condition of the teeth and tongue and breath must also be observed, and in obscure cases the possible existence of sources of reflex irritation, like ovarian disease, must be investigated. The proper cooking of the food should be insisted upon. Thorough cross-examination in regard to all of these conditions may reveal habits not suspected by the patient to be injurious, and which may be easily corrected. Slow Hating'. A simple explanation of the normal physiology of digestion will often interest an intelligent patient and secure his hearty co-operation in methods suggested for his cure, which other- wise he would find extremely irksome. He should understand that digestion commences at once in the mouth by the proper preparation there of all food and the digestion of starch in particular, and that the practice of slow eating gives time not only for more thorough mastication, but also for more abundant secretion of the necessary digestive fluids, saliva, and gastric juice. Very slow eaters are far less often dyspeptic than those who " eat and run." The sign "Quick Lunch," so commonly displayed in restaurants in business quarters of active American cities, has contributed much toward earning for Americans the title of a " Nation of Dyspeptics," for a meal quickly served is too quickly eaten as well. A dyspeptic child may be taught to count between his mouthfuls. Solid food insufficiently masticated passes into the stomach too dry and in too large masses for the gastric juice to act upon it promptly, and stomach digestion is greatly retarded. In persons with feeble digestive power who eat hastily, pieces of meat and tough vegetable fibres often appear in the stools wholly unaltered. The sense of taste may be utilised in order to prolong mastication by savoury cooking. It also stimulates the secretion of saliva and gastric juice. In such cases, as well as in those in which the teeth are absent or defective, it is well to prohibit all food which is not completely subdivided or tender, as, for example, tough meats and stringy or fibrous vegetables. THE ALIMENTARY CANAL. 489 Pain. In nervous dyspepsia pain exists as a prominent symp- tom, and is often independent of the quality of the food even a mouthful of water may cause it (Henry), but, as a rule, fatty and acid foods excite it, and must therefore be avoided. The appetite, too, varies greatly it may wholly fail at one time, and return in an exaggerated form at another. Decker reported the case of a patient who was uniformly awakened from sleep by such excessive hunger that he was obliged to take a hearty luncheon in the middle of the night. EXAMINATION OF THE STOMACH CONTENTS. In all cases of protracted dyspepsia which do not yield readily to dietetic treatment and proper medication it becomes important to ascertain the exact condition of the stomach and gastric juice, and for this purpose several ingenious clinical tests have been devised. These tests are applied to ascertain I. The degree of acidity of the gastric juice. II. The vigour of peristaltic action of the stomach wall. III. The rate of absorption from the mucous membrane. I. To determine the acidity of the gastric juice, a fresh specimen must be obtained for analysis. There are several means of doing this: 1. By a sponge. 2. By the stomach bucket. 3. By siphonage. 1. To obtain gastric juice with a sponge the patient must swallow a small piece of one tied firmly to a silken cord. When the sponge reaches the stomach it becomes saturated and swollen with the gas- tric juice. It is then carefully withdrawn, and the few drops of juice squeezed from it are tested for hydrochloric acid. This method is less disagreeable to some patients than swallowing a stomach tube, but the sponge becomes coated with oesophageal mucus and saliva, which interferes with the accuracy of the test. Its value is positive, not negative. 2. Einhorn has devised a stomach bucket about the size and shape of a small olive or a gelatin capsule, which is easily swal- lowed. It is attached to a silken cord, by which it is drawn up again, like the sponge. It is made of non-corrosive metal, and is so small and smooth that if it were lost it could do no harm, but, like a cherry pit, it would be voided with the stools. I have found its use open to the same objection with the sponge namely, that it gathers mucus and swallowed saliva from the oesophageal wall, which neutralises any gastric juice which it may contain. It also sometimes catches at the cardiac end of the stomach and causes the patient some dis- comfort, although this may be overcome by getting him to swallow as the bucket is withdrawn. Sometimes, however, it brings up a 'bucketful " of acid juice very satisfactorily. ^^ DIET IN DISEASE. 3. By far the best method of obtaining gastric juice is by siphon- age. The stomach tube is inserted in the manner described for gas- tric lavage, and the contents of the stomach are withdrawn in suf- ficient quantity to yield a satisfactory analysis. Some hysterical dyspeptics vomit so readily that the gastric juice may be obtained from the ejecta at any time. TEST MEALS. The composition of the gastric juice is best determined by fo'- lowing lavage by a test meal. After a definite period the stomach tube is again introduced and a sample of the stomach contents is withdrawn, filtered, and examined for hydrochloric acid and pepsin. If desired, other tests may be made for rennet ferment, carbohy- drates, peptones, albuminoses, lactic acid, phosphates, and fatty acids. The test for hydrochloric acid is the only one commonly applied for clinical purposes, and to aid the selection of proper diet, the others belong rather to special research. The best test meals are Riegel and Leube's test dinner, and a modification of this, known as Ewald's test breakfast, which is easier to eat and does not obstruct the stomach tube, although it stimu- lates the digestive activity of the stomach somewhat less. The stomach contents should be withdrawn for examination one hour after the breakfast, but between four and five hours after the dinner. Riegel and Leube's test dinner consists of Beef soup 400 cubic centimetres. Beefsteak 200 " " "White bread 50 " " Water 200 " " Ewald's test breakfast is 35 to 70 cubic centimetres of wheaten bread (one or two white coffee rolls) with 300 cubic centimetres of water or weak tea without sugar or milk. When the contents of the stomach are withdrawn one hour after ingestion of this meal its total quantity should be found reduced to 20 to 40 cubic centimetres. In withdrawing the contents of a stomach after a test meal the same tube is used, and in the same manner, as that employed for lavage, described on page 513. It is important that its introduc- tion should not be accompanied by violent retchkig, for when this takes place bile is very apt to be regurgitated into the stomach and neutralise its acid contents, rendering subsequent tests useless. The retching may be overcome by painting or spraying the pharynx with a 2- or 4-per-cent solution of cocaine, or, as Stewart recom- mends, by allowing the patient to swallow a few drops of the solu- tion, to anaesthetise the oesophagus. The use of a rather stiff tube. THE ALIMENTARY CANAL. 491 quickly inserted, diminishes the liabiHty to retching. The tube should not be lubricated when used for the test meals, but it may be wetted. The gastric contents may be forced out through the tube by directing the patient to forcibly expire, thereby compres- sing the stomach by the abdominal muscles, and simultaneously the epigastrium should be firmly compressed by the hands. It is also obtained by attaching to the stomach tube the bulb of a David- son syringe or a suction bottle such as that in common use for aspi- rating the thorax or abdomen. If no fluid flows, a little air or warm water may be forced through the tube to cleanse the obstructed fenestra. Dujardin-Beaumetz gives a test breakfast of coffee or tea with milk and a little sugar, and one or two plain rolls; no butter. The fluid must not exceed a pint. The normal stomach digests such a meal without sensation. If within two hours there is a sensation of heat in the stomach or burning and acidity, hyperacidity is present. If there is eructation of gas, fulness and weight at the stomach, then there is diminished or hypoacidity. If pain occurs within fifteen minutes with increasing intensity there is probably some organic lesion. In hyperacidity, moreover, Beaumetz says that the burning is worse three to four hours after eating, and is commonest in the middle of the night. It is often relieved by ingestion of food, which temporarily dilutes the acid. He urges dyspeptics to sleep on the right side, to aid the passage of food through the then dependent pylorus. TEST FOR TOTAL ACIDITY OF THE GASTRIC JUICE. Before testing for the presence of free hydrochloric acid, the total acidity of the stomach may be obtained, which is the combined acidity produced by HCl and lactic or other organic acids com- monly developed by malfermentation. This total acidity should equal normally 40 to 65 (Ewald), which represents " the number of cubic centimetres of test solution required to exactly neutralise 100 cubic centimetres of gastric filtrate " (D. D. Stewart.) The test solution is prepared as follows : " Four grammes of NaOH dissolved in one litre of distilled water is used for neutralisation ; each cubic centimetre of this solution will exactly neutralise 0.00264 gramme of absolute hydrochloric acid. The number of cubic centimetres so used multiplied by 0.00364 equals the percentage of HCl contained in 100 cubic centi- metres of the gastric filtrate " (Stewart). CHE.MICAL TEST FOR FREE HYDROCHLORIC ACID. A number of chemical tests have been devised for the detection of hydrochloric acid. .Q2 DIET IN DISEASE. Giinzberg's Test for Free Hydrochloric Acid. Phloroglucin 2 Vanillin i Absolute alcohol 30- Mix. Two or three drops of this solution are placed on a white porce- lain dish and allowed to slowly flow in contact with a similar quan- tity of filtered gastric juice. The dish is very slowly and gently heated over a spirit flame or Bunsen burner, and if hydrochloric acid is present, a faint rose-red hue appears at the line of contact, which deepens as evaporation continues into a brilliant cherry red. If the acid is abundant, minute cherry-coloured crystals will form. If the acid is feeble, it is best to concentrate the stomach filtrate upon a water or sand bath to about one tenth of its original bulk. When a very faint trace merely of the free acid is present the appearance of the colour should be carefully watched, for it is very evanescent. Gunzberg showed that one drop of the normal gastric juice i. e., juice containing 0.2 per cent of free hydrochloric acid when diluted ten times, should still give the colour. If it appears when the dilu- tion is carried beyond this limit, hyperacidity is present. This is, on the whole, the most reliable clinical test which has yet been devised, and the ease and quickness of its application for diag- nostic purposes has much to recommend it. It requires no special skill, and should always be made, to test the progress of the treat- ment, while lavage is being performed. The Boas Test for Hydrochloric Acid. The Boas test is performed in a similar manner to the Gunzberg test, but the colour produced varies from rose to vermilion, and the solution is made as follows : Sublimed resorcin 5 Sugar 3 Dilute alcohol 100. Mix. Both tests are only of value from a positive standpoint i. e., if the colour reaction occurs, free hydrochloric acid is surely present. They are, however, of little or no value as negative tests, for the reason that if peptones or certain other substances are present in the stomach contents the reaction may be entirely obscured. The latter difficulty is met by application of the calcium-carbonate test, which is uninfluenced by other substances likely to be associated with the gastric juice, with the single exception of an excess of acid phos- phates. The Calcium-carbonate Test. This is conducted as follows : A sample of gastric contents is heated to remove fatty acids, and shaken with ether to remove any lactic acid present, and blue litmus paper is dipped in the fluid. Another blue litmus paper is dipped in THE ALIMENTARY CANAL. 493 a fresh sample of the gastric contents which has been neutralised by the addition of dry pure CaCOj. The redness of the first paper when compared with the second will declare the presence of free hydrochloric acid. A strong Giinzberg reaction usually indicates normal reaction or hyperacidity. Its absence when hydrochloric acid is revealed by the CaCOj test indicates subacidity. If the latter test fails, then no free acid is present. Acid Salts. If the litmus dipped into the gastric juice neu- tralised by CaCOj is reddened, the presence of acid salts (phosphates) is indicated. The normal gastric free hydrochloric acid maintains a remarkable uniformity in strength, very rarely exceeding 0.2 per cent. It has been shown by Ewald and Leo that it is not secreted dur- ing fasting, but enters the stomach as soon as the stimulus of food is felt. At first it replaces the acids from lactates and phosphates, setting these acids free and forming chlorides with their bases. The hydrochloric acid also unites with albuminoids. For these reasons free HCl is not apparent in the gastric juice until the combinations mentioned have been all saturated, after which it increases in strength to the normal standard of 0.15 to 0.2 per cent. If alkalies are ingested, more HCl is secreted; but if acid be taken, the further secretion of HCl is checked, so that the average strength is pre- served. These conditions explain why it is that within fifteen minutes after ingestion of an Ewald test breakfast lactic acid may be found in the stomach contents, while free HCl may not appear for half or three fourths of an hour. Lactic acid is obtainable for an hour, or until the full strength of free HCl secretion is reached. If a heavy meal of bread and meat and vegetables has been eaten, the lactic-acid reaction will continue for a couple of hours, but free HCl may not be demonstrated for from three to four hours. This is an observation of considerable practical importance ; for in the early stage of digestion, the acidity being low and due only to organic acid, the ptyalin digestion of starches still continues, but it must cease as soon as any appreciable quantity of HCl is present. Free hydrochloric acid checks any further development of organic acids, such as butyric, acetic, or lactic. The Bacilli acidi lactici fail to act in its presence, and other bacilli, like those of typhoid fever and cholera, are destroyed by the antiseptic action of the HCl. HYPERSECRETION. Hypersecretion of gastric juice is determined by withdrawing the contents of the stomach in the morning after lavage the previous .g^ DIET IN DISEASE. evening. If more than fifty cubic centimetres are obtained, hyper- secretion may be said to exist (Kinnicutt), the acid nature of which is to be decermin&d by the Gunzberg test (page 492). Suggestions for the diet of such cases are given on page 500. Gastric atony is determined by finding in the morning washing of the stomach un-" digested particles of food eaten the night before. The microscopic examination of the washing will exhibit the bacteria, sarcinae, and saccharomyces. The treatment of this condi- tion is given under Chronic Gastric Catarrh, and Dilatation of the Stomach, page 511. TEST FOR PEPSIN. The presence of pepsin may be determined by digesting either egg albumen or blood fibrin, the latter being preferred. The fibrin is whipped from fresh beef blood and washed in water until it be- comes white. A small piece is placed in a test tube with fifteen or twenty cubic centimetres of filtered gastric juice, and kept at a uniform temperature of 40 C. for two or three hours. If there is but little normal HCl present, a few drops more should be added. If no digestion occurs after some hours, pepsin is absent and the fibrin will decompose. Quantitative or comparative tests may be made by using definite amounts of fibrin and gastric juice, and noting the time required for complete digestion. TEST FOR RENNET FERMENT. The presence of the rennet ferment is easily demonstrated by adding a few cubic centimetres of the filtered gastric juice to a half- teacupful of fresh milk, and keeping the mixture for a short time at 40*^ C. A loose coagulum forms with a limpid yellowish whey if rennet is present. TEST FOR MOTOR POWER OF THE STOMACH. The motor power of the stomach is demonstrated in various ways. Leube's Method. Leube's method is to empty the stomach after the ingestion of a Leube's test dinner (page 490), or Ewald's test breakfast (page 490). If the stomach is empty three hours after the former and one and a half after the latter, hypermotility is present i. e., the food is being too rapidly hurried into the duode- num. If undigested food remains six or seven hours after eating the Leube test dinner, the motility is impaired, and the diet must be regulated accordingly (see Chronic Gastric Catarrh, page 505, and Dilatation, page 511). Ewald and Siever's Method. Another method, that of Ewald and Siever's, is very simple, but not very reliable. Fifteen grains of THE ALIMENTARY CANAL. 495 salol are given in a wafer immediately after a meal, and the urine is tested for salicyluric acid, which is derived from salicylic acid formed in the alkaline intestine as one of the products of dissociation of salol. Salol escapes being acted upon by the gastric juice, and the salicyluric acid appears in the urine half an hour or an hour after it is swallowed if hypermotility be present otherwise, not for several hours. The salicyluric acid is readily detected by the violet colour which appears in the urine on adding a drop or two of ferric-chloride solution. The chief difificulty in the performance of the test is in getting urine when wanted without catheterisation. Frequent cathe- terisation merely for the purposes of such a test is to be condemned, and patients cannot usually micturate every fifteen minutes. Brun- ner and Huber prefer to make the test dependent upon the disap- pearance of all trace of salicyluric acid after ingestion of one gramme of salol. Normally it can be detected for only twenty-four hours, but if the motor power of the stomach is impaired it may be obtained as late as forty-eight hours after. Bourget found that the reaction time is delayed an hour or more by giving a dose of HCl with a meat meal, whereas it is accelerated by a less acid meal of which fruits and vegetables form a part. Stewart, in referring to this experiment, points out that hyper- acidity of the gastric juice, by neutralising the duodenal juices, might retard the salol reaction without the existence of motor in- sufficiency. Klemperer's Method. Klemperer has the patient swallow one hundred grammes of olive oil into an empty stomach, or the oil may be poured in through a stomach tube. It is left for two hours, and then the stomach contents are washed out. The oil is abstracted from the washing with ether, and the ether is separated. The oil is then measured. Between seventy and eighty grammes of oil should pass on into the intestine inside of two hours, but if it has not done so there is lack of motility. TEST FOR ABSORPTIVE POWER OF THE STOMACH. This test, as devised by Penzoldt and Faber, is very simple. Into an empty stomach are taken three grains of potassium iodide in a clean gelatin capsule, with a wineglassful of water. The saliva is collected at two- or three-minute intervals in sepa- rate saucers, and with normal absorption from a healthy stomach iodine may be detected in the secretion in from six and a half to fifteen minutes, but in gastric catarrh it may not appear for several hours. The test is made by dipping a filter paper, previously soaked in starch paste, into the saliva, and adding fuming nitric acid. A blue colour appears if iodine is present. This test is not very reli- 34 496 DIET IN DISEASE. able, for if the stomach is full of food the reaction is always much retarded, as it also is by fever and in most diseases of the stomach, notably ulcer, carcinoma, and dilatation. DIETETIC TREATMENT OF DYSPEPSIA. The foregoing details of the clinical examination of the digest- ive power of the stomach have been given in this connection as a convenient place to summarise them. It is not intended to imply that every case of simple dyspepsia should be subjected to so com- plex an examination, but, on the other hand, there are many persons afflicted with chronic dyspepsia who waste much time, energy, and expense in taking medicines and diet "cures " which are entirely un- adapted to their particular trouble because it has never been thoroughly investigated by the only means which in really serious cases permit of an accurate diagnosis. The passage of a stomach tube two or three times is all that is necessary for the patient to submit to to enable such a diagnosis to be made, and although it is never an agreeable process, it is far better than to prolong indefi- nitely a condition of great discomfort, and one which in time may develop into much more serious ills. The dietetic treatment of dyspepsia is so complex that it is easier for some persons to be put upon a very rigidly restricted diet for two or three weeks than to have to. select for themselves appropriate articles at each meal. It includes the study of all classes of foods, and for convenience they may be grouped into A. Foods forbidden in all cases. B. Foods occasionally allowable. C. Foods which are desirable. A. Foods forbidden in all Cases. 1. Rich soups, gravies, and sauces. 2. Strong condiments, pickles. 3. Fresh soft bread of any kind (which makes a tenacious bolus), hot breads, pastry of all kinds, cakes, griddle cakes, doughnuts, muffins. 4. Sweets, tarts, jam, confectionery and candies of every kind. Sugar in all forms, especially in coffee and tea with milk. 5. Raw vegetables, such as celery, radishes, coleslaw. 6. Heavy starchy vegetables potatoes, sweet potatoes, corn, peas, beans, eggplant, cabbage, cauliflower, Brussels sprouts, turnips, car- rots, parsnips (all the roots and tubers). 7. Fat in quantity, all fried or greasy food. 8. Lobsters, crabs, shrimps, salmon, herring. 9. Dried, smoked, cured, potted, or "devilled" meats, fish, and pork in every form. THE ALIMENTARY CANAL. 497 10. Corned beef, duck, goose, wild fowl, rabbit. Veal, except as broth. 11. Twice-cooked meats, hash (unless freshly made, without pota- toes), stews, ragoHts. 12. Cheese of all kinds. 13. Very acid or very sweet fruits, nuts, dried fruits in general. All skins and seeds of fruits. 14. Tea, beer, and sour wines. The excessive use of tobacco in any form should be forbidden. B. Foods Occasionally Allowable. There are foods which may be allowed to some patients but not to others, and many of them constitute exceptions to the- foregoing general rules. Such- are: Vegetables. Mealy, well-baked potatoes, not too young or new, raw tomatoes, spinach, thoroughly boiled onions, very young tender fresh peas, very young Lima beans, string beans, asparagus, stewed celery, celery plant (sea-kale). Starchy Foods. Where it is desirable to give starchy food in some form, macaroni, spaghetti, or rice may be allowed, or one of the pre- pared foods, such as Carnrick's or Mellin's. Fats. Bacon, very fat, sliced thin and well broiled ; cream, good fresh butter, olive oil. Eggs. Many patients find that -eggs disagree with them con- stantly. There are a few who can take them with impunity if rightly cooked that is, cooked very slowly and soft. They sometimes agree better when not given with other food, but as eggnog. As a rule, sweet fruits disagree, though they can be eaten by some patients. C. Desirable Foods to be recommended in Ordinary Cases are : Cereals. Wheaten bread, porous or aerated, stale or toasted ; dry, unsweetened rusk or Zwieback ; soda crackers. (The bread from some bakers is easier of digestion than that from others.) Macaroni, sometimes oatmeal, but without sugar. Fats. In moderation only ; butter to be very thinly spread and well rubbed in. Sometimes a thin rasher of bacon. Vegetables. Chiefly as purees, thoroughly cooked, made of toma- toes, asparagus, or sometimes potatoes or fresh peas. (Fresh green vegetables as in preceding list.) Lettuce. Fish. Oysters, fresh-boiled or broiled fish without rich sauces. They may be eaten with a little fresh butter and salt. (Some per- sons cannot eat fish at all.) Eggs. In any form if they are found to agree (except hard- boiled or fried). Sweetbreads, Meats. Broiled steak or chop, tender roast beef or g DIET IN DISEASE. mutton, chicken (roasted or boiled), boiled capon, roast partridge, grouse, woodcock, plover, prairie chicken, squab. All meats should be short-fibred and tender. They need not be very rare. Grilling is the best method of cooking them. Fruit. Baked or stewed apples or prunes. Occasionally a little fresh fruit in season, better eaten between meals to prevent constipa- tion. Oranges, peaches, grape fruit. Naturally, in bad cases the diet must be still further restricted, and a bread-and-milk regimen may have to be enforced until im- provement occurs. Beverages. Tea is generally injurious, especially if drunk with meals, but weak tea taken clear in very hot water is sometimes beneficial by enabling patients to imbibe the fluid which they need. Strong tea is astringent; it precipitates pepsin and provokes consti- pation. Coffee, on the contrary, favours peristalsis, and is mildly stimulating to the nervous system. Drunk with milk and sugar it often excites dyspepsia and increases flatulency. Taken black after dinner it is an adjunct to digestion. If it produces insomnia or " nervousness " it should, of course, be discontinued. Yeo says that both tea and coffee may cause dyspepsia in those who are under mental strain, but not otherwise in the same individual. Light China teas are less injurious than the stronger Indian varieties. Cof- fee contains more tannin than tea, which has only a trace. It does not itself ferment, but the milk and sugar drunk with it does. Cocoa (not chocolate, which is too sweet) may be allowed. An infusion of cocoa nibs often agrees. Milk and Vichy or milk and Seltzer may be drunk as a beverage in non-flatulent cases. As a general rule, malt liquors and beers of all kinds must be forbidden, although Fagge recommends the use of light, still, bitter ale or of porter in some cases; but he says, "Whatever causes flushing of the face after meals is bad." Alcoholic dyspepsia is only cured by entire cessation of drinking. This the patients are unwilling or unable to accede to unless very strongly influenced or frightened as to the probable outcome of continued indiscretion. In simple atonic dyspepsia the use of pure wine, or weak brandy, or whisky and water drunk at meals may prove serviceable. Some- times a little dry wine, claret, or hock may be allowed twice a day with meals. Tobacco, smoked in moderation, in the form of mild cigars or in pipes (not cigarettes), promotes digestion by slightly stimulating the nervous system and increasing peristalsis. Special Systems of Treatment. The following systems of treating dyspepsia are condensed from the writings of several of the best-known dietists: THE ALIMENTARY CANAL. 499 Dujardin-Beaumetz divides dyspepsia into three classes, and regulates their diet accordingly, as follows: I. Dyspepsia with abundant gastric juice. Diet, fresh vegetables and fruits, farinaceous food, milk, no meat or wine. II. Dyspepsia with deficient gastric juice. Diet, meat, broths, milk, peptonised food, weak brandy and water. No vegetables or saccharine food. III. Dyspepsia with sympathetic affections, especially vertigo. Diet, purely vegetable food. His diet of vegetable food is very liberal, and includes cereals as well as fruits. It contains such articles as dry bread crust, toast; farinaceous /i^r/if.y made of one of the following materials : Maize, flour, chestnut meal, oatmeal, pearl barley, potatoes, lentils, revalenta, macaroni (plain or buttered), vermicelli ; purees of fresh vegetables, such as green peas, carrots, turnips ; the vegetables of julienne soup; salads, spinach, sorrel, French beans, fruits, except grapes cooked as compote, lightly cooked eggs. Germain See's treatment of dyspepsia is exactly the reverse of that of Dujardin-Beaumetz. He divides dyspeptics into two classes: I. Those who have hyperacidity of the gastric juice, for whom he prescribes a nitrogenous diet with sodium bicarbonate after meals. II. Those having diminished acidity, for whom he prescribes a purely vegetable regimen, with dilute hydrochloric acid after meals. He directs in all cases to wash out the stomach and stimulate the gastric mucous membrane, for which he orders the alkaline sodium bicarbonate in a tumblerful of Vichy an hour and a half before eating. Leube graduates dyspeptics into four groups according to the severity of their symptoms. The diet which he recommends is as follows, commencing with the severest cases: I. Broth or clear soup, Leube's meat extract, milk, eggs (raw or lightly cooked), carbonic-acid water, Apollinaris, or Seltzer, II. Boiled calves' brains, sweetbread, breast of chicken or squab, bread and milk, custard, unsweetened tapioca pudding. III. The same as the two preceding, with the addition of raw ham \sic\ and rump steak. The latter is strongly beaten, scraped, and roasted quickly before a hot fire with a little fresh butter. IV. This diet, intended for the mildest cases or for convales- cence, includes milk, rice, spinach, roast chicken, partridge, venison, rare beef, veal, macaroni, fresh green vegetables, salads, fruit com- potes, stewed apples, and light wines. ' He sometimes allows fish, such as bass. General Rules for Dyspeptics. The followirkg general rules are applicable to all cases of dyspepsia and indigestion : I. Eat slowly, masticate thoroughly. -QQ DIET IN DISEASE. 2. Drink fluid an hour before or two or three hours after meals, rather than with food. 3. Eat at regular hours. 4. If greatly fatigued, lie down and rest quietly before and after, luncheon and dinner or supper. 5. Avoid as far as possible taking business worries or profes- sional cares to the table. 6. Take systematic exercise in the open air. Bicycle and horse- back riding are the best forms. 7. On rising, cold sponging and vigorous friction of the body is advisable. 8. The bowels should be kept open by laxative foods and fluids rather than by medicines. 9. Avoid too much variety at any one meal. Take meats and vegetables at separate meals. RULES FOR SPECIAL VARIETIES OF DYSPEPSIA. Dyspepsia with Excessive Flatulency. This often occurs in nervous women, and is especially annoying at night. Avoid particularly all sweets and amylaceous food. No fluid with meals. Drink hot water, half a pint before meals, and again two hours after. Do not eat vegetables and meat at the same meal. Try cream instead of milk in coffee, and saccharin instead of sugar. Avoid tea and alcohol, especially malt liquors and effervescing water, with meals. Dyspepsia with Hyperacidity. The diet should consist largely of rare finely minced or scraped beef (one hundred grammes, or three and a quarter ounces, is ample), with two slices of stale bread or toast, or a few crackers with a little butter (thirty grammes). Later the patient may partake of the lighter fresh vegetables and subacid fruits. Milk may be useful. Vegetables should be thor- oughly cooked and mashed or made into purees. Fruit must be stewed or, in the case of apples, baked. A six weeks' course of such a diet faithfully adhered to often results in cure. Dyspepsia with Excessive Nervousness, Irritative Dys- pepsia. Avoid tea, coffee, much alcohol, tobacco, stimulating food of all sorts, condiments and pickles, and do not overeat. Eat slowly. Avoid eating when fatigued or worried. Take one or two extra meals a day, if necessary, especially a light one before retiring, to promote sleep (see Insomnia). In the main, vegetable food will be better borne than proteids, unless flatulency is annoying. Atonic Dyspepsia, Dyspepsia with Deficient Gastric Juice. Take three meals /^r diem, and freshly cooked meat should THE ALIMENTARY CANAL. 50.1 be included in two of them. Beef, mutton, and poultry are recom- mended. Meat broths and soups, stale bread, toast, or crackers. All meats should be tender and simply cooked. In purely atonic dyspepsia, with loss of tone in the muscular wall of the stomach and sluggish secretion, a diet which is too bland and tasteless fails to stimulate the stomach sufficiently, and it is better to offer a reasonable variety and a moderate use of condi- ments. Dyspepsia in the Gouty. Avoid particularly sugar in every form, malt liquors, sweet wines, and champagne (see Gout). Dyspepsia with Bulimia. A certain class of dyspeptics are always abnormally hungry, for hunger is a general sense, due to the needs of the tissues rather than to the purely local condition of the stomach. Suffering from indigestion, they fail to assimilate food properly, become hungry again soon after meals, and do not obtain the full nutritive value of what they do eat. They therefore overeat or eat between meals, and do not give the stomach sufficient time for rest. They must be taught to restrain the appetite and to stop eating short of satiety to prevent overloading the stomach, and a sufficiently long period should intervene between meals for the thorough digestion of the food. Dyspepsia with Anaemia. Anaemic patients require abundant nitrogenous food, and well-seasoned, stimulating meat broths are recommended. Such patients may take an extra luncheon or two be- tween the regular meals and before retiring (see Anaemia, page 460). DYSPEPSIA IN CHILDREN, Children vomit much more easily than adults when they have taken improper food, and often suffer less in consequence, although, if such food is retained, they may have a gastric fever with a greater rise of temperature and, perhaps, more alarming symptoms than occur later in life. When vomiting occurs in infants the stomach should be rested by omitting the next feeding, and for the second feeding the milk should be diluted and reduced in amount. If vomiting persists, a little bicarbonate of soda or one or two tablespoonfuls of lime water should be added. Other substances, such as gelatin or one of the prepared infant foods, may be added temporarily to dilute the milk and prevent the formation of laf*ge curds in the stomach. In ob- stinate cases it may be well to change the diet completely and give up milk for a few days. In place of it a mixture may be used con- sisting of one part of cream and two parts each of whey and boiled (not boiling) water. An overfed infant vomits soon after nursing or taking the bottle, and the stools contain milk curds. When an infant receives too little tQ2 I>IET IN DISEASE. food, "the bottle is emptied quickly and ravenously ; the child cries when it is taken away, sucks violently at its fingers, and cries before the next feeding is due " (Holt). Older children should not be allowed to eat between meals, and must be forbidden the premature use of coffee, tea, spices, coarse vegetables (cabbage, turnips, etc.), and unlimited ice water, fruits, and sweets (see Diet for Infants and Diet for Children). Acute Gastric Catarrh. Causation. Acute gastric catarrh is commonly due to dietetic errors, although it is also excited in other ways. The dietetic causes are: 1. Food taken in too large quantity. 2. Food too hastily swallowed or "bolted." 3. Food in itself irritant or too highly seasoned with sauces, con- diments, fats, etc. 4. Food which has undergone decomposition, such as " high " game or fish, overripe cheese, sour milk, or improperly canned vegetables. 5. Alcohol habitually consumed in excess and in concentrated form, or a combination of drinking beer and wine or liquor, or drinking beer in excess with improper food. It may be caused by corrosive poisons. Many individuals appear to have special weakness or irritability of the stomach, so that at- tacks of gastric catarrh are excited in them by conditions which would prove insufficient in others. Excessive consumption of food beyond the wants of the system and out of proportion to the gastric juice is often an exciting cause of gastric catarrh, especially in children. This food need not in itself be indigestible. Such cases may result, for example, from eating large quantities of meat hash or of ice cream. Favourable circumstances are also present in anaemia, nervous exhaustion, con- valescence from protracted illness, and in fevers, in all of which conditions the gastric juice, and especially its hydrochloric acid, is apt to be diminished in amount or temporarily absent. In these cases digestion is retarded far beyond the ordinary limits, and the retained food decomposes by abnormal fermentation, thus becom- ing both a mechanical and a chemical irritant to the mucous mem- brane. Symptoms. The chief symptoms dependent upon the local in- flammation of the stomach are severe vomiting, nausea, pain, weak- ness, and fever. Dietetic Treatment. Acute inflammation of any structure is best treated by rest, and the stomach forms no exception. Hence total abstinence from food and great reduction in the quantity of THE ALIMENTARY CANAL. 503 fluid imbibed is often curative after an interval of twenty-four or thirty-six hours. The irritation is maintained by ill-advised at- tempts to give food at frequent intervals with the object of support- ing the strength. The attacks, from the very nature of their causa- tion, often occur in robust people who can well afford to forego nourishment for a few hours or until the nausea and pain cease. In others who have been enfeebled by continued illness or in whom the acute attack produces alarming prostration, enemata and stimu- lants and predigested albuminous food must be given. The vomiting and nausea are allayed by cracked ice, small quan- tities of iced champagne, carbonic-acid water, plain soda water, cold lime water sipped in doses of a tablespoonful at a time and at inter- vals of fifteen minutes.. Strong black coffee is also serviceable. These symptoms may also be relieved by hot poultices and turpen- tine stupes, or spongiopiline soaked in hot water and sprinkled with a few drops of laudanum placed over the epigastrium (Fagge). The thirst should not be met by large draughts of water, which only distend the stomach and excite vomiting. It may be relieved by sucking a piece of sliced lemon or by placing a few drops of mineral acid, such as dilute phosphoric or dilute hydrochloric acid, in a small tumbler of cold water and sipping it from time to time. Thirst may be lessened in some cases by holding water in the mouth for a few moments without swallowing it, for a certain amount of fluid is absorbed directly through the buccal mucous membrane. If large quantities of fluid have been vomited, a simple enema of salt and water (fifteen giains to the pint) may be injected into the rec- tum, where it is soon absorbed. When nourishment is first taken by the mouth, it must be fluid and carefully prepared, so that it will either undergo prompt absorp- tion or pass into the duodenum for digestion. It must be admin- istered only in small doses half an ounce or an ounce at a time. Pancreatinised milk, or cold milk diluted with an equal volume of lime water or soda water or alkaline Vichy, milk whey flavoured or added to beaten white of egg, beef extracts, peptone solutions, black coffee, expressed meat juice, and beef tea properly made, are all rec- ommended. Most broths contain too much fat or oil. Milk given alone or undiluted soon curdles in the stomach, and is promptly ejected in large tough coagulae. Many persons either actually can- not digest milk, or more commonly think they cannot, and avow a violent distaste for it, declaring that it leaves a perpetual bad taste in the mouth and causes headache and nausea. Their experience is usually based upon the use of undiluted and unprepared milk, and with tact and perseverance they can be got to retain and digest prepared milk very well (see Milk Predigestion, page 67). Some patients prefer warm milk diluted with water and flavoured with a 504 I5IET IN DISEASE. little cinnamon, a taste of coffee or caramel, or thej' may take barley water and rice water. If patients cannot drink milk they may be allowed mutton, veal, or chicken broths from which the fat has been removed. It is best to forbid all alcoholic fluids, even champagne, unless the patient is so exhausted that some stimulation becomes necessary, in which case brandy diluted with soda water may be given in small quantities, or it may be added to beef tea or arrowroot gruel. It is important always to aid the recovery of the digestive organs by ab- solute bodily and mental quiet. Convalescence. In convalescence the diet must be very slowly increased ; otherwise relapses may follow very easily. After some degree of improvement has been reached, the gastric mucus accumu- lates with more butyric-acid fermentation, and the vomiting and other symptoms return. At first but one article at a time should be added to the fluid food, gradually replacing it. Broths may be thickened by beaten or dropped eggs, crumbled toast, or scraped beef or chicken. Later plainly cooked meat, such as broiled tenderloin steak, chicken, a ten- der chop, squab, or a bit of broiled fresh fish with lemon juice may be allowed with dry toast and rice pudding. It is well to give dilute hydrochloric acid (ten to fifteen drops) with five grains of pepsin after each meal. When the illness has been very severe the patient must be cautioned to be careful in eat- ing for several weeks after the acute symptoms have subsided lest a relapse or gastric dilatation occur. Alcoholic subjects will probably not heed this warning, but it should be given none the less. ACUTE GASTRIC CATARRH. GASTRIC FEVER IN CHILDREN. Acute gastric catarrh in infants is oftenest due to improper feed- ing. It is also excited, or rather promoted, by teething and other reflex irritations which interfere with the normal stomach functions. There is an acute inflammation of the gastric mucous membrane, accompanied by more or less fever, vomiting, local pain, and ano- rexia. This affection is comparatively rare among nurslings. When it does occur in them, the mother's milk should be analysed, and any errors in her own mode of life, diet, etc., must be corrected. If the breast milk continues to disagree, a wet nurse must be procured, and, failing this, the child must be weaned if the disorder continues. Children just weaned acquire the disease from overfeeding and from improperly prepared food, and the number of meals must be carefully regulated according to the rules for infant feeding. Older children who are allowed to come to table develop the dis- ease from eating too rich or stimulating articles, such as pickles, sauces, spiced dishes, sweets, pastry, fried food, from drinking large THE ALIMENTARY CANAL. 505 quantities of hot or very cold fluid, from eating hurriedly without proper mastication, or from gorging themselves with enormous quantities of articles of which they are particularly fond, such as hash, cakes, etc. If seen early, if vomiting has not already occurred and the stom- ach is full, it should be emptied by an emetic dose of ipecac. Other- wise, if the stomach contents have passed into the intestine, the irri- tating food should be expelled by a laxative, such as calomel or grey powder. No food should be allowed for some hours, for it will keep up the hyperaemia. Nothing should be swallowed but a few sips of water or a teaspoonful of cool lime water or a little cracked ice. After ten or twelve hours of complete rest the stomach may tolerate one or two teaspoonfuls of pancreatinised milk or milk diluted one half with lime water or Vichy. If this is not retained, it is bet- ter to give a little meat juice or beef broth. The next day mild farinaceous food may be allowed, such as arrowroot gruel, corn- starch, or farina. Junket also, or milk toast, may be retained. It is best to return to a solid diet very slowly and carefully, and such articles as rice pudding, scraped beef, the breast of chicken, or the soft part of oysters may be given for a day or two longer before the regular diet is resumed. For some time after an attack it may be best to reduce the num- ber of meals /IET IN DISEASE. Some persons derive aid from manipulating the abdominal wall for themselves while lying in bed in the morning. A large wooden ball like a croquet ball or a heavy metal ball weighing four to six pounds may be rolled over the abdomen for five or ten minutes every morning, pressing it in deeply in the direction of the colon. This sometimes, in thin subjects, promotes the move- ment of the intestinal contents. Medicines. Discussion of the medicinal treatment of constipa- tion is not within the scope of this work, but the practice of contin- ually taking laxatives and strong cathartics cannot be too strongly condemned. The constant daily overexcitation of the bowels by such remedies as aloes produces a deplorable condition in which the bowels refuse to act at all without constantly increasing dosage. The majority of such cases can be cured by diet, but the rules must be very distinctly laid down, and the patient must exercise patience and care in adhering to them. I have sometimes been able to relieve patients who for several years had depended wholly upon strong cathartic pills or enemata, by stopping all medicine, and en- forcing simple dietetic rules, especially in regard to drinking abun- dant fluid and eating laxative and bulky food. They often think that a daily movement is absolutely necessary, and the worry and nervousness which its absence occasions in- creases the difficulty. They should be reassured, and told not to be concerned if the bowels do not move at first for two or three or even four days, and that if they do not have an unaided passage in that interval they can certainly be relieved, and diet and regimen will succeed in time if persistently followed. In very obstinate cases when diet does not succeed alone, atten- tion to its regulation will enable the patient to obtain the desired result with mild and decreasing doses of simple saline laxatives such as Congress, Crab Orchard, or Rubinat water, in lieu of strong ca- thartic pills, or patent medicines. Tobacco. Tobacco smoking increases peristalsis. Some men become constipated when deprived of their after-breakfast cigar. The effect of tobacco is not constant, however, and by disordering digestion too much smoking may be an indirect cause of constipa- tion. In those in whom it acts favourably upon the bowels, a good cigar is usually more active than any other form of the weed. Bathing. A daily morning cold bath followed by vigorous fric- tion of the skin is also of great service. Electricity. Faradisation of the abdominal walls is frequently useful, but, owing to the fact that the electric current when applied superficially radiates over the skin without penetrating to any ex- tent beneath the surface, it cannot be expected to reach the intes- THE ALIMENTARY CANAL. 553 tinal wall. Any benefit derived from such application must be purely of a reflex character from excitation of the cutaneous nerves trans- mitted through the cord to the sympathetic nerves. A much better method of applying a faradic current consists of introducing one electrode for several inches into the rectum, while the other is moved about over the surface of the abdominal muscles. In this manner these muscles may be made to contract and move the intes- tines to some extent, and it is possible for a portion of the current to pass through the sigmoid flexure. If carefully adjusted, the ap- plication of the current gives rise to no pain or discomfort. Bandaging. In very obese persons, who are liable to suffer from constipation, the pendulous and relaxed abdominal wall should be supported with an abdominal bandage. The same treatment may give comfort when the wall is much distended in child-bearing or by the presence of large abdominal tumours or accumulations of ascitic or ovarian fluid. Constipation in Infants and Children. In earliest infancy from two to three, or even four, daily evacua- tions from the bowels are considered a normal number, but in child- hood, as in adults, one passage is normal. In infancy constipation is exceedingly common on account of the milk diet. Bottle-fed babies are more subject to it than sucklings. In infancy the small intestine is relatively longer than in the adult, the large intestine easily becomes distended, the pelvis is more contracted, and peri- stalsis is usually less vigorous, owing to a less powerful musculature than obtains in adults. When constipation is present in an infant at the breast the milk may be too rich in casein and deficient in fat, salts, and sugar. This may be due to a constipated habit of the mother, and laxative foods should be given to her rather than medicines to the child. If the child is nursing a wet nurse, it may be best to change to another in perhaps an earlier stage of lactation, or one whose milk is less rich in proteids. If the infant's stools consist of dry and brittle scybalae it should be given more water to drink, or a little oatmeal water, which is laxative. Other simple and oftentimes effectual remedies are from half to a teaspoonful of olive oil, molasses, melted sugar, or butter. In the case of hand-fed babies when the milk forms large and hard curds, and when the proportion of cream is too small, the addi- tion of water and cream will often remedy the evil. As an occasional, but not habitual, simple remedy for constipa- tion in such cases relief may be obtained by making a mixture of a tablespoonful of whole-meal gluten flour in a pint of water, boil- 554 DIET IN DISEASE. ing for three hours to a thick mass, and adding a teaspoonful of the mixture, unstrained, to each feeding bottle. Artificial foods, " prepared " foods, and condensed milk are more apt to excite diarrhoea than constipation, but it should be remem- bered that they may cause the latter, and the continued use of coarse food or cathartics, or of large enemata, overstimulates the bowel and results in constipation. When it is necessary to use enemata they should be small, and not too frequently given. From ten to thirty drops of glycerin in two teaspoonfuls of water is quite sufficient for a young nursing infant. The glycerin, by virtue of its hygroscopic power, abstracts water from the rectal mucous membrane, causing hyperaemia, which in time excites peristalsis. A simple injection of two teaspoonfuls of cold water containing a pinch of salt is often successful. Suppositories may also be used. They should be small, conical in shape, and well oiled before being inserted. They may be made of glycerin, soap, molasses candy (Fruitnight), or gluten. The for- mer is the best. For older children, from three years up, some one or more of the following articles should be included in the menu. By this means it will be possible to do without castor oil, senna, rhubarb, strong ene- mata, and other remedies which are constantly abused. Foods recommended. Oatmeal, corn bread, cracked wheat, porridge, wheaten bread made of unbolted flour, bran bread soaked in warm milk (Earle), gingerbread, bread and molasses (not sirup), brown bread and honey, stewed prunes, baked apples, figs, olive oil and olives, cod-liver oil, fresh green vegetables, orange juice, peaches, and whey. The French make excellent purgative biscuits for children, and a child eight or ten years old may be given occasionally a little tropical fruit laxative or Tamar Indien. A pinch of dry salt followed by a little water sometimes improves the action of the bowels. Foods forbidden. Certain foods should be absolutely forbid- den to older children, such are cheese, dry fruits (except figs and prunes), fruits having small seeds, spices, pickles, nuts, raisins, dried, salted, or preserved foods of all kinds, canned corn, sweets, candies, cakes, and excess of farinaceous foods. All articles likely to produce flatulent dyspepsia must be avoided. Children on a mixed diet do well to avoid starchy foods and take more broths and soups. Variety in the diet is desirable. Children should be trained to go to stool at regular hours, and should be early taught the evil consequence of neglect to respond to the calls of Nature. School-teachers should not detain them at their lessons when they are inclined to seek the closet. Water-closets THE AILMENTARY CANAL. 