COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS LOS ANGELES, CALIFORNIA >-^4PV*. I 'OK WAS DONA >MLz FOR REFERENCE NOT TO BE TAKEN FROM THIS ROOM DIETOTHERAPY DIETOTHERAPY J BY WILLIAM EDWARD FITCH, M.D. MAJOR MED. RES. CORPS, U. S. A. FORMERLY LECTURER ON SURGERY. FORDHAM UNIVERSITY SCHOOL OF MEDI- CINE; ASSISTANT ATTENDING GYNECOLOGIST PRESBYTERIAN DISPEN- SARY; ATTENDING PHYSICIAN TO THE VANDERBILT CLINIC, COLLEGE PHYS. end upon a relative, but still not an abnormal, weakness of digestive ferments, or even upon abnormalities of the intestinal canal. The consumption of sugar has increased considerably during the past two or three decades, commensurate with the growth of the cane and sugar beet industries (see Volume I, Chapter XVII, Sugar, Spices and Condiments), also with the increasing magnitude of the culinary and confectioner's art. Benedict says, "An individual in normal health may ingest with impunity 100 grams a day of carbohydrates in the form of sugar, while certain persons may take double this quantity without harm." Hydrocarbons are theoretically replaceable by other organic foods and even absolute fat-free diets may be allowed without harm, but the same statement cannot be made for carbohydrates. It is a known physio- logical impossibility for the system to digest and absorb more than a given definite maximum of fats, and 80 grams of carbohydrate are re- quired to prevent catabolic disturbances. We know that a too liberal allowance of meats induces an inevitable increase of nitrogenous waste products from the vicarious use of proteins. Proteins, unlike carbohydrates mid hydrocarbons, nro employed, not 102 FACTORS IN DIET, DIGESTION AND ASSIMILATION only to furnish heat and energy, but to replace wear and tear of the tissues. They are positively non-replaceable, beyond a certain percent- age, by either carbohydrates or fats, or even non-protein nitrogenous substances, such as gelatin and purins, free or combined. However, it should be borne in mind that beyond the minimum of 60 to 100 grams a day (the precise standard being an unsettled question), proteins should be replaced by carbohydrates and hydrocarbons, provided, of course, there is no metabolic disturbance such as diabetes and obesity. We know that within the system both the protein and carbohydrates may be trans- muted into fat and so deposited. Physiology definitely proves that dextrose and glycogen may be formed from fat or protein, and possibly from both. There is a popular idea that much energy may be accumu- lated by the excessive ingestion of foods, which is partially true, but the importance of this notion lies in the fact that it leads to over- eating. Deposited fat is the only evidence that a reserve energy of any im- portance is accumulated. The human body may put on 100 pounds of fat, or over 400,000 calories in potential energy, or the requisite amount to sustain the body for 200 days. Such a demand rarely happens in civilized life, and if so the body certainly would lack the power to utilize it, even with concomitant waste of protein tissue. There is no recorded case where the body reserve energy has lasted more than about forty days without a supply of organic nutriment from without. Carbohydrates may be stored in the body as dextrose in solution, and as glycogen in muscular tissue and gland cells, particularly in the liver, to the extent of 300 grams per day, just barely enough to supply a half day's caloric demands for the regulative functions. In studying Protein and Nutrition (see Volume II, Chapter VII), the researches of Chittenden, Fischer and others give proof that a small amount of protein in excess of the daily requirement for needed calories may be stored. Voit and other investigators, experimenting with dogs, conclude that the proportionate storage is between 5 and 8.5 per cent. Von Noorden(2) estimates that the human being can store about 10 per cent of the excess protein. So we may safely conclude that the energy eliminated from metabolized protein will aggregate about 90 per cent, and the stored protein will be in the neighborhood of 10 per cent of the amount ingested. In addition, it must be remembered that a small moiety of reserve protein occurs in the circulatory and lymphatic systems, while the remainder is stored in hypertrophic or in newly formed cells. So much protein is required to supply the wear and tear of normal mus- WASTE AND DIGESTIBILITY OE FOODSTUFFS 103 cular tissues that only a very small amount can be stored as a reserve available in starvation or relative inanition. From the foregoing we may arrive at the following conclusions : (a) It is useless to increase the protein ration to create a reserve of force and tissue material, since such a course overtaxes the organs of excretion and increases the chances of auto- intoxication. (fr) It is not, at present, an accepted fact that only the protein minimum just enough to balance the nitrogen equilibrium is the ideal ration. The proper nutrients for a normal body amount to at least three meals a day of a standard dietary. (Volume II, Chapter VII.) (c) The storage of hydrocarbons in persons of small stature should not exceed the caloric requirements for a forty-day fast about 12 pounds for a man weighing 140 pounds ; a man of full stature should not carry more than 34 pounds of fat. (d) It is comparatively easy by superalimentation to increase body weight from one-half to one pound per day by depos- iting fat. Benedict believes that in the entire absence of food, even on exposure to cold or at strenuous muscular exertion, the body cannot utilize more than one-half pound of fat daily, and, while greater loss may occur in sickness, the physiological reduction of weight on a low diet will equal the rate at which fat can be deposited. WASTE AND DIGESTIBILITY OF FOODSTUFFS Benedict, who has studied this subject from every viewpoint, holds that the waste of foodstuffs occurs both economically and physiologically. First, the loss in transportation to the retail market; second, the loss in preparing and serving, besides the financial loss in using, often through ignorance, expensive nutrients of a lower protein or caloric value than cheaper foods. Again in the trimming and paring of foods, the cook often wastes large quantities and finally at the table the waste is consid- erable, when the serving is larger than is eaten, and must be borne in mind in all cases when computing nutrients from a caloric viewpoint. In the average well-to-do American family, the percentage of waste 104 FACTORS IX DIET, DIGESTION AND ASSIMILATION of digestible and assimilable foods in the kitchen and at the dining table ranges from 10 to 50 per cent. Gross waste is often due to igno- rance on the part of the cook and other servants. On the other hand, the removal of fat, skin, seed pods, husks, cores and other indigestible por- tions of food material cannot be considered as waste, but both economically and physiologically the theoretic high food-value of fat meats must be discounted, because of the ultimate rejection of fat. Physiologically, food waste can be accounted for, first, by the ex- cessive ingestion of one or more kinds of organic nutriments, and, second, by the swallowing of foods which have been imperfectly comminuted. Vegetable foods swallowed whole, such as beans, peas, corn, huckleberries, etc., largely escape digestion, because their skins or husks, composed largely of cellulose matter, are not broken up. Likewise starchy vegetables, meats, eggs, etc., swallowed without proper mastication are wasted to .a large degree. When milk is gulped down like water, it forms large curds, much of which is passed away unchanged. Alimentary saprophytosis is a possible aid in the digestion of certain food materials especially vegetable foods containing cellulose material. The efficiency of the vari- ous enzymes and hormones exerts an obvious influence on the amount of alimentary waste; even when mastication is well performed and intestinal saprophytosis is within normal limits, there is considerable loss of food material. Atkinson calculates the utilization of some of the staple foods as follows : THE UTILIZATION OF SOME OF THE STAPLE FOODSTUFFS Meat and fish, .nearly 100% of protein, 79-92% of fat Eggs 100% 96% Milk 88-100% 93-98% doubtful of carbohydrate Butter '. 98% u " Oleomargarine.. 96% " " Wheat bread. . . 81-100% " " (too little fat to estimate) 99% carbohydrate Corn meal 89% " .'. . 97% Rice 84% 99% Peas 86% 96 o^ Potatoes...' 74% 92% Beets 72% 82% " The experiments of Leo Breisacher call attention to the loss of albu- min, as ranging from 2.9 por cent to 4.9 per cent on a milk and choose diet, and 0.5 per cent, 7 to 7.1 per cent on milk alone. For loss on othor diets consult the following tables from Breisacher, referred to bv Benedict: WASTE AND DIGESTIBILITY OF FOODSTUFFS 105 PERCENTAGE OF UNABSORBED ALBUMIN (BREISACHER) Corn meal 15.5% Peas and bread 12.2% Wheat bread . . . . 19.9% Rice 20.4% Rye bread 22.2% Wheat bread 18.7% Peas, cooked soft, . .17.5% Black bread 32. % Potatoes 32.2% Peas, cooked 27.8% Lentils 40. % Potatoes, lentils and bread 53.5% PERCENTAGE OF UNABSORBED FAT (BREISACHER) Olive oil (liquid at ordinary temperatures) . . . .2.3% Butter (melting point 31 C) 1.28-6% Lard 34 C 2.5% Tallow 49 C 7.4% Stearin 60 C 86-91% unabsorbed The excretion of fat in the stools varies with the conditions under which it is ingested. During fasting there is a daily loss in the stools of somewhat more than one gram of fat. When the quantity ingested is from 25 to 40 grams, the loss varies from 10 to 15 per cent, i.e., about 4 grams. When the quantity ingested is increased to 100 grams, the gross loss remains practically the same. The reduction in percentage may reach a point as low as 1.25 per cent. The explanation of this discrepancy is found in the fact that when very little fat is eaten, it consists chiefly of beef, mutton or other meat fat, and of vegetable fat which is embedded in the cellulose. The loss of fat when small quanti- ties are taken averages about the same as the loss during fasting, about 1 gram daily. When the daily quantity of fat exceeds 150 grams, the loss increases in proportion and may reach 20 per cent. This high rate of loss is most apt to occur when oils having a direct laxative action are administered. With a coarse vegetable diet, the loss of all nutrients increases progressively. This effect is partly due to the laxative action of the so-called coarse vegetables. From these data it appears that the finer the subdivision of the food ingested, the larger will be the proportion of nutrients assimilated. For example, in the case of bread made from decorticated whole wheat meal, about 00 per cent of its protein and 02 per cent of its carbohydrates aro utilized, while fine white bread made from bolted flour yields 81 per cent of its protein and nearly 100 per cent of its carbohydrates. Pota- toes offer another interesting example: As ordinarily cooked and masti- cated, this vegetable yields about 70 per cent of its protein and 92 per cent of its carbohydrates to nearly 100 per cent. The class of coarse vegetables, including turnips, carrots, beets and cabbage after thorough cooking yield protein in the proportion of from 60 to 80 per cent, and 106 FACTORS IN DIET, DIGESTION AND ASSIMILATION from 80 to 85 per cent of carbohydrates. On the other hand, if these vegetables are not thoroughly cooked and well masticated, and if in addition they are habitually used and in generous quantities, their excre- tion may ultimately exceed their utilization. It has been estimated by Rubner that on an ordinary mixed diet the nutrient waste amounts to about 8 per cent of the total calories, and we may safely conclude, therefore, that from 200 to 300 calories of the standard ration may be considered as a physiological waste by failure of digestion. This waste is taken into consideration when estimating the required calories which are stated in terms of ingested food. Therefore this variation is not of importance, and the physiological waste of nutrients need not be given any consideration. Variations in food waste may possibly explain the fact that, say, two persons of the same weight and following the same vocation may require different amounts of food to maintain normal weight and health. The fecal excretion from a normal person averages from 100 grams per day moist weight upward, and on analysis will be found to contain 20 per cent of fat and 7 per cent of albumin, estimated by multiplying the nitrogen by 6.25. In wasting diseases, it is considered practical to try to determine the amount of waste of nutrients in the alimentary canal, but the difficulty and expense usu- ally prevent such determinations. Still something may be accomplished by ordinary chemical tests and by macroscopic and microscopic exami- nation within the abilities of the clinician. Contrary to popular belief, it is quite difficult to give an intelligent opinion concerning a general comparison of foodstuffs as regards their digestibility. A few inorganic ingredients of the diet such as water and salines require no digestion. Benedict, who has studied this sub- ject very carefully and exhaustively, holds that we have no precise en- lightenment concerning the relative digestibility of hemoglobin, nucleins, lecithin, organic combinations of iodin as in the thyroid. Carbohydrates and proteins undergo many changes before final absorption. For instance, cooked starch is partially digested, both mechanically and chemically ; dextrin, as in bread crust, is still further digested; the double hexoees, as cane sugar, maltose a stage of digestion beyond colorless dextrin and lactose require inversion into single hexoses, and of the latter dex- trose is the ultimate one ready for oxidation, while levulose and galactose must be changed into dextrose. The hydrocarbons split into glycerol and fatty acids ; the former, uniting with water, forms glycerin, and the latter joins with alkaline bases and forms soaps, yet it does not appear that either glycerin or soaps can in any particular be considered as nutrients. WASTE AND DIGESTIBILITY OF FOODSTUFFS 107 There is still considerable uncertainty as to the digestion of fats. At- water estimates that 95 per cent of fat of all animals is absorbed, and only 1)0 per cent of the fat of vegetables. Rubner declares that only 80 per cent of the fat from beef and mutton is absorbed. Butter is fairly well absorbed, while bacon fat is not so well absorbed, because it is enclosed in cells, and from 7.5 to 17.4 per cent escapes absorption. It is safe to assert that the lower the melting point of fat the greater will be the percentage of absorption. It has been found that about S 1 /^ ounces can be absorbed without any loss being detected on examination of the fecal excreta. It is held that the coagulation of protein is a preliminary step in the process of digestion. Benedict holds that there may be some good grounds for the old theory that this stage in protein digestion acts as a safeguard against excessive protein nourishment, though of course he realizes that it is not a safeguard against the after-effects of the end products of protein digestion. Rennet coagulates the caseinogen of milk. The gastric, pancreatic and intestinal juices also coagulate caseinogen, although the pathologic instances when the former fails to coagulate milk are nearly always confined to adults, and this peculiar factor of safety is not quite well understood. There is yet some question whether there exists a separate rennet ferment or ferments, or if coagulation is really brought about by pepsin, trypsin, and the intestinal activation for tryptic digestion. A certain amount of coagulation takes place in the process of cooking of proteins which may be considered a step in digestion; but the principal aim in cooking is to kill parasites, including various bac- teria, and at the same time to render the food more tasty and more readily masticated and comminuted. While artificial coagulation of milk by rennet may be considered a digestive process, yet it does not appear to aid its further digestion in the alimentary canal, and the curd if dried and reduced to a fine powder Is more difficult of digestion than raw cow's milk. Tho digestion'of proteins, artificially, has not yet been successfully accomplished. The so-called predigested protein occurs mainly as albu- mose, and if the process is carried further it reaches the peptone stage, making a disagreeable bitter product, actually toxic. When reduced to the amino-acid stage there is a question whether the nutritive value is lost, but this has recently been Stoutly denied. Vegetable foods containing a relatively high percentage of cellulose are indigestible, not that cellulose itself is a nutrient, but that a mesh- work of cellulose incloses the starchy granules and .other nutrients which escape digestion, and in this way causes considerable waste of food ma- 108 FACTORS IN DIET, DIGESTION AND ASSIMILATION terial. It must not be overlooked, however, that cellulose, especially that occurring in fine, threadlike meshes, is stimulating to peristaltic action. Cartilaginous or tendinous fibrous tissue is likewise indigestible, and when muscular tissue is not cut, chopped or comminuted sufficiently, there will be considerable waste of nutriment. Many of the older physi- ologists worked out elaborate tables to show the length of time required for the stomach to perform its functions. W. Oilman Thompsoii(3) compiled a table showing the time of the average sojourn in the stomach of various food products. Modern research emphasizes the physiological fact that this is not a test of digestion itself, because gastric digestion is not complete, for the reason that the process of digestion is only begun in the stomach. In other words, the function of the stomach is only to make ready the foodstuffs for the various processes of digestion. It is quite difficult to arrive at an accurate estimation of the digesti- bility of fruits. If they are not well masticated or otherwise comminuted there is considerable waste. When thoroughly masticated, the water and inorganic salts are ready for absorption, and the metabolism of sugars is a simple matter. Most fruits contain too little fat to be considered and there is some doubt as to the actual degree of assimilation of the protein. Bananas contain a liberal quantity of raw starch, which places them in a class by themselves, so that they cannot be digested to any appreciable extent until they have reached the duodenum and beyond. SUBSTITUTES FOR FOOD Substitutes for food are often necessary, especially under conditions in which, from poverty or exposure, sufficient quantities of food cannot be obtained. Under such conditions, the craving of hunger may be dimin- ished and actual tissue-waste may be retarded by the substitution of cer- tain mild stimulants and beverages. Tea, coffee and tobacco all possess moderate actions in this respect, and alcohol under such conditions is both a stimulant and a food. Natives in various barbarous or semicivilized countries while performing long feats of marching, being often unable to obtain sufficient food with regularity, make use of a variety of different substances as substitutes for food, among which may be mentioned betel- nut, cola-nut, Siberian fungus, the coca leaf and pepperwort, which are chewed from time to time, and hashish and opium, which are both eaten and smoked. Various forms of alcoholic fermented drinks are made use of. "Various concentrated foods of high nutritive value with small bulk may be used in the place of fresh foods. Attempts have been made from STARVATION AND INANITION 109 time to time by the heads of the principal armies of the world to supply a ration with concentrated elements for the use of troops on prolonged marches, hut after a few days' subsistence on such a ration it has been found that the men lose weight and deteriorate in strength. STARVATION AND INANITION Starvation Starvation is a condition brought about by insufficient food for the maintenance of the body. It is of rare occurrence in civilized communities. In such extreme cases, life may be maintained up to a limit of about 40 days if there is no deprivation of water and no exposure t<> cold. During prolonged deprivation of food the tissues become ex- hausted in inverse order to their functional importance. So says Bene- dict in his valuable little work, "Golden Rules of Dietetics." The gly- cogen stored as a reserve is utilized within a few days, though sugar may subsequently be formed from protein. The hydrocarbons are exhausted at a rate varying according to circumstances and individual peculiari- ties, only about 1 per cent remaining. Wherever there is interference with the oxidation of fat as in certain pathological conditions, the patient dies virtually from lack of the ability to perform the various metabolic processes, while a relative excess of fat remains. The skeleton cartilages and dense fibers remain nearly in a normal condition ; likewise the heart and brain during starvation arc almost entirely unimpaired, while the muscles and various glands are atrophied according to the ability of the body to spare their function. If water as well as food is withheld, death will occur in from five to eight days. The period of time during which different individuals can subsist without food depends upon : (a} External conditions of temperature and moisture. (6) The amount of work being performed. (c) The physiological conditions of the body. (a] The length of time that an individual can endure starvation is influenced by various factors. As has already been stated, exposures to cold reduce vitality and lessen resistance, so that under these conditions the period of endurance is shortened. A moist atmosphere by prevent- ing surface evaporation helps to prolong the possible period of starvation. And finally the maintenance of a uniform temperature of the surround- ing air also prolongs the period during which a man can abstain from food. (!>} Individuals who move along the lines of the least resistance, shun- ning every form of exercise, can live much longer without fond than those 110 FACTORS IN DIET, DIGESTION AND ASSIMILATION undergoing strenuous exercise. In time of famine, self-forgetfulness by diverting the mind from the sufferings of the body tends to prolong life. (c) The full-fed, well-nourished endure longer intervals of abstinence from food than weakened invalids. The distressed mental condition attending delirium may be increased by lack of sufficient nourishment. Sex seems to exert no influence upon the effects of starvation, which are most keenly felt at the extremes of age, by young children and aged persons. The author, while serving in the United States Marine Hospital Service, attended four sailors who had been shipwrecked and picked up at sea and brought ashore. These men, after recovery, related that when the small amount of water and food which they fortunately had, gave out, they cast lots among themselves (five in number) to determine which one of the party should die in order that the remaining four might par- take of his flesh and blood for subsistence. They were the most wretched and despicable human beings imaginable. A pathetic account of the miseries of starvation is reported in the journal of Lieutenant De Long(4). W. Oilman Thompson, in his work on "Practical Dietetics," quoting from De Long, says : "After leaving their sinking vessel, the members of the Arctic expedition were exposed, at first in open boats and later in their long sledge journey, to the most exhaust- ing 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 con- sume the meat of their last remaining dog, which they ate fried. They subsisted upon this food exclusively for four days longer, having an allow- ance 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." De Long quotes from the physician in his Arctic expe- dition: "Alcohol proves of great advantage; it keeps off the craving for food, prevents gnawing at the stomach, and has kept up the strength of the men on an allowance of three ounces per day. "The alcohol being exhausted, they lived for another day upon a tea- spoonful of olive oil, with n 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 STARVATION AND INANITION 111 farther on their journey, being driven back by intense cold and the dif- ficulty of crossing the partly frozen rivers. Their feebleness gradually overcame them, until one by one they died of inanition. Four men sur- vived for sixteen days upon absolutely no food whatever, and possibly their sufferings were even further prolonged, but the journal of their gallant and heroic commander ceased at this point, for he, too, died." Inanition Inanition is the inability of the tissues to assimilate food. The term should be restricted to those cases of acute starvation observed in early life. It is characterized by loss of weight due to a disordered metabolism. This condition is characterized by fever, and the malady is not infrequently mistaken for some other disease. It follows the ingestion of improper food or abstinence from food, where infants are abandoned, or other cases that are grossly neglected and starved. Gross errors in feeding are a contributing cause where food is given which is absolutely imsuited to the needs of the child. Individuals who are well supplied with a reserve of food stored in their tissues can resist starvation by calling upon this reserve to maintain the energy of the body in the absence of food ; and, having a larger supply than thin or emaciated persons, they can withstand starvation for a much longer period, although they may complain more bitterly of the pangs of hunger than individuals previously accustomed to a scant diet. Experiments were conducted by Chossat to determine the rapidity of the loss of body weight, etc., and it was found that starving animals, while losing 40 per cent of their body weight, lost in fat 90 per cent. "Anselmier fed starved dogs upon their own blood and succeeded in pro- longing their lives for three or four days beyond the usual limit, until 60 instead of 40 per cent of their body weight had been lost." During the winter of 1776 and 1777 an accident occurred in a colliery in South Wales which resulted in the imprisonment of four men and a boy for ten days without food. When they were rescued they were alive, though very feeble, and were able to walk when released. Fortunately, a supply of water was available and the atmosphere in which they were confined was moist. A second accident occurred in this colliery and a number of men were confined in a mine for six days without food, and while their suf- ferings were extreme, nearly all were able to walk on being rescued. From this we may assume that the lack of food may be endured with far less torture if water is applied internally and externally. When water is with- held in such a condition, the body loses weight very rapidly, the tissues become dry, thirst excessive, the secretions suppressed, and suffering is very greatly intensified. 112 FACTOES IN DIET, DIGESTION AND ASSIMILATION FASTING Fasting is one of the most ancient religious rites of winch there is any record. More than two thousand years ago the fasting cure was advocated by the school of the natural philosopher, Asclepiades(o), who also applied the "water cure." It is recorded that Plutarch said, "Instead of using medicines, rather fast a day." Fasting in Religion. It was practiced, as stated above, in connection with religious ceremonies and so came to be considered an inseparable part of almost all such observances. Thus we read in a queer old book, entitled "Of Good Workes, and First of Fasting" (6), that the Church of Eng- land speaks of fasting and of its treatment by the Council of Calderon as follows: The Fathers assembled there . . . decreed in that Council that every person, as well in his private as public fast, should continue all day without meat and drink, till the evening prayer. And whosoever did eat and drink before the evening prayer was ended should be accounted and reputed not to consider the purity of his fast. The canon teacheth so evidently how fasting was used in the primitive Church, as by words that cannot be more plainly expressed. From the above quotation we find that fasting was considered to be a highly important part of the religious ceremony, and of spiritual salva- tion. We find this same idea expressed throughout the Holy Writ in passages too numerous to mention (7). The excellent work, "Vitality, Fasting and Nutrition," by Carrington (Rebman Co.), has been freely consulted and quoted in the preparation of this section. We hardly need to be reminded that the Holy Nazarene himself fasted for forty days. Many people accept Christ's forty-day fast as sufficiently explained by his supposedly Divine Power. It was, in short, a miracle which would be impossible under ordinary circumstances for any other man. Dr. Tanner aroused the whole scientific world a few years ago by fasting forty and again forty-two days, on two separate occasions, and while charges of "fraud" were circulated at the time and believed in by many, yet no one who took possession of the facts of the case gave any credence whatever to these stories. Great as was the prejudice in profes- sional circles, and bitter as was the feeling at the time, no direct charge of fraud could be made, for no atoms of proof of such were forthcoming. The general view of fasting is probably well summed up by the Reverend Puller(8) when, in discussing the previously mentioned cases of fasting during Lent in Jerusalem, he remarks: FASTI .Mi 113 Such fasting is certainly, for the mass of English people, impossible now. It seems to me that this great difference in the power of fasting, which is quite in- disputable, must be taken into account, when we are considering how to apply the Apostolic rule to modern circumstances. Victims of forced fasting and starvation become so ravenous that all sense of taste gives place to intense hunger. .Muscular action is no longer possible. There is vertigo and faintness on raising the head, the voice is lost, and gradually the nervous system succumbs to languor and general prostration. Chambers records an occurrence where three men and two boys were starved for twenty-two days in an open boat. They had ten days' ration to start with, and subsequently nothing but old boots and jellyfish, and they fought violently with one another over these. Robert de Moleme, the founder of the Cistercian brotherhood, was overcome with grief on learning of the death of a female friend, and like General Boulangcr, resolved to follow her to the Land of Shades. Being averse to direct suicide, he retired to the mountain lodge of a relative friend, and abstained from food in the hope that one of his frequent fainting fits would fade into the sleep that knows no waking. But finding himself alive at the end of the seventieth day, he recon- sidered his resolution and began to suspect a miraculous interposition of Provi- dence. By resuming his meals, in half ounce installments, he contrived to recover from the condition of frightful emaciation, and in the supervision of an ever-in- creasing number of scattered monasteries, led an active life for the next fourteen years (9). No-Breakfast Plan. The American apostle of "fasting as cure for dis- ease" was the late Dr. Dewey(lO), who recommended fasting as a relief for certain disorders. That short fasts are beneficial to many people there can be no question. Such fasts have been practiced from time immemorial. Dewey was the first to urge the "no-breakfast" plan of restricting the intake of food, on the supposition that the majority of people consumed a great deal more food than was required. This apostle says(ll) : "There is no necessity, after a night of undis- turbed restful sleep, to partake of food ; sleep is not a hunger-causing process." He deprecates the American breakfast, holding that when "we arise in the morning with our brains recharged by sleep, we should at once go to our place of business." He also says it is "a foolish expendi- ture of energy to take any kind of physical exercise in the early morning." holding to the view that when one has worked long enough he will be- come fatigued, ami when this point is reached, he should have a period of rest preceding the partaking of food. 114 EACTOKS IN DIET, DIGESTION AND ASSIMILATION We cannot waste space in replying to his assertions. We agree, how- ever, that moderate fasts are beneficial, but should not be instituted except under the personal observation of the family physician. Dewey's no- breakfast plan is not an ideal institution for general application. It might be suited to the Eskimo, who consumes enormous quantities of meat and oil at one sitting, or for the city dweller, who keeps late hours and partakes of midnight suppers, who is a spender and not a producer, but for the business man, a light repast to break the fast is necessary. The Frenchman, as a rule, with the exception of his roll and cup of chocolate in the morning, partakes of but little food until midday. The Englishman consumes a rather hearty breakfast at an early morning hour, which the average American and Canadian consider meager. The two latter want meat, cereals, fruits and coffee. It is not disputed but that many people would be in better health if they had no breakfast at all, but, generally speaking, most Americans eat too much at all three meals. An ideal breakfast for those following sedentary occupations is a fruit, a cereal, an egg or a piece of breakfast strip, a roll and a small cup of coffee. As said before, we are opposed to the no-breakfast plan, believing that the body has need for material to produce heat and energy, and ab- stinence from food until the middle of the day tends to draw too heavily upon the reserve store of protein and glycogen, and possibly to a limited extent upon the store of fat. The no-breakfast plan would not satisfy the wants and needs of the majority of live active individuals who lead strenu- ous lives, and again the no-breakfast eater is usually a complaining, scrawny, puny individual as compared with the hearty breakfast eater. Fasting as a Cure It is claimed by devotees of fasting as a cure that the principle on which the hunger cure acts is one with which all physiol- ogists are acquainted. During a fasting condition, nature makes an effort to rid the body of effete material. This the author experienced in a ten- day fast a few years ago. He was suffering from intestinal stasis with putrefaction of the alimentary contents. The end products of protein digestion were greatly disturbing the metabolic processes of the body, re- sulting in both mental and physical hebetude. At the suggestion of a medical confrere, the author went on a ten-day fast with no aliment ex- cept strained vegetable soup made without meat or fats. The craving for food was very strong for the first two or three days, but after this, going without the ternary food elements caused very little, if any, incon- venience or annoyance, except for the elimination of most offensive ex- creta, which was aided by the self-administration of Russian mineral oil. FASTING 115 When he returned to his former dietary habits, which were slowly and carefully resumed, there was noticeable improvement in his condition. Temporary denutrition exercises a favorable influence in certain dis- orders, more particularly of the alimentary tract, such as intestinal auto- intoxication, intestinal stasis with putrefaction, intestinal toxemia, etc. It gives nature a chance to clean house. The organism, on a starvation dietary, soon begins to lessen the outgo of energy. The movements of the organs of respiration slow down, the temperature drops slightly below normal, the secretion of bile and uric acid is lessened, and later it is claimed that there is retrenchment of the assimilative functions, reacting on the intestinal organs, the colon contracting, while the "small intestine retains all but the most irritating ingesta." Beyond question, by temporarily depriving the body of the supply of food it has been continually ingesting in excess of actual needs, we give the organs of elimination a chance to clean the polluted sewers, and to un- load the superfluous impurities by the various eliminative organs, which exerts a beneficial effect to the whole organism. Long-continued Undernutrition. Man, after all, is more or less a creature of habit, and really the whole question of the amount of food daily ingested is essentially one of habit. As Chittenden(12) has aptly said: The so-called cravings of appetite are purely the result of habit. A habit, once acquired and persistently followed, soon has us in its grasp, and then any devia- tion therefrom disturbs our physiological equilibrium. The system makes com- plaint and we experience a craving, it may be, for that to which the body has become accustomed, even though this something be, in the long run, distinctly in- jurious to the welfare of the body. There has thus come about a sentiment that the cravings of the appetite for food are to be fully satisfied, and this is merely obedience to Nature's laws. The idea, however, is fundamentally wrong. Anyone with a little persistence can change his or her habits of life, change the whole order of cravings, thus demonstrating that the latter are purely artificial, and that they have no necessary connection with the welfare or needs of the body. In other words, dietetic requirements are to be founded, not upon so-called instinct and craving, but upon reason and intelligence. After all, undernutrition can only be followed by disastrous results if long continued. Many are the human derelicts stranded on the rocks of semistarvation, "especially of protein starvation, the result .of having been compelled to subsist, as many poor but respectable people have been, for a prolonged period upon 'bread and tea' because of the deficiency of protein in these foods. Deficiency of protein leads to wasting and degen- eration of all muscular and nervous tissues; and, even when it is barely 116 FACTORS IN DIET, DIGESTION AND ASSIMILATION sufficient, the individual does not always ultimately recover, but is prone to remain neurotic and subject to many ailments." Fasting Experiments Fasting, of late years, has been attempted either by love of notoriety or desire for pecuniary gain by persons exhibiting themselves for gratification of public curiosity. They are generally frauds and are fed by some one in collusion with them. In a number of cases, the subjects have been carefully studied by medical experts, and there is no question that in some instances, at least, the fasts have been conducted with honesty. Thompson (3) reports two authenticated fasts where Tanner and Succi were the subjects. A period of starvation was prolonged for 40 days and over. In both instances fluids were allowed, and in one of the men intense epigastric pain and food craving was ameliorated by medication. "Succi, an Italian subject, in 1890, undertook an absolute fast of 40 days, during which time he lost 421/2 pounds and drank an average of 2 5 y ounces of water daily. The water he consumed was in the form of plain water, mineral water and ice. He lost flesh very rapidly during the fast, but on the last day he had strength sufficient to walk around the room. When he resumed eating he first took cocoa and subsequently bouillon and other light liquid diet, gradually returning to solid food. His mental faculties were unimpaired throughout. He occasionally took small doses of a few drops of an elixir supposed to contain opium." Luigi Cornaro, a Venetian gentleman, published a treatise on a "Tem- perate Life," advocating a very abstemious diet. He says : I do not know whether some desperate degrees of abstinence would not have the same effect upon other men, as they had upon Atticus who, weary of his life as well as his physicians, by long and cruel pains of a dropsical gout, and despairing of any cure, resolved by degrees to starve himself to death, and went so far, that the physicians found he had ended his disease instead of his life! His case is often referred to as an illustration of the smallest quan- tity of food which will support life. In his early days he was a reckless, intemperate youth, and spent his time "in riotous living." Later he re- formed and by careful dieting prolonged his life to 103 years. During the last 48 years of his existence, he subsisted largely on an allowance of twelve oynces of vegetable food and 14 ounces of wine. Occasionally, he partook of eggs, but rarely took any other form of animal food. While there may be much wisdom in his doctrines as published, unfortunately no one who has attempted to put his teachings into practice has been similarly rewarded with a long life. The majority of mankind would, FASTING 117 for the pleasures of the palate, prefer to live fewer years in lieu of the pleasure of being less abstemious. Periods of voluntary fasting of varying duration are practiced by devotees of religious sects. This practice was formerly indulged in to a greater extent by ascetics than at the present time. Such practices, un- less they be definitely limited and supervised, may be carried to an ex- cessive or even injurious degree. When a man by fasting reduces him- self to the extent that his intellectual faculties are obtunded, he may be sure that he is doing himself injury. It would be far better for such individuals, for purposes of mental discipline or religious motives, to eliminate temporarily from the diet accustomed luxuries, or give up such articles in the daily ration as butter, sugar, salt, wine, tobacco, etc. This, in fact, is a custom practiced by many persons during the season of Lent. Contrary to the opinion once held by the laity, fasting cannot be regarded as favoring either clearness of intellect, muscular strength or endurance. Gerland emphasizes the folly of such practices, "the ethnologist can trace the physical and mental decay of whole nations to a long course of insuf- ficient food." Dr. William Stark, a young English physician, lived for forty-four days on bread and water, for a month on bread, water and sugar, and for three weeks on bread, water and olive oil. At the end of his experiments he was in a very enfeebled state of health ; he developed symptoms resem- bling scurvy, and ultimately died, apparently a victim of his own scien- tific enthusiasm (13). Effect of Fasting- on Metabolism. A knowledge of the metabolic changes occurring during a fast is of great importance both physiologically and pathologically. Many important physiologic discoveries were made pos- sible by experiments on fasting animals and men, while pathology has benefited by examinations of diseased persons who were starving or nearly starving. The effects of fasting on metabolism have been studied at length by Benedict (14). He carried out an experiment on a man during a seven days' fast. He found the loss was estimated to be: protein 69.5, fat 139.6, glycogen 23 grams per day, yielding 1,597 calories. The loss of protein equaled 347 grams of flesh ; the actual loss of energy measured by the calorimeter was 1,696 calories per day or 100 grams more. The heat of combustion can be calculated from the known heat value of the sub- stances, 1 gram of body protein yielding 5.65 calories, and 1 gram of fat 9.. 5 4 calories, and the total when fully oxidized would aggregate about 1,734, so that during a fast the organism lives on its own flesh and fat. 118 FACTORS IN DIET, DIGESTION AND ASSIMILATION The changes in the metabolism produced by sickness cannot be accu- rately determined without a knowledge of the changes due to simple inani- tion. The knowledge of the pathology of the metabolism of fasting is sensibly incomplete, though many additions have been made to it during the past few years. During the first few days of a fast, a man lives upon body glycogen, then upon his own protein and fat. In consequence, his respiratory quo- tient falls, which indicates the combustion of carbohydrates to approach the values indicating the consumption of protein or fat. The more abun- dantly a man is fed preceding his fast, the greater will be his reserve sup- ply of glycogen when the fast begins, and as a result, the more slowly will his respiratory quotient diminish. This explains the difference, dur- ing the first few days of fasting, between the well-fed men observed by Breithaupt and the underfed observed by Cetti (15). FASTING METABOLIC EXPERIMENTS CETTI BREITHAUPT Days Per Kg. per Minute Per Kg. per Minute of Fast 2 CO, Respiratory 2 CO, Respiratory Quotient Quotient 1 4.86 3.51 0.72 3.96 3.48 0.78 2 4.59 3.13 0.68 4.32 3.19 0.74 3 4.48 3.07 0.68 4.26 3.12 0.73 4 4.78 3.10 0.65 4.38 3.19 0.73 5 4.68 3.10 0.66 4.37 2.75 0.63 6 4.67 3.13 0.67 4.35 2.26 0.86 7 5.06 3.39 0.67 3.76 2.60 0.69 8 4.89 3.33 0.68 4.07 2.94 0.72 9 4.62 3.10 0.67 10 4.67 3.16 0.68 Von Noorden, in commenting on the results tabulated in the above table, says: The fact that the respiratory quotient at times fell below the theoretical mini- mum is explained by the conclusion that during repose and abstinence from all voluntary movements, small quantities of glycogen arising from the decomposition of protein collect in the liver and muscles. If this is so, muscular work, which decreases the decomposition of glycogen, must also increase the respiratory quotient. It is of great practical importance to know whether the physiological PERYKRSIOXS OK Ari'KTITK 119 laws of prolonged fasting hold good in chronic malnutrition. An indi- vidual in a condition of undernutrition through insufficient feeding might, under favorable circumstances, indulge in extravagant metabolism, as he does in acute fasting. "Again, he might establish a sort of automatic and purposive regulation, diminishing the amount of his metabolism when placed on a continuously inadequate diet." This brings up the interesting question, ''What amount of food is necessary to maintain patients who are markedly emaciated from prolonged fasting." A case much quoted, recorded by Klemperer, emphasized the food re- quired to maintain nitrogen equilibrium. "A tailoress, aged 22, had been improperly nourished, and her weight fell from 50 to 36 kilograms; for eleven days she remained in nitrogen equilibrium at 18 calories per kilo- gram." Klemperer concluded that, as she was in nitrogen equilibrium, his patient was also in heat equilibrium, so that her diet of maintenance would be at the rate of 18 calories per kilogram of body weight per day. Von Noorden points out the error of Klemperer's conclusion, with the sug- gestion that after protracted malnutrition, the organism can retain nitro- gen to build up the cells demanding protoplasm, even when on a scanty nitrogen diet. Von Noorden says: "When a poorly nourished individual after a protracted fast is allowed food, in an increased amount, sufficient to overcome the decrease in bodily heat, an effort is at once made to retain nitrogen and repair the loss of cellular material that has occurred. This retention of nitrogen goes on until the body has readjusted itself to the new conditions of nutrition. Then the loss of nitrogen begins anew, unless the calories required have been adequately supplied. Von Noorden conducted many experiments to determine the requisite calories per kilogram per day, in order to maintain a permanent increase of weight, and found it did not occur until an intake of 30 to 32 calories was reached. PERVERSIONS OF APPETITE Parorexia. Parorexia(16), or perversion of appetite, is manifested for special or peculiar kinds of fat. There are three types: (a) Malacia, a desire for highly spiced foods, such as mustard, vine- gar or green fruits, etc. (7>) Pica, an inexorable desire for substances which are not foods, such as earth, chalk, pencils, ashes, sand and insects, etc. (V) Allotriophagia, an insatiable craving f pounds of roast rare beef. Reference was made in a former part of this chapter to the eating powers displayed by certain races, and in the opening chapter of the first volume, dealing with the evolution of man's diet, some examples were given of these powers. Of races which inhabit the world at the present time, the Eskimo stands supreme as a devourer of meat. Cook stated that they eat but one meal a day and then gorge themselves with tough meat SUPEKALIMENTATION 135 so that they develop big jaws and enormously distended abdomens. Hayes, on an exploring expedition, had an opportunity to study the habits of these people, and says that it is not uncommon for an Eskimo to eat from 12 to 15 pounds of food, about one-third of which is fat and the rest muscle meat. Captain Hall, when on his Arctic expedition, declares that he saw a native Eskimo eat 20 pounds of raw meat and consume a quart of train oil within 24 hours. Many primitive people of the present day both in tropical and cold climates eat immensely, but as said before, while eating too much has increased generally in civilized countries, cases of inordinate eating are more rare. Gluttony in civilized people is regarded not only as a sin against the laws of health, but as a repulsive means of gratifying the sensual appetites, fraught with the most grave consequences. It is frowned upon and stigmatized in polite society, and he who sins in this respect is looked upon with contempt. Effects of Overeating. The effects of overeating on the mind and body are more or less obvious. Overeating causes congestion of the liver, and a condition known as "biliousness," in which the stomach and intes- tines are engorged. Constipation ensues, the tongue becomes heavily coated, the bodily secretions are altered in composition, and the urine especially becomes overloaded with salts. It is evident that we are not nourished by the food we eat, but by the amount we can properly use and assimilate. Probably, an excess beyond this amount is beneficial because it supplies a reserve upon which the body can depend for nourishment in time of need. However, it is absolutely patent that chronic overeating so clogs the machinery of the body that the organs of elimination and excretion are unable to work as they should, intestinal stasis follows, the surplus food material putrefies before it is absorbed in the intestine, the urinary tract becomes infected, the circulation becomes involved in the toxic invasion, and the whole system is poisoned. This condition of intestinal toxemia brings in its train many mental and physical disabilities. The nervous and muscular systems become saturated with the end products of protein digestion, producing a state of lassitude, headache, fatigue, drowsiness and even mental stupor. The effect of chronic overeating on the mental powers is very evi- dent. Indeed, it may be laid down as an axiom that a person who habit- ually overeats is incapable of good or sustained mental work. The cross, irritable dyspeptic is too greatly occupied in worrying about his own ills to be able to employ his mental faculties in other and more useful chan- nels. The brain worker or business man, who eats largely, especially in 136 OVERFEEDING AND UNDERFEEDING the middle of the day, cannot use his mental powers properly. His mind loses its acuity and as for flights of imagination, if he is a literary man, these are impossible. Overeating is an insurmountable obstacle in the way of mental endeavor. The handicap placed upon the entire system as the result of overeating is too great to be overcome, and the mind refuses to respond to the stimulus of thought. HABITUAL OVEREATING. The effects of overeating on the body have been discussed already, and little remains to be added. It is known that habitual eating to excess will in course of time bring about alimentary toxemia, and it is more than surmised that this poisoning of the system by the waste food products is mainly and sometimes wholly responsible for many serious diseases, the maladies, for instance, so frequent in these days, known as chronic. However, until our knowledge on these points is more exact and definite, it would be unwise to speak very dogmatically, that is to say, it would be unwise to say with decision that such and such a disease, gout or rheumatism, for instance, is caused chiefly by overeat- ing or errors of diet. This we do know and can state emphatically, that in the treatment of conditions of this nature, diet plays a very important, if not the most important, role. There is another point in connection with habitual overeating which should not be overlooked, and that is its effect on the internal secretions concerned in the digestive process. We do not know enough of the mode of action of the secretory glands to state exactly and in detail what their province is, but we have learned that they have very much to do with the working of the human organism and that when they secrete deficiently ill. health follows. Overeating no doubt unduly taxes the internal secre- tions, and this persistent strain results in their failure or partial failure to perform their normal functions. It is satisfactory to be able to state that knowledge about the internal secretions is increasing and that the time is approaching when the mystery that envelops them will be cleared away. Children are often habitually overfed and the old frequently suffer from the effects of chronic overeating. There is little doubt that many of the ailments with which babies and young children are afflicted pro- ceed from overfeeding. With most mothers the criterion of an infant's health is the amount of adipose deposit it carries. The fatter it is the prouder its parents are of it. The truth is that, as a rule, the fat baby is not the healthy baby. The healthy baby can digest and assimilate easily and continuously an amount of food sufficient to produce normal growth. An excess of food SUPERALIMENTATION 137 will not cause a corresponding excess in the rate of growth. A deficiency or excess of .food continued for a length of time may check growth. The rickety child is frequently extremely fat, and it is certain that harm will result from giving the infant too much to eat. With regard to overeating in the case of the aged, it goes without say- ing that the habit is to be deprecated. When middle age comes digestion often begins to lose its former vigor, and metabolism shows signs of flag- ging. With the gradual onset of old age digestive and metabolic activity further wanes. Consequently with the advance of age chronic overeating should be guarded against and simple foods should be taken sparingly. At the age of sixty an individual must reduce his intake, and at seventy his power has further diminished and the nutriment must correspond thereto, if he desires still another term of comfortable life. Sir Henry Thompson(l) says: "I desire to point out that the system of 'supporting' aged persons, as it is termed, with increased quantities of food and stimulant, is an error of cardinal importance, and without doubt tends to shorten or embitter life." Overfeeding of young children and overeating in the case of aged persons are grave dietetic errors. In early life, as Campbell has pointed out, most people can cope with a dietary which departs widely from the ideal; they are able to consume with comparative impunity not only far more food than is required, but also all sorts of foods which in later years cannot be tolerated. "Com- parative impunity" is said with intention because chronic dietetic delin- quencies, even in early life, cannot but be harmful in the long run, although an occasional lapse from a severely correct diet may in the case of the habitually abstemious, be actually beneficial, and this even after middle life. The point which should be emphasized with regard to overeating is that chronic eating to excess is extremely injurious to health, while an occasional indulgence in this direction may do good rather than harm. Another point upon which stress should be laid, is that Idiosyncrasy and custom count for a good deal in the capacity of the organism to cope with different kinds and quantities of food. The personal equation is always an important factor. Individuals vary greatly in their digestive and metabolic capacities. For example, some children are made ill by even a slight excess of food, while their grandparents, perhaps, can consume a large excess with comparative impunity. Adults in the prime of life differ widely in their digestive and metabolic capacities. One man can ingest without apparent injury an amount of food which another man leading exactly the same kind of life cannot tolerate. But often the pos- 138 OVERFEEDING AND UNDERFEEDING session of great digestive and metabolic capacities is of doubtful . value, as these are apt to be abused and the "individual with what is termed a weak stomach frequently outlasts the person of strong, vigorous frame and sanguine temperament, largely owing to the fact that he has to be careful. The creaking gate frequently hangs the longest. Also the ques- tion of heredity plays a far greater part than many people imagine. Longevity is to a considerable extent a matter of inheritance. There is another interesting point in connection with overeating that is deserving of passing mention. The capacity to cope with an excess of food differs in different races irrespective of climate or conditions of life. Custom exerts some influence. Thus the Jews seem to be conspicuous in this respect. They lead, as a rule, a sedentary life, and yet can habit- ually eat an excess of rich food without apparent injury to health, pos- sibly for the reason that because far longer than any other race, on account of their prosperity, they have been able to obtain plenty of food, and have thus become racially adapted to it. The question of overfeeding in contradistinction to overeating will now be considered. Metabolism of Overfeeding Overfeeding, speaking from the standpoint of the medical man, signifies that the object to be attempted is the build- ing up of fresh tissue in a person previously badly nourished or who has lost tissue as the result of disease. Von Noorden's definition of the term "overfeeding" is the administration of food in such a quantity as to pro- vide more energy than the needs of the body require. According to the same authority, it is a matter of indifference whether the excess takes the form of albumin or of some oxidizable substance free from nitrogen. EXCESS OF PROTEINS AND CARBOHYDRATES. If fat is ingested in excessive amounts the greater part of the energy thus created passes into tissue substance. Carbohydrates consumed to an excessive extent do not afford nutriment to the tissues in the same way. Zuntz(2) has estimated that considerably less energy is generated for digestive purposes by carbo- hydrate consumption and that with coarse kinds of bread the energy loss is much less. In addition, it has been shown by Rubner and Zuntz that carbohydrate is not changed into fat with absolutely no loss of heat. When nitrogenous substances compose the excess the results are dif- ferent from those of fat on carbohydrate excess. Several investigators seem to have demonstrated that in these circumstances the processes of oxidation are augmented. Rubner (3) fed animals with a rich meat diet and obtained values appearing to show that a daily transformation of energy exceeding those in accord with the food necessary for main- SDPKKALI M ENTATION 139 tenaiicc by 30 or 40 per cent or more was necessary. However, wlicn man is considered, no large amounts need to be taken into account. From the fact that he is omnivorous, it is known that only a compara- tively small proportion of the food ingested can be replaced from pro- tein. Rubner was able to distinguish two effects as the result of feeding on protein substances : 1. The primary effect of a meal rich in protein is an increase in the oxidation processes, which passes off in about eight to ten hours. 2. In certain circumstances, however, the continued use of a diet rich in protein leads to a long continued increase in the consumption of energy r which lasts as long as the excess of protein remains high. This increase in the waste of energy rises more quickly in accordance with the addition of protein. From the standpoint of the most recent investigations, von ]SToorden(4) thinks that, in estimating the elements of the food by which an. excess of calories is produced beyond the needs which form the basis of a diet to increase body weight, protein is the least suitable since along with a low caloric value the necessary oxidation processes must be considerably increased for its combustion. Consequently, very little of the surplus calories, which result from the excess of protein, are left at the disposal of the system. Ho well (5) point& out that if protein is eaten in excess of the real assimilation needs of the tissues, all the excess, as far as we can see, might just as well be substituted by carbohydrate or by carbo- hydrate and fat. The excess nitrogen thus eaten appears to be so much useless ballast which the body very promptly gets rid of. Better results are obtained from carbohydrates, although in their case at least one-fourth of the store of energy contained in an excess of them is lost on the way from the stomach to its final storage as fat in the fat depots. Von Noordeii is of the opinion that the conditions are most favor- able in the case of fat, as very little expenditure of energy is required on the part of the digestive organs, and the fat is stored as such without any loss of energy. Rosenfeld(G) thinks that there is reason to* believe that in animals like ourselves the carbohydrates are more easily and more quickly destroyed in the body than the fats, and that, therefore, the latter may be more readily deposited in the tissues, although an excess of car- bohydrate beyond the actual needs of the body will also be preserved in the form of fat or glycogen. The modern point of view is that body fat is formed in the first instance from food fat and food carbohydrates. It is customary to teach and put into practice the theory that carbohydrates or fat and carbohydrates are best adapted for feeding purposes and, 140 OVERFEEDING AND UNDERFEEDING despite the opinions of von Noorden, full use is seldom made of fat. However, that authority claims that, when certain pathological conditions of the stomach and intestines can be excluded, large and even enormous quantities of fat are well tolerated, with results that cannot be exceeded by an abundant exhibition of carbohydrates. This remark may be inter- polated here that while emphasis has been laid upon the importance of overfeeding, that is, of providing what Meltzer has termed a "factor of safety," a certain margin beyond a bare sufficiency which will be a re- serve against unusual demands, the question may be asked what consti- tutes the assimilation need of the tissues ? This must be known with more or less accuracy before the amount of the reserve required can be stated. If a man is accustomed to eat 100 grams of protein daily, and science demonstrates that he can maintain a nitrogen equilibrium on 30 grams, does a reasonable factor of safety require the use of the additional 70 grams, or would a less total per day, perhaps, meet every requirement? This is a point which should be elucidated by experiment and observation. Von Noorden is of the opinion that the increase in the exchange of calories following the fattening of the body tissue depends on the follow- ing two factors. 1. The increase in the amount of protoplasm disintegrated, forms the most characteristic feature. When large quantities of fat are put on, the body accumulates material which adds to its weight but hardly con- tributes at all to the energy exchange. As a result, the balance of energy based upon the body weight falls, as a rule, in individuals who are being overfed. An addition of flesh, that is, an increase in protoplasm, aug- ments the transformation of energy as shown by experiments made by Pfluger and Rubner. Zuntz(7) demonstrated that by systematic muscular exertion, continued for a considerable period, many of those experimented upon became thinner but gained a good deal of nitrogenous material. When the period of exertion was over the exchange of calories was higher, the casual factor being an increase in the protoplasm. 2. The increase in the actual size of the body, independent of the formation of protoplasm, necessitates an increase in the consumption of energy, which means that individuals of heavy weight require a greater expenditure of energy in order to move and raise their limbs and so on. It is not infrequently impossible to set up definite quantitative relation- ships between the addition of protoplasm and the increase in the trans- formation of energy. In the present state of our knowledge, it will not be wise to go further than the following statements : (a) Every increase in the amount of pro- Sri'ERALLMKXTATlOX 141 toplasm increases the energy exchange, (b) An increase in weight, due to increased intake of fat, also increases the energy exchange, (c) With the ingestion of further quantities of protein, the energy exchange often rises independently of the increase in protoplasm, probably as the result of a peculiar irritative action of the food proteins on the active cells, the exact nature of which is unknown. Kraus(8) points out with regard to the conditions which obtain in convalescents that it has long been known that convalescents, like those who have been subjected for a long period of time to insufficient food, can be made to increase in weight more readily than well-nourished persons. It has been observed that an addi- tion of protein can occur in wasted and enfeebled patients on a diet which in normally nourished individuals would be insufficient to permit a nitroge- nous equilibrium to be attained. It was further observed that especially during convalescence from severe diseases considerable amounts of protein derived from the food were daily retained in the organism, and employed in rebuilding the damaged tissues. CONVALESCENTS Svenson(9) studied the conditions of convalescents during recovery from typhoid fever and pneumonia, the only ones as yet studied. In the first days after the fever had disappeared, the values for oxygen utilized and the carbonic acid given off were found very low. After a few days, however, the exchange of energy rose, and in the following first to second weeks reached values which exceeded the normal by about 30 to 50 per cent. If, despite the much more active processes of combustion, the convalescent increases in weight and puts on a good deal of flesh, this is due to the fact that the taking up of nutriment is still more decidedly raised than the energy exchange. According to Svenson, a food intake equal to 00 or 70 calories per day and per kilogram is not unusual in the convalescent. During the period of the marked putting on of pro- tein and fat, the respiratory quotient rises considerably. This is exactly the reverse of what is met with in starvation when the respiratory quo- tient sinks abnormally. Von Noorden is inclined to doubt Svenson's figures and thinks that fresh experiments in this direction are called for. An important point is that flesh formation occurs in every case in which the body has suffered from a loss consequent to starvation, under- feeding, or disease, and again returns to a more satisfactory state of nutrition. It should also be noted that the recuperative powers of the organism with regard to nitrogen retention come into evidence when the need for calories is not thoroughly satisfied. In this event, the tissues 142 OVERFEEDING AND UNDERFEEDING have the preference when overfeeding is practiced. It is evident that the conditions for flesh accumulation are most favorable when an excess of food is combined with the efforts at regeneration on the part of the organism. Excess of food can be used to the best advantage only when the vital forces of the subject are recuperating. As said before, the sole exact experiments which have been made hitherto on this aspect of metab- olism have been made on convalescents from typhoid fever and pneu- monia. The following figures, taken from von Norden, when compared with those obtained by feeding healthy individuals, show how markedly the activity of the accumulation of nitrogen is increased in convalescents : TABLE EMPHASIZING THE INCREASED NITROGEN IN CONVA- LESCENTS, DUE TO OVERFEEDING Days of Conva- lescence Nitrogen in Food, Gms. Calories in Food Calories per Kg. Daily accu- mulation of Nitrogen, Gms. Weight, Kg. Observers 15-27 18.69 3,188 55 56.5-69.4 28-36 20.54 3,238 54 +6.54 59.4-61.4 Benedict and Sura- nyi (typhoid) 37-47 18.63 3,324 55 +7.69 61.4-64.3 3-13 21.3 3,216 about 56 +7.56 about 56 Ibid, (typhoid) 14-17 21.92 4,327 73 +7.33 57.5-58.5 18-25 17.04 4,215 71 +5.00 58.5-59.8 26-34 28.29 4,589 74 +9.82 59.8-63.7 35-42 27.17 3,598 56 +5.56 63.7-65.2 43-62 27.24 2,912 44 +4.86 65.2-68.1 3-13 18.20 2,775 50 +3.62 55.0-56.0 von Noorden, 1893, unpublished ob- servation (ty- phoid) 14-23 18.20 2,775 48 +4.05 56.0-59.4 24-33 18.20 2,775 46 +5.87 59.4-61.0 4-10 19.10 2,180 42 +3.82 52.0-52.8 11-18 19.10 2.380 45 +4.93 52.8-54.1 19-23 20.20 2,600 48 +3.14 54.1-56.0 von Noorden, 1893, unpublished ob- servation (after severe sepsis) It may then be stated that the results of experiments carried out per- mit the conclusions that the nitrogen gain is absolutely, as well as rela- tively to the simultaneous putting on of fat, greatest in those convalescing from severe acute diseases. It is less, but still considerable, in patients SUPERALIMEOTATION 143 who were in a condition of inanition before the feeding was commenced, and whose body weight had fallen greatly below the average. Of course it follows that the smallest nitrogen gain is seen in individuals who were well nourished before the experiment began. The following table, taken from von Noorden, refers to the manner in which the accumulation obtained through feeding is divided between nitrogenous material and fat: OP THE CALORIES IN EXCESS T7I J THERE WERE USED IN THE BODY Observers iood Nitro- gen Excess of Cal. For Storage as Protein For Storage as Fat Grams Absolute Per cent Absolute Per cent Grams Grams Grams Grams Krug 15.4 1,537 115 7.46 1,422 92.54 Healthy and well nourished Kaufmann and 21.5 1,906 111 5.80 1,795 94.2 Healthy ;moderate Mohr 18.4 2,775 170 6.10 2,605 93.9 state of nutrition Kaufmann and 17.8 1,683 133 8.00 1,550 92.0 As before Mohr 17.0 2,830 204 7.20 2,626 92.8 30.8 367 20 5.40 347 94.6 30.9 355 86 24.20 269 75.8 Liithje 41.7 1,505 197 13.10 1,308 86.9 Healthy 42.6 1,472 228 15.50 1,244 84.5 61.0 2,524 482 19.10 2,042 80.9 Benedict and 18.7 790 227 28.70 563 71.3 Convalescent from Suranyi .... 20.5 733 268 36.60 465 63.4 typhoid 18.6 738 263 35.60 475 64.4 24.3 830 206 24.80 624 75.2 21.9 1,723 255 14.80 1,468 85.2 17.6 1,594 174 10.90 1,420 89.1 Benedict anc 28.3 1,868 342 18.30 1,526 81.7 Convalescent from Suranyi .... 27.2 893 193 21.80 700 78.2 typhoid 27.2 258 169 65.50 89 34.5 18.2 489 126 25.90 363 74.1 von Noorden. . 18.2 387 210 54.30 177 45.7 Convalescent from 18.2 316 204 64.50 112 35.5 typhoid 16.8 342 70 20.50 270 79.5 17.2 468 49 10.50 419 89.5 von Noorden. . 17.3 662 80 12.10 580 87.9 Stomach affection 19.9 720 136 19.00 584 81.0 badly nourished 18.0 558 143 25.60 415 74.4 18.1 707 118 16.70 589 83.3 19.1 1,795 57 3.20 1,738 9.68 Hirschfield . . . 23.0 2,273 54 2.40 2,219 97.6 Badly nourished 19.2 2,197 115 5.20 2,082 94.8 144 OVERFEEDING AND UNDERFEEDING The argument has been brought against these overfeeding cures that the increase of weight obtained soon disappears. Probably, this depends to some extent on the manner in which the treatment is conducted. The originator of this therapeutic method was Weir Mitchell, who always prescribed isolation, complete bodily rest, and aliment mainly of a car- bohydrate character. However, it is not essential to follow Mitchell's trophotherapy to the letter, and in many instances, exercise in the open air, massage and so on are indicated. The main object is to admin- ister a large amount of highly nutritious food in a relatively small volume and whether absolute rest is to be a part of the treatment, or exercise, must be left to the discretion of the physician. Personally we shall advocate exercise in conjunction with the dietetic regime. How long the gain in weight in consequence of overfeeding can be maintained must be taught by therapeutical experience rather than by exact experiments. It has been pointed out that in the overfeeding treatment of wasted, ill-nourished persons, during the first weeks the body weight rises at a great rate, and this rise cannot be wholly explained by the accumulation of flesh and fat. The explanation probably is the large amount of water taken up by the blood and tissues. It is the accumulation of water in this manner that accounts for the rapid increase of weight during the first weeks. When diuresis increases the gain in weight slackens or stops, although flesh and fat are still being put on at much the same rate. The numerous investigations which have been carried on within recent years with regard to the effects of overfeeding have, from the experi- mental standpoint, been somewhat confusing. While all the investigators appear to concur in the view that overfeeding is generally indicated in cases of malnutrition resulting from lack of food or from certain patho- logical conditions, the explanations as to what form of feeding should be followed or why, that is, from the strictly scientific point of view, are not altogether satisfactory. It must be borne in mind that up to the present time exact experiments on this aspect of metabolism have been made almost exclusively on convalescents from typhoid fever and pneu- monia, and even these have been subjected to criticism. The explana- tions, other than those gained from exact experiments and from clinical experience, are after all no more than scientific surmises, although, of course, they are founded upon physiological and pathological facts and reenforced by profound knowledge as in the case of von Noorden. Moreover, the point raised by Howell is well taken: that, when a reserve supply of food provided by overfeeding is spoken of, it will be necessary to find out as nearly as may be what constitutes the assimilation CTKDERFEEDING 145 need of the tissues. From the point of view, (lien, of experiments with regard to the metabolism of overfeeding, the question whether a genuine putting-oii of flesh may be obtained from this method still remains unsolved. From all the experiments made in this direction, the most important point which has been made clear is the great selective power which the body possesses in regard to foodstuffs given in excess. It must be empha- sized that it is only by practical experience and not by experiments, except those which are generally conducted on animals, that we can learn if body weight can be increased when this is necessary, if it is to the benefit of the patient to use overfeeding and if so by what form of food this end may be best accomplished. When we turn to the clinical evidence on this point, the results are more encouraging. Overfeeding in tuberculosis has been referred to in Volume III, Chapter V, and the treatment is likewise employed in cer- tain forms of anemia and chlorosis, neurasthenia, hysteria, visceroptosis, malnutrition generally and especially in convalescence from various diseases, those of a febrile and infective nature in particular. Weir Mitchell's mode of treatment and diet have been described in Volume II, Chapter XVI, and it only remains to say that, while the rest, treatment and judicious stuffing with food are suitable for and have bene- fited many, yet whether this kind of treatment should be followed or whether a combination of overfeeding and exercise should be used must be left to the discretion of the physician. We are distinctly inclined to advocate, as a rule, exercise and overfeeding. Much the same may be said with regard to the kind of food. Although carbohydrate food is recommended by perhaps the majority, fat and carbohydrate by many, and fat by von Noorden and others, there may be cases in which an excess of protein food in the shape of meat may be of the greatest benefit. -No one dietetic procedure should be slavishly followed, but the physician should use his own judgment. On the whole, overfeeding by carbohy- drates or fat and carbohydrates seems to have had the best results. UNDERFEEDING Underfeeding is by no means uncommon in civilized communities and in urban and in industrial centers in particular. The cause is gen- erally poverty, as in all modern countries there is always a large propor- tion of the inhabitants who, while not actually starving, exist in a constant condition of semi-starvation. These people not only lack suffi- 146 OVERFEEDING AND UNDERFEEDING cient food to satisfy their appetites, but they do not ingest enough nutriment to keep their bodies in good health. Also, and this is an important point, their diet is ill balanced and usually composed of innutritions food products. If the money they spend on food were expended judiciously, that is, scientifically, they would not be underfed. But in the first place it must be remembered that the poor are compelled to buy in the dearest market ; they obtain the least value for the money they spend, and they are ignorant how to lay out to the best advantage the little they possess. This is especially the case with the city poor of the English speaking race. Probably no indigent people in the world buy food at such high rates and in such a foolish way as those who live in the big industrial cities of Great Britain. In the cities of America, too, a large proportion of the inhabitants exist on an ill-balanced diet. Perhaps here it is not so much a question of poverty as carelessness and laziness. The woman of the household prefers to buy her food ready cooked in delicatessen stores than to cook it at home. The consequence is that very large numbers drag out a bare existence continually, on the borderland of starvation. The Latin races, as a rule, live on cheap food which is, at the same time, nutritious. The Italian, for instance, subsists and does hard manual labor on food like macaroni; the majority of the inhabitants of Japan work hard and are muscular and vigorous on a diet consisting mainly of rice, and the list of these peoples who live, thrive and work hard on an inexpensive and nutritious diet, might be greatly amplified. However, the object aimed at is to demonstrate that underfeeding is widely prevalent in civilized lands rather than to explain the causes. It may be remarked, too, that children and women are the ones who suffer the most. The 'man has to have the greater and best part of the food supply, because he is the wage earner, and if he were not fed, however inadequate and ill chosen his food might be, he would not be able to work at all. Accordingly, it may be taken for granted that, in civilized countries the world over, a goodly portion of the inhabitants are underfed; that this state of malnutrition is of various degrees of severity ; that it is most prevalent in industrial countries, and that women and children suffer the most. Underfeeding may also occur when the diet is normal, but the amount of work done is excessive. Chronic or Habitual Underfeeding. Chronic or habitual underfeeding is more injurious to the health than eating to excess. Attention has already been drawn to the fact that underfeeding is quite as much due to UNDERFEEDING 147 the lack or deficiency in amount of one important constituent, as to lack of quantity. It is natural for a hungry person who has little to spend to prefer a bulky food possessing hardly any nutritive properties to a more concentrated and highly nutritious product. An individual also is largely governed by custom and taste. If she, for the woman is usually the buyer, likes tea and bread and butter and a bony herring, a form of diet to which she and her children have become addicted by long custom, these are articles in which she will invest her few cents. Therefore, it is the absolute truth that malnutrition is caused quite as often by an ill- balanced diet as by lack of quantity. It is almost unbelievable how long a person can live without food, provided that water is obtainable. Professional fasters have frequently existed for 40 days and even longer with no sustenance except some water, and lunatics have been known to refuse food for four or five weeks at a stretch, all of which seems to show that starvation may be borne with a considerable degree of impunity. In this connection, although not exactly bearing on the subject under discussion, it is interesting to know that the sensations of starving persons are not particularly unpleasant. In the popular mind prolonged starvation is associated with great pain and distress, in spite of the denials of those who have undertaken starva- tion voluntarily. Such persons, almost without exception, have stated that, after the first three or four days of starvation, the sensation of hunger is no longer felt, or, at any rate, is not excessively painful or uncomfortable. It has been demonstrated by experiment, that it is only when the weight of the body has fallen to one-half or one-third of its original weight that death from inanition ensues. When dealing with cases of acute disease, when nourishment cannot be administered by the mouth, it is well to remember these facts. According to Hutchison(lO), physicians not infrequently may be inclined to flatter themselves that they have kept a patient alive by rectal feeding, when as a matter of fact the patient has been subsisting on the reserve supply which has been stored up for an emergency of this character. He has, indeed, been living on himself or from his own tissues. One need not be unduly alarmed if a well-nourished patient is unable to take any food at all for a few days. The "factor of safety," his reserve supply, discussed on the previous pages on overfeeding, will in a large number of cases be able to tide him over the time of stress without any special injury to his health. An ill- balanced diet is one of the main causes of chronic malnutrition. Nitrogen being the element of which the body is mainly built up, it would seem that a lack of protein in the food would be more injurious than a 148 OVERFEEDING AND -UNDERFEEDING cient supply of carbohydrate or fat. The question of the protein intake has been considered in Volume II, Chapter V. Suffice it then to say, with regard to too small a supply of protein in a diet otherwise sufficient, that, according to Rechenberg(ll) and von Noorden, it is certain that in cases where the diet is full a moderate diminution in the protein acts less harmfully than a free supply of pro- tein with a caloric deficit in the dietary. In the latter case, the body goes on losing fat continuously and finally also protein ; in the former the loss in protein does not go beyond a certain limit. The protein in requirements may be reduced to a comparatively marked extent without harm ; the caloric value of the diet, on the other hand, cannot be lowered, or only very slightly. Von Noorden goes on to say that it is by no means permissible to explain any lowering of nutrition or of muscular strength, such as may occur in certain classes or among people living under unfavorable social conditions, as exclusively brought about by the small- ness of the protein intake. Many, perhaps most, observers, do not agree with von Noorden as to this point, and Hutchison expresses the most widely held views when he says that an insufficient supply of protein leads to imperfect tissue repair, more especially, perhaps, of the muscles and blood ; that it causes the body to become unduly watery, whence the pallor and puffiness of the underfed ; and that the combined effect of these results is to produce a lowering of the power of resistance to unfavorable influences, including disease. A daily ration of which the protein content is greatly below the standard of Chittenden (many are of the opinion that Ohittenden's standard is too low), is much more injurious than a short- coming in respect to carbohydrates and fat. Maleficent Sequences of Underfeeding. As the question of underfeed- ing with its maleficent sequence of untoward effects on body and mind, appears to hinge largely on the quantity of protein in the diet, and, as this is the phase of the subject which has given rise to the most strenuous arguments, protein in its relation to malnutrition, physiologically and pathologically considered, will be amply dealt with later. However, before going into the question of underfeeding from the more scientific point of view, and before attempting to sift the wheat from the chaff in the dicta of those who have experimented and made observations on the metabolism of underfeeding, it may be interesting and perhaps instructive to discuss these features from a wider aspect. The effects of insufficient and injudicious feeding are manifest on all hands. The mind, the body and, if the term is allowable, the spirit, are injuriously influenced by innutritions and insufficient food. The person UNDERFEEDING 149 who is ill- fed deteriorates in all respecls. I'nderfeeding is not the sole cause, but it is an extremely powerful contributory cause. With regard to both mental and physical deterioration brought about by an insufficient and ill-balanced food supply, perhaps the most complete and convincing evidence was afforded by reports concerning prison expe- rience in this direction published in 1898 in England. An especial sting was given to these reports, because they were partially confirmed at the time by the gruesome and powerful "Ballad of Reading Gaol/' written by that unfortunate genius, Oscar Wilde. The Parliamentary Committee, two of whom were in the prison service, who were appointed to report on the alleged insufficient feeding of prisoners and who were certainly not biased against the existing system, after a searching inquiry stated that the diet was inadequate for the labor on which the prisoners were employed, that the breakfast and supper meals of male convicts were insufficient, while the element of fat in the dietary was deficient and more variety of food was desirable. It will not be contended that ihe low diet was alone responsible for the breakdown of the health of many pris- oners. Other influences conducing to a lowering of physical and perhaps mental resistance must be taken into account, such as the probable physical and mental degeneracy of a large proportion of the inmates, their monot- onous and generally unhealthful mode of life, and so on, but it may certainly be asserted that a diet deficient in quantity and lacking certain essential nutritive elements was an important factor in rendering the inmates especially prone to disease. Phthisis in those predisposed to the disease and according to the most recent views there are few of us who are not thus predisposed is notorious for attacking those whose vital resistance is weakened ; and the records of prisons in which the inmates are habitually underfed fully bear out this universally accepted theory. The tubercle bacillus appears to find a specially favorable soil in ill-nourished individuals and the association between an insufficient diet and such diseases as phthisis and scrofula is so well established that the reiteration of the facts becomes almost tiresome. Perhaps this is why diabetics, who live in state of more or less chronic starvation, are so liable to tuberculosis. Some few years ago the Rt. Hon. Charles Booth and Mr. Rowntree inquired into and made a report upon the condition of the laboring popu- lation of England and found that very considerable numbers of unskilled laborers were poverty stricken and chronically underfed, not perhaps to such an extent as to cause immediate physical suffering from lack of food, but yet enough to diminish working power and to lead ultimately to impairment of health. The power of resistance to infection and to 110 150 OVERFEEDING AND UNDERFEEDING mental and physical deterioration is sadly impaired in these men and even more in their families, for it cannot be too strongly insisted upon that when a man earns woefully small wages, it is the wife and children who suffer the most, and therefore, in the long run, it is the race and nation who must bear the brunt of underfeeding. Large sections of the community in all countries are still habitually underfed. America, Canada and Australia compare very favorably with Euopean countries in this respect. The reports from the former lands with regard to the condition of their working population are not as precise or as voluminous as those from Great Britain, and consequently it is to Great Britain that we turn for accurate and full information respecting social, economic and public health conditions. Observations on the diet of laborers in Edinburgh showed that it con- tained an average of 107.7 grams, and an energy value of 3,228 calories, as opposed to the 3,500 believed to be necessary for a man doing a moder- ate amount of muscular work. Mr. Rowntree's inquiries into the diet of a corresponding class in York yielded somewhat similar results, the protein average being no less than 29 per cent below what is or used to be regarded as standard requirements. The Edinburgh investigators (quoted by Hutchison) held the view that in order to improve the dietary of the laboring classes, the following principles should be instilled into them: (a) That a diet of tea and bread or of tea, bread and butter is faulty; (6) that the faults of the tea and bread diet can be corrected by the free use of meat, eggs, or other animal food, but that this mode cf correction is expensive; (c) that the faults can also be corrected by the free use of oatmeal with milk, or of peas and beans, without extra cost. It has been mentioned once or twice before that the worst effects of underfeeding fall on women and children, and it is the children who are the least able to bear deprivation of food, not only from the personal point of view, but also, and this is the most essential feature, from the national outlook. Hippocrates was well aware that the lack of food affected the young most injuriously, as one of his aphorisms runs after this fashion, "Old men bear want of food best ; then those that are adults ; youths bear it least, most especially children, and of them the most lively are the least capable of enduring it." The young need plenty of nourishing food in order that they may grow up healthy and vigorous, for if a considerable proportion do not have a diet sufficient and well balanced, they, if they survive, will come to maturity stunted in physique. If not actually unhealthy, they will lack vitality and will be rendered peculiarly suscept- ible to infection, probably deficient in mental attributes and when not UNDERFEEDING 151 already steeped in crime, at least generally lacking that moral -sense which serves as a bulwark against crime. Such as these fill our prisons and asylums ; they are a menace to the community, and their very exist- ence approaches a national disaster ; they propagate their like and endan- ger the well-being of a nation. Underfeeding is a prominent factor in their production and development; the remote results from the health aspect can only be touched upon. There is no need to elaborate on the fact already strongly emphasized that underfeeding lays the system open to the inroads of disease. Investigations of a searching and impartial character have taken place into the condition of elementary school children in various parts of the world, including those attending schools in parts of the Southern States of this country, and deplorable evidences of physical deterioration have been revealed. They provide conclusive proof of the blighting influence of parsimony in nutrition while growth is going on, to say nothing of diseases and defects, mental and physical. Unfortunately, this does not only signify a temporary setback, but a lasting damage, for the manner in which a child is fed at the growth period determines all sub- sequent development. Dwarfing, permanent dwarfing of one kind or another, is the consequence of insufficient feeding in early life. Reference may be made to the effects of insufficient feeding in diminishing resistance to cold and exposure. Sir John Franklin, in describing his and his companions' journey ings in the Arctic regions, said that during the whole of their march they found that no quantity of cloth- ing could keep them warm while they fasted, but on those occasions on which they were enabled to go to bed with full stomachs, they passed the night in a warm and comfortable manner, which signified that the demand for heat in the body was so great that it could no longer be met by diminishing loss, but that the deficit had to be made up by an increase of heat production, that is, by a greater consumption of food. The influence that inadequate and unsuitable food exerts on the capacity of the system for withstanding the effects of cold was well exemplified by certain episodes of the American Civil War, an account of which has been given by Flint (12). Chronic underfeeding will sap the vital forces; the powers of resist- ance of the body will be so undermined that infection will be easily con- tracted and underfed people will be a danger to their fellowmen inasmuch as they will provide a fertile agency for the spread of infection. Its effects in producing liability to disease were illustrated in a strik- ing way by the outbreaks of relapsing fever and typhus which followed 152 OVERFEEDING AND UNDERFEEDING the potato famine in Ireland in the early part of the nineteenth century. Similar results have been observed to follow in the wake of famine everywhere, notably in India and in China where fever and plague invariably dog the footsteps of famine. It has also been pointed out by Hutchison that exposure to infection is specially apt to be dangerous on an empty stomach, as, for example, before breakfast, a fact which it is particularly important for members of the medical profession to bear in mind. Enough has been said as to the relationship of underfeeding to disease. The two are most intimately related, and it is an obvious fact* that the furnishing of cheap and good food is as much of an economic as it is a hygienic measure. There is one other phase of the subject in connection with individual and public health that is worthy of brief comment the bad effect of chronic underfeeding on the digestive oryans. In all cases of chronic underfeeding an impairment of organs concerned with the digestive pro- cess is observed. The truth of this statement may be partly verified in the case of dyspeptics. The less they eat the less they are able to digest and the more their nutrition fails. Frequently the most effective mode of curing their stomach troubles is to insist that they eat more. Unfortu- nately, so far as the poor are concerned, this remedy is impossible. But it is an interesting question whether the effect of town life, combined with poverty or merely ignorance or carelessness in impairing digestive power, may not be to a certain extent responsible for the habitual under- feeding so often found in the industrial section of urban districts. In other words, they may be instances of both cause and effect. A vicious circle has been established, and the town worker even when comparatively well-to-do may in many cases be incapable of digesting enough food to keep him in an ideal state of physical efficiency. This fact was forcibly emphasized in the early part of 1917 when the author was mustering officers for several National Guard regiments, passing on their fitness to enter the Federal service. It was observed that one-third of the young men coming from the industrial centers showed evidences of under- feeding. They were 33 per cent undersized, underfed and underweight. Diverging somewhat from the subject in hand, may not underfeeding also be a potent cause of drinking? The underfed man, even if he be poor, feels the want of some stimulating or perhaps narcotic action and he seeks and finds this spur or Lethe in alcohol. There is a definite relationship between underfeeding and the consumption of alcohol. Undoubtedly there is a close connection between underfeeding and UNDERFEEDING 153 crime. The underfed individual, especially if he or she has been under- fed from childhood up, is a potential criminal. Again it may be said that there is no intention to aver that lack of food is the sole cause of crime, but, on the other hand, it is an always present spur to crime. Poverty and underfeeding are debasing influences, morally, physically and mentally, and in the words of Dr. King Chambers (13), "deficient diet, like all morbid conditions, both corporeal and mental, is a vitiating and degenerating influence. Famine is naturally the mother of crimes and vices, not only of such sort as will satiate the gnawing desire for food, but of general violence and lawlessness, ill temper, avarice, lust and cruelty." Underfeeding if not the mother of crime is at least a very near rela- tion, and if a nation is to be happy and prosperous it is a paramount necessity that its members shall be well fed. Ignorance has much to do with underfeeding, and in order to inculcate into the minds of the mass of the people some elementary truths concerning food values, a campaign of education should be inaugurated on these lines in every civilixed country. This has been done in the large industrial centers of Great Britain and in some of the European countries. The Mothers' Welfare Associations, which have sprung up throughout the urban com- munities of Great "Britain, due to the initiative of Dr. Eric Pritchard of London, teach mothers how to feed and bring up their babies and also how to feed and bring up their families, including their husbands. With regard to food values, absolutely exact and definite knowledge is still lacking, but quite enough is known to enable us to lay down rules as to the most nutritious and suitable foods for all sorts and conditions of men living in all sorts of conditions and in any climate. Metabolism of Underfeeding Some of the recent views dealing with the metabolism of underfeeding will now be presented. PROTEIN METABOLISM. Minimum Protein Necessary to Maintain Nitrogen Equilibrium. Views as to protein metabolism are conflicting, especially with regard to the question of how much protein is necessary to maintain health, or, in other words, to maintain nitrogen equilibrium. The opinions of von Noorden and Rechenberg on this much vexed point have been stated, and the following (taken from von Noorden) is a table in which certain experiments in. this direction are noted: 154 OVERFEEDING AND UNDERFEEDING Remarks I s 1 s s? ^ s .s s .ss 03 s B Q I Tj 1 s CO b| i respective intakes were as follows: lemperer, Peschel and Glaessner (b) irscllfield, Chittenden (b), Siven littenden (a), Caspari and Glaessner (a), Lapicque (a) xpicque (b) bu, Voit and Constantinidi 'iiiiuuin, Rumpf, and Schumm, Rreisacher cs'o -g 2? 3 g a x S? Q%i3.i' Q OO 00 O O 00 OS CO CO OO O T-l CO CO OO OO CO .3-3 *i 9 * ** <-i S c8 (-) *. w ^~N a H 03 g 1* ^ s * OS ^ & ^ y -g o S -c-g ^--+ S 03 "3 " o> >> a g t^. ,3 OJ 03 "3 73^-^ r3O i^ G^ 3 CU -+^> o ^ss^fl -g T,j5 CO CJ . ,_ |. I. ' s -a ^ "S ^+1^ ^ -^ t j3 ^ T 5 25 1 ^|-|| r^; ,25 ooOco T-H O 5 o.a 5,2 i I OO IO Tjl OO O O OS to O 1>- iO t 1 T-H iO Oi O T I CO t^ GO T-H OS t>. CO o o OOOOi-H i-i OO T-H OOO^HO i rfa CO CO Tt^ CO t^ ^O ^^ *O ^^ CO gssss o t^ <^ CO WWOtJ-03 o> XI 02 ? ^O CC T^H 00 00 CO CO iO <*< (N ; OS-^-rt^oq 1 1 1 1 CO CO (N 00 CO CXI * T-H O CO * 00 CO O 1 :::::: o K O bb CD PH!*H 1 OOCOt--^ (N OOO l~ >O OOOOCO"^i>O >O 'O^'^t 1 '^ CO (N T^ r-l O ^ 00 t^ (M C^J Q '7-1 * ja o> J '^ S 22 2 - cc O IH CD * ^ e "n 1 S S 5 5 1 * & & ,C! CO t^ GC O O CO (N t^ t^ 00 OS O t^ CM (N iO O rt< O t^ CO <* O T-l T-H -*^ co J 3 ^ 3 5 SC oooo-* oqSoppTH TJH iO OS 00 CO odoiOt^COt^ COCOCOOCO Tt(gt>-iOI>-iO 'o O OOOcM iO 22 OS CO iO CO t^ iO t>- CO CO CO AUTHORS SS : ~~^3 1 1 '^ ^J 3 I 1 e S^Q oo o s ll i ^-^s! I 1 - 1 ^ 111 J^S O3 D, 03 f< 'S*O 1 ^ ^ 1 8 >.'% W O rt W PH OWPQ M * B Chittenden (a) (ft) sp 11 iiTl .S IC^^QCffiri -g D O O O O I-H "o H o t-H a TODERFEE DING 155 Ymi Xoonlen hedges somewhat with regard to the intake of protein necessary to maintain health and the nitrogen equilibrium by giving, as his opinion, that in spite of the teaching of Chittenden and others their doctrines will not attract too many admirers, nor will these doctrines bring them many adherents, for the majority of men even with the allur- ing prospect of a prolongation of life or rejuvenation prefer to enjoy the comforts of this mundane sojourn. The workman will still take a larger quantity of meat than the sedentary man. More protein is always taken during severe muscular work, and there must be a good reason for this. The Vienna scientist then proceeds to dissect the explanation brought forward by Voit and finishes by saying that while it is certainly true that, in passing to a diet poor in protein, the body loses nitrogen at the outset, nevertheless the total loss is small, and the functional capabilities may not be at all diminished. If the musculature is kept in good condition by continual exercise, even if the diet is lowered to less than two-thirds of Voit's standard, muscular strength and power of carrying out work may be actually increased. Von Noorden may be, therefore, taken as an advo- cate of a low protein intake. E. T. Spriggs(14), the British authority, who has given the question of diet the most thorough experimental study, sums up the relation of protein to activity by saying that the bulk of the caloric value required for muscular work should be supplied by carbohydrate or fat, but that it is an advantage also to increase the protein in food, and that a diet con- taining a fair amount of protein is likely to be favorable to an energetic existence. Another English authority, Sir James Crichton Browne(15), has pointed out that even if it should be fully established by experiments more extended and varied than those of Chittenden, that nitrogen equilibrium can be maintained on a much smaller amount of protein than has hitherto been supposed, there would still be a question as to whether it would be wise and prudent to adopt the minimum amount as the rule of life. With a low protein supply the organism may have to adapt itself to its situation under conditions of strain. It has a large power of adapting itself to circumstances, but that power may be overtaxed. Let it be granted that the average amount of protein food now habitually ingested does considerably exceed the quantity required to maintain at an exact point metabolic equilibrium, it does not follow that it should be lowered to the point at which, according to laboratory observations, metabolic equilibrium stands steady. Metabolic equilibrium is never 156 OVERFEEDING AND UNDERFEEDING steady or at a fixed point. It varies in different individuals and in the same individuals from hour to hour, and it is always safe to allow a margin, and a broad margin. This writer contends that not only is protein starvation manifested in diminished resistance to bacterial invasion, but in a general lowering of bodily tone, and in debility which may be traced to diminished metab- olism, owing to the withdrawal of the stimulus to it which alimentary principles of the protein class supply. Benedict (16), too, traverses Chittenden's results and concludes that permanent reductions of protein intake are decidedly disadvantageous, and not without possible danger. The relationship of a small protein intake, then, to underfeeding has been by no means made clear. Some assert and seem to have proved their assertion by careful experiments that a low protein intake has little to do with underfeeding. At least they state that a man can thrive and perform really hard labor on a diet the protein constituent of which would have been regarded only a few years ago as ridiculously inadequate. Others hold that, while most people were and are accustomed to ingest too much protein, the standard laid down by Chittenden and those who hold his views is too low. Still others, like Sir J. Crichton Browne, claim that a very considerable protein intake is necessary for the conser- vation of good health, and especially in the case of laborers and those who take a good deal of heavy exercise. The author is among those who are not extremists and is of the opinion that a fair amount of protein should be taken by persons who per- form manual labor and carry on their work in the open air. Therefore, a small protein intake is a factor of some moment so far as underfeeding is concerned. Underfeeding in the ordinary circumstances of life occurs, as a rule, from an insufficiency of nitrogen-free substances, generally associated with a diminution of protein. In all cases in which underfeeding is persisted in for long periods, it is associated with a smaller or greater loss of protein. Hirschfield (17), Kumagawa(lS), R. O. Neumann(19). Neumann supplies the best example commencing with an insufficient diet. He very gradually raised the protein and energy intake until he arrived at nitrogen equilibrium. For thirty-five days or longer he kept on the insufficient diet. The following table, taken from von Noorden, showed the conditions that existed: UNDERFEEDING 157 TABLE SHOWING EFFECT OF INSUFFICIENT DIET WITH GRADUAL INCREASE IN ALIMENT UNTIL NITROGEN EQUILIBRIUM WAS ESTABLISHED SERIES Dura- tion in Days INTAKE Cal. per Kg. NITROGEN BALANCE Differ- ence in Weight Weight at Outset, Kilo. N Pro- tein Gal Daily Of the Whole Series 1 2 3 4 5 10 12 8 5 15 S.02 9.07 11.24 12.70 12.23 51 57 70 79 76 1,535 1,599 1,909 1,037 2,659 23 24 29 30 40 -2.81 -3.11 -2.11 -2.76 +0.22 -28.1 -37.3 -16.9 -96.1 -13.8 + 3.3 +0.0 -0.9 -0.1 -0.5 + 1.3 -1.5 67.0 67.0 66.1 66.0 65.5 66.8 Aver- age 50 10.56 1,987 30 -92.8 (!) -0.2 (!) 66.1 The striking' fact to be gathered from Neumann's experiments is that in the fifty days, with an average intake of 10.5(5 grains nitrogen and 1/JS7 calories, he lost !).'5 grams nitrogen, and at the same time showed a loss of only 2 kilograms in body weight. The next table shows a series of experiments exhibiting the different amounts of protein requisite for the organism, as well as for the energy intake. G. Kenvall(20), the results of whose experiments are here given, had a different end in view from Neumann, but used the same methods to carry out his experiments. His experiment was also of long duration : TABLE SHOWING EFFECT OF INSUFFICIENT DIET GRADUALLY IN- CREASED UNTIL BROUGHT UP TO BODY REQUIREMENTS 1 INTAKE NlTROGENBALANCE SERIES Dura- tion in Days Differ- ence in Weight, Kg. Weight Kg. N Cal. Cal. per Kg. Daily Of the Whole Series 1 8 12.1 2,062 29 -5.34 -42.7 -1.5 71.1 2 7 13.7 2,617 37 -2.66 -18.6 -2.0 69.6 3 4 6 5 16.1 22.7 2,843 3,783 42 56 -2.74 0.14 -16.4 0.7 -0.4 -0.0 67.6 67.2 5 3 21.2 3,577 53 -2.47 -14.8 -0.0 67.2 67.2 Average 32 16.5 2,889 46.2 -2.9 -91.8 -3.9 68.2 i Taken from von Xoordim. 158 OVERFEEDING AND UNDERFEEDING Neumann and Renvall each lost about 92 to 93 grams nitrogen in five to seven weeks, the former on a diet which would be considered barely sufficient under most circumstances, the latter upon one which would cer- tainly be regarded as rich, and yet the former maintained his weight almost unaltered. According to von Noorden, he must have stored water, because in his opinion he could not have stored before the beginning of the experiment quantities of intracellular protein to account for so slight a loss of weight. Renvall lost flesh, some water and probably fat. In the table on the opposite page (taken from von Noorden) are in- cluded other series of experiments. All the experiments noted in the above table were carried out on the investigators themselves, who were working under practically identical conditions. The difference in the amount of nitrogen and in the protein and energy intake necessary to maintain equilibrium is remarkable and goes to show how greatly such variable results are due to the individual organism. Chemical Decomposition of Protein Tissue. It used to be the almost invariable custom to regard every sign of protein breaking down in disease as dangerous, and protein decomposition in the tissues as the origin of all grave symptoms. As a matter of fact, protein breaking down in disease is still looked upon as menacing. Von Noorden, however, thinks that in many cases this is a false conception. He is also of the opinion that the significance which is often attached to the products of the chemical decomposition of tissue protein is erroneous. There is no space to deal with the German authority's arguments against these long held beliefs, and it will be sufficient to say that in his opinion the strongest evidence against the doctrine that protein losses constitute a grave menace in disease is that in the most perfect health tissue protein breaks down. Pathology of Metabolism of Starvation. It is very evident that a knowl- edge of the metabolism during fasting is of the first importance from the outlook of physiology and pathology. Experiments upon fasting animals and men have brought out many momentous facts, while pathology has to do with diseased persons who are starving or nearly so. There are two kinds of fasting: acute starvation and chronic starvation or mal- nutrition. The former type has been most extensively studied, but the pathology of its metabolism is still incomplete. To deal with the pathology of metabolism of starvation or chronic malnutrition exhaustively would take more space than can be given to it in this work. Nor, perhaps, would much be gained by so doing, since opinions on some of the more important points have not crystallized, and UNDERFEEDING 159 1 PH * Q s - 1 ll sell 1 T3 -^ i C C "* To - CO * .5 cd a, be S -= S! O *~~ | ^ cc ^ = -^ tc -s 1 -* -s t- oT -*J >^ -3 C CO ^0 r^ 2^ S ^ = X- be o E CO O r*- CO t^ CO *""< C^ -^ GC ^ GO ^O *O CO ^ 1 "~ i ~e be S' ' 5 .S JS - c S ^ &a 5OGOiOO T * H 'o- g ^= CS ^ ^ 5 1 s * i 1 * be S IS S ;l! w CD "CT3 W 05 CO CO -H CO 10 rH ^ 2 1 3 ! S .1 B ~" co o ^J' 5 *" a ^o 2 o CO r-H S JS-f S H C >. * O ?T7+++ c i' c i 1 + + + -^ '3u E " -^ .be be . ,2 22 * K "S *r* ^ "*~* CD fc o "^ O cs g ^ iO 'O t^- 'O Tfi GO 1 ^ l|-^ c3 Q i-H C S - c -J3 -M o a -*-< cc as "^ *| , CV o w a o^^^^^^^^^gi 1 1 II 111 5 -a III < H ^ * . 11 r^ O5 o ^fc o co oo oo oo ^- 2 - ^ '" * & ~ ~ :" -*j v - B ^ !-S r-. ^ 1 CV O 5 g 3 c &, 93 "^ S " a H cs o ^o M c *^ oJ I p "S sS ^ c -= 2 S* 3 ;t g ^ S | 1-H IO CO t^ CO iO ^O CO O^ C^ *** ^"^ C^ ^^ C 1 ^ C^l i -s ff 3 1 1 S ' s -S | s - 1^ *** te -^ "" - U ^ hr JD C o E g f^ CO OO t^* CO ^o |> C^l OO O-l ^t^ i 1 T 1 i-H t 1 rH i 1 i 1 CO ^H T ( T 1 e cs +> .. -r ^ c S cv be r . o x / _^? o y ^ -' "K ~ "! -3 ,_, PS '"c a TS -2 ^'oSp' Slal Q* W gssgsssssss Co -Sc.S ^= >c -2 -S 'S o ^ 5 o tc, s f f !|i AUTHOR . |_l ' >~i ^>' h>H l ~ l *~* 1 t 1 1 H- 1 K* j-T C G q- c " JH" ^T S > d d ^ S S S S O o ^* ^* J2 O O U < x _o S y "^-x J- ~'J- '-^ - .- ~ ii;-::J;|:? X " i- ^52 >-i O a, 2 * ." d S $1 '02 I C r 1 c _ c - ( C ( C _: ^ -,- h = - = ^ *- X X X X x 1 /^ X X X '? SP C .s "5 * ^S 'S '3 -I 0) cS ^5 be 160 OVERFEEDING AXD UNDERFEEDING experiments on chronic malnutrition have been inadequate for many obvious reasons. The object of this treatise will be to discuss some of the more salient points in regard to the subject. As to the consumption of energy on the complete withdrawal of food during the first days, according to most authorities, the general metab- olism suffers no diminution. The sum of the investigations gathered from experiments on fasting men give general values of 22 to 25 calories per kilogram per day as the mean minimum conversion of energy while fasting during complete bodily rest. The expenditure of energy during starvation diminished in the same proportion as the weight of the body. The fasting man lives upon protein and fat, except during the first few days, while his muscles and liver still contain glycogen. The respiratory quotient at times fell below the theoretical minimum 0.7. Pembrey and Spriggs(21) record that in rats, during fasting, the respiratory exchange quickly reaches a minimum, and remains almost constant during the prolongation of the fast. CONSUMPTION OF ENERGY IN CHRONIC MALNUTRITION. With regard to consumption of energy in chronic malnutrition, experiments are few and inconclusive. It seems that certain individuals are able to exist with a particularly low consumption of energy. Von Noorden believes that even in chronic malnutrition, the minimum amount of energy required by persons who are bedridden or who are indoors and do little bodily work does not fall below 30 to 32 calories per day per kilogram. The following are Rubner's figures for a dog whose consumption of energy was investigated for three years : TABLE SHOWING DIMINISHING CONVERSION OF CALORIES PER KILOGRAM ACCOMPANYING PROGRESSIVE LOSS OF FLESH Variations in Weight, Kilogram Mean Weight, Kilogram Average Conver- sion of Calories Average Conver- sion of Calories per Kilogram 8.01-6.84 6.94 432.1 62.3 6.66-6.33 6.45 371.8 57.6 6.27-5.80 6.09 332.0 54.7 PROTEIN METABOLISM IN ACUTE STARVATION. The protein metab- olism of man during acute starvation has often been investigated. Fasting persons habitually drink water in small quantities. After the first day, or perhaps after the first two days, the standard loss of nitrogen TINT).K R FEEDING 161 inav be taken as 10 to 1*5 grams for the next week or ten days. The loss of nitrogen according to Pransintz(22) is relatively greater in the thin than in the fat. The nitrogen excretion of fasting women is from 20 to 30 per cent less than that of fasting men. The protein decomposition is relatively large at first, and usually sinks somewhat sharply as the starvation proceeds. Figures show how the organism spares its protein when it is ill fed. Chronic malnutrition is not characterized by a small nitrogen excretion, but the output of nitrogen depends essentially upon the preceding diet. In chronic malnutrition but little urinary nitrogen is usually found. Von Noorden is not an advocate of protein feeding and claims that pro- tein cannot prevent the loss of power in underfed people and he concludes that in heat-value starvation a protein-rich diet does not protect the tissue protein from being consumed. According to von Noorden our present knowledge of the decomposition of protein in chronic underfeeding is as follows : 1. After prolonged malnutrition the decomposition of protein is grad- ually lessened ; more of the tissue protein is lost in the earlier than in the later stages. Analogous are cases where the demand for heat is met fully while only the protein intake fails to reach the required level. Loss of the body protein does not necessarily follow in such cases. Nitrogen equilibrium can be maintained upon a protein decomposition far smaller* than that which usually obtains, as, for instance, on a daily excretion of from 6 to 10 grams of nitrogen in the urine and feces. But generally it is only weak persons who illustrate this possibility, and the question may properly be asked whether a larger protein intake would not bring them more nearly to their optimum of nutrition and strength. 2. Long continued underfeeding, apart, perhaps, from minute and hitherto unproven degrees of caloric deficiency, invariably leads to loss of body fat as well as to loss of tissue protein, whether the supply of food protein is large or small. Only the absolute extent of nitrogen excreted varies with the latter factor; the establishment of a nitrogen balance is independent of its duration. A diet of low heat value but rich in protein can diminish, or even for a time postpone, the loss of nitrogen, but in the long run the result for human beings will be the same as if all the components of the diet were diminished. If the heat value of the food be continuously inadequate, an increase of protein will perhaps put a stop to the loss of nitrogen from the body for the time being, but, in man, a moment comes when further increase of the food protein in the diet becomes impracticable. In these circumstances the tissue protein 162 OVERFEEDING AND UNDERFEEDING can only be maintained by adding nitrogen-free constituents to the diet in order to satisfy the demand for heat 3. At present no exact quantitative measurements of the relations between the caloric deficit and the loss of body protein in chronic under- feeding are extant. The loss is unexpectedly small in some cases, in others surprisingly large. 4. Whenever a poorly nourished individual receives an increased amount of food, so that the deficiency of heat is decreased, an effort is made to retain nitrogen and repair the loss of cellular material that has occurred. This retention of nitrogen goes on until the body has readjusted itself to its new conditions of nutrition. Then the loss of nitrogen begins anew unless the calories required have been adequately supplied. The influence of starvation or chronic malnutrition upon the digestive organs is that their activity is lowered although not uniformly. Malnutrition leading to extreme loss of body weight does not invariably stop the production of hydrochloric acid. SECRETION OF BILE. There is less secretion of bile during fasting than when the diet is full, but it is never entirely absent. The quantity of bile secreted is diminished but it is usually more concentrated. The glycogen in the liver is consumed rapidly, at first, but more slowly as the fasting continues. F. Muller(23) found that during starvation the feces contained hardly any soluble protein, but a relatively large propor- tion of nuclein. The excretion of fat amounted to 1.21, 0.57, and 1.14 grams a day. About half consisted of neutral fats and cholesterin, the other half being composed of free fatty acids and soaps. The absorbing power of the intestine, according to many German authorities, does not diminish in consequence of prolonged malnutrition. This is an important point with regard to dietetic treatment in connection with the evacuation of feces. A certain amount of putrefaction is said, to go on in the intestine during the withdrawal of food despite the fact that no protein reaches the intestine. THE BLOOD. In chronic malnutrition the percentage of water in the blood is maintained approximately at the normal level. During starvation the leukocytes are diminished in number. THE URINE. During starvation the average amount of urine remains sub-normal. In cases of chronic underfeeding the conditions vary greatly so that no fixed rules can be laid down. During acute starvation protein is often found in the urine, though mostly in minute quantities. Clinical experience shows that a moderate degree of chronic underfeeding does not commonly lead to the appearance UNDERFEEDING 163 of more albumin in the urine than may be present normally. The case is altogether different when marked and protracted malnutrition is met with. In such instances, alburninuria, transient or lasting, is the rule, ^lild glycosuria has been observed in a few fasting experiments and chronic underfeeding but is probably not directly responsible for any form of diabetes. Conclusions. The above brief review of the metabolism and patholog- ical metabolism of starvation and chronic underfeeding is necessarily incomplete and does not profess, as stated in the introductory remarks, to do more than give a few of the more important facts. From the experimental aspect of underfeeding, no very definite conclusions can be drawn, that is, conclusions of practical value. Among those who have studied the matter in laboratories somewhat wide difference of opinion exists with regard to important points. Animal experimentation is fallacious, or at any rate not to be entirely depended upon in drawing conclusions applicable to man. Experiments on those in a condition of chronic underfeeding are few and far between except in cases of disease, in which conditions are not analogous. Fasting experiments are valuable, but a person fasting is not in the same condition as one who is chronically underfed and consequently experiments as to metabolism on fasting per- sons are not wholly reliable. It is true that the application of the experimental method has yielded and will yield, as science progresses, some insight into the general prin- ciples which govern the nutrition of the body. Upon food depends not only life itself, but the power to work and to resist disease. An ill-fed people are a backward people, and an unhealthy and a degenerate people. From the vegetable world innumer- able examples can be gathered to illustrate the great effect of food variations upon growth and development. In a good soil a plant will evolve in a marvelous manner. On the other hand, a bad soil will yield a poor growth. The most striking example of the effect of food upon development in the animal world is afforded by the queen bee, which grows from a larva in all respects similarly to the working bee, but owes her superior growth to the fact that, different from the rank and file of the Itee tribe, she is assiduously fed on a rich diet. There are two or three points which the author desires to emphasize with regard to underfeeding. The first is that chronic underfeeding is prevalent even in this country and that it is more due to ignorance than to poverty. The poor do not know anything about food values and, more often than not, buy foods which constitute not only a comparatively 164 OVERFEEDING AND UNDERFEEDING innutritions but an ill-balanced diet. Education is needed in this direction. Another point is that scientific experiments cannot wholly determine food values. In the experience of mankind with regard to diet, there are spread out before us the results of the experiments of ages, and we must be quite as greatly influenced by such experiments as by laboratory investigations. The experiments of ages have demonstrated that man can live a healthy life under dietetic conditions of great variety. It is not wise to be bound by the teachings of one system or another. By studying in an open-minded manner the teachings of experience together with the results of scientific experiments, we shall be able to formulate dietaries suitable for conditions of health and disease. It is with these principles that the problem of underfeeding should be met. REFERENCES 1. THOMPSON,, SIR HENRY. Food and Feeding, p. 64. 2. ZUNTZ. Sind Kalorisch Aquivalente Mengen von Kohlenhydraten und Fetten fiir Mast und Gutfettung Gleichwertig ? Therap. d. Gengenw., 1901. 3. RUBNER. Gesetze des Energieverbranches, 1902. 4. VON NOORDEN. Pathology of Metabolism. 5. HOWEKL. Handbook of Physiology, 1915. 6. ROSENFELD. Ergebiiisse der Physiologic, 1902, vol. i, part i. 7. ZITNTX, SCHUMBITRG, U. Phys. des Marsches, 1901. 8. KRAUS. von Noorden's Pathology of Metabolism, Fever and Infection. 9. SVENSON. StofTwechselversuche an Rekonvaleszenten, Zeitsch. f. klin. Medi., 1901. 10. HUTCHISON. Food and Dietetics. 11. RECHENBERG. Ernahrung der Handwiber, 1890. 12. FLINT. Physiology of Man, New York, 1867, p. 35. 13. CHAMBERS, KING. Manual of Diet in Health and Diseases, 1876, 2nd ed., p. 223. 14. SPRIGGS, E. T. Sutherland's System of Diet and Dietetics. 15. BROWNE, SIR JAMES CRICHTON. Parsimony in Nutrition. 10. BENEDICT. Am. J. PhysioL, 1906, p. 409. 17. HIRSCITFIELD, F. Zur Ernahrungslehre d. Mensch., Arch. f. path, anat. u. Physiol., 114, 301, 1889. REFERENCES 165 18. KUMAGAWA. Ernahr. mit genuscht. u. rein vegetabilis Rost. Arch. f. path. anat. u. Physiol., 116, 370, 1889. 19. NEUMANN. Taglich Eiweissbedarf des Menchen, Arch. f. Heil- kunde, 45, 1, 1903. 20. RENVALL, G. Und Nig-Umsatz beim erwachsenen Mensch., Skan- dovischer Archiv. fal Physiol., 16, 94, 1904, p. 101. 21. PEMBREY AND SPRIGGS. Metabolism in Fasting and Feeding, Jour. Physiol., vol. 31, p. 343, 1904. 22. PRANSINTZ . Zur Eiweissersetzung des hungernden Menschen, Miinch. med. Wchnschr., 1891, p. 319. 23. MUI/LER, F. Untersuchnngen an zwei hungernden Menschen, Arch. f. path. anat. u. Physiol., 131, suppl., 1893. ill CHAPTER VII PROTEIN AND NUTRITION The discovery of a new dish does more for the happiness of humankind than the discovery of a new star. Nature of Protein; The Protein Poison. Metabolism cf Protein: Deaniinization of Proteins in Amino-Acids; Catab- olism of Proteins. Effect of Protein Diet on Health and Endurance: High Protein Diet; Low Protein Diet; Chittcnden's Investigations, Fisher's Investiga- tions, Haelt/'s Investigations among Japanese, Other Foreign Nations Non-Meat Eaters. Standard of Protein Requirement in Dietary. High versus Low Protein Diet: Protein Diet and the Xitrogen Equilibrium; Reduction of Protein Diet Necessary; Effect of Increased Nitrogen Diet on the Kidneys; Effect of Protein Diet on Strength and Endur- ance; Effect of Low Protein Diet on Animals; Protein Diet and Occupation: The Amino-Acid in Animal and Vegetable Proteins; Minimum Protein Requirement to Maintain Nitrogen Equilibrium; Safety Standard in Diet: Caution as to Protein Deficiency, Overfeed- ing, Underfeeding, Ill-Effects of Absorption of End-Products of Pro- tein Digestion. Protein Structure and Properties: Chemical Formation of the Protein Fractions; Quantitative Differences of Proteins, Qualitative Varia- tions in the Amino-Acids of Proteins; Physical Properties of Proteins; Relative Absorption of Proteins; Differences in Suitability for Tissue ( '(instruction. Theories of Protein Metabolism. Nature of Protein During the past few years a revolution has taken place in our conception of protein metabolism, and we should all be proud of the fact that our own country has furnished its full quota of newly discovered facts upon which our present knowledge is based. While studying the physiology of digestion (see Volume I, Chapter VII), we learned that, among the building material employed for the construction of the living organism, the proteins hold a place apart, and we also learned that protein is absorbed only after being largely or com- pletely broken down in amino-acids, which are then rebuilt into the protein organism. 