July 3, 1329. # 227811 Carter, Herbert Swift Nutrition and ollnioal dietetics* Fhila. * N.Y., 1917* Meweat ed. Marion T* Ee Fontea. Library Hall. Nutrition and Clinical Dietetics BY / HERBERT S. CARTER, M.A., M.D. *♦» 7 7 ASSISTANT CLINICAL PROFESSOR OF MEDICINE, COLUMBIA UNIVERSITY, NEW YORK; CONSULTING PHYSICIAN TO THE PRESBYTERIAN HOSPITAL, LINCOLN HOSPITAL, SKIN AND CANCER HOSPITAL, NEW YORK s! PAUL E. HOWE, M.A., Ph.D. ASSOCIATE, ROCKEFELLER INSTITUTE FOR MEDICAL RESEARCH; FORMERLY ASSISTANT PROFESSOR OF BIOLOGICAL CHEMISTRY, COLUMBIA UNIVERSITY, NEW YORK; OFFICER IN CHARGE OF LABORATORY OF NUTRITION, ARMY MEDICAL SCHOOL, WASHINGTON, D. C. HOWARD H. MASON, A.B., M.D. ASSOCIATE IN DISEASES OF CHILDREN, COLUMBIA UNIVERSITY, NEW YORK; VISITING PHYSICIAN, CHILDREN’S SERVICE, PRESBYTERIAN HOSPITAL, NEW YORK / / THIRD EDITION, THOROUGHLY REVISED LEA & FEBIGER PHILADELPHIA AND NEW YORK 1923 Copyright LEA & FEBIGER 1923 PREFACE. In presenting this book the authors are conscious of the fact that dietetics is far from a mature science and that a book founded entirely on facts proved in the laboratory is as yet impossible. So much scientific progress has been made with regard to the nature of food and its utilization and require- ments in health and disease, that were feeding merely a matter of food reactions, analogous to test-tube reactions, it would be a comparatively simple matter to prescribe a diet. In deal- ing with all things human, however, the personal equation is of immense importance and one can never foreknow how a food will affect different people under apparently similar con- ditions. It is on this account that accurate clinical observa- tion will always be a prime factor in the successful feedings of patients. Not only should the probable effect of food under particular circumstances be known, but any variation there- from should be met by an experience wide enough to indicate in which direction the next move may be made. So it is that dietetics must be deduced in part from an accurate knowledge of the chemistry of foods and of nutrition and in greater degree from a knowledge painfully acquired by previous experi- ence in somewhat similar circumstances. It is also a fact that the same goal may often be reached by several roads, so that in most conditions different men may attain the same or almost similar ends by different methods; however, the principles underlying their efforts must be in accord. In choosing data from the literature of dietetics it has been the aim of the authors to use only the more recent statements from reliable sources, the seeming exceptions only occur when facts or statistics of an earlier date have not been superseded by later investigation. The attempt has also been made to present the etiological factors of the disease under discussion III IV PREFACE in order to make the rational use of foods depend on these, as well as on knowledge of nutritional chemistry. Metabolism, in its broader aspects, has been discussed in each disease when enough is know to make such consideration profitable. The symptomatology and treatment of disease, other than by diet, have not been given except insofar as it has been necessary to do so in the interest of a better understanding of the case or where general or special treatment has been indissolubly bound up with the use of diets. A second and now a third edition goes to the public with the very sincere appreciation of the authors, for the kindly reception it has received. The whole book has been thoroughly revised, and much new matter added. The chapter on vitamins has been rewritten, and a table of relative distribution of vitamins in the various foods included. The discussion of the feeding of children over two years of age, has been enlarged to include the results of the recent critical survey of the food requirements of children by Holt and Fales. In the pediatric section, besides a general revision, the chapter on Rickets has been entirely rewritten to conform to the more recent discoveries in connection with this disease. There is also a discussion of von Pirquet’s method of feeding by “nems”, instead of calories, developed during the World War, particularly as applicable to feeding large numbers of children. The section dealing with Clinical Dietetics has been con- siderably enlarged by additional matter, particularly in digestive and metabolic diseases, including a discussion of the importance of the Ketone-antiketone properties of foods in their relation to diabetic diets. H. S. C. P. E. H. H. H. M. New York, 1923. CONTENTS. Introduction 17 PART I. FOODS AND NORMAL NUTRITION. CHAPTER I Digestion, Absorption and Excretion. Digestion 23 Enzyme Action 23 Oral Digestion 25 Gastric Digestion 27 Appetite 31 Hunger 34 Intestinal Digestion 35 Sensibility of the Alimentary Canal . • 37 Absorption 38 Bacterial Action and Feces 42 Intestinal Bacteria 42 Putrefaction and Feces 45 Excretion 48 Digestibility of Food 52 CHAPTER II. Energy Requirement. Caloric Value of Food-stuffs 56 One Hundred Calorie Portion 57 Energy Requirement of the Body 58 Determination of Energy Requirement, Calorimeter 59 Respiration Apparatus 59 Respiratory Quotient 60 Basal Metabolism 61 Total Daily Energy Requirements 69 CHAPTER III. Protein Requirement 74 Standard Dietaries 80 Protein Requirement and Standard Dietaries. V VI CONTENTS CHAPTER IV. Inorganic Salts 85 Chlorine Requirement of Man 88 Phosphorus Requirement of Man 90 Calcium Requirement of Man 93 Iron Requirement of Man 95 Iodine Requirement of Man 99 Water Requirement of Man 99 Vitamins or Accessory Food-stuff s 103 Vitamin A 106 Vitamin B 107 Vitamin C 108 Calcium-depositing Vitamin, Antirachitic Vitamin no Pathological Effects Produced by a Lack of Vitamins 11 x Distribution of Vitamins in Certain Food Materials 112 Pellagra 116 Inorganic Salts, Water and Vitamins. CHAPTER V. Food Requirements in Pregnancy and Lactation. Food Requirements and Feeding of Children. Fasting. Food Requirements in Pregnancy and Lactation 117 Energy 117 Protein Requirement 118 Diet and Lactation 120 Food Requirements and Feeding of Children 122 Energy Requirements of Children 124 Total Caloric Requirements 124 Protein Requirement 126 Fat Requirement 127 Carbohydrate Requirements 128 Total Percentage Distribution of Calories 129 Inorganic Salts 130 Vitamins 130 Water 131 Selection of Diets for Children after the Second Year 131 Food for Children 131 Milk and Eggs 131 Meat 132 Cereals, Bread or Other Grain Products 132 Vegetables 133 Fruit 133 Fats 133 Water 134 Planning the Meals 134 Breakfast 134 Dinner 134 Supper 134 School Lunches . . . . . 134 Food Habits of Children 134 Fasting and Undemutrition 136 Fasting 136 Undernutrition 138 CONTENTS VII CHAPTER VI. Dietary Essentials 141 Energy 142 Protein 142 Carbohydrate and Fat 142 Mineral Matter 142 Vitamins and Bulk 142 Planning Meals 142 Cost of Food 147 Normal Feeding and Food Economics. PART II. FOODS. CHAPTER VII. Introduction—Milk. Milk 162 Nutritive Value 162 Physical Properties 162 Chemical Properties 163 Protein 164 Fats 165 Carbohydrates 165 Salts 166 Vitamins 167 Variations in Composition 167 Condensed Milks 168 Influence of Temperature 170 Bacteria 170 Action of Bacteria 171 Action of Heat 171 Digestion of Milk 172 CHAPTER VIII. The Proteins of Food 175 Classification of Proteins 178 Simple Proteins 178 Albumins . 178 Globulins . 179 Glutelins 179 Alcohol Soluble Proteins, Prolamines . 179 Albuminoids 179 Histones 179 Protamines 179 Conjugated Proteins 180 Nucleoproteins 180 Glycoproteins 180 Phosphoproteins 180 Hemoglobins 180 Lecithoproteins 181 Protein Foods. VIII CONTENTS Classification of Proteins: Derived Proteins 181 Primary Protein Derivatives 181 Proteins . . . 181 Metaproteins 181 Coagulated Proteins 181 Secondary Protein Derivatives 181 Proteoses 181 Peptones .181 Peptides ..181 Influence of Heat 181 Effect of Low Temperatures 182 Digestion and Absorption .183 CHAPTER IX. Meat or Flesh Food. Nutritive Value 184 General Properties 184 Composition 186 Effect of Heat on Meat 189 Cooking 189 Precise Method of Roasting Meat .' 191 Chemical Changes in Meat as the Result of Cooking 192 Digestibility of Meat 192 Meat Preparations 195 Meat Extracts 196 Meat Juice 196 Meat Broths 198 Gelatin 198 CHAPTER X. Fish and Shell Fish—Poultry and Game. Fish and Shell Fish 200 Cold Storage Fish 203 Preserved Fish 203 Cooking of Fish . .204 Digestibility of Fish 204 Poultry and Game 204 CHAPTER XI. Eggs and Cheese. Eggs . 206 Nutritive Value of 206 General Properties of 206 Egg White .' 207 Egg Yolk 207 Cooking of Eggs 208 Digestibility of Eggs 209 Preserved Eggs 210 Egg Substitutes 211 Cheese 211 Nutritive Value 211 Composition and Preparation 211 Digestibility of Cheese ■ 212 Casein Preparations 212 CONTENTS IX CHAPTER XII. Protein-rich Vegetable Foods. Legumes 214 Nutritive Value 214 Soy Bean 216 Peanut 217 Preparation of Legumes 217 Nuts 218 CHAPTER XIII. Carbohydrate-rich Foods. Nutritive Value 219 General Composition 219 Sugars 220 Sucrose 221 Glucose :^2I Lactose Maltose 222 Maple-sugar 222 Invert Sugar 222 Fructose 222 Candy, Jams and Jellies 223 Digestion and Utilization of Sugar 223 Starch 224 Digestion and Absorption 225 Grains and Their Products , . 226. Nutritive Value .226 Composition 226 Barley 228 Buckwheat 228 Com 228 Oats 229 Rice 229 Rye 230 Wheat 230 Bread 233 Baking Powders 234 Rolls, Biscuits, Muffins, etc 234 Biscuits, Crackers 235 Cakes 235 Breakfast Foods 235 Macaroni 235 Celluloses 236 Potatoes 236 CHAPTER XIV. Fat-rich Foods. Nutritive Value , 239 General Properties 239 Digestion and Absorption 240 Cream 243 Butter 244 Renovated Butter and Butter Substitutes 245 Oleomargarine 246 Lard 247 Vegetable Oils 247 Cotton Seed Oil 247 Olive Oil 248 Corn Oil 248 Cod-liver Oil 248 X CONTENTS CHAPTER XV. Fruits and Vegetables 250 Nutritive Value and Composition 250 Fruit Acids 253 Cooking of Vegetables and Fruits .... . 254 Preservation 255 Food Adjuncts . 256 Spices . 256 Flavoring Extracts 257 Meat Extracts 257 Vinegar 257 Sugar and Salt (Sodium Chloride) 257 Sugar Substitutes 257 Beverages 257 Tea 258 Coffee 259 Cocoa and Chocolate 262 Mineral Waters 264 Radio-active Water 266 Alcoholic Beverages 269 Wines 272 Classification of Wines 272 Malt Liquors 273 Malt Extracts 273 Distilled Liquors 274 Foods Valuable for Their Salts, Vitamins, Water and Bulk. PART III. FEEDING IN INFANCY AND CHILDHOOD. CHAPTER XVI. Breast Feeding—Feeding Normal and Abnormal Children. Woman’s Milk 275 Colostrum . 275 General Characteristics of Woman’s Milk 276 Quantity 276 Composition 277 Fat 277 Lactose 277 Protein 278 Salts 278 Iron 278 Phosphorus 278 Salts of Woman’s and Cow’s Milk . 273 Bacteria 279 Drugs 279 Nervous Impressions 279 Menstruation 279 Pregnancy 279 Transmission of Immunity 279 Breast Feeding 280 Contraindications for Breast Feeding 281 Intervals of Nursing 281 Length of Each Nursing 282 CONTENTS XI Breast Feeding: Mother’s Diet and Exercise 283 Vomiting _ 284 Gas and Colic " 285 Normal Stool 285 Abnormal Stools 285 Mixed Feeding 285 Weaning 286 •HRvpter XVII. Artificial Feeding. Food Requirements of the Artificially Fed Infant 288 Energy 288 Protein . 289 Fat 289 Carbohydrate 290 Sugar 290 Starch • 291 Inorganic Salts 292 Water 292 Vitamins 292 Proprietary Foods 293 Preparations Containing Cow’s Milk 293 Preparations Containing Large Amounts of Maltose 293 Farinaceous Foods 293 Miscellaneous Foods 293 Artificial Feeding 294 Method of Preparing Formula 295 Increasing Formula 295 Cereal 296 Higher Fat Mixtures 299 Food Other than Milk 299 Orange Juice 299 Beef Juice and Broth 300 Beef Juice 300 Cereals 300 Egg 300 Vegetables 301 Rice and Potato 301 Bread 301 Abnormal Symptoms 302 Vomiting 302 Gas 303 Colic 303 Loose Stools 303 Diarrhea 304 Protein Milk 304 Constipation 305 CHAPTER XVIII. Feeding of the Premature Infant. Feeding After the First Year. Feeding During Acute Illness and in Nutritional Disturbances. Feeding of the Premature Infant 306 Feeding During the Second Year 307 Feeding After the Second Year 308 Pirquet Method 309 XII CONTENTS Feeding During Acute Infections 310 Infants 311 Gavage 311 Children Over One Year 311 Gavage 311 Long Illness 312 Pyloric Stenosis 312 Cyclic Vomiting 313 Feeding in Nutritional Disturbances 315 Rickets . . 315 Prevention of Rickets by Diet . * . * 316 Cure of Rickets by Diet 316 PART IV. FEEDING IN DISEASE. Introduction 317 CHAPTER XIX. Functional Cardiac Disturbances 320 Diet in Organic Cardiac Disease 320 Cardiac Decompensation 321 The Karell Cure 321 Potter’s Modification of the Karell Diet 322 Fatty Heart 324 Diet in Adolescent Heart and Cardiac Myasthenia Following Infectious Disease 325 Senile Heart 325 Diet in Disease of the Bloodvessels 326 Arteriosclerosis 326 Diet in Hypertension 327 The Effect of Various Substances on Blood-pressure 327 Aneurysm 328 Angina Pectoris 328 Tobacco in Relation to Cardiac Disease 329 Diseases of the Circulatory Organs. CHAPTER XX. Feeding in Diseases of the Lungs. Drinks 332 Bronchitis 333 Acute Bronchitis 333 Chronic Bronchitis 333 Foods to Avoid 334 Foods Suitable in Chronic Bronchitis 334 Emphysema 334 Asthma 335 Foods to Avoid 336 Pleurisy with Effusion. Hydrothorax 337 Empyema 337 Tuberculosis, Pulmonary or General 338 Diets for the Tuberculous 342 Prophylaxis for Children of Tuberculous Inheritance 343 Plan of Feeding 343 CONTENTS XIII Tuberculosis, Pulmonary or General: Special Foods for the Tuberculous 343 Milk 343 gsp 344 Fats 344 Complications 346 General Rules for Feeding in Tuberculosis 347 Diet in Diseases of the Stomach. Indigestion 349 Diet in Irritable Stomach 351 With Vomiting 331 Gastric Hyperacidity, Hyperchlorhydria 351 The Reduction of Gastric Hyperacidity by Diet 353 Diet in Hyperacidity 354 Gastric Hypersecretion 355 Gastric Hypoacidity and Achylia Gastrica 356 Gastritis 359 Acute Gastritis 359 Chronic Gastritis 360 Diet in Gastritis Accompanied by Hypoacidity or Achylia . . . .361 Peptic Ulcer (Gastric and Duodenal) 362 The Chief Methods of Dietary Treatment 362 Von Leube Diet in Ulcer 363 General Directions for Lenhartz’s Diet 366 Diet Combined with Alkaline Treatment 373 Modified Diet for Peptic Ulcer . 378 Ambulatory Diet Cure for Peptic Ulcer 380 Transgastric or Duodenal Feeding 381 Diet After Hemorrhage from Stomach or Duodenum 383 Gastric Atony 384 General Directions in Gastric Atony 385 Diets for Atony 386 Diet for Severe Atony 387 Wegele’s Diet for Atony of Stomach 387 Diet for Mild Atony 388 Organic Gastric Acidity 388 Carcinoma of Stomach 389 Diet in Carcinoma of Stomach 390 Gastric Dilatation 392 Gastric Neuroses 394 Secretary Neuroses 394 Neuroses of Sensation 395 Motor Neuroses 395 Gastric Test Meals 396 Ewald-Boas Test Breakfast 396 Ewald Test Dinner 396 Test Meal of Germain S6e 396 Reigel’s Test Dinner 396 Klemperer’s Test Meal 396 Boas (Non-lactic Acid-containing) Test Meal 396 Salzer’s Double Test Meal , 396 Fractional Test Meal 396 Gastric Motor Meals ; 396 Von Leube 396 Boas 396 Hausman’s Stagnation Test Meal 396 Test Supper 397 Water Test for Acidity 397 Intestinal Motor Meal (Schmidt-Strassburger) 397 CHAPTER XXI. XIV CONTENTS CHAPTER XXII. Acute Enteritis 399 Chronic Enteritis 400 Schmidt Test Diet 401 Acute Colitis or Acute Dysentery 403 Chronic Colitis 404 Membranous Colitis, Mucous Colitis or Chronic Mucous Colitis 405 Ulceration of the Small or Large Intestine 406 Intestinal Hemorrhage . 406 Diarrhea 407 The Causes of Diarrhea 407 Gastrogenic 407 Toxic 407 Irritative Diarrhea 408 Drug Diarrhea 408 Nervous Diarrhea 408 Habit Diarrhea 408 Diarrhea Due to Food Idiosyncrasy 408 Diarrhea of Pancreatic Origin 408 Dietary Regulations 409 Foods to Avoid in Chronic Diarrhea 409 Foods Recommended in Diarrhea 409 Foods Allowed in Certain Cases 409 Absolutely Forbidden Articles 410 Intestinal Neuroses 410 Chronic Constipation 411 Varieties of Constipation 411 Atonic Constipation 412 Chronic Constipation 413 Spastic Constipation 414 Obstructive Constipation 415 The Use of Mineral Oil in Chronic Constipation 415 Intestinal Atony 416 Appendicitis 417 Acute Appendicitis .417 Ochsner’s Treatment of Appendicitis 418 Chronic or Larval Appendicitis 419 Chronic Typhlitis and Perityphlitis 420 Intestinal Auto-intoxication 421 Dietetic Indications for Intestinal Auto-intoxication 424 General Indications for Diet 424 Hemorrhoids 427 Hirschsprung’s Disease 427 Diet in Diseases of the Intestines. CHAPTER XXIII. Diseases of the Accessory Digestive Glands. Diseases of the Liver and Gall-bladder 429 Dietetic Prophylaxis 430 Acute Hepatic Congestion 431 Acute Catarrhal Jaundice or Gastro-duodenitis with Jaundice . 431 Chronic Hepatic Congestion 432 Portal Cirrhosis 432 Biliary Cirrhosis 433 Fatty Liver 433 Acute Yellow Atrophy of the Liver 434 Amyloid Liver 434 CONTENTS XV Diseases of the Liver and Gall-bladder: Cholelithiasis 434 Prophylactic or Postoperative Diet 435 Acute Cholecystitis and Colic 436 Pancreatic Disease 437 Acute Pancreatis 438 Chronic Pancreatitis 438 CHAPTER XXIV. Psoriasis 441 Eczema 443 Acute Eczema 444 Chronic Eczema 445 Eczema in Nurslings . 445 Acne Rosacea 447 Acne Vulgaris 448 Erythema 449 Pruritus 450 Dermatitis 450 Dermatitis Herpetiformis 450 Exfoliative Dermatitis 451 Furunculosis 451 Comedones 451 Hyperidrosis 451 Diet in Diseases of the Skin. CHAPTER XXV. Diseases of the Genito-urinary System. Kidney Dietary Tests 455 Water Excretion 455 Salt Excretion 455 Nitrogen 455 Directions for Schlayer’s Nephritic Test Day (Mosenthal) 456 Albuminuria 461 Acute Nephritis 462 Diet and Treatment for Acute Toxic Nephritis from Mercury Poisoning 464 Chronic Nephritis 465 Dietetic Management of Chronic Nephritis 465 Diets in Chronic Nephritis 466 Diets for Cases with Nitrogen Retention (Chronic Uremia) . . 467 Diet in Water Retention—Edema 468 Diet in Salt Retention 469 Conclusion 473 Pyelitis 473 Cystitis 473 Gonorrhea 474 Nephrolithiasis 474 Amyloid Kidney 475 CHAPTER XXVI. Diseases or Pathological States Due to Disturbances of Normal Metabolism. Diabetes Insipidus 476 Diabetes Mellitus 477 The Relation of Protein Metabolism to Glycosuria 479 XVI CONTENTS Diabetes Mellitus: The Nitrogen Balance in Diabetes 481 Relation of Fat Metabolism to Glycosuria 482 Ketogenic and Antiketogenic Substances in Relation to Diabetic Diets 483 Hyperglycemia 485 Dietetic Treatment of Diabetes 485 Von Noorden Method 487 Standard Strict Diet 488 Standard Diet with Restricted Protein 489 Green Days 489 General Diabetic Diet List ■ 490 Foods Prohibited Except as Allowed in Accessory Diet 490 Foster’s System of Carbohydrate Units 492 Sample Diet 493 Procedure in the Medium Severe Cases 493 Severe Cases with Marked Ketonuria 493 Potato Diet 494 Allen’s Treatment of Diabetes Mellitus 494 Joslin’s R£sum6 of Allen’s Treatment 501 Diabetic Diet High in Fats 504 Diabetic Special Receipts 505 Diet for Diabetics with Gout 509 Diabetes in Elderly People or in the Young 509 Diet for Obesity with Diabetes 510 Diet in Diabetes Complicated by Nephritis 510 Obesity 511 The Causes of Obesity 511 The Conditions for Which an Obesity Cure is Indicated 513 Reduction Cures 515 Von Noorden Cure 515 Banting’s Cure 5x7 Oertel’s Cure 5x8 Ebstein’s Dietary 519 Germain See Diet 520 Tibbles’s Milk Cure 520 Salisbury Method 520 Tower-Smith Modification of Salisbury’s Diet 521 Galisch’s Cure 521 Folin-Denis Method of Reduction 522 Exercise and Massage 523 Water in Obesity 523 Gout 523 Foods in Gout 528 Carbohydrates 528 Salt 528 Alcohol 529 Coffee, Tea and Cocoa 529 Diet in Acute Gout or Podagra 529 Purin-free Foods 530 Soft Purin-free Diet. Use for Main Diet 530 Mineral Waters 532 Diet for Leanness, or Fattening Cures 534 Foods to be Used in Fattening 535 Protein 535 Carbohydrate 536 Fat 537 Alcohol 537 Phosphaturia 538 Physiological Phosphaturia 539 Nervous and Sexual Phosphaturia 539 Juvenile Type . . . ' 539 Phosphates and Calculi 540 Diet Recommended for Calculi 540 CONTENTS XVII Oxaluria 541 Diet in Oxaluria 541 Mineral Springs 542 Diet in Old Age 542 Food Requirements of the Aged 543 Foods Especially Desirable for the Aged 545 Animal Food for the Aged 545 Vegetable Foods for the Aged 546 Preparation of Food for the Aged 547 Diet Routine in Old Age 547 Osteomalacia 549 CHAPTER XXVII. Diet in the Blood Diseases. The Anemias 550 Treatment of Chlorosis 551 Rest 551 Iron . 552 Theories of the Action of Iron 552 Diet in Chlorosis 553 Diet in Anemia (Chlorosis) 553 Secondary Anemia 555 Pernicious Anemia 555 Posthemorrhagic Anemia 557 Leukemia 557 Hemophilia 557 Purpura Hemorrhagica 558 CHAPTER XXVIII. Scurvy 559 Diet in Scurvy 560 Beriberi 561 Xerophthalmia 563 Pellagra 564 Goldberger’s Conclusions 565 Diet in Pellagra 566 Deficiency Diseases. CHAPTER XXIX. Diet in Diseases of the Nervous System. Organic Nervous Diseases 568 Neuritis 568 Epilepsy . 569 Insanity 570 Apoplexy 571 Functional Nervous Diseases 572 Migraine or Periodic Headaches 572 Chorea 574 Neurasthenia 575 Weir Mitchell Diet and Treatment 576 Digestive Neuroses 578 Insomnia 578 Delirium Tremens 579 Nervous Anorexia 580 XVIII CONTENTS Acute and Chronic Infections. Fever 582 Diet in Fever 585 Carbohydrates 586 Protein 586 Fats 588 Beverages 588 Intervals of Feeding 588 Typhus Fever 589 Typhoid Fever 590 Older Diets 590 Bacteriological and Physiological Basis for More Liberal Diets . . 591 Carbohydrates 592 Fats 593 Protein 593 Energy Requirement . . . • 594 Results Obtained by Liberal Diet 594 Typhoid Diets 595 Typhoid Fluid Diets 596 Modified Milk Fluid Diets and Food Combinations and Menus . 597 For 1000 Calories a Day 597 For 1500 Calories a Day 598 For 2000 Calories a Day 599 For 2500 Calories a Day 600 For 3000 Calories a Day 601 For 3900 Calories a Day 602 Diet in Typhoid Complications 605 Intestinal Hemorrhage 606 Perforation 606 Nausea and Vomiting 606 Water 606 Paratyphoid Fever 606 Malarial Fever 606 Scarlet Fever 607 Smallpox 607 Cerebral or Cerebrospinal Meningitis 608 Measles 608 Influenza (Grippe) 609 Acute Articular Rheumatism 609 Diet in Acute Articular Rheumatism 610 Subacute Rheumatism 611 Chronic Rheumatism (Chronic Infectious Arthritis) 611 Tetanus 612 Yellow Fever 613 Cholera 614 Dietetic Rules in Cholera 614 Peritonitis 616 Acute Peritonitis 616 Chronic Peritonitis 616 Chronic Infections 617 Rheumatoid Arthritis—Arthritis Deformans 619 CHAPTER XXXI. Diet in Relation to Surgical Operations. Preoperative Diet 621 General Directions for Cases of Laparotomy 621 Diet Preparatory to Gastric Operations 622 Postoperative Diet 623 Postoperative Diet for the Digestive Tube 623 Diet after Tonsillectomy 623 Postoperative Gastric Diets 623 CHAPTER XXX. CONTENTS XIX Postoperative Diet: Diet after Gastroenterostomy and Other Gastric Operations . . . 623 The Diet 624 Von Leube Diet 625 The Absorption of Food 626 Finney’s Diet List Following Operation for Gastroenterostomy . 627 Intestinal Lesions 628 Diet after Appendectomy 629 Diet in Certain Complications Following Abdominal Operations . . 629 Vomiting 629 Vomiting from Acute Gastric Dilatation 630 Prevention of Desiccation of Tissues 630 Dietary Measures in Postoperative Intestinal Distention . . . 631 Diet after Gall-bladder Operations 632 Diet after Operations for Hemorrhoids 632 Constipating Diet 633 Feeding after Intubation ....... 633 CHAPTER XXXII. Diseases of the Ductless Glands. Acromegaly 634 Acute Thyroiditis 635 Exophthalmic Goiter 635 Diet to Meet Special Indications in Exophthalmic Goiter .... 638 Diarrhea 638 Inanition 638 Myxedema or Cretinism 638 Addison’s Disease 639 CHAPTER XXXIII. Artificial Methods of Feeding 640 Rectal Feeding 640 Protein 641 Fats 643 Carbohydrates 643 Precautions in Rectal Feeding 644 Subcutaneous Feeding 645 Protein 645 Fats 646 Carbohydrate 646 Intravenous Feeding 647 Diet in Pregnancy and its Complications 648 Nausea and Vomiting of Pregnancy 649 Nephritis 651 Mild Autointoxication 651 Contracted Pelvis or with an Oversized Fetus 651 Puerperium 652 Foods Best Avoided 652 Diet List after Normal Confinement 652 Diet for Lactation 653 Sprue 654 Dental Caries 657 Diet in Cancer 658 Diet Recommended for Speakers and Singers 660 Diet Adapted to the Use of Brain Workers 661 Diet for Athletes 661 Sugar 663 Foods to Avoid 664 Diet for Aviators 664 The Feeding of Unconscious Patients 665 Diet in Miscellaneous Conditions. XX CONTENTS Food Poisoning 665 Meat Poisoning 666 Fish Poisoning 667 Vegetable Poisoning 667 Poisoning by Canned Goods 667 Dietary Precautions 668 Special Dietary Cures 669 The Vegetarian Diet 670 Metabolism of Vegetarians 672 Vegetarian Diets 673 Fletcherism 673 Fruit Cures 677 Grape Cure 677 CHAPTER XXXIV. Food Protection. Accessory Foods. Beverages. Flies, Food and Illness 679 Beverages for the Sick 679 Flaxseed Tea 679 Orange-albumen Water 679 Wine Whey 680 Egg Lemonade 680 Artificial Buttermilk or Ripened Milk 680 Irish Moss Jelly 680 Peptonized Milk 680 Fully Peptonized Milk 680 Egg Nog 681 Cocoa Shells 681 Albumen Water 681 Cereal Gruels 681 Arrow-root Gruels 681 Barley Gruel . 681 Flour Gruel 681 Farina Gruel 682 Artificial Foods 682 Plasmon 682 Nutrose 682 Somatose 682 Beef Meal 682 Peptones 682 Roberat 682 Aleuronat 682 Tropon . 683 Olive Oil, Cod-liver Oil, Yeast and Their Uses 683 Stenosis of the Esophagus 683 Pyloric Stenosis 683 Gastric Dilatation 683 Cholelithiasis 683 Gastric Hyperacidity 684 Cod-liver Oil 684 Yeast 685 CHAPTER XXXV. Table of Food Values, Weights and Measures. Average Chemical Composition of American Foods 687 Table of Measures and Weights 695 Fisher’s Table of One Hundred Calories 698 Table Showing the Nutritive Value of the Food Materials Calculated for the Quantities Commonly Required in Cooking Small Portions .... 704 NUTRITION AND CLINICAL DIETETICS INTRODUCTION The term food may be applied to any material with the aid of which the body is able to maintain its characteristic functions: temperature regulation, the performance of work, the repair of wasted tissues, the production of new tissues and those countless factors—connoted by digestion, absorp- tion, circulation, etc.—involved in the preparation and trans- portation of the ingested food to the seat of action of the prime factor of organization, the cell. In the various kinds of cells of a complicated organism such as the human body, transformations are in progress which are qualitatively similar but which vary quantita- tively according to their specific functions: Thus we have the cells of the muscular system, whose chief function appears to be the performance of work and the liberation of energy for the maintenance of body temperature, or the cells of the glandular organs which form substances to be secreted into or from the body, and of the nervous system which are con- cerned in the conveyance of impulses. Whatever may be the specialized function of any cell, it is imbued with the fundamental characteristic activities of all cells. The sum total of the activities of the individual cell or of the body as a whole are grouped under the term metabolism, by which we mean “all chemical and physical changes which occur in living matter and which constitute the basis of the material phenomena of life.” When such changes involve the trans- formation of simple into more complex substances, they are usually associated with an increase in the energy content of the compounds formed and are designated as anabolic pro- cesses. Changes which are concerned with the disintegra- tion of complex material with the formation of simpler prod- ucts are designated as catabolic processes and are ordinarily associated with the liberation of energy. By means of anabolic 17 18 INTRODUCTION processes the products of digestion are built up into the active structural compounds of protoplasm, into secretions or into complexes suitable for storage and future use. Such processes predominate in growth and in those organs or tissues associated with the elaboration of secretions. The catabolic processes involve a disruption of food-stuffs, of cell components or of reserves, and the liberation of energy in the form of heat or mechanical work, the end-products of this activity being finally eliminated from the body. The cellular activities associated with muscular contraction and the regulation of body tem- perature are preeminently catabolic. In normal individual cells and in the body in general there is a nice balance between the anabolic and catabolic processes. Any disturbance of this equilibrium may result in a pathological condition. Con- siderations of diet in disease are concerned almost entirely with alterations in the balance between anabolic and catabolic activities. Five important classes of food-stuffs are required to satisfy the needs of the body; the lack of any one of these would result in grave metabolic disturbances. They are: Proteins, carbohydrates, fats and lipins, salts and water. To this list of general classes must be added a sixth, the accessory food substances designated as vitamins. The collective expression, food, is applied to naturally occurring combinations of the food-stuffs enumerated or to products from these. Since most foods are themselves con- glomerates of materials which have been associated with life, they contain in different proportions some of all the elements required by the human organism. Thus we have such foods as meat, eggs, etc., in which protein predominates, but which contain also fat, carbohydrates, water and salts; or certain vegetable foods whose solid material is largely carbohydrate and salts, with a very small proportion of protein and fat. The functions of the food-stuffs are varied; proteins, car- bohydrates and fats may be utilized by the body as sources of energy; the greater proportion of the energy requirement of the body is supplied, however, by the carbohydrates and fats. Protein serves not only as a source of energy but as the source of amino-acids and radicals necessary for the for- mation of body protein, secretions, etc. Salts and water, while not the source of energy, are essential factors in the constitution and activity of all parts of the body. Proteins are, as we have just indicated, important as the chief source of nitrogen-containing substances necessary for life. Because of their colloidal nature, their ability to com- bine with both acids and bases, and of absorbing or entering INTRODUCTION 19 into loose chemical combinations with salts and water, they share in a most varied activity in the body processes. In the cycle of life protein is synthetized in the vegetable kingdom, and this protein is utilized in the construction of animal protein. Animals appear to be unable to synthetize the greater number of amino-acids present in the protein molecule, particularly those containing cyclic nuclei. Plants, however, can form the amino-acids and conjugate them into protein. The animal organism is, then, dependent upon the plant for the basal units of its protein molecule. Before plant protein can be used it must be broken down into amino- acids or simple combinations of these, which are then built up into the type of protein characteristic of the particular tissue concerned. The object of feeding is to supply not only protein to the individual, but protein which will furnish the proper kinds and amounts of amino-acids. The second class of food-stuffs, carbohydrates, are used by the body as a source of energy in the performance of its many internal activities as well as of external work. They are, apparently, more readily accessible for such purposes than protein or fat; in all cases in which a sudden expenditure of energy is involved, or in states in which the body is forced to draw upon its reserve supplied the depots of carbohydrate (glycogen), are the first to become depleted, after which the fats and proteins furnish the required nutritive materials. The absence of carbohydrates from the diet often results in pronounced metabolic disturbances, e. g., acidosis. Chemically, carbohydrates consist of carbon, hydrogen and oxygen, the hydrogen and oxygen being often present in the proportions in which they occur in water. This last fact was responsible for the name. From the structural point of view we find carbohydrates to be oxidation products of polyhydric alcohols (ketone- or aldehyde-alcohols). Human food usually contains molecules consisting of chains of five or six carbon atoms or multiples of these. Starch, in which form the greater proportion of ingested carbohydrate food exists, is a polymer of the six carbon sugar—glucose. Fats and lipins serve in a varied capacity in the body. The terms include a number of different types of substances, which may be roughly divided into two groups: Fats, which are combinations of fatty acids and glycerol or other alcohols, and lipins, which resemble the fats in certain properties but which differ in chemical constitution. Lipins are substances of a fat-like nature yielding fatty acids or derivatives of fatty acids and some other radical containing nitrogen or nitrogen and phosphorus. Of the latter group lecithin has been studied 20 INTRODUCTION extensively; the other groups, such as complexes containing other lipins, protein, carbohydrate, various organic and inor- ganic compounds, have received little attention and our knowledge of their functions is limited. Recent investigation has indicated that the lipins are important factors in the transportation of fat by the blood stream to the tissues, and particularly to the mammary gland. The “fat” of food is a mixture of fats and lipins. Fats are used almost exclusively in the production of energy or in the regulation of temperature. They may function to a limited extent in temperature regulation as a source of heat and as an insulating medium in the form of deposited subcutaneous fat. Chemically considered, fats are combinations of carbon hydrogen and oxygen. As contrasted with the carbohydrates, fat molecules contain little oxygen, and consequently yield a greater amount of energy upon oxidation. A gram of fat will yield more than twice as much energy in the form of heat as will a gram of carbohydrate. The body appears to prefer carbohydrates, however, for the production of heat, at least for short intervals of time. It stores its energy-yielding material as fat; the quantity of carbohydrate stored in the body is comparatively small, not sufficient to last a man more than a day or two, even when some fat and protein are consumed at the same time, as in fasting. Water and salts are concerned not only in the structure of the cells but in the maintenance of normal physical and chem- ical relations between the parts of the cells—intracellular water and salts—and between the groups of cells which con- stitute the tissues and organs of the body—extracellular water and salts. Water gives to the blood its fluidity, and thus enables it to permeate the cellular structures of the body, carrying with it the dissolved gases and substances used in the activities of the cell. Suspended in the water (colloidal solution) are proteins and organized bodies, the blood cells. The salts which are dissolved in the water assist not only in maintaining normal osmotic conditions between all parts of the body, but also a uniform reaction by combining with acids and bases and transporting them to the lungs and kidneys for excretion. Vitamins are essential to the normal functioning of the body. The absence of these materials results in pathological changes, and the ingestion of very small amounts is accompanied by rapid recovery. There appear to be at least four types: A sub- stance soluble in fat, designated vitamin A, protective against xerophthalmia; a substance soluble in water, designated vitamin B, protective against beriberi; another water-soluble substance, vitamin C, protective against scurvy, and a vitamin INTRODUCTION 21 whose absence, combined with other deficiencies, results in rickets. We know little of the chemical nature of these substances, but their importance in the diet is, on the other hand, unquestioned. These, then, are the facts which underlie dietetics, and while they are indisputably exact, much of the success of feeding in disease still must rest on clinical experience; for given hard and fast scientific facts the personal equation always enters into the picture, and it will always be true that certain individuals will not react to food stimuli in the logical way, idiosyncrasy playing a not inconsiderable role. Since this is true in health, how much greater must be the variation in disease when one considers that all people differ in their habits, environment, age, activity of the glands of secretion and susceptibility to certain food elements, etc.? It is undoubtedly true that in health some people eat too much, this being a larger error than that they eat too little; on the other hand, in disease many if not most people eat too little and add an element of starvation to an organism already handicapped by functional disturbances, infections or what not. The crux of the matter lies in selecting a diet suited to the individual conditions under varying circumstances, not alone in quantity but in quality as well. Recent advances in our knowledge of the specific dynamic action of food-stuffs have made it easier to say what food should theoretically suit a certain set of circumstances, and on this basis one can, to a certain extent, choose suitable feedings, provided the personal equation is not too insistent. In certain diseases the indications for diet are clear-cut and are largely a matter of rule, adherence to which will usually bring about the result desired, e. g., in obesity, while in others there is no counting on the results, for the foods which suit conditions in one individual will fail to produce the desired result in another, so that while the principles remain the same the individual requirements may be quite different, and opportunity is afforded for the practice of nice judgment. In such a disease as typhoid fever this is particularly true, and the best feeding results will be obtained by the medical attendant who gives the most attention to details and uses the best judgment in the selection of foods, both quantita- tively and qualitatively. In such conditions it is possible only to indicate the principles to be used in ordering foods, leaving the rest to the individual attendant’s discretion. So it is throughout the entire range of disease—there must be a knowledge of the facts in the biochemistry of foods, com- bined with clinical experience and good judgment if one wishes the best results. PART I FOODS AND NORMAL NUTRITION. CHAPTER I. DIGESTION, ABSORPTION AND EXCRETION. Enzyme Action. —Food, when ingested, is, with but few exceptions, potential nourishment. Before it can be used in the body it must be reduced to simpler forms or liberated from structures unavailable for absorption into the blood. Until food is in a condition readily to pass through the walls of the alimentary tract, it is not available as a factor in metabolism. Such transformations are accomplished in the processes of digestion. As the result of these, solid masses of food are disintegrated, insoluble carbohydrate, fat and protein complexes are transformed into compounds which are soluble or of such size (ultramicroscopic) that they may readily traverse the walls of the alimentary tract and finally reach the blood and be carried to the various cellular struc- tures of the body. This conversion of heterogeneous food masses into a pabulum of comparatively simple and uniform consistency is accomplished with the aid of enzymes (fer- ments),1 whose activities are furthered by the mechanical movements of the alimentary tract. Enzyme action is catalytic in nature. In the presence of enzymes the rate of digestive activity increases. In the presence of water or dilute solutions of alkalis or acids the conversion of starch into maltose proceeds slowly. The addition of the salivary amylase, ptyalin, to a starch mixture under suitable conditions of alkalinity and temperature in- creases the rate of reaction of the process; instead of requiring a period of days and weeks for the completion of the digestion DIGESTION. 1 While we will confine our discussion largely to the enzymes of the digestive tract, it must be remembered that enzymes are present in all tissues and fluids of the body. 23 24 DIGESTION, ABSORPTION AND EXCRETION of a given mass of material a few minutes or hours suffice. These changes are produced, furthermore, at the comparatively low temperature of the body. Enzyme action is specific; for each kind of substance to be changed a special enzyme is elaborated. If many inter- mediate products are formed, more than one enzyme may be required to reduce a food material to its simplest state. Ptyalin, the salivary amylase, can carry the digestion of starch only so far as the maltose stage. Another enzyme, maltase, is required for the cleavage of maltose in the formation of glucose. This enzyme is restricted in its action to maltose and glucose; it cannot change sucrose or lactose or any other carbohydrate. To complete the digestion of food, then, many different enzymes are necessary. Enzymes are classified according to the types of chemical reactions they affect. They are named by adding the suffix “ase” to the type of reaction, or to the substrate, the sub- stance upon which they act. Practically all the enzymes of the digestive tract are members of the group designated as hydrolases. Their function is to aid in the disintegration of complex food molecules, changes which involve cleavages of the molecule with the addition of the elements of water. The more important digestive enzymes will be discussed in connec- tion with the digestive processes. The activities of any particular kind of enzyme are influ- enced by its environment. Such factors as (a) reaction, (b) temperature, (c) concentration of the enzyme, (d) concentra- tion of the products of reaction, ( O ffi .9 'E £ £ 0 CQ B w .9 • ’s'08 9 B m3 a iJ si 0> X & 6 N *2 2 03 O X £ d ’2 N 0) N ’2 2 0 4) bfi * O 'O' 9~ 00 £ 03 w O .9 tc 70 bC c 0 £ d 4) 0 x 0 2 £ *2 XX OQ E CQ a £ 2 0 Ul X O Glycine .... Alanine .... Valine .... Leucine .... Phenyl alanine Tyrosine Serine Cystine .... Proline .... Hydroxyproline Aspartic acid Glutamic acid ._ Hydroxyglutamic acid .... Arginine Tryptophane . Lysine) .... Histidine Ammonia . ■4:3 7.8 ii'o 87 ”4 '6' ’ 0 4.2 29'0 4.2 1.3 0.6 0.3 2.3 1.0 4.4 1.7 £>'4 + 4.3 11.0 0 8.4 if>” 2 5.2 1.0 o.'4 1.1 0 2.7 20.0 3.1 2.1 0.6 2.5 1.0 0.4 2.4 3.3 14.0 1.3 2.0 1.8 1.7 3.8 0.5 0.9 0.7 9.6 4.8 1.6 4.0 0.9 4.5 0.2 11.3 3.8 3.3 '3^2 3.4 6.7 3.5 2.2 + 18.7 3.8 2.5 0’9 2.8 2^5 8.5 3.0 3.6 1.0 15.0 2.5 3.5 0.8 1.2 3.6 2'6 10.4 3.8 3.6 + 20.9 2.4 2.1 0.3 0.3 1.7 2.0 4.5 1.3 0.4 2.1 8.0 3.8 1.6 0.5 3*2 0.4 0.3 4.1 1.0 1.9 '4.0 0.3 6.2 1.8 3.8 0.4 ilo 0.0 2.0 3.4 6.6 2.4 1.2 1.1 0.5 13.2 0.0 9.8 1.9 19.6 6.6 3.6 9'0 0 1.5 7.2 9.4 3.2 4.5 6.7 0.3 1.4 15.6 0 0.8 1.9 9.9 2.6 3.4 4^2 '2.2 13.0 25.5 8.7 0 7.1 1.4 + 0.4 9.5 14.1 3.4 5.8 0.0 8.2 0 5.9 0.9 0.4 0.5 1.6 4.5 15.3 1.9 3.6 7.5 3.7 2.5 17.2 2.7 0.2 0.7 2.3 ii'2 3.6 2.2 4.8 3.2 16.5 6.5 + 7.3 2.5 1.7 0.0 0.8 10.4 3.1 2.4 3.2 2.8 10.1 6.4 + 7.5 2.6 1.4 0.0 8^8 4.9 2.0 2.3 3.5. 14.9 7.4 + 5.8 2.0 1.1 2.1 3.7 0.8 11.7 3.2 2.2 5.8 4.5 15.5 7.5 + 7.6 1.8 1.1 1.7 3.5 2.1 + 2.3 0 3.1 7.7 9.3 12.9 10.0 3.5 + 9.9 2.6 1.3 4.1 13.0 5.3 17.0 0.7 24.0 0.7 12.7 0.6 43.7 1.7 26.2 5.5 + 3.0 2.3 1.3 5.9 + 2.8 2.8 1.4 L3 11.7 + 1.0 1.1 11.7 + 5.0 2.4 2.1 4.4 + 2.2 1.2 2.5 7.1 + 3.0 3.0 2.1 2.8 1.0 0.9 1.8 5.2 1.6 0.0 0.0 0.8 3.6 3.8 1.5 6.0 2.5 1.6 7.5 + 4.8 1.9 1.3 The Distribution of Amino-acids in Typical Proteins. 178 PROTEIN FOODS sole source of protein, was a failure to grow. In a previous chapter the inability of the body to synthetize protein and certain amino-acids was discussed (p. 74). The necessity for a liberal supply of the different amino-acids in the form of a varied selection of proteins, and for a kind of digestion that converts these structural elements in protein into readily available substances either as the amino-acids or simple complexes of these is therefore evident. Such a variety is obtained in the ordinary mixed diet; in special diets it is a factor to be considered. The influence of the ingestion of proteins homologous to those present in the body upon the minimum protein requirement has been discussed. Proteins are not ordinarily distinguished by their amino- acid content, however, but chiefly by their physical properties. Differences in chemical composition are, however, the basis of distinction between the members of one group—the conjugated proteins.1 Classification of Proteins.—The following outline of the kinds of proteins and their characteristics, the classification adopted by the American Physiological Society and the American Society of Biological Chemists, will be adhered to in our discussion. This classification differs from that of the British societies in a few instances; in most matters they are essentially identical. I. Simple Proteins. —Protein substances which yield only «-amino-acids or their derivatives on hydrolysis: (a) Albumins2. —Soluble in pure water and coagulable by heat. Albumins are present in all cells and in the important fluids of the body. Ovalbumin is the predominating protein of egg white. Other important albumins are serum-albumin present in blood plasma, lymph and other body fluids; lact-albumin of milk; the vegetable albumins, leucosin of wheat and legumelin of the pea. 1 The terms protein and proteid are often used together. The present-day German writers use the word protein to designate simple albuminous substances, and proteid for combinations with other complexes. The simple proteins and the conjugated proteins of the American classification are proteins and proteids respectively in the German classification. A distinction is sometimes made between protein and proteid among English-speaking writers. Proteid desig- nates definite chemical compounds, or isolated albuminous substances (our pro- teins), while protein is used to denote the mixture of proteids in a food, the measure of which is the quantity of nitrogen which the food yields upon analysis times 6.25, the average percentage of nitrogen in pure proteid. Protein has been adopted by English-speaking scientists as the generic term for the class of sub- stances which we are discussing—and we will use this term in that sense. 2 A distinction is sometimes made between the pure individual substances albumin and a mixture of proteins occurring naturally together, or albumen, as the white of egg. The term albumen is used very little and is now practically restricted to the expression “egg albumen.” SIMPLE PROTEINS 179 (b) Globulins.—Globulins are insoluble in pure water but soluble in neutral solutions of salts of strong bases with strong acids. Globulins are present in blood, serum globulin; egg, ovoglobulin; milk, lactoglobulin; seeds, edestin (hemp-seed); legumin (pea). (c) Glutelins.—Glutelins are simple proteins insoluble in all neutral solvents but readily soluble in very dilute acids and alkalies, e. g., the vegetable protein, glutenin, from wheat. (d) Alcohol Soluble Proteins, Prolamines.—Simple proteins soluble in 70 to 80 per cent alcohol, insoluble in water, absolute alcohol, and other neutral solvents, e. g., zein, corn; gliadin, wheat; hordein, barley. Gluten, readily obtained from wheat flour by washing away the starch, albumin, etc., is a mixture of members of the last two classes of proteins, glutenin and gliadin. (e) Albuminoids.—Simple proteins possessing a similar struc- ture to those already mentioned, but characterized by a pronounced insolubility in all neutral solvents. The pro- teins concerned in the framework of the body are the most important members of this group, e. g., elastin and collagen; connective tissue; keratin—hair, nails and horn; and fibroin from silk. Acids or prolonged boiling with water convert collagen into gelatin. Gelatin is not, however, classed as an albuminoid. The British nomenclature aptly designates the albuminoids as scleroproteins. (f) Histones.—Soluble in water and insoluble in very dilute ammonia and, in the absence of ammonium salts, insoluble even in excess of ammonia; yield precipitates with solutions of other proteins and a coagulum on heating which is easily soluble in very dilute acids. On hydrolysis they yield a large number of amino-acids, among which the basic ones predominate. In short, histones are basic proteins which stand between protamines and true proteins, e. g., globin, one of the constituents of hemoglobin; thymus histone and scrombrone from sperm. (g) Protamines.—Simpler polypeptides than the proteins included in the preceding groups. They are soluble in water, uncoagulable by heat, have the property of precipitating aqueous solutions of other proteins, possess strong basic prop- erties and form stable salts with strong mineral acids. They yield comparatively few amino-acids, among which the basic amino-acids predominate. These proteins are obtained from spermatozoa, in which they occur in combination with nucleic acid. The various members of this class are designated accord- ing to the animal from which they are obtained, as salmin from the salmon sperm; sturin from mackerel sperm, etc. 180 PROTEIN FOODS II. Conjugated Proteins. —Substances which contain the protein molecule united to some other molecule or molecules otherwise than as a salt. (a) Nucleoproteins.—Compounds of one or more protein mole- cules with nucleic acid. This type of protein is the principal constituent of cell nuclei and is found in practically all protein- rich foods. Milk and the white of egg are important exceptions. Nucleoprotein is a very complex substance yielding upon hydrolysis first protein and nuclein. Nuclein then disintegrates into a second protein, usually basic, as histone or protamine, and nucleic acid. Nucleic acid may consist of one or more combinations of phosphoric acid, carbohydrate and one of the purine or pyrimidine bases called nucleotids. Upon hydrolysis of a combination of nucleotids, the various nucleotids result. The phosphoric acid is next split off from the nucleotids leaving the purine- or pyrimidine-carbohydrate complex, nucleosid, which finally yields carbohydrate and the base. The following scheme shows the disintegration of nucleoprotein: Nucleoprotein protein nuclein protein nucleic acid (nucleotids) phosphoric acid nucleosid carbohydrate purine base pyrimidine base The purine bases from nucleoprotein are the chief source of the uric acid which appears in the urine of mammals. (b) Glycoproteins.—Compounds of the protein molecule with a substance or substances containing a carbohydrate group other than a nucleic acid, e. g., mucins and mucoids (osseo- mucoid from bone, tendomucoid from tendon, ichthulin from carp eggs, helicoprotein from snail). (c) Phosphoproteins. — Compounds of the protein molecule with some as yet undefined, phosphorus-containing substances other than a nucleic acid or lecithin, e. g., casein from milk, ovovitellin from egg yolk. (d) Hemoglobins.—Compounds of the protein molecule with hematin or some similar substance, e. g., hemoglobin from red blood cells, hemocyanin from blood of invertebrates. INFLUENCE OF HEAT 181 (e) Lecithoproteins. — Compounds of the protein molecule with lecithin. III. Derived Proteins.—A. Primary Protein Derivatives.— Derivatives of the protein molecule apparently formed through hydrolytic changes which involve only slight alteration of the protein molecule. (a) Proteins.— Insoluble products which apparently result from the incipient action of water, very dilute acids or enzymes, e. g., myosan from myosin, edestan from edestin. (b) Metaproteins.— Products of the further action of acids and alkalies whereby the molecule is so far altered as to form products soluble in very weak acids and alkalies but insoluble in neutral fluids, e. g., acid metaprotein (acid albuminate), alkali metaprotein (alkali albuminate). (c) Coagulated Proteins.—Insoluble products which result from (i) the action of heat on their solutions or (2) the action of alcohol on the protein. B. Secondary Protein Derivatives. —Products of the fur- ther hydrolytic cleavage of the protein molecule. (a) Proteoses.—Soluble in water, non-coagulable by heat, and precipitated by saturating their solutions with ammonium or zinc sulphate, e. g., protoproteose, deuteroproteose. (b) Peptones.— Soluble in water, non-coagulable by heat, but not precipitated by saturating their solutions with ammonium sulphate, e. g., antipeptone, amphopeptone. (c) Peptides.—Definitely characterized combinations of two or more amino-acids, the carboxyl group of one being united with the amino group of the other with the elimination of a molecule of water, e. g., dipeptides, tripeptides, tetrapeptides, pentapeptides. Influence of Heat.—The effect of heat upon simple pro- teins is to cause them to coagulate. Such changes are con- tinually occurring in the preparation of food for the table. The boiling of an egg, or the roasting of meat is accompanied by the coagulation of the protein, and it is to a large extent the coagulation of the protein among expanded gas bubbles which keeps bread and cake “light.” Two changes take place in the coagulation of protein: There is first a reaction between the hot water and the protein as the result of which the protein loses certain of its characteristic properties, such as solubility, i. e.> the protein is denatured. Secondly, the altered particles of protein agglutinate into visible masses or coagula which separate from the solution. When the protein is held in the meshes of connective tissue, etc., the denatured protein shrinks or contracts so that water and dissolved salts are squeezed out. This phenomenon is called 182 PROTEIN FOODS syneresis. The accumulation of beef juice around a roast when cut on the platter is the result of syneresis. The presence of acid and small quantities of salt facilitates the coagulation of protein. An excess of acid or alkali results in a solution of the protein and prevents coagulation. Certain proteins of the albuminoid class, such as collagen, are readily hydrolyzed (rendered soluble) particularly so in the presence of small quantities of acid. The long-continued cooking (usually just below the boiling-point) of tough cuts of meat accomplishes the hydrolysis of the connective tissue (rich in collagen), which tends to free the muscle fibers and permit their ready separation, i. e., makes the meat tender. The use of veal for soup stock and the ease with which the fibers of fish are separated is due to the large proportion of easily hydrolyzed connective tissue which they contain. Acid facilitates hydrolysis; it also tends to cause protein material to swell. The value of acid in cooking fish and tough meat is, then, self-evident. Protein combines with both acid radicals and basic radicals to form protein salts; the insoluble curd formed in the coagu- lation of milk occurs because the calcium salt of casein is insoluble in water; the sodium (or potassium) salts are soluble, and it is in this form that certain soluble casein preparations are placed on the market. Certain proteins of the legumes form insoluble calcium or magnesium salts, which is the reason for the objection to the use of hard water in preparing legumes for the table. The use of egg white, etc., as an antidote for poisons is due to the insoluble salts which are formed by the protein with the heavy metals. Effect of Low Temperatures.—Low temperatures have no direct effect upon protein. Its properties may be altered, however, as the result of changes produced in the medium in which it is suspended. The crystallization of the intracellu- lar water results in a concentration of the salts. This causes the precipitation of some proteins and the solution of others. Upon the return to the normal temperature the original state is restored. Long-continued low temperatures produce a change in the precipitated proteins so that they will not redissolve. The change just noted has been shown to occur in plants. During refrigeration protein food-stuffs undergo consider- able modification as the result of predominant enzyme action, autolysis, rather than of bacterial action which shares in the transformation at room and body temperatures. Low temperatures inhibit both bacterial and enzyme action, the former more than the latter, however. The changes which DIGESTION AND ABSORPTION 183 occur at low temperatures are analogous to those which take place in aseptic or sterile tissues, either in the body or out of it. The “ripening” of flesh is due to these autolytic changes brought about by the intracellular enzymes. The action of the intracellular proteases is quite similar to that of the digestive enzymes, particularly trypsin. Protein passes grad- ually through the various stages of proteolytic digestion, finally yielding amino-acids. Examination of refrigerated meat, for instance, shows an increase in the quantity of water-soluble proteins, indicating a partial digestion. Other enzymes produce changes in the fats and carbohydrate. The changes which result in foods preserved with certain chemical substances, without the use of heat, are the result of autolysis. Bacterial growth is not entirely checked at comparatively low temperatures and changes undoubtedly occur as the result of their action. At higher temperatures, room tem- peratures and above the activities of bacteria increase. The products of their action on proteins are in part similar to those produced in enzymatic digestion. The harmful effects of bacteria from a dietary point of view are not in the bacteria themselves so much as in the products (ptomaines) produced in the food, protein, during their growth. These substances are produced by non-pathogenic as well as by pathogenic organisms. The ptomaines are soluble basic substances closely related to the amino-acids; not all are toxic. Digestion and Absorption.—The changes which proteins undergo in the course of digestion and absorption have already been discussed (p. 38). The rate with which they are made available for absorption depends upon their physical properties, whether they are in solution or solid, dense or finely divided, will imbibe water easily or with difficulty; and upon their chemical properties, such as acidic or basic, complex or simple. Preparation of food for use is often accompanied by change in the digestibility as well as in the availability of the food-stuff's. This is particularly true with regard to protein. The total available quantity of the protein is often increased in the course of preparation. The effect of grinding vegetable food-stuffs very fine is to increase their total digestibility. The influence of heat upon the connective tissue of animal food-stuffs is to cause a partial conversion of collagen into gelatin; hence the ease of digestion is increased. In vegetable food-stuffs the indigestible cellulose structure is ruptured through the com- bined action of heat and water, thus promoting the action of the digestive enzymes upon the contained protein and carbo- hydrates. CHAPTER IX. MEAT OR FLESH FOOD. Nutritive Value. —The dietary value of meat is due chiefly to its protein content. It contains in addition a varying quantity of lipin or fat, a small amount of carbohydrate, salts and certain nitrogenous derivatives related to the proteins called extractives. The palatability, variety, ease with which the flavor may be modified, facility of preparation, concentration of protein and digestibility are factors which have made meat the most important protein of the adult human dietary. With regard to its biological value meat contains adequate protein and the water-soluble and antiscorbutic vitamins. It is relatively poor in vitamin A, calcium, sodium and chlorine. The use of meat in the diet, therefore, requires the correction of these deficiencies through the use of vegetables, partic- ularly the leafy vegetables. Cereals, grains and seeds will not serve to correct the deficiencies of meat. The dietary and economic advantages and disadvantages of animal and vegetable protein have been discussed (p. 150). General Properties.—Meat is derived almost entirely from the skeletal or striated muscles. Such muscles are composed of fibrils enclosed in sheaths known as sarcolemma (fibers) and bound together in the form of bundles by connective tissue. The fibers terminate in bundles of white fibrous con- nective tissue, the tendons, by means of which they are attached to the bones. Embedded in the connective tissue of the muscle bundles are cells more or less rich in fat, while between the various muscles comparatively large masses of fatty tissues are found. Living muscle is practically neutral in reaction, but after death lactic acid is formed and the reaction rapidly changes to acid. An alkaline reaction in meat is an indica- tion of putrefaction. The important proteins of muscle plasma are myogen (a globulin), which predominates, and myosin. After death these proteins become coagulated to form the muscle clot;1 this is the form in which the greater portion of the protein of meat exists. Immediately after death autolytic changes commence with the formation of lactic acid and protein 184 1 Myosin is the name given to muscle clot by some investigators. GENERAL PROPERTIES 185 digestion products and are attended by an increase in the quantity of soluble proteins. These are the processes con- cerned in “ripening.” The connective tissue contains a large percentage of the albuminoid collagen, which is a source of gelatin—the base of the jelly of cooked meat. The flesh of young animals, e. g., veal and lamb, is particularly rich in connective tissue and their bones in collagen. The readiness with which meat from such animals yields gelatin makes it valuable as the basis of soup. Fish are also rich in gelatin-yielding tissues. Blood remaining in the capillaries and bloodvessels, and in the blood plasma surrounding the cells, contains serum albumin, globulin, fibrin, etc. The hemoglobin in muscle and the residual blood give meat its red color. The identity of the coloring substance in blood and in muscle is not generally admitted, although the close relation is acknowledged. The quantity of hemo- globin varies; it is greatest in muscles concerned in long- continued and powerful contractions and least in the more passive muscles. The dark and light meat of birds show this relation. Certain species, e. g., the rabbit, are poor in hemoglobin. The muscle of the young of most species is low in hemoglobin, hence their light color. The decided red color of meat preserved with nitrates appears to be due to the presence of nitrous oxide hemoglobin. The small amount of glycogen normally present in muscle is almost entirely changed to glucose after death. The com- paratively large quantity of glycogen in fresh horse meat is one of its distinguishing characteristics. Fat varies in quan- tity, kind and color with the condition of the animal, the food ingested and the cut (portion of the carcass). Flavor in meat is due to the presence of the extractives— substances soluble in water, alcohol or ether. In addition to the carbohydrates and fat just mentioned these include certain nonprotein nitrogenous constituents such as creatin, xanthin, hypoxanthin, inosin," etc.; the latter are the chief source of the exogenous uric acid. It is the latter extractives which the gouty patient should avoid and to which vegetarians and certain food cults object, holding them to be waste products and a burden to the excretory system. The presence of purine compounds in the diet under cer- tain pathological conditions, such as gout, is objectionable. It is important to know, therefore, the relative quantity of these substances in various foods. A table giving the purine contents of various kinds of flesh and of certain other foods will be found in a subsequent discussion of diet in disease. 186 MEAT OR FLESH FOOD Meat often contains certain substances characteristic of the food ingested which give to it the flavor so prized by epicures: these are particularly evident in game. Composition. —Flesh or meat is ordinarily composed of about three-fourths water, but there is less water in fat than in lean meat and likewise in old than in young animals. In the ash of muscle the salts of potassium and phosphoric acid predominate. Traces of sodium, calcium, magnesium, iron, sulphur and chlorine are also found. The following table gives the approximate proportions in which the inorganic constituents occur in meat: Composition of the Ash of Typical Flesh Foods. CaO. MgO. KsO. NajO. P20s. Cl. s. Fe. Beef, lean . O.OII O.O4 O.42 O.09 0.50 0.05 0.20 O.OO38 Veal, lean . 0.16 O.O45 O.46 O. 12 0.50 0.07 0.23 Lamb, me- dium fat o.0039 0.04 O.29 O.O93 O.42 0.12 O.23 Pork, lean . O.OI2 O.O46 0-34 0.13 0-45 0.05 0.20 Poultry 0.015 0.06 0.56 0.13 O.58 0.06 0.216 Fish 0.03 0.04 0.40 1.30 O.4O 2.4O 0.22 O.OOO3 Edible Portion of the Ox. — Some meats when purchased contain inedible parts, such as bone, the exterior portions of the carcass, large bloodvessels, connective tissue, gristle and tendon. In considering a particular piece of meat from a purely dietary point of view allowance should be made in the calculation for the waste which these portions represent. From an economic standpoint it is essential to know the quantity of edible material likely to be derived from a given piece of meat. Fig. 5 gives the percentages of lean, visible fat and bone in the straight wholesale cuts of beef. An inspection of this chart reveals in general an inverse relation between the percentage of lean meat and that of visible fat; the relative weight of bone is more variable. The proportions of the various food-stuff's in meat varies according to the kind of animal and the portion of the anat- omy from which it is obtained. The same “cut” of meat from different animals varies according to its age and nutri- tive condition. The relative differences in the protein content of the various cuts of beef is shown in the following chart (Fig. 6), prepared by Hall and Emmett, which gives the per- centage of the total protein in the boneless meat of wholesale cuts. The curves show a relative increase in the quantity of protein as we consider the cuts from the left to right. Cal- culated on the basis of the dry, moisture-free, substance an even greater increase is found, because the cuts on the right COMPOSITION 187 LEAJN VISIBLE TAT bone Fig. 5.—Percentages of lean, visible fat and bone in the straight wholesale cuts.1 (Courtesy of the Illinois Agricultural Experiment Station.) SOLUBLE PROTEIN TOTAL PROTEIN Fig. 6.—Percentages of total and soluble protein in the boneless meat of the wholesale cuts.1 (Courtesy of the Illinois Agricultural Experiment Station.) 1 Hall and Emmett: Univ. 111. Agr. Exp. Sta., Bull. 158, 1912. 188 MEAT OR FLESH FOOD contain more lean and less fat and also because the lean meat has a greater water content. When the fat is excluded from consideration the protein content of the various cuts is quite similar. In other words, the difference in the various cuts of beef is due to the varying quantities of fat and water. HIND QUARTER Pound Rump l Rump Round: rump & shank off. £ Round steak, first cut. 3-0 Round steaks. 14 Round steak, tost cut. 15 Knuck/e soup bone 16 Pot roast Hind shank. I7./8 3oup bones !9 Hock soup bone Loin I Butt- end sirfoin steak. £. Wedge-bone sirfoin steak. 3,4 Round-bone 5,6 Double -bone 7 Htp -bone 8 ti/p - bone Porterhouse steaK. 9-/5 Regular " 16-18 Club steaks. Plank l Flank steak £ Stew. PORE QUARTER R/s / II® & 1£® R/b roast 2. 9WS 10® 3 Jtli S 8® 4 6® - Chuck / /P/A roast. £-9 Chuck steaks /0-/J Pot roasts. 14 C/od 15 Nock Plate / brisket 2 Navel 3,4- Rib ends Fore shank / Stew £ Knuck/e. soup bona. J-6' Soup bones. •RETA/L • CUTS • OF • BEEF * Fig. 7.—Method of cutting the three sides, showing retail cuts. (Courtesy of the Illinois Agricultural Experiment Station.) EFFECT OF HEAT ON MEAT 189 Percentages of Water-soluble, Insoluble and Total Protein in the Boneless Meat of the Wholesale Cuts.1 Wholesale cuts. Soluble. Insoluble. Total. Fore shank x. 42 15-56 16.98 Clod . . I.8l 14.88 16.69 Round . 2.08 14.42 16.50 Hind shank • • i-59 14.67 16.26 Neck . 1.65 13-94 15-59 Chuck • i-47 13-40 14.87 Loin • • 1-37 H-59 12.96 Rump 1.26 11.30 12.56 Rib 1.20 11.12 12.32 Plate . . . 0.83 9.76 10.59 Flank . . . 0.66 8.78 9-44 Fig. 7, p. 188 enables one to locate the portion of the animal under consideration. The differences among the percentages of the food-stuff's in the various kinds of meat are likewise due to similar varia- tions; this is shown in the following table taken from a com- pilation of analyses by Atwater and Bryant: Composition of Typical Flesh Foods. Water, Protein N. x 6.25, Fat, Ash, Fuel value per cent. per cent. per cent. per cent. per pound. Beef . . 70.0 21.3 7-9 I. I 709 Veal . . • • • - 70.3 21.2 8.0 I .O 711 Lamb . .... 63.9 I9.2 16.5 I. I 1022 Pork . . 60.0 25.O 14.4 1-3 IO42 Poultry- .... 63.7 19-3 16.3 1.0 1016 Fish . . .... 81.7 17.2 03 I .2 324 Effect of Heat on Meat. — Cooking. —The objects to be accomplished by cooking meat are the improvement of its flavor and appearance, the modification of its texture and the destruction of parasites and bacteria. Digestibility of protein is not increased by cooking; it is diminished in many cases. Such changes as the hydrolysis of connective tissue and comminution increase the ease of digestion. The flavor acquired by meat through cooking is due to changes, probably oxidative, in the soluble, extractive por- tions of the flesh and in the fats.2 A study of the develop- ment of flavor in which the juices were separated from the insoluble portions (fiber) of beef showed the flavors to develop in the juice more than in the residue, and in the extract not coagulable by heat more than in the coagulable portion. A study of the effect of various temperatures showed the flavor to develop most at temperatures above ioo° C.; below 1 Hall and Emmett: Univ. 111. Agr. Exp. Sta., Bull. 158, 1912. 2 Grindley and Emmett: U. S. Dept. Agr., Office Exp. Sta., Bull. 162. 190 MEAT OR FLESH FOOD this the taste is more or less insipid. The pronounced flavors developed by dry heat are thought to be due to the higher temperatures attained. The fat of meat when heated suffi- ciently high also gives rise to characteristic flavors. The appearance of meat is improved by cooking as the result of the coagulation of the proteins and the transforma- tions in the hemoglobin whereby the more or less objectionable reddish-purple color of uncooked raw meat is changed to the light red or brown color of cooked meat. These changes in appearance are most evident in roast beef and are enhanced by the crisp outer layer of fat. Three methods are employed to make a piece of meat tender: (1) Cooking for a long time at low temperature; simmering at approximately 8o° C. (this is sometimes incorrectly designated boiling), whereby the insoluble collagen of the connective tissue is changed to gelatin, thus loosening the fibers. (2) The mechanical separation of the fiber from the connective tissue by scraping, a tedious process practised in the preparation of a readily digestible protein food for the sick. (3) Grinding, mincing or pounding, by which means the connective tissue is mechanically severed. In the cooking of meat two general methods are employed which differ in the mode of application of the heat: (a) The direct application of radiant heat, as in roasting and broiling, and (b) the application of heat through the medium of a liquid, as boiling in water and frying in deep fat. Roasting and baking are used synonymously by the average cook. A distinction should be made, however, between so-called roasting or baking and true roasting.1 True roasting is cooking by radiated heat from glowing coals, but one side of the food being exposed to the heat at a time. Broiling is essentially the same in principle as true roasting, but the food is brought into direct contact with radiant heat. The length of time of the two processes differs, for a thinner cut of meat is used for broiling. Baking is cooking in a ventilated oven. Although frying in deep fat belongs properly, as indi- cated, to the indirect method of cooking, the results obtained are more like those obtained with the direct application of dry heat. The changes produced in meat by cooking, aside from slight differences in flavor, are of two kinds, those characteristic of roasting and of boiling A combination of these procedures —pot roasting, so admirably adapted to the preparation of 1 Bevier and Sprague: Univ. 111. Agr. Exp. Sta., Circular 71, 1903. EFFECT OF HEAT ON MEAT 191 tough, cheap cuts, yields some of the advantages of each method. In this case the tenderness of boiled meat is com- bined with the flavor of roasted meat. Grindley and Emmett have shown the effect of roasting (baking) to be similar to that produced in broiling, parboiling, sauteing and frying. Roasting is practised principally for the development of flavor and appearance. The application of a high heat sears the surface of meat and immediately coagulates the pro- teins, the hemoglobin being changed from bluish red to brown. Such treatment also causes changes in the surface fat, thus developing an additional flavor. The preliminary searing, usually conducted at a higher temperature than the subse- quent cooking, serves to retain the water and the extractives. The subsequent changes which occur within the roast are gradual, for muscle fibers are very poor conductors of heat, and the internal temperatures never reach those of the air surrounding the meat. Precise Method of Roasting Beef.— As the heat gradually penetrates inward the proteins are coagulated at a low heat, and the hemoglobin is changed in color, assuming first the pink color characteristic of rare meat, and finally becomes brownish gray—“well done.” This last color is common to all meats heated to a temperature above 70° to 75 0 C., and is due to the complete coagulation of the hemoglobin. At these higher temperatures the coagulated protein, and conse- quently the piece of meat, shrinks. Careful studies of the physical changes occurring during roasting have emphasized these points and established the conditions necessary to obtain the desired kind of roast—rare, medium or “well done” (Sprague and Grindley). The inner temperature of the meat determines the degree of the roast regardless of the external temperature. When a thermometer placed in the middle of a roast registers a temperature of approximately 43° C., 550 C., or 70° C., if the roast be removed from the oven the final temperature will be approximately 550 C., 65° C., or 70° C., and the meat will be respectively rare, medium or well done. These temperatures hold with the external temperature of the average roasting oven (1750 to 1950 C.). At lower oven temperatures the temperature at which the meat is removed will more nearly approximate the final one desired. The most desirable conditions for successful “boiling” of meat are long-continued heating at a temperature below the boiling-point, 800 to 85° C. Under such circumstances the connective tissue is softened and the protein coagulated with- out becoming hardened (toughened), characterized by the 192 MEAT OR FLESH FOOD shrinking of the meat. Long experience in cooking has demonstrated the advisability of searing the outside of the meat or plunging it into boiling water and keeping it at this temperature for a few minutes before beginning the cooking at the lower temperature. Such a practise is held to assist in the formation of a more or less impervious layer by the coagulation of the surface proteins which retains the extractives and soluble proteins and thereby improves the nutritive value and flavor. If a rich broth is desired the opposite method is used, beginning with cold water, which is gradually heated. The work of Grindley and his associates, studies on the losses in cooking meat (see below for further discussion), has shown, however, that when meat is cooked at 8o° to 85° C. there is practically no difference in the quantity of nutrients (protein, extractives and ash) which pass into the broth when the cooking is begun in hot or cold water. The length of time of cooking and the fat content have a much greater effect upon the losses than the method of cooking. Chemical Changes in Meat as the Result of Cooking.— The chemical changes which occur in meat during cooking, whether by roasting or boiling, consist in an increase of insoluble (coagulated) protein and in the removal of water and extrac- tives (nitrogenous, non-nitrogenous, fat and ash). Boiling causes a removal of a greater proportion of these substances than does roasting. Fat meats lose less water, protein and mineral matter, but more fat than do the lean cuts. Pro- longed cooking at higher temperatures is accompanied by greater losses than at lower temperatures. Under like condi- tions the larger the piece of meat the smaller are the relative losses. As already mentioned, when “boiling” at 8o° to 85° C. the effect of such preliminary treatment as placing in cold or hot water has little effect upon the quantity of material found in the broth. It is interesting to note that the beef used in the preparation of beef tea or broth loses little of its nutritive value, although it loses much of its flavoring material. The work of Grindley and his associates has been verified and extended by that of other investigators, particularly with regard to the changes in the protein and extractives under various conditions. The table on page 193 taken from their results shows the influence of cooking upon the composition of meat. Digestibility of Meat.— Many conflicting statements are made with regard to the digestibility of meats of various kinds and as prepared by the various methods of cooking. The observations upon which the conclusions regarding the digestibility of meat are commonly based are of two general DIGESTIBILITY OF MEAT 193 Protein. Extractives. Nitrogen Nitrog- Nonnitrog- Non- Water. Insoluble. Soluble. Total. enous. enous. Total. Fat. Ash. Protein. protein. Total. Beef: Fresh 69-13 15-52 2.29 17.81 1.08 1.62 2.70 10-95 I.03 2.85 0-35 3.20 Boiled ... . . 57-50 31-57 O.38 31-95 0.60 0.75 i-35 9-34 0.66 5-12 O.19 5-3i Roasted 66.14 22.54 0.82 23-36 1-35 1.65 3.00 6.96 1.24 3-74 0-43 4.17 LOSSES OR GAINS IN COOKING EXPRESSED IN TERMS (PERCENTAGE) OF TOTAL WEIGHT OF UNCOOKED MEAT. Boiling -39-09 -O.63 -0.83 -1.07 1.24 0.6l Roasting -35-31 +3-87 -9,02 -16.64 6.87 11.68 COMPOSITION OF EXTRACTS AND BROTHS. Cold-water extract: Fresh meat Broth: 2.29 1.08 I .62 2.70 O.83 0.37 0-35 0.71 Complete maximum 97.8 I.56 1.06 I.36 2.42 6.48 O.77 0.34 0-57 0.25 Complete minimum . 91.1 O. 19 0.56 0-73 1.30 0.06 0-44 0.18 O.25 0.03 Average Broth, clear (filtered): 95.62 O.58 0.83 1.07 1.90 1.26 0.6l 0.27 O.36 0.09 Maximum . . . . . 98.0 O.96 1.07 1-37 2-44 0-79 Minimum 96.6 0.15 0.60 0.74 1-39 O.46 Average 97.1 0-33 0.85 1.09 i-94 0.62 Changes in Composition of Meat during Cooking. 194 MEAT OR ELESII FOOD types: (i) The time the food remains in the stomach1 and (2) the degree of digestion, i. e., the amount absorbed, measured by the quantity of nitrogenous substances excreted in the feces. The first method is open to the objection that it measures the activity of the stomach and tells nothing of the processes which go on in the intestines. Stomachic processes involve chiefly the swelling of the protein under the influence of the hydrochloric acid and a partial hydrolysis by the pepsin, resulting in the reduction of the food to a semifluid mass; but there is little absorption through the gastric mucosa. More- over, so many variables must be taken into consideration accurately to measure the time required for food to leave the stomach that the results obtained by such experiments must, unless they are very striking, be considered as merely sugges- tive. For example, the ease of swelling or the degree of peptic activity are modified by the mode of preparation. Fat particularly tends to retard gastric digestion; there is no lipolytic activity of importance in the stomach. The com- position of the flesh likewise affects gastric digestion, very fat meats being less digestible than lean meats. The presence of large quantities of connective tissue, particularly in partially cooked food, serves to hinder peptonization. Finely divided meat is more easily attacked by the gastric juice than large masses. Foods which are acid remain a shorter time in the stomach than do alkaline foods. The quantity, strength and acidity of the gastric juice have a very pronounced effect upon the rate of ejection from the stomach. The second method of measuring digestibility—the com- pleteness of absorption of the ingested food—indicates only the extent of absorption and does not enable us to judge the length of time required for its digestion. Food which is completely absorbed leaves little residue and is likely to lead to constipation, while that which is poorly absorbed may (a) be subject to extensive bacterial action in the large intestine, (b) increase the rate of peristalsis or (c) lead to the accumulation of large masses of food residues in the intestines. In a well-selected diet, foods which are completely digested are accompanied by some of those which are difficult of diges- tion, particularly foods low in protein and rich in cellulose, such as vegetables and fruits. In the treatment of patho- logical cases it is particularly necessary to take into con- 1 For detailed studies of the gastric response of foods see the work of Hawk and his associates: Am. Jour. Physiol., 1919, 49, 174, beef; ibid., p. 204, pork; ibid., p.222,lamb; ibid., p. 254, eggs; or areview of these papers by Denton: Jour. Home Economics, 1921, 13, 26 and 58. See also p. 52. MEAT PREPARATIONS 195 sideration the degree of digestibility of the foods prescribed. The extent to which a food is absorbed depends quite as much upon the nature of food as does the ease of digestion. Foods that contain material in quantity which is not acted upon by the digestive enzymes are not only poorly absorbed but retard the digestion and absorption of other foods which are ordinarily completely digested and absorbed. The mode of preparation also influences the extent of absorption, for by its proper preparation connective tissue and cellulose structures are partially or completely hydrolyzed or disintegrated and thus become more readily and completely digested. Conventional consideration of the relative digestibilities of various kinds of meat is based, then, upon data which are not entirely satisfactory. Clinical observation is an aid in determining the digestibility of food in its most general sense, but here there may be influences of personal idiosyn- crasies as the result of pathological conditions in the patient under observation, and this is particularly true of protein foods. Some individuals show distinct reactions to certain foods. Many cases are known, however, in which the inability to eat eggs, fish or milk is a psychical factor and that the ingestion of such foods is not attended by metabolic disturbances. In feeding persons whose condition necessitates prompt emptying of the stomach, food must be selected which will pass out readily, just as in certain intestinal diseases food must be taken in such a form that complete absorption occurs without extensive intestinal digestion or in which little residue results. These factors are discussed on p. 52. It seems to us that the method of the preparation and the consistency of the food are more important factors in the treatment of nutritional diseases in which a specific food substance is not involved, such as a specific idiosyncrasy or disease, than the selection of a few from among a number of foods compatible with the patient. MEAT PREPARATIONS. Certain products prepared from meat, particularly from beef flesh, such as digested beef, beef juice, beef broth, beef extracts and gelatin, contain less insoluble materal than meat itself and are therefore held to be desirable not only for general use but for use in the sick-room and for conva- lescents. Such products are either readily soluble in water or yield fine aqueous suspensions. It is the possibility of furnish- ing protein or its digestion products in a fluid or soluble form 196 MEAT OR FLESH FOOD which makes these preparations attractive for the special diets of therapeutics. The nutritive value of meat preparations as compared with meat depends upon the mode of preparation. They are prepared from lean meat through the action of digestive enzymes, with the aid of heat, or by simple water extraction. Beef extract and some beef broths contain only small proportion of nutritive protein material, whereas cold pressed beef juice, gelatin and broths prepared with gelatin-yielding meats and flesh in which the proteins have been partially digested are highly nutritious. The table on page 197 gives the comparative composition of such products. Meat Extracts.— Beef extract, the most common meat extract, contains the water-soluble, non-coagulable substances in meat in a concentrated form. These consist essentially of nonprotein, nitrogenous extractives such as creatine, purine bases, etc.; noncoagulable products of protein hydrol- ysis, amino-acids, proteoses, peptones and gelatin, and the salts of muscle, a large proportion of which are salts of potas- sium and phosphoric acid; sodium chloride is sometimes added in the preparation of the extract. Extracts prepared from meat containing considerable quantities of connective tissue are more likely to contain greater quantities of gelatin. Gelatin, digested meat and yeast extract are sometimes used as adulterants of meat extracts. Yeast extract is being used not only as an adulterant but also as a substitute for meat extract. Meat extracts are particularly valuable as stimulants, for their salt content, and as flavoring materials for otherwise unpalatable dishes. The extractives of meat have been shown to stimulate the flow of the gastric juice; in this way they tend to increase the digestibility of foods. Extracts to which have been added gelatin or finely divided protein— made more or less soluble by digestion or solution in acid— increase the food value of the preparations. The use of beef juice is, from a nutritive point of view, to be preferred to such preparations. Meat Juice.—Meat juice, particularly beef juice, is often prepared and used in tbe diet of the sick-room and for feed- ing infants. Such extracts are prepared by pressing out the water and soluble proteins from raw or half-broiled lean meat, preferably from finely divided meat. Preparations of this kind contain a certain proportion of the water-soluble, coagulable proteins in addition to the ordinary extractives obtained by a method which involves heating to a temperature above the coagulation temperature of protein. They have, MEAT PREPARATIONS 197 Water. Forms of nitrogen. Ash. Total nitrogen. Protein (coag- ulable nitrogen). Ammonia nitrogen. “Proteose2 peptone.” Meat bases, difference Meat bases. Total. Chlorine. Phos- phoric acid. Potash. Creatin- ine. Creatine. Purine. Undeter- mined. Paste 20.5 9.41 0.37 4.51 4.44 0.86 1.30 0.76 1.50 17.60 1.90 5.00 7.60 Extracts (fluid) 42.0 4.01 0.10 0.42 1.50 1.99 0.43 0.48 0.36 0.72 21. CO 6.30 2.70 5.50 Meat juice .... 55.7 3.13 0.26 0.90 1.92 0.22 0.13 0.37 1.20 11.50 0.90 2.70 5.20 Fluid proprietary prep- arations .... 74.31 0.50 0.31 0.19 0.02 0.02 0.03 0.12 0.38 0.30 0.02 0.10 Beef powder 11.2 12.64 0.05 0.14 12.20 0.26 0.00 Trace 0.04 0.22 6.10 0.02 1.47 0.13 Fresh beef .... 69.1 3.20 2.85 0.346 1.03 Beef broth: Complete .... 95.6 0.58 0.58 0. 83 0.61 Filtered 97.1 0.33 0.33 0. 85 0.62 1 Contains alcohol, 12.52 per cent, by weight. 2 Products noneoagulable and precipitated by tannin-salt, chiefly proteose, peptone and gelatin. Compiled from Conn. Agr. Exp. Sta., Food Products Report, 1908, and Emmett and Gindley, loc. cit. Values of protein related substances are expressed in terms of nitrogen. Coagulable protein and the proteose-peptone can be expressed in their approximate protein equivalent by multiplying by 6.25. (See p. 176.) Composition of Typical Meat Preparations (Extracts, Powders, Broths). 198 MEAT OR FLESII FOOD therefore, considerable nutritive value and may be used for the administration of protein in a liquid form. Commercial preparations of meat juice can be obtained, but they are never as satisfactory as the freshly prepared juice and broths. Meat Broths.—Meat broths are of two kinds: (a) Those that have been prepared by boiling beef, mutton, veal, chicken, etc., with water and straining off the protein material; (b) those prepared by extracting the juice from finely hashed meat with a small quantity of cold water and expressing the water retained by the meat. The latter process removes a greater proportion of the soluble protein constituents of the meat and is therefore more economical. The product is, of course, more dilute than in the case of meat juice alone, but the greater proportion of protein it contains makes the two prod- ucts comparable. The composition of the water extract varies, of course, with the quantity of water used. Such products contain from 2 to 5 per cent of protein and a fraction of 1 per cent of fat. (See table, p. 197.) Meat broths, method ( The latter is often mixed with glucose, or corn syrup, and sold as “corn syrup with cane flavor.” Glucose.—Glucose (dextrose or grape-sugar) is found most widely distributed in the plant and animal kingdom. It occurs in the free state and in combination with other sugars. It is the end-product of the digestion of starch, glycogen and maltose, and one of the products of the hydrolysis of sucrose and lactose. In the body it is the form of carbohydrate present in the blood. Glucose is assuming an important 222 CARBOHYDRATE-RICH FOODS place in the manufacture of syrups and confections, and is often used by manufacturers in place of cane-sugar. It is prepared from starch by the action of acids which hydrolyze it, yielding a product known as “commercial glucose,” or “corn syrup,” a viscid liquid mixture of glucose, maltose and dextrin. The complete hydrolysis of starch yields practically pure glucose which upon recrystallization is sold as starch- sugar or grape-sugar. Glucose is often used in the preparation of preserved fruit products and as such it is considered an adulteration. Many artificial jams or fruit butters are prepared from apple pulp which when flavored and colored are sold as jams of different kinds. The present pure food laws require such preparations to be labelled as artificial. As far as their fuel value is con- cerned they are as satisfactory as the true products. Lactose.—Lactose, the sugar in milk, yields galactose and glucose upon hydrolysis. It is not as sweet as cane-sugar and is therefore often a valuable food in cases in which it is desired to raise the caloric value of the diet. It is a concen- trated form of carbohydrate and is readily absorbed. Further, it has been shown that fermentation in the stomach does not take place as readily with lactose as with sugar. Coleman has used lactose successfully to increase the caloric value of the diet of typhoid fever patients. Maltose.—Maltose, one of the digestive products of starch, is composed of two molecules of glucose. It occurs in the diet usually as the result of special preparation, as in the preparation of malt or the preliminary digestion of food. Maple-sugar.-Maple-sugar is obtained from the sap of the sugar-maple. The sap is evaporated in open kettles and the sugar allowed to crystallize into a solid mass. Maple- sugar is seldom refined; it contains in addition to the sugar certain ethereal substances and organic acids which give to it the characteristic flavor. When the concentrating process is not carried far enough for the sugar to crystallize, maple syrup is obtained; the greater part of the sugar from the maple tree is sold in this form. Invert Sugar.—Invert sugar, a mixture of equal parts of glucose and fructose, is seldom sold as such. It is found in ripe fruits and vegetables, molasses from cane-sugar, and often in jellies and confections as the result of hydrolysis. Fructose. —Fructose (levulose or fruit-sugar) is found in fruit associated with glucose as invert sugar (see above). Inulin, the starch-like substance in the roots of the dande- lion, chicory and the tubers and of artichokes, yields fructose upon hydrolysis. SUGARS 223 Candy, Jams and Jellies.