555 or privies are often dark, cold, and otherwise disagreeable, so that children dread going to them. Abdominal massage is very helpful in overcoming chronic con- stipation in young children. It may be performed two or three times a day for five minutes. The movements should be made with the fingers of a warm, dry hand, which move the integument and abdominal wall over the intestine. The treatment must be very gentle, and if the muscular wall is tense, it may be conducted while the infant is nursing or feeding, as suggested by Fruitnight. Hemorrhoids. Hemorrhoids usually complicate cirrhosis of the liver sooner or later, but they also result from chronic constipation and other causes. The dietetic treatment is substantially that of chronic constipation (page 548). Much depends upon preventing the stools from becom- ing hard or bulky. Large quantities of coarse vegetables and cereals should therefore be avoided as well as milk. Alcohol is injurious, especially in the cirrhotic cases. Fresh fruits and abundant fluids are serviceable in uncomplicated cases. Regularity in meals and in time of going to stool should be enjoined, with abundant outdoor exercise. Straining at stool must be avoided. Appendicitis. Causation. Appendicitis is mainly interesting from the dietetic standpoint on account of the possible causative relation of certain food residues. In about one third of the cases faecal concretions are found in the appendix, and in one thirteenth foreign bodies have been discovered. It is a popular belief that the disease is often es- tablished by the presence in the intestine of grape seeds or skins, lemon, orange, or mustard seeds, cherry pits, bits of chicken bone or clam shell, etc., but such is not the case. Substances of this nature are no doubt often swallowed, but they seldom make their way to the appendix or do any harm ; and it is now known that the disease, while it may exceptionally be produced by such irritants, is commonly caused in other ways, and is often of bacterial origin. I have known of one fatal case resulting from eating a large number of soft-shell crabs, but such accidents are very rare. On the other hand, as pointed out by McNutt, both overeating and overdrinking may indi- rectly cause appendicitis as well as the consumption of too highly seasoned foods, for these factors provoke catarrh of the intestine, distending the bowel with faeces and g^as, and making it easy for the catarrhal process or for bacteria of various sorts to enter the appen- dix and set up local inflammation there. The recurrent cases are more apt to be Accited directly by overeating and improper food. 556 DIET IN DISEASE. Dietetic Treatment. The dietetic treatment of appendicitis which has not yet passed into the surgeon's hands should consist in giving only such food as will be thoroughly absorbed, leaving as little residue as possible to irritate the lower bowel and excite peri- stalsis. Until the outcome of the attack is decided it is best to put the patient upon a fluid diet, consisting chiefly of nutritive broths. Beaten eggs may be allowed, and a moderate quantity of pancre- atinised milk, whey, or buttermilk. Cocoa may be given, and strained gruels of rice or barley. In recurrent cases the patient should be cautioned to eat moder- ately and avoid all coarse or hard food, such as grits, coarse oatmeal, tough meats, fibrous vegetables, the skin of fruits or potatoes in short, everything likely to overload the intestine with accumulated waste. The operative cases should have the diet recommended after laparotomy. Usually the digestive organs require almost absolute rest for twenty-four hours after the operation, and hot water may be sipped. No food at all should be given for fully six hours before operation. Acute Peritonitis. Acute peritonitis, if due to causes within the alimentary canal, demands absolute rest of the stomach and intestines, and this is se- cured by giving all nourishment, stimulants, and medicines in the form of nutrient enemata (page 375). Any food in the stomach is likely to excite vomiting and aggravate the pain and other symptoms. The patient usually has disgust for all food to such a degree that he dreads taking anything into the stomach which is likely to excite emesis. The disease is, moreover, a very serious one, and the utmost care should be given to maintenance of the strength by the use of predigested fluid food. In other cases a very little fluid nourishment may be cautiously administered per os, such as peptonised milk, light gruels of pearl barley or arrowroot, plain meat juice squeezed from a fresh steak, or one of the forms of peptonised meat or e.gg albumen in sherry should be tried. Only one or two teaspoonfuls should be given once in fifteen minutes or half an hour, and every effort must be made to prevent the occurrence of vomiting or meteorism. Twelve or fifteen ounces /^r ur/es, accompanied by rest and passive exercise (massage). After a few days the more substantial nitrogenous foods may be added. In cases associated with lithaemia or rheumatic THE NERVOUS SYSTEM. 57I diathesis, however, the quantity of such foods should be reduced, and the special regulations described under the heading of rheuma- tism and lithaemia must be followed. Coffee and tea should be used only in moderation, and in bad cases had better be prohibited altogether. Alcohol in restricted dosage benefits many cases, excepting, of course, those primarily due to alcoholism. Claret or Burgundy may be drunk with meals, but alcohol should never be taken merely to relieve pain or otherwise than as a food, for there is danger of be- coming too much addicted to its use. Substances to be especially forbidden are pastry, sweets, and confectionery of all kinds, griddle cakes, condiments, fried food, and rich, highly seasoned sauces and foods. All meats should be eaten at regular intervals, and, except as directed above, eating between meals must be prohibited. VISCERAL NEURALGIAS. The visceral neuralgias are produced in the sympathetic nerves chiefly. The digestive viscera stomach, intestines, liver, etc. in a normal state are free from sensory impressions, but their nerves are constantly conveying reflex impressions, which, however, are to be distinguished from ordinary tactile 'sensibility. Hypochondriasis, by concentrating mental attention upon the various abdominal viscera, undoubtedly develops hypersensitiveness to such nerve currents. The condition described as "ptomaine poisoning" may excite a severe neuralgia as a symptom. Dietetic Treatment of Visceral Neuralgias. Neuralgias of any of the abdominal viscera are apt to be excited by functional activity (although they also may occur independently of it), and hence the diet should be made as simple and nutritious as possible, in order that digestion shall not be unduly prolonged. If any one article of food is found to excite the paroxysms it should be aban- doned. It is often advisable in severe cases to limit the diet for a few weeks to two or three simple articles of food, such as beef, bread, milk, and rice. GASTRALGIA. Causation. In neuralgia of the stomach, called gastralgia, or gastrodynia, the pain is situated in the epigastrium, penetrating to the back. It is distinctly localised and intense. It may be wholly paroxysmal, or there may be dull constant aching with exacerbations of a moderate lancinating character. It is usually relieved some- what by moderate gentle pressure, but intensified by deep pressure. Such pain is not infrequently associated with anaemia, chronic con- stipation and hysteria, and in a severe form, accompanied by violent --2 I>IET IN DISEASE. vomiting, it constitutes the "gastric crisis" of locomotor ataxia. Gastralgia may also be occasioned by the continued excessive use of stimulants, such as alcohol, strong tea and coffee, and chewing tobacco, and by the inordinate use of sweets. An excessive forma-^ tion of hydrochloric acid in the gastric juice may occasion a very painful variety of gastralgia. Dietetic Treatment. In all cases of gastralgia careful inquiry must be made in regard to irregularities of diet, and the relation be- tween eating and the occurrence of the pain. If the pain is worse while the stomach is empty and is mitigated by taking food, it is suggested by Gowers that it is due to morbid action of those nerves which normally excite hunger. Such cases should be treated by giving nourishment in frequent small quantities. In addition to the three regular meals of the day, which should be light, a glass of wine or a cup of hot bouillon and a biscuit or two, or a glass of milk punch or eggnog, may be taken at ii a.m., 4 p.m., and again before retiring. A tumbler of milk or a few crackers may be kept by the bedside and taken in the middle of the night should the pa- tient be awakened by the pain. The pain itself is an indication of impoverished nutrition, and the nervous system requires rest while the tissues need food. In still other cases food intensifies the pain and excites immediate emesis. This is especially true of the gastric crises of locomotor ataxia. Here sedatives, such as bismuth, cocaine, or anodynes must be given to relieve the irritation of the gastric mucous membrane while food is temporarily withheld until the pain has subsided. The diet subsequently should be gradually increased, commencing with small quantities of peptonised albuminous food. In gastralgia the appetite is very capricious, and there may be ex- cessive craving for certain articles of diet, such as pickles, condi- ments, etc. In all forms of gastralgia the pain is aggravated by distention of the stomach. If starchy food tends to produce flatulency it should be avoided, together with sugars and fats. Tea and coffee and tobacco must be given up. The bowels should be kept freely open. Hnteralg^ia i. e., a true neuralgic pain in the intestines is not common if " peristaltic unrest " be excluded. It does occur, how- ever, and most frequently in the lower rectum, in which case it is to be relieved by local treatment rather than dieting. Hepatalgia, or neuralgia of the liver, is an indication of func- tional overwork of that organ, which may be relieved by a careful inquiry into the dietetic habits of the individual and correction of errors in addition to purgation. In severe forms of neuralgia which do not yield to dietetic and medicinal control prompt relief is often secured by change of scene and sea bathing, or a course of mineral baths. Hygienic measures THE NERVOUS SYSTEM. 573 improve functional activity and promote oxidation and assimilation by the tissues of the products of digestion, as well as the elimination of waste. Migraine. Migraine, or " sick headache," is a neurosis characterised by pain in the course of the fifth nerve, often accompanied by nausea, vomit- ing, mental depression, and local vasomotor disorders. There are many causes assigned to this affection, among them heredity, the gouty diathesis, improper food, etc. Some obstinate cases are unaffected by diet, but others are much benefited by atten- tion to it, and it is always worth while to attempt a cure by it. The patient should be very closely interrogated in regard to all the habits of diet and hygiene, such as the hours for eating, the kind of food eaten, its method of cooking, bathing, exercise, mental work, hours and frequency of the stools, etc. In this way only can possible faults be detected and corrected. The gouty should be forbidden the use of wines, malt liquors, sugars, and starches. The anaemic should be ordered more animal food and fats and cod-liver oil. The dyspeptic should abstain from carbohydrates. The neurotic should give up tea, coffee, and tobacco. It has been shown by Roberts that both tea and, to a lesser extent, coffee may materially retard starch diges- tion, even when drunk in very small quantities. Yet there are some patients who can ward off an impending attack of migraine by taking two or three cups of strong tea or black coffee. Plain cereal foods may be allowed, such as wheaten grits, " ger- mea," hominy, and oatmeal, but the addition of milk and sugar to them may cause fermentation and make them undesirable. In this case saccharin may be substituted, or an extract of malt. Fresh green vegetables, such as asparagus, young peas, French beans, string beans, sea-kale, and stewed celery may be eaten, but potatoes, corn, cabbage, tomatoes and rhubarb should be avoided. Excepting anaemic patients, those suffering from migraine should not eat much meat. It is best to take it not oftener than once a day, and the white meat of poultry and broiled fresh fish are better than much red meat. Milk may disagree and cause headache through lactic-acid fer- mentation, interfering with digestion. New bread, pastry, richly cooked food, condiments in excess, shell- fish, crustaceans, cheese, sauces, and desserts in general are forbid- den. Many of these foods may produce ptomaines by putrefactive fermentation, which act as poisons to the blood and nerves. Vinegar and acid fruits should not be eaten, especially in connection with amylaceous food (Roberts). Obviously no rules of diet apply to all cases of a disease which may originate from so many different causes, and in chronic cases cy^ DIET IN DISEASE. careful observation and experimentation will be necessary to estab- lish the best course. Overeating, irregular eating, and late suppers should be forbid- den. Outdoor exercise, bicycling, or horseback riding should be prescribed to aid digestion, and the bowels should be kept active by eating fruits. Patients are often found who, as a result of following every one's advice, have gradually cut down their diet, one article at a time, until they are actually suffering from inanition, and it requires no little tact and firmness to convince them that they can eat anything at all. They will live on nuts and fruit alone, or on hot water and raw beef, or follow the latest dietetic " fad," whereas they really need a common-sense diet of plain, nutritious food, such as that prescribed above for neuralgia or anaemia. Decayed teeth are a frequent cause of facial and other neuralgias, and the pain is often directly excited through the food or liquid taken being too hot or too cold, or strongly sweet or sour. Many persons experience temporary but severe frontal pain after swallow- ing iced beverages or ice cream too rapidly. In some persons the site of the pain is in the vault of the pharynx or in the throat itself. It is often relieved by momentarily compressing both carotid arter- ies. Brunton suggests that cold excites the sympathetic plexuses about the carotids and alters their calibre, putting them into a state of spasm. These forms of neuralgic pain are, however, usually triv- ial, and are to be avoided by proper care of the teeth and regulating the temperature of the food. Neurasthenia. Causation. Neurasthenia is a condition of loss of tone of the nervous system which is of a functional rather than an organic char- acter. It is also called nervous exhaustion or nervous prostration. Strictly speaking, it is not a disease, but rather a functional derange- ment of considerable duration, which, however, with proper care and dietetic treatment results usually in complete recovery. The most apparent cause of neurasthenia is overwork of the nervous system due to continued excitement or strain or prolonged emotional de- pression and anxiety. It is far more apt to be produced by overwork of the nervous system than of the muscular system, although it may be occasioned by the latter. Different individuals are endowed with varying degrees of nerve force, and the Comdex demands and great activity of highly developed civilisation tempt or compel many peo- ple to draw upon their physiological capital of energy at the expense of its income, with the result of exciting the entire central nervous system, including both brain and spinal cord, to an unwonted and sometimes dangerous degree. For this reason neurasthenia is THE NERVOUS SYSTEM. 575 essentially an affection incident to the occupations and customs of city life, rare or comparatively unknown in the repose of the coun- try. It is a curious but undeniable fact that there appears to be more or less fashion in regard to some diagnoses, in nomenclature at least, if not in the diseases themselves, and of late years "nervous prostration " has taken rank among ordinary functional disorders. The general name neurasthenia includes a large variety of nerv- ous symptoms, and while all of the physiological processes of the body are more or less impaired, the symptoms may predominate in one or more mechanisms, as, for instance, that of the circulation, gland secretion, or absorption. Men who find themselves in business straits or in circumstances of prolonged anxiety feel that they are straining their vital powers, and resort to an increased or excessive use of stimulants, such as alcohol, tobacco, coffee, and various drugs, to excite their overtaxed mental and physical powers into greater activity. By means of this substitution of force, especially with the use of alcohol, they are en- abled to work on, and still further excite a debilitated nervous system until finally the limit of endurance is reached, and some slight addi- tional strain reduces them to utter prostration. Not infrequently local functional disorders, such as writer's cramp, neuralgia, etc., give warning that a general neurasthenic condition is imminent, and if this warning be not heeded in time, more serious symptoms inevitably follow. Neurasthenia reacts on the digestive system, producing malnutri- tion and a variety of functional disorders, for so dependent is the whole alimentary canal upon a normal vigorous blood supply and nerve regulation that it necessarily suffers profoundly. General Treatment. The treatment of neurasthenia is funda- mentally based upon two absolutely essential conditions : First, complete body rest, with the necessary absence of the original ex- citing cause of the difficulty, which will enable the impoverished tissues to become regenerated and have the balance of their energy properly retarded; secondly, a nourishing diet, which will supply the material for this energy and tissue metamorphosis. Various tonics, such as strychnine, iron, and arsenic, are of recognised bene- fit to the nervous system, but the main reliance in all treatment must be placed upon rest and food. The milder cases may be re- lieved by a change of occupation and the enforcing of strict rules in regard to the hours of sleep, the methods and time of eating and taking exercise, bathing, etc. Many persons with functional nervous disorder have no appetite early in the day, but towards evening can eat a substantial meal, and they should dine late. Patients who for years have been accustomed to exceedingly active mental work find it almost impossible to endure confinement, 39 5/6 DIET IN DISEASE. absence from social intercourse, and lack of occupation, and in such cases the advantages of dietetic treatment may be enhanced by cheerful surroundings and diversion. As a rule, it is far easier for the fatigued or worried business man or " brain worker " to break off completely his accustomed occupation for a period of several weeks or months, to be spent in travel or at some foreign spa, than it is for him to continue his ordinary occupations in moderation, and take exercise and proper food and sleep in accordance with the rules laid down by the physician. In many cases of this nature travel affords a certain and fairly prompt relief, but it has the disadvantage that it involves consider- able irregularity in the hours of rest, character of diet, etc., as well as the fact that many are deterred from this means of cure by the expense involved. In another class of cases too active travelling is stimulating and fatiguing, and if such people are not made ill at sea nothing gives more benefit than the isolation, invigorating air, and enforced idleness of a sea voyage. For others, in whom the digestive system is but comparatively little impaired, camping or living an outdoor life in the woods affords the same advantage. Whatever journey is undertaken, therefore, should be in the direc- tion of rest and moderate diversion without the sight-seeing which is involved in visiting new cities. The physician should not only study carefully the previous habits of the patient, but should con- sult his tastes in regard to occupations and amusements. When this is done and his confidence has been thoroughly gained, it is far easier to have the rules for diet which are prescribed carefully adhered to. In still another class of cases of neurasthenia the general nerve ' breakdown " is so sudden and the exhaustion so ex- -treme that absolute rest at home and in bed is imperative. To this class of cases belong a large number of overworked society women whose lives of constant excitement and mental activity or stimulation, combined with the number of charitable interests or other occupations to which they give much energy, wear them out in time. The most severe cases of neurasthenia require special treatment, the principles of which are, first, complete rest for body and mind; secondly, systematic feeding; and thirdly^massage. This treatment is applicable to those cases in which the nervous system is so greatly exhausted that the patient suffers continual depression from the least exercise, exertion, or emotional excitement. In some in- stances insomnia is a predominant and serious symptom ; in others the patient is drowsy in the daytime and unable to perform any concentrated mental labour ; in others again inanition is the most pronounced feature, and the rapid loss of weight and failure of strength alarms the patient, or the body may even increase in THE NERVOUS SYSTEM. ^5/7 weight, while the muscles become soft and so feeble as scarcely to support the frame. Many cases are complicated with pronounced hysteria, hypochondriasis, or unnatural irritability. One of the first requisites in treatment is to secure a faithful and intelligent nurse and to isolate the patient from well-meaning but oversympathetic friends whose constant inquiries and sugges- tions are apt to aggravate existing conditions by focusing the attention of the patient upon them. In general, it is best to allow no one to see the patient excepting the trained nurse, the physician, and perhaps some one trusted member of the family. All business matters and domestic news of an exciting or depressing character should be carefully kept from the patient, and such connection as may be allowed with the outside world should be only of a cheer- ing and encouraging nature. It is very important that the nurse, who is so constantly with the patient, should be congenial and possessed of the requisite tact and cheerfulness of disposition. Many of these details may seem trivial, but their importance is appreciated after experience, which shows how easily infringement of the rules, such as the untimely reception of exciting news or the visit of an untactful friend, may react upon the digestive system and interrupt the favourable prog- ress of the case for several days. This is particularly true of all hysterical cases. On the other hand, there are some instances in which patients with active minds do decidedly better if mild, pleasurable occupation or entertainment, such as reading aloud, is provided for them, which is carefully limited to prevent fatigue. It is necessary to explain the general plan of cure and its object to both patient and family in order to secure their co- operation, and this having been done, the treatment which has received the name of " rest cure " should be outlined by definite rules in a most careful and systematic manner. To be of any serv- ice, the rest cure should last six weeks or more, and in severe cases it should be explained that this treatment by no means completes the restoration of the normal nerve functions, but is to be regarded as a basis for a further regimen of exercise and outdoor life. While the rules for diet for individual cases must be distinctly laid down, and conscientiously adhered to, there is scarcely any other variety of disease in which the physician is called upon to ex- ercise more tact and discretion, and the success of the treatment will depend very largely upon the extent to which he adapts its provisions to the needs of individual cases. It is comparatively easy to prescribe definite regulations for the treatment of neuras- thenia, but practically there is no case which does not present in- dividual peculiarities which require special consideration. 578 DIET IN DISEASE. THE "REST CURE." At the commencement of treatment in severe cases the patient must lie absolutely quiet in bed and not be even allowed to raise the arms or head to take food. After a week or ten days of such enforced and absolute rest, the patient may gradually be allowed to sit up and feed herself, but usually a full month or six weeks should be spent in bed with no further exertion. The lack of voluntary exercise must be supplied by the tonic effect of bathing and mas- sage. The patient should receive a sponge bath every morning soon after breakfast, which is to be given with hot water, or hot sea water if it can be obtained. A portion of the body only is to be sponged at a time, and friction with a coarse towel should immedi- ately follow. In some cases benefit results from rubbing k piece of ice or a cloth dipped in ice water over the skin for a moment after the hot-water sponging. The alternate stimulation of the cutane- ous nerves by strong degrees of heat and cold always produces a tonic effect, and the influence of the ice water and friction is analo- gous to that produced by the Brand system of cold bathing. After the bath, which, if properly given, may consume a half or three quarters of an hour, the patient must be allowed to rest, and at noon or in the early afternoon massage is to be given, at first every day, and later on alternate days. At the commencement of the case the massage should be exceedingly mild, and caution is required in this respect, for neurasthenic patients are often injured by the too vigorous or prolonged efforts of the massage operators. For the first day ten or fifteen minutes will suffice, and if the effect is favourable, the time may be gradually extended to an hour. Owing to the nature of the diet, which at first is fluid and composed of milk, and from the lack of exercise and loss of tone of the intes- tinal walls, neurasthenic subjects are uniformly constipated, and the massage should be particularly adapted to remedy this difficulty. Massage of the abdominal muscles should be performed by gently rubbing and kneading the abdomen, commencing in the right iliac fossa and following the direcflbn of the colon upward to the free border of the ribs across to the opposite side and downward to the sigmoid flexure. By this means peristaltic action is undoubt- edly stimulated, and the contents of the large intestine are mechan- ically propelled in the proper direction. Dietetic Treatment. The feeding of the patient must be based upon the principle of giving all the nourishment which can be assimilated. The stools should be carefully watched from day to day to make sure that the milk or other articles of food are thor- oughly digested. Nourishment should be given at brief intervals, which must depend somewhat upon the amount of time allotted to THE NERVOUS SYSTEM. 579 sleep, but in cases of great exhaustion patients should not be per- mitted to go more than four hours at any time without food, and sleep must be interrupted for feeding, if necessary. In^ther cases when sleep so interrupted is readily resumed, food may be given with regularity once in two hours throughout the day and night, as in typhoid fever. When improvement is attained, the intervals of sleep will naturally be longer, and it will be both unnecessary and unwise to awaken the patient for feeding. The basis of the diet in most cases should be milk, and by studying the taste and diges- tion of the patient it is usually possible to prepare it in such a manner that it is well borne (see Adaptation of Milk for the Sick, page 72). In commencing the milk diet the objection of the patient often has to be overcome, and it is advisable to begin slowly, giving skimmed milk in tablespoonful doses four or five times a day for two or three days until the patient is accustomed to it. Other food is of course allowed at first, but this is to be gradually reduced and the milk substituted for it in increasing quantity until four ounces of skimmed milk are taken every two hours. It is finally given up to eight or ten ounces at the same intervals. The taste, if disagreeable, may be overcome by the addition of a little black coffee or caramel. If it produces weight and epigastric oppression or causes flatulence and eructations it is to be diluted by one half or one third with lime, barley, or rice water or Vichy. One of the "prepared foods," such as Nestle's or Mellin's, may be added, or the milk may be pancreatinised or temporarily replaced by koumiss or matzoon. The exclusive milk diet tends to make the patient drowsy and to allay irritability in all the organs of the body, and it is actively diuretic. The constipation which the milk occasions may be overcome by a pill of ox gall or a dose of bitter water in the morning, or by enemata of warm soapsuds, when the latter do not produce the ex- haustion which occasionally follows their use. Many patients do very well on the exclusive milk diet for a period of several weeks, and they may be fed very much as typhoid- fever patients are, excepting that they may take more milk. If they can digest it, two and a half or three quarts a day should be given. Weir Mitchell, who was the pioneer of this method of treatment in this country, prescribes an exclusive milk diet less rigidly than formerly. After five or six days of such treatment a chop or a poached egg may be added at noon. The next day bread and butter or bread and milk is given, besides^ for supper, and then an egg or a little meat at breakfast, until the patient is taking three good meals of plain food daily, but in addition at least two quarts -3o DIET IN DISEASE. of milk. The exclusive milk diet is believed to prepare the digestive system for the assimilation of other foods. Playf air's Diet. Playfair's diet for neurasthenia is a good example of a milk diet, soon combined with other foods, as follows : First Day. Twenty-two ounces of milk in divided doses. Second Day. Fifty ounces of milk in divided doses. Third Day. Fifty ounces of milk in divided doses. Massage, half an hour. Fourth Day. Fifty ounces of milk in divided doses ; ^%%, bread and butter ; dialysed iron, forty minims in two doses. Massage, one hour and a half. Sixth Day. Fifty ounces of milk in divided doses ; mutton chop. Massage, one hour and fifty minutes. Eighth Day. Fifty ounces of milk in divided doses; mutton chop ; porridge and a gill of cream ; maltine, twice daily. Massage, three hours; electricity, half an hour; continued to end of treat- ment. The solid food is now gradually increased until such a diet is reached as the following for the Tenth Day. 6 a. m., raw meat soup, ten ounces ; 7 a. m., a cup of black coffee; 8 a. m., a plate of oatmeal porridge, a gill of cream, a boiled egg, three slices of bread and butter, and cocoa; 11 a.m., milk, ten ounces ; 2 p. m., rump steak, one half pound of potatoes, cauliflower, a savoury omelet, milk, ten ounces ; 4 p. m., milk, ten ounces ; three slices of bread and butter ; 6 p. m., a cup of gravy soup ; 8 p. M., a fried sole, roast mutton (three large slices), French beans, potatoes, stewed fruit, and cream; milk, ten ounces; 11 p.m., raw meat soup, ten ounces. Fifteenth Day. Three full meals daily of fish, meat, vegeta- bles, cream, and fruit ; two quarts of milk and two glasses of Bur- gundy. Twenty-second Day. Amount of food lessened. Ley den's Diet. Leyden's diet for neurasthenia is a modified form of milk treat- ment which gives excellent results in some cases : At 7 A. M., half a litre of milk, slowly sipped in half an hour, a small cup of coffee with cream, eighty grammes (nearly three ounces) of cold meat, a mealy baked potato; 10 a.m., a litre of milk with three biscuits ; 12 a. m., the same ; i p. m., broth, two hundred grammes (about seven ounces) of fowl,/r/urees, beef jelly, gruels, etc., which are made palatable to tempt the appetite, and the number of daily meals may be in- creased or nourishment may be given once in three hours. By di- verting the blood current and nervous energy for digestive processes, SKIN DISEASES. 591 the general nervous system and mental condition become soothed and quieted. Fresh fruit should be offered occasionally. Special Precautions. In acute insanity there is a tendency for the body temperature to fall two or three or more degrees below the normal. This is especially true of those cases of primary dementia which are due to exposure and privation accompanied by severe mental strain, such, for example, as occur from shipwreck or from any form of severe sudden shock. While regulating the diet, there- fore, attention must be given to the preservation of the body heat, and the patient should be surrounded by uniform temperature, to be maintained in an overheated room or by hot-water bottles and warm clothing. Sustaining the normal temperature will facilitate the digestive functions. The insane must be closely supervised while eating. They often bolt their food, when given too much at a time, in a manner that soon destroys digestion. In such cases all food should be given in a state of fine subdivision or fluid or semifluid form. Patients with advanced general paresis or different paralytic diseases may easily suffocate by getting a piece of meat in the larynx. Patients with mania gravis, or suicidal melancholia, etc., should of course never be intrusted with knives or with plates or dishes which can be easily broken into sharp fragments with which to cut themselves. DIET IN SKIN DISEASES. It has long been known that a relation exists between various errors in diet and certain skin diseases, but it is only within the pastten or fifteen years that attention has been directed to the importance of systematic dietetic treatment to aid the cure of such ailments, and a more thorough investigation of this subject is much to be desired. Skin Diseases which are caused by Improper Diet. The skin diseases commonly referable among other influences to dietetic causes are erythema, urticaria, acne, eczema, and scorbutic erup- tions. Many chronic skin diseases, if not originally caused by dietetic errors, are undoubtedly much protracted and made worse by them. This is particularly true of eczema and the cutaneous lesions of scrofula, and sometimes of psoriasis. The very important alimentary substance alcohol, when taken in excess, greatly aggravates many forms of chronic cutaneous lesions, notably those of syphilis and rosacea, and the capillary congestion and muddy complexion of chronic alcoholism is well known. The modes of production of cutaneous eruptions by dietetic errors are various. Probably in the majority of instances such eruptions are due to malfermentation products which are absorbed 40 C-Q2- r)lT IN DISEASE. through the digestive tract. In other cases they may be due to an effort to eUminate incompletely oxidised food products or poisons from the cutaneous glands (as in the case of drug rashes), and it has been suggested that they may be sometimes caused by reflex nerve irritation from the alimentary canal, although the latter theory is less tenable. It is, however, interesting to observe the fact that an intimate relation often exists between irritation and inflammation of the skin and of mucous membranes. General Principles of Dietetic Treatment. There are cer- tain general principles of dietetic treatment which are applicable to a majority of all severe cases. The food should be of simple kind, restricted in variety, and plainly cooked. Milk, meat, and stale bread are more desirable than amylaceous or saccharine food. If fever is present at the outset, a milk diet must be ordered. The strumous and gouty require fats in some form. Chronic cases with malnutrition and anaemia must have abundant nourishing animal food. In the case of scorbutic eruptions the trouble arises some- times (but not always) from malnutrition from withholding certain articles, such as fresh fruit and vegetables, from the diet. Substances to be particularly avoided in skin diseases are raw and unripe fruits and vegetables, sweets and pastry of all kinds, con- diments and highly seasoned dishes, veal, pork, and alcoholic bever- ages. Other injurious foods will be mentioned under the treatment of the several varieties of skin diseases described below. Erythema. Urticaria. Either acute erythema or urticaria may be caused in some per- sons by eating fish, and particularly shellfish and crustaceans, as oysters, clams, lobsters, shrimps, and crabs. It is also produced by strawberries, bananas, and other forms of fruit. Crustaceans and strawberries are perhaps the most common excitants. The action of the food poison is wholly different from that of ptomaines (page 350), for it originates from fresh as well as stale food, and may be derived, as in the case of strawberries, from vege- table food. Some persons have an attack regularly every spring when strawberries first appear on the table. Others show occasional immunity, depending upon their condition at the time. Those per- sons who are hurt by one kind of poisonous food are not necessarily affected by the others. The whole matter seems to be influenced solely by idiosyncrasy. Other alimentary substances which have been observed to some- times poison are pork in various forms, sausages, mushrooms, cheese, and even mutton (Jackson). Symptoms. The eruption develops suddenly and within from two to six hours after ingestion of the food. It is commonly a typ- SKIN DISEASES. 593 ical urticaria with large pink wheals, which quickly come and go over all parts of the body. They are accompanied by intense itching and burning. This affection usually lasts but a few hours, or possibly for two or three days, though sometimes it may continue for several weeks. Treatment. The eruption usually disappears upon withdraw- ing the offending article from the diet, and giving a saline cathartic and some simple remedy to regulate digestion and prevent fermenta- tion, such as salol, salicin, or rhubarb and soda. The troublesome itching is best relieved by sponging with com- mon baking soda, a teaspoonful to a quart of water, or a solution may be applied to the wheals of menthol and chloral, each a drachm, in a couple of ounces of a mixture of equal parts of alcohol and camphor water. Acne. Causation. The larger number of cases of acne are produced by improper food. The papules and pustules which constitute acne are caused by inspissation of the oil of the sebaceous glands, which plugs their orifices and irritates the glands and the hair follicles, ex- citing inflammation in them. The disease is usually first observed during puberty, a period in which important changes in the nutrition of the body are in progress, and, once established, it is apt to last for some time often for several years. It is easy to conceive how slightly altered composition of the blood, due to imperfect assimila- tion of food, may alter the composition of the sebum and irritate the sebaceous glands. In some people the papules appear as a result of eating buck, wheat cakes or oatmeal. In others they are caused by greasy food doughnuts, sausages, cheese, fried meats, ill-cooked and rich pastry excess of sweets, nuts, and other indigestible substances. Dietetic Treatment. In addition to local means, the dietetic treatment of acne is most important. Jackson says : " The well-to-do are all prone to eat too much, and it is remarkable how rapidly acne will improve by reducing their diet to the simplest elements. In many of them a milk diet for a few days, provided milk agrees with them, will accomplish a marked benefit. It is a good rule to cut off from the dietary all pastry, cake, candy, sweets, hot breads and pan- cakes, greasy soups, articles fried in fat, twice-cooked meats, rich gravies in fact, all those things that are most apt to tempt the palate." Alcohol in all forms should be prohibited, as well as tea and coffee. A tumblerful of hot water or a glass of Vichy should be drunk before each meal. With meals but little fluid should be taken, never over four or five ounces, but between meals water or aerated water should be drunk freely for its diuretiq effect. Naturally, exer- cise, bathing, and the use of laxatives should be adjuncts to the die- tetic regimen. ^q^ diet in disease. Eczema. Causation. Eczema, both acute and chronic, which constitutes so large a proportion of all cases of skin diseases, is provoked by different causes, but in a great number of instances its origin is directly traceable to dietetic faults. These may be of three kinds namely, the eating of (i) too much food; (2) insufficient food; (3) improper food. I. Cases due to Overeating. The ills of overeating have been elsewhere described (page 342). Its relation to eczema con- sists in the additional burden thrown upon the skin of attempting to eliminate waste products, which are accumulated in the blood faster than they can be got rid of. The cutaneous glands, like the kidneys, are constantly stimulated and overworked, and the char- acter of their secretion is altered. The skin, for a long time irri- tated, finally succumbs to a definite eruption. It is for this reason that robust persons apparently in the best of health and with too vigorous appetites will sometimes be sur- prised with the sudden appearance of eczema, which they have al- ways attributed solely to "bad blood." Treatment. This class of cases is to be treated by reducing the quantity of food, and by prescribing a very simple diet. In bad cases of general eczema it may be best to put the patient upon a milk or bread-and-milk diet for one, two, or three weeks. From two to two and a half quarts are taken daily with toast or crackers. Marked improvement will occasionally follow this course. For others, simply reducing the diet by excluding meat and desserts for a time, may be all that is necessary. Meats either beef, mutton, or chicken should not be allowed more than once a day. Piffard re- ports that 56 per cent of his cases were accustomed to eat meat in excess three times a day. Fish, either boiled or broiled, may be substituted for meat to advantage in neurotic subjects (Bulkley), for though it may excite urticaria, it does no harm in eczema in spite of the popular belief to the contrary. I have known the eating of shellfish, however, to intensify chronic cases considerably. Typical Diet for Eczema. The following simple diet may serve as an example : Breakfast. Bread and milk, or porridge, or wheaten grits, or cracked wheat, without cream may be added, and salt or lemon juice if preferred. Every other day a soft-cooked e.'gg may be eaten. Dinner. No soup, entre'es, or dessert. Roast beef or mutton or chicken may alternate with broiled fresh fish with white meat, one or two green, light vegetables, such as haricots, spinach, lettuce, green peas, or macaroni. As Jackson says : ' It is a good rule to SKIN DISEASES. 595 tell the patient he may eat what he likes, but not of more than two dishes at a meal. It is unlikely that he will then overeat." Fresh, ripe fruits, except apples, may be allowed Supper. Bread or toast or crackers and milk, custard, or simple rice pudding, not too sweet. A little fresh fruit. Stimulants are not usually required, but if needed for nutritive or tonic effect, di- lute liquor, brandy, whisky, or Hollands is the best form. Malt liquors of all sorts, as well as wines, should be forbidden. It is quite generally believed that tea and coffee are harmful in eczema, and drunk in excess they certainly are so, not only from disordering and retarding digestion, but from their undue stimulat- ing effect. Unless they are taken in great moderation and but once a day, it is better to forbid their use entirely. The same is true of sweet chocolate, but cocoa may be allowed. 2. Cases due to Insufficient Food. Too little food results in impoverished nutrition, and the skin, being one of the most sen- sitive organs of the body, is among the first to suffer. The habits of filth which so often accompany semistarvation among the poor are contributing causes which combine to provoke skin eruptions. The diet required for these cases does not essentially differ from those of the preceding class. An effort should be made to restore the impoverished nutrition of the body as quickly as possible by suralimentation if necessary (page 438). 3. Cases due to Improper Food. Improper food is also capa- ble of exciting outbreaks of eczema, and this is particularly true of chronic or relapsing cases. Oatmeal, for example, while it may not cause the disease, is generally believed to be capable of intensifying it. It is not possible to always forewarn against the particular arti- cles of diet which will do this, as they vary in different individuals and often in the same person at different times, but, in general, food which is called " rich " is to be avoided, such as highly seasoned meats, soups, sauces, gravies, strong condiments, sweets, pastry, hot breads, pickles, preserves, and fancy desserts of all kinds. Bulkley especially forbids sweet potatoes, fried eggplant, cabbage, cheese, bananas, apples, soda water with sirups, as well as salt food, such as ham, corned beef, and salt pork. A little bacon or a salt herring, however, is permissible. All fried food, with the above exceptions, is strictly forbidden, and " fritters," fried oysters, etc., are highly in- jurious. In a word, all those articles which are most apt to excite temporary dyspepsia and overload the urine with phosphates, urates, and calcium oxalate must be avoided. The staple diet should con- sist of whole-meal bread, fresh, plainly cooked vegetables, eggs, milk, and a little chicken, fresh fish, or meat not oftener than once a day. There are obstinate cases of chronic eczema which fail to yield 596 DIET IN DISEASE. to any dietetic regulations, but it is always desirable to thoroughly try the value of dietetics, and very often the result will be surpris- ingly gratifying. In conjunction with dietetic treatment the urine should be always carefully examined, and the bowels must of course be regulated. It is very important to control the general habits of the patient in regard to meals. He should eat at regular and proper hours and observe uniformity in the quantity of food consumed. He should be very careful to eat slowly and thoroughly masticate his food, and not drink so much fluid with meals as to dilute the gastric juice excessively. The general rules for the treatment of dyspepsia (page 500) and its avoidance are especially applicable to all skin diseases which are in any way amenable to dietetic influence. It should also be remembered that eczema frequently is associated with gouty and strumous diatheses, and the reader is referred to the sections upon these subjects. ECZEMA IN NURSING INFANTS. Bulkley points out that eczema in nursing infants is mainly due to dietetic errors of the mother, for whom, rather than for the child, treatment should be instituted. He prohibits the drinking of all forms of malt liquors and wines and rich chocolate. Anything which provokes indigestion and biliousness in the mother reacts un- favourably upon the skin disease of the infant. This is a very im- portant truth too often overlooked. If the mother becomes con- stipated, has dyspepsia and a furred tongue, and excessive deposit of urates and oxalates in the urine, her diet must be changed, the bowels must be regulated, and tonics should be given. Other cases in infants are caused by the mother's milk being poor and thin, and the breast milk should be supplemented by cow's milk properly pre- pared, or it may become necessary to wean the baby completely. Mothers often nurse their infants too long, hoping thereby to post- pone conception. When the breast milk is too poor in quality Bulk- ley believes in adding fat to the baby's nourishment in the form of a few drops of cod-liver oil or a little cream, and he recommends inunctions of almond, sweet, linseed, or cod-liver oil. Cod-liver oil is cited by some authorities as causing eczema, but this refers to its use in excess when the digestion is deranged and dyspepsia is aggravated by it. Strumous eczema is often cured by adding fat to the food. The common mistake of nursing infants too often is particularly apt to occur with eczematous babies, whose mothers mistake the child's crying for a manifestation of hunger, whereas it is often excited by the extreme itching of the eruption, which the infant is too young or too feeble to scratch. If fed oftener than once in two hours or SKIN DISEASES. 