167 168 PROTEIN AND NUTRITION The conception of the structure of a protein molecule is of special importance not only in the study of protein metabolism, for which we are to use it here, but also in enabling us to grasp the almost unthinkable varieties in which protein exists, without there being, in many instances, any outward chemical reaction or physical property by which one protein can be distinguished from another. It is interesting to note, however, that differences -in structure which are too slight to be recognizable by any ordinary chemical tests may become very apparent upon minute biological examination when we proceed to observe the behavior of an animal into whose blood some of the protein is directly injected. It is a well-known fact that symptoms of varying severity develop, from the almost instantaneous death produced by snake venom to the slowly developing anaphylactic reactions which follow the injections into the blood of many proteins that are chemically indistinguishable from those of the blood itself. The Protein Poison (Protein Absorption). Vaughan and Wheeler in 1903 found that the cellular substance of the colon bacillus (1) contains a highly active poison and that a closely related or similar poison could be obtained from other pathogenic and non-pathogenic bacteria and from vegetable and animal proteins. It is not found in gelatin. The symp- toms induced by this poison in guinea pigs are, first, peripheral irrita- tion, such as an urticarial rash ; second stage, partial paralysis, with rapid and shallow breathing, and, third or' convulsive stage, that which begins as isolated clonic movements and finally becomes general, involv- ing all the muscles of the body; with fatal doses there is a progressive fall of temperature. Kemp (2) points out that small doses administered subcutaneously in animals produce fever and that various types of fever may be stimulated by varying the size of the dose and the intervals of administration. When proteins are acted on by the digestive juices, the product becomes poisonous at the peptone stage, and if it were so absorbed into the circulation, it would be highly injurious, but with nor- mal digestion . the peptone is broken up into harmless amino-acids. If proteins, however, enter the blood without being properly changed by the action of the digestive juices, then they must be digested in the blood and tissues (parenteral digestion"), and during the process the protein poison is set free and exerts its deleterious effects on the body. It is suspected by some that protein has an influence in the production of the summer diarrheas of infancy, and studies of the protein poison and protein sensitization have demonstrated how the protein element of bacteria influences the nature and progress of the infectious diseases. METABOLISM OF PROTEIN 169 Special idiosyncrasies to certain foods may be explained on the above- mentioned grounds, as, for example, urticaria, presenting the aspect of anaphylaxis from absorption of protein. In certain conditions, at least, protein absorption with parenteral digestion is a iause of protein poisoning. METABOLISM OF PROTEIN Deaminization of Proteins in Amino-Acids. According to E. E. Smith, who has given the subject most careful study, the simple amino-acids(3) formed in the intestinal tract from protein breakdown, so far as we know, are absorbed as such and carried through the blood stream to the various tissues of the body, where they meet their fate. They are not absorbed with the same readiness, but there is apparently a decided selective action, both as to the particular amino-acids absorbed and as to the quantity. When they reach the tissues there is a recombination not to form the protein originally ingested, but rather to form the proteins of the par- ticular tissues. Protein resynthesis, not in absorption, but by the indi- vidual tissues to which the amino-acids are brought by the blood stream, must be regarded as sufficiently established to be accepted as a working hypothesis. In this way a certain portion of the absorbed amino-acids is utilized. A certain other, and usually a relatively large, portion, not needed for protein resynthesis, undergoes a different change. Instead of entering into constructive metabolic processes, it undergoes catabolic transformations. Catabolism of Proteins. When proteins are introduced directly into the blood, parenterally, as we say, they act as a foreign substance and may be eliminated more or less unchanged by the kidneys, giving rise to albuminuria; may pass into the bile, thereby reaching the intestinal tract, where they are digested; may pass directly into the alimentary tract through the intestinal walls; or finally may be split by enzymes elaborated by body cells. Sensitization to a given protein is developed as the result of the introduction of the protein into the blood and is specific to each protein. When it has once been developed, the subsequent introduction of the particular protein into the system is followed by the phenomenon of nnaphylaxis. EFFECT OF PROTEIN DIET ON HEALTH AND ENDURANCE High Protein Diet. In overfeeding of a particular protein, a condi- tion may be produced that is entirely similar to the protein sensitization 170 PROTEIN AND NUTRITION that follows the introduction of protein parenterally. Perhaps this has been most clearly observed in the forced feeding of eggs, especially to the young, though it 13 not uncommonly seen with a particular form of fish feeding, notably shellfish. Frequently, too, this has been observed with meats, and least commonly with vegetable proteins, presumably because of the less concentrated form of the latter and their slower transformation into soluble protein in digestion, though in individual instances particular vegetable proteins have produced the condition to a marked degree. Probably few physicians have failed to recognize at least some of the more marked cases of this kind, and probably few have often failed to overlook most of the less marked cases. Following an instance or period of overfeeding, there appears a con- dition of intolerance to the protein in question, which is manifest when the particular protein is again ingested by certain rapidly developing symptoms, perhaps the most constant of which is an urticaria, apt to be generalized in extent with intense itching, frequently dyspnea, sometimes muscular incoordination and often symptoms of gastro-intestinal irrita- tion. It is probable that angioneurotic edema is in some instances, at least, a manifestation of protein sensitization. It is a question for con- sideration to what extent active protein is the absorbed material and to what extent the protein is absorbed as proteose. Where the urine shows the elimination of unchanged protein, we may well believe that the offending material is native protein; and where the urine is found to contain the foreign protein as proteose, we must at least give serious consideration to the possibility of the protein having been absorbed as proteose, though even there it must be recognized that the native protein may have been transformed into protein after absorption, since it is the tendency of the tissues to bring about this change. We may well question whether urticaria following food ingestion is always to be regarded as an anaphylactic manifestation or whether it is not at times produced by a different type of gastro-intestinal toxemia. When, for example, we regard the toxemia following the ingestion of strawberries, we have a condition well explained from most points of view by the theory of protein sensitization ; but we have to face the fact that strawberries are not rich in protein and that, therefore, the sensi- tization, if present, has been produced without rich protein ingestion. Evidently some further knowledge is required before the pathology of susceptibility to strawberries can be unequivocally regarded as coming within this category. Recently, the theory of protein sensitization has attracted attention EFFECT OF PROTEIN DIET 171 and in some instances is charged with the faults that have heretofore been explained by chronic intestinal toxemia of bacterial origin. It is a matter for the future to decide to what extent toxic manifestations are to be referred to the absorption of proteins, to products of bacterial synthesis of the digestive products of food proteins. At the present time the evidence already at hand as to the part played by bacterial decompo- sition is not to be ignored (4). Low Protein Diet CHITTENDEN'S INVESTIGATIONS. Prof. Chitten- den, of Yale University, in November, 1902, began an experiment upon himself which he has recorded. At this time he was forty-seven years of age and weighed 143 pounds(5). He says that, accustomed to eating daily an amount of food approximately equal to the prevailing dietary standards, he recognized that his habits of living should not be too suddenly changed, so a gradual reduction was brought about in the amount of pro- tein or albuminous foods he was accustomed to ingest. Within the course of a month or two this gradual decrease in proteins reached complete abo- lition of breakfast, except for a small cup of coffee. A light lunch was partaken of at the noon hour, followed by a heavier dinner in the early evening. Occasionally, however, the heartier meal was partaken of at the noon hour, as his appetite suggested. It should be added that the total intake of food was gradually diminished, as well as the protein constituents. There was not, however, a change to a vegetable diet, but a simple introduction of physiological economy. The goal to which his attention was directed was the exclusion of meat in some measure, the appetite not calling for this form of food in the same degree as formerly. At the beginning, he confesses that this change to a smaller amount of food daily was attended with some discomfort, but gradually passed away, and his interest in the subject was increased by the discovery that he was unquestionably in improved physical condition. A rheumatic trouble in the knee joint, which had persisted for a year and a half, and which only partially responded to treatment, entirely disappeared. Minor troubles, such as sick headaches and bilious attacks, no longer annoyed him periodically, as in the past. He experienced greater appreciation of such food as was eaten and possessed a keener appetite. A more acute taste appeared to be developed and a more thorough liking for simple foods. According to his report, by June, 1903, his body weight had fallen to about 128 pounds. In speaking further of his experience, he says that during this sum- mer the same simple diet was adhered to: a small cup of coffee for breakfast, a fairly substantial dinner at midday, and a light supper at 172 PROTEIN AND NUTRITION night. The next two months he spent at a fishing resort in northern Maine. Part of the time he dispensed with a guide and rowed his own boat, frequently six to ten miles in the forenoon (against head winds), without breakfast, and with much greater freedom from fatigue and muscular soreness than previously on a fuller protein dietary. On his return home he weighed 127 pounds. From July 1st he remained con- stantly at this point, at which it would seem that the body had found and maintained its equilibrium. In order to determine his nitrogen equilibrium, he collected each day's output of urine for a period of eight and a half months. The urine was analyzed every day and the contained amounts of nitrogen, uric acid and phosphoric acid recorded. The daily average was as follows: from October 13, 1903, to March 12, 1904, the average volume of urine excreted was 468 grams; the nitrogen content was 5. GO grams; uric acid, 0.392 gram, and phosphoric acid, 0.904 gram. It will be observed that the volume of urine excreted was small, though fairly constant for the whole period. The explana- tion offered is that on a low intake of protein there is less thirst and less desire to drink. When nitrogenous waste is reduced to a minimum there is no need on the part of the body for any large amount of fluid to flush out the kidneys, while with heavier eating partaking of highly nitrogenous foods an abundance of water is necessary to prevent the kidneys from becoming clogged, thereby explaining the frequent bene- ficial results of the copious drinking of mineral waters, spring waters, etc., frequently called for after or with heavy eating. It is obvious, therefore, that a small volume of urine each day means so much less wear and tear of the delicate mechanism of the kidneys. The low nitro- gen output of only 5.69 grams, equal to 35.56 grams of decomposed protein, is very remarkable. Prof. Chittenden affirms that there could be little doubt that his body was in nitrogen equilibrium and that his body weight was constant during the whole period. Chittenden, in sum- ming up his observations, says (6) : Health, strength, mental and physical vigor, have been maintained unimpaired, and there is a growing conviction that in many ways there is a distinct improve- ment in both the physical and mental condition. Greater freedom from fatigue, greater aptitude for work, greater freedom from minor ailments, have gradually become associated to the writer's mind with this lowered protein metabolism and general condition of physiological economy. Chittenden was fully alive to the necessity of caution in the accept- ance of his feelings as a measure of physical or mental condition, but he was keenly watchful for any sign or symptom during the course of his EFFECT OF PKOTE1N DIET 173 experiments, and is still strongly of the opinion that there is much good to be gained in the adoption of dietetic habits that accord more closely with the true physiological needs of the body. Thus he asks: If a man of 154 pounds body weight can maintain a condition of equilibrium with continuance of health, strength and vigor (to say nothing of possible im- provement ) with a daily consumption of, say, 60 grams of protein food, and suffi- cient non-nitrogenous food to yield 2,800 calories, why should he load up his system each day with twice this amount of protein food, with enough fats and carbohydrates to yield 3,500 calories plus? The result of Chittenden's researches demonstrates that the protein intake must be a little in excess of protein catabolism, as all of the pro- tein is not available and as this is a variable amount, depending on the proportion of animal and vegetable foods to their different degrees of digestibility and availability. (Miittenden formulates the following table, showing the amount of food necessary to yield 60 grams of protein : CHITTENDEN'S TABLE VARIETY OF FOODS Protein Content Fuel Value in Calories l /i Ib. fresh lean beef (loin) 60 grams 9 hens' eggs 60 " -4- Ib. sweetbread 60 " 3 4 11). fresh liver 60 -\ Ib. lean smoked bacon 60 " % Ib. halibut steak 60 Yt Ib. salt codfish (boneless) 60 2 I Ibs. oysters, solid 60 " 1 ) II). American pale cheese 60 " 4 Ibs. (2 quarts) of whole milk 60 " 5 ^r, Ib. uncooked oatmeal 60 " IK Ibs. shredded wheat 60 1 Ib. uncooked macaroni 60 " 1 .\ Ibs. white wheat bread 60 " 1 % Ibs. crackers 60 1% Ibs. flaked rice 60 : - ! Ih. dried beans 60 " \H \bs. baked beans 60 *4 Ib. dried peas 60 I }i Ibs. potato chips 60 " * 3 "Ib. almonds 60 -?- Ib. pine-nuts, pignolias 60 " \% Ibs. peanuts 60 " 10 Ibs. bananas (edible portion) 60 " 10 Ibs. grapes 60 II Ibs. lettuce 60 15 Ibs. prunes 60 " 33 Ibs. apples , 60 308 720 660 432 1,820 423 245 506 1,027 1,300 1,550 2,125 1,665 1,520 2,381 2,807 963 1,125 827 5,728 2,020 1,138 3,584 4,600 4,500 990 5,550 9,570 174 PROTEIN AND NUTRITION Value of Meats as a Source of Nitroyen. Chittenden, in discussing "the value of meat as food," after declaring that protein food is the supply of nitrogen needed for the body, asks the question, "What advan- tages do meats possess as a source of this nitrogen ?" His answer was : "Meats represent a concentrated form of protein, their nitrogen is readily available, they are easily digestible, they have an agreeable flavor, they add variety to the diet, they contain extractives which have an exhila- rating and stimulating effect, they satisfy the 'pangs of hunger more completely and for a longer period than do the vegetable proteins. "There can be no question but that meats occupy a somewhat peculiar place in the category of dietetic articles. A close study, of the dietetic customs of civilized people indicates that two distinct objects are ever kept clearly in view, viz. : the satisfying of the grosser needs of the body, the needs of general nutrition, and the satisfying of the needs of the higher functions of the central nervous system. Meats plainly share with foods derived from the vegetable kingdom the ability to minister to the former wants of the body, but in addition they have certain stimu- lating properties which distinguish them from the grosser vegetable foods. They might also in this respect be classed, perhaps, with such articles as tea, coffee, etc., in their power of ministering to the wants of the brain and nervous system. Sir William Roberts has well said that the strug- gle for existence, or rather for a higher and better existence, among civilized men, is almost exclusively a brain struggle; and that these brain foods, as they have been not inappropriately termed, must be regarded as a very important part of the equipment for that struggle, for if we compare, with our limited information, the general charac- teristics of the high-fed and the low-fed classes and races, we would no doubt perceive a broad distinction between them. In regard to bodily strength and longevity, the difference is inconsiderable, but in regard to mental qualities, the distinction is most marked. The high-fed classes and races display, on the whole, a richer vitality, more momentum and individuality of character and a greater brain power than their low-fed brethren, and they constitute a soil or breeding ground out of which eminent men arise." FISHER'S INVESTIGATIONS. Prof. Irving Fisher, a co-worker of Chittenden's at Yale University, lias conducted some interesting experi- ments emphasizing the effect of diet on endurance (Y). In arranging the tests, a large variety of food and dishes commonly prepared in that locality was supplied, and the subjects were particularly enjoined to masticate 'thoroughly and even to keep liquid foods in the mouth until EFFECT OF PROTEIN DIET 175 well insalivated and to swallow only in response to almost compulsory inclination. The subjects for this experiment were nine in number and the experiment lasted four and a half months. The diet supplied at the beginning contained 28 grams of protein and had a fuel value of 2,830 calories. "The subjects were informed as to the protein content of the various articles of food and were requested to eat those foods poor in protein so long as the appetite evinced no disinclination to them. The exercises carried out as tests of physical endurance were as follows" : 1. Rising on the toes as many times as possible. 2. Deep knee bending as many times as possible. 3. liaising the legs from the floor to a vertical position as many times as possible while lying flat upon the back. The following table will graphically present the mathematical result of these experiments: FISHER'S TEST DIET AND ENDURANCE CALORIES PROTEIN Strength Endur- Weight Total Per cent Gr. Per cent Per cent ance Kilos At the beginning. . 2,830 100 98 100 100 100 68.2 After 1 l /2 months . 2,670 94 82 80 104 133 67.3 After 4 }/2 months . 2,220 78 51 52 93 189 65.5 Fisher's experimental findings are somewhat opposed to those of Chittenden. Chittenden's experiments evidenced an increase in strength ; in the Fisher experiments it was endurance of the men which attracted attention and with proof that endurance was increased, while their strength varied very little either way. Fisher carried out some comparative endurance tests between sixteen meat eaters (students from Yale University) and thirty-two vegetarians connected with the Battle Creek Sanitarium. The latter had been vege- tarians from four to twenty years. They not only abstained from meat, but also from coffee, tea and condiments, and they were also teetotalers and non-smokers. The endurance tests were as follows: 1. Squatting on the heels and rising thence to upright position as many times as possible. 2. Holding out the arms fully extended for as long a time as possible. Tlio results are shown in the following table: 176 PROTEIN AND NUTRITION FISHER'S COMPARATIVE ENDURANCE TESTS Meat Eaters Vegetarians Percentage of Difference Knee bendings 383 846 121% Holding arms out (minutes) . 10 49 390% According to the result tabulated above, the standard of meat eaters is shown as 100, while the endurance of the vegetarians is from 121 to 390, and we may therefore draw the conclusion that strength and endur- ance have nothing to do with the consumption of generous quantities of protein, as was formerly a matter of faith. Furthermore, it is an admitted fact that great endurance is possible on simple food of low protein value, in support of which we may cite the example of the Japanese and Arabs. BAELTZ'S INVESTIGATIONS AMONG THE JAPANESE. Professor Baeltz, 1 a keen observer and one of the best authorities on the Japanese country and people, says 2 that the people of the lower classes in Japan who subsist almost entirely on carbohydrate foods are altogether of more powerful build than those of the upper classes who eat meat. It is well known to students of dietetics that the Japanese for some thousand years past have been experimenting with vegetable and cereal foods, and at the present time the diet upon which the bulk of the Japanese people subsist is sufficient for the maintenance of an effective nitrogen equi- librium, as well as to keep them in a state of efficient nutrition. Pro- fessor Baeltz had two jinrikisha men in his employ, both powerful young fellows, aged twenty-two and twenty-five respectively, who had followed their calling for years. They were provided with an accurate amount of measured food, the chemical composition of which was ascertained by recognized men. These men received definite instructions: Every day for three weeks their duty was to drag a jinrikisha with Professor Baeltz, who weighed 170 pounds, a distance of twenty-five miles, run- ning all the time. This would seem to be an arduous task, but not more so than these men would willingly and readily undertake. It would be considered quite an undertaking to walk a distance of twenty-five miles every day for three weeks with an August sun at its best, but for these 1 Baeltz was, for some years, body-physician to the late Mikado. 2 Quoted by Dr. Albu in "Die Vegetarische Diitt." Tt should be observed that Dr. Albu writes against vegetarianism, but concedes that one may subsist on vegetarian diet, which is proved among other things by Baeltz's observations. EFFECT OF PROTK1X DIET 177 men to run this distance every day, and to drag a jinrikisha with a passenger weighing 170 pounds, is rather more than one would usually expect. During this experiment the men kept to their usual diet, which con- sisted of fats amounting to less than the proposed standard enunciated by Voit(8), while the contained protein fluctuated from between 60 to 80 per cent of his postulate. Carbohydrates were provided in exceed- ingly large quantities in the form of rice, potatoes, barley, chestnuts, lily roots and other foodstuffs peculiar to the country. The men were weighed. One had gained half a pound and the other was the same as at the beginning. Professor Baeltz now told the men that they would be allowed a liberal allowance of meat, which quite delighted them, as meat to them was a luxury. The carbohydrate ration was cut down and a proportionate quantity of meat not quite as much protein as the Voit standard, but a considerable amount was allowed. The men ate with avidity, but after three days on the meat diet they importuned Professor Baeltz to discontinue the meat and to give it to them only upon con- clusion of their probation, because they felt fatigued and could not run so well as they did previous to taking meat. Baeltz then allowed them to return to their original carbohydrate dietary, with the same result as before the one retained his weight, with perhaps a difference of 100 grams, and the other gained about half a pound. Baeltz records an even greater feat of endurance on a smaller diet. Baeltz was driving from Tokio to Nikko, a distance of about sixty-eight and a half miles. It was midsummer and fearfully hot, and it took Baeltz from six o'clock in the evening until eight o'clock the following morning fourteen hours to make the distance. He says that, just as he was driving out of Tokio, he saw a Japanese sitting in a jinrikisha ;md asked him where he was going. Nikko was likewise his destination and he was being pulled along by a man. He arrived in Nikko just half an hour after Baeltz. Baeltz records that his driver had changed horses six times, and this Japanese jinrikisha man had dragged his compatriot, an adult weighing 119 pounds, a distance of sixty-eight and a half miles at a running pace in about fourteen and a half hours, and on a vegetable diet only. It is well known that the Japanese are physically a small people, yet they are capable of remarkable feats of strength and endurance, and as recent events have shown, they are full of courage and daring, A v,riter(9) in the British Medical Journal says: "The Japanese them- selves attribute their high average of physical strength to a plain and 178 PROTEIN AND NUTRITION frugal diet, and to a system of gymnastics, jiu-jitsu, which includes a knowledge of anatomy, and of the internal and external use of water. In 1889 a commission was appointed to consider whether by a meat diet or by other means the stature of the Japanese race could be raised ; but the conclusion arrived at was that, seeing that their feats of strength and powers of endurance were superior to races mucli taller than them- selves, the lowness of their stature did not matter. Concerning the diet, they are frugal to a degree, partaking of rice at every meal. Japanese troops have often made record marches on diet consisting solely of a little rice. Vegetables and fruits are grown in abundance in Japan, and their value as a regular part of the dietary is realized with far more advantage than it is in this country. Indeed, a laborer is content to work a whole day on a dinner of tomatoes and cucumbers. Milk is scarce, because it does not pay to raise cows to produce milk alone, and the meat is not eaten." OTHEK FOREIGN NATIONS NON-MEA1 EATERS. According to Sin- clair, 1 the Hindu pattamars, carriers of dispatches, who eat only rice, run every day, passing from one town to another, twenty leagues at least, and continue thus for weeks. Russian agriculturists, who live on vegetables, black bread, milk and garlic, work sixteen to eighteen hours per day, and their strength is said often to exceed that of the American sailors (10). The Norwegian peasants scarcely know of animal ali- mentation ; they cover, however, whilst accompanying the carriages of tourists, from three to four leagues, running without stopping. Modern Egyptian workmen and boatmen, who from time immemorial have fed almost exclusively on melons, onions, broad beans, lentils, dates and maize, have remarkable muscular strength (11). The miners of South America, very sober workmen, who do not eat meat, carry on their shoul- ders weights of 200 pounds, with which they mount twelve times a day, on an average, vertical ladders 60 to 80 meters high(12). According to H. Ranke, the woodcutters of Upper Bavaria feed almost exclusively on flour (1,100 to 1,200 grams per day) cooked with hogs' lard (90 grams X without eggs or cheese; on Sundays only they have a little pork. They do, however, an enormous amount of work (13). The Turkish soldier is extraordinarily abstemious; he drinks only water or lemonade, feeds on pillauf of rice and figs and scarcely touches meat. We know that his vigor is remarkable and his courage indomitable. We might learn a great deal from the Arabs with respect to those i We extract the majority of the following facts from the interesting work of Mrs. A. Kingsford (Theses <]< contain these essential substances which need only l>e present in the most minute amount, in order to make the diet amply sufficient for growth and health. Yea*!, for instance, is a substance which is perhaps richest in 115 230 SIGNIFICANCE OF LIPOIDS AND VITAMINES vitamine. The yolk of eyys, brain, liver, kidneys, sweetbread, oatmeal, haricot, beans, peas, etc., are all fairly rich in this vitamine substance, while milk and fresh meat contain vitamines in smaller amounts. The subpericarpial or aleurone layer of rice is richer in organic phosphorus than the endosperm, and, as a result, it has been found that rice poor in phosphorus is more likely to cause beriberi (polyneuritis of fowls) than whole rice. A dietary deficient in these accessory substances gives rise to beriberi, which is a disease of the peripheral nervous system, prevalent in eastern countries, Japan and the Philippines, where the inhabitants subsist almost entirely upon a diet composed largely of highly milled "polished rice." It is believed that even in our own country an alimentation composed almost entirely of foods from highly milled wheat- "patent roller-process flour," would produce beriberi in ninety days; in fact, Little(36) reports an outbreak of beriberi among the fishermen of Newfoundland, who sub- sisted mainly upon alimentation composed largely of highly-milled pat- ent roller-process flour. It is known that beriberi does not develop in persons living on foods made from whole-wheat flour or from whole rice. In other words, as previously pointed out (Volume I, Chapter XIII, page 377), the outer portions of both the wheat and rice grain, namely, the subpericarpial or aleurone layers, contain the "accessory substances" or vitamines which are so essential to the dietary for the prevention of disease of the peripheral nervous system (beriberi and pellagra). Like- wise research by competent observers in cases of scurvy has established the fact that beriberi is not due to a deficiency of the ternary elements of the dietary proteins, fats and carbohydrates, but to certain accessory food substances highly essential to life lacking in the alimentation. Consequently beriberi, pellagra and scurvy are referred to as deficiency diseases. (See chapter on Deficiency Diseases, Volume III, Chapter XVII. The consensus of opinion of research workers in deficiency diseases, Fraser and Stanton(37), Strong and Crowell(38), in the Philippines, Van Leent(SO), Vorderman(40), Takaki(41), Fletcher(42), Highet (43), Heiser(44), Theze(45), Chamberlain (46), Vedder(47) and others, since the appearance of Funk's work on the vitamines, is that beriberi is a disease caused by dietary deficiency resulting from faulty metabolism, due to the lack of the vital accessory food substances to which Funk gave the name "vitamines." Working along this line of research, Williams (48) and Seidell have found that a similar isomerism existing in these substances also exists in VITAMINES 231 the vitamine of yeast, and is primarily responsible for the instability of these compounds, which has so far prevented their isolation. Adenin is the purin base in yeast, which has this property of isomerism. With re- gard to the antinenritic vitamine, Vedder has proposed the hypothesis that this chemical substance acts as a building stone of the complex structure of the nervous tissue, without which it cannot be repaired. All of the foregoing investigators have succeeded in obtaining from rice polishings a chemical substance which in doses of a few milligrams, was capable of curing fowls suffering with polyneuritis induced by a diet of overmilled rice. When a deficiency of vitamine exists, the nervous tissue becomes first exhausted, and then degenerated until finally the symptoms of polyneuritis appear in fowls or dry beriberi in man. This theory is based on experimental observations in man. Thus Vedder and Clark (49) found that the mitochondria in the nerves of fowls showed definite changes after seven days on a diet of polished rice, and long before the fowls showed any clinical symptoms of poly- neuritis, and these changes were progressive the longer the deficiency lasted until evident degeneration could be demonstrated. Chromatolysis and changes in the tigroid substance of the cells of the cord, similar to that observed in pigeons which have been exhausted by long flights, may also be demonstrated in birds which have developed polyneuritis. The antineuritic vitamine is the only one of the accessory food substances con- cerning which there is sufficient evidence to even theorize concerning its action in the body, and more work will be needed before any adequate conception of the physiological action of the vitamines will be known. The study of beriberi, scurvy, and other deficiencies has given a working basis that there are a number of differ- ent accessory food substances or vitamines and that each deficiency disease is caused by the absence of its particular vitamine. Vedder, from his own experiments and those of other investigators, considers that we must assume that there is a whole group of these vita- mines, but that further investigations will be necessary to determine the relation of these various substances to each other. To a limited extent, in the mountainous sections, water-ground wheat flour and corn meal are still produced on the old-fashioned buhr millstones. This water-ground flour and meal contains practically all of the vitamines and all of the mineral salts of the whole grain, while the highly milled products are decidedly deficient both in the cereal salts and in these highly essential accessory substances. Three or four decades ago all grain, especially in the South, was 232 SIGNIFICANCE OF LIPO1DS AND V1TAMINES ground at the neighborhood mill on the old-fashioned buhr millstones, and the power was furnished by the nearby stream. By this method of milling, now almost entirely replaced by the steam or electric patent roller-process, only the coarser particles of the bran and outer skin or husk were removed. Two years ago the author * spent a vacation of two months in his native state, North Carolina, and took occasion to investigate the incidence of pellagra in counties far removed from railway accommodations, particu- larly in western North Carolina, eastern Tennessee and Kentucky. The inhabitants of these sections are too far removed from railway facilities to purchase roller-process meal, and must send their corn to the nearby neighborhood mill, where it is ground in small quantities at a time, suf- ficient for immediate needs, and the whole meal is eaten, furnishing the necessary vitamine substance. The families living in the lowland section, convenient to railroads, buy their supply of patent roller-process meal at the village store. This is devoid of the accessory vitamine substance, and unless the dietary is augmented by fruits, vegetables, milk or fresh meat supplying the accessory substance, deficiency disease will soon follow. Wood (50), writing on pellagra, has observed that in an eastern county of North Carolina, remote from railroad facilities, broad areas with thou- sands of inhabitants are free from pellagra. The inhabitants of this locality consume as a food large quantities of corn meal, but it is a whole meal water-ground product. Many experiments have been conducted 2 (51) to determine the correct physiological estimation of the vitamine content of foods, and from the available data collected it is safe to assume that a perfect analogy exists between the well-known relation of polished rice to its nutritive value and the high milling of wheat and corn to the nutritive value of wheat flour and cornmeal. It is an accepted fact, proved by numerous investigations, that if the alimentation of a people is principally composed of highly pol- ished rice, and otherwise deficient in vitamines, beriberi will develop, but on the other hand, if undermilled rice is substituted for the highly milled product the disease is not so likely to develop. The extreme importance of a method for determining the vitamine content of foods, and of isolating these all important accessory substances is quite apparent. According to Funk, the vitamine theory is so new that "little progress has been made thus far in the isolation of the vitamine principle in suffi- i Dr. Fitch, 2 At the Hygienic Laboratory, Washington, D. C. VITAMINES 233 cient quantities to be of value therapeutically, because most of the vita-, mine was lost, destroyed or rendered inert in the processes of isolation." Recent investigations carried out in the Hygienic Laboratory (52) on the vitamine content of brewer's yeast, gives hope of better results. In the past, the great difficulty had been to isolate the vitamine in sufficiently concentrated amounts to make it of practical use therapeutically. This problem has at last been solved by the use of Professor John TJri Lloyd's prepared hydrous aluminum silicate (53) ; which has a very high selective absorptive power. It was found that 0.05 gram of this solid vitamine product would keep in health a 300-gram pigeon fed exclusively on pol- ished rice or would cure in a very few hours pigeons that had already manifested symptoms of polyneuritis on a polished rice diet. Control pigeons fed on polished rice and untreated with vitamine soon died with polyneuritis. According to research workers in the Hygienic Laboratory, it would seem that a proportionate dose of vitamine for a man weighing 122 pounds would not exceed 10 grams, which could easily be taken in capsule or other form for therapeutic or preventive purposes. It is now to be hoped that the isolation of vitamines from other food products rich in them will soon be accomplished. Relation of Vitamines to the Phosphorus Content of Foods. Unfortu- nately, a method for the direct isolation of vitamines from natural foods has not been devised, as in the case of yeast. However, the phosphorus content of natural foods seems to furnish a fairly accurate index of the relative percentage of vitamines present. Voegtlin, Myers and Sulli- van (54) have been able to determine that while phosphorus does not form a component part of the vitamine molecule, yet it seems, according to their views, that the distribution of phosphorus and vitamines within the grain runs practically parallel. Tibbies (5 5) in summing up the arguments of Schauman in favor of the phosphorus deficiency theory as a factor in the causation of deficiency diseases records the following: (a) that foods which cause beriberi, ship beriberi, scurvy and infantile scurvy are deficient in organic phosphorus, and (b) that the diseases are cured by foods rich in organic phosphorus compounds. It is probable that different groups of organic phosphorus compounds serve different purposes in the organism, and that their ab- sence leads to different diseases. Deficiency of one organic group may cause beriberi in adults, and deficiency of another group may cause rickets* and infantile scurvy. Children fed with boiled or condensed milk some- times develop scurvy-rickets. When milk is boiled it is to some extent denatured; the organic compounds of phosphorus are more or less de- 234 SIGNIFICANCE OF LIPOIDS AND VITAMINES stroyed. Bunge says lecithin is destroyed at 70 C. (140 F.). Rac- zowski found 25 per cent was destroyed at 60 C., 28 per cent at 95 C., and 30 per cent at 110 C. Rickets is common in children of the poor in England, less common in the highlands of Scotland and in Ireland. Many English children are fed on skim milk containing only 0.03 per cent of phosphorus pentoxid (P 2 O 5 ), white bread containing 0.2 per cent phos- phorus pentoxid and margarin. A Scotch highland child gets oatmeal containing 0.9 per cent phosphorus pentoxid and new milk containing 1 per cent phosphorus pentoxid, and German children get rye bread con- taining 1 per cent phosphorus pentoxid. Edie and Simpson (56) found that these diseases are not cured by the addition to the food of carbohydrates, inorganic phosphates, egg albumin and synthetic organic phosphorus compounds, such as glycerophosphates, albumin, metaphosphates, etc., nor did these substances prevent polyneu- ritis in birds. But polyneuritis in birds is prevented and cured by the addition to the diet of substances rich in organic phosphorus, such as rice bran, wheat bran, yeast, katjang idjoe beans, testicular extract, pancreas, etc., in such proportion as to raise the daily income of phosphorus in the food to the normal amount. The daily normal requirement for a man is 2 grams, for a dog 0.5 gram. It was found by Fraser and Stanton(57) that the beriberi causing power of rice is associated with the removal of the phosphorus-containing substances by polishing the grain. They have definitely proved that no rice connected with the outbreak of beriberi con- tained more than 0.26 per cent of phosphorus pentoxid, that rice which contained 0.37 per cent of phosphorus pentoxid did not cause beriberi, and the consumption of rice containing 0.4 per cent of phosphorus pentoxid is perfectly safe. More recent evidence is afforded by a Siamese Government Report on beriberi by Highet, which furnishes conclusive evidence that the use of rice containing less than 0.4 per cent of phosphorus pentoxid is likely to cause beriberi. If not milled so as to reduce the phosphorus pentoxid below this standard, Siamese rice is a safe food. Acting on this finding, the Sia- mese Government pushed the use of under-milled rice in all government institutions and the gendarmerie, and has practically done away with beri- beri among these people, and an attempt is now being made to enforce its use in the army and navy. Fraser and Stanton(58), basing their opinion on a large number of ob- servations and analyses, conclude that rice with a phosphorus pentoxid (P 2 O B ) content below 0.4 per cent is deficient in vitamines. Myers and Voegtlin adopted this method to correlate the vitamine content of wheat V1TAMLXKS 235 and corn products, and came to the same conclusion, that the identical rela- tion exists between the phosphorus pentoxid content of these cereals as exists in the case of rice. To arrive at this conclusion, they conducted a series of experiments on fowls, the classical animal for determining- the vitamine content of foods. It is well known that fowls will live in perfect health for many months on an exclusive diet of wheat or corn. "Whole corn meal, or the so-called "water-ground" corn meal, furnishes :t well-balanced dietary for fowls, hut, on the other hand, it is a matter of recorded fact that fowls fed on highly milled products from wheat, corn or rice will die within a month or six weeks from polyneuritis. The fol- lowing tahle from Public Health reports graphically illustrates the findings of Voegtlin and his coworkers: TABLE SHOWING THE EFFECT OF WHOLE GRAIN AND HIGHLY MILLED CEREALS ON FOWLS VARIETY OF CEREALS, WHOLE AND HIGHLY MILLED Per cent of P 2 8 dry food Number of days required for ap- pearance of polyneuritis in fowls fed exclusively on this food Wheat bread made from highly milled flour 0.114 20-32 days Whole wheat. 1.120 No symptoms developed Corn grits (highly milled) 0.169 23-50 days Corn grits (highly milled) 0.210 30 days Corn meal (highly milled) 0.30 35 days Corn meal (old fashioned rock ground) 0.659 Remained well Corn meal (rock ground) 0.772 Remained well Corn germ 2.816 Remained well Corn, whole 0.760 Remained well Myers and Voegtlin conclude from their experiments the following provision standard, phosphorus pentoxid content for wheat, flour, corn meal and grits: for corn products, the minimum phosphorus pentoxid content should not fall helow 0.50 per cent and for wheat flour not below 1 per cent, as a safe index for arriving at the relative amounts of vita- mines present. These investigators consider the determination of the phosphorus pentoxid index of considerable value in all cereal products with the exception of the so-called "self-raising flours." These latter products contain baking powders, composed largely of phosphates. Of recent years certain factors have arisen which exert a tendency to limit the vitamine content of the dietary of certain classes of our rural population. Changes in the economic conditions of food production and the methods of cooking 236 SIGNIFICANCE OF LIPOIDS AND VITAMINES seem to reduce the vitamine content of the diet of a large number of per- sons almost to the danger point. One factor involved in the reduction of the vitamine content of bread, especially cornbread, is the almost universal use of baking soda as a leavening in bread making. It has been clinically demonstrated on animals that bread made from highly milled corn meal, to which milk and soda is added for leavening, lessens the high initial content of the antineuritic substance during the process of baking as a re- sult of the destructive action of the alkali contained in the soda. We pointed out in the section on Bread Making (\ f olume I, Chapter XIII, page 386) that, where bicarbonate of soda and milk are used for leavening during the process of cooking, the sodium bicarbonate was con- verted into a strong alkali, which is not a food product. Prior to the in- troduction of the patent roller-process of grinding grains, cornbread made from the water-ground meal was mixed with salt and water and it yielded a wholesome bread ; but simultaneously with the introduction of highly milled corn meal, it was found that when this product was mixed with salt and water, it did not yield bread of the same lightness as the old-fashioned water-ground meal. It then became necessary to resort to artificial leav- ening, and sodium bicarbonate became a popular household remedy. Bread, made by means of bicarbonate of soda and salt, under present con- ditions, has a distinctly alkaline taste and reaction. The usual method of preparing bread from bolted corn meal is to mix it with water and add a small quantity of shortening and bicarbonate of soda for leavening. The resulting mushy mixture is baked in an oven, the high temperature of which liberates carbon dioxid from the sodium bicarbonate, and the latter is transformed into sodium carbonate, a strong alkali. Voegtlin and Sul- livan (59) recently demonstrated that the action of this alkali is destruc- tive to vitamines(60). It was then definitely proved that the "accessory substances" lose their physiological activity when exposed to alkalies, and more especially under the influence of the high temperature of a baking oven. Cornbread, prepared from the old-fashioned water-ground meal, sweet milk and soda, when forming the exclusive diet of chickens, soon leads to the development of symptoms of polyneuritis, but on the other hand, bread prepared from the old-fashioned w 7 ater-ground corn meal, but- termilk and salt (NaCl) does not give rise to any polyneuritic symptoms, and the fowls seem to maintain perfect health. In contrast to the de- structive action of alkalies on vitamines brought about by the use of bicar- bonate of soda in bread-baking, it is necessary to emphasize the fact that the old-fashioned way of combining baking soda with sour buttermilk in the preparation of bread is a perfectly harmless procedure, provided that VITAMINES 237 sufficient sour milk is added to neutralize the alkalinity of the baking soda. The following table worked out by Voegtlin emphasizes the destructive action of baking soda on the vitamine content of eornbread. He fed a coop of chickens on cornbread having the following composition : 600 gin. of corn meal 800 c.c. sweet milk 10 gin. of baking soda with the following result : Laboratory Num- bers of Animals Number of days be- fore appearance of polyneuritis after feeding was begun Laboratory numbers of animals Number of days be- fore appearance of polyneuritis after feeding was begun 31 13 37 19 32 14 38 21 33 27 39 18 34 13 40 16 35 22 36 14 Average 17 Vitamines and Pellagra The appearance of pellagra, a disease of the peripheral nervous system, has recently stimulated much research in the Southern States as to its causation and treatment. Voegtlin believes that the dietary of pellagrins is deficient in vitamines. It is known that pel- lagrins subsist on a dietary that is not rich in vitamines. The recent investigations made by Goldberger and other officers of the Public Health Service seem to bear out this assertion. The foodstuffs forming their principal alimentation consist of highly milled cereals, principally corn, and fat pork, in addition to carrots and turnips and similar vegetables. It is also believed that baking soda, which is used as a leavening for making cornbread, tends to further lower the vitamine content. From the available data at hand, one may conclude that the prevalence of pellagra in the South is due to several factors : (a) the highly milled wheat and corn products which are undoubtedly deficient in vitamines; (&) the preparation of bread from both highly milled flour and corn meal by using baking soda for leavening, without buttermilk or tartaric acid, which permits the deleterious effect of the strong alkali to destroy the vitamine content of the food ; (c) changes in the economic conditions of the population, and in food production and supply all of which seer" to exert an unfavorable influence on the dietary of the poorer people. The increased cost of living places beyond their reach the more expensive foods 238 SIGNIFICANCE OF LIPO1DS AND VITAMINES meat, eggs, milk, etc. having a fairly high vitamine content, which are not so liberally used as heretofore, and a reduction in the amount of these important foods, therefore, reduces the vitamine content of the ration. During the past ten years, the cost of food has increased out of proportion to the increase in wages, and pellagra has likewise increased during this decade. The reduction of the vitamine content of the diet of pellagrins is due () to the reduction, for economic reasons, of certain aliments in the dietary, of vitamine rich foods, such as fresh milk, eggs and meats; (t) the introduction of highly milled cereals, and (c) to the use of baking soda as a leavening, which exerts a destructive action on the vitamine content of bread. The fact that the above-mentioned influences, which have undoubtedly reduced the vitamine content of the diet, made themselves felt a relatively short time before the rapid increase in pellagra in the South, furnishes con- siderable evidence in favor of the vitamine-deficiency theory of pellagra. REFERENCES 1. McCoLLUM and DAVIS. The Necessity for Certain Lipoids in Diet During Growth, J. Biol. Chem., pp. 15-167. 2. LANDERS. Biochem. J., 1913, p. 78. 3. McCoLLUM. J. Biol. Chem., 1912, 11, vol. xii. 4. VOEGTLIN and SULLIVAN. Science, 1913, pp. 672, 964. 5. LOEB and BEUTNER. Ibid., pp. 672-673. 6. LILLIE. lUd., p. 967. 7. FUNK, CASIMIR. Die Vitamine, Wiesbaden, 1914. 8. COOPER. J. Hyg., 1912, vol. xii, p. 436. 9. VOEGTLIN, CARL (Prof, of Phar. IT. S. P. H. S.). Proc. Am. Soc. Biol. Chem., 1915. 10. FUNK, CASIMIR. Die Vitamine, 1914. 11. . Ztschr. f. Physiol. Chem., 1914, vol. Ixxxix, p. 378. 12. BRAPDON and COOPER. J. Hyg., 1914, vol. xiv, p. 351. 13. VOEGTLIN, CARL. IT. S. Pub. Health Service, J. Washington Acad. of Sci., Oct., 1916, vol. vi, No. 16. 14. SULLIVAN and VOEGTLIN. U. S. Pub. Health Service, Proc. Amer. Soc. Biol. Chem., 1915. 15. VOEGTLTN, CARL. J. Washington Acad. of Sci., Oct., 1012, vol. vi. No, 16. REFERENCES 239 10. THAI/BE. Biochem. Ztschr., 1909. 17. STKI-I-, W. Biochem. Ztschr., 22-452. 18. FI;.\K, ( 1 ., and MACALLI .M, A. BUI:CE. Ztschr. f. Physiol. Chem., v.45 " Protein 5.65 " The heat of combustion of various substances as well as the relation between their elementary composition will be made clearer by the study of the table on page 248 from Sherman (4), which includes the number of typical compounds found in food or formed in the body: 248 THE CALORIC METHOD OF FEEDING FIEAT OF COMBUSTION AND APPROXIMATE ELEMENTARY COMPOSITION OF TYPICAL COMPOUNDS Heat of Combustion, Calorics per gram Carbon, per cent Hydro- gen, per cent Oxygen, per cent Nitro- gen, per cent Sulphur, per cent Phos- phorus, per cent Glucose. . . Sucrose. . . Starch. . . . Glycogen. . Body fat. . Butter fat . Edestin. . . Legumin. . . Gliadin Casein .... Albumin . . . Gelatin , Creatin. . . . Urea. . 3.75 3.96 4.22 9.60 9.30 5.64 5.62 5.74 5.85 5.80 5.30 4.58 2.53 40.0 42.1 44.4 76.5 75.0 51.4 51.7 52.7 53.1 52.5 50.0 42.5 20.0 6.7 6.4 6.2 12.0 11.7 7.0 7.0 6.9 7.0 7.0 6.6 6.2 6.7 53.3 51.5 49.4 11.5 13.3 22.1 22.9 21.7 22.5 23.0 24.8 14.1 26.7 18.6 18.0 17.7 15.8 16.0 18.0 37.2 46.6 0.9 0.4 1.0 0.8 1.5 0.6 0.8 The following table from Hall (5) graphically expresses the calories represented in different foods and other substances involved in the proc- esses of nutrition : TABLE SHOWING CALORIES PER GRAM OF DRY SUBSTANCE 1 Gram dry substance Heat of combustion in calories Starch or glycogen 4.182 Cane sugar 4. 176 Dextrose 3.940 Lactose 4.162 Carbohydrates, average; absorbed and available 4.0 Fat (one form) 9.686 Fat (another form) 9.423 Butter 7.264 Fats, average; 9.4; absorbed and available 9.0 Egg, white 4.896 Egg, yolk 6.460 Egg average, white and yolk 5.678 Lean beef 5.656 Casein 5.849 Vegetable proteins 5.500 Proteins, average 5.650 Protein, unavailable energy (unabsorbed or unoxidized) 1 .650 Proteins, available energy for use in body 4.0 Carbon, per gram 8.080 Hydrogen, per gram 34.662 FOOD AS A SOURCE OF HEAT AND GROWTH 249 Standard and Sample Dietaries We have just studied "heat of com- bustion and approximate elementary composition of typical compounds," together with the "calories represented in different foods involved in the process of nutrition," and, before entering upon a consideration of the theoretical requirements of individuals, some standard dietaries and a few examples of diets consumed by people of different classes such as rep- resented in the table l below should guide us in arranging a diet for groups of people in various circumstances and following varied occupations : STANDARD DIETARIES Standard dietaries and others Protein, Grams Fat, Grams Carbo- hydrates, Grams Energy, Grams Standard Diet: Ranke's 100 100 240 2,310 Moleschott's 130 84 404 2,970 Pettenkof er and Voit's 137 117 352 3,113 Cornet's 120 60 500 3,007 Playfair's 119 51 530 3,025 Parke's 127 99 397 3,172 The diet of Harvard University boat crew .... Harvard Freshman boat crew 162 153 175 223 449 468 4,130 4,620 Yale University boat crew 145 170 375 3,705 Harvard University boat crew (2d observation) 160 170 448 4,075 Harvard Freshmen boat crew (2d observation) 135 152 416 3,675 Yale University boat crew (2d ob- servation) 171 171 434 4,070 Captain of Harvard crew 135 181 487 4,315 Average of above diets 135 177 440 4,085 Football team : Connecticut 181 292 557 5,470 Football team: California 270 416 710 7,885 Professional athlete 244 151 502 4,460 Athletes at Helsingfors | 217 259 431 5,070 Brickmakers in Connecticut { 182 222 204 265 392 758 4,254 6,484 Mechanics in United States 154 227 626 5,275 Lumbermen in Maine 206 387 963 8,140 United States Army ration 164 98 600 4.061 United States Navy ration 143 184 520 5,000 English Royal Engineers in active work 144 83 631 3,950 English soldiers on special duty. . . European soldiers in Batavia j 190 1 145 136 58 150 79 510 450 497 3,426 3,503 3,000 Mechanics in Germany 139 113 677 4,395 Farm laborers in Austria 159 62 977 5,235 Factory operatives in Russia Mechanics in Sweden 132 189 80 110 584 714 3,680 4,725 From Bull. 45, U. S. Dept. Agric., and various other sources. 250 THE CALORIC METHOD OF FEEDING Caloric Values of Ingested Foods. In the process of digestion and absorption, the combustion of fats and carbohydrates yields products identical with those in the calorimeter, and gives out an equivalent amount of heat. This does not hold true with protein, however, which in the bomb turns to carbon dioxid, water and nitrogen, but in the body yields no free nitrogen, for here urea and other organic nitrogen com- pounds are excreted as end products of protein digestion (see Volume I, Chapter VII, Physiology and Absorption). From this data it will be seen that these organic nitrogenous end products which are combustible result from a more incomplete oxidation of protein in the organism than that occurring in the bomb. The estimation of the loss of potential energy is based on the theory that the total quantity of nitrogen excreted from the body as urea would amount to about 0.9 calories per gram of protein. However, this problem is not as simple as would seem at first sight, for, owing to the excretion of other matter (creatinin, uric acid, and the like) of higher combustion, the real loss from end products is increased to the average of about 1.3 calories per gram of protein disintegrated in the organism. Therefore, it is correctly estimated that when the body burns material which it has previously absorbed it obtains: From carbohydrates 4.1 calories per gram From fats 9.35 " " " From protein (5.651.30). 4.35 " " " An allowance must be made, however, when calculating the fuel value of food to allow for the fact that a part of each of the materials is lost in digestion, so that the approximate values of a mixed diet are: Carbohydrates ... 2 per cent lost, 98 per cent absorbed Fats 5 per cent lost, 95 per cent absorbed Protein 8 per cent lost, 92 per cent absorbed When allowance is made for the above losses, biological chemists have approximated the physiological fuel value of food constituents consumed to be as follows : Carbohydrates . . (4.1 X 98 per cent) yield 4. calories per gram Fats (9.45 X 95 percent) yield 9. calories per gram Protein (4.35 X 92 per cent) yield 4. calories per gram .FOOD AS A SOUKCK OF 1IKAT AXI) GROWTH 251 Rubner's calculation shows the energy values of foodstuffs to be as follows: Carbohydrates yield 4.1 calories per gram Fats " 9.3 " Protein " 4.1 Rulnier's estimate was derived from experiments with dogs fed on meat, starch, sugar, etc., and made no calculation for the loss in diges- tion as has been found by other competent observers to occur with men living 011 an ordinary well-balanced ration. Food ingested represents potential chemical energy which is the source of all bodily energy. In order to arrive at a correct determination of the potential energy in food consumed, it is necessary to know how much food is consumed and the potential energy of the various foodstuffs. By refer- ring to page 258 will be found a table which graphically expresses the caloric value of different foods involved in the process of nutrition. The reader is also requested to consult The Analysis and Fuel Value of Foods, Volume I, Chapter XIX, which contains a list of all known American foods and graphically presents the analysis of foods, showing the percent- age of protein, fat, carbohydrate and mineral salts with the caloric value per pound and per portion. Constructive and Fuel Foods. We have previously pointed out in this chapter, the methods for calculating the fuel value or potential energy of foods. It has been determined by means of calorimetric experiments that the amount of heat given off from a known weight- of food substance is fairly constant and is called the heat value, or heat of combustion, which is expressed in calories. The consideration of a large number of estima- tions of the heat value produced in the calorimeter and of the digestibility of foods led Ilubner ( 6 ) to fix their value approximately, as graphically pointed out in table on this page. These figures are accepted by the ma- jority of observers as being approximately correct, and so have passed into common use. The experiments of Ilubner, Atwater and other investiga- tors seem to show that the various foods may replace each other in exact ratio to energy derived from, them which we have already discussed (Volume II, Chapter V, Various Factors Bearing on Diet, Digestion and Assimilation). Thus 100 grains of fat are isodynamic with 2 25 of syntonin, 243 grams of dried muscle, 232 grams of starch, 234 grams of cane sugar and 250 grams of dextrose. In other words, 227 grams of carbohydrates or protein are equal in isodynamic value with 100 grams of fat, because they yield 030 calories on combustion in the body. 252 THE CALORIC METHOD OF FEEDING As shown in a previous chapter (Volume II, Chapter VII), a certain amount of protein is necessary to sustain life. It is not sufficient to say that a food to be able to maintain life and strength can furnish a given number of calories, since any number of calories can be obtained from fat, but fat will not maintain life nor promote growth of cells. Alimenta- tion must be estimated in terms of protein required and of calories required. A large proportion of the latter can be obtained from variable amounts of fats and carbohydrates, but such an alimentation would not build the body, though it would furnish the necessary fuel for body activities. Let us emphasize at this point the two clearly differentiated needs of the body: (a) for constructive material, and (&) material for fuel. The constructive foods are : proteins, salts and water. The fuel foods are : sugar, starch and fat. Note that the fuels are composed of carbon, hydro- gen and oxygen. They are, chemically, the carbonaceous foods, which oxidize to CO 2 and H 2 O. The value of these fuel foods to the body is based wholly upon their fuel value, which is measured by the number of calories of heat which they liberate on oxidation. On the other hand, the value of the constructive foods cannot at all be measured by the number of calories which they represent. Salts, for example, are of inestimable value for body building, yet they have no caloric value no fuel value. Water and the salts are just as truly foods as are the starches, sugars and fats ; but they are constructive foods of no fuel value. Similarly, the proteins bring C, H, N, S, P and Fe, to the body in combinations readily digested, absorbed and assimilated into living active tissues. These elements and combinations are absolutely essential to growth and repair. Their constructive value their food value is very great. The fuel value of proteins (5.65 calories per gram) is partly available eventually for fuel purposes when taken in minimal quantities, and immediately available to the extent of 4 calories per gram when taken in excess of the requirements for construction. This avail- able fuel value is its fuel value, not its food value. Fuel values are meas- ured in calories and may be estimated in cents per calorie. Constructive food values can no more be estimated in money units than can the value of a living, functioning nerve or muscle cell be estimated in dollars and cents. Caloric Requirement of Man The caloric requirement of an individual depends somewhat upon his weight and the amount of energy expended. As a result of much research and investigation, in order to establish a working standard, the weight fixed upon by various investigators has been FOOD AS A SOU11CE OF HEAT AND GROWTH 253 approximately 150 pounds. The caloric requirement for a man of this weight leading a sedentary life can be determined by the following four methods, as determined by Sherman (4) : (a) By observing the amount of food ingested by many men in dif- ferent countries and under varying conditions. (6) By determining the approximate amount of oxygen consumed. (c) By determining the equilibrium or balance of intake and output. (d) By direct calculation of the heat given off by the body. These various methods give approximately the same findings : a man at rest requires 2,000 calories, and one leading a sedentary life requires 2,300 calories. The protein requirement for a man at work cannot be determined so accurately. It has been attempted by various observers with the following results : Voit in Germany fixed upon 118 grams of protein as the standard. Playfair in England fixed upon 119 grams of protein as the standard. Gautier in France fixed 107 grams as the standard. Atwater in this country fixed 100 grams of protein as the standard for a man of sedentary habits. Atwater also fixed 125 grams for a man at moderate work, 150 grams for a man at hard work, 90 grams for one completely at rest. Chittenden decided upon 60 grams as the standard. His objection to the high protein ration, given by other workers in this field of research, is based, he says, upon evidence of self-indulgence and not upon the needs of an individual or upon the most profitable use of food. We give below the results of his experiments. For a man of average weight (154 pounds), it is necessary to provide for the requisite quantity of food, 00 grams of protein and a total caloric value of 2,800 calories. The follow- ing is a sample dietary suggested by Chittenden (7), showing the protein in grams and the caloric value of each article : THE CHITTENDEN LOW PROTEIN DIETARY Breakfaai: Protein, grams Calories 1 shredded wheat biscuit (30 gm.) 3.15 106 1 teacup of cream (120 gm.) 3.12 206 1 German water roll (57 gm.) 5.07 165 2 one-inch cubes of butter (38 gm.) 0.38 284 M cup of coffee (100 gm.) with 0.26 ^ cup of cream (30 gm.) 0.78 51 1 lump of sugar (10 gm.) 38 12.76 850 254 THE CALORIC METHOD OF FEEDl.Xd THE CHITTENDEN LOW PROTEIN DIETARY Continued Lunch: Protein, grams Calories 1 teacup home-made chicken soup (144 gm.) 5.25 60 1 Parker House roll (38 gm.) 3.38 110 2 one-inch cubes of butter (39 gm.) 0.38 284 1 slice lean bacon (10 gm.) 2.14 65 1 small baked potato (2 oz.-60 gm.) 1.53 55 1 rice croquette (90 gm.) 3.42 150 2 ounces maple sirup (60 gm.) 166 1 cup tea with 1 slice lemon 1 lump sugar (10 gm.) 38 16.10 928 Dinner: 1 teacup cream of corn soup (130 gm.) 3.25 72 1 Parker House roll (38 gm.) 3.38 110 1 one-inch cube of butter (19 gm.) 0.19 142 1 small lamb chop broiled, lean meat (30 gm.).. . . 8.51 92 1 teacup of mashed potato (167 gm.) 3.34 175 Apple-celery lettuce salad with mayonnaise dress- ing (50 gm.) 0.62 75 1 Boston cracker split, 2 in. in diameter (12 gm.). 1.32 47 ^-inch cube American cheese (12 gm.) 3.35 50 % teacup of bread pudding (85 gm.) 5.25 150 1 demi-tasse coffee 1 lump sugar (10 gm.) 38 29.21 951 Total grams of protein 58.07 Total calories 2729 The total amount of protein in grams and the total calories in this dietary, as stated above, may be taken as approximately correct. It will be seen that he has reduced the protein to as low a point as is compatible with good health, mental and physical strength, but has allowed sufficient carbonaceous food to produce the requisite calories for normal energy. We have stated heretofore, and will reiterate again, that more protein is ordinarily consumed than is needed and often more than is good for one. Calorific Value of Excretory Products. All non-nitrogenous foodstuffs which have undergone complete digestion and assimilation yield in our bodies the same amount of heat as in the calorimeter, the final products being the same. The nitrogenous foodstuffs are not so completely metab- olized ; the oxidation of proteins in the body is not complete. We learned, when studying the Physiology of Digestion, that the protein molecule is made up of some twenty or more ammo-acids. We also found that the protein molecule is split into a nitrogen-moiety and a carbon- moiety (8). The carbon-moiety is as completely oxidized in the body as in the calorimeter experiments. The nitrogen-moiety is not reduced in the animal body to ammonia and water the ultimate products of nitro- genous decomposition but it is excreted as an organic compound, which FOOD AS A SOURCE OF HEAT AND GROWTH 255 iii man is chiefly urea, and a smaller proportion of quaternary substances (usually referred to as "meat bases") which have a calorie value but no food value. In order to arrive at the definite calorific value of the excre- tory products, they must be subtracted from the fuel value of nitrogenous foodstuffs as ascertained by calorimetric experimentation. The balance represents only the actual energy yielded to the body and is known as the "physiological heat" value. It may be noted in passing that the unavail- able energy of the proteins is that represented by the urea, urates, nitrates, sulphates and other more or less complex substances excreted in the urine which are subject to further combustion, so that the animal body is able to extract from proteins only about four calories, while the calorimeter experiments in complete combustion is able to extract 5.65 calories. It may be safely stated as a general working rule, that each gram of protein consumed results in the excretion of about one-third of a gram of urea. The factors of Rubner, as previously mentioned, are generally agreed upon as being approximately correct, but, in order to ascertain the physio- logical available energy, the food should be burnt in a bomb calorimeter already described, and the figure obtained will be the gross heat value. From this, as we have previously mentioned, must be subtracted the heat yielded by the urine and feces by combustion, and the net will show the physiological availability of the energy. In his physiological researches, Rubner (0) made many such experiments, and the following is summed up from his results, to which Tibbles(O) refers: RUBNER'S TABLE SHOWING LOSSES AND AVAILABLE ENERGY FOOD HEAT LOST, PER CENT Availability of Energy, Per cent In Urine In Feces Total Mixed diet : Poor in fat .... Rich in fat .... Meat diet 4.70 3.87 16.30 5.13 2.40 2.20 2.00 6.00 5.73 6.90 5.07 15.50 24.30 5.60 10.70 9.60 23.20 10.20 17.90 26.50 7.60 89.3 90.4 76.4 89.4 82.1 73.5 92.4 Cow's milk Graham bread Rve bread. . Potatoes Physiological Food Value The value of a fuel food to the body is finally measured by the number of calories which it can yield when oxidized in the tissues the physiological food value. But this value depends upon digestibility and absorbability. It was formerly considered 256 THE CALORIC METHOD OF FEEDING that the measure of digestibility of any foodstuff depended upon the length of time it remained in the stomach and freedom from discomfort during the process of digestion. In normal individuals the process of digestion is unaccompanied by any feelings save that of satisfaction and well being. It is only under abnormal conditions that the presence of food in the stomach or alimentary canal gives rise to any other sensation. Beaumont (10), in a long series of experiments on Alexis .St. Martin, who suffered from a gastric fistula, was able to determine exactly the length of time the food remained in the stomach. For many years his experi- ments w r ere accepted as authoritative, but the science of nutrition has shown many errors in his reasoning and conclusions. Physiologists in recent years have conducted experiments with the object of ascertaining the period of time various foods remain in the stomach (11). Penzoldt, in working out this question, made observations on the gastric digestion in healthy men. 1 He allowed his subjects to have a stated amount of certain foodstuffs, the exact amount and consistence of which he took careful note. He allowed this to remain in the stomach for a definite time and removed the contents with a stomach tube, and he found that the time it remained in the stomach had a marked influence upon it. Physiologists have definitely determined the fact that fluids pass out of the stomach more rapidly than solids. For instance, six to eight ounces of water or beverages pass out of the stomach during the course of 30 minutes. It was found that hot drinks did not pass out of the stomach any quicker than cold ones. Solid food substances in solution or suspension were somewhat delayed in leaving the stomach, thus it took two hours for eight ounces of milk to pass through the stomach. It is a well-known fact that the length of time food remains in the stomach is not a definite criterion of the ease or difficulty of its digestion. On the other hand, it would be an error to consider as "indigestible" those foods which remain in the stomach a longer time than others or to suggest that they should be avoided by healthy people. According to Tibbies (8) : The test of time occupied by its passage through the stomach refers only to the "apparent digestibility," while the test of "actual digestibility" is the amount absorbed. It has been truly said that "We live not upon what we eat, but upon what we digest." The term "digestibility," therefore, refers to the entire process of digestion, and not merely to that which occurs in the stomach. In this sense a "digestible food' is one of which the largest possible percentage is absorbed, and an "indigestible food" is one of which a considerable portion passes out of the system in the feces without being disintegrated and absorbed, i See Volume III, Chapter I, for Penzoldt's observations. CALCULATION OF FUEL VALUES OE FOOD 257 CALCULATION OF FUEL VALUES OF FOOD Chemical Analyses of Foods To calculate the fuel values of food it is necessary to have before one tables showing the chemical analysis of the food in question. Taking from the tables the component parts of the aliment to be used, and multiplying by the factors representing the num- ber of calories per gram of carbohydrates, fats or proteins as the case may be, one can quickly determine the calories per 100 gram or the calories per pound in any given article of food. For assistance on this point the reader is referred to an abbreviated table given on the following page, containing the estimate of protein, fats, carbohydrates and caloric value for portions ordinarily served. For a more extensive table, see Volume I, Chapter XIX, where an accurate analysis of protein, fats, carbohydrates, mineral matter and caloric value per pound and per por- tion is given for the different American foods. A study of these tables will afford a basis for calculating the requisite number of calories con- tained in different foods for a well-balanced ration. From the following table compiled from the more extensive work by Locke(12) it will be easy to estimate the percentage of ternary food ele- ments contained in the common foodstuffs, together with the caloric value given for individual portions ordinarily served : COMPARATIVE EQUIVALENTS IN METRIC, AVOIRDUPOIS AND APOTHECARIES' WEIGHTS AND MEASURES' METRIC WEIGHTS WEIGHTS MEASURES AND MEASURES Apothecaries' Avoirdupois Fluid Fluid Grains oz. gr. Ib. oz. gm. gm. or c.c. oz. minims ounces and fractions 15432.4 32 72.4 2 3 119.9 1000 33 390.06 33.814 7000.0 14 280.0 1 453.592 15 162.1 15.338 1543.2 3 103.2 .. 3 230.7 100 3 183.1 3.382 480.0 1 . . 1 42.5 31.1035 1 24.8 1.052 456.392 1 18.89 29.5737 1 1 437.5 1 28.350 . . 460.1308 0.959 15.4324 1 16.23 0.0338 1 0.06479 1.0517 0.0022 0.9508 0.06161 1 0.0021 From the United States Pharmacopeia. 258 THE CALORIC METHOD OF FEEDING VALUES OF THE ORDINARY FOODS PREPARED TO SERVE FOODSTUFFS Quantity Weight (Cms.) Protein (Gms.) Fats (Gms.) Car- bohy- drates Total Calories Beef juice 4 ounces 120 5.88 0.72 31 Corned beef hash.. . . 2 heap, tblspoon. 100 6.00 1.90 9.40 81 Roast beef 1 slice 100 22.30 28.60 357 Steak, tenderloin beef.. . Sweetbreads 1 " 2 100 80 23.50 32.00 20.40 0.45 286 135 Creamed chicken on toast Roast chicken Lamb chop with bone . . Roast lamb 2 heap, tblspoon. 1 slice 1 chop 1 slice 125 100 100 75 16.26 32.10 21.70 14.78 12.62 4.40 29.90 9.53 21.76 2.10 273 181 367 150 Boiled mutton, lean .... Mutton chop, lean Mutton, roast leg 1 1 chop 1 slice 75 100 75 23.18 22.60 18.75 3.38 4.50 16.95 126 135 234 Ham, smoked, boiled, as purchased 1 " 33 7.29 6.80 93 Ham, smoked, fried. . . 1 35 7.77 11.62 140 Sausage, uncooked 1 sausage 35 4.55 15.47 0.39 164 Roast turkey 1 slice 100 27.80 18.40 285 Veal cutlet 1 cutlet 80 22.82 1.14 104 Veal roast. 1 slice 75 21 33 1.00 97 Bluefish Average helping 100 25.90 4.50 148 Codfish 100 21.68 0.27 1.58 98 Halibut u u 100 20.35 4.04 121 Mackerel a u 70 11.73 4.48 2.62 104 Salmon u u 100 19.65 10.21 5.36 198 Sardines, canned. . 1 fish 10 2.30 1.97 28 Trout, brook Average helping 50 10.57 1.17 .62 57 Clams, long 6 clams 150 12.90 1.5 3.00 79 Clams, round. . . 6 " 100 650 0.4 420 47 Crabs, hard shelled, as purchased 1 crab 245 19.36 221 1.47 106 Lobster 105 17.22 1.89 .42 90 Oysters 6 oysters 85 5.27 1.02 3.15 44 Oyster stew 4 ounces 124 6.07 11.06 10.53 171 Scalloped ovsters 6 large ovsters 138 8.06 18.58 11.98 255 Scallops, fried.. . . 3 heap tblspoon 110 2820 1 75 602 158 Bean soup, home-made . Chicken soup, home- made 1 teacup 1 " 120 120 3.84 1260 1.68 096 11.28 288 78 72 Chicken gumbo soup, canned 1 120 456 1.08 5.64 52 Clam chowder, home- made 1 " 120 2.16 .96 8.04 51 Consomme\ canned. 1 " 120 3 00 048 14 Asparagus, cream soup. Celery cream soup 1 1 " 125 125 3.44 3.00 8.62 8.94 ' 4.87 5.01 114 116 Corn cream soup 1 " 125 3.75 8.70 10.66 140 Pea cream soup. . . 1 (i 125 629 846 1407 162 Tomato cream soup .... Mock turtle, canned. . . . Oxtail soup, canned 1 1 ( ( I (( 125 120 120 2.99 6.24 4.80 9.40 1.08 1.56 6.36 3.36 5.16 126 50 55 CALCULATION OF FUEL VALUES OF FOOD 259 VALUES OF THE ORDINARY FOODS PREPARED TO SERVE Continued FOODSTUFFS Quantity Weight (Gms.) Protein (Gms.) Fats (Gms.) Car- bohy- drates Total Calories Vegetable soup, canned . Butter 1 teacup 1 ball 120 15 3.48 0.15 12.75 0.6 17 119 Average cream 1 tblspoon. 20 0.74 5.14 0.71 54 Thick cream.. .... 1 " 20 0.31 11 22 46 108 American cheese, pale . . Camembert cheese. . . 1 cubic inch 1 heap, tblspoon. 20 20 5.70 4.20 7.18 4.34 0.06 91 58 Fromage de brie 1 cubic inch 20 3.18 4.20 028 53 Full cream cheese 1 U U 20 5.18 6.74 048 86 Neufchatel cheese 1 <( 20 3.74 5.48 .30 68 Roquefort cheese 1 <( 20 4.52 5.90 0.36 75 Swiss cheese 1 slice 20 5.52 6.98 0.26 89 Kumiss 1 wineglass 130 3.64 2.73 7.02 69 Buttermilk 1 glass 218 6.54 1.09 10.46 80 Whole milk 1 " 220 7.26 8.80 11.00 157 Whey 1 " 203 2.03 0.61 10.15 56 Hen's eggs, boiled. . . 1 eee 50 6.60 6.00 83 Omelette egg.. . . . }/2 omelette 75 9.80 14.01 1.55 177 Ingredients : 3 tblspoon . milk, 3 eggs, 1 heap, teaspoon butter. . . . Asparagus, canned 125 1.88 0.13 3.50 23 Baked beans, home-made Butter beans 3 heap, tblspoon. 4 150 180 10.83 63.78 12.76 0.24 32.84 11.60 298 65 Lima beans 2 " " 80 6.40 0.54 23.60 128 String beans 2 " 60 0.48 0.66 1.14 13 Beets 2 u 70 1.61 0.07 5.18 29 Cabbage 3 " " 100 0.60 0.10 0.40 5 Carrots 3 " " 100 0.53 0.17 3.39 18 Cauliflower 2 120 1.08 0.12 0.48 8 Celery, uncooked. 3 small stalks 55 0.50 0.05 1.43 8 Corn, canned. . 2 heap, tblspoon. 100 2.80 1.20 19.00 101 Corn, green 1 ear 100 3.07 1.10 18.78 100 Cucumber, uncooked . . . Mushrooms, broiled .... Onions 8 thin slices 2 large, on toast 1 50 57 100 0.40 3.52 1.20 0.10 8.94 1.80 1.55 12.85 4.90 9 150 42 Peas, green 3 heap, tblspoon. 92 6.16 3.13 13.43 110 Potatoes, sweet, boiled . . Baked potatoes Average size Medium " 100 130 3.00 3.77 2.10 0.20 42.1 32.07 204 149 Boiled potatoes U 150 3.75 0.15 31.35 145 Mashed and creamed potatoes 2 heap, tblspoon. 100 2.60 3.00 17.80 112 Squash 2 100 1.36 0.82 13.60 69 Spinach 2 100 2.10 4.10 2.60 57 Tomatoes, canned 2 " " 70 0.84 0.14 2.80 16 Tomatoes, uncooked.. . . Turnips Medium size 2 heap, tblspoon. 200 140 2.40 0.45 0.40 0.08 8.00 0.91 46 6 Apple Average size 150 0.45 0.45 16.22 72 Banana 194 1.55 0.78 27.74 127 Blackberries 3 heap, tblspoon. 100 1.30 1.00 10.90 59 Cantaloupe ^ melon 465 1.40 21.39 93 260 THE CALORIC METHOD OF FEEDING VALUES OF THE ORDINARY FOODS PREPARED TO SERVE Continued FOODSTUFFS Quantity Weight (Gms.) Protein (Gms.) Fats (Gms.) Car- bohy- drates Total Calories Cherries .... About }/;j pound 100 0.90 0.80 15.90 76 Currants 4 heap, tblspoon. 100 1.50 12.80 59 Grapefruit J/2 large 300 2.37 0.60 30.27 139 Grapes 1 bunch 150 1.50 1.80 21.60 112 Gooseberries 4 heap, tblspoon. 90 0.90 11.79 52 Huckleberries 4. 100 0.60 0.60 16.60 76 Lemon Average size 130 .91 .65 7.67 41 Orange u 250 1.50 0.25 21.25 96 Peach u u 128 0.64 0.13 9.86 44 Pear.. u u 156 0.78 0.62 19.81 90 Pineapple, edible portion Plum 2 slices Average size 100 35 0.40 0.32 0.30 9.70 6.69 44 29 Raspberries 3 heap, tblspoon. 82 0.82 10.33 46 Strawberries 4 100 1.00 0.60 7.40 40 Watermelon. . Large slice 300 .60 0.30 8.10 39 Apricots, dried 10 large 80 3.76 0.80 50.00 228 Dates 10 " 83 1.58 2.08 58.60 266 Figs. . 10 " 117 8.38 0.58 59.28 633 Prunes 10 very large 200 3.60 124.40 525 Raisins 10 " 25 0.57 0.75 17.13 80 Apple, baked 1 large 120 0.61 0.58 29.30 128 Apple, sauce 3 heap, tblspoon. 125 0.25 1.00 46.50 201 Cranberries, stewed Currant jelly 2 1 U U 100 35 0.27 0.36 0.41 36.00 27.16 153 113 Marmalade, orange Rhubarb, stewed 1 2 30 90 0.18 0.40 0.03 0.47 25.35 32.40 105 139 Rye bread 1 slice 39 3.51 .23 20.74 102 Graham bread . 1 " 37 3.29 0.67 1928 99 Biscuits, home-made. . . . Biscuits, soda 1 biscuit 1 35 38 3.05 3.53 0.91 5.21 19.36 19.99 100 145 Rolls, French 1 roll 39 3.32 0.98 21.72 112 Whole wheat 1 slice 42 4.07 0.38 20.87 106 Zwieback.. . . 1 15 1.47 1.49 11.03 65 Boston cracker (split) . . Graham cracker 1 cracker 1 10 8 1.10 0.80 0.85 0.75 7.11 5.9 42 34 Oyster cracker 10 crackers 11 1.24 1.16 7.76 48 Pretzels 1 pretzel 6 0.58 0.23 4.37 22 Educators, soda cracker . Uneeda biscuits 1 cracker 1 " 3 6 0.97 0.59 6.55 1.39 4.38 10 25 Chicken sandwiches .... Egg sandwich.. . . 1 sandwich 1 " 70 100 8.61 9.60 3.78 12.70 22.47 34.50 163 299 Ham sandwich 1 " 70 7.28 10.07 26.55 233 Cream toast 2 slices 136 9.03 14.60 37.15 325 Ingredients: 2 slices toast; 5 tblspoon. cream sauce. Grapenuts 5 heap, tblspoon. 65 7.78 0.40 51.51 247 Cornmeal mush 4 115 3.85 4.11 9.52 93 Ingredients: 2 table- spoons white corn meal; 2 cups milk. CALCULATION OF FUEL VALUES OF FOOD 261 VALUES OF THE ORDINARY FOODS PREPARED TO SERVE Continued FOODSTUFFS Quantity Weight (Cms.) Protein (Cms.) Fats (Gms.) Car- bohy- drates Total Calories Hominy, boiled 2 heap, tblspoon. 100 2.20 0.20 17.80 84 Indian meal mush 3 " " 115 2.10 1.18 18.50 96 Macaroni boiled 2 100 3.00 1.50 1580 91 Macaroni, baked with cheese; 2 140 19.06 20.46 43.44 447 Oatmeal, boiled... 2 " " 100 2.80 0.50 11 50 63 Puffed rice 5 " " 14 0.87 0.08 12.00 54 Rice, boiled. . i 100 2.80 0.10 24.40 112 Shredded wheat biscuit . Spaghetti, baked with tomato 1 biscuit 3 heap, tblspoon. 29 145 3.05 4.52 0.41 2.81 22.59 25.76 109 150 Apple pie Y pie 126 3.91 12.35 53.93 352 Custard pie H " 133 5.59 8.38 34.71 243 Lemon pie K " 110 3.96 11.11 41.14 288 Mince pie 1 A " 113 6.55 13.90 43.05 333 Squash pie K " 133 5.85 11.17 28.86 246 Bread pudding 2 heap, tblspoon. 105 5.52 4.79 38.48 225 Ingredients: 1 cup bread crumbs; 1 cup milk; 1 egg; ?& cup sugar; % cup raisins Baked custard. . 2 134 7.31 7.42 20.50 183 Ingredients : 2 cups milk; 2 eggs; % sugar. Soft custard 4 tblspoon. 60 4.39 6.84 12.12 131 Ingredients: Yolk 1 egg; 1/2 cup milk; 1 heap, tblspoon. sugar. Snow pudding 2 heap, tblspoon. 80 4.52 0.03 11.73 67 Ingredients: % cup water; 1 heap, tea- spoon gelatin; 2 h. tblspoon. sugar; 1 teaspoonlemon juice lemon rind; white 1 egg- Tapioca pudding. . . 3 " " 110 5.85 6.12 22.25 172 Ingredients: 2 cups milk; 1 egg, 3 table- spoons tapioca; 2 tablespoons sugar. Tapioca and apples.. . . . Ingredients: 9 small apples; 1 cup sugar % cup tapioca; 2 cups water. 2 " 100 0.21 0.22 28.58 120 117 262 THE CALORIC METHOD OF FEEDING VALUES OF THE ORDINARY FOODS PREPARED TO SERVE Continued FOODSTUFFS Quantity Weight (Gms.) Protein (Gms.) Fats (Gms.) Car- bohy- drates Total Calories Blancmange 2 heap, tblspoon. 90 4.76 4.91 16.83 134 Ingredients: 1 heap, tblspoon. corn- starch; 1 heap, tblspoon. sugar; 1 egg; 1 cup milk; 1 tblspoon. sherry Doughnuts . 1 doughnut 37 2.48 7.77 19.65 163 Egg souffle* }/2 souffle" 50 5.22 4.09 38.09 216 Ingredients: 2 eggs; l /% cup sugar; 1 table- spoon lemon juice Ice cream 2 heap, tblspoon. 100 5.21 10.16 17.73 189 Ingredients: 3 cups milk; 1 cup cream; 3 eggs; % cup sugar; vanilla Ladyfingers 1 20 1.76 1.00 14.12 74 Macaroons 1 10 0.65 1.52 6.52 44 Orange ice 2 heap, tblspoon. 100 0.94 0.23 74.68 312 Ingredients: 2% cups orange juice; Mcup lemon juice; \Yi cups sugar; 1 cup water; rind 2 oranges Prune souffle^ 2 85 3.31 0.65 18.95 97 Ingredients: % cup stewed prunes (edi- ble portion), white 1 egg. French dressing 1 dessert spoon 11 8.00 74 Ingredients : 4 tblspoon . olive oil; 1 tblspoon. vinegar; ^teaspoon salt; pepper. Mayonnaise dressing Ingredients: 2 eggs; 2 cups olive oil; 1 tblspoon. vinegar, or 1 tblspoon. lemon juice; salt, pepper, mustard. Honey 1 tblspoon. 1 " 21 30 0.2 .12 19.92 0.05 24.36 187 101 Cube sugar 1 cube 7 7.00 29 Domino sugar 1 domino 6 6.00 25 Granulated sugar 1 heap teaspoon 10 10.00 41 Powdered sugar j 12 12.00 49 Maple sugar. . 1 cake 100 82.80 339 Almonds 10 large 15 3.15 8.23 2.60 100 ( 'ALCTLATIOX OF FUEL VALUES OF FOOD 263 VALUES OF THE ORDINARY FOODS PREPARED TO SERVE Continued FOODSTUFFS Quantity Weight (Gms.) Protein (Gms.) Fats (Gms.) Car- bohy- drates Total Calories Brazil nuts 10 large 60 10.20 40.08 4.20 432 Chestnuts, roasted, as purchased 20 nuts 50 2.60 2.25 17.70 104 Cocoanut 1 slice 34 1.94 17.20 9.49 207 Filberts 10 nuts 10 1.56 6.53 1.30 72 Peanuts, as purchased . . Pecans.. 15 10 large 30 30 5.85 3.30 8.73 21.36 5.55 3.99 128 229 Walnuts 10 " 42 7.73 27.05 5.46 306 Cocoa 1 cup 227 9.08 15.53 23.85 279 Ingredients: 1 heap, tea- spoon cocoa; 1 heap, teaspoon sugar; % cup milk; 1 tblspoon. cream. Coffee or tea. ... 1 " 246 2.80 7.64 17.83 156 Ingredients % cup milk; 1 tblspoon. cream ; 2 cubes sugar; coffee or tea. Eeecnoe. 1 glass 270 13.00 12.85 29.50 294 Ingredients: 1 egg; 1 heap, tblspoon. sugar; % cup milk; 1 tblspoon. sherry. In discussing the energy obtained from different foods, it is important to distinguish between heat produced when substances are burned in the calorimeter and the heat that is available when used in the body, since it never happens that the combustible portion of a ration is entirely con- sumed in the body. The total food is never all digested, therefore it cannot all be absorbed and assimilated. Furthermore, the absorbed and assimilated proteins are never fully burned and there is usually an escape of unconsumed gases from the alimentary canal. As actual work is per- formed in the process of digestion, the term "net energy" has been intro- duced and applied to the amount of energy which is available after that used up in the digestion and preparation of the food for use in the body has been subtracted. In calculating the fuel value represented by a particular menu, one deals with several carbohydrates in various proportions ; similarly with fats and proteins derived from both animal and vegetable foods. Instead of computing the different foodstuffs separately, it will be found more convenient to use the average value given in the table on page 248 and 264 THE CALORIC METHOD OF FEEDING multiplying the total amounts of carbohydrate in the menu by this factor. The same may conveniently be done with the fats and proteins. The fuel value which any food represents is easily determined by using the factors in this table: Ascertain first the percentage of protein, fat and carbohydrate which the menu contains and multiply these several amounts by the factors given in this table; for example, oatmeal contains 7.6 per cent of water, 15.5 per cent of protein, 7.1 per cent of fat, 68.2 per cent of carbohydrates and 2 per cent of salts. One hundred grams of oatmeal represent energy, viz. : From protein 15.1 X 4.0 = 60.40 From fat 7.1 X 9.4 = 63.90 From carbohydrates . . . 68.2 X 4.0 = 272.80 ^ Total 397.10 The total fuel value of one pound of dry oatmeal is obtained by multi- plying this quantity by 4.5. The heat energy or fuel value of almost every known food is given in the table on page 702 (Analysis and Fuel Value of Foods, Volume I, Chapter XIX). These figures are suf- ficiently accurate for determining the caloric value of dietaries for insti- tutional purposes or in private practice. Method of Reckoning the Protein, Fat and Carbohydrate Rations for Diets of Definite Energy Values. Voit's dietary standard for a man at mod- erately hard work is calculated for 16 per cent of the energy to be fur- nished by protein, 18 per cent by fat, and 66 per cent by carbohydrate. Where the total fuel value of the ration represents 3,000 calories, according to Coleman, the calculation is made as follows : 16 per cent of 3,000 = . Q = 120 grams prctein 540 18 per cent of 3,000 = Q , = 57 grams fat 55 per cent of 3,000 = /Q = 495 grams carbohydrate By the employment of Coleman's method the rations may be quite accurately determined for diets of any given energy value. With the above facts before us it is easy to determine the caloric value contained in any food, provided the percentages of protein, fat and carbo- hydrate are known. These percentages multiplied by the figures given in FACTORS GOVERNING FOOD REQUIRED 265 the table previously referred to aiid their results added will give the number of calories in 100 grams of food. It* will not be such an arduous task to calculate the caloric value of a meal if one will remember the fuel values of the ordinary portions, viz.: roast beef, 357 calories; bread, 100 calories; butter, 150 calories; rice croquettes, 128 calories; a medium baked potato, 150 calories; tapioca pudding, 120 calories; sugar and cream with coffee, 100 calories which will total 1,105 calories for the meal, or about one-third of the day's requirements. FACTORS GOVERNING THE AMOUNT OF FOOD REQUIRED The amount of food required to keep any person in a normal state of health and bodily equilibrium differs according to various circumstances^ such, for instance, as the condition of rest or work, the kind of work, the training, the age, sex, size and weight of the body, restlessness or placidity, and even the individual peculiarities of the person. As an illustration, we will consider the body as an engine and the food consumed as the fuel for the engine. It has been proved as far as possible that the laws of conservation of matter and energy are followed by the human organism as they are in the engine; the body loses matter and energy, but they undergo transformation and are not destroyed in the body. Reasoning on this analogy, it may be assumed that whatever material is used in the body and however much energy is exhibited or heat evolved by it, both matter and energy have been derived from the food consumed in the process of digestion and assimilation and stored in the tissues. Amount of Heat Lost by Body It is known that the heat of the body is generated by the oxidation of food or tissue substances, and also that the food required is proportional to the extent of the surface of the body. For instance, a small animal gives off, weight for weight, more heat than a large one. A large animal has a smaller cutaneous surface in pro- portion to size and weight than a small one, and a small animal a rela- tively larger surface area than a large one. For these reasons, it will be seen at a glance that a thin, angular, lean, lanky person loses more heat, according to weight, than a larger and more rotund person, a thin, premature infant more than a plump and well-developed child. After a consideration of many experiments on animals and human beings, Camerer came to the conclusion that an. infant expendc 100 calories, a child of 4 years expends 91.3 calories, a child of 12 years expends 57.7 calories and a man of 30 years expends 42.4 calories per kilogram of body weight. Consequently, the amount of heat lost by the body is an 266 THE CALORIC METHOD OF FEEDIXG important factor in the regulation of food, and to a great extent this is f governed by the area of the body surface. Weight of Body. The amount of food required by the body, other things being equal, must be proportional to the weight of the body. The bodily heat is produced by the oxidation of food consumed or stored in the tissues. In a condition of rest, the tissues of the body are not called on for the production of heat and energy, but still there must be a mini- mum of food consumed to supply the energy utilized by, and the heat radiated from, the body. In a state of rest, a man of 154 pounds weight gives off 15 cubic feet of carbon dioxid in a period of 24 hours. The production of 1 cubic foot of carbon dioxid by combustion is accompanied by a liberation of heat equivalent to 160 foot-tons of energy, therefore 15 X 160 = 2,400 foot-tons of energy which are necessary to the main- tenance of the body temperature and the performance of bodily functions during the state of rest. Therefore 1 calorie is equal to 1.54 foot-tons of energy, and 2,400 foot-tons is equal to about 3,696 calories for a person weighing 154 pounds. Age. According to Huebner(13), the younger the animal organism, the more rapid is the rate of growth. For instance, a child's body grows seven times more rapidly from one to three months than from six to nine months of age. It is correctly asserted that a child commonly loses a little weight for a few days after birth; but the average increase of weight up to three months is 3.6 pounds; from the third to the sixth month, 3.6 pounds; from the sixth to the ninth month, 3.4 pounds; and from the ninth to the twelfth month, 3 pounds. So the amount of food required by a normal child is in proportion to its rate of growth. Further consideration of food in childhood will be found in Volume II, Chap- ter XL Sex In anthropometric tables (14) that have been carefully com- piled, the following data appear: (a) The most rapid growth occurs dur- ing the first five years after birth. In the first year the weight is trebled, in the second year it is nearly doubled. During this period the rate of growth is nearly identical in both sexes, only that boys are a little taller and heavier than girls. (6) During the next period, from five to ten years, the growth of boys is more rapid than that of girls, the weight of the former being from 2 to 3 pounds more, on the average, (c) During the third period, from ten to fifteen years, conditions are changed, the growth of girls taking the lead. From the age of twelve and a half to fourteen and a half years girls are taller than boys, and from the age of twelve and a half to fifteen and a half years their weight exceeds that FACTOKS GOVEK.MNG FOOD HEQUIKED 267 of boys of the same age by 3 or 4 pounds, (d) During the period from fifteen to twenty years, boys again come to the fore, and grow more rapidly than girls; the weight of boys increases yearly at the rate of 6.0 pounds, while that of girls is 2.75 pounds, (e) At the age of twenty- three years, boys have attained the limit of growth in height, but in breadth and weight they continue to increase. Girls, on the other hand, at about twenty years of age have attained their full height and weight, the latter remaining practically stationary until the age of twenty-five or even thirty years. (/) In general, adults begin to increase in weight after thirty-five years of age at the annual rate of three-quarters of a pound, a change most often unwelcome and not of advantage. The rela- tive weights of men and women of the same age vary with the height, up to the height of 67 inches, men as a rule weighing more than women; but when over 67 inches in height, women are generally heavier than men of the same height and age, and especially after middle life the weight of women may greatly increase. The generally accepted statement that the quantity of food ingested should be regulated by the size and weight of the body, offers no excep- tion as regards the food of individuals of different sexes; the normal height and weight of a woman being less than those of a man, a smaller quantity of food than that required by a man should meet the needs of the average woman. An important point to note is that this smaller metabolism of food should be looked at from the standpoint of the per- sonal equation relating to the sex of the individual, rather than the nor- mally lower average size and weight of a woman. The following table illustrates this fact by showing the difference in the quantity of food taken daily by an active man and woman of identical age and height who were able to maintain their nutritive and nitrogenous equilibrium upon the amounts here designated: Protein Fat Carbohydrate Cal. Man 100 gm. 70 gm. 400 gm. 2,700 Woman 60 gm. 67 gm. 340 gm. 2,263 Atwater established the principle that the daily ration for a healthy woman should be 0.8 of that of a man. As a general rule, it is usually held that a woman requires about the same amount of protein and energy, weight for weight, as a man under similar circumstances. The amount of energy required to execute a definite amount of work is the same, whether it is performed by a woman or is done by a man ; consequently, the supply of food should be the same. Tibbies says: "On the other hand, 268 it frequently happens that the expenditure of energy on the part of a woman to produce a definite amount of work is greater than that ex- pended by a man doing the same identical work." FOOD REQUIREMENTS AS INFLUENCED BY THE INTERNAL, SECRETIONS OF WOMAN. It is claimed that the internal secretion of the ovaries facili- tates the oxidation of carbohydrates and the organized phosphorus of the food. There are other circumstances in the life of a woman which influ- ence the demand for food. We know that their sex is subject to a wave of metabolic activity which is at its highest just before each menstrual period. During this metabolic disturbance the organism calls for an increase in the nitrogen metabolism, and a decrease in the carbon metab- olism. There also appears at this time the formation of new blood cells, with an increasing amount of nerve force and general vigor. During the menstrual epoch there is a small loss of weight due to the increased excre- tion of carbonic acid and water, although the protein metabolism is diminished. There is an increase in weight during pregnancy, notwith- standing the increased combustion of non-nitrogenous elements; there is usually an increase in the size of the organs of lactation and parturition and a deposition of fat in the adipose tissue. These metabolic changes call for an increased amount of food to the daily ration, which practically means that the woman should consume about double the ordinary amount of protein, and have a greatly increased amount of the fuel foods. Kind of Work. The quantity of food necessary for an adult must be regulated rather by the amount of work performed than by the size, weight or other characteristics of the body. These requirements of the body are analogous to those of a machine, and well they may be, as the body itself is a living machine. It is a truism that the greater the expen- diture of energy by a machine in the performance of work, the more fuel it will demand for the generation of that energy. The human machinery performs work of two types, internal and external work. The internal work consists of that done by the organs of digestion, respiration and circulation, by the neuro-muscular system which maintains the body temperature, and muscle tone; and by the glandular system in keeping up the supply of the secretions and excre- tions. The external work includes the activities of the voluntary mus- cular system and the process of heat radiation from the body. According to Atwater's experiments, a man at rest in the respiratory calorimeter liberated during two hours 150 calories; while working a stationary bicycle for two hours, 500 calories ; and while working the same machine against resistance for a period of two hours, 1,000 calories. It follows, .FACTORS GOYKKXiNG FOOD KEQUJKEI) 269 therefore, that the supply of food must keep pace with the. amount of work to be done, or else the body tissues themselves will be used up as fuel for the generation of the energy expended. Choice of Food. The necessity for increasing the allowance of food in proportion to the amount of work the body is expected to do has always been recognized. Many research workers have made observation upon the food consumed by individuals who were allowed a free choice of food, and found that, with diets having the fuel values in "Standard Die- taries," nutrition of such individuals was fairly normal and the nitrogen balance in the state of equilibrium. They concluded, therefore, that the menus given fairly well represented the aliment required by these persons. A close study of the table 1 on page 270 shows that when Americans and Europeans are free to choose their own food, they seldom select that which will yield less than 100 grams of protein per day. When the choice of food rests with the individual, it is often found upon observation that a male rarely consumes less than 90 grams of protein per day. For economic and other reasons, there are many thousands who necessarily consume a much smaller quantity, because meat, fish, fowl, milk, eggs and cheese are dearer than bread, potatoes, rice, oatmeal, etc. Maurel(15), who has devoted much attention to the subject, claims that, "to maintain the body in nitrogen equilibrium when no muscular work is being performed, an adult in full health and vigor weighing 154 pounds requires for maintenance 105 grams of protein in a ration yielding about 2,600 calories of energy; a woman weighing 132 pounds requires 90 grams of protein in a ration yielding about 2,200 calories of energy." Our experience leads us to assert that these figures are probably very near the mark. Kubner, in studying the specific dynamic action of foodstuffs, came to the conclusion that each type of food seemed to exert a more or less specific action upon the energy yielded ; "so that, when the foodstuffs were fed separately, somewhat different energy values were required for the maintenance of body equilibrium." He observed a man who metabolized in fasting 2,042 calories; and when fed, 2,450 calories; in the form of sugar alone he metabolized 2,087 calories ; when fed 2,450 calories in the form of meat alone, he metabolized 2,566 calories. This experiment clearly shows that the eating of protein increased the metabolism far more than could be done by eating the same number of calories in the form of carbohydrate and fat. Rnbner believes that this specific dynamic notion of protein involves the liberation of energy which has not come to i Bulletin No. 52, p. 24, U. S. Dept. of Agric., and other sources. 270 THE CALO1UC METHOD OF FEEDING _. I O 53 ll - . ' O ( - ll I 0> i02 03 1 wfflW " . .1 1 US-Si O CS -H ^ CO O COCOC-1X^CC(MOO I-H O co'co'co'co^co"^^^ co~"tf~ OOt^ O O O5 O5 Tt< O i 'O andard d FACTORS GOVKKXIXt; FOOD REQUIRED 271 the surface of the tissues and which does not directly contribute to the support of their activities, although it aids in the maintenance of the body temperature. This apparent loss of a part of the fuel value of protein of an ordinary mixed diet is not a very important factor in the total body metabolism, since this specific dynamic action and the work of digestion and assimilation together make the total daily metabolism of energy only about one-tenth higher on a maintenance ration than when no food is eaten (Sherman). Intensity of Muscular Activity. In practice, it will often be difficult to estimate the mechanical equivalent of muscular work performed and still it is often necessary to make use of such indefinite terms as "active," "severe," etc., to describe the intensity of the exertion, and thus indicate in a general way the amount of work performed. Atwater and Benedict (16), after a great deal of research and experi- mentation, epitomized the results of many work experiments w r ith vigor- ous young men in the respiratory calorimeter, and have derived the follow- ing estimates of the average rates of metabolism, under different condi- tions of activity : Man sleeping 65 calories per hour Man sitting at rest 100 " " " Man at light muscular exercise 170 " " Man at active muscular exercise 290 " " Man at very severe muscular exercise. . 600 From these estimates the requisite rations may be calculated as fol- lows : 8 hours of sleep at 65 calories equal 520 calories 2 hours' light exercise at 170 calories equal .... 340 " 8 hoiirs* active exercise at 200 calories equal. . 2,320 " 6 hours' sitting at rest at 100 calories equal. . . 600 " Total food requirement for the day 3,780 calories If the working day be spent in severe muscular exertions, the day's ration would be estimated at 5,060 calories. The requisite amount of calories for one in sedentary occupation, such as sitting at a desk, would require only 2,260 calories. Tigerstedt(17) gives the following estimates of food requirements for 272 THE CALORIC METHOD OF FEEDING different occupations, indicating the intensity of work performed and the caloric needs: 2,001-2,400 calories suffice for a shoemaker 2,401-2,700 " " for a weaver 2,701-3,200 " " for a carpenter or mason 3,201-4,100 " " for a farm laborer 4,101-5,000 " " for an excavator Over 5,000 " " for a lumberman Graham Lusk(18) gives the following estimate of food in calories for the requisite occupations of women: 1,800 calories suffice for a seamstress using a needle 1,900-2,100 calories suffice for a seamstress using a machine 1,900-2,100 " " for bookbinders 2,300-2,900 " " for household servants 2,600-3,400 " " for washerwomen Food requirements for occupations of men : 2,400-2,500 calories suffice for a tailor 2,700-2,800 " " for a bookbinder 3,100-3,200 " " for metal workers 3,200-3,300 " " for a painter 4,300-4,700 " " for stonemasons 5,000-5,400 " " for wood-sawyers The estimated amount of food in calories for wood-sawyers emphasizes the fact that "wood-sawing is a strenuous occupation." This proverbial occupation has a scientific verification in the above statement and explains the disinclination of the hungry to engage in this useful occupation as well as the unpopularity of charitable wood yards. On page 273 we give a table, taken from Lusk(19), of food values with cost per 1,000 calories for various fundamental foodstuffs and the per- centage of protein contained in 1,000 calories. The foods in the following table were purchased on the New York mar- kets at the prices named. If the expense of cooking and serving and other overhead charges be included, the cost somewhat increases. Thus, at Childs' and other similar restaurants in New York, a portion of pork and beans served with three slices of bread and a pat of butter costs 20 cents, representing a well-balanced ration of 1,000 calories. The same could be FACTORS GOVERNING FOOD REQUIRED FOOD VALUES WITH COST PER 1,000 CALORIES 273 FOODS Cost in cents per 1,000 calories Per cent of calories in protein Glucose 1% Corn meal 2 8 Wheat flour VA 12 Oatmeal 2 4 /B 13 Cane sugar 3U Dried beans 4 19 Salt pork (fat) 4^2 1 Rice 5 7 Wheat bread 5U 12 Oleomargarine 1 1 A Potatoes IVi 8 Butter 10 Milk 10 17 Smoked ham 10M 34 Cheese n% 25 Loin pork 1214 18 Leg of mutton 16M 30 Sirloin beef 24 37 Turkey ... 40*4 37 served in the home at a cost of about 10 cents, and most people, after ingesting such a repast would feel comfortably satisfied. Of course, it is understood that this menu would not satisfy everybody, especially not those in the upper classes who demand the luxuries of the world without rendering to the world an equivalent therefor. Before leaving the subject of the relation of muscular activity to metabolism, it may be well to point out that the expenditure of energy in the muscular system does not depend simply upon the muscular move- ments performed, but to a considerable extent upon the degree of tension or tone maintained in the muscle while in a condition of rest. It is obvious to the surgeon that every living muscle is always in a state of tension from the fact that it gapes when its muscular sheath is cut. It is equally true that the degree of tension varies greatly under different con- ditions. Atwater and Benedict observed the differences between the metabolism of sleeping hours and that of the hours spent sitting up with- out muscular movements which are due largely to the more complete relaxation of the muscles during sleep. From this we find that there is in the resting muscles continual expenditure of energy which takes the form of muscular tension or tone, but ultimately appears as heat, so that the heat production or energy metabolism of the body in a condition of rest depends largely upon the degree of tension which normally exists in the muscle. 274 THE CALORIC METHOD OF FEEDING REGULATION OF BODY TEMPERATURE The regulation of body temperature has been most ably discussed by Lusk(19), who avers that the maintenance of body heat beyond that of its usual environment requires a, continual output of energy. This outgo of heat is controlled by mechanisms which permit of (a) variations in the reduction of temperature due to the quantity of blood Drought to the surface of the skin radiation, conduction and sweating which is termed physical regulation; and (&) by variations in heat production brought about by an increase in the rate of oxidation in the body in response to the stimulus of external cold, which is termed chemical regulation. The increase in heat production following the ingestion of food (already con- sidered in the previous pages of this work) may take the place of "chem- ical regulation" and thereby aid in the protection of loss of body tempera- ture. The presence of a cushion of adipose tissue under the skin, together with suitable clothing for the external surface of the body also helps to keep down the loss of heat to the minimum of "physical regulation." A sudden change downward in the external temperature increases the heat formation, augments the excretion of carbon dixoid, and the consumption of oxygen in warm blooded animals. A sudden change upward in the atmospheric temperature increases metabolism in warm- blooded animals, and this change is greater if the animal be placed in hot or cold water than if it be merely subjected to the influence of hot or cold air. Von Noorden(20) explains the significance of an increase in heat production in cold weather, as due to extra precautions food, clothing, etc. to offset the increased heat losses incidental to the external tempera- ture. Senator was the first to offer an explanation of this phenomenon. He held that the increased excretion of carbon dioxid was due to active muscular movements. No one at present questions but that there is an increase of about 100 per cent in carbon dioxid excretion after a cold bath, which is due, no doubt, to active muscular movements. It may be questioned that there may be a slight rise in carbon dioxid excretion without any visible movement or alteration in the tension of the muscles. The question of an involuntary heat regulation has been definitely settled by Voit's animal experiments and also confirmed by Rubner's studies. The latter studied the metabolism of a man who was kept in the same cold room with different amounts of clothing, and he observed that when the subject was clothed sufficiently to be comfortable the "chemical regulation" was eliminated. Rubner emphasized the fact that suppres- REGULATION OF BODY TEMPERATURE 275 sion of shivering and the inhibition of muscular activity when subjected to external cold is an unnatural condition for a person subjected to great cold, and one that never occurs normally. Physical Heat Regulation.- An increase in heat dissipation by means of conduction, radiation and evaporation comes into play as Nature's means of avoiding overheating; a diminution, on the other hand, pre- vents lowering of the body temperature. The amount of heat present in the body falls under the influence of cold, and it does not rise, even when the individual is placed in a warm bed, until active movements again furnish the necessary amount of heat to raise the temperature to normal. (Johansson.) Chemical Heat Regulation Chemical heat regulation, like physical heat regulation, reaches a limit below which it cannot go. According to von Noorden, "The chemical energy set free in vital processes which is inseparably associated with the development of heat, cannot go below a certain limit. Only that form of heat production previously referred to as being associated with increased functional capacity of working organs can be excluded." The extra heat required during cold weather is, in all probability, derived in most part through the activity of the muscles. It is a matter of every-day occurrence, in cold climates during winter weather, to see a man, a wagon-driver, for instance, stop and strenuously exercise his arms if he did Jiot do this, he would sit on the driver's box and shiver a peculiar form of voluntary muscular activity whose function seems to be to increase heat production through increasing the internal work of the body. After all, it will be seen that the regulation of body temperature, even nnder exposure to cold, is brought about by the activity and tension of the muscles, the relation of which to metabolism and food requirement has just been considered. Voit, in a discussion on the 'Tieat balance" in warm and cold climates during both winter and summer, says that involuntary chemical heat regulation in the cold, which he admits exists within certain limits, is insufficient in the frozen, zone. Here the inhabitants in addition to being clothed in furs, are driven to strenuous exercise in order to maintain body temperature. Only in so far as the movements increased are the food requirements augmented in the Arctic regions. The same law holds good in tropical countries the food is lessened and the inhabitants move along the lines of least resistance. The enormous amount of food which the Eskimo can ingest with impunity has already been referred to, and emphasizes the point of the greater functional capacity of the alimentary 276 THE CALORIC METHOD OF FEEDING canal in the natives of cold countries, as compared with the abstemious- ness of the Arab and his ability to greater endurance of hunger and' thirst. Our digestive system and nervous mechanism which controls it are affected both by heat and cold, and as a result most people consume more food in winter than in summer, although the body requirements remain practically the same all the time. The Surface Areas of the Skin in Heat Regulation. The greatest loss of heat is from the body surface. Fully 90 per cent and upward of the whole amount takes place by radiation, conduction and evaporation from the skin. The actual figures are given in. a tabulation on the next page. The reason the skin is able to act as one of the most important organs for regulating body temperature are: (a) that it offers a large surface for radiation, (&) it contains a large amount of blood, and (c) the quantity of the circulating fluid is greater under the circumstances which demand a loss of heat and vice versa. The effects of a hot atmosphere on the skin surface, through the nerve fibers, causes a relaxation of the muscular fibers of the blood vessels ; and, as a result, the skin becomes full-blooded, hot and sweating leading to much loss of heat. On the other hand, with a low temperature, the blood vessels shrink, the skin becomes pale and cold and dry ; thus by means of a self-regulating apparatus, the skin is the most important organ for the regulation of body temperature. It is a recognized fact that size, height and weight are important factors in heat regulation. Actual experiments upon animals, says Howell, "show that small animals produce more heat in proportion to their weight than larger animals of the same species, owing to the relatively larger surface, and, therefore, greater loss of heat." This point was first emphasized by Riibner and, according to his law, the metabolism is pro- portional to the surface area of the body, or, in other words, for the same amount of surface area there will be the same production of heat. On the following page will be found a table giving the surface area in square meters of people of different heights and weights, showing the requisite calories during a 24-hour period, to which we will refer later. Regulation of Heat loss The regulation of heat loss is the most important problem which the physiologists of to-day have to elucidate (21). Experiments plainly show that heat regulation is very complex ; the body, as we have just emphasized, possesses a means of controlling heat loss as well as the production of heat, and under normal conditions both func- tions are in active use. REGULATION OF BODY TEMPERATURE 277 b sf 4J 02 t/r o o ." 13 "3 CJ bC bC 1 i +i~ -d J 2 ^ a a 3 S T oT ^ d "3 1 g O 0? S3 '3 3 o o T3 a ^3 ^ | a '+3 ;_ II 11 o S amount ol 3 a g 8 ci a X t: 1 o> & a o jf s .a > u, g > E & b I CO ^s .a^ c3 O SH Q CO a 43 i 1 11 K G M 9 O o 49 S3 - l 13 g | 1 o rt 1 f| 2 g I'-S o -bb;g S M 3 -*-* +* 2 +-> ^"^ <3^3^3^^3 S3 3 bC hC oj hC^g GO CO S CO ^Pnl^ ^ CO CO coco^coH *-. .-> O i ^3 G 13 ^ 3 o a; a> o -^ 'J3 g 3 IN 1 1 O ^ >4 OO ^H > 1 LO o O5 ^f O5 O5 CO ^^ *O i-O CO >O b- 00 O CO -2 ^ -g'ot: 1-H i-H CO ~i iO *O 00 OOt>I>. t*^ C 1 -! ^^ I s * o S CO (N CO U5 O5 !> t !>. 00 00 U ag S |-|s CO CO o o o o i_O (^ *O ^H 1 00 00 S O O O5 CO O iO O CO CO OO O5 O5 O5 OO l>- K g IN (N (N (N (N (N (N (N IN - CO CO iO iO OO - Tt< CO CO CD O IO *" .bC g' 00 00 o- 00 00 CO O I-H CO O CO CO g i-H T"* (N (N O5 w S3 a * rj o w S3 Q 1 < h 1 sL 00 t5 = co [> [> cJ ^ ^_o gco " CO ...> o3^ .oo i-H i-H i-H i-H CO ^ O CO t^. 118 278 THE CALORIC METHOD OF FEEDIXG As we have already seen, heat loss from our bodies is accounted for as follows : (a) From expirations from the lungs. (6) By evaporation of sweat from the skin. (c) By conduction and radiation from the skin. (d) Through the excreta, urine, feces, saliva. The approximate percentages of heat lost in this manner, according to Vierodt, are as follows: (a) From expirations from lungs 3.5 per cent or 84 cal. (6) Vaporization of water from lungs 7.2 " 182 " (c) By evaporation from the skin 14.5 " " " 364 " (d) By conduction and radiation from skin 73.0 " " "1,792 " (e) By urine and feces 1.8 " 48 Total daily loss 2,470 cal. Howell, in commenting on this observation, says the relative import- ance of these factors will, of course, vary with conditions; for instance, a high external temperature will aid in the diminishing loss from radia- tion, while increasing that from evaporation, owing to the greater pro- duction of sweat. Many examples may be given of the power which the body possesses of resisting the effects of a high temperature, in virtue of evaporation from the skin. Blagden and others supported a temperature varying between 92-100 C. (198-212 T.) in dry air for several minutes; and in a subsequent experiment the former remained eight minutes in a temperature of 126.5 C. (260 F.). According to Carpenter: The workmen of Sir F. Chantrey were accustomed to enter a furnace, ' in which his molds were dried, while the floor was red hot, and a thermometer in the air stood at 177.8 C. (350 F.), and Chabert, the fire-king, was in the habit of entering an oven, the temperature of which was from 205-315 C. (400- 600 F.) (Carpenter.) But such heats are not tolerable when the air is moist as well as hot, though this condition prevents evaporation from the body. C. James states that, in the vapor baths of Nero, he was almost suffocated in a tem- perature of 44.5 C. (112 F.), while in the caves of Testaccio, in which the air is dry, he was but little incommoded by a temperature of 80 C. (176 F.). In the former, evaporation from the skin was impossible; in the latter it was abundant, and the layer of vapor which would rise from all the surface of the body would, by its slowly conducting power, REGULATION OF BODY TEMPEKATUHE 279 defend it for a time from the full action of the external heat. (Kirk's "Handbook of Physiology.") Under ordinary conditions we are able by suitable clothing to increase or diminish the amount of heat lost by the skin. The ways by which the skin may be rendered more efficient as a cooling apparatus, too, by ex- posure, by baths, and by other means which man instinctively adopts for lowering his temperature when necessary, are too well known to require more than passing mention. Production of Heat During Rest The production of heat during rest varies in different individuals according to height, weight, to the super- ficial area of their bodies, and to their condition of health. In the following table is reproduced the metabolism of adult males per minute worked out according to Zunt's method. The subjects of these experiments were in absolute muscular rest during the observation. The age, height and weight are recorded, the respiratory quotient ascer- tained, and the total calories for the twenty-four hours estimated and the calories per hour per kilogram of body weight. The minimum resting metabolism is estimated by measurement of the gaseous interchange during sleep or during fasting, at least twelve hours after the ingestion of food. Von Noorden(20) in his research on this point "replaces the quantity of carbon dioxid excreted by the heat factor which can be deduced from the ratio existing between the quantity of carbon dioxid eliminated and the amount of heat formed during twenty-four hours." Atwater's calori- metric experiments are especially valuable, both on account of the care with which they were carried out and by reason of their repeated repetition. The table on the following page shows height, weight and the area of body surface in square meters, the calories per hour per kilogram of body weight and total calories for the twenty-four hour period. Even these numbers derived from resting metabolism, possibly do not represent the minimal metabolism during rest, since deep sleep does not usually extend over more than from six to eight hours. Resume. From previous discussion of this subject, it will be observed that although individuals of excessive weight have a greater metabolism than those of slighter build, yet the metabolism, according to von Noorden, does not increase in direct proportion to weight, but less rapidly. There- fore, when considering the unit of weight to metabolism, it is well to recol- lect it is usually smaller in the case of heavy than of light individuals. It will be seen, from carefully studying the table, that absolute metabolism does not run parallel with body weight, but more nearly proportionally 280 THE CALORIC METHOD OF FEEDING O H- 1 e Q O W ? EH o 02 Q O Q tf & 'U o O o w 02 Constitution ^ bC l"| * ' >> O2 b .e8 f3 4i ^> *< t 522-3 ^l t p 5 _s i o f-< +? a|| 1 i? S > I 3 M _ PH b o ^~* c5 ll se - M i fe "* -H O O Oi Oi S O Ci iO Oi c ^ a - c3 'ri ,} =3 1 ( o o I I 03 ^ oj ' 9 CO ~H CO O Oi O CO iO IO IO CO Tt< CO -H 5 * co 00 iO o CO S o""* (N (M 3 ^ OiT* 00 (N O iO O iO iO (M CD CO * Tf< Q d o CO CO (M 00 00 (N 00 (N - r-i oi oo : co * CO 10 :t^ NS- TJ.CO CO ^ CO CO CO CO CO (N CO CO C' gg CO CO CO CO CO CO (M CO CO CO * CO 1 00 oo g So ifr co : iO os its ; co ; 10 0 00 ^ CO |g CO 00 iO iO iO iO CO CO CO CO CO (M l^. 00 GO GO 00 |? OOx-> CO CO O "H - >o 00 J5 W^ cu be eS ^ O CO CO C<1 JT^CO *O CO CO iO COC.^-^ - 00 Oi 1 I ? 1 i-H CO i-H 1 1 REGULATION OF BODY TEMPERATURE 281 with the surface area of the body. Bergman was convinced of this fact several decades ago, and Rubner and von Noorden have confirmed it by numerous experiments. Again we reiterate that a tall thin man has a greater area of body surface for a given weight than a short stout man. "Besides, normal men may vary as much as 10 per cent from the average in relation of surface area to body weight. The spare thin man, besides having a greater surface area, also differs from the stout short man in that he has a greater per- centage of actual protoplasm." Now, since the metabolism of the body depends upon its weight of protoplasm (active tissue) rather than total corporeal weight, we have here, according to Sherman (4), an important reason for assuming that the food requirement will be greater in the tall than in the short individual of the same weight. Von Noorden tested this question by observing two individuals of the same weight but different build for a period of one day. His results were as follows : Thin man Weight, 71.0 kilo., 2,392 cal., 33.6 cal. per kilo. Stout man Weight, 73.6 kilo., 2,136 cal., 29.0 cal. per kilo. Finally, for the majority of individuals, it will be safe in calculating a dietary to proceed as if the form, height, weight and body surface area were constant without falling into serious error. REFERENCES 1. ATWATER. Methods and Results of Investigations on the Chemistry and Economy of Food, Office of Exper. Sta., U. S. Dept. Agric., 1895, Bull. No. 21; Neue Versuche ueber Stoff- und Kraft- wechsel, Ergebn. d. Physiol., vol. iii, 1904. 2. LAXGWORTHY. Digest of Metabolism, U. S. Dept. of Agric., 1898, Exper. Bull. No. 45. 3. AT WATER and SXELL. J. Amer. Chem. Soc., July, 1903. 4. SHERMAN. Chemistry of Food and Nutrition. 5. HALL, WINFIELD S. Nutrition and Dietetics, New York, 1913. f>. RI-BXER. Ztsch. f. Biol., 1885, vol. xxi, pp. 2:>0-:>r>7. 7. CHITTENDEX. The Nutrition of Man. 8. TIBBLES, WILLIAM. Food in Health and Disease. 9. RUBNER. Ztsch. f. Biol., vol. xlii. 10. BEAUMONT. Physiology of Digestion, pp. 9-115, Plattsburgh, 1833, Amer. J. Physiol. 1, p. 374, 1898. 282 THE CALORIC METHOD OF FEEDING 11. CANNON, W. 13. The Mechanical Factors of Digestion, New York, 1911. 12. LOCKE, E. A. Food Values, pub. by D. Appleton & Co., 1915. 13. HUEBNER. Deutsch. nied. Wochenschr. 14. TIBBLES. Loc cit., p. 86. 15. MAUREL. Rev. Soc. scient d'hyg. aliment., 1906. 16. AT WATER and BENEDICT. Exper. Sta., U. S. Dept. Agric., Bull. Nos. 44, 63, 69, 109, 136. IT. TIGERSTEDT. Text-book of Physiology. 18. LUSK, GRAHAM. Med. Rec., April 25th, 1914. 19. . The Elements of the Science of Nutrition. 20. VON NOORDEN. Metabolism and Practical Medicine. 21. HOWELL, W. H. Text-book of Physiology. BIBLIOGRAPHY ABDERHALDEN. Handbuch der biochemischen Arbeitsmethoden, 1910, Bd. III. ARMSBY. Principles of Animal Nutrition, Chaps. 7 to 10. ATWATER. Methods and Results of Investigation on the Chemistry and Economy of Food, Office of Exper. Sta., U. S. Dept. of Agric., 1895, Bull. No. 21. . Ibid. . Neue Yersuche ueber Stoff- und Kraftwechsel, Ergeb. d. Physiol. 