- PRACTICAL DIETETICS PRACTICAL DIETETICS WITH SPECIAL REFERENCE TO DIET IN DISEASES W. GILMAN THOMPSON, M. D. PROFESSOR OF MEDICINE IN THE CORNELL UNIVERSITY MEDICAL COLLEGE IN NEW YORK CITY VISITING PHYSICIAN TO THE PRESBYTERIAN AND BELLEVUE HOSPITALS "Good diet with wisdom best comforteth men " TUSSER (1520) FOURTH EDITION, ILLUSTRATED, ENLARGED AND COMPLETELY REWRITTEN NEW YORK AND LONDON D. APPLETON AND COMPANY 1909 COPYRIGHT, 1895, 1902, 1905, 1909, BY D. APPLETON AND COMPANY PRINTED AT THE APPLETON PRESS, NEW YORK, U. S. A. A/ PREFACE TO THE FOURTH EDITION Since the publication of the first edition of this work in 1895, great progress has been made in the study of dietetics. The scientific aspect of the subject has been notably advanced through the extensive researches of the Department of Agriculture in Washington, and of the allied Agricultural Experiment Stations in many different States, where food analyses, calorimetry computations, and investigations of the dietetic habits of different races and classes of men have done much towards placing the hitherto vague subject of dietetics upon an accurate scientific basis. In university and medical college laboratories much independent research has been devoted to the relationship between ingested food and excreta, and the complex processes of food metabolism in health and disease. In hospitals more and more attention is being directed to the prep- aration of food in diet kitchens for the sick, and more thorough in- struction is being given to nurses in the proper feeding of patients. The medical profession in general has evinced increasing interest in accuracy in dietetic methods, and special progress has been made in the dietetic treatment of such important and common diseases as chronic nephritis, typhoid fever, diabetes, intestinal autointoxication, and the gastrointestinal disorders of infancy and childhood. In order to include a full discussion of all these topics, as well as the accumulated experience of the writer, the present edition has been completely rewritten and 75 pages have been added to the text together with 42 new illustrations. It is the design of the work to furnish a source in which the ac- cepted method of dieting will be found for each condition or disease amenable to dietetic influence. To this end many brief tables and summaries of dietetic directions are appended to the discussion of the scientific principles involved in each case. The reader also will find a discussion of representative dietaries of hospitals and various Government institutions, and sections upon the proper dieting at various stages of life from infancy to old age, for various special occupations, for increasing or diminishing body weight, v 26497 VI PREFACE etc., and a section is devoted to consideration of the difficult problems which arise when diseases demanding opposite methods of dieting, exist in combination. Numerous cross references and a full index are added to aid in elucidating the text. The author disclaims advocacy of any special dietetic theory or "sys- tem." No one food is curative of any disease, just as no one food may be said to be causative of any disease. It is rarely feasible to feed the sick upon any system of accurate food weighing, laboratory calculations of calories, or the results of single analyses of gastric contents. Such systems add scientific in- terest to the general subject of dietetics, but the problems of right feeding in disease must be studied in the light of clinical experience, and modified to meet ever changing conditions. One of the com- monest of dietetic errors is the too long continuance of a dietary which, although at first beneficial, may result in anaemia or asthenia by be- coming monotonous or failing to meet all the complex demands of nutrition. These principles, which form the basis of the book, have been still further emphasized in the present edition. W. OILMAN THOMPSON, M.D. 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 usually either omitted or is disposed of in one or two brief lectures at the end of a course in general therapeutics. Upon examining the standard treatises upon the Theory and Practice of Medicine, as well as monographs upon important diseases, such as those of the cir- culation, nervous system, and skin, one cannot fail to be impressed with the meagre notice given to the necessity of feeding patients properly, and the subject is usually dismissed with such brief and indefinite phrases as "The value of nutritious diet requires mere mention," "A proper but restricted diet is recommended," and fa* vorite, if not convincing, expressions are, " The patient should be carefully fed," and " General dietetic treatment is of primary impor- tance." With such vague directions the dieting must indeed be very " general." In many excellent works upon food and dietetics the space devoted to the practical application of dietetics to disease is comparatively insignificant, and much less emphasis is given to this matter in hos- pitals and in the training of nurses than is demanded in the interests of medical science. A writer of wide experience in practical dietetics, Mrs. F. H. Rich- ards, 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 measure making good such deficiencies by furnishing a text-book in which the practitioner of medicine may find detailed the appropriate diet for each disease which is at all influenced by right feeding. vii viii PREFACE Quite as much depends upon the suitable preparation of food as upon the selection and limitation of food itself, and it has therefore been thought advisable to include a general account of the composi- tion and uses of foods, and the changes which may be produced 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 emphasized rather than unnecessary scientific detail. The reader will also find a discussion of representative hospital dietaries, the official dietaries of Government institutions, and sections upon the proper feeding of infants and children. Numerous cross references and a complete index have been added to avoid undue 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 dis- tinctly disclaim the advocacy of any special dietetic system as a cure- all, as well as the specific influence of any one food in the general 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 relative advantages 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 ad- mirable researches upon foods of our own Government, found in the published reports of the Department of Agriculture, are especially to be commended. W. GILMAN THOMPSON. CONTENTS PART I FOODS AND FOOD PREPARATIONS PAGE Elementary composition of foods 1 Food classification . . . . -4 Force production. Energy from food 6 Force-producing value of the different classes of foods .... 19 I. Water ..." 19 II. Salts 19 III. Proteids, carbohydrates, and fats 19 Oxygen and food ' r , 24 Stimulating foods 25 Economic value of food 25 Nutrition. Animal and vegetable foods compared 29 Vegetarianism 33 The classes of foods 36 I. Water '.-.'. .36 Uses of water in the body 37 Purity of water 38 Varieties of drinking water 38 Special dietetic uses of water 40 Excess of water 41 Deprivation of water. Water starvation 42 Temperature of drinking water .44 II. Salts 44 Varieties of salts 44 Uses of salts in foods 44 Excess of salt 45 Deprivation of salt 45 Sodium 46 Potassium 47 Calcium 47 Phosphorus 48 Sulphur 48 Iron 48 Vegetable acids 48 III. Animal foods 49 Milk 49 Exclusive milk diet .50 Physical properties of milk . 51 Chemical composition of milk 52 Milk ferments .... 58 Varieties of milk . 58 ix CONTEXTS PAGE Methods of milk analysis . 63 Milk adulteration and impurities 70 Milk contamination . . . 72 Prophylaxis against milk infection Uses of milk Milk digestion Adaptation of milk for the sick Methods of altering the taste of milk . Methods of improving the digestibility of milk Methods of predigestion, sour milk, 'etc Peptonized milk !) Pancreatinized milk 90 Koumiss 93 Methods of sterilization, Pasteurization, and preservation . . 96 Sterilized milk 96 Pasteurized milk 100 " Humanized milk " 103 Modified milk. Milk laboratories 103 Milk derivatives 108 Condensed milk 108 Cream 109 Butter 112 Buttermilk 114 Cheese 114 Whey 119 Eggs .120 Raw eggs. Eggnog. Egg albumen 122 The cooking of eggs 123 Preservation of eggs 124 Meats 124 Consumption of meat 124 Structure and composition of meats 126 Raw meats 127 Digestibility of meats 128 Composition of beef 130 Beef preparations for the sick 131 Solid meat preparations 132 Fluid meat preparations . 135 Various meats 141 Beef tongue 141 Veal 141 Mutton 141 Lamb 142 Venison 142 Pork 142 Ham and bacon> 142 Horseflesh 143 Ral.bit . 143 Fowl . . 143 Game ... . 144 CONTENTS xi PAGH Animal viscera , 145 Isinglass, gelatin 146 Sea Food 147 Fish 147 Crustaceans 150 Shellfish oysters, clams, scallops, mussels 151 Insects 152 IV. Vegetable foods 152 Sugars 152 Sugars and the urine 154 Cane sugar, saccharose 154 Caramel . . . . . . . 156 Candy and confectionery 156 Molasses, treacle, and syrup . . . 157 Grape sugar, glucose 157 Milk sugar 158 Mannite 158 Levulose ............. 158 Honey . - . . . . . 158 Saccharin 159 Cereals and other starch-bearing foods 159 Starch-bearing foods in general . . 159 Bread-making .... . 161 Structure of the wheat kernel . . . . ... . 162 Bran . . ... 162 Gluten . '*. . . 163 Composition of bread 164 Bread-baking 164 Variety of bread stuffs and prepared farinaceous foods . . . 169 Wheaten flour and bread 169 Whole-meal bread 170 Gluten bread . 172 Biscuits, pastry, puddings, etc 173 Prepared farinaceous foods 173 Crackers 178 Semolino 179 Buckwheat 180 Millet, sorghum, rye, corn 181 Rice . 183 Barley . . 184 Oatmeal >..-... . . .185 Arrowroot 186 Tapioca, cassava 187 Sago 187 Iceland moss 187 Starchy foods for children 188 Diastase, malt extracts, etc 188 Vegetable food in general 190 Legumes, peas, beans, lentils, peanuts 192 Roots and tubers 196 2 ll CONTENTS PAGE Potatoes .......... .... 196 Beets ....... ...... 199 Succulent tubers ........ .... 200 Green vegetables ............ 201 Fruits . . ............ 207 Composition ............ 207 Uses and properties of fruits ......... 209 Fruit ripening ............ 210 Fruit poisoning ............ 210 When to eat fruit ........... 211 Dried fruits; cooked fruits ......... 211 Digestibility of fruits .......... 212 Varieties of fruits ........... 212 Lemons, limes, shaddocks ......... 212 Oranges ............. 213 Apples ............. 214 Pears, peaches, etc ............ 215 Bananas ............. 216 Grapes ............. 219 Plums, prunes ............ 220 Berries, strawberries, etc. . ........ 221 Melons ............. 222 Figs and dates ............ 223 Fungi .............. 224 Lichen .............. 225 Nuts ............... 226 V. Fats and oils ............. 228 Animal fats ........... , 231 Bone marrow .......... . 223 Vegetable fats and oils ......... . 234 Glycerin .............. 235 Cod-liver oil ........... . 235 PART II STIMULANTS, BEVERAGES, CONDIMENTS Stimulants and beverages ....... 241 Alkaline and mineral waters, effervescing waters ... 243 Tannin Tea 247 . . ; ........... 247 ........... 218 Relative value of coffee and tea ..... 257 Cocoa ........... . . 258 Cacao butter ...... , t 259 Chocolate ....... 260 Koli > ....... ....!.] 262 Alcohol ....... 262 General discussion of the value of alcohol . 263 Physiological action ...... 265 I. As a food ' CONTENTS xiii PAGE II. As a stimulant 266 III. Action upon the muscles 267 IV. Action upon the temperature 267 V. Action as a diuretic 267 VI. Action upon mucous membranes 268 VII. Action upon gastric digestion 268 VIII. Alcohol absorption 269 IX. Alcohol elimination 269 X. Alcohol poisoning 269 XI. Alcohol and climate 269 Clinical uses of alcohol 270 Selection of proper alcoholic beverage 273 Malt liquors 274 Beer * 274 Ale 275 Porter 275 Stout 275 Wine 276 Composition 276 General properties 276 White wines 277 Red wines 278 Varieties of wines 279 I. String dry wines 279 II. Strong sweet wines 280 III. Aromatic wines 281 IV. Acid wines 281 V. Sparkling wines 281 VI. " Perfect " wines . 282 VII. Rough wines 283 Liquors 284 Adulteration of liquors and wines 286 Liqueurs and cordials 287 Cider 288 Condiments and spices 288 PART III COOKING. FOOD PREPARATION AND PRESERVATION. THE QUANTITY OF FOOD REQUIRED Cooking 294 Varieties of cooking 295 1. Boiling 296 2. Stewing .... 298 3. Roasting , 299 4. Grilling 300 5. Frying 301 6. Braising 302 xiv CONTENTS PAGE 7. Baking ... ..'..... 303 8. Steaming 303 Soups . . . 303 Cooking of fish . 304 Cooking of vegetables 304 Food concentration. Condensed food 305 Drying, desiccation, extracts 305 Diet of concentrated foods 307 Food preservation 308 I. Drying 309 II. Smoking 309 III. Salting 309 IV. Freezing 310 V. Refrigeration 310 VI. Sterilization 311 VII. Exclusion of air. Canning 311 VIII. Antiseptic and preservative substances 313 Substitutes for food . 316 Quantity of food required 317 Climate and season 318 Clothing and food 321 Exercise and food 322 General health and food 322 Age and food 322 Sex and food 323 Size and food 324 Weight and food 324 Calculation of rations 325 Forced and reduction feeding 340 Quantity of food eaten per annum 340 Measurement of food 341 Starvation and inanition 343 Voluntary fasting 344 Famine 359 Improperly balanced diet 350 PART IV SPECIAL CONDITIONS INFLUENCING FOODS Age and toou _ 352 Food in childhood , 352 Food in adult life 353 Food in old age _ 353 Diet and heredity _ 357 Diet and race 35g CONTENTS xv PART V FOOD DIGESTION. CONDITIONS WHICH ESPECIALLY AFFECT DIGESTION PAGE Digestibility of foods . . . ... ... . . .363 Hours for meals and order of taking food 364 Appetite 368 Abnormal cravings 370 Variety in diet 371 The nervous system and digestion 373 Circulation and digestion . 374 Temperature and digestion 374 Exercise and digestion 378 Rest and sleep and digestion 380 Mental emotion and digestion 382 Food in the mouth 382 Fletcherism 384 Food in the stomach 386 Quantity of gastric juice . 386 Secretion of the gastric juice 387 Hydrochloric acid 387 Pepsin, albumoses, peptones 388 Digestion of proteids in the stomach 389 Abnormalities of gastric digestion 392 Food in the intestine 393 Pancreatic juice 394 Bile 394 Digestion of fats 394 Intestinal gases 395 Artificial digestion 396 Predigestion of starches 396 Predigestion of proteids . . 397 Food absorption . ... 399 Elimination of food waste ... . .... 400 The feces and food 401 The urine and food 403 Tobacco and food 404 Food equivalents, food " portions " 404 PART VI THE GENERAL RELATION OF FOOD TO SPECIAL DISEASES. DISEASES WHICH ARE CAUSED BY DIETETIC ERRORS The general relation of food to special diseases 407 Rules for prescribing a dietary 409 Diseases caused by dietetic errors I. Insufficient food -411 II. Overeating and overdrinking . 411 III. Food which is injurious because the ingredients are not properly balanced 413 xvi CONTENTS PAGE IV. Food containing parasites or their embryos 413 Intestinal worms - 413 Trichinosis 415 V. Food containing ptomaines 419 Poisoning by meat or game 419 Poisoning by milk, cream, ice cream, and cheese 423 Poisoning by crustaceans, shellfish, and fish 424 VI. Other food poisons 425 Grain poisoning 426 Ergotism 426 Lathyrism 426 Pellagra 427 VII. Food adulteration 427 Pigments 429 National Bureau of Medicines and Foods 430 Copper, tin, lead and zinc poisoning 430 VIII. Food containing micro-organisms of infectious diseases . . . 432 Milk infection 432 Tubercular infection through milk and meat 432 Typhoid and cholera infection 435 Infection through oysters 435 Diphtheria and scarlatina 437 Foot-and-mouth disease 437 Food infection through flies 437 IX. Idiosyncrasies in regard to food 438 X. Alcohol poisoning. Alcoholism 438 Delirium tremens . 442 PART VII ADMINISTRATION OF FOOD FOB THE SICK Methods of feeding the sick 444 The appetite 445 Regularity in feeding . 445 Quantity of food in illness 445 Details of serving food 446 Feeding helpless patients . 447 Sleep and feeding . 448 Cleansing the mouth . 443 Feeding unconscious patients . 449 Nutrient enema ta t 459 Conditions demanding rectal feeding . 451 Method of injection * _ 452 Care of the rectum ....... . 454 Substances available for rectal feeding 455 Prescriptions for food enemata .... . 453 Food suppositories ...... 453 Other methods of feeding ^ 453 Inunction foods 458 CONTENTS xvii PAGE Intravascular feeding 453 Hypodermic feeding 459 Medicines and food 459 Rules for administering medicines in relation to food .... 461 Diet-kitchen outfit 402 Trained purveyors of food 402 PART VIII DIET IN DISEASE. DIET IN INFECTIOUS DISEASES Diet in fever in general 463 Beverages in fevers 468 Alcohol in fevers -. 470 Diet in convalescence from fevers 472 Typhoid fever 473 Dietetic treatment 474 Relation of intestinal antisepsis to diet 482 Convalescence 483 Rules for feeding atypical cases 485 Typhoid fever in children 487 Typhus fever 488 Smallpox 488 Scarlet fever 489 Measles 490 Mumps 490 Whooping cough 491 Influenza 491 Diphtheria 493 Intubation and tracheotomy 493 Post-diphtheritic paralysis 495 Cerebro-spinal meningitis 495 Erysipelas 496 Cholera 497 Yellow fever 499 Septicaemia 502 Malaria 503 Tetanus 504 Rabies 505 Tuberculosis 505 General considerations 505 Diet in mild cases 511 Diet in advanced cases 513 Suralimentation 514 Diets for forced feeding 515 Aids to dietetic treatment 517 Diet " cures " for phthisis 517 Syphilis 518 xviii CONTENTS DIET IN DISEASES OF THE RESPIRATORY SYSTEM PAGE Laryngismus stridulua . . .518 Tubercular laryngitis 518 Haemorrhage of the lungs . . . . . 519 Acute capillary bronchitis 520 Chronic bronchitis 520 Asthma 521 Emphysema 522 Pneumonia 523 Broncho-pneumonia 525 Pleurisy 525 Empyema 526 DIET IN DISEASES OF THE CIRCULATORY SYSTEM AND BLOOD Diseases of the heart 527 Cardiac valvular disease in children 530 Dietetic treatment of the senile heart 530 Angina pectoris 533 Cardiac palpitation 533 Arterio sclerosis 534 Aneurism 535 TufnelPs diet 536 Anaemias. Chlorosis, etc 537 Pernicious anaemia . 543 DIET IN DISEASES OF THE URINARY SYSTEM Influence of diet on the urine 543 Acute nephritis 544 Acute nephritis in children 546 Albuminuria functional and organic 547 Chronic Bright's disease 550 Salt-free diet 556 Pyelitis 556 Oxaluria 557 Calculi, renal and vesical 558 Lithaemia. Uric-acid diathesis. Gravel 559 Gonorrhoea . 562 DIET IN DISEASES OF THE ALIMENTARY CANAL Abnormal dentition 563 Stomatitis 564 Tonsilitis and quinsy ......... . 564 Dysphagia 565 Stricture and carcinoma of the -oesophagus . 566 Feeding through a gastric fistula 566 Foreign bodies swallowed . . . 567 Indigestion and dyspepsia ...... 568 Examination of the stomach contents ... . 572 CONTEXTS xix PACK Test meals 572 Te"sts for free hydrochloric acid 574 Hypersecretion 576 Tests for pepsin and rennin ' .... 57C Tests for motor power of stomach 573 Tests for absorptive power of stomach 579 Dietetic treatment of dyspepsia . . . * 579 Beverages 581 General rules for dyspeptics 583 Rules for special varieties of dyspepsia 584 Dyspepsia in infants and children . 585 Acute gastritis 586 Acute gastritis in infants and children . 588 Chronic gastric catarrh 589 Chronic gastric catarrh in children . 596 Dilatation of the stomach. Gastrectasia 596 Lavage 598 Massage . 602 Electricity 602 Vomiting 603 Seasickness 605 Vomiting of pregnancy 607 Ulcer of the stomach 607 Cancer of the stomach 611 DIET IN DISEASES OF THE INTESTINES Diarrhoea 613 Diarrhoea in infants and young children 614 Examination of infant stools 816 Entero-colitis in infants and children. Summer diarrhoea . . .617 Cholera infantum or acute milk infection 619 Cholera morbus. Acute catarrhal enteritis in adults 620 Intestinal autointoxication 621 Chronic enteritis in adults. Chronic intestinal catarrh. Chronic colitis 625 Chronic intestinal indigestion in children 626 Chronic gastrointestinal catarrh. Chronic entero-colitis. Chronic diar- rhoea in children 627 Simple atrophy. Marasmus 629 Mucous disease. Chronic pseudo-membranous gastro-enteritis. Mem- branous enteritis 630 Dysentery 631 Acute intestinal obstruction 632 Chronic constipation 633 Dietetic treatment 636 Aids to dietetic treatment 639 Constipation in infants and children 641 Hemorrhoids 643 Appendicitis 643 Acute peritonitis 645 Chronic peritonitis 645 xx CONTEXTS DIET IN DISEASES OF THE LIVEB PAGE Diet in liver diseases in general 646 "Biliousness" 646 Acute catarrhal inflammation of the gall ducts. Angiocholitis. Catar- rhal jaundice 649 Cirrhosis 650 Ascites *. 651 Dietetic treatment of cirrhosis with ascites 651 Fatty liver 652 Amyloid liver 654 Syphilis of the liver 654 Abscess of the liver 654 Gallstones 654 Diet in pancreatic diseases 657 DIET IN DISEASES OF THE NERVOUS SYSTEM Neuralgia 658 Visceral neuralgias 660 Gastralgia 661 Enteralgia 662 Hepatalgia 662 Migraine 662 Neurasthenia 664 The " rest cure " 667 Insomnia and disordered sleep 672 Vertigo 673 Chorea _ 673 Epilepsy 674 Beri-beri _ 676 Locomotor ataxia 676 Apoplexy 677 Acute insanity. Melancholia. Primary dementia. Mania .... 678 Sin-alimentation f 681 DIET IN SKIN DISEASES Skin diseases which are caused by improper diet . . . 682 Erythema. Urticaria > 684 Acne 685 Eczema ............... 685 Eczema in nursing infants ...... 688 Eczema in children ...... 089 Exfoliative dermatitis ....... . . . . 689 ........... 690 ........... 690 Eurunculosis . DISEASES ESPECIALLY INFLUENCED BY DIET Ol>o>ity (Polvsarcia) .... Dietetic treatment 694 CONTENTS xxi PAGE Banting , 697 Ebstein 697 Oertel 699 Schweninger 702 Weir Mitchell 703 Yeo 703 Dujardin-Beaumetz 704 Von Noorden 705 Bouchard 705 Chambers 706 Debove 707 "Anti-fat" remedies 710 Diet for leanness 710 Rheumatism, acute 712 Chronic 714 Arthritis deformans 714 Gout 715 Diet for the gouty diathesis and chronic gout 721 Beverages 725 Diabetes mellitus 729 Causation 729 Physiological experiments 731 The pancreas and diabetes 733 Various theories 734 Symptoms 735 Dietetic treatment 740 Foods allowed 744 Foods forbidden 747 Substitutes for bread 747 Substitutes for sugar 753 Beverages 754 Special diets 755 Ebstein's 755 Diiring's 756 Naunyn's 757 Von Noorden's 757 Diabetic coma 758 Rhachitis (rickets) 759 Scurvy 763 Hsemorrhagic purpura 767 DIET IX MISCELLANEOUS DISEASES Addison's disease 767 Osteomalacia 768 Exophthalmic goitre 768 Chronic lead poisoning 769 Dietetic difficulties arising from associated diseases .... 770 CONTENTS DIET FOB SURGICAL PATIENTS PAGE Food and anaesthetics 772 Diet after anesthesia 772 Surgical operations and injuries 773 Laparotomy. Ovariotomy 775 Surgical inflammation. Sepsis 775 PART IX RATIONS. DIETARIES Prescribing dietaries. Thompson's diet lists 777 Army and navy diets 779 The U. S. army rations 779 Foreign army rations 786 U. S. navy rations 790 Diet in prisons 792 U. S. army prison diet 793 New York State Reformatory diet 795 Dietetic cures 795 Skimmed milk cure 795 Whey cure 801 Koumiss cure 802 Various " cures " 803 Kneipp system 804 Fruit cures 804 Grape cure 805 Meat and hot-water cure 806 Dry cure 807 Purin free diet 808 Diet in athletic training 809 Dietary of the Yale boat crew 811 Dietary of the Harvard boat crew 812 Dietary of the Yale football team 815 Diet of pugilists, bicycle riders, and jockeys 815 Diet and occupation t 817 Brain workers 819 Commercial life 823 Travel 824 Diet in pregnancy 825 Diet for puerperal women 826 Selection of a wet nurse 828 Diet of a nursing mother or wet nurse 829 Drugs in human milk 830 Feeding of infants 830 Overfeeding ... 831 Methods of feeding .... 832 Feeding by the mother or wet nurse 832 Feeding by the bottle . 833 Mixed feeding 337 Gavago .837 CONTENTS -xxin PAGE Weaning ... 837 Artificial infant foods . 840 Infant stools 842 Nursing bottles 843 Care of infant's mouth 844 Weighing of infants 844 Premature infants 844 Food for young children 845 Rules for feeding young children 847 Dietaries for young children 848 Teething and food 853 Sleep and feeding 853 Diet for school children 854 Diet and puberty 855 Hospital dietaries 861 New York Hospital 864 Bellevue, Gouverneur, Fordham, and Harlem Hospitals .... 866 Presbyterian Hospital 868 Roosevelt Hospital 872 Johns Hopkins Hospital 873 Cook County Hospital 873 New York Infirmary 874 New York State Hospital 875 Utica State Hospital for Insane . 876 Dietary for Liverpool Infirmary . 878 Children's dietaries in English hospitals 878 Dietaries of army hospitals 880 United States 880 British 884 Prussian, French 885 APPENDIX Receipts for invalid food and beverages suitable for fevers and conva- lescence from acute illness 887 Beverages 887 Demulcent and nutritive 887 Diuretic and refrigerant 889 Fluid beef preparations 889 Broths and soups 891 Solid meat preparations 893 Milk preparations 894 Egg preparations 897 Farinaceous foods 898 Milk-sugar preparations 903 Gelatin preparations 904 Fat foods ...... 906 Concentrated fluid nourishment 906 Substitutes for tea and coffee 906 General rules for prescribing a dietary 906 INDEX . 909 LIST OF ILLUSTRATIONS FIGURE PAGE 1. General View of the Respiration Calorimeter Laboratory at Wesleyan University 10 2. Interior of Respiration Chamber . . 11 3. Diagram of Percentage Composition of Common Foods. . 15 4. Proportion of the Component Parts of Milk .... 54 5. A Drop of Milk Magnified, Showing Fat Globules ... . . 54 6. Chapman's Dipper for Removing the Upper Layers of Milk . . 56 TA. Human Colostrum 62 TB. Woman's Milk at a Late Period 62 8. Lactometer 65 9. Holt's Apparatus for Examination of Woman's Milk ..... 67 10. Creamometer 67 11. Tubes Used for Determining the Fat in Milk 68 12. The Babcock Cream-Testing Apparatus 69 13. The Babcock Cream-Testing Apparatus 69 14. Modern Milking Pails to Prevent Access of Dirt 78 15. Bottling Room in a High-Class City Dairy 80 16. The Arnold Sterilizer 97 17. Sterilization Oven Used in Bottling Milk Under Steam Pressure . 98 18. A Modern High-Class Pasteurizing Plant 101 19. Freeman's Pasteurizer 102 20. Centrifugal Machine 110 21. Parts of Centrifuge: Bottles Ill 22. Diagram of a Hen's Egg Showing the Proportion of Ingredients . . 121 A Piece of Beef Magnified 126 Beef Fibers Highly Magnified 126 25. Section Through Wheat Kernel 162 26. Cross Section of a Grain of Wheat as Seen Under the Microscope 163 27. Microscopic Characters of Wheat 164 28. Yeast Plant Torula cerevisise Magnified 165 29. Bread Made From Different Kinds of Flour 170 30. Bread Made From Entire Wheat, Patent, and Graham Flours, and Character of "Feces From Same . 172 31. Section of Grain of Corn .182 32. Kernels of Corn: High Oil and Low Oil 183 XXV xxvi ILLUSTRATIONS FIGURE PAGE 33. Kernels of Corn: High Protein and Low Protein 183 34. Lentil 195 35. Peanut 196 36. Diagram of a Potato, Showing Proportion of Ingredients . . . 197 37. Potato Starch as it Appears Under the Microscope 198 38. Composition of Apple 214 39. Composition of Banana 217 40. Composition of Dried Fig 223 41. Branches of Tea 247 42. Branches of Coffee 252 43. Approximate Quantity, in Grams, of Different Classes 'of Foods Con- sumed in Twenty-four Hours, Computed According to Age . . 329 44. Apparatus for Drying Feces Over Water Bath 402 45. Diagram of the Relative Proportion of Carbohydrate in Foods Al- lowed Diabetics . 745 PRACTICAL DIETETICS PART I FOODS AND FOOD PREPARATIONS ELEMENTARY COMPOSITION OF FOODS OF the eighty-two chemical elements, thirteen enter uniformly into the composition of the human body and ten more are occasionally found. Of all these, several exist in very small proportion and their uses are unknown; several are present more abundantly but are not indispensable to life, and four elements namely, carbon, hydrogen, oxygen, and nitrogen are necessary ingredients of all the tissues of the body. All food is composed of combinations of the simpler chemical ele- ments which must be subjected to alteration in the body itself to pre- pare it for assimilation by the tissues. The nutrition of the body, therefore, involves four 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 vessels and lymphatic vessels. 3. The assimilation of the absorbed nutritious products by the tissues. 4. The elimination of the waste material. The following analysis exhibits the relative proportion of the elements of which the human body is composed : Approximate Chemical Analysis of a, Man (Moss). (Height, 5 feet 8 inches; weight, 148 pounds.) Oxygen 92.4 pounds. Hvdrogen 14.6 Carbon 31.6 Nitrogen 4.6 Phosphorus 1.4 Calcium 2.8 Sulphur 0.24 Chlorine 0.12 3 1 FOODS AXD FOOD PREPARATIONS Sodium 0.12 pounds. Iron 0.02 Potassium 0.34 Magnesium 0.04 Fluorine 0.02 Total 148.00 pounds. All these elements are necessarily derived from food and water phis the oxygen of the air which is breathed. The three predominating elements oxygen, hydrogen, and car- bon are the great force producers of the body, although they are tissue formers as well, and to them must be added nitrogen, as serv- ing in this double capacity, although its relation to tissue formation and renewal is greater than its capacity for supplying energy. According to the experiments of Benedict and Milner, the weight of oxygen taken into the body in 24 hours at rest is 0.39 gram, and at work 0.86 gram per hour per kilo of body weight. Hence the amount of oxygen consumed is proportionate to muscular work. The weight of C0 2 eliminated at rest is 0.47 gram, and at work 1.01 gram. That of water is for rest 0.49 gram, for work 2.15 gram per kilo of body weight. In general the output of hydrogen is parallel with that of carbon. The common elements which enter into tissue formation chiefly and which bear no direct relation to the main sources of energy 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 calcium 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, as occurs in rickets. Lack of iron salts in the food impoverishes the coloring matter of the red blood-corpuscles on which they depend for their power of carrying oxygon to the tissues, and anaemia and other disorders of deficient oxidation result. Lack of sufficient potash salts, especially potassium carbonate and chloride, is a factor in producing scurvy, and the condition is intensi- fied by the excessive use of common salt. Lack of sodium chloride interferes with many of the functions of the body immediately concerned with nutrition, such as absorption, secretion, etc., and alters the density and reactions of the different body fluids. Tbes.<- few illustrations suggest the diversity of roles exhibited by the elements and the need for a correctly balanced diet. ELEMENTARY COMPOSITION OF FOODS 3 In order to determine what such a diet should consist of it is neces- sary to study the value of the principal classes of foods in force pro- duction and in nutrient power or " tissue building," but before pro- ceeding further with this discussion it will be advisable to adopt a simple comprehensive classification of the foods in general use by man. The following table of analyses made by Dujardin-Beaumetz shows the proportion of nitrogen present in different 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.") Nitrogen. C + H. Combustibles calculated as carbon. Beef (uncooked) 3.00 Roast beef 3.53 Calf's liver 3.09 Foie-gras 2.12 Cod, salted 5 02 Herring, salted 3.11 Whiting 2.41 Mackerel 3.74 Sole 1.91 Salmon 2.09 Oysters 2.13 Lobster ( uncooked ) 2.93 Eggs 1.90 Milk (cow's) 0.66 Cheese (Brie) 2.93 Cheese (Gruyere) 5.00 Chocolate 1.52 Rye flour 1.75 Winter barley 1.90 Maize 1.70 Buckwheat 2.20 Rice 1.80 Oatmeal , 1.95 Bread, white (Paris, thirty per cent, water) 1.08 Bread, brown (soldiers' rations) 1.20 Potatoes 0.33 Beans 4.50 Peas (dry) 3.66 Carrots 0.31 Mushrooms 0.60 Figs (dry) 0.92 Plums 0.75 Coffee (infusion of 100 grammes) 1.10 Tea (infusion of 100 grammes) 1.00 Bacon 1-29 Butter (fresh ) 0.64 Olive oil Trace Beer, strong 0.05 Wine . 0.15 11.00 17.76 15.68 65.58 16.00 23.00 9.00 19.26 12.25 16.00 7.18 10.96 13.50 8.00 35.00 38.00 58.00 41.00 40.00 44.00 42.50 41.00 44.00 29.50 30.00 11.00 42.00 44.00 5.50 4.52 34.00 28.00 9.00 10.50 71.14 83.00 98.00 4.50 4.00 4 FOODS AND FOOD PREPARATIONS To estimate the equivalent chemical elements in the different food classes the following standards are adopted : 1. To obtain the amount of nitrogen in proteid foods, divide the quantity of food by the factor 6.5. 2. To obtain the carbon in fat, multiply the quantity of fat by 0.765. 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 grams (10 ozs.). and that of nitrogen about 20 grams (308 grains.) (See tables, pp. 27, 28.) FOOD CLASSIFICATION Foods may be classed 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. 1. Physical Properties. Foods are classed in accordance with their general physical properties: First, into solid, semisolid, and liquid foods; secondly, into fibrous, gelatinous, starchy or amylaceous, ole- aginous, crystalline, and albuminous foods. A subdivision sometimes used is that of the " complete " foods, such as eggs or milk, which in a single article comprise all the neces- sary elements to support life, and " incomplete " foods, which are capable of maintaining life only for a comparatively short time. 2. Source. Foods may be classed as to their source primarily into (a) animal and (b) vegetable foods. (a) Animal foods consist of meats, fowl, fish, shellfish, crustaceans, insects and their products (e. g. honey), eggs, milk and its products, animal fats, gelatin. (b) Vegetable foods are subdivided into cereals, vegetables proper, fruits, sugars, gums and vegetable oils and fats. 3. Composition. 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. Xitroofenons. I. Xon-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. FOOD CLASSIFICATION 5 a. The nitrogenous group von Liebig regarded as containing " plastic " elements i. e., they are essentially " tissue builders " or " flesh formers." Nitrogenous foods are called proteids and include gelatinoids and albuminoids that is, substances resembling albumin. They con- sist chiefly of the four elements carbon, oxygen, hydrogen, and nitro- gen, 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-crystallizable, but coagula- ble, fluid, solid or semisolid substances. They are fermentable, and under some conditions will putrefy, both within and without the ali- mentary canal. The nitrogenous group comprises all forms of animal food, except- ing fats, glycogen, and such substances as milk-sugar and honey. Its chief representatives are milk, eggs, crustaceans, fish, shellfish, flesh, and fowl. It also contains such nitrogenous substances as exist in the vegetable kingdom or " vegetable albuminoids," notably in peas and beans. &. The non-nitrogenous group von Liebig called " respiratory or calorifacient foods," because their function in the body is to furnish fuel to maintain animal heat. Since this original classification was suggested it has been established that the non-nitrogenous aliments supply energy for muscular action, hence they are also called " force producers," in distinction from the nitrogenous or proteid " tissue builders." 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 and heat producers as well. The non-nitrogenous group consists chiefly of combinations of the three elements carbon, hydrogen, and oxygen, although various salts are mixed with both vegetable and animal foods. It includes vegeta- bles, fruits, cereals, starches, sugars, gums, fats and oils (which latter are both animal and vegetable), and organic acids. Many vegetables and cereals, besides some fruits, contain considerable nitrogen, but the " carbohydrates " i. e., starches and sugars constitute their main bulk. 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 ac- ceptance. It will be used in this book whenever a further degree of 6 FOODS AND FOOD PREPARATIONS subdivision is not needed, but always with the understanding that it has a not too literal application, and, unless otherwise distinctly specified, " nitrogenous or proteid food " will be understood to include animal foods and " non-nitrogenous food " to include vegetable foods of all kinds. For the purpose of the present work, it is convenient to subdivide foods by the following classification: I. Water; II. Salts; III. Proteids ; IV. Starches ; V. Sugars ; VI. Fats and oils. Protein is a comprehensive term used in food calculations to sig- nify all nitrogenous food substances. Proteids are nitrogenous sub- stances of definite composition forming a portion of the protein class, such as egg albumen, meat albumin, etc. Some writers class oxygen in a separate division among foods. This seems unnecessary, unless a separate division is made for hydro- gen, and in fact for each element. The primary object of food classi- fication is to obtain a practical working basis of subdivision, and the less complex this is made, the better. 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 man may be measured in foot pounds, a foot pound being the amount of energy expended or force required to mechanically lift a weight of one pound through a height of one foot. The work of the average man is calculated to be about 2,000,000 foot pounds per diem (E. H. Thurston). This may exceptionally be increased to 3,000,000 foot pounds. According to the study of 1. ('. Carpenter of a phenomenal athlete named Miller, the latter developed work amounting to over 15,000,000 foot pounds (7,500 foot tons) on the first day of a six-days' bicycle contest, and 5,500,000 foot pounds (2,750 foot tons) on the last day. A man weighing one hundred and fifty pounds or nearly 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. Ordinarily less than one-fifth of the total energy of the body is expended in motion and more than four-fifths in heat production. FORCE PRODUCTION. ENERGY FROM FOOD 7 The total intake of energy of the body is derived from foods plus the oxygen of the inspired air. The total output of energy is com- puted from (1) the heat of combustion of the unoxidized ingredients of the urine and feces, (2) the energy liberated as body heat, and (3) the energy of external muscular work, or the work of the vol- untary muscles. A useful comparison may be made between the processes of nutri- tion 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 carbon. In both cases the latent energy of the carbon liberated by oxidation proc- esses 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, there is less to yield motion, and conversely. In the athlete Miller above referred to, Carpenter found that the energy developed lr this man equaled 45 per cent of the total heat of combustion calculated for his food. Carpenter says : " The best record of any heat engine is probably that of the Deisal motor, which devolops 33.7 per cent of the heat energy of its fuel, and the best record of a steam engine is that of the Nordberg pumping engine at Pitts- burg, which develops 22.7 per cent of energy." " From this comparison it would seem that the human machine is decidedly superior to any heat engine which has been developed in form so as to be of any value for practical use." Finally, 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 con- sumed 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 addi- tional power of modifying and distributing the fuel food which it receives so as to develop its energy to the best advantage in different organs. The heat eliminated per hour per kilo (2% Ibs.) of body weight averages 1.48 calories or heat units for a man at rest, 2.83 for moderate exercise and 4.12 for arduous work. Whether alimentary substances are burned outside of the body or oxidized within the body, the resulting waste products are similar. There can be no loss of matter, and there can be no loss of energy. The matter is simply changed in form by molecTilar rearrangement, the energy is converted from one type into another. The following 8 FOODS AND FOOD PREPARATIONS 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 vapor will accumulate on the surface of the jar, and a film of calcium carbonate will form on the surface of the lime water produced 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 similarly be con- verted into carbonic-acid gas and water, and in this process the body heat will be increased. By blowing expired air through a glass tube into a tumbler containing lime water, the presence of carbonic acid is made apparent by the resulting turbidity of the lime water. No substance is a good food unless it fulfills two conditions viz., easy assimilation and complete combustion. The proportion of any given food actually assimilated (i. e., not rejected in the feces) is called its " coefficient of digestibility." Metabolism within the body is not alone controlled by muscular work, but by the nervous energy expended in its performance. The relative importance of the different food fuels should be con- sidered. This is well summarized by Major Charles E. Woodruff, U. S. A. : " For instance, cut off the supply of oxygen, and death ensues in from one to ten minutes. If water is witheld, preventing the trans- portation of the fuel and oxygen to various part 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." The energy derived from fats and from carbohydrates as sources of muscular work and as " tissue sparers " or protectors of the body ma- terial is almost equal (fats being very slightly inferior as sources of muscular work), but fats furnish energy in the form of heat in a proportion %y times greater than carbohydrates. Pfliiger and Argutinsky still hold the older view that protein is the chief source of muscular work, but this is certainly not the case on a mixed diet, with which the energy of protein oxidized is less than that of work performed. Benedict and Milner, as well as -most physiologists, are agreed upon the latter view. FORCE PRODUCTION. ENERGY FROM FOOD 9 Two methods may be employed to study the energy-producing power of food in the body. First. The protracted study of subjects who are allowed to follow their usual avocations, but whose food and excreta are carefully measured and analyzed through a period of weeks or months. This method (detailed on pages 20, 21) has yielded much valuable information, but is liable to errors arising from uncontrolla- ble circumstances, such as an attack of influenza or of indigestion, or worry, fatigue, or disgust with the monotony of a diet, or the influence of the subject's attention directed to his symptoms or his food. More- over, there is the difficulty of always collecting the excreta, and the la- bor and expense of prolonged daily analyses. Second. The second is the shorter method of enclosing a man for a brief period, not exceeding a few days, in a cabinet known as a " calorimeter " where extremely accurate and comprehensive, but necessarily brief studies are made. This method yields certain very interesting results, but is open to the objection that the subject is not living under normal conditions of life, as to occupation, locomotion, etc. In other words, it is a highly artificial method and does not admit of the study of diet in disease, as well as the former process. By either method, uniformity of the subject's conditions and diet is secured as nearly as possible through- out the experiment, and to save unnecessary repetition of food analysis, certain standard rations may be analyzed once for all. Thus canned vegetables are of fairly uniform composition for the same lot of cans purchased, bread is made from the same sample of flour throughout, potatoes are used of uniform size, meat and fish may be ground in a sausage grinder and analyzed either fresh or dried, eggs and pudding may be analyzed in a mixed standard sample, and seasoning is added only at table in measured quantity, etc. The Calorimeter. There are several types of calorimeter in which several thousand experiments have been made upon man. The most elaborate and ingenious apparatus of this sort is the "respiration calorimeter" constructed at Wesley an University by Profs. W. 0. Atwater and E. B. Eosa. It consists of a chamber seven feet long, six feet four inches high, and four feet wide, in which a man may remain day and night, being supplied with fresh air and food. The chamber is practically a many-walled, air-tight box having air spaces between the walls which are so constructed as to maintain a uniform temperature within and prevent all external temperature changes from affecting the interior. There are two inner metal walls composed respectively of copper and zinc, and three outer wooden walls rein- forced by thick builders' paper. Between these five walls, which com- pletely surround the box, over top and bottom as well as sides, are 4 10 FOODS AXD FOOD PREPARATIONS m '-5 M) sri'-s CM a; C O -* E H 3 ^2 ? '? 99 97 99 96 92 82 Esrsrs . Milk Butter Oleomarga rine Wheat bread 81 to 100 89 84 86 74 72 Corn (maize) meal Rice Peas Potatoes Beets Calculated Coefficients of Digestibility of Nutrients in Different Classes of Foods. Standards used in calculations by the U. S. Department of Agriculture. Protein. Fats. Carbohydrates. Animal foods Per cent OR Per cent. Q7 Per cent. inn Cereals and starches 85 00 oft Susars . 100 Vegetables and fruits 80 90 95 The actual cost of elementary foods naturally varies with the market, locality, season of the year, and other considerations. For- tunately, however, many foods which furnish most nutriment are among the cheapest and least variable in price. Cereals, for instance, which readily may furnish one-third of the total nutrients re- quired, do not vary greatly in price. Hence, when it is neces- sary to reduce the cost of living, peas, beans, oatmeal, and flour may be used economically to supply protein. Sugar, rice, pork, cornmeal, and potatoes all supply fuel energy at small expense. If variety rather than cheapness is desired, it is found in the use of green vegetables, fresh fruits, butter, eggs, and the better cuts of meat. Tn illustration of these principles are the following tables from nutrition investigations conducted by Isabel Bevier at Pittsburg, V;\. (V . S. Department of Agriculture Bulletin 52) ; ECONOMIC VALUE OF FOOD Cost per Pound and Amounts and Fuel Value of the Digestible Nutrients in 1 Pound and in 10 Cents' Worth of the More Important Food Materials used in a Dietary Study of a very Poor Polish Mill-worker's Family in Pittsburg, Pa. KIND OF FOOD MATERIAL. Actual cost per pound. NUTRIENTS AND ENERGY IN I POUND. NUTRIENTS AND ENERGY IN 10 CENTS' WORTH. Protein Fat. Carbohy- drates. Fuel value. Pro- tein. Fats. Car- bohy- drates. Fuel, value Cal. 1,270 995 1,205 982 1,555 2,105 430 1,400 970 4,385 3,520 3,340 3,010 2,495 2,420 Beef: Stew meat .... Cents. 5.0 8.9 9.4 18.8 8.5 5.9 14.2 25.5 2.8 3.6 5.0 3.4 5 9 Pound. 0.176 202 .176 .178 .183 .339 .126 .010 .031 .096 .133 .078 Pound. 0.073 .121 .191 .359 .233 .145 .089 .843 .025 .010 .064 Pound. 0.058 .730 .669 .532 .954 Cal. 635 885 1,130 1,845 1,325 1,245 610 3,575 270 1,580 1,760 1,135 1,775 Lb. 0.15 .14 .20 .19 .27 .25 .06 .33 .09 .03 .13 Lb. Pound. 0.35 .23 19 .09 .21 .57 .09 Bologna sausage . Pork : Hani boiled . . Head-cheese Fish, herring, smoked Errors Butter Milk 0.21 2.03 1.33 1.56 1 61 .11 .27 .27 .23 Flour Oatmeal Bread Beans 5.8 1.1 .178 .013 .016 .561 .130 1,442 265 .03 .97 1.18 .31 .12 Potatoes Summary of Dietary Studies. Quantities and Cost per Man per Day (Bevier). Cost. Pro- tein. Fats. Car- bohy- drates. Fuel value. Dietary of a professional man's family Cts. 21 13 9 22 20 16 25 20 Grms. 91 85 77 147 112 94 104 103 Grms. 145 104 90 173 144 121 125 150 Grams. 380 307 314 683 368 385 423 402 Cal. 3,280 2,575 2,440 5,010 3,305 3,085 3,325 3,465 Dietary of a mill workman's family Dietary of a mill workman's family Dietary of a boiler tender's family Average 14 dietaries of professional men's fam- Average 14 dietaries of mechanics' families.. . The following table is from the U. S. Department of Agriculture Bulletin No. 91, and summarizes dietetic studies made in widely different parts of the United States : FOODS AND FOOD PREPARATIONS Cost, Nutrients, and Fuel Value of Food per Man per Day. Cost of food. Pro- tein. Fats. Car- bohy- drates. Fuel value. Nutri- tive ratio. Teacher's family, Illinois: Food purchased Cents. 27 Grams. 124 Grams. 158 Grams. 487 Cal. 3975 Food wasted 23 45 4fi 700 Food eaten 101 113 441 3,275 1-69 Professional men, Connecticut, average of 9 dietaries: Food purchased 25 110 136 442 3 530 Food wasted 3 7 5 100 Food eaten 107 129 437 3 430 1-68 Professional man's family, Penn- sylvania : Food purchased 22 3 98 155 396 3 465 Food wasted 7 10 16 185 Food eaten 91 145 380 3,280 1:78 Teacher's family, Indiana: Food purchased 18 111 110 349 2910 Food wasted 5 8 9 130 Food eaten 106 102 340 2,780 1-54 Proposed standard for man with little muscular work (Atwater) Mechanics' boarding club, Illinois: Food purchased 23.0 112 128 171 392 3,000 3,720 1 : 5.5 Food wasted 11 25 13 330 Food eaten 117 146 379 3,390 1:61 Mechanics' families, Connecticut, average of 9 dietaries: Food purchased 113 153 420 3,605 Food wasted 7 11 14 185 Food eaten 106 142 406 3,420 1 6 9 Mechanic's family, Indiana : ' Food purchased 26 106 157 475 3 840 Food wasted 16 23 67 555 Food eaten 90 134 408 3285 1-79 Mechanic's family, Tennessee: Food purchased 16 119 224 455 4 435 Food wasted 9 14 43 345 Food eaten 110 210 412 4 090 1-81 Mechanic's family. New Jersey: Food purchased 28 103 144 431 3 530 Food wasted 3 6 6 95 Food eaten 100 138 425 3,435 1-74 Proposed dietary .standard for man with moderate work (Atwater) 125 3,500 1 :6.8 A study by Atwater made upon the diet of women students in Connecticut showed a consumption of 84 grams protein, 128 grams fat, and 264 grams carbohydrate, yielding 3,015 calories. The ac- cepted standard for woman at light muscular work calls for 90 grams of protein and a total fuel value of 2,500 calories, hence this dietary was deficient in protein, although the total fuel value was considerably above the standard requirement. This shows that a ANIMAL AND VEGETABLE FOODS COMPARED 29 considerable departure from normal dietetic standards is not incom- patible with health. NUTRITION. ANIMAL AND VEGETABLE FOODS COMPARED The study of nutrition involves the tracing of the food products after absorption from the alimentary canal, until their final excretion as waste material, chiefly water, urea and C0 2 . Animal food is believed to make the blood rich in fibrin and corpuscles, and to increase the mineral salts, especially the phos- phates ; it both repairs the old and forms new tissue ; it improves the condition of the muscles, which are made firmer than they are through a vegetable diet, and favors the reduction of stored-up or surplus fat. Under some conditions it may produce a part of the body fat, although most of it is derived from other sources. (See Obesity.) It also increases the quantity of urates, phosphates, sul- phates, and urea normally present in the urine, and tends to make the fluids of the body somewhat more acid or less alkaline. Bauer (Dietary of the Sick) says: "The functional activity and resisting power of the organism seem to be essentially connected with the presence of an ample supply of albumin." Animal food requires a considerable quantity of oxygen for its complete combustion, and a diet of this nature increases the demand for oxygen. Meat in general has a more stimulating effect upon -the system and is more "strengthening" than vegetable food, and gives rise to energy and activity. A meal consisting of meat remains an hour or more longer in the stomach than a purely vegetable meal. It seems to satisfy the cravings of hunger, bulk for bulk, to a greater extent and for a longer time than vegetable food, and a man can live longer upon exclusive proteid food than upon exclusive carbo- hydrate food. Animal food occupies less space in the stomach, and is more portable than vegetable food. Moreover, proteid foods can be eaten longer exclusively without exciting loathing, as a rule, than can fats, sugars or some of the pure starches. There is, however, a frequent, tendency to eat too much meat, and when its effects are not counterbalanced by free outdoor exercise, it produces an excess of waste matter which accumulates and causes biliousness, and some- times precipitates attacks of lithiasis, gout, etc. A carbohydrate diet taxes the excretory organs to a lesser degree than animal food. Sir Henry Thompson says : " It is a vulgar error to regard meat in any form as necessary to life." Nitrogenous food man must 30 FOODS AND FOOD PREPARATIONS have, but it need not necessarily be in the form of meat, which " to many has become partially desirable only by the force of habit, and because their digestive organs have thus been trained to deal with it." This is only partially true, for the training has become so strongly a matter of heredity through many centuries that those who possess it are certainly in better health for a reasonable allowance of meat in their dietary, and many primitive savage tribes have always subsisted largely upon meat. Errors in diet are far more common on the side of excessive meat eating than the eating of too much vegetable food, especially among civilized communities. In the temperate zones an increase in prosperity, together with the improvements made in the methods of preparing and preserving meat as well as those in breed- ing cattle for market purposes, tend to increase the habit of meat eating. The common estimate, in which meat should occupy one- sixth and vegetable food five-sixths of a mixed diet, is overstepped by many persons with whom the proportion may be three or four to six. An average of eighty-seven practical dietary studies made by the U. S. Department of Agriculture showed 'that the food consumed was 45 per cent of animal and 55 per cent of vegetable origin. The proper association of different foods always keeps healthy men in better condition than too long continuance of any selected diet sys- tem. Meats which are deficient in fat are usually eaten with added fat. Thus bacon is eaten with veal, liver, and chicken, and most fish are cooked with butter or oil. Similarly, butter, eggs, or cream are mixed with amylaceous foods, such as rice, sago, potatoes, etc., which are lacking in fat, and cheese containing fat is added to macaroni. Bacon is added to beans, and pork to greens. " Whenever one kind of food is wanting in any particular con- stituent, we invariably associate it with another that contains an excess of it" (Letheby). If a laboring man is allowed an ordinary meat ration he requires in addition, to obtain his requisite carbon, of fat 346 grams, or of starch 596 grams (Voit). But he would soon tire of such a quantity of either of these two food classes alone, and he does better to eat some of each. As pointed out by Voit more than forty years ago, the available vegetable nutrients are so enclosed in cellulose or woody fiber as to render their absorption difficult. Vegetable food eaten in excess is liable to induce intestinal fermentation, which ex- cites peristalsis, and as the intestine of man is much shorter than that of herbivores, this class of food does not have time for complete absorption, when consumed in too large amount. ANIMAL AND VEGETABLE FOODS COMPARED 31 The carnivorous animal fed upon lean meat alone requires a daily supply equal to one-twentieth of his body weight, but if a little fat be added he needs much less. Animal food is often said to be more stimulating to the passions than vegetable food, and in general the character of carnivorous ani- mals is more savage than that of herbivorous, although the angered bull is as fierce as any carnivore. It is doubtful, however, whether this is attributable so much to their different diet as to many other conditions which have contributed through the survival of the fittest to their differentiation. Carnivorous animals are obliged to work and fight for their food; they obtain it at uncertain and infrequent intervals, often when made ravenous by long periods of fasting. Herbivorous animals, on the contrary, always have their food at hand, obtainable with little labor other than that of eating. The Polynesian warrior is more ferocious at times on a diet of plantains than the Eskimo, who eats nothing but fish, meat, and fats. A man cannot perform more actual muscular labor upon an ex- clusive diet of animal food than of starchy food. He requires abun- dant animal food to replace the general wear and tear of muscular tissue, but the energy for muscular contraction is not derived so much from proteid food, as from carbohydrates, the former being used merely to keep the muscles in a state of healthful equilibrium. He who is physically feeble and who lacks muscular power cannot restore that power by an exclusive proteid diet. A man fed upon proteid diet without vegetable food may not work as well in daily labor as when given a fair proportion of the latter ; but, on the other hand, he is better fitted for sudden arduous exertion than are exclusive vegetable feeders. A mixed diet is therefore the only rational one for civilized man, and it is useless to reason otherwise from analogy with the lower ani- mals, or from certain savage tribes whose peculiar development ex- empts them from general rules. The ox is strong and performs daily labor upon a grass diet, but he extracts a large proportion of nitrogen from such food which man's feebler digestive organs do not enable him to do. The proportion of protein to carbohydrate is 1 to 4.7 in such food. The horse is fed upon oats when it is desired to increase his spirit and activity, and he derives more nitrogen from them than does man from his oatmeal. The lion derives great strength from purely nitrogenous food, but when trained he is wholly unfit for the continuous exertion that herbivores can endure. The northern Eskimo, who has absolutely no starchy or saccha- rine food, eats fat with his protein diet, and is therefore enabled to FOODS AND FOOD PREPARATIONS acquire energy to resist extreme cold and to take very long and fatiguing sledge journeys; yet he is no stronger, nor as strong, as the Central African negro, who lives upon a diet of manioc and plan- tains, without meat. " Some food rich in protein will be found in the daily diet of all peoples. The Mongol eats with his rice, which is largely starch, small quantities of fish, fish eggs, and goose livers, but for his supply of protein material he relies on his different preparations of bean cheese and on soja sauce made from- the soy bean. The Mexican, whose supply of meat is scanty and of a poor quality, uses the native bean or frijole at almost every meal, made into a stew with vegetables and perhaps shreds of sun-dried beef, well spiced with the chili or red pepper" (Mary Hinman Abel). Man is an animal of extraordinary adaptability to his environment., and one should be guarded in making dogmatic statements in regard to his diet, and such observations as the above should be taken as ap- plying only generally, for it seems possible for either class of foods to supplement to some extent the functions of the other. This fact is illustrated in disease as well as in health. For example, in the earlier stages of diabetes glucose is formed from farinaceous and saccharine food almost exclusively, but in the advanced stages, when these sub- stances are withheld, it undoubtedly may be derived from proteid material. It is a popular belief that meat requires more effort for digestion than starchy food, but in health this is probably not true, provided both varieties of food are taken in correct proportion, for it certainly would be a strain upon the digestive system to be obliged to derive all the carbon needed from an exclusive meat diet, just as it over- taxes the alimentary canal to obtain sufficient nitrogenous material from an exclusive vegetable diet. It cannot be said didactically that a piece of beef is more or less digestible than a potato, and that it taxes the energies of the digestive organs to a greater extent, al- though it is more completely assimilated and leaves less waste in the intestine. The whole question devolves upon a true balance of the ingredients of a mixed diet. As regards the actual complexity of the digestive processes of the several classes of food, there is but little difference, for both starches and proteids pass through interme- diate stages on the way to the formation of their completed products. In man, certainly. Xature never intended that all the nutrition of the body should he derived from any one class of food stuff which would require the use of certain digestive juices, and imply the disuse of other? which arc normally present. VEGETARIANISM 33 A diet of animal food is much less fattening than a vegetable regimen or than carbohydrates with a fair proportion of fats, but a stout man does not endure fatigue, or even starvation, better than a lean man. On the other hand, to increase the proteid substances of the body an albuminous diet with little carbohydrate is neces- sary. Men, unless greatly emaciated, have a reserve store of energy in their bodies sufficient to maintain their animal heat and keep them alive for from seven to nine days, and this is true whether they have been meat eaters or vegetarians. Storage of fat will help them out in emergencies, but if it has been overdone i. e., if there is too much fat in the tissues they may be weakened by it and, although they have the material for force production on hand, they are unable to utilize it, and are worse off than if they were spare. (See Obesity and Leanness.) Bauer wrote : " The material effects of albumin and of fat in the system are in a certain sense opposed, for the former increases the tissue waste and secondarily the oxidation, while fat induces the op- posite effects." When the organism is in health albumin constitutes upon the average about 10 per cent of the body weight and fat about 16 per cent, but these proportions may vary within wide limits. Animal food is easily cooked, requiring less fuel than vegetable food, and in the process develops more flavor than has vegetable food. VEGETARIANISM In regard to an exclusive or almost exclusive vegetable diet for civ- ilized man, the universal experience has been that while it may keep him in apparent health for some time, it eventually results in a loss of strength and general resisting power against disease, which becomes evident after some months, if not before. Of vegetarianism Bauer wrote : " The beneficial effects of vege- tarianism certainly do not depend on the fact that its followers take no meat, and still more no animal food, but on their giving up their former bad habits." No doubt much of the alleged benefit of vegetarianism is due to the greater freedom of action of the bowels, induced by the use of bran bread and other coarse articles of food. Those who style themselves "vegetarians" are of several classes: (1) Those who eat no meat, but eat other forms of proteid food, often in the form of puddings, pastry, etc., containing much milk and eggs. (2) Strict vegetarians, eating only vegetables and cereals (3) Fruitarians, who subsist upon fruits and nuts and sometimes 34 FOODS AND FOOD PREPARATIONS cereals. A sample diet of the latter, for a woman 30 years old, weighing 104 Ibs., is given as follows by M. E. Jaffa : Weights of Food and Nutrients Consumed. Kinds and amounts of different food materials. Composition of food per person perday. Pro- tein. Fat. Sugar, starch, etc. Crude fiber. Fuel value. VEGETABLE FOOD. Vegetables: Celery, 113 grams; tomatoes, 3 624 grams Grams. 2 5 Grams. I 1 Grams. 5 45 3 Grams. 1 24 1 Cal. 40 370 15 95 45 475 Fresh fruits: Apples, Astrachan, 9,130 grams; apricots, 3,360 grams; figs, 408 grams; olives, 630 grams; oranges, 822 grams; peaches, 4,711 grams; pears, 1,755 grams; plums, Japanese, 900 grams- plums, red, 1,080 grams Dried fruits: Dates, 93 grams; raisins, 60 grams Vegetable oils: Olive oil, 255 grams 10 Honey, 337 grams 11 8 Nuts; Almonds, 1,067 grams; Brazil nuts, 146 grams; pignolias, 765 grams, pine nuts, 142 grams ; walnuts, 672 grams . . . Total vegetable food 18 39 1 25 57 72 27 1,040 As the normal standard diet for a woman at light work should comprise 2,500 calories, it is seen that the above diet, although per- sisted in for twenty-five days, fell much below half the standard required for continued maintenance of health and strength. It is impossible to subsist for any length of time on a diet which does not contain a considerable quantity of nitrogen, which con- stitutes so important an element in the composition of the great majority of structures of the body, in fact, of protoplasm itself. Attempts have been made from time to time, for economic rea- sons, to furnish large bodies of laboring men, employed by con- tract or otherwise, with a purely vegetable diet; but this diet is found to defeat its own ends, in that the maximum of labor can- not be maintained by men who are fed exclusively on vegetable food, although some carbohydrates are essential. It gradually in- duces a condition of muscular weakness and languor with disincli- nation for either physical or mental work. In support of this state- ment Yigsford relates that for the construction of a railway from Paris to Itouen, English and French workmen were employed. The former did one-third more work than the French, until in the French diet roast beef, as in the diet of the English, was substituted VEGETARIANISM 35 for bouille and soup, after which the work done by the two gangs of men was equalized. In referring to graminivorous people, like the Bengalese, Cham- bers wrote : " If required to exert themselves in any unusual way when food is deficient, they simply die. The reason is evident they have been living on their own tissues, and the small quantity of albuminous matter in grain is a long time in building them up again, so that for weeks, or even months, their muscles are in a state of atrophy ." Animal food in some form must be regarded as absolutely essen- tial for all vigorous races. When the diet of enthusiastic "vege- tarians " is carefully investigated it is found that the strictly carbohy- drate food is supplemented by such articles as milk, eggs, etc., which are used in cooking or in other ways, although the consumption of ni- trogenous food may appear very much restricted. It is believed by Giibler and others that an exclusive vegetable diet eventually develops an atheromatous condition of the arteries, on account of the large proportion of mineral salts which thus enter the blood, but the evidence of this is not convincing. It is also claimed that a vegetable diet favors the deposition of mineral salts in different parts of the body, as phosphatic stone, gravel, and the tartar on the teeth, and that living upon coarse cereals alone makes the skin rough, and the individual dull, heavy, and ill-tempered. While it is quite true that some kinds of vegetables contain a large proportion of nitrogenous substance, it exists in a form in which it is less easily assimilated than animal proteid. In vegetable foods nitrogenous materials are more or less closely mingled with starch. Cellulose itself is often very tough and insoluble in the digestive fluids, so that as large a proportion of protein as 17 per cent may be wasted, while not over 3 per cent of the protein of animal food re- mains undigested. This is an important illustration of the fact that one must not be guided by chemical composition alone in selecting the proper dietary for man, but the question should rather depend upon the actual nutrient value of the food when absorbed. There are many facts in Nature in addition to those already discussed which indicate without doubt that man from his earliest prehistoric days has been omnivorous, adapting himself to his sur- roundings and eating, in his primitive condition, whatever his envi- ronment afforded, with least expenditure of labor to obtain it, now vegetable, now animal food. This is shown in the structure of the teeth in prehistoric skulls, and in the length of the alimentary canal and character of the digestive organs and secretions as at present 36 FOODS AND FOOD PREPARATIONS existing. There would be little use in providing man with pepsin and a strongly acid gastric juice, were it not intended by Nature for the digestion of meats. A brief glance at the dietetic habits of the primitive tribes of mankind at present living shows that no arguments may be drawn from them as to the advantages of any particular class of foods. The ancient Britons are known to have subsisted largely upon acorns, berries, roots, leaves, etc., but other primitive tribes ate fish, shellfish, and, when they could kill it, game. Many savage tribes to-day live very largely upon vegetable food, although an exclusive vegetable diet is almost unknown among them, and most of them eat meat whenever they can obtain it, or they supplement their food by nitrogenous articles, such as milk, eggs, fish, and insects of various kinds. The Chinese and Japanese coolies, who subsist principally upon simple farinaceous food, such as rice, eat also eggs, fish, pork, and chicken. On the other hand, there are tribes of men inhabiting very hot countries who eat con- siderable quantities of meat, as, for example, the Nubian Arabs and Abyssinians, and some Mongolians live by their herds upon milk products and meat bread being scarcely known to them. The Australian savage is omnivorous, and, having no cereals, he subsists upon berries, beans, pith, nuts, honey, larvae, ants, etc. The Papuan Islanders live chiefly upon sago, fish, and fruits. The New Cale- donians were formerly cannibals, but are now vegetarians by prefer- ence, and prefer to trade their pigs and goats with passing ships rather than to eat them. Vegetarianism in former times has had many famous advocates. Shelley was a vegetarian, so was Jean Jacques Rousseau, and Gold- smith also at one time. There is a Vegetarian Society in England which has established restaurants in London, Manchester, and sev- eral other localities. In London there are upward of 4,000 mem- bers of this Society. There is a similar organization in this country. The creed of esoteric Buddhism has induced some persons in this country to adopt vegetarian habits, but few of them adhere to them strictly or for long-. THE CLASSES OF FOODS I. WATER Tt is estimated that water composes about 70 per cent of the entire body weight, and it is an almost universal solvent. Its im- portanco to the system, therefore, cannot be overrated. The elastic- ity or pliability of muscles, cartilages, and tendons, and even of WATER 37 bones, is in great part due to the water which these tissues contain. As Solis-Cohen says, " the cells of the body are aquatic in their habits." The amount of water required by a healthy man in twenty- four hours is, on the average, between 60 and 70 ounces, besides about 20 ounces taken in as an ingredient of solid food, thus making a total of 80 to 90 ounces. The elimination of this water is divided as follows: 28 per cent through the skin, 20 per cent through the lungs, 50 per cent through the urine, 2 per cent through other secre- tions and the feces. This is, of course, a very general computation, for there is constant variation in the activity of different organs. A large proportion of the water is taken in the form of beverages composed chiefly of it, and by many persons they are substituted for plain water altogether. In some countries light wines, beer, and other fermented drinks wholly replace drinking water. This may be due to habit and custom, or to necessity from lack of pure natural water, but in all cases the quantity of water required to maintain the functions of the body in healthful activity remains the same, whether it be drunk pure or in beverages, or taken with succulent fruits and vegetables, or in milk, koumiss, etc. One of the most universal dietetic faults is neglect to take enough water into the system. Uses of Water in the Body. The uses of water in the body may be summarized as follows: 1. It enters into the chemical composition of the tissues. 2. It forms the chief ingredient of all the fluids of the body and maintains their proper degree of dilution. 3. By moistening various surfaces of the body, such as the mucous and serous membranes, it prevents friction. 4. It furnishes in the blood and lymph a fluid medium by which food may be taken to remote parts of the body and the waste mat- ter removed, thus promoting rapid tissue changes. 5. It serves as a distributor of body heat. 6. It regulates the body temperature by the physical processes of absorption and evaporation. The taking of much water into the stomach by its mechanical pressure excites peristalsis. One or two tumblerfuls of cold water taken into an empty stomach in the morning on rising favor evacua- tion of the bowels in this way. The water, moreover, is quickly ab- sorbed and temporarily increases the fullness of the blood vessels. This promotes intestinal secretion and peristalsis. The increased activity of the lower bowel is thus explained rather than by the idea that the water itself reaches the colon and washes out its contents, FOODS AND FOOD PREPARATIONS Lukewarm water acts as a mild emetic if drunk in large quantity. This action fails above 95 F. and below 60 F., and is most efficient at about 90 F. Purity of Water. Of recent years the importance of insuring the purity of drinking water has become more and more appreciated, and an intelligent public is now aroused to the absolute necessity of protecting their supplies of drinking water from contamination with sewage, decomposing animal matter, etc. So general has the interest in this subject become in this country that new laws are being passed constantly to protect the water supply of large cities and towns. The subject is not confined to water alone, but includes ice as well, for many of the germs and organic impurities of water are not destroyed by freezing, and impure ice added to pure water contaminates it. It has been proved very clearly that certain infections may be conveyed through the agency of water; such are the germs of typhoid fever, dysentery, and cholera. An excess of decayed vegetation in water may render it aesthetically unpleasant, but not necessarily unwhole- some, provided no specific germs are present. Varieties of Drinking Water. Water containing a moderate quantity of mineral salts, 4 or 5 grains to the gallon, is not to be regarded as impure, but the composition as well as the quantity of these salts affect its power as a solvent in the tissues, and may exert a very decided influence upon the digestive system when present in the proportion of 60 or 70 grains to the gallon. The mineral waters may contain much more. Hard and Soft Water. An excess of lime salts and of other min- eral matters in water produces constipation, flatulence, indigestion, and favors the formation of calcareous deposits in various parts of the body. By boiling, the " hardness " of water, which is due to the presence of earthy carbonates, is diminished, for the carbonic-acid, which aids in holding them in suspension, is driven off. Water is also improved for drinking by filtering through a filter paper, or clean absorbent cotton on a funnel. Boiling the water does not precipitate neutral and alkaline salts, and a purgative action may still remain if they are present. " Hard " water is made more assimilable by con- verting it into barley or oatmeal water. Water which contains sul- phate of lime causes gastric distress and dyspepsia, and it may form calculi. " Soft water " is water which is free from objection- able salts. It is more wholesome than hard water. Hard and soft water have well-known characteristics in regard to their effect upon the cooking of food. Calcareous drinking waters, and especially wa- ters derived from melting snow or glaciers, have been believed to WATER 39 be factors in the development of goiter and cretinism, notably in Switzerland and the Austrian Tyrol, but many cases occur in which such theory is untenable. Rain Water. Next to clear mountain-spring water which has run through gravel and been well aerated, rain water at the close of a shower and fresh snow water are the purest forms of natural waters excepting where the rain water has fallen through a very dusty or smoky atmosphere or run over a dirty roof. The first drops of a shower carry down with them the impurities of the air, including traces of ammonia and nitric acid. No natural water possesses abso- lute chemical purity, but water collected at the end of a hard or long shower is very pure, having been distilled by previous evaporation. River water which has run over a rocky or gravel bed, and has been well aerated, is quite pure if properly protected from sources of pollution. Free oxidation makes much organic matter harmless. Flowing water, by oxidation and dilution, becomes purified to a great extent of injurious organic matter, but is not necessarily deprived of living germs of contagion, such as those of typhoid fever or cholera. It is now so well recognized that the impurities of water which are chiefly dangerous to man are of organic germ origin that in examining water which is suspected of being the cause of a typhoid- fever epidemic a chemical analysis of the nitrates present, unaccom- panied by a proper bacteriological examination, is entirely useless. Distilled Water. Distilled water is absolutely pure, but it has a flat or metallic taste from absence of air and salts. The flat taste may to some extent be improved by agitating the water with air in a carafe. It is now extensively furnished for drinking, and is largely in use on vessels at sea. Distilled water has been recommended as a solvent for renal and vesical calculi, but it is of doubtful efficacy. Filtered Water. Filtration as employed to render drinking water more pure is a very delusive process, unless great care be taken as to the construction of the filter and the rate of filtration. Extensive experiments made at Providence, E. I., and Lawrence, Mass., have proved that the benefit of sand filtration of city water results only when the filters are frequently cleaned. The sand layer should not be less than 30 centimetres thick, nor the rate of water flow fall below 100 millimetres per second. Frequent bacteriological ex- amination of the water should be made. Koch has shown that it is not the sand which " filters," but the layer of mud or slime which is deposited upon it and which retains bacteria. In Albany, New York, the reduction in number of typhoid cases after the adoption of filtration was 73 per cent; in Binghamton, 72 per cent, and in Ithaca, 40 FOODS AND FOOD PREPARATIONS 78.3 per cent. A great variety of patent filters have been devised, and they have the power of making water appear pure by decolorizing it and removing visible organic particles and grosser impurities which it may contain, but it has been shown conclusively that the bed of a filter which has been in use for some time furnishes a favorable soil or culture medium for the development of germs, which increase very rapidly until they reach such numbers that they are washed out with the filtered water, rendering it much more injurious, in some in- stances, than it was before. Boiled Water. Boiled water is antifermentative and aseptic, i. e., it is sterilized. The object of boiling the water which is to be used for drinking purposes, or in the preparation of food, is to free it from organic impurities, and in some cases to precipitate salts of lime. There are no species of germs, and there are no ferments which are not killed by a longer or shorter exposure to the temperature of boiling water, i. e., 212 F. The process consists in the application of heat to water in sufficient degree to expand the air which it naturally absorbs and which rises to the surface in bubbles of various sizes. If the water contains gases of decomposition they are expelled, and the odor is most foul just before the boiling point is reached ; later it passes off, show- ing when the water is fit to drink. When boiled water, cooled, is drunk it tastes " flat " or insipid, but it may be freshened like distilled water by pouring it through the air from one vessel to another or by shaking it with air in a carafe. Water should always be boiled before being drunk if there is the slightest suspicion as to its purity. The population of the larger Chinese cities is exceedingly dense, and the water used by the inhabitants is impregnated with all manner of filth, but the custom of the natives of drinking tea infused with boiling water, protects them to a great extent from the ravages of certain microbic diseases. The special dietetic uses of water will receive attention under the appropriate headings of different diseases. Water may be of service to eliminate waste in various renal dis- eases, gout, lithiasis, oxaluria, renal inadequacy, fevers, and infectious diseases. If imbibed too freely with meals it lessens by dilution the activity of the saliva and gastric juice. Water taken near the end of the gastric digestion of a meal (i. e., two or three hours after taking food) serves to dilute the contents of the stomach and wash it more promptly into the intestine. If stomach digestion has been slow and feeble, so that the whole process has been greatly prolonged, the drink- ing of six or eight ounces of water, either hot or cold, two hours or WATER 41 more after taking food will facilitate its digestion. Water is highly useful in constipation. It is more quickly absorbed from the stomach or intestine when the tension in the blood vessels is low. It is imperatively needed after severe hemorrhage, or after the sudden loss of it from the system from any cause, such as the evacu- ations of cholera morbus, Asiatic cholera, etc., in which conditions it may be injected in the rectum, subcutaneously or intravenously as "normal salt solution," i. e., a 0.7 per cent solution of common salt. The use of water is to be restricted in dilatation of the stomach, the secretion of weak gastric juice, and sometimes, but not always, in diabetes insipidus, diabetes mellitus, ascites and other dropsies, ana- sarca, and in some forms of heart disease and obesity. The daily quantity of water ordinarily drunk varies between two and a half and four pints. About one and a half pint more is taken in the food, and four and a half or five pints are therefore lost through the emunctories. Natural foods which contain most water are milk and succulent fruits, such as grapes, oranges, grape fruit, lemons, melons, plums, peaches, etc., and vegetables like the tomato, squash, and many others of tropical origin. All vegetables contain more water than meats, and many, but not all, ripe fruits contain more than vegetables. Excess of Water. There is a remarkable tendency on the part of the blood to maintain equilibrium as regards its own composi- tion, volume, and density. When a large supply of water is re- ceived in the alimentary canal and absorbed by the blood vessels, the blood is momentarily diluted and the blood pressure slightly raised, although the latter effect will depend upon the facility with which the blood vessels are dilated. The blood immediately dis- tributes the water thus absorbed, and the slightly increased pressure, as well as the diluted character of the blood, hastens the elimination of water from the various gland surfaces. The kidneys are particu- larly sensitive in this respect, and when in normal condition are the great regulators of the composition of the blood and, indirectly, of blood pressure by means of the elimination of water. Perspiration is increased. There is a tendency also for all the tissues to keep abundantly supplied with water; a large amount of aqueous vapor is exhaled from the surface of the lungs, and the digestive secretions are increased in volume. The blood subsequently may become more dense than before, owing to the increased functional activity of different organs. More nutriment is absorbed and more carbonic- acid is exhaled, and urea and uric-acid elimination may be slightly increased. 6 42 FOODS AND FOOD PREPARATIONS If very large quantities of water, or any fluids consisting chiefly of water, are imbibed throughout a long period, they tend to overwork the kidneys and produce various alterations in the tissues. Practi- cally, however, it seldom happens, excepting in some forms of gas- tric or intestinal disorder, and other instances mentioned above, that too much water is taken. When drunk in such fluids as beer, or di- luted liquors, the resulting disturbances of the system are attributable to the various ingredients. The role of water in Obesity is fully discussed under that topic. Deprivation of Water. Water Starvation. More than ten or twelve hours of abstention from drinking water produces uncomfort- able thirst, and one or two hours of violent exercise or exposure to intense heat, may do so at once. Continued deprivation of water causes the blood, by virtue of its self-regulating power, to withhold fluid from the kidneys and diges- tive glands. The digestive secretions therefore become less fluid, of more intense reaction, and greatly diminished in quantity. The mucous surfaces become dry, and the dryness, owing to the passage of air and the consequent evaporation, is first felt in the mouth and pharynx. The diminution in the digestive secretions, as well as their altered strength, interferes with or retards their normal action upon the ingesta. The proper movement of the food in the stomach and intestines is retarded by its greater density and by the increased fric- tion of the mucous walls, especially in the lower bowel. Consti- pation therefore results. The absorption of fluid through the walls of the alimentary canal is lessened, and nutrition suffers in conse- quence. Meanwhile the blood, to maintain its normal character, re- absorbs water from the lymph spaces and different tissues of the body. The muscles and other structures become dry and diminish in volume. Emaciation results, which quickly reaches an extraordi- nary and painful degree. The mind dwells on water constantly, and taste is diminished. Finally, the nervous system suffers from dry- ness and various nervous symptoms ensue, so that, in addition to extreme muscular weakness and prostration, there may be convul- sions, maniacal delirium, and finally ccma and death. TJrirst. The suffering from deprivation of water is mainly con- fined to the sensations of thirst and dryness of the mouth. Thirst is commonly, and somewhat erroneously, referred to the mouth and the pharynx. Tt is true that the mucous membrane in these regions be- comes dry when water is withheld, but thirst also may be keen when these surfaces are abundantly moist. The sensation is the result chiefly of the expression through the nervous system of the need of the WATER 43 body tissues in general for fluid, and it is referred to the mouth and throat from force of habit, which associates the act of swallowing fluid, and the use of certain muscles in that process, with the subse- quent relief of thirst. In support of the above statement is a fact that I have several times witnessed in patients having a gastric fistula made in consequence of cesophageal stenosis, or in patients nourished wholly through nutrient enemata, that the sensation of thirst referred by them to the mouth is immediately relieved by the injection of water into the stomach through the fistula, or of salt and water into the rectum. It is asserted that shipwrecked sailors in open boats have relieved their thirst by immersing their bodies in salt water. A very little water is possibly absorbed under these conditions through the skin. Ordinarily, however, the skin is not capable of absorbing fluid of any kind to a practical extent, but immersion in water prevents evaporation from the surface of the body, and by saving its loss in that direction lessens thirst. Sucking a slice of lemon or drinking water acidulated with a few drops of lemon juice or vinegar some- times allays thirst better than plain water. The same may be said of barley and oatmeal waters, often used by laborers when sweating heavily. Lime juice with ice is another remedy. On one of the earlier arctic expeditions which resulted disastrously the men had no water for two months, but ate snow, having no fuel to spare to melt it. Hot water, as hot as can be sipped, may quench thirst better than cold. Glycerin and water is sometimes used to allay thirst by rinsing the mouth. The glycerin, being viscid, coats the surface of the mucous membrane and prevents to some extent the drying by evaporation, but it is hygroscopic and tends to abstract water if used too strong, and practically it is of little service. When it is undesirable to give water by the mouth, as in gastric hemorrhage, thirst may be relieved by injection of salt and water beneath the skin (see Hypodermoclysis) or into the rectum. Thirst may be controlled somewhat when it is desirable to restrict the fluids ingested by giving small doses of opium. It may be that part of the benefit derived from this drug in the treatment of diabetes is due to its controlling this symptom. It is taken sometimes by pro- fessional fasters, who aim to abstain from all food, and from as much drink as possible. When it is desirable for patients having diabetes mellitus or in- sipidus, dropsies, or a dilated stomach, to have the fluid ingested re- 44 FOODS AND POOD PREPABATIONS stricted, they should be allowed to drink only from very small re- ceptacles, like a medicine glass, which holds little at a time, or they may be made to drink only through a small glass tube or straw. Temperature of Drinking Water. Water is drunk at various tem- peratures from that of melting ice to 110 or 112 F. It is some- times stated that the temperature of water influences digestion, but the extent to which it does so is much exaggerated. Very cold water swallowed quickly in large quantity is said to contract the stomach wall and stimulate the heart action. This subject, as well as that of the local action of hot water, will be found more fully discussed under the heading Temperature and Digestion. Ice is often useful in the sick-room, but it should not be given to young infants. Cracked ice sometimes soothes an inflamed throat, and occasionally it allays nausea. It relieves thirst only temporarily, and this symptom may be increased by its prolonged use. When swal- lowed in fragments it melts almost completely before reaching the stomach, and if too much is swallowed it becomes lukewarm in the stomach and may be vomited. Ice is frequently contaminated in handling, by the men and horses employed in harvesting it, and surface filth from drainage may pollute it. Fortunately exposure of a few weeks to a freezing temperature either kills most noxious germs or so attenuates them as to nullify their virulence. II. SALTS Varieties of Salts. The principal salts derived from the food are as follows: Chlorides of sodium and potassium ; carbonates, sulphates and phos- phates of sodium, potassium, and magnesium, and phosphate of cal- cium. The majority of these salts are unaltered by digestive pro- cesses and pass into the blood or tissues without necessary chemical change. The reason for this belief is the readiness with which they may be obtained, unaltered by chemical analysis, from the different tissues of the body and the urine. Some compounds namely, the salts of iron and salts of the organic acids are ingested in very minute quantity and the uses of the latter are vaguely understood. Other salts, such as the chlorides, carbonates, and phosphates of the alkalies and alkaline earths, are taken in much larger daily amount and subserve definite purposes. Uses of Salts in Food. The uses of the salts derived from the food are summarized as follows: SALTS 45 I. To regulate the specific gravity of the blood and other fluids of the body. II. To regulate the chemical reaction of the blood and the various secretions and excretions. III. To preserve the tissues from disorganization and putrefaction. IV. To control the rate of absorption by osmosis. V. To enter into the permanent composition of certain structures, especially the bones and teeth. VI. To enable the blood to hold certain materials in solution. VII. To serve special purposes, such, for example, as the influ- ence of sodium chloride on hydrochloric-acid formation, that of lime salts in favoring coagulation of the blood, and that of iron in the formation of blood pigment. Generally speaking, fruits and nuts contain the least quantity of salts, meats rank next, after them vegetables, and pulses and cereals contain most of all. Excess of Salt. Salts of any kind when added in excess to the food disagree with digestion in various ways. They may prove lo- cally irritant to the gastric or intestinal mucous membrane; they modify the rate of absorption of digestive material, and alter the intensity of reaction of the different digestive fluids. After being absorbed in excess they may interfere with the nutritive and chem- ical processes of the blood and tissues. Some persons acquire a salt- eating habit and partake too freely of common salt with the food, eating several drachms daily, with the result of the production of more or less dyspepsia or some of the symptoms above mentioned. Too much sodium chloride in the food produces thirst, and may stim- ulate a craving for strong drink. Lime salts and phosphates when taken in food or drinking water in large quantities for several months tend to cause the deposit of renal or vesical calculi. Deprivation of Salt. Continued deprivation of any one of the common salts, so long as others are furnished in reasonable abun- dance in the food, does not result seriously. If, however, all the salts are reduced in quantity, or if they are entirely excluded from the diet, the system very soon begins to evince signs of malnutrition. This is readily accounted for by referring to the uses of salts above described. Animals or men deprived of common salt for a long time suffer greatly from indigestion and from lack of bodily nutrition. The body may not diminish in weight, but the tissues become " flabby," the muscles feeble, the mind is stupid and dull, the nutrition of the skin is altered, it becomes dry, and there is falling out of the hair. 46 FOODS AND FOOD PREPARATIONS Eventually, in animals with salt starvation death occurs in from six to eight weeks from progressive bodily weakness and inanition a condition, practically, of marasmus. Young infants who do not obtain sufficient salts of lime i. e., if fed upon proprietary " infant foods " instead of good milk become rhachitic; their bones ossify slo\dy and bend into deformities. Such children are sometimes given hypophosphite-of-lime biscuits to sup- ply the deficiency, but they should be properly fed upon fresh milk. (See Eachitis.) Sodium Chloride. Sodium chloride, or common table salt, is by far the most important and valuable salt, and is used in the largest amount. It has long been a symbol of hospitality in the East. It forms 60 per cent of the salts of the blood, and enters into the struc- tural formation of all the tissues and secretions of the body in greater or less quantity, with the single exception of the enamel of the teeth. It is estimated that the quantity which may be appropriated daily from the food is about fifteen grams (231 grains). Common salt slightly stimulates the renal secretion, which in turn leads to thirst and to drinking more fluid, which promotes interchange of the juices of the body. It also excites thirst more directly. Common salt stimulates the appetite and influences beneficially the gastric secretion. It not only furnishes the chlorine for hydro- chloric acid, but seems to act locally in the stomach by promoting this secretion as well as the conversion of pepsinogen into active pepsin. Cohn and Voit have proved that the absence of salt from the diet completely checks the production of hydrochloric acid in the stomach. There are some few tribes of flesh-eating man who do not add salt to their food, relying for their needs upon what they derive from the food itself. This supply is therefore sufficient to maintain life. In fact, as a rule, man derives enough salts from the compo- sition of his food to supply the tissues and juices of the body, and the additional quantity which he takes as table salt is mainly of serv- ice as a condiment, to give agreeable flavor to a mixed diet and to sharpen the appetite. The excess of salts in general is promptly eliminated in the urine. In most men and many of the higher mammalia the craving for sodium chloride is instinctive. Stanley records in his book " In Darkest Africa " instances wherein savages were accustomed to travel many hundred of miles under great difficulties to obtain a coveted supply of salt. Herbivorous animals are even more dependent upon salt than are SALTS 47 carnivores; cattle and sheep, for example, should be given salt in ad- dition to that contained in their food to remain in good condition. Overdoses of salt cause diarrhoea and gastroenteritis, and excite irritation of the nerves of the throat. Large doses of salt have been given in pleurisy with the view of increasing the density of the blood and causing reabsorption of the pleuritic fluid by promoting osmosis towards the vessels. This treatment has not met with success and is the reverse of the salt free diet described below. The popular use of salt to control pulmonary hemorrhage is of no practical value. Almost all vegetables contain less sodium chloride than does milk, the food of the young growing animal, although many of them have more potassium. Sodium chloride is of great service as a preservative of foods, either used as a brine in pickling, corning beef, preserving olives, etc., or in solid form to dry and keep meat and fish from decomposition. (See Food Preservation.) Salt-free Diet. Eecently much attention has been directed to the use of a salt-free diet, i. e., food to which no salt whatever is added, in the treatment of ascites and general anasarca. This is based upon the theory that the absence of salt modifies the density of the blood so that osmotic currents are reversed and the serum which has trans- uded into the tissues is reabsorbed and removed by the blood vessels or lymphatics. Such a diet may consist of raw or boiled eggs, milk, bread made without salt, cream or butter, and rice. George L. Pea- body has reported a number of cases of general anasarca and dropsy which yielded promptly to this treatment after the ordinary means of purgation, diuresis, diaphoresis, etc., had failed. Personally I have found it disappointing in many such cases, but it can do no harm when employed for short periods only. One patient, with severe chronic nephritis and oedema of the legs, who seemed much benefited by it, stated that for a week he greatly missed the salt which he had been accustomed to add liberally to his food, but subsequently his sense of taste became much more discriminating, and he much preferred his salt-free diet. Potassium Salts. Xext in importance to sodium chloride ranks potassium chloride, which is the predominant salt of the muscles, and which, like sodium chloride, is a common ingredient of nearly all the tissues and fluids. The acid and neutral carbonates and phosphates of sodium and potassium are important in regulating the reaction of the digestive secretions and the urine. Calcium. The salts of calcium are chiefly of value from their constituting a large percentage of the composition of the bones and 48 FOODS AND FOOD PREPARATIONS teeth, as well as a smaller percentage of many other tissues of the body. Their presence seems to be associated constantly with cell growth and development, and with blood coagulation. The carbonate is often found with the phosphate of lime, but in less quantity. The occurrence of cretinism and goiter has been in part attributed to an excess of lime salts in the food, more especially the drinking water. This theory is referred to upon page 38 as unworthy of credence. Young growing animals contain in their tissues a larger percentage of earthy salts than do older ones. Deposits of salts of lime occur in old abscesses, tubercular concretions, tartar on the teeth, atheromatous blood vessels, the arcus senilis of the cornea, and as calculi. Medicinally calcium chloride is employed to promote coagulation of the blood in purpura, haemophilia, etc. Phosphorus. Phosphorus is derived from phosphates in meat and its contained blood which is eaten, as well as from vegetables. It enters into the composition of the bones, muscles, blood, etc. Sulphur. Sulphur is derived from sulphates contained princi- pally in fibrin, egg albumen, the casein of milk, and from such vege- tables as corn, turnips, cauliflower, and asparagus. Iron. The iron of the body is found in the blood pigment, where it amounts, all told, to a third of an ounce. It is also present in minute traces in other pigments. Its chief source is from the blood of animals which is cooked with their meat. Two quarts of milk furnish about one-eleventh grain of iron. It is also derived from, and it may be taken with, chalybeate waters. Probably most of the iron of the body is retained and used again and again. The daily quantity of iron ingested with an ordi- nary mixed diet is about one-eighth grain. In treating chlorosis and other forms of anaemia with large doses of iron salts, it should be remembered that the iron contained in animal foods is ample for the needs of the body in health. VEGETABLE ACIDS The common organic or vegetable acids citric, tartaric, malic, etc. are derived from fresh vegetables and fruits, in which they exist usually in combination with the bases Ca, Na, K, etc. They are indispensable articles of food, for when absorbed they form carbon- ates, which aid in maintaining the akalinity of the blood. Prolonged deprivation of them may result in the condition of scurvy. ANIMAL FOODS 49 III. ANIMAL FOODS Animal foods contain much nutritive matter in a more or less con- centrated form which exists in practically the same chemical combina- tion with the body itself. They leave comparatively little residue, be- ing quite thoroughly digested. They are agreeable in flavor, and hold salts, including iron, which are of special value in the system. They are, however, inferior to carbohydrates in force production unless much fat be incorporated with them. The varieties of animal foods will be described under the head- ings, milk, eggs, meat, fish, gelatin, fats. Milk The milk of several animals, such as cows, goats, asses, mares, reindeer and camels, may be used for food, but in this country very lit- tle other than cows' milk is employed. The varieties of milk differ slightly in chemical composition, odor, and taste, but all contain the elements which are necessary for the maintenance of life in fairly eco- nomic proportion, so that for infants they constitute a " complete " food which fully meets the requirements of the growing body, and in adults they will sustain life comfortably for many months. For these reasons milk ranks among the most important of all foods, and it is necessary to determine to what extent it should be intro- duced into ordinary diet. A pint of milk may be said to represent approximately the nutrition contained in six ounces of beef or mut- ton. Although it furnishes so useful a food, milk is by no means essential to a diet designed for increasing bodily strength, and it is usually omitted from the menu of athletes in active training. Milk taken alone constitutes a poorly balanced food for adults in health, for to obtain the requisite 18.3 grams of nitrogen 2,905 grams of milk only are needed, against 4,652 which must be taken to obtain the necessary 328.9 grams of carbon (Bauer). (See Force Produc- tion, page 6.) Sir Henry Thompson, in condemning the excessive drinking of milk by persons in health who are at the same time eating large meals of meat, says: "It is altogether superfluous and mostly mis- chievous as a drink for those who have reached adult age and can digest solid food." There are, however, many diseases in which a partial, or for a time an exclusive, milk diet is to be recommended, and milk in considerable quantity i. e., equal to one-third or one-half the total amount of food consumed is often highly desirable in such diseases as tuberculosis, chronic Bright's disease, and anaemia. 50 FOODS AND FOOD PREPARATIONS Exclusive Milk Diet. An exclusive milk diet is useful in the fol- lowing conditions and diseases. 1. In infancy for the first year, and sometimes for the first eighteen months. 2. All acute infectious diseases of young children. 3. Typhoid fever. 4. Acute Bright's disease, and at times in chronic nephritis. 5 : Acute pyelitis. 6. Chronic gastric catarrh (some cases). 7. Gastric ulcer and carcinoma (at certain stages). 8. Neurasthenia combined' with a rest cure. 9. Some cases of dia- betes. A milk diet is so easy to prescribe, so cheap, and so readily pro- curable, that it is the first resource of those who, from indifference or lack of knowledge of the first principles of dietetics, are unwilling or unable to study the peculiarities and needs of the individual patient. It is an easily measured food, and it becomes a routine prac- tice in hospitals where almost always more attention is accorded to medication than to diet to order "milk diet" for all patients who are not at the convalescent or full house table. Although it is safe to err in this direction, it is by no means always the best that can be done for the patients. An exclusive milk diet in time becomes wearisome to many adults, and within a week or ten days may produce dyspepsia, constipation, and interfere with the functional activity of the liver. Aside from nausea, which the continued use of milk may excite, a positive loath- ing for the taste of it may be developed, unless the regimen is modified by occasional variation. This is a matter of considerable importance in feeding patients suffering from typhoid fever, chronic Bright's disease, chronic gastric catarrh, and other affections for which milk diet is often prescribed; for if other substances are sub- stituted from time to time in small amounts, while milk is still re- tained as the chief food, it may be continued as such for a much longer time. On seeking the cause for the disagreement of milk, it is found in the fact that it contains too large a proportion of protein as compared with carbohydrate, so that, in order to obtain sufficient of the latter, an excess of protein is ingested, which may derange digestion. For a man in health a pure milk diet, as Ewald says, is " slow starvation," although it is an excellent food for a short time. If kept ton long upon it, lie develops a condition akin to scurvy. (See Diet in Scurvy.) Tin's, however, does not invariably follow in disease, and J. K. Mitchell refers to a patient with diabetes and nephritis "who lived upon milk alone for seven years, and kept in active business. ANIMAL FOODS 51 Infants and children tire of milk less promptly than adults. Whereas the adult needs twenty-three ounces of water-free food per diem to maintain healthful equilibrium, he must consume nine pints of milk to supply it. The excess of albumin, fat, and water which he would then obtain is wasteful for him, although it is good for the young. But in illness life is comfortably maintained upon a smaller quantity of milk for a few weeks, and in typhoid fever four or five pints is an ample allowance, and it is often better to give less. (See Diet in Typhoid Fever.) In a case of chronic Bright's disease, if the patient be not confined to bed, it may be necessary to give six or seven pints. In order to digest thoroughly large quantities of milk it should be taken in measured doses at frequent intervals. In some diseases it is best to give two ounces every hour, in others six or eight ounces every three hours. Milk leaves no coarse waste residue in the intestine like the indi- gestible fiber of meat or the cellulose of vegetables and fruits. Not- withstanding this fact, an exclusive milk diet yields considerable bulk of fecal matter, and a typhoid-fever patient living on milk alone often has daily evacuations of medium size. 0. Riibner found that in health a diet of milk alone yields larger stools than either roast beef or egg alone. Yet by weight the absorption of milk is shown to be very complete, and four thousand grams of milk ingested by the mouth, when perfectly digested, yield only one hundred grams of feces. There is a marked loss through the feces of the salts of lime which have been contained in the milk. These facts explain in part why milk is so constipating. Prof. Charles E. Wait, in the course of nutrition investigations of a club of students at the University of Tennessee (U. S. Depart- ment of Agriculture Bulletin), says: " The average of ten experiments with an exclusive milk diet showed 92.1 per cent of the protein and 86.3 per cent of the carbo- hydrates to be digested. Five experiments made with an exclusive bread diet or with bread and sugar showed 82 per cent of the protein and 99 per cent of the carbohydrates to be digested. Five experi- ments with a diet of bread and milk showed 97.1 per cent of the protein and 98.7 per cent of the carbohydrates to be digested. In other words, the protein in milk alone or in bread alone seems to be much less completely digested than when the two are eaten together." (See the "Milk Cure.") Physical Properties of Milk. The milk of all animals as well as human milk is alike as regards its general physical properties and 52 FOODS AND FOOD PREPARATIONS the nature of its chemical components, differing only in degree. The solids of milk exist (a) in soluble form (salts and sugar) (b) in suspension (fat globules) (c) in semi-solid or colloidal state (part of the casein). The specific gravity of cow's milk varies between 1029 and 1035, the normal average being 1032 at 60 F. An excess of cream makes the milk lighter. If the cream be partially removed and water be added, the gravity is raised, hence the specific gravity alone is not an infallible test for the richness of milk. The reaction of normal fresh cow's milk is always slightly acid, owing to the presence of acid phosphates. Casein has an acid reac- tion also, and C0 2 may be present and affect the reaction. Lactic acid fermentation increases the acidity of milk and the greater the number of bacteria present in the milk, the greater the acidity. The acid reaction is stronger in summer than in winter. Chemical Composition of Milk. The chemical ingredients which make milk valuable as a food are water, salts, fats, milk sugar or lactose, and albuminoids, chiefly casein, with some albumin. The following table prepared by E. H. Farrington and F. W. Woll exhibits " the limits within which the components of normal American cow's milk are likely to come." The figures are percent- ages: \Vater Minimum. 82 Maximum. 90 Average. 87 4 Fat 2 5 7 8 3 5 Casein and ulbuiiiin . . . . 2 5 4 6 3 4 Lactose 3 5 6 5 Ash . g q 7 100.0 Babcock's table of average percentage analysis of American milk is very similar : Water 87.17 Fat 3.G9 Casein . .3.02 Albumin 53 Lactose ' 4 . 88 Ash .71 The following table is from the U. S. Department of Agriculture, Farmers' Bulletin. ANIMAL FOODS 53 Amounts of Nutrients in a Pound (Pint) of Milk as Compared with a Pound of Meat, Bread, and Other Food Products. EDIBLE PORTION. FOOD MATERIALS. Water. NUTRIENTS. Fuel value. Protein. Fat. Carbo- hydrates. Minera matter. Milk (1 pint.) Whole milk Pound. 0.87 0.90 0.91 0.34 0.11 0.53 0.43 0.44 0.35 0.07 0.48 0.58 0.40 0.38 0.88 0.12 0.13 0.07 0.35 0.08 0.13 0.70 0.67 0.62 0.62 Pound. 0.03 0.04 0.03 0.26 0.01 0.16 0.13 0.14 0.13 0.02 0.15 0.11 0.16 0.17 0.06 0.11 0.09 0.16 0.10 0.11 0.22 0.01 0.02 0.01 0.01 Pound. 0.04 o.'oi 0.34 0.85 0.17 0.24 0.25 0.34 0.87 0.01 o.ii 0.02 0.01 0.02 0.07 0.01 0.10 0.02 Pound. 0.05 0.05 0.05 0.02 6!03 0.75 0.75 0.68 0.53 0.69 0.59 0.08 0.15 0.06 0.12 Pound. 0.01 0.01 0.01 0.04 0.03 0.01 0.01 0.01 0.04 0.04 0.01 0.01 0.19 0.10 0.01 0.01 0.01 0.02 0.01 0.02 0.04 0.01 0.01 0.01 Calories. 325 170 165 1,965 3,605 1,040 1,275 1,340 1,655 3,715 325 205 315 1,050 235 1,645 1,655 1,860 1,205 1,895 1,590 170 325 135 255 Skim milk (0.3 per cent f at ) . . . . Buttermilk Other food materials (1 pound each). Cheese Butter Beef, sirloin Mutton, side Pork: Loin Ham Salt, fat Chicken Codfish : Fresh Salt Mackerel, salt Oysters, solids Wheat flour Cornmeal Oatmeal Wheat bread Crackers Dried beans Beets Potatoes Turnips Apples " The fuel value of a pint of cream is not far from 1,425 calories, or about the same as one and one-eighth pound of bread, or one and one-half dozen bananas, or four and one-half pounds of potatoes." Water constitutes from 82 to 90 per cent of milk. In 17 States the legal maximum for salable milk is fixed at 88 per cent. Frozen Milk. When milk freezes the water crystallizes into lumps of ice containing a trace of fat and other solids of the milk. The salts which form the " ash '"' of milk after incineration are principally chlorides of sodium and potassium, and phosphates of potassium calcium and magnesium. There are also traces of iron 54 FOODS AND FOOD PREPARATIONS phosphate, sulphuric and citric acids, lecithin, cholesterin, urea, hypozanthin, a coloring matter called lactochrome and the gases, oxygen, nitrogen and carbonic-acid. Total Solids. Water. Sugar. Fat. Casein. Ash. FIG. 4. PROPORTION OF THE COMPONENT PARTS OF MILK. (R. A. Pearson, U. S. Dept. Agric., Farmers' Bui., No. 42.) Fat and Cream. The fat of milk exists as an emulsion, and the fat globules are exceedingly minute, about 100,000,000 be- ing contained in an average drop of milk. The globules vary much in size, both according to the breed of the cow, and the pe- riod of lactation. The largest glob- ules are observed at the beginning (U. S. TVpt. Airrir.. Bui. f)G, Office of Expt. Stations.) f lactation, and f>. A DROP OF MM.K. MAGNIFIED, SHOWING FAT GLOBULES. ANIMAL FOODS 55 the smallest are found in skimmed milk. The measurements of the globules show a range in diameter between 1-1500 and 1-25,000 inch. The analyses of milk vary, chiefly in regard to the quantity of fats observed, in relation to the other solids. The following analyses are placed together for comparison : Wanklyn. London Dairy. J. C. Bell. A.H.Leeds. E. W. Stewart. Fat 3.20 4.10 4 01 3 75 3 80 Other solids . . . 9 30 8 80 9 31 8 86 9 20 Total solids . . . Water 12.50 87 50 12.90 87 10 13.32 86 68 12.61 87 39 13.00 87 00 100.00 100.00 100.00 100.00 100.00 The above London Dairy analysis is based upon the examination of 120,000 samples of milk conducted by the chemist to the dairy during a period of twelve years. Milk fat is mainly formed of glycerides of palmitic and oleic acid, with several other fatty acids, represented in lesser quantity. The fatty acids of milk are grouped with their percentages by Browne as follows: NOX-VOLATILE Palmitic 40.51 Oleic 33.95 Myristic 10.44 Stearic Dioxystearic 1.04 VOLATILE Butyric Tauric . Caproic Caprylic Capric . 6.23 2.73 2.32 .53 .34 100.00 The non-volatile fats exist in the proportion of 92 per cent, the volatile 8 per cent. These tabulated figures represent averages only, computed on a large scale, for Wing states that "the difference in the percentage of fat in milk from different cows of the same breed is quite as great as the average differences between the breeds." While the average percentage of fat in American cow's milk is about 4 per cent, the legal standard in most States is 3 per cent. Cream is not pure fat; it is an aggregation of the oil globules in the top portion of the milk with a little proteid and carbohydrate. Cow's milk very 56 FOODS AND FOOD PREPARATIONS rarely reaches as high a percentage of fat as 7, and there are few authenticated analyses above that figure. Average cream contains (according to Farrington and Woll) the following percentages : Water 66.0 Fat 25.4 Casein and Albumin 3.8 Lactose 4.3 Ash . .5 100.0 The skimmed milk after removal of the cream by a separator contains less than 0.2 per cent of fat, or if obtained by gravitation in a pan, 0.4 per cent. Average cow's milk contains 8 to 10 per cent of cream. Alderney milk may have as high as 20 or even 30 per cent. Good milk should form a layer of cream about two inches and a half thick as it stands in a quart bottle. An average yield of cream from 1,000 Ibs. of milk is 145 Ibs. from which 42 Ibs. of butter may be obtained. Butter fat melts at 92-96 F. The ordinary hardness of butter is main- tained by olein, which melts at 41 F. The odor and flavor of butter, and to a great extent of milk, is due to butyrin. When this fat decom- poses from the action of bacteria and light, it forms butyric acid, giving a rancid odor and flavor to butter. Various volatile oils in the food of the cow from time to time may be present in the milk, modifying its FH;. o. CHAPMAN'S DIPPER, FOE taste and odor, for example those de- REMOVING TIIK UPPEK LAYERS -, ,, ,, ,, . .,, OF MILK (Holt). rived irom the cabbage, turnip, wild onion or garlic. Lactose. Lactose is an important ingredient of milk, forming 33 per cont of its total solids. It is used also commercially, prepared from whey, as an ingredient of many proprietary infant and in- valid foods. AVhen chemically pure it is hard, transparent, white, and crystalline. It is now obtainable in much purer commercial form than formerly, when in addition to its diuretic effect, if given therapeutieally, it often developed irritation and even glycosuria. It is loss soluble and much less sweet than sucrose, although it pos- sesses the same chemical formula. Its chief function in human milk is ANIMAL FOODS 57 to supply energy for heat production for the infant whose muscles are not yet active in developing this force. The quantity present in cow's milk varies greatly, and, as a general rule, bears an inverse ratio to the quantity of fat and casein present. It is less liable than cane sugar to ferment in the stomach; and alone it is not susceptible to alcoholic fermentation. Certain bacteria feed upon milk sugar, con- verting it into lactic acid, making the milk sour. It is promptly absorbed from the alimentary canal, not remaining over an hour in the stomach. Casein and Albumin. The principal albuminoid of milk is casein, or caseinogen, but there are a half dozen proteids which have been described, showing different behavior on coagulation, in polariscopic rotation, etc. There are albumins present called lactoglobulin and lactalbumin or lactoprotein, which latter is coagulable at 170 F., and forms the tenacious " scum " which floats on top of boiled milk. Casein constitutes about 80 per cent of the total nitrogenous bodies in milk. It exists in normal cow's milk in the proportion of 2 to 4 per cent, and albumin is present in .5 to .8 per cent. Milk with a low fat percentage may therefore contain more protein (casein and albumin) than fat. Casein exists in milk both in solution and largely in sus- pension in a colloidal state, associated with insoluble calcium phos- phate. In the colloidal form it is retained when milk is passed through a Chamberlain porous filter. Casein is non-coagulable by heat, even by boiling, but is coagu- lated in firm tough clots by acids, such as hydrochloric acid of the gastric juice, and by many organic acids which occur as prod- ucts of malfermentation in the stomach. Lactic acid is the com- mon agent in forming the coagulae. Casein is also coagulated, but less firmly, by the special milk-curdling ferment "rennin," in the presence of soluble calcium salts. This ferment is present in the infant stomach, and in the third stomach of the calf. The casein clot formed by rennin, unlike that of lactic acid, is not redissolved by neutralization which alkalies. Dry casein is used commercially to make sizing for paper, and various artificial foods are made with it (see Somatose). It has long been taught that the casein of cow's milk was more difficult of digestion than that of human milk, but it has lately been proved by Czerny, Keller and 0. Huebner that this is an error, and the supposed undigested " curds " of coagulated casein so often seen in infant's stools are really masses of saponified fat with fatty acids, 58 FOODS AND FOOD PREPARATIONS neutral fat and bacteria. Hence it is more often the fat than the casein of cow's milk which disorders infant digestion. Other proteid substances are present in minute quantities in milk. Such are : globulin, nuclein or proteose or hemi-albumose, and fibrin. Milk Ferments. The ferments nominally present in milk are weakened or destroyed by varying degrees of temperature as shown in the following table by Hippius quoted from Roland G. Freeman. THE EFFECT OF HEAT ON CERTAIN BIOLOGIC CHARACTERISTICS OF MILK AS DETERMINED BY HIPPIUS. 1. Present in Woman's Milk and not present in Cow's Milk. Unchanged by Weakened by Destroyed by Salol-splittingferment 131 F. ' 149. F. ( 1 hr. at 140 F. 158 F. short 167 F. Ainylolytic ferment, j % hri &t 14J)0 F> time 2. Present in "Woman's Milk and, present but less active in Cow's Milk. Unchanged' by Weakened by Destroyed by Fat-splitting ferment. 143 F. 145- F. 147 F. 3. Active in both Woman's and Cow's Milk. Unchanged by Weakened by Destroyed by Proteolytic ferment, i 1 h r. 140149 F Boiling. / y 2 hr. at 149 F. 1 hr. at 140 F. . 1 min. at 169 F. Oxidizing ferment. Bactericidal action. 2 min. at 185 F. Alexius according to , ,, no ^ STa-Sta! IftJESSP* -' ^tartiff J: Boiling. Boiling. This table also shows an important fact determined by Spolverini, namely that the milk of herbivores, such as the cow and goat, lacks the amylolytie and salol-splitting ferments observed in the milk of omni- vores such as woman and the dog. Varieties of Milk. Cow's milk differs in quality according to the breed and condition of the animal, nature of its food, and care bestowed upon feeding and hygienic surroundings. The chief varia- tion concerns the quantity of fat. The milk of different breeds of cows varies so much in richness of fat and other ingredients as to be a matter of great dietetic importance especially in regard to infant feeding. The following table compiled by Henry H. Wing "from a large number of analyses made at various American Agricultural Experiment Stations'' illustrates this fact: ANIMAL FOODS 59 Solids. Fat. Jersey 14.70 5.35 Guernsey . . / 14.71 5.16 Devon 14.50 4.60 Short-horn 13.38 4.05 Ayrshire 12.61 3.66 Holstein-Fricsian 11.85 3.42 The milk of Alderney, Jersey, and Guernsey cows has more pro- tein than that of ordinary animals, and Alderneys give more fat than Longhorns. Individual cows are liable to vary both among themselves and from day to day in the quality of their milk, and therefore, notwithstanding general belief, it is a disadvantage to feed an infant always upon the milk of the same cow. More uniformity on the average, may be secured by feeding the mixed milk of several animals, the variations in the components neutralizing each other. " Strippings" is the name given to residual milk which may be drawn off shortly after the ordinary milking has been completed. Contrary to popular belief, it possesses no advantage as food over the rest of the milk, and what little difference in composition exists may be produced artificially. It is richer in fat but poorer in casein than the milk first drawn. For infant use it should be diluted with two parts of water to one of milk. Human Milk. Human milk differs from cow's milk in several important particulars. For this reason it becomes necessary when infants are fed upon the latter to so modify it as to render it more digestible for them. The essential differences between human milk and cow's milk are that woman's milk is sweeter by one-third and contains little less than half as much casein. The analyses of the United States Department of Agriculture give the percentage of casein in cow's milk as varying between 3.43 and 3.91, whereas that of mother's milk averages 1.5, hence the importance of diluting cow's milk in the early months of infant feeding. As Leeds says, the calf grows faster and has to manufacture more muscle than the baby it needs more albumin for tissue building. The casein of mother's milk, moreover, forms smaller coagula? in the stomach, which are more easily dis- solved. The reaction of human milk is alkaline to litmus, but faintly acid to phenophthalin (see p. 64). There is nearly one-half per cent more fat, and the globules exist in a finer emulsion in woman's than in cow's milk. In cow's milk there are from 6 to 8 times as much of the fatty acids, butyric, caproic, capric and caprylic, as in human milk. Cow's milk appears richer, whiter, and more opaque than human milk. 60 FOODS AND FOOD PREPARATIONS These differences are emphasized by the following comparative analyses by Leeds of average cow's milk and human milk : Sound dairy milk. Human milk. Feebly acid. Alkaline, (litmus) Specific gravity 1029.7 1031.3 Bacteria/ . Always present. Absent. Fats 3.75 per cent. 4.13 per cent. 4 42 " 71 " Albuminoids 3 76 " 20 " Ash 68 " 02 " Total solids 12 61 " 13 33 " It requires more acid to precipitate the proteid from woman's milk than from cow's milk, and it is not precipitated in large coaguke by rennin. Giving a nursing woman an excess of nitro- genous food does not increase the albuminoid elements of her milk so much as the fats, while giving fatty or rich food in excess does not increase the cream or other ingredients of her milk it may, indeed, diminish them by disordering her digestion. The nursing mother's diet therefore should be plain but substantial, especially in regard to animal foods. Excessive fat or protein in the mother's milk disorders the infant's digestion. The following analyses illustrate the extent of possible variation in good specimens of human milk : I. II. III. IV. V. VI. VII. VIII. Fat Per cent _ 4 37 Percent. 3 76 Percent. 3 16 Percent. 3 82 Percent. 2 96 Percent. 2 09 Per cent. 2 02 Percent. 2 36 Milk sugar . . . Albuminoids . . Mineral matter 6.30 3.27 0.16 6.95 2.04 0.14 7.20 1.65 0.21 5.70 1.08 0.20 5.78 1.91 0.12 6.70 1.38 0.15 6.55 2.12 0.15 7.10 2.20 0.16 Total solids. Water .... 14.10 85 90 12.89 87 11 12.22 87 78 10.80 89 20 10.77 89 23 10.32 89 68 10.84 89 16 11.82 88 18 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 For the analysis of human milk about half an ounce is required, drawn from the middle nursing period, for the milk becomes pro- gressively richer during nursing. Prof. Albert II. Leeds (American Text-book of the Diseases of Children, pp. 42, 43) lias shown, by a table of analyses of milk from eighty women of different nationalities, ages, and periods of lactation, that although " the average amount of nitrogenous matters [albumi- ANIMAL FOODS 61 noids] is somewhat greater at beginning of lactation, the difference is not very marked. . . . There is no progressive change in the composition of milk during lactation, but after the function has been normally established the milk remains substantially the same during the entire period. . . . The child obtains more nutriment day by day, but it is by spontaneously increasing the quantity according to the best rule, which is that of normal appetite, and not by absorbing stronger and stronger food." Somewhat different conclusions are reported by Vanderpoel Adriance and John S. Adriance, based upon analyses of the milk of 120 healthy mothers at the Nursery and Childs' Hospital, New York. In each case the sample was obtained after allowing the infant to nurse for two minutes, and periods studied were from the second day to the fifteenth month of lactation. They found that of all the ingredients of human milk the fat varies most, and varies throughout lactation, the extremes being 7.61 and 1.31 per cent. The fat bears a rough general proportion to the proteid of 3:1. The carbohydrate, which weighs during the middle period of lactation more than all the other solids together, increases throughout lactation, and ranges from 5.35 to 7.95 per cent. The protein percentage is highest during the colostrum period, when it may reach 8.60 per cent, and falls rapidly towards the end of lactation. Pfeiffer found it as low as 1.52 at the seventh month, but this is extreme reduction. It is increased by worry and nervous- ness and by lack of exercise; it is lessened by reduction of meat in the dietary, and vice versa. It comprises calcium-casein, lactalbumin and lactoglobulin. The salts possesses little proteolytic power. It exists more abundantly in the infant stomach than in that of the adult. Rennet may be prepared as a powder; it is sold by grocers in alcoholic solution, and when added to milk which is gently warmed, a light coagulum is formed, causing the milk to partially solidify. The coagulum contracts and squeezes out fluid, which constitutes whey. The rennetized milk when flavored with vanilla or powdered cinna- mon or nutmeg makes an agreeable invalid food or dessert called " junket," which is highly nutritious, for it contains all the valuable ingredients of milk. Abnormal Digestion. In cases of indigestion from various causes tough casein curds may remain undissolved in the stomach, eventually irritating it and causing vomiting, or they may pass along the intestine and be voided unaltered in the stools. This occurrence is more fre- quently noticed in young infants than in adults. But the " curds " found in infant stools often are composed not of casein, but of saponified fat with bacteria (see p. 57). Many substances may be added to milk which by their mechanical presence will prevent the formation of tough curds. Excessive acidity of the stomach due either to hypersecretion of hydrochloric acid or the presence of organic acids, especially lactic, derived from the food or fermentation processes, modifies the digestion of milk; the lactose is altered into lactic acid and the casein promptly coagulated. The alkaline salts of milk are split up and phosphoric acid is liberated, and complicated fermentative changes ensue which are as yet im- perfectly understood. All this causes more or less gastroenteric ir- ritation, resulting in diarrhoea. When milk or cheese remains too long in the stomach or intes- 84 FOODS AND FOOD PREPARATIONS tine a further fermentation is excited accompanied by a neutral or alkaline reaction, and which results in the final production of butyric acid, and sometimes of other substances, such as leucin, tyrosin, and ammonia. But while free hydrochloric acid exists in the contents of the stomach, the organic acids lactic, butyric and acetic which are associated with milk fermentation are unlikely to develop. Cow's milk readily may become acid from alteration in the rela- tive amount of potassium biphosphate and the two-thirds phosphate of potassium. The former, if present in excess, hastens coagulation and an acid reaction. When warm the milk again may become alka- line (Soxhlet, Heintz). These facts explain the frequent necessity of using antacids, such as lime water or sodium bicarbonate, with infant milk food. Mucous fermentation of the proteids makes the milk slimy, and it becomes stringy on boiling. Milk, according to Buhner's experiments, yields more bulky resi- due in the feces than either eggs or meat, yet its nutritive ingredi- ents are sufficiently absorbed. This is well illustrated in the ex- clusive milk diet of typhoid fever. From 8 to 10 per cent approxi- mately of the solids of milk are eliminated in the stools. ADAPTATION OF MILK FOE THE SICK AVhen patients object to the taste of milk alone, they may be induced to take large quantities by using it in various combinations or preparations, or by disguising its taste. Many patients when or- dered a milk diet positively assert that they cannot endure the taste of milk; that it always nauseates them, or that it makes them bilious and constipated, and excites headache. They say, perhaps, that they have faithfully tried to drink it before, and never could tolerate it ; but scarcely any one person has ever tried all the different methods of taking milk, and it does not follow that because it once disagreed several years before it will again. The objection to the taste may be overcome by a little tact and perseverance, and there are very few persons who cannot assimilate a more or less exclusive milk diet if the milk is given properly, and, if necessary, artificially di- gested for them. Their previous unhappy experience is probably due to having taken a large dose of undiluted rich milk, which promptly coagulated, soured, and was rejected, exciting all the distaste which they have treasured against it. When, as in some febrile cases or in acute Bright's disease, a milk diet is imperative, such patients should begin with a teaspoonful ANIMAL FOODS 85 or two at a time, repeating it once in ten or fifteen minutes. If milk is only taken slowly enough into the stomach, and mingled on the way with saliva, like other food eaten rather than drunk it is im- possible for it to form the large tough curds that it does when poured down by the tumblerful. In all cases where there is tendency for milk to disagree it is better to give it alone to the patient, by which means various expe- dients used to increase its digestibility may better be tested. Patients will often digest both milk and beef broth or milk and whisky when these substances are given at alternating intervals of one or two hours, whereas if taken in conjunction they give rise to dyspepsia. The methods of altering milk to suit the taste or digestive re- quirements are so numerous that it will be found convenient to group them under the following headings, although the classifications are somewhat arbitrary and here and there may overlap : I. Methods of altering the taste of milk. II. Methods of improving the digestibility of milk. III. Methods of predigestion. IV. Methods of sterilization, pasteurization and preservation. The first method beguiles the patient into taking larger quantities of milk without tiring of it; the second aims at preventing the for- mation in the stomach of dense tough coagula? which are difficult of solution and digestion by an enfeebled gastric juice; the third, by artificial digestion, relieves a weak stomach of much labor; the fourth prevents the accession of poisonous germs which would excite malfermentation and indigestion. I. Methods of Altering the Taste of Milk When patients object to the taste of raw milk or tire of it, it may be flavored in a variety of ways. When there is no objection on the score of the nervous system, a teaspoonful or two of black coffee is one of the best means at hand, or a little of the extract of coffee may be added. Very weak tea may be preferred. Caramel is an- other excellent flavoring substance which may be freely employed, and ginger is also used. Other patients may take a little chocolate or cocoa or cocoa nibs infusion with their glass of milk. Some prefer the addition of common salt or a little black pepper. The various meat extracts, fluid or solid (see Meat Preparations, p. 132), may be used to advantage. When alcohol is not contraindicated many patients are willing to drink much milk in the form of weak punches, or as eggnog in which cognac, whisky, sherry, or rum may be em- ployed to disguise the " flat " milk taste. 86 FOODS AND FOOD PREPARATIONS The various malt extracts are enjoyed by some when given in milk, and their disagreeable sweetness is thereby removed. A tea- spoonful of malt may be added to a pint of milk which is gently warmed for half an hour, after which it is boiled for twenty minutes. This prevents the formation of large curds. None of these additions materially affect the nutritive value of milk, and the occasional variety which may be secured by experi- menting with different substances will usually overcome all preju- dice. I often have induced patients to take large quantities of junket flavored with a little spice (see Receipts for Invalid Foods), not realizing that they were really eating only pure milk which had passed into the first stage of digestion. Patients who object to milk because they have to drink so much fluid may take the same quan- tity in the form of junket because they can eat it with a spoon. Much milk may be disguised sometimes in custards, gruels, blanc- mange, etc., where there is no objection to the addition of other easily digestible foods. II. Methods of Improving the Digestibility of Milk 1. Skimming. 2. Boiling. 3. Dilution with water. 4. Dilution with alkaline and aerated waters. 5. Dilution with amylaceous foods. 6. Addition of alkalies, acid and other substances. 1. Skimmed milk is the -residue after removal of the cream. It contains water, 90.63 per cent; proteid, 3.06 per cent; fat, 0.79 per cent; sugar, 4.77 per cent, and a residue of salts. It thus retains almost 10 per cent of solids. Skimmed milk is well digested by those patients whose stomachs do not tolerate fat in any form, but it will not long support life (see "Skimmed Milk Cure"). Yeo advises gouty subjects to drink ten minutes before each meal a breakfastcupful (eight ounces) of hot skimmed milk and water with the addition of a small saltspoonful each of potassium bicarbonate and salt. This is a good means of prescribing an alkali, but there is no specific advantage in the skimmed milk. 2. Boiling. Boiled milk exhibits a thin scum of albumin upon the surface which entangles some of the fat globules, and which is quickly replaced by another after removal. This scum should not be served to invalids. There is much discussion as to whether infants should over be given raw cow's milk, or only that which previously has been boiled, and authorities are divided upon the matter. Certainly in most eases raw milk, if pure, provokes no harm. Boiling the milk arrests the development of germs and fungi with which it may have ANIMAL FOODS 87 become contaminated, and thus may prevent the spread of some diseases, and it retards the process of " souring " and coagulation. Boiling expels about 3 per cent of gases carbon, nitrogen, and oxygen and the loss of oxygen diminishes the formation of lactic- acid and consequent souring. It alters the taste of the milk some- what, and makes it "flat." The flatness is removed by agitating the milk with air by pouring it back and forth into two cups held a little distance apart; or it may be removed by addition of soda, selzter, carbonic water or Apollinaris. As a rule, boiled milk is pre- ferred hot, but some persons enjoy it cold. It is a prevalent idea that milk is in general more digestible if boiled than if raw, but the results of experiment do not wholly confirm this view. Crolas has demonstrated that boiling has no influence upon either the lactose or casein, but it slightly increases the free soluble phosphates, which he regards as an advantage. Occasionally patients are made bilious and constipated by the use of boiled milk who digest it better raw, but the converse is also true : it is a matter of idiosyncrasy. It has decided advantage in diar- rhceal diseases, probably through the absence of germs and gases. In some cases it may be combined with thin chocolate or cocoa. " Scalded milk " is heated to about 150 F., or practically " pas- teurized," by pouring on boiling water. Thus treated, milk remains fresh a little longer than when raw. 3. Dilution with Water. Plain water, either hot or cold, may be added in proportion of one part to two or three of milk. If the milk is exceptionally rich in cream and casein this simple means often will be sufficient to ensure its better digestion, for the curds become both smaller and softer. 4. Dilution with Alkaline or Aerated Water. Lime water may be added in the proportion of two to four or more tablespoonfuls to each tumblerful of milk, taken cold. In cases with much acidity of the stomach the lime water should be mixed in the proportion of one- half or two-thirds. When so given, the taste of the milk is so little altered that very few patients object to it, and some find it more agreeable. If diarrhoea or nausea is present they are controlled to some extent, but on the other hand constipation is increased by the use of lime. When the latter exists it is better to dilute with aerated water. If lime water is added to neutralize the acidity of cow's milk the temperature of the mixture should not be raised above that of pasteurization 160 F. because the albuminoids are more or less decomposed in boiling alkaline solution. It is better to sep- arately pasteurize the milk and add the lime water afterwards. 88 FOODS AND FOOD PREPARATIONS Barley water may be used as a diluent for milk in diarrhoea, but oatmeal water is better if there is constipation. Aerated waters, such as carbonic-acid water, alkaline Vichy, Seltzer, bottled plain soda, or Apollinaris, all may be added to milk, in any desired proportion. In cases of fever four ounces of a mixture made with equal parts of the diluent may be given every hour, or eight ounces every two hours, up to three and a half or four pints of milk per diem. Most of these waters are used best with cold milk, but for many persons hot milk and Vichy make a very agreeable combina- tion, which is often soothing to the obstinate cough of bronchitis. The mixtures with Vichy and lime water are especially serviceable where extreme irritability of the stomach is present with a tendency to the immediate rejection of all fluids. 5. Dilution with Amylaceous Foods. Any form of starchy food flour, arrowroot, etc. serves as a mechanical diluent of milk by mingling with it and preventing the precipitation of tough curds. Bread and milk, rice or crackers and milk, serve the same purpose, and have the further advantage that they must be eaten slowly and mixed with saliva. When infants vomit their milk it may be attenuated temporarily with either barley water or oatmeal water added instead of plain water, and in the same proportion i. e., one-third or one-half. The much-extolled starchy "infant foods" are less useful as foods than they are diluents of milk, and if used temporarily with the latter object solely in view, are less liable to produce rickets, scurvy, or gastric catarrh. Whenever amylaceous substances are selected to dilute milk for infants they first should be converted as far as possi- ble into dextrin and glucose, for gummy dextrin, saccharine, or gelatinous materials are all better than crude starchy foods. For adults a tablespoonful of Mellin's or Nestle's food or Imperial Granum dissolved in an ounce of hot water and added to a glass of milk is both palatable and nutritious in cases of phthisis or scrofula. 6. Addition of Alkalies, Acid and Other Substances. The addition of alkalies to milk renders it much more digestible for some persons. In hyperacidity of the stomach or in the presence of abnormal fer- mentation alkalies are beneficial as neutralizing agents. On the other hand, in cases in which the gastric juice is very feeble or absent, artificially digested milk may prove more serviceable. The admix- ture of alkalies by reducing the acidity of the gastric juice makes the easein coagulate more slowly, and in flocculi rather than in large coagulae. Salt may be added a saltspoonful to the tumbler of milk. This ANIMAL FOODS 89 improves its digestibility for most persons, and renders it less likely to cause biliousness. Sodium bicarbonate, ten grains, or a salt- spoonful to the tumbler of milk, prevents malfermentation in the stomach. If hyperacidity of the stomach exist sodium bicarbonate may prove better than lime water, which is only slightly antacid, for it contains a half grain of lime to the ounce. On the other hand, if the gastric juice is too feeble to digest milk easily, it is sometimes a disadvantage to attenuate it still further with quantities of lime water, and sodium bicarbonate should be substituted to check the lactic-acid fermentation of the milk which the hydrochloric acid of the gastric juice fails to control. An excellent combination for an irritable stomach is made by adding five or ten grains of this salt and two grains of cerium oxalate to each glass of milk. The cerium oxa- late has a sedative and tonic action upon the mucous membranes and tends to allay nausea and irritation in the stomach. Other substances sometimes added in cases of gastric ulcer, etc., are sodium phosphate, saccharated lime, or a teaspoonful of milk of magnesia to the pint. A few drops of liquor potassae to the pint of milk are recommended by Bulkley for infants having eczema. Starr gives the following receipt for making saccharated lime for diluting milk for infants: Slaked lime, one ounce; refined powdered sugar, two ounces; mix, triturate, add distilled water, one pint. Shake occasionally for some hours in a bottle, let stand, and siphon out the fluid. Roberts recommends a powder containing 10 grains each of so- dium bicarbonate and common salt, and 5 grains of light magnesia, to be added to a tumblerful of one-third hot water and two-thirds hot milk. Edes strongly recommends the addition of hydrochloric acid to milk. Twenty minims of the dilute acid of the pharmacopoeia are stirred slowly, drop by drop, into a pint of milk which is gently warmed. A fine flocculent coagulum of casein floats in the whey, the digestibility of the milk is improved, and a flat or disagreeable taste is avoided. Gelatin. Gelatin may be employed in small quantity as an at- tenuant of milk. Starr gives the following receipt for its use : Soak a piece of white gelatin an inch square in half a cupful of cold water for three hours. Put the cup in a saucepan of water and boil until the gelatin dissolves. When cold it forms a jelly. For infants one or two teaspoonfuls may be put into each nursing bottle of milk. 90 FOODS AND FOOD PREPARATIONS III. Methods of Predigestion, Sour Milk, " Koumiss" etc. 1. Peptonized milk. 2. Pancreatinized milk. 3. Sour milk, kou- miss, kefir, zoolak, etc. 1. Peptonized Milk. The object of peptonizing milk is to com- plete a portion of the digestive process outside of the body, and thereby relieve the alimentary canal of this work. Powdered pepsin may be added some time before the milk is swal- lowed, and in this event it can act only in conjunction with dilute hydrochloric acid. If added to the milk at the time of swallowing, the normal acid of the gastric juice supplies the proper reaction. The process of artificial peptonizing consists in adding one of the numerous preparations of pepsin obtained at the pharmacist's to fresh acidulated milk, and allowing it to stand in a bottle immersed in warm water at approximately the body temperature. Fermenta- tion results in which the casein is more or less completely converted into albumoses. If the process be too long continued, further fer- mentation results, and the milk becomes very bitter. It is therefore checked after a few minutes, either by boiling the milk, which has the effect of destroying the pepsin, or by keeping it upon ice until ready for use, which inhibits the action of the ferment. Either peptonized or pancreatinized milk may be prepared in quantity for use by infants or invalids during the day, and if there is an ice chest to keep it in, it is better to do so, for then it is more uniform in composition. If ice is not at hand, the preparation should be made fresh for use each time, otherwise it will become bitter and spoil. 2. Pancreatinized Milk. The use of pepsin for predigestion of milk has been superseded gradually by that of pancreatin, which acts best in an alkaline medium. This ferment, like pepsin, may be pre- served almost indefinitely in powdered form. Milk thus prepared is slightly yellow and less opaque than raw milk. The process may be conducted as follows : Add a pint of fresh milk to a gill of cold water in a clean ves- sel. Put in a tubeful of Fairchild's " peptonizing powder " (pancre- atic extract 5 grains, and sodium bicarbonate 15 grains), or, instead of the pancreatic extract, substitute 1 to 2 drachms of "pancreatic solution " made by Parke, Davis & Co., stir well, and place in warm (not boiling) water for half an hour or until a slight bitter taste is present. This taste means that fermentation has proceeded far enough. To allow it to continuue will make the milk unpalatable, ANIMAL FOODS 91 and it is almost impossible to disguise the bitterness. Boiling for two or three minutes stops further fermentation, and the milk should then be placed on ice until ready for use. Such milk will keep well for several hours. When used, serve alone cold, or add carbonic-acid water to improve the taste. For adults a little coffee may be used for the same purpose. A receipt for pancreatinized milk gruel is given under Eeceipts for Invalid's Food. When pancreatinization is long continued the casein is completely digested, but the milk becomes too bitter for use. Legumin. Legumin is a vegetable ferment which is said to make milk highly digestible for invalids by converting casein into a sol- uble albuminoid. This substance, which was lately introduced by Bovet, is also given as a food. Sour Milk. Sour whole milk differs from buttermilk in that the fat has not been removed. The " souring " is due to development of lactic acid through the agency of lactacid bacilli. One variety of these, the rod-shaped Bacillus Bulgaris, or Bulgaricus (derived from milk soured in Bulgaria), is most active in developing lactic acid. According to Elie Metchnikoff, of the Paris Institut Pasteur, this bacillus colonizes in the intestine, and causes an acid reaction which is inimical to the growth of putrefactive organisms, such as produce butyric acid, indol, skatol, etc. This antagonistic action of the lactacid bacilli to putrefaction was first demonstrated by C. H. Herter of Xew York in 1897. Metchnikoff in his Essais Optimistes (1907) and "The Prolongation of Life" (1908) advances the theory that the putrefactive products of the intestine being absorbed, im- pair vitality and tend to shorten life, and that by consuming an ex- cess of the lactacid bacilli, these abnormal processes may be checked and life prolonged. He states that "this variation of the intestinal microbes in its relation to our foods permits us to modify the in- testinal flora by replacing harmful microbes with those that are use- ful/' In support of this theory, Metchnikoff adduces many historical facts. Sour milk is mentioned favorably as an article of diet in the Bible (Genesis xviii, 8; and Deuteronomy xxxii, 14) and to this day constitutes a staple food among many peoples in parts of Africa, Eastern Europe and Asia. Many instances of extreme old age (vigorous old age), have been found among habitual users of sour milk. Metchnikoff writes: " I have learned a very important fact from Charcot. During his stay of sixteen months in the Antarctic regions, neither he nor his crew ate any food save that which was sterilized. Their bill of fare con- sisted of preserves of all kinds, together with the cooked flesh of seals, 92 FOODS AND FOOD PREPARATIONS penguins, etc. They ate no raw vegetables or fruits, and, save a small quantity of cheese, their diet was strictly aseptic. The whole per- sonnel of this expedition enjoyed most excellent health and in no instance was there a single case of derangement of the digestion." " In many countries, particularly in Eussia, vegetables that have undergone an acid transformation form a large portion of the food of the population. During the long winter, in default of fresh fruits and vegetables, preserves of watermelon, cucumbers, apples and other fruits that have been subjected to an acid fermentation are con- sumed. The principal product generated in these fruits and vegeta- bles is lactic acid, and it is due to the presence of this acid that putre- faction is prevented." In some eastern countries sour milk is used to pickle meats, by preventing putrefaction through agency of its lactic acid. Sour milk may certainly be regarded as healthy, provided the " souring " is confined to the natural action of the lactacid bacteria (see "Koumiss," p. 93, and "Zoolak," p. 95), and the milk not con- taminated by streptococci or other common bacteria of dirt. The natural curdling which results from souring is due to precipitation of caseinogen and is different from the coagulation induced by rennin. " Bacillac " is a sterilized milk " activated " according to Metch- nikoff with lactic-acid bacilli, and free from yeast and consequently from alcohol. It contains about 2.5 per cent of lactic acid. " Lactobacilline " is a preparation first made in Paris in 1905 under direction of Metchnikoff from pure cultures of Bacillus Bul- garis, and a second European variety of bacillus, consisting of com- pressed tablets, one or two of which should be taken about an hour and a half after meals, at the time when they will pass promptly to the in- testine with digested food. To facilitate their multiplication (for the bacilli are still alive) they should be taken with a lump of sugar or a caramel, for they propagate best in saccharine media. Cohendy showed that an exclusive meat diet greatly increased the sulphur ethers of the urine, but when a liter of milk soured by lacto- bacilline was added to the daily proteid diet they almost entirely disappeared, and the lactacid bacilli appeared in the feces. Lactic acid may be used similarly, but the lactacid bacilli are more power- ful, and do not produce the gastric and renal irritation which the acid is liable to induce. The milk poured by lactobacilline differs from other soured milks, such as Koumiss, in the absence of yeasts, which cause in addition alcoholic fermentation. ANIMAL FOODS 93 " Lactone " is a tablet preparation of pure culture of lactacid organisms first made also in 1905 by Parke, Davis & Co. at the in- stigation of H. G. Piffard. One of these tablets may be added to a quart of fresh milk to sour it diluted with one-third hot water. One or one and a half pint may be taken daily between meals. Tissier employs pure cultures of lactacid bacteria grown in lactose broth, for intestinal disorders. Sour milk undoubtedly constitutes a wholesome and nourishing food for those who can digest it, but with invalids I often have found it to disagree, producing nausea, vomiting, and in time " biliousness." There is at present much discussion as to its value for infant feed- ing, and while there are those who strongly advocate its exclusive use, others are opposed to employing it at all. No doubt much de- pends upon the care given to its derivation, for it is easily con- taminated, especially in large cities. In fact, in New York city the sale of sour milk is prohibited by the Health Department as being, on the whole, a safer measure. Milk soured by lactobacilline is espe- cially recommended by Metchnikoff (in doses of one to one and a half pints taken three times a day with or between meals) for all diseases of the alimentary canal and kidneys and skin diseases of general or constitutional type. Metchnikoff's experiments have been confirmed by Tissier and Cohendy. 3. Koumiss. Koumiss (spelled also koumys and kumyss) is a sour whole milk artificially prepared by simultaneous lactic acid and alco- holic fermentation. It was originally made by the natives in the steppes of southeastern Eussia and other eastern countries as a re- freshing and slightly intoxicating beverage. Of late j r ears the idea has been advanced that it has some beneficial or curative influence in chronic diseases, such as phthisis, chronic bronchitis, chronic gastro- intestinal catarrh, and other wasting diseases, and as a result the manufacture of koumiss has been extensively introduced into the United States, and at many pharmacies it may be obtained daily, freshly prepared, in pint or quart bottles. The Manufacture of Koumiss. The manufacture of koumiss may be conducted by several different processes. In southeastern Eus- sia, especially in south Samara, the milk of a certain breed of mares is used, which is particularly rich in milk sugar but poor in fat and casein, and the animals are fed upon grasses which contain this sugar- forming material in abundance. Mare's milk, as compared with cow's, contains much more sugar (6 per cent) and less casein and fat (less than 3 per cent). The mares are light-colored animals, unbroken, and are guarded 94 FOODS AND FOOD PREPARATIONS with greatest care, not being allowed dry food, such as oats and hay. Pastured among mountains containing salt beds, they have access to running water, in which they can bathe frequently. They have large udders and abundant milk secretion, which is milked from four to six times daily. The best koumiss is made in the early summer by pouring fresh milk into smoked leather bottles or sabas, to which is added a little sour cow's milk or old dry koumiss ferment. These skins are kept at a temperature about equal to the body heat and are frequently shaken for thorough mixing, and fermentation is allowed to proceed for three or four days. In the United States koumiss is manufactured from cow's milk by the addition of some artificial ferment. Such home-made koumiss may be prepared as follows : Take 2 teaspoonfuls of wheat-flour dough, 2 tablespoonfuls of millet flour, 1 tablespoonful of honey, 1 tablespoonful of beer yeast. Mix into a thin paste with milk. Place in a warm place to ferment. When fermented, put into a linen bag and hang in a covered jar with sixteen pounds of fresh milk. Let stand for twenty-four hours, or until the milk becomes acid, at a temperature of 86 to 90 F. Skim, decant, agitate for an hour, bottle and cork tightly, protecting the corks with wire fastenings. Keep in a refrigerator. Absolute cleanliness must be insisted upon throughout all the various ma- nipulations; otherwise different forms of fermentation will result (Stange). Properties. Koumiss when shaken froths readily. It has, when fresh, a slightly sour odor, agreeable bitter taste, and acid reaction. The specific gravity is 1.018 to 1.029. During fermentation alcohol is developed from the milk sugar, which forms lactic acid and glu- cose, the latter making alcohol and carbonic acid. The alcohol may reach 2.5 per cent, but koumiss made from cow's milk may not con- tain above 1 per cent. Koumiss becomes stronger in both taste and smell after keeping a day or two. It is highly sensitive to tempera- ture changes. There are two varieties of koumiss prepared which differ in de- gree of fermentation and in their exhilarating and intoxicating properties. The lighter form contains less alcohol than the heavier, in which fermentation has proceeded further. The following analysis by Stange illustrates the changes in com- position which koumiss undergoes by prolonged fermentation: ANIMAL FOODS 95 Table of the Percentage Composition of the Several Strengths of Koumiss (Stange). Mare's milk. KOUMISS DURATION OF FERMENTATION. 6 hours. 18 hours. 80 hours. 4 days. Carbonic acid . . . 3.8 18.5 3.9 18.8 22.5 18.9 4.5 6.0 19.5 5.6 16.3 22.6 20.0 4.0 7.0 30.0 6.4 2o!6 19.0 4.0 11.0 30.0 6.4 ie!6 19.0 4.0 Alcohol Lactic acid Milk sugar 51 23 19 5 Albumin Fat Salts The casein, after first being precipitated, is converted into pep- tones and an acid albumin. It should be remembered that the com- position of koumiss is always changing unless the fermentation be held in check by extreme cold. Koumiss grows more and more acid and keeps but a short time when exposed to the air. If spoiled, it may produce severe symptoms of ptomaine poisoning. Koumiss is prepared in tablet form under the name of koumysgen, each tablet, it is claimed, containing 30 per cent of soluble casein. The tablets keep indefinitely in air-tight bottles, and when dissolved in water form a cooling effervescing food, possessing similar proper- ties with koumiss, and it is cheaper. It is doubtful, however, whether any preparation can be made to reproduce all the peculiarities and advantages of fresh koumiss, which is so variable and delicate a substance. The " Koumiss Cure " is described under that heading. Kefir. Kefir is another form of fermented milk which resembles koumiss, and has long been used in the Caucasus. It contains three varieties of ferments which produce complex fermentation processes resulting in the formation of one per cent of alcohol, besides lactic acid, modified albumins, and peptones. The casein of milk is in great part digested by them, and the portion which remains is pre- cipitated in flocculi instead of heavy curds. The milk sugar is al- most completely converted into alcohol and carbonic-acid gas, which bubbles to the surface. Kefir has a sour taste, due to the organic acids which it contains. Hayem and Eovighi have shown its bene- ficial effect is due to the presence of lactic acid, rather than to " pre- digestion." Zoolak. Zoolak, formerly called Matzoon, is a form of milk previously sterilized in which lactic-acid fermentation has been pro- duced by a ferment much used in Syria and southeastern Europe. The ferment, called by the Armenians "maadzoun," contains the 96 FOODS AND FOOD PREPARATIONS Bacillus Bulgaris and yeast. Its acidity equals one per cent. Fresh zoolak does not effervesce as older preparations do. It has the same general properties and effects as koumiss, and is an excellent invalid food. The trade name Matzoon was changed to Zoolak by M. G. Dadirrian, of New York. Yohourd is a soft semi-solid fermented preparation of milk fer- mented by a somewhat different process from zoolak, and sold in Philadelphia by the Eussian Kefir Co. It contains lactic-acid bacilli and yeast. Clabberade is another milk fermented by bacilli and yeast. Leben raib is a sour fermented milk used in Egypt and Algeria. It contains three species of bacteria and two of yeast. Carbonated Milk. According to L. L. Van Slyke and A. W. Bosworth of the Xew York State Agricultural Experiment Station: " Milk carbonated under a pressure of TO pounds comes from the bottle as a foamy mass, more or less like koumiss that is two or three days old. It has a slightly acid, pleasant flavor, due to the carbon dioxid, and has a somewhat more salty taste than ordinary milk. " The best results were secured when newly pasteurized milk or cleanly drawn fresh milk was treated with carbon dioxid in a tank, such as is used in bottling establishments in preparing carbonated drinks, and then placed in siphon bottles. When charged under pres- sures of from 70 to 75 pounds and kept at temperatures ranging from 35 to 60, bottles of clean fresh milk or pasteurized milk kept from four to five months without perceptible increase in acidity." IV. Methods of Sterilization, Pasteurization, and Modification. 1. Sterilization. 2. Pasteurization. 3. " Humanized milk." 4. Modified milk. Milk laboratories. 1. Sterilized Milk. The sterilization of milk is accomplished by heating to the boiling point, 212 F. In a vacuum this may be accomplished by a temperature a few degrees lower. The construction of steam sterilizers for milk, beef tea, or other foods is based upon a very simple plan. Bottles containing the food to be sterilized are suspended in racks in the upper part of a tin or copper vessel in an atmosphere of steam, and their contents soon ac- quires the temperature of boiling water (212 F.), which fills the lower part of the chamber. Mobnm preserves milk for six months by heating it in a tin re- ceptacle, the only opening of which is through a lead tube. The milk is rendered sterile by heat, and all air is driven out through the tube, which is then compressed and soldered. ANIMAL FOODS 9? The taste of sterilized milk is peculiar, resembling that of boiled milk. If put in bottles which have been sterilized by boiling water or steam (Fig. 16), by stopping them with pledgets of absorbent cotton which have been baked, the milk will keep fresh for a number of days long enough to be carried upon a voyage to England or across the con- tinent. In 1899 sterilizing apparatus was introduced at the Children's Hospital, Randall's Island, New York city, with the immediate effect of reducing the excessive annual infant death rate from 44.36 to 19.86. If milk be too long sterilized it becomes of a brown- ish hue, owing to the conversion of its lactose into caramel. It is not defi- nitely proven that prolonged use of sterilized milk causes scurvy in in- fants, and the disease may be due to other factors. According to Leeds, the following alterations are produced in milk by FIG. 16. THE ARNOLD STERILIZER sterilization at 212 F. (Fig. 17) : 1. (Holt). The amylolytic ferment is destroyed. 2. The casein is coagulated less readily by rennin. 3. The digestibility of casein by the gastric and pancreatic juices is somewhat retarded. 4. The fat is less promptly absorbed than normally from the intestine. 5. If the heating is con- tinued for some time, the milk sugar is destroyed. The mineral salts of milk are also dissociated in some degree from their organic compounds. It is thus demonstrated that the chief change produced by steril- ization of milk, and even by pasteurization at 167 F., is destruction of the enzymes or organic ferments of which this highly complex fluid contains a number. Babcock and Russell of Wisconsin have shown that when milk is rendered aseptic by salicylic acid, sodium fluoride or other germicides, a process of self-digestion goes on, which increases the longer the milk is kept. The result of this natural process is the formation of albumoses at the expense of casein, and the action is due to a ferment which these experimenters named " galactase," resembling trypsin. Another ferment, an oxydase or anaeroxydase, has been demon- 98 FOODS AND FOOD PREPARATIONS strated in cow's milk by a number of French experimenters. This ferment, as its name implies, causes a peculiar reaction in milk to- wards oxidizing agents, such as turpentine or tincture of guaiac. Spolverini identified a new ferment in cow's milk which resem- bles closely the glycolytic ferment of the blood. A ferment, called by Bourquelot "lipase," has been identified in both human and cow's milk; its action is hydrolytic, resolving mono- butyrin into glycerin and butyric acid. FIG. 17. STERILIZATION OVEN USED IN BOTTLING MILK UNDEB STEAM PRESSURE. (E. H. Webster, Bui. 41, Hygienic Laboratory.) In churning sterilized milk, butter forms more slowly than from raw milk, a period two or three times longer being required. Hirsch attributes this to toughening of the albuminoid envelopes (of lactal- bumin) of the fat globules, which is produced by the heat. Owing to the complicated changes which sterilized milk undergoes, an infant to be fully nourished on it requires more of it than of raw milk. Practically, in normal stomachs of either infants or adults these changes arc not sufficiently pronounced to interfere seriously with the digestibility of the milk, but dyspeptic and catarrhal conditions of the stomach, especially in infants, make it highly sensitive to very slight modifications in the composition and reaction of milk. ANIMAL FOODS 99 In quite recent years it has been proved that the method of pas- teurization is preferable to sterilization (see Pasteurized Milk, p. 100, but there is a decided reaction against the prolonged use of both these types of milk, in distinction from temporary emergency use, and von Behring in common with many American clinicians maintains that when mother's milk is unprocurable, the proper infant food is good, fresh, clean milk, not heated or otherwise modified by necessary dilution or sweetening. Von Behring states that fresh milk contains powerful antibodies which react against the Bacillus aci'di lactici and colon bacillus. As these are the two types of bacilli com- monly present in the infant organism, and as the heat of steriliza- tion or pasteurization promptly destroys the antibodies, by the use of heated milk the infant is deprived of a protective agent against gastrointestinal disorder. After all, in selecting a proper milk for infant feeding, the question of immediate digestibility is bound up in that of permanent effect upon nutrition. The difficulty with infant feeding among the poor is to obtain really good, fresh, raw milk; hence in a given case the choice of feeding must ultimately depend upon the character of raw milk obtainable. When this is first-class the relative digesti- bility, as well as relative permanent nutritive value, stands as follows in order of preference : (1) raw, (2) pasteurized, (3) sterilized. The directions for predigestion combined with sterilization of milk at the Philadelphia Hospital are thus given by Hirst : " 1. Have the nursing bottles prepared clean every morning. " 2. Take cream, five ounces ; milk, two and a half ounces. " 3. Put in skillet ; add pancreatin powder (pancreatin, two and a half grains; sodium bicarbonate, five grains) ; heat over alcohol flame for six minutes ; stir and sip constantly ; do not overheat. " 4. Of this mixture put in each bottle six drachms (for a two- ounce bottle). Use funnel. " 5. Add to each bottle ten drachms of sugar solution. (Make sugar solution by dissolving an ounce of sugar of milk (one powder) in a pint of warm water.) " 6. Stopper the mouth of each bottle with dry baked cotton and sterilize for twenty minutes. " 7. Set aside to cool. " 8. Before use put bottle in warming cup ; apply nipple imme- diately before giving to infant." The alimentary canal of the newborn infant is sterile it con- tains no bacteria but after the first few passages of meconium two species of bacilli and one of micrococci are found (Escherich, Bes- 100 FOODS AND FOOD PREPARATIONS lau), which disappear with the meconium. There are only two species of bacteria found in the stools of healthy nursing infants, the Bac- terium lactis aerogenes, obtained from the ileum below the duodenum, and Bacillus coli communis, from the colon. In diarrhoeal conditions other bacteria, to the number of forty species, have been found (Booker). Their action in different dis- eases is not yet differentiated, but they are associated more or less directly with malfermentation and the formation within the intes- tines of gases and irritating or poisonous products. Many of these species thrive and are reproduced in hot weather outside the body in milk, in the atmosphere, and upon diapers and utensils. This explains the importance of absolute aseptic cleanliness in every- thing that pertains to the nursing and feeding of infants cleanliness of the breasts and nipples, of the nurse's hands, of all receptacles for milk or other foods, of the child's body, and prompt removal and disinfection of soiled diapers or clothing. The most important fact in regard to both sterilized and pas- teurized milk is that these processes, while they kill all the germs already contained in milk, do not prevent its immediate reinfection when exposed to any of the common sources of contamination. In fact, as Eotch says, " form a cloak of dirt." 2. Pasteurized Milk. Pasteurized milk is similarly prepared to sterilized milk, and is, in fact, sterile, but the temperature is only raised for twenty minutes to 167 F., instead of the boiling point, 212 F. It is not certain that it is any more digestible than un- heated milk. It does not keep so long as sterilized milk and spoils in one or two days, but it has the advantage of tasting more like fresh milk. Cleansing Milk Bottles. Both sterilized and pasteurized milk should be warmed by placing the milk bottles in warm water without opening them. If the bottles are to be used again they should be rinsed and left standing full of water to which one or two teaspoon- fuls of borax or soda have been added. Before filling with milk they should be washed with a fresh swab and hot soapsuds, rinsed again with boiled water, and kept for at least twenty minutes in boil- ing water, or they may be placed in a steam sterilizing apparatus under pressure. Eubber nipples for infants' bottles should be kept in borax water and rinsed several times daily. Eubber tubing should be discarded. The thermal death point of disease germs in milk has been estab- lished by M. J. Kosenau (U. S. Hygienic Laboratory Bui. 42, 1908) as follows : Bacillus tuberculosis 140 F. for 20 minutes, or in ANIMAL FOODS 101 less time at 149 F., B. diptherice and cholera bacillus, 131 P.; J9. dys- entercw, 140 F. for 10 minutes. Practically twenty minutes' exposure to 140 F. kills all harmful germs in milk, including the Streptococcus pyogenes, the Staphylococcus pyogenes aureus, and the Bacillus coli- communis. There are a few exceptions, however, among spore forms. The Bacillus acidi lactici is also prevented from acting after ex- posure to a temperature of 160 F. It is found that by immersing bottles of milk in water which has just been removed, while boiling, from the fire, a fairly uniform FIG. 18. A MODERN HIGH-CLASS PASTEXJBIZING PLANT. (E. H. Webster, Bui. 41, Hygienic Laboratory.) temperature of 167 F. is obtained. Naturally, the relation between the volume of water used and the quantity of milk should be balanced properly, and various forms of graduated receptacles are sold which make the process very simple. A graduated covered pail, into which the boiling water is poured, is fitted with a rack to submerge enough bottles of milk for the day's use, and this is all that is necessary. After half an hour's exposure to the heat the milk, as in the case of sterilized or pancreatinized milk, is set in a refrigerator until ready for use. 102 FOODS AND FOOD PREPARATIONS Under some conditions both sterilized and pasteurized milk form smaller curds than raw milk, although this is not the case with the coagulae formed by gastric juice (Freeman). The poor in New York city are now supplied with cheap pasteur- ized milk through the philanthropy of Mr. Nathan Straus, who in 1893 opened the first milk depot for dispensing pure milk and pas- teurized milk, at a cost of but one and a half cent for an eight-ounce bottle. A sterilized nipple is also furnished with each bottle. The FIG. 19.^ FREEMAN'S PASTEURIZER. Aj Bottles in position for heating; B, Method of cooling (Holt). bottles have sloping necks, to facilitate cleansing, and spheroidal bot toms to prevent them from being left standing about uncorked (Fig. 19). In an account of this system Dr. Freeman states that: " In addition to pasteurized ordinary milk and pasteurized modi- fied milk, a pasteurized milk diluted with barley water and sweet- ened with cane sugar, and containing also table salt, has been intro- duced at the suggestion of Dr. A. Jacobi. The formula used is : Table salt % oz. White cane sugar 10 oz. Milk 1 gal. Water 1 gal. " This barley milk will be dispensed in six-ounce bottles." There has been much recent discussion as to the effect of continued use of pasteurized milk as a food. The process destroys certain natural milk ferments that aid its digestibility, as well as certain properties of fresh milk which render it resistant to bacterial growth. The acidity of milk is tested by Health Boards as a measure of its purity, owing to the parallelism between the degree of acidity and number of bacilli present, but pasteurization interferes with this test. Thus Berger found 148,000,000 bacteria per c.c. in a specimen of ANIMAL FOODS 103 pasteurized milk that was not acid enough to be condemned. Certain spore forms, mainly of the B. subtilis group, survive pasteurization. 3. Humanized Milk. Humanized milk is really Pasteurized milk with a permanent alkaline reaction and partial predigestion. Leeds claims the credit for the origin of the idea of this form of milk, and his formula is: Milk % pint. Water % " Cream 4 tablespoonfuls. Peptogenic milk powder 1 large measure. Heat to 160 to 170 F. for ten to twenty minutes. Instead of cream, some other form of fat may be added for invalids, such as olive-oil, cod-liver oil or cacao butter. The name " humanized milk " is applied somewhat indefinitely to various preparations of cow's milk in which the attempt is made to approach more nearly the composition of human milk by lessen- ing the casein and increasing the sugar and fat. These prepara- tions are partially predigested, but the pancreatinization is stopped before it has proceeded far, so that the infant stomach shall still have some work to do. Another good mixture designed to resemble human milk is that of Meigs : Cream 2 tablespoonfuls. Milk 1 tablespoonful. Lime water 2 tablespoonfuls. Water 3 Milk sugar % teaspoonful. 4. Modified Milk. Milk Laboratories. The establishment of milk laboratories having in view the object of modifying cow's milk for infant and invalid feeding has demonstrated the practical value of this work. Such milk is now called " modified milk," and the process consists in separating the chief components of cow's milk and re- combining them to resemble their proportions in human milk. Feeding infants with this milk is spoken of as " percentage feed- ing," and e. g., such a formula as 4, 7, 2 refers to the percent- age of fat (4), sugar (7), proteid (2). The first laboratory founded in Boston during 1892-'93, upon the suggestions of Dr. Eotch, com- pletely fed about twelve hundred infants and was patronized by more than one hundred and fifty physicians in its first year. Many similar laboratories subsequently have been established. The milk is derived from carefully selected animals kept at farms where their food, sta- 104 FOODS AND FOOD PREPARATIONS bling, drinking water, and pasture are under the scientific supervision of a veterinary surgeon. It is possible to avoid all variation in milk and keep it at a stand- ard which may be graded to correspond with the increasing age of the infant, by the employment of proper means in the milk laboratories, where milk may be prepared with its ingredients mixed with the accuracy of a medicinal prescription, while its freshness and purity are absolutely insured. If desired also, the milk may be predigested in the laboratory, and sweet whey and other materials derived from fresh milk may be obtained there. Physicians are furnished with blank forms upon which they may prescribe definitely the composition of the milk which they wish to order for any individual case. A sample prescription form from the Briarcliff Laboratory is herewith appended: Per cent. Remarks. Fat Milk sugar Proteids Mineral matter Number of feedings ? Amount at each feeding? Infant's age? Infant's weight? Total solids Water 100.00 Alkalinity. Raw. Pasteurised F. Sterilised F. Ordered for Date Signature M. D. " If the physician does not care to mention the especial per- centage, he can ask for percentages which will correspond to the analysis of human milk, and he can then vary any or all of these percentages later, according to the need of the especial infant pre- scribed for" (Eotch). In order to prepare modified milk by Eotch's method it is neces- sary to have: 1. Pure cream containing the fat. 2. Pure milk con- taining the albuminoids and no fat. 3. Distilled water. 4. A 20- per-cent solution of milk sugar made fresh daily with distilled water. 5. Lime water. The milk and cream are separated by an apparatus (Fig. 20, p. 110) made to revolve 6.SOO times per minute, so that they may be recom- bined in any desired proportion. The resulting cream has an aver- ANIMAL FOODS 105 age of 35 per cent of fat, but the percentage may vary between 45 and 18, hence analysis should be made whenever accuracy is essential. After separation of the cream the milk is modified according to the formula prescribed for each case, and pasteurized. Kotch gives the following sample prescriptions for modified milk to be sent by the physician to the laboratory : I (1) A girl 6 years old: duodenal jaundice. Fat 0.50 Milk sugar 6.00 Albuminoids 4.00 Give 4 ounces every two hours. Send 12 tubes, each 4 ounces; lime water, -j^. NOTE. This patient made a rapid recovery. No medicines were given. ] (2) A boy 6 weeks old: healthy. Fat 3.00 Milk sugar 7.00 Albuminoids 1.50 Send 12 tubes, each 2 ounces. Lime water, ^. Pasteurise at 167 F. Jfr (3) A boy 6 months old: healthy. Fat 4.00 Milk sugar 7.00 Albuminoids 2.00 Send 8 tubes, each 6 ounces. Lime water, ^ Pasteurise at 167 F. I (4) A girl 4 months old: albuminoid digestion weak. Fat 4.00 Milk sugar 7.00 Albuminoids 0.75 Send 8 tubes, each 4 ounces. Lime water, $. Pasteurise at 167 F. ] (5) A boy 6 months old: sugar digestion weak. Fat 3.00 Milk sugar 4.00 Albuminoids 2.00 Send 8 tubes, each 6 ounces. Lime water, ^ . Pasteurise at 167 F. I (6) A girl 4 months old: summer diarrhoea. Food has to be sent out of town by express. Fat 2.00 Milk sugar 5.00 Albuminoids 1.00 Send 20 tubes, each 1 ounce and 1 drachm. At time of each feeding add lime water, 3 drachms. Sterilise at 212< F. NOTE. In this case the diarrhoea had not been sufficiently studied to deter- mine whether it was putrefactive or fermentative, so that a safe general prescription was sent to begin with. The lime water had to be introduced at each feeding on account of the 212 F. sterilisation necessitated by the hot weather and the distance to be sent. 10 106 FOODS AND FOOD PREPARATIONS An ingenious measuring glass is recommended by L. Emmet Holt for the home modifying of milk. The glass, which is sold under the name of the " Materna " (Estraus), holds sixteen ounces and has seven paneled sides. On one side is graduated the quantity of separate ingredients of normal milk and on each of the other panels is graduated the ratio of ingredients of milk modified to suit a certain age of infancy. Milk sugar is placed in the bottom of the glass, water is added to a marked level, then, in turn, lime water, cream, and milk. The formulas given are the following (Holt) : FORMULA. 1. 2. 3. 4. 5. 6. Fat Sugar Proteids. 11 0.6% v&% 6 % 0.8% 3% 6% 1% n 1M% 4% *& For this Formula 6 see special instructions below. 8M% V:'r *%% Milk parts Cream " Lime water " Water Milk sugar " 3d day to 2dwk.to 14th dav. 6th wk. 6th wk. to llth wk. llth wk. to 5th mo. 5th mo. to 9th month 9th mo. to 12th mo. P ? i| 3* 11, 2 2 i !> t 6 2 1 11 Milk parts Cream Barley gruel " Gran, sugar " ? Holt gives the following convenient formula for modifying cow's milk: Starting with milk sugar, one ounce; lime water, one ounce, and water enough to make twenty ounces, add from time to time respectively 2, 3, 4, 5, and 6 ounces of 10 per cent, milk, giving the following percentages: fat 1, sugar 5.5, proteids 0.33; fat 1.5, sugar 5.5, proteids 0.5; fat 2., sugar 6., proteids 0.6; fat 2.5, sugar 6, proteids 0.8; fat 3, sugar 6, proteids 1. According to Eotch, " certain breeds of cows are better than others for copying human milks." List of Breeds best Adapted for Modified Milk, with Analyses (Eotch). Fat. Milk sugar. Albumi- noids. Mineral matter. Total solids. Water. Durham Percent. 4.04 Percent. 4.34 Percent. 4.17 Percent. 0.73 Percent. 13.28 Percent. 86.72 Devon 4.09 4.32 4.04 0.76 13.21 86.79 Avrshire 3.89 4.41 . 4.01 0.73 13.04 86.96 Holstein-Friesian American grades .... Common natives 2.88 4.01 3.69 4.33 4.36 4.35 3.99 4.06 4.09 0.74 0.74 0.73 11.94 13.17 12.86 88.06 86.83 87.14 The Jersey cow may yield more than 6 per cent of fat. " The time of the year, the food and care given to the cattle, the ANIMAL FOODS 107 month of lactation, and manner of milking all exert such a profound influence, that the fat may be lower than 2.5 per cent or as high as 8 per cent" (Major C. E. Woodruff, TJ. S. A.). Milk Foods. Many so-called " milk foods " are sold for infant and invalid use. Their object is to furnish a ready-made substitute for fresh milk, which is easy of preparation even by an unintelligent nurse. Generally speaking, the continued use of such foods, espe- cially for young growing infants, is to be condemned whenever fresh milk is obtainable, but in traveling at sea, or wherever good milk is not procurable, and in other emergencies, they may be resorted to with advantage, until more favorable conditions obtain. Approxi- mate analyses of some of the best known of these foods are appended below, and compared with the composition of mother's milk. NAME OF I^OOD Analysed by. Wa- ter. Sugar. Dex- trin. Starch. Fat 23.39 6.78 5.37 2.96 12.35 1.82 8.30 1.91 Albu- mi- noids. Ash. Solubility in water. Ideal mother's milk... 4 00 46 78 23.39 22.26 18.00 10.75 14.51 18.48 16.88 8 23 2.44 3.90 1.59 3.02 8.66 2.77 3.13 1.59 Very solu- ble. Insoluble. Malted milk Rach. Leeds. Stutzer. 3.27 4.51 5.93 5.80 7.80 2.18 4.72 3.42 7.76 5.17 6.52 46.63 37.47 30.12 63.38 28.66 50.40 38.95 27.08 29.65 28.11 25.52 17.16 4.84 9.14 Nestle's milk food Carnrick's soluble food Lacto-preparata 83.22 38.08 Lactated food 10.33 16.09 85.17 5.57 40.10 Malted milk Nestle's milk food Carnrick's soluble food Lactated food "9". 35 37.37 36.43 41.50 52 92 7.45 1.64 5.53 2 19 10.25 11.85 16.69 9 05 4.42 2.61 3.00 2 26 Soluble. Carnrick's soluble food Lactated food Soluble. Lacto-preparata is a preparation of pure selected milk from which the cream has been removed by centrifugal force, and for it is sub- stituted cacao butter, which keeps better and is quite nutritious. Lime water is then added and the mixture is sterilized, evaporated, powdered, and sealed hermetically in cans. The other foods of the list above given all contain considerable starch, and will therefore be described in the section upon Prepared Farinaceous Foods. (P. 173.) Gustav Gaertner's Mother Milk, according to Theodore Escherich, contains in percentages, albumin, 1.76; cream, 3.0 to 3.5; lactose, 2.5 ; ash, 0.35, thus closely approximating the composition of human milk, except that it has less sugar. The fresh cow's milk is mixed with sterilized water and placed in a centrifugal separator to re- move impurities and separate the superfluous casein, without remov- ing the fat, to form proportions more closely resembling those of human milk. The casein curds of this prepared milk are much more some of the energy may be permanently stored within the body, and 108 FOODS AND FOOD PREPARATIONS flocculent than those of the original cow's milk. By this process the milk also loses a half of the original salts and sugar, but the latter is easily added again when desired. The milk is sealed hermetically in tin cans, in which it keeps fresh for a year or two. MILK DERIVATIVES The principal foods derived from milk which are in common use are: 1. Condensed milk. 2. Cream. 3. Butter. 4. Buttermilk. 5. Cheese. 6. Whey. 1. Condensed Milk. Condensed milk is prepared by slowly evap- orating the water of milk by moderate heat in vacua to the consistence of honey. The first process was patented by Martin de Lignac in 1847, who added cane sugar to the milk and in the United States it was patented by Gail Borden in 1856. In 1879, Nageli of Munich first manufactured unsweetened condensed milk. As commonly made at present, there are two varieties : the " plain," in which the water is evaporated to about 59 per cent, and to which little or no sugar is added; a stronger sort, with which cane sugar is mixed in excess, the water being evaporated to 25 per cent. Such milk yields from 33 to 50 per cent of sugar among its solid ingredients, but some- times more is added. A good deal of the Swiss condensed milk sold in market, as well as that made in this country, contains 40 per cent of sugar. Condensed milk should also contain 10 per cent or more of butter fat. The sugar prevents fermentation and decomposition, and when condensed milk is put up while hot in hermetically sealed tin cans it will keep fresh for years. It will remain fresh for several days after a can is opened. It is soluble in water added to any degree of dilution. Condensed milk is largely used for the nourishment of infants, especially among the poorer classes. They thrive upon it for a time, occasionally even better than on raw milk, and it makes them fat, owing to the excess of sugar which it contains. It does not constipate, and may be slightly laxative. But although such babies may appear robust, their flesh is not firm, they develop poorly, are unable to resist disease, and may become rhachitic. Condensed milk should be diluted ten times for a child a month or two old. and cream should be added in liberal proportion. The formula recommended by Starr is: Condensed milk 3 j 5 Cream f^ ss. ; Hot water f^ ijss. ANIMAL FOODS 109 This milk, when diluted, speedily undergoes lactic acid fermenta- tion and causes diarrhoea and thrush. Condensed milk is serviceable on long voyages and expedi- tions where fresh milk cannot be obtained for use with tea, coffee, etc. Unsweetened canned condensed milk made of fresh Swiss Alpine milk, and sold under various brands in this country, is prepared by evaporation by heat sufficiently strong to render the milk sterile, so that no preservative materials are added. The water is reduced from the normal standard of 88 per cent to about 61 per cent. It is open to the same objections as the use of sterilized milk (see Sterilized Milk, p. 96), but it is better for infants than those forms of condensed milk in which preservation is secured by the addition of too large a proportion of cane sugar. An analysis of one brand of this milk is given by Professor Goodfellow, as follows: Water 61.3 Casein 9.1 Albumin 1.5 Fat 11.7 Lactose 14.3 Salts (mineral matter) 2.1 100.0 Milk may be preserved for some time in hermetically sealed cans or bottles without previous condensation, but a separation of the cream eventually takes place, and butter forms in the can. 2. Cream. Cream is the fat of milk, which, by virtue of its light specific gravity, floats to the top of vessels in which milk is allowed to stand for some hours. The globules collect in a yellow layer of varying thickness. The rise of the cream is retarded by coagula- tion, but favored by a cool temperature and by richness of the milk. The fatty material is complex, and consists of glycerides of stearic, palmitic, myristic, oleic, butyric, and soluble fatty acids. Churning the milk causes the globules of fat to coalesce in small lumps and form butter. It is a popular fallacy that a little warm water added to milk increases the cream formation. It lessens the specific gravity of the milk and hastens the floating of the globules, but the ul- timate quantity of cream is not affected. If the cream falls below 5 per cent of the volume of milk, the milk has been watered. The normal average quantity of cream is over 8 or 9 per cent, but there may be above 20 per cent. The breed, age, and feed of the cow have marked influence upon the quantity of cream. Alderney milk is rich in cream ; Longhorns give proportionately more casein. 110 FOODS AND FOOD PREPARATIONS The milk which comes from the cow towards the end of milking contains more cream than that which is first drawn. This fact should be borne in mind by those who use milk drawn direct from the cow into separate small vessels. Afternoon milk is richer than morning milk in both protein and fat. Centrifugal or Separator Cream. Cream may be separated from milk by centrifugal force. A small and large drum are placed one FIG. 20. CENTRIFUGAL MACHINE. The milk is poured into the square can at the top, whence it flows into the inner porous cylinder. One of the round cans receives the milk, the other the cream, and the cylinder is rotated by the hand crank. within the other, leaving a space of a few inches between. The inner drum is made of porous material. (Fig. 21, d.) It is filled with milk and set in rapid revolution. The lighter cream remains in the inner drum, while the other ingredients are thrown with such violence against the porous wall that they are forced through it into the outer drum. (Fig. 21. c.) Tt is claimed that the cream is more thoroughly separated in this manner than when it is allowed to rise on standing, Ill and the process is far more rapid. Separator cream does not remain fresh so long as that obtained by natural means, for it is separated at a temperature favorable to the growth of bacteria. Separator cream contains from 15 to 50 per cent of fat, according to the quality of the milk used and the thoroughness of the process. The average is about 25 per cent of fat. h FIG. 21. PARTS OF CENTRIFUGE: BOTTLES. a, f, Spouts for milk and cream; c, outer cylinder; d, inner porous cylin- der; 6, e, lids of cylinders; ft, receptacle into which milk is first poured, with tube at bottom leading to inner cylinder; i, j, bottles for delivering milk and cream. Condensed or evaporated cream, which is offered in market, con- sists of about one-fourth cream and three-fourths other ingredients of milk, the whole milk having been evaporated by apparatus. It is therefore a natural product, easily digestible on account of the dilution of the cream with the proteid ingredients of the milk, and, unlike much condensed milk, it is not artificially sweetened. It is sometimes mixed with malt extract. Clotted or Devonshire cream is skimmed from heated milk, so that the albumin is coagulated with it. It is warmed over a slow fire not above 150 F. Fothergill wrote, "Devonshire cream is delicious with preserved ginger, while cream and maraschino form a nutritive drink for the affluent consumptive." In cooking, suet is sometimes added to replace cream and impart additional color and flavor to milk. Cream is one of the most wholesome and agreeable forms of fat. It is often eaten too rich, and may disagree on that account, whereas, diluted with an equal bulk of water or of lime water, it is well borne. For those who cannot digest milk I often prescribe three or four 112 FOODS AND FOOD PREPARATIONS tablespoonfuls of cream in a tumblerful of Vichy, which makes a most agreeable and digestible beverage. It is an excellent substitute for cod-liver oil in pulmonary tuberculosis, for, although not quite so digestible, most persons prefer to take it. It is an excellent food also in long-continued suppurative diseases, such as empyema or tubercular joint diseases. It should be avoided in flatulent dyspepsia, in most forms of gastric disease, obesity and gallstones. It is useful as a substitute for milk when diarrhoea or maras- mus, etc., occurs in infants. It should be diluted considerably when so given. The addition of strong liquors to cream lessens its digestibility just as heat does, for alcohol coagulates and toughens the proteid envelopes of the fat globules. Ice cream was invented by a Neapolitan named Florin about 150 years ago. It is a frozen product of cream, sugar and flavoring ma- terial, and should, contain 14 per cent of cream. When very simply made, it is nutritious, and may be allowed many patients. It is sooth- ing to inflamed throats and enjoyed by convalescents from fevers, and children who object to milk will often take it. It should be eaten very slowly, so that it may become well warmed in its passage to the stomach ; otherwise it retards digestion. It is often adulterated with eggs, farina, etc. 3. Butter. Butter is made from cream by the mechanical agita- tion of the fat globules, which are thus made to adhere together in small masses. The rupture is accomplished by churning, and after the butter is of sufficient density, salt in small proportion is added, and the butter is "worked" over with a spatula and frequently washed. Butter contains on the average (according to Farrington and Woll) the following percentages: Water 13 Fat 80 to 83 Proteid and lactose 1 Salt (added) 3 The volatile fatty acids (see p. 55) impart to butter its taste and odor. The quantity of casein in butter may roughly be estimated by melting a specimen in a test tube, when the casein forms a layer at the bottom. Butter should not have less than 0.5 to 2 per cent nor more than 8 per cent of salt added. Perfectly fresh butter made without salt is comparatively tasteless and keeps poorly. The decomposition of its ANIMAL FOODS 113 proteid liberates a ferment which separates fatty acids and glycerin. Fresh butter if kept too long, especially in hot weather, soon becomes rancid, bitter, and unwholesome. Fresh butter is commonly preferred throughout southern and middle Europe. Butter is adulterated by dealers by beating it up with water and by adding other fats, especially suet and oleomargarine. The sophis- tication with water is easily detected by melting, when the sample separates into two layers. Butter which contains too much water and too many ingredients other than the fat has not been sufficiently " worked," and is also likely to become rancid and cause violent gastric derangement. Very thorough washing of butter when first made will remove much of its proteid substance and tend to prevent its fermentation; and fresh butter which has once become rancid may be rendered less so 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 grams per kilogram postpones or prevents the fermenta- tion, and sugars or sirups in which the butter may 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. Pure fresh-butter fat is not crystalline, but old or rancid butter fat becomes so. Strong-tasting butter is not necessarily unwholesome, for the flavor- may have been derived from the cow having fed upon dead leaves or turnips, and butter is more sensitive than milk in transmitting unpleasant flavors. Butter will not support life for any length of time when taken alone, although 100 grams (3*4 ozs.) furnish 837 calories. Garni vora fed upon an exclusive diet of meat and fat do not grow fat, there- fore the original Banting treatment for obesity (see Obesity) has been modified by Ebstein and others by the free addition of butter to the diet. Taken in connection with other foods, however, butter is a highly digestible and nutritious food, and it has been wittily said that "if bread is the staff of life, butter is its golden head." For 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 a man- ner which coats the food and walls of the stomach and retards gastric secretion. Most persons eat about an ounce a day of butter, but many 114 FOODS AND FOOD PREPARATIONS 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, page 228. 4. Buttermilk. Buttermilk is the residual milk Jef t after churn- ing and removing the fat. It is wholesome 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 into lactic acid. The chemical analysis of buttermilk is thus given by Farrington and Woll: Water 91.0 Lactose and lactic-acid 4.0 Casein and albumin , 4.0 Fat 0.3 Ash 0.7 Its fuel value is about that of skimmed milk 165 calories pei pint and its composition resembles skimmed milk, but it contains a little less protein and carbohydrate and a little more fat. A pint of it contains as much nourishment as two ounces of bread or a large potato. 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 protein and fats is poor it may be borne better than milk. It is of especial value in chronic gastric catarrh with atrophy of the gastric glands (Eulenburg). A "buttermilk cure" is sometimes practiced after the manner of the "whey cure" (see' Dietetic "Cures"), but buttermilk cannot long be depended upon as an ex- clusive diet. (For artificial buttermilk, see Lactone, p. 93.) 5. Cheese. Cheese is composed of the casein of milk separated by rennet, together with some of the fat and salts. 