—The sugars are important con- stituents of confectionery, preserves and jams. Candy is essentially cane-sugar or glucose to which certain flavoring and coloring substances and sometimes a filling material have been added. In the commercial preparation of many candies sugar is partially hydrolyzed to invert sugar, which gives them a greater smoothness. Preserves, jams and jellies are essentially fruit pulp or juice to which sugar has been added and the whole boiled to the proper consistency. Their food value is largely due to the sugar. The gelatinizing constituent of jellies is the pectin of the fruit. When pectin is deficient it is often obtained from other fruits, giving the mixed jellies. Acid is also necessary in the preparation of jellies, for it aids in the gelatini- zation of pectin and in the inversion of the sugar. In the latter process a large proportion of the added cane-sugar is “inverted” into non-crystallizing invert sugar. This is an important consideration in preparing such products, for otherwise the cane-sugar would crystallize and the jelly or jam would be physically unpalatable. The following table gives the comparative composition of the expressed juice and pulp and of the jelly and jams prepared from them; Composition of Jams and Jellies and the Juices from Which They Were Prepared. Urange: Juice Jelly Pulp Jam Grape: Juice Jelly Pulp Jam *-H OOCO O vO O' hOJ OC CO O Co Vj w Water, per cent. Cn VO vO Cn CO to o o o o 4* C\ C4 C4 4* h O O' o o o o 4*. Cn OCCn cn -vj Ash, per cent. o o o o 4* Q\ m KJ C4 V© C4 ON i-1 ~-J o • o o ~4 • cn vO • M O 4* • M Acid calc, as H2SO4, per cent. o o o o \D SO 4* Cn 00 H 00 ■4 Cn Co h 0-00 Cn • h w to • ~4 C4 Cn • Cn Protein (N. x 6.25), per cent. C4 C4 m OiwvOOt hUUi U CO CO Co ON to Cn H 10 H «\0 o Reducing, per cent. On • ON * vO • Cn • hh • Cn ■ Co • NO • 4* • on • to • o • 4- • to • Cn • vO • Cane-sugar added, per cent. U) B era Cn On 4-* Co to to to Co On to Co Co to vO w CO HH O O’ O CO to Cn 00 Co o VO Cane-sugar found, per cent. >-! CO (4 ►H 4^ Cn sD Cn t-i M 4=* GJ VO C4 C4 00 04 Added cane-sugar, inverted, per cent. Digestion and Utilization of Sugar.—We will confine our discussion to the utilization of sucrose and its products of hydrolysis, for the quantities of the other sugars ingested are comparatively small. The only important exception is the lactose in milk, the source of carbohydrate in the diet of infants. The digestion of sugars takes place wholly in the intestines. They are there transformed, in the processes of 224 CARBOHYDRATE-RICH FOODS digestion, into monosaccharides, and in that form are com- pletely absorbed. Under certain conditions, however, sucrose may be absorbed into the system without being first inverted. When excessive quantities of a sugar are ingested, absorption takes place more rapidly than digestion, i. e., the assimilation limit is exceeded (see page 40). When the ingestion of a sugar is distributed over long periods of time, and particularly when it is taken with other food, greater quantities than these can be given without causing glycosuria. Taylor has suggested that the assimilation limit of glucose is not as definite a quantity as formerly supposed, but that it depends upon the capacity of the individual to retain it without regurgitation. Cane-sugar when taken in concentrated solution has a disturbing effect upon the digestive processes. These dis- turbances are likely to arise from the ingestion of candies or sweet syrups except when accompanied by food or sufficient water. The effect has been shown to be a direct irritation of the gastric mucosa due to the rapid withdrawal of water, causing inflammation and excessive secretion of mucus and a highly acid gastric juice. The repeated irritation of the stomach may lead to serious gastric disturbances. Investi- gations have shown that with too large an ingestion of sugar (120 grams) the emptying of the stomach is delayed. Invert sugar does not have as pronounced an effect upon the digestive processes as sucrose. Large amounts (100 grams) of cane-sugar or of glucose in concentrated solution depress gastric secretion and delay the evacuations of the stomach. Small amounts of sugar, 10 grams, on the other hand, do not appreciably affect secretion. The effects of candies are related to their sugar content, except when gastric stimulants are included, such as milk, eggs or chocolate.1 Since sugars are not absorbed in the stomach when their passage is delayed, fermentation often takes place. The prod- ucts of such fermentation vary —there may be lactic, butyric or alcoholic “fermentation” according to the conditions which exist. Lactose has been shown to be less likely to give rise to fermentation. STARCH. Starch is the principal form of carbohydrate in the food of man. It is the form in which the plant stores the soluble carbohydrate formed in the processes of photosynthesis against the future demands of the embryo or plant itself. It is a 1 Am. Jour. Physiol., 1920, 53, 65. STARCH 225 member of the group of carbohydrates designated as poly- saccharides. A starch molecule is composed of a number of molecules of glucose which have been united into a complex structure in which one molecule of water has been removed in the union of two molecules of glucose. Upon digestion (hydrolysis) starch is broken down into simple compounds—soluble starch, dextrin, maltose and glucose —according to the nature and intensity of the digestive pro- cess. The final product, glucose, is absorbed and used in the body or synthetized into a compound, glycogen, which is similar in structure and serves as a reserve carbohydrate to the same end in the animal economy that starch does in the plant. In the plant, starch is stored in the form of fine grains or granules. These consist of alternate layers of particles of starch and of cellulose, a more dense and com- plex compound similar to starch, arranged in concentric rings. The shape of the granule and arrangement of the rings are characteristic of the plants in which they are formed. The microscopic appearance of the starch granule thus becomes a valuable means of determining its origin and of detecting the adulteration of foods. Raw starch is insoluble in cold water. Under the influence of heat (or acids) it takes up water, becomes hydrated, swells and becomes semitransparent, forming an opaque solution. This is not a true solution but one in which the starch particles are suspended in water—a colloidal solution. Careful treat- ment of starch with acids gives a partially hydrated product known as soluble starch, the dried form of which is soluble — a colloidal solution—in cold water. The hydration of starch under the influence of heat and in the presence of water causes the starch grains to swell and rupture the surrounding cellulose layers. This is the object sought in the cooking of vegetables. Dextrin is one of the first products of hydrolysis of starch formed by the action of enzymes (digestion), of acids or of heat. Although it still retains the complex structure of starch, it is more soluble in water. The carbohydrate of the crust of a loaf of bread is composed largely of soluble starch and dextrin formed during the baking process. The readily soluble and diffusible products of the hydrolysis of starch, maltose and glucose have already been considered in our discussion of sugars. Digestion and Absorption. —Starch itself is readily digested and absorbed. Glucose is the end-product of its digestion — the form of carbohydrate present in the blood stream. The digestion and absorption of starch extends over a considerable length of time, being delayed by the associated indigestible 226 CARBOHYDRATE-RICH FOODS cellulose. The result is that starchy foods yield glucose to the body over a much longer period of time than those containing soluble carbohydrates, sugars. This is in most cases an advan- tage, particularly where severe muscular work is to be per- formed. The gradual absorption of the carbohydrate keeps the body continually supplied with the most efficient food for the performance of work, yet without depleting the store of glycogen before the next meal. Raw starches are nearly as digestible as the cooked starch. The digestibility appears to be related to the size of the starch granules. Raw corn and wheat starch are completely assimilated while potato starch varies from 62 to 95 per cent in its digestibility. The digestibility of the various prepared foods, particularly bread and potatoes, will be discussed later (pages 236 and 238). GRAINS AND THEIR PRODUCTS Nutritive Value.—The cereal grains have the same general biological value as the legumes. The proteins of the grains are better than those of the legumes. The proteins of wheat are particularly good. The cereals need to be supplemented by the addition of inorganic salts and vitamins A and C. Most cereals require the addition of a supplementary protein. Nine-tenths of the protein in the diet present as wheat can be supplemented by one-tenth milk protein. Composition.—This group of foods includes the seeds of plants such as barley, buckwheat, maize, oats, rice, rye and wheat, and the products manufactured from them. Grains are harvested in the partially dried state and contain, there- fore, a lower percentage of water (io to 12 per cent) and a higher percentage of carbohydrate, protein and fat than the fresh grain. Starch is the predominating food-stuff (65 to 75 per cent of the dried grain). Small quantities of sugar and cellulose are present. The protein content is rather high (10 to 12 per cent) and a number of different kinds are present. The predominating proteins, such as the alcohol- soluble protein, gliadin, and the glutelin, glutenin, of wheat, are of a different type from those found in flesh foods. The fat content of grains may be rather high; oats and corn con- tain as much as 8 per cent; the values average between 0.5 and 8 per cent, according to the kind of grain. The fat of the grains has a low melting-point and exists as an oil. Approximately 2 per cent of ash is present in grain. This is distributed chiefly in the outer layers of the kernel and the germ. The tables on page 227 give the composition of the various whole grains and of the flours prepared from them. GRAINS AND THEIR PRODUCTS 227 Composition of Various Whole Grains as Marketed by the Farmer. Water, Protein (N. x 6.25), Fat, Carbo- hydrate, Fiber, Ash, per cent. per cent. per cent. per cent. per cent. per cent. Barley . IO.85 II .OO 2.25 69-55 3-85 2.50 Corn 10-75 10.00 4-25 71-75 i-75 I.50 Oats 10.06 12.15 4-33 57-93 12.07 3-45 Rye IO.50 12.25 1.50 71-75 2.10 1.90 Wheat . 10.60 12.25 i-75 71-25 2 40 i-75 Composition of Prepared Cereals. o CO X fl Q> fl . fl O a fe O a-o3 O O S-) a> a • £ a> .5 0 ‘S »-< 0 0 t-4 s a fl >> rfl O .§ a! O a c 0 0 1-. V a <0 0 3 - S 13 “ O u cp O **~i ’£ a~5 * ■s 0 a £ 1*3 £ S a O £ £ JS < Sft fa «o O Barley, pearled ii.9 10.5 2.2 72.8 6.5 2.6 1603 28 Buckwheat flour . 13-6 6.4 I .2 77-9 0.4 0.9 1577 29 Cornmeal, granular . 12.5 9.2 1-9 75-4 1.0 I .0 1620 28 Oatmeal .... 7-3 16.1 7.2 67-5 0.9 i-9 l8ll 25 Rice 12.3 8.0 0.3 79.0 0.2 0.4 159 29 Rye flour .... 11.4 13.6 2.0 7i-5 1.8 i-5 1626 28 Wheat flour 12.0 n.4 I .O 75 1 0-3 o-5 1610 28 With few exceptions the grains are rolled or milled before they are used in the preparation of food. In the various pro- cesses certain portions of the grain are removed, particularly the outer layers of the kernel and the germ. The accompany- ing data related to the polishing of rice gives the important changes in chemical composition during milling: Chemical Composition of the Honduras Type of Rice after Various Milling Processes of Modern Rice Mills.1 Constituents (per cent.). 0 6 Q A § CO 2 C43 d a d a V3 s- 0 "0 0 "o 0 o A A 3 0 a 0 a § < w 0 £ £ £ £ Rough rice . . . 11.27 540 1.58 8.67 7.48 590 8-43 6.65 After removal of hulls . 12.32 1.18 1.79 0.99 8.57 2.42 9.78 2.75 After removal of bran and most of the germ . 12.56 053 0.40 0-39 7-79 1.90 8.91 2.17 After further removal of bran (pearling) 12.50 0.47 0.28 0.30 7.88 i-53 9.00 i-75 After polishing . xi .89 0.36 0.25 0.30 8.06 1.80 915 2.04 Coating 12.02 0.40 0.21 0.26 7-75 1.66 8.81 1.88 Total loss2 . 66.00 85.00 73.00 10.00 32.00 10.00 32.00 1 Bulletin 330, U. S. Dept. Agr., 1916. 2 On a moisture-free basis, 228 CARBOHYDRATE-RICH FOODS Barley. — Barley is not used extensively for human food in this country. As “pearled barley,” prepared by removing the germ and the greater portion of the bran, it is used in soups. Barley water, prepared from “patent” barley flour, is used in infant feeding and in the diet of the sick room. “Patent” barley flour is finely ground pearl barley or barley which has been more thoroughly polished than pearl barley. Buckwheat.— Buckwheat, although ordinarily classed with the cereals, does not belong with them according to its botanical classification. Its use is confined chiefly to the preparation of pancakes, a hot breakfast cake. In the preparation of buckwheat flour the outer covering is removed and the remain- ing portion rolled and bolted as in the preparation of wheat flour. A rather coarse bolting cloth is used which permits a certain amount of the middlings (see flour) to pass through. A white grade of flour, bolted over a finer cloth, is poorer in protein and fat. Buckwheat is rich in “gluten,” the water- insoluble, elastic protein mixture which is the basis of a batter capable of considerable expansion, thus giving a light cake when baked. Corn.—Indian corn or maize differs in composition from the other grains with the exception of the oat, in that it has a high percentage of oil. Corn products are not readily leav- ened because of their low gluten content; wheat flour is often added to rectify this defect. Corn and corn products show the same digestibility as other grains. There are a number of varieties of corn. From a dietetic stand-point distinctions are made among them chiefly on the basis of their use for food: The variety used for cornmeal flour or hominy is field corn; for “popping,” popcorn; for use in the green state, green or sweet corn. Field corn is harvested in the semidry state; it is marketed for human food as corn- meal, corn flour, hominy and corn starch. Cornmeal or corn flour is prepared from the whole grain. “Old process” cornmeal is made by grinding the entire kernel and then separating the larger particles of bran with a sieve; this method gives a flour containing the germ and a certain amount of bran in addition to the starchy portion of the kernel. This product is rich in oil and protein. It is diffi- cult to keep such meal, for the oil tends to become rancid. By more careful milling and bolting both the germ and bran are removed, yielding a product which is low in protein, ash and particularly oil. This flour may be kept for a longer time than the “old process” cornmeal without becoming rancid. But the advantage is gained at the expense of nutritive value and accessory substances, GRAINS AND THEIR PRODUCTS 229 Yellow and white cornmeal are prepared from yellow and white varieties of corn respectively. Any preference shown for one or the other of these meals is a matter of taste, for there is essentially no difference between them. Yellow corn meal appears to contain more vitamin A than white corn. Corn starch is also prepared from maize. In its prepara- tion the corn is steeped in warm water; the swollen grain is passed through coarse mills to disintegrate the kernel with- out breaking the germ; the germ is removed by a process of differential sedimentation in which the oily germ floats off at the top while the starch granules and other particles settle to the bottom of the separator; the sedimented starch gran- ules and associated hulls are reground and passed over a fine sieve to remove the hulls, and the starch finally purified by fractional sedimentation. Purified starch is sold as such or, after being hydrolyzed with acids and steam under pressure, as glucose (page 221). Green or sweet corn is characterized by its high sugar con- tent. It is eaten in the green state, hence its place in the diet is with succulent vegetables. Large quantities of sweet corn are canned, thus making it available throughout the year. Oats.—Oats, like corn, have a high fat content. The products prepared from oats usually contain the whole ker- nel and are therefore highly nutritious. The use of oatmeal by the Scotch has won for it a reputation as a stimulating and muscle-building food which is perhaps overestimated in comparison with other grain products of a similar character. Oat preparations do not leaven readily, since little gluten is present. Oatmeal is used largely in the preparation of por- ridges and to a smaller extent in bread and cakes. Because of the presence of the germ in oat products the percentage of purine bases is higher than in products prepared from the other cereals in which the germ is removed; for this reason they are excluded from a purine-free diet. Studies of the digestibility and availability of oats show them to be fully as well utilized as bread. Rice. —Rice is particularly rich in carbohydrate. It is used among certain people as the principal constituent of the diet, which is therefore deficient in protein and fat. The lack of protein accompanying a rice diet has been assigned by certain investigators as the cause of the inferior physical and mental development of these races. Rice is supplied in three forms: Unhulled; “cured,” free from the husk but still retaining the bran; and polished. The polished rice is sometimes coated with talc, paraffin or glucose to improve its appearance. In the processes of pol- 230 CARBOHYDRATE-RICH FOODS ishing the outer layers of bran are removed and in so doing a large portion of the mineral matter, particularly phosphorus, is lost. In polishing rice some important dietary constituents (accessory substances) are also removed. People who use polished rice as the major constituent of the diet tend to develop beri beri, a disease which affects the nervous system. The ingestion of unpolished rice or the addition of foods con- taining the accessory food substances will cure beri beri. Rice is as readily and thoroughly digested as other grains. The small amount of cellulose it contains makes it a desirable food when the fecal residue is to be kept as low as possible. This applies particularly to polished rice. Because of the low protein and fat content it is advisable to eat protein- rich foods, such as eggs, cheese and milk, with it. Vege- tables should be used with rice, particularly with polished rice, because of its low content of ash and accessory food substances. Rye.—Rye is used extensively in the preparation of bread. In composition it closely approaches wheat. Its proteins are in slightly different proportions; it has considerable pro- tein corresponding to the gliadin of wheat, but the other constituent of gluten, glutenin, is lacking. Bread made from rye flour is darker, the texture is more dense, and it contains rather more nourishment than wheat bread. The digesti- bility of rye bread is approximately equal to that of white bread. Bread made from flour from which the bran is not removed is not as thoroughly digested as the bolted flour. Wheat.—Wheat is used more extensively in the human dietary than any other grain. Chemical analysis does not indicate any particular superiority of wheat over other grains, nor is it found to be more digestible. It is the appearance of the prepared product and the ease with which it may be leavened that make wheat prized above the other grains. The fact that wheat flour is comparatively rich in the water- insoluble proteins present in the gluten, the alcohol-soluble gliadin and the alkali-soluble glutenin, makes it the preeminent bread-making grain. For the elastic adherent mixture, gluten, stretches and holds the expanding bubbles of gas produced by the leavening agents. It is the coagulation around these bubbles which gives to bread the porous structure in the baked product. With wheat or its products as the basis, the addition of various substances enables the housewife to prepare an endless variety of dishes, and thus use this valuable food without creating a distaste for it because of the monotony of the diet. The following proteins have been found by Osborne to be present in wheat: GRAINS AND THEIR PRODUCTS 231 Spring wheat, Winter wheat, per cent. per cent. Glutenin .... 4.68 4-17 Gliadin ....:. 3.96 3-90 Globulin .... 0.62 O.63 Albumin .... 0.39 O.36 Proteose .... 0.21 0-43 In spite of its general adaptability to variety in prepara- tion wheat is consumed largely in one form, bread. Rye is the only other grain which approaches wheat in its bread- making properties. Rye bread is, however, a less attractive product, for it is darker and slightly more sticky than wheat bread. Wheat is seldom eaten without a certain amount of mechani- cal preparation and modification. The bulk of the wheat used is consumed in the form of products made from flour. The crushed or whole kernel is often used as a breakfast food after it has been swollen and the starch partially cooked by boiling. A recent preparation has been put on the market in which the whole wheat kernel is subjected to pressure, heated, then allowed suddenly to expand, producing a change in the structure similar to that obtained in popped popcorn. Flour is prepared by a process of grinding and sieving by which the kernel is pulverized and the outer coverings or bran and the germ are separated from the inner portion, which is rich in starch and gluten. Formerly the wheat was ground in one process and the resulting products sifted and graded according to their fineness of division. This gave three general grades: White flour (finest), middlings (which contain some fine particles of the coarse outer material) and bran. Middlings obtained from the roller process differ from the above in that they contain very little bran. The present method is to crush the grain between a series of rollers which reduce the size of the particles gradually until the desired texture is obtained. Between the different sets of rollers are sieves to separate the finely divided flour from the coarser bran and germ. Early in the rolling process a white flour poor in gluten, called “break” flour, is separated; as the grinding becomes finer more and more of the gluten-rich flour with a yellowish color, or the middlings, is obtained. A mixture of these two general classes of flour, “breaks” and middlings, give a flour containing the proper amount of gluten for bread making. The highest grades of flour are known as “patent,” “standard patent flour,” “straight grade flour,” “first clear.” The lower grades of flour are designated “second clear,” “baker’s flour” and the lowest grade is called “red dog.” The highest grades of flour are light in color and contain more gluten and show a better granulation than the lower grades. In the latter the protein content is higher, 232 CARBOHYDRATE-RICH FOODS but the gluten is less elastic and not as satisfactory for bread- making purposes. The best test of a good flour is its baking properties. A good grade of flour separates readily after being squeezed in the hand. Analysis of Wheat and the Products of Roller Milling (United States Department of Agriculture). Milling products. Water, per cent. Protein (N. x 5.7), per cent. Fat, per cent. Carbo- hydrate, per cent. Ash, per cent. First patent flour . 10.55 II.08 I-I5 76.85 0-37 Second patent flour IO.49 IX . 14 I .20 76.75 O.42 First clear grade flour . IO.I3 13-74 2.20 73 -13 0.80 Straight or standard patent flour 10-54 11.99 I ,6l 75-36 0.50 Second clear grade flour . 10.08 15-03 3-77 69-37 i-75 ” Red dog ” flour 9.17 18.98 7.00 6i.37 3-48 Shorts 8-73 14.87 6-37 65-47 4-56 Bran 9-99 14.02 4-39 65-54 6.06 Entire wheat flour . 10.81 12.26 2.24 73-67 1.02 Graham flour .... 8.61 12.65 2.44 74-58 1.72 Wheat ground in laboratory 8.50 12.65 2.36 74.69 1.80 Germ 8-73 27.24 11.23 48.09 4.71 There are a number of varieties of wheat: Spring, winter, soft and hard. By the use of these and by different methods of manipulation a number of grades of flour are produced which vary chiefly in their gluten content. In baking these dif- ferences assume more or less importance. From a nutritive point of view, however, it is the relative proportion of the inner portion of the kernel, bran, and the germ which is of importance. Certain grades of flour have distinctive names under which they are sold in commerce. Graham flour is composed of the carefully ground, unbolted entire wheat kernel. As such it contains all the constituents of the wheat, the bran, the germ and contents of the endosperm (starch and gluten). This flour derived its name from Sylvester Graham, who advocated the ingestion of the whole wheat for both economical and dietetic reasons. The greater cellulose content of the bran renders bread from such flour less digestible. The added intestinal irritation due to the bulk of the particles of indi- gestible bran, and certain substances present in the bran and germ have a mild laxative effect. Entire wheat flour is made of wheat from which the greater part of the outer covering, or bran, has been removed. It contains the germ with its added fat and protein content in addition to the usual constituents of flour. The increased nutritive value — protein, fat and ash —of the flour is of economic importance. Gluten flours are prepared by removing the greater part of the starch from ordinary flour and are supplied in various GRAINS AND THEIR PRODUCTS 233 grades according to the quantity of gluten present. They are of particular value as food for diabetics. Gluten flours are discussed further in connection with diabetes. Bread.—The term bread is usually applied to the baked, leavened preparation of wheat flour. It may, however, include similar preparations of all forms of finely divided grains, such as rye bread or corn bread. When the added ingredients used with flour assume importance with regard to flavor and texture the mixture is no longer distinguished as bread. Thus sugar, butter, eggs, milk and spices are used with flour in the preparation of cakes, puddings and pastries. Bread in the sense ordinarily used is a combination of white flour, water, salt and yeast, which has been leavened as the result of the growth of the yeast. In this process carbon dioxide is formed and the mixture “rises,” assuming a sponge-like structure. This “sponge” is kneaded with the addition of flour, divided into appropriate masses, permitted to rise again and, at the proper time, baked. In the process of baking heat causes a further expansion of the carbon dioxide and air and by coagulating the proteins retains the sponge-like structure. Various changes take place in the chemical composition of the flour during the leavening pro- cess. A certain amount of sugar is converted into carbon dioxide and alcohol; during baking there is a loss of water and fat, the protein is coagulated, the starch grains are broken and at the outer surface particularly starch is converted by dry heat into soluble starch and dextrin. The partial carameli- zation of the starch and dextrin produces the delicate brown color of a well-baked loaf. Leavening may be accomplished in a number of ways — with yeast (enzymatic), which is supplied in both moist (com- pressed yeast) and dried condition; by mechanical incor- poration of air; or by the evolution of gas as the result of chemical action (baking powder). When yeast is used the carbon dioxide is produced at the expense of the constituents of the flour, the starch is partially converted into simpler products, in addition to alcohol and certain amounts of organic acids, such as lactic or acetic, which in quantity are said to injure the flavor of bread. The simplest form of aeration with mechanical incorpora- tion of gas is that produced by “beating up” a mixture of flour and water. The entrapped bubbles of air swell and produce, when baked, porous though rather dense biscuit or bread. Unleavened bread is used in certain religious festi- vals. In the commercial preparation of bread, water satu- rated under pressure with gas, is sometimes mixed with flour. When the pressure is released the dough swells; it is then baked. This is called aerated bread. 234 CARBOHYDRATE-RICH FOODS Baking Powders.—Baking powders will leaven dough more quickly than will yeast, in a few minutes, instead of from six to ten hours. All baking powders depend in principle upon the interaction between a carbonate and an acid. Sodium bicarbonate (saleratus or baking soda) is the most common source of carbon dioxide. The old method of making certain breads with sour milk and soda often resulted in a semi- failure because of the varying degrees of acidity of the milk. The baking powders now supplied have the acid and alkali so balanced that there is complete neutralization. Prepara- tions vary chiefly in the nature of the acid constituent or its equivalent; thus we have the “tartrate” (tartar), acid, potassium tartrate or tartaric acid powders, the phosphate (calcium acid phosphate) powders and the alum powders (a sulphate of aluminum). These salts when mixed with bicarbonate are relatively inert in the dry state, but in the presence of water react readily to yield carbon dioxide. There are certain objections to the use of baking powders in that the salts resulting from their reactions may be dele- terious to the health through their action on the system in general or due to their laxative effect. While it is certain that excessive doses of these salts are harmful it is difficult to determine whether or not small amounts, such as are ingested in breads, are detrimental. Rolls, Biscuits, Muffins, etc.— Rolls are similar to bread except that they usually contain more added fat in the form of lard or butter and sometimes more sugar. They differ little in composition from bread. In baking they are ordi- narily made into small loaves or “rolls,” and have more crust in proportion to their size than bread. Such breads are often used while hot or warm. The ordinary baking-powder biscuit differs from the roll in that it is leavened with baking powder and contains more shortening, as lard or butter. The effect of the shortening is to render the gluten less tenacious. Biscuits are, therefore, readily broken into pieces when hot. Muffins are similar to biscuits; they usually contain egg in addition to other ingredients. Rolls, biscuits and muffins are often referred to as indiges- tible. This indigestibility is ascribed in part to the added fat and in part to the fact that since they are served hot they are eaten rapidly and without sufficient mastication, thus yielding a sodden mass which does not pass readily from the stomach. Experiments have shown the relative availability of the protein, fat and carbohydrate of these foods to be fully as complete as those of bread. GRAINS AND THEIR PRODUCTS 235 Biscuits, Crackers.—The term biscuit is used commonly to designate the hard, dry breads baked in thin layers and prepared with the addition of little or no baking powder. Biscuits are sold in various forms, depending upon the ingre- dients used in their manufacture. They are held to be very digestible, no doubt because of their dryness and to the com- plete salivation and mastication necessary in eating them. Cakes.—Cakes are sweetened breads in which eggs, milk, flavoring and spices and considerable shortening, such as butter and lard, are used. They are very “rich” foods, in that they contain more fat and protein than the breads. Breakfast Foods.—Certain specially prepared grains are sold as breakfast foods. These are usually patented prepara- tions. Among them will be found representatives of all the more important grains. The changes produced are chiefly of a mechanical nature associated with a certain amount of chemical change resembling the natural processes of diges- tion. The changes are in general of a fermentative nature, such as those produced by the action of malt or yeast and the action of heat upon either the moist or dry grain. Condi- ments, such as sugar and salts, are sometimes added. Those foods which are cooked are sold for direct consumption; the others must be subjected to prolonged cooking before they are ready for the table. Macaroni.—Macaroni is a preparation of a highly gluten- ous wheat flour and water. It is molded into various forms and sold under different trade names as spaghetti, macaroni and noodles. A special type of wheat, durum wheat, is used. The relative composition of macaroni will be found in the accompanying table. The composition of some wheat preparations is given in the following table: Composition of Typical Wheat Products. S O Lt ft arbohydr per cent. Jh ft £ rO 0 V 0, -a uel value pound. rams per Calories. £ Ph E O E < 0 Breakfast food: Cracked wheat IO. I II 1 1-7 75-5 1-7 1.6 1635 28 Shredded wheat 8.1 IO 5 i-4 77-9 i-7 2.1 1660 27 Macaroni . 10.3 13 4 0.9 74-i 1-3 1625 28 Rolls, Vienna Bread: 37-i 8 5 2.2 56.5 0.4 1.1 I270 36 White . . . 35-3 9 2 1-3 53-1 0.5 1.1 Il82 38 Whole wheat . 38.4 9 7 0.9 49-7 1.2 i-3 III3 41 Crackers, soda 5-9 9 8 9.1 73-1 0.3 2.1 1875 24 Cake, cup 15.6 5 9 9.0 68.5 0-3 1.0 1716 26 236 CARBOHYDRATE-RICH FOODS The digestibility and nutritive value of bread, particularly the comparative digestibility of white bread and the whole wheat or Graham bread, assumes considerable economic importance with regard to the diet of the poor, and there has been a great deal of controversy over the question. Compara- tive studies of the two forms of bread have demonstrated a lower digestibility of the protein and carbohydrates of entire wheat and Graham flours. Celluloses.—Celluloses form a large portion of the cell wall of plants. They are polysaccharides having a more com- plex structure than the starches. Celluloses differ according to whether they are composed of glucose or some other sugar, as pentose or galactose. These carbohydrates are very insol- uble in water and more difficult to hydrolyze than starch, and are practically indigestible for man. It is the indigesti- bility of the celluloses which makes vegetables and fruits a valuable means of adding bulk to the intestinal mass with the resultant stimulation of peristalsis. Cellulose is also largely responsible for the low utilization of vegetable foods. Hemicelluloses differ from true celluloses in that they are hydrolyzed by dilute acids. Of this class the sea-weed, agar agar and Iceland moss are of dietetic and therapeutic impor- tance. Because of their comparative indigestibility and their ability to absorb and hold water they yield a soft fecal mass which may be easily evacuated. Potatoes.—The true “Irish” potato, as well as the sweet potato, is used to a large extent as one of the important sources of carbohydrate. We will therefore discuss these foods here, although they possess properties which might place them with the succulent vegetables, more valuable for their salts and water. Bananas are, from a nutritive point of view, com- parable with potatoes; they are, however, ordinarily classed with fruits. Potatoes: Irish Sweet . Bananas . Cn vO 00 W OW Water, per cent. H H 10 Ck) CO to Protein (N. x 6.25), per cent. o o o M Fat, per cent. tO tO H to NJ 00 04^4^ Carbohydrate, per cent. w w O O CO Fiber, per cent. O M M 00 w o Ash, per cent. ■£* C/i C*> -t- Cn --J M CO 00 Fuel value per pound, Calories. 120 8l 101 Grams per 100 Calories. Composition. The chemical composition of potatoes varies somewhat according to the different varieties and to the portion of the country in which they are grown. The average potato con- GRAINS AND THEIR PRODUCTS 237 tains 18 to 20 per cent carbohydrate (largely starch); 2 to 2.5 per cent protein; practically no fat—0.1 per cent; and 75 to 80 per cent water. The greater proportion of the car- bohydrate present in potatoes is starch; but there is also a small proportion—0.3 to 0.2 per cent—of sugars and glu- cose. The sugar content of young or early and old, sprouted potatoes is greater than that of the mature potato. The tuber receives carbohydrate as glucose and converts it to starch; later as the potato sprouts the starch is reconverted into glucose for the use of the growing shoots. The protein of potatoes is usually expressed as the nitrogen value times 6.25. We know that in the case of the potato this does not entirely represent protein, for there is a considerable quan- tity of non-protein, nitrogenous-containing material, partic- ularly asparagin. The ash of potato contains considerable quantities of calcium, phosphorus and iron. The total ash is predominantly basic. Potatoes are fairly good sources of vitamins B and C and a poor source of vitamin A. The proteins of the potato are of about the same quality as those of the cereals. They are of a high biological value for maintenance, but apparently not so good for growth. The use of potato water as an antiscor- butic has been suggested for infants in place of the more expensive orange juice. The sweet-potato plant does not belong to the same botanical family as the Irish potato. This tuber resembles the latter, however, in its general chemical composition and is usually associated with it dietetically. The sweet potato is roughly similar in composition to the Irish or white potato; it contains a little less water—averaging 70 per cent—and a slightly higher percentage of starch, sugar and protein, averaging 24 per cent, 5 to 8 per cent, and 1 per cent respectively. The effect of the storage of sweet potatoes is to increase the sugar content. The material designated as “sugars” is chiefly sucrose with a small amount of invert sugar (glucose and fructose). Potatoes are an important source of mineral matter, hence the salts should be conserved as much as possible. In the process of paring as much as 20 per cent of the potato is lost; furthermore, a large proportion of the protein and mineral matter is in the layers beneath the skin. The skin tends to prevent the loss of protein and salts. Peeled potatoes when soaked in water and then boiled in water lose a considerable proportion of their salt content, approximately ten times as much as when they are cooked without removing the skins. When they are baked or steamed the loss is comparatively 238 CARBOHYDRATE-RICH FOODS small. If the cooking is begun in hot water the loss of material is less than when the cooking is commenced in cold water. Potatoes when properly cooked are quite digestible; approxi- mately 92 per cent of the carbohydrate and 70 per cent of the protein is absorbed. They have been found to leave the stomach quite rapidly—more so than bread. Potatoes pre- pared in various ways1 leave the stomach in from 1.5 to 2.5 hours for a fast stomach and 2 to 3.5 hours for a slow stomach. The addition of butter to baked potatoes slowed the rate of discharge—but this does not hold for mashed potatoes. Creamed potatoes and potato salad have about the same effect as plain boiled potatoes. Fried potatoes leave the stomach about as rapidly as potatoes prepared in other ways. Sweet potatoes require longer to leave the stomach than white potatoes. The low fat content of potatoes indicates the addition of fatty substances after they are cooked when they are used as the principal source of food. Because of the low cost of potatoes they have been advo- cated as the chief article of diet in some countries. There is a certain amount of objection to this because of the quan- tity which must be eaten to supply the necessary energy and protein—approximately 6.5 pounds or 3 kilos. Such quantities would contain a smaller proportion of protein than is deemed necessary by some. The energy value is, moreover, roughly a third that of white bread. Hindhede, of Sweden, who has advocated the adoption of a potato diet, has shown that the body may be maintained in perfect health over long periods of time on a diet of potatoes, milk, oleomargarine, green vege- tables and fruit, provided the total diet has an energy value in proportion to 3000 Calories for a man of 70 kilos (154 pounds). 1 Am. Jour. Physiol., 1920, 51, 332. CHAPTER XIV. FAT-RICH FOODS. Nutritive Value. —Fats are important in the diet in that they supply energy in a concentrated form and certain of them carry the fat-soluble vitamin. In general, organ fat as dis- tinct from body fat is rich in fat-soluble A; thus butter fat, kidney fat and cod-liver oil are valuable sources of this food factor. Beef fat is relatively poor in vitamin A, while in lard and the vegetable fats it is practically absent; the concen- tration is somewhat variable. Considerations of the relative value of butter, and the hydrogenated vegetable fats and the margarines must take these facts into consideration. General Properties.—Animal or plant fat is a mixture of true fats and lipins. The true fats are glycerol esters of fatty acids; they are named according to the acid from which they are derived by substituting “in” for “ic” of the name given the fatty acid, thus: Butyrin, olein, stearin or tributyrin, triolein, tristearin for fats formed from butyric, oleic and stearic acids. Fats are widely distributed in the plant and animal kingdom and are one of the most valuable sources of energy to the body. Associated with fat are the lipins, or fat-like substances related by composition and solubility. In their chemical constitution lipins may differ entirely from fats, as cholesterol, or may be compounds of fat with other radi- cals, as in the case of lecithin. The lipins are constituents of all cells and particularly of the highly organized nervous tissue. Our knowledge of their occurrence and functions is, however, very limited. The fats most commonly found in food are those derived from the saturated fatty acids, butyric acid, caproic acid, caprylic acid, capric acid, lauric acid, myristic acid, palmitic acid and stearic acid, and from the unsaturated fatty acids, oleic, linoleic and linolenic acids. Of the saturated fatty acids the first members, butyric and caprylic acids, are liquid at ordinary temperatures, while the others are solid; the melting-point increases with the complexity of the mole- cule. The unsaturated fatty acids and the glycerol esters, fats, are liquid at ordinary temperatures. Food fats are mixtures of these individual fats. Those of animal origin are composed largely of olein, palmitin and stearin. The solidity of any particular fat depends upon the relative proportion of the component fats. The more solid 239 240 FAT-RICH FOODS fats contain a greater amount of palmitin and stearin, while the softer fats contain more olein. The fat of various animals is more or less characteristic for each species. Warm-blooded animals have harder fat than cold-blooded animals, such as fishes; and of the land animals, herbivora have, as a rule, harder fats than car- nivora. The composition of subcutaneous fat appears to be determined in part by the external temperature of the air surrounding the body. The facial fat of individuals exposed to the weather is richer in olein and has a lower melting- point than of those less exposed. The fat of those portions of animals which have a poor blood supply, such as the back, is richer in olein and has a lower melting-point than fat in other parts thoroughly warmed by the blood. The fat of beef animals has been found to become richer in olein with age, fatness and nearness to the surface of the body. Butter contains a variety of fatty acids —all of those men- tioned above in the saturated fatty acid series and oleic and butyric acids. The latter acid, while not the most important from a quantitative point of view, is most characteristic. The vegetable oils contain more of the unsaturated fat com- pounds than animal fats. Certain fats —milk fat and the fat of egg yolk in particu- lar—occur in a finely divided state or emulsion. Such fats are readily digestible because of the size of the fat particles and great surface exposed to the action of the digestive enzymes. Emulsification may be produced artificially by thorough agitation of fat with water or by- the addition of protein material, certain carbohydrates, gum tragacanth or of soaps. Alkalis when added to fats form soaps which in turn aid in emulsification. Mayonnaise dressing, in which com- paratively large quantities of oil are changed from the liquid state to a semisolid form, is a case of emulsification in the presence of protein material. Digestion and Absorption.— Fats are as easily digested and absorbed as proteins and carbohydrates. In the process of digestion and absorption they are emulsified and broken down into fatty acids and glycerol, absorbed into the intestinal wall and in part at least resynthetized into fat. The pres- ence of fat tends to delay the passage of food from the stomach; the “indigestibility” of fatty foods in the sense of the “ease” of digestion is to be ascribed in part to this fact. The presence of fats in food, particularly of those having high melting- points which are not liquefied in the stomach at body tem- perature, tends to retard peptic and salivary digestion. Fats form a protective coating over the particles of protein and starch and prevent their partial digestion, thus increasing the DIGESTION AND ABSORPTION 241 extent of digestion necessary in the intestine. The effect of cooking foods in fat is to form a similar layer of fat over the surface of the food particles. This applies particularly to the ordinary process of frying, in which heavy fats are often used; cooking in deep fat results in the formation of an impervious layer on the outside of the food which prevents the further entrance of fat. The partial oxidation of fats which takes place in cooking, particularly in frying, leads to the formation of substances which may be irritating to the alimentary tract. The retarding action which fats exert upon the passage of food from the stomach has been found to be beneficial in the case of the relatively indigestible vegetables, for by subject- ing them to a more prolonged contact with the digestive juices their digestion is more complete. Vegetables to which a soft fat, such as butter, has been added, after cooking, have been found to be more thoroughly digested than those cooked in fat. Studies of the utilization of fat have shown that ordinary fats are readily absorbed, approximately 97 per cent of the ingested fat. Feces obtained from a fat-poor diet may contain more fat than is found in the food ingested. On a milk diet under normal conditions the fecal fat melts at 500 to 51 0 C., while the fatty acids of butter melt at 43 0 C.; in diarrhea the fecal fat has the same melting-point as milk fat. These facts indi- cate that considerable fat is excreted or secreted into the intestines from the body in the process of digestion. The melting-point of fat affects its digestibility. Those fats whose melting-points are close to the temperature of the body are liquefied in the alimentary canal, readily emulsified and digested in the intestines, and show practically complete absorption. The more solid fats are, on the other hand, emulsified with greater difficulty and their digestion is less complete. Certain fat-like substances, such as paraffin oil and lanolin, are not absorbed at all; it is for this reason that paraffin oils are used to relieve constipation. These facts have been brought out in the following table (Munk and Arnshink): Melting- Percentage point, loss in Fat. •c. feces. Stearin 60 91-86 Stearin and almond oil . • • • 55 10.6 Spermaceti • • • 53 31.0 Mutton fat • • • 50-51 9.2 Mutton, fatty acids .... ... 56 13-20 Lard • • • 43 2.6 Pork fat • • • 34 2.8 Goose fat ... 25 2-5 Olive oil 16 2-3 242 FAT-RICH FOODS Langeworthy and Holmes1 compared the relative diges- tibility of butter, lard, beef and mutton fat when fed with a uniform mixed diet of blanc mange, wheat biscuit, fruit and sugar. In general the digestibility decreased with an increase in the melting-point of the fat. The following table contains data demonstrating this: Comparison of Digestibility and Melting-point Coefficient of Melting- digestibility, point, Fat studied. per cent. °C. Butter fat 97 32 Lard 97 35 Beef fat 93 45 Mutton fat . . . . 88 50 In the processes of metabolism both fat and carbohydrate are used chiefly in the production of energy. Their role in the structure of the body, while little understood, is highly important; this is particularly true of the lipins, lecithin and cholesterol, which are constituents of the outer surface of all cells. As a source of energy, fats and carbohydrates may, in general, be used interchangeably. It seems necessary, how- ever, that a certain amount of carbohydrate be present in the food for the normal continuance of the metabolic processes. The entire absence of carbohydrate tends to produce certain disturbances, among which acidosis is the most prominent indication. The minimum quantity of carbohydrate needed is not known; that it may be comparatively low is illustrated in the case of the Eskimo whose diet is essentially fat and protein and in which practically the only source of carbohy- drate is the glycogen contained in meat. Although carbohydrate appears to be indispensable in the diet, the presence of fat (lipins) is also essential. Studies of growing animals have shown that certain animal fats, e. g., kidney fat, egg yolk fat and butter fat are more satisfactory than others or than plant fats for the continuance of growth. The advantage apparently does not reside in the purified fat itself, such as tristearin or triolein, for these are without effect, but in part at least in the vitamins. The functions of fat aside from supplying energy in metabolism are still relatively unknown. The necessary amount of natural fat required per day is not known —the minimum has been estimated at from 25 to 75 grams of fat per day. Fat is a much more concentrated food than carbohydrate or protein in the sense that it yields, because of its lower state of oxidation, a greater amount of energy for a given weight: 1 U. S. Dept. Agr., 1915, Bull. No. 310. CREAM 243 Calories Calories per gram. per pound. Fat 9-o 4082 Carbohydrate .... 4-0 1814 It is, therefore, the most economical means available to the body for storing energy against future need. But not all the fat of the body comes from fat; it may be formed from carbohydrate (glucose). Protein yields complexes which may be built up into fat. Fat is present in the human diet in two forms: (a) That associated with the food as it occurs naturally, and (b) that which has been extracted from the medium in which it was deposited —flesh, milk, fruits—and which is ingested as such or added to food in the process of preparation. Prepared fats are similar to the unextracted fats, for the processes of manufacture are essentially physical ones; the fatty sub- stance is separated from its surrounding medium by means of pressing, churning or heat or a combination of these; very little chemical change takes place except perhaps in some forms of rendering or heating in which there is a partial hydrolysis and slight oxidation of the original fats. We shall therefore confine our discussion largely to the manufac- tured fats and oils, indicating occasionally the relative fat content of certain particularly fatty natural foods when dis- cussing the particular prepared fat which it would yield. Two types of fat-rich foods are obtained from milk: cream, in which the finely emulsified fat is concentrated by gravity or centrifugal force, and which contains a small proportion of all the constituents of milk, and butter, in which the fat droplets are made to coalesce. Butter contains very little of the milk constituents other than the fat. CREAM. Cream is obtained from milk in two ways, both depending upon the difference in specific gravity between the fat and the other constituents. Formerly milk was placed in a cool place for six or eight hours and the fat or cream permitted to rise to the top; it was then removed or “skimmed off.” The separation of the cream from the milk is hastened by the use of a centrifuge or separator which throws the heavier portions of the milk, water, protein, insoluble salts and cells to the periphery from which it is removed while the lighter fat is drawn off from the center. With the separator vary- ing concentrations of butter fat can be obtained in the cream. 244 FAT-RICH FOODS BUTTER. Butter is obtained from cream by the process of churning, i. e., by mechanical agitation the natural emulsion of milk is destroyed and the fat droplets made to coalesce. This pro- cess is facilitated by the slight changes produced in the cream as the result of fermentation or souring. The crude butter collected in the process of churning is separated from the rest of the cream—the buttermilk—washed and worked into the final product which we know as butter. The process of working removes most of the particles of curd remaining and the soluble constituents of milk. This gives pure, uncolored sweet butter. Salt is usually added to sweet butter to give it a flavor; it also acts as a preservative. The quantity of salt added varies according to the market for which it is intended—from o to 4 per cent. In salting a very good grade of sodium chloride is used. Salted butter is then worked to distribute the salt, to remove the excess of water, to press the particles of fat together into a compact mass, and to give it the texture characteristic of the butter of commerce. The color of butter will vary according to the nature of the diet of the cow, for the coloring matter of the body fat and milk has been shown to be derived from the coloring matter of plants. Butter made from the milk of cows receiving certain green foods is particularly rich in the yellow color commonly associated with butter; thus butter made in the spring usually has a deeper yellow color than that made in the winter. To ensure a butter of uniform color throughout the year dairy- men resort to the use of coloring matter. The presence of bacteria in butter is a matter of fully as great importance as their presence in milk. The processes of butter-making tend to increase the number of bacteria: centrif- ugalization so generally employed for the separation of cream from milk tends to leave the bacteria in the cream and the conglomeration of the particles of fat in the process of churning results in a concentration of bacteria in the butter. The result is that butter often contains many more bacteria than the cream from which it is prepared. The souring of cream before its use in buttermaking results in an accumu- lation of lactic-acid-producing bacteria with an accompanying decrease in the rate of growth of certain other types. The Bacillus tuberculosis has been found in butter prepared from milk containing this organism; cold storage does not result in the death of the bacillus. The following table gives the composition of American creamery butter: BUTTER 245 Per cent Pat 82.41 Water 13.90 Lard 2.51 Curd 1.18 Variation from these figures will occur, depending upon the process of manufacture. Dividing the samples of butter into classes according to the fat content, the following gen- eral variations were observed in the case of the data given above: Butter fat, 5.0 per cent; water, 2.9 per cent; salt, 1.74 per cent; curd, 0.39 per cent. Butter fat is a mixture of the glycerides of various fatty acids with small amounts of lipoids—lecithin and choles- terol—and coloring matter. The relative proportions of these individual fats, or, as they are usually expressed in analysis, “fatty acids,” varies with the food, particularly with the fat content of the food, the individuality of the cow and stage of lactation. The taste and odor of butter are influenced by the food given the cow; garlic, for instance, gives to milk and butter a decided odor characteristic of the plant. The following table gives the distribution of the more important fatty acids found in a particular sample of butter:1 Percentage of Acid. triglycerides. Dioxystearic x. 04 Oleic 33.94 Stearic 1.91 Palmitic 40.51 Myristic 10.44 Laurie 2.73 Capric -> 0.34 Caprylic 0.53 Caproic 2.32 Butyric 6.23 Butter fat is practically completely absorbed. The aver- age caloric value of butter, based upon an 85 per cent fat content, is approximately 3500 Calories per pound or 7.7 Calories per gram. Renovated Butter and Butter Substitutes.—When butter which has become rancid is treated to restore its sweetness the product is designated as “processed or renovated” butter. The rancid butter is melted, the curd and brine drawn off, the fat separated and aerated and then rechurned with milk or cream to restore the texture and flavor. Such butter is in many respects as satisfactory as the average grade of butter; it is not equal in quality to the better grades of butter. 1 Browne: Jour Am. Chem. Soc., 1899, 21, 807. 246 FAT-RICH FOODS Oleomargarine.—A fat product prepared from various animal and vegetable fats and oils which resembles butter in its consistency is sold under various names, of which oleo- margarine or margarine are the most common. Its manufact- ure is restricted by the government; a tax is levied against it, a fourth cent per pound for the uncolored product and ten cents per pound for oleomargarine artificially colored to resemble butter. Yet oleomargarine is a satisfactory substitute for butter; it is often more desirable than some good grades of butter. One objection to oleomargarine is that it is many times sold as butter with the intent to deceive. Containing as it does a higher percentage of stearin, we might expect to find oleomargarine less readily absorbed than butter; experience has shown, however, that the losses in digestion are nearly the same for the two products. Butter is, however, in many ways a finer product and more palatable. It is much richer in the accessory substances or vitamins than oleomargarine, and is from this point of view a much more desirable food. The materials used in the manufacture of oleomargarine are chiefly neutral lard, “oleo oil,” and cotton seed oil. Neutral lard is prepared from the fresh “leaf lard” of the hog. Phis is ground up, worked with water and rendered at a temperature of 40° to 50 0 C. Only a portion of the lard is removed from the fat. The product obtained is almost neutral in reaction and practically free from taste or odor. Oleo oil is prepared by a somewhat similar process. Fat from the abdominal cavity of beef, or caul fat, is thoroughly worked in water, chilled, the hardened fat ground up and finally rendered at a low temperature. The liquid fat obtained by this process is permitted to cool, when stearin and pal- mitin partially crystallize out. The fluid portion is pressed out of the semisolid mass, run into cold water and allowed to solidify. This product is designated as “oleo” or “oleo oil.” The cotton seed oil used is especially prepared for the purpose. Cocoanut fat and peanut oil are also used. The nut margarines do not have the same biological value as butter or the oleomargarines, since they lack the fat-soluble vitamins. In the final stage of preparation the fats and oils are mixed in the desired proportion; the quantities of the various con- stituents used depends upon the market for which the oleo- margarine is intended. For warm climates more of the oleo oil and lard are used than for cold climates. I he properly mixed fats are then churned with milk or cream, or with an emulsion of milk and butter, to give the flavor of butter to the product. This yields a coarse emulsion which, upon cooling, is washed, salted and worked into the final product. The VEGETABLE OILS 247 following is the composition of oleomargarine given by Koenig in per cent: Water, 9.07; fat, 87.59; nitrogenous extractives and lactose, 0.99; ash, 2.35; sodium chloride, 2.15. Lard.—Lard is the rendered fat of the hog. The fat is extracted by means of heat which liquefies and gradually frees it from the connective tissues. Lards are designated according to the portion of the animal from which they are prepared and the mode of rendering. “Neutral’’ and “leaf’’ lard are obtained from the fat surrounding the kidneys. The preparation of the former has already been indicated (page 246). “Leaf lard” is obtained by heating the leaf fat or the residue from neutral lard to a higher temperature with steam. Kettle-rendered lard is made from leaf and back fat by heating in open-jacketed kettles. Steam lard is made from the remain- ing portions of the hog not used for direct consumption by the direct application of steam. Various substitutes for lard are prepared and sold under trade names. They are ordinarily mixtures of cotton seed oil and beef fat or specially treated cotton seed oil. VEGETABLE OILS. Cotton Seed Oil.—Cotton seed oil is used extensively as a substitute for olive oil or in the preparation of substitutes for animal fats. In the preparation of cotton seed oil the cotton seeds are cleaned and ground, the meal heated under pressure to 2io° to 215 0 F. and the oil expressed with hydraulic presses while still warm and the crude oil refined. The best grades of cotton seed oil are practically free from any char- acteristic flavor and are suitable substitutes for olive oil. As with the butter substitute, oleomargarine, the real objection to its use is the economic one, that it is often sold as olive oil. However, it lacks the characteristic natural flavor of olive oil. By a process of chilling and pressing the higher melting- point fats of cotton seed oil are partially separated from the more liquid ones. The former are used as substitutes for lard while the latter becomes a satisfactory oil for cold climates. Cotton seed oil is used extensively in the preparation of lard substitutes in which the fatty acids of the liquid unsat- urated fats are transformed, reduced, into their correspond- ing saturated compounds which are solid at the ordinary temperatures. These transformations are brought about by heating with hydrogen in the presence of finely divided nickel. The nickel is added as a catalyst to hasten the reaction between hydrogen and the fatty acid. Small quantities of 248 FAT-RICH FOODS nickel remain in the final product and there is a possibility that they may be detrimental to health. This point has not as yet been determined. Such prepared products are as well utilized as lard and other fats and might well be sub- stituted for them when cheaper were it not for the nickel present. Olive Oil.—Olive oil is prepared by pressing the flesh of the ripe olive. The selection of the olive and the mode of preparation determine, in general, the grade of oil. The highest grade of oil, virgin oil, is from selected hand-picked olives. The product is obtained by slight pressure of cold olives. Subsequent pressure of the mass, first cold and then later heated with water, gives the various more or less inferior grades of oil. In some processes the olives are macerated and crushed before being subjected to pressure. The various oils obtained are subjected to a refining process in which foreign particles are removed by filtration and by gravity in settling tanks. Of the fatty acids present in fats of olive oil, palmitic and oleic are the most important; there is little, if any, stearic acid. Other fatty acids are present but only in small quantities. Practically all of these fatty acids occur as neutral fat or glycerides; the small percentage which exists as free fatty acids varies with the ripeness of the fruit and the mode of preparation; most of the high grades of oil contain less than 3 per cent. Olive oil is eaten principally in salads; it is used to some extent in cooking. Other vegetable oils are used for food, such as peanut oil, sesame oil, cocoanut oil, etc. Vegetable oils have been found to be fully as digestible as animal fats. Corn Oil.—Corn oil is a by-product of the starch and glucose industry. It is obtained from the germ of the corn seed. The oil is golden yellow in color and has a pleasant taste and odor. It is satisfactory as a salad oil. Cod-liver Oil.—Cod-liver oil is prepared by means of pressure from the raw fresh livers of codfish. It has been used extensively because it is apparently assimilated under conditions in which other fat foods are not effective. It is particularly valuable as a source of vitamin A and the anti- rachitic food factor. The concentrations of vitamin A in fish oils probably vary at different seasons of the year and are related to the flora of the sea and the opportunity the fish have to obtain this food or fish rich in vitamin A. Cod- liver oil contains a number of low melting-point saturated fats in addition to olein, which is present to the extent of approximately 70 per cent, cholesterol, a small amount of iodine and a number of basic substances are also present. VEGETABLE OILS 249 Cod-liver oil is sometimes adulterated by the admixture of other fish oils which results in an inferior product. Prep- arations are also sold which purport to have all of the thera- peutic properties of cod-liver oil without the peculiar oily taste which is repugnant to some persons. Those preparations from which the fat has been entirely or largely removed are practically useless as substitutes for cod-liver oil, since the therapeutic value rests as much in the readily assimilable oils as in any other factor. CHAPTER XV. FOODS VALUABLE FOR THEIR SALTS, VITAMINS, WATER AND BULK. FRUITS AND VEGETABLES. Nutritive Value and Composition.—In addition to those foods which furnish primarily protein, carbohydrate or fat is a group of foods which, while supplying these food-stuffs to a certain extent, are not sufficiently rich in them to be valuable sources of such material. They form, however, an important part of the diet because they are valuable sources of inorganic salts (particularly the salts of organic acids), of water and of the vitamins. They are comparatively indi- gestible. It is the indigestible residue which serves to give bulk to the intestinal contents and thus promotes peristalsis. Some of these foods contain a certain amount of soluble material which in itself stimulates peristalsis —laxatives. These water- rich, indigestible foods are then a means of adding salts, vitamins and bulk to the diet without markedly increasing the energy or protein portion of the regimen. In addition to these purely material advantages they are in most cases appetizing and are in this way valuable as aids to digestion. To this class of foods belong the succulent plant foods —the vegetables and fruits. A clear-cut classification is difficult in a few cases. To classify dried legumes as protein foods and fresh and canned varieties of the same food as valuable chiefly for their salts and their value as appetizers may appear illogical. A consideration of their usual place in the diet, however, makes this the most desirable classification. Our discussion will confine itself, therefore, unless otherwise stated, to the succulent fruits and vegetables. Fruits and vegetables are composed largely of water; cellu- lose, the chief structural material, starches, sugars, organic acids, gums, mineral matter, protein and a small amount of fat. So far as the energy value is concerned the quantities of the food-stuffs present are so small as to be practically negligible. The small amount of protein is poorly absorbed; carbohydrate, exclusive of cellulose, and fat are almost com- pletely digested, but the small quantity ingested is very seldom of practical importance. This is particularly true of the fat. 250 FRUITS AND VEGETABLES 251 The indigestibility of fruits and vegetables, as a whole, is due to the cellulose content. Cooking will increase the digestibility of this carbohydrate to a certain extent, partic- ularly in the case of raw fruit and the starchy vegetables, for it softens the cellulose structures and ruptures the starch grains. The accompanying tables give the composition of some of the more important fruits and vegetables. Chemical Composition of Typical Fruits (per cent) FRESH. fl O s* O Li A & O D 03 G <13 Fruits. u 1 ft u o _ 0 s0 *5 t- -*-> > a> A 0 & a! OJ tH 0 a< £ ft 4) 'oi' CO 3 4 0 u OJ ft . 0 0 ft 2 Li a £ > ft —. Cfi 2 S 03-G 1/2 eg •s 0 a o3 § ft 3 O t. J3 CO Pi ft< O O < ft) 0 Apples . . . 84.6 0.4 0.5 I4.2 I .2 0.3 285 159 Bananas • • 75-3 1-3 0.6 22.0 I .O 0.8 447 101 Blackberries . . 86.3 i-3 1.0 IO.9 2-5 0-5 262 173 Cherries . . 80.9 1.0 0.8 I6.7 0.2 0.6 354 128 Grapes . • ■ 77-4 i-3 1.6 19-2 4-3 0-5 437 104 Huckleberries . . 81.9 0.6 0.6 16.6 0-3 336 Lemons . • • 89.3 x .0 0.7 8-5 1.1 05 201 226 Muskmelons • • 89.5 0.6 9-3 2.1 0.6 180 252 Oranges . . . 86.9 0.8 0.2 11.6 0-5 233 195 Peaches . . . 89.4 0.7 0.1 9-4 3-6 0.4 188 242 Strawberries . . 90.4 1.0 0.6 7-4 i-4 0.6 177 256 DRIED. Apples . . 28.1 I .6 2.2 66.1 2.0 1318 34 Dates • • 15-4 2. I 2.8 78.4 i-3 1575 29 Figs .... . . 18.8 4-3 03 74.2 2.4 1437 Prunes . • • 22.3 2.1 73-3 2-3 1368 33 Raisins . . 14.6 2.6 3-3 76.1 3-4 1562 29 tO , 0 > 0 rC O 5 $ •L2 Q, fl 0) V (H 0) . 0 ® a 3 fc. g & hz'E *■7 41 CL s ©'© Ph |8 c3 O 0, 3 a* 3° Cl ~ cn c3 Zl £ CL, 0 O < ft. a Asparagus . Beans, fresh: . 94.0 1.8 0.2 3-3 0.8 0.7 IOI 45o Lima .... • 68.5 7.1 0.7 22.0 1-7 i-7 557 82 String .... 89.2 2-3 0-3 7-4 0.8 189 241 Cabbage • 91.5 1.6 0-3 5-6 1.1 1.0 143 317 Carrots .... . 88.2 1.1 0.4 9-3 1.1 1.0 205 221 Celery .... • 94-5 1.1 0. I 3-3 1.0 84 540 Lettuce .... Potatoes: • 94-7 1.2 0-3 2.9 0.7 0.9 87 524 White .... • 78.3 2.2 0.1 18.4 0.4 1.0 378 120 Sweet .... 69.0 1.8 0.7 27.4 i-3 1.1 558 81 Pumpkins 93-1 1.0 0.1 5-2 1.2 0.6 117 389 Spinach .... 923 2.1 03 3-2 0.9 2.1 109 418 Tomatoes • 94-3 0.9 0.4 3-9 0.6 0.5 104 439 Chemical Composition of Typical Vegetables (per cent). 252 FOODS VALUABLE FOR SALTS AND WATER Fresh vegetables and fruits have long been known for their antiscorbutic properties. They are also good sources of vitamin A and B. The thin leafy vegetables are a particularly good source of the fat-soluble vitamin (see also page 103). Constituents of vegetables and fruits which make them desirable as foods are the salts and in fruits the acids or acid salts, soluble sugars and the essential oils, esters and ethers which give the pleasant taste. Cellulose is important for its mechanical laxative effect. The pleasing appearance of fresh and cooked vegetables and fruits has some esthetic value. Most fruits and many vegetables are palatable even in the raw state, in which form it is the crispness of the pulp or leaf which is particularly attractive. The delicate coloring matter which these foods contain is not only attractive to the eye but serves to stimulate the appetite. When cooked with sugar, as preserves or jellies, these coloring matters and flavors are the means of increasing the appetite not only for the conserve itself but for insipid foods, chiefly carbohydrates, to which they are added. In this way they are valuable in the diet of the sick room. Vegetable foods are comparatively tasteless. To make them palatable it is necessary to add fats, usually in the form of oil or butter, and condiments, particularly acids, e. g., vinegar. The addition of salt to vegetables is also necessary. The importance of vegetables and fruits as sources of salts is indicated by the following table, which gives the percentage of individual ash constituents of typical vegetables and fruits: Composition of the Ash of Typical Fruits (per cent).1 FRESH. Fruits. CaO. MgO. KsO. NaiiO. P2O5. Cl. s. Fe. Apples . .014 .014 •15 .02 •03 .004 .005 .0003 Bananas .01 .04 •50 .02 •055 .20 .013 .0006 Blackberries .08 •035 .20 .08 .01 Cherries . •03 .027 .26 •03 .07 .01 .01 .0005 Grapes . .024 .014 •25 •03 .12 .OI .024 .0013 Huckleberries . •035 .025 .07 .02 .013 .0011 Lemons . •05 .01 .21 .01 .02 .01 .012 .0006 Muskmelons .024 .02 .283 .082 •035 .04I .014 .0003 Oranges . .06 .02 .22 ,OI •05 .01 • 013 .0003 Peaches . .01 .02 •25 .02 .047 .01 .OI .0003 Strawberries •05 •03 .18 .07 .064 .OI .0009 DRIED. Dates . 10 •13 . 12 •32 .066 .003 Figs .... .299 •145 I.48 064 •332 .056 .056 .0032 Prunes . .06 .08 1.2 I •25 .01 •03 .0029 Raisins . .08 •15 I .O 19 .29 .07 .06 .005 1 Sherman: Food Products, 1914. FRUITS AND VEGETABLES 253 Composition of the Ash of Typical Vegetables (per cent). Vegetables. CaO. MgO. K20. Na20. P206. Cl. s. Fe. Asparagus . Beans: . .04 .02 .20 .01 .09 .04 .04 .OOI Lima . . .04 .11 •7 . 12 .27 .009 .06 .0025 String . • 075 •043 .28 •03 . 12 .0x8 .04 .0016 Cabbage . .068 .026 •45 •05 .09 •03 .07 .OOII Carrots . • -077 •034 •35 -13 . IO • 036 .022 .0008 Celery- . 10 .04 •37 .11 . IO •17 •025 . 0005 Lettuce . Potatoes: • .05 .OI .42 .04 .09 .06 .014 .OOI White . . .016 •036 •53 .025 .14 •03 •03 .0013 Sweet . • 025 .02 •47 .06 .09 . 12 .02 .0005 Pumpkins • .03 .015 .08 .08 .11 .01 .02 Spinach . . .09 .08 •94 .20 •13 .02 .04I .0032 Tomatoes .02 .017 •35 .OI •059 •03 .02 .0004 Green vegetables and fruits are an important source of iron. Investigations have shown that combined iron, such as occurs in nature, is in a readily assimilable form, prob- ably in the most desirable state. The iron compounds of vegetables and fruits are quite readily utilized. Fruit Acids.—The tables indicate only the relative amounts of the various basic elements, or their oxides, present in fruits and vegetables. If we consider them with regard to the form in which these elements exist we find the basic elements combined with both inorganic and organic radicals. The organic acids exist in many cases as the acid salts, chiefly the acid potassium salts. The organic acids as they occur in fruits or vegetables exhibit in some cases a considerable degree of acidity, e. g., the case of lemons or apples. After absorption in the body the organic acid is oxidized and the base, associated with the acid, combines with carbonic acid to form the carbonate which functions as a potential base. An examination of the ash of fruits and vegetables shows it to contain an excess of base over the acid-forming elements. The effect of the ingestion of apples, raisins, cantaloupes, bananas, potatoes, tomatoes and oranges is to produce an alkaline urine. On the other hand those fruits which con- tain benzoic acid, such as cranberries, prunes and plums, cause the production of more acid urines. In our discussion of inorganic salts it was noted that animal food is, with the exception of milk, potentially acid-yielding. Vegetables are then important in the dietary for their ability to neutralize the acids produced in metabolism. In the case of fruits and vegetables it is the small amount of nutritive material associ- ated with the salts which makes it possible to balance the diet with regard to its acid and alkali forming properties, so as to aid in the maintenance of the neutrality of the blood. For the same reason, vegetables are important when it is 254 FOODS VALUABLE FOR SALTS AND WATER desired to reduce the potential acidity of the blood and urine. The greater solubility of uric acid in an alkaline urine, resulting from the ingestion of an excess of basic material, than in a neutral or acid urine is an advantage in favor of an alkaline diet. The sugars of fruits and vegetables are chiefly sucrose (cane sugar), dextrose and levulose. Some fruits, such as the grape, often contain a high proportion of sugar. The more important plant acids are citric (lemon, tomato), malic (apple), tartaric (grape), and in some oxalic or benzoic acid. The acids occur in varying proportions in the different fruits and vegetables. The fruits designated in parentheses above are representative of the class of fruit in which the particular acid predominates; other acids are also present. The relative proportion of starch, sugar and acid in fruits varies during the process of ripening. The following table gives the variation in the composition of an apple at various stages of its growth. Composition of Baldwin Apple at Different Periods in its Growth,1 per CENT. Condition. Water. Solids. Invert sugar. Sucose. Total sugar. Starch. Free malic acid. Ash. Very green . 81-5 18.5 6.4 1.6 8.0 4-1 I .2 O.27 Green Ripe . 79-8 80.4 20.2 19.6 6.5 7-7 4-i 6.8 10.5 14-5 3-7 0.17 O.65 O.27 Overripe 80.3 I9.7 8.8 5-3 14.1 O.48 0.28 Green fruit, in general, contains considerable starch. As the fruit ripens there is a gradual reduction in the quantities of the starch and acids and an increase of sugar. Pectin, the carbohydrate which forms the basis of jellies, gradually decreases as the fruit ripens. Cooking of Vegetables and Fruits.—Vegetables and fruits are cooked to soften the cellulose structure, rupture the starch grains, improve the texture and flavor, and thereby increase digestibility and palatability. Many fruits and vegetables which are also eaten in the raw form are cooked to add variety to the diet and for purposes of preservation. Heat converts the water in the cells into steam, the expansion of which ruptures the cells, freeing the enclosed starch; an exaggerated example of the expansive action of steam is seen in the popping of corn, in which expansion takes place suddenly throughout the whole mass of starch cells when internal pressure is suffi- cient to burst the tough outer layer of the kernel. During the process of cooking hydrolytic changes occur: the starch 1 Browne: Penn. Dept. Agr., Bull. 58. FRUITS AND VEGETABLES 255 and cellulose are partially hydrated, take up water, and are transformed into simpler products—glucose and sugars; protein is coagulated; the mineral salts are only slightly affected. Since inorganic salts are, from a dietetic point of view, one of the important food factors in fruit and vegetables, it is desirable then to conserve them as much as possible. In boiling, the method usually employed for cooking vegetables, a large proportion of the salts and vitamins and also protein may be lost; by direct removal before cooking, as in peeling; by extraction in the water used in washing and soaking, or discarded with the water poured off at the end of the cooking process. Methods which will avoid these losses should be used. Baking or steaming, with the least removal of outer coverings, is the most desirable. Some vegetables, such as spinach and chard, which are cooked by steaming in the water contained in them, are found to lose a large proportion of their salts when the liquor is poured off before they are served. Losses in Cooking Vegetables (Percentage of Fresh Edible Portion).1 Kind of vegetable. Solids. Ash. P2O5. CaO. MgO. Spinach: Boiled . • • 31-59 51-65 52-33 6.89? 60.38 Steamed . 0.18 9-34 5-23 8.69 7-85 Cabbage: Boiled . . . . 32.86 42.62 33-93 27.66 26.71 Steamed . . . 2.54 11.47 i-79 9-3i 4-23 Carrots: Cut up and boiled . . . 10.05 11.48 22.88 10.88 19.19 Boiled whole . . . 6.28 7-38 17.97 8.77 19.19 Preservation. —Fruits and vegetables may be kept at ordinary temperatures for a considerable length of time before they begin to decay, wilt or dry up. With proper refrigeration many of these foods can be kept for a comparatively long time. Such a method of preservation is becoming more prev- alent, and some vegetables and fruits may be had through- out the year. Apples in particular are commonly preserved in cold storage. The process of canning fruit and vegetables has long been used by the housewife to preserve them for use when out of season. Canned foods can now be purchased in the stores in great variety, tomatoes, corn and peas being supplied in the greatest quantity. Since canned fruits and vegetables retain most of the properties of the freshly cooked food they are excellent sources of this type of food in the winter when green vegetables are generally ‘‘out of season.” Canned 1 Berry: Jour. Home Economics, 1912, 4. 256 FOODS VALUABLE FOR SALTS AND WAFER foods have lost practically all of the antiscorbutic vitamin, except in the case of acid fruits and vegetables. In canning vegetables, and to a certain extent, fruits, are heated only enough to sterilize them. This is done after the can is sealed. Sugar is often added to fruits to aid in their preservation and increase their flavor. The juice of fruits is also sterilized and kept for use as beverages or mixed with sugar and made into jellies. It is the pectin of fruit which gelatinizes and forms the basis of jellies. FOOD ADJUNCTS. Food which is entirely satisfactory, in its quantitative composition, with regard to proteins, fat, carbohydrate, salts and even the accessory substances or vitamins, may be in such a form that it is not relished; we have no desire to eat it. This distaste may be due to the appearance or taste of the particular food, or to a lack of interest in food in general. Such conditions are not confined to man alone. These factors do not affect the ultimate absorption of food so much as is sometimes thought, for food-stuffs which are ingested with much effort have been found to be just as thoroughly digested as those which are appetizing. The extent of variation in the diet is a matter largely of personal taste. Some people relish the same diet day after day, while others require fre- quent changes. Animals fed artificial diets of similar com- position from day to day often, after a time, refuse to eat. If to the same diet small amounts of flavoring substances, having no nutritive value, be added and the flavor changed from time to time, it will be eaten readily during long periods of time. There are also experiments on the flow of gastric juice which show that when there is desire for food, the mere sight of food results in a flow of highly acid and strongly active gastric juice which starts the process of gastric digestion, the products of which are capable of causing a continued secretion. Certain food constituents, such as the extractives of meat and some condiments, are capable of stimulating such a flow of gastric juice, and this in turn affects the secretion of the other digestive juices. The garnishing of food when served like- wise has, through the increased attractiveness of the dish, a beneficial effect upon the digestion of food. There is a funda- mental reason, therefore, for the use of condiments and for different methods of preparing food. Spices. —Spices are used almost exclusively for their flavor. Such spices as allspice, cloves, cinnamon, ginger, caraway, etc., are used chiefly in cooking. The peppers (black and BEVERAGES 257 white), paprika, mustard and horseradish are often added to food after it has been prepared. Flavoring Extracts.—Many alcoholic extracts of various plants, of which vanilla, lemon, orange, peppermint, spear- mint and wintergreen are the most common, are used to add an agreeable flavor or taste to foods. Meat Extracts. —Meat extracts are to be classed with the food adjuncts (see page 196). Vinegar.—Vinegar is the product of the alcoholic and acetic acid fermentation of fruit juices; its distinguishing constituent is acetic acid. It may also be prepared from the products of alcoholic fermentation of grain or is compounded from acetic acid and substances to give a flavor and color which will simulate the natural vinegars. Vinegar is used with more or less insipid foods to intensify the flavor and to soften food somewhat; for colloidal material tends to swell in acid solutions. Sugar and Salt (Sodium Chloride). —Sugar and salt may both be classified differently, but may, for convenience, be included here as condiments, for they are used to add flavor and to stimulate the appetite. Sugar Substitutes. —Saccharine, dulcin, granatose and saxin, benzene derivatives are sometimes used in place of sugar to sweeten food. These products are used particu- larly to sweeten the food of diabetics and of the obese to increase its palatability without increasing the carbohydrate content. When taken in sufficient quantity these substi- tutes for sugar are harmful. It is the contention of manu- facturers that small quantities are not deleterious to the health. While this may be true during short periods of time, it is doubtful whether their continued ingestion may not cause serious disturbances in the body. Their use in diabetes is defensible on the basis that the harmful effects are over- weighed by the possibility of reducing the carbohydrate con- tent of the food. BEVERAGES. Many foods are ingested in a liquid or semiliquid form. There are, however, liquids which, possessing a certain amount of food value, are taken for their stimulating effects upon the nervous and digestive systems. The pleasurable conditions under which they are ordinarily ingested should not be neglected in considering the effect of these beverages. Those beverages most commonly taken with food and most properly considered a part of the diet are tea, coffee, cocoa, 258 FOODS VALUABLE FOR SALTS AND WATER chocolate and the malted and spirituous (and carbonated) liquors. Tea.—Tea is prepared from the leaves and leaf buds of various varieties of hardy shrubs, Thea. Two general types of tea are used, green and black. This classification refers particularly to the general method of preparation. Green tea is prepared by steaming the withered leaves and then drying them in the sun or artificially, thus retaining the green color. Black tea has undergone a fermentation (or oxi- dation) process which darkens the color of the leaves and reduced the quantity of tannin. Numerous varieties of both kinds of tea may result from the selection of leaves from different parts of the shrub or twig or from the country or locality from which they are obtained. The active constituent of tea is theine or caffein, but cer- tain volatile oils and tannin contribute to the aroma and taste of the prepared beverage. In the preparation of the beverage it is the relative proportion of these three constituents to which most attention is given. The end commonly believed to be desirable is the extraction of the maximum amount of caffein and volatile oils, with the minimum quantity of tannin. From a study of the nature of the products extracted from tea leaves the Lancet has come to the conclusion that it is the relative proportions of caffein and tannin extracted which determine the quality of tea. They show that when caffein and tannin are present in the proportion of one part of caffein to three parts of tannin they may be precipitated completely by acidification in the form of caffein tannate. Caffein tan- nate has neither the astringent taste of tannin nor the bitter taste of caffein, and it is precipitated by acids. It has been suggested that the caffein of tea, unlike the caffein complex of coffee, is precipitated in the stomach and is not absorbed until it reaches the alkaline intestine. A comparison of the valuation of tea by tea-tasters and the proportion of caffein to tannin in the tea shows that the infusion of those teas classed as “good” contain these two substances in the pro- portion in which they exist in caffein tannate, and that inferior teas yield an excess either of caffein or of tannin in the infusion, usually the former. The following table shows the extractives from teas of three different types and the relative proportion of caffein and tannin contained. It will be seen that the high-priced teas contain a greater proportion of tannin and caffein (caffein tannate). 1 For a discussion of tea, see Usher, Jour. Home Econ., 1921, 8, pp. 127, 177 and 267. BEVERAGES 259 Caffein tannate. Deter- Tannin com- bined with Caffein com- bined with Total Total Caffein not com- Tannin not com- Price, Tea. mined. caffein. tannin. tannin. caffein. bined. bined. cents. India 8-54 6.41 2.13 6.80 2.56 0-43 0-39 15 Ceylon I3-36 10.02 3-34 IO.92 4-32 O.98 O.90 46 8.88 6.66 2.22 6.30 2.80 O.58 17 12.00 9.00 3.00 8.40 3.60 O.60 33 China 5-36 4.02 i-34 3.02 1.92 O.58 13 6.48 4.86 1.62 4.60 2.80 I. 18 35 Tea Infusions (5 Grams of Tea to 400 cc Boiling Water). The chemical composition of the water used in making tea may affect the composition of the infusion, for, should the water be rich in calcium, the calcium will tend to precipitate the tannin and leave an excess of caffein. The period of extraction affects the composition of the infusion; continued extraction of good tea results for a time in a proportionate increase in both caffein and tannin, so that the balance is but little disturbed; inferior teas, on the other hand, yield an excess of either caffein or tannin. Prolonged boiling of tea tends to extract a greater proportion of tannin. The Lancet believes that caffein and not tannin is the injurious constit- uent of tea, for tannin is rarely in excess of the ratio in which it exists in caffein tannate. Studies of the quantity of caf- fein and tannin present in tea steeped for varying lengths of time have shown that practically all of the caffein is extracted in the first three to five minutes. A longer period of extraction results in an increased proportion of tannic acid in the infusion. For those, then, who desire to obtain the maximum aroma and exhilarating effect of the caffein without the bitter, stringent tannin, tea should be extracted for a short period. The total quantity of caffein and tannin present in the average cup of tea after an infusion of five minutes varies with the kind of tea —it has been found to be roughly i grain (0.07 gram) of caffein and three or four times as much tannin. The effects of tea are discussed with those of coffee on page 262. Coffee.—The beverage coffee is prepared from the roasted bean of the Caffea arabacia. The coffee berry contains a bean composed of two elongate, hemispherical halves enclosed in a thin membranous sheath, which is surrounded by an outer layer of pulp. The berries are separated and roasted to preserve them, to render them brittle and readily ground, and to develop certain flavors and aroma. In the roasting process a large proportion of the sugar is caramelized and there are losses of water and to a certain extent of caffein. Caffeol is the name given to a mixture of substances present in the roasted product which gives to coffee its characteristic 260 FOODS VALUABLE FOR SALTS AND WATER flavor and aroma. The alkaloid of coffee is, as in tea, largely caffein. The caffein of coffee is combined in a different manner from that of tea; it is almost entirely extracted by cold water while that of tea is not. It appears to be combined with an acid designated as caffetannic acid related to tannin but exhibiting properties different from those of the tannic acid of tea. The caffein of coffee is soluble in both an acid and an alkaline medium, while that of tea is precipitated by acids. This fact may account for the greater stimulatory effect of coffee than of tea, for the caffein being in solution may be absorbed by the stomach while that of tea must pass to the intestines for solution and absorption. The several kinds of coffee vary chiefly according to the country from which they are obtained. As with tea, the advantage of the different kinds is to a considerable extent a matter of taste. The coffee bean contains roughly one-third the quantity of caffein present in dry tea. The greater quantity of coffee used gives approximately the same quantity of caffein in both prepared beverages. Coffee contains a greater amount of total extracted material. In the process of preparing coffee for its most pleasurable effects the caffein and the aroma are the two constituents which it is desirable to extract. It has been found that when 2 ounces (60 grams) of coffee are used, a teacupful of coffee will contain approximately 1.7 grains (0.1 gram) of caffein, a value which is slightly higher than that of tea; the smaller quantity of infusion taken when cream or milk is used will make this value slightly lower. The quantity of caffein and caffetannic acid extracted in the preparation of coffee varies considerably with the mode of preparation. Cold water extracts approximately the same weight of material from coffee as does hot water, but hot water extracts oils which improve the odor and taste of the beverage. Four general methods of preparing the beverage coffee are used: Boiling, steeping, percolation and filtration. Boiled coffee is prepared by heating medium-ground coffee placed in cold water to the boiling-point and maintaining it at that temperature for five minutes. This method gives the greatest proportion of extract, and one which is rich in caffein and caffetannic acid. Steeped coffee is similar to boiled coffee except that the infusion is poured off soon after the boiling-point is reached. This method yields the lowest caffein content. Percolation consists in passing warm water through finely BEVERAGES 261 ground coffee in a specially constructed coffee pot. The temperature of the water, which is forced over the coffee, seldom reaches the boiling-point. A low total extract high in caffetannic acid and caffein is obtained. Filtered coffee is made from finely pulverized coffee which has been placed in a muslin bag and over which vigorously boiling water is poured. The product is lower in total extrac- tives and contains less caffetannic acid than boiled coffee. If the water be poured through more than once a darker liquid is obtained which has a less agreeable flavor because of the additional tannin and other objectionable substances. This method of preparing coffee is in many ways the most satisfactory.1 The cloth used should not be allowed to dry but should be kept in clear cold water. A comparison of the relative quantities of caffein and tan- nin extracted by the various methods is given below. Tannin and Caffein Extracted by Various Methods of Preparation (7 Tablespoonfuls (80 Grams) Coffee to 6 Cups (750 cc) Water). Tannin, Caffein, Method of preparation. grains. grains. Boiled 2.44 2-5 Steeped 2.40 / 0.5 medium ground \ 1.75 finely ground Percolated .... . 