3, 1904. and LANGWORTHY. A Digest of Metabolism Experiments, U. S. Dept. of Agric., 1898, Bull. No. 45, Office of Exper. Sta. - and BENEDICT. A Respiration Calorimeter with Appliances for the Direct Determination of Oxygen, Carnegie Institution of Washington, 1905, Pub. No. 126. BENEDICT and CARPENTER. The Metabolism and Energy Transforma- tions of Healthy Men During Rest. Ibid. FISHER. A New Method for Indicating Food Values, A. J. Physiol., vol. xv, 417. LUSK. Elements of the Science of Nutrition, 2d ed., 1909, pp. 17-45. MENDEL and SWARTZ. The Physiological Utilization of Some Complex Carbohydrates, A. J. Med. Sci., March, 1910. MURLIN. The Nutritive Value of Gelatin, Am. J. Physiol., xix, 285-313 ; xx, 234-258, 1907-1908. BIBLIOGRAPHY 283 NAGEL. Handbuch der Physiologic des Menschen, 1909, pp. 331-375. OPPENHEIMER. Handbuch der Biochemie, II, 1-92. REITZ and MITCHELL. On the Metabolism Experiment as a Statistical Problem, J. Biol. Chem., 8, 297-326, 190. RUBNER. Der Energiewert der Kost des Menschen, Ztsch. f. Biol. (n. f.), 24, 201-308 (901). . Die Gesetze des Energieverbrauches bei der Ernahrung (1902). TALLQVIST. Zur Frage des Einflusses von Fett and Kohlenhydrat auf den Eiweissumsatz. TIGEBSTEDT. Text-book of Physiology, 1906, Chapter 4. VOIT. Arch. f. Hyg., 41, 1902, 177-189. - and ZISTERER. Bedingt die verschiedene Zusammensetzung der Eiweisskorper auch einen Unterschied in ihrem Nahrwert ? Ztschr. f. Biol. (N. F.) VON !N"ooRDEx. Metabolism and Practical Medicine, vol. i, pp. 185-207. WATSON and HUNTER. Observations on Diet. The Influence of Diet on Growth and Nutrition, J. Physiol., vol. xxxiv, pp. 111-132, 1906. CHAPTEE X GENERAL NUTRITION AND MINERAL METABOLISM General Considerations. Metabolism: Anabolism and Catabolism. Metabolism Experiments: Balance of Income and Outgo; Respiratory Quotient. Factors Which Affect Metabolism: Consumption of Food; Fasting; Effect of Nitrogenous Diet on Metabolism; Carbohydrates as Protein Sparers; Fat Versus Carbohydrates as Protein Sparers; Gelatin as a Protein Sparer; Alcohol as a Protein Sparer; Metabolism of Water; Metabolism of Mineral Substances; Acid-Forming and Base-Forming Elements. GENERAL CONSIDERATIONS In the study of metabolism, we become acquainted with the exchanges of material by which vital phenomena are produced, and the conversion of chemical force into "living energy." The various metabolic processes are not the same in all organs and tissues. For instance, the functions of the liver and of the pancreas are distinctly different. Valuable data have been obtained by physiologists who have painstakingly studied the meta- bolic changes in isolated parts of the body. By the maintenance of arti- ficial circulation through "surviving" organs, completely severed from their normal relations, the life, of the cells may be continued for many hours. Chemical examination of such tissues has thrown light on their metabolic processes ; under such conditions changes in the composition of the nutrients in the circulating medium point to the nutrient demands, the waste, or the specific elaborations of the cells. Furthermore, by the exclusion of individual organs, their normal activity may be inferred from the absence of certain functions. The metabolic work of the spleen, kidneys and thyroid has been studied by observations on individuals who have in whole or in part, been deprived of these organs through surgical intervention. Moreover, the changes in metabolism which go hand-iu- hand with diverse pathological conditions of the body have also con- tributed to our understanding of the subject. 285 286 It is readily understood that many difficulties beset the path of the investigator who studies the metabolism of individual organs, although the problems involved are of the greatest importance in physiology. Pro- fessor Lafayette B. Mendel, in discussing this question, says : The income (food and oxygen) and the outgo (excretions, urine and feces) have been determined with accuracy, under the most varied conditions, while the understanding of the intermediate processes is still largely a matter of "gaps and guesses." The body is constantly undergoing losses, which must be made good sooner or later. New material must be contributed to replace the wear and tear of the body. Certain losses may only be temporary, as in the secretion of milk, the production of eggs, the ejection of semen, and the menstrual flow, all of which, however, are relatively of little importance. The lungs give off carbon dioxid and water, the kidneys water, inorganic salts and nitrogenous compounds. The skin eliminates water and inorganic salts and traces of nitrogenous compounds, and with the feces there is excreted a residue of the digestive secretions, waste from the alimentary canal and indigestible particles of food. METABOLISM In the study of the intricate processes of digestion, assimilation and absorption, we traced the food through the digestive tract, and we come now to a consideration of those processes which are fundamentally im- portant ones the fate of the foodstuffs in metabolism, all others being only means leading toward the end. During digestion, assimilation, res- piration and excretion, the food ingested undergoes many and various changes, breaking down into simpler compounds or undergoing transmu- tation into more complex substances. This change(l) of matter into potential and dynamic energy is termed metabolism. The body converts potential into kinetic energy by metabolism in the body. The potential energy of the aliment, through the processes of digestion, is transformed into the actual energy of heat and mechanical labor. There is no dif- ference in these changes between man and other vertebrates, though there may be slight variations in details ; the end products are the same. It is admitted that there may be slight differences in the nervous and intel- lectual processes, though at present this is "seen through a glass darkly." Anabolism and Catabolism For the sake of clearness, these chemical changes are classified as follows : First, there are certain chemical processes in the animal economy where simpler substances are converted into more complex ones, which is constructive metabolism, i.e., the process of the assimilation of nutritive material from the alimentary canal and its conversion into the living substance. This process is called anaboli-sm. An example of this upbuild- METABOLISM 287 ing metabolic change is found in the first change which the fats undergo after saponih'cation. This change has already been explained (in Vol- ume I, Chapter VII, The Physiology of Absorption, to which the reader is referred). In this anabolic change the fatty acids combine with glycerin to form molecules of neutral fat. The latter molecule contains three parts of fatty acid to one of glycerin, and is therefore much more complex than the molecules from which it is built up. Second, the complex food materials or tissue constituents are oxidized and broken down into simpler materials, and finally excreted. Preceding this oxidative change, the energy of the complex material is given up in the form of heat, motion, etc. The body is never stable ; while growth and nutrition progress, destruction or demolition constantly go on. This retrograde metabolism is called catabolism, and most of the chemical changes taking place in the animal body belong to this group. It is readily seen that analysis and synthesis play their part coinci- dently or successively in the various phases of the activity of the living substance ; and when the effects of destructive or catabolic change are no longer offset by appropriate anabolic processes, the functions may be- come impaired or may cease altogether. It will be seen, therefore, ttiat the continuity of life depends upon perfect metabolism. Indeed, it is well said that "metabolism, in its entirety, is made up of a series of processes both catabolic and anabolic. In vegetable life the synthetic changes predominate, and highly complex compounds are built up, one might say, directly from the elements" (2). In animal life, on the other hand, catabolism prevails to a large extent, so that in these late years physiologists are accustomed to point out quantitative rather than quali- tative differences between animal and vegetable life. Foodstuffs, for instance, are ingested in the form of complex molecules of carbohydrate, fat and protein, and during the varied processes of digestion, absorption and assimilation undergo more or less complete combustion. Oxygen unites with carbon to form carbon dioxid and with hydrogen to form water; the nitrogen of the highly complex protein substances reappears in combination with carbon, hydrogen and oxygen, as urea, uric acid, hippuric acid, etc., and the sulphur and phosphorus of organic compounds are eliminated after oxidation to sulphuric acid. It is through these catabolic processes that the potential energy of the foodstuffs is ultimately transformed to maintain body temperature, nitrogen equilibrium, and furnish the necessary energy for the wear and tear of the body. In the cleavage of complex compounds to simpler ones, a portion of the potential energy of the ingested food, perhaps stored up temporarily in the form 288 of glycogea or tissue fat, becomes kinetic. In some cases the combustion proceeds to the same end-products which rise by oxidation outside of the body, or, again, the compounds which are discharged by the elimination of the products of catabolic changes may be completely oxidized or even undergo subsequent synthesis, as is true of such .substances as urea and hippuric acid. METABOLISM EXPERIMENTS Balance of Income and Outgo. A balance sheet of the anabolic income and the catabolic outgo will graphically show the exact amount of matter and energy used daily in the body. According to Tib- bles(l), the income consists of (a) matter: food, drink and oxygen of the air; (6) energy: the potential energy of food and drink. The outgo consists of (a) matter: in the urine, feces, perspiration and breath: (6) energy: the potential energy of urine, feces, products of perspiration and respiration. A scientific balance sheet of this process would graph- ically "show the amount of C, N, H, O, P, S, Cl, K, Na, Mg, and Fe in the income and outgo, and it would also show the compounds in the ex- creta, including proteins, fats, carbohydrates, water and carbon dioxid." Many observers have worked over this problem. Two of the most explicit results are the following, given below. The first of Ranke(3), the second by Pettenkofer and Voit(4), as shown in the following tabu- lation from Tibbies (1) : EXCHANGE OF MATERIAL WITH STANDARD DIETS INCOME EXPENDITURE Food Amount in Gms. Nitro- gen (Gms.) Carbon (Gms.) Excretions Nitro- gen (Gms.) Carbon (Gms.) Water (Gms.) Protein 100 100 250 15.5 53.0 79.0 93.0 Urine 14.4 1.1 6.16 10.84 208.00 Fat Feces Carbohydrate Total . Respiration (C0 2 ) Total 15.5 225.0 15.5 225.00 Protein 137] 117 352 J 2016 19.5 315.5 Urine 17.4 2.1 12.70 14.50 248.60 1279 83 828 Fat Feces Carbohydrate Water Respiration.... Total Total 19.5 315.5 19.5 275.80 2190 METABOLISM EXPERIMENTS 289 The researches and results of these men, now classical, have never been assailed ; but they are not so complete as the researches conducted by Atwater (5) and his coworkers. Few investigators have carried out their experiments with the completeness of those conducted by Atwater from 1897 to 1907. Atwater and his colleagues selected for their observations Fio. 5. CALORIMETER. Devised by Atwater and Rosa, Bull. G3, U. S. Dept. Agric.. 1899. Recent improvements on same by Atwater and Benedict "A Respiration Calorimeter" Carnegie Institution of Washington, 1905, used in Howell's Physi- ology, 6th Edition, Saunders, 1915. a man in normal health, with good digestion. A well-balanced palatable dietary was provided; it was well cooked, accurately sampled, and care- fully analyzed. The quantities of nitrogen and carbon were sufficient to maintain equilibrium during work or rest. Pour days before the experi- ment was begun a preliminary digestion experiment was made to determine the requisite food for equilibrium maintenance. 290 NUTRITION AND MINERAL METABOLISM 1 03 W OH 02 O - PS J O Q o o H & O Q + ^qq^o i 1 Tfl O CO g ^ fe ^H CM CM ^H * CM CO oS 1 1 1 1 >' 1 fl CO CO O GO Or-H^ T^ O co 1 10 id * w GO -<* GO T-H OS <* OS CM CO <1 CH O O O CC ^j j^ tf ^ a r-t ^H O ^2 CM CM CM CM GO O OS 1C 1C CO CO C CO CO CO CM K O Q d O GO SO -tf CO CM !>. CM 'C CM o I-H CM' CM' --! .-! CM' > ^ I 1 1 1 T ( 1 I T-H I 1 I-H 1 1 O PS CO . CO lO O OS T-H t^. 00 CM C t~-^ CO t-^ 1 CM CM CM CM >C CM CO t^ CO CO CO CM + 1 OS O5 CO GO CO O 1C t>. g 3 co '3 O 1 1 1 1 O --H O O + 11 1 CO <& f^ LO TJH t-. q co q -* CM PS *n GO iO O l>^ 1^ CO* CO 1>^ O ^ T 1 1 1 T-H 1 ( i-H i-H i-H i-H 5^ CO O OJ CM O -; CM o; q co CM O 1 1 r 1 l^H 1 1 i-H i-H T-H i-H H * 1 GO 10 10 q >C ^H CM t^ O GO O CO GO' ^H T ( r t i 1 OS cd t-." l>i t 1 i-H i-H I 1 . CO CQ I CO G CO i, CO K*^ ^ ^} ~ CM - $_i CO ^ S ^ 2 ^ CO ^ *^3 CM 0) . S H CO t+H *O CO on - ^ ^ s s co'2 o 170 ^ ^ o QJ a H P S9 i ct> o ^ 2 o ||||s| fe o S {3 CU <^ ^ 03 a^ .. .. 8 & J ^ *S ^ T3 el ** s> S >7 P " * r/") ^^ ^ ^*^ &JD tdO SOQ CO " K^J < _ C/J 53 jj -|J 4 i i b*. O CT.' o> CD CU l> ^. . > > *-" METABOLISM EXPEKIMESTTS 291 Sgb &> "8 -Q T3 "S jj iO i I C5 i i co i-! o o S3 1 1 + 1 Pi CO O r* 11 *G o q.g 02 S 00 O O5 CO -1 11 + 1 CO i i O CO CO ^H 1 + 1 1 -g 3 t ~ -t^ OJ co . T-H CO CM W^ M -^ ej o i 1 O i I CO ** OO CO CO >O Ti* CO CO O i -^ CO t>- O> OO CN H tc W : 03 c co >> GJ CO M HEAT MEASURED ABOVE EXPERII c3 "-^ * ^| ""O ^1 c^ Iliii d Qfi c C rt o o co 'i o > > ^ < k experiments: : Average of 8 day I. 9 : Average of 12 ( ge of work experim ge of all experimen t *" ~ 2 O C E p^l |^ll b ' <-! CJ '^3 ". t) q; 1 I- '~ =i~ .'- a: 2 * 'i s s f m a a* A 4f ^ i^ _ s _ 'T 1 ! W K tyi , I : f J|3 S .S or ' ^ c n c (2 EM -*3 rS a J: : ." ~ i ^ E - "^ 6 3 O *^ ct c3 * "* ct ^ PQ>-HWPS{>.HHK 292 NUTRITION AND MINERAL METABOLISM During these preliminary digestion experiments the man was ordered to work and rest just as he was to do while in the respiratory calorimeter, shown in the accompanying illustration (6). The results of some of these calorimetric investigations are given in the following tables, a study of which will show that the body has con- siderable power of adjusting the expenditure of nitrogen to the income. The catabolized protein cannot be calculated as an exact measure of per- manent demands of the body, nor as a measure of the usual requirements of a man at work ; but experiments of this type show that the body re- quires a specific quantity of energy-producing foodstuffs for sustenance, and an additional amount to supply the demands for bodily wear and tear. According to Atwater, the results of a rest experiment during a period of 45 days were as follows: Net income, 2,255 calories; net expenditure, 2,255 calories. During a period of light work lasting for 65 days, the net income amounted to 2,690 calories, the net expenditure to 2,628 calo- ries. During the 45 days of rest the elimination of energy was estimated to be: By the skin and lungs, 1,669; in the evaporation of water from the lungs, 550; in the urine and feces, 31; total, 2,250 calories. During a period of 20 days of work the heat eliminated by means of radiation and conduction from the skin and air in the lungs amount to 2,777 ; in the evaporation of water from the lungs, 1,126 ; in the urine and feces, 19; by muscular work, 234; total, 3,656 calories. The Respiratory Quotient. It has always been held that the energy expended by the body is measured by the quantity of carbon dioxid ex- creted. Parkes determined that during rest a man of 150 pounds ex- creted daily 15 cubic feet of carbon dioxid ; that 1 cubic foot of gas re- sulting from combustion meant the expenditure of 160 foot-tons of energy, and 15 cubic feet 2,400 foot-tons of energy, the equivalent of about 1,560 calories. He estimated the amount of carbon dioxid excreted hourly dur- ing a period of rest to be 0.62 cubic feet ; during a period of hard work, 1.66 ; and during laborious work, 2.75 cubic feet. Atwater and Benedict proved that carbon dioxid excretion varies with the condition. The aver- age daily amount during rest and fasting was 676 grams ; during rest with food, 812 grams; during work with carbohydrate diet, 1,820 grams; during work with fat diet, 1,665 grams; and during work with mixed diet, 1,475 grams. Parkes estimated the daily expenditure of energy dur- ing rest to be 1,600 calories; during moderate work, 2,600; and during hard work, 3,200 calories. The significance of the respiratory quotient in metabolism has been METABOLISM EXPERIMENTS 293 studied extensively by Zuntz(7) of Germany and Atwater(5) in this country. The respiratory quotient is the most delicate test of the car- bonaceous metabolism of the organism ; it is the ratio of the carbon dioxid exhaled to the oxygen consumed. Correct values for the gaseous inter- change and for the respiratory quotient can be obtained only when delicate technical precautions are observed with the Atwater-Rosa calorimeter, or by Zuntz's method. Atwater at the beginning of each experiment directs (for a period of from three to ten minutes, varying with practice and with the capability of control on the part of the individual examined) that the ventilation is to be slightly increased, and as a result of the greater activity of the respiratory musculature, the consumption of oxygen is raised somewhat above the amount consumed during rest. Von Noorden says, "As a result of the forced respiration, too much carbonic acid is with- drawn from the blood, and so the respiratory quotient is found to be too high. Subsequent to the period of forced respiration, there follows for some minutes one of quieter respiration, during which there is a com- pensatory diminution in the carbon dioxid output, below the amount that is formed, with the result that the respiratory quotient is too low. Only after these two periods are passed does the gaseous exchange become regular and the normal values for 2 , CO 2 , and the respiratory quotient can be determined." The respiratory quotient is affected by numerous other, frequently accidental, influences, apart from the purely mechanical ones associated with respiration, and so conclusions can be drawn only when the results obtained by numerous experiments are found to agree. The tabulation below from the experiments of Atwater and Benedict 1 shows : EFFECTS OF FOOD AND WORK ON RESPIRATION CONDITIONS Heat measured (Calories) CO 2 exhaled (Liters) Oxygen consumed (Liters) Respiratory quotient Rest: Fasting. . . 2,197 342.2 473.6 .727 " Ordinary mixed diet . . Moderate work: Fat diet 2,287 3,570 404.5 613.9 469.4 737.5 .862 .832 Carbohydrate diet Hard work: Fat diet 3,699 5,128 655.1 856.6 757.1 1,058.9 .865 .809 Carbohydrate diet 5,142 929.2 1,025.9 .906 i Bull. 109, U. S. Dept. Agric. 119 294 NUTRITION AND MINERAL METABOLISM The respiratory quotient is calculated as follows: Divide the amount of carbon dioxid exhaled by the amount of oxygen consumed; one liter of carbon dioxid weighs 1.9642 grams, and one liter of oxygen 1.4286 grams, and the corresponding factors are 1 -+- 1.9642 = 0.5091, and 1 -r- 1.4286 = 0.7. The amount of carbon dioxid exhaled by a man in one experiment lasting several days was 3,248.3 grams and oxygen con- sumed 2,755.3 grams. The values of the respiratory quotient, i.e., the proportion of the O 2 intake to the O 2 output in the form of CO 2 Gram O 9 in CO c.c. (XX Gram O 2 c.c. O 2 on a fat and carbohydrate dietary can easily be calculated from the ele- mentary composition of these food principles. According to von Noorden(S) : In the case of these two foodstuffs, decomposition products of different ele- mentary composition, which would require to be taken into consideration, do not, as a rule, appear either in the urine or in the feces in appreciable quantities. It is quite different in the case of protein, where the amounts of C, H, 0, and S ap- pearing in the urine and feces must be deducted in order to ascertain the quan- tity of oxygen required for the formation of H and CO 2 . As its amount varies in different experiments, and as the nature of the calculations differs not only for different proteins, but also as carried out by different authors, so the statements vary as to the amount of oxygen requisite for the combustion of the protein, and also as to the amount of CO expired. For these reasons the respiratory quotient, as well as the physiological and physical heat values, vary in the case of a protein dietary. The amount of the respiratory quotient for the most common sub- stances, according to von Noorden, is as follows: Starch, etc 1 .00 Fat ' 0.707 Protein 0.809 Alcohol 0.667 "The calculated theoretical limiting values of the respiratory quotient, in the case of the exclusive combustion of the carbohydrates, or of fats, are usually not attained within the organism, since protein is invariably oxidized along with these bodies. If we take for the fasting state (the individual being in fair average condition) the proportion on the part of the protein in the total energy exchange of the organism as 15 per cent FACTORS WHICH AFFECT METABOLISM 295 of the latter, then the limiting values of the respiratory quotient, with a distribution of the energy exchange, are as follows: With 15 per cent (energy value) protein, 85 per cent (energy value) carbohydrate = 0.971 respiratory quotient. ^With 15 per cent (energy value) protein, 85 per cent (energy value) fat = . 722 respiratory quotient. "Under normal nutritive conditions these values neither rise above this level nor fall below it, provided that the oxidation of the foodstuffs to their end-products is complete, and that no intermediate products appear." If the experimental technic be correct, and the analysis accurate, the height of the respiratory quotient gives us an idea as to the nature of the matter which has undergone metabolism in the organism. The course of the respiratory quotient has thus given definite information as to the rapidity with which carbohydrate and other food materials introduced into the body have undergone metabolism (9). The respiratory quotient is always increased after a hearty meal. All foodstuffs rich in carbon augment the outgo of carbon dioxid. According to William Tibbies (1), "A strictly carbohydrate diet is possible only for short periods during which the respiratory quotient rises to unity or nearly so." A dietary consisting largely of fat lowers the respiratory quotient, but increases the expenditure of carbon dioxid, while, on the other hand, alcohol and the ethereal oils diminish the outgo of carbon dioxid. Again the respiratory quotient falls in the formation of sugar from protein, for which considerable oxygen intake is necessary without corresponding quantities of carbon dioxid being expired, if the glucose formed is either stored as glycogen or excreted in the urine. "Rest causes a fall in the respiratory quotient to about 0.7 or 0. 8, but muscular activity causes an increase in the intake of oxygen and the output of carbon dioxid, especially the latter, and the respiratory quotient rises to 0.8 to 0.9." FACTORS WHICH AFFECT METABOLISM According to Sherman (10) : The calorimetric method of studying total metabolism permits of experiments being carried out very quickly, and is therefore especially useful for the direct investigation of conditions which affect metabolism at once, e.g., muscular work, work of digestion, etc. Moreover, the apparatus can be made portable and thus be carried by the subject like a knapsack in experiments on marching, moimtnin climbing, or bicycling. The observations cannot be made continuous, but the probable results for the 24 hours' metabolism can be estimated by the data ob- tained during frequent short periods at different times of the day and night. 296 NUTRITION AND MINERAL METABOLISM Assuming that the total nitrogen and carbon of the absorbed food existed in the form of protein, fat and carbohydrates, and that the amount of carbohydrates in the body is constant from day to day, it is only necessary to determine the car- bon dioxid of the expired air and the carbon and nitrogen of the waste products in order to calculate the amounts of material oxidized and of energy liberated in the body. Experiments of this sort have played a most important part in the de- velopment of our knowledge of nutrition. The calculations are usually based on the following average analyses of protein and body fat: Protein Fat Carbon 53 76.5 Nitrogen 16 Hydrogen 7 12 Oxygen 23 11.5 Sulphur 1 100 100 The following table shows the income and outgo of nitrogen and car- bon and was obtained by Atwater in one of his respiration experiments, from a man on ordinary mixed diet: CALCULATION OF ENERGY METABOLISM FROM CARBON AND NITROGEN BALANCE. MAN OF 64 KILOGRAMS AT REST IN ATWATER RESPIRATION APPARATUS INCOME: GRAMS PER DAY Protein Fat Carbo- hydrate Nitrogen Carbon Total in food 94.4 82.5 289.8 15.1 239.0 Lost in digestion 5.4 3.7 3.2 0.9 7.4 Absorbed 89.0 78.8 286.6 14.2 231.6 By lungs OUTGO 207.3 12.2 By kidneys 16.2 Metabolized 16.2 -2.0 219.5 +12.1 Balance The above experiment shows a loss of 2 . grams of body nitrogen plus the factor x 6.25 equals 12.5 grams of body nitrogen consumed. The in- take of nitrogen was 89.0 grams from foodstuffs absorbed, and in all there FACTORS WHICH AFFECT METABOLISM 297 were burned 101.5 grams of protein. The respiratory quotient in this experiment at the commencement of each experiment day was in equili- brium, therefore the conclusion is drawn that the amount of carbohydrate burned equaled the intake of 286.6 grams per day. Therefore, after mak- ing due allowance from this balance sheet of the carbon balance, Sher- man(10) estimates the amount of fat burned was as follows: SHERMAN'S ESTIMATES OF ATWATER'S EXPERIMENT 12.5 grams body protein yield (12.5 x 53 per cent) . . 6.6 grams carbon And there were in the absorbed food 231.6 " " .'. Total available was 238.2 But total catabolized was only 219.5 " " /. The body stored in the form of fat 18.7 " Since fat contains 76.5 per cent carbon, 1 gram carbon = 1.307 grams fat. . . 18.7 grams carbon = 24.4 grams fat. The body therefore absorbed 78.8 grams fat stored 24.4 " " burned 54.4 " " In all, the body burned per day: 101.5 grams protein, yielding (101.5 x 4.35 1 ) 442 calories 54.4 fat, (54.4x9.45 1 ) 515 286.6 carbohydrate, (286.6 x 4.1 ') 1,175 TOTAL 2,132 calories Consumption of Food. Many suggestions have been advanced in explanation of the increased metabolism following the consumption of food. Mangus Levy (11), Zuntz and others think the increase due to intestinal and glandular work, that is, to the expenditure required for the enlarged demands upon the muscular system, and for the work of secre- tion carried out by the numerous glands present in the alimentary canal. Kubner(12) assumes, in addition to the glandular work proper, a specific action on metabolism is produced by the excess of protein. He holds that every foodstuff possesses a "specific dynamic" action. He also believes that the protein molecule is decomposed in all cases into a nitrogenous com- ponent and a non-nitrogenous component of a carbohydrate nature. Von Noorden ( 8 ) recognizes a specific action of protein nutriment without adapting Eubner's explanation. He asserts that the increased oxi- dation occurring after the consumption of fats and carbohydrates, as well as that following the ingestion of protein, is due in the main to intestinal and g-landular work. 1 Here the factors for fuel value are not reduced to allow for loss in digestion, because this loss has already been deducted in computing the amount of each nutrient actually absorbed and rendered available. 298 NUTRITION AND MINERAL METABOLISM Fasting. The effect of fasting on metabolism has been studied in great detail by Atwater and Benedict (13), who were able to determine by means of the respiration calorimeter the heat production of the same (control) man during five-day fasting experiments of one or two days each, and during a four-day experiment with food about sufficient for equilibrium maintenance. They found a total metabolism on fasting days to be 9 per cent lower than on. the days when food was taken. Later, Benedict(14) found, after an extensive research, that if the fast was suf- ficiently prolonged, there would be a decrease in heat production. He conducted an experiment on a man during a seven days' fast, "while the man was living on his own flesh and fat," and found the loss to be : protein, 69.5; fat, 139.6; glycogen, 23 grams per day; total, 1,597 calories. The protein loss equaled 347 grams of flesh ; the actual loss of energy measured by the calorimeter was 1.696 per diem, or 100 grams more than the estimated cost. The heat of combustion can be arrived at from the known caloric value of the substances; for example, 1 gram of body protein yields 5.65 calories, and 1 gram of fat, 9.54 calories, and the total when fully oxidized in the human economy would aggregate 1.734 calories. The Swedish investigator Tigerstedt made a careful study of the car- bon and nitrogen balance, the metabolism of a man who abstained from food for five days, following this period with a liberal diet for the next two weeks. The production of heat during the first two days of fasting could not be as definitely determined as in the last three days because of the loss of an unknown quantity of glycogen during the first days. The following data was obtained, which we take from Sherman and append below: METABOLIC CARBON AND NITROGEN BALANCE DURING FASTING Body weight kilos Calculated total metabolism, calories Calories per kilo First fast day 67.0 2220 1 32.2 1 Second " " 65.7 2102 1 32.0 1 Third " " 64.9 2024 31.2 Fourth " " 64.0 1992 31.1 Fifth " " 63.1 1970 31.2 Fed 4141 calories 64.0 2437 38.1 " 4141 " (second day). . 65.6 2410 36.8 i These figures are slightly too high, because the loss of carbon on these days was due in part to combustion of glycogen, but is calculated as if duq simply to protein and fat. FACTOKS WHICH AFFECT METABOLISM 299 These tabulated results clearly show that during a period of fasting the metabolism remains fairly constant, notwithstanding the fact that energy is generated at the expense of the tissues. In this experiment 4,141 calories of energy were produced by the food eaten twice the amount that would have been necessary for mere maintenance. Conse- quently the work of digestion and assimilation was doubled. It appears then that as a result of fasting the entire metabolism of an individual at rest remains fairly constant, and the body possesses but little capacity for the adjustment of its energy metabolism to its food supply. Effect of Nitrogenous Diet on Metabolism. The effect of nitrogenous diet on metabolism has been studied extensively by von Noorden(S), who holds that the most striking effect of a purely nitrogenous diet is a large increase in the nitrogenous metabolism, but at the same time it also increases the metabolism of the non-nitrogenous elements of the body. As the amount of protein ingested is increased, a rise in protein metab- olism is produced. This sequence occurs to such a degree that nitrogen equilibrium can generally be maintained on the most varied quantities of protein, which goes to prove that the body is not able to store up any excess of protein. At first glance, the fact that the body has the power to break down as much protein as is given to it would not appear to be in accordance with the law that the extent of protein metabolism is governed by the tissue requirements, not by the quantity that is offered to the cells. This law is absolutely true so far as the consumption of oxygen- and nitro- gen-free substances is concerned. Usually when there is an increased consumption in protein, there is also a lessened consumption of other foodstuffs, so that with the increased proportion of protein there is a les- sened intake of other material. Thus the total energy metabolism is raised, to proportionately a small extent, only when nitrogen-free sub- stances are replaced simply by protein. Perhaps the difficulty of explana- tion might be made plainer if the hypothesis were found to be correct that the food protein is actually only in small part transformed into true protein within the body, or that it plays the part of protein within the organism only to a small extent. The statement that the body can consume all protein ingested within a period of twenty-four hours exceeds definite knowledge of the condi- tions. It is known that the nitrogen and sulphur are eliminated within this period. But whether the carbon that is eliminated during this period is derived from the protein or from other sources, and if from the latter, whether the carbon derived from the protein is stored up in any special form in the body these are problems yet to be solved. 300 NUTRITION AND MINERAL METABOLISM According to von Noorden's reasoning it is probable that the former is correct, because, as a rule, bodies of small molecular weight, such as amino acids, etc., are completely burned up as soon as decomposition and oxida- tion have once commenced. In order to learn how the body attempts to adapt the combustion of protein to its intake, it is well to observe conditions in instances in which different amounts of protein are added to a dietary which is nearly enough for the requirements of the body. If the increase or decrease is not ex- treme, the nitrogen equilibrium of the organism will not be reestablished for several days. In the ordinary daily routine when the intake of food varies with the appetite and other influences, the intake and elimination of nitrogen often take place at very short intervals, and so in general, nitrogen equilibrium is kept up on a sufficient diet for long periods. In many instances, individuals during hot weather or when in tropical re- gions cannot take enough food to supply the needs of the body, and in consequence lose both protein and fat. Von Noorden(S) proved this to be true by experimenting upon himself. He determined that the main- tenance of weight was regulated by the fact that the amount of food in- gested as governed by the appetite meets on the whole the definite needs of the body. In prolonged experiments on man it has been found that nitrogenous metabolism is not by any means as uniformly maintained on an unvaried protein and caloric intake as is the case in experiments on dogs. Rosemann in one experiment found a daily variation of 10 grams of nitrogen. He points to temporary retention and subsequent washing out of the end-products of nitrogenous metabolism as accounting for these variations. But this explanation has not sufficient foundation. Atwater and Benedict(15) note the frequent occurrence of similar irregularities. In one of their experiments, variations in nitrogen elimi- nation on a constant diet were 17.2, 17.6, 14.2, 23.8, 20.3, 17.4, 17.2 and 17.4 grams. Psychical conditions were cited as the cause of these varia- tions. The individual in question was so anxious about going into the respiration calorimeter chamber that the mental disturbance brought about a rise in protein metabolism. If, as sometimes happens on the last day of an experiment, protein metabolism is strongly influenced by certain external conditions, the result of the entire series is apt to be markedly affected. This result is naturally exaggerated in shorter series. Carbohydrates as Protein Sparers Carbohydrates as protein sparers have of late received marked attention by research workers on metabolism. It has been observed that, where there is a deficiency of protein in the food supply, the metabolism of nitrogen will be spared and the tissues pro- FACTORS WHICH AFFFCT METABOLISM 301 tected if the food contains a liberal allowance of carbohydrate and fat. Lusk(KJ) has fully investigated this subject, and found that, when, the aliment contained an abundance of protein, fat and carbohydrate, the organism would gain a little nitrogen ; when the ration contained the same amount of protein, but no carbohydrate, the body lost nitrogen. On the other hand, when the ordinary dietary contained only a sufficiency of energy, but was of a low protein content, the excretion of nitrogen was normal. Lusk, therefore, concluded that carbohydrate acted as a sparer of protein. The protein-sparing action of carbohydrates is now well known (edi- torial, Jour. A. M. A., 1917), and they are by far more efficient protein- sparers than fats. "The starvation output of nitrogenous waste products, especially urea, can be materially lessened by the ingestion of either fats or carbohydrates, though the superiority of the latter non-nitrogenous foodstuffs in lessening nitrogen waste is always greater. If the carbo- hydrates are omitted from the dietary or even replaced by fats, the effect on the amount of nitrogen excreted is promptly perceptible. "Various theories have been proposed to explain this unique function of the carbohydrates in nutrition. One view has maintained that a certain concentration of blood sugar is always necessary for proper maintenance of physiological activities. This sugar can be produced from proteins if carbohydrates are not directly available, and since, in the absence of car- bohydrates, under physiologic conditions, fat cannot well supply this want, proteins are broken down to yield the sugar that is lacking. The result is an increase in the nitrogen output in carbohydrate starvation." Another view lately championed by Cathcart(lT), of Glasgow, and Janney(18), of Xew York, postulates that carbohydrate is essential to protein synthesis. "There is no doubt at present that sugar is not oxi- dized directly in the metabolism of the organism, but is rather dissociated in a definite way into simpler derivations, of which methyl glyoxal, CH. 3 CH.CHO, lactic acid, CH 3 CHOILCOOH, and pyruvic acid, CH 3 CO.COOII, are the most interesting possibilities. There is evi- dence that these compounds derived from sugars can in turn be converted into sugar in the diabetic individual. They may, accordingly, be con- cerned in the synthesis as well as the disintegration of the sugar molecule. But there is also some evidence now available, largely from perfusion experiments on surviving isolated organs, that both pyruvic and lactic acids can be converted into the amino-acid alanin ; that is, they can add nitrogen under conditions approximating physiologic possibilities." Kocher(19) has recently reminded us that, if this process of retaining 302 nitrogen by dissociation products of sugar to form new amino-acids, and hence proteins, occurs on a large scale in the body, it will explain why ingestion of carbohydrates spares body protein. To test this point, he has undertaken a comparison of the sparing effects of ingesting lactic and pyruvic acids in contrast with equivalent amounts of undissociated carbo- hydrates, like sucrose, on the nitrogen output. The outcome of these ex- periments, conducted at the George W. Hooper Foundation for Medical Research of the University of California (Jour. A. M. A., 1917), indi- cates that lactic acid exerts practically the same sparing action on protein metabolism as do carbohydrates. "The sparing action of pyruvic acid also is very distinct, but less marked than that following sugar. In view of what has already been mentioned regarding the possibility of adding am- monia to the structures of the sugar derivatives to form alanin, it is readily conceivable that, when this process is operative, nitrogen arising from the catabolism of body proteins, instead of being promptly excreted, is util- ized to synthetize new protein. This is not a new conception of metab- olism ; but Kocher's work gives added support to the possibility that the fixing of catabolized nitrogen by the dissociation products of glucose to form new proteins is the true mechanism of the sparing effects of feeding carbohydrates on the nitrogen output." Fat versus Carbohydrates as Protein Sparers The subject of fats versus carbohydrates as protein sparers has been studied exclusively by Kayser and Landergren(20). They believe that fat quite as well as the carbo- hydrates protects protein not only in nitrogen hunger but in nitrogen abundance. According to Landergren, in certain instances, fat alone as compared with carbohydrates seemed to exert half the protective power of the latter as a protein sparer. This he attempted to substantiate on the ground of the demand of the body for carbohydrates ; and that when deprived of this food element, the glycogen formed in the tissues from protein is accepted as a substitute for combustion. The role of protein in this process cannot be taken by fat. It follows that as soon as the sup- ply of glycogen in the body is exhausted, fat has less protective power than carbohydrate as a protein sparer. Atwater(21) concluded from his experiments that the total available energy remaining uniform, protein protection by carbohydrates (largely cane sugar) is slightly superior to an isodynamic amount of fat; this fact may possibly be due to the "personal equation" of the control. Kayser (22), in a series of experiments, compared the efficiency of car- bohydrates and fats as sparers of protein by carefully determining the nitrogen balance and substituting the carbohydrates of the ration by an FACTORS WHICH AFFECT METABOLISM 303 amount of fat which would furnish the same fuel value in calories. The control who served as his subject for this experiment was a man 23 years old, of good physique, weighing 67 kilograms, with a small store of body fat. During the first and third periods of observation, his alimentation consisted of meat, rice, butter, eggs, sugar, oil, vinegar and salad. During the second period, his dietary consisted of meat, eggs, oil, vinegar and salad, all of the carbohydrates being practically withdrawn and replaced by -fat. The two rations had practically, the same fuel value and protein percentages. The results of this study are tabulated below : KAYSER'S TABLE SHOWING NITROGEN BALANCE WHEN FEEDING ISODYNAMIC QUANTITIES OF CARBOHYDRATE AND FAT Day INTAKE Output, Total Nitrogen Nitrogen Balance Total Nitrogen Fat Carbo- hydrates Fuel Value 1. . Grams 21.15 21.15 21.15 21.31 21.51 21.55 21.55 21.10 21.10 21.10 Grams 71.1 71.8 71.8 71.8 221.1 217.0 215.5 70.4 70.4 70.4 Grams 338.2 338.2 338.2 338.2 338.2 338.2 338.2 Grams 2590 2596 2596 2600 2607 2570 2556 2581 2581 2581 Grams 18.66 20.04 20.59 21.31 23.28 24.03 26.53 21.65 19.20 19.65 Grams 2.46 1.11 0.56 0.00 1.77 2.48 4.98 0.55 1.89 1.45 2 3 4 5. . 6 7 8 9 10 On carefully examining this table it will be seen from the nitrogen balance of the first period that the amount of protein in the food was more abundant than was necessary; however, the nitrogen equilibrium was established on the fourth day. When fat was substituted for carbohy- drate, there was a marked increase in protein catabolism with correspond- ing loss of nitrogen from the body. On the other hand, the loss of nitrogen increased daily while the fat diet was continued, but, upon resuming the mixed diet, not only was the loss of protein stopped, but the body im- mediately began replacing the protein it had lost, although the nitrogen and the calories of the food remained practically the same. Kayser found that "the nitrogen intake remaining constant, the sub- stitution of isodynamic amounts of fat for all the carbohydrates of the diet resulted within three days in a total loss of 9.2 grams of nitrogen. The loss on the first day was 1.Y7 ; on the second day, 2.48 ; and on the third day, 4.98, while during the periods before and after, one gram of 304 NUTRITION AND MINERAL METABOLISM nitrogen daily was retained. Landergren, who holds that the variation between carbohydrates and fats as protein sparers is not dependent upon the difference in their physical and chemical properties, advances the following explanation as a possible solution of the problem. If there are no disposable carbohydrates present, either in the food or in the storehouse of the body, then the organism must itself produce carbo- hydrate in order to satisfy its requirements. As, according to this investi- gator, a formation of sugar from protein may take place, but never one from fat (at least, under physiological conditions), then, in the absence of carbohydrate, a certain additional amount of protein must break down, in order to furnish the necessary carbohydrate requirements of the organism." This investigator finds the absolute daily carbohydrate re- quirement of the adult to be 40 to 50 grams. In his opinion, 30 to 40 grams of protein w r ill be sufficient to furnish this amount if no preformed carbohydrates are present. Atwater(23), in one of his researches, compared the protein-sparing power of carbohydrate and fat in an experiment in which his subject was an athletic young man weighing 67 kilograms, who was accustomed to perform a considerable amount of work. The fifteen-day experiment was conducted in the respiration calorimeter, and the subsistence, rich in carbohydrates, was arranged in four periods which were alternated with four equal periods in which the diet was rich in fat. The change from carbohydrate to fat and vice versa involved about 2,000 calories or nearly half the fuel value of the diet. The average results per day for this experiment were tabulated as follows : SPARING POWER OF CARBOHYDRATES AND FAT IN CALORIMETRIC EXPERIMENTS (ATWATER) On Diet Rich in Carbohydrates On Diet Rich in Fat Available calories in food 4532 4524 Heat equivalent of work performed, calories . . . Nitrogen in food, grams 558 17.5 554 17.1 " " feces, " 2.5 1.7 " " urine, " .... 16.6 18.1 " balance, " -1.6 -2.7 The difference here is in favor of the carbohydrate, but this is so small as to be of no practical significance. It appears that the carbohydrates of the dietary cannot be entirely FACTORS WHICH AFFECT .MKTAIJOMSM 305 replaced by an equal number of calories in the form of fat without jeop- ardizing the nitrogen balance. Gelatin as a Protein Sparer Gelatin as a protein sparer has been studied extensively by Voit, Wilcock, Hopkins, Kauffmann, Kolpakcha and others. According to Voit (24), it would seem that the high nitrogen content of gelatin and the fact that it is soluble led to a tendency to attribute to it an unusual nutritive value. The fact, too, that gelatin could be obtained from bones, which otherwise were burned or thrown away, was important in suggesting it as a means for the economical feeding of the poor. The history of gelatin as a food is very interesting, and indeed instructive, since it serves as a warning against a premature application of the results of scientific investigation. A committee of the Paris Academy of Medicine investigated gelatin as a food and recommended it as a most nutritious and healthful foodstuff when its natural insipidity was corrected by the addition of salts and savory herbs. On the basis of this report, gelatin was generally used in the nourishment of hospital patients, but in the coiirse of time, complaints were made and doubt raised as to its real food value. The true value of gelatin as a food, as we understand it to-day, w r as established by Voit's experiments, still it is evident that something remains to be explained. It is not clear why it cannot be better borne in a diet when used in larger quantities. Wilcock and Hopkins(25), after an extended study of this subject, conclude that the special protein-sparing properties of gelatin are due largely to the abundance of glycocoll in its composition, and aver that it shares with protein certain molecular groupings necessary to satisfy specific needs and is thus superior to fats and carbohydrate as a protein sparer. It lacks, on the other hand, certain necessary groupings, there- fore failing to supply all such needs, and thus cannot replace protein. It is a well-known fact that gelatin as a sole protein food does not suffice for the maintenance of nitrogen equilibrium. Recent study of protein chem- istry has shown that gelatin differs from most other proteins in yielding on hydrolysis no tyrosin nor tryptophan and little if any cystin. Kauffmann (26) personally experimented with a diet in which these three amino-acids were ingested along with gelatin to the exclusion of other protein, and found that nitrogen equilibrium was maintained throughout the entire five days' fast on this aliment. Von Noorden(S), after many qualitative analyses of gelatin, is certain that it contains much glycocoll and very little leucin and aromatic amino-acids. He believes 1 1n- variable composition of gelatin is but one of the reasons why it is so ill adapted for the building up of protein. He arrives at this conclusion 306 NUTKITION AND MINERAL METABOLISM after an experiment, and says a considerable quantity of gelatin in the food effects the economy from 20 to 30 per cent in the protein decomposi- tion of starvation, but quantities three or four times as great increase the economy to only 40 per cent instead of trebling or quadrupling it as might be expected. The loss of body protein cannot be prevented by add- ing much non-nitrogenous food to even the largest gelatin diets. A few years ago there was prevalent a popular idea that jelly was strengthening. Physicians concluded this to be erroneous and averred that jelly was of no use. Both were wrong. Gelatin undergoes catabolism, being- changed into urea, and is a protector of protein, not by lessening the amount of material oxidized in the same way as carbohydrate and fat, but by being directly substituted for the nitrogenous elements of the body. The addition of gelatin to the dietary aids in establishing nitrogenous equilibrium on a smaller amount of protein than when gelatin is with- held, and even the consumption of fat is lessened by the allowance of gelatin in the aliment. This is all the plainer when we consider that gelatin in the process of catabolism is split into a urea moiety and a fatty moiety, like proteins. The important point in this connection is that gelatin, alone or with carbohydrates or fats, does not suffice to maintain the nitrogen equilibrium. It does not supply the nitrogenous material requisite for the repair of tissue. This deficiency is explained by the fact that in the composition of gelatin certain important amino-acids are lack- ing tryptophan, tyrosin and cystin. Howell(27) states that "if a dog is fed upon a diet in which the nitrog- enous material is represented only by the split products of a gelatin hydrolysis, he will show a nitrogen loss. If the above named amino-acids are added, particularly the tryptophan, he will be maintained in nitrogen equilibrium. It is at present conceded that gelatin takes the place of stored or circulating protein, but not of tissue proteins, and therefore it will be seen that it does not serve the purpose of replacing the wear and tear of tissue." Nevertheless, gelatin is a more valuable foodstuff than it was formerly considered to be. Alcohol as a Protein Sparer "Alcohol as a protein sparer has been the subject of much discussion among physiologists. It would be impossible to summarize the evidence on each side of the question here, but, in brief, the results of the latest and most trustworthy researches show that alcohol undoubtedly possesses a limited power in restricting nitrogenous waste." Alcohol is unquestionably a fat-sparer, though with greater difficulty is it able to spare carbohydrate. But while sparing fat, and sometimes carbohydrates, it is itself consumed yielding heat and energy to the FACTORS WHICH AFFECT METABOLISM 307 body. This was once a mooted point with physiologists, but there is no longer any doubt that alcohol is a food, but a very expensive food. Care- ful research has shown that the complete combustion of one gram of alco- hol in the body will yield 7 calories of heat energy; so that 131 grams of alcohol will yield as much fuel to the body as 100 grams of fat, which means that one ounce of alcohol is equal in energy or fuel value to one ounce of butter (80 per cent fat). While this statement is a recorded fact, we do not intend to convey the idea that we hold that alcohol is as good a source of energy in the diet as fat. Quite the contrary is the case, for, as we have already seen (see Volume I, Chapter XVI, page 578), by dilating the blood vessels alcohol may cause m.ore heat dissipation than it is itself capable of producing. Besides, the energy which alcohol yields is very quickly dissipated, owing to the rapid oxidation of alcohol in the body, while fat produces energy in a slower and more equable fashion. Hutchison (28) thinks that larger doses of alcohol cause a general paralysis of cellular activity,, so great that heat production is diminished and heat loss increased,. with the final result of great lowering of the body temperature. If it be granted, for sake of argument, that alcohol is oxi- dized in the tissues with the liberation of energy, any value which it may possess in virtue of such metabolic action is seriously counterbalanced by its paralyzing and anesthetizing action on cellular activity. This causes the cells, for the time being, to lose their power of breaking down those compounds, such as fat, which it has, even under normal conditions of full activity, most difficulty in handling. Moreover, this dulling of the senses and inhibition of cellular activity is quite in accord with our present understanding of the effects of other cell poisons; and this knowledge should be accepted as Nature's warning, for, as experience has shown, the consumption of alcohol during muscular work augments rather than delays fatigue (29). Furthermore, a$ previously stated, it is believed that to a limited extent alcohol may lessen nitrogenous waste; however, its action in this respect is much less than that of carbohydrates, and less even than that of fats, and in addition there seems to exist some subtle influence of conditions not clearly understood, which depend, in certain instances (at least to some extent), upon personal peculiarities of the subject. Habit, also, undoubtedly is an important factor(SO), as, with those who are accustomed to alcohol, the initial loss in nitrogen is less marked than in the case of total abstainers. In the case of fever patients who have been previously accustomed to the consumption of alcohol, even large 308 NUTRITION AXD MINERAL METABOLISM quantities do not give rise to nitrogen losses. Practically all physiologists agree that alcohol spares less protein than do carbohydrates when both are given in isodynamic quantities, but in practical therapeutics this is really of little importance. The physician does not desire to make use of the protein-sparing properties of alcohol, but instead he does endeavor by its use to spare the fat of the organism. In the experiments of Atwater and Benedict (31) it was found that the utilization of the different foodstuffs was not affected by the adminis- tration of alcohol, as shown in the following table : UTILIZATION OF DIFFERENT FOODSTUFFS WITH ALCOHOL AND WITHOUT Protein Fat Carbohydrates Energy With alcohol 93.7 94.6 97.8 92.1 Without alcohol . . . 92.6 94.6 97.9 91.8 This tabulation shows the extent to which the food material was metab- olized when alcohol was administered. It has been held by some observers that the administration of alcohol exerted a favorable action in retarding tissue waste which accompanies prolonged pyrexia, but unless its metabolic action is very different in fever from its action under normal healthy conditions, and there seems to be little affirmative evidence, we are not justified in granting it any such favorable action. Finally, in summing up the influence of alcohol on metabolism, we are safe in concluding that it is burnt up in the body, sparing fat and car- bohydrates, and, to a very limited extent, it may spare protein, but the weight of evidence is against the conclusion that it exerts any important action tending to inhibit nitrogenous waste (32). Metabolism of Water. The metabolism of water in the human econ- omy has been worked over by many serious investigators. Bischoff, Foster and Hennenberg held that the "flushing" of the system with water hastened the breaking down of protein substances. Voit(24), in particu- lar, was the first to make any trustworthy experiments upon this question. He found that the rise in the excretion of nitrogen was 25 per cent, with an increase of the total urinary sulphur compounds from the tissues, and in any case it falls far short of the amount of the increase of the nitrogen excretion (33). Bidder, Schmidt, Murck and Meyer (34), on the other hand, believe that the urinary nitrogen increases because the tissues are more thor- FACTORS WHICH AFFECT METABOLISM 309 oughly flushed or washed out and thereby lose their nitrogenous end- products. The human body consists of 630 parts per 1,000 of water, and it is of the greatest importance as a component of the tissues to assist in the exchange of nutritive substances, the discharge of the products of metab- olism, the regulation of temperature and other vital functions. If the supply of water be cut off, the body will die, and it will succumb sooner from deprivation of water than by starvation. A restriction of the water supply consumed hastens the decomposition of protein and fat to replace the water essential for the body functions. Atwater and Benedict, as a result of a 49-day experiment with a control in repose, showed that the' average income of water was 2,290 c.c. and the excretion 3,700 c.c., so that at the lowest estimate about 250 c.c. of water was formed in the tissues by the oxidation of hydrogen in the food, while in the tissues and during ordinary work they found that from 510 c.c. to 540 c.c. of water was excreted daily in excess of the amount consumed in the food and drink. The amount of water ingested with food and drink varies according to position, life, habits and environments of the individual, but the above figures give a fair idea of the amounts of water taken with a mixed diet under comfortable circumstances (17). Von Noorden holds that, in addition to the fluid drunk, the body has at its disposal the "oxidation water," resulting from the combustion of the hydrogen of the food. The amount of this varies but little, depending less upon the nature of the food oxidized than upon its quantity, in other words, upon the absolute extent of metabolism. The following table graphically emphasizes this point : "OXIDATION WATER" RESULTING FROM THE COMBUSTION OF HYDROGEN IN THE FOOD Foods Contains grams H Contains grams H 2 Yields calories 100 calories yields grams H 2 100 grams fat 11.9 107.1 9,461 11.3] 100 " starch 6.78 55.5 4,181 13.3 [ 11.3 100 " protein 4.59 41.3 4,442 9.3 J 100 " alcohol . . 13.4 117.4 6,981 16.6 A careful study of the above tabulation shows that, for each 100 calories developed, the ternary food elements produce approximately the same amounts of water, 11.3 grams. On a mixed dietary, whore fifty per cent of the potential energy is derived from the carbohydrates and 120 310 NUTRITION AND MINERAL METABOLISM one-sixth from the protein, and the remaining from the fat, each 100 calories correspond to about 12 grams of water, so that we have: From 2,000 2,500 3,000 About.. 240 300 360 4,000 calories 420 "oxidation" water The approximate figures from von Noorden, just given, agree fairly well with the quantities determined experimentally by Voit, which were as follows: During starvation 32 gm. H equals 288 H 2 0, with an exchange of about 2.300 calories. With average diet and lightHO gm. H. equals 360 H 2 0, with an exchange of about work J 2,600 to 2,800 calories. With hard work 52 gm. H. equals 468 H 2 0, with an exchange of about 3,600 calories. Atwater and Benedict (35) observed that: During rest 30 gm. H equals 270 H 2 O, with an exchange of about 2,209 calories. During hard work 50 gm. H equals 451 H 2 0, with an exchange of about 3,630 calories. Neumann(36) conducted an ideal experiment upon himself, subsist- ing upon a regular and constant dietary, the chief results of which are tabulated below: NEUMANN'S DIETARY EXPERIMENT 1 2 3 4 5 H 2 Oin drinks NITROGEN BALANCE Total for Entire Period DAY 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 970 3,000-3,900 600- 900 3,100-3,700 700-1,700 +0.42 -3.8 +3.35 -3.16 +2.91 +0.19 -2.4 + 1.92 -1.51 +0.72 +0.16 -0.1 +0.78 +0.59 +0.42 -0.06 +0.4 -6.3 +6.1 -0.89 4.9 +0.51 +0.88 -0.23 +0.19 +0.59 +1.0 +1.23 In studying this table it will be seen that his consumption of water increased from 970 c.c. the first day of first period to 3,900 c.c. the last day of the second period and 3,700 c.c. the last day of the fourth period. The urinary nitrogen was increased during only the first two days. On and after the fourth day he remained in nitrogenous equilibrium, although he continued to drink abnormally large quantities of water. Dur- ing this experiment Neumann was punctiliously careful as to details and noted when he returned to the small consumption of water, as in the third period, or after he had flushed out his system for a long period, as in the fourth period, that his initial loss of nitrogen was fully compensated by the retention of corresponding amounts of nitrogenous substances. FACTORS WHICH AFFECT METABOLISM 311 Von Noorden, in commenting upon this experiment, emphasizes the facts as tabulated, and says : "For the adult healthy man the question has been answered once for all." It will be seen, therefore, that "flushing out" the system removes the end-products of nitrogenous metabolism with- out any abnormal breaking up of protein. In summing up the results- of Neumann's experiment, von Noorden concludes as follows : The amount first washed out and then retained was about six grams of nitro- gen. One might be tempted to regard this quantity as the maximum "excess of extractives loosely retained in the system," and to base other calculations upon it as such in other investigations of the metabolism. Were this justifiable, one would be able to set down any further excess of nitrogen lost with some certainty to the decomposition of protein. But this view is not justifiable, since such consumption of water produces no more than a mechanical flushing of the tissues. Under dif- ferent circumstances, it is quite possible that perhaps amounts of extractives might leave the tissues; yet it is most important that conclusions drawn from the action of the healthy bodj r should not be applied to diseased tissues. And there is one thing that these experiments bring out very clearly, and that is the tenacity with which the organism holds on to its extractives. With but few exceptions, these bodies should not be regarded as the valueless decomposition products des- tined for excretion only. They must rather have definite functions of which we know nothing for the most part to perform in the economy of the body. Metabolism of Mineral Substances The metabolism of mineral sub- stances, from a strictly chemical viewpoint, is of small moment, since they undergo only minor chemical changes, and play even a less important role in the transformation of energy ; they are not sources of energy and it is questionable even if they have any part in its development. Indeed, their exact significance in the organism is only partially understood, but at the same time it is a well-known physiological fact that life cannot be sup- ported on foods deficient in inorganic salts. Beyond question they serve most important functions in maintaining a normal composition and osmotic pressure in the fluids of the body, and, by virtue of their osmotic pressure, they play an important part in the ingress and egress of water to and from the tissues. Besides, the inorganic salts constitute an essen- tial part of the composition of all living matter. Howell says: In some way they are bound up in the structure of the living molecule and are necessary to its normal reactions or irritability. Even the proteins of the body liquids contain definite amounts of ash, and if this ash is removed, their properties are seriously altered, as is shown by the fact that ash-free native proteins lose their property of coagulation by heat. The globulins are precipitated from their 312 NUTKITION AND MINERAL METABOLISM solutions when the salts are removed. The special importance of the calcium salts in the coagulation of blood and the curdling of milk has been referred to, as also the peculiar part played by the calcium, potassium and sodium salts in the rhythmical contractions of heart muscle, the irritability of muscular and nervous tissues, and the permeability of the capillary wall and other membranes. The spe- cial importance of the iron salts for the production of hemoglobin is also evident without comment. There can be no doubt, in. fact, that each one of the salts of the body has a special nutritive value and a special metabolic history. The time will doubtless come when the special importance of the potassium, sodium, cal- cium and magnesium will be understood as well, at least, as we now understand the significance of iron, and quite possibly this knowledge will find a direct therapeutic application, as in the case of iron. In the human body the mineral salts exist partly in combination with organic substances and partly in solution in the body fluids. In- organic substances, when burned with access of air, set free the mineral substances which exist therein ; likewise, when foodstuffs containing the inorganic salts are metabolized in the body, they are (with the exception of iron) given off chiefly in the form of mineral matter. These elements and their compounds are therefore usually referred to as ash constituents, and their metabolism as mineral metabolism. The table given below shows the most important of the inorganic salts and the percentage found in bone, muscle and the various organs of the body. The inorganic salts found in the body are either eliminated from the body by the urine and other excretions, or they may be retained and recombined with freshly absorbed organic substances from the ali- mentary canal. THE PERCENTAGE OF ASH IN BONES, MUSCLES, AND VARIOUS ORGANS M S3 o'S WE ^=? iS 3 o3 Is fc-!'fl >^ g asj 14? SSI tf^O ra &> oj OJ : - s-i PQ if s b 1M? p ci >la^ i %-%* '. -^ Sg-g Sodium chlorid . . Potassium chlorid 10.59 4.74 58.81 74.48 10.73 26.33 Soda 2.35 14.53 44.33 10.69 4.15 10.35 Potash 34.40 25.23 9.60 34.42 11.97 3.25 21.44 Lime 37.58 1.99 3.61 7.48 .72 1.76 .97 18.78 Magnesia 1.22 1.45 .20 .49 1.23 1.12 .26 .87 Ferric oxid. . 2.74 7.28 8.37 .05 .10 Chlorin 2.58 .54 Fluorin 1 66 Phosphoric acid. . Sulphuric acid 53.31 48.13 50.18 .92 27.10 2.54 50.18 .92 10.23 1.67 1.09 19.00 2.64 Carbonic aicid 547 1.19 8.20 Silicic acid .81 .27 .17 .27 .42 FACTORS WHICH AFFECT METABOLISM 313 Yon Noorden says: Extract experiments have proven, once for all, the indispensable importance of the inorganic salts to the organism, and the amounts in which they are required during growth has been repeatedly investigated, while only a few serviceable de- terminations have been made upon the adult. It is known that the body takes up the organic foodstuffs to supply it with energy, in response to a definite demand. The inorganic material in the food is on a different plane ; like water, it is absorbed in excess, or, more plainly speaking, in quantities far surpassing the normal physio- logical minimum. The requisite amount of the daily decomposition under definite conditions of life and nutrition, calculated on the basis of the urinary salts, is stated by von Noorden(lT) in the following approximate figures : Gram Gram Cl 6-8 Na 2 4-6 P^Oa 2-3.5 Fe 2 3 Traces S0 3 2-3.5 CaO 0.15-0.35 K 2 2-3 MgO 0.2-0.3 The physiological minimum intake of inorganic matter has not been extensively investigated. Indeed, its determination is beset with diffi- culties, since the same differences obtain as in the case of the demand for protein and water, and these depend upon individuality, personal idio- syncrasies and upon variations of the organic constituents of the dietary. It is difficult, therefore, to arrive at a "physiological optimum." This much is certain, a marked decrease in the amount of mineral salts must take place before any impairment of mineral metabolism is noticeable. At any rate, no scientific proof of its importance is available, and beyond question there is an absence of accurate information of the physiological conditions involved. From the foregoing discussion of mineral metabolism, we learn that the salts of the body are partly bound up with inorganic substances and partly in solution in the body fluids, and are considered as ash. The prevalent custom of speaking of ash as a food is incorrect; properly speaking, ash is the term applied to the residue remaining after the incin- eration of food products in the air at a low temperature, until the carbon has disappeared. Ash is rather an indefinite term and is applied to that residual material of a mineral nature composed of sand or silica and the carbonate*, or oxids of alkalies or alkaline earths. The ash contains the principal percentage of phosphorus present in food products along with a small portion of sulphur. These bodies exist as phosphoric and sulphuric 314 ^TUTKITION AND MINERAL METABOLISM acids or their salts. Elements so closely related to chemical properties as sodium, potassium or calcium and magnesium are not only not inter- changeable, but in some of their functions are diametrically opposed. Calcium seems to bear a special affinity for, and to exert a favorable influence upon, the efficacy of iron in body metabolism, since it appears to be possible to maintain iron equilibrium upon a smaller amount of this latter element when the ingested food contains an abundance of the calcium salts. The relative quantities of water, organic matter and inorganic residue (ash) in some of the tissues and body fluids is shown, in the following table: TABLE SHOWING PERCENTAGE OF WATER, ORGANIC MATTER AND INORGANIC RESIDUE (ASH) PRESENT IN CERTAIN TISSUES AND BODY FLUIDS Water Organic and volatile matter Inorganic resi- due (ash) Blood corpuscles 54.60 44.68 0.72 Blood serum 90.50 8.68 0.82 Urine 95.70 3.00 1.30 Bone 22.10 26.00 52.00 Dentine. . 10.00 25.00 65.00 Enamel . 0.40 3.60 96.00 Blood 79.50 19.75 0.80 Human milk 86.80 12.85 0.35 Pus 87.00 12.20 0.80 Lymph 91.80 7.40 0.80 Chyle 91.80 7.40 0.80 Bile 85.92 13.30 0.78 Pancreatic mice 90.97 8.18 0.85 Gastric juice 99.43 0.33 0.24 Saliva ... . . .... 99.50 0.32 0.18 Acid-forming and Base-forming Elements. The actW-forming and base- forming elements of the aliment are interesting from a clinical point of view. For example, a dietary of proteins, fats and carbohydrates which has been demineralized and leaves no ash residue after incineration, will introduce no fixed bases in the body, but, on the other hand, will introduce sulphuric acid from the metabolism of sulphur contained in the ingested protein. Such a dietary would be "acid-forming." Doctor Taylor (37), of the University of California, subsisted for a period of nine days upon a practically ash-free aliment made up of 70-75 grams of purified egg albumin, 120 grams of washed olive oil, and 200 grams of cane sugar. He describes his symptoms as essentially those of FACTORS WHICH AFFECT METABOLISM 315 acidosis, similar to that produced from the want of base-forming elements in the diet. Later Goodall and Joslin(38) carried out experiments similar to Taylor's without obtaining confirmatory evidence, which would suggest considerable differences between persons in reference to suscepti- bility of the acids elaborated in the metabolic processes. Deprivation of the organic acids leads to a peculiar disturbance of the system resulting in the development of scurvy. Of the inorganic salts sulphur is essential to growth. The chlorids keep the globulins in solu- tion, and are the source of the hydrochloric acid of the gastric juice. The phosphates are essential for the growth of bone and to the nervous system. Deficiency of calcium and magnesium leads to rickets and other abnormal conditions. Gout has been termed the disease of luxury. On the other hand, scurvy is the disease of privation or penury. Funk and other writers hold that scurvy is a deficiency disease due to lack of vitamines in the food- stuffs. Gautier held that the class of vegetables containing a liberal amount of alkaline ash acts as an antiscorbutic. Sherman (39) avers that: If susceptibility to scurvy and the injurious results from an ash-free diet are even partly due to the disturbances of the balance of acid-forming and base-form- ing elements in the food, it would seem to follow that the normal dietary should be so chosen as to furnish the body enough base-forming elements to neutralize the mineral acids produced in metabolism. This author determines the Ixilniice of acid-forming and base-forming elements in foodsti ill's by ascertaining the presence of chlorin, sulphur, phosphorus, sodium, potassium, calcium and magnesium, computing the equivalent in acid of the first three elements, the equivalent in alkali of the last four, then determining the excess of acid or base, as the case may be, which would result from the complete oxidation in the blood. He holds that : While in actual metabolism all of the sulphur of the food is not oxidized to sulphate and the ammonia is not quite all converted into urea, yet the method is fairly satisfactory as a means of comparing foodstuffs in respect to their metabolic acid-forming and base-forming properties. For tables graphically showing the relative preponderance of acid- forming and base-forming elements in some typical foodstuffs, as worked out by Sherman, consult the following (Volume II, Chapter XI, page 357). From a study of these tables, it will be learned that lean beef and round steak, bacon and ham possess a high percentage of acid-forming elements. It will also be seen that the cereal grains show a slight prcpor- 122 316 NUTRITION AND MINERAL METABOLISM derance of the acid-forming elements. While, in the second table, it will be seen that milk, fruits and vegetables show an excess of base-forming elements. The blood is physiologically and chemically an alkaline medium and upon its alkalinity depends its power of transporting carbonic acid, and upon this fact as well depends the power of .the blood to take up, at certain times, organic acids without itself becoming acid. When large doses of alkalies are administered, the economy at once begins preparing for their excretion, so that a short while after absorption only a small portion can be found present in the organism. Just how alkali is retained in the blood, how much of it at any stated period is present in the blood and lymph, what quantities pass into the different tissues and various organs, is not definitely known. And yet an accurate understanding of this interesting phenomenon would be of great practical significance for the scientific medical man. The great variation in the alkalinity of the tissues, though often challenged by thera- peutics, is at present an admitted fact Still their percentage and extent are as yet "seen through a glass darkly." A dietary in which the acid-forming elements are present in excess calls for a withdrawal of the fixed alkalies from the tissues and circulating fluid on the one hand, or, on the other, for an increase of ammonia salts in the body, neither of which is desirable. Carnivorous animals habitually ingest foods with an excess of acid-forming elements without harmful effects, and while in man it might not be dangerous, yet it must put an extra tax upon a constitution accustomed to a mixed dietary which might better be avoided, especially, as Sherman thinks : We have no reason to anticipate any disadvantages from a preponderance of base-forming elements, which, if not used to neutralize stronger acids, would take the form of bicarbonates and thus aid in the maintenance of the normal and neces- sary neutrality or faint alkalescence of the blood and tissues. It would be a good practice, therefore, when formulating a dietary in which the foods contain acid- forming elements, to be fairly well balanced by other foods in which the base-form- ing elements predominate, so that the diet as a whole may yield sufficient fixed bases to neutralize any excess of mineral acids evolved during the processes of metabolism. If all the available information could be collected, with the opinions of critics added thereto, it would make a volume in itself. Therefore, we present only a brief prologue to mineral metabolism and the reader is referred to the succeeding chapter for value uses and sitology of the inorganic salts. REFERENCES 317 REFERENCES 1. TIBBLES, WILLIAM. Food in Health and Disease. 2. HALL, W. S. Nutrition and Dietetics. 3. RANKE. Einwirk. des Tropen klimas auf die Ernahrung des Menschen, 1900. 4. PETTENKOFER and VOIT. Respirations Versuche am Hungernden Pflanzenfresser. 5. ATWATER. U. S. Dept. of Agric., Bull. No. 109, pp. 126-127. 6. - and ROSA. U. S. Dept. of Agric., 1899, Bull. 63. 7. ZUNTZ. Nahrungszufuhrtierische Oxydations-prozesse, Arch. f. d. ges. Physiol., vol. xv, p. 634. 8. VON NOORDEN. Metabolism and Practical Medicine, Physiology. 9. BENEDICT. For description of a new form of apparatus for study- ing respiratory exchange. See Am. J. Physiol., 1909, vol. xxiv, p. 545. 10. SHERMAN, HENRY C. Chemistry of Food and Nutrition, pub. by Macmillan Co., 1914. 11. LEVY, MANGUS. Arch. f. d. ges. Physiol. 12. RUBNER. Die Gesetze des Energieverbrauches bei der Ernahrung, 1902. 13. ATWATER, BENEDICT, et al. Respiration Calorimeter Experiments, Office of Exper. Sta., U. S. Dept. of Agric., Bull. Nos. 44, 63, 69, 109, 136, 175. 14. BENEDICT. The influence of Inanition on Metabolism, Pub. No. 77, Carnegie Institution of Washington, 1907. 15. ATWATER and BENEDICT. The Nutritive Value of Alcohol, Memoirs Nat. Acad. of Sciences, 1902, p. 394. 16. LUSK. The Science of Nutrition. 17. VON NOORDEN. Loc. cit., 6th ed., 1912, p. 121. 18. JANNEY, N. W. J. Biol. Chem., 1916, vol. xxiv, p. 30. 19. KOCHER, R. A. The Mechanism of the Sparing Action of Carbo- hydrates on Protein Metabolism, J. Biol. Chem., 1916, vol. xxv, p. 571. 20. KAYSER and LANDERGREN. Skand. Arch. Physiol., 1903, p. 112. 21. ATWATER. U. S. Dept. of Agric., Bull. No. 136, p. 197. 22. KAYSER. Einfl. von Fett und Kohlenhydrat, 1902. 23. ATWATER and BENEDICT. Metabolism of Matter and Energy, U. S. Dept. of Agric., Bull. No. 176, p. 136. 318 NUTRITION AND MINERAL METABOLISM 24. VOIT. Herman's Handbuch der Physiologie, vol. vi, p. 396. 25. WILLCOCK and HOPKINS. J. Physiol. 26. KAUFFMANN. Tigerstedt's Physiology, p. 109. 27. Ho WELL. Text-book of Physiology. 28. HUTCHISON. Food and Dietetics. 29. DESTKEE. Quart. J. Inebr., Jan., 1899. 30. SCHNYDEK. Pfluger's Archiv., 1903, vol. xciii, p. 451. 31. AT WATER and BENEDICT. An Experimental Inquiry Regarding the Nutritive Action of Alcohol, Nat. Acad. of Sci., 1902, vol. viii, Memoir 6. GODDAKD. Lancet, Oct. 22, 1904. 32. ANTSIE. Practitioner, 1874, vol. xiii, p. 15. ATWATER and BENEDICT. Loc. cit. 33. TSUBAI. Zeitschr. f. Biol., 1904, vol. xliv, p. 377. 34. BIDDER and SCHMIDT. Die Verdauungssafte und der Stoffwechsel, 1852. 35. ATWATER and BENEDICT. Experiments on Metabolism, U. S. Dept. of Agric., 1903, Bull. No. 136. 36. NEUMANN, R. O. Der Einfluss grb'sserer Wassermengen auf die Nieren-Austeichung, Arch. f. Heilkunde, 1899, vol. xxxvi, p 248. 37. TAYLOR. Pub. in Pathol. Univ. Cal., vol. i, No. 7, pp. 71-86. 38. GOODALL and JOSLIN. Trans. Assn. Am. Phys., 1908, 23-92-196. 39. SHERMAN. Chemistry of Food and Nutrition. BIBLIOGRAPHY ABDERHALDEN. Text-book of Physiological Chemistry. ARMSBY. Principles of Animal Nutrition, chap, vii to x, . Ibid., chap, vi and xi. . Ibid. ATWATER. Methods and Results of Investigations on the Chemistry and Economy of Food, Office of Exper. Sta., TJ. S. Dept, of Agric., 1895, Bull. No. 21; Neue Versuche ueber Stoff- und Kraft- wechsel, Ergeb. d. Physiol., 1904, p. 3. ATWATER and BENEDICT. A Respiration Calorimeter with Appliances for the Direct Determination of Oxygen, Pub. No. 42, Carnegie Instit. of Washington, 1905. , ec al. Respiration Calorimeter Experiments, Office of Exper. Sta., U. S. Dept. of Agric., Bull. Nos. 44, 63, 69, 109, 136, 175. BIBLIOGRAPHY 319 . Comparison of Fats and Carbohydrates as Protectors of Body ' Material, Office of Exper. Sta., U. S. Dept. of Agric., Bull. 136, pp. 176-187. BENEDICT and CARPENTER. The Metabolism and Energy Transforma- tions of Healthy Man During llest, Pub. No. 126, Carnegie Instit. of Washington, 1910. . The Influence of -Muscular and Mental Work on Metabolism and the Efficiency of the Human Body, as a Machine, -Office of Exper. Sta., U. S. Dept. of Agric., 1909, Bull. No. 208. BUNGE. Physiological and Pathological Chemistry, chaps, vii and viii. CJIITTENDEN. The Nutrition of Man, chaps, i and ii. FISHER. A New Method for Indicating Food Values, Am. J. Physiol., vol. xv, p. 417. FOLIN. A Theory of Protein Metabolism, Am. J. Physiol., vol. xiii, pp. 117-138. . A Theory of Protein Metabolism, Am. J. Physiol., vol. xiii, pp. 117-138. FORBES. The Balance between Organic Acids and Bases in Animal Nu- trition, Ohio Exper. Sta., 1909, Bull. No. 213. 11 AM MARSTEX. Text-book of Physiological Chemistry. HART, MoCoixnM and FULLER. The Role of Inorganic Phosphorus in the Nutrition of Animal Research, Wisconsin Exper. Sta., 1, 1909, Bull. No. 1. HENDERSON. Das Gleichgewicht zwischen Basen und Sauren im Their- ischen Organismus, Ergebn. d. Physiol., 1909, vol. viii, pp. 254- 325. HILL. Recent Advances in Physiology and Biochemistry, chaps, xi and xii. . Ibid., chaps, viii, ix, x, xv. HONVKLL. Text-book of Physiology, chaps, xlvii and xlviii. HUTCHISON. Food and Dietetics, chaps, ii and iii. JORDAN, HART and PATTON. Metabolism and Physiological Effects of Phosphorus Compounds of Wheat Bran, Technical Bull., No. 1, New York Exper. Sta. and Am. J. Physiol., 1906, vol. xvi, p. 24. LUSK. Elements of the Science of. Nutrition. . Ibid., 3rd ed., 1909, pp. 17-45. . The Fate of the Amino Acids in the Organism, T. Am. Cliem. Roc., 1910, vol. xxxii, pp. 671-680. OSBORNE. Sulphur in Protein, U. S. Dept. of Agric., Bull. 227. PATON. On "Folin's Theory of Protein Metabolism," T. Physiol., 1905, vol. xxxiii, p. 1. 320 NUTRITION AND MINERAL METABOLISM SHERMAN and SINCLAIR. The Balance of Acid-forming and Base-forming Elements in Food, J. Biol. Chem., 1907, vol. iii, p. 307. VON NOORDEN. Metabolism and Practical Medicine, vol. i, pp. 185-207. . Ibid., vol. i, pp. 208-282. . Metabolism and Practical Medicine, vol. i, pp. 64-127, 153, 168. WILLCOCK and HOPKINS. The Importance of Individual Amino Acids in Metabolism, Ibid., 1906, 35, 88-102. CHAPTEK XI SCIENTIFIC FEEDING OF NITROGEN FOODS "Man begins to die as soon as he is born," but a competent physician who under- stands the science of trophotherapy will be able to pilot his patient through the rocks and shoals of diet and land him in a haven of safe and enjoyable life. Nitrogen in Diet: Nitrogen Equilibrium; Nitrogen in Feces; Low Protein Diet; High Protein Diet; Nitrogen-free Diet. Protein Metabolism: Urea; Ammonia; Creatinin; Uric Acid; Purin Bodies Source, Chemistry, Occurrence in the Body, Purin Bodies in Food, Effect of Purin Foods on Uric Acid, Excess of Purin Diet, Purin-free Diet, Low Purin Diet; Fat-free Diet; Carbohydrate-free Diet; Cellu- lose Diet. Mineral Metabolism: Electrolytic Properties of Salts; Sodium Chlorid; Salt-free Diet; Potassium Chlorid; Calcium Diet; Magnesium Salts; Phosphorus; Iron Salts; Sulphur Salts; Acid-forming and Base-form- ing Elements of Diet; Resume". NITROGEN IN DIET The great attention that food both in health and disease has received in recent years has yielded to the profession of medicine valuable infor- mation concerning trophodynamics. We have considered experimental researches in regard to dietetics conducted largely with a view of ascer- taining the nutritive value of food material in regard to the requisite quantities for supporting life and maintaining bodily equilibrium in all its phases and activities. We know, too, that the earliest views so ardently promulgated by von Liebig that there is a direct utilization of particular kinds of food constituents for particular purposes do not strictly hold true; that the use made of the food constituents in the body is determined not alone by the nature of the constituents, but to a certain extent by the 321 322 SCIENTIFIC FEEDING OF NITROGEN FOODS relative quantities of the various constituents on the one hand and by the particular needs of the body on the other ; that, for example, while protein is essential in food for construction of protoplasm, either in growth or repair, when it is ingested in amount greater than is required, the excess is utilized for other purposes as in oxidation to yield energy or heat, or in storage as glycogen or fat, as the case may be. Indeed, it must be clearly recognized that the knowledge of the food constituents as they enter the body and the end-products of metabolism as they leave the body, yields inadequate information as to the intervening processes of metab- olism which may or may not follow along given lines. It is the knowl- edge that we are to-day gaining of processes of intermediary metabolism, that is shedding new light on phases of nutrition, that heretofore have been merely conjectured or even altogether unknown to us. For a given individual, exercise governs largely variations in the amount of food required. Within certain limits, it is not so much what form the food is in, so long as it can be utilized. Protein metabolism does not depend so much on the amount of exercise as it does on the amount and proportion of protein food ingested. Nitrogen equilibrium in nor- mally healthy individuals may be maintained on various amounts of pro- tein. It is determined by comparing the total nitrogen intake with the total output. If the amount corresponds, or nearly so, the body is said to be in a state of nitrogen equilibrium. Equilibrium may be established at a low level on partaking of small amounts of protein and larger amounts of non-protein food, or on the other hand, it may be maintained on a high level by partaking more freely of protein with correspondingly less non- protein. Chittenden maintained health, strength and bodily vigor on 50 grams of protein daily. On the other hand, nitrogen equilibrium has been established on as much as 150 to 200 grams of protein daily. The human economy in normal conditions regulates the amount of protein metabol- ized to both the amount and, as well, the total food ingested. Nitrogen Equilibrium. Major Charles E. Woodruff, 1 in discussing the nitrogen equilibrium in the tropics, says : All natives of the tropics (where civilization causes over-population) are in a condition of nitrogen starvation and need much more nitrogen than they can pos- sibly get. The old standards of teaching that we should eat as the natives is most vicious. They do not eat meat because they cannot get it. They crave it, need it, and eat it when they can. On account of the destructive effects of the concen- trated tropical actinic rays on protoplasm, we need more nitrogen than at home. Please do not copy the old falsehood that we need less. It is also true that -we A- i Major Charles E. Woodruff, Surgeon, U. S. Army. NITKOGEN IN DIET 323 need fat, as it furnishes energy better than carbohydrate. It is eaten in prefer- ence to starches and sugars for this purpose by workers when they can afford it, but they take to starch (rice) because it is cheaper. It is incorrect to say that it overheats. It does not overheat us, and it is false to say that fat is not needed in the tropics. Nitrogen equilibrium is best maintained on a mixed diet, containing in addition to the protein both fat and carbohydrate. If the non-protein portion of the diet is reduced, other things being equal, there will be a nitrogen loss, owing to the fact that more protein is used to supply the heat and energy that formerly was supplied by the greater amount of non- protein food. It takes some days to establish a nitrogen equilibrium when the usual diet of an individual is changed. Say that the ordinary dietary contains 1(5 grains of nitrogen and the diet is suddenly changed. It will be several days before equilibrium will be established on a new level, whether it be above or below the amount usually metabolized. A slight loss of a transient character will be noted when the intake is lessened, but, if the loss persists, it means that either too little protein is being taken in the food, or that the total caloric value of the food is below the normal amount required, or the body is affected with some wasting disease attended with nitrogen loss. Nitrogen in Feces In determining the available nitrogen in food, attention must be given to the nitrogen of the feces. The feces consist of the undigested residue of the food, together with nitrogen from mucus, worn out epithelial cells from the walls of the alimentary tract, bacteria, coloring matter, bile and other residue. Therefore, the contention that all the nitrogen in the feces is derived from the food is erroneous. That which is derived from the bile, mucus and debris of broken-down epithelial cells is body waste, and has already been added to the nitrogenous content of the organism. During a fast, when no food is consumed, bile and mucus are still secreted, and the epithelial cells continue to break down and bac- teria continue to flourish, and are expelled with the feces. Heider con- ducted experiments with a nitrogen-free food, which he previously ascer- tained to be readily digestible. The subject was a man of medium height and weight. The ration was a cake made from starch, sugar, fat and a little salt leavened with cream of tartar and bicarbonate of soda. White wine and water in small quantities were the only beverages and were free of nitrogen. This ration was ingested, he believed, in sufficient quantities to secure normal secretion of the digestive juices. On such a diet, the inference is that any nitrogen found in the feces could be attrib- uted to body sources only. The average amount of nitrogen in the feces during this experiment was 0.5 grams per day, which may be taken to represent fairly the amount of nitrogen in the feces arising from body waste ; any amount above this figure ordinarily may be attributed to resi- due from the food. Low Protein Diet. The low protein diet of Chittenden has been re- ferred to above and in Volume II, Chapter V. He and his followers urge but little protein above the minimum, together with the requisite amount of fat and carbohydrates to make up the needed calories. They urge that on this diet health and weight may be maintained and that the mental and physical efficiency is greater than when more liberal diets are allowed. The experiments of Chittenden are of enormous practical value in showing that a low protein diet can be used for a long period of time with- out danger (see table, Volume II, Chapter IX, p. 254). Low protein diets are of value in gout and all gouty affections, in diseases involving the tegumentary system, more particularly when accompanying disorders of metabolism, in treating the ill effects of habitual overeating and arterio- sclerosis, and in fevers and other affections. Brain workers and others following sedentary vocations will no doubt do better on diets lower in protein than usually advised. After carefully considering all the points of a low protein diet, we are led to the conclusion that it is, at the same time, a low-purin diet; and many authorities believe that the beneficial effects are due in part to the freedom of a low-protein diet from purin bodies. Many clinicians find there are only a few cases of gout where a moderate quantity of animal food does harm, and many where it exerts a beneficial effect. As a matter of fact, the major portion of the human race will go on eating and drinking and "making merry," according to their appetites and their ability to gratify them. Still, on the other hand, the problem is one of the highest human interest, particularly in refer- ence to the "dietary in disease," and in preventing disease when danger signals loom in the distance. It is interesting to compare the navy diets (see Volume II, Chapter XVIII), which are essentially high protein diets, for the reason that the sailor prefers it, and is more contented and does better work than when on perhaps a more healthful protein, but for him less appetizing, diet. Below we append a standard for a low protein diet : LOW PROTEIN DIETARY In the morning upon waking 5 to 10 ounces of hot water containing 10 to 20 grains of sodium bicarbonate or potassium citrate. Half an hour later: NITROGEN IN DIET 325 Breakfast: A large plate of fruit and milk or cream, followed by abundant cereal and milk with bread and butter. No meat, eggs or fish. Wait five hours. Dinner: Not more than four ounces of meat or fish, which must be quite fresh; a very large plate of green vegetables, potatoes sparingly, and nothing more than a taste of sweets. Five hours later: Supper: May be a repetition of breakfast, but succulent vegetables may replace the fruit, and macaroni or a similar dish may be substituted for the cereal. Thirst and hunger between meals may be satisfied by water and fruit about one hour before a meal or during the night. Abstain from meat juices (gravy and soup), gelatin, coffee, tea, cocoa, salt and strong condiments, alcohol, pastry. All starches and meats must be well cooked. High Protein Diet A high protein diet, according to Voit's standard from 118 to 120 grams of protein daily, may be of use iii certain condi- tions during pregnancy, lactation, in convalescing from wasting diseases, in the beginning of physical training when muscular growth is great, and in combating certain diseases like tuberculosis, etc. During growth the protein requirements are higher than in adult life, but, on the other hand, high protein diets are objectionable for individuals who follow sedentary occupations, and for all of those conditions benefited by a low protein diet. When studying the subject of Protein and Nutrition in \ 7 olume II, Chap- ter IX, we learned the minimum amount of low-protein diets to be 60 grams, and for a high-protein diet, 120 grams; this leaves rather a wide range, and it is safe to say that the optimum lies between these two. We do not believe that any standard will ever be definitely fixed that will be of universal application, but we are inclined to believe that future stand- ards will be worked out to cover the various classes and normal condi- tions, as well as in different disturbances of metabolism. To-day the standards that are being put into practical use for tuberculous patients, contain 30 per cent of protein above the normal. In nephritis 60 to TO grams are allowable; in fevers, 70 grams, etc. Nitrogen-free Diet A nitrogen-free diet can be made from starch, sugar, salt and almond oil or other fat. This, material can be made pala- table and baked into a cake, with baking powder for leavening. There is no very great therapeutic use for a nitrogen-free diet nor is it conceivable that an individual would be satisfied with it for very long-. Its principal use seems to be chiefly for experimental purposes, especially when it is desired to make observations on the metabolism of nitrogen. 326 SCIENTIFIC FEEDING OF NITROGEN FOODS Lehman observed that when a man consumed a nitrogen-free diet for a period of three days, he excreted daily 7.4 grams of nitrogen. Reider, in a similar experiment, found that the average excretion of nitrogen by the kidneys was 8 . 7 grams and the f eces contained . 9 grams, which was equivalent to a loss of 56 grams of protein daily. Physiologists have not yet determined just how much "floating protein," or more correctly amino-acids, there is in the human organism. It varies daily; but it is safe to say that all the floating protein could be consumed in a very few days. If, for any reason, it should be determined to rid the system of "floating protein," it may be done by giving a comparatively free nitrogen aliment for a short period of time. This diet may be selected from the foods given in the table below, showing the percentages of protein in foods : PERCENTAGES OF PROTEIN IN PROTEIN-POOR FOODS Foods containing 0.5 per cent or less protein Foods containing 0.5 to 1.0 per cent protein Foods containing 1 to 1.5 per cent protein Foods containing more than 2 per cent protein Arrowroot starch, corn starch, sugar, honey, cottonseed oil, almond oil. Manioc starch, ar- rowroot, sago, tapioca, apples, pears, plums, rhubarb, toma- toes, cucumbers, radishes, turnips, oranges, lemons, raspberri es, gooseberries, strawberries. Grapes, bananas, leeks, onions, cabbage, celery, squash, parsnips, cauliflower, sauerkraut, horseradish, to- mato catsup, butter. Potatoes, string beans, artichokes, lard, thick cream, fat salt pork, fat ham, bone mar- row. After taking a diet consisting of the foregoing fruits and vegetables for four days, some bread, rice, oatmeal, milk pudding or soup may be added to the list. The amount of protein in these foods is as follows: Beef soup, .4 per cent; meat stew (when meat is taken out), 4.6; oxtail soup, 4.0 ; chicken broth, 3.6 ; tomato soup, 1.8 ; vegetable soup, 2.8 ; milk, 3.5 ; boiled rice, 2.8 ; boiled oatmeal (thick), 2.8 ; brown bread, 5.5 ; white bread, 8 or 9 ; zwieback, 9.8 per cent. The return to the ordinary diet, or one containing at least 55 grams of protein daily, should not be deferred longer than the eighth day. Spirits contain no protein. The amount in wine is practically negli- gible, and an infusion of cereal coffee (1 in 20) contains only 0.2 per cent PKOTEIN" METABOLISM 327 of protein. The choice of foods is large, and such a diet, while yielding sufficient energy, would speedily result in a clearance of superfluous pro- tein materials. We have learned that cell metabolism is attended by changes of a destructive nature. Carbon is oxidized, yielding carbon dioxid ; hydrogen unites w r ith oxygen and forms water. Nitrogen is burned off, but only partially reduced, urea being the chief product of protein metabolism. It is formed largely in the liver, but it is very probable that other cellular organs, such as the spleen and lymphatic glands, participate in its formation. RROTEIN METABOLISM In the study of the Physiology of Enzymes and Hormones as Applied in the Process of Digestion (Volume I, Chapter VI), we learned that the protein molecules, on being metabolized in the body, yield varying amounts of arginin, which ultimately undergoes hydrolysis into ornithin and urea. In this way it is possible to trace an appreciable part of the nitrogen of protein to the urea stage through a series of direct cleavages. The protein in digestion and in catabolism is split into amino-acids, which are even- tually deaminized, the nitrogen of the amino-group being split off as am- monia. This, with carbonic acid, forms ammonium carbonate or car- bamate which is transformed into urea by various organs of the body, notably by the liver, as stated above. The important nitrogenous end-products of protein metabolism other than urea, are ammonium salts, purin bodies and creatinin. Urea. Protein metabolism has heretofore been considered to be quali- tatively better, in proportion as a larger percentage of the urinary nitro- gen is eliminated as urea and a smaller moiety in other forms. This, however, is not always the case, since this may be largely a matter of the amounts of protein consumed. According to Folin, who made a careful and extended study of urines of healthy men partaking first of a high and then of a low protein diet, the distribution of nitrogen between urea and other nitrogenous end-prod- ucts depends very largely upon the absolute amount of nitrogen metab- olized. He observed a man who was fed on a high protein diet (free from meat) for one day and at the end of the week was partaking of a diet composed of starch and cream, which furnished in all about 6 grams of protein per day. The end-products of his protein metabolism are shown in the following table from Sherman: 328 SCIENTIFIC FEEDING OF NITROGEN FOODS END PRODUCTS OF PROTEIN METABOLISM ON BOTH HIGH AND LOW PROTEIN DIET Nitrogenous end product's of protein digestion On high protein diet (free from meat) On low protein diet (starch and cream) Grams Per cent Grams Per cent Total nitrogen 16.8 14.7 0.49 0.18 0.58 0.85 87.5 3.0 1.1 3.6 4.9 3.6 2.2 0.42 0.09 0.60 0.27 61.7 11.3 2.5 17.2 7.3 Urea nitrogen Ammonia nitrogen Uric acid nitrogen . .... Creatinin nitrogen Undetermined nitrogen An examination of this table shows there was a marked decrease in both the absolute and relative amounts of urea, as well as a decrease in the absolute, but an increase in the relative amount of uric acid excreted, while the absolute amount of creatinin remained stationary. Regarding the urea of the circulating blood, Dr. Denis, of the Massa- chusetts Hospital, l found that the intake of ordinary protein may be in- creased from the amount sufficient to give from 6 to 8 grams of urea in the 24-hour urine, to that sufficient to produce a daily urea excretion of from 30 to 50 grams without producing any material increase in the cir- culating urea. Until recently, we depended entirely upon the analysis of the urine to determine the metabolism of any dietary regimen. The toler- ance of the human economy for carbohydrate food was ascertained by examination of the secretion from the kidneys for sugar after an ingestion of varying quantities of this type of foodstuff. The ability of the kid- neys to excrete the waste products of inorganic salts was likewise ascer- tained by urinary analysis and the efficiency of the renal functions was judged on this basis. The more advanced methods for the analysis of very small quantities of blood so-called micro-analysis has transformed the seat of observation to the circulating fluid in the vascular system. To- day blood analysis for clinical purposes is making rapid strides, not only so far as qualitative tests are concerned, but for quantitative tests. At the present time, methods for the determination of the sugar content of the blood are in use; likewise, the estimation for non-protein nitrogen, urea, creatinin, uric acid, fats and lipoids has been brought within the scope of a feasible determination on small samples of blood. Editorial, J. Am. M. Ass., 1917. PROTETX METABOLISM 329 Ammonia. As previously stated, ammonia is evidently a normal pre- cursor of urea, being changed into the latter during its passage through the liver. According to this assumption the elimination of nitrogen as ammonia may be notably increased at the expense of urea : (a) by the ingestion of mineral acids, or of food yielding unusual amounts of such acids by oxidation in the body; (6) in cases yielding an excess of acids in metabolism, as the acidosis of diabetes, fevers (inanition) and pregnancy; (c) in structural diseases of the liver (acute yellow atrophy). It will be seen that the first and second methods increase the ammonia by "fixing" it as salts, thus preventing its transformation into urea, while the third diminishes the ability of the system to effect such transformation. Creatinin. Normal urine contains about 1.5 grams of creatinin per day. The origin and significance of endogenous creatinin and especially its physiological relations to creatin (of which it is chemically the anhy- drid) is still unsettled, despite much clinical research. It seems to depend on the musculature of the individual. The amount excreted is not gov- erned by the amount of protein consumed, therefore the percentage of urinary nitrogen appearing in this form tends to increase as the total nitrogen diminishes and vice versa. Sherman and Lusk agree with the above statement, but Folin, after an extended study of the urines of healthy men partaking first of a high and then a low protein dietary, con- cluded that the nitrogen excretion depended largely upon the amount of nitrogen metabolized. Uric Acid. The former theory as to the production of uric acid in the body was that it represented protein imperfectly oxidized into urea and that the uric acid diathesis was a condition of suboxidation in which the uric acid acted directly as a toxic agent. Of late, researches of physio- logical chemists have considerably modified this view, and it is now held that uric acid and allied purin bodies are entirely independent of the general catabolism of protein matter. It is a product of the final stage of catabolism of the purin bodies that in Volume I, Chapter III, we have seen enter into the construction of the nuclein and nucleoproteins. There- fore, the general clinical conception of the uric acid diathesis might be better termed "purinemia," Benedict(l). Purin Bodies SOURCE. Purin bodies are nitrogenous substances con- structed on the purin framework, C 5 N 4 . They include uric acid, xanthin, hypoxanthin, adenin and guanin, and closely related are methylxanthin and theobromin. Fischer has shown the relation of all these bodies to purin. They contain a central chain of three carbon atoms to which is attached on each side a urea group, so that they may be regarded as 330 SCIENTIFIC FEEDING OF NITROGEN FOODS diureids. These bodies arise from nucleoprotein, the components of which are normal constituents of the nucleus and protoplasm of cells. In the human economy the nucleoproteins are split into nuclein and protein, and finally the nucleic acid into purin bodies, pyrimidin bases, phosphoric acid and sugars. This is the normal order of the metabolic breakdown of nucleoproteins, and it occurs in some animals as well as in human beings. As a group the purin bodies are said to raise blood pressure and tend to produce angiosclerosis and various sclerotic changes in the viscera. In studying the characters of the proximate principles of foodstuffs (Volume I, Chapter III), we considered at some length the chemistry of purins and purin compounds, as also the pyrimidin bases to which the reader is referred. CHEMISTRY. Although current text-books on dietetics barely mention the chemistry of the individual purins, yet we consider them of sufficient importance to state some of the principal facts which underlie their group reactions in order to delineate the several phases of nuclein metabolism. According to Hall (2), the purin compounds crystallize easily, are more or less soluble in the usual solvents, and can now be oxidized and reduced. Hypoxanthin yields small crystalline scales with sharpened extremities almost like grains of wheat. Xanthin may be distinguished by its thin, flat, glistening rhombic plates, guanin by small prismatic crystals or amorphous masses, adenin by long needle-shaped prisms, and uric acid by rhombic plates. Rarer forms have been demonstrated by variations in the media and rapidity of crystallization. Their solubilities present the following remarkable differences: SOLUBILITY OF PURIN COMPOUNDS Water Cold Hot Hypoxanthin 1:300 1:78 Xanthin 1:13000 1:1300 Adenin 1:1086 Uric Acid Guanin 1:18000 Insoluble 1 :1600 Alkalies Weak Acids Soluble u Soluble u Spluble u Soluble Slightly soluble Insoluble Soluble From a synthetic standpoint the purin bodies are exceedingly interest- ing. About twelve different derivatives of the purin nucleus are known to exist in nature, but not less than 146 have been produced in the labora- tory. The closely related caffein and theobromin are largely used as medicaments for their stimulative and diuretic properties, and it is possi- ble that in the near future these may be made synthetically. Trichlor purin, obtained by the action of phosphorus chlorid upon uric acid, occu- pies a position midway between iiric acid and the methylxanthins, caffein, PKOTEIN METABOLISM 331 theobromin and theophylin. Emil Fischer, in his lucid and interesting address given in Stockholm in November, 1902, after the distribution of the Nobel prize, draws a picture of the time when the present coffee adulterants chicory and coffee surrogate will be superseded by syn- thetically made caffeiii, and suggests a period when coffee beans and their roasting will be unnecessary, since the solution of a small powder in hot water will give a well flavored, refreshing drink at a much lower cost and with much less trouble than the present conditions necessitate. OCCURRENCE IN THE BODY. Purin bodies exist ready formed in many of our foods, especially those in the animal kingdom; but on the other hand, the system can produce its own nuclein and the hi ^her com- pounds of nuclein on a diet free from purins, though, of course, containing proteins. Further, the elimination of purins is somewhat increased by increasing the intake of proteins, about half of the elimination of purins on an ordinary mixed diet being accounted for by the ingestion of more or less combined purins, and about half by the metabolism of nuclein- containing structures, such as white blood cells and the cells of viscera, namely, the kidneys, liver, pancreas, spleen and thymus. The old theory that no purin bodies are formed except from purins is false, while the older view that uric acid is a precursor of urea is true in a limited sense only. Lusk, referring to the successive steps in purin metabolism, states that deamination is brought about through the action of specific enzymes as follows: "Summarizing these results, it may be said that nucleic acid may be broken up by nuclease, a ferment found in all tissue. On the lib- eration of the purin bases, guanin and adenin are deaminized by guauase and adenase wherever these enzymes are found. Oxidizing enzymes, the xanthin oxidases, now convert hypoxanthin and xanthin into uric acid, while a uricolytic ferment of varying potency in different tissues in dif- ferent animals may break up and destroy the uric acid." Purins occur in both animal and vegetable nitrogenous bodies, in greater abundance in the former and obviously in still greater abundance in glandular viscera and white blood cells than in muscle and connective tissues, on account of the relative preponderance of nuclei, while vege- table nuclein occurs richly in yeast cells. The purins which are con- sumed with the food are termed exogenous purins, and those excreted by a healthy normal individual independent of his food the result of the metabolism of his own tissues endogenous purins. The daily "wear and tear" on metabolism of cell constituents leads to the production of a certain amount of purin bodies. These substances con- stitute the "endogenous" purins of the excreta. When tissues containing 332 SCIENTIFIC FEEDING OF NITROGEN FOODS nucleins or free purins are eaten, the "endogenous" purins of the food ingested become "exogenous" to the system which absorbs them. As "en- dogenous" purins are practically waste products on their way to excretion, when they become "exogenous" to another organism they have little nutri- tive value and demand early and rapid elimination. This is generally effected by deaminization of guanin and adenin and the oxidation of the oxypurins, hypoxanthin and xanthin to uric acid, and then the purin ring or chain in the uric acid is in the system, probably chiefly in the liver, partially split off and a portion of the uric acid excreted as urea. The course followed in the case of the nucleins is not quite clear, as a smaller percentage appears in the urine as uric acid. The amount of purins excreted in the urine due to endogenous forma- tion may be estimated after taking a purin-free diet for a few days, and the amount varies from 0.1 to 0.2 grams per day (3). The exogenous purins are principally transformed in the body, 50 per cent being ex- creted as urea and the remaining portion being eliminated by the kidneys as' uric acid with some xanthin and hypoxanthin. We can apply the term "free-purins" to purin bodies, and "bound- purins" to the purins of nucleic acid, nuclein and nucleoproteins. The process of purin formation goes on throughout life as a part of the cell metabolism, but the transformation of purin, likewise, goes on constantly. A number of enzymes cooperate in the transformation of purin-containing materials, for instance, nucleases liberate guanin and adenin from nucleic acid, these aminopurins being converted by the enzymes guanase and adenase into xanthin and hypoxanthin respectively, and oxidases trans- form hypoxanthin to xanthin and then to uric acid. The latter is finally to a certain extent decomposed and destroyed by uricolytic enzymes of varying potency present in the various organs. Hypoxanthin and xanthin are often obtained as products of decompo- sition of nucleic acid, but are generally formed by the deaminization and oxidation of guanin and adenin. It is now generally conceded that certain purin bodies are constantly being produced wherever cellular processes are in active operation, and although normally these are largely converted into other materials which are more easily excreted, practically all nitrogenous animal foods contain some of them. Lean meat, the flesh of mammals, birds and fish, contains xanthin, hypoxanthin and uric acid, besides urea, creatin, creatinin and other extractives. Liver is rich in nuclein, xanthin, hypoxanthin, urio acid, urea and other nitrogenous extractives. Spleen (milt) also is rich in nuclein, xanthin, hypoxanthin, uric acid, as well as lecithin, creatinin, PKOTE1N METABOLISM 333 leucin and tyrosin. Thymus (chest sweetbread) contains nuclein, xanthin, hypoxanthin, guanin and adenin in large amounts. Pancreas (belly sweetbread) contains the same kinds of purins, besides leucin, tyrosin and other amino-acids. Kidneys contain uric acid, xanthin, hypoxanthin, as also urea, tuarin, leucin, creatin, creatinin, etc. Beef-tea, soup and gravy contain the same kinds of purins and extractives as the substances from which they are derived. Vegetable foods, especially seeds, contain nucleo- proteins, nuclein, nucleic acid, and purin bodies, with amino-acids, such as asparagin, leucin, tyrosin, etc. Tea, coffee and kola contain caffein or trimethyl-xanthin that is, xanthin with three methyl groups in its molecule; cocoa contains theobromin or dimethyl-xanthin ; and guarana contains both caffein and theobromin. As already stated, according to Burian, all of the exogenous purins are not excreted; a small fraction remains in the organism or becomes entirely disintegrated by the oxidases of the various organs. Therefore, on ordinary diets, while the excretion of purin is necessarily increased by the exogenous or food purin, not all that is ingested is eliminated as such. The amount of exogenous purin excreted in the urine is scarcely influenced by the individuality of the subject, usually the purin excretion in normal individuals being practically the same ; but it must be borne in mind that its excretion is largely influenced by certain foods. For instance, in beef and veal, the purin content is 0,16; calf's liver, 0.12; calf's spleen, 0.16; calf's thymus, 0.4, and in coffee, 0.2 per cent. When these organs are largely partaken of or eaten alone, they lead to excretion of exogenous purin in the following proportions : beef and veal, 0.03 ; liver, 0.06 ; spleen, 0.8; thymus, 0.1; coffee, 0.075. Burian and Schurr as a result of their researches conclude that with the identical kind and same pro- portion of food the exogenous purin in the urine is virtually the same in all persons. According to Walker Hall, there is no personal equation in this metabolic process. It is known, however, that all purins in the food are not absorbed. There is a normal daily excretion of purin bodies in the feces referred to as fecal purin, to distinguish it from that ex- creted by the kidneys called urinary purin. Of course, the amount of fecal purin varies with the kind of food, and is greater where substances are eaten which are rich in nuclein and purin derivatives. Ordinarily, 60 per cent of the purin bodies are absorbed and 40 per cent excreted with the feces. PURIN BODIES IN FOOD. The chief fluctuation in the amount of nric acid in the urine can be explained by variations in the amount of uric acid yielders (purins) contained in the food. The endogenous fraction, 334 SCIENTIFIC FEEDING OF NITKOGEN FOODS on the other hand, seems to be thoroughly fixed, but as to its exact seat and mode of formation and the precise conditions which control it, we still have much to learn. It is obvious that we have at hand an important means of regulating the amount of uric acid liberated in the body, namely by controlling the amount of purins in the dietary. As stated, the foods which yield much uric acid are the cellular organs of animals. We have, then, a clear dietetic indication if we wish to lessen the liberation of uric acid in the body. The diet recommended is one composed largely of vegetables with the exception of oatmeal, beans, peas, onions and asparagus. Below we append a table from Tibbies (4) of the various foodstuffs, showing the percentage of purins contained, which are to be tabooed if we wish to lessen the manufacture of uric acid in a patient. THE QUANTITY OF PURINS IN FOOD VAKIETIES OF FOOD Purins, grains per pound Percentage of purins Codfish 4.07 Plaice 5.56 Halibut 7.14 Salmon 8.15 Tripe 4.00 Mutton 6.75 Veal: Loin 8.14 Pork: Loin 8.49 Neck 3.97 Ham (fat) 8.08 Beef: Ribs 7.96 Sirloin 9.13 Steak 14.45 Liver 19.26 Sweetbread 70.43 Chicken 9.06 Turkey 8.82 Rabbit 6.31 Oatmeal 3.45 Peameal 2.54 Haricot beans 4.16 Potatoes .14 Onions .26 Asparagus 1.50 Lager beer 1.09 Pale ale 1.27 Porter 1.35 .058 .079 .102 .116 .057 .096 .116 .121 .056 .115 .113 .130 .206 .275 1.006 .129 .126 .097 .053 .039 .063 .002 .009 .021 .012 .014 .015 EFFECT OF PURIN FOODS ON URIC ACID. The effect of purin foods on the uric acid content of the blood has recently been studied at length by W. Denis (5), who concludes that "in normal individuals no PROTEIN METABOLISM 335 increase in the circulating uric acid is produced by the ingestion of even large quantities of purins. The ingestion of purins, either free as they occur in meats, or in the form of nucleoproteins of glandular tissues like liver, sweetbread, etc.," is followed by a decided increase in the urinary output of uric acid. Denis concludes that the normal kidney reacts to an excess of uric acid in a way essentially similar to that which it conducts itself to an excess of urea, and is able to excrete the excess of uric acid presented to it when a diet high in purins is fed, thereby keeping the cir- culating uric acid at the same level as that obtained when only endogenous uric acid is to be excreted. When the kidney has been damaged, even before certain damage has reached the point where nitrogen retention is apparent, as shown by the non-protein nitrogen values, an accumulation of uric acid takes place in the blood after a short period of purin feeding. This phenomenon is interesting, not alone from the evidence that it brings of the importance of the renal efficiency for the level at which uric acid circulates in the blood, but also for its value to diagnostic procedures. Denis suggests that when the determination of uric acid in the blood is undertaken for diagnostic purposes, the insistence for a short period of purin-free foods is unnecessary, except in cases in which kidney insuf- ficiency exists, or perhaps in the case of persons who habitually consume extremely large quantities of foods of a high purin content. There are two views as to the origin of uric acid: (a) that it is formed in the kidneys; (6) that it is formed in the tissues. The view that uric acid is formed in the kidneys as well as excreted by them was taught by Garrod as early as 1848, who was able to show that the blood of gouty persons contained abnormal quantities of uric acid, which observation has since boon confirmed by many observers. FACKSS OF TURIN DIET. The continuous consumption of food con- taining purin bodies in large percentage ultimately leads to their accumu- lation and retention in the organism, when renal insufficiency supervenes. The normal liver can transform and the kidneys can excrete purin bodies so long as these organs are executing their normal functions, and no accumulation will result, but there is always danger that the constant irri- tation of the kidneys by the excess of purin, more especially uric acid, may result in chronic nephritis of the gouty type. Renal insufficiency, with the retention of purins in the system, it is thought, may be the cause of gout, but its etiological relation to so-called rheumatic gout, uric acid gravel, uric acidemia, migraine, neuralgia, sciatica, epilepsy, vascular dis- eases and many other conditions of ill health in which it has been put forth as a causative factor, is very doubtful. 