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 proteid element of their diet, and, weight for weight, cheese contains about twice as much protein as meat. They use for this purpose the heavier, less highly flavored cheeses. The wealthy classes eat cheese more as a condiment, taken after meals, and therefore they require higher flavored 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 coagulas in the stomach. Old " poor " cheese i. o., cheese made without fat, consisting of almost pure casein ANIMAL FOODS 115 is difficult to masticate thoroughly, and is slowly dissolved in the gastric juice, hence it is slowly digested. It may act as a gastric irritant and be hurried into the intestine to excite indigestion there. Such cheese may be rendered more digestible by cooking it after grating with bicarbonate of potassium in the proportion of a quar- ter of an ounce to the pound of cheese. About 250,000,000 pounds of cheese are annually produced in the United States alone, and much so-called " foreign " cheese is pro- duced in this country. There are upwards of 150 varieties of cheese made in different countries, but a few only of the better known kinds may be mentioned within the limits of this work. In general the properties of cheeses depend upon three main factors: (1) the quantity of water that they contain, which chiefly determines their hardness or softness ; (2) the quantity of fat present, which in skim cheeses is reduced and in cream cheeses is increased, as compared with the normal fat content of milk; (3) the kind and degree of fermentation proc- esses upon which the flavor largely depends. Many additional fac- tors, however, enter into successful cheese-making, and the skill with which they are applied determines the success of the final product. Such for example are the varied temperatures employed in manu- facture, the method and degree of fragmentation of the curds, the mixture of milk and cream of different grades of fermentation, the pressure applied, the frequency of turning to expose successive sur- faces, the scraping of mold from the surface, polishing, bandaging^ the duration of "curing" or "ripening" and the temperature and degree of moisture at which it is applied, the nature of the molds and bacteria which are introduced, etc. The quality of cheese largely depends upon the richness of its fat. In the richest cheeses made of whole milk, such as Stilton, double Gloucester, Gorgonzola, Edam, Cheshire 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. Fat separates the flocculi of casein and makes eheeses soft, friable, and rich, but they sooner decay. The varieties of cheese differ in percentage composition, but in general they may be said to contain from 35 to 55 per cent 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. 116 FOODS AND FOOD PREPAEATIONS Cheese is usually prepared from sweet milk. The coagulation is accomplished in a few minutes to a few hours by the addition of the ferment rennin with gentle heat (120 F.). The heat secures firmer coagulation. Casein also may be coagulated by acids. A little salt is added; the curd is strongly pressed in a mold, and the expressed fluid is called "whey." The curd is then salted and dried on the surface by frequent 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 odor and flavor. The casein also undergoes change, and is partially converted into fat. It may putrefy and evolve ammonia, or become poisonous. Eipening, when not carried too far, makes cheese more friable, and hence more digestible. Cream cheese is fresh, and usually not ripened. Pot-cheese, Dutch or Cottage cheese, is made from the curds of sour milk or buttermilk and is produced by natural lactic-acid fermen- tation and heat. It is squeezed dry, salted, and eaten with cream, butter or spice. 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. Whey cheese is made from mildly sour whey evaporated by boiling, and with addition of cream. It is eaten in Scandinavia. American cheddar is manufactured from whole milk heated to 86 F., to which rennet is added. According to Farrington and Woll its percentage composition when fresh or " green " averages : water, 37 ; fat, 34; casein, 24; lactose, lactic acid and ash, 5. The milk al- bumin is not precipitated by rennet. In " curing " or drying, the cheese loses about 3 per cent of water, and peptones, amids, etc., de- velop in the curd. The two soft cheeses most used in this country are Camembert and Brie. Camemlert is a cheese made of whole milk, which is very care- fully dried under regulated temperature. It is covered with a dark red mold, and the interior acquires a moist creamy consistence. The rennet fermentation is conducted at a low temperature and is con- sequently a slow process. The curd is not broken, but placed in molds to drain, and is frequently turned. The curing occupies some- ANIMAL FOODS 117 what more than a month in a cool, damp cellar. This cheese, as well as the following variety, is made in St. Lawrence County, Pa., as well as in Europe. Brie is manufactured in three grades of richness, according to whether the milk is whole, partly skimmed, or skimmed. The curing results in softening the casein to a moist, almost creamy consistence, and imparting a typical rich flavor. Putrefactive molds develop on the outer surface. Neufchatel is made by rennet. The curd is uncured, soft, and faintly acid. In taste it resembles slightly acid clotted milk, and it should melt at the mouth temperature. Limburger is commonly manufactured from unskimmed milk by the agency of putrefactive bacteria. It has a pungent taste and strong odor of putrefaction. Its color is reddish yellow. In ripen- ing the cheese softens from the outside inward. Sage cheese is a common American variety to which an infusion of leaves of the sage plant imparts their flavor and a greenish color. Pineapple cheese is a very firm variety of an orange color, pressed in a mold to resemble the pineapple fruit. Stilton is derived from fresh sweet milk with rennet. The curds after straining and drying in cloths by a squeezing process are al- lowed to sour. Curds of different ages, and degrees of sourness are mixed together, salted, and drained in perforated cylinders. A white mold coats the surface. The curing occupies several months. The cheese is somewhat soft, faintly yellowish within, but gray on the surface. The cut surface is irregularly marked with mold. Cheshire is a well flavored granular, soft English cheese manu- factured from ripe whole milk, although skimmed milk and cream of different ages are mingled. The curd is ground, salted, colored, and allowed to ferment in perforated cylinders, like Stilton, in which it acquires a white mold. The curing process requires about a month. Roquefort is a hard cheese made in the department of Aveyron, France, from goat's milk, partly skimmed and coagulated with rennet. 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 mold which grows on stale rye bread. This cheese is also made along the shores of the Great Lakes in this country, where conditions of climate, pasturage, and water favor its production. Swiss cheese or Schweizer of which Emmenthaler is a type, is 118 FOODS AND FOOD PREPARATIONS a firm, friable, pale cheese, perforated with small holes uniformly distributed, which are due to gases of fermentation developed by curing. The rennet curd is cut into fragments and heated to 140 F. It is subsequently bandaged and pressed. Edam is a hard, dark red, Dutch cheese, shaped like a cannon ball and made from sweet skimmed milk. The curd is forcibly broken into minute fragments, warmed to 85 F., drained, pressed in spherical molds, salted by dipping in brine, and rubbed. A white mold covers them during the month of curing. They are finally cleaned, dried and coated with linseed oil, a dark red pigment, and tinfoil. The flavor of this cheese improves continuously for six months and more. Gruyere was originally a hard Swiss cheese, but is now made also in France and elsewhere. It is dry, aerated with large holes, and it may 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 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 mold called "parsley " grows and imparts a high flavor. The curd is hung in hempen cloths to ferment. It is well salted. In the United States much of the cheese manufactured is of the common sort called " American cheddar," but Neuchatel, Stilton, pineapple, and other more highly flavored varieties are also exten- sively produced. " Swiss " cheese is made in Ohio and Wisconsin. An imitation cheese is also prepared from a mixture of one part lard and two or three parts milk, mixed or emulsionized at 150 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 " made of melted cheese with butter and beer added, are difficult of di- gestion, although 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, molds, fungi, etc., flourish in cheese and make it very irritant to the stomach. Such are the Aspergillus glaums and Sporendoncum casei, both of which give a red color, the cheese mite (A earns domesticus) and the maggots of a fly (Piophilia casei). Bnd cheese lias been known to produce poisonous symptoms ANIMAL FOODS 119 (see Ptomaine Poisoning) resembling those of poisoning by sausage meat. Cheese food, devised by J. J. Angus, is made from cheddar cheese, ground and mixed with evaporated whey. It is then compressed into cakes, and forms a soft mass with mild flavor. Plasmon is an albumin food made from milk from which the fat has been removed. It is practically a dried form of casein. It is a tasteless, odorless, white, dry powder, soluble in water. It may be given every hour or two in teaspoonful doses in ten tablespoonfuls of water, or with an equal quantity of sugar an ounce of plasmon may be stirred into half a pint of boiling milk. It may be added to broths and gruels, or to such starchy foods as boiled rice or mashed potatoes. This food contains over 90 per cent of pure protein in very digestible form. Plasmon biscuits and a plasmon chocolate are also manufactured. Nutrose or casein-sodium is a form of milk casein which may be added in half-ounce doses to broths, gruels, or cocoa, in which it is soluble. It contains, according to Bruno Oppler, about 90 per cent of pure protein. It furnishes a lessened volume of feces when this is desirable after operations upon the intestines. Sanose is an albuminous food consisting of 80 per cent of powdered casein and 20 per cent of egg albumen. It is a white, odorless, tasteless powder forming an emulsion in water. It may be given in milk, cocoa, purees, or soups. From two to six tablespoonfuls may be given daily. 6. Whey is derived from the milk of several animals, such as the sheep, goat, mare, and ass, as well as the cow. When milk has been standing for some time in the air it becomes contaminated with bacteria, which cause spontaneous coagulation, and whey is squeezed out of the contracting clot; but this is sour and not so good as that made by rennet. As ordinarily prepared whey is the residuum of milk from which the casein and fat have been squeezed out as cheese by the coagulating action of the ferment rennin. According to Farrington and Woll it possesses the percentage com- position: "\Vater, 93; lactose, o; albumin, 0.8; ash, 0.6; fat, 0.3. Hence it is practically an aqueous solution of milk sugar, whitish, translucent and opalescent. It is liable 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 bv invalids. In Europe several " whey cures "' have been established 120 FOODS AND FOOD PREPARATIONS for the treatment of renal disease, dropsical affections, etc., but whe} r is not in any case a specific, and its dietetic value is greatly overrated. (See Whey Cure.) 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 will go into whey. Add beef tea or milk juice, or egg yolk in hot water. Wheyn is a patented beverage made from a sour whey, sometimes treated with hops, or charged with carbonic acid. Eggs About nine billion eggs are produced annually in the United States and in 1907 the total value of the poultry and egg product of the United States was estimated by the Secretary of Agriculture at $600,000,000, exceeding that of wheat. 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 on some birds feathers are developed previous to hatching. The in- ner portion of the shell is dissolved by phosphoric-acid to furnish phosphates for the bones. The average weight of a hen's egg, according to Bauer, is 50 grams, or about 1% ounce, divided as follows: Shell, 7; white, 27 ; yolk, 16 grams. The eggs of pullets are smaller than those of old hens. Hens' eggs principally are used for food, but the eggs of ducks, geese, and guinea-fowl are eaten also, and occasionally those of such wild birds as the plover and sea birds. The eggs of these various species of birds have their distinctive flavor. Along the Texan coast the eggs of gulls, terns, and herons were formerly gathered for food, those of the gull and murre on the Farallone Islands off the coast of California, and those of the laughing gull off the eastern coast of Virginia. Terrapin eggs are eaten together with the flesh of the animal, and various forms of fish eggs are esteemed for food, as those of the sturgeon (caviare) and shad roe. The shell of a lien's egg weighs about one hundred grains. Its color boars no relation to the nutrient value of the egg, but white shells are heavier than brown. An egg consists approximately of ANIMAL FOODS 121 Shell 1 1 parts Carbonate of lime. Yolk 32 parts: Proteid (vitellin) 15.7 per cent. Fat 33.3 " Ash 1.1 Water 49.5 Total calories 1,705 White 57 parts : Proteid 12.3 per cent. Fat 2 " Ash 6 Water 86.2 Total calories 250 The yolk is very complex. Besides the proteid vitellin, it con- tains three fats, coloring matter, nuclein, lecithin, and salts of iron, calcium, magnesium, and potassium. Egg albumen is not pure, but consists of four albuminoid and mucoid bodies, the chief of which is oval- bumin, together with a trace of carbo- hydrate. The phosphorus equivalent is 0.03 per cent phosphoric acid (C. P. Lang- worthy), whereas that of the yolk exceeds 1 per cent. If the absorption of eggs from the in- testine is delayed, decomposition ensues with production of sulphuretted hydrogen and ammonia, which cause considerable en- teric disorder. The yolk of egg is partic- ularly responsible for this. It is therefore a matter of great importance to serve only . . , , , , , , , . , . , FIG. 22. DIAGRAM OF A eggs which are absolutely fresh to invalids. HEN'S EGG SHOWING THE No egg having an odor of stale, old straw PROPORTION OF INGREDI- ENTS should ever be offered. There are two sim- ple methods by which the nurse may test the freshness of an egg: 1. Hold the egg between the hands so that the light of a candle shines through it. If fresh, it is more transparent in the center; if stale, at the poles. 2. Make a solution of two ounces of common salt in a pint of water. An egg one day old will sink in this solution, but will not quite reach the bottom; an egg three days old will barely float be- neath the surface, and an egg a fortnight old will float above the surface, only partially dipping beneath it (Siebel). This difference is due in part to loss of water, which after ten days equals 1.60 per cent; after twenty days, 3.16 per cent; and after thirty days, 5 per cent. It is also due in part to development of gases of putrefaction. 122 FOODS AND FOOD PREPARATIONS With some persons eggs have a slight aphrodisiac effect, and they also promote costiveness. They should not be eaten in cases of flatulent dyspepsia, gastric dilatation, or any form of severe gastric derangement. The flavor of eggs is modified by the food of the hen, those from hens fed on nitrogenous food instead of carbohydrates have poor odor and flavor and small yolks. An excess of onions in the hen's diet imparts the strong odor and taste of the vegetable to the eggs laid about fifteen days after such food has been eaten. Eggs packed in stale bran or straw, or kept near decaying apples, acquire a bad flavor. Microorganisms may penetrate the eggshells and give rise to fermentation and decomposition. Raw Eggs. Whole raw eggs are very popular in dietetics at present, and they are often prescribed when a nutritious, highly con- centrated diet is desired, and in cases of tuberculosis, some forms of amemia, and various wasting diseases; sometimes from eight to ten or twelve are given daily if they can be digested. They may be advantageously combined for such purposes with milk and salt or cod-liver oil, meat broths, soups, and purees. Beaten white of egg may be added to coffee, cocoa, wine, cream, or sweetened water. Eggnog is very nutritious, and is extensively prescribed in some non-febrile diseases, especially for the forced alimentation of phthisis, neurasthenia and melancholia, and there are occasional cases of bilious habit in which eggs only can be digested when beaten in wine, but the combination of egg, milk, and sugar with alcohol, which con- stitutes eggnog, may produce nausea and vomiting in a feeble stomach, particularly in fever. Egg albumen, when eaten raw or almost raw and properly diluted with milk or water, is well absorbed. It also may be predigested, and it should be flavored with lemon juice, or sherry or other wine, coffee, cocoa, or cream, and sweetened water; otherwise it is taste- less and disagreeable, and but few can continue to eat it in any con- siderable quantity. (See Eeceipts, Preparations of Eggs.) When the fresh white egg albumen is beaten it encloses bubbles of air which expand by heat when the albumen is mixed with dough, mak- ing it porous, as in the case of sponge-cake. Old eggs lose this quality of frothiness. Egg albumen is used by Ewald to prepare fresh albuminate of iron. He adds two tablespoonfuls of a solution of one part of white of eo-cr jn two of water, to a teaspoonful of a 2 or 3 per cent solution of ferric chloride.' To be taken through a tube. Albumen water is used as a beverage in fevers. The whites of two or three eggs are beaten with lemon juice in a half pint of water. As ANIMAL FOODS 123 the white of one egg furnishes only 15 calories, it does not supply much nutriment. The Cooking of Eggs. Albumen, or the " white " of egg, is altered physically but not chemically by processes of cooking. At about 134 F. delicate fibrillae of coagulated albuminous material begin to stretch through the substance, and they increase with the temperature up to 160 F. The fibrilla? are so numerous that the entire mass is coagulated, but is still of a soft or gelatinous consistence. If the coagulated albumen is heated still further, it becomes more and more dense, hard, dry, and brittle. When heated beyond the boiling point, or 212 F., it forms a very tenacious, gluey substance, which can be used as a cement for mending broken china. Eggs baked in puddings or in any other manner form one of the most insoluble varieties of albumen possible. A raw egg is or- dinarily digested in the stomach in one and a half hour, but a baked egg requires from three and a half to four hours. Eggs cooked for persons with delicate digestions, instead of being "boiled" in water at 212 F., should be placed in water at a tem- perature between 170 and 180 F., and immersed for fully ten min- utes, at the end of which time they will be found of a uniform gelatinous consistence, very palatable, and not too tough to be readily acted upon by the gastric juice. If a cooking thermometer is not at hand, the water may be brought previously to the boiling point and then set aside, when in a moment or two it will cool to the proper temperature. This should be a little above the coagulation point of the egg albumen (134 F.), because the process of rais- ing the temperature of the egg is a slow one, and the water loses heat in warming the egg (Williams). Eggs cooked in this manner are found to have the yolks more firmly coagulated than the white, which remains quite tender. A practical way of attaining the above result is to pour a quart of recently boiled water over two eggs in a bowl and let them stand for ten or twelve minutes. Another excellent way to cook an egg, as suggested by Henry, is to immerse a teacup in boiling water until it becomes thoroughly heated. It is then removed and the egg is broken and dropped into it, and the cup may be wrapped in a cloth. Sufficient heat is retained by it to cook the egg without water and remove any raw taste. The yolk really coagulates at a lower temperature than the white, although as eggs are commonly cooked it does not have an oppor- tunity to coagulate first. The yolk is composed of albumen and casein with fat. In the ordinary rapid cooking of eggs in boiling 124 FOODS AND FOOD PREPARATIONS water the white is firmly coagulated before there is time for the temper- ature of the interior of the egg to be raised thoroughly, and conse- quently the yolk is softer than the white. The shell of the egg facili- tates the process of slow cooking of the albumen by protecting the in- terior and preventing the escape of the contents by solution, just as in the cooking of fish or flesh in water, the latter should be hot enough immediately to form an external coagulum of albumen sufficiently dense to prevent the diffusion of albuminous material and salts into the water. Custards composed largely of eggs, although unfit in active fever, are very useful adjuncts to a convalescent dietary in recovery from typhoid fever or other acute diseases. In the making of omelettes and " scrambled " eggs the white is thoroughly mixed with the yolk, and the egg is more digestible than when fried or cooked so much that the albumen is hard. Preservation of Eggs. Eggs decompose from the admission of germs through their porous shells. To prevent this occurrence it is necessary to protect the eggs from contact with air. When first laid, eggs have a protective mucilaginous coating, which is, how- ever, removed by washing. They may be coated with varnish, par- affin, tinfoil, butter, glycerin, vaseline, or any fat or oil not liable to become rancid. A 2 or 3 per cent solution of salicylic acid may be added to the oil. Packing in sawdust or bran also excludes the air to a slight extent. Lime with cream of tartar preserves eggs when coated with it, but alters their taste. According to C. F. Langworthy (U. S. Department of Agricul- ture Bulletin No. 128) the best preservative substance is a 10 per cent solution of water-glass, in which eggs will keep fresh for three and one-half months. Eggs also preserve their freshness for as much as a year in cold storage at 30 to 40 F. Eggs so stored should be turned twice, a week to prevent gravitation of the yolk, causing its adhesion to the shell. Eggs are also preserved by drying, canning, and similar processes, when designed for shipment upon long voyages. Evaporated or desiccated eggs are dried in vacua or otherwise by currents of warm air. Salt or sugar may be added, and the eggs are ground. Such eggs keep well, and often are used by bakers. Meats The Consumption of Meat. The universal consumption of meat l>y civilized man is of more recent origin than is generally supposed. McCulIooh states (Statistical Account of the British Empire, vol. ii, ANIMAL FOODS 125 p. 502) that "so late as 1763 the slaughter of bullocks for the supply of the public markets was a thing wholly unknown even in Glasgow, though the city had then a population of thirty thousand." In the past decade or two the consumption of meat has increased enormously, especially in England, owing to the development of cheap refrigerating processes, canning, and increased facilities of transportation of live cattle. The beef from Australian and New Zealand cattle is obtainable in London, and that of Texan cattle in Xew York in a state of perfection and cheapness which exceeds that of animals raised close at hand. There is a popular belief that the eating of meat increases both bodily vigor and mental capacity, and that a man fed upon animal food is livelier, keener, and stronger than the exclusive vegetarian. (See Animal and Vegetable Foods Compared, p. 29.) This comparison may not hold in all cases, nor with all people and tribes of man as, for example, the Japanese and many African tribes but it applies very well to those who have to meet the exigencies of advanced civilization. Liebig, in extolling the advantages of a liberal meat diet, wrote : " It is certain that three men, one of whom has had a full meal of meat and bread, the second cheese or salt fish, and the third potatoes, regard a difficulty which presents itself from entirely different points of view." It is true, however, that too much meat is eaten by many persons for maintenance of the best health. The annual per capita consump- tion of meat has almost doubled during the past half century. It is estimated in pounds as follows : In the United States, 147 ; England, 100; France, 77; Germany, 64; Russia, 50; Italy, 24. Very large quantities of meat much more than is necessary for sustenance are absorbed when eaten, although a few undigested muscle fibers may appear in the stools. An exclusive cooked meat diet, if long continued, tends to pro- duce scurvy, and on the other hand the prolonged absence of meat favors the occurrence of anaemia in many persons. In general, those diseases in which an exclusive meat diet, or a diet composed almost exclusively of animal food, with perhaps a minimum of dry bread, is found temporarily beneficial, are the following: Flatulent dyspep- sia, chronic gastritis and gastric catarrh and dilatation, diabetes, intes- tinal dyspepsia, phosphaturia, obesity, and some cases of chronic dys- entery. Meat should also enter largely into the diet of consumptives and anaemic subjects. It is well to prohibit the consumption of meat in fevers, acute and advanced chronic Bright's disease, acute gout and rheumatism, and to reduce it in lithgemia and oxaluria. 126 FOODS AND FOOD PREPARATIONS FIG. 23. A PIECE OF BEEF MAGNIFIED. (U. S. Dept. of Agri., Bui. 56, Office of Expt. Sta- tions.) Structure and Com- position of Meats. Meat from any animal is composed of muscu- lar fibers, but it neces- sarily contains those structures which were intimately associated with them, such as connective tissues, blood vessels, nerves, and lymphatic vessels, and more or less adi- pose tissue. Meat which is very fat con- tains comparatively little water as well as less proteid than lean meat. The toughness of meat is due to thickness of the walls of its muscle tubes and excess of connective tissue bundles associated with them, which latter is thicker in older animals than in young. Tough meat may be made more tender by pounding, to soften the connective tissue. (Fig. 24.) The flavor of meat varies with the ani- mal's age, its food, breed, and condition when killed. The meat of male animals (ex- cepting pigs) is usual- ly higher flavored than that of females. Meats contain al- buminoids and gela- tinoids. The latter, through action of hot water or steam, arc converted into gelatin. Meat " extractives/' ., . FIG. 24. BEEF FIBERS HIGHLY MAGNIFIED. nitrogen extractives. /T , * * T> i -o r\az t ^ (L. S. Dept. of Agn.. Bui. 06, Office of Expt. or "meat bases." as Stations.) ANIMAL FOODS 127 they are variously called, are cleavage products of albuminoids and gelatinoids, soluble in water and alcohol. Their special use in dietetics is described on p. 140. The following table (condensed) by Atwater and C. F. Lang- worthy gives the average chemical composition of various meats. It should be stated that the different cuts of meat from the same animal present slight differences in relative quantities of fats, pro- tein, etc. : Composition of Meats (Atwater and Langworthy). Water. Protein. Fat. Calories per Ib. 43 8 13.9 21.2 1,135 52 4 19 1 16 1 975 68 3 20.1 7.5 695 51 2 15 1 14.7 890 Mutton chops 42 13 5 28 3 1,415 52 9 15 9 13 6 860 41 8 13 4 24 2 1,245 Hani snioked 34 8 14 2 33 4 1,635 Bacon " . . 17 4 9 1 62 2 2,715 Sausage Frankfort 57 2 19 6 18 9 1,155 Beef soup 92.9 4.4 0.4 120 Chicken (fowl) . 47 1 13 7 12.3 765 Goose 38.5 13.4 29.8 1,475 Turkey 42 4 16.1 18.4 1,060 Duck 51 7 14 3 33.4 1,805 Squab .... . 58 18 6 22.1 1,430 Guinea hen 69 1 23 I 6 5 870 Quail f 65 9 25 6 8 935 When animals are first slaughtered the meat is tender and juicy, but it is seldom eaten in cold climates, before rigor mortis has set in, a process which is followed by a slow decomposition, during which the meat becomes more tender. This process, which occurs when meat is "hung" for a time, is due to development of lactic acid, which softens the connective tissue. The flavor of the meat is at the same time enhanced. Raw Meats. There is a prevalent fashion of prescribing raw meat, and in some diseases, such as dysentery or chronic gastritis, it is useful, but it should not be given with the idea that it pos- sesses any special curative virtue from the fact of being raw. Beef, . mutton, and ham are all eaten in this condition. Meat is distaste- ful to most persons in this state and soon palls upon the appetite, and may excite positive loathing. There is a natural aversion to raw flesh among even the lowest tribes of man, who only consume their meat raw from excessive hunger or when fire is unobtainable. 128 Even the primitive Australian savage cooks his reptiles and worms. Eaw meat has no advantage either in digestibility or nutrient power over moderately cooked or " underdone " meat. In fact, Uffelman, experimenting with a boy having a gastric fistula found that he di- gested raw scraped beef less quickly than roast beef, but Eiibner maintains that raw beef is more quickly but less completely digested than cooked beef. Such discrepancies of statement are due to the fact that the difference in any case is very slight, and easily reversed by extraneous conditions. See Digestion of Proteids in the Stomach, p. 389. Some danger has been attributed to eating raw meat on ac- count of the possibility of acquiring intestinal worms through it, but the fear of this is much exaggerated. On the other hand, meat is easily altered and made innutritious by prolonged cooking. Overdone meat is indigestible and tasteless, and if meat is too long boiled it becomes insipid and useless as an aliment, and the resulting soup is not a full substitute for it. Digestibility of Meats. Among the conditions which affect the digestibility and nutrient power of meats are the age at which the animals eaten were killed, and the care bestowed upon them in feeding, shelter, and transportation. Animals which have been underfed, ill- treated, and worried yield very inferior meat. Almost all meat is tougher immediately after killing, and im- proves on being kept for a day or two. Meat should never be cooked during rigor mortis. Violent exercise is believed to increase the tenderness of the meat of hunted animals. In general, the flesh of young is more digestible than that of old animals, provided they are not still suckling. When as much as two pounds of roast beef are eaten daily, all but 3 per cent of its dry matter and 95 per cent of its fat is com- pletely digested, so that such a heavy proteid diet leaves very little residue. It would be convenient if meats and animal foods of all kinds could be arranged in a table of comparative digestibility, but such tables are necessarily inaccurate, if not actually misleading, owing to the great variations produced by the character of the particular samples of food used, by the time and manner of cooking, by the condition of the digestive organs, and by personal idiosyncrasy. No two tables of this kind given by different authors are found to agree in all respects. There are several reasons for such discrepancy. In the first place the alimentary canal is not a test tube and laboratory experi- ANIMAL FOODS 129 ments cannot be made to reproduce in all respects the phenomena of digestion. Secondly, the disagreeable act of passing a stomach tube in man to determine food residues after ingestion of a meal may itself inhibit digestion through anticipation. Thirdly, there is much truth in that " digestion waits on appetite," and the person who dislikes salt pork, yet is made to eat it in a digestion experiment is far less likely to completely digest it than one who is fond of it. At one time a person may digest certain foods completely, and promptly, which at another, from trivial causes, entirely fail of digestion. Fourthly, there is marked difference between prompt and complete digestion. Of two persons in health one may digest a given food very promptly and another require half an hour or an hour longer, yet in both the process may be ultimately complete. Finally in some persons stomach digestion is relatively more complete than in others, in whom a major part of the process takes place in the intestine, but of course food residue experimentally withdrawn during diges- tion, by means of the stomach tube, can only represent the gastric phase of the process. For these reasons the following tables are not to be regarded as in any sense infallible, but merely as affording a general guide to which there must be many exceptions. (See Duration of Digestion in the Stomach. Table of Comparative Digestibility (commencing with the Most Digestible, and ending urith the Least Digestible Common Animal Foods). Oysters. Eggs, soft-cooked, scrambled or omelette. Sweetbread. Some fish, boiled or broiled, such as white fish, shad, red snap- per, weakfish, smelt. Chicken, boiled or broiled. Lean roast beef or beefsteak. Mutton, roasted or boiled, chops. Squab, partridge, quail. Bacon (crisp), lean ham. Roast fowl, chicken, capon, tur- key. Roast lamb. Young venison. Liver. Corned beef. Veal. Salmon, mackerel, herring, blue- fish. Duck, goose, and game. Lobsters and crabs. Pork. Smoked, dried, potted or pickled fish and meats in general. The table given below is published by E. Jessen as the result of giving test meals of single meats. The stomach was first cleansed and emptied by siphonage, then a hundred grains of meat were introduced with eight ounces of water. Samples of the digested stomach contents were from time to time withdrawn, and the com- plete disappearance of all muscular fiber when examined by the mi- croscope occurred as follows : 11 130 FOODS AND FOOD PREPARATIONS Beef, raw, chopped fine 2 hours. Beef, half cooked 2% Beef, well cooked 3 Beef, thoroughly roasted 4 Mutton, raw 2 Veal, cooked 2% Pork, cooked 3 These estimates fall somewhat below those of other writers, and for comparison Jessen gives the time for digestion of six hundred cubic centimeters of raw cow's and goat's milk as three and a half hours, and that of boiled milk as four hours, which is too long. H. S. Grindley states as a result of 99 digestion experiments on man (TJ. S. Dept. Agriculture, Bui. No. 193) that red beef is not less digestible than fresh pork, nor do the different cuts of meats vary in digestibility. He found that 80 per cent of meat pro- tein is digested within an hour, and 90 per cent within two hours, whatever the variety of meat, or method of cooking. This is an average, but individuals presented variations and contradictory re- sults at times, as compared with each other. As an average result of 44 other experiments with different kinds of meats ingested 98 per cent of protein and 98 per cent of fat was digested, and dif- ferences in the meat itself or in its cooking, were " too small to reckon," fat meat being as well digested as lean. Gigglberger found, as a result of feeding patients with test meals and withdrawing the stomach contents through a tube, that meat requires from two and a half to five and a half hours for gastric digestion, according to its quality, method of cooking, etc. Stewed meats need less than roasts. Pork and very fat meat may require four or five or more hours, and veal needs 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 wild birds, such as ducks, may require four hours. These are longer periods than other authors give. Composition of Beef. The composition of beef varies with the * feeding of the animal. A young steer from two and a half to five years old furnishes the best meat. If the animal is lean the meat may yield from 70 to 75 per cent of water and about 20 per cent of nitrogenous material, furnishing about 415 calories per pound, with 2 or 3 per cent of fat ; but if very fat when killed, the percentage of both water and nitrogenous material is considerably reduced, while that of the fat may be as high as 25 per cent, or more. As a general average, one-third of beef is nutritious material, the remainder is water and bone. ANIMAL FOODS 131 Beef fat is composed of glycerides of fatty acids. It melts at from 106 to 122 F. Stearic and palmitic acids are present in the propor- tion of three to one of oleic acid. The equivalent of beef is sometimes stated in terms of other foods. A pound of lean beef is believed to equal in nutrient value two and a half pints of milk, half a pound of bread, and about three eggs, but these are only approximate figures. Lean beef on an average contains 4 to 5 times the percentage of protein found in milk, and beef con- tains less protein than game birds and more than fish. Fresh beef may be eaten longer continuously than any other kind of meat. In this respect it resembles bread and rice. Attempts have sometimes been made on wagers to eat quail or partridge three times a day consecutively for a month, but disgust is sure to follow after a week or two, no matter how much such food is varied in the cooking, and by the end of a month it may excite extreme loathing, and even nausea and vomiting. Chipped beef is prepared, like corned beef, by pickling for a month,' when it is smoked for two days and dried for a fortnight, after which it is sliced thin by machinery and is ready for packing. BEEF PREPARATIONS FOR THE SICK Beef is so important a food for well and sick alike that many at- tempts have been made to improve its digestibility for the latter. Most of these efforts are aimed at concentrating the meat by re- moving all indigestible connective-tissue fiber, the muscle sheaths, sarcolemma, and blood vessels. In some cases the process of concentration is carried still further and water is driven off by evaporation, or some of the active prin- ciples of the meat are extracted and condensed. Sometimes the meat is predigested. Different meats may be prepared in these ways, but the best lean beef free from coarse fiber is usually preferred. It was long ago shown by Schiff that many fluid substances, such as meat extract, soups, peptones, and even vegetable purees when taken at the commencement of a meal, on being absorbed into the blood, favor the flow of gastric juice. This is true also of peptones injected into the rectum, so the effect is not wholly due to local stim- ulation of the inner surface of the stomach. Much attention of late has been given to the predigestion of meat, and especially to the production of albumoses, which are more soluble and assimilable than undigested meat albumin, and which are said to possess greater nutritive property than peptones. 132 FOODS AND FOOD PREPARATIONS The beef extracts made in this country usually have a less disagree- able taste and odor, and are lighter in color than those made of South or Central American beef. In general, about three grams (46 grains) of meat extract consti- tute a good soup ration, and such preparations are often valuable for addition to invalid soups and broths when thickened with eggs, rice, sago, pearl barley, macaroni, ground toast, etc. It is not desirable to rely for long upon any artificial meat prepara- tions, for they are costly, are soon tired of by the patient, and many of the fluid ones contain considerable alcohol. As a rule fresh beef juice or home-made bouillon or broths are sufficiently digestible to meet all requirements and I am inclined to agree with Hutchinson, who says of meat extracts, " Their proper place is in the kitchen, not by the bedside/' Nevertheless their use is so general that a few of the typical ones, from an almost innumerable list, will be described below. The preparations of meat for the sick are both (1) solid and (2) fluid. (1) Solid Meat Preparations. Scraped meat is made best from tender beefsteak, broiled for a few minutes over a brisk fire, but rare roast beef or mutton chops may be used. With a dull knife or an iron spoon the pulp is scraped out. The indigestible and less nutritious connective-tissue sheaths of the muscle fasciculi are broken and left behind, while the fibers themselves (or their myosin) are obtained in the form of a soft unirritating mass which readily is acted upon by the gastric juice. The pulp may be run through a sieve. It is then salted, and may be made into little balls and browned just be- fore eating. This is done by placing the balls on a hot frying pan, which is not greasy, and turning them over so that the outside be- comes well seared. They should then be set aside on a cooler part of the stove or oven and allowed to remain until the raw red color of the interior turns slightly to drab. Some patients prefer to eat the scraped meat raw or lightly cooked, spread as a sandwich between thin slices of bread and butter. This meat may be fed to infants in their second year, and the meat balls and sandwiches are invaluable in the treatment of chronic gastritis, dila- tation of the stomach, typhoid convalescence, and other affections. Moxquera's beef meal is made by digesting fresh tender lean beef witli pineapple juice until the muscle fiber is almost completely con- verted into peptones. After digestion the preparation is desiccated. Chittendcn's analysis of this meal shows it to contain 90 per cent of nutriment, 13 per cent of which is fat and 77 per cent is protein. Of the latter, almost half consists of albumoses and peptones fit for ANIMAL FOODS 133 prompt absorption. The remaining portion is believed to be in a condition in which it is more digestible than plain meat. The beef meal is tasteless and odorless, which are decided advantages, as it can be flavored according to preference. It should be salted, and may be added to broths and soups. It may be used with equal parts of sugar and cocoa, and added to hot milk. Mosquera's beef jelly is made in a similar manner, but is evaporated to the consistence of a solid extract. Analyzed by Ludwig, it was found to contain only 3 per cent of insoluble material, and of the soluble portion 53 per cent consists of albuminoids which are nearly all peptones. It is of pleasant taste and odor, and is highly nutri- tious. Dissolved in boiling water, it may be given alone with a pinch of salt or added to reinforce any broth, gruel, consomme, beaten eggs, or milk. The beef jelly is even more digestible than the meal. It is sometimes combined with cocoa. The beef meal and jelly are both excellent for use in gastritis, gastric catarrh, ulcer, and carcinoma, and many forms of enfeebled assimilation. Benger's peptonized beef jelly is another good beef preparation much in vogue in England for the same purposes as Mosquera's preparations. It may be taken cold or dissolved in hot water as a concentrated beef tea, representing a large amount of meat fiber. It is a useful stimulant for the aged who have feeble digestive power. It may be given to them in teaspoonful doses. Tropon is a condensed proteid preparation of granular consist- ence, said to contain 89 per cent of protein (Kleine). It is tasteless, insoluble, and may be added to milk, broth, rice, or other food, and several drachms may be given daily. Darby's fluid meat is a moist extract which has a strong meaty taste. It may be eaten spread on thin bread and butter or cracker, or it may be dissolved in hot water. Powdered beef is made as follows : Chop lean beef into small pieces, dry on a water-bath or in an oven with a slow fire, and powder in a coffee mill or with a machine constructed for the purpose. Do not over-dry. This powder may be mixed with hot water or any form of soup, milk, chocolate, grog, or punch. In process of drying, which occupies from five to twenty- four hours, the meat loses rather more than four-fifths of its weight. Dujardin-Beaumetz's " grog de la poudre de viande " is prepared as follows: Take two tablespoonfuls of meat powder, three dessert- spoonfuls of essence or sirup of rum punch, and add milk enough to make quite fluid. In this way he claims that the equivalent of three 134 FOODS AND FOOD PREPARATIONS and a half pounds of meat may be given daily. He strongly recom- mends powdered meat for forced alimentation (see Suralimentation in Phthisis). Professor Finkler, of Bonn, has made a proteid food which he claims " 1. Has the greatest amount of albumin possible up to 90 per cent. 2. Is digestible up to almost its entire weight. 3. Can be made equal in amount for each day. 4. Keeps well indefinitely in all climates. 5. Its flavor and taste do not interfere with that of other food. 6. Its price is the lowest possible." This food consists of the nitrogenous parts of meat, fish, and legumes. It is odorless, tasteless, and forms a light yellow granular powder. Kb'nig's anaylsis of this food follows: Protein, 89.87 per cent. Water, 8.89 per cent. Ash, 1.24 per cent. Fat, 0.20 per cent. Beef Blood. Dried beef blood, powdered, has been recommended by Regnard and others for use by addition to soups and various forms of foods. The taste and odor of dried blood is disagreeable, and the idea of eating it in any form is repugnant to most persons. It has also been used for rectal injection, but I have always ob- served it to cake inside the rectum, and there is very little evidence that it is absorbed there at all. Meat lozenges are prepared by Mason as a convenient and port- able form of condensed food. Soup lozenges and capsules are also made. *Bcef peptonoids are prepared in powdered form by several manu- facturers; one variety contains predigested and sterilized beef, milk, and gluten. Rudiscli's Iccf peptone (or sarcopeptone) is a dark-brown, semi- solid paste, having a strong meaty odor and flavor. One pound of this preparation represents eight pounds of fresh lean beef. In addition to the extractive materials which are obtainable in ordinary beef tea, it contains predigested proteids in a form suited for prompt absorption. It may be eaten spread upon crackers or toast, or it may be dissolved in chocolate or almost any suitable fluid, either hot or cold. It is given in doses varying from half a teaspoonful or less for young children, up to a teaspoonful or tablespoonful for adults. If its flavor when dissolved in water alone is disagreeable or becomes tiresome, it may be altered by giving it ice cold, or by the addition of salt, celery-salt, pepper, or "Worcestershire sauce, and for children it may lie sweetened with sugar. It is often added to milk, sherry, eggnog, gluten, and farinaceous gruels of oatmeal, rice, or arrowroot, or it may be used to reinforce soups, broths, and jellies. ANIMAL FOODS 135 The Maltine Company furnish a similar preparation which con- tains 70 per cent of albuminous material with phosphates, fat, and carbohydrates. The South American Beef Extract is a predigested preparation which, by the analysis of Kemmerich, contains, with other proteid matter, a large proportion over 27 per cent of albumoses and peptones, ready for immediate absorption. Somatose is a granular predigested meat powder which, accord- ing to analysis reported by Hildebrandt, contains 90 per cent of deutero- and hetero-albumose, and is free from peptones. It is of a yellowish color, amorphous, finely granular, having faint taste and odor. Dissolved in water, it forms a clear, light yellow or brownish solution, almost tasteless. It is not precipitated by heat or by strong acids. The latter, in fact, redissolve a precipitate which is formed by very weak acids. It is claimed for it that it is eight times as nutritious as meat, but estimates of this kind applied to artificial foods are always fallacious. Of course for an invalid who cannot digest any meat such preparations are indefinitely " stronger," but for those who can assimilate meat they are much weaker. Somatose may be injected in hypodermic solution without local irritation. It may be given as fine powder with bread and butter or spread upon toast. It is also administered like similar preparations in milk, mucilage, soup, cocoa, or coffee. When mixed with such substances it should be stirred first into a thin paste with an equal volume of the fluid and then added to the remainder. It is well tolerated by irritable stomachs and is speedily absorbed, and it possesses -the advantage of having a less disagreeble taste than many preparations of meat. Essay's Food is an albuminized food suitable for emergency feed- ing of infants and for adults with disordered stomach or bowels. Sanatogen is a nearly tasteless, odorless meat preparation espe- cially endorsed by Prof. Karl E. Ewald of Berlin. It contains casein with 5 per cent of glycerophosphate of sodium. It may be added to soup, milk, cocoa, broths, or gruels, etc. (2) Fluid Meat Preparations. Beef juice contains serum, lymph, and blood. H. P. Loomis gave 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 essen- tial. 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 to squeeze the juice is a thick round steak free from fat. 136 FOODS AND FOOD PREPARATIONS This should be seasoned with pepper and salt, broiled over a brisk fire, 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 further direct heat should 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. 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." When beef is chopped and squeezed under great pressure, juice is obtained from it in the proportion of 23 per cent, but only about 6 per cent is albumin (Bauer). Fresh beef juice is serviceable for feeding in many cases of severe gastric disturbance with vomiting and pain; also in typhoid fever, and for feeding infants at the end of the first and in the second year. From one to three tablespoonfuls may be given at once, and it forms a good introduction for the stomach to solid food. It is usually much to be preferred to any of the foregoing extracts and other prepara- tions. If desired, it may be paftcreatinized like milk (see Pancreat- inizcd Milk, p. 90). Beef Tea. The nutritive value of beef tea has formed a sub- ject for much discussion. The assertion often is made that it is a comparatively useless preparation, and it is said that a pint of it con- tains " scarcely a quarter of an ounce of anything." Hassell estimates that fourteen pounds and a half of beef would be required to make enough tea to counterbalance the daily nitrogenous waste of one man. If rightly made, however, it may be nutritious, although the quan- tity of proteid which can be dissolved in it at any time is much less than exists in a similar volume of milk or an egg. Its preparation should be conducted as follows: Tender lean raw beef is chopped into small pieces about a quarter of an inch in diameter and macerated in cold water for five or six hours. The water is to be added in the proportion of a pint to a pound of lean beef; ten drops of hydro- chloric acid are then added, and the solution is gradually heated to 160 F., but not more, for from fifteen to thirty minutes. This is best accomplished by placing the vessel in a larger outer vessel of boiling water. Various forms of water-baths, which the French call " bain marie " or milk scalders, are sold, which are conveniently adapted for the process of making beef tea. The prolonged soaking of meat in cold water dissolves its mineral ingredients chiefly chloride and sulphate of potassium, and also ANIMAL FOODS 137 extractives, principally creatin and creatinin and some lactid acid derived from the muscle fibers. There also may be a little albumin present, but the albumin of meat or muscle is very sparingly soluble in simple aqueous solutions, and hence it does not diffuse readily into the water, but the addition of hydrochloric acid converts the in- soluble myosin into an acid albumin called syntonin, which is soluble. In making beef tea, more or less fat is derived from the meat, which floats upon the surface and presents a very unappetizing appearance. This should always be skimmed or strained, and if it collects on cooling, the operation may be repeated. A crust of bread dipped beneath the surface will remove the supernatant layer of fat. It is always desirable to give special attention to the proper fla- voring of food for fever patients. In cases where a fluid diet is necessitated for many days in succession, much depends upon the willingness of the patient to take the food offered him, and a dread of too frequently recurring intervals of feeding with the positive dislike which the monotonous taste of certain meat preparations begets, reacts unfavorably upon the digestion. It is advisable to con- sult the individual taste of patients in this regard, and when they positively assert that they cannot take beef tea or bouillon or meat extracts in any form, their opposition often may be overcome by adding the expressed juice of some fresh vegetables of which they are fond. Carrots, celery, parsnips, and endives may be boiled alone or with an aromatic herb, such as parsley or green mint, and after- wards chopped fine and their juice expressed by squeezing them in a muslin bag. Such juices added to beef tea and broth impart an altogether different flavor, which may be varied from time to time by changing the vegetables (Yeo). The total quantity of albuminous material which may be obtained in the manner above described in a reasonable bulk of fluid is very little, but in febrile conditions it is usually good for the patient to ingest abundant water, and there is no objection to part of the fluid being taken in the form of beef tea. On the other hand, if patients have absolute anorexia they are soon wearied by the effort of swal- lowing, and it is preferable to give proteids in more concentrated form. Beef tea may be given with beaten eggs, or gelatin may be put in to stiffen the mass into a jelly, which, when properly seasoned, is palatable. It also may be thickened with broken crackers, and with the addition of a little butter, pepper, and salt, it becomes much more nutritious ; or sago, arrowroot, or chocolate may be mixed with it. Bouillon, or the French pot au feu, is of little more value as an ali- 12 138 FOODS AND FOOD PREPARATIONS 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- ing over a brisk fire until the meat turns of a faint drab color, 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. As ordinarily made, it contains, besides salts and extractives, % per cent each of fat and albumin and 1 per cent of gelatin. Meat Extracts, etc. Under this title are classed a variety of arti- ficial meat preparations both solid and fluid, the term being a very general one. There are three main classes, viz.: (1) True extracts containing the salts and flavoring material of meat, and little else. (2) Meat juice expressed and preserved with alcohol or otherwise, containing more or less protein. (3) Albumose or peptose prepara- tions, consisting of soluble products of artificial digestion of meat. For the most part beef is used for all the meat " extracts," but other kinds of meat may be employed. Liebig's extract of meat, or " extractum carnis," consists of fla- voring extractive matters such as creatin, isolin, decomposable hre- 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 only 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, 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). Valentine's meat juice is a clear fluid of a deep claret-color, hav- ing a meaty odor and strong meaty taste. It is prescribed in doses of one-half to two teaspoonfnls, 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 reinforce soups ANIMAL FOODS 139 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 wine 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 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 per os in doses of a teaspoonful or more, or in ounce doses with pancreatin for rectal injection. Not being predigested, it may be pancreatinized like milk. Beef Peptones. There are innumerable fluid preparations of pep- tonized beef which may be employed to tide over an emergency after a severe operation or collapse from hemorrhage, uncontrollable emesis, etc. All the products of pancreatin digestion, as well as the ferment derived from the juice itself, decompose if exposed for any length of time to the air. The use of peptones for invalid foods is open to the objection that after a short time they excite disgust, owing to their disagreeable strong meaty odor and bitter taste, and may cause vomiting and diarrhoea. The more complete the conversion of albumin into pep- tone the more bitter it becomes. This difficulty is overcome when peptones are used for rectal injec- tion. Efforts are made to disguise the disagreeable taste and odor of beef peptones in various ways. When obtained in solution, wines and aromatic substances are added to them or they are sometimes evap- orated to dryness, pulverized, and redissolved in sherry, but the taste is exceedingly persistent and it is often difficult or impossible to dis- guise it in any manner, so that patients will not sooner or later object to it. Among the principal peptones which are used are Carn- rick's, Savory and Moore's, and Benger's. Some of the pancreat- inized foods are strengthened by addition of predigested starches and sugars. They constitute good temporary foods for cases of enfee- bled digestion or diminished absorptive power. Pure meat peptones, prepared either by pepsin and hydrochloric 140 FOODS AND POOD PREPAEATIONS acid or by trypsin in alkaline solution, are ready for immediate ab- sorption, but Voit, Politzer, Gerlach, and others maintain that true peptone possesses little if any nutritive power, and that the albu- moses are directly absorbed from the alimentary canal without con- version into peptones. Bread-and-beef peptone, or " panopeptone," is a preparation in which wheat starch and beef are both predigested and preserved in sound sherry (over 20 per cent by volume). 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 also are mixed with predigested milk and gluten. All peptonized or pancreatinized foods are open to the objection that they are much more expensive if used for a long time than the preparations which easily may be 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 Peptonizing Powders and Fairchild's Zymine, which act upon lean meat as well as milk. If complete peptonization is required, large quantities of the ferment must be used, and the process should be continued longer than for a less degree of peptonization. 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 em- ployed of condensation of food by evaporation of water and compres- sion, 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 may be made to support an able- bodied man and supply him with energy for a day's work, for ex- ample, of mountain climbing. Xeither does such predigested aliment represent concentration for an invalid ; the bulk of food given is certainly reduced, and its assimila- tion may be improved, but it does not convey into the body any phe- nomenal quantity of latent force units or of heat units. It is im- portant to understand this fact; otherwise serious misconceptions arise as to the actual amount of nutriment which a patient fed exclu- sively on peptonoids and similar food preparations is receiving. It should l)e remembered that many of the fluid meat prepara- tions contain from 12 to 20 per cent of alcohol, used as a preservative and diluent, and if given in large quantity or for a long time, the patient may take too much alcohol. The following analyses illustrate the comparative composition of several of the preceding preparations as given by Chester: ANIMAL FOODS 141 Composition of Meat Extracts. (Albert H. Chester.) Water. Organic matter. Ash. Soluble albumin. Alcholic extract. Liebig's extract 18 27 58 48 23 25 05 44.11 Benger's extract of beef 40 65 39 85 19 50 1 11 13 18 Valentine's meat juice 54 40 31 84 13 75 44 26 32 In some meat extracts creatin predominates, in others creatinin. The range of each is from 1 to 4 per cent. Fresh meat contains only creatin, which is readily converted into creatinin, and both may re- appear in the urine after a proteid meal. 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 usually 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 considerably from beef in flavor, and contains more gelatin and water but less fat and protein. 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 formerly. 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. 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 work upon the Senile Heart : " "We also recommend meat with short fiber, such as chicken, rabbit, game, mutton, or well-grown lamb, in preference to such meats as beef, whose fibers are long and tough." Fat mutton is richer in fat than beef, is certainly less digestible than lean beef, and tough mutton is quite as difficult of digestion as tough beef, and in America it is harder to obtain it tender. Mutton fat contains a 142 FOODS AND FOOD PREPARATIONS larger percentage of stearic acid, which makes it firmer and less digestible than beef fat. When properly assimilated after digestion, mutton possesses equal nutrient value with beef. Mutton broth is wholesome and suitable for the sick and may be given in typhoid and other fevers. It is slightly 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, is not usually to be recommended for invalids. Venison. Venison is a tender meat with short fibers, which is very digestible when obtained from young deer, but is often eaten when aged to a degree which, while some think it improves the flavor, unfits it for dyspeptics. The meat corresponds very closely in chemi- cal composition to lean beef. Pork is a tender-fibered meat, but is notoriously indigestible on ac- count of the high percentage of fat present, which may exceed 37 per cent, or considerably more than the quantity of its proteid. 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 a variable position, according to its quality and leanness. On an average, 100 grams of ham give 30 of albuminates and 32 of fat; the salt ranges between 7 and 1 per cent" (Bauer). In Germany, and especially at Carlsbad and other mineral springs, ham is much prescribed in invalid dietaries. It is often given scraped or " rasped." Bauer says (Dietary of the Sick) : " The flesh of he hog seems to be better adapted for smoking than that of other animals, and long experience compels us to recognize 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 prevalent in England and America, where it is less used for the sick. So distinguished a dietitian as Pavy omitted mention of it in his book upon Food and Dietetics. Ham is more digestible when thoroughly boiled, cut thin, and eaten cold. It should not be fried for invalids. Hot ham is very indigestible. If cut thin and cooked crisp, fat bacon is friable and easily broken into small particles during digestion. It often may be eaten by dys- peptics, and forms an excellent variety of fatty food for consump- tives. It ha? been proved at the Minnesota Agricultural Experiment Sta- ANIMAL FOODS 143 tion that not only is 96 per cent of bacon fat digested and absorbed, but this form of fat may increase the digestibility of other foods, when cooked or eaten with them, as for example, with baked beans. Bacon contains as much protein as other meats, and double the per- centage of fat. In the ordinary ration of armies or institutions it proves less monotonous than corned beef or boiled beef, and it facili- tates the cooking of other foods. After our troops in the Philippines were deprived of bacon in their rations, it was found that they spent their wages to buy lard for frying, showing their need of fat food. Horseflesh is a nutritious meat for those who are not fastidious. It is consumed in large quantities by the poor in France (where over 5,000 tons are eaten annually in Paris alone), and to some extent in Denmark, Sweden, Germany, and Austria. It has never found favor in England or the United States, and most of the horseflesh butchered in this country is canned for consumption by foreigners. It contains neurin, and its excessive use may cause diarrhoea. Rabbit has white meat, and Belgian hare meat is partially white, but they are not proper invalid foods. Fowl. Chicken is among the most digestible of meats for inva- lids, whether cooked by broiling, roasting, or boiling, because its fiber is tender and contains little fat. The white meat is more easily di- gested than the dark, although it differs very slightly in chemical composition. Dark meat of fowl contains more pigment, extractives and a little more proteid than white meat. 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 some- times with an egg, it forms a highly desirable invalid food. " Broilers " contain about 20.7 per cent of proteid and 7 to 8 per cent of fat. In young chickens the dark meat contains only one per cent less proteid than the white meat and one per cent more fat. Capon, or the emasculated cock, develops a larger proportion of white meat than the chicken, and is very digestible. The white meat of fowl is popularly supposed to contain less pro- tein, and therefore be less " heavy " as an article of diet than red meat, such as steak or roast beef. The chemical differences are, how- ever, very slight. Chicken contains between 3 and 4 per cent more protein than sirloin steak and about half as much fat. Eed meat contains more pigment, but somewhat less of creatin and other extrac- tives than the white meat of chicken. The fiber of the latter is some- 144 FOODS AND FOOD PREPARATIONS what more tender, as a rule, and hence slightly more digestible than that of beef or mutton, although the protein content is somewhat greater. As the white meat of chicken and game is relatively expen- sive, patients are less likely to eat too much of it, as they may do with beef. Helen W. Atwater says: " As far as the nutritive value alone is concerned, the general advantage of poultry over the other meats thus appears to be that, pound for pound, it contains very slightly more of the building mate- rials needed by the body; its disadvantage is that it furnishes less of the energy-giving material than the fatter meats." The clinical significance of these observations is very important, for in cases of chronic nephritis, gout, rheumatism, lithaemia and allied conditions, patients are often told that they must abstain from mutton, beef and other red meats, but are allowed to eat the white meat of chicken, turkey, etc. In reality, however, there is little advantage in this from the standpoint of the quantity of proteid mate- rial introduced into the system and of resultant proteid waste. The question is, therefore, almost entirely one of relative digestibility, of physical rather than chemical properties, a fact which should be more widely appreciated. Turkey is sometimes as digestible as chicken, as to the white meat, but it is often tough, and the dark meat is much less digest- ible. Guinea-fowl and peafowl are very digestible and wholesome when young or caponized. These birds are somewhat darker in the color of their meat, and richer in protein than chicken, but poorer in fat. They contain as much nourishment as medium beef or mutton, and their flavor is delicate. Young pigeons are quite digestible, and the breast of a squab may be given to a convalescent from fever before other meat is al- lowed. 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, and ducklings 38 per cent of fat, as against 14 per cent of protein. Game, such as the flesh of partridge, grouse, woodcock, snipe, quail, pheasants, wild clucks, prairie chickens, etc., is by many persons pre- f erred 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 odor and flavor of commencing putrefaction are de- ANIMAL FOODS 145 rived and penetrate the meat. When the meat itself is not perfectly fresh it may produce violent gastrointestinal disorder, but many persons with good digestive organs are not disturbed by the consump- tion of such food in moderation, provided it is well cooked. The process of cooking disinfects it by heat. The fat of old birds is too strongly flavored, and their meat is tough. Young birds are digestible if properly cooked. Game is rich in extractives. Other forms of meats derived from the larger animals, such as the wild boar, wild sheep and goats, etc., are too numerous for de- tailed mention here, as they rarely are made use of except by hunters, explorers, or natives of wild countries. It is a peculiarity of game in general that it usually cannot be eaten continuously as long as beef without palling very much sooner upon the appetite. 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 little nitrogen. With the exception of sweetbread, and in some cases the thyroid gland, they should not be given to the sick. Sweetbread is the most useful in the invalid dietary. It consists of the pancreas of the calf, called by butchers " stomach sweetbread " to distinguish it from the thymus gland of the same animal, called also the " neck " or " throat sweetbread." Either gland is tender and digestible, the thymus somewhat more so than the pancreas, which has larger, more " stringy " blood vessels. The thyroid gland has lately been shown to possess remarkable power in regulating disordered nutrition in cases of myxcedema, cre- tinism, obesity, chronic skin diseases, epilepsy, and some forms of in- sanity. It is usually given as a powdered extract in five-grain doses, two or three times a day, but it is sometimes cooked fresh and eaten as a food. Tripe, 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 16 per cent of fat and 13 per cent of albuminoids 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 flavored and more tender if the animal has had fresh 146 FOODS AND FOOD PREPARATIONS 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 diabetics. These foods are often 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. Formerly there was a fashion among consumptives of going to the abattoirs to drink it warm, in the belief that it had some 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. The collagen of tendons and ossein of bones are proteids which yield gelatin and glue. Gelatin is also derived from ten- dons and fascia. 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 a curious and interesting property of gelatin that used alone it fails to have much nutritive power, but in proper combination with other foods it is a useful aliment. " By the addition of 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). It cannot wholly replace albumin, the loss of which still goes on to some extent 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, because, 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 therefore must be discussed somewhat in detail. Since bones consist of nearly two-thirds of their weight of gela- tin, the latter may be used advantageously as an inexpensive means ANIMAL FOODS 147 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 themselves may be broken and made to yield fat and gelatin for soup "stock." Edible birds' nests are not true gelatin, but a Chinese food product allied to mucin. Gelatinous substance may be obtained from boiling for several con- secutive 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. Calf's-foot jelly and calf's-head jelly, if not made too rich by added ingredients, make suitable invalid dishes, but ox-tail soup is too rich for the sick. 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 odor, and prepared with coffee or lemon juice, or other fruit flavors, it makes an easily digested invalid food. Or it may be combined with eggs or milk as blancmange. The addition of meat extracts to it improves the taste, and the admixture of wine, like good sherry, alters the taste rather by the introduction of its aromatic principles than by the alcohol itself, which is largely evap- orated from the jelly. Gelatin has been used as a food in cases of haemophilia, purpura hemorrhagica and other forms of continued bleeding, with the idea that it thickens the blood, or in some manner promotes coagulation, but in those cases in which I have given it the effect was inappreciable. It also has been used for this purpose subcutaneously. Dry gelatin contains 17.3 per cent of nitrogen, which is a larger proportion than is contained in albumin; consequently urea excre- tion 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. Sea Food Fish. The annual quantity of sea food produced in the fresh and salt waters of the United States is more than 2,000,000,000 Ibs. Fish vary both in digestibility and nutritive qualities. The chief differences are in regard to coarseness of fiber and the quantity of 148 FOODS AND FOOD PREPARATIONS fat present. Fish meat is less stimulating, sustaining, and satisfying than that of birds or mammals. Eels contain a large proportion of fat, which amounts to 28 per cent. Herring have 7, salmon about 6.05, whereas sole have but 0.25 per cent (Konig). Mackerel, trout, and shad contain considerable fat. Fish which, like the salmon, are rich in flavor and fat, although they may be very nutritious, are much less easy of digestion than are the simpler varieties, such as sole or flounders and fresh codfish. Dried codfish may be eaten on long sea voyages day after day without the repulsion which is soon excited by the continuous diet of the more highly flavored 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, salmon, 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 de- teriorate from change in food or other causes, and are less nutri- tious, besides possessing inferior flavor, and sometimes disagreeable odor. They should be eaten as fresh as possible, for there are few alimentary substances capable of exciting so violent gastrointestinal disturbance as decomposing fish. Vivid red gills and fullness and brightness of the eye are a test of freshness. The ferments which decompose fish continue to act at temperatures sufficiently low to inhibit those of meat, hence fish should be frozen and not merely refrigerated for preservation, but the practice of pre- serving fish frozen is open to the objection that the cold prevents malodors from revealing commencing putrefaction, when they be- come more or less toxic for most persons, although the Javanese eat putrid fish, and the Scandinavians prepare a variety of fermented fish as a standard food. It is a popular fallacy that fish constitute a good " brain food " on account of containing a large percentage of phosphorus, a prom- inent ingredient of nerve tissue ; but in reality many fish contain less of this clement than meat, and neither- Eskimos nor other aborignal tribes who live largely upon fish are noted for intellectuality. Fish contain less fat than moat, averaging 2-5 per cent. They contain more gelatin and collagen, and less extractive than meat. The following table of fish composition is condensed from analyses given bv C, F. Langworthv : ANIMAL FOODS 149 Composition of Fish. Kind of food material. Water. Protein by factor (N X 6.a5). Fat. Carbo- hy- drates. Ash or mineral matter. Total nutri- ents. Fuel value per Ib. FRESH FISH Alewife, whole Per ct. 37.6 Per ct. 9.8 Per ct. 2.4 Per ct. Per ct. 0.8 Per ct. 13.0 Cal. 277 Bass, sea, dressed 42.2 10.5 .2 .7 11.4 200 Bass, striped dressed 37.4 8.8 2.2 .5 11.5 249 Blackfish, dressed 35.0 8.4 .5 .5 9.4 172 Bluefish, dressed 40.3 10 .6 .7 11.3 204 Butterfish, dressed 45.8 11.8 7.2 7 19.7 503 Carp (European analysis) . 48.4 .7 .9 14.5 263 Cod, dressed 58 5 11 1 2 8 12 1 209 Cusk, dressed 49.0 10.1 .1 .5 10.7 186 Eel, saltwater, dressed .... 57.2 14.8 7.2 .8 22.8 558 Flounder, common, dressed . 35.8 6.4 .3 .6 7.3 127 Hake, dressed 39.5 7.3 .3 .5 8.1 145 Haddock, dressed 40.0 8.4 .2 .6 9.2 159 Halibut, dressed 61.9 15.3 4.4 .9 20.6 454 Herring, whole 41.7 11 2 3.9 .9 16.0 363 Mackerel, dressed 43 7 11 6 3 5 7 15.8 354 Mackerel, Spanish, dressed. 51.4 16.3 7.2 1.2 24.7 585 Mullet, dressed 38.2 9 9 2.4 .6 12.9 277 Perch, white, dressed 34.4 8.8 1.8 .5 11.1 231 Perch, yellow, dressed 50.7 12.8 .7 .9 14.4 259 Pickerel, dressed 51.2 12 2 .7 12.9 227 Pollock, dressed 54 3 15 4 6 11 17 1 304 Pompano, whole 39.5 10.3 4.3 .5 15.1 358 Porgv, dressed 34.6 8.6 2.4 .7 11.7 254 Red-grouper, dressed 35.0 8.5 .2 .5 9.2 163 Red-snapper, dressed 43.7 10.6 .3 .7 11.6 204 Salmon, Calif, (sections) . . 57.9 16.7 14.8 .9 32.4 903 Shad, dressed . . 39.6 10.6 5.4 .8 16.8 408 Shad, roe 71.2 23.5 3.8 1.5 28.8 581 Smelt whole 46 1 10.1 1.0 1.0 11.1 222 Sturgeon, dressed 67 4 15.1 1.6 1.2 17.9 340 Tomcod, dressed 39 6 8.4 .3 .5 9.2 163 Trout, brook, dressed 48 4 11.9 1.3 .7 13.9 268 Trout, lake, dressed 44 4 11.0 6.2 .7 17.9 449 Turbot, dressed 43 1 8 9 8 7 .8 18.4 513 Weakfish, dressed 46 1 10 4 1.3 .7 12.4 240 Whitefish, dressed 39 4 12.8 3.6 .9 17.3 376 General average of fresh fish as sold 44.6 10.9 2.4 .7 41.0 295 Sardines, canned 53.6 23.7 12.1 5.3 14.1 916 Some fish contain different species of tapeworm, but they are seldom transmitted to man. The sturgeon is the intermediate host of the Dibotliriocephalus latus, and when eaten raw or pickled, in Finn- land and Russia, give rise in man to a very pernicious type of anaemia. 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. 150 FOODS AND FOOD PREPARATIONS The most digestible fish are fresh sole, whiting, bluefish, white- fish, 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 flavor 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 flavor, is increased. As soon as caught, the fish is incised transversely by numerous deep cuts. On being plunged into ice-cold water, the muscle fibers 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 " appetizer," is capable of arresting digestion, especially when old, black, or rancid. Caviare contains, according to analyses by Kb'nig and Brimmer, water, 45.05 ; proteids, 31.90; fat, 14.14; salts, 8.91 per cent. It should 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, biliousness or urticaria. A few tropi- cal fish are poisonous, and constitute an exception to the general edi- bility of vertebrate animals. (See Fish Poisoning.) Tli ere 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. Crustaceans. Lobsters, crabs, and shrimps, although they consti- tute a wholesome food, when absolutely fresh, for those in health should never be admitted to an invalid dietary. They are all scaven- gers 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 indigesti- ble residue, which may prove irritating, giving rise to intestinal colic and diarrhcca. Lobsters are highly poisonous to some persons even when fresh, and especially if eaten with other food they may excite nausea, vomit- ANIMAL FOODS 151 ing, and gastroenteritis. In others they may cause urticaria or in- tensify existing skin eruptions. Shrimp resemble lobsters in general composition and digestibility, and the meat of these crustaceans, stripped for canning, contains be- tween 18 and 25 per cent of protein and a mere trace of fat and carbohydrate. Canned crustaceans are very often the cause of gastrointestinal dis- order. Potted shrimp, crabs, etc., are liable to decomposition and may produce ptomaine poisoning. Shellfish. Oysters, clams, scallops, and mussels are slightly nu- tritious food, and oysters, at least, when fresh and properly cooked, are an excellent invalid aliment. Oysters often may be digested ear- lier than meat in convalescence from fevers, and in many forms of gastric disorder. The flavor of oysters depends much upon the place in which they are grown. When taken out of salt water they are quickly decomposed by bacterial fermentation. Prejudice against eating raw oysters has arisen of late years owing to the prevailing practice of transplanting them to sewer-beds to be " fattened " before being marketed. In this way, being scavengers, they are likely to transmit typhoid fever germs (see p. 435). Deep sea oysters, how- ever, are entirely wholesome and may be eaten raw with safety. In New York city the sale of oysters is under special Health Board super- vision to guard against infection. The " soft part " of shellfish is formed chiefly by the bulky liver, while the tough, harder portion is mainly the muscle which attaches the animal to its shell. 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 oyster the liver is rela- tively larger and more nutritious than in clams. In recommending 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 " panning," 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 make a pleasant variety of food to relieve re- stricted diets. They impart an agreeable flavor to milk and broths. It is customary to forbid their use by diabetics, on the ground that their livers contain glycogen, but this is so trifling in quantity as scarcely to be worth consideration. Clam juice or plain clam broth is almost specific for some forms of vomiting, especially seasickness. It may be tried in the vomiting of pregnancy, and may be retained when beef juice and milk are not. It is mildly stimulating to the 152 FOODS AND FOOD PREPAEATIONS gastric mucous membrane, and slightly nutritious and laxative. It is best obtained fresh, but very good canned or bottle preparations 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 pro- motes the appetite. Oysters contain on an average 87 per cent of water, 6 of protein, 3.3 of carbohydrates, and 1.3 of fat. Clams contain 80 per cent of water, 10.6 of protein, 5.2 of carbohydrates, and 1 of fats. Scallops contain 14.8 per cent of protein, 3.4 of carbohydrates, and only 0.1 per cent of fats. The total nutrient material in a quart (about 2 Ibs.) of oysters is only between 3 and 5 ounces, hence they are not an economical food. 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 Poison- ing by Shellfish.) In some persons shellfish, like crustaceans, produce skin erup- tions, such as urticaria, or aggravate existing eczema. In general, shellfish are digested in an hour's less time than meats. INSECTS Insects are eaten as food in many countries, and are dried, salted or boiled, especially by the Congo natives and in South America. Some American Indians, Mexicans and Greeks eat locusts and grass- hoppers, which are dried and ground to a meal. The larvae of the stag beetle are esteemed in the West Indies. Large ants and bees are eaten in Ceylon. The Hottentots eat the white ant or termite, and Chinese eat the silk worm. The only insect product eaten by civilized man is honey (described on page 158). IV. VEGETABLE FOODS Sugars Sugars are crystallizable carbohydrates in which oxygen and hydro- gen exist in proportion to form water. There are many varieties, of which the commoner contained in food or used as an adjunct to diet are cane sugar (saccharose or sucrose), grape sugar (dextrose or glucose), levulose or fruit sugar, and sugar of milk or lactose. VEGETABLE FOODS 153 Inosite, mannite, sugar of malt or maltose, honey, a sweet nitrog- enous substance called saccharin, and fruit sugar or levulose (diabetin) are also used. Sugar may be derived from the stjems 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 polarized 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. 173), for all starch must be converted into dextrin before it can be assimilated. For this 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. Chauveau and Kaufmann have demonstrated that during muscular activity the consumption 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 grams (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. In Holland sugar is much used by athletes to lessen fatigue in rowing. Steinizer took between 10 and 20 ounces a day to lessen muscular exhaustion in strenuous Alpine climbing. Eecent experi- ments in the German, British, and other armies show that a liberal allowance of sugars in the diet tends, during manceuvers, to main- tain strength, lessen hunger and thirst, and the liability to heat ex- haustion. They possess additional properties, in that they have a more agree- able flavor than starches, are more satisfying to the palate, and they have antiseptic and preservative power. Hence sugars and sirups are extensively employed to preserve fruits either in solution or in dried form, like " candied " cherries, ginger, etc. When taken as food, sugar is quickly soluble, and on this account taxes the digestive organs very little. Cane sugar, however, needs to be converted into grape sugar before it can be absorbed and assimi- lated, and grape sugar, which needs no change, is therefore some- times spoken of as a predigested carbohydrate. Between seven and eight million tons of sugar are consumed each year in the world at large. The English-speaking nations are the largest consumers. Cane sugar was originally used exclusively in preparation of medicines, not as a food. 154 FOODS AND FOOD PKEPAKATIONS Many persons acquire an inordinate fondness for sugar, and con- tinued overindulgence in this food is sure to give rise to flatulent dyspepsia, constipation, and disorders of assimilation and nutrition. It may cause functional glycosuria. (See Diabetes.) Sugar is very fattening. In the West Indies the negroes always grow fat in the sugar season, when they chew the cane in the fields. Sugars and the TIrine. Grape sugar or glucose and fruit sugar or levulose, when eaten in large quantity in health, reappear unal- tered in the urine, but the latter sugar in diabetes is said by Moritz to be consumed within the body. Sugar eaten in excess with other food increases the quantity of urine and feces and the urea elimination. Saccharose, eaten in excess, occasionally may reappear in the urine unaltered, but oftener 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 eating 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 destroys the appetite for other food. Dextrose occurs in association with levulose in honey, grapes, seeds, nuts and various roots, but excepting as eaten in honey these sugars do not constitute an important article of diet as compared with glucose. In the stomach they are fermented by bacteria, with forma- tion of lactic acid. Cane Sugar. Cane sugar, saccharose, or sucrose is derived from the clarified and crystallized juices of the sugar cane (saccharum of~ ficinarum), but it may be made also from beet root, as originally dis- covered by Marggraf, of Berlin, in 1747. The beet product is some- what less sweet than are the better grades of cane sugar. The root contains 12 to 15 per cent of sugar. One- third of the world's com- mercial sugar is derived from sugar cane, and two-thirds from beets. The annual per capita consumption of sugar in the United States is Gfi pounds and the daily consumption varies from one-half to an ounce and a half. About one-quarter of a pound per diem may be oaten without harm. More than this in a short time is liable to VEGETABLE FOODS 155 disorder digestion, just as do the equally diffusible peptones eaten in excess. Mary Hinman Abel, in an exhaustive study of the food value of sugar, says: " There is no proof that sugar is harmful to the teeth, although doubtless sweet food, allowed to cling to the teeth after eating, rapidly ferments, and acids will be formed that, according to Professor Mill, of Berlin, may attack the teeth. This is equally true of starchy foods. It is said, however, that the negroes of the West Indies, who consume enormous quantities of sugar, have the finest teeth in the world." The maple tree yields from 2 to 10 per cent of sucrose. Maple sugar is eaten chiefly as a luxury, on account of its unique and agreeable flavor. It also makes an excellent sirup which is in great demand. Cane sugar may be obtained from the sugar pea, from the flower buds of the coca palm, and from other substances. It is soluble in half its weight of cold water and in less hot water. 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 are as follows : " 1, Melting of the sugar ; 2, straining through bag filters; 3, filtering through charcoal; 4, boiling or evaporating the decolorized liquid in vacuum pans; 5, separation of crystallized 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 1 to 2.3 per cent, with as much water (Konig). Cane sugar is about two and a half times sweeter than glucose. Cane sugar is completely digested and absorbed, leaving no fecal residue. It is better digested in propor- tion to the amount of exercise taken. " Grocer's itch " is a form of irritation of the skin of the hands 156 FOODS AND FOOD PREPARATIONS sometimes acquired from contact with moist brown sugar, adulter- ated 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-crystallizable fluid substance called caramel, having a slightly bitter but agreeable taste. Comparatively insipid farinaceous food, such as cornstarch and farina, may be flavored with it for invalid diet. Burned flour may be used in the same manner, but its flavor is less agreeable. Caramel is also useful for flavoring milk, custards, etc. At 320 F. sugar melts to an amber fluid, which, on cooling, is brittle and transparent. In this form it is called "barley sugar," and is much used in confectionery. When sugar is cooked with acid fruits it is partly converted by the heat and acid to less sweet substances, hence to sweeten cooked fruits the sugar should be added when the cooking is completed. Sugar differs from starch by containing another molecule of water. Starch, which forms fully three-fourths by weight of the solid in- gredients of wheat flour, is altered into sugar by heating with a little sulphuric acid, or even by prolonged heating alone or " torrification." The latter process converts it into dextrin, sometimes called " British gum," on account of its substitution in commerce for gum arabic. With prolonged heat there is a further change in the starch, which acquires a brownish and finally black hue, passing through a stage analogous 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 therefore similar to caramel, and every one is familiar with its gain in flavor. Sugar candy is made by extremely slow crystallization. Sorghum is a variety of grass or cane from which sugar may be extracted, but in this country it is used more for the manufacture of molasses. Candy and Confectionery. Candy contains from 75 to 90 per cent of sugar, to which may be variously added butter- or other fats, nuts, fruits, starch, glucose, and flavoring extracts. Cheap varieties are colored with aniline dyes, and are composed largely of glucose and starch. Children assimilate candy better than adults because they arc less liable to dyspepsia, and because of their relatively active muscular energy and relatively large body surface for losing heat, in proportion to their size. They do not, as a rule, care for fat meat, arid prefer sweets as a natural substitute. Plain molasses candy is a wholesome form in which to give sugar VEGETABLE FOODS 157 to growing children, if they are not allowed to eat too much and spoil their appetite for other foods. It is mildly laxative. Walker says. that "good candy is good food." Candies are often made too rich with butter, chocolate, and other ingredients, when they disagree. An infant taking two quarts of milk per diem consumes nearly three ounces of sugar in the form of lactose. In later childhood the ability to digest starches replaces to some extent the need for sugar. It is, however, important that the taste for candy and sugar common to all children should not be permitted to interfere with a wholesome and natural appetite for other foods, especially fresh vegetables and fruits. The value of sweets in the adult dietary has of late years found recognition in armies. The British War Office shipped 1,500,- 000 pounds of jam to South Africa as a four months' supply for 116,- 000 troops, and one New York firm during the Spanish-American War shipped over fifty tons of confectionery to the troops in Cuba, Porto Eico, and the Philippines. The confectionery consisted of chocolate creams, cocoanut macaroons, lemon and other acid fruit drops. Molasses, Treacle, and Sirup. Molasses and treacle are products incidentally formed in the process of crystallizing and purifying cane sugar. Treacle is the waste drained from molds 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 de- sirable food, and is highly nutritious. Its use, both for cooking and to add to farinaceous food and enhance its flavor, is too well known to require description. Molasses, according to Konig, con- tains acetic and formic acids, which impart their reaction to it. It also contains cane sugar and 30 per cent each of invert sugar and of water. Both treacle and molasses, owing to impurities, are more laxa- tive than refined sirup, and the effect, as an aperient, of plain ginger- bread made with good brown molasses is due to this property. For young children from six to ten years of age molasses sometimes oper- ates in keeping the bowels open. An old-time custom among soldiers in the field is to fill a canteen with two parts vinegar and one part molasses as an emergency sus- taining drink. 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 158 FOODS AND FOOD PREPARATIONS 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- voring other articles of food, for when so used it is apt to produce flatulent dyspepsia with acid eructations. Sucrose and maltose can only be absorbed by alteration into glu- cose. If glucose be eaten as a food, in form of candy or otherwise, it overloads the system by being too promptly absorbed. Malt ex- tracts, sirups, and preserves adulterated with glucose easily ferment with the bacteria present in the stomach. Lactose. Lactose, or sugar of milk, is taken as a food as an in- gredient of ordinary milk, and forms a very important part of the diet of the growing infant. It might be used for sweetening various articles of food, but it possesses no advantages over ordinary cane sugar, and is in fact more expensive and less sweet. It is mildly diuretic. It may be given to typhoid fever patients to lessen tissue waste. 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 crystallizes, and is white and free from odor. It does not ferment with yeast. It is laxative, and may be used in diabetes, for it is not secreted in the urine as glucose. Levulose. Fruit sugar, or levulosc, 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 may 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 cane sugar of various flowering plants gathered by bees, which convert it by hydrolysis chiefly into dextrose. They then store it in cells. Thus it is really a vegetable product, although manufactured by an insect. In addition to sugar, it holds several other ingredients, principally wax, gum, pigment, and odorous materials. The sugar exists in two forms crystallizable and non-crystallizable. The former is somewhat similar to glucose. Honey contains, according to Konig: Water, 16.13; dextrose, 78.74; cane sugar, 2.69; nitrogenous matter, 1.29; ash, 0.12 per cent, beside? traces of other ingredients. IFonoy 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- VEGETABLE FOODS 159 tries as, for example, in the Black Forest of Baden the peasants consume it as a staple article of diet. Artificial honeycombs are now made from paraffin, stamped into cells to imitate the original, which enables the bees to devote more energy to the manufacture of honey and bestow less on the combs. In a few instances, fortunately very rare, honey has proved poison- ous owing to the bees having fed upon poisonous flowers. An epi- demic of gelsemin poisoning occurred in Branchville, S. C., from this cause in which twenty persons were severely affected, three of them fatally. The poisoning of Greek soldiers by honey is mentioned in Xenophon's Anabasis (viii, 4). Saccharin. Saccharin is a crystallizable 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, 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 iiavored with it. It is antiseptic, and has the property of acidifying the urine, being eliminated unaltered by the kidneys. It may be given for months at a time without danger, if the quantity prescribed does not exceed more than one or two grains three times a day. More than this dose may cause gastric derangement. It may be added to food in cooking, and a one-quarter grain tablet may be used to sweeten a cup of coffee. Cereals and Other Starch-bearing Foods STARCH-BEARING 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 cornmeal and other preparations of corn eaten in the United States. Besides the cereals and vegetables which, like the potato, are com- posed chiefly of starch, there is a large miscellaneous group of starchy 160 FOODS AND FOOD PREPARATIONS or amylaceous foods used as flours, which are therefore conveniently considered 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 examina- tion. 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 by C. F. Langworthy. Composition of Cereal Food (Langworthy). Pro- tein. Fat. Carbo- hy- drates. Ash. Fuel value per pound. Flour, meal, etc.: Entire-wheat flour Percent. 13.8 13.3 11.4 13.4 12.1 6.4 6.8 9.2 16.7 8.0 .4 Percent. 1.9 2.2 1.0 .9 1.8 1.2 0.9 1.9 7.3 .3 .1 Percent. 71:9 71.4 75.1 74.1 75.2 77.9 78.7 75.4 66.2 79.0 88.0 90.0 Percent. 1.0 1.8 .5 1.3 1.3 .9 .7 1.0 2.1 .4 .1 Cal. 1,650 1,645 1,635 1,645 1,680 1,605 1,620 1,&35 1,800 1,620 1,650 1,675 1,200 1,040 1,195 1,130 1,170 1,630 1,925 1,910 1,875 Graham flour Wheat flour, patent roller process High-grade and medium . . . Macaroni vermicelli etc Wheat breakfast food Buckwheat flour Rve flour Corn meal Oat breakfast food Tapioca- Starch Bread, pastry, etc. : White bread 9.2 5.4 8.9 9.7 9.0 6.3 9.7 11.3 9.8 1.3 1.8 1.8 .9 .6 9.0 12.1 10.5 9.1 53.1 47.1 52.1 49.7 53.2 63.3 69.7 70.5 73.1 1.1 2.1 1.5 1.3 1.5 1.5 1.7 2.9 2.1 Brown bread Graham bread Whole-wheat bread Rve bread Cake Cream crackers Oyster crackers Soda crackers VEGETABLE FOODS 161 Farinaceous foods are composed of flour of different kinds, and constitute a subdivision of starchy foods. The different starchy and farinaceous foods are derived from a variety of plant structures, in- cluding roots, tubers, bulbs, stems, pith, flowers, seeds, fleshy fruits, etc. Some, like the banana and certain vegetables, are eaten raw, but the majority require cooking, and the starches derived from grain-bearing plants of the grass tribe or cerealia usually must be prepared by grinding and milling before cooking. About one-sixth of the . protein of the various grain flours passes through the ali- mentary canal undigested. Atwater's Table of the Percentage of Starch in Vegetable Foods. Wheat bread 55.5 Wheat .flour 75.6 Graham flour 71.8 Eye flour 78.7 Buckwheat flour 77.6 Beans 57.4 Oatmeal 68.1 Cornmeal 71.0 Rice . 79.4 Potatoes 21.3 Sweet potatoes 21.1 Turnips 6.9 Carrots 10.1 Cabbage 6.2 Melons 2.5 Apples 14.3 Pears 16.3 Bananas . . . 23.3 In round numbers it may be stated that starch composes one-fifth of potatoes, one-half of peas, beans, wheat, rye, and oats (their flours contain more), and three-fourths of rice and Indian corn. In addition to the cooking which the cerealia require, they are often predigested by diastase for invalid use. Strong heat converts starch to dextrin; but diastase, like the natural digestive ferments, can convert it into maltose, and as such it is fitted for absorption. Fortified gruels, as they are called by Eoberts, are made of cereal flours or dried legumes, with addition of milk, beef tea, or eggs. The flours if used alone, in strength of 5 per cent, become pastry and are insipid, but if one-eighth of their weight of ground malt be added they remain fluid with 20 per cent of flour, and, as this starch is largely dextrinized, they are highly nutritious. Thus made, Eoberts says they contain 2 per cent of protein and 14 per cent of carbo- hydrates. BREAD-MAKING It has been well said that the quality of the bread used by the inhabitants of any country is a fair measure of their civilization. Flour is prepared from various grains by crushing and grinding processes. The grains consist of (1) an outer layer, the husk or skin, which is woody, fibrous, and indigestible, and which in the 13 162 FOODS AND FOOD PREPARATIONS milling process is separated into "bran"; (2) a kernel within the husk, which is composed of gluten, fats, and salts; (3) starch. To appreciate the important details of bread-making, it will be necessary first to review the structure and composition of the grain from which the bread is derived. Structure of the Wheat Kernel. The wheat kernel is subdivided into four layers. The first or outermost layer (Fig. 25, H) consists of two or three strata of elongated cells the long diameters of which correspond with the long axis of the grain. From these cells slender filaments or tapering, hair-like processes project outward. The cell margins are irregular in outline, and appear somewhat beaded. Immediately beneath the outer hairy layer lies the second layer (Fig. 25, F), consisting of more or less quadrangular cells, with rounded angles, which are more uniform in size than the others, and grow at right angles to them. The third layer (Fig. 25, K] consists of a delicate, trans- parent membrane-like structure. The fourth or internal layer (Fig. 25, S) is composed of large, almost rectangular cells arranged in one or two strata, which contain a dark granular material that may be separated easily from the cell walls. The grains of other cereals conform in a general way to the structure of the wheat grain, although they differ in the thickness of the several layers, the number of their strata, and the size of the individual cells. The wheat grain contains about 14 per cent of proteids (chiefly cerealin and gluten), a trace of sugar, cellulose, much starch (70 per cent) fat (2.60 per cent), and ash about 2 per cent (mainly phos- phoric acid and potash). The remainder is water (about 10 per cent). Bran. Wheat bran contains about 15 per cent, of protein, 3.5 per cent of fattv matter, and 6 to 7 per cent of mineral substance, mainly phosphates (Yeo), all of which materials, from a purely theoretical standpoint, should be nutritious, but, practically, little bran is absorbed, and it is often irritating, especially where feeble- ness of the digestive organs exists. As proved by the researches of Professor Snyder, this is the reason why bread made from patent FIG. 25. SECTION THROUGH WHEAT KERNEL ( From Rupp). H, Hair-like processes; F, K, second and third lay- ers; S, fourth internal rectangular cell layer ; a, b, c, d, successive lay- ers represented as par- tially stripped off. VEGETABLE FOODS 163 flours is so much more digestible than that made from Graham or whole wheat flour. Gluten. Gluten is separated in the process of making starch from wheat and other grains. It is a valuable proteid consisting of (a) 60 to 70 per cent gliadin and (6) 30 to 40 per cent glutenin. The' FIG. 26. CROSS SECTION OF A GRAIN OF WHEAT AS SEEN UNDER THE MICROSCOPE. (U. S. Dept. of Agri., Bui. 56, Office of Expt. Stations.) greater part of the gluten is held in the central four-fifths of the grain. The gliadin adheres to the glutenin, retains the gas in dough, and in excess it makes the flour soft and sticky, hence soft wheat yields a flour with high percentage of gliadin, but hard wheat has a low percentage. Gluten is capable of considerable expansion independently of the 164 FOODS AND FOOD PREPARATIONS FIG. 27. MICROSCOPIC CHARACTERS OF WHEAT (+ 200) (From Landois and Stirling). a, cells of the bran; b, cells of thin cuticle; c, gluten cells; d, starch cells. development of C0 2 , and, as this power varies with different flours, it affects the quality of lightness of the bread. When pure it is so adhesive as to admit of being drawn into long shreds or bands, as in "shredded wheat." Composition of Bread. Bread is really a mixed food, in that it con- tains so many classes of ingredients^ fat, protein, salts, sugar, and starch and this is probably the explanation of the fact that its -i a daily use never cloys the ap- petite. Although it contains some fat, it has not enough for a perfect food, and hence the almost universal custom of using butter with it. Moreover, it forms a conven- ient vehicle for taking fat in this manner, and the butter aids in the mastication and deglutition of the bread. In round numbers, bread contains about two-thirds nu- trient material, or twice as much as beef, although it is of different force value in the body. One hundred grams (3i/^ ozs.) furnish 216 calories. Bread-baking. Bread is made from a mixture of the flour of any cereal with water, constituting a dough which is made uniform by kneading either by hand or by machinery. A pound of bread is made from about three-quarters of a pound of flour by the addition of 25 per cent of water. Some flours will take up 10 per cent more water. A small quantity of the ferment yeast is also worked uni- formly into the dough with a little salt and the mass is left to stand for a number of hours, during which fermentation progresses, producing from the starch alcohol, carbonic acid, and water. The best temperature at which this leavening proceeds is from 100 to 110 F. After remaining for some hours at this uniform tempera- ture, the bread is baked in a hot oven the temperature of which is sufficient to kill the yeast germs and check further fermentation. Of all the cooking processes now in use by civilized man, the making of bread is, perhaps, the most important. The object of cooking flour in this manner is to make it light and porous, so that the digestive fluids may be incorporated easily with it. Flour eaten alone forms a glutinous or sticky mass which is quite indigestible and difficult to swallow, besides being comparatively tasteless. There VEGETABLE FOODS 165 are many variations in the process of bread-making, but all are based upon the same principle the development of carbonic-acid gas throughout the mass of dough, which bubbles up and causes it to " rise " or forces it apart. In general, the process involves a loss of about 1 per cent of C0 2 and 1 per cent of alcohol. The loss of volatile products represents a loss of but 1.58 per cent of starch. Of the remaining starch less than 8 per cent is converted into soluble form (dextrin), but many of the starch granules are ruptured or dis- integrated. Development of Carbonic-acid Gas. Carbonic-acid gas may be FIG. 28. YEAST PLANT TORULA CEREVISICE MAGNIFIED. (U. S. Dept. of Agri., Bui. 56, Office of Expt. Stations.) generated or introduced in four ways: I. Indirectly by natural fer- mentation excited by the addition of the yeast fungus, Torula or Saccharomycetes cerevisice. II. By the use of " leaven," a name given to old dough in which fermentation has already occurred. III. By the addition of baking powders. IV. Directly by " aeration/' I and II. Bread Made by Yeast or Leaven. When bread is made by yeast or leaven the process, which may be divided into three stages, is as follows: 166 FOODS AND FOOD PREPAEATIONS (1) Kneading the flour thoroughly, to mix the water, yeast and salt. (2) Fermentation with moderate heat, during which the accumu- lating carbonic-acid gas endeavors to escape in bubbles, which become entangled in the more or less tenacious gluten of the flour. Upon the size and number of these bubbles depends the porosity of the bread, and this in turn is modified somewhat by the kind of flour used, the quantity of the ferment, and the rapidity with which the development of carbonic acid is allowed to proceed. (3) Baking the dough, during which the heat of the oven, by expanding the carbonic-acid gas, makes the bread still more porous and " sets " the walls of the little cavities which have formed so that the loaf maintains its shape. The gas is finally driven off, together with a large quantity, but not all, of the water, which escapes in part through evaporation, when the external portion of the bread becomes drier and browner than the interior or crumb, and constitutes the crust. The thickness of the crust will depend upon the character of the flour used, the temperature of the oven, and the duration of the process of baking. With the exception of these changes, bread has practically the same composition as its original flour. Mixing meal or flour with fat tends to prevent the evaporation of water from the bread. The chief art in baking bread consists in arresting the yeast fer- mentation of the dough by the heat of the oven (300 to 400 F.) at exactly the right period. If fermentation has not proceeded far enough the bread is tough, or sodden, or lumpy, whereas if it has gone too far it acquires a sour taste by the development from the carbohydrates of organic acids, such as acetic, butyric, and lactic, which are both unpalatable and unwholesome. Fermentation pro- duced by the use of leaven instead of yeast is much more difficult to control, and these acids, therefore, are more likely to be formed. The bread made with fresh brewers' yeast is by many esteemed to have the best flavor. There are several minor chemical changes described by H. Snyder and L. A. Yoorhees : " (1), the formation of volatile carbon compounds; (2), a change in the solubility of the protein compounds; (3), the formation of amid and ammonium compounds from soluble proteids; and (4), the partial oxidation of the fat." About 2 per cent of the weight of the flour used is lost in volatil- izing these various organic products. "With prolonged fermentation this loss may amount to 8 per cent. VEGETABLE FOODS 167 In steam-cooked cereals also, the starch is partially dextrinized and thus rendered more digestible. III. Baking Powders. Carbonic-acid gas may be developed in bread by the action of baking powders. These powders are very ex- tensively employed, and " a conservative estimate of the quantity of baking powder used in the United States each year places the figure considerably above 50,000,000 pounds" (Clark). There has been, however, much argument in regard to their wholesomeness, and elaborate researches in chemistry and the phys- iology of digestion have been conducted to determine whether or not the continued use of these ingredients in bread is injurious. The so-called baking powders are manufactured by the combination of many different ingredients, such as sodium carbonate with tartaric acid, the acid phosphate of lime with sodium carbonate and potas- sium chloride (Liebig-Horsford), or a combination may be used of ammonium carbonate with hydrochloric acid. It is claimed by the advocates of the use of baking powders that they possess many ad- vantages, such as the fact that the bread rises quicker, and that al- though fermentation does not occur, the bread is more porous, and -hence more digestible, and that its taste is not impaired. On the other hand, it is argued that such bread, especially when am- monium carbonate is employed, in time may excite dyspepsia and gastric catarrh. Even when not used for the making of bread these baking powders often are employed in the preparation of various forms of cake where lightness and quickness in making are important features. Baking powder when pure should consist only of cream of tartar (acid tartrate of potash, obtained as a precipitate in the casks in which wine is made) and soda, with a little flour added, and should be free from alum, ammonia, etc. Mixed with water and dough, the soda is split by the acid tartrate, liberating carbonic-acid gas. Alum is sometimes used in baking powders with soda. Its action is less re- liable, and in large quantities it is astringent and injurious to di- gestion. IV. Aerated Bread. The process of aerating bread consists in the forcing of carbonic-acid gas into the dough under pressure. The gas is generated by the action of sulphuric acid upon lime, and while there are several methods of its use, in general, about one cubic foot of gas is applied to fourteen pounds of flour, although not over one- half of this quantity remains in the dough. It is claimed for this process that the bread is exceptionally light, dry, and porous, that there is no danger of malfermentation, with production of acidity, 168 FOODS AND FOOD PREPARATIONS and that it sooner hardens when exposed to the air as compared with home-made bread prepared with yeast. Aerated bread keeps fresh longer than other varieties. It yields a peculiar flavor which, however, is preferred by some people. It is claimed as a further advantage for its manufacture that the bread requires less kneading by the sometimes dirty hands of the baker. Some twenty or thirty varieties of germs are usually to be found beneath the finger nails of persons who are ordinarily ' cleanly. If special care is not taken by those who prepare bread it is possible for disease germs to be introduced from beneath the nails into the dough. It has been claimed that various infectious diseases might be transmitted in this manner. The danger, aside from any aesthetic consideration, is, however, grossly exaggerated, as the fermentative processes, together with the prolonged heat used in baking, are fatal to both germs and spores. In aerated bread salt is added to the dough as in the other processes, with the result of making the bread firmer and somewhat whiter. There are many cereals, such, for example, as oatmeal and the coarser whole meals, which are exceedingly wholesome when cooked by some methods, but which cannot be baked into 'good bread be- cause of the difficulty of making them porous, and their attempted use in this form usually results in dyspepsia, with heartburn and acid fermentation. The addition of boiled rice flour in bread-making causes the bread to become more adhesive and to hold more water. Hence bakers sometimes resort to this means to make their bread heavier when it is sold by weight. Freshly baked bread is less digestible than dry bread for the reason that, being more moist, it tends to form a tenacious bolus in the mouth which is not readily mingled with the saliva or other di- gestive secretions. Dry bread, on the other hand, crumbles into smaller particles, which are easily acted upon by the saliva and pancreatic juice. For the same reason, the crust of bread is more digestible than the interior part of the loaf. Spoiled Bread. Bread may be unfit for use from being made of adulterated or too old flour, from turning sour from bad flour de- veloping excess of lactic acid, from becoming bitter from yeast, from becoming sodden from insufficient fermentation or aeration, and it may grow moldy from exposure to warm and damp air when it is too. moist. VEGETABLE FOODS 169 VARIETIES OF BREADSTUFFS AND PREPARED FARINACEOUS FOODS Wheaten Flour and Bread. Bread of different kinds constitutes the staple starchy food for Americans, as the potato does for the Irish peasantry and macaroni for the Italians. The quantity of bread consumed varies somewhat with the ability to obtain other articles of diet. For example, persons residing in large cities are wont to eat a larger percentage of animal food and less breadstuff than those in the country. The French laborer con- sumes daily eight hundred grams (nearly two pounds) of bread in the country against five hundred in the city. Tough, moist, imperfectly baked, or hot bread, is liable to ex- cite further fermentation in the stomach, causing heartburn and other symptoms of dyspepsia. The digestibility of such bread is promoted by heating it to drive off the moisture, and by spreading it well with butter to prevent it from agglutinating in the stomach. Water continues to evaporate from hot fresh bread, and such bread should not be covered tightly, or else it becomes sodden. Stale bread is more digestible than fresh bread. In stale bread water is evaporated to a great extent, so that the bread becomes friable and is more readily masticated and mingled with digestive fluids. The fact that stale bread on being warmed over becomes softer is accounted for on the hypothesis that in drying the water has not all been evaporated, but that some of it has combined with the flour, forming a new compound, which is dissociated by the further application of heat (Yeo). Toast is bread sterilized and browned by heat of about 170 C. (338 F.). The additional caramel flavor and dryness thus acquired lessens the time of digestion of toasted as compared with fresh bread by one-third, but in healthy stomachs the digestion of toast although quicker is on the whole less complete, because the proteids are rendered less soluble by 2.5 per cent. The heat evaporates the water of the bread and changes a superficial portion of the starch to dextrin, but in artificial digestion experiments the carbohydrates of bread and toast are equally digestible. (H. Snyder, Minnesota Agricultural Experi- ment Station Eeports.) A slice of bread, if cut sufficiently thin, toasts dry and crisp throughout, but if thick, the outer layers are scorched while the mass within may become softer than before toasting. Buttered dry toast is a digestible form of invalid food, for if the butter be spread thin while the toast is quite hot it penetrates to the interior, and both fat droplets and starch crumbs mutually protect 14 170 FOODS AND FOOD PREPARATIONS each other from cohering in large masses. The butter, moreover, enables one to eat more bread in this form. The same is true of milk toast, which furnishes in addition a means of giving considerable milk to patients who are unwilling to drink it. Whole-meal Bread. For some flours the whole of the wheat is used, the gluten, nitrates and phosphates all being retained. The proportion which the elements, carbon and nitrogen, bear to each other is such that wheaten bread alone is not an economical food. If man is to live upon it alone for any length of time, brown bread or Graham bread is better than the varieties made from fine FIG. 29. BREAD MADE FROM DIFFERENT KINDS OF FLOUB, A, 307.7 Grams of bread from 227 grams of graham flour; B, 302.5 grams of bread from 227 grams of entire wheat flour; C, 301.5 grams of bread from 227 grams of standard patent flour. (U. S. Dept. of Agri., Bui. 101, Office of Expt. Stations.) flour, from which latter the nitrogenous elements largely have been removed by milling. A " bread-and-water diet" is proverbially a reducing diet, and as such it is given to insubordinate prisoners (see Diet in Prisons), but they cannot subsist upon it for longer than two or three weeks at most. Bread made of whole meal is usually not so light as that made with refined white flour. The explanation of this is said to be the fact that the silieious envelope of the grain contains a ferment resem- bling diastase, which is called " cerealin." While the dough is rising, this ferment acts upon a large portion of the starch, forming viscid VEGETABLE FOODS 171 compounds of dextrin and sugar, which by agglutination prevent the carbonic-acid gas from puffing up the bread as much as it should. On the other hand, too much attrition in the mill ruptures the indi- vidual starch granules, and without the use of artificial baking powders the bread will not be light and wholesome. The British Commissioners of Prisons recommended the use of whole-meal bread for convicts at hard labor on. account' of its greater cheapness and nutritive value, but advised a modification in the proc- ess of its manufacture. The dough is made of flour from which the sharps, etc., have been removed. The latter are then added and mixed thoroughly with the dough just before it is ready for baking, and it is claimed for this process that there is not time for the cerea- lin to act, and consequently the bread is much lighter. For economical or other reasons, wheaten flour is sometimes ad- vantageously mixed with potatoes or bean flour. The latter, added in the proportion of 1 part to 10 of wheat, gives a white bread rich in nitrogen and highly nutritious. Corn flour may be mixed in the same proportion. Pumpernickel is a German black bread made with unbolted meal and sour dough. It is somewhat laxative. Zwieback is a thoroughly dry form of aerated bread, which is very wholesome for invalids. Graham bread so called after Sylvester Graham, who advocated its use differs from white bread by containing bran. The bran, however, while containing serviceable proteid and phosphates is so difficult of digestion that it tends to irritate the mucous membrane of the intestine and increase peristaltic action. For this reason it is more laxative than white wheat bread. It is a popular idea that coarse bread, black bread, whole-meal bread, etc., are more nutritious than the bread made from refined white wheaten flour or delicate French breads. This is not neces- sarily true, and much depends upon the digestive organs of the in- dividual. In a report on the digestibility and nutritive value of bread (Bulletin No. 85, U. S. Department of Agriculture) by Charles D. Woods and L. H. Merrill, they show the coefficient of digestibility of white bread averages 93.37 per cent (in some samples it is as high as 97.06 per cent), whereas that of whole-wheat bread is 91.50 per cent, and that of Graham bread is only 86.94 per cent. About 87 per cent of the protein is absorbed. They also found that bread was rendered more digestible when eaten with milk than if eaten alone, the increase in digestibility amounting to 15 per cent. There are peasants in Europe who can thrive upon the coarsest forms of 172 FOODS AND FOOD PREPARATIONS sour, black bread, and there are others who can use different forms of fermenting foods and beverages which to those unaccustomed to them would prove most injurious. According to Bauer, " with wheaten bread, rice, macaroni, .etc., the carbohydrates are utilized to within 0.8 or 1.6 per cent, whereas of black bread, potatoes, and the like, 8 to 18 per cent of the carbo- hydrates are passed with the feces." Decorticated flour is prepared by special methods of grinding with the object of removing two or three of the outermost and toughest coverings of the grain, but not the inner envelope. Yeo says of B C FIG. 30. BREAD MADE FROM ENTIRE WHEAT, PATENT, AND GRAHAM FLOUBS, AND CHARACTER OF FECES FROM SAME. A, Feces from graham bread; B, feces from entire wheat bread; C, feces from standard patent bread. (U. S. Dept. of Agri., Bui. 101, Office of Expt. Stations.) broad made from such flour, that while it may be suitable "for young and growing persons with sound and active digestion," it may " prove very indigestible to adults leading sedentary lives. It makes a bread which is usually heavier, moister, and of closer texture than that made from the finest wheat flour." AVhen digestion is not vigorous, it is better to obtain the neces- sary nitrogenous material from animal sources. The special uses of coarse forms of bread will be pointed out under the Treatment of Constipation. Gluten Bread. P>read made from gluten flour is useful where VEGETABLE FOODS 173 there is a tendency to obesity, and is given to diabetics, although with less benefit than has been claimed for it. (See Diabetes.) It may be toasted like ordinary bread. The best bread of this kind is made in Paris, and contains from 40 to 50 per cent of gluten, but there are many so-called gluten breads in market which do not contain above 16 per cent of gluten, the remainder being starch. Poluboskos is a gluten food which is said by those interested in its manufacture to contain only 0.4 per cent of starch. The name indi- cates "much nourishment." It is given to diabetics in doses of one or two teaspoonfuls in milk. Biscuits, Pastry, Puddings, etc. In addition to bread an almost innumerable variety of biscuits, cakes, pastry, tarts, pies, etc., are prepared by the addition, in various proportions, of flour, milk, cream, butter, or other fat, sugar, eggs, flavoring extracts, and fruit, such as raisins. For making pastry, cake, and puddings of different kinds, the finer grades of wheat flour usually are employed, although corn and Indian meal are sometimes used. The dough is raised in such preparations by the help of yeast, alcohol, fat, baking powders, or whipped white of egg. A hot fire is used in the cooking, and the puddings are either baked, boiled, or steamed, so that the flour is altered by the heat in much the same manner as in the manufacture of bread. These foods vary so much in richness and digestibility that it is difficult to formulate any definite rules for their use. In general, they should be avoided by persons having indigestion, dyspepsia, or, in fact, any severe illness; but farinaceous puddings, like rice or farina, simply made and thoroughly cooked, with the addition of eggs and milk, play an important part in hospital dietaries, and are very good foods for convalescents. Boiled or steamed puddings, being unfermented and surrounded with abundant water, are* very likely to be sodden or stringy, and therefore indigestible. Pastry, even when light, is apt to be too rich, and if not well cooked it is sodden or tough and almost certain to disagree, mainly because of the changes which the high grade of heat produces in the butter or other fats used in its preparation. Prepared Farinaceous Foods (often called " Infant Foods," " Pre- pared Baby Foods " or " Proprietary Foods "). Prepared farinaceous foods are made by the following methods: 1. Application of heat alone. 2. Digestion with malt or diastase combined with heat. 3. After dextrinization, the food is evaporated with milk or cream. FOODS AND FOOD PREPARATIONS The prepared farinaceous foods may be eaten alone or diluted with water, but they are usually given to invalids in a cup of broth or beef tea, which disguises their sweetness. The sweeter varieties are combined best with milk. 1. Farinaceous Foods Prepared by Heat Alone. Imperial Gran- um, Flour ball, Eidge's Food, Blair's Wheat Food, Schumacher's Food, and Robinson's Patent Barley are examples of this class. Wheat and oats are sometimes prepared by roasting (not steam- ing), a process which removes all moisture besides producing some chemical changes in the fats and starches. Cereals treated in this manner will keep from molding in any climate, and are both diges- tible and nutritious. Imperial Granum is a type of a large class of prepared foods, the basis of which is starch, modified, it is claimed, so as to render it easily digestible. Such foods are often fed to newborn infants to the exclusion of milk, but no greater mistake can be made, for their digestive apparatus is unfit to deal with very much starch. The human infant is designed to be nursed at the breast for the first year of life, and Xature has furnished ample food for it which is wholly devoid of starch. The saliva and pancreatic secretion upon which the digestion of starches depends are not adapted fully for this work during the first eight or nine months of life, and then only partially, hence starchy foods, "farinaceous baby foods," should seldom be given before that age as foods, and used very sparingly, if at all, as mechanical diluents of milk. Moreover, in such simple starchy foods as arrowroot the proportion of tissue-building to heat- producing foods is one to twenty, whereas in human milk it is one to five. Granum is composed of over three-fourths starch, made into a fine flour. One tablespoonful of it should go to each three ounces of water, in which it is boiled for ten minutes. An equal quantity of milk is then to be added, and the mixture again boiled for five min- utes. It is a useful temporary food for adults with irritable stomachs. Flour ball is prepared by boiling wheat flour tied in a bag, with the supposed purpose of converting it into dextrin, and it is a popular belief that this conversion is quite complete; but it requires a tem- perature of 250 F. to clextrinize starch, and this degree cannot be at- tained by the process. Leeds has shown that after seventy-five hours of continuous boiling the percentage of soluble carbohydrates is increased l>y only 0.05 of 1 per cent, whereas some of the pre- pared foods contain from two to six times as much soluble carbo- hydrates as wheat flour. Flour ball tastes flat and insipid, owing VEGETABLE FOODS 175 to the long boiling dissolving out fat, soluble albuminoids, and salts. Starr gives the following rule for the making of flour ball : Tie one pound of unbolted wheat flour firmly in a pudding bag and boil for ten hours. At the end of this time it will be found, on opening the bag, that the outer layer of the ball is doughy, while the interior is hard and dry, it having been baked by the long-continued heat. This hard mass may be used for infant feeding in the latter part of the first year, but it should not be given more than twice a day. The flour ball is grated fine, and it may then be prepared, according to Starr's rule, as follows : " Eub one teaspoonful of the powder with a tablespoonful of milk into a smooth paste, then add a second tablespoonful of milk, constantly rubbing until a cream-like mixture is obtained. Pour this into eight ounces of hot milk, stirring well, and it is then ready for use. The flour ball thus prepared is quite digestible, and prevents the formation of large curds of milk. As a diluent of milk it is much cheaper for the poor than the pre- pared amylaceous foods which are on sale. 2. Farinaceous -foods digested with malt or diastase with heat are often called " Liebig's Foods." Liebig's foods are made of equal quantities of wheat flour and barley malt, with bran, and 1 per cent of bicarbonate of potassium. These ingredients are mixed into a paste with water and digested for several hours at fixed temperatures, until the starch is trans- formed into soluble carbohydrates, maltose, and dextrin. The food is strained, pressed, and extracted' with warm water, evaporated, dried, and pulverized, when it is ready for use. Liebig's Infant Food is a good illustration of this type. It is pre- pared as follows: Mix a half ounce each of ground malt and wheat flour, seven 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. Eemove 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 dextrin and maltose. The food thus prepared is highly nutritious, for it not only contains the proteids of milk, but those also of wheat flour and malted barley (gluten and albumin), as well as the predigested starch. The malted foods which are made with desiccated milk and malted flour are deficient in fats, salts and protein, but the lack of these substances may be supplied by the addition to the food, when used, of cream and beef juice. The digestibility of bread 176 FOODS AND FOOD PREPARATIONS may be increased by adding 5 grains of diastase to the pound of flour mixed in the dough. For manufacturing malted foods the wheat or barley flour should be baked in order to rupture the starch granules and make them more soluble. Examples of Liebig's type of dextrinized foods are : Mellin's Food, Horlick's Food, Savory & Moore's Infant Food. According to Leed's analysis, the best samples of Mellin's and Horlick's foods contain no starch, but a large percentage (Mellin's 68.18 per cent, Horlick's 76.83) of soluble carbohydrates, and about 10 per cent each of albuminoids if the process is complete. Savory & Moore's food he finds contains considerable starch. Mellin's Food consists of brown sweetish granules, easily soluble in both hot and cold water, milk, etc. It is made of coarsely ground wheaten flour with the addition of malt and potash. It is then digested with water at a moderate temperature to form dextrin and sugar. Afterwards it is strained through sieves and evaporated in a vacuum pan. Mellin's Food is often fed to infants, but it contains too much sugar without fat for a wholesome baby's food for continued use in quantity. It may be resorted to temporarily when good cow's milk cannot be obtained. The food may be prepared for use as follows : For an Infant One Month Old. Mellin's Food .......................... 5 level teaspoonfuls. Fresh milk ............................ 10 tablespoonfuls. Hot water ............................. 22 " For an Infant of Three Months and for Delicate Children. Mellin's Food ... 8 level teaspoonfuls (equal to 1 heaping tablespoonf ul ) . Fresh milk ...... 16 tablespoonfuls (equal to % pint). Hot water ...... 16 tablespoonfuls (equal to For Infants of Sim Months and Over. Mellin's Food ...................... 2 heaping tablespoonfuls. Fresh milk ........................ 24 tablespoonfuls (equal to % pint) . Hot water ......................... 8 tablespoonfuls (equal to % pint) . Mix the Mellin's Food with a little hot water into a smooth paste, add the remainder of the water and the milk, and mix thoroughly. Keep this mixture on the ice or in a cool place. Bcngcr's Food is a preparation of wheaten flour to which, after cooking, pancreatic extract is added. When mixed with warm milk both milk and flour are newly digested. A tablespoonful of the food is dissolved in two ounces of cold milk. Then half a pint of boiling milk or milk and water is slowly stirred in. Further pancreatiniza- VEGETABLE FOODS tion is then arrested by boiling for twenty to thirty minutes. The preparation has no bad taste and is a nutritious and digestible food in cases of gastric ulcer, phthisis, dyspepsia, etc. 3. Foods Which are Dextrinized and Then Evaporated with Milk or Cream. These are sometimes called " milk foods." Such are Lac- tated Food, Malted Milk, Loeflund's Cream Emulsion, Nestle's Food, Gerber's Food. The general process by which foods of this class are made is as follows : Wheaten or other flour is first made into dough, baked, ground, mixed with more or less condensed milk or cream, and then dried at a moderate temperature. By addition of malt or diastase the starch is partially converted into dextrin and maltose, and the albuminoids are rendered slightly more soluble, the casein is dried, and the lact- albumin is precipitated. One form of " cereal milk " is made from a mixture of wheat and barley meal with milk. It is claimed for some of the malted foods prepared for infant and invalid use that the artificial digestion is not wholly completed, and this is said to be an advantage in stimulating the digestive organs. Malted milk is a powdered sterilized preparation of pure cow's milk and extracts of malted barley and wheat, the starch of which has been converted into dextrin. The mixture is dried in vacuo. The casein of the milk is predigested by a vegetable ferment. The preparation keeps well while hermetically sealed, and when re- quired for use for an infant, fron one to four teaspoonfuls are dis- solved in from eight tablespoonfuls to a half pint of water. For adults, two tablespoonfuls of the powder in a half pint of water make the strength of cow's milk. The idea of this preparation is to furnish a substitute for human milk which will keep well, be always ready for use, and in which dextrin takes the place of additional fat. It resembles Mellin's Food, except that it contains some, though not enough, fat. It is used in about the same proportion. It makes a better invalid food for adults than for infants, and patients with enteric fever and severe gastrointestinal disorder take it with benefit. NestU's Food is prepared in Switzerland, at Vevay, from pasteur- ized cow's milk, which is condensed and to which ground wheaten bread crust is added after dextrinization. Cane sugar is mixed in, and the mass is dried, pulverized, and hermetically sealed in tins. For use it requires dilution with water. It contains 25 per cent of sugar, 27.36 of maltose and dextrin, 5.50 of fat, 15.39 of starch, 6.57 of lactose and 14.34 of proteids, besides salts and water. 178 FOODS AND FOOD PREPARATIONS Carnrick's Food is composed of evaporated or desiccated milk partly peptonized and thoroughly sterilized by heat, 45 parts; dextrin and soluble starch, 45 parts : milk sugar, 10 parts. Eskay's albuminized food consists of the prepared cereals oats, barley, maize, and wheat together with lactose and egg albumin. It contains 11.33 per cent of total solids. Bread Jelly. A bread jelly may be made to add to milk for in- valids and for use while weaning infants who are old enough to digest a little starch i. e., over one year of age. The crumb of stale bread is broken into small fragments and covered with boiling water, in which it is allowed to soak until well macerated. The water is then strained off, fresh water is added, and the mass is boiled until quite soft. On cooling, a jelly forms which may be mixed with milk in any desired proportion. Farina is a general name meaning flour. As sold by grocers in this country, it is usually made from wheat, but much of the gluten and bran has been separated, rendering it less nutritious than whole wheat. In cases of diarrhoea it is more bland and less irritant than whole wheat. The name " farina " is also applied to fine white potato starch, which forms a jelly when cooke'd, like arrowroot. Wheatena is a nutritious food containing all the wheat berry ex- cepting the husk, and thereby differing from finer preparations in which the layer of gluten cells is removed with the bran. The starch granules, moreover, have been ruptured by heat. It is commonly eaten as a thin mush or porridge. Cracked or rolled wheat has similar advantages. Shredded wheat, trisket and pulled bread are modified breadstuffs which lately have become deservedly popular among dyspeptics on ac- count of their easy digestibility. Shredded wheat biscuit is made of wheat which is thoroughly cleaned, washed, cooked, and treated by machinery which draws out the wheat kernels into long, continuous filaments, thus breaking down their structure without separation of the component parts. Eighty such filaments are obtained within a space four inches wide; they are porous and, unlike dough, are capable of absorbing the diges- tive fluids, thus no leavening or baking powder is required. The shreds are folded by mashing into oblong biscuits, which are recooked at successive temperatures until all moisture is driven off and they are ready for use. They may be eaten soaked in milk, cream, or broth, or moistened with hot water and buttered. Crackers. All kinds of crackers enter more into the dietary in America and England (where they are called "biscuits") than in VEGETABLE FOODS 179 any other country. The lighter forms of wafers and rusk are nutri- tious and very easily digested by invalids having mild gastric dis- order, for the starch has been well torrefied. Crackers vary much in hardness and flavor, but, generally speak- ing, they are quite as digestible as good bread. The simplest forms, such as water crackers or milk crackers, are made with flour and water or milk, to which a little salt is added, after which they are baked in flat shapes so as to become hard and more or less brittle. Soda is sometimes added. If it is desirable to have them less friable, butter may be added in small quantity. The hard unleavened prepa- rations known as " ship biscuits," " hard-tack," and " pilot biscuits," which form an important article of diet for sailors at sea, are manu- factured upon these principles. Ship 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. Most biscuits, if kept long exposed to the air, become exceedingly dry and tasteless, although they do not readily mold. 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 re- quire soaking in milk or water before they can be eaten. Granose is a flaky form of entire wheat biscuit prepared by the Battle Creek (Mich.) Sanitarium Health Food Company. It may be eaten with cream or hot milk, and is palatable and nutritious. Gran- ola is a similar preparation. Composition of Crackers ( Clark ) . Water. Nutrients. Protein. Fats. Carbo- hydrates. Mineral waters. Boston crackers Percent. 8.2 Percent. 91.8 Percent. 10.7 Percent. 9 9 Percent. 68.8 Percent. 2.4 Soda crackers 8.0 92.0 10.3 9.4 70.5 1.8 Pilot crackers 7.9 92.1 12.4 4 4 74.2 1.1 Graham crackers 5.0 95.0 9.8 13 5 69.7 20 Oatmeal crackers 4.9 95.1 10.4 13 7 696 1 4 Oyster crackers 3.8 96.2 11 3 4 8 77.5 26 Semolino is a name having two applications. In France it de- notes the hard central substance of the wheat grains which are re- tained in the bolting machine after separation of the finer portion which has passed through: but in Italy the word is used to denote the finer portion itself, consisting of fine hard granules rounded by 180 FOODS AND FOOD PREPARATIONS grinding. The larger sizes contain much gluten, and may be used to thicken soups. The granules swell in water. When the grinding and sifting process is carried 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 current of air, cut in lengths, and dried on screens. As much as twenty million pounds of macaroni are manu- factured 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, 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." After thorough soaking and when well cooked by boiling or stew- ing in milk or stock it is very nutritious, and 'it is often agreeably combined with cheese, although this is not advised for persons with feeble digestive power. The use of Italian pastes, such as 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 large proportion of protein. Although 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 sometimes is called, is indigenous to temperate climates, and in some parts of the world, notably in Eussia, Siberia, and Brittany, it constitutes a staple of diet, but in the United States it is the least important of the cere- als, and is used rather as a luxury for making griddle cakes. The buckwheat produced in the United States is raised mainly in Xew York, Pennsylvania, and some of the New England States. Buck- wheat bread is nutritions, but it crumbles and does not keep well. Buckwheat farina and groats are made. Buckwheat flour has less protein and more carbohydrate than wheat flour. According to T. F. Hunt it contains, water 12.6 per cent, protein 10, fat 2.2, carbohy- drate 64. 5. crude fiber 8.7 and ash 2 per cent. VEGETABLE FOODS 181 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. (See Diabetes). Millet and sorghum are grown in the warmest parts of Asia and Africa, and to some extent in southern Europe. In Eussia 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 grown chiefly 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 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). Eye. Eye rriay 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 eaten mainly by the Germans. In Ger- many the rye production is double that of wheat, and in Eussia 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. Eye yields a coarser, darker, less well-raised 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 pre- ceding pages (pp. 161, 164) in regard to bread-making, etc., with wheaten flour, may be applied to rye flour. Eye bread contains a less elastic 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 flavor. Eye 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. Maize, or Indian corn, is grown very extensively 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. There are some 300 varieties of corn, but the common kinds are known simply as white, yellow, and red. 182 FOODS AND FOOD PREPAEATION8 a The chief preparations of corn are hominy, samp, cornmeal, cracked corn, cerealine, and maizena (a South American cornmeal, 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 laundry starch. Chittenden and Osborn have made an elaborate research into the chemical composition of the "proteids of the corn or maize kernel." These consist of "three globulins, one or more albumins, and an alcohol-soluble proteid" called maize fibrin or zein. Corn is a wholesome cereal, for it contains considerable fat (Fig. 32) and proteid (Fig. 33) as well as starch, and it furnishes abun- dant energy, producing heat. It is very fattening for both the lower animals and man. In the Southern States and in France it is fed largely to horses. As a fresh vegetable, corn is less used in Europe than in America, perhaps on account of the prevalent idea that it is a hog's food, although cornmeal 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 notor- iously so. This is chiefly on ac- count of the toughness of the husk of the kernel, which often is found in the feces practically unaltered by its transit through the body. Hence it may cause flatulency, indigestion, and diarrhoea. Cornmeal, on the other hand, is quite digestible, and, like oatmeal, 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, for corn contains no elastic gluten. Samp is a very digestible coarse form of corn when well boiled. When maize becomes moldy it causes the disease known as pellagra. (See Diet in Pellagra.) Polenta is a maize meal extensively used in Italy. Cornstarch is very white and soft. It contains 53 per cent of FIG. 31. SECTION OF GRAIN OF CORN. a, Skin and Testa; 6, Membrane; c. Embryo; d, Endosperm; f, Scuttelum. (U. S. Dept. of Agn., Farmers' Bui., No. 112, Helen W. Atwater.) VEGETABLE FOODS 183 FIG. 32. KERNELS OF CORN: HIGH-OIL (ON THE LEFT) AND Low-OiL (ON THE EIGHT). (U. S. Dept. of Agri., Farmers' Bui., No. 193.) starch. The best grades are used as a substitute for arrowroot., and make a -wholesome invalid food, being very white and soft. Indian meal is yellow, granular, and coarser than cornstarch. Mush is made of well-ground cornmeal or Indian 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. Corn-syrup has been especially recom- mended as a nutri- tious food for the tu- berculous. 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, " in Asia a large part of the population con- sume 275 pounds per head a year," and nearly two bil- lion 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 marsh-land, periodically in- undated. Both the Chinese and Japanese make a wine from rice 3 and a vinegar also may be obtained. The native Oriental method of treating rice is to beat the kernels of grain out of their husks in wooden mortars, and for European FIG. 33. KERNELS OF CORN: HIGH-PRO- TEIN (ON THE LEFT) AND LOW-PROTEIN (ON THE RIGHT). (U. S. Dept. of Agri., Farmers' Bui., No. 193.) 184 FOODS AND FOOD PREPARATIONS markets they are glazed by shaking in a sheepskin-lined drum. They are also bleached, and may be broken after decortication and ground into a flour. " Puffed rice " is a new preparation by which the rice kernels are expanded in a vacuum, heated and browned, so that they may be eaten with sugar and cream, without cooking. This form of rice has some- what the flavor of pop-corn and is easily digested, of agreeable taste, and very nutritious. " Puffed wheat " is similarly made. Bice contains more starch than any other cereal from 75 to 85 per cent and is exceedingly digestible for invalids 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 prevents their agglutination into a pasty mass. If the rice is insipid it may be spiced or flavored with raisins. Bice 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 dis- eases. It is also advantageous to eat rice with fruit, such as apples or prunes. Eice should not be depended upon without some form of animal food, for it contains too little nitrogen to satisfy the needs of the system. Bread cannot be made economically from rice, on account of the small amount of protein which this cereal contains, and the conse- quent 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, albuminoids, starch, and dextrin. As compared with wheat, barley contains more fat, salts, and indigestible cellulose, less protein, and less digestible carbohydrate. The proportion of bran to the grain is 21 to 79. 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 corns of their outer shells or covering, and then subjecting them to nibbing between a single millstone and a sheet of rasped iron or wire cloth, a process which polishes the kernels and rounds them off. VEGETABLE FOODS 185 Barley water makes an excellent diluent of milk and a demulcent drink for infants and invalids. For the latter it may be flavored 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 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 pre- ferred when constipation exists. The viscidity of barley water is due to its proteids. Oatmeal. Oats contain considerable fat, protein, 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 because 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 either rice or barley. The use of oatmeal porridge by all classes is very extensive through- out the United States. This is largely attributable to improved methods of its preparation by high milling, rolling, etc. Scotch groats are prepared by removing the outer husk, leaving the grain almost whole. The grain is then reground between closer set mill- stones. It forms two grades of meal, the coarser of which is used for porridge and the finer to make bannocks or oatmeal 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 infrequently cooked in such a manner that the individual grains are left whole, but in this form the flavor is less well developed than it is by prolonged cooking; the oatmeal granules are much more difficult of digestion, and are capable of exciting gastrointestinal irritation in feeble per- sons. But for many persons oatmeal thus cooked possesses a de- cided advantage from the fact that it is less completely absorbed, leaving a considerable residue which adds to the bulk of fecal 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 cooked so thoroughly as to acquire 186 FOODS AND FOOD PREPARATIONS the consistence which enables it to be poured easily, and on cooling it should form a tender, gelatinous 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 flavor, becomes moldy and sour. 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 15.0 Total 100.0 The proportion of bran to the grain is 44 to 66. Oatmeal, like cornmeal, has more protein and fat than the flours and meals derived from other cereals, and hence, like bread, it may be eaten daily without impairing the appetite. Revalenta Arabica is a farinaceous food much eaten in some parts of Europe, which is a mixture of several meals, principally ground peas, beans, corn, and lentils, but barley and oatmeal may be in- cluded. 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 pulverized into a very fine starchy flour. The best flour is made from the Maranta arundinacea. 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 se- vere cases of dyspepsia, when much gastric irritation exists, it often constitutes a serviceable article of diet. Arrowroot is fed sometimes to young infants, but it is unwholesome for them, and ferments in 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 largest VEGETABLE FOODS 187 of any of the food starches, but they are quite digestible and nutritious for invalids. 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 rhizo- mata of the Manioc utilissima or Manihot, a common plant in tem- perate 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. Cas- sava contains a poisonous juice that first must be drained off. Tapioca, which is purified cassava, is made, like sago, by drying on hot plates, the clarified starch being heated first 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 digestion. Tapioca may be eaten alone in the form of puddings with, cream or flavored with lemon juice, wine, nutmeg, or other spice or aromatic, or may be used to thicken broths or soups. " Pearl tapi- oca " is a spurious article made from potato starch. Air-dry tapioca contains 11.97 per cent of water. Water-free tapioca consists of: protein 0.79, carbohydrates 98.90, and ash 0.31 (C. D. Woods and L. H. Merrill). Sago. 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 flavor, somewhat more delicate than tapioca, which it resembles, and is an invaluable adjunct to the invalid dietary. Iceland moss (Cetraria Islandica) is a lichen sometimes employed as food 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, recommended by Senator and others for use by diabetics to replace ordinary bread, and it makes a convenient vehicle for the adminis- 188 FOODS AND FOOD PREPARATIONS tration of fats, such as bone marrow (Henry J. Walker). It also forms a good demulcent 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 whole 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 gastrointestinal disorder, they should 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 year, but only with their meals. The bread always should be porous, well baked, and stale. It may be toasted, or given dry in milk, or moderately buttered. Zwieback and plain rusk are also good foods for young children. Crackers are made in great variety for children who have passed the second year. 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, or oatmeal. DIASTASE, MALT EXTRACTS, ETC. Diastase is a vegetable ferment which has the property of convert- ing 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 1 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 iheir starches into dextrins and sugars. When malt is added to a pease pudding or other mashed vege- VEGETABLE FOODS 189 table, it separates the mass into a paste of cellulose and vegetable casein, with a supernatant solution of dextrin. The use of malt flour with cereal foods renders them more di- gestible. Malt flour alone is too sweet, but, added in the propor- tion 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 beneficial in tuberculosis, caries, chronic sepsis, neurasthenia, typhoid fever, and to some extent they may be used as beverages to replace the stronger malt liquors, ale, beer, etc., for, according to Leeds, they always contain above 3 per cent of alcohol. Malted foods are deficient in fats and protein. 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 may be used, and the preparation still remains fluid (Eoberts). 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 equal part 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, hypo- phosphites, 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. Trammer'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 flavor. The sweetness may be lessened by dilution with water, or hot milk. It is advisable, if the stomach is feeble, to give teaspoonful doses at first, 1 to be increased to a tablespoonful three times a day after meals. 190 FOODS AND FOOD PREPARATIONS 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 digestible. The hydrated starch has been converted into dextrin and sugar. There is little or no alteration produced in flavor, 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 in General 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- bivorous animals is normally alkaline when they are well fed, but during prolonged fasting it becomes acid. 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 proteids are less rich in nitrogen than the corresponding animal albuminates. 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. A purely vegetable diet is not economical for a laboring 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. (See Vegetarianism, p. 33.) 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. Among 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 pulses, contain little fat. A strict classification of vegetables is difficult in these pages. For example, green corn is a green vegetable, but it is more con- veniently described in connection with cornmeal, samp, etc., among the cereals. (Sec Corn. p. 181.) Certain vegetables are classed as " green vegetables," meaning the lighter weight vegetables which contain con-iderable earthy salts and comparatively little starch, like spinach and lettuce, in distinction from heavy vegetables which con- tain much starch, like potatoes, beans, etc. The former term is used VEGETABLE FOODS 191 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 ac- curate 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 simple division of vegetables for patients is (a) those the edible portions of which grow above ground and (&) those which grow below ground. With few exceptions, like the legumes, corn, and cabbage, the heavier vegetables i. e., those which require more digestive power, and which 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 chief part, at least as eaten, beneath the earth ; hence it is best in all important cases to specify by name the individual vegetables which may 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 used for flavoring broths and soups for invalids. Generally speak- ing, 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, peppers, 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 cucum- bers, and tomatoes, are laxative from the seeds, or, like old corn, squash and celery, from the indigestible residue which they contain. The heavier vegetables, such as peas, beans, beets, turnips, potatoes, etc., are liable to be constipating, although they aid normal peristalsis in that class of cases in which the diet has been previously mainly nitrogenous. (See Dietetic Treatment of Constipation.) 192 FOODS AND FOOD PREPARATIONS Vegetables which have a special antiscorbutic reputation are cab- bage, tomatoes, and all those used for fresh salads. These also yield calcium oxalate in the urine. All vegetables which are eaten raw should be washed thoroughly 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 used sometimes for sprinkling gardens, and it is possible for typhoid, cholera, or ether noxious germs to be spread by this means when the vegetables are eaten raw. LEGUMES Peas, Beans, Lentils, Peanuts. Legumes rank next to cereals in importance as vegetable food. In middle and northern Europe among legumes peas are preferred, but in Mediterranean countries the use of beans and lentils predominates. In this country both peas and beans are extensively eaten, the Jentil very little. Owing to the exceedingly leathery external envelope which they possess when old, legumes are very indigestible unless cooked for a long time, and if dried they require previous prolonged soaking in cold water, for drying diminishes their size and makes them extremely tough. Fresh legumes contain much water, and in percentage composition resemble the cabbage. They also contain much protein, carbohy- drates, and a little fat. Percentage Composition and Heats of Combustion of Dry Legumes. (Chas. E. Wait.) Water. Protein (NX6.25) Fat. Carbohy- drates. Ash. Heat of combustion per gram. Beans, kidney Per ct. 11.25 Per ct. 25.38 Per ct. 1.41 Per ct. 58.38 Per ct. 3.58 Calories. Beans white 11.21 18.25 1.63 64.89 4.02 3.885 Cowpeas, lady 11.32 25.50 1.73 57.88 3.57 4.023 The proteid substance von Liebig called " plant casein," from its re- semblance to casein of milk. It differs from the proteid gluten of grains and will not form dough. The percentage of protein in legumes exceeds that of the best beef (M. H. Abel). Although the legumes contain so large a percentage of protein, it is by no means all assimilated. Hoffman found that nearly one-half of the protein of lentils passed off in the feces, being unabsorbed. Striimpell found VEGETABLE FOODS 193 that 40 per cent of the protein of whole beans i. e., with the skins intact is undigested; but when made into flour only 8.2 per cent of protein was unabsorbed, the latter corresponding with the digesti- bility of meat protein. In Buhner's experiments with dried peas 28 per cent of the proteid was lost in the feces. Legumes are liable to induce intestinal fermentation, with exces- sive and often annoying production of gas (methan), hence they are not available as the sole article of diet. If eaten as an exclusive food, eighteen ounces of dried peas or beans, making six pints of thick soup, would have to be consumed daily (M. H. Abel). Dried " split " peas have had the external envelope removed, and they may be made into nutritious purees. The tough external coats of old peas may often be found unaltered in the feces. 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 than meat. The Cou'pea is especially recommended as a food for man in a study of the legumes made at the University of Tennessee in 1907 by Prof. Charles E. Wait. He finds their nutritive value equal to wheaten bread; they have a distinctive agreeable flavor, and they have long been used in the Southern States. The legumes are often cooked with pork, which adds to the per- centage of fat in this form of food. 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 out- side 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 protein 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, for which the legumes are noted. The flatu- lence is caused by liberation of sulphuretted hydrogen from legumin. Erbswurst may be made readily into soups. It figured largely in the Franco-Prussian War, and was known as the "iron ration." A powdered " pea soup " may be obtained which is composed of powdered peas and extracts of beef with salts and herb extracts for 15 194 FOODS AND FOOD PREPARATIONS flavoring. A three-and-a-half-ounce package contains in grams: proteids, 21 ; fats, 17.25 ; carbohydrates, 46.5. It is excellent for army service in the field. Percentage Composition of Some Prepared Military Pea Foods (Woodruff). Water. Pro- tein. Fats. Carbo- hydrates Wood fibre. Ash. Authority. Erbswurst . . . 12.09 7.58 8.08 4.78 31.18 16.93 15.81 21.09 3.08 8.98 24.41 17.25 47.50 53.44 36.78 46.45 6.15 11.73 13.53 6.03 Blythe Konig S.P.Sharpless Dried pea soup ( 1 ) ... " " (2) ... Kopf's " " (used by the English army) . . 1.34 1.69 4.40 Penzoldt has succeeded in obtaining predigested vegetable albu- min by the following receipt: Finest pea meal 25.0 grams. Pepsin 0.5 gram. Salicylic acid 1.0 " 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 flavored with salt, pepper, and spices. Haricots or kidney beans constitute a very serviceable article of diet, being one of the cheapest and best of all the pulses. These beans should be soaked thoroughly until swollen and soft before boil- ing, and should be eaten only when tender. Their flavor is height- ened by the addition of a little onion, parsley, or other aromatic vegetable, and their nutritive value is increased by cooking 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 indigestible. The same is true of butter beans. The red bean of the tropics, which is largely used in the Mexican army ration, is less prone to cause diarrhoea than the dry domestic white bean : but it has a more tender skin, is therefore less easily transported, and it absorbs moisture so rapidly that it is liable to ferment. The frijolc is a small, flat, reddish-brown bean much eaten in Mexico and neighboring portions of the United States. The *o//<7 bean is the chief legume of China and Japan, where it furnishes the necessary protein to add to a rice diet. From its vegetable casein several varieties of bean cheese are made. (Page 181.) 195 Lentils. Lentils are much cultivated in the south of France, and also near Paris. They are usually dried and split, in which condition they make a nutritious soup. They are used more on the Continent of Europe than in this country, and they are eaten in England, usually in the form of puree. Lentil flour con- tains twice as much pro- tein as that of oats or wheat, and nearly twice as much lime (Rob- erts). The Hindoos rely upon the lentil for its staying power when undertaking arduous journeys. Lentils are sold un- der the name of " rev- alenta Arabica " of which they form an ingredient (p. 186). Their taste is somewhat bitter, and on that ac- count, unless disguised by some vegetable fla- vor, they may be dis- liked. Like the other legumes, they contain protein and fat, and are nutritious (Fig. 34). Peanuts. The pea- nut is not a nut at all, but a legume growing at the surface of the ground. It resembles nuts, however, in its large content of fat 50 per cent. 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 been made with the view of possible introduction of this food into the German army to be used like erbswurst (p. 193). Peanuts contain consider- FIG. 34. LENTIL. (Mary H. Abel, Farmers' Bui., No. 121.) 196 FOODS AND FOOD PEEPAEATIONS able 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 imitation coffee. A form of peanut meal is prepared for diabetics which is said to con- tain little or no carbohydrate. Pancakes may be made from it. The FIG. 35. PEANUT. (Mary H. Abel, Farmers' Bui., No. 121, 1900.) meal contains 52 per cent of protein, 27 per cent of carbohydrates, and 8 per cent of fat. Four million bushels of peanuts are raised annually in the Southern United States. ROOTS AND TUBERS Eoots 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 nutritious and fattening, but in proportion to their bulk they afford less actual nutriment than either 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- VEGETABLE FOODS 197 tivation in a great variety of soils and on account of its digesti- bility when properly cooked. As an exclusive article of diet the potato is composed too largely of starch to be of much nutritive value, and several pounds a day would have to be eaten to supply enough nitrogen for the energy of the body. The potato, however, has less starch than rice, peas, or lentils. It also has less woody fibre than most underground vegetables. In Ireland this 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 supplemented largely by the cultivation of Indian corn and other products. The flavor and quality of the potato is influenced very much by the soil and climate in which it -, -ll-l ^SALT grows, a sandy soil being best. / PRQTUN "\ Konig gives the percentage composi- / CARBOHYDRATES\ tion of the potato as water, 75.77 ; nitro- ^ genous materials, 1.79 (others give 2.10) ; fat, 1.60; starch, 20.56; cellulose, 0.75; ash, 0.97. It is thus seen to con- tain about one-fourth solid material. The potato becomes a much more strengthening food when eaten, as it usually is, with meat, gravy, fat, or but- ter and salt. Potato juice has $ faintly acid reac- tion, and its vegetable acids are combined mainly with salts of potassium, but also OF INGREDIENTS. There is .., ,. T -. . TJ. i also a faint trace of fat. with sodium and calcium. It also con- tains traces of iron, phosphoric and sulphuric acids, chlorine, silica, and magnesia. Owing to the comparatively large proportion from 15 to 24 per cent of nearly pure starch which is found in the potato, it is ex- tensively used in this country and elsewhere for the manufacture of laundry starch. Old potatoes, and those which have been kept long, show some alteration in the quantity of their starch, and a part is converted into sugar and gum. Potato starch, as compared with other starches, is thoroughly di- gestible, 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, " soggy," and quite indigestible. 198 FOODS AND FOOD PREPARATIONS The following statement in regard to the potato is made in a re- port 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 cooking. The watery part of this juice is absorbed by the starch granules, 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. FIG. 37. POTATO STARCH AS IT APPEARS UJTDER THE MICROSCOPE. (U. S. Dept. of Agri., Bui. 56, Office of Expt. Stations.) Unless the potato be cooked .properly, 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.' '' \Yhen potatoes are cooked in water, it is desirable not to remove 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 drv 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 VEGETABLE FOODS 199 quite digestible if steamed, or if boiled and mashed through a colander. Potatoes should 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 be- come 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 only 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 may 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 flavor than do the white. In general, they should not be given to invalids for they are liable to produce in- digestion and flatulency. The yarn, 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 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 little starch, and is not " mealy " when cooked. It contains more sugar than the sweet potato, having 14 per cent of sugar, 3 per cent of protein, and 2 per cent of inulin. Its nutritive value is comparatively slight, but it is easily digested. Beets. The beet contains among its solids between 85 and 90 per cent of starches and sugars, a trace of salts, and somewhat over 1 per cent of protein. It is a common source of sugar, which when refined is somewhat less sweet than cane sugar, but is other- wise 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 200 FOODS AND FOOD PREPARATIONS eaten in the form of salads or with vinegar and oil, and thus con- tribute a useful variety to the diet. Succulent Tubers. Carrots, parsnips, turnips, salsify, and radishes constitute 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 digestible, and when thoroughly boiled are nutritious. 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 1 per cent of protein. The outer layers of the carrot contain a material called pectin that may be obtained as a jelly and mixed with fruit or meat jelly for flavoring invalids' food. Young carrots, when soft and friable, if boiled are very tender and highly flavored, and constitute a nutritious food. In France and Germany they are more popular than in this country and arc cooked with other vegetables, although somewhat at the expense of the flavor of the latter. At the baths of Vichy they form a part of the daily breakfast. Parsnips 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 1 per cent of protein, besides other materials. It is a rather strongly flavored vegetable, and bulky in proportion to its nutritive value, but when young and properly cooked by pro- longed boiling and seasoning it is a good food. It should be par- ticularly avoided by those persons in whom there is any tendency to flatulency, which, like the legumes, it is apt to produce. It may be fermented into an alcoholic beverage. 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 above-ground turnip, which is somewhat astringent. Salsify, or oyster plant, is a root which has a mild 'sweet flavor somewhat similar to the parsnip, and is an excellent food of easy digestibility. 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 chiefly as a relish. Being usually eaten raw, it is difficult of diges- tion, and is apt to produce eructations. It is rendered more digestible by cooking. Tt has some reputation as an antiscorbutic. VEGETABLE FOODS 201 GREEN VEGETABLES Composition. Green vegetables do not contain much nutriment in comparison with cereals and tubers, and are useful mainly for furnishing a pleasing variation in diet and supplying a large pro- portion 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. 44). 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 only a small quantity of proteid, which varies from 1.5 up to 4 per cent. In addition, they contain cellulose, chlorophyll, sugars, gum, pectin, and sometimes a little fat. Their variety of taste depends upon the presence of flavoring ma- terials, chiefly essential oils. As a rule, they have a better flavor, and are more digestible when young than old, when they become tough and " stringy " from a relatively large percentage of cellulose or woody fiber. 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. 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. The digestibility of these vegetables is rendered much greater by careful cultivation in suitable soils. Owing to the large quantity of 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 celery and winter cabbage form an exception, as they 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 accept- able form for invalids is that of purees. Varieties and Properties. Cabbages. The cabbage family, which belongs to the natural order Cruciferce, 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 contain considerable sulphur, which, if malfermentation exists in the alimentary canal, produces sulphuretted hydrogen, causing flatulence and unpleasant odor. They may also give rise to calcium oxalate in the urine, by causing indigestion, and they should be avoided by the rheumatic or gouty, and. in fact, by all classes of invalids. Cabbages and other vegetables of this 16 202 FOODS AND FOOD PREPARATIONS order impart a strong taste and odor 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 properties when fresh, which are lessened by fermentation. The principle edible representatives and preparations of the cab- bage family are the following: 1. Sauerkraut which 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 formation of organic acids. 2. Cauliflower and broccoli are the flowers of plants which are grown large and tender by cultivation. When boiled and served with a milk or butter sauce they are much esteemed for their flavor 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. Cauliflower is also used as a common ingredient of mixed pickles. Brussels sprouts like the cauliflower are flowers, and resemble it in digestive properties. 3. Cole is a plant of the cabbage family which does not " head." 4. Seakale is grown in the dark, so that it has no chlorophyll. It is equally digestible with cauliflower if well bleached. It is more often cultivated in England than in this country. Spinach, beet tops or "greens," dandelion leaves, 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. The mineral salts which they contain, especially those of spinach, have been shown by Luff, of London, to be of service in gout in increasing the solubility of sodium biurate and retarding the con- version of quadriurates into biurates. (See Gout.) 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 whole- some articles of food for the relief of chronic constipation. Spinach may be used in tests to determine the digestibility and mobility of the stomach, as it is easy to recognize in the stomach contents when undigested. The leaves of the common milkweed make an excel- lent substitute for spinach, scarcely distinguishable from it in taste. Dandelion leaves have a less delicate flavor than spinach, and are said to possess a slight diuretic action. Unless bleached they are bitter. The dandelion root is laxative, like the leaves, and it forms an ingredient of root-beer. VEGETABLE FOODS 203 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 flavor 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 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 flavor, 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. A fatal case of sorrel-poisoning in a boy five years of age has been reported. To quench thirst, excited by eating a quantity of sorrel, he swallowed some soapy water, the alkali of which produced a soluble oxalate. A quantity of oxalic acid was found in the stomach. Many other substances besides those above mentioned are used in the making of salads or pickles and as relishes. They are anti- scorbutic and serve to stimulate the digestive secretions and give a fillip to the appetite. Such are green peppers, capers, mint, tar- ragon (an aromatic Siberian plant), parsley, chervil, endive, chicory, okra, rampion (campanula), burnet (pimpernel), borage, chive, na- sturtium seeds, purslane stems, and horse-radish. Celery is a wholesome vegetable when cooked in milk until it is quite soft; but eaten raw it is stringy, and, as it has little nutri- tive value, its use in that form should be discarded by invalids. Its aromatic flavor 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. In Germany celery is regarded as indigestible because the root is chiefly eaten, instead of the bleached stalk, which is preferred in this country, and is much more crisp and tender. " Celery salt " is an agreeable flavor- ing 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 per cent of organic mat- ter. Green artichokes when tender and thoroughly cooked are easily digested, but their high cost in this country (except in California) prevents them from being consumed otherwise than as an article 204 FOODS AND FOOD PREPARATIONS of luxury. They may be given to diabetic patients. Eaten raw, as they sometimes are in France, they are very indigestible. Tomatoes. The tomato is a vegetable which was introduced into this country about seventy 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 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 is said to make it injurious in cases of gout or the uric-acid diathesis. The tomato is much prized as a canned vegetable on ac- count of the fact that it retains more of its original flavor than do most vegetables 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 assimilable, 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 fiber 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 to the large size of the seeds which the vegetable contains, and it should never be eaten by any one excepting those having vigorous stomachs. Eaten raw, even in small quantities, it may produce vio- lent colic and diarrhoea. Asparagus is a vegetable possessing a very delicate flavor, 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 green 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 owes this influence to a substance called asparagin, which may be obtained in crystalline form. As- paragus imparts a very strong and disagreeable odor to the urine which may 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 oaten stowed , is an excellent vegetable. The flavor is quite tart, and the fiber is stringy, but thorough cooking renders it soft and VEGETABLE FOODS 205 digestible. It is laxative, and is therefore useful in cases of chronic constipation, but should not be confounded with the medicinal rhu- barb. This wholesome vegetable has not received the attention 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 should therefore be avoided in oxaluria, gout, and rheumatism. Pumpkins and squash contain much water and a good deal of coarse fiber. 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, for it was grown extensively together with maize by the early Indian tribes. Vegetable marrow, like the pumpkin and squash, is a gourd. It is a succulent wholesome vegetable of agreeable flavor. In France the young marrows are called courgettes. They may be baked, boiled or stuffed. Onions, garlic, shallots, and leeks, which are edible both as fresh vegetables, and after long keeping, are useful as condiments for fla- voring salads, meat stews, and other foods. They also are 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 flavor. They possess, in common with the other green vegetables, a moderate laxative action, and are antiscorbutic. They impart a strong typical odor to the breath, which appears within two or three hours, and if constipa- tion exists, persists for twenty-four hours or more. This is due to volatile substances which are absorbed by the blood from the alimentary canal and carried to the lungs, where they are lib- erated. Taro or tania is a nutritious vegetable grown in the Polynesian Is- lands and to a limited extent in the southern United States. It is of a purple color, and root, leaves, and stalk are all eaten boiled. It is fermented to produce the " poi " of the Sandwich Islands. 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 flavor, 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 tabulated by C. F. Langworthy as follows: 206 FOODS AND FOOD PREPARATIONS Composition of Vegetables (Edible Portion). Water. Protein. Fat. Carbohy- drates. Calories per Ib. Beans, dried 12.6 22.5 1.8 59.6 1 520 Beans, Lima Beans string . 830 2 1 3 6 9 17O Beets 70.0 1.3 .1 7.7 160 Cabbage 77.7 1.4 .2 4 8 HT Celery 75.6 .9 .1 2.6 65 Corn, green (sweet), edible por- tion 75.4 3.1 1 1 19 7 44O Cucumbers 81.1 .7 .2 2.6 65 Lettuce 80.5 1.0 .2 2.5 65 Mushrooms 88.1 3.5 .4 6.8 185 Onions 78.9 1.4 .3 8.9 190 Parsnips 66.4 1.3 4 10 8 23fl Peas (Pisum sativum) 74.6 7.0 0.5 16.9 440 Potatoes 62.6 1.8 .1 14 7 295 Rhubarb 56.6 .4 4. 2 2 fin Sweet potatoes 55.2 1.4 .6 21 9 440 Spinach 92.3 2.1 3 3 2 QK Squash 44 2 7 2 4 ^ inn Tomatoes 94 3 9 4 ^ Q inn Turnips 62 7 9 1 57 I9n Vegetables Classified According to Their Dietetic Value. 1. Useful for nutriment, mainly protein, but also starch and fats: White beans. Red beans. Frijole. (haricots). Peas (dried and split, or fresh), Lentils. Peanuts. Lima beans. Kidney beans Soya beans. French beans. 2. Useful for nutriment, mainly for starch and sugar: White potatoes. Jerusalem artichokes. Sweet potatoes. Beets. Yams. Corn. Artichokes. 3. Useful for variety of flavor, as antiscorbutics, and to add bulk of undi- gested fibrous tissue to the feces in cases of chronic constipation: Carrots. Parsnips. Turnips. Kohl rabi. Salsify (oyster plant). Radishes. Cabbages (including cole, seakale, and sauerkraut). Cauliflower. Broccoli. Spinach. Beet tops. Turnip tops. Dandelion tops. Lettuce (including romaine). 31 ilk weed. Sorrel. Cress and peppergrass, Oreen peppers. Capers. Mint. Parsley. Endive. Chicory. Okra. Celery. Artichokes. Eggplant. Tomatoes. Cucumbers. Asparagus. Rhubarb ( pieplant ) . Pumpkins. Squash. Onions. Garlic. Leeks. Shallots. Vegetable marrow. Cranberries. VEGETABLE FOODS 207 Fruits Composition. The varieties of fruits 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. According to C. F. Langworthy fruits compose 5.6 per cent of the total American diet and 4.9 per cent of the total carbohydrate diet. Speaking generally, fruits are composed largely of water with starches, sugars, pectin, cellulose, organic acids, essential oils and ethers. To the two latter is mainly due their aroma and flavor which is also dependent upon varying proportions of sugars and acids. Fruit sugars are sucrose and invert sugar (containing dextrose and levulose in equal proportion). Pectin is a soluble carbohydrate substance found in ripe, pulpy fruits. It enables fruit to gelatinize when boiled with an equal quantity of sugar. Pectose and pectase are substances present in unripe fruit. The latter acts upon the former as the fruit ripens, forming pectin. If a fruit juice ferments or is cooked too long, pectin loses its gelatinizing power. 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 predomi- nates in lemons, limes, and oranges; tartaric acid in grapes; malic acid in apples, pears, peaches, apricots, gooseberries, and currants. Among the least acid of the common fruits are peaches, sweet pears, sweet apples, bananas, and prunes; moderately acid are strawberries. The most acid of all are currants and lemons, but acid fruits may also have a large percentage of sugar. Thus currants contain four or five times as much sugar as peaches, which contain less free acid and pectin. Fruits contain a smaller proportion of earthy salts than other foods. Certain fruits also hold a little protein, chiefly as albumins, but, as a rule, the starches and sugars predominate, and the nutritive value of any fruit depends upon them. 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 have more or less pigment. Many fruits are only partially edible owing to the fact that they 208 FOODS AND FOOD PREPARATIONS are composed of a pulp contained within an indigestible structure of cellulose or woody fiber. 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 amply to sup- port life for a long time; others, like the apple, are wholesome, but slightly nutritious; while others again are of little use for nutritive purposes, and are mainly serviceable for their agreeable flavor to furnish variety in the diet. Composition of Fruits, Yearbook of Dept. of Agriculture, 1905. Langworthy). (C. J. Kind of Fruit. Water. Pro- tein. Ether ex- tract. Carbohydrates. Ash. Fuel value per pound. Nitro- gen- tree ex- tract. Crude fiber. FRESH FRUITS. Apples Per ct. 84.6 85.0 81.1 75.3 86.3 79.2 80.9 88.9 85.0 79.1 85.6 77.4 82.9 81.9 89.3 87.4 89.5 82.9 67.0 86.9 89.4 80.9 80.2 89.3 78.4 76.8 79.6 85.8 94.4 90.4 92.4 Per ct. 0.4 1.1 1.0 1.3 1.3 1.4 1.0 .4 1.5 1.5 1.0 1.3 1.3 .6 1.0 .6 .6 .6 2.5 .8 .7 1.0 1.4 .4 1.0 1.5 .9 1.0 .6 1.0 .4 Per ct. 0.5 Per ct. 13.0 13 6 21.0 8.4 11.7 16.5 8.4 12 18 13 14.9 8.0 16 7.4 9.9 7.2 15 5.7 11 5.8 15.7 15.1 9.3 20 16.8 18 9.7 2.5 6.0 6 Per ct. 1.2 4 .8 1.0 2.5 3.7 .2 1.5 .8 .8 1 4.3 6.6 6 1.1 1.2 2.1 9 3.3 6 3.6 1.5 2.1 .4 1 2.7 .9 2.9 1.1 1.4 .7 Per ct. 0.3 .5 .9 .8 .5 2.7 .6 .2 .7 .6 .3 .5 .5 .3 .5 .5 .6 .6 4.4 .5 .4 .4 .6 .3 .5 .6 .6 .6 .7 .6 .3 Calories. 290 270 512 460 270 375 365 215 265 380 255 450 315 345 205 220 185 305 407 240 190 163 174 200 395 461 370 255 105 180 140 Apricots Avocado 10.2 .6 1.0 1.3 .8 .6 Bananas Blackberries Cactus fruit Cherries . . . Cranberries . .... Currants . .... Figs . Gooseberries Grapes 1.6 .7 .6 .7 .4 Guava Huckleberries Lemons Mango Muskmelons Nectarines .... Olives 17.1 .2 .1 .5 .6 .3 Oranges Peaches Pears Persimmons (Japanese) .... Pineapples Plums Pomegranates 1.6 Prunes Raspberries (red) Rhubarb stalks .7 .6 .2 Strawberries ^ atoi'melons In dried fruits the sugar content is very high, as follows : raisins 61 per cent, Zante currants 54 per cent, dates 66 per cent, and prunes 32 per cent. VEGETABLE FOODS 209 Fruits Arranged According to the Proportions between Acid, Suga/r, Pectin, Gum, etc. (Average) (Fresenius). Fruits. Acid. Sugar Pectin, gum, etc. 1 1.6 3.1 Apricots 1 1.7 6.4 Peaches 1 2.3 11.9 Raspberries 1 2.7 1.0 Currants 1 3.0 0.1 Blackberries 1 3.7 1.2 Whortleberries 1 4.3 0.4 Strawberries 1 4.4 0.1 Gooseberries . ., 1 4.9 0.8 Prunes 1 7.0 4.4 Apples . 1 11.2 5.6 Sweet cherries 1 17.3 2.8 Grapes 1 202 2.0 TJses and Properties. The uses of the different fruits may be sum- marized 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 favorably upon the se- cretions. 4. As antiscorbutics. 5. As diuretics, and to lessen the acidity of the urine. 6. As laxatives and cathartics. 7. To stim- ulate the appetite, improve digestion, and give variety in the diet. 8. As special " cures " for certain diseases, like the grape cure, al- though their specific action is very doubtful. In a study of the diet of women students at Lake Erie College in Ohio, made in 1900 by Isabel Bevier and Elizabeth C. Sprague, it was found that an increase in fresh fruit consumption, especially at breakfast, showed that more breakfast was eaten and it materially lessened the craving for sweets. 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. Those which contain the most water are muskmelons, watermelons, oranges, lemons, limes, 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 acidity of the urine or even makes it alka- 210 FOODS AND FOOD PREPARATIONS 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 sometimes beneficial in lithaemia and allied conditions to prevent accumulation of acid urates. The laxative action of fruits is partially derived from indigestible substances as cellulose, seeds, etc., and also, no doubt, from the special influence of their organic ingredients. The best fruits to offset constipation are fresh apples, figs, oranges, grape-fruit, prunes, and peaches. Dyspeptics should avoid eating all hard skins, seeds, or coarse-fibered fruits. A study of the dietary of six exclusive fruitarians (two women and four children) recently was made by Prof. M. E. Jaffa at the California Agricultural Experiment Station. They were all under- sized and underfed, and the following was an average daily ration: 475 gm. apples, 110 gm. bananas, 850 gm. oranges, 5 gm. dates, 2 gm. honey, 10 gm. olive oil, 55 gm. almonds, 70 gm. pine nuts, and 50 gm. walnuts. A fruit diet leaves very small fecal residue. Fruit Eipening. As fruit ripens it absorbs more and more oxygen, and the tannin and vegetable acids which it originally con- tained are altered, so that it becomes less astringent and acid. The starch is more or less completely turned into levulose or glucose, and soluble pectin is formed. The aroma and taste of ripe fruits depend upon the relative quantity of these different substances, to- gether 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 flavoring substance does it contain. Overripe fruit decays through action of molds and rots which thrive on the fruit sugars and proteids and develop new gases, odors and flavors. The color of green or unripe fruits is due to chlorophyll, and a yellow color is due to xanthin. Fruit Poisoning. While fruits eaten daily and in proper modera- tion 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 almost certain to cause diarrhoea with colicky pains, cramps, and sometimes nausea and vomiting. Severe attacks of gastritis may, especially in children, be produced by indulgence in unripe apples, pears, cher- ries, berries, etc., and fatal choleraic diarrhoea has been occasioned by the indiscriminate consumption of fruits which have strongly laxative action. After such fruit poisoning, emesis should be ex- VEGETABLE FOODS 211 cited 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. Certain tropical fruits possess spe- cific poisonous properties. 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 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, oranges or other fruit eaten as dessert, but which taken at night into an empty stomach or an hour before breakfast, with a glass or two of cold water, has a very pronounced favorable 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. All fruits, such as berries, the seeds of which are eaten, are much less liable to produce intestinal irritation if taken with bread or other bulky starchy food. Eaw fruit unless eaten at once after picking should be well washed. Dried fruits are eaten less abundantly than fresh fruits. Some of the dried fruits are poorly digestible; 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-crystallized 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. The word currant is a corruption of Corinth. 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 a few hours, or the fruit may be put into milk and brought to the boiling point over the fire. This method will soften them in a quarter of an hour. As Langworthy says, fresh fruits are dilute food comparable to vegetables, but preserved and dried fruits compare with cereals in food value. Cooked fruits (or " compote ") are used to a greater extent in Germany and France than in the United States, where a relatively large proportion of fruit is eaten raw. Cooking sterilizes fruit, and renders contaminating dirt innocuous, but boiling removes 4 to 7 per cent of the nutritive value. 212 FOODS AND FOOD PREPARATIONS Fruit syrups are made with about half as much sugar as fruit juice. Fruit Soups. In Germany fruit soups are more in vogue for general use than in this country, and they often are 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." Digestibility. Among the commoner fruits of easy digestion are grapes, oranges, grape-fruit, lemons, cooked apples, figs, peaches, cantaloupes, nectarines, blackberries, strawberries, and raspberries. Somewhat less digestible are watermelons, prunes, raw apples, pears, apricots, bananas, fresh currants, pineapples (except the plain juice), quinces. Naturally the digestibility depends upon ripeness and freshness of the fruit as well as personal idiosyncrasy, and any classification 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) and pineapple juice. 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 flavor to other articles of diet. For many persons the addition of a little lemon juice to some foods, such as cooked cereals and porridge or broiled fish, renders them more immediately digestible, and it may be regarded as having almost a specific action promoting gastric digestion, al- though it is difficult to say in just what manner this comes about. 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 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 su^ar, 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 Apol- linaris. Vichy, or carbonic-acid water instead of plain water, or VEGETABLE FOODS 213 effervescence may be produced by the addition of ten grains of sodium bicarbonate. Pure lemon juice poured into the nose will often control epistaxis. Fresh lemon juice has a popular reputation for warding off rheu- matism, but is has been shown to have very little influence over nitro- gen elimination, although it increases the phosphates of the urine. Limes. The lime is a thin-skinned acid fruit, but there is also a sweet variety. Although less extensively eaten throughout this coun- try than the lemon, which it resembles in effect, it is equally serviceable, and 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 removed by straining and filtering. The juice is then boiled down to a high degree of concentration. It is carried on sailing vessels to prevent scurvy, and used in almshouses and prisons, where the diet is monotonous. The shaddock, pomelo, or Citrus pomelanus, is a very large, globular pulpy fruit, which may attain to a weight of fifteen pounds. The rind is thick and acid, and the very juicy pulp is bitter. The fruit keeps fresh a long time. A smaller variety, known as the grape- fruit, has come into general use of late, although still a relatively expensive fruit. It grows in pendant clusters. Many persons find that half a grape-fruit taken at the commencement of breakfast has both a laxative and diuretic action, and it is always cooling 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 disadvan- tageous in cases of flatulent dyspepsia, but for invalids who are convalescing from prolonged fevers, suppurating disease, etc., an ex- cellent tonic may be given by cutting a grape-fruit in two and pouring a dessertspoonful of good rum or of curacoa into the fruit, with addition of a little sugar. The bitterness is entirely disguised and the combination is agreeable and appetizing. Modern cultivation methods are making this fruit less acid than formerly. Oranges. Oranges are an exceedingly useful article of invalid diet. The juice of ripe oranges allays thirst, and is well borne in cases where there is considerable gas-trie irritation and tendency to vomiting. It is only in the gravest 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 refreshing in fevers. I often give it in typhoid fever. Orange juice is laxative, particularly for infants, and is the best remedy 214 FOODS AND FOOD PREPARATIONS for infantile scurvy. It may be given undiluted or made into orangeade with one of the effervescing waters. In renal and other diseases in which it is desirable for the patient to drink large quan- tities of fluid for its diluent and diuretic effect, the addition of orange juice TO beverages will encourage their consumption. An ex- cellent remedy for constipation is the juice of three oranges squeezed into a tumblerful of Vichy, and drunk on rising and again at bed- time. Orange marmalade is a wholesome relish, having an appetizing, bitter flavor. 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 PERCENTAGE COMP&- S/r/O/V OfEOfBLE FIG. 38. COMPOSITION OF APPLE.. (Yearbook, U. S. Dept. of Agri., 1905. C. F. Langworthy.) of the throat, etc., especially in children. It is refreshing, and cooling, and is less likely to disagree than the richer ice' cream. Apples, when ripe and . properly selected, are very whole- some. 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. In dried apples the percentage of water is reduced to one-third, while "that of sugar is proportionately increased. Apples contain free organic acids (malic and gallic) as well as salts, such as malates, citrates, and tartrates. They also contain lime, phosphates, plant albumin, gum, and chlorophyll. They are good antiscorbutic remedies, and are laxative, especially, when taken into an empty stomach. There are many dyspeptics who thrive upon apples, oven if eaten raw, and who can regulate the action of the bowels with them effectually. They should be given to most in- VEGETABLE FOODS 215 valicls only when cooked. They are most digestible when baked and eaten with creamy or they may be beaten with white of egg to add to their nutritive power. They are palatable and digestible for con- valescents 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 ayoided in cases of diarrhoea, gastrointestinal irritation, and diabetes. Crab-apples are used only to make a jelly which is wholesome, but not suitable for invalids, being both too acid and sweet. 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 flavor when well pre- served in sirups, but they possess no special food value, and are mainly used for their choice- flavor, aroma, and appearance, which stimulate the appetite. Guava is a fruit of which there are many varieties, both whole- some and nutritious. In the tropics it is used almost as extensively as apples in temperate regions. In the Southern United States it is also cultivated and is eaten chiefly in the form of a jelly. Quinces are indigestible unless very thoroughly cooked, or made into jelly or marmalade. Peaches, nectarines, ami apricots are of comparatively little nutrient value, but their flavor 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. Pineapples (Ananassa satiya] , as usually obtained in this country, have been picked green in Cuba^ and if eaten raw with the fibrous structure are indigestible. Their ripe juice however, is very whole- some, and they contain a ferment capable of digesting proteid ma- terial, which is used to some extent in the preparation of predigested invalid foods, such as Mosquera's beef meal (p. 132). Prof. E. H. Chittenden has isolated this ferment, which has a rapid softening, disintegrating, and digesting effect upon such proteids as blood fibrin and muscle tissue. It is an acid fluid which acts best in a neutral medium, but, like trypsin, it also digests in both acid and alkaline solution. Three ounces of the juice will dissolve ten to fifteen grains of dried albumin in four hours. He also found a milk-curdling ferment in the juice. One ripe pineapple yields about a pint of juice, which when sweet- 216 FOODS AND FOOD PREPARATIONS ened and added to an effervescing water, makes a wholesome laxative and delicious beverage. 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. (See Receipts for In- valid Food.) 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 through an oesophageal 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 flavor 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 many score of varieties of the banana, ranging from the most delicate examples of the Musa sapientum family to the heaviest of the plan- tains, and they vary in digestibility as they do in flavor. Casati ("Equatorial Province/' 1891) names some fourteen varieties, hav- ing different characteristics and existing 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, amounting to nearly five parts per hundred of the entire 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 fruit will keep without spoiling, are accountable for this, and up- wards of one hundred thousand bunches of bananas are sold per VEGETABLE FOODS 217 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 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 ob- tainable in this country; but this no doubt depends upon the fact that the fruit shipped to the United States is picked very green, and REFUSE 4 ED/3LE PORT/ON 65J& FIG. 39. COMPOSITION OF BANANA. (Yearbook, U. S. Dept. of Agri., 1905. C. F. Langworthy.) is often immature and irregularly ripened when eaten. Imperfectly ripened bananas are composed chiefly of starch, but, as the natural ripening proceeds, the saccharine material is converted into a muci- laginous 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, as follows : " He eats porridge made with banana flour and milk. It 218 FOODS AND FOOD PREPARATIONS is very light and digestible, and has more flavor 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. It is difficult to make a good fruit flour, for most 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 constitutes an important exception, and when carefully selected and thoroughly dried may be ground into a meal or even into a flour, making as fine a powder as arrowroot, hav- ing a white or pale grayish or yellowish color, and an agreeable faintly aromatic odor 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 developed twice as much sugar as the same quantity of oatmeal or farina, and approximately one and a half times as much sugar as cornstarch. Saliva, when substituted for pancreatic extract, produces a similar effect. 