2.21-2.90 2-75 Filtered . 0.2 -0.25 2.50 Specially prepared coffees are sold for the use of those who cannot take coffee because of its caffein content, usually with the implied statement that some or most of the harmful ingredients of coffee have been removed. After a comparison of some of these with three types of pure coffee the following statement has been made:2 “‘Kaffee Hag’ is almost caffein-free but contains the normal amount of caffetannic acid. ‘George Washington Coffee’ (a soluble concentrated coffee) contains about four times as much caffein and caffetannic acid as normal coffee. ‘Cafe des Invalids’ contains about 80 per cent as much caffein as ordinary coffee, the decrease being due to its dilution with other vegetable substances; its caffetannic acid is somewhat higher than in normal coffee. ‘Richelieu Vacuum Coffee’ contains practically the same amount of caffein and caffetannic acid as ordinary coffee.” Certain coffee substitutes prepared from roasted grains are sold for the use of those who desire a beverage simulating coffee but who do not wish to ingest the alkaloid caffein. 1 Aborn: Tea and Coffee Trade Jour., 1913, 25, 568. 2 Food Products and Drugs, Report of Conn. Agr. Exp. Sta., 1911, Pt. 5. 262 FOODS VALUABLE FOR SALTS AND WATER These products accomplish this end more or less satisfactorily, although their action is chiefly that of a warm beverage. The general effect of tea or coffee is to produce wakeful- ness and relief from fatigue, increased strength and rapidity of the heart-beat and increased blood-pressure. In some people drowsiness rather than wakefulness is induced by coffee; this is usually followed by a period of wakefulness. These effects are to be ascribed chiefly to the caffein in the tea or coffee; caffein also has a diuretic effect. The feeling of well-being which accompanies the ingestion of coffee after a meal has been ascribed to the local action of the contained oils. The effect of coffee upon digestion is to increase the period of gastric digestion without affecting it quantitatively. Since the direct effect of water when taken with food is to delay evacuation of the stomach, the best results are obtained when water and other liquids are taken after food rather than when mixed with it. On the other hand, the ingestion of bread or cake with coffee is desirable, for it prolongs the feeling of satiety and delays diuresis. Coffee infusion has been found to tend to inhibit the coagulation of milk and to inhibit peptic activity outside the body while tea has a less retarding action on coagulation and appears to promote peptic activity. The harmful effects of tea and coffee are sometimes referred to the tannin content because tannic acid precipitates protein, simple protein cleavage products and digestive enzymes. The work performed for the Lancet tends to show for tea, at least, that in good teas the tannin is so combined with caffein that it will be precipitated out by the gastric juice and only become absorbable in the intestine in which the alkaline tannate would not have the precipitating powerof tannic acid. They are therefore inclined to ascribe the harmful effect of tea to caffein. The slight laxative effect of hot drinks is probably to be ascribed chiefly to the hot water. Cocoa and Chocolate.—Cocoa and chocolate are prepared from the seed or bean of the tree Theobroma cacao. The beans are removed from the pod, fermented in boxes or in holes in the ground, and then dried in the sun until they assume the characteristic brown color of the beans shipped to the market. In the preparation of the products, cocoa and chocolate, the dried beans are cleaned, roasted, crushed, and finally ground, after which the ground mass is molded or specially treated according to the nature of the final product—chocolate or a special variety of chocolate such as milk chocolate or cocoa. It is during the fermentation processes just after picking and the subsequent roasting processes that care must be taken if the product is to develop the most desirable flavor. BEVERAGES 263 Ground cocoa nibs, obtained by crushing the roasted beans, constitute the ordinary chocolate of commerce. Sugar, dried milk, flavoring extract (particularly vanilla), etc., are added to the ground mass in the preparation of sweet chocolate, milk chocolate, etc. In preparing cocoa a portion of the oil or fat is removed from the ground seeds. This fat is removed by pressure — usually when warmed slightly; the residue is the finely pul- verized cocoa of commerce. The expressed fatty material is cocoa butter, a semisolid fat used in the manufacture of chocolate and particularly in pharmaceutical preparations. Alkaline salts, sodium, potassium or ammonium carbonate, are often added to the ground cocoa ostensibly to increase the solubility of the product; such products are sometimes designated as “Dutch process” cocoa. The addition of alkali neutralizes any fatty acid present. Tests of these preparations in comparison with untreated preparations have failed to show any marked increase in solubility; such treat- ment would tend, however, to aid in the emulsification of the cocoa fat and thus produce an apparent increase in solu- bility. Specially prepared cocoas are sold which have been treated with alkali as indicated above or with the addition of sugar, starch, etc. COMPARATIVE COMPOSITION OF PRODUCTS OF THE COCOA BEAN.1 Cocoa nibs. Original Chocolate. Original Cocoa. Original material. Fat-free. material. Fat-free. material. Fat-free. Ash .... • 3-32 6.66 3-15 6-59 5-49 7-49 Soluble ash . i. 16 2-33 I.4I 2-95 2.82 3.85 Sand .... 0.02 0.04 0.06 0.I3 0.24 0.32 Nitrogen 2.38 4-77 2.26 4-73 3-33 4-54 Fat .... . 50.12 52.19 26.69 Fiber 2.64 529 2.86 5-98 4.48 6.11 Starch 8.07 16.18 8.11 16.75 11.14 5.20 Cocoa and chocolate differ, as indicated above, particularly in the quantity of fat present. Cocoa contains roughly one- half as much fat as chocolate. The fat is largely a mixture of the glycerol esters of palmitic, stearic, lauric and arachidic acids, melting-point 38° to 33 0 C. The active principle of cocoa and chocolate is theobromine or trimethylxanthin, and is closely related chemically to the caffein of tea and coffee. There is, roughly, about as much theobromine in cocoa as there is caffein in tea or coffee, between 1 and 2 per cent, less in the specially prepared prod- 1 Winton: Conn. Agr. Exp. Sta. Report 1902, p. 282. 264 FOODS VALUABLE FOR SALTS AND WATER ucts because of the dilution with other substances; a small amount of caffein is present. Tannin is also present; the reddish color of the finished product has been held to be an oxidation product of the tannin present in the raw bean. Cocoa and chocolate contain theobromine, which does not have the stimulating power of caffein, and these drinks are therefore less objectionable from that point of view. Because of the high fat content they tend to retard the passage of food from the stomach. While these beverages are prepared from substances with a high food value the prepared liquid is com- paratively low in such value because of the relatively small quantity of material used; the added milk is often of more importance. Mineral Waters.—Water may be roughly divided for convenience into three classes: Hard, soft and “mineral” water. The presence of considerable quantities of the salts of the alkaline earth metals, particularly calcium and mag- nesium, is the chief characteristic of a hard water. Water analysts recognize two degrees of hardness; temporary and permanent. The quantity of calcium and magnesium pres- ent in water as the bicarbonate which may be precipitated through the removal of carbon dioxide by boiling or by the addition of lime is an index of the temporary hardness of water. When combined with the chloride or sulphate radical calcium and magnesium are not precipitated readily by heat- ing and the water is said to be permanently hard.1 Soft waters are comparatively free from dissolved inor- ganic matter. Distilled water is an artificially prepared soft water and is free from inorganic salts; it may contain a certain amount of ammonia. Rain water when properly collected is virtually free from inorganic salts. It often contains a small amount of organic material, particularly when collected from the roof. The term “mineral water” is applied to those naturally occurring (and also artificially prepared) waters rich in par- ticular salts or gases as distinguished from the usual table water poor in such constituents and having no specific effect. The name has developed particularly in conjunction with the therapeutic use of such water. The classification of mineral waters has not been standardized. Since they are ordinarily 1 The temporary hardness of water may be removed by adding to it a saturated solution of calcium hydroxide, “lime-water.” In the presence of calcium hydroxide the calcium bicarbonate is changed into normal calcium carbonate, which precipitates, and in this way both the calcium of the water and the calcium of the added lime-water are removed. The quantity of lime-water to be added to any water must be determined by experiment or it may be approxi- mated from published analyses of the water under consideration. BEVERAGES 265 used for their medicinal effect it is perhaps best to classify them according to the nature of the substance contained, as lithium water (lithia), sulphurous water, sulphate water (aperient), iron water (chalybeate), radio-active water. To these should be added the alkaline waters, a type which may include one or more of the types of water just named. Many waters are rich in sodium chloride and are sometimes desig- nated as saline waters. Some waters are naturally charged with carbon dioxide while others are sold artificially charged. The classification indicated above recognizes only the most characteristic constituent of mineral water; it may contain one or all of the other constituents. Lithium waters, or lithia waters, are waters which have been advocated because of the supposed solvent effect of lithium upon uric acid in the body. Consideration of the ionic equilibrium in the body makes it appear very improb- able that the ingested lithium salts could dissolve uric acid to any considerable extent. Since most lithia waters are comparatively poor in lithium, large amounts of water would need to be taken to produce even a slight effect. Sulphurous water contains hydrogen sulphide gas as the most characteristic constituent. The gas is liberated readily unless properly bottled; to obtain hydrogen sulphide, there- fore, the water should be taken at the spring. The curative power of such waters is probably due to other constituents than the gas itself. It may be in the sulphur sometimes “used as a blood purifier.” Sulphurous waters are found at the Anderson Sulphur Springs in California, French Lick Springs, Richfield Springs and Cold Sulphur Springs. Sulphate waters are rich in alkali and alkali earth sul- phates, such as sodium sulphate (Glauber’s salt) and mag- nesium sulphate (Epsom salt); these two salts usually occur together. Such waters are laxative and purgative; the effi- ciency varies with the amount of magnesium and sodium present. Many of these waters are concentrated by evapo- ration and are to be diluted or dissolved before using. Salts (sulphates) are sometimes added to the natural water to increase its concentration. Some American waters rich in sulphates are found at the Mendenhall Springs, Isham and Nuvida Springs in California; the Warm Springs, Hot Springs and Healing Springs in Virginia. Foreign waters such as Hunyadi Janos, Kissengen, Seidlitz and Friedrichshall are of this type. Iron waters usually contain other mineral constituents which may have as great an effect as the iron itself, such as carbonates, sulphates, lithium and arsenic. Many waters 266 FOODS VALUABLE FOR SALTS AND WATER used as table waters are rich in iron. The presence of the associated salts must be considered in prescribing iron waters; a water containing bicarbonates is preferable as a tonic. The Berkeley Springs, West Virginia and the Round Spring at the Aurora Springs, Missouri, are examples of American iron-containing bicarbonate springs. Similar foreign waters are to be found at Spa, Belgium; St. Moritz, Switzerland; Schwalbach, Germany; Trubridge Wells and Flitwick Well, England. Radio-active Water.—The presence of traces of radium in certain waters has led to their use in therapeutics. It has been found that such waters lose their radio-activity with time. Springs which have been advocated for their healing properties because of the presence of various salts have been found to be, in addition, radio-active.' Many waters, such as those at Hot Springs, Arkansas, the mineral springs of Yellowstone Park in America, and the foreign waters at Carlsbad, Gastein, Wiesbaden, Kissengen and Bath have been found to be radio-active. Radio-active water is arti- ficially prepared and sold or may be prepared with suitable apparatus. Alkaline waters include particularly those of the lithium, sulphate and iron types. They are valuable as a means of administering alkaline salts. The alkalinity of these waters is due to the presence of bicarbonates, primarily of sodium, potassium or lithium, and secondarily of magnesium and calcium. Many alkaline waters are effervescent. Vichy water is perhaps the most generally used alkaline water. Some American alkaline waters are: White Rock and Clysmic (Waukesha, Wisconsin); Vichy (Saratoga Springs, New York); Londonderry Spring (New Hampshire); Hot Springs (Arizona). Vichy (France), Carlsbad (Austria) and Fachingen (Germany) are alkaline European waters. An analysis of the various medical data with regard to the use of mineral waters has brought out the following facts:1 (a) Many patients are improved in health under mineral water treatment; (b) waters of widely different composition have been recommended for the same disease; (c) curative properties are ascribed to many waters whose mineral con- tent is the same as, or lower than, the city supplies used daily by many people without peculiar physiological effects; (d) treatment at resorts is often recommended for those afflicted with chronic organic diseases, many of which are 1 R. B. Dole: The Production of Mineral Waters in 1911, U. S. Geol. Survey, advance chapters for Mineral Resources of the United States, 1912. This discussion of water is taken in part from this paper. BEVERAGES 267 obscure in nature or are caused by failure of nutrition. Such facts lead to the conclusion that the beneficial effects are to be ascribed more to the free use of water itself, augmented by dietetic treatment, exercise and other hygienic restric- tions and possibly change of climate and freedom from busi- ness and household cares than to the contained mineral con- stituents. The demonstration of the value of various waters will depend upon the concentration of the dissolved constituents. The determination of the effects of a particular water is dif- ficult to accomplish because of the difficulty in controlling the physiological factors associated with its ingestion. The specific action of salts may occur in three ways: As stimulants to (a) increase or (b) depress the activities of an organ or function or (c) as irritants, which cause a change in form, growth and nutrition rather than of activity. The action of mineral waters is due to the contained ions rather than to the undissociated salt. The effect of any particular ion will depend upon its associated acidic or basic radical and the presence of other ions in solution. When two ions occur together one ion may neutralize the effect of the other. Such an effect is apparently specific and not necessarily in the ratio of the combining power of the ions; thus, roughly, one part of calcium chloride will neutralize or antagonize the effect of one hundred parts of sodium chloride in its effect upon the permeability of membranes. This antagonistic action of ions may be the explanation of the tolerance of comparatively large quantities of some mineral waters. We know that a tolerance for water is acquired; the develop- ment of diarrhea in some persons upon moving from one locality to another may be looked upon as of this nature.1 The fact that an individual dose of a salt is not harmful does not mean that its continued ingestion may not be injuri- ous, for small repeated doses of a salt will in some cases induce symptoms which are more marked than from a single dose, such as in lead poisoning, or an abnormal tolerance may be acquired, as in the case of arsenic. Analyses of water do not tell the manner in which the various ions are combined but only their proportionate dis- tribution. From such analytical data we say by inference that the ions exist in certain combinations. These com- binations are hypothetical, for the complex combinations of various salts and the effect of loss of dissolved gases, particu- larly carbon dioxide, alter the molecular and possibly ionic complexes actually present in the original water analyzed. 1 Diarrhea may be due to infection from a water new to the individual. 268 FOODS VALUABLE FOR SALTS AND WATER The results of water analyses are usually expressed in parts per million. The following equivalents of certain methods of expressing analytical results will aid in understanding the significance of this expression: I part in ioo .... Equivalent in parts per million. x part in 10,000 i part in 1000 .... i part in 1,000 i gram in a liter . 1 part in 1,000 i milligram in a liter . I part Grains per imperial gallon 4- 0.07 gives parts per million. Grains per U. S. gallon . 4- 0.058 gives parts per million. Dole has suggested the use of the quantity of a specific salt in 4 kilograms of water (the water intake for a day) as the basis of differentiation between medicinal and common water with reference to the minimum dose of the individual constituent in the absence of other ions which have a phar- macological effect, ignoring as difficult of demonstration the effect of associated ions. The following table of the minimum dose of constituents common to mineral waters has been prepared by Dole: Radical. Average minimum dose, grams. Equivalent concentration, mg. per kg. Arsenite (As03) 1 (o.2 Arsenate (AsCh) J l°-3 Fluoride (F) . O.002 0-5 Barium (Ba) . O.003 0.7 Hydroxide (OH) . . . . 0.013 3-0 Aluminum (Al) O.OII 3 °t Iron (Fe) 0.024 6.0 Lithium (Li) . . . . 0.075 15.0 Ammonium (NH4) . 0.078 20.0 Manganese (Mn) . 0.12 30.0 Metaborate (BO2)) /+n Pyroborate (B4O7) J . . . . O.O35 (30.0 \30.0 Iodide (I) . 0.12 30.0 Calcium (Ca) . 0.2 50.0 Magnesium (Mg) . 0.2 50.0 Orthophosphate (P04) .... . . . . 0.23 50.0 Carbonate (C03) . 0.281 70.0 Sulphite (S03) .... O.315 70.0 Thiosulphate (S203) . O.300 70.0 Nitrate (N03) . . . . 0.5 100.0 Bromide (Br) ■ • • • O.53 100.0 Sulphate (S04) . 0.60 150.0 * Equivalent as arsenic (As), f In acid solution. J Equivalent as boron (B). In preparing the table care was taken that the concentra- tion expressed should represent a minimum below which therapeutic activity could not logically be attributed to the radical in question. BEVERAGES 269 The significance of the last column may be illustrated as follows: If the average quantity 0.53 gram of bromine were in 4 kilograms of water the concentration of the radical would be 132 milligrams per kilogram (reduced to 100 in the table), that is, a person who drank 4 kilograms of water containing 132 milligrams per million by weight of bromide might exhibit symptoms produced by bromides if the water did not contain some other radical which was antagonistic. 530 kilograms, roughly quarts, of bromide water containing one part per million of bromine would have to be ingested to obtain a similar effect. Alcoholic Beverages.—Beverages containing alcohol are used chiefly for their psychological effects. They have, as a rule, a pleasant taste, often a fragrant odor, and are usually cooled, factors which make their consumption a pleasure. In sufficient quantities their use is accompanied by pleasur- able after-effects, a sense of exhilaration, relief from fatigue and warmth, followed, however, in many cases by depression. The effect of moderate quantities, 30 to 40 cc, of alcohol is to quicken the heart-beat without materially raising the blood-pressure; larger quantities produce a fall in blood- pressure except in certain abnormal conditions of the circu- latory system, a result which is due to a depressant action on the nervous centers and in part to a weakened heart. The general effect is that of a narcotic rather than of a stimulant. There is an increased rate of respiration, disturbed heat regulation and secretion of saliva and gastric juice. While alcohol produces, for the time being, a feeling of well-being and ability to work, these are more or less subjective effects. The true result appears to be a lowered capacity for work, particularly work requiring thought, and lessened endurance. A thorough and far-reaching study of the effect of alcohol upon the body processes is being undertaken by Benedict in the nutrition laboratory of the Carnegie Institution of Wash- ington. This series of investigations has only been started. The results of a psychological study indicate that the period of response in the simple reflex arcs in the lumbar cord, the patellar reflex, and the protective-lid reflex and to more com- plex cortical arcs, certain eye reactions to peripheral stimuli, speech reactions to visual word stimuli, and free associations were increased following the ingestion of doses of alcohol containing 30 cc and 45 cc of absolute alcohol; memory and free association were only slightly affected. As a food, alcohol is of the type of the energy-yielding food-stuff's, fats and carbohydrates. It can be substituted for them at least to a limited extent and is capable of exert- 270 FOODS VALUABLE FOR SALTS AND WATER ing a similar sparing effect upon protein. Its use must, however, be considered in connection with the fact that alcohol has also a toxic effect foreign to fat and carbohydrate. It is not converted into sugar by the diabetic and may then be- come a source of energy. It is not, however, an antiketo- genic substance. The use of alcoholic beverages as food is of only secondary importance. Alcohol or even beverages fortified with sugar, such as some wines, are not economical sources of energy and there is no proof that alcohol itself is more efficient than carbohydrate in the body economy. The trend of the evidence is rather against such a possibility. Discussion of the use of alcohol as food has therefore little practical dietetic value; the food or fuel value of alcohol is a bone of contention between those advocating its use in general and their opponents. Studies of the food value of alcohol have shown that from 90 to 98 per cent of alcohol ingested in small quantities is oxidized; that the effect of the addition of the equivalent of 500 calories in the form of alcohol, 72 grams, to a standard diet was practically identical with the addition of an equiva- lent amount of sugar, and that alcohol is not as efficient in sparing protein as carbohydrate or fat. Certain investiga- tions have demonstrated in short experiments that for small amounts of alcohol there is an increased protein metabolism. Experiments of longer duration have shown that there is an initial rise in the nitrogen excretion (loss of protein) but that in the course of a few days the metabolism returns to the normal, or there may be a retention of nitrogen. The utili- zation of foods is unaffected by the ingestion of small amounts of alcohol. These observations, which apply only to small quantities of alcohol, have demonstrated quite clearly that it may serve as a food. Large doses of alcohol exert a toxic effect, increase protein metabolism, and also the respiratory exchange, as the result of the restlessness of partially intoxi- cated persons. With complete intoxication the energy exchange is decreased. The desirability of using alcohol as a food under all cir- cumstances is doubtful; the associated danger of excessive consumption should certainly bar it as a constituent of the diet. While it can replace in part fats and carbohydrates it does not serve as a reserve food in the sense that these foods do, for it is oxidized immediately. The therapeutic use of alcoholic beverages in medicine, such as in the treatment of fevers, on the basis that it is a readily assimilable and oxidizable type of food in a condition in which food is more or less contraindicated, loses its impor- BEVERAGES 271 tance somewhat in the light of our present knowledge of the effect of food in such cases. With regard to the combined stimulating and food value of such beverages and their effect upon the appetite, little of a definite nature can be said. A summary of the referendum of the American Medical Associ- ation1 upon the use of alcoholic beverages in the practice of medicine indicates the following: Out of thirty-one thousand replies the vote with regard to (a) the therapeutic necessity of whisky was; 51 per cent, yes and 49 per cent, no; (b) the therapeutic necessity of beer; 26 per cent, yes and 74 per cent, no; (c) the therapeutic necessity of wine; 32 per cent, yes and 68 per cent, no. Alcoholic beverages are products obtained as the result of the alcoholic fermentation of sugar or prepared from fer- mented products. They are of two types, fermented and distilled. Fermented liquors are the result of naturally occurring fermentations. Of these there are (a) the products of direct spontaneous fermentation of saccharine fruit juice, such as wine and cider, and (b) beverages produced from starch-bearing grains in which alcoholic fermentation takes place after the conversion of starch into sugar, such as the malted and brewed liquors, beer, ale, etc. Distilled liquors, sometimes designated as “spirits,” such as whisky, brandy, rum, etc., are obtained by the distilla- tion of naturally fermented products. Composition of Alcoholic Liquors • Carbon dioxide. Alcohol. Extract. Nitrogenous material. Sugars. Gums and dextrin. Acidity. Ash. 6 £ By weight. By volume. Fixed. Volatile. Total. Beer, lager 0.4 4.3 5.6 4.2 0.5 1.10 1.6 0.06 0.20 o. or. Porter 0.4 6. 1 7.7 5.9 0.8 0.57 2 8 0. 15 0.37 0.05 Ale 0.5 5.7 7.1 4.4 0.5 0.49 2.2 0 12 0.31 0.07 Malt extract, U. S. P * . . . 76.6 3.1 65.40 6.9 0.02 0.26 1.20 0.56 Claret 9.7 0.24 0.39 0.17 0.60 0.21 * Sherry 17.8 3.00 0.29 0.16 0.49 0.50 Port 18. 1 2.54 0.31 0.09 0.43 0.23 Champagne 13.7 3.67 1.92 0.40 43.6 51.2 0.11 3.36 41.1 48.5 0.67 3.75 Gin 40.2 47.5 0.05 38.5 52.0 36.00 32.60 0.41 Cider: Hard .... trace 5.2 6.5 0.04 0.40f 0.38 Sweet .... 1.4 1.7 6 06 0.21 0.32 * Di astatic action complete in ten minutes. t As malic acid. 1 Jour. Am. Med. Assn., 1922, 78, 210. 272 FOODS VALUABLE FOR SALTS AND WATER Fermented liquors, cider and wines are beverages in which the alcohol is formed as the result of direct fermentation of fruit juices. Cider is the fermented juice of the apple. It contains from 3 to 8 per cent of alcohol. Sweet cider is the freshly expressed juice and contains only small amounts of alcohol. Perry, or pear cider, is made from the pear. Wines.—The term wine is customarily used to designate the fermented juice of the grape. A number of wines are to be had which differ particularly in their method of prepara- tion and to a certain extent according to the country or locality in which they are prepared. Classification of Wines.—A number of terms are used to express the type of quality of wines.1 With regard to the method of preparation we have: Natural wines, wines which are prepared from the juice of the grape as expressed and to which no sugar or alcohol has been added, e. g., hock and claret; and fortified wines, to which alcohol has been added, usually before the natural fermentation is completed, e. g., Madeira, sherry, port. According to the intrinsic properties of wines we have the non-effervescing or still wines, which con- tain little dissolved carbon dioxide; effervescing or sparkling wines, more or less heavily charged with carbon dioxide (a) from natural fermentation of added sugar in the corked bottles —champagne—or (b) artificially charged with carbon dioxide; red wines, Burgundy and Bordeaux wines or claret; white wines, e. g., Rhenish and Moselle wine and sauternes; dry wines, in which the sugar has been exhausted by fermentation; and sweet wines, which possess a considerable amount of unfermented sugar and to which sugar is often added. Of the different varieties of wines: champagne is an effer- vescing, selected, sweet, white wine fortified with sugar-mixed with brandy, it contains 8 to 10 per cent of alcohol; claret is a light red wine, somewhat acid and astringent, contains very little sugar, is high in volatile ethers, alcohol 8 to 13 per cent; Madeira is a strong white wine generally fortified with alcohol and possesses a rich, nutty, aromatic flavor, alcohol 17 to 20 per cent; sherry, a Spanish wine, is a sweet wine sometimes fortified with alcohol, deep amber colored, slightly acid and possesses much fragrance, alcohol 8 to 20 per cent; hock, German wines, are white wines mildly acid, alcohol 9 to 12 per cent; port, an astringent wine, always fortified with alcohol, dark purple in color, alcohol 15 to 18 per cent. 1 The particular mode of preparation and more specific details of their compo- sition may be found by consulting such books as Leach: Food Inspection and Analysis, New York, 1913. BEVERAGES 273 Malt Liquors (Beer, Ale, Porter, Stout).—Malt liquors are made by the alcoholic fermentation of malt with hops; other grains are sometimes added. To obtain the sugar from which the alcohol is to be formed, grain is malted; that is, it is permitted to sprout. In the process of sprouting, starch is transformed in part into soluble sugars, particu- larly maltose; the quantity of the enzyme, diastase, formed is often sufficient to change the starch of added grains, rice, corn, etc., to a considerable extent. The sprouting process is stopped at the proper point and the germinating mass is dried. The temperature at which the malt is dried deter- mines to a large extent the depth of color of the final product; higher temperatures give the darker beers. In some cases caramelization of the starch is permitted, as in stout. To complete the conversion of the starch the dried malt and admixed grain, if there be any, are crushed and mixed with water to permit the diastase to continue its action. The saccharine liquor or wort is concentrated, mixed with hops and a selected yeast and permitted to ferment. The nature of the yeast added for the alcoholic fermentation is a matter of great importance in the production of good malted liquors. After fermentation has proceeded to the proper stage the beer is drawn off from the greater portion of the yeast and stored in casks or vats for an after-fermentation. When this process is completed the liquor is clarified and stored in casks or bottles. Of the different varieties of malt liquor we have beer, pre- pared as above without special modification; ale, essentially a light colored beer which usually contains more hops than beer; porter, a dark ale, and stout. The latter are prepared from roasted, partially caramelized malt. Such liquors are dark colored, usually heavy and contain considerable quantities of dextrin and starch. Malt liquors contain, in addition to water, alcohol and sugar, a variety of substances formed in the processes of malting and fermentation. Of these the carbon dioxide, which produces the effervescence, the volatile oils and the bitter principles, which contribute to the taste, are the most important; certain nitrogenous substances, chiefly peptone and amino-acids, are also present. Malt Extracts.—True malt extracts are free from alcohol and contain the soluble principles of malt. Such extracts have a high percentage of sugar, maltose, 48 to 70 per cent, a certain proportion of dextrin, 2 to 16 per cent, and a high diastatic activity. Many of the malt extracts sold have been found to have the general characteristics of beer. Some have been analyzed which contained approximately from 2 274 FOODS VALUABLE FOR SALTS AND WATER to 9 per cent of alcohol. Such extracts have no diastatic activity and their nutritive value depends essentially upon the sugar content, which is in many cases low. These extracts should not be compared with the U. S. P. malt extract described above. The following table gives the composition of commercial malt extracts in comparison with the U. S. P. extract. Analyses of twenty-one samples of commercial prepara- tions sold as malt extract gave the following maximum and minimum values:1 Commercial Preparations. Maximum. Minimum. Alcohol 9.11 2.52 U. S. P. (for comparison) Extract 15-32 5-39 76.6 Ash 0-37 0.14 1.2 Nitrogenous constituents, protein Sugar solids 1.09 14.04 0-34 4.84 3-1 Maltose 11.17 1.41 65-4 Dextrin 5.80 2.03 6.9 Distilled Liquors. —Distilled liquors, as the name implies, are the product of the distillation of fermented liquors. By this process a liquor is obtained which is high in alcohol and contains in addition certain of the higher boiling-point alcohols, their esters, and acids which pass over with the alcohol. The distillation process is usually repeated and the intermediate portions taken for the best liquors, while the first and last distillates yield inferior products. The liquor obtained is harsh to the taste and must be stored for a time in casks and aged, to soften and refine the flavor. Whisky is the product of the distillation of fermented grains, usually mixtures of corn, wheat and rye, which has been stored in casks for at least four years, alcohol content approximately 30 to 50 per cent. Brandy is the aged product of the distillation of fermented grape juice or wine. The term is sometimes applied to the distillation of the fermented juice of other fruits, alcohol 20 to 50 per cent. Cognac is a brandy distilled in certain parts of France. Rum is the dis- tillation from fermented molasses or cane juice, usually dis- tilled twice and stored for a long time. Gin is an alcoholic liquor flavored with the volatile oil of the juniper berry; other aromatic substances are sometimes used, such as cori- ander, anise, cardamom, orange-peel, fennel. Gin is water- clear and is kept in glass and not wood, as are the other dis- tilled liquors, alcohol 27.5 to 42.5 per cent. Liqueurs and cordials are manufactured beverages con- taining a large proportion of alcohol, sugar and essential oils. They are often highly colored. 1 Conn. Agr. Exp. Eta. Report, 1914, p. 254. PART III. FEEDING IN INFANCY AND CHILD- HOOD. CHAPTER XVI. BREAST FEEDING-FEEDING NORMAL AND ABNORMAL CHILDREN. WOMAN’S MILK. Milk is a secretion of the mammary glands, but a few of its normal constituents are the result of transudation from the mother’s blood. The composition of human milk is qualitatively similar to cow’s milk, but quantitatively quite different. Furthermore, woman’s milk varies in amount and composition at different times, depending upon the length of time which has elapsed since the labor, upon the health of the mother, and upon whether or not the breasts are completely emptied at each nursing. Colostrum.—Colostrum is the term applied to the milk secreted during the first few days (1 to 12) post partum, before lactation is well established. Czerny and Keller include under this term all milk that shows evidence of absorption. Colostrum is deep yellow in color, has an average specific gravity of about 1.040, a strongly alkaline reaction and is coagulated by heat. Its composition varies considerably. The following table gives the average composition of five early colostrums compiled by Holt, Courtney and Fales:1 Average Composition of Five Colostrums (i to 12 Days). Fat 2.83 Lactose 7-59 Protein 2.25 Ash 0.3077 Total solids 13.42 The fat droplets of colostrum are more unequal in size than those of milk. Colostrum contains besides the usual constituents of milk, many large nucleated granular bodies, called “colostrum corpuscles,” which are about five times as 1 Am. Jour. Dis. Child., 1915, 10, 229. 275 276 BREAST FEEDING large as ordinary leukocytes, contain many small fat droplets and have ameboid motion. They are present in large numbers for the first few days, rapidly disappear after lactation is well established, but reappear when lactation is interrupted. Czerny considers them leukocytes that appear when the breasts are not sufficiently emptied of milk and help in the absorption of fat. General Characteristics of Woman’s Milk. Woman’s milk is bluish-white in color, odorless and sweet to taste. Micro- scopically it shows many fine fat droplets which are smaller than most of the fat droplets in cow’s milk. It contains a few epithelial cells and leukocytes. The number of the latter is greatly increased when there is any inflammation of the breast. Its average specific gravity is 1.031, but it may vary between 1.026 and 1.036. Woman’s milk is neutral or slightly alkaline in reaction; and is amphoteric. The latter condition is due to the pres- ence of both mono- and diphosphates, the former being acid and the latter alkaline in reaction. The casein of woman’s milk does not coagulate in such large clots as the casein of cow’s milk. On the addition of acetic acid a fine flocculent precipitate is formed. Rennin alone does not coagulate it. Quantity.—The quantity of milk secreted increases rapidly for the first six to eight weeks, after this more slowly. To a certain extent the quantity is governed by the demands of the infant. A large, vigorous infant will obtain more milk than a smaller, less vigorous infant. Furthermore, a wet- nurse will secrete more milk while nursing two or three infants than while nursing only one. The following table gives the average daily amount of milk drawn by an infant (from Czerny and Keller) i1 Average weight The calcu- Average weight The calcu- Age of breast-fed lated day’s Age of breast-fed lated day’s in infants according amount of in infants according amount of weeks to Camerer. milk. weeks. to Camerer milk. gin. lb. and oz. gm. OZ. gm. lb. and oz. gm. oz. I . 3410 7 2 29I 9-7 H 5745 II 15 870 29.0 2 . 3550 7 6 549 18.3 15 5950 12 6 878 293 3 • 3690 7 11 590 19.7 16 6150 12 13 893 29.8 4 • 3980 8 5 652 21.7 17 6350 13 4 902 30.1 5 • 4ii5 8 9 687 22.9 18 6405 13 5 911 30.4 6 . 4260 8 14 736 ■245 19 6570 13 11 928 30.9 7 • 4495 9 6 785 26.2 20 6740 14 1 947 316 8 . 4685 9 12 804 26.8 21 6885 H 5 956 317 9 • 4915 10 4 815 27.2 22 7000 H 9 958 319 IO . 5055 10 9 800 26.7 23 7150 14 14 970 32.3 ii . 5285 11 808 26.9 24 7285 15 3 980 32.7 12 . 5455 11 6 828 27.6 25 7405 15 7 990 330 13 • 5615 11 11 852 28.4 26 7500 15 10 1000 33-3 1 Des Kindes Ernahrung, Ernahrungsstorungen und Ernahrungstherapie, Leipzig und Wien, 10, 353. WOMAN’S MILK 277 Composition.—Woman’s milk varies widely in its composi- tion. Its principal ingredients are the same as those in cow’s milk; namely, fat, lactose, protein, salts and water. The average composition is as follows: Average Composition of Woman’s Milk. Fat 3.50 Lactose 7.00 Protein 1.50 Salts 0.21 Water 87.29 Holt, Courtney and Fales1 divide lactation into four periods: The colostrum period (one to twelve days), the transition period (twelve to thirty days), the mature period (one to nine months), and the late period (ten to twenty months), and give the following figures as averages for these periods: Percentage Composition of Woman’s Milk. No. of Period. analyses. Fat. Sugar. Pro- tein. Casein. Albumin. Ash. Total solids. Colostrum, 1-12 days 5 2.83 7-59 2.25 O.3077 13-42 Transition, 12-30 days 6 4-37 7-74 I.56 0.2407 13-39 Mature, 1-9 mos. . 17 3.26 7-50 I-I5 O.43 O.72 0.2062 12.16 Late, 10-20 mos. . 10 3.16 7-47 I .07 O.32 O.75 O.I978 12.18 The sugar content remains practically constant throughout the entire period of lactation. Protein and ash are highest in the colostrum period and fall quite rapidly to the mature period after which they vary little. The fat content is low- est in the colostrum period, rises rapidly in the transition period, and then falls in the mature period. These analyses of Holt, Courtney and Fales are particularly important, because many of their specimens were entire twenty-four-hour amounts. Fat.—The fat in human milk is held in permanent emul- sion. The average percentage of fat is 3.5 or 4 per cent, but it may vary from 0.75 to 10 per cent. As a rule the amount of fat in the milk increases from the beginning to the end of each nursing. Volatile fatty acids form 2.5 per cent of the total fat of woman’s milk and 27 per cent of the total fat of cow’s milk. Oleic acid forms about 50 per cent of the non-volatile fatty acids, the remainder being composed of myristic, palmitic and stearic acids. Lactose.—The percentage of lactose in woman’s milk is more constant than that of the other constituents, being about 1 Loc. cit., p. 239. 278 BREAST REEDING 7 per cent, which is nearly twice that of cow’s milk. It is in solution. Protein.—The proteins of woman’s milk comprise casein, which is insoluble in water, and lactalbumin and globulin, which are soluble in water. Besides these there are some nitrogenous substances which do not give the protein reac- tions. A large part of the latter is supposed to be urea. There is considerable difference of opinion as to the proportions of these substances. According to Talbot the probable division of the total nitrogen is as follows: “Casein, 41 per cent; lactalbumin and globulin, 44 to 39 per cent; residual nitrogen, 15 to 20 per cent.” Thus the lactalbumin and globulin form a much larger part of the total protein in woman’s milk than they do in cow’s milk. Salts.—The average ash content of woman’s milk is less than a third that of cow’s milk, being only 0.21 per cent. The following table gives the average salt content of 100 cc of woman’s milk according to Holt, Courtney and Kales:1 Averages for the Different Periods. No. of analyses. Total ash. CaO. MgO. P 2O5. NajO. K20. Cl. Colostrum, 1-12 days 5 •3077 .0446 .OIOI .0410 •0453 .0938 .0568 Transition, 12-30 days 6 .2407 .0409 .0057 .0404 •0255 .0709 .0580 Early mature, 1-4 months ... 9 .2056 .0486 .0082 .0342 .OI54 •0539 •0351 Middle mature, 4-9 months ... 8 .2069 .0458 .0074 •0345 .0132 .0609 •0358 Late milk, 10-20 months . . . 10 .1978 .0390 .0070 .0304 •0195 •0575 .0442 The average percentage composition of the ash by the same investigation is as follows: Average Percentage Composition of Ash for the Different Periods. CaO. MgO. P2Cb. NasO. K20. Cl. Colostrum . 14.2 3-5 12-5 13-7 28.1 20.6 Transition . 17.O 2.4 16.9 10.9 30.8 22.9 Mature • ■ • 23.3 3-7 16.6 7.2 28.3 16.5 Late .... 19.8 3-6 15-5 10.1 18.8 22.3 Iron.—The iron content of woman’s milk is about three times that of cow’s milk. This makes the iron intake of an infant fed on diluted cow’s milk much lower than that of a breast-fed infant. Phosphorus.—Woman’s milk contains much less phosphorus than cow’s milk. About three-fourths of the phosphorus of 1 Am. Jour. Dis. Child., 1915, 10, 243, 245. WOMAN'S MILK 279 woman’s milk is in organic combination, as against one-fourth of that of cow’s milk. Salts of Woman’s and Cow’s Milk.—The total ash content of cow’s milk is about three and one-half times that of woman’s milk. The proportion of the different salts is quite similar, the chief differences being in the larger amount of iron and the smaller amount of phosphorus in woman’s milk. Holt, Courtney and Fales1 give the average composition as follows: Comparison of the Percentage Composition of the Ash of Woman’s and Cow’s Milk. CaO. MgO. PaOt. NasO. KaO. Cl. Mature woman’s milk . • 23.3 3-7 16.6 7.2 28.3 16.5 Cow’s milk • 23.5 2.8 26.5 7.2 24.9 13.6 Bacteria.—A few bacteria, usually staphylococci, are found in the milk of healthy women. Typhoid bacilli have been demonstrated in the milk of a woman ill with typhoid fever. Syphilis can probably be transmitted by the milk even when the breasts are apparently normal. Pathogenic bacteria may be present in the milk when the mother is suffering from a local infection of the breast or a general sepsis. Drugs. —Some drugs are excreted in woman’s milk. They are alcohol, bromides, iodides, salicylates, mercury, calomel, antipyrin, arsenic, urotropin, the saline cathartics and sal- varsan. Probably morphine and atrophine also are excreted in woman’s milk. Most of these are found in very minute amounts. Nervous Impressions.—Any severe, acute or prolonged ner- vous strain may so alter the mother’s milk as to seriously upset the infant. For this reason it is important that a nursing mother should lead a quiet life and avoid all nervous strain and excitement. Women that are prone to nervous disturbances, as hysteria, are seldom able to nurse their infants successfully. Menstruation.—Menstruation does not, as a rule, seriously affect the milk supply. Not infrequently the infant is uncom- fortable and has undigested stools at the onset. Only rarely is the disturbance more serious and prolonged. Pregnancy. —If a nursing mother becomes pregnant her milk rapidly deteriorates both in quantity and quality. Weaning is imperative. Transmission of Immunity.—A mother who is immune to one or more of the infectious diseases usually transmits a varying degree of immunity to her offspring. Some of the 1 Am. Jour. Dis. Child., 1915, 10, 246. 280 BREAST FEEDING immune bodies enter the fetus by way of the placenta, but the work of Famulener1 would seem to show that a greater number pass from the mother to the infant in the colostrum which is secreted in the first few days. He, as well as others, demonstrated immune bodies in the colostrum of immune mothers. Furthermore, the concentration of immune bodies in the colostrum was greater than in the mother’s blood serum at the same time. Milk of a later period contained a much smaller number of immune bodies. After taking the colostrum of such mothers for several days, the concentration of immune bodies in the blood serum of the young animals was greatly increased. There seems to be no reasonable doubt but that newborn infants can absorb such immune bodies from the digestive tract. Immune bodies with homolo- gous proteins, such as are present in milk of the same species, are more readily absorbed than those associated with heterol- ogous proteins, as in milk of other species. These facts would emphasize the importance of young infants nursing at least for a few days. Diet.—Within narrow limits the amount and composition of the milk may be altered by changes in the diet, l'he best results are obtained when the mother has been underfed and the milk is abundant but poor in quality, especially in fat. Increasing the diet generally, but especially the fat and car- bohydrate, will usually increase the fat content of the milk. When the fat is too high, reducing the fat and carbohy- drate in the diet and increasing the mother’s exercise will usually reduce the fat. Low protein can be overcome by increasing the diet when the mother has been underfed, but is rarely influenced when the mother is already receiving a plentiful diet. Reducing the diet and increasing the exercise will sometimes reduce a too high protein. The percentage of lactose in woman’s milk is more constant than that of either the fat or the protein and is little influenced by diet. An increase in the fluid intake will often increase the quantity of milk. BREAST FEEDING. The simplest and best way to feed an infant is to nurse it. No artificial food has been evolved which gives nearly as uniformly good results. Therefore every mother that can do so should nurse her infant. The great value of breast feed- ing as compared with artificial feeding is proved by the much higher mortality rate among artificially fed infants. Another 1 Studies from Research Lab. Dept. Health of New York City, 1911, 6, 199. BREAST FEEDING 281 factor of importance is the greater frequency of rickets among the artificially fed. With premature infants, full-term infants that are feeble and underdeveloped, and the occasional infant that is unable to digest cow’s milk, breast milk is essential. Among the poor there is very little opposition to breast feeding, unless the mother is the wage-earner and has to be away from home during the day, and even these mothers usually nurse their infants night and morning. Among the well-to-do the mothers are less frequently able to nurse their infants, and they find the frequent nursings and especially the restrictions which nursing places upon their time very irksome. Contraindications for Breast Feeding.—The most frequent contraindication is insufficient milk, but every effort should be made to increase the amount of milk before resorting to artificial feeding. Another important contraindication is serious illness of the mother, as tuberculosis, typhoid fever, puerperal fever and mastitis. When a nursing mother develops an infec- tious disease of short duration, as tonsillitis, she may stop nursing during the febrile stage and resume it later. The breasts should be emptied two or three times a day by mas- sage and the breast pump. Many women resume nursing in this way after intervals of as long as two weeks. Occasion- ally a nursing mother has to have an operation. As a rule the infant may be put back on the breast as soon as the effects of the anesthetic have worn off. For a few days after this he should nurse less frequently than usual and should receive sufficient artificial feeding to make up for the lack of breast milk. As the mother improves and her supply of milk increases the artificial feeding should be gradually stopped. Frequently an infant is taken from the breast of a healthy mother and given a cow’s milk mixture because he does not thrive or has indigestion. If the amount and quality of the mother’s milk is insufficient and cannot be improved by diet and regulation of her mode of living, there is nothing else to do. When, however, the supply of milk is ample and the quality good, every effort should be made to adapt it to the infant before beginning artificial feeding, and in only rare instances is this impossible. Occasionally a nursing mother will become pregnant. When this occurs her milk deteriorates rapidly in amount and quality. At first the infant stops gaining, later he loses weight. Artificial feeding should be begun at once. Intervals of Nursing.— Formerly an infant was nursed whenever he cried and appeared hungry, and this is today 282 BREAST FEEDING the usual procedure among the ignorant. Many such infants thrive and gain steadily, but they are usually irritable and frequently upset the entire household. Habits are soon formed by infants, and regularity is an important one. Six to eight hours after birth the infant is allowed to nurse for five minutes. After this the nursings are repeated every six hours for the first two days. When the breasts begin to secrete milk, which usually occurs on the third or fourth day, the intervals are shortened to three hours, with one nursing omitted at night. At the same time the length of time that the infant is allowed to nurse is increased to ten or fifteen minutes. From this time to the third month the infant should nurse at 6, 9, 12, 3, 6, 9, and once during the night, usually about 2 a.m. Usually the night feeding may be stopped after the first month or six weeks. It is well to stop this feeding as soon as possible, as the long undisturbed sleep is good for both mother and infant. After the fifth month the intervals may be lengthened to four hours and the number of nursings reduced to five. The hours will now be 6, io, 2, 6, io. Many babies are now put on this four-hour schedule from the start. If there is plenty of milk and the infant is vigorous the results are rather better with the longer intervals between nursings. During the day the time of feeding should be strictly adhered to. At night, however, the time may be varied considerably to suit the convenience of the mother. For example, occasion- ally an infant will wake at 5 a.m. He may be fed then instead of at 6 a.m., but he should not receive his second bottle before the regular time, that is at 9 or 10 a.m., depending on whether he is on a three or four-hour schedule. The time for giving the evening bottle may vary between 9 and 12 p.m. When the night feeding is dropped, it shortens the interval between the last evening feeding and the first morning feeding if the even- ing feeding is given at 11 p.m., instead of 9 or 10 p.m. The infant is therefore more apt to sleep until the usual time for the morning feeding. These intervals are somewhat longer than those frequently recommended for the first few months. Feeble and prema- ture infants frequently do better when nursed every two or two and one-half hours. Normal infants, however, gain just as rapidly on three or four-hour intervals, which have the advantages of allowing the stomach to empty more com- pletely between nursings, giving the mother more freedom and lessening the likelihood of cracked nipples. Length of Each Nursing.—After lactation is well estab- lished most infants will nurse fifteen to twenty minutes each BREAST FEEDING 283 time for the first few weeks. Later they will frequently be satisfied in ten minutes. An infant should never be allowed to nurse a few minutes, play a few minutes and then nurse again. They should be taught from the beginning to nurse steadily, with an occasional rest, until they have finished. An infant should never be allowed to sleep in the same bed with his mother, as this encourages him to nurse frequently during the night. An infant should seldom be allowed to nurse more than twenty minutes. If he is not satisfied by this time, he is either taking too much or the supply of milk is scanty. Weighing him before and after nursing will settle this point. Mother’s Diet and Exercise.—A nursing mother should take a plentiful diet of easily digested food, with some extra fluid, as milk, egg and milk, cocoa or gruel in the middle of the morning and afternoon and before going to bed at night. If preferred the extra milk may be taken after each meal. Besides this she should drink a plentiful supply of water. She should avoid all articles of diet that are highly spiced, very rich or difficult of digestion, such as peppers, pickles, relishes, vinegar, rich puddings and sauces, lobster, crabs, Welsh rarebit, and excessive amounts of coffee, tea and alco- hol. Most nursing mothers can take moderate amounts of raw or cooked fruits and vegetables. Occasionally, however, even moderate amounts of fruit, especially the more acid ones such as grapefruit, or green vegetables, particularly tomatoes and onions, will cause colic and indigestion in the infant. When this happens the particular fruit or vegetable causing the trouble should be omitted from the diet. If it is impossible to determine which fruit or vegetable is causing the trouble, it is well to omit all fruit and green vegetables until the infant is normal again. Then they may be resumed one at a time, the infant being watched for any return of the symptoms. In this way the cause of the disturbance can usually be identified and so eliminated. A nursing mother should be relieved, as far as possible, of all strenuous work and exercise. Moderate exercise, on the other hand, is essential for her health and counteracts the tendency to too rich milk. Walking in the open air is one of the best forms of exercise. More essential even than exercise is sufficient rest. She should have at least one long period of sleep during the night, and at least two hours of sleep during the day. The longer intervals between nursings and the early. stopping of the night feeding all help toward this end. It is possible to influence the quantity and composition of 284 BREAST FEEDING the mother’s milk to a considerable extent by altering her diet and mode of living. If the quantity is too small the mother’s diet should be increased, especially the amount of milk, eggs, and meat. Also her water intake should be increased. Her exercise should be limited and sufficient rest assured. Frequently relieving her of the physical and mental strain of caring for the infant helps a great deal. If she is anemic, run down or unable to take sufficient food because of lack of appetite, appropriate medication is indicated. If the milk is too rich, which usually means a high fat and protein content, lessening the mother’s diet (especially meat, eggs and milk), increasing the amount of water which she takes, and increasing her exercise will usually reduce the fat content of the milk. At the same time the infant may be given one-half ounce of sterile water before each breast feed- ing and the length of the nursing reduced or the interval between nursings increased. When the milk is poor in quality, that is, has a low fat content, the procedure is the same as when it is insufficient, except that it is more important to increase the solids in the mother’s diet than the fluids. It is easier to correct an abundant supply of overrich milk than an insufficient supply of milk which is poor in quality. Vomiting.—Most infants, whether breast or bottle fed, will occasionally regurgitate small amounts, from a few drops to a teaspoonful or two. This is to be expected and need cause no alarm. When, howeyer, a breast-fed infant vomits large amounts after a good many feedings, something is wrong either with the milk or the method of handling the infant. The possibility of pyloric stenosis must always be kept in mind. Not infrequently it is due to the infant’s efforts to rid himself of air swallowed during the nursing. This is apt to happen when the infant is placed in his bed immediately after nursing. C. H. Smith1 has demonstrated that under these circumstances the gas is water-locked in the stomach, and an endeavor to belch it on the part of the infant is sure to cause some vomiting. If the infant is held erect for a minute or two after nursing he will belch the gas without losing any milk. Too much milk or too high fat will cause vomiting. The amount can be determined by weighing before and after nursing. If the infant is taking too much, the length of the nursing should be shortened. If analysis of the breastmilk shows a too high fat content the mother’s diet should be cut 1 Am. Jour. Dis. Child., 19x5, 9, 261. BREAST FEEDING 285 down slightly, especially the solid food, and her water intake and exercise increased. Also the infant may be given one- half ounce of sterile water before each nursing. Gas and Colic. —Both gas and colic occur much less often when an infant is breast fed than when he is artificially fed. The usual cause of gas has been explained in the previous section on vomiting. Occasionally certain articles in the mother’s diet will cause colic in the infant. The most fre- quent are the raw acid fruits and green vegetables. The method of handling this situation has been explained in the section on the mother’s diet. Normal Stool.—A normal breast-fed infant usually has from one to four stools a day. The stools are soft, almost never formed, and yellow in color. They are not uniform in consistency, like the stool of an artificially fed infant, but contain a varying number of small, soft masses, each about a millimeter in diameter, which are light in color. Their reaction is slightly acid. Not infrequently an infant that is gaining regularly and is comfortable will have decidedly abnormal stools. This in itself is not an indication for stop- ping nursing. Abnormal Stools.—Constipation is unusual in the breast- fed infant unless the milk is insufficient either in quality or quantity. Loose, too-frequent stools, often containing considerable mucus, accompanied by colic, may occur when the mother is menstruating, after an indiscretion in diet on the mother’s part, when the mother is suffering from an acute infection, when the milk contains more sugar than the infant can digest, or when the infant is taking more milk than he can use. Most of these conditions are transient and easily righted. If the milk is at fault the first thing to do is to determine the quantity taken by the infant and the composition of the milk. The quantity taken can be determined by weighing the infant before and after nursing. If the quantity is too great the length of each nursing should be shortened. If the composition of the milk is wrong an endeavor should be made to correct the fault by changing the mother’s diet and routine, as is explained in the section on the mother’s diet. This is at times impossible, especially when the milk is both scanty and poor in quality. Unless some improve- ment is made within two weeks it is rarely wise to persist any longer. MIXED FEEDING. When a woman has an insufficient supply of milk for her infant, supplementary feedings of cow’s milk may be used. 286 BREAST FEEDING This is mixed feeding, and it is indicated whenever the breast milk is of good quality but insufficient in amount to properly nourish the infant. One of two procedures may be employed, either small bottle feedings may be given after each breast feeding, or bottle feedings may be substituted for some of the breast feedings. If the former method is followed the infant is given only one breast at a nursing. The amount of breast milk obtained is calculated by weighing the infant before and after nursing. Then a sufficient bottle feeding is given to make up the proper amount. As a rule it is not necessary to weigh the infant before and after nursing for more than a few days. If the second method is chosen, one, two or three of the breast feedings are omitted and a full bottle feeding given at these times. At the breast feedings it is best to give the infant both breasts each time, as otherwise the long inter- vals between nursings tend to diminish the amount of milk secreted. It is rarely possible to keep up the supply of milk if the infant nurses less than four times in each twenty-four hours. There is a distinct advantage in always giving one bottle feeding a day to all breast-fed infants after the third month. By so doing they become accustomed to taking the bottle and their digestion becomes adapted to cow’s milk. Furthermore, it allows the mother one long interval during the day in which she may rest or be out of doors. If at any time it becomes necessary to wean the infant suddenly it can be accomplished with much less likelihood of disturbance. In beginning mixed feeding a relatively low formula should be used at first. A three-months-old infant should begin with about a 6 in 20 and a six-months-old infant with an 8 in 20 mixture. The full amount for the infant’s age may be given from the beginning. The strength of the formula may be increased quite rapidly, about an ounce of milk being added every three days, provided there are no evidences of indi- gestion, until the strength of the formula is proper for the infant’s age. The advantages of mixed feeding over artificial feeding are that it gives the infant a considerable amount of breast milk, that it allows the infant to become accustomed to cow’s milk gradually, and that it simplifies weaning. WEANING. Few women can nurse their infants to advantage after the eighth or ninth month, and many have to give supplementary feedings long before this. Where it is possible to obtain good cow’s milk it is a distinct advantage to give the infant WEANING 287 one bottle feeding a day after the third or fourth month. This accustoms the infant to the bottle and greatly lessens the difficulty of weaning if the latter becomes necessary at any time. Infants that have never had a bottle feeding until they are six months of age or older will frequently refuse it absolutely as long as they are given the breast at* all and some- times for several days, even after the breast feedings have been entirely stopped. During this time they lose weight rapidly and not infrequently develop considerable fever. Little is gained by forcing them to take the bottle under these circumstances. The best method is to offer the bottle at the regular intervals and take it away if refused. They always give in finally. No serious results follow this method. A three-months infant, on the other hand, soon becomes accustomed to taking one feeding from the bottle. The indications for early weaning are insufficient milk, severe illness of the mother and pregnancy. When possible it is better to wean gradually. If the infant has been taking one bottle a day, another of the same strength is added and after a few days another until all of the breast feedings have been stopped. The rapidity with which this is done will depend upon the cause of the weaning and the amount of milk which the mother has. If the infant is already taking a bottle feeding, the other feedings should be of the same strength. If the infant has never taken any cow’s milk the first formula should be considerably weaker than a normal artificially fed infant of the same age would be taking. After the first few days the strength of the formula should be grad- ually increased until the food is sufficient for the infant. When it is necessary to stop all breast feedings at once it is more important to begin with a relatively weaker formula than when the bottle feedings can be gradually substituted. When the mother is able to nurse the full eight or nine months the process is much simpler. The various foods other than milk are added to the diet in the same order and amounts as with the artificially fed infant, except that it is not neces- sary to make these additions quite as early. When cereal is begun, a small amount of cow’s milk (i or 2 ounces) diluted with an equal volume of boiled water is given with the cereal. As the cereal is increased the strength and amount of milk are increased. Then one feeding of diluted milk is substituted for a breast feeding. If the mother is well and strong and has an abundant supply of milk she may be allowed to nurse to the twelfth or thirteenth month. When this is possible it may not be necessary to use bottles at all, the infant being weaned directly to the cup. In no normal case should bottles be continued after the eighteenth month. CHAPTER XVII. ARTIFICIAL FEEDING FOOD REQUIREMENTS OF THE ARTIFICIALLY FED INFANT. Energy.— Repeated efforts have been made to formulate some law or laws by which the caloric requirements of a given infant could be calculated. The first work was based entirely upon the body weight. It was soon found that the caloric requirement per pound was considerably larger for thin infants than for well-nourished infants. Then it was suggested that the surface area, and not the body weight, was the governing factor. As it is obviously impossible to actually measure the surface area of all infants, different investigators have worked out formulae by which the sur- face area of infants can be calculated. The results obtained by this method are more uniform than those obtained where the weight alone is considered, but the calculations are too complicated to be of practical use in everyday practice. Recently it has been suggested that the caloric requirement of an infant varies directly with the mass of active proto- plasmic tissue in the body. This would explain why a thin infant requires more calories than a fat infant of the same weight. Unfortunately we have no means of calculating the mass of active protoplasmic tissue of any living infant. Muscular exertion has a marked influence upon the require- ments of the infant. Hard crying may increase the energy output by ioo per cent. Thus a very active infant always requires more energy than a quiet, passive infant. For practical use the body weight must be the guide at present. The usually accepted requirement is ioo calories per kilo or 45 calories per pound of body weight for each twenty-four hours from the end of the second week to the ninth month. At the same time we must remember that a very thin infant will frequently require considerably more than 100 calories per kilo, while a very fat infant may gain and do well on considerably less. During the first two weeks the caloric requirement is considerably less than 45 calories per pound, averaging only about 30 calories. After the eighth month the requirement falls to about 40 calories per pound. 288 THE ARTIFICIALLY FED INFANT 289 Protein. —Protein is required by the infant to replace that lost in tissue waste and for the formation of new tissue in growth. This double demand makes the protein require- ment of a growing infant relatively greater than that of an adult. Furthermore, as the most rapid growth takes place during the early months, the protein requirement is greatest during these months. Morse and Talbot1 say, “The aver- age protein need of infants is at least 1.5 grams per kilogram, or 0.7 gram per pound of body weight.” In order to obtain this amount an infant must take nearly an ounce of cow’s milk per pound of body weight. The generally accepted rule of 11 ounces of cow’s milk per pound of body weight furnishes considerably more than this amount. Almost all cow’s milk mixtures contain more protein than woman’s milk. This is especially true of whole-milk mix- tures. The low fat content of the latter makes it necessary either to use a very high sugar content or to raise the protein considerably above the theoretical requirement in order to furnish the necessary calories. Thus the whole-milk mixtures which are commonly used contain about if ounces of milk per pound of body weight. Animal protein is more easily digested and more com- pletely absorbed than vegetable protein. The protein of milk is most readily digested by infants, that of woman’s milk more easily than that of cow’s milk. Formerly most of the digestive disturbances of infants were attributed to the protein, but of late the tendency has been to minimize the importance of protein as a cause of indigestion. Some justification for the larger amounts of protein frequently fed in cow’s milk mixtures is found in the smaller amounts of some essential amino-acids in the pro- tein of cow’s milk. Fat.—As fat furnishes approximately twice as many calories per gram as carbohydrate or protein, it is a very important element in the food, and small variations in the fat content of the food have a marked influence upon its energy value. In health from 90 to 98 per cent of the fat in the food is absorbed. In digestive disturbances, especially those conditions which are associated with diarrhea, a much smaller portion of the fat ingested is absorbed. Holt, Courtney and Fales2 found that from 90.3 to 99.2 per cent of the fat intake was absorbed in healthy breast-fed infants and an average of 91.3 per cent by healthy infants fed on modified cow’s milk. In normal infants they found the average fat 1 Diseases of Nutrition and Infant Feeding, 1915, p. 201. 2 Am. Jour. Dis. Child., 1919, 17, 241, 423. 290 ARTIFICIAL FEEDING per cent of the dried stool to be 34 per cent whether the infant was taking woman’s or cow’s milk. The fat in the stools of breast-fed infants was divided as follows: Soap fat 43.1 per cent, free fatty acids 36.7 per cent, neutral fat 20.2 per cent. In the stools of healthy infants fed on modified cow’s milk the fat was divided as follows: Soap fat 60.5 per cent, neutral fat 12.1 per cent. In both groups of infants suffering from diarrheal conditions the fat retention fell markedly. At the same time the percentage of soap fat in the stools fell and the percentage of free fatty acids and neutral fat rose. There is considerable difference of opinion as to the amount of fat which a normal infant’s food should contain. Many physicians use top milk mixtures and thus keep the fat con- tent of the food about twice that of the protein. Others use whole-milk mixtures which make the fat content of the food only slightly greater than the protein. Both methods have their advantages and disadvantages. An infant fed on the higher fat mixtures will gain more rapidly and be satis- fied with smaller amounts of food, especially during the early months, than one fed on whole-milk mixtures. Further- more, the higher fat content permits the use of smaller amounts of sugar, which is necessary in feeding infants with an intolerance for sugar. The disadvantage is that infants fed on high fat mixtures are more apt to have digestive disturb- ances. For this reason whole-milk mixtures with their lower fat contents are safer in the hands of those with comparatively little experience. Carbohydrate.—Sugar.—All milk contains lactose or milk- sugar. The sugar content of woman’s milk is about 7.5 per cent, which is nearly twice that of cow’s milk. When cow’s milk is diluted its sugar content is still further reduced, so that a considerable amount of sugar has to be added to cow’s milk mixtures in order to bring their sugar content up to the required amount. As a rule sufficient sugar is added to make the sugar content of the mixture about 6 per cent, rarely more than 7 per cent. An infant fed on woman’s milk receives slightly more calories in fat than in sugar, while an artificially fed infant taking cow’s milk mixtures receives a rather large part of his calories in the form of sugar. Three sugars are used in infant feeding: Lactose (milk-sugar), saccharose (cane-sugar) and maltose. All of these sugars are disaccharides and in the process of digestion they are broken down into monosaccharides. The rapidity with which they are absorbed differs and hence their effect upon intestinal fermentation and peristalsis. Lactose is more slowly absorbed than either maltose or THE ARTIFICIALLY FED INFANT 291 saccharose. Its longer stay in the intestinal canal is sup- posed to favor the normal fermentation processes and thus to hold in check excessive putrefaction. Furthermore, it is slightly laxative. For these reasons it is the sugar of choice for feeding normal infants. Pure maltose is never used in feeding because of its cost. The maltose used is always a mixture of maltose with dextrin, the maltose forming about 50 per cent of most of the preparations. The dextrin content is more variable. The following table, taken from Morse and Talbot,1 gives the percentage of maltose and dextrin in the more common preparations used: Food. Maltose, per cent. Dextrin, per cent. Loflund’s Nahrmaltose . 40.OO 60.00 Mead’s Dextrimaltose . . . 51.00 47.00 Neutral Maltose (Maltzyme Co.) . 63.00-66.00 8.00-9.00 Loflund’s Malt Soup Extract • • • 58-9I I5 42 Maltose (Walker-Gordon laboratory) . • 57-io 30.90 Mellin’s Food . . . 58.88 20.69 Malted Milk • • • 49-15 l8.80 In digestion one molecule of maltose is split into two mole- cules of dextrose. For this reason it is more rapidly absorbed than either lactose or saccharose. This rapidity of absorption and the fact that some infants that have developed a fer- mentative diarrhea while taking lactose will digest maltose easier than lactose are the chief reasons for its use. Saccharose (cane-sugar) is split into dextrose and levulose in the process of digestion. As the levulose has to be changed into dextrose before being absorbed, cane-sugar is more slowly absorbed than maltose. Cane-sugar is somewhat less laxative than lactose. Furthermore, it is much cheaper than either of the other sugars. Many normal infants will thrive as well on cane-sugar as on lactose or maltose. Its cheapness is its chief recommendation. Starch.—Starch is used for two purposes in infant feeding: First to prevent the formation of large casein curds in the stomach, and second to increase the strength of the food. For the first purpose only a small amount of starch is neces- sary, 0.75 per cent of starch in the food being as effective as larger amounts. This amount of starch may be added to the food of very young infants. After the second month some form of starch is usually added to most artificial mixtures. At first a cereal water, made by boiling one level tablespoonful of either oat or bar- ley flour and a pinch of salt in a pint of water for three-quarters of an hour, is used. After the fifth month two level table- 1 Diseases of Nutrition and Infant Feeding, 1915, p. 194. 292 ARTIFICIAL FEEDING spoonfuls of flour may be used. Barley water is generally believed to be slightly more constipating than oat water. Inorganic Salts.—The salt content of cow’s milk is about three and one-half times that of woman’s milk. The result is that the ordinary infant fed on diluted cow’s milk receives a considerably greater amount of salts than a breast-fed infant. Furthermore, the relative proportions of the various salts differ somewhat in the two feedings, the chief difference being in the phosphoric acid. These differences are believed to have a considerable influence upon the growing infant, especially in disturbances of digestion. The following table from Holt1 gives the relative percent- age of the different salts in both cow’s and woman’s milk: Cow’s. Woman’s. CaO 22.8 23-3 MgO 2.8 3-7 p2o6 27.4 16.6 k2o 24.7 28.3 Na20 IO.Q 7.2 Cl 15-5 16.5 Water.—The amount of fluid required by an infant increases rapidly during the first three months and more slowly after that. A normal infant usually requires about 12 ounces at the end of the first week, 24 ounces at the end of the first month, 30 ounces by the end of the third month, 36 ounces by the fifth month, and 40 ounces by the eighth month. As a rule the fluid intake is about one-seventh of the body weight. As long as all the food is fluid, little addi- tional water need be given, but as soon as part of the food is solid additional water must be given. Vitamins.— Besides fat, sugar, proteins, salts and water, milk contains certain “accessory food factors,” or vitamins. Already three separate and distinct vitamins have been identi- fied and the recent work of McCollum and others makes the presence of a fourth extremely probable. In order that health may be maintained and growth proceed in an orderly manner, the food of an infant must contain a sufficient amount of each vitamin. It has now been shown that the amount in milk is dependent upon the amount in the food of the cow. So far as we know the animal body does not synthesize these substances. Thus cow’s milk in winter contains smaller amounts than in summer. This deficiency can be largely overcome by regulating the cow’s diet. 1 Diseases of Infancy and Childhood, 1916, 7th ed., p. 150. PROPRIETARY FOODS 293 PROPRIETARY FOODS. There are many so-called “infant foods” on the market. While these differ greatly in composition they all have cer- tain common characteristics. Almost all contain large amounts of carbohydrate and small amounts of fat and pro- tein. It is well to remember that similar mixtures can be produced with the usual ingredients of infant’s food without using these proprietary preparations. They may be divided into four classes: First, those con- taining cow’s milk; second, those containing considerable amounts of maltose and dextrins; third, farinaceous foods; and fourth, miscellaneous preparations. Preparations Containing Cow’s Milk.—This group includes the malted milks, Allenbury’s milk food No. i and No. 2, and Nestle’s food. The basis of all these is milk that has been evaporated to dryness. All have considerable quanti- ties of carbohydrate added. Their fat content is consider- ably higher than that of any of the other classes. Preparations Containing Large Amounts of Maltose.— Mellin’s food, which contains about 60 per cent of maltose, is the best example of this group. Mead’s dextrimaltose No. 1 contains about 53 per cent of maltose. The malted milks are usually included in this group, but their fat content is a great deal higher, due to the milk used in their manu- facture. These foods may be used when maltose is indi- cated, but should never be used without milk. Farinaceous Foods.—This group includes imperial granum, Ridge’s food, Robinson’s barley and oat flour, Brook’s barley flour and the Cereo Company’s flours. The group differs from the first in that they contain almost no fat, and from the second in that they all contain considerable amounts of unchanged starch. They may be used when it is desir- able to add some carbohydrate partly in the form of starch to the food. The Cereo Company also furnishes an enzyme preparation called cereo. By its use from 70 to 98 per cent of the starch is converted into soluble carbohydrates. Miscellaneous Foods.—Eskay’s albumenized food is made from egg albumen and cereals. Peptogenic milk powder is largely milk-sugar. The following table1 gives the composition of most of the foods mentioned: 1 The figures for fat, protein, starch and ash in the above table are taken from the Report of the Connecticut Agricultural Experiment Station, 1916, p. 328. Those for sugar are for the most part from Morse and Talbot: Diseases of Nutri- tion and Infant Feeding, 1915, p. 230. 294 ARTIFICIAL FEEDING Name. Fat, per cent. Sugar, per cent. Protein, per cent. Starch, per cent. Ash, p. c. milkl 49 -151 Horlick’s malted milk . 8.10 67-95- maltj 15.OO 4.OO dextrin i8.8oj milk 42.00] Allenbury’s food No. i . 13.80 66-55 malt 14.00I 9.88 3-98 dextrin 10.00! milk 36.001 Allenbury’s food No. 2 . 14.20 ~b O' O t'. malt 20.00}- 9-75 3-70 dextrin 13.00I milk 6-571 Nestle’s food 5-70 58.93' cane malt dextrin 25-0 27 - 361 11.94 20.25 i-45 Name. Fat, per cent. Sugar, per cent. Protein, per cent. Starch, per cent. Ash, p. c. Mellin’s food Mead’s dextrimaltose, . No. i I .80 79-57 93 • 0° malt dextrin malt .dextrin aex- 58.88I 20.69 f 52.00I 41.oof II .31 4-45 2.00 Imperial granum O.50 1.80 trose dextrin 0.42 [ 1.38J '13-88 72.79 0.50 Ridge’s food . . 0-33 2.96 IO.31 70.93 0-75 Robinson’s barley . I .40 2.92 6-75 70.20 0.85 Brook’s barley . I.03 3-48 8.69 68.51 0.88 Cereo barley .... 2.03 5.20 14.88 58.39 1.48 Cereo oat .... 6.4O 2.36 "milk dextrin 54-12'! 1.70/ 16.44 56.31 2-53 Eskay’s food I .28 55 • 82 the extractives, for the lower the percentage of the latter in meats the less prone are they to increase blood-pressure. For this reason glandular organs are usually more likely to increase 1 Southern Med. Jour., 1912, 5, 244. 2 Trans. Eng. Chem. Soc., 1909, 95. 3 New York Med. Jour., 1912, 96, 315. 328 DISEASES OF THE CIRCULATORY ORGANS blood-pressure than other parts of the animal, and meat that is roasted or broiled has more effect than if boiled and, least of all, if boiled in two waters. Here too food of almost any kind is much more apt to increase pressure if taken in large amounts, for, as already stated, overeating seems often to be one of the chief factors in the production of arterio- sclerosis and hypertension. Alcohol in moderate dosage probably has little or no effect on blood-pressure—when taken more liberally it causes a fall in pressure. The question as to the effect of taking large amounts of fluid upon blood- pressure in normal or hypertensive cases has received much consideration. It was formerly thought that the effect was definitely to raise pressure in both classes of cases, but the general consensus of opinion as voiced by Miller and Williams1 seems to be that when water elimination is normal, as it may of course be, in hypertensive cases with or without chronic nephritis, the pressure is little if at all affected. On the other hand a rise of pressure does occur if water elimination is poor. F. M. Allen in discussing this paper says that even hypertensive cases that have good water elimination when salt is given the pressure will go up. He found the type of nephritis with normal pressure in whom there was a great lag of excretion, the blood showed a volumetric increase, but there was no rise of pressure because the patients got edema. 2. Those foods which tend to decrease blood-pressure are the carbohydrate foods; farinaceous foods, vegetables, fruits, fats and milk preparations, as the latter are purin-free. Aneurysm.—Aneurysm has also been the subject of special dietary attention, Tufnell prescribing the best-known regimen which is noted for its extreme restriction; breakfast, 2 ounces of bread and butter, 2 ounces of milk or cocoa. Noon, 3 or 4 ounces of meat with 2 or 3 ounces of potato or bread and 3 or 4 ounces of water. Night, 2 ounces of bread and butter, 2 ounces of milk or tea. Of course this is an absurd diet and only a strong person could stand it at all; the resulting blood con- centration which it is hoped to gain is more than offset by the starvation necessary and would be distinctly bad for weak persons. All blood-pressure-raising foods should be avoided, however, as well as psychic irritation, intestinal fermentation and bodily overwork.2 Angina Pectoris. — Both the rules for avoiding the produc- tion of arteriosclerosis and hypertension should be made use of, special attention being given to the avoidance of acute attacks of indigestion which often accompany a fatal attack 1 Tr. Am. Phys., 1920, 35, 68. 2 Hecht Zwit. Fr. med. Klin., 1912, 76, 87. DIET IN DISEASE OF THE BLOODVESSELS 329 of angina, although many times indigestion is undoubtedly secondary to the claudication rather than the cause of the anginal attacks. The evening meal should be simple and light. Tobacco in Relation to Cardiac Disease.—While not a food, tobacco is so generally in use that a word as to its place in cardiovascular cases is not amiss. Not much is really known about the continued effect of small doses of tobacco and its contained alkaloids, although there are many theories; there is, however, practical unanimity of opinion regarding its large or excessive use and that so used it is of distinct dis- advantage. By its blood-pressure-raising qualities, its prone- ness to disturb digestion in some persons, to cause irritation of the myocardium (extrasystoles) it is certainly best let alone in these conditions; whether a very moderate use of tobacco by its soothing and contenting effects may not offset the possible bad effect of continued small amounts is a question to be decided in each case. If a patient becomes susceptible to its effects, or if used in large amounts, there is every reason for interdicting the use of this substance. CHAPTER XX. FEEDING IN DISEASES OF THE LUNGS. Much of what has been said in regard to the relation of diet to diseases of the circulatory apparatus holds equally true for the pulmonary diseases. In addition, food must be considered in its relation to acute or chronic infections, and from the mechanical standpoint as a possible factor in increasing symptoms by pressure from an overloaded or dis- tended stomach; besides, of course, its nutritional value. In pneumonia, lobar or lobular, we are dealing for the most part with a self-limited disease of short duration, i. e., as compared with typhoid for example. On this account the food quantities that are given would perhaps not be so important if we could be sure a case would run for not more than seven to ten days. Unfortunately some of the cases run considerably longer or else develop serious complications, such as empyema, in which it is of the utmost importance that the patients should not have lost flesh and strength unnecessarily and so arrive at the late stages of the disease or its complications, in an overweakened condition. On this account the proper dietary treatment may have a very real bearing on the prognosis of the disease. The routine diet in these cases has usually been feeding of milk, broth, albumen water and gruels with a total nitrog- enous content and caloric value far below the body’s require- ments. Coleman, on the other hand, has applied the prin- ciples of the high caloric diet as used in typhoid, and appar- ently with some success; but the need for the prevention of abdominal distention makes the giving of large quantities of food, especially carbohydrates, questionable, and as the majority of cases run but a week, it is perhaps wisest to be content with nourishing patients, if not to the full limit of a theoretical capacity, at least sufficiently to prevent undue losses. The necessity for keeping the excretory organs unhampered by excessive amounts of the products of food metabolism must also be kept in mind, for at times it seems as if we could ask little more than that the organs should remove the disease toxins as rapidly as they are formed. It is, never- 330 FEEDING IN DISEASES OF THE LUNGS 331 theless, most important that sufficient food of the right sort should be given in order that the natural antitoxin-producing organs should run at their highest efficiency under the cir- cumstances, and as well, to prevent a starvation acidosis from further complicating the picture. We know, too, that in pneumonia the percentage of uric acid in the blood is always higher than normal, due to an excessive endogenous uric acid metabolism, and one should therefore avoid as much as possible feeding the purin bodies in the food. These two indications are met by giving a fair but not excessive amount of carbohydrate and fats and a low purin or nearly purin-free diet, during the acute stage of the illness, all in a liquid or semisolid form, the total amount of protein should seldom exceed I gram per kilo of body weight, and less may often be advantageously used. To adults accustomed to their cup of tea or coffee in the morning, this should be continued, but not in large amount, for Mosenthal has shown that the giving of caffeine to an already inflamed and overburdened kidney sometimes brings disaster. The broths and meat extracts and jellies are best left out of the dietary, as they contain only infinitesimal amounts of food and a high percentage of purin bodies. There is one legitimate use of meat extracts or broths in small amounts, namely, when anorexia is present a small cup of well-seasoned broth does more to cheer up a forlorn appetite than anything else. The diets No. I and No. 2 as outlined for typhoid fever represent a very good assort- ment of foods, leaving out the broth where indicated, also omitting some of the lactose if there is any indication of tympanites. A good diet for an average-sized person might be formulated somewhat as follows: 8.00 a.m. Milk and coffee, each 120 cc (4 oz.), 240 cc (8 oz.); sugar. 10.00 a.m. Milk in any form, hot or cold, 240 cc (8 oz.). 12.00 m. Gruel, 120 cc (4 oz.), with milk 180 cc (6 oz.). 2.00 p.m. Milk feeding, as at 10.00 a.m., 240 cc (8 oz.). 4.00 p.m. Gruel, 120 cc (4 oz.), with milk, 180 cc (6 oz.). 6.00 p.m. Custard with lactose (4 oz.) 1 cup. 8.00 p.m. Milk feeding, as at 10.00 a.m., 240 cc (8 oz.). 10.00 p.m. Whey, 180 cc (6 oz.), with one whole egg and sherry, 15 cc G oz.). 12.00 p.m. Gruel, as at 12.00 o’clock noon. 2.00 a.m. Milk as at 10.00 a.m. 4.00 a.m. Whey, 180 cc (6 oz.), or hot milk, 240 cc (8 oz.). 6.00 a.m. Milk, as at 10.00 a.m. 332 FEEDING IN DISEASES OF THE LUNGS Approximate values: Protein, 90; fat, 91; carbohydrate, 220 gm.; calories, 1825. The value of this diet can he considerably increased by adding 500 cc (1 pint) of cream if divided between each milk or gruel feeding, which would make the total values: Protein, 103; fat, 180; carbohydrate, 235; and calories, 2800. Since sleep is of the utmost importance in pneumonia, a rest from feedings at night of from six to eight hours is advis- able if the patients will sleep, but they are to be fed when awake not oftener than every two hours. With the onset of tympanites, feedings must be stopped for a few hours so that the beneficial effect of stupes to the abdomen and a hypo- dermic of pituitary extract, etc., may be obtained. When feedings are resumed it is often better to leave sugar and milk out of the diet unless the latter is fully peptonized (2 hours) or else given in some other form than raw milk. The use of other artificial digestants is often of service, e. g., pepsin and dilute hydrochloric acid, particularly in elderly people or those known to have diminished gastric secretion; taka- diastase or pancreatic extract, the latter in enteric coated capsules. In this connection it seems worth calling attention to the use of a good Bulgarian bacillus culture given in a little sweetened water, three times a day, on an empty stomach; often buttermilk acts well. The apparent effect of this is often most happy in reducing the distention, as is also indi- cated in the discussion of typhoid fever. The feeding of cases of pneumonia complicated by neph- ritis will depend upon the severity of the latter disease, but the aforementioned diet usually serves well, although it is often wise to have it prepared without salt. Drinks.