336 SCIENTIFIC FEEDING OF NITROGEN FOODS PURIN-FREE DIET. Purin-free diet is indicated in gout and wherever it is desirable to reduce renal irritation. The foods enumerated in the table on page 334 should be interdicted and the following foods, which contain practically no purin, advised: milk, cheese, cream, butter, eggs, white bread, macaroni, rice, sago, tapioca, cabbage, cauliflower, lettuce, water- cress, fruit, sugar, honey, marmalade, jam, jelly, sherry, port, volnay. and claret. Four articles of diet milk, butter, eggs and cheese form together our most valuable means of withholding purin substances from the body and yet allowing the intake of a diet at once digestible, easily ab- sorbed and capable of maintaining nitrogenous equilibrium. It is a milk and fruit diet with bread and butter, milk puddings and salads added to it. Milk and milk products contain only traces of purin. Potatoes and onions contain very little, and are allowed. Oatmeal, peameal and malted lentils contain from 2l/> to 3^/2 grains of purins per pound, and should not be allowed. Asparagus contains very little purin, but much asparagin, which is a valuable protein-sparer. The following articles should be alto- gether forbidden : tea, coffee, cocoa, kola, guarana, fish, fowl and butcher's meat, brown bread, peas, beans, asparagus, ale, stout and lager beer. Cider, perry and a small quantity of spirits, claret, sherry or volnay, may also be allowed. Wines do not appear to contain any purin bodies and their harmful properties in gout must be due to some other constituent. The purin bodies in coffee, tea and chocolate are largely methyl-purin, and do not undergo the same metabolic changes as other purins, so they need not be excluded from the diet of the gouty or rheumatic as rigorously as other purins. Dr. Alexander Haig is authority for the following purin-free diet, which yields about 90 grams of protein, enough to meet the daily re- quirement : PURIN-FREE DIET TO SUPPLY PROTEIN 12 ounces of white bread contain 372 grains 25 grams 4 " oatmeal " " 208 " 14 2 " " rice " 86 " 5.6 " 3 pints of milk " 572 " 38.1 " 16 ounces of vegetables and fruit contain 140 " 9.3 " LOW-PURIN DIET. A low-purin diet consists of the same articles of food mentioned in the purin-free diet, with the following additions : tripe, codfish, potatoes, onions and particularly all fruits and green vegetables. Puddings may be made of milk, sugar, eggs, rice, sago, tapioca and maca- roni or flour, and custard, junkets, jellies and suet may be used. PROTEIN METABOLISM 337 One of Haig's disciples suggests the following for purin-f ree meals : FIRST DAY Lunch: Green vegetables, baked potatoes, butter, stewed figs, ^ pint of junket, 2 ounces of pine nut kernels (grated), with whipped cream. Dinner: Biscuits and butter, 1 ounce of grated cheese or some milk curds, light pudding, stewed fruit and cream. SECOND DAY Lunch: Green vegetables, potatoes with butter, cheese sauce and dry toast, fruit tart with cream, ^ pint of milk. Dinner: Two boiled eggs, biscuits and butter, milk pudding containing ^ pint of milk, stewed fruit and cream with biscuits. THIRD DAY Lunch: Potatoes and butter, green vegetables or salad, pudding or "cutlet" made of two ounces of ground nuts, stewed fruit and cream with biscuits. Dinner: Biscuits and butter, with cheese souffle* or omelette, stewed fruit and cream with biscuits, roasted chestnuts. It must be realized that a purin-free diet is only a temporary measure. A purin-free diet is at best only a low protein diet, and the physician must see that the proteins consumed do not fall below 60 or 70 grams per day. This diet should not be continued longer than two or three months before fish, tripe, pork and ham are allowed. Part of the meat bases and purins will be washed out during the boiling of these foods. It is claimed by some dietitians that the first meat allowed should be sweetbread, because the purins in it are "bound-purins." Equally competent observers, Walker Hall, Burian and Schurr, and Tibbies, do not favor the allowance of sweetbread for the reason that, on analysis, it shows a very high percentage of purins. These observers find that from 60 to 70 per cent of those purins are absorbed and, at the most, only 40 per cent escape absorption. It is advisable, when an ordinary diet is resumed, to make additions gradually. First allow boiled leg or loin of mutton, boiled rabbit or boiled fowl, as the breast of fowl contains less extractives than the other portions. The physician can conservatively allow pigeon, breast of turkey or other fowl, well roasted rib of beef, sirloin of beef and steak, the latter being added last. The following articles of food should be per- manently excluded : veal, pork, except the neck, goose, duck, high game and greasy foods. The question has been asked : "Is a purin-free or a low- purin dietary useful in the treatment of gout ?" Most certainly it is. If 338 SCIENTIFIC FEEDING OF NITKOGEN FOODS gout be due to the defective metabolism of nuclein or accumulation of purin bodies from renal insufficiency, these substances should certainly be excluded from the diet until the organism recovers its powers of elimi- nating them. The diet doubtless has its limitations. It is not a panacea, and in gout its use is limited by the nature of the disease. Fat-free Diet. A fat-free diet is of value in hypochlorhydria, catarrh, atony and dilatation of the stomach and in carcinoma of the stomach. For some time it has been known that the presence of an excess of fat, particularly of butter, in. the contents of the stomach, will check the secre- tion of gastric juice, and advantage has been taken of this fact in the treatment of hypochlorhydria. On this account, the absence of fat from food allows a more generous secretion of gastric juice, including hydro- chloric acid. In various disorders of the stomach, a condition of hypo- chlorhydria exists, where the normal proportion of hydrochloric acid is absent, in consequence of which the mucous membrane of the stomach may become infected by microorganisms, which give rise to catarrh, organic acidity, atony of the muscular coat, and dilatation. In carcinomatous conditions of the stomach, near the pylorus, there is likewise a diminu- tion of free hydrochloric acid, and some authorities consider the cachexia produced by this disease a consequence of the subnutrition resulting from hypochlorhydria. It is argued that the elimination of fat from the di- etary encourages a freer secretion of gastric juice with a larger propor- tion of free hydrochloric acid, and the normal (nascent) hydrochloric acid comes into direct contact with the crypts of the mucous membrane, which it slowly but effectively disinfects, and at the same time gives tone to the muscular coat. A fat-free diet is of value in such conditions. On the opposite page we give a table of fat-free foods, foods containing 0.5 per cent, foods containing less than 1 per cent of fats, and foods with 1 to 2 per cent of fat. It is practically impossible to provide an absolutely fat-free diet. However, we can get near enough to a fat-free diet by removing as much fat as possible from the meat and milk and avoiding the use of butter, suet and other fats and oils. The table will serve as a guide to the phy- sician or dietitian in directing a practically fat-free diet which would consist largely of bread, marmalade, white of eggs, meat extracts, soups, broths, oysters, light fish, lean meat and the breast of fowl, potatoes, vegetables and fruits. Carbohydrate-free Diet. A carbohydrate-free diet is one practically consisting of meat, green vegetables and hot water. A diet free from starch, sugar and other carbohydrates is recommended in the treatment PROTEIN METABOLISM PERCENTAGES OF FAT IN FOODS 339 Fat-free Foods Foods containing 0.5 per cent or less Foods containing less than 1 per cent of fat Foods with 1 to 2 per cent of fat Sugar Skim milk Fine white flour Sole, plaice Honey Casein powders White bread Smelt Treacle Sugar, pears Ryemeal Sturgeon Starch Corn-starch Rye bread Weakfish Dextrin Arrowroot, sago Beef tea Skate Beef tea Apples, tapioca Meat extracts Bluefish Meat extracts Green peas Beef broth Blackfish Casein preparations String beans Meat stews when Kingfish Potatoes, Litchi nuts skimmed Venison Parsnips, muskmelons Tomato soup Partridge ' Carrots, turnips Oxtail soup Breast of boiled fowl Radishes,watermelon.s Mulligatawny soup Wheat Beetroot, salsify Pea soup, Gumbo soup Brown bread Scorzonera Turtle, frog's legs Wholemeal bread * Cabbage, plums Oysters, clams Buckwheat flour Cauliflower Scallops Macaroni Brussels sprouts Crab, Crayfish Vermicelli Spinach, currants Shrimps Haricot Vegetable marrow Fish: Navy beans Squash, lettuce Bass, cod Dried peas Asparagus, oranges Cusk, flounder Frijoles Tomatoes, peaches Haddock, hake Green corn Mushrooms, truffles Yellow perch Grapes Onions, melons Perch-pike Bananas Leeks, cucumbers Gray pike Celery, rhubarb Pickerel-pike Strawberries Pollock Raspberries Red grouper Gooseberries Red snapper White of eggs . of certain gastric ailments, rheumatism, gout, diabetes and uric acidemia. Dr. Salisbury first recommended this form of diet, and according to his directions it consists of from two to four pounds of beef freed from fat, gristle, connective tissue and bone. It is chopped very fine, made into patties about three inches in diameter and one inch thick, and fried in a pan without fat or water. These are heated rapidly on one side and then on the other to coagulate the albumin, after which the process of cooking is allowed to proceed very slowly, and they are served while slightly underdone. (See Volume II, Chapter XII.) Cellulose Diet The cellulose diet furnishes nutritive subsistence for the lower animals, the herbivora being able to digest from 60 to 70 per cent of the crude fiber of dried grasses (hay) and cereals ; 47 to 62 per cent of that in carrots, cabbage and celery, and 25 per cent of that in 840 SCIENTIFIC FEEDING OF NITROGEN FOODS lettuce. It is within the bounds of probability that primitive man pos- sessed this faculty in common with herbivorous animals. It is stated by competent authority that at the present day some of the existing primitive races, the Bushman, Nilotic negro, and others, possess a very large cecuin, and that their colon secretes an enzyme which dissolves the outer covering of vegetable cells, and the fluid from the vermiform appendix digests cellulose. The civilized races of mankind have lost the power of digesting cellulose material. Bunge is authority for the assertion that "the epi- thelium of the colon secretes an enzyme which has a slight action on the cellulose coverings of cells"; notwithstanding, he practically agrees with the majority of clinicians that putrefaction is practically the only change which cellulose, or crude fiber, undergoes in the intestines of man, and that its principal and only use in the human economy is a mechanical stimulus to peristalsis. Cellulose undoubtedly possesses irritating quali- ties which it is necessary to minimize in cases of chronic gastric and in- testinal catarrh, ulcer of the stomach, cancer or stricture of the pylorus. Physiologists tell us that the presence of cellulose acts as a stimulant, and as a result the food is hurried along in the alimentary canal more rapidly than when this substance is absent. This irritating effect is desirable in cases of atony of the intestinal canal, and advantage should be taken of it in prescribing, while the conclusion to be drawn from the observations of Bunge and others is that the advantages arising from the presence of cellulose in the food of the average individual will far outweigh its disadvantages. Von Noorden prescribes a whole-meal Graham bread, all sorts of legumes, including the skins, coarse oatmeal and vegetables containing a high percentages of cellulose, fruits having thick skins and large quantities of butter, bacon and ham. In cases of chronic constipation, and especially those complicated with mucous colitis, he claims that this diet permanently cures 50 per cent of all cases and that 28 per cent are probably improved or partially cured. The following foods contain considerable cellulose and are recom- mended as adjuvants to the diet for the relief of chronic constipation: wholemeal bread of any description, eaten with plenty of butter, fat ham, bacon, treacle or marmalade ; fat meat, bacon or ham for dinner, with a large proportion of dried peas, cabbage, savoy, lentils, Brussels sprouts, cauliflower, one or two eggs daily, poached, buttered or scrambled in pref- erence; turnips, parsnips, onions, okra, swedes, scorzonera and leeks. Dessert should consist of raw or cooked fruit, pears, strawberries, cur- rants, apples, grapes, raspberries, gooseberries, loganberries, blackberries, MINERAL METABOLISM 341 whortleberries and cranberries. Plenty of cream should be taken with cooked fruit. Sugar is allowed. Apples, apricots, plums, peaches and acid fruits in general also stimulate peristalsis by means of their organic acids. Oatmeal is of great value. The coarse meal is the best form, but oat-cakes and groats may also be eaten. Barley bread, pearly barley, buckwheat cakes and rye bread are useful. MINERAL METABOLISM The salt metabolism of disease is a most important subject. Few studies of the balances of the various salts in disease have as yet been made at the hands of biochemists, but the therapy of the future will un- doubtedly include the practical application of salt metabolism to the prin- ciples of nutrition. Wellman, who has given some thought to this sub- ject, finds that there was a greater loss of salts in fasting than was accounted for by the metabolism of the fleshy portion of the body. The principal loss was phosphorus pentoxid and calcium and magnesium oxids, in about the same proportion as contained in bone; and the skeletons of animals were found to have actually lost from 6 to 7" per cent of their weight. In many diseased conditions, there was present a lowered calcium excretion; for instance, in pleurisy with effusion, pneumonia, delirium tremens, and in typhoid and malarial fevers. Senator, in writ- ing on this subject, said that there was in pulmonary tuberculosis an excess of calcium excretion. In osteomalacia the calcium balance is also dis- turbed, more being excreted than is taken into the body. The calcium excretion is lessened by phosphoric acid, which fact might be of use in experimental therapeutics. It is said that castration restores the CaO equilibrium, which also influences the restoration of sulphur equilibrium. In myostitis ossificans, on the other hand, the calcium output is less than normal. In arthritis deformans there is a retention of lime salts. Also in endarteritis the excretion of calcium is hindered and one observer even claims to have obtained good results by the administration of salts, viz., lactic acid, sodium lactate, sodium citrate, sodium carbonate and sodium chlorid, which, according to his contention, aid in the excretion of calcium. It is probably unsafe to assume that a diet containing sufficient protein and energy necessarily furnishes sufficient calcium and other salts for the metabolism of the body. This point can only be settled by metabolism experiments in which a balance is made between the intake and the output. The most recent investigation and thorough research into this subject has been made by Sherman, Mettler and Sinclair(G). Space forbids an 122 342 SCIENTIFIC FEEDING OF NITEOGEN FOODS extended review of their interesting experiment, but the table below * shows the average amount of. calcium, magnesium, phosphorus and iron consumed daily in the various dietaries. THE MINERALS IN TYPICAL DIETARIES: DAILY QUANTITIES PER MAN SUBJECTS OF THE STUDY Fuel Value (Calo- ries) Protein (Gms.) Iron (Fe) (Gms.) Phos- phoric acid (Gms.) Cal- cium oxid (Gms.) Mag- nesium oxid (Gms.) Maine lumbermen. . ... 6,780 179 .035 5.88 1.27 1.21 School superintendent's family, Chicago.. 3,260 123 .021 3.97 1.09 .55 Students' Club, University of Ten- nessee 3,595 123 .019 4.05 1.22 .63 Decorator's family, Pittsburgh. . . . Farmer's family, Connecticut 3,305 3,545 112 108 .019 .021 3.44 3.53 .90 1.15 .48 .55 Teacher's family, Indiana 2,780 106 .016 3.64 1.42 .44 Teacher's family, New York City . Mechanic's family, Tennessee Farmer's and mechanic's families, Tennessee 3,180 4,060 2,820 102 97 95 .017 .017 .019 3.92 3.58 3.56 1.69 .90 .83 .54 .72 .59 Glass-blower's family, Pittsburgh. Lawyer's family, Pittsburgh 3,085 3,280 94 91 .016 .015 2.73 2.82 .49 .83 .36 .40 Women Students' Club, Ohio Lawyer's family, New York City.. Laborer's family, Pittsburgh 3,330 2,325 2,525 85 84 83 .015 .014 .013 2.88 2.41 2.40 .97 .47 .50 .67 .30 .34 Negro family, Alabama 4,955 80 .012 3.25 .21 .74 Laborer's family, Pittsburgh 2,440 77 .012 1.52 .40 .19 Laborer's family, New York City.. Farm Students' Club, Tennessee. . Sewing-woman's family, New York City. . 2,430 3,560 1,500 71 66 54 .012 .011 .009 2.27 2.08 1.84 .50 .46 .68 .29 .34 .23 Very poor negro family, Alabama . 2,240 44 .007 2.05 .08 .52 Tachau(7), who has done much experimental work in salt metabolism, holds that the catabolism of easily burned carbohydrates often furnishes too much heat. Then, unless the "windows are opened, the house may get too warm," or they may, in too large quantities, be incompletely burned and thereby produce substances which will seriously interfere with the protoplasm (cellular) chemical processes (cellular asphyxia). The split products of both fats and carbohydrates may indeed menace the body, and the lack or overabundance of the mineral salts may surely tend to change the reactions of the living cells. If the results of experiments are correctly interpreted, we find that i From Bull. 227, Exp. Sta., U. S. Dept. Agric. MINEKAL METABOLISM 343 the "living organism may be regarded as a highly unstable chemical sys- tem which tends to increase itself continuously under the average of the conditions to which it is subject; it undergoes disintegration as a result of any variation from this average" (8). With the lights before us, there is no reason to charge any harmful results to starch itself. "It is only when ingested in excessive amounts for. long periods of time that harm results, and this is due not so much to the starch as to the attendant depri- vation of other foodstuffs, protein, hydrocarbons and organic mineral matter" (9). If an animal is allowed a liberal, well-balanced dietary, con- sisting of protein, fats, carbohydrates and water with no organic mineral salts, it will die more quickly than if it received no food at all (10). For this reason, the importance of salts has been extensively dwelt upon (see Volume J, Chapter IX, Volume II, Chapter VIII) by various workers, but no one has shown in simpler way, or a more convincing form, the reasons for the value of salts in the economy than Fischer (11). "The great importance of the organic mineral salts in the human organism is due to their effects upon the physical condition of the proteins of the body. It is true they furnish practically no energy and yet are essential." Schaefer(12) has said that "the chemistry and physics of the living organism are essentially the chemistry and physics of the nitrogenous colloids," and Guyer(13) voiced the opinion that what we call protoplasm is really an aggregate of colloids, holding water for the most part, in which are contained certain salts and non-electrolytes. Electrolytic Properties of Salts. Water forms a large percentage of the substance of the cell, and is essential for its existence as providing the medium wherein those chemical processes which constitute metabolism take place. This medium is a dilute solution of sodium chlorid in which the molecule of the salt has become dissociated into its free constituents or ions sodium and chlorin. These, charged respectively with negative and positive electricity, are what are termed cath-ions and an-ions. These ions act as independent particles and by means of their powers of electric attraction and repulsion are the forces which directly cause bodily chemical changes. The presence of salts in the .cells and their con- dition of dissociation or ionization are matters of great practical interest, because, in the first place, as regards the very ordinary salts, the phe- nomena of endosmosis and exosmosis are largely due to their presence in the cell, and also because the protein molecules only manifest their activity in a dilute saline solution under the conditions of ionization therein. These salts, it seems, are of inestimable value, because they change the affinity of the protoplasm for water, so that at one time when there is 344 SCIENTIFIC FEEDING OF NITROGEN FOODS relative lack of salts the protoplasm loses water and at another time it absorbs water and with it food materials. Without doubt, the salts of the foods are the agents which control to a large extent the secretion and absorption, but it must not be forgotten that the formation of salts enters into the regulation of neutrality in the body; but that is only a part of the problem of secretion and absorption, which was fully considered in Volume I, Chapters VI and VII. Sodium Chlorid. The importance of sodium chlorid in the diet was considered in Volume I, Chapter XI, where we learned that it "protects protein substances from disassimilation," i.e., it produces assimilation, and its use from this viewpoint is economical. The sodium chlorid con- tent of the body is of great importance and what might be termed sodium chlorid equilibrium is maintained. In normal individuals, if sodium chlorid is partaken of too liberally, there is an increase in the elimination, and if the amount is partaken of sparingly there is a diminution in the output; but a certain amount, about 2 grams per day, must be partaken of to make up for the daily loss. Bunge considers the presence of sodium chlorid essential to prevent the toxic effects of potassium. There is no question but that it plays an important part in the nutritive exchange between the cells and the plasma and stimulates the excretion of waste products by the kidneys. Exclusion of common salt from the food leads to dehydration of the tissues, and this is the basis of the salt-free dietary. Salt is found in varying quantities in all foodstuffs,, and the daily require- ment is from 15 to 20 grams. The presence of an abnormal amount of sodium chlorid in the blood and tissues is one of the causes of edema. The amount of salt consumption per capita per diem for the Ameri- can people is more or less an unsettled question, since medical literature contains no statistics on the question. According to Archard the average consumption of salt by the French people is 300 grains per day. According to United States Army regulations, the allowance for the soldier is about 300 grains daily, which is practically a large heaping table- spoonful. We may, therefore, take the soldier's allowance as a criterion for the amount used by the American people. Physiologists tell us that 95 per cent of the salt ingested is eliminated unchanged within 24 hours. Then, of the 300 grains consumed daily by the average American, 285 grains are excreted and cast out of the body as foreign material as rapidly as the organs of excretion can accomplish the task. Can this large excre- tion of salt be carried on daily for years with impunity ? The history of salt-using nations leads us to ask the question : If something is transpiring that may make them the unhealthiest animals in existence, since daily MINERAL METABOLISM 345 repeated exhaustion of glandular organs by exosmosis tends to, logically, and practically does produce the very condition of glandular torpidity that afflicts mankind ? The retention of sodium chlorid in the tissues is due to one of the following causes: (a) the kidneys may be unable to excrete it, or (6) it forms chemical combination with the cells. According to some authorities, this combination occurs in the preliminary stages of edema when the cells become saturated with water and the chlorid begins to accumulate in the surrounding fluids. Whether this explanation is satisfactory or not, this much is known. Marie argues that, when water is retained in the tissues, it requires the presence of sodium chlorid to balance the osmotic pressure of the salt in the blood (see Volume I, Chapter VII, Osmosis and Diffu- sion ). The greater the amount of water retained in the tissues the more sodium chlorid will be accumulated therein, and the less will be excreted by the kidneys. In Bright's disease, for instance, where the kidneys are unable to excrete salt even when diuresis has been established, it has be- come the custom of clinicians to reduce the intake of common salt with a view of relieving the kidneys of the extra work of excreting it. The indica- tion, then, for a salt-free diet is where there is failure of compensation characterized by diminution in the excretion of water. The diseased con- ditions in which it has been found beneficial and practical to withhold sodium chlorid are dropsy from cardiac, renal or hepatic diseases, obesity, diabetes insipidus and epilepsy. A salt-free diet is also useful in chronic parenchymatous nephritis with edema or dropsy, and granular kidney when there is a failure of compensation. SALT-FREE DIET. In selecting foods for salt-free diet, it is unneces- sary that it should be absolutely salt-free, besides it is almost impossible to prepare food quite free from it. The table on page 346 shows the per- centage of sodium chlorid in raw and cooked foods, taken largely from an article by H. Strauss (14) on the best method of reducing the amount of salt in the diet : In selecting articles of food for a rigid salt-free diet, an attempt should be made to keep the amount of sodium chlorid down to between l 1 /^ to 2 grams per day, which will mean the exclusion or reduction of the allowance of meat, fish and meat broths. According to Tibbies (4) : The proteins should be derived from milk, eggs, chicken cooked without salt, tripe, fresh-water fish, cheese made without salt, and bread made without salt. Milk can be taken alone or with eggs, in the form of custard, in puddings with rice, sago, oatmeal, etc. Eggs can be taken in many ways without the addition of salt e.g., custards, milk puddings, poached eggs, boiled eggs, omelettes; the latter 346 SCIENTIFIC FEEDING OF NITROGEN FOODS can be seasoned with sugar instead of salt. Eggs can also be taken in "cream," souffles and sauces. Jellies made of gelatin or isinglass and meat jelly are permis- sible. The fats should be derived from milk, eggs, unsalted butter, fat meat eaten without salt, cheese made without salt, cream cheese and salad-oil. Carbohydrates may be obtained from sugar, treacle, golden sirup, jam, marmalade, bread made without salt, milk puddings without butter, blane mange, jelly, milk sauces, fruit and vegetables. Bread and pastry made without salt are not unpleasant when eaten with stewed fruit, jam, marmalade and unsahed butter. Vegetables should be allowed ad libitum, because they can be made the vehicle of flour and fat in the form of "white sauce." It is recommended that all vegetables should be cooked in plenty of water, with a minimum of salt, thereby reducing the proportion of in- organic constituents. No salt must be used when cooking or eating the food, except the small amount absolutely necessary to give flavor to potatoes, cabbages and other green vegetables, and the salt must be put into the process of diffusion. The absence of flavor may be obviated to a great extent by a careful employment of spices, condiments such as mint, thyme, parsley, marjoram, savory, bay-leaf, chut- ney, horseradish sauce, tomato sauce, mustard, nutmeg, cinnamon, allspice, va- nilla, lemon, cocoa, chocolate and coffee, and in some cases a small amount of pickles, such as red cabbage, onion or cauliflower. The liquids allowed are milk, whey, buttermilk, weak tea, cereal or fig coffee, lemonade, fruit juice and aerated waters, or a small amount of wine or spirit and water. THE PERCENTAGE OF SODIUM CHLORID IN FOODS Raw food Per cent Cooked foods Per cent. Unsalted butter .02 Poached eggs.. . 5 Yolk of eggs .02 Fruit, usually less than. . . .5 Fruit not more than .06 White bread .48-.07 Meat, unsalted. . .10 Brown bread .75 Vegetables and salads .10 Cauliflower .5-.9 Cereals and legumes .01-. 10 Cabbage .5-.9 Milk. . .15-.18 Mashed potato .5-1.0 Eggs. . .14 Roast beef 1.9-2.8 White of eggs .19 Beef steak 3.0 Salted butter . 1.00 Buttered eggs. 2.4 Cheese. 1.5-2.5 Omelettes 2.7 Caviar 6-7 Asparagus 2.7-3.5 Moderate variations in the amount of salt ingested have no significant effect upon the protein metabolism. Large amounts increase the quantity of protein catabolized, and, through overstimulating the digestive tract, may also interfere with the absorption and utilization of the food. Below we append a few examples of diets containing not more than two grams of salt (Tibbies) : MINERAL METABOLISM 347 (a) Balint prescribed: Milk, !}/ to 2^ pints; butter, \Yi ounces; three eggs; salt- less bread, 9> to 12^ ounces, and weak tea or coffee. Calories, 2,300 to 2,400. (b) Archard and Widal drew up the following series of diets: (1) Potatoes, 35 ounces; meat, 10J/ ounces; butter, 1% ounces; rice, 4^ ounces; protein, 98 grams. Calories, 2,295. (2) Saltless bread, 7 ounces; meat, 14 ounces; butter, 3 ounces; sugar, 3^ ounces; protein, 117 grams. Calories, 3,037. (3) Saltless bread, 7 ounces; potatoes, 10^ ounces; rice, 3% ounces; sugar, y/2 ounces; butter, 1 ounce; protein, 33 grams. Calories, 1,891. (4) Milk, 2 pints; two eggs; meat, 10 ounces; flour, 2 ounces; sugar, 1% ounces; butter, 1% ounces; protein, 125 grams. Calories, 2,292. From the above table it will be seen that the dietary can be varied so that the consumption of protein will vary but little from the standard advocated in these pages. The following dietary will possibly be accept- able by most Americans : Breakfast: Oatmeal porridge; saltless bread and butter; one or two eggs (poached or but- tered); raw egg-and-milk; fresh-water fish, eaten with lemon juice or vinegar. Jam, marmalade, tomatoes, or other fresh fruit; tea or cereal; coffee made with water or milk. Midday Meal: Vegetable soup; saltless bread; cow-heel, tripe, unsalted tongue, fresh meat or fowl. Fish may be taken once or twice a week, with mayonnaise sauce, white sauce, or bread sauce. Milk puddings; cream; custard, junket; blanc mange; jelly, stewed fruit, salt-free biscuits, or crackers. Salt-free cheese. Green vegetables, kidney or snap beans, vegetable marrow, spinach, scorzonera, celery, cauliflower, and potatoes, all cooked without salt, or the minimum required to give flavor. 5 p.m.: Tea; with salt-free bread and butter; cakes, honey, marmalade, and other con- fections. Evening Meal: Any article from list for the midday meal or breakfast. Bunge(15) records extended and interesting observations and discus- sion upon the relation of diet to the craving for salt, and concludes that it is possible for one to live on a diet largely vegetarian, without the addi- tion of salt, yet on such a diet one should have a strong disinclination to partake freely of vegetables rich in potassium, such as potatoes. The use of salt enables us to employ a greater variety of the earth's products as food than we could do without it. But according to Bunge : We are accustomed to take far too much salt with our viands. Salt is not only an aliment; it is also a condiment and easily lends itself, as such things do, to abuse. 348 SCIENTIFIC FEEDING OF NITROGEN FOODS Sodium and chlorin equilibrium can apparently be maintained on less than one-fourth the amount of salt ordinarily consumed. Sodium chlorid partaken of with the diet passes out of the body through the kidneys without undergoing any chemical changes; the rate of excretion adapts itself to the rate of intake within wide variations. According to Goodall and Joslin(16), when no salt is taken, the rate of excretion falls rapidly to a point where the daily loss is extremely slight. In one of their experiments upon a salt-free diet, the chlorin excretion upon successive days was as follows: 1st day 4.60 grains chlorin 7th day 0.46 grams chlorin 2nd day 2.52 " 8th day 0.40 " 3rd day 1.88 9th day 0.26 " 4th day 0.87 10th day 0.22 5th day 0.69 " llth day 0.22 6th day 0.48 12th day 0.17 " 13th day 0.17 grams chlorin Potassium Chlorid. Potassium chlorid is next in importance to sodium chlorid. It is a predominant salt in the muscular tissues, and, like sodium chlorid, is a common ingredient of nearly all the tissues and fluids of the body. The acid and neutral carbonates and phosphates of sodium and potassium exert their greatest importance in regulating the reaction of the digestive secretion and of the urine. Sodium is required in the body for the proper constitution of its fluids, potassium for the construction of cells and especially, perhaps, of the red blood cells and the muscles. Clinical experimentation has emphasized the fact that young animals and children deprived of potassium salts in the foods do not develop good muscles. Foods derived from the vegetable kingdom furnish the richest supply of potassium-bearing salts, by three or four times, while foods from the animal kingdom contain a larger percentage of the sodium salts. If potassium chlorid is substituted for sodium chlorid in the food, various disturbances arise, owing to the deficiency of the sodium salt. The tissues of the body retain common salt most tenaciously, and when food is ingested which is low in this elementj it gradually disappears from the urine. When the supply of common salt is below the body requirement, the elimination of chlorid in the urine decreases. When there is a lack of sodium chlorid as compared with potassium chlorid in the food, potassium combinations replace sodium combinations in the body and new combina- tions of sodium and potassium are formed and excreted in the urine. Human beings who consume a large amount of potatoes or other vegetables rich in potassium salts should of necessity partake freely of common salt, not merely as a condiment, but as an essential part of the food. MINEliAL METABOLISM 349 Low Calcium and High Calcium Diets. We learned, when studying mineral salts in the body and in foods (Volume I, Chapter XI), that the calcium salts are of value chiefly from their importance in the com- position of the bones and teeth, as well as in many of the tissues of the body, more particularly with cell growth and development. The bones and tissues of young growing animals, and children as well, require and contain a larger percentage of earthy salts than older ones. Calcium is taken into the body in organic forms through the ingestion of milk, yolk of egg, and cereals, and in inorganic forms chiefly in drink- ing water, such as the carbonates, sulphates and phosphates. Both forms are more or less readily absorbable, depending in a measure upon what salts are taken with it. The minimum amount of lime by which calcium equilibrium may be maintained ranges from 1 to l-l/G grams per day for the average sized adult. There seems to be great variation in the quanti- ties by which a calcium diet may be established ; 5 to 10 per cent of that ingested is excreted in the urine, while the remainder is found in the feces, whether unabsorbed or absorbed and then eliminated in the intestine. The amount of lime eliminated through the kidney varies greatly prob- ably does not average much over one-tenth of that taken in the food. The fact that the greater part of the calcium ingested in food reappears in the feces has often been interpreted as meaning that the requirement of the body for calcium is low, and the absorption of calcium from the food is poor. It must not be lost sight of, however, that the calcium found in the feces comes from the various organs and tissues of the body as well as from the food. The elimination of calcium from the food through the intes- tinal wall has been proved. The elimination of lime salts through the intestinal wall continues in fasting, and constitutes the principal way in which lime is lost from the body whenever the food supplies contain insufficient lime for equilibrium. The calcium excretion in the urine may be increased by the ingestion of large quantities of water, and by the administration of dilute hydrochloric acid ; and again, it may be in- creased by the administration of lactic acid and sodium lactate. There is a loss of lime over that taken into the body in such diseased conditions as osteomalacia, pernicious anemia, advanced tuberculosis and in diabetes. This is to some extent associated with phosphate elimination. On the other hand, in arteriosclerosis, the excretion of lime is deficient. If, on a given diet, the calcium is low, the loss will greatly exceed the intake. If, on the other hand, the diet contains excessive amounts of calcium, some of the lime will be retained in the body and apparently stored up in the bones, though it may not produce symptoms. 350 SCIENTIFIC FEEDING OF NITROGEN FOODS Voit experimented on a pigeon for a period of twelve months, giving it a diet poor in calcium, without observing any deleterious effects attrib- utable to the diet. But when the bird was killed and dissected, there was found marked wasting of lime salts from the bones of the skull and sternum, which were so soft as to be perforated with ease. However, the long bones, those concerned in locomotion, were still sound. The injuri- ous effect of foods containing insufficient lime is more noticeable in grow- ing than in full grown animals. Abnormal weakness, flexibility of the bones will be noticed (like rickets in children). Puppies fed with lean and fat meat only develop rickets, while control puppies from the same litter receiving the same food with an additional allowance of bones to gnaw upon develop normally. From the above, it is apparent that the growing skeleton needs an abundance of calcium. Before birth the lime requirement of the child is satisfied through the maternal blood, and for many months afterward, through the mother's milk, which is relatively rich in calcium. The weakening of the bones and the disintegration of the teeth during preg- nancy and lactation is largely due to the amount of calcium going to the child in utero and during lactation in the secretion of milk. After weaning and throughout early childhood, there are apt to be frequent dis- turbances of the absorption and metabolism of lime, due, in some in- stances, to disorders of digestion, in other cases, to deficiency of lime in the nutrients ingested by the child. To prevent this fluctuation, so as not to interfere with the steady growth of the child, it is imperative that the food furnish a liberal supply of calcium. Under the most favorable conditions, a rapidly growing child will need and consume more bone- making material in proportion to its total food than is required by men who serve as subjects for metabolism experiments. For this reason, among others, lime water is added to the various artificial foods given during infancy and early childhood. Unless a very "hard" water is used for drinking purposes, it is unlikely that the lime from this source will sup- ply more than a very small part of the calcium required, so that there should be great attention given to the choice of such foods as will increase the calcium content of the dietary. The table on page 351 gives the calcium content of a number of staple articles of food. A study of the table on page 353 will show that there are enormous dif- ferences in the calcium percentage of different food products, milk being so rich in calcium that the quantity necessary to produce 400 calories contains 1 gram of lime. In order to get the same amount of lime from round steak MINERAL METABOLISM 351 and white bread, it would be necessary to consume enough to furnish 10,000 calories. A low calcium diet is recommended in many cases of arteriosclerosis, exerting, as is claimed, a beneficial effect by checking alimentary toxemia, reducing blood pressure and increasing diuresis. The idea is, that to keep blood pressure low, lime salts should be eliminated from the diet as far as possible. In conditions of cardiac failure, lime salts are allowed, but when compensation is reestablished, their use should be discontinued. It should be pointed out, however, that it has not been proved that blood and tissues retain calcium during the course of arteriosclerosis. If at any time it is desirable to give a calcium-poor diet, it can be arranged from the following table: CALCIUM IN FOODS 1 BASAL FOODS: Per cent Meat 002 Eggs 100 Cream 147 Milk 172 Cheese 1.240 Bread 021 Flour: Fine 028 Entire wheat 037 Cornmeal 009 Rice 012 Pearl barley 0.25 Macaroni, vermicelli 028 Oatmeal 078 VECETABLES: Asparagus 038 Beans: Dried 215 Fresh, string 073 Beetroot 019 Cabbage 058 Carrots 077 Celery 094 Cucumber 028 Greens, turnip tops 508 Lettuce ; 425 Onions 040 Parsnips 076 Peas, dried 137 Potatoes 0.16 Sweet. . .025 VEGETABLES (Continued): Per cent Pumpkins 032 Radishes 025 Rhubarb 060 Ruta baga (swedes) 103 Spinach 064 Tomato 019 Turnips 0.87 Vegetable marrow 0.32 Watercress 259 FRUITS: Apples Oil Apricots 021 Bananas 009 Blackberries 099 Bilberries 045 Cherries 026 Cranberries 021 Currants 046 Dried 169 Grapes 014 Grapefruit 029 Huckleberries 037 Oranges 043 Peaches 0.15 Pears 018 Pineapple 008 Plums 022 Raspberries 072 Strawberries 057 Water-melons. . .018 Magnesium Salts. Magnesium is usually present in foods in much the same proportion as calcium. There are exceptions, however, to this rule, hull, of Exper. Sta. No. 45, U. S. Dept. of Agric. 352 SCIENTIFIC FEEDING OF NITROGEN FOODS for in milk, magnesium is less and in meat considerably more abundant than calcium, while in bread there is actually five times as much mag- nesium as calcium. Magnesium, however, is of much less importance to the body than calcium. Very little magnesium is absorbed from the food, and one-third of the intake is excreted in the urine and about two-thirds in the feces. The bones contain 99% per cent of the entire calcium content of the organism, but only 71 per cent of the magnesium. On the other hand, the muscles contain more magnesium than calcium, but again there is in the blood more calcium than magnesium. The solubility of magnesium salts in the body fluids is greater than that of lime. Absorption of mag- nesium both in organic and inorganic combinations takes place from the intestinal canal. Experiments in which animals are given food with scanty lime content, but rich in magnesium, have demonstrated that while the bony structure resulting from such diet contains twice the normal amount of magnesium, the development of the osseous system is stunted. These data offer practical proof that lime cannot be replaced by mag- nesium. Since the magnesium salts are more soluble than the lime salts, they are eliminated in greater proportion than the latter by the kidneys. As a matter of fact, most of the absorbed magnesium is excreted in the urine, while the unabsorbed magnesium salts in the form of insoluble soaps are eliminated in the feces. The table on the opposite page shows comparative amounts of the lime and magnesium salts. Phosphorus Phosphorus is essential for all cell life and its impor- tance as a building material in the body can scarcely be overrated. Wher- ever growth is most active, there also most phosphorus is found. It is a component part of all cell nuclei and is found abundantly in the bones and in the central nervous system. Wherever the building up of such a tissue is going on rapidly, a large supply of phosphorus in thq food is required. It is not surprising, therefore, to find that the development of young animals which are deprived of phosphorus is apt to be seriously impaired. The importance of a sufficient amount and a proper form of phosphorus in the food of growing children is to be emphasized; and it is essential for the growth of new tissues that phosphorus should be stored in the body as well as nitrogen. Whenever there is a storage of nitrogen a corresponding storage of phosphorus is also found. The importance of phosphorus as a building material was shown by Bunge when he dis- covered that the proportion of phosphorus, calcium and protein in the milk of animals is directly proportionate to their growth. The table given on page 354 very graphically emphasizes Bunge's discovery. MINERAL METABOLISM 353 APPROXIMATE AMOUNTS OF MAGNESIUM AND CALCIUM OXID IN FOOD MATERIALS 1 VEGETABLE FOODS Ash in per cent of substances Magnesium in per cent of the ash Calcium in per cent of the ash Millet 5.1 Cocoa 4.9 Cornmeal .... Rice 0.67 Nut kernels. .... Wheat flour 2.3 Buckwheat .... Barley 2.5 Apples 0.27 Coffee extract 3.4 Peas 2.6 Rye flour 1.97 Oatmeal 2.3 Tea extract 3.1 Potatoes 5.0 Grapes 2.25 Cherries 0.4 Plums 0.31 Asparagus 6.4 Lemon juice 0.2 Bananas .... Spinach 2.03 Savoy .... Cauliflower 8.8 White cabbage 11.6 Kohlrabi 8.9 Radish 6.4 Cucumbers 4.8 Gooseberries 0.4 Lentils Beans 3.1 Schoten 0.7 Clover .... Poppy seeds Sorrel .... Pears 0.4 Strawberries .... Carrots 5.4 ANIMAL FOODS Beef Albumin of hens' eggs Woman's milk Yolk of egg Cow's milk . . 25.8 15.9 14.9 13.4 13.0 10.9 10.3 9.6 8.7 8.6 8.1 7.9 7.0 6.8 2.5 8.8 5.5 4.7 6.3 3.3 8.8 5.3 2.9 Trace 3.7 3.2 3.5 3.0 5.8 1.9 6.5 6.3 4.8 9.5 8.3 5.2 Trace 2.3 2.8 6.3 0.8 8.6 2.2 6.6 3.5 4.0 3.6 5.1 1.02 3.0 1.2 0.8 36.9 7.5 4.9 15.9 7.9 12.5 13.1 27.9 21.7 12.6 10.2 8.8 6.9 12.2 5.1 8.6 7.8 36.1 35.1 31.6 7.9 14.2 5.6 15.2 13.0 5.0 6.0 20.0 2.9 13.0 24.3 38.0 151.0 From von Liebig and other sources. 354 SCIENTIFIC FEEDING OF NITROGEN FOODS IMPORTANCE OF PHOSPHORUS AS A BUILDING MATERIAL (Bunge) Time required to double the weight of a new born animal (Days) MILK OF MOTHER CONTAINS Protein per cent Ash per cent Lime per 1,000 P 2 5 per 1,000 Man 180 60 47 17 10 8 1.6 2.0 3.5 4.3 6.5 7.1 .2 .4 .7 .8 .9 1.3 .328 1.240 1.600 2.100 2.720 4.530 .473 1.310 1.970 3.220 4.120 4.930 Horse Cow Goat Sheep Dog... Rohmann(l7), in studying this subject, asks the question: "What in- fluence have the inorganic phosphates on the construction of phosphorized proteins in the body?" In an experiment to answer this question, says Tibbies, he fed animals on a diet containing earthy phosphates and diets consisting of (a) phosphorized proteins (casein and vitellin), (6) non- phosphorized protein (edestin). In animals which subsisted on the former diet, there was a retention of nitrogen and phosphorus in the body, while in animals fed on the latter no retention occurred. His conclu- sion from these observations is that the body does not appear to have the power of building up the phosphorized proteins of the cells from the non-phosphorized proteins and inorganic phosphates. On the other hand, he concluded that the phosphorized proteins are built up from lecithin and non-phosphorized protein. From his observations, we must look to the phosphorized organic constituents of the food for our supply of phosphorus, viz., nucleoproteins, phosphoproteins, nuclein, lecithin, phosphocarnic acid and glycerophosphoric acid found in the cellular ele- ments, particularly in the yolk of eggs, sweetbread, fish roe, the germ of cereals and legumes, and in casein. (For the amount of phosphorus con- tained in foods, see Volume I, Chapter XI, pages 271-272.) Bunge (18) has demonstrated the content of phosphorus pentoxid (P 2 O 5 ) in 100 grams of dried food to be: egg yolk, 1.90 ; cow's milk, 1.86 ; beef. 1.83 ; peas, 0.99 ; wheat, 0.94 ; potato, 0.64 ; egg albumin, 0.20 grams. In his work along this line, \ 7 oit gives the following estimate of the amount of phosphorus in the various structures of a human body weigh- ing 154 pounds: 1,400 grams in the bones; 130 grams in the muscles, and 120 grams in the nervous system. The determination of the exact phosphorus requirement of the human organism is not an easy problem. Available data on this subject are even fewer than those dealing with MINERAL METABOLISM 355 nitrogen. Sherman and Sinclair (19) have pointed out that the daily amount of phosphorus received by the body varies from 0.9 to 1.5 grams, this variation depending upon the amount of phosphorus in the food in- gested. Interesting and instructive as this work is, it is not exhaustive. But from these studies it may be inferred that a normal individual by training himself to exist on a low protein diet, or on a diet whose phos- phorus content exists almost exclusively in organic combination, may maintain phosphorus equilibrium on food containing about 0.9 grams of phosphorus or 2 grams of phosphorus pentoxid. But to maintain a nor- mal phosphorus equilibrium on an average unrestricted diet, it would seem that a daily intake of about 1.5 grams of phosphorus or 3.5 grams of phosphorus pentoxid is required. Iron Salts. Iron is one of the mineral constituents of the diet which is always present in an organic form. It is largely excreted in the feces, which fact has led to great difficulty in attempting to estimate the usual amount of iron required. Roughly speaking, there are about 10 milli- grams of the metal contained in an ordinary mixed diet (15). This quan- tity may therefore be taken as sufficient to meet all physiological demands. It is difficult to estimate correctly the amount of iron contained in the different articles of food. In foods derived from the animal kingdom much depends on whether the animal was bled when slaughtered or not, while, with foods derived from the vegetable kingdom, it varies very greatly, depending largely upon the amount of iron in the soil in which the foods were grown. For the estimated amount of iron contained in different vegetable and animal foods, the reader is referred to Volume I, Chapter XI, page 269. Physiological chemists estimate that the blood (4) of an adult contains 3 grams of iron ; the liver, spleen, skin and hair con- tain smaller amounts. According to N"asse, the conglomerate masses in the spleen pulp of old horses contain about 5 per cent of iron, while Oidlmann estimated that the ash of the spleen contains from 7 to 16 per cent of iron. The iron content of the blood in the form of hemoglobin amounts to about 0.04 per cent. The iron of the liver is stored in the cells as compounds of iron in nuclein and protein. Physiologists desig- nate two of these compounds as Jiepatin and ferratin, and the iron is either the ferric or ferrous oxid. The iron in the liver of a new-born animal is greater than that in the adult of the same species. Bunge teaches that the liver acts as a storage house for iron, which is subse- quently used to form the hemoglobin of the red blood corpuscles. Dele- piene coincides with this view. He even considers the liver as not only the storehouse of the nucleoprotein compounds containing iron, but that 356 SCIENTIFIC FEEDING OF NITKOGEN FOODS the liver cells are capable of elaborating these compounds into new hemo- globin for the young red blood corpuscles, which he describes as the ferrogenic function of the liver and which he believes persists throughout life. The bile pigment is derived from hemoglobin, but is free from iron. Tibbies thinks this pigment is split off from the hemoglobin, while the iron-bearing nucleoproteins are stored in the cells of the liver. Considerable variations in professional opinion have arisen as to whether inorganic iron given as a drug for the cure of anemia and chlorosis is absorbed. Von Noorden and others believe that inorganic iron is absorbed and they hold that it is very efficient in the treatment of these maladies. Hamburger and Morden, on the other hand, believe that little or none of the inorganic preparations of iron is absorbed from the alimentary canal. Bunge believes that iron is of therapeutic value in the treatment of anemia and chlorosis. As Tibbies puts it : ''Chlorosis is attended by considerable fermentation in the alimentary tract, whereby much sulphuretted hydrogen is evolved, and this gas fixes and prevents the absorption of organic compounds in the food which are normally made use of in the manufacture of hemoglobin." Should there be an excess of inorganic iron present, a large proportion of the sul- phuretted hydrogen evolved will combine with such iron to form sulphid, and in this manner protect the organic iron combinations from destruction by the hydrogen sulphid (H 2 S). If a condition arises wherein the blood is deficient in iron it will scarcely be possible or practicable to make good such deficiency by ordering inorganic salts in the food. There are very few foods which contain much inorganic iron, although Stock- man and von Noorden believe that the inorganic iron contained in the food is absorbed and utilized in the production of hemoglobin. If for any reason the food is deficient in iron, it necessarily leads to a condition of anemia, which conclusion is supported by various experimental observa- tions. It is known that the blood of dogs fed with bread contains less iron than the blood of the same animals when they are fed upon meat; or even children, when they receive only the same proportion of iron per kilogram of body weight as is necessary for an adult. These tend to become anemic. Sulphur Salts. Sulphur is present in foodstuffs almost entirely in organic combination, chiefly in proteins. The amount present varies considerably, as shown in Volume II, Chapter IX, page 272. Sulphates are derived from sulphur contained principally in fibrin, egg albumin, the casein of milk, and from such vegetables as corn, turnips, cauliflower and asparagus. The knowledge at the present time of the advantages MINERAL METABOLISM 357 or otherwise of an increase or diminution of sulphur in the food is want- ing. Where food prepared with so-called alum baking powder is eaten, considerable sulphate may appear in the urine from this source. The inorganic constituents of food are of importance from the point of view, not alone of the individual ingredients, but of their relations to one another as well. As we have seen, even such elements as sodium and potassium, or calcium and magnesium, that are closely related in chemical properties, are not interchangeable in the animal economy, and, more- over, in some physiological functions are actually antagonistic (20). On the other hand, in some instances certain elements do to a degree replace other elements, as, for example, the sparing influence of calcium on iron metabolism as a result of which an abundance of calcium renders less the amount of iron necessary to maintain iron equilibrium. Acid-forming and Base-forming Elements of Diet. Another important relation is that of the acid-forming and base-forming elements of the diet. It appears important that the base-forming elements of the food should be sufficiently abundant, largely, if not wholly, to neutralize the acids formed in catabolism, since otherwise there is a tendency to the production of a condition of acidosis, with the withdrawal of fixed alkalies from the blood and tissues and an increased fixation of ammonium salts whereby the ammonium is not transformed into urea. While it is not absolutely demonstrated that these conditions are immediately productive of disease, it must be regarded as physiologically wrong for man and correspondingly disadvantageous. Moreover, it is quite likely that in cer- tain pathological conditions (see Gout, Volume III, Chapter XII) the lack of base-forming elements is actually harmful. Sherman gives the following tables : FOODS IN WHICH ACID-FORMING ELEMENTS PREDOMINATE Estimated excess acid-forming elements equivalent to c.c. normal acid per 100 calories Beef, free from visible fat 10 Eggs. . . 9 Round steak , 6.7 Oatmeal 3.2 Wheat flour 2.7 Wheat, entire grain. 2.6 Rice. . . 2.4 Bacon 1.0 Corn, entire grain (high protein) 0.1 123 358 SCIENTIFIC FEEDING OF NITROGEN FOODS FOODS IN WHICH BASE-FORMING ELEMENTS PREDOMINATE Estimated excess base-forming elements equivalent to c.c. normal alkali per 100 calories Celery 40 Cabbage. . . 10-13.6 Potatoes 9-12 Prunes 7.9 Turnips 6.6-12.5 Apples 5 Milk 3.3 Beans.. . . 2.9- 6.8 Peas 1.9 Corn, entire grain (low protein) 0.8 Starch, sugars, fats and oils do not ordinarily contain acid- or base- forming elements. Resume. The older view of Wright (21), as to the relation of the diet to scurvy, is probably correct, so far as concerns its following a withhold- ing of a base-yielding diet, but, in view of the recent works on vitamines, it appears that it is not the mere absence of bases but of vitamines that is the causative factor. From the foregoing pages, the reader is able to grasp the great impor- tance of the functions of the mineral elements in the processes of metab- olism. Viewing their nature and importance, it is at once obvious that life could not endure if its complex mineral requirements were not auto- matically and constantly maintained in a proper adjustment. While highly developed processes of food manufacture and efficient world-wide transportation facilities give us the greatest opportunities for correct dietetics, yet there are important facts bearing on the relation of food materials and the metabolism of mineral nutrients which open the way to greater injudiciousness and positive abuse in dietetics than could have been possible in our more primitive days. The net result emphasizes an obligation on our part to prepare a defense of knowledge against the misfortunes of plenteous prosperity. In order to emphasize sufficiently the importance of mineral metabolism. in the processes of nutrition just considered in the preceding pages, we will outline briefly some of the functions of the mineral elements in animal metabolism: As bearers of electricity the mineral elements dominate the whole course of metabolism. They conduct nerve impulses, and play a leading role in the general process of cell stimulation. MINERAL METABOLISM 359 They govern the contraction of the muscles, including those of the heart. They compose the central agency for the maintenance of neutrality in the blood. They enter into the composition of every living cell. They compose supporting structures. They assist in the coordination of the digestive processes. They activate enzymes, and through their control of the chemical reaction of the blood and tissues they govern enzyme action. They unite with injurious products of metabolism and render them harmless or useful. As catalyzers they may alter the speed of reactions, and the rate of metabolism generally, as measured by oxygen consumption. Through their effects on osmotic pressure they govern the movement of liquids, and maintain the proper liquid contents of the tissues. Through their control of the imbibition of water by the colloids they govern absorption and secretion. Through their control of the affinity of the blood for gases they govern respiration. Finally, they control the state of solution, precipitation, mechanical aggregation, chemical association and ionizatiou of the colloids which compose living tissue. REFERENCES 1. BENEDICT, A. L. Golden Rules of Dietetics. 2. HALL, L WALKER. Chemistry and Physiology of Food Purins. 3. BURIAN and SCIIURR. Pfluger's Archiv, 1900. 4. TIHULES, WILLIAM. Food in Health and Disease. 5. DENIS, W. The Effect of Ingested Purins on the Uric Acid Con- tent, of the Blood, J. Biol. Chem., 1915, vol. xxiii, p. 147. (!. SHERMAN, METTLER and SINCLAIR. Exper. Sta., U. S. Dept. of Agric., Bull. No. 227. 7. TACIIAU. Biochem. Ztschr., 1914, vol. Ixvi, p. 253. S. STARLING. Human Physiology, 1912, p. 5. '.). Abt. J. Am. Med. Assn., 1913, vol. Ixi, p. 127r>. GRAFE. Peutsch. Arch. f. klin. lied., vol. cxiii, p. 1. 10. STARLING. Human Physiology, 1912, p. 724. 11. FISCHER. Edema and Nephritis, 1915. 360 SCIENTIFIC FEEDING OF NITHOGEN GOODS 12. SCHAEFER. Science, 1912, vol. xxxvi, p. 289. 13. GUYEB. Tr. Amer. Micros. Soc., 1911, vol. xxx, p. 145. 14. STRAUSS, H. Zschr. f. phys. u. diatet. Therap., April, 3908. 15. BUNGE. Physiological and Pathological Chemistry, chap. vii. 16. GOODALL and JOSLIN. Tr. Assn. Am. Phys., 1908, vol. xxiii, pp. 92, 106. 17. ROHMANN. Pfluger's Archiv, vol. Ixvii. 18. BUNGE. Loc. cit., p. 84. 19. SHERMAN and SINCLAIR. Exper. Sta., U. S. Dept. Agric., Bull. No. 227. 20. SHERMAN, H. C. Chemistry of Food and Nutrition. 21. WRIGHT. On the Pathology and Therapeutics of Scurvy, Army Med. Reports, 1895. CHAPTER XII DIET IN HEALTH WINFIELD S. HALL, PH.D., M.D. The destiny of nations depends upon the character of their diet. Dietotherapy General Principles: Amount of Food Required; Distribu- tion of Meals ; Composition of Meals ; Influence of Diet on Constitu- tion and Health ; Influence of Diet on Character ; Influence of Diet on Races; Occupation and Diet; Climate and Diet. Diet Studies: Students' Clubs; Mechanics and Laborers; Standard and Actual Dietaries Compared; Negroes and Poor Mexicans. Use of Alcohol. Diet in Tropical Climates: General Considerations; Fruits and Vege- tables; Milk; Meats; Sweets; Diet and Disease; Conclusions. Alcohol and Beverages in the Tropics. DIETOTHERAPY GENERAL PRINCIPLES Dietotherapy is the proper application of suitable food elements to secure a well-balanced alimentation necessary for the preservation of health and the maintenance of bodily strength and energy, or for their restoration during convalescence after having been impaired by disease. It goes without saying that the value of foods in health must be under- stood in order properly to appreciate their relative dietetic value in disease. When studying "The Chemical Constituents of the Body and of Foods" (Volume I, Chapter II), we learned that the human organism is composed of some twenty different universally distributed chemical ele- ments, of which the following are most essential : C, H, O, N, S, P, Cl, Na, K, Fe, and Mag, combined in the most complex molecules, some of which contain many hundreds, even thousands, of atoms. We also learned, when studying the "Characters of the Proximate Principles of 361 362 DIET IN HEALTH Foods" (Volume I, Chapter III), that the chemical composition of the human body is not always an adequate guide to the selection of the essen- tial food elements, though it is an indisputable fact that food that is to nourish an infant's body and sustain it through childhood and puberty must contain these elements. However, it is quite impossible to feed human beings upon chemical elements to be useful these must be fur- nished in certain suitable combinations. The table in Volume I, Chapter II, graphically shows the composition of foods. Many of these com- pounds during the process of digestion and assimilation (Volume I, Chapter VII) are transformed into other compounds which are peculiar to the human body. Even when food material has been adapted to the needs of the body by digestion, it still undergoes further chemical modi- fication before it can be taken up by the cells for their repair, or stored by them, or, by contact with them, be transformed into heat or muscular power. Thus we see that the human economy requires foods similar in com- position to its own substance for growth, development and repair, while it needs fuel foods from which to produce active energy for the work of the body. We have already studied these two phases of body require- ments growth and repair on one side, and work on the other and find that they make the basis for the classification of foods, as outlined in Volume I, Chapter IX. Man is an omnivorous animal and can subsist on either animal or vegetable foodstuffs, and derive force and bodily heat from any of them, and, as the body soon adapts itself to its food, very few rules need be formulated. People in the upper walks of life, as a rule, consume more protein and ingest less carbohydrates than do the working classes. The dietaries of public institutions are more liberal with allowances of carbo- hydrate foods than with protein, on account of economic advantages, but, as stated elsewhere (Volume II, Chapter IX), the protein from vege- tables, especially from beans, peas or lentils, can be secured at very reason- able prices and ought to be more universally used, especially when the prices of meats are prohibitive. Amount of Food Required. The amount of food necessary for a healthy individual depends upon his age, the amount of muscular activity he ex- pends, the climate (or the weather), and certain other factors, such as the activity of one or more of the ductless glands, as well as on certain indefi' nite and little understood factors which we group together as "inherited." All physicians called upon to treat disorders incident to childhood are well aware of the enormous appetites of normal children who are active; but DIETOTHERAPY GENERAL PRINCIPLES 363 they sometimes lose sight of the fact that the dosage of milk, which is accepted for a six-months' child, is for tlie average liosptlnl child and not for the normal, healthy, active child, which would grow faster on a more liheral allowance of food. Students of dietetics understand that what is needed during hot weather is sufficient food with a liberal allowance of water to counteract the heat liberated in burning the food. The value of peppers and other condiments in the tropics is that, given water enough, perspiration is stimulated and the more it is stimulated the more rapidly the body is cooled. THE RELATION OF HEIGHT TO WEIGHT. This is by no means a fixed ratio, as considerable variations may exist without indication* of disease; on the other hand, any great disparity, other things being equal, shows that the balance of nutrition is disturbed, and in consequence the chances for longevity are lessened. Height is qualified by the adjectives: dwarf- ish, short, medium, tall ; while the patient is described, from the weight point, as emaciated, thin, spare, medium, stout or obese. Insurance com- panies have adopted a general ratio of height to weight for different ages with a minimum, - average and maximum weight which is graphically illustrated in the table on pp. 364-5. Changes in body weight varying from the normal, form, in most instances, a reliable index to the tendency of the malady; progressive loss indicates an advance of the disease, while progressive increase in weight suggests a lessened activity of the disease. As a rule, individuals of moderate height and weight are best adapted to pass successfully through the ordinary trials of life and the extraordinary ordeals of disease, but the thin, "wiry" person may accomplish an enor- mous amount of work without excessive fatigue, and emerge triumphantly from a severe attack of illness. On the other hand, there are stout, hale and hearty individuals who refuse to grow thin, be worn out, or to degen- erate, but who hang on to life in spite of serious, acute or debilitating disease. The food requirements for adults living under similar environments vary with the weight of the individual. The larger the body the more food will be required (see Volume II, Chapter IX), for, as has already been pointed out, the extent of the body surface influences in a measure the radiation of heat or energy, and the larger the surface the more food per kilo will be consumed. This has been tested experimentally, both in man and animals, and the conclusions reached are that the food must be pro- portional to the weight of the body and area of body surface. The dissipation of liont varies with the condition of rest or \\-ork. While at rest an individual weighing 154 pounds (70 kilos) during a 364 DIET IN HEALTH TABLE OF STANDARD HEIGHT AND WEIGHT AT VARYING AGES (Based upon an analysis of 74,162 accepted male applicants for life insurance, as reported to the Association of Life Insurance Medical Directors, 1897) (The figures above and below are 20 per cent over and under the average) Ages. 15-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 5 feet inches . 5 " 1 " 5 2 u 5 " 3 5 " 4 5 5 5 " 6 5 " 7 " 5 " 8 " 5 9 5 10 5 11 96 120 144 98 122 146 99 124 149 102 127 152 105 131 157 107 134 161 110 138 166 114 142 170 117 146 175 120 150 180 123 154 185 127 159 191 100 125 154 102 128 154 101 103 126 , 129 151 155 102 128 154 105 131 157 108 135 162 110 138 166 114 142 170 118 147 176 121 151 181 124 155 186 127 159 191 131 164 197 105 131 157 107 134 161 110 138 166 113 141 169 116 145 174 120 150 180 123 154 127 159 191 131 164 197 135 169 203 105 131 157 105 131 157 106 133 160 109 136 163 112 140 168 114 143 172 118 147 176 122 152 182 126 157 185 188 130 162 194 134 167 200 138 173 208 106 133 160 107 134 161 109 136 163 111 139 167 114 143 172 117 146 175 120 150 180 124 155 186 128 160 192 132 165 198 136 170 204 140 175 210 107 134 161 109 136 163 110 138 166 113 141 169 115 144 173 118 147 176 121 151 181 125 156 187 129 161 193 133 166 199 137 171 205 142 177 212 107 134 161 109 136 163 110 138 166 113 141 169 116 145 174 119 149 179 122 153 184 126 158 190 130 163 196 134 167 200 138 172 206 142 177 212 107 134 161 109 136 163 110 138 166 113 141 169 116 145 174 119 149 179 122 153 184 126 158 190 130 163 196 134 168 202 138 173 208 142 178 214 105 131 157 107 134 161 110 137 164 112 140 168 115 144 173 118 148 178 122 153 184 126 158 190 130 163 196 134 168 202 139 174 209 144 180 216 D1ETOT1IEKAPY GENERAL PRINCIPLES 365 TABLE OF STANDARD HEIGHT AND WEIGHT AT VARYING AGES Con. Ages 15-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 6 " inches 132 165 198 136 170 204 141 176 211 136 170 204 142 177 212 147 184 221 140 175 210 145 181 217 150 188 226 143 179 215 148 185 222 154 192 230 144 180 216 149 186 223 155 194 233 146 183 220 151 189 227 157 196 235 146 182 218 150 188 226 155 194 233 146 183 220 151 189 227 155 194 233 148 185 222 151 189 227 154 192 230 148 185 222 151 189 227 154 192 230 6 " 1 " 6 " 2 " . ... period of twenty-four hours gives off 15 cubic feet of CO 2 . Since 1 cubic foot of CO 2 produced by combustion involves an expenditure of heat equivalent to 160 foot tons of energy, it follows that 15 x 1GO (2,400) foot tons are required for the maintenance of normal temperature and the ordinary functions of the organism while the body is at rest. And since one calorie equals 1.54 foot tons of energy, 2,400 foot tons are equivalent to about 1,550 calories, i.e., 22.3 calories for each kilo of body weight. Playfair and Parkes conducted studies to determine the minimum food requirement and concluded that this amount of heat and energy would be furnished from the combustion in the body of dry albumin, fat and carbohydrate barely yielding the "sustenance diet." Later investigations show that the amount of food required to supply the heat expended per kilo of body weight by an adult under various conditions, from absolute rest to strenuous activity or laborious work, ranges as follows : TABLE OF ADULT REQUIREMENTS PER KILO For sustenance only 23.0 calories During rest in bed 25.0 " Sedentary occupations 35.0 " Very light work 40.0 " Moderate work 42.0 " Laborious work 60.0 " Extra strenuous labor 120.0 " A normal individual free from digestive disturbances and physically fit, who ingests a well-balanced ration scientifically calculated according to his age, height, weight and area of body surface will, without question, maintain the normal ratio of weight for his age and height, 366 DIET IX HEALTH When the normal amount of food is consumed by a healthy individual, other things being equal, physiological growth will occur, but if food is ingested in too large quantities, or if the body is inactive, food above the actual requirements will be stored in the form of fat. Lack of exercise in such a case will tend to stoutness, for the "contented" person, as a rule, moves along the lines of least resistance ; his mind and muscles are oftener at ease, and so he burns less of his food and stores more than an active, energetic person. "Laugh and grow fat" is a physiologic truth, but, 011 the other hand, many adipose persons are impetuous, impatient and discon- tented, and, again, many are strenuously active. In such cases one of two things has happened : either they have inherited a type of metabolism which is not normal for the race, or something is wrong with the internal secre- tory organs, especially the pituitary, the thyroid, or the sex glands. The thin, lean, lanky individual is one who eats too little or exercises too much for the diet consumed, is nervous from some ductless gland disorder, or is just naturally "skinny." Distribution of Meals. The early founders of this country, like the an- cient Greeks, partook of three meals daily: two light repasts, breakfast in the early morning, and supper at the close of the day ; and the principal meal, dinner, at mid-day, usually followed by an hour or two of rest. This custom still prevails in most agricultural districts. In the busy metro- politan centers the needs of modern activity have changed the distribu- tion of meals, and the full mid-day repast is now replaced by a light lunch, which allows, without the rest of the old regime, intellectual or muscular work almost immediately following, but which necessitates a substantial meal or dinner at six o'clock in the evening, several hours before retiring. This arrangement of meals, without being absolutely hygienic, appears fairly suitable. According to Gautier(l), the well-to-do English families of what is termed the middle class, and the German families in easy cir- cumstances, have breakfast at nine o'clock, dinner at two (this is the prin- cipal meal), tea at five, consisting of tea, coffee, cocoa or beer, with bread, butter and cheese or ham, and lastly a light supper just before retiring. Composition of Meals. The composition of the meals, as pointed out in Volume II, Chapter "VII, should vary with the nature of the occupation. A light but sufficient repast at the noon hour suits those who are occupied chiefly with office work or business activities; but for the workman or peasant who from six or seven o'clock in the morning to mid-day or one o'clock, has been engaged in strenuous, tiring exercise, the noon repast should be sufficiently liberal to allow him. not only to make good his losses, but also to provide him afresh with expendable energy. According to DIETOTHERAPY OENERAI PRINCIPLES 367 Pavlov, it is necessary to normal digestion, that food should bo taken* at regular intervals. He cautions against the ingestion of too large a meal at one time, which overloads the stomach and hinders digestion. Recent physiological experiments emphasize the fact that meat remains in the stomach several minutes ( 1 5 to 4."> ) before pepsin is secreted, which, without doubt, is a provision of Nature to allow the ptyalin of the saliva to transform some of the cooked starches into sugar, as well as to make an alkaline coating to the bolus of starchy food. Later the acidity of the gastric juice produced must be sufficient to excite, in the duodenum, the pancreatic and intestinal secretions. The inhabitants of the Polar regions subsist almost entirely upon food from the animal kingdom, which is rich in fat, the dwellers on the borders of the Frozen Sea Laplanders and Greenlanders feeding almost entirely on fish and the flesh and fat of seals, probably as much from in- stinct as from the impossibility of securing other food. The Arab, on the contrary, is satisfied with a few dates and a little couscous(2), the latter a kind of food used by the natives of Northern Africa, made from flour cooked with flesh and other ingredients, as the leaves of baobab. The Italian finds his macaroni quite sufficient, while the inhabitants of the intermediate /one use a ration well balanced with nitrogenous, fatty and carbohydrate foods. The annual consumption of meats in different countries may be of interest to the reader. In the United States the annual consumption per capita per annum is 172 pounds, or about one-half a pound per day for each individual, man, woman or child. As many women and children consume very little, there must, therefore, be a large number of men who ingest enormous quantities of meat. Gautier(l) points out that the Eng- lishman consumes 130 pounds- per capita ; the Frenchman's annual con- sumption of meat is 86 pounds; while the dweller in the City of Paris consumes 207 pounds: the average consumption per capita in the larger 1t>wns in France is ir>8 pounds, while the peasantry can sea reel v afford. 42 pounds per annum. According to this figure, the peasantrv are com- pelled to subsist on about 26 grams of fresh meat per meal. The Aus- tralian is the greatest meat consumer of all, the annual consumption per capita being in the neighborhood of 240 pounds. AY hen studying the subject of "Protein and Nutrition," 1 we found that the lowest protein demand was about 65 grams per day; the quantity that the French peasant consumes, therefore, is insufficient for the workman and laborer who have most need of it. Gautier states that "even at the i Rcc Volume II, Chapter VFT. 368 DIET IN HEALTH present time meat is only, so to speak, a relish for the countryman. A townsman, on the other hand, generally eats more meat than agrees with him. We have seen that in Paris the alimentary principles of animal origin exceed 480 grams per day, 260 grams of which are meat, and this figure must at least be doubled for many unemployed townsmen." As the opium smoker feels the need of the drug when he does not have it, so the individual who accustoms himself to partaking excessively of animal foods misses them when he fails to consume the usual excessive quantity. In contrast with the large meat eater of easy circumstances, the peasant does not eat enough meat. His dietary is too exclusively vegetable and forces upon him a regular digestion of dishes of great volume potatoes, green vegetables, fruits, etc. which bring him only an insufficient supply of nitrogen. In this class it is common to find gastralgia, dyspepsia and enteritis. This unbalanced diet is fortunately offset, to a large extent, by strenuous exercise in the open air, ventilated, isolated, sunny dwellings, good rest at night, and sometimes in the summer months a siesta at noonday, with the minimum of inducements to intem- perance and vices which beset the city dweller ; but in spite of the great and many advantages of living in the open, the average life of the coun- tryman, according to Gautier(l), is shorter than that of a man in the middle class in the towns. Gautier's statement may be correct for French peasants, but the agricultural classes in this country outlive by many years the working men of the cities. Influence of Diet on Constitution and Health The influence of standard dietaries on constitution and health has been referred to already when considering the subject of "Protein and Nutrition." There was outlined the standard dietary for different occupations, founded principally on the experiments of Chittenden and other workers in this field of research. This dietary provides for the physiological needs and losses of the system in quantities and kinds of foods best suited for a healthy adult whether engaged in strenuous exercise or living a more or less inactive life. On the other hand, a careful examination of the tables in Volume II, Chapter ^ 7 ", will show the quantity of protein, fat and carbohydrate necessary to provide for the requirements of ' calorification, which varies greatly according to the temperature of the surrounding atmos- phere. Gautier estimates that a Frenchman, in relative repose, needs from 80 to 82 grams of protein (one-half of which should be furnished by animal food and the other half by vegetable food). He considers this sufficient, and if the daily diet is increased, as often happens in Paris, to 102 grams of protein, the difference of 20 or DIETOTII K RAPY GENERAL P1UNC1PLES 369 more grams constitutes a reserve supply. The day laborer who lives from hand to mouth, for economic reasons, receives only the necessary amount of food for daily wear and tear, and, as a consequence, is constantly in danger of a deficiency. If he happens to be called upon to carry out a strenuous task, if any of the bodily functions be slightly disturbed, and if his sleep is not sufficient for repair, these causes, and many others besides, by diminishing the receipts or increasing the expenditures, will augment the deficiency, and if there are no storage reserves to meet this condition, it will have to be supplied by combustion of the substance of the organs. Henceforth, a part of the mechanical work, or even the maintenance of animal temperature, will be affected. If the store of fats is exhausted, the bodily functions will destroy some portion of the proteins of the tissues in place of the sugars or the defaulting fats. In order to prevent such deficiencies and losses and not to be driven to heat the house by burning the furniture- 1 the system must have a reserve at its disposal, namely that- created by ingesting slightly more at each meal than is required for body metabolism. The old adage, that we should "lay by something for a rainy day," is as true in nutrition as in finance. It is necessary that the gain of to-day should suffice to compensate for the loss of to-morrow, and that, by means of a sufficient surplus beyond the daily requisite allowance, it should be possible to provide not alone for mobile equilibrium, but to pre- pare the system so that the losses will never exceed the supply. This is especially important with reference to proteins and organic mineral salts. From the above it may be seen how important it is to eat slightly more than the minimum requisite daily ration. At the same time it must be borne in mind that this excess may in turn become dangerous if carried beyond certain limits. The proteins, if not utilized by means of mechan- ical labor, by jmwerfnl work of the lungs and skin, by a sufficient combus- tion and normal radiation of heat, will, when all their waste accumulates in the organism, accentuate a predisposition to obesity, arthritis, and diseases of the skin, and augment visceral congestion and neuropathic conditions. A well-balanced dietary for the working man engaged in strenuous occupations in the open air would be a dangerous ration for the sedentary citizen who expends but little muscular energy, or for the artist and stu- dent who devote themselves entirely to intellectual occupation (3). In young people during adolescence, or in those individuals whose organs, whatever be their age, have largely preserved their normal activity, a slight indulgence beyond the normal requirements of a well-balanced dietary will exert 110 other effect than necessitating a greater activity of the excretory organs lungs, liver, skin and kidneys. But this will not 370 DIET IN HEALTH apply to those whose constitution or bodily habits are defective to begin with. In such individuals a dietary in excess of actual requirements will daily accentuate decay; hepatic or pulmonary congestion, arteriosclerosis, degenerative conditions of the kidneys and of various other organs will in- crease, and there will be eventually established, little by little, if not dis- ease, at any rate a predisposition to it(l). It will readily be seen, there- fore, that the ingested aliment should be well balanced and in proportion to our needs, and regulated not by natural appetite alone, but by reason, aided, when necessary, by the advice of those who have devoted much time and energy to working out these intricate problems. Influence of Diet on Character.. The character of individuals is un- doubtedly more or less influenced by diet. If a certain alimentation influences the general health by reason of its abundance or insufficiency, why may it not act still more by its nature ? It is a universally accepted fact that the most robust, active and aggressive people are great meat eaters. People whose chief subsistence is composed largely of carbohy- drate foods vegetables and fruits are nearly always peaceful, as, for instance, the inhabitants of Central Asia, with whom rice and vegetables with a little pork or fish form the principal articles of diet (4). We cannot help coupling these facts with the statement previously made that carniv- orous animals are generally fierce and savage, while the herbivora, on the contrary, are easy to tame and domesticate. Excessive or exclusive flesh diet plays even a greater role than racial peculiarities in influencing the temper of an individual. Gautier(l) is authority 'for the statement that white (laboratory) rats are manageable and easy to tame as long as they are fed on bread or grain, but when fed on flesh they become snappy and aggressive given to biting. Liebig relates that a bear kept in a museum at Giessen was a gentle, docile animal when fed exclusively on bread and vegetables, but a few days on animal diet caused it to become fierce and dangerous, even to its keeper. We may, then, safely adduce the theory that diet influences tempera- ment. An exclusive animal diet makes one more aggressive, pugnacious, determined and self-willed ; while an exclusive vegetable diet depletes and enfeebles the violence of temperaments and softens and subdues manners. This fact has long been understood by the founders of religious orders in Europe, India and Asia, who have, accordingly, limited or prohibited the allowance of animal food in the dietary. In studying the "Processes of Digestion," we learned that vegetable food is less completely assimilated than animal food, imposing greater exertions on the part of the intestine, thereby diverting part of its energy DIETOTHERAPY GENERAL PRINCIPLES 371 to the accomplishment of these lower functions; it introduces into the system far less nutrition than meats, and far less of those sapid extractive matters which stimulate the heart, prod the muscle, and augment mechan- ical energy (1). It is, therefore, plain that an exclusively vegetable diet perceptibly weakens and softens the will. The wolf and wild cat speci- mens of the most dangerous carnivorous animals have been domesticated by a change of diet into docile, peaceable, friendly household pets dogs and cats. Influence of Diet on Races If we accept the theory that diet affects the development of the organs and character, we can hardly deny that it also modifies races. Uarwiii voiced the opinion that alimentation which creates internal conditions is, with the influence exercised by external con- ditions and selection, the preponderant cause of the variations observed in animals. Gautier believes that the qualities peculiar to each individual and each race are perceptibly influenced by the continuous action of diet, and that, reciprocally, when habits are contracted and temperaments created by long heredity, a special diet often becomes necessary. He says an Englishman or Dutchman will become weakened on being deprived of meat far more quickly than the Spaniard, Southern Frenchman or Italian, and that the latter races, when fed on the same food, if almost entirely vegetable, will be able to perform much more work than a member of the Northern races. Beyond doubt diet influences the physiological vigor and character of races. As a consequence, it must also have a bearing on intellectual aptitudes. Occupation and Diet We know that a man doing mechanical work re- quires a dietary abundant in ternary principles carbohydrates, hydro- carbons and meat, especially the latter. Such a dietary, we have seen, develops muscular force, energy, vigor and even violence, while on the contrary, it is not very favorable to the culture of the artistic or scientific temperament. According to Gautier, those who would give themselves up to speculation and thought, to the exercise of their powers of observation or generalization, the development or expression of their artistic senti- ments, the cultivation of the abstract sciences, etc., require bread, green vegetables, ripe fruits, and, for nitrogenous food, 150 to 200 grams (5 to 6 ounces) of meat, fish or poultry per day, eggs, milk and other foods easily digested (rice, carrots, cauliflower, asparagus, mushrooms, a small quantity of potatoes, etc.), and finally a few aromatic condiments, together with a little coffee or tea. Such a diet is far more suitable than one rich in animal proteins and fats, and the more so because those who devote themselves to exercising the mind or imagination generally take insuf- 372 DIET IX HEALTH ficient physical exercise, thus constituting themselves candidates for arthritis, gout, hepatic, cerebral and renal congestions. Such predisposi- tions are often increased by the abuse of coffee or tea, sometimes of alcohol or tobacco, and the desire for condiments which momentarily excite the appetite which sedentary work tends to weaken. For them the dishes to avoid are those which are difficult to digest or which require to be taken in a great quantity, too abundant meats and too starchy vegetables. For individuals who devote their energies to intellectual research, in whom artistic impressions predominate, the dietary allowance should be that which corresponds to their vocation as well as to the climate in which they live. Beyond doubt, all brain work consumes energy corresponding to the effort expended. Moritz Schiff has "demonstrated that every im- pression heats the brain and the organism and causes as a consequence an expenditure of energy." Physiologists have pointed out the fact that intel- lectual fatigue does not increase the quantity of the total urinary nitrogen and consequently the amount of protein broken up or the combustion of fats (5) or even the amount of phosphorus excreted in a given period of time. When considering the subject of "Hygiene of Eating," we empha- sized the point that intellectual effort should never .be undertaken imme- diately after or following a large meal, when the organs of digestion are most active and require that the blood should not flow to the brain, but to the stomach. During sleep, the destruction of the nitrogenous principles of our tissues does not appear to vary ; but that of the fatty bodies becomes greatly enfeebled without the amount of oxygen absorbed always diminish- ing in proportion. There is often an accumulation of oxygen in the system during the night's rest, especially in the case of young children (6). Climate and Diet. Climate and season beyond question have an im- portant bearing on the necessary dietary. In cold climates and seasons more heat is radiated from the body, and the loss from breathing is much greater ; therefore a richer dietary for the same amount of work becomes necessary, and, similarly, a poorer dietary will suffice in a warm country. As will be seen further on in this chapter, when considering diet in the tropics, it is obvious that more heat is radiated by evaporation of the water from the lungs or in the form of perspiration in hot climates, which diminishes the proportion ' of energy otherwise capable of being trans- formed into muscular exertion. It is apparent, therefore, that this loss by cooling is slight, and the individual will be able to discharge his functions and allotted tasks equally well on a smaller diet. Gautier records an in- stance where Catalonians lived on a dietary which provided them with no more than 1,900 to 2,000 calories, yet they were none the less good- DIETOTHERAPY GENERAL PKItfCIPLES 373 tempered, healthy and muscular, and capable of executing a great amount of work. This author also quotes Maurel of Toulouse, who has done some interesting research work along this line(7). Below is inserted a table worked out by Prof. Maurel for the maintenance allowance in hot seasons and hot countries, cold seasons and cold countries, and finally the inter- mediate climates for normal individuals from twenty to thirty: MAINTENANCE ALLOWANCE ACCORDING TO CLIMATES Climate and Seasons Number of Calorics per kilogram CALORIES PER 24 HOURS Man weighing GO kilograms Man weighing 70 kilograms Man weighing 80 kilograms Hot season of hot countries. . Cold season of hot countries and summer of temperate countries 30 35 40 45 50 1800 3100 2400 2700 3000 2100 2450 2800 3150 3500 2400 2800 3200 3600 4000 Intermediate season of tem- perate countries and sum- mer of cold countries Cold season of temperate countries and intermediate season of cold countries . . . Cold season of cold countries In the beginning of this chapter we referred to diet in cold climates and to the enormous amount of meats and fats consumed by the inhabi- tants of the Polar and Arctic regions. Wherever muscular exorcise be- comes a necessity, animal food should form a large part of the dietary, and the allowance should be relatively more liberal in proportion to the degree of work to be performed. Explorers have given us the advantage of their experiences in the Arctic regions in allowing a certain propor- tion of alcoholic beverages with meals(8). During a cold season or in the Arctic regions the question of resisting cold is a vital one. We have seen that the ingestion of large quantities of fat and flesh, with this object in view, is of the utmost importance. The Eskimo and Greenlander when exposed to the cold will drink and relish several pints of fish oil per day. On the other hand, in tropical climates and hot seasons, fats, the great producers of heat, should naturally form only a small part of the daily ration, and soft drinks, lemonades, etc., should take their place. This point will be further elaborated on in the section on "Foods in Tropical Countries." 124 374 DIET IN HEALTH DIET STUDIES The dietaries of the inhabitants of the United States vary with differ- ent classes and in different sections of the country. Numerous investiga- tions upon nutrition have been made in the various parts of the United States under the auspices of the Department of Agriculture(9). The table on page 249 shows the dietaries of various classes of laborers, students and professional men. This table contains facts and figures with reference to the diet of students' clubs and colleges and contrasts them with the diet of professional men and mechanics. It must be borne in mind that the dietaries contained in this table(lO), giving the protein, fat, carbohydrate and energy content of the various standard diets and of the diet in the principal universities and for mechanics and other day laborers, does not portray accurately the dietary of the people of the different sections of the country. It is evident from the facts and figures in these statistics that people eat what their markets provide, except when poverty prevents pur- chasing. For instance, the family of a sewing woman in New York City (11) averaged for one person a day: DIETARY OF A POOR PERSON IN NEW YORK CITY, SHOWING THE FOOD ELEMENTS AND CALORIES Protein Fat Carbo- hydrate Energy Equivalent Animal food Grams 26 Grams 34 Grams 15 Calories 485 Vegetable food 31 7 222 1,100 Total 57 41 237 1,585 Or a total of 57 grams of protein and 1,585 calories, this being less than a mere subsistence. The articles of food consumed by this family were beef shank, pork chops, sardines, eggs, butter, milk, barley, wheat flour, rye bread, wheat bread, rolls, cakes, crackers, sugar, beans, potatoes, rad- ishes, rhibarb and tomatoes. The principal quantities of animal food consumed were in the form of eggs and milk; of carbohydrate, bread, sugar, potatoes and canned tomatoes. Students' Clubs The table below outlines the various articles of food comprising the dietary of students' clubs in four different states, as men- tioned in the table on page 249, Volume II, Chapter IX. DIET STUDIKS 375 WEIGHT OF DIFFERENT CLASSES OF FOOD PURCHASED PER MAN PER DAY(16) Tennessee Missouri Connecticut Maine Hoof veal mutton Grains 187 Grams 160 Grams 245 Grams 231 Pork 89 113 91 98 Poultry . . 28 12 6 100 Fish . 12 6 24 77 Eecs. . 32 55 35 53 Butter 39 27 60 52 Cheese 7 7 Milk 97 680 457 910 Buttermilk 108 Cereals, sugar, etc 564 524 361 835 Vegetables. . 250 266 189 530 Fruits. . . 50 51 89 48 A study of this table reveals the fact that the greatest quantities of animal foods were consumed by the students' clubs in Maine, Missouri and Connecticut, and the least in Tennessee. The consumption of carbo- hydrate foods was largest in Maine and least in Connecticut. It will be noticed also that the students in Connecticut and Maine consumed a larger proportion of beef than was used by the students in Tennessee or Missouri. In the latter state the students consumed a noticeably large amount of pork. While in Maine poultry and fish comprised a large part of the animal food, these were little used in the colleges in Tennessee and Mis- souri. Milk formed a conspicuous percentage of the diet in the schools of Missouri, Connecticut and Elaine, while in Tennessee it was used spar- ingly. The dietary of the student clubs in Maine seems to be much more generous in all respects than the others. In Tennessee the average of five student clubs was 92 grams of protein, yielding 3,545 calories of energy ; 38 per cent of the food value was obtained from animal food and 62 per cent from vegetable food. In Missouri the average of three student clubs was 06 grams of protein, the menu yielded 3,560 calories of energy, and the food value was about equally divided between the animal and vegetable kingdoms. In Connecticut, of 5 student clubs the average was 106 grams of protein, the ration yielding 3,280 calories of energy, 53 per cent of which was furnished by animal food and 47 by vegetable food. In Maine, the average of 5 student clubs was 121 grams of protein, the menu yield- ing 4,269 calories of energy, -40 por cent of which was furnished by animal food and 00 per cent by vegetable food. Although these dietaries do not portray the actual dietaries of the people in the sections of the country 376 DIET IN HEALTH where these schools are located, yet they may be accepted as an approximate criterion of the usual dietary of the inhabitants of the various sections. Mechanics and Laborers. The dietary of most mechanics in the United States affords them from 100 to 150 grams of protein, and yields from 3,000 to 5,000 calories of energy. A list of occupations requiring a great expenditure of energy and the necessary energy required expressed in calories will be found by referring to previous pages in this chapter. It is not, after all, such a formidable task to reckon the caloric value of a meal. For instance, take the principal meal (dinner) of a laborer or mechanic: roast beef, 100 calories; bread, 150 calories; butter, 150 calories; rice, 128 calories; baked potato, 100 calories; bread pudding, 128 calories; sugar and cream with coffee, 100 calories; total, 960 calories, about one-third of the day's requirements. A meal of this composition is over-rich in protein, but the balance would be restored by lack of protein and an excess of green vegetables and fruits at the other two meals. It will be taken into consideration that the ordinary portions of these sub- stantial foods average about 100 calories. When extra strenuous effort is put forth in an occupation, the portions of bread and potatoes, butter and rice can be increased and easily raise the meal to the energy require- ment without adding to the main protein ration, whatever it may be meat, cheese, chicken or fish. If a laborer has been subjected to strenu- ous exercise and is hungry, allow him to fill up on non-protein elements of the meal, help him to more potatoes and vegetables or simple pudding, instead of increasing the animal foods. It has been found in the South that cornbread and molasses will fur- nish the necessary energy to carry a negro through a cold day. If he works hard, he will burn it up completely, and there will be no ashes as would be the case if he overate of meat or other protein. Late researches tend to prove that the protein elements can be stored, at least for a short period of time, in the tissues ; but such a storage is more or less dangerous from the extra strain put on the liver and kidneys to excrete the waste. Carbonaceous foods sugar, starches and fats can be stored in the form of tissue fats. The average human body weighing 154 pounds should have about six- tenths of its heat or fuel units supplied from carbohydrates, sugar, pota- toes, bread, cereals and vegetables; three-tenths should be supplied by fats, butter, oils, cream or meat fats the last being the least desirable form in which this element may be supplied. These energy or fuel foods should be increased in quantity in proportion to the energy expended in strenuous exercise or in the performance of hard work. DIET STUDIES 377 It has always been recognized by scientific men that the allowance of food should be in proportion to the work the body is expected to do. Play- fair (12), who has given this subject a great deal of attention, has worked out a table with the corresponding amounts of matter and energy in grams and calories, estimated by Rubner's factors. PLAYFAIR'S TABLE OF REQUIREMENTS FOR WORK Subject and Condition .Sf "go II o - O 02 r o |8 3 "*^ am |>J a . '53 2 1 Pi *' oj 1 1 -8 o3 g E -c 2 la . - OQ **\ || HO Subsistence diet 2.230 .840 11.69 2,453 63.25 22.0 330 1,820 Moderate work 4.075 1.557 18.80 1.963 4,072 115.00 44.0 534 14.00 3,070 Soldiers: During peace Infantry in the field . Royal Engineers in the field 4.215 5.410 5.080 1.397 2.410 2.910 18.69 17.92 22.25 .714 .680 .930 4,026 4,458 5,232 120.00 154.00 144.00 40.0 68.0 82.5 510 610 610 19.25 19.07 26.36 3,037 3,374 3,858 English sailors 5.000 2.370 14.39 3,911 142.00 65.0 410 3,067 Navy 5.640 2.340 20.41 4,839 160.00 67.0 578 3,650 Prisoners : Under 7 days 1.800 .480 10.71 1,938 51.00 14.0 304 1,626 Under 21 days . . . 2.448 .608 14.80 2,650 68.00 17.0 2,179 Light labor 3.508 .315 16.72 1.715 3,577 100.00 9.0 470 50.00 2,420 Industrial labor .... Hard labor 3.710 4.075 1.562 1.557 17.31 18.80 1.616 1.963 3,787 4,072 105.00 116.00 44.0 44.0 495 534 46.00 14.00 2,870 3,075 Undergoing punish- ment 1.296 .256 8.16 .368 1,541 36.00 71 230 1060 1,154 Many physiologic investigators have devoted considerable time and research to determine the alimentation consumed by individuals who were allowed a "free choice of food," and have come to the conclusion that the dietaries having the food value given in Playfair's table would furnish a nutrition that was fairly normal and that the nitrogen balance would be kept in a fair state of equilibrium. The conclusion is that the Play fair dietaries represent fairly well the amount of food required by persons studied in these tables, which we will now compare with the alimentation outlined in the table given on page 270. The list of examples of food con- sumed is compiled from data collected by Tibbies (18) in Europe, Asia and America, and shows that when Europeans or Americans are free to choose their own food they seldom select what will yield less than 100 grams of protein per diem. When the choice of food rests with the indi- vidual (American), he seldom partakes of less than 90 grams of protein per day. In this country there are many thousands of individuals who, from force of circumstances, are necessarily compelled to subsist on a 378 DIET IN HEALTH dietary with a much smaller quantity of protein, because eggs, meat, fish, fowl, milk and cheese are more expensive than bread, potatoes, rice, -oat- meal, etc. Standard and Actual Dietaries Compared. We will now study the fol- lowing standard daily dietaries as suggested by Hutchison (14), all con- taining a high protein content, founded on the investigations by At- water(15) : DAILY STANDARD DIETARIES (Food materials furnishing approximately the 0.28 pound = 125 grams of protein and 3,500 calories of energy of the standard for daily dietary of a man of moderate muscular work.) Food Materials Amount Total Organic Matter Protein Fats Carbo- hydrates Fuel Values I Beef, round steak Ounces 13 Pounds 0.26 Pounds 0.14 Pounds 0.12 Pounds Calories 695 Butter. . . 3 0.16 0.16 680 Potatoes ... 6 0.17 0.02 0.15 320 Bread 22 0.89 0.12 0.02 0.75 1760 II Pork, salt 44 4 1.48 0.21 0.28 0.30 0.21 0.90 3455 880 Butter 2 0.11 0.11 450 Beans 16 0.84 0.23 0.02 0.59 1615 Bread 8 0.33 0.04 0.01 0.28 640 Ill Beef, neck 30 10 1.49 0.19 0.27 0.10 0.35 0.09 0.87 3585 550 Butter 1 0.05 0.05 255 Milk, one pint. . 16 0.13 0.04 0.04 005 325 Potatoes 16 0.17 0.02 0.15 320 Oatmeal 4 0.23 0.04 0.02 0.17 460 Bread 16 0.67 0.09 0.02 0.56 1280 Sugar 3 0.19 0.19 345 IV Beef, upper shoulder 66 10 1.63 0.22 0.29 0.09 0.22 0.13 1.12 3535 800 Ham 6 0.19 0.06 0.13 650 Eggs, two 3 005 003 002 135 Butter. . . . 2 11 11 450 Milk, one pint 16 0.13 0.04 0.04 0.05 325 Potatoes 12 12 001 11 240 Flour 9 044 005 001 038 825 Sugar 1 006 006 115 59 1.32 0.28 0.44 0.60 3540 DIKT STUDIES 379 DAILY STANDARD DIETARIES Continued Food Materials Amount Total Organic Matter Protein Fats Carbo- hydrates Fuel Values V Sausage Ounces 4 Pounds 0.14 Pounds 0.03 Pounds 0.11 Pounds Calories 510 Codfish 14 0.07 0.07 140 Butter. . . 2 11 11 450 Milk, one pint 16 13 0.04 0.04 0.05 325 Beans 5 0.26 0.07 0.01 0.18 505 Rice 2 Oil 0.01 0.10 205 Potatoes 16 0.24 0.01 0.23 420 Bread 9 0.33 0.04 0.01 0.28 640 Sugar 3 0.19 0.19 345 VI Beef 71 8 1.58 18 0.27 008 0.28 10 1.03 3540 560 Mackerel, salt 4 0.08 004 0.04 230 Two eggs 3 0.05 0.03 0.02 135 Butter 2H 0.13 0.13 565 Cheese 1 0.04 0.02 0.02 130 Milk, one pint 16 0.13 0.04 0.04 0.05 325 Potatoes. 8 009 001 008 160 Rice 2 11 001 0.10 205 Bread ... . 9 0.38 0.05 0.01 0.32 720 Sugar 1 1 A 0.69 0.09 175 55 1.88 0.28 0.36 0.64 3205 The standard daily dietaries given are constructed from theoretical data taken from Hutchison on this and the preceding page. It will now be interesting to make a comparative study of these dietaries with the com- position of ordinary daily dietaries actually consumed by individuals of different countries, of different social rank, following various and sundry occupations. In the table on pages 378-0, modified from Atwater(lG), studies are compiled from a large number of actual dietaries. On careful study of the tables (pages 380-1 ) of actual dietaries, it will be observed that they conform closely to the ideal standard dietary on the preceding page. Discrepancies of course will be noted here and there. For instance, the diet of the sewing girl in London is altogether insufficient for bodily requirements, while, on the other hand, the diet of some well-to-do American families, bricklayers, and teamsters is needlessly liberal, espe- cially with the protein allowance (compare low protein allowance sug- gested by Chittenden(lT) in his standard dietary table given in Volume II, Chapter VII). Taking the preceding table as a whole, it is gratifying 380 DIET IN HEALTH ACTUAL DIETARIES CLASSES NUTRITIVE CONSTITUENTS Potential Energy Protein Fats Carbo- hydrates Total United States Dietaries Factory operatives, mechanics, etc., Mass. Glass-blowers E. Cambridge, Mass Grams 127 95 114 129 128 161 138 115 104 181 182 222 254 180 120 143 103 104 101 105 109 118 107.7 115 63 73 100 155 53 52 60 Grams 186 132 150 183 177 204 184 163 136 292 254 263 363 365 161 184 138 125 139 147 109 204 88.4 113 3 30 84 177 33 53 28 Grams 531 481 522 467 466 680 622 460 421 557 617 758 826 1,150 454 520 436 423 414 465 527 549 479.4 289 481 472 264 440 316 301 398 Grams 844 708 786 779 771 1,045 944 738 661 1,030 1,053 1,243 1,443 1,695 735 847 677 745 871 675.5 402 406 486 Calories 4,428 3,590 4,002 4,146 4,082 5,345 4,827 3,874 3,417 5,742 5,638 6,464 7,804 8,848 3,851 4,998 3,500 3,325 3,405 3,705 3,622 4,632 3,228 2,705 2,258 2,512 2,470 4,085 1,820 1,940 3.138 Factory operatives, dressmakers, clerks, etc., boarding-house Well-to-do private family, Connecticut: Food purchased Food eaten College students from Northern and East- ern States; boarding club, two die- taries of the same club: Food purchased Food eaten Food purchased Food eaten College football team food eaten. Machinist, Boston, Mass Brick-makers, Middletown, Conn Teamsters, marble- workers, etc., with hard work, Boston, Mass Brick-makers, Cambridge, Mass U. S. Army ration U. S. Navy ration Average of 53 American studies Professional men in America (average of 14 studies) Average of 4 women students' clubs in America Average of 16 men students' clubs in America. ... Canadian Dietaries French Canadians, working people, in Canada French Canadians, factory operatives, mechanics, etc European Dietaries Average diet of laborer's family in Edin- burgh. . Chinese dentist's family Japanese professional man Malays (professional men) Europeans in Java (professional men) .... University boat crews (average of 7 studies) London, sewing girl, wages 3s. 9d. per week Leipsic, Germany, factory girl, 5s. per week England, weaver, time of scarcitv . . DIET STUDIES ACTUAL DIETARIES Continued 381 CLASSES NUTRITIVE CONSTITUENTS Potential Energy Protein Fats Carbo- hydrates Total European Dietaries Continued Lombardy, Italy, laborers; diet mostly vegetable Grams 82 68 97 100 80 131 87 77 131 151 131 151 176 133 167 223 114 134 157 132 134 189 Grams 40 11 16 100 125 95 69 57 39 54 68 43 71 113 117 113 39 58 285 80 79 110 Grams 362 469 438 240 222 327 366 466 525 479 494 622 667 634 675 909 480 489 331 583 523 714 Grams 484 548 551 440 427 553 522 600 695 684 693 816 914 880 959 245 633 681 733 Calories 2,192 2,304 2,343 2,324 2,401 2,762 2,500 2,757 3,053 3,085 3,194 3,569 4,117 4,195 4,641 5,692 2,798 3,098 4,652 3,675 3,436 4,726 Trappist monk in cloister; very little ex- ercise, vegetable diet. . . . Japan, students Munich, Germany, university professor, very little exercise Munich, lawyer Munich, physician Leipsic. Germany, painter Leipsic, Germany, cabinet-maker England "fully fed" tailors Munich, Germany, "well-paid" mechanic. Munich, Germany, carpenter England, "hard-worked" weaver England, blacksmith Germany, miners at very severe work. . . . Munich, brick-makers (Italians at con- tract work) Munich, brewery laborer, very severe work, exceptional diet German soldiers, peace footing German soldiers, war footing. ... .... German soldiers, Franco-German War, ex- traordinary ration Russian workmen Swedish workmen (moderate labor) Swedish workmen (hard labor) to observe the closeness with which the actual dietaries correspond to the standard. We must not overlook the fact that the standard dietaries such as we have been considering have only a limited range of usefulness. It would not be wise to apply them rigidly in any particular case, since they have been formulated to meet the demands of typical vocations living under well-known and regulated conditions and engaged in occupations calling for only a moderate amount of muscular work. Still they are of value in guiding us to formulate well-balanced rations for persons who have no decided choice in their alimentation, and who are living under fairly uniform regulations such as soldiers, inmates of prisons, homes and workhouses. Besides, these studies furnish us with standard infor- mation hy which to regulate well-balanced rations for any collection of individuals, 382 DIET IX HEALTH Col. Melville, in discussing "The Food Requirements for Sustenance and Work" (18), reported before the British Medical Association his studies on the observation of men doing a measured amount of work with a measured quantity of food. Twenty soldiers walked for periods of five and six days an average of twelve to thirteen miles, carrying their kit, the weight of which averaged 54 pounds (24.5 kilos). The average weight of the men was 141 pounds (64.15 kilos). The expenditure of energy was calculated from Zuntz's factors: For every kilo trans- ported horizontally at the rate of 94 meters (102 yards) per minute the expendi- ture was 0.0006 calorie; and for every kilo raised 1 meter vertically the expenditure was 0.0075 calorie; whence it was determined that the average expenditure in walking one mile and carrying 54 pounds over an ordinary give-and-take road was 90 calories, and the total daily expenditure in external or mechanical work amounted to 1,034 calories. According to the above, it will be readily seen that the total energy expended by these men was as follows : ENERGY EXPENDED BY MARCHING SOLDIERS (a) Energy spent in sedentary occupation (Zuntz) 2,200 calories (b) Energy spent in work to camp life, and in playing quoits and foot- ball 800 (c) Energy spent in walking and carrying load 1,034 " Total average daily expenditure 4,034 " The march was done on six days continuously, then one day's rest in- tervened before the second period of five days' walking completed the work done. The food consumed was as follows : FOOD CONSUMED BY EACH SOLDIER PER DAY First Week Second Week Average Proteins 190 grams 145 grams 168 grams Carbohydrates 510 450 480 Fat 58 " 110 " 84 Calories 3,426 " 3,503 3,481 Unavoidable waste, 10 per cent: net calorific value, 3,140. A careful examination of the above tabulation by Melville (19) em- phasizes the fact that there was a deficiency of 890 calories in the alimentation. Negroes and Poor Mexicans. Atwater and Wood (20) call special at- tention to the fact that "our dietary is out of balance," and aver that "the one-sidedness is greater in the South than in the North," by which they mean that the ratio between protein and calories is greater than it should be. The table on page 384 gives data with reference to the protein require- ment of the diet of both men and women in various occupations. Hoff- DIET STUDIES 383 mail, in writing on the diet of the Southern negroes(21), emphasizes the point that the negroes of the Southern States subsist on an unvaried diet, consisting- either of staple foods of fat, salt pork, corn meal and molasses, and that with them cooking is most primitive. The following from Hoff- man's views 011 the subject is of interest: The daily fare is prepared in very simple ways. Corn meal is mixed with water and baked on the flat surface of a hoe or griddle. The salt pork is sliced thin and fried until very brown and much of the grease fried out. Molasses from cane or sorghum is added to the fat, making what is known as "sop," which is eaten with the corn bread. Hot water sweetened with molasses is used as a beverage. This is the bill of fare, three times a day during the year, of most of the cabins on the plantations of the "black belt." It is, however, varied at times; thus, collards and turnips are boiled with the bacon, the latter being used with the vegetables to supply fat, "to make it rich." The corn-meal bread is sometimes made into so-called "cracklin bread," and is prepared as follows: A piece of fat bacon is fried until it is brittle; it is then crushed and mixed with corn meal, water, soda and salt and baked in an oven over the fireplace. Occasionally, the negroes may have an opossum. To prepare this for eating it is first put into hot water to help in removing a part of the hair, then covered with hot ashes until the rest of the hair is removed; thereupon it is put in a large pot, surrounded with sweet potatoes, seasoned with red pepper, and baked. One characteristic of the cooking is that all meats are fried or otherwise cooked until they are crisp. Observation among these people reveals the fact that very many of them suffer from indigestion in some form. Arthur Goss(22), in writing on the dietary standards of the Alabama negroes, makes a comparison of their diet with that of the Mexicans of New Mexico, and the following from his observations is of interest in this connection : Mexicans of the poorer class raise the greater part of their food, which is p 1 nost entirely of vegetable origin. Flour and corn are used, the relative amounts depending upon the amount of money available. If it is necessary to reduce the cost of living to the minimum, as is often the case, more corn and less flour is used. Piobably the next article in amount, and a very important one, is the native bean or "frijole" (Phaseolus sp.), which, together with peas and lentils, is used to supply the protein necessary in the absence of meats and other nitrogenous foods of animal origin. Another universal article in the Mexican diet is red pepper, or "chili," which, while it constitutes comparatively a rather small proportion by weight of the total food, is still consumed in enormous quantities as compared with the use of such material by the people of the eastern states. Chili is probably used more for its stimulating effect on the digestive organs than for the actual amount of nutrients which it furnishes. In point of cost, probably the most important article used by the Mexicans not home produced is coffee. Lard is another very important article which is usually purchased, and which is used in considerable quantities. As the vege- DIET IX HEALTH table foods used contain very little fat, it is necessary to increase the amount of this substance by addition from outside sources, usually either lard compound or beef tallow, which are the cheapest forms of fat in this region. In the houses of the poorer class the cooking is done in an open fireplace, usually located in one corner of the room. The "tortillas" (23), or cakes made from flour or ground corn, are one of the most generally and extensively used foods. When the tortillas are made from corn, the kernels are first boiled with lime, which softens them. The skin is then usually, though not always, removed, and the grain is ground in a crude stone grinding apparatus, or "metate," consisting of a concave slab of stone and a smaller convex piece, which is held in the hands and which serves as a pestle. The grinding is not rotary, however, as in an ordinary mortar, but up and down, toward and from the body. The corn used is usually a small blue kind, rather soft, which seems to contain somewhat more than the average amount of fat. After the corn has been ground into a mush on the metate, it is patted out in the hands into the tortillas. Corn tortillas are never rolled, as is the case with those made from flour. If flour is used, it is mixed into a dough with water and the cake rolled out from it. The flour used is not ground in the metate, but in the ordinary flouring mills. It is usually of poor quality, coarse and dark colored. After being worked into the proper form, the tortilla is baked on a flat piece of iron, supported directly over the fire in the open fireplace, the iron being first greased with lard. As soon as it is done on one side the tortilla is turned by pressing the moistened fingers against the upper side of it, thus causing it to adhere to the fingers, whereupon it is deftly turned and the opposite side is browned. The frijoles, or beans, are cooked in small, home-made earthenware pots, and are almost invariably combined with a very liberal proportion of chili and also with a considerable amount of lard. DAILY DIETARY OF NEGRO FARMER AND POOR MEXICAN Protein Fat Carbo- hydrate Calories Negro fanner: Animal Grams 52 Grams 119 Grams 65 1585 Vegetable 40 5 360 3270 Same Animal 2 41 395 Vegetable 42 16 372 1845 Same: Animal 26 74 26 900 Vegetable 33 11 403 1890 Poor Mexican Animal 56 520 Vegetable 107 19 713 3540 Same' Animal. 61 565 Vegetable 93 19 644 3200 Same: Animal 4 49 470 Vegetable 82 23 571 2890 Same: Animal 29 60 680 Vegetable 72 7 572 2705 USE OF ALCOHOL 385 The chili is cooked alone, and also with various other articles of food. It is prepared hy first removing the stems and seeds of the pods, which constitute somewhat more than half of the total weight, after which it is sometimes ground in the metate, but is usually soaked in water and the inner or edible portion separated from the outer skin by squeezing in the hands. Owing to the extremely strong irritating effect on the hands, this operation cannot be performed by an amateur. The Mexican women, however, become so accustomed to it that it seems to have no effect on them. Among the poor families the meals are served on the floor in the middle of the room, the family sitting on the ground around the food and eating without knives, forks or plates. The exceedingly small amount of animal food consumed by some of the negro families studied by Hoffman, and its entire absence, except as represented by lard, in some of the Mexican families as studied by Goss, are shown in the table on the preceding page. This research shows a suf- ficient source of heat units obtained from vegetable fuel foods, but at the same time it shows an insufficiency of protein, most of which is derived from vegetable foods and in some instances altogether so. For the sake of comparison, consult the Standard Dietary as outlined by Chit- tcnden(17). USE OF ALCOHOL A healthy normal individual does not need alcohol. As a beverage it undoubtedly exerts harmful influences upon the human economy. It is absolutely unnecessary in health, but it is so extensively employed in all parts of the world either to produce fictitious exhilaration or, by lessening sensibility, to mitigate fatigue and discomfort, sorrow and suffering, and it has been so largely and so injudiciously used in disease, that it demands sonic consideration. (See also Volume I, Chapter XVI, "Beverages and Stimulants"). Its habitual use prods the heart to greater activity. Richardson, writing on the subject, says: "One ounce of alcohol daily will increase the heart beats 430 ; 2 ounces, 1,872 ; 4 ounces, 12,960 : 6 ounces, 30,670." But while increasing the rate of the heart, it weakens the fdrce so that the final result is to lower the blood pressure. In other words, while the heart seems to be stimulated, it is really weakened. It is not surprising therefore that a period of enfeeblement of this organ follows the habitual use of alcohol. The use of alcohol does not increase muscular energy, but on the other hand fatigue is hastened by it. Its effect on individuals varies ercatlv; sonic show ill effects on small doses and others are seemingly resistant to large ones. Some people are stimulated by it to eat more hcartilv and to 386 DIET IS HEALTH put forth less muscular exertion, and since oxidation goes on more slowly in these individuals, they easily accumulate fat, but, although they may appear plump and full fed, they are not, as a rule, resistant to disease nor capable of prolonged, strenuous, muscular exertion. Its habitual use is of no advantage in normal health, while those who are not strong-willed or self -control led, and those who inherit a love for liquor or have a tendency to inebriety, gout, arteriosclerosis, or other degenerative changes, will be far better without it. It is true, many persons can use it in strict modera- tion without apparent harm ; the majority, however, sooner or later awake to the realization that even with moderation they are not so well when they use it habitually. The continued and habitual use of alcoholic bev- erages invariably exerts a harmful influence on the human organism. The wisdom or folly of their use in health is not a question that the physiologist alone can determine. The ease with which the habit of im- bibing spirituous liquors grows to an excess, and the harmful influences exerted by them on the body politic, make the desirability of their use a social problem as well as a physiological one. Since alcohol is really a narcotic and not a stimulant at all, and since it is not a food in any real scientific sense, it need not, therefore, be further discussed under the present caption : "Diet in Health." DIET IN TROPICAL CLIMATES (24) It has been generally taught that in tropical climates a smaller amount of nitrogenous food is required than in the temperate zones. Of course, it must be premised that the natives of tropical lands are better fitted physically and physiologically to withstand excessive heat and the actinic rays of the sun in hot climates than are the white men who, as a rule, are only sojourners. But even in the case of natives, the long-held ideas that "they should eat the kind of food which is habitual with them because it best suits their requirements," are lapsing into something like disrepute. In fact, within recent years opinions as to diet in the tropics both for natives and for white men have changed very considerably. General Considerations. We will present herewith the views of various authorities on the subject, and then endeavor to sift the evidence or leave it to our readers to form their own opinions. The late Dr. Charles Wood- ruff (25), a man of very decided views and one who was not afraid to express them, however much they might clash with those of other observ- ers, delivered himself somewhat ns follows with respect to diet in hot climates. "It used to be an article of faith in physiology, that wherever 387 we go in the world we should imitate the natives in food, clothing, houses and methods of work. Upon acquaintance with the native \ve found him poverty stricken, weak, undersized, even half starved, badly housed, filthy, diseased, and of such lack of vitality as to average less than fifteen years of life. To imitate him, as our physiologists taught, was merely to die twenty or twenty-five years before our time." According to Woodruff, false notions are now gradually disappearing in the light of new facts. Take, for exam- ple, the matter of meat in the tropics. The orthodox theory was that we must cut down animal foods below the limit found necessary at home, because, forsooth, the native dying of nitrogen starvation could not get as much as he should. The theory was put into practice with disastrous results, and nowadays every army officer knows that to avoid the awful exhaustions caused by tropical climates and the consequent infections, such as tuberculosis, etc., we must have as much animal food as we have at home, or even more. Perhaps Woodruff was inclined to exaggerate the value of nitrogenous food in the tropics, but there are many who have had experience in the Philippines and in India who hold views very much to his way of think- ing. At any rate, the old-time conception that nitrogenous food was con- tra-indicated in the tropics has been almost exploded. Lukis and Blackham(26) uphold the teaching that in cold climates the fats should be increased and in warm climates the carbohydrates. Yet they do not insist on a vegetarian diet for white men or natives. They point out in support of the argument, that fats are not suitable for con- sumption in hot climates, that, while butter is eaten with avidity in the temperate zone, butter or fats of any description are regarded with dis- taste in the plains of India. These same authorities are not in accord with Chittendeii's views, that the current estimations of the amount of protein and total fuel value necessary for hard work are excessive, and they draw attention to the fact that the most recent researches fail to agree with these opinions. In any climate, the body seeks to maintain a reserve supply of nitrog- enous food for its cells. Consequently, a man having a small reserve supply may be considered on a low plane of nutrition, and, per contra, one with a large reserve supply may be regarded as on a high plane of nutri- tion. It also stands to reason that those on a high plane are better able than those on a low plane to resist those infectious diseases which are more or less prevalent in the tropics, as bubonic plague, cholera, tuberculosis, pneumonia, typhoid fever, typhus, relapsing fever and plague. It would seem to follow, in the regular order of things, that white men in the 388 DIET IN HEALTH tropics not well fed on nitrogenous food should readily fall victims to infectious diseases. And this is exactly what happens. They have placed themselves from the dietetic standpoint on a level with the natives, and like them suffer from a lowered vitality, which renders them exceedingly susceptible to infection and liable to succumb to the -same, while their wiser or more fortunate meat-eating brothers are easily able to resist. The argument, then, that, because the natives of the tropics eat little nitrogenous food, white men should follow suit, will not bear close dissec- tion. The natives do not consume nitrogenous food for the very sufficient reason that, as a rule, they are not able to procure it. As referred to previously, a large proportion of the natives are in a state of chronic star- vation, and it would be the height of folly, in the opinion of Lukis and Blackham(20), to place white men in a similar position. These writers claim, and doubtless with good reasoning, that the comparative immunity of Englishmen to the infectious diseases that decimate the natives of India is due, in part at least, to their being better fed on nitrogenous food. Major McCay 1 has been engaged during the past few years in experi- mental research into the question of the effect of a nitrogenous diet, and in his final report shows in a decisive manner that, other things being equal, diet is an all-important factor in determining the degree of physical development and general well-being of a people, and that with a low level of nitrogenous interchange, deficient stamina morally and physically must be expected. It is obvious that in the performance of manual labor the same expen- diture of energy is required in every climate, but, as Tibbles(13) points out, because the climate influences the radiation of heat from the body, and that this radiation is greater in a cold or wet climate and less in a hot than in a temperate climate, more food is needed in a cold than in a hot climate. However, this is considerably modified by circumstances. In civilized countries, and especially in America, the greater loss of heat in a cold climate is prevented by heating the houses and by wearing warm clothes, and the radiation of heat and evaporation from the body in a hot climate is promoted by wearing thin clothing. Although body metabolism is slightly decreased by the greater heat of tropical climates, the produc- tion of heat is really not much less than in a temperate climate. Where- fore the conclusion has been reached that it is well not to take less food in hot climates, but to increase slightly the intake of carbohydrates in order to supply the heat radiated from the skin, and with the special object of promoting perspiration. Tibbies, however, doubts whether it is good ad- i Professor of Physiology at Calcutta Medical College. DIET IN TROPICAL CLIMATES 389 vice for white men who make their home in the -tropics to follow the dietetic habits of the natives and eat a comparatively very small quantity of animal food and large amounts of vegetables and fruits. From long centuries of usage in hot climates, the natives are accustomed to consume such large quantities of rice, pulse and other vegetables as a person unused to such food would be positively unable to take and to digest. The fact must also be taken into account that there should be a fairly definite ratio between the proportion of nitrogen and carbon in the alimentation. The natives of India are not influenced by poverty alone in their choice of food. Not only does necessity impel very large numbers of them to con- sume materials from the vegetable kingdom, but many are bound by religious scruples to avoid meat. To most of the millions of India the ox is sacred. The hog is anathema maranatha to the Hindus and the Mo- hammedans, as it was to the Egyptians of old and to the Hebrews of the present day (27). Some Hindus are strictly vegetarians, some take no animal food but a little milk and ghee, while others indulge in eggs, fish and game. The Sikhs eat mutton and goat flesh. The Hindus of Punjab eat no meat, but the Mohammedans living in the same region eat meat to a certain extent. It may be said that evidence seems to show that those natives who eat meat are finer and stronger specimens of humanity than those who desist from flesh consumption. Indeed, the Sikhs, who eat mutton and goat's flesh, are models of good physique and are easily the most vigorous race physically of the inhabitants of India. Nevertheless, it may be pointed out that the variations of climate in India are considerable and, as Sir Havelock Charles aptly says, "it is impossible to formulate exact rules for dietary in the tropics generally because the differences of climate entail modifications." While the same authority says nothing with regard to limiting the consumption of meat, he does say that "no cold meat whatever should come on the table," and that it is important that everything should come straight from the fire to the table, for then it cannot serve as a carrier of disease germs or parasites, and there need be no fear of cholera or dys- entery. Boiled water only should be drunk, and no salads of any kind should be used except with the greatest moderation. Fruits and Vegetables As for fruit, that kind which possesses a rind that can be removed may, according to Tibbies, be eaten with impunity by a healthy man at any time of the year. On the other hand, fruits without a rind or peeling are incapable of being thoroughly cleansed and in consequence may be contaminated and dangerous to the consumer unless cooked before eating. Following this rule, oranges, grapefruit, pears, 125 390 DIET TN HEALTH apples, bananas, mangoes, pineapples, custard apples, mangosteen, toma- toes, etc., may be eaten raw after having been peeled, but grapes, currants, strawberries and those fruits which cannot be peeled are on the taboo list until they have been cooked. Vegetables, such as cabbage, cauliflower, kidney beans, green peas, pumpkins and vegetable marrow, should be eaten fresh boiled. It can be stated, broadly speaking, that the alimentary principles are the same in the tropics as elsewhere, and, according to Simpson (28), the simple and for the most part vegetable diet of the indigenous inhabitants of the Tropics contains the same nutrient principles as the more complex and varied admixtures of animal and vegetable foodstuffs which form the ordinary diet of races living in colder climates under a modern civiliza- tion. In Europe, meat chiefly supplies the protein in the food ; bread, po- tatoes, etc., the carbohydrates ; and butter the fat ; while in tropical lands, the protein in the food is supplied mainly by fish, peas, beans and other legumes ; the carbohydrates by millet, cereals, manioc, yams, etc., and the fat by vegetable oils such as ground nut and olive oil. Butter ghee, of animal origin, is clarified butter made from the oil from the liver of fish and the fat of beef and mutton. It is a good butter, but its peculiar flavor renders it distasteful to a European palate. The vegetable oils are ex- pressed from various seeds and are used either for cooking purposes or in place of butter. Vegetable foods are represented by cereals, pulses, tubers, herbaceous vegetables and fruits. Of roots and tubers, the chief are the sweet potato, the yam, the tars and the cassava or manioc. According to Simpson, there is in the roots less than 1 per cent of protein and of fat, and their food value consists in the potash salts and the amount of starch which they con- tain, the latter constituent varying from 15 to nearly 30 per cent; tapioca contains about 86 per cent of starch. Rice, ragi, millet, maize, and other cereals form, as a rule, the staple foods of the tropics. They contain too small proportions of protein and oil to furnish sufficient protein by them- selves, and consequently their deficiencies are made up by an admixture of a small quantity of legumes. The pulses or peas and beans are particu- larly rich in nitrogenous, starchy and phosphorated principles. They contain, at least, 20 per cent of proteins. But, after all, for the great mass of the people of India in fact, for the vast majority of the inhabi- tants of tropical Asia rice is the staple food. There are two principal varieties, Burma and country rice. Burma rice, being highly milled, has the husk, pericarp and outer layer removed by machinery, stripping it of its protein, phosphorus and vitamines. Country rice is soaked in water DIET IN TROPICAL CLIMATES 391 TABLE I PROTEIN AND STARCH EQUIVALENTS IN CEREALS AND BUCKWHEATS (Church) ' (The figures represent ounces and decimals of an ounce) 1 oz. 2 oz. 3oz. 4 oz. 5 oz. 6 oz. 7 oz. 8oz. 9 oz. Ragi : Protein .059 .118 .177 .236 .295 .354 .413 .472 .531 Starch .764 1.528 2.292 3.056 3.820 4.584 4.348 6.112 6.876 Koda: Protein .07 .14 .21 .28 .35 .42 .49 .56 .63 Starch .82 1.64 2.46 3.28 4.10 4.92 5.74 6.56 7.38 Rice: Protein .073 .146 .219 .292 .365 .438 .511 .584 .657 Starch .797 1.594 2.391 3.188 3.985 4.782 5.579 6.376 7.173 Sanwa: Protein .084 .168 .252 .336 .420 .504 .588 .672 .756 Starch .794 1.588 2.382 3.176 3.970 4.764 5.558 6.352 7.146 Gundi : Protein .091 .182 .273 .364 .455 .546 .637 .728 .819 Starch .773 1.546 2.319 3.092 3.865 4.638 5.411 6.184 6.957 Maize: Protein. .095 .190 .285 .380 .475 .570 .665 .760 885 Starch .790 1.580 2.370 3.160 3.950 4.740 5.430 6.320 7.110 Joar: Protein .093 .186 .279 .372 .465 .558 .651 .744 .837 Starch .769 1.538 2.307 3.076 3.845 4.614 5.383 6.152 6.921 Shama: Protein .096 .192 .288 .384 .480 .576 .672 .768 .864 Starch .757 1.514 2.271 3.028 3.785 4.542 5.299 6.056 6.813 Bajra: Protein. .104 .208 .312 .416 .520 .624 .728 .832 .936 Starch .791 1.582 2.373 3.164 3.955 4.746 5.537 6.328 7.119 Kangni : Protein .