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 flavor, lemon juice with powdered sugar upon the banana porridge is found very acceptable. The records of some fifty patients in the New York and Presbyterian Hospitals to whom 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 cases of simple gas- tritis and acute gastritis complicating chronic indigestion and in the early convalescent stage of typhoid fever. It was used with ad- VEGETABLE FOODS 219 vantage 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 indefinitely in a concentrated dry state, ready for im- mediate use. Grapes. Perfectly ripe and seedless grapes, such as the Black Hamburg and other varieties, have long been recognized as an ex- cellent food for invalids. Grapes contain so large a proportion of water that they possess little nutrient property, although they hold considerable sugar, but the salts which they furnish to the system are useful. These are the sulphates, phosphates, and chlorides of sodium, potassium, calcium, magnesium, and iron. The average percentage composition of grapes is given by Konig as : Water 78.17 Sugar 14.36 Free acid 0.79 Nitrogeneous material 0.59 Extractives 1.96 Stones and woody fibre 3.60 Ash 0.53 The habit some persons have of swallowing the pulp whole with the seeds, however small the latter may be, cannot be condemned too strongly. The seeds under no circumstances are digested, being too hard and tough to be affected by any of the juices of the di- gestive tract, and therefore act as irritants or foreign bodies. It was originally believed that inflammation of the appendix vermiformis was often caused by the entrance of one or two sharp-pointed grape seeds into this small division of the alimentary canal, but this has been proved to be an exceedingly rare occurrence. The seeds eaten in excess are liable to cause diarrhoea, enteritis, or intestinal obstruc- tion. Swallowing the skins of grapes is equally harmful. Grapes, on account of their sugar, should be excluded in cases of diabetes and gout. A special " grape cure " has been established for some diseases. (See Grape Cure.) IJnfermented California grape 220 FOODS AND FOOD PREPARATIONS juice constitutes an agreeable, wholesome, and slightly laxative, non- alcoholic beverage, which may be prescribed during mild fevers and in convalescence. Prof. Albert E. Leeds sent me the analysis of a grape food which he says " is entirely different from the grape juice, inasmuch as it contains, both in amount and condition, the con- stituents of the grape to a point of practical completeness to which the manufactured juices have failed to attain. I have verified by most exhaustive tests' the absence of all germs of fermentation, and this sirup will certainly keep indefinitely, even in the absence of alcohol or antiseptic." This "liquid grape food" contains protein and 64 per cent of grape sugar, with no alcohol and no starch. Raisins, prepared by sun-drying from certain species of grapes which are particularly rich in sugar, form a useful food, chiefly on account of the agreeable flavor which they impart to more insipid substances. (See also Eaisin Wine, p. 284.) Raisins are usually made from white grapes, but they turn dark purple or brown from oxidation of the tannic acid of their skins. 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 di- gestion 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 should not be swallowed. The latter contain a whitish waxy material which keeps the grapes waterproof. Raisins form an ingredient of pemmican (p. 233). Plums. Plums and greengages 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 prone to excite diarrhoea and intestinal colic. Prunes. Primes 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 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 good effect in regulating the bowels in children, and three or four prunes given once or twice a day hetwo?n meals will sometimes prove quite sufficient for this VEGETABLE FOODS 221 purpose. The tough skins should be removed before serving to chil- dren and invalids. Prunelles are sold in masses dried like dates. They have a pleas- ant acid flavor, but are not very digestible. Olives are eaten for their agreeable flavor and nutrient value, which is due to the oil they contain. (See Olive Oil.) They are much eaten as a relish, either plain or stuffed with peppers, and are used for garnishing salads, sauces, etc. About seventy varieties are now grown in California. They may be eaten fresh with bread 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, (&) fresh water, and (c) salt solution, and are left in the latter for preservation. The lye neutralizes their bitter taste. In Greece small, black, dried olives are much eaten. The composi- tion of the ash of California olives presents, among other ingredients, 60 per cent of potash, 16 per cent of lime, and 8.3 per cent of phos- phoric acid. Composition _of Pickled Ripe and Green Olives. (C. B. Smith and F. Langworthy). Water. Fats (oil). Carbohy- drates. Protein, ash, etc. Pickled ripe olives Per ct. 65 08 Per ct. 25 52 Per ct. 3 75 Per ct. 5 65 Pickled green olives 78.41 12.90 1.78 6.91 Berries. The strawberry, on account of its exceptionally agree- able flavor, 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 is promptly developed by taking 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 ex- ceptionally 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 mention. FOODS AND FOOD PREPARATIONS 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 (whortle- berries), raspberries, blackberries, and gooseberries all contain con- siderable 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 laxative when eaten with their seeds and skins, but Wmternitz has 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 sometimes may be used in fevers, although lemon or orange 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- tizing and wholesome flavoring 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 older children to be eaten with bread and butter. They aid in satisfying the natural craving of children for sweets, and, if taken in moderation, are wholesome, and their flavor may encourage the eating of more nutritious but less agreeably flavored 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 somewhat diuretic and sudorific. In general, berries having tough skins like the blueberry are less digestible than those without skins like the raspberry, and the skins and seeds often are found undigested in the feces. Melons. Melons are of little service for nutrition, but are so VEGETABLE FOODS 223 agreeable to the palate that they are in general favor. The varieties commonly obtainable in this country are the cantaloupe, or musk- melon, and watermelon, and of these, the former is less likely to pro- duce gastrointestinal disorder when not eaten too freely. These fruits contain so large a proportion of water upward of 95 per cent that they do not quickly satisfy 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 often may be eaten by invalids in modera- tion to promote the appetite, served at the commencement of a meal, at which time it is best that most fruit should be eaten if taken with other food. Citrons are most indigestible. ED/BLE 'POR77ON /OO/<3 /oo.o 91 11 72 08 90 00 Non-nitrogenous substances .... Fat 2.57 13 8.91 62 3.48 24 Grape sugar mannite 1.05 72 Other non-nitrogenous substances Woody fibre 3.71 0.67 7.54 7.92 3.95 0.67 Ash 0.76 2.21 0.94 Edible Fungi. Mushrooms. Mushrooms, on account of their nitrogenous material, are of some slight use as food; but if eaten in sufficient quantity to yield much nutriment, they always disagree. Bauer says : " Judging from their chemical composition, they ought to have no small value as foods, but it is doubtful how far they are really utilized in the alimentary canal." Mushrooms have a tempting flavor, 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 who never can 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. Their digestion requires fully three hours. The common mushroom con- sists of 01 per cent water, besides 31/2 per cent of carbohydrates, and 4 per cent of proteid, with salts and other substances. Truffle*. The truffle is a subterranean fungus of the order of pliore. Tt is an expensive luxury, and is used to add flavor in VEGETABLE FOODS 225 cooking and as an ingredient of rich meat sauces, pates, 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 odor. 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 truffling swine, broken for the purpose. The morel is a friable, grayish-black, cone-shaped mushroom, which grows extensively in a variety of dry soils, but, like the cepe, is ob- tained principally in France. It may be cultivated artificially. It is used for flavoring, like the truffle. Cepe is a name given to several edible mushrooms belonging to the Boletus family, which are globular in shape, and colored orange or white. The chantreul is a large orange-colored, cup-shape fungus eaten ex- tensively in' France, but also in this country. It flourishes in New England in August. Poisonous Fungi. Most poisonous fungi are distinguished from the non-poisonous by a warty cap and bulbous stem. They are often viscid and have other peculiarities of structure, color, etc. They are acrid or astringent, and have a pungent, disagreeable odor. Poison- ous mushrooms may either produce violent gastrointestinal symp- toms, which are seldom fatal, owing to the prompt evacuation of the poison from the system, or these symptoms are followed by a condi- tion of narcosis ending in fatal collapse. The pupils are contracted, the urine is suppressed, the face is livid, and there is general vaso- moter paralysis. The conjunctivas are congested. 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 antag- onized by belladonna. Lichen Iceland moss (Cetraria) is used extensively as a food by dwellers in the Arctic regions. Kb'nig gives the percentage composition of the dried moss as fol- lows: AVater, 15.96; nitrogenous matter, 2.19; fat, 1.41; non-ni- trogenous matter, 76.12. A bread is made from it after carefully washing out two bitter or* ganic acids which it contains. Senator has recommended it for diabetics. 17 226 FOODS AND FOOD PREPARATIONS Nuts Nuts contain protein, with some starch, more or less fat, and very little water. From 50 to 65 per cent of the common nuts is shell. With the exception of the cocoanut, chestnut, almond, and Englisli walnut, the varieties eaten in this country furnish little nutriment. Their chief value is to stimulate the appetite and afford variety in the diet. Excepting chestnuts and cocoanuts, they are usually eaten raw, as dessert, but they are much used in confectionery. A few nuts are used in salads and as dressing for fowl. As a rule, they are to be proscribed from invalid dietaries, but, with the exception of chestnuts and peanuts, they may be allowed to diabetics. A preparation of malted nuts which may be obtained in market is both nutritious and digestible. It contains emulsified nut fat, maltose, and vegetable protein. 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 sometimes are used as a substitute for bread after being ground into meal. (See Diabetic Breads.) Macaroons are a digestible form of cake for convalescents and chil- dren, composed chiefly of almonds and sugar. Almonds are wholesome and nutritious. They should not be eaten in cases of gastric irritability, but occasionally dyspeptics in whom gastric digestion is slow derive benefit from eating a few salted al- monds 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- flavoring cough mixtures. Almonds are im- ported chiefly from Italy, France, and Spain, but of recent years they have been extensively grown in California. English walnuts eaten liberally between meals may assist in over- coming constipation through the bulk of insoluble residue which they leave, and possibly also from the oil which they contain. Cocoanuts are very indigestible even when thoroughly desiccated and grated. The cocoanut contains a proteolytic ferment which con- verts moat into albumoses with considerable activity. The cocoanut has been successfully grown in Florida. Brazil nuts, pccnn nuts, beechnuts, hazel nuts, hickory nuts, pine nuts, butternuts, flberts, etc., all hold much oil, and are difficult of digestion. Butternut? easily become rancid after being shelled. Chestnuts contain lo per cent of sugar with so much starch that VEGETABLE FOODS 227 they are highly 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 highly indigestible, but if thoroughly roasted or, better still, if long boiled, they become much less so. They should, however, not be given to invalids. The pistachio, a native nut of Syria, has a greenish, almond-like kernel. It is chiefly used in confectionery and ices for both its color and delicate flavor. Acorns are used as a food in some countries. Americus Vespucius in his voyage to Brazil in 1499 drank a wine distilled from acorns and wrote of them : " They are a very good fruit, savory to the taste and healthful to the body/' Like the chestnut they are rich in starch. Peanuts are described under Legumes, p. 195. Composition of Nuts (C. F. Langworthy). Refuse. Edible portion. Composition and Fuel Value of the Edible Portion Water. c 2 OH Fats. Car- bohy- drates. Ash. Fuel value per pound. \lmonds Per ct. 64.8 49.6 52.1 62.2 53.2 58.0 16.0 24.0 35.6 40.8 86.4 74.1 48.8 Per ct. 35.2 50.4 47.9 37.8 46.8 42.0 84.0 76.0 64.4 59.2 13.6 25.9 51.2 100.0 100.0 59.4 75.5 67.4 58.4 Per ct. 4.8 5.3 3.7 3.7 3.0 2.8 45.0 5.9 4.1 4.0 4.5 2.5 14.1 3.5 4.2 3.4 9.2 1.6 17.9 Per ct. 21.0 17.0 15.6 15.4 11.0 16.7 6.2 10.7 8.1 21.9 27.9 27.6 5.7 6.3 22.6 14.6 25.8 30.5 2.9 Per ct. 54.9 66.8 65.3 67.4 71.2 64.4 5.4 7.0 37.4 57.4 61.2 56.3 50.6 57.3 54.5 61.9 38.6 49.2 .2 Per ct. 17.3 7.0 13.0 11.4 13.3 14.8 42.1 74.2 48.0 13.2 3.4 11.7 27.9 31.6 15.6 17.3 24.4 16.2 77.5 Per ct. 2.0 3.9 2.4 2.1 1.5 1.3 1.3 2.2 2.4 3.5 3.0 1.9 1.7 1.3 3.1 2.8 2.0 2.5 1.5 Cal. 3,030 3,329 3,432 3,495 3,033 3,305 1,125 1,875 2,718 3,263 3,371 3,105 2,986 3,125 3,010 3,364 2,560 3,177 1,453 Brazil nuts Filberts Hickory nuts Pecan nuts English walnuts . ... Chestnuts, fresh Chestnuts dried . ... Acorns Beechnuts Butternuts \Valnuts Cocoanuts Pine nuts or pinons (Pinus edulis) 40.6 24.5 32.6 41.6 Peanuts, raw Peanuts, roasted Litchi nuts " The meat of nuts, excepting chestnuts and cocoanuts, contains nearly 50 times as much fat and less than one-fifth as much carbo- hydrates as wheat flour, and has about double the fuel value i. e., energy-producing power. A pound of unshelled nuts will furnish about half as much protein and the same amount of energy as a pound of flour. Owing to their high fuel value and low protein content, nuts would not make a well-balanced food when eaten by themselves " 228 FOODS AND FOOD PREPARATIONS (C. F. Langworthy). Eaten with fruit, however, they are an ex- cellent form of food, and if carefully selected and thoroughly masti- cated their coefficient of digestibility is high for persons in health, and they furnish very little residue of waste. The relatively high price of nuts as a food is offset by the fact that they demand no expense for cooking. A number of savage tribes live almost exclusively upon fruits and nuts. V. FATS AND OILS Fats and oils contain only 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, H 2 0, 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, very little oxygen is present, 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 ac- tive, always tends to prevent its accumulation. The storage of fat is favored by sleep as well as inactivity. (See Obesity and Leanness.) 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 certain conditions it also may be derived from fatty food. Besides the visible fat found in meat, such as suet, etc., it con- tains smaller particles in its substance. 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 as impossible to live in perfect health without fatty food, as it is to live long upon fat alone, for eaten in bulk it soon disorders digestion. Uses of Fats. The chief uses of fats are: 1. To furnish energy for the development of heat. 2. To supply force. 3. To serve as covering and protection for the body. 4. To make more plastic vari- ous structures of the body and give rotundity to the form. 5, To spare the tissues from disintegration, for, although the combustion FATS AND OILS 229 of fats in the body results largely in the production of heat, they probably take part to a limited extent in tissue formation. 6. To serve for storage of energy. The value 'of fat food consists undoubtedly in its highly concen- trated body fuel and its power of saving other tissues, especially the albuminous, from destruction by oxidation, whereas its secondary use is in connection with tissue formation, for fats enter into the com- position of many different tissues, even those of the nervous system. Fat yields 2^4 times the fuel energy derivable from either proteids or carbohydrates. 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 recognized mainly in one or two simple forms, chiefly as stearin and olein. 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 ema- ciated patients. (See Marasmus.) One or two teaspoonfuls of the oil may be rubbed in twice a day on the thighs, abdomen, and chest. The statement that the application of fats to the surface of the body by inunction reduces the body temperature is not substantiated by expe- rience. 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. The treatment of biliary calculi by the administration of large doses of olive oil two or three ounces at a time given upon 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 feces as a result of this treatment, but it has been shown that the oil may become mixed with inspissated intestinal mucus and form small, hard- ened masses, which have been mistaken for gallstones. There is no foundation for the belief that oil is of any value for cholelithiasis, nor is it possible that it should enter 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 230 FOODS AND FOOD PREPARATIONS on top of a flask of wine is capable of preserving its delicacy of flavor for a long time. Oil preserves fish, like sardines, and layers of lard are used to protect jars of potted meat, pate-de-foie-gras, etc. Oils and butter protect eggs from decomposition. Digestibility of Fats. There is some difference of opinion as to what extent fat may aid or "retard the process of digestion, but it is a matter of common experience that those persons whose digsstive 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 parti- cles of food with a thin film which materially interferes with the normal action of the gastric juice. For this reason most 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 sometimes may 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 invalid by being mashed with a little butter or cream. The digestibility of fats may be much en- hanced by the process of emulsification i. e., of securing an ex- tremely fine subdivision of the oil globules, provided pancreatic extract or fresh pancreas is used, but the so-called mechancial emul- sions made with lime salts, gum arabic, sugar, etc., are of little value. More than fifty years ago Horace Dobell, of London, emulsified beef fat and lard by means of pancreatic juice, and recently John F. Russell, of Xew York, has modified and extended the principle so as to emulsify all fats, fluid or solid, deriving products of permanent fine emulsion, capable of dilution with hot water, and possessing high nutritive value. These emulsions consist of one-half fat, which is predigested and easily assimilated. Most of the fat used as food melts at the temperature of the body, which facilitates its digestion. 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. Overdoses of fat at any time are apt to give rise to the formation of FATS AND OILS 231 irritating acids which cause nausea and vomiting, with possibly ab- dominal cramps and loose evacuations. Since fat is exclusively digested in the small intestine, diseases of any part of the alimentary canal are contraindications for its use. 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 chew- ing with starchy food, or used as suet in the form of a farinaceous pudding, it becomes much more digestible. Children usually dislike fat meat, but they are quite willing to take suet puddings, which, if light and well-cooked, are wholesome. They usually prefer butter to any other form of fat except cream. Although 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 suet, butter and cream, are the most serviceable of all. 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 suffi- cient degree a mucous membrane which is already moistened with watery mucus. 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. Fat is also a constituent of the yolk of eggs. Butter and cream have been discussed under the heading Milk Derivatives (pp. 108-112). 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 sub- stances. " Cuisine " is a preparation of cotton-seed oil designed to replace lard and cheap cooking butter. " Cottohne " is another substitute used for cooking. Stearins are the solid residue of animal fats remaining after pres- 232 FOODS AND FOOD PREPARATIONS sure has separated the fluid fats. They are used in making com- pound lard, butterine, and similar foods. Suet is the fat which surrounds the kidneys of the ox, sheep, and other animals. Oleo oil is made from the rich caul fat of the steer. Oleomargarine. Oleomargarine was invented in 1870 by a French chemist, Mege-Mourier, who discovered that beef fat from certain por- tions of the bullock would melt at the same temperature with butter, and would keep longer without becoming rancid. It was patented in the United States in 1873. 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 thousand part 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. The Internal Revenue Commissioner has published its composition as follows: Composition of Oleomargarine. Per cent. Per cent. Neutral lard 34.37 Stearin 07 Oleo oil 26.82 Glucose 03 Cottonseed oil 4.77 Milk 15.55 Sesame 53 Salt 7.42 Coloring matter 16 Butter oil 1.76 Sugar 12 Butter 1.72 Glycerin 01 Cream 3.86 The volatile fats of oleomargarine are 5 per cent, as compared with 8 per cent in good butter. 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 la\vs. It has been declared perfectly 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, and is very digestible. 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. Beef Fat, Fork. etc. Beef, mutton, and pork fat consist princi- pally of the glycerides of such common fatty acids as stearic, palmitic, and oleic. FATS AND OILS 233 The fat of good roast beef is nutritious, and a highly 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 assimilable fat which has long been used as a food. The long bones of the ox are cut cross- wise in pieces about two inches in length and cooked with the marrow within them. Red marrow is a useful food in cases of tuberculosis, secondary and pernicious anaemia, and chlorosis. It contains consid- erable iron. The marrow of young animals, such as the calf or lamb, is preferred for this purpose, because their tissue-building power is so active. J. S. Billings, Jr., recommends a preparation made from sheep's ribs, chopped, rubbed in a mortar with glycerin, macerated and strained. Henry ~F. "\Valker, of New York, uses a preparation made by mix- ing thoroughly the red marrow of the long bones of the ox with Cetraria (Iceland Moss). This makes an agreeable whitish paste pleasant to the eye, and tasting not unlike good butter. 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 enable the body to withstand the rigor of the climate. It is easily masticated, and the sweet fruit promotes the flow of saliva. Calves' brains and liver contain considerable fat. The common fish which furnish 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 Australia. The oil of the sturgeon is employed for preserving caviare. Turtle oil arid butter is made extensively in Brazil from both the eggs and fat of the animal (Clark). Cod-liver oil is separately considered on page 235. Eggs contain considerable fat in their yolks. Some eggs, like the plover's, are very rich in this ingredient. They are described in de^ tail on page 120. Lecithin is a form of fat contained in a variety of animal cells, but predominating in eggs and brains. Various preparations of it 18 234 FOODS AND FOOD PREPARATIONS have been placed on the market as food, but it is best to administer it through modification of the dietary by increased use of such foods as eggs and calves' brains. 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 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 likely to become rancid than the first (Clark). The best oil generally obtainable comes from France and Italy, but an excellent quality is manufactured in Southern Cali- fornia. The paler variety is preferable, but, unfortunately, it is con- stantly adulterated or imitated. (See Olives, p. 221.) Olive oil is eaten with salads, and is also useful for frying. Cotton-seed oil, and to some extent poppy-seed oil, are now fre- 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 flavor and odor, which resemble linseed oil, are not agree- able when it is eaten raw with salads or fish, and, unless extremely pure, it leaves an unpleasant after-taste in the mouth. It is com- posed principally of palmitin and olein. It is a harmless food. Linseed oil is sometimes substituted for olive oil, but is not as digestible. Cacao I utter, oil of theobroma, is a firm oil obtained from cacao seeds during the manufacture of chocolate. It easily melts at the body temperature. It is used for inunctions and for making sup- positories, and sometimes as an ingredient of infant foods, such as Lacto-prcparata (p. 107). Nuts, especially English walnuts, cocoanuts, hickory, pecan, and Brazil nuts, all contain considerable vegetable oil. (See Nuts, p. 226). The oil of nuts which have been too long kept sometimes becomes rancid and unwholesome. Cocoanitt oil is 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. Java almond oil also may be used for cooking. FATS AND OILS 235 The " Blossom " fat food is made in the Philippines by Captain J. E. Bloom, U. S. A., from the " pile nut/' which grows upon a tree in Luzon. From this nut an oil is extracted by hydraulic pressure which is combined with olein from lard and palmitin from cotton- seed oil, also extracted by pressure under certain conditions of tem- perature. The resulting product is said to be well tolerated by the stomach, and constitutes a highly nutritious food. Dietetic Uses of Fats and Oils. Because fats are essential for growth and nutrition as well as force production, fatty food is in- dicated for convalescence from severe acute diseases, and for patients suffering from chronic wasting diseases. Persons whose general health has been impaired by poor hygienic surroundings, children who have been wrongly fed by ignorant or poor parents, and aged per- sons in whom the nutritive processes are becoming less and less vigor- ous, may all be benefited by supplying a sufficient quantity of fatty food in the dietary. Diseases in Which Fats are Most Beneficial. There is a large number of diatheses and diseases, both local and general, which may be benefited by improving the nutrition of the body and increasing force production through the agency of easily digestible forms of fat. (See Appendix for list of Fat Foods.) Such are: Tuberculosis, pulmonary as well as other forms; anaemia; chronic wasting diseases with secretion of pus, as empyema, chronic abscesses, etc.; maras- mus; rickets; chronic bronchitis; many chronic diseases of the skin and nervous system; diabetes. Diseases in Which the Use of Fats Should Be Forbidden or Re- stricted. All forms of acute gastrointestinal disease ; chronic gas- tritis; dilatation of the stomach; chronic diarrhoea; obesity; fatty and waxy liver; gallstones; acne; urticaria; eczema. Generally speaking, fats are laxative, and by most persons fat can- not be eaten continuously in large quantities without producing indi- gestion. The stools become offensive and diarrhceal, there is nausea and gastric indigestion, and disgust for such a diet very soon arises. There are those who are unable* to digest fats in any degree, however small, and they must derive their energy from carbohydrates. Glycerin. Glycerin plays an inconspicuous role as a food. It is mainly used 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 hygro- scopic, and if taken in the mouth undiluted makes the mucous mem- brane sticky and unpleasant, but it is used as a mouth wash in a diluted form in the proportion of a drachm to the ounce of water. 236 FOODS AND FOOD PREPARATIONS 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 more comfortable. In such cases it sometimes diminishes thirst, although its effect in this respect is very uncertain. Glycerin is also laxative, and it may be given either per os, as an enema or in the form of the well-known glycerin suppositories for the purpose of increasing peristaltic action. Cod-liver Oil The best cod-liver oil is known as "cold-drawn oil," and is pre- pared from the raw fresh livers of the codfish by subjecting them to heavy pressure, by which the oil is squeezed out. Chemical and Physical Properties. Cod-liver oil, according to analyses made by De Jongh, contains glycerin, olein (70 per -cent), myristic, butyric, acetic, margaric, and other acids, biliary elements such as cholesterin, also iodine, bromine, chlorine, and phosphorus in small quantity, and a peculiar material which is called " gaduin." Gautier and Mourges obtained, besides a half dozen substances re- sembling alkaloids and other materials, a basic substance which they call morrhuine, about one-half milligram, .0075 gram of which oc- curs in each gram (15.43 grains) of the oil, and has, it is claimed, all of its active medicinal properties. The refined oil may contain no iodine, and it is seldom present in greater proportion than 0.5 per cent ; hence the value of the oil does not depend upon this substance, as at one time suggested. When pure, its odor resembles shoe leather. On adding strong acid, the biliary odor is intensified if the oil is unadulterated. If the odor is absent, the oil is spurious. Cod-liver oil is one of the most easily absorbed of all the oils, owing to the quantity of its fatty acids. It is quickly oxidized in the body. It is highly nutritious and alterative, and is slightly laxative, espe- cially for infants. Some of the oil supplied in market is derived from the livers of other fishes than the cod, but the cod-liver oil is undoubtedly the best. Pains should be taken to secure a pure preparation thoroughly clarified from the impurities which oil may contain, such as traces of iodine, phosphorus, and sometimes bile salts. None of these sub- stances add to its food value, and, if present in excess, the oil is much more likely to disagree. Cod-liver oil is sometimes adulterated with the cheaper cotton-seed oil. to which a fishy flavor is artificially given, and it should therefore FATS AND OILS 237 only be purchased from a well-known and responsible firm. The clarified Norwegian oil is the best variety to prescribe. An advantage of cod-liver oil is that when pure it may be taken longer than any other fat excepting butter and cream without disor- dering the stomach. This is no doubt owing to the fact that the oil is already in a condition in which it has once served in the fishes' body for nutrition or at least for storing up energy. This form of oil is readily emulsified and saponified, and is absorbed by the intestinal villi with great facility. Dosage. Many patients who dislike the taste of the oil at first soon acquire tolerance for it if given in small and gradually increas- ing dosage, commencing sometimes with not over 10 to 30 drops twice a day, and children not rarely become so fond of it as to ob- ject to its discontinuance. Infants may be given from 5 to 20 drops two or three times a day. If it is not digested at first, but one dose of two or three teaspoonfuls a day need be given, and this should be at night. Those who like it can sometimes take as much as an ounce three times a day with advantage, although half an ounce is all that usually can be tolerated. Patients who dose themselves with it often use too much, and al- most invariably take it at the wrong time in relation to meals. It is best to take the oil about two hours after dinner. If taken earlier, it remains in the stomach, interfering with the digestion of other food, whereas if digestion is already well under way, it passes with the chyme into the intestine, where it is absorbed. While the oil is being taken the stools should be examined occasionally, as the absence of fat globules in them is a proof of its complete absorp- tion. Methods of Administration. Many patients can take perfectly pure, well-clarified cod-liver oil better than the emulsions and prep- arations in which it is offered in the market, while others prefer it in the form of the so-called emulsions with hypophosphites of lime, soda, or iron, or with other substances. Some of these emulsions are rendered almost tasteless, while others are flavored with wintergreen, ginger, or some other aromatic. Emulsions are seldom as good as the pure oil, and are only to be preferred when the latter is not digested or when the taste proves too nauseous. They usually do not contain above 50 per cent of the oil, and often only 33 per cent; hence the dose is unnecessarily bulky. Moreover, they rapidly deteriorate with age, so that if emulsions are to be used they should be freshly made with yolk of egg and glycerin or mucilage of tragacanth. FOODS AND FOOD PREPARATIONS The late Dr. James Stewart, of Montreal, gave excellent formulae for this purpose as follows : ] Cod-liver oil 6 ounces. Oil of wintergreen '. 1 drachm. Chloroform 2 drachms. Glycerin, yolk of egg, each 5 " Orange-flower water, sufficient to make 12 ounces. M. Dose, one tablespoonful. ]J Cod-liver oil 6 ounces. Oil of wintergreen ( or any essential oil ) 1 drachm. Mucilage of tragacanth 2 ounces. Orange water, sufficient to make 12 " M. Dose, one tablespoonful. This latter emulsion is somewhat thicker than the preceding one. Oil of bitter almonds may be used in the proportion of three drops to the ounce, instead of the wintergreen oil. Lefaki recommends an emulsion made with an equal part of lime water flavored with lemon sirup or vanilla. This may be prescribed when diarrhoea exists. Another method is to add two ounces of finely chopped and strained fresh pancreas to the gallon of oil to produce an emulsion. Stewart suggested rinsing the mouth before taking the oil with undiluted brandy or whisky and two or three drops of oil of pepper- mint. Children may be given a peppermint lozenge. If preferred, the dose of pure oil may be poured upon the surface of some fluid, such as orange or ginger bitters, strong black coffee, lemon juice, weak brandy and water, ale or beer. Pains should be taken to float the oil in the center of the surface of the fluid, so that it is to some extent coated by it and does not come in contact with the glass or cup and produce a lingering, disagreeable taste in the mouth. Ringer suggested adding a few drops of catsup to disguise the taste, or the use of a mixture of equal parts of the oil and fresh aqueous solution of gum acacia with two minims of oil of lemons added to each ounce. A little salt taken in the mouth before and after each dose may neutralize the taste. He also referred to the use of a cod- liver-oil jelly containing 70 per cent of the oil. This disguises the flavor. The oil is sometimes given with different preparations of meat juice. In this country cod-liver oil is extensively used in the form of capsules of gelatin which are shaped like an olive, and which some patients can swallow with ease, although they are rather bulky and not always reliable. A child of ten years came under my observa- tion who for sonic time previously had been given four or five of these FATS AND OILS 239 capsules daily, each containing a teaspoonful of cod-liver oil. She had developed an exceedingly irritative stomach cough, for which a variety of sedatives had been administered without any effect; but when she at one time vomited seventeen of the undissolved capsules, which represented four or five days' dosage, the cough ceased. The oil is sometimes administered in the form of " oleochyle," in which it is claimed it has been predigested. Claude Bernard first showed that ether given by the mouth acts as a stimulant to the secretion of the pancreas and the glands of Brun- ner which aid the digestion of fat, and that it increases the absorp- tion of fats. Acting upon this suggestion, Dr. Balthazer Foster found that pure ether added to fats and oils in the proportion of five or six minims to a drachm of the oil would often insure its digestion, whereas previously it had excited nausea and vomiting, and this method has proved of service in the hands of others. The ether itself disguises somewhat the taste of the oil, but I have sometimes found it to produce unpleasant eructations. In fact, in some hospitals a " malingerer's mixture " has been employed composed of a disagree- able combination of ether, oil and asafoetida, which has the result of causing eructations and maintaining an exceedingly disagreeable taste in the mouth. Cod-liver oil is added in the proportion of 30 per cent to maltine, or 50 per cent to malt extract, and when not so sweet as to be disliked by the patient it proves a very serviceable food. In very hot weather it is usually best to suspend the administration of oil, as it is liable to disagree, even if it does not become rancid. Substitutes. Many substitutes for cod-liver oil have been pro- posed, but it is doubtful whether any of them except cream can be made to yield all the benefits to be derived from the genuine substance. Efforts have long been made to determine whether the alkaloidal or other substances obtainable from cod-liver oil do not possess all the nutritive and stimulating properties of the oil itself in equal or oven greater degree. Some of them are doubtless capable of pro- ducing active symptoms, but if the oil itself is a true food, there can be no advantage in attempting to concentrate it beyond the minor consideration of avoiding its nauseous, fishy taste. M. Chapoteau describes a crystalline substance which he terms "morrhuol," and which exists in the oil in the proportion of 1.5 to 6 per cent, the lesser quantity being found in the purest oil. It is claimed that three to five drops of this substance possess all the properties of a drachm of cod-liver oil. It may be given in capsules or disguised with olive oil, fat, or cream. 240 FOODS AND FOOD PREPARATIONS Von Mehring and Hauser recommend " lipanin " made by adding to olive oil 6 per cent of oleic-acid. It is devoid of disagreeable taste and odor, and one to four teaspoonfuls may be given three times a day. Uses. Cod-liver oil is not a specific for any disease, and there are many clinicians who prefer to prescribe other forms of fat when possible. Of late years I often prefer to prescribe cream diluted with Vichy or water in equal parts, or weaker. Nevertheless, there are often seen cases of phthisis in which a decided gain in weight follows the administration of a disproportion- ately small quantity of the oil. It is a good food in many conditions of debility, and in the treatment of rickets, in a variety of forms of chronic inflammation and in cases in which there is old purulent dis- charge from any part of the body, as from the middle ear, or from a chronic abscess, like empyema, and in chronic bone diseases, such as caries and tuberculosis. Among other chronic diseases for which cod-liver oil is recom- mended may be mentioned chronic rheumatism and gout, arthritis deformans, a variety of skin affections, and advanced syphilis. It is of service also in pulmonary emphysema and in cases of chronic bronchitis with tenacious purulent expectoration, and by many it is believed to be of some specific value in loosening cough. It should be observed that oil when absorbed passes through the lymphatic system and is carried with tolerable directness into the pulmonary circulation, where fats in general are believed to be oxidized. It is suggested that this fact may possibly have some bearing on the in- fluence attributed to cod-liver oil as an expectorant, although it seems more probable that the effect is derived from the improvement pro- duced upon the general nutrition. Brunton attributes it to a stimu- lating action upon the epithelium of the bronchi. In cases of atonic dyspepsia, particularly among elderly people, cod-liver oil often re- lieves the "sinking " feeling at the epigastrium and faintness. It is also serviceable in relieving constipation in young infants, and it may be given sometimes with advantage in lieu of castor oil. Its loosening effect is more decided in children than in adults, and it is loss likely to produce subsequent constipation than castor oil, besides being less disagreeable to take. For marasmus the use of cod-liver oil is particularly indicated, and in infants when chronic diarrhoea obtains, some benefit may be derived from the topical application of the oil to the skin. To tuber- culous children of the emaciated marasmic type in whom the skin is dry and wrinkled 1 5 or 20 drops of the oil may be given at night with- out fear of increasing the diarrhoea. PART II STIMULANTS, BEVEKAGES, CONDIMENTS STIMULANTS AND BEVERAGES IT is the almost universal experience of mankind that the taking of food and drink merely to satisfy the cravings of physical needs does not at the same time wholly satisfy the desire of the mind for occasional invigoration, for restoration of bodily functions after fa- tigue, for support during sustained muscular exertion, for an incen- tive to activity, and for conviviality. In some form or other, al- though in greatly varying degree, a stimulant is demanded by almost everyone to meet the emergencies with which he is from time to time confronted. To this end the civilized European imports his tea from China, his coffee from Java, his cocoa from Brazil, his tobacco from America or Cuba, his opium from India, and his alcohol from more immediate neighbors. His. semicivilized or wholly barbaric brother who lacks the ability or means to procure such refreshment from foreign sources relies upon his own ingenuity to devise fermented drinks from every available substance. Thus, the Tartar ferments milk into koumiss, the Mexican ferments the Maguey (Agave Americana) into pulque, the Central African ferments a wine from the palm, the Apache of southern Arizona ferments a cactus into the intoxicating mescal, the Kamtchatkan ferments a peculiar drink from a poisonous fungus, and honey, rice, corn, barley, rye, grapes, dates in fact, nearly every cereal and every fruit is in some part of the world made to yield the cup that cheers, and too often inebriates as well. It is true that there are those who find it possible to live without ever tasting even the mildest stimulants of any kind, and there are sects of men, like the Mohammedans and Buddhists, to whom the use of alcohol in every form is absolutely forbidden by their religion; but most of them discover other means of satisfying an instinctive craving for occasional stimulation, and ready substitutes for the prohibited intoxicants are found close at hand in hasheesh, opium, excessive tea consumption, etc. The economic and social aspects of 241 242 STIMULANTS, BEVERAGES, CONDIMENTS this subject alone are of vast importance, and the question of the utility of stimulants and beverages is an important branch of dietetics. The effects of all beverages and stimulants are far more pro- nounced if they be taken into an empty stomach, which insures their prompt absorption. The several substances classed under these headings are found to serve in one or more of the following ways : I. To relieve excessive thirst all fluids which are not too sweet may be used, but sour beverages, such as acid lemonade or raspberry vine- gar, the effervescing carbonated waters, solutions of potassium bitar- trate, or dilute mineral acids in water, are generally the most accept- able. II. As diuretics the mineral waters and carbonated waters hold the first rank. With many persons coffee is also an active diuretic. So are beer, gin, champagne, and, to a lesser degree, other forms of alcohol, and tea. III. As diaphoretics, hot spirits and water, hot lemonade or hot tea may be used. IV. As diluents of the ingested food and of the waste material of the body the alkaline and carbonated effervescing or bland spring waters are the best. V. As stimulants of the nerves and other organs, the milder forms of alcoholic beverages, diluted spirits, tea, and coffee are used. YI. As intoxicants, beers, ales, strong wines, champagne, strong liquors and cordials are the most powerful agents. VII. As demulcents, mucilaginous, farinaceous, and gelatinous beverages are used for fevers, etc. Such are decoctions of Iceland moss (cetraria) or Irish moss, barley or oatmeal water, arrowroot and other light gruels, solutions of gelatin, flaxseed tea, etc. When taken hot they are soothing for coughs and promote expectoration. Till. As tonics and to aid digestion may be mentioned koumyss and similar fermented milks, malt extracts, ales, light wines, clarets, Burgundies, diluted brandy or whisky, chalybeate and arsenical wa- ters, and alkaline waters drunk before meals. IX. As astringents, red wines and tea are of chief importance. X. For nutrition, cocoa, chocolate, fermented milks, such as kou- myss, etc., malt extracts, "grape food," and, because of the milk or cream added, tea and coffee. Stimulants have two separate actions: First, a prompt exhilarat- ing effect or exaltation of the nervous system, which endures for a few hours, and, secondly, a period of depression which usually bears a more or loss definite relation to the degree of previous excitation. STIMULANTS AND BEVERAGES 243 The second period is sometimes longer or more intense than the first, producing an actual balance of loss of vitality in the system. Various dietetic drinks have been advocated for their supposed specific action in stimulating a torpid liver and as laxatives or as diuretics ; such, for example, are various " herb teas," etc., but they are of uncertain efficacy. Many fruit essences and sirups are offered for sale for use in mak- ing cooling drinks and invalid's beverages. When thoroughly reliable preparations are obtained they are of good service, but many of them are adulterated. For example, for lemonade, mixtures of malic, citric, and tartaric acids are often substituted. As a rule, it is better to extract the juice from the fresh fruit, and unless large quantities are required, this is almost as cheap. Unfermented California grape juice may be had in very pure condition, and it constitutes an excel- lent beverage for invalids, being wholly free from alcohol. " Grape food " serves a similar purpose (p. 220). The preparations under consideration may be diluted with ice water, or with any one of the simple effervescing waters, such as carbonic- acid water, Vichy, Seltzer, Apollinaris, etc. Of all these beverages, lemonade and orangeade are perhaps the most useful in the sick-room. These are agreeable, cooling, and refreshing in fevers, mildly diuretic, and beneficial in many ways. A very wholesome drink is made by putting the juice of two lemons with three or four lumps of sugar into a tumbler of iced Vichy, Seltzer, or Apollinaris, and stirring in a saltspoonful of bicarbonate of sodium; to be drunk while effervescing. The various fruit . Acidulous waters contain C0 2 in excess, but little salts of any kind. Such are the waters of Clysmic Spring, in Wisconsin; STIMULANTS AND BEVERAGES Blue Lick, in Kentucky; Carlsbad (Dorotheenquelle), in Bohemia. 6. Various waters are the Alum Springs, in Virginia; Oak Orchard Acid Spring, in New York; Bourboule, in France, which contains arsenic. Eoncegno water is a ferruginous arsenical water from the Tyrolean Province of Trent. The springs of Baden Baden are also of this nature. Tannin Tannin is an astringent of vegetable origin which exists in tea, coffee, and many wines, especially the red wines, and as such it is worthy of brief separate consideration. It possesses no nutrient power whatever, and is mainly of interest to the dietetist from the harm it may occasion if taken too freely. In strong solution it precipitates the ferment of the gastric juice and renders it inert, and also gives rise to constipation by its astringency, which affects the mucous membrane of the intestine. For these reasons strong tea or tea drunk to excess materially hinders gastric digestion. According to Fraser, the tannin in tea interferes with the diges- tion of fresh meat, but to a less extent with that of dried or smoked meat, such as tongue or ham, the fibers of which are already shrunken by curing. Coffee contains much less tannin than tea, thus it has not the same effect upon the alimentary canal; in fact, it may be laxative. Tannin is contained in red wines in considerable quantity, hence clarets are mildly astringent and constipating. Tannin is useful for a variety of local astringent applications. Tea Method of Preparation. Tea is a prep- aration made from the leaves of various species of a hardy evergreen shrub called Thea. (Fig. 41.) The manufacture con- sists in plucking the young leaves of the plant and placing them in the sun; after they have become withered they are rolled and twisted. This process is sometimes conducted by hand, or even by the feet of the natives in China, and sometimes by FIG. 41. BRANCHES OF TEA machinery. The leaves are next passed * a ) bud> * b ) flower - . , 1% n j j. -, (U. S. Dept. of Agri., Bui. into small masses or rolled into balls and 56.) 248 STIMULANTS, BEVERAGES, CONDIMENTS allowed to ferment while still moist, after which they are dried over a fire of a temperature sufficient to evaporate all the moisture. They are finally sifted and assorted into different qualities. Green and Black Tea. The distinction between black and green teas is due to the variations in their mode of preparation, and not to separate species of the plant. Green tea is made by steaming the leaves before they are rolled and dried. The further difference between green and black tea consists in the relatively larger quan- tity of astringent material (tannin) which predominates in green tea. The following table, from an analysis by Mr. Y. Kozai, illus- trates this point and exhibits the proportionate quantity of some of the more important ingredients of tea. It presents the difference in percentage composition between green and black tea prepared from the same plant : Green tea. Black tea. Crude protein 37.43 38 90 Fiber 10.06 10 07 Ash 4.92 4.93 Theine 3.20 3.30 Tannin . . 10 64 4 89 Total nitrogen 5.99 6 22 Because green tea contains more than twice as much of the as- tringent tannin as black tea it is generally regarded as less whole- some than the latter. It is also believed to have a somewhat less stimulating effect upon the nervous system, though this hardly can be accounted for by the slight variation in the percentage of theine shown to exist by the above table, this latter substance being the alkaloid, which is chiefly responsible for the stimulating influence of tea upon the nerves. There has been some discussion in regard to the identity of theine with caffeine, and by many writers they are believed to be the same alkaloid. Rice says that most of the commercial caffeine is derived from tea leaves, but May finds that in frogs, at least, "theine pro- duces spontaneous spasms and convulsions, while caffeine does not. Theine impairs the nasal reflex early in the poisoning process, while caffeine does not, if at all, until the very last stage." Properties. The peculiar stimulating properties which tea pos- sesses, as well as its color and agreeable flavor, depend upon the season of the year at which the leaves are gathered, the variety of the plant, the age of the leaves, which naturally become tough as STIMULANTS AND BEVERAGES 249 they grow older, and the care exercised in their preparation. The flavor is produced by the formation of volatile oils which develop during fermentation. It is these substances which cause the minor differences in effect of tea and coffee. The aroma as well as the flavor of tea is often artificially in- creased by the addition of such substances as the leaves of orange flowers, jasmine, or roses. Tea made of small leaves packs closely, and if measured by the spoonful gives a stronger beverage than the coarser-grained varieties. Infusion. The flavor of tea depends not only on the character and fermentation of the leaves, but upon that of the water which is added to them. About a drachm of leaves should be used for one infusion. The water should be poured upon the tea leaves when boiling, and the infusion should not last beyond three or four minutes if the flavor is to be delicate; if it is continued beyond this point materials become extracted from the leaves which, while they may make the tea appear stronger, materially diminish the delicacy of its flavor. The water should be neither too hard nor too soft. Soft water extracts more of the soluble materials of the leaves and yields a beverage of darker color. Water which contains iron or lime salts should be boiled with sodium carbonate before it is used for tea infusion. Physiological and Therapeutic Action. Good. Effects. Tea is mildly stimulating to the nervous system and tends to increase the activity of certain vital functions. It is refreshing and relieves bodily fatigue. For the latter purpose it has been found especially useful for soldiers on the march in hot climates. Major Woodruff, U. S. A., says : " The universal experience of military men testifies to the absolute necessity of tea or coffee. The latter is generally preferred, but the writer's experience points to tea as preferable in the long run." For this purpose both these substances are better preserved if compressed into small bulk. In persons having nervous exhaustion a cup of hot tea affords prompt and decided relief from headache, and when taken quite strong it is sometimes serviceable in the cure of chronic alcoholism. It is also used as an antidote for opium poisoning, but coffee is preferable. The " strength " of tea as applied to the appreciation of its taste in distinction from its effect on the nerves is due to the quantity of tannin present, which is bitter. A bitter tea is not therefore neces- sarily a strong one in its stimulating properties, which are owed to the theine. 250 STIMULANTS, BEVERAGES, CONDIMENTS Tea, when employed as a beverage, possesses some effects which are not strictly due to action upon the nerves. It introduces con- siderable hot water into the system, which is beneficial when taken at the proper time in relation to meals, and when milk or cream and sugar are added its nutritive value becomes appreciable. Tea is moderately sudorific in action, and it has a slight influence in regulat- ing the circulation and temperature of the body, which, if too cold, becomes warm by the stimulating effect upon the heart, whereas if the body is too hot, tea may exert a cooling influence by increasing perspiration and evaporation from the surface. Hot tea will some- times increase the action of aperients, but it is doubtful whether it has any more effect than a similar quantity of hot water. Roberts gives the following analysis of The Effects of Tea and Coffee on Gastric Digestion. Digesting mixture: 2 grams of dried beef fiber, 0.15 c. c. hydrochloric acid, 1 c. c. glycerin extract of pepsin, varying proportions of tea and coffee, water to 100 c. c. PROPORTION OF TEA OR COFFEE CONTAINED IN THE DIGESTING MIXTURE. TIME IN WHICH DIGESTION WAS COMPLETED. (NORMAL, 100 MINUTES.) Tea, 5-per-cent strength. Coffee, 5-per-cent strength. Coflee, i5-per-cent strength. 10 per cent 105 minutes. 140 180 " Embarrassed. 105 minutes. 140 180 Embarrassed. 160 minutes. Embarrassed. Almost no action 20 " " 40 " " 60 " " Many elderly people find tea particularly satisfying and soothing after reaching a period of life when the functional activity of the stomach is gradually weakened. A disproportion may exist between the quantity of food which the stomach can digest and the actual need of the body for nutritive materials to counterbalance the daily waste. In such cases tea enables the aged poor to live on less food than they would otherwise require, and is thus economical for them. The refreshing effect of tea when taken into an empty stomach after bodily fatigue may continue between three and four hours, a period considerably longer than that of coffee or light wine. /// Effects. The ill effects of excessive tea drinking the " tea habit " are referable to its action on the digestive and nervous systems and are cumulative. If taken in large quantities with meals, tea precipitates the digestive ferments, retards the activity of diges- tion, and may occasion gastric irritation and catarrh. Constipation usually results, though there is sometimes diarrhoea, and more or STIMULANTS AND BEVEKAGES 251 less flatulency. The latter may cause insomnia. The effect of the "tea habit" on the nervous system is to overstimulate and then depress it, first producing restlessness, worry, and insomnia, and finally muscular tremors, sensory disturbances, and palpitation. Per- sons who are subjected to some unusual strain or anxiety may find that tea for the time being disagrees with them, whereas they are able to drink it regularly when in ordinary health. Cheap teas are always much more liable to produce ill effects than the more expensive varieties. In many persons five cups of strong tea per diem pro- duce symptoms of the "tea habit." Indian teas contain a larger proportion of tannin than do those from China. For this reason they are more likely to produce disor- ders of digestion and constipation. They also occasion nervousness and sleeplessness to a more marked degree when drunk in excess. The ill effects of poor tea and of tea rich in tannin may be over- come in some degree, as suggested by Eoberts, by the addition of carbonate of sodium in the proportion of ten grains to the ounce of dried tea leaves ; this does not materially interfere with the taste. When tea taken with milk and sugar is found to disagree, sub- stitution of the juice of a slice or two of lemon makes it acceptable and beneficial to many persons. Tea which is " steeped " is more unwholesome on account of the extra tannin, etc., which is extracted. Tea should be avoided in dyspepsia, gastric irritability from any cause, constipation, anemia, insomnia, " nervousness," and gastric catarrh. A case of multiple neuritis caused by drinking between two and three pints daily of strong tea has been reported by Spratling, and I have met with one or two similar cases. In a recent report upon insanity in Ireland tea is mentioned as a contributing factor. A very poor quality is there used, and it is often stewed nearly all day, water being added from time to time. This report continues: "Undoubtedly the method of preparation adopted and the excessive use of this article of diet, now so general among our poorer population, tends to the production of dyspepsia, which in its turn leads to states of mental depression highly favorable to the production of various forms of neurotic disturbance." Excep- tionally the " tea habit " has been acquired through chewing the leaves. Adulteration of Tea. The adulteration of tea is extensively prac- ticed. The adulterants are either added in very minute proportion, as in the case of plumbago, indigo, or Prussian blue, for the purpose of coloring or " facing " the tea, or foreign leaves are mixed with the 252 STIMULANTS, BEVERAGES, CONDIMENTS tea, which merely dilute it without necessarily making it injurious. Green tea is more likely than black to be adulterated. Catechu as well as salts of iron are sometimes added to increase the astring- ency. Quantity Consumed. The quantity of tea consumed per capita in the United States is 1.33 pound; that of coffee is 7.8 pounds. Slightly more than half of the tea drunk in the United States comes from China, and a large part of the remainder from Japan. The India teas are nearly twice as strong as the others, but they are much less drunk in this country except- ing in mixtures where they have been added to Chinese or Japanese teas to improve their flavor and strength. Coffee Composition. Coffee consists of the ber- ries or seeds of Coffea ardbica, which are dried, roasted, ground, and subjected to infusion. The coffee drunk in the United States is mainly imported from South and Central America, Mexico, and Java, 63 per cent being imported from Brazil. The Rio berry is smaller than that from Java. The composition of coffee beans varies some- what, but an approximate idea of it is obtained from the following table from Konig, which gives the percentage of the important ingredients: FIG. 42. BRANCHES OP COFFEE. (a) flower, (b) berry. (U. S. Dept. Agri., Bui. 56.) Water 1.15 Fat 14.48 Crude fiber 19.89 Ash 4.75 Caffeine 1.24 Albuminoids 13.98 Other nitrogenous matter 45.09 Sugar, gum, and dextrin 1.66 The exhilarating and stimulating effect of coffee is caused by the ingredients caffeine, caffeotannic and caffeic acids, and a volatile oil developed during roasting. Caffeine is chemically identical with theine and possesses the same physiological properties, its action being chiefly upon the nerves and kidneys. The coffee berry contains no starch, and Wiley has shown that its principal carbohydrate is cane sugar or sucrose. There are STIMULANTS AND BEVERAGES 253 present also a substance allied to dextrin and a reducing sugar. Cof- fee also contains a little aromatic oil which is moderately stimulating to the nervous system. It has less oil than tea. Method of Preparation. The preparation which the coffee beans require consists of drying them by roasting at a temperature of fully 200 C., after which they are ground into small fragments to facilitate the solution of their ingredients by hot water. The heat converts the sugar of the beans into caramel and develops volatile and aromatic substances to which the agreeable aroma of the cof- fee is due. These substances being volatile, the aroma soon for- sakes the beans, and they should not be roasted or ground long before they are to be used. The roasting also liberates gases in the beans, which cause them to increase in bulk while losing in weight. The methods of preparing coffee as a beverage are three: (1) In filtration boiling water is allowed to percolate slowly through finely ground coffee. Air should be excluded as much as possible during the process; otherwise the oxygen alters the aroma. According to von Liebig, filtration only dissolves from 11 to 15 per cent of the coffee instead of 20 or 21 per cent, which is obtainable by other means. (2) Infusion is the common mode of preparation of coffee em- ployed in this country and in Europe. It is said to reduce the ex- citing influence of strong coffee without destroying its aroma or otherwise altering it. In conducting this process the finely ground coffee is put into water previously boiled, but removed from the fire, and allowed to stand for about ten minutes at a temperature of 180 or 190 F. - (3) Decoction is the method principally used in Turkey and else- where in the East. The coffee beans are ground to powder and placed in cold water, which is then heated to boiling. The beverage is drunk without straining. If boiled a few minutes some aroma still remains, but it is soon driven off, and continued boiling extracts more caffeine and tannin than is obtainable by infusion. Soft water extracts more coffee from the berries than hard, as it does from tea leaves. Coffee should always be made from newly roasted and ground beans; and when economy is to be considered, or when strength and aroma are both desired, a larger proportion of the soluble ingredients may be obtained by combining the second and third processes, as described by Yeo : " After first preparing an infusion by passing boiling water over the coffee, the grounds left should be boiled in more water, and the boiling decoction thus obtained should be poured 254 STIMULANTS, BEVERAGES, CONDIMENTS over another portion of freshly ground coffee; this, in turn, is also boiled with more water, to be used again with fresh coffee in the same manner, and so on. By this method all the soluble matters in the coffee are extracted and none of the aroma is needlessly dis- sipated/' Eeady-made coffee is sometimes preserved with condensed milk and sugar in tin cans. This preparation merely requires to be put into a cup of hot water to be fit for drinking. Physiological Action. Good Effects. Coffee, when taken as a beverage, has well-marked physiological effects, chiefly upon the mus- cular, vascular, and nervous systems. It removes the sensation of fatigue in the muscles and increases their functional activity ; it allays hunger to a limited extent; it strengthens the heart action, and con- stitutes a valuable cardiac stimulant in some forms of collapse by its moderate quickening effect upon the pulse and influence upon the vascular tone; it acts as a diuretic, and increases the excretion of urea ; it has a mildly sudorific influence ; it counteracts nervous ex- haustion and stimulates nerve centers. It is used sometimes as a nervine in cases of migraine, and there are many persons who can sustain prolonged mental fatigue and strain from anxiety and worry much better by the use of strong black coffee. In low delirium, or when the nervous system is overcome by the use of narcotics as in the case of opium poisoning, or by alcohol, or by excessive hemorrhage, strong black coffee is serviceable to keep the patient from falling into the drowsiness which soon merges into coma. In such cases as much as half a pint of strong black coffee may be injected into the rectum. Drunk in moderation, coffee is a mild stimulant to gastric diges- tion. In the bowels coffee has an opposite effect to that of tea, for it stimulates peristalsis, and for many people, when drunk early in the morning, it possesses a distinctly laxative effect. It thus in- directly benefits the liver. Strong coffee with a little lemon juice or brandy is often useful in overcoming a malarial chill or a par- oxysm of asthma. The stimulating and diuretic effect of coffee is more decided when it is taken into an empty stomach. The nutrient value of coffee alone is too slight to be considered, but the addition of sugar and milk, as in the case of tea, makes it a valuable food. It does, however, possess some effect in diminishing tissue waste. The very general fondness which exists for the taste of coffee makes it a useful means of flavoring many kinds of foods for invalids, such as jellies, custards, ice cream, etc. When the taste of milk is objected to, the addition of two or three teaspoonfuls STIMULANTS AND BEVERAGES 255 of coffee to the tumblerful of milk will often overcome the dislike for it. Coffee is a useful temporary cardiac stimulant for children suffer- ing collapse, but should not be given them as a daily beverage. Caffein is much used in medicine as a cardiac and nerve stimulant and diuretic. Ill Effects. Strong black coffee taken after dinner tends to re- tard the digestive processes somewhat, and for this reason it should be avoided by dyspeptics; but to persons with sound digestion who, perhaps, have eaten rather more food than they need, this influence may not prove a disadvantage, and meanwhile its stimulating effect may arouse the overtaxed digestive functions. Many persons find themselves able to perform much more active brain work by the stimulus afforded by drinking coffee and strong tea. If one is obliged to work late by night at severe mental labor, sleepiness may be avoided by this means. The continuance of this practice, however, soon results in forming a coffee or tea habit, in which the individual becomes a slave to the beverage and feels an imperative need for it at certain hours of the day, when, if it can- not be obtained, the system suffers from languor, prostration or rest- lessness, and craving. Exceptionally the coffee habit takes the form of eating the coffee beans. By drinking two or three cups of strong black coffee at every meal muscular tremors sometimes are developed, especially in the hands, with "nervousness," anxiety, dread of im- pending ill, with palpitation and feeling of precordial oppression, bradycardia, tinnitus aurium, hyperasthesia, muscular lassitude, vertigo, heartburn, dyspepsia, constipation, and insomnia. In such cases the symptoms usually promptly subside on suspending or re- stricting the beverage; but if they have been continued long, the use of sedatives may be necessary to control the ill effects. Extreme cases suggest the condition resulting from some drug habits, and there is irritability of the whole nervous system and mental ex- citement. Emaciation is common, and pruritus ani has been observed by Brown-Sequard. Those who are habituated to immoderate tea or coffee drinking do well to stop the habit abruptly in order to observe the degree of craving which results and the influence which these beverages is acquiring over the system. As an aid to break- ing off the coffee habit, " postum " may be used. It is composed of cereals and has a flavor which many find agreeable. The pub- lished analysis gives 13.13 per cent protein, 6G.11 per cent carbo- hydrates, 1.60 per cent fat, besides salts and water. In children the habitual use of coffee gives rise to insomnia, night terrors, nervous- 256 STIMULANTS, BEVERAGES, CONDIMENTS ness, and tremor. Acute coffee poisoning differs from the chronic form in producing greater excitability, with tendency to delirium and tachycardia. Some persons are so sensitive to coffee that a few teaspoonfuls promptly give rise to toxic symptoms. Quantity Consumed. In connection with the comments often made in regard to the nervousness of temperament which characterizes many Americans, it is not without interest to note a fact which may stand in the relation of either cause or effect to this condition namely, that the people of the United States consume one-third of the total coffee produced, or more than Germany, Austria, Hungary, France, and the United Kingdom combined. On the other hand, England and her colonies consume one-half of the world's output of tea, and the United States but one-fifth of it. Adulteration. The adulteration of coffee, more particularly when it is ground, is so easily accomplished that it affords great tempta- tion to unscrupulous dealers. Almost all ground coffee sold to the poor is adulterated, but the adulterants are not usually of a char- acter to render them injurious to health. Chief among them is chicory, which is added both for dilution and for its influence on the color and flavor of the coffee. This substance, however, is actually preferred by many persons, and, as it is in no wise injurious, it is hardly fair to consider it as an adulterant when its admixture with coffee is acknowledged. Chicory is prepared from the root of the chicory plant, or wild endive, which is roasted and ground. By roasting, an aroma is de- veloped, as in the case of the coffee berry. Chicory contains no caffeine, but it holds a volatile oil and a bitter principle. Its ad- mixture with coffee is detected by bleaching with chlorinated soda, which acts promptly on the pigments of chicory, but very slowly on those of the natural coffee. In France, coffee is frequently flavored with caramel instead of chicory, which is more extensively used in England and the United States. Coffee is also diluted with various substances, such as peas, beans, peanuts, dried sweet potatoes parched, and ground acorns, corncobs, or date stones are sometimes used. Imitation coffee beans are composed of pellets of roasted wheat flour, or sometimes wheat flour and chicory, or sawdust. Eye, corn, and barley are also mingled with wheat for the same purpose. Fat globules are present in impure coffee in considerable quan- tity. The substitutes for coffee are easily detected by the fact that, unlike the true coffee bean, which, unless overroasted, floats after roasting, they usually sink to the bottom of a glass of water. STIMULANTS AND BEVERAGES 257 Coloring matter, like ochre, burnt umber, charcoal, Prussian blue, and lead chromate, is added occasionally before the roasting, as well as burnt sugar and sirups, in order to affect the appearance and color of the beans. The beans are sometimes polished in cylinders, in which they are made to revolve with soapstone. Substitutes for Coffee. A substitute for coffee may be made from wheat, rye, or oatmeal, to which butter is added in the propor- tion of one part to eight of meal. The butter is melted in a hot iron frying pan and the meal is sprinkled over it and briskly stirred with- out burning. Thus prepared, the meal resembles roasted coffee, and when half an ounce is boiled in a pint of water it makes a beverage which is rather agreeable in taste. In Bavaria this substitute for coffee is used largely by the peasants, and it is also supplied in some charitable institutions in this country. Its use necessitates boiling the water, which, if it contains any impurities, is thus rendered harmless. There are several cereal substitutes for coffee sold in open market which are advertised as being highly nutritious. A number of them were analyzed for the United States Department of Agriculture (Bulletin 122) by C. F. Langworthy, who says of them: " The average cereal coffee infusion had the following percentage composition: Water, 98.2; protein, 0.2; and carbohydrates, 1.4, while the fuel value was 30 calories per pound. Skim milk, which is ordi- narily considered a rather " thin " beverage, contains 3.5 per cent pro- tein, 0.3 per cent fat, 5.15 per cent carbohydrates, and 0.8 per cent ash, or almost twenty times as much food material as the average of the beverages made from cereal coffee. If made according to directions, one would have to drink 4% gallons of an infusion of one of them which made an especial claim to high nutritive value in order to get as much food as is contained in a quart of skim milk." Mate, called also Paraguay tea, is manufactured from the dried leaves of a plant resembling holly. It is a mildly stimulating bever- age which contains theine, but it has no special dietetic advantages over tea or coffee. Postum is described on page 255. RELATIVE VALUE OF COFFEE AND TEA Much argument has been expended on the relative digestibility and usefulness of tea and coffee, but about all that can be said definitely in regard to the matter is, that many persons who can drink tea with impunitv are made nervous and are kept awake by 19 258 STIMULANTS, BEVERAGES, CONDIMENTS a similar quantity of coffee, whereas there are others who find that coffee aids their digestion while tea interferes with it, and that it affects them in every way more agreeably than tea; and still a third class cannot take either tea or coffee without producing indigestion, insomnia, and nervousness. Speaking generally, coffee is believed in the United States to be more digestible and useful than tea, but in other parts of the world, especially in England, China, and India, tea is regarded as more beneficial than coffee. In equal weight, tea contains more than twice as much caffeine or, as it is also called, theine. In this country, however, it is customary to use about 50 per cent more of coffee than of tea to the same quantity of water. Coffee is said to irritate the mucous membrane of the stomach less than tea when drunk in very large quantities. It has a more decided stimulant action than tea upon both the force and frequency of the pulse. Cocoa Cocoa and chocolate are both prepared from the cocoa bean, or pulpy seeds of the exotic cacao tree, Theobroma cacao. The major portion of the supply consumed in the United States is derived from Brazil, the British West Indies, Ecuador, Venezuela, and Dutch Guiana. The cacao tree attains a height varying up to thirty-five feet. It blossoms frequently and yields two crops a year of a bright-yellow soft fruit. The fruit, which bears some resemblance to a small cucumber, contains two or three dozen colorless seeds embedded in mucilaginous material. When dried in the sunlight, the seeds acquire a bright-yellow or brown color and harden. The cocoa starch grains are spherical. Preparation. Cocoa may be either fermented or unfermented. The former variety is dried in the sun at once, and the latter is kept for some time, in quantity, in a cool, moist place, while fermen- tation proceeds. The process of fermentation greatly improves the product, for the natural acidity and bitter taste of the seeds suc- ceeds to a milder, somewhat aromatic, and more agreeable flavor. The husks of the cocoa beans are irritant to the alimentary canal, and possess little nutrient material. The kernels when finely ground constitute "cocoa nibs," from Avhich a decoction is made by boiling in water for about two hours, and removing the insoluble residue by straining or decanting; but the cocoa usually sold in market is made by grinding the kernels into a paste, to which starch or sugar is added. If starch has been STIMULANTS AND BEVERAGES 259 used, the cocoa must be boiled for some minutes, but if diluted with sugar it is only necessary to mix it with boiling water or milk. The different preparations of cocoa are very numerous, but the quantity commonly used fcr making a single cup of the beverage is a heaping teaspoonful or more. Composition. The cocoa beans, after being husked and dried, con- tain fat and theobromine, besides a little albumin, starch, pigment, and salts. The average percentage of the principal ingredients of cocoa prepared for a beverage is shown in the following analysis by Stut- zer of a specimen of Holland cocoa : Theobromine 1.73 Total nitrogenous substances 19.88 Fat 30.51 Water 3.83 Ash 8.30 Fiber and non-nitrogenous extract 37.48 Theobromine is the principal alkaloid of cocoa, and is almost identical, both chemically and in its physiological effect, with caffeine. Cacao Butter. The fat, which is called cacao butter, is the nutri- ent ingredient of most importance. It usually constitutes 50 per cent of the cocoa bean. It has an agreeable flavor and odor, and may be kept indefinitely without change. Because it melts readily at low temperatures, it is quickly dissolved in the alimentary canal, and it is therefore used for making suppositories. Uses. Cocoa is not as digestible as is generally supposed, because it leaves a large residue of unabsorbed protein and its relative de- ficiency in starches and salts prevents it from being regarded as a " complete " food. Whatever nutritive power cocoa possesses de- pends upon its fat and a small percentage of digestible albumin. If the cocoa is roasted by too high a temperature, the latter is destroyed. The term " soluble cocoa " is erroneous, because neither the fat nor much of the albuminous material is truly soluble, and if they are removed the food value of the cocoa preparation is much im- paired. These substances may, however, be reduced to a fine state of subdivision and held in suspension, but the cocoa bean contains so much fat that it cannot be powdered unless the fat is partially removed by artificial process or diluted with sugar or some form of starch. The various powders recommended for invalid diet, and which are sold as cocoa or broma, under different proprietary names, are made in this manner. They possess rather less strength than chocolate, but, on the other hand, because they contain less fat, 260 STIMULANTS, BEVERAGES, CONDIMENTS they may be better borne by an enfeebled stomach. The Holland cocoa and other preparations are made with the object of obtain- ing a digestible cocoa without removal of the fat, which for this purpose is saponified by the use of sodium and potassium hydrate and magnesia. These alkaline substances, while they may be beneficial in some forms of dyspepsia, in olher cases tend to interfere with digestion by neutralizing the gastric juice. Both cocoa and chocolate differ from tea and coffee in the fact that besides making an agreeable and very slightly stimulating drink, they contain more food substance. Their actual use for this purpose, however, is exaggerated. Cocoa further differs from tea and coffee in that the insoluble material is consumed as well as the soluble. Various cocoa powders, essences, etc., are sold for use by infants, a teaspoonful of which may be dissolved in a half pint of hot water. Or an infusion of cocoa nibs may be made. Such preparations should never be given to very young infants, and, as a rule, it is best not to allow their use before the completion of the third year, but for young growing children after that age they afford an excellent beverage. After suspension in hot water cocoa exhibits a scum of fat float- ing upon the surface of the cup. This may be skimmed off on a piece of bread or cracker and eaten in lieu of butter a practice common among the Italians. Cocoa, on account of its large percentage of fat in comparison with starchy ingredients, forms a very good addi- tion to a vegetarian diet. Adulteration. The sophistication of cocoa is very easy of accom- plishment as well as profitable. It is principally done with sugars, starches, and fats. Iron salts and other coloring matters are often added. These adulterations are fraudulent, but not necessarily harmful. Chocolate Preparation. Chocolate is manufactured from the husked, dried, ground, and fermented cocoa seeds, which are then roasted and made into paste and compressed into cakes by moderate pressure. To increase the flavor and nutrient power of the cakes more or less sugar (but at least 50 per cent) is added, and various flavoring ex- tracts, such as vanilla, etc., or spices, are mixed with the paste before compressing it. The husks of the seeds are separately sold, and are used for adulteration in making cheaper varieties of chocolate. They arc inferior to the seeds in all their properties. STIMULANTS AND BEVERAGES 261 Uses. The value of chocolate as a concentrated food is in part derived from the sugar which is added, but it is very nutritious. Tested at the Austrian army manoeuvres, a chocolate ration was found to equal five times its weight of beef. Like cocoa, if pure and carefully prepared, its ingredients are easily digested and ab- sorbed. In cases of dyspepsia and various gastric disorders it forms an agreeable and wholesome drink, and enables the patient to take additional nourishment in the form of the milk and sugar mixed with it. It is also mildly stimulating and exhilarating to the nerv- ous system when exhausted through overwork or worry, and pos- sesses the advantage over tea and coffee that it does not produce wakefulness. The free use of chocolate, either eaten or drunk as a beverage, constituting what almost might be called a "chocolate habit," is not injurious to the nervous system after the manner of overindulgence in tea and coffee, but it produces more or less gas- tric dyspepsia on account of the large quantity of sugar which it already contains or which is added to it when drunk. I have seen a case of temporary glycosuria in a chocolate manufacturer, who ate large quantities in testing samples. Chocolate made into compressed cakes forms a convenient portable food that will keep well for a long time, especially when protected from drying by a coating of tinfoil or otherwise. These cakes con- tain condensed nutriment which makes them very serviceable upon expeditions where provisions can only be carried in limited quantity. Condensed milk may be carried to drink with the chocolate. The fact that its flavor is so universally liked is an additional advan- tage. The chocolate cakes are sometimes prepared with meat extract, or when dissolved and drunk, meat powder or raw meat may be added to them for phthisical patients or other invalids who require concentrated food. Chocolate, when not too rich in fat, is a very wholesome food for growing children, and is better for them than the more stimulating beverages tea and coffee. Its agreeable flavor causes it to be used extensively as an ingredient of starchy foods and confections, and also to disguise the taste of disagreeable or bitter medicines, such as quinine. Many articles of invalid diet, such as cornstarch, farina, gelatin, etc., may be made palatable by the addition of chocolate, while their nutritive qualities are enhanced. A pint of milk and four ounces of chocolate yield about 800 calories, which is a fair meal for an invalid. 262 STIMULANTS, BEVERAGES, CONDIMENTS Kola Composition. The kola nut is the fruit of a tall tree of the order Sterculiacece, growing in the island of Jamaica, on the west coast of Africa, East India, and Ceylon. It resembles both coffee and chocolate in some of its properties, and its uses are practically the same. It contains caffeine, or theine and theobromine, besides a lit- tle fat, glucose, dextrin and starch, cellulose, albumins, tannin, mu- cilaginous material, a diastatic and a milk-digesting ferment, and other substances. Uses. Kola is believed to exercise a restraining influence upon tissue waste. It is also mildly stimulating to the heart and nervous system, and is diuretic as well as somewhat tonic in its action on the stomach. It is said to increase the capacity for endurance of mus- cular work. As a substitute for food on forced marches or in moun- tain climbing it is said by those who have tried it to sustain strength as long as forty hours, and to serve better than tea or coffee. Its efficacy has been repeatedly tested by European army surgeons, especially in France and Switzerland, for troops on the march, and has been shown to lessen fatigue and diminish the craving for both food and drink. Kola made into an infusion like coffee, but only one-third or one- half the strength of the latter, forms a smooth, rich, dark-brown fluid without sediment or oily scum. It is drunk, like coffee or chocolate, with milk and sugar, and has a not unpleasant flavor. It is said to be well borne by delicate stomachs, and may be prescribed in fevers. In large doses it may cause insomnia. Alcohol Alcohol is a substance produced by a process developed in cer- tain sugar-yielding substances (such as grains, molasses, sugar cane, etc. ) by the action of an organized ferment, the yeast fungus Saccha- romyces cerevisice. The chemical changes involved are complex, but the chief products are ethyl alcohol and carbon-dioxide gas. A little glycerin, succinic acid, and other bodies may be formed. The fungus is always floating in the air, so that when saccharine fluids are ex- posed to it the fermentation proceeds of itself. Two parts of sugar yield approximately one of alcohol. Alcohol may be derived from any starches or sugars by fermenta- tion, but in the United States the chief sources of alcoholic beverages are grains such as oats, corn, wheat, rye and barley, molasses and fruits, such as grapes, apples, peaches, and to a limited extent pears, apricots, figs, prunes, cherries and berries. STIMULANTS AND BEVEKAGES 263 About 150,000,000 gallons of spirits are produced annually in the United States from grains and molasses, and 5,500,000 gallons of fruit brandy (U. S. Dept. of Agriculture Bull. No. 269, 1906). There are no civilized races, and few uncivilized or semi- civilized people, with the exception of Mohammedans, Buddhists, the north- ern Eskimos, and one or two other tribes mentioned below, who do not practice the distillation of alcohol in some form or other from the materials most available. For example, the spirit fermented from the potato is drunk in Lombardy, and that from rice in Japan, and the Fiji Islanders use a drink, " Tcava," made by fermenting with their own saliva the Piper methysticum. Even the stems of plants are used, as in the case of alcoholic beverages made from the sugar cane and the palm. (See also p. 241.) General Discussion of the Value of Alcohol. The question whether alcohol is, properly speaking, a food, or is only to" be regarded as a beverage and stimulant without power of nutrition, has given rise to much warm discussion, and it invariably plays an important role among the advocates of teetotalism. A full presen- tation of the alcohol question would be foreign to the limits of the present work, but the following general propositions comprise the belief of many authorities who have devoted careful research to this exceedingly important topic : 1. The use of alcohol in any form is unnecessary for the human organism in health. It does not exist as a natural product. The very lowest types of man Australian and many Polynesian sav- ages know nothing of it, and drink only water and fresh fruit juice, such as that of the cocoanut, although they speedily acquire a fond- ness for alcoholic beverages when given them. 2. A large number of persons are undoubtedly better without alcohol and may prolong their lives by total abstinence. 3. The lifelong use of alcohol in moderation as an occasional beverage with meals does not necessarily shorten the duration of life or induce disease in some persons, while in others it undoubtedly produces gradual and permanent changes, chiefly of a cirrhotic char- acter, in the blood vessels, nerves and in the viscera, especially the liver and kidneys. These alterations, which may be slow and subtile in character, may not in themselves materially impair the health or cause an ultimately fatal result, but they tend to weaken vital organs and produce premature senility, so that if the patient acquire any severe disease as, for example, an acute infection, like pneu- monia, or a chronic one, like tuberculosis the resistance of the body to the invasion of the disease is impaired. There is a prevalent 264 STIMULANTS, BEVERAGES, CONDIMENTS belief that these cirrhotic changes are as much due to toxic products of indigestion caused by alcohol as to the alcohol per se. 4. There are many persons whose constitutional inheritance of inebriety is such that they should be warned particularly against the use of alcohol, and in some such cases, as, for example, among those who are subjects of well-marked gouty diathesis, it is better that its use should be forbidden imperatively. 5. The abuse of alcoholic stimulation is invariably injurious, al- though the extent to which evil influences become manifest depends upon the constitution of the individual, in connection with the fac- tors of heredity, environment and activity of excretory organs. 6. There are a few diseases in which the temporary use of alcohol is of positive service, and there are certain cases in which it becomes a necessity in order to prolong life. 7. In certain cases of malnutrition and malassimilation of food, alcohol is itself a food, and its consumption under proper direction results in an increase of body weight and strength and improve- ment of functional activity. These results are accomplished in part through the action of the alcohol as a definite food, and in part through its remarkable effect in force production. The latter is due to its own direct combustion, by which in chronic disease and in critical acute and exhausting affections it spares that of the tissues of the body. This value exists especially in the malt bever- ages. Although alcohol is such a strong force producer and heat gen- erator, its effect in this direction is very soon counterbalanced by its stronger influence in lowering the general tone of the nervous system and in producing positive degeneration in the tissues. In the condition of health more food usually is eaten and more force developed than is actually necessary for the body, and there is al- ways a reserve supply of energy on hand which may be utilized for any extraordinary exertion, and hence the constant use of alcohol as a food or stimulant in health is both unnecessary and inadvisable. When alcohol is consumed in health in addition to a normal or ex- cessive quantity of solid food by its more ready combustion it pre- vents the coniplete oxidation of the latter and favors accumulation of suboxidized waste products which are always harmful in the system. Excesses in eating are thus doubly aggravated by the ef- fects of alcohol. It is the almost universal testimony of army surgeons and the experience of those who, like Greely, Stanley, and others, have led long and perilous exploring expeditions, involving great fatigue and unusual endurance, that muscular overwork and STIMULANTS AND BEVERAGES 265 climatic hardships are endured much better if alcohol is entirely ab- stained from. It often has been found in armies that when good food was at hand the issue of alcohol with the regular ration produced an in- creased percentage of sickness and of incapacity for work. While all this applies to prolonged effort of any kind and to conditions where other food can be obtained and assimilated, it does not detract from the fact that alcohol is a most helpful food and stimulant in emergencies when other food cannot be had or when the body is temporarily endangered from acute disease and the higher rate of combustion in fever, or from failure to assimilate other nourishment. Major Woodruff, U. S. A., says : " Spirits can never be used in the army as a regular issue; the practice is thoroughly vicious, and was virtually abandoned seventy years ago. On extraordinary oc- casions of great fatigue they are allowable in moderation. Under such temporary stimulation the men will brace up and perform the necessary work of making earthworks, etc., when without it they' would be too exhausted to do anything. Without stimulation a man is not worth much after he has made a forced march of forty miles/' The problem whether the world as a whole is better or worse for the existence of alcohol aside from all ethical questions, and viewed merely from the scientific standpoint of the influence of alcohol upon mortality, is difficult of solution, for to offset the numerous cases of fatal alcoholism and the still larger number of cases of dis- eases which would not presumably be fatal without the existing con- dition of chronic alcoholic poisoning of the system, are very many cases in which life is undoubtedly saved by the prompt resort to this food and stimulant and its energetic use. So long as man is exposed to hardships and conditions arising from improper and de- ficient food supply as well as to the numerous infectious diseases to which he is heir, alcohol should be regarded rather as a bless- ing than a curse, for there is no form of stimulant and food combined or stimulant alone which, taken all in all, can be relied upon so com- pletely in cases of emergency. Alcohol when taken alone will pro- long life beyond the period at which it would terminate from starva- tion. Physiological Action. I. As a Food. As a food, alcohol adds to the nutrition of the body by its prompt absorption, requiring no preliminary preparation by the digestive organs, which are therefore not taxed in any degree, and it is immediately conveyed in the general 20 266 STIMULANTS, BEVERAGES, CONDIMENTS circulation to the liver and other parts of the system. The chemical changes involved in the assimilation of this form of hydrocarbon are ill understood. Alcohol, even when digested in considerable quantity, does not reappear to any extent unaltered in the urine, and, if not taken in excess, it is not exhaled from the breath, demonstrating that its combustion is complete. This combustion results in the formation of water and carbon dioxide. The fact that the body weight may increase under its use, and the storage of fat in the tissues increase to an abnormal degree, does not prove that the alcohol itself has entered into their structure, for its action may be exerted through modification of oxidation processes or by preventing the burning up of other food materials. The fool value of alcohol, is, however, easily surpassed if too much be taken, and usually not more than V/ 2 oz. of an equivalent of pure alcohol can be utilized daily within food limits. Writing of the nutritive value of alcohol in disease, Atwater says : " It does not require digestion, is absorbed by the stomach, and presumably by the intestine, with great ease. Outside of the body it is oxidized very readily, within the body it appears to be quickly burned, and it supplies a large amount of energy." He has further proved in calorimeter experiments that alcohol protects body pro- tein and fat from oxidation. It is, however, inferior to carbohydrates in regard to protein pro- tection and in some cases may increase protein consumption, as, for example, when taken in such excess as to affect the nervous system and inhibit normal metabolism. Bauer says: "Alcohol, in consequence of its fat-sparing action, behaves in the character of a food." The sugar which is contained in considerable quantity in sweet wines, liqueurs, etc., is an addi- tional source of nourishment or of fat production. It is a matter of common observation that many heavy drinkers are stout so long as their digestion remains unimpaired. Heavy drinkers are often heavy eaters, and may be as unable to control their appetite for food as for drink. This of course does not apply to cases of alcoholic gas- tritis, in which, temporarily at least, all desire for food may be in abeyance. II. As a Stimulant to the Nerves and Circulation. The influence of alcohol upon the nervous system in moderate doses is to quicken the transmission and enhance the effect of nerve currents, accelerating slightly the heart action and, to a lesser degree, the respiration, while the mental processes are stimulated in part by its direct influ- ence upon the cerebrum, and in part also by the greater rapidity of the circulation. STIMULANTS AND BEVERAGES 267 If alcohol is given in large doses or at too frequent intervals, it may overstimulate the heart, which subsequently becomes exhausted. III. Action upon the Muscular System. Experiments to test the sustaining power of alcohol were made upon three regiments of the British army and reported in 1899. The men were subjected to fatiguing exercises. To one regiment a ration of whisky was allowed, to a second a ration of malt liquor, and to the third no alcohol. The men taking whisky exhibited more energy for about four days than either of the other groups, but then became fatigued and weak; whereas those taking none steadily gained in endurance, and those taking malt liquor showed an intermediate condition. As a result of these experiments, the use of liquor was absolutely forbidden in Kitchener's Soudanese campaign, which was characterized by remark- able immunity from disease in the Desert. Alcohol is usually for- bidden to athletes in training, for although it may temporarily lessen muscular fatigue, and increase muscular force, it soon reduces the powers of endurance. IV. Action upon the Body Temperature. The physiological effect of alcohol upon the body temperature proceeds primarily from its stimulating influence upon the vasomotor nerves. In moderate doses, alcohol, by quickening the rapidity of the circulation and by dilating the peripheral blood vessels, enables more blood to reach the surface of the body and to pass through the superficial capillaries in a given time, and hence there is a tendency to lower slightly the body tempera- ture. On the other hand, the combustion of the alcohol itself within the body results in the production of a large number of heat units. The total balance of these processes is usually on the side of an ab- solute reduction of the temperature. This effect is so slight, how- ever, that alcohol cannot be relied upon solely for reduction of tem- perature in fevers. As a result of an elaborate series of experiments made by Reichert to determine the action of alcohol on animal heat functions, he con- cludes " that alcohol does not affect the total quantity of heat pro- duced; that more heat is dissipated than produced; that the fall of temperature is due to the excess of dissipation, and is in direct pro- portion; and that in all likelihood alcohol, by undergoing oxidation, yields energy in the form of heat, thus conserving the tissues and acting as a food." V. Action 0,9 a Diuretic. Alcohol in some persons is a strong diuretic in health, and its effect depends largely upon the variety of the beverage used. For some persons gin has a much more decided diuretic action than other strong liquors, such as rum or brandy, 268 STIMULANTS, BEVERAGES, CONDIMENTS and in many beer possesses a diuretic action which indicates a special stimulating effect upon the total quantity of urine excreted beyond that produced by a similar bulk of water, but the total quantity of urea, sulphates, and phosphates eliminated is diminished. Chitten- den found that uric-acid excretion is doubled. As a general rule, alcohol which is moderately diluted, and which is taken upon an empty stomach, is much more promptly absorbed and possesses a stronger diuretic action than when taken with food or when given in a concentrated form. Owing to its irritant action upon the kid- neys alcohol cannot be relied upon as a diuretic in nephritis. VI. Action on Mucous Membranes. Strong alcohol is astringent to mucous surfaces, and is sometimes used diluted with equal parts of water as a gargle for sore throat. Claret, which also contains tannin, may be employed in this way. If taken in too large quantity or too strong, the astringent effect upon the stomach is highly irritating, causing local congestion, and inflammation. The tongue becomes coated, and the appetite is de- stroyed as well as the secreting power of the gastric glands. VII. Action upon Gastric Digestion. Taken with food in the stomach, alcohol in small quantities, not exceeding the equivalent of a quarter of an ounce of the pure substance, given in the form of any dilute alcoholic beverage, does not inhibit the action of the gastric juice, but may stimulate its secretion so that, as Moleschott says, " a glass or two of good old wine increases the quantity of gastric juice, which performs mainly the digestion of albuminous foods." In larger quantities, or if the gastric juice is weak, alcohol precipitates pepsin, coagulates the albuminous materials of the food and greatly retards if it does not altogether destroy gastric digestion. Some interesting experiments were reported by Eoberts (Lec- tures on Dietetics and Dyspepsia) upon the effect of malt liquors on gastric digestion. They were conducted by adding together 2 grams of dried beef-fiber, 0.15 c. c. of hydrochloric acid, 1 c. c. of glycerin extract of pepsin, and varying quantities of malt liquor, with water up to 1 00 c. c. The result is tabulated : PROPORTION OF MALT LIQUORS CONTAINED IN THE DIGEST- ING MIXTURE. TIME IN WHICH DIGESTION WAS COMPLETED. (NORMAL, 100 MINUTES.) Burton ale. Light English table beer. Lager beer. 10 per cont 115 minutes. 140 200 " Embarrassed. 100 minutes. 115 " 140 180 " 100 minutes. 115 140 " 180 20 " " 40 " " 60 " " STIMULANTS AND BEVERAGES 269 In considering the relation of alcohol to other foods, the fact should be emphasized that monotony of diet with bad cooking of coarse, tasteless food, especially when associated with overwork, may be a potent factor in establishing a liking for liquors among the poor, particularly in the United States, where among the poorer classes the art of varying the diet and of serving food in an agree- able and properly seasoned manner is imperfectly understood. Osier endorses the opinion that more ill arises from abuses of eating than of drinking, especially in America. VIII. Alcohol Absorption. Alcohol is highly diffusible, and is promptly absorbed from mucous surfaces as well as from subcutaneous tissue. When taken into an empty stomach, it is rapidly absorbed, and its influence is exerted suddenly. When there is food in the stomach, some of the alcohol is temporarily taken up by it like water by a sponge, its absorption is delayed, and, as its combustion is rapid, the system is less likely to become surcharged with it. Alcohol is. well absorbed from the rectum, and to patients who for any reason are unable to retain it in the stomach it may be given in enemata. For this purpose it is best to use an ounce of whisky or brandy diluted with 3 or 4 parts of water. Hypodermic Use. Very little alcohol can be made to pass into the body by rubbing it upon the skin, although it is a diffusible sub- stance, but it is promptly absorbed when injected hypodermically. Owing to the local irritant action of alcohol, not over a drachm or two of spirits should be placed beneath the skin at any one point, for it is often quite painful. The surface should be rubbed to pro- mote absorption. In emergency, an ounce or more may be given in this way in divided doses. IX. Elimination. It may be regarded as proved that when taken in moderation alcohol is completely consumed within the body, or so completely that a mere trace escapes in the urine and perspiration, and a little more in the exhaled air. If the dosage of alcohol is large, however, its elimination, unaltered, becomes proportionately active, although it is still consumed in large amount in the body. X. Alcohol Poisoning. This topic will be more conveniently dis- cussed with the treatment under the heading Alcoholism. XI. Alcohol and Climate. Many persons find that they can drink more spirits and wine during a prolonged residence in a cli- mate like that of England without ill effect than they can in the more stimulating climate with greater extremes of temperature which exist in many parts of the United States. If men are to be exposed to cold 270 STIMULANTS, BEVERAGES, CONDIMENTS and hardship for a considerable period of time it is unwise to indulge freely in alcoholic drinks on account of the fall in the body tempera- ture, which is promoted by the external cold when alcohol relaxes the capillaries. In illustration of this principle, a story is told of a party of engineers who were lost during the winter in the Kocky Mountains, where, after prolonged exposure to cold and hardship, they were one night obliged to sleep without shelter with the ther- mometer below zero. They had whisky with them, but little food; some of the party drank heavily, others drank in moderation, and a few of the wiser took no alcohol at all. In the morning the latter awoke, cold but refreshed by the night's rest, while others who drank in moderation had suffered far more from the exposure, and one or two of those who had drunk freely were frozen to death. Otto Snell interrogated sixty expert mountain-climbers, and only five declared that liquor was not injurious if taken before or during their exertions. In the Arctic expeditions of Greely, De Long, and others, although pure alcohol was carried for cooking purposes, stringent regulations were enforced to prevent the men from drinking alcoholic beverages, which were kept only for emergencies and sickness. CLINICAL, USES OF ALCOHOL, 1. Use as a Tonic. Very moderate doses of alcohol increase the flow of gastric juice, and for this reason it may be employed in cases such as the following: 1. By those whose nervous system is readily overtaxed and who when fatigued or worried lose all appetite. 2. By persons of sedentary habits who have enfeebled digestion. 3. In protracted convalescence from severe forms of acute disease. For any of these patients a little whisky and water, or a glass of simple bit- ters may be ordered to be taken directly before meals in order to improve the " tone " of the stomach. In all cases care should be exercised, especially among persons who may possibly inherit the al- coholic habit, that the beverage be not prescribed too often, for many cases of chronic alcoholism originate among persons who begin by resorting to this food and stimulant to tide them over emergencies, and who find when the emergency is passed that they are unable to re- linquish the acquired fondness for the drink. Major Charles E. Woodruff says that experience based on service of the troops in the Philippines "lias demonstrated that in a hot climate the moderate use of intoxicating drink is essential to continued health and efficiency." 2. Use as a Vascular and Cardiac Stimulant. If there is general arterial relaxation from debilitating disease, the combined action of STIMULANTS AND BEVERAGES 271 alcohol in strengthening the heart and regulating the caliber of the blood vessels is sometimes useful. For this purpose it is best to use strong liquors, such as brandy or whisky, which vary little in composition, and which may be diluted according to need. In cases of sudden heart failure occasioned by shock, fainting, etc., it is best to give alcohol in the form of diluted spirits, when required. It is an interesting fact that the mechanical action of deglutition stimulates the heart action and increases the rate of pulse beats by ten or twenty in the minute. Stimulants sipped slowly by repeated acts of swallowing for this reason may have a greater effect than the same quantity of fluid drunk all at once. In extreme emergencies, as, for example, in shock from prolonged anaesthesia, when alcohol is given by hypodermic injection, the stimulation of the pulse may be appreciated in two or three minutes. A little more time is required for the full effect if the stimulant is given by the stomach or rectum. The benefit of alcohol is further shown by the tongue and skin becoming more moist, by the slowing of the pulse, and by the breathing becoming more tranquil. The very soft pulse of con- siderable volume may diminish in volume under the use of alcohol, but it becomes firm and of better character, showing an improvement in the arterial tone. 3. Use in Nervous Diseases. Alcohol is occasionally of service for certain diseases of the nervous system. Neuralgic pains are some- times allayed by the use of alcoholic drinks which contain volatile 'ethers, but they should be prescribed with caution. In neuralgic or nervous affections, such as hysteria, which are more or less chronic, it is well to observe that many of the so-called proprietary elixirs, nerve tonics, etc., which are recommended for cases of fhis nature, and especially for treatment of nervous prostration, contain a large percentage of alcohol, and their use is liable to establish permanent alcoholism. 4. Use in Fevers. Usually in acute febrile diseases, such as pneu- monia, in which the emergency of cardiac failure or great prostra- tion may be anticipated, it is better to withhold alcohol until there are definite indications for its use than it is to prescribe it in a routine manner at the commencement of the disease ; its effect when actually needed is enhanced if it has not already been given for too long a time. For persons with feeble constitutions, however, and for aged people it may be necessary to commence the use of alcohol at an earlier period. In urgent cases full doses, such as an ounce of whisky an hour, may become necessary for a few times, and the quantity and intervals for its administration may then be reduced gradually. 272 STIMULANTS, BEVERAGES, CONDIMENTS Usually however, when the stimulating and supporting influence of alcohol is needed it is better to give it in quite frequent doses and in moderate quantity than in large amount infrequently. The stimula- tion is then more uniform and constant, and the digestive organs are less likely to be deranged. There is at present a strong reaction against the prescribing of large doses of alcohol in pneumonia and other infectious diseases, as in fevers in general, and personally I make much less use of it than formerly, and in a majority of serious cases of pneumonia and ty- phoid fever, I have witnessed recovery without its use at any time throughout the disease. In the London hospitals forty years ago, the total cost of alcoholic drink used was nearly three times that of milk, but at the present time this proportion has been reversed. The volatile stimulants such as ether, camphor, aromatic ammonia, and digitalis may be employed often with greater benefit than alcohol, and as an antipyretic the value of alcohol is slight and unre- liable. The indications for the use of alcohol in fevers are found in the pre- dominance of one or more of the following symptoms: Increased weakness or faintness, low muttering delirium continued even when the patient is undisturbed, tremor of the tongue and hands, great dryness of the tongue, extreme feebleness of the voice, irregularities in the respiration and pulse, enfeebled or irregular heart action, and absence of either of the cardiac sounds. In using alcohol in fevers if the odor persists in the breath and the pulse is not improved, or the patient becomes more delirious, too much is being given, and the dosage should be reduced. Proper Time for Giving Alcoholic Beverages. When needed as a tonic, the beverage should be given either immediately before or in connection with meals, in order that its effect may be modified by that of other foods. There is less fear of establishing a craving for drink if this rule be observed. It is the habit of drinking between meals without definite purpose which is particularly dangerous. In some cases of neurasthenia, anasmia, etc., it may be advisable to recommend a glass of claret or sherry between the principal meals, and it should be taken with some article of light and easily digestible food, such as a biscuit or sandwich. There are some patients having chronic atonic dyspepsia or limited nervous energy for whom it is better to prescribe alcohol half an hour before eating in order that its stimulating influence may be Mt in the system before the nervous forces are called upon for digestive functions. STIMULANTS AND BEVERAGES 273 Selection of the Proper Form of Alcoholic Beverage. The stomach is much less likely to be upset by adhering to a single form of beverage than by making frequent changes. Persons hav- ing robust physiques may be able to assimilate several kinds of wines, including champagne, at dinner, followed by liquors and brandy; but these beverages, if taken in such variety without food, will almost invariably derange the stomach. The combination of whisky and beer or strong liquors and champagne will promptly disagree with many persons who could take either form of alcohol alone with im- punity. In fever the stomach is always temporarily enfeebled, and the importance of adhering to one simple form of alcoholic beverage is emphasized. It may be changed from time to time in conformity with the taste of the patient, but mixtures never should be given. Beer, ale, porter, and stout, cannot be drunk by some persons without producing a subsequent feeling of lassitude and drowsiness with headache and suffusion of the face, and yet diluted spirits may be well borne. Some persons find that sherry produces acid dys- pepsia, and others find that different sweet wines, such as port, similarly disagree, and in others again they excite attacks of gout. When porter, ale, or stout do not derange the stomach, they may be drunk advantageously by women who are weakened by prolonged suckling. Alcohol should be emphatically forbidden in all forms of gonorrhoea and syphilis, and a single infringement of this rule may aggravate the complaint. Some clinicians prefer the use of wines which are well charged with volatile compound ethers as a stimulant for enfeebled heart action and weak digestion. The use of beer as a beverage for fevers is common in Continental Europe, but not in the United States. Passing fashion to some extent influences the variety of alcoholic beverage consumed, as illustrated by the fact that in this country the annual importation of Scotch whisky has lately risen from 30,000 to 100,000 gallons for a single firm. Eum and port are much less drunk than formerly in the United States. As a preventive of drunkenness and the evils of chronic alcohol- ism, the introduction of the milder malt liquors into this country to partially supersede the use of strong spirits has proved a decided advantage. The total annual consumption of all alcoholic beverages in the United States exceeds one billion gallons. In 1870 the per capita consumption of distilled liquors was 2.07 gallons, and twenty- five years later this fell to 1.12 gallons, whereas during the same period the consumption of malt liquors rose from 5.31 to 14.95 gal- lons. The consumption of wines has remained at about 0.32 gallon. There is prevalent a widespread tendency towards restriction of 274 STIMULANTS, BEVERAGES, CONDIMENTS the use of alcoholic beverages in the United States, England, Canada, and other British Colonies, and in two-thirds of the United States in 1908 the saloon had been abolished by prohibition laws. Malt Liquors Beer. The lager-beer industry was introduced into the United States in 1842. Composition. Beer contains alcohol in strength varying between 3. and 8 volumes per cent (sometimes 10 per cent). Besides this alcohol and much water, beer contains a variety of ingredients, such as bitter and resinous extractives from hops, sugar, dextrin, albuminates, glycerin, free acids, and a trace of ash. The sugar of beer is fattening, and the bitter substances are more or less of a stomachic tonic. By process of manufacture much beer is made to contain only water, alcohol, and bitter principles. Hop extracts possess a nar- cotic influence, and hence beer may give rise to drowsiness, whereas other alcoholic beverages like champagne or whisky prove en- livening. This effect is, however, quite variable. Beer produces biliousness in persons of weak digestion. It is sometimes called " fluid bread/' but the expression conve} r s a wholly exaggerated idea of its food value, although it is often fattening when drunk in large quantity. Beer Brewing. Malt is the name given to any germinating ce- real, but to prepare it for beer brewing, malt is made from barley grains as follows: The grain is steeped in water at a temperature which causes germination and the development of the ferment dias- tase. It is next couched and " floored/' during which process ger- mination continues, and it is finally kiln-dried. Brewing of beer is accomplished as follows: The prepared bar- ley malt is first cleaned by screening, sifting, and blowing, is crushed and then " mashed " or infused with water in large tubs at a proper temperature. This process extracts the existing sugar and dextrin and aids in converting the residue of starch into maltose and dex- trin. The " wort " thus formed is a solution of diastase, dextrin, sugar, proteids, and salts. It is drawn off, and the residue of grain is washed with hot Avater by a process called " sparging," which extracts any remaining useful material. The wort is run into cop- per kettles and boiled for about four hours. During the last hour hop? are poured in. The boiling concentrates the wort, extracts the hop essence or lupulin with tannin, causes coagulation and pre- cipitation of any albuminous substance, and finally it checks further STIMULANTS AND BEVERAGES 275 fermentation for the time being. The wort is next cooled and yeast is added in the proportion of about a pound to the barrel. The yeast sets up a new fermentation, which converts the saccharine substances into alcohol and carbon-dioxide gas. This fermentation is retarded by continued application of cold. When it is concluded, the beer is drawn into settling tuns, and then into casks, where it is stored from five to eight months, after which it is ready for bottling. While resting in the casks the beer is subjected to "fining" i. e., beech- tree shavings are added to it, to collect any floating solid particles. This process allows so much carbonic acid to escape that a second fermentation is sometimes set up by adding new beer to the old in the proportion of 1 to 5. Beer which is kept long fermenting increases in alcohol and diminishes in extractives. Its natural intensity of color varies with the method of drying the malt, and increases with long boiling. White beer (" Weissbier ") is brewed from wheat instead of rye. It is less clear than rye beer, paler, and more frothy and sour. The low Bavarian beer is fermented by a variety of saccharomyces, which acts at a temperature of 43 to 46 F. Certain varieties of saccharomyces, acting at different tempera- tures, set up undesirable fermentation in both beer and wine, mak- ing them sour, and developing peculiar odors. Ale. Ale is made from pale* malt by processes resembling the brewing of beer. It contains from 3 to 6 per cent of alcohol. Strongly alcoholic ales are less used than formerly, having been largely supplanted by the lighter varieties and by beer. The quan- tity of hops used determines the bitterness of the ale, and their aromatic bitter principles furnish the peculiar flavor. Bitter ale has been so far fermented as to contain very little sugar. Porter. Porter is made from pale malt with the addition of high dried malt, which gives it color and flavor. It contains about 6 per cent of alcohol, and is regarded as more digestible than ale of the same alcoholic strength. Both ale and porter contain sugar and acid, but these substances are present in less degree in malt liquors than in wines. Stout. Stout is similar to porter, but is characterized by a pre- ponderance of extractives. It is fermented with hop yeast from barley. The stronger malt liquors, such as porter, stout, and heavy ales, are nutritive and fattening. All stale, flat malt liquors without a " head " are liable to nauseate and prove unwholesome. 276 STIMULANTS, BEVERAGES, CONDIMENTS Wine Composition. Wine made from the expressed juice of different varieties of the grape consists of an alcoholic solution varying in strength from 6 to 25 volumes per cent, and containing flavoring and other substances. The maximum normal percentage of alcohol which fermenting grapes are capable of developing is not above 15 per cent, but alco- hol is often added to equal 18 or 25 per cent or more. The pulp of the grape furnishes sugar for fermentation of alcohol, and also organic acids or their salts, such as citrates, malates, and tartrates. The stones or seeds furnish essential oils, some of which give the "bouquet" of volatile ethers, and the skins and stems fur- nish pigments and tannin. The latter is preservative ; it precipitates albuminous substances and prevents moldiness. The chief pigment of wines is primarily of a blue color, but it is reddened, like litmus, by free acid, more or less of which is always present. The fermentation of wines is caused by yeast germs, which exist upon the stems or skins of the grapes. Besides water, sugar, alcohol, volatile ethers, and carbonic acid are added in the manufacture of the different kinds of wine. Leoser gives the following list of minor substances, traces of which are more or less constantly present in wines : " Gelatin, gum, fat, wax, albumin, gluten, tartaric acid, potassic tartrate, racemic acid, malic acid, calcic malate, oxide of manganese, oxide of iron, potassium sulphate, sodium chloride, calcium phosphate, magnesia, silicic acid, tannic acid." The composition of the subtle substances which impart the flavor and aroma or bouquet to different wines is unknown. Most of these substances develop during fermentation, but a few grapes, such as the Muscatel, yield their own aroma to the wine. According to Konig, the average percentage composition of grape must is water, 74.49 ; sugar, 19.71 ; nitrogenous material, 0.28 ; non- nitrogenous material, 4.48; ash, 0.40; acid, 0.64. The grape sugar fluctuates sometimes as much as 24 per cent and the acid 1.2 per cent, and these substances usually stand in inverse proportion to each other. General Properties. The perfected wine has the properties of color, " body " or substance, and flavor, aroma, bouquet, or " fruiti- nese." Different wines are valued for their astringency (tannin), sweetness (grape sugar), strength (alcohol), acidity (organic acids), color or sparkle, flavor, and ability to stimulate the appetite and digestion. STIMULANTS AND BEVERAGES 277 Fermentation. Wines are both naturally and artificially fer- mented, and many varieties are reinforced by flavoring extracts and fortified by addition of alcohol. The latter method has the twofold effect of adding to their strength and of preserving them from further fermentation, and hence is used especially for the wines of the Cape, Madeira, and Portugal. In the cooler climate of France, Germany, and Hungary fermentation proceeds more slowly and fortification is less necessary, for the wines of these countries are drier (i. e., less sweet), less fruity, and require less time to mature. They also have stronger bouquet, because they possess more acid, which combines with alcohol to furnish the aroma (Pavy). Sugar. The quantity of sugar present in wines varies consider- ably. It is sometimes almost completely eliminated by fermentation into alcohol, or it may be added in excess to make the natural flavor sweeter. Flavor and Bouquet. Some Greek wines have a peculiar flavor, the liking for which is an acquired taste. This flavor is derived from rosin contained in the wood of casks used for preserving the wines, which induces chemical changes. The Hungarian wines possess agreeable fruitiness, but are not so completely ripened as French wines, and are hence likely to turn sour when transported. Both glucose and saccharose may be oxidized into acids instead of fermenting to alcohol, and when this process occurs extensively in a wine it becomes sour, like vinegar, and unfit for consumption. In general the flavor and bouquet of a wine depend upon (1) the nature of the soil in which the grape is grown, (2) the climate and temperature, (3) the quality of the grape, (4) the use of only a single variety of grape for a given wine, (5) the ripeness of the grape, (6) the duration of fermentation, (7) the addition or subtraction of ma- terial by the art of the wine grower, (8) the age of the wine. In vineyards where the best wines are made the grapes are tested from day to day to determine the right time to pick the vines, for the quantity of sugar and acid present depend upon the degree of ripen- ing and influence the flavor of the wine. White Wines. White wine is made from grapes of any color, the greatest care being taken not to macerate the berries in express- ing the juice, and to allow no colored juice to flow. As a rule, how- ever, the better class of white wines is made from selected white grapes, which are crushed with their skins. The mass is left for several days, so that the skins may impart what little soluble matter they contain to the pulp. The juice is then obtained by further pres- 278 STIMULANTS, BEVERAGES, CONDIMENTS sure and allowed to ferment. The crushing of grapes was formerly done by the feet of men who trampled upon them, but several lives were lost by carbonic-acid gas poisoning, and -the process is now gen- erally conducted by machinery. After several months, or longer, the ferment and the salts which are insoluble settle in a sediment called lees, and the supernatant fluid is carefully drawn off and casked or bottled. During the first year or so of storage some wines are recasked sev- eral times, for they continue to deposit lees on the bottom and sides of the cask, consisting mainly of "argol," an acid salt from which cream of tartar may be prepared. When fermentation has proceeded long enough it is stopped, accord- ing to the nature of the wine, by the addition of alcohol or strong sugar solution, or if left to continue after the wine is stored, the sugar and extractives very gradually disappear, and alcohol continues to develop. Hence, if a wine can be bottled early without being too green or immature it is sometimes a decided advantage, for more of the aroma 'and flavor may thus be retained. In other cases wines should remain in the casks for from one to four years before bottling the more delicate varieties being kept the longest for certain changes depend upon the size and nature of the containing receptacle, which are checked by bottling. White wines are produced in more variety than red wines. On the average they contain from 9 to 12 per cent of alcohol, from 0.30 to 0.50 per cent of sugar, and about 0.50 per cent of acid. Red Wines. In making red wine dark grapes are used, and both skins and stones are left to ferment with the pulp, to which they fur- nish tannin, pigment, and extractives. Eed wines, on the average, contain from 8.5 to 11 per cent of alco- hol, 0.55 to 0.65 per cent of acid, and 0.15 to 0.20 per cent of tannin and pigment. The red wines are, as a rule, more easily digested than white, and are more nutritive. The following practical statements are quoted from Leoser : " Bottled red wines that are rich in tannic acid, like port, for in- stance, deposit a sediment and grow lighter in color. Those that contain less tannic acid generally grow darker. The cause of this is a gradual diminution in the quantity of free acid in the wine. The effect of this acid is to turn the coloring matter red, and as it dimin- ishes, therefore, the wine grows darker or more purple." Red wine (claret) is often drunk diluted with Vichy, when "the potassium carbonate of the water saturates the free acid of the wine, and so destroys the red color and permits it to become darker, while STIMULANTS AND BEVERAGES 279 the action of the alkali upon the coloring matter gives it a cloudy appearance/' The deeper the color the rougher is the flavor of the wine in most cases. " If two wines of equal alcoholic strength be taken it will be found that equal doses of each will produce their effect much more quickly in the case of the white wine than in that of the red. The reason of this is that the astringent action of the tannic acid retards the effect of the alcohol upon the organism. It may be that this indicates in a general way the superiority of white wines as stimulants and red wines as tonics." Various substances are used for " fining " that is, to clarify wine such as cream, milk, blood, solutions of egg albumen, gelatin, isinglass, nutgalls, lime, etc. Their effect is largely mechanical, but the alkalies neutralize part of the acids. Other substances are occasionally employed, having in view the better preservation of wine, but many of these are unhealthful in their effects on the system. Such, for example, is the use of calcium sulphate, which is converted into potassium sulphate, or the use of alum, sulphuric or other acids, etc. Impure alcohol holding fusel oil is sometimes added. The object of storing wine in enormous tuns is to diminish the surface exposed to the air in comparison with the bulk. THE VARIETIES OF WINES The following classification of wines, with the examples and com- ments, is largely derived from Chambers, and will be found convenient and practical from a purely dietetic standpoint. Wines may be classed as I. Strong Dry Wines. II. Strong Sweet Wines. III. Aromatic Wines. IV. Acid Wines. V. Sparkling Wines. VI. Perfect Wines. VII. Rough or Astringent Wines. I. Strong Dry Wines are those in which the sugar of the ex- pressed grape juice or "must" has fermented into alcohol, either by process of time or by artificial means. When left to itself, this alcoholic fermentation is extremely slow, occupying many years before its completion, but the natural process is better than any artificial one yet discovered. These wines also contain considerable alcohol, often 17 or 18 per cent, which makes them less available for general dietetic uses than weaker wines. Examples are strong, dry old sherry, port, Madeira, and Johannisberg. (The name "sherry" is often used as a generic term for white wines grown in Spain. 280 These wines, especially sherry, are sometimes used for stimulation in fevers or other diseases, in lieu of spirits, where the taste of the latter is strongly disliked. If drunk too freely they congest the stomach, and have the evil effects of strong spirits or of strong alcohol in general. (See Alcohol, evil effects, p. 264.) They often contain sugar, and taken with meals may cause acetic fermentation, especially disturbing the digestion of fats. Port is a wine in which the original fermentation has been arrested by addition of alcohol, and it has a proverbially bad reputation for precipitating attacks of gout. It is well known that port improves more by long rest in the bottle than does any other wine except Madeira. It is a useful temporary tonic, and, like claret, its astringency makes it serviceable in diarrhceal diseases, but many persons, especially in this country, find it alto- gether too heavy for daily use. This is not altogether due to its high percentage of alcohol, for a greater quantity of strong spirits will sometimes be found to do less damage. It is a poor wine for dys- peptics, and should be proscribed in all bilious states, lithiasis, cases with tendency to gallstone formation, gravel, gout, and rheumatism. It has largely been replaced of late years as a dinner wine by other wines. Port as well as Burgundy is sometimes spiced or " mulled," and prescribed diluted, as a tonic for elderly people. .Taken before retir- ing, with a biscuit, or mixed with a light gruel, it may promote their sleep. II. Strong Sweet Wines are those which contain, either natural or artificially added, fruit sugar in sufficient quantity to exercise a preservative influence, and further fermentation is checked by boiled grape juice. Examples are Tokay, Malaga, sweet sherry, sweet cham- pagne, Malmsey, sweet Madeira, Lachrymse Christi, and other vins de luxe. They are much too sweet to be drunk in quantity, but this quality is sometimes made to disguise the bitterness of other sub- stances, as when Tokay is added to cocoa extract to make " wine of cocoa." If long kept, the sweetness is reduced but the peculiar agreeable flavor remains. Alcohol may be added to further insure preservation and increase the strength of the wine, and sweet port is sometimes made in this manner. The sweet heavy wines, such as sweet port, sherry, and Madeira, contain about 19 to 22.5 per cent of alcohol, 3.5 to 6 per cent of sugar, and about 0.50 per cent of acid. Malaga and Tokay contain more sugar and less alcohol. The chief use of these wines is for their agreeable flavor. They are STIMULANTS AND BEVERAGES 281 better taken between meals, if at all, both because the delicacy of their flavor is more appreciated when the mouth is free from other tastes and because their sweetness may interfere with digestion. Like all sweet wines, they must be forbidden to the gouty, rheumatic, bilious, lithsemic, and dyspeptic. III. Aromatic Wines have a peculiarly choice bouquet, and con- tain abundance of essential oils with considerable alcohol. They are best when drunk in their native countries in Spain, France, Italy, etc. for they bear transportation poorly unless reinforced by ad- ditional alcohol, which detracts from their delicacy of flavor and aroma. Examples are the choicer Ehine wines, Moselle, Capri, Cha- teau- Yquem, and Orvieto. Some wines of this class are " more noted for their acid than aroma " (Chambers). Such are white Burgundy (Chablis) and white Bordeaux (Sauterne), which are often drunk with salads and rich foods. The Moselle and Ehine districts produce acid grapes with abundant aroma, and the wines which bear these names are many of them almost free from sugar. IV. Acid Wines owe their distinguishing property to tartaric acid chiefly, but wines which have turned sour on keeping or by exposure to the air contain acetic acid and resemble vinegar. V. Sparkling Wines are thpse in which carbon-dioxide gas, formed by fermentation after the wine is bottled, is set free upon uncorking, and continues to be liberated for sometime thereafter. The gas im- parts additional flavor to the wine and increases its exhilarating effect. Such wines are champagnes, sparkling Moselle, and vino d'Asti. The better the wine, the longer it continues to give off gas and aroma after uncorking. Good champagne is bottled under a pres- sure of about five atmospheres. These wines, especially good champagne, are very serviceable for invalids, and some persons with delicate stomachs can digest no other form of alcohol; but poor champagne causes gastric derangement sooner than any other wine. When nausea and vomiting exist they have special power for allay- ing the gastric irritation. They are absorbed with great rapidity, and act promptly by invigorating the nervous system and circulation. They may sometimes be substituted for spirits in fevers when there is need of alcoholic stimulation. Their cost, unfortunately, places them out of the reach of many, and it also affords much tempta- tion for adulteration. CHAMPAGXE. The essential difference between champagne and the non-effervescing wines is that it contains carbon-dioxide gas in solution. 282 STIMULANTS, BEVERAGES, CONDIMENTS Manufacture. Champagne is made of different grades, represent- ing the first, second, and third expressing of the grape juice re- spectively. It contains approximately 12 per cent of alcohol, or less. Good champagne is made as follows: The juice is allowed to ferment for about two weeks, when it is poured into casks and kept for a period varying from two to six months, after which it is bottled and kept from two to nine years in racks arranged to hold the bottles with their mouths down, so that on opening them all sediment which has collected in their necks can be removed or " disgorged." The final process is the addition of sugar-candy sirup dissolved in old wine and white cognac brandy. For the " sec " brand 8 per cent of sirup is added ; for other brands varying quantities up to 16 per cent are poured in. A little alcohol, too, may be added, after which the wine is again corked, and left standing. French champagnes sometimes have liqueurs or cordials added for flavoring, but- American champagnes depend solely upon the grape flavor. Dry ness. Much emphasis is placed on the value of " dry " cham- pagne for invalids, which means that the sugar which it originally contained has disappeared, and hence the wine is less likely to produce flatulent dyspepsia or aggravate conditions in which saccharine food is harmful. True " dryness " is the result of age, and is due to a very slow conversion of sugar into alcohol, such as goes on in port wine which has been kept for several decades, but, as pointed out by Chambers, this process of slow ripening does not remunerate the dealer, so he induces a quicker acetous fermentation by which all the sugar is transformed in a few months, instead of many years, or else he puts only half the quantity of sirup into the wine 4 instead of 8 per cent. It is champagne manufactured in this manner which is usually shipped out of France for foreign consumption, and hence this wine often has a " dry " taste because it is sour, and not because it is wholly free from sugar. When this is the case, it imparts a bright red color to blue litmus, after the free carbonic acid which it contains has been allowed to escape. The various brands called " dry," " extra dry," or " sec," " ires sec," usually represent only varying de- grees of acidity. " Brut " refers to wines left to undergo natural fer- mentation. YL " Perfect " Wines are those which are classified by Cham- bers as having their several ingredients "alcohol, water, sugar, ethereal flavors, fruity extractives, and acids" commingled without giving characteristic prominence to either one. Such are many of STIMULANTS AND BEVERAGES 283 the best clarets, but the red wines usually, from one cause or another, fall under some other class. Bordeaux, Burgundy. The best Bordeaux is fully fermented, but the commoner Burgundies and red Khones contain " too much fruity extractive, which decomposes unless reinforced by alcohol, and are unwholesome unless ripe when drunk" (Chambers). When a red wine is so decomposed it is unfit for consumption. Ee-fermentation in it may be discovered by lightly corking a half -filled bottle, letting it stand for some hours in a warm place, and then shaking it. If car- bonic acid is present, it will rise in bubbles and expel the cork. Wine of this sort deranges digestion, causing acid eructations and gastric discomfort. Prime Burgundies, on the contrary, like Chambertin, have more " body," and, because they contain a larger percentage of alcohol, do not ferment. Moleschott gives the average volumetric percentage of alcohol in red wines as follows : Clarets or red Bordeaux, 10.61 ; red Ehone, 10.39; red Burgundy, 11.19. Therapeutic Uses. Prime clarets, Bordeaux, and Burgundies are useful tonics for invalids, to be given in moderation with meals, or in some cases with a biscuit or light sandwich as a luncheon between meals. They contain little or no sugar, and are of excellent service in convalescence 'from protracted fevers, such as typhoid, or from the grippe, etc. The lighter forms, if of good quality, are the best form of wine for daily consumption by brain workers or those whose seden- tary habits or whose advanced age make desirable a slight stimulus to appetite and digestion. Claret is almost the only wine which it is at all safe to allow gouty or diabetic patients. Beaujolais is intermediate in effect between claret and Burgundy. In diarrhoea, the red wines, according to Lichtenstern, have a two- fold beneficial action : first, by depressing exalted reflex excitability in visceral nerves, and, secondly, by controlling intestinal putrefaction. Those which contain considerable tannin are also mildly astringent. VII. Rough Wines are those in which an excess of tannin causes decided astringency. They usually contain pigment, but not much alcohol. Some clarets belong with this group. As a rule, these wines are not available for general dietetic or invalid use, and are mainly employed to add to other wines to aid in their preservation and otherwise alter them, although they are sometimes drunk by peasants in the countries in which they are produced. Concentrated Wines. Attempts to concentrate wines by heat evaporation of the water contained in them result in the loss of the 284 STIMULANTS, BEVERAGES, CONDIMENTS ingredients which furnish "bouquet" or "aroma," and which are more volatile than the alcohol. A process has been devised in France by which concentration is secured by cold without this loss. In con- gealing to ice the water does not include the volatile ingredients of the wine. The wine is submitted to a temperature below freezing, the ice meanwhile being mechanically broken into minute particles, which are then separated by a centrifugal machine. The result is a wine composed of uncongealed concentrate and condensed to from 60 to 80 per cent of its original bulk, thereby improving its capacity for preservation and greatly lessening cost of storage and transporta- tion. The same ingenious process has beeen applied successfully to milk and fruit juices. Upon addition of water the original bulk and degree of flavor is restored. Raisin Wine. An inferior quality of wine is made by restoring the water of the grapes which has been lost by drying them into raisins. Wine is now sometimes made in France from raisins dried in California. Influence of Wines upon Digestion. Eoberts determined the ef- fect of several wines upon peptic digestion by adding together two grams of dried beef-fiber, .0.15 per cent of hydrochloric acid, 1 c. c. of glycerin extract of pepsin, varying proportions of hock, claret, or champagne, and water to 100 c. c. PROPORTION OF HOCK, CLARET, OR CHAMPAGNE IN THE DI- GESTING MIXTURE. TIME IN WHICH DIGESTION WAS COMPLETED. (NORMAL, 100 MINUTES.) Hock. Claret. Champagne. 10 per cent 100 minutes. 115 150 Embarrassed. 100 minutes. 140 180 " Embarrassed. 90 minutes. 100 130 180 " 20 " " 40 " " 60 " " Liquors Strong spirits, such as rum, whisky, brandy, and gin, are the worst forms of alcohol for daily drinking, and liquors of this class are re- sponsible for nine-tenths of the evils of inebriety. As the system re- quires toleration for the stronger forms of liquor, it is found that its desired effects only can be obtained by constantly increasing the strength or frequency of the drinks, and meanwhile the alcohol ab- sorbed is gradually converting the different tissues of the body into pathological specimens. The drinking of new and raw liquors is particularly injurious, STIMULANTS AND BEVERAGES 285 for time mellows them somewhat and reduces the quantity of their most hurtful ingredient fusel oil while their flavor improves. The difference in taste of liquors depends upon the substances from which they are made much more than upon any skill in their manu- facture or modifications in their fermentation, circumstances which so materially affect wines. The taste varies with the relative quan- tity present of aldehyde, compound ether, higher alcohol (fusel oil), and volatile bases. Brandy and other strong spirits are distilled from a variety of carbohydrate foods: such are potatoes, corn, rye (whisky), beets, rice (arrack and sake), molasses (rum), crushed grapes, apples (applejack), peaches, plums, cherries (Kirsch), and other fruits. These spirits contain from 45 to 60 per cent of alcohol, besides cane sugar and extractives. French Cognac is a strong, pure brandy, distilled either from wine, or directly from crushed grapes. It may be colored by caramel. Common brandy is distilled from wine. Whisky. American whiskies are classed as (1) rye and (2) Bour- bon, from the county of that name in Kentucky. Manufacture. The percentage of materials used in making the " mash " for distillation is, on the average, cornmeal 80, rye 10, and malt 10. This mixture is placed in tubs, and scalded with " slop," the refuse from former distillation. After cooling, it is raked, or mixed by a stick called a "masher." Water is added, and the mass ferments for two or three days. Sweet mash is scalded with water instead of slop, and yeast is added to induce fermentation. Sour-mash whisky is made without yeast but with slop. The wort is then heated by steam, and the low wines, called " singlings," are run off from the residue or slop and redistilled, and the whisky is ready for barreling. It should then be kept from three to five years to ripen, according to the details of its manufacture. Pure rye whisky is distilled by an identical process, but the corn is wholly replaced by rye. Scotch and Irish whiskies are distilled from a barley mash. American whiskies are kept in charred barrels, and grow darker from color derived from the wood. Scotch whisky derives its color from lying in old sherry casks. Proof spirit contains equal parts of absolute alcohol and water. Leoser says : " The difference in quality in different kinds of whisky is infinitesimal, and for therapeutic processes may be neg- lected, provided the taste of the patient is consulted." 286 STIMULANTS, BEVERAGES, CONDIMENTS The evil effects of poor whisky are largely due to the presence in excess of a regular constituent, an aldehyde called furfural. Gin is distilled from rye mash, and flavored by immersing a bag of juniper berries in the vat towards the completion of distillation. It is variously known under the names Geneva, Hollands, and Schiedam, the two latter referring to its Dutch source, the former being derived from the French word for juniper, genievre, of which gin is a corruption (Pavy). Gin may contain 17 per cent of alcohol, but it is often diluted, and when sweetened besides, it is known as " Old Tom." Rum is distilled from a mash of molasses. The wort contains about 15 per cent of sugar, and the fermentation process requires from nine to fifteen days. Eum was formerly made in New England, but it now comes chiefly from the West Indies, and that made in Jamaica is considered the best. Other rum is made from rectified proof spirit. It is a liquor which improves very much on keeping for several years. The flavor of rum, which is principally due to butyric ether, is produced by adding molasses, caramel, and some- times fruits, such as pineapple or guava. Acetic and other ethers are also present. Therapeutic Uses of Liquors Compared. The spirits in common use have different physiological action. As their alcoholic basis is substantially the same in quality, the effects are varied mainly by aromatics. Gin is the most distinctly diuretic of the liquors. Given with a little lemon juice and diluted with some effervescing water, it promptly increases the urinary secretion. Brandy is somewhat more astringent than whisky, which is sometimes laxative. Brandy is therefore to be preferred in cases of diarrhoea, but in this country at least it is very likely to be impure. The role of liquors as tonics and stimulants will be referred to under the heading of the jdifferent diseases in which they may be required, and their influence in pro- ducing alcoholism is discussed under that heading. ADULTERATION OF LIQUORS AND WINES Liquors are flavored and also adulterated by a variety of substances. Among those mentioned by Chambers as oftenest found are cocculus indicus, ginger, quassia, wormwood, caraway and coriander seeds, hartshorn shavings, nux vomica, gentian, alum, cream of tartar, chamomile, juniper berries, bitter almonds, orange peel, licorice, honey, rhatany, and catechu. Much of the cheapest claret sold in this country is little more than a decoction of logwood, and the flavor of some of the better grades STIMULANTS AND BEVERAGES 287 is cleverly imitated. For example, Chateau-Latour is sophisticated with almonds or other nuts, Chateau-Lafitte with violets and nuts, and to other grades cherry juice is added. Wines are often adul- terated with artificial pigments, alum, tannin, fusel oils, cider, perry, and lime salts. The cheaper grades of strong liquors contain an excess of fusel oil or amylic ether, which is not an adulterant in the sense that it has been added for sophistication, but because it is a poisonous natural product which is difficult to eliminate. It is responsible for much of the headache, foul tongue, nausea, dyspepsia, and cirrhotic changes in the viscera which are incident to dram drinking. The following table by Duckworth is a convenient summary of the average percentages of alcohol in round numbers in the different beverages above described : Spirits 35 to 44 per cent. Port wine -19 " Madeira 18 " Sherry 17 Champagne 11 " Burgundy 10 " Bordeaux 8 per cent. Rhine wines 8 " " Porter 6 per cent, or more. Ale 3 to 6 per cent. Cider 4 per cent. Liqueurs and Cordials Liqueurs and cordials play no part in invalid diet. With the ex- ception of absinthe and Angostura, they contain a very high percent- age of sugar with essence, and they all have a large proportion of alcohol. They are used as luxuries, and are seductive beverages, for their agreeable flavor sometimes begets the habit of alcoholism. This is specially the case with absinthe. Analysis of Liqueurs (Rupp) 100 C C. LIQUEUR ALCOHOL. Extracts. Sugar. Salt. Volume. Weight. Absinthe Per cent. 55.0 40.0 32.5 35.0 48.0 52.5 53.0 44.0 Percent. 44.0 32.0 26.0 28.0 38.4 42.0 42.4 35.2 Grains. 1.80 33.20 29.80 44.00 12.00 27.90 35.00 35.40 Grams. 1.10 30.90 28.20 43.20 7.50 26.50 33.40 34.00 Grams. 0.220 0.310 0.100 0.090 0.140 0.075 0.110 0.091 Anise Kummel Peppermint Angostura Curac.oa . ... Benedictine Chartreuse The essences are distilled or expressed from aromatic plants, and such coloring agents are used as saffron, cochineal, indigo, etc. 288 STIMULANTS, BEVERAGES, CONDIMENTS Anisette is distilled from aniseed, curaqoa from orange rind, menthe from peppermint, maraschino from small cherries, grown es- pecially in Dalmatia. Chartreuse was formerly distilled from a variety of herbaceous plants grown in the convent gardens by the monks of the Grand Chartreuse, who since their expulsion from France, have transferred the industry to Tarragona. Vermouth is a white muscat wine made aromatic with extracts of herbs and spices, sweetened with 10 to 15 per cent of sugar and fortified with grape alcohol up to 17 per cent. It is manufactured in Pied- mont. Fig wine is made in countries bordering upon the Mediterranean, and has an alcoholic strength of between 7 and 8 per cent. It also contains considerable mannite. It is often used for the sophistication of grape wines. Cider. Cider made from ripe apples usually contains from 4 to 8 volumes per cent of alcohol besides malic acid, extractives, sugar, and salts. It is slightly laxative and diuretic and constitutes a whole- some beverage. The excess of carbonic acid generated by cider pro- tects it from the atmospheric air, but when the gas disappears acetic fermentation converts the cider into vinegar. It may be preserved for a year or two by being surcharged with carbonic-acid gas under pressure. It is then known as " champagne cider/' Cider is sometimes made from condensed apple juice, which is added in the proportion of one part to twenty of water when ready for use. " Hard cider " is derived by natural fermentation of the sugar in apples. Yeast fungi, which grow upon the surface of the apples, convert the sugar into alcohol, which may become as strong as 6 per cent. Cider drunk to excess has been known to cause peutosuria. CONDIMENTS AND SPICES Properties. Condiments and spices are substances used as ad- juncts to food, and which in themselves supply but little nourishment, their effect being mainly of a stimulating character either to the nerves of taste or secretion. They add flavor to otherwise insipid food, and relieve monotony in diet. Some condiments, such as mus- tard, contain a slight amount of nutritious material, but the total quantity of any of them which can be taken is so small in comparison with the bulk of the food that they hardly may be said to subserve nutrition. Some foods are themselves so stimulating to the mucous mem- CONDIMENTS AND SPICES 289 brane that they answer the double purpose of food and condiment combined; such, for example, are onions, peppers, and garlic. In the mouth condiments produce an agreeable taste, with an in- creased flow of saliva, and the desire for food in the stomach is stim- ulated. They also increase the secretion of gastric juice. Curry powders of various sorts are prepared by mixing strong condiments, such as Cayenne pepper and ginger, with starchy food and tumeric. Uses. In some dyspeptic conditions of the stomach accompanied by retarded digestion and local sensation of weight or oppression, or even of pain, the use with the food of strong condiments such as mustard, Cayenne pepper, or Tabasco affords relief by exciting the functional activity of the stomach. Cayenne, in fact, is a favorite ingredient of various dinner pills. With the exception of salt, the use of which is fully described on page 46, none of the condiments are absolutely indispensable in the sense of being essential for prolonging health, but so accustomed are all classes of men to their use from heredity or personal experience that, despite the aphorism of Plutarch that " hunger and salt should be man's only sauce," without other relishes the appetite soon fails. Harmful Effects. The use of some condiments is likely to be abused, and this is particularly true of peppers, curry, pickles, and vinegar. If consumed habitually in excess, these substances excite gastric hypersemia and catarrh by overstimulation, and may disorder intestinal digestion as well. They at first cause more food to be eaten than necessary, and eventually destroy the appetite, develop- ing chronic dyspepsia of an aggravated type. Persons living in tropical climates where food and service are cheap are apt to lead indolent lives and indulge too liberally in the pleasures of the table, and the overloading of the stomach tempts them to add quantities of condiments to their food for the purpose of stimulating an already overworked digestive system. The heat of the climate prevents ac- tive exercise, which in turn reduces the oxidation processes of the assimilated food. The rational diet for those not acclimated to the tropics should consist largely of vegetables and fruits, while nitrog- enous food, strong condiments, spirits, bitter beer, etc., should be carefully shunned. I have seen one case of the ginger habit, in Bellevue Hospital, in a woman thirty years of age. It was first acquired by chewing the roots of Jamaica ginger, and subsequently the patient drank large quan- tities of the beverage sold under that name, and ate powdered ginger 21 290 STIMULANTS, BEVERAGES, CONDIMENTS of every variety. The patient became maniacal and greatly emaciated. The symptoms in general resembled those of the cocaine habit. Varieties of Flavoring. Next to salt (see p. 46), the most useful condiments are pepper, mustard, ginger, and vinegar, but much differ- ence in taste exists in the use of condiments, and their selection is to some extent a rare characteristic. Thus the Persian prefers his asafcetida, which no one else can tolerate; the Spaniard and Mexican his garlic; the East Indian his curry; and the Frenchman his salad with vinegar. From long-continued association certain condiments appear to serve best with definite foods, and so accustomed are most persons to their combination that they cannot easily recall the one flavor with- out the other; thus mustard is associated with ham, black pepper with eggs, red pepper with raw oysters, vinegar with spinach and raw tomatoes, etc., and when deprived of the usual relish the food tastes insipid. Such details, insignificant as they may ordinarily appear, become very important for certain classes of invalids in whom it is necessary to preserve the appetite by pleasing the palate in order that they may take food enough to sustain them. Such are cases of phthisis, empyema, and other forms of chronic wasting diseases. - Beef tea and meat broths, which become wearisome to many in- valids, will be relished if a taste of some savory aromatic herb be added, such as parsley, thyme, sage, marjoram, or mint. Mustard does not greatly stimulate the gastric secretion, but many persons find that it increases the appetite somewhat, and it often pro- duces a sensation of warmth or mild burning in the stomach or a feel- ing akin to hunger. It is used to advantage in moderation in salad dressings or with cold meat, and is sometimes serviceable in those cases in which the main difficulty is a lack of appetite without special enfeeblement of the digestive organs. The general irritating effect of mustard in large quantities applied to the skin or gastric mucous membrane is well known, and diluted with lukewarm water (a tea- spoonfnl of mustard to a pint of water) it constitutes a very prompt and valuable emetic. Mustard seeds are sometimes eaten for their laxative action. Blade pepper is the berry of a plant, the Piper nigrum, which grows in the West Indies, Sumatra, and other Eastern countries. The whole berry is dried and ground for use. White pepper is made from the same berry by previously soaking off the outer husk in water. About thirteen million pounds of black pepper are annually consumed in the United States. It is often CONDIMENTS AND SPICES 291 adulterated, and to avoid deception it may be purchased in corns and freshly ground at the table. Cayenne pepper is not a true pepper, but is made from the crushed pod of various species of Capsicum. It grows in the tropics, espe- cially along the eastern coast of Africa and in Zanzibar. The Capsicum annuum is cultivated in this country for the making of pickles from the large unripe green fruit. The Capsicum fasligiatum is a variety employed medicinally, and recognized by the Pharmacopoeia. Chilies is a common name given to this pepper in England, and chili sauce is an essence prepared from it. It is the strongest variety of capsicum. Capsicum, called also Cayenne or red pepper, like mustard, is a strong irritant to both the skin and the mucous membrane. Over- doses of it excite violent local inflammation and gastroenteritis. Like mustard, it is doubtful whether capsicum in any degree pro- motes the secretion of the gastric juice, but it sometimes stimulates a flagging appetite and produces a feeling of warmth in the stomach; the latter readily becomes tolerant to increasing doses of capsicum, and it is found that more and more is required by those who use it habitually to excite the accustomed stimulation. It is used as a sub- stitute for alcohol for dipsomaniacs, especially where the effort is being made to stop drinking abruptly. When chronic alcoholic gas- tritis exists, the stomach digestion is often improved and the craving for strong liquor may be relieved by the tincture of capsicum given in doses of ten or fifteen minims diluted. The use of capsium in health is far from necessary, but it is an agreeable condiment. It forms an ingredient of many dinner pills which are taken by elderly people with inactive digestion for the pur- pose of promoting the appetite. Eed pepper, like black, is often adulterated. When pure it may be suspended partially but not entirely in water. Eed lead has crim- inally been used as an adulterant. Capers are the flower buds of a bush, the Capparis spinosce, which grows in Eastern countries bordering on the Mediterranean. They are preserved in salt and vinegar, and are used for flavoring sauces for mutton and other foods. They contain tannin, volatile oil, yel- low pigment, and a bitter principle. Spices are solely of value in giving variety of taste to the food, and hence tempting invalids or convalescents with lagging appetites to eat more. Comparatively tasteless food, such as rice, may be made very attractive by spicing. For children the most useful flavoring substances are cinnamon 292 STIMULANTS, BEVERAGES, CONDIMENTS and ginger, and, although not a spice, vanilla extract. For invalids there may be added nutmeg and cloves, although any, agreeable spice may be used in moderation, such as mace or allspice. Patients who will not drink hot water when it is ordered will often do so if they can steep a few cloves or a small piece of cinnamon in it, and this can rarely do harm. Those who object to the taste of milk punch, junket, custards, and simple farinaceous foods will often take these substances when slightly flavored with a trace of some agreeable spice. The latter as ordinarily used for flavoring is never injurious. Only in large doses are such spices as those above mentioned capable of such irritant action in the stomach as may be produced by curry or mustard. Several cases of nutmeg poisoning are recorded. The symptoms are excessive thirst, vertigo, delirium, stupor, epigastric pain, tremor and twitching and muscular prostration. Toxic effects have been produced by taking a whole nutmeg, ground and mixed with hot water. Ginger is useful both as a condiment and as a food. It is the dried root of the Zinziber officinale, which grows in Jamaica, China, and elsewhere. The rhizome is scraped and either dried and pow- dered, or, if it is to be preserved, it is washed and boiled for twenty- four hours, and then soaked for another day in salt water. It is next washed, sun-dried, and "boiled for half a day with an equal weight of sugar (Clark). It is placed in jars for several days, and then once more boiled, when it is finally sealed in jars. It is excellent for flavoring rice and other insipid farinaceous foods for convalescents and children. Vanilla is derived from vanilla beans, grown in Mexico, Java, and other tropical regions. It makes an agreeable flavoring extract for foods for invalids and children, such as farinaceous gruels, custards, blancmange, or ice cream, for, unlike the spices, it is very bland. Its chief use is in the manufacture of chocolate (p. 260). Vinegars are made from wine, beer, cider, various fruits, and even from the dry distillation of wood. They contain, besides acetic acid, traces of dextrin, sugar, organic acids, pigment, extractives, and acetic ether. White vinegar is the best in taste and odor. The acetic acid in good French vinegar exists in the proportion of 5 per cent. Ordinary table vinegar contains between 2 and 7 per cent. The acidity enables this condiment to soften muscle fiber so that the digestion is facilitated of tough meat, such as corned beef, boiled beef, and other foods with firm structure, like salmon, lobsters, or hard-boiled eggs. Mild acids, such as vinegar, favor digestion of tough cellulose, and CONDIMENTS AND SPICES 293 aid the formation of sugar. For this reason vinegar is a wholesome addition to coarse, fibrous, or stringy vegetables, such as beets, cab- bage, and spinach, and to raw vegetables, such as cucumbers, celery, cole, lettuce, and like materials used in salads. If vinegar taken in a salad dressing disagrees, white wine may be substituted with pepper or mustard and oil. Vinegar often is eaten with baked beans, but it is said to make their legumin less soluble. Vinegar has a, well-known antiseptic and preservative action, and hence its use for pickling fish, oysters, fruits, and vegetables. Pickles are indigestible, and should take no part in an invalid dietary. An excess of vinegar habitually consumed with pickles, or otherwise, causes anemia and emaciation by lessening the number of red corpuscles and reducing the alkalinity of the blood. Vinegar is often adulterated, and this is especially true of that used for the cheaper varieties of pickles, and weak sulphuric acid is quite often employed for this purpose. Spurious vinegar is made by passing alcohol over beechwood shav- ings which supply bacteria that develop acetic acid by oxidation of the alcohol, which is then diluted and colored to appear like vinegar. Sauces, such as Worcestershire, Tabasco, tomato catsup, etc., are used to stimulate a flagging appetite, and add flavor to soups, broths, etc. Taken in moderation, they are not injurious, and in cases of alcoholism sometimes are useful by inducing the patient to take more food and less liquor. For invalids, for whom strong sauces of this kind always should be forbidden, a very good substitute may be made for use with broiled fish, etc., as suggested by Chambers, by boiling a few plain aromatic herbs, like parsley or mint, in a little water, and adding pepper and salt. Horse-radish is a condiment which excites the flow of saliva and gastric juice when eaten early in the course of a meal with meat or raw oysters, or otherwise. Flavoring substances are numerous, such as paprika, capers, cara- way seeds, aniseed, saffron, wintergreen, bay, paprika, liquorice, mint, peppermint and various essential oils. Their use is purely to furnish variety and stimulate the appetite, and they have no nutrient value. PART III COOKING FOOD PEEPAEATION AND PEESEEVATION THE QUANTITY OF FOOD EEQUIEED COOKING The Object of Cooking Food. Although man is so constituted that it is possible for him to live upon raw food there are no savage races known who do not practice the art of cooking, in however elementary a fashion, and progress in the scale of civilization is uniformly ac- companied by advance in this art. Prehistoric man may have lived wholly on raw food, berries, fruits, shellfish, etc., but this diet is not suited for most tribes of man to-day, although the northern Eskimo still prefers his meat raw and frozen. It is owing to the practice of cookery that the dietary of civilized man has been so much enlarged, and it is far less difficult to modify the mechanical preparation of foods than the secretions which digest them. Of the different varieties of food, that which is derived from ani- mals as a rule requires cooking more than vegetable food. It is well known that some vegetables and most fruits are eaten raw by prefer- ence without palling upon the appetite, but raw meat of almost any kind soon becomes obnoxious to civilized man. Eaw milk, eggs, and bivalves are an exception to this statement as regards animal foods. The process of cooking food accomplishes in general the following purposes : I. Cooking develops certain flavors in the food, in meat particu- larly, which are agreeable to the palate, and thereby enables man to secure variety in taste, which is so' important a stimulus to the ap- petite. IT. Most food is altered in consistence and made softer by cook- ing, although this is not always the case (eggs, for example, become harder when boiled). The food is therefore easier masticated and mixed with the various digestive fluids. The solidity of food does not necessarily imply greater toughness in fact, the albuminous ingredients of meat are coagulated and made actually more solid by 294 COOKING 295 cooking, but at the same time become less tough or more friable, in which condition they are more easily ground, torn, and separated by the teeth. III. The chemical changes produced in food by cooking in some instances favor the action of the digestive juices. This is particu- larly true of starch and of many meats. Analyses of food are usually conducted upon the raw materials, and the important alterations which are occasioned by heat in vari- ous degrees are imperfectly understood by most persons. IV. By cooking, many varieties of parasites and germs which may be contained in the food are destroyed, and spoiled food which other- wise might be poisonous or injurious owing to their presence may be- come harmless. V. The temperature of food which is sometimes eaten hot may in some cases favor the digestive processes, although the importance of this consideration may be exaggerated. VI. The appearance of the food is improved, and it becomes more appetizing on this account. Varieties of Cooking. The several processes of cooking in common use are as follows : 1. Boiling. 2. Stewing. 3. Boasting. 4. Grill- ing, or broiling. 5. Frying. 6. Braising. 7. Baking. 8. Steaming. There is undoubted advantage in varying the different methods of cooking as well as of flavoring the food from time to time. Mo- notony of diet and of flavors lessens the appetite and fails to stimu- late the digestive organs. When variety in foods cannot be obtained, variety in cookery may be made to replace its advantages. Every one is familiar with the effect on the appetite of an occasional change of cooks or of a meal served amid unwonted surroundings. It is not within the scope of this work to discuss the details of cooking for the sick. Miss Xightingale wrote that " a good sick- cook will save the digestion half its work/' and invalid cookery should form the basis of every trained nurse's education. It is impossible herein to do more than explain the theory of the chief methods of cooking and suggest their influence upon digestion. As a rule, twice-cooked meats are undesirable for invalids. They are apt to be drier and less nutritious and digestible than when fresh. In meat "hash," for example, the meat fiber is too much hardened. Such preparations are often made too greasy by recooking for delicate stomachs. The same statement applies to canned meats when warmed over, for they have been already cooked once in the tin. It is undesirable to combine foods which require different periods for their thorough cooking. For example, soup needs less boiling 296 FOOD PREPARATION AND PRESERVATION than the vegetables added to it, and they should be partially cooked alone beforehand, or they will be underdone. The necessary heat for cooking is obtainable in many ways from coal, wood, gas, oil, steam, and electricity and these different meth- ods each possess advantages for particular foods. Cooking, as a rule, at a prolonged low temperature is more eco- nomical in its results upon food than a much shorter application of high heat, and this is the theory of the famous " Count Eumford kitchen." 1. Boiling. In some excellent remarks by Williams on the subject of so-called boiled food, he points out that the expression " boiled " beef, or eggs, or potatoes, implying that the food has been boiled in the same manner in which the water is boiled, i. e., raised to 212 F., is an absurdity. The food is merely heated by immersion in boiling water, and even such water as is contained in the meat or potato is not itself boiled in the process, for, he says, "its boiling point is higher than that of the surrounding water, owing to the salts it holds in solution. Thus, as a matter of chemical form the boiled leg of mutton is one that has been cooked but not boiled, while the roasted leg of mutton is one that has been partially boiled. Much of the constituent water of flesh is boiled out and fairly driven away as vapor during roasting or baking, and the fat on its surface is also more or less dissociated into its chemical elements, carbon and water, as shown by the browning due to the separated carbon." It is a scientific fact which is not appreciated by many persons that when water has once reached the boiling point, its temperature cannot be further elevated until it is all converted into steam, for all the additional heat which is required above that needed to warm the water and drive off the air-bubbles in the process of ebullition is expended in vaporizing the water. Consequently, however hot the fire, or however prolonged the cooking, the temperature of the food suspended in boiling water cannot be increased above that of the water itself; and, in fact, the temperature of the interior of large masses of food, like potatoes or meat, is only raised to about 190 F. Food in the process of canning placed in the can in a boiling salt water bath, is raised to from 165 to 208 F. There is practically no distinction between " simmering " and boil- ing as a process of cooking, except that the violent boiling of some foods tends to soften them on account of the commotion produced in the water by the rising bubbles which cause currents to form that carry particle? of suspended food with them and triturate them. COOKING 297 The operation of boiling if continued for an hour or more gradu- ally converts the connective tissue of meat fiber into gelatin, which is partially dissolved in water, and the heat of the boiling water usually melts a little of the fat, which, being unable to mix with the water, forms a scum upon the surface. A small proportion of the juices of meat usually osmoses out into the surrounding water, and the aqueous solution thus formed is called broth or bouillon. The richness of the broth will depend principally upon the method of conducting the boiling process. When it is desired to have the broth as nutritious as possible the meat should be finely minced and put into cold water, which is gradually warmed but not actually brought to the boiling point. By this process the juices of the meat are slightly dissolved out into the warm water, and thereafter, if the temperature is not carried above 160 F., coagulation of the albumin in the muscle fibers does not occur, and more and more of their constituents are dissolved out into the surrounding water but this is not true boiling. In this manner the natural flavor is much better preserved ; in fact, the common extracts of meat are made by soaking finely chopped meat in cold water and subsequently evaporating the water from the ingredients which are found in it. On the other hand, when broth is not wanted for nutriment it is desirable to prevent the solution of the juices in the water by im- mersing the meat suddenly into water actually boiling, so that the outer layer of the mass will be hardened by coagulation and have a firm coating which is not permeated by the juices within. When meat is cooked in this manner the broth is scarcely of any food value, but the meat is much more palatable. After the boiling tem- perature of the water has been maintained for five minutes the further cooking should be continued at a lower temperature of, say, 165 to 170 F. If the heat is less than this, the interior of the joint or other piece of meat is imperfectly cooked and its albumin is insufficiently coagulated, so that it has a raw appearance. If the actual boiling point is long maintained, the albumin is too firmly coagulated, and the meat becomes tough and stringy. The latter error in boiling is very commonly perpetrated by cooks. The coagula- tion point of different forms of albumin varies, ranging from below 90 to above 165 F., and since many varieties of albumin occur in the different kinds of animal food, it will be found that they are not all equally well cooked by exactly the same temperature. Am- monium sulphite is liberated by continued boiling, and also an acid resembling acetic acid. When meat is plunged into boiling water so that the external 22 298 FOOD PREPARATION AND PRESERVATION layers are solidified, some of the water which they contain, with 5 to 8 per cent of soluble substances, is squeezed out into the surrounding fluid, and an actual loss of weight in the meat occurs which may reach as high as 30 per cent. The addition of salt to water in boiling fish or meat is described by Williams as having a threefold action: (1) It directly acts on superficial albumin with coagulating effect; (2) it slightly raises the boiling point of the water; (3) by increasing the density of the water, the exosmosis or oozing out of the juices is less active, and hence the flavor is better retained. When very salt meat is to be cooked, if steeped too long in boiling water its nutritive properties are impaired, the muscle sarcolemma becomes too hard, and the meat tasteless and tough. In such cases it may be well to boil meat less completely, and finish the cooking by some other method, such as frying. 2. Stewing. Stewing differs from boiling in the fact that the juices of the meat or vegetables are dissolved in the heated water. The proper temperature for stewing is between 135 and 160 F. In thick stews the juices dissolved in the water are eaten together with the cooked food, but in some instances, as in the making of beef tea and some kinds of soups, the aqueous solution only is used. Ob- viously, the more the food is subdivided the greater the surface ex- posed to the solvent action of the water, and hence the object of mincing meat thoroughly which is to be used in the preparation of beef tea. If such minced meat has been soaked for a long time in cold water, a part of the albumin and the extractive materials are obtained in solution, but the meat which is left is colorless, taste- less, and unpalatable; in fact, animals fed upon it soon deteriorate in strength. More or less water enters the substance of the meat to replace the juices which have passed out by osmosis and diffusion into the surrounding fluid. After meat has been stewed for some time a scum containing a little coagulated albumin and more or less fat is seen floating upon the surface. This is usually removed in the preparation of beef tea for invalids in order to make it more palatable and agreeable to the eye, but its removal is at the expense of con- siderable nutritious material. In the preparation of extracts- of meat, such as Liebig's Extractum Carnis, the scum is removed be- fore the solution is concentrated by evaporation. Stows made in the manner described above, and which consist largely of meat and plain sliced vegetables, are fairly digestible: but if other materials or rich sauces are added to them, this is not COOKING 299 the case, and if saturated with fat, they are quite unfit for invalids. As both the solid substance of the meat and vegetables and the fluid materials which have been extracted from them are eaten together in the stew, this is an economical form of preparing food. 3. Roasting. 4. Grilling. The processes of roasting and grilling or broiling, when performed over a very hot fire, result in cooking the meat in a manner which is in some respects analogous to stew- ing; in fact, the interior portions of the meat are stewed in their own juices instead of in water as in boiling (Williams). A coating of coagulated albumin forms upon the outer surface of the meat, while the albuminous material or myosin of the interior is gradually warmed and slowly coagulated. The outer coating prevents the evaporation of the juices of the meat which, together with the ex- tractive materials, are retained, and add flavor to it. Eoasted and broiled meats therefore have a decided advantage in flavor as well as in nutritive value over meat which has been boiled for a long time, although the latter may be tender and easily digested. Roasting and broiling are the most universal methods of cook- ing. For them the savage or the hunter requires no utensils, but boiling implies the aid of the potter or worker in metals. The Polynesian cooks his meat by roasting it on a hot stone, and sprinkles it with sea water to obtain the salt. The primitive hunter incases his meat or wild fowl, skin and all, in damp clay and roasts it in hot coals. The Australian savage, the lowest type of man, does all his cooking by roasting. In roasting as in boiling, the heat should be strong when first applied, but it subsequently should be reduced to prevent charring of the surface. This may be accomplished by removing the meat farther away from the fire. The main object of an oven is to pre- vent burning by uneven cooking. The principle of a roasting oven is formulated by Williams, who says "the meat should be cooked by the action of radiant heat pro- jected towards it from all sides while it is immersed in an atmos- phere nearly saturated with its own vapor/' and the heat applied after reaching a maximum is kept uniform throughout the process. In boiling or stewing, the heat is applied to the meat by convec- tion through water, and this is an important discrimination because the air which surrounds the roasting meat is constantly removing the water which tends to evaporate upon its surface, and therefore to dry the external surface of the meat, From 20 to 34 per cent of water is lost in this manner, and the meat therefore weighs less. The evaporation of this water, which continually passes from the 300 FOOD PREPARATION AND PRESERVATION interior of the meat towards the outer surface, produces a loss of heat in the meat itself which keeps the interior from bcoming over- heated. If the roasting or broiling be long continued, the water gradually passes out more and more from the interior of the mass, which finally becomes dry and hardened or burned. If too much air surrounds the meat, it is poorly roasted, dry, and leathery, whereas if the heat be applied more directly by radiation from glowing embers, the sudden hardening of the outer coating of the meat, even though it be slightly burned, forms a barrier against the evaporation of water from the interior. Broiling or grilling is a means of quick cooking which requires very much less time than roasting or boiling, because intense heat is applied to comparatively small pieces of meat or fish. It is really roasting on a smaller scale. The object of broiling as well as of quick roasting should be to raise the interior of the mass promptly to the point of coagulation, or about 180 F., so that the water within shall not have time to evaporate wholly. It is for this reason that steaks and chops are often best cooked in restaurants, where specially adapted grills are used which bring the meat in closer relation to a radiant surface of glow- ing coals than is usually possible in domestic cookery. A properly cooked steak or chop is thickened in the center. It should be re- membered that the evaporation depends upon the extent of the surface of the meat, and for this reason thinly cut steaks or chops become comparatively dry and shriveled in the center. This prin- ciple is well described by Williams, who says that "the smaller the joint to be roasted, the higher the temperature to which its surface should be exposed," and when very large masses of meat are being cooked, it becomes necessary to secure time for the heat to penetrate into the interior without drying up the outside. This object is ac- complished by constantly basting the surface in order to keep it wet and prevent evaporation, for while the surface is moistened, its temperature will not rise above the boiling point of the liquid which is used to moisfen it. Pouring melted fat or melted butter over the meat checks evaporation almost completely. The roasting of any meat, however, cannot be accomplished with- out the effusion of some of the meat juice and the melting of a portion of the superficial fat and of gelatin. These substances to- gether constitute the meat gravy, which is itself quite nutritious. In overroasted or " burned " meat the external layers become scorched or charred, and this is due chiefly to the carbonizing of the fat. Before the fat has become fully burned, certain volatile fatty acids COOKING 301 are liberated which have a very disagreeable odor, and various prod- ucts are developed which are not only of no value for nutrition, but which may be positively irritating to the alimentary canal. A little lactic acid and glycerin are formed. According to Yeo, for beef, mutton, and game, a temperature of 130 F. is sufficient for proper cooking and the meat is " rare " or " underdone/' retaining much of its reddish color; but veal and poultry should be cooked at a higher temperature at from 158 to 160 F. These temperatures are lower than those often used, which range from 300 to 480 F., and apply rather to the degree which is to be maintained after the meat is first placed in position for roasting, when as previously stated, the temperature should be much higher. A rough rule is to roast meat 15 minutes for each inch of thickness of the cut, and add 15 minutes "for the oven;" or 13 minutes per pound produces " rare " meat and 20 minutes " overdone." Basting lowers the temperature slightly and produces a rarer meat. Game or meat which is " high " or somewhat tainted is extremely repulsive if cooked by boiling or stewing, when it disintegrates more or less and the elements of decomposition pass into and flavor the whole mass. Such meat, however, is sometimes palatable, and is not necessarily unwholesome if cooked by roasting, when the ex- ternal layers which have first commenced to decompose are thoroughly browned and thereby disinfected. Some persons prefer that a leg of mutton should be hung until it becomes slightly odorous before it is roasted, but it should be fresh for boiling. 5. Frying. Frying is a process of cooking by which the heat is transmitted by the contact of the food with melted fat, butter, or oil, and not by radiation, as in the case of broiling or roasting. As ex- plained by Williams, the fat does not necessarily boil, for the food, as well as the fatty material itself, may contain a considerable pro- portion of water which, by being suddenly vaporized, produces the familiar spluttering which accompanies the process of frying. The boiling point of fats is very much above that of water, but fats and oils used in cooking when heated above 400 F. turn dark brown or black and emit a disagreeable odor and smoke, leaving a nonvolatile carbon residue. In frying, the heat is suddenly applied, and as a result the ex- ternal surface of the food mass is coagulated and hardened before the juices in the interior have time to escape. For this reason, deli- cate fish, like the trout, is more highly flavored and palatable when fried than boiled. More or less butyric acid is developed from fat in frying. 302 FOOD PREPARATION AND PRESERVATION The popular idea in regard to frying is that the fat used, whether butter, lard, or drippings, is simply for the purpose of preventing food from adhering to the frying pan, but, from the explanation of the process quoted above, it is seen that this is not the case, and the best frying is done by immersing the food completely in a bath of fat or oil. Even olive or sperm oil may be used for this purpose, and the fish or other food is lowered in an open wire basket or net- ting into a deep pan which contains the fat, in which it is completely submerged. There is no danger of the fat soaking into the food if it is sufficiently hot and if the process be not too long continued, for, as stated by Williams, " the water amid the fibers of the fish is boil- ing and driving out steam so rapidly that no fat can enter if the heat is well maintained to the last moment." Fritters cooked in this way are light and puffy from the sudden expansion of the water which they contain into large bubbles of steam, and are consequently decidedly more digestible. Bacon fries in its own fat. Frying is less perfectly understood by cooks than almost any other method of preparing meat, and the process as usually carried out results in very unwholesome products. The pans used are too shallow, and both food and fat are apt to become scorched. When the meat or other material is dipped into hot melted oil or fat, more or less of it clings to the surface of the food, and for this reason may render it unfit for persons with feeble digestive powers. In the case of fish cooked in this manner with their scales, the fat which adheres to them may be removed easily when eaten, and the meat within will be found to be quite digestible; but meat, such as steak, cooked by frying is notoriously indigestible. Salt meat may be cooked first by boiling before frying, as in the case of hams, although the latter may be roasted subsequently instead of fried. Such meats always require prolonged cooking. According to Yeo, the addition of a little vinegar tends to make them more tender. 6. Braising. Braising is a method of cooking meat by which it is immersed in a solution of vegetable and animal juices called " braise," contained in a covered vessel, in which it is exposed to a high but not boiling temperature. It is of value especially for cooking tough meat of any sort or meat which is too fresh or young. The cover of the kettle is so arranged as to prevent evaporation; the meat becomes permeated in the long cooking with the juices of fresh vegetables and herbs, and is kept from drying. Towards the end of the process cooking-sherry or spices may be added, such as cloves or mace, or thin slices of bacon. The amount of fluid used should be barely sufficient to cover the meat, and in COOKING 303 this way the surrounding broth is kept very concentrated. Some- times the meat which is braised is partially roasted. 7. Baking. Baked meat is prepared by cooking in a confined space, which prevents the volatile products which are driven off in roasting from escaping, and consequently the meat has a somewhat stronger and less delicate flavor than when roasted; it is also richer, and disagrees with dyspeptics. It becomes saturated with empyreu- matic oils unless its surface is protected by a pie crust, but that does not add to its digestibility. The baking of bread is described on page 164. 8. Steaming. Cooking by steaming is a method little used, ex- cept in hospitals or other institutions where large quantities of food are prepared simultaneously; it is mainly applied to cereals and puddings, but also to meats, etc. Soups. Meat soups and broths are made by continued boiling, which converts the connective tissue of meat fibers into gelatin, which is gradually dissolved into the water. The soup thus becomes an aqueous solution of gelatin, with some of the extracts of the meat for flavoring. Whatever albumin is dissolved and what little fat may be melted forms a scum on the surface. The insoluble albumin becomes coagulated and floats about in small particles, which are strained away if the soup is to be clear, but this process makes it less nutritious for invalids. If a really rich soup or nutritious broth is to be made from any piece of meat, so much of the latter is dis- solved into the water that the residue is tasteless, tough, and so indigestible that it is practically useless. On the other hand, there are many scraps of meat or parts which are unsightly or less useful for food from which very nutritious soups may be made, and the inedible bones are utilized in the same manner. The extent to which soups and broths may be made nutritious depends largely upon the character of the meat used, and Parkes placed meats in the following order in regard to the nutritive value of their broths, commencing with the strongest: Chicken, mutton, and beef. He stated that the best broth made from beef contains 150 grains of proteid to the pint and 90 grains of salts, for nearly all of the salts of the beef, chiefly chlorides and phosphates, dissolve out into the surrounding water. Beef tea is described on page 136. Experiments on losses in cooking meat, conducted in 1903 by H. S. Grindley and Timothy Mojonnier, at the University of Illinois, led to the following very practical conclusions: " 1. "When beef was cooked in water in these experiments, 3.25 to 12.67 per cent of the nitrogenous matter, 0.60 to 37.40 per cent 304 FOOD PREPARATION AND PRESERVATION of the fat, and 20.04 to 67.39 per cent of the mineral matter of the original uncooked meat were found in the broth. The nutritive ma- terial thus removed has been designated as a loss, but it is not an actual loss if the broth is utilized for soup or in other ways. " 2. When meat is sauteed 2.15 per cent of the nitrogenous mat- ter and 3.07 per cent of the ash occurring in the uncooked meat were taken up on an average by the fat in which the meat was cooked, while the cooked meat contained 2.3 times more fat than before cooking. " 3. When the meats were roasted, 0.25 to 4.55 per cent of the nitrogenous matter, 4.53 to 57.49 per cent of the fat, and 2.47 to 27.18 per cent of the mineral matter present in the uncooked meat were found in the drippings. " 4. Beef which has been used for the preparation of beef tea or broth has lost comparatively little in nutritive value, though much of the flavoring material has been removed. Cooking of Fish. Fish may be cooked by boiling, grilling, baking, frying, or stewing. Of these several methods, boiling is decidedly the most advantageous for persons with feeble digestions, and next in order is broiling. When fish is boiled without the addition of salt to the water it becomes soft and disintegrated, but if boiled in sea water or artificially salted water it maintains its shape and flavor, for the salt regulates the osmosis of the juices of the fish into the water. As a rule, fish requires much less time than meat for cooking. If fried fish is to be eaten by dyspeptics, it should be cooked whole, and the skin carefully removed subsequently. It is never as di- gestible as boiled fish. Cooking of Vegetables. The object of cooking vegetables, as in the case of cooking meat, is to render them more digestible, to give variety, to modify their flavor, and in some cases to preserve them. Some coarse vegetables, such as turnips, carrots, beets, and pota- toes, while they make good raw food for animals, are unpalatable and indigestible for man, and require softening and alteration by prolonged boiling in soft water or by some other form of cooking. The cooking of vegetables macerates the cellular fibers or walls of the cells and softens their contents, rendering them more easy of mastication, while the effect of the heat and moisture is to cause swelling and rupture of the starch granules, in which condition they are more easily and promptly acted upon by the starch-digesting ferments contained in the saliva and pancreatic juice. Most vegetables contain a very large percentage of water in their FOOD CONCENTRATION CONDENSED FOOD 305 natural state, but in many of the cooking processes to which they are subjected, excepting perhaps in baking potatoes and the like, water is added in considerable quantity, either hot or cold. FOOD CONCENTRATION CONDENSED FOOD The concentration of food is based upon the fact that many foods contain a large percentage of free water, which can be driven off by evaporation, thereby reducing the weight, and usually the bulk of the food as well. Slight further condensation may be accomplished by hydraulic pressure. Drying. Desiccation. Extracts. If the process of drying is not carried beyond a partial evaporation, the food is called " condensed." It may, however, be continued until the food is completely dry, in which case the substance may be either " desiccated " i. e., torn into shreds or pulverized. Condensed and powdered foods may be added to other foods in order to thicken them or increase their nutritive power. The nutritive principles of foods may be extracted by glycerin or acid solutions and other materials, and the resulting extract is con- densed by evaporation to the consistence of a paste or powder. Be- yond this it is not possible to concentrate foods by chemical process, for a definite bulk of food must be daily consumed from which to derive the energy for the body and the substances needed for repair. Drying is conducted either in the heat of the sun or by artificial means. The class of dried foods embraces the various forms of dried and desiccated meat and fish, dried milk, dried vegetables and fruits, such as peas, beans, lentils, corn, okra, apples, peaches, cocoanuts, grapes (raisins), dates, prunes, figs, etc. The addition of sugar, flour or salt by abstracting moisture, aids the drying and helps to prevent decomposition. Milk may be dried in vacua and preserved by itself as a powder, or mingled with other materials, such as malt and various starchy foods. Condensed milk is described on p. 108. Eggs may be successfully dried; they keep well, especially when mixed with farinaceous materials (p. 124). Froissart relates how the King of France in the invasion of Eng- land in 1386 had the yolks of eggs packed and stored in barrels to furnish rations for the troops. Egg albumen dries in the form of thin scales which may be preserved indefinitely. Meat. The preservation of meat and fish by drying is probably the most primitive method in use. Meat drying is practiced ex- 306 FOOD PREPARATION AND PRESERVATION tensively among savage tribes in almost all parts of the world, but especially where purity of the atmosphere combined with intense heat and dryness of climate will cause the water to evaporate from the meat so rapidly that germs do not have time to decompose it. For this purpose only lean meat can be used, as the fat does not part with its water with sufficient readiness. " Jerked " meat is prepared by cutting into thin slices and drying in the sun for several days. Dried meat loses much in weight, becomes hard and tough, and in many cases tasteless. It is therefore usually indigestible, and requires pro- longed cooking and proper seasoning. Dried meat may be predi- gested, evaporated, powdered, and made into a paste for broths, or used to reinforce various food preparations for invalids. Powdered meat is sometimes mixed with sugar and salt, or pulverized dried cooked vegetables, bread, etc. Dried meat extracts have been de- scribed in detail on pp. 132 to 135. Pemmican is a preparation of dried powdered meat, which has been described on p. 233. Dried vegetables keep even better than dried meats. Tea and coffee are good examples of dried vegetable substances. They may be extracted and then concentrated by evaporation. Potatoes are concentrated by drying to less than one-third of their original weight, and they may be preserved thus in slices or granular form. Many other vegetables are prepared by drying, and, in addition, some are compressed, as, for example, cabbage, cauliflower, carrots, etc. The compression still further excludes air and moisture. As a rule, dried vegetables are only serviceable for relieving monotony of diet when fresh vegetables cannot be obtained. Desiccated vegetables have been used with some success in the United States navy, but they have less antiscorbutic property than fresh foods. Bread may be preserved for a long time by drying, but it usually becomes tasteless, and is useful in this condition only in emergencies, or to make variety in the rations of sea biscuits, hard-tack, etc., which are furnished to soldiers and sailors in active service. Major "Woodruff, Surgeon, U. S. A., writes on this subject: "By a new process, which probably consists in drying the bread and at the same time compressing it by improved machinery, the Germans have secured a variety of field bread which is spoken of in very high terms. Small bits of it thrown into soup swell up like a dried sponge when thrown into hot water. The soldiers are said to be very fond of it, and as far as known it is entirely successful. . . . " The French Department of Intendance has been experimenting with dried bread, which is said to be superior for campaigning pur- FOOD CONCENTRATION CONDENSED FOOD 307 poses both to biscuit and ordinary bread. From the results of the experiment, which are given in the Eevue du Service de 1'Intendance Militaire, it appears that this dried bread will absorb from five to six times its own weight of water, milk, tea, coffee, or bouillon. Biscuit absorbs hardly its own weight of liquid, although when thoroughly dried it contains only about 10 per cent of water, whereas the bread contains from 12 to 14 per cent. It can be made in cubes of con- venient form." Diet of Concentrated Foods There are many complex dried foods in market prepared espe- cially for invalid diet, and supposed to possess high nutritive value with small bulk. As compared with fresh food, their lighter weight and greater concentration make them valuable articles for temporary invalid diet, but they cannot be said to possess any special advan- tage over freshly-made broths, scraped beef, etc., excepting in those cases in which it is important to lessen the bulk and increase the strength of the food. Attempts have from time to time been made in the German army and elsewhere to supply healthy men with a daily diet of concen- trated foods. If this could be done, it would be of great economic advantage for troops on the march, explorers in unknown countries, sailors on long voyages, and for use in many ways, but after a few days or a week of such treatment men lose in weight and deteriorate in strength. It is not found practical to give food for any length of time in which the total solid ingredients are concentrated to less than twenty-two or twenty-three ounces for the day's ration, although for a few days food may be used in which they have been reduced to ten or twelve ounces. Pea meal (p. 193) and pemmican (p. 233) are the most noted rations of this class, to which bacon, hard-tack, concentrated meat extracts, coffee, and chocolate are often added. In a series of very instructive and important articles upon Military Food, published in the Journal of the American Cavalry Associa- tion, Major Woodruff says : " Concentration only means the exclusion of the indigestible portions and part of the water. Thus the gar- rison ration gives to each man about five pounds of food, of which only four pounds are eaten, and it is impossible to condense this amount so that it will be much less than three pounds. All foods that are compressed and dried still contain from 5 to 12 per cent of water. The German soldier's war ration is equivalent to about two pounds of water-free food in the above sense. This is not enough for American soldiers during hard work, yet it is possible in an 308 FOOD PREPARATION AND PRESERVATION emergency to give the soldier fairly good nourishment with these improved foods, and not allow the weight to be over two pounds, as seen in the following table, in which the analyses are only ap- proximate : ARTICLES. GRAMS. Calories. Weights Protein. Fats. Carbo- hydrates. Salts. 