597 more, the infant's digestion becomes deranged, and any existing eruption is made more unbearable. Bottle-fed infants are more likely to have eczema than sucklings, probably because they oftener have gastro-intestinal disorders. Underfed infants are less subject to the disease than are the overfed. ECZEMA IN CHILDREN. Eczema in young children is often due to dietetic errors, and in all cases care should be exercised to cure it by regulation of the food. The commonest fault in feeding young children consists in giving them too much starchy food, which they cannot as yet digest, and the innumerable prepared infant foods, consisting largely of starches and sugars, are responsible for much of this trouble. Some parents, aware of this fact, go to the other extreme, and give the child too much animal food in the form of meat juice, broths, and eggs. A diet improperly balanced in either direction induces a strumous diathesis with a special tendency to the'development of eczema. Older children should be denied candy, chocolate, and indulgence in sweets of all sorts, and must be fed upon the simplest diet, in which starch, and especially sugar, should be reduced, and pure fat increased. The latter is to be prescribed in the form of cream, fresh uncooked butter, fat beef, and cod-liver oil. Bulkley recommends the use of whole-meal bread, cracked wheat, hominy, and corn grits with salt and butter or cream. Oatmeal is prohibited ; likewise tea and coffee. EXFOLIATIVE DERMATITIS. Exfoliative dermatitis should be treated upon substantially the same dietetic plan as eczema. An exclusive milk diet for a month or six weeks may prove beneficial. Jackson advises chewing flax- seed or taking, in milk, several ounces of flaxseed tea every day. Rosacea. Causation. Rosacea is a chronic skin affection disfiguring the middle parts of the face, about the nose, mouth, cheeks, and some- times the forehead, by red patches of dilated capillaries. It is regarded as a reflex neurosis of the local vasomotor nerves. It is oftenest caused by erroneous diet, and especially by strong drink, which dilates the facial arterioles and also excites gastric catarrh. Jackson says : " The inordinate use of strong tea acts in the same way, and probably gives rise to as many cases as does alcohol." Dietetic Treatment. The dietetic treatment is very impor- tant. It involves the prohibition of all alcoholic drinks, as well as hot beverages of every kind, such as tea, coffee, and soup. Existing 598 DIET IN DISEASE. dyspepsia should be' treated, and all rich food, desserts, sauces, pickles, strong condiments, dried, salted, or canned foods, fried substances, and sweets should be withheld. The patient must be kept for sev- eral weeks or months upon a low, non-stimulating diet of plainly cooked food, such as that advised for the treatment of eczema. Psoriasis. Causation. Psoriasis is a chronic skin disease characterised by the appearance of isolated red patches of considerable size, covered by shining white scales. The aetiology of this eruption is not under- stood. It may be hereditary or follow nerve shock, but in many cases it is directly attributable to imperfect assimilation of nourish- ment, and accumulation of waste products in the system, such as occur in gout and rheumatism. The excessive consumption of oatmeal has been observed to cause it (Hardaway). Dietetic Treatment. This disease is less amenable to dietetic treatment than are some other skin affections ; nevertheless, this must not be neglected, as it may prove a valuable aid to local measures. The diet should always be restricted both in quantity and variety. Some patients improve upon a purely vegetable regimen (Fox). This is true of obese and plethoric patients. In bad cases it will be best to put them upon a bread-and-milk diet for a week. Vegetable food may then be added, but sweets and meats should be withheld. Feeble, anaemic patients usually improve rather upon an animal diet, consisting largely of milk, with eggs, beef, and mutton. Bread may be allowed. Elaborately cooked and highly seasoned food must be forbidden, as well as all forms of malt liquors. If any alcohol is re- quired it should be prescribed in the form of well-diluted whisky and taken only with meals, but as a rule patients are far better without it. Pruritus. Patients suffering from pruritus should partake only of non-stim- ulating food. They must particularly avoid tea, coffee, alcoholic drinks of every variety, condiments, fish, pastry, cheese, sauces, pickles, made dishes, and fried food. Tobacco should be tempora- rily withheld. FURUNCULOSIS, OR BOILS. Furunculosis is often wrongly attributed to dietetic errors or high living, but it is now known to be of germ origin due to the action of the Staphylococcus pyogenes aureus et albus, which penetrates the skin, through abrasions or otherwise, so that the supposed influence of diet is only remote, in that poor hving tends to lower the general vitality DISEASES ESPECIALLY INFLUENCED BY DIET. 599 and make the body more susceptible to any form of inoculation. Special dietetic treatment becomes necessary only in debilitated cases, such as complicate anaemia, diabetes, or convalescence from protracted infectious diseases, and the rules for it will be found under those headings. DISEASES ESPECIALLY INFLUENCED BY DIET. Obesity (Polysarcia). Causation. Obesity is a diseased condition of the body, de- pending upon alteration in the proper balance of nutrition, with an accumulation of suboxidised fat in and between the tissues. It may affect either sex, but is much more common among women, in whom it is particularly noticed during and after the climacteric. It may develop at any age after early childhood. When appear- ing early it is usually the immediate result of heredity. It is, how- ever, most common after middle age, when the functional activity of the body IS diminished and when habits of systematic exercise are re- placed by a sedentary life of luxury and ease, combined with over- eating. Aside from heredity, an important cause of obesity is excessive eating, which is a fault among the majority of persons who have passed middle life. When the growth of the body has been com- pleted there is a stage of equilibrium in weight which lasts for several years, and the waste matter of any excessive food taken is eliminated through the emunctories, which are kept active by exercise and work. After middle age, activity is considerably diminished, while the habit of fully satisfying a vigorous appetite may be continued, resulting in the consumption of a larger amount of food than is required for maintaining the vital functions. It is extremely difficult for people who feel in robust health and whose mental is proportionately greater than their physical activity, to realise that they not only require less food than they did ten, fifteen, or twenty years earlier in life, but that eating as they do they may be producing positive harm by overloading the excretory organs. It is for this reason that many persons accumulate weight after reach- ing a certain advanced period of life. /'According to Sir H. Thompson's view, overeating in the first half or so of life may be relieved by occasional bilious attacks, which enable the system to cast off accumulated waste, but later "the un- employed material may be relegated in the form of fat to be stored on the external surface of the body or be packed among the internal organs, and thus he or she may become corpulent and heavy." The constant use of alcoholic stimulation in its milder forms, such 5oo I>IET IN DISEASE. ^^s beer and ale, favours obesity, and in many individuals seems to be a direct cause of it.) There are other cases in which it is difficult to attribute the accumulation of fat to any faults in either eating or drinking. CVery stout persons are occasionally extremely moderate eaters, and in these cases the difficulty lies apparently in poor oxi- dation and insufficient exercised The condition of obesity is somewhat modified by climate and race. It is less common in the United States than it is among elderly women in England and Germany. Not infrequently obesity occurs in connection with pronounced anaemia and hysteria. It prevents such patients from taking an ordinary amount of exercise. This is owing to the increased weight and difficulty of moving about, as well as to the lassitude and posi- tive dislike for muscular exertion which is felt by them. Obesity once established is apt to increase unless properly treated. So long as the fat is simply stored up as adipose tissue, and be- tween and not within the cellular elements of the body, it is compar- atively harmless, excepting as it indicates a disproportion between functional activity and the amount of fuel taken in to develop force, and excepting also as it may interfere with personal convenience in movement and cause greater muscular fatigue from the increased work thrown upon the muscles in supporting so heavy a body. In other cases (and this may be the outcome of any advanced case of polysarcia) the fat may invade the cellular elements of the body, particularly the muscles, and fatty degeneration is produced in the muscular tissues, which very seriously weakens and impairs their functional activity. The special danger in all cases of this class is that the heart muscle may become affected in this manner, which renders it liable to cease beating whenever the slightest additional strain is thrown upon the circulation. It follows that it is most de- sirable in the dietetic treatment of obesity to determine the original cause of fat accumulation, and to ascertain to what extent it is ac- I ojmpanied by fatty degeneration. ^ Bauer says : " The fat stored up in the body acts in like manner I with the fat contained in the food, since it likewise lessens the waste ^ of tissue and secondarily the oxidation. Thus we understand why abstinence can be longer borne by organisms rich in fat than by those poorly furnished with it, the former consuming less of the albumin of their organs. fThe stock of fat stored up in the body is moreover the cause why corpulent individuals frequently continue to gain in bulk although they are not in the habit of indulging in food immoderately. \ I " If an increase of albumin be desired without a considerable addition to the store of fat, a liberal allowance of albumin with relatively small quantities of carbohydrates must be provided. N If, led.N DISEASES ESPECIALLY INFLUENCED BY DIET. 6oi /on the other hand, a substantial addition to the fat appear desirable, the food must contain less albumin and more carbohydrates, with a fair proportion of fats." J Voit claims that albumin circulating in the blood is more readily oxidised than either fats or carbohydrates, and that the fat existing in the tissues acts like free circulating fat, not primarily by saving proteids from oxidation, but by causing a larger proportion of them to enter into the organised tissues, thus saving tissue waste. The tissues use up the circulating albumin, and, not being exhausted thereby, go on and oxidise the fat besides, and in this manner the store of fat in the body is reduced on a meat diet. An exclusive lean-meat diet increases the circulating albumin, and, the nitrogenous waste being correspondingly increased, fat does not accumulate in the body. If now fat be added, then fat is de- posited in the body. /^The carbohydrates, like fat, can protect circulating albumin from destruction and aid its transformation to organic albumin, but it is not proved that they themselves make fat, as at first supposed, for they are very completely destroyed even when eaten in excess.^ They merely protect other foods from oxidation under such conditions. Meat and carbohydrates alone increase the fat in the body with- out the aid of fatty food, for fat, which originates from splitting up albumin, is spared further metabolism. J Hence fatty metabolism in the body may be quite independent of fat ingestion. Dietetic Treatment. The question of the treatment of obesity, owing to the frequency with which the physician has to deal with it, is a matter of great importance, and demands special consideration. For a long time it was believed that excessive consumption of car- bohydrates was the cause of increased fat production within the body. The pig is fattened on corn, and cattle upon various cereals. Undoubtedly, many persons who are of spare habit can increase their weight by eating a larger proportion of starches and sugars. It is a fact, moreover, that starches contain oxygen in the exact pro- portion necessary for the formation of water and carbon dioxide, and on being disintegrated in the body, they naturally produce these two forms of waste matter which are promptly eliminated from the surface of the lungs and kidneys respectively. The pro- teid material of the food requires a larger percentage of oxygen for the metabolism involved in its complete conversion into urea. It is an undoubted physiological fact that the fat of the body may be made from a variety of different foods, and that some indi- viduals are capable of producing it from a particular class of food materials moite readily than from others. Thus one person may become fat from overindulgence in saccharine food and another from ^2 DIET IN DISEASE. eating purely starchy foods and taking large quantities of malt and beer, and still another from the excessive use of quantities of fat meat. Accordingly the rules which are formulated for the treat- ment of obesity must be regarded as referring to the majority of cases only, whereas there are many exceptions which must be indi- vidually studied. Many special dietetic systems are in vogue for the treatment of obesity. In some cases if the total quantity of food is diminished no special diet is necessary, but in many persons obesity is not due to overeating, but to other causes. Some patients improve at once when they give up all alcoholic beverages. An ounce of food eaten daily in excess of that which is eliminated, and which is capable of being stored in the tissues in the form of fat, very soon produces a considerable increase in the body weight, which in a year's time would amount to many pounds. Among the different systems which have been advocated for the cure of obesity the best known are those of Banting, Ebstein, and Oertel. Schweninger's cure is practically Oertel's modified by with- holding fluid from the meals, and giving all fluid at least two hours after ingestion of food. Schleicher's system is also similar to Oertel's. The principal systems which have been especially devised for the treatment of obesity will be separately discussed in detail. Nearly all of these systems agree in two principles : First, to reduce the total quantity of food ingested as much as possible without impair- ing the strength of the patient. Secondly, to diminish the amount of fluid drunk by prescribing what is called a dry diet. The treat- ment, moreover, is usually accompanied by systematic exercise or bathing, and it is highly important to keep the bowels active. Some persons attempt to cure obesity by allowing the patient to eat any food he chooses, but insisting that he shall eat only one kind of food at any one meal. As a natural result, the appetite soon palls, and he eats less than he otherwise would. This is an unscientific method, and an unwholesome one for serious cases. As a general principle, corpulent persons should restrain them- selves to as great an extent as possible from drinking fluids, espe- cially with meals. Exceptions to this rule occur when obesity compli- cates certain other diseases, such as gout or rheumatism, where the use of an increased quantity of fluid may temporarily be necessary in order to act vigorously upon the kidneys. Hot-water beverages taken half an hour before meals, and again at night and on rising in the morning, are beneficial, and less fluid is required with the meals. As a rule, never more than five ounces of fluid should be taken with a meal, or fifteen ounces per diem, and this amount may be still further curtailed by giving water between meals instead. DISEASES ESPECIALLY INFLUENCED BY DIET. 603 ' Soups of all kinds should be forbidden as well as alcoholic beverages, and what little fluid is allowed should consist of plain or aerated water. But little, if any, milk should be taken. The food should be as dry as possible without interfering with its flavour and nutrient value. Highly succulent fruits, such as watermelons, and vegetables like raw tomatoes, which consist largely of water, should not be eaten. Sugar should be absolutely forbidden, and fat must be used very sparingly, and only in the form of a little butter. The allowance of farinaceous food must also be cut down as much as possible. It will not usually be found practicable to do without bread for any length of time, but patients are often willing to re- strict themselves to a very rigid diet for two or three weeks if the positive hope of cure or amelioration of symptoms can be held out to them, if they are made to understand the rationale of the treat- ment, and if they are given some objective point to anticipate when a promised improvement will admit of greater laxity in regard to diet. If desirable, gluten bread may be substituted for wheaten bread. The deprivation of starchy foods can always be better and longer tolerated if a little fat is given, and the obese do not well en- dure deprivation of all fats, even when starchy food is supplied in moderation. This is more often true of those engaged in mental work than of those employed in muscular exercise. Salts and fresh green vege- tables " vegetables which grow above the ground " should not be withheld. Lean meat should form the basis of all diet, but an unrestricted flesh diet in obesity may give rise to dyspepsia and gastric and intestinal catarrh. THE BANTING SYSTEM. The diet which Mr. Banting practised upon himself and others with considerable success, and which bears his name, was exceedingly rigid in regard to restricting the quantity of food and in forbidding starches and sugars to the greatest degree possible. The patients were starved to the extent of being allowed only between twenty-one and twenty-seven ounces of dry food in the twenty-four hours, about one half of which was meat. Only two ounces of bread could be taken, and the balance of the diet was composed of fresh fruits and the lighter forms of green vegetables. The fluid drunk in each twenty-four hours was reduced to thirty-five ounces. It should be remembered that the normal quantity of urine passed by an adult is, on the average, fifty-two ounces in addition to the water lost by perspiration and respiration. His dietary, which was based on the suggestions of his physician, Dr, W. Harvey, has been found too 6o4 DIET IN DISEASE. severe in many cases, and is apt to enfeeble the digestion, especially when patients are too quickly restricted in their food, and at present it is not much prescribed in this country, excepting in modified forms. The fats and albuminoids are not well balanced in this diet, and it is apt to cause constipation and malnutrition. Mr. Banting began his treatment upon himself in 1862, and in a single year lost forty-six pounds in weight. Sudden restriction in diet in obesity may sometimes precipitate attacks of renal or hepatic colic from the presence of calculi. Their deposition is brought about by altering the composition of the blood, and while practising any dietetic system for obesity one should be certain that the elimina- tion of waste matter from the system is not impaired, as it is apt to be if water is too suddenly withheld. On this account largely the stricter diets for corpulency, such as the Banting system, sometimes result in failure by producing a condition of the system which is far worse than the original corpulency, THE EBSTEIN SYSTEM. The Ebstein treatment, as originally employed in Germany, has been attended with considerable success. The theory of this system is that animal as well as carbohydrate food is capable of being con- verted into fat, especially when used in combination with starches and sugars. The latter are believed to furnish force for the body, and by their combustion to spare the complete oxidation of albu- minates, which are therefore stored in the tissues in a suboxidised form. It is a part of this theory that fatty food does not give rise to or promote the storage of fat in the body, and hence it may be al- lowed in the dietary ; in fact, Ebstein recommends its use on account of its effect in producing satiety. By sooner diminishing the ap- petite, there is less craving for other food and drink. In accordance with this belief, he proscribes the use of sugar, potatoes, and all forms of farinaceous food with the exception of three ounces and a half of bread, which is allowed each day. He permits the use of fats, such as fat meat, cream, butter, and fatty soups. Among vegetables he allows asparagus, spinach, cabbage, peas, and beans. A moderate amount of meat of any kind is also included. The quantity of fluids allowed is restricted. Ebstein allows the patient to take three meals a day. Breakfast consists of a cup of black tea without sugar or milk and two ounces of buttered toast. Dinner, which is given at noon, comprises a meat soup or broth, four to six ounces of boiled or roasted fat beef with meat gravy, not thickened, one or two fresh vegetables, in moderation, and for des- sert salads and fresh or dried fruits. He allows a little light wine and black tea without milk or sugar. DISEASES ESPECIALLY INFLUENCED BY DIET. 605 Supper includes tea as before, a soft-cooked egg and a moderate allowance of fish, ham, or cold fat meat, an ounce of thin buttered bread or toast, and fresh fruit. Comparison of Dietaries for Corpulence with Ordinary Dietaries (Atkinson). DIETARIES. Banting system Ebstein system Play fair's standard for " subsistence diet" Playfair's standard for adults with moderate exercise Voit's standard for labouring man at moderate work Atkinson's standard for man with light exercise Atkinson's standard foT labouring man at moderate work Poor sewing girl, London ; diet barely sufficient for subsistence University professor, Germany ; very little exercise Well-to-do family, Connecticut ; food actually eaten Mechanics and factory op>eratives, Massachusetts; food purchased..,. Food actuallyeaten by college students: From Northern United States From Eastern United States NUTRIENTS. Potential energy in nutrients. Protein. Fats. Carbo- hydrates. Total. Grammes. 171 102 Grammes. 8 85 Grammes. 75 47 Grammes. 254 234 Calories. 1,085 1,400 57 14 341 412 1,760 119 51 531 701 3,140 118 56 500 674 3.050 100 100 360 560 2,815 125 125 450 700 3,520 53 33 316 402 1,820 100 100 240 440 2,325 128 177 466 771 4,080 127 186 531 844 4,430 138 104 184 136 622 421 944 661 4,825 3,415 THE OERTEL SYSTEM. A more recent system for the dietetic treatment of obesity is that practised by Oertel and modified by Schweninger. The distinctive feature of the Oertel treatment is the attention which is paid to im- proving the condition of the circulation by strengthening the heart action, and this, he claims, so much improves the general condition of the patient that the fat once eliminated is not reformed. According to his theory, corpulent patients may be subdivided into two different classes, whose diet is regulated accordingly. They are: " (a) Cases of fat accumulation in which the respiratory and cir- culatory apparatus have undergone no special derangement, and the patient is capable of muscular effort and locomotion. A much more serious form is that in which the condition of fatty heart is present, with consequent enfeeblement of circulation and visceral engorge ment. "(/J) Cases in which, in consequence of advanced stasis and hydraemia (with deficiency of haemoglobin), the amount of oxygen taken up from the lungs is extremely reduced, and the slightest 5o6 I>IET IN DISEASE. muscular efforts are enough to disturb the respiration and provoke dyspnoea." For the first class his maximum allowance of fat is fifty grammes and of carbohydrates two hundred grammes, with a minimum of one hundred and fifty grammes of albumin. For the second class the maximum allowance of fat is twenty-five to thirty grammes, with one hundred grammes of carbohydrates, but the albumin must consider- ably exceed one hundred and fifty grammes. In this class especially the amount of fluids drunk must be curtailed. By withholding fluid, Oertel argues, blood pressure is reduced, venous stasis is lessened, the vessels of the body will adapt themselves to the reduced quan- tity of fluid, and to supply the glandular organs and muscles with their normal proportion fluid will be " drained away from places where the tissue changes are less energetic, and which are less favourably innervated. Such vessels are, above all, in the fatty tissues vessels branching in the panniculus adiposus." Nutritive changes ensue in the fatty tissues, the fat is disin- tegrated, conveyed away, and burned up. This is certainly an ingenious, and withal very plausible theory which has many facts of clinical observation to recommend it. Besides holding the view that the fluid in the body must be re- duced before the accumulated fat can be diminished, Oertel says : " Since the force required to raise the body through a great height entails the destruction of large quantities of fat, the above exertion [mountain climbing] will also lessen the fat accumulation, on condi- tion only that we give less fat and carbohydrates in the food than are used up in the work done." He gives some fat and carbohydrate food, but not very much, with proteids, for he believes that, anaemia being present, an exclu- sive meat diet would not be completely oxidised. It is better, there- fore, to restrict all three classes of foods, but not to entirely exclude either, and the proteids must decidedly preponderate. He also believes that anaemia has weakened the vascular tone through supplying a blood deficient in circulating albumin, and hence a diet rich in proteids is further indicated. The Oertel system includes almost twice the quantity of animal food allowed in the Ebstein diet, and double the quantity of carbo- hydrates and less than half the quantity of fats. It is distinguished from the Banting system also by the greater preponderance of fats and starches. The following table from Yeo contrasts these differ- ent systems of diet. For comparison, the diet of Voit is added, which gives the proportion of the three chief varieties of foods upon which a man in health will decrease in weight. The figures rep- resent grammes : DISEASES ESPECIALLY INFLUENCED BY DIET. 607 Daily Diet. Albuminates. Fats. Carbohydrates. Moleschott, normal average 130 140 170 100 155-179 84 44 10 85 25-40 404 165 80 Voit, " " Ebstein, " " 50 70-110 Oertel, " " It will be observed that in all these diets the starches and sugars chiefly are proportionately much reduced, and the more liberal dietary of Oertel is particularly suitable for those classes of cases in which exercise can be joined with dietetic treatment. The combined effect of the diet with exercise results in the absorption and oxida- tion of the fat deposited between the muscular tissues and in the renewal of more vigorous action of the muscle fibres, which are shielded from waste by the liberal proportion of proteid food which is admitted. The whole treatment is aimed especially at increasing the vigour and force of the heart action, and in many cases it suc- ceeds admirably. In the more serious type of obesity the deposition of fat around the base of the heart as well as between and within the heart muscle fibres enfeebles the strength of the cardiac systole and results in engorgement of the venous circulation. The heart is unable to propel the blood through the arteries and capillaries, and there is very little vis a tergo remaining for the blood in the veins. Lack of exercise also retards the venous circulation. As a result, there is a constant venous congestion which is particularly notice- able in the viscera, and there may be dropsical accumulations in the different serous cavities or general anasarca. Exercise. In the treatment of such cases Oertel withholds fluid from the diet as much as possible, and to assist the elimination of water from the body the patient is made to exercise by climbing carefully graded paths, which are measured and adapted with refer- ence to use by patients of different strength. During muscular exer- tion the destruction of non-nitrogenous food stuffs is increased. Palpitation and dyspnoea, which are so frequent accompaniments of excessive obesity, are not especially dreaded, and exercise is pushed until these symptoms occur that is, the patients are made to climb the graduated ascents, walking slowly and systematically and covering a prescribed distance each day. As soon as they experi- ence palpitation, or if shortness of breath appears, they are to stop and rest standing until the breath is regained. In this way it is believed by Oertel that the heart action, is actually strengthened, and the fat is certainly reduced. Of course, due care must be ob- served to prevent exhaustion, and the patients must be warned 41 6o8 I^IET IN DISEASE. against any sudden movement or overexertion which might occasion fatal heart strain. This exercise by cHmbing ascents is sometimes called the "terrain cure." In case the patient is unable to take any exercise at all, the ob- ject is attained by massage and friction, and the promotion of per- spiration is secured by baths of different sorts. In the treatment of such cases, among the solid ingredients of the food, the fats and starches are still further reduced. Anaemia is believed to be counteracted by the use of albuminous food, and the following articles are allowed when this is a prominent symptom : Lean roast and boiled beef and veal, mutton, game, and eggs. Vegetables, spinach, and cabbage may be eaten. From four to six ounces of bread per diem are given, and fats and starches are restricted as much as possible, ancf sugars are withheld altogether. The fluid prescribed consists of a moderate cup (about six ounces) of coffee or tea or milk twice a day, with twelve ounces of wine with an equal quantity of water, which may be taken at dinner. If pa- tients perspire very freely, a somewhat larger quantity may be given, and no other beverages of any kind are permitted. The fluid allowed should not all be taken with the meals, but may be drunk at intervals between the times of eating to allay thirst. In the less serious type of cases, where the heart action is unim- paired, Oertel allows the fluid to be gradually increased, and he gives four to six ounces of wine at noon time, with a half bottle in the evening. Bathing should be carried out systematically, and the patient may be packed with cloths dipped in hot water in order to promote perspiration. The baths are given at least twice a week through a period of a month or more. A typical menu under the Oertel treatment is the following : Oertel' s Diet for Obesity. Morning. One cup of coffee or tea, with a little milk altogether about six ounces ; bread, about three ounces. Noon. Three to four ounces of soup, seven to eight ounces of roast or boiled beef, veal, game, or not too fat poultry, salad or a light vegetable, a little fish (cooked without fat), if desired, one ounce of bread or farinaceous pudding (never more than three ounces), three to six ounces of fruit, fresh preferred, for dessert. It is desirable at this meal to avoid taking fluids, but in hot weather or in the absence of fruit, six to eight ounces of light wine may be taken. Afternoon. The same amount of coffee or tea as in the morning, with at most six ounces of water, and an ounce of bread as an ex- ceptional indulgence. Evening. One or two soft-boiled eggs, an ounce of bread, per- DISEASES ESPECIALLY INFLUENCED BY DIET. 609 haps a small slice of cheese ; salad and fruit, six to eight ounces of wine with four or five ounces of water. After patients have undergone a special course of treatment for obesity and their weight has been sufficiently reduced, it is desirable to establish a diet for them which will prevent a return of the fat. For this purpose Oertel recommends the following regimen after a nine years' experience with this class of cases ; it is intended for patients in whom obesity has complicated organic disease of the heart or lungs : '''Morning. One cup of coffee or tea with some milk = 150 grammes (6 ounces), and bread = 75 grammes (2'/, ounces). ''Midday. Soup = 100 grammes (3% ounces) ; lean meat, roasted or boiled, game or fowl = 200 .grammes (7 ounces) ; fish, not too fat = 25 grammes (nearly i ounce) ; bread or starch stuffs = 100 grammes at most (37^ ounces) ; as dessert 100 to 200 grammes (3'/^ to 7 ounces) of fruit, fresh preferred a smaller quantity if preserved, especially by Nagelis's method. Liquids are better avoided. At dinner time, only in very hot weather or in the absence of fruit, perhaps '/g to '/, litre of light wine may be allowed (6 to 9 ounces). ''Afternoon. The same quantity of coffee or tea as before, with at most '/g litre of water (6 ounces) ; occasionally 25 grammes of bread (nearly i ounce). ^'Evening. One or two soft'-boiled eggs; meat, 150 grammes (nearly 5 ounces) ; bread, 25 grammes (nearly i ounce) ; a bit of cheese, a little salad and fruit. As a regular drink, '/^ to '/^ litre of wine (6 to 9 ounces), with perhaps '/g litre of water (4'/, ounces)." Water should never be allowed in quantity, and what little is drunk should be distributed through the day. THE SCHWENINGER SYSTEM. Schweninger's system is essentially that of Oertel, but the for- mer absolutely forbids the use of drink of any kind with meals, and the little fluid that is permitted must be taken fully two hours afterwards. His treatment is substantially as follows : Moderate exercise for an hour before breakfast, after a cold bath with friction. Breakfast, 8 A. M. Meat, eggs, or milk. A' walk. Second Breakfast, 10.30 a. m. Meat or fish and a glass of white wine. A walk. Dinner, i p. M. Meat, vegetables, and fruit compote. Supper, 7 p. M. Meat and fruit compote or salad, a glass of white wine. No other fluid is given with meals. Bread is eaten very spar- ingly. 5 10 DIET IN DISEASE. Schleicher's Diet for Obesity. Breakfast, 7 A. m. A mutton or veal cutlet or a portion of sole as big as the palm of the hand ; the same quantity oS bread without butter. 8 a. m. A cup of tea with sugar. 10.30 a. m. A sand- wich of bread and meat or sausage. Noon. Meat, eggs, green vegetables, cheese, an orange. Two glasses of white wine. (No soup, no potatoes.) 4 p. m. Tea, with sugar. 7 P. M. A small quantity of bread and cheese. 9 p. m. Cold meat, eggs, salad. Two glasses of wine, and sometimes more. This is practically the diet of Schweninger, but without the absolute prohibition of drink at meals. THE GERMAIN SEE SYSTEM. Germain S^e, who, holds some original theories in regard to dietetics, declares that the use of abundant drink is distinctly in- dicated in the treatment of obesity. He allows a diet of proteids and fats, withholding sugars and starches, and requires his patients to drink hot weak tea and water in large amount. He prohibits alcohol in every form, excepting a little dilute wine, which may be allowed in exceptional cases. His treatment is no doubt more serviceable in those cases of corpulency which complicate gout and rheumatism and in which, as above mentioned, it is desirable to eliminate the waste matter from the system'-as completely as pos- sible. THE WEIR MITCHELL SYSTEM. Weir Mitchell, for the treatment of obesity, relies mainly on rest and passive exercise in the form of massage and Swedish move- ments with a skimmed-milk diet, which latter may be given at in- creasing rate, gradually replacing the accustomed food, until in a week's time the patient is living wholly upon milk. Upon this diet, the patient may lose half a pound or more in weight per diem. Careful watch is kept of the strength. The patient should be fre- quently examined with special reference to loss of weight and to any unfavourable increase in the heart action or feebleness of the pulse. If the latter conditions arise, it may be necessary to increase the diet or to give stimulation. Weir Mitchell is accustomed to allow a small quantity of beef, chicken, or oyster soup in such cases to relieve the monotony of an exclusive milk diet. The patient is kept quiet in bed for ten days or a fortnight, and afterwards allowed to move about the room, but must spend most of his time upon a lounge. Massage is performed once or twice a day at. first, and subsequently the more active Swedish movements are applied to the extremities. After from four to six weeks of this treatment the weight is usually reduced by a number of pounds, and the gen- DISEASES ESPECIALLY INFLUENCED BY DIET. 6ll eral condition and strength are found to have improved. The diet is gradually increased by the addition of lean meats, beef, mutton, poultry, shellfish, and boiled fish. For a long time, however, milk plays an important role, four or five glasses being taken daily. Weir Mitchell argues that so sudden a loss of weight as occurs in his treatment would be serious were the patient walking about, but when resting quietly in bed the danger of sudden exhaustion of the heart action is reduced to a minimum. His patients bear the treatment fairly well, and are frequently much pleased with the pronounced improvement in appearance and condition which they recognise. The treatment is not adapted to persons leading active lives who are unable to relinquish their business or other duties, for it requires a considerable length of time and the entire aban- donment of all labour. THE YEO SYSTEM. The diet recommended by Yeo is as follows : All fats and animal food are to be strictly limited, and farinaceous and starchy foods should be reduced to a minimum. Sugar must be entirely prohibited, but a moderate quantity of fat is allowed to secure the proper dilu- tion and digestion of the food. Hot water and hot aromatic drinks may be taken freely in the intervals between meals, especially in gouty cases. He allows the patient to drink a little hock and still Moselle, or light claret with alkaline table water. Beer, porter, and sweets of all kinds are to be prohibited, and no spirits should be drunk unless for some special need as a tonic. Meat is not to be eaten more than once a day, and not more than six ounces should be taken at any one time. The meat which Yeo allows is lean beef, mutton, lamb, poultry, game, and sometimes fish and eggs. Two lightly cooked or poached eggs may be taken once a day, or a little grilled fish. He allows thoroughly toasted bread in thin slices and crackers. Soups in general and milk, unless skimmed, milk pud- dings, farinaceous puddings, pastry, salmon, and mackerel must all be avoided. Fresh vegetables and fruits are allowed. He believes it is useless to attempt to give rules in regard to the actual quantity of dry food permitted, because it must necessarily vary in accord- ance with the weight and strength of the patient in each case. A quantity of food which might constitute an excess for one person would perhaps be wholly insufficient to support the strength and activity of another. Later a full diet of meat may be allowed, but sugars and starches must still be excluded to as great an extent as possible. The patient may be taught to supplement passive exercise by calisthenics. 5i2 J5IET IN DISEASE. THE DUJARDIN-BEAUMETZ SYSTEM. Dujardin-Beaumetz believes that the diets allowed by Oertel and Ebstein are too restricted to support the body in a condition of nor- mal nutrition and activity, and his system of treatment is as follows : For the milder cases in which fatty degeneration has not yet invaded the heart and other viscera he gives half a pint of water or light wine diluted^with Vichy, or some alkaline effervescent water, with each of the three meals of the day. Soup of all kinds is forbidden, wine or tea being recommended instead. If the gastric juice is apparently deficient, or if there is much dyspepsia, no fluid is allowed with the meals, but the patient is ordered to take a pint of weak tea without sugar or milk two hours after the completion of each meal. No other beverages are permitted excepting a small cup of black coffee with breakfast. Soup is also forbidden, and so is pastry. He allows dry bread in moderation, such as the outer part of Vienna rolls, or " soup sticks," which are chiefly crust, and he recommends animal food of all classes and several varieties of fresh vegetables and juicy fruits, such as oranges. For breakfast he gives three quarters of an ounce of dry bread, one and a half ounce of meat, and a cup of weak tea or a glass or two of light wine. Lunch is served at noon, and consists of double the quantity of bread and meat permitted at breakfast, with three ounces of fresh vegetables, salad, a small piece of cheese, and fruit. Eggs may be substituted for the meat, or fish may be given at either breakfast or luncheon. The quantity of the several foods allowed may be varied slightly. THE MEAT AND HOT-WATER TREATMENT. This method, mainly advocated by Salisbury in this country, is a treatment for obesity and chronic gastric catarrh, which consists in the restriction of the diet exclusively for several weeks to large quantities of rare beefsteak, and salt codfish and hot water for the first fortnight, three pounds of rump steak, one pound of codfish, with six and one third pints of hot water, are subsequently given for two or three weeks. The water is gradually reduced to four pints, and lean beef and fresh fish may be eaten with dry toast or Zwieback, and a very little green vegetable food. After five or six weeks the hot water is still further reduced to a quart a day, and dry crackers and dry toast and stale bread crusts, poultry, and game are added to the diet, and the patient may be allowed to drink hock diluted with carbonic or Seltzer water. The hot water, if desired, may be flavoured with fresh lemon juice, and five or ten grains of bicar- bonate of soda are given twice a day. This treatment is found im- practicable by many persons, who rebel against the extreme monot- ony of it, and are unable to eat so large an amount of meat either DISEASES ESPECIALLY INFLUENCED BY DIET. 613 with or without other food ; it is principally adapted to persons who are habituated to overeating, and is not to be recommended for the majority of cases. THE BOUCHARD SYSTEM. According to Bouchard's method, the frequent observation of the urine should form the basis of the treatment of obesity. When the nitrogenous waste is increased in the urine he reduces the allowance of animal food ; but he also believes, in opposition to many other theories of treatment of obesity, that the total quantity of farina- ceous and fatty food allowed should be five times greater than the quantity of animal food, and asserts that giving vegetable acids with the carbohydrates favours the oxidation of the latter. He therefore prescribes such fruits and fresh vegetables as are rich in the potassium salts of the organic acids. He forbids the use of vinegar and other acids, which he claims diminish the alkalinity of the blood and thereby increase the formation of fat. The patient's exercise is also governed by the elimination of urea and phosphates. When these salts are present in excess, he argues that the oxidation of the tissues is being unduly stimulated ; but if they are not present in too large quantity, exercise before meals is recommended. A review of the principles involved in this theory does not strengthen the belief in their value. The oxidation processes in the body are still too obscure to en- able one to take the urine as an absolute criterion of the conditions of metabolism, especially in those cases where a large reduction in the body weight is being obtained by the consumption of previously stored-up material. It is true that superfluous fat, when fully oxi- dised, leaves the body in the form of carbonic acid and water from the lungs, and in the form of water and carbonates in the urine ; but it is not definitely known to what extent this combustion spares the proteid materials of the body from disintegration and allows the animal food products to pass directly into the urine as urea or other nitrogenous waste matter. While the urine should be carefully studied in these cases, a much better guide for the treat- ment of obesity is found in the observation of other symptoms and in the disappearance of previously existing abnormal conditions. THE CHAMBERS SYSTEM. " Days Regimen for a Three Weeks' Course. Rise at 7. Rub the body well with horsehair gloves, have a cold bath, take a short turn in the open air. Breakfast (alone) at 8 or 8.30, on the lean of beef or mutton, cutting off the fat and skin, with dry toast, biscuit, or oatcake, a tumbler of claret and water or tea without milk or sugar, or made in the Russian way with a slice of lemon. Luncheon at i 6i4 DIET IN DISEASE. on bread or biscuit, Dutch cheese, salad, water cresses, or roasted apples (without sugar or cream), hung beef, or anchovies, or red herring or olives, and such like relishes. Drink, after eating, claret and water, unsweetened lemonade, or plain water, in moderation. Dinner at any convenient hour. Take no soup, fish, or pastry, but plain meat of any kind except pork, rejecting the fat and skin. Spinach, French beans, or any other green vegetable may be taken, but no potatoes, made dishes, or pastry. A jelly or a lemon water ice, or a roast apple must suffice for sweets and dessert. Claret and water at dinner, and one glass of sherry or Madeira afterwards. " Between meals exercise, as a rule, in the open air, to the ex- tent of inducing perspiration, must be taken. Running, when prac- ticable, is the best form in which to take it." Chambers also advised giving liquor potassae with the proteid diet, or the remedy of Dancel, consisting of one half or a teaspoon- ful of sodium bicarbonate added to five o-r ten grains of tartaric acid in a small tumblerful of water, and drunk while effervescing. He re- stricted sleep to seven hours a day, for it is weakening for the obese to remain too long in bed in a close room. Turkish baths were also recommended. Chambers's further directions to be observed by the patient to prevent a possible return to corpulency were as follows: Continue to avoid fat meats, rich milk, butter, malt liquors, sweet wines, starches, especially pastry and puddings, and sweet vegeta- bles, such as parsnips and beets. The patient may have lean beef or mutton, venison, game, poul- try, boiled fish, poor new cheese, green vegetables and fresh fruits, oranges, lemons, almonds, roast apples, salads, olives, buttermilk, claret, hock. Bread should be aerated or toasted. Captain's bis- cuits may be eaten. Among the green vegetables which may be eaten are tomatoes, celery, stuffed red and green peppers, radishes, asparagus, artichokes, oyster plant, squash, and spinach. Of the various systems above described, that of Oertel is, on the whole, the best adapted for the greater number of cases. The Eb- stein treatment diminishes the appetite and is useful for robust patients, but if there is enfeebled digestion and weakness, this diet is not to be recommended on account of the large proportion of fat and the relatively small amount of proteid foods. Schweninger's system has the disadvantage that although the withholding of all fluid at mealtime lessens the capability of taking solid food in ex- cess, there are many persons in whom the gastric juice is deficient in quantity, and its proper action can only be secured by dilution with a moderate amount of fluid during gastric digestion. The Banting method, besides being too rigorous for many, has the disadvantage of allowing no fat to be eaten. The essential value of all methods of dietetic treatment of obesity DISEASES ESPECIALLY INFLUE^XED BY DIET. 6l$ is based upon two objects to be attained : First, to enable the pa- tient to fully oxidise and eliminate the fat which is already accumu- lated in various parts of the body, and, secondly, to make it impos- sible for it to be reformed. From what has been said already concerning the cause and nature of obesity in relation to the different classes of cases, it follows that no one system of treatment is applicable in every instance. Discre- tion must be used in individual cases and the effect of any treat- ment should be observed from day to day, especial care being taken that the patient while losing flesh does not at the same time lose in strength to a degree which may become dangerous. In all cases frequent and thorough examinations should be made of the heart action, the circulation, and the urine. The favourite baths which are resorted to in Europe for the treatment of obesity are Carlsbad and Marienbad, but there are many others. "ANTI-FAT" REMEDIES. A host of quack nostrums are offered to a credulous public un- der the claim that they reduce corpulency. Some of them have achieved reputation because while they are taken the patient is also induced to regulate his diet; others merely because they have de- stroyed the appetite or digestion and have made it impossible to eat too much food. But the whole lot of " reduction pills," concentrated salts and purges, extracts of phytolacca berries, Fucus vesiculosus^ and other so-called " specifics " for reduction of obesity cannot be too strongly condemned as thoroughly unscientific, if not positively harmful or dangerous, as many of them are. It cannot be expected that any chemical remedy can control the complex processes involved, and the substances which are in exten- sive use by credulous persons for this purpose diminish the appetite, impair the digestion, and at the same time seriously interfere with nutrition. There is no drug or remedy known which acts specifically either in retarding fat formation or in causing its destruction in the body, and when any such remedy appears to have that effect, it is acting indirectly by a general lowering of vitality. The dietetic treatment of obesity is the only rational one, and when that fails it is hazard- ous to employ other means. Diet for Leanness. The foods which tend to produce fat in the body are chiefly sugars and starches. Eating fat in excess does not necessarily cause fat to accumulate in the system, for it may- be completely oxidised. To increase the albuminous constituents of the body without the accession of fat, a diet should be ordered in which proteid food pre- 5i6 DIET IN DISEASE. dominates, with a moderate allowance of carbohydrates. To in- crease the body fat, however, the proportion of carbohydrate should considerably exceed the proteid food and a little fat should be added. In seeking to remedy excessive leanness by dietetic treatment it is obviously necessary to first ascertain, if possible, its cause. It may be due to the use of improper food, to erroneous habits of eat- ing, bad cooking, maldigestion or malassimilation, overwork and nerv- ous exhaustion, disease of the various organs connected especially with nutrition, and besides these and other causes there are some persons in whom leanness seems to be constitutional. They may enjoy excellent health, but are always so thin as to be the subject of comment. No diet seems to have much effect in increasing their weight. Another class of persons are those whose weight is con- stantly fluctuating and whose annual variation is as much as ten or even twenty pounds. In winter, in town life, when overworked, wor- ried, or oppressed with mental strain, they lose weight rapidly, and in summer, in a brief holiday in the country, with little to do but eat and sleep, they gain at the rate of two or three pounds a week. This is true more often of those whose general tendency is towards obesity rather than towards leanness. It is almost hopeless to attempt to remedy obstinate leanness by diet unless other favouring conditions can be secured. First among these is entire freedom from mental strain, and of almost equal im- portance is abundant and regular sleep. A warm climate and inac- tive life favour increase in weight. In most "respects the diet for leanness must be the reverse of that for obesity, as would be natu- rally expected, and in prescribing starchy foods it must be remem- bered that the leanness is often caused solely by an entire inability to digest amylaceous or saccharine material owing to " nervous dys- pepsia," gastric catarrh, etc. These conditions should receive careful treatment on the lines recommended on pages 500 and 504. By a little care it will often be found possible to find some forms of starches which can be digested. It is a good rule in such cases to give the cereals or vegetables at one meal and meat at another, so that articles involving different rates and organs of digestion do not interfere with each other. All bread should be stale or toasted. Crackers and Zwieback may be allowed. As a rule such patients can be made to digest starches before they can sugars oatmeal will be better digested without sugar, and a cup of sweetened coffee with a meal of starchy foods may produce flatulency which lasts for hours. When the digestive organs admit, the following articles may be prescribed in the diet for leanness : Abundant fat meats, butter, cream, milk, cocoa, and chocolate. Bread, potatoes, legumes, well-cooked cereals, especially oatmeal and corn meal, farinaceous puddings with sugar and cream, cake, sweets. DISEASES ESPECIALLY INFLUENCED BY DIET. 617 sirup, honey, sweet wines, port, porter, stout, ales, and beer. Malt preparations of all sorts are also useful. Sweet fruits may be eaten. To be avoided are pickles, acids, condiments, much bulk of green vegetables, and strong liquors. Diet in Acute Rheumatism. Causation. It has not been proved that any special articles of diet lead to the development of rheumatism, although indulgence in sweets, starchy foods, and malt liquors is sometimes held respon- sible for it. Poor living seems to favour the attacks. In regard to this point Captain Woodruff, U. S. Army, says: " The enormous number of cases of rheumatism occurring during the rebellion and since the rebellion in veterans may not be entirely due to the exposures, as popularly supposed. These men were hard- ened to exposure and should not have had more rheumatism than hunters, trappers, and the aboriginal Indians. The limited, often insufficient, ration and the absence of fresh articles may have been one of the factors at work." Dietetic Treatment. While the fever lasts and other symp- toms are acute, such as pain and swelling of the joints, the patient should be put upon a fluid diet. The majority of cases do best at this time with an exclusive milk or bread-and-milk diet. Those pa- tients who cannot take milk, however, may be allowed soups and broths flavoured with vegetable extracts, chicken tea, milk toast, barley or oatmeal gruel, clam broth. Thirst is often a prominent symptom, especially if there be much fever, and it is advisable for the patient to drink fluid freely to assist in washing out the waste products from the body. Lemonade and slightly acid drinks of various kinds, such as dilute phosphoric acid or the effervescent mineral waters, are recommended. Boiled milk and Seltzer or Vichy may be drunk, or oatmeal or barley water flavoured with lemon. Alcohol should be avoided while the acute symptoms last, unless the complication of inflammation of the endo- cardium or pericardium enfeebles the heart action to such a degree as to make stimulation necessary. If convalescence is prolonged and anaemia is considerable, alcohol may be given as a tonic two or three times a day in the form of a glass of claret or Burgundy (one to two ounces), or diluted whisky. During convalescence the appetite is not usually vigorous, and it is not necessary to urge the taking of much food at first. The diet should be principally farinaceous, but not saccharine. Such articles may be given as rice (plain or spiced), arrowroot, oat- meal, corn meal, semolina, wheaten grits, panada, milk toast, simple unsweetened puddings, "meagre" soup, wine jelly, blancmange, malted foods. 