~77 . .108 .216 .324 .432 .540 .648 .756 .864 .972 Starch .801 1.602 2.403 3.204 4.005 4.806 5.607 6.408 7.209 Barley: Protein .115 .230 .345 .460 .575 .690 .805 .920 1.035 Starch .730 1.460 2.190 2.920 3.650 4.380 5.110 5.840 6.570 Chena : Protein .126 .252 .378 .504 .630 .756 .882 1.008 1.134 Starch .777 1.554 2.221 3.108 3.885 4.662 5.439 6.216 6.993 Amaranth: Protein .143 .286 .429 .572 .715 .858 1.001 1.144 1.287 Starch .760 1.520 2.280 3.040 3.800 4.560 5.320 6.080 6.840 Wheat: Protein .135 .270 .405 .540 .675 .810 .945 1.080 1.215 Starch .712 1.424 2.136 2.848 3.560 4.272 4.984 5.696 6.408 Buckwheat : Protein .152 .304 .456 .608 .760 .912 1.064 1.216 1.368 Starch .714 1.428 2.142 2.856 3.570 4.284 4.998 5.712 6.426 Quinoa : Protein .192 .384 .576 .70S .960 1.152 1.344 1.536 1 728 Starch.. . .578 1.156 1.734 2.312 2.890 3.46S 4.04C. (LM 5 202 i Simpson in "Tropical Hygiene." 392 DIET IN HEALTH TABLE II PROTEIN AND STARCH EQUIVALENTS IN PULSE (Church) (The figures represent ounces and decimals of an ounce) 1 oz. 2oz. 3oz. 4 oz. 5 oz. 6oz. 7 oz. Soy Beans: Protein .353 .706 1.059 1.412 1.765 2.118 2.471 Starch .694 1.388 2.082 2.776 3.470 4.164 4.858 Vetchlings : Protein .319 .638 .957 1.276 1.595 1.914 2.233 Starch .521 1.042 1.563 2.084 2.605 3.126 3.647 Lupines: Protein .317 .634 .951 1.268 1.585 1.902 2.219 Starch .452 .904 1.356 1.808 2.260 2.712 3.164 Vetches: Protein .315 .630 .945 1.260 1.575 1.890 2.205 Starch .497 .994 1.491 1.988 2.485 2.982 3.479 Guar: Protein .298 .596 .894 1.192 1.490 1.788 2.086 Starch .494 .988 1.482 1.976 2.470 2.964 3.458 Lentils: Protein .249 .498 .747 .996 1.245 1,494 1 743 Starch .595 1.190 1.785 2.380 2.975 3.570 4.165 Peanuts: Protein .245 .490 .735 .980 1.225 1.470 1.715 Starch 1.267 2.534 3.801 5.068 6.335 7602 8869 Moth: Protein .238 .476 .714 .952 1.190 1.428 1 666 Starch .580 1.160 1.740 2.320 2.900 3.480 4.060 Peas: Protein .236 472 .708 944 1 180 1 416 1 652 Starch .575 1.150 1.725 2.300 2.875 3.450 4025 Catiang-beans: Protein .231 .462 .693 .924 1.155 1.386 1.617 Starch .578 1.156 1 734 2312 2890 3468 4046 Haricots: Protein .230 .460 .690 .920 1.150 1 380 1 610 Starch .576 1.152 1.728 2.304 2.880 3.456 4.032 Mung-beans: Protein .227 .454 .681 .908 1 135 1 362 1 587 Starch.. . 608 1 216 1 824 2432 3040 3648 4276 Horsegram : Protein .225 .450 675 900 1 125 1 350 1 575 Starch.. . . 603 1 206 1 809 2412 3 015 3 618 4 221 Lablab-beans: Protein .224 448 672 896 1 120 1 344 1 568 Starch .574 1.148 1 722 2296 2870 3444 4018 Pigeon-peas: Protein .203 406 609 812 1 015 1 218 1 421 Starch 596 1 192 1 788 2384 2980 3376 4 172 Chick-peas: Protein 195 390 585 780 975 1 170 1 365 Starch .643 1 286 1 929 2572 3215 3*858 4 501 Inga-beans: Protein 176 352 528 704 880 1 056 1 9 32 Starch .807 1.614 2^421 3.228 4.035 4.842 5.649 Simpson in "Tropical Hygiene.' DIET IX TROPICAL CLIMATES 393 for at least a day and night, and then strained and dried in the sun, after which the husk is roughly removed. It therefore retains most of its peri- carp and outer layers, which contain protein, phosphates and vitamines. Kice is the poorest of the cereals in protein and mineral matter. On the other hand, it has the advantage of occurring in small and easily digested grains. Boiled rice swells and absorbs nearly five times its weight of water, while some of its mineral constituents are lost by solution. Rice, being largely starch, is only in very small part digested in the stomach, but Lukis and Blackham state that its solid constituents, being quite com- pletely digested in the small intestine, enter the blood almost as completely as those of meat two and one-half ounces cooked by boiling requiring three and a half hours for disposal. Practically none of the starch is lost, whereas the waste of protein foods amounts to about 19 per cent. It follows from this that rice is one of the foods which leaves the smallest residue in the intestine, a property which gives it a considerable value in some cases of disease. As Simpson points out, in the construction of European standard diets the basis has generally been a person weighing 154 pounds and doing a day's work of 300 foot-tons, or about 2 foot-tons per pound of body- weight. In Indian and Japanese dietary tables the lesser body-weight of 105 pounds has usually formed the basis, the 2 foot-tons of w r ork being retained. Church gives the following standard diets for Indians weighing 105 pounds, expressed in avoirdupois ounces and decimals of an ounce: CHURCH'S STANDARD DIET FOR INDIANS RATION Protein Oil Starch Starch equivalent Nutrient ratio Bare sustenance 1 . 2.1 0.752 7.520 9.250 1 :4.34 Moderate work Hard work 1954 3.035 1.412 2.506 12.531 11.190 15.779 10.954 1:5.34 1 :4.6G Lukis and IMaekham give the following as the scale in a Bengal jail: Burma or country rice 20 ounces Different dais 6 " Vegetables 6 " Flour, Wheat or Indian Corn 10 or 12 ounces These amounts represent only what is absolutely essential. Perhaps a better standard is furnished by the war ration of the Indian sepoy, 394 DIET IX HEALTH which generally consists of atta or rice, 2 pounds, or sometimes meat or fish, 2 pounds; ghee, 2 ounces; dal, 4 ounces; salt, % ounce; also meat and condiments on payment. In some expeditions onions and dried man- goes have been issued. The following ration has been suggested for Aden camel drivers: Biscuit or rice, l ] /> pounds; dates, wet, 1 pound; ghee, 2 ounces ; sugar, 2 ounces ; coffee, '^ ounce ; salt, 1/2 ounce ; onions, 2 ounces, or dal, % ounce. Church, quoted by Simpson, gives several examples of rations, viz. : A dietary for moderate work, according to this author, calls for 2.954 oz, protein, 1.412 oz. oil, and 12.531 oz. starch, the starch equivalent of which is 15.779. Soy beans, 5 oz., furnish protein 1.765, starch 3.470. Rice, 16 oz., furnishes protein 1.163, starch 12.752. Total protein 2.928. Total starch 16.222. As the oil, however, in this ration is but 1 oz. and should be 1.4 oz., it will be necessary to add the lacking four-tenths. To do this without disturbing the ration, l*/^ oz. of rice should be withdrawn, and 1/2 oz. of soy beans added. Then the amounts will be, soy beans, 51/2 oz., furnish protein, 1.942, starch 3.817. Rice, 14 1 /o oz., furnishes pro- tein .954, starch 11.552, oil .4 oz., the oil being equal to starch .920. This ration has, therefore, 2.896 oz. protein and the equivalent of 16.289 starch. Church lays down two guiding principles, one is to keep down the legume constituent to an amount not exceeding 7 ounces per diem, and if possible not more than 5 ounces per diem ; the other is to ensure the presence of a sufficiency of protein (or albuminoids, as he calls them) by increasing the cereal constituents of the ration, even if in so doing the quantity of starch required be raised above the necessary amount. Milk. Manson(29), referring to the milk supply in tropical coun- tries, says, in part, "that in many tropical countries, such as West Africa, milk cannot be obtained except in preserved form. In other countries, as India, cow's, goat's or buffalo's milk can be readily procured. Buffalo's milk is very rich in fat, there being nearly twice as much as in cow's milk. It is also richer in proteins, though not so rich in lactose. It is less digestible, has a peculiar smell and flavor, and, as a rule, is not suited for invalids. Goat's milk differs less from cow's milk ; but as the groat is c^ susceptible to Malta fever, and the Micrococcus melitensis is discharged in the milk of infected animals, it is better not to use the milk unless efficiently pasteurized or well boiled." The Board of Agriculture and Fisheries of Great Britain published, in the early part of February, 1916, a circular relating to goat's milk, in which it was stated that it is, as a rule, a most wholesome milk, and that its flavor, if the food of the animal DIET Itf TllOPICAL CLIMATES 395 is regulated, is not any real drawback to its employment. Moreover, goat's milk is easily digested by children, and is far less likely than cow's milk to contain tubercle bacilli. The composition of cow's milk and goat's miJk is much the same, although goat's milk is superior as regards fat, which is an advantage. AYhere cow's milk is available it should be used in preference to pre- served milk. In the tropics, as stated previously, unless milk can be con- sumed fresh from the cow, it must be boiled, or efficiently pasteurized, and thus rendered slightly less digestible and deprived of certain of its nutritive properties. Manson states that it is necessary to boil' milk in the tropics, "because (a) under tropical conditions, the multiplication of bacteria is so rapid that milk quickly turns sour; (6) the natives fre- quently add water to the milk and are apt to be careless as regards the washing and scalding of the utensils used; (c) the water used for such dilution and for washing utensils is usually drawn from shallow pools or wells liable to contamination, especially as inspection and regulation of the milk supplies in the tropics are very lax; (d} obvious impurities are strained off with old rags or articles of clothing actually in use; (c) cattle are often fed on garbage of all kinds." The alternative to boiling milk, when it is intended for consumption by Europeans, or for use in hospitals, is to keep the cows under the best sanitary conditions possible and to be sure that they are milked under strict sanitary precautions. It is patent that the difficulties in the way of insuring a comparatively pure milk are so great in tropical countries as to be nearly insuperable. Moreover, in many districts fresh milk is not available. It therefore follows that canned milk is largely used. Manson is of the opinion that the sweetened milks should be avoided for the use of invalids, and thinks that the best tinned milks are those in which the milk is not reduced to a paste but merely concentrated and is still in fluid form. The can must be carefully examined to see that there has been no previous puncture or bulging, and the milk must be odorless. A can once opened must be used quickly. Meats. Simpson, unlike Lukis and Blackham, is inclined to agree with the views of Chittenden that most people eat more protein food than is requisite to preserve health and maintain energy. But it must be taken into consideration that, since Simpson wrote his work on diet in the tropics, the investigations of other workers appear to have demonstrated with greater or less certainty that Ohittenden's views are not altogether borne out by facts, and are in some degree misleading. Simpson draws from a study of Ohittenden's experiments the conclusion that not only 396 DIET IN HEALTH does the European standard of diet err in the direction of allowing too great an amount of proteins, but argues that greater efficiency in working power, and a better feeling of well being and health are attained by a smaller amount of proteins than with the excessive amounts taken in ordi- nary diets, which, as a rule, contain even more than outlined in the standard diets. He thinks that the evidence put forward in favor of these views is strong, and. is supported by the fact that nations such as the Japanese or Indians, living a simpler life, and more given to vegetarianism than the Europeans or Americans, are maintained in health on a much smaller amount of protein food than these standards indicate is necessary. According to Simpson, although man requires a mixed diet, with some reservations relating to custom and climate, it is a matter of indifference whether the mixed diet is obtained wholly from vegetable products, or partly from animal and partly from vegetable products, and it is further his opinion that whether grains or meat shall enter most largely into the diet depends a great deal on climate, on the habits of the people, whether indolent or active, and on other circumstances. However, although this authority seems to favor a vegetarian diet for natives and a diet for white men in the tropics in which the carbohydrates preponderate, the force of his argument is somewhat lessened, so far as the natives are concerned, by the following statement made by him. The inhabitants of hot climates are generally content with milk products, legumes, fruits and sugars, but though cereal grains, as a rule, form the chief food of such people, rice being the staple wherever there is plenty of water and rain, still there are considerable numbers whose food is largely from the animal kingdom. Thus, the Arabs of East Africa, the Pampas Indians, and the Abyssinians are often quoted as instances of consumers of large quantities of meat. They are all very active races. Indeed, as pointed out before, the mass of the inhabitants of India who exist mainly on rice and some other cereals are, generally speaking, miser- able specimens of humanity, exceedingly prone to infection, and so de- ficient in vitality that when attacked by disease they die like flies. The vigorous races of India are those who eat flesh, not to excess, but still suf- ficient in amount to supply the protein needs of the organism. It is also worthy of notice that the Japanese, who of all the Asiatic peoples are especially capable, physically and mentally, do not, by any means, restrict themselves to a vegetarian diet. It is true, though, that at one time the Japanese might have been termed a vegetarian people, but this was more from necessity than choice, and they have always been great fish eaters. During the Russo-Japanese war, when the Japanese soldiers were justly DIET Itf TROPICAL CLIMATES 397 lauded for their remarkable powers of eudurauce, their capabilities in this direction were attributed to their being vegetarians. When, however, the matter was more closely investigated, it was found that the Japanese soldiers' rations comprised a certain amount of meat. A point, too, to which attention is not sufficiently paid, is that while diet must be modi tied to some extent to adapt it to the physiological re- quirements of varying climates, to insist that a white man in the tropics must eat the same food as the native is carrying this principle to absurd lengths. Evidence, and recent evidence in particular, would seem to go to show that even the native who has been so long accustomed to a carbo- hydrate diet that it has become a fixed habit, is all the better for some meat. Simpson takes the stand that the most probable defect in the diet of a European in the tropics is that it is too nitrogenous and fatty, and illus- trates this contention by an instance drawn from history or tradition. When the Aryans first descended into the plains of India they were meat eaters, but the experience of the centuries evidently taught them to be vegetarians, or to be very sparing in the amount of meat they ate, and at the same time to become total abstainers. This, says Simpson, is an expe- rience and a lesson which Europeans who go to the tropics are inclined to ignore. Accustomed to living well in their own country, on large quanti- ties of meat, fats and rich foods, to which wines and spirits are added in considerable quantities, they are tempted to follow, as closely as possible, a similar diet in the tropics. This procedure is generally followed by injurious results due to want of adjustment of the diet to the new con- ditions, and is often disastrous to the health, as attested by the history of the British occupation of India. Within recent years an adjustment has taken place, and the health and mortality of Europeans have undergone a great change for the better. Emphasis may again be laid on the point that the present inhabitants of India eat mainly carbohydrate food simply from economical reasons or because their religion forbids them to consume meat, and, as stated before, those of the natives who eat meat in India are greatly superior in physique and in powers of endurance to the vege- tarians. With regard to the too indulgent habits of the white men who come to the tropics, it is no doubt true that they eat and drink more than is good for them, though this was more frequently the case in former times than at the present. But as Sir Patrick Manson(29), who is probably the greatest living authority on such matters, says, the effects of dietetic errors in Europeans in the tropics are, on the whole, more marked than would be the case from similar errors in temperate climates. This is 398 DIET IN HEALTH especially so as regards the abuse of alcohol and condiments, and also as regards the deficiency of fresh vegetables, of fruits and occasionally of meat. Mansoii has at once placed his finger on the dietetic error of the European in the tropics which most tends to injure his digestive organs, upset his nervous system, impair his health generally, and sap his vital forces. This is the too great consumption of alcohol and condiments. It must be borne in mind that the meat one gets in the tropics is not like the meat of temperate climes. The animals there are not well fed, and their meat is usually stringy, tough and of an insipid flavor. The. consequence is that more thorough cooking is resorted to. This in itself destroys or les- sens the already somewhat meager nutritive properties of the meat, and, in addition, to give some zest to the food the dishes are frequently highly spiced and a larger variety of methods of preparation are employed. The result is that, while the bulk of the food taken is as much or even more than in Europe, the good effects of the protein material are greatly de- creased by its being taken in indigestible forms. In fact, food so cooked and spiced often does more harm than good. Again, the fruits are some- times comparatively dry and tasteless, as is apt to be the case in all tropical climates where they mature quickly, and the vegetables are liable to be indigestible and of inferior quality. It must, then, be taken into consideration that in the tropics neither meat nor foods from the vegetable kingdom are of the same high standard as in temperate climes. When injudicious cooking and the too liberal use of condiments are added to these drawbacks, it may be well understood why digestive disorders prevail. Nevertheless, with all dietetic and culi- nary obstacles with which the white man has to contend, the fact stands out clearly that he possesses a resisting power to infection and disease which is absent from the native. Moreover, it may be once again insisted upon that the meat-eating native has a superior vitality to the vegetarian inhabitant of tropical Asia, which goes to show that the ma- jority of the indigenous population of the tropics do not eat enough pro- tein material. Sweets. A very interesting and instructive feature in connection with diet in the tropics is that Europeans born and bred in tropical lands have less desire for meat and a special predeliction, sometimes amounting to a craving, for sugar. Inhabitants of the Far East and the dwellers in hot climates generally exhibit an excessive desire for sweet things. When presents are made in Asia, they usually take the form of sweetmeats, and the ladies of the harem are depicted, as a rule, lolling on couches and for- over eating sweets. No doubt this craving has a physiological basis. DIET IN" TROPICAL CLIMATES 399 Sweets take the place to some extent of protein material, or rather are protein sparers, being rapidly oxidized. In the Boer war the British soldiers were supplied with a daily ration of chocolate, for it is known to liberate energy rapidly with the least possible strain upon the digestive system. Sugar,, an almost pure soluble carbohydrate, is perhaps the best food for this purpose. Mosso first demonstrated that sugar lessened fatigue, while Vaughan Harley showed that it was an excellent spur to energy with which extraordinary muscular exertion could be made. Simpson mentions that among the troops engaged in Porto Rico and in the Philippines whose appetites had become impaired, there was a craving for candy and sweets which was relieved by a supply of these Articles. Numerous experiments have demonstrated that fatigue' is more quickly relieved by sugar than by any other kind of food, and in the tropics, where exhaustion, by reason of the heat and the actinic rays of the sun, is most likely to occur, the value of sugar can scarcely be over- estimated. Diet and Disease. When writing or speaking of diet in the tropics one must be careful to avoid the faults of exaggeration. To assert that a white man should eat as much meat or more than in a temperate climate would be, perhaps, to sin in this direction. On the other hand, to aver that a strictly carbohydrate diet was the one most suitable for the white dweller in a hot climate would be to err even more grossly. Although white men have dwelt in the tropics for generations, scientific men still agree to differ as to the form of diet best adapted to the climate. Recent investi- gations appear to prove that a mixed or modified diet is not only the best for white men but for the natives themselves. It is absolutely certain that rice, and especially milled rice, the form of food most largely eaten by the natives, is deficient in nitrogenous matter and over bulky in carbonaceous matter. The best rice is also deficient in phosphoric acid, lime and other mineral matters. As a matter of fact, the diet of the natives is responsi- ble for lowered vitality and is directly responsible, according to many authorities, for beriberi. Accordingly, diet may be a direct cause of disease. Excess of protein material in the diet of the European, and deficiency of proteins in that of the poorer classes of natives, and in some institutions, are instances of this. In the prevention of disease, it goes without saving that diet plays n role of the utmost importance. Putting on one side the chronic diseases which are likely to occur in tho tropics from errors of diet more quickly than in colder lands, it must be remembered that food contamination is 400 DIET IN HEALTH rife in hot climates. Flies in such countries are indeed a veritable plague, and if extreme care be not taken to protect food, epidemics will be spread far and wide. Human excreta are less thoroughly dealt with and provide a remarkably favorable means by which flies may convey disease. Cholera, as well as typhoid fever, has been shown to be carried in this manner, and flies are under suspicion of being concerned in the dissemination of other diseases. Canned Foods. Before leaving the subject of diet in the tropics, it may not be out of place to consider briefly the question of canned foods. In the torrid lands, for obvious reasons, canned foods are largely con- sumed. Of course, they are more frequently used than they should be, for their nutritive value is less than that of fresh meat and their consump- tion is open to several other objections. There is a certain amount of risk of metallic poisoning, but the gravest charge that can be brought against the indiscriminate use of canned meat is that it is always difficult to deter- mine how long the food has been tinned. The temptation to send abroad tins already old is too great for some unscrupulous dealers. In any event, tins of meat which have been kept for a considerable period are retailed in all parts of the tropics with the result that serious digestive disorders are frequent, and even ptomaine poisoning is by no means rare. Conclusions. In the light of the most recent researches, it would seem to have been demonstrated that a goodly amount of protein material should be eaten by the white dwellers in the tropics, and that it is not in the interests of health that the protein part of the diet should be unduly de- creased. It would be manifestly unwise for the white man to endeavor to subsist on the form of food eaten by the native. A modified diet is best suited to the bodily and mental requirements of the white man in the tropics, but as in temperate climates he must be largely guided by his mode of life. Such a diet should not contain so much protein matter as in colder climates, but the carbohydrates and proteins should be judiciously distributed in proportion to the individual's needs. In the case of white men, at any rate, most of the protein material should be supplied by moat. Meat should not be cooked too long nor should condiments be added to any great extent. Great care should be exercised in protecting foodstuffs, and especially meat and milk, from contamination or infection, and milk and meat should be consumed as fresh as is possible. Moderation in eating should be the slogan of the white man in the tropics, and if the above rules are carefully observed, there is no reason, at least so far as diet is con- cerned, why he should not enjoy good health. It must be remembered, however, that he must accommodate his diet, to a certain extent, to the ALCOHOL AND I3EVEKAGES IN THE TllOPICS 401 variations of climate, which are more frequent in tropical than in tem- perate zones. Into the question of the diet of the natives, it is superfluous to enter at length. Suffice it to reiterate that investigations seem to show that those who eat meat are more vigorous than those who are vegetarians. It will be observed that in this section the diet of India has been mainly discussed. This is because more is accurately known, of the diet question in India than in other tropical parts of the world. Still it is known that, in Africa and in other tropical climates, those natives who eat meat are stronger than those who subsist solely on vegetable foods. The subject has been treated in a broad way and only general principles have been laid down, and while the authors are conscious that the matter has been dealt with somewhat discursively, it is hoped that the information given may prove of some practical value. ALCOHOL AND BEVERAGES IN THE TROPICS The question of alcohol as a beverage or as a medicine is a vexed one among scientific and medical men, and has been the cause of a good deal of acrimonious discussion. There are those who, like Sir Victor Horsley, hold that it is a poison in any circumstance, and contend that its value as a medicinal remedy is nil. Again there are those like Karl Pearson, At- water and others, who deny that alcohol is absolutely useless, and argue that it has a food value and that, when taken in discretion, it by no means always does harm, and may, on occasions, do good. Pearson appears to have proved that the sins of the fathers are not visited on the children, that is, so far as the hereditary influence of alcohol is concerned. He made a series of careful investigations and seems to have demonstrated that the children of habitual drinkers differ but little, if at all, from those of the abstainer or from the ordinary moderate drinking individual. However, this assertion and the investigations upon which it was based were severely criticised by Horsley and his followers, and it does appear probable that the offspring of drunkards exhibit certain inherited physical and mental characteristics of an abnormal nature. They have handed down to them, as a rule, a somewhat unstable nervous system, which renders them more prone to the effects of stimulating drinks than their fellows who have not had as their progenitors those addicted to the excessive use of alcohol. However, alcohol and its effects have been exhaustively discussed from the scientific standpoint in the chapter on "Stimulants," and, as recapitulation is a weariness of the flesh, we will refrain from offending our readers in this respect. 402 DIET IN HEALTH The subject of the use of alcohol in the tropics will be gone over briefly, and its pros and cons considered impartially. For some time now, it has been taught by the majority of medical men who have had such a varied and lengthy experience of life in the tropics as to warrant them to speak with authority, that alcohol wreaks more injury on the human organism than in temperate climes. This may be so, but the evidence forthcoming does not appear to be entirely convincing. It is assuredly true that in bygone days both meat eating and heavy drinking were the custom in the tropics, as elsewhere, and that the consequences were in a high degree injurious. Even now it is said that in some tropical lands, East Africa, for instance, the white men- eat unsuitable food, drink to excess, and suffer accordingly. In India this is the exception rather than the rule. There the white man is generally absteminous with correspond- ingly good results. Exactly the same thing, however, has occurred in Europe, and especially in Great Britain. It is not so very many years ago, in fact, almost within the memory of the older members of the com- munity, that gross feeding and heavy drinking were habitual with a large proportion of the prosperous and well-to-do in the United Kingdom. In recent years such habits have fallen into disrepute, and, although spirit and beer drinking have prevailed in the British Isles, members of the pros- perous and well-to-do class, from which the white civil officials of India and the officers of the Army are drawn, no longer gorge themselves with food and drink. As said before, both in India and Europe the results of this moderation have been exhibited in superior efficiency of mind and body. However, the point is as to whether alcohol is more harmful in tropical climates than in temperate countries. IVfanson says that the abuse of alcohol and condiments is a fruitful cause of digestive derangements and of various diseases in tropical climates, but so is the abuse of alcohol and of indigestible foods in colder lands. The majority of authori- ties are of the opinion that alcohol is more injurious in the tropics or, at any rate, they strongly urge against the use of alcohol and usually advise white men sojourning there to be abstainers. The late Dr. Charles Woodruff, who, as mentioned previously, com- bated the crystallized view that the meat part of the white men's dietary should be decreased in the tropics, also stoutly defended the use of alcohol in strict moderation in both the tropics and in other portions of the globe. Among the numerous statistics he brings forward and the many authori- ties he cites, is a statement made by Dr. Leon Meunier of Paris, published in the Cosmos, July 14th, 1903, that with regard to small amounts of ALCOHOL AND BEVERAGES IN THE TROPICS 403 alcohol the experience of centuries was to the effect that such an amount is not only harmless, but is a beneficial food, which can take the place of an equal energy in butter and similar fuels, irrespective of the state of rest, work or any circumstance relating to the consumer. Woodruff goes on to say that the great majority of the medical profession have reached the decision that alcohol is like every other chemical, whether it be a poison like strychnin or a food like protein ; that is to say, there is an amount below which it is not a poison and above which it is poisonous. Wood- ruff's array of figures and authorities seems to bear out his own view, that in the terribly depressing, anemic conditions brought about by living in a tropical climate, against whose onslaughts he has no protection like the dark-skinned native, a white man who is not assisted by a little alcohol is more harmed by the climate than the man who is so aided. Simpson does not commit himself to the expression of any very decided opinion on the subject, but gives this guarded statement, that it is safest for the newcomer to abstain from alcoholic beverages, especially so if much exposure to the sun is to be endured. Tea and coffee are the customary drinks of many of the inhabitants of the tropics, and where these are not in use, water is generally the only beverage. He thinks it is well to follow the custom of the country in this respect. When alcoholic drinks are used and they are often found necessary to the European after he has been some years in the tropics they should only be taken at meals, preferably with the dinner ill the evening, and then in extreme mod- eration. Lukis and Blackham are of the opinion that "a certain amount of alcohol may be safely consumed as a heat-producing food." This amount is certainly very limited, not more than one or, at the outside, two ounces in twenty-four hours. Its unsuitability as a food is shown by its other effects on the body which are so well known as to need no description, and which, in fact, have been fully described in the section of this book dealing with stimulants. It is allowable in some cases when, for some reason, in- sufficient food is taken. When sufficient food is taken, alcohol is unneces- sary, and when excess of food is taken the addition of alcohol may do serious harm. It may also be said and this point has been elaborated in the section on alcohol that this stimulant is exceedingly valuable in cases of exhaustion arising from sickness or fatigue, because of its anes- thetic effect. This property of alcohol would seem to have been proved times without number. When very hard work has been done under ad- verse climatic conditions, and when extreme fatigue supervenes as a result of the excessive expenditure of muscular energy, and the vital forces are 404 DIET IN HEALTH brought to a very low ebb, alcohol acts as an anesthetic and one forgets his depression. However, the present tendency perhaps of scientific and military authorities is to frown upon the habitual use of alcohol in the tropics and to deprecate even its use as a spur in cases of exhaustion. Kitchener, it is said, would not permit soldiers under his command in the Soudan cam- paign to take alcohol, and substituted tea, coffee or cocoa. Sir R. Have- lock Charles, a soldier of wide tropical experience, recorded his opinion in The Practitioner, 1910, that alcohol is absolutely unnecessary, and if taken at all should be as a luxury. Tibbies says that it is admitted by all authorities that the use of alcohol in the tropics is a matter requiring grave consideration, and that men are better in health and can perform their duties more satisfactorily without it. Cantlie wrote that the natives of warm climates, both by their religion and their habits, shun alcohol. This statement must be taken with a certain amount of reservation. The Mohammedan religion is against the use of alcohol, but in India and else- where many Mohammedans drink when they can afford to do so, and pos- sibly the chief deterrent to the use of alcohol is the extreme poverty of the mass of the tropical population. All those who have studied the question either from the practical or scientific standpoint are agreed on the point that if alcohol be taken at all in the tropics, it should be drunk in moderation and even sparingly. Lukis and Blackham say that in hot, moist (that is, tropical) climates, beer can rarely be taken with impunity, but that no harm is done by light wines (white or red), champagne and good whiskey well diluted and taken either with meals or after excessive fatigue in small quantities. On the contrary, it is evident that a weak "peg" or glass of wine with the evening meal is beneficial to the harassed Indian official at the end of a strenuous day's work. It promotes digestion and has a soothing effect on the nerves. What does most harm in India and in other parts of Asia where white men congregate is the practice of "pegging," or of taking "short drinks" at the club bar before dinner. It is obvious that spirits, if as harmful as many scientists say, are less harmful when freely diluted. Therefore, when drunk customarily, and not wholly employed as a spur in cases of exhaustion, they should be well diluted and taken in strict moderation. Tibbies says "that about half a pint of red wine or one pint of beer daily is considered a fair allowance, but he is of the opinion that even such a modicum is better replaced by tea, coffee, cocoa or their sub- stitutes, caffer tea, dorn-the, gooranut, kola, kat, mote, guarana, and other native beverages." Natives in all tropical climates, when not debarred by ALCOHOL AND BEVERAGES IN THE TROPICS 405 poverty or restrained by religious scruples, drink spirituous beverages of domestic manufacture. These are made from any article of food which will ferment. Whether made in South America, in Asia, or in Africa, they are, generally speaking, deadly to the natives and more deadly to the white men who are foolish enough to partake of them. This has been proven by the disastrous experience of American soldiers in the Philippines. Native drinks are many and various. Doasta distilled from rice liquor is sold in Calcutta. Mann states that it is 20 degrees under proof, but contains 0.56 per cent of higher alcohols or 491 grains per gallon. Sugar refuse yields a liquor known as Shajehanjur rum, which is sold 53 to 56 degrees under proof. In Bengal and Assam, the flowers of Bassia latifolia contribute a spirit named Mahua. It is sold 22 to 50 degrees under proof, and contains 0.004 to 0.33 per cent of higher alcohols and is a very poi- sonous and deleterious concoction even to the natives. The notorious arrack is distilled from the sap of the palm tree in India and Ceylon, but the characteristic which has given it its evil name is the fact that it is frequently drugged. Other vile beverages are fairly common among the inhabitants of Asia and other tropical countries. Some of these native drinks are less harmful than the European spirits, but some of them are most pernicious. It is difficult, indeed impossible, to write dogmatically with regard to the effects of the imbibing of alcohol in the tropics, or to state definitely that it is more injurious to the human being there than in temperate climates. Drinking to excess is harmful everywhere, and its baneful effects are too plainly evident in every civilized land. Two reasons, and these not scientific ones, why white men should be abstemious as regards alcohol, in the tropics, are that by so doing they set a good example to the natives and that if they drink more than is good for them they are apt to deteriorate more quickly in the tropics than in a colder climate. While the last word has not been said on the question of alcohol as a beverage, it must be confessed that the weight of scientific evidence is on the side of those who contend that the use of alcohol is almost always contra-indicated. Some, like Horsley, say always. Nevertheless, there is a large number of men, few of whom perhaps are of so high a scientific caliber as the opponents of alcohol, but who have had more practical expe- rience, who hold that alcohol has its value and that its use as a beverage should not be entirely barred. Problems of this kind cannot be wholly solved in the laboratory. The argument that, because an undue proportion of a population undergoes deterioration, mental and physical, through 12G 406 DIET IN HEALTH drink, it should be abolished, may be good and sound from the scientific point of view, but it may not be an altogether practical position to take. There is one feature in connection with the consumption of alcoholic beverages in the tropics of which little notice seems to have been taken. This is, that, owing to the heat, elimination and excretion are more pro- fuse and rapid by far than in cold climates. Consequently it is reasonable to suppose that alcohol will pass out of the system more quickly and do less harm than in more frigid lands. It is acknowledged that the most injurious effects of alcohol are on the nervous system, rendered possible by prolonged poisoning. Dr. Winfield Scott Hall points out(30) that the theory that alcohol is a food is disproved by recent researches. All life activity is accompanied by oxidation, and all oxidation by waste. Any sparing action which alco- hol may possess is easily accounted for as being in harmony with its gen- erally accepted narcotic action. Narcotic action is followed by decreased activity, therefore decreased oxidation, therefore "sparing." Nobody has contended, much less proven, that this so-called sparing action is an econ- omy of food material in connection with activity. With the influence of alcohol as without it, a given amount of life activity is accompanied by a given consumption of body substance, and it is inane and foolish to con- tend that the sparing action of alcohol, due to its narcotic effect, should be accepted as an argument proving its food value. The oxidation of alcohol liberates heat energy, but this energy cannot be utilized by the body, even for the maintenance of body temperature. If a food is defined as a substance which, taken into the body, is assimi- lated and used either to build up or repair body structure, or to be oxidized in the tissues to liberate the energies used by the tissues in their normal activity, then alcohol is not a food. If alcohol is not a real food, what is the significance of its oxidation? It has long been known that the liver produces oxidases, and that it is the site of active oxidation of mid-products of catabolism, of toxins, and of other toxic substances. Alcohol, while usually formed as an excretion of the yeast plant, is also found as a mid-product of tissue. It belongs clearly, then, to the group of excreta. Experiments conducted by Dr. Reid Hunt and other experi- ments carried out by Dr. Beebe prove with sufficient clearness that alcohol is a toxic substance and not a food in any sense. With regard to alco- holic beverages, Hall has this to say: Alcoholic beverages contain from 3 per cent to 40 per cent of ethyl alcohol. Beers and ales contain the lower percentages of alcohol ; whiskey, rum and brandy the higher percentages, while wines are about midway between. ALCOHOL AND BEVERAGES l.\ THE TROPICS 407 X<> alcoholic beverage has so low a percentage of alcohol as to be with- out danger. The amount Imbibed by the addict is usually so much that the alcohol taken exceeds the "physiological limit," that is, there is more alcohol taken than can be oxidized in the liver, so that there is an escape into the general system not only of deleterious toxins, which should have been oxidized in the liver, but also of the excess of alcohol, which is car- ried to brain and to muscles, seriously disturbing their normal activity and decreasing their efficiency. The evidence, on the whole, gathered from the views of authorities on tropical hygiene, appears to point in the direction of abstinence from liquor or strict moderation in its use in the tropics. The arguments, how- ever, in support of complete abstention from alcoholic beverages are no more decisive as regards the tropics than they are with respect to temper- ate climates. It is true that scientific and public opinion are veering towards the view that alcohol is unnecessary and ofttimes very harmful; therefore, it may be stated that when the opinions of various authorities' on the subject of alcohol in the tropics have been carefully considered, the preponderant view, at any rate, from the scientific standpoint, seems to be that its use is unnecessary, and, when it is recognized that its abuse is injurious, the best means of avoiding harm is to abstain from it entirely. Among other beverages largely used in the tropics, tea is the most popular, but coffee, cocoa and aerated drinks are consumed largely. The properties of all these beverages have been amply discussed in the section dealing with beverages. REFERENCES 1. GAUTIKK. Diet and Dietetics, tr. by A. J. Rice-Oxley, 2nd ed., Lippincott, HUM;. 2. Ht'Tcinsox. Food and the Principles of Dietetics, 4th ed., Wood, 1917. .'{. CIIITTKXDKX. Physiology of Man. 4. BENEDICT, A. L. Golden Rules of Dietetics. 5. SPECK. Arch. f. exp. Pathol. u. Pharrn., Bd. xv, p. 81. 0. VOIT, C. Ztschr. f. Biol., Bd. xiv, p. 57. 7. MAUREL (of Toulouse). Influence des climats et des saisons sur les depenses de 1'organisme chez 1'homme. Arch, de med. nav., vol. Ixxiv, p. 30fi ; vol. Ixxv, pp. 5, 81. 8. DK LOXO, GKOKMJK W. Voyage of the .leannetfe. 408 DIET IN HEALTH ( J. Bull. No. 227, Exper. Station, U. S. Dept. of Agric. 10. . Ibid., No. 27. 11. DAVIS. Foods in Health and Disease. 12. PLAYFAIR. Text-book of Physiology. 13. TIBBLES, WILLIAM. Food in Health and Disease. 14. HUTCHISON. Food and the Principles of Dietetics. 15. ATWATER. U. S. Dept. of Agric., Bull. No. 38. 16. . Report of U. S. Commisisoner of Fish and Fisheries. 17. CHITTENDEN, R. H. Nutrition of Man. 18. MELVILLE, COL. Brit. Med. J., 1910, vol. ii, p. 1337. 19. TIBBLES, WILLIAM. Food in Health and Disease. 20. ATWATER and WOOD. TJ. S. Dept. of Agric., Bull. No. 38. 21. HOFFMAN. Food of the Negro in Alabama, U. S. Dept. of Agric. Bull. No. 38. 22. Goss, ARTHUR. Dietary Studies in New Mexico, U. S. Dept. of Agric., Bull. No. 40. 23. DAVIS. Food in Health and Disease. 24. MANSON. Tropical Diseases. 25. WOODRUFF, CHARLES. American Medicine, 1914. 26. LTJKIS and BLACKHAM. Text-book Tropical Hygiene, 2nd ed. 27. Holy Bible. 1st Cor., 16th chap., 22nd verse. 28. SIMPSON. Principles of Hygiene as Applied to Tropical and Sub- Tropical Countries, Wood, 1908. 29. MANSON. Sutherland's System of Diet and Dietetics. 30. HALL, WINFIELD S. Med. Times, Feb., 1916. CHAPTER XTTI DIET IN CRITICAL PHYSIOLOGICAL PERIODS Old men bear want of food best; then those that are adults; youths bear it uiffl cufx'cidllii children, and of them ihe most lirelif are the least capable of ctiditr'nn) it. Diet in Childhood: Early Childhood; Diet for School Children. Diet during Puberty. Diet in Sedentary Occupations. Diet during Menstruation. Diet during Pregnancy. Diet during the Puerperiura. Diet during Lactation. Did during the Menopause. Diet in Old Age. DIET IN CHILDHOOD In this chapter no reference will be made to the alimentation for the infant, as this will he fully discussed in subsequent chapters. We will begin with early childhood (from the third to the sixth year before school), during which time the child should have four meals each day and a nap in the afternoon. There should be no sudden change of diet during this period, but the proportions of milk should be gradually decreased and mushy cereals increased, and a greater proportion of breadstuff's, cookies, etc., should be allowed. According to the researches of Atwater, at the end of the second year the child weighs about one-fifth as much as the adult, and requires three-tenths of the standard adult ration, the relative- excess being due to the fact that the child is growing and depositing tissues and fat. From the third to the fifth year the growing child requires four- tenths of the adult ration; from the sixth to the ninth year one-half, and from the tenth to the thirteenth year six-tenths. From this age on much depends upon the habits and life. For instance, a girl from fourteen to sixteen requires seven-tenths of the adult ration, and a boy of the same age requires a full adult ration. 409 410 DIET IN PHYSIOLOGICAL PERIODS Early Childhood. Dr. M. Allen Starr(l) has worked out the accom- panying table of the dietetic needs in childhood collected from the actual food consumption by large groups of healthy children. STARR'S TABLE OF DIETETIC NEEDS IN CHILDHOOD 2-3 years (28 cases) 3-6 years (12 cases) 4-10 years (24 cases) Bread 7.5 ounces 10.3 ounces 10.23 Ounces Butter .98 " 1.08 .99 Beef 4.6 12.1 " 12.46 Potatoes or rice 3.9 " 13. " 10.23 " Milk 32.6 48.6 38.5 Cereals, fruits and eggs should enter largely into the composition of the alimentation of the growing child, and there is no objection to an allow- ance of a minimum amount of meat. During this period of development, from the third to the sixth year, the child is building up tissue, muscle, brain, bone and gland, and must, therefore, have plenty of protein. Milk, eggs and cereals will furnish these in abundance. At this time, also, the child is acquiring habits, and it should be impressed upon him that the habit of proper mastication is an important acquisition. This can only be attained by necessity. The mother should be instructed not to feed the child on a diet consisting too largely of pultaceous foodstuffs of a semi- liquid character, as these will be swallowed without chewing and thereby become a hindrance to dental development and a possible detriment to the development of the digestive organs. Such a diet leads, in the first place, to imperfect development of the muscles of mastication and the jaws, with the result that the post-nasal space is small and liable to be encroached upon by adenoids, with unfavorable effects upon growth and general nutri- tion, while in the second place the particles of carbohydrate food will lodge around the teeth and undergo acid fermentation with resulting dental caries. The great necessity for giving the child food that requires chew- ing cannot be too strongly emphasized. The healthy growing child will get hungry between meals, and if he is doled out soft bread with jam he is pretty certain first to swallow the food with inadequate chewing and, sec- ond, to eat more than he needs, overloading his stomach, overtaxing his digestive activities, and perhaps retarding his appetite for the next meal. This point is particularly emphasized by Watson (2), who urges that a child be taught early to develop the art of mastication, which favors the normal development of the nasal and nasopharyngeal cavities which are of DIET IN CHILDHOOD 411 so much importance, for the purpose of respiration and general nutrition. The cereal foods are of first importance oatmeal, hominy and samp, thoroughly cooked and served with butter, cream, milk or sirup. Well- cooked farinaceous pudding of all kinds are wholesome and readily taken by children. Of fresh vegetables the potato is the most popular, and one of which young children will not tire. It may be served boiled, baked or mashed and creamed, but never fried. Fresh cauliflower, cabbage, spinach, asparagus, beans and peas may be allowed, but canned vegetables should never be used when fresh ones can be had. We fully appreciate the craving of the growing child for sugar, candy and sweets, a demand which must be satisfied. It is far better to do this, however, by the use of sugar in the food than by allowing the artificially colored sweets of the candy manufacturer, which are often taken in ex- cess apart from the meal. Many fruits contain a considerable amount of sugar in an assimilable form, as well as certain mineral properties which are of inestimable value and importance in maintaining a healthy condi- tion of the blood. Apples, peaches, pears, plums, grapes, oranges, bananas, cherries, etc., are suitable wholesome fruits, and some of these, according to season, should form a part of the child's dietary each day. The first permanent molar teeth appear about the sixth year, while the deciduous incisors are already undergoing decay. Children at this stage require careful preparation of food by fine cutting, scraping, etc. At this time, also, the child should be initiated into the use of the tooth- brush, and if necessary the dentist should be consulted as to the preserva- tion even of the deciduous teeth by means of temporary soft fillings. Not only are these deciduous teeth more valuable for mastication than parents sometimes think, but with cavities they furnish a home for the colonization of bacteria, which hasten the early loss of the permanent teeth. The normal day's ration for a healthy child of four to six years, ac- cording to Hall, may be as follows (3), necessary variations being made in accordance with the season, climate, etc. : Breakfast 7 A.M. A glass of whole milk; small portion of thoroughly cooked oatmeal with cream and sugar; baked apple; small piece of buttered toast. Lunch 10 A.M. A small portion (equal to a heaping tablespoon) of parched sweet corn, or two graham crackers; glass of water. Dinner 1 P.M. Cup of cambric tea (hot water and cream sweetened); broad and butter; cn-ann >] potatoes; fruit, stewed or fresh, 412 DIET PHYSIOLOGICAL PEKIODS Tea 4 P.M. A dry crust or a piece of cold, dry toast, or a pretzel, or two graham crackers. Supper 6 P.M. Glass of milk; soft-boiled egg; shredded- wheat biscuit with cream; fruit (apple, grapes, banana or orange). There are several points in reference to a child's diet which should be specially emphasized, as pointed out by Hall. First, his food should be dry and hard to chew. Second, one meal each day should be rich in pro- teins. Third, any lunches partaken of in the midforenoon or midafter- noon should be small in volume and should always be dry, requiring very slow mastication, which will insure the ingestion of small quantities and rapid digestion. Furthermore, such a repast will not interfere with the full meal which is to follow some two hours later. A normal child of two years and upwards has a well-developed digestive apparatus and a keen appetite, and is well able to digest most foodstuffs if given in moderate quantities. Watson has compiled a very practical table of average weights and heights of children at different ages. The averages in these tables were calculated from weights and measurements taken from a large number of observations, and, though fairly accurate, are not necessarily true in all cases. The discrepancy, however, will not vary more than 15 per cent either way. The point of greatest importance is the proportion between height and weight. To be exact in recording observations in weight, the periodical weighing should be done under precisely corresponding condi- tions, the same clothes, same scales, etc. COMPARATIVE HEIGHTS AND WEIGHTS OF CHILDREN MALES FEMALES Age last birthday Age last birthday Height Weight Height Weight 1 2 2 ft. 5^ in. 2 8p^2 18^ Ibs. 1 2 2 ft. 3^ in. 2 " 7 " 18 Ibs. 3 2 11 34 3 2 10 31M " 4 3 " 1 37 4 3 " " 36 5 3 4 40 5 3 " 3 " 39 6 7 8 3 " 7 " 3 " 10 3 " 11 44^ " 49% 55 6 7 8 3 6 3 " 8 3 " 10^ " 41% " 47^ " 52 9 10 11 4 ^ 4 3% 4 " 5J / <2 " 72 2 9 10 11 4 0% " 4 3 4 5 53^ " 62 68 12 13 4 " 7 " 4 9 76% 82^ 12 13 4 " 7^ " 4 " 9% 76^ " 87 DIET IX CHILDHOOD 413 A point, emphasized by Watson, and often overlooked at this period of life, is the necessity for adapting the alimentation to the diathesis of the child. For instance, the needs of a child of tuberculous parents, say, at the fifth year, are different from those of a gouty child of the same ago. The child of a tuberculous diathesis is usually of comparatively feeble development, shows little muscular activity, is slightly anemic and possibly under size. The principal point in arranging the diet in such cases is to provide the necessary increase in the amount of animal pro- tein, more particularly meat and raw meat juice. The great benefit de- rived from a properly planned alimentation in these cases is little less than remarkable, but to secure lasting results, the dietary must be religiously continued for many months, sometimes for as long as two years. The following diet list will be found of practical importance and suitable for a child of five or six years, with a tuberculous diathesis. It contains a more liberal supply of animal proteins in the form of milk, eggs, meat, and soup than an ordinary diet, including two pints of milk, and meat foods at least three times daily. This point should be insisted on and continued during the growing period. DIETARY FOR TUBERCULOUS CHILDREN First Breakfast 6.30 A.M. Milk; biscuit and butter. Breakfast: Milk; butter; bread; egg; fish or bacon. Lunch: Cup of soup (meat stock), or egg flip. Dinner: Soup with raw meat; curds and cream; glass of milk; pounded meat and vege- table; stewed fruit cream; glass of milk. Fish, with sauce; potato; custard pudding; glass of milk. Chicken, bread sauce; vegetable; blancmange; cream; glass of milk. Tea: Milk; bread and butter. Supper: Good meat soup, thickened with milk; or egg; or meat pure"e; or lentil pure*e. The diet for a child of the gouty diathesis should be most careful I v regulated, since it is without question that proper alimentation will do much to eradicate the tendency to disease. "The special features in the dietary treatment are (a) the necessity of bringing the child up on a strictly lacto-vegetarian diet, red meats of all kinds to he forbidden, or, at most, only allowed occasionally, and very sparingly; (J>} the importance of a restricted allowance of sugar and of foodstuffs rich in sugar. If a 414 DIET IN PHYSIOLOGICAL PERIODS child with a gouty tendency is dieted along these lines during the period of growth and development, he will be much less prone to develop gouty symptoms in later life." Diet for School Children. Growing boys and girls during school life from the sixth year until puberty require a large amount of wholesome, nutritious food (4). During this stage of life the rapid growth and inces- sant activity of the child continue, and to these is now added the mental work of laying the foundation for an education. In a child that has been wisely brought up under normal conditions and has had a due amount of work, play and sleep, the appetite will be the best guide for the amount of food required. On the other hand, the appetite of a child who has been in- dulged with too many sweets and highly seasoned dishes, to the exclusion of the plainer, more wholesome foods, and who has been petted, pampered and brought up like a hothouse plant, will not be a trustworthy guide to the food requirements. Children with a debased appetite of this sort, which is, of course, due to faulty feeding at home, had better be sent to a boarding school at once, where the social customs will soon effect a per- fect, if at first a somewhat painful, cure. It is not uncommon at this age to have the parent tell us that "Johnny cannot take this and cannot take that food at home," although on physical examination no defects will be found. It cannot be too strongly impressed on parents that the inability of healthy children to take ordinary food is imaginary, brought about largely by previous erroneous feeding and fostered by paternal weakness, proof of which is furnished by the fact that when the child is placed among other children who are eating ordinary food this inability at once passes away. It must not be lost sight of, however, that we not infre- quently meet with a neurotic boy or girl with personal idiosyncrasies to certain articles of diet. Such children require special study and special treatment. The greater the amount of exercise a child takes in the open air, the greater will be his appetite, which will directly influence the quantity of food he should take. Strenuous exercise up to the moment of coming to meals should not be allowed, as such exercise is liable to produce exhaus- tion, which will affect both appetite and digestion. The normal adult likes to indulge in a short rest after meals, but the healthy child will be eager for exercise, which should not be forbidden, provided it is the nature of the child to be active in play and not easily tired. Still, it is well to re- member that a strenuous game of football immediately after dinner is distinctly injurious. In estimating the requisite caloric value of the dietary of children DIET IN CHILDHOOD 415 some formulae will have to be followed as a guide. Children of normal size, development and activity Sherman thinks require the following calories per kilogram of body weight. REQUISITE CALORIES PER KILOGRAM FOR VARIOUS AGES From 1 to 2 years 100-90 calories per kilogram 900 to 1200 calories 2 " 5 " 90-80 " " " 1200 " 1500 " 6 " 9 " 80-70 " " " 1400 " 2000 " 10 13 " 70-60 " " 1800 " 2200 " Girls 14 " 17 " 65-45 " " 2200 " 2600 " Boys 14 17 " 60-40 " " " 2500 3000 " In calculating a dietary for children the factors of growth and devel- opment must always be taken into consideration. The child needs pro- tein for the ordinary wear and tear and also requires an additional amount for the production of bone and muscle. The child has an intense metab- olism, more general than the adult; owing to the period of growth the food must supply material to be added to the body in the form of bone and brawn in addition to that which is oxidized for normal metabolism. In selecting the proper alimentation of young subjects, the most im- portant consideration is that of not starving the child on any one food- stuff (5). A requisite amount of protein, fats and carbohydrates is abso- lutely essential. To stint is very often to starve ; therefore, in arranging the diet, the meals should be at regular intervals, at least three good meals being given daily. The chief difference from the feeding in the early years is that a large amount of beef and mutton is now demanded. Meat should be given twice a day, once to provide for the wear and tear, of the body, and once to "supply the means for growth," as Dr. Clement Dukes rather quaintly expresses it. It is needless to say that the freshness of the food is a most important consideration. Salted meats and canned meats are, useful in supplying variety in the dietary, but if used too frequently they fail to supply the proper amount of nutrition and their continued use becomes monotonous, leading to loss of appetite. Likewise, canned vegetables and fruits are to be considered as inferior to fresh ones for regular use. The question of hours for meals is important. Breakfast should be punctual to allow the child time to eat a good hearty meal, to masticate its food properly, and to have time before starting for school to attend to the bowels. School children are often upset through neglect of this wholesome rule. The value of a liberal diet during school life cannot be too strongly emphasized. Dr. Watson(2) speaks with authority on the subject, and 416 DIET IN PHYSIOLOGICAL PERIODS the following articles of food are selected from those given by him as suitable at this age : * SUITABLE DIETARY FOR SCHOOL CHILDREN Breakfast: This should be the heartiest meal of the day. Begin with a small plate of por- ridge and glass of milk; follow by an egg or fish, bread and butter, or toast and butter, and tea or coffee, largely made with hot milk; jam or marmalade and oatcake. Lunch 11.30 A.M. A dry biscuit and a drink of milk (not hot scones, buns, or pastry) ; a little fresh fruit, apple, orange, or banana. Dinner in the middle of the day: This should consist of soup, meat, vegetables, and pudding. The soup does not require to be made of rich meat stock lentil, pea, broth, or rice soup are all excellent, giving a good foundation for the meat course. Roast, boiled meat, and stews are the best, served always with potatoes and a vegetable. Pud- ding should be varied: suet pudding with fruit or jam, milk puddings, or stewed fruit. A glass of milk may be given with this meal, and as much bread as the child wishes to take. Tea, not later than 5.30 P.M. Beverage, milk or cocoa (not tea as a rule) ; as much plain bread and toast as the child can eat; plain cake; sometimes an egg, or fish, or potted meat, marma- lade, jam, or honey. Supper: A drink of milk and a biscuit is all that is necessary; a large supper is not advisable. It is better for all children to go to bed with the stomach comparatively empty. Weak tea and coffee, well diluted with milk, may be added to the dietaries given, but should not be taken in excess. Milk at this age will be made much more palatable and attractive to the palate if flavored with tea or coffee. The question of an allowance of alcohol for schoolboys may be answered by asking the question : "Is it necessary, and is it beneficial ?" The consensus of opinion of both physicians and dietitians has decided both questions in the negative. If, then, the use of alcohol by the school- boy has been considered unnecessary on physical grounds and not bene- ficial on normal grounds, one can safely assert with confidence that alcohol should not form a part of the youth's diet during school life. (See section on Alcohol, Volume I, Chapter XVI, page 568.) The chief meals of the day should be three in number : breakfast, din- ner and supper. The first two should be the substantial meals, while sup- per should consist of less stimulating food. Under no consideration should schoolboys and girls have a heavy meal of stimulating food a short time before retiring. Neither should they be set to the task of doing lessons in the morning before partaking of food, but should spend a half hour in the open air, after which a substantial meal should be served, with plenty of time for thorough mastication. The dinner hour usually follows four or 1 For additional dietaries see Volume III. Chapter XXVTTT. DIET IN CHILDHOOD 417 five hours after breakfast. For some children this may prove too long an interval without food. If so, a piece of bread with an apple or some light food may be allowed in the midforenoon. The supper should be a light repast, as outlined above, and should be taken^ some two or three hours before retiring. It will be admitted that a diet selected from the above list proves amply sufficient, liberal and varied. It should meet all the requirements of the growing body and even the special weakness of the schoolboy or girl in the matter of sweets. Although no mention is made of fresh fruit, this is to be regarded as an essential part of the daily diet, for though its nutritive value is not great, the carbohydrate matter, which is abundant, is in a form which appeals' to the youthful palate. The action of fresh fruit on the bowels and the blood renders this food material specially desirable and suitable for growing boys and girls. The medical inspection of school children has been the means of detect- ing and remedying many defects which hamper the child in his studies, and it may be safely stated that a child who cannot easily and without physical detriment keep up with his class is defective, due to imperfect vision or hearing, to sluggish respiratory changes due to adenoids, etc., to imperfect nutrition at home, or to some other remediable condition that is more likely to be detected by regular school inspection than by the ob- servation of ignorant and careless parents. With three good meals daily from the above dietary, no boy or girl should suffer from hunger or from failure of nutrition from lack of food. The superintendent of schools should see that the hygienic condition of the building is such as to favor the working of a pupil without undue fatigue, which might lessen appetite and thereby interfere with nutrition. Tasks should not be imposed that would be arduous for the average child to perform, for the most part during school hours. Neither should the discipline be such as to overtax the child or interfere with his meal hours. If greediness in partaking of food is observed in a youth, it must be dis- couraged and checked, as it breeds physical ills if tolerated. However, one must not allow a healthy appetite to remain unsatisfied on the ground that moderation is a desirable virtue. Some parents and the heads of boarding schools consider that the mininmm allowance of food compatible with health is all that is desirable, and in many such cases children are kopt in a chronic state of starvation. It is true that certain children with strong constitutions, ruddy, rugged and robust, might stand this without ill health accruing, but there are instances where the future growth and development of a child have been permanently stunted by a scanty allow- 418 DIET IN PHYSIOLOGICAL PERIODS ance of food. If at this period of growth and development there must be error, let the error be on the side of allowing the maximum rather than the minimum amount of food. DIET DURING PUBERTY The period of pubescence begins in the girl usually about the thirteenth year and the boy about the fourteenth year. This period in both sexes is marked by great physical growth and development, and the dietary, to meet these new demands, should be rich in easily digested proteins. There is no time in man's existence when there is greater need for wholesome, suitable, nutritious food that which will build up good rich, red blood than at this period. The adolescent should have liberal allowances of bread, eggs, meat and foods of every kind, provided he digests them well, but highly spiced dishes and wine should be tabooed. The paucity of reliable statistics on the normal consumption of food in adolescence is a serious drawback to the dietary guidance in the feeding of young boys and girls. It is difficult and unusual to collect the basic facts regarding the functional needs and performances in this period of youth. A recent investigation by Gephart(5) gives an idea of the actual amounts of nourishment ingested by more than 300 boys in one of the largest private boarding schools in the United States. The total animal supply for such an institution containing 355 boys was computed as follows, in metric tons : Protein Fats Carbohydrates Food supply 20.5 25.6 60.5 Waste 3.8 5.4 4.2 Food fuel . . 16.7 20.2 56.3 The quantity of food computed on the basis of the individual meal served, appears as follows: Pounds Grams Calories Calories (Per cent) Protein 1107 50.2 206 14 1 Fat 0.1332 60.4 562 39 Carbohydrates 0.3717 168.8 692 47 1,460 1 Seventy per cent of this was in animal protein DIET DURIXG PUBERTY 419 The food was of the best quality, and included 193 separate varieties. The cost per meal was 20 cents, or 13.8 cents per thousand calories. This is twice what the poor man in New York City pays for his food. But these growing athletic boys were not satisfied with the conventional 3,000 calories per day. The investigator of their dietary ascertained that beside the 4,350 calories which they consumed daily at the table, they bought 650 additional calories in food at a neighboring store, the principal item being chocolate. Graham Lusk(G) has pointed out the fact that the 5,000 calories con- tained in the daily alimentation of active American boys of school age are half again as much as a farmer at strenuous work is thought to require. The total fuel intake of the boarding school just mentioned was three times that necessary for the heat production of boys from 13 to 16 years of age when asleep and resting. As previously emphasized, these findings serve in a way to explain the ravenous appetite of growing boys and girls. Lack of appreciation of this factor and lack of provision for it are a fre- quent cause of much under-nutrition in children. The adolescent girl in particular needs good wholesome rich foods, more especially those containing iron. We have already called attention to the iron content of many foods. Lean meat, eggs, and the dark green leaves of vegetables, as spinach, are all rich in iron. A well-balanced rational menu for a fourteen-year-old girl or her sixteen-year-old brother would be somewhat like the following(T) : SUITABLE MENU FOR A FOURTEEN-YEAR-OLD GIRL OR HER SIXTEEN-YEAR-OLD BROTHKK' Breakfast: Oatmeal with cream and sugar; buttered toast; one or two boiled eggs; fruit (grapes, apples, bananas, oranges or berries) ; coffee, with cream and sugar. Lunch: A pure"c of cream soup with crackers or croutons; bread and butter; fruit; rice pudding or custard. Dinner: An ample portion of meat; potatoes (baked or boiled); side dish of vegetables; fruit, stewed or canned, with graham wafers; bread and butter. This dietary is rich in protein, sufficient to nourish an adult at mod- erate work. But we must remember that the adolescent has need for a great excess of meat, and, as a matter of fact, the pubescent boy or girl, in school, office or factory, will eat quite as much and often even more than an adult, and will bo far more seriously injured if he does not get the requisite alimentation. If a boy or girl craves a light lunch in the mid- afternoon, it should be allowed. A young ii'ii-l, especially, if sho begins to 420 DIET IN PHYSIOLOGICAL PERIODS show signs of pallor, as is frequently noticed in high school girls, may be directed to prepare for herself an egg lemonade, using two yolks instead of the yolk and white of one egg. Such a lunch will not interfere with the dinner later on. The best stimulants of the appetite at this age are fatigue for the boy, from swimming, walking in the open air, and moderate exercise for the girl, tennis and golf, which ought to hasten the return of color to her cheeks. The craving for sweets by the adolescent boy or girl is a natural one, and should be satisfied. Fudge and other sweets should be allowed, but as a rule it is preferable for these to be eaten immediately following meal time. When partaken of in this manner they serve an important purpose in the alimentation and seldom give rise to any disturbance of digestion. As sweets are the most condensed sources of carbohydrates and per volume are great sources of energy, the insatiable desire for them seems to be more or less instinctive. A few generations back, it was thought and taught that the consumption of sweets had a tendency to produce decay of the teeth, but at the present time the toothbrush brigade has robbed them of any bad reputation which they have possessed in this connection. The present curriculum in most high schools and girls' colleges is faulty and could be greatly improved upon. Long sessions impose too long and severe a strain on the boy or girl, more particularly if they happen to be puny and with little or no desire for breakfast. A more sensible plan would be to arrange the courses of instruction so that no pupil would be required to attend more than four consecutive periods without a recess. An insufficient breakfast, hastily ingested, due to late rising or to late hours the evening before, either on the part of the pupil or family, so that breakfast is not served in due time, is frequently a cause for digestive disturbances on the part of the pupil, besides furnishing in- sufficient nutrition. The adolescent attending high school should have a well-balanced midday meal, consisting of good wholesome food. Such an arrangement need not in any way interfere with the full evening dinner with the family. Pupils of this age should be restrained from social dissi- pation during school sessions except on Friday and Saturday evening. About this time of life the question of the proper allowance of alcohol, tea, coffee or tobacco, etc., is one that will have to be met and answered. Abstinence from alcoholic liquors is desirable even for the adult, and almost imperative for the adolescent if health is to be maintained. Strong coffee and tea likewise should be shunned. Weak cocoa will afford an excellent substitute for both. According to Benedict (8), "It should be impressed on the boy or girl DIET IN SEDENTARY OCCUPATIONS 421 that there are purely physical conditions during the period of growth, aa well as differences in the business and social demands upon the adoles- cent and the adult, which render abstinence necessary in the former, and indulgence comparatively harmless in the latter. If the appeal to judg- ment based on these grounds is not sufficient, parental discipline may be necessary, and it is even worth considering whether the health of the youth is not worth the argument of example as well as precept. The prejudice against cigarettes, as compared with stronger forms of tobacco, is due almost entirely to their premature use by boys too young to tolerate tobacco in other forms." DIET IN SEDENTARY OCCUPATIONS Persons engaged in sedentary occupations which confine them indoors, and whose work is largely mental rather than muscular, require a diet suitable to their needs rather than one adapted to the requirements of a laborer or "lumber jack." Sedentary workers sooner or later realize from experience that they must give attention to their diet if they would remain in good health. If a man whose vocation does not permit of any physical exercise indulges in a heavy diet in which meat is ingested two or three times a day, he is almost certain, sooner or later, to suffer from serious nutritional disturbances. First, he is apt to put on an excess of flesh; second, his excretory organs, more especially the kidneys, will suffer from the extra strain in eliminating waste products of protein metabolism, with the result that at first he will be annoyed with occasional and later almost continuous disabilities of a rheumatic or a lithemic character; third, his digestive organs will sooner or later fag under the burden of overeating, especially of foods from the animal kingdom. As a result he will suffer from constipation, which, if prolonged, will lead to an altered bacterial activity resulting in auto-intestinal intoxication with accompany- ing stasis and putrefaction. The injurious effects of over-indulgence at the table by the sedentary, are of far-reaching importance, and are claimed to be the chief factor in the development of many serious diseases. There can be no question that the excessive ingestion of protein food induces a temporary albuminuria, similarly glvcosuria, pentosuria, etc. The great- est danger from the excessive ingestion of proteins, and more especially animal protein, is due to the fact, as previously pointed out, that they are incompletely oxidized, which tends to the accumulation of waste products in the blood protein poisons acting injuriously in different directions already mentioned ; all of which may easily be avoided by proper alimen- tation. 127 422 DIET IN PHYSIOLOGICAL PEEIODS Energy diverted for mental work is apt to be at the expense of the digestive process; consequently, it is highly important that the alimenta- tion should be closely studied, so as to exactly meet the requirements of the case, and not unduly tax the organs of digestion nor overwork the organs of excretion. As a rule, meat should be indulged in but once a day, and then only in moderation, while individuals of slender physique and frail constitution will do well occasionally to replace meat by other animal foods, as eggs and fish. Persons engaged in literary pursuits, writers and brain workers, often suffer from lithemia, which in many cases is unquestionably due to other causes than errors in diet such as anxiety, worry or overwork, "burning the candle at both ends." This class of patients do better on a full diet of good, wholesome, well-cooked food, which is nourishing, light and digestible. They should be instructed to avoid fatty and purely starchy dishes, but they need meat, and it may be allowed in moderate amount. Variety in fruits and fresh green vegetables is also desirable. The following aliments should be rigidly restricted: rich gravies, sauces, custards, patties, lean meat in made dishes, pastry, highly seasoned or fried entrees. The menu for the sedentary, whether professional, literary or business man, should be somewhat as follows (Hall) : SUITABLE DIETARY FOR THE SEDENTARY Breakfast: Fruits, preferably a baked apple; breakfast bacon; buttered toast; muffins or gems; coffee with cream and sugar. Lunch: A cream soup or pure"e with crackers, or sandwich and fruit, with a cup custard. Dinner: Meat, white bread, potatoes; vegetables; salad; fruit; a light, easily digestible pudding, such as rice, chocolate, or bread pudding with fruit sauce; gelatin or tapioca with fruit; coffee or tea with cream and sugar. By some this dinner may be thought to be rather heavy, but we will assume that the sedentary gentleman will partake of the different courses rather sparingly ; that he will linger long at the table in a social hour with the family in regular deipnosophistic fashion, with quip and repartee, keeping the whole dinner circle in good spirits, which will give him suf- ficient time to thoroughly masticate his food. The brain tissue is composed very largely of fat three times as much as in muscular tissue, while the nerves contain an even greater percentage. Non-lithemic brain workers may advantageously partake of fats and car- bohydrates foods which may be supplied in the form of cream, butter DIET IN SEDENTARY OCCUPATIONS 423 and well-cooked bacon, bread, potatoes and vegetables. The reason that some writers laud fat as a food for brain workers is the ease with which it is metabolized into energy. The popular idea that fish, owing to the large percentage of phosphorus contained in it, possesses some specific action as a brain food is now an exploded theory. Fresh fish is, however, very wholesome, and by replacing meat in the menu is more easily metab- olized by the digestive organs. The sedentary brain worker who desires to keep in a fit condition should have a light lunch and dine late in the day. It is desirable during the active hours of close mental application to supply only the food actually necessary for the prompt production of the requisite energy without borrowing, so to speak, or drawing upon the digestive organs for the expenditure of energy in elaborating food which is only needed for storage. A tour of inspection of the downtown metropolitan district of any large city at the noon lunch hour reveals two sharply-defined classes of patrons: (a) Those who believe in steaks and chops as the best brain and nerve food, and with whom economy is of no moment, and who spend a dollar or a dollar and a half for luncheon; (6) those who believe in stay- ing the pangs of hunger for the least money. Members of this class spend ten cents for a piece of pie and some cheese and five cents more for a cup of coffee or a glass of milk, and get just as much fuel value or force and energy as the former provided, of course, the ingested food is assimi- lated. COMPARATIVE LUNCHES Proteins Fat Carbo- hydrates Calories (a) Chops 15 grams 20 grams 247.5 Potatoes 2.1 " .1 17.7 grams 82 Salad .5 " 1.6 1.4 23 Orange ice 12 49 17.6 grams 21.7 grams 31.1 grams 401.5 (6) Mince pie (slice) 6 grams 15 grams 66 grams 436 }/2 oz. cheese 3.5 " 4.1 " 0.3 53.7 }/2 pt. milk 8.3 10 * 12.5 178 17.8 grams 29.1 grams 78.8 grams 668.7 Mrs. E. H. Richards (9) has worked out a daily ration for the seden- tary business man, professional man or literary worker, but in our opinion, the protein allowance is entirely too liberal. We give the table below : 424 DIET IN PHYSIOLOGICAL PEKIODS RICHARDS' RATION FOR SEDENTARY OCCUPATIONS FOOD Amount Proteins Fats Carbo- hydrates Calories Bread. . 16 oz. 32.0 grams 3.0 grams 258.0 grams 1,216.6 Meat 16 " 50.0 " 30.0 "" 481.0 Butter 1 " 25.0 " 230.0 Sucar 4 110.0 grams 451.0 Milk 8 18.0 grams 18.0 grams 22.0 " 329.6 Oysters.. . . . 4 " 7.0 " 1.0 " 37.8 Soup 4 " 4.0 " 3.0 " 44.0 Potatoes , 6 " 3.0 " 38.0 grams 168.1 Ecscs 3 " 10.0 " 9.0 grams 123.8 Oatmeal 2 " 1.0 " 0.5 " 4.0 grams 25.1 Cream 1 " 1.5 " 6.5 " 1.0 " 70.1 Fruit 8 " 0.5 50.0 " 207.1 Additional liquid tea, coffee or water 30 " Total.... 77 oz. 127.0 grams 96.0 grams 483.0 grams 3,384.2 Contented should be the man whose digestive organs are functionating normally, who is so well balanced that he takes his breakfast, as his news- paper, as a matter of course, and who is no more perturbed by the fraction of variation in the stiffness of his boiled egg than by the rumor of an out- burst of Mt. Vesuvius. Happy is he who sits down to the dinner provided for him without thought of what he must partake of and what he must not, with a mind free for social pleasure, secure in the skill and exercise in the culinary department of his household. Who would not strive to have this feeling of self-assurance ? And yet how few are willing to pay the price ! A little thought, a little self-control, and then forget that there is such a thing as digestion. Blessed be the man whose organs and espe- cially the organs of digestion are functionating normally and properly without his being conscious of it. Only in such cases is he a whole man. Overeating should be religiously avoided by the sedentary individual. We have already emphasized this point (Volume II, Chapter VI), but again we caution against overloading the system with incompletely as- similated foods which obtund intellectual activity and lead to exhaustion of the nervous system. If some arduous task requiring long hours and absorbing concentration and painstaking care is imposed, it will be better to take two light lunches during the day. If the task proves fatiguing, a little Burgundy or white wine may be taken with the lunch. It may, according to Chambers, "stay the weariness of the system and allow the nerve force to be diverted to the digestion of the meal, but to labor on and DIET DURING MENSTRUATION 425 continue to take this anesthetic between meals is inconsistent," and "when extraordinary mental toil is temporarily imposed, extreme temperance or even total abstinence should be the rule, for mental activity makes the brain bear less alcohol than rest and relaxation." The sedentary person who remains much indoors should have frequent week-end outings of two or three days when all the cobwebs may be blown away and all his arterioles flushed out with ozone from the ocean breezes or mountain blasts. The stimulus of change, even if the food is only mod- erately good, is invaluable. DIET DURING MENSTRUATION A perfectly well woman whose menstrual periods recur with clock- like precision need not be treated as an invalid during menstruation, and her alimentation need not be other than usual. Of course it is understood that during the catamenial period she should avoid very cold or very hot baths, and should also shun excessive physical exertion or severe mental strain. Absence of the menstrual function is a frequent accompaniment of mental disturbance due to great grief, fright or anxiety, while an exces- sive development of fat may prevent the flow appearing even in persons whose general health appears to be excellent. Here proper dieting will be beneficial. Menstruation may be absent without causing the slightest inconvenience or perturbation ; on the other hand, there may be present, coincident with the menstrual period, a feeling of general disturbance accompanied by headache, flashes of heat, nervousness, nausea and vomiting, due largely, if not altogether, to a run-down condition of health, both mental and physical, which appropriate, wholesome, nutritious, nitrogenous diet will greatly benefit. Various menstrual disturbances may be expected in a certain percent- age of young girls, especially during the first year or two following the appearance of the catamenia, which indicate rest, confinement to the room or to bed, and a dietary corresponding to the physical condition of the patient, and to her relative quiescence and environment. Anemia, chlorosis and thyroid disturbances depending on menstruation will receive attention elsewhere. DIET DURING PREGNANCY A good, simple, well-balanced dietary is best adapted for the normal pregnant woman, and unless complications arise it is not customary to direct any definite system of alimentation. 426 DIET IN PHYSIOLOGICAL PERIODS As soon as pregnancy is positively determined, the hygienic and dietetic care of the woman should be outlined. First, she should take daily the requisite amount of exercise in the open air; second, too much im- portance cannot be laid upon the necessity of preventing constipation; third, her alimentation should be regulated to fit her requirements and environment; fourth, gastric disturbances, usually termed "morning sick- ness," which may or may not be a harassing symptom, must receive atten- tion. If serious vomiting occurs in the early months, the most careful and painstaking attention should be given the dietary. The first principle in the dietetic treatment of vomiting, according to Watson, is to give the stomach a rest. Then the dietetic substances usually prescribed for the relief of nausea and vomiting and for nourishment are indicated, among which may be suggested cracked ice ; pancreatized milk, milk with sodium bicarbonate (ten grains) ; milk and lime water, milk and vichy, soda, seltzer, or carbonic acid water ; whey and kumiss ; beef extracts and pepto- noids; raw meat juice; raw meat pulp; scraped meat; clam broth; dry toast, etc. The "longings" of pregnant women for various indigestible articles, such as dill pickles, etc., so far as they are kept within reasonable bounds, may be gratified, but there seems to be no reasonable evidence that the refusal to satisfy such caprices has any effect upon the physical or mental development of the child. These "longings" are largely mythical and occur, if at all, only as an accompaniment of a general hysterical condition, and not as a peculiarity of the period of pregnancy. Albuminuria and dropsy are serious symptoms complicating pregnancy, and their presence demands the most careful attention to the dietary. In these complications the lightest possible diet should be outlined, throw- ing the least strain upon the kidneys and other glandular organs. In very severe cases it may be necessary to prescribe an exclusive milk diet ; in less severe cases a diet of milk, bread, farinaceous foods, and simple fruits may suffice ; while in the milder forms of derangement all that is necessary will be to avoid red meats and richer dishes of all kinds and subsist on the lacto-vegetarian diet described in Volume II, Chapter XV. The quantity of food during pregnancy should not exceed what is usually required by a healthy woman, the meals should be taken at regular intervals, and those articles of food known to disagree should be avoided. The diet throughout the period of gestation should be simple and whole- some but varied. Tea, coffee and alcoholic beverages should be allowed with caution. The vulnerability of the liver raises the question of doubt as to whether ale, beer or stout should be permitted. Large amounts of DIET DURING PREGNANCY 427 meat more particularly canned meat, canned vegetables, sea food at a dis- tance from the ocean, undrawn poultry and stale eggs, in which decompo- sition may have already begun, should be avoided also, as should liver, thymus and kidney on account of extractive waste and excessive amounts of purins. Animal foods, even when sparingly taken, force the already congested liver to supplementary work in eliminating toxins arising from muscular tissue, and should be entirely stopped if even traces of albumin appear in the urine. Milk should be discontinued altogether if there are any symptoms of eclampsia. In general, however, cereals, milk, cream and butter, fresh eggs, small amounts of fresh meat especially poultry and fresh fish, fresh (pod) vegetables, sweet and white potatoes and other vegetables rich in nutriment and with only a small percentage of indiges- tible residue, and fresh fruits, omitting strawberries, blackberries, blue- berries, etc., should be the mainstays of the pregnant woman's dietary. The idea, formerly prevalent among the laity and to some extent among medical men, that pregnant women should partake largely of foods con- taining abundant phosphates and lime salts to furnish the embryo with material for the production of bone, is now an exploded theory, since the organic salts in question are plentifully supplied in an ordinary mixed diet. Another fallacious theory, equally as ingenious, though directly op- posed to the foregoing, is interesting only historically. It was once claimed that the agonies of labor would be less severe if the pregnant woman lived upon a diet composed largely of fruits and meat, avoiding fresh vegetables, on the assumption that the lime salts contained in them would favor early ossification of the infant's skeleton and thus add to the difficulties of par- turition. It is so well known that Nature is abundantly competent to regulate this process unaided that this theory, like the first, is no longer accepted. However, the size of the child can be, to some extent, regulated by diet. The trend of modern thought, experience, and to a certain extent, scientific research, according to Watson (2), tend to show that scientific alimentation can influence material and fetal tissues in such a way as to make labor more easy and to increase the chances for a viable child being born. This is of special moment to the physician who has under his care a woman with a small or contracted pelvis who has, in consequence of the dangers associated with labor under these anatomic conditions, given birth to one or more still-born children. Watson records the claims of Prochownick(lO) and other investigators who prescribe a diet deficient in carbohydrates and fluids that result in a small child which, in every other particular, is well developed. The 428 DIET IN PHYSIOLOGICAL PERIODS claims of Prochownick are that with a conjugate diameter of 8 cm. a diffi- cult labor can be obviated and the induction of premature labor rendered unnecessary. He suggests that the following dietary should be prescribed, beginning from ten to twelve weeks before labor is expected, and rigidly adhered to, more particularly during the last two months of parturition: PROCHOWNICK'S ORIGINAL DIET Breakfast: Small cup of coffee, 3 ounces; breadstuff, 1 ounce, with a little butter. Dinner: Meat, eggs, or fish, with a little sauce; green vegetables, prepared with cream; salad; cheese. Supper: Much as dinner 1 to 1^ ounces of bread with butter (water, soups, potatoes, sugar, and beer are strictly withheld). This average diet consists of: Protein 140 to 160 grams Fat 80 to 130 " Carbohydrates 100 to 110 " Fluids, about 500 c.c. daily Altogether a fuel value of 1800 to 2000 calories According to Watson, polydipsia is complained of during the first few days of this dietetic regimen, but it soon passes off. He also records that some patients complain of the large amount of animal food. "All the confinements reported were much easier than on former occa- sions, even when the child was large and fat. All the children were born alive. The children were usually lean at birth, with the bones of the head unusually mobile. They were apparently mature in every way, and in the majority of cases the child gained normally after birth, and the diet had apparently exercised no injurious effect whatever on the child, or on the mother during pregnancy or the period of lactation. On such a diet, it is essential that the condition of the urine should be carefully observed, the amount of urea and the presence or absence of albumin in the urine being specially noted. Unlike what might have been expected, it was found that this diet did not apparently favor the onset of eclampsia." In the majority of instances it has been observed that the child thrived normally after birth, and the diet had no bad effects on lactation. DIET DURING THE PUERPERIUM The dietary of the puerperal woman has undergone a revolution dur- ing the past few decades. She is no longer kept for ten days upon a diet of toast, weak teas and other "slops," with the idea that semistarvation would lessen the chances of puerperal fever and "milk fever." These changes are largely due to modern obstetric teaching, and to the applica- DIET DURING LACTATION 429 tion of antiseptic and aseptic precautions during labor. Immediately after delivery, a woman may be allowed a cup of warm tea or warm milk. Later she may be fed milk, soft-boiled eggs and dry. buttered toast ; the next few days bread, milk, soup, chops or steaks in limited quantities. She can then gradually return to the diet which she naturally prefers, avoiding, of course, indigestible dishes, as cabbage, fried foods, seed vegetables and, above all, dried beans and other legumes. Immediately after a prolonged labor the woman is left so exhausted by excessive muscular effort and agonizing pain that she is too tired to eat, and is more thirsty than hungry, so she may have a glass of milk and vichy at this time. As many of the complications of labor, as mania, are favored by exhaustion and inanition, a sustaining and stimulating diet is of the greatest importance. The nursing woman, moreover, requires a more liberal diet than other patients, as her mammary excretion, to furnish the requisite food for the child, must contain a large percentage of protein and fat, and, since she is constantly losing a protein substance in the lochia, she must be full fed or her milk will be poor and insufficient. It is a bad practice to allow a healthy lying-in woman to fast too long. She needs to be well and full fed and will sleep better and feel better than if she receives too little food. While the patient's own appetite is a better guide for feeding than any hard and fast rule that may be formu- lated, she should be urged to take food unless greatly exhausted, but care must be exercised not to overload the stomach. After the milk secretion has been established and the bowels regulated, she may be allowed a rea- sonable quantity and variety of food, though while in bed she requires less than later when up and about. Any complication with a rise in tem- perature is a contra-indication for allowing much animal fotod, except milk, but extreme exhaustion without febrile action demands it DIET DURING LACTATION The period of lactation usually lasts for about one year, though towards the end of the seventh or eighth month the quality and quantity of the milk secreted begin to fall off. Some mothers nurse their children far into the second year, but the nutritive properties of the milk are, of necessity, very poor. The diet of the nursing mother must be regulated to prevent noxious substances from passing into the breast milk and to keep her in the best possible condition of health, so that she does not suffer from digestive disturbances. Edgar says(ll) : "If milk is readily assimilated and does 430 DIET IN PHYSIOLOGICAL PERIODS not tend to constipation, she may drink it abundantly. She may also be allowed gruels, meat broths, meat, eggs, vegetables, and other simple nour- ishing food. Fruits, even if acrid, are not objectionable if they do not react unfavorably through the breast milk upon the child, and if the mother's digestion is good they serve to keep the child's bowels active. A nursing woman should be given meat as lamb chops, beef and bacon fish, beans, etc. A reasonable amount of fatty foods in all forms if they are well digested, and cheese, potatoes, bread, rice, green and dry peas and lentils, which excite mammary secretion (but not dry haricot beans). Green vegetables are also allowable, with the exception of cabbage, cress, garlic, leaks, onions, mushrooms, salads and sorrel, which permit noxious substances to pass into the mammary secretion. Rich and indigestible foods and alcoholic drinks, beyond a glass of white wine and a pint of beer or cider, should be avoided." While malt liquors sometimes cause an in- creased secretion of milk, this is because more fluid is drunk and is not due to any specific action of the drink, and the breast milk is not improved. A reasonable quantity of fluids is beneficial and is necessary to maintain the mammary secretion, but milk broths, soups and plain vichy water are far preferable to beer, ale or porter. Weak tea and coffee in small quan- tities are not objectionable if the mother craves them. As already stated, a nursing woman should be full fed, but not "stall fed," that is, to excess. Her daily alimentation should furnish her with : Protein 150 grams 600 calories Fat 100 900 Carbohydrates 500 " 2000 Total 3500 Below is given an allowance for one day's ration as calculated by Gautier (12). The weight of the constituent alimentary principles of the allowance is as follows : A DAY'S RATION FOR A NURSING WOMAN Kinds of Food Weight Protein Fat Carbo- hydrates Bread 600 grams 50 grams 5 1 grams 300 grams Meat 400 * 80 " 28 2 Beans, peas, lentils 100 " 23 2 " 59 " Potatoes 150 " 24 " 0.5 " 30 " Butter 65 " " 60 " " Beer, \\t> pt.. . 7 " " 20 " 1,315 grams 162.4 grams 95.6 grams 411 grams DIET DURING LACTATION 431 This ration will furnish fuel energy to the extent of 3,150 calories. The beer may be replaced with a pint of milk, and the meat may be reduced and eggs and fresh vegetables substituted. After all has been said, the best galactagogue is good, nourishing, wholesome, simple food, espe- cially rich cow's milk, not so much because it is milk, but because, 011 the whole, it is easily digested and readily assimilated and furnishes approxi- mately the right proportion of solids and water needed in the secretion of the mother's milk. Benedict advises withholding all drugs during lactation, more especially laxatives, iodids, mercury, etc., unless there is special indication to medicate the child. In cases where opium, alkaloids, atropin, bromids or any "strong" medicines which act directly upon the nervous system, must be given, nursing should be suspended, and the child fed artificially for the time. The breasts, in the interval, should be evacu- ated by means of the breast pump, and a twenty-four or forty-eight hour interval should elapse after medication is suspended. Foods which con- tain volatile substances, onions, garlic, or hypnotic substances, such as let- tuce, hops or beer, or meats or fowl that is "high," should not be per- mitted. To a limited extent the quantity of the mammary secretion can be increased by the allowance of liquid foods and more water than is habitu- ally taken. On the other hand, it can be reduced by withholding water, or by withdrawing serum from the blood, as, for instance, by purgation. The ingestion of more carbohydrates and hydrocarbons does not modify the milk, but an abundant consumption of proteins increases the percentage of fat, which is the only ingredient of milk that can be influenced by diet. The protein content can be lessened to some extent if the mother is en- gaged in any occupation which calls for strenuous daily exercise to the point of moderate weariness. The influence of diet and exercise upon the secretion of the mammary glands has led Rotch(13) to formulate the following rules : To increase the total quantity of milk: (a) Increase proportionately the amount of liquids in the mother's diet; and (6) encourage her to be- lieve that she can nurse her infant. To decrease the total quantity : Decrease proportionately the amount of liquids in the mother's diet. To increase the total solids: (a) Shorten the nursing intervals; (6) decrease the mother's exercise; (c) decrease the proportion of liquids in her diet. To decrease the total solids: (a) Prolong the nursing intervals; (fr) 432 DIET IN PHYSIOLOGICAL PERIODS increase the mother's exercise ; (c) increase the proportion of liquids in her diet. To increase the fat : Increase the proportion of meat in her diet. To decrease the fat : Decrease the proportion of meat. To decrease the proteins : Increase exercise up to the limit of fatigue. A nursing mother should cancel social obligations so as not to interfere with the nutrition of her child, and all excessive physical strain and ex- citement are to be avoided. No engagements which conflict with the regu- lar times of nursing should be made, and only the most pressing demands . for recreation or important business transactions should excuse the nursing of an infant in public places. DIET DURING THE MENOPAUSE The menopause climacteric, or "change of life," in females is attended by marked disturbances of the nervous system, the precise nature of which is not thoroughly understood, but which are beyond doubt influenced by the functions of the ovaries. The reproductive organs are undergoing a complete change. The caliber of the vessels is shrinking, the blood supply is lessened, and atrophy of the ovaries, tubes and uterus is slowly taking place ; even the breasts become flat and shriveled, and other parts lose the form and appearance characteristic of the reproductive period (14). The menopause(15) occupies about five years two or three from the commencement of irregularity to the cessation of the menstrual function, and a similar period during which time involution becomes complete and the normal activity of the body is established. An important point in the management of women at this period of their lives is to forcibly impress upon them the fact that they have no definite disorder, but are merely undergoing a perfectly normal physio- logical cessation of a function (8), and that, while they are likely to be annoyed with various manifestations of physical and psychic disturbances, they will in all probability pass through the "change" without serious consequences. Even in a normal menopause a multitude of symptoms may be present, such as headache, trembling, flashes of heat, palpitation and shortness of breath, insomnia, nervousness, irritability, nervous depression and "nagging." During its course all physiological functions are weak- ened, and all pathological conditions aggravated (16). If, however, a woman presents a train of symptoms indicating distinct pathological changes, she should be examined and treated appropriately. There is usually a marked derangement of the nervous system at this DIET IN OLD AGE 433 period, in some instances even affecting the mentality of the patient. The patient may present slight vagaries, a loss of interest in the affairs of life, and iii extreme cases melancholia or other forms of a loss of mental bal- ance may be observed. During the "change" the excretions and secretions should be watched; the nutrition should be carefully looked after; waste and repair should balance ;' dietetic excesses and irregularities should be avoided, and care should be exercised in the preparation and serving of meals so as to appeal to the five senses. The diet should be simple, un- irritating and easily digested and assimilated. Meats should be restricted and fresh vegetables liberally consumed. As sugar is apt to set up fermen- tation in the stomach, candies, preserves, jellies and sweet puddings are to be taken in moderation. Pastry, hot breads, fried foods and rich dishes must be interdicted. The patient should imbibe freely of good spring water, drinking three or four pints daily. Stimulants are to be taken very sparingly and alcohol in any form is prohibited. The patient should lead a regular and careful life, taking gentle exercise in the open air. She should be kept as free from worry, anxiety and mental strain as possible, should be instructed to rest in bed during the menstrual period, and to observe early hours, bathe regularly and keep the skin and bowels active. It must not be overlooked that certain diseases have a predilection for development at the menopause, such as thyroid disturbances, diabetes, hepatic and renal degenerations. The use of ovarian extracts, after or ^during the climacteric, is now thought to be of doubtful propriety, yet some clinicians claim good results from the administration of corpus luteum products. If the health is carefully looked after during this period, the pathological conditions will subside, but, according to Tibbies (15), "Negligence and disregard of the physician's advice may result in a serious breakdown from nervous or other causes, and may lead to permanent im- pairment of the health. Due care as to the alimentation, proper attention to the functions of the skin, kidneys and bowels, a careful mode of life, proper rest and freedom from worry and excitement, will lead to the re- establishment of health and formation of mens sana in corpore sano." DIET IN OLD AGE Before discussing the question of diet in old age, it may be well to attempt a definition of old age. By no means can this be reckoned by the number of years a man or woman has attained. There are old young men and young old men. Premature senility overtakes some individuals, gen- erally of the male sex, at middle age or even before, while, on the other 434 hand, there are men old in years who retain the physical and mental char- acteristics of healthy middle age. What then constitutes old age ? What are the physical and physiological criteria that go to mark the failing of the bodily powers ? For in the case of premature senility it is the bodily powers that have lapsed or are lapsing and not, as a rule, the mental fac- ulties. A philosopher once said that a woman was as old as she looked and a man as old as he felt. While this aphorism is true, old age is per- haps most aptly denned by the statement that "a person is as old as his arteries." This would seem to be a correct explanation of the term old age, for when the arteries have hardened, or are becoming hardened, the "decensus Averni" has commenced. As Allbutt states in his work on arteriosclerosis, we recognize now, all of us, that in the lapse of man's years, one long reckoning of his mortality is, and from all known ages has been, written on the walls of his vessels. We may assume that in primitive man, by external conditions, if not by innate capacity, life was of comparatively brief duration. Domestic animals seem, as a rule, not to live long enough to use up their arteries or not to live long enough to abuse them and among these creatures atheroma, although not unknown, has not been commonly observed. Arteriosclerosis, then, may be taken as the sign manual of decaying physical powers (17), that is, of old age, and the person who has hardened arteries may be termed old. Premature senility is far more frequent under the trying conditions of civilized life than when life is passed under natural conditions. The artificial life of cities, sedentary occupations, the stress and strain of business, and, above all, unhygienic habits of living, of which the most harmful are overeating, errors of diet and too great indulgence in spirituous beverages, combine to place old arteries in young bodies and to shorten greatly the normal span of life. One cannot "burn the candle at both ends" with impunity- First, it may be as well to deal with the means for preventing old age, and, as it appears to have been decided that diet is the prominent factor in its production, the attempt will be made to show how this is so. According to Allbutt, one form of arteriosclerosis is due to the excessive or relatively excessive consumption of meat and wine, and this form is accompanied by a persistence of high arterial pressure. Conheim recognized high blood pressure and big heart in gluttons. Traube was one of the first in recent times to marshal clinical evidence on "luxus consumption" and to argue the question on scientific lines. Frantzel followed him, with the theory that with gluttony arose an overcharge of the veins and a fall of centrifu- gal velocity, which propagated a rise of pressure backwards to the capil- DIET IN OLD AGE 435 laries and arteries. The fact must not be forgotten that the arteries of the alimentary tract are among the most muscular in the body and have a very complex nervous endowment a mingled vasoconstrictor, vasodilator and vagus supply; and in no arteries is medical hypertrophy without calcifi- cation so well marked and so palpable. This change, even when absent elsewhere in the system, may be found here. Stengel emphasizes as causes overfeeding and hereditary predisposition, and says that regulation of diet and habits, if it cannot cure, may alleviate the malady even in its ad- vanced stages. Sir Lauder Brunton, Dr. W. Russell and many others are of the same opinion. Allbutt(18) says that we, as other engines, differ widely among ourselves, not only in the quantities of food we need for given work, but also in our capacity for dealing with it economically. For example, a small eater may be a bad metabolizer. He would, therefore, iirii'e that while one man can be gluttonous with impunity, and another on a moderate diet become "plethoric," nevertheless, the average man who indulges his appetite for food and drink, especially if his habits be seden- tary, runs no little risk of high arterial pressure and of imperiling the integrity of his arteries. Huchard attributes the spread of arteriosclerosis to the increased use of meat during the nineteenth century. As Fanny Burney neatly put it, "Tharle's miscalculation of his digestive powers ended in apoplexy." Another witty person remarked that a good cook is more to be feared when one is in perfect health than a bad doctor when one is ill. However, whether mere overfeeding apart from a toxemia can raise the blood pressure, as if by a parenchymatous surfeit, is a question as yet unanswered. But we do know that overeating and overdrinking frequently bring about chronic constipation and intestinal stasis, which result, more often than not, in alimentary toxemia. The blood becomes surcharged with the end products of protein digestion toxic materials and' if this condition be allowed to persist, blood pressure is raised, the arteries begin to harden, the natural powers of the body abate, and, in short, the individual is on the high road to old age. When discussing overeating and injudicious diet as factors in bringing about untimely senility, it should be well understood that these are by no means the only causes. There are persons who, no matter how much they may abuse their bodies in this direction, still live to be old in years, whose arteries do not harden prematurely, and who, although gross eaters and drinkers, continue to enjoy life. On the other hand, there are spare people who do not eat or drink to excess, yet their arteries harden, they exhibit the symptoms of senility before their time, and become old prematurely. Their metabolism is probably defective. In spite of such exceptional 436 DIET IN PHYSIOLOGICAL PERIODS cases, there is little doubt that errors of diet, in the direction chiefly of self-indulgence, are largely responsible for the great increase of chronic diseases more frequently than not accompanied by arteriosclerosis so melancholy a feature of modern life, and that diet does play a part, the importance of which can scarcely be overestimated, in the causation of certain conditions distinguished by hardening of the arteries. Theognis, an old Greek writer, said: "Surfeit has killed more men than famine," and perhaps this saying is even truer to-day than when it was penned. Surfeit helps to bring on old age, and to prevent this occurrence, food and drink should be taken sparingly. As the diet calculated to prevent old age is much the same as that best suited to those who have become prema- turely old or who are old, that question will be dealt with when diet for the aged is discussed. The warding off of old age is obviously of greater concern than its treatment when it has come(19), for after the arteries have become hard- ened there is no means, medicinal or dietetic, which will bring back their pristine softness and flexibility. Remedial treatment by diet and drugs, mainly by diet, may greatly prolong life, but will not cure the condition. For these very substantial reasons those who are young, and those who lead an indoor life, in particular, should see to it that they exercise a wise moderation as regards food and drink and a due discretion as to the kind of food. Observe a dictum of Hippocrates that "everything in excess is unusual to nature." With regard to diet in old age, the consensus of opinion of those who have studied the subject is that less food is needed than at other periods of life. In fact, this is not a matter of opinion, but of exact knowledge. In youth we are going uphill, in old age downhill. In childhood and in early youth the physiological powers are concerned with building up the organism and developing its various functions, and an ample supply of food is required to further these operations. In these days the supply exceeds the losses and acts in developing the organism, and the body increases in height and weight. The child or youth can eat, and indeed needs, an amount of food which the ordinary adult would find beyond his requirements. Also during this most active physiological period of life the impaired cells are regenerated rapidly and with ease, and new cells spring r.p like flowers in the spring and more than counterbalance the decay of the affected ones. Nevertheless, the time comes when the proc- esses of decay and repair are exactly balanced, and the body has reached its full growth or maturity. On reaching manhood the individual generally acquires the prevailing DIET IN OLD AGE 437 dietetic habits of his associates, with little disposition to question their suitability to himself. If he leads an active life and has plenty of exercise in the open air, he may largely exceed, both in quantity and variety of food, what is necessary to supply the demands of his system without pay- ing a very exorbitant price for the indulgence. A "bilious attack" at in- tervals affords a safety valve and gets rid of the undesirable balance which remains in the case of every hearty eater. In the normal condition of things this state of affairs is maintained for many years. After the first half or so of life has passed away, however, instead of producing these periodical attacks of sickness, the unemployed material may be relegated in the form of fat to be stored on the external surface of the body or to be packed among the internal organs, producing obesity to a greater or less extent. There are some individuals who do not seem to be able to store fat, however rich their diet may be or however inactive their habits. In such persons, and on occasions in those who do store fat, the excess of food material ingested must go somewhere to produce disease in some other form, probably at first interfering with the action of the liver, the next appearing as gout or rheumatism, or as the cause of fluxes and obstruc- tions of various kinds. Gout is, to some extent, a safety valve in the same way as bilious attacks in youth, except that it is really damaging to the constitution and materially injures it. Up to the time of middle age, if a person be robust and vigorous, and possesses a strong digestion, he can con- vert a large mass of food into fluid aliment suitable for absorption into the system. Moreover, his eliminating powers are active and can pass out of the body superfluous material otherwise destined to produce mischief in some form. As he advances in years, however, his powers of elimination diminish proportionately ; less nutriment should therefore be taken, and the kind of food in many cases should be different. A due relation should be preserved between the "income" and "output," and if this be neglected for any considerable time, injury will be done to some of the organs or functions of the body. It must be remembered that, even if the body be in a healthy condition in normal old age, there is a great difference between the health of youth and that of age. In youth vitality is strong and the recuperative powers are great, the abundant vital forces render the organism elastic so that severe illness does not unduly drain the system, and there is a reserve of energy which can be called upon, and which is generally equal to the demands. In old age there is not this reserve force, the constitution is en- feebled and has lost much of its resiliency, vitality is weak, the spring of youth is lacking and no longer acts with a force equal to that with which 128 438 DIET IN PHYSIOLOGICAL PEKIODS it is expended in short, the body cannot respond to the demands made upon it as of yore. As Tibbies points out, slight deviations from the normal performance of function occur, which may, however, for a long time be imperceptible. These gradually increase in extent until they become manifest indications of a failure of the bodily powers or of dis- ordered health. Exertion produces results which formerly would not have been noticeable and exhaustion is out of all proportion to the work per- formed. Among the most marked indications of failing metabolism and consequent disturbance of the functions are symptoms of disorder of the alimentary system. With old age and approaching old age the muscular power of the whole system wanes. The muscular fibers of the stomach and bowels participate in this decline. But, although the digestive powers and those of assimilation diminish, the appetite often remains good, or in some persons the custom of eating and drinking freely is so ingrained that it has become a habit. More food is therefore consumed than can be digested or absorbed, rnd, as mentioned previously, the unabsorbed portion prob- ably undergoes putrefaction, and in the end produces that condition known as alimentary toxemia ; high blood pressure ensues, and arteriosclerosis is aggravated. The pathological changes incident to age have been summed up by Metchnikoff as a sclerosis which may affect the brain, liver, kidneys and other organs, but is mostly seen in the blood vessels. There are many other degenerative changes,' but to mention all of these would be superflu- ous. Arteriosclerosis is the most important. Perhaps too great emphasis has been laid on, the point that arterio- sclerosis is synonymous with old age. We intend to convey by this state- ment that thickening of the arteries may be considered as; physiological old age. It may occur prematurely, when it is termed premature senility, and to a greater or less extent it is generally an accompaniment of advanced years, though by no means always. However, whether the condition be that of physiological old age or of old age without obvious injury of the arteries, the question of diet is all important. In healthy old age, where the organs and functions show only the normal and some- times but comparatively few degenerative changes, there is, nevertheless, always a certain failing of the bodily powers. There are variations and changes accompanying the progressive deterioration of the organism in which all the organs and functions participate more or less, although it is doubtful, except in the case of definite disease of the excretory organs, whether the aged suffer in any marked degree from their inefficiency. Constipation is usually the most troublesome affliction of senility and the DIET IN OLD AGE 439 phagocytes are particularly active. The object, then, should he to discover a meaiis to strengthen the most valuable cellular elements on the one hand, and weaken the phagocytosis on the other. The elixir of life is yet to be found and, therefore, other and more prosaic methods must be sought to achieve this end. While the problem of how to effect this is still far from solution, the consensus of opinion is that judicious eating, combined with hygienic modes of life in other respects, will do most in this direction, and that diet is the main staff upon which to lean. All are agreed that in old age the diet should be lighter than in younger years, and that the amount of food eaten should vary with the needs of the individual. The food should be of an easily digestible kind, and, accord- ing to Friedenwald and Ivuhrah, it should be given in smaller quantities at a time, and the intervals between meals should be shortened. JS"ascher(19), on the other hand, says that the oft-repeated advice that the aged should eat little and often is irrational, for digestion is naturally slower in old age and frequent feedings keep the stomach constantly at work, there being always a mass of food in the stomach in different stages of digestion. This, he thinks, is the most common cause of flatulence, heartburn and senile gastric catarrh, with its attendant pyrosis and gas- trodynia. In old age, according to this writer, food should not be taken oftener than once in five- or six-hour intervals, at fixed hours each day. The number of meals, like the time of day at which the principal meal is taken, is a matter of habit, often of nationality, and does not affect the rule. As at all adult periods of life, if there be a tendency to obesity, food that is apt to be converted into fat should be given in diminished amounts. The proteins should be somewhat lessened from time to time. Some authorities, including Sir Henry Thompson, advocate a vegetarian diet for the old, believing in the proverb, "Much meat, many maladies," but others see no valid reason why animal proteins should not be given in moderation, especially if the subject has been a consistent meat eater. There are those who regard heavy suppers as an abomination. Possibly such meals are blazing indiscretions at any period of life, and certainly in old age they should be most severely condemned. Likewise eating be- tween meals is a habit that is discountenanced, although it is probably less harmful than is supposed. The personal equation with regard to diet and particular kinds of food holds good just as much with the aged as with the person in the prime of life. ^Yhon an individual has reached the age of (50 years he ought to have learned which articles of food disagree with him, and should refrain from these. A diet laid down on strictlv scientific lines 440 DIET IN PHYSIOLOGICAL PERIODS will not suit all old people, and a fairly wide latitude should be allowed for personal likes and dislikes and for individual idiosyncrasies. Especially should monotony in diet be avoided, no matter how perfectly adapted it may seem to be from the laboratory standpoint. Cowper's saying, that "variety is the spice of life and gives it all its flavor," applies with as much truth to food as to other things. Now it is allowed that food is perhaps the most essential factor in warding off old age, or rather in avoiding many of the disagreeable accom- paniments of old age which are certain to occur if the habit of indulging in food to excess or of eating unsuitable viands is persisted in. Dr. Harry Campbell (20) states that in his opinion the most suitable dietary for the aged is that which constitutes the ideal diet for many in general. Such a dietary demands (a) moderation in quantity, (6) simplicity in quality, and (c) the avoidance of those starchy foods which are apt to slip into the stomach without having first been adequately insalivated. A moderate diet is one just sufficient supposing the various foodstuffs, fats, proteins, etc., to be properly balanced to maintain a person at the slightest weight consistent with the most perfect health of which he is capable. Simplicity is constituted by such items as bread, plain biscuits, plain puddings, plainly cooked vegetables, fruit, meat, fowl, fish, milk, Cheddar cheese, tea, coffee, cocoa, salt. Dishes calculated to tickle the palate are not in- cluded in the simple diet ; neither are alcohol nor condiments other than salt and, occasionally, pepper and mustard. Avoidance of soft starchy foods is essential. All through life, starch should, as far as possible, be taken in a form compelling mastication. Soft starchy foods such as pud- dings are only admissible on condition that they be thoroughly masti- cated. The diet of early man conformed to these three requirements. It was simple, consisting as it did of unprepared animal and vegetable substances. The quantity was not, on the whole, in excess of physiological needs ; and all the starchy food, being raw, had to be abundantly masticated in order to break up the non-digestible cellulose framework and thus liberate the contained foodstuffs. When we come to compare the ideal with the actual in the present day, the contrast is discouraging. Too often the stomach and bowels are burdened with an excess of food and harassed by a too great variety. Efficient digestion is rarely possible under these circum- stances, and the blood is surcharged with nutrient matter, much of which is in an imperfectly digested form. The tissues being thus bathed in an overrich and perverted plasma, metabolism fails to proceed normally and health suffers. DIET IN OLD AGE 441 Inasmuch as after early adult life there is a steady waning in the ability of the organism to digest and metabolize the food taken, it follows that the need to conform to the requirements of the ideal dietary becomes increasingly pressing with advancing years. Campbell elaborates the points which we have touched upon, with re- gard to the capacity of the organism to cope with different kinds of food, the influence of custom and idiosyncrasy, as well as of age, and his remarks are so instructive that it will be fitting to refer to them at length. As to the first of these influences, while one should be cautious in recommending to an aged person a diet very different from that to which he has for years been accustomed, the experience derived from prisons, workhouses and similar institutions shows that the ability of the aged to adapt themselves to novel kinds of diet is by no means small. It is indeed astonishing what can be achieved in this direction if the necessary pressure be brought to bear. The factor of idiosyncrasy is important. Individuals differ greatly, quite irrespective of age, in their digestive and metabolic capacities. We meet with children who are unable to tolerate foods which old people can digest quite easily, and with others who are made ill by even a slight ex- cess, while their grandfathers can, perhaps, consume large quantities with comparative impunity. Some old people have, in fact, prodigious powers of digestion and metabolism, and we may look upon them as corresponding in the physiological sphere to the Shakespeares and Newtons in the realm of mind. They are physiological geniuses. Most of these old people would, however, doubtless enjoy better health, be more amiable and have greater consideration for others, on a more abstemious diet ; nevertheless, in regulating their food, we must make due allowance for their prodigious powers, though not infrequently, by the gratification of their inordinate appetites they are paving the way for many and diverse complications. If they have high blood pressure and exhibit any of the symptoms of apo- plexy, the amount of the food they take should be limited. According to Friedenwald and Ruhrah(21), milk may be taken in all forms when easily digested, and when it is not well borne the addition of warm vichy or warm water will often prove helpful, or the milk may be diluted with cereal gruels, or have sodium citrate, one grain to the ounce, added to it. Beef tea is often useful, and beef juices may be used if de- sired. Eggs, lightly cooked or beaten up with milk are very good, as are nutritious soups, such as chicken or fish purees, mutton, beef or chicken broth. Young and tender chicken, game and other tender meats and good quality potted chicken or other potted meats may be taken. Sweetbreads 442 DIET IN PHYSIOLOGICAL PERIODS are easily digested if fresh and properly prepared, but may be contra- indicated on account of the purin nitrogen contained. White fish, such as sole, whiting, smelts and the like, are all suitable, and are best when boiled. Crisp grilled bacon is relished by many. The following foods are also suitable : bread and milk made with the crumbs of stale bread and without lumps; porridge and oatmeal gruel; puddings of ground rice, tapioca, arrowroot, sago or macaroni, with milk or eggs, and flavored with spices or served with fruit jelly ; bread and but- ter, the latter at least a day old; rusk, to be soaked in tea or milk and water; prepared foods, consisting of predigested starches. At this age digestive ferments are scantily provided by the digestive organs, and soluble carbohydrates are valuable for maintaining the body heat. All farinaceous foods should be subjected to a high temperature for some time during the cooking process, so as to render the starch granules more di- gestible. Vegetable purees of all kinds may be taken in moderation, e.g., potatoes, carrots, spinach and other succulent vegetables. Potatoes and fresh vegetables are a necessity ; if omitted, a scorbutic state may be en- gendered. Stewed celery and stewed Spanish or Portugal onions lend variety to the diet, and stewed or baked fruits, fruit jellies, and the pulp of perfectly ripe raw fruits may be taken in small quantity. With respect to a diet for old age based on scientific investigations, Vbit(22), who founded his conclusions on researches made by Forster, considered that the conditions of old age indicate a ration of 0.8 the value of that for men and women of mature age, in good health and doing mod- erate work, as follows : VOIT'S DIETARY STANDARD FOR AGED PERSONS Protein Energy Old man, no work 90 grams 2 116 calories " " light work 100 " 2,689 " Old woman, no work 80 1 831 " " " light work . ... 