—In addition to large amounts of plain water (provided the circulatory apparatus is in order), patients are usually grateful for fruit juices with water, such as lemonade, orangeade, grape juice, etc. When the ordinary foods are taken poorly a 5 per cent solution of gelatin flavored with one of these juices makes it possible to supply a good deal of nourishment, almost without the patients’ realizing that they are taking anything but flavored water. When the temperature falls and the symptoms of toxemia are past, a gradual return to a more normal diet may be begun, first by using soft diet, later adding meat and vege- tables as convalescence proceeds. A thorough emptying of the intestine by a cathartic, after the temperature is normal, is an invaluable aid to the digestion and helps the appetite to return. BRONCHITIS 333 BRONCHITIS. Acute Bronchitis.—In adults, this is a condition sui generis, or a result of infection, possibly also due to sudden climatic changes, although this latter is presumably only predisposing. Then, too, there are the complicating cases of acute bronchitis occurring in the course of almost all the infec- tious diseases, such as pneumonia, typhoid fever, measles, etc. In certain elderly people acute bronchitis is a local manifes- tation of some general diathesis, e. g., gout and nephritis, and in these cases certain dietetic regulations referable to the underlying cause must be taken into consideration and the diet made to harmonize with it. Again in other cases it is a matter of general undernutrition and the bronchitis con- tinues to recur indefinitely until the organism is put in fight- ing trim by forced feeding and all measures to raise the phy- sical resistance, e. g., fresh air, exercise and general hygiene. When fever is present the diet should consist of liquid and soft solid foods, milk, cream, cereals, fruit juices, egg, creamed toast, bread, butter, coffee, cocoa, weak tea, mineral water and a large amount of any good drinking water. The appetite must be consulted, and as this is often very poor, the patients for the first day or two frequently wish for nothing but cold liquids of one or another sort. If the intestinal canal has been thoroughly emptied at the outset, the appetite frequently improves, and it is then more easily possible to increase the food. Whenever possible it is always advisable to feed these patients up to the limit of their diges- tive capacity, as it shortens convalescence, and Coleman and Shaffer have found in their typhoid diet investigation that even a high degree of body temperature is not incompatible with liberal feeding, as the average patient is able to digest and metabolize food practically as well as in health, provided the proper foods are used. As soon as the patient wants solid food it may be given, omitting only the well-known indigestibles and much meat. Chronic Bronchitis.—Chronic bronchitis is frequently a condition accompanying chronic emphysema, and when so present is to be dieted in accordance with the suggestions detailed for that disease. In many cases it is the initial feature of asthma and as such is in need of an etiological diagnosis, when possible, in order to prescribe diet on any satisfactory basis. Thus we may find it a local expression of a general erythema, urticaria or anaphylactic reaction to foreign protein; or a reaction to some form of endogenous toxicosis, gout or uremia; a complication of pulmonary 334 FEEDING IN DISEASES OF THE LUNGS tuberculosis or a reflex from some distant organ. Where any one of these causal conditions are found, the diet appro- priate for the underlying condition must be made use of. If, however, none of these factors can be found as responsible for the trouble, the only possible method is to proceed on empiric lines and frame the diet with a view to the least disturbance of digestion, both from the direct digestive point of view and the avoidance of mechanical factors which would work adversely in causing precordial pressure and embarrassment of respiration. Foods to Avoid. —Keeping in mind both these possibilities, we must avoid ordering foods in themselves indigestible, or which are easily fermentable, such as members of the cabbage family: Cauliflower, cabbage, brussels sprouts and heavy sweets. Foods Suitable in Chronic Bronchitis.—All simple foods, simply prepared, keeping down the amount of protein food, especially in elderly people; fat foods, such as cream, butter, fat meat, etc., enjoy a favorable reputation in all chronic pulmonary affections and should be freely used. Laxative foods, such as fruits, green vegetables and simple salads should form a con- siderable element in the diet, as excretion is to be promoted in every direction and a clear colon is of especial importance, for an acute exacerbation of the bronchitis is often traced to an increase in constipation. Water drinking, up to six to eight glasses a day, should be insisted on, either as plain water or in the presence of any considerable degree of urinary acidity, partly as mineral alkaline water. EMPHYSEMA. Emphysema being for the most part a presenile change and usually accompanied by a general sclerosis of the other organs and bloodvessels, its dietetic treatment resolves itself principally into dietetics of the concomitant conditions, such as bronchitis, chronic nephritis and arteriosclerosis. The food should be simple, easily digestible and not apt to cause flatulence; the sugars and starches should on the latter account be largely restricted. In fact, any embarrassment of the circulation by abdominal distention may easily prove serious, particularly in the presence of marked arterial changes. There is no way of directly influencing the emphysema except by promoting the general health by means of careful attention to the details of eating, not alone in the character of the foods ingested, but the method of eating plays a considerable part in the care that can be given these people. In the first place great care should be taken not to overeat, ASTHMA 335 not alone on account of the possible mechanical factors, but because the waste products of digestion play such a part in the increase of symptoms due to the complicating conditions already enumerated. On the same account elimination should be promoted in every way and often the discomforts of digestive disturbances of all sorts are minimized by this means. It would seem as if Fletcher’s principles of eating might afford great relief from the annoying complications, reducing, as it does, the protein ration to the low level of physiological economy in nutrition and rendering the methods of forced elimination almost unnecessary, as there is the minimum of waste matter to be gotten rid of (see Fletcherism, page 674). Whether one follows this philosophy or not there is unquestionable virtue in keeping the intake of protein low and rendering combustion and elimination of food products as complete as possible. ASTHMA. As asthma is but a symptom of disturbance either primarily in the bronchial tree or remote in other organs, the first step in ordering a diet must be to determine what the underlying pathological condition is. If it is due to a bronchitis, to a toxicosis as in nephritis or from gastro-intestinal disease, relief must be sought in the correction of the abnormal conditions, including the diet suitable for each (q. v.). Formerly asthma was thought to be due to many nervous influences acting in a reflex manner, and while this may be true in a certain small proportion of the cases, it is by no means proved. A true explanation of many of the hitherto obscure cases is found in the phenomenon of anaphylaxis due to the effect of a foreign protein on an organism already sensitized to that protein. This is seen in hay fever very frequently and from dietary indiscretions where persons with a known idiosyncrasy to egg white, for example, develop an attack of asthma after eating some dish made with egg. Where the cause is known or easily found, the diet may be readily adjusted. But there remains a large number of cases of asthma which cannot easily be etiologically classified—in these persons it is often helpful to test out the skin reaction to different proteins in the food, and where a protein is found to give a positive skin reaction it should be eliminated from the diet. After such a change in diet it is necessary to persist in it for at least ten to fourteen days, until all that particular protein from previous ingestion is eliminated, before it is possible to decide whether the sus- pected protein is responsible for the attacks of asthma or not. In certain individuals when the anaphylactic reaction is not 336 FEEDING IN DISEASES OF THE LUNGS too marked, it is often possible to overcome this condition by repeated feeding of small amounts of the food in question, gradually increasing the amount.1 When it is not possible by any method to come to a definite conclusion as to the cause of the asthma in a particular case it is necessary to order diet on purely empirical lines, keeping in mind the following points: 1. Indigestion, either gastric or intestinal, should be avoided by ordering only simple food simply prepared. 2. The diet should be laxative as far as possible, as intes- tinal torpor in all its forms distinctly predisposes to the pro- duction of asthmatic attacks. 3. It is probable that in many cases of unknown origin some one or other of the proteins is at fault, most often per- haps an animal protein. On this account it is often useful to curtail the amount of protein ingested, keeping the total daily intake down to the lower limits of physiological econ- omy in nutrition, as suggested by Chittenden. Another reason why this is often helpful is that in many of the older or long- standing cases, renal excretion is deficient and with nitrogen retention, symptoms of toxemia often develop. 4. Where the asthma is nocturnal, the evening meal should be exceedingly sparing and nothing allowed which by its bulk or from fermentation would add an element of embarrass- ment to the circulation in the lungs, by pressure upon the thoracic organs. 5. Patients with asthma should take sufficient mild exer- cise to assist in the complete burning of the food-stuffs, leaving as little residue, either intestinal or systemic, as possible. 6. Most of these patients are helped by drinking a fair amount of water, particularly between meals, and night and morning—six to eight glasses. With these suggestions in mind it should be a simple matter to order foods which meet the necessary conditions so far as it is possible to know them. Foods to Avoid.—Much sweet food, or heavy sweets of all kinds—syrups, candy, layer cake and preserves. Readily fermentable vegetables, such as cauliflower, cabbage, brussels sprouts, much onion or potato. Alcohol, except in the most sparing amount, and then only for some special indication. Indigestible meats, as goose, duck, veal (unless very tender) and fresh pork. Tobacco should be used sparingly, if at all. What has been said in regard to diet in asthma holds equally true for cases of urticaria, which is usually, if not always, an anaphylactic skin reaction. 1 Am. Jour. Elec. Rad., 1917, 35, 529. EMPYEMA 337 PLEURISY WITH EFFUSION. HYDROTHORAX. In both of these conditions there is fluid in the pleural sac. In the case of a pleurisy it comes as a product of inflammation, in hydrothorax it is merely a transudation, principally from stasis, although even this is said by some authorities to be due to a low-grade inflammation. In the early stages of pleurisy if there is fever the patient must be fed as for any fever. When the exudate is estab- lished and the patients afebrile an attempt may be made to regulate the diet so as to assist in the removal of the fluid, for although not successful in the case of large exudates, small ones may be absorbed, often without recourse to tap- ping. To this end the two chief indications are to curtail the water intake to 800 to 1000 cc and exclude salt from the diet by the use of one of the salt-poor diets. (See Neph- ritis.) It must be remembered in employing these diets that fre- quently little result, so far as diminishing fluid or edema, occurs during the first few days, then, when the sodium chloride reserve is considerably diminished the free excretion of the fluids often begins. The dietetic treatment of hydrothorax depends more or less upon the underlying condition which is the cause of the fluid accumulation, e. g., nephritis and cardiac decompensa- tion. In either condition the same regimen as prescribed for pleuritic effusion is indicated, viz., limitation of fluids and a salt-poor diet, the details of either being dependent on the form of the nephritis or the degree of decompensation. Empyema whether due to invasion of the pleural sac by one of the ordinary pus organisms or whether the original infection is tuberculous with a secondary infection added, the dietetic indications are the same. The formation of pus, particularly in such great quantities as takes place in empy- ema, takes a large amount of fat from the body, as the per- centage of fat in pus is exceedingly high. On this account it is necessary to feed fat liberally and as well to prevent undue loss of body weight. If the fever is high it will be necessary to modify the usual diet in accordance with the principles of fever requirements both in quantity and quality, but the fact must not be forgotten that if we are to hope for any success in our treatment the chief requisite is a body nourished up to the height of its capacity. EMPYEMA. 338 FEEDING IN DISEASES OF THE LUNGS To this end it is essential that a careful record be kept and the caloric value of the food estimated, for it is likely that if the patient’s appetite is allowed to dictate the terms of the menu the total energy value of the food will be too low. If the appetite is poor, remember that milk either alone or modified upward by the addition of cream and lactose (see Typhoid Fever) can practically always be digested, even in the absence of appetite, provided too high a formula is not used. If the appetite is fair or good, then one must go ahead and feed liberally all digestible and nourishing foods, making sure that the proportion of fat in the diet is high by giving cream, 250 to 500 cc, | or 1 pint per day, butter up to 250 grams (j pound), or as nearly that amount as will agree with the patient; for the rest the appetite may be trusted largely to determine the choice of foods. If the case is tuberculous in origin the diets as recommended for tuberculosis will be found useful. In either case great attention should be paid to the digestion to make sure that through light exercise or massage the muscular system is kept in condition. TUBERCULOSIS, PULMONARY OR GENERAL. In none of the infectious diseases is a proper dietary of so great importance as it is in tuberculosis; one has only to think of its older name “consumption” to realize the truth of this statement; and whether the disease is seen in its acute or chronic form, pulmonary or other distribution, the neces- sity for a definite feeding plan is paramount. There can be no possible doubt that food, good food, properly chosen, properly prepared and eaten in cheerful surroundings is our sheet-anchor in this disease. So much has been written in all languages in regard to this, that it hardly seems necessary to dwell upon it, but apparently many practitioners either do not appreciate these facts or are too easy-going to take them seriously and valuable time is lost, to say nothing of the patient’s weight. The influence of lack of proper diet on the incidence of tuberculosis was strikingly shown accord- ing to the Zeitschrift fur Tuherkulose, which published the mortality statistics of the health department of the German Government for all cities with a population of 40,000 and over. In 1914 the number of calories consumed per capita in Germany was approximately 2600. This was decreased in the summer of 1916 to 1983; in the winter of 1916 to 1344 and in 1917 to 1100. In 1916 the rise in tuberculosis mortality TUBERCULOSIS, PULMONARY OR GENERAL 339 was rapid and reached its height in 1918 and then dropped back to pre-war figures as the country’s rations were increased. Among the earliest symptoms of tuberculosis, the various disturbances of digestion rank a good second in importance, as many of the incipient cases first complain of gastrointes- tinal symptoms, such as gas, heaviness after meals and often sour stomach. Jacob,1 who examined the gastric contents after test meals in 50 cases, found hyperacidity or normal acidity the rule in incipient cases, and that the symptoms complained of were often similar to those of organic gastric lesions. He also concluded that the secretion of hydrochloric acid in fever was quite independent of the height of the tem- perature. By the older method of stuffing these patients with food, particularly in using large amounts of milk, the patients often developed the symptoms of gastric atony and many cases returned from sanitoria with a well-marked atony, due, of course, to the very real weakness of the gastric muscle which was part of the general asthenia, but immensely exag- gerated by overfeeding. Fortunately this mistake is now more rarely seen, particularly where any sort of intelligent care has been exercised in the selection of a diet. Toxemic dyspepsia in the tuberculous is also a cause for loss of weight or failure to gain. What, then, should be the general prin- ciples upon which a suitable diet may be constructed? To this question one will find many answers. Some advocating high protein diets, others high fats and still others a diet high in both of these elements. First, the question of what should be the object sought in diet may well be asked. There is now unanimity in the belief that a great gain in weight above the normal for the individual should not be sought and a weight of not over five to ten pounds’ overweight represents the optimum. Too much weight increases the work of the other organs and hampers the heart and lungs When this has been gained Brown’s2 advice is certainly founded on experience and com- mon sense, when he advises patients to eat just enough to maintain this increase, avoiding milk. The little flare-ups and upsets in the course of the disease which cause loss of weight will come, and he then advises patients to take milk in addition to their regular diet until this weight is regained, then to drop it. (The use of milk will be further discussed later on.) The amount of protein proper for the tuberculous to eat 1 New York Med. Jour., 1913, 97, 297. 2 Canada Pract. Rev., 1912, 38, 529. 340 FEEDING IN DISEASES OF THE LUNGS has been the subject of much comment and discussion, one set of clinicians insisting that a considerable increase in this should be the rule, particularly as applied to animal protein, and Watson1 estimates that this diet should be one-third more nutritive for the tuberculous than for the non-tuber- culous. This increase he applies to proteins and fats but not to carbohydrates on account of their tendency to fer- ment. In recommending this increase in animal protein he refers to experiments proving that meat in uncooked form is especially beneficial, the effect being from the juices of the meat rather than from the fiber, and that in some way the thyroid is favorably influenced by uncooked meat, eggs and milk. He probably has in mind Cornil and Chautemesse’s experiments, in which they found that dogs fed on raw meat resisted artificial tuberculous infection better than those fed upon cooked meat. In advocating the meat diet (zomo- therapy) in certain cases, Sutherland advises keeping up an exclusive meat diet as long as the patient continues to gain weight, weeks or even months. As they get better, heavier (having been underweight), the meat diet may be relaxed and varied menus given. If gastro-intestinal symptoms develop the meat diet should be stopped, calomel or other cathartic given and the patient put on a milk diet 3 to 4 pints (1500 to 2000 cc) daily, diluted with barley, lime or soda water. After two or three days the meat diet may be resumed. Kendall,2 on the other hand, is against an excessive pro- tein feeding on account of the extra work thrown on the kidneys in excretion, and quotes Bardswell and Chapman, who thought that “patients made less satisfactory progress on diets of very large nutritive value than when smaller value, and any considerable increase in the amount of pro- tein in the diet produced a disproportionate excretion of nitrogen, an increase in the amount of imperfectly oxidized proteins in the urine, a decrease in the percentage of nitro- gen absorbed and an increase in the amount of aromatic sul- phates excreted, indicating increased intestinal putrefaction.” Certain it is that we wish to keep the patient in at least full nitrogenous equilibrium, and while this can be worked out with scientific accuracy in a fully equipped sanitarium or hospital where nitrogen estimations can be made of intake and output, such a procedure is outside the range of possibility in ordinary practice. McCann3 working on the metabolism of tuberculous patients and controls using the respiratory 1 Practitioner, 1913, 90, 102. 2 Canada Med. Assn. Jour., 1912, p. 670. 3 Arch. Int. Med., 1921, 28, 847. TUBERCULOSIS, PULMONARY OR GENERAL 341 quotient as an index of the effect of different food-stuffs con- cluded : 1. The total pulmonary ventilation was approximately twice that of normal controls. The percentage of C02 pro- duced and 0 absorbed in terms of expired air was much reduced as compared with normals. 2. The alveolar ventilation of tuberculous patients was greater than that of normal subjects, as was the ratio of alveolar ventilation to volume of C02 expired. 3. The ingestion of protein food increased both heat pro- duction and total pulmonary ventilation in a corresponding degree in both tuberculosis and controls. 4. In the form of fat, the greatest number of calories may be ingested with the least effect on pulmonary ventilation. Carbohydrates increase the ventilation out of all proportion to the effects upon the general oxidative processes and heat production. This latter is a scientific justification of the old empiric habit of placing large reliance upon the fats in the dietary of those with pulmonary tuberculosis. In planning the ideal diet for the tuberculous, one must take into consideration several factors. The question whether the patient has fever or not, whether it is necessary to con- tinue at work or whether freedom from care and work can be assured, for naturally the fever patient or one who is obliged to work needs more food than another, and individual judg- ment on the part of the physician must be used; but for the ordinary resting case, protein 80 to 100 grams, fats 100 to 150 grams, carbohydrates 250 to 300 grams would represent a good average, giving a total caloric value of 2500 to 3000 calories, or in accordance with McCann’s findings the fat may be still further increased to advantage. These, as in the case of other diets, can be worked out from the table of 100- calorie portions. Suitable diets for the tuberculous are so much a matter of money that although the patient with means can usually reach a good dietary under supervision — the poorer members of society often have an exceedingly hard time to secure even a maintenance diet. A detailed study of some T. B. Dispensary families’ diets for two weeks among Russian Jews, Poles, Italians and negroes showed:1 1. The average dispensary family obtains about four-fifths the nourishment it should. 2. Ignorance of food values, poor judgment in buying were largely responsible, besides the poverty. 1 13th Rep. Phipps Inst., 1917. 342 FEEDING IN DISEASES OF THE LUNGS To offset this condition Chadwick advocates a cafeteria service for the tuberculous poor as offering the most for the expenditure.1 Diets for the Tuberculous.—As an example of the high protein diet we did have the following published by Watson2 which he especially recommends, No. i is largely a milk diet, No. 2 is largely a meat diet. No. I 7.00 a.m. Milk, \ pint (250 cc). 8.30 a.m. Milk, \ pint (250 cc) with casein \ ounce (15 grams), flavored with coffee or cocoa; gruel made with milk and flavored with cream. 11.00 a.m. Soup, thickened with \ pound (120 grams) raw scraped beef; or soup thickened with an egg. I. 00 p.m. Chicken essence or veal jelly, strengthened with casein \ ounce (15 grams) and milk \ pint (250 cc); or raw meat minced \ pound, with milk; or raw meat rissoles, with milk or raw meat sandwiches with milk, 3.00 p.m. Milk with egg or thin custard. 5.00 p.m. Milk tea, \ pint (250 cc) with cream. 7.00 p.m. Meat juice, e. g., Wyeth’s Leube-Rosenthal’s meat solutions mixed with port or Bur- gundy; or soup with raw meat, or beef extract with egg and milk forming a custard; or milk and arrow root, with casein and cream \ pint (250 cc); (brandy may be added). 8.00 p.m. An invalid food made with milk, \ pint (250 cc), and casein. 11.00 p.m. Milk and egg or chicken broth and egg. In severe cases milk may be taken peptonized or fermented, e. g., kumyss, zoolak; buttermilk or ripened milk (Bulgarian bacillus) may agree better. No. 2. A diet largely of meat, often helpful when dyspep- sia follows large meals. 6.00 a.m. Milk, \ pint (250 cc). 8.00 a.m. Milk, | pint, with casein | ounce (15 grams), flavored with coffee, or cocoa and pepton- ized; slice of toast with butter; bacon, ham, eggs, fish, meat rissoles or steak (taking two things). II. 00 a.m. Glass of hot milk with eggs, or raw meat soup. 1 Mod. Hosp., 1917, 14, 403. 2 Practitioner, 1913, 4C, 102 TUBERCULOSIS, PULMONARY OR GENERAL 343 i.oo p.m. Luncheon—soup from strong stock, or fish soup or a helping of fish; mince, lightly grilled tender steak or chop, slice of under- done sirloin of beef, or roasted leg of mutton; stewed fruit and custard or jelly with cream; toast, glass of milk. 4.00 p.m. Cup of milk, tea, toast, butter, or biscuit and butter. 7.00 p.m. Dinner—same as luncheon; a little wine. Prophylaxis for Children of Tuberculous Inheritance.— When one has to do with children of tuberculous parents or those who are more or less constantly exposed to this infec- tion, the necessity for a proper feeding plan is self-evident. Especial attention should be given to following the weight of the child from month to month so that the first sign of loss or even of failure to gain may be noted. The food should be especially nourishing with a high vitamin content and all other foods eliminated from the diet as much as possible. Particular hygienic care should be exercised in the daily routine and everything done in diet, work, play, sleep and fresh air to promote the greatest degree of physical efficiency. Plan of Feeding.—When a patient is able to take ordinary full diet the best plan is to give only three meals a day, pro- vided, of course, the patient can eat sufficient at a meal to produce the required gain or to maintain an increase already accomplished. When a patient cannot attain this result on three meals alone, it is best to try between-meal lunches of reinforced milk, sandwiches, etc. Still other patients, of course, can eat only smaller amounts at a time and here the feedings must be more frequent; but, if possible, three or four hours should elapse between them, using the two-hour inter- val only if necessary and taking care not to overcrowd a gastric muscle which may be already losing its tone. On account of the tendency to gastric atony the feedings should be rather dry, allowing only small amounts of liquid at a time, as in atony liquids are less well evacuated from the stomach. When the stomach is very irritable, any of the feedings referred to under gastric irritability may be used for this condition, or even gavage if necessary, as this often results in more food being retained than when given by mouth. Special Foods for the Tuberculous.—Milk.—Milk has from time immemorial held the first place as an extra in the diet of these cases, but of late years a certain prejudice has arisen, particularly against its large use. The . reasons for this 344 FEEDING IN DISEASES OF THE LUNGS have already been intimated in that it takes an excessive amount of milk, if one attempts to feed milk alone, which overdistends the stomach, often resulting in atony, so that many clinicians have discarded its use entirely, while others use it for certain indications in very moderate amounts. The exclusion of milk from the dietary is no more sensible than its excessive use, but the indications for it may be perfectly definite and it then is, of course, most useful, e. g., to add an extra to the diet in cases of failing nutrition; when people are especially fond of milk and in irritable conditions of the gastro- intestinal tract. In the latter, especially for cases with nausea, vomiting, diarrhea or fermentation, buttermilk or artificially ripened milk, kefir, zoolak, etc., may be used to the greatest advantage. A very good way in these cases is to feed one of these prepared milks every two hours and with every other feeding to add some soft solid. Eggs. — Another form of food long popular in the treat- ment of tuberculosis, eggs still hold a prominent place in its dietary, but in the light of present-day physiological chemistry, eggs must be used as a very potent albuminous and fat food and enter into calculations of the diet as such, not to be taken indiscriminately in massive daily quantities in addition to regular meals, on the assumption that for the tuberculous patient the more food the better. Incidentally, slightly cooked eggs are better and more completely digested than raw eggs, since often only one-third of the raw albumin- ous portion is digested at all, as shown by examination of the stools. If the raw egg white is whipped it is better digested than otherwise. Fats.—These hold a high place in the diet, for they are non-fermentable and their excretion does not tax the kidneys, being oxidized into water and CO2. Animal fats being more nearly homologous are probably better than vegetable oils, and the fat from cod livers stands at the head of the list; for certainly this fat furnishes something which is in addition to its hydrocarbon content. Possibly it is its iodine and possibly something belonging to that little-understood class of food-stuff's called vitamins, but at all events clinically it does more for the patient than other fats do. To be sure, this can be taken only in limited quantities and the bulk of the fat in the diet must be made up of meat fat, butter, eggs and cream. The latter should always be taken fresh and not altered by pasteurization or sterilization. This applies to milk as well. The working standard for a diet in tuberculosis, according to King,1 must take into consideration the following factors: 1 Med. Rec., October 16, 1909. TUBERCULOSIS, PULMONARY OR GENERAL 345 “(a) Men of the same respective age and weight seem to require a larger diet than do women. “(b) All other conditions being equal, a larger diet is apparently required by persons under thirty years of age than is the case after that period. “(c) The laboring class, i. e., those who earn their living by muscular work, require more food than is the case with those living a more sedentary life, and in a certain measure the dietetic habits necessitated in the first place by occupa- tion persist after occupation distinctions are removed. “(d) The urban dweller consumes a larger relative amount of animal food and therefore derives a larger percentage of his energy from the protein constituent of his diet than is the case with the country dweller. This, of course, applies only to the higher orders of civilization.” King then goes on to say, with these points in view and also keeping in mind individual variations, we may assume the following standards for ambulant cases of comparatively quiescent tuberculosis under sanitarium treatment. “(i) For young adult men of the ‘working class’ on very light exercise from 2800 to 3200 calories of which from no grams to 125 grams shall be protein. “(2) For the same class on five or six hours’ vigorous exer- cise (sawing or chopping wood, working with shovels, pick- axes, barrows, etc.), from 3100 to 3600 calories of which 125 grams to 140 grams shall be protein. “(3) For women of this class 200 calories and approxi- mately 10 grams protein may be deducted in each case. “(4) For young adult men whose occupation has been more sedentary —e. g., clerks, bookkeepers, tailors, students, etc., on moderate exercise (walking from one to three hours daily), 2600 to 3000 calories, of which not over 115 grams need be protein. “(5) For women of this class not to exceed 2500 calories and 100 grams protein. “(6) For older patients a slight reduction in caloric value and a considerably lower protein constituent are desirable in each case. “(7) For the country dweller a somewhat larger bulk with- out increase in protein value is usually desirable, all other conditions being similar, than is the case with the patient from the city.” King1 then reports interesting experiences with diets in the Loomis Sanitarium. In 1905 the ration was about as 1 Diets in Tuberculosis. 346 FEEDING IN DISEASES OF THE LUNGS follows: Protein 166 grams (5! oz.), fat 214 grams (7 oz.), carbohydrate 323 grams (io| oz.), calories 3955. While on this the patients seemed to thrive and gain, but digestive disturbances were common. The following year the standard diet was changed to protein 131 grams (4! oz.), fat 113 grams (3I oz.), carbohydrate 385 grams (i2| oz.), calories 3166. On this diet the gains in weight were equally satisfactory and there were very few digestive disturbances. It was also found that those patients who were able to work consumed more food and had a better digestion than those who did not or could not. The comparison of these diet values with those worked out by Bardswell and Chapman is as follows: Bardswell and Chapman. Former Loomis Annex standard. Later Loomis Annex standard. Protein 150 gm. Protein . . 166 gm. Protein . . 130 gm. Total calories 3200 Total calories 3667 Total calories 3200 While the caloric value of Bardswell and Chapman is the same as the later Loomis standard, King felt that the lower protein allowance was a distinct advantage on account of {a) economy, (b) increased efficiency, (c) better digestion. Complications. —In pregnancy complicated by tubercu- losis the diet should receive special care and on account of a tendency to decalcification, said by some to exist,1 some form of lime should be freely supplied in milk and gelatin (the calcium content of milk and gelatin being comparatively high), or even as calcium lactate in regular daily amounts. This question of decalcification is still unsettled so far as the biochemists are concerned, but until it is positively determined it would be the wiser error to give calcium to these cases in some form, and according to recent findings the addition of cod-liver oil will assist in calcium deposition to compensate for any loss. The diet should also contain more protein than at other times. Diabetes, from a dietetic point of view, is one of the most difficult complications of tuberculosis to treat. This is not an infrequent association and certainly taxes the ingenuity of the physician to the utmost. The associated hypergly- cemia apparently favors the further development of the tubercle bacillus, and yet a marked reduction in carbohy- drates is not always easy to obtain. The rules laid down for diabetes must be followed and an attempt made by increas- ing the proteins and fats to keep the body weight up to normal, and of course under these circumstances the kidneys 1 Dreman: Am. Jour. Obst., 1913, 77, 893. TUBERCULOSIS, PULMONARY OR GENERAL 347 cannot be spared, as they must be called on to excrete the excess nitrogen. General Rules for Feeding in Tuberculosis.—An epitomized statement for diet in tuberculosis might be put somewhat as follows: 1. Forced feeding is not necessary. 2. Milk and eggs are to be used strictly with respect to their food values. 3. A protein content of the food which furnishes a little in excess of ordinary requirements is best. 4. Fats are especially useful. 5. Three meals alone or three meals with three small lunches between and at bedtime offers the best distribution of meals. 6. Avoidance of very bulky or fermentable foods should be insisted on. 7. After normal weight or a weight slightly in excess of normal is reached, as little food should be taken as will maintain this weight. 8. Food should be eaten slowly under the most agreeable circumstances possible. CHAPTER XXI. DIET IN DISEASES OF THE STOMACH. The most important factor in the treatment of diseases of the digestive system is, of course, proper food, as this far out- weighs everything else, medicine and mechanical treatment taking an inferior position. The selection of a proper diet for these diseases depends upon a number of things which must be taken into account if one wishes to obtain anything like satisfactory results. When the trouble is in the esophagus, one has to meet the conditions of stricture, dilatation or ulceration, either singly or combined. In gastric disturbances we have, speaking broadly, conditions of hyperacidity, hypoacidity, disturbed motility, narrowing at the pylorus, dilatation and inflam- matory conditions ranging from the simplest catarrhal inflammation to severe ulceration or cancer. In the intestinal canal we must reckon with inflammatory conditions, narrowing, dilatation, disturbances of secretion or motility or any combination of these. Besides the elements already enumerated there must be considered the integrity of the accessory digestive glands, such as the liver and pan- creas. Hence it can be seen at a glance how many possi- bilities must be considered in choosing a rational diet for disease in any part of the gastro-intestinal tract. Among the most important factors that must be taken into account are the influences exerted upon gastric secre- tion by various agents. In general these may be classed as either excitants to gastric secretion or depressants. Among the former may be included acids, spices, condiments, water, alcohol, rough foods, proteins with high percentage of extrac- tives, concentrated sugar solutions. Among the depressants, fats (if they are bland) and alkalis are most important. Nervous influences, either reflex or psychic, act either as excitants or depressants to gastric secretion. In no other class of diseases is the personal factor so great as in digestive disturbances, for foods which may be per- fectly digested by a patient in health may not be in illness, so that one is constantly forced to vary the diet, not only for the different phases of these digestive troubles, but for each individual and the individual variations in each patient. 348 INDIGESTION 349 There is however, immense satisfaction in the careful diet- ing of gastro-intestinal cases, for in no other diseases is the proper diet more salutary than in these, save alone possibly some of the diseases of metabolism, notably diabetes. INDIGESTION. The proper digestion of food is such a complex matter that when one speaks of “indigestion” an endless variety of conditions naturally come to mind. Some of these are directly connected with the digestive processes and one may expect to get symptoms of so-called “indigestion” of an acute or chronic nature when any one of the digestive organs is involved in some form of derangement, and as well the accessory digestive glands. On the other hand, one can have the most violent and persistent forms of indigestion referred to the stomach, whose origin is almost at the other end of the digestive tube; witness the effects on gastric digestion of a chronically diseased appendix, nephrolithiasis, cholelithiasis, adhesions, bands, etc., which may all result in digestive symptoms and which the patient refers to the stomach. It is in many ways unfortunate that the stomach seems to be the mirror for the whole abdominal cavity, and almost everything that happens within the abdomen, partic- ularly when of a severe nature, has its gastric reflex, and the stomach, itself to blame for a sufficient amount of trouble, has been obliged to carry the opprobrium for digestive troubles which have their origin elsewhere. Then, too, when one uses the word “indigestion” one thinks at once of the gastric and intestinal variety, so that it is necessary, so far as possible, to fix the blame where it belongs and use a term as broad as this with caution, properly hedged with a definite statement as to the organ at fault. Almost every form of pathological, anatomical or functional disturbance affecting the abdominal organs has its gastric or intestinal symptomatology. As an example of this one has only to mention any one of the chronic catarrhal conditions affecting stomach or intestine to bring to mind certain so-called symp- toms of indigestion, and to this must be added various abnormal states of pancreas, liver, kidneys, etc., with gastro- intestinal symptoms in order to realize what a loose generali- zation the term “indigestion” denotes. Given, however, a normal gastro-intestinal canal and acces- sory glands there are certain conditions and substances which can produce symptoms which pass under this general name; various individuals differing in their reaction to 350 DIET IN DISEASES OF THE STOMACH different forms of irritation which may be mechanical, chemi- cal or thermal in origin. What suits one individual’s diges- tive apparatus may have an entirely different effect on another’s, and one has only to mention such substances as lobster, deviled crabs, hot breads, certain heavy sweets or fats with a high melting-point in order to realize that some people cannot take articles of food without a digestive upset, whether from anaphylactic action or a difference in digestive juices or motor function, while still others can take them with impunity. Foods, such as those undergoing putrefaction or fermentation, almost universally cause a more or less serious disturbance because very few possess the ability to detoxify these materials. Then, too, faulty mastication either from bad teeth, or lack of them, is very apt to result in disturbances which may be only functional, but are usually in the long-standing or chronic cases due to actual pathological lesions of the gastro-intestinal tract. Rapid eating acts in the same way, also improperly prepared food, to say nothing of vegetable substances which are unripe. Experience has shown that certain foods are always better borne when cooked than if eaten raw, and there is no doubt but that individual differences and habits cause the digestive apparatus to adjust itself to conditions which would cause trouble for people not accustomed to such a dietary. Could we eat the food of our ancestors of the stone age without disaster to our digestions? And the diet of our Eskimo brothers would, if eaten by us, cause many a troubled dream. Hence we see that the variety of differences in different peoples and different individuals of the same people is infinite, not only in face and form, but in their reaction to different foods, and it is a wise man who early learns his own dietary impossibilities and has the strength of mind to avoid them. Still another factor enters into the question of the digestibility of foods, such as, for example, the physic effect of anger, fear, etc., which inhibits the action of the secretory glands or causes motor irregularities of the stomach and intestine. Great stress is laid by Hayden1 on treating cases of chronic indigestion by advanced suggestion (neuroinduction) after first finding out about physiological possibilities. Among the cases successfully treated are those who have been unable to take certain foods since childhood (excepting, of course, from anaphylaxis). These are often cured in one treatment. Emile Coue’s method of autosugges- tion may also be of service in the various forms of functional digestive disturbances. Again, the effect of overwork, muscular 1 Med. Press and Circl., 1918, n. s., 105, 146. GASTRIC HYPERACIDITY, HYPERCHLORHYDRIA 351 or mental, is often to inhibit the digestive processes with the well-known sequelae of digestive disturbance; and everyone knows that some foods which may be eaten at one time with- out difficulty prove a veritable source of sorrow when taken under other circumstances. One might go on indefinitely multiplying the factors which modify the digestibility of food- stuffs, but enough has been said to make the fact evident that there are individual differences in people, in foods and in the circumstances under which they are eaten, that play an enormous role in the production of digestive unrest and result in what is generally spoken of as “indigestion” in some one of its forms. One must, on the other hand, always seek for the underlying cause whether it be a condition of true pathology, functional derangement or individual idiosyn- crasy, else one easily falls into the habit of thinking of “indi- gestion” as an indefinite, but comfortably large scrap-basket into which may be tossed a digestive symptom-complex with- out taking the trouble to really get at its true significance. Diet in Irritable Stomach.1—With Vomiting.—An irritable stomach with nausea or vomiting is often a difficult problem in feeding. From whatever cause (after all that is possible has been done to find and remove it) it is usually best to give a stomach absolute rest. The length of time this is necessary will depend on many factors, but generally a rest of from four to eight, twelve or twenty-four hours is enough, after which we may begin feeding somewhat on the following plan: Chloroform water (perfectly fresh), i dram (4 cc). Pepton- ized milk (given five minutes later), oz. (15 cc). Repeat every hour, four doses. If there is no vomiting give chloroform water, 1 dram (4 cc). Peptonized milk (given five minutes later), 1 oz. (30 cc). Repeat every hour for four doses. If no vomiting advance to peptonized milk, 2 oz. (60 cc). GASTRIC HYPERACIDITY, HYPERCHLORHYDRIA. Acid dyspepsia is a very common diagnosis and it is prob- ably true that more than half of the patients who consult a physician for gastric troubles are found on examination to have a hyperacidity due to an excess of free HC1. The time has gone by, however, when one can rest content with such a diagnosis, for hyperchlorhydria is in almost every, if not in every instance merely a symptom and not a disease entity. One must therefore seek for the underlying cause, which, with care, can almost always be successfully done. 1 AllenJWhipple. 352 DIET IN DISEASES OF THE STOMACH Kauffman’sv classification covers the etiology satisfactorily and divides the cases into: 1. Those with an inborn disposition toward acidity. 2. Due to faulty habits. 3. Chronic intoxications. 4. Reflex from disturbances in other organs (or in the stomach itself). 1. Little is known about the first class except that one occasionally does find people who have always had a hyper- acid stomach extending from childhood, without evidence of a pathological basis. In these cases, at the same time, must be borne in mind possible, but hidden, reflex causes, such as chronic appendicitis. 2. Faulty habits account for a certain number of cases, of which may be mentioned rapid eating, highly spiced foods, a great amount of acid food, or very sweet food and mental overwork. Students are very prone to have an exacerba- tion of hyperacidity during examination times, whether they have a real pathological lesion or not. 3. Too free use of tobacco in any form accounts for cer- tain cases, and for some this means any use whatever of the weed. Some patients can smoke cigarettes or cigars in moder- ation without symptoms, while others have been known to precipitate an attack of hyperacidity by a few days of pipe smoking so regularly that the pipe has been given up. Alcohol, particularly when taken strong on an empty stomach, in the form of cocktails or neat spirits, frequently leads to a hyperacidity, and of course an actual catarrh later on if persisted in. Some patients cannot take coffee with- out increasing considerably the hyperacidity. 4. The reflex conditions which may produce a hyper- acidity are legion and one has but to mention chronic appendi- citis, cholelithiasis, nephrolithiasis and peptic ulcer to bring to mind numberless cases falling into this class. Given a case of hyperchlorhydria, if the cause can be found, of course treatment and diet must be directed along lines suitable for the particular condition at fault; but neverthe- less a certain number of cases remain which are evidently hyperacidity with the symptoms of pyrosis, eructations, often very acid, and some discomfort or burning in the epi- gastric region at the height of digestion. When there is actual pain, repeated daily, usually one to three hours after meals, there is almost always an organic lesion at fault, but if this can be reasonably ruled out, we must take dietetic 1 Kauffman, in Forchheimer, 3, 75. GASTRIC HYPERACIDITY, HYPERCHLORHYDRIA 353 measures to reduce the hyperacidity to a minimum. A diagnosis of hyperacidity can only be made satisfactorily by means of a test meal and, in fairness to the patient, this precaution should never be omitted. The Reduction of Gastric Hyperacidity by Diet.—This is done first by the avoidance of certain foods which are sure to induce a certain amount of physiological increase in acidity, and secondarily to give such foods as will render the excess of acid as innocuous as possible. To these ends one must avoid taking all acids, spices, condiments, salt meat or salt fish, and the use of salt on the food should be reduced to the minimum. It has been shown possible, in dogs, to feed meat boiled in distilled water until the salt intake is reduced almost to zero; when this is done the free hydrochloric acid production is actually controlled. This cannot be continued indefinitely in human beings, as sodium chloride in a certain minimal amount (i or 2 grams per day) is necessary to health, but all excess can be obviated with some resulting diminu- tion in acid values in their gastric secretion. All foods must be avoided, which by their tough consistency would remain in the stomach a long time, such as very coarse vegetables, seeds, fruit skins or fats with a high melting-point, as mutton fat. Very hot or cold drinks or foods act in much the same way and must be let alone. Alcohol is especially bad in all forms. Meat soups are stimulating and are best omitted from the diet as are all hors d’oeuvre, such as caviare, olives, pickles, etc. Very sweet food has much the same effect, so all candy, rich cake, heavy preserves, sweet jellies must be left out of the diet. On the other hand certain authorities find sweets actually depress gastric secretion unless com- bined with chocolate, which in itself is stimulating. When one comes to construct a diet suitable for these cases one meets at once theoretical objections to many forms of food, and authority can be found for barring carbohy- drate or protein food, especially meats in all forms, for although they have a high combining power for the free HC1, they in turn are gastric excitants and would thereby defeat their own object. Diets based on this view are constructed largely of carbohydrates, and theoretically these should be well tolerated, but as a matter of fact for one reason or another they do not seem to act practically as we should expect, probably because although they call out a smaller acid secretion, they have little to offer to combine with the free HC1, which, once it accumulates in any quantity, causes the symptoms for which we are attempting to find the ideal diet. Fats do actually depress the acid secretions and when 354 DIET IN DISEASES OF THE STOMACH of a low melting-point, such as sweet butter, or when bland and liquid, as olive, peanut or cotton seed oil, they are very valuable foods in hyperacid conditions for this quality, as well as for their high nutritive and caloric value. But one cannot live on fats, so that to a certain extent a mixed diet must be used. Experience has shown that although milk is more or less a gastric stimulant, it offers such a high percentage of protein for binding the free HC1 that it is of great value, and a few days of a milk-and-cream diet is often most useful in quieting an overproductive gastric secretion. Eggs are good for the same reason although some authorities think that as the fat is in emulsion it is more stimulating than should be used; this is not, in the view of most clinicians, of sufficient weight to prevent their free use to advantage. The fine cereal preparations, such as farina, cream of wheat, malted breakfast food, wheatena, are all usable and are better than oatmeal. Bread is at times a marked gastric stimulant, and Kauffman refers to hyperchlorhydria in vegetarians for which he largely blames the excessive use of bread. Stale bread, toast, zwieback or crust of roll may be taken by these cases in moderation. Diet in Hyperacidity.—The diet in hyperacidity may be advantageously made up of the following articles, using con- siderable quantities of the less stimulating proteins: Raw oysters with a very little salt or a few drops of lemon juice. Soups: Cream or puree (except tomato) and made with- out meat stock. Fish: All white-meated, non-fatty fish, such as fresh cod, halibut, bass, white fish, boiled and served with egg sauce, or broiled (never fried). Meat: In marked hyperacidity meat is best let alone, except occasionally boiled or roasted and chicken or turkey. In less severe cases, minced lamb without fat, guinea-hen, well-done beef without gristle, fat or gravy, in small amounts and never more than once a day, may be allowed. Vegetables: The soft green vegetables, such as young peas, string beans, spinach with egg, beet tops, celery, squash, vegetable marrow, rice, all boiled. Baked Hubbard squash, baked white potato, spaghetti. (No cabbage, brussels sprouts, cauliflower or onions to be used on account of their tendency to ferment and cause flatulence.) Cheese: Cream, Neufchatel, Swiss. Desserts: All cream desserts, those made of egg and milk, such as custards, blanc mange, floating island, junket, soft rice, farina or bread puddings without rich sauces and best GASTRIC HYPERSECRETION 355 eaten with cream. Gelatin desserts if not highly flavored, all made with the minimum amount of sugar. Fruit: None at all in severe cases. In milder cases when constipation is marked, soft, subacid, stewed fruits may be taken in fair amount, but no fruits with seeds or those with tough skins should be used, such as figs, raspberries, black- berries, gooseberries and prunes. Fruit should be stewed or baked with very little sugar. Bread: Toast, dry roll, zwieback, toasted crackers. Butter: Either fresh butter, or salted butter, if used, should be worked over in fresh water to take out as much of the salt as possible. Drinks: Weak tea, cocoa made with milk, cream, water, Vichy not too cold and never sparkling. Cereals: All fine well-boiled cereals. Eggs: In any form but fried or hard-boiled and not made into fancy entrees. Cake: A little cup cake, dry cookies and sponge cake. Foods to Avoid: All highly spiced, sour, salty foods, condi- ments, pickles, jellies, salted nuts, olives, raw vegetables as celery, salads, radishes, etc. Very cold or hot foods or drinks, or if taken in small amount they should be kept in the mouth long enough to bring their temperature to about body heat. Uncooked vegetables of all sorts and hard sub- stances as corn. Coffee, wines, beer, liquors, cordials, ale, ginger ale and cold soft drinks. Pies, syrups, pancakes, hot biscuits, cake other than those already mentioned. GASTRIC HYPERSECRETION. Since hypersecretion whether intermittent or continuous is a symptom of disease and not a disease itself, it is neces- sary, in order to prescribe a rational diet, to know if possible what the underlying cause may be. In the intermittent variety we may be dealing with merely a part of a general neurosis or it may be a gastric manifestation of a lesion of the central nervous system, such as tabes or lateral sclerosis, where it is regularly an accompanying feature of the gastric crisis. It may also follow the excessive ingestion of alcohol or gastric irritants or accompany acute gastric dilatation (q. v.). In the intermittent variety the diet should be arranged so far as possible in accord with the etiological factor. Since hypersecretion is practically always accompanied by a defi- nite hyperchlorhydria the diet should be chosen on the basis of the foods recommended for this condition. A few days 356 DIET IN DISEASES OF THE STOMACH or a week or more of a milk diet with or without the addition of very soft-boiled eggs, gives relief to most of the cases, regardless of the etiology, excepting only those cases due to a lesion of the central nervous system, as tabes. The relief is, however, often only symptomatic and a test meal will still show hypersecretion and hyperacidity unless in case of ulcer there had been actual healing. Continuous hypersecretion is for the most part a symptom of gastric or duodenal ulcer and unless this can in some way be excluded, as by roentgen-ray examination, it is fair to assume such a relationship, particularly in the presence of ulcer symptoms, and institute an ulcer cure. The pain which so often accompanies hypersecretion may be ascribed probably to pylorospasm or possibly to an irri- tated ulcer, and while a milk diet will also bring relief to this symptom it will do so permanently only so far as the diet is successful in curing the underlying ulcer. While usually a high protein diet is advocated for hyper- secretion, it will be seen from what has been said that this is rather a shot in the dark and that if one wishes to use foods intelligently it is absolutely necessary to first make an etio- logical diagnosis. In general it may be said that the protein of milk and egg is the best for all cases of hypersecretion, whereas, meat or meat products are distinctly stimulating to gastric secretion and should be omitted from the diet at first, and later allowed only in small amount and in the more easily digested forms, e. g., chicken, mutton and sweetbreads. Soft farinaceous puddings and cereals are allowed in moderation and puree of vegetables, as in hyperchlorhydria (q. v.). Especial impor- tance is attached to the avoidance of condiments, acid food and drink, rough foods, skins, seeds, corn, etc., all of which remain a long time in the stomach and produce thereby irritation. * In addition the thermal irritants, such as very hot or very cold foods, are to be avoided. GASTRIC HYPOACIDITY AND ACHYLIA GASTRICA. Diminution or absence of gastric acid and ferments, as its name implies, is the direct opposite of hyperchlorhydria and may be due to a variety of causes, either organic or func- tional. Of the organic causes any long-standing catarrh of the stomach will lead to it and it is found as a frequent com- plication of catarrhal gastritis and gastric carcinoma, per- nicious anemia, severe infectious diseases at times and in many elderly people. In any event permanent achylia is GASTRIC HYPOACIDITY AND ACHYLIA GASTRICA 357 accompanied by atrophy of the mucous membrane of the stomach and its secreting glands. Of the functional causes, many cases are due to profound neurasthenic conditions and as a reflex from organic disease in some of the other abdominal organs, e. g., chronic appen- dicitis or cholelithiasis. There is still another class of case in whom the achylia gives rise to no symptoms and is only found by accident in the course of a routine examination. The cause of this variety is far from clear. The degree of the hypoacidity varies within wide limits and runs from a slight reduction in the free HC1 and total acid values and without change in the pepsin-rennin secretion, all the way to complete achylia with total absence of acids and ferments. In passing, it might be remarked that the acids are diminished more frequently and in greater propor- tion than the ferments. In the cases in which the hypo- acidity is dependent on a definite lesion, as for example gastritis, the return of the acid is greatly dependent on the outcome of the underlying cause, which if cleared up may result in a return of the secretions. Other cases are found without definite cause as already stated and remain achylia to the end of the chapter, apparently with little effect on the general health. The diet problem in hypoacidity is in many respects a much more simple matter than in most cases of marked hyperacidity and within certain limits the foods which are inadvisable in hyperchlorhydria, on account of their tending to excite gastric secretion, are the ones which we may often freely use in this opposite condition. Mention has already been made of the diet best for these cases in connection with chronic gastritis with hypoacidity, (page 361), but it is necessary to go more into detail. Where there is a definite organic cause, or accompanying condition, to the hypoacidity or achylia, the diet must be in accordance with this complicating feature and all foods which are in any way irritating must be avoided, such as condiments, strong acids, very rough or hard foods, skins, seeds, etc., as the mucous membrane in many of these cases is exceedingly vul- nerable and bleeds easily, even on the introduction of the stomach-tube. Very hot foods or large quantities of acid food or drinks must be avoided. Theoretically very limited protein should be given, as in the absence of the normal HC1 and pepsin, gastric digestion is at a minimum or entirely absent. Within certain limits this objection holds good, namely, for all protein foods difficult of digestion, e. g., veal, tough meats of all sorts, con- 358 DIET IN DISEASES OF THE STOMACH nective tissue (which latter is only digested in the presence of free HC1 and pepsin) and tough clams, lobster, etc. On the other hand, the patients must receive their full daily allowance of protein and will be able to digest the proper kinds in the course of pancreatic and intestinal digestion. Of these, milk, eggs, tender meats and fowl cut very fine with- out gristle or connective tissue, mild cheeses, tender white- meated fish and vegetable protein of all sorts must form the bulk of the protein ration, but given preferably in only moderate amount say from 70 to 90 grams per diem, and not to the high limit allowable in a normal person. While a moderate amount of these protein foods can be entirely digested in the intestines, any excess will throw too much work on these accessory digestive processes which may easily go out of commission on this account, with the result that the proteins in excess undergo putrefaction in the intestine, giving rise to many uncomfortable symptoms of toxemia. This is the more prone to happen as the normal gastric juice is a strong antiseptic for all foods brought to the stomach and it is a hardy germ that can live through the acid immer- sion it receives there. On this account the normal chyme is comparatively free from bacteria; a fortunate provision of Nature when one considers the quantity of poor gastric surgery that is done, much of which would be followed by greater disaster were it not for this fact. Since the natural barrier to the entrance of pathological bacteria is largely or entirely missing in these cases of hypo- acidity, it is of the greatest importance that the food taken be all thoroughly cooked to render it sterile. Fruit with skins may be an exception to this rule, as they are really practically sterile within their skins. For the same reason great care should be taken of the mouth and its toilet made before and after meals, using toothpick, dental floss, tooth brush and a good mouth wash. This seems excessive care, but many cases of diarrhea and chronic intestinal infection are started by reason of carelessness in these respects. Clear soups are good for their appetizing and stimulating effects on the gastric glands that are still capable of stimu- lation and other protein foods as already indicated, may be eaten. All vegetables that are soft and non-irritating, fats, particularly butter and oils and cream. All carbohydrate foods are easily digested, as the gastric ptyalin digestion pro- ceeds uninterruptedly in the absence of gastric acidity. At the same time excessive use of sweets should be avoided as likely to disturb digestion. All simple desserts may be used to advantage. GASTRITIS 359 There is still another condition which must be reckoned with in these patients, namely, that while the gastric motility is usually well preserved in all but cancer cases, there may be the opposite condition of gastric atony. In this latter com- plication one may use the same class of foods as recommended for the cases with good motility, but they should be given in smaller amounts and at more frequent intervals, following generally the dietetic rules laid down for atony, particularly with reference to restricted fluids at meals. Many of these cases of achylia are complicated by diarrhea probably of pancreatic origin, at all events there are few more brilliant results in medicine than those obtained in most of these cases of achylia diarrhea by the giving of dilute HC1, either alone or with pepsin; and all cases of unexplained and long-standing diarrhea should have deter- mined, by a gastric test meal, the presence or absence of HC1. The addition of this dilute acid to the dietary in all cases of achylia is of distinct advantage, although it must not be given in too large doses, and later when digestion is regulated it may be possible to omit the acid altogether. GASTRITIS. Acute Gastritis.—Acute gastritis, except that caused by a toxicosis, must be considered a rare disease, in spite of the frequency of the diagnosis. When the toxicosis is constitu- tional of course the dietary treatment is along lines laid down for the particular disease at fault, e. g., renal insufficiency, etc. There are, however, a fair number of cases caused by the direct effect of irritating substances such as strong acids, alkalis and abuse of condiments, but formerly most frequent of all, the excessive use of alcohol; and it is after a drinking bout that this is most frequently met with. In any case, the cause being what it may, the dietary treatment is practically the same. The first step is starvation, nothing whatever should be given by mouth and the fluids which the system craves in severe cases accompanied by much nausea and vomiting, may be supplied by the rectum, either in the form of a Murphy drip or by giving from six to eight ounces of warm saline by rectum, every two, three or four hours. After twelve to twenty-four hours, or when the vomiting has ceased, one may begin to feed small amounts of cold peptonized milk, or kou- myss, buttermilk, white of egg in dilute orange juice beaten 360 DIET IN DISEASES OF THE STOMACH up and strained; milk; Vichy or Delafield’s mixture:1 begin- ning all in very small amounts (a teaspoonful every twenty to thirty minutes) and increasing the amount and lengthen- ing the interval. In certain cases small amounts of iced champagne or ice-cold ginger ale are well borne and may even be of assistance in controlling the vomiting. In acute gastritis, or esophagitis, due to taking a corrosive poison, demulcent drinks are of especial value in not only supplying some nourishment, but in quieting an inflamed mucous membrane. Of these drinks a thin solution of gum arabic (2 to 5 per cent) flavored with a little orange syrup is acceptable. Also a solution of Iceland moss made in the same way. After the acute stage is past one begins with gruels, fine cereals, milk, plain or diluted; then soft solids and so on up the scale until the full diet is reached. All rough, highly spiced and peppery, very hot or very cold foods and drinks should be avoided for some time. Chronic Gastritis.—In contradistinction to the acute variety, chronic gastritis is fairly frequently seen and is practically always secondary to a chronic disease with poor elimination, to chronic congestion, as in hepatic cirrhosis or cardiac decompensation or a chronic form of irritation, of which latter, of course, alcohol is the chief example. During an acute exacerbation the diet should be the same as that detailed for acute gastritis. When the disease is found in its later stages many digestive symptoms are traceable to its presence. In arranging the diet for such cases it is almost absolutely essential to have an analysis of a gastric test meal for diag- nosis, as many digestive symptoms referred to the stomach and lumped as chronic gastritis are nothing of the sort. They are quite as likely due to secretory or motor disturbances, often secondary to other conditions such as peptic ulcer, chronic appendicitis or gall-bladder disease, and have nothing to do with an increased production of mucus, which is a sine qua non of true gastritis. Then, too, some cases of chronic gastritis are accompanied by hyperacidity, others by normal or hypoacidity running even into an achylia gastrica, the certain knowledge of which will be of great assistance in selecting a proper dietary. In general it may be said that after removal of the cause, whenever that is possible, a certain amount of rest and the entire absence of all irritating food should be insisted upon. Diet.—When the gastritis is accompanied by hyperacidity, the following articles of food should be forbidden: 1 Delafield’s mixture: Cream, 120 cc (oz. 4); milk, 120 cc (oz. 4); Vichy, 120 cc (oz. 4); soda bicarbonate, gm. 1.3 (gr. 20); cerium oxalate, gm. 0.6 (gr. 10). GASTRITIS 361 Salt foods, spiced foods, acid foods, rough or mechanically irritating foods, fermented foods, e. g., wines, beers and ales. Of course, no case of gastritis should take alcohol in any form except possibly when the patient has been long accustomed to its use, a little whisky or red wine, both diluted with Vichy, may be allowed for a short time. Nothing very hot or very cold is allowed. On the other hand, as there is usually good digestive power to the secretions, a fairly high protein allowance of a non-stimulating sort may be allowed. In a general way the diet may be advised as follows: Early morning on awakening a half-glass of warm Hopital or Celestin Vichy, or water with half a teaspoonful of arti- ficial Vichy salts. This taken at least one-half hour before breakfast, acts as does a gastric lavage. If the bowels are constipated an occasional small dose of some of the laxative soda salts may be given, phosphate or sulphate of soda. Breakfast: Cocoa, made with milk, or weak tea; fine cereal—farina, cream of wheat, wheatena with cream, and very little sugar; soft toast or soft part of stale bread, well chewed; eggs in any simple form. Later, apple sauce or baked sweet apple. Luncheon, Dinner or Supper: Cream or puree soup (no meat stock). Simple egg entree. A little boiled chicken or young lamb, scraped or finely cut beef, all without rich gravies or sauces; puree of soft, green vegetables, put through a colander, without seeds or rough cellulose or skins; cauliflower, cabbage or tomatoes are not allowed, desserts, soft custards, puddings, gelatin desserts with cream, cream desserts; ice-cream occasionally. Later soft stewed fruits, not acid, and cooked with little sugar; junket. Beverages: Alkaline waters, Vichy, High Rock, plain water; cocoa or weak tea; milk. Milk food should be reduced to a minimum in the presence of gastric atony. The quantity of food given at each feed- ing and the length of the feeding interval will depend on the condition of gastric motility. When this is good, three normal-sized meals may be given, when impaired, frequent, small, dry feedings are better. This is, of course, true of gastritis by whatever degree of acidity it is accompanied. (See Diet in Gastric Atony.) It is advisable to eat a meal which is easily digested and passed into the intestine as rapidly as possible, so giving the maximum degree of rest to the stomach. Diet when Gastritis is Accompanied by Hypoacidity or Achylia.—Early morning alkaline waters as for hyperacid 362 DIET IN DISEASES OF THE STOMACH cases, except that, to them may be added a little sodium chloride; or Carlsbad water or sodium salts may be allowed when constipation is present, or plain water, 6 ounces (180 cc), with salt gr. 5 (| gram), soda bicarbonate gr. 15 (1 gram). The chief difference in the diet from that given for hyperacid cases is that less meat protein is allowed. Stewed fruits may be used earlier than in hyperacid cases and stock soups are permitted largely for their appetizing qualities. With impaired motility, however, soup of all kinds is best omitted, as fluids then leave the stomach slowly. Water should be taken in only small amounts with meals and it is well to order patients to drink water about an hour before meals, between meals and at bedtime. PEPTIC ULCER (GASTRIC AND DUODENAL). In the acute and so-called medical ulcer of the stomach or duodenum or in the acute exacerbation of a chronic ulcer, the management and dietary are the chief essentials, except- ing, of course, those cases which on account of some compli- cation demand surgical intervention. In response to this need, there have sprung up a number of different forms of treatment, some advocates of all of them being found in each community. The fact that the acute medical ulcer has a tendency to heal spontaneously, if given a fair chance, probably accounts for the claims of one or another of the different methods in vogue. With the acute exacerbation of a chronic ulcer it is somewhat different, and although the acute symptoms may promptly subside when treated as an acute simple ulcer, the ultimate end sought, namely cicatri- zation of the old ulcer, is a most uncertain chance, although it does take place in perhaps a larger proportion of cases than the surgeons would have us believe, as proved by autopsy findings. The gastric and duodenal ulcers are dealt with together, as their dietary treatment is identical. The Chief Methods of Dietary Treatment for ulcer may be classed as: 1. Absolute physiological rest to the upper digestive tract, with later mouth feedings either with or without rectal alimentation in addition. 2. Almost continuous, but reduced, physiological activity of the stomach but with food that is in small amounts, principally protein, and which has the quality of quickly binding the free hydrochloric acid, turning the albumin into the comparatively unirritating syntonin, and of leaving the stomach quite promptly. PEPTIC ULCER 363 3- Transgastric or duodenal feedings. 4. An essential feature of still another form of treatment is the use of alkalis to reduce the exaggerated acidity, usually present in these cases, together with the feeding of small quantities at frequent intervals of highly albuminous foods. The use of alkalis may, of course, be combined with any of the forms of treatment and has many advocates. The first plan has the disadvantage, if carried out to the letter, of almost complete starvation during the time of digestive rest. Where this has been modified by attempts at rectal feeding or water is introduced by rectum, physiology has shown that at once peristaltic unrest is set up through- out the entire gastro-intestinal tract and it also gives rise to gastric secretion, although this is denied by some authorities. Von Leube Diet in Ulcer.—In the first type of diet as exemplified by the von Leube cure and modified most satis- factorily by G. R. Lockwood, absolute rest is given for three days and not even water is allowed, but the mouth is kept moist by mouth washes. If after twenty-four to forty- eight hours the thirst becomes too excessive, and earlier if there has been no hemorrhage, the Murphy drip is instituted whereby from 20 to 50 drops of normal saline solution are allowed to flow into the rectum each minute, depending on the patient’s rectal tolerance. To this Murphy drip there may be added sufficient glucose to make a 2 per cent solution. It also helps to make the patient relaxed, and comfortable to add 50 grains (3.5 gram) strontium bromide to the day’s allowance. If given continuously about three pints of fluid may be introduced into the system preventing absolutely the thirst which is so trying. In patients who are old, feeble or desiccated by vomiting and insufficient food beforehand, the first period of starvation is limited to twenty-four hours. On the second day in these cases, and the third day in sthenic cases, 2 ounces of Celestin or Hopital Vichy is given every two hours and the following days this is alternated with 2 ounces of albumen water, so that liquids are there- fore given every hour. Von Leube also recommends very strongly the continuous use of local heat over the upper abdomen either as hot compresses or the use of the electric pad over a moist compress, except in cases of recent hemor- rhage. On the next day fully peptonized milk, 2 ounces at each feeding, every two hours is alternated with the Vichy, so that the patient gets one or the other every hour. Dur- ing the first few days of this diet, if the thirst is troublesome, either the Murphy drip can be continued or from 4 to 6 ounces of warm saline may be given by rectum every three 364 DIET IN DISEASES OF THE STOMACH or four hours. Each day the peptonized milk is increased i ounce until 8 ounces are being taken. The Vichy is increased i ounce daily until 4 ounces are given at a time. Both Vichy and fully peptonized milk1 have been shown by Can- non to leave the stomach very rapidly. The bowels are kept regular by enemeta and if there is troublesome gastric acidity, alkaline powders are given. About the tenth day soft milk toast, junket or fine cereal may be added. It is well to add these to one of the peptonized milk feedings, then to two, three or until with every other milk feeding the patient gets a soft solid. When a soft solid is given it is better not to give over 4 ounces (120 cc) of the peptonized milk. In the third week, the quantities may be increased and creamed mashed potato, fresh creamed halibut or cod fish, macaroni, puree soups made without meat stock are added, also puree of vegetables, such as puree of peas. Farinaceous desserts can then be added, such as cornstarch, farina, blanc mange and custard. During these three weeks the patient remains in bed, still continuing the hot appli- cations. During the fourth week they may be allowed up in a chair and put gradually on any soft food, leaving out fruit, coffee, acids, irritants of all kinds, whether mechanical, thermal or chemical. This dietary cure takes time and cannot be hurried if one wishes to give the patient the best chance of recovery. When the mouth feedings have begun some clinicians prefer to use nutrient enemata as an additional supply of fluid and some nourishment. The best food for this purpose is undoubtedly fully peptonized milk, the same as that given by mouth with or without the addition of glucose sufficient to make a 2 to 4 per cent solution. Often the milk alone is better borne in varying quantities, some patients taking as much as 1 pint every six hours, others a less amount at more frequent inter- vals, all of which must be determined for each case individually. (For details see Rectal Feeding.) Those who prefer to use the von Leube diet as originally outlined by him, will find the following plan useful. Von Leube’s Diet2 {Original): First Three Days: 7 a.m. 150 cc of milk (5 oz.). 1 For complete peptonization of milk, Lockwood’s directions are most satis- factory: Divide a quart of milk in half, bring one-half (i pt.) to boiling and add the other cold pint. This produces the correct temperature. To this add two tubes of Fairchild’s peptonizing powder rubbed up in 4 ounces of water. Put the milk in scalded bottles and stand in a pail of water at 105 0 F and keep there with occasional shaking for two hours. Then scald and put on ice. 2 Smith: What to Eat and Why, p. 193. PEPTIC ULCER 365 8 a.m. 150 cc of milk (5 oz.). 10 a.m. 150 cc of milk (5 oz.) with strained barley water. 11 a.m. 150 cc of milk (5 oz.). 1 p.m. 150 cc bouillon with peptone preparation. Fourth to Eleventh Day: 7 to 9 a,m. 300 cc of milk (10 oz.). 11 a.m. 300 cc of milk with barley, rice or oatmeal water. 1 p.m. 1 cup of bouillon (200 cc) with a beaten egg. 3 to 5 p.m. 300 cc of milk (10 oz.). 7 p.m. Milk with barley water. 9 p.m. 300 cc of milk (10 oz.). Eleventh to Fourteenth Day: 7 to 9 a.m. 300 cc of milk (10 oz.) and 2 crackers, soft- ened with barley water. 11 a.m. 300 cc of milk (10 oz.). 1 p.m. 200 cc bouillon (6| oz.), 1 egg, 2 crackers. 3 p.m. 300 cc of milk (10 oz.), 1 egg. 5 p.m. 300 cc of milk (10 oz.), 2 crackers. 7 p.m. Milk with barley water. 9 p.m. 300 cc of milk (10 oz.). Fourteenth to Seventeenth Day: 7 to 9 to 11 a.m. As above. 1 p.m. Scraped meat 50 gm. (if oz.), 2 crackers, 1 cup of bouillon, 200 cc (6§ oz.). 3 p.m. 300 cc of milk (10 oz.). 5 p.m. 300 cc of milk (10 oz.), 1 soft-boiled egg, 2 crackers. 7 p.m. 300 cc of milk (10 oz.) with farina. 9 p.m. 300 cc of milk (10 oz.). Seventeenth to Twenty-four Day: 7 a.m. 2 soft-boiled eggs, butter (1 gm.), toasted bread 50 gm. (if oz.), 300 cc of milk (10 oz.). 10 a.m. 300 cc of milk (10 oz.), crackers 50 gm. (if oz.). 1 p.m. Broiled lamb chop 50 gm. (if oz.), mashed potato 50 gm. (if oz.), butter 10 gm. (f oz.), cup of bouillon 200 cc (6f oz.). 4 p.m. Same as 10 a.m. 6.30 p.m. 300 cc (10 oz.), of milk with farina, crackers 50 gm. (if oz.), butter 20 gm. (f oz.). 9 p.m. 300 cc milk (10 oz.). Of the second method of feeding these cases, viz., that of continued physiological activity with small amounts of bland and highly albuminous food, the Lenhartz diet is the best known and most generally used. One great object of this diet is to do away with any period of actual starvation, on the principle that the better nourished a patient can be kept 366 DIET IN DISEASES OF THE STOMACH the greater chance for healing. In addition, what has already been said, in regard to the favorable influence of the rapid combining of the free hydrochloric acid with the albumin in the diet, of which there is great abundance, holds true. General Directions for Lenhartz’s Diet.— Patients must be in bed and kept there the entire time, not even allowed up for use of the commode; naturally the best and sunniest room available should be chosen for all of these cases, regardless of the form of diet. The eggs used in each day’s feedings should be beaten up raw and divided equally into seven feedings, putting the feedings into seven medicine or small glasses for accuracy and keeping them all in the ice-box until used. The milk used for the day should be put on ice and the feeding spoon kept on ice. All feedings should be very slowly given by spoonfuls. A very little salt may be allowed on the egg feedings, otherwise none. As will be seen from the schedule of feedings, they are given every hour from 7.00 a.m. to 7.00 p.m., or 8.00 a.m. to 8.00 p.m. if more convenent, leaving a full twelve-hour rest. The following are the details of each day’s diet. First Day. 7.00 A.M. Egg. 8.00 A.M. Milk, 20 CC (I oz.). 9.00 A.M. Egg. 10.00 A.M. Milk, 20 CC (I oz.). 11.00 A.M. Egg. 12.00 NOON Milk, 15 CC (I oz.). 1.00 P.M. Egg. 2.00 P.M. Milk, 15 CC (I oz.). 3.00 P.M. Egg. 4.00 p.m. Milk, 15 cc (| oz.). 5.00 P.M. Egg. 6.00 p.m. Milk, 15 cc (| oz.). 7.00 P.M. Egg. Total, first day, eggs (raw), 2; milk, 100 cc oz.); calories, 280. Second Day. 7.00 A.M. Egg. 8.00 a.m. Milk, 35 cc (1 oz.). 9.00 A.M. Egg. 10.00 a.m. Milk, 35 cc (1 oz.). 11.00 A.M. Egg. 12.00 NOON Milk, 35 cc (1 oz.). 1.00 P.M. Egg. PEPTIC ULCER 367 2.oo p.m. Milk, 35 cc (i oz.). 3.00 p.m. Egg. 4.00 p.m. Milk, 35 cc (1 oz.). 5.00 p.m. Egg. 6.00 p.m. Milk, 30 cc (1 oz.). 7.00 P.M. Egg. Total second day, egg (raw), 3; milk, 200 cc (6f oz.); calories, 470. Third Day. 7.00 a.m. Egg; sugar, 2 gm. (f dr.). 8.00 a.m. Milk, 50 cc (if oz.). 9.00 a.m. Egg; sugar, 3 gm. (f dr.). 10.00 a.m. Milk, 50 cc (if oz.). 11.00 a.m. Egg; sugar, 3 gm. (f dr.). 12.00 noon Milk, 50 cc (if oz.). 1.00 p.m. Egg; sugar, 3 gm. (f dr.). 2.00 p.m. Milk, 50 cc (if oz.). 3.00 p.m. Egg; sugar, 3 gm. (f dr.). 4.00 p.m. Milk, 50 cc (if oz.). 5.00 p.m. Egg; sugar, 3 gm. (f dr.). 6.00 p.m. Milk, 50 cc (if oz.). 7.00 p.m. Egg; sugar, 3 gm. (f dr.). Total, third day, eggs (raw), 4; milk, 300 cc (10 oz.); sugar, 20 gm. (5 dr.); calories, 637. Fourth Day. 7.00 a.m. Egg; sugar, 2 gm. (f dr.). 8.00 a.m. Milk, 70 cc (2f oz.). 9.00 A.M. Egg; sugar, 3 gm. (f dr.). 10.00 a.m. Milk, 70 cc (2f oz.). 11.00 a.m. Egg; sugar, 3 gm. (f dr.). 12.00 noon Milk, 65 cc (2 oz.). 1.00 p.m. Egg; sugar, 3 gm. (f dr.). 2.00 p.m. Milk, 65 cc (2 oz.). 3.00 P.M. Egg; sugar, 3 gm. (f dr.). 4.00 p.m. Milk, 65 cc (2 oz.). 5.00 p.m. Egg; sugar, 3 gm. (f dr.). 6.00 p.m. Milk, 65 cc (2 oz.). 7.00 p.m. Egg; sugar, 3 gm. (f dr.). Total fourth day, eggs (raw), 5; milk, 400 cc oz.); sugar, 20 gm. (5 dr.); calories, 777. Fifth Day. 7.00 a.m. Egg; sugar, 4 gm. (1 dr.). 8.00 a.m. Milk, 80 cc (2f oz.). 368 DIET IN DISEASES OF THE STOMACH 9-00 a.m. Egg; sugar, 4 gm. (1 dr.). 10.00 a.m. Milk, 80 cc (2§ oz.). 11.00 a.m. Egg; sugar, 4 gm. (1 dr.). 12.00 noon Milk, 80 cc (2f oz.). 1.00 p.m. Egg; sugar, \\ gm. (1 dr.). 2.00 p.m. Milk, 80 cc (2f oz.). 3.00 p.m. Egg; sugar, 4I gm. (1 dr.). 4.00 P.M. Milk, 80 CC (2§ oz.) 5.00 p.m. Egg; sugar, 4! gm. (1 dr.). 6.00 p.m. Milk, 90 cc (3 oz.). 7.00 p.m. Egg; sugar, 4! gm. (1 dr.). Total, fifth, day, eggs (raw), 6; milk, 500 cc (i6§ oz.); sugar, 30 gm. (1 oz.); calories, 966. Sixth Day. 7.00 a.m. Egg; sugar, 4 gm. (1 dr.). 8.00 a.m. Milk, 100 cc (3! oz.). 9.00 a.m. Egg; sugar, 4! gm. (1 dr.); scraped beef, 12 gm. (3 dr.). 10.00 a.m. Milk, 100 cc oz.). 11.00 a.m. Egg; sugar, 4! gm. (1 dr.). 12.00 noon Milk, 100 cc (3! oz.). 1.00 p.m. Egg; sugar, \\ gm. (1 dr.); scraped beef, ’ 12 gm. (3 dr.). 2.00 p.m. Milk, 100 cc (3! oz.). 3.00 p.m. Egg; sugar, 4! gm. (1 dr.). 4.00 p.m. Milk, 100 cc oz.). 5.00 p.m. Egg; sugar, 4 gm. (1 dr.); scraped beef, 12 gm. (3 dr.). 6.00 p.m. Milk, 100 cc (3! oz.). 7.00 p.m. Egg; sugar, \\ gm. (1 dr.). Total, sixth day, eggs (raw), 7; milk, 600 cc (20 oz.); sugar, 30 gm. (1 oz.); scraped beef, 36 gm. (9 dr.); calories, 1135. Seventh Day. 7.00 a.m. 1 soft-boiled egg. 8.00 a.m. Milk, 100 cc oz.). 9.00 a.m. Egg; sugar, 13 gm. (3 dr.). 10.00 a.m. Milk, 100 cc oz.); scraped beef, 23 gm. (6 dr.); boiled rice, 33 gm. (1 oz.). 11.00 a.m. 1 soft-boiled egg. 12.00 noon Milk, 125 cc (4 oz.). 1.00 p.m. Egg; sugar, 13 gm. (3 dr.). 2.00 p.m. Milk, 125 cc (4 oz.); scraped beef, 23 gm. (6 dr.); boiled rice, 33 gm. (1 oz.). PEPTIC ULCER 369 3-00 p.m. i soft-boiled egg. 4.00 p.m. Milk, 125 cc (4 oz.). 5.00 p.m. Egg; sugar, 14 gm. (3I dr.). 6.00 p.m. Milk, 125 cc (4 oz.); scraped beef, 24 gm. (6 dr.); boiled rice, 34 gm. (1 oz.). 7.00 p.m. 1 soft-boiled egg. Total, seventh day, eggs (raw), 4; soft-boiled, 4; milk, 700 cc (23! oz.); sugar, 40 gm. (i| oz.); scraped beef, 70 gm. (2-5 oz.); boiled rice, 100 gm. (3! oz.), with beef juice; calories, 1580. Eighth Day. The diet changes on the eighth day, requiring only 4 raw eggs, which may be divided into three feedings. The other 4 eggs are to be soft-boiled and given as directed by diet. 7.00 a.m. 1 soft-boiled egg. 8.00 a.m. Milk, 135 cc (4! oz.). 9.00 A.M. Egg; sugar, 13 gm. (3 dr.). 10.00 a.m. Milk, 133 cc (4! oz.); scraped beef, 23 gm. (6 dr.); boiled rice, 33 gm. (1 oz.). 11.00 a.m. i soft-boiled egg; zwieback, 10 gm. (2! dr.). 12.00 noon Milk, 133 cc (4! oz.). 1.00 p.m. Egg; sugar, 13 gm. (3 dr.). 2.00 p.m. Milk, 133 cc (4I oz.); scraped beef, 23 gm. (6 dr.); boiled rice, 33 gm. (1 oz.). 3.00 p.m. 1 soft-boiled egg. 4.00 p.m. Milk, 133 cc (4! oz.). 5.00 p.m. Egg; sugar, 14 gm. (3I dr.); zwieback, 10 gm. (2! dr.). 6.00 p.m. Milk, 133 cc (4I oz.); scraped beef, 24 gm. (6 dr.); boiled rice, 34 gm. (1 oz.). 7.00 p.m. 1 soft-boiled egg. Total eighth day, eggs (raw), 4; soft-boiled, 4; milk, 800 cc (26! oz); scraped beef, 70 gm. (2! oz.); boiled rice, 100 gm. (3I oz.); zwieback, 20 gm. (5 dr.); sugar, 40 gm. (ij oz.); calories, 1720. Ninth Day. 7.00 a.m. I soft-boiled egg. 8.00 a.m. Milk, 150 cc (5 oz.). 9.00 a.m. Egg; sugar, 13 gm. (3 dr.). 10.00 a.m. Milk, 150 cc (5 oz.); scraped beef, 23 gm. (6 dr.); boiled rice, 66 gm. (2 oz.). 11.00 a.m. 1 soft-boiled egg; zwieback, 20 gm. (5 dr.). 12.00 noon Milk, 150 cc (5 oz.). 1.00 p.m. Egg; sugar, 13 gm, (3 dr.). 370 DIET IN DISEASES OF THE STOMACH 2.oo p.m. Milk, 150 cc (5 oz.); scraped beef, 23 gm. (6 dr.); boiled rice, 67 gm. (2 oz.). 3.00 p.m. 1 soft-boiled egg; zwieback, 20 gm. (5 dr.). 4.00 p.m. Milk, 150 cc (5 oz.). 5.00 p.m. Egg; sugar, 14 gm. (3I dr.). 6.00 p.m. Milk, 150 cc (5 oz.); scraped beef, 24 gm. (6 dr.); boiled rice, 67 gm. (2 oz.). 7.00 p.m. 1 soft-boiled egg. Total, ninth day, egg (raw), 4; cooked, 4; milk, 900 cc (30 oz.); sugar, 40 gm. (if oz.); scraped beef, 70 gm. (2f oz.); rice, 200 gm. (6§ oz.); zwieback, 40 gm. (if oz.) or toast, 20 gm. (dr.); calories, 2138. Tenth Day. 7.00 a.m. i soft-boiled egg. 8.00 a.m. Milk, 166 cc (5! oz.). 9.00 A.M. Egg; sugar, 13 gm. (3 dr.). 10.00 a.m. Milk, 168 cc (5! oz.); scraped beef, 23 gm. (6 dr.); boiled rice, 66 gm. (2 oz.). 11.00 a.m. 1 soft-boiled egg; zwieback, 20 gm. (5 dr.); butter, 4 gm. (1 dr.). 12.00 noon Cooked chopped chicken, 25 gm. (6 dr.); milk, 166 cc (5! oz.). 1.00 p.m. Egg; sugar, 13 gm. (3 dr.). 2.00 p.m. Milk, 166 cc (5! oz.); scraped beef, 23 gm. (6 dr.); boiled rice, 66 gm. (2 oz.); butter, 4 gm. (1 dr.). 3.00 p.m. i soft-boiled egg; zwieback, 20 gm. (5 dr.); butter, 4 gm. (1 dr.). 4.00 p.m. Cooked chopped chicken, 25 gm. (6 dr.). 5.00 p.m. Egg; sugar, 14 gm. (3I dr.). 6.00 p.m. Milk, 166 cc (5I oz.); scraped beef, 24 gm. (6 dr.); boiled rice, 67 gm. (2 oz.); butter, 4 gm. (dr.i). . 7.00 p.m. i soft-boiled egg. Total, tenth day, eggs (raw), 4; cooked, 4; milk, 1000 cc oz.); sugar, 40 gm. (if oz.); scraped beef, 70 gm. (2f oz.); boiled rice, 200 gm. (6f oz.); zwieback, 40 gm. (if oz.), or toast, 20 gm. (5 dr.); chicken, 50 gm. (if oz.); butter, 20 gm. (5 dr.); calories, 2478. Eleventh Day. 7.00 a.m. i soft-boiled egg; milk, 250 cc (8f oz.); zwie- back, 10 gm. (2! dr.); butter, 4 gm. (1 dr.). PEPTIC ULCER 371 8.oo a.m. Egg; sugar, 13 gm. (3 dr.); scraped beef, 20 gm. (5 dr.); boiled rice, 75 gm. (z\ oz.); zwieback, 10 gm. (2! dr.); butter, 6 gm. (if dr.) 11.00 a.m. 1 soft-boiled egg; milk 250 cc (8f oz.); butter, 6 gm. if dr.); zwieback, 10 gm. (2f dr.). 1.00 p.m. Egg; sugar, 13 gm. (3 dr.); cooked chopped chicken, 25 gm. (6 dr.); boiled rice, 75 gm. (2f oz.). 3.00 p.m. i soft-boiled egg; milk, 250 cc (8f oz.); scraped beef, 20 gm. (5 dr.); boiled rice, 75 gm. (2! oz.); zwieback, 10 gm. (2f dr.); butter, 6 gm. (if dr.). 5.00 p.m. Egg; sugar, 14 gm. (3I dr.); cooked chopped chicken, 25 gm. (6 dr.); boiled rice, 75 gm. (2f oz.); butter, 6 gm. (if dr.). 7.00 p.m. 1 soft-boiled egg; milk, 250 cc (8§ oz.); zwie- back, 10 gm. (2f dr.); butter, 6 gm. (if dr.); scraped beef, 30 gm. (1 oz.). Total, eleventh day, eggs (raw), 4; cooked, 4; milk, 1000 cc (331 oz.); butter, 40 gm. (if oz.); sugar, 40 gm. (if oz.); scraped beef, 70 gm. (2f oz.); boiled rice, 300 gm. (10 oz.); zwieback, 60 gm. (2 oz.); chicken, 50 gm. (if oz.); calories, 2941. Twelfth Day. 7.00 a.m. I soft-boiled egg; milk, 250 cc (8f oz.); zwie- back, 10 gm. (2f dr.); butter, 4 gm. (1 dr.). 9.00 a.m. Egg; sugar, 13 gm. (3 dr.); scraped beef, 35 gm. (1 oz.); boiled rice, 75 gm. (2f oz.); zwieback, 10 gm. (2f dr.); butter,6 gm. (i| dr.). 11.00 a.m. i soft-boiled egg; milk, 250 cc (8f oz.); zwie- back, 20 gm. (5 dr.); butter, 6 gm. if dr.). 1.00 p.m. Egg; sugar, 13 gm. (3 dr.); cooked chopped chicken, 25 gm. (6 dr.); boiled rice, 75 gm. (2f oz.); zwieback, 10 gm. (2f dr.); butter, 6 gm. (if dr.). 