3 cubes dried compressed bread, 14 pound each .... 3 packages compressed soup, 6 ounces each 35 100 4 150 250 200 2 28 1,233 2,625 1 pound. 1J " 1 " 3 tablets compressed tea or coffee ready for use, possi- bly a tablet of dried fruit Total 135 154 450 30 3,858 * 2 pounds. * Gross weight. " For purposes of detached service the United States soldier has been supplied with a concentrated ration as seen in the following table : ARTICLES. GRAMS. Calories. Weights. Protein. Fats. Carbo- hydrates. Salts. 1 pound hard-tack 50 27 5 236 340 HNH (NOD OS 1,644 2,310 1 pound. 1 1 " % pound bacon Coffee, sugar, and salt .... Total 77 , 241 340 30 3,954 2 pounds." FOOD PRESERVATION The different methods of food preservation have of late years re- ceived much attention, for it is owing to them very largely that it is possible to maintain large armies and navies in action and to permit of the aggregation of men in communities away from all immediate sources of food supply. It was originally believed that contact with air was per se the cause of the decomposition of food, but it is now known that the great number of germs contained in even comparatively " pure " atmospheric air are the agents of putrefaction rather than the air itself, but the exclusion of the latter implies the exclusion of the former. FOOD PRESERVATION 309 The conditions inimical to the development of bacteria are those which may be adapted to the preservation of food, i. e., sterilization. Ferments and putrefactive germs require for their activity a fair degree of moisture, 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: I. Drying. II. Smoking. III. Salting. IV. Freezing. V. Ke- frigeration. VI. Sterilization. VII. Exclusion of Air Canning. VIII. Addition of Antiseptic and Preservative Substances. I. Drying. Is discussed under Food Concentration (p. 305). II. Smoking-. Smoking is the preservation of meat or fish by means of volatilized 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 ma- terials, 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 solution 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 tough by the smoking if it was originally tender. The digestibility of hams is enhanced by smoking. The process of smoking is applied to fish upon a very large scale, and in many instances, as in smoked mackerel, herring, and salmon, while the flavor is different from that of the fresh fish, it is agree- able. III. Salting. The process of salting is a primitive but desirable method of preserving meat and fish. Salted meat usually becomes pale from the action of the salt upon the haemoglobin contained in the blood vessels of the muscle fiber. The addition of a little saltpeter helps to preserve the original reddish color of salted meat. Salt absorbs moisture from food, dries and preserves it. Brine, a strong solution of common salt, may be used temporarily to preserve meat and other substances. The Chinese have long prac- ticed the art of preserving fruits, roots, and flowers in it. Corned beef is made by soaking the meat for some da} r s in such a solution. The brine acts upon the muscular tissue and toughens it. Brine, concentrated by long-continued use, has been known- to acquire 310 FOOD PREPARATION AND PRESERVATION 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 require prolonged cooking. Salt meat is drier, less digestible, and slightly less nutritious than fresh meat. IV. Freezing. Food may be kept in a frozen condition almost in- definitely. On being thawed, it should be cooked immediately, other- wise decomposition may set in at once, and, excluding milk and cream, food is not easily eaten in a frozen state, except by the northern Eskimos. Meat and fish may be kept many days in blocks of ice without much loss in flavor, but vegetables are not as good after freezing. In 1867 Dr. Carl von Baer reported the discovery in arctic Siberia of a frozen mammoth, the meat of which was preserved. As this animal has been extinct since the days of prehistoric man, it afforded an illustration of the marvelous preservative power of intense cold. Another such animal was found, in 1799, being eaten by wolves in Siberia. In 1861 the entire bodies of three Swiss guides, who forty-one years before had been buried by an avalanche over the Glacier de Boissons, were found in a state of excellent preservation. In freezing meat for export it is subjected to a temperature of about 20 F. below zero. When quite hard the carcass is sewn in cotton cloth and placed in a refrigerating chamber on shipboard. 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 thawed imperfectly, in which case the central portion may remain frozen after the external layers have begun to cook, and when the latter are thoroughly roasted, the inside may be found almost raw. Frozen meat loses 10 per cent of its nutritive value in cooking. Such meat has been transported in fresh condition as far as fifty miles inland in the Philippines. Y. Refrigeration. The process of refrigeration or " cold storage " preservation does not involve the actual freezing of meat, fish, eggs, fruits, or vegetables, but implies their preservation in chambers at a temperature which is maintained but a few degrees above the freez- ing point. Tin's causes somewhat less alteration than freezing. From the purely epicurean standpoint, both freezing and refrigeration of all foods deprive them of much natural delicacy of flavor. FOOD PRESERVATION The cold is artificially generated, and beef, fish, fruits, and vege- tables are now successfully transported for thousands of miles in refrigerator cars and rooms fitted for the purpose on steamships. The refrigerating processes applied to the preservation of meat, etc., are several. In most of them the reduction of temperature 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 compressed 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 England is thus brought from New Zealand and the Eiver Platte. In time of war refrigerated dressed beef may be supplied to troops in lieu of the former practice of trying to follow them with cattle on the hoof, or furnishing only salt meat. The cold storage of fowl and game should be preceded by remov- ing ("drawing") the viscera, otherwise decomposition products are liable to taint the meat, alter the flavor and disorder digestion. When fruits are kept in cold storage at 31 to 23 F., their ripening is checked, as well as development of any fungous growths. VI. Sterilization. By sterilization of food is meant the process of rendering it germ-free by heat, and it includes the preservation of such food in sterilized vessels. Practically all thoroughly cooked food is for the time being "sterilized," and overdone meat keeps longer than underdone meat, for if the outer layers are firmly coag- ulated and dried by the heat of boiling or roasting, they form an envelope which is less pervious to atmospheric air and germs. VII. Exclusion of Air. Exclusion of air and consequently of germs 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 comparatively impermeable, as in the case of varnishing eggs, covering fish with oil, or pate de foie gras with lard. Eggs undergo decomposition from the entrance of air and germs through their shells, and this process may be prevented, sometimes 312 FOOD PREPARATION AND PRESERVATION for several years, by covering fresh eggs with almost any substance which is more impermeable than their shells, such as gum, fat, but- ter, oil, beeswax, or fresh milk of lime. The sawdust or salt in which eggs are commonly packed serves the double purpose of in- suring 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 man- ner of potted meats. Beef has been sent in good condition from Australia to England by dipping it into hogsheads of melted fat, in which it was left after the fat cooled and solidified. The preserva- tion of meats in air-tight skins, like sausages, has long been practiced. When food is preserved by any of these methods care should be exercised to have it perfectly fresh at first and to drive off by heat any air present in the food itself or its containing vessel. Canning. Frangois Appert first employed the process of her- metically sealing fruit to preserve it from the oxygen of the air. It is now known, however, that many putrefactive bacteria are anaerobic, and that the food must be sterilized thoroughly before the can is closed. This should be done by heat, but since it may also be accomplished by the addition of antiseptics, the introduction of the latter is practiced by unscrupulous manufacturers. The process of canning meat, fruit, or vegetables is conducted as follows : The fresh food is placed in clean new tin cans, filling them as completely 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. Before the cans cool, their minute openings are soldered. The long boiling of meat in this manner toughens its fibers by hardening the syntonin. Such meat is apparently tender, but in reality it is not very digestible. 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 Adulterants, made by him for the United States Department of Agriculture: " All manner of food is canned, and . . . vegetables out of FOOD PRESERVATION 313 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 Louisiana, sweet corn from New York, string beans from Scotland, mutton from Australia, sardines from Italy, stand side by side on the shelves." Wiley thus refers to the economic value of canned foods: " The quantity of dry food material in canned goods varies within wide limits. It is very low in such vegetables as string beans, aspara- gus, etc., and quite high in such materials as canned corn, succo- tash, 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 material the consumer purchases 95.83 pounds of water. " Such food materials must be regarded in the light of luxuries or condiments 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." Canned beef is boiled and steamed under pressure at 250 F. It loses most of its extractives and has the tastelessness, therefore, of meat from which soup has been made. Vegetables may be added to improve the taste, either in the canning process or subsequently. Vegetable canned foods when opened are readily spoiled by yeast fungi. (For acute poisoning from eating canned food see Ptomaine Poisoning, and Lead Poisoning.) VIII. Antiseptic and Preservative Substances. The use of anti- septic or preservative fluids is designed to prevent the activity of germs and fermentation. Sugar, like salt, in strong solution possesses decided antiseptic power, 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, onions, peppers, and other vege- tables, as "pickles." Spices, mustard, etc., are usually added. " Soused " fish, such as mackerel, are immersed in mixtures of cider vinegar flavored with cloves, nutmeg, parsley, bay, onions, etc. After being "soused" once or twice the food is heated to 140 F., flavoring substances are added, such as Worcestershire sauce, extract of anchovy, and lemons, and the whole is put in air-tight jars. Among the materials employed for preserving foods may be men- 314 FOOD PREPARATION AND PRESERVATION tioned the fumes of burning sulphur (sulphurous acid), acetic, salicylic and boric acids, borax, sodium benzoate, formalin, glycerin, weak carbolic acid, bisulphite of calcium, and the injection into the blood vessels of meat of alum, chloride of aluminum, etc. Sodium sulphite is added to preserve chopped meat and Hamburger steak, and a mixture of borax, niter, and salt is used in sausages. The modern use of chemical food preservatives has increased so much of late years as to require restriction by legislation. Many chemical preservatives from their lack of odor, color or taste as applied to food are not easily detected by the consumer. Their use, moreover, lends a false security and leads to lack of proper cleanliness and careful selection and handling of foods. The effects upon the health of the consumption of these chemicals has been the subject of recent exhaustive research by H. W. Wiley, who experimented with a number of soldiers and others, who volunteered their services and who became known as " the Poison Squad." His results (pub- lished in Bulletin 84, parts I, II, III, U. S. Dept. of Agriculture, 1906) are summarized briefly as follows: Salicylic acid " as a preservative increases the solubility and ab- sorption of the food in the alimentary canal," but "the tissues are broken down more rapidly than they are built up, and thus the normal metabolic processes are interfered with in a harmful way," and the body weight is diminished, although the food eaten may be increased. The drug increases the acidity of the urine and gives rise to faint albuminuria, for fully one-half of the drug ingested is ex- creted unaltered in the urine. The solids of the feces are lessened and abdominal discomfort and overworked kidneys are the result of its protracted use in food. These effects are more pronounced with salicylic acid than with sodium salicylate. The French Commission of Public Hygiene made an exhaustive investigation of the subject of adulteration of bottled beer, cider, milk, grape juice, 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 exist it may become so, for under these conditions it is not promptly eliminated. Used in any considerable quantity, it in time produces anasmia, as it does in rheumatism, but it is constantly employed medicinally in doses far exceeding the quantity likely to be ingested with food, and without harmful effect. Boric acid, sodium benzoate and borax or sodium biborate are used in preservation of milk, beer, meats, sausage, and of butter when FOOD PRESERVATION 315 destined for distant transportation. Neither of these chemicals is harmful if taken in very small amount, and not continuously. One- half per cent is the quantity rarely exceeded as a preservative, and one is not likely to consume more than half a gram (~i^ grains) a day. About three-fourths of all the butter imported into England contains boric acid, and some samples contain 40 grains to the pound. When either borax or boric acid is ingested with food in excess, 80 per cent of these substances is excreted in the urine and 20 per cent in the perspiration. Existing albuminuria is increased by their use, body weight is lost, nitrogen elimination is inhibited, and more phosphoric acid than normal is eliminated. Prof. B. H. Chittenden and William J. Gies, after elaborate experiments upon animals, conclude as fol- lows: Doses of borax up to 5 grams (77 grains) per diem, con- tinued for some time, do not disturb proteid metabolism or general nutrition. In larger doses borax retards proteid and fat assimilation and increases the weight of feces. Very large doses cause nausea, vomiting,, mucous diarrhoea, and lessen the urine secretion (through which borax is eliminated). Boric acid in doses amounting to 10 or 15 grains per diem, unless long used, does not affect nutrition or proteid metabolism; it does not affect the volume of urine or irritate the alimentary canal. Neither drug controls intestinal putrefaction. A method of meat preservation has been introduced by a Mr. Jones in England, which consists of injecting the animal the mo- ment after it is killed with a solution of borax, which is so uniformly distributed through the circulation to all the fibers of the meat that only a very small quantity of the antiseptic need be employed. Dr. Wiley having reported adversely on the use of sodium benzoate as a food preservative, as a result of experimentation upon the " Poison Squad " above referred to, and the matter having excited much con- troversy in reference to the prohibitive sections of the Pure Food Act of Congress, a special Commission was appointed by the National Government to experiment and report upon this question. The re- port, signed by Professors Ira Eemsen, Eussell H. Chittenden, John H. Long and Christian A. Herter (known as the Eeferee Board), gives the following main conclusions : First: Sodium benzoate in small doses (under 0.5 gram per day) mixed with the food is without deleterious or poisonous action and is not injurious to health. Second: In large doses (up to 4 grams per day) mixed with the food it has not been found to exert any deleterious effect on the health. There were slight modifications in certain physiological processes, the exact significance of which is not known. 316 FOOD PREPARATION AND PRESERVATION Third : Its admixture with food in large doses has not been found to impair the quality or nutritive value of food. It is strange that if sodium benzoate is as deleterious to health as has been claimed, .that medical literature contains no reference to cases of chronic poisoning by its use. On the contrary, in the pre- antitoxine days it was much used in the treatment of diphtheria. The National Dispensatory refers to such use in daily dosage of 120 grains to a child of 3 years, and 360 grains to adults. Since the in- troduction of antitoxine, however, the use of the drug has become obsolete. Sulphurous acid gas in solution and sulphites are alike moderately injurious as preservatives. Where these substances are used sulphur metabolism is increased in the body, so that more is eliminated in the urine and feces than is digested. The kidneys are overworked and albuminuria may occur. Anaemia is produced and the body loses weight. There is diminished food absorption and urea excretion. " Embalmed beef" This term is applied to meat which has been coated with a preservative antiseptic wash of some sort. A solution of boric acid is sometimes employed, but formalin is used more often. Flies avoid the coating and do not deposit putrefactive germs upon it. Formaldehyd, or formalin, is a strong antiseptic. It is not espe- cially harmful in moderate doses, but Halliburton, of London, has shown that it is especially active in inhibiting the action of the nor- mal digestive ferments. Given in milk it is injurious to infants. Glycerin has been used as a preservative, but it cannot be employed in any quantity on account of its aperient action. It is true of practically all of these latter substances that food preserved by them if used in great excess or for too long a time is apt to endanger the normal digestive functions, besides being somewhat less nutritious and more tasteless than other food. 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 possess moderate action in this respect, and alcohol, under such con- dition?, is both a stimulant and a food. The natives of various bar- barous or somicivilizecl countries, while performing long feats of endurance, such as marching, being often unable to obtain sufficient QUANTITY OF FOOD REQUIRED 317 food with regularity, make use of a variety of food substitutes. 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, either with or without exertion. According to Wiley, a fair average of the total quantity of food required each day for maintenance of healthful equilibrium in the adult man, measured in grams (not calories) is as follows: Moist food = 2,500 to 3,000 grams ; dry material = 550 to 650 grams (453.5 grams = 1 Ib. avoirdupois), or in round numbers respectively 4 per cent and 1 per cent of the body weight. In civilized 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 consequently more food is eaten than is necessary or desirable to maintain the " optimum " bodily health and vigor. 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, p. 40.) Gluttony results in overdevelopment and overwork of the digestive 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 only one meal a day and then gorge themselves with tough meat, develop big jaws and distended abdomens (Cooke). Sir Henry Thompson says (Diet in Relation to Age and Activity) : " More mischief in the form of actual disease, of impaired vigor, and of shortened life accrues to civilized man. so far as I have observed in our own country and throughout western and central 318 FOOD PREPARATION AND PRESERVATION Europe, from erroneous habits in eating than from the habitual use of alcoholic drink, considerable as I know the evil of that to be." The quantity of food required to maintain the body in vigor de- pends upon the following conditions: 1. Climate and season. 2. Clothing. 3. Occupation, work, and exercise. 4. The state of individual health. 5. Age. 6. Sex. 7. Size of body. 8. Body weight. (For the Quantity of Food in Ill- ness, see p. 445.) 1. Climate and Season. Much has been written about the need of man changing his diet when he removes from one climate to an- other, in the belief that the natives always eat the kind of food best adapted to the climate in which they live. This is superficial reason- ing, and too much importance is attached to the relations of climate to diet per 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 civilized 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, pre- dominate in their food. Barley grows the farthest north of all the cereals" (Clark). The Hindu subsists mainly upon rice, one of the simplest types of farinaceous food, and he derives his nitrogen from corn and len- tils. He must consequently eat a large bulk of food in order to obtain sufficient 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 arctic re- gions, nor do they require fats in excess, although they take some fats and oils. While these general statements apply to a majority of mankind, they arc by no means without exception, and it should not be argued 319 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, a fact amply demonstrated in the history of the North American Indians. Far from depending solely upon vegetable food, most savage tribes living in the torrid zone eat meat ravenously 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 p. 36). 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 entirely on breadstuffs 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 selected by the experience of most civilized nations, and it is also best for the individual who is accustomed to it to adhere to under whatever 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 much more depends upon the previous habits and occupation of the individual than upon external tempera- ture. Meat eaters find it easier to adopt quickly another form of diet than vegetarians. The Dominican friars deteriorated so much in health in the British climate that they were gbliged while resident in England to obtain special dispensation allowing them to eat meat four times a week. English soldiers transported to India or Africa are not required to become exclusive vegetarians : and the French in Africa or Panama have done best upon a mixed 4iet. In the United States Surgeon General's report for 1900 the statement is made that " experience in the Philippines has shown that though it is undoubtedly true that while leading quiet lives men eat less in a tropical climate than in a temperate or cold climate, and particularly of meat or fatty sub- stances, our soldiers during the active operations of last year have shown no marked tendency to lessen the quantity of fresh meat eaten. Exhausting labors and fatigues with corresponding wear and tear of the muscular system requires a liberal meat issue, which the soldier uses with satisfaction and advantage." " Well-clad and sheltered soldiers require less rations than poorly 320 FOOD PREPARATION AND PRESERVATION clad men exposed to the weather a good thing to know in times of great privation " (Woodruff). Men often become involuntary vegetarians while traveling in hot climates from inability to procure meat, and may partially starve 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 persons with a tendency to corpulency, find that during the heat of the summer season, 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 little animal food of any kind. The total quantity 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 directed especially in the matter, and the rule applies to infants as well as adults. 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 unhealthful, an addi- tional excuse is often made for drinking too much liquor. By these means the foundations for hepatic and renal troubles, such as 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 uniformly disagree, and lighter beverages, such as beer and wines should be taken. very sparingly; but there is no objection to tea, coffee, and chocolate. The diet in winter should comprise both more nitrogen and more carbon than in summer. Cold, bracing atmosphere stimulates the appetite, circulation and respiration, and consequently the rate of oxidation processes. It tempts one to exercise vigorously, and hence demands a larger con- sumption of food for fuel. A hot climate or season, with enervating, moist air, disposes to languor and inactivity, and diminishes the ap- petite as well as the need for food. Dr. Frederick A. Oooke, physician to the Peary expedition to the north pole in 1890-1892, wrote me in reference to the quantity and quality of food required in the coldest climate known, as fol- lows : " The members of our expedition took very few forced marches in low temperatures. The one over the interior of Greenland was QUANTITY OF FOOD REQUIRED 321 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 1% 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 tallow, half and half, a few currants, and a little sugar, but no salt. On several expeditions during the spring of 1892, while the thermometer 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 unlimited. There was no time that we craved fat. We enjoyed the pemmican im- mensely, 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 disfavor, for the variety and character of the food seemed to be of very little consequence ; indeed, our appetites were such that we were ready to eat anything and every- thing placed before us. We were, however, always liberally sup- plied 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." 2. Clothing and Food. Abundant clothing in a cold climate con- serves the body heat, and less food is therefore required to maintain life than if the body is scantily clad. 23 322 FOOD PREPARATION AND PRESERVATION 3. Exercise and Food. Exercise and muscular work also promote oxidation in the tissues and augment waste production from the mus- cles. This waste must be replaced, and energy supplied for work by additional consumption of food. Outdoor work demands more food than indoor work, and mental labor less than physical. Where men are fed upon a carefully regulated diet as in prisons it is found that those who are performing hard labor require about one-fifth more solid food than the others. 4. General Health and Food. The state of health of the indi- vidual greatly modifies the amount of food required both indirectly, through influencing exercise and work, and directly, by the local con- dition 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 to maintain their strength against the constant drain on their systems. The nursing mother should have abundant food, for she must eat for two. 5. Age and Food. The age of the individual not only modifies the absolute amount of food required, but also the relative quantity in proportion 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 increase more uniformly, but the child still should have a large relative quantity of food, a great proportion of which should be tissue-forming i. e., protein. The following table comprises the standards adopted by the United States Department of Agriculture: One 7ncal of boy 14 to 16 years of age, inclusive, equivalent to 0.8 meal of man. One meal of girl 14 to 1G years of age, inclusive, equivalent to 0.7 meal of man. One meal of child 10 to 13 years of age, inclusive, equivalent to 0.6 meal of man. One meal of child G to 9 years of age, inclusive, equivalent to 0.5 meal of man. One meal of child 2 to 5 years of age, inclusive, equivalent to 0.4 meal of man. One meal of child under 2 years of age equivalent to 0.3 meal of man. QUANTITY OF FOOD REQUIRED 323 The rapidly-growing, active boy oftens 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. (This topic is further dis- cussed under Age and Food, p. 322.) 6. 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 superstition is allowed full sway. The northern Eskimos, for instance, have a belief that if women eat eggs they cannot become pregnant, which is a curious contrast to the reputation for aphrodisiac effects which this food has among civilized people ! 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 may be shown to be due more to other considerations of habit and custom than to sex. The use of tobacco and alcohol by many men, for instance, makes them care less for such foods. Sex influences to a considerable extent the quantity of food consumed, but allowance should be made for totally different habits of life. There are many women who eat as much as men, but the majority require less food, although doing the same work. Under equal conditions 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. Prof. Arthur Goss gives the equivalent that one meal of woman averages 0.8 meal of man at moderate muscular labor. 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 many exceptions to all these general statements. Mrs. E. H. Eichards, as the result of observations (Food as a Factor in Student Life) upon 130 young women students at the University of Chicago, whose average weight was 120 pounds, gives the following table of food consumption in grams per diem: Protein 120 Fat 161 Carbohydrates 402 Total . 659 Potential energy in calories 3,383 324 FOOD PREPARATION AND PRESERVATION Woman with little muscular work demands 80 grams protein, and a total food value of 2,400 calories ; at moderate muscular work woman requires 90 grams protein and 2,800 calories; man with little mus- cular work requires 112 grams protein and 3,000 calories, and at moderate muscular work 125 grams protein and 3,500 calories. 7. 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 gen- eral 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 often can 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 insufficient 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 respectively large or small bodies, and differ- ent diets, demonstrating that " it is not quality or monotony of food, but its quantity that affects development" (Gerland). The Japanese having followed the vegetarian doctrines of Buddha for a thousand years, lately have been increasing their meat consumption in the hope that in time it may bring the height of their bodies up to European standards, but there are many other factors concerned. 8. 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 ap- propriateness of any diet is important. In prescribing systems of diet for many diseases, such as dyspepsia, obesity, diabetes, phthisis, etc., it is desirable to have the patient 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 conditions, may be much more rapid than gain ever is. The latter at best does not usualh 7 proceed at a rate of more than four or five pounds in a week, even during con- valescence from such an illness as typhoid fever; but in diseases like cholera, for example, in which emaciation is extremely rapid, the loss QUANTITY OF FOOD REQUIRED 325 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 found that in fever, while the proteids of the body are diminishing, there may be more water stored in the tissues, and in cases of anasarca and dropsical ac- cumulations 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 conclusions for feeding the patient from the weight alone. Another important con- sideration is the rapidity of loss of waste food products from the body. The normal weight of feces 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 inges- tion 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 ex- haustion which they occasion. The loss of weight through the aque- ous vapor 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 investigate conditions thor- oughly before adopting 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 frequently be weighed, for in them, for obvious reasons, the record of slight variations in weight may be much more accurately utilized in regulating feeding. Calculation of Rations It is ordinarily impossible or impracticable definitely to weigh the food for individual consumption, but where large numbers of men 326 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 the quan- tity of food required per diem to maintain optimum health and vigor. To facilitate such estimates, tables have been computed based upon the nutrient value of different foods. In the preparation of food to be eaten it is customary to allow 10 per cent of waste in calculating the gross quantity for dietaries of institutions, army rations, etc. Mrs. E. H. Eichards found that this percentage is somewhat too low. In computing the quantity of food needed for daily consumption its composition should be taken into account. The estimates of differ- ent authors vary somewhat in regard to the necessary quantity of different kinds of food in a mixed diet, but notwithstanding this there is a general correspondence between them. The chief dis- crepancy concerns the quantity of fat to be eaten, and it will be noticed in the following tables that, as a rule, when the fat is cut down the carbohydrate estimate is correspondingly increased. Standard Daily Diet for an Adult Male at Ordinary Work. Computed in Grams. Mole- schott. Pettenkofer and Voit. Ranke. Play- fair. Foster. Lan- dois. Dujardin- Beaumetz. Voit At- water. Protein 130 137 100 119 133 130 124 118 125 Fats 84 117 100 51 95 90 55 56 125 Carbohydrates 404 352 240 530 422 330 430 500 450 Salts 30 30 25 Total water- free food . 648 636 465 700 650 540 609 674 700 The amount of nutrient material required per diem by a healthy adult male doing moderate manual labor is represented 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 labor ob- tains 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. QUANTITY OF FOOD REQUIRED Healthy Adult Man, Abundant Diet and Rest (Bauer). 327 Taken in. Consumed. Stored up. 137 137 Fat "... 117 52 65 Carbohydrates 352 352 An Ideal Ration of Solid Food (Mrs. E. H. Richards) MATERIAL. AMOUNT. PROTEIN. FAT. CARBOHYDRATES. Calories. Grms. Oz. Grms. Oz. Grms. Oz. Grms. Oz. Bread 453.6 226.8 226.8 28.3 113.4 453.6 28.3 14.17 16 8 8 1 4 16 1 1 31.75 34.02 12.52 6.60 3.63 18.14 1.12 1.20 0.44 0.23 0.13 0.64 2.26 11.34 2.04 7.50 4.42 18.14 0.08 0.40 0.07 0.26 0.16 0.64 257.28 4.04 1,206.82 243.72 70.01 135.42 75.55 613.21 112.17 118.62 Meat Oysters "9". 60 4.88 90.72 27.36 6. '34 0.17 3.20 0.96 Breakfast cocoa Milk Broth Sugar Butter 0.14 12 27 Total ... 106.80 .... 57.97 389.84 2,574.60 An Ideal Ration of Liquid Food (Mrs. E. H. Richards). MATERIAL. Amount. Protein. Fat. Carbo- hydrates. Calories. Beef broth or consomme 1 pint. Grams. 20.5 Grams. 0.5 Grams. 88.70 To which has been added one large egg, minus shell .... Dried fruit soup 2 oz. 1 quart. 7.1 6.8 166 6 91.67 410 00 Lemon jelly i pint. 6 5 12 5 77 90 Whole milk 1 quart. 34 36 44 651 00 Rice or arrowroot 3 oz ( dry ) . 6 3 3 67 2 304 11 Grape sugar, or some one of the prepared foods (dry) 2 ^ 100 4.20 oc Total 2.5 quarts to 7fi Q jq c ooq 7 2fHO 00 3.0 quarts * * According to how the rice is given. A Common Invalid Ration too Low in Protein (Mrs. E. H. Richards). Protein. Fat. Carbo- hydrates. Calories. 1 pint of beef broth or consomme Grams. 20.5 Grams. 0.5 Grams. 88 7 1 pint of dried fruit soup 50 205.0 1 pint of lemon whey 21.5 79 521.7 1 pint of Imperial Granum, containing 3 oz. 6.8 0.4 64 294.0 2 Quarts of liquid Total 27.3 22.4 193 1,109.4 328 FOOD PREPARATION AND PRESERVATION A Ration Rich in Protein After Acute Disease (Mrs. E. H. Richards). MATERIAL. Amount. Protein. Fat. Carbo- hydrates. Calories. Bread Grms, Oz. 453 6 16 Grams. 31 75 Grams. 2 26 Grams. 257 28 1 205 81 Meat 453 6 16 64 04 22.68 487 62 Milk without cream . '. 453 6 16 29 02 18 00 39 00 444 48 Coffee or tea with cream 453 6 16 4 60 3 25 V 14 53 43 Butter 14 17 i 14 12 27 118 62 56 7 2 54 72 224 35 129.55 58.46 352.14 2,746.12 Less 10 per cent for indigesti- bility 12.95 5.84 35.21 274 61 Total 116.60 52.62 316.93 2,534.31 Table Compiled by Mrs. E. H. Richards and Miss Marion Talbot. One day's food, at the University of Chicago, calculated to determine the amounts and proportions of the various constituents and their comparison with the general average. Pounds. Per cent protein. Per cent fat. Per cent car- bohy- drate. Pounds protein net. Pounds fat net. Pounds carbo- hydrate net. Calo- ries. 50.0 Stew and cold meat . . 21.0 8 10.5 4.0 90.0 White potatoes 1.8 ?, 19 1 1.6 0.18 17.2 45.0 Sweet potatoes 1 5 4 ?,6 0.7 0.2 11 7 4.0 Dried beef 34.0 7 5 1.4 0.3 77.0 Flour and grain 11.5 1 8 70 8.9 1.4 53.9 3.0 Tapioca 1.3 83 2.5 192.0 Milk 3.5 3 7 4 7 6.8 7.1 9.0 13.0 Cream 3.0 1?, 3 0.4 1.6 0.4 15.0 Butter 2.0 83 5 0.3 12.5 15.0 Sugar 96 5 14.5 6.0 9.0 Prunes Oranges, less 20 per 3.5 1.0 65.0 11 0.2 4.0 0.8 50.0 7 2 Bananas, less 50 per cent waste Eafsjs . 4.85 12 5 i^i'o 19.7 1.3 0.9 Q.S 5.0 41 Lamb 20.0 15 8.2 6.2 26 Turkey 19 5 5.0 1.3 14 Steak 15 ??, 2.1 3.1 657 2 48.3 38.68 119.0 76.0 (Less turkey, lamb, and broad left over) . . 7.9 2.06 23.6 .81 9 Divided by 130 40.4 36.62 95.4 & 4 Per person nutrients 0.310 0.281 0.733 Grams. 126.5 Grams. 114.7 Grams. 332.0 ?,946 Daily average for the 6 months, nutrients 108.0 102.0 381.0 2,953 329 As a fair average for computation it may be said that 300 grains of nitrogen and 4,800 grains of carbon are daily required. In order to obtain the nitrogen necessary for the system from a diet composed exclusively of starchy food as, for example, pota- toes it would be necessary to eat ten pounds. If bread alone is eaten, four 'pounds would be required, and this contains more than twice the carbon needed. About fifteen pounds of cabbage would have to be eaten for the same purpose. On the other hand, to ob- tain sufficient carbon from an exclusive meat diet at least six pounds of beef must be consumed. If eggs were used exclusively, about twenty-three pounds would have to be eaten. An ordinary lump Years of age 4 8121620342332 40 44 48 52 56 60 64 68 72 "76 90 FIG. 43. APPROXIMATE QUANTITY, IN GRAMS, OF DIFFERENT CLASSES OF FOODS CONSUMED IN TWENTY-FOUR HOURS, COMPUTED ACCORDING TO AGE. (Mrs. E. H. Richards.) of sugar is the food equivalent of an ounce of potato. A quart of milk, three-fourths of a pound of beef, and five ounces of bread are all approximately equal in nutrient value. 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 protein on the one hand and the requisite carbohydrate on the other. For the purpose of comparison these authors estimate the necessary daily amount of carbohydrate at 448 grams and the protein at 130 grams: 24 330 FOOD PREPARATION AND PRESERVATION Protein. Carbohydrate. Rice 2,562 gra 1,444 491 582 968 2,875 388 10,000 614 HIS. 572 gra 625 806 819 902 930 2,011 2,039 2,261 ms. Wheat bread Lentils Peas E eres . Rye bread Cheese Potatoes Beef [i. e. to obtain a normal day's ration of protein from rice alone, one must eat 2,562 grams, but to obtain a normal day's ration of carbohydrates, one need only eat 572 grams.] If a man doing hard labor 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 single foods greatly over- taxes the digestive system. In fact, it would be impossible for most persons to eat meals of this character. The food would be too heavy; it would take too long to consume it, and it would become too monotonous. It is absolutely essential, therefore, for man so to regulate the composition of his diet as to balance properly its neces- sary chemical elements. This balance is best secured by a diet in which nitrogen bears the relation to carbon of 1 to 3.5 or 4. In bread the proportion of carbon to nitrogen is 3.0 to 1, and in meat it is reversed, and stands 1 to 3.5. Munk and Ufflemann state that the ratio between animal and plant albumin in the diet should be 3 to 7. 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 coal is oxidized to develop force for lifting through the engine. The carbon in all the forms of fats, starches, and sugars is utilized in the body of man to enable him to do the same work. The laborer does right therefore when he eats bacon with his cabbage and treacle with his oatmeal. There is one fallacy in the above comparison that should not be overlooked, which is that the more fuel the machine consumes, the more work it does ; this applies to man only within narrow limits, and too large a quantity of food promptly brings him into trouble with his di- gestive organs. (See Overeating, p. 411.) Water-free Food. The average percentage of water in bread is QUANTITY OF FOOD REQUIRED 331 37 per cent; in cooked meat, 54 per cent; in vegetables, 7 per cent or more (Letheby). " Assuming the food average as 23 water-free ounces daily and the mean body weight 150 pounds, the body receives 1-105 of its own weight in water-free solids. The range in different persons is 1-80 to 1-120 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 1-24 of his body weight, or 6 pounds, in nourishment per diem, divided as follows : Inorganic food i. e., water and salts 3.5 pounds. Organic food (animal food, 1 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 than the above allowance, and to drink a little more fluid. The average quantity of dry (i. e., water-free) food by weight re- quired for breakfast may be put at 8 ounces, for luncheon 6 ounces, for dinner 9 ounces, total 23 ounces. The "middle diet" at Guy's Hospital, which is supplied to the majority 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, 1 ounce of butter, 0.75 ounces of sugar, 0.25 ounces of tea, and 2.5 ounces of milk. Chaumont estimates that a man of 150 pounds can do an average day's work upon a diet of proteids, 4.5 ounces; fats, 3.75 ounces; carbohydrates, 18 ounces, and salts, 1 1-12 ounce. These estimates are of water-free constituents. 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 pos- sible 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 FOOD PREPARATION AND PRESERVATION acts favorably in promoting assimilation of other classes of food and diminishing to a great extent the wear and tear of the tissues. With active work, especially in a cold atmosphere, more than double this amount is consumed with advantage, and even 2.5 ounces form an average allowance 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 work. Salts. The quantity of salts required for daily use varies from 0.5 to 1 1-12 ounce. This quantity is less affected by conditions of temperature and exercise than are other food constituents. Water. The quantity of water drunk per diem is usually less than should be taken. Many persons believe that it is injurious to drink much fluid with meals and forget to take any between, and as a result not enough water is consumed to dissolve thoroughly 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 between 40 and 45 ounces per diem, and the total amount of food, including plain water and all other 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. 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. 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. 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 liim that he is obliged to desist from a part, at least, of QUANTITY OF FOOD REQUIRED 333 his labor. Should the disproportion between output and income continue, he becomes so enfeebled as to be liable to the inroads of hardship in various forms especially those of cold and zymotic diseases. 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 vigor. For these reasons the rations for arctic travelers 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 traveler, 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, 1 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 starva- tion, but as stated on p. 269, alcohol is injurious to the prolonged maintenance or robust health in cold climates.) While performing active service in the cold a diet of 1.5 pound of stewed deer's meat did not prevent 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 for some time. On leav- ing the ship and starting on their long sledge expedition, the follow- ing daily ration was allowed each man by Lieutenant De Long: BREAKFAST Pemmican 4 ounces. Ham 1 ounce. Bread 3 " pieces." Coffee 2 ounces. Sugar % ounce. 334 FOOD PREPARATION AND PRESERVATION DlNNEB Pemmican 8 ounces. Liebig's extract 1 ounce. Tea 1/2 Sugar % " SUPPER Pemmican 4 ounces. Tongue 1 ounce. Tea 1/2 " Sugar % Lime juice 1 Bread 4 ounces. While held fast in the ice, and still on the steamer, the average allowance of food per day was about four pounds, but some com- plained of being hungry on this ration. In the voyage of the Jeannette to the arctic zone in the polar expedition of 1879-'81 a very liberal diet was allowed the sailors on entering the arctic regions, the average quantity of food allotted per man per 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, consti- tuting about two-thirds of the whole amount of food. The diet at first included large quantities of condensed milk, butter, eggs, oat- meal, 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 10.0 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." He adds that tomatoes proved to be the most serviceable vegetable, and apples and peaches the best fruits. The beverages consisted of coffee, tea, chocolate, cider, and a small quantity of QUANTITY OF FOOD REQUIRED 335 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 humor 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 menu was as follows: Breakfast. Corn beef, oatmeal, fresh bread, chocolate, or coffee. Dinner. Vegetable soup, baked pork and beans, corn 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 39 ounces, to which was added an ounce of lime juice. The lime juice was carried solidified in the form of 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 10 " Sugar 2 " Milk y 2 ounce. Tea or chocolate 1 " Salt % Pepper & therefore the ration contained 40.5 ounces. Greely says again: " Three-fourths of the ration were about equal quantities of pem- mican, bacon, and frozen musk-ox meat, while the balance was made up of canned sausages and corned beef in about equal quantities " (Three Years of Arctic Service). He suggests as a still further im- provement that the vegetable ration should consist of 3 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 used chiefly in the field in 336 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 1, 1883, to June 23, 1884, Greely's per capita ration for his entire party was: 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 0.1 Bread 6.0 ounces. Dog biscuit 0.8 ounce. Butter 0.5 ounce. Lard 0.26 Rice 0.1 Raisins 0.16 Tea, compressed 0.3 Extract of coffee 0.44 Extract of chocolate . . 0.3 Milk 0.2 Mulberries . 0.2 It is noticeable that alcohol is omitted from this ration. C. E. Borchgrevink (First on the Antarctic Continent, 1898-1900) made extensive use of dried vegetables, and such articles as ham, bacon, curry and rice, cheese, dried fish, sardines, jam, marmalade, and cocoa. Among the advocates of restricted eating, especially of proteid food, is Prof. Eussell H. Chittenden, of the Yale Scientific School, who in his work " Physiological Economy in Nutrition," details the dietetic experiments made upon a number of students, professional men (including himself) and a selected group of 13 members of the U. S. Army Hospital Corps in 1903. The subjects of the ex- periments took daily gymnasium and other exercise and careful records of their strength and weight were compared with the intake of food and excretion of waste. Prof. Chittenden defines " phys- iological economy in nutrition " as meaning " temperance, not pro- hibition." Neither is it strict vegetarianism, but implies a reduc- tion of proteid food to 55 grams per diem, which is not quite one-half that ordinarily consumed by the average man, which, ac- cording to accepted standards, is 125 grams per diem for a work- ing man. The total food consumption is also much reduced. It is claimed that for a healthy man of 140 Ibs. 210 calories of protein per diem is ample in a diet of 2,800 calories, as against the usual 512 protein calories in a diet of 3,500. Or stated otherwise, the usual estimate for protein ingestion for a normal man is 2.4 to 2.7 calories of protein energy per pound of body weight per diem, but Chitten- den's diet allows only 1.3 to 1.7 calories. QUANTITY OF FOOD REQUIRED Chittenden's sample dietary is as follows: 337 BREAKFAST. Proteid, Grams. Calories. One shredded wheat biscuit 3 . 15 One teacup of cream 3.12 One German water roll 5.07 Two one-inch cube of butter 0.38 Three-fourth cup of coffee 0.26 One-fourth teacup of cream 0.78 One lump of sugar 12.76 LUNCH. One teacup homemade chicken soup 5.25 One Parker House roll 3.38 Two one-inch cubes of butter 0.38 One slice lean bacon 2.14 One small baked potato 1 .53 One rice croquette 3.42 Two ounces maple syrup One cup of tea with one slice lemon One lump of sugar 16.10 DINNER. One teacup cream of corn soup 3 . 25 One Parker House roll 3.38 One-inch cube of butter 0.19 One small lamb chop, broiled 8.51 One teacup of mashed potato 3.34 .Apple-celery-lettuce salad with mayonnaise dressing 0.62 One Boston cracker, split 1 .32 One-half-inch cube American cheese 3.25 One-half teacup of bread pudding 5.25 One demi-tasse coffee One lump of sugar 29.21 106 206 165 284 38 850. 60 110 284 65 55 150 166 '38 928 72 110 142 92 175 75 47 50 150 '38 951 This system results, it is stated, in greater simplicity and economy in diet; lessened burden is placed upon the digestive and excretory functions; lessened liability to fatigue, and actual improvement in physical and mental standards results. The leucomaines resulting from katabolic transformation of proteid material within the body may, under some conditions, produce toxic effects, and their trans- formation and elimination may overtax the liver and kidneys, pos- sibly laying the foundation of disease processes. Prof. Chittenden does not profess to establish dogmatic numerical standards and ad- mits that under varying conditions of labor or strain, larger quan- tities of proteid and other foods may be required temporarily. He claims that young, vigorous athletes can maintain their physical and mental vigor upon a daily output of only 8.8 grams of nitrogen (as 338 FOOD PREPARATION AND PRESERVATION against the customary 16 or 18 grams), representing a metabolism of 55 grams of protein. Prof. Chittenden's views have excited considerable controversy, not from their novelty, for there have been many previous disciples of extreme temperance in eating, but because of the number of per- sons simultaneously experimented upon, and the details of the nitro- gen determinations. They do not concern any special restriction in quality but rather quantity of food. As he himself admits, they are in opposition to the almost universal standards recommended by physiological chemists, as for instance, the elaborate researches made at the Agricultural Experiment stations throughout this country upon much larger groups of persons of varied occupations, ages and races. (See pp. 17, 18, 326-328.) For example, Benedict and Milner of the Wesleyan Station state that: " As a matter of fact, all evidence thus far accumulated goes to show that large quantities of food accompanied by increased mus- cular activity result almost invariably in the same proportional digestibility of the nutrients of the food as under ordinary con- ditions." Sir James Crichton-Brown writes: " All the successful races have habitually consumed proteid far in excess of the Chittenden standard and far in excess of what was required for tissue repair, and when we find a definite relation between proteid consumption and racial success there is good ground for believing that behind it there is biological law." The fundamental questions involved are two: first, does the con- sumption of a reasonable excess of food beyond the lowest nitroge- nous equilibrium compatible with normal weight, strength and health, really overtax the chemical organs of the body, or pave the way to functional or organic disease? Second: does such low equilibrium better fit the body to cope with the manifold mental or physical emergencies which arise in daily life, in those who are not, for the time being, under the placid influence of a daily monotonous routine of "training." The answer to the first question involves many complex theories of the origin of certain diseases, which cannot definitely be decided in the state of present knowledge. Proteid overeating certainly does not uniformly produce any one disease or group of diseases, and many races or tribes of man live in health and vigor upon predominant proteid diet (vide Diet of the Eskimos, etc., pp. 359). Conversely, however, it is equally true that many persons, and many existing QUANTITY OF FOOD REQUIRED 339 diseases are benefited by temporary or permanent protein restriction. The answer to the second question is not solved by the experi- ments under discussion, which do not include endurance tests, or the effect of strain, or the result in after life of a comparatively short course of special diet undergone by a group of selected men in previous health, most of them at a period of life which admits of great variation in diet of any sort, without marked immediate disturbance one way or the other. Temperance in eating, as in drinking, in exercising or working, should unquestionably be the aim of a well-regulated life, but the advocacy of a wholesale permanent reduction of the total proteid food of man to less than one-half of what heredity, habit or circum- stance has inured him to, admits of so many exceptions as to appear unnecessarily extreme. As an illustration of how far authorities disagree, F. W. Pavy of London, the well-known author of works on dietetics has said: "Undoubtedly, millions of human beings are to-day committing slow suicide by a too excessive ingestion of the carbohydrates." E. Maurel of Toulouse inclines towards a moderate proteid re- striction in the diet for those in normal health. His standard given MAXJBEL'S STANDARD DIET. Total Grams. Pro- tein. Fat. Carbo- hydrate. Calories. Total Calories. /. Breakfast 50 4.g 25. 120 1 Coffee 10 2.5 10 Milk 100 3.5 4 5.5 75 [ 245 Sugar 10 10. 40 J II. Breakfast or luncheon Bread . .... 150 12. 75 360 1 Wine 250 140 EOTOTS or . 2 15. 11 180 Fish or 100 18. 10 180 Meat 100 18. 15 250 [ 995 Fresh Vegetables .... 100 3. 10 10 145 Cheese 30 9. 5 90 Fresh fruit 100 5 60 J Dinner Bread 150 12 75 360 "1 Wine 250 140 I Soup Bread or vermicelli or vegetables 200 6. 5 25 175 1 Chicken or meat 100 18. 10 5 200 f 1,205 Fresh vegetables 100 3 15 10 190 Cheese 30 9. 5 90 Fresh fruit . . . . .... 100 12 50 96.5 66 2,445 340 FOOD PREPARATION AND PRESERVATION in his "Traite de 1'Alimentation et de la Nutrition" (1908), is subjoined for the 3 meals of the day. As general rules he recommends eating not more than two dishes and two desserts at luncheon and dinner, one dish consisting of animal and one of vege- table food, besides not more than 150 grams of bread (nearly 5 ozs.) and 250 c. c. (9 ozs.) of wine. Hors-d'oauvres are omitted. Forced and Reduction Feeding By forced feeding or " suralimentation " is meant the giving of a highly nutritious diet, chiefly of animal food, at frequent inter- vals in the maximum quantity which a patient can digest. Its chief benefit is in the treatment of tuberculosis, and the method is fully discussed under that heading (see Tuberculosis). It is also useful in chronic syphilis, with inanition in diabetes, mellitus and insipidus, neurasthenia, melancholia, hysteria and exophthalmic goitre. By reduction feeding is meant a diet especially designed in quality as well as quantity to reduce weight. Its essential value is in the treatment of obesity, under which heading the method is fully dis- cussed elsewhere. It is also beneficial in selected cases of gout, chronic heart disease, arteriosclerosis, asthma, cirrhosis and chronic nephritis, especially with anasarca. Quantity of Food Eaten Per Annum 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. Following is the estimate of total food supply for eighteen months for one man in the Yukon region. The total weight, about one ton, is considerably less than that of food ordinarily eaten, because fruit and vegetables must be carried in an evaporated condition. " The chief items are 600 pounds of flour, 300 pounds of bacon, 150 pounds each of beans and sugar, 75 pounds each of rolled oats or other mush material and cornmeal, 50 pounds of rice, six dozen cans of condensed milk, 35 pounds of butter in sealed cans, 150 pounds of evaporated vegetables, 100 pounds of evaporated fruit, 50 pounds of primes and raisins, 30 pounds of dried fish, 40 pounds of coffee, with baking powder, soda, salt, pepper, ginger, mustard, yeast cakes, tea, lime juice (very important), dried beef, extract of beef, soups in tins, sausage, etc., as desired, bearing in mind al- ways that variety of food promotes health. There has been more or less said in the newspapers about various concentrated foods, but, QUANTITY OF FOOD REQUIRED 341 with the exception of evaporated vegetables and fruit, condensed preserves, condensed milk, and beef extract, nothing yet has been brought forward which has been proved desirable. One cannot afford to experiment with his stomach in Alaska." 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 tables of the total quantity of foods con- sumed by a man during his lifetime. He estimates that a man dur- ing sixty years of life after early childhood eats 33% 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. Measurement of Food For most patients the weighing of food at meals is inconvenient or impracticable. It is, however, desirable to have some rough method of measuring foods so that the quantities eaten may be compared with published food analyses and their energy computed. Foods like lumps of sugar, crackers, etc., exist in fairly uniform portions, and others may be measured by the tablespoonful, teaspoonful or teacup- ful. A pound is the equivalent of 453.5 grams and an ounce of 28.3 grams avoirdupois. (A five cent piece (nickle) weighs 5 grams.) A tablespoon holds 15 c. c., a teaspoon 5 c. c., a common tumbler or coffee cup holds 200 c. c. The following estimates are given by A. L. Benedict of Buffalo. Grains. Lump of sugar 6. Soda crackers 25. Shredded wheat biscuit 30. Hard roll 60. Lamb chop (meat) 30. Thin slice roast beef 25. Small potato 50. Slice of bread 3 ins. scj 25. A " portion " or " helping " of butter 15. " Portion " of ice cream 125 c c. Tea, coffee and cocoa may be estimated by the amount of sugar and milk or cream added. "When it is necessary to keep close account of the nutrition of a patient, it is well to reserve for him a loaf of bread, a special sugar bowl, a package of cereal, etc., and to obtain the amount used in a certain period by subtraction." Dudley Roberts gives the following convenient summary of 342 FOOD PREPARATION AND PRESERVATION D DO d^ a fa . d "3 a 3 c 1 a i i i 3 a [ a " Np o ol .i a d d n ^ = I 8 I S s o E ll ^^ ~ a 's O a 1 I '.marks. depends on / u 1 1 due to larg d peas to a h CD 3 "o n the sugar e *S IS P g 3 C > "S i c ^; in f _, tc a "*a X M -* S c B O a 'C fl 9 a- 5 -: -Is 1 a 1 3 1 1 ! 3 111 |i 2| 1 I rfel o a e - I | K * ^ g d d 11 ^CDO^ ^ r -"<-.'- OOO C ?? oo ooo r i COP4GO NOCCM , : J? "* S iSxSSBwS SSOOBOO Cereals, eaten Shredded whe Triscuit Peas, fresh or Peas, dried.... Beans, dried.. Beans, fresh o Potatoes med Jelly, sweetenc Apples Oranges Bananas Dried fruit, pi QUANTITY OF FOOD REQUIRED 343 Starvation and Inanition Starvation, or asitia, is a term which technically applies 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 ingested in abundant quantity, but inanition results from lack of ability to absorb it and develop force and nutriment from it. The interval through which man can subsist without food depends upon: 1, External conditions of temperature and moisture; 2, the amount of work being performed; and 3, the condition of the body. 1. 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 reducing 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-nourished persons can endure longer intervals of absti- nence from food than the weak or diseased. The distress of delirious or apparently insensible persons may be augmented by lack of suffi- cient food. Sex has no influence with the effects of starvation, but they are most keenly felt at the extremes of age, by young children, and senile subjects. Those who have much 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 endure starvation much longer, although they may complain more bitterly 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. When food is completely withheld, life cannot be prolonged beyond six to ten days in the majority of instances. During the winter of 1876-'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 344 FOOD PREPARATION AND PRESERVATION a supply of water, and the atmosphere in which they were confined was moist. At another 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. As a result of an earthquake in Calabria, Sicily, in 1783, several persons were imprisoned in falling ruins. A girl of eleven years survived, having been six days without food, and another girl of sixteen years survived eleven days of starvation. The lack of food may be endured with far less torture if water be applied in abundance to the system. When water is withheld in addition the body loses weight much more rapidly, the tissues become dry, the thirst excessive, the secretions are suppressed, and the suf- fering 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- 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 pro- longed 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 25% ounces per diem. This he took in the form of plain water, ' mineral water, and ice. He became alarmingly emaciated during the fast, but even on the last day had strength to walk about the room. He resumed eating by first taking cocoa, and subsequently bouillon and other light ar- ticles, 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 food cravings surreptitiously.. They are very likely to be impressed strongly at the same time by religious beliefs, and in their disordered mental condition to acquire the de- QUANTITY OF FOOD REQUIRED 345 lusion 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 over-sympathetic friends and dealt with kindly but firmly. Hydrotherapy yields excellent results, and a good spanking may not be amiss in awaking the patient to a realiz- ing 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 quan- tity 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 grad- ually, especially in elderly people, their systems become slowly ac- customed 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 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 claimed to have subsisted on a daily allowance 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 general wisdom in some of his doctrines, but, un- fortunately, no one else who has attempted to practice his rules has met with similar success in prolonging life. The majority of man- kind 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 practiced 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 cultivation of will power, fasting may in some instances be defended, but fasting "to be useful must be voluntary" (Chambers), otherwise it is prone to cause irritability of temper, and it may even lead to deception to obtain food. Such fasting may be carried to an excessive and in- jurious degree unless it be limited definitely and supervised. It is more powerful in its effect, moreover, if it only seldom be undertaken. If a man so reduces himself by fasting that he cannot use his in- 346 FOOD PREPARATION AND PRESERVATION tellectual faculties with accustomed vigor he may be sure that he is doing himself injury. Better than complete fasting for purposes 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 practiced by many persons during the Lenten season. The day has long since passed when fasting can be regarded as favoring either clearness of intellect, muscular strength, or endur- ance, and, as Gerland has said, "the ethnologist can trace the physical and mental decay of whole nations to a long course of in- sufficient 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 marriages as inversely related to the price of wheat. Symptoms. The symptoms which result from complete starva- tion are characteristic. If food be withheld suddenly, 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. The sensation of thirst, on the contrary, when all fluid is withheld, persists until death or until the subject becomes insane or unconscious. 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. The facies are typical, the expression is anxious and staring, the orbital fat disappears, and the eyes are sunken and glassy. Corneal ulceration may be present. General bodily emaciation ensues, the muscles are soft and reduced in size by more than one-half, and the abdominal viscera to a similar degree, the skin becomes pale, loose, and, from change in the secretion of perspiration, emits a peculiar fetor and acquires a clay-like color. 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 and such substances as leather may be devoured to produce a sensation of satiety. Upon one of the ill-fated arctic QUANTITY OF FOOD REQUIEED 347 expeditions, on one occasion, the tea accidentally being omitted from the kettle, dirty water was drunk by the starving men without recognizing the difference. The secretions are altered, and become inactive. The urea excretion falls to one-fourth the normal. The total volume of blood is diminished, and anaemia is extreme. 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 gradually the nervous system succumbs to languor and general prostration; 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 be- comes 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 which latter state they have been known to devour human flesh. In 1874 three men and two boys were castaway 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. 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 whereas the muscles lost 30 per cent in weight, the brain lost but 3 per cent and the heart 2.5 per cent. The ultimate effects of starvation are identical whether the proc- ess 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. 348 FOOD PREPARATION AND PRESERVATION 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 more 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 temporarily may be appeased by eating other sub- stances than food, like bits of old leather, for example, which appear to act mechanically in the stomach. For this purpose 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 starva- tion exists than is found in the journal of Lieutenant De Long, com- manding the expedition of the Jeannette, which visited the arctic regions in 1879-'81 (The Voyage of the Jeannette, Journals of George "W. De Long, 1883). After leaving their sinking vessel the mem- bers 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 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 difficulty of crossing the par- tially unfrozen rivers. Their feebleness gradually overcame them, until one by one they died of inanition. Four men survived for sixteen days upon absolutely no food whatever, and possibly their QUANTITY OF FOOD REQUIRED 349 sufferings were even further prolonged, but the journal of their gal- lant 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 intensified by the presence of the game in sight but out of reach. A few shrimp and lichens were obtained and stewed with seal skin. During the siege of Paris in 1871, 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. If barely sufficient to maintain life, and hard labor be imposed, weak- ness, sickness, and death will inevitably follow. In an overcrowded prison a daily ration of twenty-eight ounces of unbolted meal and five ounces of bacon has been known to cause death by slow star- vation. As a means of discipline a starvation diet is sometimes en- forced in penal institutions for a few days, and it is usually quite as efficacious as corporal punishment. A diet which is designed to effect its aim by monotony as well as reduction in quantity, but with- out 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 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 should 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, meat juice, or egg albumin, may be given at intervals of fifteen minutes or half an hour. If no vomiting or evil symptom results, small quantities of peptonized milk may be tried at half-hour intervals. Alcoholic stimulants in large quantity are to be avoided, but a few drops of brandy or whisky may 350 FOOD PREPARATION AND PRESERVATION be given from time to time in water. If the stomach be irritable, nutrient enemata should be employed. The following day the quan- tity of food may be increased slightly, but if emaciation is extreme and enfeeblement is pronounced, the patient should be kept upon a fluid diet for ten days or more. Easily digested forms of starchy food then may be added, such as bread, arrowroot, gruel, cocoa, boiled rice, and the like. Famine "When starvation occurs upon a large scale, affecting a community with famine, pestilence is sure to accompany it. Disease has al- ways been rampant in Ireland when the potato crops have failed, and in India when the grain supply has given out. Much of the ill- ness which occurred in the early history of the Crimea was due to insufficient food, and in the Middle Ages the ravages of pestilential diseases, such as typhus, smallpox, 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. Physicians and nurses in charge of contagious cases are particu- larly cautioned to eat well and not expose themselves to infection while suffering from fatigue and lack of food. Improperly Balanced Diet Improper diet is often quite as injurious as slow 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 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 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, rachitis, or tuberculo- sis, and sometimes also the stomach and bowels become permanently distended. (See Diet for Infants and Children.) The effect? above described are commonly produced by excessive ingestion of starchy and saccharine foods to the exclusion of pro- QUANTITY OF FOOD EEQUIRED 351 tein, and, on account of the cheaper cost, the children of the poor are more likely to be injured in this manner than the rich, among whom the opposite diet an excess of proteids is more common. The latter sometimes gives rise to circulatory disturbances, over- works the kidneys, and produces nervous irritability. PART IV. SPECIAL CONDITIONS INFLUENCING FOODS Age and Food Diet and Heredity Diet and Race. AGE AND FOOD Food in Childhood A CHILD at three or four years of age 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 growing age. Inquiries made in this country in regard to the diet of older chil- dren and young adults demonstrate that it contains a proportionately large quantity of fatty food much more than is customarily con- sumed 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. Protein. Fats. Carbohydrates. Infant until one and a half year Child from six to fifteen years .... Grants. 20-36 70-80 Grams. 30-45 37-50 Grams. 60-90 250-400 Man ( moderate work ) 118 56 500 Woman 92 44 400 Aged man 100 68 350 Aged woman 80 50 260 The special diet regulations for infancy and childhood are de- scribed at length under the headings Diet in Infancy and Diet in Childhood, p. 352. 352 AGE AND FOOD 353 Food in Adult Life The full adult weight is not usually attained before the twenty- fifth year, although in some cases it is reached earlier. In many instances adults after the age of forty or forty-five years increase considerably in weight. In men the bones continue to solidify until about the thirtieth year; in women this condition is reached a few years earlier. When the growth of the body and development of the vital organs is completed the use of food consists simply in maintaining the equilibrium of the tissues by replacing waste with new material and in furnishing fuel for the development of force. Many persons eat more than is required for these purposes. 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 an athletic life to realize, as he grows older and passes on towards forty-five or fifty years of age, that he requires less food to maintain equilibrium than formerly, and his habits of eating ac- quired 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 postponing the luncheon hour, 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 indulgent in overeating as in overdrinking is less productive of harm than habitual indiscretions of a lesser degree. So much is due to habit in the different organs of the body in rela- tion to food that the stomach and intestine will usually reject undi- gested the contents of an occasional excessive meal, whereas with habitual overeating they become accustomed to appropriating large quantities of food, which are absorbed, but not eliminated without straining the excretory organs, or which may be stored in the body in the form of incompletely oxidized material. The latter accumulates until the system rebels and a violent bilious attack by vomiting and purging relieves the overburdened organs. There are persons who have so little restraint over their appetites that they persistently in- dulge themselves in this manner. Food in Old Age In old age there are inevitable changes which slowly arise in the circulatory and digestive organs of the body. Although the general 25 354 SPECIAL CONDITIONS INFLUENCING FOODS health may be unimpaired, the circulation is less vigorous, and the nervous system less responsive 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 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 in- testine is apt to deteriorate and produce constipation and a relaxed condition resulting in dilatation. The circulation through the mesenteric vessels and those of the portal system becomes inactive, with a consequent reduction in the rate of absorption, and a dimin- ished and altered secretion in the liver and pancreas. 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 circulation, respiration, and metabolic changes in the tissues being less active, there is a correspondingly restricted expenditure of energy. Persons of very advanced age those who are past eighty years or more sometimes may 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 grams, albumin, 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 present in individual cases. Sir Henry Thompson (Diet in Eelation to Age and Activity), in commenting upon the progressive 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 abundant 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." In the dietetic treatment of cases of extreme old age the rules which are naturally suggested are: 1. To diminish the total quantity of food ingested. AGE AND FOOD 355 2. To prescribe food at frequent intervals in small quantity. 3. To prescribe 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. The idea is prevalent that the quantity of food and stimulants should be increased 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 may be taken in- definitely in the same degree. In commenting upon Professor Humphrey's report upon cente- narians, made for the British Medical Association, 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 alcoholic 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 only one meal a day, while others ate four or five; some drank 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 lean physique, and the universal testimony in regard to cente- narians 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 direc- tion by depriving them of their teeth, making it practically impos- sible to eat animal food, which requires mastication, and, as Yeo sug- gests, " if artificial 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 protein) 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 should be avoided, yet the food should not be exclusively 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 hours. 356 SPECIAL CONDITIONS INFLUENCING FOODS It is common for elderly people to awaken in the morning at three or four o'clock and be unable 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 often may continue their sleep. I have found the vacuum or " thermos " bot- tle of service in such cases. It is a double bottle with a vacuum be- tween the walls which acts as a nonconductor of both heat and cold. Fluids poured into it retain their temperature for a dozen hours or more; hence hot milk or bouillon, etc., may be obtained at any hour without the trouble of heating it at inconvenient hours. Malt liquors are very good for the aged, and a moderate amount of alcoholic drink 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, tender chicken, game and other tender meats. " Minced chicken, game, and others meats, sweetbread. "White fish, as soles, whiting, smelts, flounders, etc. Best when boiled. " Bacon, grilled ; eggs lightly cooked or beaten up with milk. " Xutriftous soups, such as chicken or fish, beef tea, mutton and chicken broths. " Milk in all forms, when easily digested. " Beef tea and milk supply the needed mineral substances, and the former is an excellent stimulant. " The addition to milk of an equal quantity of warm Vichy, or of warm water, will often help to make it agree. "Of vegetable foods the following are all suitable : " Bread and milk made with the crumb of stale bread and with- out any lumps. Porridge and oatmeal gruel. Puddings of ground rice, tapioca, arrowroot, sago, macaroni with milk or eggs and fla- vored with warm spices, or served with fruit juice or jelly; bread and butter, at least a day old; rusks for soaking in tea, or milk, or water. " Artificial foods, consisting of predigested starches. The diges- tive ferments are scantily provided by the digestive organs at this age, and soluble carbohydrates are valuable for maintaining the body heat. DIET AND HEREDITY 357 "All farinaceous foods should be submitted to a high temperature for some time, so as to render the starch granules more easy of digestion. " Vegetable purees of all kinds may be 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 perfectly ripe raw fruits in small quantity. The acidity of certain stewed fruits may advantageously be neutralized 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. 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." 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 circum- stance 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," as well as a tendency to biliousness 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 genera- tions. So is occasionally the inability to digest special foods, such as crustaceans, milk, 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, 358 SPECIAL CONDITIONS INFLUENCING FOODS like gout and diabetes, and in such cases improper diet and careless habits of eating may develop latent disease. Stoutness and leanness are conditions modified to some extent by heredity, as well as many other factors. 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 insects (see p. 371). 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 cultivated require its use to fit them for digestion. As Gerland has said, men obtain their food either from natural products, by cultiva- tion, or by barter and commercial exchange, according as nomadic or fixed habits predominate, and " no mere hunting or fishing tribe can be large and remain in one place," for it is estimated that in the temperate 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 dis- tant sources, and the economic, commercial, and social development of all matters pertaining to food among civilized people to-day far exceeds in importance all other practical questions. Following is a synopsis of an exceedingly interesting report writ- ten for me by Dr. Frederick A. Cook, the physician to the Peary expedition to Northwestern Greenland in 1891- J 92, which is ap- pended 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 neighbors. One cannot peruse the account without being impressed with the fact that generalizations in regard to the influence of diet upon the sys- tem should lie made with great caution when applied to different races of man. For example, both scurvy and rheumatism are some- times attributed to an excessive meat diet, yet the Eskimo has al- DIET AND RACE 359 most no starchy food and does not suffer from these diseases, and, moreover, his bodily vigor and power of endurance compare favorably with that of any other race or class of men, and in some respects it is greater. 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 suste- nance. Their diet consists almost exclusively of meat, composed principally of the muscular tissues of the following animals, in the order of their importance to the natives: Seal, walrus, norwhale, white whale, polar bear, reindeer, arctic hare, and sea fowls, such as guillemots, gulls, eider ducks, etc. When food is scarce they eat every part of the animal, including the stomach and intestines; indeed, the only vegetable food that the most northern Eskimo 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 sacrificed 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 odor. " 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- 360 SPECIAL CONDITIONS INFLUENCING FOODS 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 eating 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 fed only every two days. " The Eskimos endure fasting very well, and after a good, full meal they can fast for two or three days, apparently without serious inconvenience. 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 debil- itated, and are not capable of great muscular exercise during this time. " 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 start- ing upon a journey a native will fill up with water. It should be remembered 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 one time. Variation in diet does not seem to be a necessity to the Eskimo unless he is feeling ill, when he recognizes the importance of a change of food and surroundings. " The Eskimo mother nurses her child until the next is born or shortly before it, a period which varies 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 DIET AND RACE 361 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 average weight of these northern Eskimo men is one hun- dred and thirty-five pounds, but that of the women one hundred and thirty-eight pounds. Obesity is foreign to the Eskimo, and lean- ness is equally rare." Studies of negro diet have been made for the United States De- partment of Agriculture by H. B. Frissell and Isabel Bevier, with the following result: Cost, Nutrients, and Fuel Value of Food per Man per Day in Dietary Studies in Virginia and Elseichere. Pro- tein. Fats. Carbo- hydrates. Fuel value. DIETARIES OF NEGROES IN ALABAMA Dietary with minimum protein Grams. 26 99 31 93 62 109 Grams. 83 252 27 283 132 159 Grams. 225 666 304 649 436 444 Calories. 1,800 5,480 1,625 5,670 3,270 3,745 Dietary with maximum protein Dietary with minimum energy Dietary with maximum energy Average of 20 negro families in Alabama . . . Average of 19 negro families in Virginia . . . Tentative standard for man at moderate work 125 ... 3,500 The preponderance of protein in the diet of Virginia negroes as compared with those investigated in Alabama is due to residence nearer the sea and large consumption of fish, especially salt herring. Arthur Goss (Xutrition Investigations in New Mexico, U. S. De- partment of Agriculture) gives the following dietary of a Mexican living in Xew Mexico and an Alabama negro: NUTRIENTS IN GRAMS. Fuel value in calories. Protein. Fats. Carbohydrates. 68 62 73 132 572 436 3,320 3,270 In this dietary the Mexican subsists upon little more than half of the standard requirement of protein, and the negro upon less than one-half. The Mexican eats chiefly flour and frijoles, with little meat, and the negro subsists upon bacon, fish, and cornmeal. Eacial peculiarities in diet are often not referable to any inherent peculiarity in race, but rather to environment. Man naturally eats 26 362 SPECIAL CONDITIONS INFLUENCING FOODS what he can obtain easiest in the locality in which he lives, and if he has not attained to a degree of civilization in which commercial interchange brings him a variety of foods foreign to his locality, his diet remains restricted. With changed surroundings also, he promptly modifies many of his racial food habits, as proved by ex- perience with the Chinese, Bohemian, Italian, Mexican and other classes of immigrants to this country, as studied by the numerous State Agricultural Experiment Stations. PART V FOOD DIGESTION CONDITIONS WHICH ESPECIALLY AFFECT DIGESTION IN the previous part of this work there have been incorporated a number of tables of the so-called "nutrient values" of foods as computed by physiological chemists. Such analyses are of unques- tioned scientific interest, but it is necessary to caution against their too rigorous application in practical feeding, either in health or disease. For example, as pointed out by Halliburton, pork is the most highly nitrogenous of meats by analysis, yet its muscular fibers are so associated with fat that much of this food fails to be acted upon by the digestive agents of the body, and passes out as waste. Similarly whole wheat bread is chemically more nutritious than the bread of refined flour, yet so much of the proteid-bearing bran is undigested, that bulk for bulk, the whole-wheat breads are much less nutritious. As Halliburton states, "a common error, which it seems impossible to dislodge from the medical mind, is that 'nu- tritive ' and ' nitrogenous ' are synonymous terms." Another example is found in the application of analyses of red versus white meats to the feeding of patients with enfeebled diges- tion. The differences in proteid content and extractives may be very slight, yet the variation in toughness of fiber and consequent digestibility may be considerable. For such reasons I desire particularly to emphasize that it is wholly impracticable to prescribe an invalid dietary on a strict basis of " calories " as representing energy, or heat, or a matter of storage of body substance, as one would definitely prescribe a medicine. More- over, for obvious reasons, nearly all the calorifacient food experi- ments made with man have been conducted upon those in health, not in disease. Even a healthy man inclosed in a calorimeter for a few days' experimentation is in reality under highly artificial con- ditions as compared with a healthy man under stress of mental work, physical labor out doors, or subjected to any of the manifold changing conditions of daily life. 363 364 FOOD DIGESTION In the ensuing chapters, therefore, the conditions especially af- fecting food digestion and the true nutrient value of food in dis- ease will be considered from practical and clinical standards, without placing undue emphasis upon analyses and "calories." Patients often conceive erroneous ideas regarding the digestibility of special foods. The food supposed to " disagree " may have done so because it has been improperly prepared or cooked, or because it has been eaten with other foods forming improper combinations. For example, an exclusive milk diet may be well tolerated, whereas the milk taken with other foods may produce dyspepsia or bilious- ness. Moreover, it is quite possible that a food which at one time proved indigestible, may have done so because of transient abnormal conditions in the digestive apparatus, rather than from any injurious quality in the food itself. Finally, digestion often varies much in the same healthy person at different epochs of life. 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 dif- ferent times in the day, and experience teaches that they should 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 best meets the needs of the system as well as the requirements of personal convenience. In the rural districts, however, and in many countries where life is less hurried and active than under the condi- tions of the extraordinary 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 proper hours for infant feeding are described under the head- ing Infant Feeding. Children should always dine early in the day. There are in general 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 only 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 i> a breakfast eaten in the late morning, usually HOURS FOR MEALS 365 at or before twelve o'clock. This meal is substantial, consisting of several 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 traveling abroad, who are accustomed to eat a heavier meal for early break- fast, often experience difficulty in adapting themselves to the French custom, but many learn to like it, and as the traveling public are commonly for 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 or Butter-brod soon after rising, but they dine very early, often at half-past twelve, taking a heavy, deliberate 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 theaters 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 taking 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 between one and two, take a cup of tea and perhaps a biscuit at four or five, and dine at 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 laboring class, whether employed in the city or country, almost universally dine at noon, at least when they can return home for their meals. It is mainly the mercantile and professional classes in large cities who dine be- tween 6 and 7 p. M., while the more fashionable or leisure classes dine later often at eight o'clock. Many of the latter, however, on going to the country for a summer holiday, 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 common to dine 366 FOOD DIGESTION in the neighborhood of half -past two or three o'clock. Many persons in cities who habitually dine late on week days from long-continued custom, on Sundays dine shortly after noon, taking supper in the evening. This is an old custom handed down from days in which less exacting occupations favored noon dining throughout the week, but due in part also to economic 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 break- fast, consisting of a roll and cup of coffee or tea, may be digested per- fectly for years, yet reversing the order of meals may entirely disorder the digestion. For professional and other classes of men in the United States who are not occupied in physical labor or outdoor pursuits the following system is found to possess decided advantages: A break- fast is taken soon after rising, at half-past seven to half-past eight, which consists of fresh fruit, porridge or oatmeal, or other variety 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 stewed or baked potatoes, and a simple lettuce salad, or perhaps a little cheese or light pudding, for dessert. If a heavy meal be taken at this hour by persons unac- customed 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 incapacitated from active mental work. The dinner should be from half-past six to half-past seven, after the principal labors of the day are over, and at an hour early enough to allow of the complete digestion of the heaviest meal of the day before re- tiring. This may consist of several courses, which are conventionally arranged in the order which appears to be most rational and phys- iological namely, soup, fish or an entree., a steak or joint with potatoes and one or two fresh vegetables, a salad, and a pudding or cooked fruit. Order of Dinner Courses. A clear soup at the commencement of a meal promotes digestion. The fluid, if taken in a quantity not exceeding eight or ten ounces, for the greater part, is promptly absorbed in the stomach, and its warmth and the sustenance it con- tains act favorably upon the circulation, stimulate the secretion of gastric juice, and satisfy temporarily the cravings of hunger which HOURS FOE MEALS 367 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 eat- ing of meat, which is destined to remain in the stomach for two hours or more, and requires all the energy of digestive processes. The saccharine or farinaceous food, which does not undergo diges- tion 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 sufficient holidays and trips to noted spas to enable them to periodically relieve the digestive system of the strain put upon it. Persons who rise late and dine early should eat 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 so to order one's occupation that neither severe mental nor physical labor need be undertaken im- mediately 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 im- mediately thereafter, or at 2 P. M. ; yet cases of indigestion are com- paratively infrequent among them; and the ordinary day laborer begins his work again without detriment almost immediately after a hearty noon meal, and continues it while gastric and intestinal digestion are still necessarily incomplete. Invalids often require modification in the accustomed hours for meals, and Balfour says that "all invalids should have their im- portant meal in the middle of the day." Between three and four hours, on the average, should 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 a day that is, in ad- dition to three ordinary meals, they should have light lunches in 368 FOOD DIGESTION 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 din- ner or supper and breakfast. On the other hand, dyspeptics and pa- tients 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 under- taken, 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 persons who maintain better health on only two meals a day, and occasionally, although it must be regarded as an eccentricity (except in the case of some savages and the Eskimos) (see p. 359), there are persons who thrive upon only one meal a day. The monks of La Trappe eat but one meal daily, as a religious 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 eating, but, like the carnivores, take their food whenever and how- ever 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 line 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. APPETITE 369 " As a general rule, though by no means without exception, sub- stances pleasing to the jpalate are useful and not injurious to the organism" (Lauder 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 gratifica- tion, 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, such salt foods as caviare or herring, 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. A substance known as orexine, in the form either of a hydrochlorate, tannate, or simple basic condition, has been recommended as having the special function of exciting the appe- tite in convalescents. It does not, however, give uniform results, and I have seen little or no benefit from its use. To obtain the most complete satisfaction from the sense of taste one should swallow the food, and not merely take it into the mouth. (Compare " Fletcherism," p. 384.) The appetite is usually somewhat more keen in winter than in summer, but many persons observe no difference, and if the winter be spent indoors and the summer in outdoor life, the condition of appetite may be reversed. The different nature of summer and winter foods causes variations in appetite. It is depressed or de- stroyed by mental emotion, especially grief, anxiety, and worry; by the sight, smell, or taste of ill-prepared or improperly cooked or badly served food; foul air and poor hygienic surroundings; fatigue and exhaustion; many diseases, more particularly febrile diseases and most gastric disorders; nausea; the abuse of strong condiments, and of 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 such food. The appetite is very dependent upon habit and upon the usual order and arrangement of the meal. An attempt to eat a lump of 370 FOOD DIGESTION butter alone usually fails, but it is easily consumed if spread upon bread. Eeversing the customary order of the different foods served at dinner usually produces disgust, and may even excite nausea. Pawlow has shown by a series of elaborate digestion experiments, made at the St. Petersburg Institute of Physiology, that there are two "tides" of gastric-juice secretion. The first, "appetite juice," is induced by hunger and the pleasurable sight or smell of food, or the sounds associated with its preparation, and is psychic; this secre- tion is abundant and actively digestant. The second is excited by the mechanical and chemical action of food in the stomach. Of the two the former often proves the more important, for food which is unappetizing, or food which for any reason is eaten without relish or while the mind is strained in other channels, may remain for hours undigested. Hence the failure oftentimes to secure hydrochloric acid after an unappetizing " test meal " of bread and water. Bulimia, which means excessive craving for food, is by no means an indication of vigor, and is often due to an irritable condition of the nerves of the stomach with hyperacidity, and may be brought about by eating at irregular intervals, which results in disturbance of the gastric secretion. A voracious appetite sometimes occurs in children. 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 common among the epileptic, insane, es- pecially maniacs, paranoiacs and the degenerate. (See Appetite, p. 368, and Bulimia, p. 370.) Abnormal Food 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 liable 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 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 expression VAKIETY IN DIET 371 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 victim of flatu- lent dyspepsia longs for saccharine, and perhaps amylaceous or fatty foods confectionery, pastry, and the like and the diabetic often has an inordinate craving for bread or sugar, 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 arise. Such patients have been known to eat chalk, earth, or sour food, or con- sume large quantities of salt, sodium bicarbonate, etc. With the exception of chronic alcoholism if alcohol be regarded as a food as well as a stimulant there is no distinct food "habit," in the sense that any particular food is likely to be long eaten to an injurious excess. Those articles of diet which are oftenest abused in this manner are condiments, especially pepper and salt, and con- fectionery. 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 ar- ticles only, but for the reasons given in discussing the force value of different foods (p. 6) there is no single food, not even milk, which will support adult man in optimum health and vigor for long. There are many primitive races and tribes of man who live comfort- ably 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 and race. 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 subsists chiefly upon the plantain. The Central American Indian lives almost entirely upon maize, and some of the Polynesians eat breadfruit 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 mainly upon oatmeal porridge. Such a monotony of diet is, however, usually a question of en- vironment or necessity and not of choice. The carnivorous Eskimo enjoys canned vegetables when they are offered to him, and the vege- 372 FOOD DIGESTION tarian African native gorges himself with meat when he can obtain it. 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 climate to another. This adapta- tion is also possible because the elementary foods possess general nutritive properties for all the organs of the body, rather than spe- cial value for individual structure; for example, there is no "brain food " in distinction from food which nourishes other organs as well. An ideally perfect food combination is based upon purely theo- retical considerations of the needs of the body, for just so much albumin, fat, starch, sugar, salts, and water would be a compound which in a very short time would become too monotonous 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 flavor 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 animal with corn than with skimmed milk, and salmon and shad acquire a more delicate flavor when feeding in fresh-water rivers. In a report of digestion experiments made for the U. S. Department of Agriculture by Charles D. Woods and L. H. Merrill, the state- ment is made that " it is a matter of common observation that di- gestion experiments made with one kind of food material do not give on the whole as reliable results as those in which two or more food materials are used. In other words, it appears that with a mixed diet the same person will digest a larger proportion of nutrients than with a diet composed of a single food material." 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 prohibition of swine flesh. When a variety in food cannot be secured the de- sired effect in stimulating the appetite and digestive secretions may be obtained by altering the methods of cooking and by modifying the taste and odor of food. On the other hand, too great variety, as well as too elaborate cooking, becomes equally tiresome. Those who cat 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 hotter. THE NERVOUS SYSTEM AND DIGESTION 373 "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 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 recognized by physicians that chronic constipation cannot be properly treated with drugs, and it must be rectified by diet." THE NERVOUS SYSTEM AND DIGESTION The influence of the nervous system on digestion is very com- plex. In a general way, the nerves may affect the digestive 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 vagus, through its association with the cardiac, vasomotor, and respiratory centers in the medulla oblongata, places the vital functions 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 diges- tion through the circulation by their vasomotor control, regulating the caliber of the vessels and quantity of blood supplied to the walls of the alimentary canal, the local blood pressure, and the consequent rate of secretion and absorption. (&) Action through Motion. The nerves influence the movements of the entire alimentary canal, either accelerating or inhibiting them, thus controlling the propulsion of the food, its admixture with secre- tions, and its contact with absorbing surfaces. (c) Action through the Glands. The nerve supply of the diges- tive glands is distributed to their blood vessels, and also probably to some extent to the cells of the gland parenchyma. This latter dis- tribution 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- ical 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 (psychic influences) or from 374 FOOD DIGESTION 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 excite- ment, 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 altering gland secretion. In its later stages the effect of the nervous system will be more pronounced in con- trolling or inhibiting absorption. 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 diges- tion 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 its rate of supply to the digestive glands. Vigorous active circulation accompanies good di- gestion 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. The salivary secretion becomes watery and contains a smaller percentage of solids, after stimulation of the chorda tympani, and 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 modify- ing its composition. Blood which is watery, anaemic, or deficient in proteid ingredients, furnish poor materials for the manufacture of the digestive se- cretions, and, further, the muscular walls of the alimentary canal suffer from malnutrition and peristaltic action is diminished. TEMPERATURE AND DIGESTION Both the external temperature and the internal body heat in- fluence digestive processes. The effect upon the system of the tem- perature of food and drink is also a matter of important consideration. 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 375 Sudden modifications in the atmospheric temperature of either ex- cessive heat or cold react upon the circulation, respiration, and the nervous system in a variety of ways and indirectly affect the digestive 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 conse- quence. A local application of heat and of cold over the abdominal wall during activity of the digestive organs has limited influence. Patients 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 do those who are having poultices con- tinuously applied to the abdomen. In a series of experiments which I made to determine the extent of heat penetration through the abdominal wall (" Local Thermotherapy," X. Y. Medical Record, April 13, 1907) it was shown that the application of heat or of cold of such extremes as may be borne without discomfort 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 neutralization of the heat or cold applied externally by the constantly changing layer of blood flowing beneath the surface. In anaesthetized 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 animal be killed, circulation ceases, and the temperature of the thermometer will immediately be affected to the extent of fifteen or twenty de- grees. It is doubtful, therefore, whether enfeebled digestion can be much influenced by the local application of warmth over the ab- dominal wall. Many persons, however, who have a tendency to in- testinal indigestion find it both agreeable and salutary to wear continuously a broad flannel bandage about the abdomen to favor uniformity in temperature and prevent the liability of taking cold. The variations of body temperature between the highest fever and the lowest depression do. not exceed the limits of temperature at which digestion is known to proceed when artificially conducted, so that such variations do not of themselves alone destroy digestive power in the stomach. The latter is usually diminished or lost during fever, but this is owing more to disturbances of the circulatory and nervous svstems than to increased warmth of the stomach. 376 FOOD DIGESTION Efforts to raise or lower the local temperature in the stomach during digestion by swallowing, respectively, hot water or pounded ice are not productive of very striking results, as may be determined in a patient having a gastric fistula, or by means of the cesophageal tube. Nevertheless, it is customary, and no doubt best, to administer stimulants hot in collapse from any cause. Wunderlich, Fothergill, 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 ex- ample, 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, because the quantity of heat units which may thus be conveyed into the body is too small to merit serious consideration. 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. Hot fluids drunk favor perspiration, and sometimes aid expectora- tion, 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 endeavored to show by sphygmograms that the imbibition of cold fluids increases arterial tension, and that of hot fluids lessens it. This may be true, but the sphygmograph is not at all a reliable instrument, and certainly the clinical ap- plication 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. 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 swal- lowed 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 person? who cannot digest hot mutton fat can take it cold be- cause it becomes friable and mixes better with other food. Some per- TEMPERATURE AND DIGESTION" 377 sons 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 for invalids than iced milk, yet the latter may be better borne if vomiting be present. Much depends 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 abun- dantly within its walls and those of the oesophagus maintains the necessary normal average most favorable 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 neces- sitate slow swallowing. Swallowing several tumblerfuls of iced wa- ter in quick succession does cool the stomach and inhibit digestion by local reduction of temperature, and also by shock to the gastric nerves; but this effect is less than is commonly supposed. There are about fourteen pounds of blood in the body, having an average tem- perature of very nearly 100 K, all of which in turn keeps cir- culating 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 hemorrhage, much less pulmonary hemorrhage, although it may relieve nausea some- what. In support of these statements are the results of many ex- periments which I have made upon patients undergoing treatment by lavage, to whom I have given fluids at different temperatures, which were immediately siphoned out of the stomach, and tested for heat loss or gain. (" Local Thermotherapy," N. Y. Medical Eecord, April 13, 1907.) Two tumblerfuls of ice water may be swallowed slowly, and if siphoned out again in five minutes the temperature of the fluid will be found to have risen to fully 95 F. The question often has been raised as to whether the body tem- perature can be affected permanently by alterations in the quality of the diet. It may be stated definitely that so long as the diet is abundant and nutritious it makes no difference whether man is car- nivorous., 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 378 FOOD DIGESTION below normal, but this is mainly due to the enfeebled circulation and lessened rate of general metabolism. Excess of alcohol also re- duces body temperature slightly. Improper and indigestible food may cause temporary rise in tem- perature, but this is usually caused by more or less gastritis or gastroenteritis, 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 % F., 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 cow has a temperature three degrees above man's and quite equal to that of many strictly carnivorous animals. The graminivorous pigeon has a temperature as high as that of the fish-eating gull. N"o deductions can therefore be made in regard to any permanent influence of diet upon normal body temperature in healthy animals or in man. The loss of body heat consequent upon Starvation and Inanition is further discussed under those headings (p. 347). 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 perhaps 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 asserted definitely, that they may interfere temporarily with the digestive secretions. Young children between the ages of four or five and ten or twelve suffer much less from the influence upon di- gestion 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 indigestion a habit which would be very disastrous to adults. On the other hand, exercise has a very important relation to digestion when taken at proper times and in right degree. 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 EXERCISE AND DIGESTION 379 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 favor the elimination of bile from it and increase its functional activity. For this reason horseback riding is the most useful form of exercise for many varieties of dyspepsia and so-called " bilious- ness/' Moderate exercise often may be taken advantageously in the morn- ing on rising for ten or fifteen minutes in order to produce good perspiration before taking a cold bath. Such exercise with dumb- bells, Indian clubs, or weights with pulleys does not harm the ap- petite, 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 maintain good health and a normal appetite. 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 laborers. The influence of food upon muscular activity has been studied by Hodge, who 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 kymo- graphion. 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 cornmeal alone may be active but a few minutes in the day, whereas the same animal fed upon meat and cream alone will exer- cise 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 functional activity of different organs of digestion, and of the circulation and nervous system. It is to be hoped that future in- vestigations will differentiate more clearly between these factors. 380 FOOD 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 whigh puts the latter into the most favorable conditions. Dyspeptics and persons subject to an irritable or feeble digestive system may 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 overexertion demand food for the replenishment of waste material, but the im- mediate 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 in Relation to Meals. Sleep is often affected by the quan- tity of food taken. Overeating, with lack of physical exercise com- bined with sedentary habits and brain work, is very likely to induce drowsiness. During profound sleep the functions of the body are all more or less reduced in activity, and the motility of the stomach is less- ened. 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 period of gastric digestion is in part com- pleted. It is true that many of the lower animals, particularly the carnivores, are accustomed to lie down and sleep immediately after taking their food, but their functions in so many ways differ from those of man that little is to be gained by a comparison with them, and their sleep is usually light until digestion is accomplished. On the other hand, in man, if profound sleep follows eating of a heavy meal, digestion is very apt to be disturbed. A large volume of blood is kept in the abdominal vessels during digestion, and the cerebral circulation is 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 one awakes fatigued. Persons whose health is below the average on account of disor- ders of digestion and assimilation not infrequently find that they REST AND SLEEP AND DIGESTION 381 become very sleepy after eating, more particularly after eating a heavy meal at noon; this condition is sometimes very annoying, and always indicates a lack of balance between the income and output of energy, which should be regulated by proper attention to diet and exercise. Usually in such cases the difficulty consists in habitually eating more food than the system can appropriate, and cleansing the body through the emunctories, whereas 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 properly to conduct two functions at once that is, to regulate diges- tion and at the same time exercise the mind. Obviously, in such cases, rest and tonic treatment are indicated. Food should be given more often, but in small quantity. In England the custom is prevalent among some classes outside of the larger m 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 between five and six, which is followed by supper from eight to nine. This practice is well adapted for some persons, 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 bedtime. If the alimentary canal is too empty sleep will be retarded, and the earlier stages of hunger, before great exhaustion has occurred, may be accompanied by restlessness and insomnia. A very little food taken into the stomach under these conditions will often pro- duce sleep promptly. The aged, whose systems are susceptible to slight changes in their condition or environment, are liable to be- come sleepy after their meals, and they find it to their advantage to take a brief nap after dinner; but this sleep is not usually pro- found, and if it is too prolonged it indicates exhaustion, which should be met by more careful attention to diet and stimulation. Starvation may cause persistent insomnia. Eetiring 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 glass of beer. In all ordinary cases of insomnia it is well to see what help may be got from diet and regular habits before resorting to hypnotics. (See Insomnia.) In some diseases it becomes a grave question between nourish- ment and sleep as to which is the more important. Sleep often is 382 FOOD DIGESTION 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 ex- hausting disease, protracted typhoid or other fevers, etc., nourishment should be given once in two hours by day, but once in three or four hours by night. In cases in which the patient does not readily sleep again after being aroused for food it is well to relax the rule, and give the patient a good night's rest of five or six hours without awakening him for food; but the degree of exhaustion and need of cardiac stimulants should be the guide in each separate case. MENTAL EMOTION AND DIGESTION Strong mental emotion, such as fright, terror, or excessive ex- citement of almost any kind, inhibits the digestive functions, espe- cially 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, how- ever, affect digestion favorably, and the expression " laugh and grow fat" is certainly not without physiological basis. Huf eland 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." By compression of the stomach under the movements of the diaphragm in laughter, the food currents are accelerated. Prolonged anxiety and worry, in almost every instance, result in more or less gastric indigestion and malassimilation, so that, although the appetite may remain good, nervous dyspepsia, constipation, and loss of weight result. FOOD IN THE MOUTH In patients who are unable from weakness or the prostration of fever, to take 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 moistened frequently by the FOOD IN THE MOUTH 383 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, p. 474. Food which is allowed to collect in the cavities of decayed teeth favors the development of bacteria, which on being swallowed may become a cause of dyspepsia by exciting malfermentation in the stom- ach, especially of milk. Much bacterial filth accumulates beneath artificial teeth which are not frequently cleansed. Imperfect or painful teeth, or swollen gums, interfere with the 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. Young children sometimes appear to have lost appetite, whereas the difficulty exists in soreness of the mouth. The digestion of carbohydrate food begins in the mouth, and de- pends upon the activity of the salivary ferment ptyalin, which converts 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 cesophagus, and also in the stomach, 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 neutralizing saliva, ptyalin fermentation proceeds well in the presence of 0.005 per cent of hydrochloric acid, but stops with 0.025 per cent. Dufresne is responsible for the statement that ptyalin recovers its activity in the alkaline intestine, and that diastase is completely de- stroyed by the gastric juice. In feeble and ill-nourished persons the salivary digestion becomes much impaired, and consequently their farinaceous food should be partially dextrinized 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 neutralizes the gastric juice. A dry diet (see Dry Diet) improves this condition. 384 FOOD DIGESTION Too rapid eating, or tachyphagia, without thorough mastication, is a, very common fault, and from time to time apostles of deliberate mastication or bradyphagia have attained notoriety by magnifying its desirability as a means of prolonging life. Among the latest of these is Horace Fletcher, whose work, " The A. B. Z. of Our Own Nutrition," is largely devoted to this topic, so that slow eating has heen described as " Fletcherism." Fletcher's theory, as practiced for many years by himself, involves two principles ; first, to masticate all food until it no longer tastes agreeably, before swallowing; and second, to follow instinct; i, e., desire in the choice of food not to eat unless hungry, even if a meal be omitted occasionally, and to se- lect such foods as one naturally craves, irrespective of habit, con- ventionality or preconceived theory. It is not intended to count the number of " chews " given each mouthful (like Mr. Gladstone, who was said to have chewed each morsel thirty-six times), nor to make eating a bore, but merely while eating to direct attention to the pleasurable sensation of taste in the mouth, as long as it lasts. Pawlow, of St. Petersburg, has demonstrated experimentally, that the flow of gastric juice is stimulated by such enjoyment of food, apart from the * advantage which thorough mastication possesses in insalivating, giving time for copious salivary and gastric secretion to form, and in mascerating and mixing the food particles. On the other hand, it may be possible to overdo mastication and prevent the mechanical stimulus to digestion which is undoubtedly afforded by coarser food in the stomach. Benedict and Milner state that : " It would also appear that when the common food materials make Tip the diet in proportions in which they are ordinarily used, in general at least 95 to 96 per cent of the total organic matter is digested and utilized by the body. With such an average efficiency there is little opportunity for improvement in the thoroughness of digestion of the ordinary diet. Any dietetic practice, therefore, such as excessive mastication, which may be claimed to result in greater economy in the utilization of food so far as it relates to thoroughness of digestion, must improve upon a condition in which there is already almost complete utilization." Fletcher further claims that his method of eating leads naturally to a selection of a smaller proteid ration, which is an advantage. His system has received recent support from Prof. Irving Fisher of Yale, who conducted a series of experiments upon nine students. The experiments were in two groups of ten weeks each and " en- durance tests " were made three times, i. e., at the beginning, middle and end of the periods. The endurance tests comprised running, lift- FOOD IX THE MOUTH 385 ing heavy dumbbells repeatedly, holding the arms or legs in positions of unwonted exertion, etc. The men practiced " Fletcherism," and Fisher added a third rule, " when instinct is in doubt, use reason," i. e., if one was in doubt as to which food to choose, that having a known low proteid content was to be selected. A liberal mixed diet was allowed. At the close of the experiments, it was found that the men were eating much less proteid than at the beginning, and that they lost weight and strength, but gained in endurance, i. e., single muscular feats of strength were less well performed, but muscular exertion could be performed longer, with less resulting fatigue or exhaustion. Whether or not it is an advantage for the average man to go on losing weight and strength for the sake of gain in endurance, is a question which may be deter- mined properly only for the individual subject. In another series of experiments upon 49 persons (Yale Med. Jrn., March, 1907), Fisher found further confirmation of his theory that a low proteid diet is conducive to endurance, but his results as reported show much variation. Some of his subjects could perform one en- durance test best, others another (deep knee-bending, holding the arms raised for long periods, etc.), and others failed to show uniform results in their own endurance. In direct opposition to these dietetic theories of Fletcher and Fisher are many scientific experiments, and many well-known facts. For instance, the health and certainly the endurance of the entire Japa- nese army and navy has increased many fold since there has been a more liberal proteid allowance in the ration. No better example of endurance can be cited than the Japanese coolie runner, who easily covers 20 to 30 miles a day with his carriage, and as much as 45 miles has been run by one in less than nine hours. Kintaro Oshina, who made a special study of this topic at the Agricultural Experi- mental Station in Sapporo, Japan, found the average protein in the diet of such a man to be above 40 per cent. This authority says : " Contrary to the public belief, it is the general impression of close observers that these jinrikisha men commonly spend a comparatively large part of their income on animal food. According to the obser- vations of Tiegel the jinrikisha men eat a large amount of rice during their working periods, taking meals every two or three hours, but during the period of rest they eat considerable quantities of fish, eggs, beef, and pork. With regard to the opinions concerning the small amount of protein in the diet of these people, he believes that the con- dition has been considerably misrepresented." Gardiner (British Med. Jour., 1901, p. 1010) writes: " During their period of rest they - 27 386 FOOD DIGESTION (jinrikisha runners) consume large quantities of meat in order to build up strong muscles, but while actually working they subsist mainly on rice." The lifelong habits of a particular race, or large group of men, are more convincing than a small series of experiments in which for periods of a few days or weeks, selected men are made temporarily to change their dietetic habits. The Eskimo is another large proteid eater, whose phenomenal feats of endurance in his coast voyages and prolonged inland marches often have been recited by arctic explorers. Directing persons to follow " instinct " in their appetite is as grave an error as to urge everyone to follow the same dietetic fad. It surely would work havoc with young children, as much as it would with domestic animals. Craving for special foods is easily acquired, and if yielded to as a principle would frequently result in dyspepsia and biliousness if not more serious digestive disorders. (See Slow Eating in Dyspepsia, p. 571.) 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 entire digestive work. The stomach has been excised from man and in several cases a fair measure of digestion has been retained. The really important action of the stomach 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 digestion of starch, inaugurated by ptyalin in the mouth, is continued for a varying length of time in the stomach, until the hydrochloric acid reaction of the gastric juice be- comes sufficiently strong to inhibit it. The stomach warms and macerates all classes of food, so that it relieves the small intestine of much preliminary work. Quantity of Gastric Juice and Other Digestive Fluids. No exact estimates of the quantity of gastric juice, or, in fact, of any of the several digestive fluids, are obtainable, for such estimates vary greatly according to different authorities. An abundant secretion is not nec- essarily an active one in ferment or acid, and the constant reabsorp- tion of the water makes it quite impossible to say how much fluid has FOOD IX THE STOMACH 387 been secreted, for if the digestive juices be drained off and measured, the natural conditions are disturbed. Bile or pancreatic fluid allowed to drain off constantly through a fistula soon becomes altered in qual- ity and weakened in digestive power. Secretion of the Gastric Juice. When food enters the stomach it immediately incites the secretion 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 ex- tent, 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 secretion is also in- fluenced by psychic processes, connected with the appetite. (See Appetite, p. 368.) The gastric juice is secreted more abundantly in response to the chemical stimulus of some substances 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 derange- ment 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 quantity for two or three hours. After this period the secretion gradually diminishes. If the food has not been digested properly within a limit of three and a half hours, it may fail to pass on into the intestine, and while remaining in the stomach it undergoes vari- ous processes of malfermentation which are entirely different from the normal. These processes will be more fully discussed under the headings of the several forms of dyspepsia. Hydrochloric Acid. Hydrochloric acid exists in the human gastric juice in the average proportion of 0.2 per cent. Experimentally it FOOD DIGESTION is found that the best proteolytic digestion results with 0.1 to 0.2 per cent of hydrochloric acid. The acidity is slightly reduced upon a vegetable diet. The acid is secreted during active digestion but not normally at other times. It is often diminished in quantity, and less often it may be abnormally increased. Its action upon proteids is to cause them to swell, become somewhat translucent, and it converts a portion of them into acid albumin. It contributes the necessary acid reaction in which the ferment pepsin causes solution of these and other proteids and converts them into albumoses or proteoses, and lastly peptones. 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 lessens and finally ceases. Roberts furnished the following table illustrating the effect of varying quantities of hydrochloric acid on the speed of peptic di- gestion : Proportion of dry HCl in Time in which digestion the digesting mixture. u~as completed. 0.05 per cent 500 minutes, almost no digestion. 0.08 0.1 0.15 0.2 0.3 0.4 0.6 200 130 115 100 115 160 350 minutes, embarrassed. The acid has an antiseptic influence, preventing the decomposition of food and checking it if already begun. Pepsin. Pepsin is a hydrolytic ferment which is found in the cells of the tubules of the gastric mucous membrane, chiefly near the cardiac portion. According to Chittenden 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 con- vert the propepsin into true pepsin, the active ferment, is hydro- chloric 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-crystallizable, indiffusible substances. 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 1 influence no influence at all, in fact. FOOD IN THE STOMACH 389 Eecently Pawlow has demonstrated that the same gastric ferments have more than one activity, possess both peptic and milk-curdling function, and are activated by a new series of ferments known as " kinates," or " activators." Rennin has been described on p. 83. Albumoses, Peptones. The final product of food digestion as ac- complished by pepsin with the hydrochloric acid of the gastric juice is peptone. Kuhne showed that peptone is seldom, if ever, formed pure in the stomach, but the substance there 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 diffu- sible than peptones. Undoubtedly both peptones and albumoses are formed during digestion, and both may be absorbed from the stomach in small quantity. The albumoses may be separated from peptones by complete pre- cipitation by saturation in aqueous solution with sulphate of ammo- nium. 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 utilized in the nutrition of the body to an even greater degree than the pep- tones of meat. Digestion of Proteids in the Stomach. The various albuminoids are digested best, each with a different degree of acidity, and it is probable that throughout a meal the intensity of reaction of the gas- tric juice varies considerably, becoming stronger as more food is ab- sorbed 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 opportunity for timely digestion. The products of proteid digestion in the stomach have been care- fully anaylzed by Kuhne and Chittenden, and are found to succeed each other in the following order : 1. Albuminoids or proteids. 2. Syntonin or acid albumin. 3. Albumoses or proteoses proto-albumose (protoproteose), hetero- albumose (heteroproteose), deutero-albumose (deuteroproteose). The latter form 4. Peptones. Peptones in the intestine undergo katabolism through action of erepsin, the cleavage taking place in the intestinal mucosa. 390 FOOD DIGESTION Baw meat in the stomach turns gray-brown and swells, the connec- tive tissue is first broken down by gastric juice, then the sarcolemma, and finally the substance between the striae of the muscle fibers. (Compare Eaw Meat, p. 127, and Digestibility of Meats, p. 128.) Vegetable albumin is digested in the stomach in a manner quite similar to the digestion of animal proteid. Gluten and vegetable casein are also dissolved by the gastric juice when strongly acid. Gelatin is one of the substances most easily dissolved in the stom- ach. It is altered by the hydrochloric acid of the gastric juice, so that it no longer can be solidified by cold. It is finally converted into a diffusible substance somewhat resembling peptones, but not identical with them. 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: 1. To mingle the contents of the food thoroughly with the gastric juice. 2. To cause moderate trituration of the particles of food which are made to move in cur- rents. 3. To bring the food in contact successively with different portions of the mucous membrane, and thus to stimulate it and favor absorption. 4. To favor the occasional emptying of a portion of the contents of the stomach into the duodenum, the move- ment 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 also may be stimulated in other ways, which will be described more fully in connection with intestinal peristalsis (see Diarrhoea and Constipation), for it may be said in general that those stimuli which affect 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 abso- lute 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 pre- ponderance of one or other article of food in a mixed diet may affect FOOD IX THE STOMACH 391 somewhat the whole period of digestion. (See Digestibility of Meats, p. 128.) The duration of gastric digestion depends upon: 1. The variety and quantity of food eaten. 2. Its state of subdivision, solubility, complexity, and the process of its cooking. 3. The thoroughness of mastication and rate of deglutition. 4. The activity of the stomach. 5. The interval which has elapsed since the previous meal. 6. The condition 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, neutralizing it or not. 10. The rate of gastric absorp- tion. 11. 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 func- tions, 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 min- utes; that raw oysters require one hour and fifty-five minutes and roasted oysters two 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 important, however, to ascertain, if possible, the approximate time required for gastric diges- tion of certain general classes of food, and the following estimates are as nearly correct as possible in view of the above statements. The average time required for meats cooked by broiling, roasting, or boiling is fully three or three and a half hours for their complete gastric digestion, but much depends upon the ease with which the gastric juice can penetrate their muscle fibers. (The subject of the relative digestibility of various meats is discussed in connection with their nutriment value on page 129.) 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. Eaw 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 392 FOOD DIGESTION 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 between three and three and a half hours, but potatoes, if baked and mealy, may remain only two and a half hours. Eaw vegetables, such as coleslaw or raw cab- bage and lettuce, etc., may remain two and a 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, such as rice, hominy, and also sago, tapioca, etc. should pass from the stomach within two hours. Fats and oils taken alone may remain in the stomach only a few moments before entering the intestine. Sugars may, to some extent at least, be absorbed from the stomach wall in the course of the first hour of digestion. Gastric juice being 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 per- sons, even in health, stomach digestion may be uniformly 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. Coarse food, badly cooked starchy food, excess of fats, tough-fibered meats, unripe fruits or vegetables, all retard digestion, and may prove very irritant. Among articles of diet, substances are sometimes eaten which are purely refuse material, such as the skins of potatoes and of coarse fruits, grape seeds, shells of soft-shell crabs, etc. They may pass on unaltered into the intestine and cause diarrhoea, or may linger for several days and excite reflex irritation. (The temperature of food and drink as affecting gastric digestion is discussed under the heading Temperature and Digestion, p. 374.) Abnormalities of Gastric Digestion. 1 Hypersecretion or increase in quantity of gastric juice gives rise to thirst, sour eructations, and more or less epigastric distress. The secretion may digest pro- teids well, but carbohydrates are ill borne in this condition, which is believed to be caused chiefly by some form of neurosis. An excess of more or less acid gastric juice passes on with the chyme into the small intestine, and causes an acid reaction therein, requiring more of the intestinal digestive fluids bile, pancreatic juice, etc. to neutralize it. The saliva is often increased at the i The clinical examination of the stomach contents is described under sepa- rate heading on p. 572. FOOD IN THE INTESTINE 393 same time, and Eoberts suggests that this may be a provision of Nature to neutralize the acid in the stomach, Hyperacidity or increase in the hydrochloric acid of the gastric juice, does not necessarily imply hypersecretion of juice. Hyperacidity is common, and prone to be present in connection with gastric ulcer and certain forms of chronic dyspepsia. Anacidity or the persistent absence of hydrochloric acid from the gastric secretion, does not indicate the presence of any one disease. It may be absent in nervous dyspepsia without organic lesion, or with carcinoma. Pyrosis, or eructation of gas from the stomach, if it occurs soon after ingestion of food, is usually due to lactic or other organic acid fermentation. Occurring later, during active digestion, it may be due to the same cause or to hyperacidity from excess of hydrochloric acid. When due to lactic acid, the giving of hydrochloric acid stops fur- ther fermentation. Sodium bicarbonate, although it momentarily neutralizes 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 may be checked by alkalies. FOOD IN THE INTESTINE After preliminary maceration under 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 are al- most identical with those found in the stomach, but the chemical com- position of the new digestive juices 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 only partly 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. Proteids which have escaped complete gastric digestion are con- verted successively into (1) alkali albumins, (2) deutero-proteose, (3) antipeptone and amido acids. Those proteids, on the other hand, which the gastric juice has altered into proteoses, albumoses or pep- tones are further converted into antipeptone and amido acids, through action of the trypsin ferment of the pancreatic juice. In this latter form of antipeptones, the proteid foods are chiefly absorbed from the 28 394 FOOD DIGESTION small intestine, not more than about 14 per cent being absorbed from the large intestine. Pancreatic juice is the most active and comprehensive digestive fluid of the body. It is not only stronger than the gastric juice in action upon proteids, being able to form peptones with fewer inter- mediate products, but possesses the distinct advantage that it also digests fats and carbohydrates by a ferment, called steapsin, which acts in either acid or alkaline media. Its amylolytic power is stronger than that of the saliva, for it di- gests the raw starch and cellulose which is eaten in such vegetables as celery, lettuce, or radishes, and in fruits like the apple. It is made active through the agency of entero-kinase, one of the newly discovered activator group of ferments. Trypsin acts best in a medium rendered alkaline by from 0.5 to 1 per cent sodium bicarbonate. It also digests proteids energetically in a neutral medium, but free acid soon destroys it. E. H. Chittenden has shown that combined acids do not necessarily stop trypsin pro- teolysis. The l>ile plays several roles in intestinal digestion, but its chief ac- tion is in aiding the emulsion of fats, described below. It can accom- plish the absorption of fats in the absence of pancreatic juice. When bile is absent the fatty food may decompose in the intestine and de- velop gases and foul odors. Voit says that the white color 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 color. 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. The quantity of bile secreted is increased by a proteid diet, and diminished upon an exclusive fat diet (Uffelmann). Vegetable foods color the bile green ; animal foods make it yellow 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 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. Digestion of Fats. When fat is cooked in food, much 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 lib- FOOD IN THE INTESTINE 395 erates some of the fat globules, which are melted by the natural warmth. If eaten in the form of oil or butter, with starchy or veg- etable food, the fat coats the particles of food in the mouth. Bread thus mingled with butter is less likely to form a large and too tena- cious bolus. In the stomach fat remains unaltered, and when the semifluid chyme begins to flow into the intestine it passes in with it. The con- nective tissue elements of fatty meats, etc., are digested like other proteids. In the intestine fat is subjected to a double process of emulsifica- tion 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 favored by the admixture with bile, which simultaneously occurs in the duodenum. According to Rach- ford, the fat-splitting power of pancreatic juice is more than quad- rupled by the agency of 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 sodium bile salts and liberates their sodium, which unites with a portion of the free fatty acid, forming 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. It is, however, not a necessary part of the theory of digestion of 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 favor the absorption of fats by emulsification. Undigested food reaches the intestines under the following con- ditions : (a) When the food is improper in kind, (&) when too much food is eaten, (c) when gastric digestion is imperfect, (d) when the motility of the stomach is abnormally increased. 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 agglu- tinating, 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 gases 396 FOOD DIGESTION evolved by several different kinds of foods (in which the numbered columns represent separate samples) : GAS. MILK. MEAT. PEAS OR BEANS. 1. 2. 1. 2. 3. 1. 2. 3. CO 2 16.8 43.3 0.9 38.3 9.9 54.2 SG'.I 13.6 3.0 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 19.1 38.4 1.5 49.3 10.6 21.0 4.0 55.9 18.9 H CH 4 N, Test for Intestinal Digestion Max Einhorn has devised a test for intestinal digestion. Small beads are filled with fragments of meat, hot fat which congeals, etc. They are strung together with catgut, placed within a gelatin capsule and swallowed. In from one to two days they appear in the stools and examination of their contents shows whether digestion of the in- gredients has been imperfect. ARTIFICIAL DIGESTION The different ferments which may be used for increasing the ac- tivity of digestion within the body or for partially digesting foods outside of the body are principally diastase, pepsin, and extracts of pancreatic juice, usually called " pancreatin " and which are com- pounds of several substances. Besides these there are several vegeta- ble ferments, such as papain from the American papaw, and ferments present in the juice of the pineapple, the century plant or agave, vari- ous lichens and gums. Predigestion of Starches. There are a variety of ferments and other materials which have the power of converting starch into dex- trin 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 lichenin. The latter is obtainable from lichens, such as Iceland moss. Mucin and certain gums are also amylolytic. Of these the one which is of the most practical service is diastase. 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, for example, as a meal made of malt, which may be added to farinaceous food*, and in the form of malt extracts, and various malted foods (malted milk, etc.) are sold for invalid use or for infant feeding. (See Malt Extracts, p. 189.) ARTIFICIAL DIGESTION 397 Takadidstase is a stable concentrated form of diastase, devised by Dr. Takamene, and said to possess the power of converting 100 times its weight of starch into sugar in ten minutes. The dose is 2 l / 2 grains after eating. In such preparations the predigestion of amylaceous foods is car- ried to the extent of more or less complete conversion of tne 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, but it may act in the stomach for half an hour or more before the reaction of the gastric juice becomes too strongly acid. The presence of alkaline carbonates also retards the action of diastase. In early infancy the amylolytic ferments of the salivary and pancreatic fluids are not well developed and are meager in quantity. If a young child be unable to digest milk for any reason, malted food may temporarily be supplied. In general, the value of malted foods and malt extracts depends upon the predigested starch which they contain, which furnishes nutriment, rather than upon the action of the diastatic ferment within the ali- mentary canal. Ground malt possesses stronger digestive action upon starches than malt extracts. The latter contain the ferment diastase, dextrin, mal- tose, and a portion of the salt and some nitrogenous 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 food, types of which are described upon page 189. Predigestion of Proteids. The digestion of proteids may be ac- complished either within the body by prescribing pepsin and hydro- chloric acid, or without the body by use of the same agents, or, as it is more often done at present, by pancreatinization. Pepsin was the first among the digestive ferments to be isolated and employed for artificial fermentation. This ferment may be prescribed in cases of deficient gastric secre- tion, to be taken with meals, or immediately after, as a powder or in solution. The action of pepsin is confined to the digestion of proteid food, and it requires an acid reaction. It is prepared in a number of forms, 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 manufac- ture and differences in the processes of extracting the ferment ; but all of them have some digestive action, although they are less serviceable than pancreatine. 398 FOOD DIGESTION In regard to the artificial digestion of proteids by pepsin, Chitten- den says : " Peptones are truly formed, and many times in large amount, but never under any circumstances have I been able to effect a complete transformation of any proteid into true peptone by pepsin-proteolysis ; there is always found a certain amount of pro- teoses more or less resistant to the further action of the ferment. Even with a large amount of active ferment, an abundance of free hydrochloric acid, a proper temperature, and a long-continued period of digestion, even five and six days, there is never found a complete conversion into peptone. Indeed, the largest yield of peptone I ever obtained in an artificial digestion is 60 per cent, while the average of a large number of results under most favorable circumstances is somewhat less than 50 per cent/' Hence, artificial pepsin is not a complete digester, as often supposed, and too great reliance should not be placed upon it. Pepsin should never be given in combination with an alkali, such as sodium bicarbonate. 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 importance 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 hydrochloric acid is equally if not more important. 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 per diem, it may excite purgation. Pancreatin is the name given to a complex fermentative body de- rived from extracting the pancreatic gland. It is prepared in the form of a dry powder, and also as a solution or liquor. Its introduc- tion is mainly due to the researches of Dr. William Eoberts, of Lon- don. It is a powerful digestant, more serviceable for the prediges- tion of food than any of the other ferments. It contains both trypsin and amylopsin. It also emulsifies fats. Its action is so powerful and varied, that the majority of the predigested food preparations the so- called " peptonized foods "- are made with pancreatin instead of pep- sin. Pancreatin is sometimes prescribed by physicians for internal use, but unless protected in a keratin or similarly coated capsule the ferments are destroyed by the action of the gastric juice. It is cus- FOOD ABSORPTION 399 ternary to add some alkali, such as sodium bicarbonate, to pancreatin in the process of artificial digestion, although it will also operate on protein in the presence of a neutral reaction. (Typical varieties of pancreatinized proteids are described under Fluid Meat Preparations, p. 135, and Pancreatinized Milk is described on p. 90.) A typical pancreatinized carbohydrate is Benger's Food, which is made with cooked wheat meal and pancreatic extract. The latter partially con- verts 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. Papoid is a vegetable ferment derived from the papaw tree (Carica Papaya) which is thus described by E. H. Chittenden: " Extended study of the reactions of the vegetable ferment papoid shows that it is composed essentially of a mixture of vegetable globu- lin, albumoses and peptone, with which is associated the ferments characteristic of the preparation. " Papoid, so far as my observations extend, has the power of digest- ing to a greater or less extent all forms of proteid or albuminous mat- ter, both coagulated and uncoagulated. Furthermore, papoid is peculiar in that its digestive power is exercised in a neutral, acid, or alkaline medium. " Papoid will act in dilute solutions, but the best and characteristic action is seen only when a small volume of fluid is present. In this respect it differs very markedly from the animal ferment pepsin." After ingesting the ferment it is found in the stools, showing that it is not wholly destroyed in the alimentary canal. The dose is from one to three grains after each meal. Caroid is a vegetable digestive ferment made, like papoid, from the papaw (Carica Papaya) in the form of a dry yellowish powder. According to Chittenden's analysis, it retains a strong proteolytic action in either acid, neutral, or alkaline media. It softens and dis- integrates proteids, coagulates milk like rennet, and is also amylolytic. It is a solvent of gastric mucus. 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 degree from the large intestine. The rectum is capable of absorb- 400 FOOD DIGESTION 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 lym- phatics, 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 ab- sorbed : WEIGHT OF FOOD. Absorbed. Residue. Of 100 parts of solids of mixed diet 89.9 11 1 " albumin 81 2 18 8 fats or carbohydrates 96 9 3 1 ELIMINATION OF FOOD WASTE The data given below, derived from Bauer, exhibit the balance of income of food and output of waste of the body under different con- ditions of rest and activity. Income of Food and Output of Waste (Bauer). Rest and abundant diet. Work and abundant diet. Small, ill-nour- ished man; rest and abundant diet. Income. Meat Grams. 139.7 Grams. 151.3 Grams. 151.1 \Yhite of e fror 41.5 48.1 61 8 Bread . . 450.0 450.0 450.0 Milk 500.0 500.0 509.6 Beer 1,025.0 1,065.9 1,012.7 Suet 70.0 60.2 58.8 Butter 30.0 30.0 30.0 Starch 70.0 70.0 70.0 Sujjar . . . 17.0 17.0 17.0 Salt 4.2 4.9 4.3 Water 286.3 489.1 41.4 Oxygen from air . ... 709 9 1,006 1 600 7 Total 3,342.7 3,892.6 3,007.4 ELIMINATION OF FOOD WASTE Income of Food and Output of Waste (Bauer), Continued. 401 Rest and abundant diet. Work and abundant diet. Small,'ill-nour- ished man; rest and abundant diet. Output. Urine Grams. 1,343 1 Grains. 1 261 1 Grams. 1 069 6 Feces 114 5 129 137 1 Breath 1 739 7 2 545 5 1 597 8 Total 3 197 3 Q QQB; 9 804. ^ Balance -i-l 45 4 ^Q A J-909 Q 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 J, on an average, amount to 20 grams (300 grains) of nitrogen, 310 grams (4,650 grains) of carbon, 30 grams (450 grains) of salts, and 3 litres (about 6 pints) of water. The chief part of the nitrogen (14.5 grams) passes away in the urine in the form of urea and uric acid, and the remainder (5.5 grams) in the feces, perspiration and mucous discharges. Of the carbon, 350 grams are eliminated from the lungs, 45 grams are eliminated by the kidneys, and 15 grams in the other secretions. The water passes off by the skin, lungs, kidneys, and bowels. A man's food must contain the elements necessary to repair these incessant losses. " The 20 grams of nitrogen represent 124 grams of dry proteid mat- terials, and as these contain 64 grams of carbon, on subtracting the 64 grams from the 300 grams necessary for nutrition there remain 236 of carbon to be derived from starch substances or from fats." As much as 0.64 gram (8 grains) of nitrogen may be eliminated per diem through the skin and over 0.5 (7~y 2 grains) is common. (Benedict and Milner.) The Feces and Food Until recently it has been customary to regard the feces as com- posed almost exclusively of the residue of indigestible food, i. e., material which has never been acted upon by digestive fluids or ab- sorbed. Prausnitz, however, has demonstrated that this is inac- curate and that a large proportion of the feces consists of true metabolic products. This fact has been confirmed at the Maine 402 FOOD DIGESTION Agricultural Experiment Station, by Woods and Merrill, and by others. It is thus important to supplement microscopic examination of the feces, with chemical analyses, especially as to the nitrogen out- put. Caspari examined the feces of a vegetarian who partially fasted for 41 days, and found that whereas only 0.86 gram (13 grains) of nitrogen was taken in the food, 1.18 (16 grains) grams was excreted per diem. Among the food substances often found in the stools of healthy FIG. 44. APPARATUS FOB DRYING FECES OVER WATER BATH. a, Section of can; 6, water reservoir; c and d, tubes for preserving constant level of water in bath ; e, e, valves regulating water supply for reservoir ; /, overflow pipe for water bath. (H. W. Wiley, Bull. 84, Part I, Health Bur. of Chem.. U. S. Dept. Agri.) persons who have eaten with imperfect mastication, or have eaten coarse food imperfectly cooked, are: Meat fibers, fragments of con- nective tissue, tendons and cartilage, seeds of many kinds, husks of grain, the rough outer envelope of peas, beans, corn, etc., vegetable fibers (celery, rhubarb, etc.), THE URINE AND FOOD The relation of the composition of the urine to the quality and quantity of the food is highly important. THE URINE AND FOOD 403 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 proteid waste is accumulating faster than it is being removed. The urine excretion is normally increased in quantity after meals, and is diminished during fasting and in sleep. The increased rate of excretion lasts 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 absorp- tion of fluid which occurs with the heavier meal i. e., while solid food is retained in the alimentary canal, it holds back the fluids like a sponge. The maximum rate of secretion is also reached somewhat later after dinner, sometimes not for four hours. After mixed 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, carbonates and sul- phates. In diseases characterized by nitrogenous tissue waste the latter is reduced by giving carbohydrates. In other words, the carbohydrates spare 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, fruits, and vegetables make it more alkaline. Estimation of the nitrogen output in the urine affords a means of determining the rate and extent of proteid katabolism within the body. This at least is the modern method, regarded as the best by most clinicians. It is, however, not infallible, as criticised by F. G. Benedict and E. D. Milner in a record of recent calorimeter, " Experi- ments on the Katabolism of Matter and Energy" (U. S. Dept. of Agriculture, Bull. 175). These authors say: " Thus an excretion of a certain amount of nitrogen in a 24-hour period from 7 A. M. to 7 p. M. is assumed to indicate that during this time there was a katabolism of a corresponding amount of pro- tein. This assumption is open to serious error. In the first place, it is not true that all the nitrogen of food, or indeed of body material, is in the form of protein; yet by assuming that the excretion of nitrogen corresponds to the katabolism of protein, no allowance is made for the possible excretion of nitrogen in the form of creatin, uric acid, hippuric acid, and other nitrogenous bodies, the store of which may be considerably altered in the body as a result of muscular activ- ity, larger quantities of water, or other factors as yet but little under- 404 FOOD DIGESTION stood. Obviously, then, the deduction that any gain of nitrogen by the body is in the form of body protein, and moreover that the quan- tity of nitrogen multiplied by the factor 6.0, or indeed any other con- stant factor, represents the total amount of protein gained, is not necessarily final." The authors quoted assign 33.53 per cent of ni- trogen in the organic ingredients of urine (i. e., in water and ash free urine), as the average of fifty-eight rest and work experiments. In some cases the percentage was slightly higher during rest, in others during work. TOBACCO AND FOOD The effect of tobacco upon digestion is a subject very closely allied to dietetics, but brief mention of it only may 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, the branches of which control so many digestive functions. 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 pro- motes the secretion of gastric juice, and there are those in whom a mild cigar after breakfast promotes peristalsis and the evacuation of the bowels. If there be any tendency to indigestion of starchy or sac- charine foods, it is usually intensified by the use of tobacco in any form. As stated elsewhere, when food cannot be obtained after fatigu- ing exercise or a forced march, the moderate use of tobacco is often found temporarily to replace it, at least to the extent of lessening the feeling of weariness. (See Substitutes for Food, p. 316.) Smoking immediately before meals may destroy the appetite and interfere with the digestion of the food. FOOD EQUIVALENTS FOOD "PORTIONS" It is easy to compute the chemical equivalents of foods as ana- lyzed outside of the body. It is quite another matter to compute them with accuracy within the body. Most writers upon dietetics, however, make some attempt to do this, and the following data may bo accepted as approximately correct: One pound of lean beef equals in nutrient value three eggs or two pints of milk. Boast beef con- FOOD EQUIVALENTS 405 tains about the same protein percentage as an egg, but much more fat. 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." It requires about 27 pounds of milk to make a pound of butter, and about 10 pounds to make a pound of cheese. Von Noorden estimates that as a fat former 7 grams of fat equals 9.3 grams of alcohol. 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 1 10 Eersrs . 2 Lean beef 2 1 Wheat bread 3 13 Potatoes 24 White turnips 54 4 Cow's milk 6 8 Rice 3 7 To obtain the necessary daily supply of carbon : Pounds. Ounces. Bacon 1 Cow's milk 8 Wheat bread 2 8 EwgS . 5 3 Rice 1 11 Turnips 20 Lean beef 6 6 Potatoes 6 6 Food " Portions." For convenience in estimating the caloric value of ordinary meals, food may be measured in " portions " or " help- ings." This method is of course less accurate than weighing, but is much less troublesome, and for practical purposes often suffices. Prof. Irving Fisher gives a convenient list of such portions as follows : "A 'portion' of 100 calories may be ascribed to each lamb chop, or its equivalent in other meat, each (large) egg, each two-thirds of a glass of milk, each ordinary potato, large slice of bread, large banana, ordinary pat or square of butter, shredded wheat biscuit or its 406 FOOD DIGESTION equivalent in other cereal, eight almonds, half-dozen English walnuts, one and one-half lumps of sugar, etc." Most persons have little idea of the weight of the foods they eat, yet the usual dietetic tables of " food values " are based upon gram measurements. Following is a list of approximate weights of foods as used in ordinary " portions " or " helpings " at the table by the average person in health. Of course such an estimate cannot be very accurate, yet it may afford interest. Quantities of Foods for Single Meals. Grams. Ounces (ap- proximate). Calories. Porridge oatmeal wheat, cornmeal, etc 200 6 175 Sugar on porridge 10 1 A 10 Milk ( one tumblerful ) 180 6 200 Bread (three slices) 100 3 200 Butter on bread 15 1 A 120 Steak 50 l2 165 Soup, or meat broth or pur6e 120 4 100-200 Fish 200 6 200 Potatoes 50 1 1 A 60 Green vegetables 100 3 50 Peas, beans or corn 75 2*4 300 Crackers and cheese 75 2 1 A 300 Bread or Indian pudding 100 3 200 Cocoa ( one cup ) 150 PART VI THE GENERAL RELATIONS OP FOOD TO SPECIAL DIS- EASESDISEASES WHICH ARE CAUSED BY DIETETIC ERRORS THE GENERAL RELATIONS OF FOOD TO SPECIAL DISEASES THERE are two methods of adapting diet for the sick: First, by merely reducing the ordinary quantity of food for health; second, by altering the quality of the different classes of foods, and reducing the total quantity simultaneously or not, as required. The former method is simpler and less troublesome, and for some few cases 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 obtained more rapidly by drugs, is yet of immense mo- ment." 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 intensify the proteid waste. In the majority of serious diseases, and especially of acute and febrile diseases, the proteids and fats, aside from those of milk, become less assimilable than the carbohydrates. Beneke attributes this to the fact that carbohydrates are respiratory foods i. e., their consump- tion 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 furnished, inanition ensues, for the tissues begin to consume their own substances. There are, on the other hand, some few diseases, such as tuber- culosis, chlorosis, and secondary anaemia, in which proteids and fats distinctly may be required, and others again may temporarily de- mand a purely nitrogenous diet. 407 408 RELATIONS OF FOOD TO SPECIAL DISEASES 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, p. 343, and Famine, p. 350.) The important relation of food to disease in regard to its quantity and composition, as well as the frequency and method of its ad- ministration, 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," and finally to better analyses of waste products in urine and feces. 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 practiced 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 relation of diet to disease a constantly broadening subject, the importance 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 most 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 minutia? of dietetics are beneath consideration, whereas in reality, like the details of good nursing, they are most important, and a careful attention to them and a close interrogation into the ordinary habits of the patient in regard to his daily regimen is certain of ap- preciation and of beneficial results. RULES FOR PRESCRIBING A DIETARY 409 In all acute febrile diseases and in all so-called " wasting " dis- 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 endeavoring to sup- ply the increased demand for food, every effort should be made to relieve the alimentary canal of unnecessary labor by supplying those preparations which will yield the proper degree of nutrition and force with a minimum expenditure of digestive 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 ailments 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 preparation, diges- tion, absorption, and assimilation, have received full consideration in the preceding pages. In the following chapters the principles briefly outlined above will be considered in detail 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 com- prehensive as possible under the different headings considered, and to emphasize its value by a brief synopsis of the more important symp- toms which arise, and a discussion of the indications to be met by appropriate dieting. GENERAL RULES FOR PRESCRIBING A DIETARY 1. All directions should be made specific, and in writing. 2. The patient's previous experience with the foods recommended should be investigated. Often a supposed difficulty in digestion is due to errors in cooking or in the combination with other foods. 3. The patient should understand that no one food is curative, and in recommending any dietary, however limited, regard should be had, as far as possible, to the patient's taste and to stimulation of the appetite by acceptable flavors. 410 DISEASES CAUSED BY DIETETIC ERRORS 4. In some cases it is preferable to have the patient submit his own diet list for correction. 5. In some cases it is the quantity of a food which requires re- duction rather than its total proscription. 6. The relation of proper intervals of rest, exercise, and work to meals should be prescribed as definitely for those who are not bed- ridden as the diet. 7. The daily quantity of fluid ingested may be as important a consideration as the regulation of food. 8. It is undesirable to prescribe any strict dietary for too long a period, or for an indefinite period, otherwise failure of appetite, inanition, anaemia, and weakness may ensue. If a strict diet is bene- ficial, it will become so within a few days, or, at the most, within from three to six weeks. The question of its continuance or modi- fication should then be relieved, for in some cases positive- harm may result without such revision. 9. In some few cases radical changes in diet should be made gradually at the outset, but in the majority of cases immediate change does no harm, and produces more prompt results. On the other hand, a return to the normal diet should be made by slow grada- tion. 10. It is most undesirable to base any dietary upon too rigid formulae or preconceived " systems." Normal idiosyncrasies in re- gard to digestion and assimilation are numerous, but morbid idiosyn- crasies in disease are far more so; hence, each important case sKould be made the subject of independent study and frequent careful ob- servation of the excreta should be made. 11. In cases requiring protracted dieting the use of the scales in determining the body weight is most important. DISEASES CAUSED BY DIETETIC ERRORS While the course of the majority of all diseases is obviously in- fluenced by the quantity and quality of the food eaten, there are particular diseases which are directly caused by improper diet. This causative relation concerns: I. Insufficient food. II. Overeating and overdrinking. III. Food which is injurious merely 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 containing adulterants. VIII. Food containing microorganisms. IX. Food which is in itself whole- OVEREATING AND OVERDRINKING 411 some, but against which personal idiosyncrasy exists. X. Alcohol as a food and poison. I. Insufficient Food The general effects of starvation are described in the study of the proper quantity of food (p. 343). The effects of the depriva- tion of water are discussed on p. 42. Insufficient food may cause the condition of marasmus, and is an important agent in producing some forms of anaemia. (See Marasmus, and Anaemia.) II. Overeating and Overdrinking Both overeating and overdrinking may be (1) temporary that is, the result of an occasional debauch; or (2) chronic. 1. Temporary overeating may apply to the excessive consumption (a) of a mixed diet, or (&) of particular articles of food. The former (a) causes dyspepsia, or, in extreme cases, acute gastroenteritis and sometimes fecal impaction. The latter (6) may also cause dyspepsia and diarrhoea, or such affections may be produced as glycosuria, from excessive indulgence in candy and sweets, and acne or other skin dis- eases, from the too liberal 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 be 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 un- altered. Second, if the excess be absorbed the blood is overwhelmed, and the excretory organs are overworked. The inability to sing with precision after a too hearty meal is often attributed to temporary congestion of the vocal cords. While this is observed in the thickened speech of alcoholism, the difficulty in singing caused by overeating is mainly due to inability to regulate the actions of the diaphragm and other respiratory muscles when the stomach is greatly distended. 2. Chronic overeating may cause such diseases or diatheses as obesity, gout, lithaemia, oxaluria. and the formation of renal, vesical, and hepatic calculi. It is very certain to cause congestion of the 412 DISEASES CAUSED BY DIETETIC ERRORS liver and the condition known as " biliousness," in which the stom- ach 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 becomes congested, and finally the nervous and muscular systems are 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 that of vegetable food, for the reasons given above, although obesity is more favored by excess in vegetable diet and sweets. Proteid foods, requiring, as they do, a large consumption of oxygen for their complete combustion and re- duction to urea and allied products, produce forms of waste matter 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 proteid katabolism alters the composition of the blood and paves the way for disorders of nutrition, and especially hepatic and renal disease. 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 con- valescents from typhoid fever. Bulimia is a form of perverted sensation, causing inordinate craving for food, which is described on page 370. Overeating, especially among the well-to-do, is the commonest dietetic error, and there are some examples of alcoholism in which the desire for drink is aroused and fostered by previous excesses in eating. Overdrinking, except of alcohol (which is considered under the heading of Alcoholism, p. 438), is not common, and is mainly con- fined to the excessive consumption of tea and coffee, which results in insomnia, cardiac palpitations, and various neuroses (see pages 250, 255). Dilatation of the stomach has been attributed in some cases to overindulgence in mineral waters, but such cases 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 constipa- tion, but for the reason that it is really a solid food that is, it be- comes such immediately on entering the stomach, owing to the forma- tion of tough coagulrip. Excessive consumption of beer may cause dilatation of the stomach. FOOD CONTAINING PARASITES 413 III. Food Which is Injurious Merely 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 marasmus, 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 ; con- stipation, from a too nutritious and concentrated diet; gout from various dietetic errors. IV. Food Containing Parasites or their Embryos Food sometimes serves as the mediuin for the introduction of para- sites or their embryos, such as various species of tapeworm, the roundworm, echinococcus, and trichina. In many cases the source of infection is found in the consumption of raw or imperfectly cooked swine flesh and other meats used in the manufacture of sausages and similar preparations which are care- lessly handled and come in contact with the viscera of the animals in which the parasites or embryos reside in some intermediate stage of development. Another possible source of infection, especially of intestinal worm larvae, is in the excrement of animals, which is per- mitted to pollute raw vegetables growing upon the ground. Manure is freely spread about, and dogs infested with worms, or a casual pig roaming at large in a vegetable garden, may contaminate by their feces such vegetables as grow low upon the ground and are usually eaten raw, as lettuce, celery, etc. Fortunately, this is by no means a common source of infection, but it is well to remember that several cases of infection have been traced definitely to such a source, and this explains the occasional presence of tapeworms in people who never eat raw meats, ham, or sausage, or the flesh .of swine in any form. No domestic animal should ever be allowed to roam in a vegetable garden. Other varieties of parasites or their larvae may oc- casionally be introduced with the food or water, such, for example, as the Dracunculus medinensis, which produces the Guinea- worm disease, or Draconiiasis, the larvas of which are sometimes swallowed in drink- ing water by the natives of parts of Africa and the East Indies. INTESTINAL WOKMS 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 414 DISEASES CAUSED BY DIETETIC ERRORS raw or imperfectly cooked flesh, and if it has been eaten, submitting to a period of starvation for twenty-four hours, in order that the in- testine may be emptied completely 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 de- rived from the lower animals through habits of filth or carelessness in preparing food. Of these two varieties, the commonest in this country is the Tcenia saginata, or mediocanellata; the other, the pork tapeworm, or Tcenia solium, is more often found in Europe and Asia. The larval stages of Tcenia solium and Tcenia echinococcus also are observed in man, and, according to C. W. Stiles, one-half the persons affected by the latter die within five years. H. 0. Sommer has collected 100 cases of echinococcus (hydatid) disease in this country. The larvae are derived from the dog. "With the recent increase in Italian immigra- tion, cases have become not infrequent among these foreigners. They are accompanied by a form of pernicious anaemia. The Tcenia 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 millimeters and a length of seventeen to eighteen millimeters, 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 by the waste matter of the food, and with it are swept out of the gut. The larvas live in swine. 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 a 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 millimeters by ten millimeters. Each mature segment contains an enormous number of ova often several thou- sand and 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 feces. Pis^s oat the ova. and digest them. The ova consists of shells FOOD CONTAINING PAEASITES 415 which contain minute embryos with six hooklets. The embryos make their way into the viscera or muscles of the animal, where they lodge and develop to form the Iarva3 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 ravenous ap- petite, as they interfere with intestinal digestion and absorption. They occasionally excite reflex nervous disturbances. Their presence is made certain by the finding of either the ova or the complete seg- ments in various lengths in the stools. The dibothriocephalus latus is another form of tapeworm, rarely imported into this country by natives of Poland, who ingest the ova which infest certain species of fish, like the sturgeon, which they eat raw. The worm produces a toxin in the intestine, which being absorbed, produces a pernicious anemia with hemorrhages. Treatment. The patient infested by a tapeworm 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 taeniacide the next morning fasting. By this means the intestines become al- most 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 Graham bread and potatoes, for a day or two, and keeps the bowels active, the worm may be dislodged and crowded out. The stools should be floated in water and closely ex- amined for the* head, for if this is not obtained the worm is sure to grow again in three or four months. There are many taeniacides. One of the least disagreeable and most efficient when properly ad- ministered is pumpkin seed. The seeds should be husked, and three ounces may be pounded in a mortar, mascerated, mixed with honey into a paste, and eaten spread like jam upon a thin slice of bread. TRICHINOSIS (Trichiniasis) Etiology. Trichinosis is a parasitic disease produced by the em- bryos 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 most fatal, although I have seen many mild cases of infection. The habitat of the adult worm is the small intestine. The parasites have 416 DISEASES CAUSED BY DIETETIC ERRORS the following appearance: The adult male measures 1.5 millimeter in length; the female is from two to two and a half times as long. The embryo is 0.6 to 1.0 millimeter in length, and when at rest, en- capsulated 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 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). Natural History of the Parasite. After eating flesh which con- tains the embryos the process of digestion dissolves their capsules, and they are liberated, passing into the small intestine, where, with the presence of the favorable condition of warmth, moisture, and food, they reach their adult growth in from three to six days. Eapid 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 mesen- tery, seeking the muscles, which they enter; they then work their way through the connective tissues between the fasciculi or the sepa- rate muscle fibers, and finally enter the latter, where a fortnight's further development produces the complete muscle form. The observations of Askanazy point to the conclusion that the adult female deposits the embryos within the walls of the intestinal villi, not setting them free in the intestine, as originally supposed. From the villi they penetrate the muscles, as above stated. Thornbury reported at the Buffalo Academy of Medicine the results of analysis of 500 cases of infected swine. In these animals the parasite was found in the diaphragm 400 times, in the loin 290 times, and in the neck 170 times: "The point of predilection there- fore appears to be the diaphragm. This is explained by its close proximity to the digestive tract, from which the trichinae primarily 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 fibers, act as foreign bodies or irritant? and excite an interstitial myositis with the forma- tion of a capsule around each embryo. One embryo may be lodged in a single capsule. Once within the muscle fibers, embryos remain FOOD CONTAINING PAKASITES without change until the capsule, the completion of which requires about six weeks, is in some way destroyed. After formation of the capsule a precipitation of lime salts occurs slowly within it for four or five months. The embryos, thus securely protected in a strong envelope, may retain their vitality for many years, but the worms themselves not infrequently become calcified. Other animals besides hogs may harbor this parasite, among which are the rat, cat, mouse, and fox. Prophylaxis. The prevention of trichinosis 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 em- bryos. Pickling or corning meat or smoking ham and bacon are not necessarily fatal to them. " In the usual curing solutions trichina 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. Frequency. Cases of trichinosis are often reported in this coun- try chiefly among the Germans, Poles and other foreigners, whose fondness for raw ham and a variety of sausages is well known. Osier reported the finding of 456 cases, including 122 deaths recorded in the United States. I have seen more than thirty cases. Many per- sons are often simultaneously affected from eating the meat of the same animal, thus giving the disease the character of an epidemic. Symptoms. The symptoms vary with the number of parasites 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 gastrointestinal irrita- tion followed by systemic infection. The patient, three or four days after eating raw pork or ham, suffers from more or less severe ab- dominal cramps, with anorexia, vomiting, and diarrhoea. The latter occasionally becomes severe. General muscular prostration is also present, and there may be chills. In a number of cases the gastro- 29 418 DISEASES CAUSED BY DIETETIC ERRORS intestinal symptoms may not be severe enough to attract attention, and the first symptoms are those of general infection, which develop at the commencement of the second week. There is an increase of temperature, which reaches 103 or 104 F., of an intermittent or remittent character. As soon as the embryos have penetrated the muscles they give rise to local pain and tenderness, accompanied by swelling and tension. These symptoms increase in intensity, and general oedema is apt to follow, which may appear first in the eyelids and elsewhere in the' face. When certain muscles are implicated more serious symptoms may result. *If the diaphragm is invaded or other muscles of respi- ration, there may be extreme or even fatal dyspnoea. If the parasites reach the muscles of the face, jaw, and pharynx, mastication and de- glutition become difficult or impossible. There is more or less itching and burning of the skin and perspiration. Urticaria has been ob- served; anaemia and a marasmic condition eventually develop in a majority of cases, and marked eosinophilia amounting to GO or 40 per cent is observed in the blood in this type as it is in certain other varieties of intestinal parasitic disease. 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 super- venes with delirium. Prognosis. Many cases are fatal. Mild cases may end in recov- ery within a fortnight. In severe cases in which there has been great prostration and emaciation 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 end favorably, probably because some of the parasites are eliminated in this manner. Mortality. The greatest mortality occurs between the fourth and sixth week. The causes of death may be exhaustion from choleraic discharges, dyspnoea, and inability to swallow. Diagnosis. The most valuable features in determining the diag- nosis are the extreme tenderness to pressure of the muscles, their swollen condition, the eosinophilia and the general oedema and dysp- noea. Under cocaine anaesthesia a small piece of muscle may be excised from the arm or thigh for microscopic examination. On searching the stools for the parasites, they may be found with a low-power lens as glistening threads. Treatment. The basis of treatment is at once to evacuate the alimentary canal, providing the fact of eating the infected meat is 419 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 should be purely symptomatic, because there is no known remedy which will reach and destroy the trichinae. Every effort should 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 proteid foods. They may also form in such food outside of the body. This decomposition is the result of the action of certain microorganisms simultaneously first described by Gautier in France and Selim in Bologna. Many microorganisms flourish in beef juice, milk, and various solutions of proteids; and in the alimentary canal, when such food is taken, all the most favorable conditions are pres- ent for the development of toxic substances. When toxigenic germs are ingested, their toxins are readily absorbed by the intestinal mucosa, and it is probable that ptomaine poisoning would occur much oftener were it not that the liver, acting as it does as a " gateway " for the admission of nutritive material for the body, is capable of destroy- ing many poisons which enter it from the intestines through the branches of the portal vein. This fact is confirmed through the effect of putrefying meat, which in very small quantities may not produce severe gastrointestinal symp- toms or constitutional disturbances, and yet if inoculated through a cut in the finger may cause symptoms of a violent septic character. Ptomaines may be developed from a variety of foods, but the prin- cipal 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 contaminated in an}' manner with putrefactive bacteria, it is unfit for food, yet if thoroughly cooked it may not be poisonous necessarily. This is the case with " high " game. The bacilli especially associated with meat poisoning are classed in three groups. (1) The anaerobic bacillus botulinus causing through its toxin the condition of " botulis- mus," derived most often from eating tainted ham, sausage, game, etc., which has not been heated above 70 C., at which temperature 420 DISEASES CAUSED BY DIETETIC ERRORS the organism is killed. (2) Bacilli of the proteus group, putrefac- tive bacteria developing in wholesome food. The bacillus butyricus of van Ermenghem is an especially active agent. (3) Bacilli of the hog cholera group and especially the bacillus enteritidis of Gartner, and a series of paratyphoid bacilli. Cattle and swine slaughtered while having acute interitis constitute sources of infec- tion from these organisms when their flesh is eaten by man, or the milk of such cows is consumed. Dangerous and not infrequently fatal cases of systemic poisoning by meat ptomaines result from eating sausages, pork pie, ham, meat juice, beef, head-cheese, mutton, or veal. Eichard (Diseases of Modern Life) reports a fatal case of poison- ing from eating tainted hare. The victim had had a small ulcer be- neath the tongue for some time, which became gangrenous after eat- ing the meat, and which was the undoubted source of inoculation. Two hundred and ninety-one severe cases of meat poisoning, one of which ended fatally, developed upon the U. S. transport City of Rio de Janeiro, in 1899, while proceeding from Honolulu to Manilla. Putrefactive changes may have already begun in meat although this may not be apparent 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. Tissier and Martally ate rotten meat as an experiment, without disagreeable effect^ but this result was exceptional. Among civilized races, and especially in England, the use of " high " game and mutton is much less in vogue at present than formerly, but the Eskimos and many savage tribes in Africa eat with relish, and digest well, de- composing meat the mere odor of which nauseates 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 Dutrid eggs several months old are enjoyed as a delicacy. Swine flesh rapidly decomposes, when the various processes of drying,, smoking, and salting still leave it unfit for food. On the contrary, drying and smoking affect the superficial layers only, while the inner portion furnishes a culture medium for bacilli. Gluck- mann has reported a case of poisoning by the Bacillus proteus vulgaris from eating " cured " ham. The meat of very young animals should never be eaten, and the sale of young or " bob " veal two or three weeks old is prohibited by law. It is indigestible, innutritions, and readily decomposes. FOOD CONTAINING PTOMAINES 421 Of the dangers of poisoning from canned foods, Wiley says: " 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 this is unlikely in the case of preserved vegetables." Canned beef should be eaten promptly after opening, for it is liable to spoil within a few hours, especially in tropical climates. Severe gastroenteric disorders may arise, from eating such spoiled meat, and epidemics of such poisoning have been observed in a French garrison at Tours (1898), among the British troops in South Africa (1900), and among our own troops in Cuba (1899). In the latter case much public scandal arose in connection with this subject, and from the further fact that manufacturers do not always resist the temptation to can meats of inferior quality, or which may be already partially decomposed, especially when hurried demands for canned goods are made to meet the exigencies of warfare. At the commencement of the Spanish-American "War, in 1898, 7,000,000 pounds of canned roast beef were purchased by the Commissary De- partment for use by the United States soldiers. When very large cans are used for large pieces of meat it may be unevenly cooked and contain decomposing areas in the center. Symptoms. The symptoms of meat poisoning from these various substances are substantially the same in each case, being those of serious gastrointestinal irritation, and in severe cases they are accom- panied by dangerous collapse. The symptoms may follow almost immediately or after an interval of four or five or more hours. The former is much better for the patient, for the sooner vomiting and diarrhcea relieve the alimentary canal of the toxigenic material, the greater the chance of recovery. The symptoms usually begin with suddenness and violence, but they may be preceded by malaise, nau- sea, lassitude, and mild abdominal cramps. The sudden onset is ushered in by rigors 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, es- pecially between the shoulders. Intense thirst has also been ob- served. Soon after one or more of these symptoms have appeared there is violent colicky pain in the bowels, accompanied by retch- ing and vomiting, sometimes hpematemesis, and profuse watery diarrhoea. 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 also occurs independently. The tongue is dry and coated with a thick brownish-yellow fur on the 422 DISEASES CAUSED BY DIETETIC ERRORS dorsum, but the margins are of a bright red with distinct papillae. Fever is usually present, and the temperature may rise to 103.5 3 or 104 F., although the skin may feel cold and moist. The pulse is accelerated and the rate may reach 130 or 140. Occasional symptoms noted are severe cramps in the legs and arms, convulsive twitching of the muscles of the face and hands, stiffness in the joints, and various abnormalities of sensation, such as numbness, tingling, and flashes of heat and cold in the extremities. There may be also drowsiness, photophobia, and, in the worst cases, insomnia, nervous excitement, or mild delirium. If the poison re- sult fatally, prostration increases, the pulse grows rapid and feeble, the watery evacuations are uncontrollable, and rapid emaciation en- sues. The patient becomes 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 as to food content at the time. In mild cases, more or less abdominal pain, vomiting, diarrhoea, and headache, with slight prostration, are the only symptoms. In the grave 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 slowly, after an interval of a day or more the nervous symptoms predominate over those of the gastroenteric system. There are painful muscular cramps, dyspnoea, aphonia, de- lirium, and palpitation. This variety of poisoning is extremely dan- gerous. There is another group of cases, less often seen, in which the symptoms are of gradual onset, longer duration and closely resemble those of paratyphoid fever, including an agglutination reaction, which may be obtained from the blood. In acute botulismus there may be paralysis of the ocular and pharyngeal muscles and other nerve symptoms. Diagnosis. The diagnosis is almost always obtainable from the history of the case in connection with the symptoms above described, 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 p. 430). Game sometimes disagrees on account of the nature of the food upon which the animal has previously been living. This is said to FOOD CONTAINING PTOMAINES 423 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 re- ported 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. POISONING BY MILK, CREAM, ICE CREAM, AND CHEESE Poisoning by milk is less common than from certain varieties of cheese and from cream. When ice cream is made in large quan- tities, the cream is allowed to accumulate, and if a portion of it be- comes infected with pathogenic organisms it will soon convert the whole mass into highly poisonous material. In a small town in Indiana, in 1900, over one hundred persons were seriously poisoned by ice cream from soiled cans. Many other such casualties have been observed of late years. Sixty-seven men, at the San Juan garrison in Porto Eico, were poisoned in 1900 by condensed milk. In the U. S. Surgeon-General's report for 1900, the symptoms are described as follows by Assistant Surgeon George M. "Wells, U. S. A.: " The symptoms were persistent vomiting, severe cramps in the stomach, purging, great prostration, dilatation of the pupils, head- ache, clammy perspiration, chilliness, and great thirst. The stomach in each case was washed out by means of the stomach tube. In some cases the stomach was empty, and nothing but water and mucus came away; in others the washings were tinged with bile, and in others again a moderate amount of food that had been eaten for breakfast was washed out, but in no case was the stomach overdistended or even full. The prostration was so great that some of the patients fainted before reaching the ward. A large number vomited blood in small clots, in most instances mixed with nothing but mucus, showing that the hemorrhage had not taken place until after the contents of the stomach had been expelled. Purging began in most before the vomiting had ceased, and continued for twelve to fifteen hours. At first the stools were natural, soon watery, after- wards becoming mucous and blood tinged. Cramps in the voluntary muscles were mild in some, but other patients writhed in agony, their sufferings being relieved only after thorough kneading and massage by the hospital attendants. Forty were discharged from hospital on the following morning: the others from day to day until the fifth morning, when all were returned to duty." Vaughan and Novy have thoroughly studied the whole subject of 424 DISEASES CAUSED BY DIETETIC ERRORS ptomaine poisoning, and Vaughan isolated from cheese and ice cream a toxin to which he has given the name of " tyrotoxicon," and in Michigan in 1883-'84 nearly three hundred instances of cheese poison- ing were collected by him. The symptoms of tyrotoxicon poisoning are substantially the same with those of meat poisoning, consisting of severe gastrointestinal disturbance with collapse. This toxin 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, p. 620.) 