85 " 2 096 " In this standard, as Tibbies points out, no age is stated, and the amount of protein is considered by some authorities to be too great. Maurel(23) points out that, as age increases, the amount of external muscular work becomes smaller, internal muscular work becomes less, and therefore the nutritive requirements of the body are correspondingly decreased. DIET IN OLD AGE 443 MAUREL'S MAINTENANCE RATIONS FOR OLD PEOPLE Age Protein per Kilo Energy per Kilo Adult '. 1.5 grams 35 to 38 calories Fifty to seventy years 1.25 " 30 " 35 Seventy years and over 1.00 25 " 30 Extreme old age 0.75 " 20 25 Langworthy(24), by using Maurel's maximum factors and taking the average weight of old men and women to be the same as found by Quatelet(25), has framed the following table to show the estimated re- quirements of aged people : LANGWORTHY'S DIETARY STANDARD FOR THE AGED AND INFIRM Subjects Age Average Weight Protein required Energy required Men Years 60 Kilos 65.50 Pounds 144.1 Grams 81.9 Grams 1,965 70 63.03 138.7 78.8 1,891 80 61.22 134.7 45.9 1,531 u 90 57.83 117.2 43.4 1,446 Women 60 56.73 124.8 70.9 1,702 70 53.72 118.2 67.2 1,612 u 80 51.51 113.3 38.6 1,288 u 90 49.34 108.5 37.0 1,234 Kosevi(26) found that the food consumed by women aged, seventy- six and seventy-eight years was as follows : KOSEVI'S MAINTENANCE RATION FOR THE AGED Protein Calories Woman, seventy-six years, 45 kilos, first diet 77 grams 1,361 45 " second diet 66 " 1,361 45 " third diet 66 " 1,165 Woman, seventy-eight years, 61 kilos, first diet 41 1,275 " " " 61 " second diet 41 " 1,575 61 " third diet 67 " 1,207 Guriev of Petrograd undertook some experiments to ascertain the amount of protein required by old people, and to study the metabolism of nitrogen. Five men were selected from sixty-eight to eighty-eight yeara of age. The three younger were hale and hearty, the two elder somewhat 444 DIET IN PHYSIOLOGICAL PERIODS decrepit. The dietaries were given in each case, the first including meat and milk, the second beef tea, but no meat or milk. The dietaries and nitrogen balance are given below : NITROGEN METABOLISM IN OLD AGE . Protein Fat Carbohydrate Calories First diet (a) . ... 90 grams 42 grams 372 grams 2,296 Second diet (6) .... 55 87 385 2,615 Age Dietary Days NITROGEN Grams in Food Grams in Urine Grams in Feces Gain or Loss Man, 68 years Man, 74 years Man, 75 years Man, 88 years Man, 88 years (a) Meat 100, milk 250, bread 600, butter 20, sugar 60 grams; tea 1,800 c.c 5 5 10 8 5 7 5 5 5 8 12.7 8.9 17.4 10.9 13.0 8.9 15.1 6.7 13.7 8.9 8.4 6.5 14.6 7.7 9.0 6.7 10.7 4.3 10.9 8.1 1.0 .9 1.2 .8 1.2 1.8 1.2 1.1 1.8 .14 +4.3 +2.5 + 1.6 +2.4 +2.8 + .4 +3.2 +1.3 +1.0 + .6 (6) Beef tea 500, tea 1,800 c.c.; po- tatoes 600, bread 400, butter 70, sugar 60 grams (a) Meat 142, milk 500, bread 600. butter 22, sugar 60 grams; tea 1,200 c.c (6) Beef tea 500 c.c. ; potatoes 300, bread 500, butter 90, sugar 60 grams; tea 1,200 c.c (a) Meat 100, milk 250, bread 55, butter 20, sugar 60 grams; tea 2,100 c.c (b) Beef tea 500 c.c. ; potatoes 600, bread 400, butter 90, sugar 60 grams; tea 2,160 c.c (a) Meat 100, milk 500, bread 600, butter 30, sugar 60 grams; tea 1,530 c.c (6) Bread 340, butter 120, sugar 60, potatoes 400 grams; tea 1,530 c.c (a) Meat 100, milk 250, bread 600, butter 20, sugar 60 grams; tea 2,200 c.c (6) Beef tea 500 c.c. ; potatoes 600, bread 400, butter 90, sugar 60 grams; tea 2,200 c.c The conclusions drawn from the observations were: (a) The amount of protein ordinarily consumed by old men may be diminished if an abun- dance of fat and carbohydrate is taken to replace it. (6) The assimilation of nitrogen by old men is somewhat less than normal. During the first DIET IN OLD AGE 445 dietary the assimilation of nitrogen averaged 91.15 per cent; in the sec- ond diet period, 86.17 per cent. The assimilation of nitrogen by young men on a similar diet was found to be 94 per cent. In the first, or meat period, the ratio of incompletely oxidized products to urea in the urine was greater than normal; therefore, the metabolism was inferior to that of young men on a similar diet. In the second, or non-meat period, this ratio decreased somewhat. When the diet contained less protein, but an abundance of fat, the subjects maintained their usual weight and health. The recent researches of Schlesinger and Neuman upon the digestive functions of thirty healthy individuals over sixty years of age have demon- strated that while starch and fat are thoroughly digested, the digestion of meat is, as a rule, imperfect. According to Munk and Ewald(27), a man doing no work requires the following amount of food : Protein Fat Carbohydrates Man 90 grams 40 grams 350 grams Woman 80 35 * 300 If this be translated into ordinary articles of diet, it would mean: Meat, 80.3 grams; milk, \ pint; bread, 10 oz. ; biscuit, 2 oz. ; butter, 1 oz. ; potatoes, | Ib. ; sugar, f oz. ; wine, 6f oz. ; coffee, 14 oz. Von Xoorden(28) has suggested the following scale for the reduction of the fuel value of the dietary of the aged : Age in Years Percentage of Reduction 60-70 10 70-80 20 80 30 Saundby, in his book on "Old Age, Its Care and Treatment," says that the diet of the aged should be reduced in amount in proportion to their in- activity. So long as they can work, or take active exercise, they may enjoy the diet of adult life, 35 calories per kilogram of body weight, but they should be careful to avoid large meals and indigestible food. On account of their defective teeth all food should be easily masticated, as, for ex- ample, minced or pounded meat and vegetables in puree. The diet should contain few toxins, especially purins; a little meat once a day may be allowed, preferably at the midday meal, while eggs may replace meat at the evening meal. But little alcohol is required, but plenty of water should be taken. Little salted food should be given, as we are ignorant of the conditions in which chlorids are eliminated. 446 DIET IN PHYSIOLOGICAL PERIODS Old persons leading more or less vegetative lives require a smaller amount of food than active adults. We may take it that 30 calories per kilo is a sufficient basis for their dietaries, and if they are obese they should do with less, as fat ought not to be reckoned in estimating the fuel requirements. Saundby thinks these 30 calories might be made up by 1 gram per kilo of protein, 1 gram per kilo of fat, 4 grams per kilo of carbohydrates, so that an old person weighing 70 kilos or 140 pounds might be allowed 70 grams of protein, 70 grams of fat and 280 grams of carbohydrates, which would give a little over 2,000 calories as against 2,450 calories for an adult of the same weight leading a moderately active life. Thus the daily dietary might be composed of the following articles : SAUNDBY'S DAILY DIETARY FOR THE AGED Amount of Food Protein Fat Carbohydrate Calories Bread, 250 grams (8 oz.) 22.08 3.12 127.4 640 Milk, 568 grams (1 pt.) 17.9 19.6 26.88 375 Tapioca, 45 grams (1 oz.) 0.3 0.0 36.0 150 Sugar, 30 grams (1 oz.) 0.0 0.0 29.2 120 Potatoes, 120 grams (4 oz.) 1.8 0.12 24.0 105 Lean meat, 100 grams (3 J^ oz.) .... Fat bacon, 30 grams (1 oz.). 27.0 2.6 7.0 20.75 0.0 00 185 187.5 Butter, 30 grams (1 oz.) 0.21 24.3 0.15 270 Total 71.89 74.89 243.63 2032.5 Tea and coffee, beef tea and bouillon, green vegetables and fruit in moderation contain so little heat-forming substances that they may be left out of account, but may be added to the diet. It will be pertinent to the subject in hand to interpolate some rules as to the feeding of the aged, and a diet table compiled by Dr. Reynold Webb Wilcox(29). 1. Never less than five hours between meals. 2. No solid food between meals. 3. Principal meal near midday. 4. All meals to be as dry as possible. 5. Avoid food likely to cause flatulence. 6. Not more than 5 oz. of fluid with each meal. Alcohol only for those who are accustomed to its use oz. of brandy or whiskey in three or four ounces of water, a single glass of port or sherry. Breakfast, 8 A.M.: Small slice of toast, 1^ oz., with butter; one soft-boiled or poached egg, or half a small haddock or other white fish; 3 to 5 ounces of tea or coffee with cream and sugar; tea may be replaced by cocoa or milk with hot water; well- boiled oatmeal, 3 to 4 ounces with 4 to 5 ounces of milk may be substituted for tea. DIET IN OLD AGE 447 Dinner, 1 P.M.: Two courses fish or meat; pudding or fruit; white fish, short fiber, boiled, steamed or broiled half; small chicken, white meat or sweetbreads; game, lamb, small potato boiled or baked or a small portion of spinach; pudding, a simple milk pudding, or rice, sago, tapioca or suet; fruit, as ripe pears, apples, grapes, 4 to 6 ounces; hot water to be taken if desired. Tea, 5 P.M.: Tea with cream and sugar but no food; in place of tea, a teaspoonful of solid beef extract in hot water may be taken. Supper, 7 P.M.: White fish and one potato or toast with butter. Milk pudding or bread and milk. 10 P.M.: Five ounces of hot water to be sipped. For the relief of thirst, beef tea or hot water, to be sipped four hours after each or the principal meal. Saundby, in order to illustrate the distribution of the amount of food in his table still further, suggests the following arrangement of meals : SAUNDBY'S DAILY DIETARY FOR THE AGED SHOWING DISTRIBU- TION OF MEALS NO. I Breakfast 1/2 pint of tea 3 oz. milk Dinner 3H oz. meat 4 oz. potato Tea i/ pint of tea 3 oz. milk Supper 10 oz. milk 1 oz. bread }4 oz. sugar 3 oz. bread 1 oz. tapioca 4 oz. milk ^ oz. sugar 3 oz. bread 1/2 oz. butter 1 oz. bacon Yz oz. sugar 1 oz. bread % oz. butter NO. II i/ pint coffee 6 oz. fish J/ pint tea 10 oz. milk 1 oz. oatmeal 4 oz. potato 3 oz. milk 1 oz. bread 6 oz. milk 1 oz. milk % oz. sugar % oz. sugar 1 oz. butter 3 oz. bread y^ oz. butter Stewed fruit ^ oz. butter 3 oz. bread ^ oz. sugar 1 oz. bread Another dietary for an old person of seventy, weighing from 120 to 140 pounds, affording 1,950 calories, would contain: 47 grams albumin 314 " carbohydrates 54 fat 20 alcohol 448 DIET IN PHYSIOLOGICAL PERIODS Such a diet may be thus distributed : Morning meal: Milk 8 oz. Sugar % oz. Bread 2 oz. Butter H oz. Midday meal: Bread 3 oz. Meat or fish 2 oz. Vegetables or fruit 2 oz. Beer Yi pint Evening meal: Bread 3 oz. Eggs 2 oz. Light pudding 4 oz. Whiskey Yz oz. The caloric value of a diet may be raised easily by adding to the fat in the form of butter, cream, fat bacon, suet pudding or cheese. With re- gard to cheese, it may be said that a plain, good, wholesome cheese is peculiarly well adapted as a food for the aged. It is palatable and nutri- tious and, while it requires sufficient mastication to produce insalivation, it can be readily masticated by the toothless or by those who lack their full quota of teeth. Cod-liver oil, when it can be taken, is useful, a*s half an ounce of oil daily will afford approximately 150 calories. After fat come the starches and sugars. Cane sugar, as almost pure carbohydrate, can be tolerated in only small quantities. Old men who have been meat eaters, drinkers and smokers, have lost their taste for sweet things, and, in fact, often have a distaste for them, but this aversion can be overcome. Cane sugar is nourishing and by some British authorities is highly lauded in the treatment of arteriosclerosis. It is better assimilated if cooked, as in milk puddings or added to fruit well stewed. Raw sugar should be viewed somewhat askance, as it is likely to upset the digestion, but small quantities will do no harm. Perhaps as much milk as can be digested without discomfort may be taken, but a pint daily is sufficient. Sour milk of late has been given great prominence by Metchnikoff, and is undoubtedly useful in old age. If too sour for. the palate, it may be sweetened with sugar, honey, jam or treacle, and may be added to por- ridge, hominy, boiled rice, or to any breakfast food. It is especially val- uable, being slightly laxative, in cases of chronic constipation, the greatest bane of old age. Metchnikoff recommended its use on account of its power of diminishing the toxicity of the bowel contents, and thereby pre- DIET 1.X OLD AGE 449 venting those senile degenerative changes which he deems largely the result of intestinal intoxication. Buttermilk is also valuable when whole milk cannot be properly digested. The casein it contains furnishes its nutritive value, but its caloric value is on the average only about half of that of milk. Kumiss or kelir when fresh acts as a laxative. It is easily digested and highly nutritious in large quantities from a pint and a half to three pints daily. Campbell (30), who is the chief prophet of thorough mastication and spare living, points out that the appetite for plain food may continue to extreme old age. At one of the large London workhouses the daily diet for men over 00 years of age is as follows : Bread, 20 oz. ; margarin, 1 oz. ; sugar, 1 oz. ; meat, 4 oz. ; potatoes, 8 oz. ; greens, 4 oz. ; pudding, once weekly; stewed fruit, once weekly; tea, 2 pints; salt and pepper daily; mustard once a week; no alcohol. Campbell says that the inmates con- sume it all and enjoy it thoroughly, complain very little of indigestion, and, what is more surprising, suffer little from constipation. The alimentary pastes have high food value and are easily digested if cooked simply. Thus they are eminently suitable as a diet or part of the diet of old people. According to Combe, they are composed of the gluten of wheat with a considerable proportion of starch, and are of especial value in the dietetics of intestinal diseases. !N"ot only is the nutritive 1 value of these foods high, but they are cheap. They cost but little more than rice, sago and tapioca, and have at least double the nutritive value. ALIMENTARY PASTES: FOOD VALUE Protein Carbo- hydrate Fat Calories per 300 Grams Macaroni 12.15 74.58 0.78 340 Vermicelli 12.82 70.78 0.74 335 Italian Paste 12.31 75.16 1.95 345 Rice, boiled 2.77 27.33 0.07 119 Tapioca 5.40 87.18 0.19 350 With regard to the question of allowing old people tea, coffee or cocoa, opinion is divided. Coffee and tea are barred by some authorities as pos- sessing no food value and as containing a poisonous principle caffein, theobromin and, on occasion, a considerable amount of tannin. They delay digestion, and when tannin is present in relatively large quantities they tend to irritate the mucous membrane of the alimentary tract. They stimulate to some extent the heart and nerve centers. Thus, the case 450 DIET IN PHYSIOLOGICAL PERIODS against the use of such beverages for the old would seem at first thought to be very strong, yet when we look at the other side of the mirror and con- sider that the drinking of tea or coffee is a life-long habit and, like all habits, hard to discontinue, our view is somewhat modified. However, there are many harmful habits which it is wise and expedient to break, and if it were proved beyond the shadow of a doubt that either tea, coffee or cocoa drinking really injured old people, then our advice would be not to take any of these infusions or mixtures. But when these beverages, are of good quality (in the case of tea that variety which contains the least amount of tannin) and prepared with care, we are of the opinion that the harm done, in the majority of instances, is counterbalanced by their pleas- ure-giving physiological effect. They are indulgences, it is true, and stimulants in a slight degree, and should only be taken in strict modera- tion by those elderly people who have been accustomed to their use all their lives, and who suffer no inconvenience from their use. The condition of the teeth.of the aged is a matter of much importance and is not infrequently responsible, to some extent, for some of the digest- ive troubles from which they suffer. This loss or partial loss of the me- chanical means provided to man for masticating his food is regarded in different lights by different authorities. Sir Henry Thompson is of the opinion that the disappearance of the masticating powers is mostly coinci- dent with the period of life when that species of food which most requires their action namely, solid animal fiber is little if at all required by the individual. It is during the latter third of his career that the softer and lighter foods, for which teeth are barely necessary, are particularly valu- able and appropriate, and the man with imperfect teeth who conforms to nature's demand for a mild non-stimulating dietary in advanced years will mostly be blessed with a better digestion and sounder health than the man who, thanks to his artificial machinery, can eat and does eat as much flesh in quantity and variety as he did in the days of his youth. Campbell takes an opposite view. He points out that people who have no teeth at all are often better able to masticate than those with a few only, for in the former case the gums are allowed to come together and harden, enabling them to cope with many kinds of food, whereas if the mouth is furnished with teeth, no two of which are opposed, they are useless for purposes of mastication. He says that though the former argument seems plausible enough, prima facie, when examined critically, it will be found to have no basis in fact. If senile edentation has any biological meaning at all, it indicates not that nature desires a return to the diet of infancy, but rather that the time has come to cease eating altogether and to lie down DIET IN OLD AGE 451 and die, for under natural primitive conditions the lack of teeth implies death from starvation. Consequently, properly fitting teeth cannot but be of very great advantage to the aged. The latter argument seems to us stronger by far than the assertion that because in old age teeth come out it signifies that they are no longer needed. Mastication, if not so essential in old age as in the adult period, is yet a valuable power to possess. If food, carbohydrates in particular, is not masticated, it is not sufficiently insalivated, and digestion, thereof is hindered and stomach and intestinal troubles are certain to ensue. Moreover, a mainly pap diet, consisting largely of soft starchy food, is not the kind of diet to suit a healthy or, indeed, even a somewhat feeble old person who has been in the custom of eating heartily of more substantial fare. We agree with Campbell that thorough mastication is good for the old. for, be the diet mainly protein or carbohydrate, mastication and in- salivation are aids to proper digestion the importance of which can scarcely be overestimated. We agree, too, with Thompson (31) that the old do not require their teeth to consume as much animal protein as they were accus- tomed to when in full vigor of manhood, for they most assuredly need, as a rule, but a limited amount of animal food. Campbell, however, is in favor of a simple diet with not a large amount of animal protein through- out life, and indeed sees no reason to differ the dietary of healthy old age and adult life to any great extent. The consumption of meat in old age is still in some degree a mooted question. There are many of the opinion of Sir Henry Thompson, who hold that at any period of life the use of meat should be limited, and others, like Campbell, who believe that to be full fed throughout life is in the best interests of good health. There are yet others, like Woodruff, who think that no particular stint of animal food is necessary. As a matter of fact, it is impossible and would be pre- sumptuous to lay down any rigid rules of diet in order to prolong life. Heredity is one of the most important factors in the attainment of this consummation, while diet undoubtedly is of the first significance and of special import in advanced age. Scientific investigations and observations and practical experience have both taught that less food is needed after a certain age has been reached and that the ingestion of meat should be diminished. Nevertheless, a great deal depends on what kind of life is led. If active and fairly strenuous, a person, although old, requires a suf- ficiently generous amount of food, and if he is accustomed to eating meat, the amount should not be unduly restricted. In most cases it is advisable to reduce the amount of animal food to one-half of that consumed by people 452 DIET IN PHYSIOLOGICAL PERIODS in middle life. Certain it is that, if arteriosclerosis has made much head- way, very little meat should be eaten. Allbutt says on this point that the sum of the argument is, so far as butcher's meat and arteriosclerosis are concerned, that certain observations which we owe to Abelous and others offer evidence with some clearness to show that one or two definite and separable crystalline products produced by bacteria, especially by a specific bacillus of the colon group, can affect the blood pressure. Dietetic restrictions are obviously indicated in the bronchitis of the aged. Many of such patients are allowed to die through carelessness in diet. As Campbell shows it is not merely that overeating begets bron- chitis. The bronchitis and the emphysema that goes along with it curtail the respiratory capacity, and so prevent the excess of food from being burned off. In fact, the only hope of saving the obese bronchitic patient is by a systematic semistarvation. Campbell (30) thinks that for elderly and aged gourmands it is gen- erally even more necessary to cut down the allowance of starch and sugar than animal food, although this should also be curtailed if excessive. All appear to be agreed that alcohol in any form is of little value in the diet of the aged, and should never be taken when a high blood pressure exists. The warding off of old age, and more particularly the warding off of premature old age, can perhaps in the majority of cases be effected by care- ful diet. But it must ever be remembered that as there are all sorts and conditions of men, so there are all sorts and conditions of constitutions and idiosyncrasies. Some, whether they eat sparingly or profusely, suffer from digestive troubles and are apt to grow old prematurely. They are bad metabolizers. This class is not a very large one, and even with them life may be prolonged by paying extreme attention to their alimentation. Again there are those who possess sensitive stomachs and whose digestive processes are easily upset, albeit they may be sound in constitution. These are generally persons of nervous temperament, who, if they exercise care in their dietetic regimen, may live to be very old. This type, like creak- ing gates, lasts longest. Then there are the hale and hearty individuals who by reason of their robustness and strong digestive and assimilative powers, eat and drink to excess, and who frequently by so doing bring their lives to an abrupt end. As a rule, the moderate eaters and drinkers live the longest. Yeo(32) gives the following useful suggestions in regard to the diet of the aged : Any sudden changes in diet should be avoided, and the intervals between the ingestion of food should not exceed six or eight hours. DIET IN OLD AGE 453 It is very common for elderly people to awaken early in the morning, at three or four o'clock, and to be unable to drop off to sleep again, but if they have some light form of nourishment at the bedside, such as a glass of milk or a little gruel, which they can take at that time, they will often continue their sleep. The acidity of certain stewed fruits may be advantageously neutralized by the addition of a little bicarbonate of soda, so as to avoid the use of a large quantity of cane sugar, 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 food to be accompanied with some kind of condiment, which promotes their digestion and prevents flatulence. Caviare and the roes of smoked and salted herrings are of this nature. For sweetening food, milk sugar is much less prone to excite acid fermentation than cane sugar. A very digestible form of fat when it is needed is cream, mixed with an equal quantity of hot water and about ten drops of sal volatile to each fluid ounce. REFERENCES 1. STAKE, M. ALLEN. Diseases of Infancy and Childhood. 2. WATSON. Foods and Feeding. 3. HALL, WINFIELD S. Nutrition and Dietetics. 4. FITCH, W. E. Rations for Young Boys' Military Training Camp, Mil. Surgeon, April, 1917. 5. GEPHART. Russell Sage Institute of Pathology; Editorial, J. Am. Med. Assn. 6. LUSK, GRAHAM. Food Economics, J., Washington Academy of Sci- ence, 1916, vol. vi, p. 390. 7. HALL, WINFIELD S. Nutrition and Dietetics, pub. by D. Appleton & Co., 1913. 8. BENEDICT, A. L. Golden Rules of Dietetics. 9. RICHARDS. A Study in Dietaries, 1901. 10. PROCHOWNICK. Zentralbl. f. Gynak., 1899, p. 33. 11. EDGAR. J. C. Practical Obstetrics, pub. by Blakiston, 5th ed. 12. GAUTIER. Diet and Dietetics. 13. ROTCH, T. M. American Text-book of Pediatrics, W. B. Saunders, Philadelphia. 14. TILTS. Change of Life, London. 15. TIBBLES. Food and Hygiene, published by Rebman Co. 16. THOBURN. .Diseases of Women. 17. BISHOP, L. FAUOERES. Arteriosclerosis, Oxford Med. Publication, London, 1915. 18. ALLBUTT. System of Medicine. 129 454 DIET IN PHYSIOLOGICAL PEEIODS 19. NASCHER, I. L. Geriatrics Diseases of Old Age, pub. by Blakis- ton, 1916. 20. CAMPBELL. Sutherland's System of Diet and Dietetics. 21. FRIEDENWALD and RUHRAII. Diet in Health and Disease. 22. VOIT. Zschr. f. Biol., 1876, p. 32. 23. MAUREL. Rev. Soc. scient. d'hyg. aliment., 1906, p. 763. 24. LANGWORTHY. U. S. Dept of Agric., Bull. 22. 25. QUATELET. Landois and Stirling's Human Physiology, 1891. 26. KOSEVI. Centralbl. f. inn. Med., 1901, p. 121. 27. MUISTK and EWALD. Diseases of the Stomach. 28. VON NOORDEN. Metabolism and Practical Medicine. 29. WILCOX, R. W. The Treatment of Disease, pub. by Blakiston. 30. CAMPBELL. Brit. Med. J., May, 1907, p. 1229. 31. THOMPSON, W. GILMAN. Practical Dietetics. 32. YEO, BURNEY. Text-book of Physiology. CHAPTER XIV HYGIENE OF THE INTESTINES WILLIAM P. CUNNINGHAM, A.M., M.D. General Considerations. Chronic Intestinal Stasis; Diseases Due to Chronic Intestinal Stasis; Considerations of Diet in Chronic Intestinal Stasis; Hygiene of the Intestinal Canal. GENERAL CONSIDERATIONS The subject of this chapter has a great deal broader scope than would appear upon cursory examination. The hygiene of the intestinal tract has a deeper significance than the relief of certain local disturbances, de- pendent upon the imperfect evacuation of the lower segment. It has to do with problems of a grave and far-reaching character. To appreciate this, it will be necessary to recall the construction of the abdominal viscera with especial reference to the matter of drainage. We shall content ourselves by simply recalling that the human being is a hollow organism from the mouth to the anus. There exists, then, a continuous membranous tube with dilatations and constrictions demanded by the exigencies of the situation. The pharynx, the esophagus, the stom- ach, the small and the large intestine vary in size, but constitute one con- tinuous canal. Anything that enters at the mouth, must exit at the anus unless absorbed in transit. It is obvious that for the proper functioning of such a tubular organ, there must be an unobstructed right of way. Any unusual constriction anywhere in its course may convert it into "no thor- oughfare" and induce a train of consequences of the most surprising and deplorable kind. The numberless evil things that accumulate in the prog- ress of a more or less thoroughly digested mixture from the stomach to the rectum, may be detained by abnormalities of the channel, until they have accomplished various toxic reactions and been absorbed into the gen- eral circulation. Locally also they produce irritations of a serious nature. 455 456 HYGIENE OF THE INTESTINES An uninterrupted fair way would in all likelihood have been main- tained had man not risen from the posture for which he had originally been designed. Going on all fours, his intestines swung free from their mesenteric attachments to his spine. There was no danger of kinking, fouling or jamming of the various loops. The chylous tide swept on with perfect freedom to its destination. But when in the assumption of his new-found dignity he proudly drew himself erect, the relation of the gut to its attachments was entirely altered. It now dragged upon a mesentery clinging to a perpendicular support and was thrown into unpremeditated disarray. It sustained "strained relations" with its environment. As the advance of man in the refinements of civilization entailed in- creasing impairment of the muscular energy of his aboriginal forbears, he began to experience the inevitable results of the faulty position of his ab- dominal contents. Debility, disease, corsets, gluttony, sloth, obesity, caused the prolapse of the imperfectly secured intestines, and they sagged into feeble pouches, incapable of adequate peristalsis, and making a con- stant traction on the contiguous sections. Nature, ever conservative, strove to offset this injurious derangement by passing supporting bands under the dragging loops. As frequently happens, nature overreached her- self. The new supports became added elements of danger and distress. The weight of the prolapsed portion caused an angular distortion at the site of the (Supplementary slings, for all the world as if one hung an empty hose over a fence. Against this added obstruc- tion the already fatigued intestine struggled with di- minishing success. The ac- cumulation behind the ob- struction steadily increased, while the gut in front was empty and collapsed. Here FIG. S.-CASE X. INFLAMMATORY, SUPEBIMPOSED was established what Sir UPON EVOLUTIONARY STASIS. Lane's band, . , , T , with potential kink; prolapsed transverse colon, ascending colon, and sigmoid; Jon- aptly termed a cesspool, and nesco's fold; Jackson's membrane. Three sets jjj that cesspool are ffen- of firm fibrous bands, just below ileocecal . j .1 , , , . , , ... , crated, as in the most pro- valve, extend from ileum to right iliac fossa, . ' one to right ovary. ductive culture medium, a GENERAL CONSIDERATIONS 457 host of microbial invaders whose varied activities are responsible for most of the ills that flesh is heir to. This is no overdrawn or fanciful picture. It is a plain statement of truth susceptible of the completest corroboration. No fact in medical practice is of more ancient usage than the effort to overcome constipation. The evil of the inactive bowel has ever been recognized. "Make a hole through" was the homely dictum of the old schoolmen. In this injunction they epitomized the whole question of in- testinal stasis and adequate drainage. They did not comprehend the causes at work in preventing this essential function. They attributed to many agencies, conditions which we have found largely confined to one. They talked of diet and torpid liver and insufficient exercise and defective innervation, and they some- times cured a case where such factors had brought about a fecal blockade in the rectum. But they realized that the failure of the bowel to empty itself created a pathological situation of serious import which demanded all their sci- ence to remove. It consti- tuted the stopping of a sewer with a backing up of its dele- terious contents. No discrim- ination was made between the massing of dried effete detritus of a comparatively harmless . character in the part of the. tract least provided with ab- sorbents, and a fluid compound of putrescent material stagnant at the gaping mouths of numberless lymphatics. The lower bowel could be emptied ; its repacking could be prevented. Diet, exercise and laxatives were all-sufficient here. Just a little care and watchfulness achieved the desired result and made the reputation of some wonderful cathartic. But of the organic barrier above, of the angular kink, of the saccu- lated cesspool, they had no glimmering, and consequently could not intelli- gently direct their therapeutic fire. It remained for the adventurous English surgeon. Sir Arbuthnot Lane, to discover the obstructing abnor- mality, and boldly proclaim it to a skeptical profession. So ill was his 7. E. H., FKMALE, 30, SINGI.K. Lane's band; ileal stasis; appendix and ovary caught in band; caecum dilated. 458 HYGIENE OF THE INTESTINES evangel received by rock-ribbed conservatism that he was hooted out of his scientific societies. He was thrust outside the breastworks by his English confreres, and stigmatized as something uncanny and unclean. It was only when he appealed to the surgeons of America that he began to make impression on the general incredulity. He proved his case and the repute of his success traveling back to the slower innovators at home, rehabili- tated him in the good opinion of his own people. The doubt, reproach and derision with which he had been originally received gave place to confidence and respect. CHRONIC INTESTINAL STASIS Chronic intestinal stasis due to mechanical obstruction was firmly planted in the pathology of advanced medical thought. Not that all oppo- sition to the idea has been overcome. While man has power of cerebration, differ- ences of opinion will persist. It is impossible to break down the adamantine resist- ance of prejudice and con- ceit. Both will hold out against the plainest evidence of their erroneous attitude. But men of ordinary sober judgment, comprising as they Fio. 8.-J. S. CHRONIC INTESTINAL STASIS, WITH do the S reat majority of our VERY BROAD BAND ANGULATING DUODENO- confraternity, are susceptible JEJUNAL JUNCTION. Dilated duodenum; band t o conviction and ready to an2 o u 6 36-40 c* # ft / j/ u " 3 " " f 6 " "8 M Q 9 48 i 5 " 9^ 2_^ 511 Artificially fed infants, like the breast-fed, should be given their food at regular intervals. This is important in order to obtain good results. The intervals may be one, two, three, four or five-hour periods to suit digestive capacity as well as age and weight of the child. Usually night feeding can be omitted after the fourth month. The feedings between 6 A.M. and 10 P.M. must be observed with the strictest regu- larity. When the child is about eight months old four feedings in the twenty-four hours are enough, beginning at 6 or 7 A.M. and finishing at 6 or 7 P.M. While the infant is taking his food, he should be quiet, free from light and excitement. Food given while the child is surrounded by noise^ light, and various members of the family, creates irritability and disturbs diges- tion, laying the foundation for many ills later in life. Infants should be taught to lie quietly and their surroundings should be quiet to secure pro- found sleep. The rapidly growing nervous system of the infant is easily excited by an outside factor, exerting an unfavorable influence on the digestive organs. Good air is as important to the infant as clean milk, and as early as the first week in summer, provided the weather permits, the child should sleep out of doors during the day. During winter the first outings should consist in widely opening all windows. By the time the child is two months old, most of the sleeping during favorable weather should be in the open. Undue light and drafts can be controlled by the proper adjust- ment of couch, carriage or hammock. The infant's food should contain the necessary elements, fat, protein and sugar, in reasonably accurate percentages in order to maintain good health. If fever occurs, as a result of improper food or feeding, or by reason of any acute infection, then the withdrawal of the milk-formula is necessary. As Jacobi well states, "Milk is food for infants when well, but food for bacteria when sick." After an illness has subsided, the gradual return of the whole formula is necessary not omitting protein and fats, as so many do. Barley water, orange juice, or plain water will tide an infant over an illness lasting one week or more before milk can be resumed with safety. It is a well-known fact that the fat of cow's milk is not easy to digest. It is necessary to remember this and to place the percentages of fat in modified milk-mixtures for young infants much lower than found in human milk. The excess of fat which is usually used too freely, is one of the most common causes of indigestion in young infants. When the child is restless, colicky, and has loose stools, the first correction in the 512 REQUIREMENTS OF INFANT FEEDING food formula to be made in the trial change should be a reduction of fat and a corresponding increase in calories, namely sugar. The further indications for this change in the food formula are, viz., (a) if the infant regurgitates its food; (&) or is constipated, with gray dry stools, and (c) if it voids irritating urine which stains the napkin with uric acid constituents. The management of the casein of cow's milk usually causes the least trouble in our milk formula. Cow's milk casein may, however, be a cause of indigestion. After a reduction of the fat has failed to improve condi- tions, we are called upon to prevent the coagulation of casein in the stomach by adding a diluent or some alkali that will 'split up the coagu- lated casein. Sodium citrate in solution, a grain to one grain and a half for each ounce of food, is sufficient. Barley water may have to be used as a diluent, or it may prove necessary to boil the milk. Sodium citrate in solution is perfectly reliable and long experience has proven its value. If, however, these measures fail and casein indigestion continues, we may reduce the casein content of our food formula and make up the deficiency by the addition of whey proteins. When this trouble is cor- rected, we can slowly increase the fat and proteins to the original formula. Casein indigestion is revealed by large tough curds, loose alkaline stools, fever, and irritability ; the latter will be found a constitutional symptom. The sugars are the most easily digested of the food ingredients of the modified milk mixtures, and for this reason are frequently increased at the expense of the fat and protein. For this reason we frequently find sugar intoxication in young infants. These cases are associated with a watery acid diarrhea, producing irritation of the buttocks. Fever, general constitutional symptoms, much gas formation and intestinal catarrh are usually present. When these symptoms occur, it is necessary to withdraw the sugar entirely, or what is possibly the best procedure, to substitute another sugar. Theoretically, milk sugar should be the first choice, but practical experience has demonstrated that cane sugar is better than milk sugar and that malt sugar is superior to both, so we use malt sugar in all of our artificially fed children. HOME MODIFICATION OF COW'S MILK In feeding infants in the home under the physician's care, some modification or adjustment of cow's milk must be made to suit the individual infant this is called ''home modification" and does not refer to any exact changes to be made in the milk, except rendering it more suitable to the baby's digestive capacity and nutritional demands. Every physician of experience has worked out, for himself, a plan for modifying milk, which his clinical ARTIFICIAL FEEDING OF INFANTS 513 experience has taught him will serve his purpose better than any other that he has been able to find, and nearly every writer offers his own formula for home modification of milk by which a certain degree of accuracy in percentage feeding may be obtained. This is a true state- ment, and is proof that there is no single method superior to all others. The infant is a changeable factor, as much as the milk ingredients and the infant must be modified as well as the milk. The prime object of these methods is to give the physician certain rules so he may arrange milk formulas containing definite percentages of protein, fat, sugar and salts. Nearly all existing methods of feeding are more or less complicated in the sense that they strive to give very exact percentages of protein, fat and sugar, in the idea that the exact percentage is necessary to success in feeding. This is not true for the formula, nor is it true for the infant. Very few physicians work out the exact per- centage, nor is it necessary. While there can be no objection to accurate percentages in infant feeding, yet the experience of the world has demon- strated that these accurate percentages are not absolutely necessary to suc- cess, and that on the whole, infants thrive just as well upon a milk mixture which is intelligently modified so as to contain protein, fat, sugar, and salts in fairly definite percentages, and in such quantities that the infant will not suffer from starvation in any one of these important ingredients. By reason of the many complicated methods given in our text-books, most physicians resort to the use of whole milk and a diluent in the form of some malted sugar food. These simple mixtures appeal to the young mother and the result is that most of our infants are thug reared. The following table is taken from Morse and Talbot : ANALYSIS OF WHOLE MILK VARYING CREAM PERCENTAGES SKIMMED AND SEPARATED MILKS Fat Milk Sugar Protein Whole Milk 4.00 4.50 3.50 7% Cream 7.00 4.45 340 10% " 10.00 4.40 3.25 16% " 16.00 4.20 3.05 32% " 32.00 3.20 2.50 Skimmed Milk 1.00 5.00 3.55 Separated " 0.25 5.00 3.65 Whey 0.25 5.00 0.90 While the simplicity of the whole milk method of modifying infant feeding has made it popular, there is no question that much better results 514 [REQUIREMENTS OF INFANT FEEDING can be obtained by a method which uses top milk as well as whole milk in the preparation of infant foods. In this way the fat percentages can be better adapted to the nutritional demands of the infant. Feeding may be greatly simplified and its efficacy not materially diminished by making all food formula from three ingredients, viz., 1, whole milk, which to simplify computations one may assume contains 4 per cent fat, 4 per cent protein and 4 per cent of sugar; 2, top milk, containing 7 per cent cream this is obtained by taking the top half of the milk after it has stood for two hours ; this contains very nearly 7 per cent fat, 4 per cent protein and 4 per cent sugar ; 3, a carbohydrate solu- tion made of sugars or starches containing one-half ounce of carbohydrate to the pint. In infants under six months of age, because of the great dilution of the milk, the 7 per cent top milk should be used, so as not to get a too low percentage of fat. In infants over six months of age whole milk may be used. In making modified milk mixtures from these ingredients the physi- cian should be guided by the principles underlying the artificial feeding of infants, as pointed out in the earlier portion of this chapter. In the table it is shown how the ingredients may be combined in the production of an infant food which will answer all practical purposes. It possesses the proper number of calories, and contains the important per cent of protein, fat, sugar and salts in such relative quantities that the infant will be satisfied. After all, the true test of feeding is the child itself. If the infant gains in weight, six to eight ounces per week while under four months ; sleeps well from twelve to fifteen hours in the twenty- four; doubles its birth-weight at six months and triples it at one year, we may well feel that the food is meeting all requirements. Between the sixth and twelfth month the food of the average well infant should be supplemented by the addition of orange juice, raw egg albumen, thick cereal gruels, meat juice and meat broths. All this addi- tional food should precede or follow the bottle, except orange juice, which should be given at least one hour after the bottle. Milk should always remain the chief food of the infant and can be continued until the third year, or until the child has been taught to chew thoroughly the food suitable for its age. After nursing, any food remaining in the bottle must be thrown away. Flies should never be allowed to touch the baby, food, or utensils. It should be understood that the mother or nurse will never touch the nipple with their lips. AETIFICIAL FEEDING OF INFANTS 515 The temperature of the milk may be tested before giving it to the baby by allowing a few drops to fall on the back of 'the hand. The bottle must be held inverted by the mother or nurse during the feeding, so that the child will not suck air. If the milk flows too freely, ofttimes a most perplexing problem in artificial feeding, the nipple needs changing, or possibly, a light gauze packing is required. The time required to take six to eight ounces of food should not exceed iwenty-five minutes of continuous nursing. This is necessary to develop the salivary glands and promote good digestion. Regularity is of prime importance. The number and length of inter- vals should be about the same as those given for infants at the breast. Water is of vital necessity and must be given at least three times a day ; this is best done from a bottle, two to three ounces at a time. I am in the habit of ordering a small quantity of sugar or soda mint, or both, in the bottle. This is of value if the child is constipated. It is a good rule to start with formulas of low percentages in com- mencing artificial feeding in normal babies. This is true of fats and proteins. Taking the mother's milk as a standard, the percentage of sugar and protein may be about the same, but the fats should be about one-half, remembering that temporary error on the side of underfeeding is much easier of correction than the more common mistake of overfeeding. The final rule is to keep the child in a cool, quiet, and dark room where all external irritations are reduced to a minimum. Summary of Rules to Be Observed in Artificial Feeding The aseptic care of the bottles, nipples and utensils, including the person of the nurse or mother, cannot be over-emphasized. This rule is as important as clean milk, and without clean milk the first and most important link in the chain is broken. The once familiar death-trap known as the long-tube nursing bottle, still frequently seen in children's dispensaries, has at last attracted the attention of legislators, so that in many localities not only the use, but even the sale is prohibited by law. In the home modification of milk the mother or nurse must be care- fully instructed by the attending physician in regard to all details. All the necessary utensils should be on hand for the proper and scientific preparation of the baby's aliment. These include a good medium sized ice box, two siphons, sterilizer, or pasteurizer, thermometer registering to 212 F., a dozen graduated feeding tubes or bottles (large mouth with- out shoulder with small lip), bottle brushes f absorbent cotton, straining 516 REQUIREMENTS OF INFANT FEEDING gauze, non-absorbent cotton for use as stoppers, mixing pitcher, glass funnel, tall cup for warming bottle, six black rubber nipples (reversible for cleaning), package of bicarbonate of soda and boric acid. Lime water should be kept in a well-corked bottle. The sugar (malt or cane) solution should be prepared fresh for each day's use. The supply of food should be prepared once or twice in the twenty- four hours, dependent upon the time of the milk delivery, and the number of tubes to be used. The milk should always be kept on ice before and after preparation. All bottles and utensils should be washed with hot soap-suds, then boiled and rinsed. The feeding tubes, after boiling, should be filled with hot boric acid or soda solution and left covered until used again. The tubes, when filled, should be stoppered with non-absorbent cotton so that in cooling the air may pass through. After warming to about 100 F. by standing the bottle in a cup of hot water, the cotton in the bottle is replaced by the nipple. The nipples must be boiled daily and then kept dry in a closed box. REFERENCES 1. DAVIS. Am. J. Dis. Child., 1913, vol. v, p. 234. 2. HOLT. J. Am. Med. Assn., 1908, vol. li. 3. KOPLIK, HENRY. Ibid., 1912, vol. Iviii, p. 75. 4. PRITCHARD, ERIC. Infant Nutrition and Management, 1914. 5. GRAHAM. J. Am. Med. Assn., 1908, vol. liv, p. 1045. 6. HOLT. Ibid., 1910, vol. liv, p. 682. 7. DAVIS, A. J. Dis. of Child., 1913, vol. v, p. 234. 8. LTTLING. These de Paris, 1900. 9. ARMSTRONG. British J. Dis. of Child., 1904, vol. i, p. 115. 10. ESCHERICH. Fortschr. d. Med., 1885, vol. iii, p. 231. COHN and NEWMAN. Virchow's Arch. f. path. Anat, 1891, vol. cxxvi, p. 391. PALLESKE. Virchow's Arch., 1892, vol. cxxx, p. 185. HONIGMANN. Ztschr. of Hyg. u. Infect., 1893, vol. xiv, p. 207. RINGEL. Munch, med. Wchnschr., 1893, vol. xl, p. 513. GENOND. Sur la presence du staphlocoque dans le lait des aecou- chees bien portantes. These de Lyon, 1894. KNOCHENSTIERN. Hyg. Rundschau, 1894, vol. iv, p. 231. HALLEUR. Inaug. Diss., Leipzig, 1893. BRUMM. Arch. f. Gynaekol., 1886, vol. xxvii, p. 461. REFERENCES 517 MERIT. These de Paris, 1887. JOHANNESSEN. Jalirb. f. Kinderh., 1895, vol. xxxix, p. 398. ROEPER. Inaug. Diss., Marburg, 1896. KOESTLIN. Arch. f. Gynaekol., 1897, vol. liii, p. 201. 11. UHLENTEUTH and MULZER. Med. Wcbnschr., 1913, vol. xxxix, No. 19. 12. LAWRENCE. Boston Med. and Surg. J., 1909, vol. clxi, p. 152. 13. MORO. Jahrb. f. Kinderh., vol. lii, p. 542. 14. ENGEL. Sommerfield's Handbuch der Milchkunde, Wiesbaden, 1909, p. 774, Konig, Note 9. 15. CRAMER. Klinische Beitrage zur Frage der Kiinstlichen Ernah- rnng des Neugeborenen, Inaug. Diss., Breslau, 1896 ; taken from Czerny and Keller, Des Kindes Ernahrung, Ernahrungs- storungen und Erniihrimgstherapie, Leipzig u. Wien, 1906, vol. i, p. 356. 16. CZERNY and KELLER. Ibid., p. 353. 17. . Ibid., p. 458. 18. RIETSCHAL. Jahrb. f. Kinderh., vol. Ixiv, p. 125. 19. . Loc. cit., p. 407. 20. ENGEL. Sommerfeld's Handbuch der Milchkunde, Wiesbaden, 1909. 21. . Arch. f. Kinderh., 1906, vol. xliii, p. 181. 22. MOLL. Ibid., 1908, vol. xlviii, p. 161. 23. SKVORLZOV. Russki Vratch, vol. ii, p. 1392, Ref. Chem. Abstract, 1913, vol. vii, No. 18. 24. DENIGES. Contribution a 1'etude des lactoses, Paris, 1892. BOMMARTINI. Rev. gen. du lait., 1896, vol. ii, No. 1. 25. PORCHER. Biochem. Ztschr., 1909-10, vol. xxiii, p. 370. PATON and CATHCART. J. Physiol., 1911, vol. xliii, p. 179. 26. PFEIFFER. Verh. II. Versamml. d. Gesellsch. f. Kinderh., Wien, 1894, p. 131. 27. SCHLOSSMANN. Arch. f. Kinderh., 1900, vol. xxx, p. 324. 28. LUST. Monatschr. f. Kinderh., 1913, vol. xi, p. 236. 29. SCHAFER and MACKENZIE. Proc. Roy. Soc., London (B), 1911, vol. Ixxiv, p. 16. 30. HAMMOND. Quart. J. Exper. Physiol., 1913, vol. vi, p. 311. 31. GAVIN. Ibid., 1911, vol. vi, p. 13. 32. MACKENZIE. Ibid., 1911, vol. iv, p. 305. OTT and SCOTT. Therap. Gazet, 1911, vol. xxxv, p. 689. 33. ASCIINER and GRIGORI. Arch. Gyn., vol. xciv, No. 3. 133 518 34. BASCH. Munch, med. Wchnschr., 1911, vol. Iviii, p. 2261. 35. WOLF. Zentralbl. f. Biochem. u. Biophys., 1913, vol. xiv, p. 224. 36. CHATIN and RENDU. Lyon med., 1912, vol. cxvii, p. 161. 37. MORSE and TALBOT. Diseases of Nutrition and Infant Feeding. 38. CKAMEK. Miinch. med. Wchnschr., 1909, vol. Ivi, p. 1521. 39. BASCH. Ibid., 1911, vol. Iviii, p. 2266. 40. D'EKRICO. La Pediatria, Abstr. in Jahrb. f. Kinderh., 1910, vol. xxii, p. 504. 41. OPPENHEIMER'S Handbuch der Biochemie, Jena, 1910, vol. iii, p. 403. 42. KONIG, J. Des Menschen Nahrungs- und Genussmittel, 1904, Ber- lin, vol. ii, p. 598. 43. KIRSCHNER. Handb. d. Milchwirtschaft, Berlin, 1907, pp. 7, 40. 44. BARTHE. Quoted in Maly's Jahres, 1906, p. 230. 45. FLEISCHMANJST. Lehrbuch der Milchwirtschaft, 3rd ed., Leipzig, 1901, p. 57. 46. HAMMARSTEN. Text-book of Phys. Chemistry, New York, 1912. 47. CAMAILLE, C. R. 63, 692. 48. BACKHANS. Quoted in Maly's Jahres, 1906, p. 299. 49. BUNGE. Ztschr. f. Biol., 1874, vol. x, p. 309. 50. ABDERHALDEN. Ueber Sauglings-Ernahrung, Berlin, 1912, p. 55. 51. SOLDNER. Die Landwirthsch. Versuchsstat., 1888, vol. xxv, p. 361 ; quoted from Voltz in Oppenheimer's Handbuch, vol. iii, i, ' p. 398. 52. RICHMOND. Dairy Chemistry., Phila., 1899. 53. SCHLOSS. Loc. cit., Dairy Chemistry, Phila., 1899. 54. FUNK, CASIMIR. Die Vitamin etc., Wiesbaden, pub. by J. F. Bergman, 1914. CHAPTER XVI SPECIAL DIETS H. LYONS HUNT, M.D., L.E.C.S. and P. (Edinburgh), L.F.P. and S. (Glasgow) Food, and only food, makes blood, and blood, as we know, makes body; so that our body structure is dependent upon, and only upon, the food we eat. Vegetable Diet: Vegetable Diet and Energy; Vegetable Diet and Health; Vegetable versus Animal Protein; Summary. Meat Diet: The Salisbury Diet; Zymotherapy. Fruit Diet: Fruit Diet in Disease; Lemon Cure; Grape Cure. Tufnell and Bellingham Diets. Weir Mitchell Diet. Training Diet. Reducing Diet. Diet for Professional Singers and Lecturers. The Dry Cure. The Yolk Cure. Milk Cures: Kumiss Cure; Matzoon Cure; Buttermilk; Cure; Sour Milk Cure; Milk Cure; Skim Milk Cure; Whey Cure. Prom time immemorial man has fed on the fruits of the earth and the flesh of animals. At certain epochs in his history, under the sway of philosophic speculation or religious tenets, sometimes on account of careful hygienic considerations, or even under force of necessity, he has, voluntarily or not, subjected himself to special forms of diet, sometimes eating only fruits and herbs, sometimes adding milk to his fruits and vegetables. At other times, on the contrary, his alimentation has been ex- clusively from the flesh of animals, and again he has seen fit to subsist upon a mixed diet, to the rigid exclusion of all meat. These exclusive methods of alimentation have led to favorable hygienic and dietetic re- sults which find ready application in trophotherapeutic treatment. 519 520 SPECIAL DIETS Various systems of special diets and diet cures have been devised to meet the requirements of disease or the fancies of the faddist. Some of these consist solely in the elimination of certain articles of food from the dietary, due to esthetic tastes or humanitarian principles. In some in- stances the particular modification is based on trophotherapeutic reason- ing with a view of economic simplicity, the desire to give the digestive apparatus a complete rest from some particular food constituent, or the necessity of curtailing the amount of nutrients in the dietary without reducing the actual quantity of the diet or of limiting the total caloric value. Many of the special diets and diet cures which embody this object are outlined in the present chapter; and those prescribed in obesity are referred to in the section dealing with Diet in Diseases of Metabolism (Volume III, Chapter XII). The dietaries here considered are of prac- tical use in various conditions of health and disease, in different indi- viduals in different climates, or in the same individuals under different environments. VEGETABLE DIET Vegetarianism (1), or a vegetarian diet, will be the first of the special diets and diet cures to receive attention, because, in one form or another, it is, and has long been, the alimentation of entire races of people numbering many millions, and of late years has become a fad with many Americans and Europeans, who find it more economical to patronize the green grocer than the butcher, and who believe, in many instances, that a vegetable dietary is conducive to health, longevity, good temper and a mildness of disposition which a carnivorous dietary obliterates. Often, too, believers in this special form of dietary object to the flesh of animals for esthetic or religious reasons, since they consider the slaughter of ani- mals unjustifiable to furnish food for man. A dietary which excluded the flesh of all animals was at first a re- ligious practice. The Hindoos, followers of Brahma and Buddha, believ- ers in the doctrine of the transmigration of the soul, still hold to the teach- ing that the spirit can migrate from man to animals, which are our in- ferior brothers. It has, therefore, always been repugnant to followers of this cult even to think of eating the flesh of an animal, which to them is a kind of sacrilegious cannibalism. For a similar reason the religious be- liefs of the ancient Egyptians forbade the use of meat, this doctrine hav- ing been brought by Pythagoras (2) from that country into Greece, whence it has been transmitted to us by time. The human race is omnivorous by instinct, by its dentition, by its digestive secretion, and by its need of ac- VEGETABLE DIET 521 tivity. To work quickly and well, the modern man, especially, must Lave a stimulating dietary which will furnish him with the most active and most digestible plastic matter in the smallest volume. A diet of meat and vegetables seems to agree with him from every point of view. The strict vegetarian partakes of no animal food, and no tubers nor foods grown under ground, limiting his alimentation entirely to fruits and vegetables grown in the sunlight. Many vegetarians, however, in addition to vegetables, consume milk, butter, cheese and eggs, and are classed as lacto-vegetariaris. In reality they are no more vegetarians than the man who eats meat, fish or fowl. The alimentation of the lacto-vege- tarian, consisting of milk, cheese, butter, eggs, cereals, legumes, fruits, nuts and other vegetables, is advantageous to many people and more par- ticularly in the trophotherapeutic treatment of certain types of disease. Vegetarianism has its advantages in that its supporters do not overeat while getting a fairly bulky meal; the amount of protein consumed is smaller and the proportion absorbed is less from a vegetarian diet than from a mixed diet, which is of great advantage to many patients. A lacto- vegetarian dietary, such as the following from Tibbles(3), is valuable in the dietetic treatment of high arterial tension, the forerunner of arterio- sclerosis, of some forms of renal disease, as albuminuria, and of Graves' disease, gout, calculi, hepatic troubles, rheumatism, intestinal toxemia and intestinal fermentation, chronic skin diseases and chronic nervous affec- tions. LACTO- VEGETARIAN DIET Breakfast: Milk, whole meal bread, butter, one egg. Lunch: Baked beans and tomatoes, potatoes, cabbage, stewed fruit, bread, cheese, and salad. Dinner: Lentil soup or oatmeal porridge, bread and butter, dates and walnuts, or grapes and bananas. This dietary can be varied in many ways. The use of sauces, such as walnut and mushroom ketchup, or ripe tomatoes, added to beans or macaroni, makes them more palatable and gives zest to the appetite and at the same time provokes the stimulation of the secretion of gastric juico. Beans and peas boiled with savory herbs mint, thyme, savory, marjoram, etc. are more palatable and better flavored than when cooked without them. Lunch is generally more difficult to provide than the other meals. The following dietaries outline lacto- vegetarian lunches for a week: 522 SPECIAL DIETS LACTO-VEGETARIAN LUNCHES Monday: Steamed rice and tomatoes, with grated cheese; boiled cabbage or other green vegetables; whole meal biscuits; custard pudding. Tuesday: Steamed broad beans and macaroni, with parsley sauce; steamed green vege- tables; potatoes cooked in their skins. Wednesday: Nut-roast, mushroom gravy; steamed vegetables; plain steamed pudding with jam or syrup. Thursday: Macaroni and cheese, with apple sauce and steamed potatoes; ginger pudding; fruit. Friday: Baked Irish stew containing nut-meal or peas or beans in place of meat; milk pudding; unfermented bread; cheese. Saturday: Lentil-roast with apple sauce or gravy; boiled cabbage; baked or steamed potatoes; maizene pudding; nuts and fruit. Sunday: Savory pie, consisting of steamed haricot beans and vegetables; or macaroni and eggs, moistened with milk and seasoned; baked potatoes; tomatoes and salad; ground rice, blanc mange; fruit. It is no longer questioned that a dietary composed entirely of vege- tables will supply all the food constituents, carbohydrates, fats and pro- teins. A menu can be planned so as to supply all the necessary food ele- ments requisite for body metabolism. The nitrogenous matter obtained from vegetables, however, is less easily digested than that from animal foods, and a much larger percentage passes from the alimentary tract unutilized. Individuals subsisting entirely on a strict vegetarian diet for any prolonged period of time are apt to lose strength as well as physical and mental vigor and endurance and show languor and disinclination for work, and they become less able to resist disease (4, 5). Laborers are unable to perform the same amount of work they could accomplish on a dietary containing animal food. As previously stated, the animal king- dom supplies man with protein food, and the vegetable kingdom provides carbohydrates except honey; fats being derived about equally from both sources. The percentage of starch in different vegetables varies greatly, being highest in tubers. Green vegetables are practically fat-free, con- taining a very small percentage of protein, one-tenth of which is lost in cooking, and from two to eight per cent of starch, of which one-third is lost in cooking. They possess the advantage of being able to take up a great VEGETABLE DIET 523 deal of fat during the process of cooking. Fats are negligible constituents of vegetables, but are apparently quite as nutritious and even more di- gestible than animal fats. A careful consideration of the elementary con- stituents of a vegetable dietary shows that the principal advantage of a strict vegetable diet is the reduction of all protein, notwithstanding a large bulk of vegetables may be taken. The exclusion of animal foods, with the exception of eggs, milk and milk products, from the diet is strenuously advocated by certain sentimentalists who are opposed to slaughtering ani- mals for food. According to Edmund Caultey(G), universal lacto-vegetarianism is an impossibility. Carried out thoroughly to its logical conclusion it would have a most pro- found effect on life generally. Under such a scheme of diet all animals except those used for draught purposes and pleasure would gradually be abolished. Were fowls only kept to supply eggs and feathers, the price of eggs would rise considerably. So, too, the supply of milk would be insufficient and its price prohibitive, for cattle could not be kept profitably for the supply of milk and leather alone. Woolen clothing would become the luxury of the rich. The bulk of the grass grown would be absolutely wasted unless the science of the vege- tarian were able to prepare from it a food for man. The productive value would be, however, increased if the grass plains were converted into arable land for the growth of cereals and sugar beets and into orchards for fruits and nuts. We should have an insufficient and expensive sup- ply of milk, milk products, and eggs, wool and leather. We should be dependent on cotton and linen for clothing and on compressed cellulose for boots and many other purposes. But although universal vegetarianism is opposed to the scheme of na- ture, there are cases in which the diet, or one modified by the addition of milk and eggs, is particularly suitable. As has been stated above, its advantage largely depends on a relative starvation, when compared with the previous mixed diet. The patient no longer overeats. Vegetarians claim that they live longer and are healthier, physically and morally, than flesh-caters, and it is true that they may be healthier, physically, if they have been subject previously to ailments due to an excess of nitrogenous food or overeating generally. The diet is more suited to those engaged in hard physical work, for they sweat freely and get rid of the excess of water in the diet, and they require much carbohydrate food to provide for muscular energy. A sedentary person on a vegetarian diet is liable to develop a distended, flatulent abdomen, watery blood, and diarrhea from the excessive peristalsis set up, while the excess of waste products puts extra work on the organs of excretion. 524 SPECIAL DIETS Tibbies (3) does not agree with the assertion that vegetarianism leads to mildness of temper or to gentleness of disposition. He points out that the buffalo, the rhinoceros and the Chinese pirate, all vegetarians, are equally remarkable for their cunning and ferocity. It is universally known that the carnivora are more active, more alert and more powerful than the herbivora, while the meat-eating races of man are physically supe- rior to those who subsist entirely on a vegetable diet. He also calls atten- tion to the superior physique of the American or European soldier over that of the Japanese or Chinese. Again, the races of mankind who subsist on a mixed dietary are more progressive and more alert than the vege- table-eating races. We learned when studying Protein and Nutrition that the Japanese as a race have made wonderful progress since the adoption of a larger protein ration and especially since eating animal food. This same statement applies equally to the Chinese, Siamese and Burmese. Vegetable Diet and Energy. The principal influence of a vegetarian diet on metabolism is a lessening of many of the vital forces. According to Tibbies, "The influence of vegetarian diet is to slow down many of the vital processes, to make the person, if anything, less energetic, or of a quieter disposition only in proportion as all his functions become some- what more languid. That animal food is proper for children is suggested by the fact that milk is the natural food of infants and young children. It may be admitted that less animal food than the amount usually con- sumed is quite sufficient, and it is probable that two-thirds of the amount of protein required might be derived from vegetable sources." Hueppe is the authority for the statement that "man was originally a mixed feeder, but evolved into a flesh-eater, and lastly into a vegetarian; but vegetarianism only became possible after the introduction of fire and dis- covery of the art of cooking. Man has neither the teeth nor the gut of a vegetarian animal, or he would naturally graze in the fields in the sum- mer, and in winter eats oats from a manger." As a source of energy, there can be no possible advantage in adhering to a vegetable dietary, but on the other hand, there is a decided disad- vantage owing to the vegetarian diet being more difficult of digestion. The amount of energy expended in the performance of bodily functions and the amount expended under various conditions and circumstances has been fully discussed in a previous chapter. It has already been stated that the required energy can be obtained from a purely vegetarian diet provided the amount consumed is sufficient, but a strict vegetarian diet does not appear to give the amount of strength obtained from a mixed diet. This view is generally held and is well expressed by Tibbies (3) : VEGETABLE DIET 525 No vegetarian animal can lift the weight of his own body, not even the horse, ox, camel, or elephant. On the other hand, the carnivorous lion, gripping a calf his own weight, can jump a hurdle six feet high. The lifting power of man, the mixed feeder, exceeds that of any other mammal. It is recorded of Louis Cyr that he lifted 2,672 pounds; of Little, that he carried 1,560 pounds for fifteen steps; of a Tyrolese, that in six hours he carried a load weighing 262 pounds up an ascent 5,000 feet high. A laborer weighing 165 pounds, working around the New York docks, will many times a day carry a sack weighing 220 pounds. A negro helper on the freight trains in the South will carry a 500-pound bale of cotton and think nothing of such a feat. The street porters of Salonica and Constantinople, who feed on pillaf of rice and figs, with a little meat, are noted for their proverbial strength. It is not at all unusual to see one of them carrying a grand piano about the streets on his back. Hence the saying, "As strong as a Turk." Vegetable Diet and Health Vegetarian faddists claim that a strict vegetable diet is more healthful than a mixed diet, also declare that it tends to health and longevity, but statistics show that the vegetarian is just as liable to disease, and possibly more so, through his food than the flesh eater. Vegetarians also claim that meat causes diseases of the liver, gout, stone, gravel, chronic rheumatism, skin diseases, disturbances of the vascular system, arteriosclerosis, and other similar diseases; that pto- maine poisoning may follow the ingestion of animal food; that the animal whose flesh is consumed may have been the subject of anthrax, glanders, foot-and-mouth disease, or some of the various other maladies communi- cable to man. They also assert that oysters and other shellfish are a causative factor in outbreaks of typhoid fever. Many instances, however, can be cited to show that a vegetable diet may also be the means of dis- seminating diseases. Bread and other starchy foods from the vegetable kingdom taken in excess lead to indigestion, flatulence, acidity, congestion of the liver, and hemorrhoids, and tend to obesity, while overmilled rice is the cause of that scourge of the East known as beriberi, or kakke. While sugar possesses enormous value as a provider of energy, if ingested in excess it will produce evils similar to those following an excefts of starchy foods, especially catarrh of the stomach. Again, the ingestion of hard fruit, nuts and fibrous vegetables may be a contributing cause to digestive difficulties. Animal foods are by no means the only source through which disease may be transmitted. Practitioners in the tropics invariably give this advice, "Eat no uncooked vegetable, nor any raw fruit, unless you can pare it or peel it." Outbreaks of typhoid fever, dysentery, cholera, diarrhea and various other diseases have often spread from disregard of this warning, and the consumption of imported raw, 526 SPECIAL DIETS unripe or over-ripe fruit is frequently a cause of tropical diseases in tem- perate countries. Nor is it safe to eat any variety of fruit purchased from the fruit stands of our northern cities, without peeling, as the fruit vender often has the industrious habit of polishing his apples with a rag on which he frequently spits. Again many diseases are communicated from the ingestion of green vegetables, more especially that class of diseases pro- duced by animal parasites. Hydatid disease, one of the most terrible of this type, is caused by the Tsenia echinococcus, a small tapeworm which is taken into the body in the form of ova or partially developed Tsenia on green vegetables, such as watercress, celery, lettuce, etc. Actinomycosis also enters the organism with green vegetables and cereals, while ergotism is a disease common among consumers of rye bread. Pellagra and beri- beri are deficiency diseases due to vegetable foods, which will be consid- ered elsewhere in this work. 1 Tibbies coincides with Hueppe's opinion that the supposed health- giving properties of a strictly vegetarian diet are questionable. "The vege- tarians of our time," Hueppe avers, "belong to the class of neurotic men who, failing to meet the strain of town life, ever seek for a 'heal-all' in one or another crank. Their doctrines, pushed with fanatic zeal, make no impression on the healthy, and only tend to overthrow the balance of others, who, like themselves, are the victims of unnatural modes of exist- ence." Waylen(7), himself a believer in this cult, and one who had inti- mate acquaintance with many vegetarians, in writing on this subject says that for eight years he was a vegetarian, wore sandals and went without a hat; but it gradually dawned upon him that man is somewhat different from the beasts; that if a monkey can do something, it does not follow that a man should do likewise. He says : "Vegetarians as a rule are not healthy folks. They present either a wizened and emaciated appearance or a tendency to flabbiness. They have a poor circulation, and are liable to chills. They suffer from dyspepsia, flatulence, bad breath and anemia. Their liver and kidneys are commonly affected, and altogether there is a wanj of vitality among them. They burden their stomachs with masses of crude stuff, and practically deprive themselves of fat and oil; and while they daily grow thin and nervous, they think they are improving in health." Waylen in summing up this question says that when the human body is starving, it begins to feed upon itself, and vegetarians may be charged with being guilty of a species of cannibalism. We have already shown in "Feeding in Health," 2 what the influence 1 Volume TIT, Chapter XVII. 2 Chapter X, this volume. VEGETABLE DIET 527 of flesh food is on the character of animals, and this we will supplement by the opinions of two celebrated men who were keen observers of them- selves : Porphyre(2), a philosopher who gave up the Pythagorean doctrine to eat meat, in writing to his friend Firmus, says : It is not amongst the eaters of simple and vegetable foods, but amongst the eaters of flesh, that assassins, tyrants and thieves are met with. I cannot believe that your change of diet is due to reasons of health, for you yourself have con- stantly affirmed that vegetable diet is much more suitable than any other, not only to give perfect health, but even a philosophic and balanced judgment, as a long experience had taught you. And Seneca, who, preoccupied with the same considerations, had slowly adopted vegetarianism, writes : Struck by such arguments, I also have given up the use of the flesh of ani- mals, and at the end of a year my new habits have become not only easy to me, but delicious; and it even seems to me that my intellectual aptitudes have been more and more developed. We learned when studying foods from the vegetable kingdom that green vegetables and fresh fruit are absolutely necessary to the well-being of mankind, but particularly for the inhabitants of the cities and towns. Scurvy, which once was a scourge, is now rarely seen, due largely to the fact that all people realize the necessity for adding fresh vegetables and fruits to the dietary. As previously stated, fresh vegetables, potatoes and fruit contain certain salts which are absolutely essential to the proper constitution of the blood and other fluids of the body. "Tf these salts are withheld from the dietary," according to Tibbies, "the blood becomes im- poverished, and scurvy results" (3). The necessity for vegetables and fruit in the diet, therefore, cannot be denied, but, at the same time, we must insist that an exclusive vegetable diet is inconsistent with the ability of man to live upon all kinds of food ; that vegetable foods alone entail a laiger amount of work on the digestive organs; and that they do not fur- nish sufficient stimulating 'energy for our present mode of civilization. It is an admitted fact that some people feel better on a vegetarian diet than one containing meat. Plethoric individuals often complain of physical hebetude and want of energy after a heavy dinner of hot meat with the usual accompaniments, but are free from these symptoms after partaking of a vegetarian meal. We have shown in a previous chapter that the wealthy classes, who have the opportunity and can afford the luxury, dine too often and partake too freely of meat and game, and as a consequence they are troubled with disorders little known among vegetarians. How- 528 SPECIAL DIETS ever, a vegetarian diet, as a rule, is not more healthy than a mixed dietary, nor does it give an assurance of a longer life. Moreover, insurance statis- tics place less value on the life of a vegetarian than on the life of the aver- age American or European who subsists on a mixed ration. According to' Tibbies, there are large numbers of people who live on a more or less vege- tarian diet. "The peasantry of Ireland subsist upon a dietary consisting largely of potatoes with a little milk, eggs and pork, occasionally replacing potatoes by oatmeal. This dietary is also that of the poorer classes in Scotland. The lower classes of Germany and Russia live largely upon rye bread, potatoes and fat. The Italians subsist upon cornmeal, chest- nuts and acorn meal. In India and China the poor live largely on rice, millet and vegetables, with more or less pulse and other legumes." Wait (9), of the United States Department of Agriculture, reports an investigation of the dietary consumed by a subject under a two weeks' observation. A small amount of meat was added, as a seasoning to the peas, the digestibility of which was the main object of the research. WAIT'S VEGETARIAN AND FAT DIETARY RATION Total Food for Four Days CONTENTS OF FOOD: GRAMS Energy, Calories Protein Fat Carbo- hydrates Ash Bread Grams 1,170 2,600 130 78 910 130 1,100 112 81 2 4 11 219 11 138 116 71 7 16 679 132 "l83 130 684 11 18 4 2 7 39 3,600 2,182 1,048 670 817 515 4,299 Milk Butter Pork Bananas Sugar Peas .... Total 429 107 78 67 359 90 97 94 1,808 452 94 85 81 20 64 49 13,131 3,283 88 75 Daily average Proportion digested: total food per cent Proportion digested: peas, per cent Vegetable versus Animal Protein. In studying the subject of protein and nutrition(l), we found that the protein of vegetables is not so readily digested, absorbed and assimilated as the proteins from animal food. During the process of digestion a much larger proportion of nitrogenous compounds escapes the influence of the digestive ferments and hormones, principally due to the difference in the solubility of the connective tissue VEGETABLE DIET 529 enveloping the animal cells and the cellulose surrounding the vegetable cells. It is easily understood, therefore, that, in order to secure from a purely vegetarian dietary the amount of protein usually considered neces- sary for the organism, a great deal more labor is demanded on the part of the digestive organs than is required in the digestion of animal pro- tein from an ordinary mixed diet. We have previously pointed out the fact that it is more economical to secure protein from legumes than from meat, milk or eggs, and for this reason, the use of legumes should be en- couraged where the diet is deficient owing to a limited income. The question whether vegetable protein has the same physiological value when absorbed as animal protein is a debatable one. Vegetarians claim that vegetable proteins are specifically different in their action from animal proteins. They go so far as to make the statement that they have a different effect on the body, and also on the character and morale. Our present knowledge of the demolition of the protein molecule is such as to lead us to question that any specific difference exists. Moreover, we do not think the point a good one for vegetarians to raise, for it is barely possible that animal protein requires a less complete deamination than vegetable protein prior to assimilation. We all know that the protein molecule is composed of twenty or more amino-acids and that the proteins of animal foods have been constructed out of vegetable proteins eaten by an animal. Physiologists tell us that the same kind or the same proportion of amino-acids is not contained in all proteins, the principal difference being one of percentage or proportion. We believe the consensus of opin- ion at the present time is that it matters little whether the amino-acids are obtained from the animal or vegetable foods, that whatever their source they have practically the same value. At best, a vegetable diet furnishes a low protein alimentation, and this deficiency is one of its greatest disadvantages, especially among the poorer classes, in the case of growing children, who are so much in need of a bountiful supply of protein to build up their tissues. As we have previ- ously recorded, it is possible to maintain the nitrogen balance in equilib- rium when the amount of protein actually absorbed is around 56, 58 or GO grams daily. An adult can maintain this equilibrium on a low protein diet, but this cannot be done in the case of a child. Physiologists who have given this siibject great attention claim that a low average of protein in the food is one of the chief causes of the high mortality among the chil- dren of the poor(10). It has been stated by competent authority that "the protein of vegetables is not as valuable from a nutritive standpoint as the protein from animal foods." But protein is protein, whatever be its ori- 530 SPECIAL DIETS gin; albumin or globulin is of the same nutritive value whether it be obtained from animal or vegetable foods. It has been well said by Tib- bies, however, that we cannot get away from the practical fact that meat gives a greater degree of energy than peas or beans. Vegetarians may deny this, but it is founded on general experience that a man has a more buoyant feeling when living on an ordinary mixed diet than when living on a strict vegetarian diet. It has been authoritatively stated that most vegetarians are neurotics. They do not possess the energy, activity and endurance of an ordinary individual. Tibbies explains this as fol- lows^) : Given an equal amount of protein from the two sources, they have an equal value so far as anybody can tell. The proteins in animal foods are albumins and globulins; those in vegetables belong chiefly to the class of globulins. There are nucleo-proteins in both animal and vegetable foods. The non-protein nitrogen of animal foods consists chiefly of the extractives, creatin, creatinin, xanthin, hypoxanthin, carnin, urea and uric acid; that of vegetables is chiefly in the form of amides and amino-acids leucin, tyrosin, asparagin, etc. Herein lies the chief difference in the properties of animal and vegetable protein foods. The extractives of animal foods are more stimulating than those of vegetable foods. It is not con- tended that they give greater bodily strength. Energy is not to be confounded with muscular strength; energy is the property of the nerves, strength of the muscles. Physical work is done by the muscles, but it is initiated and controlled by the nervous system. The extractives of meat are valuable nerve stimulants. Leucin, tyrosin, and other amino-acids of a like character are not stimulants, and, unless they are utilized by the cells of the intestinal mucosa in the construction of proteins, they pass on to the liver, where they are broken down into urea, uric acid, and ammonia. If they are too abundant to be broken down by the liver, they affect the organism adversely and give rise to some of the symptoms of intestinal toxemia. The last argument has been applied with equal force to the extractives and purin bodies in meat. But the display of energy by the carnivora is very much greater than that exhibited in general by the herbivora, and this is accounted for not only by the greater consumption of protein, but by the different character of the associated non-protein nitrogen compounds. The question has been asked, "Has the character of the protein any influence upon the development of organs and the performance of their functions?" This subject was alluded to when studying the section on Protein and Nutrition(l). The great importance of protein in the ali- mentation cannot be too strongly emphasized. In a previous chapter, we stated that during the period of growth and development of the body an abundance of protein was necessary. It is generally acceded to by physi- ologists that a low protein diet is unsuitable for growing children and young adults. Notwithstanding this fact, there are many thousands of VEGETABLE DIET 531 growing children in the East Side districts of New York, for instance, who subsist oil a diet very low in protein. The question before us is, however, "Does the kind of protein influence this period of growth ?" Tibbies points out that the consumption of meat in England at the present time is seventeen times greater per person per annum than it was in 1850. During the intervening period he declares there has been a very marked decline in the birth rate. He also records that this decline is most marked in the classes of society who have an unrestricted allowance of the more expensive proteins of meat, game, fish and fowl. In our own country, and especially in New York City, the most fertile families are the poorest classes in the East Side tenements, whose consumption of animal protein is restricted for economic reasons and naturally whose proteins are chiefly derived from the vegetable kingdom. It has been pointed out by some authorities that the increasing consumption of animal foods affects the development of the organs of generation, "acts prejudiciously upon repro- duction and lactation, and is thereby an important factor in the causation of the declining birth rate and diminishing power of lactation." This opinion, it is claimed, has been confirmed by experiments on animals(3). Tibbies, in discussing this subject, says: The fecundity of the poor and comparative sterility of the rich in highly civilized communities is a matter of common knowledge, but to claim that one condition is due to a vegetarian or low protein diet and the other to animal pro- teins or a high protein diet, is at present beyond our power of conception. There is in fact very good evidence that a flesh diet does not diminish fecundity when the consumers live a normal life. The Eskimo women are not sterile, and the Indian women who subsist largely on a flesh diet are fertile. The Boer women eat meat at every meal, new vegetables and potatoes being seldom seen on their tables; nevertheless they are most prolific and feed their children at Nature's fountain. Summary. By way of conclusion, we will summarize the main points in this section in favor of and against vegetarianism. (a) Foods from the vegetable kingdom are rich in carbohydrates and poor in protein and fat. They are bulky from their richness in starch, from the presence of cellulose, and from the large amount of water, (ft) The foods from the animal kingdom are rich in protein and fat, and, with the exception of milk, poor in carbohydrates. They occupy little bulk in the raw state, and. even less after cooking, (c) Foods from the vegetable kingdom are less easily digested and on the whole less completely absorbed than foods from the animal kingdom ; owing to their bulkiness and the indigestible cellulose which invests their nutritive constituents 532 SPECIAL DIETS they are prone to fermentation in the alimentary canal, with the produc- tion of acids which tends to augment peristalsis. The protein constituents of vegetable foods are more difficult of absorption than protein from ani- mal food, (d) A strictly vegetarian diet is apt to be deficient in protein, due to its imperfect absorption, so the question of vegetarianism becomes a question whether it is advisable to live on a low protein diet or not. (e) The strict vegetarian, who subsists entirely upon foods grown in the sunlight, must either live upon a diet relatively poor in protein or else consume an excessively large amount of food. (/) Statistics seem to em- phasize the point that a strict vegetarian aliment tends to diminish energy, both mental and physical, as well as the power of resisting disease, and if a vegetarian attempts to consume sufficient food to yield the required amount of protein, the bulkiness of the diet is apt sooner or later to lead to derangement of the stomach and bowels. (#) Both of these results may be overcome by supplementing the vegetable part of the diet with animal substance rich in protein, but a large part of the necessary protein can be safely taken from the vegetable kingdom, (h) Milk and milk products, eggs, fish and meat may be used as protein carriers, but for per- sons in a normal condition of health the moderate use of meat and fish is advantageous. For the individual of a gouty diathesis, possibly milk and cheese are preferable, while skimmed milk or buttermilk and the cheaper kinds of cheese will be found more economical, (i) From an economical standpoint, there is no doubt that it will pay to patronize the green grocer instead of the butcher in purchasing the necessary food elements for subsistence. Vegetable foods can be purchased to better ad- vantage both as sources of building material and energy than animal foods, so that vegetarianism may be recommended on the grounds of financial economy. (/) It is a fact that vegetable foods are less highly flavored and less appetizing than some of the animal foods, but they have the ad- vantage of not being liable to undergo putrefaction and of rarely produc- ?'ng disease. MEAT DIET An exclusive alimentation from the flesh of animals is sometimes ac- cepted through necessity. There are certain individuals who think that meat forms the most nourishing and most fortifying food. In fact, some men who are obliged to live a very fatiguing life, as the northern trappers and hunters, and the inhabitants of excessively cold climates, such as the fishermen living on the banks of the frozen seas, can subsist almost en- tirely upon enormous quantities of meat or fish without suffering any MEAT DIET 633 untoward effects. Two conditions are, however, essential : The meat must be ingested with its fat, and the individuals partaking of such a diet must lead a very active life in the open air. There is no evidence to lead us to believe that the primitive peoples of antiquity were vegetarians, for the adaptability of the human body to the use of animal foods, as well as our earliest historical records, disproves this; while some of the most savage peoples of the present time subsist almost exclusively on fish and game. Darwin records that the gauchos of the American pampas can sustain themselves for whole months on the fat meat of the oxen over which they watch. The Eskimos can devour five to six pounds of reindeer meat per day and almost twice that amount of the fat and flesh of the seal, concerning which we have already made mention. This diet of animal food becomes unbearable if the meat is all lean. Gautier has made some experiments on dogs with a lean meat diet. A dog weighing 40 pounds required 1,500 grams of lean meat as the necessary requirement to keep its weight constant, whereas 400 grams of meat, 200 grams of fat or 100 grams of meat, 100 grams of milk and 300 grams of bread were amply sufficient to obtain the same result. The findings from this experiment hold good in the case of man. In order to secure the 280 grams of carbon necessary for the repair of his organs and the discharge of his functions, 1,600 grams of lean meat would be essen- tial for the average man. This quantity would introduce as pure waste four times more protein than could be metabolized. Such enormous quanti- ties of meat from the point of view of hygiene and economy could only lead to unfavorable conditions ; besides, no one could for any length of time consume such enormous quantities of meat without suffering from symp- toms of auto-intestinal intoxication. A mixed alimentation composed of a rather larger percentage of meat than the standard requirement permits of furnishing the system, in the least bulk, with the greatest amount of the most nitrogenous, stimulating and useful food principles. However, it would be erroneous to conclude that an alimentation en- riched in meat to the point of being exclusively carnivorous would in- crease the physical power of the subject. Although a dietary taken ex- clusively from the animal kingdom raises the nitrogenous coefficient in comparison with a mixed or vegetable alimentation, a meat diet acidifies the blood and hinders oxidation. It overburdens the organs of excretion with a superabundance of nitrogenous waste, urea, uric acid, etc. ; it con- gests the liver; it causes obstinate constipation; it brings on dyspepsia, gastric disturbances and enteritis; it induces intestinal putrefaction and intestinal stasis ; it brings about rheumatic, arthritic, gouty and nervous 134 534 SPECIAL DIETS tendencies. A dietary not exclusively meat but only too rich in meat could not be borne for long. According to Huchard, such a diet would produce arterial hypertension and heart fatigue, and sooner or later be- come an active predisposing cause of arteriosclerosis. Houssaye has shown that in the case of fowls, an exclusive meat diet produces sterility and causes an arrest of development with an excessive proportion of males. In view of the foregoing facts, then, an exclusive diet of flesh, or even a mixed diet wherein meat is liberally ingested, is not looked upon favor- ably from any point of view. A dietary composed too largely of meat tends to make individuals more aggressive, more headstrong, and the in- telligence less keen. The well-to-do classes are too carnivorous. Accord- ing to Herbert Spencer(ll), there is a marked contrast between the chil- dren of families where the diet is largely animalized and those where the ciiet is largely potatoes and bread. From both points of view, that of physical and that of intellectual vivacity, the peasant's' child is far inferior to that of the gentleman. From the point of view of physical health and strength in actual life, Spencer's dictum does not appear to hold good; as to the intellectual vivacity of the child in the well-to-do classes of so- ciety, it is far more influenced by heredity the selection of progenitors and by educational advantages. An exclusive meat diet has long been used in the dietetic treatment of tuberculosis, on the assumption that the association of gout with high living is largely due to the free ingestion of animal food ; that a gouty condition can be artificially brought about through a dietary consisting largely of flesh foods ; and, as is held by some, that there is an antagonism between a gouty diathesis and a tuberculous tendency. The main object, therefore, of an exclusive carnivorous diet is to induce that condition which is believed to be antagonistic to the growth of Bacillus tuberculosis or its toxins(l). When a meat diet is ordered, the meat must be freed from bone, gristle and connective tissue, and only slightly cooked. It must be taken in quantities sufficient to yield energy or fuel value to sup- ply the heat expended by the body 2,000, 2,700 calories or more, depend- ing upon the condition of the patient. An exclusive diet of flesh of ani- mals, fowls and fish is also recommended for obesity setting up a species of starvation, and for dyspeptic ailments, because of its simplicity and freedom from carbohydrate fermentation. It is necessary for a patient on a meat diet to consume from two to two and a half pounds of the edible portion of average beef or mutton to supply the body with the requisite amount of nutriment to meet the de- mands of the organism. One pound of beef or mutton freed from bone, MEAT DIET 535 gristle and connective tissue equals 453 grams. Rubner conducted a series of experiments with an exclusive carnivorous diet upon healthy medical students. The alimentation consisted of from 738 to 884 grams of the edible portion of beef. It was prepared with a little butter, onion, salt and pepper. The beverage prescribed was water or aerated water. After being cooked, specimens of the food were analyzed to determine the percentage of protein and fat. The students' digestion was normal in every particular, the feces containing only 1.2 grams of nitrogen or about 7 grams of protein. The nitrogen balance was maintained in a state of equilibrium with a slight gain in weight. Solntzer conducted experiments with beef and mutton, and Atwater experimented with both beef and fish. The results of some of these ex- periments recording the nitrogen equilibrium are graphically set forth in the following table from Tibbles(3) : METABOLISM WITH MEAT DIET NITROGEN FOOD PER DIEM Days Au- thority Grams Grams Grams Gain or in Food in Urine in Feces Loss Beef, 884 grams 3 3 48.8 39.8 47.2 37.6 1.2 1.1 0.4 \ 1.1 / Rubner 738 " 715 " 1 31.9 25.6 4.6 1.71 Mutton, 1,671 grams 1 90.9 58.5 5.0 27.4 1,336 " 1 56.4 50.5 3.9 2.0 [ Solntzer Canned beef, 895 grams. . . . 1 43.9 27.8 7.5 8.6 " mutton, 1643 grams . 1 75.2 65.3 8.6 1.3 J Beef 1,200, butter 30. wine 367, beer 1,250 grams.. . . 3 38.5 37.2 1.0 0.31 Fish 1,549, butter 50, wine Atwater 700, beer 1,250 grams.. . . 3 45.6 44.1 0.9 0.6 J The value of an exclusive meat diet in the treatment of tuberculosis, obesity, dyspepsia, and gout has already been pointed out, and will be further elaborated upon when these different ailments are discussed. It also has been recommended in chronic dyspepsia, especially in a condition of atony and in dilatation of the stomach, and its value is unquestioned in hyperchlorhydria. The fact must not be lost sight of, however, that sufficient nutriment must be consumed to meet the demand of the body, which will require from two to three pounds of the edible portion daily. The quantity of moat should never lie less than six ounces of thoroughly minced meat, slightly cooked, ingested at least three times per day, the intervals being from 4 1 /L> to 5 hours. 536 SPECIAL DIETS Salisbury Diet. The Salisbury diet (12) is a typical meat diet con- sisting of from 2 to 4 pounds of beef and 3 to 5 pints of hot water daily for from 4 to 12 weeks. It has been recommended as a means of treating certain diseases of the skin, as psoriasis (13), which have resisted the usual forms of medication. It is also recommended by Dr. Salisbury for the dietetic treatment of gout, obesity, chronic intestinal derangements, and disorders of nutrition which are attributed to abnormal carbohydrate fermentation. The treat- ment aims at the thorough cleansing of the stomach before eating, by giv- ing a pint of hot water an hour and a half before each meal and at bed- time. If the water is drunk slowly, the patient will not experience any sense of discomfort nor will the stomach become distended. The slightly nauseating taste of plain hot water may be overcome by the addition of ginger, lemon juice or weak tea, and in cases where intense thirst is pres- ent, the addition of a little nitrate of potash makes the water a more effi- cient thirst quencher. If constipation is present, a teaspoonful of mag- nesium sulphate may be added to the water. The urine should be exam- ined frequently to obtain the specific gravity, and the amount of water should be regulated accordingly. If the specific gravity falls below 1.010, the patient may become asthenic and the amount of water may be con- siderably reduced. The specific gravity of the urine should be kept be- tween 1.012 and 1.015. Caultey(14) gives the following directions for the preparation of the Salisbury diet: "The meat is chopped up quite fine with an American chopper, and all gristle, bone, fat and visible connective tissue are re- moved. It is made into patties, sufficiently firm to hold together, three to stand near it until of a drab color. Salisbury recommends that they in a frying pan, without fat or water, and rapidly heated, first on one side and then on the other. On removal from the fire they are allowed to stand near it until of a drab color. Salisbury recommends that they should be broiled slowly and moderately well. Butter, pepper, salt, Worcestershire sauce, mustard, horseradish, celery salt and lemon juice may be added as condiments. Advocates of this diet have recommended three pounds of rump steak and one of codfish, with six pints of hot water daily, for two weeks. For the next three weeks the hot water is reduced to four pints, and other kinds of meat are allowed, with a little green vege- table and unsweetened rusks. During the next four weeks the hot water is further reduced to two pints ; hock and claret with seltzer are permitted, as are grilled meat, poultry or game, crusts of stale bread and captains' biscuits. The meat must not be raw and must be quite fresh. MEAT DIET 537 "The hot water should be given in doses of one-half to one pint, four or more times a day, say at (> and 11 A.M., and 4 and P.M., one or two hours before meals and half an hour before retiring. It should be of a tempera- ture of 110 F. to 150 F. and should be sipped slowly in one-fourth to one-half hour." There are obvious objections to this diet. It is absolutely unphysio- logical, being a starvation diet in respect of fat and carbohydrates. The quantity is much too large for most people. It throws a great strain on the organs which have to do with the metabolism of protein, as well as on the organs of excretion. It is essential to be sure that the kidneys are sound before adopting this treatment. Oysters are a welcome addition to the monotony of a meat diet and may be prepared as follows (15) : Panned Oysters: Take 6 deep-sea oysters, place them in a colander, and pour cold water over them. Drain for ten minutes. Place the oysters in a very hot iron pan, add salt, pepper, a small piece of butter, and a teaspoonful of meat stock. Cook for a few minutes, and serve the oysters garnished with a thin slice of lemon. Broiled Oysters: Take 6 large oysters. Lay them on a board and dry, then season with salt and cayenne pepper. Have a gridiron thoroughly heated, place the oysters on the gridiron and brown them on both sides. Place the oysters on a very warm plate, and pour round them a little heated beef juice and a little melted butter. Watson(15) considers the Salisbury diet seldom necessary or advis- able, but he recommends a modified Salisbury dietary as of great value in some cases of indigestion and chronic auto-intoxication associated with it. His modification of the Salisbury diet given below, while rather low in nitrogenous material, is amply sufficient for the short period of time in which the diet is necessary. Its use exerts a profound improvement in the state of intestinal excretions and a corresponding improvement in the digestion as a whole. MODIFIED SALISBURY DIET 7 A.M. : ^2 pint or more hot water. Breakfast, 8.30 A.M. : 4 to 6 oz. meat rissoles; 2 Kalari biscuits with a little butter; small cup of very weak tea. Forenoon Lunch, 11.30 A.M.: J/2 pint or more of hot water, flavored with lemon if desired. 538 SPECIAL DIETS Dinner, 1 P.M.: Breakfastcupful of beef tea with }/ Ib. scraped meat: thin slice of baked bread or dinner toast; half a dozen oysters as above; consomme" with custard or consomme* with egg, with baked bread or toast. SP.M.: ^ pint or more of hot water. Afternoon Lunch, 4 P.M. : Breakfastcup of skimmed milk, to which is added a full tablespoonful of Carnine Lefranc or other meat juice; or plain egg flip flavored with cinnamon in place of sugar; unsweetened rusk or crisp biscuits. 6 P.M.: }/?, pint hot water. Supper, 7.30 P.M. : 4 to 6 oz. meat rissoles or mince, followed by an egg jelly hi which the sugar is reduced in amount; or a blanc mange made with milk hi place of cream. The above alimentation should be maintained for ten days to a fort- night, after which additions in the form of steamed fish, chicken, green vegetables, malted breads, jellies and fruit may be allowed. The return to ordinary carbohydrate foods must be made gradually. Zymotherapy Zymotherapy is the name given to the treatment of disease by the administration of muscle juice or raw meat. This method of treatment is in contradistinction to the meat or Salisbury diet just de- scribed, which includes the entire edible portion of the meat. The raw meat diet is an ancient remedy ; in recent times it was first recommended for phthisis, empyema and pyogenic infections by Fuster of Montpellier, in 1865. Richet and Hericourt(16), in a series of experiments carried out in 1889 on tuberculous dogs, determined the value of raw meat and subsequently showed that the benefit was derived from the muscle juice and not from the muscle fiber deprived of its juice by expression. They reported that this method of feeding is not a matter of hyperalimentation, for only 50 to 100 c.c. of the muscle juice is suggested as the daily dosage which was sufficient to cure the dogs, whereas hyperalimentation with the washed muscle fibers exerted no beneficial effects. The juice contained 2M> per cent of protein. "Its administration produces an increase of vigor and muscular power, the proportion of hemoglobin is increased, blood pressure is raised, digestion is improved, weight is increased, and the physical signs of phthisis pulmonalis or tuberculosis are abated." If we accept the theory that tuberculosis is due to an infection in early life through tuberculous cow's milk, it is reasonable then to assume that undercooked or raw meat should enter largely into the diet of young chil- dren. Meat juice and raw meat are prescribed in anemia, dyspepsia, neu- MEAT DIET 539 rasthenia, debility, convalescence from typhoid fever, and after hemor- rhage. llericourt, following the publication of his initial observations (17) on the value of raw meat juice in tuberculous dogs, recently published another paper on the subject, from which we quote the following: "It is probably no exaggeration to say that the raw meat treatment in pulmonary phthisis yields results not approached by any other means at present available." Eichet coincides with his associate's observations, and to- gether they undertook researches to determine which constituent in the muscular tissue possesses antagonism to the progress of tuberculosis. After much experimentation they came to the conclusion that the solid constituents of the flesh had no therapeutic action ; "tuberculized animals fed on flesh from which the muscle plasma had been expressed, died in approximately the same lapse of time as the control animals who were fed with ordinary food. The deduction drawn from the above experiment is that the agent of raw meat which produces this effect is contained in the muscle plasma, i.e., the meat juice." The muscle or meat juice must be prepared from perfectly fresh meat, soon after the animal dies and before rigor mortis has set in ; the muscle that has undergone rigor mortis loses its glycogen and contains lactic acid and more or less toxic products of decomposition. Hence the juice should be prepared as soon after death as possible. If meat or muscle juice is prepared from commercial or cold storage meat, it is less beneficial, more toxic and possibly infective. The animal whose muscle is to be used should neither be overworked nor underfed before death. According to Caultey(14) : "The meat must be finely minced, wrapped in stout linen, put in a sieve, and subjected to slow pressure. Small house- hold presses will yield about 20 and larger presses 30 to 60 per cent of juice. If one-fourth the weight of sterilized water is added and the meat allowed to stand for an hour or two before compression, more fluid is ob- tained, but the bulk and the increased decomposition are disadvantages. Presses, mincer and linen should be well boiled or washed in boiling water before use. In hot weather the juice should be collected in a vessel sur- rounded by ice. Even in winter the juice should be taken at once, because of its liability to decomposition. As it is repulsive to the patient, it should be given in a colored glass or with warm beef tea. Intestinal disorders are due to neglect of some detail in the technique, generally to the impos- sibility of getting the meat sufficiently fresh, and unless great care is exer- cised, it is liable to set up alimentary, hepatic or renal troubles. "The dose should be 9 to 15 ounces daily, with or between meals, in 540 SPECIAL DIETS water, aerated water, or tepid beef tea, with or without salt or sugar. Three to six ounces is sufficient for early cases. If raw meat is given, as much as a pound a day can be ordered, but few patients can take more than one-fourth to one-half pound. Raw meat and muscle juice can be combined in the dietary. No cooked meat should be allowed. "Possibly the muscle juice contains a substance which is antagonistic to the tubercle bacillus and its toxin, for muscle fibers are not invaded by the organism, and during the course of the disease they waste, perhaps being sacrificed in the defense of the body. More probably the good eifects depend on the nutritive value of the fluid as a stimulant of the nervous system or of thyroid activity." According to Galeotti and Lindermann, raw meat and milk stimulate thyroid activity and they also are of the opinion that the decomposition products of raw meat increase the colloid material of the thyroid. It is known that defective thyroid activity and predisposition to tuberculous affections are apt to follow rapid growth at puberty, infectious diseases, prolonged lactation, sexual excess and alcoholism, in all of which the thy- roid secretion is liable to be used up and the gland to atrophy from over- stimulation. It is believed that human milk contains some of the internal secretion of the thyroid gland, for iodin can reach the infant through the breast milk. Infantile myxedema is rarely observed until after weaning, and moreover the infant's thyroid gland contains little colloid material. Caultey, in summing up the advantages of zymotherapy, says: "Im- provement in a tuberculous patient fed on raw meat and muscle juice is noticed, (a) by increased muscular power, (6) by the increased hemoglobin, (c) by rise of blood pressure, and (d) by better diges- tion and improvement in the physical signs. In the very young the prognosis varies according to the loss or gain in weight, especially during the first month. The treatment should be continued for a varying period depending upon the extent of the disease and the improvement following its administration. It may be resumed at intervals depending on the condition of health. FRUIT DIET The fruitarian diet is an aliment composed exclusively of fruits and nuts. Of late years many experiments in metabolism have shown that it is possible for individuals to maintain a nitrogen equilibrium on such a diet. M. E. Jaffa 1 has thoroughly investigated the fruitarians in Cali- Professor of Nutrition, Univ. of California. Bui. 132, U. S. Dept. of Agric. FKUIT DIET 541 fornia. His reports are interesting and valuable, and from them we have drawn largely in preparing this section. It is not questioned that an alimentation composed of fruits and nuts is pleasant and agreeable. At the same time, it is, at best, only a low pro- tein diet, rarely containing more than 50 to 60 grams of protein. It is unnecessary to refer to the arguments for and against a low protein dietary, as this subject has already been fully considered. Chittenden and other physiologists have found 50 to 60 grams of protein in the daily food sufficient for physiological needs, and many people have maintained their health and vigor for years on a fruit and nut or other low protein aliment, yet they seldom look rugged or robust. The fruit and nut diet, like the more common vegetarian diet, must be considered of questionable value and unlikely to become popular as a regular method of feeding, with peo- ple who have an inborn taste and desire for animal foods. We have already shown that, as compared with the so-called standard dietaries, the vegetarian and fruitarian are lamentably poor in protein and fat, and in some instances deficient in caloric value. See also the fol- lowing tables abstracted from the excellent study of Fruitarianism by Professor Jaffa (8). Below are appended the records (taken from Voit and Alba) of three subjects who subsisted on fruits, as recorded by Tibbies: Man, twenty-eight years old; height, 5 feet 5 inches; weight, 125 pounds. His daily diet consisted of: rye bread (pumpernickel), 131 grams (4V 2 ounces); graham bread, 438 grams (nearly 1 pound) ; apples, 777 grams (I 3 /! pounds) ; dried figs, 114 grams (4 pounds) ; dried dates, 247 grams (8 ounces) ; oranges, 66 grams (2 ounces); olive oil, 21 grams ( 3 /4 ounce). It contained: protein, 54 grams; fat, 22 grams; carbohydrates, 573 grams; and had a heat value of 2,775 calories. (Voit's observation.) Min, forty-eight years old; height, 5 feet 8 inches; weight, 153 pounds. He consumed daily: potatoes, 1,000 grams (2 1 /! pounds); hazel nuts, 166 grams (6 ounces) ; peanuts, 12.5 grams (V 2 ounce) ; plums, 83 grams (3 ounces) ; sugar, 71 grams (2V 2 ounces) ; raisins, 93 grams (3V 2 ounces) ; apples, 354 grams (% pound); oranges, 63 grams (2V 2 ounces); olive oil, 50 grams (1% ounces). It contained : protein, 63 grams ; fat, 66 grams ; carbohydrates, 593 grams ; and had a fuel value of 3,302 calories. (Alba's observation.) The following example of a moderate vegetarian diet is outlined by Jaffa. His subject was a man, aged sixty-four years, height 5 feet 8 inches, weight 136 pounds; he had been a vegetarian for eleven years. The total food consumed by him during a period of twenty-four days was as follows: 542 SPECIAL DIETS JAFFA'S VEGETARIAN DIETARY Cereals : Carried forward 8,790 grams Granose 2,155 grams Fresh fruit: Gluten flour 454 " Apples 5585 " Flaked rice 1,673 " Bananas 2,722 " Honey 1,985 " Grapes 3,317 Vegetables: Raspberries 397 " Baked beans 1,021 Nuts: Dried fruits: Almonds 907 Dates 425 " Brazil nuts 1 361 " Figs. . 