3.00 p.m. 1 soft-boiled egg; milk, 250 cc (8f oz.); scraped beef, 35 gm. (1 oz.); boiled rice, 50 gm. (if oz.); zwieback, 10 gm. (2f dr.); butter, 6 gm. (if dr.). 5.00 p.m. Egg; sugar, 14 gm. (3f dr.); cooked chopped chicken, 25 gm. (6 dr.); boiled rice, 75 gm. (2f oz.); zwieback, 10 gm. (2f dr.); butter, 6 gm. (if dr.). 372 DIET IN DISEASES OF THE STOMACH 7-00 p.m. I soft-boiled egg; milk, 250 cc (8§ oz.); zwie- back, 10 gm. (2! dr.); butter, 6 gm. (i| dr.). Total, twelfth day, eggs (raw), 4; cooked, 4; milk, 1000 cc (33! oz); sugar, 40 gm. (i| oz.); scraped beef, 70 gm. oz.); boiled rice, 300 gm. (10 oz.); zwieback, 80 gm. (2§ oz); chicken, 50 gm. (if oz.); butter, 40 gm. (i| oz.); calories, 2941. Thirteenth Day. 7.00 A.m. 1 soft-boiled egg; milk, 142 cc (4! oz.); zwie- back, 10 gm. (2! dr.); butter, 4 gm. (1 dr.). 9.00 a.m. Egg; sugar, 13 gm. (3 dr.); milk, 142 cc (4! oz.); scraped beef, 20 gm. (5 dr.); boiled rice, 75 gm. (2§oz.); zwieback, 20 gm. (5dr.); butter, 6 gm. (i| dr.). 11.00 a.m. 1 soft-boiled egg; milk, 144 cc (5 oz.); zwie- back, 10 gm. (2! dr.); butter, 6 gm. (i| dr.). 1.00 p.m. Egg; sugar, 13 gm. (3 dr.); milk, 142 cc (4! oz.); cooked chopped chicken, 25 gm. (6 dr.); boiled rice, 75 gm. (2! oz.); zwieback, 10gm. (2! dr.); butter, 6 gm. (i| dr.). 3.00 p.m. 1 soft-boiled egg; milk, 144 cc (5 oz.); scraped beef, 20 gm. (5 dr.); boiled rice, 75 gm. (2| oz.); zwieback, (2| dr.); butter, 6 gm. (i| dr.). 5.00 p.m. Egg; sugar, 14 gm. (3! dr.); milk, 142 cc (5 oz.); cooked chopped chicken, 25 gm. (6 dr.); boiled rice, 75 gm. (2! oz.); zwie- back, 10 gm. (2! dr.); butter, 6 gm. (i| dr.). 7.00 p.m. 1 soft-boiled egg; milk, 144 cc (5 oz.); zwie- back, 10 gm. dr.); butter, 6 gm. dr.). Total, thirteenth day, eggs (raw), 4; cooked, 4; milk, 1000 cc (33l oz.); sugar, 40 gm. oz.); scraped beef, 70 gm. (2! oz.); boiled rice, 300 gm. (10 oz.); zwieback, 80 gm. (2| oz.); chicken, 50 gm. (if oz.); butter, 40 gm. (if oz.); calories, 3007. Fourteenth Day. 7.00 a.m. 1 soft-boiled egg; minced chop; buttered toast; milk, 142 cc (4I oz.). 9.00 a.m. Boiled rice; buttered zwieback; custard; milk, 142 cc (4f oz.). n.00 a.m. i soft-boiled egg; buttered zwieback; junket; milk, 144 cc (5 oz.). 1.00 p.m. Minced chicken; boiled rice; buttered zwie- back; custard; milk, 142 cc (4I oz.). PEPTIC ULCER 373 3-00 p.m. I soft-boiled egg; cooked scraped beef; boiled rice; buttered toast; milk, 144 cc (5 oz.). 5.00 p.m. Minced chicken; boiled rice; buttered zwie- back; custard; milk, 142 cc (4I oz.). 7.00 p.m. 1 soft-boiled egg; buttered toast; milk, 144 cc (5 oz.). Total, fourteenth day, eggs (raw), 4; cooked, 4; milk, 1000 cc (33i oz.); sugar, 40 gm. oz.); scraped beef, 70 gm. (2| oz.); boiled rice, 300 gm. (10 oz.); zwieback, 100 gm. oz.); butter, 40 gm. (i| oz.); chicken, 50 gm. (if oz.); calories, 3007. Many patients are unable to take the full amount of food ordered after the sixth day, particularly women who may have long been small eaters. If pushed, the feedings may result in an acute gastric upset, anorexia, nausea, vomiting; in fact this has been very frequent in the writer’s experience, often making it necessary to stop all feedings for twenty- four hours, or at least after the sixth day, only advancing the diet every other day, thus giving a little more time to become adjusted to the quantity of food. In fact this is the writer’s custom whenever this form of diet seems indicated. Whenever any hard substance like zwieback is called for, it is wiser to substitute a little softened toast or even the zwieback softened with hot water. The usefulness of the Lenhartz diet is confined almost entirely to the treatment of acute ulcer cases, and even in these the amount of food given after the first few days is too large for most patients, nausea and vomiting, being, not infrequently, the result. In chronic ulcer it is distinctly less valuable for the same reason and also because meat is added too early to the diet. Diet Combined with Alkaline Treatment.—There have been advanced many forms of the alkaline treatment com- bined with proper diet for cases of gastric and duodenal ulcer, but apparently the one most specifically and carefully worked out for this is the treatment arranged and practised by B. W. Sippy,1 of Chicago. By this method he feels that an operative procedure is scarcely ever necessary, as the cases are so regularly cured by medical means, and he even includes all cases of pyloric stenosis, except those of extreme narrowing, due to definite cicatricial contraction following a healed ulcer. He says that after three, four or more weeks of this treatment the spasm is relieved, the round-celled infiltration disappears as well as the edema of the inflammatory tissues, and the 1 Sippy, in Musser and Kelly: Jour. Am. Med. Assn., 1915, 64, 20, 1625. 374 DIET IN DISEASES OF THE STOMACH Milk, Sugar, Scraped beef, Boiled rice, Zwieback, Butter, Chicken, Day. Calories. Eggs. cc. gm. gm. gm. gm. gm. gm. I 280 Raw 2 100 ( 3! oz.) 2 470 Raw 3 200 ( 6f oz.) 3 637 Raw 4 300 (10 oz.) 20 (5 dr.) 4 777 Raw 5 400 (13! oz.) 20 (5 dr.) 5 966 Raw 6 500 (i6f oz.) 30 (1 oz.) 6 ii35 Raw 7 600 (20 oz.) 30 (1 oz.) 36 (9 dr.) 7 1580 Raw 4, 700 (23-I oz.) 40 (if oz.) 70 (2§ OZ.) IOO ( 3§ OZ.) soft 4 8 1720 Raw 4, 800 (26I oz.) 40 (if oz.) 70 (25 OZ.) 100 ( 3J OZ.) 20 ( f OZ.) soft 4 9 2138 Raw 4, soft 4 900 (30 oz.) 40 (if oz.) O O 200 ( 63 OZ.) 40 (if OZ.) or toast, 20 ( § oz.) 20 ( | OZ.) 50 (if oz.) 10 2478 Raw 4, soft 4 1000 (33J oz.) 40 (1$ oz.) 70 (2| oz.) 200 ( 63 OZ.) 40 (if oz.) or toast, 20 (1 oz.) 40 (l£ OZ.) 50 (if oz.) ii 2941 Raw 4, 1000 (33* oz.) 40 (if oz.) 70 (2* oz.) 300 (10 oz.) 60 (2 oz.) soft 4 12 2941 Raw 4, 1000 (33* oz.) 40 (if oz.) 70 (2! oz.) 300 (10 oz.) 80 (2§ oz.) 40 (l| OZ.) 50 (if oz.) soft 4 • 13 3007 Raw 4, 1000 (33* oz.) 40 (if oz.) 70 (2§ OZ.) 300 (10 oz.) 80 (2§ OZ.) 40 (13 OZ.) 50 (if OZ.) soft 4 14 3007 Same as the thirteenth day. Table of Lenhartz’s Diet. PEPTIC ULCER 375 Day. l. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Egg i 15 2 25 3 33 4 4 3 3 3 2 2 2 Milk oz. 3 4l 6 73 9 iof 12 17 18 19 20 21 22 23 Glaxo, half strength oz. 5 7\ IO I2§ 15 173 20 25 25 25 25 25 25 25 Sugar dr. 6 6 8 8 12 12 14 14 14 14 14 14 Plasmon dr. 2 3 3 3 3 3 3 3 3 Blanc mange oz. 35 33 7 7 10 10 10 Rusks oz. 3 4 13 13 23 3 4 Pounded fish oz. 2 2 2 2 2 2 Butter oz. 3 4 13 13 15 15 Quantity given each feed oz. i 2 2| 3 33 4 5 5 5 5 5 5 5 Calorie value approximate 160 240 400 475 580 685 825 1115 1185 1650 1820 2010 2080 2200 Ten feedings in twenty-four hours, 2 hourly by day and 4 hourly by night. To relieve thirst, saline enemata, \ pint twice daily if necessary or one ounce of water by mouth. Soap enema every other day, or daily if necessary. Olive oil enema at night. Mouth swabbed out before and after feedings with a solution of soda bicarbonate, one teaspoonful to five ounces of water. Keep fluid diet standing on ice. 1 As used by St. Bartholomew’s Hospital, London. Courtesy of Sir Henry Huxley. Lenhartz Diet (Modified).1 376 DIET IN DISEASES OF THE STOMACH lumen is again established so that in practically every case a motor meal, consisting of meat and vegetables, leaves the stomach within the normal limits of six or seven hours. This is, of course, quite radical and might be considered an extreme statement. Sippy, however, is most definite in his statements as to methods, what is to be expected and the results obtained, and since they are made on such responsible authority they warrant a respectful hearing and a very thorough trial in practice. He limits surgical interference in ulcer cases to the following conditions and complications. 1. Perforation. 2. Perigastric abscess. 3. Secondary carcinoma. 4. Hour-glass or other deformity. 5. Hemorrhage of a serious nature under certain condi- tions. 6. Pyloric obstruction of high grade not influenced by medical treatment. The underlying principles on which the diet and treatment are founded may be stated as follows: Peptic ulcers would tend to heal spontaneously, as ulcers situated elsewhere, were it not for the fact that they are constantly subjected to the corrosive action of the gastric juice, and that if this can be neutralized continuously during the period of gastric and upper intestinal digestion by proper diet and alkalies and the removal at night of any product of continuous hypersecre- tion, the ulcer will heal without difficulty. With this as a basis, Sippy treats and diets these cases as follows: Patients are put to bed from three to four weeks, at the end of which time they are gradually allowed up and out as one would after any illness of a corresponding length, but no real work should be attempted for a period of seven or eight weeks at least. As originally outlined the initial treatment consists of a period of five days in which no food or drink was given by mouth, but about twelve ounces, more or less, of saline was given by rectum four times a day. Subsequently, this period of starvation was abandoned, and presumably, except in the case of severe hemorrhage, the feedings were begun at once. Each morning one-half hour before the first feeding a dram of subnitrate of bismuth is given in a little water. Feedings are given every hour from 7 a.m. to 7 p.m., consisting of equal parts of milk and cream in amounts of a total of 1 to 3 ounces. Although acidity is more easily controlled by hourly feedings, some cases do well on two, three or four hourly feedings. Half-way between each feed- ing a powder consisting of 10 grains each of calcined magnesia PEPTIC ULCER 377 and sodium bicarbonate is given, alternating with another powder of io grains of bismuth and 20 to 30 grains of soda bicarbonate. It is best to give the powder containing mag- nesia as often as possible as the magnesia has four times the power of neutralizing the free hydrochloric acid as compared with the soda; diarrhea, however, is apt to follow its free use, so that one must alternate these powders according to this condition. After two or three days, soft eggs and well- cooked (fine) cereals are added so that at the end of about ten days the patients are receiving the 3 ounces of milk and cream mixture every hour from 7 a.m. to 7 p.m., 3 soft-boiled eggs, one at a time, and 9 ounces of cereal, 3 ounces given at each three feedings. These extras are added one at a time until the six extra feedings of eggs and cereals are given evenly spaced throughout the day. The bulk of each feeding should not exceed a total of 6 ounces. In order that the treatment should be successful, an accurate control of the acidity must be maintained throughout the twenty-four hours. This is accomplished by testing the gastric contents from time to time, during the treatment, by the stomach-tube (or Ein- horn’s duodenal tube may be used to advantage, as very easy of application). Sippy’s method for accurate control of the free hydrochloric acidity is somewhat as follows: The first day or two the tube is passed occasionally to check up the presence of free HC1; if present in the stomach contents the alkali powders must be increased, as the treatment aims absolutely to keep the free HC1 down to zero. After a day or two this is done as a routine two or three times a week, as practically that is all that is necessary to ensure the absence of the hydrochloric acid. The amount of alkali can be varied as determined by the examination of the stomach contents. It is particularly necessary to be sure that the stomach does not contain free acid during the night and it may be necessary to give two or three alkali powders between 7 and 10 p.m. to ensure this. At 10 o’clock the tube should be passed and all acid hyper- secretion removed. If there is a considerable amount of this, the tube should be passed again during the night two or three times. After the first few days’ treatment this is rarely necessary as the hypersecretion is usually well controlled and at 10 p.m. nothing but a very few cubic centimeters of gastric contents are found, which are unimportant. In the diet, cream soups, vegetable purees or other soft foods may be added or substituted, such as jellies, custards, creams; keeping, however, the milk, cream, eggs and cereal as the basis of the diet. The best cereals are farina, cream 378 DIET IN DISEASES OF THE STOMACH of wheat, rice cooked to a soft pulp. With this diet it is quite regularly that the cases, according to Sippy, show a gain of from i to 4 pounds a week. During the third week, soft toast or crackers, puree of potato, cream soups may be added. In the fourth week the milk and cream may be made 2| ounces each at each feed- ing and the period between feedings lengthened to two hours. After two or three weeks more, three-hour feedings may be given, but if the ulcer is of some months’ duration it is best not to increase the periods too rapidly and for several months it is wise not to have the patients take less than five feedings a day. The morning bismuth should be taken for from six to eight weeks and then stopped and the alkaline powders should be continued between feedings for several months. During a period of a year or more, milk, cream, eggs, vegetables, purees, cereal, bread and butter and meats should form the basis of the diet. In cases that for one reason or another milk is distasteful, it often can be given if flavored with tea, cocoa, etc.; frozen balls of butter may be substituted for cream and a small quantity of cereal gruel may be given each hour. Modified Diet for Peptic Ulcer.—In this the essential features of both the Sippy and von Leube methods are com- bined and fully peptonized milk (two-hour peptonization) is used instead of the milk and cream mixture of Sippy. This modified method reproduces medically the conditions that are sought by operation, viz., a continued greatly reduced gastric acidity and even a real alkalinity of the stomach contents, as well as a rapid emptying time, for Cannon has shown that fully peptonized milk leaves the stomach with great rapidity. The following are the details of the method: The patient is kept in bed for three weeks and the hot pad kept continuously on the epigastrium as in the von Leube routine. The continuous Murphy drip of 2 per cent glucose solution is started at once to which is added 50 grains (3 grams) strontium bromide for the daily allowance. Nothing by mouth is allowed for three days. Mouth washes are used several times a day. Mouth feeding is begun on the fourth day, consisting of 2 ounces (60 cc) fully peptonized milk, every hour from 7 a.m. to 7 p.m. Half-way between feedings the alkaline powders, as recommended in the Sippy routine, are given in 2 ounces of water (60 cc). Each day the milk is increased 1 ounce (30 cc) until 4 ounces (120 cc) are taken every hour (or 8 ounces (240 cc) every two hours in some cases). The water allowance is not increased to over 3 or 4 ounces PEPTIC ULCER 379 (90 to 120 cc) with the alkali. After eight or ten days of feeding a tablespoonful of well-cooked farina is allowed, first twice a day with two milk feedings, which are kept up continuously. The tenth day farina, cream of wheat or wheatena are allowed with three of the milk feedings. The twelfth day one may increase the cereal to 2 tablespoonfuls and a small sprinkling of powdered sugar is allowed. The fifteenth day four soft feedings are given evenly spaced through- out the day, still continuing the peptonized milk feedings; of these soft feedings one may be one slice of milk toast. The seventeenth day a soft egg is allowed or custard and the milk feedings may be reduced to 2 ounces (60 cc). After the twenty-first day the feedings are arranged so as to give three soft meals at eight, one, and six-thirty with a mid-feeding at 11 a.m. and 4 p.m. of milk, custard, junket or cream cheese sandwich. In the fourth week creamed fresh cod or halibut are added, cream or puree soups, mashed potatoes and well- cooked rice. From the end of the third week the peptonization of the milk is reduced fifteen minutes a day until plain milk is taken, but always scalded. During the entire treatment the alkaline mixtures are given in sufficient amount at first to maintain as nearly as possible a continuously alkaline reaction to the gastric contents, and when soft feedings are added, sufficient to prevent the formation of free HC1 at least. The stomach contents must be tested by passing a stomach or duodenal tube and emptying the stomach at bedtime and during the night if necessary, as recommended in the Sippy routine. Coleman1 has devised a diet to meet the two essentials of any peptic ulcer diet in that it is claimed: 1. To protect the ulcer from mechanical or chemical injury. 2. To maintain the nutrition of the patient at a level which will favor the healing of the ulcer. The procedure is to give the stomach complete rest for three to five days through the use of glucose enemata, 300 cc of a 7 per cent to 12 per cent solution by the Murphy drip three or four times a day (these solutions may cause rectal irritation). Theoretically egg-albumen to supply the necessary protein is best, as according to Pawlow egg-albumen alone does not call forth gastric secretion; to this is added olive oil to furnish the energy requirements as nearly as possible. The oil inhibits gastric secretion and protects the ulcer. The oil is given at first in moderate hut gradually increasing amounts up 1 Proc. Soc. Exp. Biol. Med., 1920, 18, 43. 380 DIET IN DISEASES OF THE STOMACH to a total of 150 cc a day = 1395 calories. The whites ol 2 or 3 eggs a day are added shortly after the oil is begun and is later increased to 5 or 6 (7.0 to 8.0 grams nitrogen), 450 calories. During the treatment 100 grams of glucose is given daily by rectum. Good results are claimed for this treatment, but no series of cases has been reported with a follow-up history. Theoretically it has some decided points in its favor. Ambulatory Diet Cure for Peptic Ulcer. —There are always a certain number of cases that are seen in whom the symp- toms are very suggestive of chronic ulcer, but in whom the diagnosis is not sufficiently certain or for one reason or another the patients will not or cannot give the time for a regular course of treatment in bed. In these cases it is advisable to put them on a bland diet which has sufficient food value to keep up the patient’s strength, and combine well with the usual large excess of free hydrochloric acid and be obtainable almost any and everywhere. In this day of the “dairy lunch,” it is very easy to obtain this diet any- where about a city. If the case is actually one of gastric or duodenal ulcer the chances are very great that at least there will be decided temporary relief, sometimes for a year or more, and in a few cases, particularly if persisted in for three or four weeks, the writer has seen clinical cures. The diet is also of considerable diagnostic value, as the case which is clinically ulcer but does not get very great or complete tem- porary relief for weeks or longer, is very probably not ulcer but chronic appendicitis, gall-bladder disease or something else which simulates ulcer. The diet for these ambulatory cases is planned as follows: For two (or more) full weeks they take at 8 a.m., i and 7 p.m., 2 glasses of milk (£ cream) and 2 soft-boiled eggs (1 minute), without salt at first. At 11 a.m. and 4 p.m. i| glasses of milk. This gives milk (1680 cc), 56 ounces. Cream 13 ounces (390 cc) 6 eggs. Protein 105 grams (3! ounces); fat 177 grams (6 ounces). Carbohydrate 85 grams (3 ounces), calories 2400. Before breakfast a dram (4 grams) of bismuth subnitrate is given in an ounce of water. One-half hour after the three principal meals, 5 to 1 dram (2 to 4 grams) of the following powder: Equal parts of bismuth, soda bicarbonate and cal- cined magnesia is given in 4 ounces (120 cc) of water. The magnesia may be reduced and an equal amount of soda added if the bowels are made too active by the magnesia. One- half hour after the 11 a.m. and 4 p.m. feedings one teaspoonful of soda is given in | glass of water. At night after the seven PEPTIC ULCER 381 o’clock feeding the magnesia mixture is given at 7.45 and a teaspoonful of soda at 8.45 p.m. and 9.45 p.m., each in \ to f glass of water. If possible it is well for the patient to empty his stomach by the tube at 10.30 p.m. In all these forms of ulcer treatment, except when there has been a recent hemorrhage, if pain persists, relief is often obtained by an early morning lavage of the stomach with a silver nitrate solution 1 to 4000 increasing to 1 to 2000 followed after the stomach is left clean by plain water lavage, by the bismuth. After the two weeks are up, or longer in severe cases, fine well-cooked cereals, custards, gruels, cream soups, soft toast; later boiled fish, etc., can be added as in the third and fourth weeks of the von Leube diet. One does not expect to get the best results with this diet, and it should not be advised unless the patient refuses for one reason or another to take a full course of diet with rest in bed. Vichy is the best form in which to take water between feedings or if more alkali is indicated by much acidity. Alkali powders may be given an hour after the principal feedings. If the milk mixture does not seem to agree, some of the alkali may be added directly to each feeding.1 An occasional case has to omit the cream on account of increased gastric acidity. Transgastric or Duodenal Feeding.2—This method of feed- ing has been devised by Einhorn and is recommended by him in gastric or duodenal ulcef cases or chronic gastric dila- tation, to prevent weight on the gastric walls and to allow them to contract down to more nearly their normal size, this of course provided there is no organic obstruction. Also in extreme atony, whether there is pylorospasm or not; in cases where nutrition is difficult on account of asthenia, absolute anorexia and nervous vomiting. Einhorn also recom- mends it in severe liver diseases to reduce the physiological congestion of that organ and also in inoperable carcinoma of the stomach where the taking of food is painful. In gastric or duodenal ulcer with which we are particularly concerned here, its usefulness is claimed to lie in the rest, both secretory and muscular, which it gives to the stomach and possibly to a less extent to the duodenum. The duodenal tube is introduced as follows: The tube is 1 A very good form of alkaline powder to use is equal parts of soda bicarbonate, heavy burned magnesia and subnitrate of bismuth. Bismuth subnitrate in dram doses is useful to control pain when given on an empty stomach early in the morning. 2 Einhom: Post Graduate, 1913. 382 DIET IN DISEASES OF THE STOMACH put in the patient’s mouth and he is given a swallow or more of water, to wash it down, taking care only that it is not swallowed too quickly, so that it does not rotate on itself, but will go straight into the stomach. The patient then lies on the right side to facilitate the passage of the tube into the duodenum by gravity. This takes a varying amount of time, depending on the acidity present, the motor power of the stomach muscle and the presence or absence of pyloro- spasm, entering the duodenum quickest in hypoacidity or achylia when accompanied, as it usually is, by good muscu- lar action and no spasm of the pylorus; the time varying from ten to twenty minutes under the latter conditions, to two or three hours for normal individuals and even up to thirty-six hours at the longest. When the tube is beyond the pylorus it is difficult to obtain fluid and what little can be obtained is alkaline and usually contains bile. If still in the stomach the fluid aspirated by the syringe is of course acid and is in greater quantity. If there is achylia and con- sequently no acid to test for, we can give a little milk or colored fluid by mouth and immediately aspirate; if the tube is beyond the pylorus no milk will be aspirated. After the tube is once in the duodenum it is left there throughout the period of feeding, twelve to fifteen days, and the mouth kept clean by frequent use of mouth washes. The regular feedings recommended by Einhorn consist of milk, 7 or 8 ounces (210 to 240 cc) one egg and a tablespoon- ful of lactose. If diarrhea develops the lactose is omitted. Where it is necessary to prevent loss of weight or to increase weight, 1 or 2 drams (2 to 4 grams) of butter may be added to each feeding. Where patients for one reason or another can- not take milk, gruels may be substituted but always being sure that the feedings are all free from lumps. The number of feedings is eight a day, at two-hour intervals, and must be given slowly, taking at least twenty minutes to each; for if given rapidly they cause overdistention of the duodenum and great discomfort. The best way to introduce the food is by means of a syringe with a three-way stopcock so that it need not be disconnected each time, or it may be allowed to flow by gravity. The food should all be strained and given at body tem- perature and the thinner the tube the more comfortable for the patient, although the smaller tubes necessitate slower feeding. A very important rule is, that after the food has been given, a little water, then a little air should be passed through the tube to be sure the tube is clean and empty; otherwise the tube is apt to be blocked in a day or two, neces- DIET AFTER HEMORRHAGE FROM STOMACH 383 sitating its removal for cleaning. Besides the feedings at least a pint of warm normal saline should be given once a day, or this may be given by rectum. After the period of transgastric feedings is finished one begins mouth feedings with fully peptonized milk, then soft thin cereals and gradu- ally increasing the feeding as recommended in the von Leube cure, only one need not begin with such small feedings, but the feeding recommended for the eighth feeding day may be used at the start and increased as indicated for that regimen. Duodenal Feeding Diet. (Einhorn.) 7.30 A.m. Oatmeal gruel 180 cc (6 oz.) One egg Butter 15 gm. ( 5 oz). Lactose 15 gm. ( £ oz.) 9.30 A.M. Pea soup 180 cc (6 oz.) One egg Butter 15 gm. ( § oz.) Lactose 15 gm. ( \ oz.) 11.30 a.m. Same as at 9.30 a.m. 1.30 p.m. Bouillon 180 cc (6 oz.) One egg 3.30 p.m. Oatmeal gruel 180 cc (6 oz.) Butter 15 gm. ( \ oz.) One egg Lactose 15 gm. ( \ oz.) 5.30 p.m. Same as at 9.30 a.m. 9.30 P.M. Bouillon 180 cc (6 oz.) One egg Total amount: Calories. Oatmeal gruel 360 cc (13 oz.) = 1476 Eggs 8 =1352 Pea soup 720 cc (26 oz.) = 384 Lactose 90 gm. ( 3 oz.) = 369 Bouillon 360 cc (13 oz.) = 39 Butter 90 gm. ( 3 oz.) = 715 4335 DIET AFTER HEMORRHAGE FROM STOMACH OR DUODENUM. At the first evidence of hemorrhage the patient is to be kept absolutely at rest and quiet in bed. If the hemorrhage is severe so that life is threatened from exsanguination, the foot of the bed should be elevated on shock blocks and the patient’s limbs tied off with broad bandages to keep as much hlood in the trunk and head as possible. Each limb should be left tied off not longer than ten minutes at a time; they can be used thus in rotation, one or two at a time. Absolutely nothing should be given by mouth, not even cracked ice, but if there has been great loss of blood, saline may be given by rectum either in 4- to 6-ounce amounts, every three or four 384 DIET IN DISEASES OF THE STOMACH hours or by continuous Murphy drip. If the hemorrhage is extreme a saline infusion may be given, or better still a blood transfusion from a suitable donor. If the hemorrhage is recurring and too excessive the question of immediate laparot- omy must be considered. After hemorrhage it is best, if possible, not to use rectal saline or feeding for at least twenty-four to forty-eight hours unless the thirst becomes too excessive. The chief reason is, that anything put into the rectum starts antiperistalsis which may reach the stomach, and also that it is capable of starting gastric secretion. After this period is past one may begin on one or two lines of treatment. 1. Feeding by rectum entirely, for from two to five days, or even longer, and then begin on the Lenhartz, von Leube, or Sippy diets. 2. By beginning at once with an ulcer diet, as already explained. In the author’s opinion the Lenhartz is better suited to acute ulcerative conditions than to chronic, while the von Leube, particularly as modified by Lockwood, is better for either condition, acute or chronic. From this point the diet is arranged in accordance with the details of the diet selected. Practically all clinicians of experience favor at least a period of twenty-four to forty- eight hours’ absolute rest to the stomach before food or even water is given by mouth. GASTRIC ATONY. (Impaired Gastric Motor Function or Myasthenia Gastrica.) Enough has been said of this condition of atony when complicating chronic gastritis to indicate quite fully the principles involved in prescribing a dietary for the use of patients suffering from motor insufficiency of the stomach. Since the condition is almost always secondary to a general muscular and nervous debility often found in patients after exhausting or long-continued disease, and in those of enter- optotic habitus, the greatest care must be exercised in choos- ing a diet in order to overnourish these patients, if possible, so that they can gain in general ways, while at the same time preventing gastric overdistention and the introduction of foods which leave the stomach slowly or with difficulty, such as all coarse or tough foods, heavy fats, etc. Many patients with motor insufficiency of the stomach get fixed ideas as to what they can or cannot eat, and since it is GASTRIC ATONY 385 usually the latter, they very quickly add to their troubles marked malnutrition and eventually settling down to a die- tary which is hopelessly inadequate to nourish them, with the result that their stomach musculature becomes still further weakened. Motor insufficiency has been termed by some authorities as “an indigestion of liquids,” which simply means that liquids remain in the stomach longer than solids in this con- dition, so giving rise to fulness, splashing and regurgitation for a longer or shorter time after the stomach should be nor- mally empty. It must also be kept in mind that many if not most of these patients show general improvement, when on a proper diet, a considerable time before the gastric muscle regains its tone and they are constantly tempted to break rules and eat or drink as they choose because they feel so much better and stronger; only a firm adherence to diet and general hygiene with graduated exercises will bring the desired result with a return to normal of the gastric functions. Associated with the myasthenia one finds very frequently a condition of gastric hyperacidity which must also be taken into consideration in the diet planned for these individuals, also many persons with congenital or acquired ptosis of the stomach show the same combination of patho- logical conditions, namely, myasthenia and hyperacidity, either separately or combined. General Directions in Gastric Atony. —Before touching directly on the foods best suited to these cases it would be worth while to formulate certain rules for these patients to follow, which will aid the stomach in performing its motor functions with the greatest efficiency under the individual circumstances. 1. Patients should always have a period of absolute rest before meals, reclining for fifteen to thirty minutes. It is astonishing how much this rest will improve the appetite and muscular tone; it means that they eat when rested and do not hurry into a meal from some occupation; this is one of the greatest aids to good digestion in any abnormal condi- tion of the gastro-intestinal tract. 2. Meals should be small, well-cooked and of easily digested materials, rather dry and of concentrated caloric value, with- out skins of fruit and vegetable seeds, gristle or fat which does not melt at body temperature, e. g., mutton fat. 3. The interval for feeding in severe cases should be every three hours; 3 or 4 ounces or more of water should be given three-quarters of an hour before meals, best at room tem- perature or warm, never cold. 386 DIET IN DISEASES OF THE STOMACH 4. At meals it is best to take no liquids or at most not over 3 ounces and then only in the less severe cases. 5. It should be remembered that milk often fails to agree with these patients, increasing flatulence. 6. After meals when possible (and always in severe cases) patients should lie for half an hour to an hour on their right side in order to facilitate evacuation of the stomach by gravity. 7 Many cases, particularly those complicated by gastro- ptosis, will get great digestive benefit by wearing a proper corset or belt. This helps to fix a usually flabby abdominal wall and improves the splanchnic circulation, often result- ing in a general increase of the systolic blood-pressure; such patients often having an abnormally low blood-pressure, 85 to 100 mm. Hg. 8. Other hygienic measures useful in this condition will be found in books dealing with this particular subject, e. g., exercises, bathing, sleep and rest. Keeping in mind the foregoing rules it would hardly seem necessary to give a specimen dietary for such a case, but many are too busy or lack enthusiasm for these details, hence the following sample diets are given with the caution that such conditions as hyperacidity or hypoacidity, fermentation, pyloric spasm, etc., must be recognized if present and due allowance made in the selection of a diet. (See Special Rules for Diet in Hyperacid and Hypoacid Gastric Conditions.) Diets for Atony (rather liberal): 7 a.m. 2 tablespoonfuls of any well-cooked cereal with butter and sugar (heavy cream if it agrees). Bread or toast and butter, two slices; 1 soft- boiled egg. 10 a.m. Custard (unsweetened) with cream, 2 or 3 toasted saltines. 1 p.m. Chopped meat or chicken or fish; bread and but- ter; rice, cooked to a pulp, with butter and salt, or beef juice or baked potato. Later a small portion of baked Hubbard squash, stewed celery, or rice or bread pudding, but both dessert and vegetables should not be taken at the same meal. 4 p.m. Cream cheese with toasted and buttered saltine biscuits, as a sandwich, one or two of these. 7 p.m. Fish or eggs (except fried), bread and butter, rice with butter and cream, a simple dessert such as custard, blanc mange, Spanish cream, GASTRIC ATONY 387 10 p.m. Same as io a.m. or 4 p.m., feedings or a plain sandwich made of beef, chicken or mutton; Swiss cheese, bread and butter. For those who can take milk, it may be used in various ways, plain, buttermilk, junket, etc. Many of these cases of myasthenia being merely a part of a general neurasthenia with malnutrition, do well on the Weir-Mitchell rest-cure routine, care only being taken that large quantities of food shall not be taken at one time. In the severe cases it is often best to feed every two hours instead of every three, using small feedings of concentrated nourishment, then gradually increasing the intervals of feeding and the quantity of food at each feeding. Diet for Severe Atony: 8 a.m. Junket, 240 cc (8 oz.), with cream, 60 cc (2 oz.). 11 a.m. 4 saltines with cream and cheese. 1 p.m. Sandwich of bread and beef. 4 p.m. Cocoa, junket, 360 cc (12 oz.). 7 p.m. Custard, baked or boiled, 180 grams (6 oz.). 9 p.m. Sandwich, with chicken and bread. Wegele’s Diet for Atony of the Stomach: Morning.— Dry toast, 30 grams (1 oz.); a cupful of cocoa made of leguminose cocoa and 60 grams (2 oz.) of cream. Forenoon.— An egg (poached or soft-boiled) and 30 grams (1 oz.) of toast. Midday. —Scraped meat, 100 grams (3! oz.); mashed potato, 7 ounces (210 gm.); toast, 30 grams (1 oz.); followed by 30 grams (1 oz.) of extract of malt. Afternoon.—A cupful of cocoa with 60 cc (2 oz.) cream. Evening.—Tapioca cooked to a pulp, 300 grams (10 oz.). Followed by 20 cc (f oz.) of malt extract. 10 p.m. —A tumblerful of milk with a dessertspoonful of cognac brandy. Tibbies,1 on the other hand, recommends only three meals at 8 a.m., 2 p.m. and 8 p.m., two of them mainly protein, giving most of the carbohydrate at midday, as follows: Breakfast, 8 a.m.—Fish (sole, haddock, weakfish, seabass, halibut), with a little lemon juice; 1 or 2 eggs poached or lightly boiled. A small amount of crisp dry toast or stale bread, and a cupful of coffee with cream and one piece of sugar (if it agrees). Midday. — 2 p.m. (No meat.) Boiled macaroni with a trace of grated cheese or boiled rice with tomato, puree of cabbage, savory or potato with gravy or extract of meat; 1 Dietetics, Lea & Febiger, p. 295. 388 DIET IN DISEASES OF THE STOMACH boiled spinach, vegetable marrow or squash, string or snap kidney beans. Any milk pudding which has been cooked slowly (four or five hours). Jellies or creams made with gelatin, or fruit jelly or cooked apples, plums, prunes and raw fruit rubbed through a sieve (raspberries, strawberries, blackberries or currants). At the end of the meal 4 or 5 ounces of water, diluted spirit, Burgundy or Bordeaux. Evening.— 8 p.m. Soup about 90 cc (3 oz.); fish (same as at breakfast), tender lean beef or mutton, poultry, veni- son, pheasant or other game (except hare); 30 grams (1 oz.) of potato puree or boiled rice or toast or stale bread; no pud- ding or dessert. At the end of meal 2 glasses of wine or 30 cc (1 oz.) of whisky in 120 cc (4 oz.) of water. The food has a heat value of 2150 calories and contains: Protein. Fat. Carbohydrates. Alcohol. 209.6 gm. 58.7 gm. 142.5 gm. 350c Diet for Mild Atony i1 8 a.m. Cup of coffee or cocoa, with cream, sugar, fine cereal. n a.m. Egg shake, Russell’s emulsion or koumyss. i p.m. Steak or chop, one vegetable, rice pudding, bread and butter. 4 p.m. Chicken sandwich and a glass of hot milk. 7 p.m. Fish or chicken, two green vegetables, tapioca pudding. For advanced atony, still smaller meals are best, e. g.: 8 a.m. Cup of coffee or cocoa with cream, sugar; soft- boiled egg, bread and butter. II a.m. Baked custard. i p.m. Minced chicken on toast, cornstarch pudding. 4 p.m. Scraped beef sandwiches. 7 p.m. Small broiled chop, creamed spaghetti, io p.m. Cup of malted milk. The same rules in regard to drinking as before outlined. Meals should be dry, never more than one glassful of fluid and better less, half a glassful between meals once or twice. ORGANIC GASTRIC ACIDITY. Phis may be of two sorts, one due to the ingestion of organic acids in foods, such as acetic acid in pickles, cider, vinegar or acid-wine preparations; butyric acid from butter, lactic acid from buttermilk or other fermented or ripened milks. The other form of organic acidity is that due to the develop- 1 Lockwood: Diseases of the Stomach, p. 327. CARCINOMA OF THE STOMACH 389 ment of acids arising in the process of gastric fermentation, thus lactic acid from bacterial action on carbohydrates, butyric acid from dextrose and in fact any sugar, also from lactic acid. When gastric hydrochloric acidity is normal, bacterial activity is checked and organic acids are not found in the gas- tric contents unless they are ingested, except in minimal amounts. The dietary treatment of organic acidity depends, of course, first on the prevention of the ingestion of the acids and then upon the omission from the diet of acid-forming bodies, such as wines, butter, sugar and starches. At times it is best to put the patient on a milk diet for two or three days, then to add eggs, meat, fish, green vegetables and fruits, but omit- ting all farinaceous foods for a time. When all symptoms have subsided, well-toasted bread or cereal food may be allowed once a day, then twice a day and later three times a day and so on until the patient is back to a full mixed dietary. CARCINOMA OF THE STOMACH. The presence of a cancerous growth anywhere in the body is a guarantee that sooner or later the patient’s nutrition will suffer and in spite of a sufficient intake these people lose weight out of apparent proportion to the size of the growth or indeed its location. To this rule there are numerous exceptions and all clinicians are familiar with the latent type of carcinoma that develops silently without giving the usual outward signs of nutritional disturbance until toward the end of the course of the disease. Some of these cases main- tain a remarkable degree of nutrition up to the end, but, of course, most of them lose very rapidly as the disease pro- gresses and the emaciation in long-standing cases, particu- larly where the digestive tube is involved, is often extreme. The toxic destruction of tissue protein keeps a negative nitro- gen balance in spite of a high protein intake and when the amount taken is below the average normal, the emaciation is especially rapid. The partial or complete failure of free hydrochloric acid in the gastric secretion is a usual accompaniment of gastric carcinoma at some time in the course of its development, although it may not be evident in the earlier stages, but what is often lost sight of, is the fact that this same hypo- acidity may be present, when carcinoma is present at some point remote from the stomach. This fact has in all prob- ability much to do with the disturbances in digestion, as the lack of normal gastric secretion results not only in the 390 DIET IN DISEASES OF THE STOMACH lessening of gastric digestion but the normal stimulus for the pancreas and intestine is diminished or wanting, and so the normal preparation of food-stuffs for absorption is inter- fered with, the results of which soon become evident. Diet in Carcinoma of the Stomach.—The diet suitable for this disease depends principally upon the complications which may be present, and there are some fundamental facts which must be kept in mind. 1. These cases of carcinoma on account of the hypoacidity should be given only moderate amounts of meat products, unless there are other further contraindications. 2. The gastric motility is apt to be disturbed with delayed emptying of the stomach, particularly in the later stages; when this is present it is necessary to diet according to the rules laid down for myasthenia gastrica (atony). 3. When ulceration is evident one must be governed some- what by the principles advised for a peptic ulcer diet, in that the foods should be soft and non-irritating. It is not necessary to reduce the quantity except in the presence of rather extreme ulceration, for there is no chance of healing a carcinomatous ulcer by diet, and it is most important to keep up the patient’s nutrition to as high degree as possible, so these patients should be fed to the limit of their capacity with suitable liquids, semiliquids and soft foods. 4. Where ulceration is extreme or the anorexia so severe that nutrition is interfered with out of proportion to the development of the growth, good results may be obtained by duodenal feedings, using liquid foods of high caloric value, as suggested under the chapter on Duodenal Feeding (page 381). A fair amount can be done in this way to maintain the patient’s weight and strength. The use of an early morning saline drink is especially good both for the cleansing effect on the gastric mucous membrane and for a laxative effect when this is necessary. Those waters with sodium chloride are good for their cleansing effect, partic- ularly as there is usually an absence of chlorides in the stomach. Wiesbaden or Carlsbad sprudel represent the two types, Wiesbaden that without laxative effect and the Carlsbad when a laxative effect is needed. For most cases Vichy, either French or artificial, 4 ounces, does very well, or failing this, the use of 20 grains of soda bicarbonate and 10 grains of common salt in 6 ounces of water answers every purpose, with the addition of sodium sulphate or phosphate when additional laxative effect is desired. Most of these patients crave food more highly seasoned than usual and there is no objection to this within reason. CARCINOMA OF THE STOMACH 391 In the apparent absence of ulceration, alcohol should be taken only sparingly on account of its tendency to disturb digestion. As an appetizer with meals, a little diluted wine or whisky finds no contraindication in fact unless, again, ulceration is present. Foods that irritate or ferment readily should not be taken and are hardly likely to be, as anorexia is often a prominent symptom. When the growth involves either the cardia or pylorus, after a time only liquid food will pass a stricture. This food should be chosen with a view to its concentration as well as its fluid consistency and to this end milk, cream and lactose mixtures, with gruels made from cereals, pea soup with con- siderable amounts of butter, or puree soups in which cream is a large ingredient, and with ice-cream, made with eggs and liberally sweetened with lactose must form the bulk of the diet. In the preparation of milk to be used in the pres- ence of pyloric stenosis it is well to boil it first then flavor it with cocoa, coffee, tea, etc., as boiling causes the curd to be fine and soft and to offer less difficulty in passing the pylorus. This is a necessary precaution, as even in the absence of normal gastric digestion whole milk will curd from what little acid there may be present, but the further chymifica- tion is interfered with on account of the diminished hydro- chloric acid and pepsin, so that the thick curd may remain in the stomach an indefinite length of time. Adding i or 2 grains of sodium citrate to each ounce of milk has the effect also of preventing the formation of any but light flocculent curds. The liquid beef preparations are good as appetizers and for their stimulant effect, but their food value is so small that one must not be deceived by their bulk in thinking that anything of great food value is being given. The malted milk or dried-milk preparations are good to use for the sake of variety, but after all the more normal the constituents of the diet can be kept the better the appetite and nutrition will be preserved. Any one of the predigested proteins is good to use. In the presence of hemorrhage, unless excessive, it is not wise to stop food for more than a few hours, although the quality and quantity of food taken afterward might better conform for a time to one of the peptic-ulcer diets; but, as already stated, in connection with severe ulceration, the quantity must be rapidly advanced after a day or two of semistarvation, otherwise the loss of flesh and strength will be out of proportion to the uncertain improvement in the pathological condition present. 392 DIET IN DISEASES OF THE STOMACH When the pain from ulceration is so great as to cause great distress on the ingestion of food, it is well to give the patient a 5-grain orthoform tablet to dissolve in the mouth before meals or a small amount of cocaine in solution may be given, 1 or 1 grain, but this should not be done regularly. Anes- thesin, 2 per cent, in olive oil may be given in |-dram doses before meals, or bits of cracked ice with or without a little elixir of menthol1 may add greatly to the patient’s comfort if given before feedings. When the cancerous condition reaches this stage it is of course best to keep up a certain amount of morphine regularly, and the question of gastros- tomy or gastroenterostomy must be considered as a tempori- zing measure. The relief to certain cases from these operations is, at times, exceedingly great, depending on the anatomical con- dition present, often permitting the patients to gain weight and a certain amount of well-being which may last several months before they finally succumb to the disease. When all else fails resort may be had to rectal feeding, but this, as already pointed out in the chapter on Artificial Modes of Feeding, is inadequate in furnishing sufficient food to main- tain life for any considerable length of time, except at a low ebb, and acts as little more than a placebo, although suffi- cient fluid can be given to prevent great thirst and desiccation. In considering the question of gastric dilatation one natu- rally divides the condition into an obstructive and non- obstructive variety and again into an acute and chronic type. In the acute form whether from obstruction, such as an arterio-mesenteric constriction, in very thin individuals, or obstruction due to acute kinking of the duodenum, or that due to paralytic causes, either central or peripheral, of which postoperative or postanesthetic, overdistention or toxic are the chief varieties,2 the treatment is identical and so far as diet goes is quickly written. Give nothing whatever by mouth, neither food nor water. The former is not needed for a time and the latter may be supplied by rectal salines, or if necessary by hypodermoclysis. Lavage every two or three hours to remove the accumulated fluid with proper postural treatment with the patient lying well over on the right side or on the stomach are the forms of treatment GASTRIC DILATATION. 1 Elixir of menthol: Menthol i.o, Spts. Vin. 25.0, Aq. destil. and Syr. simpl. aa 12.0. 2 Lockwood: Diseases of the Stomach, p. 335. GASTRIC DILATATION 393 needed. After it is seen that the dilatation has subsided and one no longer gets the characteristic brownish fluid by the stomach-tube, one can begin to feed small amounts of peptonized milk or gruel, gradually increasing the amount of food and the quality from fluid to semisolid and then to soft until after a period of three or four days to a week one can return to soft solid food, provided the general condition of the patient warrants it. In the chronic forms of dilatation, if this is due to obstruc- tion at the gastric outlet, one usually finds a good gastric muscle tonus, in fact it is often hypertonic, as the visible peristaltic waves testify; but the difficulty is that the outlet is more or less narrowed so that first, heavy coarse articles of food fail to pass the obstruction, then later ordinary mixed or soft foods cannot leave the stomach completely and stag- nate, until finally, in the more advanced stage, even liquids cannot pass the pylorus. Of course before one considers dietetic treatment an accurate diagnosis is necessary for any intelligent mode of action. Having determined the degree of stenosis one gives a diet suitable for the underlying cause, whether it be ulcer or simple cicatricial stenosis of varying degree. In the latter, if moderate, only soft diet finely divided, milk citrated to prevent a heavy curd (i grain sodium citrate to the ounce of milk) or boiled for the same purpose, may be given, with lavage at bedtime to prevent stagnation. In the more advanced cases when only fluids pass one can use fully peptonized milk, puree soups, cream soups with butter and meat extract or meat jelly. Of course in such an instance of extreme stenosis, operative procedure must be contemplated and decided upon before the patient loses vitality and strength. If Sippy’s claims are substan- tiated most of the cases due to ulcer and round-celled inflam- matory exudate recover without operation on the diet as outlined by him (see page 373). Where the chronic dilata- tion is secondary to a general or gastric myasthenia the diet must be in accordance with that laid down for the dietetic treatment of atony (page 386), and the principles of small dry meals with total reduction of fluid during the twenty-four hours to one quart, or at times less, must be adhered to. Certain authors recommend in this condition small feedings of concentrated soups frequently repeated, and this plan may be followed if that already referred to does not succeed. The acute form of dilatation is most satisfactory to treat if recognized early, the chronic form most unsatisfactory as a rule, for if the dilatation is due to an actual obstruction, although the diet may be modified, as already explained, to 394 DIET IN DISEASES OF THE STOMACH meet varying degrees of stenosis, the time eventually comes in practically all cases when the case becomes a surgical condition (if indeed it is not from the beginning), and an operation imperative. GASTRIC NEUROSES. The forms which gastric neuroses can take are many, but they group themselves naturally about disturbances in — I, secretion; II, sensation, and III, motility. The neuroses play a much smaller role in diagnosis than they formerly did, since we have come to know that many conditions previously considered neuroses have a definite pathological basis, that, for example, Reichman ’s disease or continuous gastric secretion can no longer be placed with the neuroses but is due to some form of chronic irritation along the gastro-intestinal canal, and is perhaps most frequently associated with chronic gastric or duodenal ulcer. So too, if one considers the so-called neuroses of sensation we find it necessary to recast most of these diagnoses and the persistent gastralgia formerly classed as a neurosis is now known to betoken real trouble in practically every instance, due to chronic ulcer, appendicitis or gall-bladder disease in most instances. So it goes throughout the entire list; neverthe- less there are some real digestive neuroses left belonging to all three classes which require attention, medically and dietetically. Secretory Neuroses. —By far the greatest number of these cases have an excess of secretion, particularly of hydro- chloric acid. This gives rise to nervous hyperchlorhydria with its attendant symptoms of acid eructation, belching, constipation, etc., all coming on at times of stress when the nervous system is overirritated, as for example in students preparing for examination, young speakers and actors. Even in these cases if there is continued repetition of the symptoms one must be on the lookout for a pathological basis. The diet here should be that described for hyperchlor- hydria, avoidance of all irritants must be insisted upon, such as chemical, e. g., acids, alcohol and condiments; mechanical, e. g., seeds or hard substances; thermal, e. g., hot or iced drinks or foods; and as well, food should be simply prepared, eaten slowly at regular intervals and with full attention to proper methods of eating. The general hygiene of the nervous system should also receive attention (see Hyperchlorhydria). Excessive secretion may at times be GASTRIC NEUROSES 395 purely nervous, but continuous secretion is usually of patho- logical significance. In other cases the neurosis takes the form of a hypoacidity even to an achylia gastrica which has been supposed at times to be of nervous origin, although probably even in many of these an anatomical basis may be found. The diet for this should be that advised for hyposecretion or achylia gastrica (see page 356) and in general should be stimulating but not irritating. Neuroses of Sensation.—All sorts of morbid gastric sensa- tions may be felt by the neurasthenic, ranging from merely a sense of uneasiness or fulness to actual pain, the latter, how- ever, as already stated if persistent or recurring is almost always due to some pathological state of the digestive tube itself and is not a neurosis. The treatment here should be of course, largely along neurological lines, the diet must be full, simple and nutritious and if the symptoms occur in patients (especially women) who are thin, and so to speak “on wires” nervously, they should be put to bed and given the rest cure regimen, such as that devised by Weir Mitchell or some modification of it. The digestive symptoms usually disappear within the first week of this routine. Motor Neuroses.—Many of the abnormal sensations included under this last group are due to a nervously disturbed gastro-intestinal musculature, giving rise to peristaltic unrest which in a normal state passes unnoticed, but which loom large to the nervous person. Another and familiar form of motor disturbance is seen in nervous vomiting which is often so difficult to control. All these forms of motor neuroses must be treated first from a general hygienic and neurological point of view by hydrotherapy, suggestion, etc., diet may often be ignored and in many instances if we can gain the patient’s confidence they can often be told to eat anything they want and it will many times be found that such seeming indulgence works wonderfully well, anything within reason being digested. At other times one must treat these cases as one does a stomach which is irritable from some patho- logical cause, for often a digestive organ that has been.mis- behaving for a long time develops a secondary irritation which is real and must be definitely treated by a diet that is useful in any irritable stomach, e. g., fluids, as milk and Vichy or buttermilk and Vichy, egg albumen in cracked ice and water, iced bouillon, iced malted milk, gruels, thin soft solids, cereals, custards, blanc mange, soft eggs, cream toast, back to solids with white meat of chicken, baked farina, vermicelli, noodles and by degrees to a normal dietary. 396 DIET IN DISEASES OF THE STOMACH GASTRIC TEST MEALS. Ewald-Boas Test Breakfast.— Water, 400 cc (13 ounces); bread or roll, 40 grams (if ounces). Given on an empty stomach. Expressed by aspiration one hour later. Ewald Test Dinner. —Chopped meat, 165 grams (5! ounces); stale bread, 35 grams (1 ounce); butter. Aspirate three hours afterward. Test Meal of Germain See. —Chopped meat, 100 to 150 grams (3! to 5 ounces); white bread, 60 to 80 grams (2 to 2§ ounces); water, 300 cc (10 ounces). Examine contents two hours later. ReigeVs Test Dinner. — Meat broth, 400 cc (13 ounces); beefsteak, 150 to 200 grams (5 to 7 ounces); mashed potato, 50 grams (if ounces); roll, 35 grams (1 ounce). Should be aspirated four hours later. Klemperer’s Test Meal. — Milk, 500 cc (1 pint); 2 rolls (70 grams). Give on empty stomach and aspirate two hours later. Boas (Non-lactic Acid-containing) Test Meal. — 1 ounce (30 grams) rolled oats boiled in 1 pint (500 cc) water; salt q.s., or 2 shredded wheat biscuits with 300 cc (10 ounces) water. To use when testing for lactic acid the stomach should be washed out the night before. Salzer’s Double Test Meal.— Beef, 40 grams (if ounces), scraped and broiled; milk, 250 cc (8 ounces); boiled rice, 50 grams (if ounces); 1 soft-boiled egg. Four hours later give Ewald-Boas test meal and remove one hour afterward; Fractional Test Meal.— The Ewald meal may be used or 1 pint of gruel made of strained oatmeal or any cereal just thin enough to be aspirated through the small tube ordinarily used. A sample of the gastric contents is aspirated and tested chemically one-half, one, one and a half, two and two and a half hours after taking the meal. GASTRIC MOTOR MEALS Von Leube. — Soup, 400 cc (13 ounces); beef, 200 grams (6§ ounces); bread, 50 grams (if ounces); water, 200 cc (6§ ounces). If at the end of six hours gastric lavage fails to show a residue, the motor power of the stomach is normal. Boas.— If two hours after an Ewald-Boas test meal the stomach is empty by lavage, there is normal motor power. Hausman’s Stagnation Test Meal.— Four tablespoonfuls of boiled rice and a glass of water are given at 9 p.m. (a little sugar and milk may be taken on the rice). If at 9 a.m. next GASTRIC MOTOR MEALS 397 morning fasting, lavage fails to show macroscopic or micro- scopic rice residue, there is no stagnation. (A drop of Lugol ’s solution stains any starch granules blue, so that they are easily seen.) Test Supper. — For supper, meat, bread, butter and water or two cups of tea. Lavage in the morning following should fail to show any residue in a normal stomach. Water Test for Acidity.1—Carlson, Orr, Hanke, Brackman and Rehfuss all observed that the taking of water stimulated gastric secretion, producing an acidity that was about 100 in less than twenty minutes after stimulation. They found that in ten to twenty minutes 500 cc (10 ounces) of water would leave the stomach (? Ed.) and also that after drinking 50 cc (if ounces) of water as much as 225 cc (7 ounces) of gastric juice could be obtained. Austin’s meal directions are as follows, partially based on the foregoing: Previous evening the patient takes a meal of meat, potato, bread, butter, rice and raisins and presents himself the next morning for examination, fasting. Then 350 cc (12 ounces) of water are given and removed by the stomach-tube in twenty minutes. Austin found the total acid values much lower than those already quoted, varying from 19 to 31. Intestinal Motor Meal (Schmidt-Strassburger).— With the meal two capsules, each containing 0.5 gram (7I grains) of charcoal are given to mark the meal, then the following: Finely cut meat, 80 grams (2§ ounces); mashed potato, 200 grams (6f ounces); eggs, 2; butter, 40 grams (if ounces); oatmeal gruel made with milk, 1500 cc (3 pints); clear soup, 250 cc (8 ounces); very dry toast or zwieback, 100 grams (3! ounces). In health it is said this should pass through the intestine in fifteen to twenty-five hours. In diarrhea due to colitis, in ten to fifteen hours. In enterocolitis with diarrhea, in three to five hours (Strauss). For further intestinal test diet see Schmidt, Intestinal Diet (page 401). 1 Austin: Boston Med. and Surg. Jour., 1915, 172, 857. CHAPTER XXII. DIET IN DISEASES OF THE INTESTINES. In diseases of the intestines, no less than in gastric disturb- ances, diet plays a most important role, not alone from the therapeutic standpoint but from that of prevention as well. Another interesting development of more recent years is the effect of various foods on the intestinal flora and the possibility of changing this at will by the institution of a definite diet. One group of bacteria designated as putrefactive thrive particularly in the large intestine.1 A second group, the fermentation bacteria, may also thrive, and where they do, acid conditions are likely to arise which inhibit the growth of the putrefactive organisms. According to Hester and Kendall2 the absence of carbohydrate in the diet allows the proteolytic bacteria to predominate —this is told by the fecal discharges, as well as the finding of indican and its con- geners in the urine. Torry3 found in typhoid cases fed with an unusual quantity of lactose that the ordinary type of flora was changed to one largely dominated by the bacillus acidophilus. Lactose and dextrine added to a meat and rice diet caused a marked develop- ment of aciduric bacteria, of the Bacillus acidophilus type, almost to the suppression of the proteolytic type. Glucose did not have this effect. Starchy food also had the tendency to eliminate the putrefactive bacteria. Protein foods failed to produce a stereotyped change. Milk, for example, was less likely to give rise to putrefaction than did meat. Torry also found that vegetable protein was less likely to encourage the putrefactive bacteria than animal protein. Fats seemed to lack a determining influence. From all this it can be readily seen that the dieting of some cases of chronic intestinal disturbances must be founded on carefully collected data in which the examination of the stools, not only for gross and chemical changes, but for bac- terial divergences from the normal, is made. 1 Ed. Jour. Am. Med. Assn., May io, 1919, p. 1370. 2 Jour. Biol. Chem., 1910, 7, 203. 3 Jour. Inf. Dis., 1915, 16, 72, 398 ACUTE ENTERITIS 399 Then too, certain cases of diarrhea originate from abnor- malities in the gastric or pancreatic secretions, which must be tested if one is to come to a rational etiological diagnosis. Thus one sees cases diagnosed as chronic enteritis in which the intestine is practically normal except for slight secondary inflammatory changes and the diarrhea is caused by a failure of gastric secretion, the so-called gastrogenic diarrhea already referred to. In the intestine too, we have the most marked examples of functional neurosis, due to lack of nervous stability, resulting in diarrhea of various types, as well as constipation. ACUTE ENTERITIS. Enteritis, or inflammation of the small intestine, is of fre- quent occurrence and one has only to glance over the etiologi- cal factors to realize how many conditions there are that may give rise to it. Among these causes may be mentioned diet- ary indiscretions, unhygienic surroundings, frequent exposure to sudden atmospheric changes, irritants, as some acids, mercury, arsenic, cantharides, copper, tartar emetic, garlic, alcohol. Blood irritants, seen in uremic conditions; mechanical irritants; bacillary infections of the intestinal tract; parasites; the exanthemata; chronic constipation; intestinal obstruction; disturbances of circulation; drinking ice-water to excess,1 etc. The inflammation may affect any part of the small bowel, so that we may have a duodenitis (distinguishable from the other locations on account of the frequency of a compli- cating jaundice), jejunitis and ileitis. Aside from the duo- denitis, of course it is impossible clinically to distinguish which part of the bowel is involved. Cohnheim2 divides enteritis into; 1. Mild enteritis without diarrhea, but with numerous symptoms, such as meteorism, abdominal pains, flatulence and loss of strength. 2. Moderately severe enteritis with much intestinal fer- mentation and frequent diarrhea. 3. Severe cases with persistent diarrhea. The dietetic treatment of the acute cases resolves itself into a negative and a positive phase. Under the former we are content during the acute onset to withhold all food for twenty-four hours or possibly longer, giving only water and a good cathartic to relieve the bowels of any offending matter; 1 Gant: Diarrhea Inflammation and Parasitic Intestinal Diseases, p. 176. 2 Forchheimer: Therapeutics, 3, p. 197. 400 DIET IN DISEASES OF THE INTESTINES for in spite of the diarrhea which is present in the moderate or severe cases, Nature usually needs assistance in this. This is particularly true in the severe acute type, ordinarily known as cholera morbus. After the preliminary period of starvation one may begin feeding thin gruels, albumen water, rice, or toast, water and weak tea. Milk is best left out of the diet at the outset, for it is seldom properly digested while peristalsis is so active and even in the late stages it fails to agree as well as some of the carbohydrate or other protein foods. Some cases, however, do well on boiled milk, for the boiling causes it to respond to the gastric enzymes in a fine flocculent curd; in still others it can be given advantageously raw and over long periods. When the disease reaches the subacute stage in mild cases, one may feed most of the soft foods, such as eggs, soft meats, sweetbreads, stewed or boiled chicken, creamed fresh cod, halibut and whitefish. If there is not much flatulence one may give the fine cereals well cooked, farina, cream of wheat, rice, wheatena, malted breakfast food with a little butter and salt. These cereals are not good when there is a tendency to or actual excessive carbohydrate fermentation in the intestine, as shown by explosive acid stools and an active formation of C02 in the fermentation tube. Later on soft-cooked or puree vegetables put through a colander are allowable, such as spinach, peas, potatoes, carrots and celery, but, as a rule, vegetables should be left out of the diet on account of their laxative effect. Soft custards, blanc mange, farina or rice pudding and gela- tin desserts are allowable in the mild or subacute cases. There are very definite foods which should not be eaten at any time in any type of this trouble, such as coarse or irri- tating foods, those which ferment easily or putrefy readily, and all the foods given must be soft and free from indigestible particles. Not much sugar should be given. Wines, beer or champagne are not allowed with the exception that in the later stages a little diluted claret or sherry may be permitted. Among the vegetables under the ban are cauliflower, tur- nips, cabbage, radishes, onions, tomatoes, celery root, oyster plant and brussels sprouts. No fruit may be taken, nor cake, rich jellies or other sweets. Rich cheese, high meat or game are also forbidden. In general the milder the case the less strict need the diet be, and vice versa. CHRONIC ENTERITIS. This may be chronic from the start or may be the remains of an acute attack, the etiology being the same as that of the CHRONIC ENTERITIS 401 acute cases, but acting more slowly, or it may be an accom- paniment of other diseases of the bowels, as, e. g., carcinoma, intestinal obstruction, fecal impaction, etc.1 In the chronic forms of enteritis, it is particularly satisfactory to make a definite test of the patient’s digestion as affecting the proteins, fats and carbohydrates, after which it is possible to plan a rational diet suited to that individual’s needs. This is arrived at most certainly by placing the patient on a Schmidt test diet, which is as follows: Schmidt Test Diet.— In the morning, 0.5 liter (16 oz.) milk, or, if milk does not agree, 0.5 liter (16 oz.) cocoa, pre- pared from 20 gm. (| oz.) cocoa powder, 10 gm. (| oz.); sugar, 400 cc (13 oz.); and water 100 cc (3! oz.) milk. In the forenoon, 0.5 liter (16 oz.) oatmeal gruel, made from 40 gm. oz.) oatmeal, 10 gm. (f oz.) butter, 200 cc (6f oz.) milk, 300 cc (10 oz.) water; 1 egg strained. At noon, 125 gm. (4 oz.) chopped beef (raw weight), broiled rare with 20 gm. (f oz.) of butter, so that the interior will still remain raw. To this add 250 gm. (8 oz.) potato broth, made of 190 gm. (6| oz.) mashed potatoes, 100 cc (3! oz.) milk and 10 gm. oz.) butter. In the afternoon as in the morning. In the evening as in the forenoon. This diet consists of: Milk 1.5 liters (15 qt.) Zwieback 100.0 gm. oz.) Eggs 2.0 Butter 50.0 gm. (if “ ) Beef 125.0 gm. (4 “ ) Potatoes 190.0 gm. (6f “ ) Oatmeal (gruel) . 80.0 gm. (2f “ ) This contains protein, 102 gm. oz.); fat, ill gm. (4 oz.); carbohydrates, 191 gm. (6| oz.); calories, 2234. In order to carry this diet out most satisfactorily it is best to give it for a couple of days and then give two capsules each containing 10 grains of charcoal. This is given again at the end of the test period of two, three or four days as may have been decided and the stools and urine saved accurately for the period which is marked at its beginning and end by the charcoal. The result of the examination of the feces will show whether the stools contain undigested food, meat fibers, connective tissue, free starch, fat drops, fatty acid crystals, soaps or parasites. At the same time the pancreatic ferments may 1 Stengel, in Osier’s Mod. Med., 1914, 2d ed, 402 DIET IN DISEASES OF THE INTESTINES be tested for and the presence of carbohydrate and protein fermentation disclosed if it is present. Also the prevailing bacterial growth whether Gram-negative (normal) or Gram- positive. It will be found that a good many patients, particularly women, and especially so, if both their stomach and intestinal digestion are poor, cannot take the full Schmidt diet, the quantity is too great. In such instances the test diet as modified by the author will be found very serviceable as containing the proper proportions of food elements and of sufficient caloric value. Protein. Fat. Carbohydrate. Calories. Oatmeal . . 165 gm (5! oz.) 4.4 0.8 18.2 IOO Rice ... 90 “ (3 “ ) 2.4 0.8 21.0 IOO Milk . 1500 cc (50 “ ) 49.5 60.0 67-5 1080 Butter . . 40 gm (1* “ ) 0.6 34-0 318 Bread . . 120 “ (4 “ ) I3-1 2.4 80.0 400 Chopped meat 65 “ (2 “ ) 17.1 4-7 IOO 87.1 gm. 102.7 gm. 186.7 Sm- 2088 Breakfast. Dinner. Supper. Oatmeal, 165 gm. (5! oz.) Meat, 65 gm. (1 oz.) Rice, 90 gm. (3 oz -) Milk, 250 cc (3 “ ) Bread, 40 “ (11 “ ) Bread, 40 “ (I* “ ) Bread, 40 gm. (ij “ ) Milk, 250 cc (8 “ ) Butter, 15 “ (* “ ) Butter, 15 “ ( i “ ) Butter, 10 gm. ( § “ ) Milk, 250 cc (8 “ ) At 10, 3 and 9 o’clock, 250 cc milk. Modified Schmidt Diet. Having determined the digestive capacity of the pan- creatic or intestinal enzymes by the use of the Schmidt diet, the task still remains of constructing a suitable diet for these patients. Chronic enteritis is not a condition that shows rapid improvement and weeks and months must often elapse before anything like satisfactory progress can be expected. On this account patients must be warned and told to expect slow changes, as otherwise they are quite sure to become discouraged and blame their medical attendant for failure to improve rapidly. When the stools show undigested food, whether diarrhea is present or not, the diet is not what it should be and the first constant aim must be to get a diet that can be digested, showing a normally smooth stool, even though its consistence may be too soft or fluid. This, of course, can only be done by painstaking changes with con- stant stool inspection to check up the condition of digestion. It is usually a good plan in starting the dietary treatment of these cases to begin with a liquid or semiliquid diet. Just which combination of foods will fit the individual case can only be determined by trial, but an ordinarily successful ACUTE COLITIS OR ACUTE DYSENTERY 403 plan is to feed them every two hours with gruel, malted milk, cocoa and soft egg alternately. Some cases digest boiled milk well and it is often deserving of a trial. If it is not digested as shown by curds and more active diarrhea, then it should be omitted, even in the cocoa, which should then be made with water. After a few days of this rigid diet, one may begin to add one extra at a time, preferably with every other feeding, i. e., every four hours. These extras may be in the form of fine cereal, farina, cream of wheat, wheatena, eaten with a little butter and salt or with a little malted milk over them. Then dry toast with or without butter is added. After which one may keep on gradually increasing the foods to boiled rice, macaroni, dry cheese, cream cheese, toasted crackers. By this time it is well to lengthen the feeding interval to three or four hours. The character of the diet can be changed as rapidly as improvement in symp- toms comes, adding next finely minced chicken and sweet- breads, lamb, boiled fresh white-meated fish. Desserts made of gelatin, egg or farinaceous puddings, later cream desserts, all made with the minimum amount of sugar. All vegetables should be left out of the diet for a long time, but when taken they should be thoroughly cooked, soft, and put through a colander, or in the form of a puree. Fruits should be added last and then only well-cooked, soft fruits, such as baked apple (without the skin), apple sauce, etc. Of course, fruit should not be given until the stools are of normal consistence and well digested and it will be probably weeks or months after starting treatment before it can be given. ACUTE COLITIS OR ACUTE DYSENTERY. Acute dysentery is caused by a variety of factors, bacillary, protozoan and constitutional, and results in an acutely inflamed colon mucous membrane which may or may not go on to ulceration, depending on the form and severity of the exciting cause. It is often found as a part of an infection involving the small intestine as an enterocolitis, or it occurs alone. When it occurs as part of an infection higher up, the diet- ary treatment is in accordance with the needs of the small intestine, when it occurs alone it is often very sudden and severe in its onset and requires great care in treatment. After a complete emptying of the bowel by catharsis, it is a good plan to withhold food for twenty-four hours in order to quiet the peristalsis, using opium or other antiperistaltic agent. When feedings are begun they should be liquid and 404 DIET IN DISEASES OF THE INTESTINES at first largely protein, as whey, albumen water and clear soups, then gruel made of oatmeal, farina or wheat cereals or kounryss; sweet milk should not be given, as it tends to increase the diarrhea, although this is less marked if the milk is boiled. Later scraped meat, dry toast, well-cooked fine cereals, soft-boiled or poached eggs, macaroni, well- boiled rice, weak tea’ or a little dilute whisky or claret form, the bulk of the diet. When the acute symptoms subside the patients are either well or the disease goes on into the chronic stage. In the acute stage fruit and vegetables are to be avoided. In the severe forms, withholding food for several days is often a good plan. CHRONIC COLITIS. Whatever the origin of the colitis or whatever pathological form it takes, there are certain dietary conditions which must be taken into consideration and met in all cases. 1. That the diet must be made up of easily digestible foods. 2. That all foods must not be stimulating to peristalsis. 3. That all food must be finely subdivided, soft and with as little digestive residue as possible. 4. The quantity of food must be sufficient for complete nutrition in nitrogen and caloric content. As to the first point the foods particularly suitable are: Clear, cream or puree soups, white-meated fish (other richer forms later if they agree with gastric digestion); soft part of oysters, beef, mutton, chicken, sweetbreads, eggs, fine cereals, farina, cream of wheat, malted breakfast food, wheatena, tea, coffee, cocoa made with water, butter, toast, stale bread, roll, puree of vegetables, such as potato, lima beans, peas, spinach, stewed celery, baked Hubbard squash. (In many cases no green vegetables can be taken at all on account of increased peristalsis.) Farinaceous puddings, gelatin des- serts, egg desserts. (For foods stimulating to peristalsis see Section on Diarrhea.) In general it may Be said that fruits, coarse vegetables (in some cases any vegetables), very sweet foods, much fat food, are all stimulating and must be avoided. Milk is also in this class for most patients, although occa- sionally a patient can take it boiled or diluted with gruels. Sometimes koumyss will be better digested than plain milk. White wine, beer, ale and champagne are contraindicated. That patients should receive sufficient food for nutritional uses is self-evident, but it is not by any means easy to nour- ish many of these patients completely, as there is often much MEMBRANOUS COLITIS 405 anorexia, and if pain is also present, it is still more difficult to feed them. In the long-standing cases, particularly those due to ulcer- ative colitis, malnutrition is more or less the rule and some patients lose as much as half their body weight, it being impossible to get them to take a sufficient supply, and the ingenuity of the physician is put to a severe test. In these long-standing and severe cases the use of artificial food materials is often useful (see Artificial Foods) to fortify soups and gruels. MEMBRANOUS COLITIS, MUCOUS COLIC OR CHRONIC MUCOUS COLITIS. It was formerly thought that these cases were in the last analysis of a neurotic origin, occurring only in nervous per- sons; and while many of the patients were nervous it was also observed that the disease occurred in those who were not at all so. Nothnagel was largely responsible for this general belief, but time has proven it untenable when applied to the cases as a class. The characteristic feature of the disease is the passage of mucous strips, bits, ribbons or even entire casts of parts of the colon and accompanied by more or less abdominal pain. There are two groups1 ordinarily distinguished: 1. Those with pain along the colon and a tendency to diarrhea, i. e.> chronic mucous colitis. 2. Those occurring in nervous persons who have chronic constipation and attacks of “membranous colitis” or “mucous colic.” The diet in the first group is so constructed as to spare the bowel as much irritation as possible and consists largely of albuminous foods together with farinaceous gruels; all coarse foods are excluded as well as vegetables and fruits; the rest of the feedings are as already described in the section on Enteritis or Chronic Colitis. In the second group there is really a catarrh of the bowel and in addition chronic constipa- tion. Von Noorden fastened upon the chronic constipation as the essential feature of the disease and by combating this was able to clear up the mucous stools. In order to accomplish this he prescribed a diet with much cellulose, indigestible residue in skins and seeds, coarse black or rye bread, crude vegetables, raw or cooked, but the rougher the better, cab- bage, tomatoes, turnips, carrots, celery, cauliflower, brus- 1 Forchheimer, vol. 3. 406 DIET IN DISEASES OF THE INTESTINES sels sprouts, corn, etc., also large amounts of fats in the form of cream, butter, fat meats and oils. Cider and buttermilk are both good for this purpose. The following diet devised by Butman is recommended and is also good for chronic constipation generally: On rising a glass of cold water. Breakfast: Oatmeal, whole wheat or graham bread (or bran bread), butter, coffee, raw or cooked fruit. Marmalade (honey). Midmorning: A glass of buttermilk or cider or water, dried fruit, figs, dates or prunes. Luncheon: A small amount of meat, fish or other sea- food, two or more green vegetables, coarse bread, butter. Fruit. Midafternoon: A glass of buttermilk or cider, etc. Dinner: Fruit, meat or fish, two or more green vege- tables, coarse bread, butter (bran bread or biscuits), salad, dessert, preferably a fruit dessert. Bedtime: Same as midmorning. Or the diet recommended under Chronic Constipation. ULCERATION OF THE SMALL OR LARGE INTESTINE. Ulceration of the small or large bowel occurs in a variety of conditions, e. g., simple ulceration as in duodenal ulcer or as the result of typhoid fever, tuberculosis or other bac- terial or protozoan diseases. In simple or typhoid ulceration the diet has already been described under these headings. In tuberculous ulceration and that due to other bacteria, as in chronic dysentery or amebic dysentery, the dietary regulations are practically alike. The diet should be free of irritating foods, seeds, skins, raw vegetables or those with a rough residue, as corn, bran, etc. Everything should be exceedingly soft and of moderate bulk. When diarrhea is present one must be gov- erned in the selection of food by a knowledge of what foods are naturally laxative and avoid them, using, on the contrary, the classes of foods which have been described under Enteritis and Diarrheal Diseases in general. Laxative foods include fruit, vegetables, indigestible fats, sugars, game, “high” meat, malt liquors, rough substances, such as bran. INTESTINAL HEMORRHAGE. The diet in intestinal hemorrhage, if at all severe, should he regulated much as has already been described under DIARRHEA 407 Hemorrhage in Typhoid. All food by mouth should be stopped at once. If the hemorrhage is from a point high up in the intestine, as that from duodenal ulceration, not even water should be given for from forty-eight to seventy-two hours. (See Duodenal Ulcer, page 362.) If the patient is desiccated it will be necessary to give warm saline by the rectal route within six hours of the hemorrhage, either as a continuous Murphy drip, or in repeated amounts of 4 to 6 ounces every two, three or four hours. If the hemorrhage is from lower down, as from the ilium in typhoid, water may be begun within six hours, and within twelve to twenty-four hours one may again begin mouth feedings with broth, albumen water, malted milk or diluted citrated milk (1 grain of sodium citrate to the ounce). After another six to twelve hours the feedings may be gradually and steadily increased again until full fluids are being taken. It is not necessary to interdict water in these cases and this may be given in small amounts, frequently repeated two or three hours after the hemorrhage. Large or very hot enemata of water should not be given on account of their tendency to dilate the abdominal vessels, which, of course, increases the danger of hemorrhage. When the hemorrhage is from the colon, it is scarcely ever severe enough to cause anxiety and only in exceptionally large hemor- rhages need one hesitate to continue giving fluids by mouth. Of course, in this condition no fluid should be given by rectum. DIARRHEA. As diarrhea is merely a symptom, a classification of its etiology would include a discussion of every condition which may give rise to this symptom, the treatment being often quite as various as the etiology. The Causes of Diarrhea.—In general the causes of diarrhea may be enumerated as follows: Gastrogenic.— When achylia gastrica is present this in some way predisposes to diarrhea, probably the lack of acid secretion fails to call out the pancreatic enzymes sufficiently to properly digest the food, and diarrhea results. Toxic. — In cases of chronic Bright’s, diarrhea is often present and represents the attempt of nature to eliminate water, chlorides, toxic material and probably nitrogen by way of the intestinal mucosa, being therefore a vicarious diarrhea. Other varieties of toxic origin are seen in the acute bacterial intestinal diseases, typhoid, cholera and cholera morbus; ptomaine toxemia including all forms of food poisoning, which are almost invariably accompanied by 408 DIET IN DISEASES OF THE INTESTINES diarrhea. The toxic effect of the inorganic salts must also be included, principally arsenic, mercury and antimony, and to the milder toxic infections, such as intestinal catarrh, acute and chronic. Irritative Diarrhea, which may be toxic or merely mechani- cal, as the eating of quantities of indigestible food such as corn, fruit in excess, etc., excess of gastric HC1. Drug Diarrhea, due to ingestion of laxative drugs, which, if taken in excessive amount or over long periods, often con- tinue the diarrhea after the complete elimination of the drug, which is then probably due to a catarrhal inflammation. Ulcerative conditions of the gastro-intestinal tract—peptic, tuberculous and simple ulcer or the numerous forms of diarrhea due to a diseased colon. Nervous Diarrhea.—Ninny people have this difficulty in the face of some unusual excitement, soldiers, musicians and in hysteria, and are all due to vasomotor dilatation in an unstable nervous system, causing the so-called “sweating” of the intestine. Under this heading the diarrhea of hyper- thyroidism may belong, although this is quite as likely to be due to the general toxemia seen in these cases. Reflex diarrhea is also of nervous origin. Habit Diarrhea.— Some persons normally have several more or less watery stools a day, or they may have a morning diarrhea, often due to catarrh, however. Diarrhea Due to Food Idiosyncrasy .—In these cases some one article of food may habitually excite a diarrhea quite apart from any known toxic or mechanical effect, although it is probably of toxic origin in the last analysis. Diarrhea of Pancreatic Origin. —Where the ferments are deficient, as the well-known fatty diarrhea. Diarrhea occurring as secondary to periods of fecal impaction with a tunnelling of the fecal mass, or alternating with severe constipation. With all these forms of diarrhea the etiology gives the clue to the dietetic treatment and an accurate diagnosis is always essential to a satisfactory and intelligent ordering of foods. It is unfortunately not possible to find in every case the actual cause, so that the clinician is not infrequently called upon to prescribe a diet for diarrhea in which the etiology is obscure and eludes the most painstaking investigation. The underlying principles are much the same in ordering diets for almost all the forms of diarrhea and may be described as follows: DIARRHEA 409 Dietary Regulations.—The diet should be non-irritating, easily digested, not a stimulant of peristalsis, free from taint of putrefaction, finely comminuted, and should include as many articles of food that are naturally astringent as pos- sible, and not apt to ferment. In acute diarrhea from any cause a period of starvation following an intestinal purge is the best dietetic routine, allowing fresh but not cold water in abundance. When the appetite begins to demand food, clear broth, beef tea, cereal gruels, dry toast and tea are best for a day or two, gradually extending the list from foods which are allowed in chronic diarrhea. Foods to Avoid in Chronic Diarrhea.—Very fatty foods, except a moderate amount of butter. Raw milk and cream. Green vegetables of all sorts. Boiled potato. Corn is especially irritant. Fruit in all forms is forbidden, whether stewed or fresh. Salads, nuts, pickles, condiments. Salt meat or salt fish. Smoked meats or fish. Goose, duck, pork, as too fat. Sweets, cake, pie, candy and preserves. Cream or milk desserts. Sweet wine, beer and ale. Foods Recommended in Diarrhea.—Clear soups, white-meated fish (not fatty), e. g., cod, halibut, bass. Chicken, mutton or lamb, scraped beef, soft part of oysters. Guinea hen. Soft eggs. Rice, macaroni, noodles. Baked potato may agree. Cereals except oatmeal or Pettijohn. Stale bread or dry toast, crust of roll. Toasted crackers. Cream, Edam, Canadian cheese. Farinaceous puddings made with little sugar, preferably baked. Calf’s foot or wine jelly. Tea, clear coffee (in some cases this is laxative), water, claret, Burgundy. A little diluted whisky or brandy. In some instances malted milk is well tolerated, while in others it is laxative. In a few cases it is possible to give boiled milk, but for the most part milk in any form is very badly tolerated, causing an increase in the diarrhea with the passage of undi- gested curds. Foods Allowed in Certain Cases.—The use of malted milk or cereal is useful unless it proves laxative. Crisp bacon, turkey, koumyss, zoolak, buttermilk. Thoroughly stewed celery, baked Hubbard squash, creamed spinach, tender boiled peas or lima beans mashed through a colander, remov- ing the skins. Chronic Diarrhea — Cohnheim’s Diet List (American Modifi- cation). 7.00 a.m. Mineral water, 75 to 150 cc (2% to 5 oz.), taken hot on rising. The choice of water will depend on gastric secretions, with hypo- 410 DIET IN DISEASES OF THE INTESTINES acidity or achylia, sodium chloride and alkaline waters are best. At home io grains of salt and io of bicarbonate of soda may be added to the allowance of hot water. 7.30 a.m. Philip’s digestible cocoa (2 teaspoonfuls to a cup) made with water. Toasted white bread and butter. 10.30 a.m. Fine cereal, cream of wheat or farina or malted breakfast food, one soft-boiled egg or scraped meat or lamb chop cut fine. 1.00 p.m. Broth with macaroni, vermicelli or noodles. In mild cases vegetable purees. One glass of claret. 4.00 p.m. Same as 7.30 a.m. 6.00 p.m. Mineral water as in early morning. 7.00 to 8.00 p.m. Tea or claret. Toast, butter and a little cold chicken. 9.00 to 10.00 p.m. A cup of hot peppermint tea or chamo- mile tea. If the case is mild and the stools soft rather than liquid, some soft carrots, filet of sole or baked fish is allowed. Absolutely Forbidden Articles.—Cold drinks, all rough or coarse vegetables, rich sweets—coffee—“high” cheese. All legumes unless served in soups; goose, duck, fat fish, as salmon, mackerel, blue fish, meat fats, gravies, raw fruits. INTESTINAL NEUROSES. These follow much the same classification as the gastric neuroses, except that the intestinal pain of a purely nervous origin is rare, and as a diagnosis should only be made after a careful process of exclusion, and even then with reservation. The diet in these intestinal cases is much on the same lines as that recommended for definite intestinal pathological states which symptomatically they often so closely simulate, e. g.y in nervous constipation. Besides the general tonic treatment of the nervous system, the diet should be that recommended for chronic constipation with a large percent- age of roughage in the form of fruits, vegetables and bran. With the opposite condition, namely, that of a nervous diarrhea, a diet such as that advised for chronic diarrhea is advisable (page 409). On the other hand, one sees not a few cases of a type of nervous diarrhea which present a characteristic picture of an undernourished, anemic, worried, irritable individual, man or woman, who gives a history of a CHRONIC CONSTIPATION 411 diarrhea of months’ or years’ standing, from whom the history is obtained that little by little they have curtailed their diet with the idea that first one thing, then another disagrees and causes the diarrhea, until they are living on perhaps only three or four articles of food with an entirely inadequate number of calories. The stools are more or less numerous, liquid or semiliquid, which on analysis show no other abnor- mal characteristic than possibly some little mucus and a few leukocytes. If one is sure of one’s ground in dealing with these people and can reassure them and gain their confidence it is usually possible to begin feeding them liberally at once, and a good meal of finely cut tenderloin, baked potato or rice, green peas and a simple dessert will do more to restore confidence than anything else. The character of the stool may not change at once, but will usually return to normal within a few days and the diet can then be rapidly increased to a general mixed one with full confidence that it will be satisfactorily digested. The anemia should also be treated and a general course of sensible hygiene insisted upon. CHRONIC CONSTIPATION. If an aboriginal text-book on medicine should be found, it would probably be noted that there was no chapter on chronic constipation, this being a disease of modern life, a product of inactivity and a non-stimulating diet. The causes of constipation are numerous, some predisposing, some direct. Faulty habits of eating are most largely responsible and a diet with little residue from cellulose will be very apt to result in constipation. Any condition which tends to the weakening of the voluntary or involuntary muscles will also tend to produce or exaggerate a tendency to constipation, such as illnesses of all kinds, lazy habits of exercise and irregularity in attempted evacuation, all have much to do with it. Chronic constitutional diseases pro- ducing a congestion of the abdominal organs will result in constipation. Varieties of Constipation.