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 intestine is bleached and softened, and possibly deprived here and there of its superficial epithelium." The poison apparently acts somewhat as the toxin of Asiatic chol- era, by absorption from the intestine, and by violently deranging the nervous and vascular systems, producing sudden and extreme loss of fluid from the body through osmosis into the intestine. C. A. Herter has recorded the case of a man who died five days after cheese poisoning, with vomiting prostration and cardiac de- pression. The proteus vulgaris bacillus was obtained from the vomitus. POISONING BY CRUSTACEANS, SHELLFISH AND FISH Poisoning by shellfish and fish results from infection with pto- maines developed by microorganisms, as in cases of milk and meat poisoning. In addition, it should be remembered that there are a number of persons who, from idiosyncrasy, possess extreme sensi- tiveness to the action of shellfish of all kinds. To such persons the eating of clam broth or raw oysters, crabs or lobsters, 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 persons by certain vegetables and fruits, like the strawberry. Among shellfish the mussel furnishes the most violent poison. This substance Briefer has isolated under the name of " mytilotoxin." 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 mussels mav become nontoxic in different waters. GRAIN POISONING 425 Mytilism also occurs from eating clams. The name ichthysmus is applied to fish poisoning in general, osteotoxismus to oyster poison- ing. Three deaths occurred in Dover, Michigan, in 1907, from eat- ing tainted oysters at a banquet. The salted sturgeon which is eaten extensively as a food in parts of Eussia has caused death from its decomposition, and a variety of fishes both in European and Eastern waters are capable of developing very active toxins. In Kussia poison- ing has been produced by eating the ova of the pike, barbel, and perch, and decomposed sturgeon roe (caviare). Portions of the porpoise, eaten in China, may prove poisonous unless thoroughly boiled. The mackerel family has three species which are poisonous, namely the jurel, bonito, and chicaro. They are found in the West Indies. Two species of herring are poisonous; one of them, the meletta, taken along the Atlantic coast from Florida to New York, has caused several fatal cases of poisoning. 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. Symptoms. The symptoms of poisoning from eating fish or mussels in which ptomaines have developed are usually different from those of meat and milk poisoning in that they concern the nervous system with less gastrointestinal disorder. For this reason the poison is much more dangerous, and cases have been known to result fatally two hours after eating mussels. In such instances there may be no nausea, vomiting, or fever, but there is sudden and extreme prostra- tion, with numbness, faintness, coldness of the surface, dilatation of the pupils, double vision, restlessness, nervousness, anxiety, and a feeble and very rapid pulse. In France hard-roed herrings have caused such symptoms. Decomposing oysters and fish also may pro- duce symptoms of gastrointestinal poisoning resembling those from the use of tainted meat. Georgii reported in 1901 the poisoning of 24 men from eating a salad of canned lobster. The symptoms resembled fish poisoning. Urticaria was absent, but in one case there was glycosuria. VI. Other Food Poisons Grain Poisoning, etc. Flesh may become poisonous from the animal having fed upon some noxious substance shortly before it was killed. The flesh of pigs fed on garbage may cause diarrhoea (Parkes). The flavor and digestibility of game, and fish, varies much with the season of the 30 426 DISEASES CAUSED BY DIETETIC ERRORS year and the consequent nature of the food which the animal has had. Oysters are not wholesome food from May to September, or in " the months without an ' R.' ): Cow's milk becomes unhealthful for in- fants when the animal eats improper food (see p. 72), and rare in- stances have been reported of illness of adults caused by eating meat poisoned during the animal's life, as in the case of a sick ox to which a large dose of tartar emetic was given. The animal died, and the meat contained enough of the substance to poison severely those who ate it. Nutmeg poisoning is described on page 292, and poisoning by honey on page 159. GRAIN POISONING Old unripe grain and moldy 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 symptoms are described as " ergotism," and they are commonly divided into two varieties, the gangrenous and the convulsive. The ergot-con- taining flour or meal must have been eaten for a considerable time, as a rule, in order to develop the symptoms. In the gangrenous form of ergotism the early symptoms are refer- able to local vasomotor disturbances, affecting principally the ex- tremities. 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 nervous system is profoundly disturbed. After a period of indefinite symp- toms, such as lassitude, headache, and prickling sensations, spasms of the muscles with contractures begin. The spasms may be inter- mittent, or may assume a tetanic character, lasting sometimes through many days; the arms are strongly flexed and the legs and toes ex- tended. 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 present sometimes. In cases reported 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 for adulteration of flour from various cereals. Several varieties are used which have a similar effoct to ergot in producing a condition of FOOD ADULTEKATION 427 spastic rigidity in the lower extremities. This form of poisoning has been observed in India by James Irving, and by others in Italy and France. It is, however, rare, and little is known as to the exact nature of the lesions. Pellagra. Pellagra is a disease caused by eating fermented un- ripe maize or Indian corn, made into polenta. It is unknown in this country, but prevails in the south of Europe, in portions of Spain, France, and Italy. The first symptoms noticed are those of dyspepsia with more or less nervousness, insomnia, and debility. These symp- toms are followed by an eruption, the pellagral erythema, which de- velops in the spring. After the eruption has lasted for some time, the skin becomes dry and extensive desquamation ensues accompanied by burning pains, or, if neglected, the surface may become infected 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 convalescence, or else, in the worst forms, the nervous system is involved and emaciation, headache, con- vulsions, delirium, and paralysis of the legs may appear. The peas- ants 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 degeneration of various organs (Arnold). The disease 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, may fail to make use of it. VII. Food Adulteration Food adulteration consists of : 1. The addition of deleterious sub- stances. 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 report to the United States Department 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. The extent to which food adulteration prevailed in this country prior to the passage in 1906 of the Pure Foods Act is illustrated in the following table of examinations made in a single State (Ken- tucky) by the Agricultural Experiment Station. Forty per cent of all samples taken were found adulterated. 428 DISEASES CAUSED BY DIETETIC ERRORS Kind and Number of Samples Collected from June 13, 1898, to December 31, 1899. ARTICLES SAMPLED. Not found adulterated. Adulterated. Total. Baking powder 11 45 56 Butter 118 29 147 Canned goods 6 6 Catsups, pickles, etc 12 45 57 Coffee 2 1 3 Cornstarch 1 1 Flour (wheat) 20 20 Jellies, preserves, etc 5 18 23 Lard . 29 11 40 Milk (sweet and buttermilk) 115 35 150 Milk color 1 1 Mince-meat 7 7 Oleomargarine 2 16 18 Olive oil 1 1 2 3 11 14 Sweet cider and grape juice 3 3 Soda ( cooking soda ) 3 3 Sirups, honey, and sugar 41 9 50 Vinegar 67 59 126 Total 437 290 727 At the Connecticut Agricultural Experiment Station, 41^ per cent of 574 samples of spices were found adulterated, and over 25 per cent of coffee samples were adulterated (1899). The object of adulteration of food namely, to cheapen cost of production is attained by (a) increasing the bulk, (&) altering the appearance, and (c) giving false strength. In many States as well as by the Congress, stringent laws have been enacted against all adulteration of food products, beverages, and drugs, but the ingenuity of manufacturers and dealers in evading them neces- sitates the constant vigilance of the experts of health boards. Among the common adulterations may be mentioned the follow- ing: Isinglass adulterated with gelatin; wheat flour with bran or cowpeas ; powdered sugar with barium sulphate ; mustard with flour and turmeric or cornmeal to the extent of 90 per cent; "essences" of peppermint, cinnamon, etc., with poisonous wood alcohol; distilled colored vinegar sold as cider vinegar; pickles adulterated with iron and copper; oleomargarine sold as butter; ground spices are adul- terated with cocoanut shells, rice, flour and ashes; 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 haematoxylon. Candies arc adulterated with terra alba, kaolin, and various pig- FOOD ADULTERATION 429 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 sugar " is also derived from other sugars and artificially flavored 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 frequently but harmlessly with both starch and sugar. Coffee is extensively adulterated with sugar, caramel, pea meal, chicory, and saccharin extracts. Coffee berries are artificially made in molds out of mixtures of starch, molasses, or caramel, chicory, etc. Baking powder is often adulterated. Vaseline is sometimes used to adulterate butter for making pastry and cakes. It does not become rancid, and is therefore difficult of detection. Fortunately, it is not especially harmful. Pigments. Artificial coloring matters are added to foods, both to deceive intentionally and also merely to make different substances, such as preserved green vegetables, candies, or confections, appear more attractive to the eye. Formerly highly injurious copper or zinc salts were much used to color canned peas and beans, and not infrequently they were found in poisonous quantities, but the green plant pigment chlorophyll is so much cheaper, and is so abundant and harmless, that it has superseded them almost entirely since its introduction for this pur- pose in 1877. Ultramarine is much used to color sirups; safranin, eosin, fuch- sine, anilin violet, and many other anilins are employed in the manu- facture of candies, as is also cochineal. So little of these substances is required, however, as seldom to prove injurious. The pigments most in vogue to color butter and cream are tur- meric, saffron, an orange pigment from the stigmas of a flower, sul- phonated anilin yellow, and annotto, a yellow pigment derived from the fruit of a South American tree. Annotto as used by dairymen to color milk and cream is not harmful. To detect it, add a tea- spoonful 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- colored if annotto is present (Leffmann). Certain substances like borax and salicylic acid are added to foods as preservatives, rather than adulterants, although strictly speaking they may be classed as adulterants. They are described on page 314. 430 DISEASES CAUSED BY DIETETIC ERRORS NATIONAL, BUKEAU OF MEDICINES AND FOODS Efforts to establish a National Bureau of Medicines and Foods, designed especially to prevent adulteration and misrepresentation, are being made by the American Medical and the American Pharma- ceutical Associations, and it is to be hoped that Congressional sanction of the plan soon may be obtained. If such a Bureau were established as a part of a broader Department of Public Hygiene, with repre- sentation in the Cabinet, it would contribute towards advancing this country in matters sanitary and hygienic to the standards of some of the continental countries which, in these respects, are at present far in the lead. The importation of adulterated foods from foreign countries is well guarded against by existing customs regulations, but the various State laws against such adulteration are in great need of uniform codification. It is to be expected that the National Pure Foods Act will in future prohibit such adulterations as those herein described. COPPER, TIN, LEAD AND ZINC POISONING These forms of poisoning may arise from the prolonged use of canned meats, vegetables, or fruits. In tin cans lead is derived 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. 312.) Wiley says : " The tin of some cans has been found to contain as high as 12 per cent of lead. ... In addition 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 carefully examine the contents of a can without finding pellets 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." In De Long's Arctic Expedition several men suffered severely 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. 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. FOOD ADULTERATION 431 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. Professor Bettink declares that malic acid is the solvent of the tin when fruits and vegetables are canned. Hehner examined many canned foods, and found tin present, in most of them as a stannous hydrate, which existed in sufficient quan- tity to be fatal when given to guinea pigs. Ungar and Bodlander have reported a number of cases of poison from canned asparagus. Tin present in such food in an insoluble form may be dissolved and absorbed during digestion. Professor Beckurts reported 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 cases of severe poisoning of this nature have come under my per- sonal observation. Violent gastrointestinal symptoms occurred, such as severe vomiting and diarrhoea, accompanied by faintness and vertigo. The symptoms appeared within two or three hours after eating the asparagus from cans which had been kept for a long time. Winckel reported the cases of 270 soldiers who 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 milli- grams per kilogram. Eoos advises the coating of such cans on the inside with insoluble varnish, which prevents the albuminoids 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 com- pletely dissolved in the liquid. A can of beef preserved for eight years, weighing 976 grams, contained 77 milligrams of oxide of tin, and a can of asparagus preserved only four months contained 11 milli- grams 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 prevented 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. One hundred and fifty cases of serious metal- lic 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. 432 DISEASES CAUSED BY DIETETIC ERRORS VIII. Food Containing Microorganisms of Infectious Diseases MILK INFECTIONS 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 furnishes substance out of which to develop powerful toxins for absorption. The following are the chief diseases whose germs are capable of being conveyed by milk: Tuberculosis, typhoid fever, cholera, diph- theria, 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 Milk Infection. This matter is of special importance in regard to the danger of conveying tuberculosis to infants through raw milk. The transmission of tuberculosis to man from cow's milk was first definitely described by Klencke in 1846, who demonstrated tuberculous conditions in 16 children, and in the cows from which the children had been given milk. The identity of bovine and hu- man tuberculosis was universally accepted until 1896, when Theobald Smith pointed out certain biologic and morphologic differences, and Koch in 1901 asserted that bovine tuberculosis is nontransmissible to man, thereby retracting his former views stated in 1882. Koch declared in 1901 that bovine tuberculosis bacilli are more fatal to cattle and other domestic quadrupeds than are the human tubercu- losis bacilli to these animals, and that primary intestinal tubercu- losis is so rare in man as to preclude the possibility of milk infection. This unexpected statement gave a great stimulus to further research and a large number of competent bacteriologists have since demon- strated beyond question that human tuberculosis may be inoculated in cattle, and both human and bovine tuberculosis may be inoculated in monkeys. George M. Kober in 1903 tabulated 86 cases of hu- man tuberculosis derived from cow's milk, and a number of others have been reported by different clinicians. Thus, although the dan- ger of milk infection from cows to man is slight, it is distinctly established (notwithstanding Koch's views), and the morphological differences in ihe two varieties may be offset by degrees of virulence which make the interchange of the disease possible from cattle to man and vice versa. FOOD CONTAINING MICROORGANISMS 433 D. E. Salmon in the U. S. Bureau of Animal Industry, No. 38, 1905, presents the following conclusions based upon extensive re- search in that Department. " 1. Bovine tuberculosis may be communicated to human beings, and in such cases it is usually children that are affected. " 2. Tuberculosis of other domesticated mammals (hogs, sheep, goats, etc.) also may be communicated to human beings. It is usually, but not always, of the bovine type. " 3. The tuberculosis of poultry is not communicable to human beings. " 4. The tuberculosis of human beings, as a rule, is not com- municable to cattle, but is communicable to pigs, dogs, and cats. The bacilli in a certain proportion of the cases of human tubercu- losis, however, are virulent for cattle and produce in these animals a fatal generalized tuberculosis. " 5. Precautions should be taken to protect human beings from animal tuberculosis by a careful inspection of meat-producing animals at the time of slaughter and of the cows from which milk, cream, and butter are produced." Bovine tuberculosis has also been communicated to man by ac- cidental inoculation of wounds, fresh tattoo marks, skin eruptions, etc., to which tuberculous milk had been applied for its supposed healing action. Butchers and veterinarians have been inoculated through accidental wounds while handling the carcasses of tubercu- lous cattle. State boards of health in this country are everywhere endeavoring 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 may occur in infants. H. C. Ernst produced tuberculosis in pigs by feeding them milk from tuberculous cows when the latter had normal udders. Cow's milk may contain tubercle bacilli when the disease is located in the lungs of the animal (Ernst). It is possible that this is the case with the milk of tuberculous 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 recog- nized in time to discontinue breast nursing. It is difficult to arrive at any accurate estimate of the total num- ber of tuberculous cows in the United States, where upwards of 5,000,000 milch cows are maintained, and systems of dairy inspec- tion are of comparatively recent date. It has been estimated in regard to the Eastern States that 15 per 434 DISEASES CAUSED BY DIETETIC ERRORS cent of the common dairy stock was tuberculous, prior to State regula- tion of this matter. Stall-fed animals who live in filthy barns and have little exercise show the largest percentage of infection. In healthy adults the gastric juice may succeed in destroying 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 large dairies the cows should be given the tuberculin test once in six months, and if they respond should be condemned as milk producers. (Conference of State Boards of Health.) The tuberculosis bacillus has-been kept alive in butter 128 days, and animals have been given tuberculosis by experimental inocula- tion with butter made from the milk of tuberculous cows, but there are no authentic instances of the transmission of the disease to man through this agency. The germ has also been found in cheese. 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 im- perfect 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 by 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 com- petent inspection, and not only should the animals be examined be- fore 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. The bacillus is not killed by salting meat nor always by its digestion in the stomach. Moreover, salt meat is not so thoroughly cooked as fresh meat, as a rule. Theobald Smith states that it is doubtful whether the muscles of cat- tle ever contain bacilli, but the latter are liable to be smeared over the meat by the butcher's knife fresh from cutting into a tubercular lymphatic gland or lung. The total number of tuberculous cattle in the United States is not known. The tuberculin tests reveal many herds entirely free from it, whereas others have been found almost universally infected, there being much variation in different parts of the country. The FOOD CONTAINING MICROORGANISMS 435 State Veterinarian of Pennsylvania estimates that 2 per cent of cattle in that State are tuberculous. D. E. Salmon, chief of the Bureau of Animal Industry, reported in 1899: " The beef-cattle which come from large abattoirs are singularly free from tuberculosis, only 1 animal in 1,500 or 2,000 being af- fected to an extent to cause condemnation of any part of the carcass. Dairy cattle may be affected to the extent of 5 to 10 per cent! In Europe, the slaughter-house statistics show from 20 to 50 per cent of all cattle slaughtered to be affected with tuberculosis." " Tuberculosis is one of the principal diseases of swine, but is found only in 1.3 carcasses per 10,000 animals. Among sheep tuberculosis is very rare. The Bureau of Animal Industry in 1905 found only 27 cases among 7,872,671 animals slaughtered. Other Infections. Meat from animals dead of various acute dis- eases is sometimes eaten, and if well cooked may be 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, actino- mycosis, anthrax, septicaemia, swine plague, sheep or cowpox, pneu- monia, trichinosis, or tuberculosis should ever be eaten. TYPHOID AND CHOLKRA INFECTION Typhoid infection is undoubtedly conveyed through milk which has been diluted with water contaminated from a barnyard well or cesspool, or which has been placed in cans rinsed in such water. Hankin describes cases of this fever derived from eating dahi, a curdled milk made by East Indian confectioners. Fraenkel found that typhoid bacilli may live in acid buttermilk. Three hundred and eighty-six cases from milk infection occurred at Stamford, Conn., in May, 1895. Another epidemic occurred in York, Pa., in 1899, and two extensive epidemics were traced to this source in Philadelphia in 1903, the milk dealers having been found to have cases of typhoid fever in their own families. At Coseley, near Birmingham, England, five cases of typhoid fever were traced to infection from ice cream. Infection with Typhoid-fever Germs Through Eating Oysters. An epidemic of typhoid fever occurred at Wesleyan University in the latter part of November, 189-i, which affected only certain stu- dents to the number of thirty, who had attended a college-society supper and eaten raw oysters. A very thorough investigation was made by Prof. H. W. Conn into the etiology of the epidemic, and 436 DISEASES CAUSED BY DIETETIC ERRORS the following account of it was published in the New York Times on November 20, 1894: " The oyster grower, who lives on the shore of the Quinnipiac Eiver, a stream which flows into New Haven harbor, 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 oysters 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." According to Foote, of New Haven, the typhoid bacillus will live eight days in water from an oyster bed. The oyster juice also con- tains the bacilli, and the bacilli injected into oysters live a fortnight in abundance, and a few have survived for thirty days. Two fatal cases of typhoid fever have been reported in Berlin as due to infec- tion from raw oysters. Sir William Broadbent reported in the Brit- ish Medical Journal ten cases which he saw during November and December, 1894, and attributed to the same origin. A number of cases have been traced in Italy and France to the eating of raw oys- ters. Arthur Newsholme, of Brighton, England, studied 181 cases of typhoid fever occurring there from 1893 to 1896, of which nearly one-third were attributed to eating raw shellfish 36 to oysters, and 20 to other varieties. All the shellfish were contaminated by sewage. In 1903 an epidemic of typhoid fever in London was traced to the eating of shellfish contaminated by sewage, and in the same year 18 cases occurring in Glasgow were traced to the eating of cockles sim- ilarly contaminated. Typhoid bacilli were obtained from the cockles and gave the agglutination reaction. Eight other cases developed in one family in a neighboring town, all of whom had eaten the cockles. Oysters may also give rise to severe enteritis, and possibly cholera when derived from infected sewage beds. Frankland, however, has determined that cholera bacilli injected into oysters do not survive more than twenty-four hours. It is possible, although 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 this way. For this reason, as well as from the necessity FOOD CONTAINING MICROORGANISMS 437 of avoiding diarrhoea, it is customary to advise against the use of all raw fruits and vegetables during the prevalence of a cholera epidemic. DIPHTHERIA AND SCARLATINA Diphtheria germs, and those of scarlatina, may 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 the other disease. In Buffalo, N. Y., in 1899, an epidemic of 29 cases of scarlatina was definitely traced to consumption of milk delivered by one milkman, who obtained the sup- ply from a farmer who had the disease at the time of milking. 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 odor, or it may 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 into small flocculi in a bluish whey. Such milk is rendered innocuous by the process of boiling. Children are more likely to contract the disease in this way than are adults, owing to their greater consumption of cow's milk. The gums become swollen, red, and tender, aphthous ulcers appear on the lips and gums, the submaxillary glands and tonsils may be swollen, vesicles and pustules may appear on the tongue, lips, and extremities, and there is moderate fever with vomiting and diarrhoea. The disease promptly subsides on stopping the use of infected milk. FOOD INFECTION THROUGH FLIES The importance of preventing food infection through the agency of common house flies is very great. These insects are admirably adapted to convey infection owing to their large 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 intes- tines, retaining their virulence for 15 days (F. T. Lord), 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 cholera epidemic in Hamburg Dr. Sim- monds found cholera bacilli in the intestines of flies in the post- mortem room where dead cholera patients were examined. The 438 DISEASES CAUSED BY DIETETIC ERRORS bacilli remained one and a half hour in the flies time enough to be carried a long distance or to be widely distributed. Ordinary pus infection is readily carried by flies. In the hastily constructed camps of our troops in the Spanish-American War, and in those of the Brit- ish soldiers in the Boer War, many cases of typhoid fever were traced to infection by flies that had access to the latrines into which typhoid stools had been emptied. When the matter is further investigated it doubtless will be shown that other kinds of infection are often spread by the medium of these vulgar pests. IX. Idiosyncrasies in Regard to Food Idiosyncrasies are found to exist with some persons in regard to special foods which cannot readily be explained. As a rule, if marked, they extend throughout life, but it is not seldom the case that some persons pass through periods when a particular food disagrees with them which they have been able previously to eat with impunity. Some are unable to digest milk and are immediately nauseated or made "bilious" by it. There are several authentic cases on record of persons who cannot eat eggs in any form, even disguised in pud- dings, etc., without distinct toxic symptoms, such as severe headache, nausea, vomiting, urticaria, etc. Some persons cannot eat fat in any form or are unable to digest some one variety of fat, especially hot mutton fat. Some persons acquire a headache whenever they eat butcher's meat in excess. Among the commoner 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. Temporary or functional visual disturbances may be produced by alcohol and by indulgence in " high " game. Casey A. Wood, of Chicago, has reported a case of recurrent amblyopia in a physician of fifty-four years of age, who invariably had an attack resulting from the eating of chocolate in any form. Food idiosyncrasies are not infrequently hereditary, and may affect several members of one family. They are independent of ordinary dyspeptic conditions, and may be present in those whose digestive organs are exceptionally robust. (See Idiosyncrasies and Dyspepsia, p. 569.) X. Alcohol Poisoning Alcoholism Delirium Tremens (Tito position of alcohol as both a food and a stimulant is discussed on pages ?0-x 2(1(1.) ALCOHOLISM 439 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 patient. 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 quart or more of whisky on a wager. Although, according to Professor Atwater, two and a half ounces of alcohol may be oxidized daily by a person in health, the continued use of beverages con- taining this quantity is liable to produce chronic alcoholism in any one. When alcohol is taken to excess as a stimulant its effects are mani- fested by the increased mental excitement of intoxication. There is a period of restlessness, insomnia, loss of memory, and irritability. The stage of insensibility and final stupor or coma develops later after long taking large quantities of alcohol. Patients suffering from alco- holic coma are always in danger of heart failure from paralysis of that organ, which forms no exception to the general rule that overstimula- tion of any muscle produces exhaustion and paresis. When in this condition, however, they are fortunately incapacitated from making any sudden or violent exertion, and in acute cases alcohol is eliminated with considerable rapidity from the various excretory organs of the body. The continued use of strong spirits, as well as their occasional use in excess, almost invariably results in the establishment of chronic gastric catarrh, which is characterized by the formation of thick, ropy mucus, and thickening 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 accumu- lated over night. 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 part before entering the intestine. In addition to the gastric catarrh and inflammation which it may produce, alcohol gradually alters various viscera, causing cirrhosis of the liver, nephritis, chronic endarteritis, etc. Chronic alcoholism is one of the commonest causes of multiple neuritis, chronic pachy- meningitis, and myelitis. The chronic toxic effect of alcohol exerts a 440 DISEASES CAUSED BY DIETETIC ERRORS curiously selective action, for in some patients the liver is affected, in others the kidneys, in still others the peripheral nerves or the brain, etc., while other organs remain comparatively normal. In others many organs are simultaneously affected. 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 ex- cesses may be prolonged for several weeks or months, during which 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 irresistible that if they cannot obtain liquor they have been known to drink cologne or raw alcohol from spirit lamps, or in any form in which they can obtain 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, although the effect on the will power is more disastrous. The dietetic causes of inebriety form an interesting study. The craving for alcohol is undoubtedly fostered in many cases by monot- ony of diet, by ill-prepared food, and the resulting catarrh of the alimentary canal and lack of nutrition. To meet the symptoms of anorexia, heartburn, and weakness from malnutrition " tonics " and " bitters " containing alcohol are resorted to, or alcohol is taken more directly in the form of strong spirits. While this may tem- porarily relieve the craving for stimulation, it often merely makes the digestive disturbance worse and increases the mental depression of " biliousness." In such manner the drink habit is easily estab- lished. Dietetic Treatment of Mild Cases. In the milder cases charac* terized by nervousness, muscular tremors, indigestion, dyspepsia, a foul breath, coated tongue, and urine loaded with urates or crys- talline 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 appro- priate diet is the following from " Foods and Dietaries ": " Breakfast. A lightly boiled egg, a little whitefish or bacon, or a light savory omelet; toast, or bread and butter; a cup of weak tea or of coffee and milk. "Early Dinner, 1 o'clock. A slice of roast mutton, the wing of a chicken or a plain cutlet, with a spoonful of mashed potato and some ALCOHOLISM 441 well-boiled green vegetable. A few spoonfuls of any plain milk or bread pudding, with occasionally some stewed fruit. Beverage. 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, bird, calf's head, or 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 nonstimulating 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 in moderation, for in some of these cases over- indulgence in food excites the craving for alcohol. Dietetic Treatment of Serious Cases. The treatment of the se- verer cases, in which dyspeptic or gastrointestinal symptoms predom- inate, but in which delirium tremens is not necessarily present, is mainly that of gastric catarrh, described on page 587. It must be adapted to the degree of inflammatory or cirrhotic changes which have already taken place in the different organs. The patients usually feel much worse in the mornings, having nausea and vomiting 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 Dieta- ries " is well adapted to this stage of chronic alcoholism : " Breakfast, say 8 o'clock. A cup of weak tea with an egg beaten up in it, and a slice of toast. " Second Meal, 10.30. A cupful of good meat soup, thickened, or a cup of peptonized milk, warmed, with toast or rusk. " Early Dinner, 1 o'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. Half 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. A cup of soup or of mutton broth, as at the forenoon meal. " 9.30 or 10. A cup of peptonized milk and a slice of thin bread and butter. "Food During the Night. In case of wakefulness there should be 442 DISEASES CAUSED BY DIETETIC ERRORS within reach, and arranged so as to be readily wanned, peptonized 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. It is sometimes excited by a temporary debauch, but as a rule this results in a condi- tion of coma rather than maniacal excitement. It is much more char- acteristic of chronic than of acute alcoholism. In the earlier stages the heart action may be apparently vigorous and the pulse full and bounding, but the heart may become suddenly exhausted and cardiac failure is the chief danger. Dietetic Treatment. The indications for dietetic treatment are to make sure that the alimentary canal, which previously has been disordered and congested, if not inflamed by the excessive irritation of strong alcoholic drink, is emptied of any accumulation of abnor- mally fermenting food. In the earlier stages brisk purgation or an evacuant enema should be given. If the stomach is overloaded with improper food, free vomiting should be produced by ipecac or apo- morphine, provided the condition of the patient is sufficiently vigor- ous 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 nec- essary to support the patient's strength with abundant nourishment. The appetite for food is usually entirely absent, being replaced by that for drink, but the patient should be made to take all the nourish- ment possible, and to this end it should be given in fluid form in small frequent doses. The food should be stimulating and predigested. If there is much gastrointestinal irritation, pancreatinized milk, strong meat soups, beef tea with dropped eggs added to it, and egg albumin may all be given. The mucous surface of the stomach has long been 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 relieved by using strong spices or condiments, such as ginger or Cayenne popper, 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 stomach may be actively inflamed. Experience proves that highly seasoned ALCOHOLISM 443 food is sometimes borne with the effect of diminishing the suffering of the patient. This applies, of course, only to robust patients, in whom 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 be limited only by the ability to digest it. 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 be- ing somewhat laxative, diuretic, and mildly stimulating to the stom- ach. 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 liable 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 a little alcohol temporarily to maintain the accustomed influ- ence. The conditions here to be met are very different from those resulting from an ordinary debauch, when liquor should be withheld entirely. PART VII ADMINISTEATION OF FOOD FOE 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 im- possible to formulate rules for feeding which shall cover all cases; but the following suggestions will be found applicable in many in- stances. 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 Illness. In judging of the patient's appetite it should 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 inopportune 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 atten- tion in the curriculum of training schools than is at present bestowed. The nurse has a far better opportunity than the physician to judge of the patient's appetite and study his whims and fancies in 444 METHODS OF FEEDING THE SICK 445 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 humor them and substitute one form of food or drink for another. Directions are apt to be given too in- definitely to the nurse, and with the best intentions, from lack of instruction, she may neutralize the effects of medicines by overfeed- ing, or by irregularities in feeding which disorder digestion and in- terfere with the action of the 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 di- rected 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 forgotten to allow the nurse any latitude or discretion. (See the section on Normal Appetite, p. 368.) Regularity in Feeding-. The nurse should be taught that it is as important to give food as medicines at regularly appointed inter- vals. 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 o-f receiving food may vanish if the meal be 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 hospital 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 in Illness. Among the first considerations is the proper quantity of food to offer the sick, and the extent of its dilu- tion. 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 patient. (See Quan- tity of Food, pp. 327, 328.) 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 first be 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 merely too ill to speak of them, and a refined, fastidious, or nervous patient may have the appetite 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. Uneaten food, dishes after use, or half-emptied cups or glasses should never be left stand- ing 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 be any suspicion of the absolute freshness of milk, eggs, but- ter, or fish, they never should 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 always should be wiped dry on the outside, and pains should be exercised not to spill the contents 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 almost solely of his immediate surroundings. The taking of food is the chief event of the day for him, and too much care cannot be bestowed upon the minutifc of service, while the natural stimuli to appetite such as outdoor air, exercise, and enlivening companionship are necessarily wanting. When patients are able partially to sit up for their meals, the nurse should sec 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 econ- METHODS OF FEEDING THE SICK 447 omy is an important consideration, it is better to cook 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 objections to the use of meat broths. Mutton or chicken broths should be several times skimmed before they are given, and blotting paper or a bit of bread may be passed over the surface to remove the last trace of oily substance. A chafing dish is invaluable for the convalescent from protracted illness. 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. Patients who have been fed long upon fluid foods exclusively, are much encouraged by re- ceiving any solid food. It should be remembered that junket and baked custard are merely solid forms of milk and eggs, which are no less digestible than fluid forms. In other cases, when a patient first is allowed to sit up for half an hour or more beside the bed, it may be well to utilize this time for giving the principal meal of the day, which will be eaten with more relish, and prehaps better digested in consequence. Patients having nausea or other gastric disorder or diarrhoea should be given only little food at a time. Small, oft-repeated feedings are best for them. As a rule, invalids need more salt as a condiment, but less sugar, than those in health. When patients are being fed with fluids, different receptacles 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 appetite. She should never offer nourishment too soon after remov- ing 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 ail- ments while feeding him. by introducing some cheerful or interesting 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 lifting it gently. This affords much better support, and is more comfortable for the patient, for the head 448 ADMINISTRATION OF FOOD FOR THE SICK is less likely to be bent so far forward as to interfere with swallowing. If a tumbler be used, it should always be small and not more than two-thirds filled. An average breakfast-cup holds eight fluid ounces, and an average teacup 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 center 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 fluid is likely 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 tumbler or cup may be raised by the nurse, so that the fluid flows into the mouth without effort. The cup and tube should 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 frequently is more beneficial than food, but there are cases in which a patient awakens to take a sip of milk or a few mouthf uls 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 be kept on hand during the night, for drink- ing a cup of hot bouillon or cocoa will often enable them to fall asleep again for two or three hours. (The use of the vacuum bottle for this purpose is described on p. 356.) Cleansing the Mouth. The patient's comfort is very dependent upon keeping a clean mouth, aa indeed are his appetite and sense of taste. A helpless patient whose mouth and lips are allowed to become parched and sour will refuse nourishment which he might otherwise gladly take. The mouth should be rinsed each time after eating with pure water, hydrogen peroxid (diluted one-half), or diluted Lis- terine (four tablcspoonfuls to the tumbler of water), or boric acid water of saturated strength. It is much easier to keep the mouth clean in tliis manner than to disinfect it after it has been neglected. Milk especially lingers on the mucous surface, and, fermenting there, de- METHODS OF FEEDING THE SICK 449 stroys the sense of taste and develops germs that interfere with diges- tion. When the patient cannot rinse his own mouth, it should be cleansed frequently 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 uncov- ered from the accumulated debris which coats them, and the appetite will be improved. Dry lips should be moistened with vaseline or cold cream, not glycerin. Small pieces of cracked ice may be given. Cracked ice will keep much longer if not allowed to float in melting 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. Disinfection of Utensils. All dishes or utensils used in serving food to patients having syphilis, stomatitis, erysipelas, diphtheria, ty- phoid fever or any other infectious disease likely to be communicated through the mouth or by handling should be boiled for at least half an hour in water containing a few teaspoonfuls of soda. Syphilitic pa- tients, especially, should have their own set of food receptacles, spoons, forks, etc., properly labeled, to prevent any one else from using them. For napkins, cheese cloth or tissue paper should be used, which may be burned. Feeding Unconscious Patients. The feeding of unconscious and delirious patients demands special care and skill. They never should be given anything but fluid nourishment, and this should be fed with a spoon or through a catheter. Sometimes, if the jaw is set, a medi- cine dropper may be utilized. 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 mechan- ism 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 comatose infants or children with tubercular meningitis, apo- plexy, etc., fluid may be poured 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 danger 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. 31 450 ADMINISTRATION OF FOOD FOR THE SICK 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 should be made certain that the patient is breathing easily, and that the tube has not made a false passage into the larynx. Such an acci- dent is very rare. (See also Lavage on p. 598.) Gavage, or feeding with the stomach tube, is described under that heading on p. . Nasal feeding is employed sometimes as 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. 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 protein. 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. Eichards, and those previously given on p. 327. A Common Invalid Ration Too Low in Carbohydrates (Mrs. Richards). Protein. Fat. Carbo- hydrates. Calories. 1 pint of beef juice, containing 7 per cent. . 1 pint of whole milk Grams. 31.5 17.0 Grams. is!6 Grams. 22 129.0 325.5 I quart of flour gruel made with whole milk 18.2 18.2 38 397.9 2 quarts of liquid. Total 66.7 36.2 60 852.4 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 recognized; 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 lie utilixcd for accessory feeding for many cases in which the stomach is able to digest some food, but not in sufficient quantity to prevent emaciation. METHODS OF FEEDING THE SICK 451 Whenever rectal food enemata are employed certain principles should be observed: 1. The rectal surface should be cleansed from all mucus and feces. 2. Irritation of the rectum should be allayed as far as possible. 3. The quantity and quality of food thus administered should be so regulated as to avoid exciting peristalsis, and allow of the complete absorption of one injection before another is given. The minutest details which will secure the best conditions for ab- sorption 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 usually may be overcome. ; CONDITIONS DEMANDING RECTAL FEEDING The conditions which may require the use of rectal feeding are as follows : I. Temporary obstruction to the entrance of food into the alimen- tary canal. Eectal feeding should be resorted to until the obstruc- tion such as the presence of new growths and foreign bodies, or inflammatory conditions with swelling in the mouth, pharynx, or resophagus can be overcome. II. Inability to swallow food from coma, delirium, or paralysis affecting the mechanism of deglutition, as, for example, post-diph- theritic paralysis, and tubercular laryngitis. 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. YI. 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 suffi- cient 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 dur- ing the course of grave fevers in which absorption of even predigested food is largely suspended. X. For the insane who refuse food bv the mouth. 452 ADMINISTRATION OF FOOD FOR THE SICK 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 symptoms are not necessarily present after the first day or two of rectal feeding. In an obstinate case of gastric hemorrhage in which absolutely noth- ing 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, 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 nourishment consisting of from four to six ounces of beef tea and milk, which were given on an average once in three hours, with the occasional 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 craving of hunger and prevent a feeling of faintness ; but these symptoms were overcome by giving four nutrient injections daily in addition to the milk taken by the stomach. Method of Injection. The common practice of giving nutrient enemata by a Davidson syringe with a short hard-rubber or steel nozzle is to be condemned. In the hands of an unskillful nurse, ir- ritation, and sometimes hemorrhages are likely to be produced 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 in, 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 Xo. 14 ordinary "velvet-eyed" flexible catheter may be used, and passed as high as the sigmoid flexure. For adults the tube should be of moderate caliber, not exceeding the diameter of a stout pen handle. The tubo or catheter should be dipped in sweet oil, melted butter, or vaseline; but glycerin should not be used, for it excites peristalsis. METHODS OF FEEDING THE SICK 453 In adults the tube should be passed in from ten to twelve inches, for the injection should be placed up as high as possible. When this is done there is less liability to its rejection, and it is brought in con- tact with an extensive mucous surface. There is a further physiolog- ical or anatomical reason for placing the injection as far 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 farther up is absorbed by veins whose contents reach the liver directly through branches of the vena porta. It is in the liver that the further assimilation of protein takes place in great part, and hence the desira- bility of observing this rule. It was found by Brown, in the case above cited (p. 452), that the patient was able to discriminate between the taste of iodide of potas- sium and ergot, etc., in from a quarter to half an hour after those medicines had been given per 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 absorp- tion 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 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 rectum, the absorbing surface is so limited that compara- tively little material is taken up; but if given in the manner pre- scribed above, much more will be retained. The injection should be applied by means of a small hard-rubber syringe, which need not hold over four ounces. Very little force should be used, and the patient 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 injected, is lia- ble to excite peristalsis and evacuate the bowel. The use in unskill- ful hands of a funnel or fountain, syringe for filling the tube is open 454 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. Quantity. The proper quantity of food for a nutrient enema for an adult is 4 to 6 ounces; for a young child, 2 to 3 ounces, given every four to six hours. Aids to Retention. Upon withdrawing the tube, if there is danger that the injection may 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 " gynecological 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 likely to excite peristalsis than if administered very hot or very cold. Number of Injections. The question of how many injections can be given depends 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. 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 ascertained by the physician, and the most minute direc- tions should be given to the nurse. As 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 administered they soon will be re- tained successfully. But it is only in the most favorable cases that rectal alimentation can be long continued without eventually produc- ing irritation and mucous diarrhoea, and in the majority of instances this is likely to occur after two or three weeks. The enemata should then be discontinued, but may, if necessary, be resumed again after a brief interval. The presence of hemorrhoids is a serious drawback when the use of rectal feeding becomes imperative, and care should be exercised not to irritate or inflame them. In such cases it is necessary to use only METHODS OF FEEDING THE SICK 455 a very soft and flexible catheter, and to allay irritation by the topical application of a 4-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 given advantageously, and a drachm of common salt should be added to each quart. If the rectum is irri- table, and much mucus coats its inner surface, it may be well to add boric acid to the water in saturated solution. The injection washes out any particles of waste matter or remains of a previous nutrient injection, cleanses the mucous surface, stimulates its circulation, and prepares it for better absorption. Opium in Enemata, Opium, while it prevents peristaltic action and favors retention of the enema, may tend also to interfere with its absorption. It is consequently to be avoided, if possible, but when irritation of the rectum exists it becomes necessary to inject a little laudanum. Ordinarily, three to four minims is sufficient, but ten may be required in some cases. This dosage should not be repeated often, and its effect should be watched. 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 giving an enema allays the irritation more completely than if the opium be given with the food. Injected by itself, the quantity of opium is so small that it is not ejected, but is absorbed, and its local action is ob- tained before the larger bulk of fluid enema is injected. In some cases tincture of belladonna (4 or 5 minims) is to be preferred to the opium. Substances Available for Rectal Feeding. Of the different classes of food stuffs, there are some which are absorbed readily by the rec- tum, while others are scarcely taken up at all. To the latter class belong starches and most of the fats. Those starches which are pre- digested 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 absorbed. 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 456 ADMINISTRATION OF FOOD FOR THE SICK 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 benefit 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 should 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 that expressed from chopped meat or egg albumen, but it is much better to pancreatinize it at least partially. Pancreatinized Meat. In preparing proteid food for absorption one of the forms of pancreatic extract or pancreal^n may be used. (See p. 398.) Extracts of pancreas are open to the objection that they do not keep very long, and unless perfectly fresh they are likely to prove 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 in- jected by means of a suitable syringe with a rather wide nozzle. The digestion, which is begun outside, is continued within the rectum. Leube sometimes adds egg albumen to the mixture. Sansom gives the following formula for a meat peptone enema suitable for an infant or young child : Shred raw beef or mutton in bulk about two tablespoonfuls, add an equal bulk of water, and let stand for an hour; then add gradually four tablespoonfuls of milk heated to boiling. When all is well mixed the temperature of the mixture will be about 140 F., then add a teaspoonful of Savory & Moore's or Benger's liquor pancreaticus, and a pinch of bicarbonate of soda. Let the whole remain for six hours, and heat to boiling. Strain through muslin and preserve the liquid, which will suffice for several enemas. Blood. Dried lieef blood has been used as a rectal food, but there is no evidence that it is absorbed. In those cases in which I have employee! it it has usually caked within the rectum and pre- vented the absorption of other materials. Fresh defibrinated blood METHODS OF FEEDING THE SICK 457 has also been used for the same purpose four ounces may be given every six hours but it possesses no advantage over predigested niilk or peptones, and is not to be recommended. Milk. Pancreatinized 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. It may be given alone or with beef juice, beef peptonoids, spirits, etc. From two to four ounces are given at a time, after cleansing the rectum. The simple mucous secretions of the rectum have no proper diges- tive action upon milk, but they may cause putrefaction of its album- inous matter, with formation of tyrosin, indol, etc. Eggs. Huber proved by experiments upon patients in nitrogenous equilibrium that the rectum absorbs 25 to 35 per cent of the nitrogen of raw eggs, 70 per cent from raw eggs with sodium chloride, and 75 per cent from peptonized eggs. The whites of two eggs may be added to peptonized milk, or, better, to peptone solution or one of the meat extracts. Karl E. Ewald, of Berlin, who has experimented exten- sively with rectal alimentation, states that unpeptonized egg albumen is absorbed as promptly from the rectal surface as commercial pep- tone, while peptonized egg albumen is taken up better. The absorp- tion of albumen is furthered by the addition of a little table salt to the injection about fifteen grains to each egg. 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, that it is useless. Grape Sugar. Of the various carbohydrates, it has been proved by Schonborn that a solution of glucose is best absorbed. The solu- tion should not be stronger than 10 per cent in water, and should not be used too often, as it may prove irritant and excite diarrhoea. As much as 95 per cent of such solution may be absorbed. The addition of salt to all forms of food enemata aids in their absorption. Alcohol. The alcohol used for rectal injection should be in the form of good liquor, somewhat diluted. If pure alcohol be 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 absorbed. 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 rum and water given alone, will be retained and completely absorbed, when a larger volume of fluid added to the alcohol will not be re- 32 458 ADMINISTRATION OF FOOD FOR THE SICK tained, and the whole enema will pass out again. When alcohol is given in connection with other rectal foods, it may be unnecessary to dilute it with water, but undiluted whisky may cause precipita- tion in milk. If added too strong it coagulates casein which has not been pancreatinized. Prescriptions for Food Enemata. Ewald recommends the follow- ing : Beat the whites of two eggs with a tablespoonf ul 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 teaspoon- ful of peptone solution. Mix at a temperature below the coagula- tion 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 (p. 456). Eoberts 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. I commonly give 4 ozs. of pancreatinized milk with the white of two eggs and 2 teaspoonfuls of milk sugar, or 2 ozs. each of beef juice and milk pancreatinized. 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 occasionally prove useful, and are certainly convenient, but they possess no real advantage over nutrient enemata, and if rectal feeding is to be long continued, the latter are far more practical. Other Methods of Feeding Inunction Foods. Attempts are made occasionally to put nourish- ment into the body by means of inunction through the skin, and olive oil, cod-liver oil, and cacao butter are rubbed into the integu- ment of the abdomen and thighs. This means is employed naturally only in cases of extreme emaciation from wasting diseases, such as carcinoma, marasmus, 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 shriveled skin, and retaining some of the body heat in case of great feebleness. Intravascular Feeding. In extreme cases of collapse, where death lias seemed imminent, nutrient infusions have sometimes been given directly into the veins. Of late years, however, it has been shown that in collapse from hemorrhage, or from loss of fluid in the evacua- MEDICINES AND FOOD 459 tions of Asiatic cholera and cholera morbus in infants, salt-water in- fusions (a drachm to the pint) answer as well, and have the advan- tage of being much safer and easier of application. Edward M. Hodder, of Montreal, was the first to practice the in- travenous injection of milk in 1850 for collapse from Asiatic cholera, and the late T. G. Thomas, of New York, was among the first to inject warm milk into one of the veins of the arm. In 1878 he reported seven cases, in one of which eight ounces of milk administered in this way saved life. Both goat's and cow's milk have been so used, and the milk must be alkaline. Down reports similar success. Fowler tried intravenous injection of peptone solution, and has given as much as six ounces of a digested beef solution in this man- ner. The peptone does not reappear in the urine, but the casein of milk does, as well as solutions of sugar or albumin when injected into a vein. Some of the fat droplets in milk have greater diameter than the capillaries, which might prove a practical objection to the injection of unskimmed milk. Hypodermic Feeding 1 . Feeding in cases of desperate exhaustion by hypodermic injections of milk and of peptone solutions has been several times attempted, but the results, beyond the use of alcohol by this method, have not proved sufficiently satisfactory to warrant its continuance. Bayle has employed the yolk of egg diluted with an equal weight of normal salt solution (7:1,000), giving three drachms at a dose. Lecithin has similarly been injected. Crede has made use of a preparation, which he calls " Kalodol," containing 95 per cent of soluble meat albumin and 0.2 per cent of salt. He adds 50 grams (l 1 /^ oz.) of a 10-per-cent solution of Kalodol to 500 c. c. (about one pint) of normal salt solution for hypodermoclysis. This preparation is also quickly absorbed from the rectum. Van Leube has injected butter into dogs and showed that the fat was absorbed and consumed. 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 fullness 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 460 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 alter the com- position 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 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 thal- lin sulphate on the proteolytic action of pepsin-hydrochloric acid, and we find that small quantities (0.1 to 0.3 per cent) tend to in- crease the rate of proteolysis, while larger amounts, say one per cent, decidedly check proteolysis. Similarly, among inorganic com- pounds, arsenous oxide, arsenic oxide, boric acid, and potassium bromide in small amounts increase the proteolytic power of pepsin in hydrochloric-acid solution, while larger quantities check the action of the ferment in proportion to the amount added. Again, with the enzyme trypsin, similar results with such salts as potassium cyanide, sodium tetraborate, potassium bromide and iodide may be quoted as showing not only the sensitiveness of the ferment towards foreign substances, but likewise its peculiar behavior viz., stimulation in the presence of larger quantities. Furthermore, we have found that even gases, as carbonic-acid and hydrogen sulphide, exert a marked re- tarding influence on the proteid-digestive power of trypsin." These gases, being a product of intestinal malfermentation, may thus in- terfere 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 promotes the growth of lactic-acid organisms. Ac- cording to Leffmann and Beam, beta-naphthol stops the action of diastase, but not that of the amylolytic ferment of pancreatin, hence it is useful as an intestinal antiseptic without completely 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 upon digestion, but the ef- fect of digestion upon the drugs is imperfectly known. The following rule? are subject to many exceptions, but they may serve a* a general guide : MEDICINES AXD FOOD 461 Rules for Administering Medicines in Relation to Food 1. Alkalies are best given shortly before meals, unless designed to neutralize hypersecretion of hydrochloric acid. 2. Acids should be given within an hour after meals. 3. Bitters should be given before meals. 4. Eemedies such as iron and arsenic, which may prove some- what irritant to mucous membranes, should be given either soon after the regular meals or after taking some simple article of food. Ammonium carbonate and potassium iodide, for example, may be prescribed in milk. 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 stomch, and are less liable to be altered in composition by digestive fluids or to inhibit digestion. 6. Eemedies designed to act in the intestine and not in the stomach, such as salol, creosote, naphthol, etc., should be given at the end of gastric digestion, when the stomach contents are about to pass into the intestine. 7. Saline laxatives always should 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 two hours after meals, or on an empty stomach before retiring. Amylaceous food should be avoided while iodine preparations are being administered, because of the insoluble compound likely to be formed of iodine and starch. Syphilitics should therefore eat meat and green vegetables only, in order to get a maximum effect from the remedy, especially if they are taking very large quantities, such as half an ounce or more a day. Foods and beverages may be used to disguise the taste of dis- agreeable or bitter medicines, especially for children. An unpleas- ant dose may be smuggled down in a teaspoonful of jam or a little molasses. It may be given in solution to adults in coffee. Castor oil is given floating on coffee or beer. Both milk and Vichy partially disguise the taste of potassium iodide. Hot milk is an excellent vehicle for insoluble powders, such as bis- muth, magnesium carbonate, or sulphonal. Many bitter medicines may be followed by a lump of sugar or a strong peppermint lozenge, or the mouth may be rinsed with a little brandy and water. Chocolate is also a good vehicle for the administration of bitter medicines, siich 462 ADMINISTRATION OF FOOD FOR THE SICK as quinine, and it may be employed to emulsify cod-liver oil, or used in the form of lozenges for various medicines. 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: double porcelain-lined saucepan for a hot-water bath; cooking thermometer for use in hot fluids; measur- ing glass to hold six or eight ounces; pancreatin powders; bottle of rennet ferment; sodium bicarbonate, two or three ounces; borax, half a pound (to clean utensils); glass funnel with filter papers; meat- mincing machine. A good chafing-dish and a pair of scales, although not necessary, are desirable. TRAINED PURVEYORS OF FOOD The training of food purveyors for hospitals, asylums, and other institutions has only lately received the attention which it deserves, and hospital managers are awakening to the fact that it is economical to employ a skillful 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, offers a series of three-months' courses for both men and women, which are to cover the following topics: (1) The selection of food material as to quality, food value, and cost. Marketing and buying by sample. (2) Methods of preparation in a large way and by ap- propriate apparatus. (3) The care of food, cold storage, etc. (4) Serving, embodying general dining economy, labor-saving appliances, etc. (5) 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 conditions present, and second, the giving of the food best adapted to relieve the digestive organs of unnecessary labor and to maintain nutrition. In addition, for certain special diseases there are classes of foods which have distinctly curative value for example, the use of fresh fruits and vegetables in scurvy, fats and oils in septicaemia and tuberculosis. Although there is no curative food for fevers, it should be remem- bered that there is nothing so easily assimilated as water, and ad- vantage may be taken of this fact to introduce other foods into the body with it, giving them therefore in fluid form. Pathological Physiology 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 scientific methods. This early treatment culminated in France in the first part of the last century, and was first combatted in England by Graves, who " fed fevers," and his successful followers. It is now known that in fevers by supplying the patient with abund- ant food the tissues of the body are spared from consumption in other words, that the food is burned up or oxidized instead of the proteid matter of the patient's muscles and other structures. The food thus given does not usually add to the substance of the tissues, but saves them from wasting and combustion. For this purpose both carbohydrates in the form of gruels, and especially milk sugar, and simple proteids are best. (See Coleman's experiments in feeding typhoid fever patients, p. 478.) 463 464 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 substituted for them, yet he adds that while " an exclusive use of albuminates is undesirable ... in fever a larger relative pro- portion of albuminates is requisite than in health, and so much larger as the albuminous metabolism is greater." Fever patients commonly excrete 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 previously ab- sorbed 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 an ounce or an ounce and a half 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. In chronic fevers with remissions, like tuber- culosis, 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 proteid 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 large 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 similar processes. A single proteid meal adds protein to the circulation, which in starvation would aid in re- storing equilibrium; but in fever it fails to do so, and the loss con- tinues because the tissue 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 tissues 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 metab- olism 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. DIET IN FEVER IN GENERAL 465 This subject is physiologically very closely related to the paren- chymatous and fatty degenerations of organs which attend many diseases, but it is impossible within the practical limitations of this 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 katabolism does not keep pace with proteid katabolism. 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 liable to remain longer than it should and undergo- mal- fermentation, causing oppression or pain, nausea, and vomiting. Absorption also is reduced in fevers. The stomach may completely give out, and, as Eoberts observes, it becomes merely a conduit, so that the intestine must carry out the work of digestion unaided. Dietetic Treatment. The conditions to be met in the dietetic treatment of fevers 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 katabolism. In all fevers presenting periods of remission it is desirable to supply the greater portion of the food while the temperature is lowest, so that it will be digested and absorbed better, for at this time the tissues appear to recover temporarily 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 be 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 at 2 or 3 hour intervals. To offer solid food in serious fevers is practically to place foreign bodies in the alimentary canal which merely ferment and putrefy, causing dis- comfort with flatus, fetor, and diarrhoea. There are some exceptions to this, notably the fever of phthisis, some forms of protracted sepsis, and acme. 466 DIET IN DISEASE 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 use arises from its coagulating in lumpy masses, which act practically as solid food, but the many means which are at the dis- posal of the physician and nurse make it possible to overcome this difficulty almost completely, and by processes of artificial digestion milk may be given ready for absorption, so that nutrition is rendered quite independent of stomach and intestinal digestion. In the ma- jority of cases, therefore, milk is altogether the best food as a basis. The methods of giving it are described in the section upon Adapta- tion of Milk for the Sick (p. 84), and upon the Treatment of Typhoid Fever (p. 474). Next in importance to milk in the diet of fever are to be men- tioned the various preparations of meat infusions, extracts, ex- pressed juice, powder, broths, etc. (p. 135). These preparations may be made from tender veal, chicken, roast beef, and beefsteak. Clear soups or consommes are nutritious and mildly stimulating in fevers, but if given often or in large quantities patients usually tire of them, and they may be considerably varied by flavoring with vegetable juices and extracts or aromatic herbs, which afford variety, and as a rule do no harm, unless exhausting diarrhoaa be present. Purees may be given, made by thickening clear soup with well- cooked arrowroot, or finely ground rice, or thoroughly baked wheaten flour. Bauer recommends the use of " fruit soups," which are pre- pared by boiling fruit, either fresh or dried, with the addition, if desired, of grape sugar, lemon peel, etc. The mass is then compressed and strained, and the fluid obtained has an agreeable taste and some- what laxative action. In cases of moderate severity and short duration, when the di- gestive organs are not greatly disturbed, it is not necessary to confine 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 pud- ding. Thoroughly boiled oatmeal gruel sustains strength while un- dergoing 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 467 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 flavoring, they may be made very palatable. Thin gruels of rice, oatmeal, or barley, from which all solid matter has been removed very carefully by straining through a cheese-cloth bag, may be salted and flavored with any desirable aromatic, such as cinnamon, clove, nutmeg, lemon or orange peel; grape sugar also may 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 assimilable carbohydrate which, to a great extent, may prevent tissue 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 grams of protein 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, or meat broths, should therefore be added. Eggs may be eaten, but they should never be hard boiled, and in fact they require little cooking. They may be beaten with boiling water and strained and dropped into consomme or light broth or gruel. The yolk and the white may be used either separately or to- gether. 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 gallici, Br. Ph.) is made as follows: The yolks of two eggs with half an ounce of refined sugar are beaten and added t<> four ounces of Cognac and an equal amount of cinnamon water. The brandy in this mixture may be diluted still further 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- bumin is coagulated in a soft gelatinous mass instead of the hard, white, tough coagnlum which is produced by greater heat (see p. 123). Cold meat jellies as well as simple sherry wine and lemon jellies occasionally may be given, but gelatin alone is not particularly nu- tritious, and, in proportion to the bulk occupied by this class of 468 DIET IN DISEASE foods, comparatively little benefit is derived from them, except as "tissue sparers" (see p. 146). Gelatin given with other foods, especially those of proteid com- position, is assimilated much better, and makes a desirable addition 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. Orange juice and pineapple juice may be given. SUMMARY OF FOODS FOR FEVERS. Beef juice, beef tea, beef ex- tracts, solid or fluid (p. 135), peptonoids. mutton, chicken or veal broth, meat soups flavored with vegetable extracts, celery salt, etc., bouillon, consomme. Eggs, raw or soft cooked, dropped into bouillon or soups, beaten with milk. White of egg in sherry or milk. Eggnog, milk, plain, peptonized, diluted with water, lime water, Vichy or carbonic water. Buttermilk, milk punch, koumiss, junket. Cream diluted with one-fourth to one-half Vichy. Milk sugar one or two teaspoonf uls in water or added to milk or other foods. Gruels of rice, farina, cornstarch, arrowroot, banana meal. Gelatine foods, as chicken or beef jelly, blancmange, arrowroot, sherry or port wine, lemon, or coffee jellies. Fruit juices, oranges, pineapple. (See Eeceipts for Invalid Diet.) Beverages in Fevers The Value of Water and Other Beverages. In almost all febrile affections the liberal use of water, or some beverage composed 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 metabolism of the fever is eliminated through the kidneys. A dry mouth destroys ap- petite. (See care of the Mouth, p. 482.) The toxins produced by the action of typhoid-fever germs and other microorganisms are diluted 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 al- though their mouths are dry and parched, and it should always be the duty of the nurse to give water in proper quantity at regular intervals. In long-continued fevers there is a tendency for an in- creased 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 be not taken to replace the fluid in the body the effects DIET IN FEVER IN GENERAL 469 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 of beverages. It is not likely to disorder the stomach, especially if taken in the intervals between the ingestion of food, and to many persons it is very acceptable. It may be made effervescing by the addition of Vichy, carbonic-acid water, soda water, or ten grains of sodium bicarbonate. Orangeade may be made with Vichy. Barley and rice water with a little lemon juice and sugar, or with cinnamon, wine, and sugar, afford refreshing drinks to many per- sons, especially children, but they contain very little nourishment. Either tea or coffee may be allowed once a day in many cases of fever, although 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. Persons who object to the taste of milk may take it if a tablespoonful of good coffee be added to the tumblerful. Strong black coffee, moreover, is useful in con- trolling vomiting, and is mildly stimulating in cases of heart failure. Its diuretic action is also serviceable in fever, but it should be recol- lected that those who are not ordinarily disagreeably affected by the daily use of strong coffee may be made very nervous by small quan- tities given when the system is reduced by the wasting processes of fever. Both tea and coffee should be used, therefore, with discre- tion. 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. 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 (p. 375) that the body temperature can be little if any affected by that of ingested fluids, and it is of 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. SUMMARY OF BEVERAGES FOR FEVERS Water, barley, rice, or oatmeal water, weak tea or coffee, cocoa, lem- onade, orangeade, effervescing waters, as Appollinaris, Vichy, or car- 470 DIET IN DISEASE bonic water, flaxseed tea, cream-of -tartar drink, whey posset. (See Receipts for Invalid Diet.) Alcohol in Fevers The principal theory of the action of alcohol in fevers is that it serves as a readily absorbable food; and it is believed that its com- bustion 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 becomes burned to waste products, but spares the carbon of the wick. The latter is not itself burned up or oxidized until the al- cohol has been exhausted. Another theory of the use of alcohol is that it possesses a positive antipyretic action by which it controls the body temperature by restricting heat production. It is also believed that alcohol in fever acts upon the nervous system, strengthening and sup- porting it, in this manner indirectly controlling the nerve currents which preside over the activity of nutrition, chemical change, and heat production. The subject is a broad one, and obscured by lack of definite knowledge of the chemical processes concerned in heat production. It is possible that alcohol may act simultaneously in all the ways suggested, having the combined effect of a food, a nerve tonic, and an antipyretic. This view has been advocated ably by Dujardin-Beaumetz, who gives an exhaustive discussion on the sub- ject in his work on alimentation in fevers (Du Regime Alimentaire dans les Maladies Febriles, p. 227). Light white wines, diluted claret, and beer are recommended in fevers by many foreign writers on dietetics, especially in those coun- tries in which good water is unobtainable, or in which for other reasons wine drinking is in more common daily use than it is in America, where there is an abundant supply of pure water. In France and Germany light red wine is customarily allowed through- out 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 grams (5-10. ozs) of light red wine or white wine. Beer is much used in Germany for fevers, and contains some nourishment. In this country alcohol is not much relied upon as a food in fevers and its use as a stimulant also is at present very much less than one or two decades ago. In a large general medical hospital service I have known many of the gravest cases do perfectly well without it. If alcohol is not required for its stimulating effect upon the cir- culatory or nervous systems it is better to withhold it, for in continued fevers emergencies may at any time arise in which it is DIET IN FEVER IN GENERAL 471 imperatively demanded to strengthen the failing powers or aid in con- trolling the exhaustion of delirium. Its influence will always be more decided and its action can be much better controlled if spirits have not been given previously, and when it is needed for any such reason it is best to prescribe it in the form of brandy or whisky, or champagne, if vomiting be present. The " typhoid condition " super- vening in the course of any fever often demands it i. e., the condition characterized 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 occasionally 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. 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 bathed constantly in alcohol. To withhold the long-accustomed stimulation in these cases is often to precipitate serious exhaustion, and the problem of properly adapting the quantity of alcohol to the patient's actual needs becomes a serious one to the physician, to which he should give careful study. Caution should be given against the continued use of alcohol by patients in whom there is danger of inducing the alcohol habit. It not infre- quently happens that those who have been addicted to excessive drink- ing, but who have been cured temporarily of the habit, and who have taken no liquor for possibly several years, acquire some acute disease in which there is need of active alcoholic stimulation. In such cases, having in view the possible recovery of the patient, with a renewal of his alcohol habit, this stimulant should be withheld as long as possible while efforts are made to sustain the enfeebled heart power by strychnine, digitalis, or diffusible cardiac stimulants, such as ether, ammonium carbonate, aromatic spirit of ammonia, camphor, etc. From the above account it appears that the question of the use of alcohol in febrile disorders should be considered from two stand- points, embracing, first, its value as a food, with its relation to other foods and to nutrition; second, its value as a stimulant and the ex- tent to which it may be replaced or re-enforced by drugs. The con- tinued use of strong alcohol always disorders digestion, and since the stomach is weakened in fevers, it is more susceptible to such in- fluences, and this is an additional argument for not employing al- 472 DIET IN DISEASE cohol in a routine method, but for saving it for positive indications, such as asthenia. Diet in Convalescence from Fevers Convalescents who have long subsisted solely upon fluids should be careful in resuming solid diet, for the rapidity of recuperation of the digestive organs varies in different persons, and taking meats or other solid foods too soon may cause rise in temperature, quickened 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 amylaceous foods are found to be very acceptable, es- pecially 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. Other ingredients which may be added to thicken soups during convalescence are panada, semolina, tapioca, spaghetti and macaroni. Custard puddings, cooked fruits, wine and beef jellies, blancmange, or baked custard may be allowed. Cornmeal " mush," fine hominy, corn- starch, farina, and boiled rice, with beef juice, may 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 Hand- book of Invalid Cooking: FIRST DAY Breakfast. Poached egg 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 egg. Milk punch. Coffee with sugar and cream. Lunch. One cup of soft custard. Dinner. Cream-of-celery soup. Sippets of toast. A little barley pudding, with cream. Sherry wine if desired. Lunch. Milk punch. Supper. Water toast, buttered. Wine jelly. Tea. THIRD DAY Breakfast . Scrambled egg. Cream toast. Cocoa. Lunch. One cup of hot chicken broth. Dinner. Chicken panada. Bread. Light wine if desired. A little tap- ioca cream. Lunch . An eggnog. tiuppcr. Buttered dry toast. Baked sweet apples and cream. Tea, J)IET IN FEVER IN GENERAL 473 FOURTH DAY Breakfast. An 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. Raw oysters. Banquet crackers. Graham bread, toasted. Wine jelly. Tea. FIFTH DAY Breakfast. An orange. Coffee. Oatmeal, with cream and sugar. Broiled mutton crop. Toast. Lunch. One cup of mulled wine. Dinner. Chicken soup. Bread. Creamed sweetbreads. Duchess potato. Snow pudding. Cocoa. Lunch. Siphon soda, with coffee sirup and cream. Supper. Buttered dry toast. Orange jelly. Sponge cake and cream. Tea. (See Diet in Convalescence from Typhoid Fever, p. 483, which may be taken as a standard for other fevers.) DIET IN INFECTIOUS DISEASES TYPHOID FEVER Careful nursing and diet regulation are the life-saving agents in typhoid fever. In few diseases does a closer relation exist between right feeding and symptoms. Pathological Physiology. 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, six, or more weeks, and the disease may be prolonged further by relapses. There is a convales- cent period of at least two weeks, and often as many months, dur- ing all which time constant care in feeding must be exercised. At any time during the prevalence of the fever 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 Peyer'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, sometimes per- forating through the serous layer. An overloaded intestine or a distended bowel may precipitate perforation at any moment. It is therefore important to select a diet which will leave small residue. Intestinal as well as gastric catarrh is often present, interfering with both digestion and absorption. The prolonged fever is itself a menace to life by the secondary 474 DIET IN INFECTIOUS DISEASES changes which it induces in the alimentary system. The digestive secretions are altered in quality and lessened in quantity. Enfeebled circulation retards or inhibits absorption, and the functional activity of the liver is in abeyance. Toxins in the blood, as well as its elevated temperature, interfere with the normal rate of metabolism throughout the body, and finally the excretory organs are overworked. The typhoid bacillus has curious behavior in relation to certain food materials, e. g., if cultivated in milk it prevents coagulation; whey cultures become distinctly acid, and potato cultures show pe- culiar modes of growth. Dietetic Treatment There are two chief factors which should influence the selection of a proper diet for typhoid fever: 1. 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. Milk Diet. In regard to the first factor the objection that parti- cles of solid food may act as mechanical irritants, erode a partially or recently healed ulcer, and thereby induce relapse, is hardly con- sistent with the modern view of typhoid fever, as a disease in which the germs are by no means confined to the alimentary canal, but are widely distributed throughout the body. Many persons overlook the fact that undiluted milk, on entering the stomach, becomes in great part solid, and large- firm milk curds are likely to prove as irritating to the ulcerating surfaces, or even more so, than are starchy foods. Wlien 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 ele- ments of nutrition, is easily digested, furnishes fluid to the tissues, is a good diuretic, and, if properly administered, in many cases 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 six weeks. Emphasis, however, 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 (notably TYPHOID FEVER 475 Shattuck of Boston, A. K. Barrs of London, and Puritz) have advo- cated 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 by such articles as strained vegetable soups, boiled rice, macaroni, soft-cooked eggs, meat juice and broths, soft cream toast, cream and water, or Vichy, buttermilk, softened soda crackers, blancmange, wine jelly, milk sugar, and ice cream. It is simpler to put all hospital cases of typhoid fever on a routine milk diet, but it is much better to devote a little study to se- suring suitable variation in the food. Every effort should be made to maintain good stomach digestion. If all food is thoroughly disintegrated before it enters the intestine there need be little fear of a mechanical irritation of the ulcerating surfaces. Far more danger may occur through malnutrition of the intestinal wall, which prevents absorption of nutriment. An ac- cumulation of undigested food in the intestine is therefore highly undesirable, and the stools should be examined periodically to see that undigested milk eurds do not appear in them. Milk for some persons in health is really a poison. They completely fail to digest it. It causes constipation with clay-colored 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. Several times I have seen cases of typhoid fever with symptoms which resembled scurvy, with swollen and bleeding gums and great emacia'tion, 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 only food, enough should be given, and the problem of what constitutes enough must be solved in each case separately. Harm is done by overfeeding, which induces indigestion and restlessness, increases the pulse rate, and intensifies the abdominal symptoms such as tympanites, diarrhoea or constipation, hemorrhage, and abdominal pain. Inges- tion is very different from digestion. There are many writers upon dietetics who give a special caution against the practice of overfeeding in cases of typhoid fever on ac- count of the fact that more or less gastric catarrh is usually present 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, under- feeding causes malnutrition, favors the occurrence of complications, slow healing of the ulcers, and prolongs convalescence. 476 DIET IN INFECTIOUS DISEASES For an exclusive milk diet the outside limits lie between one and three quarts per diem, depending somewhat upon the age and size of the individual, but more upon the condition of his digestion. Three quarts furnish about 100 grams (3^ ozs.) of protein and a total energy of 2,000 calories. 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 should be done: (a) The quantity may be reduced; (6) the mode of administration may be changed i. e., the milk must be predigested; (c) other foods may be substituted, either wholly or in part. (a) Quantity. When milk appears to be well digested, but the patient emaciates rapidly early in the disease, he is not receiving nourishment enough, and the quantity should be increased or other food 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 sustain the patient properly. It is best to give as much as can be assimilated thoroughly according to the symptoms above noted. 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 allowance to this figure if severe gastroin- testinal disturbance occurs, or to discontinue temporarily the milk entirely, and give only cracked ice or half-ounce doses of iced cham- pagne, but patients kept too long on so low a diet emaciate, grow feeble to an alarming degree, and require stimulation. (&) Mode of Administration Changed. The milk may be given raw, boiled, diluted with plain water, barley water, lime water, Vichy, Seltzer, or Apollinaris, or pancreatinized according to taste and need. Gelatin, as well as gum arabic, is sometimes added to milk to dilute it and prevent tough curds from forming. The milk should never be skimmed. Its flavor may be disguised 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 he preferred with a cup of cocoa in which the milk predominates. If diarrhoea be present, a milk diet is especially use- ful, and the milk should he boiled. TYPHOID FEVER 477 When vomiting occurs (which is unusual), it is better to use peptonized or pancreatinized milk than soda or lime water, for the latter tend to neutralize the activity of an already enfeebled gastric juice. These fluids may be given either hot or cold, according to fancy. If cold, the nausea is sometimes controlled, but digestion may be somewhat retarded. If the vomiting is obstinate, koumiss, kefir, or zoolak 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. The late A. L. Loomis of New York recommended from four to six quarts of the latter per diem. (c) Substitutes for Milk Diet. When milk is obviously disagree- ing 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 in which, after fair trial, it is 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 used gruel made from banana meal, which is palatable, highly nutritious, and easily digested (see p. 218). Junket and cream are very nutritious and agreeable to the palate. Egg albumen may 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 diges- tion, are improved, and by alternating one or more of these articles with the milk a much larger quantity of nourishment will in the end be taken and absorbed. Typhoid patients may sometimes lose 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. Patients fed in this manner are less likely to become ravenous during convalescence. 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 should be avoided when diarrhoea is present; but in cases where there is a tendency to constipation this may be a decided ad- 478 DIET IN INFECTIOUS DISEASES vantage. Veal and chicken broth are less likely to have a laxative ef- fect 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 flavored with a little celery salt or, if there is no diarrhoea, with a very little tomato juice or other simple vegetable extract. Henry advocates the use of gelatin as an " albumin sparer," al- though it should not be given if diarrhoea is present. As much as a claret-glassful may be given on alternate days, and it may be in the form of simple blancmange or peptonized milk jelly, which is made by adding, while hot, gelatin dissolved in a little water to pep- tonized or pancreatinized milk, and flavoring 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 advantage of giving farinaceous gruels, for, despite the fact that many writers are op- posed to them on the ground that they may excite tympany, I be- lieve them to be at times of great service. Stromeyer feeds his patients largely upon oaten grits boiled for three hours without sugar. Da Costa recommended 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 should not be given too sweet, and cream or lemon juice may be added with milk sugar. It is often advisable to add a tablespoonful of malt extract, or one of the "prepared foods/' such as Mellin's, Horlick's, Eidge's, or malted milk may be given in milk. I have . long used cream and Vichy in proportion of 1 to 4 or 1 to 2 with benefit. Sugar has been employed with benefit as a tissue sparer to pre- vent emaciation in typhoid fever. Klemperer found that the addition of about 50 grams of sugar and 100 c. c. of cream to the liter of milk, decidedly increased its nutritive value. K. E. Ewald gives 100 grams of milk sugar a day to typhoid patients, furnishing 410 calories. "\Varren Coleman and P. A. Shaffer of the Cornell Uni- versity Medical College have recently conducted some valuable ex- periments in ample feeding of typhoid patients with carbohydrates. They argue as follows: Granted that the minimum nutrition re- quirement of a normal man at rest, to prevent starvation, is 2.300 calorics : in fever the increased heat production averages 20 per cent TYPHOID FEVER 479 (Krehl), which added to the 2,300 calories makes more than 2,700 calories, required to maintain nutrition and prevent emaciation in fever. To this Eiibner would add another 10 per cent to make good the stimulation of metabolism caused by food, hence about 3,000 calories represent the daily requirement of the average typhoid fever patient. Carbohydrates are better " tissue sparers " than " heat producers/' and Coleman and Shaffer found that by supplying a maxi- mum of carbohydrate in the form of the easily assimilable milk sugar (400-600 grams per diem) not only saved much loss of tissue nitrogen, but in some cases resulted in actual increase in the patient's weight. Moreover this liberal diet was not, in their experience, attended by any ill effects, beyond occasional slight nausea and vomiting, and when relapses occurred (as they do under any system of treatment) the patients were better fortified to bear them. Dr. Coleman writes me: " The plan of feeding is to give a diet as rich as possible in calories and to furnish as many of the calories as possible in the form of carbohydrates. " The result in sparing body protein is constant and the amount of sparing bears a direct relation to the number of calories which the patients absorb. In some cases when they were taking food repre- senting about 4,000 calories, a plus nitrogen balance was obtained in the urine, even when the afternoon temperature was rising to 103 F. A striking result is the greater relative sparing action of a large excess of calories over the supposed requirement 500 calories added to 3,000 cause the sparing of relatively much more protein than 500 added to 2,000." The maximum diet to be attained to consists of milk iy 2 qt., cream 1 qt., milk sugar y 2 to 1 lb., and 2 to 4 eggs. The milk sugar may be given: 2 ozs. in milk or water, 8 ozs. on milk toast, or by special receipt. (See Eeceipts for Invalid Diet.) The cream is given with Vichy or milk, milk toast, etc. The eggs are beaten in milk or poached or soft cooked. The experiments have demonstrated that it is possible for typhoid fever patients to assimilate much larger fuel values than they are generally supposed to be capable of doing, and to retain their nutrition meanwhile. With the accurate nitrogen determinations in the urine, which con- stituted an important feature of the experiments, they form another argument in favor of a liberal dietary for typhoid fever. 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 480 DIET IN INFECTIOUS DISEASES 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 con- siderably retard their recovery. It is sometimes best to let them sleep for three or four hours without being aroused, for the rest may be of more benefit 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 more than four hours pass while the fever lasts without giving food. If pa- tients 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 drowsiness may indicate a need of more food. The nurse should always furnish a daily record of the total quantity of milk or broths 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 typhoid fever, and cool water should be given in abundance by the nurse, without wait- ing for the patient to ask for it. Water favors nutrition and the elimination of waste. If diarrhoea be absent it is well to acidulate the water with a little dilute phosphoric or hydrochloric acid, ten or fifteen drops to the tumblerful, and flavored with infusion of orange or serpentaria. Hoppe-Seyler washed out the stomach in cases of typhoid fever, and showed that while the temperature remains 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. (For relief of the latter symptom, see care of the mouth, p. 482.) The use of cracked ice in excess augments 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 acceptable, and in the absence of serious complications it can do no harm. AYeak iced tea may prove agreeable. As a rule, it is well to restrict the use of effervescent drinks for the control 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 febrile action through the kidneys. Many clinicians make it a special feature of their treatment to give large draughts of water. Henry advises giving each patient eighty ounces of water (including that TYPHOID FEVER 481 contained in fluid food) per diem, and Meigs has given as much as one hundred and thirty ounces with benefit. 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 is seldom required at all in the first fortnight. Later the heart is enervated and its muscular tissue is enfeebled. In com- plications which threaten life, such as severe hemorrhage, sudden cardiac dilatation, hyperpyrexia (106 F.), pneumonia, or uncon- trollable diarrhoea, alcohol may be required. When the complication is passed the dosage should be reduced gradually. Twenty-five years ago I saw whisky prescribed as a routine practice at the rate of 20 or 24 ounces per diem. At present I rarely use it in typhoid fever, except in small doses, before a cold bath, and usually prefer digitalis when a heart stimulant is needed. Sometimes delirium will disappear when excessive dosage of alcohol is discontinued. By giving small doses of digitalis or strophanthus, or the two in com- bination, by the use of caffeine, camphor, small doses of morphine, and other remedies in combination with alcohol, much less of the latter will be required, and there is less danger of inducing the alcohol habit. Strong whisky often intensifies the stomach catarrh and interferes with the natural absorption of food. One very notice- able 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 should depend upon the circumstances of the case. Brandy and whisky possess the ad- vantage that the dosage is more uniform and the bulk is not great. It is a matter of routine hospital practice, founded largely on eco- nomic reasons, to give whisky or brandy, but in private practice, especially among women, liquors may be distasteful, and equally good results may be obtained by ordering some good strong wine which is more agreeable to the taste, such as one of the Hungarian Avines, 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 convalescence 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 33 482 DIET IN INFECTIOUS DISEASES 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 in the breath, delirium, tongue, and pulse. If the breath has no odor of alcohol an hour or two after the dose has been taken, if delirium 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 an ounce of whisky or three or four of Burgundy a day, for example may sometimes be needed as a tonic, but should be given only with food. The malt extracts (p. 189). are useful in this stage. 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 (Eachford). The starches do not make ptomaines. The typhoid germs certainly thrive upon nitrogenous media, and 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, at least in some part, the symptomatic phenomena of the disease. While there are as yet no remedies 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 the question of asepsis of the ali- mentary canal, which should not be overlooked that is, the pre- vention of those fermentative changes which accompany indigestion in any fever. In typhoid fever the importance of maintaining as nearly as possible the normal digestion and absorption of the food is of special urgency on account of the long duration of the disease. Moreover, it would appear that the overdistention of the intestine by flatus must have a very injurious effect upon the ulcerating surfaces by stretching them. At autopsies upon typhoid patients ulcers are often seen which may be torn easily by slight distention, and the prognosis of typhoid fever is more grave whenever extreme and ob- stinate intestinal flatulency appears. Care of the Mouth. The mouth should be washed frequently at regular intervals, and always after taking a glass of milk, for noth- ing causes coating of the tongue more than a milk diet, or forms a better field for the development of fermentation bacteria, which are constantly being carried down to the stomach to excite indigestion and flatulency there. Listerine and hydrogen peroxid diluted make most satisfactory and cleansing mouth washes. A whalebone bent TYPHOID FEVER 483 in a loop forms a good " tongue scraper," and cleans its surface thor- oughly. If patients are too feeble to rinse the mouth, the nurse should swab it out for them with a bit of cotton moistened with an antiseptic. 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 pa- tient. 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 much moisture is absorbed by the mucous membrane. The proper care of the mouth will lessen the liability to parotitis and catarrh of the middle ear. The Stomach. The dangers of overfeeding with milk have been considered upon page 475. Milk disagrees with many patients sooner or later, and the fermentation processes of which it is capable pro- duce large quantities of gas and sometimes elevation of temperature. Small doses of salicin or cerium oxalate with each tumbler of milk may prevent dyspepsia, and the milk, if pasteurized, may be re- tained and digested where vomiting has been extreme. If there is the least indication of ordinary milk disagreeing, it should be changed at once for some other form pancreatinized, diluted, or boiled. With a clean tongue, and with sterilized milk in the stomach, much may be done to favor the further digestion of milk in the intestine. The Intestine. Many typhoid patients are constipated by an ex- clusive milk diet. Constipation favors abnormal fermentation, and begets the flatulency which is so injurious. Such patients should not, as a rule, be allowed to go more than twenty-four hours without obtaining a movement with an enema. The judicious daily use of rec- tal enemata does not excite intestinal hemorrhage, and excessive consti- pation provokes meteorism, stretches the thin ulcerating surfaces to the point of rupture, and tends to keep the temperature elevated. If re- lapses are due to reinfection or simple septic absorption through ulcer- ating intestinal surfaces, there is all the more reason for the prevention of accumulation of food waste in the intestine. Convalescence As the fever subsides, it becomes an important question how soon to permit a return to solid food. Eelapses may be induced by indis- cretion 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 484 DIET IN INFECTIOUS DISEASES 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 typhoid- fever patients is difficult to manage, as a bread riot is constantly menaced. Ill-advised but sympathetic friends attempt to smuggle in all manner of forbidden fruits, and the patient just arrived at the hungry stage is tempted to steal solid food from his more advanced neighbor. In the milder cases it is undoubtedly both safe and wise to allow a strengthening diet at an early date, and it may prolong convalescence to forbid it. Light farinaceous diet tapioca, rice, vermicelli, cream toast, a cracker soaked in cream, etc. may be given with im- punity in cases which have run a mild course as soon as the tempera- ture remains normal during the greater part of the day. 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 intes- tinal injury. A better guide for feeding than the temperature alone, is the pres- ence of these conditions: a clean tongue, a soft abdomen, normal stools, a good pulse rate, a good appetite, and a brightening facial expression and sensorium. In such cases I am accustomed to begin the use of semisolid feeding several days before the temperature is absolutely normal and have seen no harm result. The following is a list of foods suitable for the different days of convalescence, commencing a day or two after the disappearance of all fever. Milk should be given in lessening quantity until gradually entirely replaced by solid food. CONVALESCENT TYPHOID FEVEE DIET First Day. Chicken broth thickened with thoroughly boiled rice. Milk toast or cream toast once only during the day. Beef juice, orange juice, weak tea, coffee, or cocoa. Second Day. Junket, mutton broth, and bread crumbs. Cocoa. Milk toast. A piece of tender steak may be chewed but not swal- lowed. One of the prepared farinaceous foods, such as Mellin's or Horlirk's, may be given with a cup of hot milk. 77? inl Day. A small scraped-beef sandwich at noon. A soft- cookod e<: thus may be pro- moted, and the poison which occasions the constitutional symptoms of the disease 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 im- perfectly aerated blood. In such instances the addition of large 524 DIET IN DISEASES OF RESPIRATORY SYSTEM quantities of fluid to the circulation, 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 very tenacious. The diet should be fluid until defervescence has occurred, with a normal temperature and commencing disappearance of the exudation in fact, it is well to prolong the fluid diet for three or four days after the temperature has become normal. 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. Tympanites is a most undesirable symptom on account of the increased difficulty in breathing which it causes. When present it is best to withhold milk temporarily (as in tympanites with typhoid fever, p. 477) and rely upon meat juice, broths, peptonoids and eggs. During the entire period of convalescence the diet should be very nourishing and of easy digestion; milk may still be given, with other food, and after slowly returning to the regulation three meals a day (see Convalescent Diet). Very feeble patients do well to take milk punch, or eggnog, or a glass of wine and a biscuit three or four times a day in the intervals between meals. In alcoholic subjects who have been drinking up to the time of the onset of the disease it may be indispensable to continue the use of alcohol, for the sudden withdrawal of its stimulating effect on the organism may give rise to rapid collapse. In aged and con- stitutionally weak persons it is also often indicated, but the majority of patients if given abundant fresh air, are better without it. The custom of prescribing other forms of cardiac stimulants, such as digitalis, strychnine, strophanthus, makes the employment of ex- cessive doses of alcohol unnecessary. It should be remembered that it is undesirable to produce toxic symptoms of alcoholism in pneu- monia 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 odor 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. For several years I have treated the majority of my pneumonia cases without any alcohol whatever. BRONCHO-PNEUMONIA PLEURISY BRONCHO-PNEUMONIA Symptoms. Broncho-pneumonia is common at the extremes of age, in the very old and very young. The mortality is high in chil- dren under two years of age. It is the sequel to many of the acute diseases of childhood, and also is produced by aspiration of particles of food or fluid which are drawn through the larynx to the bronchi by inhalation during the act of swallowing, especially during de- lirium, and when the mouth is dry and foul. The latter variety, known as " aspiration pneumonia," may 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 normal sensitiveness of the larynx and the reflex action of the epiglottis and vocal cords, such as profound uraemia or apoplectic or alcoholic coma, and post-diphtheritic or laryngeal paralysis. A few cases have been produced by carelessness in passing an cesophageal 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 feeding. Stimulation may be required early in considerable quantity. 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. When disease occurs 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 predigested 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. For adults the diet should be the same as in Pneumonia (p. 523). 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 pleural sac. A diet is therefore advised which shall consist of nutri- tious solids with a minimum amount of fluid, in order that the 526 DIET IN DISEASES OF RESPIRATORY SYSTEM blood may become more dense and that favorable osmosis may take place from the pleuritic cavity into the blood vessels; at the same time free action of the kidneys should be promoted. To still further favor the absorption of fluid, the " salt free " diet may be tried, which is described on page 556. 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 exudate 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 pa- tient. The treatment is continued for a week or more after the exudation has been absorbed, and return to a solid diet should 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. If the pleuritic exudate accumulates in sufficient quantity to severely embarrass respiration or the action of the heart, it is so easy absolutely to 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 satisfactory. Patients who are fairly robust will naturally endure privation of food and drink better than the feeble and anaemic. A majority of cases of pleurisy are of tubercular origin, and the dietetic treatment of incipient cases of tuberculosis is applicable (see p. 511). EMPYEMA The dietetic treatment of empyema is based upon the need for nutrition to supply the drain on the system of the constant excre- tion of pus, and fatty food, such as butter, cod-liver oil, and cream. DIET IN DISEASES OF THE CIRCULATORY SYSTEM 527 should therefore fill a large portion of the dietary. The general supporting treatment prescribed for the early stages of pulmonary tuberculosis (p. 511) and septicaemia (p. 502) is recommended. DIET IX DISEASES OF THE CIRCULATOKY SYSTEM AND BLOOD. 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 ob- served in any case when particular symptoms arise. The dietetics of cardiac diseases may, accordingly, conveniently be 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. The heart may be regarded as 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- sistance. 2. The balance of blood pressure in the vessels is usually disturbed and the rate of blood flow 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 leakage of serum in various places, producing dropsies or general anasarca. Or these conditions may result from a diminu- tion in the vitality of the peripheral blood vessels or change 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 blood and lymphatic cir- culation i. e., upon the rapidity of renewal of the layer of blood in the capillaries of the absorbing 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 or lymphatic system promptly checks absorption. Moreover, the reabsorption of transuded serum depends upon reversal of the conditions which originally caused it. 5. The elimination of waste and the various processes of secretion depend upon almost identical physical or physiological conditions 528 DIET IN DISEASES OF THE CIRCULATORY SYSTEM with absorption, and while not due merely to filtration, are never- theless controlled promptly by alterations in vascular pressure and the velocity of the blood-current. Bearing in mind these elementary principles, the first question which arises in the dietetic treatment of advanced cardiac disease concerns the administration of fluids. Fluids. An additional pint of fluid beyond the needs of the sys- tem may be sufficient to overtax the heart, alter the balance of blood pressure, disturb a temporary compensation, and precipitate anasarca, renal congestion, pulmonary oedema, or other symptoms. 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 desirable. 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 by the com- parison 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 presence of oedema. Each case must be studied independ- ently and variations in the quality of the pulse and of arterial pressure should be regulated as far as possible, by observing the effect of the ingestion of fluids, and comparing the output in the urine. 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 appear is great. The forms of valvular disease which are most likely to result in disturbances of digestion are those in which obstructed venous circulation results in local engorgement of the abdominal viscera, producing nausea, vomiting, and great distaste for food. Constipa- tion and more or less chronic gastric and intestinal catarrh may be among the symptoms. The hypostatic congestion of the liver re- tards the activity of that organ, and the ingredients of the food which are brought to it by the portal system are no longer properly elaborated, so that general nutrition and assimilation suffer in con- sequence. A depleting diet is, therefore, sometimes to be recom- mended, and concentrated food is required to prevent overburdening the circulation. If gastric catarrh necessitates the use of fluid food, such as milk and soups or broths, the quantity of beverages taken in addition si ion Id bo restricted considerably. When acute attacks of indigestion supervene in the course of chronic valvular disease, the DIET IN DISEASES OF THE CIRCULATORY SYSTEM 529 bowels should be kept thoroughly open, and a diet of milk, beaten eggs, and broths, taken once in three hours, should be prescribed for a few days, after which boiled fish, broiled chicken, scraped beef, beef- steak, or rare roast beef may be added. Fats, farinaceous foods, and sugars should not be allowed, owing to their tendency to pro- duce flatulency and intensify existing symptoms. The use of alco- holic stimulation may at times become necessary, and whisky diluted in some non-effervescing water is perhaps the best. Beer should be avoided particularly, 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 be- come permanent. 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, and especially should not drink too much fluid at once. Fluid quickly taken into an empty stomach is promptly absorbed, whereas the same quantity sipped slowly may not overtax the heart. It is better to take four or five meals a day, if necessary, and eat only small quantities. A large meal always distends the stomach considerably for several hours, causing this organ to crowd against 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 degree of displacement, and it is indirectly affected by the greater difficulty of breathing, as well as by reflex irritation from the dis- ordered stomach. All food which is liable to ferment in the stomach, such as sugar and indigestible starches and fats, should be avoided. Gastric catarrh is readily initiated or aggravated by coarse or fer- menting 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 to- bacco should be prohibited, and tea and coffee, if permissible, are to be taken only in very dilute form. The tendency to constipa- tion may be overcome by attention to diet, and a moderate portion of fruit, such as baked or stewed apples, stewed prunes, stewed peaches, pineapple juice, oranges or grape fruit, may be allowed be- tween meals. When the terminal stage of valvular heart disease results in drop- sies or general anasarca, the salt-free diet recommended for pleurisy (p. 525) has sometimes proved beneficial. 530 DIET IN DISEASES OF THE CIRCULATORY SYSTEM CARDIAC VALVULAR DISEASE IN CHILDREN Children who have chronic valvular disease or enlargement of the heart, but who are not confined strictly to bed, should be supervised closely in regard to their habits of eating. They should eat slowly and moderately, and have their meals at regular intervals, taking the prin- cipal meal at noon, and a light supper two hours before bedtime. In general, animal food is better for them than vegetable, but they may eat the lighter fresh vegetables, such as spinach, tomatoes, string beans, or stewed celery in season, and sometimes a little roast or mashed potato. Eice and macaroni may be given. Bread should be eaten only stale 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 harm- ful. In acute endocarditis it is very important to avoid all food likely to cause dyspepsia. Eaw eggs with broths, and chiefly milk and custards should be prescribed, and if the stomach is weak and irritable, a part of the nutriment may be given per rectum (p. 455). THE SENILE HEART In persons past middle life the heart may become enfeebled from a variety of causes independent of inflammatory conditions or valv- ular lesions. Fatty degeneration is a common cause of such weak- ness, and in other cases the heart 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 fibrosis or 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 maintenance 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 malfermentation, organic acids, accumulated undigested food, or THE SENILE HEART 531 gaseous distentlon, may affect the heart through reflex action. Me- chanically, too, a stomach distended by gas presses upon and irritates the heart. Balfour (The Senile Heart) says: "If the heart is weak the discomfort induced by such irregularities is after mid- dle life more apt to be felt in connection with that organ than in the stomach itself." The results are intermission in the pulse rate, unevenness in force and frequency of the heart beat, its " fluttering " action, and sensations of palpitation, pracordial distress, fullness or constriction, and dyspnoea. In order to avoid these symptoms as far as possible, the patient should have his diet carefully supervised. A sufficient interval fully five hours should elapse for the com- plete 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 summarizes 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." BALFOUR 'S RULES FOR DIETING FOR WEAK HEARTS " 1. 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 mid- dle of the day. 4. All those with weak hearts should have their food as dry as possible." A good typical menu is given by the writer above quoted : BALFOUR 'S DIET FOR THE SENILE HEART "Breakfast, 8.30 A. M. 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-fibered 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. 532 DIET IN DISEASES OF THE CIRCULATORY SYSTEM " 5 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 limited regimen the patient, if heavy and water- logged, at first loses weight by absorption of " cedematous soakage," or if much wasted he may gain in weight. In this manner the natural equilibrium of the body is re-established. In not too critical cases a little more latitude is permitted, and such vegetables may be eaten occasionally as asparagus, onions, leeks, tomatoes, lettuce, cress. The heavier, coarser vegetables (like cab- bage, sprouts, turnips, parsnips, carrots, beets, legumes), pastry, nuts, dried fruits, and sweets of all kinds are forbidden, as well as fried food, twice-cooked or "made over" dishes, dried, canned, potted, pickled or preserved foods of all kinds, pastry, cake, condiments, and confectionery. Equal care should be given to the selection of proper beverages. If there is much palpitation, tea, coffee, and chocolate should be pro- scribed. Cocoa or alcathrepta may be drunk at 5 p. M. or on re- tiring, when the stomach is empty. These beverages should 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-glassful) 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 drunk in the small quantity recommended in the menu given above. Alcohol is by no means a necessity, and 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 shown elsewhere that the fre- quent acts of deglutition performed in sipping any fluid tend to in- crease the pulse rate slightly through reflex stimulation of the vagus branches which are concerned in the act. ANGINA PECTOEIS CARDIAC PALPITATION 533 As the heart becomes more and more feeble, the inactive circu- lation, perhaps aided by alteration in the composition of the blood or by albuminuria, results in the production of localized oedema or general anasarca. In referring to the use of dry diet for these conditions as occur- ring in connection with the senile heart, Balf our 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. A single slice of dry toast, without butter. A cup of tea (infused only four minutes). Dinner. Two lean chops, or their equivalent in chicken or fish. No vegetables. Dry toast ad libitum. 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. There are, however, many cases complicated by chronic nephritis, and if too little urine is being voided, it may not be safe to adopt the dry diet. In all such com- plicated cases, choice of the lesser evil should be made. ANGINA PECTORIS The chief 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, p. 719.) Meats are likely to overcharge the system with proteid waste, which may prove irritating and provoke an attack. CARDIAC PALPITATION The dietetic treatment of cardiac palpitation is sufficiently indicated under the heading of Flatulent Dyspepsia, (p. 584). Overeating should be avoided, as well as all stimulating foods and beverages. Tea, coffee, and tobacco should be forbidden at least temporarily. 534 DIET IN DISEASES OF THE CIRCULATORY SYSTEM Effervescing drinks of all kinds, from their tendency to produce flat- ulency, should also be proscribed, as well as all sweets and much amylaceous food. Laxative foods, especially fruits, will be found useful, for the reason that the primary cause of functional palpitation is often autointoxication from intestinal indigestion or an overtaxed liver. (See Intestinal Autointoxication, p. 623.) ARTERIOSCLEROSIS The etiology of arterio-sclerosis is varied. In many cases it is traceable to toxaemias, as lead poisoning, gout, chronic alcoholism, or syphilis. In other cases it accompanies autointoxication from deficient elimination of waste, as in chronic interstitial nephritis. In a very large number of cases it appears to be the result of severe mental or physical strain. In my wards in Bellevue Hospital, filled with representatives of the hardest working laboring classes long- shoremen, diggers, foundrymen, truckmen, etc. it is the exception to find a man past thirty-five years of age who does not present an advanced grade of it. There is some doubt as to the influence of diet as a causative factor, but it is probably at least a contributing factor, and the results of dietetic treatment are often beneficial. The question of fluid restriction should be decided upon the merit of each case, rather than by rule. Much fluid taken into an empty stomach, being promptly absorbed, tends to raise arterial tension and tax a heart already working against greatly increased arterial resistance, thereby accelerating cardiac hypertrophy. In cases complicated with cardiac dilatation or myocarditis, it is desirable to restrict fluids as much as possible in order to lessen the weight of fluid that an en- feebled heart, already working against great arterial resistance, is obliged to pump through the circulation. On the other hand, too little fluid ingested lessens renal activity and the excretion of waste, and should be avoided whenever interstitial nephritis or renal inade- quacy exists. Tobacco should be much restricted, and fried foods, much fat, and any indigestible foods should be prohibited. The dietetic treatment of arterio-sclerosis should be substantially the same as that of lithaemia (see Litha3mia, p. 560), with such com- mon-sense modifications as the patient's social position may dictate. It is futile to tell a day laborer to lie down and rest before or after his meals, but it is possible to keep his elimination of waste products active through catharsis and diuresis, and to regulate his diet, while it may ho possible to induce him to drink water occasionally, in lieu of poor beer and worse whisky. ANEURISM 535 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. If too much red meat be eaten the ex- tractives irritate the vascular system and increase arterial tension. Although white meats contain slightly less proteid than red, they are alike in the quantity of extractives present, hence a diet largely vege- tarian is to be recommended in this condition. Patients living in lime-water districts should obtain some less harmful potable water, such as Poland or Manitou. SUMMARY OF FOODS FOR ARTERIO-SCLEROSIS. Fish of any kind. Roe. Meats: Tongue, ham, bacon, tripe, liver, sweetbread (as substi- tutes for beef and mutton). Vegetables: Potatoes (white or sweet), peas, corn, beets, spinach, cabbage, cauliflower, Brussels sprouts, onions, celery, lettuce, turnips, parsnips, string, Lima and butter beans, eggplant, oyster plant, tomatoes, cucumbers, radishes, carrots. Butter, milk, buttermilk, cheese. Eggs in any form. Custards. Cereals: Oatmeal, rolled oats, rice, puffed rice, wheatena, wheaten grits, trisket, shredded wheat, hominy, cornmeal. White and Gra- ham bread. Gelatin food's; Wine jelly, blancmange, unsweetened fruit jellies. Fruits: Oranges, lemons, grape fruit, apples (raw, baked or stewed), apple sauce, plums, prunes, pears, peaches, grapes, cherries, berries of any sort, melons. The more fruit and green vegetables the better. As the disease is permanent, it is not well to give up red meats indefinitely. A good rule is to turn vegetarian for definite periods, of say 6 weeks, and then eat meat sparingly twice a week, or every other day and never more than once daily. Beverages: Tea and coffee in great moderation, cocoa, chocolate, effervescing waters, lemonade. ANEURISM In " aneurism " of the large arteries the vascular 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 536 DIET IN DISEASES OF THE CIRCULATORY SYSTEM sudden movement, or otherwise. The most favorable result of treat- ment which may be anticipated is thickening of the diseased vessel by the deposit of coagulated fibrin. The coagulability of the blood varies with its composition, and is favored by increased density of the blood and by quantitative change in its fibrin. To a limited extent this process may be aided by diet. The feeding of patients with gelatin has been recommended, on the ground that gelatin notably increases the firmness of clotted blood, but it is so altered in the process of digestion and absorption as to be of no practical value for aneurism. The real object to be attained in the dietetic treatment of aneu- rism is to reduce the volume, and consequently increase the density of the blood. The latter does not necessarily increase its coagulability, unfortunately. 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 strict 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 bed, and not be permitted to make exertion of any kind, and mental strain and emotion should carefully be guarded against. He should be fed by a nurse, and not allowed to sit up at any time. By rest alone the rate of the heart beat is materially slowed, and this is aided also by the reduced diet. The aneurism, in consequence, is distended less often and submitted to less pressure, The treatment originally recommended by Tufnell is as follows : TUFNELL 'S 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 at break- fast, This extremely strict diet is rebelled against by most patients, but it serves as a basis for the commencement of other treatment, and if it be 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 that of bread or vary it with crackers or some light form of amylaceous diet. The fluid, however, is in all cases to bo restricted as much as possible. Patients usually complain bitterly of thirst, and while it is more desirable to restrict the fluids than the solids in the dietary, the thirst may be alleviated somewhat ANEMIAS CHLOROSIS 537 by acidulated drinks, such as sour lemonade, dilute phosphoric acid in cinnamon water, etc. A " salt free " diet also may lessen thirst. (See p. 556.) If the bread and butter be made without salt, and none be added as a condiment with meals, the Tufnell diet becomes prac- tically salt free. The danger which menaces the patient and the ob- ject of his treatment should be explained clearly to him and his co-operation secured in the effort for relief. Upon this reduced diet improvement in physical signs of the aneurism such as dimin- ished pulsation and intensity of bruit and lessened pain is occa- sionally decided. In favorable cases improvement may be looked for at the end of a week, and if the dietetic treatment be persisted in for six weeks, the benefit may be considerable. Tufnell reported 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 worthy of trial in an otherwise hopeless condition. I have several times known it to produce considerable lessening of pain, dyspnoea, and other symptoms, but it requires firm- ness and perseverance to carry it out successfully. The curative re- sults have, unfortunately, not verified TufnelPs original claims, and as pointed out by the late A. L. Loomis, if the method be too rigidly and too long enforced for six or eight weeks an extreme degree of anaemia may develop 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, cereals, and fruits, with but little meat and no coffee, tea, con- diments, or spices. Anything likely to produce flatulency or gastric dyspepsia should be avoided, alcohol should be forbidden, and all fluids should be drunk slowly and in small quantities at a time. ANEMIAS CHLOROSIS, ETC. Pathological Physiology. The proper nutrition of all the tissues of the body is directly dependent upon the quality of the blood plasma and of the quantity 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. Ana?mia, whether acute and due to hemorrhage or disease, or chronic from any cause, by depleting the cellular elements of the 538 DIET IN DISEASES OF THE CIRCULATORY SYSTEM blood, interferes with the proper oxidation of food after absorption. On the other hand, a diet which is sufficient in amount or inappro- priate in quality, if long continued, is certain to produce an impov- erished condition of the blood with a diminution in the number of corpuscles or structural changes in them ; hence there is a double rela- tion existing between the power of the blood to insure complete absorption and metabolism, and of the food itself to maintain the normal balance of the ingredients of the blood. Anemia, therefore, demands special feeding, the basis of which should be an effort to re- store as soon as possible the -proper number of red corpuscles and the normal quantity of other ingredients of the blood (especially protein). When proteid food is excluded from the diet for some weeks the hemoglobin of the red blood corpuscles may be reduced considerably in amount and hydraBmia ensues, but the pigment is increased by an excess of proteid food. Chlorosis is most common at the age of puberty, and shortly there- after, among young girls who are growing or who are overworked at school or in factories while beginning menstruation, and who are im- properly fed. It is observed among young servant girls who live largely upon tea and toast. The disease is far less frequently en- countered at the present time, since the " outdoor life " has come into vogue. The diversion of considerable nervous energy for other func- tions than those of the circulation at this time may interfere some- what with the nervous mechanism of digestion and absorption. In other cases there is a constitutional or hereditary weakness of the digestive system, which is intensified by exceptional strain or over- work of the nerves. At the period of growth and development, there are always unusual demands upon the nervous system, and overstrain at this time is especially to be guarded against. Prolonged constipa- tion, giving rise to intestinal autointoxication, is a potent factor in maintaining, if not also in causing anemic conditions. Symptoms. Among the many symptoms referable to the nervous system which arise in the course of protracted ansemia are languor, vertigo, various forms of neuralgia and megrim, with indefinite mus- cular pains, which to some extent are produced by enfeebled circula- tion, which allows waste material produced by muscular action to accumulate in the tissues. Depression of spirits and drowsiness are also observed, and palpitation is easily excited. The poor circulation may result in the production of fainting, or of cedema 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 modifica- tions in the relative consumption of certain foods by the tissues. A ANEMIAS CHLOROSIS 539 large excess of urea is commonly observed, which indicates an active combustion of proteids. Owing to the small number of the red blood disks, or oxygen carriers, or their poor structure, the final oxidation of fatty matter is retarded, and it is for this reason that anaemic subjects often appear plump or even corpulent from the deposition of a large amount of fat derived from incomplete combustion of fats and starches, whereas their muscles, from the increased proteid waste, are reduced in size and weak. Von Noorden, Kraus, Bohland, and others believe that whereas chlorotic patients feel tired, sleep long, and are disin- clined to expend energy in muscular exertion, 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 cases of extreme anaemia, found especially among young chlorotic girls, the dietetic treatment should be accompanied by careful regulation of all hygienic conditions. Sufficient rest for the tissues, and especially for the digestive organs, should be secured. These patients, who appear so well nourished, may in reality be quite weak, and it is a mistake to compel them to rise early and perform tasks and indulge in exercises of the same character and degree with those of healthy persons. For many pa- tients it is well to insist on a prolonged, 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 should be cautioned against allowing themselves to become unduly fatigued. They are often able, under the influence of stimulants and excitement of various sorts, to perform feats 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 improvement may be checked by infringement of nec- essary regulation. 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 air, and the patient should sit outdoors nearly all the re- maining 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 unfavorable the cure will be more rapid if the patient can be moved to a more salubrious locality. Fresh air is more important than exercise or iron, for an abundant oxygen supply increases the appetite and distinctly promotes assimilation of the food. Dietetic Treatment The dietetic treatment of anaemia requires, in the first place, that the most nutritious food should be supplied; 540 DIET IN DISEASES OF THE CIECULATORY SYSTEM secondly, care should be taken to insure its complete digestion and absorption. In all cases of serious anaemia the impoverished and watery condition of the blood reacts unfavorably upon the character of the digestive secretions and diminishes their organic elements. The secretions are therefore unable to digest the food with the neces- sary vigor, and it is often desirable to re-enforce them by the use of artificially 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 pp. 188, 189.) At the commencement of treatment rest and a small quantity of food may be required, but with improvement of the digestive organs the quantity of food may be increased rapidly, 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 espe- cially 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. Eggs in all forms which are of fairly easy digestion are an excellent food for anasmic 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 sandwich makes it still more palatable and wholesome. Pa- tients of this class often object very strongly to eating meat, and prefer pastry and sweets, but with tact and persuasion they may usually be induced to take it in some form. Meat broths and con- sommes may be thickened with scraped meat, or raw scraped beef may be added to chocolate 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 anaamic women are very apt to do. Young chlorotic girls should receive at least five or six ounces of albumin per diem. See gives as much as fourteen ounces of raw meat daily in some cases of chlorosis, and finds it especially serviceable for those patients 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 ANEMIAS CHLOROSIS 541 albuminous food to counteract this condition. Von Noorden's system is excellent, and he describes it as follows: " I recommend chlorotic girls to drink slowly half a liter [one pint] 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 con- suming this quantity. They ought to rise half an hour later, and they should be rubbed briefly with a dry rough woolen 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, fol- lowed immediately afterwards by drinking a quarter of a liter [one- half pint] of milk/' If the large quantities of meat recommended are not perfectly digested and absorbed, it is well to prescribe nux vomica with dilute hydrochloric acid. A concentrated meat diet almost always produces constipation if this condition does not exist already 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 of purees of fresh vegetables, whole-meal bread, oatmeal, and such fruits as stewed prunes, apples, and the juice of oranges and grape fruit. (See Constipation, p. 636.) 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. For others who, besides being anaemic, are thin and poorly nour- ished, it is well to add some simple forms of starchy food and a liberal allowance of fat with the meals. Von Noorden says: " For a well-nourished, moderately fat, chlorotic girl, weighing 125 Ibs., I would consider the following diet eminently suitable : " 120 grams (4 ozs.) protein 492 calories. 60 " (2 ozs.) fat = 558 270 " (9 ozs.) carbohydrates = 1,110 " Total 2,160 (i. e., 36 calories per kilo of body weight.) " The eating of fats is to be increased to the limit of toleration. Cream and large quantities of butter are recommended when easily digested, and they may be made to replace cod-liver oil when the 542 DIET IN DISEASES OF THE CIRCULATORY SYSTEM patient is unable to take this form of fat, Many patients digest broiled fat bacon with ease. Two or three eggs beaten with boiling water or milk, with the addition of sugar and spices, may be given two or three times during the day between meals. The use of glycerin extracts and emulsions of bone marrow has been advocated for anaemia, but the results have not been markedly satisfactory. The method of preparation is described on p. 233. The majority of anaemic patients have no appetite, or lose it, during the early part of the day, and careful attention should be given to making all food as agreeable to them as possible in taste and manner of serving. Meat should be prepared so as to require the least possi- ble effort in mastication, and much additional food should be con- sumed in a fluid and semisolid form. Simple condiments are serviceable, for they render food more agreeable and stimulate the enfeebled gastric secretion. Moleschott insists on the free use of salt by chlorotic patients on account of its alleged favorable action in restoring the blood corpuscles and plasma. Alcohol is not indicated for all, but there are some patients who are benefited by its use, and a good form of alcoholic tonic for an anaemic patient is a rich claret, Burgundy, or Madeira. Some of the milder cases, especially in 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 pro- mote the accumulation of fat, and this is undesirable in anaemic subjects who already possess that tendency. SUMMARY OF DIET FOB SIMPLE FUNCTIONAL ANAEMIAS Meats: Rare roast beef, steak, chops, lamb, mutton, ham, bacon, tongue, chicken, turkey. Eggs: Beaten raw, or boiled, scrambled, or as an omelette. Cus- tards. Fish: Fresh fish of any sort boiled or broiled, but not fried or baked. Cereals: Graham bread, brown bread, oatmeal, wheaten grits, hominy, corn broad. VcyctahJt'x: AVliite potatoes, baked, mashed, or "creamed," string PERNICIOUS ANAEMIA 543 beans, lettuce, celery, spinach, tomatoes. (There is no objection to vegetables, but if too much variety is eaten, less meat will be taken.) Milk, buttermilk, cream, butter. Desserts: Junket, blancmange, wine or lemon jelly, bread pud- ding, rice pudding with stewed fruit. Fruits: Oranges, peaches, plums, pears, melons, nectarines, apri- cots, tamarinds, grapes, limes, lemons, grape fruit, strawberries, ap- ples (raw or cooked), olives. Beverages: Cocoa, koumiss, lemonade, orangeade. Foods Forbidden : Fried foods, twice cooked and " made over " dishes, pastry, confectionery, "cakes," cake, "preserves," jams, vine- gar, pickles, gravies, sauces, nuts, raisins, canned, dried, salted, and preserved foods of all kinds. Tea and coffee, as a rule. PERNICIOUS ANEMIA The most successful treatment of pernicious anaemia is based upon securing comparative asepsis of the alimentary canal. The mouth should be cleansed thoroughly with an antiseptic wash always after taking food and the teeth should be put in the best possible order. Effort should be made to avoid gastric and intestinal malfermenta- tion which results in flatulency, constipation and autointoxication. I have obtained the best results from careful dieting, abundant fresh air, laxatives and daily intestinal irrigation with salt solution. Lac- tobacilline should be used (p. 92). Fresh fruit and fresh green veg- etables are recommended, such as oranges, lemons, grape fruit, apples, string beans, lettuce, celery, tomatoes (not canned), and potatoes. Red meat should be given not more than once a day and it may be made to alternate with chicken, fish, bacon, and eggs. Water should be drunk between meals in considerable quantity five or six tum- blerfuls a day, and after eating meats, dilute hydrochloric acid in large doses with nux vomica is indicated. In about one-half of all the cases gastric atony is present, hence the desirability of supplementing deficient gastric secretion. DIET IN DISEASES OF THE URINARY SYSTEM INFLUENCE OF DIET ON THE URINE The quantity as well as the composition of the food eaten exer- cises an important influence over the composition of the urine. Animal food increases the acidity of the urine and naturally also- 544 DIET IN DISEASES OF THE URINARY SYSTEM its nitrogenous elements, 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 beverages 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 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. Phosphaturia or the excessive deposit of phosphates in the urine is best treated dietetically by the use of meats, eggs, cheese, cereals, and legumes. Potatoes, fresh green vegetables, and fruits should be avoided. A diet rich in fatty food,, or an excess of cod-liver oil, may some- times give rise to fat in urine, or lipuria. The volatile fatty acids may be present. The presence of the fat makes the urine somewhat turbid, and oil globules and fat crystals sometimes may be seen under the microscope. A milk diet makes the urine alkaline, and increases the indican. Foods producing oxaluria are described under Oxaluria, p. 557. The odor imparted by asparagus to the urine is explained on p. 204. (See also The Urine and Food, p. 403.) ACUTE NEPHRITIS Symptoms. Acute nephritis is an inflammation of the kidneys, principally caused by exposure to cold and wet, by certain medicinal poisons, or by the toxins developed in the course of acute infectious fevers, especially the exanthemata and diphtheria. It is unnecessary to discuss its varieties here, as the dietetic treatment is the same for all. Among the important symptoms are anaemia and a scanty secre- tion of urine containing abundant serum 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. Dietetic Treatment. The dietetic treatment should be adapted to prevent overloading the digestive organs, which are easily deranged, and to prevent overworking the kidneys. A light diet is therefore necessary. The patient will do best to live exclusively upon milk for ACUTE NEPHRITIS 545 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, lime 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 disagrees with the patient, other simple foods may be allowed, such as koumiss, buttermilk, and gruels of oatmeal, groats, rice, barley, flour, or arrowroot, or toast or crackers may be eaten in the milk. 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. Animal broths dissolve substances from meat which may develop into toxins 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, cream toast, plain puddings, such as sago, farina, or corn- starch, 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 meat broths may be allowed, and finally a little white meat of poultry, bacon, fish, oysters, and squab. Any return of the albuminuria should immediately be met by a reduction in the diet to its original simplicity chiefly milk. A patient may lose thirty or forty grains of serum albumin in twenty-four hours without serious harm, but if three to four hundred grains are lost the condition is in itself alarming, for he is losing one-fifth to one-fourth of his total proteid 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. Milk, sugar, or lactose is sometimes given separately for its diuretic action. See 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 undoubtedly a good mild excitant of renal activity, but this is due to its water as 37 546 DIET IN DISEASES OF THE URINARY SYSTEM much as to any other ingredient, and the diuretic effect of lactose is much overrated, although it furnishes abundant heat units. Should vomiting occur at any time, the diet should be reduced, 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 may be raised by ingestion of abundant fluid, pro- vided the tendency to dropsical effusions is not great. Water, alka- line, mineral, or effervescing waters, soda lemonade, or cream-of- tartar lemonade should be drunk freely, the latter especially if there is constipation (Dickinson). Osier recommends the following: A drachm of cream of tartar in a pint of boiling water with the addi- tion 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 forbid- den during convalescence: Grills, roasts, sauces, pastry, spices, pick- les, preserves, rich cake, very acid foods, strong alcoholic drinks, tea and coffee. Strong wines, sweet wines, and all sorts of liqueurs are absolutely prohibited. 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 should consist exclusively 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 sub- side 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 favorably upon the bowels. It is best, as in the case of adults, to forbid meat broths, and eggs and meat in any form should be withheld for three or four weeks after the urine has regained its normal composition. Subse- quently 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 with cream, crackers, boiled rice and cream, and fresh ripe fruits. ALBUMINTJRIA, FUNCTIONAL AND ORGANIC 547 ALBUMINURIA, FUNCTIONAL AND ORGANIC Pathological Physiology. Albuminuria may be produced by al- terations in the composition of the blood and by structural or func- tional changes in the kidney itself, or by both. The albumin is derived from the blood serum, which in turn comes from the protein of the food. Tinder ordinary circumstances protein in passing through the body undergoes several transformations which affect its degree of solubility and its ability to osmose or pass through animal membranes such as line the alimentary canal, the blood vessels, and the tubules of the kidney. The conditions of osmosis also depend in part upon the relative density of the fluids on either side of the membrane, hence alterations in the composition of the blood plasma may permit the osmosis of serum albumin into the tubules of the kidney. It is important to observe that the presence of serum al- bumin in the urine in excess not only indicates a functional or struc- tural weakness in the kidneys themselves, or in the composition of the blood, but it represents actual loss of substance from the body in other words, there is a leak of nutrient matter from the kidneys. It might seem feasible to disregard the leakage and increase the amount of proteid food sufficiently to counterbalance the loss sus- tained. 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 comparison, for excess of sugar is really a foreign body in the blood, while albumin is not. Clinically, moreover, it has been found that when either of these conditions of loss of substance through the kidneys exists it is better to withhold as much as pos- sible the particular variety of food which is leaking through them and reduce the work of these organs. Functional Albuminuria. It is not many years since the detec- tion of albumin in the urine was regarded as an infallible indication of some form of renal disease, but' the fact is now established that errors in diet and faulty assimilation produced by mental and nerv- ous strain, overwork, and worry, and more particularly by the phe- nomena of very rapid growth in the later years of childhood and early youth, may give rise to temporary or " functional albuminuria." A solution of meat albumin experimentally transfused into the venous circulation of a dog, or 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 albu- 548 DIET IN DISEASES OF THE URINARY SYSTEM mjnuria, although the percentage of albumin in the blood plasma has been raised considerably above the normal. Moreover, if a man in health eats eight or ten raw eggs in the course of five or six hours, traces of serum (not egg) albumin may appear in the urine. The matter is of interest in connection with the diet for chronic Bright's disease (p. 551). Albuminuria thus produced is merely temporary, and is directly dependent on the nature of the food. When so much of this proteid has been eaten a portion of it is absorbed directly into the blood without formation of intermediate products of digestion. Similarly this albumin may be excreted by the kidney. But if the digestive activity in the stomach is 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 ap- pearance of albuminuria. It is no doubt true in such an instance, as suggested by Yeo, that the vigor of digestion converts egg albumen into peptones, which finally form serum albumin, whereas with a slower digestion more is absorbed unaltered. According to the ex- periments of Stokvis, coagulated egg albumen cannot be made to reappear in the urine of healthy animals, but raw egg albumen can. Oertel (Therapeutics of Circulatory Derangements, von Ziemssen's Handbook of General Therapeutics), as a result of numerous experi- ments 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 albumen absorbed is all destroyed in the blood or tissues and excreted as urea from the kidneys. He further says that " a great increase of albumen supplied to the blood causes no increased excretion of albumen by the kidneys, and, in particular, that egg albumen gives rise to no irritation of the renal vessels and no albu- minuria (nor does it increase an existing albuminuria)." I have long been in the habit of allowing eggs to be eaten in chronic cases of nephritis and have never known them to increase the albumin output. Of all the varieties of albuminuria, those which are most amen- able to dietetic treatment are the functional form and that which accompanies chronic Bright's disease. The functional albuminuria which is produced by eating an excess of protein or by muscular 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. In the instance given above of albuminuria caused by eating large numbers of eggs, it was emphasized that the proteid in the urine ALBUMINURIA, FUNCTIONAL AND ORGANIC 549 is egg albumen and not serum albumin. When albuminuria already exists, meat proteids will increase the amount eliminated by the kid- neys. It is probable that some persons inherit a special weakness of the kidney structure or an abnormal irritability of the renal cells which favors the occurrence of albuminuria from slight provocation. Granger Stewart (Lectures on Important Symptoms of Albuminuria) states that he has observed in certain persons that cheese, as well as eggs, is capable of producing temporary albuminuria. In regard to the production of functional albuminuria from die- tetic errors Yeo argues, 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 excreted) that a temporary functional hyperaemia 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, from active congestion and inflammation, irritant metallic poisons, the toxins of the exanthemata, especially scarlatina and erysipelas and those of typhus fever, diphtheria, etc., all of which may prove highly irritating to the renal epithelium. Dietetic Treatment. The frequent return of functional albumi- nuria should be regarded as an indication of special weakness of the kidneys in the same way that frequent functional glycosuria in- vites suspicion of the strength of the digestive power of the liver, and demands a careful regulation of the diet. Meat should be forbidden temporarily, as well as all forms of alcoholic drinks or other substances liable to produce renal irritation, and the diet should consist chiefly of fruits, cereals, vegetables, and milk. Attention should be paid to increasing the activity of the bowels. When functional albuminuria is observed in children and adoles- cents, the following dietary, from which a considerable variety of foods may be selected, is recommended : Bacon, sweetbreads, custards, butter, cream, milk, cereals, and breadstuffs, gingerbread, potatoes, beets, lettuce, spinach, string beans, tomatoes, celery, blancmange, Bavarian cream, whipped cream, and sponge cake, wine or lemon jelly, junket, bread pudding, apple sauce, oranges, ripe bananas, pineapple juice, prunes, cocoa, lemonade, orangeade. 550 DIET IN DISEASES OF THE URINARY SYSTEM Causation. Chronic interstitial nephritis may be of primary origin, or develop as a result of arterio-sclerosis and other conditions. It is usually a slow process, and is often provoked by chronic alcoholism and chronic metal poisoning, especially by lead and arsenic. The arterial walls are thickened and arterial tension is high. The urine varies in composition and quantity, according to the variety of lesions present. That an exclusive meat diet is not the cause of chronic Bright's disease is proved by the fact that Eskimos and other races, who sub- sist altogether upon it, are not especially liable to the disease, al- though in the long sunless winter they live under very bad hygienic conditions. (See the relation of proteid food to albuminuria, p. 547.) It is nevertheless a fact that the disease is very prevalent in this coun- try among men past forty years of age who for years have been overworked with business cares, and who have neglected to take suffi- cient exercise and care in eating. In all stages of the disease much may be accomplished by dietetic treatment. Cooked meats, spices and highly seasoned food in general are in- jurious in all cases of existing albuminuria. The fluctuations ob- served are often due to diet merely, and the albumin may be con- siderably reduced in quantity, or absent temporarily from the urine, although the lesion of the kidneys is making uninterrupted progress. The volume of albumin in the urine should not, therefore, be regarded alone as an indication for dietetic treatment; it is merely one of many symptoms 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 interferes with the normal elimination of proteid waste which accumulates in the system until it finally produces toxic or uramic symptoms of a most serious character. If the alimentary canal is overloaded with food above the actual requirements of nutrition, or beyond the capabilities of the system for oxidizing certain food products, toxic symptoms follow. For these reasons the diet in chronic Bright's disease should be regulated definitely, and a mean maintained between overburden- ing the digestive apparatus and withholding food which is needed to support the bodily strength. This applies especially to proteid waste, which passes off through the kidneys, whereas the waste of carbohydrate food is eliminated from the lungs, in the form of water and carbonic-acid, in water from the kidneys and skin, and as carbonates and other salts in the urine. CHRONIC BRIGHT 'S DISEASE 551 Dietetic Treatment It is generally believed that meat is harmful in chronic nephritis, although it is probable that the danger lies more in the extractives than in the albumin of the meat. Of late, however, there has been a decided tendency to allow a more liberal dietary to the nephritic, depending, of course, upon the stage of the disease. F. C. Shattuck of Boston declares that "more patients with recognized nephritis suffer from insufficiency than excess of proteids," and Von Noorden recommends a varied diet with reduced proteid content, rather than an exclusive milk diet for most chronic cases. A purely vegetable diet often has been tried for albuminuriacs, but it causes too pronounced anaemia if its use is persisted in, and a minimum of animal food should 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 nutritious as possible, and then certainly fresh meat is by no means injurious." AVith failing cardiac compensation the heart muscle may give out unless meat be eaten. In the early stages, often for a period of several years, the patient may feel well and present no symptoms other than the albuminuria. To withhold meats altogether in such instances may be to induce anaemia and reduce the patient's strength, without corresponding gain in the condition of the urine. My rule is to allow such pa- tients, without anasarca or uraemic symptoms, to eat red meats spar- ingly, once or twice a week, and sometimes once a day, but much depends upon the age of the patient, duration of the nephritis, the existence of complicating diseases, etc. With the onset of any uraemic symptoms or of high arterial tension, headache, gastric disturbances, etc., meat should be withheld, at least temporarily, and resort should be had to a milk diet as in acute nephritis. Chicken, tongue, ham, fish, and eggs are forms of proteid food which, although some of them are rich in proteid content, are less likely to be eaten to excess than beefsteak, roast beef or mutton. Milk Diet. In many cases of chronic Bright's disease with ad- vanced symptoms, the effect of feeding the patient for six weeks, or even two or three months, upon an exclusive milk diet, is remark- ably gratifying. The quantity of urine, urea, and extractives in- creases, while the albumin diminishes, and cedema and general anasarca disappear. The patient's strength and general condition improve, the pulse is strengthened, and if dyspnoea pre-existed it subsides. 552 DIET IN DISEASES OF THE URINARY SYSTEM The quantity of milk to be prescribed for an exclusive milk diet depends on the age and size of the patient, as well as- upon his ability to exercise and use force in muscular energy. If the patient is invalided so as to be confined to his room or the house, from five to seven pints of milk daily are sufficient. Seven pints of milk contain 216 grams of albumin and casein, 172 grams of fat, and 161 grams of lactose; whereas, according to Pettenkofer and Voit, a healthy adult requires 137 grams of dry albumin, 117 grams of fat, and 352 grams of carbohydrates (see p. 326). The milk diet is therefore deficient in carbohydrates, but the latter are estimated in Voit's table for a person taking active exercise, and requiring the development of more muscular energy and heat than the invalid. If the patient lose weight on a milk diet, although it otherwise agrees with him, it may be well to add farinaceous food in the shape of rice, bread, crackers and milk sugar. Oranges also may be eaten. Many patients live contentedly with no other food than a bowl of bread and milk four or five times a day. In some cases it is in- advisable to commence the milk diet immediately, and a good result may best be attained by cutting off one article of solid food after another and replacing the loss by an additional tumblerful of milk. Where it is expected to employ a milk diet for many weeks, 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 with- out flavoring of any kind. Although the treatment may seem severe at first, if the patient understands the gravity of the situation he often is willing to accept it, and after a few days seldom com- plains of the monotony. In the gravest 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 tumblerful at night, and on awakening in the morning. Ordinarily, however, it is tiresome to have to drink milk so often, and the quantity may be so regulated as to give the requisite amount once every three hours. The quan- tity 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 should take from twelve to fourteen six- ounce tumblerfuls of milk in the twenty-four hours. It is usually impossible to commence at this rate without producing gastric dis- turbance from souring of the milk in the stomach, and possibly diarrhoea. The latter symptom is a certain indication that the milk is being imperfectly digested, and a temporary reduction in its quan- tity is advised. It is very important thoroughly to cleanse the mouth after drink- CHRONIC BRIGHT 'S DISEASE 553 ing the milk, in order to avoid coating the tongue and a dis- agreeable taste which destroys the appetite and interferes with the efficacy of the treatment. For discussion of this subject see Milk Diet in Typhoid Fever (p. 474). Obstinate constipation, which almost invariably results from a milk diet, may be met by medicinal treat- ment, or enemata. As a rule, the milder laxatives are the only remedies necessary; a glass of citrate-of-magnesia 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 stewed prunes or the soft part of two or three baked apples, or the juice of two or three oranges in a tumblerful of Yichy. It will be observed that whereas the normal average quantity of urine for an adult male is 52 ounces for the twenty-four hours, the milk diet under discussion requires the ingestion of upward of 80 ounces of fluid. This necessitates increased activity of the kidneys, but the polyuria usually results in the removal of the anasarca which frequently exists. The body weight may remain normal, be slightly increased or it is not infrequently diminished, much depending upon the condition of the patient at the time when the milk diet is in- augurated. 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 dilution. 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 the milk diet should be continued from 4 to 6 weeks, after which a slight variation may be allowed in the form of cereals and fresh vegetables, and fruit. In other cases it may be neces- sary to prolong the treatment for several months, 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 incur- able, and the most that can be hoped for from any treatment is an amelioration of the gravest symptoms. 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 flavors (see p. 85) and with light farinaceous foods, of which milk forms nn important basis, such as bread, crackers, and 38 554: DIET IN DISEASES OF THE URINARY SYSTEM rice pudding. Much milk may be taken in very weak coffee or tea, or in the form of soups and purees made with celery or po- tatoes, or gruels may be given, or milk thickened with tapioca, ver- micelli, sago, or rice, and flavored with a very little lemon or orange peel, cloves, or allspice. It is not desirable to use much high season- ing for fear of irritating the diseased kidneys. As the patient improves, the milk diet may be given up, but not too suddenly. A sudden restriction of fluids in chronic nephritis is injurious, and their quantity should be regulated by the vascular tension. In adopting any other diet it is a good rule never to let the proteid food bear a greater proportion to the carbohydrate than one to four. The former increases the proportion of urea in the urine, the latter reduces it. 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 frequency, and some of the milk may be replaced by boiled fish, chicken, or game, and fresh green vegetables, potatoes, cream, butter, eggs, ham, and bacon. Cereal foods may be eaten ad libitum, such as hominy, corn bread, oatmeal, sago, tapioca, rice, vermicelli, bread pudding, and macaroni. Cheese may be eaten occasionally. The urine should be periodically examined, and if it is found that the eating of meat is followed by an increase in the albuminuria the patient should return to the milk diet. It not rarely happens that strict adherence to a milk diet for several weeks produces more lasting improvement in the action of the kidneys, so that a diet to which steak, roast beef, chops, and eggs are admitted not only may 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 easy 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 should live upon a carbohydrate diet, consisting of fresh vegetables and fruits, with butter, cream, and olive oil. Dujardin-Beaumetz allows pork and ham to be eaten by those who refuse to relinquish meat entirely. An exception to the value of an exclusive milk diet exists in cases in which, owing to persistent high arterial tension (chronic in- terstitial nephritis) the large amount of fluid ingested increases the tension, and overtaxes an already hypertrophied heart. In such cases milk should be in great part replaced by cereals, cooked fruits and green vegetables. Water Drinking. It was formerly taught that the chronic CHRONIC BRIGHT 'S DISEASE 555 nephritic should drink as much water as possible to promote elimina- tion of waste, and wash out casts from the renal tubules, but several writers, and notably Von Noorden, have pointed out the danger of raising arterial tension by drinking too much fluid, to a point which may cause a breakdown of the compensatory cardiac hypertrophy. The quantity of water ingested should be adapted according to the individual case; thus patients having high tension or anasarca re- quire less than those who have merely a reduced output of a con- densed urine. When there is high tension, water should be drunk from a small wineglass, rather than a tumbler, or sipped, rather than drunk, and taken at frequent intervals. By this means the sudden strain upon the circulation of absorbing a large bulk of fluid may be avoided. In general, the patient had better leave alcohol alone, especially in the form of strong liquors. If habituated to its use, a feeling of dullness and drowsiness after a glass of wine is a strong reason for giving it up. Tea, coffee, and cocoa are permissible during intervals of betterment. The effect of dietetic treatment will be much enhanced by securing systematic outdoor exercise, and freedom from worry and anxiety, and particular attention should be paid to keeping the bowels open, for which laxative fruits may be taken freely. The patient should be cautioned against overeating, and all food should be masticated thoroughly. SUMMARY OF DIET FOR THE CHRONIC NEPHRITIC (Without Anasarca, or Other Grave Symptoms, Either Digestive or Circulatory, and urith Fairly Good Urine) : Meats: Bacon, ham, sweetbread, tripe, tongue, liver, chicken (oc- casionally). A chop or thin slice of rare beef two or three times a week. Milk, butter, buttermilk, cheese, cream, eggs in any form, custards. Fish of any kind. Cereals and farinaceous foods, especially bread, shredded wheat, hominy, cornmeal, puffed rice, boiled rice, macaroni, spaghetti, wheaten grits, wheatena. Vegetables: Potatoes both white and sweet, beets, new peas, corn, string, Lima, or butter beans, tomatoes, celery, lettuce, spinach, cauliflower, Brussels sprouts, eggplant, cucumbers, onions, carrots. Gelatins: Plain blancmange, chocolate blancmange, fruit jellies. Fruits: Apples in any form, oranges, peaches, pears, plums, 556 DIET IN DISEASES OF THE URINARY SYSTEM prunes, grapes, berries of any kind (except cranberries) ripe bananas, pineapple juice, nectarines, apricots, melons. Beverages: Weak tea, cocoa, and exceptionally, cafe au lait. Koumiss. Forbidden Foods: Condiments, spices, pickles, all red meat (ex- cept as specified above), fried foods, rich sauces, gravies, potted or devilled meats, dried, salted, canned or preserved foods, beef juice, meat extracts or essence, pastry, cake, confectionery, sweets of all kinds (as being liable to cause dyspepsia). DIET FOB CHRONIC PARENCHYMATOUS NEPHRITIS WITH GENERAL ANASARCA SALT-FREE DIET. A " salt-free " or " declorinated " diet lately has been recommended to promote absorption in chronic parenchymatous nephritis, pleurisy with effusion, anasarca from any cause, ascites, and all cases of ex- tensive serous effusion. The treatment is certainly not new, having been described in the Hindu medical work, the Charaka, compiled 1,000 years B. C. The treatment has been endorsed by Widal, Strauss and Eumpf and in this country by J. L. Miller of Chicago, G. L. Peabody of New York, and others. The normal salt require- ment in health is from 15 to 30 grains per diem (Bruge) but the majority of persons consume much more usually y to 1/2 oz. In the salt-free diet foods are chosen which contain a minimum of inorganic salts, and no table salt at all is added in cooking, or eaten as a condiment. In detail this diet consists of milk, eggs, butter, chicken, bread made without salt, cereals cooked without salt, fruits, jellies, tea, coffee. Peabody reports (N. Y. Med. Eecord, March 9, 1907) several obstinate cases of general anasarca which were temporarily much benefited by this diet. In some cases it undoubtedly lessens oedema and anasarca, but my personal experience has not been to realize all that is claimed for it. It does no harm, and is worth trying. PYELITIS Most cases require abundant fluid, such as alkaline mineral wa- ters, 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 after the manner de- scribed above for treatment of nephritis in the preceding section. The foods especially to be avoided are also mentioned in the section on nephritis. OXALURIA 557 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- late in the urine need not be considered as abnormal, but the con- tinued presence of this substance in excess is mainly caused by eat- ing certain kinds of food and by dyspepsia and perverted nutrition, involving incomplete oxidation in the system of amylaceous, saccha- rine, 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 possibility of its forma- tion from the imperfect oxidation of these substances in the body." Mugge has shown that bacteria can form this acid, and its crys- tals occur in the intestine and are found in the feces. Oxaluria is common in connection with dyspepsia, and it is not 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. 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 proteids. Fasting animals may show traces of calcic oxalate in their urine, and both increased and diminished oxi- dation have been held accountable for oxaluria. Vegetables and fruits containing oxalic acid and its salts, and which may cause oxaluria when eaten in excess, are rhubarb, toma- toes, turnips, onions, sorrel, spinach, figs, strawberries, apples, pears. Many other fruits and vegetables contain traces of oxalic acid, but this fact is of little or no dietetic importance. Eaw fruits and vege- tables 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 food substances. Dietetic Treatment. The diet should consist of such animal food only as eggs, fish, and poultry with cereals, stale bread or toast and a minimum of butter. Tea, coffee, carbonic-acid water, and alcohol should be forbidden temporarily. 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- 558 DIET IN DISEASES OF THE URINARY SYSTEM chloric, are beneficial if taken immediately after meals in doses of fifteen or twenty minims in water. CALCULI, RENAL AND VESICAL The treatment of calculi involves discussion of beverages and foods. r Beverages. When the presence of vesical calculus has been demon- strated it becomes important to regulate the diet so as to prevent, if possible, increase 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 controlling vesical catarrh. 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 im- portance, as the most noted waters in the treatment of stone seem to have purity as their chief recommendation." The milk is soothing, and while it is a good diuretic, it lessens the desire for frequent micturition which is often such an annoying symp- tom of vesical stone. The still spring waters, such as Poland, Londonderry, or Bed- ford, 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. The occurrence of vesical calculus in children is believed by Cadge, White, and others to be directly proportional to the diffi- culty of getting good milk. It is therefore 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, etc." Young infants should not be given lime water indefinitely with their milk. It is best for adults to relinquish the use of alcoholic stimulants, but if this is not feasible light Ehine wine or still Moselle is ad- missible, especially if neutralized by some alkaline table water. 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, ale, porter, and stout are forbidden. Weak tea and coffee may be drunk sweetened with saccharin. Only such beverages should be allowed as contain no LITH^EMIA URIC-ACID DIATHESIS GRAVEL 559 free acids and no sugar, and those having the greatest diuretic effect are the best. Foods. All highly seasoned and irritating articles, like vinegar, pickles, strong condiments, such as mustard, should be forbidden, AS well as anything prone to excite acid^ dyspepsia. Among patients who have calculi of various kinds a considerable number are at the same time afflicted with obesity. Such persons should 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, suet puddings, pastry of all kinds, meat fat, and fat pork. Bread, oatmeal, hominy, cracked wheat, cornmeal bread, custards, blancmange, boiled fish, and eggs are all admissible. In cases of uric acid calculi total abstinence from animal food for three or four weeks 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 flavored with some bland aromatic, like cinnamon, nutmeg, or cloves. In other cases it may not be necessary to withhold meat completely, but it should 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 more than the total withdrawal of meat. The above general directions apply to the treatment of most va- rieties of calculi, but should be modified from time to time to suit particular cases. In elderly subjects, in whom calculi are relatively common, the functional elimination of waste from the body is considerably im- paired. 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^EMIA URIC-ACID DIATHESIS GRAVEL Symptoms. Lithaemia is a vague condition in which the system contains an excess of uric acid or its salts, and is usually productive of such symptoms as insomnia, vertigo, tinnitus aurium, disagreeable fullness of the head, and general " nervousness." The urine becomes loaded with nitrogenous waste. It is uncertain how much harm is 560 DIET IN DISEASES OF THE URINARY SYSTEM due to uric acid itself, and how much to autotoxins formed in the intestines or tissues as an accompanying process. When uric acid appears in excess as a sediment in the urine it is desirable that its formation 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 pres- ence of crystals (" gravel ") gives rise to attacks of ureteral or vesical colic, causing agonizing pain, and often haBmaturia. A ma- jority 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 urinary system, which, in addition to the other symptoms, may possibly cause ulceration and inflammation of the mucous membrane or serious 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 associated with proteid katabolism. Nucleins are derived by digestion from peculiar nucleo-proteids which are contained chiefly in the thymus gland, liver, and spleen, but also in slight proportion in meat and meat extracts, and they appear to be at least one of the principal sources of uric-acid formation. Tea, coffee, and cocoa are believed to aid in the process of uric-acid formation in some manner in the body, whereas milk and eggs do not have that effect. The final destination of uric acid is its conversion into urea, but from lack of perfect oxidation this process is checked. Dietetic Treatment. The indications for dietetic treatment are, therefore, to reduce the animal foods in amount or temporarily with- hold them altogether, while giving large quantities of plain water and of waters containing potassium or lithium salts to aid in dis- solving the uric acid already existing in the kidneys or bladder. Although the acidity of the urine is not caused by uric acid, but by acid sodium phosphate (Na 2 P0 4 ), the deposition of uric acid is accomplished in an acid menstruum, and it is well to reduce the urine temporarily to a neutral or somewhat alkaline reaction. Animal food, except milk, tends to make the urine acid, whereas milk and vegetable food favor alkalinity. In speaking of the lithic- acid diathesis in children, J. M. Fothergill wrote that " lean meat, raw meat minced, and beef tea are so much poison." Lithsmic head- aches will often cease Avhen the patient stops eating butcher's meat, cheese, etc., if excessive indulgence in animal food has been the previous habit. Meat extracts are worse, for the dyspepsia which often accompanies litha?mia is a conservative process, checking the digestion of animal foods, whereas the predigested foods are more promptly and easily carried to the overburdened liver. Some li- LITHJEMIA TRIG- ACID DIATHESIS GRAVEL 561 thaemis patients cannot take meat well in hot weather, but can do so at other seasons. An excessive meat diet cannot be regarded as the sole cause of lithaemia; other factors are concerned, such as over- eating and the abuse of saccharine food, which causes malfermenta- tion, deranges the functions of the liver, and alters the composition of both blood and urine. Murchison long ago declared that " habitual lithasmia 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 reduces the work of the liver and kidneys. For some patients especially the obese it is more important than entirely 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 serious cases he advised giving up amylaceous foods as well, and forbade the eating of potatoes, rice, sago, fruits, etc., and bread was allowed only in moderation. Many acids contained in fresh fruits, such as benzoic or quinic acid, have a favorable solvent action. These acids are found in the external cuticle of fresh fruits and vegetables, which may be eaten in cases of lithsemia. According to the late Dr. Lyman of Chicago, eating raw, unpeeled apples in considerable quantities supplies potas- sium salts, which tend to increase the alkalinity of the blood, but sweet fruits, pears, grapes, plums, strawberries, etc., may not be indulged in. Patients may eat abundantly of oatmeal, wheaten and Graham bread toasted, macaroni, fresh young peas, string beans, Lima beans, rice, spinach, asparagus, eggplant, celery, lettuce and other salads, except tomato (without oil). Meat should not be eaten oftener than twice a week. Fresh fish, sweetbread, poultry, and game may be taken sparingly. No diet should be strictly enforced in every case alike. Alexander Haig (Diet and Food) classifies as "uric-acid- free " foods, milk and its products, breadstuffs, cereals and glutens, nuts, vegetables, and fruits. If lithaemia is present in young 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 562 DIET IN DISEASES OF THE URINARY SYSTEM puddings of bread, crackers, rice, or sago, but not of raw flour. They should not be offered sweets. They have poor appetites, and variety ought to be prescribed, or they will lose weight and strength. The cooking is as important as the composition of the food. Beverages. Various alkaline mineral waters are constantly pre- scribed for adults, and patients who can afford to take the course are' benefited by the waters of Vichy $ Evian, 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. Waukesha, Londonderry, and Buffalo lithia waters are also used, but it may 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, but they should make a strong effort to give it up completely. Malt liquors and sweet wines, champagne, and spirits had better be forbidden absolutely. A little good, sound claret or Scotch whisky in water is the least harmful drink. Gravel is much less common among habitual beer drinkers than among those whose daily beverage is wine. This is attributed by Moleschott to the greater acidity and larger proportion of alcohol in the latter. On the contrary, Ebstein holds that beer is not in- jurious in lithiasis, and tea has some reputation in checking the deposition of uric acid. Coffee does no harm. Important adjuncts to dietetic treatment are exercise to the de- gree of inducing free perspiration, Turkish or electric light baths, and an open air life. GONORRHOEA The dietetic treatment of gonorrhoea consists in avoiding all al- cohol and stimulating 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 at- DIET IN ABNORMAL DENTITION 563 tracting attention to their ailment, are often unwilling to restrict their meals, but they, should avoid acid fruits, red meats, all highly seasoned and fried food, pickles, condiments, and pastry. Alcoholic drinks in all forms are absolutely prohibited. Malt liquors are espe- cially bad, as they are in all diseases of the urethra, bladder, or pros- tate. No late meals should be taken. By observing these directions troublesome chordee and ardor urinae, so liable to appear in the first fortnight, may be prevented. Large quantities of such waters as soda, Seltzer, Apollinaris, besides two quarts of plain water should be drunk daily. The fluid dilutes the urine, diminishes the danger of cystitis, and has the additional advantage of decreasing the appe- tite. DIET IN DISEASES OF THE ALIMENTARY CANAL DISEASES OF THE STOMACH 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 is to be placed upon building up general nutrition. In all cases of dyspepsia, gastric catarrh, rickets, or syphilis the teeth should be examined carefully before prescribing special dietetic treatment. If the teeth are broken or irregular all solid food should be pre- pared by mincing or otherwise reducing it to a form requiring but little mastication. In a young child a sore mouth from swollen gums is often overlooked as a cause of anorexia. 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. Their use enables meats and other solid food to be eaten, and the act of mastication increases the flow of saliva, which not only digests starchy food but tends to neutralize a too acid gastric juice, if the latter be present. 564 DIET IN DISEASES OF ALIMENTARY CANAL 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 food which is easily swallowed and which is. free from the above objections. When the disease arises in infants their diet may 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 should be given by the rectum. (See Nutrient Enemata, p. 455.) Otherwise small quantities of fluid food should 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 the food should all be pre- digested with pancreatin. The above directions apply also to cases of inflammation of the mouth and pharynx caused by corrosive poison, 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 may be swallowed most easily. The pain caused by this act is often so extreme that it is advisable to concentrate all food, to lessen the number of necessary acts of deglu- tition. Meat juice, peptonoids, and beaten eggs, may be added to good milk. Junket and custards are easy to swallow. 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 utilized for swallowing considerable nourish- ment. This is rarely necessary, for unless the patient is emaciated by previous serious illness, he is not likely to be in need of much food for a day or two. In serious cases of suppurative tonsilitis the strength suffers more, and stimulants may be given by the rectum if deglutition bo impossible. DYSPHAGIA 565 After all forms of tonsilitis there is often considerable anaemia, and the patient for a week or two should eat abundantly of animal food. Eggnog and milk punches may be needed for the first few days of convalescence from quinsy. 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; retropharyn- geal abscess; stricture or carcinoma of the oesophagus; pressure from new growths external to the oesophagus; paralyses (sometimes of central origin) ; operations upon or near the pharynx; or the wearing of an O'Dwyer intubation tube in the larynx. The devices employed to enable the patient to overcome pain or difficulty in swallowing should include reduction of the efforts at swallowing to a minimum. A raw egg or oyster may sometimes 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 consist therefore of concentrated nutriment in a smooth, semisolid or gelatinous form. Wine jelly may be re-enforced with beef peptonoids, beef meal, or egg albumen, and custards may be thickened with farinaceous material to a consistence which will enable them to be swallowed quickly. Milk or cream toast may be prescribed. When patients are unable to swallow, an cesophageal tube is in- serted for feeding, which, however, should be a catheter of small caliber (English 8 to 18), and which need not be passed very far down into the oesophagus. If necessary, a 2- or 4-per-cent solution of cocaine may be applied first to the pharynx to relieve pain and irritation. The fluid food eggnog, broths, thick gruels, milk, cream, etc. is poured into the tube through a funnel. When tube feeding cannot be practiced, 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. D. B. 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 cancerous or tubercular ulceration of the 566 DIET IN DISEASES OF ALIMENTARY CANAL epiglottis, tonsils, etc., which are intensely painful, it may be justifi- able 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 worse than the pangs of hunger. STRICTURE AND CARCINOMA OF THE OESOPHAGUS In diseases of the oesophagus which render swallowing difficult all food should be given in semisolid or fluid form. Many vegetable substances may be made in purees, which may be strengthened by meat juice, meat extracts, or beef meal. Milk junket or cream in various forms, is always soothing, and may be the only food which the patient. can take. Eichardson states that in cesophageal stricture cold food relaxes the circular fibers of the oesophagus and dilates its lumen, whereas hot food has an opposite effect. In some nervous patients this may prove true, but in most cases of genuine stricture or occlusion the temperature of the ingested food makes 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 cor- rosive poisons have been swallowed he should be fed by nutrient enemata. Should the trouble not be overcome, a gastric fistula may be made. 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, having- a double flange, like a spool. The tube, if metal, is nickel-plated to prevent 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 lies 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 and water is poured directly through the fistulous opening 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 may be pushed into the stomach with a glass rod or forceps. Medicines are conveniently given through the same opening. When the fistula lias been made for other cause than malignant disease the tube may bo worn indefinitely with no other inconvenience than that attending the peculiar process of feeding. I have seen several pa- FOREIGN BODIES SWALLOWED 567 tients who have worn such tubes for years, and who go about like other men, excepting that they take their meals in private and feed themselves while lying on the back. One of these patients, who was operated upon in Bellevue Hospital by F. S. Dennis for a benign stricture of the pylorus following typhoid fever (an extremely rare lesion), first masticates his food, then expectorates it and pushes it into the tube with a glass rod. He maintains robust health and on one occasion returned to the hospital in a state of hilarious inebriety, having fed himself the greater part of a quart bottle of whiskey through his funnel. In some cases the use of the tube may be discarded, the opening into the stomach being automatically closed by a flap-like valve of tissue. 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 having passed beyond the reach of the finger or cesophageal probang, an emetic may be given. If this fail to return the foreign body from the stomach, the patient should eat large quantities of bread, oat- meal, or potatoes. The plan of this treatment is to furnish a bulk of fecal matter, which in the intestines may envelop the pin or bone, and prevent its sharp or roughened ends from injuring the mucous membrane. Three hours later a dose of castor oil should be given. By this means many dangerous objects may be voided safely. If the foreign body does not appear after the oil has acted, the treat- ment should be repeated next day, and the stools 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 exhibiting themselves as possessing " iron stomachs," and who swallow broken glass, coins, nails, etc., take con- siderable 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 outlined above, they manage to escape death. The insane, imbeciles, and idiots, often swallow foreign bodies of various kinds, the former sometimes with suicidal intent. Pins, needles, fragments of broken china and other sharp bodies are some- times used for this purpose. 568 DIET IN DISEASES OF THE STOMACH INDIGESTION AND DYSPEPSIA Symptoms. Indigestion and dyspepsia are terms which refer essen- tially 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 epigastrium and prsecordium, eructations, "water brash," palpitations, vertigo, head- ache, 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 restlessness, and despondency. As Sir Henry Thompson said : " The word indiges- tion denotes not a disease, but an admonition." The late J. M. Fothergill wrote: "If it were not for the pro- tection of indigestion, of which many so bitterly and ungratefully complain, the lives of a large number of individuals would not at- tain their furthest potential expansion." Many of these symptoms, especially those referable to the nervous and vascular systems, are due to the fact that morbid products which closely resemble poisonous alkaloids in their action (as indeed in their composition), are easily absorbed, and produce effects varying in intensity from slight headache to the collapse of violent ptomaine poisoning (p. 421). Other symptoms are doubtless due to imper- fect elimination of waste matter of food or " ashes " from the system. Bauer says : " It is beyond doubt that insufficient secretion is the essential cause of most dyspeptic symptoms as they appear in various disorders of the stomach." In severe fevers and conditions of advanced anasmia 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 hypera?mia and inflammation of the stomach excited by* coarse irritating food have the same result, and the free acid, if se- creted, is neutralized by abundant mucus. Deficiency of hydrochloric acid in the gastric juice has a three- fold effect: 1, Failure to digest proteids; 2, failure to arrest mal- fermentation or putrefactive changes in the food; 3, failure to excite gastric peristalsis, so that the food lingers too long in the stomach. INDIGESTION AND DYSPEPSIA 569 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 atmospheric air; but food which is improperly fermenting is capable of evolving others, and those which have been determined by analysis of eructa- tions are C0 2 , H 2 , 2 , N 2 , CH 4 (marsh gas) C 2 H 4 (olefiant gas). Karl Emil Ewald reported a case in which sufficient marsh gas was evolved from the stomach to be collected and ignited and 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 usually of a dull aching variety, but is sometimes sharp and acute. It is often erroneously referred to the heart, but is due rather to hyper- aesthesia of the stomach wall, excited by products of imperfect di- gestion. In all diseases of the stomach the prolonged retention of any particles of undigested food gives rise to irritation and malfermenta- tion, which still, further complicates the diseased condition of the organ itself and interferes with its proper action upon fresh quan- tities of food. This occasionally may be relieved by vomiting or by the ingestion of some simple fluid which will aid in washing the stomach contents onward into the intestine. Etiology. Idiosyncrasies. Personal idiosyncrasy is a very potent factor in dyspepsia. Xot only do individuals vary from one another in this regard, but the same person varies at different periods, in different stages of health, or at different ages. One not uncom- monly observes persons who are 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 570 DIET IN DISEASES OF THE STOMACH hand, many whose digestion is normal at home are made constipated and dyspeptic by lack of exercise and other conditions at sea, even though they be never " seasick." How often do dyspeptics who have been kept long upon a strict regimen break away from all restraint and give astonishing accounts of the forbidden 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 preposterous 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 persons cannot eat strawberries without attacks of heart- burn, dyspepsia, and angina, while for others they are very whole- some 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 intolerance for twice-cooked meats, new bread, potatoes, sweet jams of any kind, etc. (See Idiosyncrasies in Eegard to Food, p. 438.) Other Causes. Fats and greasy foods set up butyric-acid fermenta- tion which causes heartburn, regurgitation, and a rancid disagreeable 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, 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 list of foods, a fact which explains many of the conflicting dietetic rules which are didactically formulated by would-be authorities. Each new case should be studied separately, and general rules admit of many exceptions. Balfour concisely sums up the relations of food to enfeebled stom- ach digestion by saying : " Three things greatly disturb gastric com- fort 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 INDIGESTION AND DYSPEPSIA 571 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 urine and stools, and the nature of any irregularity such as 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 should be observed also, and in obscure cases the possible ex- istence of sources of reflex irritation, like ovarian disease, investigated. Proper cooking should be insisted upon. Thorough cross-examina- tion in regard to all of these conditions may reveal habits not sus- pected by the patient to be injurious, and which easily may be cor- rected. Slow Eating. 