28 " Pine-nuts 198 " Prunes 794 " Walnuts 907 " Raisins 255 " Total 24 184 grams 8,790 grams These items furnished an average weight of 21,4 pounds of food daily at a cost of IS 1 /^ cents, containing: protein, 53.5 grams; fat, 76.9 grams; sugar and starch, 301.8 grams; crude fiber, 10 grams. The fuel value was 2,043 calories. The man was healthy and well, and lived on a dietary containing 50 to 60 grams of protein, or about half the amount commonly accepted as being necessary for a man having a sedentary occupation. It is unquestioned that a fruit diet in certain diseased conditions is a valuable trophotherapeutic measure. The subject of Professor Jaffa's investigation was a healthy, vigorous university student, aged twenty-two, well set up, and prominent in athletic sports. For the first week he ate his ordinary mixed food; the next nine days he con- sumed a diet in which fruit replaced a large proportion of the meat, eggs, fish, milk and cereals; finally he consumed for eight days a diet consisting entirely of fruit and nuts. An examination of the urine and feces of other consumers showed that in many instances, although the diet was of a low protein character, the amount of protein digested and absorbed from the food was enough to maintain the nitrogen balance in equilibrium during the experiment. When the amount consumed daily consisted of 5 1 /2 pounds of grapes, 6 ounces of walnuts, and a little granose, there was an actual gain of 1.29 grams of nitrogen, equal to 8 grams of protein. In another instance the average daily consumption consisted of 4^4 pounds of apples, 8 ounces of dried figs, and 4% ounces of walnuts, which also resulted in a gain of 1.28 grams of nitrogen, or 8 grams of protein. With a diet averaging 3 l /% pounds of apples, 9J ounces of dates, 6 ounces of peanuts, a little granose, milk, olive oil, and tomato, the gain of nitrogen was 2.26 grams, equal to 14.13 grams of protein. With 5^2 pounds of pears, 7 ounces of walnuts, a little granose and milk, there was a gain of 4.25 grams of nitrogen, equivalent to 26.5 grams of protein; and with a diet averaging 16 ounces of walnuts, 18^2 ounces of dried prunes, and 18 ounces of oranges, there was a gain of 3.42 grams of nitrogen, or 21.38 grams of protein. FRUIT DIET 543 The experiments in feeding with bananas did not give such good results. Bananas, dates, and walnuts resulted in a loss of 1.82 grams of nitrogen, or 11.38 grams of protein; bananas, oranges and walnuts gave a deficiency of 1.89 grains of nitrogen, or 11.8 grams of protein. The consumption of 5 pounds of bananas a day resulted in a loss of 1.34 grams of nitrogen, or 8.38 grams of protein; 4 pounds of bananas and 4 1 > ounces of almonds daily gave a deficiency of 0.86 grams of nitrogen, or 5.38 grams of protein; 2 1 > pounds of bananas, 21 ounces of oranges and 5 ounces of pecan nuts gave a deficiency of 1.69 grams of nitro- gen, or 10.56 grams of protein. A diet of 22 ounces of dates, 2% ounces of almonds and 12 ounces of olives gave a deficiency of 2.06 grams of nitrogen, or 12.88 grams of protein. A diet of pears and cocoanut gave a loss of 1.57 grams of nitrogen and 8.8 grams of protein. The deficiency is not great in any of these cases, but the continued daily loss of 1 or 2 grams of nitrogen by the body is deleterious and must ultimately result in ill health. It is possible, as we have seen, to prevent such a loss by means of a carefully regulated diet; but it is difficult for the non-scientific subject to adjust his diet so carefully to the needs of the body. In this respect, therefore, we are bound to state that very few fruitarian diets contain enough protein to maintain the nitrogen balance in equi- librium, and still fewer contain the amount of protein required by the standards set up by numerous authorities. The amount of fat in the food is also almost always below the standard required, and only reaches the standard when the food contains a large proportion of nuts, olives or olive oil. The nutriment in fruit consists chiefly of carbohydrates, the digestibility of which compares very favor- ably with the carbohydrates in a mixed diet. Respecting the heat value of the food, the following table shows that the amount of energy yielded by the food is greater in proportion to the amount of fat ; it is low with bananas, but better when bananas and nuts are consumed together; it is also low with apples, pears or grapes as a diet, but is considerably improved by the consumption of half a pound of brazil nuts, pecans or walnuts. A diet of apples, figs and walnuts, or of pears, figs and walnuts, is capable of supplying enough protein, fat and carbo- hydrate for the use of the body, and sufficient energy for a man doing moderate work. Carefully recorded studies of persons subsisting upon fruits and nuts are scarce; therefore, the observations of Jaffa(18) are of special interest. The instructive table on page 544 contains a summary of the food elements contained in the dietary which each individual, described by Jaffa, ate. The first six of these people lived on apples, dates, figs, peaches, apri- cots, bananas, grapes, oranges, pears, plums, raisins, olives, almonds, pig- nolia, pine nuts, brazil nuts, walnuts, sometimes tomatoes, celery and honey. The individuals comprising the subjects for Jaffa's studies were all vigorous and healthy people. The six-year-old girl had subsisted <>n a fruit diet since infancy. She was undersized, but this may have been from in- heritance. During the ten days that she was under observation she gained 544 Age in Years Weight in Pounds Protein: Grams Fat: Grams Carbo- hydrate : Grams Crude Fiber: Grams Calories Woman 33 90 33 59 110 40 1,300 Woman 30 104 25 57- 72 27 1,040 Girl 13 75.5 26 52 111 46 1,235 Boy.. 9 43 27 56 102 50 1,255 Girl 6 30.5 24 58 97 37 1,190 Girl 7 34 40 72 126 8 1,385 Man 63 124 40.3 53.7 286.3 24.6 1,713 Woman 64 136 53.5 76.9 301.8 10 2,043 Boy.. 10 58 48.4 67.7 246.7 13.4 1729 Girl 8 37 32.3 81.7 155 10.7 1,403 Woman 34 93.5 42.5 81.1 156.8 9.8 1,432 Man 22 170 85 158.7 366.3 2,936 Man 25 152 68 103 550.1 64.7 3,305 Man 48 153 63 98 401 2,493 Man 28 125 54 22 573 2,775 Man 64 136 54 77 312 2,004 a pound, and her brother, aged nine, gained a pound in a period of twenty- two days. The thoroughness of digestion and absorption was comparable with that of an adult on a mixed diet, 80 per cent of the fibrous cellulose being completely digested. The fourth study of this table was a boy aged nine, who first subsisted on bananas, oranges and pecan nuts. This same boy was studied a few months later, and during the observation he sub- sisted on pears and walnuts, granose and milk. Some of the other persons in this study ate cereals to a limited extent. The twelfth individual sub- sisted on grapes, brazil nuts, tomatoes, granose and olive oil. He was not accustomed to a fruitarian diet, but tried it at the time of the experi- ment. A striking feature of these fruitarian dietaries is the small amount of protein and the low caloric value of the diets. However, they approach very closely to whajj Chittenden has shown is all that is needed to maintain health and strength. Fruit Diet in Disease. The value of a fruit diet is especially marked when employed as a temporary measure in those instances of illness or poor health in which the protein intake must be diminished, particularly when the necessity arises for cutting down the purin bodies to the lowest possible point. When the ordinary diet is confined to fruits and nuts, the latter should be ground in a mill, mastication should be thorough, only a moderate quantity of food should be allowed, and the daily meals should FRUIT DIET 545 not exceed three. The best subjects for the "fruit cure" are those who habitually overindulge in food and drink,- and whose systems become choked with the "clinkers" of imperfectly oxidized food. Symptoms com- monly complained of in this condition are a foul tasting mouth after the night's sleep, early morning headache and lassitude. This cure is often useful in intestinal fermentation and putrefaction; in albuminuria, gout, obesity, hemicrania, and other disturbances common to individuals and families originally accustomed to plain and wholesome country living. The attempt of an organism with such a background to adapt itself to the modern demands of city life, often results in disaster to the bodily mech- anism. The "fruit cure" in such instances is often beneficial. The low protein intake allows an increased alkalinity of the blood and decreased acidity of the urine; in addition, its action is laxative and diuretic, and the liver cells are stimulated to greater activity, and hinders intestinal fermentation. In the dietetic treatment of acute nephritis, fruits, such as oranges, raisins, pears, etc., will augment the carbohydrates of the milk. This mixed treatment of milk and fruits diminishes the albuminuria, encourages diuresis, and drives away edema. If a pa- tient has lost weight, raisins or raisin juice, added to a diet rich in fat and albumin, will help to regain the loss. If, on the other hand, it is thought wise to decrease the patient's weight, increase the raisins and decrease the fats and albuminoids, other fruits and vegetables being par- taken of at the same time. The fruit diet is useful when occasionally it is thought wise to institute a fast day, when the only food should consist of apples, grapes, pears, bananas, or some other variety of fruit. In some sections, "apple-fasts" have been very popular with many persons, especially society matrons who have become "fair, fat and forty" and are anxious to reduce their weight. They are also recommended in gouty diathesis, chronic rheumatism and chronic disturbances of the liver, Bright's disease, and in the condition of high blood pressure pre- ceding the development of arteriosclerosis, and in intestinal fermentations and putrefaction, etc. "Fasts" on apples alone do not -agree with all pa- tients, and there are some individuals who believe they cannot abstain from their ordinary dietary for a period of twenty-four hours, even though they may consume large quantities of fruit. The partaking of fruit in acute febrile conditions is a very ancient practice. Fruits such as grapes, strawberries, oranges, bananas and baked apples may be taken with impunity in many febrile affections. When studying the various fruits we learned that the fruit juices nro of consid- erable dietetic value in the treatment of diseases. The trophotherapeutic 546 SPECIAL DIETS action of fruit juices increases the secretion of urine and its alkalinity, and stimulates the kidneys and indirectly the skin; at the same time these juices act as thirst quenchers. The juices of grapes, oranges, pine- apples, currants, gooseberries, raspberries and strawberries are freely used for this purpose. The juice of the lemon is one of the commonest articles in the sick room in the form of lemonade. The many recipes for its use in the sick room will be found elsewhere in this volume. 1 The juice of the orange is also as useful in illness as it is palatable in health. Various recipes for using orange juice will also be found in the reference just cited. LEMON CURE. The "lemon cure" is a very ancient practice in the treatment of obesity and the gouty diathesis and is highly recommended when combined with thermotherapy. The usual method is to take the expressed juice of three fresh lemons in sweetened water three times a day with the exclusion of milk and fatty foods. Preserved lemon juice is not as effective as that of the fresh fruit. It is questionable, however,, if there is any scientific basis for the consumption of lemon juice as an anti-fat. The manufacturer of quack remedies for obesity uses a large percentage of citric acid in his remedies which are practically worthless. The effect of lemon juice upon the food seems to exert an inhibitory power over steapsin and amylopsin, which retards the digestion of fat and carbo- hydrates. GRAPE CURE. Ampelotherapy, or "grape cure," is probably the best known of the fruit cures. It is usually carried out in southern Europe at places like Meran and Montreux, but is available wherever grapes can be obtained. The grape cure depends largely for its good effects on change of diet and manner of life, the climate and surroundings, and the aperient action of the grapes. When aided by a simple supporting aliment, it is a suitable dietary for the overworked, the weak and the convalescent. It is recommended in conjunction with the spare diet limited particularly as to hydrocarbons and carbohydrates, in cases of abdominal plethora, chronic bronchitis and emphysema, chronic constipation, and chronic gastro-intestinal catarrh. Its use is also valuable in the dietetic treatment of obesity. When the grape cure is taken in Germany, from one to eight pounds of grapes are eaten daily and little or no other food allowed. Those who take the cure are expected to pick the grapes for themselves, which insures exercise in the open air. This method is particularly adapted to the obese and to those who lead a sedentary life. The treat- ment ordinarily consists in taking one pound or more of grapes three Volume II> Chapter XVII, page 579. TUFNELL AND BELLINGHAM DIETS 547 times daily from half to one hour before meals, the meals consisting of light, easily digested foodstuffs, for example, fish, chicken, milk puddings, stewed fruit, toasts or rusks, and green vegetables, avoiding all rich made dishes, rich sauces, pickles, potatoes, lentils, pastry, cheese and sweets. The duration of the course is from four to six weeks. The chief effect of this alimentation is a laxative one, which renders it suitable in hepatic ailments, chronic constipation and hemorrhoids. For the analysis of grapes, see Volume I, Chapter XIX, page 752. Caultey(14) recommends the following mode of treatment: "Begin with half a pound of grapes when fasting, an hour or two after a light breakfast, and again at 5 P.M. In three days give a third half-pound at noon, or after the midday meal if there is dyspepsia. Gradually increase the dose to one pound at a time. The aperient effects are manifest in a few days. It is rarely advisable to give more than two pounds in lung cases ; three pounds in gastric and intestinal catarrh, the diet being care- fully regulated at the same time ; and four pounds in other conditions ; but the amount may be increased to five to six pounds for abdominal plethora, hepatic constipation and chronic constipation. Figs and prunes can be added to relieve the monotony of the diet. The course of treat- ment lasts for six weeks. Small quantities of white bread may be eaten after the grapes to remove acids from the teeth, and if the gums become irritated, the mouth should be rinsed out with bicarbonate of soda solu- tion." TUFNELL AND BELLINGHAM DIETS Tufnell's diet for the treatment of aortic and other aneurisms is a modification of the methods formerly employed by Albertini and Val- salva(19) in cases which could not be treated surgically. The plan of treatment was to "detain the patient in bed for forty days, and during this period to subject him to repeated bleedings, while at the same time the diet and drink were carefully ordered, so that the daily allowance ad- ministered in three or four meals should never be such as to fill up the blood vessels. The practice formerly was to diminish the quantity of meat and drink gradually every day, until it was cut down to about half a pound of pudding in the morning and in the evening half that quantity and nothing else except water, and this also within a certain measure. After having sufficiently reduced the patient by this method so that by reason of weakness he could scarcely raise his head from the bed in which he lay, the quantity of aliment was increased again by degrees until the necessary strength returned sufficiently to allow him to rise in bed." 548 SPECIAL DIETS Bellingham in 1852 omitted the blood-letting and devised a method which was continued by Tufnell, who in 1875 published a monograph on the subject, the principal aim being the reduction of the force and fre- quency of the heart's action and to favor the deposition of fibrin on the wall of the aneurismal sac. The treatment is very debilitating and "only suitable for cases of saccular aneurism unassociated with disease of the aortic valve, and for patients who are sufficiently intelligent to understand the importance of carrying it out strictly and who have sufficient will power to put up with its discomforts." Bellingham's dietary is very much the same as Tufnell's, both of which are given below. They are modifications of the methods adopted by Albertini and Valsalva, who treated their patients by bloodletting, rest and modified diet. BELLINGHAM TUFNELL Breakfast Milk or tea 2 oz. Milk or cocoa 2 oz. Bread 2 oz. Bread and butter 2 oz. Dinner Liquid 2-4 oz. Water or light claret 4 oz. Bread 1-2 oz. Bread or potato. 3 oz. Meat 1-2 oz. Boiled or broiled meat 3 oz. Supper Liquid 2 oz. Milk or tea 2 oz. Solid 2 oz. Bread and butter 2 oz. Tufnell's diet contains eight ounces of fluid and ten ounces of solids. It is true that this dietary, or one quite similar, though not so severe, has often modified pain or caused it to disappear entirely, while the aneurism has become smaller and pulsated less ; but many patients refer to the cure as worse than the disease. The method of treatment as outlined by Caul- tey(14) directs that the "patient should rest on a water bed and remain absolutely still, doing nothing whatever for himself, a restriction which few people have the strength of will to adhere to. The mouth may be- come so dry and parched that even the limited amount of solids cannot be taken. Sucking a pebble or button will relieve the thirst a little. An- other great trial to the patient is painful micturition, because of the ex- treme acidity of the urine. It can be reduced by alkalies. Constipation must be relieved by oil enemata if necessary. There is so little waste matter in the food that an action of the bowels once a week is sufficient. The heart and aneurism must be carefully watched. If the pulse becomes more and more frequent, the patient restless, and the dryness of the mouth so great that he is unable to take food, the treatment must be modified." Such a restricted diet is no longer believed bv able clinicians to be WEIR MITCHELL DIET 549 essential to good treatment, while an abstemious, nutritious diet is. This starvation treatment is only advisable in well-nourished subjects, espe- cially those with a plethoric temperament. It is, on the other hand, al- together unsuitable in weak or debilitated subjects. In the latter class there is more often than not an enfeebled digestion and it may be advis- able in the beginning to resort to a milk or lacto-vegetarian dietary. Rest in bed or in mild cases gentle exercise should be insisted upon. To-day the iodids are almost universally relied upon. In recent years the sub- cutaneous or intravenous injection of gelatin has been used with some success. Of course, the gelatin should be sterilized and the strictest care taken to prevent sepsis. The important points to keep in mind in prescribing a dietary in all cases are, according to Watson (15), the following: (a) Restriction in the amount of fluids of all kinds. Not more than from 20 to 30 ounces in the twenty-four hours. (6) Meats and meat foods to be given in very sparing amount, the stimulating effects of these foods on the circulation being prejudicial. (c) A light, simple, nutritious diet, given thrice daily, with no food between meals. The meals should be much on the lines of the diet laid down on page 548. (d) Alcohol in all its forms is inadvisable, excepting in cases of feeble diges- tion, where its use in small doses may prove beneficial. WEIR MITCHELL DIET The Weir Mitchell diet(20) is recommended by the author for the dietetic treatment of neurasthenia and disorders of malnutrition independ- ent of organic disease. The principal points in carrying out this method of treatment are isolation, massage and forced feeding. The isolation from friends, callers and the family exerts a beneficial and moral effect. Massage and electricity aid in promoting digestion and the nutrition of the muscles. A good nurse is essential. She must be kind, bright, sen- sible, and able to make a favorable impression on the patient. The patient should be kept in bed for at least six weeks, leaving it only to go to the toilet. Mitchell recommends that the milk diet should be instituted gradually, especially if the patient has an aversion for milk. It should be given in doses of one or two ounces every two hours and gradually increased until as much as two quarts are drunk in the twenty- four hours. In some cases Mitchell recommends that the milk should be given even at night as often as every three or four hours. At the end of the tenth day an egg or chop should be eaten at noon in addition to the usual allowance of milk. Often earlier than this Mitchell proscribes 135 550 SPECIAL DIETS meat juice once or twice a day. A day or two later bread and butter are given and an egg or some meat at breakfast as well as at dinner. By degrees the patient is placed upon a diet of three simple but generous meals' daily, and in addition, three or four pints of milk are consumed, the latter being administered partly with the meals and partly between meals. The following is a synopsis of the management of an individual case of Weir Mitchell's and is appended to illustrate the practical application of his rest cure : WEIR MITCHELL'S DIETARY Mrs. C., kept in bed, fed by an attendant, rise only to relieve bladder and rectum. First Day: One quart of milk in divided doses every three hours. Second Day: Cup of coffee on awakening. Two quarts of milk in divided doses every two hours. Aloetic pill at night. Third to Sixth Day: Same diet. Seventh, Eighth, and Ninth Days: Same diet, with a pint of raw soup in three portions. This is made by chopping up one pound of raw beef and placing it in a bottle with a pint of water and five drops of strong hydrochloric acid. The mixture stands in ice all night; in the morning the bottle is put into a pan of water at 110 F., and kept two hours at about that temperature. This mixture is then thrown into a stout cloth and strained until the mass that remains is nearly dry. If the raw taste proves very objectionable, the beef to be used is first quickly broiled on one side and then the process is completed in the manner previously described. Tenth Day: 7 A.M., Coffee; 7.30 A.M., 10 A.M., 12 M., 2, 4, 6, 8, 10 P.M., Half a pint of milk; 11 A.M., 5 and 9 P.M., Soup. Fourteenth Day: Eggs, and bread and butter added. Sixteenth Day: Dinner added and iron. Nineteenth Day: The entire diet was as follows: 7 A.M., Coffee; Breakfast, 8 A.M., Iron and malt extract, chop, bread and butter, a tumbler and a half of milk; Lunch, 11 A.M., Soup; Dinner, 2 P.M., Anything liked, with six ounces of Burgundy or dry champagne, and at the end one or two tumblers of milk. Iron and malt; Tea, 4 P.M., Soup; Supper, 7 P.M., Malt, iron, bread and butter, usually some fruit, and two glasses of milk; Late Supper, 9 P.M., Soup; 10 P.M., Aloetic pill. At 12 noon, massage for an hour. At 4.30P.M., electricity applied for an hour. Sixth Week: Soup and wine were dropped, iron lessened one-half; massage and elec- tricity only on alternate days; 1/30 of a grain of strychnin sulphate thrice a day at meals given (continued for several months). Ninth Week: Milk reduced to a quart. All mechanical treatment ceased. RESULT: Gain in flesh about face in second week. Weight rose in two months from 96 to 136 pounds; gain in color equally marked. On thirtieth day patient had normal catamenial flow after five years of failure to menstruate. Ninth week, drove out. Cure complete and permanent. WHIR MITCHELL 1)1 KT 551 By the end of the sixtli week of this treatment, the patient may be returned to a full diet and in addition take at least from 00 to 80 ounces of milk per day. FULL NEURASTHENIA DIETARY (Weir Mitchell) Early Breakfast, 7 A.M. : 10 ounces of milk. Breakfast, 8.30A.M.: Plate of porridge or gruel, or hominy; or bowl of bread and milk with a gill of cream; fish, bacon, eggs, or kidney; cocoa or coffee; bread or rolls; butter or marmalade. Lunch, 9 A.M.: 10 ounces of milk. Second Lunch, 11 A.M.: Cup of beef tea with 2 teaspoonfuls of beef peptonoids. Dinner, 1 .30 P.M. : Fish, tripe, sweetbread, cutlets, game or poultry, served with one .vegetable, with a sweet such as stewed fruit; 10 ounces of milk to be sipped slowly during this meal. Afternoon Lunch, 4 P.M. : 10 ounces of milk with sponge cake; bread and butter, or rusk. Supper, 6.30 P.M. : A three-course meal. Soup or fish; joint or poultry; sweet or savory, or dessert; taking with meal 10 ounces of milk. Late Supper, 8.30 P.M. : Beef tea and 2 teaspoonfuls of peptonoids. 10 P.M. : 10 ounces of milk. Occasionally a physician is called upon to attend a stout patient with llabby muscles presenting the usual symptoms of neurasthenia. In the successful handling of this type of patients, a mild starvation is a neces- sary preliminary for a few days prior to beginning the Weir Mitchell treatment. This method of treatment is recommended by Playfair as fol- lows : Confine patient strictly to bed; diet with skimmed milk, at first two quarts per diem, given in small quantities every two hours; after a day or two lessen this gradually till not more than a pint per diem is taken. If the patient's strength fail unduly under this, some beef tea or soup may be temporarily substituted for the milk. Under the minimum diet the weight gradually loses about ^2 pound per diem (the patient should be weighed every second day), and when some 1-1 to 20 pounds have, been taken off, pure milk may be substituted for skimmed, and the treatment as detailed above pursued. 552 SPECIAL DIETS TRAINING DIET The training diet is a question which has been agitated during recent years by the leaders in field athletics at the greater schools and universities both of this country and Europe (21). Of late, a great deal has been written pertaining to the diet best adapted for athletes, both amateur and professional, when training for a contest, in order to have them physically fit for feats of ^endurance. The necessity of this training is fully recog- nized by all athletes, and while opinions may differ as to the methods, there is more or less accord in the ideal that is sought. The object of training is to put a man in condition to execute a large amount of work, and sometimes skilled work, in a very short period of time, which is quite a different problem from feeding a laborer or artisan. The latter re- quires an alimentation which will enable him to do a large amount of work daily, continuing over a long period of time. The usual training diet has been based on a liberal allowance of meat, on the assumption that the wear and tear of muscular tissue is great and that meat is the greatest source of strength and less fattening than other foods. The great nervous and muscular energy of carnivorous animals is often quoted to substantiate this assumption. We know that the race horse is the fastest animal for a reasonable distance, but certain species of the carnivora can maintain a short burst of speed which will exceed that of the race horse. It is not questioned that a liberal supply of animal food is suitable for a short distance runner, but it certainly is not a suit- able diet for prolonged exertion, as may be seen in the case of the Japan- ese, who on a vegetable diet are able to run continuously for hours at a time and drag a jinrikisha occupied by a passenger. The general principles of training are: (a) the reduction of weight by the removal of superfluous fat; (6) the improvement of the tone of the muscles and heart, inducing long "wind" and endurance. During the period of preparation for an athletic test, muscles must be made to grow and the waste caused by trial tests of strength be repaired. Proteins are necessary for cell growth and repair, as well as to furnish nervous energy. Although carbohydrates are an economical source of a large number of calories or units of energy, so that muscular work can be performed on such a diet, nevertheless rapid and accurate muscular work, that entailing correct correlation of movements, demands much nervous energy, and for this type of work proteins are necessary. Under conditions re- quiring the ingestion of large quantities of food, a generous proportion of proteins should be furnished on account of their ease of digestion. The TKAINING DIET 553 carbohydrate intake should be carefully choseii and skillfully prepared, so that this part of the diet may also be easily digested. Professional athletes recognize the importance of keeping "fit" and being in perfect trim in order to perform feats of strength and endurance. In. a well- trained athlete the muscles are hard and firm, the fat is reduced to a minimum, the skin is clear, the eyes bright, the expression indicative of perfect health, the body is active and the "wind" good. The length of time necessary to train varies with the previous habits and mode of life of the individual. Ordinarily, the average college youth of the athletic type can be put in fit condition in six weeks, and it must be borne in mind that the transition from ordinary habits to those of train- ing should be gradual both as to the regulation of the alimentation and of exercise. Practice and experience have emphasized the advisability of a gener- ous mixed, liberal, full diet as the one calculated to put an athlete in the best trim. At the training tables of the Harvard and Yale crews such food as the following is eaten : Good lean beef or mutton, best given under- done, toast made from stale bread, and potatoes and green vegetables of all kinds. Fruits, beef, lamb, mutton, chicken, fish, bacon and eggs, and simple pudding's are allowed, but no highly seasoned food is permit- ted (22). The following articles are prohibited: entrees, rich puddings, pastries, sauces, pickles, spices, appetizers, and all fanct and complex dishes. Made dishes or dishes made from twice-cooked meats, all spirits and strong alcoholic drinks, as well as tea, coffee and nerve stimulants are prohibited. Tobacco, in all forms, is strictly forbidden. Water is allowed in liberal quantities, but if there is a tendency to obesity, the amount is somewhat limited, the quantity being gradually reduced and only suffi- cient quantity allowed to allay thirst. We have already referred to carbo- hydrates as producers of strength. In this connection it is interesting to note the experiences of the Holland oarsmen, who, according to Davis (23), "while in training began to show signs of overwork, loss of flesh, a lack of ambition and energy, and a disinclination for study and work. By eating sugar as freely as they wished, sometimes as much as one-third of a pound a day, they were refreshed and able to win the race against the antagonists who did not believe in its use." Sugar, ;i crystal- lized carbohydrate, is permitted as an adjunct to the dietary of the athlete in training, but pies, cakes and other sweets and more or less indigestible dishes, as already pointed out, should bo forbidden (24). Atwater and Bryant(25) conducted experiments on this particular question, from which we cite the following : 554 SPECIAL DIETS Two young men, with only two hours a day for practice, at the end of two months entered for the race. No change had been made from their usual diet, except that they ate as much sugar as they wished, sometimes as much as a third of a pound at the time of their daily exercise. One of them, however, did not make this addition to his diet until the third week, when he began to show all the signs of overtraining loss of weight and a heavy, dull feeling, with no desire for study. On the third day after beginning the use of sugar these symptoms disappeared. At the time of the race both youths were victorious over their antagonists, who did not. believe in the use of sugar. No bad effects were observed. An athlete in training must ingest more food and in larger amounts than a person of the same physique following an ordinary vocation, but care must be taken not to overeat and thereby derange digestion ; nor must the meals be eaten at too long intervals. The following report of the Yale crew, on the authority of Dr. Hart- well, formerly a captain of the University crew and of the University football team, is quoted from Thompson (26) : The training covered a period of ten and one-half weeks. DIETARY, YALE TRAINING CREW Breakfast, 7.30A.M.: Fruits (oranges, tamarinds, figs, and grapes): cereals with rich milk and sugar, etc.; beefsteak, usually rare; chops, stews, hash, with once or twice a week some salt meat, as bacon or ham, usually accompanied by liver; stewed, browned, or baked potatoes; eggs served in different ways: oatmeal- water and milk as beverage, with tea on special occasions for some particular individual. Dinner, 1 P.M.: Soups, meats, fish, vegetables, with a simple dessert, such as rice, bread, or tapioca pudding, some fruit, and the same beverages as at breakfast were also used. The meats included roast beef, mutton, or chicken, two kinds being always served. But little gravy was used. Fish was served twice a week. The vege- tables included potatoes, mashed or boiled; tomatoes, peas, beans, and corn. Two vegetables besides potatoes were usually served. Supper, 8 to 8.15 P.M.:' Cereals, as at breakfast; chops, stews, or cold meat from dinner; rarely beef- steak; potatoes, stewed or baked; and eggs about three times a week, usually not on the same days that they were served for breakfast. Sometimes ale was permitted to some individual. After the crews were in final preparation for the race at New London the diet varied somewhat: Breakfast and dinner remained about the same, but a light luncheon of cold meat, stewed or baked potatoes, milk and toast was served at 4.30 in the after- noon. After this the evening exercise was engaged in for about two hours. Forty- five minutes after this was completed cold oatmeal or other cereal with milk and toast was served. A light supper was served at 9.30, just before the men retired. This diet was much more liberal than that served ten years before. The men were allowed as much food as they desired. TRAINING DIET 555 The table of dietary studies incorporated herewith is taken from the extensive studies of Atwater and Bryant, giving the summary -of results of dietary studies of university boat crews, football teams, and of pro- fessional athletes, and compares them with the standard dietaries of men engaged in various occupations. DIETARY STUDIES OF UNIVERSITY BOAT CREWS NUTRIENTS ACTUALLY EATEN PER MAN PER DAY Crews Protein, grams Fat, grams Carbo- hydrates grams Calories Harvard University Crew 162 175 449 4,130 Harvard Freshman Crew 153 223 468 4,620 Yale University Crew 145 170 375 3,705 Harvard University Crew (Gales Ferry) . . Harvard Freshman Crew (Gales Ferry).. . Yale University Crew (Gales Ferry) 160 135 171 170 152 171 448 416 434 4,075 3,675 4070 Captain Harvard Freshman Crew 155 181 487 4,315 Average 155 177 440 4,085 It is interesting to note that these dietaries for the university crews are very similar to that advised for Americans during a period of hard work. They are a little fuller than the English and German standards. Football teams lead in the quantity of food ingested. Relative to the other carbonaceous foods, the proportion of protein is markedly increased. Comparing the dietary of college students in training with that of an ordinary college club, the excess of proteins in the former is very notice- able. The average diet of a training crew contains 1 .">."> grams of protein and yields 4,085 calories, making a difference in fuel energy between the two of alxmt 400 calories. The diet furnished the oarsmen at Gales Ferry yielded the oarsmen one-ninth more energy than that of the men not en- gaged in athletic work. In other terms the difference amounted to 48 grams or an increase of nearly one-half of protein. Atwater and Bryant (27) outlined the following account of the dietary of the Harvard boat crew at Cambridge : The diet was simple, and consisted of roast and broiled beef and lamb, fricasseed chicken, roast turkey and broiled fish. Eggs, ra\v, poached or boibd in the shell, were used plentifully. Large amounts of milk and cream were also consumed. Oatmeal, hominy and shredded wheat were eaten extensively, and corn cakes were served occasionally. Bread was almost always taken in the form of dry toast. Potatoes were served twice a day, either baked or boiled and mashed, with the addition of a little milk and butter; occasionally they were creamed. Boiled rice, prepared with a little cream and sugar, was served instead 556 SPECIAL DIETS 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, custard, or other pudding containing a large proportion of milk and eggs, was served. The members of the crew were allowed beer once a day. Milk was obtained from one of the large creameries supplying that vicinity, and was of unusually good quality, containing 5.8 per cent of butter fat. A very thick, heavy cream was also used, diluted about one-half with milk. This mixture, or thin cream, contained about 16 per cent of butter fat. The animal food consumed during this study was entirely from the loin of the beef. Occasionally the roasts were from the fillet, and at other times the ordinary loin roast with the bone was used. The meat was sliced in liberal por- tions, being previously practically freed from all the clear fat and tissue, and sent to the table on a large platter from which the men were served individually. The beef was cooked underdone and served rare. When the beefsteak was served, it was freed from the bone, nearly all of the visible fat being removed. Lamb chops were served with the bone. Lamb and mutton roasts were all taken from the leg, and were also clear meat, trimmed free from visible fat. The turkey used was shipped from a distance and had been in cold storage. It was baked with stuffing and dressing, although very little of the latter was served to the crew. Chicken was always prepared fricasseed and served free from bone, except the leg and wing. Fish was usually served for breakfast, bluefish and Spanish mackerel, broiled. Eggs, either raw or poached, were also allowed. No pastry was permitted, and puddings, as previously stated, were composed largely of eggs and milk-. No fresh fruit except oranges for breakfast was permitted. Stewed prunes, rhubarb, or apples were eaten most abundantly. No beverages other than water or beer were allowed. Yeo(28) gives the dietary of the English boat crews at Oxford and Cambridge. It may be interesting in this connection to compare the A DAY'S TRAINING FOR THE SUMMER RACES OXFORD 7 A.M. : Rice; a short walk or run. Breakfast, 8.30 A.M. : Underdone meat; crust of bread or dry toast; tea (as little as possi- ble). Dinner, 2 P.M. : Meat (as at breakfast); bread; no' vegetables (not strictly adhered to); 1 pint of beer. 5 or 5.30 P.M. Rowing exercise. Supper, 8.30 or 9 P.M. Cold meat or bread; sometimes jelly or water-cress; 1 pint of beer. 10 P.M.: Retire to bed, CAMBRIDGE A run of 200 yards as fast as possible. Underdone meat; dry toast; tea, 2 cups (later only IK); water-cress (occasionally). Meat (as at breakfast); bread, pota- toes, and greens; 1 pint of beer. Dessert: oranges, biscuit, or figs; 2 glasses of wine. Rowing exercise. Cold meat; bread; lettuce or water- cress; 1 pint of beer. TRAINING DIET 557 A DAY'S TRAINING FOR THE WINTER RACES OXFORD CAMBRIDGE 7.30A.M.: 7A.M.: Rice. A short walk or run. Exercise as for summer races. Breakfast, 9 A.M. : Breakfast, 8.30 A.M. : As in summer. As in summer. Luncheon, I P.M.: Bread or a sandwich and j^> pint of A little cold meat; bread and j/ pint beer. of beer, or biscuit and glass of sherry (sometimes yolk of egg hi the sherry) . 2 P.M. : Rowing exercise. Rowing exercise. Dinner, 5 P.M.: Dinner, 5 to 6 P.M.: Meat as in summer; bread; same As in summer, rule as in summer as to vegeta- bles; rice pudding or jelly; ^pint of beer. 10 P.M.: Retire to bed. Water strictly forbidden. As little liquid to be drunk as possible. English dietaries with the dietaries at Yale and Harvard. Maclaren gives the following schemes of training as carried out at Oxford and Cam- bridge : In making a resume of the results of their observations, Atwater and Bryant state that, in a "general way, the difference between the food of the athletes and that of other people represents a difference in actual phys- ical need even if neither is an accurate measure of that need." The prin- cipal difference in the food of athletes as compared with that consumed by ordinary working people or college men is that the dietary of the former, owing to the large percentage of protein, is productive of a larger amount of energy. An increase of protein is necessary, not so much to provide additional energy as to make good the wear and tear of the strain, on muscular tissue expended in the performance of strenuous exercise or laborious work, as well as in certain cases to enable the muscle to add sub- stance to its bulk. The daily excess of the athletic diet over ordinary diet is about 400 calories or 10 per cent. The amount of protein consumed in the Atwater experiments was about 45 per cent above standard dietaries. "In other words, the difference in protein was four and one-half times as great as the difference in fuel value, and the excess in protein would ac- count for a considerable part of the excess of energy of the diet of the athletes as compared with men in ordinary occupation." In the final summing up of their research and experiments, Atwater and Bryant record the following interesting observations: 558 . SPECIAL DIETS In this connection it is interesting to observe that many physiologists arc coming to entertain the view that the amount of metabolism in the body is regu- lated not simply by the muscular work, but also by the nervous effort required in the performance of this work. The especially large proportion of protein ob- served in the dietary studies of the university boat crews, of football teams, of the professional athlete and of the pugilist, as compared with the dietary studies of college men with ordinary exercise, and with ordinary families of workingmen and professional men, accords well with a view not uncommon of late among physi- ologists. According to this view, men who perform continued " muscular labor, even if it is active enough to make the total amount large, do not require espe- cially large amounts of protein in their food so long as they undergo no especial mental strain or muscular fatigue, the principal requirements being an abundant supply of easily digested food material. On the contrary, when a man or animal must perform intense muscular work for a short period of time, and is, there- fore, under more or less nervous as well as muscular strain, a considerably larger supply of protein seems to be required than under normal conditions of slow, long-continued work. In other words, if a large amount of work must be done in a short time, a considerable excess of protein is required in the food. This view, which has been especially advocated by Zuntz(29), seems to be favored by the results of dietary studies above discussed. Recent experiments made by Dunlop, Paton, Stockman and ]\Fac- adam(30) have to do with the amount of protein required when severe muscular work is performed. The results are discussed with especial ref- erence to training, and are believed to "show the importance of two points long known to athletes and others doing excessive muscular work." The one is the importance of proper training, for by it an abstraction of protein matter from tissues other than muscle can be avoided; the other is the importance of there being a sufficiency of protein in the diet to compensate for the loss which occurs. An abundance of protein in the diet of an athlete has other functions to fulfill besides this. It is required during training for building up the energy-liberating mechanism the protoplasm of muscle; and it is also required after work to repair that mechanism. The benefits of training are well known in other ways, such as preparing the heart for suddenly increased duty and limiting the after fatigue effects. The power of the body to perform the maximum of muscular work within a comparatively short time and with a minimum amount of fatigue is secured by means of training. Of course, skill in application of muscular strength is as essential as is the amount of power exerted. The skill is sought by exercise and practice. The object of regulating the diet in training is not only to furnish the material to supply the power, but also to put the machine in the best condition for developing as well as applying the power. In other words, the man is to be subjected for a short time to intense muscular strain and considerable nervous effort. This he is to bear with a maximum of result and the minimum of fatigue. For this he needs practical training, on the one hand, and proper diet, on the other. If the views above presented are correct, the diet for men from whom m-:i>rri\(; DIKTAIJY intense muscular effort is required for short periods should supply liberal amounts oi' energy and especially large amounts of protein. REDUCING DIETARY A reducing dietary may be so planned that one may dine both well iiiid wisely, omitting the fat-forming foods. Of late, the slim, sylph-like figure has become fashionable, and the physician is daily importuned with: "Doctor, what shall I do to reduce?" When a society matron be- comes "fair, fat and forty," she is desperate to reduce and will rigidly adhere to any dietary her physician will outline. Lately both men and women of the first "four hundred" have fasted and fumed, boiled in Turkish baths, and rolled the floor in various gyratory calisthenic con- tortions, strenuously fighting the tragedy of fat. We have previously pointed out that everyone, as a rule, and more especially the corpulent individual, eats too much and sleeps too much. In the majority of instances, corpulency is due directly to overeating, and the average dietary consists largely of fat-making foods, from soups to nuts. It follows then that the natural cure for corpulency is to restrict the ingestion of fat-producing foods carbohydrates and hydrocarbons. Of the former, ^lahdah advises the elimination from, the dietary of the following: bread, biscuits, crackers, and anything made from wheat, corn, rye, barley, oats, cereals and breakfast foods ; rice, macaroni, potatoes and dried legumes; pies, cakes, puddings, pastries and custards; candies, bonbons and all sweets, including ice cream and sirup-sweetened soft drinks. Of the latter class, we would advise the total abstinence from pork, ham, bacon and the fat of any meat; milk, cream, cheese, butter, olive oils and any foods seasoned with grease (Mahdah menus). At first glance, it would seem that there is little left to eat, but one may dine well and wisely from a menu made up of the following: All kinds of meat except swine flesh ; all kinds of game, including fowls : all kinds of sea food, fish, lobsters, clams and oysters; all fresh and dried fruit with the exception of grapes and bananas; all varieties of salad made from fresh vegetables and served with dressings free from olive oil; all types of meat jellies; cucumbers, celery, mushrooms, tomatoes, olives, pickles and chili and Worcestershire sauce. Of green vegetables, any of the following are permissible: Brussels sprouts, string beans, cauliflower, beets, spinach, lettuce, beet-tops and turnip-tops cooked as purees, carrots, squash, celery root, salsify, cabbage, endives, artichokes, radishes, par- snips, eggplant, onions, asparagus (Vance Thompson, Mahdah). "From the foregoing, a menu can be made up that w r ill be satisfying 560 SPECIAL DIETS and contain sufficient food value for healthful maintenance. In Mahdalr s "Eat and Grow Thin" * will be found menus especially calculated to get rid of excess fat. By following these menus religiously, it is believed that corpulent individuals, without question, lose from fifteen to thirty pounds within a period of three months. It will be noted that these menus do not provide for breakfast. This meal consists largely of fresh or stewed fruit and twice a week boiled or poached eggs may be served ; tea or coffee is allowed without cream or milk; other than this, no fiuids are to be taken with the meals. Of course, between meals sufficient water to quench thirst may be taken with impunity. DIET FOR PROFESSIONAL SINGERS AND LECTURERS Beyond question diet exerts more or less influence on the fullness and richness of the- voice. A hearty meal interferes with full, free respiration to the extent that singing is practically or even entirely impossible. The vocal cords may become congested following the ingestion of food or drink, and smoking often exerts an injurious effect upon the voice. Alcoholic drinks imbibed to excess, as well as irritating articles of food, may, and often do, impair the tone of the voice and should be .omitted. Opera singers possess peculiar and curious idiosyncrasies. Certain articles of alimentation exert a deleterious effect upon the voice of some, while the same food will have just the opposite effect on others. Ruh- rah(31), quoting Russell in "Representative Actors," delineates an inter- esting list of foods and beverages partaken of by prominent stage folk prior to appearing before the footlights. He states that "Edmund Kean, Emery and Reeve drank cold water and brandy; John Kemble took opium ; Lewis, mulled wine and oysters ; Macready was at one time accus- tomed to eat the lean of a mutton chop previous to going on the stage, but subsequently lived almost exclusively on a vegetarian diet ; Oxbury drank tea ; Henry Russell ate a boiled egg ; W. Smith drank coffee ; Braham drank bottled porter ; Miss Catley took linseed tea and Madeira ; G. F. Cook would drink anything; Henderson used gum arabic and sherry; Incledon drank Madeira ; Mrs. Jordan ate calves'-foot jelly and sherry ; C. Kean took beef tea : Mrs. Wood sang on draught porter ; Harley took nothing during a performance. Malibran, it is said, ate a lunch in his dressing-room half an hour before singing. This consisted of a cutlet and half a bottle of white wine, after which he smoked a cigarette until it was time to appear." i Volume III, Chapter XXVII, "Mahdah's Menus," '^at and Grow Thin," by Vance Thompson, pub. by E. P. Dutton, N. Y. THE DRY CUKE 561 While discussing food and drink for actors and their peculiar idio- syncrasies, we will relate the dietary habit of Mr. Edmund Kean, who, according to Smith, 1 "was in the habit of adapting the kind of meat he ate to the part he had to play, choosing pork for tyrants, beef for murderers, and lamb for lovers." This may seem a stretch of the imagination, a but it may indicate that there are subtle differences in the different kinds of meat which chemistry has not enabled us to detect, but which are yet not without influence upon the body." Ordinarily, no food should be partaken of immediately before singing or speaking, but a good meal should be ingested some three hours before, which should be somewhat lighter than usual. It is the habit of many singers and speakers to refrain from food prior to their performance or lecture, and to partake of a good full meal soon after. According to Ruh- riih, the food much used by singers is the so-called "Jenny Lind soup," which is a very bland potion, and does not impair the voice. "It is made of bouillon and sage, to w r hich are added the yolks of two eggs and half a pint of cream before serving; sugar and spices are added according to taste. Many prominent singers suck an orange, while others chew dried plums immediately preceding their performance." During the interval between performances, a singer, like any other professional person, should subsist on a well-balanced general diet, of course avoiding irritating foods. Singers who have a tendency to obesity should follow the dieting and exer- cise laid down in "Volume III, Chapter XII, for the treatment of this condition. Alcoholic liquors and strong beverages do not in any way im- prove the voice, but on the other hand may exert a deleterious effect, and should therefore be avoided. Light wines and beer in moderation may usually be taken with impunity. They are best avoided, however, as their continual use may possibly lead to the formation of a drinking habit. M:my of the best singers are of the opinion that smoking is injurious to the voice ; on the other hand, many famous male singers are habitual users of tobacco and are rarely seen without a cigar in their mouth. THE DRY CURE The dry cure consists in withholding fluid from the diet, Driving less and less each day, until the patient takes the least possible amount that will sustain life. If carried to this extreme, the thirst becomes both in- tolerable and practically unbearable, and as a result, patients strenuously rebel. It has been found from actual experiment that the minimum 1 Dr. Smith in his work on Foods. 562 SPECIAL DIETS amount of water, aside from that contained in the food, which patients can bear is about 15 ounces per diem, which should be taken during the in- tervals between meals. For the relief of the insatiable thirst in these cases, various measures are employed. It is said that shipwrecked sailors in open boats have relieved their thirst by immersing their bodies in salt water. Under ordinary conditions, however, the skin is not capable of absorbing fluid to any appreciable extent, but, on the other hand, im- mersion in water prevents evaporation from the surface of the body, which to some extent saves a loss in this direction and thereby satiates thirst. Sucking a slice of lemon or drinking water acidulated with a few drops of lemon juice or vinegar is said to allay thirst better than plain water. Barley and oatmeal waters are occasionally used as thirst quenchers. A dry diet has been extensively tried by German clinicians, especially in cases of gastric dilatation and in chronic effusion in the joints and in peritoneal cavity. Many types of disease are benefited by a temporary restriction in the daily amount of fluids consumed, but it is hardly ever justifiable to resort to the extreme degree recommended by enthusiastic devotees of the dry cure. Thompson says that patients in charge of advocates of the dry cure have developed fatal cases of scurvy, as well as cases of fever with a temperature running sometimes as high as 104 F. A temporary restriction in the quantity of fluid is of dietetic value in gastric dilatation, chronic serous effusion, flatulent dyspepsia due to ingestion of sweets, coffee and tea in too large amounts. It is also ad- visable in some cases of obesity and aneurism to withhold fluids. Con- sult the Bellingham and Tufnell Dietary, previously outlined (see page 547). The "dry diet cure," says Albu(32), "is as old as the Greeks, but was revived by Schroth in his so-called semmelkur, and has achieved some no- toriety in Europe, where several 'institutes' have been established for its practice." The alimentation consists of the consumption of five or six dry rolls in the course of a day, while liquids are entirely restricted for a period varying from five to six days. The method is so rigorously dry that many patients find it difficult to endure, saying the "cure is worse than the disease." Boiled vegetables are allowed for dinner, otherwise nothing is given but dried bread. Thirst becomes so extreme after three or four days that the patient is allowed hot wine freely as a thirst quencher, after which the quantity of fluid is again out down to two glasses a clay until the patient is again obliged to have more fluid. .Tergu- son found Schroth's diet useful in the treatment of plethora and perito- THE YOLK CURE 563 neal effusions. He observed that abstinence from fluid caused great dis- tress, so he modified the diet by giving from one-third to two-thirds of a pound of lean beef with bread and light red wine. Sweiten found the dry diet useful in the treatment of dilatation of the stomach. Albu(32) found the dry diet valuable in the dietetic treatment of renal and cardiac dropsy. The patient 011 returning to the accustomed diet must be cautioned to do so with great care, taking food only in very small portions, a very little at a time. A rapid gain in weight will be noted, which is attributed in part to the restoration of water to his tissues. Bartels observed an increase in urea which was greatest immediately after the treatment. The high temperature accompanying this method of treatment is explained by the fact that but little water is evaporated from the lungs and skin, causing the body heat to be retained. As has been suggested, the dry diet cure has in many instances been carried to the verge of starvation with extreme prostration, fever and fatal cases of scurvy, and has little or nothing to recommend it. THE YOLK CURE Egg yolks as an addition to the diet of the underfed and badly nour- ished are often of the greatest service in a variety of forms of faulty nutrition. In certain instances in which there is inability to assimilate the entire egg, the yolks are of great value. A daily portion of from ten to forty yolks may be added to the customary diet. The white of the egg consists of a solution of protein shut up in the interior of many millions of cells. The protein of the white of egg is called "egg-albumin." The yolk is a storehouse of nutriment for the young chick, and conse- quently has a very different composition from the white. 1 It contains much less water and more solids, among the latter being a large proportion of fat. The general composition of the white and yolk is contrasted in the table on page 351, to which the reader is referred. The palmitin, stearin and olein are simply fats such as we have already encountered in butter and have the same nutritive value as these. Their presence in the form of an emulsion in the yolk makes them more easily digested, which renders the yolk particularly suited to individuals whose nutrition is below par and who do not do well on ordinary diets. Stern (33) gives the following simple dietary for a patient whose nor- mal weight should be 140 pounds, but who, owing to debilitation, weighs only 110 pounds : See Analysis of Eggs, Volume T. Chapter XTT, p. 351. 564 SPECIAL DIETS DIETARY FOR DEBILITY Number of yolks Calories in the yolks Total num- ber of calories Breakfast: 250 c.c. skim milk with 4 yolks; 30 grams wheat toast 4 200 200 75 Forenoon Lunch: Cup of coffee, 2 yolks 2 100 100 Dinner: One plate of soup, 4 yolks; beef (very lean), 150 grams; 30 grams wheat toast 4 200 225 125 75 Afternoon Lunch: 25 c.c. skim milk, 30 c.c. whiskey, 3 yolks. . 3 150 370 Supper: Porridge of farina or rice, 100 grams; 1 yolk, skim milk; apple sauce, 75 grams 1 50 350 30 At Bedtime: Night cap (90 c.c. hot water, 10 c.c. whiskey, 1 yolk, teaspoonful gran- ulated sugar) 1 50 110 15 750 1660 If it should be deemed expedient to continue this dietary over any great period of time, the dishes in which the yolks of eggs are incorporated should be varied as much as possible. The great richness of yolk of egg in fat and lime salts and in organic compounds of phosphorus and iron make it peculiarly valuable as an adjunct to the dietary of infants and young children, especially those which are suffering from rickets, mal- nutrition, athrepsia, etc., for it is these very compounds which the child needs, especially the rickety child. MILK CURES Kumiss Cure. Kumiss is an agreeable milk preparation readily digested and easily absorbed. It has been made for many hundreds of years by tribes of nomadic Tartars in eastern Europe from mare's milk. A substitute for it made from cow's milk is called . STOCKMAN and MACADAM. Jour. Phys., 1897, vol. xxii, p. 69. .'51. FRIKDKNWALD and RUHRAH. Diet in Health and Disease. :'>:'.. ALBU. Dentsch. med. Woehenschr., 1907. 33. STERN. Med. Rec., Dec. 31, 1904. '54. STRANGE. (On Kumiss Cures). Zeimssen's Hand Book of Gen- eral Therapeutics. 35. TIBBLES, WILLIAM. Brit. Med. J., Sept. 6, 1902. 30. MITCHELL, WEIR. Treatment, Philadelphia. 37. THOMPSON, W. OILMAN. Practical Dietetics, pub. by D. Appleton & Co. CHAPTER XVII PREPARATION OF SPECIAL BEVERAGES AND FOODS WITH Directions for Their Preparation General Considerations; Beverages; Peptonized and Predigested Foods; Beef Teas; Meat Juices; Broths; Bouillon; Vegetable Soups; Meat Soups; Farinaceous Foods; Bread; Cereal Foods; Gruels; Eggs; Fish; Poultry; Meats; Vegetables; Purees; Fruits; Nuts; Jellies; Custards; Puddings; Ice Cream; Recipes for Diabetic Foods. GENERAL CONSIDERATIONS In the chapter on the Hygiene of Eating, the necessity for making foods as palatable and as attractive as possible was emphasized. The appetizing preparation of food for the sick is just as important as the careful compounding of a prescription containing medication. Convales- cent patients, as well as patients ill with gastric disturbances, can easily be nauseated by the repugnant appearance of a dish, while, on the other hand, the appetite may be stimulated by food of an inviting attractive appearance. The tray on which it is served should be covered with pure white linen without a crease or wrinkle, the best that the home of the patient can afford. The silver should be spotless ; the china, the daintiest, and the glassware, the clearest; all arranged neatly and conveniently. This arrangement of the tray is of the utmost importance, and the slightest departure from regularity and immaculate cleanliness should be avoided. Foods should never be served too hot, lest the patient be tempted to partake of it in that condition in spite of the physician's or nurse's warn- ing. On the other hand, it should not be served too cold. For this reason it is advisable to serve such dishes as are liable to cool off rapidly in ves- 577 578 PREPARATION OF SPECIAL BEVERAGES AND FOODS sels of a double bottom, the interspace being filled with hot water. Condi- ments have no place in the dietary of the invalid or convalescent. Spices, however, may be used with caution, but only with permission of the physician. A tray with food should always be carried into the sick-room covered with a clean napkin or tray cover.- When the dietary ordered is 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. A patient suffering with bowel disorder should never be offered food until some time has elapsed after using the bed-pan. Needless to state, the diet of a patient should be under the supervision of the physician and his direc- tions followed implicitly, for much unnecessary suffering and even death has followed the ingestion of forbidden food. BEVERAGES PLAIN BEVERAGES Lime Water Place a handful of fresh unslaked lime in an earthen jar containing hot water ; stir, pour off, and throw away the water as soon as it has settled. This first water contains the soluble potash salts which may be present in the lime. Add more water; allow it to settle, then de- cant the clear fluid and bottle it. Water may again be added to the lime, and the mixture covered and allowed to stand to be decanted as needed. Apple Water. Water (boiling) 1 cupful 250 c.c. Apples 2 mashed baked 150 gm 144 calories Pour the boiling water over the apples ; cool, strain and sweeten. Serve with shaved ice if desired. Tamarind Water Boiling water 1 cupful 250 c.c. Preserved tamarinds 1 tablespoonful 20 grams 100 calorics Pour the boiling water over the preserved tamarinds ; allow this to stand until cool, then strain and serve with shaved ice. Currant Juice (Fitch). Currant juice 1 ounce 30 c.c 25 calorics or Currant jelly 1 tablespoonful 35 grams 113 " Boiling water 1 cupful 250 c.c. Over the currant jelly pour the boiling water (use cold water with the juice) and sweeten to taste. BEVERAGES 579 lemonade No. 1 (Thompson). Lemon juice 3 tablespoonfuls 45 c.c. Sugar 3 " 30 grams 123 calories Cold water 1 cupful (6 ounces) 250 c.c. To the juice of the lemon add the sugar and the cold water. Serve with cracked or shaved ice if desired. Lemonade No. 2 (Pavy). Rind of lemon 1 3 grams. Boiling water 1 pint 480 c.c. Sugar 1 ounce 30 grams 114 calories Pare the rind from the lemon, cut the lemon into slices, and place both in a pitcher with the sugar. Over this pour the boiling water and let it stand until cool. Strain arid serve with cracked ice. Effervescent Lemonade. This may be made by using a carbonated water or by adding half a teaspoonful of bicarbonate of soda or potash to a glassful of either of the foregoing lemonades. Albuminized Lemonade (Watson). Water 1 cupful 250 c.c. Lemon juice 2 teaspoonfuls 30 " Sugar 2 " 20 grams 82 calories Egg 1 white 32 30 " Shake all the above ingredients together. Serve at once. Orangeade (Ruhrah). Rind of orange 1 3 grams. Boiling water 1 cupful 250 c.c. Juice of orange 1 45 " 60 calories Sugar 1 tablespoonful 20 grams 82 " Cut the rind from the orange ; over this pour the boiling water, then add the juice of the orange and* the sugar; cool, strain and serve with shaved ice if desired. If this is too sweet, a teaspoonful of lemon juice may be added. Imperial Drink (Gautier). Cream of tartar 1 teaspoonful 4 grams. Boiling water 1 pint 480 c.c. Juice of lemon % 15 " Add the cream of tartar to the water. Into this squeeze the juice of half a lemon, or more if desired, sweeten to taste and serve cold. This drink is most useful in fevers and in nephritis. 580 PREPARATION OF SPECIAL BEVERAGES AND FOODS Barley Water (Caultey )(!). Thin: Put a teaspoonful of prepared or pearl barley, previously washed in cold water, into a jug; pour half a pint of boiling water on it, and add a pinch of salt. Stand it by the fire for an hour, stirring occa- sionally, and then strain through fine muslin. Similar thin cereal decoc- tions may be made from rice, arrowroot or oatmeal. Thick: Put a heaping tablespoonful of washed, prepared or pearl bar- ley into a clean saucepan, and add a quart of water and a pinch of salt. Boil slowly until it has evaporated down to about two-thirds of a quart, and strain. It may be flavored as desired. The addition of a little lemon peel, while boiling, is best. The composition of barley water is 0.09 per cent protein, 0.05 per cent fat, 1.6 per cent carbohydrate. It furnishes 14 calories to 100 c.c. Toast Water (Caultey). Pour a pint of boiling water over two or three slices of well-toasted bread. Let it stand until cool ; strain. Linseed Tea (Yeo). Water 1 pint 480 c.c. Linseed 2 tablespoonfuls 60 grams 60 calories Juice of lemon % 15 c.c. Bruised licorice root (or a piece of licorice the size of a filbert) % ounce 8 grams 10 " To the water add the linseed, the juice of the lemon, the licorice root, and rock-candy to taste. Boil for one and one-half hours and strain. Orgeat (P av y). Sweet Almonds 2 ounces 32 grams 200 calories Almond seeds (bitter) 4 1 gram. Orange-flower water a little 30 c.c. Milk 1 pint 480 350 " Water 1 " 480 * Blanch the sweet almonds and bitter almond seeds. Add the orange- flower water and pound into a paste. Rub this with the milk, diluted with the water, until it forms an emulsion. Strain and sweeten with sugar. (A demulcent and nutritive drink.) NUTRITIOUS BEVERAGES Albumin Water (Friedenwald and Ruhrah). Egg 1 ounce 50 grams 80 calories Water 6 ounces 180 c.c Sugar 1 teaspoonful. 10 grams 41 " Lemon juice 1 " 4 c.c BEVERAGES 581 Beat the white of the egg until very light and strain through a clean napkin. Add the water. If intended for an infant, a pinch of salt may be added. The sugar and lemon juice, or sherry wine, may be added to enhance its palatableness. This drink may also conveniently be made by placing all the ingredients in a lemonade shaker, shaking until thoroughly mixed and then straining. Serve cold. Egg Albumin Water (Watson). Take the white of an egg (30 calo- ries) and to it add twice its own volume of water and strain through muslin. This gives about three ounces of a clear solution, containing as much protein as is found in the average sample of commercial beef juice. This fluid, added to home-made beef tea, makes a nutritive solution almost indistinguishable from beef juice and at a fraction of the cost. Egg Albumin Water (Caultey). Take the white of a fresh egg (30 calories) and cut it in numerous directions with scissors. Shake it up in a flask with a pinch of salt and six ounces of cold water. Strain through muslin. It can be made with thin barley water, and cream or sugar added. Egg Broth (Drexel Institute). Egg 1 (whole) 50 grams 80 calories Sugar H teaspoonful 5 " 20 u Salt a pinch 1 " Hot milk 1 glass 250 c.c 180 Beat up the egg, and add to it the sugar and a pinch of salt; over this pour the milk and serve immediately. Hot water, broth, soup, or tea may be used in place of milk. Egg Cordial. Egg 1 white 32 grams 30 calories Cream. 1 tablespoonful 50 " 54 " Sugar y 2 " 20 82 " Brandy 1 " 16 c.c 65 " Beat up the white of the egg until light ; add the cream and beat up together ; then add the sugar and the brandy. Caudle. Egg 1 (whole) 50 grams 80 calories Sherry wine 1 wineglassful 30 c.c 38 " Sugar 1 teaspoonful 10 grams 41 " Gruel barley y z pint 120 c.c 130 " Beat up the egg to a froth, add the wine, and sweeten with the sugar ; if desired, flavor with lemon peel. Stir this mixture into the gruel, over this grate a little nutmeg, and serve with hot toast. 137 582 PREPARATION OF SPECIAL BEVERAGES AND FOODS Cocoa with Milk. Cocoa 1 rounding teaspoonful. . 4 grams 50 calories Milk-sugar 2 ounces 60 " 240 Milk 4 120 c.c 80 Cream 2 " 60 " 120 " Mix the sugar and cocoa; cook in the milk until dissolved. Serve with the cream. Cocoa. Cocoa 1 heaping teaspoonful. . . 4 grams 50 calories Milk-sugar 2 ounces 60 240 " Water % cup (4 ounces) 125 c.c. Cream 3 ounces 90 " 180 " Mix the cocoa and sugar, add the water, and boil for four or five minutes. Then add the cream, or use less and serve with whipped cream. Coffee. Milk-sugar 2 ounces 60 grams 200 calories Strong coffee 4-5 " 120-150 grams. Cream 2 60 c.c 120 Milk-sugar may be used likewise to sweeten tea, which may be served with or without cream. Almond Milk (Wegele). Almonds, sweet 1 pound 453 . 5 grams. . . . 3,030 calories bitter 2 pounds 1,000 ... .6,060 . Milk 8 ounces 250 c.c 165 " Blanch the almonds that have been soaked in cold water for twenty- four hours. This is done by pouring boiling water over them, when, after a few. minutes, they can easily be pressed out of their hulls. Grind the almonds in a mill or pound them in a mortar; mix with a half-pint of warm milk or water, and allow the mixture to stand two hours, after which strain through a cloth, pressing the juice out well Thirty grams of almonds yield 200 calories of heat; 250 grams of milk yield 170 calories. Lemon Whey Lemon juice 3 tablespoonfuls 45 c.c. Milk sugar 2-4 ounces 50-100 grams 200-400 calories Kumiss No. 1 (Drexel Institute). Skim milk 1 quart 1,000 c.c 340 calories Cake of yeast '/ 3 grams. Sugar 2 tablespoonfuls 80 " 328 BEVEKAGES 583 Heat the milk. Dissolve the yeast in a little water and mix it with the sugar and lukewarm milk. Pour the mixture into strong bottles, stopper them tightly with new corks, and tie down the corks with stout twine. Shake the bottles well and place in a refrigerator. This will allow the mixture to ferment slowly. After three days lay the bottles on their sides, turning them occasionally. Five days are required to complete the fer- mentation ; the kumiss is then at its best. Kumiss No. 2 (Holt). Fresh milk 1 quart 1,000 cc 650 calories Sugar ^ ounce 15 grams 62 " Yeast cake piece 3 " Pour into wired bottles the fresh milk, sugar and fresh yeast cake (half an inch square), and keep at a temperature between 60 and 70 F. for one week, shaking five or six times a day ; then put upon ice. Further directions for preparing kumiss and kephir with kefilac tablets will be found in the section on Milk, in the chapter on Animal Foods (Volume I, Chapter XII, page 338). For the analytical value, see Vol- ume II, Chapter XVII, pages 566-568. Milk Mixture (A. V. Meigs). Cream 2 pints 1,000 c.c 1,820 calories Milk 1 pint 500 " 325 Lime Water 2 pints 1,000 " Sugar water ' 3 1,500 512 For the sugar water use seventeen and three-fourths drams of milk sugar to a pint of water. Milk and Cinnamon Drink (Ringer). Add a small amount of cinnamon to the desired quantity of milk and boil it. Sweeten with sugar and add brandy if desired. Albuminized Milk. Milk 1 cupful 250 c.c 170 calories Lime water 1 tablespoonful 15 " Egg 1 white 32 grams 30 " Shake in a covered jar or lemonade shaker the milk, lime water and white of the egg. Sweeten, flavor as desired, and serve at once. Irish Moss and Milk. Irish moss 2 tablespoonfuls .... 28 grams. Milk 1 cupful 250 c.c 170 calories 584 PBEPABATION OF SPECIAL BEVEKAGES AND FOODS Soak the Irish moss for five minutes and wash thoroughly in cold water. Add the milk and soak for half an hour; then heat slowly, stir- ring constantly, and boil for ten minutes, preferably in a double boiler; strain, and pour into cups to cool. This may be served while hot, and may be rendered more nutritious by the addition of the white of an egg stirred into it just before serving. Egg and Buttermilk Mixture Egg 1 white 32 grams 30 calories Cream 2 ounces 80 " 216 " Buttermilk 1 glass 250 c.c 78 Beat the egg and cream lightly. Pour into a glass and fill with fresh buttermilk. Stir well. Milk and Other Diluents Milk may be diluted with advantage in many cases by adding lime water, or vichy, apollinaris, or some other sparkling table water. From one-half to one-eighth the total volume may be added. Grape Juice (Drexel Institute) (2). Pluck Concord grapes from the stem. Wash and heat them, stirring constantly. When the skins have been broken, pour the fruit into a jelly bag and press slightly. Measure the juice and add one-quarter the quantity of sugar. Boil the juice and sugar together and then pour into hot bottles ; cork and seal with paraffin or equal parts of shoemaker's wax and resin melted together. Less sugar may be used. Vanilla, Bitter Almond or Strawberry Junket Vanilla or bitter almond extract.^ teaspoonful 2 c.c. or Pure concentrated strawberry sirup 1 tablespoonful 15 " 88 calories Whole milk \i pint 250 " 170 " Add the flavoring extract to the cold milk and then prepare in the usual way. The vanilla or bitter almond extract or the strawberry sirup should be allowed to a half-pint of milk. Milk Lemonade (Kuhrah). Sugar 2 ounces 56 grams 224 calories Boiled milk 5 150 c.c 115 " Lemon ^ " 65 grams 20 or White Wine 2 " 120 c.c 83 " Boiling water. 5 150 Rind of lemon Y?. " 5 grams. BEVERAGES 585 Pour the boiling water over the peel and the sugar; allow it to cool, add the milk, and then the lemon juice or wine. Strain after ten minutes. Milk Porridge (Drexel Institute). Flour 1 tablespoonful 50 grams 85 calories Cold milk Y cupful. 63 c.c 45 " Hot milk Y " 63 45 Salt M teaspoonful 1 gram. Mix the flour with the cold milk and stir into the hot milk ; if desired add two raisins cut into quarters. Cook over boiling water for one hour, and add the salt just before serving. Plain Egg Flip (Watson). Milk 1 teacup 250 c.c 150 calories Sugar 1 teaspoonful 10 grams 41 " Egg 1 white 32 " 30 " Boil the milk or make it thoroughly hot ; beat up the white of egg to a stiff froth. Pour the boiling milk over the white of egg, stirring all the time. Add sugar to taste, and serve. BEVERAGES WITH EGG AND ALCOHOL Rich Egg Flip (Watson). Egg 1 white 32 grams 30 calories . ( 'ream 1 tablespoonful 20 54 Brandy 1 15 c.c 58 Sugar to taste 1 teaspoonful 10 grams 41 " Beat, up the white of egg stiffly; add to it the brandy and cream, with a little sugar if wished. Mix very thoroughly and serve. Egg-nog (Fitch). Egg 1 (freshly laid) 50 grams 80 calories Powdered sugar 1 tablespoonful 40 " 160 " French brandy 1 ounce 30 c.c 105 " Santa Cruz rum 2 drams 75 " 25 " Fresh milk 1 glassful 250 " 170 ( 'ream 1 wineglassful (2 ounces) .... 64 " 225 " Break the egg, separating the white from the yolk, and beat the yolk slowly, adding the sugar until it is thoroughly dissolved ; then add the brandy, at first drop by drop, vigorously beating the mixture all the time until one-half is added, then increase the flow until all the brandy is added. Now add the milk, pouring very slowly, beating the mixture all the while. Continue beating while the rum is being slowly added. An 586 PREPARATION OF SPECIAL BEVERAGES AND FOODS assistant should have the white of egg beaten to a froth, which is now dropped on top of the mixture. Add a small pinch of grated nutmeg, dusting over the frothy whites, and set mixture on ice for an hour, when it will be read}- to serve. Cold Egg-nog (Watson). Egg 1 whole 50 grams 80 calories Sugar 2 teaspoonfuls 20 " 80 " Milk 1 glassful 250 c.c 170 " Brandy or good whiskey 1 tablespoonful 15 " 55 " Beat up the egg, add the sugar and milk and then the brandy or whiskey; mix thoroughly. Hot Egg-nog Egg 1 yolk 18 grams 68 calories Sugar 2 teaspoonfuls 20 " 180 Hot milk 1 glassful 250 c.c 170 Brandy or old whiskey 1 tablespoonful 15 " . . 55 " Beat the egg, add the sugar and milk, and then the brandy or whiskey ; mix thoroughly. Brandy-and-Egg Mixture (Stokes). Eggs 2 yolks 36 grams 138 calories White sugar ^ ounce 20 " 80 " Cinnamon water 4 ounces 120 c.c. Brandy 4 120 " 468 " Rub the yolks of the eggs with the white sugar, add the cinnamon water and then the brandy. Dose: One or two teaspoonfuls every two hours, according to age. Brandy-and-Egg Mixture for Infants (Louis Starr). Egg 1 yolk 18 grams 68 calories Brandy Y^ ounce 15 c.c 60 " Cinnamon water 1 teaspoonful 4 " White sugar 1 coffeespoonful 20 u 80 Beat all these ingredients up well. Egg-nog (Ruhrah). Egg ,1 large 60 grams 80 calories Sugar 1 tablespoonful 30 " 120 Whiskey 2 tablespoonfuls 30 c.c 90 Cream 7 " 140 grams 210 " Add the sugar to the yolk of egg and beat until very light. Whip the white of the egg and then the cream until very stiff. Add the whiskey BEVERAGES 587 to the yolk of egg and sugar. Mix well. Add one-half the cream to this, then one-half the beaten white of egg. then the remaining cream, and finally the remaining white of egg. Mix lightly. This recipe makes a glass and a half. Egg-nog (Bartholow)(3). Scald some new milk by putting it, con- tained in a jug, into a saucepan of boiling water; it must not be allowed to boil. Beat an egg with a fork in a tumbler with some sugar ; add a des- sertspoonful of brandy, and fill the tumbler with the scalded milk when cold. This egg-nog will furnish about 300 calories. Beef -tea Egg-nog (Davis). "Soluble Beef" H teaspoonful 0.5 grams 20 calories Hot water ^ cupful 125 c.c. rT^ndy 1 tablespoonful 15 60 L 1 (whole) 50 grams 80 " Sugar 2 teaspoonfuls 20 85 " Salt a pinch 1 " Beat the egg slightly, and add the salt and sugar. Dissolve the "Soluble Beef" in the hot water, add to the egg, and strain. Mix thor- oughly, adding wine, and serve. Grape Juice and Egg. Egg 1 white 32 grams 30 calories Grape juice 2 tablespoonfuls 30 c.c 20 " Beat the egg lightly, strain through a napkin, and add to it the grape juice. Fill a large wineglass half full of cracked ice. Pour the egg and grape juice over this, sprinkle sugar over if, and serve. Milk Punch Milk 1 glass 250 c.c 170 calories Rum 1 tablespoonful 15 " 45 " Sugar 2 teaspoonfuls 20 grams 81 " Shake together in a lemonade-shaker the milk, rum, brandy or good old whiskey, and the sugar. After it has been poured into a glass, a little nutmeg may be grated over the top. Egg Flip. Boil or heat thoroughly a teacupful of milk, beat the white of one egg to a froth. Pour the milk over the egg, stirring con- stantly. Add sugar to taste. This will furnish 230 calories. Caudle (Yeo). Beat an egg to a froth; add a glass of sherry and half a pint of gruel. Flavor with a lemon peel, nutmeg and sugar. This will furnish 120 to 150 calories, according to the consistency of the gruel. If milk is used to make the gruel it will have a higher value. 588 PREPARATION OF SPECIAL BEVE11AGES AND FOODS Wine Whey. Milk 1 cupful 250 c.c 170 calories Sherry wine K " 60 76 Cook the milk and sherry wine together. As soon as the curd sepa- rates, strain and sweeten. This may be eaten hot or cold. Mulled Wine (Drexel Institute). Hot water % cupful 30 c.c. Stick cinnamon Y^, inch 2 grams. Cloves 2 whole 0.5 Nutmeg tiny bit 05 " Port (heated) ^ cupful 60 c.c 106 calories Sugar 2 tablespoonfuls 28 grams 112 " Boil all the ingredients except the wine and sugar for ten minutes; then add the wine and sugar, strain, and serve very hot. PEPTONIZED AND PREDIGESTED FOODS Predigested protein, in the form of peptone and albumose, is of value principally in increasing the nutritive properties of liquid foods. Its principal value as an aliment is in its nutritive property in long-continued wasting 'diseases. It also has some value as an appetizer when there is diminished secretion of the gastric juice, and is of use where gastric mo- tility and secretion are low, on account of its being a concentrated food. It is useful in artificial feeding by the stomach tube or for rectal alimen- tations. Peptonized Beef (Fairchild). Finely minced lean beef ^ pound 100 grams 255 calories Cold water J^ pint 250 c.c. Extract of pancreas 20 grains.. 1 . 25 grams 2 " Bicarbonate of soda 15 " 1 " Egg 1 white 30 " 30 Salt and pepper 1 saltspoon 1 " Cover the lean beef (or beef and chicken mixed) with the cold water. Cook over a slow fire until it has boiled for a few minutes, stirring con- stantly. Pour off the broth and rub or pound the meat to a paste. Put meat and broth and half a pint of cold water in a glass jar, and add the extract of pancreas and bicarbonate of soda. Mix well and keep in a warm place at about 110-115 F. or place it in warm water and allow it to stand three hours, stirring or shaking occasionally. Boil quickly; strain or clarify with the egg, and season with salt and pepper. BEVERAGES 589 If desired, it need not be strained, as the small particles of meat are usually easily digested. Cereals may be added, boiling with half the amount of water previously directed, and mixing all together before pep- tnni/ing. At the end of three hours the mixture must be boiled or it will spoil. Peptonized Oysters (Fairchild). Oysters ^ dozen 85 grams 44 calories Water H pint 250 c.c. Extract of pancreas 15 grains 1.4 grams 2 " Bicarbonate of soda 15 " 1 " Milk '.Hpint 250 c.c 170 Salt 1 saltspoon 1 gram. Pepper 1 1 To the oysters with their juice add the water, and boil for a few minutes. Pour off the broth and set it aside. Mince the oysters, and with the aid of a potato-masher reduce to the consistence of a paste. Place this with the broth in a glass jar and add the extract of pancreas and the bicarbonate of soda and mix. Allow this to stand in hot water (115 F.) for one and one-half hours. Pour into a saucepan and add the milk ; heat over a slow fire to boiling point. Flavor with salt and pepper and serve hot. Let the heating be done gradually, and be careful to bring the mixture to a boil before taking it from the fire. Partially Digested Cereals Prepared at the Table. To a saucer of well- cooked oatmeal, wheaten grits or rice, at the customary temperature, add one or two teaspoonfuls of Fairchild's Diastasic Essence of Pancreas, or fifteen grains of Fairchild's Dry Extract of Pancreas. Stir for a few minutes before eating. When the ferments are added to the very hot foods their power becomes impaired. About 100 grams, energy value about 200 calories. Partially Peptonized Milk (Ruhrah). Milk 1 pint 500 c.c 325 calories Water 4 ounces 120 " Fairchild's peptonizing tube 1 1 gram 2 " or Pancreas extract 5 grains 0.33 " Bicarbonate of soda 15 " 1 " Into a clean granite-ware or porcelain-lined saucepan place the milk, water and the contents of tlio tul)o, or the pancreas extract, and bicar- bonate of soda. Heat gradually until it boils, stirring constantly. Boil gently for ten miimtes, strain into a clean bottle, cork and keep in a cool 590 PREPARATION OF SPECIAL BEVERAGES AND FOODS place. Before using, shake the bottle well ; serve hot or cold. Prepared in this way it will not become bitter. Peptonized Milk. Cold Process. Mix milk, water and peptonizing agents as directed in the preceding recipe, and immediately place the bottle on ice. Use when ordinary milk is required. This is particularly suited for dyspeptics and individuals with whom milk does not, as a rule, agree. The flavor of the milk remains unchanged. Warm Process. Milk 1 pint 500 c.c 325 calories Cold water 4 ounces 120 " Extract of pancreas 5 grains 0.33 gm 2 " Bicarbonate of soda 15 " 1 " Put the milk and cold water in a glass jar, add the extract of pancreas and the bicarbonate of soda. After mixing thoroughly, place the jar in water as hot as can be borne by the hand (about 115 F.). This should be heated for from six to twenty minutes. At the end of this time it may be placed upon ice until required. The contents of one of Fairchild's pep- tonizing tubes may be used in place of the pancreas extract. If the milk is to be kept for any length of time, it should be brought to a boil, to pre- vent the formation of too much peptone, which renders the milk bitter. Hot Peptonized Milk. Mix together the usual peptonizing ingredients and add a pint of fresh cold milk. After thoroughly shaking the bottle place it on ice. When needed, pour out the required amount, heat it, and drink it as hot as it can agreeably be taken. If required for immediate use, the ingredients may be mixed together in a saucepan and slowly heated to the proper temperature. Effervescent Peptonized Milk Put some finely cracked ice in a glass, fill it half full of Apollinaris, vichy or siphon water, and immediately add the peptonized milk. Drink while effervescing. Brandy may be added if desired. Specially Peptonized Milk This is to be used in the preparation of jellies, punches and all recipes where the milk is to be mixed with fruit juices or acids. Prepare according to the hot process; keep the milk at a temperature of 115 F. for one hour; pour into a saucepan and bring to a boil. If required hot, this may be used immediately, or it may be set aside on ice, to be used later. If not heated for an hour, the milk will curdle on being mixed with an acid. If not boiled, the peptonizing ferment will digest gelatin and prevent the formation of -jelly. BEVERAGES 591 Peptonized Milk Jelly (Friedenwald and Ruhr ah). Cox's gelatin % box Water 4 ounces 120 c.c. Hot specially peptonized milk ... 1 pint 500 " 325 calories Sugar 4 ounces 112 gm 410 " Fresh lemon 1 whole 130 41 Orange 1 250" 96 " St. Croix rum or brandy 3 tablespoonfuls. . . 50 c.c 245 " Soak the gelatin well in the water. Take the peptonized milk and add the sugar. Put in the gelatin and stir until it is dissolved. Pare the lemon and orange, and add the rinds to the mixture. Squeeze the lemon and the orange juice into a glass, strain and mix with the rum or brandy if preferred. Add the juices to the milk, stirring constantly. Strain, and allow it to cool to the consistence of sirup. When almost ready to set, pour into cups and set in a cold place. Do not pour the milk into moulds until the mixture is nearly ready to set, otherwise it will separate in setting. Peptonized Milk Lemonade. Cracked ice % glass 80 c.c. Juice of 1 lemon 20 " Sugar 3 teaspoonfuls 30 gm 100 calories Squeeze into the cracked ice the lemon juice, and add the sugar dis- solved in water. Fill the glass with fresh specially peptonized milk and stir well. If preferred, equal parts of milk and of an effervescent mineral water may be used. Pour the water on the lemon juice and ice, and im- mediately fill the glass with milk. Peptonized Milk Punch Finely crushed ice 1 A goblet 80 c.c. Rum 1 tablespoonful. ... 15 " 50 calories Curacao a dash 5 " 15 " Nutmeg a pinch In the usual milk punch recipes the specially peptonized milk may be used in place of ordinary milk. Take the ice, pour on it the rum and Curacao, or any other liquor agreeable to the taste. Fill the glass witli peptonized milk; stir well, sweeten to taste, and grate a little nutmeg on top. Peptonized Milk Gruel. Wheat flour 1 teaspoonful Cold water 1 A pint '. 250 c.c. Cold milk 1 pint 500 " 340 calories 592 PREPARATION OF SPECIAL BEVERAGES AND FOODS Mix the wheat flour, arrowroot flour or Robinson's barley flour with the cold water. Boil for five minutes, stirring constantly. Add the cold milk and strain into a jar; add the usual peptonizing ingredients; place in warm water (115 F.) for twenty minutes and then upon ice. Junket, or Curds and Whey Fresh milk Yi pint 250 c.c 180 calories Fairchild's essence of pepsin 1 teaspoonful To the milk add the essence of pepsin and stir just sufficiently to mix. Pour into custard cups, and let it stand until firmly curdled. It may be served plain or with sugar and grated nutmeg. It may be flavored with wine, which should be added before curdling takes place. Junket with Egg. Egg 1 whole. 50 gm 80 calories White sugar 2 teaspoonfuls 20 " 42 " Warm milk ^ pint 250 c.c 180 " Essence of pepsin 1 teaspoonful 4 " Beat the egg to a froth, and sweeten with the sugar; add this to the warm milk, and then add the essence of pepsin and let it stand until curdled. Cocoa Junket (Fairchild). Cocoa 1 even tablespoon- ful 16 gm 100 calories Sugar '. . . 2 teaspoonfuls 20 " 82 " Boiling water 2 tablespoonfuls. . . 30 c.c. Fresh, cool milk % pint 250 180 * Fairchild's essence of pepsin 1 teaspoonful 4 " Put the cocoa and sugar into a saucepan ; scald with the boiling water and nib into a smooth paste; then stir in thoroughly the milk; heat this mixture until it is lukewarm not over 100 F. ; add the essence of pep- sin, and stir just enough to mix ; pour quickly into small cups or glasses, and let it stand until firmly curdled, when the junket is ready for use. It may be placed on ice and eaten cold ; as a dessert it may be served with whipped cream. Coffee Junket Sugar 2 teaspoonfuls 20 gm 82 calories Clear, strong coffee 2 tablespoonfuls. . . 30 c.c. Fresh, cool milk Y 2 pint 250 " 180 " Fairchild's essence of pepsin 1 teaspoonful 4 " BEEF TEAS 593 Dissolve the sugar in the coffee; mix this thoroughly with the milk; add the essence of pepsin as directed above, and serve in the same way. Iodized Junket. Milk ]/2 teacupful 120 c.c 85 calories Pepsin 2 or 3 teaspoonfuls Prescribe a saturated solution of potassium iodid and also a bottle of essence of pepsin. Take the milk and add the required number of drops of the iodid solution. Heat the milk lukewarm and add the two teaspoonfuls of pepsin and let it stand until curdled. This will be found useful where it is difficult to administer the iodid by ordinary methods. Whey. Fresh milk Y^ pint 250 c.c 180 calories Essence of pepsin 1 tablespoonful Heat the milk lukewarm (115 F.), add the essence of pepsin, and stir just enough to mix. When this is firmly coagulated, beat up with a fork until the curd is finely divided and then strain. For flavoring pur- poses lemon juice or sherry wine may be added. Grape Juice Whey. Orange 1 , juice of 60 c.c 45 calories Grape juice Y pint 120 " 180 " Make whey as in the above recipe. To this add the juice of the orange and the grape juice. Strain again if necessary. This may be served hot or on cracked ice. It may be sweetened if desired. Energy about 225 calories. Cream-of-Tartar Whey (Paw). CYram of tartar 1 heaping teaspoonful Boiling water 1 pint Milk 1 cup 250 c.c 180 calories Add the cream of tartar to the boiling water. Strain, sweeten to taste, and serve cold. Energy about 180 calories. BEEF TEAS Beef Tea ( Pavy). Finely minced beef 1 pound 454 gm 1,000 calories Cold water 1 pint 500 c.c. Salt l / 2 teaspoonful 2 gm. Put tho boef with tlio cold water into a suitable vessel. Let it stand for an hour, stirring occasionally. Put the vessel containing the beef into 594 PREPARATION OF SPECIAL BEVERAGES AND FOODS a saucepan of water, place it over the fire, and allow the water to heat 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. A fine sediment appears in the fluid, and this should be drunk with the liquid. Flavor with salt. At no time should the beef extract be exposed to a temperature of more than 170 F. Beef Tea (Bartholow). Beef 1 pound 454 gm 1,000 calories Cold water 1 pint 500 c.c. Chop the beef fine, free from fat, tendons, etc., and soak with the cold water for two hours. Let it simmer on the stove for three hours at a tem- perature never above 160 F. Replace the water lost by 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 with Oatmeal (Yeo). Groats 1 tablespoonful 30 gm 104 calories Cold water 2 tablespoonfuls. . . 30 c.c. Boiling beef tea 1 pint 500 " 150 " Mix thoroughly the groats and cold water ; add to this the boiling beef tea. Boil for ten minutes, stirring constantly. Strain through a coarse sieve. Beef Tea (Caultey). 1. Mince one pound of lean beef, and add to it one pint of cold water and ten drops of dilute hydrochloric acid. Let it stand for two or three hours, with occasional stirring, and then simmer for ten to twenty minutes. Do not let it boil. Skim well. Energy value 25 calories to 100 c.c. 2. Mince one pound of lean beef as fine as possible, and pound it in a mortar with a small teaspoonful of salt. Add the meat and its juice to one pint of water at 170 F. in an earthen vessel, and stand it for an hour by the fire, stirring at times. Then strain it through muslin, taking care to squeeze all the juice out of the meat. It furnishes 25 calories to 100 c.c. The composition of beef tea, Nos. 1 and 2, is 92.9 per cent water, 4.4 per cent protein, 0.4 per cent fat, 1.1 per cent carbohydrate. Beef Tea, Flavored (Yeo). Beef tea may be flavored agreeably by boiling in it a pinch of mixed herbs, a bay-leaf or a bit of onion, carrot, turnip or celery and a few peppercorns. The roots should either be chopped small or be scraped to a pulp before being added to the broth. MEAT JUICES 595 Thick Beef Tea, No. 1 (Watson). Beef tea (made) .1/2 pint 250 c.c 75 calories Egg 1 yolk 18 gm 68 Tapioca grout 1 teaspoonful 5 " 15 " Warm the beef tea and sprinkle in the tapioca, stirring all the time. Let it simmer "slowly by the side of the fire until the tapioca turns quite clear. This will probably take about fifteen minutes. Beat up the yolk of an egg in a cup, pour the beef tea gradually over it, stirring all the time. It is now ready for serving. Beef Tea, No. 2 (Watson). Beef tea (made) Y?. pint 250 c.c 75 calories Arrowroot 1 teaspoonful 5 gm. . .' 15 " Cold water 1 " 4 c.c. Mix the arrowroot and the water in a small basin until quite smooth. Then add it to beef tea that is being warmed in a pan ; stir well for a few minutes to prevent it from becoming lumpy. Then simmer slowly for fifteen minutes. MEAT JUICES This variety of food differs greatly in nutritive value from the beef teas and essences previously mentioned. The meat juice is extracted with- out any heat and under strong pressure, and thus a large portion of the albumin is present. Home-made meat juice is cheaper than the proprietary preparations, and is more valuable on account of its freshness, and the absence of pre- servatives. It contains a relatively small quantity of extractives, and can be given in considerable amounts without causing diarrhea or thirst. The great drawback to the home-made product is its red color, which is de- cidedly objectionable. This can be partially overcome by serving in a red glass or a cup. Home-made Meat Juice (Watson). Rump steak (best) ^ pound 115 gm 330 calories Cold water 1 gill 125 c.c. Pinch of salt or sugar to taste. Wipe and shred the meat very finely, pound it well, and rub it through a fine wire sieve. Place in a basin with water and salt, and let stand, stirring occasionally, for a couple of hours. The liquid will then be a bright red color. Strain through a fine strainer, pressing the meat with 596 PREPARATION OF SPECIAL BEVERAGES AND FOODS the back of a spoon. The fluid obtained will contain 4 to 5 per cent of protein. Meat juice should be made in very small quantities, as it very soon be- comes rancid. Another method, such as squeezing the meat in a lemon squeezer, may be tried, but this is wasteful, as the pressure is not suf- ficiently powerful to extract all the juice. Meat-Juice Mince (Watson). Rump steak (best) K pound 230 gm 660 calories Butter 1 small piece 15 120 " Pepper and salt Y^ teaspoonful each. 2 " Rub the meat through a hair sieve until all the red juicy part has gone through; scrape the bottom of the sieve. Melt a very little piece of the butter in a small frying-pan; toss the meat juice in it for three or four minutes, until it loses its red color. Flavor and serve with toast. This looks just like mince, but as none of the fiber is present, it is very digesti- ble. This meat-juice mince can be made more easily digestible by omit- ting the butter, and adopting the following method: Add to the scraped meat a teaspoonful of beef tea or simple stock, and stir in an iron pan for three or four minutes, when the juice granulates and becomes brown in color. If an enamel pan is used, the meat has a very unappetizing appearance. Beef Juice (Bartholow). Broil quickly some pieces of round or sir- loin steak, of a size to fit in the cavity of a lemon squeezer previously heated by dipping in hot water. The juice should be received into a hot, colored (preferably red) wine glass, seasoned to taste with salt and cayenne pepper, and taken hot. Beef Juice (Caultey). Chop lean beef fine, or scrape with a fork or meat scraper to separate the connective tissue, and put it in a jar or cup with a pinch of salt and enough cold water to cover it. Allow it to stand from one to six hours, and then squeeze well through coarse muslin. It may be given alone or mixed with other foods, warm or cold, but not hot. It should be warmed by heating the vessel in hot water. Beef Juice (Ringer). Take one ounce of fresh beef, free from fat, chop fine and pour over it eight ounces of cold water ; add five or six drops of dilute hydrochloric acid and fifty to sixty grains of common salt, stir it well, and leave for three or four hours in a cool place. Then pass the liquid through a hair sieve, pressing the meat slightly, and adding grad- ually toward the end of the straining about two more ounces of water. The liquid thus obtained is of a red color, possessing the taste of soup. BKOTHS 597 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. It furnishes 25 calories to 100 c.c. The composition of beef juice is 90.6 per cent water, 5 per cent pro- tein, 0.0 per cent fat. Beef Essence (Yeo). Lean beef 1 pound 460 gm 1,320 calories Salt a little Chop the lean beef very fine, free from fat and skin ; add the salt and put into an earthen jar with a lid; fasten up the edges with a thick paste, such as is used for roasting venison in, and place the jar in the oven for three or four hours. Strain through a coarse sieve, and give the patient two or three tablespoonfuls at a time. Energy value 25 calories to 100 c.c. Cold Beef Juice. Finely chopped lean beef 1 pound 452 gm 1,000 calories Cold water 8 ounces 250 c.c. Cover the beef with the cold water and allow it to stand for eight or ten hours. Squeeze out the juice by means of a muslin bag ; season with salt or sherry wine, and drink cold or slightly warmed. It may be added to milk, care being taken that the milk is not too hot before the juice is added. Iced Meat Extract (v. Ziemssen). - Fresh beef 2 pounds 1 kilo 2,000 calories Sugar % pound 250 gm 1,000 Freshly expressed lemon juice ... 7 ounces 200 " 50 " Cognac containing vanilla extract % ounce 20 " 5 " Eggs 3 yolks 54 204 Cut the fresh beef into pieces the size of a hand; wrap in a coarse, lattice-like linen bag, put under a lever press, and press slowly. The juice should be caught in a porcelain dish. This is best done by a drug- gist. By this method about 500 grams of juice are obtained. Mix the juice with the sugar and lemon juice (this last is best omitted in the case of dyspeptics) and the cognac; stir in well the yolks of the eggs, and place the entire mixture in a freezer. Energy value 25 calories to 100 c.c. BROTHS Broths, hoof teas, etc., are home-made infusions of beef, mutton, veal or ehiekrn, and are always in demand for the sick-room. They are to be 138 598 PREPARATION OF SPECIAL BEVERAGES AXD FOODS regarded, however, more in the nature of pleasant, palatable and stimu- lating beverages than as foods. Their nutritive value depends entirely on the method of preparation. If the process of cooking is carried to the point that the infusion contains a portion of the protein of the meat, then there is some nutritive value ; but, on the other hand, if prepared after the ordinary routine, only the extractives and salts of the meat are dissolved out and, from the point of view of nutrition, the value is practically negative. Meat Broth (Beef, Veal, Mutton or Chicken) (Sutherland). Chopped lean meat 1 pound 450 gm 1,000 calories Water 1 pint 500 c.c. Cover the meat with the water and allow it to stand for from four to six hours. Then cook over a slow fire for an hour until reduced to half the quantity. Cool, skim, pour into jar and strain. Chicken Broth (Bartholow). Skin arfd chop fine a small chicken or half a large fowl, and boil it, bones and all, with a blade of mace, a sprig of parsley and a crust of bread, in a quart of water for an hour, skim- ming it from time to time. Strain through a coarse colander. It fur- nishes 50 calories to 100 c.c. The composition of chicken broth is 84 per cent water, 10.5 per cent protein, 0.8 per cent fat, 2.4 per cent carbohydrate. Veal Broth Water 1 pint 500 c.c. Lean veal % pound 225 gm 500 calories Pour the water on the finely chopped lean veal and allow it to stand for three hours. Boil for a few minutes, strain and season with salt. Clam or Oyster Juice (Drexel Institute). Cut the clams or oysters into pieces and heat for a few minutes in their juice. Strain through muslin and serve while hot. In straining great care must be taken that sand does not pass through the muslin. The juice should be diluted and may be frozen. Clam Broth (Drexel Institute). Clams 3 large 75 gm 40 calories Cold water J^ cupful 125 c.c. Wash the clams very thoroughly, using a brush for the purpose. Place in a kettle with the cold water. Heat over the fire. As soon as the shells open, the broth is done. Strain through muslin, season and serve. BROTHS 599 Mutton Broth with Vegetables Neck mutton 1 pound 450 gm 1,375 calories Water 1 pint 500 c.c. Carrots 2 whole 200 gm 36 Turnips 1 200 54 " Onions 3 200 18 Barley 4 tablespoonfuls. . . 75 " 40 " Allow one pound of neck mutton to each pint of water; add the above ingredients. Let all simmer together for three hours. Mutton Broth without Meat "Shankends" 2 bones 1,000 gm 200 calories Cold water 1 pint 500 c.c. Cook the "shankends" in the cold water, add vegetables as directed in the foregoing recipe ; simmer for three hours and strain. Invalid Broths (Thompson) (4). To one pound of chopped lean meat chicken, mutton or beef add one pint of cold water; let stand in a covered glass fruit jar from 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 use warm or cold. These broths, except the chicken broth, possess essentially the same fuel value as beef tea. Beef Broth with Poached Eggs. Prepare the broth in the proportion of half a teaspoonful of "Soluble Beef" to one cupful of hot water and add a poached egg. A Nutritive Drink for Delicate Women and Children. "Soluble Beef" .% teaspoonful 2 gm 30 calories Boiling water 5 ounces 150 c.c. Cream % ounce 20 gm 72 " Mix the "Soluble Beef," water and cream, season with salt and pepper to suit the taste. Beef Broth and Grain. "Soluble Beef" 1 teaspoonful 2 gm 30 calories Water 1 quart 1,000 c.c. Rice 1 tablespoonful. ... 15 gm 20 " Take the above ingredients and add salt to taste. Dissolve the "Solu- ble Beef" in the hot water, and add the well-washed rice. Simmer slowly until dissolved and absorbed by the rice, adding more beef broth if too much boils away. If not entirely dissolved, the broth should be strained before using. 600 PKEPAIIAT1OX OF SPECIAL BEVEKAGES AND FOODS BOUILLON Plain Bouillon (Wegele). Lean beef M kg. (1 lb.) 453 gm 1,086 calories Cut the beef into small pieces and put same in a vessel holding about 3 pounds (6 pints) and having a well-fitting cover (or use a double boiler). Fill vessel with cold water and allow it to cook for 3 to 4 hours. According to the strength required, it is better to add boiling water afterward, mak- ing the bouillon stronger or weaker, as desired. This makes about 2 pounds (4 pints) of bouillon meat not to be used again. To obtain a better taste and color, one can brown the meat in a hot dry pan before putting the meat into the 6 pints of water. Clam Bouillon (Pattee). Cold water % cupful 187 c.c. Clam broth l / 2 u 125 * 42 calories Scalding milk % " 30 " 45 Butter 1 tablespoonful. ... 15 gm 120 " Salt, pepper each % teaspoon ... 4 " Celery sauce 1 tablespoonful 15 " 48 " Whipped cream 1 .... 30 " 81 Blend the water and clam broth, heat to the boiling point, then add the scalding milk, the butter and stir well ; season with salt, pepper and celery sauce to taste. A small quantity of cracker crumbs may be added to thicken it. Serve in heated bouillon cups and garnish with the whipped cream. Clam Bouillon Bisque (Pattee). Butter 1/3 tablespoonful ... 8 gm 60 calories Chopped onion 1 " 5 " ' 15 " Chopped carrot Yi " ....80 * 38 Clam broth 1 cupful 250 c.c 84 " Flour H tablespoonful. ... 20 gm 15 " Boiling water 1 cupful 250 c.c. Egg 1 yolk 18 gm 68 Cream Y cup 40 " 120 " Melt the butter, add the finely chopped onion and carrot; cover and cook until the onion and carrot are tender, stirring occasionally. Add the flour, blending well ; then pour on gradually the boiling water and the clam broth. Cook five minutes, strain and return to saucepan. Mix the yolk of egg with the cream, and add it slowly to the bisque. Pour into heated bouillon cups and serve with small oyster crackers. VEGETABLE SOUPS 601 American Bouillon, American Broth (Yeo). Place in a tin vessel that can be sealed hermetically alternate layers of finely minced meat and vegetables. Seal it, and keep it heated in a water bath (bain marie) for six or seven hours, and then express the broth. Bottle Bouillon (Uffelmann). Cut beef, free from fat, into squares. Place these in a stoppered bottle, put the bottle in a basin of warm water, heat slowly, and boil for twenty minutes. There will be about an ounce of yellowish or brownish fluid for each three-quarters of a pound of meat used. The flavor is that of concentrated bouillon. VEGETABLE SOUPS Soups without Meat (Drexel Institute). These soups are thickened by using butter and flour. This prevents a separation of the thicker and thinner parts of the soup. The butter should be heated until it bubbles, the flour and seasoning added, and enough of the hot liquid to make a smooth sauce thin enough to pour easily. This should be poured into the rest of the hot liquid and cooked in a double boiler until the soup is of the proper consistence. In soups made of dried peas and beans, soda is used to soften the casein. It is also used in tomatoes to neutralize the acid. These soups must be served in hot dishes as soon as ready. Crisp crackers, croutons, or soup sticks may be served with them. Crisp Crackers. Split and butter thick crackers and brown in a hot oven. Cream-of-Tomato Soup Tomatoes 1 can 450 gm 105 calories Soda % teaspoonful 1 " Butter H pound 183 " 1,000 Flour y z " 183 " 500 Salt 3K teaspoonfuls 12 " White pepper K teaspoonful 2 " Milk 1 quart 1,000 c.c 720 Stew the tomatoes slowly one-half to one hour, strain and add soda while hot; make a white sauce and add the tomato juice. Serve im- mediately. Vegetable Soup. Spinach 1 handful 200 gm 16 calories Beet 1 large 200 29 Carrots 2 small 200 " 18 Chop the vegetables fine and add to one quart of water. Boil two C02 PREPARATION OF SPECIAL BEVERAGES AND FOODS hours, add water to make quantity up to one quart and strain. Add salt if desired. This contains a large amount of inorganic salts. Cream-of -Celery Soup (Ruhrah). Celery lj^ cupfuls 250 gm 45 calories Water 1 pint 500 c.c. Milk 1 cupful 250 170 Cream 1 " 250 " 440 Butter 2 tablespoonfuls. . . 30 gm 240 Flour K cupfu 1 140 " 400 Salt K teaspoonful 2 White pepper K .... 2 Cook the celery in the boiling water until very soft ; strain and add the hot liquid ; make a white sauce and cook until it is thick cream. Cream-of -Potato Soup (Wegele). Potatoes, white 3 whole 300 gm 450 calories Milk 2 cupfuls 500 c.c 340 Cream K cupful. . 125 " 220 Eggs 2 yolks 54 gm 204 Salt 1 teaspoonful 4 " Pepper H " 1 " Onion juice H " 2 " Cook the potatoes until soft, drain, mash, add the hot liquid and strain ; add the beaten yolks and seasoning. Cook in a double boiler until the egg thickens, stirring constantly. Serve immediately. Tapioca Soup (Yeo). Meat broth or stock 1 pint 600 gm 454 calories Previously washed tapioca % ounce 21 " 21 " Boil the broth or stock, and, while stirring constantly, sprinkle in the tapioca. Cover the saucepan, and let it stand until the tapioca is quite soft. Skim and serve. Julienne Soup (Vegetarian) (Watson). Vegetable stock (clarified) 1 quart 1,000 c.c 360 calories Mushroom ketchup 2 tablespoonfuls. . . 30 " Salt and pepper l /% teaspoonful 2 gm. Turnip, carrot, celery, onion .... 4 ounces, each .... 400 " 160 " Walnut ketchup 2 tablespoonfuls. . . 30 c.c. Sherry ^ cup 120 160 Cut the vegetables into fine strips about the size and shape of a small match, and boil them separately until tender but not broken. Have the VEGETAHLK SOUPS 603 stock rcadv boiling; add salt, pepper, a very little ketchup and sherry to taste; put in the prepared vegetables, cook for fifteen minutes and serve. White Soup (Watson). Onions 2 small 200 gm 84 calories Celery 1 head 200 32 Milk % pint 250 c.c 170 Turnip 1 whole 560 gm 24 Artichokes 2 French 720 194 Flour 1 dessertspoonful . . 15 " 15 " Potatoes (white) 1 pound 550 385 " Water 3 pints 1,500 c,c. Butter 1 ounce 30 gm 240 Cut about 2 pounds weight of any white vegetables, wash and peel and cut in pieces and boil until soft in the water ; salt and butter. Rub them through a sieve or colander, put them back in the stewpaii with the milk, and let it boil. Put in the flour, mixed smoothly with cold water, let the soup boil for ten minutes and serve with slices of fried bread. Clear Soup or Consomme (Watson) (5). Soup stock 1 quart 1,000 c.c 360 calories Lean, juicy beef % pound 260 gm 700 " Sugar 1 lump 10 41 Egg 1 whole 50 80 The stock should be in the form of a good jelly. Method: Carefully remove all fat from the top of the stock, and put it into a clean lined saucepan. Wipe the beef with a damp cloth, and shred it finely as you would for beef tea, removing all fat and skin. Add this to the stock, with the white of the egg and the shell, well washed and crushed. Whisk these over the fire with a wire whisk until the soup just comes to the boiling point. Then remove the whisk, and let the soup boil up. Draw the pan to the side of the fire, where the soup will keep warm but not simmer, and cover it with a plate. Let it stand there from ten to fifteen minutes. Tie a clean cloth on to the four legs of a chair turned upside down, letting it fall slightly in the middle so as to form a bag. Pour some boiling water through the cloth into a basin to heat the cloth thoroughly. Then strain the soup. Tt will not be clear the first time, so change the basin and pour the soup through again, repeating this process until it is quite clear. In repeating, add a lump of sugar, which makes the soup sparkle. This soup can be varied by the addition of different garnishes, c.f the chemical constituents were calculated, and the results tabulated as given below. Space will not permit an accurate comparison of the analyses given of the rations supplied to the armies of the various European countries, nor the vastly different systems in vogue for supply- ing the food. In European countries, fresh meat is expensive ; therefore, from econ- omy, the nitrogen in the ration is supplied principally in the form of peas, beans, cheese, etc. In Russia, the meat ration is low, and the deficiency of protein is made up by free allowances of pulses and bread. The Amer- ican soldier, from custom, requires the stimulating effects of an abundance of good, wholesome, fresh meat, and the United States is the only country which furnishes its soldiers with the whole ration. Other countries fur- nish part, and the soldier purchases an additional aliment from his pay 698 ARMY AND NAVY RATION'S or from allowances for this purpose. In England, bread and meat in moderate quantity are supplied, but the soldier must pay for the rest and as much as twenty-five per cent of his pay may be thus deducted. In Germany, he is furnished only bread and must find the rest of his ration, but if the portion is supplied officially, the cost up to three and one- quarter cents is charged against his pay ; anything over this is paid by the government. COMPARATIVE TABLES OF FOREIGN ARMY RATIONS (Woodruff) NATION Ration Pro- teins Fats Car- bohy- drates Cal- ories Re- marks 1. ENGLAND 1 . Home Gm. 93 Gm. 61 Gm. 244 1,938 2. Foreign station or under canvas at home 111 80 244 2,175 (a) 3. March 120 80 324 2,550 4. War : Maximum 165 128 425 3,634 Minimum.. . 133 92 425 3,204 (b) Sometimes 2 oz. of rum . 175 2. SPAIN 1. Peace: Maximum 147 87 588 3,729 1 / N Minimum 120 62 500 3,421 (c) 2. War, on march or in the field : Maximum 131 94 522 3,327 Minimum. . . . 113 55 485 2,550 Sometimes 1.7 oz. of brandy 150 (d) 3. AUSTRIA 1. Peace 155 125 504 3,865 1 / \ 2. War 165 130 504 3,952 } (e) 4. ITALY 1. Garrison 111 130 600 4,129 2. Camp 115 133 600 4,163 3. Marching 125 143 600 4,307 1 (0 Usually wine added.. . . 250 5. GERMANY 1. Small rations and por- tions in garrison and cantonments: Maximum 150 40 703 3,947 Minimum 99 40 502 2,827 (g) 2. Large rations and por- tions on march or in maneuvers: Maximum 172 62 915 4,961 Minimum 138 57 644 3,744 3. Field: Maximum 195 151 703 4,786 Minimum 78 75 515 3,413 Commanding general may add 3 l /i oz. of whiskey 268 RATIONS OF FOREIGN ARMIES 699 COMPARATIVE TABLES OF FOREIGN ARMY RATIONS Continued NATION Ration Pro- teins Fats Car- bohy- drates Cal- ories Re- marks 6 UNITED STATES 1. By law: Maximum 183 260 621 5368 Minimum 105 103 500 3,712 2. Usually in field (by law) : Maximum 106 320 540 5,166 (h) Minimum 64 240 460 4722 Average 85 280 500 5,000 3. Food actually eaten in cold climate, moderate work, including all ex- tras from garden and purchases 155 180 597 4,907 7 FRANCE War: Maximum 183 300 690 5,455 I Minimum 146 127 520 4,015 0) Add 2 1-10 oz. of brandy 184 1 w 8 RUSSIA 1. Peace: Maximum 233 114 976 5,884 Minimum 165 65 746 4,450 (i) Add 3 oz. of wine 223 2 War: Maximum 174 62 805 8.583 Minimum 149 50 640 3,307 (k) Add 4j/ rH\i-?\ r4\i-<\ O O 1-H CO\ci\e>\o\o>\o>\c>\Ci\ Fruit: (Continued) Fresh : (Continued) Plums. . . .... % pound /MS /K l /8 V32 * %> quart As needed u u % pt. weekly % " " li lb. daily As needed u u 7 Ibs. to every 100 Ibs. flour as bread As lard sub- stitute in the proportion of 1 gal. to 10 pounds lard 1 A lb. weekly 1/32 Yt " " t / U H 1 A pt. " \l jjj \i " daily As needed } 'oS o a I 1 -D g 3 CO o> I '3 O 1 1 |S ^ 6 8 1 6 Ballod OZ. 3.10 3.30 3.70 3.25 oz. 2.15 3.75 3.11 2.33 oz. 14.5 18.7 20.1 16.0 2,708 3,642 3,550 2,790 oz. 0.85 0.90 1.13 0.90 oz. 0.88 1.60 1.06 1.06 oz. 0.8 1.5 1.4 1.4 450 715 473 550 oz. 2.25 2.40 2.57 2.35 oz. 2^10 2.05 1.27 oz. 13.5 17.2 18.7 14.6 2,480 2,927 3,077 2,204 Eltzbacher Kuczynski and Zuntz. Taylor In the Eltzbacher report the German population was put down as 68,000,000. The number of children of each year and the number of adult males and females were known. The figure for the number of children of each year of age was multiplied by the figure for the food need of that year. The number of adult females and the number of adult males were multiplied respectively by 85 and 100. The final figure for the needed food units, a compromise between several standards, was 51,822,908. This means that the population of 68,000,000 would be nourished if it received the ration of 51,822,908 adults. Three thousand calories was the figure set for the adult need. The caloric needs of the German people were, therefore, determined by the simple multiplication 3,000 x 365 x 51,822,908 = 56,750,000,000,000 calories. When this figure for total calories, determined on the basis of man ration, was divided by the figure for the population, the result was 2,280 calories a day. The protein needs of the people were also calculated. Children under six years of age were allotted 1.4 ounces a day ; from six to twelve, about 1.75 ; from twelve to eighteen, about 2.3. Adult men were allotted 2.9 ounces; adult women, 2.4. Taylor, taking into consideration that all work harder in war time, especially women, and further considering that the estimate for children 746 FOOD ECONOMICS IN WAR from 12 to 18 was too low, calculated the protein and caloric needs of the German people in war time as follows: protein, 1,524,000 tons; calories, 63,000,000,000,000. The protein needs as set forth by figures supplied by Eltzbacher, Tay- lor and Chittenden are as follows : PROTEIN NEEDS IN OUNCES Per Capita Man Ration Eltzbacher 2.30 oz. 2.83 oz. Taylor 2.15 war-time 2.5 " Chittenden 1.5 1.8 " CALORIC NEEDS Per Capita Man Ration Eltzbacher 2,380 peace-time 3,000 Taylor. . . 2,510 war-tune 3,300 Chittenden 2,030 2,600 The peace-time consumption of protein in Germany, according to the Chittenden standard, was 50 per cent in excess of requirements, and the domestic production of protein was just large enough to cover the need. It seemed also apparent from the data that the fat consumption in peace- time was too large, and that the fat of domestic origin should be enough to satisfy normal requirements. Consequently, it appeared evident to the German scientists, at any rate, that if the German people would reduce their consumption to the plane of physiological needs, that is. physiolog- ical needs chiefly computed by means of laboratory experiments, and maintain the domestic production on the peace-time basis, they would not experience much harm by a blockade. When one compares what has been achieved in production with what the commission of German scientists believed could be attained, the re- sults are not creditable to the agricultural classes, even when the influ- ences of unfavorable weather are fully allowed for. The Eltzbacher Commission made the following estimates: (a) peace-time use: protein, 2,261,000 tons, and calories, 88,694,000,000,000, including protein of domestic origin, 1,650,000 tons, and calories, 71,282,000,000,000. (fe) physiological need: protein, 1,605,000 tons; calories, 56,750,000,000,000. (c) attainable production under blockade: protein, 2,022,000 tons; calo- ries, 81,250,000,000,000. Actual production in 1914-15 in foodstuffs FOOD SITUATIONS IX COUNTRIES AT WAR 747 was: protein, 1,510,000 tons; calories, 63,410,000,000,000. Actual pro- duction in 1915-16 was: protein, 1,100,000 tons; calories, 57,000,000,- 000,000. The dietary of the industrial classes of Germany was from March to September, 1916, reduced to the physiological minimum. This diet was low in animal protein, very low in fat, and low in calories, and when the work that had to be done was considered, manifestly insufficient. A sur- vey of the chief manufacturing cities of the empire carried out during the late months of 1916 indicated that the average intake for adults varied from 1.6 to 2 ounces of protein and from 1,800 to 2,500 calories per day. As Taylor remarked, since this was not sufficient to maintain the physical labor that was being done, this was accomplished by utilization of the body fat of the workers. Food Situation in Great Britain. It was not until the early part of the year 1917 that the British Government took any very definite steps lead- ing to a control of the food supply, though a ban had been placed on some articles of food and, of course, advice had been given as to the need for economy of food and warning against waste had been freely tendered. The report on the food supply of the United Kingdom, drawn up by a committee of the Royal Society, was published in the first week of Feb- ruary, 1917, and provided some very interesting information. The first part contained an estimate of the annual food supply of Great Britain, im- ported and home-produced, in the period before the war, 1909-1913. It may be said here that, according to Taylor (2), in the year before the war, about 13,750,000 tons of foodstuffs and feeding stuffs were im- ported into the United Kingdom, nearly ten millions of which were food- stuffs. It was not possible' to give more than approximate figures, since there was overlapping, as, for example, between food fat and industrial fat. The total food consumption for Great Britain was probably about twenty million tons. To make the gross figure for importation of food- stuff more concrete, it may be stated that in 1914 the importation per capita was: wheat, 250 pounds; flour, 23.9 pounds; potatoes, 8 pounds; sugar, 80 pounds; rice, 14.2 pounds; ham and bacon, 14.2 pounds; beef, 20 pounds; mutton, 12.4 pounds; other meats, 8.4 pounds; butter, 9.46 pounds ; cheese, 5.75 pounds, and eggs, 46 per head. To turn again to the Committee's report, it is there stated that, after consideration of the dietary requirements of a nation for the most part engaged in active work, the Committee was convinced that they could not be met satisfactorily on a less supply in the food than 100 grams pro- tein, 100 grams fat, and 500 grams carbohydrates, yielding approximately 748 FOOD ECONOMICS IN WAR 3,400 calories per man per day, a "man" being an average workman doing an average day's work. The Committee adopted this as the minimum standard. Generally speaking, a woman or child requires less food than a man, and to convert the population of men, women and children into units, or "men," as denned above, the total number must be reduced by 23 per cent. In reckoning diet, 100 men, women and children equal 77 units, that is to say, men. The total quantities of foodstuffs available during the period 1909-13 provided 4,009 calories per "man." There had been a certain margin, and the Committee calculated, taking the minimum physiological stand- ard mentioned above, that there had been either wasted, or consumed in excess of requirements, of proteins 11 to 14 per cent, of fats 25 to 30 per cent, of carbohydrates 10 to 14 per cent. It should be noted that the fig- ures for quantities of food are for weights as purchased, no attempt hav- ing been made for loss during distribution, nor for digestibility. The second part of the report dealt with the food supply in 1916. The Committee stated that down to the end of July in that year, the supply of food had provided a general margin of about 5 per cent above the minimum necessary for proper nutrition and rather more as regards the supply of energy, so that a reduction to this extent would still furnish amounts of the essential food constituents conforming to the standard adopted. Such a reduction could be borne without serious injury to the community, provided steps were taken to ensure the equitable distribu- tion of the available food throughout the population. Speaking as physi- ologists, the members of the Committee laid stress on the fact that in buy- ing food the laboring population was buying energy. If rising prices curtailed for any class of the community its accustomed supply of food, its output of work would of necessity be reduced, and it was important to remember that a slight reduction of food below the necessary amount caused a large diminution in the working efficiency of the individual. In an appendix to the report, some particulars were given of army rations. The weekly rations issued to the army at home in England were as follows: beef, 84 ounces; bacon, 14 ounces; bread, 112 ounces; sugar, 14 ounces, and in addition, the men were in the habit of purchasing vari- ous articles of food from a long list yielding on an average 1,510 calories a day, giving a total energy value for the diet of a man in the British home army of 4,031 calories a day. The civil population at a similar rate, but with a reduction of 23 per cent for women and children, would be entitled to a diet yielding an energy value of about 2,667 calories a day. FOOD SITUATIONS IN COUNTRIES AT WAR 749 The following are figures estimating the food consumption of Great Britain during the first year of the war compiled by a German statisti- cian, Ballod, a British physiologist, Thompson, and Dr. Alonzo E. Taylor. FOOD CONSUMPTION PER HEAD PER DAY IN UNITED KINGDOM Protein Fat Carbohydrate Calories Thompson 2.70 oz. 3.60 oz 15 5 oz 3 100 Ballod 3.75 " 2.58 " 156 " 2900 Taylor 3.25 " 3.18 " 15 1 " 3 000 According to Thompson for Great Britain, and the Eltzbacher Com- mission for Germany, the subsistence of one hundred inhabitants would be about covered by the food required by seventy-five adult males, and the man rations of the three estimations would be as follows, in ounces and calories : FOOD REQUIRED Protein Fat Carbohydrate Calories Thompson 3.59 4.81 207 4 130 Ballod 5.0 3.45 208 3860 Taylor 4.38 4.24 20.1 4000 The caloric need of the adult man was put by the Eltzbacher Com- mission at 3,000 calories, somewhat low for the extraordinary work of war time, lower by 400 calories than that set as a minimum by the Com- mittee of the Royal Society of Great Britain. However, reckoning it at this figure, 40,240,000,000,000 calories would be required to maintain the bodily heat and energy of the 45,370,000 inhabitants of the British Isles for a year. The protein requirements calculated in similar fashion, on the com- putation of the Eltzbacher Commission, 80 grams per day for an adult man, would work out at 1,130,000 metric tons. The British Committee considered that the minimum protein requirement for an adult man was 100 grams, while Chittenden and other physiologists have contended that this amount could be greatly reduced without injury to the public health. The German experience during the war seems to lend some support to the view that Chittenden and his followers were correct, but until more is 750 FOOD ECONOMICS IN WAR known concerning conditions in Germany than is known at the time of writing, it will not be discreet to be dogmatic on this point. There is lit- tle doubt that the Germans concealed the true state of affairs to a large extent. Probably much more food was imported than was believed, and also it is not unlikely that the condition of their industrial classes was worse than it was credited to have been. Little bad news was allowed to leak out, and it must be borne in mind that the main almost sole object of the German rulers was to feed their army and workers directly con- nected with military supplies and to pay much less attention to the other members of the community. The fact must also be taken into considera- tion with respect to protein ingestion that the British have always been heavy meat eaters, and that inherited and ingrained habits count for a good deal when the, nutritive value of a diet is concerned. Nevertheless, we will take it for granted that the British consumption of protein was larger than physiological requirements. Taking the physi- ological requirements of protein daily for an adult man at eighty grams a day and the caloric need at 3,000 calories, the amount of waste in a year would read somewhat as follows: Protein Tons Billion Calories Consumption 1,660,000 53,900 Need. . 1,130,000 40,240 Waste 530,000 13,660 According to the Eltzbacher Commission, the waste of the German people was: protein, 650,000 tons, and calories, 31,899,000,000,000. The per capita waste was thus greater in protein in Great Britain, greater in calories in Germany. From all available data, one might adjudge seven hundred thousand tons as a reasonable figure for domestic production of protein in Great Britain. This leaves a deficit of nearly 500,000 tons. In other words, the domestic production of protein was about 55 per cent of the require- ments. According to Taylor'G estimate, the following figures show ap- proximately the situation in Great Britain in the early part of 1917 as regards protein and calories: Protein Tons Billion Calories Consumption 1,660,000 53,900 Requirements 1,130,000 40,240 Domestic production. . . 700,000 19,000 Deficit 430,000 21,240 FOOD SITUATIONS IN COUNTRIES AT WAR 751 In Taylor's papers on the food situation in Germany, which have been largely employed as a basis for this chapter, the lack of sugar was referred to and attention was drawn to the fact that saccharin was used as a substitute. In a report which the same author wrote for the Amer- ican Embassy at Berlin, he gave a detailed analysis of the food of the civil prisoners at Ruhleben Camp. But before giving a part of this report and the references therein to saccharin, a few comments will be made on the feeding of military prisoners. The ration established for military prisoners in Germany in the month of June, 1916, contained 2,700 calories a day, made up of 80 grams of protein, 29 of fat, and 500 of carbohydrate. This, though not plentiful, was adequate as regards its caloric value for average men not doing much muscular work. The pro- portion of fat is low, but such a diet need not endanger nutrition in adults, provided the requisite food value is made up by other foodstuffs. The diet, however, for certain prisoners at Ruhleben Camp, and concerning which Taylor wrote, was indeed sparse in fact, a starvation diet. In the following table the Ruhleben diets are compared with ordinary stand- ards of living: RUHLEBEN DIETS COMPARED WITH STANDARD DIETARIES Calories Protein Fat Carbo- hydrate English laborer 3,655 184 71 570 German farm laborer (Ranke) 4,696 143 108 788 Standard diet for a man of moderate activity 2,820 100 100 360 Military prisoners of war in Germany. Ruhleben diet before reduction . . . 