—The cases divide themselves into: 1. Functional, either (a) atonic or (b) spastic. 2. Organic from mechanical obstruction of the lumen of the gut, from within or without. Of all forms, the atonic comprises most of the cases, pos- sibly 90 per cent, and is due to a lazy or inactive bowel. The spastic variety is the direct opposite of this, in that it occurs 412 DIET IN DISEASES OF THE INTESTINES as a product of overstimulation of the intestinal nerve end- ings, giving rise to spastic contraction of the bowel and pain. The form of constipation due to mechanical obstruction speaks for itself and is of only minor interest from a dietetic point of view. In the atonic constipation, every means possible must be used to awaken the bowel by mechanical stimulation, as by massage, exercise of the abdominal muscles and general body exercise, calisthenics or out-of-door work. In the selection of a diet the two important facts to be remembered are that the food must be as coarse and rough as possible, and that all sorts of fats are very valuable in pro- moting ease of evacuation. In many or most of the patients suffering from chronic constipation the stools are of small bulk, and the more severe the constipation the smaller the bulk of the stool, as the sluggishness gives an extra amount of time for the further and more complete disintegration and absorption of the foods. In other words, digestion and absorption are often at their highest in chronic constipation, and if there was not sometimes absorption of other things besides the food, such as various digestive by-products and the products of bacterial putrefaction, chronic constipation would not be so undesirable. As it is, the condition is not ordinarily a favorable one for health or well-being; although there are many cases who do not have a movement of the bowels more often than once or twice a week, yet who seem to keep in perfect health and vigor. Taking food into the stomach at once excites not only peristalsis of the stomach but also of the bowels and partic- ularly of the caput coli, so that there is good physiological reason for the desire to defecate shortly after a meal and particularly after breakfast, which should be the preferable time for evacuation. Peristalsis is especially “stimulated by indigestible meat residue, vegetable fiber, cellulose, sugar and organic acids. Peptones stimulate it feebly, oils more strongly, and gases, especially CH4 and H2S even more powerfully.”1 Atonic Constipation.—Since in this condition the bowel needs stimulation one must give a coarse diet with a large residue much as has been recommended for “membranous colitis,” following von Noorden’s suggestion and copying artificially, so far as one can, the diet that is eaten by semi- civilized or wholly barbarous people. This should include much uncooked food in the form of vegetables, nuts and 1 Tibbies: Food in Health and Disease, p. 349. CHRONIC CONSTIPATION 413 fruits of all sorts. The bread eaten should be whole wheat, rye, gluten or bran bread, to which nuts and raisins can be added. Vegetables.— All vegetables are good, raw celery and cole- slaw or cooked cauliflower, turnips, asparagus, carrots, par- snips, salsify or oyster plant are especially good. Jerusalem artichokes, raw or cooked celery, squash, either the summer variety or Hubbard squash, the latter preferably baked; all beans and all vegetable and fruit salads. A good rule for these patients is to help themselves to a double portion of vegetables. Meat. — Fat meats are best, unless it is important to keep down the weight. Eggs and fish are also allowed. Cheese, except cream cheese, is forbidden. Fruits, especially those with much residue, pears, melons, apple (a raw apple at bedtime often being very serviceable). Oranges and grapefruit, if the section divisions are also eaten, particularly in oranges. All berries except black- berries, which are rather constipating. Dried fruit of all sorts, figs, pulled or stewed, dates and raisins and all nuts. Desserts. — Fruit desserts or puddings, blanc mange, made with prunes, figs, raisins or fresh fruits. Other desserts are allowed, but are less stimulating. Salads. — All kinds. The coarser the better. Those made of fruit and vegetables are particularly good, as apples and celery, alligator pear or any other fruit salad with lettuce. Fats. — Fats of all sorts, animal, vegetable and mineral, are useful. The mineral oils introduced by Lane for intestinal stasis are often very beneficial. Each case of atonic constipation must be considered indi- vidually in prescribing a diet, as for example it would be actually wrong to order a diet with high fats for a person already overweight, or a diet principally vegetable and fruit for a person suffering from inanition. Chronic Constipation.—The following diet will be found generally useful, having due regard for the foregoing factors. On rising drink a glass of water, f to \ grape juice or 2 glasses of plain water. Breakfast: Stewed fruit or fresh fruit. Oatmeal or Petti- john breakfast food (25 per cent bran), with cream and sugar, white or brown; or cornmeal mush with molasses, golden drip or maple sugar; eggs or bacon, whole-wheat bread or bran bread or Grant’s health crackers (bran) with fresh butter, if it is obtainable (one eats more butter when it is fresh than when 414 DIET IN DISEASES OF THE INTESTINES salted), or cooked bran may be mixed with the morn- ing dish of cereal. Midmorning: Drink a glass of water or eat some dried fruit, figs, dates or Bordeaux prunes, or fresh fruit in season. Luncheon or Supper: Small piece of meat or fish, green vegetables from the list, whole-wheat bread and fresh butter, bran bread or crackers. Fruit fresh or stewed. Prune or fig pudding, or salad with oil dressing. Dinner: Grapefruit, vegetable soup. Entree of fish or egg with caper sauce or plain. Small piece of fowl or red meat with fat. Two or more green vegetables from list, taken in double quantity, and cooked with butter or oil, unless it is necessary to keep the weight down. Salad of celery and fruit or lettuce and other vegetable with ship biscuit or bran cracker. Cole- slaw. Olives, radishes. Dessert—a fruit pudding, fresh fruit, stewed fruit, figs, nuts, raisins. Bedtime: Two figs, prunes or several dates. Of course one is not supposed to eat all the articles men- tioned at one meal, but a choice made for each, varying it as to fats or vegetables, as necessity requires. Drinks.— Coffee, buttermilk, cider, water, Vichy, grape- juice, raspberry vinegar or some sweet wine, if one must have alcohol. The use of agar-agar preparations is sometimes recom- mended in these cases to give bulk to the feces owing to their power of taking up water. But much the same result can be obtained by the use of good amounts of vegetables and fruit. Spastic Constipation.— In this form of constipation it is necessary to furnish considerable bulk to the feces, but keep- ing all the foods soft and non-irritating, also include a large percentage of fats and oils, making an especial point of this latter feature. It is here that the mineral oils may have their best effect and should be tried freely and thoroughly and as well, the injecting of 2 to 4 ounces of some bland oil into the rectum at bedtime. For this purpose one may use olive, cotton seed, peanut or sweet oil. Larger quantities are often recommended, but serve no more useful purpose than the small amount. In this diet the fruits should be freely used, but not those with seeds or skins; and raw, rough or uncooked vegetables must be left out of the diet. Potatoes, spaghetti and all cereal foods are good, except oatmeal or bran preparations and, of course, fish, eggs and a moderate amount of meat, free of connective tissue, are all allowable. CHRONIC CONSTIPATION 415 If one will keep in mind the facts already stated, that the diet must contain a greatly increased bulk of soft vegetables and fruit and as large an amount of oils and fats as one can digest readily, the diet may be easily constructed. It is often better to take all the vegetables as a puree or after being passed through a colander. Obstructive Constipation.—The texture of the diet in this condition will depend largely upon the degree of obstruction; if slight, it will be only necessary to exclude all coarse food from the diet which will leave us much the same diet as has been recommended for spastic constipation. When the obstruction is more marked or severe, it will be necessary to confine the foods to those which leave the stomach largely in fluid or semifluid form, such as malted milk, citrated milk (1 grain of sodium citrate to 1 ounce of milk), cream and puree soups, cream, meat cut very fine or scraped. Soft eggs. Mashed potato, oils, butter, fine cereal gruels, ice- cream and syrups. Of course when an obstruction reaches this point it becomes a surgical condition and should be so treated. The only cases of severe obstruction in which it is necessary to consider the diet for any but a few days are those cases which, for one reason or another, are inoperable. The Use of Mineral Oil in Chronic Constipation.—This oil comes in various grades, heavy and light, made here and abroad, formerly in Russia, hence the common name “Rus- sian mineral oil.” Many cases of chronic constipation are greatly helped by varying doses, from a tablespoonful morn- ing and night to double that dosage or more. Still others find that a tablespoonful at bedtime is amply sufficient. In short, each patient has to find the individual dose suited to the needs of their case. Many patients cannot take this oil at all, for although it is not absorbed, the entire amount ingested being recoverable in the feces, it not infrequently interferes with the normal digestive processes, giving rise especially to intestinal indigestion characterized by the symptoms of a mild enteritis accompanied by loss of appe- tite. Whether this acts partly on account of the depressing effect of oils on gastric secretion, or possibly on account of the same effect on the intestinal enzymes, or again by mechanically preventing the digestive juices from attacking the foods, is not definitely known. The essential thing, how- ever, to remember is that it does not agree with all patients by any means and its effect on digestion must be watched. After considerable investigation in regard to the different mineral oils and the different methods of giving it, Bastedo1 1 Jour. Am. Med. Assn., 1914, 64, 808, 416 DIET IN DISEASES OF THE INTESTINES came to the following conclusions, which are borne out by clinical experience. Dosage. — Half an ounce to three ounces a day. In the same patient, the same amount of each of the oils was required, i. e., heavy and light oil. Frequency of Dose.— The same amount daily seemed as efficient when given in one dose as when given in divided doses two or three times a day. Number of Stools.— To produce one or two copious stools a day the dose required varied considerably, but there was no difference noted on account of difference in the specific grav- ity or character of the oils. So far as therapeutic results are concerned the differences in the action of the three varieties of liquid petroleum, namely, light Russian liquid petrolatum, heavy Russian liquid petrolatum and American liquid petrolatum, are too slight to be of importance. Character of Stools. —The stools were soft, usually formed, sometimes mushy, obviously greasy. They had a peculiar odor, described as sour. Their consistency varied with the dose, but was the same for the different kinds of oil. Admixture of Oil with Other Ingredients of Stools. —Generally well mixed, but from time to time a patient would have a stool of free oil. This occurred with all varieties of oil. (It necessitated reduction of the dose, and if then the bowels were not active enough, the administration in addition of cascara, aloin, etc.) The increase in the quantity of oil used in America has stimulated production on this side of the water until now all grades of mineral oil may be had of native manufacture which are in every way as good as the imported brands. INTESTINAL ATONY. 1'his condition affects chiefly the muscular coat of the large bowel and results in constipation, in fact a large majority of cases of chronic constipation are the result of an atonic colon. The diet to combat intestinal atony should be much the same as that recommended for chronic constipation and con- tains as large a percentage of cellulose and fats as possible. Suitable foods are: The breads which should be those made with whole-wheat flour, rye flour or bran; vegetables; the best varieties of which are those having the largest residue, such as the cabbage family, spinach, string beans or dried beans, peas, parsnips, sweet potatoes, beet tops, etc.; the APPENDICITIS 417 rough cereals as oatmeal (Irish) or Pettijohn (which is 25 per cent bran) or Kellogg’s cooked bran, which can be eaten alone or mixed with other cereals. All fruits, fresh, stewed or dried, are useful and should be taken in some form at least three times a day. Molasses, honey, marmalade and maple syrup are all stimulating to the intestine. The best fats are cream, olive oil, butter and fat meats—as bacon. Pro- tein foods may be unrestricted in kind but should be some- what limited quantitatively, for when taken in large amounts they tend to spoil the appetite for the more bulky and neces- sary vegetables and fruits. There are cases in which this plan does not work well for if the atony is too severe the fecal masses cannot be moved. In these cases the diet recommended for use in intestinal obstruction of mild degree is suitable. As additional measures, massage of the colon and elec- tricity (given with one electrode in the rectum) assist in W’aking up a sluggish bowel, and general hygiene. APPENDICITIS. Acute Appendicitis.—Acute appendicitis, whether catar- rhal, suppurative, gangrenous or perforative, is essentially a surgical disease and should be so considered from the onset. There are certain conditions, however, under which acute appendicitis may arise, which, for one reason or another make an operation either impossible or inadvisable, as for example, if the patient absolutely refuses surgical aid, in spite of knowing the dangers of that course; when surgical aid is not to be had or only a very poor variety; in people of great age where it is feared the shock of any operative interference would be fatal and last but not least important, in those cases which have been neglected until general peri- tonitis is present with distention and an almost moribund condition, when operation is considered as a last hope. These last-named cases almost invariably die if operated upon and are likely to die if they are not, but a few may survive care- ful medical treatment. Of course, it is a matter of very fine distinction and surgical judgment when this point is reached and rejection of surgery should not be encouraged except after mature deliberation and full consultation. In all these conditions it will be necessary at times to turn to general medical care without operation and the dietary and general routine care of such patients are of the utmost importance. Formerly in these conditions reliance was placed on opium in full doses, and many cases were success- fully carried through with its aid. The effectiveness of 418 DIET IN DISEASES OF THE INTESTINES opium depended on the fact that it quieted the bowel, tend- ing to stop peristalsis and the consequent transference from the iliac fossa of the septic material all over the abdominal cavity, an easy matter when peristalsis is active; and no doubt also to the fact that it helped to destroy the appetite, and so limit distention from fermentation of ingested food. Of late years this method has fallen into disrepute because of the fact that opium so completely masks the symptoms in the early stages that one cannot tell of the progress of the disease and one is apt to miss the true significance of the patient’s condition. Ochsner’s Treatment for Appendicitis.1—In the early nineties, Ochsner devised the treatment which goes by his name, and although it has been the storm center of many arguments, under the conditions mentioned, where operation is impossible or inadvisable, it remains today the best method we have and often gives surprisingly good results. In a word it consists of withholding everything by mouth, forbids catharsis and insists upon gastric lavage .when there is nausea or vomiting and depends upon rectal absorption of small amounts of predigested food and salines. Ochsner bases his recommendation of this method founded on experience on these two cardinal facts. 1. “The anatomical location of the appendix makes it easy to be shut off from the general abdominal cavity, if the surrounding structures remain at rest for a time.” 2. “If at rest, the cecum, omentum and small intestine surround the diseased appendix, no matter what its patho- logical condition—so shutting it off from the general cavity.” The effect of taking food is to excite peristalsis, and no matter how light the food, it may, by exciting peristalsis, carry septic material all over the peritoneum and the gas produced by food passing down disturbs an inflamed appen- dix. He therefore forbids absolutely everything by mouth. This does not mean that a little broth or water or milk may be given, but means that at first nothing is to pass the lips. Ochsner further states, “No matter whether the patient has a catarrhal appendicitis with or without a foreign body in the appendix, or whether the appendix, is gangrenous or per- forated, he will almost invariably recover, if from the begin- ning of the disease absolutely no food is given by mouth.” He also insists on gastric lavage if there is nausea or vom- iting or if the patient begins his appendiceal symptoms shortly after a meal. This removes material that excites 1 Handbook of Appendicitis, 1906, p. 132. APPENDICITIS 419 peristalsis and will later surely ferment and form gas if it be not promptly removed. The lavage is to be repeated at least once if the nausea and vomiting recur; usually after the first twenty-four hours water may be given by mouth in small amounts, but if peristalsis is thereby excited it must be given only by rectum. The last feature of Ochsner’s treatment is to give nutrient enemata every three to six hours, not to exceed 4 ounces at a time, made up of f or 1 ounce of some predigested commer- cial food in 3 or 4 ounces of normal saline solution and given by a small tube, after adding 20 drops of tincture opii deodorata, for an adult, to the first feeding, and one-half that amount to the other feedings (children in proportion), unless the patient is entirely free of pain or restlessness. These directions are to be followed until the patient is well along toward recovery and in very severe cases he continues the rectal feeding for ten days or even longer. Theoretically there is objection to giving anything by rectum, as peristal- sis is at once excited in the entire length of the large intestine, as it is so clearly shown by the fluoroscope when bismuth or barium are mixed with the enema. Practically, however, this objection does not seem to invalidate the treatment, probably because the peristalsis is along definite and fairly fixed lines, unlike the movement of the small intestine. Of course, as shown in the chapter on Rectal Feeding, these enemata furnish little besides fluid, although some protein in the form of amino-acids and some of the sugars are absorbed in solution. Probably completely pancrea- tized (“peptonized”) milk (two hours) after being sterilized is quite as efficient as the commercial predigested foods. Ochsner himself is a strong advocate of surgical interven- tion in appendicitis and only recommends the foregoing when an operation is either impossible or inadvisable, as already explained. Chronic or Larval Appendicitis.—In chronic appendicitis or larval appendicitis, conditions are quite different from the acute variety and while operation is advisable when a diag- nosis is made, it may for one or another reason be necessary to postpone it until some later time. Then too, when not acutely ill it is not always so easy to persuade one’s patients to undergo the operation, although they should be warned that an acute exacerbation is possible at any moment which may make an operation imperative. If, on the other hand, it is necessary to tide these patients along for one or another reason, dietary regulations will help in reducing the symp- toms in many cases until an operation can be done. 420 DIET IN DISEASES OF THE INTESTINES In very many of these patients there is an accompanying constipation which is more or less marked and in them the diet as advised for chronic constipation will be of distinct value, for by facilitating the constant removal of fecal masses from the colon the congestion of the caput coli and appendix region will be considerably reduced, so lessening at all events the pain and many of the symptoms of chronic indigestion which these patients have, also any pressure on the appendix from impinging fecal masses will be relieved. In these patients it is advisable to give a morning dose of some one of the saline cathartics, at least until the bowels act regularly themselves. The following mixture as recommended to the author by R. Freeman, has proven its value many times. Sodium salicylate 5j (4 gm.), sodium phosphate gss (16 gm.), sodium sulphate giss (45 gm.), giving a teaspoonful of this combination (more or less as required), in the early morning, at least one-half or three-quarters of an hour before break- fast. It should be dissolved in a little hot water and the glass filled at least three-quarters full with cool but not cold water. The addition of the salicylate salt helps to reduce fermentation and consequent distention. The chronic cases with constipation have the latter feature lessened by the use of some preparation of mineral oil, provided it does not dis- agree. (See Chronic Constipation.) When constipation is not a feature of the condition a diet containing the minimum amount of fermentable vegetables is advisable, i. e., leaving out potatoes, onions, cauliflower, cabbage, brussels sprouts, sweets, fresh breads or uncooked starches, pies, cakes, syrups, fried foods or foods that are famously indigestible. (See Section on Indigestion.) Here too, it is advisable to give a smaller dose of the saline or the above- mentioned salts, which help to drain the appendix and reduce congestion about it. Rest before and after meals is advis- able and it is especially desirable that these patients should eat without haste and thoroughly masticate their food. The author has seen many cases in which this plan of treatment has reduced the symptoms to a minimum and in a number relieved the patients entirely, although, of course, it is presumable that further trouble will recur at a later time, particularly if the appendicitis is of the chronic invo- luting variety. CHRONIC TYPHLITIS AND PERITYPHLITIS. The dietary routine for these conditions is much the same as that given for chronic appendicitis, although here oil and INTESTINAL A UTO-INTOXICATION 421 fat foods play a more prominent part and the injection of two or three ounces of oil in the rectum at bedtime is most useful. In some cases it will be necessary to revert to the diets recommended for chronic colitis of which these condi- tions are often a part. The use of salines is also useful in keeping the caput as free of feces as possible, and a moderate dose of a mild saline cathartic in the early morning is helpful. INTESTINAL AUTO-INTOXICATION. The entire subject of auto-intoxication is far from clear, particularly in its clinical bearings, and there may be found great difference of opinion among biological chemists as to the significance of the products of intestinal fermentation and putrefaction in their relation to conditions of actual disease or clinical symptoms. Thus Taylor1 says that intoxica- tion by resorption of the digestive juices, by products of normal digestion and by abnormal products of digestion is not proven experimentally and probably does not exist, and in “normal bacterial disintegration of food-stuff's in the alimentary tract no known toxic substance is found,” for the products of carbo- hydrate fermentation—formic, acetic, butyric, valerianic, propionic, lactic, succinic acids and a trace of oxalic acid— are not toxic. So too, according to Taylor, although protein putrefaction yields phenol, skatol, indol and cresol from amino- acids and hexone bases, none of these are toxic. Also there is “no constant relation between the protein ration and the output of aromatic substances, and a high urinary output of aromatic substances indicates active putrefaction in the colon, which may be innocuous or not. On the other hand, a low output need not indicate a low degree of bacterial activity in the intestines and need not speak against a bacterial intestinal intoxication.” Cytolytic degeneration seems allied to the process of fer- mentation, the functions of the tissues are disturbed by the cytolyses and an auto-intoxication may result, also the prod- ucts of tissue degeneration may be toxic themselves, so that according to Taylor again it is not possible to separate auto- intoxication from the general pathology of metabolism. In so-called gastro-intestinal auto-intoxication there is no constant relation, according to the same authority, between constipation, excess of indican and conjugate sulphates in the urine, nor does the degree of these substances bear any relation to the severity of the symptoms. 1 Osier’s Mod. Med., vol. 2, p. 503. 422 DIET IN DISEASES OF THE INTESTINES Combe,1 on the other hand, is an enthusiastic supporter of the gastro-intestinal origin of certain toxic states of the organ- ism and marshals his proofs in very clear and logical order. We all know that bacteria play a large part in the digestive processes and the questions are asked: 1. Is the microbic intervention useful to the body? 2. Is it indispensable? 3. Can it become harmful? 1. The answer to the first is positively affirmative, as the bacteria digest foods as do the enzymes and in some instances digest portions of the food (cellulose) which the enzyme cannot. 2. The bacteria are also indispensable as proven by Nut- tall, Thierfelder2 and Schottelius,3 who showed that animals born and raised aseptically did not thrive or, in many instances, live at all. 3. In answer to the third question as to the possible harmful qualities of bacteria in digestion, Combe gives positive assent, although it has been strongly combated by the German school, who admit the symptomatology and the probable focus but find the proofs insufficient. He further fortifies his position by pointing to the autotoxic and detoxifying powers of nature’s three lines of defence against intoxication found in the intestinal epithelium, liver, glands of internal secretion and external secretion as e. g., the kidneys, through which intestinal toxins are constantly eliminated. Phenol, indol and skatol are all formed in the intestine as a result of putrefaction of nitrogenous food-stuff's, principally meat. Phenol is formed in the large intestine as a result of bacterial activity in the presence of stasis there, but when small in amount is oxidized in the organism or is eliminated by the bowel and only when the formation exceeds the oxidiz- ing powers is it excreted by the urine. Indol is formed in the small intestine as a result of stasis in this part of the bowel and never when the stasis is in the large intestine. It is oxidized into indoxyl, which combines with sulphuric acid in the liver to form indoxyl sulphuric acid; this appears in the urine as a salt of potassium, potassium indoxyl sulphate or indican. This substance in turn is oxidized into sulphuric acid and indoxyl, the latter into indigo red or indigo blue if an oxidizer is present. Both indol and phenol excretions depend on: 1. The composition of the food (which varies). 1 Auto-intoxication. 2 Ztschr. f. phys. Chem., 22, 71. 3 Arch. f. Hyg., 24, 210. INTESTINAL AUTO-INTOXICATION 423 2. On the degree of peristalsis. 3. On the power of absorption. 4. On putrefaction intensity.1 It is strongly disputed whether indicanuria has any effect in producing symptoms of so-called auto-intoxication, but there seems little doubt but that it is at least the index for other conditions which result in symptoms, and the associa- tion of marked indicanuria and evidence of renal irritation (as a trace of albumin, casts, etc.) is too definite to be dis- missed without adequate explanation, particularly as reliev- ing the indicanuria often results in a return to a normal urinary output. The effect of the indican, perhaps, while not deleterious in itself, may be to cause renal irritation and consequent reduc- tion in the kidney’s power for excretion of other toxic sub- stances at present unknown but standing in a causal relation to the symptoms of intoxication. At the same time there is no end of clinical evidence that when symptoms of a toxemia are present in connection with considerable amounts of indol in the urine, relief is seldom or never obtained until measures are adopted to restrict its formation (diet) and to favor its elimination (catharsis and intestinal irrigation). On the other hand, there are undoubtedly many cases of indicanuria which are entirely without symptoms, so that while the specific variety of auto-intoxication depends on chemical, physiological and pathological facts too intricate to be as yet made out with clearness and it is not possible to speak of treatment based on specific etiological factors, we know something of the course of development of the intestinal poisons from fermentation and putrefaction2 and the clinical conditions that lead directly to it, as well as the factors that modify it. Dyspepsia and stasis either gastric or intestinal; diseased conditions of the intestinal walls with consequent lessening of the defense mechanism; parasites; diminished activity of the antitoxic organs; bad eating habits, hurry, working too soon after a meal, all may be of etiological importance. The symptoms attributed to intestinal auto-intoxication are said by some authorities to be due solely to the mechanical pres- sure of fecal masses in the rectum. This they say is proved by producing all the symptoms by mechanically distending the rectum with packing or a distended rubber bag. A point in favor of this is the well-known fact that the symptoms often clear up almost immediately on removing the mechanical rectal pressure. 1 Combe: Auto-intoxication, p. 61. 2 Forchheimer: vol. 2, p. 664. 424 DIET IN DISEASES OF THE INTESTINES Dietetic Indications for Intestinal Auto-intoxication.—When one comes to consider the necessary factors in diminishing nitrogenous intestinal putrefaction one finds that Combe1 sums up the indications as follows: 1. Modify the intestinal culture medium in which the pro- teolytic bacteria thrive by. {a) Introducing an antiputrefactive lactofarinaceous diet. {b) Introducing antagonistic bacteria into the intestinal medium. 2. Diminish the vitality of the proteolytic bacteria in the intestine by means of germicidal medicines (there is as yet no known way to accomplish this satisfactorily). 3. Evacuate the proteolytic bacteria and their products by intestinal lavage. The first indication, namely, that of modifying the culture medium, is the one with which we are particularly concerned and leads us to a study of diet for this condition. General Indications for Diet.—Nitrogenous Foods.—1. Diminish these as much as possible, keeping to the low level of physio- logical requirement, 40 to 60 gm. (i| to 2 oz.) of protein, per diem. 2. Absolutely prohibit those forms of nitrogenous foods that favor the development of putrefactive bacteria, par- ticularly animal protein except milk, e. g., meat, fish and eggs. 3. To choose among these, milk in one of its many forms— whole, skimmed, zoolak, koumyss, buttermilk, kefir, loppered milk, cream or pot cheese. Fatty Foods.—1. Avoid meat fat as increasing putrefaction. 2. Give fat best in the form of fresh butter and cream. Farinaceous Foods.—1. Give as large a proportion of farina- ceous foods as possible, saturate the intestines with them, giving five or six meals in the proportion of five times as much farinaceous as protein foods, whenever the latter are given. 2. In auto-intoxication from acute enteritis an exclusive farinaceous diet must be given for several days. 3. In auto-intoxication due to chronic enteritis, the diet should be lactofarinaceous, giving later a little meat or eggs. 4. In ordinary auto-intoxication milk mixed with fari- naceous food is best, for the lactose of the milk on account of its lactic acid-forming abilities is a strong antiputrefactive element.2 Foods to Especially Avoid. — Bouillon, meat soups, meat juices and jellies, meat extracts, white of egg or dishes which are made of it. Milk, unless mixed with farinaceous food. 1 Auto-intoxication, p. 234. 2 Combe: Auto-intoxication. INTESTINAL AUTO-INTOXICATION 425 High or tainted meats or those which decompose rapidly, game, rare or raw meats, fish, shell-fish. In severe auto-intoxication absolutely no meat should be taken, and when it is begun later only in small progressive quantities, not forgetting that it should be taken with five times its bulk of farinaceous foods. Foods to Take.—Fruits raw orcooked. Vegetables, thoroughly cooked and soft, all farinaceous foods, as rice, noodles, macaroni, puddings, puree of vegetables, bread, yolk of eggs. Sauerkraut is a valuable anti-putrefactive food. Modified Sample Menus. Farinaceous without Meat. 7.30 a.m. Cereal prepared with water or milk. Rolls and fresh butter. 10.00 a.m. Some form of gruel made with milk or water. 12.30 p.m. 1 or 2 yolks of eggs, raw or boiled, maca- roni, rice, farina with salt and fresh butter. Farinaceous pudding. Rolls and butter. Later fruit and soft green vegetables. 3.30 p.m. The same as at 10.00 a.m. 7.00 p.m. Same variety as at 12.30 p.m. 10.00 p.m. Infusion of chamomile, peppermint, fennel or anise. After eight to ten days of this, add potatoes, puree or baked. Whortleberry juice or jelly. No fluids with meals. Later tea, coffee, cocoa, vegetables, and fruits, may be added in the order named with a little meat, first at one and then at two meals, watching the effect. In choosing a diet one must also be somewhat guided the conditions so often associated with intestinal auto- intoxication, e. g., stasis, chronic constipation, torpid liver or actual hepatic disease and circulatory disorders. Jack1 recommends loppered milk diet in auto-intoxication associ- ated with emaciation or not, given with well-cooked fruit and cereal, thus 1 pint of loppered milk with buttered-toast or a cheese or butter sandwich with baked apple or stewed fruit every two hours. After ten or eleven days increase the diet. When on regular diet again he advises taking as much as 5 pints of the loppered milk—1 pint at each meal and 1 between meals. (This is probably too much for the average case.) A sample diet covering the most usual associated condition, viz., that of chronic constipation or intestinal stasis might be chosen somewhat as follows: Early morning, f or \ glass of grape juice with equal amount of water. 1 Buffalo Med. Jour., 1917-1918, 99, 501. 426 DIET IN DISEASES OF THE INTESTINES Breakfast: Glass of milk or buttermilk with cereal and cream (tea or coffee later). Bread and fresh butter. Fruit. Midmorning: % glass of buttermilk and slice of bread. Dinner or Supper: Cream vegetable soup made without stock, or thickened with flour. Yolk of 2 or 3 eggs poached or scrambled; macaroni, cream cheese, potato, rice, baked farina, green vegetables (that grow above ground). Glass of milk or buttermilk. Bread and fresh butter. Farinaceous pudding with fruit sauce or stewed figs, prunes, apricots, pears, cherries or peaches. Midafternoon: Cream cheese and crackers. At Bedtime: \ to 1 glass of buttermilk with 2 or 3 toasted crackers and several dates or figs. This should be kept up for a long enough time to get rid of the subjective symptoms and any abnormal urinary find- ings, and then little by little one may add a little meat and other foods, gradually returning to a! normal dietary, but for a long time keeping the protein at a low level as already indicated before. The treatment should be begun with a mercurial purge and the use of some laxative or mineral oil continued for some time. When the symptoms are severe great assistance is obtained from high colon irrigations with normal saline or a 1 per cent solution of ichthyol. In so-called toxemia without acid bacilli in the stool, Norman1 puts patients on a diet of fruit, green vegetables, milk and chicken, gives colon irrigations followed by implantation of Bacillus acidophilus in a lactose and agar-agar medium. He also gives 10 to 12 heaping tablespoons of lactose daily. If the patients find that they cannot take the lactose he orders a package of dates and a package of figs for the contained dextrin. The intestinal flora can be changed almost at will, hence if there is an excess of the putrefaction bacteria, reducing the total amount of protein and using only milk products to furnish the needed amount, and giving large amounts of carbohydrate foods will result in the production of great numbers of acidophilic bacteria. Conversely when there is acid intestinal fermentation changing the diet to one princi- pally protein will change the bacterial growth. General bodily exercise regularly every day and hygiene are all of great assistance in ridding the gastrointestinal tract of the toxic materials. In some instances a complete change of life, a trip to Europe 1 Med. Times, 1921, 49, 126. HIRSCHSPRUNG’S DISEASE 427 or elsewhere, taking the patient out of his usual routine may be necessary to accomplish the end desired. The usefulness of this has been proven more than once in the writer’s experience. HEMORRHOIDS Hemorrhoids are caused by a dilatation of one or more of the veins at the anal ring, which at any time may be throm- bosed. The dilatation is due either to a temporary and local obstruction to the return venous flow, as in constipa- tion or fecal impaction or just mere straining at stool, or to a permanent interference with the return flow, as seen in cirrhosis of the liver or chronic cardiac disease. The dietary prevention of the temporary venous obstruc- tion is very important and one can do much to obviate the production of hemorrhoids by giving a diet which will be laxative, such as is recommended in chronic constipation, including as it does a large amount of cellulose in green vege- tables and fruits, fresh and dried; oils, fats and liquids in excess. When the hemorrhoids develop as a result of straining and tenesmus in prolonged diarrhea, a diet to control the loose- ness will be of use, as in chronic diarrhea, unless one can find the direct cause of the diarrhea and correct it. In the cases of hemorrhoids dependent on hepatic or car- diac disorders it will be necessary to insure regular bowel movements, using an anticonstipation diet so far as one can in consideration of the underlying causes. Measures directed toward the relief of the hepatic or general intestinal conges- tion are necessary in addition to the suitable diet. HIRSCHSPRUNG’S DISEASE. In this disease, which is a chronic or congenital dilatation of the colon, there are certain dietary indications which are designed to combat rather the symptoms (which are often secondary to the condition, such as chronic constipation and stasis with at times symptoms of toxemia) than the dilata- tion itself. There is one exception to this, namely, that foods which are particularly prone to be stored up in the colon and increase the dilatation should be avoided, as for example an excess of tough cellulose. The diet recommended for chronic constipation is best suited to this disease, with the precaution that all vegetables 428 DIET IN DISEASES OF THE INTESTINES and fruits should be soft when fed and not given in indiges- tible bulk, although the total quantity of such foods should be great. It would seem as if in this disease the regular use of mineral oil might accomplish much by its lubricating qualities, and it certainly deserves a trial, which, with massage of the colon, may help to preserve the muscular tone of the intestine. A surgical procedure is the only permanent way of reliev- ing Hirschsprung’s disease, either as a colectomy or iliosig- moidostomy. CHAPTER XXIII. DISEASES OF THE ACCESSORY DIGESTIVE GLANDS. The action of these glands and their secretions are so indissolubly connected with the processes of digestion that the consideration of one implies consideration of both. We have dealt with dietetics of diseases of the digestive tube separately, but as a matter of fact, unconsciously we are compelled to take account of the state of the accessory glands in doing so, and of making allowances for their integrity or lack of it. On the other hand, there are certain diseases or pathological states of these glands that arise, which demand attention aside from the questions of digestion, as well as the bearing of these conditions on the normal utilization of food-stuff's, and with some of these we are now particularly concerned. It is much to be regretted that the dietetics of hepatic dis- eases cannot be more serviceable as curative agents and still more to be regretted that most people are not willing to exer- cise the common sense and self-restraint in drinking and eat- ing, the failure of which in so large a measure is responsible for the frequency of diseased conditions in these organs. In other words, dietetics here are much like locking the stable door after the horse has been stolen, for the dietetic prophylaxis is all important. After the damage is done patients are willing to go anywhere and spend any amount to be rid of their troubles or do anything that offers a chance in the prevention of a return or continuance of their symp- toms. In the matter of diets for hepatic disorders and disease we could act a good deal more intelligently if we had a simple and reliable method for testing hepatic functions, for if our choice of a diet could be made to depend on definite knowl- edge of just what food elements were poorly metabolized by the liver, we could choose a diet especially adapted to the individual case. DISEASES OF LIVER AND GALL-BLADDER. 429 430 DISEASES OF ACCESSORY DIGESTIVE GLANDS The methods in vogue for testing liver functions are too uncertain or too complicated to be of much practical use, although there is no doubt but that there is progress being made in this direction. Strauss used ioo to 150 grams levulose to test liver functions, a resulting levulosurea indicating a disturbed hepatic func- tion. As a matter of fact, most diseased livers respond to this test, but in many of the cases of cirrhosis the glycogenic function is perfectly well preserved and we get no resulting levulose in the urine. Opie1 found that when the liver was poisoned by certain substances, as, e. g., chloroform, the susceptibility to intoxica- tion is greatest after a diet of fats, less after meats and least in animals fed on carbohydrates. This by analogy can be used in choosing the diet in threatened cholemic states where the liver cells are failing in their power to functionate, over- whelmed as they are by the poisons in the system. Here carbohydrates should be given fully and may even be given subcutaneously, as a 5 per cent solution of glucose. Dietetic Prophylaxis.—This question is practically a state- ment of the etiology of many abnormal liver conditions and while it is to be feared that few will heed advice until expe- rience has taught its bitter lesson, it is certainly a necessary thing to state how most of these diseases may be avoided, excepting of course those due to direct infectious agencies. It is only necessary to remind the reader of the physiology of the liver to see that almost everything absorbable that is ingested finds its way sooner or later to the liver, which is endowed with extraordinary powers. These powers may be spoken of as the detoxifying, lipogenic, glycogenic and urea- forming functions. In a normal liver these operate to per- fection, but in disease are more or less disturbed or permanently disabled. For the exact mechanism by which this is accomplished, one is referred to Physiology, and all that is necessary here is to enumerate the “dont’s” of die- tetics to point the way to a preservation of normal functioning. The excessive ingestion of any one of the food elements— protein, carbohydrates and fat—will lead eventually to dis- turbed liver function, and a continuance of this results in permanent damage to the cells. Among the articles of food especially to be avoided are condiments of all sorts, alcohol, vegetables rich in irritating oils, such as garlic, radish and horseradish and the continued use of phosphorus or arsenic in course of treatment. This does not mean that one must 1 Jour. Exp. Med., 1914, 21, 1. DISEASES OF LIVER AND GALL-BLADDER 431 go through life without the use of any condiments, for a little at times can be successfully detoxified by the liver, but taken in large amounts or continuously they form a very distinct danger to the integrity of the cells by chronic irri- tation and the production of connective tissue. Alcohol is, of course, the chief offender and it hardly seems necessary to mention this point, it is so generally known and recognized even by the laity. Spirits, as whisky, gin, brandy, etc., are especially bad and all other alcoholic drinks directly in pro- portion to their alcohol content. When taken on a full stomach and largely diluted they are, of course, least irritat- ing, but the dilution does not lessen the absorbability of the alcohol but merely spreads it over a longer time, giving the liver a better chance to handle it. Especially bad are undiluted spirits on an empty stomach, as cocktails or neat spirits taken as an appetizer before meals, as here the absorption is quickest and most complete and is apt to be regularly repeated. While the spirits have a tendency to produce cirrhosis, the beers do so also, but to less extent, and their damaging effects are seen as well in the deposition of excessive amounts of fat in and about the liver cells and as a fatty degeneration of the cell itself. With the new pro- hibition laws it is probable that cirrhosis of the liver will become comparatively a rare condition. Acute Hepatic Congestion.—This is caused frequently by overeating and drinking, and from a dietetic point of view requires starvation or semistarvation until the appetite, which is usually completely lost, returns. During this day or two of starvation water can be given freely, and as soon as the patient is able to take food he may be given small amounts of milk, skimmed or whole, diluted with alkaline waters; also gruels, cream soups, milk toast and soft cereals, custards, soft green vegetables, chicken and so back to full diet, giving the articles in about the order listed. This condition of acute congestion of the liver is usually designated by the layman as a “bilious” attack, at all events that covers the situation, although nobody knows just what a “bilious” attack is, it seems to be so many things to different people. Acute Catarrhal Jaundice or Gastro-duodenitis with Jaun- dice.—In this condition we have not only the catarrhal inflam- mation of the bile ducts but primarily of the stomach and duodenum, so that the catarrh of this part of the digestive tract must be taken into account in the choice of a diet. Fortu- nately the same diet fits both conditions. As fat is very badly digested in this, it is best to reduce it to a minimum 432 DISEASES OF ACCESSORY DIGESTIVE GLANDS until the jaundice is largely over; to this end skimmed milk is an ideal diet, although here again a day or two of starvation at the outset may be quite the most serviceable procedure, provided water is given in large amounts. After the skimmed milk we can give broth, gruels and soft foods generally in pro- gressive order. An early morning saline laxative is essential, particularly when constipation is marked, but all cases are benefited by it, as it has a favorable influence on the gastric and duodenal catarrh. According to Forchheimer jaundice causes a hyperchlorhydria in direct proportion to its intensity, and the diet must be chosen with this in view, avoiding stimulating acid or irritating foods. Chronic Hepatic Congestion.—This is usually passive and due to cardiac disease with failure of compensation. The diet should be light, non-stimulating and attention directed to the cause of the congestion. Portal Cirrhosis.—Although this disease does occur occa- sionally in children and young adults without known cause, it is for the most part, par excellence, the disease of retribu- tion and can usually be traced to chronic hepatic irritation from overindulgence in irritating foods and drinks, especially alcohol. Where the diagnosis is fairly certain and especially in the earlier stages, it is necessary to institute at once a rigid milk cure (as milk is nourishing and absolutely non- irritating), given continuously and alone for from four to six weeks,1 2 or 3 quarts per diem, diluted with soda water, Vichy or Apollinaris or flavored with tea, coffee or cocoa. This diet reduces intestinal putrefaction to a minimum, so causing less hepatic irritation, the fat is in emulsion and absorption can take place in spite of an intestinal catarrh.2 When nausea or vomiting are sources of trouble, skimmed milk often agrees better than whole milk.3 After this period of milk diet one may add eggs, gruel, cereals, fresh green vegetables, stewed fruits. Much sugar is forbidden, as it is apt to cause fermentation. Fats, too, often give rise by fermentation, to the formation of acetic, lactic or butyric acids and should be avoided. After a month of this diet Osier recommends a return to the milk period again for a time, alternating with the addi- tional diet as indicated. Of course all the foods that belong to the irritating class are to be permanently studiously avoided. Besides those already mentioned one must include meat or strong meat broths, neither of which should be taken 1 Osier’s Modem Med., vol. 3, p. 444. 2 Rolleston: Diseases of Liver, p. 297. 3 Herter: Lectures on Chem. Path., 1902, p. 88. DISEASES OF LIVER AND GALL-BLADDER 433 for a long time in order to keep the production of urea down to the minimum. Occasionally the milk may be advantageously given in the form of the Karell cure, particularly if the cirrhosis is compli- cated by ascites or obesity. The low salt content of this diet (1.3 gram per day) acts as one of the salt-poor diets does in nephritis and often helps in the removal of the fluid, at least in part. Einhorn recommends duodenal feeding in cirrhosis on account of its sparing the portal congestion; reports on its usefulness are, however, meager. Biliary Cirrhosis.—Here we have more often an extension, via the bile ducts, of a direct infection of the biliary system, the cause often originating in the intestine. The diet is much the same as that recommended for portal cirrhosis, although the milk diet may not need to be so rigorously or so long continued. Constipation must be especially combated and is best managed by a morning saline laxative. After the milk period of feeding is over we may give sago, zwieback, rice, potato, fish, chicken, etc., avoiding all the irritants as in all other diseased states of the liver. Fatty Liver.—Since the chief cause of fatty infiltration of the liver is the excessive ingestion of alcohol or fats, the natural recommendation for prophylaxis would be to take less or none of either. The fatty degeneration of the liver will hardly be affected by diet, except as it may modify the acute infection which is the cause of the degeneration. As a matter of fact, fatty infiltration and degeneration usually go hand in hand; one or the other predominating, depending upon the etiological factors. When one has a well-developed case of fatty liver due pri- marily to infiltration, it is necessary to oversee the patient’s diet with great care. If the individual is obese it will be necessary to institute a reduction diet cure combined with suitable exercises (see Obesity). In this way a certain amount of excess fat can be removed in the general course of reduction and with the improvement in the patient’s general condition in consequence of this it is also probable that the fatty infil- tration will become less marked, unless it has already gone on until the liver tissue has become very fat, as occurs in the more severe cases. Overeating and alcohol are especially to be forbidden, although this is true, too, of all the conditions already de- scribed. Fat food must be interdicted and only a moderate amount of carbohydrate allowed. In hot climates a vegetable diet with milk is particularly recommended. Where there 434 DISEASES OF ACCESSORY DIGESTIVE GLANDS is fever, meat must be restricted, otherwise it may be allowed in moderation,1 and all the lighter proteins are well borne, as fish, eggs, milk and cheese, if not too rich. As has been already said, when the fatty liver is part of a general adiposis the patients must be treated as for obesity with the hope that much of the excess of fat can be gradually removed as the patients return more nearly to their normal condition and weight. Acute Yellow Atrophy of the Liver.—Since the admitted cause of this condition is a toxemia, not always due to the same agent, the treatment consists in prophylaxis so far as possible. Any form of jaundice, therefore, particularly that occurring in a pregnant woman, should always be viewed with suspicion. When the condition has been diagnosed the diet plays a not inconsiderable part in the treatment, and since there is apt to be an acid intoxication present the giving of cereal gruels other than oatmeal is important, which with milk should form the basis of the diet. The drinking of a large amount of an alkaline water or even plain water, to which sodium bicarbonate is added or not, is recommended by Kelly.2 Amyloid Liver.—The etiological factor in this disease is some focus or foci of chronic suppuration, and the diet should be constructed with an idea of increasing the food consumption to the maximum, compatible with health, in order most successfully to combat the chronic infection, which should, of course, be treated surgically if possible. All fat foods, such as cream, butter, fat meats; concentrated carbohydrate foods, as breads, cereals, macaroni; sugars and honey are especially good. The protein of the diet should be increased to approximately 120 grams if the patient can take this amount, for combined with exercises this amount of protein will favor the formation of tissue and thus increase the active protoplasm. Cholelithiasis. —From the dietitian’s point of view nothing can be done to aid in the removal of gall-stones when already formed, although much has been written on the possibility of dissolving gall-stones in situ. Their partial disintegra- tion and occasional complete disappearance does take place experimentally, when gall-stones are placed in a dog’s bladder, either in its normal condition or when an experimental inflammatory condition has been produced in the gall-bladder, but this is very different from the conditions under which 1 Quincke, Hoppe Seyler: Die Krankheit. d. Leber, p. 122. 2 Osier: Modern Medicine, 1st ed., vol. 3, p. 477. DISEASES OF LIVER AND GALL-BLADDER 435 the stones form in the human subject and when formed seldom, if ever disappear spontaneously. This does not mean that the gall-stones may not “go to sleep,” so to speak, and remain quiescent for years or permanently, as this often happens in the experience of every physician. While diet has little or nothing to do with the disappearance of stones when already formed, it has much to do with their formation in the first place, and still more to do with their recurrence after operation, for statistics show that a fair number of patients in whom the gall-bladder is not removed at time of operation suffer from recurrence of gall-stones. Naunyn, Kehr, Aschoff and others regard the formation of gall-stones as merely an incident in disease in which infection, bile stasis and inflammatory manifestations are the principal factors1 and it is against these factors of disease that dietetic treatment should be directed, rather than against their results. Dietetic indiscretions, long continued, that lead to catarrh of the stomach, duodenum and gall-bladder tend to produce gall-stones indirectly by affording means for the access of bacteria2 to the biliary tract, so that little need be said to press home the importance of diet as a preventive measure. While a large majority of gall-stones are formed of choles- terol, almost every one has at its center a bacterium of one sort or another, so that infection is perhaps the first and chief necessity in the production of stones. Lime salts are frequently superimposed on the cholesterol stones, as well, and bile pigments, particularly bilirubin, form part of many stones. Prophylactic or Postoperative Diet.—There are no new principles involved in choosing a diet to prevent re-formation of gall-stones, and with certain exceptions it is probably as much a matter of the quantity of food ingested as the qual- ity. These exceptions will, of course, include all foods or drinks that tend to produce gastro-intestinal catarrh or those which have a direct effect on the liver by virtue of their intrinsic irritating character and the fact of their being carried directly to the liver by the portal system. Such foods and drinks have already been spoken of in connection with portal cirrhosis and include condiments as peppers, mustard, curry, spices, salty foods, alcohol in all forms and very hot foods or drinks and ice-water in large amounts. Meats.— Only easily digestible meats should be taken and “high” meats, pork, fatty meat and fish, such as goose, duck, mackerel and blue fish, should be avoided. 1 Anderson: Canada Med. Assn. Jour., 19x4, vol. 4. 2 Osier: Modern Medicine, vol. 3, p. 444. 436 DISEASES OF ACCESSORY DIGESTIVE GLANDS Fats. — Some dietitians condemn the use of all fats, but there does not seem to be any reasonable basis for such com- plete prohibition. Fat is an essential food element and is a necessary part of any mixed diet. What should be avoided is fat that is particularly indigestible, such as all those that melt only at a higher temperature than the body, e. g., mutton fat, salt fat, as bacon or pork, or excess of even simple fat is to be avoided. There is no objection to sweet butter, cream in moderation and vegetable oils and meat fat in great moderation that has a low melting-point, as beef fat. Carbohydrates.— Sugar should be restricted as liable to ferment and cause indigestion; pies, preserves, candy, rich cakes, syrup, etc., are all to be avoided. Aside from these restrictions one may eat almost anything provided it is not in excessive amounts sufficient to cause overloading of the digestive tract. All means to stimulate the flow of bile are especially indi- cated and to this end it is often better to give five small meals a day than three larger ones, as each time food is taken, bile is expressed from the gall-bladder. Vegetables and Fruit.— All vegetables that do not ferment are allowable but the cabbage family, radishes, horseradish are barred, also according to Tibbies1 peas, beans, lentils and carrots as containing phytosterol, a vegetable form of choles- terol, the principal constituent of gall-stones. Fruits that are not too sour may be taken, but they are possibly better borne stewed with a little sugar. Exercises. —Exercises that tend to stir up the liver are all good, such as horseback riding and calisthenic exercises which include bending and compression of the liver area. Alcohol.— As already stated patients are better off without any alcohol whatever, but when it is insisted upon, they may take light Rhine wines, well diluted with an alkaline water, such as Vichy, and only with meals and in the greatest mod- eration. Not over 3 or 4 ounces of wine with one meal a day. Spirits, all forms, are particularly bad as tending to produce a catarrh of the stomach and intestines, besides irritating the liver cells. Acute Cholecystitis and Colic. —During the attack usually nothing can be taken by mouth, often not even water. Later when the stomach is not rebellious, one had best begin with milk diluted with an alkaline water, Vichy, soda or Apolli- naris. This should be kept up until all signs of inflammatory reaction have disappeared, although possibly thin cereals 1 Food in Health and Disease, p. 384. PANCREATIC DISEASE 437 may be begun a while before this, but milk should form the basis of the diet. Later solid food may be taken as outlined in other hepatic conditions. Here again a mild saline cath- artic should be given in the morning regularly for a time as recommended for catarrhal jaundice and to which a small amount of sodium salicylate may be added to promote the flow of bile; possibly the sulphates are best for this laxative purpose. In all forms of gall-bladder disease from cholecystitis to stone there is great necessity for drinking water very liber- ally, and patients should be given a definite amount of water to take in the twenty-four hours. PANCREATIC DISEASE. The point at which disease of the pancreas touches die- tetics is when the function of the gland is interfered with, so that we find an insufficient, deficient or excessive secretion. Heretofore it has been possible only to arrive at abnormal conditions of the secretion by watching the effects on food digestion, and numerous tests sprang up for determining which element of the secretion was deficient, so we had tests for tryptic digestion, that for pancreatic amylase and pan- creatic lipase. Since the introduction by Einhorn of the duodenal tube it is possible in many cases to obtain samples of pancreatic juice, sufficiently large for chemical analysis and to make satisfactory biological tests of its digestive capability. Einhorn and Rosenbloom1 have done this very satisfactorily from a clinical standpoint and have deter- mined the composition of the normal pancreatic juice. Ihere are variations in the secretion of a purely functional nature, as well as variations due to pathological changes. Defi- ciency of trypsinogen produces azotorrhea or meat indiges- tion, lessened lipase a steatorrhea or fat indigestion, and diminished amylopsin results in carbohydrate fermentation. When we have a new growth or interference with the pan- creatic internal secretion, pancreatic diabetes may be the result with an alimentary glycosuria and hyperglycemia. Still another result of pancreatic and intestinal disturb- ance is the production of that curious condition of arrested development known as infantilism, where the subjects develop mentally, but physically they do not increase much in size, although they may take on the adult characteristics. 1 Arch. Int. Med., December, 1910. 438 DISEASES OF ACCESSORY DIGESTIVE GLANDS Besides a disturbance in pancreatic secretion in infantilism the intestinal flora is an entirely abnormal one. Acute Pancreatitis.—In acute pancreatitis there is usually little time to resort to diet, for the patients are for the most part in shock. If they survive this initial period, then they may continue to improve, in which case diluted milk, gruels and other liquids (without meat stock) and farinaceous foods generally may be added to the diet, and later chicken and soft vegetables. Chronic Pancreatitis.—Here the pancreatic secretions may be disturbed in any one of the directions indicated, i. e., there may be a failure or diminution of the trypsinogen, steapsin or amylopsin with resulting characteristic evidences of this failure in the so-called pancreatic indigestion. It is here that we are apt to encounter the cases of marked steatorrhea characterized by stools with yellow masses of fat, fluid or semisolid, which if not accompanied by jaundice may amount to an average loss of 64 per cent of the ingested fat. If there is mild jaundice the loss will be greater (72 per cent) and if the jaundice is marked and bile is completely shut off the loss will amount to 87 per cent.1 Naturally when this con- dition obtains the diet must be made up almost exclusively of carbohydrate and easily digestible protein, although by giving artificially prepared pancreatic extract it is usually possible to give a minimum amount of simple fat. In this form of pancreatic deficiency sweetbreads, lean meats, cheese, fowl, breads, macaroni, baked potato, rice and other cereals, sugars, soft vegetables and fruits only if there is no accompany- ing diarrhea, which is regularly present in the cases of extreme deficiency of steapsin. When there is a diminution or absence of trypsinogen we find azotorrhea present, in which condition striated muscle fibers can be found in the stools, a condition often associated with marked intestinal putrefaction of protein and with an accompanying indicanuria. Under these circumstances the diet should be largely carbohydrate with some fat in the form of butter, eggs and thin cream. Milk will be fairly well digested if the gastric secretions are approximately normal, or failing this the deficiency in trypsinogen may be supplied again by the pancreatic extract. Cream cheese may also be used to supply protein, besides the vegetable protein. All forms of farinaceous foods may be used in large amounts together with soft green vegetables and stewed fruits. In fact almost any food low in protein will be well digested. 1 Brugsch, T.: Lehrb. klin. Untersuch. Method, p. 371. PANCREATIC DISEASE 439 When the amylase is deficient in the pancreatic secretion, marked fermentation of the stool will take place in the fer- mentation tube, so that here it is necessary to reduce the starches to the minimum and give them preferably malted or with a diastatic ferment to compensate for the loss of the natural ferment. In the condition of achylia of the stomach the starch in moderate amount will be digested by the ptyalin of the saliva, but with normal or increased gastric acidity, this is soon stopped and the starches pass into the intestine imperfectly dextrinized. In selecting a diet for these cases any of the simple fats and protein foods may be given, but the carbohydrates best tolerated are those partly malted, as malted breakfast food, toast dried to a brown crisp, dry and partially malted cereals in flakes. Next best are fine cereals well-cooked, such as farina, wheatena, cream of wheat and well-boiled rice. Potato and breads are best let alone unless each meal is followed by some artificially prepared diastase, and this may be necessary even with the carbohydrates already partially prepared by previous malting. Where the internal secretion of the pancreas is disturbed and we have a glycosuria the diet must be in accordance with the dietary principles recommended for diabetes mellitus, although here, too, artificial diastase helps in the starch digestion. But these cases are practically diabetics and should be so treated. In carcinoma, cyst or other pancreatic disease the diet should be chosen with reference to the functional integrity of the gland or the lack of certain of the digestive elements, as we have just seen in chronic pancreatitis. CHAPTER XXIV. DIET IN DISEASES OF THE SKIN. In order to prescribe a rational diet for any disease it is necessary to understand its etiological factors, at least to some extent. It is therefore unfortunate that thus far there are very few skin diseases in which any definite general meta- bolic changes are known. With the skin lesions caused by parasites, irritants, etc., we have as dietetians no concern, as food plays no part either in their production, course or cure. It has long been the custom to place the blame for many skin lesions at the door of the digestive canal, and in some instances rightly, though often without adequate scientific basis of fact, to be sure, and only on the strength of clinical evidence. There is therefore a vast field as yet inadequately explored, and until painstaking nutritional studies are made on more diseases, we can for the most part only prescribe diets on the basis of bedside experience. The dermatoses due to disturbed metabolism may be divided as Johnson1 says into: 1. Disorders due to derangement of digestion. 2. Disorders of intermediary nitrogen metabolism. 3. Disorders due to anaphylaxis. The alimentary eruptions von Noorden2 divides into: (a) Acute alimentary eruptions from dietetic causes, such as the urticarial erythemata of the vesicular and bullous types, which may be produced by strawberries or other fruits, asparagus, cabbage, fish, cheese, spices and in some even by fresh eggs. (b) The chronic alimentary eruptions, for example, pella- gra, ergotism and scurvy, although we know now that scurvy and possibly pellagra are dependent for their production in some way on lack of vitamins. Of the disorders of digestion which give rise to eruptions we have changes in gastric secretion, notably hyperacidity, which give rise to vasoconstriction of the skin vessels, as seen in loss of hair.3 In disorders of intermediary nitrogen metabolism Johnson 1 Jour. Cut. Dis., 1912, p. 136. 2 Path, of Metab., vol. 3, p. 759. 3 Quart. Jour. Med., 1915, 8, 156. 440 PSORIASIS 441 found that the N partition gave evidence of disturbance shown by a “decrease of urea and a corresponding increase of rest nitrogen, and when this was marked, symptoms could be looked for.” A change in the nitrogen partition occurs in eczema, prurigo and dermatitis herpetiformis, particularly in the beginning of the attack. It is not at all sure, how- ever, that the lack of nitrogen balance is merely a symptom. In the class of dermatoses due to anaphylaxis we have a definite protein hypersensibility in certain individuals which results in such conditions as urticaria and angioneurotic edema. These diseases are of course of alimentary origin, as already explained, but they may occasionally occur from parenteral protein intoxication. Tidy, on the other hand, concludes from a study of nitro- gen metabolism in dermatoses, that: 1. Changes in the nitrogen excretion in various derma- toses are the result of the condition of the skin and are not connected with the cause of the disease. 2. Retention of nitrogen is apparent, not real, and is accounted for by the abnormal excretion of nitrogen by the skin. 3. Changes in the nitrogen excretion may precede the eruption and it is possible that these may survive it. In spite of these findings Tidy suggests that a low protein diet is worth a trial in dermatoses which are associated with disturbances of nitrogen excretion. Although authorities differ in their findings, enough has been said to show that the storm center is about the metab- olism of the protein molecule and that carbohydrate and fat enter very little into the discussion of etiology, except in so far as they may give rise to some form of gastro-intestinal disturbance more from quantity than quality. One notable exception to this is, that according to some authorities, fat stands in the first place in the etiology of eczema, particularly in infants. The relation of diet, therefore, to diseases of the skin is undoubtedly, in many instances, a most intimate one, but too little has yet been done, with one or two possible exceptions, to place the question on a basis of established fact. PSORIASIS. This is one disease of which considerable study has been made by Schamberg1 and his collaborators, to determine the metabolic changes. In their investigations the complement- 1 Jour. Cut. Dis., October, 1913, p. 698; November, 19x3, p. 802. 442 DIET IN DISEASES OF THE SKIN fixation test was not found to be positive, nor was any organ- ism to blame, but a marked nitrogen retention was found throughout the period of the experiment and it was felt that a definite relationship between the amount of nitrogen in the food and the cause of the disease' was established. The corresponding clinical evidence corroborated this, as the patients improved on a low protein diet and became worse on a high protein allowance; this finding was verified in a number of patients. The retention of nitrogen in these cases resembled that seen in convalescence and in one instance amounted to 4.89 grams nitrogen per day. Curiously enough, however, these patients suffer from what Schamberg calls “nitrogen hunger” and patients with “severe psoriasis present a state of remarkable protein undernutrition.” This is because the retained protein goes into making the psoriatic scales which are almost pure protein. The success of the low protein diet in these cases is due to the fact that we can reach the point in diet at which the protein goes only to the vital organs at the expense of the scales, so that the latter do not grow. The amount of protein is therefore only sufficient to cover the wear and tear of the body and leaves nothing to supply the rapidly growing scales. Scham- berg ends his conclusions by saying that “the low nitrogen diet has a most favorable influence on the eruption of psori- asis, particularly when it is extensive, almost to the point of the disappearance of the eruption.” A high protein diet, on the other hand, has an unfavorable influence on the disease and commonly causes its extension. The practical application of these findings in choosing a diet is therefore plain; one should keep the protein down to the low level determined by Chittenden; 45 to 60 grams to 2 ounces) of protein per day or for a short time on even less, of which the following menus are examples. Low Protein Diets in Psoriasis. Grams. Ounces. Bread • 245.5 8 Sugar 63.0 2 Coffee (breakfast) 2X0.0 7 Custard 76.O 2§ Milk . 25O.O 8| Coffee (lunch) . . 125.0 4 Potato . 150.0 5 Lima beans 80.0 0 2. Coffee (dinner) . 210.0 7 Applejdumpling Candy Total nitrogen in food, 8.83 grams = Fuel value of the food, 1929 calories. . . 131.0 27.O 55 grams protein. 4§ ECZEMA 443 Grams. Ounces. Bread' 52 Sugar 89.0 2§ Coffee (breakfast) . 210.0 7 Sweet potato • 135-0 42 Quince preserve 73-0 2i Apple turnovers I18.O 4 Coffee (lunch) . 310.0 io| Potato • 175-0 6 Peas 2§ Apple pie • HI-5 4§ Coffee (dinner) . 210.0 7 Total nitrogen in food, 7.31 grams = 45 grams protein. Fuel value of the food, 2057 calories. Grams. Ounces. Bread . 221.5 72 Sugar 77.0 O I Banana 92-5 3 Coffee (breakfast) . 210.0 7 Baked potato I65.O 52 Apple sauce 4 Coffee (lunch) 210.0 7 Succotash 75-o 2| Mashed potato 200.0 61 Chocolate cake 80.0 2§ Ice-cream 73° 22 Coffee (dinner) . 210.0 7 Total nitrogen in food, 7.63 ounces = 47 grams protein. Fuel value of the food, 2065 calories.1 Foster’s experience, that he could get much more rapid results in psoriasis by making the patients vegetarians, is easily explained on the basis of facts already submitted. ECZEMA. This skin disease is of great importance, as it constitutes, according to Bulkley, one-third of the entire number of skin diseases and its dietetic management is at times exceedingly satisfactory. In discussing the etiological factors of eczema one must take into consideration the following points. 1. Eczema occurring in people with nitrogen retention, particularly urea and uric acid, as in chronic nephritis and gout. 2. In individuals who eat too much or too little (malnu- trition). 3. In individuals who have a diminished tolerance for fats or certain sugars, especially maltose2 and some starches, associated with either fat or carbohydrate intestinal indigestion. 1 Chittenden: Physiological Economy in Nutrition, p. 62. 2 Griffith: New York Med. Jour., 1921, 114, 153. 444 DIET IN DISEASES OF THE SKIN 4* When protein sensitization is present, eczema being the skin equivalent of anaphylaxis, more often expressed as asthma or urticaria. So in constructing a diet for these cases one must take into consideration the probable cause of the trouble, e. g., in nitrogen retention, a purin or purin-free diet may be useful and one with a low total protein content as recommended in chronic nephritis with nitrogen retention. One may also use a diet of buttermilk with soda biscuits or milk and crackers or toast, orange or lemon juice from ripe fruits for three or more days exclusively. Buttermilk, 2 liters (2 quarts), 8 milk crackers, 4 slices of toast, 3 or 4 oranges or lemons equaling 1200 to 1400 calories, giving also soda bicarbonate 1 to 2 teaspoonfuls. Later adding cooked cereals, 2 or 3 slices of bacon, soft boiled eggs, stewed fruit and vegetables, as spinach and celery and later potatoes, butter and meats, the latter only on certain days in the week.1 In those who eat too much or too little, proper regulation often results in a relief of the skin manifestations. Those who show diminished tolerance for fats and car- bohydrates of various kinds show pathological changes in the stools which should be the key to the diet regulation. In those in whom eczema is a manifestation of protein sensitization, skin tests should be made to discover the partic- ular protein or proteins at fault, as is done in asthma, hay fever and urticaria. The proteins most commonly at fault in anaphylactic eczema are those of milk, egg albumen, wheat, buckwheat, shell fish. Less common are pork, veal, mutton and tomatoes. Acute Eczema.—The consensus of opinion is that a limited and simple diet is indicated in acute eczema and in fact this rule is applicable to all acute inflammatory skin lesions. Such a restriction is best accomplished by placing the patients either on an exclusive milk diet or with cereals, bread, butter, and fresh green vegetables or on the so-called rice diet which Bulkley2 recommends from large experience. Bulkley’s diet consists exclusively of rice, bread and butter and water for at least five days, after which other foods are gradually added. The rice should be thoroughly cooked for from thirty to sixty minutes in water, not with milk. It can be dried out a little after cooking if it is more palatable in this form. Butter and salt are to be eaten on the rice, which should be taken very slowly, accompanied by thorough mastication. The bread should be stale. According to 1 Nelson: Med. Clin. North Am., 1920, 4, 301. 2 Diet and Hygiene in Diseases of the Skin, p. 70. ECZEMA 445 Bulkley the rationale of this diet lies in the fact that acute eczematous manifestations are due to retained nitrogen waste products, and giving a diet that is of low nitrogen con- tent, allows the kidneys to excrete the retained matter, and when this is accomplished the acute stage of the eruption comes to an end. At the end of five days it is advised to return gradually to a mixed diet, taking first one regular mixed meal at midday and the rice diet morning and night. If this is successful a light breakfast is given, such as cereal with butter, eggs and bacon and possibly a little weak tea or coffee, soft green vegetables, farinaceous puddings, whole meal bread, eggs, milk, chicken, fresh fish are then added. Many authorities forbid fruit in any form while others allow it stewed without sugar and still others fresh, if ripened nearby and not picked green. Chronic Eczema.—In chronic eczema the question as to “too much,” “too little” or “improper food” comes up, in a way, for consideration much more than in the acute form. Here much can be done to bring about a favorable progress of the disease by cutting down the food of the glutton, feed- ing up the poorly nourished and regulating the diet of those who habitually eat indigestible or improper foods. Among articles of food that should not be touched by these patients are spices, condiments, alcohol, fried foods, rich gravies, pastry, sweets, cake, cheese, salt food, ham, nuts, corned beef, salt pork, much meat and meat soups, salads and twice-cooked meats and curries. The low (Chittenden) level of protein is advisable for those who habitually overeat. These prohibitions also hold for the “after-diet” in acute cases. Eczema in Nurslings.—Here the dietetic and hygienic faults are the mother’s, and attention to her intake, exer- cise and bathing will often result in the relief of the infant’s eczema. There are commonly two varieties seen: 1. In overnourished, fat babies who have shown evidence of eczema since birth. 2. In those babies who have previously thriven, but who develop gastro-’ntestinal trouble and eczema, seen espe- cially when they are weaned and put on an improper milk mixture. In the first group the mothers are usually found to overeat or take too much alcohol and too little exercise. In the second group the babies’ stools indicate indigestion, which if rectified results in a cure of the eczema. Finckelstein has obtained good results by feeding nutrose (casein prepara- 446 DIET IN DISEASES OF THE SKIN tion) before each feeding or by giving buttermilk twice a day with some additional carbohydrate.1 In artificially fed chil- dren with eczema Holt advises giving food moderately high in fat and low in protein, and if not successful he reduces both fat and protein. In some instances, according to C. M. Williams, it is advisable to withdraw milk entirely from the diet and substitute wheat jelly, thin gruels, beef juice and eggs. Also careful attention must be given to the regulation of the times of feeding. Still other children are benefited as soon as they can be placed on mixed feedings; this is particularly true in the chronic form. It is also true here, as in adults, that those children who are overfed will do better if the food is reduced both in quantity and quality and, vice versa, the undernourished fed more liberally. Meyer found that children with chronic eczema showed salt retention, which in turn leads to water retention, predis- posing to eczema. On this basis Finckelstein fed a salt- free milk diet with high protein and carbohydrate with good results. This salt-free milk is prepared by removing the salts by washing the casein in water, then mixing the curd with f water and \ whey, with the addition of 40 to 50 grams of salt- free carbohydrate. This is known as “eczema soup.” This is not applicable to all cases, but does best in fat babies with a moist, “weeping,” impetiginous eczema, when protein digestion is poor, as shown by curds and undigested stools. Reducing the percentage of the protein in the food will often result in clearing up the eczema.2 In certain cases cutting out all sugars and carbohydrates and putting the children on a skimmed milk diet does much to clear up the disease—this of course is almost another way of saying to starve the children moderately. Of course if the eczema is due to protein susceptibility no measure will be definitely efficient until the offending protein is discovered and eliminated from the diet. This diagnosis is made by testing the skin reactions as is done in asthma and urticaria. O’Keefe,3 on the basis of an investigation of eczema in younger children, found that on examination of the stool, 20 per cent showed lowered fat digestion shown as free fat or as a definite excess of soap in the stools. In half of these, i. e.y 10 per cent, there was also evidence of carbohydrate indigestion. In 131 cases of bottle-fed children he found 1 Lyman: Arch. Ped., 1915, 32, 175. 2 Lyman: loc. cit. 3 Jour. Am. Med. Assn., 1921, 78, 483. ACNE ROSACEA 447 35 per cent showing sensitization to one or more of the com- mon proteins, principally egg, milk, potato, wheat and oat. 1'his was a marked contrast to findings in normal children as shown by Barker1 where sensitization was an almost negli- gible factor. In 41 cases of eczema in breast-fed children, where no outside protein was taken, O’Keefe found 60 per cent of these children showed protein sensitization, 40 per cent were positive to egg protein, 39 per cent to cow’s milk, 5 per cent to oat, 2 per cent to wheat, 14 per cent to both egg and milk protein. No patient was found sensitive to human milk protein. O’Keefe draws the only obvious conclusion that foreign protein is ingested in the mother’s milk, so causing sensitization. Dietary Treatment: Breast feeding should be continued and the offending protein removed from the mother’s diet. Whenever it is necessary to remove eggs or milk from the diet, cod-liver oil and green vegetables should be given to maintain the vitamin content. Meat proteins are given to supplement the protein element in the diet. Since there is apt to be a very high urinary acidity in all chronic cases of eczema this should be rectified by giving large amounts of water, plain or alkaline. The dietary regulations given are good so far as they go and in some instances are sufficient for a cure, but almost all cases require local treatment as well. The underlying condition in acne rosacea is a vasomotor instability affecting particularly the blood supply of the skin of the nose and cheeks, resulting in abnormal flushing of these parts of the face.2 Such a condition can be brought about temporarily, even in normal persons, by hot drinks as soups, tea, etc., particularly in an overheated room. Alcohol is of course the greatest etiological factor in the production of chronic rosacea, although it by no means follows that all chronic cases can be traced to this as a cause. The alco- hol acts largely through the gastritis which it causes and vasodilatation of the facial capillaries; gastric hyperacidity from other causes being also frequently responsible for the production of acne rosacea. Chronic indigestion, gastric or intestinal, associated with the putrefaction of animal protein and often accompanied by high percentage of indican ACNE ROSACEA. 1 Am. Jour. Dis. Child., 1920, 19, 114. 2 Jackson, G. T.: Diseases of the Skin. 448 DIET IN DISEASES OF THE SKIN in the urine, acts much in the same way and must be kept in mind when prescribing a diet. The proper diet in rosacea is one from which are excluded all the known etiological factors, e. g., alcohol, hot tea, coffee, soup, spices, condiments, fried food, rich sauces, gravies, made-over dishes, pastry, heavy sweets, rich cake, and every- thing known by the individual to be a possible cause of gastro-intestinal indigestion. Patients should themselves notice the effects on the skin of any particular kind of food and learn to avoid those things which cause flushing. Of the greatest importance is the patient’s general hygiene—baths, exercise, fresh air and water drinking—all of which is equally true in both acne rosacea and acne vulgaris. ACNE VULGARIS. In acne vulgaris the ducts of the sebaceous glands become closed, the plugs consisting almost entirely of epithelial cells with practically no foreign substances in them. A secondary staphylococcus infection is then engrafted on this, as the opsonic index is low to the staphylococcus, and results in pustulation or at least deep skin infection which may be only inflammatory, short of the production of pus. One factor which probably favors the infectious element, is the fact that in acne vulgaris the percentage of blood sugar is higher than normal. This form of acne is most frequently seen in young people at puberty and often disappears after a few years, although in some cases it is of exceedingly prolonged duration and taxes the ingenuity of the dermatologist. Where the patients are found to be excessive eaters, the quantity of food should be cut down and will often give relief. In some cases Jackson obtained the best results on an exclusive milk diet. On the other hand, when the acne is an accom- paniment of malnutrition the patients should be liberally fed and everything done to improve their general health with consequent raising of their opsonic index. Tea, coffee and alcohol and all indigestible foods are forbidden. The amount of fat food should be limited and much the same restrictions insisted upon as indicated for acne rosacea. Williams1 bars cheese, pickled food, sausage, cabbage, cauliflower, griddle cakes, oatmeal and pastries, fresh bread and salads. Sweets are especially to be forbidden as favoring a still further increase in the percentage of blood sugar, as well a large use of car- bohydrates in general. 1 Food and Diet, p. 337. ERYTHEMA 449 ERYTHEMA. Erythema occurs in so many forms—simple erythema, erythema nodosum, multiforme, urticarial and hemorrhagic erythema—all of which are undoubtedly varying skin reactions to a variety of toxic ingesta, and it is difficult to know just where to begin a discussion of the subject from a dietetic point of view. Many persons learn early in life what foods will produce these effects and avoid them; again per- sons seem susceptible at one time to a certain food and not at another, so that to know just which form of food is respon- sible for a particular attack, often presents a problem of some difficulty. Where erythema multiforme is seen with urticaria it is probably of gastro-intestinal origin; if with purpura it is more apt to be due to some focus of infection or from a ptomaine toxemia.1 Of course, it goes without say- ing that where a certain form of food is at fault that food should be avoided in future and the best method of treat- ment in addition to this advice is an initial thorough empty- ing of the digestive canal combined with the simplest sort of diet possible, in order to keep down intestinal putrefaction with its accompanying by-products, which are most often at fault. To this end a lactovegetarian and farinaceous diet is best and is usually promptly efficient in the transient forms, such as in acute urticaria, so often caused by fish or shell fish. In the more prolonged types, such as erythema multiforme, it is often necessary to continue such a diet or at least a very bland and unirritating diet for a considerable length of time or until the eruption is entirely cleared up. In chronic urticaria we have a difficult problem and from a dietetic point of view an almost hopeless one unless we are fortunate enough by a process of exclusion to find some par- ticular food which is at fault. Testing the skin reactions with the different proteins sometimes shows which protein is at fault. Often, however, this is impossible and the most one can do in diet is to give simple and easily digested foods which, at least, will not increase the trouble by adding intestinal indigestion. Since urticaria is thought by some to be always an anaphylactic phenomenon, the dietetic sug- gestions detailed under Asthma may prove most helpful in arriving at a proper dietary regimen. (See page 335.) Erythema accompanying infection cannot, except second- arily, be influenced by diet, but at least nothing should be 1 Anthony: Jour. Cut. Diseases, 1912, p. 112. 450 DIET IN DISEASES OF THE SKIN given to increase the skin irritation and avoidance of the class of so-called food irritants, such as condiments, spices, garlic, and alcohol, should be insisted upon. PRURITUS. Pruritus in any of its forms is an itching condition and may be due to many causes, ranging from an inherited irritable skin to that due to hemorrhoids or fissure, tobacco in excess, renal poisoning, diabetes, cold, ascarides, etc.1 Most of these conditions, it will be readily seen, are not amenable to dietetic relief and yet we can do much to add to the discom- fort of an already irritable skin by an improper diet. When the itching is intense and the skin at all generally hot and inflamed it is a good plan to put the patients on a very bland lactovegetarian diet for a few days, as is true of all acute inflammatory skin lesions. Later avoidance of the stimulating class of foods such as condiments, is indi- cated. Jackson especially interdicts the use of alcohol, tea, coffee and tobacco; some of the worst cases are seen in heavy smokers, and the condition is distinctly aggravated by even moderate smoking. “Prurigo and lichen urticatus are closely related to urti- caria and are accompanied by a highly susceptible vasomo- tor or sensory nerve system set in action by a variety of excitants which often elude one’s investigation.”2 In these conditions the diets suggested for rosacea and urticaria are useful. DERMATITIS. Dermatitis Herpetiformis.