6,8 DIET IN DISEASE. The return to solid diet should be gradual, and for a long time the patient should abstain from eating meats as well as from pastry and sweets. Fagge states that no meat or fish should be allowed for at least a week after subsidence of the fever and acute symptoms, or, better, for a fortnight, and many believe that beef tea is harmful. Meat can undoubtedly induce a relapse. When convalescence becomes established, eggs, fish, oysters, and the white meat of broiled or roasted chicken may be given, and one or two such vegetables as asparagus, spinach, or stewed celery, with a baked apple or fresh fruit, but sweets and alcohol should long be withheld. The patient should be fed often, having one or two extra lunches during the day, for anaemia is apt to prevail for some time, and abundant nutriment is required. Diet in Chronic Rheumatism. In the dietetic treatment of chronic rheumatism, especially if the patient is anaemic, animal food cannot be excluded, but the basis of the diet should be farinaceous food with a few fresh green vegeta- bles. Fish, eggs, and fowl may be eaten, but dark meat is not de- sirable. Sweets and alcoholic beverages should be omitted from the menu, and all foods should be plainly cooked and eaten in moderation. Rheumatoid Arthritis. Causation. Rheumatoid arthritis is a chronic disease in which the joints of the body, and particularly those of the extremities, are affected. The disease may originate independently, or it may ap- pear in connection with, or as a sequel to, gout, acute articular rheu- matism, or gonorrhoeal rheumatism. The alterations in joint struc- tures are produced mainly by impoverished nutrition, and the disease is especially one of advanced life, occurring in persons in whom various evidences of senility have begun to appear. The structural changes in the joints involve proliferation of the cellular elements of the cartilages, with thickening and erosion and with the production of osteophytes. In mild cases there is not much impairment of gen- eral health. In severer cases the patient is confined to the house and, on account of pain or immobility of the joints, is unable to take ordinary exercise. Digestion and nutrition suffer considerably in consequence. Dietetic Treatment. Since the disease is one of debility and impoverished nutrition, it follows that a low diet is harmful and a nourishing diet, with increased frequency of meals, is desirable. James Stewart says: "The practice of limiting the amount of nitrog- enous food is not to be commended. Provided there is no gen- eral or local contraindication, the patient should be directed to DISEASES ESPECIALLY INFLUENCED BY DIET. 619 take as much nitrogenous food as can be digested with facility." And Garrod wrote : " I consider it of the utmost importance through- out the whole course of the disease to support the system and to allow the patient as nourishing a diet as he is capable of properly digesting." Good roast beef, beefsteak, mutton, fowl, fish, eggs, and milk may be eaten. Mustard and horseradish are recommended by Lyman as useful adjuncts to the diet on account of the sulphur which they contain. Alcoholic beverages taken with meals in proper moderation are beneficial for their strengthening and tonic effect, and bitter tonics may be combined with them to advantage. The objection which exists to the use of alcohol in gout and acute rheumatism does not apply with such force in this disease. Malt liquors may be given, such as ale or stout, and it is often desirable to prescribe a good Burgundy, port, or sherry. If it is well borne by the stomach, cod- liver oil should be given in teaspoonful doses, an hour after meals, three times a day. It is an excellent food in this disease, and its use should be long continued. Other forms of fat may be used, such as butter, cream, or bone marrow, olive oil, etc. When acute exacerbations occur the quantity of food and stimu- lants should be reduced, but otherwise it is important that the diet should always be ample. Intractable cases do well to try the effect of a course of treat- ment at the hot springs of Virginia, Arkansas, or Banff. Gout. Gout is a constitutional disease which has local manifestations appearing from time to time in the joints, especially the metacarpo- phalangeal articulation of the great toe, but it must be remembered that the gouty diathesis is a condition which once acquired may exist for years, producing many other and more serious symptoms or structural changes in the body than the local inflammation of one or more joints. Causation. Gout has been defined as a condition dependent upon disturbed retrograde metamorphosis of the nitrogenous in- gredients of the food a high-sounding phrase, which, it must be confessed, carries with it very little genuine explanation of the nu- tritive processes involved. Whatever may be the theories in regard to the production of an attack of acute gout, it is universally ad- mitted that careful regulation of the diet is the most important factor in its treatment. Gout and the various conditions allied to it are dependent upon retention in the blood or other fluids of the body of forms of waste matter which nor^mally should be oxidised and completely converted into the soluble materials which are excreted in the urine. For some reason the oxidation of waste 620 DIET IN DISEASE. matter is suspended, and, as a result, a variety of intermediate prod- ucts of imperfect solubility may be deposited in the joints or tissues of the body. The active manifestations of gout are due to an accu- mulation of insoluble urates in the joints. In conditions which are closely allied to gout, such as the uric-acid diathesis, there is a deposition of crystals of uric acid in some portion of the urin'ary tract or, in other conditions, deposits of insoluble cholesterin are formed from the bile and accumulate as gallstones in the gall bladder. The direct relation existing between uric acid and gout has been most exhaustively investigated by Garrod, and this relation may be briefly summarised as follows : First, the gouty diathesis is associated with a more or less constant excess of uric acid in the blood ; sec- ondly, the quantity of uric acid normally present in the urine is di- minished by at least one half during a severe attack of gout, and increases beyond the normal as soon as the acute symptoms subside. An acute attack of gout is therefore preceded by accumulation of uric acid in the blood, which is a substance that in itself represents incomplete combustion of nitrogenous waste material in the body. The retention of this form of waste in considerable quantity proves markedly irritating to the nervous and other organs of the body. Sir Dyce Duckworth writes: "We perhaps come nearer a com- plete understanding of this matter if we regard as present in the gouty a peculiar incapacity for nornial elaboration within the whole body, not merely in the liver or in one or two organs, of food, whereby uric acid is formed at times in excess, or is incapable of being duly transformed into more soluble and less noxious products," and he agrees with Ralfe that the failure to complete the metabolism of uric acid is dependent primarily upon disturbed innervation. In referring to the habit of overeating, Sir H. Thompson says that in early life it may give rise to occasional attacks of biliousness, but after the first half of life has been spent the remaining half may be affected in a different way, and " recurring attacks of gout per- form the same duty, or nearly so, at this period of life that bilious attacks accomplished in youth." On the other hand, in persons who are subject to attacks of gout starvation may bring it on (Senator), and "poor man's gout" is by no means a disease induced by plenty. Sugar eaten in excess is not of itself a direct cause of gout, but sweets combined with certain other foods, such as certain fruits and wines, will precipitate an attack in a gouty subject with cer- tainty. According to the view of Sir Dyce Duckworth, it is the com- bination of sugar with vegetable acids which is especially injurious. Sugar, under some conditions of fermentation in the stomach and intestines, forms lactic acid, which is capable of splitting so as DISEASES ESPECIALLY INFLUENCED BY DIET. 62 1 to produce carbon dioxide, which, according to Ralfe, forms acid salts of sodium and potassium from their neutral compounds. Lack of exercise is often assigned as a cause for gout, and with many persons it is true that outbreaks of gout may be intensified in this way ; but it is not uncommon for the disease to affect men who lead lives of considerable activity or who practise athletics, but who at the same time consume large quantities of nitrogenous food. By free perspiration the amount of fluid present in the blood is reduced and the solids become both relatively and absolutely increased, making it difficult or impossible for them all to become thoroughly oxidised. Symptoms. The most distinctive symptoms of gout are the local joint manifestations of pain, swelling, redness, and tenderness. These symptoms usually occur together in an acute attack, but either one may occasionally be absent. Other symptoms may appear from time to time, such as disorders of the mucous membranes, espe- cially of the stomach and bowels; a tendency for the catarrhal affections of the mucous membranes of the respiratory passages; chronic endarteritis ; alterations in the composition of the urine; and various forms of irritation of the nervous system and the skin. Children who inherit the gouty diathesis are very apt to present some one or more of this group of symptoms, especially neuralgic pains, digestive disturbances, and skin diseases, which appear at an early age and long before the gout is fully developed with typical localised joint symptoms. The symptoms connected with this diath- esis are believed to arise from obscure alterations in the composi- tion of the blood which are more or less remediable by dietetic treat- ment. Preventive Treatment. The prophylactic treatment of gout in those who inherit a constitutional predisposition to the disease is very important. From birth onward the children of gouty parents should be abstemious, have the diet carefully balanced so that neither animal nor vegetable food predominates in great excess. As the child grows older, confectionery and sweets in general should be avoided, especially with other food or at the conclusion of meals, as well as alcohol in every form. In youth all varieties of beer, ale, cider, etc., are particularly injurious. Tea and coffee, if allowed at all, should be taken in moderation, and some persons can often precipitate a violent attack of gout by a single glass of champagne or sweet wine. If they are accustomed to the use of alcoholic beverages and it is impossible for them to go without them, those which are least injuri- ous are a dry white wine or old Bordeaux, but all wines containing sugar or tannin must be absolutely prohibited. Cyr says: "If a glass of beer, spirits, or wine is habitually fol- lowed by pain in a joint or nerve it is gouty." 522 DIET IN DISEASE. Theory of Dietetic Treatment. An important question in re- gard to the theory of gout is still under discussion namely, whether the increased quantity of uric acid is to be attributed to overproduction or merely to faulty elimination. It is conceivable that the fluids of the body, by becoming less alkaline than normal, may fail to retain the salts of uric acid in solution, and are consequently precipitated in the joints and elsewhere. The matter is of vital importance in the selection of the proper diet for gouty patients. If the disease is caused merely by imperfect oxidation of nitrogenous food, the indi- cation is clearly to diminish the quantity of such food ingested and to promote oxidation by exercise and fresh air. If, on the other hand, oxidation processes are fairly normal, but the blood is in a morbid state in which it becomes less alkaline than normal and loses its solvent power upon the nitrogenous waste matters, it is possible that other causes may be responsible for the condition produced. Albumins contain both sulphur -and phosphorus which are destined to leave the body in the form of salts of sulphuric and phosphoric acids respectively. If these acids fail to be wholly neutralised while yet in the blood they will lessen its alkalinity, and in this way over- indulgence in albuminous food by furnishing an excess of sulphur and phosphorus may diminish the alkalinity of the blood and produce uricsemia. This explains why the use of alkaline waters is so gener- ally beneficial in gout and lithaemia. Such fluids assist in regulating the normal alkaline reaction of the blood. This is the line of argu- ment which has been advanced by many physiological chemists, and it applies in equal force to the method of formation of renal calculi and gravel. The acidity of the urine is increased by a meat diet and reduced by a vegetable diet. With the latter it may even become strongly alkaline. Whether we adopt the theory of deficient oxida- tion or of diminished alkalinity of the blood, the indications for die- tetic treatment of gout are the same namely, reduction of proteid food and increase of vegetable food. It does not follow that albu- minates must be entirely given up in all cases of gout, but they should be so restricted that the normal balance of the metabolism of the blood shall be restored. It will be found necessary for those who live luxurious and idle or sedentary lives to give up nitrogenous food absolutely while those who are accustomed to take active mus- cular exercise may be allowed animal food in very moderate quanti- ties once a day. Dietetic Treatment. Although no one food is invariably in- jurious at all times, it is almost universally agreed that for the gouty fat and nitrogenous food should be greatly restricted and saccharine food should be entirely prohibited. It may be established as a general rule that the diet of the gouty should consist principally of easily digested fresh green vegetables DISEASES ESPECIALLY INFLUENCED BY DIET. 623 and sometimes certain fruits, in addition to which a moderate quan- tity of lean meat (beef, lamb, and mutton) may be eaten to prevent the necessity of taking an excessively bulky diet, which in order to furnish sufficient nitrogen for the needs of the body would unduly tax the digestive system. Fruit is less apt to disagree if taken by itself, not with sugar or other food. It is a serious mistake to prescribe any treatment for the gouty which tends to lower the general vitality of the system too much. The diet, therefore, must be so adjusted as to secure the right pro- portion of the different classes of foods. Atonic cases require a gen- erous diet with more proteids. Gout is often combined with excessive corpulency, and when this is the case no chronic disease, with the exception, perhaps, of dia- betes, requires more strict regulation of the diet and hygiene of the patient. While it is undesirable to allow animal food in large quan- tities in gout, it is also true that vegetables are fattening, and if the diet is too restricted in both these classes of foods the obese patient suffers from lack of nutrition, and digestion becomes still further im- paired in consequence. The theory has been held that but little fat should be eaten by the gouty, for it fixes oxygen which would otherwise complete the oxidation of albuminates, and hence it favours accumulation of pro- teid waste products. On the other hand, it has been shown that the accumulation of uric acid is not due to lessened oxidation, but that it is increased by proteid metabolism, and its elimination by the kid- neys is actually promoted by fats. Clinically, however, it is found best to control the use both of albumins and fats. Sugars and gelatinous material, like fats, all tend to retard the complete combustion of proteid food, and the latter therefore remains in an imperfectly oxidised condition which may give rise to uricaemia. The combination of the latter classes of foods, therefore, is particu- larly injurious in gout. On the other hand, Ebstein favours the use of fat in moderation, on the ground that it appeases the appetite and makes the consumption of a large quantity of carbohydrates unneces- sary. If fat is allowed at all in the diet, it is best to give it in very small amount; otherwise it interferes with the local digestion in the stomach and tends to aggravate the dyspepsia which is so common in gouty subjects. It will be better borne in those cases which are not complicated by a tendency to obesity. In the dietetic management of gout in robust subjects it is of quite as much importance to reduce the quantity of food consumed as to restrict the variety. Robust gouty patients must be made t.o restrain a too vigorous appetite, and especially the eating of all sorts of foods between meals, for, as Balfour says (The Senile Heart), "there is nothing 42 624 DIET IN DISEASE. SO destructive of gastric comfort as the continual pecking induced by gouty bulimia." They should never be allowed to eat to complete satiety at meals, and all rich sauces, pastry, and strong condiments and fried food should be avoided. The majority of gouty patients have been in the habit for a long time of eating too much meat, and some of them of partaking too freely of carbohydrates. Overeating is almost as bad for patients as drinking too much. "Gout is evidence of an overfed, overworked, and consequently clogged machine " (Osier). As Bence Jones says : " It is best to allow a minimum of albu- minous food to produce the least amount of uric acid and a mini- mum of carbohydrates, in order to give the uric acid formed op- portunity to be oxidised as much as possible." When an acute exacerbation of gout occurs it is necessary to curtail all variety in diet, and put the patient upon light farinaceous food with abundant diluents, alkaline waters, weak tea. Gruels of sago, arrowroot, or barley may be given, with bread or toast. When the fever subsides and the acute symptoms abate, bouillon, clam juice, simple broths made of lean mutton or chicken with rice, may be allowed. Later, a little whitefish or breast of chicken. Meat should be given only when absolutely necessary for nourish- ment, for, as Garrod says of it, " everything beyond what is abso- lutely required for the nourishment of the body only feeds the disease." Sir Dyce Duckworth's treatment of the acute disease is briefly as follows: He recommends such substances as rice, bread, arrowroot, sago, tapioca pudding, and semolina. He allows milk, weak tea, and infusion of cocoa nibs. Later, chicken broth may be given, fol- lowed by fish and a mealy roasted potato. No meat should be given until all acute symptoms are over, and then it should be allowed but once a day. Elderly persons may have a little dilute whisky or brandy, not to exceed two ounces /^r diem. He also favours the use of hot water, as in the treatment of dyspepsia, but discountenances the eating of fruits, especially with sugars. When the acute attack subsides and chronic gout supervenes Garrod replaces the farinaceous diet gradually by fruit, fish, fowl, and finally by meat, but any dishes containing free acids or sweets are liable to cause a relapse. DIET FOR THE GOUTY DIATHESIS AND CHRONIC GOUT. In the following dietary a liberal variety of foods will be found, some of which may be selected and changed from time to time ac- cording to need in the intervals between the exacerbations or in chronic gout. Should an acute attack occur at any time in the course of the disease, the diet must be at once restricted, as described DISEASES ESPECIALLY INFLUENCED BY DIET. 625 above. The number of dishes allowed at any one meal should be few. In dealing with any case of chronic gout for the first time it is injudicious to make radical changes in the diet too suddenly. Soups. Soup should be free from all fat, and it is better made of vegetables than meat, and purees of potatoes, celery, etc., may be recommended. If the taste of meat is desired, as suggested by Yeo, it is best imparted to the soup by one of the meat extracts which contain simply the highly flavoured extractive matter without contributing to the bulk of proteid food. A teaspoonful or two of Valentine's meat juice or Liebig's extract of meat in a half pint of vegetable soup accomplishes this result. Milk. Milk wholly disagrees with some gouty persons, but in those who digest it well, if it be not too rich in fat or if it is taken skimmed or diluted, it forms an excellent food. Many are, however, opposed to its use in any form, even when rendered alkaline by the admixture of alkaline waters or a few grains of bicarbonate of sodium. Yeo gives a small salt-spoon full each of potassium bi- carbonate and common salt in a breakfast-cup full of hot milk and water. Others give it with warm water. The attempt has been made to place gouty patients upon an exclusive milk diet. This sometimes, but not often, aids those who are robust and young, but it is injurious to older patients. Cheese, being a concentrated, proteid food, should not be eaten. Eggs. Eggs should be avoided as a rule, on account of the excessive proportion of fat and albumen and lecithin which they contain. Garrod allows eggs and bacon for breakfast, and Ralfe recom- mends an occasional " savoury omelet." Eggs cooked with milk and custard puddings (unsweetened except with saccharin) may some- times prove harmless, but Senator is opposed to them on account of the fat and lecithin which they contain. Shellfish and Crustaceans. The soft part of oysters and clams may be eaten, but crabs, lobsters, and shrimps may not be allowed, least of all in salads. Fish. Some writers maintain that fish should constitute the chief nitrogenous food, while others prescribe it very moderately, if at all. Broiled or boiled fish, such as bluefish, whitefish, bass, shad, are permissible occasionally for variety, but fish having firm flesh and those which contain considerable fat are not good. Salmon, mack^ erel, halibut, codfish, should therefore be avoided, although Garrod allows salmon served with salt and Cayenne, but without sauce. Rich sauces must not be eaten with fish qr salads. In lieu of them, a simple dressing of an infusion of aromatic herbs and pepper, or a plain bread sauce, may be employed. 526 I^IET IN DISEASE. Smoked and pickled fish are forbidden. Fish roe, such as shad roe and caviare, is admissible. Meats. Meat cannot be prohibited entirely for months at a time in chronic gout, especially for a middle-aged man, although the young may thrive better without it. It should be only eaten once a day in any case, and roasting or broiling is the best form of cooking it. Twice-cooked meats should not be eaten. Beef, lamb, and poul- try may be allowed sparingly. Generally speaking, white meat is better than brown. Veal, pork, fat bacon and ham, game, and dried, smoked, pickled, or salted meats must all be forbidden. Only one kind of meat should be eaten at a meal. Fats. Fats should be used sparingly, and all food fried or cooked in grease must be forbidden. Fat meats and fat fish are to be avoided. A little well-cooked bacon may occasionally be eaten, and butter may be taken only in moderation. The objection to the use of fats and oils is that, unless the general nutrition is very poor, they interfere in gouty subjects with complete oxidation of proteid elements. Farinaceous Food. Farinaceous food is allowable, and in the acute stage of gout it should constitute the main diet. Bread (not fresh), rice, sago, tapioca, oatmeal, cracked wheat, may all be eaten. Pastry, cake, hot rolls, hominy, griddle cakes, preserves, and confec- tionery of all kinds are forbidden. Sugar. Sugar has not proved to be always harmful to the gouty, but eaten with a mixed diet, especially with fruits or drunk with wines, it undergoes fermentation processes which are at once dis- tinctly harmful. It is generally admitted that carbohydrates eaten in excess with other food are more injurious than fats in excess. Sweets, jams, and jellies of all kinds are forbidden. When sugar positively disagrees, a little glycerin or, better, saccharin or diabetin (levulose) may be substituted for it. Vegetables. Of vegetables, although a great variety are eaten, there area few which are prohibited on account of the fact that they contain oxalic acid, which is closely allied to uric acid, and which produces oxaluria. These are sorrel, radishes, asparagus, rhubarb, tomatoes, and spinach. The two latter are allowed by some au- thorities, however. Beets are forbidden. Vegetables, such as cab- bage, onions, old peas, beans, and corn, if they occasion flatulence, must be eschewed. The following may be eaten : French peas {petit pots) and young French beans, string beans, celery, young tender green corn, carrots (very moderately), turnips, parsnips, po- tatoes (except sweet potatoes) sparingly, well-baked and mealy, cu- cumbers, broccoli, beet tops, cauliflower, celery plant, eggplant, okra, artichokes. Salads, provided they are not dressed with much DISEASES ESPECIALLY INFLUENCED BY DIET. 627 oil, are allowable. Vegetables which act injuriously on account of their acids are made still more harmful by being cooked with sugar. Fruits. Some writers allow fruits of almost every kind, both raw and cooked, but Sir Dyce Duckworth and many authorities de- clare that fruits in general are harmful. Sir Andrew Clarke forbade their use in toto. If they produce no dyspepsia, and are ripe and fresh, a few fruits may be eaten, such as stewed pears, or apples stewed, baked, or roasted ; but all those fruits which contain large quantities of sugar, such as grapes, figs, bananas, prunes, etc., must be forbidden, as also acid fruits, especially strawberries. No fruits cooked with sugar can be allowed. Melons are forbidden. Garrod expressly forbids all stone-bearing fruits, and says that subacid fruits furnish alkaline salts that split up in the blood and reappear in the urine, chiefly as potassium carbonate, and stimulate the kid- neys. Melons are usually the least hurtful of fruits. Fothergill wrote : " The potash in the strawberry renders its juice a desirable drink for the gouty and for strumous children," but there are many patients who cannot eat a half dozen strawberries without an exacerbation of inflammation in a gouty joint. If any fruit is eaten it should not be in connection with other food or with sugar. Hence all candied fruits are proscribed. Nuts are forbidden. Pickles, vinegar, spices, strong condiments, salted foods, mush- rooms, and truffles must all be forbidden. Eating between meals and at irregular intervals is injurious. Fresh air and exercise are often more needed than extra luncheons of bouillon, broths, wines, etc. Ralfe gives the following menu for breakfast and lunch : Breakfast. A poached ^g%, bacon, or fresh fish, tea (coffee and cocoa disagree) without milk or sugar. Light Lunch. A clear soup, vermicelli or julienne, sandwiches, cold meat with salad. Dinner is to be eaten not too late, and fully three hours before retiring. Cantani's treatment of gout is based on the belief that all sub- stances should be withheld from the diet which retard the oxidation of nitrogenous food or lessen alkalinity of the blood. He there- fore prohibits all fatty, farinaceous and saccharine food, including bread and potatoes, sweet fruits, etc., but allows fish, eggs, broth, and fresh green vegetables to be eaten. Especially to be avoided are milk, cheese, all acid foods, pickles, sweets, pungent condiments, bread, rice, potatoes, all farinaceous foods, and coffee. 628 I5IET IN DISEASE. BEVERAGES. Water. It has been already stated that to favour the washing of waste matter from the system it is desirable to drink considerable quantities of fluid, and gouty people who are corpulent usually per- spire with freedom ; their urine therefore becomes concentrated, and there is a tendency to the precipitation of uric acid, urates, and oxalate of lime. It must be observed that the presence of uric acid in the urine does not always indicate an excess of that acid, and it may happen that the urine is too concentrated or otherwise altered to hold it in solution, and hence precipitation results. An excess of acid phosphate may combine with the sodium and potassium which are necessary to hold the uric acid in solution in the form of urates, and it is deposited in insoluble crystals. Copious draughts of hot water at bedtime or taken on rising in the morning are often pre- scribed, but it is doubtful whether the temperature of the water makes any difference in the desired result so long as plenty of fluid is taken. Fluid should be drunk half an hour before meals, when the stomach is empty. Besides serving to cleanse the mucous mem- brane of the alimentary canal, the diuretic action of water will be greater when absorbed at such times. Sir Dyce Duckworth holds somewhat different views in regard to water drinking, although he does not make clear his reasons for so doing. He says : " I feel sure that Sydenham was right in condemn- ing water drinking for the gouty. * Water alone is bad and danger- ous, as I know from personal experience. When taken as the regu- lar drink from youth upward it is beneficial.' " He prefers to allow a moderate quantity of wine from four to six ounces of good sound Bordeaux, and adds : " The least excess is harmful, but a little good wine is better for most gouty persons than water drinking, espe- cially after middle life." This, of course, was written for English- men in the upper classes, whose ordinary consumption of wine is greater than that of Americans in the same social position. Much depends upon one's previous habits of life, and in this country ex- amples of gout may not rarely be found among patients who have never been in the habit of drinking alcoholic beverages daily, and such persons do best to abstain from them entirely. Tea, Coffee, etc. Tea and coffee are admissible among bever- ages for the gouty, and it will be found that they are less likely to cause dyspepsia if taken quite weak without sugar. A quarter of a grain of saccharin may be added instead. Senator forbids tea and coffee, and prescribes " acorn coffee." Infusion of cocoa nibs is less to be recommended on account of the excessive fat which it holds. Esbach states that he has found oxalic acid in it also, amounting sometimes to 0.4 of i per cent. Chocolate is forbidden. DISEASES ESPECIALLY INFLUENCED BY DIET. 629 Patients who are still able to lead active outdoor lives are able to drink more alcohol than those of sedentary habits, without aggravat- ing their symptoms. In general the quantity consumed is as im- portant as the quality, and it should be definitely prescribed and kept within bounds. Alcoholic Drinks. With regard to the use of alcoholic bever- ages it is their acid and saccharine ingredients rather than the alcohol itself which disagree. Strong liquors, diluted, may not be injurious, but nothing is worse than rich sweet wines and malt liquors. It is, however, true that alcohol in all forms lessens the elimina- tion of tissue waste, and decreases the volume of urea and uric acid excreted. According to Pfeiffer, both beer and wine may lessen this volume by one half; on the following day it is increased, and subse- quently diminished again. The longer wines have been fermented, or the more complete the conversion of their sugar to alcohol, the less hurtful they become to the gouty. While free perspiration exists in warm weather, and free diuresis as well, alcoholic drinks of all kinds are less harmful. Whatever form of alcohol is taken, it should be drunk to the exclusion of all others, for mixtures are particularly bad. Strong beer, ales, porter, stout, all malt extracts, and sweet cider must be absolutely prohibited. Sir Henry Thompson and Germain See regard cider as beneficial as a solvent of uric acid, but by others it is looked upon as injurious on account of the malate of potassium which it contains, and which it is claimed favours the formation of uric acid (Yeo). Undoubtedly the alcoholic drinks which are best tolerated by the gouty are good French Cognac or old Scotch whisky well diluted with water, ApoUinaris, or soda water. Scotch whisky is by many found to agree better than any other variety. Weak brandy and soda may be substituted, or un- sweetened Plymouth gin. It is the part of wisdom to abstain entirely from alcohol. Very many persons are so habituated to its use that they are unwilling to abandon it, and a compromise must be effected. It is easier for them to give up certain foods than drink. There are certain wines which should be absolutely prohibited, among them all which are re-enforced by, or which contain a large proportion of saccharine material. Strong port, sherry, champagne, Madeira, Canary, claret, and Burgundy are comprised in this list. Port wine has even acquired the reputation of being a primary factor in producing gout, when a hereditary diathesis does not exist. It is an incompletely fermented wine to which alcohol has been added for preservation, and all wines of this class are the worst forms of alcohol for the gouty. Garrod says that exceptionally a sound sherry, Amontillado or Manzanilla, may be prescribed. There 630 DIET IN DISEASE. are patients, too, who maintain that they do better with port as a daily beverage than with any other form of wine, but their example would be a very unsafe one to follow, and their experience is due to constitutional idiosyncrasy. Duckworth says: " Rhenish wines are acid and harmful; those of the Moselle district are, however, less acid, and rather better borne. Australian, Californian, Hungarian, Greek, and other Mediterranean wines are too strong, and after a time generally disagree." An absolutely dry champagne may sometimes be permitted, or very dilute and weak pure claret. The stronger clarets containing more tannin, and all wines with much free acid, are injurious. Among the light wines, several may be permitted in moderation, but they should be diluted with an alkaline water in order to com- pletely neutralise any acidity. Such wines should be either long bottled or drunk fresh from the cask, for newly bottled wines are more injurious. The best Bordeaux and lightest Hungarian wines, light hock and a still Moselle, such as Zeltinger, may be drunk, for these wines are quite thoroughly fermented, and therefore contain no sugar or free acid, though they have salts, such as cream of tartar. These wines should only be allowed in extreme moderation, not over half a pint in a day. Yeo says: "The more distinguished the diuretic effect of the wine, the better, as a rule, will it agree with the gouty." Ralfe's practice is to allow no wine of any sort with dinner, but afterwards two claret-glassfuls of some light wine are permitted ; and he says that a tablespoonful of brandy in half a tumblerful of water before meals increases the secretion of gastric juice. If the patient is weak, or suffers from insomnia, he gives brandy or whisky at bedtime in some effervescing water. He states that in his experience patients who have been long habituated to the daily use of port, sherry, or ale, often become worse when a sudden change is made to claret or hock. In such cases he advises changing gradually by substituting at first a drier port or sherry. Usually such red wines as St. Julien and St. Estephe are preferable to the higher class, such as Lafitte or La Rose. Different persons show peculiar idiosnycrasies in regard to the gout-producing influence of certain wines. Some will always have gouty inflammation set up within a few hours in a particular joint by one form of liquor or wine and not by others. Saline W^aters. Alkaline and saline mineral waters have a well-deserved reputation for benefiting gout. Many persons, espe- cially obese gouty subjects, are helped by taking one or two " courses " of treatment a year for two or three successive years at DISEASES ESPECIALLY INFLUENCED BY DIET. 631 Carlsbad, in Bohemia, or elsewhere. Carlsbad water may be drunk at home, four or five ounces being taken on rising in the morning, or an equivalent of the evaporated salts chiefly sodium sulphate. The water of the Kreuzbrunnen at Marienbad has essentially the same composition with that of Carlsbad, and contains even more sodium sulphate. Elderly persons may be injured by a too vigorous use of these salines, and they should take only milder alkaline waters containing less sodium. The German Fachingen water has proved very serviceable. It contains 3 5 per cent of bicarbonate of sodium and 6 per cent of bicarbonate of lime. Vichy is good for strong patients, but not for the feeble or anaemic. It also contains considerable sodium bicarbonate, and the Vals water has more sodium carbonate than many alkaline waters. These waters favour the elimination of uric acid as a salt rather than in the free state. Saratoga alkaline water is among the best in this country for gouty patients. It contains carbon dioxide, sodium and alkaline carbonates, and chlorides. The waters of the St. Clair Spring in Michigan, and St. Catherine Spring in Ontario, are good alkaline salines for gout. Many lithia waters are also recommended, but they contain little lithium. Apollinaris and Johannis water are good. All beverages drunk by the gouty should be well diluted, and mildly alkaline mineral waters are especially valuable for this purpose. Aids to Dietetic Treatment. The individual peculiarities of digestion should be carefully studied in each case by the physician, and the patient must be very thoroughly examined in regard to the minutiae of all his hygienic and dietetic habits. Meals should be taken at stipulated hours the breakfast on rising, dinner not later than three o'clock, when practicable, and late suppers should be avoided. Between the acute attacks it is absolutely necessary to maintain digestion in a normal condition. The bowels must be kept open, and the condition of the skin should be actively maintained by cold bathing and friction. Exercise should be taken in the open air. The urine should be frequently examined, with especial refer- ence to the hour of the day at which it is passed and the relation which its composition bears to the food eaten. Diabetes Mellitus. Nature of the Disease. Diabetes mellitus is a disease charac- terised by the passage of a large quantity of urine containing grape sugar or glucose and usually of high specific gravity 1.035 or more excessive thirst, and sometimes e;caggerated or perverted appetite ; progressive emaciation ; muscular weakness and languor. The disease runs a chronic course, and the majority of cases ter- 632 DIET IN DISEASE. minate fatally in from two to four years. Death may result from inanition or from "diabetic coma " or other causes. Our knowledge of the disease has been very largely obtained from experimentation upon the lower animals, in whom diabetes can be artifically produced. The treatment is almost entirely dietetic and hygienic, for as yet no medicinal remedy has been found which is curative, and very few have been discovered which are even palliative in any number of cases. Diabetes is therefore essentially a dietetic disease, for although not usually caused by errors in diet it may be exception- ally so produced, and most cases are more or less benefited by dietetic treatment, while some may undoubtedly be cured by it. The terms " glycosuria " and " glucosuria " are employed by some authors to denote the disease diabetes mellitus. Their proper use, which will be followed in this article, is in a more restricted sense to imply merely the existence of saccharine urine, which may be of temporary occurrence independent of the other symptoms of diabetes. Owing to the somewhat obscure aetiology of diabetes it is classed by different authors among various diseases. Thus it is placed among diseases of the kidney for convenience of examination of the urine, or it is described in connection with diseases of the liver, constitutional diseases or disorders of the digestive system, or of alimentation. In the mortality statistics of the United States Census it is classed among General Diseases, and the latter class has certainly the advantage of being non-committal, for while the liver is mainly at fault in diabetes it may not be exclusively so, and the disease certainly has nothing to do with the kidneys beyond the fact that they have extra work thrown upon them. Diabetes has long been known, and was described more than a century ago ; and Rollo inaugurated the dietetic treatment by withholding vegetable food. In 1838 Gmelin and Tiedemann estab- lished the existence of the relation between the digestion of car- bohydrates and the formation of sugar. In 1848 the eminent physiologist Claude Bernard began elaborate researches which first threw definite light upon the relations of the liver to the con- sumption of sugar and the formation of glycogen, and since that day a number of physiologists and clinicians in many countries have contributed extensively to the knowledge of the disease. Notwith- standing this fact, however, the true cause of this affection is still obscure, and aside from dietetic treatment but little advance can be claimed in regard to the controlling influence of medicine. The method of production and elimination of the sugar and the in- fluence of the disease upon general nutrition is understood, but its real exciting cause and the fundamental reason for the interesting departure from the normal metabolism of starchy foods which is its basis is still unknown. DISEASES ESPECIALLY INFLUENCED BY DIET. 633 Frequency. Diabetes is not a very rare disease, and a few cases occur from time to time in the experience of almost every general practitioner. It is reputed to be of more common occur- rence to-day than it was forty or fifty years ago, but this fact is possibly due to the much more careful and frequent urinary analy- ses which are made as a matter of routine by all physicians, that often reveal a latent diabetic condition which might otherwise have been overlooked. In regard to those cases which are of neurotic origin, the general increase in the proportion of diseases of the nervous system which has been observed in the United States must be taken into consideration. In the United States Census for 1880 there are reported 1,443 deaths from diabetes mellitus (or 1.9 per cent of all cases), against 837 deaths (or 1.7 per cent) in 1870. Dia- betes may occur alone or in association with a variety of diseases, particularly those of the liver, pancreas, lungs, and nervous system. Causation. The influence of heredity can be traced as a factor in about one third of all cases. The disease may occur in any climate and in any age with either sex, but it is commonest with males in the proportion of three to one. In females it occurs oftenest between twenty and forty years ; in males, between thirty and forty-five years. It is somewhat more common among the wealthy than the poor because of sedentary habits combined with overindulgence in eating. The obese, particularly those who have much omental fat, are more liable to diabetes than are thin persons who are more active. Cantani has observed the unusual prevalence of diabetes in southern Italy, where carbohydrates are so extensively used, and he believes that the liver is exhausted by digesting such food, while at the same time it is weakened by failure to receive proteids. This view will hardly withstand the criticism that in many other coun- tries the natives have lived for generations upon carbohydrates without developing diabetes. Among the various determining causes of the disease have been reported blows and shocks affecting particularly the nervous sys- tem, injuries to the back of the head and blows over the liver, as well as general concussion, such as that produced in railway acci- dents ; exposure to cold, wet, and fatigue ; convalescence from fevers; emotional strain, worry, mental fatigue, and anxiety. Tu- mours and haemorrhage at the base of the brain and circumscribed lesions of the floor of the fourth ventricle have been known to oc- casion the disease. Overindulgence in Food. There is some doubt whether any one article of diet can determine an attack of diabetes, although inordinate eating of candy, preserves, raisins, fruit, confections, etc., may occasionally cause temporary glycosuria. 634 DIET IN DISEASE. Bernard claimed that taking excess of starch into an empty stomach caused transient glycosuria in animals, but this observation has not been uniformly confirmed in man. Fowler wrote some time ago : *' I have been in the habit of sup- plying my classes with saccharine urine simply by taking about four ounces of dried dates or about a tablespoonful of pulverised glucose upon a fasting stomach." According to Harley, temporary glycosuria may be induced by eating asparagus. Rich food of either an animal or vegetable nature keeps the liver constantly overtaxed, and unrestrained indulgence in sweets, new wines, and sweet fruits is said to excite diabetes. Sugar may be present in the urine in the proportion of from five to ten parts per thousand, but so long as its occurrence in this manner is of brief duration, and so long as it can be immediately traced to indiscre- tion in the abuse of saccharine foods, it is of little practical signifi- cance. It has been claimed that continued eating of predrgested starchy foods containing too much glucose may result in the pro- duction of diabetes. In transient glycosuria the ingestion of excess of cane sugar does not, according to Worm-Miiller and others, produce glucose in the urine, but saccharose, and he attributes diabetes to overfermen- tation on the part of the liver. In diabetes lactose reappears in the urine as glucose, but under normal conditions if eaten in excess it causes a transient lactosuria. RELATION TO GOUT AND OTHER DISEASES. The frequent association of gout and diabetes has long been ob- served, and in "gouty glycosuria" (Brunton) comparison is made between the chronic hypersemia of the diabetic liver and the acute hypersemia of the gouty joints. Occasionally persons past fifty years of age who are gouty may present the symptom, of glycosuria without other accompanying manifestations of diabetes, such as emaciation and debility. This symptom may persist for a number of years and end in recovery, or the patient may die of some intercurrent disease in no way con- nected with diabetes. In a long series of cases of diabetes reported by Ord, gout oc- curred in over one third, and in some there was rheumatoid arthritis. In these cases not only does the urine contain sugar in excess, but the urea and uric acid are largely increased. It is interesting to remark in this connection that similar dietetic treatment benefits gouty, obese, and diabetic patients, for they live best upon a nitrog- enous diet with alkalies. The occurrence of an excess of uric acid in the urine (uricsemia) is often a forerunner of diabetes (Coignard, DISEASES ESPECIALLY INFLUENCED BY DIET. 635 Comillon). Diabetes is also often associated with neuralgia, phthisis, hepatic engorgement, and congestion. There is no one form of dis- ease of the liver in which diabetes is uniformly or frequently asso- ciated. In about one third of the cases a history is obtainable of mental strain or overwork, and in about one third there is a history of alcoholism. PHYSIOLOGICAL EXPERIMENTS. In order to understand fully the dietetic treatment of diabetes, it will be necessary to discuss somewhat at length certain physiological experiments and theoretical causes in relation to aetiology. These topics will be found to throw some light upon the relations of diet to the symptoms. The experiments of Claude Bernard above al- luded to were made to determine where the sugar which has been ingested by an animal is destroyed. Claude Bernard was the first to accurately determine the amount of sugar normally present in the blood. According to his estimate, when this quantity does not ex- ceed three parts in one thousand, the limits of health are not sur- passed, and sugar does not appear in the urine, as it promptly does when the proportion is increased. He fed animals heavily upon sugar, killed them, and examined the blood from various blood vessels. In this manner he ascertained that a good deal of sugar is destroyed by the passage of the blood through the lungs, but he also found it to be carried by the hepatic vein, while the portal vein contained a trace only. He demonstrated that the liver, excised from the body and washed free of all blood by a stream of water injected through the portal vein, would, after standing for a few minutes, still yield sugar. He thus proved that the liver is capable of forming sugar by some process which is con- tinued independently of its blood supply. He next searched for the source of the sugar formed by the liver, and discovered the sub- stance, to which he gave the name of " glycogen." Glycogen, or animal starch, is a normal ingredient of the liver cells, in which it is stored in the form of amorphous granules around their nuclei. When treated by diastatic ferments or boiled with dilute mineral acids, it is converted into a grape sugar or glucose, Hensen, of Kiel, dis- covered glycogen independently of Bernard and at nearly the same time. This substance, which is isomeric with starch, occurs in the skeletal muscles as well. Bernard also found that the quantity of sugar which he could collect from the hepatic vein at any time did not increase when the animal was fed upon a large amount of sugar; this circumstance led him to argue that the liver arrests the sug^r ingested on its way to the general circulation, and thus acts as a regulator of the amount of sugar contained in the blood. 636 DIET IN DISEASE. Man takes his food at comparatively infrequent intervals, and it is important that the energy derived from the ingestion of a large meal of carbohydrates should not be immediately expended, but should be stored in some form which will enable it to be gradually used in the intervals between digestion of meals, and in any emer- gency when food is withheld for a longer time than usual. The liver affords this means of storing a considerable amount of energy by converting the sugar brought to it in the portal system which has been absorbed from the intestinal wall into glycogen, a temporary product which is stored and held back in the liver cells, but which can be readily paid out in small quantities from time to time into the hepatic blood as it leaves the liver. In this manner an excess of sugar ingested or an excess of sugar derived from the digestion of starchy food is normally kept from immediately entering the circulation, and its use is economised by holding it back until it is required for force production. The ultimate destination of the sugar reformed from the glycogen of the liver is that it is consumed either in the capillaries or intercellular spaces or in the muscular and other tissues of the body by obscure ultimate processes of nutri- tion, which result in its splitting up into carbonic acid and water with the evolution of heat. In support of this view Claude Bernard proved that there was less sugar in systemic venous blood than in arterial blood. Bernard extracted with glycerin a diastatic ferment from the liver and blood, which he supposed had the function of converting the glycogen into glucose; this action he called the "glycogenic" function of the liver. The sugar absorbed from the intestines and arrested in the liver he supposed to be there converted into glycogen by the glycogenic ferment. Glycogen is also formed from peptones. Foster says that glycogen may be accumulated in the liver upon a mixed diet, and that it may be in part formed by dehydration of sugar derived from metabolism of proteid food. It is a fact that when diabetes is once established, the elimination of sugar in the urine will sometimes continue in both man and animals kept upon an exclusive nitrogenous diet. The foregoing experiments, verified by many physiologists, have given rise to three principal theories regarding the origin of glyco- suria, which are as follows : 1. It is due to impaired glycogenic function, and the sugar taken as a food is at once passed into the general circulation unaltered. 2. It is due to increased glycogenic function ; there is an over- production of sugar from the glycogen, the latter being derived both from sugar and peptones, and the newly formed sugar is swept into the blood. 3. The conditions of absorption of carbohydrates and of the DISEASES ESPECIALLY INFLUENCED BY DIET. 637 functional activity of the liver may remain normal, and yet the final combustion of sugar by the tissues or its assimilation by them may be imperfect and lead to its accumulation in the blood and sub- sequent appearance in the urine. The three conditions mentioned above imply either diminished activity of the liver, increased activity of the liver, or a normal liver, the fault being in other tissues of the body. , Either one will give rise to the presence of an abnormal amount of sugar in the blood (glycohaemia), which is excreted by the kid- neys (glycosuria). To aid in substantiating these theories, it should be proved: (a) That there is a definite relation between the quantity of sugar that leaves the liver and the quantity of glycogen remain- ing in the liver, (d) That the "glycogenic ferment" resembles diastase, (c) That the glucose passing through the hepatic vein is identical with the sugar which can be formed from starch by fer- mentation, (d) That there is a definite relation between the quan- tity of hydrocarbons (and peptones) entering the liver and the quantities of glycogen and glucose subsequently obtained. The ex- periments of Bernard have been in the main confirmed by other physiologists, but there is exception taken to some of them, and his theories are not universally accepted. It is probable that in the majority of cases the primary difficulty is to be found'in altered metabolism in the liver. Pavy strongly favoured the view that diabetes is due to a faulty action of the liver in not preventing the sugar which is brought to it by the portal vein from reaching the general circulation. The essential difference between the theories of Bernard and Pavy in regard to the glycogenic function of the liver concerns merely the final destination of the glycogen. Both agree as to the primary conversion of sugar from the portal vein into glycogen, but while Bernard believed that the glycogen is reformed into glucose and consumed in the tissues, Pavy held that the normal use of glycogen is in the formation of fat. Pavy believed that a small amount of sugar may be absorbed by the lacteals during the digestion of sugars or starches passing through the thoracic duct directly into the venous circulation with- out entering the liver. This he considered a normal condition. It, however, requires the use of far more delicate tests than those com- monly employed in clinical work to detect the minute traces of sugar in the urine which Pavy claimed are normally present. Pavy has lately propounded another ingenious theory to account in part for diabetes, even though other theories be not wholly aban- doned. It is that the intestinal epithelium of the villi ordinarily ex- erts a sort of glandular control over the sugar absorbed from the bowel, and converts it into glycogen and fat as it reaches the blood. 