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 earn- ing for Americans the title of a " Nation of Dyspeptics," for a meal quickly served is too quickly eaten as well. A dyspeptic child should 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 fibers often appear in the stools unaltered. The sense of taste may be utilized in order to prolong mastication, by savory 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 com- pletely subdivided or tender, as, for example, tough meats and stringy or fibrous vegetables. (See " Fletcherism," p. 384.) Pain. In nervous dyspepsia pain exists as a prominent symptom, and is often independent of the quality of the food even a mouth- ful of water may cause it, but, as a rule, fatty and acid foods excite it, and therefore should be avoided. The appetite, too, varies greatly 572 DIET IN DISEASES OF THE STOMACH it may completely fail at one time, and return in an exaggerated form at another. Decker reported the case of a patient who was uni- formly awakened from sleep by such excessive hunger that he was obliged to take a hearty luncheon in the middle of the night. Such patients usually secrete an excess of hydrochloric acid in the gastric juice. 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 1. The degree of acidity of the gastric juice. 2. The vigor of peristaltic action of the stomach wall. 3. The rate of absorption from the mucous membrane. To determine the acidity of the gastric juice, a fresh specimen of an ounce or two should be obtained for analysis, and the best method is by siphonage. The stomach tube is inserted in the manner de- scribed for gastric lavage (p. 598.) 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 determined by following lavage by a test meal. After a definite period the stomach tube is again introduced and a sample of the stomach contents withdrawn, filtered, and examined for hydrochloric acid and pepsin. If desired, other tests may be made for rennet ferment, carbohydrates, peptones, albuminoses, lactic acid, phosphates, and fatty acids. The test for hydrochloric acid is the 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 Eiegel 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 stom- ach contents should be withdrawn for examination one hour after the test breakfast, but between four and five hours after the dinner. Riegel and Leube's test dinner consists of: Beef soup, 400 c. c. ; beefsteak. 200 c. c. : white bread, 50 c. c. ; water, 200 c. c. Ewald's test breakfast is 35 to 70 c. c. of wheaten bread (one or two whito coffee rolls) with 300 c. c. (10 ozs.) of water or weak tea INDIGESTION AND DYSPEPSIA 573 without sugar or milk. When the contents of the stomach are with- drawn one hour after ingestion of this meal its total quantity should be found reduced to 20 to 40 cubic centimeters, or an average of one ounce. Dujardin-Beaumetz' test breakfast consists of coffee or tea with milk and a little sugar, and one or two plain rolls; no butter. The fluid should 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, fullness and weight at the stomach, there is diminished or hypoacidity. If pain occurs within fifteen minutes with increasing intensity there is probably some organic lesion. In hyperacidity, moreover, the burn- ing 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. Boas' test breakfast consists of an ounce of rolled oats boiled in a quart of water to a pint, and salted. The absence of lactic acid makes this a useful meal when it is desired to test the presence of that acid in the stomach. Various combination meals are also used to test the combined proteolytic and amylolytic power of the gastric juice. A sample meal of this sort contains bread, rice, eggs, and meat with a glass of milk. In withdrawing the contents of a stomach after a test meal the same tube is used (Xo. 23, A), and in the same manner as that em- ployed for lavage, described on p. 598. It is important that its intro- duction should not be accompanied by violent retching, for when this takes place bile is liable to be regurgitated into the stomach and neu- tralize 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 recommends, by allowing the patient to swallow a few drops of the solution, to anesthetize the oesophagus. The use of a rather stiff tube, quickly inserted, diminishes the liability to retching. The tube should not be lubricated when used for the test meals, but it should be wetted. The gastric contents may be forced out through the tube by direct- ing the patient to forcibly expire, thereby compressing 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 Davidson syringe. If no fluid flows, 574 DIET IN DISEASES OF THE STOMACH a little air or warm water may be forced through the tube to cleanse the obstructed fenestra. 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 HC1 and lactic or other organic acids commonly developed by malfermenta- tion. This total acidity should equal normally 40 to 65 units, which represents the number of cubic centimeters of test solution required to neutralize exactly 100 cubic centimeters of gastric filtrate. The test solution is prepared as follows : " Four grams of NaOH dissolved in one liter of distilled water are used for neutralization ; each cubic centimeter of this solution will exactly neutralize 0.00365 grams of absolute hydrochloric acid. The number of cubic centimeters so used multiplied by 0.00365 equals the percentage of HC1 contained in 100 cubic centimeters of the gastric filtrate" (D. D. Stewart). Chemical Tests for Free Hydrochloric Acid. A number of chemical tests have been devised for the detection of hydrochloric acid. Gunzlerg's Test for Free Hydrochloric Acid. Phloroglucin, 2 gs. ; vanillin, 1 g. ; absolute alcohol, 30 gs. Mix. Two or three drops of this solution are placed on a white por- celain dish and allowed to flow slowly in contact with a similar quantity 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-colored 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 merely a faint trace of the free acid is present the appearance of the color should be watched carefully, for it is very evanescent. Giinzberg 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 -color. If it appears when the dilu- tion is carried beyond this limit, hyperacidity is present. The Boas Test for Free Hydrochloric Acid is performed in a sim- ilar manner to the Giinzberg test, but the color produced varies from rose to vermilion, and the solution is made as follows: Sublimed resorcin, 5 gs. ; sugar, 3 gs. ; dilute alcohol, 100 gs. Mix. Both tests are only of value from a positive standpoint i. e., if the color reaction occurs, free hydrochloric acid surely is present. They are, however, of little or no value as negative tests, for the reason INDIGESTION AND DYSPEPSIA 575 that if peptones or certain other substances are present in the stomach contents the reaction may be obscured entirely. The latter difficulty is met by application of the calcium-carbonate test, which is uninflu- enced by other substances likely to be associated with the gastric juice, with the single exception of an excess of acid phosphates. The Calcium-carbonate test 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 a fresh sample of the gastric contents which has been neutralized by the addi- tion of dry pure CaC0 3 . The redness of the first paper when com- pared 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 CaC0 3 test indicates subacidity. If the latter test fails, then no free acid is present. If the litmus dipped into the gastric juice neu- tralized by CaC0 3 is reddened, the presence of acid salts (phosphates) is indicated. Sahli's test for free hydrochloric acid is qualitative, not quantita- tive. It is most ingenious, and has the advantage that it does not require the passage of a stomach tube. It is performed as follows: One grain each of powdered iodoform and methylene blue are placed upon a small piece of thin dental rubber dam, not over an inch square. The ends of the square are then gathered together so as to make a tiny bag, and firmly tied with a piece of crude (not sterilized) catgut. The bag, which is about the size of a large pea, is then swallowed by the patient immediately after a meal. If no free hydrochloric acid be present the bag passes on and is voided unopened with the stools, for the catgut with which it is tied is not dissolved in a neutral or alkaline medium. If, however, free hydro- chloric acid and a little pepsin be present, the catgut dissolves, liberat- ing the contents of the bag. The patient's urine is examined in about six hours and again in twelve hours, and it will be found to be stained bright blue by the aniline, and also to give an iodine reaction. In a number of cases in which I have tried it, the test has given a uni- formly positive result, but in one case of carcinoma, the patient hav- ing died three weeks later, the autopsy showed that the small piece of gutta percha was still retained, and acted like a valve, lying over the greatly narrowed pyloric orifice! The normal gastric free hydrochloric acid maintains a remarkable uniformity in maximum strength, rarely exceeding 0.2 per cent. It has been shown bv Ewakl and Leo that it is not secreted dur- 576 DIET IN DISEASES OF THE STOMACH 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 HC1 is not apparent in the gastric juice until the combinations mentioned have all been saturated, after which it increases in strength to the normal standard of 0.15 to 0.2 per cent. If alkalies are in- gested, more HC1 is secreted; but if acid be taken, the further secre- tion of HC1 is checked, so that the average strength is preserved. 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, whereas free HC1 may not appear for half or three- fourths of an hour. 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 HC1 is present. Free hydrochloric acid checks 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 chol- era, are destroyed by the antiseptic action of the HC1. Hypersecretion. Hypersecretion of gastric juice is determined by withdrawing the contents of the stomach in the morning after lavage the previous evening. If more than 50 c. c. are obtained, hypersecre- tion may be said to exist, the exact nature of which is to be determined by the Giinzberg test (p. 574). Suggestions 'for the diet of such cases are given on p. 584. Gastric Atony. Gastric atony is determined by finding in the morning washings of the stomach undigested particles of food eaten the night before. The microscopic examination of the washings will exhibit bacteria, sarcinas, and saccharomyces. The treatment of this condition is given under Chronic Gastric Catarrh (p. 590) and Dila- tation of the Stomach (p. 597). 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 becomes white. A small piece is placed in a test tube with 15 or 20 c. c. of filtered gastric juice, and kept at a uniform temperature of 40 C. for two or three hours. If there is little normal HC1 present, a few drops more juice should be added. If no digestion occurs after some hours, pepsin is absent and the fibrin will decompose. Quan- titative or comparative tests may be made by using definite amounts INDIGESTION AND DYSPEPSIA 577 of fibrin and gastric juice, and noting the time required for complete digestion. Test for Rennet Ferment. The presence of the rennet ferment or rennin is easily demonstrated by adding a few cubic centimeters 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 rennin be present. Clinical Value of the Chemical Tests of Gastric Contents. It is important not to place too much reliance upon a single gastric juice analysis, for the following reasons: (a) The test meals are usually not sufficiently appetizing to stimulate copious secretion. The gas- tric secretion is stimulated into activity in part through the senses of smell and taste, in part through the mechanism of deglutition, and in part by the mechanical and chemical influences exerted by the food when in the stomach. A roll and glass of water or cup of weak tea may entirely fail to promote secretion through these means. (&) The mechanism of secretion is further complicated by the extensive nerve influences which control it, and which easily may . inhibit it. Thus the nervous dread of the passage of the stomach tube, or the disagreeable choking sensation induced by its first passage, may modify, if they do not inhibit, gastric secretion. I have a large number of records of analyses made by Dr. William Armstrong at my Clinic upon patients upon successive days, which show, for example, anacidity one day, hyperacidity the next, hypoacidity the next, etc. Such patients are often neurasthenic, but I have known patients in hospital with minor ailments who kept on eating full house diet and grew stout upon it, yet who were reported from the clinical laboratory as having entire absence of free hydrochloric acid and a mere trace of combined acid. For these reasons little satisfactory conclusion is to be drawn in a given case unless the average be taken of at least three analyses made under varying conditions and with different kinds of test meals for comparison. For example, the Ewald test breakfast may fail to promote an acid secretion, which is obtainable promptly with a Leube test meal. The presence of hyperacidity is somewhat more reliable than that of anacidity, and in general a better knowledge of the condition of digestion and of the stomach itself is obtained by tests of motility, inflation, and percussion, the microscopic examination of food con- tents, the search for mucus, fungi, bacteria, etc., than by purely chem- ical analyses. The quantity of a test meal recovered by siphonage depends upon the motility of the stomach, as well as the activity of secretion, and 578 DIET IN DISEASES OF THE STOMACH percentage acidity is therefore a very imperfect index of the activity of secretion. Tests 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 examine the stomach with a tube after the ingestion of a Leube's test dinner (p. 572), or Ewald's test breakfast (p. 572). 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 duodenum. If undigested food remains six or seven hours after eating the Leube test dinner, the motility is impaired, or gastric atony is present, and the diet should be regulated accordingly. (See Chronic Gastric Catarrh, p. 590, and Dilatation, p. 597.) Ewald and Siever's Method. Another method, that of Ewald and Siever, is simple, but not very reliable. Fifteen grains of 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 color which appears in the urine on adding a drop or two of ferric-chloride solution. The chief difficulty in the performance of the test is in getting urine when wanted without catheterization. Frequent catheterization merely for the purposes of such a test is to be condemned, and patients usually cannot micturate every fifteen minutes. Brunner and Huber prefer to make the test dependent upon the disappearance of all trace of salicyluric acid after ingestion of one gram of salol. Normally it may 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 ingestion. Bourget found that the reaction time is delayed an hour or more by giving a dose of HC1 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 neutralizing the duodenal juices, might retard the salol reaction without the existence of motor insufficiency. Klcmpcrcrs Method. Klemperer has the patient swallow 100 grams 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 stom- ach is washed OUT. The oil is abstracted from the washing with ether, INDIGESTION AND DYSPEPSIA 579 and the ether is separated. The oil is then measured. Between 70 and 80 grams of oil should pass on into the intestine inside of two hours, but if it has not done so there is lack of motility. Sahli has devised a test meal of a soup of butter, flour, salt, and water to test the mobility and other functions of the stomach, but its preparation and use is too elaborate for ordinary clinical purposes. 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 separate saucers, and with normal absorption from a healthy stomach iodine may be detected in the secretion in from six and a half to fifteen min- utes, 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 color appears if iodine is present. This test is not very reliable, for if the stomach is full of food the reaction is much retarded, as it also is by fever and in most diseases of the stomach, notably ulcer, carcinoma, and dilatation. Bacteria in the Stomach. The bacterial flora of the stomach is highly varied, and its study quite as important as mere chemical anal- yses of gastric juice. Abelous has described 16 species of microorgan- isms from the stomach contents in health, including the Bacillus putrificus and Bacillus acidi lactici and various yeasts and molds, sev- eral of which cause active fermentation of sugars. Dietetic Treatment of Dyspepsia The foregoing details of the clinical examination of the digestive power of the stomach have been given in this connection as a con- venient place to summarize them. It is not intended to imply that every case of simple dyspepsia should be subjected to so complex 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 unadapted to their particular trouble because it has never been inves- tigated thoroughly. The stomach is useful more as a receptacle for food than for its necessary digestion or absorption, for in cases of its total extirpation or total abolition of function digestion and nutrition may be maintained fully through the intestine. Hence it follows that in all gastric derangements it is desirable to impose as slight a burden upon the organ as possible. To this end food should be masticated 580 DIET IN DISEASES OF THE STOMACH thoroughly, or given only in a state of fine subdivision. The food should also be as concentrated as possible, and if necessary given in small quantities at frequent intervals. The dietetic treatment of dyspepsia is so complex that it is easier for some persons to be put upon a very 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 con- venience 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. Eich soups, gravies, and sauces. 2. Strong condiments, pickles, vinegar. 3. Fresh soft bread of any kind (which makes a tenacious bolus), hot breads, all kinds of pastry, cakes, griddle cakes, doughnuts, muffins. 4. Sweets, tarts, jams, confectionery and candies of every kind. Sugar in all forms, especially in coffee and tea with milk. 5. Baw vegetables, such as celery, radishes, cucumbers. 6. Heavy vegetables sweet potatoes, corn, peas, beans, beets, egg- plant, cabbage, cauliflower, Brussels sprouts, turnips, carrots, parsnips (nearly all the roots and tubers). Peppers, romaine. cucumbers, rad- ishes, cranberries. 7. Fat in quantity, all fried or greasy food. 8. Clams, mussels, lobsters, crabs, shrimps, salmon, herring, bluefish. 9. Dried, smoked, cured, potted, or " devilled " meats or fish. 10. Corned beef, duck, goose, wild fowl, rabbit. Veal, except as broth. Venison, pork. 11. Twice-cooked meats, hash (unless freshly made, without pota- toes), stews, ragouts. 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 consti- tute exceptions to 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). INDIGESTION AND DYSPEPSIA 581 Starchy Foods. Where it is desirable to give starchy food in some form, macaroni, spaghetti, or rice, may be allowed, or one of the prepared foods, such as Carnrick's or Mellin's. All starchy foods should be cooked most thoroughly, for salivary digestion is often feeble in connection with gastric disorders. 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. Fruits. As a rule, sweet fruits disagree, though they may be eaten by some patients. C. Desirable Foods to Be Recommended in Ordinary Cases. 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 because bet- ter aerated.) Macaroni, puffed or boiled rice, hominy without sugar. Fats. In moderation only; butter to be very thinly spread and well rubbed in. Sometimes a thin slice 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 mutton, chicken (roasted or boiled), boiled capon, roast partridge, quail, grouse, woodcock, plover, squab, guinea-chicken. All meats should be short-fibered 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 consti- pation. Oranges, peaches, grape fruit. In serious cases the diet should be restricted further, and a bread- and-milk regimen may have to be enforced until improvement occurs. Beverages. Tea is generally injurious, especially if drunk with meals, but weak tea taken clear in very hot water with lemon is some- times beneficial by enabling patients to imbibe the fluid which they need. Strong tea is astringent; it precipitates pepsin and provokes 582 DIET IN DISEASES OF THE STOMACH constipation. Coffee, on the contrary, favors peristalsis, and is mildly stimulating to the nervous system. Drunk with milk and sugar it often excites dyspepsia and increases flatulency. Coffee does not itself ferment, but the milk and sugar drunk with it does. Taken black after dinner it is an adjunct to digestion. If it produces in- somnia or " nervousness " it should, of course, be discontinued. Cocoa (not chocolate, which is too sweet) may be allowed. An infusion of cocoa nibs often agrees. Milk or cream with Vichy, Seltzer or soda may be drunk as a beverage in non-flatulent cases. Koumiss and buttermilk are al- lowed. As a general rule, malt liquors and beers of all kinds are forbid- den, 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 in non-alcoholic patients, the use of pure wine, or weak brandy, or whisky and water drunk at meals may prove service- able. Sometimes a little dry wine, claret, or hock may be allowed twice a day with meals. Tobacco, smoked in great moderation, in the form of mild cigars or in pipes (not cigarettes), sometimes promotes digestion by slightly stimulating the nervous system and increasing peristalsis. (See To- bacco and Food, p. 404.) Special Systems of Treatment. The following systems of treat- ing dyspepsia are condensed from the writings of several of the best- known dietists: Dujardin-Beaumetz divides dyspepsia into three classes, and regu- lates the 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, peptonized food. 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 purees made of one of the following materials: Maize, flour, chestnut meal, oatmeal, pearl barley, potatoes, lentils, reva- lenta, macaroni (plain or buttered), vermicelli; purees of fresh vege- INDIGESTION A'ND DYSPEPSIA 583 tables, 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 taken shortly after meals. He directs in all cases washing out the stomach and stimulating the gastric mucous membrane, for which he orders the alkaline sodium bicarbonate in a tumblerful of Vichy an hour and a half be- fore 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 gravest 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 convalescence, includes milk, rice, spinach, roast chicken, partridge, venison, rare beef, veal, macaroni, fresh green vegetables, salads, fruit compotes, stewed apples, and light wines. He sometimes allows fish, such as bass. General Rules for Dyspeptics. The following general rules are ap- plicable to all cases of dyspepsia and indigestion: 1. Eat slowly, masticate thoroughly. 2. Avoid too much variety at any one meal. Take meats and vegetables at separate meals. 3. Drink fluid an hour before and two or three hours after meals, rather than with food. 4. Eat at regular hours. 5. If greatly fatigued, lie down and rest quietly before and after luncheon and dinner or supper. 6. Avoid as far as possible taking business worries or pro- fessional cares to the table. 7. Take systematic exercise in the open air. Bicycle and horseback riding are the best forms if patients are strong enough. 8. On rising, cold sponging and vigorous friction of the body is advisable. 9. The bowels should be kept open by laxa- tive foods and fluids rather than bv medicines. 584 DIET IN DISEASES OF THE STOMACH Rules for Special Varieties of Dyspepsia Dyspepsia with Excessive Flatulency. This often occurs in ner- vous women and neurasthenic men, and is especially annoying at night. Avoid particularly all sweets and amylaceous food. Take 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 waters, with meals. Dyspepsia with Hyperacidity. The diet should consist largely of rare finely minced or scraped beef (three and a quarter ounces is ample), with two slices of stale bread or toast, or a few crackers with a little butter (an ounce). Later the patient may partake of the lighter fresh vegetables and subacid fruits. Milk may be useful, with 10 grains of sodium bicarbonate to the tumblerful. Vegetables should be thoroughly cooked and mashed or made into purees. Fruit may be stewed or, in the case of apples, baked. Alkaline Vichy may be drunk after meals. A few weeks' course of such a diet faithfully adhered to often re- sults in cure. Dyspepsia with Excessive Nervousness; Irritative Dyspepsia. Avoid tea, coffee, much alcohol, tobacco, stimulating food of all sorts, condiments and pickles, and do not overeat. Eat slowly. Avoid eat- ing 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 tolerated better than proteids, unless flatulency is annoying. Atonic Dyspepsia ; Dyspepsia with Deficient Gastric Juice. Take three meals per diem, and freshly cooked meat should be included in two of them. Beef, mutton, and poultry are recommended. Meat broths and soup, 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 condiments. Dyspepsia in the Gouty. Avoid particularly sugar in every form, much meat, pastry, malt liquors, sweet wines, and champagne. (See Gout for details.) INDIGESTION AND DYSPEPSIA 585 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 should 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. These patients often have hyperacidity. (See Bulimia, p. 370.) Dyspepsia with Anaemia. Anaemic patients require abundant nitrogenous food, and well-seasoned, stimulating meat broths, eggs, and custards are recommended. Such patients may take an extra luncheon or two between the regular meals and before retiring. (See Anaemia, p. 539.) Dyspepsia in Infants and 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. Infants may suffer from three forms of milk indigestion, i. e., indigestion of fats, sugar, or proteids, either singly or combined. By far the commonest type is proteid indigestion, when the infant is fed upon cow's milk. The treatment is dietetic, by first withhold- ing milk altogether for a short time, substituting egg albumen, or farinaceous gruels, etc., and then using modified milk (p. 103), ac- cording to the type of indigestion. The latter is determined by exam- ination of the vomitus and stools. Whey is often a useful tem- porary food when proteid digestion is at fault. 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 quantity. If vomiting persists, a little bicarbonate of soda or one or two tablespoonfuls of lime water should be added to each feeding. Other substances, such as gelatin or one of the prepared infant foods, may be used to dilute the milk and prevent the formation of large 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 consisting 40 586 DIET IN DISEASES OF THE STOMACH of one part of cream and two parts each of whey and boiled (not boil- ing) water. An overfed infant vomits soon after nursing or taking the bottle, and the stools contain milk curds. When an infant receives too little 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 should be forbidden the premature use of coffee, tea, spices, coarse vegetables (cabbage, turnips, etc.), and unlimited ice water, fruits, and sweets. (See the sections on Diet for Infants, and Diet for Chil- dren. ACUTE GASTRITIS 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. Many persons appear to have special weakness or irritability of the stomach, so that attacks of gastric catarrh are excited in them by con- ditions 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 bolting large quantities of meat hash or of ice cream. Contributing factors exist in anaemia, nervous exhaustion, convalescence from pro- tracted illness, and in fevers, in all of which conditions the gastric juice, and especially its hydrochloric acid, is liable to be diminished in amount or temporarily absent. In these cases digestion is re- tarded far beyond the ordinary limits, and the retained food decom- poses by abnormal fermentation, thus becoming both a mechanical and a chemical irritant to the mucous membrane. ACUTE GASTRITIS 587 Symptoms. The chief symptoms dependent upon the local inflam- mation of the stomach are severe vomiting, nausea, local pain and tenderness, weakness, 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 reduction in the quantity of fluid imbibed is often curative after an interval of twenty-four or thirty-six hours. The irritation is maintained by ill-advised attempts to give food at frequent intervals with the object of supporting the strength. The attacks, from the very nature of their causation, often arise in robust persons who may well afford to forego nourishment for a few hours or until the nausea and pain cease. To others who have been en- feebled by continued illness or in whom the acute attack produces alarming prostration, enemata and stimulants and predigested albu- minoid food should be given. The vomiting and nausea are allayed by cracked ice, small quan- tities of iced champagne, carbonic-acid water, plain soda wa^er, 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 be relieved also by hot poultices and turpen- tine stupes, or spongilopiline soaked in hot water and sprinkled with a few drops of laudanum placed over the episgastrium. 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 (a half drachm to the pint) may be injected into the rec- tum, where it is soon absorbed. When nourishment is first taken by the mouth, it should be fluid, so that it will either undergo prompt absorption or pass into the duodenum for digestion. It should be administered only in small doses half an ounce or an ounce at a time. Pancreatinized milk, or cold milk diluted with an equal volume of lime water or soda water or alkaline Vichy, milk whey flavored with beaten white of egg added, beef extracts, peptone solutions, black coffee, expressed meat juice, and beef tea properly made, are all recommended. (See Keceipts for Invalid Foods.) Milk given alone or undiluted soon curdles in the 588 DIET IN DISEASES OF THE STOMACH stomach, and is promptly ejected in large tough coagulse. Many per- sons either cannot digest milk, or more often 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 not predigested milk, and with tact and perseverance they may be got to retain and digest milk in some form. (See Milk Predigestion, p. 90.) Some patients prefer warm milk diluted with water and flavored with a little cin- namon, a trace of coffee or caramel, or they may take barley or 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, unless the patient is so exhausted that some stimulation becomes necessary, in which case champagne or 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 abso- lute bodily and mental quiet. Convalescence. In convalescence the diet should be increased very slowly; otherwise relapse may follow, and the gastric mucus accu- mulates with more butyric-acid fermentation, and the vomiting and other symptoms return. At first only 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 tender chop, squab, or a bit of broiled fresh fish with lemon juice may be allowed with dry toast and rice pudding, or baked custard. It is well to give dilute hydrochloric acid (15 to 20 drops) with 10 drops of tincture of nux vomica after each meal. When the illness has been very severe the patient should be cautioned to be careful in eating for several weeks after the acute symptoms have subsided lest a relapse or gastric dilatation occur. Alcoholic subjects will prob- ably not heed this warning, but it should be given none the less. Acute Gastritis in Infants and Children Acute gastritis in infants is oftenest due to improper feeding. It is also excited, or rather promoted, by teething and other reflex irrita- tions which interfere with the normal stomach functions. There is an acute inflammation of the gastric mucosa, accompanied by more or less fever, 'vomiting, local pain, and anorexia. This affection is comparatively rare among nurslings. When it does occur in them, the mother's milk should be analyzed, and any errors in her own mode CHRONIC GASTRIC CATARRH 589 of life, diet, etc., corrected. If the breast milk continues to disagree, a wet nurse may be procured, and, failing this, the child should be weaned if the disorder continues. Children just weaned acquire the disease from overfeeding and from improperly prepared food, and the number of meals should be carefully regulated according to the rules for infant feeding. Older children who are allowed to come to table develop the disease from eating too rich or stimulating articles, such as pickles, sauces, spiced dishes, sweets, pastry, fried food, from drinking large quan- tities of very hot or very cold fluid, from eating hurriedly without proper mastication, or from gorging themselves with enormous quan- tities of foods of which they are particularly fond, such as meat hash, cakes, etc. If seen early, if vomiting has not already occurred and the stomach 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 gray powder. No food should be allowed for some hours, for it will main- tain 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 pancreatinized milk or milk diluted one-half with lime water or Yichy. If this is not retained, it is better to give a little meat juice or beef broth. The next day mild farinaceous food may be allowed, such as arrowroot, gruel, cornstarch, 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 is best to reduce the number of meals per diem a child who has been taking five should take four, or one who has had four should take three. CHRONIC GASTRIC CATARRH OR CHRONIC GAS- TRITIS Causation. Chronic gastric catarrh may be the outcome of such errors in diet as have been described as causative of the acute form. It commonly results, however, from alcoholic excess. It also accom- panies diseases in which the hepatic, and consequently the portal cir- culation is obstructed, producing engorgement of the vessels of the gastric mucous membrane. It may complicate pulmonary and car- 590 DIET IN DISEASES OF THE STOMACH diac diseases which cause obstruction to the venous circulation. It also is caused by the severer forms of stomach diseases. Pathological Physiology. Besides congestion of the blood ves- sels, which interferes with the maintenance of proper secretion and with absorption, the glands of the stomach furnish a hypersecretion of tenacious, ropy, alkaline mucus, which clings to the mucous coat and prevents the food from exciting the secretion of the gastric juice, and it neutralizes and prevents the latter from reaching the food. The food therefore is retained for hours in an alkaline me- dium, where it undergoes maceration and fermentation, which is par- ticularly liable to develop large volumes of carbonic-acid and marsh gas, which are periodically belched up with such force as to carry out the acrid fluid, and even particles of disintegrated food, produc- ing a bitter and nauseous taste in the mouth. The symptom of heartburn is due to the eructation of organic acids. The appetite is not always lost. It may, in fact, be excessive, and it is usually ca- pricious. Thirst is often a prominent symptom. Vomiting takes place at intervals, especially on rising in the morning, after the gastric mucus, mingled with the saliva swallowed, has accumulated during the night. Dietetic Treatment. If improvement is to be hoped for in the condition of a patient with chronic gastritis it is absolutely necessary to secure the intelligent co-operation of the patient himself by strict obedience to rules which should be specific and distinct. Many pa- tients will be found to have so little will power that, with the best intentions, when they sit at the table with others whose good health enables them to partake of all the luxuries of the season they are unable to resist temptation. A person suffering from chronic gastritis often seems to have only a small amount of nervous energy to expend, and if too much is diverted in other channels, little is left for the processes of digestion, and gland secretion is altered or withheld. It is a matter of every- day experience with such persons that when free from all concern and anxiety their digestion promptly improves and they can often eat quite indigestible food, whereas much plainer food disagrees with them while under mental strain. It is important for them that meals should be taken with regularity and that abundant time should be allowed for mastication. Eegular habits, outdoor exercise, and daily sponge bathing in cold water, followed by active friction of the skin, are to be recommended to patients whose strength permits. In forbidding certain classes of food, it is often observed that the patient has discovered that some one apparently indigestible material may be CHROXIC GASTRIC CATARRH 591 eaten with impunity, and there may be no harm in allowing this to be continued in mild cases. Sometimes merely eliminating from the diet such obviously indigestible rich foods as pies, griddle cakes, pickles, fried foods, or rich cheese, will produce marked improvement, but it is usually necessary to enforce a very strict regimen. Milk Diet. Serious cases, especially those complicating Bright's or cardiac disease, demand rigorous restriction of the diet, and it may become necessary to give milk exclusively for two or three weeks. From two to two and a half or three quarts of fresh milk are required for this diet in the twenty-four hours, the amount depending upon the size and weight of the patient. The milk may be given either hot or cold, but hot milk is better. It should be diluted with soda water or an alkali, such as sodium bicarbonate or magnesia, and salt should be added. Grave cases with extensive atrophy and abundant mucous secretion may require pancreatinized milk and beef prep- arations. In some cases, especially those due to chronic alcoholism, there is annoying thirst, which is relieved by diluting the milk with equal parts of Vichy or Apollinaris water. The fluid has the additional advantage of increasing the elimination of waste from the system through the kidneys. To most patients who are ill enough to require a fluid or an exclu- sive milk diet, it is preferable to give food frequently, at the rate of four ounces of the above mixture once in two hours, until the condi- tion of the stomach improves when the dilution of the milk is to be reduced, and it is given in larger quantity (six to eight ounces), while the intervals may -be prolonged to three hours. When much gastric irritation or nausea exists, the milk, if at all rich in cream, should be skimmed, as fat is not well tolerated. Buttermilk is used extensively in Germany and somewhat in this country for the treat- ment of gastric catarrh. It may be taken undiluted. To some per- sons the taste is more agreeable than that of ordinary milk. The casein of the buttermilk is already coagulated and exists in a con- dition of fine subdivision, so that it does not form large clots in the stomach. Patients usually tire sooner of buttermilk than of plain milk. Milk, no matter how given, is prone to produce constipation and if there is much dilatation of the stomach it usually is contraindi- cated. Other Diet. Should it prove impossible for the patient to digest enough milk to support strength, his diet should be supplemented with other articles of food, such as scraped meat or pancreatinized meat juice. As a rule, the food should be either fluid or al- 592 DIET IN DISEASES OF THE STOMACH most entirely solid; drinking considerable fluid with solid food dilutes the feeble gastric juice too much for proper digestion. No broth or soup should be allowed with meals. Alcohol should in gen- eral be forbidden, and tea, coffee, or cocoa are to be taken only in moderation, much diluted, and without milk and sugar. Occasionally light wine, such as hock and Moselle, may be given, but effervescing wines are forbidden. Fluids should not be taken too cold. Oysters may be allowed either raw, broiled, or panned. Butter may be allowed very sparingly, and cream sometimes, but in gen- eral fats and oils should be avoided as well as all fat meats, pork, sausages, and solid food cooked in grease. Eich gravies and sauces of every kind must be forbidden, and all solid food should be masti- cated thoroughly. Many patients live best on a diet of lean roast beef, rare steak, or white meat of chicken, eaten with stale white bread or dry toast and very little butter. This diet may be taken for some time before serious objection is made to it. One occasionally meets with persons in whom the digestion of salt and smoked meats seems to be more easily accomplished than that of fresh meat. The explanation offered by Niemeyer was that these preparations are less likely to decompose and form abnormal fermentation products in the stomach. Dried smoked beef, cut in thin slices and eaten almost or quite raw, is palatable and easily digested. Some dyspeptics can digest lean boiled ham, lean smoked bacon, and salt fish, such as shredded codfish, thoroughly cooked, better than they can fresh meat. Sweetbreads and calves' brains are digestible. Tough meat and flesh of young animals recently killed, such as " bob " veal, should not be eaten. Fish and soft-cooked eggs disagree with some persons, but others digest them without difficulty. Saccharine and farinaceous foods are to be avoided. Sooner or later they are certain to undergo lactic and butyric-acid fermenta- tion in the stomach with the production of much eructated gas, " sourness " and flatus. Sugar especially excites the secretion of gastric mucus. When improvement is established, the patient may gradually be allowed a little carefully prepared starchy food, but still no sweets of any kind. A single lump of sugar in a cup of cafe au lait drunk at breakfast can produce an acute dyspepsia, lasting all day. The varieties of starchy foods which first may be eaten are those which have been thoroughly subjected to the heat of baking or long boiling. Such are : Dry bread thoroughly toasted, bread crust, plain crackers, zwieback, gruels or meat soups thickened with arrowroot, thoroughly cooked sago, or ground rice, vermicelli, CHRONIC GASTRIC CATARRH 593 and macaroni well boiled. The purest carefully baked wheat bread from hard white wheat flour agrees better than the coarser varieties of brown bread, whole-meal breads, etc. Many persons who take an intelligent but not hypochondriacal interest in their digestion find by repeated trial that the bread of a certain baker agrees with them, while that of another does not, although its nutritive value for normal stomachs may be the same in both cases. This is due to differences in alteration of the bread. Potatoes are apt to produce flatulency with sour eructations, and when this is the case they should be forbidden. If roasted and very mealy they sometimes may be allowed. Among vegetables those which are especially forbidden are cabbage and cauliflower, the leg- umes, and corn. A little fruit may be allowed between meals, such as cooked apples, either baked or stewed, oranges or stewed prunes, if not too sweet. Especially forbidden are pastry, sweets of all sorts, sweet puddings and cakes, griddle cakes, hot breads, pickles, fried foods, and strong condiments. In all cases of chronic gastric catarrh it is important to reduce the bulk of food taken so as to diminish the liability of its remain- ing in the stomach undigested. Food which is so selected and pre- pared as to diminish the work of the stomach should be given only at long intervals in order that the digestion of one meal may be thoroughly accomplished before the next is eaten. It is well to order at least six-hour intervals between the meals, and they should not be eaten too soon after exercise. Convalescence. As the patient improves, the dietary may be some- what enlarged, and thoroughly cooked fresh vegetables, such as spinach, celery, asparagus, onions, string beans, lettuce, and fresh young peas, may be added. Fresh ripe fruit will be found serviceable in curing constipation, which almost invariably follows as a result of concentrated diet. In many cases this trouble should be counteracted by the daily morning use of some aperient, and a half tumblerful of hot Hunyadi water, or of Friedrichshall bitter water, or a drachm or two of Carlsbad salts in a tumblerful of hot water, should be taken each morning before any food is swallowed. The salts are further serviceable by diminish- ing hyperasmia of the stomach and hepatic engorgement. Much benefit is derived from drinking a glass of hot water or a glass of hot Vichy from half to three-quarters of an hour before each meal, the object being to separate the layer of thick ropy mucus which over- lies the orifices of the gastric tubules. Much of the advantage to 594 DIET IN DISEASES OF THE STOMACH patients with chronic gastric catarrh received from a course of treat- ment at Carlsbad, Marienbad, and similar spas is due to the action of sulphate of soda and other alkalies in removing mucus from the stomach, rather than to any specific virtue in the salts contained in the waters of such springs. Hydrochloric Acid. The value of hydrochloric acid given to aid digestion consists quite as much in its power to promote the con- version of pepsinogen into active pepsin as to act directly upon the food. The latter may be accomplished very well by artificial digestion outside of the body. If, therefore, there is complete atrophy of the gastric tubules in chronic gastric catarrh of long standing, the giving of the acid fails to excite secretion from tubules permanently de- stroyed, and Boas declares that the acid combines so readily with the salts and albuminoids of the food that it is not practicable to give enough of it to have any free acid remaining, and he only recommends it for those cases where the function of the gastric tubules, as shown by testing the digestive power of a sample of the stomach juice, is not completely abolished. He admits its usefulness as an antifermentative. This view is not generally held by other clinicians, however, and, as a matter of practical experience, the majority of these pa- tients improve by taking dilute hydrochloric acid with any solid animal food which is allowed them which is otherwise found to cause discomfort. It is best to give the acid not immediately with the food, but half an hour later, and twenty minims may be prescribed in one dose, or two or three doses of ten or fifteen minims may be given at intervals of half an hour. It may be prescribed alone in half an ounce of water, or mixed with a little glycerin in a claret glassful of water, and it should be swallowed through a glass tube to save the teeth from injury. It is advantageously combined with nux vomica. Exercise, Massage, Lavage, etc. Exercise should be recommended, but so regulated as not to interfere with digestion. It should be postponed until digestion has been in progress for at least an hour or two, and, when the patient's strength admits of it, gentle horseback or bicycle riding is beneficial for the young and middle- aged. Otherwise special exercises designed to strengthen the ab- dominal muscles and thoracic respiratory muscles may be em- ployed. Massage of the stomach, performed two hours after meals, is of service, and early morning lavage is of value when pyrosis and gastric distress occur so soon after eating as to indicate active malfermenta- tion. CHRONIC GASTRIC CATARRH 595 SUMMARY OF FOODS FOE CASES OF CHRONIC GASTRIC CATARRH IN WHICH A FAIRLY LIBERAL, DIETARY IS PERMISSIBLE Fish: Fresh fish, boiled or broiled, as bass, whitefish, whiting, sole, redsnapper, shad, weak fish, butterfish, smelt, perch, trout, with lemon, or a little plain butter sauce. Oysters (soft parts only) stewed, broiled or panned. Eggs, scrambled, shirred, poached or soft cooked. Meats: Eare roast beef, tenderloin steak, French mutton chops, roast or boiled mutton, lamb, lean ham, crisp thin-cut bacon, chicken, broiled or roasted, white meat of turkey, capon, guinea hen, grouse, partridge, quail, squab, tongue, sweetbread. Butter and cream, very sparingly. Saccharin in lieu of sugar. Cereals in small quantity, trisket, shredded wheat, puffed rice, puffed wheat, boiled rice, fine hominy, stale wheat bread, dry toast, milk toast, crackers, thin ginger snaps, dry sponge cake, zwieback, Huntley and Palmer wafers, pulled bread. Vegetables: White potatoes (sparingly, baked or mashed), as- paragus, artichokes, string beans, young new peas, spinach, lettuce (French dressing, not mayonnaise), oyster plant, squash, tomatoes (stewed or raw). Desserts: Bread or rice pudding, junket, blancmange, wine jelly, baked custard, Bavarian cream, plain vanilla ice cream. Fruits: Apple sauce, baked apples, stewed prunes (without the skins), oranges, cantaloupe, ripe peaches, or plums, pineapple juice (without the fiber.) Beverages (between meals), weak tea, coffee, soda lemonade. Kou- miss, zoolak, buttermilk. From this liberal dietary it is best to select not more than 3 courses or half a dozen kinds of food for one meal. This greatly lessens the complexity of the digestive processes. FOODS FORBIDDEN: Pastry, pies, puddings (except as specified above) brown bread, hot bread, cake, " cakes," sirup, candy and con- fectionery, honey, sugar, jams, marmalade, preserves, rich soups, gravies, sauces, veal, pork, sausage, pate de foie gras, canned foods, stews, hashes, ragouts, "stuffing" of fowl, condiments and spices, mustard, pickles, cheese, mushrooms, lobster, crabs, terrapin, clams, chowder, herring, mackerel, cod, halibut, salmon, sweet potatoes, radishes, corn, beets, baked beans, turnips, carrots, onions, cucumbers, cabbage, cauliflower, horse-radish Brussels sprouts, Lima beans, nuts, raisins, berries, cherries, banana?, grapes, grape fruit. 596 DIET IN DISEASES OF THE STOMACH t Chronic Gastric Catarrh in Children Children with chronic gastric catarrh should always eat their prin- cipal meal in the middle of the day, and take only a light supper. When of nervous temperament, they bolt their food without proper mastication. At the age too, when their deciduous teeth are being replaced they may from time to time have difficulty in eating solid food. This matter should be inquired into, and if necessary all such food should be minced before it is given to the child. Children accustomed to luxury usually overeat, and suffer in consequence. Their supervision at table is often left to ignorant or careless serv- ants, who should be cautioned, and better heed will be taken if the instruction is given by the physician rather than by an indulgent mother. In young children gastric lavage is easily performed, and may be beneficial, but older children are apt to * struggle and resist it. The tube may be passed as in gavage (see Gavage), and directions for lavage are given on p. 598. Their diet should be restricted mainly to bread and butter, rice, chicken, scraped beef, eggs, cus- tards, milk, baked potatoes, milk toast and milk. DILATATION OF THE STOMACH GASTRECTASIA Causation. Dilatation of the stomach may result from stricture of its pyloric end, or from chronic gastritis, in which case it is ac- companied by the secretion of much tenacious mucus. The stricture may be due to a carcinomatous growth, hypertrophied mucous mem- brane caused by chronic gastritis, or contracture following gastric ulcer. Gastric dilatation is also produced by loss of tone or paresis of the muscular coat, destruction of the muscular coat due to ulcer- ation, and lack of proper nervous or nutritive supply, such as results from debilitating illness, like typhoid fever, tuberculosis, or general nervous prostration. Less often it is caused by abuses of diet, especially those which give rise 7 to much gas by excessive use of effervescing beverages, beer, etc. The varieties due to gastritis, de- bility, and dietetic errors are most amenable to treatment. Pathological Physiology. The food is imperfectly digested owing to want of gastric juice and of peristalsis or to admixture with quan- tities of mucus : it therefore lingers in the stomach beyond the usual time, ferments, interferes with thorough digestion of the next meal, and renders the chyme unfit for the intestine. Food may lie un- DILATATION OF THE STOMACH GASTRECTASIA 597 digested in a dilated stomach all night, and be vomited with ac- cumulated mucus in the morning or perhaps after 24 hours. The undigested food by its weight drags down the stomach and favors further dilatation by stagnation and development of gases. The motor function of the stomach is almost completely suspended. Dietetic Treatment. For these reasons it is necessary to limit the quantity of solid, and especially of fluid nourishment. Nothing but the simplest articles of diet should be allowed. All food should be given in a concentrated and readily assimilable form, so that it will either be absorbed directly from the stomach wall or pass promptly into the duodenum. In advanced cases food should be predigested as much as possible. The more concentrated varieties should be chosen. Ewald recom- mends the employment of pancreatinized condensed milk, which is very nutritious and of agreeable flavor. It should be condensed with- out addition of the usual excess of cane sugar, which will surely fer- ment in the stomach. The patients are often thirsty, and, in fact, the original dilatation may have been caused by excessive imbibition, but the amount of fluid drunk with meals should be restricted to four or six ounces, or in serious cases no fluid at all should be allowed at mealtimes. If the thirst is considerable, a tumblerful of hot water may be taken a half hour before meals, to be absorbed or pass into the intestines before the food enters the stomach. Water is more quickly absorbed hot than cold. Thirst may be relieved by salt water enemata, but they rarely are necessary. The proper diet for gastric dilatation is the same as that recom- mended for serious cases of chronic gastritis (p. 590), except that it is more concentrated and smaller in bulk, and farinaceous food is almost entirely forbidden. At first only animal food should be given, such as scraped beef, beef juice or a piece of broiled chicken, with perhaps a very little dry toast or toasted cracker. If vomiting is a persistent symptom, the patient may drink milk very slowly, taking crushed ice with each mouthful. Later, after from two or three to six weeks, if improve- ment has resulted, more latitude is permissible, and the food ad- vised is lean meat free from coarse fiber; fresh vegetables, such as string beans, asparagus, tender and well-cooked purees, dry bread, lettuce or cress with vinegar, simple starches, such as sago, macaroni, rice, tapioca, and vermicelli, boiled or broiled oysters or fish, soft- cooked eggs, orange juice, stewed or baked apples without sugar, stewed prunes. Some patients may drink a tumblerful of boiled 598 DIET IN DISEASES OF THE STOMACH milk between meals, but, as a rule, it is best to take nothing. There should never be more than three meals a day, at six hour intervals, and some patients do better with only two. In mild cases, coffee and tea without sugar are allowed. To be avoided are most forms of starchy food, and sugar, pota- toes, old peas, beans, corn. Fruit consists largely of water in pro- portion to its nutritive value, and its vegetable acids are likely to disagree. It should therefore be eaten sparingly. Fats, butter, and oils are not digested in the stomach. Thirst-exciting foods, as salt fish, should not be taken, nor beer, effervescing mineral waters, red wine, or thin soups. In all cases too long continuance of a very strict diet is liable to cause the patient or the stomach itself to rebel. The patient should be weighed once a week. The stools should be examined and the general nutrition carefully considered. If weight is rapidly lost, the food, whatever it may be, is not being assimilated, and should be changed. It may become necessary to disregard the rules for fluid and put the patient for a time upon a diet of predigested milk. Aids to Dietetic Treatment. Other means of treatment which are really adjuncts to dietetic measures should be recommended. Such are lavage, massage, and electricity, which will be considered below. Mucus, especially that which is accumulated overnight, may be washed out of the stomach by sipping a cup of 'very hot water or taking alkaline mineral water, or a pint of water with ten grains of bicarbo- nate of soda, on rising. It is desirable for the patient to lie down for an hour and a half after eating, and he should especially avoid mental and bodily fatigue, which tend to divert both nerve energy and the blood from the func- tions of digestion. Lavage. In cases of either dilatation or catarrh of the stomach which fail to improve on restricted diet and other methods of treat- ment, lavage or stomach washing becomes necessary. This is an entirely safe procedure, and one to which patients become readily accustomed, provided sufficient tact and care is employed when the method is first applied. It was first practiced by Kussmaul in 1867. It should be attempted in all serious cases in which other methods to relieve the patient have been already tried and failed. It is almost indispensable in those cases in which the atony of a greatly distended stomach wall prevents the food from being expelled into the in- testine, causing constant fermentation, or in cases in which decom- posing food passes into the duodenum, exciting dyspepsia, meteorism, and diarrhoea. DILATATION OF THE STOMACH GASTRECTASIA 599 As many as sixteen varieties of bacteria have been obtained from the washings of a dilated stomach in which food had been stagnating. The advantages of lavage are twofold; it not only removes irri- tating and fermenting material from the stomach, and the ropy, tenacious mucus which it contains, and allays vomiting, but the water applied to the mucous membrane cleanses it and stimulates the gastric glands to normal secretion and the stomach wall to contrac- tion. It also promotes more regular action of the bowels. The relief from the sensations of weight, oppression, discomfort, and nausea which is promptly experienced after lavage is usually immediate and lasts for several hours. It is so great that patients not infrequently learn to pass the cesophageal catheter themselves, and, holding a pitcher of warm water in one hand and a funnel in the other, they wash and siphon out their own stomachs with ease. Usually it is sufficient to wash the stomach once a day. In extreme cases it may be necessary to perform the operation twice a day, but when improvement is once established, washing may be limited to every other day or may be employed occasionally, according to need, but it should be continued for several weeks after the subsidence of all symptoms. As a result of this treatment, the stomach may diminish in size, and the food is better digested and more completely absorbed, while nutrition and assimilation are correspondingly im- proved. The best time for digestion of the principal meal of the day is within an hour after lavage, when the stomach is empty and thor- oughly cleansed, and the meal often may be assimilated completely. If decided repugnance to food exists, the tube may be used for forced feeding, and peptones and predigested milk and eggs may be poured in before it. is withdrawn from the stomach, although, as stated above, it is best that too much fluid food should not be given. In performing lavage a medium-sized cesophageal tube should be selected, about one-third of an inch in diameter, having two or three large smooth eyes or "velvet" fenestra and made of good, smooth, red rubber which is sufficiently flexible without being so easily bent as to allow the tube to double upon itself in its passage. This tube should be fully eighteen inches long, and it is attached to a length of three feet of common rubber tubing by means of a small glass tube; the other extremity of the rubber tubing is fastened to a fun- nej through which warm water is poured into the stomach. A glass funnel is preferred, which makes it easier to examine the washings as they return. The patient is cautioned to keep the head thrown back, and the tube is gently pushed over the dorsum of the tongue 600 DIET IN DISEASES OF THE STOMACH and along the posterior pharyngeal wall into the oesophagus. The inser- tion of the tube will be facilitated by moistening it with water, white of egg or milk. If there is any difficulty in introducing the tube, its downward passage may be aided by passing the forefinger to the back of the pharynx. If the patient, who either sits or stands, be instructed to make an effort at swallowing while the tube is being inserted it will descend much easier, and pains should be taken to explain the process and reassure him, for nervousness and struggling may excite spasms of the laryngeal muscles and make it difficult or impossible to pass the tube. On reaching the cardiac end of the stomach, the tube is occasionally stopped for a moment, but the patient should be instructed to try and swallow, and with gentle pressure the orifice soon relaxes and the tube enters the stomach. Or a little water poured into the tube may cause the cardia to relax. The funnel is raised above the patient's head, but before pouring in much fluid it should be ascertained that he is able to breathe comfortably and quietly when the tube is momentarily compressed. He should be reassured that he will not choke. Accidents have occasionally hap- pened from passing small tubes down into the larynx, and I have known of one fatal case in which a nasal tube was thus passed and milk was poured into the lungs. A case has been reported in which beef tea was poured into the lungs in this manner, but the patient recovered and the beef tea was coughed up or absorbed. There is very little danger of introducing an cesophageal tube of the ordinary size in the wrong direction, for any attempt to push it into the pharynx will be met by obstruction and spasmodic coughing. If the stomach is full when the tube is first passed, some of the contents may be siphoned out immediately by lowering the funnel below the stomach level and holding it over a ^oot-tub or pail. If neces- sary, water may be poured in gently to the extent of a quart, or until the patient complains of uncomfortable fullness in the stomach. Care should be exercised not to admit air bubbles. The tube and funnel are then inverted over a foot basin and the contents of the stomach are quickly siphoned out. This procedure may be repeated a number of times until all the food and mucus have been removed and the washings return quite clear and neutral in reaction. The quantity of water used in the washing should be measured so that it all may be siphoned out again, as it is undesirable to leave any fluid behind. When the tube is introduced for the first few times it may excite efforts at vomiting, but it is not necessary to remove it, for the pa- DILATATION OF THE STOMACH GASTRECTASIA 601 tient can usually regurgitate the long, stringy mucus alongside of it. Salivation is often produced in the first few trials. After two or three passages patients will learn to swallow the tube with very little assistance and cease to gag upon its introduction. If there is hyperassthesia of the pharynx the pharyngeal wall may be touched with a 4-per-cent cocaine solution just before the introduction of the tube, or several large doses of bromide of potassium may be administered during the previous twenty-four hours. If nausea oc- curs when the tube first reaches the cardia it is usually overcome by pouring in a little fluid. The success of the operation at the first trial depends largely upon the skill of the physician and the degree to which he has obtained the confidence of his patient, and has been able to overcome any nervous feeling in regard to a process which is at best highly disagreeable. After the sufferer from gastric dilata- tion has experienced the relief which lavage of the stomach can give, he usually requires no urging to allow the process to be repeated. In withdrawing the tube it should be compressed in order to avoid having any of its contents trickle into the larynx; in this manner retching is less likely to ensue. The fluid used for washing the stomach may be either cool, or very hot water. Hot water is best, and it is well to sterilize it by previous boiling. If much mucus is present or much acidity, sodium bicarbonate may be added in the proportion of two or three per cent (15 grains to the pint), or a similar quantity of sodium borate or boric acid, a one-half-per-cent solution of salicylic acid, or a 1-per- cent solution of sodium salicylate. The best time for conducting lavage is shortly before the midday meal, the patient having had a very light breakfast, and it should only be performed when the stomach is believed to be comparatively empty. If the tube is introduced before breakfast, having had noth- ing to eat for a number of hours, patients are more apt to be dis- agreeably affected, especially if the washing be long continued, and I have seen them become faint under these circumstances. It is better, therefore, that a light breakfast of bread and milk, pancreatin- ized milk, or of a scraped-beef sandwich and a cup of black coffee should be taken; three hours later the stomach is to be washed. There are exceptional cases in which the patient is so distressed by the effort to pass the tube or by the operation of rinsing the stomach itself that it has to be abandoned. Lavage should be avoided in cases complicated by much prostration, feeble heart action, aneurism, hgematemesis, or haemoptysis. Accessory measures which are to be used in connection with lavage 602 DIET IN DISEASES OF THE STOMACH and careful regulation of diet are massage of the stomach, and medicinal treatment which consists largely of the administration of tonics, especially strychnine or nux vomica, with the object of increas- ing the muscular action of the stomach. Massage. Gastric massage should be performed about two and a half or three hours after each meal for ten minutes. The patient lies upon his back, with knees drawn up and muscles relaxed. The movements, stroking and kneading, always should be made over the stomach in the direction of the pylorus. If not too weak, the pa- tient may be taught to perform these movements himself. This treat- ment is often of considerable aid in mixing the food and gastric juice and in propelling the food into the intestine. It increases peristalsis. Electricity. Faradization of the stomach is believed by many to increase its muscular tone, and various forms of electrodes have been devised for this purpose. It is probable that very little, if any, electric stimulation reaches the stomach when currents of ordinary strength are applied over the epigastrium, although Ewald and Sievers claim that it does in some cases. This is especially true of faradism. Canstatt first proposed to apply the current directly within the stomach wall, and methods have been devised by Bardet, Einhorn, and others to serve this purpose. The ingenious electrode invented by Einhorn, of New York, is easily passed into the stomach. It consists of a hard-rubber capsule about the size of a small French olive. The hollow capsule has numerous perforations and within it is a small metallic electrode. The capsule is fastened to a fine flexible conducting wire, which is attached to the battery, and the wire is protected by a minute soft- rubber tube one inch in diameter. This electrode is readily swallowed by placing it upon the dorsum of the tongue and then drinking water. About 16 inches of the wire should be swallowed. In withdrawing the electrode after use it sometimes catches at the cardiac end of the stomach, but if the patient swallows a little water it slips past. When this electrode is in the stomach, which previously has been filled partially with a pint or more of warm saline solution, the second electrode, broad and flat, is placed over the epigastrium or over the back to the left of the seventh dorsal vertebra, and the electric cur- rent is turned on. This treatment is designed especially to increase the muscular tone of the stomach in atonic dilatation and stimulate peristalsis, but it also serves to promote secretion, and hence it doubly aids digestion. The electric current may be applied daily, immediately after lavage, for ten or fifteen minutes, and should be strong enough to induce VOMITING 603 active peristalsis. Even patients who are not accustomed to lavage seldom object to swallowing the electrode. Medicines. A variety of medicinal remedies are also used with the object of preventing fermentation of food in the stomach and intestine and for artificially aiding digestion by these organs. Among the former are to be mentioned creosote and other substances allied to carbolic acid, naphthaline, salicylic acid, etc. The use of hydro- chloric acid has been mentioned in connection with chronic gastric catarrh (p. 594). VOMITING SEASICKNESS VOMITING IN PREG- NANCY Vomiting occurs as a symptom of so many diseases and func- tional derangements that it will be advantageous to consider col- lectively the general dietetic means for its relief. The details of treatment will be explained under the headings of the various dis- eases in which vomiting may become a serious or prominent symptom. Pathological Physiology. Vomiting as related to dietetics may be caused by: 1. Excess of food. 2. Foods and drinks improperly combined (as crabs and milk, beer and champagne, etc.). 3. Fer- menting or poisonous food. 4. Irritating and indigestible food, in- cluding that which is improperly cooked. 5. Hastily eaten food. In hysterical patients and in very neurotic conditions of the sys- tem, either the sight, taste, smell, or mental suggestion of food may excite nausea and vomiting. Instances of the influence of the mind over stomach digestion and the mechanism of vomiting are too familiar to need elaboration. Food which is in itself nourishing may promptly nauseate through disgusting association or environment. For example, a party of early California settlers while crossing the continent were lost dur- ing a severe winter in the Sierras. When nearly dead of starvation some friendly Indians took compassion and fed them upon a delicious finely ground meal, which for some days was their staple article of diet, and on which they rapidly gained strength and weight. Being at first unable to understand the Indians, the emigrants could not learn of what the meal was composed. When at length they found that it was made from pounded dried grasshoppers it produced such nausea that none could touch the food again. Dietetic Treatment. The first principle in the dietetic treatment of vomiting from any cause is to give the stomach rest. If it has been overloaded with a large bulk of food, or with indigestible ma- 604 DIET IN DISEASES OF THE STOMACH terial, it is well to encourage emesis, and distressing retching may be overcome by taking large draughts of lukewarm water. A quart or two will rinse out the stomach and allay irritation to a marked degree. Well-nourished patients when serious vomiting first occurs should usually refrain from taking food of any kind for from ten or twelve to twenty-four hours. Exceptions to this rule are some- times found in that type of seasickness, and sometimes in the vomiting of pregnancy, in which, as soon almost as the stomach is emptied, there is a desire to replenish the loss. In any case in which gastric irritation is persistent it is necessary to give fluid food, and only in small oft-repeated doses, preferably in predigested form. The food is best given cold, as a rule, although some persons can relieve nausea by sipping very hot water. A teaspoonful of pancreatinized milk, or in extreme cases a few drops only, given with a medicine dropper once in ten or fifteen min- utes, may be all that the stomach will tolerate at first. The following is a list of dietetic substances which are commonly prescribed for the relief of nausea and vomiting, or for nourishment while those conditions exist : Cracked ice ; pancreatinized milk ; milk with sodium bicarbonate (ten grains), and cerium oxalate (five grains) ; milk and lime water in equal parts; milk and Vichy, soda, Seltzer, or carbonic-acid water; whey; koumiss and zoolak; beef ex- tracts and peptonoids, such as Johnson's Fluid Beef and Carnrick's Beef Peptonoids, somatose, Valentine's or Liebig's meat juice; raw meat pulp, scraped; strong black coffee; sour lemonade or lemonade and Vichy; clam broth. Dry crackers, dry toast, and gingersnaps will sometimes be retained in seasickness, or a cracker buttered and sprinkled with a little Cayenne pepper; brandy and soda; iced dry champagne; iced brandy diluted with water, plain soda water, or Apollinaris, Imperial Granum. Severe and protracted cases may require lavage or nutrient enemata. Vomiting after abdominal surgical operations is often controlled by lavage. Recurrent or " cyclic " vomiting is a gastric neurosis due to proteid putrefaction in the intestine, or possibly to an acidosis, occurring usually in young children up to the twelfth year. The vomiting re- sults from overexcitement, or fatigue, and occurs irrespective of the ingestion of food. The attacks are accompanied by serious prostra- tion, and often for a day or two no food whatever can be retained. In such cases rectal feeding may be resorted to (p. 455) with pep- tonized milk. When the vomiting has been quieted by rest and SEASICKNESS 605 medicinal measures, feeding per os should be resumed with gruels, vegetable purees, rice, etc., and proteid foods should not be given until the child is well, and then very sparingly. To avoid future attacks, it is well for the child once a month to be placed on a modified vegetarian diet with cereals, green vegetables, potatoes and fruits for a week, and then resume ordinary meals. By this alterna- tion of diet, combined with prevention of fatigue and excitement, es- pecially during the hours of digestion, the recurrent attacks may be avoided, or lessened. Seasickness There is no known dietetic treatment of seasickness which is ap- plicable to all cases. There are those who overeat because of the tonic of the bracing sea air. The idleness and lack of accustomed exercise, and perhaps something in the quality of the air itself, all contribute to make them bilious, and unloading stomach and bowels thoroughly once for all suffices to cure them for the rest of the voy- age. The habit of indulging in late " farewell suppers " is naturally the worst preparation possible for a sea voyage. Some persons at sea can leave the table, vomit the first two or three courses of a dinner, return, and finish the meal with astonish- ing equanimity. With them nausea is not a persistent or annoying symptom, and they need no treatment. Others are always nauseated, but fail to vomit, and consequently grow weak from lack of food. They do well to take a mild emetic at first, and usually a tumblerful of lukewarm water will serve to empty the stomach of food lying there undigested and fermenting. They are then temporarily re- lieved, and may assimilate some form of predigested food. Others, after severe experience with emesis, strongly crave and uch quantity that the liver fails to destroy them. Bouchard has at- tempted to show that the ptomaine-destroying function of the liver "BILIOUSNESS" 647 is aided by glycogen, and is consequently favored by ingest ion of starches. Dietetic Treatment. The digestive functions of the liver are so varied that it is difficult to arrange any diet for either functional or organic diseases of that organ which meets all the requirements of theory, but clinical experience has abundantly proved the value of certain general principles, the most essential of which is that the liver should be taxed as little as possible, and a non-stimulating diet is required of reduced bulk. Food in general after it has reached the duodenum acts as a stim- ulant to the liver, and two or three hours after a full meal the bile secretion is increased; but there are a few foods to which a special stimulating effect has been attributed, although their influ- ence, if any, is slight. Condiments, such as pepper, mustard, spices, and especially curry, may have such effect, and should be avoided. Fats and sugars eaten too freely disturb the action of the healthy liver, especially during hot weather. Coffee and tea may be allowed only in such moderation as one cup a day. Beer, ale, porter, strong liquors, liqueurs, and all sweet wines, such as champagne, sherry, Madeira, port, and Tokay, are absolutely forbidden. Alcohol should be prohibited as a rule, but if necessary, a little Rhine wine, hock, or Moselle may be used (not over a couple of glasses daily), or much-diluted whisky. Of all the organs of the body, none is more often poisoned and made cirrhotic b} r alcohol than the liver, and the moral needs no further emphasis. Many medicines, such as opium, derange the liver functions and inter- fere with the elaboration of food. More or less intestinal dyspepsia always results from alterations in the quantity or composition of the bile, and on this account as well, the food should be selected carefully, and all sugars and most farina- ceous aliments forbidden as well as fats. Among the articles especially prohibited in all cases of liver dis- ease are condiments, spices, curries, pickles, sauces, rich soups, fried food of every kind, veal, pork, sausages; salt foods, such as corned beef and salt fish ; crustaceans, new bread, preserves, and sweets of all sorts; pastry, puddings, cakes; all the heavier starchy vegetables, such as potatoes, corn, peas, beans, beets; salad oil, oily fish, like salmon and sardines. Only fresh food should be given. In acute functional derangement of the liver, at first, if there are vomiting and headache, only light gruels, and perhaps dry toast or crackers should be eaten. In regard to the suggestions given below, it may be stated that 648 DIET IN LIVER DISEASES IN GENERAL they are very general, and are applicable rather to the chronic types of hepatic disease, although they will serve also for those afflicted with recurrent or intermittent attacks of biliousness, and should be followed between the attacks. In very active disease, such as acute congestion, acute yellow atrophy, abscess of the liver, etc., obviously the diet should be limited much more. In ordinary uncomplicated bilious attacks induced by high living, a day or two of practical starvation with the use of a mercurial cathartic, is curative. The following articles usually may be allowed in moderation ex- cepting in very serious cases: Animal Food. Fish, such as sole, flounder, halibut, smelt, white- fish; the soft part of oysters, sweetbread; lean meat, such as rare roast beef, broiled beefsteak, mutton chops, or chicken (lean beef is better than game) ; eggs, milk preparations, such as koumiss, whey, buttermilk, junket, malted milk. Many persons with hepatic disorder insist that pure milk always makes them bilious. If this proves to be true of natural milk, it should be predigested or given with sodium bicarbonate or Vichy, or in one of the numerous ways described on p. 90. All meats and eggs should be allowed only in great moderation. In advanced cases of hepatic disease milk constitutes an excellent food, and may be used abundantly, provided the proper form for its administration in a given case is determined. Baked custard and blancmange or other forms of gelatin may be eaten. Vegetable Food. Of fresh green vegetables the following may be eaten: Spinach, string beans, asparagus, tomatoes, squash, celery, oyster plant, beet tops, cresses, lettuce (without oil). Potatoes, mashed or baked may be eaten. Cereals, Bread should be eaten in small amount, stale or toasted. Zwieback is good, and dry rusk, not too sweet. Graham, gluten, or wheaten crackers may be permitted. Other starchy foods should be taken sparingly; but boiled rice, rice puddings, sago, and tapioca are admissible occasionally. Fruits. Fresh fruit in season is wholesome, and useful to over- come the tendency to constipation. Grapes, oranges, pineapple juice, plums, peaches, and roast apples may be eaten. "Water should be drunk freely, except when ascites is present; and light beverages, such as lime juice in aerated water, lemonade, or orangeade vinegar, may be serviceable. Directions for Eating. The manner of taking food is important. There is hypersemia of the stomach and intestines from time to time, as a result of engorgement of the portal system, and catarrhal condi- tions are easily excited in these organs by food which is hastily bolted CATARKHAL JAUNDICE 649 without thorough mastication or which is not well cooked or not perfectly fresh. The teeth should be examined to ascertain if the patient can masticate properly. Fluids should not be drunk with meals. The patient should not eat directly after violent exercise or fatigue, but should first lie down and rest for three-quarters of an hour. If he suffers from dyspepsia, he should rest after meals as well. In many cases three meals a day suffice, and should be given at intervals of five hours, to insure complete digestion between. In others, when the patient is considerably enfeebled, or in cases of hepatic congestion and advanced cirrhosis, it is better to order meals four or five times a day, or once in three hours, giving a smaller quantity of food which is readily digested. It is advisable to take the principal meal at noon. Constipation is the rule, and laxatives should be prescribed fre- quently if the bowels cannot be kept in order by fresh fruit. Hot water in an empty stomach is quickly absorbed, and passes directly to the liver through the portal vessels. If salts, such as Carlsbad salt, are given, they are absorbed with the water, and pos- sibly stimulate the liver cells. The water increases the portal blood pressure, and thus indirectly the pressure of the gall ducts, promotes elimination of bile, and dilutes toxins. Moderate systematic exercise should be prescribed whenever pos- sible, and the best forms are horseback and bicycle riding. The " jouncing " movements of the former shake and compress the liver, and stimulate its circulation and the elimination of bile. ACUTE CATARRHAL INFLAMMATION OF THE BILE DUCTS ANGIOCHOLITIS CATARRHAL JAUNDICE A bland or non-stimulating diet is appropriate for the acute stage of angiocholitis. Vomiting is sometimes present, so that the stomach is not in a condition to bear solid food. Moreover, too much food on entering the duodenum will increase the local inflammation of the common bile duct. Diluted or peptonized milk is to be given, or buttermilk, whey, light meat broths, clam broth, pressed-beef juice, egg albumen. In a few days, if pain, tenderness, vomiting, and fever subside, the diet is to be increased slowly, and such articles may be added as milk toast, bread and milk, broths and light soups without vegetables, the breast of chicken, oysters, sweetbread, meat jellies. Later, eggs, and boiled or broiled fresh steak may be eaten. Fat and butter should 44 650 DIET IN LIVER DISEASES IN GENERAL be avoided, for occlusion of the crystic duct lessens fat absorption by withholding bile from the intestine, and pains should be taken to prevent constipation and putrescence of the intestinal contents. Fatty, amylaceous, and saccharine food is forbidden, and for some time after the acute symptoms have subsided the basis of diet should be fish, lean meats, and fresh green vegetables. Cooked fruits, not too sweet, and to which sugar has not been added, such as sour apples, prunes, etc., may be eaten. Considerable fluid should be taken both as a diluent and to promote the action of the kidneys and lessen the tendency to constipation. Water acidu- lated with lemon juice or effervescent waters (soda water, Seltzer, and Apollinaris) may be drunk three or four times a day between meals. Coffee and tea are permissible only during convalescence. CIRRHOSIS ASCITES Causation. Cirrhosis is a disease of the liver occasioned by irrita- tion of that organ .by substances in the blood derived among other sources from the portal system after direct absorption from the in- testine. Among such irritants may be mentioned as the foremost excitant, alcohol, which produces fully 60 per cent of all cases. Strong alcoholic stimulants often contain fusel oil or other especially noxious impurities. The prolonged excessive use of strong condi- ments, or spices, such as curry and peppers, may contribute to, if they do not directly cause cirrhosis. Experimentally, ptomaines have been made to excite the disease in the lower animals, and continued poisoning by such agents may possibly contribute to it in man. Cirrhosis may be caused in other ways, but the facts above mentioned show its possible relation to dietetic errors. As a result of fibrous hepatitis, the terminals of the portal vein are obstructed and the portal venous system is congested, the blood being dammed back in the vessels of the stomach, spleen, intestines, and pancreas. Owing to the congestion there is frequent vomiting, sometimes of blood, and there is marked interference with the character of the digestive se- cretions as well as the process of intestinal absorption. Dietetic Treatment of Cirrhosis without Ascites. Cirrhosis with- out accompanying ascites is often best treated by a milk diet for two or three weeks. Bread and crackers may be allowed with the milk, but nothing else. Hot water and aerated waters should be drunk in large quantities, fasting, to " flush " the system. Subsequently a light diet is to be prescribed in accordance with the suggestions given for tin.- Treatment of liver diseases in general (p. 647). All condi- CIRRHOSIS ASCITES 651 ments, relishes, sauces, fats, fried food, pastry, and sweets should be withheld, as well as alcohol in every form. The skin and bowels should be kept active. Ascites Pathological Physiology. A further important symptom which is often observed toward the close of a protracted cirrhosis, is ascites, or accumulation of serum in the peritoneal cavity, which has been produced by the altered blood pressure of the portal system and the altered composition of the blood itself. The fluid accumulates with considerable rapidity, and may reach an enormous quantity sometimes as much as twenty-four quarts greatly distending the abdominal walls, floating the viscera out of position, and by pressure interfering with digestion and absorption. In addition the loss of so large a quantity of serum from the blood is a serious detriment to nutrition, inasmuch as the ascitic fluid not only contains water in large quantity, but serum albumin, which may be present in the proportion of from 1 to over 6 per cent. In the ascites accompanying cirrhosis the loss of albumin in this manner may be somewhat less than when the serous accumulation is due to other causes. Repeated aspiration of the abdominal cavity not only abstracts large quantities of water from the system, but also abstracts considerable protein. In those cases in which fluid refills the peritoneal cavity promptly after aspiration, it is a question whether the nutrition of the body may not suffer by drawing off so much serum albumin. On the other hand, when once transuded, it is of no further service to the organism unless it can be reabsorbed. The point for considera- tion is whether too frequent removal of the ascitic fluid will cause greater drain on the blood than would be consequent upon letting it accumulate in the abdominal cavity. Much will depend upon the relative pressure within the peritoneal sac and the bloodvessels, which will affect the rate of osmosis of albumin. This discussion leads to the queries, first, whether it is not necessary to supply the constant loss of albumin by an increased allowance of animal food, and, secondly, to what extent water should be withheld from the dietary. Dietetic Treatment of Cirrhosis with Ascites. When uncomplicated ascites is present it is generally best to restrict the quantity of fluid ingested and put the patient upon a " dry diet," consisting of stale bread and butter, and meat chiefly. By simply withholding liquid and stimulating the force of the heart and the action of the kidneys I have sometimes seen diminution in the abdominal fluid, but this treatment is not always successful. There is more hope of success 652 DIET IN LIVER DISEASES IN GENERAL when the disease occurs, as it rarely does, in young persons. Cirrhosis and ascites are very apt to be associated with renal and cardiac lesions and gastric catarrh, which make it much easier to say what food the patient must not eat than what he may have. If the urine is very scanty it may not be wise to withhold fluids, and some clinicians of wide experience believe in giving liquids in unrestricted quantity, holding the view that this will increase diuresis to such an extent that not only will all the fluid drunk be eliminated promptly, but that the active kidneys will drain more from the blood, which will in time be replaced by reabsorption of the ascitic fluid. The same reasoning is applicable in cases of pleurisy, general anasarca, etc. It seems more rational to endeavor to promote diuresis when possible by medicinal measures than to add a large bulk of fluid to an already overbalanced circulation. If the fluid diet is followed by rapid reaccumulation of ascitic fluid after aspiration, for example, within a fortnight, it is desirable to replace it by as much simple solid nutriment as the patient can digest, or by predigested and con- centrated foods. An outline of the appropriate diet for such cases is given upon p. 592. The " salt-free " diet recommended for pleurisy with effusion, on page 556, may prove advantageous. It is of importance in every case to measure and estimate care- fully the total quantity of liquid ingested both in beverages and as food and make a comparison with the quantity of urine voided, and if possible with the weight of the patient and girth of the abdomen at different levels. The " grape cure " and " milk cure " have been strongly recom- mended in Europe for the treatment of cirrhosis and ascites. They are said to ameliorate the symptoms and promote reparative processes, both acting largely through diuretic influence. FATTY LIVER Pathological Physiology. The liver is the great storehouse of latent energy in the body, which is accumulated in glycogen and fat. A certain proportion of fat is to be regarded as a normal con- stituent of the parenchyma of the liver. This varies with the char- acter of the food ingested and degree of its oxidation in the liver and other tissues. After a diet consisting largely of fats and oils or of carbohydrates the accumulation of fat in the liver is considerable. Lack of exercise and unfavorable hygienic conditions, by retarding oxidation processes, also promote its accumulation. Persons addicted FATTY LIVER 653 to constant overeating of carbohydrates are therefore liable to this affection. They become stout, take less and less exercise, and the second condition favoring fatty infiltration of the liver namely, lack of oxidation is added. Fatty degeneration of the liver is caused by various diseases in which the composition of the blood is altered and the metabolism of oxidation is interfered with. Such are advanced anaemia, chronic alcoholism, and tuberculosis. It is sug- gested by R. H. Fitz that the fatty diet often recommended for the latter disease consisting of cod-liver oil, rich milk, butter, cream, etc. may be productive of fatty disease of the liver. Dietetic Treatment. The dietetic treatment is indicated by the previous considerations, but since the local condition is commonly merely an accompaniment of more serious general disease, it may be unwise to advise too sudden or extreme alterations in the accustomed diet of the patient. In general, all forms of sugar, starch, and fat should be reduced gradually to a minimum, excepting in tuberculous patients whose general bodily nutrition is of more importance than the danger of local fatty infiltration. In these cases the object de- sired is better promoted by increasing oxidation processes by climatic and hygienic treatment rather than by withholding carbohydrates. Malt liquors and alcoholic drinks in general are forbidden. In other cases, especially in the alcoholic form, the diet should consist of proteid food, fresh green vegetables, and fresh succulent fruits. SUMMARY OF DIET FOR FATTY LIVER Meats: Beefsteak, rare roast beef, lean mutton, roast lamb, chops, veal, chicken, capon, turkey, squab, sweetbread. Fish: Fresh fish, boiled or broiled, of any sort except salmon, mackerel and bluefish (as containing too much fat). Vegetables: White potatoes (very sparingly) string beans, lettuce, cauliflower, spinach, celery, tomatoes, artichokes, squash, parsnips, onions, eggplant, oyster plant. Cereals: Dry toast, crackers, Huntley and Palmer wafers. Gra- ham bread and oatmeal in small quantity. Fruits: Oranges, grape fruit, peaches, pears, plums, prunes, figs, apples (raw or cooked), melons. Beverages: Weak tea or coffee with saccharin in lieu of sugar. Alkaline effervescing waters. Lemonade, orangeade. Foods Especially Forbidden Are: Butter, cream, eggs, fried foods of every sort, bacon, ham, pork, sausage, pickles, condiments, pastry, confectionery, preserves, sirup, puddings, desserts of all kinds ex- cept simple gelatin foods (p. 147). 654 DIET IN LIVER DISEASES IN GENERAL AMYLOID LIVER The condition of amyloid liver after it has become sufficiently pronounced for diagnosis is usually fatal within a short period, and consequently little aid can be derived from dietetic treatment. The diet should be so regulated as to burden the digestive organs as little as possible, and in advanced cases such predigested foods as peptonized meat or milk ought" to be given. If the stomach diges- tion is fairly active, proteids will agree better than the carbohydrates. SYPHILIS OF THE LIVER In advanced syphilitic hepatic disease very simple food only is permissible, such, for example, as milk and eggs, chicken, beef or mutton broths, fresh fish, oatmeal, boiled rice, toast or stale bread, and light farinaceous puddings such as tapioca, sago, blancmange, and custards. Alcohol in all forms is prohibited. ABSCESS OF THE LIVER In hepatic abscess the same dietetic treatment is to be followed as that indicated for syphilitic disease of the liver. The aim should be to avoid overloading the digestive organs at any time, and to give assimilable and predigested food in small quantities at frequent inter- vals. Animal broths and light vegetable purees, with various com- binations of milk and eggs, should form the staple articles. No solid food should be given, except perhaps, a little fresh fish, such as sole or whitefish, a few oysters, sweetbread, and milk toast. Fats in all forms are forbidden. Malt liquors, port, sherry, and all varieties of strong alcoholic drinks are prohibited. GALLSTONES Pathological Physiology. Gallstones are formed in the gall blad- der or larger bile ducts by precipitation from the bile of cholesterin, mixed with more or less mucus and often a bacterial nucleus. Oc- casionally they contain bile pigment (bilirubin) or calcium carbonate. Cholesterin is an alcoholic substance which may be extracted in vary- ing amount from the blood or nervous tissues, especially the brain, and from the bile. It may be obtained in flat, rhombic, colorless crys- tals. Somewhat rarely it is excreted in the urine. It also exists in the waste matter contained in the lower bowel. It is maintained in solu- GALLSTONES 655 tion in the bile by alkaline salts, the sodium and potassium taurocho- late and glycocholate. Calcium unites with the latter substances, forming new compounds with the biliary acids which are insoluble salts that no longer hold cholesterin in solution. When organic acids exist in excess in the tissues calcium is liberated, and on reaching the liver produces the above reaction. An excessive accumulation of cholesterin in the system will result in its precipitation from the bile, and this occurs when for any rea- son the bile has long been retained in the gall bladder, where it has been concentrated by reabsorption of some of its fluid ingredients. Bacteria are undoubted agents in the formation of many stones. The precipitation of cholesterin is favored by the presence of a pre-existing hepatic stone or any foreign body in the gall bladder, such as an intes- tinal parasite, or its ovum, or thickened mucus or a group of bacteria. Gallstones are oftenest present in advanced life and among those who adopt sedentary habits which lead to accumulation of bile in the gall bladder. On the latter account they are more common among females, and their occurrence may be related to excesses of the table, in regard to both food and drink. All diseases of nutrition, such as long-continued dyspepsia, chronic rheumatism and gout, diabetes, and obesity, may be accompanied by the formation of biliary calculi. Among other explanations given for the formation of gallstones is an excessive proportion of fat in the diet, although cholesterin is not true fat, but an alcohol allied to fats in some of its properties. Lack of exercise is a strong contributing factor. Harley, who has given more careful attention than any other writer to the prevention of a return of gallstones by dietetic treatment, called attention to their greater prevalence in cold latitudes than elsewhere, and attributed this fact to the influence of certain foods, especially meat, fat and suet. He wrote : " Starchy puddings and fat bacon cause more gallstones in this country [England], I believe, than all the other kinds of food put together." The hydrocarbons are more completely consumed in early years than after middle life, and hence the greater prevalence of gallstones in the latter period, as above mentioned. Bauer believes that "the formation of gallstones may often be referred to a faulty diet, for an excessive consumption of meat or free indulgence in fat and in spirits would probably favor their formation." In many cases the stones exist in considerable number and size without giving rise to any symptoms or discomfort, but the smaller- 656 DIET IN LIVER DISEASES IN GENERAL sized stones occasionally find their way into the common bile duct, and their passage provokes intense agonizing local pain, known as biliary .colic. Dietetic Treatment. From the above account of the manner of formation of bile stones it is evident that patients who have once suffered from biliary colic or other symptoms of the presence of con- cretions should exercise care in their diet and habits of life, in order to prevent the further formation of stones, although it is probably impossible to dissolve those already present. The diet should be regu- lated with the object of lessening the production of cholesterin and of diluting the bile. Animal food may contain cholesterin, and should therefore be taken very sparingly. A diet of concentrated animal food, by diminishing the alkalinity of the fluids of the body, favors the deposition of cholesterin from the bile, although this ingredient may not be present in abnormal amount in such food. Patients should be cautioned against excessive indulgence in any particular article of food, all richly cooked food should be given up, and if they are in the habit of eating proteids in excess, a larger proportion of fresh vegeta- bles or farinaceous food should be substituted. Calves' brains and the viscera of animals used as food in general, and particularly the liver, should be interdicted. Sugars and fats should be forbidden in every variety. Butter and cream should be omitted also from the dietary. Some vegetables, such as peas and carrots, are believed to contain material which closely resembles cholesterin. Carrots, moreover, are sweet, and sweet vegetables and fruits should be avoided, and also egg yolks, on account of the fat they contain. Fresh green vegetables and acid fruits which, by virtue of their alkaline salts and organic acids, easily combine in the blood with alkaline bases should make the basis of the diet. The potassium salts which are contained in potatoes and other vegetables in abun- dant quantity are believed to be serviceable, because they retard the liberation of calcium, which, it has been shown, precipitates choles- terin. Bread and well-cooked cereals and fresh fish, except salmon, bluefish, and mackerel, may be eaten. Chicken or lean beef may be allowed, but all meat should be taken sparingly and not oftener than once a clay. For the purpose of diluting the blood and, through it, the bile, large quantities of fluid should be ingested, but it is best to avoid ai'-rated waters and mineral waters which contain salts of lime. A tumblerful of hot water should be drunk at night, and another on rising in the morning. Champagne and other beverages which hold DIET IN PANCREATIC DISEASES 657 much carbonic-acid gas in solution should be avoided, as well as malt liquors. Coffee, tea, and claret may be drunk in moderation. If the case is one in which considerable gastric catarrh or dilatation of the stomach is present, it is inadvisable to give much fluid by the mouth, and sometimes the desired result may be obtained by inject- ing salt water through a long flexible rubber tube into the colon. Intestinal irrigation as well as active purgation favors removal of the bile and prevents its accumulation in the gall bladder. It is well to give one or two drachms of sodium phosphate or sulphate daily to pre- vent concentration of the bile. For occasional purgation the Carlsbad Sprudel salts and Saratoga water salts are valuable. In women tight lacing should be prevented, and the habit of sitting long in cramped positions which interfere with free hepatic circulation. Although dietetic treatment for prevention of a return of at- tacks of gallstone colic should be undertaken as described above, it is by no means always successful, and recent knowledge of the bacterial origin of gallstones has discredited to some extent previous theories of their dietetic origin. Many cases require operative relief. Large doses of olive oil, several ounces at a time, have been recom- mended for use during the passage of a gallstone, with the idea appar- ently of in some mysterious way lubricating the channels through which the stone is carried. But the oil, if absorbed, is taken up by the lacteals and emptied into the thoracic 4uct without going any- where near the liver or bile passages, so that such an explanation of its use is absurd. The foreign bodies which it is claimed appear in the stools after giving oil in this manner have proved to be not stones, but inspissated masses of oil. Disease of the pancreas is usually difficult to diagnose with ac- curacy until far advanced, and little may be expected from dietetic treatment. Whereas the pancreatic juice is the most important of all the digestive fluids, being a universal digestive agent for all foods, and the most active one, its absence or deterioration results promptly in emaciation, which becomes extreme. When the presence of disease of this gland, such as a cyst, is established, it is best to withhold all fats and carbohydrates from the diet. They are not digested in the stom- ach, and when the pancreatic juice fails, they merely ferment in the small intestine and do positive harm. Milk, pancreatinized meat preparations, beef peptonoids, and egg albumen constitute the chief reliance for nourishment. 658 It is of interest to note that the continued presence of fat or oil in stools after ingestion of large amounts, is regarded as a strong diag- nostic point in favor of the absence of pancreatic juice. As a positive test this may have some value, but not as a negative one, for if bile be present in normal quantity the fat of food may still be emulsified and, to some extent, absorbed. In a half dozen cases of undoubted pan- creatic cyst in which the diagnosis was established by aspiration or autopsy, I have known doses of several ounces of olive oil administered for diagnostic purpose to give no residue in the stools. The absence of fat in the feces does not therefore necessarily exclude pancreatic disease. Pentose may appear in the urine. (Cammidge). DIET IN DISEASES OF THE NEKVOUS SYSTEM NEURALGIA GASTRALGIA ENTERALGIA Causation. Neuralgia is a term applied to a variety of nerve pains which may be associated with organic lesions of various struc- tures which irritate the peripheral nerves, or which may be purely functional and temporary excitations of the nerve trunks or their end organs. Lesions involving the nerves themselves are not described as neuralgias. The proper functioning of nerve fibers is so dependent upon nutrition that debility resulting from imprudent living and im- proper or insufficient food naturally ranks among the chief predis- posing causes of this affection. Persons undergoing severe mental worry or strain, physical fatigue, prolonged exposure to cold, prolonged lactation, etc., may suffer from indigestion or mal-assimilation of their food, and the one condition reacts upon the other in altering the tone of the nervous system. Moreover, many diseases which may be called dietetic in that they are closely associated with or influenced by dietetic errors (acting eventually through the composition of the blood) are very commonly accompanied by neuralgic pains. Such are gout, rheumatism, lithremia, arthritis deformans, diabetes, and chronic alcoholism. To benefit the diseased condition by appropriate diet, among other means, is to cure the neuralgia. Neuralgic pains are often connected immediately with the digestive tract, especially in cases of neurasthenia and hysteria among women, and are excited by irritating foods or fermentative processes. They are particularly caused by intestinal autointoxication, (p. 621.) Dietetic Treatment. The dietetic treatment of neuralgia is based upon general principles which may be observed wherever they do not NEURALGIA 659 conflict with the special disease of which the pain may be merely an incidental symptom. This treatment is liable to be overlooked while attention is directed to devising new remedies for the immediate, though often merely temporary, relief of the pain. It is essential to ascertain the cause of the pain and learn whether it be not due to one of the conditions above mentioned, which may be found to exist in a latent form. Examination of the urine should be made in all cases to ascertain the possible presence of the uric-acid diathesis, of sugar, of phosphaturia, etc. A majority of cases are accompanied by general debility and occur in anaemic, constipated women who take little outdoor exercise, hence the blood also should be examined for ansemia. If anaemia be present, an ample diet should be prescribed, accompanied by moderate exer- cise and abundant fresh air, to insure more perfect oxidation. Anstie says correctly that " neuralgic patients require, and greatly benefit by, a nutrition considerably richer than that which is needed by healthy persons." This is particularly true of the extremes of age. Fats and oils are most serviceable, and under this heading cream, Devonshire cream, butter, bacon, fat meat, salad oil, olives, and cod- liver oil may be used. Neuralgic patients usually dislike fats, perhaps on the general prin- ciple that people are likely to prefer different food from that which they most need for disordered conditions of the system. Some are made bilious by fat, but with a little tact and perseverance in se- lecting the proper kind of fatty food and directing the mode of tak- ing it these objections may be overcome. Patients may take more butter than usual, though they refuse cream, or they will take diluted cream though they refuse cod-liver oil. Salad oil and fat bacon are not apt to provoke objection. In neuralgia due to general debility or anemia without lithiasis, proteids are indicated in addition to the fats above mentioned, and good roast beef, beefsteak or chops, eggs, milk with bread and butter, light starchy foods, and fresh vegetables should be ordered. Meat should be eaten two or three times a day, and additional lunches may be given between meals, consisting of milk, a glass of claret and a sandwich, a cup of cocoa and a biscuit, or broth thickened with beef meal or an egg. Gowers says that he has sometimes known "severe neuralgia to occur first on the patient commencing a purely vegetable diet, to disappear when meat was taken, and recur with severity on each of four successive attempts to return to vegetarianism." If the nervous system has been greatly overtaxed or the digestive 660 DIET IN DISEASES OF THE NERVOUS SYSTEM organs are exceptionally feeble, it may be advisable to place the patient for a few days on a diet consisting largely of milk, eggnog, beef broths, and purees, accompanied by rest and passive exercise (massage). After a few days the more substantial proteid foods may be added. In cases associated with lithaemia or rheumatic diathesis, however, the quantity of such foods should be reduced, and the special regulations described under the heading of rheumatism and lithsemia followed. (See pp. 560, 713.) It is thus seen that neuralgias due to anaemia and debility require diametrically opposite treatment from those due to lithasmic con- ditions. Coffee and tea should be drunk only in moderation, and in serious cases had better be prohibited altogether. Alcohol in restricted dosage benefits many anaemic cases. Claret or Burgundy may be drunk with meals, but alcohol should never be taken merely to relieve pain or otherwise than a food, for there is danger of becoming too much addicted to its use. Substances to be especially forbidden in all cases are pastry, sweets, and confectionery of all kinds, griddle cakes, condiments, fried food, and rich, highly seasoned sauces and foods. All meals should be eaten at regular intervals, and, except as directed above, eating between meals is prohibited. Visceral Neuralgias in General 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 and various forms of autointoxication may excite severe visceral neuralgias. Neuralgias of any of the abdominal viscera may be excited by func- tional activity (although they also may occur independently of it), and hence the diet should be made as simple as possible, in order that digestion shall not be unduly prolonged. If any one article of food is to be found to excite the paroxysms it should be abandoned. It is often advisable in serious cases to limit the diet for a few weeks to two or three articles of food, such as beef, bread, milk, and rice. Details of treatment are described under the following headings : GASTRALGIA 661 Gastralgia Causation. In neuralgia of the stomach, called gastralgia, or gas- trodynia, the pain is situated in the epigastrium, penetrating to the back. It is distinctly localized and intense. It may be paroxysmal, or there may be dull, constant aching with exacerbations of a mod- erate lancinating character. It is usually relieved somewhat by mod- erate gentle pressure, but intensified by deep pressure. Such pain is not infrequently associated with anaemia, chronic constipation and hysteria, and in a severe form, accompanied by violent vomiting, it- constitutes the '* gastric crisis " of locomotor ataxia. Gastralgia also may 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 formation of hydrochloric acid in the gastric juice may occasion a very painful variety of gastralgia. Dietetic Treatment. In all cases of gastralgia careful inquiry should 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, a glass of milk punch or eggnog or a custard, may be taken at 11 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. Hyperacidity is often present (p. 584). In other cases food intensifies the pain and excites immediate emesis. This is especially true of the gastric crises of locomotor ataxia, for which sedatives, such as bismuth, magnesia, or anodynes may be given to relieve the irritation of the gastric mucous membrane while food is temporarily withheld until the pain has subsided. The diet sub- sequently should be increased gradually, commencing with small quan- tities of pancreatinized albuminous food, and followed by the general Diet for Convalescence given on page 472. In gastralgia the appetite is very capricious, and there may be excessive craving for certain arti- cles of diet, such as pickles, condiments, etc. In all forms of gastralgia the pain is augmented by temporary dis- tention of the stomach. If starchy food tends to produce flatulency 662 DIET IN DISEASES OF THE NERVOUS SYSTEM it should be avoided, together with sugars and fats. Tea, coffee, and tobacco should be given up. The bowels should be kept freely open. Enteralgia i. e., a true neuralgic pain in the intestines is not common if " peristaltic unrest " be excluded. It does occur, however, and oftenest in the lower rectum, in which case it is to be relieved by local medicinal treatment rather than dieting. Hepatalgia, or neuralgia of the liver, is an indication of functional 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. The appropriate diet is the same as that pre- scribed for " biliousness " on page 647. In severe forms of neuralgia which do not yield to dietetic and medicinal control prompt relief often is secured by change of scene and sea bathing, or a course of mineral baths. Perspiration may be induced by electric light baths. Hygienic measures improve func- tional 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 characterized 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 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 may possible faults be detected and corrected. The gouty should be forbidden the use of wines, malt liquors, sugars, and starches. The ana?mic should be ordered more animal food and fats and cod-liver oil. The dyspeptic should abstain from carbohydrates, especially sweets. The neurotic should give up tea, coffee, and tobacco. It has been shown by Eoberts that both tea and, to a lesser extent, coffee may materially retard starch digestion, even when drunk in very small quantities. Yet there are some an.Tmic 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 MIGRAINE 663 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 corn, cabbage, cauliflower, tomatoes and rhubarb should be avoided. Excepting very anaemic patients, those suffering from migraine should not eat much meat. It is best to take it not oftener than once every other day, and the white meat of poultry and broiled fish are better than any red meat. Milk may disagree and cause headache through lactic-acid fermentation, interfering with digestion. New bread, pastry, richly cooked foods, fried and preserved foods, condiments, shellfish, crustaceans, cheese, sauces, and desserts in gen<- eral are forbidden. 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 foods (Roberts). Obviously no rules of diet apply to all cases of a disease which may originate from so many different sources, and in chronic cases careful observation and experimentation will be necessary to estab- lish the best course. The section" on Dietetic Treatment of Intestinal Autointoxication, p. 623, may be applied for many migraine cases. Overeating, irregular eating, and late suppers should be forbidden. Outdoor exercise 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 suffer from inanition, and it requires no little tact and firm- ness to convince them that they can eat anything at all. They will live on nuts and fruits 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 for neuralgia or anaemia (pp. 539, 658). Decayed teeth are a frequent cause of facial or 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 swallowing 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. It is relieved by momentarily compressing both carotid arteries. Lauder Brunton suggested that cold excites the sympathetic plexuses about the carotids and alters their caliber, putting them into a state of spasm. These forms of neuralgic pain are, however, usually trivial, and are to be 664 DIET IN DISEASES OF THE NERVOUS SYSTEM 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 functional rather than organic character. It is also called nervous exhaustion or nervous prostration. Strictly speaking, it is not a disease, but rather a functional derangement of considerable duration, which, however, with proper care and dietetic treatment results usually in complete recovery. The most obvious cause of neurasthenia is overwork of the nervous system due to continued excitement, strain or prolonged emotional depression and anxiety. It is far more likely to be produced by overwork of the nervous than of the muscular system, although it may be occasioned by the latter. Different persons are endowed with varying degrees of nerve force, and the complex demands and great activity of highly developed civilization tempt or compel many to draw upon their physi- ological capital of energy at the expense of its income, with the re- sult 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 essentially an affection incident to the occupations and customs of city life, rare or comparatively unknown in the repose of the country. 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 func- tional 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 secre- tion, 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. NEURASTHENIA 665 Neurasthenia reacts especially on the digestive system, producing malnutrition and a variety of functional disorders. General Treatment. The treatment of neurasthenia is fundamen- tally based upon three essential conditions : First, complete body rest, with the necessary absence of the original exciting cause of the diffi- culty; second, a nourishing diet, to supply the material for energy and tissue metamorphosis ; third, wholesome mental diversion or occu- pation. Various tonics, such as strychnine, iron, and arsenic, are of recognized benefit to the nervous system, but the main reliance in treatment should be placed upon rest, food, and mental or moral sup- port. The milder cases may be relieved in addition 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, absence from social intercourse, and lack of occupation, and in such cases the advantages of dietetic treatment may be enhanced by cheerful sur- roundings and diversion. As a rule, it is 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 or domestic spa, than it is for him to continue his ordinary occupations in moderation, and take exercise and proper food and sleep at home 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 traveling is stimulating and fatiguing, and if such people are not made ill at sea nothing gives more benefit than the isolation, invigorating air, and en- forced idleness of a sea voyage. For others, in whom the digestive system is comparatively little impaired, camping or living an outdoor life in the woods afford the same advantage. Whatever journey is undertaken, therefore, should be in the direction of rest and moderate diversion without the " sight-seeing " which is involved in visiting new cities. The physician not only should study carefully the previous habits of the patient, but consult his tastes in regard to occupations and amusements. When this is done and the patient's confidence has been 66 DIET IN DISEASES OF THE NERVOUS SYSTEM gained, it is easier to have the rules for diet which are prescribed care- fully adhered to. In still another class of cases of neurasthenia the general nerve collapse is so sudden and exhaustion so extreme that absolute rest at home and in bed is imperative. To this class belong a large number of overworked society women whose lives of constant excitement and mental activity or stimulation, combined with the number of social or charitable interests or other occupations to which they give much energy, wear them out in time. This type of patient suffers continual depression from the least ex- ercise, exertion, or emotional excitement. It is not easily realized by persons in health, how much energy is expended, i. e., how much food fuel is consumed, by minor muscular activities, yet in calorimeter experiments it may be shown that such movements as turning over in bed, raising one limb, turning the pages of a book, etc., are all measurable degrees of effort in terms of foot pounds or calories, which in the feeble neurasthenic may result in sensible fatigue re- actions, (p 12). In some instances insomnia is a predominant and serious symp- tom ; in others the patient is drowsy in the daytime and unable to per- form any concentrated mental labor; 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 increase in weight from accumulation of fat and water in the tissues, while the muscles be- come soft and so feeble as scarcely to support the frame. Many cases are complicated with pronounced hysteria, hypochondriasis, unnatural irritability, and entire lack of decision. 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 suggestions magnify existing conditions by focusing the attention of the patient upon them. In general, it is best to allow no one to see the patient ex- cepting 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 kept from the patient, and such connection as may be allowed with the outside world should only be of a cheerful 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 NEURASTHENIA 667 the digestive system and interrupt the favorable progress of the case for several days. To be of any service, the " rest cure " should last six weeks or more, and in severe cases it should be explained to the patient that this treat- ment by no means completes the restoration of the normal nerve func- tions, but is to be regarded as a basis for a further regimen of exer- cise and outdoor life. The " Rest Cure." At the commencement of treatment in grave cases the patient should lie absolutely quiet in bed and not be even al- lowed 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 should be supplied by the tonic effect of bathing and massage. The patient should receive a sponge bath every morn- ing 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 a 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 cutaneous nerves by strong degrees of heat and cold always produces a tonic effect, and the influence of the ice water and friction is analogous to that produced by the Brand system of cold bathing in typhoid fever. After the bath, which, if properly given, may consume a half or three-quarters of an hour, the patient is left alone, and at noon or in the early afternoon massage is to be given, at first every day, later on alternate days. At the commencement of the case the massage should be exceedingly mild, and caution is required in this respect, for neu- rasthenic patients are often injured by the too vigorous or prolonged efforts of the massage operators. For the first day twenty or thirty minutes will suffice, and if the effect is favorable, the time may be gradually extended to an hour. Owing to the nature of the diet, which at first is of milk, and from the lack of exercise and loss of tone of the intestinal walls, neurasthenic subjects are uniformly con- stipated, and the massage should be adapted particularly to remedy this difficulty (p. 640). Dietetic Treatment. The feeding of the patient should be based upon the principle of giving all the nourishment which can be as- similated. The stools should be watched to make sure that the food is thoroughly digested. Xourishment should be given at brief inter- vals, depending somewhat upon the amount of time allotted to sleep, 668 DIET IN DISEASES OF THE NERVOUS SYSTEM but in cases of great exhaustion patients should not be permitted to go more than four hours at any time without food. In other cases when sleep interrupted for feeding is regularly resumed, food may be given with regularity once in three hours throughout the night, and once in two hours during the day, as in typhoid fever. When improve- ment is attained, the intervals of sleep will naturally be longer, and it will be both unnecessary and unwise to awaken the patient for feed- ing. The basis of the diet in most cases should be milk, and by study- ing the taste and digestion of the patient it is usually possible to pre- pare it so that it is well borne. (See Adaptation of Milk for the Sick, p. 84.) In commencing the milk diet the objection of the patient often has to be overcome, and it is advisable to begin slowly, giving skim- med 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 allowed at first, but this is to be reduced gradually in bulk and the milk sub- stituted for it in increasing quantity until four ounces of skimmed milk are taken every two hours. It ia finally given up to eight or ten ounces at the same intervals. The taste, if disagreeable, may be over- come by the addition of a little black coffee or caramel. If it pro- duces weight and episgastric oppression or causes flatulence and eructations it is to be diluted by one-half or one-third with lime, bar- ley, or rice water or Vichy. One of the "prepared foods," such as Xestle's, Mellin's, or Imperial Granum may be added, or the milk pancreatinized or temporarily replaced by koumiss, zoolak or beef juice and albumen water. 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 exhaustion which occasionally follows their use. Many patients do very well on the exclusive milk diet for a week or two, 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 as recommended by Weir Mitchell, who was the pioneer of this method of treatment in this country. 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 of milk. The exclusive milk diet is believed to prepare the digestive system for the assimilation of other foods. NEURASTHENIA 669 Playfair's Diet for Neurasthenia Playfair's diet for neurasthenia is a good example of a milk diet, subsequently 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; egg, bread and butter; dialyzed iron, forty minims in two doses (continued daily). 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 treatment. 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 savory 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, vegetables, cream, and fruit; two quarts of milk and two glasses of Burgundy. Twenty-second Day. Amount of food lessened. Von Leyden's Diet for Neurasthenia Yon Leyden's diet for neurasthenia is a modified form of milk treatment which gives excellent results in some cases : At 7 A. M., half a liter of milk, slowly sipped during half an hour, a small cup of coffee with cream, eighty grams (nearly three ounces) of cold meat, a mealy baked potato; 10 A. M., a liter of milk with three biscuits; 12 A. M., the same; 1 p. M., broth, two hundred grams (about seven ounces) of fowl, puree of potatoes, green vegetables, one hundred and twenty grams (nearly four ounces) of compote, and pastry; 3.30, 5.30, 8, and 9.30 P. M., half a liter of milk, making a daily consumption of three liters and a half of milk. In the after 670 DIET IN DISEASES OF THE NERVOUS SYSTEM part of the day, two meals each of eighty grams (three ounces) of roast meat with bread and three biscuits. Keating's Diet for Neurasthenia Keating's diet for neurasthenia is adapted to patients who need not be kept constantly in bed. It is as follows: At 6 A. M., a tumblerful of strong hot beef tea ; 8 A. M., a half tum- blerful of iron water, and breakfast of fruit, steak, coffee, and a goblet of milk; 8.30 A. M., a goblet of milk with a dessertspoonful of malt extract, six grains of citrate of iron and quinine; 10 A. M., elec- tricity; 12 A. M., a goblet of milk and malt; 2 p. M., dinner, preceded by a half tumblerful of iron water and a third goblet of milk and malt ; 6 P. M., third dose of iron water. Light supper of fruits, bread and butter, and cream; a fourth goblet of milk and malt; 10 p. M., beef soup, four ounces, preceded by massage with cocoa oil for an hour. Two quarts of milk are taken daily, in addition to all other food. The patient on this diet is allowed to be out of bed for four hours every day, one of which may be spent in business. If milk cannot be made to agree with the patient in any form, meat broths and purees and light farinaceous food may be prescribed. Eggs may be given dropped into bouillon or any of the preparations of egg albumen. Meat essences and extracts, such as Liebig's or Valentine's, are serviceable, but the latter are so merely for their stimulating effect upon digestion. If the condition of the stomach is good, the constipation resulting from so concentrated a diet may be overcome by the use of oatmeal porridge for breakfast, whole- meal bread, and fresh fruits, such as the juice of the shaddock or dried or stewed prunes or figs. The receipts under the heading " Receipts for Invalid Diet " for the several kinds of fluid food will enable the physician to prescribe suffi- cient variety to stimulate the appetite of the patient, and in many cases a slightly different menu can be ordered for each day in the week. Most patients after a fortnight to three weeks of semisolid diet are able to digest meat and other solid foods. As an example of an excel- lent typical dietary for this stage of the treatment, the following is given by H. C. Wood: At S A. M., rolls or toast, cocoa, weak coffee or roasted wheat cof- . fee, beefsteak, tenderloin, or mutton chop; 9 A. M., bathing; 11 A. M., oatmeal porridge with milk or else a half pint of molasses; 12 noon, massage: 2 r. M., dinner, bouillon with or without egg, beefsteak, rice, white potatoes roasted; dessert of bread pudding, blancmange, NEURASTHENIA 671 or similar farinaceous articles; 4 p. M., electricity; 5 p. M., milk toast; 9 P. M., a half pint of skimmed milk or koumiss. Billinger dissents somewhat from other teaching and believes that a modified vegetable diet is most useful in the treatment of neuras- thenia, being less irritant to the nervous system than a preponderance of animal food, and for anaemic subjects who require proteids he pre- scribes milk and oatmeal porridge and preparations of ground meal of legumes. He allows chocolate and cocoa for beverages. A vegetable diet is recommended in certain chronic cases in which the patient is much worried over the smallness and infrequency of the stools. Ac- companied by large draughts of water such diet begets copious and ready evacuations. For this purpose such vegetables should be pre- scribed as celery, string beans, spinach, peas, and potatoes and beans in purees. Graham bread, wheaten grits, and cracked or shredded wheat also may be eaten. Meat should not be allowed more than once a day. SUMMARY OF DESIRABLE FOODS FOR NEURASTHENIA Light luncheons between meals ; a cup of beef juice, two beaten eggs, baked custard, cup of malted milk or Imperial Granum, chicken broth with crackers; a bottle of koumiss, a glass of cream (one-third) and Vichy (two-thirds), 2 scraped-beef sandwiches and a glass of claret or malt extract, a saucer of stewed fruit with rice ; baked apples and cream; cocoa or chocolate with sponge-cake, or macaroons. Breakfast: A grape fruit or two oranges, bacon and eggs, a cereal, such as oatmeal, hominy, or mush, buttered toast, cup of cocoa or postum, or hot water and lemon. Dinner (at noon) : Beef soup, bread, beefsteak, mutton chop, rare roast beef, lamb or mutton, boiled mutton, veal, boiled ham, white or baked potatoes, beans, peas, beets, cauliflower, tomatoes; lettuce with olive oil, butter (added to bread, potatoes, steak, etc., in abundance), puddings of Indian meal, apple or bread, with sugar and cream. Stewed fruit. (There is no objection to fish, but the diet is intended to make the patient eat a maximum of meats, with bread, potatoes, butter and cream, and not " fill up " with other foods.) Supper: Minced chicken or lamb, cream toast, a fruit omelette, chicken or calves' foot jelly, apple sauce or peaches, or berries and cream, cocoa or chocolate, crackers or gingersnaps, bread and butter. Electricity. The use of the electric current is of service in pro- moting the nutrition of the body during the period of absolute rest from the voluntary movement. It should be remembered that the electric current possesses no special nutritive value or " vitalizing " DIET IN DISEASES OF THE NERVOUS SYSTEM influence, such as is often claimed for it, but that it acts favorably upon the muscular system by causing the muscles to contract, and in that way also quickens the circulation. The contraction of muscles compresses the contents of their lymphatic vessels and venous radicles, thereby aiding circulation, while the phenomena are accompanied by metabolism which involves the appropriation of the ingredients of the food which have been absorbed. The f aradic current is used for this purpose. It may be applied to special groups of muscles at first, and subsequently to the entire body. Care should be taken not to fatigue individual muscles, and the current should be carefully regu- lated and applied in accordance with the condition of the patient. The use of electricity in relation to the treatment of constipation has been referred to under that heading (p. 641). It is doubtful whether the local application of electricity over the abdominal wall exercises any definite influence upon the digestive processes which may be going on in the viscera beneath the electrodes. The use of electricity serves to occupy and interest the patient, and thus make easier the carrying out of the more essential parts of treatment. INSOMNIA AND DISORDERED SLEEP Insomnia is due to many causes, but those which concern die- tetics are the opposite extremes of overfeeding and starvation or in- anition. Overfeeding or eating improper food may cause disordered sleep, nightmares, or temporary insomnia from attacks of acute in- digestion, dyspepsia, or biliousness, but inanition or malnutrition is more likely to cause true insomnia from exhaustion. Intestinal indi- gestion with much flatulence may develop five or six hours after a hearty late dinner or supper, and either awaken the patient or cause restlessness, jactitation and unrestful sleep. Neurasthenic subjects whose nerve energy is insufficient to conduct their digestive and ab- sorptive functions completely are very liable to suffer from insomnia. They unfortunately resort to hypnotics, instead of first trying the efficacy of dietetics. It is a good rule in such cases to improve the nutrition by regulated feeding at frequent intervals. In addition to three good meals a day, the patient should be made to take a quart of milk, with beef tea and one or two ounces of malt extract. By gradually increasing the diet according to such rules as those given for the treatment of neurasthenia, in a week or ten days the patient often may be made to reach the maximum above given, and improvement is almost certain to follow. It is best to take the heaviest meal of the day in VERTIGO CHOEEA 673 the early afternoon, and not as late as six o'clock, for an overloaded stomach with indigestion is itself a cause of insomnia, but, on the other hand, going to bed with an empty stomach is usually undesirable. In mild cases a glass of hot milk, a couple of teaspoonfuls of meat extract in hot water, or a cup of good beef tea and a biscuit, or a cup of cocoa, or chicken broth, or a light sandwich and a glass or two of beer or ale, taken just before retiring, will serve to divert the blood current from the brain to the stomach and induce cerebral anasmia and sleep without the use of medicines, strong stimulants, or " nightcaps," and if anodynes have to be given, a little food taken in this manner increases their efficacy and makes a smaller dose possible. Elderly persons often awaken at four or five o'clock in the morning and are unable to regain sleep. If they take a little food at this time, a few crackers and a glass of milk, or cup of hot bouillon, they often will at once go to sleep. It is inconvenient to rise and heat food at this hour, but a non-radiating double bottle has been devised, having vacuum between its two layers, which will keep hot fluids hot, or cold fluids cold for many consecutive hours. VERTIGO Vertigo, although it arises from many causes, very often may be occasioned by digestive disorders, such as the production of flatulency with palpitation, or by the absorption of products of indigestion which act as irritants of the vascular system. Such products, for ex- ample, are developed in some persons by eating shellfish, strawberries, etc. (See Autointoxication, p. 623). Lack of sufficient food may cause it. The dietetic treatment is that of dyspepsia (p. 579). Fats and sugars are forbidden, and alkaline and laxative waters, such as Con- gress, or Hathorn water, are of service to open the bowels and increase the activity of the kidneys. Lithaemic patients should be kept for a week or two upon a vegetable diet (p. 560). In most cases of vertigo the diet recommended for biliousness (p. 647) should be followed. CHOREA Mild cases of chorea require no special regulation of diet beyond that which is directed towards the prevention of flatulent dyspep- sia (p. 584) and constipation (p. 636). In more pronounced cases it is sometimes advisable to order the patient for a time upon a milk diet. Sweets and farinaceous foods should, as a rule, be forbidden 45 674 DIET IN DISEASES OF THE NERVOUS SYSTEM for fear of increasing palpitation through exciting flatulence. Other patients do better with a diet of animal food without meat, consisting of fish, eggs, and oysters with bread and milk, koumiss, or zoolak. They are prone to anaemia, and should be encouraged to take as much food as the digestive organs will tolerate. Cod-liver oil and cream are useful. EPILEPSY Epilepsy is a functional nervous disorder, which may often be improved by attention to diet. A very large proportion of cases ap- pear in childhood at a period when existing functional derangements of the nervous system are readily intensified by improper food. Rhachitic children with imperfect development of the teeth, feeble digestive organs, and consequent malnutrition may acquire epilepsy while teething. Many cases are closely associated with errors in diet or affections of the alimentary canal, and while such conditions do not cause the disease, they readily precipitate epileptic seizures. This statement applies to grand mal and petit mal rather than to the localized or partial convulsions know as Jacksonian epilepsy. Of the varieties of epilepsy, petit mal is more favorably influenced by diet than are the other forms. Patients should have their eating supervised with care. They should be well fed, but eat only easily digestible food and have their meals at regular intervals, and the principal one in the middle of the day, in order that digestion at night may be completed before going to sleep. All food should be eaten slowly, and meat, if given, should be masticated very thoroughly, and the stomach should never be over- loaded. Meat should be allowed only two or three times a week. Some children with petit mal, or even grand mal, improve rapidly on a strictly vegetarian diet or on a bland diet of which milk, bread and butter, and simple farinaceous foods, such as rice pudding, cornstarch, Indian-meal pudding, etc., form the basis. I have seen cases of epi- lepsy among young children in which, while the medicinal treatment remained constant, a return to meat diet was invariably followed by convulsions, which were absent on a vegetable or exclusive milk regimen. As a rule, adults do not seem to be aided by dieting to such a degree as children: nevertheless, they do well to eat very little meat and to be abstemious and regular in their habits of eating. Dr. Mersan. of the West Riding Asylum, in England, tried the experi- ment of putting a number of chronic epileptics for some weeks first EPILEPSY 675 upon a diet of flesh and then upon a vegetable diet, and vice versa. The results showed that their convulsions were not materially lessened in number or severity, but it was noticed that while their food con- sisted largely of meat their mental condition was more stupid. At the epileptic colony of Chalfont St. Peter, the patients are allowed meat once a day, but all the inmates are men, leading an active outdoor life, and hence better able to digest stimulating proteid food. Gowers, on the contrary, allows his patients meat twice a day, and asserts that he has seen cases in which fewer epileptic seizures occurred while eating flesh than when abstaining from it. One patient had par- oxysms only after eating beef, but not in connection with other va- rieties of meat. It is evident that no definite rule should govern all cases. It is worth while to reduce the proteid food for a month or two, and if improvement does not follow, or nutrition becomes less active, it may again be added to the dietary. Dr. Whitmore Steele, formerly of the Utica State Asylum, in speaking of the treatment of chronic epilepsy at that institution, in- forms me : " We endeavor to reduce the amount of albuminous foods, giving a more liberal and easily assimilated diet also. Invariably overalimentation in our epileptics produces attacks." Chronic epi- leptics and epileptic degenerates will often gorge themselves with food and drink if allowed to do so. Some of the carnivores, as well as animals accustomed to a mixed diet, like the felines, develop convulsions from a too liberal allowance of meat, if at the same time they are kept in confinement. In these cases, however, the convulsions may be due to reflex irritation from the stomach or bowels, produced by large masses of slowly digested food, rather than to the chemical nature of the food. The same thing may occur in young children who are allowed to gorge themselves with any hastily eaten bulky diet, and the resulting convulsions should not be confounded with genuine epileptic seizures accompanied by loss of consciousness, and recurring periodically. Some patients have a dis- tinct epigastric aura preceding the convulsions. Joseph Collins, of ISTew York, gave a salt-free diet (described on p. 556) to 25 epileptics, with a reduction of one-third in the number of their attacks. It is extremely desirable to prevent intestinal putrefaction, the diet for which condition is given on page 623. Should the stools become very offensive, or Tnuch flatulence or indicanuria appear, the patient first should be given a milk diet for a week or two, and cathartics and intestinal antifermentatives should be employed, such as salol, creosote, or guaiacol carbonate, and lactobacilline (p. 92). Many are obliged to take large doses of the bromides and other 676 DIET IN DISEASES OF THE NERVOUS SYSTEM medicines. It will be found that the disagreeable symptoms of bromism are less likely to occur if the diet be so regulated as to avoid constipation and to insure the consumption of abundant fluid diluents. Vichy or carbonic-acid water and water should be drunk freely be- tween meals, and especially after taking medicine, and daily thorough evacuations of the bowels should be secured by the use of fresh vege- tables and fruits, such as prunes, figs, apples, oranges (the latter to be taken with water between meals), etc. Adults should abstain from agents which are likely to over-stimulate the nervous system, such as alcohol, strong tea and coffee. The use of tobacco also should be in- terdicted. BERI-BERI Beri-beri, or kakke, is a form of multiple neuritis very rarely im- ported into this country by Chinese, Ceylonese, Japanese, or Philip- pine Islanders, who have acquired it in their native countries or on the voyage. It is characterized by anaemia, general oedema, and more or less stiffness and paralysis of the extremities, with dyspnoea and serous effusions. Sometimes there are muscular spasms. Beri-beri has been attributed to the absence of fresh animal food from the diet, a sort of antithesis to the cause often assigned to scurvy. It has more specifically been attributed to the excessive consumption of rice and adzuki beans to the exclusion of other food. According to Oshima, prior to 1883, thirty-two per cent of the Japanese marines suffered from this disease, their diet being extremely low in proteid. In 1884 a new food supply act went into effect for the navy, which greatly increased the protein ration, and within three years the disease was practically exterminated from the navy. Similar results were obtained in the Japanese army through the effort of the former Surgeon-General, Baron Takaki. LOCOMOTOR ATAXIA Locomotor ataxia is a disease which cannot be said to be particu- larly influenced by any system of dietetic treatment, although it is believed by some writers that the quantity of meat ordinarily eaten should be reduced. As in many other forms of very chronic nervous disease, a generous diet is desirable, with an abundance of fat, butter, cream, cod-liver oil, etc.. when the stomach will tolerate it. Strong liquors should be forbidden, but light wines, malt liquors, tea, and coffee may be allowed in moderation. A reasonable use of tobacco need not be proscribed. APOPLEXY 677 In those cases in which the " gastric crises " predominate the diet should be restricted for a few days when the crises occur, upon the principles established for the treatment of gastralgia. (See p. 661.) It may be necessary at such times to order a simple bread and milk diet. Other diseases of the spinal cord usually do not demand particular dietetic treatment, but Bauer says that " some diseases of the spinal cord lead to an extraordinary falling off of the demand for nutri- ment." This is due to alterations in general metabolism, and is most striking in cerebrospinal meningitis. APOPLEXY The several forms of cerebral hemorrhage may interfere with nu- trition in a variety of ways. If coma be present, voluntary degluti- tion being suspended, great care is to be exercised in feeding the patient. Liquid food is best given in teaspoonful doses, and the effect of each spoonful should be watched to see that it is successfully swallowed before another is given, otherwise fatal choking may result from food passing over an insensitive epiglottis and larynx, when par- ticles may be drawn into the lungs and excite aspiration pneumonia. Concentrated meat extracts, beef peptonoids, and peptonized milk may be given in this manner. When rigidity of the jaw interferes with feeding, or when paralysis involves the mechanism of deglutition, a long, slender catheter may be introduced through the nose and passed into the stomach, through which fluid nourishment is poured, after the manner of feeding pa- tients suffering from melancholia. (See Melancholia, p. 680.) The rectum may be utilized for nutrient enemata (p. 455). In unilateral facial paralysis without unconsciousness patients may be willing and able to swallow, but mastication is difficult or impos- sible. The food constantly passes into the buccal cavity behind the teeth of the paralyzed side, and the tongue, perhaps also partially paralyzed, dislodges it with great difficulty. The retention of food is accompanied by a copious secretion of saliva, which, dribbling from the depressed angle of the mouth, adds greatly to the discom- fort of the patient. All nourishment should therefore be given in fluid form, or in such finely divided state that it does not require mastication, and may readily be washed down with water. Milk, thick broths, purees thickened with macerated vegetables, long-boiled rice, sago, or barley with cream, custards, soft-cooked eggs, etc., may be given. The patient should be fed very slowly to prevent the 678 DIET IN DISEASES OF THE NERVOUS SYSTEM food from running out of the mouth. The mouth should frequently be cleansed with hydrogen peroxid and a saturated aqueous solu- tion of boric acid. In cases of hemiplegia without facial paralysis the patient can masticate and swallow, but the mental condition or loss of appetite makes the use of such food desirable as may be swallowed with the least possible effort. Convalescent hemiplegic patients having a very protracted recovery suffer from lack of exercise, and almost invariably become constipated. It is well in such instances to recommend simple and non-nitrogenous diet, containing laxative food, such as cooked fruit, and coarse cereals, to regulate the bowels. It is important to reduce arterial tension, to prevent, if possible, a repetition of the intracranial hemorrhage. Large draughts of fluid rapidly absorbed tend by adding to the volume of the blood, to increase temporarily the intravascular pressure (p. 528). The bloodvessels, however, show a very remarkable ability to maintain an average pressure of the fluid within them, and the possible danger from this source of an exclusive fluid diet may be averted by increasing the functional activity of the kidneys by diuretics and reducing the ar- terial tension by the remedies in common use, such as chloral, nitro- glycerin, and the nitrites. When the tension is very high, it is well to give a bland diet without much meat, and bread and milk and cereals with cream should form the basis of it. Alcoholic stimulants should be forbidden. ACUTE INSANITY MELANCHOLIA PRIMARY DE- MENTIA MANIA Acute insanity may result from overwork or severe mental strain, or from numerous diseases. It overtaxes the vital powers and causes wasting, inanition, and exhaustion. As the symptoms may result quite suddenly, often within a few hours after intense emotional strain or excitement, the digestive system is at first not disturbed to any considerable extent, although the appetite may be absent entirely. Subsequently various digestive disorders and malnutrition supervene. The insane, especially the melancholic, often refuse food abso- lutely, or can be induced to take it only very sparingly. Forced Feeding. When food is refused by the patient, the ques- tion of forced feeding should be considered in order to tide him over the emergency and support life until confusional insanity or delirium subsides. Concerning this problem opposite views are held. Some alien- ists regard the operation of compulsory feeding as good mental dis- MELANCHOLIA MANIA 679 cipline, others decry it, and defer it as long as possible. It should be understood that the refusal of food may be either a complication or a symptom of the special form of insanity in which it occurs, and the patient should be studied to determine which condition is present. As a complication, it may be caused by central nerve lesions that hinder deglutition, such, for example, as those found in either acute or chronic paralytic dementia. Or digestive disturbances, dyspepsia, or gastric catarrh may cause a loss of appetite which in the patient's disturbed mental state is exaggerated into a refusal of all food. Such local disorders may themselves cause hallucinations or delusions, giving rise to " sitophobia," or horror of taking food. Obviously in such cases cure of the complication may be effected by treating the local condition. Lavage will sometimes relieve it entirely. When the refusal of food is purely a symptom of the disease, as it occurs in melancholia or delusional insanity, an attempt always should be made to learn the exact nature of the delusion, and to try whether it cannot be dispelled or offset, as in the case of some para- noiacs. For example, the delusion may apply merely to food cooked in particular ways, or served in a certain manner or by certain per- sons, and the patient may have no real loss of appetite, but may try to obtain food by stealth and be pleased at his success in that di- rection, and his food should be placed where he can find it unobserved. Some patients will refuse liquid foods who are willing to take solids, or vice versa, or they may refuse food offered by an attendant and yet accept it from a fellow-patient. If their delusions take the form of suspicion of poisoning, they sometimes may be overcome by showing them eggs in the shell, milk in sealed bottles, unpeeled potatoes and fruits, which obviously cannot have been poisoned beforehand, and which are then cooked in their presence. Some patients will only eat if left alone or after others have finished, because they feel unworthy to eat with them. I have sometimes persuaded others who persistently refused food to take it greedily if an apparent show of force was made in placing it within their mouths. Patients with chronic or asthenic mania may refuse food from inattention, although able to eat if their surroundings are quiet and their attention can be momentarily obtained. If they can be induced to take but a few mouthfuls at a time they should be fed repeatedly at short intervals. Food should be cooked and served as temptingly as possible, and the patient, if unable to keep himself in order, should have his mouth cleansed and clothing protected from soiling. 680 DIET IN DISEASES OF THE NERVOUS SYSTEM The appetite is seldom a safe guide in insanity, and when it fails completely forced feeding should not be postponed until the patient has become too exhausted to rally. Cases of depressive insanity are apt to require it sooner or later, and sometimes it is practiced con- tinuously for a year or more. In acute mania, however, it may only be necessary to employ the method for a few days, after which the patient will eat of his own accord if given the opportunity. In a former service in the Bloomingdale Asylum, with cases of melancholia, after one or two feedings with the stomach tube, I have sometimes, by a little firmness and patience, satisfied the patient that swallowing a glass of milk himself was more agreeable than having it poured in through a tube. When voluntary starvation is the fixed intent, owing, perhaps, to a delusion of command from some higher power, if the patient can be convinced that he has to take food in some manner, he may yield to the inevitable and choose the lesser of what he regards as two evils. With a stomach tube in one hand and a glass of milk in the other the argument for choice may be made very forcible. The physician himself should always direct the passage of the tube for the first few times. Afterwards, if the patient be not refrac- tory, an attendant may do it. Occasionally the aid of two or three assistants is necessary to overcome resistance. The patient should be made to sit down or lie upon his back, and either an cesophageal or nasal tube may be used, according to the directions given on p. 599. There are certain advantages in the use of each tube. The cesophageal tube does not so readily admit of regurgitation alongside of it as the nasal tube does (although occasionally patients can re- gurgitate through the tube itself). If it be filled before it is inserted, and if a little fluid be squeezed out of it when part way down the oesophagus, reflex swallowing occurs, which may be taken advantage of to further propel the tube. The disadvantage of this method of feeding is that the patient often struggles and must be gagged. A wooden gag shaped like a bit, with a central perforation through which the tube is passed, prevents it from being compressed by bit- ing. But the gag is disagreeable, it may slip and break a tooth, and the head and arms must be rigidly held by two assistants. I have known a refractory patient with melancholia to bite off and swallow eleven inches of stiff oesophageal tube, which remained in the stom- ach for eleven days before it was ejected by vomiting ! The nasal tube possesses the advantage that it may more easily be introduced with much less struggling, but it has the disadvantage that greater care is required to prevent passing it into the larynx, MELAXCHOLIA MANIA 681 for the insane are sometimes strangely insensitive. The former diffi- culty may be obviated by making the patient speak, or closing the tube after it has been inserted and before fluid is introduced, in order to make sure that breathing is not obstructed. This form of tube should be of as large a size as can be passed conveniently. A N"o. 8 catheter will serve. To prevent the patient from pulling out the tube, his arms may be wrapped in a large sheet wound several times around the body, after the manner employed with gavage for a struggling infant. For forced alimentation it is necessary to give food in fluid form, and a quart of milk, with one or two beaten eggs, either raw or slightly cooked or made into eggnog, may be prescribed two or three times a day. Nutritious meat broths, thickened with barley, rice, or vermicelli and strained, or potato puree, may also be given through a large tube. Cream and cod-liver oil should be added to the diet. In a case reported by H. Cf. Wood, for six weeks the patient lived with the greatest benefit on six pints of milk and sixteen raw eggs taken daily. If an ounce of malt extract be added to oatmeal, hominy, or potato gruel in milk, it soon makes the mass sufficiently fluid to pass through the tube. As this method of feeding prevents the saliva from commingling with the food, there is additional ad- vantage in giving malt or diastase to replace it. For obstinate patients, feeding with the tube twice a day at say 8 A. M. and 5 or 6 P. M. is sufficient, and a quart of food may be introduced at once, but more feeble patients require feeding three or four times in 2-i hours. If gastric catarrh, gastric dilatation or dyspepsia is present, pre- liminary lavage may be employed, and then food and medicines may be poured through the tube. Both hypnotism and primary anaethesia under chloroform have been utilized in extreme cases to enable food to be given to the in- sane, but the latter method is only necessary or justifiable in very exceptional cases. Nutrient enemata are of little value in the feeding of the insane who resist feeding, for if the patient realizes their use he can make it more difficult to be nourished in this way than by the stomach or nasal tube, although I have seen patients who would submit to it who refused mouth feeding. Suralimentation is to be recommended when feasible. It is de- scribed on page 514. Brush says : " In acute delirious mania, in melancholia with frenzy, and in some of the maniacal seizures incident to the aged, the 46 682 DIET IN SKIN DISEASES great importance of a liberal persistent use of milk, eggs, and animal broths cannot be overestimated." If patients will eat they should be given abundant nutritious food, such as tender meats, custards, cereals with butter, sirup, or cream, eggnog, thickened broths, purees, beef jelly, gruels, etc., which are made palatable to tempt the appetite, and the number of daily meals may be increased or nourishment may be given once in three hours. By diverting the blood current and nervous energy for digestive proc- esses, the general nervous, system and mental condition become soothed and quieted, and the mind improves as nutrition gains. Mens sana in corpore sano. Fresh fruit and fruit juices 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 should 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 need to 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 served in a state of fine subdivision or fluid or semifluid form. Patients with advanced general paresis or different paralytic diseases may suffocate by impacting a piece of meat in the larynx. Patients with mania gravis, or suicidal melancholia, etc., should of course never be in- trusted with knives or with plates or dishes which may be broken into sharp fragments with which to cut themselves or others. DIET IX SKIX DISEASES It long has been known that a relation exists between various errors in diet and certain skin diseases, but it is only within the past few years that attention has been directed to the importance of sys- tematic 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 dis- eases commonly referable among other influences to dietetic errors are DIET IN SKIN DISEASES 683 erythema, urticaria, acne, eczema, psoriasis, exfoliative dermatitis, and scorbutic eruptions. 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 impetiginous and seborrhceic ecthyma, strophulus, and cutaneous lesions of the tuberculous diathesis. Alcohol beverages drunk in excess intensify many forms of chronic cutaneous lesions, notably those of syphilis and rosacea, and the capil- lary 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 irritation by malfermentation products, ptomaines, etc., which are absorbed through the digestive tract. (See Autointoxica- tion, p. 623.) In other cases they may be due to an effort to eliminate incompletely oxidized food products or poisons from the cutaneous glands (as in the case of drug rashes), and it has been suggested that they sometimes may be caused by reflex nerve irritation from the ali- mentary canal, although the latter theory is less tenable. It is, how- ever, interesting to observe the fact that an intimate relation often exists between irritation and inflammation of the skin and of mucous membranes. Overeating, and especially the overfeeding of infants, is a common cause of skin eruptions, and the attempted elimination by the sweat glands of fatty acids is irritant. General Principles of Dietetic Treatment. There are certain gen- eral principles of dietetic treatment which are applicable to a major- ity of all severe cases. The food should be of elementary kind, re- stricted in variety, and plainly cooked. Milk, eggs, and stale bread are more desirable than amylaceous or saccharine food. If fever be pres- ent at the outset, a milk diet should be ordered. The tuberculous and gouty require fats in some form. Chronic cases with malnutri- tion and ana?mia require abundant nourishing animal food. In scor- butic eruptions the trouble arises sometimes (but not always) from malnutrition from withholding particular foods, such as fresh fruit and vegetables, from the diet. (See p. 763.) Substances to be avoided in skin diseases are raw and unripe fruits and vegetables, sweets and pastry of all kinds, condiments and highly seasoned dishes, fried foods, butter, oils, lard, and other fats (except in tuberculous cases), veal, pork, and alcoholic beverages. Other injurious foods will be mentioned under the treatment of the several varieties of skin diseases described below. The underlying dietetic principle is to restore the balance of nutrition, not to enforce an 684 DIET IN SKIN DISEASES inflexible routine, for example, eczema in one patient may do better with vegetarianism, but in another with a meat diet, according to general conditions of nutrition. ERYTHEMA URTICARIA Either acute erythema or urticaria may be caused in some persons by eating fish, and particularly shellfish and crustaceans, as oysters, clams, lobsters, shrimps, and crabs. It also occasionally is produced by strawberries, bananas, and other forms of fruit. Crustaceans and strawberries are perhaps the most common excitants, but there are many curious examples of individual peculiarities. The action of the food poison is different from that of ptomaines (p. 419), for it originates from fresh as well as stale food, and may be derived, as in the case of strawberries, from vegetable 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 persons 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 sometimes to poison are pork in various forms, sausages, mushrooms, eggs, cheese, and mutton. Symptoms. The eruption develops suddenly and within from two to six hours after ingestion of the food. It is commonly a typical 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 only a few hours, or possibly for several weeks. Treatment. The eruption usually disappears upon withdrawing the offending article from the diet, giving a saline cathartic and some simple remedy to regulate digestion and prevent fermentation, such as salol, salicin, or rhubarb and soda. Lactobacilline should be tried (p. 92). Large quantities of water should be drunk, 8-10 glasses a clay between meals. The troublesome itching is relieved best 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. A 1-40 carbolic-acid solution may be similarly applied over k the affected parts of the body. ACNE ECZEMA 685 ACNE Causation. The larger number of cases of acne are produced by improper food. The papules and pustules which constitute acne are formed by inspissation of the oil of the sebaceous glands, which plugs their orifices and irritates the glands and the hair follicles, exciting inflammation in them with pyogenic bacteria. 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 liable to last for some time often for several years. It is easy to conceive how slightly altered composition of the blood, due to im- perfect assimilation of food, may modify the composition of the sebum and irritate the sebaceous glands. In some patients 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, and the recent treatment according to Sir A. E. Wright's method, with homologous vaccines, the dietetic treatment of acne is most important. G. T. Jack- son says : " The well-to-do are all prone to eat too much, and it is re- markable how rapidly acne will improve by reducing their diet to the simplest elements. In many of them a milk diet for a few days, pro- vided milk agrees with them, will accomplish marked benefit. It is a good rule to cut off from the dietary all pastry, cake, candy, sweets, hot breads and pancakes, 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 little fluid should be taken, never over four or five ounces, but between meals water or aerated water should be drunk freely for its diuretic effect. Exercise, bathing, and the use of laxatives should be adjuncts to the dietetic treatment. 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 trace- able to dietetic faults. These may be of three kinds namely, the eating of (1) too much food; (2) insufficient food; (3) improper food. 686 DIET IN SKIN DISEASES 1. Cases Due to Overeating. The ills of overeating have been de- scribed on page 411. Its relation to eczema consists in the additional burden imposed 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 character of their secretion is altered. The skin, for a long time irritated, 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 sometimes will be surprised with the sudden appearance of eczema, which they have always at- tributed solely to " bad blood," i. e., to some disease taint. Treatment. This class of cases is to be treated by reducing the quantity of food, and prescribing a very simple diet. In cases of in- tractable general eczema it may be best to order the patient 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 im- provement will occasionally follow this course. For others, reducing the diet by excluding meat and desserts for a time, may be all that is necessary. Eed meats either beef, beefsteak, mutton, lamb, or veal should not be allowed more than once a week. H. G. Piffard reports that 56 per cent of his patients 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 (L. D. Bulkley), for though it may ex- cite 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 in- tensify chronic cases considerably. Typical Diet. The following simple diet may serve as an example : Breakfast. Fresh fruit, bread and milk, porridge, wheaten grits, cracked wheat, without cream, but salt or lemon juice may be added if preferred. Every other day a soft-cooked egg may be eaten. Cocoa or postum. Dinner. ISTo soup, entrees, or dessert. Chicken may alternate with broiled fresh fish, one or two green, light vegetables, such as haricots, spinach, lettuce, green peas, or macaroni, with tomatoes. As Jackson says : " It is a good rule to 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, omelette, scrambled eggs, or sweetbread and junket, wine jelly, or simple rice pudding, not too sweet. Fresh fruit is desirable. Stimulants are ECZEMA 687 not usually required, and malt liquors of all sorts, as well as wines, expressly should be forbidden. It is 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 stimulating effect. Unless they be taken in great moderation and only 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 im- poverished nutrition, and the skin, being one of the most sensitive organs of the body, is among the first to suffer. The habits of filth which so often accompany semi-starvation among the poor are con- tributing causes which combine to provoke skin eruptions. The diet required for these cases differs essentially from those of the preceding class by addition of meats, butter, and cream. An effort should be made to restore the impoverished nutrition of the body as quickly as possible by suralimentation if necessary (p. 514). 3. Cases Due to Improper Food. Improper food is capable 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 always to forewarn against the particular articles of diet which will do this, as they vary in different persons 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, pies, puddings, cake, cakes and sirup, canned dried foods, hot breads, much butter, lard, pickles, preserves, and fancy desserts of all kinds. Bulkley especially for- bids 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 injurious. In a word, all those articles which are liable to excite temporary dyspepsia and over- load the urine with phosphates, urates, and calcium oxalate should be avoided. The staple diet should consist of whole-meal bread, fresh, plainly cooked vegetables, eggs, milk, and a little chicken, or fresh fish, with red meat not oftener than once or twice a week. There are obstinate cases of chronic eczema which fail to yield to any dietetic regulations, but it is desirable always to try the value of dietetics, and often the result will be surprisingly gratifying. In conjunction with dietetic treatment the urine should be examined, and the bowels kept active. 688 DIET IN SKIN DISEASES 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 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 (p. 583) and its avoidance are especially applicable to all skin diseases which are in any way amenable to dietetic influence. Eczema frequently is associ- ated with gouty and tuberculous diatheses, and the reader is referred to the sections upon these subjects (pp. 505, 717). Eczema in Nursing Infants L. D. Bulkley points out that eczema in nursing infants mainly is 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, wines and rich chocolate. Anything which provokes indigestion and biliousness in the mother reacts unfavor- ably upon the skin disease of the infant. This is an important truth too often overlooked. If the mother becomes constipated, has dys- pepsia and a furred tongue, and excessive deposit of urates and oxa- ates in the urine, her diet should be changed (according to the rules for dyspepsia on p. 583), the bowels regulated, and tonics given. Other cases in infants are caused by the mother's milk being poor and tkin, and the breast milk should be supplanted by cow's milk properly prepared, or it may become necessary to wean the baby completely. Mothers occasionally nurse their infants too long, hoping thereby to postpone conception. When the breast milk is too poor in quality Bulkier 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 aggra- vated b}' it. Eczema sometimes is often cured by adding fat to the food. The common mistake of nursing infants too often is particularly observed with eczematous babies, whose mothers mistake the child's crying for a manifestation of hunger, whereas it is 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 longer, the infant's digestion becomes deranged, and any existing eruption i> made move unbearable. Bottle-fed infants are more likely to have eczema than sucklings, probably because they oftener have gastro- EXFOLIATIVE DERMATITIS ROSACEA 689 intestinal disorders. Underfed infants are less subject to the disease than are the overfed. Eczema in Children Eczema in young children often is 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 very young children consists in giv- ing them too much farinaceous food, and the innumerable prepared infant foods, consisting largely of starches and sugars, are responsi- ble 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 " bilious " condition with a special tend- ency to the development of eczema. Older children should be denied candy, chocolate, pastry, jams, preserves, and indulgence in sweets of all sorts, and be fed upon the simplest diet, in which starch, and especially sugar, is 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 In exfoliative dermatitis I have seen more benefit from an exclu- sive milk diet for a month or six weeks than from any other treat- ment, combined with intestinal irrigation and asepsis. G. T. Jack- son advises chewing flaxseed or taking, in milk, several ounces of flaxseed tea every day. Subsequently it should be treated upon sub- stantially the same dietetic plan as eczema. ROSACEA Causation. Eosacea is a chronic skin affection disfiguring the mid- dle parts of the face, about the nose, mouth, cheeks, and sometimes 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 important. It 690 DIET IN SKIN DISEASES involves the prohibition of all alcoholic drink, as well as hot beverages of every kind, such as tea and coffee, and also soup. Existing dys- pepsia should be treated, and all rich food, desserts, sauces, pickles, strong condiments, fat, dried, salted, or canned foods, fried sub- stances, and sweets and desserts should be withheld. The patient should be kept for several weeks or months upon a low, non-stimulat- ing diet of plainly cooked food, such as that advised for the treatment of eczema (p. 686). PSORIASIS Causation. Psoriasis is a chronic general skin disease characterized by the appearance of isolated red patches of considerable size, covered by shining white scales. The etiology 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 takes place in gout and chronic rheumatism. The excessive consump- tion of oatmeal has been observed to develop an attack (Hardaway). It has great tendency to recurrence. Dietetic Treatment. The disease is less amenable to dietetic treat- ment than are some other skin affections ; nevertheless, this should not be neglected, as it may prove a valuable aid to local measures. The diet always should be restricted both in quantity and variety. Obese and plethoric patients improve upon a purely vegetable regimen. In severe cases it will be best to order a bread-and-milk diet for a week or longer. Vegetable food may then be added, but sweets and meats should be withheld. On the contrary, feeble, anaemic patients usually improve upon an animal diet, consisting largely of milk, with eggs, beef, and mutton. Bread may be allowed. Elaborately cooked and highly seasoned food is forbidden, as well as all forms of malt liquors. If any alcohol is required it should be prescribed in the form of well-diluted whisky and taken only with meals, but as a rule patients are better without it. PRURITUS Patients suffering from pruritus should partake only of non-stim- ulating food. They should temporarily adopt vegetarianism, give up all meats and drink abundant water. They should particularly avoid tea, coffee, alcoholic drinks of every variety, condiments, pastry, cheese, sauces, sweets, pastry, preserves, canned foods, pickles, made dishes, and fried food. Tobacco should be withheld. FURUNCULOSIS OBESITY 691 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 and other microorganisms which pene- trate the skin, through abrasions or otherwise, so that the supposed influence of diet is only remote, in that poor living tends to lower the general vitality and make the body more susceptible to any form of inoculation. Special dietetic treatment becomes necessary only in debilitated cases, such as complicate anemia, diabetes, or convales- cence from protracted infectious diseases, and the rules for it will be found under those headings (pp. 472, 539, 740). DISEASES ESPECIALLY INFLUENCED BY DIET OBESITY (CORPULENCY, POLYSARCIA) Causation. Obesity is a diseased condition of the body, depending "upon alteration in the proper balance of nutrition, with an accumula- tion of fat in and between the tissues. This lack of equilibrium theo- retically may be due to (1) excessive ingestion of food with dimin- ished exercise. (2) Lowered oxidation activity. (3) Retardation of normal metabolic activities. Obesity may affect either sex, but is much more common among Tvomen, in whom it is particularly noticed during and after the cli- macteric. 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 soon after the fortieth year, when the functional activity of the body is diminished and when habits of systematic exer- cise are replaced by a sedentary life of luxury and ease, combined with overeating. Aside from heredity, an important cause of obesity is excessive eat- ing, which is a fault among many persons who have entered middle life. When the growth of the body has been completed 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 satis- fying a vigorous appetite may be continued, resulting in the consump- tion of a larger amount of food than is required for maintaining the yital functions. It is extremely difficult for people who feel in robust health and whose mental is proportionately greater than their physical 692 DISEASES ESPECIALLY INFLUENCED BY DIET activity, to realize 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 reaching an advanced period of life. According to Sir Henry 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 as beer and ale, favors obesity, and in many persons 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. Very stout persons are occasionally extremely moderate eaters, and in these cases the difficulty lies apparently in poor oxida- tion and insufficient exercise. 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 ordi- nary amount of exercise. This is owing to the increased weight and difficulty of moving about, as well as to the lassitude and positive dis- like for muscular exertion which is felt by them. Obesity once established is likely 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 compara- tively harmless, excepting as it indicates a disproportion between functional activity and the amount of fuel taken 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- OBESITY 693 sirable in the dietetic treatment of obesity to determine the original cause of fat accumulation, and to ascertain to what extent it is ac- companied by fatty degeneration. Suppose a woman to weigh 120 pounds at 20 years of age and 240 at 40 years. In doubling the size of the body she has the same sized heart to maintain the circula- tion, that she had at 20 years, but it has much more work to do, for every time she walks or climbs a flight of stairs, she raises the addi- tional 120 Ibs. of dead weight. Bauer says : " The fat stored up in the body acts in like manner 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. The stock of fat stored in the body is moreover the cause that corpulent individuals frequently continue to gain in bulk although they are not in the habit of indulging in food immoderately. " If an increase of albumin be desired without a considerable addi- tion to the store of fat, a liberal allowance of albumin with relatively small quantities of carbohydrates must be provided. If, 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/' Voit claims that albumin circulating in the blood is more readily oxidized 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 organized tissues, thus saving tissue waste. The tissues use up the circulating albumin, and, not being exhausted thereby, go on and oxidize 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 to the diet, fat is deposited in the body. The carbohydrates, like fat, can protect circulating albumin from katabolism 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 694 DISEASES ESPECIALLY INFLUENCED BY DIET albumin, is spared further metabolism. Hence fatty metabolism in the body may be quite independent of fat ingestion. It has lately been shown that fluctuations in body weight are largely dependent upon the gain or loss of water temporarily stored in the tissues and fluids of the body. A. Gouin and P. Andouard proved that animal tissues tend to store water when a sugar diet is employed. Weighing the body does not demonstrate the true gain or loss in either fat, proteid or carbohydrate. Benedict and Milner in a comparative study of a fat and a carbohydrate diet, each with 4,500 grams of water a day, found that on a carbohydrate diet, a man gained 61.3 grams a day in weight, but lost weight on a fat diet, though both diets furnished the same amount of energy 69 calories more heat were developed on the fat diet. A transition from the carbohydrate to the fat diet caused a marked loss of water from the body. Although the metabolism resulting in obesity is probably substan- tially the same in all eases, it is nevertheless convenient to recognize several clinical types, differing somewhat in the possible results of treatment. These may be grouped as follows : I. Obesity in children and youth, often hereditary. In these casea reduction treatment should be intermittent in order not to limit nor- mal growth and development. II. Moderate obesity in the middle-aged, capable of being held in check by periodical reduction cures. Such patients weigh 20 to 30 Ibs. more than the normal average. III. More obstinate cases, tending to excessive corpulency and re- quiring constant treatment. Such patients may weigh 30 to 60 Ibs. more than the normal average. IV. Cases of extreme obesity, patients weighing 250 to 400 Ibs. or more, in which reduction treatment is not always safe, and seldom is even partially successful. 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. The best results from treatment are obtained in patients less than thirty years of age. For a long time it was believed that excessive consumption of carbo- hydrates was the cause of increased fat production within the body. The pig is fattened on corn, and cattle upon various cereals. Un- doubtedly many persons who are of spare habit can increase their weight by eating a larger proportion of starches and sugars. It is a OBESITY 695 fact, moreover, that starches contain oxygen in the exact proportion necessary for the formation of water and carbon dioxide, and on be- ing 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 proteid 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 persons are capable of producing it from a particular class of food materials more readily than from others. Thus one may become fat from over- indulgence in saccharine food and another from eating purely starchy foods and taking large quantities of malt and beer, and another from the excessive use of quantities of fat meat. Accordingly the rules which are formulated for the treatment of obesity should be regarded as referring to the majority of cases only, whereas there are many exceptions to be individually 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 solely 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. As stated above, the majority of the obese eat too much and exer- cise too little, or at least they have originally eaten more than they consumed, i. e., although they may delude themselves to the contrary and claim to be small eaters, they have at some period consumed too many calories, hence it makes little difference whether the curative diet be restricted in fats or in carbohydrates, so long as the total caloric energy be cut down. As pointed out by von Xoorden, the detailed mode of restriction may be left in great part to the individual patient's liking, so long as the general principles are adhered to of reduction in quantity of food and increase in oxidation by exercise and outdoor air. As a general statement, from one to two-fifths should represent the degree of reduction in quantity of food in an average case, and in general this may be accomplished by eliminating sugars and alcohol in toto and reducing to a minimum the consumption of fats and of bread, potatoes, cereals, and other forms of starch. Among the different systems which have been advocated for the 696 DISEASES ESPECIALLY INFLUENCED BY DIET cure of obesity the best known are those of Banting, Ebstein, and Oertel. Schweninger's cure is practically Oertel's method 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 devised especially 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. Second, to diminish the quantity of fluid drunk by prescribing what is called a dry diet. The treatment, moreover, is usually accompanied by systematic exercise and bathing, and it is important to keep the bowels active. The attempt is sometimes made to cure obesity by allowing the pa- tient 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 un- scientific method, and an unwholesome one for serious cases. Patients should acquire the habit of slow eating, which tends to lessen the amount of food taken. 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 com- plicates certain other diseases, such as gout or rheumatism, where the use of an increased quantity of fluid may be temporarily neces- sary 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. Never more than five ounces of fluid of any sort should be taken with a meal, or fifteen ounces per diem, and tli is measure may be further curtailed by giving water between meals instead. Soups of all kinds should be forbidden as well as alcoholic bev- erages, and what little fluid is allowed should consist of plain or aerated water. Little, if any, milk should be taken. The food should be as dry as possible without interfering with its flavor and nutrient value. Highly succulent fruits, such as watermelons, and vegetables like raw tomatoes, which consist largely of water, should not be eaten. S\igar should be forbidden absolutely, and fat should be used very sparingly, and only in the form of a little butter. The allowance of farinaceous food should also be cut down as much as possible. Tt will not usually be found practicable to do without bread for any length of time, but patients are often willing to restrict them- OBESITY 697 selves to a very strict diet for two or three weeks if the positive hope of cure or amelioration of symptoms may be held out to them, if they are made to understand the rationale of the treatment, and if they are given some objective point to anticipate when a promised improve- ment 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 be given, and the obese do not endure well deprivation of all fats, even when farinaceous food is supplied in moderation. This is often more true of those engaged in mental work than of those employed in muscular exercise. Fresh fruit and fresh green vegetables "vegetables which grow above the ground," except the legumes and corn 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 intes- tinal catarrh. THE BANTING SYSTEM The diet which Mr. Banting practiced upon himself in 1862 with considerable success, and which bears his name, was exceedingly strict in regard to diminishing the quantity of food and 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 respira- tion. In his dietary, which was based on the suggestions of Dr. Wil- liam Harvey, the fats and albuminoids are not well balanced, and it may cause constipation and malnutrition. THE EBSTEIN SYSTEM The Ebstein treatment, as originally employed in Germany, has been attended with considerable success. The theory of this system (which in part accords with that stated on page 693) is that animal as well as carbohydrate food is capable of being converted into fat, espe- cially when used in combination with starches and sugars. The latter are believed to furnish force for the body, and by their combustion 98 DISEASES ESPECIALLY INFLUENCED BY DIET to spare the complete oxidation of albuminates, which are therefore stored in the tissues in a suboxidized 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 allowed in the dietary ; in fact, Ebstein recommends its use on account of its effect in producing satiety. By sooner diminishing the appetite, 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. The patient is permitted 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. A little light wine and black tea without milk or sugar may be drunk. 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 (Atwater). DIETARIES. NUTRIENTS. Potential energy in nutrients. Protein. Fats. Carbo- hydrates. Total Grams. 171 102 57 119 118 100 125 53 100 128 Grams. 8 85 14 51 56 100 125 33 100 177 Grams. 75 47 341 531 500 360 450 316 240 466 Grams. 254 234 412 701 674 560 700 402 440 771 Calories. 1,085 1,400 1,760 3,140 3,050 2,815 3,520 1,820 2,325 4,080 Plavfair's standard for " subsistence d'i e t " Playfair's standard for adults with Voit's standard for laboring man at moderate work Atkinson's standard for man with lifht exorcise Atkinson's standard for laboring man at moderate work Poor sewing girl, London; diet barely sufficient for subsistence . . University professor, Germany; very light exercise Well-to-do family. Connecticut ; food actually eaten OBESITY 699 Comparison of Dietaries for Corpulence with Ordinary Dietaries (Atwater). Continued. NUTRIENTS. DIETARIES. Protein. Fats. Carbo- hydrates. Total. energy in nutrients. Grams. Grams. Gtams. Grams. Calories. Mechanics and factory operatives, Massachusetts ; food purchased . . 127 186 531 844 4,430 Food actually eaten by college stu- dents : From Northern United States . . . 138 184 622 944 4,825 From Eastern United States .... 104 136 421 661 3,415 THE OERTEL SYSTEM Another system for the dietetic treatment of obesity is that prac- ticed by Oertel and modified by Schweninger (who prescribed it for Bismarck with benefit). The distinctive feature of the Oertel treat- ment is the attention which is paid to improving 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 pa- tients may be subdivided into two different classes, whose diet is regu- lated 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 engorgement. " (6) 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 muscular efforts are enough to disturb the respiration and provoke dyspnoea." For the first class his maximum allowance of fat is 50 grams and of carbohydrates 200 grams, with a minimum of 150 grams of albu- min. For the second class the maximum allowance of fat is 25-30 grams, with 100 grams of carbohydrates, but the albumin must con- siderably exceed 150 grams. In this class especially the amount of fluids drunk is 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 quantity 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 favorably innervated. Such vessels are, 700 DISEASES ESPECIALLY INFLUENCED BY DIET above all, in the fatty tissues vessels branching in the panniculus adiposus." Nutritive changes ensue in the fatty tissues, the fat is disintegrated, 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 [graduated hill climbing] will also lessen the fat accumulation, on condition 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 exclusive meat diet would not be completely oxidized. It is better, therefore, to restrict all three classes of foods, but not entirely to exclude either, and the proteids must decidedly preponderate. He also believes that anaemia weakens 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 more liberal dietary of Oertel is particularly suitable for those cases in which exercise can supplement dietetic treatment. The com- bined effect of the diet with exercise results in the absorption and oxidation of the fat deposited between the muscular tissues and in the renewal of more vigorous action of the muscle fibers, which are shielded from waste by the liberal proportion of proteid food which is admitted. The whole treatment is aimed especially at increasing the vigor 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 fibers enfeebles the strength of the cardiac systole and results in engorgement of the venous circulation. Lack of exer- cise also retards the venous circulation. As a result, there is a con- stant venous congestion which is particularly noticeable in the viscera, and there may be dropsical accumulations in the different serous cavities or general anasarca. Anaemia is believed to be counteracted bv the use of albuminous OBESITY 701 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, and 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 unimpaired, 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. Exercise. 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 meas- ured and adapted with reference to use by patients of different strength. During muscular exertion the destruction of non-nitrog- enous foodstuffs is increased. This exercise by climbing ascents is sometimes called the " terrain cure/' In case the patient is unable to exercise at all, the object is at- tained by massage, passive or " resisted " movements and friction, and the promotion of perspiration 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. Bathing should be carried out systematically, and the patient may be packed with cloths dipped in hot water in order to promote per- spiration. 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 alto- gether 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 702 DISEASES ESPECIALLY INFLUENCED BY DIET 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- haps a small slice of cheese; salad and fruit, six to eight ounces of wine with four or five ounces of water." (In this country it is found desirable to omit wine, as well as other forms of alcohol. Due allowance should be made for Continental habits.) After patients have undergone a special course of treatment for obesity and their weight has been reduced sufficiently, 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; it is intended for patients in whom obesity has complicated organic dis- ease of the heart or lungs : " Morning. One cup of coffee or tea with some milk = 150 grams (6 ounces), and bread = 75 grams (%y 2 ounces). "Midday. Soup = 100 grams (3y 2 ounces); lean meat, roasted or boiled, game or fowl = 200 grams (7 ounces) ; fish, not too fat = 25 grams (nearly 1 ounce) ; bread or starch stuffs = 100 grams at most (3!/o ounces) ; as dessert 100 to 200 grams (3y 2 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 % to *4 liter of light wine may be allowed (6 to 9 ounces). " Afternoon. The same quantity of coffee or tea as before, with at most y 6 liter of water (6 ounces) ; occasionally 25 grams of bread (nearly 1 ounce). "Evening. One or two soft-boiled eggs; meat, 150 grams (nearly 5 ounces) ; bread, 25 grams (nearly 1 ounce) ; a bit of cheese, a little salad and fruit. As a regular drink, y e to % liter of wine (6 to 9 ounces), with perhaps % liter of water (4i/> ounces)." Water should never be allowed in quantity, and what little is drunk should be distributed through the day. THE SCHWENINGEE SYSTEM Schweninger's system is essentially that of Oertel, but the former absolutely forbids the use of drink of any kind with meals, and the little fluid that is permitted is to be taken fully two hours afterwards. OBESITY 703 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, 1 p. M. Meat, vegetables, and fruit compote. Supper, 7 p. M. Meat and fruit compote or salad, a glass of white wine. Xo other fluid is given with meals. Bread is eaten very sparingly. 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 upon milk exclusively. 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 fre- quently be examined with special reference to loss of weight and to any unfavorable 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. A small quantity of beef, chicken, or oyster soup is allowed 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 permitted to move about the room, but must spend most of his time upon a lounge. Massage is per- formed 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 num- ber of pounds, and the general 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. THE YEO SYSTEM The diet recommended by Yeo is as follows : All fats and animal food are to be limited strictly, and farinaceous and starchy foods 704 DISEASES ESPECIALLY INFLUENCED BY DIET should be reduced to a minimum. Sugar must be prohibited entirely, 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 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 puddings, farinaceous pud- dings, pastry, salmon, and mackerel are all to 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 accordance 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 insufficient to support the strength and activity of another of larger physique. Later a full diet of meat may be allowed, but sugars and starches are still excluded to as great an extent as possible. The patient may be taught to supplement passive exercise by calisthenics. THE DUJARDIN-BEAUMETZ DIET 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 OBESITY 705 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 break- fast, 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. vox NOORDEN'S DIET Von Noorden recommends the following dietary for ordinary cases : At 8 o'clock 80 grams (2 l / 2 ozs.) of lean cold meat, 25 grams (nearly 1 oz.) of bread, one cup of tea, with milk and no sugar. At 10 o'clock one egg. A 12 o'clock one cup of strong broth. At 1 o'clock a small plate of meat soup, 150 grams (5 ozs.) of lean meat, flesh or fish; 100 grams (3~y 2 ozs.) of potatoes with salad; 100 grams (3y 2 ozs.) of fresh fruit. At 3 o'clock one cup of black coffee. At 4 o'clock 200 grams (70 ozs.) of fresh fruit. At 6 o'clock one-quarter liter of milk with tea. At 8 o'clock 125 grams (4 ozs.) of cold meat or 180 grams (6 ozs.) of meat, raw and grilled, and eaten with radishes and salads; 30 grams (1 oz.) of Graham bread, and two to three tea- spoonfuls of cooked fruit with sugar. 