2,700 1,580 80 59 29 12 500 308 Diet actually taken when increased by food left by other prisoners 2,725 98 24 523 Ruhleben diet since reduction 1,220 39 6 255 Reduced diet when increased by food left by others 1,930 55 10 410 The substitution of saccharin for sugar in the diet of the Ruhleben prisoners was commented upon in the Journal of the American Medical Association, Aug. 12, 1916, as a war food abuse. When sugar became scarce in Germany, the law prohibiting the use of saccharin was abro- gated. Two months later its use was made compulsory in certain direc- tions. However, as Taylor points out, saccharin can never be termed a substitute for sugar from the gustatory or any other point of view. Cer- tain articles of food containing saccharin have the normal taste ; to other 752 articles of food, however, an abnormal after-taste is given, a condition particularly noticeable in beer. Before food regulation was introduced into Great Britain, the diet of the munition workers had been regulated with surprisingly good re- sults. It must be borne in mind that an immense army of such workers, a large proportion of whom were women and children of over twelve years of age, had been organized. It was incumbent on the state from every point of view that their health should be carefully safeguarded, and naturally a sufficiently nutritious diet was a sine qua non in the achieve- ment of this object. The soldier and the sailor expected that their diet would be arranged to meet their particular needs, and when the great rise in the price of food occurred, it was found that, in order to supply the munition workers with food of a character calculated to enable them to fulfill their important duties with efficiency, they must be dieted accord- ing to their special requirements. Dr. Leonard Hill was chosen to make an investigation into the mat- ter, so that he might supply data upon which improvements in diet might be based. He laid down the principle that the amount of food taken should be regulated solely by the loss of energy it was required to replace, and pointed out that fortunately the chief foodstuffs really provided all the nourishment that was requisite for and consistent with health, better probably than the more highly flavored and expensive foods which artifi- cially stimulate the appetite. Of such foods, Dr. Hill gave the following list: bread, margarin, porridge, milk, herrings, cheese, beans, cabbages, oranges, and the cheaper kinds of meats. Under his direction the canteen meals for munition workers who came from some distance were analyzed after the following method: The in- gredients were all thoroughly mixed, after weighing each separately, so that dietaries could afterwards be constructed from the weights. An ali- quot part of the intimate mixture was thoroughly dried and weighed. In the dry material protein was determined from a nitrogen estimation, the fat by ether extractions in a Soxhlet's apparatus, the ash by burning and weighing, and the carbohydrate by difference. In this way the amounts of dry protein, fat and carbohydrate respectively in the meal were ob- tained, and from these the caloric value was determined. An analysis of twelve canteen meals showed that they afforded on an average, protein, 42.43 ; fat, 36.7 ; carbohydrate, 146.9 grams, yielding 1,114 calories per capita. The average canteen dinner was found to be good, containing an energy value of 1,114 calories well distributed among the amounts of protein, fat and carbohydrate. FOOD SITUATIONS IN COUNTRIES AT WAR 753 The meals brought from home by the workers were also submitted to analysis. The workers whose meals were thus obtained were not asked beforehand to bring a sample meal, but were interrogated at the entrance gates and asked to exchange the contents of their basket for a sum ample to buy a meal at the canteen. In the case of men, these meals were found to be adequate, but in the case of girls there was a very wide variation, from 300 up to 1,100 calories. As for the latter, the breakfast meal be- fore starting work was often found to consist of white bread and boiled tea. Although there was nothing in the investigation which was very new, it showed that a valuable degree of practical certainty was being reached in regard to the minimum adequate diet required for a certain type of manual labor. The following table (3) may be of interest as showing the diet during the war, but before voluntary restriction, of three middle class families in England. The families consisted of 16 persons, 3 men (sedentary), 9 women and 4 children: DIETARIES FOR THREE MIDDLE-CLASS FAMILIES, SIXTEEN PERSONS, IN ENGLAND BEFORE VOLUNTARY RESTRICTION Weekly DAILY YIELD IN GRAMS Energy Weight in Ounces Protein Fat Carbo- hydrate Value in Calories Meat, sausages, bacon 50.5 28.8 52.4 1.1 663 Bread 58.0 18.7 2.8 123.1 580 Sugar 8.9 36.3 145 Total 117.4 47.5 55.2 159.5 1,388 Cheese 4.0 4.5 4.9 0.4 63.4 Butter, etc.. 13.2 0.5 43.3 424.0 Potatoes.. 32.0 2.27 0.13 27.2 122.0 Flour and Oatmeal 7.0 16.2 2.3 21.3 103.0 Rice, lentils, etc 11.6 1.6 0.7 24.3 270.0 Jam and dried fruits 3.8 3.7 0.2 8.7 37.8 Total.. .. 71.0 28.77 53.53 81.9 1,020.2 Total ration of restricted articles 47.5 55.53 159.5 1,388 Total of extras 28.77 53.53 '81.9 1,020.2 76.27 108.73 241.4 2,408.2 754 So far as this examination went, it appeared to show that the mem- bers of middle-class families in England during the war, when left to their own devices, received rather less protein, somewhat more fat, and considerably less carbohydrates than the standard per head of the whole population, and that the yield in calories was about 15 per cent less, waste not being reckoned. From the above table, the average weekly consumption of milk was omitted. This reached the amount for the three families of 4.8 pints per week, or 0.7 pints a head, bringing up the energy value of the diet per capita per day to 2,910. Voluntary Rationing Scheme in Great Britain A voluntary rationing scheme had been initiated in Great Britain, and was favorably commented upon in an editorial which appeared in the Lancet, November 17, 1917. It was pointed out that while a faithful adherence to the limited amounts of the staple foods outlined in the scheme would save a grave situation, no hard dietetic or physiological sacrifice was called for. The staple foods named were bread, flour and other cereals, meal, butter, margarin, lard and sugar. Outside this list no rationing was suggested. Potatoes were not included and therefore, as a valuable carbohydrate supply, might be largely employed to eke out the stock of scheduled foodstuffs, and so save the staples. In addition an exchange could be made in certain cases, notably with regard to bread and meat. Thus any person might take half a pound of meat over and above his meat ration in exchange for half a pound of bread to be deducted from his bread ration and vice versa. The Lancet thought that the scheme bears evidence of being well thought out from the economic point of view, while it provided a physiological suffi- ciency for all. The public of the United States would do well to bear this in mind, for it is important to remember that a voluntary rationing scheme which provides amply for all physiological needs is much less a hardship than actual famine, while its adoption means the releasing of so much tonnage, and adding to the efficiency of transport service. In plain words, the individual who loyally enters into the spirit of the scheme will be helping to win the war, and is doing so in contradiction to no law of physiology or of medicine. The English scheme applies with force to the food situation in Amer- ica. The people must cooperate in thrift so far as food is concerned and especially with respect to the staple foods. However, the food situation in the United States will be dealt with at some length further on. The following table gives at a glance the new rations proposed in Great Britain in November, 1917: FOOD SITUATIONS IN COUNTRIES AT WAR 755 ADULT RATIONS IN GREAT BRITAIN, PER HEAD PER WEEK Occupations Bread ( Other Cereals, Butter, Fats, Margarine, Meat, lh Sugar, C\1 Oz. Lard, Oil, 1U. \Jt t Oz. 1. Men on very heavy industrial or on agricultural work 81b. Ooz. 2. Men on ordinary industrial or other manual work 7 " " 3. Men unoccupied or on seden- tary work . 4 " " 2f\ ' 4. Women on heavy industrial 12 10 .0 8 work or on agricultural work 5 " " 5. Women on ordinary industrial work or in domestic work . . 4 " " 6. Women unoccupied or on sed- entary work. 3 " " j The bread rations included all flour, whether used for bread or for cooking. Flour might be taken instead of bread at the rate of % Ib. of flour for every pound of bread. The other cereal rations included oatmeal, rice, tapioca, sago, barley meal, corn flour, maize meal, dried peas, beans and lentils, and all cereal products except bread and flour. The weight given was the weight of the dry article, as bought. If the full bread ration was not used, the amount saved could be taken in other cereals. The "meat" rations in- cluded the average amount of bone, which might be taken as one quarter of the weight of the actual meat. Any parts of meat, such as rump steak, bacon or suet, which were bought without bone, must count for one- quarter more than their actual weight. On the other hand, any bone in excess of a quarter of the actual meat bought might be deducted. Poultry and rabbits might be counted at half their actual weight. The meat rations included suet. Sir Arthur Yapp, who outlined the scheme, divided the population into six sections, three for men and three for women. Children were to receive their reasonable ration of essential foods, and as their needs differ so widely, a definite ration was omitted for them. Broadly, the scheme provided more bread but less meat and sugar. A very pertinent table on the unrestricted diet of a sedentary worker was published by Dr. A. D. Waller, F.R.S. (4), a well-known physiologist and the author of a standard text-book on physiology. The following table gives the constituent parts of Dr. Waller's meals on three successive days, and it will be gathered from this table that his average caloric consump- 756 FOOD ECONOMICS IN WAR tion for the three days was 2,471, inclusive of 227 calories of claret and whiskey, of which the caloric value is not undisputed. Of the total 2,471, breadstuffs constituted 840 calories, which is equivalent to 334 grams of breadstuffs; of the 334 grams of breadstuffs, 200 grams were loaf bread and 134 grams were puddings, etc. ; 100 parts of his bread material, there- fore, were made up of 60 parts of loaf bread and 40 parts of other farina- ceous materials. THE UNRESTRICTED DIET OF A SEDENTARY WORKER OCTOBER SBD, 1916 1. EARLY TEA c/o assumed Grams Protein Fat Carbo- hydrate Calories Protein Fat Carbo- hydrate 8 1 3.5 1 80 4 50 Bread 20 5 20 10 1.6 0.05 0.7 0.2 4.0 0.8 10.0 1.6' ' 10.0 49.42 37.405 14.41 41.0 Butter 5 100 Milk Sugar 2.35 5.0 11.0 142.235 2. BREAKFAST g 1 50 Bread . . . 75 6.0 0.75 37.5 185.325 1 80 Butter 30 0.3 24.0 224.43 3.5 4 5 Milk 300 10.5 12.0 15.0 216.15 10 50 Bacon 20 2.0 10.0 101.20 12 12 Egg 50 6.0 6.0 100 25 25.0 102.50 05 0.1 50 Marmalade 50 0.25 0.5 25.0 103.99 25.05 52.8 1025 1,013.995 3. LUNCH 8 1 50 Bread 60 4.8 0.6 30.0 148.26 1 80 Butter. 15 0.15 12.0 112.215 15 5 25 3.75 1.25 270 25 25 25 15 3.75 3.75 0.375 51.7875 100 Sugar 10 10.0 41.0 5% Ale Wine . . (150) (52 5 cals ) 12.45 17.6 40.375 380.262 4. AFTERNOON TEA NIL. 5. DINNER 2 2 6 150 3.0 3.0 9.0 77.1 10 2 Fish 40 4.0 0.8 23.84 15 5 Meat : 60 9.0 3.0 64.8 g 1 50 Bread 30 2.4 0.3 15.0 74.13 2 2 40 50 1.0 1.0 20.0 95.4 2 0.1 20 Potatoes 50 1.0 0.05 10.0 45.565 1 80 Butter. 5 0.05 4.0 37.405 25 25 2.5 Cheese 10 2.5 2.5 0.25 34.525 10 1.0 85 Biscuits 25 2.5 0.25 21.25 99.7 5% Ale. Wine. . . .... (300) (105 cals.) 100 Sugar 15 15.0 61.5 25.45 14.9 90.5 613.965 6. SUPPER 50% Ale. Whiskey.. . ... (30) (105 cals.) 10 1 85 Biscuits 25 2.5 0.25 21.25 99.7 2.5 0.25 21.25 99.7 Total 67.8 99.55 280.625 2,270.657 +Total(262.5) Total calories 2,533.157 FOOD SITUATIONS IN COUNTRIES AT WAR 757 THE UNRESTRICTED DIET OF A SEDENTARY WORKER Continued OCTOBER 4-rir, 19 10 1. EARLY TEA c/o assumed Grains Protein Fat Carbo- hydrate Calories Protein Fat Carbo- hydrate 8 1 3.5 1 80 4 50 "5 100 Bread 20 5 20 10 1.6 0.05 0.7 0.2 4.0 0.8 10.0 ' i.b 10.0 49.42 37.405 14.41 41.0 Butter. Milk Sugar 2.35 5.0 21.0 142.235 2. BREAKFAST 15 8 8 1 60 50 Porridge (20 dry) . . . Bread 100 60 3.0 4.8 1.0 0.6 12.0 300 76.38 14826 1 80 Butter. 30 0.3 24.0 224.43 3.5 4 5 Milk 400 14.0 16.0 20.0 288.20 10 50 Bacon 20 2.0 10.0 101 20 12 12 Egg 50 6.0 6.0 80.40 0.5 0.1 50 50 0.25 0.05 250 10399 100 Sugar 25 25.0 102.0 30.35 58.25 112.0 1.125.36 3. LUNCH 8 1 50 Bread 45 3.6 0.45 22.5 111 195 1 80 Butter 10 0.1 8.0 74.81 10 2 Fish 60 6.0 1.2 35.76 2 2 40 Pudding 60 1.2 1.2 24.0 114.48 5% Ale. Wine.. . . . . (150) (52.5 cals ) 10.9 10.85 46.5 336.245 4. AFTERNOON TEA 8 1 50 Bread . . 40 3.2 0.4 20.0 98.84 1 80 Butter 10 0.1 8.0 74.81 100 5 5.0 20.50 3.5 4 5 Milk 10 0.35 0.4 0.5 7.205 3.65 8.8 25.5 201.355 5. DINNER 15 5 Meat 40 6.0 2.0 43.2 8 1 50 Bread 45 3.6 0.45 22.5 111.195 2 2 40 Pudding 80 1.6 1.6 32 152.640 2 0.1 20 80 1.6 0.08 16 72.904 1 80 Butter 5 0.05 4.0 37.405 25 25 2.5 Cheese 10 2.5 2.5 0.25 34.525 10 1 85 Biscuits 12.5 1.25 0.125 10.625 49.850 100 Sugar 5 5.0 20.500 5% Ale. Wine. . . (100) (35 cals.) 16.6 10.755 86.375 522.219 6. SUPPER 8 1 50 Broad . . . 15 1.2 0.15 7.5 37.065 25 25 2.5 Cheese 20 5.0 5.0 0.5 69.050 50%Alc Whiskey (30) (105 cals.) * 6.2 5.15 8.0 106.115 70.05 98.805 299.375 2,433.529 +(192.5) Total calories = 2,626.029 148 758 FOOD ECONOMICS IN WAR THE UNRESTRICTED DIET OF A SEDENTARY WORKER Con tinned OCTOBER STH, 1916 1. EABLT TEA c/o assumed Grams Protein Fat Carbo- hydrate Calories Protein Fat Carbo- hydrate 8 1 3.5 1 80 4 50 5" 100 Bread. 30 5 30 5 2.4 0.05 1.05 0.3 4.0 1.2 15.0 1.5 ' 5.0 74.13 37.405 21.615 20.5 Butter. . . Milk Sugar 3.5 5.5 21.5 153.65 2. BREAKFAST 15 8 8 1 60 50 Porridge (20 dry) . . . Bread 100 60 3.0 4 8 1.6 06 12.0 300 76.38 148 26 1 80 Butter. . . 15 0.15 120 112 215 3.5 4 5 Milk 400 14 16 200 288 2 10 2 Fish 65 6.5 1.3 38 74 100 Sugar 10 10.0 41.0 0.5 0.1 50 Marmalade 50 025 05 250 10399 28.7 31.55 97.0 808.785 3. LUNCH 8 1 50 Bread 40 3.2 0.4 20.0 98.84 15 5 30 4.5 1.5 32.4 2 0.1 20 Potatoes 30 0.6 0.03 6.0 27.339 1 80 Butter. 5 0.05 4.0 37405 5% Ale. Wine (150) (52 5 cals 8.35 5.93 26.0 195.984 4. AFTERNOON TEA 3.5 4 5 Milk 15 0.525 0.6 0.75 10.8075 100 Sugar 5 5.0 20.5 0.525 0.6 5.75 31.3075 5. DINNER 2 2 6 200 4 4 12.0 102.8 15 5 Meat 85 12.75 4.25 91.8 3 1 50 Bread 60 4 8 06 30.0 14826 2 1 20 60 1.2 0.06 12.0 54 (i~S 2 2 40 80 1 6 1.6 32.0 152 64 25 25 2 5 15 3.75 3.75 0.375 51.7875 1 80 Butter 10 0.1 8.0 74.81 05 0.1 50 Jam 20 0.1 0.02 10.0 41.596 5% Ale Wine (200) (70 cals ) 28.3 22.28 96.375 718.3715 6. SUPPER 50%Alc Whiskey (30) (105 cals.) 10 1 85 Biscuits 30 3.0 0.3 25.5 119.64 Total 72.375 66.16 272.125 2,027.738 +(227.5"cals.) Total calories = 2,255.238 SUMMARY Protein Fat Carbohy- drates Calories Calories (Ale.) October 3rd. 67.8 90.55 280 625 2,270 657 262.5 October 4th 70.05 98.805 299.375 2,433.529 192.5 October 5th 72.375 66.16 272 125 2,027 738 227.5 Total for 3 days 210.225 255.515 852.125 6,731 924 682.5 Average for 1 day 70.075 85.1717 284.0417 2,243.975 227.5 2,471.475 USE OF CERTAIN FOODSTUFFS IN WAR 759 Of course, Dr. Waller's case was not representative. He was 60 years of age, weighed 190 pounds, and belonged to the class of sedentary workers whose caloric requirements are considerably lower than those of the manual worker. Still it is a matter for some surprise that his calories should be as low as 2,244. It is interesting to note that Waller in his "Text-book of Physiology" has given 3,000 as the average calorie re- quirement per working man per day for food as eaten, and that this should have as its foundation 1 pound of bread per day. USE OF CERTAIN FOODSTUFFS IN WAR Bread and Cereal Foods. With regard to the value of bread as a staple diet, it is instructive to note that the ordinary prison diet in an English jail, adopted in 1889, contains 3,040 calories, of which the bread, inclusive of flour and oatmeal, amounts to 2,378 calories, of which 1,715 calories are afforded by 22 ounces per day of actual bread. On this diet it was found that 82 per cent of the prisoners gained weight, while 18 per cent lost weight. This brings us to the question of bread and its value as a food. One of the most valuable, perhaps the most valuable, lesson that the war has taught us, or rather has emphasized, is that highly milled bread is less nutritious than whole-meal bread. It is now known that the con- sumption of cereals from which the husks have been removed, when used as a sole or main means of nutriment, is responsible for disease. 1 Beri- beri, pellagra, scurvy and probably rickets have all been traced more or less to this cause. Bread made from highly milled flour when constituting but a part of the diet, is not directly responsible for diseased conditions, but from the outlook of health is not to be recommended. It tends to con- stipation, because it requires little mastication and also requires little ex- ercise by the organs of digestion; it is smooth and does not irritate the digestive organs, or induce internal secretions to exertion, and conse- quently it is apt to take an undue time for assimilation and absorption, and for its waste products to pass through the intestinal tract. Moreover, according to the most recent views, the very part of the cereal that is milled or taken away is that which contains food elements which are indispensable for growth and the maintenance of life. These have been termed "accessory diet factors" or "vitamines." They may be conceived of as stimulating certain physiological processes and as essential to cer- tain functions. 1 Sec also Volume II, Chapter VIII; Volume III, Chapter XVII. 760 FOOD ECONOMICS IN WAR As Mendel(5) has pointed out, the lubricant is quite as important to a machine as the energy-furnishing fuel. In a similar way these diet ac- cessories or "vitamines" may possess peculiar usefulness. Some of them are believed to be easily impaired by heat ; in the language of the chem- ist, they may be thermolabile. Hence the use of heat for preserving or sterilizing foods suggests new difficulties. They may be lost in the wastes of the modern technical processes, as in the milling of cereals. Wheat, for example, by modern milling is denuded of its pericarp. A beauti- fully smooth white flour results which has been deprived of a considerable amount of its nutritive virtues and is hardly suitable as food for a human being, supplied with a strong jaw and teeth intended to be employed in mastication. The food orders in Great Britain, promulgated chiefly with the view of economizing food, although, of course, distasteful to the mass of the population, have proved with regard to the preparation of bread, a bless- ing in disguise. Bread in all countries, and in Great Britain in particu- lar, is the chief means of sustenance of the working classes, and it is somewhat curious that the necessities of war should have brought into force a measure which, regarded from the public health standpoint, is as important as any measures which have been brought forward in modern times. Wheat, of all the cereals used for the manufacture of bread, is, perhaps, the most nutritious. At any rate, it has the most delicate flavor, it contains a large amount of gluten, and for making bread is, on the whole, the most popular product of the earth. In addition, wheaten flour, unlike the flour of other cereals, is readily kneadable, and can therefore be made into bread, macaroni, vermicelli, pastry, and all kinds of puddings and cakes. The first food orders issued in England called for the extraction of 76 per cent from the total grain; a few weeks later the extraction of a further 5 per cent was ordered ; and it may be said that, after the early summer of 1917, the wheaten bread consumed in Great Britain was to all intents and purposes whole-grain bread. An option, however, was given to millers to mix with the wheat, flour derived from barley, maize, rice or oats, to the extent of 10 per cent. This meant that the miller need not mill his wheat further than the original allowance of 76 per cent, provided he added a proportion of other flours. It is possible to add to flours rich in gluten a proportion of starch, as for example, flour made from corn, without materially reducing the nitrogen value when compared with a low-grade wheaten flour. The energy value of a loaf from such flour would be quite high, while its nourishing properties would be littls USE OF CERTAIN FOODSTUFFS IN WAR 761 impaired. Corn flour and rice, however, would somewhat detract from its protein value, while barley and oats would add proteins and fat. The loaf containing an addition of barley and oats would, from a dietetic point of view, likely enough, have a superior value to the loaf made with a similar proportion of corn or rice. To those who hold that bread is primarily eaten not so much as a source of protein, but as an easily digestible, attractive form of starch, it matters little which flour is employed. Obviously, however, in war time, the question of cost is predominant and the wheat substitutes can be used for no good purpose unless they are cheaper than wheat flour itself. It may be pointed out that in America, from this standpoint, corn particu- larly commends itself as a food. Apart from this point, the physical qualities of a loaf of bread must be considered, texture for one thing being an important property. The characteristics which formerly chiefly com- mended a loaf of wheaten bread were that it was light and spongy, easily masticated and digestible. It goes without saying that the lumpy, sodden loaf is unattractive and indigestible, and its food value may be largely discounted owing to its causing gastric troubles. On the other hand, while a loaf should be light, it is an advantage that it should be so baked that externally it is hard and crusty, affording plenty of work for the jaws, teeth and salivary glands. Nearly all the vegetable foods which invite mastication are crusty bread, dry toast, hard biscuits, salads, nuts and apples. Our staple vege- table food wheaten bread is almost invariably eaten in a spongy form. The loaves are shaped so as to afford a minimum of surface for crust, and are lightly baked so that the crust shall be as thin as possible. In fact, the prejudice that the majority of people have against crust is such that the most crusty loaves, those which have rested on the floor and against the sides of the oven, fetch a lower price than the others. The more thoroughly a farinaceous food, as bread, is chewed, the more intimately will it be mixed with the saliva, and the more efficiently is it likely to be digested. It is certain, furthermore, that when food is well digested, it will go further, and less of it will be required than when it is not well digested. Thus, a piece of crusty bread well masticated will go a longer way to satisfy the appetite and the nutritive requirements of the system than an equivalent of pudding or of some of the soft mushy food which has such a vogue in this country. While by no means a dis- ciple of Fletcher, who unduly exalts the merits of mastication, and who advocates its practice to absurd lengths, the author is convinced that it would be in the best interests of the health of the community at large if 762 FOOD ECONOMICS IN WAR more mastication were practiced, particularly with regard to the carbo- hydrates in short, if less soft food were eaten. The best way to secure adequate mastication is to select foods which invite or even compel it. It is chiefly in regard to wheaten flour, oatmeal and rice that reform is most needed. Many people in England, at the time of writing, are wondering, now that war bread has made its appear- ance, why they ever preferred the bread made from highly milled flour. The ideal loaf of wheaten bread from the nutritive standpoint is the crusty one made from whole-meal, which needs more mastication than the spongy loaf, promotes good digestion, excites peristaltic action, and, above all, contains those food elements known as vitamines, which stimu- late certain physiological processes and are essential to the perfect well- being of the organism as a whole. Of other cereal foods than wheat, oats in the form of oatmeal, corn and rice occupy the first places. From the aspect of protein value, oat- meal is the most nutritious, containing as it does more protein than wheat and considerably more fat. Rice is less nutritious than wheat or oats, and inasmuch as it is polished rice which is imported, and which, eaten solely, constitutes the deficiency diet par excellence, its employment as a staple of diet is not indicated. With regard to oatmeal as a war food, it may be recommended both on the grounds of economy and nutritive properties. It is in itself a valuable food, but in the form of porridge does not conduce to mastica- tion. Moreover, the oatmeal flour sold nowadays is made from oats which have been denuded of their husks, and is, when made into porridge, an especially soft and pappy article of diet. The good, coarse Scotch oat- meal porridge of yore, which required a certain amount of mastication, and which contained the husks of grain in which were the vitamines, is no longer seen in this country. In its place is offered a smooth bland sub- stance, wholly devoid of the irritating, health-giving elements referred to and affording not the slightest exercise to the jaws, teeth or the salivary glands. From the point of view of mastication, oatmeal biscuits are pref- erable to oatmeal porridge, but the latter is so popular and valuable a food that it may be permitted in war time with the proviso that it is made from whole-meal and that it is subjected to some sort of chewing. While the good influence of protein consumption on health may have been exaggerated, and while the need for a large protein intake may have been overestimated, it is still allowed on all hands that a certain amount of protein is necessary for the maintenance of the bodily powers at a high standard. Many even hold that a considerable protein intake is benefi- USE OF CEKTA1N FOODSTUFFS IN WAK 763 cial, aud the author is one of these. It must be remembered that the pro- tein molecule is composed of a group of dissimilar chemical units, many of which appear to be indispensable for the nutritive functions. As the animal body cannot construct all of these synthetically, it is dependent for a supply thereof upon the diet. The proteins of foods commonly eaten provide these essential units in unlike yields. Accordingly, the view is gaining ground that an adequate ration must furnish these units in amounts sufficient quantitatively and qualitatively. Corn possesses satisfactory nutritive properties in many directions, but is somewhat lacking in its protein contents, or perhaps it would be more correct to say that corn and the by-products of the corn kernel are considered as a result of laboratory analysis, inadequate for good feeding purposes unless they are supplemented by other protein-containing food. It has been suggested by scientific authorities that the addition of supple- mentary proteins perhaps those which are present in dried milk prod- ucts might render such a food as corn, which in this country is plentiful and inexpensive, but to some extent possibly inefficient from the protein standpoint, considerably more valuable as a staple article of diet. By many it is argued, however, that the slight lack of protein in corn, com- pared with wheat and oats, detracts little if any from its nutritive value. Practical experience has demonstrated that it is a wholesome food, and, after all, it is experience that is, taking everything into consideration, the siirc-t guide. According to Dr. Haven Emerson, Health Commissioner of New York, corn meal afforded the same amount of nourishment as wheat flour and was, at any rate, in April, 1917, 25 per cent cheaper. No doubt, from several points of view this statement is correct, and corn meal is a nourishing form of food and one considered from the outlook of food economies in war time, to be advocated as a staple diet. Yet, as in the case of wheat, oats and rice, in fact of all cereals, corn deprived of its husks is a less nutritive aliment by far than when these are allowed to remain. More than a strong suspicion has been aroused, approaching indeed conviction, by the researches of Voegtlin and others, that pellagra is a deficiency disease, and that its prevalence in the Southern States is largely if not entirely owing to the manner in which corn, which is the staple diet of the population, is milled. It is, then, as obvious in the instance of corn as in that of rice, wheat, oats and other cereals, that it should not be highly milled in order to obtain the greatest nutritive benefit from its consumption. The war has taught and emphasized the point that all cereals regarded from the health and economical aspects 764 FOOD ECONOMICS IN WAR should be so milled or prepared for human consumption that the coarser parts should be left for reasons which have been fully explained in differ- ent portions of this work. A great advantage possessed by corn as a food is that it is pleasant to the palate and that it may be cooked and prepared in a variety of ways, while above all it is cheap. Our readers may be reminded of the fact that during the Civil War soldiers subsisted for considerable periods of time almost wholly upon corn, employing it even as a vehicle for making a substitute for coffee. Potatoes. It is hardly necessary to dwell upon the fact that potatoes are factors of much importance in war-time feeding. A bountiful potato crop probably saved Germany at a very critical period. Potatoes, how- ever, do not provide such reliable crops as the cereals, and if a potato crop fails, it usually fails wholly. It may be pointed out that, as a rule, there is gross waste in the preparation of potatoes for food. There is no need indeed, in war time, the custom should be strongly discountenanced if not prohibited of peeling potatoes before cooking them. A useful part of the potato is removed with the skin, and the majority of people can eat potato skin with advantage. Special care should be taken not to waste the highly nutritious potato. Potato bread is a pleasant and sat- isfying food, and it is a good plan to make it of cooked potatoes which might otherwise be wasted. Milk. The question of milk is a very obtrusive one in war time. It has become almost an article of faith that a large supply of milk is indis- pensable to the maintenance of good health, and that, if a milk supply failed wholly or in part, the consequences would be disastrous. In time of war, foodstuffs and feeding materials must be economized. To find feeding material sufficient to maintain cows in such a condition that they will provide a good supply of milk, implies a great deal of labor and also the importation of an amount of feeding material which is inconvenient when not impossible under war conditions. It is assuredly true that to conserve infant life, a certain supply of cow's milk is necessary, that is, in the existing state of affairs, when so many women do not suckle their offspring. But that, after the baby age is passed, milk is an absolutely essential article of diet is strongly combated by many authorities. Camp- bell (6) went so far as to declare that the child, as distinguished from the babe, does not need milk and would not suffer greatly if the supply of dairy milk suddenly failed. He argued, in the first place, that milk, affording as it does a peculiarly favorable soil for the growth of disease germs, has carried disease and death to hecatombs of children. It has USE OF CERTAIN FOODSTUFFS IN WAR 765 further acted injuriously by favoring the consumption of soft, pappy foods. It is obvious that the infant, like the young of other mammals, requires milk for the first period of its life, and that the proper milk for it is that of its own mother. When this source of supply fails or is not available, as so frequently occurs in these days, resort must be had to the milk of other animals, cows or goats. This has not proved an unmixed blessing, but the question has been so thoroughly covered in Volume II, Chapter XV, and Volume III, Chapter XXIV, that it would be super- fluous to lay further stress on this phase of the matter. According to Campbell, while the infant needs milk of some kind during the first nine or ten months of life, it does not need any after that period. Why should the young of man any more than the young of other mammals require milk after it has left the breast ? It is only since man first domesticated the cow and goat and this from the point of view of his evolution was but as yesterday that he has been supplied with any milk other than human, and it is absurd to suppose that before that time his health suffered from the lack of cow's or goat's milk. The pre-agri- cultural tribes to this day are without any, and until civilized man de- teriorated them by the introduction of alcohol and European vices, they were magnificent physical specimens of manhood. The argument is not made that dairy milk is a useless food for man, but merely that it is not essential to him after the nursing period. Its chief value to the human race is as a source of butter and cheese, two highly concentrated and agreeable foods, admitting of prolonged storage, as not only cheese but salt butter may be kept for many months. Un- doubtedly cheese is a very valuable form of food in war time, on account of the large amount of protein that it contains. The manufacture of milk into butter and cheese rather than its use in the form of milk, especially into cheese, is prompted by considerations of health and economy alike. Sugar. Another article of food which has given rise to violent and persistent discussion, and the use of which has been the most vexed ques- tion of all with regard to food economics in Great Britain and Germany, is sugar. In Germany sugar was consumed in immense quantities, mainly, perhaps, because that country produced it on the largest scale. Now so short. is the supply there that, as noted previously, saccharin has been substituted. It was not long ago that sugar was lauded as an essen- tial. Now neither scientific men nor practical observers speak so de- cidedly in favor of sugar as a necessary ingredient or part of a diet. Mendel says that, although sucrose, the form in which it is generally used, has a considerable fuel value in the organism, its dietary use is primarily 766 dictated by considerations of flavor. Opinions are occasionally divided as to the place of this sugar in the dietary. Mendel is of the opinion that the artificially colored white sugar has nothing except a false standard to recommend it in place of the natural cream-colored sugar. It will be ob- served that Mendel appears sceptical as to white sugar being of any great nutritive value, but does not comment on the cream-colored product. Campbell, referred to above, propounded as iconoclastic opinions with regard to the food value of sugar as he propounded concerning milk. He stated that we could get on very well without sugar at all. Primitive man had none but the limited quantity furnished by wild honey. War prices are exorbitantly high, and it consequently behooves everyone to be eco- nomical. He maintained that all money spent on candy is worse than wasted, and recommended that none should be so spent, that the money saved in this way should be loaned to the state, and that the multitude of persons engaged in the sweet industry should be transferred to occupa- tions more profitable to the country. More than one well-known physiological authority has stated that sugar is not a natural food, inasmuch as the human economy is con- structed to convert carbohydrate, e.g., starch, which they claim to be a natural foodstuff, into sugar. It is certain that if sugar were tasteless or not sweet, it would not be so popular as it is, and thus it must rank as a condiment as well as a food. It is interesting to recall that sugar was scarcely a commercial commodity a little over a century ago, and that before that our ancestors got on very well without it, while, as a matter of fact, a big section of the community consumes nowadays very little or none of it. The history of starch in the dietary, on the other hand, goes back to the very beginning of things, and there was a supply of starches long before sugar was thought of in its present form. . Custom and cheapness have brought sugar into wide use, but in time of war its employment in many extraneous and totally unnecessary ways should be prohibited. After all, diet is largely ruled by custom, and war has gone to show that many customary articles of food which were con- sidered essential by the public cannot only be dispensed with, but be dis- pensed with to the benefit of the general health. Alcohol in War Economics. The war in Europe has had a great effect on the consumption of alcohol. It need hardly be pointed out that in the economics of war the question of alcohol stands out most prominently. The value of alcohol as a food or even as a fuel may be dismissed as trivial in comparison with the harm that it does, and the waste of men and food and feeding material in its manufacture. USE OF CERTAIN FOODSTUFFS IX WAR 767 The food or fuel value of alcohol is so slight as to he a negligible quan- tity. It has been established that about one ounce of absolute; alcohol is the limit which can be burned up in the body within a period of twenty- four hours without paralyzing or narcotic effect, and without the appear- ance of unchanged alcohol in the excreta, and one ounce of alcohol sup- plies about as much fuel as one ounce of margarin, 200 calories. Xow one ounce of alcohol costs in the form of cheap spirit not more than four cents ; in the form of beer less ; in the form of heavy wines, 8 to 12 cents ; in the form of light wine, 24 cents; while to these prices must be added some 40 or 50 per cent during war time. One ounce of margarin costs about 2 cents. Therefore, even if alcohol is regarded as a food, it is an extremely wasteful and expensive one. Perhaps the sudden withdrawal of alcohol in any form from those with whom its use has been habitual may be followed by injurious effects on muscular and nervous energy. It is conceivable that men who for years have been accustomed to taking some form of alcoholic beverage as a part of their diet after a hard day's labor, might be affected by its sudden and complete withdrawal. Possibly in any regulations drawn up for the re- striction or prohibition of the manufacture or sale of alcohol, it might be deemed wise to make allowance for the cases of those in whom total abstinence produces ill effects. There are other difficulties in the way of enforcing prohibition, such as the probable development of an illicit traffic in alcohol and the introduction of substitutes for alcohol which might be infinitely more detrimental to public health and order. When all is said that can be said in favor of alcohol and of the dis- advantages of its total withdrawal, these will weigh almost as nothing against the obvious manifest advantages of prohibition as a war-time measure. When food is scarce and the food situation serious, the question of the control of the liquor traffic becomes insistent from the point of view of national efficiency. To this argument may be added the further con- tention that the loss of energy value involved in the conversion of the carbohydrate of grain and sugar into alcohol represents in itself a serious leakage in food supplies. It must be remembered that there is an in- evitable loss of energy in the conversion of these more highly organized bodies into the simpler alcohol ; only some 60 per cent of the energy in the barley grain or the potato flour remains in the resulting beer or spirit. In itself brewing or distilling is a gross waste of food products. By the enforcement of total abstinence at a stroke, the consumption of the thousands of tons of grain employed in the manufacture of beer and spirits would be saved, a vast amount of energy now employed in 768 FOOD ECONOMICS IN WAK brewery, distillery and saloons would be diverted into more profitable channels, and the health and morals of the nation would be raised. By the cessation of the manufacture of alcohol, and the utilization of its raw materials, especially of potatoes and grain, as immediate sources of food supply, the strain of providing the population with nutriment will be, to that extent, relieved. For industrial and scientific purposes, alcohol is valuable, and to sup- ply the needs in this direction, the manufacture, perhaps, of a limited amount should be permitted. But so far as beverage is concerned, the war has taught the lesson that human efficiency can be maintained at a higher standard without alcohol than with it. The Food Situation in the United States. More food is produced in this country than in any one country of the world, and yet at the present time there is a food shortage. This shortage is due to many causes: (a) Food production has not kept pace with the growth of population and has been giving alarm to agricultural experts for several years. During the past three decades Americans have been forsaking the farms for city life, and as a consequence agricultural labor has been becoming more and more difficult to obtain. Thus the food problem has been greatly hampered by the lack of agricultural workers, and this has been especially noticeable since the outbreak of the great European War. (&) The opportunity for securing employment in manufacturing establishments, the consequent high rate of wages and the inducements of city life have enticed many agricultural workers to forsake the farm, which has seriously interfered with the necessary labor for agricultural work and has added much to the serious phases of agricultural pursuits. Since 1884 the production of wheat in this country has dropped a very considerable extent, due to the inability of the farmer to procure the necessary help. Farmers are now killing their live stock and as a conse- CEREAL PRODUCTION OF THE UNITED STATES IN 1915 Cereal Acreage Bushels Corn 108,321,000 3,054,535,000 Wheat 59,898,000 1,011,505,000 Oats 40,780,000 1,540,362,000 Barley 7,565,000 237.009,000 Rye. . 2,856,000 49,190,000 Buckwheat 806,000 15,769,000 Rice 694,000 65,691,700 USE OF CEKTAIN FOODSTUFFS IN WAR 769 quencc supplies of meat in cold storage have fallen off enormously. The high prices of all kinds of foodstuff since the beginning of the European War, have resulted in a very marked increase in the export of all food- stuff, which unfortunately does not signify an increased ability to produce food, but on the other hand means rather that we are depleting our exist- ing stock of supplies. In 1910. harvest conditions in the United States were much below normal production and, in short, it has been plainly demonstrated that our reserves in cereal grains are being rapidly exhausted. It has been com- puted that our Allies' cereal crop this year has shrunk to about 525,- 000,000 bushels below normal, and if consumption in the allied coun- tries is to be maintained at or near normal no less than 1,250,000 bushels of grain must be exported by the United States. The cattle and hogs in the allied countries are diminished in number by something like 30,- 000,000 head, and these reductions will continue with increasing severity for the reason that animals must be slaughtered on account of shortage in food supplies. We have not only to feed the people of our own coun- try, but we are also expected to make up the food deficiency of our Allies, and thus the burden of the war, so far as supplying subsistence to the Allied armies is concerned, falls most heavily on the United States. If this war is to be won by our Allies, food must be strictly conserved by the American people. We shall consider briefly the food problem from an economic viewpoint. It may be safely said that our own people, up to the present time, seem to have failed to realize adequately the all- important role that food will play in this war and there is grave danger in the fact that the necessity for economy in diet is not sufficiently appreci- ated. It has been pointed out in a previous section of this chapter, that under the compelling stress of circumstances, the nations at war in Europe have restricted and regulated the consumption of food, and avoided waste in every possible way, and, moreover, that up to a certain point, this has been done with correspondingly decided benefit to the public health. As a matter of fact, economy in diet in this country, if arranged on sensible and scientific principles, should be attended with little or no injurious effects on the health of the population. Such econ- omy may be uncomfortable for a time, but man is extraordinarily adapt- able, and in a short time, provided ho gets a sufficient quantity of fat and energy-producing foods in well-balanced proportions to keep the human machine working, it does not matter much whether his subsistence is derived mainly from the vegetable or animal kingdom. As previously 770 FOOD ECONOMICS IN WAR pointed out in this work Americans are large meat eaters but so were the Germans and British before the war. The Germans and, to a lesser extent, the British, have denied them- selves meat with a good deal of philosophy and with benefit rather than harmful results. Educational propaganda with regard to food economy in this country should not only dwell on the need for economy and self- denial, but should lay special stress upon the point that comparative de- privation of meat and the substitution of nutritious articles of food for those to which the population has by long use become accustomed, invokes no special hardships, while in many instances a restricted diet may be beneficial. In the first place the foodstuffs exported by us must be of a most con- centrated kind, as for example, wheat, beef, pork, dairy products, fats and sugar. Although we have a surplus of potatoes, vegetables, fish and poultry, these, with the exception of vegetables in dehydrated form, do not lend themselves to shipment. As said before, the wheat supply is short and the food administrator has requested the population of this country to eat corn bread and conserve the wheat for our Allies. Corn meal, when properly prepared, can be made as nutritious, as wholesome, and as palatable as wheat bread. We are the largest corn growing nation in the world and our people, unlike the Frenchmen and Englishmen, are not averse to eating corn bread. Accordingly the first logical step in adapting our food supplies and con- sumption to the needs of our Allies is to substitute, as far as possible, corn for wheat on our own tables. Furthermore, when wheat bread is placed upon the table it should be baked from whole wheat meal. The bread on which our sturdy grandsires throve was made from the whole wheat berry and the ingenuity of man has never devised a more wholesome, more palatable nor more nutritious bread than that made from the whole wheat grain. This point has been previously dwelt upon in other portions of this work. The reasons' why whole wheat flour should be used are as fol- lows: When properly made and baked, bread made from whole wheat flour is more nutritive and digestible than bread made from highly milled and finely bolted white flour; besides it contains all of the cereal salts (1.75 per cent), while highly bolted white flour is deficient in cereal salts (only .44 per cent). Moreover, the modern patent roller process flour is deficient in vitamines, while the whole wheat flour contains all of the vitamines which nature grew into the wheat berry. Graham Lusk, who has devoted much research to the subject of scien- tific nutrition, advocates the consumption of graham (whole wheat) bread, USE OF CERTAIN FOODSTUFFS IN WAR 771 and several authorities on nutrition, both in this country and in Europe, are enthusiastic over the nutritive properties of whole wheat bread. In fact, just a few months ago an edict went forth in Great Britain that all flour should be ground from the whole wheat grain. A feature in favor of whole wheat meal is that bread made from it requires more mastication and exerts a considerably more laxative effect than bread made from highly bolted patent roller process flour which predisposes to constipation and intestinal stasis, complaints which are widely prevalent in this coun- try. However, the advantages of whole wheat bread have been sufficiently emphasized. The question of protein consumption has given rise to considerable discussion, or, perhaps, it is more correct to say that the discussion has hinged on the point as to which form of protein should be taken as food. There is virtually no difference of opinion with regard to the need of protein. To a greater or lesser extent, it is known, that on the whole, more protein in the form of meat is eaten than is physiologically required. It certainly is a fact that owing to the false teaching and long held beliefs of the strengthening effects of meat, too much meat is consumed by both young and old with harmful results to both. This subject has been previ- ously considered and we will not enter into a dissertation here regarding protein as a food ; it will suffice to say that the protein of meat can be re- placed by vegetable protein, such as that from the legumes, whole wheat flour, and various vegetables. These are cheaper by far, more easily and economically produced, and will maintain the body at a high standard of efficiency and health; therefore, the next step in the direction of food economy is to substitute, as far as possible, protein from the vegetable kingdom. Moreover, fish can be largely used as a substitute for meat and we have fish in great abundance. Unfortunately the fat content of a well-balanced ration is not trans- mutable. No substitute can be offered in the place of fats, but some very useful advice can be tendered. A large reduction in the ordinary con- sumption of fat by the well-to-do citizen will be helpful to the nation and to the individual. Graham Lusk, writing in the Scientific Monlhly, October, 1917, draws attention to the fact that it is not at all difficult to reduce the body weight by reducing the consumption of fats and starches and cutting down the energy value of their ration from 2,800 calories to about 2,200 calories. The fuel foods for the human machine are principally made from wheat, corn, rice and the sugar cane. The average American consumes more sugar than is necessary or beneficial and if we are to be able to export any sugar to our Allies the 772 FOOD ECONOMICS IN WAR per capita consumption must be reduced in this country. This is one aspect of the food situation in this country which has not been met as it should have been met. The author, at the outbreak of the war, suggested that the use of grains for the manufacture of intoxicating beverages should be stopped. The grain that is now being used for the manufacture of intoxicating drinks, if employed for human consumption or for fodder for animals, would relieve the present stress to an unbelievable degree. The employees thrown out of work by prohibition would soon find other spheres of human endeavor in which they would be much more useful to the community. The greatest source, perhaps, for the inflation of the prices of foodstuffs is the present manipulation of the food markets by speculation. And another point in the present high cost of living and bad food preparation is a want of knowledge in the culinary department. For a couple of decades past the science of cookery has not been taught in the home as it should be, and as a result the daughters, with the exception of a few who have been trained in domestic science schools, are unacquainted with the uses of the culinary utensils of the modern household. Lusk, referred to previously, formulates the following propositions, which are so apropos to the subject that no excuse for quoting them is necessary: "(a) Eat corn bread and save the wheat for France and our other Allies; (&) Let no family of five persons buy meat until it has bought three quarts of milk; (c) Save the cream and butter and eat vege- table oils and oleomargarin ; (d) Eat meat sparingly, rich and poor, laborer and indolent alike; (e) Be a prohibitionist for the period of the war; (/) Save everything that can be used for food, because food is precious; (#) Finally, remember that the whole world is seeking for food with which to work and although our wheat crop is short, still we are the nation most richly endowed with fuel food. It remains to be seen whether we have the intelligence to fitly utilize for the welfare of mankind the resources which God and nature have placed in our hands." The only solution of the food problem is to eat more of the foods which can be easily raised and less of those which are so urgently needed by our Allies. As our food dictator has stated, "There is no real conservation without reduction in consumption, and the elimination of personal waste." If the people of this country will heartily cooperate with the food conservator in the endeavor to conserve the food supply, and will endure for a while some discomfort, there will be no difficulty regarding the food problem. Sufficient food can be produced to keep the population supplied with a well-balanced dietary with sufficient to export for the Allies. The SUMMARY 773 case of Germany has plainly demonstrated this fact, but in this country the populace must be educated with respect to scientific nutrition and must come to realize that personal selfishness must be subordinated to the national interest. SUMMARY As remarked in the introductory sentences of this chapter, the author is of the opinion that in a work on diet, notice should be taken of the food question in war, and that an attempt should be made to extract whatever lessons in this direction might seem apposite. The conclusions to be drawn as the result of this survey for it can hardly be termed a close study are: That the limitation of food conse- quent upon a short supply brought about by war conditions is beneficial to a certain proportion of the population, further demonstrating the fact that in the ordinary way the majority of persons eat more than their phys- iological requirements call for. On the other hand, a restricted food sup- ply presses heavily on those least able to bear the pressure, that is, on those who, on account of the greatly enhanced price of food, are unable to obtain the kind of diet to which they are accustomed and indeed suffer from a paucity of nutritive elements. It seems to have been proven that over- feeding is injurious, but that underfeeding is worse. So far as the different essential constituents of the food are concerned, at the time of writing it is impossible to speak dogmatically. It appears to have been demonstrated that more protein is generally eaten than is needed, and not enough fat. The Germans, according to Taylor, suffered from the limitation of fat in their diet, and it may be stated that fat is a more important factor in the promotion of physical efficiency than hith- erto has been believed. One of the chief lessons learned from the war so far has been the great economical and nutritive value of whole-grain bread. The proven dietetic value of whole-grain bread, and of cereals from which the husks have not been removed, suggests the reflection that possibly the value of food, after all, depends no more on its protein, fat or carbohydrate content, as the case may be, than on the possession of those food elements termed vitamines. Certain it is that when these are absent, ill health and disease are generally the sequence. In this chapter some opinions have been expressed with regard to milk which do not seem to be in accord with the views of authorities. The opin- ions propounded here, while not entirely those of the author, still are his to this extent, that he does believe that milk per se is not an indispensable article of diet except for infants, and that the best use that can be made 149 774 FOOD ECONOMICS IN WAR of milk, in war time at any rate, is its conversion into cheese, one of the most wholesome and nutritive foods known. A good hunch of crusty bread, with butter and cheese or fat bacon, followed by a little raw fruit, such as an apple, constitutes a well-balanced meal. It has been pointed out that the question of sugar is a vexed one. In England it appears to have been concluded that its dietetic virtues have been exaggerated, and that in war time its consumption, with great benefit to all concerned, might be very considerably restricted. With regard to the liquor traffic in war time, there is and should be very little difference of opinion. The grain, potatoes, etc., that are employed in the manufac- ture of alcohol in war time should be utilized for feeding men and animals and in every respect the manufacture of alcohol to be used as a beverage should be restricted to a minimum or wholly interdicted. Finally, there are at least four ways of reducing the consumption of food : 1. By preparing the food in the most economical way. 2. By mini- mizing waste. 3. By selecting the right kinds of food and in the right proportions. 4. By limiting to a sufficiency the quantity of food con- sumed. 1. TAYLOR, A. E. Saturday Evening Post, Feb. 17, 1917. 2. . Ibid., Apr. 14, 1917. 3. British Medical Journal, Feb. 17, 1917. 4. WALLER, A. D. Lancet, Feb. 17, 1917, p. 273. 5. MENDEL. Changes in the Food Supply and Their Relation to Nutri- tion. 6. CAMPBELL. Lancet, Apr. 1, 1916. INDEX A Absorption, of end products of protein di- gestion, ill-eft'ects of, 198. Acid-forming and base-forming elements, 314. Acid-forming dements of diet, 357. Acidosis. due to chronic intestinal stasis, 463. Acne, diet in, 4(i7. Aerophagy, treatment of, 122. Akoria, 121. Albumin, purin-free diet to supply, 330. Albumins, coagulation point of, 57. Albumin water. preparation of, 580. < x j_ r g, preparation of, 581. Album in i/ed lemonade, preparation of, 579. Albuminized milk, preparation of, 583. Albuminous bodies, in breast milk, 477. Albumipuria, in pregnancy, diet in, 466. Alcohol, as a beverage or as a medicine, 401. effect of, 385. as a food, 406. as a protein sparer, 306. use of, 385, 401. in puberty, 420. in tropical climates, 401. in war, 766. utilization of different food stuffs with and without, 308. Alimentary hygiene. See Eating, hygiene of. Alkali, added to milk, to prevent clotting, 494. Allotriophagia, 119. Almond milk, preparation of. 582. Ami no-acids, deamini/ation of proteins in, 169. in proteins, 194. qualitative variations of, 200. as reserve energy supply, 211. ultimate fate of, after absorption by tissues, 210. Ammonia, in protein metabolism, 329. Anabolism. definition of. 286. Aneurisms. Bellingham'a diet for, 5 IS. TufneH's did for, 547. Animal protein, vegetable protein versus, 528. Anorexia, 120. Appetite, loss of, 120. perversions of, akoria, 121. anorexia, 120. bulimia, or hyperorexia, 120. parorexia, 119. polydipsia, 121. polyphagia, 121. rumination, 121. seasickness. 122. "Apple-fasts," 545. Apples, dried, 25. Apple water, preparation of, 578. Apricots, dried. 24. Army rations, foreign. See Rations, of foreign armies. U. S. See Rations, U. S. Army. Arteries, hardening of, sign of old age, 434. Arteriosclerosis, and old age, 439. as sign of old age, 434. Arthritis, rheumatoid, due to chronic in- testinal stasis, 460. Ash, percentage of, in bones, muscles and various organs, 312. Atwater's experiment for calculation of energy metabolism, 296. Austria, army daily ration of, 715. B Baeltz's investigations among the Japan- ese, in regard to diet and endur- ance, 176. Baking of meat, comparison of, with roasting, 60. mechanical and chemical changes in, 60. as practised by savage tribes, 60. process of, 60. Banana figs, 27. Bananas, dried, 27. dried products of, 27. Barley water, preparation of, 580. Base-forming and acid-forming elements, 314. Base-forming elements of diet, 357. Beans, dehydrated. 41. cooking of, 43. food value of, 44. dried, 41. composition of fresh and, 41. lima, dehydrated, 4'J. soy, dehydrated, 4'2. Beef broth, preparation of. See Recipes. broths. 775 776 INDEX Beef, dried, 2. Beef essence, preparation of. See Recipes, meat juices. Beef juice, preparation of. See Recipes, meat juices. peptonized, preparation of, 589. Beef tea egg-nog ( Davis ) , preparation of, 587. preparation of. See Recipes, beef teas. Beets, dehydration of, 36. advantages of, 37. Beet-sugar industry, 36. Bellingham's diet for aneurisms, 548. Beriberi, due to lack of vitamines, 230. Berries, drying of, 27. Bevenot de neveu process of desiccation of miJk, 13. Beverages, preparation of. See Recipes, beverages. in tropical climates, 405. Bile, secretion of, in underfeeding, 162. Biliousness, due. to overeating, 135. Biltong, or dried beef, 2. Blood, effect of underfeeding on, 162. Body weight, protein minimum necessary to, table showing, 154. Boiling of fish, 66. of meat, 55. action of salt in water, 57. for broth or bouillon, 56. correct procedure for, 56. difference between stewing and, 57. effect of, 55. primitive method of, 55. Borax, use of in rreservation of meats, 7. Bouillon, procedure for making, 56. See also Recipes, bouillons. Boys' military training camps, rations for. See Rations, for Boys' Mili- tary Training Camps. Bradyphagia. 82. advocates of, Fletcher, 82. Gladstone, 83. definition of, 83. ill effects of, 84, 85. Braising of meat, 64. Brandy and egg mixture, preparation of, 586. Bread, advantages of wholemeal over high- ly milled, 749. use of, in war, 759. Bread-making, history of, 49. See Recipes, breads. Breast feeding, age for, 481. axioms for, 481. colostrum, 475. centra-indications to, 488. daily bowel movement during, 482. diet during period of, 481. duration of weaning, 483. gain in weight after each meal, 485. galactagogues, 479. importance of weighing baby during period of, 485, 486. Breast feeding, increased percentage of mothers capable of, 471. indications for discontinuing, 485, 486. micro-organisms in milk, 474. necessity for intelligent mothers, 480. a normal function, 482. regularity of, 483. relative frequency of, 472. stimulation of lacteal secretion, 479. successful, 484. unsuccessful, 484. women of to-day better fitted for, 472. Breast milk, coagulation of, 477. comparative analysis of cow's milk and, 490. consideration of, 485. constituents of, albuminous bodies, 477. casein, 478. coagulation, 477. fat, 478. ferments (enzymes), 479. lactose, 478. deficiency in proteins and fats, 487. indications for analysis of, 485. lack of uniformity in, 487. micro-organisms in, 474. nitrogenous substances in, 475. quality of, 485. quantity of, 476. daily average drawn by baby, 477. daily secreted by healthy young mothers, 476. in secretion by primipara and multi- para, 476. Broiling of meat, 63. Bronchitis, of the aged, diet in, 452. Broth, procedure for making, 56. See also Recipes, broths. Bulimia, 120. Butter-fat, and vitamines, 228. Buttermilk, in infant feeding, chief value of, 501. class of infants benefited by, 501. composition of, 500. origin of, 500. preparation of, 500. Buttermilk cure, 566. Buttermilk and egg mixture, preparation of, 584. Cabbage, dehydrated, 40. Cactus fruit, dried, 28. Calcium content of foods, 350, 351. Calcium excretion, 349. lowering of, in disease, 341. Calcium oxid, in foods, approximate amounts of, 353. Calcium salts, importance of, 349. in infancy and childhood, 350. ingestion of, 349. INDEX 777 Caloric method of feeding, calculation of fuel values of food, 257. comparative equivalents in metric, avoirdupois and apothecaries' weights and measures, 257. heat produced from substances burned in calorimeter distinguished from heat available when used in body 263. represented by a particular menu, 263. table of, 258-263. caloric requirement of man, 252. caloric values of ingested foods, 250. calorific value of excretory products, 254. constructive and fuel foods, 251. food requirement, factors governing, 265. heat of combustion of various sub- stances and foods, 247. introductory, 243. method of reckoning the protein, fat and carbohydrate rations for diets of definite energy values, 264. physiological food value, 255. regulation of body temperature, 274. standard and sample dietaries, 248. unit and method of measurement, 246. Caloric requirement of man, 252. Calories, income and outgo of, in meta- bolism experiments, 291. Calorific value of excretory products, 254. Rubner's table showing losses and avail- able energy, 255. Calorimeter, forms of, 246. use of, 246. Calorimetric combustion, average results of, 247. heats of, and approximate elementary composition of typical com- pounds, table of, 249. Canned foods, in diet of tropical climates, 400. Canning, chemical agents used in, 7. process of, for preservation of food, 6. other foreign nations, 178. Carbohydrate diet, people subsisting al- most entirely on, Japanese, 176. Carbohydrate and fat, Kayser's table showing nitrogen balance when feeding isodynamic quantities of, 303. sparing power of. in calorimetric ex- periments ( Atwater ) , 304. Carbohydrate-free diet, 338. Carbohydrates, amount of, contained in vegetables, before and after cook- ing of, 69. contained in cow's milk, 494. easily burned, catabolism of furnishing too much heat, 342. excess of, in metabolism of overfeeding, 188. Carbohydrates, fat versus, as protein sparers, 302. function of, in nutrition, 301. as protein sparers, 300. transmutability of, 101. Carbon, income and outgo of nitrogen and, in metabolism experiments, 290 296. Carrots, dehydration of, 37. Casein, in breast milk, 478. in cow's milk, 493. dehydration of, 17. Catabolism, definition of, 287. Candle, preparation of, 581, 587. Celery, dehydration of, 40. Cellulose diet, 339. Cellulose, foods containing, 340. Cereal foods, preparation of. See Recipes. Cereal grains, exhaustion of reserve in, in U. S., 769. Cereals, partly digested, prepared at table, 589. protein and starch equivalents in buck- wheat and, in diet of tropical climates, table of, 391. use of, in war, corn, 763. oatmeal, 762. wheat, 759. Certified milk, 489. Character, influence of diet on, 370. Chemical agents, antiseptic, treatment with, in preservation of food, 7. Chemical elements, composing human or- ganism, 361. Chestnut, dried, 28. Chicken broth, preparation of, 598. Childhood, diet in, 409. See also Diet in Childhood. Chinese raisins, 28. Chittenden's experiments in low protein diet, 171. conclusions of, 186, 190. Chittenden's low protein dietary, 253. Chittenden's table, 173. Chlorin equilibrium, maintenance of, 348. Church's standard diet for Indians, 393. Climate, and diet, 372. maintenance allowance according to climates, 373. tropical, diet in. See Diet in Tropical Climates. Cocoa, preparation of, 582. Coffee, preparation of, 582. Cold storage, preservation of meat by, 3. prolonged, effect of, 4. requisite temperatures for preservation of certain animal foods, 5. Colostrum, appearance of, 475. composition of, 475. specific gravity of, 476. Concentrated proteins, 70. Condensed foods, as means of food concen- tration, 70. Condensed milk, in infant feeding, l!Mi. 778 INDEX Constipation, ancient usage of medical practice for overcoming of. 457. Constitution, influence of diet on, 368. Convalescents, exchange of energy in, 141. flesh formation in, 141. interchange of nitrogen and storage, protein and fat, absolute and per- centage, in overfeeding, table showing approximate values of, 143. nitrogen increase in, due to overfeed- ing, table emphasizing, 142. nitrogen retention in, 141. Cookery, varieties of, 54. Cooking, changes produced by, 53. coagulation point of different albumins, 57. difference between French, English and American, 53. of dried beans, 43. of fish, 66. history of, ancient British, 50. berries, fruit, etc., 50. as branch of woman's education in this country, 51. bread-making, 49. fish, 50. French, 50. meats, 50. of meat, baking, 60. boiling, 55. braising, 64. broiling, 63. comparative composition before and after, 65. comparative composition of water-free substance before and after, 66. frying, 58. grilling, 63. "high" or slightly tainted, 62. losses in, 65. roasting, 61. steaming, 65. stewing, 57. poor, evil effects of, 54. principles of, changes produced by, 53. digestibility, 51. foods requiring, 51. knowledge of, necessary to physician, 51. scientific application of heat, 51. scientific application of heat, to animal foods, 52. coagulation of proteins, 52. dextrinization of starch, 52. to fats, 52. gelatinization of starches, 52. to sugar, 52. to vegetable foods, 52. of vegetable foods, objects to be achieved in, 67. of vegetables, action of, 67. amount of carbohydrates contained, before and after, 69. Cooking, of vegetables, deficiency of fat in vegetables made up in prepara- tion of, for table, 69. gain of water on, 68. lengths of time required for, 69. Corn, dehydration of, 44. protein of, 199. relation of, to pellagra, 44. use of, in war, 763. Cornmeal mush, preparation of, 609. Creatinin, in protein metabolism, 329. Crime, relation of underfeeding to, 152, 153. Curds and whey or junket, preparation of, 592. Cures, buttermilk, 566. dry, 561. grape, 546. kumiss, 564. lemon, 546. matzoon, 566. milk, 569. skim milk, 572. sour milk cure, 567. whey, 573. yolk, 563. Currant juice, preparation of, 578. Custards, preparation of. See Recipes, custards. Cutaneous lesions, due to chronic intes- tinal stasis, 463, 466. acne, 467. itching dermatoses, 468. D Dates, curing of, 27. Debility, dietary for, 564. Decomposition of food, causes of, 1. Deficiency diseases, due to lack of vita- mines, 230. Dehydration, advantages of, 9. economic, 46 of casein, 17. of eggs, 17. of fish, 20. of foods used in the army, 37. of fruits, advantages of, economic, 30. analysis and caloric value of dried fruits, per pound, 29. as an ancient procedure, 20. apples, 25. apricots, 24. by artificial drying, 21. bananas, 27. cactus fruit, 28. chestnut, 28. comparative cost of total nutrients and fuel value of some fresh and dried fruits, 31. dates, 27. litchi nut or Chinese raisin, 28. I X I )EX 779 Dehydration, of fruits, methods of, 24. old-fashioned, or household method 24. olives. i'S. peaches. 24. persimmon. 2S. preparation of fruit for, 23. proper storage of, 26. prunes, 22. raisins, 2(i. small fruits and berries, 27. by sun drying, 21. unusual, 28. in Germany, 10. of meat, ancient and modern methods of, 18. as a concentrating and preserving process, 71. powdered meats, 20. disadvantages of, 20. Italian method for making, 20. Tellier method of, 10. of milk. See Desiccated Milk; also Desiccation of Milk, success of, 46. value of, 9. of vegetables, 11, 32. advantages of kiln method for, 41. beans, 41. cooking of, 43. lima, 42. soy, 42. beets, 36. cabbage, 40. carrots, 37. celery, 40. corn, 44. importance of, as food, 32. as means of food concentration, 70. methods of, 32. onions, 40. potatoes, 33. composition of, 34. composition and fuel value of, un- der various methods of prepara- tion, 34. methods of, 33. potato flour, 35. relative weights of green and kiln- evaporated, 40. salsify, 37. starch-yielding tubers, 36. sweet potato, 35. turnips, 37. used in the army, 37. vegetable flours, use of, 44. of yeast, 45. flee also Desiccation. Dehydrator, most efficient form of, for home use, 45. Denutrition, temporary, benefit of, 115. Dermatoses, itching, treatment of, 468. Desiccated eggs, 71. Desiccated milk, 71. advantages of, 16. comparison of kinds of, 15. reconstruction of, for infants, 15. Desiccation, as means of food concentra- tion. 70. of milk, from which fat has been re- moved, 15. historical development of process of, 12. present methods of, Bevenot de neveu process of, 13. Ekenberg process, 13. Just-Hatmaker process, 13. Stauf process, 14. as recent discovery, 12. of vegetables, as means of food concen- tration, 70. Diabetic foods, recipes for. See Recipes, diabetic foods. Diastatic ferment, in milk, 497. Diet, acid-forming and base-forming ele- ments of, 357. in acne, 467. army. See Rations. Bellingham's, for aneurisms, 548. carbohydrate-free, 338. cellulose, 339. character of, and protein content, 212. in childhood, adaptation of, to diathesis of child, 413. comparative heights and weights of children, 412. early, 410. factors of growth and development, 415. for gouty diathesis, 413. greediness discouraged, 417. important points, 412. rations required, 409. from four to six years. 411. requisite amount of all foodstuffs, 415. requisite calories per kilogram for va- rious ages, 415. for school children. 414. arrangement of meals, 416. suitable dietary, 416. Starr's table of dietetic needs, 410. for tuberculosis, 413. Church's standard table of, for Indians, 393. climate and, 372. maintenance allowance according to climates, 373. dry cure. 561. fat-free, 338. fruit. Kec Fruit Diet, high protein, 325. importance of caloric value of, 148. influence of, on character, 370. on constitution and health, 368. of, on races. 371. in intestinal stasis, chronic, 464. after labor, 42!. 780 INDEX Diet, during lactation, 429, 481. day's ration for nursing women, 430. decrease or increase of quantity of mammary secretion, 431. rules formulated by Rotch, 431. lacto vegetarian, 521. low protein, 324. meat. See Meat Diet, during menopause, 432. during menstruation, 425. in military prison camps, 718. milk cure, 569. buttermilk cure, 566. kurniss cure, 564. matzoon cure, 566. skim milk cure, 572. sour milk cure, 567. Avhey cure, 573. navy. See Rations, nitrogen. See Nitrogen Diet, nitrogen in. See Nitrogen in diet, nitrogen-free, 325. non-meat eating, Japanese, 176. other foreign nations, 178. and occupation. 371. in old age. according to Dr. Harry Campbell, 440. according to Friedenwald and Ruhriih, 441. alimentary pastes: food value, 449. in bronchitis. 452. and condition of teeth, 450. idiosyncrasy a factor in, 441. Kosevi's maintenance ration, 443. Langworthy's dietary standard, 443. Maurel's maintenance rations, 443. meat consumption, 451. nature of, 439. and nitrogen metabolism, 444. for the obese. 446. quantity of food, 436, 439. raising caloric value of, 448. reduction of fuel value in, 445. Saundby's daily dietary, showing dis- tribution of meals, 447. suggestions of Yeo, 452. for those leading vegetative lives, 446. Voit's dietary standard, 442. during pregnancy, 425. to insure small but well-developed child, claims of Prochownick, 427. "longings" for various indigestible ar- ticles, 426. in presence of albuminuria and dropsy. 426. Prochownick's, 428. quantity of food, 426. theory of abundant phosphates and lime salts, 427. theory of avoiding fresh vegetables, 427. for professional singers and lecturers, 560. protein. See Protein Diet. Diet, during puberty, 418. craving for sweets, 420. during puerperium, 428. purin, excess of, 335. low, 336. purin-free, 336. dinners suggested by Haig's disciple, 337 . relation of, to craving for salt, 347. of to scurvy, 358. safety standard in, 195. caution as to protein deficiency, 196. overfeeding, 197. undereating, 196. Salisbury, 536. modified, 537. salt-free, 345. in sedentary occupations, 421. comparative lunches, 423. Richards' ration, 424. suitable dietary, 422. training, 552. in tropical climates, alcohol and bev- erages, 401. amount of, required, 388. canned foods, 400. cause of digestive disturbances, 398. Church's standard diet for Indians, 393. conclusions on, 400. and disease, 399. fruit, 389. Indians, 393, 394. meat eating, effect of, in, 389. meats, 395. milk, 394. of natives and whites, 397. nitrogenous foods, comparative im- munity of white men due to feed- ing on, 388. lack of, among natives, 388. protein and starch equivalents in ce- reals and buckwheats, table of, 391. in pulse, table of, 392. sweets, 398. vegetables, 390. views on, changes in, 386. Lukis and Blackham, 387. Woodruff's. Dr. Charles, 386. Tufnell's for treatment of aortic and other aneurisms, 547. variety in, necessity for, 94. vegetable. See Vegetable Diet. Weir Mitchell, in treatment of neu- rasthenia and disorders of nutri- tion independent of organic dis- ease. 549. yolk cure, 563. zymotherapy, 538. Dietaries, actual, 380. actual and standard, compared, 378. company, in U. S. army rations. 675. of individuals allowed a "free choice of food," 377. INDEX 781 Dietaries, of inhabitants of United States, 374. Playfair's table of requirements for work, 377. standard, 248. standard and actual, compared, 378. standard daily, 378, 379. tropical, in U. S. army, 676. typfcal, minerals in, daily quantities per man, 342. Dietary, in boys' military training camp, Fort Terry, New York, for one week, 686-690. showing requisite amounts of ternary food elements and fuel or energy value in calories, 692-697. for debility, 564. fat and vegetarian. Wait's, 521. of laborers, in United States, 376. low protein, Chittenden, 253. of marching soldiers, 382. of mechanics, in United States, 376. of Mexicans, 383, 384. of negroes, 382, 384. in old age, 440. of poor person in New York City, show- ing food elements and calories, 374. in puberty, 419. reducing, 559. for school children, 416. for the sedentary, 422. of students' clubs, 374. for tuberculous children, 413. of University boat-crews, studies of, 555. vegetarian, Jaffa's, 542. vegetarian and fat, Wait's, 528. well-balanced, vitamines in, 224. of Yale training crew, 554. Dietary experiment, Neumann's, 310. Dietotherapy, alcohol, use of, 385. definition of, 361. diet studies, 374. general principles of, 361. amount of food required, 362. climate and diet, 372. influence of diet on character, 370. on constitution and health, 368. on races, 371. meals, composition of, 366. distribution of, 366. occupation and diet, 371. Diets, of definite energy values, method of reckoning protein, fat and car- bohydrate rations for, 264. special, 519. standard, exchange of material with, 288. Diet studies. See .Dietary and Dietaries. Digestibility of foodstuffs, 104. comparison as to, 106. fats, 105. the finer the subdivisions of food in- gested, the larger the proportion of nutriments assimilated, 105. Digestibility of foodstuffs, fruits, 108. proteins, 107. utilization of some of staple foodstuffs, 104. vegetable foods, 107. Digestion, effect of manner of eating on, bradyphagia, 82. euphagia, 78. rapidity of mastication, 86. tachyphagia, 84. occupation and, 94. salivary, manner and time of, 85. sleep and, 93. and variety in diet, 94. See also eating, hygiene of. Digestive disturbances, in tropics, cause of, 398. Digestive glands, action on, of emotional excitement, 81. Digestive organs, evil effects of underfeed- ing on, 152. Digestive process, first stages of, started by pleasurable smell and sight and taste of food, 80. Dry cure, 561. Drying of food, 2. See also Dehydration, and Desiccation. Dyspepsia, meat diet in treatment of, 535. E Eating, abnormally slow, or bradyphagia, 82. effect of manner of, on digestion, brady- phagia, 82. euphagia, 78. food and emotions, 79. food and work, 79. rapidity of mastication, 86. tachyphagia, 84. hasty, or tachyphagia, 84. hygiene of, 77. and appetizing ailments, 78. effect of manner of, on digestion, 78. meals, order and frequency of, 90. regularity of, 92. occupation and digestion, 94. personal idiosyncrasies, 89. principles involved in, 78. relation of medication to meals, 96. and sacrifices in food, 88. sleep and digestion, 93. variety in diet, 94. water drinking with meals, 88. personal idiosyncrasies in. 89. proper, or euphagia. 78. role of senses in pleasure of, 75. Egg dumplings, preparation of, 607. Eggs, cold storage, 5. dehydration of, 17. desiccated, 71. dried, 17. 71. preparation of. See Recipes, eggs, preparation of beverages with. N< r Recipes, beverages. 782 INDEX Eggs, preservation of, by drying, 17, 71. Ekenberg process of desiccation of milk, 13. Emotions, food and, 79. Endurance, Baeltz's experiments in diet and, among the Japanese, 176. effect of protein diet on, 192. Fisher's experiments on effect of diet on, 174. Fisher's test diet and, 175. Flint's observations on effects of five- day pedestrian feat performed by Weston, 183. Endurance tests, comparative, Fisher's, 176. Energy, consumption of, in chronic mal- nutrition, 160. expended by marching soldiers, 382. and vegetable diet, 524. Enzymes, in breast milk, 479. Epicures, 131. Euphagia, 78. Evaporation in preservation of food. See Dehydration. Excretion of fat, in stools, percentage of, 105. Excretory products, calorific value of, 254. Riibner's table showing losses and available energy, 255. F Farinaceous foods, preparation of. See Recipes. Farina dumplings, preparation of, 610. Fasting, as ancient religious rite, 112. as cure for disease, 113, 114. effect of, on metabolism, 117, 298. forced, ravenous hunger result of, 113. long-continued, 115. metabolic carbon and nitrogen balance during, 298. no-breakfast plan, 113. in religion, 112, 117. Fasting experiments, 116. metabolic, 118. Fat, in breast milk, 478. in cow's milk, 493. excretion of, in stools, percentage of, 105. percentage of, in foods, 339. perversion of appetite for special or pe- culiar kinds of, 119. versus carbohydrates as protein sparers, 302. Fat and carbohydrate, Kayser's table showing nitrogen balance when feeding isodynamic quantities of, 303. sparing power of, in calorimetric experi- ments (Atwater), 304. Fat and vegetarian diet, Wait's, 528. Fat consumption in United States, 771. Fat-free diet, 338. Fatless milk, desiccation of, 15. Fatigue poisons, due to meat eating, 207. Fats, action on, of heat, 52. deficiency of, in breast milk, 487. Feces, nitrogen in, 323. Feeding, caloric method of. See Caloric Method of Feeding. of infants. See Infant Feeding. Ferment, diastatic, in milk, 497. * Fermentation of milk, analysis of changes occurring in, 568. Ferments, in breast milk, 479. Ferratin, 355. Fish, cooking of, 66. history of, 50. dried, 20. preparation of. See Recipes, fish, preservation of, by chemical agents, 7. by drying, 20. by freezing, 3. by salting, 3. by smoking, 2. Fish soup, preparation of, 606. Fisher's comparative endurance tests, 176. Fisher's experiments in effect of diet on endurance, 174. Fisher's test diet and endurance, 175. Fletcherism. See Bradyphagia. Folin's views on protein diet, 187. Food, decomposition of, causes of. 1. effects of work and, on respiration, 293. and emotions, 79. purin, effect of, on uric acid, 334. purin bodies in, 333. quantity of, 334. as a source of heat and growth. See Caloric Method of Feeding, substitutes for, 108. weight of different classes of, purchased per man per day, 375. and work, 79. Food concentration, basis of, 70. composition of components of ration of United States soldier, 72. composition of emergency ration of German soldier, 72. concentrated proteins, 70. condensed foods, 70. desiccated eggs, 71. desiccated milk, 71. desiccated vegetables, 70. desiccation, 70. dried meat, 71. dried vegetables, 70. Food economics in war, 739. food situations in countries at war, 740. summary of, 773. use of certain foodstuffs in war. See Foodstuffs, use of, in war. Food economy, dehydration as factor in, 10. necessity for, 10. Food material, amount required, 129. dependent on idiosyncrasy and cus- tom, 137. dependent on individual capacity, 138. INDEX 783 Food material, amount required, in early life, 137. influence of work on, 1N4. reserve supply of. desirable, 120. Food preservation, basis of, 1. methods of, 1. canning, or exclusion of air, 6. classification of. 2. cold storage or refrigeration, 3. dehydration. See Dehydration. drying, 2. freezing, 3. salting, 3. smoking, 2. sterili/ation. 6. treatment with antiseptic chemical agents, 7. Food requirement, 12. adult, per kilo, table of, 365. dependent on idiosyncrasy and custom, 137. dependent on individual capacity, 138. in early life, 137. examples of food actually consumed, 270. factors governing, 265. age, 266. amount of heat lost by body, 265. choice of food, 269. intensity of muscular activity, 271. kind of 'work, 184, 268. sex, 266. influence of internal secretions of woman, 268. weight of body. 266. necessary for healthy individual, 362. relation of height to weight. 363. storage of food ingested above, 366. Foods, in which acid-forming elements predominate, 357. in which base-forming elements predomi- nate, 35S. calcium content of, 350, 351. calcium oxid in, approximate amounts of, 353. canned, in tropical climates, 400. Foods, chemical analysis of, 257. choice of, as factor in food requirement, 269. constructive and fuel, 251. consumption of. actual, table of. 270. increased metabolism following, 297. by marching soldiers per day, 382. containing cellulose, 340. containing potassium chlorid, 348. containing vitamines. and their anti- neuritic and antiscorbutic quali- ties, 228. butter fat, 228. rice, L'-JS. fat in. percentage of. 339. fuel and constructive. 251. fi:e! values of. calculations of, 257. table of, 258-263. Foods, fuel values of, unit and method of measurement of, 24ti. included in training diets, 553. ingested, caloric values of, 250. inorganic constituents of, importance of, 357. iron salts contained in. 355. magnesium salts in, 351. approximate amounts of, 353. palatable preparation of, general con- sideration, 577. phosphorus content of, 354. relation of vitamines to, 233. preparation of. See Recipes, reservation of, 102. sodium chlorid in, percentage of, 346. sulphur salts in, 35(5. transmutability of, carbohydrates, 101. hydrocarbons, 100, 101. proteins. 101, 102. salines, 99. used in the army, dehydration of, 37. used in the army and navy. See Ra- tions. vitamine content of, 226. physiological estimation of, 232. Food situation, in countries at war, Ger- many, 740. agricultural classes, 746. caloric needs, 746. consumption of food units, 1912- 1913, 745. dietary of industrial classes, 747. drying process, 743. fat a prominent factor, 744. feeding of military prisoners, 751. finding new fodder, 742. liberal rations for women engaged in manual work in open air, 744. peace-time needs, "46. population of, and caloric needs for, 745. protein needs in ounces, 746. use of leaves. "42. Great Britain, adult rations in, per head per week, 755. caloric needs, 749. diet of munition workers, 753. dietaries for three middle-class families, sixteen persons in Eng- land before voluntary restriction, 753. dietary requirements, 747, 749. during first year of war, 749. during year 1916, 748. first definite steps to control of supply, 747. importations of food supplies before the war. 747. particulars of army rations. ~ is. protein requirements. 749. ton! quantities of foodstuffs avail- able during 1909, 1913, 748. INDEX Food situation, in countries at war, Great Britain, unrestricted diet of a sedentary worker, 756-758. voluntary rationing scheme in, 754. Ruhleben diets compared with stand- ard dietaries, 751. sugar situation, 751. in United States, causes of food short- age, 768. cereal grains, 769. concentrated nature of our food ex- ports, 770. economic viewpoint, 769. fat consumption, 771. propositions for food conservation, 772. protein consumption, 771. sugar consumption, 771. use of grains for manufacture of al- cohol, 772. wheat production, 768. Foodstuffs, digestibility of. See Digesti- bility of Foodstuffs. staple, percentage of utilization of, 104. use of, in war, alcohol, 766. bread, 759. cereals, 749. corn, 763. extraction from total grain, 760. oatmeal, 762. milk, 764. potatoes, 764. requiring mastication, 761. sugar, 765 utilization of, with and without alco- hol, 308 Food values, with cost per 1,000 calories, 273. of fruits, comparison of fresh and dried, 28. physiological, 255. Food waste, from economical standpoint, 103. fats, 105. nutrient, percentage of, in ordinary mixed diet, 106. physiological, 104. France, army rations of, 702. daily, 716. Freezing of food, as agency of preserva- tion, 3. Fruit, in diet of tropical climates, 389. digestibility of, 108. dried, analysis and caloric value of, per pound, 29. comparison of food value of fresh and, 28. drying of. Sec Dehydration of Fruits, fresh, comparison of food value of dried and, 28. necessity of, in diet. 527. preservation of, by dehydration. 9. Sec also Dehydration of Fruits, by drying, 2. Fruit, preservation of, by sugar, 7. waste of, in America, 10. Fruit cure, 545. Fruit diet, apple-fasts, 545. in disease, 544. - experiments with various fruits, 542 543. grape cure, 546. Jaffa's observations on fruitarians, 543, 544. Jaffa's vegetarian dietary, 542. lemon cure, 546. low in protein, 541. low in protein, fat and sometimes caloric value, 541. nitrogen equilibrium maintainable on, 540. records of three subjects subsisting on, 541. Fruits, comparison of food value of, fresh and dried, 28. cooked, preparation of. See Recipes, fruits. dried, comparative cost of total nu- trients and fuel value of some fresh and, 31. economic advantages of, 30. fresh, comparative cost of total nu- trients and fuel value of some dried and, 31. Frying of fish, 66. of meat, definition of process, 58. mediums suitable for, 59. procedure for, 59. temperature of fats in, 59. Fuel foods, 251. Fuel values of food, calculation of, chem- ical analyses of foods, 257. comparative equivalents in metric, avoirdupois and apothecaries' weights and measures, 257. heat produced and substances burned in calorimeter distinguished from heat available when used in body, 263. represented by a particular menu, 263. table of values of ordinary foods pre- pared to serve, 258-263. unit and method of measurement of, 246. G Game flavor, cause of, 63. Gastric peristalsis, inhibition of, by sen- sory stimuli, 81. Gelatin, as a protein sparer. 305. Germany, armv rations of, 700. daily. 716. food situation in, 740. Gluttons, differentiated from epicures or gourmets, 131. from large eaters, 132. of history, 132, 133, 134. INDEX 785 Gluttony, 132. chronic. 131. Gourmand, 132. (iourmandizing, chronic, 131. Gourmets. 131. Gouty diathesis, in children, diet for, 413. Grape cure. 5 tti. Great Britain, army rations of, 713. food situation in, 747. Gustation, scat of. 76. Gustative bulbs, veritable savors recog- nizable through, 77. Gustative sense, 70. If Health, influence of diet on, 368. and vegetable diet, 525. Heat, destructive action of, on vitamines. 222. Heat of body, loss of, amount of, 265. regulation of, 276. production of, during rest, 279. Heat energy, liberated by oxidation of al- cohol, 406. Heat production in twenty-four hours and gaseous exchange per minute, during absolute muscular rest in fasting condition, 280. Height and weight, comparative, of chil- dren. 412. relation of, 363. at varying ages, standard, table of, 364. Hepatin, 355. Home modification of cow's milk, 506, 512. Hominy mush, preparation of, 609. Human economy, foods required by, 362. Hutchinson's views on protein diet, 187. Hydrocarbons, transmutabilitv of, 100, 101. Hydrolytic cleavage, preceding every metabolic transformation of pro- tein, 209. Hyperorexia. 120. Hypozanthin, formation of, 332. Ice cream, making of. See Recipes, ice cream. Idiosyncrasies, personal, in eating, 89. Inanition, causes of. 111. deatli from, in relation to body weight, 147. definition and symptoms of, 111. Indians, diet of, 393. Infant feeding, artificial, addition of al- kalincs. to prevent clotting, 494. analysis of whole milk varying cream percentages skimmed and sepa- rated milks, 513. Infant feeding, artificial, buttermilk, 500. certified milk, 489. (beadle's principles of, 506. clinical application of, 509. condensed milk, 499. difficulty of digestion of cow's miiK, 511. failure to assimilate salts of cow's milk, 496. and good air, 511. home modification or adaptation of milk, 506, 512. importance of mineral salts, 497. importance of sugar, 495. importance of water, 497. important rules to be followed in, 514, 515. summary of, 515. making all food formulae from three ingredients, 514. management of casein of cow's milk, 512. necessary elements, 511. overfeeding, 510. pasteurized milk, 503. peptonized milk, 501. proper intervals for infants of vari- ous ages, 510. proprietary or patent foods, 504. percentages, 508. quiet in, 511. selection of cow's milk for, 489. sterilized milk, 502. success in, 510. sugars in, 512. supplementary articles of diet be- tween sixth and twelfth month, 514. breast feeding, 471. See also Breast Feeding, mixed, 488. Infants' milk, desiccated, reconstruction of, 15. Insalivation, in process of digestion, 85. Intestinal canal, hygiene of, 469. Intestinal stasis, chronic, constant ab- sorption of poisonous elements in, 459. diet in, 464. diseases due to, 460. acidosis. 463. cutaneous lesions, 463, 466. acne, 467. itching dermatoses, 468. of internal secretions. 462. rheumatoid arthritis, 460. ulcer of stomach and duodenum, 461. due to mechanical obstruction. 458. maladies without satisfactory etiology traceable to. 45!. treatment of, by diet. 464, 465. I >y manipulation, 464. by surgery, 465, 466. 786 INDEX Intestinal toxemia, due to overeating, 135. Intestines, construction of abdominal vis- cera with especial reference to drainage, 455. faulty position of abdominal viscera due to refinements of civilization, 456. hygiene of, and effort to overcome con- stipation, 457. general considerations, 455. intestinal canal, 469. intestinal stasis, chronic, 458. Invalid broths, 599. Iron, inorganic, given as drug, 356. Iron salts, compounds of, 355. contained in body, 355. contained in foods, 355. excretion of, 355. Italy, army ration of, daily, 717. Itching dermatoses, treatment of, 468. Jaffa's vegetarian dietary, 542. Japan, army rations of, 701. daily, 717. Jellies, making of. See Recipes, jellies. Julienne soup, 602. Just-Hatmaker process of desiccation of milk, 13. Kayser's table showing nitrogen balance when feeding isodynamic quan- tities of carbohydrate and fat, 303. Kosevi's maintenance ration for the aged, 443. Labor, diet after, 429. Laborers, dietary of, 376. Lactalbumen, in cow's milk, 493. Lactation, daily bowel movement during, 482. diet during, 429, 481. day's ration, calculated by Gautier, 430. in regard to quantity of mammary secretion, 431. rules formulated by Rotch, 431. influence of diet and exercise on, 431. period of, 429. Lactic acid, in souring of milk, 569. Lactic acid therapy, 569. Lacto-vegetarian diet, 521. an impossibility, according to Caultey, 523. Lactose, in breast milk, 478. Langworthy's dietary standard for aged and infirm, 443. Lecturers, diet for, 560. Legumes, composition and fuel value of fresh and dried 42. dehydrated, 42. Lemon cure, 546. Lentil soup, preparation of, 604. Lipoids, bio-electric potentiality of, 221. in metabolism, 220. nitrogenous importance of, 219. substances comprised under, 220. M Magnesium salts, 351. in body, 352. in food, 351. approximate amount of, 353. Malacia, 119, 120. Malnutrition, chronic, consumption of energy in, 160. Weir Mitchell diet in treatment of, 549. Malted milk, in infant feeding, 505. Mastication, act of, 83. foods requiring, and greater nutritive value of, 761. of meat, 87. moderate, necessity for, 83. prolonged, overdoing of. See Brady- phagia. rapidity of, 86. Matzoon cure, 566. Maurel's maintenance rations for old peo- ple, 443. Meals, composition of, 366. distribution of, 366. drinking of water with, 88. order and frequency of, in diseased con- ditions, 90. in normal health, 90. for persons engaged in commercial life, 91. for persons engaged in manual labor, 90. for persons engaged in night work, 91. for persons engaged in professional vocations, 91. for persons engaged in skilled labor, 91. for persons leading life of leisure, 91. regularity of, 92. relation of medication to, 96. Meat, baking of, 60. boiling of, 55. braising of, 64. broiling of, 63. comparative composition before and after cooking of, 65. comparative composition of water-free substance of meats, before and after cooking, 66. concentration of, by drying, 71. consumption of, in America, 206. in different countries, 367. in old age, 451. in tropical climates, 395. INDEX 787 Meat, cooking of, history of, 50. *S'ee (ilno Cooking, of Meat, digestion of, and bolting of, 88. and mastication, 87. eating of, direction of allowance of, 206. and fatigue poisons, 207. restriction of, 206. frying of, 58. grilling of, 63. mastication of, 87. effect of bolting, 88. need of, felt by those accustomed to, 368. overfeeding on, ailments and disorders due to, 207. powdered, 20. disadvantages of, 20. Italian method for making of, 20. preparation of. Flee Recipes, meats, preservation of, by antiseptic chemical agents, 7. by canning, 6. by cold storage, 3. by dehydration. See Dehydration of Meat. by drying, 71. See also Dehydration of Meat, by freezing, 3. by smoking, 2. by sterilization, 6. roasting of, 61. as a source of nitrogen, 174. steaming of, 65. stewing of, 57. tropical disorders due to eating of, 179. Meat diet, amount necessary to supply re- quisite nutriment, 534. effects of, 534. exclusive, 532. metabolism with, 535. peoples subsisting on, 533. and physical power, 533. Salisbury diet, 536. modified, 537. in treatment of dyspepsia, 535. of gout, 535. of obesity, 535. of tuberculosis, 534. zymotherapy, 538. Meat extract, iced, preparation of, 597. Meat juices, preparation of, 595. Meat soups, preparation of. See Recipes, Soups. Meat supply, of French army, 711. Mechanics, dietary of, 376. Medication, relation of, to meals, 96. Menopause, derangement of nervous sys- tem during, 432. diet during, 432. diseases developing at, 433. period of, 432. Menstruation, diet during, 425. disturbances accompanying, and diet, 425. Mental powers, effects on, of overeating, 135. of underfeeding, 149. Metabolic carbon and nitrogen balance during fasting, 298. Metabolism, chemical changes of, classi- fied, 286. constructive, or anabolism, 286. definition of term, 286. dependence of life on, 287. effect of fasting on, 117. experiments in, 118. energy, calculation of, from carbon and nitrogen balance, Atwater's ex- periment, 296. factors affecting, acid-forming and base- forming elements, 314. alcohol as a protein sparer, 306. calorimetric method of studying, 2{)~. carbohydrates as protein sparers, 300. consumption of food, 297. fasting, 298. fat versus carbohydrates as protein sparers, 302. gelatin as protein sparer, 305. metabolism of mineral substances, 311. metabolism of water, 308. nitrogenous diet, 299. functions of different organs and tissues in, 285. general considerations on, 285. lipoids in, 220. with meat diet, 535. mineral, 311. acid-forming and base-forming ele- ments of diet, 357. calcium diets, low and high, 349. in disease, 341. electrolytic properties of salts, 343. importance of, in processes of nutri- tion, 358. iron salts, 355. magnesium salts, 351. minerals in typical dietaries, daily quantities per man, 342. percentage of ash in bones, muscles and various organs, 312. phosphorus, 352. potassium chlorid, 348. salt-free diet, 345. sodium chlorid, 344. sulphur salts, 356. and variations in amount of salt in- gested, 346. nitrogen, in old age, 444. nitrogen balance, Neumann's dietary ex- periment, 310. of overfeeding, excess of proteins and carbohydrates, 138. "oxidation water" resulting from com- bustion of hydrogen in the foot 1 , 309. 788 INDEX Metabolism, processes of, series of, 287. various, 285. protein, 327. ammonia, 329. carbohydrate-free diet, 338. catabolism of proteins, 169. cellulose diet, 339. creatinin, 329. deaminization of proteins in amino- acids, 169. end products of, on both high and low protein diet, 328. fat-free diet, 338. purin bodies, 329. urea, 327. uric acid, 329. retrograde, or catabolism, 287. salt, in disease, 341. of starvation, acute, protein, 160. pathology of, 158. of underfeeding, acute, protein, 160. in the blood, 162. pathology of, 158. protein, 153. secretion of bile, 162. Siven's table showing gradual rise in protein intake but with a con- stant and sufficient energy intake, 159. in the urine, 162. vitamine r6le in, 224, 229. of water, 308. Metabolism experiments, balance of income and outgo, 288. effects of food and work on respiration, 293. exchange of material with standard diets, 288. respiratory quotient, 292. summary of, income and outgo of energy: calories, 291. income and outgo of nitrogen and car- bon, 290, 296. Mexicans, dietary of, 383, 384. Microorganisms in breast milk, 474. Military training camps for boys, rations for. See Rations, boys' military training camos. Milk, analysis of changes occurring in fer- mentation of, 568. boiling of, value of, 493. breast. See Breast Milk, certified, 489. clots of. in cow's and human, 493. prevention of, by addition of alkali, 494. coagulation of, 477. comparative analysis of human and cow's, 490. comparative composition of, from dif- ferent animals, 490. composition of, carbohydrates, 494. chemical, 491. diastatic ferment, 497. Milk, composition of, fat, 493. inorganic contents, 495. lack of uniformity, 492. proteins. 493. salts, 496. vitamines, 498. condensed, in infant feeding, 499. description of, 492. desiccated, 71. desiccation of. See Desiccation of Milk. in diet in tropical climates, 394. fatless, desiccation of, 15. home modification or adaptation of, in infant feeding, 506, 512. for infants, reconstruction of desiccated milk into, 15. malted, in infant feeding, 505. pasteurized, in infant feeding, 503. sour, composition of, percentages, 566. souring of, by lactic acid, 569. sterilized, in infant feeding, 502. use of, in war, 764. varying composition of morning and evening, 492. Milk cure, 569. application of, 570. buttermilk cure, 566. indications for, 571. kumiss cure, 564. matzoon, 566. quantities administered, 571. skim milk cure, 572. sour milk cure, 567. whey cure, 573. Mineral metabolism, 311. acid-forming and base-forming elements of diet, 357. calcium diets, low and high, 349. in disease, 341. electrolytic properties of salts, 343. importance of, in processes of nutrition, 358. iron salts, 355. magnesium salts, 351. minerals in typical dietaries, daily quan- tities per man, 342. percentage of ash in bones, muscles and various organs, 312. phosphorus, 352. potassium chlorid, 348. salt-free diet, 345. sodium chlorid, 344. sulphur salts, 356. Minerals in typical dietaries, daily quan- tities per man. 342. Mitchell, Weir, diet in treatment of neu- rasthenia and disorders of mal- nutrition independent of organic disease. 549. Modification or adaptation of milk, home, in infant feeding. 506, 512. Muscular activity, as factor in food re- quirement, 271. Mutton broth, preparation of, 598. INDEX 789 N Negroes, dietary of, 382, 384. Nesfle's food. 505. Neumann's dietary experiment, 310. .Neurasthenia, Weir Mitchell diet in treat- ment of, 5 (!). full dietary, 551. synopsis of management of individual case, 550. Nitrogen, in diet, 321. in feces, 328. income and outgo of carbon and. in metabolism experiments, 290, 200. requirement of, for maintenance, 181. value of meats as a source of. 174. Nitrogen equilibrium, Kayser's table showing, when feeding isodyna- 111 ic quantities of carbohydrate and fat, 303. maintenance on fruit diet, 540. maintenance of, 323. minimum protein necessary to main- tenance of. 153. Neumann's dietary experiment, 310. and protein diet. Benedict on, ls. interchange of nitrogen and stoi,.-e. protein and fat in. table showing approximate value- of. absolute and percentage. 143. nitrogen increase due to, table empha- si/.ing. 142. dangers of. 197. 790 INDEX Overfeeding, definition of, 138. of infants, 510. of meats, ailments and disorders due to, 207. metabolism of, excess of proteins and carbohydrates, 138. prevalence of, 128. in youth and early adult life, 197. Overmastication. See Bradyphagia. "Oxidation water," resulting from com- bustion of hydrogen in the food, 309. Oyster juice, preparation of, 598. Oyster soup, preparation of, 608. Oyster stew, preparation of, 607. "Palatability," use of term, 77. Parorexia, 119. Pasteurized milk, in infant feeding, 503. Patent foods. See Proprietary or Patent Foods. Peaches, dried, 24. Pellagra, due to vitamine deficit, 232, 237. relation of spoiled corn to, 44. Peptonized beverages and foods, prepara- tion of. See Recipes, beverages and foods. Peptonized milk, in infant feeding, 501. Persimmon, dried, 28. Perversions of appetite. See Appetite, per- versions of. Phosphorus, importance of, 352. as building material, 354. Phosphorus content of foods, 354. relation of vitamines to, 233. Pica, 119. Playfair's table of requirements for work, 377. Poison, protein, 168. Poisoning, from canned goods, 6. Polydipsia, 121. Polyphagia, 121. Potassium chlorid, foods containing, 348. importance of, 348. Potato flour, 35. Potato soup, preparation of, 604. Potatoes, dehydrated, 33. composition of, 34. composition and fuel value of, under various methods of preparation, 34. method of dehydration, 33. potato flour, 35. sweet, dehydration of, 35. use of,' in war, 764. white, value of, 213. Poultry, preparation of. See Recipes, poultry. Pregnancy, albuminuria and dropsy com- plicating, 426. diet during, 425. longings for various indigestible arti- cles, 426. Prochownick's diet for pregnancy, 428. Proprietary or patent foods, 'in infant feeding, 504. in infant feeding, list of, 508. malted milk, 505. Nestle's food, 505. percentages, 508. Protein consumption in United States, 771. Protein content, character of diet and, 212. Protein deficiency, caution as to, 196. Protein diet, effect of, on health and en- durance, high protein diet, 169. low protein diet, 171. on strength and endurance, 192. end products of protein metabolism on, 328. high, 169, 325. versus low, 185. low, 324. Baeltz's investigations among the Jap- anese, 176. Chittenden's investigations, 171. effect of, on animals, 192. Fisher's investigations, 174. high versus, 185. and nitrogen equilibrium, Benedict on, 189. Folin's views on, 187. Halliburton on, 189. Meltzer on, 189. and occupation, 193. reduction of, necessary, 190. value of meats as a source of nitroeen, 174. Protein digestion, 107. ill-effects of absorption of end-products of, 198. Protein fractions, chemical formation of, 198. Protein metabolism, 327. ammonia, 329. carbohydrate-free diet, 338. cataboiism of proteins, 169. cellulose diet, 339. creatinin, 329. deaminization of proteins in amino- acids, 169. end products of, on both high and low protein diet, 328. fat-free diet, 338. governed by tissue requirements, 299. purin bodies, 329. revolution in conception of, 167. of starvation, acute, 160. theories of, 203. of underfeeding, 153. urea, 327. uric acid, 329. and variations in amount of salt in- gested, 346. Protein molecule, structure of, 168. Protein poison, 168. Protein-poor foods, percentages of protein in, 326. INDEX 791 Protein requirement, Chittenden low pro- ten dietary, 253. determinations of, 253. for growing boy, 690. minimum to maintain nitrogen equi- librium, 194. standard for, 180. Proteins, amino-acids in, 194. animal versus vegetable, 528. building up of, 208. catabolism of, 169. coagulation of, 107. by heat, 52. combustion of, adapted to intake of, 300. concentrated, 70. in cow's milk, 493. deamini/ation of, in amino-acids, 169. deficiency in, in breast milk, 487. differences in suitability for tissue con- struction, 202. excess of, in metabolism of overfeeding, 138. form of absorption of, 209. importance of, in alimentation, 530. minimum, necessary to maintain nitro- gen equilibrium, 153. nature of, 107. necessity of, to blood and muscles, 205. percentages of, in protein-poor foods, 326. physical absorption of, differences in suitability for tissue construction, 202. physical properties of, 201. relative absorption, 202. qualitative variations in amino-acids of, 200. quantitative differences of, 199. relative absorption of, 202. relative values of meat and vegetables, 204. surplus of, from suitable food mate- rials, 203. of the tissues, interchange of, 209. transmutability of, 101, 102. vegetable, 212. vegetable versus animal, 528. Protein sensitization, attention given the- ory of, 170. condition similar to, produced by over- feeding of a particular protein, 169. Protein sparers, alcohol as, 306. carbohydrates as, 300. carbohydrates and fat in calorimetric experiments (Atwater), 304. fat versus carbohydrates as, 302. gelatin as, 305. Protein and starch equivalents, in cereals and buckwheat*, table of, 391. in pulse, in diet of tropical climates, table of, 392. Protein starvation, effects of, 156. Protein structure and properties, chem- ical formation of protein frac- tions, 198. qualitative variations in the amino- acids of proteins, 200. quantitative differences of proteins, 199. Protein tissue, chemical decomposition of, 158. Prunes, dried, 22. Ptomaine poisoning, from canned goods, 6. due to "high" or slightly tainted game or meat, 63. Puberty, beginning of period of, 418. diet during. See Diet during Puberty, improvements desirable in present cur- riculum of schools, 420. question of stimulants in, 420. Puddings, preparation of. See Recipes, puddings. Puerperium, diet during, 428. Purin bodies, in animal and vegetable ni- trogenous bodies, 331. chemistry of, 330. in food, *333. quantity of, 334. occurrence in body, 331. production of, in presence of cellular processes, 332. in protein metabolism, 329. source of, 329. Purin compounds, solubility of, 330. excess of, 335. low, 336. Purin foods, effect of, on uric acid, 334. Purin-free diet, 336. dinners suggested by Haig's disciple, 337. indications for, 336. to supply albumin, 336. Purins, bound, 332. endogenous, 331. exogenous, 331. excretion of, 333. free, 332. R Raisins, methods of preparing, 26. Ration, definition of, 666. emergency, 666. field, 666. Filipino, 666. garrison, 666. Imversack, 666. supplementing of, 666. travel, 666. Rations, army, 663. for boys' military training camps, 684. dearth of statistical material on, OS 4. dietary for one week. Fort Terry, New York. 686-090. showing requisite amounts of ter- nary food elements and fuel or * energy value in calories, 692-697. 792 I^DEX Rations, for boys' military training camps, importance of sufficient vitaminc principles, 691. protein requirement. 690. for boys' private boarding school, 685. of foreign armies, 697. comparative, Austrian, 715. English, 716. French, 716. German, 716. Italian, 717. Japanese, 717. Russian, 717. comparative tables of eight countries, 698. 699. emergency ration, 700. of France, 702. amount given out and carried at one time, 708. authorized extraordinary supple- ments. 706. authorized substitutive equivalents, 705. in the cavalry, 708. commutation of, in times of peace, 706. components of garrison and field rations, 702. composition of, 704. daily allowance for additional sup- plies, 706. meat supply, 711. methods of cooking in the trenches, 703. normal, 707. in peace and in war, 703. reserve, 707. strong, 707. trains, 709. in the trenches, 706. of Germany, 700. of Great Britain, 713, 748. during Boer War, 723. of Japan, 701. meat allowance as compared with that of U. S. army, 697. of Russia, 701. systems of supply, 714. of French navy, 729. military, conclusions regarding compo- sition and food value of (Har- vard), 722. in military prison camps, 718. menu taken from Camp Guterslohe for one week, officers' section, 719. menu taken from Camp Munster for one week, 718. weekly diet sheet typical of period prior to stringency in foodstuffs, 721. typical of period of stringency in * foodstuffs, 721. navy, comparative nutritive energy of American and foreign, 729.* Rations, U. S. army, additional articles consumed, 6*65. allowance and consumption per man, 665. company dietaries, 675. company dietary at a southern post, 676. at a western post, 675. component parts of, 681, 726, 727. concentrated foods, 674. dehydration of foods, 37. emergency, 673. field ration, 670. Filipino ration, 672. garrison ration, component and sub- stitutive articles and quantities, 667. Colonel Harvard on, 666, 668, 669. haversack ration, 671. ordering of, 664. past and present, 681. amount and kind of food, 682. cases of rheumatism among veter- ans, 683. during the Civil War, 683. present policy of improvement, 682. percentage of waste in, 665. quantity of stores required for one dav's subsistence of 150,000 men in "field, 683. savings, 672. selection of, 674. ten days' ration uncooked food for an average daily of 440.4 men, 664. travel ration, 672. in tropics, 676. tropical dietaries, 676. average nutrient composition of, 680. tables of, 678, 679. U. S. navy, 724. commissar} 7 store, establishment and administration. 734. daily and weekly, 725. extra allowance, 723, 728. general mess, bakers, 734. commissary, 732. commissary stewards, 733. cooks, 733. organization and administration, 730. preparation of food, cooking, 737. galley, 737. ration, 736. study and arrangement of, from point of view of efficient service, 728. Recipes, beverages, with egg and alcohol, brandy and egg mixture, 586. caudle, 587. egg flip, 587. egg-nog, 585. 586, 587. egg-nog, beef-tea, 587. egg and grape .juice, 587. milk punch, 587. wine, mulled, 588. INDEX 793 Recipes, beverages, with egg and alcohol, wine whey, 588. nutritious, albumin water, 580, 581. albuminized milk, 583. caudle. 581. cocoa, 582. coffee, 582. diluents, various, 584. egg and buttermilk mixture, 584. egg broth, 581. egg cordial, 581. egg drink. (i23. egg flip, 585. grape juice, 584. junket, vanilla, bitter almond or strawberry, 584. kumiss, 582* 58:5. milk, albumini/ed, 583. almond, 582. and cinnamon drink, 583. and other diluents, .1st. and Irish moss, 583. milk lemonade, 584. milk mixture, 583. milk porridge. 585. whey, lemon, 582. plain, apple water, 578. barley water, 581). currant juice (Fitch), 578. imperial drink, 579. lemonades, 570. lime water, 578. linseed tea, 580. orangeade, 579. orgeat, 580. tamarind water, 578. toast water, 580. blancmange, 645. chocolate or cocoa, 653. Irish-moss, 646. bouillon. American, linl. boiling of meat for, 56. bottle. 601. clam. 600. clam bouillon bisque, 600. general procedure for, 56. . plain, 600. bread, aleuronat bread, 657. bran mullin for constipation, 613. brown, 612. cornmeal gems, 614. for diabetics, almond biscuit, 660. bran, 657. bran cakes. Oamplin's, 657. gum gluten, 656. gum gluten muffins, t;."">7. waffles, 658. Drexel Institute recipe, 612. graham. 613. nut In-own, 612. pulled. 613. toast. 614. cream. 615. milk. 614. Itecipes, white gems, 613. whole-wheat, 612. zwieback, 613. broths. 51)7. American, 601. beef, 59S. with egg gruel, 618. and grain. 599. with poached eggs, 599. boiling of meat for, 56. chicken, 598. clam, 598. clam juice, 598. egg, 581. in general, 56. invalid, 599. mutton, 598. mutton, without meat, 599. with vegetables, 59!). nutritive drink for delicate women and children, 599. oyster juice, 598. veal, 598. cakes, for diabetics, aleuronat and al- mond, 659. almond cakes, 658, 659. bran, Camplin's, 657. cocoanut, 659, 661. cocoanut and almond, 661. cereal foods, flour ball, 617. general, 615. gruels, arrowroot, 619. barley, 619. with beef extract, 618. barley meal. 619. barley and oatmeal jelly, 618. cornmeal gruel, til 7. til 8. cracker gnirl. tilii. til 7. egg. 618. farina, tilti. flour, tilti. flour, or thickened milk, til9. flour ball uruel, 617. gluten, til 8. imperial granum, 616. meal >oii]>, til 7. oatmeal, tilti. oatmeal, ti'20. oatmeal and barley jelly. 618. port wine, 619. Racahout des Arabes, til 7. length of time for cooking. 616. for constipation, bran miillins, 613. custards, baked, 650. baked or cup, 648. chocolate. ti4!). cocoa junket. (ir>it. peach meringue. 649. rennet, or plain junket, 650. rules for. 647. sauce. 648. savory. (148. soft. (H 7. 650. -oilllir. til!). 794 IXDEX Recipes, desserts. See Blancmange, Cus- tards, Ice Cream, Jellies, Junkets, Puddings, for diabetic foods, aleuronat bread, 657. aleuronat pancakes, 660. aleuronat and almond cakes, 659. aleuronat and suet pudding, 660. almond biscuit, 660. almond cakes, 658, 659. almond pudding, 662. bran cakes, Camplin's, 657. cocoanut and almond cakes, 661. cocoanut cakes, 659, 661. cocoanut pancakes, 661. cocoanut pudding, 662. gum gluten bread, 656. gum gluten muffins, 657. waffles, 658. dressings, cream, 638. mayonnaise, 637. dumplings, egg, 607. farina, 610, 611. potato, 611. for dyspeptics, jelly, 643. eggs, cooking and digestibility of, 620L egg drinks. See Beverages, nutritious, and Beverages, egg and alcohol. egg gruel, 618. hard-cooked, 620. omelet, 621. omelet souffle, 621. poached, 623. with cheese, 624. prairie oyster, 622. rumbled, 623. snowball, 622. soft-cooked, 621. farinaceous foods, cornmeal mush, 609. farina dumplings, 610, 611. hominy mush, 609. macaroni, boiled, 610. and rice, 610. oatmeal mush for children and in- valids, 609. potato dumplings, 611. rice, boiled, 608. Italian (with cheese), 610. and macaroni, 610. plain boiled, 610. fish, baked, 624. in butter, 626. dietary value of, 624. frying of, 66. oysters, broiled, 627. panned, 627. sole or whiting, steamed, 625. souffle, 627. steamed sole or whiting, 625. stewed, 625. fruit ice creams. See Ice Cream, fruits, apples, baked, 639. apricot and prune sauce, 639. figs, stewed, 640. orange, 640. peach meringue, 649. Recipes, fruits, pineapple, 640. pineapple cream, 652. prunes, stewed, 640. gruels, egg, 618. See also Cereal Foods, ice cream, caramel, 656. chocolate. 655. junket, 655. peach, 655. strawberry, 655. vanilla, 656. jellies, 642. calf's foot, 643. chicken, 642. coffee, nutritious, 646. cream, or blancmange, 645. for dyspeptics, 643. general directions for dishes made with gelatin, 644. Irish-moss blancmange, 646. lemon, 645. meat, 642. with gelatin, 647. with Irish moss, 647. with tapioca, 647. milk, 644, 646. orange, 645. veal-bone, 642. wine, 645. sweet, from gelatin, 645. junket ice cream, 655. junkets, cocoa, 650. plain, or rennet custard, 650. vanilla, bitter almond or strawberrv, 584. meat juices, 595. beef essence, 597. beef juice (Bartholow, Cautley and Ringer), 596. cold, 597. beef teas, 593-595. meat extract, iced (Ziemssen), 597. meat- juice mince ( Watson ) , 596. Watson's home-made, 595. meat jellies. See Jellies, meat soups. See Soups, meats, baking of, 60. beef, Hamburger steak, 632. beef pulp, 631. beef quenelles, 631. raw. beefsteak, .633. general method of preparing, 632. juice, 633. with milk and sugar, 633. soup, 633. succus carnis (meat juice), 633. boiling of, 56. braising of, 64. broiling of. 63, 630. frying of, 59. general rules for preparing, 630. grilling of, 63. pan-broiling of, 631. roasting of, 630. sweetbreads, stewed, 632. INDEX 795 lleeipes, meats, veal, roast, 631. venison, roast, 632. meringues, peach, 649. mush. Kee Farinaceous Foods, nuts, chestnut puree, 641. cooking of, 641. digestibility of, 641. nutritive value of, 641. pancakes, for diabetics, aleuronat, 660. cocoanut, 661. peptonized and predigested foods, 588. cereals partially digested, prepared at table, 589. grape juice whey, 503. junket, or curds and whey, 592. cocoa, 592. coffee, 592. with egg, 592. iodized, 593. milk, partially peptonized, 589. peptonized, 590. milk gruel, peptonized, 591. milk jelly, peptonized, 591. milk lemonade, peptonized, 591. milk punch, peptonized, 591. peptonized beef, 588. peptonized oysters, 589. whey, 593. grape juice, 593. poultry, broilers, boiled, 629. stewed or potted, 629. capons, 629. cliickon, broiled, 628. chicken puree, 638. chicken salad, 628. flesh of, 628. partridge, stewed, 629. roast, 629. squabs, boiled, 629. stewed or potted, 629. puddings, aleuronat and suet, for dia- betics, 660. almond, for diabetics, 662. arrowroot, 651. bread, 051. and butter, baked, 654. plain, 653. chocolate or cocoa blancmange, 653. cocoanut, for diabetics, 662. cornstarch, 652. pineapple cream, 652. rice. 651. and egg, 651. plain, 652. sponge, 654. tapioca and sago, 653. purees, chicken, 638. endive. 039. lettuce. 638. red cabbatre, 630. salads, chicken, 628. sauces, custard, tilS, for vegetables. 63.1. soups, egg dumpling, 607. Recipes, soups, fish, 606. oyster soup, 608. oyster stew, 607. meat, 605. first stock for clear brown soup, 606. general directions for, 605. raw-beef, 633. sweetbread soup, 607. vegetable, 601. brown, 605. Brunoise, 604. clear, or consomme, 603. consomme and egg, 604. \ cream-of-celery, 602. cream-of-potato, 602. cream-of-tomato, 601. Julienne, 602. lentil, 604. without meat, 601. potato, 604. tapioca, 602. white, 603. toast, 614. cream, 615. milk, 614. vegetables, asparagus, 635. carrots, 636. cauliflower, 636. cauliflower a PIndienne, 636. dressings, cream, 638. mayonnaise, 637. endive puree, 639 general rules for cooking, 634. lettuce puree, 638. oyster plant, 635. peas, green, 636. potatoes, mashed, 636. red cabbage puree, 639. sauce for, 635. spinach, 635. string beans, 636. time-table for cooking, in water, 634. tomato savory, 637. Reducing dietary, 550. Refrigeration. X. Teeth, condition of. in old age, 450. Tollier method of dehydration of moat, 1!). Temperature of the body, heat production during rest, 279. in sleep calculated for twenty-four hours, table of, 277. regulation of, 274. chemical, 275. gaseous exchange per minute and heat production in twenty-four hours, during absolute muscular rest in fasting condition, 280. involuntary. -274. physical, 275. resume of. 27!'. surface areas of skin in, 276. regulation of heat loss. 272. Tissue construction, differences in suitabil- ity of proteins for, 202. Toast, preparation of. See Recipes. Toxemia, intestinal, due to overeating, 135. Training, general principles of, 552. length of time necessary for, 55:}. Training camp, boys' military, rations for. Sec Rations, for boys' military training camps. Training diet, basis of, 552. dietary studies of university boat crews, 555. food included in, 553. general difference between food of ath- letes and other people, 557. necessity and object of, 552. for one day for summer races, Oxford and Cambridge, 556. for one day for winter races, Oxford and Cambridge, 557. summing up of researches and experi- ments of Atwater and Bryant, 557, 558. of Yale training crew. 554. Transmutability of foods, carbohydrates, 101. hydrocarbons. 100, 101. proteins. 101, 102. salines. 99. Tropical climates, alcohol in, 401. beverages in. Id"). diet in. /s'rr Diet in Tropical Climates. Tropical dietaries, in U. S. army, 670. Tropical dieases, due to meat eating. 170. Tuberculosis, meat diet in treatment of, 534. treatment of. by /ymothorapy, 538. Tuberculous children, dietary for, 413. Tubers, starch-yielding, dehydration of. 36. Tufnell's diet for treatment of aortic and other aneurisms, 547. Turnips, dehydration of, 37. Typhoid bacilli, in breast milk, 474. U Ulcer of stomach and duodenum, due to chronic intestinal stasis, 461. Undereating, caution against. 1!7. coupled with indigestion, 196. Underfeeding, acute, protein metabolism of, 160. calorie deficit of gravest import in, 148. cause and prevalence of, 145, 146. chronic or habitual, 146. conclusions on, ]63. consumption of energy in, 160. and crime, ]^2. 153. maleficent sequences of, 148. crime, }~r2. l.~>3. on digestive organs. 152. in diminishing resistance to cold and exposure, 151. drinking. 152. increased liability to disease, 151. mental and physical deterioration. 149. sapping of vital forces, 151. in women and children, 150. metabolism of, in the blood, 162. consumption of energy in, 160. pathology of. 158. protein metabolism. 153. secretion of bile, 162. Siven's table showing gradual rise in protein intake but with a con- stant and sufficient energy intake, 159. in the urine. 162. prevalence of, in all countries, 150. in laboring population of England, 14!). in laboring population of Scotland, 150. relationship of, to disease, 151. 152. Undernutrition. long-continued, 115. temporary. 115. Uric acid, effect of purin foods on, 334. origin of, 335. in protein metabolism, 329. Urine, effect of underfeeding on, 102. Vegetable diet, disadvantages of, low pro- tein alimentation, 529. and energy. 524. all food constituents contained in, 522. and health. 525. history of. 520. indications for. 523. .lall'a's vegetarian dietary. 542. lacto vegetarian diet. 521. opinions of Porphvre and Seneca on, 527. 798 IXDEX Vegetable diet, opposed to scheme of diet, 523. partial, necessity of, 527. and question of fecudity or sterility, 531. reasons for, 520. summary of main points in favor of and against, 531. vegetable versus animal protein, 528. Wait's vegetarian and fat dietary, 528. Vegetable foods, cooking of, 67. See also Cooking of Vegetables, digestibility of, 107. Vegetable flours, use of, 44. Vegetable protein, 212. Vegetable protein, versus animal protein, 528. Vegetable soups. See Soups, vegetable. Vegetables, dehydration of, 11. See also Dehydration of Vegetables, desiccation of, as means of food concen- tration, 70. in diet of tropical climates, 390. drying of, as means of food concentra- tion, 70. necessity of, in diet, 527. preparation of. See Recipes, vegetables, preservation of, by dehydration, 9. by drying, 2. waste of, in America, 10. Vegetarianism. See Vegetable Diet. Vinegar, use of, in preservation of food, 7. Vitamine content of foods, 226. physiological estimation of, 232. relative, table of, 226. Vitamines, antineuritis, 223, 231. beri-beri due to lack of, 230. in cow's milk, 498. destructive action of heat on, 222. . isolation of, 221. in metabolism, 224, 229. nature of, 221. and pellagra, 232, 237. pharmacological properties of, 222. physiological properties of, 222. relation of, to phosphorus content of foods, 233. scurvy in infants due to destruction of, v 498. tables showing effect of whole grain and of highly milled cereals on fowls, 235. in well-balanced dietary, 224. Voit's standard dietary for aged persons, 442. W Wait's vegetarian and fat dietary, 528. War, food economics in. See Food Econo- mics in War. food situation in countries at. See Food Situations. Waste of foodstuffs, economically, 103. fats, 105. physiologically, 104. nutrient, percentage of, in ordinary mixed diet, 106. Water, drinking of, with meals, 88. importance of, to infants, 497. metabolism of, 308. Weaning, duration of, 483. false indications for, 485. Weight of body, food requirement propor- tionate to, 266. Weight and height, comparative, of chil- dren, table of, 412. relation of, 363. at varying ages, standard, table of. 364. Weir Mitchell diet in treatment of neu- rasthenia and disorders of mal- nutrition independent of organic disease, 549. Wheat, production of, in United States, 769. use of, in war, 759. Whey cure, 573. Work, effects of food and, on respiration, 293. and food, 79. influence of, on food required, 184. Playfair's table of requirements for, 377. Xanthin, formation of, 332. Yeast, dehydration of, 45. Yolk cure, 563. Zymotherapy, 538. Date Due PRINTED IN U.S.*. CAT. NO. 24 161 A 000510213 2 WBUOO 1918 v. 2 Fitch, William Edward. Dietotherapy , nutrition and diet in health. WBUOO 1918 v. 2 Fitch, William Edward. Dietotherapy, nutrition and diet in health. MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664