638 DIET IN DISEASE. Failure to perform this function results in the production of glyco- suria. This failure, Pavy holds, is due primarily to faulty nerve action affecting the calibre of the arterioles and capillaries with hy- peroxidation, which favours the too rapid conversion of carbohy- drates into glucose, causing glycosuria. This theory has been some- what severely criticised by Paten, and is opposed to Seegen's views, but it does not exclude belief in the storage of carbohydrates as gly- cogen in the liver it is merely accessory to it. If the liver of an animal be rapidly excised and cut into small fragments to prevent further fermentation, it will be found on anal- ysis to contain sugar in a small proportion which varies, according to different observers, between 0.2 and 0.6 of i per cent (Bernard and Seegen) ; hence but little sugar is to be found "in the liver during life, or immediately after death, and it has been suggested by Flint that whatever sugar may be found is immediately washed out by the hepatic blood stream. If the excised liver be not boiled, but be allowed to remain at the body temperature for some minutes, or if the portal circulation be suddenly cut off while the liver remains in the body, it is found that the formation of sugar continues for at least an hour, owing to a process of fermentation which produces it from glycogen. From these and other experiments it is believed that the glycogen stored in the liver is constantly but gradually con- verted into sugar, which is carried off in the general circulation in such small quantities that it is often difficult to detect its presence in the blood. Glycogen is found in the muscles, and in some other tissues of the body, and it has been suggested that sugar might be formed in the blood vessels, quite independently of the liver, by a ferment car- ried in the blood, but the hepatogenous origin of the glucose is the view generally accepted at present. THE NERVOUS SYSTEM AND DIABETES. It is a curious fact that the irritation or puncture of a very cir- cumscribed area in the floor of the fourth ventricle in the medulla is followed by the appearance of sugar in the urine. This spot is called the " diabetic centre," and it is in close, relation with the sym- pathetic and vasomotor ne.rves that control the capacity of the he- patic blood vessels. In animals in which fatty degeneration of the liver cells has been artificially produced by metallic poisoning, punc- ture of the diabetic centre produces glycosuria. Glycosuria is also observed in men after the inhalation of chloroform and in animals after the inhalation of irritant vapours and after stimulation of the pneumogastric nerve. Schiff produced glycosuria experimentally by" the removal of the spleen from animals, but it does not follow this operation in man. He also tied off successive portions of the liver DISEASES ESPECIALLY INFLUENCED BY DIET. 639 from connection with the circulation, and found the production of sugar proportionately decreased. The frog is capable of surviving extirpation of the liver for three weeks, and at the end of this time no sugar is found in the blood (Schiff). If the vagus nerve is di- vided in the neck, or if the spinal cord be divided above the origin of the great sympathetic nerve, diabetes may result. Bernard sug- gested that glycosuria might be cured if it were possible to galva- nise the sympathetic nerves. The foregoing experiments demon- strate that glycosuria may be caused by a variety of nerve lesions and irritations. It is also frequently associated with modifications in the activity of the hepatic circulation. THE CIRCULATION AND DIABETES. The occurrence of diabetes in connection with acute inflamma- tions of the liver and passive hepatic congestion secondary to ad- vanced cardiac disease favours the hypothesis that glycosuria may be developed by an increase in the amount of blood flowing through the liver, which is thereby stimulated to an active conversion of its glycogen into sugar, or else the blood passes so rapidly through the liver that the sugar absorbed from the food by the branches of the portal vein does not have time to be converted into glycogen, but goes through the liver into the general circulation unaltered. Thus, whether the glycogenic function be increased or diminished in gly- cosuria, either condition would demand altered activity of the portal circulation. VARIOUS THEORIES OF DIABETES.* Huppert, Pettenkofer, and Voit advocate the following theory : Sugar, like urea, is a normal product of the decomposition of albu- minous bodies. In health the sugar is oxidised; in diabetes less oxygen than normal is absorbed, owing to the destruction of the red blood-corpuscles occasioned by malnutrition ; therefore sugar accumulates in the blood. Sugar is formed from the albuminous constituents of the body which undergo rapid chemical change. This fact they regard as proved by the increase in the quantity of urea eliminated. Von Mehring found sugar in the urine of a dia- betic patient after a twenty-six hours' fast. Porter believes that the renal epithelial cells, which he claims are frequently enlarged in diabetic patients, take an active part in the manufacture of glucose because the blood of diabetic patients never contains enough sugar at any one time to account for all which is found in the urine. The epithelial cells are supposed to manufac- ture the sugar out of carbon dioxide and water. This theory lacks confirmation, however, and it should be observed that a very small amount of sugar, which furnishes a mere trace in the blood at any 43 640 DIET IN DISEASE. one time, but which is constantly eliminated from the large quantity of blood continually passing through the kidneys, may amount in the course of twenty-four hours to a number of grammes. In view of the established facts in regard to the glycogenic function of the liver, it seems wholly unnecessary to believe that the renal epithe- lium exercises any special metabolic power in diabetes; moreover, the kidneys may appear quite normal in severe cases of diabetes. Brunton reports several cases due to the presence of a tape- worm. He thinks that the increased appetite caused by the presence of the worm may have been instrumental in causing the glycosuria from overeating, but it is possible that the peripheral irritation of sympathetic nerve fibres may have been conveyed to the diabetic centre in the medulla, and thence reflected to the vasomotor system of the liver. Some recent experiments and clinical observations justify the belief that the skeletal muscles play a more important role in the production of diabetes than has heretofore been supposed. During their activity they normally consume glycogen in con- siderable quantity. If they fail to perform this function properly, it accumulates in the system. Kiilz has shown that muscular activity favours the consumption of sugar in the organism of the diabetic, and that much less sugar is eliminated while such patients are taking vigorous exercise. It must be admitted that there are many hepatic diseases and lesions in which a large part of the secreting surface of the organ is destroyed, and in which glycosuria may never be present, but in these conditions it is possible that while a part of the liver is totally destroyed there may be some remaining cells which are still endowed with normal functional activity, whereas in the disease under discus- sion it is probable that none of the parenchyma of the liver main- tains its normal control over metabolic processes, and hence, what- ever sugar is brought to the organ by the portal vein passes into the general circulation unaltered. In the graver forms of diabetes, in addition to the functional disturbances of the liver, there is believed to be present also a condition of malnutrition in which sugar either fails to be consumed or, as suggested by Yeo, " we may suppose that in these cases a morbid ferment is formed in the system, possibly in connection with some radical fault of stomach or intestinal digestion, and that this determines the rapid reconversion of glycogen into sugar." Symptoms. The most important symptoms of a typical case of diabetes which are to be combated by diet are (a) extreme thirst, {b) the large quantity of urine voided and rapid emaciation and loss of strength. {a) Thirst. The Mouth. Thirst becomes extreme, and is not DISEASES ESPECIALLY INFLUENCED BY DIET. 64I quenched by drinking, although patients will drink almost any avail- able fluid even their own urine in their endeavour to relieve it. The absorption by the blood vessels of fluid from the tissues is held to be the main cause of this extreme thirst (Vogel), which is most intense one or two hours after meals, when sugar formation is most active, and ten or fifteen quarts of water may be consumed daily if patients are not restrained from drinking freely. The saliva is thick, frothy, and acid, and often contams sugar. The mouth becomes sticky or dry, even to the extent of interfer- ing with articulation, and there is often a sweetish taste, which may be accounted for by the sugar present in the saliva and the blood of the capillaries which circulate among the taste bulbs. The tongue is at first moist and sticky and coated with promi- nent papillae; later it may become dry, dark red, and fissured. The appetite is at first excessive ; it amounts to bulimia in some cases ; at other times it is capricious or intermittent, and subsequently it fails completely when the digestion becomes impaired through the symp- toms of gastric and intestinal catarrh. [b) The Urine. The average quantity of urine voided is between two to three times the normal amount that is, from 3,000 to 4,500 cubic centimetres. If water is being drained from the tissues the quantity of urine voided may exceed the amount of fluid ingested, but obviously tiiis condition cannot last very long. Exceptionally as much as 5,000 to 10,000 cnbic centimetres or more may be voided within twenty-four hours. Frequent calls to micturate at night greatly interfere with the patient's rest. As a rule, the more sugar present the paler is the urine, and it grows turbid soon after standing, from the development of yeast fungus [Torula cerevisid), derived from the atmosphere. The sediment, if present, is usually light, and the odour may resemble whey or hay. The urine is sweetish ; the reaction is usually quite acid, but may be neutral or alkaline, and the acidity is usually proportionate to the quantity of sugar ; it is increased by develop- ment of carbon dioxide and acetic acid, products of fermentation. After standing it does not become alkaline from ammoniacal fermen- tation, but undergoes saccharine fermentation. In a majority of cases the specific gravity is considerably higher than the normal, rising to between 1.035 ^"^ 1-050 or more. Bouchardat reports a case with a specific gravity of 1.074, and Pavy one with a specific gravity as low as i.oio, which is certainly exceptional. The specific gravity rarely falls below this limit if any sugar is present, but it has been found as low as 1.002. It should be remembered that the quantity of urea present as well as sugar affects the specific gravity. The urea is proportionate to the amount of proteid food elements ingested, and as patients are usually fed upon nitrogenous food, urea 642 DIET IN DISEASE. is naturally increased beyond the normal average. Sometimes two or three times the normal quantity is excreted. Urea, however, always exists in small proportion in comparison with the whole quantity of urine voided. There are some instances in which there is appar- ently an increased waste of the albuminous tissues of the body, resulting in the production of more urea. The quantity of sugar present varies greatly; an average may be stated as from thirty-two to thirty-five parts per thousand of urine, but the total may even exceed five hundred grammes /(?r diem. The effect of a heavy meal of starchy food in increasing the sugar is promptly shown by the urine, usually within two hours, and it lasts during several hours. In some cases very little sugar is eliminated, and yet the symptoms are very severe ; in others a great deal is voided and the symptoms are not at all severe, but, as a rule applying to a majority of cases, the severity increases or dimin- ishes with the quantity of sugar passed. After grape sugar has dis- appeared during dietetic treatment, inosite is sometimes found in the urine, as in simple polyuria. Other substances found occasionally in connection with sugar are acetone, alcohol, or peptones. More or less albuminuria is observed. While dietetic treatment is in progress the urine should be period- ically tested with careful relation to the ingested food, and speci- mens should be examined which are passed from two to four hours after eating various articles of diet in order to observe as exactly as possible the influence of such diet upon the elimination of glu- cose. The Skin and Bowels. Because so much water is eliminated in the urine there is scarcely any perspiration, and the skin becomes dry and wrinkled, the face looks drawn and pinched, and the eyes are hollow. In advanced cases a sweetish, sickening odour is ex- haled from the skin and in the expired air. From lack of intestinal secretion the bowels are usually constipated, although diarrhoea may alternate with constipation in the later stages of the disease. Hunger. At first the food eaten does not supply the needs of the body and there is constant craving for more. To obtain the requisite carbon from fats a labourer, taking his ordinary allowance of proteids, would in addition have to eat about three hundred and fifty grammes of fats, which would be manifestly impossible. The diabetic is practically in this position when all carbohydrates are denied him, and a much larger bulk of food is necessary for him than if he could eat food containing more carbon but less proteid. This accounts in a measure for the extreme hunger which is felt by many diabetics when suddenly deprived of their ac- customed starchy foods. Some writers attribute the diuresis to the increased consumption of albumins which is necessitated. DISEASES ESPECIALLY INFLUENCED BY DIET. 643 Later Symptoms. In the later stages of the disease dyspeptic symptoms are prominent with flatus, sour eructations, and a disgust for all kinds of food. The teeth decay, the gums become tender, and mastication is difficult. The alimentary canal is frequently the seat of chronic gastric catarrh, with thickening of the mucous lining of the stomach and small intestine. Diarrhoea may be caused by the excretion of sugar from the intestinal mucous surface. Occasionally nausea and vom- iting are present, and the ejecta may contain acetone. The secre- tion of bile is lessened. Emaciation sooner or later becomes extreme and progresses, although the appetite remains normal or may be still increased. The loss of weight, which is so pronounced a feature of most advanced cases of diabetes, is attributed in part to the non-burning of carbohydrates, and in part to the loss of their albumin-protecting action (Graham Lusk), In health, oxygen is used to consume sugars, which in diabetes, when sugars are withheld, burns the fat of the body instead, so that the quantity of oxygen inhaled and carbon dioxide exhaled may remain nearly identical in the two conditions, while emaciation progresses. In addition to lack of nitrogen of the tissues the wasting is also in part to be accounted for by the drain of fluid from the system which takes place when once over- action of the ki^dneys is established. Phthisis is often present and increases the rapidity of the emaciation. Exceptionally, early in the disease the patient, owing to the greater appetite and the large amount of fluid drunk, may increase somewhat in weight. Muscular weakness and debility rapidly supervene to a greater extent than is to be accounted for by the usual loss of flesh. In general, it may be said in the milder forms of diabetes that the sugar in the urine is derived from carbohydrate foods, while in the more serious forms it is also derived from the nitrogenous metab- olism. The sugar which is eaten as food or which is formed by starch in the alimentary canal, after absorption is mainly used under normal conditions in the production of force, but in diabetes it is eliminated unaltered from the body, and there is consequent lack of heat production and muscular power. Since a large amount of heat-producing material passes from the body without complete oxidation, the body temperature is not in- frequently subnormal, and it may so remain throughout the disease unless there be some inflammatory complication. The axillary tem- perature may be 97 or even 95 F. The occurrence of any acute joint or visceral inflammation or of any acute fever causes a reduc- tion in the quantity of sugar eliminated while the pyrexia lasts. The explanation of this fact is by some observers thought to be due to 644 DIET IN DISEASE. increased combustion of sugar in the body during the pyrexial stage, but Bernard attributed it to an interference with the glycogenic function of the liver. The pulse becomes rapid and feeble and the temperature is subnormal. When great feebleness compels the patient to become bedridden, bedsores and excoriations from frequent passage of acid and sac- charine urine add to his discomfort. Diabetic coma is the precursor of sudden death in a certain num- ber of cases, and it is also to be regarded as the worst possible symp- tom which may arise. Many theories have been offered in explana- tion of this symptom, and the one which is at present in vogue is that it is produced by the accumulation of acetone in the system (acetonsemia). Acetone is also observed in other forms of disease, and although it may be present in the expired air, urine, ejecta, or blood of diabetic patients, it is not invariably found. When present it is a very serious symptom. Gangrene, asthenia, or intercurrent diseases cause a number of deaths. There are other symptoms affecting the nervous system, the eyes, etc., and there are many complications which may arise in the course of the disease, but a consideration of them would lead too far from the object of the present discussion, which is to deal with those symptoms which bear a more immediate relation to the metabolism of the food. Some of the complicating diseases with which diabetes may be associated make it impossible to adhere to a rigid regimen without producing more harm than good. Such, for example, are acute gout and chronic nephritis, in both of which a meat diet is injurious, and if carbohydrates are also cut off the patient has little or nothing left to eat. In these cases the diet must be determined by the graver complication (see page 470). Course. The course of diabetes is so protracted that there is abundant opportunity and usually necessity for trying dietetic ex- periments, for it will be found impossible to establish rules for die- tetic treatment to which exceptions may not arise from time to time in the course of any individual case. The disease is sometimes well established long before its symptoms become. sufficiently urgent to attract the attention of the patient. Persons who believe themselves to be in perfect health and who apply for life-insurance examination may be informed for the first time of the presence of glycosuria, and many cases are now discovered through incidental examination of the urine in connection with some other disease, which would have been overlooked a few decades ago, when clinical urinalysis was very imperfect. If treatment is begun before the symptoms are well advanced the lives of many patients may be prolonged in some cases for more DISEASES ESPECIALLY INFLUENCED BY DIET, 645 than ten or twelve years whereas, of seven hundred cases reported by Prout which occurred over thirty years ago, only two lived be- yond ten years. Frerichs reported one case which extended through twenty years and several more in which the disease lasted between ten and eighteen years. Occasionally diabetes is extremely acute, and may prove fatal within three weeks, but in such instances it is probable that glycosuria has been present for a long time with- out discovery. Prognosis. Between 50 and 60 per cent of all cases are fatal in less than three years; undoubtedly a few which are recognised- sufficiently early may be completely cured, but glycosuria, like al- buminuria, indicates a weakness of the system in a special direc- tion, and, the disease having once occurred, the patient should be under reasonable supervision for many years. It has been aptly said that " the only chance that a diabetic has of being cured is to believe that he never is cured" that is, to be constantly on the alert to avoid all indiscretions in hygienic and dietary matters. There seems to be a relation between the general bodily nutrition and the chance of recovery or improvement. Usually stout, middle-aged men yield best to treatment; thin persons withstand the disease less well, and rapid emaciation is always more to be dreaded than the presence of sugar. The prognosis is more favourable in those cases which are readily amenable to the influence of a strict dietetic regi- men. The prognosis is more favourable if the sugar does not speedily return if the dietetic treatment be interrupted, and also if the amount of urea excreted is large and the quantity of uric acid small. Cases which occur in connection with gout are relatively light. In emaciated cases the malnutrition is so great that the pa- tients easily acquire other diseases, especially pulmonary tubercu- losis, and many die from complications rather than from the imme- diate effect of the disease itself. Diagnosis. Temporary glycosuria may be caused by a variety of conditions, such as excessive indulgence in sweets, poisoning from amyl nitrite, mercury, chloroform, alcohol, etc. It has been ob- served during pregnancy and after anthrax, diphtheria, scarlatina, typhoid fever, etc. In the transient form of glycosuria the urine contains much less sugar than in diabetes mellitus, and all the severe symptoms of excessive thirst, emaciation, and extensive tissue waste, leading to local disease and usually death, are wanting. In polyuria or diabetes insipidus there is no sugar in the urine, and the specific gravity is very low 1.002 to 1.005. Primary peptonuric diabetes is described by Quinquand as a dis- ease presenting the clinical features of niellituria thirst, marked cachexia, polyuria, etc. but instead of sugar, the urine contains peptones; it polarises to the left, and is of low specific gravity. 646 DIET IN DISEASE. Temporary lactosuria sometimes occurs as an accompaniment of the puerperal state, and is not of special dietetic significance. Treatment. The treatment of diabetes to-day is much more successful than it was thirty or forty years ago, when every case was regarded as necessarily fatal. The treatment should be (i) prophy- lactic, (2) dietetic, (3) hygienic, and (4) medicinal. Prophylaxis. Until more is known of the aetiology of dia- betes definite prophylactic rules cannot be established ; but in gen- eral, where there is distinct heredity to be feared, or when the lithic- acid diathesis exists, all excitement of the nervous system, mental or physical, as well as indulgence in alcohol and sweets, should be strenuously avoided. Dietetic Treatment. General Observations. When pre- scribing any dietetic regimen for diabetic patients, the general con- dition of bodily nutrition must be carefully considered. Obese, naturally robust, and sometimes gouty patients will be benefited by very strictly limited and carefully regulated diet, but emaciated and feeble patients cannot always endure the severity of a strict diabetic diet without too great loss of vitality, and it becomes necessary to maintain their strength even at the cost of sometimes increasing the amount of sugar in the urine. Obese persons make their fat largely out of carbohydrates, and hence a nitrogenous diet is particularly well suited to their condition, whereas emaciated, weak patients gain no flesh upon an exclusive nitrogenous diet, and it may barely sup- port life for them. Some persons with diabetes have been said to excrete more sugar on a diet of animal food than on the hydrocarbons, but it will gener- ally be found that such patients have eaten some farinaceous food, bread, etc., with their meat, and the combination seems particularly favourable to the maintenance of a secretion of saccharine urine once established. Regulation of the diet should be faithfully tried before any medi- cation is resorted to, for the latter frequently becomes superfluous, but a placebo may be given if necessary. During the siege of Paris in 187 1 it was observed that a number of diabetics improved consid- erably owing to the enforced restriction in their diet (Bouchardat). Cantani advises a preliminary fast of twenty-four hours before commencing dietetic treatment, but the value of this expedient is questionable. Phenomenal improvement follows in many cases upon a diet which excludes starches and sugars almost completely, but this is a difficult regimen to enforce, for the craving for carbohydrates espe- cially for bread, becomes so fierce that patients whose veracity is otherwise unimpeachable will resort to lying or any form of decep- tion to obtain this coveted food. DISEASES ESPECIALLY INFLUENCED BY DIET. 64/ It is a matter of common experience that the most difificult of all food for a man to be deprived of, when once accustomed to it, is bread. This has always been found to be the case in arctic expedi- tions in which men have been reduced to a starvation dietary, and it is usually observed in any form of largely restricted diet, although patients who are living upon an exclusive diet of milk appear to have somewhat less craving for it than diabetics, who are allowed a greater variety of food, especially meat. This is due in part to life- long association of certain kinds of food with one another at meals and the habit of eating this one article of food with more constancy than any other, but it is also undoubtedly referable to a positive craving of the system, which is particularly marked in diabetes, for a kind of food which the tissues need but cannot assimilate. For this reason it is generally advisable to allow patients from two to four or even six ounces of bread a day in divided portions; other- wise the craving for it does them positive harm, and a loathing for all food results, or they break all restraints and injure themselves more by overeating. It should be remembered that diabetic patients are very sus- ceptible to the influence of the nervous system, and that worry and anxiety about themselves, with too close an observation of their own diet, will often react unfavourably. Moreover, it is undoubt- edly much harder for these patients to restrain themselves from eat- ing varieties of Food which are not wholesome for them if they sit at a general table where others are indulging in various luxuries of the season. It is sometimes possible for them, as has been proved by Cantani, to maintain good health for many years upon a strictly nitrogenous diet, but in attempting to enforce any rigid dietetic sys- tem one is compelled to have some regard for the environment and general habits of life of the patient, and it is easy to make the indi- vidual so miserable by too harsh rules as to defeat the very object in view, and the adoption of a too restricted system of diet may result in disastrous failure. For these reasons it is now customary to allow patients a more liberal dietary in diabetes than was at first permitted after the discovery of the real nature of the disease and the influence of carbohydrates upon it, but they should always be given carefully written directions as to what articles they may eat and what must be avoided. While it is necessary to secure the intelligent co-operation of the patient in regard to carrying out his treatment, it is highly undesir- able that he should devote too much time and attention to it, and, when possible, it is better to have some one else select and provide food for him in order that his mind may not be constantly occupied with questions of dietetics which tend to restrict the appetite, and, sometimes to materially interfere with the beneficial effects of the 648 DIET IN DISEASE. diet. There is the more need for supervision of the diet by a second person, because the craving of diabetic patients often attains an ascendency over their will power and habits of truthfulness; in fact, a lack of mental force and even imbecility are quite characteristic of the advanced disease. Deception should be suspected in those cases in which there is more urine passed than is to be accounted for by the quantity of fluid allowed in the diet, and in those cases which apparently ought to improve upon dietetic treatment, but in which after repeated trials no headway is made in regard to controlling the amount of sugar in the urine. I have known hospital patients to steal bread and potatoes and consume them surreptitiously in spite of repeated warnings, and also to acquire such a craving for fluid as induced them to drink their own urine. With regard to the suddenness with which the diabetic regi- men should be adopted by the patient, it is found to be the rule that it is easier for most patients to begin with the fully restricted diet at once than to gradually eliminate one article after another from the menu. The urine should always be thoroughly examined, both qualitatively and quantitatively, for sugar, urea, and albumin, before the restricted diet is commenced, and periodic examinations must be made during the course of the treatment in order to deter- mine the effect upon the disease of withholding difl^erent articles of food and drink. At first it is well to make such examinations daily, and subse- quently, if the patient is doing well, once or twice a week is suf- ficient. The effect of no dietetic system is immediate, and at least two days may be required for the patient to come fully under the influence of treatment, because the materials already present in the body when the new diet is commenced may serve as a source of sugar for some little time afterwards. The general principles for the dietetic treatment of diabetic pa- tients are, first, to exclude from the diet, when possible, all those articles which are most likely to result in the formation of sugar ; secondly, to devise means for relief of the craving for starchy and saccharine foods which patients kept on a nitrogenous diet are cer- tain to experience before long, and to see that while reducing the amount of sugar in the food, the patient is not suffering to a danger- ous extent from lack of nutrition. It is difficult to formulate rules of diet which can be adhered to in all cases. There are many pa- tients confined to an exclusive nitrogenous diet who lose flesh and strength so rapidly that although the advantage of reducing the glycosuria is attained, a new danger arises from anaemia and emacia- tion. DISEASES ESPECIALLY INFLUENCED BY DIET. 649 For convenience of description of dietetic treatment cases of diabetes may be subdivided into three classes : (o) Those patients who pass a considerable quantity of urine containing a large percent- age of sugar, but in whom the general health is still good, (d) Cases in which, in addition to the passage of considerable sugar in the urine, there is more or less dyspepsia, emaciation, and debility, (c) Cases in which the constitutional symptoms become rapidly severe after the first appearance of sugar in the urine. (a) In the first class of cases the dietetic treatment is productive of the greatest benefit, and not rarely the patients begin to gain flesh and strength ; they sleep better ; the daily quantity of urine falls perhaps from three hundred ounces to seventy, and it approaches the normal composition ; the excessive appetite and thirst diminish ; the digestion improves, and in one to three weeks the sugar may en- tirely disappear. Such patients are not to be regarded as cured, however, as soon as the sugar disappears not, in fact, until they can eat starches in ordinary quantity without exciting the appearance of glycosuria. According to the statement of Dujardin-Beaumetz, pa- tients of this class may be cured who have been eliminating as much as three thousand grains of sugar />er diem. Whenever sugar, or amylaceous food absorbed as sugar, passes through the circulation unaltered, it is of no value to the system, and, as Bauer says, it serves merely as "useless ballast." {b) The secoftd class of cases is also amenable to dietetic treat- ment, but the benefit is not so immediate and usually not so great as in the first group, and it may be impossible to cause the total dis- appearance of the sugar, although it may be reduced to two hundred or three hundred grains a day. When the amount of urine is less- ened by the changes of menu, the specific gravity remains high, and sugar is abundant, the prognosis is very grave. The patient cannot tolerate the diet, and drugs must be resorted to. [c). In the third and most severe class of cases dietetic treat- ment is sometimes of avail, and it should be always undertaken, for it may prevent the patient from becoming worse, although it is un- able to accomplish a cure. But usually the treatment of these cases is unsatisfactory, be- cause the patients, who are often young subjects, continue to form sugar from nitrogenous food after starches and sugars have been proscribed, and it is practically impossible to devise any special com- bination of food, or to find any single food upon which they can sup- port life and from which they are not able to produce sugar. Their nutrition is extremely poor, and they go rapidly from bad to worse. Not seldom they are thin, neurotic subjects when the disease first attacks them, and therefore have very little capital to draw upon. In extreme cases a careful comparison between the amount of food 650 DIET IN DISEASE. ingested and sugar eliminated has furnished evidence that they are even capable of manufacturing sugar or glycogen out of the muscu- lar tissues of their own bodies. A clinical comparison of the different varieties of diabetes above described, with the theories which have been discussed in regard to the possible method of the production of the disease, emphasises the conclusion that cases of diabetes may not all have exactly the same aetiology. By different writers all gradations of diet have been recom- mended, so long as the carbohydrates are restricted, from the ab- solute meat diet of Cantani to the skim-milk diet of Donkin and the more liberal menu of the majority of authorities. Some patients who have a very good appetite when allowed a mixed diet lose it altogether when put upon an exclusive nitroge- nous regimen. There are those who can live contentedly on an ex- clusive diet of proteid food and fats for a certain length of time say ten days or a fortnight if the principle of the treatment be ex- plained to them and they are anxious of being cured, but sooner or later they almost always find it intolerable to wholly abstain from starchy and saccharine foods, and the craving for such articles in some cases is so great that the patient's moral nature suffers se- verely. Many prefer to live less long, but in more comfort than such restriction implies. This is probably attributable more to long-continued habit or heredity than actual inability to support life on a purely nitrogenous diet, for, as stated elsewhere (page 292), the Eskimos thrive upon a diet absolutely free from starches and sugars of every kind. It is believed by Ebstein and others that an exclusive meat diet may be injurious on account of a tendency to produce acetongemia, and it may favour the increase of uric-acid deposits in those having the uric- acid diathesis. To obtain enough carbon from such a diet for the needs of the system, a very large quantity of proteid food must be consumed. When chronic nephritis complicates diabetes the difficulty of diet- ing is much enhanced, for meat is injurious for the nephritis, and starches are prohibited in diabetes. This condition has been aptly described as the " Scylla and Charybdis of the diabetic." As a com- promise such patients must usually be put upon a milk diet. Dujardin-Beaumetz states that when the quantity of sugar elimi- nate^ falls to ten grammes a day, less rigorous withholding of starches is needed. In prolonged cases it will usually be found that patients do better with occasional variation in their diet, even if it involves giving a little amylaceous food for a few days. Mild cases of diabetes seldom occur in children, hence the diet DISEASES ESPECIALLY INFLUENCED BY DIET. 65 1 for them must be even more closely confined to proteids than for adults. A fair sample diabetic menu is- the following (Pepper, Medical Record, New York, 1884, vol. xxv, p. 11) : Breakfast or Supper. Tea, lemonade (no sugar), soft-boiled eggs, broiled chop, beefsteak or any fish, raw tomatoes or onions with vinegar, a very little toasted bread or biscuit, butter, cream. Dinner. Meat (fat), string beans, cauliflower, lettuce, game (ex- cept their livers), cheese, nuts (except peanuts and chestnuts). Many elaborate diet tables have been prepared, and for those whose means permit of indulgence in delicacies considerable variety may be secured without the use of carbohydrates ; but for the poor in hospitals and at home it is a difiicult problem to furnish inexpen- sive variety without occasional recourse to starchy foods. Foods allowed in Diabetes. Soups and broths made of meat of any kind without vegetables, ox- tail and turtle soup, gumbo, curry. ggs in any form. Crustaceans, crabs, lobsters, shrimp. Fresh fish of all kinds and fish roe. Caviare, anchovies. Salt fish, cod, mackerel, and herring may be allowed, unless they increase thirst too much. Fresh meat, fowl and game of all kinds. Ham, bacon, smoked beef, tongue, sweetbreads,- kidneys. Fats. Olive oil and all animal fats and oils, such as butter, cream, cod-liver oil, bone marrow. Some authorities, however, ex- clude all fats. Senator objects to them on the ground that they form glycerin. Cantani excludes butter because it may contain some milk sugar. But usually such rigidity is unnecessary. In some dia- betic patients the power of fat digestion is apparently increased, so that they tolerate larger quantities than in health. Vegetables. Spinach, cress, sorrel, chicory, rotnaine, dandelions, beet tops, horseradish, radishes, celery, sea-kale, artichokes, vegetable marrow, okra, lettuce, endives, pickles, cucumbers, gherkins, cran- berries. The following vegetables are allowed by some writers, pro- hibited by others : Green French string beans, asparagus, summer squash, onions, leeks, carrots, cauliflower, cabbage, sauerkraut, cole- slaw, kohl-rabi, parsley, parsnips, eggplant, artichokes. Osier says that because potatoes contain somewhat less starch than is found in bread they may sometimes be allowed in moderation when the latter is found to disagree. Germain S^e gives five ounces of potato meal daily as a substitute for bread. The following statement made by Fagge is useful : " The general rule is that all white parts of vegetables in which chlorophyll has not 652 DIET IN DISEASE. been developed by exposure to sunlight contain no sugar, and are not harmful. But by boiling in a large quantity of water, even the forbid- den kinds of vegetables, if they contain sugar only and not starch, may be rendered much less injurious." There is a decided advantage in using such green vegetables as are allowed in diabetic diet on ac- count of their adding to the bulk of waste matter in the intestine and preventing constipation, which almost inevitably results from a meat diet. Miscellaneous. Kidneys, tripe, pig's feet, truffles, mushrooms, sweetbreads, terrapin. Cheese, cream cheese, milk curds. Jellies made of gelatin, calf's foot, with wine, but unsweetened except with saccharin, coffee jelly, lemon jelly. Van Abbott recom- mends an ivory jelly made from ivory. Fruits, if acid, not sweet. In England, where gooseberries are eaten much more than in this country, they, as well as apples, red currants, and sour cherries, are sometimes allowed. Many of these fruits contain more levulose than grape sugar. Sour oranges, lemons, grape fruit, olives, sour apples, peaches in brandy (without sugar), raspberries, and strawberries are allowed by some, but are usually forbidden. Muskmelons and watermelons may sometimes be eaten. Nuts. Oily nuts, such as almonds, walnuts, Brazil nuts, hazel- nuts, filberts, pecan nuts, butternuts, cocoanuts. The articles above enumerated afford considerable choice, and it is to be distinctly understood that only so many of them are to be allowed at a time as may serve to divert the craving of the patient from his chief enemy concentrated hydrocarbons. Some patients will be found who can eat any of the above articles with impunity, while others can take but very few, and others can consume certain foods for a short time without increasing their sugar elimination, which suddenly will be found to agree no longer, when some other food must be at once substituted. It is apparently true that there are some individuals for whom one or two articles of starchy food can be found which do not produce sugar in the urine. Fothergill reports several cases of this kind. One of his patients passed urine free from sugar while eating vermicelli pudding and arrowroot. Another one took raspberry jam with im- punity. When such cases are thoroughly investigated, however, it is usually found that they have reached an intermittent period in the activity of the disease which is not infrequent in this chronic affec- tion, and in which for the time being the patient is very much better, and the urine remains for a little while practically normal. Such in- stances occur in the milder types of cases. The following articles are absolutely DISEASES ESPECIALLY INFLUENCED BY DIET. 653 Forbidden Foods. Sugar in any form sirups, molasses, confectionery, jams, and sweets of all kinds. Honey is forbidden, for it contains both dex- trose and levulose. Starches. All the elementary forms of starchy and farinaceous food, such as rice, sago, tapioca, arrowroot, oat meal, corn meal, hom- iny, samp, buckwheat, barley, semolina, macaroni, spaghetti, vermi- celli. All pastry, cake, puddings, pies of every description in short, everything made of flour excepting a little bread as specified above. Vegetables. Potatoes, beets, carrots, parsnips, turnips, peas, beans (except string beans), lentils, cauliflower, broccoli, Brussels sprouts, rhubarb. Some writers, like Dujardin-Beaumetz, occasionally allow a well-baked potato in mild cases. It contains only 15'/^ per cent of starch, or one fifth as much as rice, and one half as much as peas and beans. Shellfish. The soft parts or livers of clams, oysters, and mussels contain glycogen. By some these foods are entirely forbidden, but many diabetic patients can take them occasionally without injury. Liver of all animals (it contains g\ycog&n), jt>dt^-de-/oie-gras. Fruits. In regard to the use of fruits there is some difference of opinion. Sweet fruits, such as figs, dates, plums, prunes, bananas, apricots, all preserved, candied, or sugared fruits must be absolutely interdicted. Pears, melons, and berries are forbidden by many, but allowed by others. Nuts. Chestnuts, peanuts. Substitutes for Bread. After all, the problem for selecting a suitable starchy food for the diabetic is governed as much by the necessity of furnishing some form of food which will satisfy the craving for farinaceous material as for the actual nourishment which it may contain. The most difficult of all starchy food for the patient to forego is bread. Much ingenuity has been expended in attempts to devise substitutes for it, and many preparations for making artificial breads, biscuits, rusk, or cakes with eggs and butter are sold in market for this purpose. Some of these are palatable for a time, but many have been found to contain 60 or 80 per cent of starch fully as much as wheaten bread while others contain no nutriment at all. Some authorities, as Germain S^e and Dujardin-Beaumetz, advise giving potato meal instead of bread, five ounces per diem, which may be cooked in any form without sugar. Terrified starch may be used by somCvdiabetics. The starch is prepared by baking a large ball of flour so thoroughly that the starch granules in the interior of the mass are burst open by the 654 DIET IN DISEASE. heat. Terrified bread or toast consists of thin cut pieces of bread which are toasted through and through until almost black before a hot fire until both the gluten and the starch are disorganised to some extent. Well-browned bread crust is of the same nature. The breads made from flour especially prepared for diabetics are: (a) Gluten bread; (^) bran bread; (c) almond bread; {d) inu- lin bread ; (e) soya bread. (a) Gluten Bread. Gluten bread was first used by Bouchardat. It is made by washing wheat flour in such a manner as to remove the starchy granules, leaving the gluten behind. Such bread is cer- tain to contain more or less starch, and not seldom it has both starch and sugar. It is much more tiresome to eat than any ordi- nary bread, and unless prepared by a very reliable manufacturer it has little to recommend it. It is not pleasant to masticate, for it is often unpleasantly tough and stringy. It is difficult to panify, but it may be aerated. Gluten biscuits are more palatable than gluten bread, but most of these preparations have the disadvantage of not keeping fresh for more than a week or ten days. 6^// ^^(\ -^^ - -^ Causation. Scurvy is a disease dependent upon malnutrition, which is customarily attributed to lack of fresh vegetables in the dietary ; but this statement is somewhat vague, in that it is not ex- actly known which articles of diet are most liable to produce the disease by their absence, although many believe that the cause is due to deficiency of salts whose acids citric, malic, lactic, acetic, and tartaric form carbonates, but no preventive food has been found which is absolutely successful in all cases. At all events, it is a disease due to omission and not to consumption of certain foods, and it depends rather upon the quality than quantity of food. In opposition to the theory that the want of fresh vegetables acts as a cause of scurvy in a man, the fact is stated by Lieutenant Greely that among the Danish Eskimos, who have a population of ten thou-, sand, not a pound of vegetables nor a dozen pounds of bread per man are eaten annually, and yet they are practically free from the dis- ease, and the same statement is made in regard to the most northern tribes of Eskimos of pure blood who were studied by Lieutenant Peary, and also in regard to the natives of the Alaskan archipelago and some tribes of North American Indians who do not include either vegetables or bread in their food. It is an undoubted fact that the disease is much oftener present among people who have lived for some time in bad hygienic surroundings and in damp, dirty quarters, and who have been subjected to mental depression, monotony of occupation and diet, or excessive work and fatigue, as well as the abuse of alcohol. It has often been known in prisons. It is therefore possible for scurvy to occur in any part of the world among men affected by these conditions, but it is much less common at the present time than formerly. In the British arctic expedition of i875-'76 over 48 per cent of the men suffered from scurvy, and a still larger percentage existed among those who were exempt from field service and outdoor life. When the potato crop failed in Great Britain and Ireland in 1846 scurvy became very prevalent. In the war of the Grimea twenty- three thousand cases occurred among the French troops alone. Woodruff, referring to scurvy in the United States Army, writes : " If transportation is so deficient that only bacon, hard-tack, and coffee can be carried, actual scurvy is the result. The company commander must secure something else for his men. The lack of DISEASES ESPECIALLY INFLUENCED BY DIET. 669 fresh vegetables and fresh meat is the chief fault. Why fresh things are needed is not known, but it is believed to be due to the fact that the body thus received certain salts and unknown substances neces- sary as stimulants or tonics to the tissues, which salts and substances are destroyed by the usual methods of preservation. It is not to be denied that men may live for many years without tasting such articles of diet, though it is rare for a man to be denied all three meats, fresh vegetables, and fresh fruits. If they are so denied they are not pos- sessed of that health which permits of the highest mental and physi- cal development." Scurvy contributed 15 per cent to the death rate from diseases in the late civil war, and it was formerly prevalent among seafaring men when upon long voyages, who lived upon salt pork or pickled meats; but the disease is encountered much less often at the present time, owing to the better means of preserving foods, securing variety in diet, and better hygiene. The regulations of boards of trade usually require that antiscorbutic foods and remedies should be carried upon vessels, and the development of scurvy on board ship, unless in exceptional cases of shipwreck or in voyages prolonged beyond the expected limit, subjects the captains or owners to indict- ment for criminal negligence. The English law early required that lime juice should be carried on long voyages, and this formerly earned the nickname of " lime juicers " for British sailors. Many almshouses have similar regulations. Scurvy has been known to occur from failure of intestinal absorp- tion, in which case it is less easily preventable. Garrod holds that scurvy is caused by absence of potash, for^in this disease the blood is deficient in potassium salts. He regards this fact also as an explanation of the muscular weakness which is a prominent feature, and observes that all good antiscorbutics fresh milk, meat, lemons, and fresh vegetables contain abundant potash. Garrod's theory is modified by Immermann, who believes that a temporary lack of these salts may cause trophic disorders, which may continue for some time after the deficiency in salts has been made good, and Duchek has even found that in exacerbations of symp- toms occurring in scurvy there may be an increased elimination of potash salts in the urine. The body is capable of retaining and re- using its various salts for a considerable time, so that withdrawal of the potash does not necessarily induce scurvy at once (Bauer). Northrup and Crandall recently investigated the causes of scurvy in a number of infants, and report that they find the employment of proprietary foods which for various reasons are substituted by the mother for fresh food is the most important cause of scurvy, and "even fresh milk in small proportions is not sufficient to insure per- 6/0 DIET IN DISEASE. fection." Their report continues (New York Medical Journal, May 26, 1894) : " The exact diet is known in thirty-three cases. We find that twelve of these children (;i6 per cent) were fed on a proprietary food exclusively, six (18 per cent) had received an exclusive diet of con- densed milk or evaporated cream, while three received a combination of these two foods. Over 6^ per cent, therefore, were fed upon a diet of proprietary foods and condensed milk. Two children re- ceived sterilised milk exclusively, and three a weak mixture of milk and water. One was fed on condensed milk, one on boiled and pep- tonised milk, and one on barley water." " It is a significant fact that the country which furnishes most of the literature of scorbutus in children is the same which is posted from end to end with advertisements of proprietary foods " (Northrup). Prophylaxis. So long as the hygienic conditions are good and the food is of the best quality and variety, and if proper discipline and regular habits of eating and sleeping are insured, scurvy may be prevented among soldiers and sailors, although fresh vegetables may not be obtainable. The introduction of canned and compressed vegetables in sea- men's rations has done much to prevent scurvy, but fresh food is always to be preferred for this purpose to preserved food of any kind when it can be obtained. Dried legumes are quite useless. For travellers in the far North, Nordenskiold advises the use of cloud berries {^Rubus chamcBmorus). Dietetic Treatment. In mild cases of scurvy of comparatively short duration patients rapidly improve under proper dietetic treat- ment if it can be obtained. The juice of two or three limes or lemons, or a few fresh vegetables eaten daily, may be all that is necessary, and the former is one of the best preventives as well as curative agents. A. E. Wright dissents from this view (British Medical Journal, July, 1894, p. 57), at least in regard to such cases as may suffer from bleeding from the gums. He claims that the acids, tartaric and citric, have a decided inhibitory action upon intravascular coagu- lation when given per os, and maintains, contrary to general experi- ence, that in scurvy with persistent haemorrhage the use of fresh lemon juice tends to keep up the oozing of the blood. He says that the neutral citrates and tartrates do not act in this manner, and they should therefore be prescribed instead of fresh lemon juice. Stomatitis is often the most prominent symptom, and if the mouth is very tender, the gums are swollen and bleed readily, and the stomach is irritable, the diet must be limited to fluid or some solid food which requires no mastication. Beef tea, broths and MISCELLANEOUS DISEASES. 67 1 meat soups thickened with vegetables, fresh vegetable purees, eggs, and milk are recommended. To these substances the juice of two or three fresh oranges, limes, or lemons should be added. If the pa- tient is able to masticate food thoroughly, and the stomach is not too feeble, fresh meat, baked or mashed potatoes, cabbage, sauer- kraut, pickles, salad, and "greens," such as water cress, fresh mus- tard, or radishes, may be given. The citrate of iron, vinegar, acetic acid, and potassium chlorate and bitartrate have all proved benefi- cial. During the War of the Rebellion the expressed juice of sor- ghum was tried with some success. The treatment of scurvy in children consists first in throwing away all proprietary foods, and then if the disease has not pro- gressed too far, improvement and cure rapidly follow change to a normal diet of mother's milk or fresh cow's milk, expressed beef juice, and a little fresh orange or peach juice. H.