—Hardouin found retention of urea in the system just before the eruption in 8 cases, so that this is undoubtedly the local manifestation of a general metabolic disturbance and as retention of purin bodies probably lies in a causal relation to the disease it would be appropriate to prescribe a diet similar to that advised in gout or at least a very low purin diet, accompanied by effec- tual elimination through all the exits. Other investigators found normal urinary excretion, and cultures and experi- mental inoculations of the liquid from the bullae negative, and think much points to a deranged nervous system as the cause of dermatitis herpetiformis. During the acute stage the diet should be simply milk; tea, coffee and alcohol are forbidden—when the inflammatory condition has subsided 1 Jackson: Disease of the Skin, p. 450. 2 Sutherland’s Dietetics. DERMATITIS 451 vegetables, farinaceous foods and eggs may be added to the diet, returning gradually to a normal diet, excluding indi- gestible and purin-rich foods. (See Diet in Gout.) Exfoliative Dermatitis. —Probably the best results are obtained with a milk diet and in addition the use of colonic irrigations. Jackson (G. T.) advises flaxseed tea several times a day. After the acute stage is over a diet as in eczema is valuable.1 Furunculosis. —Furunculosis should be treated dietetically like acne vulgaris and the same rules hold good. As it is especially prone to develop following severe illness during the period of convalescence, the indications are usually for a full nourishing diet, but simple withal. The feeding of one or two yeast cakes daily is often of great service. Comedones.—Comedones are due to the blocking of the sebaceous gland ducts by a disordered secretion and are often accompanied by gastro-intestinal disturbances. The diet should conform to the actual digestive disorders present in an individual case and besides careful hygiene of the skin, elimination should be increased by copious water drinking. Hyperidrosis. — Since the sweating which accompanies hyperidrosis is caused by a vasomotor disturbance, general hygiene plays a part in the cure, which must be included of course, and although there is no specific diet that is indicated, patients with hyperidrosis should avoid digestive risks and generally keep to a very simple diet. When the hyperidrosis is accompanied by obesity, uricacidemia or some nervous condition, these should receive their appro- priate hygienic and dietetic treatment. 1 Thompson: Practical Dietetics, p. 685. CHAPTER XXV. DISEASES OF THE GENITO-URINARY SYSTEM. In attempting to discuss the food factor in nephritis, it must be kept in mind that the relation of diet to nephritis is two-fold: (i) In its causation role, about which we know little, and (2) in its relation to rational treatment and dietetics of the disease, about which we know more but still too little. That food does often stand in an important role as the causation of nephritis must be admitted, although as yet we have but a glimmering of its true significance—but when we stop to think of the known drugs and foods which directly irritate the epithelium in greater or less degree, such as cantharides, turpentine, lead, arsenic, salicylic acid, mustard, peppers, the oil from garlic, onion and celery and numerous other substances—it is but a short cry to the possibility of repeated minimal irritation by foods less well recognized as renal irritants. The analogy of liver cirrhosis is sufficient for purposes of comparison, and while the liver is damaged in the attempt it makes to detoxify the irritating alcohol, hot sauces, etc., the kidney must run an equal risk in its excretion of most of the products of protein metabolism. That this is so has been increasingly evident and we have come to recognize still another form of renal irritant in repeated anaphylactic shocks as demonstrated by Longcope by the injection into animals of protein after previous sensi- tization to these same proteins. After a large secondary dose of protein, acute degeneration of the renal epithelium is seen, or if less acute, one finds collections of round cells about the vessels and in the intermediate zone. If the pro- cess is long continued there is found a connective tissue increase and glomerular lesions. These changes are not confined to the kidney but are seen in the parenchyma of other organs. It can therefore be seen that a patient may unconsciously be constantly receiving mild, unfelt anaphyl- actic shocks from certain food proteins to which he is sensi- tive, with resulting renal changes. Again, any food that has a tendency to produce acid or to lower the alkaline reserve of the blood will result in damage to the kidney. Among such foods may be mentioned excessive protein or fats, also inorganic acids. 452 DISEASES OF THE GENITOURINARY SYSTEM 453 So presumably anything that reduces the alkaline reserve causes a damage to the cell protoplasm, which if constantly repeated may well result in nephritis. Besides the lessened alkalinity of the blood, Auld suggests demineralization (cal- cium loss) and impaired metabolism as results of an acid excess. The subject of acidosis in nephritis is one about which there has been much discussion and experimentation. There is no doubt but that in the later stages of chronic nephritis there is a definite lowering of the alkaline reserve due to the accumulation of retained phosphates and there is no doubt but that this condition further cripples the kidney. The index of the acidosis is the concentration of carbon dioxide in the alveolar air, as this corresponds with that in the blood. Dietetically, therefore, all foods that tend to reduce the urinary acidity are valuable in nephritis, provided there are no contraindications from other viewpoints. To this end, potatoes, apples, bananas, raisins, oranges, cantaloupe, sweet potatoes and carrots are especially good, for through them considerable amounts of the desired alkaline bases are gotten into the system. Blatherwick1 showed that vegetables, fruits (the foregoing particularly) as a class on burning leave base or alkaline elements Na, K, Mg., Cal., while meat, fish, cereals (especially oatmeal), peanuts, plums, prunes and cranberries are not good, as they cause acid production, the last four named, due to their benzoic acid content. When we are in the presence of complications, such as edema or marked nitrogen retention, it may be necessary to modify the use of the foods especially recommended above but at least these suggestions apply strongly to the period in chronic nephritis before complications supervene and will surely help to put off their evil day. Gross overeating is undoubtedly a cause of kidney change probably of a fibroid nature, as we know that the same cause acts in producing arteriosclerosis, in which process the kid- ney shares, as do other organs. Taken then all together, there are definite ways in which food may act in the produc- tion of renal changes, although it is often a matter of great difficulty to decide in a given case just which cause is pri- marily at work, after the exclusion of the more usual causes of renal irritation, such as the infectious diseases, intestinal toxemia, focal infection, etc. The newer studies in kidney functions have brought to light many facts which have helped us to understand find- ings which were for so long obscure. Unfortunately they 1 Arch. Int. Med., vol. 14, 409. 454 DISEASES OF THE GENITO-URINARY SYSTEM have not yet gone so far that we can classify all cases of nephritis, acute and chronic, to our entire satisfaction, but enough has been accomplished by experimentation to justify certain therapeutic conclusions that have proven of great value. The factors which must be taken into especial consider- ation in dealing with the dietetics of nephritis have to do with the excretion of various substances derived from the digestion of foods, and the different behavoir of the diseased kidney from the normal kidney with respect to their elimi- nation. One starts with the premise that the healthy kid- ney can perfectly eliminate water, nitrogenous products of protein combustion, certain inorganic salts, notably sodium chloride, and organic compounds, which result from bac- terial activity. When one then begins to classify the cases of nephritis with respect to the individual’s power to excrete these substances, one soon finds that they are almost never found to be of one simple type, since the structures of the kidney are all more or less involved, the excretion of one, two or all classes of constituents of normal urine may be interfered with, so that the kidney’s behavior to the excre- tion of these various substances is not absolutely fixed. In spite of this fact, most of the cases may be grouped separately according as the excretion of one or another urinary constit- uent is chiefly interfered with. With experimental nephri- tis it is somewhat different; we can by means of various kidney poisons, artificially introduced into the animal’s body, produce what is practically a pure type of tubular, glom- erular or interstitial nephritis. It has been by watching the elimination of the normal urinary constituents under one or another form of artificially produced nephritis that we know as much as we do in regard to the behavior of the kid- ney toward the normal urinary constituents with respect to their elimination. In this connection the effect of certain foods on the behavior of the kidneys in eliminating dyes is the subject of much experimentation by Salant1 and others with certain conclusions which are of great interest clinically. 1. Small doses of tartrate of soda injected subcutaneously produced an inhibition of elimination of phenolsulphonephtha- lein. When rabbits were fed on oats (acidophylic) it never went back to normal. 2. Evidence of disturbed renal function was seldom ob- tained with much larger doses if the rabbits were on a diet of young carrots. Large doses of the tartrate gave some de- crease in elimination but excretion went back to normal. 1 Proc. Soc. Exp. Biol. Med., 1917-1918, 15, 8. KIDNEY DIETARY TESTS 455 3. If the tartrate was injected gradually in increasing doses, no impairment of function was noted even with very large doses (4 to 6 grams per kilo) if carrots were used alone as diet. This was not so with a diet of oats. For a full discussion of the various diagnostic methods to determine the renal function founded upon the results of experimental nephritis, such as the sulphophenolpthalein test, salt test, potassium iodide test, lactose test, the determi- nation of the Ambard coefficient, water test and diet test days, the reader must be referred to any one of the newer editions of standard text-books on internal medicine. In order to know just which type of renal hypofunction a given case belongs to, some of these tests must be made and together with the history and clinical findings a fairly accurate idea can be obtained as to which function or functions of the kidney are disturbed and the diet arranged accordingly. Kidney Dietary Tests.—Water Excretion.—It is a simple matter to determine the water excretion by ordering a definite amount of water for the twenty-four hours and measuring the actual fluid intake and urinary output; thus if 1500 cc (50 ounces) are taken and 1200 cc (40 ounces) or thereabouts represents the output for twenty-four hours, the water excretion is considered normal under ordinary conditions of temperature and humidity, as the 300 cc (10 ounces) discrep- ancy between intake and output is lost by bowel, skin and lungs. This of course is rather a rough method of estimation, as it does not take into account the water content of solid foods fed—nor the water derived from the combustion of fat and carbohydrates. Salt Excretion.—This is determined by noting the daily salt output both as to concentration (percentage of NaCl in the urine) and the total twenty-four-hour output on a known salt intake. For this purpose one of the salt-poor diets is used with a known salt content, to which a definite amount of salt is added after weighing. This should be done for several days and accurate daily estimations made. Normally the kidney should be able to concentrate chlorides up to 0.6 to 0.9 per cent with a total daily excretion of practically the entire intake.1 Nitrogen.—The determination of nitrogen excretion is somewhat more difficult, but it can be done if the patient is 1 Test for the Amount of Salt in the Urine.—Dilute io cc of urine with 900 cc of water and add one or two drops of 25 per cent nitric acid. This mixture should be made alkaline with a 10 per cent solution of sodium carbonate adding a few drops of a 10 per cent potassium chromate for an indicator. Titrate with tenth- normal silver chloride solution. Every cc of silver solution used equals 0.00583 gm. of sodium chloride. 456 DISEASES OF THE GENITO-URINARY SYSTEM placed upon a fixed nitrogen diet and the daily nitrogen balance determined. For this a well-equipped laboratory is necessary, while for the determination of water and salt excretion very little is needed in the way of apparatus. Schlayer’s nephritic test day, as modified by Mosenthal, gives the information desired in the matter of water, sodium chloride and nitrogen excretion in the most convenient way as follows: Directions for Schlayer’s Nephritic Test Day (Mosenthal). Needed in the Ward. 7 wide-necked bottles, each labelled. I bottle to hold 1000 cc for night specimen. 6 bottles to hold 500 cc for two-hour specimens during day. Salt in capsules, each capsule to contain 2.3 grams sodium chloride. Preceding day’s diet should be “soft salt-free” with fluids limited to 1500 cc. Test Day.— All food is to be salt-free, from diet kitchen. Salt for each meal will be furnished in weighed amounts (one capsule containing 2.3 grams of sodium chloride with each meal). All food or fluid not taken must be weighed or measured after meals and charted. Allow no food or fluid of any kind except at meal times as directed. Note any mishap or irregularities that occur in giving the diet or in collection of specimens. Meals to be given at the following hours: Breakfast, 7.45 a.m. Dinner, 11.45 a.m. Supper, 4.45 p.m. No fluids between meals or during the night. Collections of urine during the day every two hours, and from 7.45 p.m. to 7.45 a.m. Empty bladder at the following times: No. of specimen: 7.45 a.m. discard. 1 9.45 a.m. save in separate bottle. 2 11.45 a.m. “ “ 3 1.45 P.M. 4 3.45 P.M. 5 5.45 p.m. “ “ 6 7.45 P.M. “ “ 7 7.45 P.M. to 7.45 A.M. “ “ KIDNEY DIETARY TESTS 457 Label each bottle with period of collection, number of specimen and name of patient and send to laboratory. Breakfast, 7.45 a.m. — Chart food or fluid not taken. Boiled oatmeal, 100 grams; sugar, \ teaspoonful; Milk, 30 cc; 2 slices of bread (30 grams each); butter, 20 grams; Coffee, 160 cc; milk, 40 cc; sugar, 1 teaspoonful; Milk, 200 cc; Water, 200 cc. Dinner, 11.45 a.m.— Meat soup, 180 cc; Beefsteak, 100 grams; Potatoes (baked, mashed or boiled), 130 grams; Green vegetables as desired; 2 slices bread (30 grams each); butter, 20 grams; Tea, 180 cc; milk, 20 cc; sugar, one teaspoonful; Water, 250 cc; Pudding (tapioca or rice), no grams. Supper, 4.45 p.m. — 2 eggs (cooked in any style); 2 slices of bread (30 grams each); butter, 20 grams; Tea, 180 cc; milk, 20 cc; sugar, 1 teaspoonful; Fruit, stewed or fresh, one portion. One capsule of salt with each meal = 3 X 2.3 grams. Time. Amount cc. Sp. gr. Sodium chloride. Nitrogen. Approximate intake. Per ct. Total. Per ct. Total. 7.45 to 9.45 9.45 to 11.45 11.45 to 1.45 1.45 to 3.45 3.45 to 5.45 5.45 to 7.45 155 97 98 255 43 325 1013 IOII 1014 1010 1015 1011 Fluids 1760 CC Salt 8.5 gms. Nitrogen 13.4 “ Total day Night 983 800 1014 . 16 •215 1-57 1.72 •37 .48 3-63 3-85 Total 24 hours Intake 1783 1760 329 8-5 7-49 13-4 Balance —23 +5-21 +5-91 Findings in a Case of Chronic Hypertensive Nephritis. The figures show a negative water balance, but retention of both chlorides and nitrogen. In discussing the various urinary elements and their excre- tion, from the clinical point of view, we have a number of questions to be kept in mind. 458 DISEASES OF THE GENITO-URINARY SYSTEM Water. — It was long thought that the giving of large amounts of water in any form of nephritis was the best thing one could do for the patient, with the idea of washing out the poisonous products of incomplete or even complete metab- olism. Von Noorden differed from this view and showed that in certain cases the kidney could not eliminate water as well as it could other substances and the only effect of giving it in large amounts was to increase the edema, or if there was no edema, to overfill the circulatory apparatus, putting an extra strain on the heart and bloodvessels. In the normal individual there is a loss of water through skin and pulmonary excretion of approximately one-fifth of the intake, so that if a patient is given 2000 cc (66 ounces) of fluid, i .e., 1500 cc (50 ounces) as fluid direct and about 500 to 750 cc (16 to 25 ounces) in the food taken (which Mohr cal- culates to be about the amount of fluid contained in the ordin- ary diet) only 1600 to 1700 cc or thereabouts will be excreted by the kidney (53 to 56 ounces) and the rest is lost in the ways already referred to. When in nephritis the amount excreted is still markedly less, one may be sure that one is dealing with a nephritis which finds difficulty in eliminating water, the unexcreted balance being held in the serous cavities, subcutaneous tissues or circulation. The question may well be asked, What then is the optimum amount of water to give in nephritis? To this no hard and fast rule can of course be given, but Mohr1 found by experimentation that “in any form of nephritis the maximum amount of solids were eliminated if the patient passed from 1250 to 1500 cc (42 to 50 ounces) of urine.” Miller2 further states that when the kidney is able to excrete the normal amount of fluid and there is no evidence of edema, 1500 to 2000 cc (50 to 66 ounces) of fluid is quite enough to give in twenty-four hours. When there is difficulty in water excretion then the total amount of water best to give must be determined in accordance with that particular patient’s capability as determined by daily measuring the intake and the urine, the doing of which is only a detail of general management Salt. — In the consideration of the salt excretion, two classes of salts are to be considered: the chlorides, of which sodium chloride is the most important example, and the sulphates and phosphates, both of which latter behave much as the nitrogenous products do and not as the chlorides. If the patients have no subcutaneous edema the chloride elimi- 1 Beitrage zur Diatetik der Nierenkrank., Ztschr. fur klin. Med., 1903, p. 1377. 2 Forchheimer’s Therapeutics, vol. 4, 34. KIDNEY DIETARY TESTS 459 nation is normal even if the nitrogen elimination is poor. In other words, nephritis with edema invariably shows salt retention.1 Strauss puts the principles involved thus: “The human organism holds fast with extreme tenacity to the percentage concentration of the fluids in sodium chloride.” This is done by a regulating mechanism of which the kidney stands in the first rank. When more than enough salt is taken by a healthy person it is promptly eliminated and when the organism is starved, as in extreme vomiting,- the output of salt in the urine is at once diminished in order to keep the blood concentration at about 0.6 to 0.9 per cent.2 Strauss also reached the conclusion that the chloride retention in nephritis with edema was of renal origin and that withdrawal of salt from the diet (all but the necessary 1.5 or 2 grams per day) was necessary for treatment. The three factors on which he based his views were: (1) That in unilateral ne- phritis lower chloride values are found in the urine from the diseased kidney; (2) in an exacerbation of the disease the value of sodium chloride excreted often falls off; (3) that only dropsies were helped by remedies which caused not only an increased water output but at the same time a polychlor- uria. Dechlorination according to the same authority con- sists of two elements: (1) A salt-poor diet and (2) salt elimination from medicaments. The minimum of salt which is necessary to maintain the normal molecular salt concentration, as already stated, is about 1.5 gram per day, but as it is almost impossible to con- struct a salt-poor diet with much less than this amount, there is no practical danger of actual salt starvation, provided there are enough calories in it to meet nutritional demands. Nitrogen. —When we turn to nitrogen elimination we find that in the mild types of nephritis the nitrogen elimination is delayed as compared with the normal person, this delay being caused (judging by experimental nephritis) by injury to the glomeruli.3 When one has to do with a more severe nephritis it is found that the nitrogen compounds are retained in the blood and tissues. These facts are of para- mount importance in prescribing definite amounts of pro- tein food, for with the more severe cases accompanied by nitrogen retention we must reduce the protein intake not only to the nutritional minimum but below this for a short time. 1 Forchheimer’s Therapeutics, vol. 4, 22. 2 Strauss: Post-Graduate, 1913, 28, 532. 3 Manakow: Deutsch. klin. Med., April, 1911. 460 DISEASES OF THE GENITO-URINARY SYSTEM Goodall1 discovered that by placing chronic nephritis on a low protein diet the blood-pressure fell and on examining the blood of these cases that had been so dieted he found the non-protein nitrogen lowest and he therefore concludes that the general condition and blood-pressure were improved when the end-products of protein metabolism in the blood were lowest. Frothingham and Smillie2 tried diets in chronic nephritis of low, medium and high protein content and concluded “that in certain types of chronic nephritis the nitrogenous content of the diet should be carefully watched in order to prevent an increase in non-protein nitrogen in the blood. The exact effect of an increase in blood nitrogen produced by a high nitrogenous diet is not known at present, but presumably it is unfavorable to the best interests of the patient, since in some it increases their discomfort. A diet low in nitrogen content will frequently keep down to normal the non-protein nitrogen of the blood in chronic nephritis. In uremia the non-protein nitrogen is always high.” To this last statement there are known exceptions. While the foregoing facts represent the general opinion in regard to kidney function and the influence of the various food-stuffs in the matter of excretion, another school of clinicians, of whom Martin Fischer is perhaps the best known, take exception to almost all of these ideas and contradict flatly many of the foregoing statements, in fact most of them; thus for example Fischer recommends in all cases of nephritis that large amounts of water should be given even if apparently the patient is not excreting the normal pro- portion of the fluid intake. This is done to dilute the body acids so that they can be excreted, for “a kidney that is killing itself clearly needs water to rid itself of the poisons that are killing it.”3 Too much water he admits sometimes increases the swelling of the kidney and washes out valuable salts, but these objections are overcome by giving certain salts with the water, notably sodium chloride and sodium carbonate.4 If ordinary dried sodium carbonate is obtainable only one- third as much as the crystallized should be used. In regard to the use of the salt-poor diets Fischer and his school, as championed by Lowenburg5 feel that the salt-poor 1 Boston Med. and Surg. Jour., 1913, 168, 761. 2 Arch. Int. Med., 1914, No. 2, 15, 225. 3 Martin Fischer; Nephritis, Cartwright Prize Essay, 1911. 4 The solution Fischer uses is: Sodium carbonate (crystallized) . 20 gm. f oz. Sodium chloride 14 gm. \ oz. given by rectum. Water q. s. ad 1000 cc quart 5 Jour. Am. Med. Assn., November 28, 1914, p. 1906. KIDNEY DIETARY TESTS 461 diet may lead to albuminuria and nephritis which Fischer explains as being “due to the low salt content of the body occurring as a result of food without salt,” which as already stated he believes washes out the salts naturally present. This salt starvation leads to renal acidosis and this to nephritis as represented by albuminuria, cloudy swelling, casts and edema.1 Lowenburg’s conclusions in regard to NaCl based on Fischer’s teachings are: 1. Sodium chloride neither produces nor increases water retention in nephritics and non-nephritics. 2. It is curative in cases of edema from any cause provided the kidneys are not too much damaged. 3. When combined with alkalis and plenty of water it exerts a beneficial effect on the symptoms of nephritis. 4. The best method of giving the salt is in an alkaline solution by rectum or intravenously (not hypodermically). The answer to Fischer’s objection, that a salt-poor diet causes sodium chloride starvation and low salt content in the body, is, that first, in severe nephritis the salt concentra- tion in the blood is above normal and second that it is practi- cally impossible as already explained, to give a salt-poor diet which contains less than 1 or 1.5 grams sodium chloride, sufficient for the body needs for a considerable time, and at best a salt-poor diet of the lowest salt content is only a temporary expedient and a matter usually of not over ten to fourteen days. In dealing with the actual diets recommended for the various types of nephritis and their complications, the classification of renal diseases must necessarily be a simple one and a division into acute and chronic nephritis with or without nitrogen, salt or water retention, one or more in combination, is about as far as we can go at present. The older method of ordering diet merely upon the basis of the supposed pathological changes in the kidney is no longer useful in the light of our present knowledge of renal function. Albuminuria.—Albuminuria, being a symptom of renal irrita- tion, may be produced in a great variety of ways. It may be toxic in origin from chemical irritants that may have been ingested, e. g., turpentine, cantharides, mercury, etc., or from the toxemia arising from bacterial infection in the course of any of the acute or chronic infections, or as an early mani- festation of primary renal disease or finally as a part of a general asthenia characterized by visceroptosis, small heart and ordinarily designated as an orthostatic albuminuria. 1 Loc. cit. 462 DISEASES OF THE GENITO-URINARY SYSTEM When the albumin in the urine is a symptom of actual renal irritation, chemical or bacterial, it is necessary to treat the causal conditions by removal of poisonous materials from the food and to furnish such a dietary that no unneces- sary strain shall be put upon the renal epithelium. For this purpose a milk or lactofarinaceous diet is best, milk alone being used for the more serious cases and farinaceous addi- tions being made in the milder grades. When the albumin- uria is a part of a general acute or chronic infection, the diet must conform largely to the requirements of the particular infection at fault, but in general the milk or lactofarinaceous diet fills the requirements perfectly and must be kept up as long as the signs of renal irritation persist. Where there are difficulties in the excretion of water, salts or nitrogen, as shown by edema or any evidences of acute uremia, it is often best to use either the Karell diet or one of the soft salt-poor diets, or with impending uremia a day or two of starvation, giving only water combined with hot packs, and colon irrigations, to relieve the internal congestion. In the ordinary milk diet, when that is applicable to these cases, we may order from 1500 to 2500 cc (3 to 5 pints) of milk per day given in 180 to 240 cc (6 to 8 ounces) dosage, every two hours. As the albuminuria and other evidences of any inflamma- tory reaction subside and remain in abeyance, other articles of diet may be added—all farinaceous foods, vegetables, except those which contain irritating oils such as onion, garlic and celery; and lastly when things have settled back to what is practically a normal condition, a small amount of meat may be allowed. In the case of orthostatic albuminuria it is not necessary to diet strictly, for it has practically no effect on the quantity of albumin in the urine, all that can be done is to avoid an excess of any food or drink, particularly meat products and alcoholic beverages. Acute Nephritis.—In cases of acute nephritis from what- ever cause (except mercury poisoning, q. v.) the diet must be exceedingly sparing, and it is often best in acute uremia, pro- vided there is no water retention, to give nothing but water for twenty-four hours in rather considerable amounts, reliev- ing the kidney from the necessity of excreting nitrogen except that of endogenous origin. In these cases water excretion is often low, not so much as a result of any imper- meability of the kidney to water as from conditions arising in any disease accompanied by fever, which is usually pres- ent in acute cases. The various methods to get water into ACUTE NEPHRITIS 463 and out of the system are advisable in certain cases, such as water by mouth, hot colon irrigations, hypodermoclysis, saline infusion (in very severe cases), hot packs and catharsis. All these methods both spare the kidney and at the same time act favorably by flushing them out; just which methods shall be used must depend on the severity of the case. In the less serious cases, and on the second day in serious cases, feedings may be begun. Tyson1 recommends 2 ounces of milk every two hours for a few days. This is of course a modified form of the Karell diet which will be described under chronic nephritis. The quantity of milk can be increased as the urine secretion rises and to it may be added within several days farinaceous articles of diet, especially bread, cereals and barley gruel, all served with a moderate amount of sugar. Nothnagel recommends adding fats, as butter and cream, then light, green, vegetables; these latter according to most American usage are chosen chiefly from those varieties which grow above ground. Practically all authorities agree that a prolonged and exclu- sive milk diet is distinctly a bad thing, as it results in ano- rexia, coated tongue and often in intestinal indigestion with diarrhea. There is no doubt, however, that milk should form the bulk of the diet in the acute cases, although it is well not to give a daily total of protein over 30 to 40 grams at first, gradually increasing this perhaps to 70 to 80 grams, depending on excretion and the size of the patient. This lactofarinaceous vegetarian diet fills the requirements of food value, variety and bulk, with the minimum of renal irrita- tion. The appetite can usually be trusted to take approxi- mately sufficient food with the restrictions exercised par- ticularly in the protein foods as indicated, and although the total caloric value of the food will necessarily be low at first, it is better so, and as the appetite returns the quantity may be increased at will. Fischer’s explanation of the benefit from a lactovegetarian diet is, that it contains much fluid and that the salts in the vegetable fruits produce carbonates in the blood which in turn counteract renal acidosis. He also explains in the same manner the usefulness of the old empirical alkaline mixtures given for nephritis, such as the potash salts. If these cases are prolonged and become subacute, develop- ing edema and difficulty with salt and water excretion, they had best be put on one of the salt-poor diets, although accord- ing to Fischer even these cases need to have water in large New York Med. Jour., January 31, 1914, p. 223. 464 DISEASES OF THE GENITO-URINARY SYSTEM amounts, which, if given by rectum and combined with sodium chloride and sodium carbonate, as already stated, reduces the general body acidity and results in the disappearance of the edema. As yet this plan has not met with general accept- ance, although there are some favorable reports. Most of the acute cases complicating or following infectious diseases fortunately clear up with care and gradually they may be returned to a normal diet, taking care for months that all irritants are excluded from the diet, such as much meat or meat soup, celery, garlic and onion, which on account of irritating oils are injurious. Alcohol is best left absolutely alone and is not to be recommended for any pur- pose. If patients refuse to do entirely without alcohol, some of the light white or red wines when diluted with carbonated waters are preferable, but strong liquors, beers and ales should not be taken under any circumstances. Certain cases of acute nephritis, particularly those of idio- pathic or unknown origin, tend to continue indefinitely and trail off into a subacute condition or one that becomes chronic. These, in their early stages are treated as are the other acute cases and when they may be said to have become chronic they follow the dietary rules of that class. Diet and Treatment for Acute Toxic Nephritis from Mercury Poisoning.—Mercury is not infrequently taken with suicidal intent or by mistake for headache tablets; unless the poison is at once removed a severe form of toxic nephritis is set up if the dose is large, resulting eventually in complete anuria, coma and death unless relieved. The following treatment for these cases has been devised by Lambert and Patterson1 on the basis of laboratory experimentation by K. C. Vogel. The first indication is to give the patient the whites of several eggs as soon as it is known that mercury has been taken unless it is possible to perform lavage at once, which should of course be done, leaving in a pint of milk after the lavage. Lavage should usually be performed as soon as the patient is seen. The following routine is instituted as soon as the patient ceases to vomit, the termination of which may be hastened by regular lavage. i. “Every other hour the patient is given 250 cc (8 ounces of this mixture: Potassium bitartrate, 4 grams (1 dram); sugar, 4 grams (1 dram); lactose, 15 grams (f ounce); lemon juice, 30 cc (1 ounce); boiled water, 500 cc (16 ounces). Eight ounces of milk are given every alternate hour.’’ 1 Arch. Int. Med., November, 1915, p. 870. CHRONIC NEPHRITIS 465 2. The drop method of rectal irrigation with a solution of potassium acetate, 4 grams (1 dram) to the pint (500 cc) is given continuously. The amounts of urine secreted under this treatment are often very large. 3. The stomach is washed out twice daily. 4. The colon is irrigated twice daily in order to wash out whatever poison has been eliminated that way. 5. The patient is given a daily sweat in a hot pack. The colonic drip enteroclysis is kept up day and night with- out interruption. When one dose of mercury has been taken, the treatment may be stopped after two negative examinations of the urine for mercury. For the less severe cases treatment had best be kept up for one week. When large or repeated doses have been taken or where an old kidney disease is present the treatment should be kept up for three weeks, as the mercury is very slowly eliminated by the kidneys, stomach and bowel. Chronic Nephritis.—The diet in chronic nephritis in its various forms is a trying matter, for the cases are apt to run for years with occasional acute exacerbations, and great care is constantly required in order to prevent the recurrence of symptoms from injudicious diet and hygiene. In the acute cases of nephritis dieting is more stringent but of com- paratively short duration and the need for long-continued watchfulness is less imperative. The dietary treatment of the acute exacerbations, occurring in the course of chronic nephritis, is the same as in the acute cases and afterward the cases must be fed and managed with the idea in mind that they may live a fairly long life. Before turning directly to the subject of specific diets it seems worth while to give some attention, in a short para- graph, to the general management of chronic nephritis from a dietetic point of view. Dietetic Management of Chronic Nephritis. — 1. As most cases of chronic nephritis have distinct limitations in regard to their excretory power of nitrogen, salts and water, it is absolutely necessary for their most intelligent dietary treatment that these limitations be determined, at least approximately. 2. Since in these cases diet is a matter of months or years, it is necessary to make sure that any diet chosen is palatable, supplies the full requirements in protein, fat, carbohydrate, salts, and calories adjusted to the requirements of the par- ticular case and avoiding undue increase in weight. 3. In the long-standing cases it is not necessary to exclude meat absolutely, except possibly in the cases with high 466 DISEASES OF THE GENITO-URINARY SYSTEM arterial tension. Most authorities agree with Hare1 in think- ing that the removal of red meat from the diet for a long period is harmful. Since it is the extractives which seem to contain the pressor substances, meat soups are much better excluded from the diet and boiled meat is better than meat broiled or roasted, as the boiling removes a large proportion of the extractives. Boiling in two waters is better still. 4. The diet, so far as possible, must be kept laxative, as many cases of chronic nephritis are made distinctly worse when there is constipation. 5. Von Noorden recommends once a week the giving of an extra 1 or 2 liters of water for the sake of its flushing effect. On these days the food is best limited to not over half the usual allowance. Of course when the patient is not excreting the ordinary daily allowance of water, it would be of doubtful utility to give this extra amount, although again Fischer insists that a kidney that is not secreting water in normal amount needs more water, provided it contains the necessary salts and alkali. 6. The use of vegetables and fruits in large amount, as already explained, is of the greatest value in furnishing alkaline basic salts. Diets in Chronic Nephritis.—When in chronic nephritis there are no particular evidences of renal insufficiency, the diet should be distinctly of a prophylactic nature and should contain only the mild foods and unirritating substances. Such a diet may contain: Oysters, fresh fish, cream soups, vegetable purees made without meat stock. Eggs in limited number, not over one or two a day. Green vegetables, exclusive of those already mentioned as irritating to the kidneys, and of these the leafy ones are best, being highest in water soluble vitamin. Fruits of all sorts. Meat, a little once a day (if there exists no con- traindication in hypertension), simply prepared. There is little difference between light meat or dark meat, mammalian meat, or that of fowl, except the latter probably contains a lower percentage of extractives. Fats, cream butter and oil, mild cheese, farinaceous products such as cereals, breads, preferably stale, simple puddings and desserts. Milk, cream. Vichy, cider if sweet, orange juice, grape juice or other unfer- mented fruit juices. Tea and coffee in moderation, avoid- ing other articles likely to disturb digestion. Alcohol has been disposed of under acute nephritis and what was said there applies equally to chronic nephritis and needs no dis- cussion—it should not be used. 1 Therapeutic Gazette, 1914, p. 615. CHRONIC NEPHRITIS 467 Diet for Cases with Nitrogen Retention (Chronic Uremia).— — In these individuals there is the very distinct indication to feed small quantities of concentrated food with low total nitrogen content. Miller1 recommends for this purpose cream in a total daily amount of i pint, or i quart half milk, half cream. This pint of cream furnishes 12.5 grams protein, 92.5 grams fat, 22.5 grams carbohydrate and about 1000 calories, or for the quart of half milk—half cream, pro- tein 29 grams, fat 112 grams, carbohydrate 47 grams, 1350 calories; to be sure an amount entirely inadequate to the general nutritional needs but sufficient for temporary use. These cases of chronic or acute uremia often do surprisingly well on this diet for a few days, extra water being allowed and given by mouth, hypodermoclysis, rectum or intraven- ously, with or without venesection. Nothnagel praises a milk diet in these uremic or near uremic conditions and recommends 1 liter of milk in twenty-four hours, then when better, increasing it to to 21 liters per day. This is carried out for two weeks when the conditions are acute. At all other times an exclusive milk diet is unsuitable, but should constitute a considerable proportion of the daily ration plus vegetables, fruits and farinaceous foods. Mosenthal2 recommends in cases of nitrogen retention, a diet low in protein and high in carbohydrate, as it spares so much of body protein and is therefore, he thinks, better than the Karell diet. Salt, sugar and butter may be used as desired and need not be weighed or measured, assuming of course, normal salt excretion. Breakfast: Baked apple, stewed prunes or orange. Hominy, cornstarch cereal (§ hominy, cornstarch); cream, 15 cc (jounce); sherry, 30 cc (1 ounce) if desired. Dinner: Potato, baked or mashed. String beans, cabbage, carrots, lettuce, onions (?), tomatoes, cucumber, pickles. Fruit, cornstarch pudding, fruit tapioca pudding. Sherry, 30 cc (1 ounce). Supper: Same as dinner. One can eat as much as the appetite demands without fear of taking too much protein. When the waste products in the blood have been reduced to normal, or earlier in mild cases, protein should be added up to 40 to 60 grams per day. This condition of uremia with failure of nitrogen excretion Fischer ascribes to extreme renal acidosis and this condition 1 Forchbeimer’s Therapeutics, vol. 4. 2 Med. Clin, of North Am., 1919, 20, iii, 353. 468 DISEASES OF THE GENITO-URINARY SYSTEM of acidosis unquestionably exists as proven by estimations of C02 in the expired air. Acting on this theory cases are given alkalis by mouth, rectum or intravenously, often he says with marked benefit in the diminution of the uremic symptoms. In renal acidosis Mosenthal1 recommends water with calcium in order to combine with the phosphates to assist the elimi- nation of the acid salt. Packs are also given. He recommends the giving of alkali (soda bicarbonate) only when it is possible to watch the effect on the C02 tension of the alveolar air. When the immediate danger of uremic coma or convul- sions is past one may increase the quantity of milk allowed, adding cereals at first, then vegetables, etc., gradually building up the diet unless there are contraindications on account of an existing edema with salt retention or water retention or both, when the limitations of diet for these conditions must be observed. In nephritis with nitrogen retention, but without difficulty in water elimination, Foster has shown it is often advan- tageous to push the water ingestion up to 3000 to 4000 cc (3 or 4 quarts), as in this way more nitrogen is swept out, for such patients cannot concentrate their urine and the only way of accomplishing elimination is by this method. One prerequsite, however, is a fairly competent circulatory apparatus. Diet in Water Retention.—Edema.—This seldom occurs alone but is usually a part of a total picture of sodium chloride and water retention together. It was formerly thought that the water retention was primary, but later the chloride retention assumed the leading role and the water retention went with it hand in hand in order to keep the chlorides at their normal concentration of a 0.6 to 0.9 per cent solution. In these cases the salt-poor diets are often useful, or the Karell diet may be used to advantage. Morse2 determined that water with lower salt content was more quickly absorbed and excreted, distilled water fastest of all. The details of the Karell diet are as follows: For first five to seven days: 200 cc (6| ounces) milk every four hours at 8, 12, 4 and 8. No other fluids allowed. Eighth day: Milk as above and in addition. 10 a.m. i soft-boiled egg. 6 p.m. 2 pieces of dry toast. Ninth day: Milk as above and in addition. 10 a.m. i soft-boiled egg and 2 pieces dry toast. 6 p.m. 1 soft-boiled egg and 2 pieces dry toast. 1 Med. Clin. North Am., 1919-1920, 3, 353. 2 Am. Jour, et Th. Rad., 1920, 38, 109. DIET IN SALT RETENTION 469 Tenth day: Milk as above and in addition. 12 noon Chopped meat (?), rice boiled in milk, vegetables. 6 p.m. i soft-boiled egg. Eleventh and Twelfth days, same as tenth day. No salt is used at all throughout the diet. Salt-free toast and butter used. Small amounts of cracked ice are allowed with the diet. This method gives the kidney little water to excrete and later it may resume secretion probably as a result of its rest. On the other hand, cases are sometimes seen in which the fluids have been limited to 800 to 1000 cc (27 to 33 ounces) but without therapeutic success, improve as soon as water is pushed, giving an extra 2000 cc or even more. Diet in Salt Retention.—Although this has been discussed slightly in connection with acute nephritis, it is in the chronic forms that we are apt to meet the long-standing and persist- ent cases with edema, due to chloride retention, accom- panied of course by water retention and where some form of diet poor in salt is indicated. Having determined the daily output of salt on a fixed salt diet, as well as the elimination time for some definite extra amount of salt, say 10 grams, we are in a position to know what form of salt-poor diet is indi- cated. Where no means exist for determining the chloride excretion it may be concluded with considerable confidence that when one finds edema complicating nephritis, in the presence of a fairly competent heart, it is due to primary chloride retention. If one finds sufficient indication for the use of milk from the character of the urine, e. g., much albumin, blood cells and casts, we can remember that the chloride content of 1 liter of milk is 1.6 grams, and if one uses the Karell diet of course in the 800 cc there would be only 1.2 grams, of salt for the first few days of milk. When it is not necessary to use solely a milk diet even for a few days one can make use to advantage of one of the salt-poor diets, beginning with No. 1, then No. 2 or No. 3, gradually working toward a modified normal dietary exclusive of the renal irritants. In using the salt-poor diets it is necessary to keep in mind the fact that many cases in whom the edema is due unques- tionably to chloride retention do not begin to clear up on the salt-poor diet as rapidly as one could wish or might expect, but that in many instances the diet has to be continued for a week or longer before the rapid emptying of the tissues of salt and water takes place. Still other cases are even more resistant. 470 DISEASES OF THE GENITO-URINARY SYSTEM The explanation of this fact is not always clear but it seems likely that sparing the kidney for some time finally results in a restoration of its power to excrete salt. While these salt-poor diets are primarily designed for use in the diet of nephritis, other conditions accompanied by edema, such as chronic cardiac diseases, are often greatly benefited, and in fact collections of fluid in the serous cavi- ties are frequently favorably influenced by one or another of these forms of salt-poor diet. In this diet the cereals—butter, bread, etc.—used are all prepared without salt. Salt-poor Diet No. i. Breakfast. * Gm. Oz. Farina .... 60 2 Bread .... 30 I Butter (unsalted) . 30 I Sugar .... 10 I 3 Egg (i) . . . . 40 It Coffee . . . . 175 5f Prunes, stewed . 60 2 405 I3§ Dinner. Gm. Oz. Supper. Gm. Oz. Rice 60 2 Toast 15 1 2 Farina IOO 3I Egg (1) 40 It Bread 30 1 Bread . 30 1 Butter (unsalted) 20 2 3 Butter (unsalted) . 15 1 2 Sugar .' 10 1 3 Sugar . IO 1 3 Tea 175 5? Custard. IOO 3t Baked apple 60 2 Tea . 175 5§ 395 13 445 I4t Approximate Values. Protein, 36 gm. (i| oz .); fat, 65 gm. (2! oz.); carbohydrate, 160 gm. (5! oz.); calories, 1350; chlorides, 1 gm. Salt-poor Diet No. 2. Breakfast. Dinner. Oz. Gm. Oz. Gm. Egg (1) 40 it Egg (1) 40 it Farina 60 2 Bread . 60 2 Bread 65 2h Butter (unsalted) . 35 15 Butter (unsalted) 30 1 Farina . IOO 3t Coffee 175 5t Sugar . 10 1 3 Prunes or baked apple . 60 2 Rice 60 2 Tea . 175 5t 430 14 480 i5t Supper. Gm. Oz. Toast . . . . 15 1 2 Egg (1) . . . 40 it Butter (unsalted) 30 1 Bread 60 2 Custard . IOO 33 Baked apple 60 2 Prunes . 60 2 Tea .... 175 5§ 540 I7t Protein, 51 gm. (if oz.); fat, 100 gm. (33 oz.); carbohydrate, 250 gm. (83 oz.); calories, 2150; chlorides 1.4 gm. DIET IN SALT RETENTION 471 Breakfast. Gm. Oz. Luncheon. Gm. Oz. Bread 30 1 Potato or young car- Egg (i) 40 i? rots . 50 t 2 13 Wheat or corn cereal 60 2 Bread . 30 1 Orange juice .... 200 CC 6§ Rice 80 2f Sugar 25 t Tomato IOO n 1 Butter 20 2 Butter 20 2 Cream . . 50 T 2 1 3 Raisins . 15 1 Sugar 10 * Ice cream TOO 3§ Supper. - Gm. Oz. Bread .... 40 Butter .... 30 1 Wheat or corn cereal 60 2 Cream .... 50 T 2 Raisins .... 10 i Sugar .... 35 1 Potato or young carrots 50 T 2 1 3 Egg (i) Salt-poor Diet No. 3. Approximate Values. Protein, 37 gm. (if oz.) (5.9 gm. nitrogen); calories, 2000; chlorides about 1 gm. (15 grains). Salt-poor Diet No. 4. Breakfast. Luncheon. Gm. Oz. Gm. Oz. Bread 60 2 Bread .... 40 if Orange juice . 200 CC 63 Butter .... 20 2 3 Butter .... . 40 if Egg (1) ... 40 if Cream • . . . . 30 I Potato or carrots . . 125 4 Farina .... 50 If Cream cheese . 20 2 3 Sugar • 30 I Sugar .... • 30 1 Coffee 01 tea . 180 CC 6 Rice .... 50 T 2 1 3 Cream .... 30 1 Supper. Gm. Oz. Bread . . .... 50 T 2 1 3 Butter • • • • 35 1 Farina .... 50 if Cream .... 40 if Cream cheese .... 30 1 Olive oil .... 15 1 2 Lactose . . . . 8 i Sugar .... 30 1 Potato or carrots • • • • 75 2! May have in addition moderate amount of tomatoes, lettuce, cabbage, cauli- flower, spinach (fresh), beets, carrots, squash, oranges, grapefruit, peaches, grapes, apricots, pears, melons, jams. Approximate Values. Protein, 35 gm. (if oz.) (5.6 gm. nitrogen); calories, 2600; chlorides about 1 gm. (15 grains). 472 DISEASES OF THE GENITO-URINARY SYSTEM Salt-poor Diet No. 5. Breakfast. Luncheon. (Higher protein). Gm. Oz. Gm. Oz. Bread 60 2 Bread 40 if Orange juice .... 200 6§ Butter IO f Butter 30 I Potato or carrots . 80 2 f Eggs (2) 80 2§ Meat—choice of: Wheat or corn cereal 90 3 Lamb chop or . 100 3f Fresh fruit .... 50 if Steak or . 100 3f Cream . . . . 40 If Chicken .... 125 4 Sugar 50 if Fish 70 2f Tea or coffee .... 150 cc 5 Rice 80 2f Cream •20 2 Vegetables from list. Supper. Gm. Oz. Bread .... .... 50 T ~ 1 3 Butter .... • • • • 30 1 Cream .... . . . . 40 if Lactose .... . . . . 8 1 Cereal .... . . . . 30 1 Stewed fruit . 100 3f Olive oil . 20 2 Eggs (2) ... 80 2 — z 3 Sugar .... . . . . 30 1 Tea . ... 150 5 The same list of accessory fruits and vegetables that was given with Diet No. 4 is available here. Approximate Values. Protein, 69 gm. (2f oz.) ; nitrogen 11 gm. (f oz.); chlorides, 1 to 1.5 (15 to 23 grains); calories, 3000. Per cent. Milk Beef broth • • O.735 i egg . 0.086 Chicken broth • • O.35 Pea soup • • O.499 Ordinary white bread (not salt-free) . O.701 Rice . . O.748 Boiled potato . 0.058 Chicken . O.OI Beef 0.04 Lamb chops • • 0.97 (Coleman) Pickerel . O.IO] Cod • • 0.59 Salmon . . 0.46 Schall-Heisler Haddock • • 0.59 Oatmeal gruel . . 0.07 Macaroni . 0.07 Beans . 0.0058 Carrots 0.029 Apple sauce . 0.0025 1 See also table of chlorine content of foods, p. 89. Table of Salt Content of Common Foods.1 CYSTITIS 473 Conclusion.—Thus it will be seen that if care is taken in determining the type of nephritis, whether acute or chronic, and as well, which of the functions are principally disturbed, much can be done by dietary regulation to spare a diseased kidney unnecessary labor, and at the same time furnish the organism with the food distinctly appropriate to the needs of each individual case. PYELITIS. Whatever the cause of the irritation in the pelvis of the kidney may be, whether from calculus or infection, the dietetic indications are plain enough. As soon as the trouble is recognized the patient should be put on a milk diet with a certain allowance of farinaceous gruel and large amounts of water urged, either as plain water or mild, alkaline drinks, such as Vichy or Vichy and water, equal parts, or water with i gram (15 grains) of bicarbonate of soda added to each glassful. (If urotropin is used to combat the infection, nothing should be used to reduce the natural acidity of the urine, as this drug is only decomposed in an acid medium.) As soon as the fever is over one may give a lactofarinaceous diet with green vegetables and later return to a mixed diet, but with the meat strictly limited to a very small portion, not more than once a day. No condiments of any kind should be allowed and alcohol in every form is contraindicated. If nephritis occurs as a complication of the infection, the diet should be regulated in much the same way except that the return to mixed feeding should be delayed until all signs of the acute process in the kidney substance have subsided. Attention must be given to preventing constipation, and for this purpose some of the mild saline laxative waters may be used or aloes and podophyllin, cascara, etc. If edema develops as a consequence of nephritis it will be necessary to make use of one or other of the salt-poor diets, as detailed under nephritis. One important fact to remember is, that a continued flush- ing of the kidney pelvis by large quantities of ingested fluid removes the products of irritation and helps greatly in the healing process. CYSTITIS. Practically the same dietetic rules given for pyelitis hold good in cystitis for the difference in the location of the infec- tion does not cause any change in the dietetic requirements. A bland diet at first, largely fluid, and always containing 474 DISEASES OE THE GENITO-URINARY SYSTEM considerable amounts of liquids, is the factor of chief impor- tance; the same abstinence in the use of alcohol and condi- ments or irritants is observed as in pyelitis. GONORRHEA. Even with a specific infection of the anterior and posterior urethra and possibly the complicating cystitis and prosta- titis the diet conforms very largely to that already recom- mended for pyelitis and cystitis. In the early stages a milk diet for a few days, to reduce the irritation, combined with alkaline drinks, to change the reaction of the urine to alka- line, will make the patients much more comfortable. The diet may then be enlarged by the use of all farinaceous and vegetable foods, eggs, milk products, cheese, etc., and, when the inflammatory process reaches the subacute stage, the addition of meat once a day is entirely allowable. Foods to be particularly avoided are: all forms of spiced and highly seasoned food and condiments, alcohol in any form whatever, strong tea and coffee, acid fruits, tomatoes and asparagus. It should be remembered that a discharge that is almost cured may be readily started again by an indulgence in irri- tating foods or drink. This is especially true of the use of alcohol. If it should seem necessary for any reason to take some form of alcoholic drink, a diluted light claret or white wine is best, using an alkaline water, such as Vichy or Apolli- naris as a diluent. However, too much stress cannot be laid upon the avoidance of any alcohol. NEPHROLITHIASIS. The majority of calculi belong to one of three classes, uric acid, phosphates or oxalates. Uric acid and oxalate calculi are found in acid urine, phosphatic calculi in alkaline urine and these latter are more apt to come secondary to infection and fermentation. The usefulness of diet is practically con- fined to prophylaxis. The diet must be simple, avoiding all rich foods and sauces or a great variety at one meal and should be sufficient for the needs of the body but with no surplus. If the stone is of uric acid, a purin-free or low purin diet should be insisted upon, omitting meats, particularly glandular organs, soups and all highly seasoned foods. Sugar and fat may be taken moderately. Hindhede has shown that vege- table eaters’ urine has an increased ability to dissolve uric acid, AMYLOID KIDNEY 475 so that presumably a low purin and high vegetable diet does most in preventing uric acid stone formation. When the stone is of the oxalate variety all the foods that contain oxalic acid in excess should be left out of the diet, notably strawberries, rhubarb, figs, apples, peas and spinach. Most of the other vegetables except beans and peas are also theoretically best let alone, as they all contain an excess of lime, rendering the oxalate more insoluble. As a matter of fact, however, the fruits and vegetables containing an excess of oxalic acid are the ones to be curtailed. Meat, in all except glandular form, is allowed freely. This same general dietary rule holds for phosphatic calculi. In all but phosphatic stones the use of alkaline mineral waters is allowed and does good not by virtue of dissolving the stone, but by flushing the kidneys, rendering the urine less acid, with the consequent lessened chance of further cal- careous deposit. It is best to keep the urine faintly acid or neutral but not alkaline; in the latter instance it favors the deposit of phos- phates either as calculi or as a coating to a uric acid calculus. Water in large amounts is recommended to dilute the urine and flush the kidneys, so preventing much of the further deposition of salts. AMYLOID KIDNEY. There are no special indications for diet in this condition so far as the amyloid disease itself is concerned, but since in this condition the excretory power of the tubules is dimin- ished the nitrogenous foods should be kept at rather a low point, 40 to 60 grams (if to 2 ounces) per day, while the total food value of the diet should be high to help combat the chronic infection almost always present somewhere in the body, which is usually the active cause of the amyloid degen- eration. CHAPTER XXVI. DISEASES OR PATHOLOGICAL STATES DUE TO DISTURBANCES OF NORMAL METABOLISM. Of course in all diseases there are disturbances of metab- olism, so in setting apart a classification such as this we mean merely that in the following diseases the abnormal anabolism or catabolism assumes the chief role, notwithstanding every- thing else. On this account it is not always easy to say just which diseases shall be included in this class, and as in the other classifications it is more than probable that a certain amount of rearrangement will be necessary as time passes. In all these states the resultant conditions are more com- parable to the results of hyperfunction or hypofunction of certain sets of glands which control growth and body exchange, rather than to actual disease, although the line is often not sharply drawn between the two, for that which starts merely as a functional disturbance may progress to the proportions of a fatal disease, e. g., alimentary glyco- suria changing to a definite diabetes. DIABETES INSIPIDUS This disease, characterized by the passage of large amounts of urine of low specific gravity, is probably due to a functional or organic disease of the brain and there is also a possibility that the center in the medulla which controls the renal blood supply as well as excretion, is affected.1 Disease in or about the hypophysis is often associated with diabetes insipidus and Frank2 has suggested the theory that excessive function of this gland is the cause of the disease. The injection of pituitrin often helps these cases, which would rather make it seem as if a hypofunction of the gland were more probable than excessive secretion. “Minkowski3 advises that the amount of chlorides and specific gravity of the urine be determined after the ingestion of considerable salt. If both increase relatively more than the urine does, he believes that the power of excreting a con- 1 Ref. Handbook Med. Sci., 3d ed., p. 516. 2 Berl. kin. Wchnschr., 49, 9. DIABETES MELLITUS 477 centrated urine is still possessed by the kidneys. Therefore diminishing the amount of water drunk by the patients will help them. If the amount of urine increases relatively the more, a salt-free diet and one poor in protein will be a help.” In choosing a diet it is necessary to avoid foods that cause indigestion or flatulence, particular restriction being placed on sugar, for when an excess of this is taken it tends to raise the percentage of sugar in the blood, which aggravates the polyuria. Cold drinks which are diuretic must be given up, as cold milk, beer, cider, also watery fruits. A salt-poor and low protein diet tends to diminish the quantity of urine when the kidneys do not concentrate the urine normally. DIABETES MELLITUS. In perhaps no other disease is diet such a matter of vital importance as in diabetes mellitus, for as time has gone on and one after another procedure or drug has been vaunted as a cure only to be cast aside as entirely wanting, diet has remained as the one factor which is capable, if properly employed, of resting the glycogenic function of the liver, and in all but the most severe and necessarily fatal cases is also capable of bringing about a condition more or less approach- ing the normal. By its proper employment the mild cases are clinically cured, the moderately severe are rendered mild and the most of the very severe are changed to cases of moderate severity. The discovery of Insulin (an extract of islands of Langerhans) is said to make diets unnecessary, but as yet its production is limited and the cost almost prohibitive. Diets will therefore still be necessary in most of the cases. An extended discussion of the pathological-physiology and disturbed metabolism of diabetes is not necessarily a part of a book on dietetics but it is necessary to discuss the impor- tant changes of metabolism if one is to appreciate, to even a small degree, the importance and significance of diet in the varying phases of this disease. Interest naturally centers about carbohydrate metabolism which formerly was thought to be the only matter of im- portance and that the metabolism of protein and fat in no way entered into the question for the diabetic. Following this, the importance of fats in the production of acidosis was discovered, and last of all the fact that the body could syn- thesize sugar out of protein. With this last the whole ques- tion of diet in diabetes was revolutionized at a stroke and an explanation was at hand as to why certain cases failed to become sugar-free on a meat-fat diet. Another significant 478 DISTURBANCES OF NORMAL METABOLISM change of thought has been that formerly attention was focussed on the glycosuria as the most important index of a disturbed sugar metabolism, whereas now the hypergly- cemia, which always accompanies glycosuria, except in the few cases of so-called renal diabetes, occupies chief attention, since it is found that many cases of diabetes get rid of their glycosuria and would formerly have been pronounced cured but are found to retain their hyperglycemia, thus still show- ing evidence of a disturbed sugar metabolism. When we come to study the various aspects of the sugar question we do not find unanimity of opinion. Claude Ber- nard, Lowe and von Noorden believing that diabetes is due to disturbance of sugar production, while Naunyn and Min- kowski believe it due to a disturbance of sugar burning.1 Hepatic disorders or pathological states were blamed in time past while now the liver is believed by most to be little more than the organ which stores sugar or glycogen and is “played upon,” so to speak, by other organs by which the process of sugar excretion by the liver is stimulated or depressed. If we will refresh our memories by reference to normal physi- ology and then its application to diseased states, we will get a better idea of the question which is so well put by von Noorden.2 The liver is the organ which renders sugar available for an immediate source of energy and maintains the sugar content of the blood at 0.075 to O-1 Per cent. If the liver produces more sugar than is required by the tissues, there is an increased amount of it in the blood (hyperglycemia), under which condition some escapes in the urine. If, on the other hand, the liver does not supply enough sugar to the blood, the muscles are the first to suffer and the individual feels fatigue, as occurs after severe labor. In a condition of alimentary glycosuria the amount of sugar ingested is excessive and cannot be used up, so is excreted in the urine. In order to prevent this, however, the liver stores the sugar as insoluble glycogen which forms a reserve supply. By the action of glycogenase (also found in large amounts in the liver and more or less universally in the body), the glycogen is reconverted into soluble sugar again and so goes into the blood. If for any reason the ordinary supply of carbohydrate is withheld the liver can form sugar out of the protein and fat. In health the supply and demand for sugar in the blood are exactly balanced and regulated, i. e., the liver does not 1 Berl. klin. Wchnschr., 1913, p. 2161. 2 Am. Jour. Med. Sci., 1913, 145, 1. DIABETES MELLITUS 479 split up more glycogen for the use of the body than neces- sary. There are at least two factors which according to von Noorden influence the function of sugar making, viz., the pancreas and the suprarenals, the former a depressant, the latter excitants to sugar formation. According to this theory, from the pancreas there goes to the liver a specific secretion (an internal secretion, presumably from the islands of Langerhans) which acts as a depressant to sugar formation in the liver. If the pancreas is removed, so is this break in sugar production, and the diastase acting unhindered causes an excessive sugar output from the liver, which is excreted in the urine. This, von Noorden says, is really a severe diabetes. Adrenalin excites the production of sugar by the liver and a small amount of it is constantly being excreted by the suprarenals and absorbed by the blood. Therefore the suprarenals antagonize the action of the pancreas in its relation to sugar production and these two glandular sys- tems really control the sugar production by the diastase in the liver. The suprarenals do not act alone, for “they are especially under the control of the nervous system.” The Claude Bernard center in the medulla is the point from which go out impulses that stimulate the suprarenals to hyperfunc- tion through the sympathetic nerves, and thereby cause glycosuria. The pancreas is not independent either, for it is under the control of the thyroid and when the thyroid overfunctionates the pancreatic function is paralyzed and the glycogenase in the liver again acts unhindered, resulting in the overproduction of sugar and glycosuria. So in Graves’s disease we see glycosuria and in myxedema increased sugar tolerance. The pancreas is also probably affected by other factors as yet unknown. This theory is visualized by the diagram on page 480. The arrows represent the direction of the stimuli and the plus or minus signs whether the stimulus is an excitant or depressant on the next organ. Besides the disturbance in carbohydrate metabolism we have to consider carefully that of protein and fat. The Relation of Protein Metabolism to Glycosuria.— Protein metabolism in the mild forms of diabetes probably proceeds normally and requires no further discussion, but in the more severe varieties we have other factors that must be taken into consideration. In 1913, Cammidge1 called attention to the fact that in estimating the degree of toxicosis 1 Lancet, 1913, 2, 1319. 480 DISTURBANCES OF NORMAL METABOLISM in diabetes, one should take into consideration the complete picture and that three stages should be distinguished. In two of the three “the defect in metabolism is confined to a more or less complete inability to make use of the sugar derived from the carbohydrate foods, but amino-acids are still available as a source of energy and the body makes use of these supplemented in the milder forms by a certain amount of sugar derived from starchy foods and fats, for its needs. In the third form, to which the name ‘diabetes’ is confined by some writers, the power to metabolize amino- acids is diminished, with the result that these bodies appear in the urine and gradually increase in amount as the meta- bolic defect becomes more pronounced. Even in the most Central Nerve System Tissues . Thyroid \Glands/ Para \Th yroid s/ . Hypophy- \ sis / 'Urine i n. y y.Diabetes\J Liver Chromaffin System Intestines Panoreas Adrenals etc. Fig. 8 serious cases, however, some of the amino-acids are diamin- ized and converted into dextrose, thus contributing to the sugar excreted in the urine, while the fatty acids of others are imperfectly oxidized and give rise to the ‘acetone bodies’ (acetone, aceto-acetic acid and /3-hydroxybutyric acid) that are passed at the same time. Estimations of the amino- acids, ‘acetone bodies’ and sugar give therefore a much more complete picture of the state of the metabolism than any one of these taken alone, and by considering them in conjunction with the effects produced by a diet of which the qualitative and quantitative composition is known, we can determine the stage that has been reached and the probable expecta- tion of life.” These findings go with the clinical observation that when DIABETES MELLITUS 481 the diabetes is severe, the protein should be curtailed and intervals of a meat-free diet given. Animal food is rich in those forms of protein which the disturbed organism finds it difficult to break down and utilize, while vegetable proteins are poor in these constituents and a larger proportion of amino-acids which can be made use of to supply the energy needed by the tissues. Egg pro- tein is more like vegetable protein in this respect and can be used safely where other animal protein is forbidden. Milk however, is like the meat protein. When we find a patient with amino-acids in the urine we must determine whether they are from the food or from breaking down of their own tissues and if from the food whether they can still take care of the protein from egg and vegetable. If omitting animal proteins results in freeing the urine of amino-acids, as is the case in gout, the prognosis is better and the outlook with proper diet of getting rid of glycosuria is good, but if we are not able, by regulating the diet, to get rid of the amino-acids the outlook is poor. This constitutes the third or true diabetic stage. The Nitrogen Balance in Diabetes.— Cammidge1 in calcu- lating the intake and output of nitrogen in a severe case of diabetes found that with an intake of 12 grams nitrogen and 52 grams carbohydrate, the urine showed 31.8 grams nitrogen with high acetone bodies, ammonia nitrogen, calcium and magnesium and 229 grams sugar. This demonstrated that the patient was forming sugar from his own tissues. This together with the abnormal excretion of amino-acids, uric acid and creatinin showed that there was a high degree of tissue waste accompanied by defective protein metabolism. When in this case the nitrogen intake was reduced to 3 grams, still keeping the sugar value of the diet at nearly the same level, resulted in the fall of sugar excretion to less than one- half its former amount, the blood sugar fell from 0.3 to 0.2 per cent and the alveolar carbon dioxide rose to 4.6 per cent from 0.75 per cent before; the /3-oxybutyric acid also fell from 19.7 to 3.6 grams accompanied by a clinical improvement. Sufficient has been said to leave no doubt in the mind that the sugar excretion is markedly influenced by protein metab- olism and that it is not possible in severe diabetes to make up a deficiency of carbohydrate in the diet by feeding large amounts of protein. Until this fact was learned it was not understood why a diabetic continued to excrete sugar on a carbohydrate-free diet and that it was not until the protein 1 Lancet, 1915, 2, 1187. 482 DISTURBANCES OF NORMAL METABOLISM was reduced or changed from a meat to an egg protein that the patient began to be sugar-free. In this connection reference should be made to coma occur- ring in some cases of severe diabetes due to a perverted pro- tein metabolism not associated with a ketonuria. Kraus,1 Rumpf2 and Lepine3 and others showed that cases of diabetic coma occurred without any increase of organic acids in the urine and Rosenbloom4 reports 3 cases of typical coma occur- ring in severe diabetes with no carbohydrate tolerance, and even with a restricted protein intake the glycosuria was not diminished. They were observed weeks or months during all of which time the urine contained an average normal amount of ammonia nitrogen, no ketone bodies nor was there any evidence of kidney disease. All 3 cases died in typical diabetic coma. Here we have an effect from abnormal pro- tein metabolism which must be taken into account when dealing with severe diabetes, and its clinical application to dietetics is plain. Relation of Fat Metabolism to Glycosuria.—As is well known the normal end-products of fat metabolism are water and C02; the body fats are chiefly palmitic, stearic, and oleic acids, all of which contain an even number of carbons in their respective molecules. Although protein can add to the formation of actone bodies, they arise mainly from fat. The complete breaking down of the fatty acids is not alto- gether an independent process, as it is largely dependent on the presence of carbohydrate in the diet as well as upon the ability of the organism to metabolize carbohydrates.5 Fat does not act as a stimulant to sugar production as does protein but is a source of sugar, although it is only used by the liver in making glycogen when other supplies fail. In severe diabetes, however, the body fat is used in large amount, so resulting in emaciation.6 In severe diabetics with no carbohydrate tolerance the butyric acid molecule formed in intermediary metabolism of the fatty acids becomes incompletely oxidized only to /3-oxybutyric, aceto-acetic acids, and acetone, which last is derived from the two former acids. Ringer believes that “one of the functions of the glucose molecule in normal metabolism is to make /3-oxybutyric acid, which arises con- stantly in the catabolism of the higher fatty acids, combus- 1 Zeit. f. Heilk., 1906, 10, 1899. 2 Berl. klin. Wchnschr., 1895, 32, 185, 669, 700. 3 Rev. d. med., 1887, 12, 224; 1888, 13, 1004. 4 New York Med. Jour., August 7, 1915. 5 Ringer: Tr. Assn. Am. Phys., 1913, 28, 469. 6 Von Noorden: Am. Jour. Med. Sci., 19x3, 145, 1 DIABETES MELLITUS 483 tible,” and he concludes that if we could find fats with an uneven number of carbon atoms they would be oxidized into glucose instead of acetone bodies. In these conditions of perverted fat metabolism and ketonuria, although we speak of acidosis, by this is meant the accumulation of acid bodies in the blood and tissues sufficient to neutralize enough of the sodium bicarbonate there present to reduce the alka- line reserve to a level below normal; it does not mean that blood and tissues become actually acid in reaction.1 Although ketonuria is more apt to be extreme when there is no carbohydrate tolerance, it is a fact that considerable amounts of acid bodies may be excreted when the carbohy- drate tolerance is 20 to 30 grams. In long fasting, man shows a fall in his respiratory quotient while the diabetic shows some tendency to a rise. Such observation leads to the belief that the diabetic even in the severest cases burns some sugar or some other body substance to compensate for it. Joslin2 says there is much experimental evidence that the other body substances are the acids. /3-oxybutyric acid has a high caloric value and yields a high respiratory quo- tient. Ketogenic and Antiketogenic Substances in Relation to Diabetic Diets.—It has long been known that fats are metab- olized in the body satisfactorily and completely only in the presence of a certain amount of carbohydrate, without which the combustion is incomplete and results in the formation of ketones. It has not been known with any degree of cer- tainty (nor is it yet entirely settled) how much COH, as glucose, is necessary for this process. Schaffer3 found that “glucose oxidized by hydrogen peroxide in alkaline solution brings about the rapid disappearance of aceto-acetic acid if the latter be present.” From his study of this reaction in the test tube, and from analyses of the diets of different diabetic subjects (dividing these diets into assumed ketogenic and antiketogenic portions), he concludes that “definitely abnormal amounts of acetone bodies first appeared when the molecular ratio of ketogenic to antiketogenic substance exceeded 1 to I.”4 He gives the probable border-line diet as one in which the total calories were derived, 10 per cent from protein, 10 per cent from carbo- hydrate and 80 per cent from fat. On the basis of this a theory was formed, viz, “that aceto- 1 Stillman: Med. Rec., 1916, 89, 390. 2 New York Med. Jour., 1915, 101, 628. 3 Jour. Biol. Chem., November, 1921, 49, 143. 4 Quoted from same paper, p. 144. 484 DISTURBANCES OF NORMAL METABOLISM acetic acid is not easily burned in the body, but that it forms with glucose, or with degradation products of glucose and related substances, a compound which is easily burned.” Ketogenic is the name applied to substances in the food giving rise to aceto-acetic acid in metabolism; antiketogenic to substances “which furnish glucose or other related com- pounds with which the acetone combines.”1 The ketogenic compounds in the diets are the fatty acids contained in the fats and a-amino-acids, leucin, tyrosine, phenylalanine and perhaps histidin. The antiketogenic substances in foods are probably glucose and related sugars such as levulose. Also all protein metab- olized is assumed to yield its carbohyrate quota. The most generally assumed percentage is 58 per cent of grams protein metabolized as available to the body as glucose. Glycerol from metabolized fat may possibly yield carbohydrate. Assuming this ketogenic antiketogenic balance in the body “so long as an abundance of carbohydrates can be burned with ease, the appearance of ketone substances will be averted as in normal persons.” When the carbohydrate tolerance is lowered, however, it must be assumed that ketosis can be avoided only by controlling the antagonistic factors so that either the antiketogenic components will be increased or the sources of aceto-acetic acid and its concomitants decreased.”2 According to Woodyatt “the rationale of dietetic manage- ment in diabetes is to bring the quantity of glucose enter- ing the metabolism from all sources below the quantity that can be utilized without abnormal waste; and to adjust the supply of fatty acids in relationship to the quantity of glucose.”3 He also has divided the three food elements into possible ketogenic and antiketogenic portions as follows: 100 gm. carbohydrate yields in the body 100 gm. G and O gm. FA 100 gm. protein “ “ 58 gm. G and 46 gm. FA 100 gm. fat “ “10 gm. G and 90 gm. FA and proposes that for clinical purposes a diet composed accord- ing to this formula should avoid ketosis. G = C + -58P_+_.iF FA- .94P + .9F ~~ 1 Although these ratios and formulas probably serve as a safe guide for all except, perhaps, the most severe cases of 1 Hubbard and Wright: Jour. Biol. Chem., February, 1922, 50. i Editorial, Jour. Am. Med. Assn., May 6, 1922, 1392. 3 Woodyatt: Arch. Int. Med., 28, 128, DIABETES MELLITUS 485 diabetes, the limits of this relationship of fat to carbohydrate are still in debate and cannot as yet be considered established. Newburgh1 has reported the giving of diets with higher ratios without deleterious effect. Palmer and Ladd2 report that their work tends to show that the same ratio holds in diabetic metabolism as in normal metabolism. This ratio, according to Zeller, is supposed to be one molecule of carbohydrate to two molecules of fatty acid. Hyperglycemia.— Before proceeding to the discussion of diets in diabetes a word about hyperglycemia is in place, the various causes of which as given by Dock3 are as follows: 1. Excessive ingestion of sugar. 2. Reduction of liver function. 3. Exaggeration of the glycolytic function of the liver. 4. Reduction of the glycolytic function of the muscles. 5. Exaggeration of the glycolytic function of the muscles. 6. Reduction of formation of fat from glucose. 7. Reduction of combustion of glucose in the muscles. Since in diabetes mellitus one or more of these functions may be disturbed, we see what a various etiology of hyper- glycemia there may be, and it is a much more accurate index of perverted metabolism in diabetes than is glycosuria. While an increase of blood sugar over the normal (0.07 to 0.14) per cent is usually unfavorable in diabetes, Mosenthal4 says that diabetic patients by raising the fasting or basal blood sugar percentage, tend to adjust their carbohydrate metab- olism in such a manner that they are able to utilize the food offered them to better advantage. While a low blood sugar is usually considered best it may not be desirable in all cases of diabetes mellitus to reduce this. According to Williams and Humphrey5 the renal threshold for blood sugar tends to rise with the age of the patient — younger diabetics have a low or normal threshold and when the diabetes is mild or quiescent the point at which the kid- neys eliminate sugar is stationary, but when the disease becomes progressive the threshold tends to rise. Before death the blood sugar renal threshold may reach great heights with little or no sugar in the urine. Dietetic Treatment of Diabetes.—The dietetic treatment of diabetes mellitus resolves itself into the questions as to how much carbohydrate the individual can utilize and how a tolerance for carbohydrate can be obtained or increased. 1 Newburgh and Marsh: Arch. Int. Med., 26, 647, also 27, 699. 2 Proc. Soc. Exp. Biol, and Med., 1920-1921. 3 Int. Cong. Med., 6, p. 234. 4 Johns Hopkins Hosp. Med. Bull., 1918, 29, 94. 5 Arch. Int. Med., 23, 537. 486 DISTURBANCES OF NORMAL METABOLISM If, as Allen says, we compare the glycosuria to a gastro- intestinal indigestion, due to either a functional or organic disturbance, we see at once that what is needed is rest for the deranged function, followed by a gradual system of dietetic reeducation, principally so far as the carbohydrates are con- cerned, until step by step the body can take care of slowly increased amounts of this food element. The avoidance of overstrain of the glycogenic function must be kept ever in mind, for if during the process of reedu- cation sufficient food is given to again precipitate the gly- cosuria this puts off the further advance disproportionately and if it is continued, quickly results in the loss of the bettered function obtained by previous careful dieting. In other words, “ overstrain weakens while rest strengthens any damaged function.1 Mosenthal2 studying the maintenance diet in diabetes found the standard in one of two criteria: 1. The caloric requirement as determined by the height: weight formula of Du Bois and Du Bois. 2. The nitrogenous equilibrium as the lowest possible food standard of maintaining physical and mental well-being. On this basis the loss of weight found favorable nowadays in diabetes comes from fat and not from vital protein. He further investigated the food value of protein, fat and alco- hol in nitrogenous equilibrium of diabetes and concluded that “the addition of an equal number of calories of protein, fat or alcohol to a low caloric carbohydrate-free diet in cases of diabetes, results in the assimilation of considerable amounts of nitrogen when protein is used, a favorable N balance in only occasional instances with fat, and no change in N equilib- rium when alcohol is given. This would point to a high protein diet as the most desirable low caloric carbohydrate- free diet by which to conserve the body tissues and furnish a maintenance diet for the diabetic.” On the basis of what is known in regard to the relation of amino-acids to sugar production the high protein diet advised by Mosenthal would better be of the protein with little or no purin. (See Purin Content of Various Foods.) In considering the details of dietetic management we have two principal methods of treatment, one the European, best exemplified perhaps by the von Noorden routine, and the other an American method, known as Allen’s fasting cure for diabetes. While there are of course numerous modifications 1 Foster: Diabetes Mellitus, p. 183. 2 Arch. Int. Med., 1918, 21, 269. DIABETES MELLITUS 487 of these methods and to a certain extent they are modifica- tions of each other, the von Noorden cure puts the emphasis on first finding the carbohydrate tolerance, if any, by begin- ning with increasing or diminishing amounts of carbohy- drate with a certain amount of modified starvation in severe cases, for a day or two. Allen’s method lays stress on the fasting phase of the treatment, the reduction of weight of the patient and keeping the total caloric value of the food low when feedings are begun. The fats are kept particu- larly low, for if given in any considerable quantities the car- bohydrate tolerance is reduced. The fast is persisted in until the urine becomes sugar-free and the ketone bodies usually drop, but do not as a rule disappear until the patients are fed after their fast. When the patient is sugar-free, carbohydrate is allowed in small amount and gradually increased to tolerance, quite as much emphasis being also put on the protein and fat tolerance in their relation to hyper- glycemia. Von Noorden Method.— For a differentiation of the treat- ment we may arbitrarily divide diabetics into three classes of cases. 1. Those in whom the sugar excretion is less than 50 grams without ketonuria. 2. Those in whom the sugar excretion is more than 50 grams also without ketonuria. 3. Those in whom the sugar excretion is more than 50 grams with ketonuria.1 The first step is the determination of the individual’s carbohydrate tolerance if such be present. In the very mild cases associated with overeating of sweets and starches it is usually only necessary to order a rational diet curtailing these food elements to promptly and permanently render these people sugar-free. On the other hand any glycosuria even a so-called alimentary form due to excessive ingestion of sugar-forming foods, must be viewed as a real diabetes, although mild, and with potency for developing into a severe grade if neglected. (Even these mild cases should be taught to examine their own urine with Benedict’s solution once in so often in order to be sure that the sugar does not recur.) In all but these very mildest cases it is necessary, as the first step, to determine the individual’s carbohydrate toler- ance. This is done by gradually reducing the patient’s carbohydrate allowance until after about five days they are put on a standard strict diet containing only 15 grams of car- 1 Foster: Diabetes Mellitus, p. 188. 488 DISTURBANCES OF NORMAL METABOLISM bohydrate in the green vegetables allowed. To this is added a definite carbohydrate allowance in the form of white bread (55 Per cent carbohydrate), Huntley and Palmer biscuits 5 grams, Uneeda biscuit, 4.6 grams carbohydrate each. A convenient method is to allow with the Standard Strict Diet 25 grams carbohydrate in any one of these three forms, at each meal, testing the urine of the second twenty-four hours. If it still contains sugar, reduce the carbohydrate allowance one-half and so by a process of reduction or addition, in case the tolerance is over the 75 grams carbohydrate, the point at which sugar just fails to show in the urine is reached. The amount of carbohydrate that will accomplish this constitutes the carbohydrate tolerance. When this is determined the patient is put on a diet which contains not over one-half the tolerance, the reason for this being that while the urine may become sugar-free on the full tolerance, the hyperglycemia does not disappear so easily and ordinarily needs a greater reduction in the carbohydrate to reduce this to normal. After the patient has been on this tolerance for some weeks it is safe to gradually increase the amount of carbohydrate and determine its utilization by frequent urinary tests. In this way over a period of months by resting the disturbed function it is usually possible to materially increase the amount of carbohydrate beyond the original tolerance and gradually bring the patient up to an improvement which allows of a fair diet. In order to vary the diet as much as possible it is necessary to know the actual carbohydrate con- tent of the different food-stuffs and to construct a diet that shall not be monotonous. The use of the table of carbohydrate equivalents will materially aid in doing this. One pre- requisite of success is the actual weighing of the foods, in the mild cases only of the carbohydrate foods, in the more severe the protein and fats must also be weighed. Standard Strict Diet: Breakfast: Eggs, 2; ham, 90 gm. (3 oz.); coffee (with- out sugar); butter, 15 gm. (| oz.), this used on bread or biscuit; if no carbohydrate is allowed, cooked in with the eggs; cream, 45 cc (i-| oz.). Luncheon: Meat (chops or steak), 120 gm. (4 oz.); green vegetables allowed from list, 2 tablespoonfuls; wine, white or red (2 claret glasses), 6 ounces, or brandy or whisky (2 tablespoonfuls), 1 ounce; butter, 15 gm. (| oz.), cooked with the vegetables or on bread if allowed. Afternoon tea with 15 gm. oz.) cream (no sugar). DIABETES MELLITUS 489 Dinner: Clear soup; fish, 90 gm. (3 oz.); meat (fowl, beef or mutton), 120 gm. (4 oz.); green vegetables, 2 tablespoonfuls (see list); salad, with 15 gm. (f oz.) of oil with dressing; cream cheese, 30 gm. (1 oz.); red or white wine or whisky as at luncheon; coffee, small cup; butter, 30 gm. (1 oz.) on the fish, meat or green vegetables in case no bread is allowed. Bedtime: A cup of bouillon with a raw egg. This represents: Protein, 112 gm. (3! oz.); nitrogen, 18 gm. (270 grains); fat, 160 gm. (5f oz.); calories, 2200. Standard Diet with Restricted Protein. Breakfast: Eggs, 2; bacon, 15 gm. (f oz.); coffee, with cream, 45 gm. (if oz.); butter, 20 gm. (f oz.). Luncheon: Egg, 1; bacon, 15 gm. (f oz.); meat (ham steak or chops), 60 gm. (2 oz.); salad, with 15 gm. (f oz.) oil for dressing; wine, white or red, 2 claret glasses, 180 cc (6 oz.), or whisky or brandy, 2 table- spoonfuls, 30 cc (1 oz.); butter, 40 gm. (if oz.). Afternoon tea with 15 gm. (f oz.) cream. Dinner: Clear soup; meat (mutton, beef, turkey or chops), 90 gm. (3 oz.); vegetables from list, 2 table- spoonfuls; salad with 15 gm. (f oz.) oil; cream cheese, 30 gm. (1 oz.); wine, red or white, 2 claret glasses, 180 cc (6 oz.), or whisky or brandy as at luncheon; coffee; butter, 30 gm. (1 oz.). Bedtime: Bouillon with 1 egg. This represents: Protein, 70 gm. (2-f oz.); nitrogen, 10 gm. (150 grains); fat, 180 gm. (6 oz.); calories, 2500. Green Days: Breakfast: Egg, 1; cup of coffee, without cream or sugar. Dinner: Spinach with 1 egg, hard-boiled; bacon, 15 gm. (f oz.); salad, with 15 gm. (f oz.) oil; wine, red or white, 250 cc (8 oz.), or whisky or brandy, 30 cc (1 oz.). 