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 favors oxidation of the latter. He therefore pre- scribes 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. 47 706 DISEASES ESPECIALLY INFLUENCED BY DIET 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- dized, 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 carefully be stud- ied in these cases, a much better guide for the treatment of obesity is found in the observation of other symptoms and in the disappear- ance of previously existing abnormal conditions. THE CHAMBERS SYSTEM " Day's Regimen for a Three Weeks' Course. Eise at 7. Rub the body well with horsehair gloves, have a cold bath, take a short turn in the open air. Breakfast at 8 or 8.30, on the lean of beef or mut- ton, 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 1 on bread or biscuit, Dutch cheese, salad, water cresses, or roasted apples (with- out sugar or cream), hung beef, or anchovies, or red herring or olives, and such like relishes. Drink, after eating, claret and water, un- sweetened 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 extent of inducing perspiration, must be taken. Running, when practicable, 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 teaspoonful of sodium bicarbonate added to five or 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 OBESITY 707 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 vegetables, such as parsnips and beets. The patient may have lean beef or mut- ton, venison, game, poultry, boiled fish, poor new cheese, green vege- tables and fresh fruits, oranges, lemons, almonds, roast apples, salads, olives, buttermilk, claret, hock. Bread should be aerated or toasted. Sea biscuits 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. THE DEBOVE SYSTEM Debove's theory of obesity is that the nervous system is at fault through failure to regulate metabolism. His treatment comprises (1) a period of reduced feeding, (2) a period of voluntary regu- lation. His sample diet is as follows: For breakfast, a cup of tea or milk; mid-day meal, one or two slices of meat, a few vegetables or a little salad, a hundred to a hundred and fifty grams of bread, a little cheese, fruits as desired, and a cup of black coffee without sugar. For supper, a glass of hot milk, sweetened, 30 to 50 grams of bread, and fruits as desired. Summary of Dietetic Treatment. The above systems, comprising the theories of distinguished Ameri- can, English, German and French dieticians, are of interest in con- firmation of the oft-quoted adage, " One man's meat is another man's poison," and confirm the fact that obesity is a complex condition arising from varied causes, and therefore amenable to varied treat- ment. 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. The essential value of all methods of dietetic treatment of obesity is based upon two objects to be attained: First, to enable the patient to oxidize fully and eliminate the fat which is already accumulated in various parts of the body, and, secondly, to make it impossible for it to be reformed. From what has been said of the cause and nature of obesity, it follows that no one system of treatment is applicable in every in- stance. The effect of any treatment should be observed from day 708 DISEASES ESPECIALLY INFLUENCED BY DIET to day, care being taken that the patient while losing flesh does not at the same time lose in strength to a degree which may become dangerious i. e., more than two or three pounds per week. Under any " system " frequent examinations should be made of the heart action, the circulation, and the urine. The aged seldom become obese, or rather the very obese seldom be- come aged, but when they do, reduction treatment is ill borne and liable to induce fatal weakness. In many cases, especially among children and youth and in all patients having weak hearts, it is better to prescribe a reduction treatment of limited duration six weeks or two months and alternate it with longer t intervals of less re- stricted diet. In this manner strength is better maintained and de- velopment is not checked. Moderate increase in body fat in the middle-aged, does not necessitate reduction treatment (except on esthetic grounds), but it should be kept from advancing. As a rule, rapid reduction cures produce less lasting effects than slower treat- ment. Dangers of Reduction Cures. At the extremes of age, and in enormously fat subjects, reduction when it has caused a loss of 20 or 30 pounds or more sometimes causes evil effects, such as cardiac weak- ness, hernias, gastroptosis or nephrotosis, owing to a pendulous, flabby abdomen, or gallstone colic from the same cause. Cases complicating gout are described on page 717. Following is a list of foods which may be eaten by those who wish to prevent growing stouter or regaining weight which has been lost under a more strict reduction diet. PREVENTIVE DIETARY FOR OBESITY FOODS ALLOWED. Shellfish and Crustaceans: Oysters, clams, scallops, lobster. Eggs in any form, but not more than two a day. Meats: Lean, red meats; beefsteak, chops, lamb, mutton, veal, chicken, capon, turkey (without "stuffing" or sauces), sweetbread, lean ham, corned beef, smoked beef. All meats to be eaten sparingly and not oftener than once a day. Fish: Fresh fish of any kind except salmon, mackerel, bluefish (as being too rich in fat). Vegetables: String beans, lettuce, spinach, cress, celery, Brussels sprouts, cauliflower, cabbage, onions, okra, carrots, turnips, parsnips, squash, tomatoes, cucumbers, artichokes, leeks, radishes, cranberries, oyster plant. Fruits: Oranges, lemons, pears, apricots, peaches, cherries, berries OBESITY 709 (without sugar and cream), plums, pineapples, apples in any form. Mushrooms. Pickles, spices, condiments, vinegar. Stale bread and dry toast with two meals only, and in moderate quantity. Butter, not more than one-fourth ounce a day. Saccharin in lieu of sugar. Tea, coffee, with cream and sugar. SPECIAL EULES. Desserts: Unsweetened gelatin foods, cooked fruits. 1. Do not drink water within an hour before or two hours after meals. 2. Eat slowly; masticate thoroughly. 3. Do not have more than three courses or five kinds of food at any one meal. 4. Eat moderately, not to satiety. FOODS FORBIDDEN. Soups, broths, purees. Cereals and breadstuffs of all kinds, except a little white bread or toast. Gingerbread, crackers, brown bread, corn bread, rice, hominy, oatmeal, wheaten grits, shredded wheat, crackers, macaroni, spaghetti, farina, sago, cornstarch, tapioca, muffins. Fats and oils, olive oil, cream, fat bacon, lard. Desserts: Preserves, puddings, pies, pastry, cake, cakes, sugar, sirup, candy and confectionery, fancy desserts of all kinds, nuts, raisins, jams, marmalade. Game, goose, duck, pork, sausage, patties. Vegetables: White and sweet potatoes, peas, beans, corn, Lima beans, eggplant, beets. Miscellaneous: Liver, kidneys, marrow, tongue, cheese, terrapin, chowder, milk, chocolate, cocoa, effervescing waters, lemonade, orange- ade. All food should be cooked simply, and twice-cooked or " made over " dishes should be avoided, as well as all fried foods. Do not add in cooking foods which should be withheld, such as butter, flour, cream, milk and eggs. The thyroid-gland extract has a remarkable effect in reducing obesity in some cases, even without accessory treatment. The ka- tabolism of the process is not understood, but the C0 2 elimination is increased, and in addition to increased consumption of fat tissues there is increased nitrogenous waste. The effect is not permanent, and the lost weight is soon regained if the patient fails to persist in dietetic treatment with exercise. The powdered gland is given in 710 DISEASES ESPECIALLY INFLUENCED BY DIET tablet form, in doses not exceeding five grains three times a day. It is best not to give more than one or two grains at first in twenty- four hours, for the remedy sometimes produces serious cardiac weakness and digestive disturbance. I have usually found that after a reduc- tion in weight of about thirty pounds the extract had to be discon- tinued. C. P. Beebe has derived a modified extract. " 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 destroyed 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 condemned too strongly 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 physiological and metabolic processes involved, and the sub- stances which are in extensive use by credulous persons for this pur- pose diminish the appetite, impair the digestion, and seriously interfere with nutrition. In such manner only do they reduce corpulency. Excepting the thyroid extract 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. 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 oxidized completely, but it may be a contributing factor. To increase the albuminous constituents of the body without the addition of fat, a diet should be ordered in which proteid food pre- dominates, with a moderate allowance of carbohydrates. To increase the body fat, however, the proportion of carbohydrate should con- siderably exceed the proteid food and a little fat should be added. Fn seeking to remedy excessive leanness by dietetic treatment it is obviously necessary first to ascertain, if possible, its cause. It OBESITY 711 may be due to the use of improper food, to erroneous habits of eating, bad cooking, mal-digestion or mal-assimilation, overwork and nervous exhaustion, disease of the various organs connected especially with nutrition, and besides these and other causes there are those cases in which leanness seems to be constitutional or hereditary. Patients of the latter type 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 constantly fluctuating and whose annual variation is as much as ten or twenty pounds. In winter, in town life, when overworked, worried, or oppressed with mental strain, they lose weight rapidly, and in summer, during a holiday in the country, with little to do but eat, sleep and live an outdoor life, 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 lean- ness. Leanness is a decided advantage in heart disease, gout, and chronic rheumatism, because less effort is required by a light-weight body in locomotion, but in tuberculosis, neurasthenia and diabetes it is distinctly a poor symptom to be lean. It is almost hopeless to attempt to remedy obstinate leanness by diet unless other favoring 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 favor increase in weight. In most respects the diet for leanness is the reverse of that for obesity, as would naturally be expected, and in prescribing starchy foods it should be remembered that the leanness often is caused solely by an entire inability to digest amylaceous or saccharine material owing to " nervous dyspepsia," gastric catarrh, etc. These conditions should receive treatment on the lines recommended on pp. 583, 584. By a little care it will often be possible to discover some forms of starches which can be digested. It is a good rule in such cases to prescribe cereals or vege- tables at one meal and meat at another, so that articles involving different rates and organs of digestion do not interfere with each other. (See Digestion in the Stomach, p. 390, and Intestines, p. 393.) All bread should be stale or toasted. Crackers and zwieback may be allowed. Usually such patients may be made to digest starches be- fore they can sugars oatmeal will be better digested without sugar, and a cup of sweetened coffee with a meal of starchy foods may pro- duce flatulency which lasts for hours. It is desirable to increase the body weight (a) after serious acute 712 DISEASES ESPECIALLY INFLUENCED BY DIET disease, (&) in chronic wasting disease (especially tuberculosis), (c) in conditions of nervous exhaustion (neurasthenia). When the digestive organs admit, the following articles may be prescribed in the diet for leanness : Abundant fat meats, eggs, bacon, butter, cream, milk, cocoa, and chocolate. White and sweet potatoes, baked beans, Lima beans, but- ter beans, string beans, peas, beets, corn, samp, macaroni, bread and well-cooked cereals, especially oatmeal, hominy, and cornmeal, farinaceous puddings with sugar and cream, sago, tapioca, cake, cus- tards, sweets, sirup, honey, chocolate, sweet wines, port, porter, stout, ales, and beer. Malt preparations are also helpful. Sweet fruits may be eaten. To be avoided are pickles, acids, condiments, much bulk of green vegetables or lean meat and strong liquors. Muscular as well as mental rest should be enjoined if any dietetic treatment for leanness is to be successful. It is by no means always necessary or possible to keep the patient in bed, but disproportionate exercise (especially long, fatiguing walks), offsets the benefits of diet. Excessive leanness may not be incompatible with the enjoyment of perfect health, and, upon the whole, it is less uncomfortable than excessive stoutness; yet in the very lean, bodily resistance against certain forms of disease, especially chronic ailments, is diminished, the subject of leanness is prone to suffer from cold and often from digestive disorders, muscular fatigue may be easily induced, and in youths who have grown rapidly to extreme height, disproportionate leanness leads to stunted development in other directions, especially that of normal chest expansion. Other persons, especially young women, complain of their leanness upon aesthetic grounds. The important principle to impress upon the subject of leanness is that he should learn to make a storage battery of himself ; i. e., if he expend his energies too fast in any direction, the food which is their ultimate source will never be stored as a source of latent energy. The difficulty may be hereditary, constitutional, or acquired, but it only may be overcome by appreciating the full significance of this prin- ciple. 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 responsible for it. The prevailing opinion is that acute rheumatism is an infec- tions disease, hence there is no reason that diet should exercise any ACUTE RHEUMATISM 713 primary etiological influence in producing rheumatism or in prevent- ing recurrent attacks, beyond the obvious fact that a diet which dis- orders digestion or gives rise to malnutrition places the system in a condition more susceptible to the inroads of any microbic disease in other words, it lowers resistance. This statement, however, by no means precludes the fact that during an acute attack diet may exert profound influence as it does in many other febrile diseases which it does not originate. Dietetic Treatment. While the fever lasts and other symptoms are acute, such as pain and swelling of the joints, the patient should be put upon a fluid diet. The majority of patients do best at this time with an exclusive milk or bread-and-milk diet. Those patients who cannot take milk, however, may be allowed soups and broths fla- vored with vegetable extracts, chicken soup, milk toast, barley or oat- meal gruel, caudle, 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 with soda, Seltzer or Vichy may be drunk, or oatmeal or barley water flavored with lemon. Alcohol should be avoided while the acute symptoms last, unless the complication of inflammation of the endo- cardium or pericardium enfeeble the heart action to such degree as to make stimulation necessary. If convalescence be prolonged and anaemia considerable, alcohol may be prescribed 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, oatmeal, hominy, cornmeal, semolina, wheaten grits, panada, milk toast, simple unsweetened puddings, wine jelly, blancmange, and malted foods. 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. The late Sir Hilton Fagge stated 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 undoubtedly may induce a relapse. "When convalescence becomes established, eggs, sweetbread, fish, 48 714 DISEASES ESPECIALLY INFLUENCED BY DIET 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. I am often asked for preventive diet for rheumatism, especially for children who have had one or more acute attacks, but I know of none beyond general directions to eat simply cooked, plain food, avoid- ing excess of red meat and sweets, and taking fresh fruit for laxative effect. CHRONIC RHEUMATISM . In the dietetic treatment of chronic rheumatism, especially if the patient is anaemic, animal food should not be excluded, but the basis of the diet should be farinaceous food, with fresh green vegetables and fruits. Fish, eggs, and fowl may be eaten, but much red meat is not desirable. Sweets and alcoholic beverages should be omitted from the menu, and all foods should be plainly cooked and eaten in moderation. ARTHRITIS DEFORMANS Causation. Arthritis deformans is a chronic disease in which the joints of the body, and particularly those of the extremities, are affected. The alterations in joint structures are produced mainly by impoverished nutrition, and the disease is often, but not always, 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 general 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. Whereas the disease is one of debility and im- poverished nutrition, it follows that in it, unlike acute rheumatism, a low diet is harmful and a nourishing diet, with increased frequency of meals, is desirable. The late James Stewart of Montreal, wrote: "The practice of limiting the amount of proteid food is not to be commended. Provided there is no general or local contraindication, AETHRITIS DEFORMANS GOUT 715 the patient should be directed to take as much nitrogenous food as can be digested with facility." And Garrod wrote : " I consider it of the utmost importance throughout 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, with fresh vegetables, fruits and cereals. 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 tablespoonful doses, an hour after meals, three times a day. It is an excellent food in thia disease, and its use should be long continued. Other forms of fat may be used, such as butter, cream, or bone marrow, olive oil, fat bacon, etc. When acute exacerbations arise the quantity of food and stimu- lants should be reduced, but otherwise it is important that the diet always should be ample, and in debilitated patients the " forced feeding" detailed on page 515 may prove beneficial. Practically the only restrictions in quality of food are to omit sweets, desserts and " fancy " dishes, which satisfy the appetite without leaving room for more wholesome food. Patients do well to try the effect of a course of treatment at the "Hot Springs" of Virginia, Arkansas, Mount Clemens (Michigan), French Lick (Indiana), Banff (Canada), Aix les Bains (France), Wiesbaden (Germany), or Marienbad (Bohemia). 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, the finger, knee, and other joints, but 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, must be confessed, carries with it very little genuine explanation of the nu- tritive processes involved. Whatever may be the theories in regard 716 DISEASES ESPECIALLY INFLUENCED BY DIET to the production of an attack of acute gout, it is universally ad- mitted that careful regulation of the diet is a 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 normally should be oxidized and com- pletely converted into the soluble materials which are excreted in the urine. For some reason the oxidation of waste matter is sus- pended, and, as a result, a variety of intermediate products of im- perfect solubility may be deposited in the joints or tissues of the body. The active manifestations of gout are due to an accumulation of in~ soluble sodium biurate in the joints. In a condition closely allied to gout, the uric-acid diathesis, there may be a deposition of crystals of uric acid in some portion of the urinary tract. The direct relation existing between uric acid and gout has been exhaustively investigated by Garrod, and this relation may be briefly summarized as follows: First, the gouty diathesis is associated with a more or less constant excess of uric acid in the blood; secondly, the quantity of uric acid normally present in the urine is diminished 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, a substance that in itself represents incomplete proteid katab- olism in the body. The retention of this fo,rm of waste in con- siderable quantity proves markedly irritating to mucous and serous membranes, as well as 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 normal 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 Henry Thompson says that in early life it may cause 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 perform 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 oaten in excess is not of itself a direct cause of gout, but GOUT 717 sweets combined with certain other foods, such as special sweet fruits and wines, will precipitate an attack in a gouty subject with certainty. It is the combination of sugar with vegetable acids which is injurious. Sugar, under some conditions of fermentation in the stomach and intestines, forms lactic acid, which is capable of splitting so as to produce carbon dioxide, which, according to Ealfe, forms acid salts of sodium and potassium from their neutral compounds. Among the laboring classes in my wards in Bellevue and the Pres- byterian Hospital are many cases of acute Sydenham's gout. Such cases are sometimes met with among cooks who have tasted much rich food, sometimes among ill-fed men who have lived upon poor, coarse food and drunk a poor grade of malt liquors and spirits. Lack of exercise is often assigned as a cause for gout, and with many persons it is true that outbreaks 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 practice athletics, but who at the same time consume large quantities of proteid and sweets. In the latter class, 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 oxidized. Symptoms. The distinctive symptoms of gout are the local joint peripheral manifestations of pain, swelling, redness, and tenderness. These symptoms usually occur together in an acute attack, but either one occasionally may be absent. Other symptoms may appear from time to time, such as catarrhs of the mucous membranes, especially of the stomach, bowels, and respiratory passages ; arterio-sclerosis ; al- terations in the composition of the urine; and various forms of irri- tation of the nervous system and the skin. Children who inherit the gouty diathesis are very liable 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 localized 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 and have the diet balanced so that neither animal nor vegetable food predominates in great excess. As the 718 DISEASES ESPECIALLY INFLUENCED BY DIET 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, etc., are particularly injurious. Among adults tea and coffee, if allowed at all, should be taken in moderation, and some persons may 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 to do without them, those which are least injurious are a dry white wine or old Bordeaux, but all wines containing sugar are absolutely pro- hibited. Cyr says : " If a glass of beer,, spirits, or wine is habitually fol- lowed by pain in a joint or nerve it is gouty." Theory of Dietetic Treatment. An important question in regard 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 re- tain the salts of uric acid in solution, which are consequently precipi- tated in the joints and elsewhere. The matter is of vital importance in the selection of the proper diet for gouty patients. If the disease were caused merely by imperfect oxidation of proteids, the indication would be to lessen 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 proteid waste, it is possible that other causes may be responsible for the condition produced. Proteids contain both sulphur and phos- phorus which are destined to leave the body in the form of salts of sulphuric and phosphoric acids respectively. If these acids fail to be neutralized wholly while yet in the blood they will lessen its alkalinity, and in this way overindulgence in proteid food by furnish- ing an excess of sulphur and phosphorus may produce uricaemia. This theory explains why the use of alkaline waters is so generally beneficial in gout and lithgemia. Such fluids assist in regulating the normal alkaline reaction of the blood. This is the line of argument 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 re- duced by a vegetable diet. With the latter it may even become strongly alkaline. Whether we adopt the theory of deficient oxidation or of diminished alkalinity of the blood, the indications for GOUT 719 dietetic treatment of gout are the same namely, reduction of proteid food and increase of vegetable food. It does not follow that proteids must be given up entirely 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 relinquish proteid food altogether, while those who are accustomed to take active muscular exercise may be allowed animal food in very moderate quantity once a day. Dietetic Treatment. Although no one food is invariably injurious at all times, it is almost universally agreed that for the gouty, fat and proteids should be greatly restricted and saccharine food 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 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 likely to disagree if taken by itself, not with sugar or other food. Luff, of London, believes that the mineral salts of such vegetables as spinach, turnip-tops, Brussels sprouts, string beans, cabbage, and celery act chemically in preventing formation of gouty deposit in the tissues by increasing the solubility of sodium biurate and retarding the conversion of quadriurates into biurates. 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, should be adjusted so as to secure the right pro- portion of the different classes of foods. Atonic cases require a gen- erous diet with more proteid. 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 many 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. It is best in these cases to adopt a "reduc- tion" treatment for the corpulency (p. 708) for a few months, and give a proteid diet, for the gout will often improve of itself as obesity lessens. The theory has been held that very little fat should be eaten by 720 DISEASES ESPECIALLY INFLUENCED BY DIET the gouty, for it fixes oxygen which would otherwise complete the oxidation of proteids, and hence favors accumulation of waste products. On the other hand, it is held 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 kidneys is promoted by fats. Clinically, however, it is found best to control the use both of proteids and fats. Sugars, gelatinous material, and fats all tend to retard the com- plete combustion of proteid food, being " tissue sparers," and the latter therefore remains in an imperfectly oxidized condition which may give rise to uricaemia. The combination in excess of these classes of foods, therefore, is particularly injurious in gout. On the other hand, Ebstein favors the use of fat in moderation, on the ground that it appeases the appetite and makes the consumption of a large quan- tity of carbohydrates unnecessary. If fat is allowed at all in the diet, it is best to give it in very small amount ; otherwise it interferes with the digestion in the stomach and tends to augment the dyspepsia ' which is so common in gouty subjects. It will be borne better 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. Such patients should be made to restrain a too vigorous appetite, and especially the eating of food between meals, for, as Balfour says (The Senile Heart), "there is nothing 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 al- most 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 albuminous food to produce the least amount of uric acid and a minimum of car- bohydrates, in order to give the uric acid formed opportunity to be oxidized 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, and weak tea. Gruels of sap-o. arrowroot, or barley may be given, with bread or toast. When iho fever subsides and the acute symptoms abate, bouillon, clam juice, simple broths made of lean mutton or chicken with rice, may GOUT 721 be allowed. Later, a little whitefish or breast of chicken. Eed meat should be given only when really necessary, for, as Garrod says of it, "everything beyond what is absolutely required for the nourishment of the body only feeds the disease." Sir Dyce Duckworth's treatment of the acute form of the disease is briefly as follows: he recommends such substances as rice, bread, arrowroot, sago, tapioca pudding, semolina, milk, weak tea, and in- fusion of cocoa nibs. Later, chicken broth may be given, followed by fish and a mealy roasted potato. Xo 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 per diem. He also favors 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 Gar- rod 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 should at once be curtailed, as described above (p. 718). 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 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 flavored 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 disagrees with some gouty subjects, but in those who digest it well, if it be not too rich in fat or if taken skimmed or diluted, it forms an excellent food. Many are, however, opposed to its use in any form, even when its alkalinity is increased by the admixture of alkaline waters or a few grains of bicarbonate of sodium. Yeo gives a small salt-spoonful each of potassium bicarbonate and 722 DISEASES ESPECIALLY INFLUENCED BY DIET common salt in a breakfast-cupful of hot milk and water. An ex- clusive milk diet sometimes, but not often, aids those who are robust and young, but is injurious to older patients. Cheese, being a concentrated proteid food, should not be eaten. Egg 8 - Garrod allows eggs and bacon for breakfast, and Ralfe rec- ommends an "occasional savory omelet." Eggs cooked with milk and custard puddings (unsweetened except with saccharin) may 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, owing to their tendency to cause dyspepsia. Fish. Broiled or boiled fish, such as whiting, sole, herring, weak- fish, butterfish, trout, smelts, porgies, whitefish, bass, shad, are per- missible for variety, but fish having firm flesh and those which contain considerable fat are not recommended. Salmon, mackerel, halibut, cod, should therefore be avoided, although Garrod allows salmon served with salt and Cayenne, but without sauce. Rich sauces should not be eaten with fish or salads. In lieu of them, a simple dressing of an infusion of aromatic herbs and pepper, or a plain bread sauce, may be employed. Smoked and pickled fish are forbidden. Fish roe, such as shad roe and caviare, is admissible. Meats. Meat should not 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 eaten only 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, mutton, lamb, and poultry and squab may be allowed sparingly. Veal, pork, game, and potted, dried, smoked (except ham or bacon), pickled, or salted meats are 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 is forbidden. Fat meats are to be avoided, but 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. Cream should not be used, and very few eggs. Farinaceous Food. Farinaceous food is allowable, and in the acute stage of gout it should constitute the main diet. Bread (not fresh), boiled rice, puffed rice, sago, tapioca, oatmeal, cracked or shredded wheat, rolled oats, hominy, Graham bread, crackers, gingersnaps, GOUT 723 macaroni and spaghetti may all be eaten. Pastry, cake, hot rolls, griddle cakes, preserves, and confectionery of all kinds are forbid- den. 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 delete- rious. It is generally admitted that sugar eaten in excess with other food is 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 are a 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 authori- ties, however. Beets are forbidden. Vegetables, such as cabbage, onions, and old peas, beans, and corn, if they occasion flatulence, must be eschewed. The following may be eaten: French peas (petit pois) and young French beans, string beans, Lima beans, celery, young ten- der green corn, carrots, turnips, parsnips, well-baked and mealy pota- toes (except sweet potatoes) sparingly, cucumbers, broccoli, beet-tops, cauliflower, Brussels sprouts, squash, lettuce, romaine, celery, egg- plant, okra, artichoke. Salads, provided they are not dressed with much oil, are allowable. Vegetables which act injuriously on account of their acids (like tomatoes) 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 declare that fruits in general are harmful. The late Sir Andrew Clarke for- bade 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. I am accustomed also to allow melons, oranges, pineapples, and peaches. All those fruits which contain large quantities of sugar, such as grapes, figs, bananas, prunes, etc., should be forbidden, as also acid fruits, especially strawberries. No fruits cooked with sugar are allowable. 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 kidneys. Fothergill wrote : " The potash in the strawberry renders its juice a desirable drink for the gouty and for strumous children/' but there DISEASES ESPECIALLY INFLUENCED BY DIET are patients who cannot eat half a 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 should all be forbidden. Eating between meals and at irregular intervals is injurious. Fresh air and exercise are more needed than extra luncheons of bouillon, broths, wines, etc. Ealfe gave the following menu for breakfast and lunch : Breakfast. A poached egg, bacon, or fresh fish, tea (chocolate 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. Sir Dyce Duckworth prescribes the following excellent menu for goutiness or chronic gout in Allbutt's System of Medicine : " Six or eight ounces of hot or cold water may be taken half an hour before breakfast. Breakfast should consist of one or two ounces of well-toasted stale bread without butter, grilled whitefish, grilled mutton chop or beefsteak, or cold chicken, game, beef, tongue, or lean ham. One or two small cups of tea or coffee, with a little skimmed milk and without sugar may be taken. Saccharin may be used as a sweet flavoring agent, but is commonly disliked. Six ounces of bouillon or clear soup may be taken by weakly patients between breakfast and luncheon, and a gluten or almond biscuit with it. For luncheon order cold meat or a poached egg with spinach or lettuce, or other green vegetable, as water cress and mustard and cress, or a small omelet. Crust of bread or hard biscuit in small amount is allowable and a small quantity of fresh butter. A glass of good Bordeaux or Moselle wine (dry) may be taken with as much water. A cup of tea with a little skimmed milk and a rusk or gluten biscuit may be taken in the afternoon. For dinner no soup is to be taken, as a rule, but occasionally about eight ounces of a thin consomme may be allowed, then a little grilled or boiled fish, without starchy or fatty sauces, but flavored sometimes with anchovy or some other sauce, oysters, or. caviare, a little grilled or roasted meat, mutton, game, or fowl, with a small proportion of fat, green vegetables, and some stewed fruit fla- vored with saccharin or made less tart by the addition of half a tea- spoonful of Eochelle salt. Two classes of claret or of a dry Moselle GOUT 725 diluted with water are allowable. Later in the evening a cup of hot weak tea, without milk, or as much hot water should be taken." Beverages. Water. It has been stated above that to favor the washing of waste matter from the system it is desirable to drink con- siderable quantities of fluid, and gouty patients who are corpulent usually perspire with freedom; their urine therefore becomes concen- trated, and there is a tendency to the precipitation in it of uric acid, urates, and oxalate of lime. It should be remarked that the presence of uric acid in the urine does not always indicate an excess of that acid, for it may happen that the urine is too concentrated or other- wise altered to hold it in solution, and hence precipitation results. An excess of acid phosphate may combine with the sodium and potas- sium 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 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 imbibed. Fluid should be drunk half an hour before meals, when the stom- ach is empty. Besides serving to cleanse the mucous membrane of the alimentary canal, the diuretic action of water is 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 regular 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 was written for Englishmen 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 examples of gout may be found not rarely among patients who have never been in the habit of drinking alcoholic beverages daily, and such persons do best to con- tinue to abstain from them entirely. Tea, Coffee, etc. Tea and coffee are admissible among beverages for the gouty, and it will be found that they are less likely to cause dyspepsia if taken qu'ite weak without sugar. A quarter of a grain of saccharin may be added instead. Senator, of Berlin, on the contrary 726 DISEASES ESPECIALLY INFLUENCED BY DIET forbids tea and coffee, and prescribes "acorn coffee." Infusion of cocoa nibs is less to be recommended on account of the fat which it contains. Esbach states that he has found oxalic acid in it also, amounting sometimes to 0.4 per cent. Chocolate is forbidden. Alcoholic Drinks. In this country it is the part of wisdom to abstain entirely from alcohol, but 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. With regard to the use of alcoholic beverages 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. Patients who are able to lead active outdoor lives may drink more alcohol than those of sedentary habits, without augmenting their symptoms. In general the quantity consumed is as important as the quality, and should be prescribed definitely and kept within bounds. 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 the sugar to alcohol, the less hurtful they become to the gouty. If free perspiration exists in warm weather, and active diuresis as well, alcoholic drinks of all kinds are less harmful. Whatever form of alcohol be taken, it should be drunk to the exclusion of all others, for mixtures are particularly injurious. Strong beer, ales, porter, stout, all malt extracts, and sweet cider are 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 favors the formation of uric acid (Yeo). The alcoholic drinks which are tolerated best by the gouty are good French Cognac or old Scotch whisky, well diluted with water, Apollinaris, or soda water. Scotch whisky is by many found to agree better than any other variety. Weak brandy and soda may be substituted, or unsweetened Plymouth gin. There are some wines which should be prohibited absolutely, among them all which are re-enforced by, or which contain, a large pro- portion of saccharine material. Strong port, sherry, sweet cham- pagne, Madeira, Canary, claret, and Burgundy are comprised in this list. GOUT 727 Port wine has even required 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 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 : " Ehenish 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." 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 neu- tralize any acidity. Such wines should be either bottled or drunk 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 moderation, not over half a pint in a day. An absolutely dry champagne may sometimes be permitted, or very dilute and weak pure claret. Yeo says : " The more distinguished the diuretic effect of the wine, the better, as a rule, will it agree with the gouty/' Ealfe'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 expe- rience patients who long have been 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 sub- stituting 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 Eose. ' Different persons show peculiar idiosyncrasies in regard to the 728 DISEASES ESPECIALLY INFLUENCED BY DIET 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 Waters. Alkaline and saline mineral waters have a well- deserved reputation for benefiting gout. Many persons, especially obese gouty subjects, are helped by taking one or two " courses " of treatment a year for two or three successive years at 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, but contains more sodium sulphate. Elderly persons may be injured by a. .too energetic use of these salines, and they should take only milder alkaline waters con- taining less sodium. The German Fachingen water has proved very serviceable. It con- tains 3.5 per cent of bicarbonate of sodium and 6 per cent of bicar- bonate of lime. Celestins Vichy is good for strong patients, but not for the feeble or anremic. It also contains considerable sodium bicarbonate, and the Vals water has more sodium carbonate than many alkaline waters. These waters favor the elimination of uric acid as a salt rather than in the free state. Apollinaris and Johannis water are good. 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. Glair Spring in Michigan, and those of the St. Catherine Spring in Ontario, are good alkaline salines for gout; Many lithia waters are also recommended, but they contain little lithium. All alcoholic 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 di- gestion should be studied in each case by the physician, and the pa- tient 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 seven o'clock, and late suppers should be avoided. Between the acute attacks it is absolutely necessary to maintain digestion in a normal condition. The bowels should l)e kept open, and the condition of the skin actively main- tained by cold bathing and friction. Exercise should be taken in the open air. The urine should be examined frequently, with especial DIABETES MELLITUS 729 reference 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 character- ized by the passage of a large quantity of urine containing grape sugar or glucose and usually of high specific gravity 1.032 or more excessive thirst, and sometimes exaggerated or perverted appetite ; progressive emaciation; muscular weakness and languor. The disease runs a chronic course, and the majority of cases terminate fatally in from two to four years, although some patients live 20 years or more. Death may result from inanition, " diabetic coma " or other causes. The knowledge of the disease has been aided by experimentation upon the lower animals, in which diabetes may be produced experimentally. The treatment is almost entirely dietetic and hy- gienic, for as yet no medicinal remedy has been found which is cura- tive, and very few have been discovered which are palliative in any considerable number of cases. Diabetes is therefore essentially a die- tetic disease, for although not usually caused by errors in diet it may be so produced exceptionally, and most cases are more or less ben- efited by dietetic treatment, while some may undoubtedly be cured by it. Diabetes was described more than a century ago; and Kollo in- augurated the dietetic treatment by withholding vegetable food. In 1838 Gmelin and Tiedemann established the existence of the relation between the digestion of carbohydrates and the formation of sugar. In 1848 the eminent physiologist Claude Bernard first threw definite light upon the relations of the liver to the consumption of sugar and the formation of glycogen, and since that day physiologists and clinicians in many countries have contributed extensively to the knowledge of the disease. The method of production and elimination of the sugar and the influence of the disease upon general nutrition is understood, but its exciting cause and the fundamental reason for the interesting departure from the normal metabolism of starchy foods which is its basis is still unknown. Causation. The influence of heredity may be traced as a factor in about one-third of all cases. The disease may arise in any climate and in any age with either sex, but it is commonest in males as com- pared with females in the proportion of three to one. In the latter it occurs oftenest between twenty and forty years; in males, between thirty and forty-five years. It is somewhat more common among the 730 DISEASES ESPECIALLY INFLUENCED BY DIET wealthy than the poor because of sedentary habits combined with over- indulgence in eating. The obese, particularly those who have much omental fat, are more liable to diabetes than are thin persons who are more active. 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 accidents ; exposure to cold, wet, and fatigue; convalescence from fevers; emo- tional strain, worry, mental fatigue, and anxiety. Tumors and hemor- rhage at the base of the brain and circumscribed lesions of the floor of the fourth ventricle have been known to occasion the disease. A number of cases are associated with disease of the pancreas. Overindulgence in Food. True diabetes is not to be traced to any constant dietetic factor, although inordinate eating of candy, choc- olate, preserves, raisins, sweet fruits, confections, etc., may occasionally cause temporary glycosuria. G. P. Fowler wrote : " I have been in the habit of supplying my classes with saccharine urine simply by taking about four ounces of dried dates or about a tablespoonful of pulverized glucose upon a fast- ing stomach." The order of harmfulness of carbohydrates in diabetes may be stated as follows, commencing with the most injurious: 1, glucose; 2, saccharose ; 3, starch ; 4, lactose ; 5, inulin ; 6, levulose. 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 immediately may be traced to indiscretion in the abuse of saccharine foods, it is of little practical significance. In transient glycosuria the ingestion of excess of cane sugar does not, according to Worm-Muller and others, produce glucose in the urine, but saccharose. In diabetes lactose reappears in the urine as glucose, but under normal conditions if eaten in excess it causes a transient lactosuria. Ac-hard and Weil proved experimentally that lactose injected hypo- dermically in solution is not assimilated in diabetes, and a milk diet almost always increases the glycosuria, in spite of which the patient may gain weight, owing to improved digestion. Relation to Gout and Other Diseases. Occasionally obese 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 DIABETES MELLITU8 731 mtercurrent disease in no way connected with diabetes. In a long series of cases of diabetes reported by Ord, gout occurred in over one- third, and in some there was arthritis. deformans. 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 connec- tion that similar dietetic treatment benefits obese and diabetic pa- tients, for they both live best upon a proteid diet with alkalies. Dia- betes is also often associated with neuralgia, phthisis, and hepatic con- gestion. There is no one form of disease of the liver or pancreas of which diabetes is a uniform or frequent accompaniment. In about one-third of the cases a history is obtainable of mental strain, worry or overwork, and in about one-third there is a history of alcoholism, which, however, may be incidental. Physiological Experiments. Claude Bernard was the first to de- termine accurately the amount of sugar normally present in the blood. According to his estimate, when this quantity does not exceed three parts in one thousand, the limits of health are not surpassed, 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 much sugar is destroyed by the passage of the blood through the lungs, but he also found it to be carried by the hepatic vein, whereas the portal vein contained a mere trace. 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, is normally pres- ent in the skeletal muscles as well. Bernard also found that the quantity of sugar which he could col- lect 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 sugar ingested on its way to 732 DISEASES ESPECIALLY INFLUENCED BY DIET the general circulation, and thus acts as a regulator of the amount of sugar contained in the blood. 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 expended immediately, but should be stored in some form which will enable it to be used grad- ually 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. In this manner an excess of sugar ingested or an excess of sugar derived from the digestion of starchy food is normally kept from entering the circulation immediately, and its use is economized by holding it back until it is required for force production. The ulti- mate 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 nutrition, 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 " func- tion 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 may be formed in part by dehydra- tion of sugar derived from metabolism of proteid food. When dia- betes is once established, the elimination of sugar in the urine may sometimes continue in both man and animals kept upon an exclusive proteid diet. The foregoing experiments have given rise to three opposing theo- ries regarding the origin of glycosuria, 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 cine 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 func- tional activity of the liver may remain normal, arid yet the final com- DIABETES MELLITUS 733 bustion of sugar by the tissues or its assimilation by them may be imperfect and lead to its accumulation in the blood and subsequent 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 may give rise to the presence of an abnormal amount of sugar in the blood (glycohasmia), which is excreted by the kidneys (glycosuria). It is probable, however, that in the majority of cases the primary difficulty is to be found in altered metabolism in the liver or pancreas. 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 con- version 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 forma- tion of fat. Pavy propounded another ingenious theory to account in part for diabetes, which is that the intestinal epithelium of the villi ordi- narily exerts a sort of glandular control over the sugar absorbed from the bowel, and converts it into glycogen and fat as it reaches the blood. Failure to perform this function results in the production of glycosuria. This failure, Pavy held, is due primarily to faulty nerve action affecting the caliber of the arterioles and capillaries and hyper- oxidation, which favors the too rapid conversion of carbohydrates into glucose, causing glycosuria. This theory has been somewhat severely criticised by Paten, and is opposed to Seegen's views, but it does not exclude belief in the storage of carbohydrates as glycogen in the liver it is merely accessory to it. The Pancreas and Diabetes. Extirpation of the pancreas in man has been shown by the late William T. Bull, of New York, to some- times produce diabetes, and experimental extirpation of this gland in dogs has the same result. In many, but not all fatal cases of diabetes, more or less pancreatic disease, usually of the nature of chronic inter- stitial inflammation, has been observed. The gland is known to pro- duce an internal secretion i. e., a secretion passed into the circula- tion, which is a glycolytic ferment and when the gland is diseased this ferment is reduced in quantity, sugar fails of conversion to glyco- gen, and diabetes results. Opie believes that the islands of Langer- hans are the structural portions of the pancreas concerned with the production of the ferment, and degenerative changes have been ob- served in diabetes in these islands of polygonal cells which are supplied 73-i DISEASES ESPECIALLY INFLUENCED BY DIET with a rich capilliary network. Atrophy and fibroid overgrowth of the pancreas are especially prone to cause diabetes. The Nervous System and Diabetes. It is a curious fact that the irritation or puncture of a very circumscribed 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 center/' and it is in close relation with the sympathetic and vasomotor nerves that con- trol the capacity of the hepatic blood vessels. Glycosuria is also ob- served in man after the inhalation of chloroform and in animals after the inhalation of irritant vapors and after stimulation of the pneu- mogastric nerve. If the vagus nerve be divided in the neck, or if the spinal cord be divided above the origin of the great sympathetic nerve, diabetes may result. Bernard suggested that glycosuria might be cured if it were possible to galvanize the sympathetic nerves. The foregoing experiments demonstrate that glycosuria may be caused by a variety of nerve lesions and irritations. The Circulation and Diabetes. The occasional occurrence of dia- betes in connection with acute inflammations of the liver and passive hepatic congestion secondary to advanced cardiac disease favors the hypothesis that glycosuria may be developed by an increase in the amount of blood flowing through the liver, which is hereby stimu- lated 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 intestine by the branches of the portal vein does not have time to be converted into glycogen, but passes through the liver into the gen- eral circulation unaltered. Various Theories of Diabetes. Huppert, Pettenkofer, and Voit advocated the following theory : Glucose, like urea, is a normal prod- uct of the rapid decomposition of albuminous bodies. In health this glucose is oxidized; 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. Lauder Brunton reported several cases due to the presence of a tapeworm. He thinks that the increased appetite caused by the pres- ence of the worm may have been instrumental in causing the gly- cosuria from overeating, but it is possible that the peripheral irrita- tion of sympathetic nerve fibers may have been conveyed to the diabetic center in the medulla, and thence reflected to the vasomotor system of the liver, or the worm may have produced a toxin. Some recent experiments and clinical observations justify the belief that the skeletal muscles play a more important role in the produc- tion of diabetes than has heretofore been supposed. During their DIABETES 1MELLITUS 735 activity they normally consume glycogen in considerable quantity. If they fail to perform this function properly, it accumulates in the system. Kiilz has shown that muscular activity favors 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 never may 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 endowed with normal functional activity. 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/' Crofton discovered in 1901 that injection of extract of the adrenal bodies into animals may produce glycosuria, and subsequently C. H. Herter, experimenting with adrenal extract applied to the pancreas surface, gave rise to glycosuria in the dog. Lepine found that normal blood, which has been warmed for some time in an incubator, con- sumes dextrose, and diabetic blood does so in lesser degree, an experi- ment which suggests that one factor in the production of diabetes may reside in the blood possibly as an enzyme derived from the pancreas, absence of which may cause glycosuria (Carl Ramus). A type of renal diabetes is developed by the experimental ingestion of phloridzin. From all the experiments thus far recorded on the production of glycosuria, the conclusion is inevitable that diabetes may be the resultant of varied conditions, such as abnormal functioning of the liver, the pancreas, the kidneys, the blood, and possibly the adrenals, and thyroid, to which may be added functional nervous disturbances as affecting these organs. Whatever the origin of diabetes in differ- ent cases, however, the disease being once established, the dietetic influences are practically the same for all. Symptoms. The most important symptoms of a typical case of diabetes which are to be combated by diet are (a) extreme thirst, (&) hunger, (c) the craving for sugars and starches, (d) the large quantity of urine voided and rapid emaciation and loss of strength. (a) Thirst. The Mouth. Thirst becomes excessive, and is not 736 DISEASES ESPECIALLY INFLUENCED BY DIET quenched by drinking, although patients will drink almost any avail- able fluid even their own urine in their endeavor to relieve it. The absorption by the blood vessels of fluid from the tissues is held to be the main cause of this 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 contains 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 prominent papillae ; later it may become dry, dark red, and fissured. ( 6 ) Hunger. 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 im- paired through the symptoms of gastric and intestinal catarrh. (c) The craving for sugars and starches appears as a special symp- tom in many cases, for other patients temporarily placed upon a meat diet for other diseases do not manifest it in like degree. (d) The Urine. The average quantity of urine voided is between two to three times the normal quantity that is, from 3,000 to 4,500 cubic centimeters. If -water is being drained from the tissues the quantity of urine voided may exceed the amount of fluid ingested, but obviously this condition cannot last very long. Exceptionally as much as 5,000 to 6,000 cubic centimeters or more may be voided within twenty-four hours. Frequent calls to micturate at night greatly interfere with the pa- tient's rest. As a rule, the more sugar present the paler is the urine, and it becomes turbid soon after standing, from the development of yeast fungus (Torula cerevisia), derived from the atmosphere. The sediment, if present, is usually light, and the odor may resemble whey or hay. The urine is sweetish ; the reaction is usually acid, but may be neutral or alkaline, and the acidity is usually proportionate to the quantity of sugar ; it is increased by development of carbon dioxide and acetic acid, products of fermentation. In a majority of cases the specific gravity is considerably higher than the normal, rising to be- tween 1.030 and 1.050 or more. It should be remembered that the quantity of urea present as well as sugar affects the specific gravity, and as patients are usually fed upon nitrogenous food, urea is natu- rally increased beyond the normal average. DIABETES MELLITUS 737 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 exceed five hundred grams (16^ ozs.) per 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 intense; in others a large quantity is voided and the symptoms are not at all severe, but as a rule applying to a majority of cases, the severity increases or diminishes with the quantity of sugar voided. After grape sugar has disappeared during dietetic treatment, inosite is sometimes found in the urine, as in sim- ple polyuria. Other substances found occasionally in connection with sugar are acetone, alcohol, alkapton, diacetic acid, aceton, ,/J-oxy- butyric acid, peptones, and fat (lipuria). More or less albuminuria is observed. 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 odor is exhaled from the skin and in the expired air. From lack of intestinal secretion the bowels are usually constipated, although diarrhcea may alternate with constipation. 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 loss of weight, which is a pronounced feature of most advanced cases of diabetes, is attributed in part to the non-burning of carbo- hydrates, and in part to the loss of their proteid-protecting action. 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 polyuria is established. Muscular weakness and debility rapidly supervene to a greater extent than is to be ac- counted 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 derived also from proteids. The sugar which is eaten as food or which is formed by starch in the alimentary canal, 49 738 DISEASES ESPECIALLY INFLUENCED BY DIET after absorption is mainly used under normal conditions in the pro- duction of force, but in diabetes it is eliminated unaltered from the body, and there is consequent lack of heat production and muscular power. Diabetic coma is uniformly fatal. Many theories have been offered in explanation of this symptom, and one is that it is produced by an acid intoxication produced by accumulation in the system of /3-oxy- butyric acid, constituting an acidosis (B. Naunyn). This acid is found in the tissues and blood, and also, in combination with bases, in the urine. It is not present, however, in all cases. It is derived from tissue albumins, and possibly fats, and over 200 grams may be present in the tissues in a fatal case. Gangrene, asthenia, or intercur- rent 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 symp- toms which bear immediate relation to metabolism of the food. Some of the complicating diseases with which diabetes may be associated make it impossible to adhere to a strict regimen without producing more harm than good. Such, for example, are acute gout and chronic nephritis, in both of which an excessive diet is injurious, and if carbohydrates are also cut off the patient has little or nothing left to eat. In these cases the diet should be determined by whichever constitutes the graver complication (see pp. 551, 721). The course of diabetes is so protracted that there is abundant oppor- tunity for trying dietetic experiments, for it will be found impossible to establish rules for dietetic treatment to which exceptions may not arise from time to time in any individual case. Prognosis. If treatment is begun before the symptoms are well advanced the lives of many patients may be prolonged in some cases for more than ten or twenty years but between 50 and 60 per cent of all cases are fatal in less than three years; undoubtedly a few which are recognized sufficiently early may be cured in time, but glycosuria, like albuminuria, indicates a weakness of the system in a special direction, 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 dietetic mat- ters. Occasionally diabetes is extremely acute, and may prove fatal within three weeks, but in such instances it is probable that glycosuria DIABETES MELLITUS 739 has been present for a longer time without discovery. There seems to be a relation between the general bodily nutrition and the chance of recovery and improvement. Usually stout, middle-aged men yield best to treatment; thin persons withstand the disease less well, and rapid emaciation is more to be dreaded than the mere presence of sugar. When a mild type of carbohydrate diabetes passes into the severer proteid type, i. e., when sugar is formed from proteids as well as carbohydrates, there is usually an increase of nitrogen elimination in the urine. Hence when glucose is found in the urine of a patient who has been taking an exclusive proteid diet, a fatal termination of the disease is to be expected very soon. The prognosis is more favora- ble if the sugar does not speedily return if the dietetic treatment be in- terrupted, and also if the amount of urea excreted is large and the quantity of uric acid small. Cases associated with gout are relatively light. In emaciated cases the malnutrition is so great that the pa- tients easily acquire other diseases, especially pulmonar}^ tuberculosis, and many die from complications rather than from the imme- diate effect of the disease itself. In youth the prognosis is always grave. Diagnosis. To determine the presence of permanent glycosuria, the patient should be 'placed for two days upon a standard diet con- taining no other carbohydrate food than 100 grams (S 1 /^ ozs.) of wheat bread (von Noorden). The urine passed during twenty-four hours is then collected and analyzed by polarization and titration or fermentation. If sugar be present, the carbohydrate allowance should be varied for a day or two, both in kind and quantity, in order to de- termine its effect upon the quantity of sugar eliminated, and serve as a guide for dietetic treatment. By this test, diabetics may be grouped in three classes : (1) Mild cases in which glycosuria disappears on withdrawal of carbohydrates from the diet. (2) Medium cases in which glycosuria is diminished but does not disappear completely upon a proteid diet. (3) Severe cases in which glycosuria continues unabated upon a pro- teid diet. 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 observed during preg- nancy, 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 grave symptoms of excessive thirst, emaciation, and extensive tissue waste, leading to local disease and usually death, are wanting. 740 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 or peptonuria is described by Quin- quand as a disease presenting the clinical features of mellituria thirst, marked cachexia, polyuria, etc. but instead of sugar, the urine contains peptones; it polarizes to the left, and is of low specific gravity, Temporary lactosuria sometimes occurs as an accompaniment of the puerperal state, and is not of special dietetic significance. Treatment The treatment should be (1) prophylactic, (2) dietetic, (3) hy- gienic, and (4) medicinal. (1) PROPHYLAXIS Until more is known of the aetiology of diabetes definite prophy- lactic rules cannot be established; but in general, where there is dis- tinct 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 avoided. (2) DIETETIC TREATMENT General Observations. In recent years the dietetic treatment of diabetes has undergone radical changes. Originally the diabetic was placed upon an almost exclusive proteid diet, with the minimum of carbohydrates contained in a few fresh green vegetables. Subse- quently fats were added, and at present an "isoglycosic diet" is in vogue, i. e., a diet containing carbohydrates up to the limit of tolera- tion of the system for them, the limit at which they may not produce an excess of glucose in the urine. Finally, it is recognized that in cases in which glucose is derived from proteids, a liberal mixed diet presents the best means of limiting proteid tissue waste and conse- quent emaciation. The rule advocated especially by von Noorden, and now generally accepted, is to begin treatment by testing the carbohydrate toleration of the patient. Carbohydrates are withheld completely for a few days, and then given and slowly increased in amount until sugar again appears in the urine, when the limit is reached, and the diet is maintained at this standard. By this method a carbohydrate tol- eration may be re-established in many cases, so that patients who pre- viously had taken carbohydrates in excess, with decided glycosuria, may continue for years to take a fixed moderate quantity with a DIABETES MELLITUS minimum glycosuria. It is also found that some patients tolerate one or another form of carbohydrate better than do others. Thus some may do best with potatoes, others with oatmeal, others with restricted quantities of bread, etc. Periodically (once in three months is my personal rule) it is well to again resort to an exclusive proteid diet, for two or three weeks, to rid the system of any excess of glucose. Upon this alternating system I have seen very favorable progress in cases lasting for a number of years. As soon as the urinalysis shows that increasing loss of weight and strength is due to glucose derivation from the ingested and body proteid, dietetic rules should be relaxed, and excepting a reasonable restriction as to sugars, the patient may be allowed to eat what he chooses, with the result, not infrequently, of temporary improvement in all the symptoms. As an intermediary " tissue sparer " and " force pro- ducer/' the fats are most valuable, as they do not, except in most advanced cases, augment the glycosuria. They should, however, be given in moderation at first, and occasionally be reduced in quantity, for fatty acids are the forebears of acetone, and acetone with diacetic acid and beta-oxybutyric acid are often associated with diabetic coma, although it is not yet definitely established that this type of acidemia is the direct cause of it. The Scylla and Charybdis of the diabetic is not to be starved to death for lack of carbohydrates on the one hand, or driven to acidemia and coma from excess of proteids and fats on the other. The danger is best avoided, therefore, by occasional radi- cal changes in the diet, dictated by the results of urinalysis, the pa- tient's weight, strength, and other symptoms. It is important to remember the influence of the mental and nerv- ous system upon diabetes, for a too restricted diet may produce de- pressing effects upon appetite, digestion and nutrition, which more than counterbalance the risk of allowing perhaps another potato or slice of bread. One of my patients with unusual fondness for the pleasures of the table actually wept over the prohibition of buckwheat cakes and maple syrup. When allowed this unusual clemency twice a week he promptly gained in weight and strength, and showed no serious increase in glycosuria! Such a case is not cited as a model, but as an illustration of the necessity of making life as endurable as possible for the sorely afflicted diabetic, whose mind is unfor- tunately focused upon his malady three times a day, whenever he sits at table. Phenomenal improvement follows in many cases upon a diet which excludes starches and sugars completely, but this is a diffi- cult regimen to enforce, for the craving for carbohydrates, especially 742 DISEASES ESPECIALLY INFLUENCED BY DIET for bread, becomes so intense that patients whose veracity is other- wise unimpeachable will resort to any form of deception to obtain the coveted food. I have known hospital patients to steal bread and potatoes and consume them surreptitiously in spite of repeated warn- ings, and also to acquire such a craving for fluid as induced them to drink their own urine. It is a matter of common experience that the most difficult of all food for a man to be deprived of, when once accustomed to it, is bread. This is due in part to lifelong 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 advisable often to allow patients two or three ounces of bread a day in divided portions. While it is necessary to secure the intelligent co-operation of the patient in regard to carrying out his treatment, and to furnish written directions, it is highly undesirable 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. The effect of no dietetic system is immediate, and several days may be required for the patient to come fully under the influence of treat- ment, 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. For convenience of description of dietetic treatment cases of dia- betes may be subdivided into three classes: (a) Those patients who pass a considerable quantity of urine containing a large percentage of sugar, but in whom the general health remains good. (&) 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 serious 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 entirely disappear. Such patients are not to be regarded as cured, DIABETES MELLITTJS 743 however, as soon as the sugar disappears not, in fact, until they can eat starches in ordinary quantity without exciting the appear- ance of glycosuria. According to the statement of Dujardin- Beaumetz, patients of this class may be cured who have been elimi- nating as much, as six ounces of sugar per diem. (&) The second 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 or three hundred grains a day. When the quantity of urine is lessened by the diet, but specific gravity remains high, and sugar is abundant, the prognosis is very grave. The patient cannot tolerate the diet, and drugs may be resorted to. (c) In the third and very critical class of cases dietetic treat- ment is much less successful, but it should be undertaken, for it may prevent the patient from becoming worse, although it is unable to accomplish a cure. 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 and the skim-milk diet of Donkin to 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 rebel, and may prefer to live less long, but in more comfort than such restriction implies. This is probably at- tributable more to long-continued habit or heredity than actual in- ability to endure life of this sort, for, as stated elsewhere (p. 359), the Eskimos and other tribes of man 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 acetonaemia, and may favor the increase of uric-acid deposits in those having the uric-acid diathesis. It de- velops pruritus (p. 560), and may irritate the kidneys. When chronic nephritis complicates diabetes the difficulty of dieting is much enhanced, for meat is injurious for the nephritis, as starches are in diabetes. As a compromise such patients may be given a milk diet for a few weeks at a time. In patients over 50 years of age, whose general health remains 744 DISEASES ESPECIALLY INFLUENCED BY DIET fairly good, I am accustomed to alternate periods of restriction and relaxation in dieting, depending upon the condition of the urine and other symptoms. In a disease which lasts for years it" is so great a relief to be released occasionally from routine that the moral effect often benefits the patient, and he may temporarily gain in weight and strength. If, for example, the sugar in the urine remains at 0.5 of one per cent or less, and the specific gravity below thirty, it may be safe to allow temporarily a lump or two of sugar, a slice of toast, a griddle cake, or some other form of sweets which the patient may particularly crave. I have patients who have been under observation for six or eight years who have been none the worse for such latitude. 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 difficult 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. Eggs in any form. Crustaceans, crabs, lobsters, shrimp. Terrapin. 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, tripe, calf's brains. Fats. Olive oil and all animal fats and oils, such as butter (in moderation), cream, cod-liver oil, bone marrow. In some diabetic patients the power of fat digestion is apparently increased, so that they tolerate larger quantities than in health. Vegetables. Spinach, cress, sorrel, chicory, romaine, dandelions, beet-tops, horse-radish, radishes, celery, sea-kale, artichokes, vege- table marrow, okra, lettuce, endives, pickles, cucumbers, gherkins, cranberries. The following vegetables are allowed by some writers, prohibited by others : green French string beans, asparagus, summer squash, onions, leeks, carrots, cauliflower, cabbage, sauerkraut, kohl- rabi, parsley, parsnips, eggplant, tomatoes, rhubarb. Because potatoes contain about one-fifth as much starch as that present in bread they may be allowed in moderation when the latter is found to disagree. (Fig. 45, p. 745). The following statement made by Fagge is useful : " The general DIABETES MELLITUS 745 rule is that all white parts of vegetables in which chlorophyll has not been developed by exposure to sunlight contain no sugar, and are not harmful. But by boiling in a large quantity of water, even the forbidden 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 account of their adding to the bulk of waste matter in the intestine and preventing constipation, which almost inevitably re- sults from a meat diet. Truffles, mushrooms. Milk, cheese, cream, milk curds, buttermilk, Koumyss. Jellies made of calf's foot gelatin with wine, but unsweetened except with saccharin, coffee jelly, lemon jelly. 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 FIG. 45. BREAD. POTATO OATMEAI DIAGRAM OF THE RELATIVE PROPORTION OF CARBOHYDRATE IN FOODS ALLOWED DIABETICS FAT fruits contain more levulose than grape sugar. Sour oranges, lemons, grape fruit, pineapple juice, olives, sour apples, peaches in brandy (without sugar), raspberries, and strawberries are allowed by some, but are usually forbidden. Muskmelons and watermelons may be eaten. Nuts. Oily nuts, such 'as almonds, walnuts, Brazil nuts, hazel- nuts, filberts, pecan nuts, butternuts, cocoanuts, beechnuts. 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 carbohydrates. Some patients will be found who can eat any of the above articles with impunity, while others can take very few, and others may 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 may be substituted. 50 DISEASES ESPECIALLY INFLUENCED BY DIET A Useful Diabetic Diet in Detail I recommend the following dietary (alternatives in brackets) in average cases : Breakfast, 8 A. M. A sour orange [grape fruit, melon] ; eggs, scrambled, with much butter; fresh mackerel [salmon or other fat fish] ; two slices buttered toast, three inches square, one-third inch thick = about one ounce ; coffee, with cream and saccharin. II A. M. A glass of cream diluted with water or Vichy to the consistency of milk [a glass of eggnog with saccharin] . Luncheon, 1 p. M. Bacon and eggs [sardines] ; spinach [rad- ishes, celery], olives, lettuce, with oil dressing, and cheese; nuts. Tea, 5 p. M. A cup of tea with cream and saccharin; a baked apple with eream; a slice of buttered toast (as at breakfast). Dinner, 8 P. M. Meat soup ; fresh fish with butter sauce ; cucum- bers with oil; entree, marrow bones; meat (any sort); a baked potato (three inches long), well mashed, with much butter; string beans [cauliflower, vegetable marrow, Brussels sprouts, onions, asparagus with butter sauce]; (fat corn-beef and cabbage or pork and sauerkraut may be allowed once a week) ; game; sliced tomatoes with oil; baked custard [blancmange made with diabetic milk and saccharin; fruit jelly made with gelatin and imbedded fruits, such as oranges, cherries or currants, unsweetened] ; black coffee ; very dry Moselle or dry champagne. This dietary should be varied from time to time. As the tol- erance for carbohydrates increases the fats may be reduced, and vice versa. If after a brief test of animal food exclusively the glucose in the urine remains above 0.5 of one per cent, and glycosuria and weight rapidly diminish, meats should be replaced to the extent of not more than one-half by carbohydrates and fresh fruits and vegetables. It will be noticed that both toasted bread and potatoes enter into the above dietary. If, with a test diet of carbohydrate-free food, to which 100 grams (S 1 /^ ozs.) of bread is added, no excess of glucose is ex- creted, but it is excreted with 200 grams (6% ozs.) of bread added, then a moderate toleration for bread is demonstrated, and it may be given up to this limit of, say 100 grams (3% ozs.) per diem. A similar test may be applied to potatoes. In the poor man's anti-diabetic dietary, pork, bacon, tripe, cab- bage, sauerkraut, carrots, turnips, onions, leeks, and milk cheese may form the basis of the heavier meals. Lard, suet, and margarine should be used freely in the cooking. DIABETES MELLITUS ?47 Forbidden Foods Sugar in any form sirup, molasses, confectionery, jams, and sweets of all kinds ; honey, for it contains dextrose and levulose. Starches. All the elementary forms of starchy and farinaceous food, such as rice, sago, tapioca, arrowroot, oatmeal, cornmeal, hom- iny, samp, buckwheat, barley, semolina, macaroni, spaghetti, vermi- celli. All pastry, cake, preserves, confectionery, sweet sauces, pud- dings, pies of every description in short, everything made of flour excepting a little bread as specified above. Vegetables. Sweet potatoes, beets, carrots, parsnips, turnips, peas, corn, beans of all kinds (except string beans), lentils, cauliflower, broccoli, Brussels sprouts. Some writers, like Dujardin-Beau- metz, occasionally allow a well-baked white 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. I frequently prescribe it in lieu of bread. Shellfish. The soft parts or livers of clams, oysters, and mussels contain glycogen. By some these foods are entirely forbidden, but many diabetic patients may take them occasionally without injury. Liver of all other animals (it contains glycogen), pate de foie gras. Fruits. In regard to the use of fruits there is some difference of opinion, as stated on page 745. Sweet fruits, such as figs, dates, plums, prunes, bananas, apricots, all preserved, candied, or sugared fruits must be absolutely interdicted. Apricots, peaches, nectarines, plums, pears, melons, and berries are forbidden by many, but allowed by others. Nuts. Chestnuts, cocoanuts. Peanuts are not nuts at all, but contain much starch, and are therefore forbidden. Substitutes for Bread The problem of selecting a suitable starchy food for the diabetic is governed by the necessity of furnishing it in some form which will satisfy the craving for farinaceous material and not seriously impair nutrition. The most difficult of all starchy food for the patient to forego is bread. Much ingenuity has been expended in attempts to devise sub- stitutes 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. 748 DISEASES ESPECIALLY INFLUENCED BY DIET Some authorities, as Germain See and Dujardin-Beaumetz, advise using potato meal instead of bread, five ounces per diem, which may be cooked in any form without sugar. Mosse is alone in the be- lief that the potassium salts of the potato possess special curative value. Sawyer suggests the use of potato flour in bread, cake, etc., for diabetics, and gives the following prescription : Bran and potato bread. Take half a pound of flour of steamed potatoes, quarter of a pound of bran, half an ounce of German yeast, half an ounce of butter, one egg. Twenty-four hours before making the dough cook the potatoes by steaming them in their jackets, then peel and break up into flour with the fingers. Mix all the ingredients together, and let the paste stand near the fire for an hour to rise. Bake in greased tins for an hour and a half. The breads made from flour especially prepared for diabetics are: (a) Gluten bread; (&) bran bread; (c) almond bread; (d) inulin 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 usually soon tired of, and unless prepared by a very reliable manufacturer it has little to recommend it. It is not agree- able to masticate, for it is often unpleasantly tough and stringy. It is difficult to panify, but 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. Gluten flour is used for thickening broths, egg puddings, etc. Following are two receipts for utilizing gluten flour : Jeffrie's Gluten Biscuit for Diabetics. Gluten flour 1 cup. Best bran, previously scalded 1 cup. Baking powder (or the equivalent of bicarbonate of soda and cream of tartar) 1 teaspoonful. Salt to taste. Eggs 2. Milk or water 1 cup. Mix thoroughly. James Stewart's Diabetic Bread. "Take one quart of sweet milk or milk and water, one heaping teaspoonful of good butter, one-fifth of a cake of compressed yeast beaten up with a little water, and two eggs well beaten. Stir in gluten flour until a soft dough is formed, knead as in making ordinary bread, put in pans to raise, and when light bake in a hot oven." DIABETES MELLITUS 749 Van Abbott recommends the use of gluten macaroni, gluten ver- micelli, and gluten semolina, which may be made into puddings with- out sugar. Liebig proposed to prepare bread for diabetics by pouring a malt infusion over thinly sliced wheaten bread. The sugar which is thus formed is washed away, and the gluten residue may be eaten. It is very difficult to obtain a reliable gluten flour. Much that is sold in open market contains more starch than wheaten bread it may hold 60 or 75 per cent. It may also contain sugar. The gluten flour obtained in market in London or Paris contains about 15 per cent of starch, whereas that sold in the United States frequently has two or three times as much. In 1903 the New Hampshire State Board of Health reported that of thirteen samples of " diabetic " and " gluten " flours, seven con- tained nearly the average starch percentage of ordinary wheaten flour, and only two were almost free from it. James Stewart gave the following test for starch to be applied to gluten flour: A little of the flour is shaken well with boiling water, and cooled. A few drops are then added of an aqueous solu- tion of iodine and potassium iodide (Gram's solution). If starch be present, a decided blue color develops. Dujardin-Beaumetz declared that gluten bread contains more than three times as much sugar-forming material as potatoes, and hence he prescribed the latter instead. A serious objection to the use of gluten flour and gluten biscuits, etc., is that patients often buy these articles for themselves and, be- lieving that they are free from starch and sugar, eat all they desire, whereas, if ordinary toasted bread or potatoes be prescribed in limited quantity, the physician may know exactly how much carbohydrate is being consumed with gluten he is uncertain, and I have long ceased to recommend it. Most gluten bread keeps fresh only a few days. An exception to this statement is found in a bread made by 0. Eademann, of Frank- fort a. M., which, according to von Xoorden, contains only 25 per cent carbohydrates. Tyson of Philadelphia says : " One of the best English houses, Cal- lard, Stewart & Watt, 65 Eegent St., London, has opened an agency in New York City, whence may be obtained a variety of pure gluten foods. They are called casoid diabetic foods. I add a list of some of them: Casoid flour for making starchless and sugarless bread, cakes, bis- cuits, pastry, etc. Said to keep indefinitely. 750 DISEASES ESPECIALLY INFLUENCED BY DIET Casoid biscuits No. 1 (plain). Suitable for use instead of bread at all meals. Excellent with cheese. Said to keep in good condition indefinitely if stored in a cool place. Casoid biscuits No. 2. Plain biscuits for general use instead of bread. Should be stored in a cool place. Casoid biscuits No. 3. Sweetened with saccharin. For use at breakfast and tea. Casoid sugarless chocolate. In small tablets, slightly sweetened, consisting of pure concentrated chocolate. One tablet dissolved in hot water makes a cup of chocolate. The flour and biscuits I have tested and found starch and sugar free." These foods are also recommended by von Noorden, and A. L. Winton of the Connecticut Agricultural Experiment Station found Casoid Four entirely free from carbohydrates, but the biscuits con- tained 8.07 per cent. Protene Diabetic Bread, made in England by the Protene Com- pany, has its basis in casein, and is said by Eobert Hutchison to be " entirely free from carbohydrate." It may be toasted with advantage to taste. Fromentine is another form of diabetic flour made from wheat germs. They contain less starch than mature wheat, but hold an oil which is purgative and which prevents proper panification, and causes the bread to sour easily. Polubos'kos is another form of flour said to contain a minimum of starch. Embryonine or legumine is a substance isolated from the casein of legumes, and which is sometimes given in diabetes. (&) Bran Bread. The use of bran bread was first suggested by Prout, but, like gluten bread, it is liable to contain starch, and in addition tough cellulose, which is of little nutrient value and which may prove irritating to the mucous membrane and alimentary canal, causing diarrhoea. It is, moreover, somewhat tasteless, and patients quickly tire of it. Bran bread cakes may be purchased prepared expressly for the use of diabetics. They are made according to Dr. Camplin's receipt, as follows : Cam pirn's Bran Bread. "Boil one quart of wheat bran in two successive waters, wash in a sieve with hot water until the water runs through clear. Squeeze in a cloth after each washing. Spread thinly on a dish, and dry in a slow oven. Grind in a fine mill, and sift by brushing through a very fine sieve. Grind the residue again and sift. Take of the powder three ounces, three new laid eggs, DIABETES MELLITUS 751 butter two ounces, and half a pint of milk. Mix the eggs with a little of the milk, warm the butter with the rest. Stir the whole and flavor with nutmeg or ginger. Bake in thin cakes in a quick oven for half an hour." More eggs may be used, and Roberts adds sodium bicarbonate. The object of drying the bran before it is ground is to make it friable, otherwise it is too soft to be easily powdered. These cakes or biscuits may be eaten with butter or cheese, and taken with meals two or three times a day. (c) Almond Calces. Pavy first suggested the use of almond cakes for diabetics, which he prepared by making a meal of sweet almonds. This meal when washed in acidulated water is freed from sugar, and may be made into cakes or crackers. Seegen gives the following receipt for almond cakes: Seegen's Almond-flour Calces. " Take of blanched sweet almonds a quarter of a pound, reduce to powder in a stone mortar, steep in linen in boiling water, acidulated with vinegar, for fifteen minutes to remove sugar. Mix the paste with three ounces of butter and two eggs, add the yolks of three eggs, a pinch of salt, stir well. Whip the whites of three eggs and stir in. Put the dough into greased molds, dry at a slow fire." Almond-flour preparations con- tain so much fat that they often prove indigestible after a few days' trial, and they are relatively expensive. Macaroons, if unsweetened, may be used. Many physicians prefer to discard the use of all substitutes for bread, such as bran and almond cakes, and to allow the patients a limited amount of plain bread. A nut flour, the Chicago Sanitary Flour, is recommended by N". S. Davis, Jr., of Chicago. Analysis by Prof. J. H. Long shows it to contain : Water 8.01 Fat 19.82 Albuminoids 55.65 Sugar 6.25 Mineral salts 6.32 Fibre and other non-nitrogenous matter 3.95 100.00 It is thus seen to contain no starch, and most of the 6.25 per cent of sugar is said to be lost by conversion to CO, in the fermenta- tion process of breadmaking. It is alleged to be useful not only for diabetics but for those having flatulent dyspepsia. ( d) Inulin Bread. A form of bread has been made by Kiilz from inulin and lichinin. Inulin is derived from the root of elacam- pane (Inula lielenium). 752 DISEASES ESPECIALLY INFLUENCED BY DIET Kiilz's Inulin Biscuits. " Fifty grams of inulin are to be put in a large porcelain basin, and while standing over a water bath to be rubbed up with thirty cubic centimeters of milk, and as much hot water as may be necessary, into a uniform dough, with which the yolks of four eggs and a little salt are to be mixed. To this the whites of four eggs are to be added, having first beaten them to a foam and carefully worked them in. The dough is finally to be baked in tin molds, previously smeared with butter. The taste of the biscuits may be improved by the addition of vanilla or spices." (Dietary of the Sick. Yon Ziemssen's Handbook of General Thera- peutics.) These biscuits are not agreeable to the taste and patients soon tire of them. (e) Soya Bread. A meal is made from the fruit of the Soya hispida, a bean which is grown in China and Japan and also raised in Austria. It is very rich in protein. It has a peculiar flavor and holds a purgative oil. The published percentage composition of the more important in- gredients of soya bread is as follows: Water 45.000 Protein 20.168 Fats 9.350 Starch and sugar 2.794 Phosphoric acid 0.863 Soya bread' is nutritious on account of the large percentage of fat which it contains, but according to an analysis made by an expert chemist it contains carbohydrates in considerable amount. This, in fact, is true of all the breads and biscuits made of substitutes for flour. Cocoa and chocolate in special preparations are recommended by von Xoorden. Such are: a saccharin chocolate made by Hcevel of Berlin, Germany, and a saccharin " cocoa for diabetics " made by 0. Rademann of Frankfort a. M., Germany, each containing 12 per cent carbohydrates. The dose is 5 ounces. Stollwerk's levulose chocolate contains 50 per cent of levulose and 5.6 per cent of other carbohydrates. Von Xoorden gives a useful quantitative summary as a guide for feeding: 3 grams (46 grains) of carbohydrates are contained in each of the following measures: One tablespoonful of mashed potato. Two tablespoonfuls of green vegetables. Eight almonds, six English walnuts, t.en hazelnuts. Two tablespoonfuls of berries. DIABETES MELLITUS 753 Substitutes for Sugar Kiilz states that certain of the sugars and allied bodies may be used with the food without increasing the glycosuria, being very thoroughly consumed within the body. Such, for instance, are inu- lin, inosite, mannite, and levulose or sugar derived from fruits. A preparation of the latter is sold under the name of " diabetin." An- other sugar substitute known as "crystalose" is much prescribed at Carlsbad, and extensively used in this country. Glycerin has also been used, but Senator and Frerichs are op- posed to it. If given in quantity, such as one or two ounces a day, it occasions intestinal disorder, and may prove too laxative. It also causes a continuous sweet taste in the mouth. Saccharin is employed with success to take the place of cane sugar for sweetening foods for diabetic patients. It may be used to sweeten coffee and other materials. It is a crystalline nitrog- enous body derived from coal tar, which is sparingly soluble in cold water, more soluble in hot water, and very soluble in glycerin. It is about three hundred times as sweet as cane sugar, and when taken not to exceed four or five grains daily it is quite harmless. Eaten in large quantity it disorders digestion and causes gastric pain. A convenient formula was given by James Stewart for saccharin pastilles as follows: Saccharin gr. xlv. Sod. bicarb, sice 3 ss. Manniti 3 xijss. M. Make 100 pastilles; one will sweeten a cup of tea or coffee. Cooking Care should be exercised in the preparation and cooking of the food for diabetic patients that injurious ingredients are not added for the purpose of flavoring or thickening. For this reason all ar- ticles of diet should be cooked as simply as possible, and rich sauces containing flour are forbidden. Melted butter may be used as a sub- stitute. Eoast beef should not be basted with flour, and meat soups should not be thickened. Vegetables which have been boiled for a long time in a large bulk of water have most of their sugar dissolved out, and on that account are less injurious. Very acid fruits may be sweetened with saccharin or cooked with a little sodium or potassium bicarbonate to neutralize their acidity. The latter, process does not impair their flavor. 754 DISEASES ESPECIALLY INFLUENCED BY DIET Beverages Water. It is an important matter to decide to what extent to restrict the quantity of water and other fluids drunk by diabetics. When so much urine is voided that the patient's rest at night is dis- turbed by acts of frequent micturition, it is always annoying, and may be serious. The increased work thrown upon the kidneys is less harmful than might be supposed, and taxes the renal epithelium less than the excretion of the solids of the urine. Protracted cases of diabetes do not necessarily exhibit serious renal degeneration. For these reasons, if the water drunk is restricted, it should be so more on account of relieving the patient of an uncomfortable con- dition than from fear that the act of passing so much urine may be injurious per se, and the restriction should never be enforced too suddenly. As a rule, when dietetic regulation reduces the glycosuria and improves the patient's condition there is, part passu, a diminution of thirst and in the quantity of urine voided. In other words, the polyuria takes care of itself. A reasonable restriction of the fluids allowed is to be recommended, but when thirst is extreme it becomes unendurable torture to withhold them strictly, and, moreover, the water is apparently needed to wash out the sugar which would other- wise accumulate in the blood and tissues. In fact, the occurrence of impending coma has been postponed by flushing the circulation by means of large draughts of water or enemata of salt water. When the thirst leads to excessive drinking, salt foods and condi- ments should be withheld, and some relief may be obtained by suck- ing a slice of lemon or by using a little potassium bitartrate and lemon juice, or dilute phosphoric acid in water. The patient should drink only from a small glass, for there is more satisfaction in drain- ing it than in taking the same quantity of fluid from a large goblet which one is not allowed to empty. I have known decided benefit from adopting this simple means. It is important not to distress the patient so much by denial that the nervous system suffers in consequence. Beverages Forbidden. As a rule, patients do better without al- cohol, and strong spirits should be interdicted absolutely as well as sweet and sparkling wines, all wines with "bouquet," especially Ma- deira, port, sweet sherry, Sauternes, and sweet champagnes. No punch or liqueurs, cider, beer, root-beer, grape juice, ginger or sweet ales may be allowed. Soda water with sirup is prohibited. Beverages Alloiccd. If it becomes necessary to give alcohol as a tonic or stimulant, an acid claret or Burgundy, hock, or still Moselle DIABETES MELLITUS may be prescribed diluted with mineral water; or a little much- diluted brandy, whisky, or unsweetened gin may be allowed. Weak brandy sometimes allays thirst better than water. Dry sherry, Cha- blis, and Burton bitter ale are prescribed occasionally, and the Cali- fornia Riesling or Zinfandel may be used. Bass's ale may be allowed because the sugar which it originally contained has been entirely converted into alcohol and carbonic acid (Flint). Tea, alone or with lemon, coffee, and infusion of cocoa nibs, sweetened with a quarter of a grain of saccharin, are allowed. Choc- olate may be manufactured without sugar (p. 750). Buttermilk and koumiss may be given. They allay thirst and in koumiss the milk sugar has been fermented into lactic acid. Sour lemon or orange juice in Vichy with a pinch of sodium bicarbonate makes an agreeable and cooling draught. Saccharin may be added. In Ger- many acorn coffee is sometimes used. As an adjunct to the dietetic treatment, the alkaline mineral waters are extremely serviceable, especially those obtained from nat- ural wells. The baths and waters of Carlsbad in Bohemia, Ems in Germany, and Vichy and Contrexeville in France have achieved a considerable reputation for the cure of diabetes, and after due allowance for the improvement consequent upon proper regimen, dietetic regulation, and systematic habits of life which are enforced at these spas, there seems to be special benefit derived from the waters themselves. Other waters which may be drunk are Apollinaris, Johannis, Saratoga Vichy, plain soda or potash water, Seltzer, the alkaline calcic Waukesha, or the different lithia waters. , Special Diabetic Diets Ebstein's Diabetic Diet Early Breakfast. One cup of coffee or tea (black), without milk and sugar. White bread toasted, thirty to fifty grams (1-1% ozs) ; or brown bread well buttered butter, twenty to thirty grains (1 oz.). The yolk of an egg, a little fat ham, or some German sausage, if re- quired. If any food be needed between this meal and dinner, let it be a cup of broth, with the yolk of an egg. Dinner. Broth, with yolk of egg or marrow (the marrow bone is boiled for half an hour, to solidify the marrow). Peptone may be added to the broth. Meat, one hundred and eighty grams (6 ozs.), free from bone, roasted, boiled, or stewed beef, mutton, pork, veal, fowl, or venison (fat meat preferred). Gravies, to be made with cream or yolk of egg. not flour. Fish to be served with melted butter. Vegetables prepared with much fat; puree of leguminous 756 DISEASES ESPECIALLY INFLUENCED BY DIET plants; salads, dressed with vinegar and oil. The food should be well salted and spiced. After dinner, a cup of coffee or tea with sac- charin if desired. Supper. One cup of tea or broth. Meat (roasted), or cheese, or an egg, or fish, caviare. Bread, thirty to fifty grams (1-1% ozs), with butter, twenty to thirty grams (%-l ozs). Apples, pears, and stone-bearing fruits are allowed in small quantities. Beverages. Ebstein forbids absolutely the use of beer, limits the use of spirits, and allows about half a bottle of wine daily. If the patient can digest milk well, it is allowed in moderate doses, and cream is especially recommended. In the following diet, recommended by During, it will be noticed that, contrary to most other systems, fat is excluded as much as pos- sible. During claims that prolonged boiling so alters the carbohydrates as to prevent them from being eliminated in the urine as sugar, and he gives his patients a diet consisting largely of rice and fruits which have been soaked in water and boiled for several hours. The details of his regimen are as follows : During' s Diet for Diabetes Early Breakfast. Milk, with a little coffee but no sugar (lime water, to prevent milk from souring in the stomach) ; stale white bread ad libitum, or, if it is not well borne, oatmeal, barley, or rice gruel made with water, a little salt, but no butter. Second Breakfast. White bread, stale and well baked; an egg, lightly boiled; rice or oatmeal gruel, with or without milk, a break- fast-cupful; or half a glass of good red wine (with water in certain cases). Dinner (taken between two and three o'clock). Soup, with rice, barley, or oatmeal; meat, roasted, two hundred and fifty grams (S 1 /^ ozs.) (game, ham, and smoked meats, as free from fat as possible, are permissible) ; no condiments, no fatty sauces; compote of dried apples, plums, cherries; dried peas or white beans in some cases; green vegetables, asparagus, French beans, carrots, cauliflower, cabbage (boiled in water with salt, not with fat or stock) ; dessert of a little raw fruit, apples, cherries, and one small glass of red wine diluted with water. Supper (about 7 p. M.). Gruel or barley, oatmeal, or rice, with salt (but no butter), and strained, which in some cases may be made with milk. Ice or iced water, to relieve thirst between meals. DIABETES MELLITUS 757 Naunyn's Diet B. Naunyn divides cases of diabetes into three varieties mild, severe, and intermediate. For the most serious cases he prescribes a diet of fat meat; the intermediate cases are treated at first on an exclusive diet of fat meat, then, as the sugar disappears from the urine, he adds eggs, milk, and a small allowance of bread to the diet. In mild forms he directs the use of a few green vegetables, salads, fruits, and other articles, unless the sugar reappears in the urine, when the patient is to be put back upon a strict nitrogenous diet. He claims that in mild cases of diabetes patients do not re- quire more than from sixteen to eighteen ounces of meat a day, with two or three ounces of bread and six or seven ounces of vegetables. Von Noorden's Oatmeal Diet Karl von Noorden of Vienna advocates the use of oatmeal in diabetes, on the ground that carbohydrates, especially in this form, do not yield low fatty acids, such as oxybutyric, and give rise to ace- tonuria. The salted oatmeal is long boiled, with butter, and after cooling, beaten egg albumen or a vegetable albumin is added, such as Eobrat or rice albumen. The quantity given per diem comprises, oatmeal 250 gram (S 1 /^ ozs.), butter 300 grams (10 ozs.), albumin 100 grams (3y 3 ozs.). He also prescribes a little wine or brandy and coffee. On this diet, which contains 3,200 calories, given every two hours, he reports marked improvement, an eventual increase in car- bohydrate toleration. He points out, however, that the more severe cases do better upon this temporary diet than very mild ones. The oatmeal diet is continued for ten days or a fortnight, when the ordi- nary diabetic diet is gradually resumed. The oatmeal preparation may be fried in cakes if preferred. It is open to the objection that it contains a large quantity of butter, which mav result in acidosis from /?-oxybutyric acid. (3) HYGIENIC TREATMENT Patients should guard themselves as far as possible from taking cold, and when possible should live in a moderately warm and tem- perate climate. If their surroundings permit, it is important to take moderate exercise and to remain in the open air. Flannels should be worn next to the skin in winter, and the body should be kept always warm, for there is less heat-producing power than normally. The skin should be maintained in good condition by frequent warm baths or alternate hot and cold douching, dry rubbing, or massage. All 758 DISEASES ESPECIALLY INFLUENCED BY DIET muscular or nervous or mental fatigue is to be avoided. It is claimed by Kiilz that muscular exercise tends to increase the con- sumption of sugar or glycogen in diabetes and to lessen its elimination by the kidneys. This applies to more robust patients only, for in the serious type of the disease with great emaciation much exercise be- comes harmful or impossible. (4) MEDICINAL TREATMENT The medicinal treatment of diabetes is exceedingly unsatisfactory. In a certain proportion of cases of diabetes cure may result by ex- clusive dietetic treatment. There are others in which the use of medicines is found to be of some service, but it may be stated posi- tively that there are no cases which are curable by medicines without proper dietetic treatment. Opium and codeia are successful in some instances in reducing the amount of sugar voided. Commencing with half-grain doses, the lat- ter is to be gradually increased until ten or fifteen grains are taken in a day ; alkalies, such as the citrates and acetates, are also occasion- ally found beneficial. Clemen's liquor arsenici bromati has attained success in some hands. Digestive tonics, aromatic bitters, mineral acids, and cod-liver oil are frequently indicated, and strychnine and ergot are to be employed as vasomotor tonics when desired. They regu- late the arterial tension, and may reduce the quantity of urine and relieve the thirst. The nitrogenous diet is apt to excite diarrhoea, which may be controlled by such remedies as salol, or salicylate of bismuth. For the intense craving for food experienced by some patients, with a hollow, sinking feeling at the epigastrium, Roberts recom- mends a two- or three-grain asafoetida pill three times a day. Diabetic Coma When coma supervenes in diabetes, the patient is beyond all dieting, but when it is threatened by the appearance of drowsiness, with acetonuria, or diacetic or /?-oxybutyric acid in the urine, all fats should be withheld from the dietary, as the fatty acids are the pre- cursors of those substances. This is especially true of the lower fats, olein and butyric acid, rather than of the higher fats, palmitin and stearin. Hence an excess of cream and butter is undesirable for diabetics, but such fats as exist in the form of lard, suet, egg yolk, cod-liver oil, olive and other vegetable oils, bone marrow, meat fat, and fat bacon are all good diabetic foods. It is established that when a moderate quantity of a carbohydrate is ingested with such fats, they RHACHITIS 759 are more completely oxidized than if eaten alone, and hence are less liable to occasion acidosis, which is favored by starvation and a heavy exclusive meat diet. RHACHITIS (RICKETS) Causation. Eickets is a disease of malnutrition. The fault may lie in a hereditary weakness of the digestive organs, or the influence of some concurrent disease, but the majority of cases are directly caused by improper or insufficient food. This food may be the breast milk of a mother or wet nurse, who is herself enfeebled by chronic disease, by oft-repeated pregnancies, or whose mammary secretion is modified by dietetic errors, loss of sleep, emotional or neurotic dis- orders, or the milk supply may be insufficient from too long-continued nursing or the intervention of pregnancy, or some other factor. Breast-fed infants may become rhachitic if the milk is watery, of low specific gravity, too poor or too rich in fat or in lactose. The poor, for reasons of economy, often suckle their children for too long a period in fact, until they are two years of age but even before weaning them they allow them to go to the table and share in the general diet of fried fish, pickles, potatoes, pork, raw fruits, beer, etc. Children treated in this manner are especially prone to develop rickets. In all doubtful cases the milk of the mother or nurse should be analyzed before weaning, and an effort made to improve its quality. If the child is already weaned, the cause of the rhachitic condition may be a poorly selected diet, such as condensed milk, or a patent or proprietary " baby food " with insufficient fat and earthy salts and excess of starch. Eickets has been experimentally produced by Cheadle, Guerin, and others in young animals by depriving them of animal fats and earthy salts. It is caused by withholding all lime salts from the food (Voit), but especially calcium phosphate, and young, growing animals failing to receive a fresh supply absorb lime salts from bones already ossified for the benefit of the newer ones, and thus all the bones become soft. Baginsky found that this process is ex- aggerated in young animals by the presence of lactic acid in the food, and Wegner proved that phosphorus has a similar effect. Forster has calculated from the lime ordinarily present in milk that an infant four months of age receives lo 1 /^ grains each day. Indiges- tion lessens hydrochloric-acid secretion and increases lactic-acid for- mation, and reduces absorption of lime salts. Starchy and saccharine foods not onlv contain little or none of 760 DISEASES ESPECIALLY INFLUENCED BY DIET the necessary lime, but readily undergo lactic-acid fermentation, thus intensifying the rhachitic processes. Bottle-fed infants are very subject to rickets, especially if the milk be sterilized. Prophylaxis. The best prophylactic against rickets is nursing dur- ing the first year by a healthy mother or a carefully selected wet nurse. It is a very common practice in this country for mothers in good circumstances to wean their babies too early, and without a phy- sician's advice to resort to one of the much-advertised patent infant foods, with the result above described. Dietetic Treatment. The dietetic treatment of rhachitis in a weanling consists, first of all, in supplying good fresh cow's milk modi- fied to resemble as closely as possible the best mother's milk. It is important that the milk should contain sufficient fat, and it should be modified accordingly by the addition of cream or oil. (See Modified Milk, p. 103.) If the child must be bottle fed, the milk temporarily may be pas- teurized in order to diminish the liability of its fermentation in the alimentary canal, and among the poor, who cannot afford to purchase modified milk, the ordinary milk as soon as purchased should be heated, and a few grains of bicarbonate of sodium may be added to it. A plug of previously baked cotton should be used in the bottle in place of a cork. When given, the milk may be diluted with barley water, or, if constipation be present, with oatmeal water. These waters are made by boiling a tablespoonful of pearl barley or of good oatmeal in a pint of water until the meal is completely softened. A little salt is then added, and the mass is strained through a fine cloth. It is advisable also to add milk sugar. The proportion of milk for the diluent should be half-and-half for the first six weeks of infancy ; after this the pro- portion is to be gradually increased, and when six months of age the infant should be given three parts milk and one part diluent. The quantity of milk is to be continuously increased, and at the ninth month it may be in the proportion of four to one, and at the end of the year dilution is no longer required. Very young infants who are fed by artificial means should not be given farinaceous food too freely. In the first two or three months of infant life the saliva from deficiency in ptyalin is incapable of digesting much starch, and starch is also poorly digested by the pan- creatic juice in the intestine. Starch, therefore, acts as a foreign body and a gastrointestinal irritant, and passes through the alimentary canal unaltered. Tt is advisable in all rachitic children to restrict the giving of farinaceous foods until some time after the period when they RHACHITIS 761 are often allowed, and, as a rule, children having rickets should not be fed any starchy food until after the twelfth or fourteenth month ex- cept as a diluent of milk as above described. They need fats much more than starches or sugars. There are some apparent exceptions to this rule in which infants be- come seemingly robust while fed upon amylaceous foods at a very early period, but they are less healthy as they grow older or exhibit malnutrition or some constitutional weakness. Such exceptions by no means controvert the value of the rule in general, as above stated. Preparations of condensed milk which contain large quantities of sugar are sometimes given to infants, and they produce a prompt in- crease in weight, due to stored-up fat and water, but the appearance in these cases is deceptive, and the muscles and other tissues are less firm and strong than they should be. This is proved by the fact that children erroneously fed in this way succumb readily to various dis- eases of infancy, especially to diarrhceal troubles. After the first year a little of some malted or predigested form of starchy food may be added to the milk. Whenever amylaceous food is mixed with the milk it should previ- ously be converted, as far as possible, by diastase into dextrin or glu- cose, and added rather with the object of mechanically preventing the formation of coagulas of casein than with the idea of feeding the infant upon a substance which its digestive organs are not yet fitted to act upon. J. Lewis Smith says : " If a heaping teaspoonf ul of barley flour be boiled in twenty-five teaspoonfuls of water, and when it is lukewarm ten or fifteen drops of diastase be added to it, the gruel in a few minutes becomes much thinner from the digestion of starch, and it is a useful adjuvant to the milk employed in the nursery, especially for infants over the age of six months." At this time or later a little albuminous food in the form of mutton or chicken broth or the expressed juice of rare roast beef or beefsteak may be given. After a year or fourteen months the diet should consist of cow's milk, cream, beef juice squeezed from a fresh steak, and broths, and stale bread crumbs in milk may be added. Later, the child may take scraped beef or a raw beef sandwich made with thin layers of bread and butter with meat pulp between them. Beef tea, mutton, and chicken broths are good. Fresh fruit juice, especially orange juice, is excellent. A little sweet currant jelly added to the meat will improve its flavor for older children who object to taking it. When a year and a half old the child may be given eggs, either beaten with milk and sweetened or soft-cooked. If attacks of diarrhrea supervene, 762 DISEASES ESPECIALLY INFLUENCED BY DIET it will be well to discontinue the meat broths temporarily and place the child for a few days on a diet of koumiss or pancreatinized milk. In some cases maltine is found to agree well with rhachitic children, and if diarrhoea does not exist they should be given pure Norwegian cod-liver oil three times a day in doses of a few drops for a young infant, up to a teaspoonful for a child a year or two old. Older chil- dren should have abundant fat, in the form of fresh butter on bread, or cream upon stewed fruit or baked apples. Olive oil is also service- able. Fothergill wrote : " The liquid fat of fried bacon is most digestible, and the child should be allowed to dip its bread in it or have it crumbed into the fluid fat." Or it occasionally may be given a piece of bacon to suck. Inunctions of two or three tablespoonfuls of olive oil may be given daily over the legs and abdomen. Ehachitic children, on account of their poor nutrition, usually have a deficient number of teeth or their teeth are imperfect or quickly decay. It is therefore important that when they have passed the first dentition food should be given them in a state of fine subdivision, otherwise it will be bolted without mastication and gastrointestinal dis- order will result. Meat should be hashed thoroughly or pounded in a mortar, and solid meat never should be given the child to masticate until it is over two years of age. Potatoes should be given baked in a soft and mealy form. Some breast-fed infants may become rickety, while others ill-fed by artificial means may not, and the extraordinary instances of tolera- tion of improper food which one constantly finds among the children of the ignorant poor, at times severely test one's faith in dietetic rules, but much allowance should be made for the constitution of individuals and for race characteristics. The subsequent history of wrongly fed children often points directly to original faults in diet which have affected the general nutrition of the body, although the immediate effect of such errors may not have been apparent. Aids to Dietetic Treatment. Ehachitic babies, as well as older children, should be weighed at regular intervals as an important guide for their correct feeding. In rickets more or less gastric catarrh is commonly present, which interferes with normal digestion and absorption, and appropriate me- dicinal remedies should be employed to regulate this condition when necessary. There is often excessive acidity in the stomach which may be neutralized by sodium bicarbonate. The hygienic treatment in con- junction with dietetic measures is of the utmost importance. Eickety children should live outdoors in all seasonable weather, and it is bet- SCURVY 763 ter for them to remain out in fresh, cold air than be kept at home in a damp, dark, overheated, and badly ventilated tenement. They should be bathed frequently in order to keep the skin in as good condition as possible, and prevent the occurrence of skin diseases, which are a com- mon accompaniment of malnutrition. They should be kept quiet and not worried, and if they are weak and feeble, great care should be exer- cised in handling them and placing them in proper positions upon beds which are firm but not hard, in order to prevent the weakened bones from becoming deformed by pressure. SCURVY Causation. Scurvy is a disease dependent upon malnutrition, which is customarily attributed to lack of fresh vegetables in the diet ; but this statement is somewhat vague, in that it is not known ex- actly 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 abso- lutely successful in all cases. At all events, it is a disease due to omission and not 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 man, the fact is stated by Lieutenant Greely that among the Danish Eskimos, who have a population of ten thousand, not a pound of vegetables nor a dozen pounds of bread per man are eaten annually, and yet they are practically free from the disease, 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 can not include either vegetables or cereals in their food. The disease may arise among those 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 overcrowded prisons and barracks. It is therefore possible for scurvy to occur in any part of the world among men affected by these conditions. When the potato crop failed in Great Britain and Ireland in 1846 scurvy became very prevalent. In the war of the Crimea twenty-three thousand cases occurred among the French troops alone. In the British arctic expedition of 1875-'?6 over 48 per cent of all 764 DISEASES ESPECIALLY INFLUENCED BY DIET the men suffered from scurvy, and a still larger percentage existed among those who were exempt from field service and outdoor life. Major 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 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 receives certain salts and unknown substances necessary as stimulants or tonics to the tissues, which salts and substances are de- stroyed by the usual methods of preservation. Men may live for many years without tasting such articles of diet, though it is rare for [civil- ized] man to be denied all three meats, fresh vegetables, and fresh fruits. If they are so denied they are not possessed of that health which permits of the highest mental and physical 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 excep- tional cases of shipwreck or in voyages prolonged beyond the expected limit, subjects the captains or owners to indictment for criminal neg- ligence. 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. 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, oranges, and fresh vegetables contain abundant potash. His theory is modified by Immermann, who believes that a tem- porary lack of potassium salts may cause trophic disorders, which may continue for some time after the deficiency in salts has been made good, and Duchek found that in exacerbations of symptoms occurring in scurvy there may be an increased elimination of potassium salts in the urine. The body is capable of retaining and re-using its various salts for a considerable time, so that withdrawal of potash does not necessarily induce scurvy at once (Bauer). SCURVY 765 W. P. Northrup and Crandall investigated the causes of scurvy in a number of infants, and report that the employment of proprietary foods which for various reasons are substituted by the mother for fresh food is the most important cause of infantile scurvy, and " even fresh milk added in small proportions is not sufficient to insure perfec- tion." Their report continues : " The exact diet is known in thirty-three cases. We find that twelve of these children (36 per cent) were fed on a proprietary food exclu- sively, six (18 per cent) had received an exclusive diet of condensed milk or evaporated cream, while three received a combination of these two foods. Over 63 per cent, therefore, were fed upon a diet of pro- prietary foods and condensed milk. Two children received sterilized milk exclusively, and three a weak mixture of milk and water. One was fed on condensed milk, one on boiled and peptonized 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." Louis Starr furnishes a list of the common dietetic causes of scurvy in infants, as follows (they will be seen to be very diverse) : " The different proprietary infants' foods administered without or with slight addition of cow's milk; these foods are responsible for the greatest number of cases, and the variety most harmful depends greatly upon the degree to which it is used; oatmeal or wheat gruel; barley and other farinaceae administered with water alone or with water and insufficient cow's milk; condensed milk and water; sterilized milk; properly modified milk mixtures, but subjected to a temperature of 212 F. from thirty minutes to an hour or more; too dilute milk-and- cream mixtures; laboratory mixtures with too low albuminoid per- centages." Scurvy is found more frequently in infants reared in lux- ury than in the very poor, because the parents of the former can afford to buy prepared foods. Scurvy in infants presents definite peculiarities due to subperi- osteal effusions of blood along the femoral and tibial shafts, which are accompanied by hypersesthesia, local pain, tenderness, swelling, and immobility. Occasionally the cranial bones, ribs, and bones of the arms are involved. The pain and immobility formerly led to mistaken diagnoses of rheumatism, spinal cord disease, etc. Haema- turia may occur. 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 pre- 766 DISEASES ESPECIALLY INFLUENCED BY DIET vented among soldiers and sailors, although fresh vegetables may not be obtainable. On American ships potatoes are always used. Cran- berries keep well and are excellent antiscorbutic food. For travelers in the far North, Nordenskiold advised the use of cloud berries (Eubus chamcemorus) . The introduction of canned and compressed vegetables in seamen's rations has done much to prevent scurvy, but fresh food is always to be preferred to preserved food of any kind. Dried legumes are quite useless. 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 lem- ons, 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. Sir A. E. Wright dissents from this view, 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 coagulation when given per os, and maintains, contrary to general experience, that in scurvy with persistent hemorrhage 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. This view is theoretical, and opposed to much practical experience. Stomatitis is often the most prominent symptom, and if the mouth is very tender, the gums are swollen and bleed readily, and the stom- ach is irritable, the diet should be limited to fluid or some solid food which requires no mastication. Beef tea, broths and meat soups thick- ened with vegetables, fresh vegetables, purees, eggs, and milk are rec- ommended. To these substances the juice of two or three fresh oranges, limes, or lemons should be added. If the patient is able to masticate food thoroughly and the stomach is not too feeble, fresh meat, baked or mashed potatoes, cabbage, sauerkraut, salads and " greens," such as water cress, fresh mustard, or radishes, may be given. The citrate of iron, vinegar, acetic acid and potassium chlo- rate and bitartrate have all proved beneficial. During the Civil War the expressed juice of sorghum was tried with some success. The treatment of scurvy in children consists in discarding all pro- prietary foods, and then if the disease has not progressed too far, im- provement 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. ADDISON'S DISEASE 767 The following dietary is recommended by Louis Starr for scurvy in an infant eight months old : "At 7 A. M., cream, y 2 ounce; milk, -iy 2 ounces; milk sugar, 1 drachm ; water, 3 ounces. At 9 A. M., one or two teaspoonf uls of fresh orange juice, according to the effect on the bowels. At 10.30 A. M., same as 7 A. M. At 11.30 A. M., two teaspoonfuls of raw beef-juice, free from fat, and with little salt. At 1 P. M., one to two teaspoonfuls of fresh orange juice. At 2 p. ii., same as at 7 A. M. At 3 P. M., two teaspoonfuls of raw beef-juice with salt. At 5 p. M., one to two teaspoonfuls of fresh orange juice. At 6 p. jr., same as at 7 A. M. At 8 P. M., two teaspoonfuls of raw beef-juice with salt. At 10 p. M., same as at 7 A. n. " A substitute for orange juice may consist in scraped ripe apple or fresh grape juice. Iron is indicated. The body may be gently rubbed with warm olive oil." H.EMORRHAGIC 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 hemorrhages. 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 toleration in these cases." The dietetic treatment recommended for scurvy should be employed in these cases, but unfortunately it is usually less successful. DIET IX MISCELLANEOUS DISEASES ADDISON'S DISEASE The aetiology of this affection is somewhat obscure, but in the major- ity of instances it results from tuberculosis or other disease of the adrenal bodies, perhaps associated with functional or organic change in the neighboring sympathetic ganglia. At first no dietetic treatment is required, but in advanced cases there is always weakness of the digestive system, and vomiting becomes a persistent symptom. There is also progressive inanition, which be- comes extreme. The diet, therefore, should be of a light and easily digestible character. In some of the advanced cases the best results are obtained from an exclusive milk diet. For others, when milk is 768 DIET IN MISCELLANEOUS DISEASES 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, imperial granum, somatose, or somatogen. Nourishment should be given at short intervals, at least once in three hours, and the patient should be encouraged to take all that he can possibly digest. The intermittent vomiting may necessitate the use of nutrient enemata. Champagne may be retained. See diet for Vomiting (p. 603). 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 characterized 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 known definitely in what manner these salts are dissolved 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 defi- ciency of salts in the diet causes the disease, which has been observed in well-fed subjects. It is, however, customary to arrange the diet with regard to furnishing an abundance of salts in fresh green veg- etables together with such foods as eggs and meat. It is advisable also to prescribe cod-liver oil either alone or in com- bination 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. EXOPHTHALMIC GOITRE It is only very advanced cases of exophthalmic goiter with consider- able 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 ex- cite the nervous system should be withheld. Hence, 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 consist of abundant meats, milk, fats (such as cream, butter, and cod-liver oil), carefully pre- pared cereals, fresh fruits, and green vegetables. CHRONIC LEAD POISOXIXG 769 The theory has been advanced that proteid foods should be with- held in this disease, on the ground that they may intensify the nervous symptoms, but this does not accord with my experience in a very large number of these cases. It would doubtless be ill-advised to order an exclusive proteid diet, but anemia is often a prominent feature and the goitrous case is always made worse when the heart muscle is weakened by anaemia, hence it is desirable to employ a mixed dietary of animal and vegetable food, avoiding such substances only as may produce dyspepsia, as indicated above. Karl von Noorden classes this disease among the few which like tuberculosis and diabetes may be benefited by forced feeding as described on page 515. CHRONIC LEAD POISONING Causation. Chronic lead poisoning is common among all artisans or mechanics who work much with lead in any form, but especially white lead. Plumbers and house painters are therefore particularly subject to it. It also may be acquired by eating improperly tinned or hadly soldered canned food, although such cases are usually acute. (See Lead Poisoning, p. 430, and Canning, p. 312.) 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 neuritis with colic, wrist-drop and other symptoms. The cheap ale, or " four ale," as it is called, sold in London to the low- est classes, has been sometimes kept in contact with pewter pipes until it contained toxic quantities of lead. Lead is occasionally contained in poisonous amount in beer or wine which has been contaminated by the metal during its careless manufacture. Some persons are exceed- ingly 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 containing white lead. Dietetic Treatment. Chronic lead poisoning is always accompanied by constipation, and it is desirable to overcome this difficulty by such foods as will keep the bowels actively open. Fresh fruits and coarse cereals (such as oatmeal, cornmeal, wheaten grits, Graham bread), and molasses are recommended, with such other foods and regulations as are given under the heading of the Treatment of Con- stipation (p. 636). Water should be drunk in large quantity, not solely to increase the digestive secretions and keep the feces moist, but to act as a diluent and aid in washing out the poison. 51 770 DIET IN MISCELLANEOUS DISEASES 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 other- wise than as a good diuretic. DIETETIC DIFFICULTIES ARISING FROM ASSOCIA- TION OF DISEASES There are certain diseases and conditions which are not infre- quently associated in the same patient, the dietetic treatment of each of which may be directly opposed to that of the other. Such,- for example, are: (1) Diabetes and chronic Bright's disease, the former requiring chiefly meat, the latter none; (2) extreme leanness and chronic gastric catarrh, the former condition requiring fats, starches, and sugars, the latter prohibiting them; (3) obesity and chronic ne- phritis or gout, the obesity requiring animal food, the latter none (unless it be milk) ; (4) acute rheumatism and extreme anaemia, the former requiring no solid animal food, the latter demanding it; (5) ascites and chronic nephritis, where the quantity of fluid ingested as well as the diet may present 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 give place to the greater, and a gener- ous mixed diet may sometimes be found to serve the patient bet- ter than one too much restricted by theoretical considerations. (1) In diabetes with chronic nephritis, foods which will do no harm to cither are : Egg?, milk, cream, junket, butter, bacon, squab or chicken (occasionally), c'bee?e, custards, sweetbread, tongue, brains, tripe, marrow, fresh fish and crustaceans (occasionally), oysters and ASSOCIATED DISEASES 771 clams, and any of the fresh green vegetables allowed diabetics, as listed on page 744. (2) In chronic gastric catarrh with tuberculosis and extreme lean- ness, predigested cereal foods and meats may be tried, with eggs, and diluted cream. Milk sugar will sometimes be tolerated, and it is a good tissue-sparer. In extreme cases one or two nutrient enemata may be given daily to supplement other food. (3) In obesity with either chronic nephritis or gout, if the symp- toms of the latter diseases are not urgent, it is best to try reduction treatment for the obesity for about a month or six weeks, by giving a dry proteid diet and also active catharsis. Then the reduction treatment should be suspended and emphasis may be given to treating the albuminuria or gout. In either one of these conditions foods that will not prove harmful are eggs cooked in any form, and any of the fresh green vegetables. The least harmful albuminoid foods are tongue, sweetbread, lean ham, squab, chicken, liver, and fresh fish of any species. (4) In acute rheumatism with extreme anaemia, it is essential to treat the more urgent rheumatism first by a diet of milk, bread or crackers, diluted cream and junket. Later, as acute symptoms subside, fresh green vegetables (containing salts of iron) and eggs may be given, with crisp bacon or ham, but the full proteid diet for anemia should not be given until all acute symptoms of rheumatism have been absent for a fortnight or more, and even then it should be suspended every three weeks, by a temporary return to vegetarianism until re- covery is assured. (o) In ascites with chronic nephritis, a salt-free and dry diet (p. 556) should be tried, and the reduction of fluids desirable for ascites may be supplemented by diuretics to stimulate the kidneys. If the ascitic fluid can be drained off through the kidneys to any extent (which unfortunately is not often possible), it will itself serve as a diuretic, and the ingestion of so little fluid will not be missed by the kidneys. There are, however, cases in which a milk diet proves the best compromise. The foregoing examples serve to illustrate the principles which should govern dietetic treatment in the many complex dietetic prob- lems which arise from association of different diseases. Each case should be treated according to the balance of symptoms, and the diet frequently changed as they may vary. Fixed routine in such conditions does more harm than good, and no subject taxes the skill and in- genuity of the dietist more than the treatment of such complications, when ordinary rules appear contradictory. 772 DIET FOR SURGICAL PATIENTS DIET FOE SUKGICAL PATIENTS, DIET IN KELATION TO OPEKATIONS, ETC. FOOD AND ANESTHETICS Preparation for the Administration of Anaesthetics. When an anaesthetic, such as ether or chloroform, is demanded, care should be exercised that the stomach is empty, otherwise vomiting may occur at a critical moment. Being unconscious, the natural reflexes of the process, including the closure of the epiglottis, are not well carried out, and food is readily drawn into the trachea and excites serious, if not fatal, choking. For this reason, when time permits, the patient is usually prepared for the anaesthetic by giving a light and easily di- gested breakfast, consisting solely of milk with, perhaps, a little far- inaceous food, or a cup of coffee and a roll, 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 four hours after ingestion of a full meal. It impedes anesthetization, besides causing the dangers above mentioned. It is better to allow six or more 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 before the patient becomes unconscious. 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 anaesthetizer in not observing proper precautions, they are usually inexcusable. Ether is more likely than chloroform to prove irritating and excite vomiting while being inhaled. When retching is violent it sometimes may be overcome by " crowding " the anaesthetic that is, by causing it to be inhaled more energetically for a moment, until reflex irritation is overcome. In laparotomy it is especially desirable to have the stomach and intes- tines as empty of food and gas as possible, to facilitate exploration of the abdomen. Diet After Anaesthesia. Ether, much more than chloroform, is liable 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- DIET AFTER SURGICAL OPERATIONS 773 found narcosis, even when only used to assist physical examinations for diagnostic purposes, it is well that caution should be observed for some hours afterwards by withholding food, and thereafter a light fluid diet of peptonized milk, beef tea, or a cup of cocoa, tea, or coffee only should be allowed when any tendency to nausea or vomiting exists. If the patient has been much exhausted by hemorrhage during the operation or by prolonged anesthesia, nourishment may be given by the rectum (p. 455). In cases of laparotomy for operations upon any part of the alimentary canal, such as appendicitis, it may prove best to give the digestive organs physiological rest for one or two days, but if the patient is in need of nourishment one or two food enemata may be administered. The following schedule of diet for the day may be taken as an example for a minor operation under anesthesia : 7 A. M. A cup of beef tea, coffee, or cocoa, or a cup of bread and milk. 11 A. M. Anaesthesia and operations. 5 p. M. Iced milk and Vichy, beef essence, or peptonoids. If vomiting occurs, give hot water, or half an ounce of brandy with soda. 9 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 dis- ease or complications arising from the operation, as in laparotomy, the patient's previous customary diet may be resumed gradually. DIET AFTER INJURIES AND SURGICAL OPERATIONS Fractures, wounds, ulcers, and all grave surgical injuries naturally heal the sooner the better the condition of the blood. Abundant nour- ishing diet, properly selected in regard to its ready digestibility, 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 observed that the channels for removal of waste from the body do not become clogged 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 urine should be examined to in- sure proper assimilation of all the food taken. In the absence of sep- sis, 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 774 DIET FOR SURGICAL PATIENTS the patient is normally accustomed, or, if the appetite fails, consider- able variety in the dietary may be permitted advantageously. If there has been no loss of blood and no severe shock, soon after an ordinary aseptic operation is over the patient is practically as well as he was before it was performed. Sir Watson 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, provided it is wholesome, and the more nutritious the food the better." In fact, after opening a large abscess or a carious joint the appetite may soon return and "hunger becomes the chief trouble." As a rule stimulants are necessary if the appetite be 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 grave injuries, such as serious 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. In such cases it may become nec- essary to allow a little 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 delirium subsides. Critical Cases. If severe pain has preceded an operation, if the operation has been prolonged, or if there has been much shock, even under ansesthesia, the diet should be supervised with great care. Pain is a strong depressant, and after 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 appropriate to keep the patient for three or four days upon a diet of milk or pancreatinized milk. Broths, meat extracts, and beaten eggs may be added when the stomach regains its tone. If nausea, anorexia, or disgust for food exist, or if there be much distention of the stomach, it is unwise to force food upon the patient. It is better to utilize the rectum in such cases, and strong coffee, pancreatinized milk, egg albumen, and alcohol are given in enemata. Opium or other necessary medication may be added. If extensive loss of blood has taken place, 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 rectal injections, or in severe cases DIET IN SURGICAL INFLAMMATIONS 775 hypodermic injections of saline solutions, help restore the lost fluid to the blood and improve vascular tone. Laparotomy, Ovariotomy, Etc. After all operations involving opening the peritoneal cavity com- plete rest of the stomach is necessary for twenty-four hours, and not infrequently for two or three days. Food and stimulants may be given by enemata (p. 455). If fed per os by the second or third day not more than a tablespoonful of pancreatinized milk or milk with lime water or barley water should be allowed once in two or three hours. Later the quantity may be increased, the intervals diminished, and beef tea, beef peptonoids, and egg albumen added. In these cases the duration of anaesthesia has usually been pro- longed, and shock is considerable. The danger from the occurrence of vomiting, malfermentation of food, and flatulent distention of the abdomen is far worse than that of inanition from abstinence. When time permits it is well also to precede the operation by a day or two of dieting in order to lessen the bulk of intestinal waste. To this end the diet should, when possible, consist chiefly of lean meat and dry toast, vegetables, cereals and especially sweets being avoided. 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 so be administered, and all nourishment should be supplied for 4 or 5 days by the rectum. The return to mouth feeding should be made very slowly and cautiously by at first giving not over one or two tablespoonfuls of pancreatinized milk or beef juice at a time. There is often much thirst following operations involving the peritoneum, 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 fluids swallowed exciting emesis, a hot salt-water enema once in three or four hours will alleviate thirst (p. 452). DIET IN SURGICAL INFLAMMATIONS, SEPSIS, ETC. The diet in surgical inflammatory conditions was reduced originally 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 diet absolue, as the French surgeons of the first half of the last cen- tury termed it, meant virtual starvation, barley water, arrowroot water, or toast water being all that was allowed. With improve- 776 DIET FOR SURGICAL PATIENTS merit in feeding fevers came a change in the diet of inflammatory con- ditions, and it was recognized 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 pneumonia, nor yet does an intense local inflammation of a joint demand that the patient should have solid meat meals, but there is an appropriate mean to be observed between overfeeding and starvation. Sepsis is not avoided by starving, and the patient's strength should rather be supported by easily assimilable food. In acute inflammatory conditions tissue waste is rapid and appetite and digestive power are lessened. In critical 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 extracts (p. 135). These substances at first may be given alone, and then added to strong beef, mutton or chicken broth. Gruels of arrowroot or oatmeal, raw eggs alone, or beaten and added to sherry or brandy, custard, milk pud- dings, and beef jelly are all recommended. When improvement occurs, a light convalescent diet may be pre- scribed, such as that detailed on p. 472. Acidulated drinks, sour lem- onade, oatmeal or barley water, and effervescing waters may be used to alleviate 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 given. Elderly patients and those who have previously been reduced by wasting diseases require earlier stimu- lation in the form both of meat extracts or meat juice and alcohol. From four to six ounces of liquor may be prescribed in twenty-four hours, according to its effect on the pulse. In the milder inflamma- tions, 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 opiates. Burns, when severe and extensive, require prompt and energetic stimulation. In such cases a pint of brandy may be given in twenty- four hours. In chronic surgical diseases, attended by formation of pus, fresh green vegetables and fresh fruits are serviceable, both for their antiscorbutic and laxative effect. Lemonade, oranges, baked apples, or stewed prunes are recommended. Fats also are needed especially, and butter, cream, olive oil. bacon, or cod-liver oil should be added liberally to the diet when the patient is able to digest foods of this class. PRESCRIBING DIETARIES In prescribing dietaries for private patients, it is well to be sys- tematic and exact. Patients are very appreciative of attention to their gastronomic needs, and in all important diseases modified or induced by diet it is desirable to make out a full list not only of foods which may be eaten, but of prohibited foods. In order to save time in office work, after trying various methods, I have found it convenient, ac- curate and time-saving to furnish patients with a printed card, con- taining a menu of the ordinary foods arranged in two major groups, the first comprising such foods as are most often desirable, or " foods allowed/' the second comprising those foods which experience has shown are most often to be " f orbidden." In a given case it is easy to erase foods on either list, or to transfer them from one list to the other. The cards are printed on both sides to economize space, and of a size convenient for the patient to carry in the pocket. As this system may prove convenient to others, I append the menu herewith : Dietary for Date . FOODS ALLOWED. Purees; Soups, (Vegetable, meat.) Shellfish: Oysters, clams, scallops, (stewed, broiled or escalloped, not fried), (soft parts only). Oyster broth, clam broth. Fish: Fresh fish, (boiled or broiled, not fried) as; bass, blue- fish, butterfish, cod, flounder, haddock, halibut, mackerel, perch, red snapper, shad, shad roe, smelts, sole, weak fish. Eggs: Soft -cooked, scrambled or poached (not hard boiled). Cereals: Stale bread, toast (dry milk), Graham bread, pulled bread, crackers, Huntley and Palmer wafers and biscuits, zwie- back, shredded wheat, trisket, oatmeal, wheatena, wheaten grits, thin ginger snaps, cornmeal, (mush), boiled rice, puffed rice, farina, corn starch, hominy, sago, tapioca, samp, macaroni, spaghetti (without cheese). 52 777 778 DIETARIES, RATIONS Butter. Cream. Vegetables: Artichokes (French, Jerusalem), asparagus, beet tops, Brussels sprouts, butter beans, cauliflower, celery (raw, stewed), egg plant, lettuce (French dressing), Lima beans, okra, onions, oyster plant, parsnips, young fresh peas, white potatoes (baked, mashed, stewed), rhubarb, spinach, squash, string beans, tomatoes. Bed Meats: Rare roast beef, beaf steak, chops, mutton, lamb (sparingly, once a day only), Poultry and Chicken, capon, turkey, squab, Guinea fowl, duck, goose, Game: quail, partridge, snipe, grouse, pheasant. Miscellaneous: Sweetbread, ham, thin crisp bacon, liver, tongue. Desserts: Rice pudding, bread pudding, junket, custard, baked cus- tard, Bavarian cream, whipped cream, sponge cake, maca- roons, gelatine foods, as plain wine or lemon jelly, blanc- mange; ice cream, plain vanilla. Fruits: Oranges, lemons, grape fruit, pineapple (juice only) peaches, plums, stewed prunes, apples ( raw, baked, stewed ) , cantaloupe, bananas, grapes, olives. Beverages: Tea, coffee, cocoa, alkathrepta, lemonade, orangeade, milk or cream with Celestin Vichy, buttermilk, ginger ale, apol- linaris, koumyss, matzol, zoolak; hot water with Liebig's or other meat extract; Postum, Poland water, White Rock, Lithia. water. FOODS FORBIDDEN (Other forbidden foods may be erased from above list). Sweets of all kinds, as: confectionery, bonbons, candy, honey, sugar, cake, " cakes," syrup, molasses, jams, marmalades, preserves. Pastry, pies, puddings, corn bread, Boston brown bread, muffins, gingerbread, hot bread, patties. Eich soups, gravies, sauces, " dressing " or " stuffing," hashes, stews, ragouts. Fried food of all kinds, all twice cooked or " made-over " dishes, canned, dried, smoked, salted, potted, candied and preserved food of every kind. Veal, pork, sausage, pate" de fois gras, corn beef, brains, tripe, kidneys, marrow. Condiments and spices, vinegar, mustard, pickles, cheese, mushrooms. Lobster, crabs, terrapin, caviare, herring, salmon, sardines, chowder. New Potatoes, sweet potatoes, radishes, cucumbers, cabbage, corn, beets, tur- nips, horseradish, cranberries, beans. Nuts, raisins, berries. GENERAL RULES. 1. Eat slowly: masticate thoroughly. 2. Have meals at regular hours. 3. Avoid anxieties or business cares at table. 4. Rest for half an hour or more after luncheon and dinner. 5. Do not eat more than a half-dozen kinds of food at any one meal. 6. Do not eat too much. 7. Take but little fluid of any sort with meals, but do not fail to drink a glassful of water half an hour before and two hours after meals. ABMY DIETS 779 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, not excepting hospital patients. While seek- ing 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 value of which is closely related; thus eggs may occasionally be 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 principles upon which military rations have been selected are thus summarized by Major Charles E. Woodruff, Surgeon, U. S. A. : " 1. 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. " 6. It must be 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. " For these reasons the soldier's ration has always been simple and dry." Some of these principles, as the author quoted points out, are radi- cally wrong. It is false economy to furnish too cheap or monotonous 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 German soldier is expected to eke out his peace ration by sup- 780 DIETARIES, RATIONS plies 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 economical 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 surrounding country. The importance of an adjustable army ration is appreciated when it is considered that within the limits of service in the territory owned by the United States may be found a temperature range of 150 F. Diet suitable for Alaska is radically unfit for Manila. UNITED STATES ARMY RATIONS 1. For Troops in Garrison STANDARD ARTICLE S. SUBSTITUTIVE ARTICLES. Kinds. Quantities. Kinds. Quantities. Meat components Bread compo- Fresh beef . . Flour 20 ounces . . 18 ounces.. 2 ounces . . 16 ounces. - Ig ounce... Ig ounce... 3i ounces . . f Fresh mutton 20 oz. 12 oz. 16 oz. 14 oz. 18 oz. 16 oz. 18 02. 16 oz. 20 oz. 2g oz. Ig oz. Ig oz. 12| oz. 3J oz. 12f oz. 34 oz. lli oz. 4f oz. 2g oz. Ig oz. Ig oz. Ij 7 5 OZ. & oz. *!! A g 111 - j Bacon J Canned meat 1 Dried fish j Pickled fish [ Canned fish f Soft bread { Hard bread Vegetable com- ponents Dried (or evapo- rated) fruit components . . Coffee and sugar components . . Seasoning compo- nents . . . Beans ... ( Cornmeal r Peas j Rice . Potatoes .... (_ Hominy f Potatoes (^ Onions f Potatoes I Canned tomatoes . . f Potatoes changed to suit ) climate. \ Mm. Sometimes 2 oz. rum 175 Sufficient for such 2. Spain . . 1. Peace { \fi*' 147 120 87 62 588 500 3,729 3,421 a mild climate and very moder- ate work. 2. War, on f Max. march or in-| 131 94 522 3,327 } Varies enormous- ly according to class of rations the field I Min. 113 55 485 2,550 issued. Very Sometimes 1.7 oz. brandy 150 many extra al- lowances of mon- ey for food. v This is augmented by four cents per day for vegeta- bles, etc. On the march a limited emergency ration, 3. Austria . 1. Peace 155 125 504 3,865 is used. The 2. War 165 130 504 3,952 war ration is so insufficient that commanders of armies or small- er forces may change, supple- ment, or even. ' double it. Allowances of one- fifth cent per day for condiments; 4. Italy . . . 1. Garrison 111 115 125 130 133 143 600 600 600 4,129 4,163 4,307 250 occasional extra money allow- ances for food. Excepting the protein, it is a 2. Camp 3. Marching Usually wine added. very liberal diet for such a mild J country. 789 NATION. RATION. Protein. tn a Carbohy- drates. Calories. REMARKS. Cms Cms Cms 1 This is what the government may 5. Germany 1. Small ra- ] supply. Usually tions and the soldier feeds portions in [ Max garrison [ Min. 150 99 40 40 703 502 3,947 2,827 himself and is I given seven cents a day, or more, and can- | to reimburse tonments J himself. Food eaten is more than this defi- cient diet. 2. Large ra- ~) tions and | M portions on 1- vl ax march or in 1 Min " 172 138 62 57 915 644 4,961 3,744 manoeuvres J 3. Field j Max. 195 151 703 4,786 \ Mm. 78 75 515 3,413 Commanding gen- eral may add 3J oz. whisky 268 6. United States 1. By law . .. |^ x ' 2. Usually in f Max. field (byJ Min. 183 105 106 64 260 103 320 240 621 500 540 460 5,368 3,712 5,166 4,722 Maxima due to fats if all the ba- con is used and no meat. The whole ration is supposed to be law) [ Ave. 85 280 500 5,000 supplied and eaten. 3. Food actually " eaten in cold climate, moder- ate work, in- cluding all ex- 155 180 597 4,907 ^ras from gar- dens and pur- chases J - Peace *ation not stated. It is pur- chased as need- ed and charged against soldier. War . ..%!' 183 300 690 5,455 War ration is subject to great / . Jr rmicc \ Mm. Add 2 T \y oz. brandy 146 127 520 4,015 184 augmentation for increased work or cold climate. The commanding officer can aug- ment ration on the march. Also allowed mon- ey to buy one- half to one and 8. Russia . -r. f Min. 1. Peace . . . .\ Max 233 165 114 65 976 746 5,884 4,450 one-half ounces extra meat, and Add 3 oz. wine . . 223 one to one and one-half cents for vegetables, salt, butter, lard, and groceries. o TTT f Max. !. War . . < -Kf 174 62 805 4,583 Extra meat and ) spirits may be \ Mm. 149 50 640 3,307 J. ordered by the Add 4J oz. wine 362 \ commander in ' chief. 790 DIETARIES, RATIONS As stated by Major Woodruff, the United States is the only nation in the world that in time of peace pretends to supply the entire ration. Soldiers living in densely populated European countries supplement their rations by local purchases from a mess fund or, as in Germany, from supplies from home. In Austria bread alone is furnished as a peace ration, other food being purchased from a money allowance. At remote frontier posts in the United States a variety of local purchases is frequently unobtainable, and hence the attempt to supply the whole ration in kind. United States Navy Rations Table showing the different U. 8. "Navy Rations and their Component Parts, as established by Law, with the Substitutes legally alloiced for each Article. ALLOWANCE FOB GENERAL USE RATIONS AS COMPOSED BY LAW. EITHER OF THE FOLLOWING Specified by law. Substitutes authorised by law. Ration No. 1 .... Ration No 2 1 Ib. salt pork. J pt. beans or peas. 1 Ib. salt beef. J Ib. flour. 2 oz. dried fruit. 2 Ib. preserved meat. J Ib. rice 2 oz. butter. 1 oz. desiccated mixed vege- tables. | Ib. preserved meat. 2 oz. butter. 6 oz. desiccated tomatoes. 1J Ib. fresh meat, or 2 Ib. preserved meat. Vegetables of equal value, or i Ib. rice. 1J Ib. fresh meat, or 2 Ib. preserved meat. Vegetables of equal value. No substitute. | pt. beans or peas. No substitute. 6 oz. canned vegetables. No substitute. No substitute. 6 oz. canned tomatoes. Ration No. 3 Ration No. 4 WEEKLY ALLOWANCE J pt. pickles, i pt. molasses. J pt. vinegar. DAILY ALLOWANCE 14 oz. biscuit. i oz. tea. 4 oz. sugar. 1 Ib. soft bread. 1 Ib. flour. 1 Ib. rice. 2 oz. coffee. 2 oz. cocoa. For coffee and sugar, extract of coffee combined with milk and sugar may be substi- tuted by the Secretary of the Navy, if not more expensive. NAVY DIETS 791 The law allows one of the above complete rations to be used on any or each day of the week, or they each may be used in turn as convenient, in case it becomes necessary to vary the order prescribed elsewhere. (Estimated average cost per capita per diem, thirty cents.) The following statement is from the New York Medical Eecord: " The naval full-diet table is as follows for one day in the week, the number after each article relating to ounces: Breakfast cof- fee, 1 ; bread, 4 ; butter, 1 ; milk, 6 ; sugar, 1 ; oatmeal, 1 ; beefsteak, 6. Dinner rice soup, 8 ; bread, 4 ; roast beef or roast or boiled fowl, 8 ; potatoes, 8; other vegetables, 6; pickles, 1; bread pudding with sauce, 6; or custard frozen, 8; fresh fruit, 6. Supper tea, 14 ; bread, 6 ; butter, 1 ; milk, 2 ; sugar, 1 ; cold roast mutton or cold roast beef, 4 ; stewed dried fruit or baked fresh fruit or apple sauce, 4. The staples coffee, bread, butter, milk, sugar, and fresh and dried fruit are the same for each meal, but there is a daily variety in meats and other articles for breakfast, dinner, and supper. The proportions are about the same, however, especially in the matter of meats, as in the specimen diet table given above. In addition to its use for convalescents, the table is now observed for all naval-hospital em- ployees, and is gradually becoming the standard aboard ship and in the marine corps. Its adoption was the result of most patient and thorough investigation by Surgeon I. D. Gatewood, who consulted all the leading authorities on the subject." Table showing the Quantities of the Different Articles of the U. S. Navy Ration which are required for One Man for One Year Biscuit 3191 pounds. Biscuit ( with flour) 182 Cornmeal 52 Oatmeal 52 Rye flour or hominy 52 " Wheat flour 52 Salt pork 104 Beans 6| gallons. Peas 31 Salt beef 52 pounds. Rice 26 Dried fruit 13 Butter 19J " Tomatoes 19J " Canned meal 78 Ham or bacon 39 Sausage or salt fish 39 " Coffee 26 Tea 4| Cocoa 19J " Sugar 91J " Pickles 26 " Molasses 31 gallons. Vinegar 3-J " Canned vegetables 39 pounds. 792 DIETARIES, RATIONS 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. In comparing navy with army rations it should be remembered that on shipboard a proper cooking range, utensils, and fuel are al- ways obtainable, whereas entirely different conditions obtain with an army in the field. Table showing the Different Articles of the U. 8. T$avy Ration, for which Practical Equivalents or Substitutes are permitted, with the Quantity of each allowed for Issue. ARTICLES NAMED IN THE LAW. Articles considered as included under names given in preceding column. Quantity allowed per ration. / Biscuit 14 oz. 1 Ib. As substitute for 1 Ib. bread. 12 oz. 2 oz. J oz. 2 oz. U Ib. U Ib. 6 oz. Bread Flour 1 Soft bread . . C Cornmeal . . . . . "1 Corn (hominy K Oatmeal .... I Preserved meat . . Dried fruit Rye f Wheat I f Roast beef . . . } Canned muttoi Chicago cornec Brawn [ beef Ham Bacon . Sausage .... ( Dried Fish \ Smoked I ( Pickled f Dried apples. " Peaches. Raisins. -{ Currants. Prunes. Figs. [ Dates. I May be substii C Beef. ] Mutton. J. Veal. 1 U Pork. I Poultry. J f Fresh (such a 1 Canned (assor Or any other kind of \ Tea uted for each other > r any other kind of fresh Cocoa ' Fresh Meat Vegetables s can be procured ) ... ted kinds ) 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 community. A brief review of such established diets is useful in furnishing an idea of quantity and quality of food required to fulfil the necessary conditions. DIET IN PEISONS 793 Voit calculated that for a prisoner not engaged in hard labor the following diet is sufficient to maintain health : Carbohydrates, three hundred grams ; albumin, eighty-five grams ; fat, thirty grams/ or a proportion of about 10, 3.5, and 1. In some penal institutions the inmates are placed upon a progressive diet that is, a diet which is regulated according to the duration of their sentence, the degree of labor exacted from them, and their con- duct. Such a diet has been recommended by the British Commis- sioners of Prisons, graded for: (1) Periods of seven days or less. (2) Periods between seven days and one month. (3) Periods be- tween 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. Eoast beef and gravy, three days each week. Boiled beef and gravy, two days each week. Vegetable soup, daily except Sunday. 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 available from the prison farm. Supper. Tea or coffee, one quart; bread, as much as required. Stewed apples or prunes on alternate days. Diet No. 1. The following diet, known as " Solitary," is given pris- oners confined in cells for punishment, while not performing any labor : 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. Diet No. 2. The following diet, known as " Restricted," is given prisoners confined in cells for punishment, while not performing any labor : Breakfast. Hash or stew, eight ounces. Bread, seven and a half ounces. 794 DIETARIES, RATIONS 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. Diet No. 3. The following diet is given to prisoners who have undergone punishment: Breakfast. Hash or stew, ten ounces. Bread, ten ounces. Cof- fee 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 " Eestricted 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 " Eestricted Diet " for twenty days or more, or on " Solitary Diet" for fifteen days, the above diet (Xo. 3) is given for three days. At a Conference of the Prison Association of New York, the follow- ing bill of iare was recommended for general adoption in prisons. The quantity of food is not specified : 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. Clipper. Bread and milk, molasses. Wednesday Breakfast. Pea soup, bread. Dinner. Beef or mutton stew, with vegetables. (Rice may be used in place of potatoes.) Supper. Cornmeal mush, molasses. Thursday Breakfast. Bread and butter, milk. Dinner. Baked beans, bread, fruit. Supper. Bread and butter, cereal, coffee. THE SKIMMED MILK CURE 795 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 dietary of the New York State Beformatory follows in tabular form on pages 796-798. The comparison of this Beformatory Diet with other standard rations is presented in the following table of actual nutrient values: NUTRIENTS, IN GRAMS. Protential energy, in calories. Pro- tein. Fats. Carbo- hydrates. Reformatory standard dietary daily ration * 119 167 154 154 119 118 85 105 61 75 69 69 51 56 30 40 556 810 794 776 531 500 300 500 3,334 4,696 4,524 4,452 3,140 3,050 1,857 2,852 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 THE SKIMMED MILK CURF The milk " cure " does not apply to the temporary exclusive milk diet of typhoid fever and similar acute febrile conditions, but it is bel \eved by its advocates that this food not only counteracts certain abnormal conditions and meets definite requirements of the body, but that the exclusive milk diet possesses a special curative value in some classes of cases. Bauer says emphatically : " It is an indisput- able fact that in certain diseases a methodical use of the milk cure gives results such as can be attained by no other treatment." It has been carried out successfully by Pecholier, "Weir Mitchell, Karell, and others for the treatment of obstinate chronic intestinal disorders, especially enteralgia, intestinal dyspepsia and colitis; in chronic congestion, hypertrophy, and fatty degeneration of the liver; in asthma, pulmonary catarrh, and emphysema; in dropsies of renal, * 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 excess 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 Play- fair. 796 DIETARIES, RATIONS I 4 < [^ > ''=8 ' u QO GO *4| 1O Clp t* A Ct 00 O) CX -f CO t~ eoeDcocSNSS 2 B 2s 3 S J,}BUI COt*00 O Cb JO CDOcDO-^t ' UI W KB ooo o oetenfto > . ' SN" ^- us * ^ o oocxoo S" a . 2 OOO^HOOOOSOO o -"--NIO-* & k* c- O^-t-Ct-^TOH CM ^ U3 CO O t OOCBiO t-O O cot-t-O-rf H y CO -^ T COCO CO ^- ^H ^* W t-H Q Refuse. D G y D * CR O O O O i* 3-' 388888S888g88Sc5{28 K5-* CO 84 O H II O .goo-88*^^-o.o 2 o-- I" < & M S o oo oo^^w^^ ^ o re tfl - 00 CO^ * ^ CO t> pound may be lost through worry and excitement immediately preceding the race.) DIET IN ATHLETIC TRAINING 813 " The diet was simple. Eoast and broiled beef and lamb, fric- asseed chicken, roast turkey, and broiled fish, made up the meats. Eggs were used plentifully either raw, poached, or boiled in the shell. Large amounts of milk and cream were also consumed. Oatmeal, hominy, and shredded wheat were eaten largely, and corn cakes were occasionally served. Bread was almost always taken in the form of dry toast. Potatoes were served twice a day. These were sometimes baked, sometimes boiled and mashed with a little milk and butter added, and at other times 'creamed.' Boiled rice, prepared with a little cream and sugar, was served instead of potatoes at some meals. Beets, parsnips, green peas, and tomatoes were used to furnish a variety of vegetables. Macaroni was occasionally served. For des- sert, apple tapioca pudding, custard pudding, or other pudding con- taining a large proportion of milk and eggs was used. The mem- bers of the crew were allowed beer once a day. No pastry was allowed, and the puddings were, as above stated, composed largely of eggs and milk. A small amount of coffee jelly was served, and at one meal during the study, ice cream. No fresh fruit was served, with the exception of oranges for breakfast. Stewed prunes, rhubarb, or ap- ples were also eaten, prunes most abundantly. No beverages were allowed other than water, milk, and beer. Breakfast was served at 8, lunch at 1, and dinner at 6 o'clock/' These experimenters found that the average nutrients consumed per man per diem amounted to 145 grams protein, 170 grams fat, and 375 grams carbohydrates, aggregating 3,705 calories. Just be- fore racing each man received one ounce of beef extract with eight ounces of dry toast. A subsequent study of the Harvard University Boat Crew was made by E. A. Darling, who reported as follows : "Diet. The diet allowed was a very generous one, consisting of a hearty breakfast at 7.30, lunch at 1, and dinner after the even- ing row. For breakfast the fare consisted of fruit, oatmeal, or shred- ded wheat, eggs, some form of meat, bread and butter, potato, and milk. At noon there was cold meat, potato, bread and butter, mar- malade, preserved fruit, and milk. Dinner comprised soup, occa- sionally fish, roast beef or some other hot meat, several vegetables, bread and butter, and a simple dessert. No tea or coffee was allowed, but ale or claret was permitted at dinner, also water in small amounts, as desired. During the last week before the race each man received a dish of calf's-foot jelly with sherry wine after the morning row, and a light lunch of oatmeal, milk, and bread was served at 4 o'clock in the afternoon." 814 DIETARIES, RATIONS Another study of the Harvard Freshman Crew during training was made by Atwater and Bryant: " The men arose at about 7 o'clock. Before- this time no noise was allowed in the kitchen or elsewhere. After a short run, break- fast was served at 7.30 o'clock and was quite a hearty meal, consist- ing principally of oranges, a breakfast cereal, hot meat or fish, and potatoes. During the morning there was usually a practice row on the river, followed by a light lunch at about 11.30 to 12 o'clock. The principal meal of the day was taken early in the afternoon. In the late afternoon the crew had another season of hard work on the river, after which another hearty meal was served. Leisure time was spent in study or recreation." Cane or grape sugar in large quantity may be added with advantage to the diet of athletes and soldiers on the march. It may be given with other food, such as cereals, tea and coffee, etc., as is customary with the Cornell University Crew; or it may be given separately either as plain confectionery or in the form of cakes of chocolate. In a recent study of the training diet of boat clubs in Holland as much as one-third of a pound of cane sugar per man per diem was found to be consumed with very marked benefit. Summary of Results of Dietary Studies of University Boat Crews and ofher Dietary Studies, by W. 0. Atwater and A. P. Bryant (Nutrients in food actually eaten per man per day) Pro- tein. Fats. Carbo- hydrates. Fuel value. DIETARY STUDIES OF UNIVERSITY BOAT CREWS Harvard University crew at Cambridge Grms. 162 Grms. 175 Grms. 449 Cals. 4,130 Harvard Freshman crew at Cambridge 153 223 468 4 620 Yale University crew at New Haven 145 170 375 3 705 Harvard University crew at Gales Ferry 160 170 448 4 075 Harvard Freshman crew at Gales Ferry 135 152 416 3 fi?T Yale University crew at Gales Ferry 171 434 4 070 Captain of Harvard Freshman crew TSfi 181 487 4 31 T \vpra r e l^T 440 4 ORTi SUMMARISED RESULTS OF OTHER DIETARY STUDIES Football team, college students, Connecticut . . Football team, college students, California . . . Professional athlete, Sandow 181 270 244 292 416 151 557 710 502 5,740 7,885 4,460 Pri/e fighter. England 278 78 83 2,205 Average of 15 college clubs 107 148 459 3,690 Average of 14 mechanics' families 103 150 402 3,465 Average of 10 farmers' families 97 130 467 3,515 Average of 24 mechanics' and farmers' families. Average of 14 professional mens' families 100 104 141 125 429 423 3,480 3,325 DIET IN ATHLETIC TRAINING 815 Pro tem. Fats. Carbo- hydrates. Fuel, values. DIETARY STANDARDS Man with moderate muscular work, Voit Grms. 118 119 125 145 156 150 185 175 Grms. 56 51 ioo 71 'ii Grms. 500 531 450 568 568 Cats. 3,055 3,140 3,500 3,370 3,630 4,500 3,750 5,700 Man with moderate muscular work, Playfair . . . Man with moderate muscular work, Atwater . . . Man with hard muscular work, Voit Man with hard muscular work, Playfair Man with hard muscular work, Atwater Man with severe muscular work, Playfair Man with severe muscular work, Atwater Diet of Yale Football Team " The diet of the football team is practically the same as for the crew except for lunch, which is eaten at 1 p. M., the practice taking place from 2.30 to 3.45 or 4 p. M. This one-o'clock meal consists of cold meat, one chop or eggs, hot broth or bouillon, and toast. Milk and oatmeal-water are drunk. Apple sauce is sometimes allowed" (John A. Hartwell). Diet of Pugilists, Bicycle Racers and Jockeys Chambers gives the following example of a diet used by pugilists : 7 A. M. Light breakfast : oatmeal with little or no milk and sugar ; one to three eggs, poached or raw; a cup of tea with little or no milk or sugar; a slice or two of toast. The eggs may be varied by a rare or well-broiled chop. 12 NOON". Dinner (following a half hour of rest) : roasf beef or mutton and vegetables ; cup custard and plum pudding. A heavy dinner may be eaten, unless it is desired to reduce the weight. Old, mixed, or Bass's ale is allowed, but only a little water should be drunk, for it favors obesity. If thirst is annoying, a pebble or bit of rubber tub- ing may be carried and rolled in the mouth to increase the flow of saliva. An hour or two of rest should be taken after dining. 6 p. M. Light supper : toast, a mutton chop or an egg, a vegetable, and a cup of tea. Percy studied the diet of a light-weight prize fighter twenty-two 3 r ears of age, 5 feet 6 inches in height and weighing 119 pounds. " He breakfasted at 9 A. M., and ate one pound of mutton, weighed before cooking. He dined at 1 p. M., and ate the same quantity of mutton, with the addition of about two ounces of bread. And again at supper, at 8 p. M., he had the same quantity of mutton. At each meal he drank half a pint of ale, but no other liquid at any other 816 DIETARIES, RATIONS time of the day. Nor did he eat any other vegetable matter whatever besides the small quantity of bread mentioned. He walked seven- teen miles per day." Such a diet would not be indorsed by most trainers, nor would it fit a man for sustained effort. A noted New York prize fighter says that in training he is accus- tomed to eat almost any plain substantial food that he likes, relying largely upon beef, mutton, bread, and potatoes, but avoiding pastry and sweets. He drinks fluid freely until within a week of the con- test, when he reduces the water ingested to a minimum. Bicycle racers entering six days' contests undergo the severest kind of muscular strain and require a diet rich in protein and energy. They work from eighteen and a half to twenty-one hours out of the twenty-four, and have a minimum of sleep. They take most of their food in fluid or semisolid form, in part to save time and in part because it is easily digestible. Water is not drunk during the race. A dietetic study of bicycle racers was made in 1898 in New York by W. 0. Atwater and H. C. Sherman. The most remarkable con- testants were C. W. Miller, who rode 2007.4 miles in six days, 'and F. Albert, who rode 1822.6 miles. Miller lost four pounds the first day, but subsequently maintained his average weight. His average daily food consumption in grams was: Protein, 169; carbohydrates, 585 ; fat, 181 ; having a total fuel value of 4,770 calories. His food was of very simple character, and pastry and pork, as well as alcohol and tobacco, were excluded during a month of training. Albert, on the other hand, limited his diet chiefly by the exclu- sion of veal and fat meats. He smoked tobacco in moderation but did not use alcohol. He lost three pounds and a half in weight on the first two days of the contest, but subsequently regained them. His average daily food consumption in grams was: Protein, 179; carbohydrates, 859; fat, 198; having a total fuel value of 6,079 calo- ries. The protein metabolized by these two contestants was found to be about twice as much as that metabolized by the average me- chanic, and they did more than two days' work in one. Each con- testant lost " body protein equivalent to two or three pounds of lean flesh, and that no injury resulted therefrom would seem to indicate that these men had stores of protein which could be metabolized to aid in meeting the demands put upon the body by the severe exer- tion, without robbing any of the working parts, and at the same time relieving the system of a part of the labor of digestion. Possibly the ability to carry such a store of available protein is one of the fac- tors which make for physical endurance" (Atwater and Sherman). DIET AXD OCCUPATION 817 The dietetic training of jockeys is merely for the purpose of re- ducing weight without regard to endurance, and more depends on their eating a small quantity of food than upon its restriction in variety. They should make their fare chiefly bread and meat, and abstain from much fluid. Chambers points out that men who have brief holidays in the country often fail to get the maximum good of their outdoor life, because they are not in proper condition for it. If a shooting or walking trip is to be undertaken for a week or two, it is well to ab- stain for a fortnight beforehand from eating elaborate dinners, and to leave off sweets and pastry and live on a drier diet than usual. In general the athlete in training, when not trying to reduce his weight, develops more energy from food and consumes more pro- tein than the ordinary working man. In the case of the crews studied by Atwater this excess of energy equalled 400 calories, or 10 per cent, and the protein consumption was increased by 45 per cent. This ex- cess of protein is demanded by the increased nervous tension which is lacking in the slow, methodical, muscular exertion of the day laborer. DIET AND OCCUPATION There are some occupations which are more or less closely con- nected with dietetics. Workers in lead, plumbers, painters, polish- ers, pottery glaziers, et aL, should be taught to be very careful to cleanse the clothing, hands, and especially their finger nails, before eating. The soft crumb of bread getting under the nails easily be- comes contaminated with lead salts, which by this means are con- veyed to the stomach, where the white-lead carbonate, which is insoluble in water, is dissolved by the gastric juice into a more dan- gerous chloride. Workers in dyestuffs, artificial flowers, green wall papers, and other materials in which arsenic is used, should be simi- larly careful, and never be permitted to bring their food into the workrooms. Some occupations e. g., those of foundrymen, stokers, and porce- lain manufacturers necessitate exposure to extremely high tem- peratures. Profuse sweating results and thirst. The thirst is quenched by subsequently drinking enormous quantities of fluid, which should be water or oatmeal water, not too cold, rather than beer or other alcoholic beverages. Their lives at best are liable to be shortened by the suddenness and severity of the changes to which their kidneys and circulation are subjected, and a resort to alcohol is soon fatal. 818 DIETARIES, RATIONS Tea tasters acquire more or less poisoning, although they do not swallow the beverage, for a good deal is absorbed by the mucous membrane of the mouth. The symptoms are insomnia, nightmare, headache, "nervousness," tremors, dyspepsia, and constipation (see p. 250). Even smelling the tea infusions constantly is poisonous to some sensitive persons (Chambers). To mitigate the danger they should eat abundantly before exposing themselves to the noxious ef- fects of their occupation. Among diseases occasioned by the handling of food products may be mentioned the grocer's itch, from handling low grades of sugar (now much less common than formerly, owing to better methods of refining), and the bronchial diseases produced by the inhalation of flour and grain dust in grist mills and grain elevators. There are, in addition, many occupations which directly interfere with the proper digestion of food, such as those of tailors and shoe- makers, whose cramped positions compress the abdominal viscera and impede full respiratory action. Their discomfort from dyspepsia and flatulency teaches them to avoid eating vegetables and sweets. All occupations conducted in close, ill-ventilated apartments are injurious by depriving the system of sufficient oxygen to consume the food ingested. The following Table, compiled by A. P. Bryant for the Yearbook of the "U. 8. Department of Agriculture for 1898, presents a Comparison of the Aver- age Food Consumption of People of Different Occupations or in Different Conditions of Life (Per man per day) FAMILIES STUDIED. Cost. Pro- tein. Fat Carbo- hy- drates. Fuel value. Cts. Gms. Gms. Gms. Cals. Average < is i families 1 FOO( J purchased. 101 136 483 3,655 in eimont, Connecticut, and p FoO( j ea t en 97 130 467 3,515 Average of 14 mechanics' fam- "| - ~ , , -, ilies in Connecticut, New Jer- LIH P 1 cha9e(L m j T j I -c ooa eaten .... sey, lennessee, and Indiana. J 19 110 103 161 150 425 402 3,690 3,465 Average of 14 professional "1 men's families in Connecticut 1 Food purchased. 108 132 429 3,435 Pennsylvania, Indiana, and f Food eaten .... 28 104 125 .423 3,325 Illinois 1 Average of 15 college clubs inl Food purch ased. Maine, Connecticut, Tennes- f FoO( j eaten 130 107 187 148 519 459 4,390 3 690 see, and Missouri } f Food purchased. Average of above 3 3 studies . . \ Food ten 113 103 156 138 463 436 3,810 3 500 Average of 12 labourers' fami- 1 Food purchased. 103 119 356 2,950 lies in New York city f Food eaten .... 19 101 116 344 2,905 Average of 1 1 poor families in \ Food purchased. 96 98 414 3,005 New York citv f Food eaten .... 15 93 95 407 2,915 DIET AND OCCUPATION 819 FAMILIES STUDIED. Cost. Pro- tein Fats. Carbo- hy- drates. Fuel Value. Cts. Cms. Cms. Cms. Cats. l ~ 1 Food purchased. 81 98 311 2,525 ie&, very ] >or, n g, rp OO( j ea te n .... ii 80 95 308 2,485 Average of 2 labourers' famiO Food purchased 121 148 534 4,055 cumstances, in Pittsburg, Pa. J 19 120 147 534 4,045 Average of 12 negro families in t ,,, , Alabama .... j Food Purchased. 9 67 134 453 3,375 ^CMcaeo 111 & f Food purchased. 16 103 111 391 3,060 Average of 5 French Canadian i ,_, , families in Chicago, 111 ) Food Purchased. 22 118 158 345 3,365 Average of 4 families of Rus- I , sian Jews in Chicago, 111. . . ) Food Purchased. 19 120 101 406 3,095 Average of 8 Bohemian fami- 1 lies in Chicago, 111 ) Food purchased. 12 115 101 360 2,885 Diet for Brain Workers Persons constantly employed in mental labor, and consequently leading sedentary lives, usually find from experience, sooner or later, that they must pay attention to their diet in order to maintain the best condition of health. Energy is diverted for mental work at the expense of digestive activity, consequently it is important that the meals should be of such a character as not to unduly tax the stomach and intestines. As a rule, meat should be eaten only once a day, and then only in moderation, and persons who are not of strong physique do well to replace meat for a time by other varieties of animal food which require less time and energy for their digestion. Milk, eggs, fresh fish and abundant fresh fruit, with light, porous and dry bread, should constitute their staple dietary. Brain workers may suffer from lithaBmia, which is undoubtedly often due to other causes than dietetic errors, such as anxiety, worry, and overwork. Patients of this class do better with a good, full, nourishing diet, largely vegetarian, provided their food is thoroughly well cooked and is light and digestible. They may follow the dietary for Lithaemia given on page 560. The brain contains nearly three times as much fat as the muscles, and in nerves a yet larger percentage is present. For this reason carbo- hydrates and fats are of value for brain workers, and the latter food may be supplied in the form of cream, butter, or fat well-cooked bacon. It is believed by some writers that the fact that fat is good food for brain workers depends upon the ease with which it develops energy with less complex metabolism than starches, and the nervous energy 820 DIETARIES, RATIONS of many Americans is sometimes attributed to the greater consump- tion of fat in this country as compared with Continental Europe and England. The popular idea that fish has some specific action as a brain food on account of the phosphorus which is present in some species in considerable amount, and which is also an ingredient of nerve tissue, is not founded upon fact. Fresh fish is very wholesome, and by replacing meat in the menu less labor is required of the digestive organs, and some forms of fish contain abundant fat or oil, but aside from this, fish cannot be said to be especially a brain food. It has been pointed out elsewhere (p. 358) that the tribes of man who live mainly upon fish are by no means noted for their intellectual develop- ment. For brain workers who desire to keep in health the alternative is either to take at least two hours of rest after a noon dinner or else to eat a light meal at noon and dine later in the day. This fact should be recognized in the arrangement of meals for college students. It is far better during the active hours of brain work to supply only such food as is necessary for prompt force production without calling upon the digestive organs for the expenditure of much energy in elaborat- ing food which is only needed for storage. Breakfast should consist of fresh fruit, a cereal with cream, a poached egg, a bit of broiled (not fried) fresh fish, or a rasher of bacon, with tea, coffee, or cocoa. Luncheon may comprise such articles as a roast potato with butter and cream, or beans and bacon, one or two light sandwiches made with a slice of game or a relish of some sort, cheese, lettuce or salad, and a baked apple and cream. Dinner should be a hearty meal with soup, a roast or joint, vege- tables, and a light farinaceous pudding. If evening work must be done, there should be an interval of at least an hour for rest and recreation. A Work Ration for a Professional or Literary Man (Mrs. E. H. Richards) Ounces. Pro- tein. Fats. Carbo- hydrates. Calories. Bread 16 Grains. 32.0 Grams. 3.0 Grams. 258 1216 6 Meat 16 50 30 481 Butter 1 25 230 ISuLiar 4 110 451 Milk 8 18 18 22 329 6 Oysters 4 7 1 37 8 DIET AND OCCUPATION 821 Ounces. Pro- tein- Fats. Carbo- hydrates. Calories. Soup 4 Gtams. 4.0 Grams. 3 Grams. 44.0 Potatoes 6 3.0 38 168 1 Eargs . 3 10.0 9 123 8 Oatmeal 2 1 5 4 25 1 1 1.5 6 5 1.0 70 1 Fruit 8 5 50 207 1 Additional liquid tea, coffee or water 30 Total 127 96 483 3,384.2 Overeating should studiously be avoided. Loading the system with incompletely assimilated food products impairs intellectual ac- tivity and exhausts the nervous system. If some special task requires long hours of work and absorbing concentration, it may be better to eat but little at a time, and take one or two extra lunches during the day. When such labor proves fatiguing, alcohol may be temporarily employed, but only with meals, and not as a stimulant between. The quantity may be regulated somewhat by the appetite, but it should never be large. If a glass or two of claret or Burgundy or of malt liquor with lunch or dinner improves the appetite for solid food and aids its digestion, it is beneficial, for, as Chambers wrote, " it stays the weariness of the system and allows the nerve force to be diverted to the digestion of the meal," but to labor on and " continue to take this anaesthetic between meals is inconsistent " ; and " when any extraordinary mental toil is temporarily imposed, extreme tem- perance or even total abstinence should be the rule, for mental activity makes the brain bear less alcohol than rest and relaxation." The varieties of beverages named are all better than port, sherry, or the stronger liquors. It is a mistake to suppose that violent muscular exercise is an offset to mental strain. Very moderate exercise combined with abundant fresh air and with mental diversion and relaxation are more benefi- cial, and do not add physical exhaustion to mental fatigue already present. Tobacco and coffee, like alcohol, are stimulants which are useful in such cases only in proportion to the moderation in which they are employed. Tea may be allowed in the earlier part of the day if it does not cause wakefulness. Following is the dietary at the Lake Erie College, at Painesville, Ohio, for ten days for women students: 822 DIETARIES, RATIONS DAILY MENU Wednesday Dinner. Corned beef, mashed potatoes, turnips, bread, butter, rice pudding. Thursday Breakfast. Baked apples, hominy grits, creamed dried beef, bread, butter, milk, coffee. Luncheon. Cheese, pudding, raspberry jam, bread, butter, milk, tea. Dinner. Roast beef, potatoes, parsnips, bread, butter, chocolate pudding. Friday Breakfast. Oranges, wheat breakfast food, corned-beef hash, corn rolls, butter, milk, coffee. Luncheon. Oyster stew, wafers, bananas, bread, butter, tea. Dinner. Pot roast, potatoes, beets, bread, butter, brown betty, lemon sauce. Saturday Breakfast. Wheat breakfast food, bacon, baked potatoes, bread, butter, milk, coffee. Luncheon. Beef in gravy, pickles, sauce, milk, bread, butter, tea. Dinner. Lamb chops, potatoes, canned peas, bread, butter, cherry tapioca, cream. Sunday Breakfast. Oranges, wheat breakfast food, fried mush, maple sirup, bread, butter, milk, coffee. Luncheon. At evening on Sunday. Stewed apricots, cake, milk, tea, bread, butter. Dinner. Stewed chicken, mashed potatoes, cranberries, bread, butter, cot- tage pudding, hard sauce. Monday Breakfast. Bananas, wheat breakfast food, rolls, codfish balls, bread, but- ter, milk, coffee. Luncheon. Beet salad, raspberry jam, milk, bread, butter, tea. Dinner. Hamburg steak, browned potatoes, squash, bread pudding. Tuesday Breakfast. Hominy grits, minced lamb, milk, bread, butter, coffee. Luncheon. Pea soup, crackers, bananas, tea, bread, butter. Dinner. Roast pork, baked sweet potatoes, cole-slaw, bread, butter, dates. "Wednesday Breakfast. Bananas, hominy grits, bacon, potato cakes, bread, butter, milk, coffee. Luncheon. Baked beans, brown bread, pickles, milk, bread, butter, tea. Dinner. Roast beef, boiled potatoes, spinach, bread, butter, boiled rice, maple sirup. Thursday Breakfast. Oranges, wheat breakfast food, meat hash, French toast, bread, butter, milk, coffee. Luncheon. Cheese, gingerbread, bread, butter, cocoa. Dinner. Beefsteak, mashed potatoes, Lima beans, bread, butter, baked po- tatoes. Friday Breakfast. Cream of wheat breakfast food, creamed beef, rolls, bread, butter, milk, coffee. Luncheon. Pea soup, croutons, apple butter, bread, butter, tea. Dinner. Baked ham, catsup, stewed tomatoes, potatoes, -bread, butter, fruit custard. DIET AND OCCUPATION" 823 Saturday Breakfast. Oranges, wheat breakfast food, beef in gravy, bread, butter, ttilk, coffee. Luncheon. Boiled rice, stewed prunes, milk, bread, butter, tea. Diet in Commercial Life The responsibilities and anxieties of active business life at times react unfavorably upon digestion, producing dyspepsia, headache, constipation, and biliousness. As a rule, there are few patients less willing to listen to advice in regard to diet and habits of life than the overworked business man engaged in the strife of active competition and with large financial interests at stake. He expects a dinner pill or laxative or the latest fashionable " tonic " to counteract the per- sistent violation of the simplest dietetic and hygienic laws, and, ob- taining temporary relief, goes on overtaxing his alimentary canal, liver, and nervous system, laying the foundation of more serious ills, such as lithaemia, arteriosclerosis, or possibly gout, gravel, or cirrhosis. The prevalence of chronic Bright's disease, arteriosclerosis, diabetes, and neurasthenia in this country is in part attributable to such fac- tors. Imperfectly oxidized waste materials in the circulation may irritate kidneys and vascular system alike, and long-continued over- stimulation eventually results in structural changes. While prescribing remedies for individual symptoms the physi- cian should not neglect to give wholesome counsel concerning diet, and such advice, however little heeded by itself, will sometimes be regarded as an essential part of other remedial measures, and ac- cepted accordingly. The too hasty consumption of food, the neglect of securing proper action of the bowels, and carrying the concerns and worries of the counting-house to the table, combined with loss of sleep and of outdoor exercise, are the principal difficulties which beset this class of patients. Three good meals a day should be eaten. The breakfast should be substantial, comprising meat or eggs or fish with some cereal and fresh fruit ; and dinner should be the last meal of the day, eaten preferably late seven o'clock allowing an interval before the meal for recreation or diversion. The luncheon should be the lightest meal of the day, for the reason that it is difficult for many to take it always at a fixed hour, and still more difficult to allow sufficient time for due mastication and diges- tion. Sydney Smith said, referring to the bad habit of hasty eating, that "many a man digs his grave with his teeth." It is neither necessary, nor advisable to eat meat three times a day, and many of these patients who are made dyspeptic by eating meat and vegetables together find that they have less flatulence and discomfort after meals 824 DIETARIES, RATIONS if they take these classes of foods independently, eating meat and no vegetables or sugars at one meal, and vegetables without meat at another. The reason for this should be explained to them namely, that carbohydrates, digested only by alkaline saliva and pancreatic fluid, may interfere with the acid digestion of animal food in the stomach. The luncheon should consist, therefore, of simple fari- naceous food with one or two plainly cooked vegetables, a poached egg, or a salad and a relish of some sort. Alcoholic stimulants of any kind are not required, except to coun- teract exceptional fatigue, and, as a rule, these patients are better without their habitual use. If allowed, they should be drunk at dinner only. Malt liquors taken at luncheon may cause drowsiness and dullness in the afternoon. As adjuncts to the dietetic treatment other measures should not be' neglected. Cold bathing with vigorous rubbing is desirable on rising, and an occasional Turkish or electric light bath may be service- able if there is a tendency to heavily loaded urine and biliousness. Exercise in the open air is very important. Golfing is of value, but too much walking is fatiguing. Bicycling furnishes more active ex- ercise and diverts the mind; but horseback riding is preferable, even if it can be indulged in only once a week. Boxing, fencing and the use of the punch bag and Indian clubs are good exercise for this type of patient. The bowels should be kept active, and fresh fruit and abundant draughts of pure water are the best means for this purpose. Diet and Travel In traveling one is often placed in circumstances in which it is difficult or impossible to obtain wholesome food, but must either be content with badly cooked or positively repugnant food, or go with- out. Under such conditions it is a decided advantage to have a varied taste, so that something may be found which will not disgust. It is difficult to give any but the most general directions, for circumstances which are so various. It is a common fault to eat too much when traveling, and the lack of exercise combined with an excess of food results in indigestion, constipation, and biliousness. Sea voyages sometimes benefit invalids and dyspeptics more than the healthy, for the latter, if not seasick at first, often overeat, and suffer in consequence. The " stand-up lunch counters " of American railway stations freighted with doughnuts, tough ham, and pie are a constant invi- tation to dyspepsia with the hurried eating of such indigestible arti- DIET IN PREGNANCY 825 cles as they afford, but which the more general introduction of dining cars is fortunately replacing, at least for those whose means allow them to consult the best interests of their digestive organs. In warm climates olive oil may be often obtained and made to replace rancid butter upon baked potatoes. Much garlic may cause diarrhoea and colic in those unaccustomed to its. use, but mustard will counteract its effect. Lemon juice also forms a wholesome relish and aids in checking diarrhoea. It is well to avoid raw or imperfectly cooked ham and sausage of every sort, for fear of para- sitic infection. If the food is greasy its digestion may be promoted by the use of condiments, such as vinegar, Cayenne, or lemon juice. All milk as well as water drunk should be previously boiled. Fresh fruits, crackers, bread, cold meats, soft-cooked eggs, and milk will be found to comprise digestible articles for a railway journey, and invalids or travelers who have wandered far from good food supplies do well to carry some of the concentrated preparations which with the aid of a little hot water may be made into a nutritious beverage, such, for example, as malted milk and cereals, beef meal or beef jelly, chocolate, condensed coffee, meat extracts, etc., besides which there is an almost inexhaustible variety of canned foods, meats, vegetables, and fruits from which the traveler or explorer may re- plenish his table. For infants sterilized milk may be carried which will keep fresh for a week, or canned milk may be provided for a longer period. Lime tablets are prepared which may be conveniently used in traveling when fresh lime water is likely to be required for dilution of milk or for use in seasickness. DIET IN PREGNANCY It is not customary to adopt any definite system of diet for preg- nancy unless complications arise. If serious vomiting occurs in the early months, this should be treated in the manner described on p. 603. If albuminuria is discovered, meat and other proteid food must be restricted, in accordance with the directions given under albuminuria (p. 555). If the patient becomes very anaemic, without albuminuria, meat, eggs, and milk should be eaten in abundance (p. 542). The " longings " of pregnant women for various indigestible ar- ticles, such as pickles, chalk, etc., are largely mythical, and occur, if at all, only as an accompaniment of a general hysterical con- dition, not as a peculiarity of the period of pregnancy. Pregnant 826 DIETARIES, RATIONS women, however, should live simply and avoid foods which are likely to produce dyspepsia, heartburn, and colic, such as sweets, pastry, fried food, rich sauces, salads, crustaceans, spiced dishes, and heating drinks. They often suffer from constipation, in which case fruits and coarse cereals, such as oatmeal or wheaten grits, may be of service (p. 636). The stomach, especially at night, should not be overloaded. The idea formerly prevalent that pregnant women need to eat food containing abundant phosphates and lime salts, to furnish the embryo with material for making bones, as a hen eats lime to make egg shells, is no longer accepted. The salts in question are suffi- ciently contained in an ordinary mixed diet, such as any pregnant woman may eat, if plainly cooked. Another theory, equally ingenious and directly opposed to the one above mentioned, is only interesting historically, for efforts to aid Nature in a process which she is abundantly competent to regu- late unaided are now regarded as futile. This theory was that the agonies of labor would be less severe if the pregnant woman lived upon a diet of fruits and meats, avoiding bread and fresh vegetables during gestation, on the ground that the lime salts which the latter contain would favor early ossification of the infant's bones, and thus make the labor proportionately difficult. It will be observed that the first theory favors the child, and the second the mother, but practically it has been found that diet has little or no influence either way, so long as it is digestible, nourishing, and sufficient to keep the mother in good general con- dition. DIET FOR PUERPERAL WOMEN Within the past generation a revolution has been experienced in the dietetic treatment of puerperal women, and they are no longer, as formerly, placed for ten days or a fortnight upon a diet of toast water, " slops," etc., with the idea that semistarvation would keep off puerperal fever and " milk fever." This change is largely due to methods of antiseptic midwifery, but the reaction started even earlier, and in 1876 the late Fordyce Barker of New York, who was one of the first to forsake the old routine, wrote of the puerperal state : " I have never seen the slightest evil result from good, ample, judicious alimentation," and " I have had patients eat a good piece of tenderloin steak the day after labor with a relish, and with happy results." A pregnant woman may eat her ordinary diet up to the com- mencement of labor. If the labor be greatly protracted, the first DIET FOR PUERPERAL WOMEN 827 stage lasting, as it exceptionally does, for more than a few hours, it will not do to let her strength become further exhausted from lack of food, and she should be urged to take stimulating hot broths, gruels, or similar easily digested food. Under the circumstances she is naturally nervous and may decline all food, so she should be given only that which is quickly swallowed without effort. In ordinary cases, however, no food is necessary or desirable during labor. Immediately after delivery the woman, exhausted by muscular effort and agonizing pain, and possibly also under the influence still of an anaesthetic, needs rest rather than food, and as she is more thirsty than hungry, she may drink freely of water or Vichy. On the other hand, many puerperal complications, including mania, are favored by exhaustion and inanition, and good feeding should not be delayed too long. The nursing woman, moreover, needs a more liberal diet than do other patients. Her milk contains a large percentage of proteid and fat, and she also loses proteid sub- stance to a greater or less extent through the lochia. A low diet means poor breast milk, for it diminishes both the milk fats and proteids. Spiegelberg says : " It is a bad practice to allow healthy lying-in women to fast long; they need to be well fed, and if the appetite is good they may be encouraged to eat." If they are well nourished they both sleep and feel better. "Four or five hours after con- finement the patient may be given a cup of hot bouillon or chicken or mutton broth. She usually does not care for meat before the second or third day, but she may have it then. Meanwhile she is allowed broths of any kind, thickened with egg or rice, milk, tea, light farinaceous gruels or puddings, soft-cooked eggs, toast, milk toast, custards." Schroder gives meat and vegetables within a day or two after the conclusion of labor. Lusk recommended a light fluid or semisolid diet for the first three days. Then, after the bowels have moved once or twice and the appetite returns, steak, chops, a piece of fowl or a bird, eggs, and cooked fruits are given. Playfair adopted the following system: If the woman is confined in the early morning hours, at 9 A. M. she is given a cup of tea and a piece of toast; at 1 P. M. a light lunch of some form of predi- gested meat preparation; at 5 p. M. tea or beef tea, and at 7 P. M. a small bit of chicken with bread and butter or milk toast. Tea again at 9 P. M. He discountenanced a continued use of gruels, "slops," and stimulants. During the next day or two if the patient is hungry, she is allowed sweetbread, chicken, fish, eggs, and milk. On the whole, the patient's appetite is a better guide for feeding 828 DIETARIES, RATIONS than are any rules as to the exact time which has elapsed since parturition. She should not be urged to take food, unless greatly exhausted, and the stomach must not be overloaded; but if hungry after the establishment of the milk secretion and after free action of the bowels, she may take a reasonable quantity and variety, though while still in bed she needs less than if up and about. The occur- rence of fever is a contraindication for giving much proteid food ex- cept milk, but extreme exhaustion without febrile reaction demands it. SELECTION OF A WET NURSE The selection of a wet nurse should be based upon the following data: Her own general health and digestion should be good, and her bowels not habitually constipated. All evidence of syphilis, tubercu- losis, or other disease should be excluded strictly. A primipara is to be preferred to a multipara as having milk somewhat richer in fat. Her best age is between twenty-two and thirty years, and she should be of good temper and have cleanly habits. Her period of lactation should not be too widely different from the age of the infant to be nursed. The breasts should be firm, and the nipples fairly prominent and free from fissures. Breasts which are always oozing spontane- ously are by no means always the best, for their milk is soon ex- hausted. The nurse's own child, if living, should be examined, for if it has been nursing at the breast its condition is a better index of suitable- ness of the mother's milk than her own appearance. The child should be in good flesh and firm, without evidence of gastric catarrh, fever, eruptions, or indigestion, and of good development for its age. The question whether it is possible for a wet nurse to transmit her own mental and physical characteristics to the child at her breast has given rise to much discussion, but there is no more reason why she should transmit an evil temper through the food she gives than that a cow should transmit a bland one. An ill-tempered, iras- cible wet nurse may sometimes give milk which disagrees with the child's stomach, but beyond that there is nothing in the belief that she can affect it mentally or morally by this agency. The milk which can be expressed from the breast should have the following properties: Reaction amphoteric or faintly alkaline to litmus, but acid to phenophthalin, color an opaque blue-white, specific gravity 1.031, taste sweetish. Examined microscopically, the fat corpuscles should abundantly fill the field and be of nearly equal size. DIET OF A NURSING MOTHER OR WET NURSE 829 Human breast milk on an average has a specific gravity of 1.031 at 70 F., but it varies between 1.017 and 1.036 (Holt). The fat varies less than the sugar and proteids. If the specific gravity of the milk is high, and at the same time the percentage of fat is considerable, the gravity must be due to a larger quantity of proteids than usual, because fat tends to lower it. If the fat percentage is small and the specific gravity of the milk is low, the proteids must also be reduced. Holt furnishes the following convenient table for determining the richness of human milk in fats and proteids, which gives results that are sufficient for practical pur- poses in examining the milk of a wet nurse: Specific gravity 70 F. Cream 24 hours. Proteids (calculated). Normal average . . 