^MORRHAGIC PURPURA. With regard to idiopathic purpura, which sometimes appears in well-nourished subjects, it has been stated that a non-stimulating diet, by reducing the activity of the heart, may prevent the recur- rence of haemorrhages. Bauer says: "Such patients should take all foods and drinks cool, and never in large quantities at a time ; they should abstain altogether from alcohol, and milk is to be recom- mended for its easy tpleration in these cases." MISCELLANEOUS DISEASES. Addison's Disease. The aetiology of this affection is still obscure, it being by some regarded as a blood disease, by others as a condition depending upon irritation of the sympathetic nervous system produced by a lesion of the adrenals involving the abundant nerve supply of those structures. Some cases show tubercular degeneration of the ad- renals. At first no dietetic treatment is required, but in advanced cases there is always weakness of the digestive system, and vomiting may be a common symptom. There is also progressive inanition, which becomes extreme. The diet, therefore, must be of a light and easily digestible character. In some of the advanced cases the best re- sults are obtained from an exclusive milk diet. For others, when milk is not well borne, the diet should consist of beef or mutton broth, with eggs beaten with milk or sherry, gruels with added milk extracts or peptonoids, custard, rennet, milk toast. Nourishment should be given at short intervals, at least once 45 6/2 DIET IN DISEASE. in three hours, and the patient should be encouraged to take all that he can possibly digest. The intermittent vomiting may neces- sitate the use of nutrient enemata. Wine or spirits are usually required for tonic and stimulant , effect ; the special variety is im- material. Osteomalacia. The dietetic treatment of the condition of osteomalacia is sug- gested by what is known of its aetiology, but the results are seldom encouraging. It is characterised by progressive softening of the bones, a disease in which the salts, especially the carbonate and phosphate of lime, are reduced to about 30 per cent of the normal quantity. It is not definitely known in what manner these salts are dis- solved out of the bony structures, and excess of both lactic and carbonic acid have been regarded as probable solvents. It is not proved that a deficiency of salts in the diet causes the disease, which has been observed in well-fed subjects. It is, however, cus- tomary to arrange the diet with regard to furnishing an abundance of salts together with such articles as milk, eggs, and meat. It is advisable also to prescribe cod-liver oil, either alone or in combination with various phosphates or hypophosphites, and this food proves on the whole the most serviceable. Trousseau thought that it cured one or two of his cases. It is a rare affection in its worse type, although cases of moderate severity are less uncommon. Exophthalmic GoItre. It is only very advanced cases of exophthalmic goitre with considerable cardiac palpitation that require careful dieting. The indications for treatment are to support the strength and avoid flatulency and constipation, and any substances liable to increase palpitation or excite the nervous system must be withheld. Stimulants of all kinds should be avoided. Tea, coffee, alcohol, condiments, and tobacco are all forbidden, as are also sugar, sweets, pastry, fried food, and " made dishes." The food should be plainly cooked, and should consist of abun- dant meats, milk, fats (such as cream, butter, and cod-liver oil), care- fully prepared cereals, fresh fruits, and green vegetables. Chronic Lead Poisoning. Causation. Chronic lead poisoning is common among all arti- sans or mechanics who work with much lead in any form, but espe- cially white lead. Plumbers and house painters are therefore ^particularly subject to it. It may also be acquired by eating MISCELLANEOUS DISEASES. ^3 improperly tinned Or badly soldered canned food, although such cases are usually acute. It is sometimes caused by using drinking water which has passed through new lead pipes. When present in the strength of only one one-hundredth of a grain to the gallon it may cause palsy. The cheap ale, or " four ale," as it is called, sold in London to the lowest classes, is sometimes kept in contact with pewter pipes until it contains toxic quantities of lead. Lead is sometimes contained in poisonous amount in beer or wine which has been contaminated by the metal during its careless manufacture. Some persons are exceedingly susceptible to lead, and cases are recorded of poisoning from the medical use of a few doses of lead and opium pills, and also from that of cosmetics con- taining white lead. Dietetic Treatment. Chronic lead poisoning is nearly always accompanied by constipation, and it is highly important to over- come this difficulty by such foods as will keep the bowels actively open. Fresh fruits and coarse cereals (such as oatmeal, corn meal, wheaten grits, Graham bread), and molasses are recommended, with .such other foods and regulations as are given under the heading of the Treatment of Constipation (page 548). Water should be drunk in large quantity, not only to increase the digestive secretions and keep the faeces moist,^ but to act as a diluent and aid in washing out the poison. Lemonade, acidulated with dilute sulphuric acid, fifteen drops to the tumblerful, or with a similar dose of aromatic sulphuric acid, is much in vogue as a prophylactic beverage, for it forms an insoluble lead sulphate from the more soluble carbonate or other salts of lead which may have reached the stomach by being taken with food or drink. This insoluble salt is not absorbed, and hence poisoning may be averted. Men employed in the manufacture of white lead or other prep- arations of lead believe that drinking milk freely as a beverage is prophylactic against poisoning, but it is doubtful whether it acts otherwise than as a good diuretic. Lead colic is sometimes benefited by gastric lavage (Kussmaul, Riesland). Dietetic Complications arising from Associated Diseases. There are certain diseases and conditions which are not infre- quently associated in the same individual, the dietetic treatment of each of which may be directly opposed to fhat of the other. Such, for example, are : Diabetes and chronic Bright's disease, the former requiring chiefly meat, the latter none ; extreme leanness and chronic 674 DIET IN DISEASE. gastric catarrh, the former condition requiring fats, starches, and su- gars, the latter prohibiting them ; obesity and chronic albuminuria, the former requiring animal food, the latter none (unless it be milk); acute rheumatism and extreme anaemia, the former requiring no solid animal food, the latter demanding it ; intestinal dyspepsia and gall- stones, the former benefited by a meat diet and no starches or veg- etables, the latter doing better with opposite diet ; ascites and chronic albuminuria, where the quantity of fluid ingested as well as the diet may present very opposite requirements. When such complications arise it is possible to compromise for a time upon a milk diet, this being the most natural food,.and one which, on the whole, is capable of more universal adaptation than any other. In other cases, as, for example, in the first instance men- tioned above of diabetes accompanied by severe Bright's disease one must be governed by the patient's general condition, the gain or loss of body weight, the strength of pulse and muscle tone being the important guides for one or other system of dieting. The lesser evil, whichever it may be, must naturally give way to the greater, and a generous mixed diet may sometimes be found to serve the patient better than one too much restricted by theoretical consid- erations. No subject taxes the skill and ingenuity of the dietist more se- verely than the treatment of such complications, when ordinary rules .appear most contradictory. DIET FOR SURGICAL PATIENTS AND AFTER OPERATIONS, ETC. Food and Anesthetics. Preparation for the Administration of Anaesthetics. When an anaesthetic, such as ether or chloroform, is to be given, care should be exercised that the stomach is empty, otherwise vomiting is apt to occur at a critical moment when the patient is weak, and, being uncon- scious, the natural reflexes of the process, including the closure of the epiglottis, are not well carried out, and food is very easily drawn into the trachea and excites serious, if not fatal, choking.- For this reason the patient is usually prepared for the anaesthetic by giving a light and easily digested breakfast, consisting largely of milk with, perhaps, a little farinaceous food, and three or four hours later the anaesthetic may be administered with safety. Feeble patients sometimes require an ounce of brandy or whisky half an hour before the operation long enough before for it to become absorbed. It is never desirable to give an anaesthetic within three hours SURGICAL PATIENTS AND AFTER OPERATIONS. 675 khet the ingestion of a full meal. It impedes anaesthetisation, be- sides causing the danger of vomiting and choking. In many cases it is better to allow five or six hours to intervene. In an emergency where an accident occurring shortly after a heavy meal requires the immediate use of anaesthesia, it may be well to give an emetic first for the purpose of completely unloading the stomach while the pa- tient is conscious. The instances of fatal choking from vomiting and aspirating food into the larynx are fortunately rare, as they are preventable, but they are by no means unknown. Since their occurrence is almost always due to negligence on the part of the anaesthetiser for not observing proper precautions, they are inexcusable. Ether, by some specific action, is more likely than chloroform to prove irritating and excite vomiting while being inhaled. When retching is violent it may be sometimes overcome by "crowding " the anaesthetic that is, by causing it to be inhaled more energetically for a moment, until reflex irritation is overcome. Diet after Anaesthesia. Ether, much more than chloroform, is apt to occasion prolonged nausea and vomiting after its adminis- tration has ceased, and. this may last in very susceptible persons for a day or two. In all cases where ether is employed to produce pro- found narcosis, even when only used to assist physical examinations diagnostic purposes, it is well that caution should be observed for some hours afterwardsSn giving food, and a light fluid diet of milk, beef tea, or a cup of cocoa, tea, or coffee only should be allowed when any tendency to nausea or vomiting exists. Under ordinary circumstances no food is required until the effects of the anaesthetic have mainly passed off, and with continued gastric irritation it is necessary to confine the patient to a fluid diet for twenty-four hours or more, and give but little of that. If the patient has been much exhausted by haemorrhage during the operation or by prolonged anaesthesia, nourishment may be sometimes given sooner, but in concentrated predigested form. Brandy and soda is useful under these conditions, and often allays gastric irritation. Very hot water is to be recommended for the same purpose. In cases of laparotomy for operations upon any part of the alimentary canal, such as ap- pendicitis, it may prove best to give the digestive organs entire physiological rest for twenty-four hours at least, but if the pa- tient is in need of nourishment one or two food enemata may be given. The following schedule of diet for the day may be taken as an example for an ordinary operation under anaesthesia : 7 A. M. A cup of beef tea, coffee, or cocoa, or a cup of bread and n^lilk. II A. M. Anaesthesia and operation. 676 DIET IN DISEASE. 3 P. M. Iced milk and Vichy, beef essence, or peptonoids. If vomiting, hot water, or one half to one ounce of brandy with soda. y P. M. Bread and milk, or beef jelly, or cocoa and a biscuit. Nothing more until the next day, when, if there are no special reasons to the contrary from existing disease or complications arising from the operation, the patient's previous customary diet may be grad- ually resumed. Diet after Surgical Operations and Injuries. Fractures, wounds, bruises, ulcers, and all surgical injuries natu- rally heal the sooner the better the condition of the blood. Abun- dant nourishing diet, properly selected in regard to its ready digesti- bility, is therefore indicated. Starvation promptly impoverishes the blood and retards all healing processes. Mild Cases. In feeding surgical patients who are confined to bed or who, from the nature of their injuries, are unable to exercise, care should be taken that the channels for removal of waste from the body do not become choked and inert. In the zeal to promote rapid healing by a liberal diet it is quite possible to overcharge the blood with products of nutrition and defeat the object in view by burdening the liver and other organs, and inducing "biliousness." The patient's appetite should not be the only guide, but the con- dition of the tongue, the stools, and the urine should be examined to insure the proper assimilation of all the food taken. In the absence of sepsis, fever, and all affections of the alimentary canal there is usually no harm in allowing the full diet of animal and vegetable food to which the patient is normally accustomed, or, if the appetite flags, considerable variety in the dietary may be advantageously per- mitted. If there has been no loss of blood and no severe shock, as soon as an ordinary antiseptic operation is over the patient is practically as well as he was before it was performed. Cheyne says: "After operations performed aseptically there is no reduction of diet even for a few days. A hospital patient remains on full diet, and a private patient may have anything he fancies, pro- vided it is wholesome, and the more nutritious the food the better." In fact, after opening a psoas abscess or a carious joint the appetite soon returns and "hunger becomes the chief trouble." As a rule, stimulants are unnecessary if the appetite is keen, but otherwise beer or Burgundy or dilute whisky may be prescribed in moderation as an aliment, to be taken with the meals only. Hard drinkers who receive bad injuries, such as severe fractures, fre- quently develop delirium tremens in the course of a few days, and this may occur even when they have not been indulging in stimu-- lants for some weeks previously. la such cases it may become ne- SURGICAL PATIENTS AND AFTER OPERATIONS. 677 cessary to allow a certain quantity of alcoholic stimulation at stated intervals between meals, in order to tide them over an emergency which threatens an immediately fatal result, trusting to reduce the quantity as the delirium subsides. Severe Cases. If severe pain has preceded an operation, if the operation has been prolonged, or if there has been much shock, even under anccsthesia, the diet must be supervised with great care. Pain is a strong depressant, and after severe shock rest and stimulation is usually more desirable than food. Positive harm results from over- feeding. Black coffee is very serviceable for such cases or whenever there is lack of nerve energy, and it may be necessary to keep the patient for three or four days upon a diet of milk or pancreatinised milk. Broths, meat extracts, and beaten eggs may be added when the stomach regains its tone. If nausea, anorexia, or disgust for food exists, or if there is much distention of the stomach, it is un- wise to urge food upon the patient. It is better to utilise the rectum in such cases, and coffee, pancreatinised milk, egg albumen, and alcohol are to be given in enemata. Opium or other necessary medi- cation may be added. If extensive loss of blood has occurred, the volume of fluid should be replaced in the body as soon as possible, and liquid food is needed, such as milk, beef broths, peptonoids, and brandy or whisky, if the stomach retains them. Salt-water injections, or in severe cases hypodermic injections of saline solutions, help restore the lost fluid to the blood and improve vascular tone. It was noticed long ago that persons past middle life who were of full habit and addicted to excesses at the table or in drink were more apt to suffer from septicaemia after sustaining a compound fracture or an amputation than thinner, more abstemious subjects. This observation led to the practice of keeping these patients, and the former class especially, for a protracted period upon a very meagre diet; but it proved to be a mistaken view, for suppuration, inflam- mation, and fever are all exhausting processes, accompanied by in- creased tissue waste, which must be compensated by abundant nutritious food, and whether plethoric or spare, the patient must be well fed. Diet after Laparotomy, Ovariotomy, etc. After all operations involving opening the peritoneal cavity complete rest ot the stomach is necessary for at least four or six hours, and not infrequently for two or three days. Food and stimu- lants may be given by enemata (page 375). If fed />er os for the first three days not over a tablespoonful of pancreatinised milk or milk with lime water or barley water should be allowed once in two cr three hours. Later the quantity may be increased and the inter- 6/8 DIET IN DISEASE. vals diminished, and beef tea, beef peptonoids, and egg albumen may be added. In these cases the duration of anaesthesia has usually been pro- longed, and the shock is considerable. The danger from the occur- rence of vomiting, malfermentation of food, and flatulent distention of the abdomen is far worse than that of inanition from absti- nence. After wounds and operations affecting the stomach or intestines no food at all should be given by the mouth. Nothing but a little cracked ice should be so administered, and all nourishment must be supplied for several days by the rectum. The return to mouth feed- ing must be made very slowly and cautiously by at first giving not over one or two tablespoonfuls of pancreatinised milk or beef ex- tract at a time. There is often much thirst following operations involving the peritonaeum, which is relieved more by hot fluids than by ice, which sometimes irritates the throat and increases the desire for drink. If there is danger of all fluids exciting emesis, a salt-water enema once in three or four hours will alleviate thirst (page 36). Diet in Surgical Inflammations, Sepsis, etc. The diet in surgical inflammatory conditions was formerly re- duced to a minimum, with the idea that the healing process would be more sure if the stimulating influence of food was removed, and that the inflammation, like an infectious fever, should be "starved out." The dief adso/ue, a.s the French surgeons of the first half of this century termed it, meant virtual starvation, barley water, arrow- root water, or toast water being all that was allowed. With im- provement in feeding fevers came a change in the diet of inflamma- tory conditions, and it was recognised that the waste of tissue material and the expenditure of force in the evolution of heat must be replenished by nutritious food. No one to-day starves pneu- monia, nor yet does an intense local inflammation of a joint demand that the patient should have solid meat meals, but there is an appro- priate mean to be observed between overfeeding and starvation. After operations inflammation will not be avoided by starving, and the patient's strength must rather be supported by easily assimilable food. In all acute inflammatory conditions tissue waste is rapid and appetite and digestive power are lessened. In severe cases a diet of milk, diluted by one third or one half with Vichy or Seltzer water, may be given, four ounces every hour and a half or six ounces every two hours. Other articles should be added, such as expressed beef juice or beef peptonoids. These sub- stances may at first be given alone, and then added to strong beef,' mutton, or chicken broth. Gruels of arrowroot or oatmeal, raw SURGICAL PATIENTS AND AFTER OPERATIONS. 679 eggs alone, or beaten and added to sherry or brandy, custard, milk puddings, and beef jelly are all recommended. When improvement occurs, a light convalescent diet may be pre- scribed, such as that found on page 395. Acidulated drinks, sour lemonade, oatmeal or barley water, and effervescing waters may be used to relieve thirst. In mild cases, and in the early stages of many inflammations, alcohol is not required, but if at any time the pulse becomes feeble, the tongue grows dry, or delirium supervenes, stimulants, such as whisky or brandy, should be freely given. Elderly people and those who have been previously reduced by wasting diseases require earlier stimulation in the form both of meat extracts or meat juice and al- cohol. From four to six ounces or half a pint of liquor may be pre- scribed in twenty-four hours, according to its effect on the pulse. In the milder inflammations, especially those of tubercular joints, malt liquors may be of service. A good strong toddy at night may be made to take the place of opium. Burns, when severe or extensive, require prompt and energetic stimulation. In bad cases a pint and a half of brandy must be given in twenty-four hours. In chronic surgical diseases, attended by the formation of pus, fresh green vegetables and fresh fruits are often serviceable, both for their antiscorbutic and laxative effect. Lemonade, oranges, baked apples, or stewed prunes are recommended. Fats are also especially needed, and butter, cream, olive oil, or cod-liver oil should be added liberally to the diet when the patient is able to digest foods of this class. PART IX. RATIONS, DIETARIES. ARMY AND NAVY DIETS. The food furnished to soldiers and sailors, both in time of peace and war, is more accurately weighed and measured, and its effects are more accurately studied, for economic reasons than is the diet of any other class of men, even including hospital patients. While seeking to furnish wholesome variety it is necessary to keep the quantity of food as uniform as possible, and this may be done by substitution of articles the nutrient power of which is closely re- lated ; thus eggs may be occasionally substituted for milk, or peas or beans may be served for a change instead of cereals. The United States Army Rations. A "ration" is technically the total quantity of food issued for one man for twenty-four hours in accordance with law, and not, as often supposed, the allowance for one meal. The original prin- ciples upon which military rations have been selected are thus sum- marised by Captain Charles E. Woodruff, Assistant Surgeon, U. S. Army. (Journal of the United States Cavalry Association, March, 1894, p. 74.) " I. Economy is essential. " 2. The food must be the product of the country at large, neither a specially prepared article nor the output of a few manufacturers. " 3. The articles must be easily preserved in all climates by the most ignorant men. ** 4, The articles must be easily transported and capable of the roughest handling during transit. " 5, The ration is intended for the strongest and most robust men in the nation, and it is acknowledged that the sickly would be killed. " 6. It must approximate to the food used by the nation at large, so that there will be no rapid change of diet on enlistment that would impair the health. 680 ARMY AND NAVY DIETS. 68 1 ^ " For these reasons the soldier's ration has always been simple and dry." Some of these principles, as the author quoted points out, are radically wrong. It is false economy to furnish too cheap or mo- notonous diet, which only courts disease and swells the pension roll. After the Revolutionary War, in 1785, the army ration consisted of one pound of beef, one pound of bread, and one gill of rum. This was quite insufficient, and was subsequently increased (Woodruff). During that war, in addition to the above ration, the soldier received one pint of milk, a little molasses, and a few dried vegetables, with a quart of beer in place of rum. The present United States army ration costs less than fifteen cents. The German soldier is expected to eke out his peace ration by supplies contributed from his home, and the French and English soldier by contributions from his pay, but in the United States the men usually serve so far from home that this system is neither eco- nomical nor desirable. Moreover, with the improvements in canning and other methods of food preservation and condensation, it is no longer necessary for the ration to be the product of the immediate country, U. S. Army Ration (Captain Woodruff, U. S. Array). Component. Meat. Bread . Dried vege- tables . . . Fresh vege- tables . . . Coffee . Sugar . Condiments and addi- tional ar tides One article of each list. 12 oz. pork 12 oz. bacon 22 oz. salt beef 20 oz. fresh beef 20 oz. mutton 14 oz. dried fish 18 oz. pickled fish 18 oz. fresh fish 18 oz. flour 18 oz. soft bread 16 oz. hard bread 20 oz. corn meal 2? oz. beans or peas. i| oz. rice or hominy. I lb. potatoes or -^Q potatoes and -^ onions or ^ potatoes and ^ onions or 4t5 potatoes and t^o canned tomatoes, jV potatoes and 1^ vegetables, such as cab bage, beets, carrots, turnips, squash, etc. I I oz. green coffee. IjV oz. roasted coffee. ^ oz. tea. 2f oz. sugar. \^ gill mo!asses or sirup. ^ gill vinegar. \^ oz. salt. iSf oz. pepper. ^ oz. candles. [In the field.] \% oz. soap. In 10 days it is usual to give 7 days' ration of fresh beef, 2 of bacon, and I of salt pork. The other articles are very seldom issued. Soft bread is the in- variable issue in garri- son. 68^ RATIONS, DIETARIES. It is poot economy to make the change too radical between the garrison and field ration, for in the latter service men are exposed to conditions of hardship and fatigue which demand a more nutritious and varied diet than they obtain in barracks. As shown by Wood- ruff, the history of all prolonged wars presents a far greater death rate from disease than from the wounds of battle, and much of the former is caused by improper or insufficient food. The active soldier should have meat three times a day (Woodruff). When leading a comparatively inactive post life the foregoing ration may prove too large i. e., the food furnishes more energy than the body needs, but there is not always enough variety. Any excess of food is then sold to a co-operative store, and the money thus acquired is expended in securing a few luxuries to give the needed variety to stimulate the appetite. U. S. Army Ration in the Field (Woodruff). Meat.. Bread . Vegetables Fresh vegetables. Coffee Sugar ( 12 oz. fat pork or \ 12 oz. fat bacon, j i8. oz. flour or \ i6 oz. hard bread. {2f OZ. beans or 2f oz. peas or if oz. rice or if oz. hominy. i6 oz. potatoes (if they can be carried). ( if oz. green cofifee or \ 1^5- oz. roasted coffee or ( /,- oz. tea. 1^ oz. brown sugar. ~ ( Maximum. Grammes. { n/r- I Minimum.. Average . Protein. Fats. Carbo- hydrates. 106 64 320 240 540 460 85 280 500 Calories. 5,166 4.722 4.944 The most concentrated ration which it is practical for soldiers to carry in the field consists of bacon, hard-tack, and coffee. This is a scorbutic diet, and it always produces constipation, which may cause considerable suffering. To obviate this it is now customary to carry desiccated fruits, which are concentrated by drying, and which are not spoiled by extremes of temperature (Woodruff). U. S. ARMY TRAVEL FATION (Woodruff). " When cooking is impracticable on account of travelling by cars or rapid marches, or for other reasons, a special cooked ration is issued. The items of this ration are stated below. ARMY AND NAVY DIETS. " Travel Ration. 683 Meat Bread | Vegetables Coffee 12 oz. canned beef, fresh or corned. 18 oz. soft bread or i t .. 1 u* * i lu 16 oz. hard bread j- Total weight, 2 to 2i lbs. g^ to ^ lb. baked beans, J 21 cents a day for the purchase of liquid coffee en route. " The above has the followin g composition (approximately) : Protein. i?-,c 1 Carbo- ^^^^- hydrates. Calories. 150 120 170 417 oj. 1 iSn 3.900 2,900 Orammes. \ Ar:: 135 132 400 3.400 " This ration is insufficient for active men, being equivalent to the food of men of sedentary habits. The protein is the only ingredient in nearly the proper amount, and this arises from the meats and beans." Uncooked Food of Garrison Ration for Ten Days. Weights in Pounds. Daily Average, 4404 Men (Woodruff). Bacon Beans Pork Sugar, brown . . . Flour Beef Potatoes Onions Oatmeal Com meal Apples, canned . Apples, dried . . . Tapioca (26) and cornstarch (13) Butter Sirup Lard Rice Com, canned... Tomatoes, can'd. Macaroni (51) and vermicelli (li) Milk, fresh, lbs.. Milk, condensed, lbs Cheese Prunes Cabbage and sauerkraut .... Ham Apricots Barley Peas Raisins Chocolate Totals Gross weight. Waste 27:^1 42a 34-1 731 4.379 5,025 5, "6 700 44 85 10 183 39 58 16s io7i 26 63 332 5=* 31 31 I 10* 35 250 33 20 5 ! 14 I 3 3* 31 I26i 1. 131 1,386 150 Net weight. 270 42?* 312* 731 4,252* 3.894 3.730 550 44 85 10 183 39 58 165 107* 26 63 332 52* 31 31 10 15 200 28 Water. 54.00 54-05 37.85 21.93 531.56 !,i96.70 ,943.00 481.80 3-34 12.75 8.32 46.85 0.78 6.09 70.60 12.90 3.22 51.22 318.72 6.88 25.61 7.75 350 10.00 182.00 11.63 13-50 0.55 6.45 0.48 Protein. 21.60 99.10 2.82 467.78 682.97 78-33 7-70 6.65 7.82 0.02 1.65 0.58 0.65 1.92 1.77 2.66 4-73 1.58 5-27 3-30 0-75 4.30 4.68 0.40 0.65 1.20 0.05 0.60 18,598 ,2,9oei 15,689*7.120.501,413.21 1,657.175,343.65154.8219,446,960 Fats. 187.65 8.57 259.00 46.78 978.38 3-73 1.65 3-13 3-23 0.04 3. Carbo- hydrates, 353.80 49-30 89.66 0.14 0.70 1.33 0.15 1.50 3.41 2.20 0.60 11.00 0.14 0.08 1.50 705-42 3,185.12 667.67 55.55 30.01 60.01 1-59 130.85 38.14 0.29 90.60 20.65 8.32 8.30 40.32 2.00 13-64 0.50 4.00 11.00 6.00 3-8o 2 54 3.5c 0.30 Salts. 6.75 13.29 13 14 3-66 21.26 35-95 37 30 3-30 0.88 1.19 0.03 2.57 0.08 1.74 3.80 4.30 0.14 0.38 0.42 0.31 0.93 0.50 0.25 2.30 0.76 0.12 0.15 0.12 0.08 Calories. 831,600 691,228 1,097,753 1,312,081 6,991,110 5,409,392 1,398.750 123,750 81,400 139.825 3,150 259,494 70,980 209,670 168,795 383.775 42,380 21,735 26,560 73.81S 12,552 49.442 16,000 3,500 31,000 54,880 9,2CO 9,000 7,043 6,153 7,950 684 RATIONS, DIETARIES. - - Pounds Grammes. Daily average per man 4.22 0.66 3.56 733 145 17X 550 16 Counting flour as bread, amount eaten is 4 lbs. per man. Per cent of amount 4; c II 34 1 4,416 The usual army-ration tables are misleading in that they omit to account for the consumption of considerable accessory food, which is purchased by the soldier in addition to the portion he receives as fixed by law. Captain Woodruff has taken pains to carefully com- pute the nutrient value of the entire food eaten by the men of his garrison at Fort Assinniboine, Montana, during a period of ten days. His table, taken from the Journal of the American Medical Associa- tion, December 3, 1892, p. 651, is above. Additional Articles consumed. 338 lb. green coffee 8 lb. tea 20 gall, vinegar \ 128 1b. salt ) 10 lb. pepper 11 bottles flavouring ext'ts. 3 lb. mustard. 24 lb. baking powder. 6 lb. currants. 5 gall, pickles. 4 kegs pickled pigs' feet . . Daily per man. 1 . 23 OZ. 0.03 OZ. 0.14 gill 0.46 OZ. 0.036 OZ. Allowance. 1 . 60 OZ. or 0.32 OZ. 0.32 gill 0.64 OZ. 0.04 OZ. r Allowance is large, to allow of J making a saving to be used I in making sauerkraut and [ pickles in the fall. Though containing much energy, it is omitted because composition is unknown, and the actual amount per man is very small. Foreign Army Rations. Soldiers' Daily Peace Ration, in Ounces Avoirdupois. British (average). French. Austrian. German. Bread 24.0 12.0 35-2 10.6 3I-0 9.87 26.50 (8.81 (larger ration) ( 3 . 80 (smaller ration) Meat (uncooked) It is apparent from this table that the French, Austrian, and Ger- man rations all contain more bread and less meat than the English. In addition, the men have potatoes and other vegetables, green or ARMY AND NAVY DIETS. 685 dried, besides sugar, coffee, salt, etc., which are either issued with the ration or purchased with a special allowance of pay, so that the above figures, which apply to only two articles, fall somewhat short of the actual food consumed. For example : The British soldier re- ceives a total of sixty-five ounces of solid food against the French soldier's fifty-one ounces (Parkes) ; but many of them are under- grown men, being several years under twenty-five, up to which period the formation of the bones is not always complete. In England the daily ration of the soldier on home service con- sists of one pound of bread (twenty-four ounces is given above as the average for foreign service) and three quarters of a pound of meat, which is supplemented by an allowance of about fivepence a day to be expended on minor articles of diet, green vegetables, milk, sugar, and beverages. Colonel WoodhuU states that " in active field service the whole ration is supplied outright by the Government. It varies with the climate and the campaign, but the standard schedule is as follows: Meat, fresh, salt, or preserved, one pound. Bread, one and a quarter pound, or biscuit [hard bread], one pound, or flour, one pound; tea, one sixth of an ounce; coffee, one third of an ounce; sugar, two ounces; salt, half an ounce; pepper, one thirty-sixth of an ounce; fresh vegetables, when procurable, half a pound, or compressed vege- tables, one ounce. Also, 'when ordered by the commanding gen- eral on the recommendation of the medical officer, lime juice, half an ounce ; sugar, a quarter of an ounce ; rum, two and a half ounces." In the French army legumes form an important element of the ration, to some extent replacing animal food, and many experi- ments have been made with the German army in regard to the introduction of vegetable food, especially pea meal, which is rich in nitrogenous material. In France and Holland during active service in the field, in manoeuvres, or in battle the diet is materially increased. The larger ration of the German army, issued during the marches or manoeuvres, contains about five ounces more meat and several ounces more vegetable food, and in war thirteen ounces of meat are given. Bacon, salt meat, and rice are also supplied. Parkes gives the following detailed table for a liberal war ration : Bread li pound. Fresh meat, without bone i Peas or beans 3 ounces. Potatoes and green vegetables i pound. Cheese 2 ounces. Sugar * 2 Salt i ounce. Pepper I'ir 686 RATIONS, DIETARIES. Ground coffee I ounce. Tea i " Red wine lo ounces. Or beer 20 " All the chief armies of Continental Europe issue a wine ration m war times. To the French war ration are added nine ounces of wine or two and a quarter ounces of brandy /^r diem. Navy Rations. From Table A, showing the Different U. S. Navy Rations and their Compo- nent Parts, as established by Law, with the Substitutes legally allowed for each Article. Allowance for General Use. Rations as composed BY Law. EITHER OF THE FOLLOWING Specified by law. Substitutes authorised by law. Ration No. i I lb. salt pork. \ pt. beans or peas. \\ lb. fresh meat, or f lb. preserved meat. Vegetables of equal value, or \ lb. rice. Ration No. 2 Ration No. 3 1 lb. salt beef. \ lb. flour. 2 oz. dried fruit. f lb. preserved meat. \ lb. rice. 2 oz. butter. I oz. desiccated mixed vege- tables. \\ lb. fresh meat, or f lb. preserved meat. Vegetables of equal value. No substitute. \ pt. beans or peas. No substitute. 6 oz. canned vegetables. Ration No. 4 1 lb. preserved meat. 2 oz. butter. 6 oz. desiccated tomatoes. No substitute. No substitute. 6 oz. canned tomatoes. Weekly Allowance. \ pt. pickles. \ pt. molasses. J pt. vinegar. Daily Allowance. 14 oz. biscuit. I lb. soft bread. I lb. flour. \ lb. rice. \ oz. tea. 2 oz. coffee. 2 oz. cocoa. 4 oz. sugar. For coffee and sugar, extract of coffee combined with milk and sugar may be substitut- ed by the Secretary of the Navy, if not more expensive. The law allows one of the above complete rations to be used on any or each day of the week, or they may each be used in turn as convenient, in case it becomes necessary to vary the order prescribed elsewhere. Estimated average cosX. per capita per diem^ thirty cents. ARMY AND NAVY DIETS. 687 From Table C, showing the Different Articles of the U. S. Navy Ration, for which Practical Equivalents or Substitutes are permitted, with the Quan- tity of each allowed for Issue. Articles named in THE Law. Articles considered as included under names given in preceding column. Bread . Flour . Preserved meat. Dried fruit Tea.. Cocoa. j Biscuit ] Soft bread Corn meal Corn (hominy) Oatmeal Rye Wheat ' Roast beef Canned mutton Chicago corned beef. Brawn Ham Bacon Sausage i Dried Fish \ Smoked ( Pickled ' Dried apples. ~ Peaches. Raisins. Currants. Prunes. Figs. Dates. - May be substituted for each other. Quantity allowed per ration. 14 OZ. I lb. As substitute for I lb. bread. }-0r any other kind of dried fruit Fresh meat . Vegetables - Or any other kind of fresh meat . Beef. Mutton. \ Veal. Pork. Poultry. , Fresh (such as can be procured). ' Canned (assorted kinds) i^ OZ. 2 OZ. lilb. lilb. 6 OZ. From Table F, showing the Quantities of the Different Articles of the U. S. Navy Ration which are required for One Man for One Year. Biscuit 319I pounds. Biscuit (with flour) 182 Com meal 5* Oatmeal 52 Rye flour or hominy 52 Wheat flour 52 Salt pork 104 Beans 6^ gallons. Peas 3i Salt beef. 52 pounds. Rice 26 Dried fruit I3 Butter igi Tomatoes ^9 Canned meal 78 46 688 RATIONS, DIETARIES. Hatn or bacon 39 pounds. Sausage or salt fish 39 " Coffee 26 " Tea 4 Cocoa 19^ " Sugar 9ii " Pickles 26 " Molasses 3i gallons. Vinegar 3i " Canned vegetables 39 pounds. The British Navy ration contains one pound of fresh meat, one pound and a half of bread, or one pound and a quarter of sea biscuit. DIET IN PRISONS. In prisons, penitentiaries, or reformatories the diet should be adapted to keep the patients in good health through periods of years, while it is maintained at a minimum of expense to the com- munity. A brief review of such established diets is useful in furnish- ing an idea of quantity and quality of food required to fulfil the necessary conditions. Voit calculated that for a prisoner not engaged in hard labour the following diet is sufficient to maintain health : Carbohydrates, three hundred grammes; albumin, eighty-five grammes; fat, thirty grammes, or a proportion of about 10, 3.5, and i. In some penal institutions the inmates are placed upon a pro- gressive diet that is, a diet which is regulated according to the duration of their sentence, the degree of labour exacted from them, and their conduct. Such a diet has been recommended by the British Commissioners of Prisons, graded for: (i) Periods of seven days or less. (2) Periods between seven days and one month. (3) Periods between one and four months. (4) Periods exceeding four months. A somewhat similar system is detailed below that of the United States Army Prison at Fort Leavenworth. Diets of the United States Army Prison, Fort Leavenworth, Kansas. general diet. Breakfast. Hash, on Tuesday, Wednesday, Thursday, Saturday and Sunday. Mutton or beef stew, on Monday and Friday. Coffee, one quart each morning. Dinner. Pork, one day each week. Corned beef, one day each week. Roast beef and gravy, three days each week. Boiled beef and gravy, two days each week. Vegetable soup, daily except Sunday, DIET IN PRISONS. 689 One pint of coffee each Sunday. Pork may be substituted for corned beef or boiled beef one day each week during cold weather. To the above will be added pickled cucumbers, beets, or toma- toes on alternate days, and such other vegetables as may be avail- able from the prison farm. Supper. Tea or coffee, one quart ; bread, as much as required. Stewed apples or prunes on alternate days. No. I. The following diet, known as " Solitary," is given prison- ers confined in cells for punishment, while not performing any labour : Breakfast. Bread, eight ounces; water ad libitum. Dinner. Bread, eight ounces; water ad libitum. This punishment is given only for short periods, varying up to twenty days. Total farinaceous foods, sixteen ounces. No. 2. The following diet, known as "Restricted," is given prisoners confined in cells for punishment, while not performing any labour : Breakfast. Hash or stew, eight ounces. Bread, seven and a half ounces. Dinner. Soup, eight ounces. Bread, seven and a half ounces. Salt ad libitum. Supper. Bread, eight ounces. The eight ounces of bread for supper to be given after the twenty days of subsistence on the previous diet. Total proteid food, eight ounces ; total farinaceous food, twenty- three ounces. No. 3. The following diet is given to prisoners who have under- gone punishment : Breakfast. Hash or stew, ten ounces. Bread, ten ounces. Coffee and sugar in the usual amounts. Dinner. Soup, the usual amount. Beef, eight ounces, or pork, six ounces. Peas or beans, six ounces, or hominy in the usual amount, or potatoes, eight ounces. No other vegetables except such as are contained in the soup. Supper. Bread, ten ounces. Tea and sugar in the usual amounts. To prisoners who have been on " Restricted Diet " for more than ten days and less than twenty days, or on "Solitary Diet" for ten days, the above diet (No. 3) is given for two days. For those who have been on " Restricted Diet " for twenty days or more, or on '* Solitary Diet " for fifteen days, the above diet (No. 3) is given for three days. Following is the dietary of the New York State Reformatory, copied from the annual report of that institution for 1893. 690 RATIONS, DIETARIES. Q 1.3 i U 1 oo CO '^ IT) in Q CO COOCO 00 H d d vO "t d N CO c) d ll CO M W O^ P-l 00 t^ r< t-> 0> t^ M W CO CO w CO M p< CO M M in n VI m M vO >r) Tt in M vO M Tj- * moo r^ r^ CO r^O mo r^o 1 N CO M H d CO d d in c^ N M M r^ m C^ M d d d >n PI M w. r^ M m 00 w c<-)0 a^t\ N j^ M d d M M M m 't M I^ N 1 H + 't ^ M 00 w COO CO r~ r^ <* a K <: Q z 1 u |888 vO N CO H CO OOO>nO0Oin Mco N in^Tj-M m >n m m N n 00 CO Tt-*) N r+.r-tSHN '+ .0 CO vO '^s T3 c fa CO 73 vO CO r^-^ 1-1 N HI J3 00 3 " 1 CO T3 M 00 J3 1 CO B " 1 CO T3 1 00 00 tJ-Hn N HnHoHn M ^ I CO Hc^ in V 3 H " 1 oo T3 1 vO CO Tl"-fJ> M IH W r-fj) ,+^-t^>-Hi at* h .Q 1 00 vO 1 " 1 CO rt 73 1 00 N M Hn h > Xi 1 CO rf c4 c 3 le CO -4; > - "d M 1 w CO v 3 - H 1 ^ CO * n3 c y J! 1) M c 3 1-1 Ph ci D a. w a,ortrtoct;5;-!-;S3Bc.2i(Li p5pL,OHueL,pqHfjHOmmPi! 1 DIET IN PRISONS. 691 CO -i- Tf CO 00 in t-i 5i rt " 2 - = <0 >n .2 rt o t> 3 u-.oo N in CO O QO m in ecO 00 t^ \n c> CO %z CO CO -to OO M r^ CO n\0 00 O rt ti 00 e M .2 e O CO M M H 00 C &> s. O O <; E et r li d ^. o! I T 692 RATIONS, DIETARIES. From the New York State Reformatory Annual Report for iSgj. Calculations based on Prof. Atwater's tables, with Reformatory standard diet added. COMPARISON OF DAILY DIETARIES Carbohydrates Fats m Protein Potential energy Nutrients, Grammes- 200 400 600 800 1000 1200 I i 1 1 1 1 Potential Energy, Calories, 1000 2000 3000 4000 5000 6000 7000 8000 Subsistence diet (Playfair) Under-fed labourers, Lombardy, Italy Students, Japan Lawyers, Munich, Germany Well-paid mechanic, Munich, Germany Well-fed blacksmith, England German soldiers, peace footing German soldiers, war footing French-Canadian families, Canada Mechanics and factory operatives, Massachusetts . Well-to-do family, Connecticut College students. Northern and Eastern States . Machinists, Boston, Mass Hard-worked teamsters, etc., Boston, Mass. U. S. Army ration U. S. Navy ration N. Y. State Reformatory standard Reformatory standard daily ration * Actual upper first grade dietary Actual lower first grade dietary ... Actual second grade dietary Playf air's standard for adults, moderate exercise. Voit's standard for labouring men at moderate work. Voit's standard for prisoners in idleness Voit's standard for prisoners at work DIET IN PRISONS. 693 Exact figures corresponding to these lines are presented here- with : NUTRIENTS, IN GRAMMES. Reformatory standard dietary daily ration * Actual upper first grade ration Actual lower first grade ration Actual second grade ration Playfair's standard for adults, moderate exercise. . . . Voit's standard for labouring men at moderate work Voit's standard for prisoners in idleness Voit's standard for prisoners at work Protein. 119 167 154 154 119 118 85 105 Fats. 61 75 69 69 51 56 30 40 Carbo- hydrates. 556 810 794 776 531 500 300 500 Potential energy, in calories. 3.334 4,696 4,524 4.452 3.140 3.050 1.857 2,852 At a Conference of the Prison Association of New York, held in 1893, the following bill of fare was recommended for general adoption in prisons. The quantity of food is not specified (Forty- ninth Annual Report of the Prison Association of New York, for the year 1893, pp. 90-91) : SUNDAY. Breakfast. Pea soup, bread and butter. Dinner. Baked beans, brown bread, pudding. Supper. Bread or crackers, cheese, milk. MONDAY. Breakfast. Oatmeal or boiled rice, with sugar and milk. Dinner. Salt fish, vegetables, fruit. Supper. Bread and butter, milk. TUESDAY. Breakfast. Bean porridge, bread. Dinner. Roast beef, two or more kinds of vegetables, bread. Supper. Bread and milk, molasses. WEDNESDAY. Breakfast. Pea soup, bread. Dinner. Beti or mutton stew, with vegetables, used in place of potatoes.) Supper. Corn-meal mush, molasses. (Rice may be * All food supplies are issued according to this standard dietary, except bread, which is unlimited. The average consumption of bread per man is somewhat in ex- cess of one and one half ration per meal, thus accounting for the increase in value of the actual ration over that of the standard dietary, which conforms very nearly in food values to the standards of Voit and Playfair. 6q4 rations, dietaries. thursday. Breakfast. Bread and butter, milk. Dinner. Baked beans, bread, fruit. Supper. Bread and butter, cereal, coffee. FRIDAY. Breakfast. Pea soup, bread. Dinner. Fresh fish, vegetables. (Rice may be used in place of potatoes.) Supper. Bread and milk, cheese. SATURDAY. Breakfast. Oatmeal mush, milk, bread. Dinner. Corned beef, vegetables. Supper. Bread and milk, molasses. THE MILK CURE. An exclusive diet of milk as a cure for certain chronic diseases is advocated by some physicians, and in whose hands it has met with considerable success. Karell, of St. Petersburg, and Weir Mitchell are to be mentioned among those who have extensively used this form of treatment. The treatment as a " cure " does not apply to the temporary exclusive milk diet of typhoid fever and similar acute febrile conditions, but it is believed by the advocates of the milk diet that this form of food not only counteracts certain abnormal conditions and meets definite requirements of the body, but that the milk diet itself possesses a special curative value in some cases. Bauer says emphatically, " It is an indisputable fact that in certain diseases a methodical use of the milk cure gives results such as can be attained by no other treatment." It is recommended in obstinate cases of chronic intestinal disorders, especially neuralgia, intestinal dyspepsia, and colitis; in chronic con- gestion, hypertrophy, and fatty degeneration of the liver; in asthma, pulmonary catarrh, and emphysema; in dropsies of renal, cardiac, and hepatic origin ; in hysteria and hypochondriasis, in which the predominant symptoms are dyspepsia and malnutrition ; and in chronic catarrhal conditions of the whole alimentary canal. The milk cure is also recommended in cases of neurasthenia, obesity, rheumatism, gout, chronic valvular cardiac diseases, chronic Bright's disease, and endarteritis. Lebert had good results from it in the treatment of gastric ulcer. Weir Mitchell observes : " The study of the therapeutic influence and full results of the exclusive milk diet is yet to be made. Nor can I but believe that accurate THE MILK CURE. 6gg dietaries will come to be a far more useful part of our means of managing certain cases than as yet seems possible (Fat and Blood, fifth edition, 1888). Dosage and Method of giving the Milk. The milk used is skimmed, and it is important to have it obtained as fresh from the coun- try as possible. It is customary to begm with comparatively small doses about four ounces, once in two hours throughout the day, with one or two doses at night. Karell gives the milk lukewarm. At the end of a few days the dosage may be increased to six or eight ounces, and the intervals made three-hourly, and finally four-hourly, when twelve tumblerfuls are given daily. Pecholier gave three litres /% " (fair milk). Unhealthy " Below 1.028 High (above 10^). " or slightly below. " " Normal (5^10^). Low " " Low (below 5^). Very low (very poor milk). Above 1.033 High. Very high (very rich milk). Normal. High " " Low. Normal (or nearly so). To calculate the actual fat from the cream multiply by three fifths. In examining the composition of the milk of a wet nurse it is only fair to the nurse to remember that, like cow's milk, her own contains less fat when the milk is first drawn than after the breast has been nursed for a few moments. The quantity of the milk may be best estimated by weighing the infant immediately before and after suckling, when the gain should be between three and six ounces. DIET OF A NURSING MOTHER OR WET NURSE. The diet of the nursing mother or wet nurse must be regulated, to prevent noxious substances from passing into the breast milk and to keep her in good health, so that she does not suffer from constipa- tion, indigestion, or anaemia. Her weight should not alter, and if she has menstruated once or twice the milk changes and may dis- agree. If milk does not make her constipated or bilious she may drink it abundantly. She may take gruels and meat broths, and she should eat simple nourishing food, meat, eggs, vegetables, and fruits. The latter, even if sour, do not react unfavourably upon the child, pro- vided the mother's digestion is good, and they serve to keep the child's bowels active. The mother should forego the drinking of much tea and coffee. Beer and wine also should not be drunk unless they are especially prescribed as a tonic. Wet nurses often demand 7i3 RATIONS, DIETARIES. beer, ale, or porter with their meals if they have been accustomed to it ; but the popular idea that such beverages are especially beneficial is fallacious. Malt liquor sometimes causes the secretion of more milk, because more fluid is drunk, but the milk is no better for it. A reasonable quantity of fluids should be drunk, however, or the secretion of milk will suffer. The fluid may be in the form of plain or effervescing water, milk, soups, etc. The mother or wet nurse should avoid all fatigue, worry, and emotional excitement of any kind, which may inhibit her digestive functions, and should take daily outdoor exercise. On the whole, the best indication for the dietetic treatment of the wet nurse is the study of the condition of the child's digestion, bowels, and nutrition. A too meagre diet for the nurse is soon evi- dent in lack of nutrition and development of the infant. Drugs in Human Milk. Not many drugs pass unchanged into the milk which are likely to poison the child through its food, but there are some which should be carefully avoided on this account. Such are belladonna, opium, morphine, and other alkaloids ; iodine and its preparations ; mercury and its salts ; salicylic acid (see page 48). When, for any reason, it becomes necessary to discontinue the nursing and to stop further secretion of milk, the diet should at once be made as dry as possible, and a minimum quantity only of fluid is allowed. THE FOOD OF INFANTS. Size of the Infant Stomach. With regard to infant nursing, it is never sufficient to give general directions about an infant's food. The physician should supervise the exact mode of its prepara- tion, and order both the quantity to be given and the intervals at which it is to be given. Mothers seldom know what is best for their infants in these matters. It is therefore well to explain to them fully the facts as to the proper hours for feeding and the amount of food required, and also to give them some idea of the size of the infant stomach, for many have a vague idea that the word " stomach " includes almost the en- tire abdominal cavity. Rotch gives the following table of capacities of infant stomachs : 1. Premature 8 months' infant 8 cubic centimetres. 2. Infant 5 days old 25-30 " " 3. Infant 4 weeks old 75 " " 4. Infant 8 " " 96 " " 5. Infant 16 " " 107 " " 6. Infant 20 " " 108 " * THE FOOD OF INFANTS. 719 It is advisable to show the mother or nurse an empty bottle rep- resenting the capacity of the infant's stomach, in order to impress upon her the danger of overloading it. Overfeeding. It is sometimes said that overfeeding kills more babies than starvation, and certainly it is responsible for a large proportion of the ailments of early infancy, such as gastric catarrh and diarrhoea. This is especially true in summer, when the fretful- ness of the child, which is often mistaken for hunger, may be due to thirst, the external temperature, too warm clothing, or indigestion. At such times Holt advises reducing the bulk of each meal by one quarter and giving the infant more water to drink, for, as he says, infants, like adults, require less food in excessively hot weather. It is difficult to impress mothers with the fact that milk should never be given to soothe a baby's fretfulness merely, and "unme- thodical and improper feeding is quite as bad as feeding with im- proper aliments " (Adams). The young infant secretes no ptyalin to digest starch, and Biedert finds that the infant stomach does not well digest albumin when its solution is stronger than i per cent. Methods of Feeding. Infants may be given their food in one of four ways : I. By mother's milk. II. By milk from a wet nurse. III. By bottle feed- ing. IV. By mixed' feeding i. e., when the mother's or nurse's milk is supplemented by bottle feeding. There is no room for doubt that infants brought up on breast milk are stronger and better able to remain in good health and re- sist disease than those who are hand fed, for no infant food has ever been devised which is in every way as satisfactory as good mother's milk. I. AND II. feeding by the mother or wet nurse. Starr advises putting the infant to the breast as early as six or eight hours after labour is completed, which is good for both mother and child. For the mother it improves the nipple, stimulates the true milk secretion, and reflexly the uterine contractions; for the infant it is also desirable, for it insures the ingestion of colostrum. Colostrum constitutes the secretion of the first three days. This secretion is mildly laxative, and it cleanses the child's alimentary canal of the waste matter called meconium, which is found within it at birth. Colostrum contains an excess of albumin, so that boiling coag- ulates it. It also has large corpuscles, which may be seen with the microscope throughout the first week of lactation, gradually lessen- ing in number. They then rapidly disappear, and none should be 48 720 RATIONS, DIETARIES. present after a fortnight. If found later, the milk is certain to dis- agree and a change of nurse is necessitated. Intervals for Feeding. Infants during the first three days should be nursed only four or five times a day. Water may be given, but no bottle food, which only upsets the stomach and lessens the" ability to suck. After this period once every two hours is the proper interval for suckling for the first six weeks or two months. The child should be nursed at this interval between 5 a. m. and 11 p. m., with one feeding only in the middle of the night. If absolute regu- larity is always observed in the hours for nursing, the child's digest- ive organs keep in much better condition, it sleeps better, and is much less likely to be overfed. During the first four or five months of life an infant should be fed once during. the night ; after that it need not be fed between 10 p. m. and 7 a. m. When a year old, if strong and well, it need not be fed between 7 p. m. and 7 a. m. If fed or nursed oftenerthan this, the child receives too much food, and digestion and rest are both disturbed. Sometimes an infant will demand milk at night and not take it in the daytime as well as it should, but with a little firmness and by starving it for a few hours until it is really hungry, it can often be trained to suckle in the manner which experience has proved is best for both itself and its mother. From fifteen to twenty minutes is sufficient time to keep the child at the breast, and it will often doze off to sleep after nursing. As the child grows older the intervals between the hours of nurs- ing are to be prolonged, in accordance with the tables given below (pages 727, 728), and the child may be allowed to remain a few moments longer at the breast. The infant while sucking should always be held in a comfortable position with the nipple within easy reach. After a three-hour interval for feeding has been reached, it may be maintained in many cases until lactation is completed, but after reaching six months of age some infants do better with a three and a half or four hours' interval. Infants born with a cleft lip cannot be properly nursed at the breast, for they are unable to make the necessary vacuum in the mouth to draw the milk. They may be unable to take the bottle successfully, and must then be fed by gavage or with a spoon. III. FEEDING BY THE BOTTLE. When it becomes necessary to employ artificial feeding there are two principles upon which it may be conducted. The first and most extensively practised is to endeavour to obtain a food by modify- ing cow's milk, which corresponds as nearly as possible to the com- position of average human milk. The second is to adapt the pre- THE FOOD OF INFANTS. 721 pared milk to the needs of each particular infant, as suggested by the state of its digestive organs and existing nutrition and develop- ment. The first method seeks to bring the child up to the standard of the milk, the second to bring the milk to the standard of the child. The latter has been newly elaborated, and the minute details with which it is now conducted should be allowed the test of more extended clinical experience than has been yet accumulated before they are accepted or condemned. This system of "prescription writing " as applied to milk seems, in some cases of severe illness and great impairment of digestion, more rational than the older method, but it presupposes much experience and care on the part of the physician. Due regard must be had, of course, for the circumstances of those for whom an especially modified diet is ordered. For the very poor, milk is a serious item of expense, and cream and sugar may be out of the question. Condensed milk is usually cheaper in large cities than fresh cow's milk, for less care and expense is involved in its transportation, and it is accordingly much used by the poor. More- over, in hot weather it keeps without ice, but for reasons given else- where (page 8i) it is never to be preferred when good fresh cow's milk is obtainable. Cow's milk contains approximately half the quantity of sugar present in human milk. Leeds says that the curd derivable from human milk is only one fifth as much as that of cow's milk, and there are other striking differ- ences in regard to the quantity of casein precipitable by acid, as compared with the non-coagulable ingredients of both forms of milk. For this reason it must be diluted for very young infants with two parts of water, in order to bring the casein nearer to the right proportion ; but the addition of water reduces the percentage of fat and of sugar. E.scherich has shown that the infant fed upon diluted cow's milk has to take much more fluid than when nursed by breast milk to get the same quantity of nutriment, with consequent distention and pos- sible enfeeblement of the stomach. The disproportion of fat may be counterbalanced by using "top milk " i. e., the upper layer which forms after the milk has stood for about eight hours, and which contains most of the cream. Milk sugar is then to be added in the proportion of one heaping teaspoonful to four ounces of the diluted milk. If cane sugar is used, which is less desirable, as it is more apt to ferment, only one teaspoonful to every six ounces is necessary. From a quart of ordinary milk six ounces of top milk may be skimmed, seven ounces from rich, and five from poor milk. In lieu 722 RATIONS, DIETARIES. of top milk a mixture of equal parts of cream and of ordinary milk should be used (Holt). When the milk causes dyspepsia, and large curds are vomited, it is well to substitute barley water for plain water in the same pro-^ portion. If pearl barley is used it should be boiled a long time for six or eight hours the water being replaced as it evaporates. The pro- portion usually employed is two tablespoonfuls of barley to the quart of water. After careful straining through a linen cloth, a pinch of salt is added, and when cool the fluid is ready for use. Instead of pearl barley, one of the barley flours may be employed. This answers the purpose as well, and has the advantage of requiring much less time, boiling for haff an hour being sufficient. Holt gives the following formulae for an infant two months old receiving twenty-four ounces a day : Top milk 8 ounces. Barley water i6 " Milk sugar 6 heaping teaspoonfuls, or Cane sugar 4 " " The quantity is to be slightly increased, but the proportion may remain the same until the seventh or eighth month, when the mix- ture should be changed to Top milk . 19 ounces. Barley water 19 " Milk sugar 9 teaspoonfuls, or Cane sugar '5 " In answer to the question, " Can a child one year old take plain cow's milk ? " Holt says: " Many children can, but the majority do better when the milk is modified by the addition of cream and water, or by the use of diluted top milk. After standing six hours six ounces should be taken off from the top of the milk bottle and ten ounces more should then be poured off and the two mixed. This may be diluted with an equal quantity of water or barley water." It is generally conceded that fresh raw cow's milk derived from a healthy cow, and carefully kept from germ contamination, is a more wholesome food for babies than milk which is either boiled, sterilised, Pasteurised, or peptonised. But in cities always, and everywhere in summer, it is difficult or impossible to obtain such milk, and one or other of the means of disinfection becomes im- perative. The heat required for sterilisation in some manner destroys the vital properties of nuclein of the milk (Starr). According to the observations of Toch (Archiv f. Kinderheilkunde, xvi) on the stomach contents, the peptonising of milk for infants THE FOOD OF INFANTS. 723 is useless, for he has demonstrated the presence of pepsin in the gastric juice of infants, even when having gastric catarrh. Peptonised milk is used much less for infant feeding than for- merly, for it has been found that they do not thrive if continuously fed upon it. Care of the Milk. In order to keep milk fresh and pure for infant use in hot weather it should be at once artificially cooled, and if intended for city consumption, during transportation both car and delivery wagon should be supplied with ice, so that the milk temper- ature never rises above 50 F. The milk when received at the deal- er's should also be kept in refrigerators, for it is exceedingly im- portant that it should not become lukewarm even temporarily. It would be an undoubted advantage to have the whole system of milk supply under proper inspection and licensing. The cows when stabled should be kept in clean, well-ventilated quarters, and should always have the udders washed before milking. Every receptacle used for holding the milk should be thoroughly scoured with boiling water each day, but after first rinsing with cold water. If this pro- cess is reversed, particles of scalded milk may cling to the pail or can and give rise to subsequent fermentation. Milk should never be allowed to stand about in uncovered vessels, especially in a bath room, near an open sewer pipe or drain, or in a damp cellar. When given to the infant the milk, as well as all infant food, should be moderately warmed to approximate its body temperature (99 F.). When the milk temporarily disagrees it becomes necessary to sub- stitute for it some other form of food. Useful formulae for this purpose are given by Starr as follows : Substitutes for Milk in Infant Feeding (Starr). Veal broth (i lb. of meat to the pint) f 5 Jss. Barley water f jss. Mix. j; , y* ) each, one and a half ounce. Barley water, \ Milk sugar half a drachm. Give one portion at two months. Raw beef juice (one teaspoonful every two hours) will "be re- tained when everything else is rejected." Both barley water and lime water are sometimes added when temporary looseness of the bowels occurs. In using lime water (carbonate of lime) as a diluent of cow's milk in infant feeding, it should be remembered that in the latter the phosphate of lime is four times greater in quantity than in human milk (Leeds), and it is of questionable utility to continue the practice beyond the requirements of a temporary fit of indigestion. 724 RATIONS, DIETARIES. Many persons suppose that the milk from a single cow is to be preferred to the mixed milk of several animals, and formerly some dairies used to supply such milk in separate bottles. It has been proved, however, that there is less variation in the quality of mixed milk, and t,he infant is not so apt to become dyspeptic while tak- ing it. The milk of fancy breeds of cows, such as that of thoroughbred Alderneys or Durhams, is often too rich both for infants and invalids, IV. MIXED FEEDING. There is no harm whatever in partly feeding infants with the bottle who are at the same time being nursed. If the mother is suf- fering from want of sleep she will be of more value to her infant if allowed to sleep at night while her child is hand-fed once or twice. When the breast milk is insufficient or poor in quality the child must be fed by hand several times a day in addition to nursing. A hun- gry, ill-nourished child cries continuously in a fretful manner and nurses irregularly, either taking the breast too long and eagerly or stopping too soon if it cannot obtain the milk without much effort. The sleep is fitful, the abdomen is tender and usually distended with gas. There may be vomiting, and the stools are malodorous and contain milk curds. Sometimes such babies may be given the bottle for the greater part of their food for a few days, until the mother's milk is found to agree with them better, and thus the necessity for absolute weaning may be postponed. Infants who are brought up to take the bottle once or twice at night, being nursed at the breast in the daytime, are usually more easily weaned when the period for entire hand-feeding arrives. When a mother who has abundant miik supply is obliged to be temporarily absent from her infant beyond the period when a meal is due, she may beforehand express into a clean glass a little milk which may be kept and fed to the child with a teaspoon while the mother is away. Weaning. The period for weaning varies considerably, according to the health and vigour of both mother and infant. As a rule, it should be between the tenth and eighteenth month, ordinarily not before the tenth or twelfth month has been passed. Many infants are nursed for fifteen months, but after, if not before the eighteenth month the mother's milk deteriorates, and the child's needs will be better met by bottle feeding. There can be no fixed rule about this, however, and much depends upon the nationality and social position of the mother. The poor, for reasons of economy, sometimes nurse their children longer than is good for them, and many foreigners in THE FOOD OF INFANTS. 725 this country seem able to nurse their infants longer than native Americans. The eruption of the eight incisor teeth, which should be com- plete by the end of the first year, is often regarded as an indication for weaning. At this time the digestive organs become stronger, the saliva becomes more abundant, and the appearance of the an- terior molar teeth is a sign that the child is gradually preparing for solid food. Usually, even though the anterior molar teeth are cut, the child, if weaned, should still be fed chiefly upon milk until the eighteenth month. It is best not to wean a child during very hot weather, but when this is imperative milk only should be given, otherw'se a small quantity of beef juice, egg, etc., may be allowed by degrees. An infant may be weaned at any time, and occasion may require its being done suddenly, but ordinarily the process should occupy at least one or two months. When the child is nine or ten months of age the bottle may be given once a day in place of the breast ; later two or three times, and so on, until at the end of a year the weaning is completed. This, however, is a very general rule, subject to modifications necessitated by the ill health of mother or child, or by hot weather, etc. The circumstances which necessitate earlier weaning than the period after the twelfth month may be due to the condition of the infant, who may have malformation of the mouth or be congenitally too feeble to suckle, or rendered so by some disease, such as rickets or hereditary syphilis, or the condition of the mother may be at fault, either from constitutional disease, such as tuberculosis or syphilis, from local disease, abscess, or malformation of the nipples, from insufificient or poor milk, or from the recurrence of menstrua- tion or pregnancy. If an infant be nursed after the mother's milk has grown poor in quality it may acquire rickets and digestive disorders. The following directions for weaning an infant from the bottle and for feeding during the second year are concisely given by Holt in his admirable brochure on The Care and Feeding of Infants (1894). They summarise concisely a very large experience : " At ten months the bottle or breast milk may be supplemented by a little beef juice or a portion of a soft-boiled tgg. If the bottle is given, arrowroot or farina may be added to one feeding each day. . . . " A child should always be weaned as early as eighteen or twenty months, but it can be easily done at twelve or fifteen months. . . . During the second year a healthy child never requires more than five, and some do better with four, meals during the latter half of the year. ... -26 RATIONS. DIETARIES. " If five meals are given, the best hours are 7 a. m., 10 a. m., I p. M., 4 p. M., 7 p. M., with nothing whatever during the night. It is better to make the 10 a. m. and 4 p. m. meals rather smaller than the others." Starr gives the following mixture for use in commencing weaning at the tenth month : Weaning Mixture at Ten Months (Starr). Cream f 5 ss. Milk f iv. Sugar of milk f j. Water f jss. * If disorder of digestion occurs return to the breast. Dencke, of Jena, publishes the following table (Centralbl. fiir Gynakol., vol. xv) as a result of feeding normal infants on Swiss milk for the first nine days : Daily amount consumed, in ounces . Relation of this amount to body weight, in percentage Quantity per meal, in ounces.. ..*... Number of meals /^r diem DAYS I. 2. 3- 4- 5- 6. 7- 8. 1-5 4.6 6.5 9.0 II. 8 12.5 13.0 14. 1 r.4 4-5 6.4 8.7 "3 II. 7 12.3 13.2 0.65 0.79 1.06 1-37 1-75 I-.";? 2.06 2.1 2.1 5-7 6.2 6.7 7.0 6.8 6.3 6.8 14-5 13-9 2.2 6.7 Holt presents the following table, based on the measurement of forty infant stomachs and the weighing of infants immediately be- fore and after nursing. The table gives the averages computed from such data, but the robust will require a little more, and the feeble will take less food. The measurements are in ounces : Age. Quantity suckled at one feeding. Number of feedings. Total daily amount. 2 weeks 2 3 4 5 5i-6 7-7* 8-9 8 8 7 6 6 5 5 16 I month 24 28 2 months 4 months 30 33-36 35-38 40-45 6 months 9 months 12 months The average weight of the child at birth may be given as three kilogrammes (Widerhofer). If it weighs less than two kilogrammes it is usually very feeble. After the twelfth month three pints is the limit of digestive capacity for food for the stomach for one day. If the child seems to need more nourishment, the strength of the food, but not its bulk, may be increased. THE FOOD OF INFANTS. 727 The following table is from Rotch's Pediatrics (page 266) : Table showing Management of the Food and Increase in Weight of a Healthy Infant {Case g2) during the First Fifty-two Weeks of its Life. Date. Weeks of life. Weight. Amount at each feeding. Fat. Sugar. Pro- teids. Lime- water. Grms. Lbs. Oz. C.c. Oz. Nov. I I 3,180 7 I 8 2 3,180 7 I 60 2 2.00 5.00 1. 00 5.00 " 15 3 3,180 7 I 60 2 4.00 7.00 1. 00 " 22 4 3.430 7 10 90 3 4.00 7.00 1. 00 " 29 5 3,520 7 14 75 2i 300 7.00 1. 00 Dec. 6 6 3,730 8 5 3-00 6.00 1. 00 " 13 7 3,980 8 14 3.00 7 00 1. 00 " 20 8 4,160 9 4 90 3 4.00 7.00 1. 00 10.00 " 27 9 4,340 9 10 105 3i 4.00 7.00 1.25 5.00 Jan. 3 . 10 4,590 10 4 4.00 7.00 1.50 10 II 4,870 10 14 " 17 12 5,060 II 4 " 24 . 13 5,270 II 12 " 31 . 14 5,560 12 6 Feb. 7 15 5,870 13 I 120 4 .... .... .... 12.50 " 14 . 16 6,070 13 8 135 4i 10.00 " 21 . 17 6,300 14 I 5.00 " 28 . 18 6,370 14 4 March 7 . 19 6,510 14 8 " 14 20 6,650 14 13 150 5 4.00 7.00 2.00 " 21 21 6,920 15 7 " 28 22 6,980 15 9 April 4 . 23 7,150 15 15 " II . 24 7,240 16 2 " 18 . 25 7,560 16 14 " 25 . 26 7,600 16 15 May 2 . 27 7,800 17 6 " 9 . 28 7,730 17 4 " 16 . 29 7,840 17 8 " 23 . 30 8,070 18 180 6 " 30 . 31 8,160 18 3 June 6 . 32 8,190 18 4 " 13 33 8,490 18 15 195 6i 4.00 7.00 a. 50 " 20 34 8,470 18 14 " 27 . 35 8,700 19 6 July 4 36 8,762 19 8 " II . 37 8,824 19 II " 18 . 38 8,950 19 14 " 25 39 8,970 20 Aug. I . 40 8,980 20 8 41 9,060 20 3 " 15 . 42 9,140 20 6 " 22 43 9340 20 13 " 29 . 44 9,170 20 7 Sept. 5 45 9,290 20 II " 12 . 46 9,340 20 13 " 19. 47 9,470 21 2 " 26. . 48 9,640 21 9 Oct. 3. 49 9,630 21 7 " 10 . 50 9,740 21 10 4.00 6.00 3.00 " 17. 51 9,870 22 Whole milk. " 24 . 52 9,890 22 I Whole milk a nd oat jelly. The whole heated throughout the year at 75' C. (167 F.)." 728 RATIONS, DIETARIES. tr. < rt '3 S S *i=2' < 0. o 2 a. 3 " '^ .;: "rt ^ S o ^ i c o'o 2 ^ 3-2 H i MO S X -^ + 3 O 6-^ I 3 o b( o ..s-r -0.0.05! o ? * u .f S S - s 1^ g -^ 5 u.SfS a; S p; S - M <; M < . ;; o c . < CJ 1) ^ < I UTH u ji rt ' o 5 . S o c 5 n "^ 2 p S 2 <:!= p. < a, <1 Sf O k0 K> MO b0 MO 5 fco Z. V- MO .S; .S:E-P MO N0.5 MO MO 5 MO 2 THE FOOD OF INFANTS. 729 Holfs ' Schedule for Feeding an Average Child in Health " for the First Year. 1 week 2 to 3 weeks 4 weeks. . . . 6 " .... 3 months . . . 5 " . 6 " ... 9 " ... 12 " ... to 6 A. M. 10 2 hours. 10 2 9 2 8 2i 7 3 6 3 6 3 5 3 5 3 Quantity for each meal. I OZ. li " 2\ " 3 " 4 " 5i " 6 " 1\ " Quantity for 24 hours. 10 OZ 15 ' 20 ' 24 ' 28 ' 33 ' 36 ' 37i ' 40 Christie's Table for Infant Feeding. Age. 1st week 2d to 4th week.. . 2d to 3d month . . 3d to 4th month , 4th to 5th month 6th month 8th month loth month , Number of feed-j Amount of food Total amount ia mgs in 24 hours at each feeding.! 24 hours. 10 OZ. I3i OZ. 18 OZ. 24 OZ. 24-27 OZ. 30 OZ. 36 OZ. 40 OZ. The foregoing tables differ only in a few unimportant details less, in fact, than the digestive powers of infants differ from each other. Artificial Infant Foods. Very young infants fed upon "proprietary " or "prepared " baby foods, to the greater or less exclusion of mother's or good cow's milk, soon become rhachitic or scrofulous. Wiederhofer says that " the numerous infant foods, although much bepuffed, are of no value whatever." This is certainly true of all non-malted amyla- .ceous foods. The common fault of nearly all such preparations is that they contain too much sugar or starch and too little fat^which latter is very difficult to preserve without becoming rancid. For example : Prof. Leeds says that Mellin's food has only 0.15 part fat in 144.74, and Nestle's food only 1.91 part in 139.69, but human milk has 3.90 per cent and cow's has 3.66 per cent. Two extreme conditions are seen in such infants those who are emaciated and marasmic, and those who are stout and apparently robust, but whose strength and power of resistance to disease is very deceptive. As described by Holt : " When children are fed upon foods lacking in fat, the teeth come late, the bones are soft, the mus- cles flabby," whereas "children fed upon foods containing too much 730 RATIONS, DIETARIES. sugar are frequently very fat, but their flesh is very soft, they walk late, and they perspire readily about the head and neck." They pre- sent a variety of rhachitic deformities, and are subject to catarrhal and other diseases. Such foods should never be fed to young in-v fants unless under a physician's direction. For the further discus- sion of this topic the reader is referred to the section upon Pre- digested Foods, page 131. Another objection to feeding infants with starchy food, even when partially converted by diastase into dextrin and maltose, is that the final products are unlike the carbohydrate of normal milk (lactose), and it is doubtful whether they are as readily assimilated and as useful in the obscure metabolic processes of infant growth. Predigested proteid foods, such as somatose and various forms of meat extracts, albumoses, etc., are sometimes used to re enforce the milk of very young infants by addition to it. This is a mistake, for the cow's milk is already too rich in proteids. If temporary indiges- tion requires their use, they should be substituted for milk, and not given with the idea of re-enforcing it. Infant Stools. The stools of the infant should be observed from time to time in order to ascertain whether the milk is being properly digested. The stools of an infant fed exclusively on milk should number two (or only one) a day, and be of uniform soft consistence, smooth, of inoffensive odour, and of a gamboge-yellow colour. If meat juice or meat broth of any kind is given, the stools usually become darker. If too much is given they are apt to be acid, malodorous, very dark brown, and diarrhoeal. Abnormal appearances of the stools will be found described in cunnection with the dietetic treatment of infantile diarrhoea (page 532). When farinaceous or any amylaceous food is being given, it is well to test the stools with a few drops of tincture of iodine which imparts a purple colour to any particles of undigested starch which they may contain. Nursing Bottles. Ever since the influence of bacteria upon the fermentation of milk has been established the necessity for ob- serving carefully the most minute details for cleansing all the in- fant's utensils has been apparent. The necessity for use of the bottle for feeding is always to be regretted on account of the difficulty of keeping the milk from bacterial infection. Adams says : " One of the greatest nuisances in infantile life is the popular feeding bottle. It probably causes more intestinal diseases in the infant under two years of age than any other article." The use of nursing bottles with long rubber tubing is to be un- hesitatingly condemned, although it saves trouble in holding the THE FOOD OF INFANTS. 731 bottle. It is impossible to keep the tubing sterile. The bottle should be of pure glass, white, of half-pint capacity, with a wide mouth and a sloping neck, and never with a shoulder, which pre- vents cleaning every part of the interior with a sterilised cotton swab. A measure of ounces should be blown in the side, and it should be fitted with a short black rubber nipple, which can be removed and turned inside out for thorough cleansing. This short nipple has the further advantage that the child is less apt to be left by the nurse alone with the bottle. The latter is a slovenly way to feed an infant, and should be discountenanced, for the child gets its milk with periods of delay and irregularity. The bottle may slip out of reach, or after it is empty the child keeps on sucking or draws in air, and obtains the milk at uneven temperatures, or sometimes the child goes to sleep with the nipple in its mouth, and, awaking, it finishes the bottle. " The sucking power of the child is to a great extent produced by the. muscles at the posterior portion of the mouth ; if this action is carried on to a great extent it has a ten- dency to contract the width of the mouth and cause protrusion of the teeth" (Cryer). For these reasons the nurse should always con- tinue holding the bottle in a comfortable position for the child until it has taken its portion. This usually requires a few minutes less time than is occupied in nursing at the breast. The usual time is not above ten minutes (Dencke). Any residue in the bottle should be at once thrown away, and not warmed over for a second feeding. For washing the milk bottles a solution of sodium bicarbonate or salicylate, a teaspoonful to the pint, should be first used, after which they must be thoroughly scalded in boiling water. If fitted with a plug of sterilised baked absorbent cotton they will remain sterile until ready for use. When from six to eight teeth have appeared the bottle can usu- ally be discarded. Care of the Infant's Mouth. Cryer says that mothers or nurses in caring for the infant "will give attention to dirty hands or face and bathe the body daily, but how few keep the mouth as clean. The teeth should be gently and thoroughly brushed with a small soft tooth brush as soon as they make their appearance. . . . Fer- mentation of residual portions of milk remaining in the mouth of the infant after feeding is a prolific source of gastric curd, intesti- nal irritation, giving rise to colic and diarrhoea. The mouth of the child should therefore be kept carefully cleansed, and before each feeding be washed out with a solution of boric acid in distilled water applied on a soft linen rag." Weighing of Infants. The systematic weighing of infants at least once a week is a very useful indication of the progress in nu- 732 RATIONS, DIETARIES. trition and growth which they are making, and it should not be" neglected. Budin has recently reported some interesting experiments with three classes of infants namely, (i) suckled, (2) partly suckled, partly artificially fed, (3) artificially fed. During the first fortnight of life he found that the gain in weight was considerably more rapid with suckled infants, but during the first year of life the infant will gain as much weight if fed upon cow's milk as if suckled. Roughly speaking, the infant's weight should be doubled in the first five months of life and trebled in the first year. Premature Infants. .The feeding of premature infants de- mands unusual care. Their bodies are small ; their vitality is low ; their digestion is feeble, and their rate of heat loss is rapid. They are sometimes advantageously reared in incubators. They are often too weak to suckle or even to take the bottle unless they are very carefully hand-fed so as to obtain the milk without effort. It may be best to feed them by gavage. This method takes less time than any other. A small, feeble, puny infant at nine months of age may not take as much as ten ounces of milk a day, and yet keep alive. Such a baby must be fed at shorter intervals than the rule allows for well-developed infants at the same age. A two-hour interval will often be best. FOOD FOR YOUNG CHILDREN. The infant, although weaned, should receive all its food from the bottle until at least the twelfth month, and then very gradually a few other articles than milk or beef juice may be added. Children often do best, however, upon a milk diet up to the end of the second year. " Towards the end of the second year all the milk teeth have cut through, and the digestive functions have greatly increased in power. The lower maxilla becomes stronger, the muscles of mastica- tion more powerful, the cavity of the mouth larger, the lips more fleshy, the oesophagus wider; the salivary glands are better de- veloped, and secrete a larger quantity of saliva ; the shape of the stomach changes, and its walls grow thicker, the intestinal canal longer and more capacious; in short, all the digestive organs are more adapted to an animal diet. At this period milk alone could not satisfy the child. It may be dispensed morning and evening, but during the day more substantial food is of absolute necessity " (Ammon). Should illness of any kind occur after a child has been put upon solid diet, it should at once be given only fluid food again, and this does not mean a diet of tea and toast water, but of milk or meat broths. FOOD FOR YOUNG CHILDREN. 733 Servants are often very careless in regard to the food which they put within reach of young children, who wish to eat everything they see, and ignorant mothers sometimes give children at the breast tea, coffee,, or beer, and their older children are allowed to eat such sub- stances as the skin of potatoes and fruits, sausages, or canned corn, with the result of causing acute gastritis or convulsions. On the other hand, children should not be allowed to grow up with too little variety in taste. An occasional departure from strict rules or a single indulgence in some ordinarily prohibited article .may do no harm, but serve to gratify and educate the child. Young children of four or five years of age or more commonly crave sugar, but do not care for fatty foods. They are apt also to like vegetable acids, and are therefore fond of fruits. These acids are wholesome, and the fruit is laxative and healthful when ripe and fresh. It may seem superfluous to separately name the chief prohibited substances which must be kept from young children, but experience proves the contrary, and when common sense is lacking in those who are entrusted with their care, a written list of these foods should be given them. If the child's food is too coarse, too much energy is diverted in the attempt to digest it, and this is at the expense of normal growth and development. Young children should be kept out of the pantry and kitchen, where their attention is attracted by forms of food which they cannot have. It is estimated by Edward Smith that in proportion to its weight, . the growing child requires about three times as much carbonaceous food as the adult and six times as much animal food. Foods Forbidden to all Young Children. The following articles are particularly indigestible for children, and should not be allowed them under four years of age, and most of them should not be given under seven or eight years : Fried food of all kinds, game, salt food, the flesh of swine in all forms (pickles, salads, condiments, except salt), "stews," the "dressing" of fowl, sauces, visceral foods (such as liver, kidneys, tripe, etc.), all raw vegetables, potatoes (except baked), tomatoes in any form; the coarser vegetables, such as beets, turnips, cabbage, etc. ; fancy bread, cake, and pastry ; griddle cakes, canned food of all kinds ; fancy con- fectionery, sweets, and preserves; cheese, rich soups, jellies, dried or unripe and overripe fruits (bananas, so often given to young children, are very bad for them), nuts, fruits with large seeds, such as grapes, the skin of all poultry, fruits, or vegetables. All food should be plainly and thoroughly cooked. No greasy or highly seasoned dishes are permissible, and as a rule twice-cooked meats are indigestible. 734 RATIONS, DIETARIES. Tea, coffee, and alcohol in every form must be withheld. The two former beverages interfere with digestion and make the child nervous, and the latter lays the foundation for a permanent alcohol habit. Soda water with sirups should not be given. Too much water should not be allowed with meals, and what is given should not be ice cold. Children, as they grow up, should continue to observe regularity in the hours for taking meals, and the habit of perpetually nibbling at cake, crackers, and confectionery between meals should not be tol- erated. It is best for young children not to be put to sleep immedi- ately after their most substantial meal of the day. As they require a nap in the early afternoon, many advise giving this meal at 4 p. m. The following is a useful summary (taken in part from Holt) of General Rules for Feeding Young Children. 1. Allow time for meals. 2. See that the food is thoroughly masticated. 3. Do not allow nibbling between meals. 4. Do not tempt the child with the sight of rich and indigestible food. 5. Do not force the child to eat against its will, but examine the mouth, which may be sore from erupting teeth ; and examine the food, which may not be properly cooked or flavoured. If good food is refused from peevishness merely, remove it and do not offer it again before the next meal time. 6. In acute illness reduce and dilute the food at once. 7. In very hot weather give about one fourth or one third less food, and offer more water. The young infant depends wholly upon animal food, and derives the necessary carbon largely from the sugar of milk. The older child lives in part only upon animal food, and begins to derive addi- tional carbon from bread and other cereal foods. Quantity of Food Required. Experiments have been made by Ueffelmann, Hasse, and others, to determine the necessary per- centage of albuminous food required per diem per kilogramme of body weight, by growing children, with the following result : Average weight of child. At 2 years 4 grammes. 12.5 kilogrammes. At 3 to 5 years : 3.5 " 15 At 8 to II years 2.5 " 24 " Thus it is seen the percentage of albuminous food required di- minishes as the child gains in weight, and more carbohydrate food is used to replace it. FOOD FOR YOUNG CHILDREN. 7,5. The daily average quantity of food required by each child in an aggregate of twenty-eight healthy children between the ages of two and three years is reported by Starr to be as follows : Bread, 7.5 ounces; butter, .98 ounce; meat (beef), 4.6 ounces; potatoes, 3.9 ounces; milk, 32.6 fluid ounces. The daily average for each child in an aggregate of twelve children between the ages of three and six years was: Milk, 48.6 fluid ounces; beef, 12.1 ounces; rice, 13.0 ounces; bread, 10.3 ounces; butter, i.oS ounce. The daily average for each child in an aggregate of twenty-four children between the ages of four and ten years was: Roast beef, 12.46 ounces; bread, 10.23 ounces; potatoes, 10.03 ounces; butter, .99 ounce; milk, 38.5 fluid ounces. Dietaries for Young Children. The following diets are recommended by Starr as types for use from the period of weaning up to three and a half years or more: Diet from the Twelfth to the Eighteenth Month (Starr). 7 A. M., stale bread soaked in a breakfast cup of new milk. 10 A. M., milk, six ounces, and soda biscuit, or a thin slice of but- tered bread. 2 p. M., beef tea, six ounces, bread, and a tablespoonful of rice and milk pudding. 6 p. M., same as first meal. 10 p. M., a tablespoonful of Mellin's food in eight ounces of milk. In alternation a lightly boiled ^gg with bread crumbs and six ounces of milk may be given at 7 a. m., and at 2 p. m. a mashed baked potato moistened with four tablespoonfuls of beef tea, two tablespoonfuls of junket. Diet from the Eighteenth to the Thirtieth Month (Starr). 7 a. m., new milk, eight ounces ; the yolk of an ^gg lightly boiled; two thin slices of bread and butter, or else milk, and two tablespoon- fuls of well-cooked oatmeal or wheaten grits, with sugar and cream. 11 A.M., milk, six ounces, with a soda biscuit or bread and butter, 2 p. M., one tablespoonful of rare mutton pounded to a paste, bread and butter, or mashed potatoes moistened with good dish gravy, a saucer of junket; or else a breakfastcupful of beef tea or mutton or chicken broth, a thin slice of stale bread, a saucer of rice and milk pudding. 6.30 p. M., a breakfastcupful of milk with bread and butter, or soft milk toast. 49 736 RATIONS, DIETARIES. Diet from Tiuo and a Half to Three and a Half Years of Age (/. er diem, and nothing else. II. Convalescent Diet, or half diet, or light diet, as it is vari- ously called, intended for patients convalescing from acute disease, or for patients who are unable to digest the full house diet. In the average medical ward the majority of patients live usually upon this diet, which is not adapted for the special requirements of any particular disease, but is simply light, nutritious, and easy of diges- tion, and is therefore serviceable in a very large number of cases which do not need more careful selection of their food. III. Farinaceous Diet, from which animal food, with perhaps 748 RATIONS, DIETARIES. the exception of milk and butter, is excluded. This diet is not of very general use, but is temporarily serviceable in some forms of disease, such as chronic Bright's disease and acute gout. IV. Nitrogenous Diet, or animal food, which is somewhat more, used than the preceding diet, and from which sugars and almost all forms of starchy food excepting a little dried bread, toast, or Gra- ham bread, are excluded. This diet is particularly serviceable in cases of flatulent dyspepsia, chronic gastric catarrh, and dilatation of the stomach, in which the starches and sugars invariably undergo acid fermentation, with eructations and flatulence. It also serves for diabetics. V. House or Full Diet should be the most economical diet for the hospital upon which patients who have nearly completed their convalescence may be placed, as well as those patients, including cer- tain medical cases and a large number of minor surgical cases, whose digestive organs are in normal condition. It usually includes the coarser articles of food, sometimes corned beef and cabbage, pota- toes, codfish, etc., and it is very often the general diet for the serv- ants and attendants in hospitals as well as patients. VI. Articles of Special Diet. Under this list are included luxuries and delicacies, such as oysters, jellies, custards, etc., and extra allowances of eggs, chicken, cream, and fruits, which may be desirable to furnish in a few individual cases. With a system arranged upon this plan, as will be seen by the accompanying sample tables, used in some of the representative hospitals, the ordering of the diet is simplified for the visiting physician or surgeon, and is much less apt to be relegated by him to subordinates than it is if he is obliged to spend the time required for selecting a separate menu for each patient in the ward. The limitations of each separate diet should be distinctly understood by all the attendants and nurses, and a printed diet list of articles included under the headings "nitrogenous diet," "farinaceous diet," etc., should be conspicuously posted in the ward dining or service rooms. The daily variations within the limits of these diets should be regulated by the superintendent of the hospital or an assistant, whose special duty it is to provide the food for the institution, and select such articles as will give reasonable variety, due allowance being made for variations in regard to price and season of the year. In many large hospitals not only is the arrangement of the diet imperfect, but the details of preparing and serving food are so in- efficiently supervised that there is great loss from waste and imper- fect cooking, and the additional expense of employing one or two specially trained persons to superintend these matters would be more than counterbalanced by the saving in the waste and in the benefit to the patients. HOSPITAL DIETARIES. 749 Overfeeding. Too much food is often given hospital patients by overzealous nurses, who are anxious to hasten convalescence. This is particularly true in the treatment of simple surgical cases where there is no special digestive disorder. A man accustomed to doing eight hours of active physical labour when put to bed for six weeks or more with his leg immobilised for a fracture, does not need to be constantly stuiffed with large quantities of food, and yet such patients, if the matter is not carefully directed, will be often found to receive full house diet, which in itself is ample for the working attendants of the hospital, and in addition to be given two or three quarts of milk a day as a beverage. The natural result is consti- pation, indigestion, with a heavily coated tongue and more or less biliousness, which in turn is counteracted by a compound cathartic pill or a dose of calomel. I have known of night nurses going through wards with pitchers of milk, and pouring out tumblerfuls for any patients who were at all thirsty, quite irrespective of any supervision. In a large hospital, where the monthly consumption of milk is from ten thousand to fifteen thousand gallons, it may be easily seen that its indiscriminate use as a beverage is an item of very considerable and unnecessary expense to the institution, besides being an actual detriment to many of the patients. AiDOther undesirable tendency among American hospital dietaries is to include too much meat. The ordinary hospital menu compared, for instance, with that of the agricultural labourer, shows this fact very strikingly. Certainly not over four ounces of cooked meat (without bone) should be allowed in the ration for men. " Fish Diet." In some hospitals in addition to the subdivisions of the diet above given, a " fish diet " may be ordered, which is very useful and should be generally adopted. In the London Fever Hos. pital this diet consists of a ration of bread ten ounces and fish eight ounces (the uncooked measure), such as haddock, cod, or sole or some similar fish, potatoes eight ounces, cocoa one ounce, with half an ounce of sugar and a sixth of a pint of milk. This is a service- able and economical form of diet for a considerable class of patients for whom large quantities of meat are not only unnecessary but in- jurious. Broth Diet. In children's hospitals a diet is sometimes classi- fied as the " broth diet," with mutton broth flavoured with vegetables, and bread and butter, with milk; or a "beef-tea diet," in which the beef tea replaces the broth ; and in the lighter diet of children, gruels, bread and molasses, and simple artices of farinaceous food such as farina, corn starch, rice, etc., should play an important role. Some- times such diet goes under the name of " soft food." In some of the English hospitals, as in the London Fever Hos- pital, beer is allowed with the full diet, and in this hospital also a 750 RATIONS, DIETARIES. discrimination is made in ordering the diet according to sex, females being given from two to four ounces less bread and two to three ounces less meat than males. This discrimination is not usually made in American hospitals. Sample Hospital Dietaries, dietary of the new york hospital, 1895. "All patients shall be furnished the regular house diet, unless otherwise specially directed by the attending physician or surgeon. As a substitute for the house diet, there may be furnished, on the order of the attending physician or surgeon only, either of the fol- lowing : " I. Restricted diet. " 2. Milk diet. " The attending physician or surgeon shall specify, on the occa- sion of his first visit to a patient, which diet shall be furnished. This duty may not be delegated to the house physician or house sur- geon, except that, on the admission of a patient to a ward, it shall be the duty of either to give instruction on the subject to the nurse in charge, and such instruction shall be followed until the first visit of the attending physician or surgeon. " The wards shall be supplied with blanks, called diet lists. The head nurse shall carry one of these with her regularly when accom- panying the attending physician or surgeon on his visits, and shall note down carefully all his instructions as to diet ; he shall sign these lists before leaving the ward. " Milk diet, or restricted diet, may not be ordered in addition to the regular house diet, but only as a substitute therefor, but the attending physician or surgeon may order items of special diet in particular cases. " Lists defining the different classes of diet shall be furnished each attending physician and surgeon. " Cards, appropriately inscribed, shall be placed at the head of each bed, which shall designate the class of diet, and also the amount of stimulant, which is furnished each patient. " A diet kitchen is established, under the direction and control of the directress of nurses, wherein articles of special diet shall be pre- pared and served as ordered. " Daily House Diet. ^^ Breakfast. Oatmeal or hominy ; tea or coffee, with milk and sugar ; bread and butter. " Dinner. Potatoes ; bread and butter ; one or more of the fol- lowing vegetables : turnips, sweet potatoes, beets, spinach, squash. HOSPITAL DIETARIES. 75 1 '' Supper. T&a. vi'iih milk and sugar; bread and butter; stewed or fresh fruit. "/ addition on Sunday. Breakfast: eggs. Dinner: roast beef, corn-starch pudding. J/^^a'.^)'. Breakfast : baked potatoes. Din- ner : stock soup, stewed beef or mutton, rice pudding. Tuesday. Breakfast: Mutton chops. Dinner: pea soup, roast mutton, bread pudding. Wednesday. BxtakidiSX.: fried or stewed potatoes. Din- ner : roast beef, corn-starch pudding. Thursday. Breakfast : eggs. Dinner : stock soup, stewed beef or mutton, tapioca pudding, ^r/- t/ay. Breakfast : salt mackerel or codfish. Dinner: bean soup, baked fish, beans, rice pudding. Saturday. Bxtskisist: beefsteak. Dinner : corned beef, cabbage, bread pudding. " J^es trie ted Diet. '' Breakfast. Tea. or coffee (with milk and sugar), farinaceous food (with milk), eggs. "Z>/^/-. Soup ; either of the following : raw oysters, roast beef, steak, chicken with vegetables, pudding (bread, rice, tapioca, or corn starch), " Supper. Tea (with milk and sugar), bread (with butter), fruit (fresh or dried). " Milk Diet. "Six pints of milk daily. " Articles of Special Diet. " Milk, eggs, beef tea, oysters, corn starch, chops, steak, chicken, chicken soup, rice, broth, farina, ice cream, as ordered by the attend- ing physician or surgeon. "Salt fish, jellies, custards, gruels." At the New York Hospital a carefully graduated diet list, made out in ounces /(?/- capita, was formerly in use, but it was found both un- necessary and unpractical. Separate tables are laid for the patients, nurses, and servants; but the amount of food is estimated in a gen- eral way, the terms being based rather upon the cost price /^r capita than upon the number of ounces, and it is proportioned by the house- keeper and her assistants with due regard to economy. DIETARY OF THE PRESBYTERIAN HOSPITAL, NEW YORK. 1898. Although the diet is very satisfactory and ample at the Presby- terian Hospital, New York, the food allowance /<'r capita for patients is not separately estimated, and the house diet, convalescent diet, and diet for the servants are all originally prepared in bulk, and subse- quently subdivided by the cooks and nurses, under the order of the visiting physicians and surgeons, but without regard as to accurate measurement of quantity in ounces. 50 752 RATIONS, DIETARIES. House Diet. Convalescent Diet. Nitrogenous Diet. BREAKFAST. BREAKFAST. BREAKFAST. Tea or coffee (milk and Tea or coffee (milk and Tea or coffee (milk sugar). sugar). Bread and butter Bread and butter Bread and butter Graham bread. White bread, or White bread, or Graham bread, or Graham bread, or Corn bread, or Corn bread, or Rolls, or Toast. Rolls, or Toast. Porridge Porridge Oatmeal, or Hominy, or Wheaten grits, or Farina. Indian meal, or Hominy, or Farina, or Samp. Meats Meats Meats Hash, or Eggs, or Eggs, or Eggs, or Fresh fish, or Fresh fish, or Salt fish, or Stew (plain). Stew without vegeta- Fresh fish, or bles, or Stew. Meat hash without po- tatoes. DINNER. DINNER. DINNER. Soup Soup Soup Stock, or Stock, or Stock, or Mutton broth, with bar- Chicken, or Chowder. ley or vegetable, or Mutton broth, with bar- Chowder. ley or vegetable. Dry bread. Dry bread. Graham bread. Meats- Meats Meats Beef (roast or boiled), or Beef (roast or boiled), or Beef (roast or boiled), or Mutton (roast or boiled), or Chicken, or Mutton(roastorboiled),or Corned beef, or Fish (fresh). Fresh fish, or Fresh fish, or Irish stew. Irish stew. Vegetables V^etables Vegetables Potatoes, baked, boiled. Potatoes (baked), or Spinach, or or mashed, and Rice, or Lettuce, or Tomatoes, or Macaroni, or Celery, or Baked beans, or Samp. String beans. French beans, or Turnips, or Beets, or Rice, or Macaroni, or Samp. Pudding Pudding Pudding Rice, or Rice or Custard. Bread, or Bread, or Tapioca, or Tapioca, or Farina, or Farina, or Corn starch, or Custard. Com starch, or Custard. SUPPER. SUPPER. SUPPER. Tea (sugar and milk). Tea (milk and sugar). Tea (milk). Bread and butter, or Bread and milk, or Graham bread and but- Toast and butter. Milk toast, or ter, or Bread and butter, or Bread and milk. Toast and butter. Eggs, or Fruit Fruit Cold meat. Apples, stewed or baked, or Apples, stewed or baked, or Prunes, or Pears. Prunes, or Pears. HOSPITAL DIETARIES. 753 Farinaceous Diet. Milk Diet. Extras. BREAKFAST, BREAKFAST. ORDERED ONLY BY THE Tea or coffee (milk and One quart of milk. ATTENDING PHYSICIAN sugar). OR SURGEON. Bread and butter Mutton chops. White bread, or Beefsteak. Graham bread, or Scraped beef. Com bread, or Beef tea (made with hy- Rolls, or drochloric acid). Toast. Chicken (broiled, fricas- Porridge seed, or roast). Hominy, or Chicken broth. Farina, or Eggs. Indian meal. Milk. Oysters. Clam broth. Gruels. Crackers. Gingerbread. Custard. Milk toast. DINNER. DINNER. Soup One quart of milk. Vegetable, or Macaroni, or Barley broth. Dry bread. Vegetables Baked potatoes and Tomatoes, or French beans, or Rice, or Macaroni, or Samp. Pudding Rice, or RrpnH, or Tapioca, or Farina, or Comslarch. SUPPER. Tea (milk and sugar). Bread and milk, or Milk toast, or Hominy, or Boiled rice, or Farina. Fruit Apples stewed or baked, or Prunes, or Pears. SUPPER. One quart of milk. 754 RATIONS, DIETARIES. ?^ < H m O K < 01$ M s ^ ' 1 1 S a 1 a o U 3 e f 2 . a 8 u a c (2 4 I 5 Q f^ ii w G Si a u 2; HOSPITAL DIETARIES. 