1.031 7% 1.5% Healthy variations 1.028 1.029 8% 12% Normal ( rich milk ) . <( ' 1.032 1.033 5% 6% " (fair milk). Unhealthy " Below 1.028 High (above 10%). " or slightly below. <( " << Normal (5% 10%). Low. << tt n n Low (below 5%). Very low (very poor milk). H (( Above 1.033 High. Very high (very rich milk). ft ft (C Normal. High. (1 ft (t 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 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 If half the care bestowed upon cows in a model dairy were given to the period of lactation in women, there would be far less need of artificial feeding of infants. The diet of the nursing mother or wet nurse should 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 consti- pation, indigestion, or anaemia. Her weight should not alter, and 830 DIETARIES, RATIONS if she has menstruated once or twice her milk changes and may dis- agree. The nipples should be kept in good condition. If cow's milk does not make the mother constipated or bilious she may drink it abundantly. She may take gruels and meat broths, and should eat simple nourishing food, meat, eggs, vegetables, and fruits. The latter, even if sour, do not react unfavorably upon the child, provided the mother's digestion is good, and they serve to keep the child's bowels active. Thomas S. Southworth especially recom- mends the taking of cocoa and thin corn meal gruel in addition to a quart of milk daily. 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 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 liquid is drunk, but the milk is no better for it. A reasonable quantity of liquids should be drunk, however, or the secretion of milk will suffer. The liquid 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 nursing mother or wet nurse is the study of the condition of the child's digestion, bowels, and nutrition. A too meager diet for the nurse is soon evident in lack of nutrition and development of the infant. Drugs in Human Milk. Xot 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. When, for any reason, it becomes necessary to discontinue the nursing and stop further secretion of milk, the diet at once should be made as dry as possible, and a minimum quantity only of fluid is allowed. THE FEEDING OF INFANTS Size of the Infant's 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 preparation, and order both the quantity to be given and the intervals at which it THE FEEDING OF INFANTS 831 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 re- quired, and also to give them some idea of the size of the infant stomach, for many have a vague idea that the word " stomach " in- cludes the entire abdominal cavity. Rotch gives the following table of capacities of infant stomachs : 1. Premature 8 months' infant 8 c. c. 2. Infant 5 days old 25-30 ' about 1 oz. 3. Infant 4 weeks old 75 ' 4. Infant 8 " " 96 ' 5. 'Infant 16 " " 107 ' " 3 ozs. 6. Infant 20 " " 108 ' 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 overfeeding 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 f retf ulness merely, and " un- methodical and improper feeding is quite as bad as feeding with improper aliments" (Adams). The new-born infant secretes ptyalin only from the parotid glands. After the second month the amylolytic ferments are secreted from other glands, namely, the submaxillary and the pancreas. Not until the sixth month, however, or the period of teething, are these fer- ments strong enough to enable the infant to digest large quantities of starch, although very young infants may digest moderate quantities of dextrinized cereals, used as diluents of milk to prevent formation of large curds. Rennet is secreted by the infant stomach, and is the first secretion to act upon milk. When 10 per cent of lime water or two grains of sodium bicarbonate to the ounce of milk is added to the feeding mixture, rennet fails to act in this medium, and the milk remaining uncoagulated, passes more promptly into the in- testine. 832 DIETARIES, RATIONS Methods of Feeding Infants may be given their food in one of five ways: I. As mother's milk. II. As 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. V. By gavage. There is no room for doubt that infants brought up on breast milk are stronger and better able to remain in good health and resist disease than those who are hand fed, for no artificially prepared infant food has ever been devised which is as accurately balanced in its various ingredients as good mother's milk. This method is unquestionably better for the infant in all cases where it is feasible than any method of artificial feeding. In lands without cow's milk, such as Japan or the arctic regions, infants are singularly free from digestive disorders. Artificial feeding, if care- lessly performed, is full of dangers to the infant. Statistics might be cited indefinitely, showing the relative high mortality rate among artificially fed infants. For example: in Germany, which has the second highest infant mortality of Continental Europe (ranking next to Russia), in Berlin during the quinquennium from 1900 to 1904 inclusive, among the deaths of infants under one year of age, 90 per cent were artificially fed and only 10 per cent exclusively breast fed. In Paris the same ratio, 1 : 10, obtains. I AND II. FEEDING BY THE MOTHER OE WET NURSE Louis Starr advises putting the infant to the breast as early as six or eight hours after labor 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 mammary secretion of the first three days. This secretion is mildly laxative, and 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 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 THE FEEDING OF INFANTS 833 no bottle food, which merely disorders 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 fed with 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 oftener than 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 may be trained to suckle in the manner which experience has proved will be best for both itself and its mother. From fifteen to twenty minutes is sufficient time to keep the child at the breast, and often it will doze off to sleep after nursing. As the child grows older the intervals between the hours of day nursing are to be prolonged, in accordance with the tables given on pages 839-841, 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 hour or four hours' interval. Infants born with a cleft lip or palate cannot be nursed properly 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, the prin- ciple involved is to obtain a food by modifying cow's milk, which food shall correspond as nearly as possible to the composition of aver- age human milk, but be adapted also to the needs of the par- ticular infant, as suggested by the state of its digestive organs and existing nutrition and development. 55 834 DIETARIES, RATIONS Due regard should be had, of course, for the financial condition of those for whom an especially modified milk 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. Moreover, in hot weather it keeps without ice, but for reasons given elsewhere (p. 108) it is never to be preferred when good fresh cow's milk is obtainable. It is deficient in protein, and this may be cor- rected by adding meat broth, beef juice, or egg albumen. It is also deficient in fat, and cod-liver oil may be added, if cheaper than cream. 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 differences in regard to the quantity of casein pre- cipitable by acid, as compared with the non-coagulable ingredients of both forms of milk. (See comparative analyses of human and cow's milk, p. 60.) For this reason cow's milk should be diluted for very young infants, in order to bring the casein nearer to the human standard ; but the addition of water reduces the percentage of fat and of sugar, which therefore must be provided separately. Escherich 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 teaspoon- ful to four ounces of the diluted top milk. If cane sugar is used, which is less desirable, as it is more apt to ferment, only one tea- spoonful 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 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 proportion as a diluent. 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 proportion usually employed is two tablespoonfuls of barley to the THE FEEDING OF INFANTS 835 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 half 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 16 " 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 mixture should be changed gradually to Top milk 19 ounces. Barley water 19 " Milk sugar 9 teaspoonfuls, or Cane sugar 5 In answer to the question, " Should 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 sterilized, or pasteurized. But in cities always, and everywhere in summer, it is difficult or impossible to obtain such milk, and one or other of these means of disinfection may become imperative. The heat required for sterilization in some manner destroys the vital properties of nuclein of the milk (Starr). (See page 96.) Pancreatinized milk is used much less for infants than for- merly, for it has been found that they do not thrive if continuously fed upon it. The preparation of scientifically " modified milk " in milk labora- tories is fully described on page 103. Care of the Milk. In order to keep milk fresh and pure for in- fant use in hot weather it should be cooled at once artificially, and if intended for city consumption, during transportation both car and 836 DIETARIES, RATIONS delivery wagon should be supplied with ice, so that the milk tem- perature never rises above 50 F. The milk when received at the dealer's should also be kept in refrigerators, for it is exceedingly important that it should not become lukewarm even temporarily. It is 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 proc- ess 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. (See Milk Contamination, p. 72.) 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 in any form temporarily disagrees it becomes neces- sary to substitute for it some other form of food. Useful formula? for this purpose are given by Starr as follows : Substitutes for Milk in Infant Feeding (Starr) Barley-water ^ ""*. * *** .^1 .' j each > one and a half ounce ' Mix. Whey ? Barley water \ ...................... each > one and a half ounce - 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 sometimes are added when temporary looseness of the bowels occurs. In using lime water (carbonate of lime) as a diluent of cow's milk it should be remembered that in the latter 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 require- ments of temporary indigestion. 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 from many cows, and the infant is not so apt to become dys- peptic while taking it. THE FEEDING OF INFANTS 837 The milk of fancy breeds of cows, such as that of thoroughbred Alderneys or Durhams, is often too rich both for infants and in- valids. IV. MIXED FEEDING There is no harm in partly feeding infants with the bottle who are at the same time being nursed. If the mother is suffering from want of sleep she will be of more value to her infant if allowed to sleep at night while her child is bottle-fed once or twice. When the breast milk is insufficient or poor in quality the child should be fed by hand several times a day in addition to nursing. A hungry, ill-nourished child cries continually 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 ab- solute 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 en- tire hand-feeding arrives. When a mother who has abundant milk supply is obliged to be temporarily absent from her infant beyond the period when a feeding is due, she may express beforehand into a clean glass a little milk which may be kept and fed to the child with a teaspoon while the mother is away. V. GAVAGE When infants have irritable stomachs, gastric catarrh, or when they persistently refuse food or are too feeble and marasmic to take sufficient food, they are fed by the method of "gavage," which con- sists in pouring liquid nourishment into the stomach through a glass funnel attached to a catheter. A soft-rubber catheter (No. 7) may be used. The child is wrapped in a sheet to restrain the arms, and then laid on its back upon a table. The catheter is passed through the mouth for a distance of about 8 inches, and warm milk or broth and, if necessary, medicines may be poured in. Weaning The period for weaning varies considerably, according to the health and vigor of both mother and infant. Usually it should be 838 DIETARIES, RATIONS 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, how- ever, 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 foreign emigrants to 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 stomach 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 alone should be given; otherwise 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 the change 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 modi- fications necessitated by the ill health of mother or child, or by hot weather, etc. The circumstances which necessitate earlier weaning than 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 suck, or rendered so by some disease, such as rickets or hereditary syphilis, or the condition of the mother may be at fault, either from constitu- tional disease, such as tuberculosis or syphilis, from local disease, ab- cess, or malformation of the nipples, from insufficient or poor milk, or from the recurrence of menstruation 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 L. Em- THE FEEDING OF INFANTS 839 met Holt in his admirable brochure on The Care and Feeding of Infants. They summarize 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 egg. If the bottle is given, arrowroot or farina may be added to one feeding each day. . . . " 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. . . . " If five meals are given, the best hours are 7 A. M., 10 A. M., 1 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." Louis Starr gives the following mixture in commencing weaning at the tenth month: Weaning Mixture at Ten Months (Starr) Cream f 3 ss. Milk f I iv. Sugar of milk 5 j. Water 3 jss.' If disorder of digestion occurs, return the infant temporarily to the breast. 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 feed- ings. Total daily amount. 2 weeks 2 8 16 1 month 3 8 24 2 months 4 7 28 4 months 5 6 30 6 months 5J-6 6 33-36 9 months 7-7 i 5 35-38 12 months 8-9 5 40-45 After the twelfth month three pints is the limit of digestive ca- pacity 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, mav be increased. 840 DIETARIES, RATIONS Quantity of Food required in the First Year of Infancy ( Rotch At each feeding. Number of daily feedings. Total daily amount. During the 1st week in At the 3d week 11 in 1C < At the 6th week 2 1 1; At the 3d month 3 9J. ' At the 4th month 4 7 00 ( At the 6th month 6 g Qfl ( At the 10th or 12th month 8 5 40 * Holt's " Schedule for Feeding an Average Child in Health " for the First Tear AGE. Number of meals. Interval by day between meals. Night feed ings, 10 P.M. to 6 A.M. Quantity for each meal. Quantityfor 24 hours. 1 week 10 10 9 8 7 6 6 5 5 2 hoi 2 2 2i 3 3 3 3 3 irs. 2 2 1 1 1 1 11 21 3 4 5J 6 7J 8 z. 10 15 20 24 28 33 36 37J 40 z. 2 to 3 weeks .... 4 weeks 6 " 3 months 5 " 6 " 9 " 12 " " NOTE. A large child may be given a few ounces more in the 24 hours than the quantity above specified, a small child a little less. A large child may pass from one formula to the next a little more rapidly than at the time specified, but a small child, or one with feeble digestion, will have to proceed more slowly. The hours for feeding should in all cases be observed with regularity." The preceding 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 (see p. 173), to the greater or less exclusion of mother's or good cow's milk, soon become rhachitic or scorbutic. 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 ex- ample: 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 average human milk has 3.90 per cent and cow's has 3.66 per cent. THE FEEDING OF INFANTS 841 ri S ~j o j: cs r= o^ co 73 s ^'l^^-ioS OJ ^ ^ ^ S ^ . Js v 3^3 "3 >, J= >^ S ^J *" * *S B ** "eo .53 ^^TS 2 wo a B i Water mus L^ "^ "^ S r2 ^ 1 I 1^1* 1" eg |_^ r^lil is" 1 ^!!! O ^ (^ D 4J ^2 j<^ 5^ >, "^ M ^ 'P 'S B X wo A. ^ X X Iwo * IM ^_ ^' wo wo QQ <-. 03 ti 03 B g ,313 g ; |1 O 11* 1 Il HC OQ Jo ^ '-' o lJ-*J^ -*J' . "o si .5 3 < * 'i H ^^^i l^lifi 1 us" 4 ^ iO i5 IO 2 *^ *""* F-H ^ ^ H S i-T O ^_^_ ^^s c^i^i, 1^ en o s rt* f * **"* 2 ""* "*"* ~ ~ *tn *^" *'~>i ( 73 * ji* O ^ ^ g"c 4 2 3 o o ' '. .S .3 .5 " ' _u l - re <> S J5 X X li O X aJ-P a. S .- X 03 . c.tJ.>>- lo K? ' ^ ^ S fe *C 5 * 02 *t- rt 2 * 1 u sj .^, X "-> "- * "~> "- o W<* O WO WO WO *" WO HO p *( O3 ..O3 O3O3.,;O3 (B jj tn X 03 '-^ s f*- WO lO WO^Q WO k.^. **<*-! 4H ,^ 1 to >H : : : : : : i B A it T. r f. T. !f. ~ T- 00 -^ on QD BD n s CD MO u T3 ^ . -S^^'cc'^cg ^ HS 4* ^j * " -^ C K ** ^3 C , ""5 C3 j^ CO GJ ^ S *^ ^ 5 *O ~ tf OS u u * -c S ^ 'I t-C'^ 5 ^ -g 'O+jCM'^C OO Q C S SE^S-^3 C:=O5 b 22soJ52 S O 56 842 .DIETARIES, RATIONS Two extreme types 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 muscles flabby," whereas " children fed upon foods containing too much sugar are frequently very fat, but their flesh is very soft, they walk late, and they perspire readily about the head and neck." They present a variety of rhachitic deformities, and are subject to catarrhal and other diseases. Such foods should never be fed to young in- fants unless under a physician's direction. Another objection to feeding infants with farinaceous 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 various forms of meat extracts, albumoses, etc., are sometimes used to re-enforce the milk of very young infants. This is a mistake, for the cow's milk is already too rich in proteids. If temporary indigestion requires their use, they should be substituted for milk, 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 prop- erly 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 odor, and of a gamboge-yellow color. If meat juice or meat broth of any kind is given, the stools become darker. If too much is given they become acid, malodorous, very dark brown, and diarrhceal. \Yhen firm, tough curds of paracasein are voided, the milk has been exposed to too great acidity, either of hydrochloric acid in the stom- ach, or of lactic acid in gastric juice, or else the milk has soured before feeding. To correct this error the milk should (1) be fresh and kept cool after pasteurization; (2) lime water or sodium bicar- bonate may be added to the milk; (3) gruels may be added to mechanically prevent the formation of large curds; (4) the milk may be peptonized; (5) the quantity of milk may be reduced by dilution, or ((5) the proportion of its components may be altered. When farinaceous or any amylaceous food is being given, it is well to tost the stools with a few drops of tincture of iodine which ini- THE FEEDING OF INFANTS 843 parts a purple color 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 need for observing carefully the most minute details for cleansing all the infant's feeding utensils has been apparent. The necessity for use of the bottle for feeding is always to be re- gretted on account of the difficulty of keeping the milk from bacterial infection. Adams says : " One of the greatest nuisances in in- fantile 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 unhesitatingly condemned, although it saves trouble in holding the 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 prevents clean- ing every part of the interior with a sterilized cotton swab. A measure of ounces should be blown in the side, and it should be fitted with a short black rubber nipple, which may be removed and turned inside out for thorough cleansing. This short nipple has the further advantage that the child is less likely 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 too great an extent it has a tendency to contract the width of the mouth and cause protrusion of the teeth " (Cryer). For these reasons the nurse should always continue 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 at once be thrown away, and not warmed over for a second feeding, for it is liable to germ contamination. For washing the milk bottles a solution of sodium bicarbonate or salicylate, a teaspoonful to the pint, should be used first, after which they are thoroughly scalded in boiling water. If fitted with a plug of 844 DIETARIES, RATIONS sterilized baked absorbent cotton they will remain sterile until ready for use. When from six to eight teeth have appeared the bottle usually may 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 brushed gently and thoroughly 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 nutrition and growth which they are making, and it should not be neglected. Budin reported some interesting experiments with three classes of infants namely, (1) suckled, (2) partly suckled, partly artifi- cially 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. Upon the average the infant's weight should be doubled in the first five months of life and trebled in the first year. The nursing infant during the first three weeks of life consumes daily one-fifth of its own body weight of milk. Premature Infants. The feeding of premature infants demands 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 very 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 should be fed at shorter intervals than the rule allows for well-developed infants at the same age, and a two-hour interval will often be best. Newborn premature infants at first may require feed- FOOD FOR YOUNG CHILDREN 845 ing every hour, not above a drachm or two of milk being given at a time. FOOD FOR YOUNG CHILDREN The infant, although weaned, should receive all its food from the milk bottle until at least the twelfth month, and then very gradu- ally a few other articles than milk or beef juice may be added. Children often do well, 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 masti- cation more powerful, the cavity of the mouth larger, the lips more fleshy, the oesophagus wider; the salivary glands are better devel- oped, and secrete a larger quantity of saliva; the shape of the stom- ach 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 develop after a child has been put upon solid diet, it should at once be given only liquid food again, such as milk or meat broths. It sometimes happens that a growing child acquires a distaste for plain water and plain milk, and needs encouragement to take fluid enough for physiological requirements or the elimination of waste. In such cases the following named articles afford consider- able variety for selection, and not only supply necessary fluid, but small quantities of nutriment as well: toast water, thin farinaceous gruels, such as arrowroot gruel, etc.; egg albumen water flavored with cinnamon or vanilla ; " cambric tea " (i. e., a cup of hot water with sugar, a little milk, and a mere trace of tea to impart flavor) ; whey, buttermilk, koumiss, and matzol; malted milk; broths of beef, mutton, or chicken ; various meat extracts in hot water ; orangeade or pineapple or unf ermented grape juice ; somatose in peppermint tea. Young children of four or five years of age or more, commonly crave sugar, but do not care for fatty foods. They also like vegetable acids, and are therefore fond of fruits. These acids are wholesome, and the fruit is laxative and healthful when ripe. It may seem superfluous to separately name the chief prohibited substances which must be kept from young children, but experience 846 DIETARIES, RATIONS 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 ought not to have and with which they are liable to gorge themselves. Foods Forbidden to all Very Young Children The following named substances are particularly indigestible for children, and should not be allowed them under four years of age, and some of them should not be given at any period of childhood: Fried food of all kinds, game, salt food, the flesh of swine in all forms, pickles, salads, condiments, except salt, " stews," the " dress- ing" 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 confectionery, sweets, and preserves; cheese, rich soups, jellies, dried or unripe and overripe fruits (bananas, so often given to young children, are not good for them), nuts, fruits with large seeds, such as grapes, the skin of all poultry, fruits, and vegetables, such as that of potatoes. 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. 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 tolerated. It is best for young children not to be put to sleep im- mediately after their most substantial meal of the day. As they re- quire 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 L. Emmet Holt) of FOOD FOR YOUNG CHILDREN 847 General Rules for Feeding Young Children 1. Allow ample 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 or stomatitis; and ex- amine the food, which may not be properly cooked or flavored. 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. 8. Children who persist in eating too rapidly should have small quantities of food put on their plates at a time, and should be given small-sized forks and spoons (coffee spoons) instead of the larger adults' size. The young infant depends exclusively upon animal food, and de- rives the necessary carbon largely from the sugar of milk. The older child lives in part only upon animal food, and begins to derive additional carbon from bread and other cereal foods. Quantity of Food Required. Experiments have been made by Ueffelmann, Hasse, and others, to determine the necessary percent- age of albuminoid food required per diem per kilogram of body weight, by growing children, with the following result : Albumin. Average weight of child. At ' 4 grams. 12.5 kilograms. At 3 3.5 15 " At 8 2.5 " 24 Thus it is seen the percentage of albuminoid food required di- minishes as the child gains in weight, and more carbohydrate food is used to replace it. 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 Louis Starr as follows: Bread, 7.5 ounces; butter, 0.98 ounce; meat (beef), 4.6 ounces; potatoes, 3.9 ounces; milk, 32.6 fluid ounces. The daily average for each child 848 DIETARIES, RATIONS 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 ounces; bread, 10.3 ounces; butter, 1.08 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, 0.99 ounce; milk, 38.5 fluid ounces. Dietaries for Young Children The following diets are recommended by Louis 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 buttered 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 egg 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. Following is the sample diet given by L. Emmet Holt for a child eighteen months old: First Meal. A tablespoonful of some cereal with salt and one tablespoonful of cream, one-half pint of milk. Second Meal. One-half pint of milk. Third Meal. One tablespoonful of scraped meat, two small pieces of dried bread, half a pint of milk. Fourth Meal. Milk. Fifth Meal. Milk with farina or arrowroot. Instead of a portion of milk scraped meat (p. 132), beef juice (p. 135) or a soft cooked egg may be substituted occasionally. Of the beef juice from one to three tablespoonfuls may be given at a time. " The quantity of milk allowed at a single feeding for a child during the second year should be from eight to ten ounces during the first half and from ten to twelve ounces during the latter half of the vear." FOOD FOR YOUXG CHILDREN 849 Diet from the Eighteenth to the Thirtieth Month (Starr) 7 A. M., new inilk, eight ounces; the yolk of an egg lightly boiled; two thin slices of bread and butter, or else milk, and two tablespoonfuls 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. Diet from Two and a Half to Three and a Half Years of Age (i. e., for Children who have cut their Milk Teeth) (Starr) 7 A. M., one or two tumblers of milk, a saucer of thoroughly cooked oatmeal or wheaten grits, a slice of bread and butter. 11 A. H. (if hungry), a tumbler of milk or a teacupful of beef tea with a biscuit. 2 p. M., a slice of underdone roast beef or mutton, or a bit of roast chicken or turkey, minced as fine as possible, a mashed baked potato moistened with dish gravy, a slice of bread and butter, a saucer of junket or rice and milk pudding. 7 P. M., a tumblerful of milk and a slice or two of soft milk toast* Diet from Three and a Half Years up (Starr) Breakfast, Every day: Milk, porridge and cream, bread and butter. One dish only each day: Fresh fish, eggs lightly boiled, eggs poached, eggs scrambled, or as a plain omelet, chicken hash, stewed kidney, stewed liver. Sound fruits may be allowed before and after the meal, according to taste, as oranges without pulp, grapes (seeds not to be swal- lowed), peaches, thoroughly ripe pears, and cantaloupes. Dinner. Every day: Clear soup, meat roasted or broiled and cut into small pieces, bread and butter. TVo dishes each day: Potatoes baked, potatoes mashed, spinach, stewed celery, cauliflower, hominy, macaroni (plain), peas, string beans (young), green corn (grated). Junket, rice-and-milk or other light pudding, and occasionally ice cream, may be allowed for dessert. 850 DIETARIES, RATIONS Supper, Every day: Milk, milk toast or bread and butter, stewed fruit. From the third to the fifth year the child has twenty teeth, and often three meals a day suffice, although from the third to the fourth year four may be given. After three years of age it is not possible to lay down definite rules for the exact quantity of food allowed, for much depends upon the child's size, rate of growth and other con- ditions. In health, the appetite may be taken as a fair guide, and the child will not eat too much if taught to eat very slowly and thor- oughly chew each mouthful. When the second set of teeth begin to replace the deciduous or milk teeth, which gradually decay, digestion is sometimes interfered with temporarily from lack of ability to masticate thoroughly, and food should be subdivided before it is offered to the child. The following rules for meats and vegetables for young children are given by L. Emmet Holt : " Meats. After eighteen months, if most of the teeth are present, once daily, finely bruised or scraped rare roast beef, roast lamb, broiled mutton chop or beefsteak, white meat of chicken or turkey, fresh fish boiled or broiled bones the only objection. " Vegetables.- Potatoes (not till after second year) roasted, peas, asparagus tops, spinach, string beans, boiled onions, stewed celery; all should be very well cooked, in season, and fresh." Fruits are very wholesome food for young children from three or four years onward, provided they are properly selected and not allowed in excess, which is almost the only source of trouble from them. They serve to maintain the blood in good condition, favor di- gestion, and prevent constipation. After the fifteenth month two to six teaspoonfuls of orange juice may be given, and a little later the soft pulp of two or three stewed prunes, or a half-baked or stewed apple. A child three or four years of age may have a piece of ripe pear, peach, or plum, or strawberries in season. Cherries and bananas should be forbidden. Grape juice is allowed without the skin or seeds. During very hot weather great caution should be observed in giving fruit of any kind to infants. Bread, rice, oatmeal, and other cereal foods should always enter largely into the dietary of healthy children after they are able to digest them. Their fats should be derived chiefly from butter and cream. Thomas S. Southworth gives the following table of hours for feeding during the second year: FOOD FOR YOUNG CHILDREN 851 7.30 A. M., Breakfast, including bottle of milk (diluted if necessary). 11 A. M., Bottle of milk, with crust of zwiebach. 2 P. M., Dinner, with rather less milk as the other food is increased. U P. M., Supper, including bottle of milk. 10 P. M., Bottle of milk. During the second half of the year milk may be taken from a cup instead of the bottle. Children between three and four years of age should be fed when in health four times a day at 7 A. M., 10.30 A. M., 1.30 p. M., and 6 p. M. The following is Holt's " Sample Diet for a Child Four Years Old" First Meal. Half an orange, one and a half tablespoonfuls of oatmeal or hominy, well salted, with two tablespoonfuls of cream, but no sugar, and one glass of milk. Second Meal. A glass of milk or cup of broth and one slice of stale bread. Third Meal. Meat either steak, chop, or chicken one green vegetable (e. g., spinach), one starchy vegetable (e. g., potato), water to drink, stewed prunes for dessert. Fourth Meal. Bread and milk or milk and toast. Desserts for Children " After two and a half years plain custard, ice cream (not oftener than once a week), rice pudding (no raisins), baked apple, stewed prunes" (Holt). The following rules for feeding young children are given by Adams: When the child has its first sixteen teeth it is to be given more varied food than before, such as stale bread and butter, crackers, mashed potato and gravy, scraped beef sandwiches with salt or sugar, a piece of rare beef, or a chicken bone to suck. He gives during the period of sixteen teeth: 6 A. M., a cup of milk, cream biscuit, or slice of buttered bread; 8 A. M., stale bread broken and soaked in a tumblerful of rich milk; 12 M., slice of buttered bread, half a pint of weak beef tea, or mutton or chicken broth; 4 p. M., tumblerful of milk with cracker or a slice of buttered bread; 8 P. M., a tumberful of milk with bread or crackers. At the end of the period of sixteen teeth: 6 A. M., bread or crackers with half a pint of milk; 8 A. M., a tablespoonful of oatmeal, cracked wheat, or cornmeal mush with milk and a couple of slices of buttered bread; 12 M., bread and 852 DIETARIES, RATIONS butter, milk, and a soft-boiled egg; 4 p. M., a piece of rare roast beef to suck, mashed boiled potatoes, moistened with dish gravy, bread and milk, and a small portion of rice, jelly, or farina ; 8 p. M., milk and bread or crackers. Adams usually prefers, however, to give milk and oatmeal water or barley water through the second. summer. If the child vomits sour food, a little alkali should be added to the food (sodium bicarbonate, etc.). Diarrhoea may be excited by a too solid diet. He prescribes for a child with all the milk teeth, and able to walk, up to the third year : 8 A. M., well-cooked oatmeal, wheaten grits, or cornmeal mush, with a liberal supply of milk, cold bread and butter, a piece of finely cut, tender beefsteak or a soft-boiled egg; 12 M., bowl of chicken or oyster soup, or weak beef tea, milk with bread or crackers, and butter; 4 p. M., roast beef, mutton, chicken, or turkey, fresh white fish, mashed white potato moistened with gravy, bread and butter, and rice and milk ; 8 P. M., milk with bread or crackers. Bread and milk or butter may be given between the first and sec- ond meal or before the first, also ripe fruit later. For a child from the third to the fifth year Adams allows : Breakfast. Cornmeal mush, oatmeal, wheaten grits, hominy, plenty of cream; potatoes, baked or stewed; eggs, poached, soft- boiled, omelet; fish, fresh broiled; meats: beef hash, broiled steak, lamb chops, chicken fricassee; tomatoes, sliced; bread (cold); light Graham, entire wheat, corn muffins (plain), and occasionally Gra- ham, corn, and rice cakes ; fresh, ripe fruit. Luncheon. Soups : oyster, clam, bean, chicken, consomme; vege- tables: potatoes, baked or stewed, sliced tomatoes; beefsteak, lamb chop, cold roast lamb; cold rolls, soda crackers; fruits in season; rice and milk. Dinner. Soups: consomme, oyster, cream of barley, potato; fish: baked, broiled, or boiled; roast beef, chicken, lamb; stewed potatoes, rice, cauliflower, macaroni, peas, tomatoes, beans; bread, well-cooked wheat. Desert: rice and milk, light pudding, ice cream, fruits, and berries. According to Minck and Ewald, children from two to six years of age should be given per kilogram of body weight per diem, proteid 3.7 grams, fat 3 grams, hydrocarbons 10 grams, which furnish col- lectively To calories. E. Mam-el ( Trait e d' Alimentation et de la Nutrition) declares that up to the end of the fifth year children should have no butcher's FOOD FOR YOUNG CHILDREN 853 meat, but they may have chicken and fish not rich in fat (p. 148). They should be given only well-cooked foods, and should subsist for the greater part upon milk, bread, butter, sugar, soups, and eggs. During the sixth and seventh years he allows fresh vegetables, well cooked, and fruits in the form of marmalade (jam) or compote. His diet limitations are as follows per diem: Proteid. Fat Carbohy- drates. Calories. 3d year 20.5 33 66. 663.5 4th " 25. 40 71 715 5th 7th year 32 40 94 5 870 10th year 49 49 145 1,330 14th " 70 5 61 269 1 998 5 18th " 93 82 293 2 415 Maurel states that in early childhood the food should be in fluid and semisolid form, and if cereals and vegetables be utilized without removal of cellulose and fiber, they will furnish sufficient proteid without resort to meat. Moreover, sugar should be added freely to food at the table. (This dietary represents an extreme French point of view, leaning toward modified vegetarianism.) Teething and Food Much illness and digestive disturbance in infancy and early child- hood is popularly ascribed to " teething," and the gums do occa- sionally become swollen and inflamed during dentition, but the evils of this process are exaggerated in the lay mind and wrong feeding is much more often accountable for the disturbance. In regard to this matter Adams says, " My experience has taught me that when- ever the child has become ill during this physiological process, some other cause than the mere cutting of the teeth can be found to account for the illness." Sleep and Feeding The relation of sleep to infant feeding is very well summarized by Adams as follows : " A young infant has nothing to do but eat and sleep. As soon as he is fed he will take a nap and will prob- ably sleep for an hour and a half. After the first year the naps become shorter and less frequent. During the second year a nap in the morning after breakfast, one in the afternoon about one or two o'clock for an hour or an hour and a half are usually sufficient, and these naps should be insisted upon for the rest of his mind and body, 854 DIETARIES, RATIONS and to enhance his growth and health. As the child attains the third year, he can usually drop the morning nap. The afternoon one should be insisted upon very soon after the child has its noon- day meal, in winter as well as in summer." DIET FOR SCHOOL CHILDREN Too much attention cannot be given by teachers to the diet of the pupils under their care in boarding schools, and they should exercise some supervision in regard to the matter in day schools as well, for the subject is often ill understood by parents. The period for training most school children is from the tenth to the seventeenth or eighteenth year, but with the present system of kindergarten training the attendance at school may begin much younger. During the entire time both mind and body are under- going development, which in many instances is exceedingly rapid, and in the midst of this period the condition of puberty is attained, which in itself requires additional care and watchfulness, especially in girls. (See p. 855.) Throughout the whole school period the growth of the body is con- tinued until almost completed. The individual organs and structures increase in actual size, and there are unusual demands, therefore, upon the functions of absorption and assimilation. The food should be abundant and of the proper character to furnish new tissue and to yield energy in the form of heat and muscular activity. The former condition is met by a proper allowance of animal food in the diet, and the latter by sufficient fats and carbohydrates. The food should also contain salts of lime, to meet the requirements of formation of the bones and teeth. While the material or structural development of the body progresses, there is also a marked development in the func- tions of the various organs ; the muscles are trained to act with vigor and with proper co-ordination, and the nervous system is constantly receiving and storing new impressions and regulating their transmis- sion and the proper relations of inhibitory and reflex actions. The metabolic processes of the body are extremely active and the digestive secretions are vigorous. To maintain the proper standard, therefore, of growth and development requires care in the selection of the right quantity and quality of " fuel " or food for the body, and the lack of such care too often lays the foundation of an enfeebled con- stitution. Many children inherit feeble constitutions or diatheses, which must be combated throughout the whole period of childhood. Such chil- dren are better kept at home, where they can be under constant DIET FOR SCHOOL CHILDREN 855 observation and proper dietetic treatment, or country schools may be found for them where such matters are made the subject of special consideration. Many cases of anaemia and chlorosis, which are so commonly seen in young girls during or shortly after the attainment of the condition of puberty, are directly traceable to malnutrition from faulty diet. Girls take less exercise than boys, as a rule, and are more likely to become constipated. This difficulty may be enhanced by a lack of sufficient fresh vegetables or fruit in their diet, and if prolonged it is enough in itself to cause anemia. The latter also may be brought about by insufficient good animal food. It should be the imperative duty of every head master of a school for children to realize the re- sponsibilities of rightly developing the physical constitutions of those entrusted to his care, and to make a thorough study of "the questions of dietetics involved. The mind continues developing long after the body, and the period under discussion is one in which the constitution is established for the remainder of life, and when success in digestion and assimilation is of greater importance than success in mental attainments. Variety. An important consideration in school diet is to prevent monotony, which becomes so common from economic reasons, or often from carelessness. But a little study and thought expended upon this subject can always result in furnishing variety in a wholesome diet without material increase of expense. The French Minister of Public Instruction appointed a Commission to recommend a proper diet for school children. Eeporting for this Commission, Bouchard declared that for adolescents the proportion of proteid to carbohydrate food should not exceed the ratio 1:5. If it becomes 1 : 4 digestive disorders may ensue, with fetid stools, skin eruptions and excess of urinary sediment. Diet and Puberty At the advent of puberty special care should be exercised in dieting children, for it is believed that condiments, peppers, spices, eggs, oysters, and especially an excess of animal proteid food is prone to overstimulate the sexual organs. Bouchard, Le Gendre, E. Maurel all emphasize the importance of reducing the meat diet to a minimum at this period. Maurel, moreover, believes that vegetable proteid does not possess this stimulating effect in common with meat proteid, hence, he argues, it may not be due to the proteid, but some other ingredient [extrac- tives?] taken with it in meat. The quantity of food also should not 856 DIETARIES, RATIONS be excessive at this period, or it will tend to produce indigestion and disordered sleep. Hours for Meals The hours for study and for meals should be so regulated that suffi- cient time be allowed before each meal for children to prepare them- selves comfortably without going to the table excited by hurry, and they should be required to remain at the table throughout a fixed time, never being allowed to swallow hastily their food in order to complete an unfinished task or game. An interval of half an hour or more should intervene for recreation after meals, in order that diges- tion may be well under way before any mental exertion is required. Constant nibbling at food between meals should be forbidden; it de- stroys the appetite, increases the saliva, and interferes with gastric digestion. The number of meals for children should be adapted to the age of the pupils. For young children from ten to twelve or thirteen years of age it may be necessary to furnish food somewhat oftener than for older ones. If children live at a distance from their school, or if they are weak and easily fatigued and inclined to sleep long in the morning, their hours for study should be so adjusted that they are never obliged to hurry their eating in order to be on time for school work. Their appetites are often poor at this hour from the effects of an ill-ven- tilated sleeping apartment, and if they are subsequently kept at school for five hours without luncheon they are ill fitted for mental work. Or they ride to school without exercise after a hasty breakfast, take a hurried cold lunch at noon, and perhaps a warmed-over late afternoon dinner, and at six or seven o'clock a fourth meal, after which they are expected to study and go to bed. A fact which is sometimes overlooked in the dietetic treatment of growing children is that their digestive processes are so active that the stomach is emptied somewhat sooner than in the case of adults, and their meals being promptly absorbed, it is natural for them to become hungry if the intervals between the hours of eating are pro- longed. In some schools, children are given their last meal of the day at six o'clock in the evening, and they may not breakfast until seven or half-past seven or later, leaving an interval of over thirteen hours during which they have had no food at all. The evening meal is usually made light, on the ground that they can sleep better, and it is, therefore, sooner digested. Robust children may thrive on this treatment, but those less strong are injured by it. For some school children of from ten to fourteen years of age it is better to serve the DIET FOR SCHOOL CHILDREN 85? evening meal later, at, say, seven o'clock, and the breakfast at seven, and if they awaken hungry during the night there is no harm in their having a glass of milk and a cracker. Delicate children whose appetites are poor and who do not do proper justice to their regular meals should be offered an extra portion of hot broth or hot milk or an occasional cup of chocolate with bread and butter and rusk between meals. These general rules are applicable to those children who, during one or two years, seem to develop with extraordinary rapidity, grow- ing sometimes two inches or more in six months and attaining a height quite disproportionate to their frames. The demands of this rapid growth must be met by proper nutrition or serious subsequent impairment of vitality may result. Such children should have their meals made tempting by good cooking and pleasant variety as well as an agreeable appearance of the food. Meat which is carved in un- sightly masses and vegetables which are sodden and tasteless may be refused, and an ill attempt is made to supply the deficiency in proper food by eating indigestible candy, nuts, etc. Children often have no natural liking for meat, and prefer puddings, pastry, or sweets when they can obtain them, and it is the more important that meat should be made attractive to them at the age when they need it. It is unnecessary to discuss further, questions which after all must be controlled by tact and circumstances of individual cases, and the line should be drawn with care between making a child too fastidious on the one hand in regard to the nature of its food, and on the other impairing its constitution by monotony of diet and ill-cooked viands. Children at school especially should be required to eat slowly, for the habit of fast eating is contagious, and as it is much easier to acquire than to overcome, the foundation of dyspepsia and lifelong discomfort may be laid in this way in childhood. The food served should be given in successive helpings, rather than all at once. A Sample Diet If early rising be insisted upon, a child should never be set at any task before breakfast, especially in winter, and if not expedient to serve a full breakfast at half-past six or seven the child should be given a bowl of hot milk and bread, or a cup of cocoa with a roll, or other light food: breakfast may be served later after the first exer- cises of the morning, and should be a substantial meal with animal food in the form of either fish, or eggs, or cold meat of some sort, with porridge of wheaten grits, or hominy with milk or cream and abun- dant sugar, also bread and butter, with sweets in the form of jam, or 858 DIETARIES, RATIONS marmalade, or stewed fruit. Dinner, which should be served near the middle of the day, may comprise meat, potatoes, with one or two green vegetables, and some form of sweet pudding. The supper should com- prise only easily digestible articles of food, and such substances as pastry, cheese, and meats, are better omitted. It should consist of either a porridge with milk or cream, or a light farinaceous pudding of rice, tapioca, sago, and the like, with bread and butter, and a sim- ple form of preserve, or stewed apples or prunes. Very light plain cake, or a good bowl of nutritious broth with bread or crackers may be substituted for the porridge or pudding. It will sometimes be found best to serve this meal at seven o'clock or half past seven, and if hungry the child may be given a slice of bread and butter and a cup of weak tea or coffee, mostly hot milk, at half past five or six o'clock. Sample diet from a well-known Boys' School in New England. Breakfast, 7.30 A. M. Oatmeal. Bread and butter. Stew or hashed meat, or beefsteak or chops. Twice a week, griddle cakes with sirup. Dinner, 1 p. M. Soup. Fish once or twice a week. Meat, either roast beef, beefsteak, mutton, or chicken. Potatoes and green vege- tables in season. Pudding, or pie, or plain cake, and lemonade. Fruit. Supper, 7 P. M. Cold meat, or hashed meat, or fish balls. Pota- toes. Bread and butter. Cake. Preserved fruits. Time Allowed for Meals. Breakfast and supper, each half an hour ; dinner, three-quarters of an hour. Intervals of rest or recrea- tion for the younger boys (thirteen to fourteen years), after break- fast, half an hour; before dinner, three-quarters of an hour; after dinner, two hours and a half; before and after supper, fifteen minutes. On Sundays, breakfast an hour and dinner half an hour later than on week-days, and supper five hours after dinner. Some of the more important articles of school diet require special mention. Bread, as a rule, should be made of whole meal, but should not be too coarse. The advantage of this bread for children consists in its containing a larger proportion of salts, which they need, than is found in refined white flour, and butter should be freely served with it. to supply the deficiency of fats which exist in wheat. Children need fat. but they do not digest meat fat well, as a rule, and are very apt to dislike it. They will often take suet pudding, however, when hot mutton fat disagrees. DIET FOR SCHOOL CHILDREN 859 Milk should be supplied freely not only in the form of puddings and porridges, but as an occasional beverage, and children should understand that when hungry they may obtain a glass of milk, or a bowl of crackers or bread and milk, for the asking. Chambers says : " The best luncheon that a growing young man can have is a dish of roast potatoes well buttered and peppered and a draught of milk." Fresh Fish, eggs, and bacon are all wholesome and serviceable foods for children. Meat, as a rule, may be given twice a day, but not oftener. It may sometimes be advisable to give it only once a day when fish or eggs are supplied; it should, however, always be given at least once daily, and better twice to rapidly growing children. Large, strong boys require much meat, and its use should not be stinted. The larger boys may eat from seven to nine ounces of cooked meat in the day, although many children may not require so much, smaller boys doing well with from five to six ounces. During midwinter, however, when fresh vegetables are almost un- obtainable in severe climates, vigorous boys sometimes have too much meat given them, and Yeo calls attention to the fact that eczema may be produced in them by a too exclusive animal diet. Sweets. The greater number of children have a natural craving for sweets. The important role of sugars in furnishing energy for the body has been discussed (p. 22}, and the energy developed in active childhood necessitates the consumption of a larger proportion of sugar than is required by adults. The craving of children for confections, candy, etc., furnishes a true indication of the actual requirements of Mature, and a moderate amount of wholesome candy, like plain molasses candy or plain chocolate caramels, not only does most children no harm, but may serve them as an excellent food. The main difficulty with such forms of sugar, however, often is that children are not furnished with a proper proportion of sugar with their meals, and the meals themselves are not so regulated as to prevent their becoming very hungry between them; consequently, if they can obtain candy, which satisfies them for the time, they eat too much, with the result of producing dyspepsia and diminishing the normal appetite. If pains be taken to give such children a slice of bread and butter with a little honey or jam between meals and a proper proportion of saccharine food with their meals, they are much less likely to obtain candy surreptitiously and gorge themselves with it. Simple forms of well-cooked pastry and of cakes with stoned raisins should be furnished as dessert occasionally. It is better to give such 860 DIETARIES, RATIONS food from time to time with the meals under proper supervision than to have children indulge themselves in it. Milk sugar is an excellent children's food, as it is good for infants. Alcohol in every form should be forbidden to healthy children. If given during early youth it is particularly prone to develop a taste which may become uncontrollable in later years. Habit. Many children acquire a habit of dislike or even disgust for certain articles of food, which becomes so fixed in later life that they find it very inconvenient, especially when placed in circum- stances, as in traveling, where one cannot always obtain the accus- tomed diet. Giving in to such habit is often a serious obstacle to normal development. There are children who acquire a dislike for meat and who persistently refuse to take it, until they become anaemic and feeble, and there are others who refuse fresh vegetables, which they need. It is a great misfortune for a child to be indulged in such likes or dislikes. With a little tact and persuasion the repug- nance usually may be overcome before the habit becomes rooted, and the question is largely a matter of proper education. How often is the physician baffled in the treatment of a serious disease like typhoid fever, which requires the use of a milk diet, by the patient's insisting that he has never been able to drink milk since childhood ! If there be any taste which is natural to all men it is that for milk, upon which all must live during early infancy ; and while it is better after a certain period of growth to restrict the quantity of milk in the diet, there is no reason at all why children should not retain a normal fond- ness for it. There are, no doubt, cases in which it disagrees (see p. 83), but they are exceptional as compared with the number of persons who can digest milk, when properly prepared, with perfect ease, but whose antipathy for it prevents them from taking it in the emergen- cies which may befall them in acute disease. Children who object to vegetables sometimes may learn to eat them when cooked in an unusually attractive manner or served in soup. Overeating should be guarded against, for habits of gluttony may be acquired in youth, especially between puberty and full develop- ment, which are never overcome, and which may lead to visceral dis- tention and hypertrophy, obesity and other troubles, that develop in adult life. The habit of slow eating should be insisted upon. Exercise, etc. As a general rule, active muscular exercise in chil- dren disturbs their digestive processes far less than mental effort when taken immediately after meals, and every adult is familiar with the romping which children can undertake straightway after dinner, often, though not always, with impunity, whereas a proportionate amount of HOSPITAL DIETARIES 861 exercise on the part of an adult might produce a severe dyspeptic attack. It is well to allow children to play only moderately imme- diately after eating, and to require no mental work of them at such time. For some reason both the diet and exercise in girls' schools is often less carefully regulated than in corresponding schools for boys. This applies not only in the United States, but has been found the com- mon experience in England and France; it is the more unfortunate, since girls from their greater delicacy of constitution, especially at the period of puberty, require more careful nurture. Differences in habits and exercise and outdoor recreation, no doubt in part, are responsible for the comparative lack of proper development in some girls' schools, but this should be recognized and regulated with as much care as the diet. During the establishment of puberty it is best for children to avoid stimulating and highly seasoned food, and eating late at night, which is apt to excite the sexual organs reflexly and cause lascivious dreams. (See Diet and Puberty, p. 855.) HOSPITAL DIETARIES Statistics of the most economical quantity and quality of food for men in health, and under different conditions of activity, have been very accurately and practically determined, but such data for the sick are in most cases unobtainable, and obviously so, for the condition of individual cases and the severity of diseases are constantly varying from day to day, and no definite rules for the exact quantity of food needed could be formulated which would be of general application. For this reason in many hospitals no attempt is made to classify the diet beyond the very elementary subdivisions, consisting, first, of milk diet i. e., milk alone, or of milk with a little bread, and light farinaceous food ; secondly, the " full diet," which is commonly known either by that name or as " house diet " or " ordinary diet." Where no further general classification of the diet is attempted, it is cus- tomary to have a supplementary list of foods, usually called " articles of special diet," from which the visiting physician or surgeon is to select appropriate food for individual cases. The expression "low diet," indicating that for very sick patients, is an unfortunate one, as it has a depressing sound. In other institutions, where more care is bestowed upon dietetics, it is found both convenient and prac- tical to subdivide the diet under several additional headings. This arrangement is commended, as it not only saves time and confusion, 862 IflETARIES, RATIONS but is economical to the institution in preventing waste, instead of sending a large number of " full diets " from the kitchen to the ward, where the lighter or more easily digestible articles are selected for the sicker patients by possibly inexperienced nurses, much of the food being returned uneaten. If the diet is assorted in the kitchen and sent to the ward in a properly classified condition that is, so many rations of each specified class there is very much less waste and confusion. Under this system, the subdivisions which I have introduced in several metropolitan hospitals are as follows : I. Milk diet, consisting of from two and a half to three quarts of milk per 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 aver- age 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 digestion, and is therefore serviceable in a very large number of cases which do not need more careful selection of food. III. Non-nitrogenous diet, from which animal food, with perhaps the exception of milk and butter, is excluded. It comprises bread and other cereals, vegetables and fruit. This diet is not of very gen- eral use, but is temporarily serviceable in some forms of disease, such as chronic Bright's disease and acute gout. IV. Proteid diet, or animal food, which is somewhat more used than the preceding diet, and from which saccharine and almost all forms of starchy food excepting a little dried bread, toast, or Graham bread are excluded. It consists mainly of meats, but comprises also fish and eggs. This diet is particularly serviceable in cases of flatu- lent dyspepsia, chronic gastric catarrh, and dilatation of the stom- ach, in which the starches and sugars invariably undergo acid fer- mentation, with eructations and flatulence. It also serves for diabetics, with slight modification. V. House or full diet should be the most economical diet for the hospital upon which patients who have nearly completed their con- valescence may be placed, as well as those patients, including certain medical cases and a large number of minor surgical patients, whose di- gestive organs are in normal condition. It comprises many coarser articles of food, sometimes corned beef and cabbage, potatoes, codfish, etc., and it is very often the general diet for the servants and attend- ants in hospitals as well as patients. HOSPITAL DIETARIES 863 VI. Articles of Special Diet. Under this list are included lux- uries and delicacies, such as oysters, jellies, custards, gruels, etc., and extra allowances of eggs, chicken, cream, and fruits, which it may be desirable to furnish in individual cases. With a system arranged upon this plan, as will be seen by the ac- companying sample tables, used in some of the representative hos- pitals (pp. 868, 869), the ordering of the diet is simplified for the visiting physician or surgeon, and is less likely to be relegated by him to subordinates than it is if he be obliged to spend the time required for selecting a separate menu for each patient in the ward. The lim- itations of each classified diet should be distinctly understood by all the attendants and nurses, and a printed diet list of articles included under the headings " proteid diet," " special 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 purveyor, whose special duty is to provide the food for the institution, and select such articles as will afford reasonable variety, due allowance being made for fluctuations 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 a specially trained person to superintend these matters would be more than coun- terbalanced by the saving in waste and in added benefit to the patients. (See Trained Food Purveyors, p. 462.) 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 labor when put to bed for six weeks or more with his leg immobilized for a fracture, does not need to be con- stantly stuffed with large quantities of food, and yet such patients, if the matter be not directed carefully, often will be found to receive full house diet, which in itself is ample for the working attendants of the hospital, and in addition a quart of milk a day as a beverage. The natural result is constipation, 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 irre- spective of any supervision. In a large hospital, where the monthly 864 DIETARIES, RATIONS consumption of milk is from ten to fifteen thousand gallons, it read- ily may be 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. (See Overeat- ing, p. 411.) Another undesirable tendency among American hospital dietaries is to include far too much meat. The ordinary hospital menu com- pared, for instance, with that of the agricultural laborer, shows this fact very strikingly. Not over four ounces of cooked meat (without bone) need be allowed in the meal for men. In the house diet cheese and legumes may be substituted in great part economically. 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 adopted generally. In the London Fever Hos- pital this diet consists of a ration of bread (ten ounces) and fish (eight ounces, 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 serv- iceable and economical diet for a considerable class of patients for whom large quantities of meat are not only unnecessary but injurious. Broth Diet. In children's hospitals a diet is sometimes classified as the " broth diet," i. e., mutton broth flavored 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 farinaceous foods, such as farina, corn- starch, rice, etc., should play an important role. Sometimes such diet goes under the name of " soft food." In German hospitals and some of the English hospitals, as in the London Fever Hospital, beer is allowed with the full diet, and in the latter hospital also a discrimination is made in ordering the diet ac- cording to sex, females being given from two to four ounces less bread and two to three ounces less meat than males. This distinction is not made in American hospitals. Sample Hospital Dietaries DIETARY OF THE NEW YORK HOSPITAL " 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: 1. Eestricted diet. 2. Milk diet. HOSPITAL DIETARIES 865 "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 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. "Supper. Tea with milk and sugar; bread and butter; stewed or fresh fruit. "In addition on Sunday. Breakast: eggs. Dinner: roast beef; cornstarch pudding. Monday. 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. Breakfast: fried or stewed potatoes. Din- ner: roast beef, cornstarch pudding. Thursday. Breakfast: eggs. Dinner: stock soup, stewed beef or mutton, tapioca pudding. Fri- day. Breakfast : salt mackerel or codfish. Dinner : bean soup, baked fish, beans, rice pudding. Saturday. Breakfast: beefsteak. Din- ner : corned beef, cabbage, bread pudding. 57 866 DIETARIES, RATIONS " Restricted Diet "Breakfast. Tea or coffee (with milk and sugar), farinaceous food (with milk), eggs. " Dinner. 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, cornstarch, 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 per capita, was formerly used, but it was found both unnecessary and impractical. Separate tables are laid for the pa- tients, nurses, and servants; but the amount of food is estimated in a general way, the terms being based rather upon the cost price per capita than upon the number of ounces, and it is proportioned by the housekeeper and her assistants with due regard to economy. DIETARY IN BELLEVTJE, GOUVERNEUR, FORDHAM, AND HARLEM HOSPITALS, NEW YORK 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; po- tatoes, eight ounces; vegetables, four ounces; bread. Supper. Tea, one pint, with half an ounce of milk and half an ounce of siurar; 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 quarter 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. Xuppcr. 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. HOSPITAL DIETARIES 867 Wednesday Breakfast. Coffee, 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. Dinner. Roast beef, eight ounces; barley soup, one pint; potatoes, eight ounces; bread, five and one-third ounces. Supper. Tea, 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; stewed prunes, one ounce. Thursday Breakfast. Coffee, one pint, with half a pint of milk and half an ounce of sugar; five and one third ounces of bread and a quarter of an ounce of butter; oatmeal, one ounce; crackers, one ounce; milk, one quart. Dinner. Beef stew, eight ounces ; potatoes, eight ounces ; vegetables, four ounces; bread, five and one-third ounces. Supper. Tea, one pint, with half a pint 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. Friday Breakfast. Coffee, 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; two eggs; crackers, one ounce; milk, one quart. Dinner. Baked fish, eight ounces; potatoes, eight ounces; vegetables, four ounces; bread, five and one-third ounces; rice pudding, two and a half ounces. Supper. Tea, one pint, with half a pint of milk and half an ounce of sugar; five and one-third ounces of bread and a quarter of an ounce of butter. Saturday Breakfast. Coffee, one pint, with a quarter of a pint of milk and a quarter of an ounce of sugar; five and one-third ounces of bread and a quar- ter of an ounce of butter; hominy, one ounce; crackers, one ounce; milk, one quart. Dinner. Mutton stew, eight ounces; potatoes, nine ounces; vegetables, four ounces; bread, five and one-third ounces. Supper. Tea, one pint, with milk half a pint, and half an ounce of sugar; bread, five and one-third ounces; butter, a quarter of an ounce; stewed prunes, one ounce. Sunday Breakfast. Coffee, one pint, with half a pint of milk and half an ounce of sugar; five and one-third ounces of bread and a quarter of an ounce of butter; crackers, one ounce; milk, one quart; two eggs. Dinner. Corned beef, eight ounces; bean soup, one pint; potatoes, eight ounces; bread, five and one-third ounces; cornstarch pudding, two and a half ounces. Supper. Tea, one pint, with half a pint of milk and half an ounce of sugar- bread, five and one-third ounces, and butter, a quarter of an ounce. Uilk Diet To be prescribed by attending physicians or surgeons. Articles of Special Diet soup Beefsteak, half a pound; beef tea, one pint; chicken, half a pound; chicken up, one pint; rice and milk, one pint; two eggs; milk, one quart. 868 DIETARIES, RATIONS DIETARY OF THE PRESBYTERIAN HOSPITAL, NEW YORK, 1909. Although the diet is very satisfactory and ample at the Presby- terian Hospital, New York, the food allowance per capita for patients is not separately estimated, and the house diet, convalescent diet, and diet for the servants on pages 870, 871 are all originally pre- pared in bulk, and subsequently subdivided by the cooks and nurses under the order of the visiting physicians and surgeons, but without regard to accurate measurement of quantity in ounces much less in " calories." In fact, the latter method of calculation is rarely used in American institutions, practical experience usually being pre- ferred. The diet sheet printed below is in daily use in the wards at the Presbyterian Hospital, New York City, where it has proved very satis- factory. It will be observed that it is properly 'classified according to quality, but not as to quantity. It was introduced several years ago after a careful comparison with diets of other institutions, and it has proved very practical. It is the most liberal and the most conveniently classified diet of any hospital with which I am fa- miliar. The following two diet sheets are to be filled and signed by the medical staff daily: THE PRESBYTERIAN HOSPITAL Extra Diet Sheet Medical Division Ward No.. New York 1906 NAME. BREAKFAST. DINNER. SUPPER. Milk Toast 12 Chicken 12 Milk Toast 12 Toast 10 Chops 4 Toast 10 Chops 6 Rice 15 Chops 6 Lemons 8 Custard 15 Custard 15 Eggs 46 Baked Apples 4 Baked Apples 6 Scraped Beef 9 oz. Raw Oysters 6 Chopped Beef 4 Ibs. Chicken Broth 4 pts Pressed Beef Juice 7 oz. Baked Potatoes 6 Milk 1 can Milk 1 can Milk 2 cans TOTAL Attending Physician: Surgeon House Physician: Surgeon HOSPITAL DIETARIES 869 CO i 1 1 8 8 SC 6jD c o" iy *y S^ "co s I '-3 1 w fe 1 4) P PH 03 O W S -g 1 5 S < a i Js PH 03 S H g O S 03 1 PH <*- o 1 6 z ~ 5 1 e -s "2 I o 3 S o g 5 fe g 1 NAMES OK PATIENTS. 2 -3 aa o w Convalescent diet . . . Nitrogenous diet .... Farinaceous diet .... 2 '-3 i 2 '-3 hi M S o !^ o cc -4-1 ^ PH *- O ^ S !Z5 870 DIETARIES, RATIONS THE PRESBYTERIAN HOSPITAL IN THE CITY OF NEW YORK PATIENTS' DIETARY 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 Graham White Bread or Graham Bread or Corn Bread or Bread or Corn Bread or Meats Rolls or Toast Rolls or Toast Eggs or Fresh Fish or Porridge Porridge Stew without Vegetables or Meat Hash without Oatmeal or Wheaten Hominy or Farina Potatoes grits or Indian Meal or Hominy or Farina Meats Eggs or Fresh Fish or Meats Stew (plain) Hash or Eggs or Salt Fish or Fresh Fish or Stew Dinner. Dinner. Dinner. Soup Soup Soup Stock or Mutton Broth Stock or Chicken or Stock or Chowder with barley or vegetable or Chowder Mutton Broth with bar- ley or vegetable Graham Bread Dry Bread Dry Bread Meats Meats Meats Beef (Roast or Boiled) or Mutton (Roast or Beef (Roast or Boiled) Beef (Roast or Boiled) Boiled) or Fresh Fish or or Mutton (Roast or or Chicken or Fish Irish Stew Boiled) or Corned Beef or Fresh Fish or Irish Stew (Fresh) Vegetables Vegetables Spinach or Lettuce or Vegetables Potatoes (Baked, Boiled Potatoes (Baked, Boiled or Mashed), Rice or Macaroni or Hominy Celery or String Beans Pudding or Mashed) and Toma- toes or Baked Beans or Pudding Custard French Beans or Turnips Rice or Bread or Tapi- or Beets or Rice or Ma- oca or Farina or Corn caroni or Hominy Starch or Custard Pudding Rice or Bread or Tapi- oca or Farina or Corn Starch or Custard Supper. Supper. Supper. Tea (Milk and Sugar) Tea (Milk and Sugar) Tea (Milk) Bread and Butter or Bread and Milk or Milk Graham Bread and But- Toast and Butter Toast or Bread and But- ter or Bread and Milk, ter or Toast and Butter Eggs or Cold Meat Fruit Apples (Stewed or Fruit Raked) or Prunes or Apples (Stewed or Pears Baked) or Prunes or Pe^rs HOSPITAL DIETARIES 871 (PRESBYTERIAN HOSPITAL DIETARY Continued.) FARINACEOUS DIET. MILK DIET. Typhoid Fluid Diet. Breakfast. Tea or Coffee (Milk and Sugar) Bread and Butter White Bread or Graham Bread or Corn Bread or Rolls or Toast Porridge Hominy or Farina or In- dian Meal Dinner. Soup "Vegetable or Macaroni or Barley Broth Dry Bread Vegetables Baked Potatoes and To- matoes or French Beans or Rice or Macaroni or Hominy Pudding Rice or Bread or Tapioca or Farina or. Corn Starch Supper. Tea (Milk or Sugar) Bread and Milk or Milk Toast or Hominy or Boiled Rice or Farina Fruit Apples (Stewed or Baked) or Prunes or Pears Breakfast One quart of milk Dinner. One quart of milk Supper. One quart of milk Milk, Broth, Egg Albumen Typhoid Delicacies. Hice (well cooked), Jun- ket, Custard, Gruels, Milk Toast, Scraped Beef, Eggs Typhoid Extra Diet. Broths, Beef Soups, Oys- ters, White Fish, Beef Chops, Mutton Steak, Custard, Egsrs, Chicken, Rice, White Bread, Toast, Farinaceous Puddings. No Vegetables, Fruit, Pas- try or Hot Bread. FLUID DIET. Milk, Beef Tea, Chicken Broth, Mutton Broth. Egg Albumen SOFT DIET. Cereals, Eggs, Milk Toast, Custard, Farinaceous Puddings, Tea, Coffee, Milk After Two Days of Normal Temperature. Strained Vegetable Soups, Baked Apples, Baked Po- tatoes, Oatmeal EXTRAS. Ordered only by the at- tending Physician or Sur- geon. Mutton Chops, Beef Steak, Scraped Beef, Beef Tea (made with Hydrochloric Acid), Chicken (Broiled, Fricasseed or Roast), Chicken Broth, Eggs, Milk, Oysters, Clam Broth, Gruels, Crackers, Gingerbread, Custard, Milk Toast DIABETIC DIET. Buttermilk, Koumyss, Beef Tea, Coffee, Cocoa, Tea, Saccharin in lieu of sugar, Clams, thin soup, Fish, Poultry, Beef, Mut- ton, Bacon, Eggs, String Beans, Cabbage, Toma- toes, Lettuce, Spinach, Greens, Lemons, Apples. Oranges, Strawberries No Milk or Sugar The Fresh Fruit and Vegetables above specified will be furnished only season." 872 DIETARIES, RATIONS DIETAKY OF THE ALLEGHENY (PENNSYLVANIA) GENERAL HOSPITAL Liquids, semi-liquids (without starch and sugar), soft or light, selected house. I. LIQUID. (a) Milk Modified Milk. Whey. Koumiss. Laban. Milk Jelly (Irish Moss). (I) Meat Foods Beef Juice. Beef Tea. Beef Broth. Consomme. Bouillon. Beef Jelly (Gelatine). Beef Jelly (Irish Moss). Mutton Juice and Broth. Chicken Broth and Jelly. Clam Broth and Juice. Oyster Broth and Juice. LIQUID FOODS FBOZEN. (c) Starchy Liquid Foods. (d) Cream II. SEMI-LIQUIDS. (Without Starch and Sugar.) Liquid Food. Gluten Gruel. Irish Moss Gruel. Irish Moss Chicken Jelly. Irish Moss Thickening for soups and sauces. Soups Chicken Broth, Croutons, Egg. Consomme and Egg. Irish Moss Thickening for soups and sauces. Oyster, Thickened with Yolk 'of Egg. Chicken Puree. Cream of Celery Soup Thick- ened with Yolk of Egg. Clam, Thickened with Yolk of Egg- Sweetbread Puree. Tomato, using Irish Moss Thickening. Egg, Poached, Soft Boiled. Beef Paste. III. SOFT OB LIGHT DIET. Cereals. Cream Soups. Egg Soft Boiled, Poached, Omelette. Zwieback. Oysters. Chicken Puree. Sweetbreads Puree. Stewed Fruits. Jellies. Soft Desserts. Ice Cream. Ices. Milk Toast. Cream Toast. Oranges and Grape Fruit. IV. SELECT DIET. Soups Meats Beef Broiled, Baked. Lamb Broiled, Baked. Chicken. Fish and Oysters. Eggs. Vegetables Potatoes. Lettuce. String Beans. Spinach. Squash. Tomatoes. Peas. Asparagus. Water Cress. Celery. Light Desserts Toast. Oranges. V. HOUSE. Pastry and Fried Foods omitted. DIETARY OF THE ROOSEVELT HOSPITAL, NEW YORK The ward diet of the Eoosevelt Hospital, New York city, is classified as follows: Full Diet Dally. Meat, dressed, eight ounces; potatoes, eight ounces; bread, twelve ounces; butter, one ounce; sugar, two ounces and a half; milk, half a pint; HOSPITAL DIETARIES 873 coffee, half an ounce; tea, an eighth of an ounce. On Sundays, Tuesdays, and Thursdays, other vegetables in addition to potatoes, two ounces; bread, rice, or tapioca pudding. On Mondays and Wednesdays, soup, one pint. On Fridays, fish. Breakfast. Coffee with sugar and milk, bread and butter, porridge of oatmeal, wheaten grits, or samp. Dinner. Sunday : Roast beef, potatoes, tomatoes, or other vegetable, bread, and bread pudding. Monday: Soup, boiled mutton, potatoes, and bread. Tuesday: Corned beef twelve ounces; cabbage or turnips, pota- toes and bread. Wednesday: Soup, roast beef, potatoes and bread. Thurs- day: Soup, boiled beef, potatoes, onions, tapioca, sago, or farina pudding, and bread. Friday: Fish, boiled or roast beef, potatoes, bread, boiled rice sweetened with sugar and milk, and raisins. Saturday: Stew of mutton, potatoes and bread. Supper. Tea with sugar and milk, bread and butter, baked apples, or stewed pears, or prunes, or green or dried apple sauce, and, on Sundays, gingerbread varied, alternate weeks, with currant buns. Half Diet Daily. Meat, dressed, four ounces; potatoes, four ounces; bread, six ounces; of other articles, the same as in full diet. Milk Diet Daily. Milk, two pints ; bread, twelve ounces ; rice or samp, two ounces ; butter, one ounce. Extras In addition to the above, the following extras may be ordered by the visit- ing physicians and surgeons: Beefsteak, chicken soup, gruel, beef tea, oysters or clams, cornstarch, mutton chops, milk, rice, chicken, eggs. NOTE. This dietary is estimated in ounces on paper, but the food is not weighed out for any patient. DIETARY OF THE JOHNS HOPKINS HOSPITAL, BALTIMORE At the Johns Hopkins Hospital the Free Ward Diet is liberal, but no attempt is made to classify the food qualitatively as served to the wards. A sample Sunday menu given there is the following. It is expensive, owing to the excess of animal food : Breakfast. Corned-beef hash, oatmeal, toast, eggs, bread and butter, coffee or tea, and milk. Dinner. Soup, roast beef, potatoes, rice, turnips, toast, pudding and milk, bread and butter. Supper. Cold roast beef or pressed corned beef, bread and butter, coffee or tea, and milk. DIETARY OF THE COOK COUNTY HOSPITAL, CHICAGO In the Cook County Hospital, of Chicago, the official diets are four viz., ward diet, light diet, special diet, milk. Extras may be or- dered, such as chicken, chops, beefsteak, eggs, cream, crackers, lemons, or additional butter, milk, sugar, sirup, and vinegar. Here again no special attempt is made to classify foods qualitatively. Following is a sample midsummer diet, from a small hospital, having about seventy beds, in which attention is economically given 58 874 DIETARIES, RATIONS to variety in food cookery which would be impossible in a larger in- stitution without incurring needless expense: WARD DIETARY OF THE NEW YORK INFIRMARY FOR WOMEN AND CHILDREN Sunday Breakfast. Full Diet : Hominy with milk, fish balls or creamed fish, brown bread or biscuit, coffee with milk and sugar, fresh fruit. Half Diet: Hominy with milk, toast, coffee, fresh fruit. Dinner. Full Diet : Soup, bread, roast beef, sweet or white potatoes, spinach or egg plant, pudding. Half Diet: Clam broth, toast, chicken or beef jelly, rice, or ice cream. Supper. Full Diet : Pressed beef or cream salmon, bread and butter, cocoa. Half Diet: Indian meal porridge and milk, toast, cocoa, fruit. Monday Breakfast. Full Diet : Oatmeal and milk, bread and butter, poached eggs on toast, coffee with milk and sugar. Half Diet: Oatmeal, eggs on toast, coffee, fresh fruit. Dinner. Full Diet : Soup, bread, roast lamb, spaghetti, tomatoes or lima beans, rice pudding or prune pudding or cottage pudding. Half Diet: Chicken broth, toast, spaghetti, rice pudding or cottage pudding. Supper. Full Diet: Baked potatoes and bacon or creamed beef or toast, bread and butter, tea, fruit. Half Diet: Hominy and milk, bread and butter or toast, tea, fruit. Tuesday Breakfast. Full Diet: Wheat flakes and milk, beef mince or hash, bread and butter, coffee. Half Diet: Wheat flakes, buttered toast, coffee, fresh fruit. Dinner. Full Diet : Soup, bread, steak, cresses, potatoes, beans or carrots or beets, boiled or baked custard or ice cream. Half Diet: Mutton broth, rice, toast, custard or ice cream. Supper. Full Diet : Brown bread and butter, cream cheese or boiled eggs or sliced beef, fruit, cocoa. Half Diet: Oatmeal jelly and milk, toast, fruit, cocoa. Wednesday Breakfast. Full Diet: Hominy with milk, lamb mince or lamb with cream sauce, bread, butter, coffee. Half Diet: Hominy with milk, buttered toast, boiled eggs, coffee, fresh fruit. Dinner. Full Diet: Soup, bread, chicken, potatoes or rice, peas, tapioca or fruit pudding or custard. Half Diet: Broth, rice, toast, tapioca. Supper. Full Diet : Spaghetti and tomato or sliced tomatoes or baked corn, bread and butter, tea, fruit. Half Diet: Wheat flakes and milk, toast, tea, fruit. Thursday Breakfast. Full Diet: Oatmeal and milk, fresh fish, bread and butter, coffee. Half Diet: Oatmeal and milk, toast, coffee, fresh fruit. Dinner. Full Diet: Soup, bread, braised beef, macaroni, spinach or string beans, wine jelly or fruit jelly. Half Diet: Chicken broth, macaroni, toast, wine jelly. Supper. Full Diet: Beef stew or cream toast or pea soup, bread and but- ter, cake, fruit, cocoa. Half Diet: Cream toast, cocoa, fruit. Friday Breakfast. Full Diet: Wheat flakes and milk, scrambled eggs on toast, bread and butter. Half Diet: Wheat flakes and milk, eggs, toast, coffee, fresh fruit. HOSPITAL DIETARIES 875 Dinner. Full Diet : Soup, bread, fish, potatoes, tomatoes or peas, bread pudding or Indian pudding or ice cream. Half Diet: Lamb broth, rice, bread pudding or ice cream. Supper. Full Diet : Chowder or boiled eggs, bread and butter, tea, fruit. Half Diet: Oatmeal jelly, toast, tea, fruit. Saturday Breakfast. Full Diet: Indian meal porridge and maple sirup or milk, beef ragout, bread and butter, coffee. Half Diet: Indian porridge, toast, coffee. Dinner. Full Diet: Soup, bread, steak, potatoes, cauliflower or squash. Half Diet: Chicken broth, toast, rice, rennet custard, blancmange. Supper. Full Diet: Lamb stew or baked beans, bread and butter, tea, fruit. Half Diet: Wheat flakes and milk, toast, tea, fruit. Food which may be ordered by resident or attending physicians when daily diet is not adequate or suitable: Beefsteak, chops, chicken, beef jelly, chicken jelly, scraped beef balls, raw beef sandwiches, clam broth, crackers, extra eggs and milk, gruels, oat- meal jelly, wine or fruit jelly, cold beef extract made with hydrochloric acid. In this same institution is given the Average Daily Dietary for Adult Women Patients, not including Milk, Eggs, or Beef Tea for Special Cases Flour, meal, rice, or beans, uncooked J ounce. Bread 8 ounces. Butter and fat 2J " Sugar , 2 " Breakfast cereals, uncooked 1 ounce. Meat or _fish, dressed but uncooked 8 ounces. Potatoes, dressed but uncooked 5 to 6 " Fresh or canned vegetables, cooked 4 to 5 " Stewed or fresh fruit, prepared or cooked 3 to 4 " Soup | pint or 8 " Milk 1 . " "16 Coffee & " " 8 " Tea or cocoa J " " 8 " Eggs, one every other day J ounce. NEW YORK STATE HOSPITAL PROPOSED DIETARY Austin Flint recommended the following dietary and food supply for the New York State Hospital : " The table is intended for patients not upon extra diet and attend- ants only, and I have suggested that 25 per cent in the rations of meat, flour, and potatoes be added for workers." NEW YORK STATE HOSPITAL Daily Ration Meat, with bone, including salted meats, fresh and salted fish, and poultry 12 ounces. Flour, to be used in making bread and in cooking ( may in part be substituted by cornmeal and macaroni ) 12 Potatoes 12 " Milk 16 One egg 2 Sugar 2 Butter 2 Cheese 1 Rice, hominy, or oatmeal 1J Beans or peas ( dried ) 1 J Coffee ( in the berry and roasted) i Tea (black) i 876 DIETARIES, RATIONS Supplies for One Hundred Persons for Thirty Days Meat, with bone, including salted meat, fresh and salted fish, and poultry, total 2,250 pounds. Flour (may be in part substituted by cornmeal and macaroni ) 2,250 " Potatoes 2,250 " Milk 1,500 quarts. Eggs 250 dozen. Sugar 490 pounds. Butter 430 Cheese 215 Rice 108 Hominy 108 Oatmeal 108 Coffee 180 Tea 26 " Flour should be interchangeable, on this basis, with potatoes, rice, hominy, and oatmeal. Butter and cheese may be interchange- able in the proportion of one pound of butter to two pounds of cheese; and eggs and milk, in the proportion of two eggs to one pint of milk. There are occasions when eggs may be substituted with advantage for meat. This may be done on the basis of eight eggs for one pound of meat. When fruits, fresh and dried, are used in abundance, a reduction may be made in eggs, butter, cheese, and milk." DIETARY OF THE TJTICA STATE HOSPITAL, FOR THE INSANE Monday Breakfast. Cold corned beef, oatmeal, boiled potatoes, bread and butter, tea or coffee. Dinner. Roast beef, boiled potatoes, gravy, boiled rice, bread and butter, tea. Supper. Roll, bread, sirup, butter, tea. Tuesday Breakfast. Cold roast beef, oatmeal, boiled potatoes, bread and butter, tea or coffee. Dinner. Vegetable soup, boiled mutton, boiled potatoes, bread and butter, and tea. Supper. Molasses cookies, bread and butter, tea. Wednesday Breakfast. Roast mutton, oatmeal, boiled potatoes, bread and butter, tea or coffee. Dinner. Roast veal, boiled potatoes, Indian pudding, gravy, bread and butter, tea. Supper. Stewed prunes, bread and butter, tea. Thursday Breakfast. Cold roast veal, oatmeal, boiled potatoes, bread and butter, tea or coffee. Dinner. Baked salt pork, baked beans, boiled potatoes, bread and butter, tea. Supper. Cheese, roll, bread, sirup, butter, tea. Friday Breakfast. Codfish, oatmeal, boiled potatoes, bread and butter, tea or coffee. Dinner. Fresh fish, boiled potatoes, dried raspberry pie, bread and butter, tea. Supper. Sugar cookies, bread and butter, tea. HOSPITAL DIETARIES 877 Saturday Breakfast. Cold roast beef, oatmeal, boiled potatoes, bread and butter, tea or coffee. Dinner. Corned beef, boiled cabbage, boiled "potatoes, bread and butter, tea. Supper. Corn and wheat bread, cheese, butter, tea. Sunday Breakfast. Boiled eggs, oatmeal, boiled potatoes, bread and butter, tea or coffee. Dinner. Cold boiled ham, boiled potatoes, pickled beets, canned corn, bread and butter, tea. Supper. Ginger cookies, bread and butter, tea. Fresh vegetables and fruits in their season. Extra diet may be ordered as follows: Milk toast, dry toast, egg on toast, beef tea, beefsteak, chops, ham, scrambled eggs, fried and boiled eggs, baked custard, cornstarch, rice and milk, gruel, sauce, hot milk, and chocolate. For each patient the daily allowance is : Butter 1 J oz. Sugar 1 J Potatoes 11 Coffee ^ T Tea | ' Flour Ill ' Fresh beef 10 Fresh vegetables in season and in varying amount. Extra Diet f Milk toast (for breakfast) \ mv. A- J ** te (<* extra <*> / ^ *""* * Acute mania. , ) Gruel (at night). Melancholia. Melancholia, re- fusing food fed by tube twice daily. (about three quarts daily). Breakfast Egg on toast ( no coffee ) . Dinner Steak ( rare ) or chops, fresh vegetables. Supper Gruel, sauce (apple), custard or boiled egg- Milk, one quart. Three eggs. Cod-liver oil. Whisky. Sugar. Salt. Pancreatin, three grains. Pepsin, three grains. Sodium bicarbonate, fifteen grains. This amount given twice a day is varied once a week by chicken or mutton broth. " Two of the patients fed by tube with this combination for over a year remained in good condition" (Whitmore Steele). In the Cochin Hospital in Paris there are 8 classes of diet as follows : The diet for healthy persons, for convalescents, for dyspeptics, for the tuberculous and for diabetics, the milk-vegetable diet, the exclu- sive milk diet and the salt-free diet. 878 DIETARIES, RATIONS DIETARY FOR LIVERPOOL INFIRMARY Sample Diet suggested for the Liverpool Infirmary and other English Hospitals Sick. Normal. Convalescence. Breakfast, 8.30 A. M. h pt. milk. 3 oz. bread or oatmeal 2 pt. of new milk. 6 oz. bread. 2 oz. oatmeal. 1 pt. new milk. 8 oz. bread. 3 oz. oatmeal. Dinner, 1.30 P. M. Supper, 6.30 to 7 P. M. Bed at 8 P. M. If cocoa or coffee is given with sugar, omit the oatmeal and give 1 pt. of milk. | pt. of milk, made into pudding with rice, sago, etc. J pt. beef tea. 4 oz. bread. Meat, 4 oz. (men). Meat, 4 oz. " 3 oz. Bread, 8 oz. Potato, 8 oz Cheese, 1 oz. 3 oz. (women). Bread, 6 oz. Potato. 8 oz. Cheese, J oz. Same for all as the breakfast, but with addition of a cereal. | pt. broth with boiled meat. Salt ad libitum. Malt liquor as exceptional treat. Total bread, 18 oz. Total bread, 24 oz. Full Dietaries for Children at Various English Hospitals (Chambers) Age. Bread. Butter. Milk. Meat. Vegeta- bles. Pudding? Hospital. Under 7. Un- 1 OZ. Jpt. 2oz. 4 oz. Unlimited. St. George's. limited. Under 7. 12 oz. ? Ipt. 2oz. Soz. Twice London. a week. Under 8. 5| oz. About Jpt. 2oz. 4oz. 4 pint. Children's Hospi- oz. tal, Great Or- mond Street, and Evelina Hospi- tals. Under 8. 8 oz. About ? 2 oz. 4 oz. Leed's Infirmary. 1 oz. Above 8. Soz. About |pt. 3oz. 6oz. Gruel, Children's, Great loz. broth. S pint. Ormond Street Ipt. and Evelina Hos- pitals. Under 9. Goz. V Ipt. 2 oz. Coz. i pint gruel Birmingham Gen- or broth. eral Hospital. Under 9. 7 oz. I oz. Ipt. 4 oz. 4oz. To order. St. Bartholomew's. Under 10. 12 oz. I oz. Ipt. 2 oz. 4oz. Goz. St. Thomas's. Under 10. Goz. 1 11 pt. 2 eggs. f Soz. King's College. HOSPITAL DIETARIES Diet of Northeastern Hospital for Children, London 879 Milk diet. Fish Diet. Full diet. Breakfast, 7 A. M. Dinner, 12 M Milk, J pt. ; bread, 2 oz., with butter. Milk J pt. rice 01 Milk or cocoa, \ pt. ; bread, 2J oz., with butter. Fish boiled, 2J oz. Milk or cocoa, J pt. ; bread, 2J oz., with butter. Roast boiled or Tea, 3.30 p. M Supper, 6 P. M. ... other milk pud- ding. Milk, i pt. ; bread, 2 oz., with butter. Biscuit ( cracker ) or slice of bread and butter. potatoes, mashed, 3 oz. ; bread, 1 oz. ; milk pud- ding. Milk, J pt.; bread, 2 oz., with trea- cle or butter. Bread, 2 oz., with butter, or cracker. minced mutton, or roast or minced beef, 2 J oz. ; mashed potatoes, 4 oz., to alternate with green vegetables bread, 1 oz.; milk pudding. Bread, 2J oz., wit"h butter, treacle, or drippings ; milk, J pt. Bread, 2 oz., with butter, or cracker. Dietary of the Kaiser and Kaiserin Friedrich Children's Hospital, Berlin, for children 5 to 9 years of age. There are three diets, I, II, and III, affording respectively about 2,000, 1,800, and 1,100 calories. (The figures in the columns represent grams.) I II. III. First Meal Milk (or for 1 oatmeal with molasses or mar- malade ) . . 500 100 80 50 333 50 40 '56 10 1 333 250 '75 250 333 50 40 250 1 333 333 250 1 333 333 Crackers Or zwieback Second Meal Bread or crackers Crackers Butter 15 Effff Relishes 30 333 250 Milk Third Meal Effff .... 125 332 Vegetable puree Fourth Meal Milk ass 50 Fifth Meal 250 1 30 Or sausage . 880 DIETARIES, RATIONS Dietary of the Kaiser and Kaiserin Friedrich Children's Hospital, Berlin, for children 10 to 14 years of age : There are three diets, I, II, and III, affording respectively about 3,200, 2,900, and 1,800 calo- ries. (The figures in the columns represent grams.) I. II. III. First Meal Milk or oatmeal with molasses or marmalade . . 500 100 .333 100 500 Second Meal 120 50 Butter 30 15 1 && 30 Milk 500 333 500 Third Meal Bouillon broth or milk soup (porridge) 250 250 333 150 75 Effff 1 666 333 Potatoes 300 25 Fourth Meal Milk 500 333 500 Crackers 100 100 Fifth Meal 120 Crackers 50 Alilk soup 333 333 333 Or milk and 400 333 Ess 1 1 Or sausage 30 DIETARIES OF ARMY HOSPITALS United States Army Hospitals Special Diet. The medical officer will select from this list ac- cording to his discretion: Bread, butter, coffee, tea, toast (dry), toast (milk), eggs (boiled), eggs (poached), milk, beefsteak, milk por- ridge, ham, beef extract, oatmeal mush and milk, chicken (stewed), chicken broth, mutton chop, mutton broth, chocolate, oysters (stewed), beef tea, rice (boiled), farina pudding, cornstarch, crackers (soda or cream), potatoes (baked), potatoes (mashed), beef essence, macaroni (boiled), canned peaches (stewed), canned apples (stewed), canned pears, grapes, oranges, lemons, apples, watermelons, cantaloupes, etc. DIETARIES OF ARMY HOSPITALS 881 The following comprises the list of articles allowed in the ration of the II. S. A. post hospitals : BREAKFAST Bread 6 ounces. Butter i ounce. Coffee 1 pint. Tea 1 " Toast, dry 4 ounces. Toast, milk 6 " Eggs, boiled 1 Eggs, poached 1 Milk 12 ounces. Beefsteak 6 " Milk porridge 1 pint. Ham 4 ounces. Beef essence 2 " DINNER Bread 4 ounces. Chicken, stewed 6 " Chicken broth 1 pint. Mutton chop 6 ounces. Mutton broth , 1 pint. Milk 12 ounces. Oysters, stewed 1 gill. Beef tea 12 ounces. Rice, boiled 1 ounce. Farina pudding 4 ounces. Cornstarch pudding 4 " Milk porridge 1 pint. Beefsteak 6 ounces. Potatoes, mashed 6 " Beef essence 2 " SUPPER Tea 1 pint. Butter \ ounce. Bread 4 ounces. Toast, dry 4 " Milk 12 " Eggs 1 Milk porridge 1 pint. Beef essence 2 ounces. Following is the dietary issued for one of the largest United States General Hospitals situated at the Presidio of San Francisco, Cali- fornia : 882 DIETARIES, RATIONS UNITED STATES ARMY GENERAL HOSPITAL BREAKFAST. DINNER. SUPPER. Sunday. Oatmeal and milk Vermicelli soup. Veal stew or boiled ham. Ham and eggs. Bread and butter. Roast veal, sage dressing, or Turkey or chicken and dress- Apple sauce. Cake. Fruit. ing. Bread and butter. Coffee. Stewed peas. Mashed pota- Tea. toes. Farina pudding. Fruit. Bread and butter. Coffee. Monday. Germea and milk. Roast beef. Codfish balls or hash. Beefsteak. Mashed potatoes. String Bread and butter. Fried potatoes. beans. Pickles. Bread and butter. Fruit. Tapioca pudding. Bread and butter. Fruit. Jam. Sweet crackers. Prunes. Tea. Coffee. Coffee. Tuesday. Oatmeal and milk. Vegetable soup. Fried liver and bacon. Sausage. Baked pork and beans. Corn bread and sirup or Fried potatoes. Baked tomatoes. Biscuits. Bread, butter, Bread pudding. Bread, butter, tea. coffee. Bread, butter, cocoa, fruit. Fruit. Fruit. Wednesday. Milk toast. Roast mutton with dressing. Mutton stew. Beefsteak. Mashed potatoes. Pickles. Sweet crackers. Bread. butter, coffee. Corn or fresh vegetables. Chocolate pudding. Fruit. Bread, butter, tea. Peach cobbler. Fruit. Bread, butter, coffee. Thu rsday. Germea and milk. Hash. Oyster soup. Corned beef and cabbage. Sliced roast beef. Macaroni and cheese. Bread, butter, Boiled potatoes. Radishes. Preserves. coffee. Rice pudding. Fruit. Bread and butter. Fruit. Bread, butter, coffee. Tea. Friday. Oatmeal and milk. Baked fish with sauce. Salmon salad. Potato salad. Bacon and eggs. Bread, butter, coffee. Plain boiled potatoes. Fresh salad. Farina pudding. Fruit. Apple sauce. Ginger crackers. Bread and butter. Fruit. Bread, butter, cocoa. Tea. Saturday. Germea and milk. Roast beef, veal or pork. Baked hash or stew. Beefsteak. Mashed potatoes. Stewed prunes. Fried potatoes. Hot slaw. Cauliflower Assorted cakes. Bread, butter, Bread pudding. Bread and butter. coffee. Bread, butter, coffee. Tea. Fruit, DIETARIES OF ARMY HOSPITALS 883 LIGHT DIET BREAKFAST. DINNER. Sunday Oatmeal and milk. Rice soup. Soft-boiled eggs. Farina pudding. Milk toast. Coft'ee. Coffee. Plain tomato soup. Bread pudding with lemon sauce. Coffee. Monday. Germea and milk. Milk toast. Boiled eggs. Coffee. Tuesday. Oatmeal and milk. | Barley soup. Boiled eggs. Tapioca pudding. Coffee. Cocoa. Wednesday. Oatmeal and milk. Soft-boiled Coffee. eggs. Consomme" vermicelli. Cornstarch pudding. Vanilla sauce. Coffee. Thursday. Germea and milk. Oyster soup. eggs. Rice pudding. Boiled Coffee. Coffee. Friday. Oatmeal and milk. Fish chowder. Boiled eggs. .Farina pudding. Milk toast. Coffee. Cocoa. Saturday. Oatmeal and milk. : Vermicelli soup. Boiled eggs. Sago pudding. Coffee. Coffee. SUPPEK. Milk toast. Cup custard. Tea. Farina mush and milk. Sweet crackers. Jelly. Toast. Tea. Biscuits or corn bread. Maple sirup. Boiled rice. Milk toast and tea. Sweet crackers. Milk toast. Tea. Jam. Macaroni and cheese. Milk toast. Maple sirup. Tea. Tapioca pudding. Milk toast. Ginger crackers. Boiled eggs. Tea. Germea mush. Assorted cakes. Milk toast. Tea. Jelly. In addition to the regular diet table a special diet list is provided for use of ward surgeons for cases requiring this class of diet ; it also contains a list of broths intended for liquid diets. DIETARIES, RATIONS Ward. Daily Order List of Special Diet U. S. A. GENERAL HOSPITAL, Presidio of San Francisco,. .... .1900. K. D. S. Number of light diets Number of full diets . Stewed chicken Chopped beef Steaks Mutton chops Baked potatoes French-fried potatoes . Saratoga chips Creamed potatoes Baked apples Wine jelly Cup custard Milk toast Poached eggs Coffee Tea BROTHS Beef broth Mutton broth Chicken broth Consomme" broth Oyster broth Ward Officer. British Army Hospitals The following statement is quoted from a report made by General Alfred A. Woodhull, who was sent abroad by the U. S. Army De- partment to investigate certain medical features of the British army : " The British army hospital uses seven diets, known as tea, milk, beef tea, chicken, convalescent, roast, and varied. Each is formulated with exactness, and parts of two diets may not be ordered together. The tea diet is: Bread, twelve ounces; tea, half an ounce; sugar, two and a half ounces; milk, six ounces. The varied diet is: Beef or mutton, twelve ounces without, or fifteen ounces with, bone ; bread, eighteen ounces; tea, half an ounce; sugar, one and a half ounce; milk, six ounces; butter, one ounce; potatoes, sixteen ounces; vegeta- bles, four ounces, with salt, pepper, and mustard, and optionally wine, spirits, malt liquors, and diet drinks may be ordered. These diets represent the extremities of the scale through which the others run. DIETARIES OF ARMY HOSPITALS 885 The ordinary drinks allowed for patients are: Barley water, rice water, gruel, and lemonade, each prepared by formula." Prussian Army Hospitals In four grades of diet in Prussian military hospitals the propor- tionate allowance of food classes is as follows : I. II III. IV. Albumin 115 81 52 18 Fat 55 39 32 15 Carbohydrates 522 315 127 French Army Hospitals Kirchner gives the following analysis of the nutrient ingredients of the seven different classes into which diet in the French military hospitals is divided. " Absolute diet" (diet absolue) is practical starvation, at most, only a little toast water being given, and is of temporary service only : Albumin. Fats. Carbohydrates. Full diet Grams 119 Grams. 57 Grams. 448 diet 91 47 357 1 " 70 39 225 1 " 35 25 134 ft " 19 17 89 Bread diet 14 36 89 Absolute diet APPENDIX EECEIPTS FOE INVALID'S FOOD AND BEVEEAGES, SUIT- ABLE FOE FEVEES AND CONVALESCENCE FEOM ACUTE ILLNESS BEVERAGES i. Demulcent and Nutritive Barley Water (Pavy). Take two ounces of pearl barley and wash well with cold water, rejecting the washings. Afterwards boil with a pint and a half of water for twenty minutes in a covered vessel, and strain. The product may be sweetened and flavored with lemon peel, or lemon peel may be introduced while boiling is carried on. Lemon juice is also sometimes added to flavor. A bland, demulcent, and mildly nutritive beverage. Barley Water (Bartholow). Wash two ounces of pearl barley with cold water; boil for five minutes in fresh water, and throw both waters away ; pour on two quarts of boiling water, and boil down to a quart. (Stir and skim occasionally.) Flavor with thinly cut lemon rind; add sugar to taste, but do not strain unless at the patient's request. Barley Water (Ringer) . To a tablespoonf ul of pearl .barley washed in cold water add two or three lumps of sugar, the rind of one lemon, and the juice of half a lemon. On these pour a quart of boiling water, and let the mixture stand for seven or eight hours. Strain. The barley water should never be used a second time. Half an ounce of isinglass may be boiled in the water. If not needed at once, these barley preparations should be kept in the refrigerator and warmed when required. Rice Water or Mucilage of Rice (Pavy). Thoroughly wash one ounce of rice with cold water. Macerate for three hours in a quart of water kept at a tepid heat, and afterwards boil slowly for an hour, and strain. A useful drink in dysentery, diarrhoea, and irritable states of the alimentary canal. It may be sweetened and flavored in the same way as barley water. 887 888 APPENDIX Demulcent Drink (Ringer). Take a pinch of isinglass, and boil it in half a pint of new milk with half a dozen bruised sweet almonds and three lumps of sugar. Linseed Tea (Chambers). Whole linseed, white sugar, each one ounce; licorice root, one half ounce; lemon juice, two ounces. Mix. An agreeable dumulcent. Flaxseed Tea. One-half cupful of flaxseed to one quart of boil- ing water; boil thirty minutes and let stand a little while near the fire to thicken more. Strain, and add lemon juice and sugar. Currant Jelly (Fagge). Red or black currant jelly, dissolved in hot or cold water, or strained tamarind tea, make excellent invalid beverages. 2. Diuretic and Refrigerant Lemonade (Pavy). Pare the rind from a lemon thinly, and cut the lemon into slices. Put the peel and sliced lemon into a pitcher with one ounce of white sugar, and pour over them one pint of boiling water. Cover the pitcher closely, and let stand until cold. Strain or pour off the liquid. Citron may be used, instead of lemon, and like- wise furnishes a soothing and refrigerant beverage. Lemonade, Effervescing (Ringer). To the expressed juice of a large lemon add a lump or two of sugar previously lightly rubbed on the rind. Pour on it half a pint of cold or iced water. To cause it to effervesce put it into a large tumbler and add half a teaspoonful of bicarbonate of soda or potash. Stir and drink while effervescing. A very agreeable and refreshing beverage. Lemonade (Ringer). Pare the rind of three lemons as thin as possible, add one quart of boiling water and a quarter of an ounce of isinglass. Let them stand till next day covered; then squeeze the juice of eight lemons upon half a pound of lump sugar; when the sugar is dissolved, pour the lemon and water upon them, mix all well together, strain, and it is ready for use. Orangeade ( U. S. Army Hospitals) . One orange. One teaspoon- ful of sugar. Three-fourths of a coffee cup of water (six ounces). Wash and wipe the orange. Squeeze the juice into the sugar. Add the cold water, previously boiled. Strain and serve. Cream-of-tartar Drink. Potus Imperialis. Imperial Drink (Pavy). Dissolve a drachm or a drachm and a half of cream of tartar in a pint of boiling water, and flavor with lemon peel and sugar. When cold, strain and take ad libitum as a refrigerant drink and diuretic. Cream-of-tartar Whey (Pary). Stir a quarter of an ounce of BEVERAGES 889 cream of tartar (a large teaspoonful piled up) into a pint of boiling milk, and strain. A refrigerant and diuretic drink, which is rendered more agreeable by the addition of sugar. Raspberry Vinegar (Maria Parloa). Put four quarts of rasp- berries in a bowl and pour over them 2 quarts of vinegar. Cover and set in a cool place for two days. On the second day strain the vinegar through cheese cloth. Put 4 quarts of fresh raspberries in the bowl and pour over them the vinegar strained from the first rasp- berries. Put in a cool place for two days, then strain. Put the strained juice in a preserving kettle with 3 quarts of sugar. Heat slowly, and when the vinegar boils skim carefully. Boil twenty min- utes, then put in sterilized bottles. About 2 tablespoonfuls of vinegar to a glass of water makes a refreshing drink. Similar vinegars may be made from blackberries and strawberries. White Wine Whey or Posset (Pavy). To half a pint of milk while boiling in a saucepan add one wineglassful of sherry or white wine and afterwards strain through a muslin cloth. Sweeten with pounded sugar according to taste. A useful diuretic drink in colds and mild febrile disorders. For a child, give a tablespoonful every two hours. Wine Whey. Milk, one pint; wine of pepsin, one teaspoonful. Heat gently to 115 or 120 F., let stand, break the curd, strain, and add sherry in the proportion of 1 to 8 or 10. Drink cold. Tamarind Whey (Pavy). Stir two tablespoonfuls of tamarinds into a pint of milk while boiling, and afterwards strain. This forms a refrigerant and slightly laxative drink. Mulled Wine (Ringer). Boil some spice, cloves, nutmeg, cinna- mon, or mace in a little water to flavor the wine ; add a wineglassful of sherry, port or other wine and some sugar; bring it to the boiling point, and serve with sippets of toast. If claret is used, it will re- quire more sugar. 3. Milk Beverages Koumiss, kephir, matzoon, malted milk, whey, skimmed milk, but- termilk, milk diluted with equal parts of Vichy, carbonic water, or lime water ; milk flavored with coffee, caramel, vanilla, or spice ; cream diluted with water or Vichy to the consistency of milk. FLUID BEEF PREPARATIONS Beef Juice (Bartholow). Broil quickly some pieces of round or sirloin of a size to fit in the cavity of a lemon squeezer previously 890 APPENDIX heated by being dipped in hot water. The juice, as it flows away, should be received into a hot wineglass, and, after being seasoned to the taste with salt and a little Cayenne pepper, taken while hot. Beef Essence (Yeo). Cut the lean of beef into small pieces and place them in a wide-mouthed* bottle securely corked, and then allow it to stand for several hours in a vessel of boiling water. This may be given to infants, who cannot take milk, in teaspoonful doses, and in larger quantities to adults. Beef Tea (Pavy) . Put a pound of finely minced beef into a suit- able vessel with a pint of cold water. Let it stand for an hour, stir- ring occasionally. Place the vessel containing the beef into a sauce- pan of water, place over the fire, and allow the water to boil gently for an hour (or the vessel containing the beef tea may be put into an ordinary oven for an hour). Pass the beef tea through a strainer. It contains a quantity of fine sediment, which should be drunk with the liquid. Flavor with salt. In this process the beef extract should not be exposed to a temperature of more than 170 F. Beef Tea (Bryce). Lean beef, chopped fine, free from fiber, one pound ; water, one pint ; sodium bicarbonate, ten grains ; simmer half an hour in a glass-covered preserve jar, decant the fluid, squeeze the meat to a pulp in a lemon squeezer, return both to jar, add extract of pancreas, cover, keep at 140 F. for twelve hours, shaking occasionally. When an acid taste appears, boil two or three minutes to stop further fermentation. This tea, it is claimed, equals the same bulk of peptonized milk in nutrient value. Chrystie's Beef Tea. Macerate for one hour one pound of finely minced lean beef in a pint of water, containing fifteen grains of sodium chloride and five drops of dilute hydrochloric acid, at 100 F. Filter through cheese cloth, and wash the residue with half a pint of fresh water. The filtrate is transparent, has a not unpleasant taste, and contains a considerable amount of albuminoids. A child of two years may take two or three ounces daily. Beef Tea (Bartholow). Chop fine a pound of lean beef free from fat, tendons, etc., and digest with a pint of cold water for two hours. Let it simmer on the stove for three hours, at a temperature never over 100 F. Make up the water lost in evaporation by adding cold water, so that a pint of beef tea shall represent a pound of beef. Strain, and carefully express all fluid from the beef. Beef Tea (U. S. Army Hospital Receipt for Twelve Men). Beef, twelve pounds : salt, one ounce. The beef should be lean and juicy, and cut into small pieces. Put BROTHS AXD SOUPS 891 it into one gallon and a half of cold water with the salt. Let it boil gently for three hours. If it should boil away too fast, add the req- uisite quantity of boiling water and let it boil fifteen minutes longer. When done it should measure twelve pints. Set it aside to cool. Eemove every particle of grease, and heat when required. In case of a deficiency of fresh beef, use the beef extract supplied in the hospital stores. Beef Extract (U. S. Army Hospital Receipt for Twelve Men). Infuse a third of a pound of fresh beef, finely minced, in fourteen ounces of cold soft water, to which a few drops (four or five) of muriatic acid and a little salt (from ten to eighteen grains) have been added. After digesting for an hour to an hour and a quarter, strain it through a sieve and wash the residue with five ounces of cold water, pressing it to remove all soluble matter. The mixed liquid will contain the whole of the soluble constituents of the meat (albu- min, creatin, etc.), and it may be drank cold or slightly warmed. The temperature should not be raised above 100 F., as at the temperature of 113 F. a considerable portion of the albumin, a very important constituent, will be coagulated. Meat Extract (Rosenthal and Leube). One thousand grams ojf lean meat, minced fine, are placed in a porcelain vessel with one thousand grams of water, and twenty centigrams of dilute hydro- chloric acid. This is placed in a closed Papin's digester and boiled for ten to fifteen hours. The mass is then taken out and rubbed in a mortar to a paste. It is again boiled in the closed digester for another sixteen to twenty hours; after this it is neutralized with pure sodium carbonate, and evaporated to a sirupy consistence. Restorative Beef Essence (Ringer). Take one ounce of fresh beef, free from fat, chop fine, and pour over it eight ounces of soft water, add five or six drops of dilute hydrochloric acid, and fifty or sixty grains of common salt, stir well, and leave for three hours in a cool place. Then pass the fluid through a hair sieve, pressing the meat slightly, and adding gradually toward the end of the strain- ing about two more ounces of water. The liquid thus obtained is of a red color, possessing the taste of soup. It should be taken cold, a teaspoonful at a time. If preferred warm, it must not be put on the fire, but heated in a covered vessel placed in hot water. BROTHS AND SOUPS Chicken Broth (BartlioJow). Skin and chop up fine a small chicken or- half a large fowl, and boil it, bones and all, with a blade 892 APPENDIX of mace, a sprig of parsley, and a crust of bread, in a quart of water for an hour, skimming it from time to time. Strain through a coarse colander. Chicken, Veal, or Mutton Broth (Yeo). Chicken, veal, or mutton broth may be made like beef tea, substituting chicken, veal, or mut- ton for beef, boiling in a saucepan for two hours, and straining. For chicken broth the bones should be crushed and added. For veal broth the fleshy part of the knuckle should be used. Either may be thickened and their nutritive value increased by the addition of pearl barley, rice, vermicelli, or semolina. Mutton and Chicken Broths (Osier). Mince a pound of either chicken or mutton, freed from fat, put into a pint of cold water, and let stand in a cold jar on ice two to three hours. Then cook three hours over a slow fire, strain, cool, skim off fat, add salt, and serve hot or cold. Such broth is much better than any manufactured meat preparations. Good mutton broth is difficult to make on account of the meat containing so much fat. Chicken Broth (U. 8. Army Hospital Receipt for Twelve Men). Chicken, one ; salt, two ounces ; flour, two ounces. Cut the chicken into pieces. Put it with the salt into the kettle with twelve pints of cold water. Let it simmer gently two or three hours, carefully and frequently skimming off the grease. Make a paste of the flour with some cold water; stir it in and boil ten minutes longer. It should measure ten pints when done. Mutton Broth (U. 8. Army Hospital Receipt for Twelve Men). Mutton, six pounds; salt, two ounces; rice, two ounces. Break the bones without separating the meat. Put it into twelve pints of cold water, with the salt and rice or barley. Boil gently two hours and a half, carefully removing all the scum and fat. If the broth should boil away too much, add the requisite quantity of boiling water to make twelve pints, and let it boil fifteen minutes longer. Invalid Broths. To one pound of chopped lean meat, either chicken, mutton, or beef, add one pint of cold water (or one pint and a half on ice for a young infant), let stand in a covered glass fruit jar for four to six hours, cook for three hours in a closed jar over a slow fire, strain, cool, skim off the fat, clear with egg, season, and feed warm or cold. Bouillon (Broth) as TJsed in the Hospitals of Paris (Yeo). Eaw meat, without bone, one kilogram; fresh vegetables, four hundred grams (about one pound) ; salt, ten grams (about one hundred and fifty grains). Boil very slowly over a gentle fire. SOLID MEAT PREPARATIONS 893 Nourishing Soup (Ringer}. Stew two ounces of the best well- washed sago in a pint of water till it is quite tender and very thick; then mix it with half a pint of good boiling cream and the yolks of two fresh eggs. Blend the whole carefully with one quart of essence of beef. The beef essence should be heated separately, and mixed while both mixtures are hot. A little of this may be warmed at a time. Consomme'. Consomme may be flavored with vegetable extracts or expressed juice of vegetables boiled in it. Thicken soups with arrowroot, ground rice, or cornflour. Beef Tea with Oatmeal (Anderson). This forms a very nutritious food. Take two tablespoonfuls of oatmeal and two of cold water and mix them thoroughly; then add a pint of good beef tea which has just been brought to the boiling point. Boil together for five minutes, stirring it well all the time, and strain through a hair sieve. SOLID MEAT PREPARATIONS Eaw-meat Diet (Ringer). From two ounces of rump steak take away all fat, cut into small squares without entirely separating the meat, place in a mortar, and pound for five or ten minutes; add three or four tablespoonfuls of water and pound again for a short time, afterwards removing all sinew or fiber; add salt to taste. Be- fore using, place the cup or jar containing the pounded meat in hot water until warm. Or scrape the beefsteak with a sharp knife and, after removing all fat and tendon, if not already in a complete pulp, pound in a mortar. Flavor with salt and pepper. This may be taken in the form of a sandwich between thin bread and butter or mixed with water to the consistence of cream. If preferred, the meat may be rolled into balls with a little white of egg and broiled for two min- utes, or until the outside turns gray just long enough to remove the raw taste. This diet is excellent for children with diarrhoea, also for adults who suffer from irritable bowels or chronic diarrhoea. Scraped Beef (U. 8. Army Hospitals). Cut a piece of steak from the round, about half a pound in weight and about an inch thick. Lay it on a clean meat board and with a dull knife scrape out the pulp until there is nothing left but stringy fiber. Season the scraped pulp with salt and make it into small cakes. Broil for two minutei either by direct heat over a clear fire, or by heating a clean pan or plate and, when hot, placing the meat on it. Have both sides cooked 894 APPENDIX sufficiently. This is a safe food for a patient beginning to take solid nourishment. Scraped beef may be prepared very easily over an alcohol lamp. Scraped-beef Sandwiches ( U. 8. Army Hospitals) . Place a piece of round steak on a meat board and scrape out all of the pulp with a dull knife; add to the pulp a little salt and pepper and enough raw beef juice to make it into a firm jelly. Have stale bread cut into very thin slices and spread the beef pulp on them; cut the sandwiches quite small. Never use butter in making beef sand- wiches. Meat Biscuits (ParJces) . Mix together, cook, and bake one pound of flour, one pound of meat, one-quarter of a pound of suet, one-half pound potatoes with a little sugar, onion, salt, pepper, and spices. A palatable meat biscuit, weighing about one pound and a quarter, containing 10 to 12 per cent of water, is thus obtained which keeps quite unchanged for four months. Raw-meat Sandwiches (from "Food"). Three ounces of raw beef or mutton, one ounce of very fine bread crumbs, one teaspoonful of sugar; cut the meat very fine, rub it through a hair sieve, then pound it in a mortar into a paste. Mix with it the bread crumbs, sugar, a little salt and pepper ; spread it between thin slices of either brown or white bread and butter. Chicken Jelly (Adams). Clean a fowl that is about a year old, remove skin and fat; chop fine, bones and flesh, place in pan with two quarts of water; heat slowly; skim thoroughly; simmer five to six hours; add salt, mace, or parsley to taste, strain; cool. When cool, skim off the fat. The jelly is usually relished cold, but may be heated. Give often in small quantities. Enema of Meat and Pancreas (Leube}. Mince from one hundred and fifty to three hundred grams of meat, and mix with fifty to one hundred grams of finely chopped pancreas, free from fat. Beat the mixture into a paste with a pestle or spoon, adding a little lukewarm water to make it of a suitable consistence for injection through the enema tube. Use warm; if cold it may excite the rec- tum and cause expulsion. If thought desirable, from twenty-five to fifty grams of fat may be mixed intimately with the mass by the help of a warm pestle. A syringe with a wide nozzle must be used. MILK PREPARATIONS Milk-and-cinnamon Drink (Ringer}. Boil in one pint of new milk sufficient cinnamon to flavor it pleasantly, and sweeten with white MILK PREPARATIONS 895 sugar. This may be taken cold with a teaspoonful of brandy, and is very good in cases of diarrhrea. Children may take it warm with- out brandy. Albuminized Milk (U. S. Army Hospitals). Beat up the white of an egg till light. Add a good-sized pinch of salt, and four ounces of fresh, cool milk which has been sterilized. A little sugar may be added if desired. Milk Punch. Make by adding brandy or whisky or rum to milk in the proportion of about one to four or six parts of milk; flavor with sugar and nutmeg; shake well. Sherry or Brandy and Milk (Ringer) . To one tablespoonful of brandy or one wineglassful of sherry, in a bowl or cup, add pow- dered sugar and a very little nutmeg to taste. Warm a breakfast- cupful of new milk and pour into a pitcher. Pour the contents from a height over the wine, sugar, etc. The milk must not boil. Rum and Milk (Fothergill) . Half a pint of new milk, one egg. one to two teaspoonfuls of powdered sugar, grated nutmeg, one to two teaspoonfuls of good old Jamaica rum. Mix. Junket (Anderson). Sweeten with white sugar one pint of good milk. If wine is allowed, a dessertspoonful of sherry is an improve- ment. Heat to new milk warmth, pour into a shallow dish, and stir in two teaspoonfuls of essence of rennet. This will form a slight curd. Grate a little nutmeg over it or add a pinch of powdered cinnamon. Serve when quite cold. In cold weather the milk should be placed in a warm room to set. An excellent food, and good sub- stitute for milk in typhoid fever, etc. Artificial Human Milk (FranJcland) . Allow one-third of a pint of new milk to stand twelve hours, remove the cream, and. mix it with two-thirds of a pint of perfectly fresh cow's milk. Take the milk from which the cream was removed and put a piece of rennet about an inch square (fluid rennet may be employed) into it. Keep the vessel containing it in a warm place until the milk is fully curdled, an operation requiring five to fifteen minutes, according to the activity of the rennet, which should be removed as soon as the curdling commences, and put into an eggcup for use on subsequent occasions, as it may be employed daily for a month or two. Break up the curd repeatedly, and carefully separate the whole of the whey, which should then be heated rapidly to boiling in a small tin pan, placed over a spirit or gas lamp. During the heating a further quantity of casein [albumin?], technically called "fleet- ings," separates, and must be removed by straining tli rough clean muslin. Xow dissolve one hundred and ten grains of powdered 896 APPENDIX sugar of milk in the hot whey, and mix it with two-thirds of a pint of new milk to which the cream from the other fluid has been added, as already described. The artificial milk should be used within twelve hours of its preparation. Biedert's Cream Mixture. Mix four ounces of cream with twelve ounces of warm water and add one-half ounce of milk sugar. Koumiss (Anderson). To one pint of new milk add three ounces of water, three ounces of old koumiss (for a ferment), and one ounce of saturated solution of sugar of milk. Put all in a large jug, cover carefully, and set the jug in a warm place for twenty-four hours. By that time a thick crust will have formed on the surface of the mixture; beat this up thoroughly and mix all well. Then put the whole into champagne bottles, which should be no more than two- thirds full, and cork and wire. Shake the bottles daily. The kou- miss will be fit for use in two days, but it is much improved by keeping for about six weeks. It should be drawn off with a tap. Home-made Koumiss. Boil fresh milk, and when nearly cold put into quart bottles, leaving room to shake. Add half an ounce of crushed lump sugar and a piece of Vienna yeast the size of a hazel nut (i. e., twenty grains), cork with new corks, tie down, keep cool, lay the bottles horizontal, but shake twice daily. Eeady to drink on the sixth day, or earlier in hot, later in cold weather. The koumiss may be made thinner by using skimmed milk. Home-made Lime Water. Pour two quarts of hot water over fresh, unslacked lime (size of a walnut), stir till slacked, let stand till clear and bottle. Often ordered with milk to neutralize acidity of the stomach. 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 Peptonized Kindermilch. One or two drachms of Benger's Liquor Pancreaticus with fifteen grains of sodium bicarbonate will completely peptonize half a pint of milk in a few minutes if the bottle be immersed in water which is heated, but which is not too hot for the hand to bear. Eoberts's rule for pancreatinized 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 teaspoonfuls 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 EGG PREPARATIONS 897 peptonized, but the starch of the material is converted into sugar and its albuminates are peptonized. The bitterness of the pepton- ized milk is scarcely perceptible in this gruel." EGG PREPARATIONS Eggnog. Eggnog is made by adding the beaten yolk of an egg and a little spirits to a tumblerful of milk, stirring well, adding sugar and the white of the egg, separately beaten. The digestibility of both of these highly nourishing and stimulating preparations is enhanced by the addition of half an ounce of lime water, which does not affect the taste. Egg and Wine (Ringer). Take one egg, half a glass of cold water, one glass of sherry, sugar, and a very little nutmeg grated. Beat the egg to a froth with a tablespoonful of cold water. Make the wine and water hot, but not boiling; pour on the egg, stirring all the time. Add sufficient sugar to sweeten, and a very little nut- meg. Put all into a porcelain-lined saucepan over a gentle fire and stir one way till it thickens, but do not let it boil. Serve in a glass with crisp biscuits or sippets of toast. Eggnog (Bartholow). Scald some new milk by putting it, con- tained in a jug, into a saucepan of boiling water, but it must not be allowed to boil. When quite cold beat up an egg with a fork in a tumbler with some sugar; beat quite to a froth; add a dessertspoon- ful of brandy and fill up the tumbler with scalded milk. A nutritive drink in acute disease. Brandy and Egg Mixture (British Pharmacopoeia). Eub together the yolks of two eggs and half an ounce of refined sugar, and add four ounces of Cognac and four ounces of cinnamon water. A more generally useful mixture may be made with half this quantity of brandy. Stokes's Cognac Mixture. Best Cognac, distilled water, each fif- teen ounces ; yolk of one egg ; sirup, six ounces. Mix. Give a table- spoonful every two or three hours. Egg and Brandy Mixture (Anderson). Beat up three eggs to a froth in four ounces of cold water and then add four ounces of brandy. Mix well and sweeten to taste. A little nutmeg may be added. Give a tablespoonful or so at a time. Lemonade with Eggs (Einger). The juice of four lemons, the rinds of two, half a pint of sherry, four eggs, six ounces of loaf sugar, one pint and a half of boiling water. Pare the lemon rind thinly, put it into a pitcher with the sugar, 59 898 APPENDIX and pour the boiling water on it. Let it cool, then strain, and add the wine, lemon juice, and eggs, previously well beaten and strained. Mix all together and it is ready for use. Savory Custard (Anderson). Add the yolks of two eggs to a cupful of beef tea, with pepper and salt to taste. Butter a cup or jam pot, pour the mixture into it, and let it stand in a pan of boiling water till the custard is set. Milk for Puddings or Stewed Fruit (Ringer). Boil a strip of lemon and two cloves in a pint of milk; mix half a teaspoonful of arrowroot in a little cold milk and add it to the boiling milk; stir it until about the consistence of cream. Have ready the yolks of three eggs beaten up well in a little milk. Take the hot milk off the fire and as it cools add the eggs and a tablespoonful of orange-flower water, stirring it constantly till quite cool. Keep it in a very cool place till required for use. Kice Soup (Ringer) . Take three ounces of rice, the yolks of two eggs, half a pint of cream or new milk, one quart of Stock. Boil the rice in the stock and rub half of it through a tammy, put the stock in a stewpan, add the rest of the rice whole, and sim- mer gently for five minutes. Have ready the milk or cream, boiled. Beat the yolks of the eggs and mix them gradually with the cream. Take the soup off the fire, add the cream and egg, stirring them well together as you mix them. Heat gradually, but do not boil, or the eggs will curdle. A Gruel (Ringer). Beat an egg .to a froth, add a wineglass of sherry, flavor with a lump of sugar, a strip of lemon peel, and a little grated nutmeg. Have ready some gruel, very smooth and hot, stir in the wine and egg, and serve with crisp toast. Arrowroot may be made in the same way. Caudle (Yeo). Beat up an egg to a froth; add a glass of sherry and half a pint of gruel. Flavor with lemon peel, nutmeg, and sugar. FARINACEOUS FOODS Arrowroot Blancmange (Ringer). Take two tablespoonfuls of arrowroot, three-quarters of a pint of milk, lemon, and sugar to taste. Mix the arrowroot with a little milk to a smooth batter ; put the rest of the milk on the fire and let it boil, sweeten, and flavor it, stirring all the time, till it thickens sufficiently. Put into a mold till quite cold. Arrowroot Blancmange (U. S. Army Hospitals). Two table- FARINACEOUS FOODS 899 spoonfuls of arrowroot. Two-thirds pint of hot water. Two table- spoonfuls of sherry or brandy. Two teaspoonfuls of sugar. Mix the arrowroot into a smooth paste with three tablespoonfuls of cold water. Add this to the hot water. Bring to a boil, stirring constantly till well blended and free from lumps. Let it boil for ten minutes. Add the sugar and sherry or brandy. Beat up quickly and pour into a bowl or mold to cool. Arrowroot blancmange may be made with fresh hot milk or condensed milk diluted. If boiling water is used it causes the starch of the arrowroot, when first poured in, to form into lumps. Hence it is best to have the water not quite at boiling point. Arrowroot (Pavy). Mix thoroughly two teaspoonfuls of arrow- root with three tablespoonfuls of cold water, and pour on them half a pint of boiling water, stirring well meanwhile. If the water is quite boiling, the arrowroot thickens as it is poured on, and nothing more is necessary. If only warm water is used, the arrowroot must be afterwards boiled until it thickens. Sweeten with loaf sugar and fla- vor with lemon peel or nutmeg, or add sherry, port wine, or brandy, if required. Boiling milk may be employed instead of water, but when this is done no wine should be added, as it would otherwise curdle. Oatmeal Gruel (plain) (from "Food"). Two tablespoonfuls of oatmeal, one saltspoonful of salt, one scant teaspoonful of sugar, one cupful of boiling water, one cupful of milk. Mix the oatmeal, salt, and sugar together, and pour on the boiling water. Cook for thirty minutes; then strain through a fine wire strainer to remove the hulls, place again on the stove, add the milk, and heat just to the boiling point. Serve hot. Scotch Beef Broth. To a pint of beef broth which has been care- fully strained and seasoned and from which all the fat has been removed, add a teaspoonful of oatmeal and boil gently for two hours. Strain and serve hot. In this preparation the oatmeal should be soft and jellylike, and if too much water evaporates during the boiling, more should be added. Cornstarch (U. S. Army Hospital Receipt for Twelve Men). Cornstarch, six ounces ; milk, three pints ; water, twelve ounces. Mix the cornstarch into a smooth paste with cold water. The milk and water must be boiling, to which add a little salt. Stir in the cornstarch. Let boil three or five minutes. Farina Pudding (U. S. Army Hospital Receipt for Twelve Men). Farina, half a pound ; milk, two pints ; water, one pint ; sugar, two and a half ounces; eggs, four ounces; nutmeg, half an ounce. 900 APPENDIX Put the water into a stewpan with a little salt. When it boils, stir in the farina. Let it boil twenty minutes. Stir in the milk, which must be hot. Beat the eggs until they are very light; mix the sugar with them. Stir in the eggs and sugar with the farina. Add the spice. Put it into a moderate oven and bake a half or three- quarters of an hour. Farina Gruel (U. 8. Army Hospitals). One tablespoonful of farina. One pint of water. One teaspoonful of sugar. One-half teaspoonful of salt. Into one pint of water, raised to boiling, put a half teaspoonful of salt; then add the farina and cook for twenty minutes. Flavor with sugar and condensed milk, if fresh milk is not available. Strain and serve hot. In this recipe, as in others, condensed milk is used in a strength of one teaspoonful to the half pint of gruel. Boiled Rice (U. S. Army Hospital Receipt for Twelve Men). Eice, twelve ounces; salt, half an ounce; water, three pints. Put the salt and water into a stewpan. When boiling, add the rice, previously thoroughly washed. Boil for ten minutes, or until each grain becomes soft. Drain on a colander. Grease the stew- pan with clarified drippings or lard. Put back the rice. Let it swell slowly near the fire, or in a slow oven, for about twenty minutes, until the grains are well separated. Rice Gruel (Chambers). Ground rice, two ounces; powdered cin- namon, quarter of an ounce; water, four pints. Boil forty minutes and add a teaspoonful of orange marmalade. Rice Gruel (U. S. Army Hospitals). Two tablespoonfuls of rice, or one tablespoonful of rice flour. One pint of boiling water. One- half teaspoonful of salt. One teaspoonful of sugar. Wash the rice thoroughly in two waters, after removing any specks that may be mixed in the grain. Have the cooking water boiling. Rice Milk (Anderson). Wash two tablespoonfuls of good rice and put it into a saucepan with a quart of milk. Let it simmer gently till the rice is tender, and stir from time to time to prevent burning; sweeten to taste. If desirable, it may be served with stewed apples or with prunes. Sago, tapioca, etc., are prepared in the same way. If an egg is to be added, beat the white and yolk separately, and add them to the rice after it has been taken from the fire. Rice and Apple (Pinger). Boil about two tablespoonfuls of rice in a pint and a half of new milk, and simmer, stirring it from time to time till the rice is quite tender. Have ready some apples, peeled, cored, and stewed to a pulp, and sweetened with a very little loaf FARINACEOUS FOODS 901 sugar. Put the rice round a plate and the apple in the middle, and serve. Rice Cream (Ringer] . To a pint of new milk add a quarter of a pound of rice, a lump of butter the size of a walnut, a little lemon peel, and a tablespoonful of powdered sugar. Boil them together for five minutes, then add half an ounce of isinglass which has been dissolved, and let the mixture cool. When cool add half a pint of good cream whisked to a froth, mix together, and set it for a time in a very cool place, or on ice; when used, turn it out of the basin into a dish, and pour fruit juice around it, or some stewed apple or pear may be served with it. Rice Cream (from "Food"). Two tablespoonfuls of rice. Two cups of milk. One saltspoonful of salt. Two tablespoonfuls of sugar. Two eggs. Cleanse the rice by washing it several times in cold water; cook it in a double boiler with the milk until the grains will mash. Three hours will generally be required to do this. Should the milk evap- orate, restore the amount lost. When the rice is perfectly soft, press it through a coarse soup strainer or colander into a saucepan, return it to the fire, and while it is heating beat the eggs, sugar, and salt together until very light. When the rice boils, pour the eggs in rather slowly, stirring lightly with a spoon for three or four minutes, or until it coagulates, and the whole is like a thick, soft pudding; then remove from the fire, and pour it into a dish. By omitting the yolks and using the whites of the eggs only, a delicate cream is obtained. Malt (Ground) and Rice Pudding (Yeo). Stir an ounce of ground malt into a pint of boiling milk, strain through a sieve, and add the milk to two ounces of well-soaked rice. Mix well, and stand for ten minutes in a warm place, then bake for an hour. This makes an excellent predigested food. Cracker Gruel (from "Food"). Two tablespoonfuls of cracker crumbs. One scant saltspoonful of salt. One scant teaspoonful of sugar. One cup of boiling water. One cup of milk. To make the cracker crumbs, roll some crackers on a board until they are fine. Water crackers are good, cream crackers are better; mix the salt and sugar with the crumbs, pour on the boiling water, put in the milk, and simmer for two minutes. The gruel does not need long cooking, for the cracker crumbs are already thoroughly cooked. Do not strain. Indian-meal Gruel (from "Food"). Two teaspoonfuls of corn- meal. One tablespoonful of flour. One teaspoonful of salt. One APPENDIX teaspoonful of sugar. One quart of boiling water. One cup of milk. Mix the cornmeal, flour, salt, and sugar into a thin paste with cold water, and pour into it the boiling water. Cook in a double boiler for three hours. No less time than that will cook the corn- meal thoroughly. Then add the milk, and it is ready to serve. Hard-bread Gruel (U. S. Army Hospitals). Toast hard bread thoroughly and grind it into a powder. To one pint of boiling water, to which one-half teaspoonful of salt has been added, add two tablespoonfuls of hard-bread powder. Boil ten minutes and then strain. Flavor with one teaspoonful of sugar and one teaspoonful of condensed milk to each cupful of the gruel. Bread Jelly (Chrystie). Pour boiling water on stale bread, and let it soak for an hour. Pour off the water, add fresh water, and boil down until a thick mass is obtained which becomes jellylike on cooling, and may be eaten with milk or cream and sugar. Milk Porridge (U. S. Army Hospital Receipt for Twelve Men). Milk, eight pints ; flour, twelve ounces ; water, three pints. The flour to be used for milk porridge should previously be pre- pared by being tied up closely in a bag and boiled four or five hours. It can then be grated to a powder, which should be mixed into a smooth paste with cold water. Add to the milk the prescribed quan- tity of water, and stir in the flour, with a little salt. Let it boil ten minutes, stirring all the time. Fothergill's Amylaceous Food. Of rice, well washed, of arrow- root, tapioca, and pearl barley, take each an ounce, add two quarts of water, and boil down to a quart; then flavor with candied eringo. Barley Jelly (Eustace Smith). Put two tablespoonfuls of washed pearl barley into a pint and a half of water, and slowly boil down to a pint; strain, and let the liquid settle into a jelly. Two tea- spoonfuls of this, dissolved in eight ounces of warmed and sweet- ened milk, are enough for a single feeding, and such a meal may be allowed twice a day. Panada (Ringer). Take the crumb of a penny roll and soak it in milk for half an hour, then squeeze the milk from it; have ready an equal quantity of chicken or veal, scraped very fine with a knife; pound the bread crumb and meat together in a mortar. It may be cooked either mixed with veal or chicken broth, or poached like an egg. By taking it up in two spoons, in pieces the shape of an egg, after seasoning, it may be served with mashed potato. Another Caudle (Ringer). Mix well together one pint of cold MILK-SUGAR PREPARATIONS 903 gruel with a wineglassf ul each of good cream and sherry and a tablespoonful of noyau, and sweeten with sugar candy. Almond Cakes for Diabetics (Seegen). Take of blanched, sweet almonds a quarter of a pound, beat them as fine as possible in a stone mortar; remove the sugar contained in this meal by putting it into a linen bag and steeping it for a quarter of an hour in boiling water acidulated with vinegar; mix this paste thoroughly with three ounces of butter and two eggs. Next add the yolks of three eggs and a little salt, and stir well for some time. Whip up the whites of three eggs and stir in. Put the dough thus obtained into greased molds and dry by a slow fire. Macaroni Boiled (U. 8. Army Hospital Receipt for Twelve Men}. Macaroni, one pound ; salt, a quarter of an ounce ; boiling water, six pints. Wipe the macaroni carefully. Break into four-inch lengths. Put with the salt into cold water and boil until tender, but not until it bursts or becomes a pulp. Drain off the water at once, and season with butter. The liquor from the macaroni makes a good broth. MILK-SUGAR PREPARATIONS Following are receipts devised by Miss Cutler, Dietitian to Belle- vue Hospital, for " forced feeding," and for the special Coleman- Shaffer diet for typhoid fever, described on p. 478. Cocoa With Milk. 1 teaspoon of cocoa. 2 tablespoons of milk-sugar. 4 oz. milk. 2 oz. cream. Mix the sugar and cocoa, cook in the milk until dissolved. Serve with the cream. Cocoa. 1 teaspoon of cocoa. 2 tablespoons of milk-sugar. J cup water. 3 oz. cream. Mix the cocoa and sugar, add the water and boil 4 or 5 minutes. Then add the cream or use less cream and serve with whipped cream. Coffee. 1J tablespoons milk-sugar. 4 to 5 oz. strong coffee. 2 oz. cream. Plain Junket or Rennet Custard. 1 tablespoon milk-sugar. 5 oz. milk. \ junket tablet. 1 oz. cold water. Few drops vanilla. See directions for Cocoa Junket. 904 APPENDIX Cocoa Junket. 1 teaspoon cocoa. 1 tablespoon milk-sugar. 5 oz. milk. 4 junket tablet dissolved in 1 oz. cold water. Mix the cocoa and sugar, add milk and heat lukewarm, stirring constantly, add the dissolved junket, stir thoroughly and leave in a warm place, to set. Lemonade. 1 to 8 tablespoons milk-sugar. 7 oz. cold water. 2 tablespoons lemon juice. Boil the sugar and water 2 minutes. Add lemon juice to taste, strain and cool. Soft Custard. 1 cup of milk. 1 egg. 2 tablespoons of milk-sugar. Speck of salt. 2 or 3 drops of vanilla or Caramel made of 3 tablespoons of granulated sugar. Beat the egg slightly, add sugar, salt and hot milk slowly. Cook in a double boiler, stirring constantly, until it thickens a little. (If cooked too long, the custard will curdle, but may be made smooth again if set in a dish of cold water and beaten at once). Flavor and cool. Baked Custard. 1J tablespoon milk-sugar. 6 oz. milk. 1 egg. Nutmeg or vanilla. Speck of salt. Beat egg slightly. Warm the sugar and the milk, stirring constantly, add to the egg, strain into a custard cup and flavor. Bake in a pan of water in a moderate oven until a knife, when cut into it will come out clean. (30 min. to 1 hr.). Bread Pudding. 1J tablespoons milk-sugar. 6 oz. milk. 1 egg. 1 slice of bread (| in. thick). \ oz. butter. Spread the bread with the butter and cut into squares. Beat the egg slightly: heat the milk and sugar, stirring constantly, mix with the egg and pour over the bread. Grate nutmeg over the top and bake the same as the custard. GELATIN PREPARATIONS Port-wine Jelly (Ringer) . Put into a jar one pint of port wine, two ounces of gum arabic, two ounces of isinglass, two ounces of powdered white sugar candy, a quarter of a nutmeg grated fine, and a small piece of cinnamon. Let this stand closely covered all night. The next day put the jar into boiling water and let it simmer until all is dissolved, then strain, let stand till cold, and then cut into small pieces for use. Milk, Rum, and Isinglass (Ringer). Dissolve in a little hot water GELATIN PREPARATIONS 905 over the fire a pinch of the best isinglass; let it cool, and mix a dessertspoonful of rum with it in a tumbler, and fill up the glass with new milk. Nutritious Coffee (Ringer). Dissolve a little isinglass in water, then put half an ounce of freshly ground coffee into a saucepan with one pint of new milk, which should be nearly boiling before the coffee is added; boil both together for three minutes; clear it by pouring some of it into a cup and dashing it back again, add the isinglass, and leave it to settle on the hob for a few minutes. Beat up an egg in a breakfast cup, and pour the coffee upon it; if pre- ferred, drink it without the egg. Lemon Jelly (U. S. Army Hospitals). One-fourth box of gelatin (one-half ounce). One-fourth cup of cold water. One-fourth cup of fresh lemon juice (about the amount yielded by two lemons). Three tablespoonfuls of sugar. One and one-fourth cups of boiling water. Put the gelatin to soak in the cold water, about twenty minutes be- ing required for this process. When dissolved, pour on the boiling water. Add the lemon juice and sugar. Stir thoroughly and strain through a fine-meshed cloth into a china or granite-ware mold, cooling in a refrigerator or by placing in a pan of cold water. Xever use tin molds for lemon jelly. Coffee Jelly (U. S. Army Hospitals). One-fourth box of gela- tin (one-half ounce). One-fourth cup of cold water. One cup of boiling water. One-half cup of strong coffee. Two tablespoonfuls of sugar. Soak the gelatin in the cold water for half an hour. Pour on the boiling water, then put in the sugar and coffee. Strain it through a cloth into a mold or dish in which it may be cooled, either in a pan of iced water or in a refrigerator. Coffee jelly may be served with cream and sugar. Have the coffee strong, two tablespoonfuls of coffee to each cup of water. Where vanilla extract is available, one-half teaspoonful may advantageously be added to the above recipe. Wine Jelly (U. S. Army Hospitals). One-fourth box of gelatin (one-half ounce). One-fourth cup of cold water. One-half cup of sugar. One-half cup of sherry wine. One and one-fourth cup of boiling water. One small piece of cinnamon. Put the gelatin and cold water together in a dish large enough to hold the whole mix- ture. Let it soak for half an hour, then pour the boiling water (in which the piece of cinnamon has been simmering) over the softened gelatin. Add the sugar and wine, strain through a clean cloth into a china or granite-ware mold, and cool in a refrigerator or a pan of cold water. 906 APPENDIX FAT FOODS (Useful in diabetes and in emaciation not due to gastrointes- tinal disorder, such as that of chronic phthisis and chronic sepsis, empyema, etc.) Fresh butter, one-quarter pound or more per diem; suet, lard, margarine, and " drippings " used in excess in cooking, fat soups and broths, rich cheese, Devonshire clotted cream, cream diluted with water or Vichy to the consistency of milk, and drunk as a beverage (a pint or more per diem), olives, olive oil on salads, sardines, etc.; fat fish, such as mackerel and salmon ; the fats of Bussell's Emulsion, cod-liver oil, oily nuts, such as fresh English walnuts, butter- nuts, pecan, and Brazil nuts; bacon, pork, fat ham, fat tongue, fat goose and duck, and any form of fat meat, such as the tender fat of corned beef, bone marrow, egg yolk. CONCENTRATED FLUID NOURISHMENT (Sometimes useful in fevers and conditions in which only very small quantities of food can be taken.) 1. Milk, peptonized, to which is added in each tumblerful one or two tablespoonfuls of (1) milk sugar (first dissolved in hot water), (2) the albumen of one or two eggs, (3) a tablespoonful of malted milk, Nestle's, Carnrick's, Benger's, or other proprietary food dis- solved in milk. 2. Meat juice squeezed, or strong broths, to which may be added one of two teaspoonfuls of such concentrated foods as Plasmon, Mosquera's Beef Meal, Nutrose, or Somatose, or Imperial Granum Sanatogen, or one of the fluid beef preparations, such as Johnson's Fluid Beef, etc. 3. Cream, half a tumblerful, with the albumen of one egg and a teaspoonful of some cordial, such as Curagoa or Benedictine, and a teaspoonful of milk sugar. (Suitable especially for consumptives.) SUBSTITUTES FOR THE MORNING TEA OR COFFEE Patients often insist upon having some form of hot drink to replace the breakfast cup of tea or coffee of which they have been deprived. There is no true substitute for these beverages in the sense that their mildly stimulating effects are replaced, but the habit of taking " something hot "' with the first meal may be satisfied by use of one of the following: SUBSTITUTES FOR TEA AND COFFEE 907 Hot water flavored with lemon and cloves; hot malted milk, hot cocoa, cocoa nibs, chocolate, or alkathrepta; a cup of hot broth or of hot water, with addition of a teaspoonful of some meat extract like Liebig's or Valentine's Meat Juice. There are also the artificial " coffees," made from parched grains, beans, etc., which are much ad- vertised, and one made from torrefied bananas; caudle; gruels made with Irish or Iceland moss and spiced, or flavored with lemon. INDEX Abscess of liver, 653. Absinthe, 287. Absorption, food, 399. Acid, acetic, 292; boric, 314, 315; citric, 207; hydrochloric, 387; hydrochloric, free, 574; lactic, 57; malic, 207; tartaric, 207. Acid test for milk, 64. Acidity of gastric juice, 574. Acidosis, 758. Acids, organic, 207; vegetable, 48. Acidulous waters, 246. Acne, 685. Acorns, 227. Acute gastritis in children, 588. Acute nephritis in children, 546. Addison's disease, 767. Adult life, food in, 353. Adulteration of food, 427; of liquors, 286; of milk, 70. Aerated bread, 167. Age and food, 322. Albumen, 121. Albumen water, 122. Albumin, 57; vegetable, 390. Albuminoids, estimation of, 70. Albuminuria, functional, 547; organ- ic, 547. Albumoses, 389. Alcohol, 262; absorption of, 269; action of on circulation, 270; on digestion, 268; on muscles, 267; on temperature, 267 ; and climate, 269; as a diuretic, 267; as a food, 265; as a heart stimulant, 270; as a nerve stimulant, 266; as a tonic, 270; clinical uses of, 270; elimination of, 269; force value of, 264 ; hypodermic use of, 269; in fevers, 271; in gout, 762; in nervous diseases, 271; physio- logical action of, 265; poisoning by, 438; in tuberculosis, 510; in typhoid fever, 481; uses of, 263. Alcoholic beverages, 272. Alcoholism, 438; treatment for, 440, 441. Ale, 268, 275. Alewife, 149. Alimentary canal diseases, 563. Alimentary pastes, 180. Alkaline purges, 246. Alkaline sulphur waters, 246. Alkaline water in diabetes, 755. Alkaline waters, 245. Allantiasis, 420. Allegheny General Hospital diet, 872. Allspice, 292. Almond cakes, 751, 903. Almond oil, 234. Almonds, 226. Alum in food, 314. Amylaceous foods, 173. Anacidity, 393. Anaesthesia, diet after, 772. Anasarca, 556. Anemia and rheumatism, 771 ; die- tetic treatment of, 539; perni- cious, 543; rest and exercise in, 539; symptoms of, 538. Anemias, 537; dietaries for, 542; physiology of, 537. Aneurism, 535. Angina pectoris, 533. Angiocholitis, 649. Angostura, 287. Animal and vegetable foods com- pared, 29. Animal viscera, 145. Anise, 287. Anisette, 288. Annoto, 429. Anti-fat remedies, 710. 909 910 INDEX Antiscorbutics, 206. Antiseptics and foods, 313. Apollinaris, 245. Apoplexy, 677. Appendicitis, 643. Appendix, 887. Appetite, 368; in illness, 444. Appetite juice, 370. Applejack, 285. Apple sauce, 215. Apples, 208, 209, 214. Apricots, 208, 209, 214. Arabs' diet, 319. Argol, 278. Army diets, 779. Army hospital dietaries, 880. Army prison diet, 793. Army ration, Austrian, 786; British, 786; foreign, 786; French, 786, 789; German, 789; Italian, 788; Russian, 789; Spanish, 788; United States, 789. Arnold's sterilizer, 97. Aromatic herbs, 290. Arrack, 285. Arrowroot, 186. Arrowroot blancmange, 898. Arterio-sclerosis, 534. Arthritis deformans, 714. Artichokes, 203; Jerusalem, 199. Artificial digestion, 396. Artificial infant foods, 840. Ascaris lumbricoides, 413. Ascites, 651. Asitia, 343. Asparagus, 204. Associated diseases, diet in, 770. Ass's milk, 63. Asthma, 521. Ataxia, locomotor, 676. Athletic training, 809. Atrophy, simple, 629. Austrian Army ration, 786. Autointoxication. 621; dietetic sum- mary for, 623-625. Babcock's cream tester, 68, 69. Racillac, 92. Bacillus acidilactici, 77, 101; Bacillus botulinus, 419; bulgaris, 91; butyricus, 420; tuberculosis, 434. Bacon, 142. Bacteria in infant stools, 616; in milk, 75, 80; in the stomach, 579; thermal death, point of, in milk, 100. Baking, 303; bread, 164. Baking powders, 167. Balfour's diet for the senile heart, 531. Banana flour, 218. Bananas, 208, 216. Bananose, 218. Bandaging and constipation, 641 ; Banting system, 697. Barley, 184. Barley jelly, 902. Barley milk, 102. Barley water, 887. Bass, 148, 149. Bean, kidney, 194. Beans, 194; kidney, 194; red, 194; soya, 194; vanilla, 292. Beanjolais, 283. Beechnuts, 226. Beef, boiled, 297; canned, 313; chipped, 131; composition of, 130; concentrated, 131; corned, 309; "embalmed," 316; fluid, 889; powdered, 133; prepara- tions of for the sick, 131; rare, 301; refrigerated, 310; roast, 299; smoked, 309. Beef blood, 134. Beef broth, 138. Beef essence, 890. Beef extract, 131, 891; South Ameri- can, 135. Beef fat, 131, 232. Beef jelly, 133. Beef juice, 135, 136, 889. Beef meal, 132. Beef peptones, 139. Beef peptonoids, 134. Beef tea, 89, 136. Beef tongue, 141. Beer, 268, 274; Bavarian. 275: brew- ing of, 274; English, 268; lager, 268; white, 275. INDEX 911 Beet sugar, 154. Beets, 199. Bellevue Hospital dietary , 866. Benedictine, 287. Benger's extract, 141. Benger's food, 176. Benger's ^peptones, 139. Benger's peptonized beef jelly, 133. Beri-beri, 676. Berries, 221. Beverages, 241, 887; demulcent and nutritive, 887 ; diuretic and refrigerant, 888; use of in fevers, 468; in lithsmia, 562; milk, 889. Bicycle rider's diet, 815. Biedert's cream mixture, 896. Bilberries, 222. Bile, 394. Biliousness, 646; directions for eating in, 648; dietetic treatment of, 647. Birds' nests, 147. Biscuits, 173. 178; casoid, 750; meat, 894; pilot, 179; ship, 179. Bitter milk, 73. Blackberries, 208, 209, 222. Blackwheat, 180. Blair's wheat food, 174. Blancmange, 898. Blood, 146; diseases of, 537. " Blossom " fat food, 235. Blueberries, 222. Boar, 145. Boas' test breakfast, 573. Boas' test for free hydrochloric acid, 574. Boat crew dietary, Harvard, 812; Yale, 811. Boat crews, dietary, summary of, 814. Bob veal, 420. Body weight and food, 324. Boiled beef, 296. Boiled fish, 298. Boiled milk, 86. Boiled water, 40. Boiling, 296. Boils, 691. Bone marrow, 233. Borage, 203. Borax, 315. Bordeaux wine, 283. Boric acid in food, 314; in milk, 72. Bottle feeding, 833. Bottled milk, 100. Bottles, nursing, 843. Botulism, 420. Bouchard's system, 705. Bouillon, 137, 297, 892. Bourbon whiskey, 285. Bovine tuberculosis, 432. Bovinine, 139. Brain food, 372. Brain workers' diet, 819. Brains, 146, 233. Braise, 302. Braising, 302. Bran, 162; and potato bread, 748. Brandy, 285. Brazil nuts, 226. Bread, 161; aerated, 167; bran, 750; composition of, 164; compressed, 306; diabetic, 748; dried, 306; for children, 858; gluten, 172, 748; Graham, 171; inulin, 751; making of, 161; protene, 750; pulled, 178; rice, 184; rye, 181; soya, 752; spoiled, 168; substi- tutes for in diabetes, 747; whole- meal, 170. Bread jelly, 178, 902. Bread pudding, 904. Brewing, 274. Brie, 117. Bright's disease, acute, 554; causa- tion of, 550; chronic, 550; treat- ment of, 551. Brine, 309. British army hospital dietaries, 884. Broccoli, 202. Broilers, 143. Broiling, 300. Bronchitis, capillary, 520; chronic, 520. Bronchopneumonia, 525. Broth, 138. Broths, 891. 912 INDEX Brussels sprouts, 202. Buckwheat, 160, 180. Bulimia, 370; and dyspepsia, 584. Burgundy, 280, 281, 283. Burnet, 203. Butter, 112. Butter, cacao, 259. Butter fat, 56. Butter fish, 149. Butterine, 232. Buttermilk, 114. Butternuts, 226. Cabbages, 201. Cacao butter oil, 234. Caffeine, 252. Calcium, 47. Calcium-carbonate test, 575. Calculi, biliary, 653; renal, 558; vesi- cal, 558. Calf's foot jelly, 147. Calorie, 31, 361. Calorimeter, 9. Camembert, 116. Camplin's bran bread, 750. Candies, adulterated, 428. Candy for children, 859. Cane sugar, 154. Canned beef, 421. Canned foods, 153. Canning, 312. Cantaloupe, 223. Capers, 203, 291. Capillary bronchitis, 520. Capon, 143. Capsicum annuum, 291; fastigiatum, 291. Caramel. 156. Carbohydrates, 19, 25 ; in obesity, 693. Carbonated milk, 96. Carbonic acid in bread, 165. Carbonic waters. 244. Carcinoma of oesophagus, 566; of stomach, 611. Cardiac valvular disease. 528; in children. 530. Carnrick's food, 107, 178; peptones, 139. Caroid, 3P9. Carp, 149. Carrots, 200. Casein, 57; vegetable, 192, 390. Casoid biscuits, 750. Cassava, 187. Catsup, 293. Caudle, 898. Cauliflower, 202. Caviare, 120. Cayenne pepper, 291. Celery, 203. Celulose, 14. Centrifugal machine, 110, 111. Cepe, 225. Cereal coffee, 257. Cerealin, 170. Cerealine, 182. Cereals, 159; composition, 160; in chronic constipation, 636. Cerebrospinal meningitis, 495. Certified milk, 80. Cetraria Icelandica, 187, 225. Chablis, 281. Chalybeate waters, 246. Champagne, 281, 284. Champagne cider, 288. Chantreul, 225. Chapman's dipper, 56. Chartreuse, 287, 288. Cheddar, 116. Cheese, 114; poisoning by, 423; ripening of, 116; varieties of, 115. Cheese food, 19. Chemical analysis of a man, 1. Chervril, 203. Cheshire cheese, 117. Chestnuts, 226. Chicago sanitary flour, 751. Chicca, 182. Chicken, 143. Chicken broth, 891. Chicken jelly, 894. Chicory, 203, 256. Childhood, food in, 352. Children, diarrhoea in, 614; diet for school, 854; dietaries, 848; in English hospitals, 878; dyspepsia in, 585; food for, 845; intestinal INDEX 913 indigestion in, 626; sample diet for, 857; starchy foods for, 188; typhoid fever in, 487. Chilies, 291. Chipped beef, 131. Chittenden's diet, 336. Chive, 203. Chlorosis, 538. Chocolate, 260; casoid, 750; for dia- betics, 752; uses of, 261. Cholera, infection of food, 436, 437; prophylaxis, 497 ; symptoms, 498; treatment, 498. Cholera infantum, 619. Cholera morbus, 620. Chorea, 673. Chronic diarrhoea in children, 627. Chronic gastritis, milk diet in, 591. Chronic gastrointestinal catarrh in children, 627. Chronic nephritis and ascites, 771. Chronic nephritis and diabetes, 770. Chronic nephritis and obesity, 771. Chrystie's beef tea, 890. Cider, 288. Cinnamon, 291. Circulation and digestion, 374. Circulatory diseases and diet, 527, 528. Cirrhosis, 650. Citrons, 223. Citrus pomelanus, 213. Clabberade, 96. Clams, 151. Claret, 278, 283, 284. Climate and alcohol, 269; and food, 318. Clothing and food, 321. Clotted cream, 111. Cloud berries, 766. Clouty cream, 77. Cloves, 292. Cochin Hospital dietary, 877. Cocoa, 258, 903; adulteration of, 260. Cocoanut oil, 234. Cocoanuts, 226. Cod, 148, 149. Cod-liver oil, 236 ; administration of. 237; dosage, 237; inunction, 240. 458; properties of, 236; substi- 60 tutes for, 239; in tuberculosis, 509. Coefficient of digestibility, 8, 26. Coffee, adulteration of, 256, 429; composition of, 252; ill effects of, 255; nutritious, 905; physio- logical action of, 254; prepara- tion of, 253; quantity of con- sumed, 256; substitutes for, 257, 906; and tea compared, 257; Coffee jelly, 905. Cognac, 285. Cold storage, 310. Cole, 202. Coleman and Shaffer's diet for ty- phoid fever, 478. Colitis, chronic, 625; membranous, 630. College diets, 821. Colostrum, 61, 832. Commercial life, diet in, 823. Compote, 211. Concentrated food, 305; fluid, 906; concentrated wines, 283. Condensed cream, 111. Condensed milk, unsweetened, 108. Condiments, 288; harmful effects of, 289. Confectionery, 156. Consomme", 893. Constipation, chronic, 633; in infants, 641; pathology of, 634; symp- toms of, 635; treatment for, 636. Convalescence in typhoid fever, 483- 485. Convalescent diet in fevers, 472, 893. Cook County Hospital dietary, 873. Cooking, 294; for diabetics, 753; of eggs, 123; of fish, 304; of meat, 303 ; varieties of, 295 ; vegetables, 304. Cordials, 287. Corn, 181. Corn meal, 160, 182. Corn starch, 182, 899. Corn syrup, 183. Cornaro's diet, 345. Corpulence, 691, 698. Corpulency and gout, 719. 914 INDEX Cost of food, 28. Cottage cheese, 116. Cottolene, 231. Cotton seed oil, 234. Courgettes, 205. Cowpeas, 192, 193. Cows, unhealthy, 73. Crab-apples, 215. Crabs, 150. Cracked wheat, 178. Cracker gruel, 901. Crackers, 160, 178. Cranberries, 205. Craving, abnormal, for foods, 370. Cream, 54-109; centrifugal, 110: clotted, 111; clouty, 77; condensed. Ill; Devonshire, 111; estimation of, 66; evaporated, 111; poison- ing by, 423; separator, 110. Cream cheese, 116. Cream-of-tartar drink, 889. Creamometer, 67. Cress, 203. Crimping, 150. Crustaceans, 150; poisoning by, 424. Crystalose, 753. Cucumbers, 204. Cuisine, 231. Curacoa, 287, 288. Curds, 82, 83. Cure, dry, 807; fruit, 804; grape, 805 ; koumiss, 802 ; meat and hot water, 806; reduction for obesity, 708; rest, 667; skimmed milk. 795; whey, 801. Cures, dietetic, 803. Currant jelly, 889. Currants, 202. 211, 222. Curry powders, 289. disk. 149. Custard, 904. Dahi. 435. Dairies, 79. Dandelion. 202. Darby's fluid meat. 133. Dates. 223. Debove's forced feeding, 515. Declorinated diet. 556. Decorticated flour, 172. Delirium tremens, 442. Dementia, 678. Demulcents, 242, 887. Dentition, abnormal, 563. Dermatitis, exfoliative. 689. Desiccated eggs, 124. Desiccated vegetables. 306. Desiccation, 305. Desserts for children, 851 Deutero-albumose, 389. Devonshire cream, 111. Dextrin, 153. Dextrinized foods, 173. 177. Dextrose, 154. Diabetes, diagnosis of, 739 ; dietetic treatment of, 740; Diiring's diet for, 756 ; Ebstein's diet for, 755. foods allowed in, 744; foods for- bidden in, 747; and gout. 730; hygienic treatment of, 757; later symptoms of, 737; medicinal treatment of, 758; Naunyn's diet for, 757; and nephritis, 770; and pancreas, 733; physiological experiments, 731 : prognosis of, 738 ; symptoms of, 735 ; theories, 734; urine in, 736; varieties of, 742, 743; von Noorden's diet for, 757. Diabetes mellitus, 729. Diabetic beverages, 754. Diabetic coma, 758. Diabetic diet, 755; Thompson's. 746. Diaphanometer, 67. Diarrhoea, 613; in children, chronic, 627; in infants, 614; physiology of, 613; summer, 617. Diastase, 188, 396. Diathesis, gouty, 721. Dibothriscephalus latus, 149, 415. Diet, broth, 864; convalescent, 862; "cures" for phthisis, 517; fish, 864; for bicycle riders, 815; for brain workers, 819; for football players. 815; for forced feeding, 515, 516; for jockeys, 815; for nursing mother, 829; for puer- peral women, 826; for pugilists. 815: for school children. 854; for surgical patients, 772; for wet INDEX 915 nurse, 829; and habit, 36; half, 862; house, 862; improperly bal- anced, 350; in abnormal denti- tion, 563; in athletic training, 809; in commercial life, 823; in disease, 463; in diseases of the alimentary canal, 563; in dis- eases of the circulation, 527; in diseases of the nervous system, 658; in miscellaneous diseases, 767; in prisons, 792; in relation to operations, 772; in skin dis- eases, 682; light, 862; milk, 50, 862; minimum, 352; non-nitrog- enous, 862; of concentrated foods, 307; proteid, 862; and rest, 327; salt-free, 556; soft, 445; variety in, 371; and urine, 543. Diet absolue", 775. Diet-kitchen outfit, 462. Dietaries, 777; of hospitals, 861; of United States Army hospitals, 880-884; standard, 17, 20, 27, 28, 796, 797. Dietary of Harvard boat crew, 812; of Yale boat crew, 811; rules for prescribing, 409. Dietetic difficulties in associated dis- eases, 770. Dietetic errors, 410. Digestibility of food, 363. Digestion, abnormal, 392; artificial, 396; and circulation, 374; and emotion, 382; and exercise, 377; and the nervous system, 373; and rest, 380; and sleep, 380; and temperature, 374; and wines, 284 ; duration in stomach, 390; in intestine, 393; in mouth, 382; of fats, 394; of meats, 128; of milk, 82; of proteids in stom- ach, 389. Dilatation of the stomach, 596. Dinner courses, 364. Diphtheria, 493. Diseases caused by dietetic errors, 410; especially influenced by diet, 691. Disinfection of food utensils, 449. Distilled water, 39. Diuretic beverages, 888. Dough, 166. Doura, 181. Drugs in human milk, 61, 830. Dry diet, 305, 330, 536, 807. Duck, 144. Duckworth's diet for gout, 724. Dujardin-Beaumetz's diet for obesity, 704. Dujardin-Beaumetz's test breakfast, 573. During's diet for diabetes, 726. Dutch cheese, 116. Dysentery, 631. Dyspepsia, 568; and anemia, 585; atonic, 584; beverages in, 581; dietetic treatment of, 579; etiology of, 569; flatulent, 584; foods allowed in, 581; foods for- bidden in, 580; general rules, 583; gouty, 584; in infants, 585; irritative, 584; nervous, 584; special treatment for, 582. Dysphagia, 565. Ebstein's diabetic diet, 755. Ebstein's obesity diet, 697. Economic value of food, 25. Eczema, 685; in children, 689 j in nursing infants, 688. Edam cheese, 118. Eels, 148. Egg albumen, 122. Egg preparations, 897. Eggnogg, 122, 897. Eggplant, 204. Eggs, 120, 233; and albuminuria, 548; boiled, 123; composition of. 124; cooking of, 123; dried, 305; in fevers, 467; preservation of, 124; raw, 122; test for fresh- ness, 121; white of, 123. Elderberry, 222. Electricity and constipation. 641 ; in neurasthenia, 671. Elements, chemical, 1. Elimination of food waste, 400. Embalmed beef, 316. Embryonine, 750. 916 INDEX Emergency ration, 785. Emphysema, 522. Empyema, 526. Emulsions, 237. Endive, 203. Enemata, 450; alcohol in, 457; blood, 456; eggs in, 457; grape sugar in, 457; method of injection, 452; of meat and pancreas, 456, 894; of milk, 457. Energy from food, 6. English hospital dietaries, children's, 878. Enteralgia, 662. Enteritis, acute catarrhal, 620; chronic, in adults, 625. Enterocolitis in children, 617, 627. Epilepsy, 674. Erbswurst, 193. Ergotism, 426. Erysipelas, 496. Erythema, 684. Eskay's food, 135, 178. Eskimo diet, 358. Essence, beef, 891. Evaporated cream, 111. Evaporated eggs, 124. Ewald and Siever's test for motor power of stomach, 578. Exercise and digestion, 377; and food, 322; and obesity, 801. Exophthalmic goitre, 768. Extract of beef, 891; of pancreas, 190, 398. Extractives, 126. Extracts of foods, 305. '. Extractum carnis, 138. Famine, 350. Farina, 178. Farina gruel, 900. Farinaceous foods, 161, 173, 898. Farinaceous gruels in typhoid fever, 478. Fasting, voluntary, 344. Fat, of beef, 131; of butter, 56; of milk, 54. Fat foods. 331. 906; in obesity. 693. Fats, 19, 228; animal, 231; digesti- bility of, 230; in anemias. 541; in diabetes, 744; in gout, 722; in neuralgia, 659; uses of, 228, 239, 235; vegetable, 234. Feces, from bread, 172; examination of diarrhoeal, 616; and food, 401. Feeding children, general rules for, 847; adults, general rules for, 444; forced, 340, 515; help- less patients, 447; hypodermic, 459; intra vascular, 458; in- fants, 841; rectal, 450; and sleep, 853; the sick, 444; uncon- scious patients, 449. Fermentation, intestinal, 621. Ferments in foods, 309. Fever, diet in, 463, 465; milk in, 466; pathological physiology of, 463. Fevers, alcohol in, 470; beverages in, 478; intermittent, 503; remit- tent, 503. Fig wine, 288. Figs, 208, 233. Filberts, 226. Filtered water, 39. Fining, 279. Tinkler's proteid food, 134. Fish, 147; dried, 305; poisoning by, 424; roe, 150; smoked, 309. Fish oils, 233. Fisher's endurance tests, 385. Flatulency, 584. Flaxseed tea, 889. Fletcherism, 384. Flies, food infection by, 437. Flounder, 148, 149. Flour, 160, 161; ball, 174; banana, 218; casoid, 749; gluten, 748; malt, 189; wheaten, 169. Fluid beef preparations, 889. Fluids in circulation diseases, 528. Food, absorption of, 399; adultera- tion of, 427; age and, 322, 329, 352, 353; and anaesthetics, 772; animal, 29-33; calorifacient, 5; carbohydrate, 5 ; and cholera in- fection, 436 ; classification of, 4 ; climate and, 318; clothing and, 321; concentration of, 305; con- densed, 305; containing para- sites, 413; cost of, 27, 28; crav- INDEX 917 ings for, 370; details of serving, 446; elementary composition of, 1; elimination of, 400; enemata, 458; equivalents for, 322, 404; exercise and, 322; factors, 322; and feces, 401; for young chil- dren, 845; force producing value of, 19; improperly balanced, 413; in childhood, 352; infection through diphtheria, 437 ; infec- tion through scarlatina, 437 ; in the intestine, 393; measurement of, 341; and medicines, 459; ni- trogenous, 5 ; non-nitrogenous, 5 ; order of taking, 364; and oxy- gen, 24; percentage composition of, 15, 16; physical properties of, 4 ; poisons, 425 ; portions, 404; preservation of, 308; pro- teid, 4; and ptomaines, 419; quantity of required, 317, 333, 334, quantity per annum, 340; and race, 358; in relation to special diseases, 407 ; respira- tory, 5; restriction of, 336; and salicylic acid, 314; sea- son and, 318; sex and, 323; size of body, and, 324 ; sleep, and, 479; source of, 4; stimulating, 25; substitutes for, 316; teeth- ing and, 853; temperature, 375, 377; and tobacco, 404; and ty- phoid fever, 435; and urine, 403; vegetable, 34, 190; waste, 400; water-free, 330; and weight, 324. Foods, animal, 49; artificial infant, 840; classes of, 36; concentrated, 307; farinaceous, 173; and idio- syncrasies, 438; malted, 189; National Bureau of, 430; pro- prietary, 173; vegetable, 152. Foot-and-mouth disease, 74, 437. Football dietaries, 815. Force production, 5. Forced feeding, 340, 515; in insanity, 678, 681. Foreign bodies swallowed, 567. Formaldehyde, 316. Fowl, 143. Freeman's pasteurizer, 102. Freezing of foods, 310. French army hospital dietaries, 885. Frijole, 194. Fromentine, 750. Fruit, dried, 211; when to eat, 211. Fruit essences, 243. Fruit ripening, 210. Fruit sirups, 243, 244. Fruit soups, 212, 466. Fruit sugars, 207. Fruits, 207; composition of, 207; cooked, 211; digestibility, 212; in chronic constipation, 637; in gout, 723; poisoning by, 210; properties of, 209; uses of, 209; varieties of, 212. Frying, 301. Fuel value of food, 13, 27, 28, 361. Fungi, 224; in milk, 76; poisonous, 225. Furunculosis, 681. Fusel oil, 287. Gaduin, 236. Gaertner's mother milk, 107. Galactase, 97. Gallstones, 653. Game, 144; poisoning by, 419, 422. Garlic, 205. Gases in dyspepsia, 569. Gastralgia, 661. Gastrectasia, 596. Gastric atony, 576. Gastric catarrh, in children, 596; dietetic summary for, 595. Gastric contents, 577. Gastric digestion, 390. Gastric fistula, 566. Gastric juice, 386, 387, 574. Gastritis, acute, 586, 587; chronic, 593, 594, 589. Gastrodynia, 661. Gavage, 608, 837. Gelatin, 146; and milk, 89; prepara- tions of, 904. Gerber's food, 177. German army ration, 789. Germs in food, 308, 313; in milk, 73, 74. Gin, 286. 918 INDEX Ginger, 292. Ginger ale, 243, 244. Globulin, 182. Glucose, 157. Gluten, 163; vegetable, 190. Gluten bread, 748. Gluttony, 317. Glycerides of cream, 109. Glycerin, 235; in diabetes, 753. Glycogen, 23. Glycosuria, 739. Goats, 145. Goat's milk, 62. Goitre, exophthalmic, 768. Gonorrhoea, 562. Goose, 144. Gooseberries, 208, 222. Gorgonzola, 118. Gout, 715; aids to treatment of, 728; chronic, 721; and diabetes, 730; dietetic treatment for, 719; Duckworth's diet, 724; and obesity, 771; preventive treat- ment for, 717; symptoms of, 717; theory, 718. Gouty diathesis, 721. Graham bread, 171. Graham flour, 160. Grain of corn, 182; of wheat, 162, 163. Grain poisoning, 426. Granose, 179. Granum, 174. Grape cure, 805. Grape fruit, 213. Grape juice, 158. Grapes, 208, 209, 219. Gravel, 559. Green gages, 220. Green vegetables, 191. Greens, 191, 202. Grilling, 300. Groats, 185. Grocer's itch, 155. Grog de la poudre de viande, 133. Ground pear, 199. Grouse, 144. Gruels. 161, 808-902; farinaceous, 478. Gruyere. 118. Guava, 215. Guinea fowl, 144. Gum, 209. Gunzberg's test, 574. Habit, and diet, 36; in eating, 860. Haddock, 148, 149. Halibut, 148, 149. Ham, 142. Hard-tack, 179. Haricots, 194. Hasheesh, 317. Hazel nuts, 226. Health and food, 333. Heart, 145; senile, 530. Heart disease in children, 530. Hemorrhage of lungs, 519. Hemorrhoids, 643. Hepatalgia, 662. Herb teas, 243. Herbs, aromatic, 290. Heredity and diet, 357. Herring, 149. Heteroalbumose, 389. Hickory nuts, 226. Hock, 284. Hoff's malt extract, 189. Holt's dietaries for infants, 850, 851 ; lactometer, 67; milk formulas, 106; milk measuring glass, 106; schedule for infant feeding, 840. Hominy, 182. Honey, 158. Horlick's food, 176. Horse flesh, 143. Horse-radish, 203, 293. Hospital army dietaries, 880. Hospital dietaries, 864, 866, 870-872. Hours for meals, 364, 856. Huckleberries, 222. Hunger, 348. Hydrochloric acid, free, 574. Hyperacidity, 393; and dyspepsia, 584. Hypersecretion, 392, 576. Hypoacidity, 393. Hypodermic feeding, 459. Ice, 44. Ice cream, 112; poisoning by, 423. IXDEX 919 Iceland moss, 187, 225. Ichthysrnus, 425. Ideal mother's milk, 107. Idiosyncrasies in dyspepsia, 569; and food, 438. Imperial granum, 174. Inanition, 343. Indian corn, 181. Indian meal, 183. Indigestion, 568; intestinal, in chil- dren, 626. Infancy, diet in first year, 840. Infant food, Liebig's, 175. Infants, constipation in, 641 ; diar- rhoea in, 614; eczema in, 688; enterocolitis in, 617.; feeding of. 830, 832; feeding of by wet nurse, 832 ; premature, 844. Infection of milk, 432. Infectious diseases, diet in, 473. Infectious germs and food, 432. Influenza, 491. Insalivation, 383. Insane, diet for, 876. Insanity, acute, 678. Insects, 152. Insomnia, 672. Intermittent fever, 503. Intestinal antisepsis and typhoid fever, 482. Intestinal autointoxication, 621. Intestinal catarrh, 625. Intestinal gases, 395. Intestinal indigestion in children, 626. Intestinal obstruction, 632. Intestinal worms, 413. Intestines, digestion in, 393 ; in ty- phoid fever, 483. Intoxication, alcoholic, 439. Intravascular feeding, 458. Intravenous injection of milk, 81. Intubation, 493. Inulin biscuits, 752. Inunction foods, 458. Iron. 48. " Iron ration," 193. Isinglass. 146. Italian army ration, 788. Italian paste, 180. Jam, 222. Jaundice, acute catarrhal, 649. Java almond oil, 234. Jellies, 147, 222. Jerusalem artichoke, 199. Jockey's diet, 815. Johannis water, 244, 245. Johannisberg, 279. Johns Hopkins Hospital dietary, 873. Junket, 895. Kaiserin Friedrich's Children's Hos- pital dietary, 879, 880. Kakke", 676. Kalodal, 459. Kava, 263. Kean's tropical ration, 783. Keating's diet for neurasthenia, 670. Kefir, 95. Kepler's extract of malt, 189. Kidneys, 145. Kirsch, 285. Klemperer's test for motor power of stomach, 579. Kneipp system, 804. Kohl rabi, 200. Kola, 262. Koumiss, 93, 94, 896; home made, 94. Koumiss cure, 802. Koumys, 93. Koumysgen, 95. Kiilz's inulin biscuits, 752. Kiimmel, 287. Lactalbumen, 57. Lactated food, 107, 177. Lactic acid, 57. Lactobacilline, 92. Lactometer, Holt's, 67; Quevenne's, 66. Lactone, 65, 93. Lacto-preparata, 107. Lactoscope, 67. Lactose. 56, 70, 134, 158. Lager beer, 268. Lamb, 142. Laparotomy, diet after, 775. Lard, 231. Laryngismus stridulus, 518. Laryngitis, tubercular, 518. 920 INDEX Lathyrism, 426. Lavage, 598, 601. Lead poisoning, 419, 430c Leanness, diet for, 710. Leaven, 165. Leben raib, 96. Lebert's milk cure, 514. Lecithin, 233. Leeks, 205. Legumes, 192. Legumin, 91, 750. Lemon jelly, 905. Lemonade, 212, 889; effervescing, 889. Lemons, 208, 212. Lentils, 195. Lettuce, 203. Leube's soluble meat, 609; test for motor pow.er of stomach, 578. Levulose, 158. Leyden's diet for neurasthenia, 669. Lichen, 225. Liebig's extract, 138. Liebig's foods, 175. Lima beans, 194. Limburger, 117. Lime, saccharated, 89. Lime water, home made, 896, and milk, 89. Limes, 213. Linseed oil, 234. Linseed tea, 889. Lipanin, 240. Lipase, 98. Liqueurs, 287. Liquid diet, 237. Liqucr pancreaticus, 140. Liquorice, 293. Liquors, 284; adulteration of, 286; malt, 274; uses of, 286. Litchi nuts, 227. Lithsemia, 559. Liver, 145; abscess of, 654; amyloid, G54; diseases of, 646; fatty, 652; syphilis of, 654. Liverpool Infirmary dietary, 878. Lobsters, 150. Locomotor ataxia, 676. Loeflund's cream emulsion, 177; malt extract, 189. Lying-in, diet for, 826. Maazoun, 95. Macaroni, 160, 180, 903. Macaroons, 226. Mace, 292. Mackerel, 148, 149. Madeira, 279, 280. Maize, 181. Maizena, 182. Malaga, 280. Malaria, 503. Malarial cachexia, 503. Malmsey, 280. Malt, 274, 397. Malt extracts, 188. Malted foods, 176. Malted milk, 107, 177. Maltine, 189. Maltose, 158. Mango, 216. Mania, 678, 877. Manioc, 187. Mannite, 158. Maple sugar, 155. Maranta arundinacea, 186. Marasmus, 629. Marchand's process, 67. Mare's milk, 63, 94. Marrow, bone, 233; vegetable, 205. Massage, 602 ; and chronic constipa- tion, 640. Mastication, 383. Mate", 257. Materna, 106. Matzol, 95. Matzoon, 95. Maurel's standard diet, 339. Meal, Indian, 183. Meals, hours for, 264, 367. Measles, 490. " Measles," 415. Measurement of foods, 342. Measures for food, 342. Meat, consumption of, 124; dried, 305; extracts of, 138, .891; for children, 859; and hot water cure, 806; in anemias, 541; in epilepsy, 674 ; in gout, 722 ; in obesity, 693; infection by tu- bercular, 434; jerked, 306; poi- soning by, 419; preparations of INDEX 921 fluid, 135; preparations of solid, 132, 893 j raw, 132, 354; smoked, 309. Meat bases, 126. Meat biscuit, 894. Meat extractives, 126. Meat lozenges, 134. Meats, 124; canned, 312; comparative digestibility of, 129; composition of, 126, 127; digestibility of, 128; raw, 127. Medicines, and food, 459; rules for administration of, 461. Melancholia, 678, 680, 877. Mellin's food, 176. Melons, 222. Meningitis, cerebrospinal, 495. Metal poisoning, 430. MSteil, 181. Metschinkoff on milk, 91. Migraine, 662. Military foods, 307. Milk, 49; adaptation of for the sick, 84; adulteration of, 71; albumin- ized, 895; alkalies with, 88; amylaceous foods, 88, 177; anal- ysis, 60-63; artificial human, 895; bacteria in, 80; blue, 76; care of, in infant feeding, 835 ; certified, 80; and cinnamon drink, 894; color of, 64; color- ing matter in, 71, 72; composi- tion of, 52, 54; condensed, 108; contamination of, 70, 72; cow's, 58; derivatives of, 108; digestion of, 82; dilution of, with aer- ated water, 87; diphtheria and, 76; and disease germs, 73; diuretic action of, 81; dried, 305; drugs in, 61; estima- tion of solids in, 65; fat of, 54; ferments in, 58 ; flavor of, 64 ; frozen, 53; human, 59; human, drugs in, 830; humanized, 103; impurities in, 70; in acute ne- phritis, 545; in chronic nephritis, 551-554; in fever, 466; in gout, 721; in tuberculosis, 513; in ty- phoid fever, 474 ; infection by, 432; infection, acute, 619; in- fection, prophylaxis of, 77; infec- tion, tubercular, 432 ; lead poison- ing and, 81; malted, 177; methods of altering taste of, 85; mode of administration, 476; modified, 103, 105; odor of, 64; pancreatinized, 80; pasteurized, 100; peptonized, 101 ; physical properties of, 51; poison- ing by, 423 ; and poisonous foods, 72; predigestion of, 90; prepara- tions of, 894; prescriptions, 104, 105; reaction of, 64; quantity in typhoid fever, 475; and salt, 88; skimmed, 86, 795 ; souring of, 77 ; specific gravity of, 66; sterilized, 96; substitutes for, 477; substi- tutes for in infant feeding, 836; sugar preparations of, 903; thickening, 72; typhoid fever, and, 75; uses of, 81; variations in composition of, 60; varieties of, 58 ; of various breeds of cows^ 106; woman's, 58. Milk Commission, 74, 80. Milk foods, 107. Milk laboratories, 103. Milk punch, 895. Millet, 181. Mineral waters, 243. Mint, 203, 293. Mitchell, Weir, and neurasthenia, 668; and obesity, 703. Mixed feeding for infants, 837. Molasses, 157. Molasses candy, 156. Morel, 225. Morrhuol, 239. Moselle, 281. Mosquera's beef jelly, 133 ; beef meal, 132. Mouth, care of infant's, 844; care of in typhoid fever, 483; cleansing of, 448; food in the, 382. Mucous disease, 630. Mulberries, 222. Mulled wine, 280. Mullet, 149. Mumps, 490. Muscarin, 225. 922 INDEX Mush, 183. Mushrooms, 206. Muskmelon, 223. Mussel poisoning, 424. Mussels, 151, 152. Must, 279. Mustard, 290. Mutton, 141. Mutton broth, 892. Mutton fat, 232. Mytilotoxin, 424. Nageli's condensed milk, 108. Nasturtium, 203. Naunyn's diabetic diet, 757. Navy ration, British, 792; United States, 790. Nectarines, 208, 215. Nephritis, acute, 544; chronic, 550, 555. Nervous prostration, 664. Nervous system, diet in diseases of, 658. Nestles milk food, 107, 177. Neufchatel, 117. Neuralgia, 658 ; visceral, 660. Neurasthenia, 664 ; dietetic treatment for, 667 ; general treatment for, 665; summary of foods for, 671. New York Hospital dietary, 864. New York Infirmary dietary, 874. New York State Hospital dietary, 875. Nitrogen balance, 21. Nitrogen lag, 21. Nitrogen output, 403. Nitrogenous food, 331. Northeastern Hospital for Children dietary, 879. Nucleins, 500. Nursing mother's diet, 829. Nut flour, 751. Nutmeg, 292. Nutrients, 23, 53. Nutrition, 29. Nutrose. 119. Nuts, 220. 227, 234. Oatmeal, 185; in diabetes. 757. Oatmeal flour. 10S. Oatmeal gruel, 898. Oats, 185. Obesity, 691; Bouchard's system in, 705; Chambers' system in, 706; Debove's system in, 707 ; dietetic ' treatment for, 694, 701 ; Dujar- din-Beaumetz system in, 704 ; and exercise, 801; and gout, 771; and nephritis, 771; Oertel's diet for, 699, 701; preventive dietary for, 708 ; Schweninger system in, 702 ; summary of dietetic treatment for, 707; von Noorden's system in, 705; Weir-Mitchell system in, 703; Yeo's system in, 703. Obstruction, acute intestinal, 632. Occupation and diet, 817, 818. Oertel system, 699, 701. Oesophagus, carcinoma of, 566; stric- ture of, 566. Oidium lactis, 76. Oils, 228; vegetable, 234. Okra, 203. Oleo oil, 232. Oleomargarine, 232. Olive oil, 234; for gallstones, 657. Olives, 208, 221. Omelette, 124. Onions, 205. Operations, diet for, 772. Opium in enemata, 455. Orangeade, 889. Oranges, 208, 213. Osteomalacia, 768. Osteotoxismus, 425. Ovariotomy, diet after, 775. Overdrinking, 412. Overeating, 411; and eczema, 686. Overfeeding, 863; of infants, 831. Oxaluria, 557. Ox-tail, 147. Oxydase, 97. Oxygen, 24. Oyster crackers, 179. Oyster plant, 200. Oysters, 151, 152; and typhoid fever, 435 ; poisoning by, 425. Palpitation, 533. Panada, 902. IXDEX 923 Pancreatic disease, 657. Pancreatic extract, 190, Pancreatic juice, 394. Pancreatic solution, 90. Pancreatin, 398. Pancreatinized foods, 398. Panopeptone, 140. Papoid, 399. Paprika, 293. Paralysis, post diphtheritic, 495. Parasites in food, 413. Parsley, 203. Parsnips, 200. Partridge, 144. Pastes, 180. Pasteurizing plant, 101. Pastry, 173. Pea sausage, 193. Pea soup, 193. Peaches, 208, 215. Peafowl, 144. Peanut oil, 234. Peanuts, 195, 227. Pearl sago, 187. Pearl tapioca, 187. Pears, 208, 215. Peas, 192. Pecan nuts, 226. Pectase, 207. Pectose, 207. Pellagra, 427. Pemmican, 233, 333, 334. Pepper, black, 290; cayenne, 290; white, 290. Peppergrass, 203. Peppermint, 287, 293. Peppers, 203. Pepsin, 388, 397; test for, 576. Pepsinogen, 388. Peptones, 139, 389, 398. Peptonized foods, 398. Peptonizing powders, 90. Peptonoids, 134. Perch, 149. Peritonitis, acute, 645; chronic, 645. Peristalsis, 390. Pernicious anemia. 543. Pheasant, 144. Phosphorus, 48. Phytolacca berries, 710. Pickerel, 149. Pickles, 293, 313. Pieplant, 204. Pigeons, 144. Pigments, 429. Pilot biscuits, 179. Pine nuts, 226. Pineapple cheese, 117. Pineapples, 208, 215. Pistachio, 227. Plant casein, 192. Plasmon, 119. Playfair's diet for neurasthenia, 669. Pleurisy, 525. Plums, 208, 209, 220. Pneumonia, 523. " Poison Squad," 314. Poisoning, alcohol, 438; cheese, 423; copper, 430; cream, 423; fish, 424; game, 419, 422; grain, 426; ice-cream, 423; lead, 419. 430; meat, 419; metal, 430; milk, 423; mussel, 424; ptomaine, 421; sausage, 420; tin, 430; zinc, 430. Poisons of food, 425. Poland water, 244. Polar expedition diet, 321, 333. Polenta, 182. Pollack, 149. Poluboskos, 173, 750. Polysarcia, 691. Pomegranate, 208, 216. Pomelo, 213. Pompano, 149. Porgy, 149. Pork, 142; fat of, 232. Porridge, 902. Port, 279, 280. Port wine jelly, 904. Porter, 275. Posset, 889. Pot au fteu, 137. Potassium salts, 47. Potatoes, 196; sweet, 199, 206. Pot-cheese, 116. Prairie chicken, 144. Pregnancy, diet in, 825. Prepared baby foods, 840. Presbyterian Hospital dietary, 868. Prescribing dietaries, 777. 924 IXDEX Preservatives and foods, 313; of milk, 72. Prickly pear, 223. Prison diet, 792; United States Army, 793. Proenzyme, 388. Professional man's diet, 820. Proof spirit, 285. Propepsin, 388. Proprietary foods, 840. Proteid, 6. Proteids, 19; digestion of in stomach, 389; predigestion of, 397. Protein, 6. Protene diabetic bread, 750. Prunelles, 208, 211. Prunes, 208, 220. Pruritus, 690. Prussian Army Hospital dietaries, 885. Psoriasis, 690. Ptomaine poisoning, 421 Ptomaines, 419. Puberty and diet, 855. Puddings, 173. Puerperal women's diet, 826. Puffed rice, 184. Puffed wheat, 184. Pugilist's diet, 815. Pulmonary hemorrhage, 519. Pulque, 241. Pumpernickel, 171. Pumpkins, 205. Pure"e, meat, 138. Purees, 466. Purin-free diet, 808. Purpura-hemorrhagica, 767. Purslane, 203. Purveyors of food, 462. Putrefaction, 420; intestinal, 621, 622 Pyelitis, 556. Pyrosis, 393 Quail. 144. Quantity of food, for children, 847; in illness, 445 ; for single meals, 406. Quevenne's lactometer, 66. Quince, 215. Quinsy, 564. Rabbit, 143. Rabies, 505. Race and diet, 358. Radishes, 200. Rain-water, 39. Raisin wine, 284. Raisins, 220. Rampion, 203. Raspberries, 208, 222. Raspberry vinegar, 889. Ration, emergency, 785; for profes- sional men, 820; garrison, 784; in foreign armies, 786; invalid, 327, 328; maximum and mini- mum, 18; peace, 786; of single foods compared, 330; standard, 796, 797; tropical, 782; war, 307, 780; work, 18. Rations, calculation of, 325; United States Army, 779; U. S. Navy, 790. Raw meat diet, 893. Rectal absorption, 450. Rectal feeding, 450, 451. Rectum, care of, 454. Red bean, 194. Red grouper, 149. Red snapper, 149. Reduction cure for obesity, 708. Reduction feeding, 340. Reformatory diet, New York State, 798. Refrigeration, 310. Regularity in feeding, 445. Regulin, 638. Reindeer milk, 63. Relapses in typhoid fever, 486. Renal diseases, diet in, 543. Rennet, 83, 903; test for, 577. Rennin, 83. Respiratory diseases diet, 518. Rest cure, 667. "Restricted diet," 336. Revalenta Arabica, 186, 195. Rhachitis, 759-762. Rheumatism, and anemia, 771; acute, 712, 713; chronic, 714. Rhine wines, 281. Rhubarb, 204. Rice, 160, 183. INDEX 925 Rice cream, 901. Rice flour, 168. Rice gruel, 900. Rice milk, 900. Rice soup, 898. Rice water, 887. Rickets, 759. Ridge's food, 174. Riegel and Leube's test dinner, 572. River water, 39. Roasting, 299. Robinson's patent barley, 174. Roe, 150. Roosevelt Hospital dietary, 872. Root beer, 244. Roots, 196. Roquefort, 117. Rosacea, 689. Rotch's milk formulas, 106. Roundworm, 413. Rudisch's beef peptone, 134. Rules for feeding, 444. Rum, 286. Rye, 181. Rye flour, 160. Saccharin, 159; in diabetes, 753. Saccharomyces cerevisise, 165. Saccharose, 154. Saffron, 293, 429. Sage cheese, 117. Sago, 187. Sahli's test for free hydrochloric acid, 575. Sake", 285. Salep, 187. Saline waters in gout, 728. Salisbury diet, 806. Salmon, 149. Salsify, 200. Salt, celery, 203. Salt-free diet, 47, 556. Salting, 309. Salts, 18; deprivation of, 45; excess of, 45; required, 332; uses of, 44; varieties of, 44. Samp, 182. Sanatogen, 135. Sandwiches, scraped beef, 894. Sanose, 119. Sarcopeptone, 134. Sardines, 149. Sarsaparilla, 243. Sauces, 293. Sauerkraut, 202. Sausage poisoning, 420. Savoury and Moore's infant food, 176; peptones, 139. Scalded milk, 87. Scallops, 151. Scarlet fever, 489. School dietaries, 858. Schroth's dry cure, 807. Schumacher's food, 174. Schweizer cheese, 117. Schweninger system, 702. Scotch broth, 899. Scraped beef, 893. Scraped meat, 132. Scurvy, 763; dietetic treatment for, 766 ; in children, 766 ; in infants, 765. Sea food, 147. Seakale, 202. Seasickness, 605. Season and food, 318. Seegen's almond cakes, 751. Seltzer, 244. Semolino, 179. Sepsis, diet in, 775. Septicaemia, 502. Serving of food, 446. Sex and food, 323. Shad, 148, 149. Shaddock, 213. Shallots, 205. Shellfish, 151; poisoning by, 424. Sherry, 279. Ship biscuits, 179. Shredded wheat, 178. Shrimp, 151. Shrubb, 222. Sick headache, 662. Sirup, 157. Size and food, 324. Skin diseases diet, 682. Skimmed milk cure, 795. Skimmed milk diet, 800. Sleep, and digestion, 380; disordered, 926 INDEX 672, and feeding, 448, 853; and food, 479; in relation to meals, 380. Slow eating, 571. Smallpox, 488. Smalt, 113. Smelt, 149. Smoking, 309. Snipe, 144. Soda crackers, 160. Sodium benzoate, 315. Sodium chloride, 46. " Soft diet," 445. Somatose, 135. Sorghum, 156, 181. Sorrel, 203. Soups, 303, 891. Sour mash, 285. Sour milk, 91. Soused fish, 313. South American beef extract, 135. Soya bean, 194. Soya bread, 181. Spaghetti, 180. " Special diet," hospital, 863. Spices, 288, 291. Spirits, 265. Split peas, 193. Spinach, 202. Squab, 144. Squash, 205. Stale bread. 169. Standard diet. 326. Starch, 160_; foods, containing, 159; percentage of, 161 ; potato, 197. Starches, predigestion of, 396. Starr's dietaries for young children, 848, 849; table for infant feed- ing, 841. Starvation, 343-349. Steaming, 303. Stearins. 231. Sterilization, 98; of food, 311; of milk, 99. Stewart's diabetic bread, 748. Stewing, 298. Stilton cheese. 117. Stimulants. 241. Stoke's mixture, 807. Stomach, absorptive power of. 579; carcinoma of, 611; contents of, examination, 572 ; digestion in, 390, 392; dilatation of and elec- tricity, 602; dilatation of and lavage, 598; food in the, 386; motor power of, 578; size of in- fants, 831. Stomatitis, 564. Stools, infants', 616, 842. Stout, 275. Strawberries, 208, 209, 221. Stricture of oesophagus, 566. " Strappings," 59. Sturgeon, 149. Succi's fast, 344. Sucrose, 154. Suet, 232. Sugar, beet; 154; cane, 154; diet of, 22; fruit, 207; invert, 207; ma- ple, 155; substitutes for in dia- betes, 753. Sugar candy, 156. Sugars, 152. Sulphites, 316. Sulphur, 48. Sulphurous acid gas. 316. Superalimentation. 514. Suppositories, food, 458. Suralimentation, 514; in insanity. 681. Surgical inflammation, diet in, 775. Surgical operations, diet after, 772, 773. Sweetbread, 145. Sweets for children, 859. Swiss cheese, 117. Syntonin, 389. Syphilis, 518; of liver, 653 Syrup, 157. Tabasco, 293. Taenia mediocanellata. 414; solium, 414. Takadiastase, 397. Tamarind whey, 889. Tamarinds, 216. Tania, 205. Tannin, 247. Tapeworm, 413. Tapioca, 160, 187. INDEX 927 Taro, 205. Tarragon, 203. Tea, black, 248; green, 248; infusion of, 249 ; preparation of, 247 ; properties of, 248; substitutes for, 906; therapeutic action of, 249. Teeth and food, 355. Teething and food, 853. Temperature and digestion, 374; and food, 375-377. Terrapin eggs, 120. Test for intestinal indigestion, 396. Test breakfast, 573. Test dinner, 572. Test meals, 572. Tetanus, 504. Theobromine, 259. Thermos bottle, 356. Thermotherapy, 375. Thirst, 42; in diabetes, 735; in ty- phoid fever, 480. Thompson's dietary tables, 777, 778. Thyroid extract in obesity, 710. Thyroid gland, 145. Tissue sparers, 8. Toast, 169. Tobacco and constipation, 641 ; and food, 404. Tokay, 280. Tomatoes, 204. Tomcod, 149. Tongue, 141. Tonsilitis, 564. Torula amara, 73. Tous-les-mois, 186. Tracheotomy, 495. Trained purveyors of food, 462. Training diet, 809. Travel and diet, 824. Treacle, 157. Trichina spiralis, 415. Trichinosis, 415; treatment for, 418. Tripe, 145. Trisket, 178. Trommer's extract of malt, 189. Tropon, 133. Trout, 148, 149. Truffles, 224. Trypsin, 394. Tubercular meat infection, 434. Tubercular milk infection, 432. Tuberculosis, causation of, 505; ce- reals in, 509; and cod-liver oil, 509; diet in advanced cases of, 513; in mild cases of, 511; die- tetic treatment for, 505; and al- cohol, 510; and eggs, 509; and gastric catarrh, 771; and milk diet, 513; meats in, 508. Tubers, 196; succulent, 200. TufnelPs diet, 536. Tuna, 223. Turbot, 149. Turkey, 144. Turmeric, 429. Turnips, 200. Typhoid fever, alcohol in, 481 ; die- tetic treatment for, 474; feeding of typical cases, 485 ; pathological physiology, 473. Typhoid food infection, 435. Typhus fever, 488. Tyrotoxicon, 424. Ulcer of stomach, 607, 608. Ultramarine, 429. United States army rations, 789. Uric acid diathesis, 559. Urinary diseases, diet in, 543. Urine, and food, 403; and sugars, 154. Urticaria, 684. Utica State Hospital dietary, 876. Valentine's meat juice, 138, 141. Vanilla, 292. Veal, 141. Veal broth, 892. Vegetable foods, 152, 190. Vegetables, canned, 312; for children, 850; in chronic constipation, 636; classification of, 206; com- position of, 201, 206; dried, 306; in gout, 723 ; properties of, 201 ; varieties of, 20 L Vegetarianism, 33. Venison, 142. Vermicelli, 160. 928 INDEX Vermouth, 288. Vertigo, 673. Vichy, 244, 245. Vinegar, 292, 313. Viscera, 145. Vomiting, 603; cyclic, 604; of preg- nancy, 607. Von Noorden's diet for diabetes, 757 ; oatmeal diet, 757; diet for obes- ity, 705. Walnuts, 226. Water, 19, 36 ; alkaline, 243 ; depriva- tion of, 42; dietetic uses of, 40; effervescing, 243; excess of, 41; in chronic Bright's disease, 554; in diabetes, 754; in gout, 725; purity, 38; quantity per diem, 332; temperature of, 44; uses of, 37; varieties of, 38. Water starvation, 42. Waters, acidulous, 246; chalybeate, 246 ; in chronic constipation, 638 ; in fevers, 468; lithia, 245; min- eral, 243; table, 244; thermal, 244. Watermelons, 208. Weakfish, 149. Weaning, 837. Weighing of food, 34; of infants, 844. Weight and food, 324. Weissbeer, 275. Welch rarebit, 118. Wet nurse, selection of, 828. Wet nurse's diet, 829. Wheat kernel, 162; puffed, 184. Wheaten bread, 169. W T heatena, 178. Whey, 116, 119; cream of tartar, 889. Whey cheese, 116. Wheyn, 120. Whisky, 285. W T hite beer, 275. Whitefish, 149. Whooping cough, 491. Wine, composition of, 276; mulled, 889; properties of, 276. Wine jelly, 905. W 7 ine whey, 889. Wines, acid, 281; adulteration of, 286, 428; aromatic, 281; concen- trated, 283; dry, 279, 282; per- fect, 282; red, 277; rough, 283; Darkling, 281; sweet, 280; va- ieties of, 279; white, 277. Wintergreen, 293. Whortleberries, 202, 222. Woodcock, 144. Wood's diet for neurasthenia, 670. Worcestershire sauce, 293. Work and food, 332. Yam, 199. Yeast, 165, Yeast fungus, 262. Yellow fever, 499; treatment for, 501, 502. Yeo system for obesity, 703. Yohourd, 96. Yolk, 121. Zein, 182. Zoolak, 95. Zwieback, 171. Zymine, 140. (16) Date Due T REC'D INTED IN u.s.4. CAT. NO. 24 161 3 1970 00364 UC SOUTHERN REGIONAL LIBRARY FACILITY A 000441 122 9 WBUOO TUT8p 1909 Thompson, W G Practical dietetics . . . Thompson, W G Practical dietetics , 1909 MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664