755 The foregoing is a copy of the diet sheet in daily use in the wards at the Presbyterian Hospital, New York city. It will be observed that it is properly classified according to quality as well as quantity. It was introduced several years ago after a careful com- parison with diets of other institutions, and it has proved very prac- tical. It is the most liberal and best-classified diet of any hospital with which I am familiar. DIETARY IX BELLEVUE, GOUVERNEUR, FORDHAM, AND HARLEM HOSPITALS, NEW YORK, 1897. Monday. Breakfast. Coffee, one pint, with half an ounce of milk and half an ounce of sugar ; bread, five and one third ounces, and a quarter of an ounce of butter ; oatmeal, one ounce ; crackers, one ounce ; milk, one quart. Dinner. Roast beef, eight ounces ; rice, one ounce ; soup, one pint; potatoes, eight ounces; vegetables, four ounces; bread. Supper. Tea, one pint, with half an ounce of milk and half an ounce of sugar; five and one third ounces of bread and a quarter of an ounce of butter ; one ounce of stewed apples. Tuesday. Breakfast. Coffee, one pint, with half an ounce of milk and half an ounce of sugar; bread, five and one third ounces, and a quar- ter of an ounce of butter ; hominy, one ounce; crackers, one ounce; milk, one quart. Dinner. Mutton stew, eight ounces ; potatoes, eight ounces ; vegetables, four ounces ; bread, five and one third ounces ; bread pudding, two and a half ounces. Supper. Tea, one pint, with half an ounce of milk and half an ounce of sugar ; bread, five and one third ounces ; butter, a quarter of an ounce. Wednesday. Breakfast. Cofi:t, one pint, with half an ounce of milk and half an ounce of sugar ; five and one third ounces of bread and a quarter of an ounce of butter; rice, one ounce; crackers, one ounce; milk, one quart. X)/>/// Diastase, 330. Diet, alimentary-canal diseases and, 481 ; anaesthetics and, 675 ; arctic expedi- tion, 271-273, 296 ; average daily, for adult, 266 ; blood diseases and, 450 ; brain workers, 708 ; circulatory system and, 450; commercial life and, 7" i concentrated fowls, 251 ; convalescent fever, 395 ; convalescent typhoid fever, 406 ; Cornaro's. 276 ; cures for phthisis, 440 ; dry, 449, 454 ; exclusive milk, 43 ; fever in general and, 387 ; heredity and, 2gi ; improperly balanced ingredients of, 281 ; in disease, 387 ; infectious dis- 788 INDEX. eases and, 387^ kitchen outfit, 386 ; leanness and, 615 ; liver diseases and, 557 : method of adapting, for the sick, 339 ; milk, in tuberculosis, 437 ; milk, in typhoid fever, 398 ; miscellaneous dis- eases and, 371 ; mixed, 26 ; monotony of, 305 ; nervous-system diseases and, 569 ; occupation and, 707 ; pancreatic dis- eases and, 568 ; prison, 688 ; puerperal women and, 714; race and, 291 ; respi- ratory-system diseases and, 440 ; school children's, 740 ; standard daily work, 264 ; starvation, 279, 280 ; travel and, 712 ; Tufnell's 457 ; urinary-system dis- eases and, 463 ; variety in, 305 ; vege- tarian, 30. Dietaries, 680, 659 ; army hospital, 763 ; for young children, 732 ; hospital, 750 ; standard, 12, 264, 265 ; weight of nutri- ents in, 12. Dietetic breads, 127 ; causes of disease, 339, 341 ; complications from associated diseases, 673. Digestibility, comparative, of meats, 95 ; of nutrients, 21. Digestion, 307, 316 ; alcohol and gastric, 211 ; artificial, 329 ; circulation and, 308 ; conditions especially affecting, 299 ; duration of gastric, 322 ; exercise and, 312 ; external heat and, 309 ; in the intestine, 326 ; in the mouth, 316 ; in the stomach, 317; of fats, 328; of food, 299 ; of proteids in the stomach, 325 ; salivary, 317 ; sleep and rest and, 313 ; temperature and, 313. Digestive ferments, 329. Dilatation of the stomach, 511 ; dietetic treatment, 511 ; electricity for, 511 ; lavage, 513 ; massage, 516 ; pathological physiology, 511. Dinner, 299 ; hour, 3CX3. Diphtheria, 414; feeding in, 315; paraly- sis in, 418. Diseases, diet in, 450 ; caused by dietetic errors, 341, 399 ; especially influenced by diet, 599 ; of the alimentary canal, 481 ; miscellaneous, 671 ; of the blood, 458 ; of the circulation, 450 ; of the heart, 450 ; of the intestines, 529 ; of the liver, 557 ; of the mouth, 481 ; of the nervous system, 566 ; of the oesopha- gus, 484 ; of the pancreas, 568 ; of the stomach,485; of the urinary system, 463. Disinfection of utensils, 374. Disordered sleep, 582. Diuretic beverages, 768. Donkin's diet for diabetes, 659. Dough, 122, 129. Doura, 135. Dried dates, 160 ; fruits, 254 ; vegetables, 250. Drink, excess of, 343. Drinks, effervescing, 189. Drugs in human milk, 718. Dry diet cure, 702 ; for the senile heart, 449. 454 ; Tufnell's, 457. Drying of food, 249, 253. Duck, 107. Duckworth, Sir Dyce, on gout, 624, 628. Dujardin-Beaumetz, average daily dietary, 266 ; grog de la poudre de viande, 99 ; treatment of dyspepsia, 499 ; system for obesity, 612. Diiring's diet for diabetes, 661. Dysentery, acute, 543 ; chronic, 544. Dyspepsia, 485 ; alcohol in, 217 ; anaemia and, 501 ; atonic, 5C0 ; beverages for, 498 ; bulimia and, 501 ; children with, 501 ; desirable foods for, 497 ; dietetic treatment, 496 ; Dujardin-Beaumetz's treatment, 499 ; flatulency and, 500 ; foods forbidden in all cases, 496 ; foods allowable, 497 ; gout and, 501 ; hyper- acidity and, 500 ; irritative, 500 ; Leube's treatment, 499 ; lules for special vari- eties, 500 ; See's treatment, 499 ; sys- tems of treatment, 498. Dyspeptics, general rules for, 499. Dysphagia, 483. Ebstein, diabetic diet, 660 ; on gout, 623 ; on obesity, 604. Economic value of foods, 19, 21. Eczema, 594 ; children and, 597 ; insuffi- cient food and, 595 ; nursing infants and, 596 ; overeating and, 595 ; shellfish and, 113 ; typical diet for, 594. Eels, no. Effervescing waters, 188. Egg albumen, 90 ; brandy and, 775, 776 ; composition of a hen's, 89 ; prepara- tions, 775 ; wine and, 775. Eggnog, 90, 775. Eggplant, 153. Eggs, 89, 178, 250, 257; absorption, 89 ; boiled, 91 ; cooking, 90 ; dried, 92 ; INDEX. 789 enemata of, 381 ; freshness, 90 ; gout and, 625 ; in fever, 391 ; in tubercu- losis, 432 ; plover's, 178 ; preservation of, 92, 256 ; raw, 90 ; scrambled, 92. Einhom's gastric electrode, 517; stomach bucket, 489. Elderberry, 169. Electricity for gastric dilatation, 517 ; in chronic constipation, 552. Elements, chemical, i ; analysis of, in foods, 4 ; quantity of, in standard diets, 16. Embi^onine, 655. Emphysema, 445. Empyema. 449. Endive, 153. Enemata, nutrient, 375 ; aids to retention. 378 ; composition of, 380 ; methods of injection, 377 ; opium in, 379 ; pancreas and meat, 773. Energy from food, 7 ; sugar and, 114. English army ration, 684 ; hospital diet- ary for children, 762 ; walnuts, 171. Enteralgia, 572. Enteritis, acute catarrhal, 536 ; chronic, 470, 536 ; membranous, 541. Enterocolitis in infants and children, 534 ; chronic, 539 ; dietetic treatment, 534 ; prevention, 534. Epilepsy, 583. Erbswurst, 146. Ergotism, 355. Erysipelas, 419. Erythema, 592. Escherich on diarrhoea! stools. 532, 533. Eskimo, dietetic habits of, 292, 342. Ewald, test for motor power of stomach, 494. Exclusion of air from food, 257. Exercise and digestion, 312 ; for school children, 740. Exophthalmic goitre, 672. Extracts, 249 ; of beef, 98 ; of pancreas, 68, 332. Extractum camis, 103. Famine, 281 ; crime and, 277. 281. P'arina, 133. Farinaceous diet in hospitals, 747 ; gruels in typhoid fever, 401. Farinaceous foods, prepared, 130. Fasting by Eskimos, 294 ; girls, 276 ; hysteria and, 276. Fat, albumen compared, 27 ; beef, 177 ; diarrhoea! stools and, 532 ; estimation of, in milk. 50 ; of cream, 83 ; of pork, 177 ; storage, 27. Fatigue and food. 313. Fats, animal, 176 ; cooked, 175 ; corrosive poisons, and, 175 ; dietetic uses, 179 ; digestibility, 174; digestion of, 328; diseases in which fats are forbidden, 179 ; diseases in which fati^ are useful, 179; excess of, 175; gout and, 626; heat producers, 16 ; laxative action, 180 ; of milk, 45 ; percentage of, in foods, 1 1 ; tuberculosis and, 433; uses of, 173; vegetable, 178. Feeding, forced, 439, 588 ; helpless pa- tients, 372 ; hypodermic, 383 ; intravas- cular, 383 ; irregularity in, 370 ; of in- fants, 263, 719 ; rectal, 375 ; sleep and, 373 ; the sick, 369 ; through gastric fis- tula, 4S4 ; unconscious patients, 374 ; young children, 734. Ferments, 329 ; in food, 253. Fever, alcohol in, 215 ; beverages in, 392 ; convalescent diet in, 395 ; diet in, 387 ; intermittent, 426 ; malarial, 426 ; patho- logical physiology, 387 ; receipts suitable for. 767 ; remittent, 427 ; scarlet, 411 ; typhoid, 397 ; typhus, 410. Field ration. 682. Fig wine, 232. Figs, 160, 169. Filbert, 172. Fining of wines, 224. Fish, no; desiccated, in ; diet, 111,749; digestibility of, in; dried, ni, 250; fat. 178 ; frozen, 255 ; gout and, 625 ; oils, 178; poisoning, 353; roc, in; smoked, in. Fistula, gastric, 484. Flavouring fluid food, I02. Flaxseed tea, 768. Flies, infection of food by, 363. Flour, 118; balls, 131 ; banana, 164; de- corticated, 128 ; rice, 124 ; wheat, 126. Fluid, hot, 310 ; iced, 310; meat, 98. Food, absorption, 334 ; age and, 283 ; ad- ministration of, for the sick, 369 ; adult life and, 284 ; adulteration, 356 ; amount required per diem, 267-269 ; amesthctisation and 674 ; antiseptics in, 259; artificial. 729 ; Hengcr's, 132; body heat and, 311 ; body weight and. 790 INDEX. 289 ; Camrick's, 81, 133 ; childhood and, 263 ; classification, 4 ; climate and, 296 ; concentration, 104, 249 ; cost of, 19 ; daily allowance, 14 ; death from lack of, 9 ; details of serving, 370 ; dextrinised, 132 ; digestion, 299 ; eco- nomic value of, 19, 21 ; enemata, 375, 382 ; energy from, 7 ; equivalents, 267, 268, 337 ; Eskimos', 293 ; evaporated, 132 ; excess of, 342 ; exercise and, 312 ; farinaceous, with malt, 131 ; farinaceous, receipts for, 767 ; fatigue and, 313 ; fe- ver and, 387; flavouring fluid, 102 ; for special conditions, 283 ; for young chil- dren, 735 ; frozen, 255 ; general rela- tion to special diseases, 339 ; hypoder- mic injections of, 383 ; ideal ration of fluid, 265 ; ideal ration of solid, 265 ; idiosyncrasies, 364 ; improperly bal- anced ingredients of, 344 ; income of, 336 ; individual size and, 289 ; infants and, 732 ; infection through flies, 363 ; insufficient, 342 ; insomnia and, 315 ; in the mouth, 316 ; in the stomach, 317 ; inunctions, 382 ; lactated, 81 ; medi- cines and, 383, 385 ; Mellin's, 132 ; micro-organisms in, 360 ; minimum amount for difl"erent ages, 383 ; modifi- cations produced in urine by, 463 ; mineral, for daily use, 270; Nestle's, 81, 133 ; old age and, 285 ; parasites and, 344 ; preservation, 253 ; propor- tion of carbohydrates, 267, 269, 270 ; proportion of proteid, 267, 269 ; pur- veyors, training of, 386 ; ptomaines in, 350 ; quantity eaten in lifetime, 274 ; quantity for the sick, 270 ; quantity re- quired, 261 ; raw, 293 ; receipts, 767 ; rest and, 313 ; season and, 296 ; sex and, 290; sleep and, 313, 314 ; substi- tutes' for, 260 ; suppositories, 382 ; teething and, 739 ; temperature of, 308, 309 ; undigested, 329 ; vegetable, 143. Foods, albuminoid, 5 ; amylaceous, 113, 119; animal, 4, 41 ; animal, in bilious- ness, 559 ; animal and vegetable com- pared, 22; azotised, 5; baby, 130; brain, 20 ; calorifacient, 5 ; cereal, 118 ; classes of, 30 ; complete, 4 ; composi- tion of common, 6 ; duration of diges- tion of different, 322 ; elementary com- position, I ; farinaceous, 113, 119 ; fatty, 176, 178 ; force producers, 6 ; force-producing value of different classes, 15 ; heat givers, 20 ; infant, 130; Liebig's, 131; material for mus- cles, 20; military pea, 146 ; nei"ves and, 30 ; nitrogenous, 5 ; non-nitrogenous, 5 ; order of taking, 299 ; pancreatin- ised. 333 ; peptonised, 333 ; prepared farinaceous, 130, 133 ; relative value of, 20 ; respiratory, 5 ; salts of, 38 ; special conditions and, 283 ; starch percentage in vegetable, 119; starchy, 118; stimu- lating, 20 ; tissue formers, 5 ; vegetable, 4 ; vegetable, in biliousness, 560 ; water in, 34- Foot-and-mouth disease, 363. Foot-ball-team diet, 707. Foot tons of engine compared with body, 8 ; heat and. 7 ; latent energy and, 8 ; per diem, 7, 12, 14 ; potential energy in diff'erent dietaries, 22. Force production, 7 ; of diff'erent classes of foods, 15. Forced feeding, 439, 588. Fordham Hospital dietary, 755, Foreign bodies swallowed, 484. Fothergill's amylaceous food, 779. Fowl, 107. Freezing food, 255. French army hospital diet, 765 ; army ra- tion, 680 ; Cognac, 230. Fresenius's tabletof fruit composition, 157. Fruit, biliousness and, 560 ; constipation and, 548, 549 ; diabetes and, 652, 653 ; essences, 188 ; gout and, 627 ; poison- ing, 159 ; sirups, 188. Fruits, acids of, 156 ; antiscorbutic use of, 158 ; candied, 113 ; classification of, 156 ; composition of, 157 ; cooked, 159 ; daily diet of, 159; digestibility, 160; diuretic use of, 158 ; dried, 160 ; flavour of, 156 ; glucose in, 116 ; laxative action, 158, 161 ; organic acids, 156 ; pectin, 156; properties, 158; ripening, 159; soups, 160 ; sugar, 114, 117, 157 ; table of com- position, 157 ; uses, 158 ; varieties, 161 ; water in, 158 ; when to eat, 159. Frying, 246. Full diet, 748. Functional albuminuria, 466. Fungi, 169; poisonous, 171. Fungus, of ergot, 355 ; yeast, 205. Furunculosis, 598. Fusel oil, 229, 231. INDEX. 791 of, Gaduin, 180. Gall ducts, acute inflammation of, 561 Gallstones, 565 ; dietetic treatment 567 ; olive oil for, 174. Game, 107, 246; "lugn," 246, 351; poi- soning, 351, 355. 7 Garlic, 154. / Garrod on gout, 624/; theory of scurvy, 669. / Gases, of indigestion,; 486 ; intestinal, 329. Gastralgia, 571. / Gastric catarrh, acute, 502 ; causation, 502 ; convalescerice, 504 ; in children, 504; symptoms,' 502 ; treatment, 502. Gastric catarrh, chronic, causation, 505 ; convalescence, ^09 ; dietetic treatment, 506 ; electricity I for, 5 10 ; exercise for, 510; in childien, 510; hydrochloric acid for, 509 ;i lavage, 510; massage, 510; milk die|, 506 ; other diets, 507; pathological physiology, 505. Gastric digestion^ 317; alcohol and, 211 ; duration, 322.1 Gastric juice, 31I3, 491 ; abnormalities of, 326 ; absence \>{ hydrochloric acid, 326 ; hyperacidity, 326 ; hypersecretion, 326, 493-, secretion of, 319; fistula, 484; fever in children, 504 ; ulcer, 523. Gastritis, chronic, 505. Gastro-intestinal catarrh, chronic, 539. Gastro-enteritis, chronic pseudo, 541. Gelatin, 108, 325 ; capsules of cod-liver oil, 183 ; in fever, 392 ; milk and, 67 ; preparations of, 780. Geneva gin, 230. German army ration, 684. Germs in food, 253, 260. Gin, 229, 230. Ginger, 236 ; ale, 188. Glucose, 116. Gluten, 325 ; bread, 128, 654 ; casein, 121 ; fibrin, 121 ; flour, 654 ; vegetable, 144. Glutin, 121. Gluttony, 261. Glycerin, 180 ; laxative action, 180 mouth wash, 37. Glycogen, 18. Glycosuria, 114. Gonorrhoea, 481^ Goose, 107. Gooseberries, 168, 169. Gorgonzola, 88. Gout, aids to dietetic treatment, 631 ; beverages and, 628; causation, 619; chronic, 624 ; diabetes and, 634 ; die- tetic treatment, 622 ; preventive treat- ment, 62'i ; saline waters, 630 ; symp- toms, 621 ; theory of dietetic treatment, 622. Gouty diathesis, 624. Gouverneur Hospital dietary, 755. Graham bread, 125 ; crackers, 125, Grain poisoning, 354. Granum, 130. Grape cure. 699 ; must, 221. Grapes, 166; sugar in, 114, 116. Gravel, 478. Greely expedition, diet in, 272 ; diet for arctic expedition, table of, 274. Green tea, 192 ; vegetables, 151. Greens, 144. Grilling, 243. Groats, Scotch, 139 Grocer's itch, 115. Grog de la poudre de viande, 99. Ground pear, 149. Grouse, 107. Gruel, banana, 165 ; cracker, 779 ; Indian meal, 779 ; milk, 69 ; oatmeal, 777 ; re- ceipts for, 777 ; rice, 778 ; typhoid fever and, 401. Gruy^re, 88. Guinea-worm disease, 345. Gum in fruits, 157. GQnzberg's lest for free hydrochloric acid, 492. Habit in children's diet, 745. Haemoptysis, 442. Ham, 106. Hard-labour prison diet, 262. Hard-tack, 134. Haricots, 147. Harlem Hospital dietary. 755. Hartwell on athletic training, 707. Hash, 240. Hasheesh and fasting, 261. , ^^HarT disease, diet in, 108, 450; senile, ^ diet for, 453. Heat, external, and digestion, 309. Haemorrhage of the lungs, 443. Hrcmorrhagic purpura, 67 1. Hscmorrhoids, 555. Hepatalgia, 572. Herb teas, 188. 792 INDEX. Herbs, aromatic, 237. Heredity and diet, 291. Hetero-albumose, 325. Hindu, diet of the, 296. Hock, 229. Hoff's Malt Extract, 143. Holland gin, 230. Holt, dietaries for young children, 738 ; formul?e for infant feeding, 727 ; on weaning, 724. Honey, 117. Hop extracts 219. Horseradish, 237. Hospital dietaries, 750. Hospitals for children, dietaries of, 762, 763. Hot drinks, 308, 310 ; fluids, 310 ; food, 308 ; water cure, 701. Hours for meals, 299 ; for children's meals, 741. House diet, 748. Huckleberries, 168. Human milk, analysis, 47 ; artificial, 77 ; - drugs in, 48, 718. Humphrey's diet of centenarians, 286 ; report upon centenarians, 286. Hunger, 279, 315; in diabetes, 642; rec- tal feeding and, 316. Hydrochloric acid, 320 ; absence of, 326 ; Boas test for, 492 ; calcium-carbonate test for, 492 ; free, 491 ; gastric catarrh and, 509 ; Gunzberg's test for, 492. Hydrogen, i, 2 ; combustibility in foods, 3 ; in iocA per diem, 13 ; quantity elimi- nated, 13. Hyperacidity of gastric juice, 326. Hypersecretion of gastric juice, 326. Hypodermic feeding, 385. Ice, 37 ; cracked, 37 ; purity, 31. Ice-cream poisoning, 353. Iced fluids, 310. Iceland moss, 41, 171. Ideal ration of liquid food, 265 ; of solid food, 265. Idiosyncrasies in regard to food, 364 ; of dyspeptics, 487. Immermann, theory of scurvy, 669. Imperial drink, 768. Imperial Granum, 130. Inanition, 274. Indian corn, 136. Indigestion, 485 ; chronic, in children, 538. Infant feeding, 263, 718. Infant feeding tables, 727 ; Chrystie's, 729 ; Dencke's, 726 ; Holt's, 729 ; Purdy's, 727 ; Rotch's, 727 ; Starr's, 726, 728. Infant stomach, size of, 718. Infants, eczema in, 596. Infants, premature, 732 ; weighing of, 731. Inflammations, surgical, 678. Influenza, 413. Injuries, surgical, diet after, 676. Insane, dietary for the, 587. Insanity, 587 ; from hunger, 279. Insomnia, 582 ; and food, 315. Intermittent fevers, 426. Intervals of infant feeding, 720. Intestinal antisepsis in typhoid fever, 404 ; catarrh, 537 ; catarrh, chronic, 539 ; gases, 329 ; indigestion, chronic, in children, 538 ; obstruction, acute, 544 ; worms, 345. Intestine, food in the, 326. Intravascular feeding in, 416. Inunction foods, 382. Inulin bread, 656. Invalid ration too low in carbohydrates, 375 ; in proteid, 265. Irish whiskies, 230. Iron, 2, 41 ; ration, 146. Isinglass, 108. Jam, 168. Jaundice, catarrhal, 561. Jeannette expedition, starvation, 279. Jeff"ries's gluten bread, 654. Jellies, no. Jelly, barley, 779 ; bread, 779 ; calfs-head, 109 ; calfs-foot, 109 ; chicken, 773 ; currant, 768. Jerusa'em artichokes, 149. Jessen's table of digestibility of meat, 95, 96. Jockeys' training diet, 707. Johannisberg wine, 225. Johannis water, 1S9. Johns Hopkins Hospital dietary, 758. Johnson's fluid beef, 103. Jones, Bence, on gout, 624. Jones's method of meat preservation, 260, Juice, beef, 769 ; 100 ; clam, 112. Junket, 64. Kava, 206. Keating's diet for neurasthenia, 581. index; 793 Kefir ferments, 72. Kepler's malt extract, 143. Kidney beans, 147. Kidneys, 108. Kindermilch, 333. Kirscb, 230. Klemperer's test for motor power of stom- ach, 495. Kneipp system, 699. Kohl rabi, 150. Kola, 205 ; composition, 205 ; infusion, 205 ; uses, 205. Konig, analysis of grape must, 221 ; com- position of coffee, 196 ; composition of mushrooms, etc., 170. Koumiss, 6g ; composition, 71 ; cure, 71 ; diabetes and, 660 ; ferment, 70 ; home- made, 70, 775 ; manufacture of, 69 ; properties, 70; sterilised, 73. Koumysgen, 71. Kronenquelle water, 190. Kulz's inulin biscuits, 656. Kummel, 232. Kumyss, 69 (see Koumiss). Kussmaul's method of lavage, 513. Laboratories, milk, 78. Labour and food, 262. Lachrymoe Christi, 225. Lactalbumin, 46. Lactated food, 81. Lactic acid, 46. Lactometer, 50. Lacto-preparata, 81. Lactose, 117 ; estimation of, in milk, 51. Lamb, 106. Landois and Stirling, table of, 267. Laparotomy, diet after, 677. Lard, 176. Laryngismus stridulus, 441. Laryngitis, tubercular, 441. Lathyrism, 355. La Trappe monks, dietetic habits of, 302. Lavage, 513 ; in gastric carcinoma, 528. Lead poisoning, 358 ; chronic, 672. Leanness, 615. Leaven, 122. Lebert's milk cure, 437. Leeks, 154. Legumes, 145. Legumin, 69, 144, 655. Lemon, 161 ; ice, 162 ; juice, 161. Lemonade, 161, 188, 768 ; effervescing, 768 ; in fever, 392 ; substitutes for, 188 ; with eggs, 776 . Lenten fasting, 277. Lentils, 145, 147. Letheby, oatmeal analysis, 140. Lettuce, 152. Leube's test for motor power of the stom- ach, 494 ; treatment of dyspepsia, 499. Levulose, 117, Leyden's diet for neurasthenia, 580. Lichen, 171. Liebig-Horsford baking powders, 123. Liebig's extract of meat, 103 ; foods, 131. Life ration, 13. Lima beans, 147. Lime, 38, 39; saccharated,67 ; water, 775. Lime juice, i6i ; biscuit, 39. Limes, 161. Linseed tea, 768. Lipanin, 184, 220. Liqueurs, 232 Liquor, consumption of, 219 ; pancreati- cus, 333. Liquors, 229. Litterateur, diet for, 708. Litha;mia, 478. Liver, 108 ; abscess, 565 ; amyloid, 564 ; diseases of the, 557 ; fatty, 564 ; syphi- lis, 565. Liverjwol Hospital dietary, 758. Lobsters, 112. Locomotor ataxia, 586. Loeflund's Malt Extract, 143. Lupulin, 220. Macaroni, 134 ; boiled, 780. Macaroons, 171. Mace, 236. Madeira, 225, 226, 232. Maize, 136. Malaga, 225, 226. Malarial fever, 426. Malmsey, 225. Malt, 142, 330 ; cod-liver oil and, 184 ; extracts, 142 ; flour, 142 ; food, 142. Malt extracts, ground, 330, 779 ; HofTs, 143; Kepler's, 143; Loeflund's, 143; Trommer's, 143. Malt liquors, 219, 287 ; gastric digestion and, 211. Malted milk, 81, 132. Maltose, 116, 142, 330. Mammoth, frozen, 255. 794 INDEX; Mania, 587. Manioc, 140. Mannite, 117 ; for diabetics, 657. Marasmus, 540 ; cod-liver oil in, 185 ; in- unctions in, 174. Maritime people, diet of, 296. Marrow, vegetable, 154; bone, 177. Mash, sour, 230 ; sweet, 230. Massage, 516 ; in chronic constipation, 551. Mate, 201. Matzoon, 73. Meal, 137; banana, 164; corn, 137; In-- dian, 137 ; peanut, 172. Meals in relation to sleep, 314. Meningitis, cerebro-spinal, 418. Measles, 412. , Meat, biscuits, 773 ; composition, 93, 105 ; consumption, 92 ; diet, 93 ; digestibility, 27, 95 ; dried, 250 ; extract, 770 ; extract, composition of, 105 ; fluid preparations, 100 ; frozen, 255 ; gout and, 626 ; hot water and, 612 ; infection, 361 ; juice, fresh, 100 ; lozenges, 99 ; obesity and, 612 ; pancreatinised, in enemata, 380 ; poisoning, 351 ; preservation, 260 ; pu- rees, 102 ; quantity eaten, 93 ; rare, 245 ; raw, 94, 325, 772 ; salt, 242 ; school chil- dren and, 744 ; scraped, 97 ; short-fibred, 105 ; solid preparations, 772 ; soups, 248 ; sterilised, 256 ; tubercular infec- tion, 361 ; tuberculosis and, 431 ; un- derdone, 245, 256 ; Valentine's juice, 103 ; young children and, 737. Medicines and food, 383, 385. Meigs's milk mixture, 77. Melancholia, 587. Melons, 160, 169. Membranous enteritis, 541. Mental emotion and digestion, 316. M^teil, 136. Micro-organisms in food, 360, Migraine, 573. Milk, 41 ; abnormal digestion of, 61 ; ab- sorbent power of, 57 ; absorption, 43 ; acid with, 67 ; acute infection, 535 ; adaptation for the sick, 62 ; adulteration of, 51; alcohol with, 65, 66; analyses, 44, 50, 51 ; artificial human, 723 ; artifi- cially thickened, 53 ; ass's, 49 ; bacteria in. 55. 56, 75 ; best form for modifying, 80 ; boiled, 64 ; bottles, 76 ; Bright's dis- ease and, 471 ; care of, 723 ; chemical composition, 44 ; cholera infection by, 361 ; chronic gastric catarrh and, 506 ; cinnamon and, 773 ; colour, 49 ; coloured artificially, 52 ; composition, 44 ; con- densed, 81 ; condensed formula, 82 ; constipation and, 43 ; cure, 44, 694 ; de- rivatives, 81 ; diabetes and, 659; diet, 42 ; diet in hospitals, 747 ; digestion, 60 ; dilution, 65 ; diphtheria germs in, 363 ; disease germs in, 54, 55 ; dispensary, 77 ; diuretic action, 58 ; dosage, 62, 727, 728 ; dried, 250 ; drugs in human, 48, 718 ; enemata, 59, 381 ; estimation of al- buminoids, 51 ; estimation of fat, 50 ; es- timation of lactose, 51 ; exclusive diet of, 42 ; faeces, 43, 62 ; fat, 45, 50 ; fever and, 389 ; foods, 80, 81 ; fungi in, 56 ; gelatin and, 67 ; globules, 45 ; goat's, 48, 49 ; gout and, 625 ; gruel, 69 ; human, 49 ; human, analyses, 46 ; humanised, 77 ; hy- podermic injections, 60 ; impurities, 51 ; infection, 360 ; inspection, 52 ; intra- venous injection, 60 ; inunction, 60 ; laboratories, 78 ; lead poisoning and, 59 ; Lebert's cure, 437 ; legal standard, 52; malt and, 63; malted, &*, 132; mare's, 49, 70 ; Meigs's mixture, 77 ; methods of altering the taste of, 63 ; methods of improving the digestibility of, 64 ; modified, 78 ; pancreatinised, 68 ; Pasteurised, 75 ; peptonised, 67 ; poi- soning, 353 ; porridge, 779 ; prediges- tion of, 67, 75 ; preparations, 67, 773 ; prescriptions, 78, 79 ; preservatives, 53 ;^ prophylaxis against infection by, 57 ; punch, 63 ; quantity required, 43 ; reac- tion, 49 ; residue, 43 ; rum and, 774 ; rum and isinglass, 780 ; scalding, 62 ; sherry and, 774 ; skimmed, 64 ; solids, 45, 49, 62 ; sour, for carcinoma, 527 ; specific gravity, 50 ; starchy foods with, 66 ; steiilisation, 63, 73 ; strippings, 46; substitutes for, 400, 723 ; taste, 49, 62 ; tubercular infection by, 360, 437 ; ty- phoid fever and, 378 ; typhoid infec- tion by, 361 ; uses of, 58 ; varieties, 46; vehicle of medicines, 59 ; watered, 52 ; diet in Bright's disease, 471. Millet, 135. Minced meat, 248. Mineral-water cachexia, 189. Mineral waters, 188. Mint, 153, 237. INDEX. 795 Mixed diet, 26 ; feeding, 724. Molasses, 116. Moleschott, daily quantity of food re- quired, 269. Monotony of diet, 212, 305. Morel, 170. Moselle, 226. Mosquera's beef jelly, 98 ; beef meal, 98. Moss, Iceland, 171. Moss on meat composition, 94 ; sugar in fruits, table of, 157. Motor power of stomach, 494. Mouth, care of, 373 ; care of infants', 731 ; in typhoid fever, 405. Mucidin, 121, Mucin, 330. Mucilage of rice, 767. Mucous disease, 541. Mulberries, 168. Mulled wine, 769. Multiple neuritis caused by tea, 195, Mumps, 412. Munich school, table of food necessary for different ages, 283. Murchison on biliousness, 557. Musa sapientum, 163. Muscarin, 171. Muscular exertion and food, 313 ; labour and animal food, 26. Mush, 137. Mushrooms, 170. Muskmelon, 169. Mussels, 112, 113. Must of wines, 224. Mustard, 233, 234. Mutton, 105 ; broth, 771 ; fat, 177. Mytilotoxine, 354. Playfair's diet, ^80 ; Weir Mitchell's diet, 581 ; Wood's diet, 581. New York Hospital dietary, 750. New York Infirmary dietary, 758. New York State Hospital dietary, 759. New York State Reformator)' diet, 690. New Zealander's diet, 296. Nitrogen, i, 2 ; consumption of, /^r Am, 16 ; percentage of, in proteid food, 16 ; potential energy, 18 ; quantity elimi- nated, 13 ; quantity in different foods, 3. Northeastern Hospital for Children, diet- ary of, 763. Nursing mother, diet of a, 717 ; bottles, 76. Nutmeg, 236. Nutrient enemata, 375 ; aids to retention, 378 ; composition of, 380 ; methods of injection, 377 ; number of, 37S ; opium in, 379- Nutrients, weights of, in standard diet- aries, 12 ; in dietaries of different peo- ple, 22. Nutrition, 22 ; processes involved, I ; percentage of, in various foods, 21. Nutritive beverages, 767. Nuts, 171, 179 ; betel, 261 ; diabetes and, 651 ; kola, 205, 261 ; oil of, 179. National dietary, 296. Naunyn's diet for diabetes, 661. Navy dietary, 680 ; rations, 686. Nephritis, acute, 464 ; dietetic treatment, 464 ; in children, 466. Nervous system and digestion, 307 ; dia- betes and, 638 ; diet in diseases of the, 569. Nestle's food, 81. Neuralgia, 569; alcohol in, 215; causa- tion, 569 ; dietetic treatment, 569. Neujasthenia, 217, 574 ; Bilfinger's diet, 581; causation, 574; dietetic treat- ment, 568 ; general treatment, 575 ; Keating's diet, 581 ; Leyden's diet, 580 ; Oatmeal, analysis of, 140 ; beef tea and, 772 ; cooking of, 139 ; gruel, 777. Oats, composition, 139. ^^besity, 599 ; Banting system, 603 ; Bou- chard system, 613 ; Chambers system, 613 ; dietaries for, 605 ; dietetic treat- ment, 601 ; Dujardin-Beaumetz system, 612 ; Ebstein system, 604 ; exercise for, 607 ; fruit diet in, 160 ; meat and hot water for, 612 ; Oertel system, 605 ; Schleicher's system, 610; Schwenin- ger system, 609 ; See system, 610 ; water in, 35 ; Weir-Mitchell system, 6to ; Yeo system, 611. Occupation and diet, 707. Oertel on functional albuminuria, 468 ; on obesity, 605. Oesophagus, carcinoma of, 484 ; stricture of, 484. Oil, almond, 179; cocoanut, 179: cod- liver, 180; cotton-seed, 178; dietetic uses of, 179 ; for corrosive poisoning, 175 ; fusel, 229, 231 ; Java almond, 179; linseed, 179; olive, 178; peanut, 179; theobroma, 179 ; tuberculosis and, 433. 796 INDEX. Oils, 172; vegetable, 178. Okra, 153. Old age, dietetic treatment in, 286 ; food in, 283. Old Tom gin, 230. Oleochyle, 183. Oleomargarine, 176. Olive-oil inunction, 174. Olives, 167. Omelets, 92. Onions, 154. Operations, diet after, 676. Opium and fasting, 261 ; in enemata, 379. Oppolzer, on gastric carcinoma, 527. Orange juice, 162 ; marmalade, 162 ; wa- ter ice, 162. Orangeade, 162. Oranges, 162. Orvieto wine, 226. Osteomalacia, 672. Ovariotomy, 677. Overdrinking, 342, 343. Overeating, 342 ; and diabetes, 633. Overfeeding, 719; in hospitals, 750. Oxaluria, 475. Oxygen, i, 2, 7 ; death from lack of, 8 ; in food per diem, 13 ; quantity elimi- nated, 13. Oyster plant, 150. Oysters, 112; poisoning from, 354; ty- phoid infection and, 362. Palpitation, 456. Pampas, diet of, 297. Panada, 780. Pancreas, and meat enema, 773. Pancreatic, disease, 568 ; extract, 143, 332 ; juice, 327, 328 ; solution, 68. Pancreatin, 332. Pancreatinised milk gruel, 69. Panopeptone, 104. Papain, 334. Papoid, 334. Paraguay tea, 201. Paralysis, post-diphtheritic, 418. Parasites in food, 344. Parke's table for war ration, 685. Parkes, daily food required, 269 ; on ba- nana flour, 165. Parotiditis, 412. Parsley, 153. Parsnips, 150. Partridge, 107. Pastry, 129. Pates, truffles in, 170. Pavy on diabetes, 637, 638. Peaches, 163. Pea meal, 146 ; sausage, 146 ; soup, Peanuts, 172. Pearl barley, 138 ; sago, 141. Pears, 163. Peary expedition, diet of, 271. Peas, 145. Pecan nuts, 172. Pectin in fruits, 157. Pellegra, 355. Pemmican, 178. Penzoldt's vegetable albumin, 147. Pepper, 234 ; black, 235 ; Cayenne, red, 235 ; white, 235. Peppermint, 232. Peppers, 233 ; green, 153. Pepperwort, 261. Pepsin, 321, 331 ; test for, 494, Peptone, 104. Peptones, 321, 325, 333 ; beef, 104 cess of, 322. Peptonising powders, 68, 333. Peristalsis, 31, 322. Peritonitis, acute, 556 ; chronic, 557. Pernicious anremia, 463. Pertussis, 413. Pestilence and famine, 281. Petit pois, 146. Phosphate of lime, 39, 40. Phosphorus, 40. Phthisis, cures for, 440. Pickles, 233, 237. Pieplant, 154. Pigeon, 107. Pigments in food, 357. Pilot crackers, 125. Pineapples, 163. Piper nigrum, 235. Plantago musa, 163. Playfair's diet for neurasthenia, 580 ; for puerperal women, 715. Pleurisy, 448. Plums, 167. Pneumonia, 445. Poisoning by alcohol, 364 ; carbonic from wine making, 223 ; cheese, cream, 353 ; fish, 353 ; fruits, fungi, 171 ; game, 351 ; grain, 364 cream, 353;. lead, 360; meat, milk, 353 ; shellfish, 353 ; tin, 360. 146. 233; diet acid, 353; 159; ; ice 351 ; *3^ INDEX. 797 Poland water, i8g. Polenta, 137. Poluboskos, 129. Polysarcia, 599. Pomelo, 161. Pomegranates, 163. Pork ribs, 106. Porridge, banana, 165. Porter, 221, 232. Port wine, 225, 226, 232. Posset, 768. Pot-au-feu, 102. Potassium, 40 ; caseinate, 46. Potato composition, 148 ; starch, 148. Potatoes, 147 ; baked, 149 ; sweet, 149. Potus imperialis, 768. Powder, baking, 123 ; beef, 98. Prairie chicken, 107. Predigestion of proteids, 331 ; starches, 330. Pregnancy, vomiting of, 520 ; diet and, 713. Premature infants, 732. Presbyterian Hospital dietary, 751. Preservative substances, 259. Prison starvation diet, 280 ; diet, 688. Professional men, diet of, 301, 708. Proof whisky, 230. Proteids, 325 ; as force producers, 16 ; as tissue formers, 16 ; digestion in stom- ach, 325 ; in intestine, 327 ; prediges- tion of, 331 ; vegetable, 144. Protein, percentage of, in foods, il. Proteoses, 325. Proto-albumose, 325. Prunelles, 167. Prunes, 167. Pruritus, 598. Prussian army hospital diet, 764 ; army rations, 685. Pseudo - membranous gastro - enteritis, chronic, 541. Psoriasis, 598. Ptomaines in food, 350. Ptyalin, 317. Puddings, 129. Puerperal woman, diet of, 714. Pugilist diet, 707. Pulque, 186. Pumpkins, 154. Purdy, table for infant feeding, 727. Puree, 147, 390 ; bean, 147 ; mtat, io2 ; vegetable, 145. Purges, alkaline, 188, 190 ; saline, 191. Purpura haemorrhagica, 671. Pyaemia, 126. Pyelitis, 475. Pyrosis, 326. Quantity of food of Eskimos, 295. Quantity of food required, 261 ; for young children, 734. Quinces, 163. Quinsy, 482. Rabies, 428. Race and diet, 291. Rachford, theory of fat digestion, 328. Radishes, 1 5 1. Raisin wine, 229. Raisins, 167. Raspberries, 160, 163. Ration, estimated life, 13; garrison, per- centage composition of, 11 ; ideal, with solid food, 14 ; low in proteid, 265 ; rich iQ proteid, 265 ; war, 685 ; work, 13. Rations, navy, 686 ; United States field, 682; United States garrison, 680; Unit- ed States travel, 683. Revalenta arabica, 140, 447. Raw meat, 325, 772 ; sandwiches, 773. Receipts for invalid food, 767. Rectal feeding, 375 ; methods of, 377. Rectum, alcohol absorption from, 312 ; care of, 379. Red wine, 223. Reformatory diet, 690. Refrigerant beverages, 768. Refrigeration, 256. Religious fasting, 276, 277. Rennet, 46, 61. Rennin, 60, 61, 494. Rest and sleep and digestion, 313 ; cure, 578. Restorative beef essence, 771. Rhachitis, 664 ; causation, 664 ; prophy- laxis, 665 ; dietetic treatment, 665. Rheumatism, aids to dietetic treatment, 667 ; acute, 616 ; chronic, 618. Rheua.atcid arthritis, 618. Rhine wines, 226, 232. Rhone wines, 228. Rhubarb. 154. Rice, apple and, 778 ; l)oilcd, 778 ; cream, 778; digestibility of, 138; flour in bread, 124; gruel, 778; milk, 778; oup, 776 ; water, 767. 798 [iJIp^T Richards, Mrs. E. H., convalescent, ra- tion, 265 ; food composition, table of, 282 ; food consumption by young wom- en students, tt^bHof, 263 ; ideal ration of liquid food, 205 ; ideal ration of solid Leube's test dinner, 490. ?g, 243- s, effect of tea and coffee on gas- digestion, 193, 194 ; hydrochloric digestion, table of, 320 ; influence wines on digestion, 229 ; malt liquors and gastric digestion, 211. Roe, III. Rolls, 121. Roosevelt Hospital dietary, 757. Root beer, 188. Roquefort, 87. Rosacea, 597. Rotch's method of modifying milk, 79 ; table for infant feeding, 727. Round worms, 145, 304, 345. Rubeola, 412. Rudisch's beef peptone, 99. Rules for feeding young children, 734. Rum, 229, 230; and milk, 774. Rye, 129, 136; bread, 125, 129; whisky, 230. Saccharin, 117 ; for diabetes, 657. Saccharomyces cerevisiae, 205 ; in beer, 220. Saccharose, 114. Sago, 141. Sake, 230. Salep, 140. Salicylic acid in food, 260, 358. Saline purges, 191 ; waters in gout, 630. Saliva, 317. Salivary digestion, 317. Salmon, no. Salsify, 150. Salt, 37 ; celery, 253 ; craving for, 40 ; de- privation of, 38 ; excess of, 38, 40 ; habit, 38 ; meat, 242 ; starvation, 39 ; uses in food, 38 ; varieties, 37. Salts, deposition of, 40 ; in calculi, 38 ; gastric juice and, 493 ; percentage of, in foods, II. Salting, 254. Samp, 137. Sarco-peptones, 99. y Sarsaparilla, 188. Sauces, 237. Sauerkraut, 152. Savory and Moore's Food, 131, 132. Scarlatina, 411 ; infection by milk, 363. Schiedam, 230. Schleicher's diet for obesity, 610. Schlossberger's mea^ composition, table of, 93. School children's diet, 740. Schroth's dry diet, 449. Schweninger system, 6og. Sclerosis, arterial, 456. Scotch beef broth, 772 ; groats, 139 ; whis- ky, 230. Scrofula, 662 ; dietetic treatment of, 663. Scurvy, raw meat in, 94 ; causation of, 668. Seakale, 152. Seasickness, 519 ; lemons^in, 161. Secretion, of gastric juice, 319 ; of saliva, 317- See's treatment of dyspepsia, 499 ; of obesity, 610. Seegen's almond cakes, 656. Semolino, 134. Senile heart, diet for, 453, Sepsis, 678. Septicaemia, 426. Shaddock, 161. Shallots, 154. Shellfish poisoning, 353. Sherry, 225, 226, 232 ; and milk, 774. Ship biscuits, 134. Shore dinners, 112. Shrimps, 112. Siberian fungus, 261. Siever's test for motor power of stomach, 494. Sirup, 113 ; maple, 114. Skin, absorption of water by, 36 ; diseases, diet in, 591 ; diseases dietetic aetiology, 591 ; in diabetes, 642. Sleep, 314 ; disordered, 582 ; feeding and, 373, 739 ; food of the Eskimos and, 294 ; food in typhoid fever and, 402 ; in rela- tion to meals, 314 ; rest, digestion, and, 313- Smallpox, 410. Smoked beef, 254. Smoking, 254. Snipe, 107. Sodium, 2. Sodium carbonate in milk, 260 ; in tea, 195. ^ ^tf INDEX. Sodium chloride, 39 ; as a preservative, 40 ; waters, 190. Soft-shell crabs, 112. Solid meat preparations, 97. Solis-Cohen diet for forced feeding, 439. Somatose, 100. Sophistication of food, -356. Sorghum, 116, 135. Sorrel, 15^ 390, 772 in gout commission, 625 ; ox-tail. Soup, 248, 301, 107 ; fruit, 160 109 ; rice, 776. Soused fish, 260. South American beef extract, 99. South Sea Islander, diet of, 297. Soya bread, 135, 656. Soyer, food eaten during lifetime, table of, 274. Spaghetti, 135. Special diets in hospitals, 748. Spices, 233, 236 ; properties of, 233 ; uses of, 236. Spiegelberg on diet for puerperal women, 715- Spinach, 152. Spirits, 230, 232. Spratling, tea causing multiple neuritis, 195. Squash, 154. Standard daily diet, 264, 265 ; dietaries, 12. Starch, 118. Starches in intestine, 327 ; predigestion of, 330. Starchy foods in general, 118; for chil- dren, 141. Starr, dietaries for young children, 735 ; on infant feeding, 728 ; table of infant feeding, 72S ; weaning mixture, 726. Starvation, 274 ; during siege of Paris, 280 ; diet in prison, 280 ; diet in U. S. military prison, 280 ; fat loss in, 172 ; insomnia and, 315 ; of De Long expe- dition, 279 ; of Greely expedition, 280 ; symptoms of, 277 ; treatment of, 281. Stature and food, 289, 294. Steaks, 245. Steaming, 247. Steam sterilisers, 73. Steapsin, 328. Stearin, 176. Sterilisation, 256. Stewart, formulae for cod-liver oil emul- sions, 182. 53 799 Stewart, . Granger, on functional allu- minuria, 469 ; diabetic bread, 654. Stewing, 247. Stews, 243. Stimulants.^P ; action of, li uses, 187. xnRl fat^L' , 73I9 Stimulating foods, it Stokes's Cognac mixr Stomach, acute catarrh 489 ; chronic catarrh, 525 ; dilatation, 511 contents, 489 ; faradisa^ typhoid fever, 405 ; of i? test for absorbent power, motor power, 495 ; ulcer, 522. Stomatitis, catarrhal, 482. Stone in the bladder, 476 ; in the ]|:idney, 476. . . "^ ^5 Stools, diarrhoeal, bacteria in, 532 532 ; casein in, 532 ; infants', meat fibre in, 533 ; starch in, 533. Stout, 221. Stracchino, 88. Strawberries, l6o. Stutzer, analysis of cocoa, 202. Succi, voluntary fast of, 276. Succulent tubers, 150. Sucrose, 114. ^,^^ Suet, 176. Sugar, beet, 115, 150; cane, 114; in in- testine, 327 ; composition in body, 1 14 ; from rags, 10; grape, 114, 116; gout and, 626; in fruit, 114, 157; maple, 114; milk, 116; refining, 115; source, 113; substitutes for, in diabetics, 657 ; sugars, 113 ; the urine and, 114. Sulphates, 41. Sulphur, 41 ; waters, 19a Summer diarrhoea, 534. Superalimentation, 438. Supper hour, 300. Suppositories of food, 382. Suralimentation, 438. Surgical inflammations, 678 ; operations, diet after, patients' injuries, 676. Syntonin, 325. Syphilis of liver, 565. Sweetbread, 107. Sweet potatoes, 149. Sweets for children, 745. Swiss milk, 82 ; Alpine milk, 82. Tabasco, 233, 237. Table waters, 189. 8oo INDEX. Tjenia, 345. Tallow, 176. Tamarind whey, 769. Tamarinds, 163. Tanner, voluntary fast of, 276. Tannin, 191. Tapeworms, 145, 345 ; pomegranate for, 163. Tapioca, 140. Tarragon, 153. Taste and food, 303. Tea, 192, 260 ; adulteration of, 196 ; anal- ysis of, 192 ; beef, 769 ; coffee com- pared with, 201 ; flaxseed, 768 ; good eff"ects of, 193 ; gout and, 628 ; habit, 199 ; ill effects of, 105 ; influence of, on gastric digestion, 194 ; infusion, 193 ; lin- seed, 768 ; method of preparation of, 192 ; Paraguay, 201 ; physiological action of, 193 ; properties of, 193 ; quantity "con- sumed, 196 ; therapeutic action of, 193. Teething and food, 739. Temperature and digestion, 308. Tests for absorptive power of stomach, 495 ; for motor power of stomach, 494 ; meals, 490. ests for acid salts, 493 ; for free hydro- chloric acid, 491, 492 ; for stomach con- tents, 325. Tetanus, 427. Theobroma cacao, 201. Theobromine, 202. Therapeutic use of liquors, 231. Thirst, 36, 298 ; diabetes and, 640 ; ice for, 37 ; lemons for, 36, 161 ; rectal feeding and, 376 ; relief of, 36. Thompson, Sir H., on biliousness, 557; on food in old age, 286 ; on obesity, 599 ; on overeating, 262. Thyroid gland, 108. Tin poisoning, 358. Toast, dry, 126. Tobacco, 260 ; food and, 337 ; in chronic constipation, 552. Tokay, 225, 226. Tomato catsup, 237. Tomatoes, 153. Tongue, 105. Tonsilitis, 482. Torrefied bread, 654. Torula, 121. Tous-les-moisy 140. Tracheotomy, feeding in, 417. Trained food purveyors, 386. Training, athletic, 703. Travel ration in army, 683 ; and diet, 712. Treacle, 116. Treatment, dietetic, of typhoid fever, 398. Trichiniasis, 346 ; diagnosis of, 349 ; pro- phylaxis for, 348 ; symptoms of, 348 ; treatment of, 350. Tripe, 108. Trommer's Diastatic Malt Extract, 143. Truffles 170. Tubercular laryngitis, 441. Tuberculosis, aids to dietetic treatment, 440 ; alcohol in, 434 ; causation, 428 ; cod-liver oil, 433 ; diet in advanced cases, 436 ; diet in mild cases, 434 ; eggs in, 432 ; fats and oils, 433 ; gen- eral consideration of dietetic treatment, 429 ; meats in, 431 ; milk diet in, 437. Tubers, 147. Tufnell's diet for aneurism, 457. Turkey, 107. Turkish figs, 169. Turnip tops, 152. Turnips, 150. Typhoid fever, 397 ; alcohol in, 403 ; con- valescent diet, 406 ; dietetic treatment, 398 ; feeding atypical cases, 408 ; in children, 409 ; milk infection and, 361 ; oyster infection and, 362 ; pathological physiology, 397. I'yphus fever, 410. Tyrotoxicon, 353. Tyson's diabetic diet, 659. United States army diet, 680 ; army hos- pital dietary, 763 ; army prison diet, 688 ; navy diet, 686 ; navy ration, 687. Ulcer of stomach, 522. Urea and animal food, 25. Uric-acid diathesis, 478. Urinary system, diet in diseases of the, 463- Urine, alkalinity from fruits, 158 ; dia- betic, 641 ; food and, 336 ; sugar in, 114; modifications caused by food, 463. Urticaria, 592. Utica State Hospital for Insane, dietary of, 760. Valentine's meat juice, 103. Vanilla, 236. Van Noorden's treatment of anaemia, 461. I INDEX. 80 1 Varieties of cooking, 239. Variety in diet, 305 ; in army diet, 307 ; in children's diet, 741. Variola, 410. V^arious waters, igi. baseline in butter, 358. V^aughan on ptomaines, 353. V^eal, 105 ; broth, 771. V^egetable and animal foods compared, 22 ; acids, 41 ; albumin, 147, 325 ; case- in, 325 ; diet, 144 ; extract for flavour- ing, 102 ; foods and bile, 327 ; marrow, 154; proteids, 144; purees, 145. V^egetables, antiscorbutic, 145 ; classifica- tion of, 144 ; composition of, 151 ; con- stipation and, 548; diabetes and, 651, 653 ; dried, 250 ; gout and, 626 ; green, 151 ; laxative, 145 ; raw, 249 ; stimulant, 145 ; table of composition of, 155 ; in diabetes, 651, 653 ; young children and, 737- Vegetarians, 297. Venison, 106. Vermicelli, 135. Vermuth, 232. Vertigo, 582. Vichy, 189, 190. Vin d'Asti, 226. Vinegar, 233, 234, 236 ; excess of, 237 ; white, 236. Fins du luxe, 225. Visceral neuralgias, 571. Voit on functional albuminuria, 469 ; on obesity, 601. Voluntary fasting, 275. Vomiting. 518; dietetic treatment, 519; pathological physiology, 518; pregnan- cy, 521. Von Bibra's table of meat composition, 93. Walnuts, English, 171. War ration, 685. Waste, elimination of, 335, 336. Water, 30 ; a force producer, 15 ; amount used, 30; as a food, 15; barley, 767 ; boiled. 33; constipation and, 550; death from lack of, 8 ; deprivation of, 35 ; diabetes and, 658 ; dietetic uses, 34 ; distilled, 33 ; elimination of, 30 ; emetic use of, 31 ; excess, 34 ; filtered, 33 ; filtration, 32 ; gases in, 33 ; germs in, 31-33 ; gout and, 628 ; hard, 32 ; hot, for obesity, 612 ; hot, for thirst, 37 ; in blood, 34 ; in fevers, 392 ; in food, 34 : in solid food, 15 ; Johannis, 189 ; Kronenquelle, 190 ; lime, home-made, 775 ; lithia, 190 ; percentage of, in foods, 11; Poland, 189; purity, 31; quantity, 30 ; quantity eliminated, 13 ; quantity required per diem, 270; rain, 32 ; rice, 767 ; river, 33 ; salts in, 32 ; secretion, 30 ; soft, 32 ; spring, 32 ; starvation, 35 ; temperature of drinking, 37 ; uses, 31 ; varieties of drinking, 32. Waters, carbonic-acid, 189 ; sodium-chlo- ride, 190 ; sulphur, 190 ; table, 189 ; thermal, 189. Watermelons, 169. Weaning, 724. Webster's diet for forced feeding, 449. Weighing of infants, 731. Weir Mitchell's treatment for neurasthe- nia, 579 ; for obesity, 610. Wet nurse, diet of, 717 ; selection of, 716. Wheat-kernel structure, 120. Wheatena. 133. Whey, 88 ; cream of tartar, 768 ; cure, 697 ; tamarind, 769 ; wine, 768. Whisky, 229, 250. White wine, 223. Whiting, III. Whooping cough, 413. Wiley on canned foods, 259. Williams on boiling, 240 ; on frying, 247 ; on stewing, 243. Wine, 221 ; bouquet, 221, 222 ; coca, 225 ; composition of, 221, 223 ; consumption of, 219 ; elderberry, 169 ; fermentation of, 221, 222 ; fig, 232 ; flavour of, 222 ; fruitiness of, 222 ; general properties of, 222 ; mulled, 225, 769 ; sugar in, 222 ; whey, 768. Wines, acid, 226 ; in fevers, 394 ; influ- ence upon digestion, 229 ; perfect, 227 ; red, 223 ; Rhine, 226, 232 ; rough, 229 ; sparkling, 226 ; strong dry, 224 ; strong sweet, 226 ; uses of, 228 ; varieties of, 224 ; white, 223. Woman's milk, analysis of, 47 ; drugs in, 48. Woodcock, 107. Woodhull on army ration, 685. Woodruff', on army rations, 684 ; on com- position of military pea food, 146 ; on compressed bread, 251 ; on food con- centration, 252 ; on variety in army 802 INDEX. diet, 194 , use of alcohol in the army, 208 ; use of tea and coffee in the army, 194. Wood's diet for neurasthenia, 581. Worcestershire sauce, 237. Worit ration, 13. Wort, 220. Yale crew diet, 705 ; foolball-team diet, 707. Yeast fungus, 121, 205 ; leaven, 122. Yellow fever, 422 ; dietetic treatment, 424. Yeo, composition of fruits, table of, 157 ; diet for the aged, table of, 287 ; system for obesity, 611. THE DISEASES OF THE STOMACH. By Dr. C. A. EWALD, EXTRAORDINAISY PROFESSOR OF MEDICINE AT THE UNIVERSITY OF BERLIN. Second American Edition, translated arid edited, icith mimerous Additions, from the Third German Edition, By MORRIS MANGES, A. M., M. D., ASSISTANT VISITING PIIVSICIAN TO MOTNT SINAI HOSPITAL; LECTURER ON GENERAL MEDICINE, NEW YORK POLYCLINIC, ETC. This work has been thoroughly revised, rearranged, largely rewritten, and brought up to date from the most recent literature on the subject. 8vo, 602 pages. Sold by subscription. Cloth, $5.00 ; sheep, $6.00. "In giving the medical profession this second revised translation of Prof. Ewald's treatise on the Diseases of the Stomach, Dr. Manges has placed the profes- sion under even greater obligations than we owed for the first. The first transla^ tion was then an almost exhaustive treatise, and now, with so much new and valuable data added, the work is a sine qua non." Atlanta Medical and Surgical Journal. " This work as it now stands is the best on the subject of stomach diseases in the English language. No physician's library is complete without it. It is in every way well atlapted to the requirements of the general practitioner, although complete enough to meet also the requirements of the specialist." American Medico- Surgical Bulletin. " The present American edition is a peculiarly valuable one, as the editor. Dr. Manges, has done his work in a thoroughly creditable manner. His numer- ous notes, additions, and new illustrations have made the book a classic one. Under these circumstances it should find a place in the library of every Amer- ican physician, as their clientele is composed of such a large proportion of patients suffering from gastric conifilaints and more or less improper medication which most often ends in failure. There is no doubt that more properly directed efforts in the proper direction, as outlined in Ewald's book, would soon remove from Americans the reputation of being a nation of dyspeptics." St. Louis Medical and Surgical Journal. " Dr. Ewald's book has met with a very cordial reception by the medical pro- fession. Within a short period three editions have appeared, and translations published in England. Spain, France, Italy, and the United States. To the present edition the author has not only added considerable now matter, but he has also entirely rewritten the work. The arrangement nf the chapters has been somewhat changed, and many new personal observations and therapeutic experi- ences added. The desirability of surgical interference is carefully considered, and the pros and cons given so far as would 1 necessary to enable a physician to determine whether the aid of the surgeon might Ije required. The translator has done his work well, and has incorporated much new matter into the text and footnotes." North American Journal of Homceopathy. D. APPLETON AND COMPANY, NEW YORK. A New, Thoroughly Revised, and Enlarged Edition of QUAIN'S DICTIONARY OF MEDICINE. BY VARIOUS WRITERS. Edited by Sir RICHARD QUAIN, Bart, M. D., LL. D., etc., Physician Extraordinary to Her Majesty the Queen ; Consulting Physician to the Hospital for Diseases of the Chest, Brompton, etc. Assisted by FREDERICK THOMAS ROBERTS, M. D., B. Sc, Fellow of the Royal College of Physicians, etc. ; And J. MITCHELL BRUCE, M.A., M. D., Fellow of the Royal College of Physicians, etc. With an American Appendix by SAMUEL TREAT ARMSTRONG, Ph.D., M. D., Visiting Physician to the Harlem, Willard Parker, and Riverside Hospitals, New York. IN TWO VOLUMES. Sold only by subscription. This work is primarily a Dictionary of Medicine, in which the several diseases are fully discussed in alphabetical order. The description of each includes an account of its etiology and anatomical characters ; its symptoms, course, duration, and termination ; its diagnosis, prognosis, and, lastly, its treatment. General Pathology comprehends articles on the origin, characters, and nature of disease. General Therapeutics includes articles on the several classes of remedies, their modes of action, and on the methods of their use. The articles devoted to the subject of Hygiene treat of the causes and prevention of disease, of the agencies and laws affecting public health, of the means of preserving the health of the individual, of the construction and management of hospitals, and of the nursing of the sick. Lastly, the diseases peculiar to women and children are discussed under their respective headings, both in aggregate and in detail. The American Appendix gives more definite information regarding American Mineral Springs, and adds one or two articles on particularly American topics, besides introducing some recent medical terms and a few cross-references. The British Medical yournal says of the new edition : "The orii^inal purpose which actuated the preparation of the original edition was, to quote the words of the preface which the editor has written for the new edition, ' a desire to place in the hands of the practitioner, the teacher, and the student a means of ready reference to the accumulated knowledge which we possessed of scientific and practical medicine, rapid as was its progress, and difficult of access as were its scattered records.' The scheme of the work was so comprehensive, the selection of writers so judicious, that this end was attained more completely than the /nost sanguine expectations of the able editor and his assistants could have anticipated. ... In preparing a new edition the fact had to be faced that never in the history of medicine had progress be^n so rapid as in the last twelve years. New facts have been ascertained, and new ways of looking at old facts have come to be recognized as true. . . . The revision which the work has undergone has been of the most thorough and judicious character. . . . The list of new writers numbers fifty, and among them are to be found the names of those who are leading authorities upon the subjects which have been committed to their care." D. APPLETON AND COMPANY, NEW YORK. A TREATISE ON THE DISEASES OF THE NERVOUS SYSTEM. By WILLIAM A. HAMMOND, M.D., Surgeon-General U. S. Army (retired list). With the Collabobatiox of GRAEME M. HAMMOND, M. D,, Professor of Diseases of the Mind and Xervous System in the New York Post-Graduate Medical School and Hospital, etc. With 118 Illustrations. NINTH EDITION, WITH CORRECTIONS AND ADDITIONS. 8vo. 932 pages. Cloth, $5.00; sheep, $6.00. " Dr. riammond's treatise on the diseases of the nervous systm is a work which has been long familiar to the profession, and has attained a great reputation among the standard books for reference. In the preparation of the present edition the author has been aided by his son, A vast amount of clinical material is made use of, and the results of experimental investigation recorded. The book is written in a clear and pleasing style, and obscure conditions are dealt with in a manner which will prove of great assistance in the study of this most interesting class of diseases." Canadian Practitioner, "Dr. Hammond published the first edition of his 'Treatise on Diseases of the Xervous System ' in 1871. It has therefore been before the profession for twenty yeai-s, and during these years it has continued to grow in public favor, this being the ninth edition that has been issued. Appreciation of this work has not only been shown in this country, but abroad, as it has been translated into the French, the Italian, and the Spanish languages. The present edition has been thoroughly revised, and several new chapters added. This is a book of such great value, and is referred to so frequently by the medical press and other medical works, that no library is complete without it." Alabama Medical and Surgical Age. " There are few books, even upon those subjects which are constantly in the ordinary physician's mind, which succeed as has that of Dr, Hammond ; and when we recollect that when the first edition of this work appeared, neurology in America was in its very infancy, the rapid exhaustion of its editions is the more remarkable. In the ninth edition the writer's son has done much toward keeping the work abreast of the times, and, with more confidence than ever, it can now be regarded as one of the best and most satisfactory works on nervous diseases, either for the practitioner or for the advanced student. The book is beaiitiflp