4.30 p.m. Cup of broth or beef tea. Supper: Egg, 1, best scrambled with a little tomato or butter; bacon, 15 gm. (f oz.); cabbage, sauerkraut, string beans, cauliflower or asparagus; wine, red or white, whisky or brandy as at dinner. Give 15 to 30 gm. (f to 1 oz.) of bicarbonate of soda in the twenty-four hours. This diet represents the following values: Protein, 32 gm. (1 oz.); nitrogen, 5 gm. (75 grains); carbohydrate, 5 gm. (f oz.); fat, 65 gm. (2 oz.); calories, 575- 490 DISTURBANCES OF NORMAL METABOLISM In any of these diets if there are reasons for not using bacon, beef 30 gm. (1 oz.) may be substituted for it. Oatmeal Days: Porridge made from oatmeal, 250 gm. (8 oz.); butter, 250 gm. (8 oz.), salt and pepper. The oatmeal should be boiled all night in a double boiler with the butter and whites of 6 eggs added next morning. “This constitutes the food for one day and may be eaten as gruel, mush or fried mush, divided into seven equal parts, one part to be taken every two hours.” Two cups of black coffee and 180 cc (6 oz.) of red or sour white wine or 30 cc (1 oz.) of whisky or brandy may be taken during the day. This represents: Protein, 63 gm. (2 oz.); nitrogen, 16.8 gm. oz.); carbohydrate, 170 gm. (5I oz.); fat, 212 gm. (7 oz.); calories, 3300. General Diabetic Diet List. May take —Soups: Meat soups and broths. Egg, cheese or allowed vegetables may be added. Meats: All kinds of fresh, smoked and cured meats (except liver), poultry. Pate de fois gras, no sauces that contain flour. Fish: Every kind (except shell fish), dried, fresh, smoked or pickled. Egg: Cooked in any style but without flour. Fats: Lard, butter, oils, suet. Cheese: Swiss, English, cream, pineapple cheese. Vegetables: Cabbage, cauliflower, celery, chicory, cress, asparagus, beet tops, sprouts, cucumber, eggplant, endive, lettuce, kohlrabi, okra, pumpkin, radish, rhubarb, sauer- kraut, spinach, tomatoes, string beans, vegetable marrow. Salads and Pickles: Made of above vegetables, unsweet- ened. Mushrooms and truffles. Cream: If allowed in tolerance, 90 cc (3 oz.) per day. Condiments: Pepper, salt, curry, cinnamon, mustard, nut- meg, caraway, capers, vinegar. Desserts: Custards, ice-cream, made with eggs and cream. Lemon water-ice, jellies made with gelatin. No sugar to be used but saccharine only for sweetening and flavored with brandy, coffee, vanilla or lemon. Beverages: Tea, coffee sweetened with saccharine. Whisky or distilled liquor, 150 cc (5 oz.). Red or white wine (sour) up to 500 cc (1 pint) per day. Foods Prohibited Except as Allowed in Accessory Diet: Sugars or sweetening other than saccharine, saxin, garan- tose, dulcin. DIABETES MELLITUS 491 Puddings, preserves, cake, pastry or ice-cream. Bread, biscuit, crackers, toast, etc. Cereals of all kinds, macaroni, potatoes, or other under- ground vegetables, as carrots, parsnips, beets, turnips, also beans, peas and corn. Fruit, fresh or dried. No flour allowed in soups or gravies. Ale, beer, porter, sweet wines, sparkling wines, cider, milk, chocolate, cocoa, sweet drinks, liquor.1 Table of Carbohydrate Equivalents. Carbohydrate Equivalents. White bread: Grams 4 8 16 25 32 40 Drams I 2 4 6 8 10 Potato Gms Equals 22 44 88 132 176 220 Hominy (cooked) U 25 50 xoo 150 200 250 Oatmeal (cooked) it 40 80 160 240 320 400 Rice (cooked) .... 15 30 60 90 120 150 Farina (cooked) .... 25 50 100 150 200 250 Shredded wheat .... u 5 10 20 3° 40 50 Indian-meal mush . u 27 54 108 162 216 270 Macaroni u 30 60 120 180 240 300 Corn bread u 10 20 40 60 80 100 Barker’s gluten food, A u 102 204 408 6x2 816 1020 Barker’s gluten food, B u 74 148 296 444 592 740 Barker’s gluten food, C 54 108 216 224 432 540 Almond meal .... 65 130 260 390 520 650 Gum gluten (ground) 12 24 48 72 96 120 Soja-bean meal .... 50 100 200 300 400 500 Casoid flour u 55 no 220 330 440 550 Pure gluten biscuit . u 50 100 200 300 400 500 Proto Puff No. i ... 45 90 180 270 360 450 Proto Puff No. 2 . . . u 12 24 48 72 96 120 Salvia sticks u 25 50 IOO 150 200 250 Milk (whole) .... u 112 224 448 672 896 1120 Cream u 112 224 448 672 896 1120 Grapefruit weighed with skin u 187 375 750 1125 1150 1875 Rice pudding .... 14 28 56 84 112 140 Tapioca pudding 15 30 60 90 120 150 Beets (cooked) .... 65 130 260 390 520 650 Custard (baked) 30 60 120 180 240 300 Carrots 65 130 260 390 520 650 Com (canned or green) 22 44 88 132 176 220 Eggplant ..... 90 180 360 540 720 900 Parsnips 35 70 140 210 280 350 Green peas 30 60 120 180 240 300 Turnips 56 112 224 336 448 560 Baked beans 22 44 88 132 176 220 Apples (< 45 90 180 270 360 450 Thus 4 gras, of white bread (by which the tolerance was determined) contains the same amount of carbohydrate as do 22 gms. of potato, 40 gms. of oatmeal, 30 gms. of macaroni, etc. 1 These diets are adapted from Janeway in Musser and Kelly’s Therapeutics. 492 DISTURBANCES OF NORMAL METABOLISM Equals Bananas Gms. 20 40 80 120 160 200 Oranges “40 80 160 240 320 400 Peaches “50 100 200 300 400 500 Pears “50 100 200 300 400 500 Prunes “ 24 48 96 144 192 240 Watermelon “ 225 450 900 Method of using the table of carbohydrate equivalents: Take for example a case with a carbohydrate allowance of 32 gm. (1 oz.) Proto Puff No. 1 . 45 gm. = 4 gm. carbohydrate (as bread) Potato 22 “ = 4 “ “ Oatmeal 40 “ = 4 “ “ Beets 33 “ = 2 “ “ Orange 40 “ = 2 “ “ Rice pudding .... 56 “ = 16 “ “ * 236 “ = 32 “ Foster’s System of Carbohydrate Units. —For the milder grades of the disease Foster has devised a system of carbohydrate units, each unit representing 10 grams of carbohydrate. Of course these quantities are not absolutely accurate but are approximately so, and when the tolerance has been determined the allowance of carbohydrate can be conveniently taken from this table without weighing, the patients learning soon to remember the units.1 Soups: Bean Average portion equals x unit Clam chowder . U U U l “ Cream of com . u u U I “ Pea puree u u u I « Potato u u u I “ Vegetables: Beans, baked . . 2 tablespoonfuls 2 units Beans, butter . . 2 “ u i unit Beans, lima . 2 “ u 2 units Beans, kidney . ... 2 u 2 “ Beets ... 2 I unit Corn, canned . ... 2 u 2 units Corn, green I ear « 2 “ Onions I unit Green peas . 2 tablespoonfuls a i « Potato, baked . i medium-sized 2 units Potato, boiled . i “ u 3 “ Potato, mashed . 2 tablespoonfuls u 2 “ Fruits: Apple u 2 “ Blackberries 2 tablespoonfuls u i unit Cantaloupe One-half 2 units Currants . 3 tablespoonfuls u I unit Huckleberries . ... 2 ic I “ Orange u 2 units Peach ... I u i unit Pear ... I u 2 units Plum . 2 “ u i unit Raspberries u i “ Strawberries • • • 4 u i “ 1 Foster: Diabetes Mellitus, p. 201. DIABETES MELLITUS 493 Cereals: Bread Slice 3 x 4 x § in. equals 2 units Hominy, boiled i tablespoonful U i unit H. 0. (oatmeal), boiled 2 tablespoonfuls U i “ Macaroni, baked with cheese . 2 “ u 2 units Macaroni, boiled .... . 2 “ u 2 “ Oatmeal, boiled . 2 “ u i unit Rice, boiled i tablespoonful u 2 units Shredded wheat biscuit i biscuit u 2 “ Spaghetti, baked with tomato . 2 tablespoonfuls u 2 “ Sample Diet, (six units allowed, i. e., 60 gm. carbohydrate): Breakfast: Bacon and eggs; cereal (equal to I unit), with tablespoonful of cream. Lunch: Clear soup; meat and green vegetable; bread, \ slice (i unit); mashed potato (2 units). Dinner: Soup; meat and green vegetable; baked beans (2 units); salad and cheese. Foster suggests that this table of units should not be used when the glycosuria is over 70 gm. Procedure in the Medium Severe Cases (over 50 grams glucose in urine).—If the case has no carbohydrate tolerance and does not become sugar-free on the Standard Strict Diet without added carbohydrate, the next step is to put the case on the Standard Strict Diet with restricted protein. If after two or three days the glycosuria does not clear up, put on two green days, then back on Standard Strict Diet with restricted protein for a few days. If this results in freeing the urine of glucose then the regular Standard Strict Diet may be used and if the urine still remains sugar-free it may be possible to add carbohydrate, preferably in the form of green vegetables as recommended by Joslin, using weighed amounts of vegeta- bles containing 5, 10, 15 or 20 per cent of carbohydrate (page 500). These are ordinarily better borne than any form of bread or biscuit, although bread may be tried tentatively in definite, small amounts. Often this routine will result in free- ing the urine of sugar and with care a certain amount of carbo- hydrate tolerance may be developed, but in any case the total amount of carbohydrate allowed should be kept dis- tinctly below the point of tolerance for the reasons already explained. In these cases the use of the table of carbohydrate equiva- lents or Foster’s carbohydrate units will be found useful. Severe Cases with Marked Ketonuria. —The best plan is to put the patients at once on the oatmeal diet for several days, two to ten, without regard to the sugar in the urine, at the same time giving considerable amounts of bicarbonate of soda, enough to render the urine alkaline, which should be attained if possible. If the acidosis diminishes but the sugar 494 DISTURBANCES OF NORMAL METABOLISM content of the urine remains high, patients are often bene- fited by two green days and from this to the Standard Strict Diet with restricted protein, then the full Standard Strict Diet, if the acidosis remains in control. von Noorden recommends what he calls a “set of days” consisting of two days of restricted protein diet, two days of green diet and three days of oatmeal diet. We then return to the restricted protein diet or even full protein, but if sugar again appears the “set” is repeated. Often the patients become sugar-free and acid-free on this plan when a little carbohydrate can again be tried, preferably in vegetable form. When the acetonuria is extreme or coma threatens, von Noorden found “alcohol days” of great benefit and recom- mends giving 90 to 150 cc (3 to 5 ounces) of whisky daily well diluted and no food. This often diminishes the ketonuria and the general condition is much improved. The alcohol diet is limited to one or two days and then the oatmeal days, etc., are again tried as before. This is practically a fasting cure and in some form has been found by many observers to be of great service under these conditions. Instead of using oatmeal some clinicians prefer to use potato days or bread-and-butter days, or as Falta recom- mends, a rotation of the different starchy foods, taking one at a time. Potato Diet Breakfast: 1 baked potato with butter; 1 cup of coffee, cream, 25 cc (1 oz.). Luncheon and Dinner: Potato boiled, butter; green vege- table; whisky or wine. Bread-and-Butter Diet :2 Breakfast: 2 pieces of bread or toast, buttered; yolks of 2 eggs, cooked. Luncheon and Dinner: 2 slices of bread and butter; green vegetable, with oil or egg sauce; a rasher of bacon; wine, whisky or coffee. Allen’s Treatment of Diabetes Mellitus. — This treatment, based on results of extensive animal experimentation, has only been used for human diabetes during the past six or seven years, and although apparently very successful it has not as yet stood the test of time nor has it been used long enough to judge of the late results years after treatment was begun. As already stated in this form of treatment emphasis is placed upon an initial fast period sufficient to clear up the 1 Foster: Diabetes Mellitus, p. 186, 2 Loc. cit. DIABETES MELLITUS 495 glycosuria and acidosis, if that is present, and it has been found practically without exception that fasting from two to ten or twelve days at the outside will accomplish these ends. As Allen says in speaking of this treatment in dogs: “It was found that the grave condition of diabetes yielded to an initial fast of days or weeks with a subsequent diet which kept the animals at a low level of weight and metabolic activity. Anything that tended to increase the weight or metabolism brought back the glycosuria and acidosis. If the animal was allowed to go down by glycosuria with emaci- ation, weakness and death, it was found that degenerative changes took place in the islands of Langerhans and if this decline was prevented the islands remained intact.” The two cardinal points in Allen’s treatment are: 1. An initial fast to the point of clearing up the glycosuria, accompanied by a reduction in weight which should be permanent. 2. The subsequent diet, which does not allow of a return of the glycosuria, but if by chance there is a return an immediate fast day or two is given to clear it up again. Before speaking in detail of the method, it is necessary to emphasize one point upon which Allen lays great stress and which is entirely contrary to the older teachings, namely, that a loss of weight is of distinct advantage, as it tends to increase carbohydrate tolerance and makes the patients feel much better, which suggests the possibility that the weakness and many of the other symptoms are due to an intoxication and more than likely from the unexcreted end-products of protein metabolism. If these patients are made to gain by adding fats to the diet or trying to give larger amounts of food, as is the custom with the older forms of treatment, at once glycosuria and the acidosis return. This loss of weight is of course of greatest benefit in those cases who are rather overweight to begin with, but even the moderately well- nourished or spare individuals bear the fast advantageously with the consequent loss of weight, although, surprisingly enough, the diabetic does not seem to lose weight as rapidly as in starvation of the normal man, due to the fact that a certain amount of energy is derived from the burning of the ketone bodies. As in severe diabetes, there is more or less of a breakdown all along the line, Allen urges limiting the total caloric intake and the body mass to correspond to the assimilative function. He therefore warns against efforts to maintain patients on a high level of diet or weight. In a few cases the starvation causes alarming symptoms of 496 DISTURBANCES OF NORMAL METABOLISM nausea and vomiting which disappear on feeding and when a second fast is instituted, after a few days or a week or two, these patients stand it perfectly well and become sugar-free. The old theory that a dangerous acidosis is engendered by a prolonged fast has absolutely to be given up as untrue. During the fasting period the patients, being kept in bed, are allowed the following diet: Whisky, black coffee, bouillon, water, tea. Thrice-cooked green vegetables (whereby all starch is removed) may be given, but are not a necessary part of the diet in the period of star- vation. They merely give a sense of fulness to the patient. The whisky given in amounts of 50 to 120 cc per day (if to 4 ounces) is not an essential part of this period but may be used, and if so furnishes 7 calories per cc. It has no influence on sugar formation and aside from this the other articles allowed have practically no food value. (Whisky is said not to have any influence on acetone formation in normal individuals.)1 Twenty-four to forty-eight hours after the urine becomes free of glucose, cautious feeding is begun, individualizing the diet as much as possible, but it is absolutely essential that the patient remain sugar- and acid-free. In the feed- ing, one usually begins by using carbohydrates most easily by prescribing 100 to 200 grams to 6f ounces) of green vegetables (cooked once) of the 5 and 10 per cent classes according to Joslin’s classification. (See page 500.) This is increased in amount daily until possibly a trace of glucose appears which is at once cleared up by a fast day. This marks the patient’s carbohydrate tolerance. Next the protein tolerance is determined in the same way by giving the whites of one or two eggs, then meat is added until either glycosuria appears or the patients reach a fair, physiological protein allowance, or one tests the protein tolerance first, then the carbohydrate; in either case in finding the tolerance only one food element is used at a time, protein or carbohy- drate. If for example in a given case we were to have a pro- tein tolerance of 60 grams (2 ounces) protein and 20 grams (f ounces) carbohydrate, such a patient would be put on a diet with probably 50 grams protein and 10 grams carbohydrate which is gradually increased. In other words, just as we saw in the von Noorden regimen, the patients do best when they are allowed only about one-half their carbohydrate tolerance at first, which can be gradually increased. Geyelin’s method of using the Allen treatment in the Presbyterian Hospital, New York, is somewhat as follows: 1 Jour. Am. Med. Assn., September 9, 1916, p. 84. DIABETES MELLITUS 497 The patient is arbitrarily placed on a low caloric diet con- sisting of 15 grams (§ ounce) carbohydrate; 30 grams (1 ounce) fat; 30 grams (1 ounce) protein (diet No. 1). This is con- tinued for a few days to determine the effect of this low food intake in overcoming the glycosuria. This is a more agreeable diet than a virtual fast, but if after from one to four days of this diet the glycosuria is not decreasing or is per- haps increasing a definite fast is instituted (diet No. 2). As soon as the patient is free from sugar, a diet of from 10 to 20 grams (f to § ounce) carbohydrate is given with 30 grams (1 ounce) protein and 30 grams (1 ounce) fat. Keeping the carbohydrate at a constant level (10 to 20 grams) the protein and fat are increased 10 grams (§ ounce) daily, until sugar appears, or until the protein intake has reached a level of grams (22 grains) per kilo of body weight and the fat 100 to 150 grams (3I to 5 ounces). If on this diet the patient is still sugar-free the carbohydrate is increased 10 grams (| ounce) daily until sugar appears in the urine, a fast day is then given. After the urine is again clear of sugar, the diet is arranged with the same protein and fat content, but with only one-half to two-thirds the carbohydrate tolerance as determined by the point at which we found the patient “spilled” sugar in the urine. If glycosuria appears while the patient is on a fixed, low carbohydrate diet and while the protein and fat are being increased, a fast day is given; following the fast the protein and fat intake is lowered from 10 to 20 grams (f to § ounce) and kept constant while the carbohydrate is gradually increased 5 grams (75 grains) daily until glycosuria again appears. Another fast day is then given after which the increase in protein and fat is again begun as before. Later the carbohydrate is also gradually increased 10 grams Q ounce a day). For the most part the increase in carbohydrate is best made with once boiled vegetables, at first of the 5 per cent class and later of those with higher percentage of carbohy- drate. It is not until the carbohydrate tolerance is consider- able that we allow any actual starch in the form of bread or bread substitutes. The increases in diet can be worked out most conveniently from the food tables (pages 698 and 704). In the more severe cases with only moderate acidosis at most, the patient’s diet is gradually decreased in carbohy- drates until after a few days they are fasted and put on diet No. 2 or No. 1. This results, as a rule, in converting a severe into a moderately severe case, 498 DISTURBANCES OF NORMAL METABOLISM If coma is impending, the best plan is to give the patient a plain saline infusion into the vein and urge them to take from 5 to io grams (f to f ounce) of salt by mouth with the idea of inducing a subcutaneous edema and so storing the ketone bodies in the tissues. In addition glucose is given by mouth, particularly if the patients have been starved of carbohydrates. After the danger of coma is passed the cases are treated as are those of medium severity. Standard Strict Diet (Geyelin). Diet No. i: 15 gm. carbohydrate, 30 gm. fat, 30 gm. protein. Breakfast: 2 eggs. 1 cup coffee, 200 cc (6| oz.) and saccharine, no cream. Luncheon: Tomatoes (fresh), 200 gm. (6J oz.); 7.8 gm. (117 gr.) carbohydrate. Broth, 200 cc (65 oz.). 3 P-M. White of 1 egg. Broth, 200 cc (6J oz.). Supper: String beans (canned), 200 cc oz.); 7.2 gm. (108 gr.) carbohydrate. Butter, 7 gm. (| oz.). 2 eggs. 1 cup of tea, no cream. Next day 25 gm. (f oz.) carbohydrate. To increase diet No. 1 10 grams carbohydrate, add 250 grams (8 ounces) cooked beans at luncheon (once boiled). For the following day 35 grams (if ounces) carbohydrate. To increase 10 grams (150 grains) more carbohydrate, add 180 grams (6 ounces) of once boiled cabbage at 3 p.m. feeding. For 45 grams (if ounces) carbohydrate, add, 250 grams (8 ounces) raw or canned tomatoes for breakfast. For 55 grams (if ounces) carbohydrate add 180 grams (6 ounces) cabbage. All vegetables are to be served salt-free. Diet for Fast Day. Diet No. 2: Breakfast: Cup of coffee, 200 cc (6§ oz.), saccharine. No milk or sugar. Thrice cooked 5 per cent vegetables. 200 gm. (65 oz.), e. g., string beans, spinach, cauliflower, etc., with vinegar q.s. Mid. A. m. : Salt-poor broth, 200 cc (65 oz.). Luncheon: Salt-poor broth, 200 cc (6| oz.). Cup of tea or coffee, 200 cc (65 oz.) or more if desired. 5 per cent vegetables, 200 cc (6§ oz.). Whisky or brandy, 30 cc (1 oz.) if desired. Supper: Same as luncheon. Using other of the 5 per cent vegetables. Bedtime: Salt-poor broth. Water. DIABETES MELLITUS 499 In those cases accompanied by old age, obesity or nephritis, it is better to omit the initial fast at first and put them directly on a 15 : 30 : 30 food formula (diet No. 1.), as food fasting sometimes causes these patients to pass rapidly into coma. If this brings about a sugar-free urine, that is favorable, if not, then it may be advisable to try a fast, watching the ketonuria carefully. Allen says that “fat is less urgently needed except in very weak and emaciated patients and can be added gradually.”1 In the severe cases it is necessary to test in this way the toler- ance for all classes of foods, carbohydrate, protein and fat one at a time. Carbohydrate is given if possible, but is kept safely below the limit of tolerance. Protein must be kept fairly low, sometimes very low. With a dangerously low protein tolerance the working rule has been to exclude all carbohydrate, then feed as much protein as possible with- out glycosuria. Experience seems to indicate that every patient can tolerate his necessary minimum of protein and that glycosuria appears only when this is exceeded. The severe diabetic is often thin and weak because he cannot metabolize enough food to be strong and well, but as long as his weakened function is not overtaxed he seems to be able to retain such weight and strength as he has, at least for a considerable period. Any attempt to build him up with any kind or quantity of food beyond that which he is able to metabolize perfectly, apparently hastens a fatal result.2 The mild or moderately severe cases are usually cleared of their glucose and acetone, with a fast of one or two days, the subsequent period of observation being devoted to an educa- tion of the patient in food values (after determining the car- bohydrate tolerance), for these cases can usually take a full allowance of protein and fat. With the really severe cases, of course, the initial fast is usually necessarily of longer duration and with no carbohydrate tolerance the feeding of the proper amount of protein becomes a nice problem. With perseverance, almost all the cases can be taken along to a point where they can take their minimum of protein, some fat and later probably a little carbohydrate which if the progress be fortunate may be gingerly increased. There is still a small class of cases that resist every effort at reaching a maintenance diet and who must inevitably perish of their disease;* fortunately these are few and the 1 The Treatment of Diabetes, Boston Med. and Surg. Jour., February 18, 1915. 2 Loc. cit. * Even these cases seem to be rescued at all events for the time being by hypodermics of Insulin, 500 DISTURBANCES OF NORMAL METABOLISM favorable reports of Allen’s treatment make it seem probable that they may be still further reduced in numbers. The best results in this treatment are naturally obtained in hospitals or sanatoria where everything is readily con- trolled; but Geyetin has had marked success with this treat- ment in ambulatory cases at the Vanderbilt Clinic, New York City. The patients are taught when leaving the hospital how regularly to examine their own urine with Benedict’s solution and to take one fast day every seven, ten or four- teen days, according to the severity of the case when under treatment. Allen recommends exercise in the cases which reach a fair tolerance, not only light but very active and vigorous exer- cises, as tending to keep the patients in better physical con- dition and actually increasing carbohydrate tolerance. One fact needs repetition, when after a fast of eight to ten days the urine does not become sugar- and acid-free it is well to give a food protein in small amount, 30 to 50 grams (1 to if ounces). This usually increases the sugar, but if after a day or two of this diet a fast is again instituted the urine usually becomes promptly sugar- and acid-free. This is shown by the illustrative case on January 20th to 23d, although of course this is not a severe type of case, but it serves well for the illustration of the method and of charting. A separate sheet is kept on which the actual foods and their amounts are recorded. The following short resume of Allen’s treatment given by Joslin1 is of value for its clearness and forms a good working basis for those wishing to use this treatment. Strict Diet. Meats, Fish, Broths, Gelatin, Eggs, Butter, Olive Oil, Coffee, Tea and Cracked Cocoa. (Foods Arranged Approximately According to Per Cent of Carbohydrates.) 5 per cent. Lettuce Cauliflower Spinach Tomatoes Sauerkraut Rhubarb String beans Egg plant Celery Leeks Asparagus Beet greens Cucumbers Water cress Brussels Cabbage sprouts Radishes Sorrel Pumpkin Endive Kohlrabi Dandelions Broccoli Swiss chard Vegetable Sea kale marrow Vegetables, 10 per cent. Onions Squash Turnip Carrots Okra Mushrooms Beets 15 per cent. Green peas Artichokes Parsnips Canned lima beans 20 per cent. Potatoes Shell beans Baked beans Green corn Boiled rice Boiled macaroni 1 Am, Jour, Med. Sci., 1915, 150, 492. DIABETES MELLITUS 501 Fruits. Ripe olives (20 per cent fat) Grapefruit Lemons Oranges Cranberries Strawberries Blackberries Gooseberries Peaches Pineapple Watermelon Apples Pears Apricots Blueberries Cherries Currants Raspberries . Huckleberries Plums Bananas Nuts. Butternuts Pignolias Brazil nuts Black walnuts Hickory nuts Pecans Filberts Almonds Peanuts Walnuts (English) Beechnuts Pistachios Pine nuts 40 per cent Chestnuts Miscellaneous: Unsweetened and un- spiced pickles, clams, oysters, scallops, liver, fish roe. Reckon actually available carbohy- drates in vegetables of 5 per cent group as 3 per cent, of 10 per cent group as 6 per cent. Joslin’s Resume of Allen’s Treatment. —Fasting. —Fast until sugar-free. Drink water freely and i cup of tea and i cup of coffee if desired. If sugar persists after two days of fasting, add in divided portions 300 cc clear meat broth. Alcohol.— If acidosis (diacetic acid) is present, give 0.5 cc of alcohol per kilogram body weight daily until acidosis dis- appears. Alcohol is best given in small doses every three hours. Carbohydrate Tolerance.— When the twenty-four-hour urine is sugar-free, add 150 grams of 5 per cent vegetables, and continue to add 5 grams carbohydrate daily up to 20 grams, and then 5 grams every other day, passing successively upward through the 5, 10 and 15 per cent vegetables, 5 and 10 per cent fruits, potato and oatmeal to bread, unless sugar appears or the tolerance reaches 3 grams carbohydrate per kilogram body weight. Protein Tolerance.— When the urine has been sugar-free for two days, add 20 grams protein (3 eggs) and there- after 15 grams protein daily in the form of meat until the patient is receiving 1 gram protein per kilogram body weight or if the carbohydrate tolerance is zero, only f gram per kilogram body weight. Later, if desired, the protein may be raised to 1.5 gram per kilogram body weight. Fat Tolerance.— While testing the protein tolerance, a small quantity of fat is included in the eggs and meat given. Add no more fat until the protein reaches 1 gram per kilo- gram body weight (unless the protein tolerance is below this figure), but then add 25 grams fat daily until the patient ceases to lose weight or receives not over 40 calories per kilo- gram body weight. 502 DISTURBANCES OF NORMAL METABOLISM Date. 24-hr. volume cc. Sp. gr. Ace- tone. Diace- tic. 0-oxy- butyric. Output glucose. calories. Na balance Cl. gm. Total N ur'ne. D M N. Am- monia N. Weight. Reac- tion. Blood C02. Miscellaneous. Per cent. Total gm. Jan. 46.9 14-15 1480 19 4" + + O + 17.82 0 XX 7.03 2.5 3-4i IO3.2 ac. Ft. 46.9 M Cm 1 O' 2395 21 tr. 0 + 21-39 0 XV 9.02 2.37 463 103.2 ac. 34-3 350 ale. Not Whisky, 16-17 2975 19 + + + II.9 cal. XX 9.81 1.52 4-54 weighed ac. 120 CC. 350 Not ale. weighed 17-18 3715 14 + + 11.6 + II . 14 cal. XX 7.645 1.46 3-99 Unable ac. Whisky, to stand 120 CC. 18-19 4050 14 ++ + + 10.0 350 ale. XX 0 00 I 03 4.20 Not ac. 38.675 Whisky, cal. weighed 120 cc. Trace 350 Ft. only ale. Not Ft. Whisky, 19-20 3830 10 tr. Tr. 7.12 + cal. XX 6.97 2-57 weighed acid 120 CC. Very 262 Ft. W ale. Not Whisky, 20-21 2290 13 Tr. Tr. 5-77 tr. cal. XX 7-37 2.29 weighed ac. 90 cc. 82 pro. Pro., 20; Ft. Ft. 262 ale. Not whisky, 21-22 3125 14 Tr. tr. 5-7 tr. w cal. XX 5.108 1.9 weighed ac. 39-90 90 cc. 262 ale. Not Ft. Whisky, 22-23 4120 13 Tr. Tr. 0 0 cal. XX 8.10 2.19 weighed ac. 90 cc. Ft. 82 pro. Not Pro., 20; 23-24 2700 15 tr. Tr. 2.4 0 0 0 ale. XX 7.41 2.59 weighed ac. 0 whisky. 123 Ft. pro. Not 24-25 1640 10 tr. Tr. 0 0 cal. XX 6.53 2.05 weighed ac. 42.35 Pro., 30. 205 Not 25-26 2820 15 + Tr. 0 0 pro. XV 10.94 1.38 weighed ac. Pro., 50. Ft. ? Not 26-27 2330 15 tr. Tr. 0 0 287 XV weighed ac. Pro., 70. 15 Tr. 0 0 0 369 Not Ft. 27-28 + ? ? ? pro. XV weighed ac. 39-20 Pro., 90. 18 Ft. Not Ft. 28-29 2420 ? tr. 0 Tr. 451 XV weighed ac. Pro., no. Ft. Ft. Not Fast day a thrice-cooked 29-30 3335 13 tr. 0 tr. 0 XV weighed veg. Not Pro., 10 gms. given. Par- 30-31 2660 14 0 0 0 0 41.0 XV weighed ac. tial taste 3b veg. Feb. Ft. Not Ft. Pro. Fat C.H. 3i- 1 1720 15 tr. 0 0 0 412 XV weighed ac. 50 20 0 Feb. 44-3 Ft. Pro. 1- 2 3000 15 Tr. 0 0 0 0 584 XV 97-4 alk. 50 4^ O O Partial Record of a Case of Moderately Severe Diabetes. DIABETES MELLITUS 503 Reappearance of Sugar.— The return of sugar demands fasting for twenty-four hours or until sugar-free. The diet preceding the reappearance of sugar is then resumed except that the carbohydrate should not exceed half the former tolerance until the urine has been sugar-free for two weeks, and it should not then be increased more than 5 grams per week. Weekly Fast Days. —Whenever the tolerance is less than 20 grams carbohydrate, fasting should be practised one day in seven; when the tolerance is between 20 and 50 grams carbohydrate, 5 per cent vegetables and one-half the usual quantity of protein and fat are allowed upon the fast day; when the tolerance is between 50 and 100 grams carbohydrate the 10 per cent and 15 per cent vegetables are added as well. If the tolerance is more than 100 grams carbohydrate, upon the weekly fast day the carbohydrate should be halved. Bread is seldom prescribed, because it is so easy for a patient to overstep the limits. Many patients use bread substitutes, such as Huntley and Palmer’s Akoll Biscuits, Barker’s Gluten Flour1 (Brand A), Hepco Flour,2 Lyster Bros. Diabetic Flour, Whitefield, New Hampshire. The quantity of fat which it is necessary to give a severe case is considerable. A diabetic weighing 60 kilograms requires at least 30 calories per kilogram body weight to be up and about the hospital, with an occasional walk. Since in the severe cases not more than 10 grams carbohydrate, represent- ing 40 calories, can be given in this form, and seldom more than 75 grams protein (1.25 grams per kilogram body weight) which would amount to 300 calories more, the balance of the diet must be made up of 150 grams fat, amounting to 1350 calories, and even more unless 15 grams alcohol are given, which would amount to 105 calories. Quantity of Food Required by a Severe Diabetic Patient Weighing 60 Kilograms. Quantity, Calories, Tota Food. grams. per gram. calories. Carbohydrate . IO 4 40 Protein • • 75 4 300 Fat • 150 9 1350 Alcohol .... ... 15 7 105 Total • 1795 Should the patient remain sugar-free and the weight be maintained upon this diet, gradually the quantity of fat 1 Herman Barker, 433 Broadway, Somerville, Mass. 2 Waukesha Health Products Co., Waukesha, Wisconsin. 504 DISTURBANCES OF NORMAL METABOLISM could be lowered and the carbohydrate increased. A very few of the patients have a tolerance for between 200 and 300 grams of carbohydrate. With most, the tolerance is below 100 grams, and with the majority it is under 50 grams. The patient should have one day of restricted diet each week, no matter how mild the case. This is done partly to spare the function which controls the carbohydrate metabo- lism, but also to remind the patient of what a strict diet really is. The patient is told to gain little or no weight, and as Allen advises, not to come up to his former weight. The more severe cases examine the urine daily and the milder ones once a week. The patients are instructed to lead less strenuous lives. Unfortunately, they feel so well that often this advice is disregarded, and he believes that all of us err in allowing our patients to do too much. They should have nine hours in bed at night and should have a quiet hour of rest each day, no matter how well they feel. Diabetic Diet High in Fats.—The tendency for some time in forming diabetic diets has been to put the protein high and the fat and carbohydrate low, fearing the ketosis from the fat if used at all liberally. This gives a diet low in total energy and on it many patients with a moderate degree of diabetes are unable to keep at work. Newburgh1 changed this about and put these patients on high fat and low carbohydrate and protein. On admission patients are put on a diet of P. 10, F. 90, COH 14 = 900 to 1000 calories. After they have been sugar-free for one or two weeks the diet is increased to 1400 calories: F. 140, P. 28, COH 12 to 20 for small individuals; if larger persons, an in- crease to 1800 calories: F. 170, P. 30 to 40, COH, 25 to 30. Newburgh says the four things necessary to prove a diabetic diet are: 1. Glycosuria avoided in severe diabetes. 2. That the diet does not precipitate acidosis. 3. The maintenance of nitrogen equilibrium. 4. That the patient shall be able to lead a moderately active life. In summing up this method of feeding, he says that “patients with severe diabetes, as a class, do not remain sugar-free on the usual high protein diet, unless the total energy intake is kept so low that incapacity from starvation results. The only satisfactory diet is one which will keep the diabetic sugar-free.” On the basis of 73 cases, so treated, he feels that he has proven his thesis. The results have not as yet 1 Arch. Int. Med., 1920, 26, 647. DIABETES MELLITUS 505 been obtained by any considerable number of observers and at the Presbyterian Hospital this method in impending acidosis failed to stay its progress and the diet had to be changed to starvation in order to clear up the ketosis. It is probable at least that we can use considerably more fat with safety than was formerly thought wise. Diabetic Special Receipts.—The curtailment of the carbo- hydrates in diabetes is the most difficult problem to deal with and it is usually upon this rock that patients wreck their treatment unless they are exceptionally determined. With the newer method of giving the carbohydrate largely in the form of the 5, 10, 15 and 20 per cent vegetables there is intro- duced a considerable food bulk which is satisfying and makes the loss of concentrated carbohydrate foods such as bread, cereal, etc., less disturbing. But there is in addition the necessity of supplying a variety in the diet and the cry for bread substitutes is more or less universal. The following bread substitutes and “near” carbohydrate recipes are given to assist those who must make up the dia- betic’s menus. Akoll Biscuit (Huntley and Palmer). —Carbohydrate, 2.7 per cent; nitrogen, 7 per cent. Each biscuit weighs 5.1 grams and contains 0.14 gram carbohydrate and 0.41 gram nitrogen. Soja-bean Meal Biscuit, made from soja-bean meal, to be procured from Thos. Metcalf Co., Boston, Mass. Sugar, 9.34 per cent; starch, none; protein, 44 to 64 per cent; fat, 19.4.3 per cent. Gluten-meal Biscuit, made of Barker’s Gluten Food A, pro- cured from H. B. Barker, Somerville, Mass. Carbohydrate about 4 per cent; nitrogen, 13 per cent. Gluten Biscuit and potato-gluten biscuit procured from Battle Creek Sanitarium Food Co. Carbohydrate, 10 per cent; nitrogen, 12 per cent. Casoid Biscuit, procured from Thos. Leeming and Co., New York City. Carbohydrate, o to 2 per cent; nitrogen, 10 per cent. Proto Puff No. 1, procured from Health Food Co., Lexing- ton Avenue, New York City. Carbohydrate, 10 per cent; nitrogen, 12 per cent. Diabetic Milk {Wright).— Take a definite quantity of milk and dilute with three or four volumes of distilled water to which glacial acetic acid has been added, e. g., 6 to 12 cc (i| to 3 drams) to 500 cc (1 pint) of water. This precipitates the casein and fats. Allow it to settle and strain through cheesecloth, wash 506 DISTURBANCES OF NORMAL METABOLISM repeatedly. Redissolve the curd in a 1 per cent solution of the following mixture, sufficient to make the original amount of milk used. Potassium chloride 9-9 Sodium chloride . . . xi-5 Monopotassium phosphate 13.B Dipotassium phosphate 10.o Potassium citrate 5-9 Dimagnesium phosphate 4.0 Magnesium citrate 4.4 Dicalcium phosphate 8.0 Tricalcium phosphate 9.6 Calcium citrate 25.5 Calcium oxide 5-5 Sodium carbonate 40.0 Analysis of Wright’s Diabetic Milk (Granat) Specific gravity 1011 Carbohydrate 0.015 per cent Protein 1.907 Fat 3.600 Ash 0.200 “ Total solids 5-722 Sodium chloride 0.110 Special Recipes for the Use of Oatmeal. — (On oatmeal days the oatmeal porridge may be varied with these.) Oatmeal Griddle Cakes.—Into the beaten white of i egg stir ioo grams (3! ounces) of cooked oatmeal and 5 grams (| ounce) (full teaspoonful) of melted butter. Cook on hot griddle. Eat with butter and cinnamon. Oatmeal Popovers. — Into the white of 1 egg, beaten up, stir 100 grams ounces) of cooked oatmeal. Mix well. Bake for twenty minutes in hot popover pan. Serve with butter. Oatmeal Muffins.— Finely ground oatmeal 130 grams (2 half-pint cups). Add 1 heaping teaspoonful of baking powder and teaspoonful of salt. Mix well and add i| cups of cold water and add melted butter or lard 30 grams (1 ounce). Beat well and bake in a very hot oven in buttered muffin pans. Soja-hean Meal Biscuits. —1 cup cream, 2 eggs, 1 teaspoon- ful baking powder, salt q. s. Use enough soja-bean meal to make a batter, not very thick. Make into 8 cakes and bake. Soja-hean Pancake. — Sift 1 tablespoonful of soja-bean flour with a little salt, add water until a thin batter is made, then beat in thoroughly the yolk of an egg, then mix in the beaten white of an egg. Cook brown on a hot griddle. Baked Custard.— 3 tablespoonfuls of cream; 1 egg; 5 table- spoonfuls of water; 2 or 3 saccharin tablets (or less) to taste; 10 drops of vanilla essence. Beat well; bake in buttered dish for twenty minutes; grate a little nutmeg on top. DIABETES MELLITUS 507 Ice-cream.— 3 tablespoonfuls of water; 3 tablespoonfuls of cream; 2 tablespoonfuls of coffee with 2 or 3 saccharin tablets dissolved in it; 1 egg. Mix in sauce pan and beat until thick. Cool and freeze. Cranberries, stewed and sweetened with saccharin to taste. These special recipes are largely adapted from Janeway’s Treatment of Diabetes, in Musser and Kelly’s Therapeutics. Bran Biscuits (Rockefeller Institute Recipe). — Bran, 60 (2 oz.) grams; salt, \ teaspoonful; agar-agar (powdered), 6 grams; \ oz. cold water, 100 cc glass). Tie the bran in cheesecloth and wash under cold water tap until water is clear. Mix agar in the water cold 100 cc (f glass) and bring to the point of boiling. Add to washed bran the salt and agar-agar solution. Bake in a moderate oven from forty-five to fifty minutes. Lyster Brothers1 put up a Prepared Casein Diabetic Flour for gems, muffins, etc., which is said to be practically starch-free. Carbohydrate Content of Foods Commonly Used in Diabetic Diets. Under 5 Per Cent. Carbohydrates.2 Per cent. Per cent. Casoid Baking Powder . O Soson I . I Dr. Bouma Sugar-free Fat-milk Van Abbott’s Diabetic Table 0 Rose’s Diabetesmilch . I .2 Casoid Sugarless Marnfalade . I .2 Jelly, Orange Whiting’s Sugar-free Milk . O Energin 1-3 O Casoid Sugarless Jam . i-5 Rademann’s Johannisbeer Saft Kalari Biscuit i-7 ohne Zucker O.9 Casoid Dinner Rolls 2.1 Kalari Batons (’09) .... O.9 Casoid Flour 2.2 Glidine X .0 Tropon 2.7 Roborat 2.9 Barker’s Gluten Food “ A ” 4.1 Gericke’s Aleuronat .... 31 Bauer’s Sanatogen .... Kellogg’s Pine Nuts Kellogg’s 80 per cent. Gluten 4.2 Jireh Diatetic Pine Nuts Rademann’s Preserved Fruits, 3-4 4.2 “entzuckert” 3-5 Biscuits 4-4 Kellogg’s Protose .... 3-6 Amthor’s Weizen-Protein . 4.8 Hundhausen’s Aleuronat (pure) 4.0 Bischof’s Gluten Flour 5-0 5 to 10 Per Cent Carbohydrates. Per cent. Per cent Casoid Biscuits No. 2 5-6 Barker’s Gluten Food “C” 7-7 Rademann’s Preserved Fruits Casoid’s Biscuits No. 3 7.8 “in eigenem Saft” 5-7 Gumpert’s Ultrabrot . Kellogg’s 80 per cent Gluten 7.8 Casoid Biscuits No. 1 (’13) Barker’s Gluten Food “ B ” 5-8 5-9 (’12) 7-9 Kellogg’s Nuttolene 6-3 Van Abbott’s Almond Flour . 7-9 Nashville Nutcysa .... 6-3 Casoid Biscuits No. 1 (’06, ’09) 8.0 Huntley and Palmer’s Akoll Kellogg’s Almond Butter . Fromm’s Uni Bread 8.2 Biscuits 6-5 9.0 Nashville Nutfoda .... 6.8 Plasmon 9-3 Rademann’s Preserved Fruits Gumpert’s Ultramehl . 9-4 “ohne Zucker” .... 7.0 Metcalf’s Vegetable Gluten Muller’s Tomatoes fur Dia- (’13) 9.8 betiker Kalari Batons (’13) . 7-3 7-4 Groetzsh’s Pfefferniisse 9.8 1 Lyster Brothers, 105 Barnard Street, Andover, Mass. 2 J. P. Street: Eighteenth Report of Food Products, 1913, Conn. Agr. Ex- periment Station. 508 DISTURBANCES OF NORMAL METABOLISM 10 to 15 Per Cent Carbohydrates. Kellogg’s Pure Gluten Biscuit (’06) Per cent. Per Kellogg’s 80 per cent Gluten (’09) cent. 12.6 Hundhausen’s Aleuronat (less Van Abbott’s Gluten Flour 12-5 pure) 10.6 Van Abbott’s Gluten Butter Gumpert’s Diabetiker-Stangen 11.0 Biscuits 12-7 Health Food; Pure Washed Nashville Nut Butter . 13.0 Gluten Flour (’13) 11.1 Van Abbott’s Euthenia Bis- Health Food; Alpha Diabetic cuits 13.2 Wafers 11 -3 Kellogg’s Nut Butter . Bischof’s Diabetic Gluten 13-9 Loeb’s Imported Gluten Flour 11.8 Health Food No. 1; Proto Puffs 11.9 Bread 14-3 Kellogg’s Potato Gluten Bis- Fromm’s Litonbrot 14-3 cuit (’06, ’09) 11.9 Gericke’s Sifarbrot .... 15.0 Kellogg’s Nut Meal .... 12.1 Jireh Diabetic Baking Powder 15.0 Van Abbott’s Walnut Biscuits 12.3 Peanut Butter (range 12-20) . 15.O 15 xo 20 Per Cent Carbohydrates. Per cent. Per cent. Fritz’s Litonbrot .... 15-4 Groetzsch’s Essschokolade 17.2 Van Abbott’s Caraway Biscuits 15-9 Hundhausen’s Aleuronatzwie- Van Abbott’s Diabetic Rusks . 16.0 back 17.7 Casoid Chocolate Almonds 16. I Callard’s Ginger Biscuit . 18.I California Paper Shell Almonds 16.3 Callard’s Prolactic Biscuit 19-3 Callard’s Cocoanut Biscuit 16.4 Rademann’s Erdnuss-Brot I9.7 Van Abbott’s Ginger Biscuits . Rademann’s Diabetiker-Schoko- 16.7 Fritz’s Braunes Luftbrot “B” Groetzsch’s Diabetiker-Salz- 19.8 lade . » Health Food Almond Meal 16.9 16.9 brezeln 20.0 20 to 25 Per Cent Carbohydrates. Per cent. Per cent. Goldscheider’s Sinamylbrot 20.2 Rademann’s Litonbrot 21.6 Callard’s Almond Shortbreads 20-7 Rademann’s Diabetiker-Schoko- Callard’s Casoid Rusks . 20.8 lade-Biskuit 21.9 Rademann’s Diabetiker-Makro- Fritz’s Mandelbrot 23.I nen 20.8 Cereo Soy Bean Gruel Flour . 23 -7 Plasmon Cocoa . Health Food Protosoy Diabetic 20.9 Health Food Salvia Sticks Health Food Protosoy Soy 24.0 Wafers 21.2 Flour 24-5 Jireh Patent Cotton Seed Flour Casoid Lunch Biscuit 2I.3 21.6 Metcalf’s Soja Bean Meal 25.0 25 T0 35 Per Cent Carbohydrates. Per cent. Per cent. Jireh Soja Bean Meal . Gericke’s Dreifach-Porterbrot . 25.8 Fromm’s Luft Bread . 30.7 26.0 Van Abbott’s Gluten Bread . 30-9 Groetzsch’s Kochschokolade 26. I Spencer’s Almond Paste . 31.6 Brusson Chocolate with Added Van Abbott’s Midolia Biscuits 31.6 Gluten 26.4 Van Abbott’s Gluten Semola . 32.4 Rademann’s Diabetiker-Stangen 27.O Fromm’s Conglutin-Diabetiker- Rademann’s Diabetiker-Dessert- Schokolade 32.7 Geback 27-5 Frank’s Protein-Roggenbrot . 33-0 Nashville Malted Nut Food 27-5 Van Abbott’s Gluten Biscottes 33-0 Gumpert’s Doppel-Diabetiker- Health Food No. 2; Proto Puffs 33-3 Zwieback 27.6 Frank’s Protein-Weizenbrot . 33-5 Metcalf’s Vegetable Gluten Ferguson Gluten Bread 33-6 (’06) 28.1 Gum Gluten Breakfast Food . 34-2 Health Food Pure Washed Gluten Flour (’06) 29-5 Gericke’s Sifarbiskuits 35-3 DIABETES MELLITUS 509 Diet for Diabetics with Gout. — When gout accompanies or complicates diabetes the necessity for regulating the diet in conformity with the necessities of both diseases is evident. When a case of diabetes with very low carbohydrate toler- ance has a fairly good protein tolerance, and one naturally comes to rely on the latter for furnishing a fair number of calories, in the presence of gout, care must be exercised with regard to the sort of protein that is ordered. If the case shows very mild evidences of gout it may only be necessary to curtail an excess of purin bodies by entirely eliminating stock soups and giving only meats with the lowest purin content, such as fish and chicken, either but once a day or once every other day. When the case is more pronounced it is necessary to eliminate the purins from the diet as much as possible, using the animal albumins which are purin-free, such as egg albumen and cheese principally, and the vege- table proteins contained in beans, peas and lentils. In this way we can secure the required amount of albumin which is purin-free or nearly so, in conformation with the require- ments of gout. Exerting care in the selection of foods it is thus possible to construct a diet which is suitable for both diabetes and gout. Diabetes in Elderly People or in the Young.—In many text-books these extremes of life are treated dietetically somewhat differently from the ordinary average adult. In elderly people it is often felt that a small amount of sugar (below 2 per cent) is no particular menace and therefore need not be treated very rigorously, particularly if the subjects are obese. As a matter of fact every case of glycosuria has potentialities of disaster and if untreated tends to grow progres- sively, although often very slowly, worse; on this account they should all be made and kept sugar- and acid-free (ketonuria). In the mild cases this is usually a simple matter, in the more severe they should be treated more vigorously and not treated lightly as of little importance, as is so often done; one great reason for this care being the fact that such elderly people with even a mild diabetes are prone to intercurrent infections, gangrene, etc., all of which are rendered much less probable if the hyperglycemia can be reduced to normal. In diabetes in the very young there is the necessity for the most painstaking care, as these cases tend to grow progres- sively worse, most of them ending fatally. Allen’s treatment offers the best plan of attack and some really remarkable cases are on record in which this treatment has at least put off indefinitely the fatal acidosis. While 510 DISTURBANCES OF NORMAL METABOLISM it is not such a difficult matter to render them sugar- and acid-free, it is usually extremely difficult to get them up to a fair maintenance diet and almost impossible to keep them nourished in accordance with the demands of the growing organism. It should be nevertheless tried and every effort made to prolong life with the hope that the disturbed func- tion may again be reestablished. Diet for Obesity with Diabetes.—As in the case with gout associated with diabetes we must find certain means by diet for controlling the obesity factor in this case. In mild cases regulating the diet on the caloric basis by giving a diet one-fourth to one-third lower in calories than would be ordinarily required by a person of the same height, we can without difficulty reduce the patient; all foods that are allowable so far as the diabetes is concerned may be used, but in reduced amount. In the more severe cases of dia- betes there is usually no difficulty in reducing patients, for with Allen’s method of treatment fasting is the means by which the glycosuria and ketonuria are cleared up, and the patients readily lose about one pound a day or thereabouts. When feedings are again begun the patients continue to lose weight, since for a considerable time, while testing out the protein, fat and carbohydrate tolerance, they are on an insufficient diet. The dietary regulation of this complica- tion of diabetes must receive especial attention in that it is recognized that a too rapid withdrawal of carbohydrates often hastens an impending acidosis. These patients should never be jumped from ordinary diet to fasting diet, but the reduction must be made gradually, extending over several days, watching the ketonurea as a guide to the rapidity of carbohydrate reduction. As has already been pointed out this loss of weight is a distinct advantage and care must be exercised not to allow it to increase to the former proportions. Diet in Diabetes Complicated by Nephritis. —It is unfor- tunately true that many cases of diabetes are complicated by nephritis, particularly among older people. This always adds a difficult factor to the situation, and in choosing a suit- able diet for such cases it must be first determined which disease is of chief importance. If for example the nephritis presents the picture of an acute disease, the diet must con- form to that useful in such a condition (more or less regard- less of the diabetes, although of course, one would naturally omit from the diet all food which is primarily carbohydrate). In this condition one should rely upon an exclusively milk diet for a time, later adding egg albumen and fats in the OBESITY 511 form of cream and butter and as the patient showed an improvement in the renal condition, an attempt may be made to increase the diet along the lines best suited to diabetics. Of course a day or two of starvation at the outset would be good for the diabetics and would rest the kidneys as well, water alone being given or the so-called “fasting” diet, (page 498), but a return to milk diet would probably cause a reappearance of the glycosuria unless the case were very mild. If the nephritis is a chronic affair of some time standing, one must treat primarily the diabetes, taking care in planning the diet that the protein ration shall be kept as low as pos- sible to maintain nitrogenous equilibrium and that no purin- containing protein shall be used or at most only those animal proteins that contain the lowest percentage of purin bodies (see Purin Bodies). In such cases it is well to place as much reliance on the fats as the metabolism will stand, with the hope that the carbohydrate tolerance may be increased rapidly. At best it is often a nice point to select a diet which is suitable to both conditions, but with care it can usually be done unless the diabetes is of the most severe variety. OBESITY. In America there are fewer cures for obesity undertaken than abroad, for probably, partly on account of national characteristics, partly on account of the climate, and partly because our leisure class is not so large as one formerly found abroad, there are fewer obese people here. Whatever the causes, fewer people take up seriously the matter of reduc- tion of weight than one finds on the other side of the water. The Causes of Obesity. —The causes of obesity may be divided into: First, lack of exercise; second, overfeeding; third, heredi- tary constitutional causes. For certain reasons, not thoroughly understood, the ten- dency to obesity may not, and in fact usually does not, show itself until toward middle life, at which time all three factors seem to be the most active in its production. There are, of course, numerous cases of obese youngsters of both sexes, usually from constitutional causes, such as hypopituitarism, in which there is an increased tolerance for carbohydrates, but these are the exception and do not fall into the class of cases that apply for relief of their obesity per se. . Most persons in adult life attain to the use of what von Noorden calls their “maintenance diet,” i. e., their regular dietary which suffices, without effort on their part, to keep 512 DISTURBANCES OF NORMAL METABOLISM them at an average, even weight. If these people reduce their activities without reducing the total quantity of food, the result will be an increase in weight, which if maintained long enough will result in obesity. Or these same people on their maintenance diet may entirely change their mode of life and in more attractive surroundings unconsciously eat more with the same result, so far as increase in weight goes. There are always exceptions to these conditions and one often sees a spare individual who eats much more than would suffice to fatten him, but who does not get fat. So, too, some obese persons are comparatively small eaters and in old age with metabolism at low speed weight is maintained often on very little food. So far as the constitutional causes go, hypopituitarism has already been spoken of. Hypothyroidism is a fairly fre- quent cause for increase of weight and may develop at any time, but usually at middle life or in women at the climac- teric, for in men diminished thyroid secretion is an extremely rare cause for obesity. What it is that makes an obese parent pass his or her fat characteristics to the children is still a mystery. Given a case of increased fat deposition, what must be our criteria for saying whether such an individual should under- take a reduction cure or not, as many may think that they are overweight and yet when judged by the average, are found to be within normal limits ? The method most in vogue is to judge the normal by the relation of height to weight, for which numerous tables have been prepared. In America the tables prepared by one of the life insurance companies are much in use; or abroad, Tibbies’s table answers the same purpose. Average Weights for Men and Women, as Compiled by the Metropolitan Life Insurance Company. Men. Women. Height, Weight, Height Weight, Ft. In. lbs. Ft. In. lbs. 5 I 120 4 IO 108 5 2 125 4 11 112 5 3 130 5 114 5 4 135 5 I Il8 5 5 141 5 2 I23 5 6 145 5 3 . 126 5 7 150 5 4 129 5 8 154 5 5 133 5 9 159 5 6 137 5 IO 164 5 7 I42 5 ii 169 5 8 146 6 175 5 9 150 6 i I8l 5 10 154 6 2 188 5 II 158 OBESITY 513 Normal Weight of Males at Various Ages.1 Height. Ft. In. 15 to 24 years. Lbs. 25 to 29 years. Lbs. 30 to 34 years. Lbs. Ages. 35 to 39 40 to 44 years. years. Lbs. Lbs. 45 to 49 years. Lbs. 50 to 54 years. Lbs. 55 to 59 years. Lbs. 5 o 120 125 128 131 133 134 134 134 5 i 122 126 129 131 134 136 136 136 5 2 124 128 131 133 I36 138 138 138 5 3 127 131 134 136 138 141 I4I 141 5 4 131 135 138 140 H3 144 145 145 5 5 134 138 141 143 I46 147 149 149 5 6 138 I42 145 147 150 151 153 153 5 7 I42 147 150 152 155 156 158 158 5 8 I46 151 154 157 160 l6l 163 163 5 9 150 155 159 162 165 166 167 168 5 IO 154 159 164 167 170 171 172 173 5 ii 159 164 169 173 175 177 177 178 6 165 170 175 179 180 183 182 183 6 i 170 177 I8l 185 186 189 188 189 6 2 176 184 188 192 I94 196 I94 194 6 3 l8l 190 195 200 203 204 201 198 Having this standard before us we can decide quickly whether a given individual is overweight or not, so far as can be said for a healthy man or woman, although conditions of disease may indicate the necessity for a reduction of weight below that which is normal in health. The Conditions for Which an Obesity Cure is Indicated Are: 1. Those people whose weight is excessive for their height. 2. Those who are within the normal limits but who on account of some disability or occupation would be better off with less weight. 3. Those who have serious circulatory diseases are almost invariably improved if relieved of excessive weight. This refers especially to cardiovascular renal diseases. 4. Those who have a fairly high grade of chronic emphy- sema or bronchitis. Of those who fall in the first class, there is little more to be said, if the excess of weight is considerably above the aver- age, they would be better for having less. Obesity also pre- disposes to diabetes. Those in the second class may be those with some disa- bility of their locomotive apparatus or who, on account of their occupation, must remain a little underweight, e. g., dancers, acrobats, etc. Of those in class three, more needs to be said. There is every reason to feel, and from clinical experience to know, that cases of chronic renal or cardiovascular disease, whether valvular or muscular, are much better off if their excessive weight is removed and are brought even below their normal 1 Tibbies: Food in Health and Disease, p. 465. 514 DISTURBANCES OF NORMAL METABOLISM weight for their height. The results in this direction are often brilliant and it should be insisted upon in all such cases that an earnest attempt be made to reduce the weight. The results are seen in a lessened tendency to dyspnea, edema and palpitation, all present in cases of circulatory disease complicated by obesity and to a less extent even in cases with normal circulatory apparatus, but accompanied by obesity. In cases of hypertension the results are often even more brilliant and if we can reduce these patients we almost always reduce the blood-pressure to a greater or less extent and often very markedly. The most convincing statistics on this are published by Gaertner, showing the relation of the decline in blood-pressure to the decrease in weight. No. Sex. Age. Weight, kg. Height, cm. Blood-pressure, mm. Hg. I F. 32 114 l6l 165-115 2 F. 31 82 164 I15- 90 3 M. 49 103 170 2OO-155 4 F. 16 77 167 165-130 5 M. 67 90 168 165-120 6 F. 37 82 157 105- 95 7 M. 34 105 174 100- 90 8 F. 5i 91 153 120-100 9 M. 40 88 177 no- 95 IO M. 3i 102 169 120-100 ii F. 33 117 162 130-100 12 F. 52 79 163 140-100 13 F. 28 90 164 no- 90 14 F. 26 106 176 116-100 15 M. 44 96 176 150-108 16 F. 40 84 166 130-100 17 M. 53 87 175 140-118 18 F. 42 103 155 145-100 20 F. 55 74 157 140- 95 21 F. 52 80 l6l 135-i15 22 M. 66 114 170 145-118 23 M. 44 81. 174 150-120 24 F. 22 115 170 130-115 25 F. 38 72 159 180-110 26 F. 42 93 167 140-128 27 M. 39 105 l8l 115-110 28 F. 23 92 157 no- 95 There is one class of cases in whom the question comes up as to whether or not they should be subjected to a reduction cure, namely, old people who are more or less obese. The general consensus of opinion for these people is that they should not undergo a marked reduction unless they have serious cardiac, circulatory, renal or pulmonary complica- tions, for if otherwise healthy they will naturally tend to grow thinner as they approach extreme old age, at least this seems to be the rule and they bear reduction cures rather badly. OBESITY 515 The Objects of a Reduction Cure are: 1. To effect a slow consumption of the previous fat deposits. 2. To maintain the normal metabolic processes.1 There are two types of obese persons: 1. Plethoric type, occurring in healthy, often athletic per- sons, with an exaggerated normal appetite. After forty they are apt to develop serious organic trouble. They often show increased blood-pressure. 2. Anemic type, occurring for the most part in women who are flabby and anemic and who suffer from all sorts of disor- ders but who are less apt to develop serious troubles than the plethoric individuals.2 Having decided upon a reduction cure in any patient, what are the steps and methods by which this may best be accom- plished ? It is here that we meet with a bewildering array of methods for the reduction of obesity, probably any one of which will result in the object sought, some methods being more applicable to one temperament or set of conditions, another to a different kind, and the cases must be individual- ized to some extent, even in the use of any one method. In the lesser degrees of obesity where only slight, or at most, very moderate reduction is sought, it is usually enough to regulate the patient’s diet by cutting out certain classes of foods, e. g., sugars much starchy or fat foods, and increasing the bodily exercise; but where anything like a severe reduc- tion cure is indicated, it is often necessary to weigh all the food, as otherwise the error is too great and our efforts are not successful, the method and the physician both coming in for the blame. In the treatment of the plethoric type of obesity we can use more stringent methods as to diet and more vigorous exercises. In the anemic type the reduction must be made possibly more slowly and carefully with attention fixed on the upbuilding of the patient’s blood and general condition, as well as on the details of the reduction. Reduction Cures.—von Noorden Cure.—Among all the methods to be found none appeals more strongly to the intelligence than the reduction cure recommended by von Noorden, as it places the emphasis on the regulation of food intake as affecting; first, slight obesity, second, moderate obesity and third, marked obesity. The assumption is made that a patient weighing 70 kilos (154 pounds) requires for ordinary activities 37 calories per kilo or 2590 calories in all as his “maintenance” diet; if this 1 Anders: New York Med. Jour., 1914, 100, 1. 2 Saundley: Med. Press and Circul., 1914, N. S., 98, 1x2. 516 DISTURBANCES OF NORMAL METABOLISM patient weighs ioo kg. (220 lbs.) this is 30 kg. over what he should weigh for his height, and while the 2590 calories are enough to maintain him at 70 kg. (154 lbs.) it would require mo extra calories to feed these 30 kg. extra. The ideal weight for his height being 70 kg., his maintenance diet is therefore 2590 calories, so that in calculating the calories necessary for any individual, account must be taken of the maintenance diet for that particular person from which must be taken one-fifth, two-fifths or three-fifths of the main- tenance allowance, e. g.: 1st. Degree of reduction diet, four-fifths of the demand, 2000 calories. 2d. Degree of reduction diet, three-fifths of the demand, 1500 calories. 3d. Degree of reduction diet, three-fifths to two-fifths of the demand, 1500 calories down to 1000.1 It is easy to arrange Diets I and II, for all that is needed in Diet I is to omit all visible fat, such as oil, butter, fat meat, etc., to have vegetable and farinaceous dishes made with little fat and to prohibit the use of alcohol. In Diet II dishes made from flour, stewed fruits, milk and soups containing flour must be forbidden as well. The results of these diets are slow, but if lived up to, the reduction will come gradually. In Diet III, the foods should be chosen from this list: “ Coffee, tea without milk or sugar; meat broth (fat skimmed off) with vegetables; lean meat or fish (total weight 250 to 350 grams [8 to 12 ounces], weighed, cooked); lean cheese; abundant green vegetables and salads, prepared with as little fat or oil as possible; vinegar, lemon, pickles, tomatoes, celery, radishes (abundant raw fruit with small percentage of sugar, as apples, peaches, strawberries, raspberries, cur- rants, blueberries, sour cherries, grapefruit, early oranges, etc.); coarse bread (bran or graham bread) in quantities of from 40 to 70 grams (i| to 2f ounces) per day only; potatoes prepared without fat, in quantities of from 80 to 150 grams (2§ to 5 ounces), mineral waters ad libitum; wine in weak per- sons up to 200 cc, but preferably omitted altogether; eggs, 1 or 2; skimmed milk; buttermilk.”2 The diet must be calculated in calories necessary for the individual, and von Noorden advises against this third degree of reduction except under direct supervision of the physician, best in a sanitarium. 1 Disorders of Metabolism and Nutrition, von Noorden, Obesity, p. 31. 2 Von Noorden, ibid. OBESITY 517 Fat and Carbohydrate Restriction.— The fats must be restricted to 30 grams (1 ounce) per day, but considerable carbohydrate in fruit, potatoes, bread and buttermilk are allowed, von Noorden says that it is not necessary to go below 100 grams ounces) of carbohydrate in a day’s ration, and he usually permits 120 grams (4 ounces). This fairly generous supply of carbohydrate contributes to sparing of the body albumin better than 53 grams of fat, although the latter has the same caloric value. Hunger should not be allowed, for it will result in the fail- ure of the cure or else a rapid return to overeating as soon as the cure is over. This may be accomplished by feeding foods of considerable bulk but of low food value. Protein Allowance.— The diet allows a fair amount of pro- tein, 120 to 180 grams (4 to 6 ounces), which is necessary to spare the body albumin. On the basis of what has been said von Noorden builds his minimal and maximal diets as follows: . Minimal. Maximal. Protein 120 gm. (4 oz.) 492 cal. 180 gm. (6 oz.) 738 cal. Fat .... 30 gm. (1 oz.) 280 cal. 30 gm. (1 oz.) 280 cal. Carbohydrate xoo gm. (3! oz.) 410 cal. 120 gm. (4 oz.) 492 cal. 1182 cal. 1510 cal. A Sample of the von Noorden Diet:1 Breakfast: Lean meat, 80 gm. (2§ oz.) bread, 25 gm. (1 oz.); tea, 1 cup with milk, no sugar. Midforenoon 1 egg. Luncheon: Soup, 1 small portion; lean meat, 160 gm. (5I oz.); potatoes, 100 gm. (3! oz.); fruit, 100 gm. (31 oz-)- Afternoon: 3 p.m. Cup of black coffee. 4 p.m. Fruit, 200 gm. (6f oz.). 6 p m. Milk, 250 cc (8 oz.). Dinner: Meat, 125 gm. (3! oz.); bread (graham), 30 gm. (1 oz.); fruit, small portion as sauce without sugar; salad, vegetable or fruit, radishes, pickles. Banting’s Cure (very severe): Breakfast 8 a.m. : 150 to 180 gm. (5 to 6 oz.) meat or broiled fish (not a fat variety of either); a small bis- cuit or 30 gm. (1 oz.) dry toast; a large cup of tea or coffee without cream, milk or sugar. Dinner, 1 p.m.: Meat or fish as at breakfast, or any kind of game or poultry, same amount; any vegetables except those that grow under ground, such as potatoes, 1 Osier’s Practice. 518 DISTURBANCES OF NORMAL METABOLISM parsnips, carrots or beets; dry toast, 30 gm. (1 oz.); cooked fruit without sugar; good claret, 300 cc (10 oz.). Madeira or sherry. Tea, 5 p.m.: Cooked fruit, 60 to 90 gm. (2 to 3 oz.); 1 or 2 pieces of zwieback; tea, 270 cc (9 oz.) without milk, cream or sugar. Supper, 8 p.m.: Meat or fish, as at dinner, 90 to 120 cc (3 to 4 oz.); claret or sherry, water, 210 cc (7 oz.). Fluids restricted to 1050 cc (35 oz.) per day. OertePs Cure. —In Oertel’s obesity cure great stress is laid upon the condition of the heart and any circulatory changes, large meals being distinctly apt to embarrass either. The object of the diet is to furnish food and exercise so that the patient may burn his own body fat, but not allow any destruction of protein which is not fully supplied by the diet. Each case must be studied with a view to seeing what function must be safeguarded while the process of reduction is in progress. OerteTs calculations for the needs of the body are: Protein, Fat, Carbohydrates, grams. grams. grams. Calories. Minimum • • 156 (5i oz.) 25 ( I oz.) 75 (2j OZ.) Il80 Maximum . . 170 (5f oz.) 45 (ii oz.) 120 (4 OZ.) 1608 Restriction of fluid is an essential part of the treatment, and while he allows 1500 cc (if quarts) in average cases, it may be best to reduce it to 1250 or 750 cc (41 to 25 ounces). Solid foods must be taken alone and fluids between meals, five or six meals are given in the day. Exercise is regarded as of equal importance with diet, and ordinarily out-of-door exercise of five hours per day is insisted upon, beginning with what the patient is up to and gradually increasing. In European health resorts hill- climbing is much in vogue, there being four different grades, as follows: First incline from o to 5 degrees. Second “ “ 5 to 10 “ Third “ “ 10 to 15 “ Fourth “ “15 to 20 “ At first the patient takes only the first or second climb, avoiding overexertion and walking about from one to two hours, not taking into account the down-hill return. If necessary, from the patient’s condition, the first walking must be on level ground, and where even this causes cardiac or respiratory distress it is especially useful to have them OBESITY 519 given resisting exercises to all muscles, beginning with 5 to 10 movements to each set, increasing the amount of resistance and the number of movements up to 20 to 25 for each set of muscles. If there is angina, great caution must be used in all exercises, not to allow anything that will materially raise the blood-pressure. After sufficient reduction in weight has been accomplished Oertel puts patients on an “after-diet” as follows: Breakfast: Coffee or tea with milk, 150 to 200 cc (5 to oz.); bread, 75 gm. oz.). Midmorning: Soft eggs, 1 or 2, or 30 to 40 gm. (1 to i| oz.); meat, 100 gm. (3! oz.); wine or port, 50 cc (if oz.); a little bread. Dinner: Soup, 100 cc oz.); meat or fowl (not fat), 150 to 200 gm. (5 or 6 oz.); fish, cooked without fat, 100 gm. (3 oz.); dessert, fruit, 100 to 200 gm. (3 to 6f oz.); light wine or beer, 160 to 250 cc (5 to 8 oz.); water. Midafternoon: Coffee or tea, 150 to 200 cc (5 or 6 oz.); water, 250 cc (8 oz.); bread, 30 to 60 gm. (1 or 2 oz.). Supper: Meat as at dinner, or eggs; bread, 30 gm. (1 oz.); small amount of cheese, salad or fruit; wine or beer, 300 to 500 cc (10 to 16 oz.), with water or not. Ebstein’s Dietary.—Ebstein modified existing obesity cures by allowing a considerable amount of fat but notably restricting the carbohydrates, forbidding all sugar, sweets and potatoes, but allowing 180 to 210 gm. (6 or 7 oz.) of bread. Vegetables that grow above ground are allowed and all sorts of meat, especially is fat meat permitted. Fats are allowed, 120 to 180 gm. (4 to 6 oz.) per day. Three meals, with the heartiest at midday. Breakfast: One large cup of black tea, without cream or • milk or sugar; white or brown bread, 60 gm. (2 oz.) with plenty of butter. Dinner: 2 p.m. Clear soup; meat, 120 to 180 gm. (4 to 6 oz.), with gravy and fat meat, is especially recom- mended; vegetables in abundance (as noted above); small amount of fresh or stewed fruit (without sugar) or salad; 2 or 3 glasses of light white wine. Shortly after dinner a cup of tea is allowed with sugar or milk. Supper: 7.30 p.m. Large cup of tea, without sugar or milk; 1 egg with or without a small port on of meat, preferably fat. Occasionally a little cheese or fresh fruit. 520 DISTURBANCES OF NORMAL METABOLISM Total values: Protein, 100 gm. (3! oz.); fat, 85 gm. (3 oz.); carbohydrate, 50 gm. (2§ oz.). Schweninger’s Dietary.—Absolutely no fluids are allowed with meals but must be taken at least two hours afterward. Breakfast, 8.00 a.m. Meat, eggs or milk. Lunch, 10.30 a.m. Fish or meat with 90 cc (3 oz.) light wine. Dinner, 1.00 p.m. Meat, vegetables and fruit. Supper, 7.00 p.m. Meat, stewed fruit or salad and 90 cc (3 oz.) white wine. As little bread as possible to be taken. Exercise is to be taken frequently during the day, in fact some time after each meal. Germain-See Diet.—The chief recommendation in this diet is that fluids are forced and no wine allowed. Tibbles’s Milk Cure:1 Breakfast: Milk, 500 cc (1 pint). Lunch: Meat, 180 gm. (6 oz.); plate of boiled vegetables (bread and potatoes are not allowed); junket, 250 gm. (§ pint). 5 p.m. Junket, 250 gm. (| pint); 2 cups of tea, very little sugar. Dinner: Milk, 500 cc (1 pint); 2 apples, 1800 calories. Tibbies has used this with great success. Total values: Protein. Fat. Carbohydrate. Calories. 100 gm. (3I oz.) 60 gm. (2 oz.) 50 gm. (if oz.) 1800 Salisbury Method.—In cases of obesity with carbohydrate dyspepsia, accompanied as it is by a great amount of flatu- lence, it is always advantageous to reduce the carbohydrate intake to a minimum. At times it may be necessary to go still further and put such a patient on a diet that offers no substance for fermentation. Such a diet is Salisbury’s. In this only finely chopped beef and hot water or weak tea are allowed. One hour before breakfast a pint of water is to be drunk hot, also one and a half hours before dinner and supper. Breakfast: 180 to 250 gm. (6 to 8 oz.) finely chopped meat, made into cakes or broiled. A pint of water, plain or flavored with a little tea, coffee or orange juice, without sugar. Dinner and Supper the same as breakfast. If patients are faint between meals, broth or a little chopped meat is allowed. The amount of meat is increased 1 Tibbies: Diet in Health and Disease, p. 462. OBESITY 521 up to i pound (500 grams) at each meal, but no more. This can be kept up for a considerable length of time, but ordi- narily a few days or a week is sufficient, after which other meats may be allowed, also eggs, rice, baked potato and a little stale or toasted bread. Later green vegetables are added and gradually the patient returns to a full mixed diet, keeping down the carbo- hydrate intake to the minimum and permanently excluding all sugars and sweets. Tower-Smith’s Modification of Salisbury’s Diet.— First Stage: Fourteen days. The diet is restricted to 3 pounds of lean beef, 1 pound of codfish and 6 pints of water, preferably hot. Bread 60 to 90 grams (2 to 3 oz.). This is divided into four meals. The water should be taken as follows: 1. One pint early morning. 2. One pint half an hour before breakfast. 3. One pint an hour before midday meal. 4. One pint before the afternoon meal. 5. One pint before the evening meal. 6. One pint at bedtime. Condiments are allowed. The meat contains 286 grams ounces) protein, 43 grams (i| ounces), nitrogen. Second Stage: Twenty-one days. The water is now but 4 pints, the beef and fish together but 3 pounds. Any fat-free meat or fish of the non-fatty variety may be used. Bread, as before 60 to 90 grams (2 or 3 ounces). Dry white wine or tea is also allowed. No person with organic disease should take this cure and if not carefully carried out it may result in the production of mental disturbance amounting at times to mania. Galisch’s Cure.1—The principle of this diet is to give very little food at night so that during sleep the body has less food to store up. Diet.— Early a.m. Tea with white bread and butter. 10 a.m. i egg with a little bread and butter. 1 p.m. Meat and vegetable, a little sauce, potato salad and stewed fruit. Afternoon: Coffee with zwieback or white bread and a little butter. Evening: A small piece of bread and butter. A little beer or wine (or cider). At breakfast and dinner enough is allowed to satisfy the appetite, but during the afternoon for a few days the patients are very hungry; this disappears, however, when more break- fast is taken. 1 Med. Klin., 1912, 8, 1909. 522 DISTURBANCES OF NORMAL METABOLISM When the patient is down to normal weight, more food is cautiously allowed at night. Brauer recommends at the outset a Karell cure for ten days, then an after-cure given in bed.1 Folin-Denis Method of Reduction.2—Since the essence of the successful reduction method in obesity lies in keeping the intake of energy below that of the output, complete fast- ing would theoretically, at least, accomplish this purpose most promptly. Unfortunately this is not possible without the production of symptoms such as headache, nausea and dizziness which indicate abnormal metabolic conditions. It was found that these symptoms could be easily made to disappear if even a little food were given. On account of these symptoms it has been the habit to underfeed the obese in reduction cures rather than starve them in order to cause a loss of weight due to the actual oxidation of the body fat. In the course of observations on the voluntary fasting of two exceptionally obese patients in the Massachusetts Gen- eral Hospital in Boston, Folin and Denis noted “the usual development of the indications of ‘acidosis,’ that is, an increased elimination of acetone aceto-acid and particularly of /3-oxybutric acid and ammonia in the urine. In one of the subjects the figures were exceptionally high, amounting to over 18 grams of /3-oxybutyric acid and no less than 2.5- grams of ammonia-nitrogen during the fourth day of starva- tion. The appearance of such products in these amounts is in accord with the widespread scientific belief that the acetone bodies are derived chiefly from incompletely oxi- dized fat. When the obese are compelled to depend on their store of fat for maintenance, one might reasonably expect these intermediary products to crop out.” In order to relieve the subjective symptoms associated with this fasting acidosis, Folin and Denis interrupted the period of complete starvation by a period of very moderate diet, just sufficient to cause the disappearance of the acetone bodies from the urine. Thereupon a second fast was begun. Here the striking observation was made that the acidosis did not manifest itself anew until the third day of this fast, and the patient felt well until the fourth day. After an interspersed repeti- tion of “low” diet a third fast was begun five days later. Here again the onset of acidosis was even slower than during the second period. These facts, supported by confirmatory evidence in a similar case, have suggested to the observers 1 Deutsch med. Wchnschr., 1913, 39, 1336. 2 Jour. Biol. Chem., 19x5, 21, 183. GOUT 523 that with regard to the complete oxidation of body fat in starvation, the human organism is capable of at least a cer- tain amount of adaptation, and that it is this individual factor rather than the tendency to obesity or the extent of the fat deposits in the body which chiefly determine the onset and the degree of acidosis. Folin and Denis conclude that one of the effects of repeated fastings is habituation to the complete oxidation of mobilized body fat, and a consequent retardation of the development of acidosis. These results suggest, in the words of their discoverers, that one perfectly safe, rapid and effective method of reduc- ing the weight of very obese persons is by a series of repeated fasts of increasing duration, the ammonia or /3-oxybutyric acid determination being used as a guide to the length of each fast.1 This might be said to be the last word in obesity cures. Exercise and Massage.—Exercise and massage form part of the treatment in every case Massage does not remove fat but only helps to keep the muscles in good condition. Exercise often with extra clothing helps to burn up the excess of fat, but patients must be careful that the increased appe- tite which follows exercise does not cause them to regain at the next meal all they have lost. Water in Obesity.—Just a word in closing on this mooted subject. Water per se does not increase weight unless there is chloride retention, but it acts indirectly to increase weight by making the swallowing of food more easily accomplished so that one is apt to eat more; water also increases the appe- tite. Denning2 who investigated this question, found that the amount of water taken exerts very little effect upon either the production or loss of fat. von Noorden probably voices the rational view of the question in saying that the restriction of water is not important except in four condi- tions: (i) In cases with weak circulation; (2) at the com- mencement of an obesity cure to make a mental impression on the patient, for by restriction of fluids loss of weight is greater; (3) when reduction of water causes less appetite for fat-producing foods {e g., water after sweets); (4) when the sweat excret on is excessive the water intake should be reduced to 1100 cc (2} pints) per day. GOUT. Although a detailed discussion of the etiology of gout is not a part of a book on dietetics, a certain understanding of 1 Jour. Am. Med. Assn., October 23, 1915, p. 1462. 2 Zeit. f. Diet und Physik. Therap., vol. 2, p. 292. 524 DISTURBANCES OF NORMAL METABOLISM the causes producing this disease are essential to an intelli- gent application of dietary principles, so that even at the risk of repeating what many of the readers already know, enough must here be incorporated to accomplish this end. The final word has not been said in the biochemistry of gout and we are a long way still from understanding much about it, yet it can be definitely stated that whatever else may be at fault, the inability of the organism to properly metabolize the food purins is primarily disturbed, according to most authorities. In some instances, possibly in most, there is also an accompanying failure in excretion due to deficient renal function; indeed, many authorities assert that this renal complication is the chief factor in the precipitation of gouty symptoms. So long as elimination is good great increase of uric acid production can occur without there being any resulting gouty symptoms. This actually is shown to be the case in lobar pneumonia and acute leukemia, where the percentage of uric acid in the blood is often very high, yet no symptoms referable to it are found, as the excess is prevented from backing up, through sufficient elimination. That the amount of uric acid in the blood is the index of a disturbed purin metabolism is, of course, generally believed, but that uric acid is the only substance at fault seems improb- able. Of course the cogeners of uric acid, xanthin, hypo- xanthin, guanin, theobromine, etc., are all included in the generic term “uric acid.” Hence we see that it probably takes at least two factors to account for gouty manifestations. First, increased uric acid production through perverted metab- olism of purin bases and second a deficient excretion. In certain cases of clinical gout the excretion of exogenous uric acid is not always delayed, as shown by Magnus-Levy, Weintraud, Rommel, Pratt and Rosenbloom.1 McClure2 after a study of uric acid in gout comes to the following conclusions: 1. More than 3 mg. of uric acid per 100 cc of blood with the patient on a purin-free diet is a symptom of gout but is not diagnostic of the disease. 2. No relation exists between the amount of uric acid and total non-protein nitrogen found in the blood of gouty persons. 3. A marked retention of non-protein nitrogen is not fre- quent in gout. 4. The excretion of exogenous uric acid by normal, by arthritic and by gouty persons varies greatly both in amount and duration. 1 Jour. Am. Med. Assn., 1918, 70, 285 2 Tr. Assn. Am. Phys., 1917, 32, 186. GOUT 525 5- The retention of exogenous uric acid is a symptom of questionable importance in the diagnosis of gout. The source of blood uric acid is twofold: 1. That derived from catabolism of the body tissue nucleins (the nuclei of cells) called endogenous uric acid. 2. That derived from the foods called exogenous uric acid. Naturally there is always a certain amount of uric acid in the blood even on a uric acid-free diet due to the breaking down of cell nuclei. This, however, should not exceed 0.5 to 1 mg. per 100 cc of blood and is of no pathological importance, provided elimination is sufficient. In severe nephritis, even though the uric acid production is not increased, the difficulty in excretion results in a uricacidemia. This, however, does not by any means invariably produce gouty manifestations and in fact few cases of chronic Bright’s show them. This fact seems to prove that there is still another element in the production of gout that has thus far eluded us. Duckworth1 says that gout is caused by an excess of uric acid in the blood but further states that it is the result of a special disturbance of the nervous system, there being a trophic center for joints in the medulla and the sudden pre- cipitation of an attack is due to nervous causes, given the underlying uricacidemia and poor elimination. Ebstein showed that in the deposition of the sodium biurate in the joints a destructive process always precedes the deposition of the salts due to the local effect of the cir- culating uric acid. Today it is easier to believe that this pre- liminary destructive process may be rather due to some process of chronic infection and the association of this with what are apparently gouty lesions must not be forgotten. Infection may play a much more important role than we have been wont to imagine and may supply the missing link in the chain of evidence that might connect the uricacidemia with the arthritic changes. This is admittedly an elusive factor in the production of gout for which the nervous system is blamed by some. In other words, uricacidemia plus chronic infection may result in the deposition of biurate of soda in the connective tissues, so-called “gout”—whereas chronic infection plus certain other unknown conditions may result in arthritis of other kinds—the so-called chronic rheumatoid arthritis, etc. Garrod2 says that there are only three established facts in gout. 1. The deposits in the tissues are sodium biurate. 1 Jour. Advanced Therap., New York, 1913. 2 Lancet, 1913, 1, 1790, 526 DISTURBANCES OF NORMAL METABOLISM 2. The blood contains an excess of uric acid. 3. Except during attacks there is no excess output of uric acid in the urine (although there is an increased percentage of it in the blood almost constantly). In patients past forty-five or fifty, it is frequently the cus- tom to ascribe almost all irregular and unexplained aches and pains to gout, but undoubtedly innumerable cases of non-gouty arthritis, luetic lesions and occasionally tuberculous joints are treated as gout, so that a careful diagnosis is of special importance if one wishes to be successful in the dietetic handling of this disease. There is also another reason for an accurate diagnosis, in that to put a patient on a purin- poor diet for a prolonged period, without adequate cause, is not without its dangers, for nowadays we have come to know that some disease conditions are brought about by a lack of certain food elements in the diet and one has only to mention scurvy and beriberi, both due to the absence of accessory food substances or vitamins, to realize that a con- tinuous diet which almost entirely leaves out these useful food factors may result in damage to the organism, and “until these factors are known and reckoned with, rules of diet on scientific lines are not possible.”1 Before proceeding to a discussion of the foods and actual dietaries in gout, it would be quite worth while quoting von Noorden’s2 and SchleipV methods of making a diagnosis of actual gout by the dietary regulation. Their practice is to put a patient on a purin-free diet for five days and estimate the urinary uric-acid. The normal person on such a diet should daily excrete an average of 0.45 gram uric acid (endog- enous). If during this period less uric acid is excreted each day than is normal, gout may be suspected. A definite amount of purin-containing food is then added for two days, 400 grams of beef, weighed raw (or 50 grams thymus gland). The 800 grams of beef (or 100 grams thymus), the supply for two days, are equivalent approximately to 1.4 grams uric acid, of this 0.7 gram may be expected to show in the urine in twenty-four hours after the last day on which the meat was taken. If this extra uric acid elimination is below 0.7 gram or delayed in elimination over several days, the uric acid from this amount of beef or thymus is too much and is beyond the individual’s tolerance. If this is so, repeat the test, using one-half the amount of meat; when the tolerance is found it shows how much purin food can be given daily 1 Garrod: Lancet, 1913, p. 1790. 2 Gout, p. 73. 3 Berl. klin. Wchnschr., 1905, 41, 1297. GOUT 527 with the expectation of complete elimination and without causing a uricacidemia. As compared with the normal individual, Pratt has shown that a dose of ioo grams of meat for a gouty person causes the blood uric acid curve to rise and remain up much longer. Umber’s1 elimination curve is determined in much the same way, as the initial steps are the same, but only 200 grams of meat are given, or one can use 25 grams thymus. The length of time for complete elimination is noted. Normally this excess uric acid should be eliminated in twenty-four hours. In mild cases of gout it may be delayed over three or four days, in more severe cases five or six days may be required before the normal limit is reached. The number of days it takes to eliminate the extra with a return to the normal level will indicate the period there should be between purin days. This will often show that a mild case of gout should take meat or purin food only twice a week and more severe cases only once a week, or at even longer intervals. Clinically this plan of giving meat or purin food only once every few days has long been in use and has been found a satisfactory way to allow it. The use of thymus instead of beef is advised by Fine, for in such large amounts as 400 to 800 grams of beef, the excess of meat alone is apt to delay the elimination of the uric acid. As already indicated 50 grams of thymus yields the same amount of uric acid as 400 grams of meat. The diagnosis of uricacidemia is made now so easily by means of the direct examination of the blood for uric acid by Folin’s method, that it can readily be determined whether an excess of uric acid is circulating in the blood or not. The longer method described is therefore less useful for diagnos- tic purposes than it is for the determination of the length of time required for uric acid elimination and its degree after a definite dose of purin-containing food. So much then for a brief theoretical discussion of the under- lying facts which must govern us in the construction of a gouty diet, the object of which is to prevent the development of a gouty condition and to control the active symptoms of an acute attack. We see that the best we can do is to give a diet which will not increase the uric acid in the blood, on account of there being a disjointed eliminative system, but at the same time keeping in mind that a gouty person cannot stand protein starvation any better than anyone else, although such a one is probably improved by keeping the protein of the diet somewhere near the low level suggested 1 Lehrbuch d, Ernahrung u. d, Stoffewec. Krankht., Berlin, 1909. 528 DISTURBANCES OF NORMAL METABOLISM by Chittenden, not over 50 to 70 grams protein per day. This latter provision is also important, as with a complicating contracted kidney there is apt to be more or less nitrogen retention. Another further consideration in the regulation of the diet is the fact that we must keep in mind the general nutrition of the patient, who, if already poorly nourished will hardly improve if his nutrition is still further disturbed by an insufficient diet. One must also diet with reference to complicating obesity or glycosuria, both not infrequently accompanying conditions of gout. Foods in Gout.—The actual dietary management of acute or chronic forms of gout will be given under a separate head- ing, but it is necessary to indicate here not only the best forms of protein, fat and carbohydrate, but what is quite as impor- tant, those forms which must be especially avoided. Protein food derived from glandular organs is especially to be avoided as containing the higher percentages of nucleic acid, derived from cell nuclei in which such organs abound. Soups made with meat stock may all be labelled “poison” for gouty people, containing as they do such a high percentage of extractives, almost a solution of purins. In fact these patients might much better eat the meat from which the soup is made than the soup itself and a safe rule for them is to forget that such a thing as a clear or meat soup exists. Rich gravies and sauces should also be omitted from the diet as should con- diments of all sorts. Only the simple hydrocarbons should be taken, such as butter, cream and vegetable oils. Carbohydrates.— Rich or concentrated sweets should be avoided as tending to disturb digestion and cause flatulence, but a moderate amount of simple sweetened food is allowable as palatable, of high caloric value and purin-free. All foods that have a well-earned reputation for indigestibility, quite independent of their constituents, must be avoided. Salt.—While it is not necessary to resort to extreme limita- tion of common salt, it should be kept at the lowest possible level compatible with palatability, for Lindsay1 says that sodium has the effect of throwing sodium biurate out of solu- tion from the blood, and it is known that the deposit of sodium biurate occurs in a distinct ratio to the amounts of sodium salts in the various tissues in the body. The joints and tendons which are most highly sodium-containing are the most frequent sites of the uratic deposits. Hence, keep- ing down the soda intake to the lowest level reduces, theo- retically at least, the chance for a deposit of sodium biurate in the joints. 1 Gout, Oxford Press, 1913. GOUT 529 Alcohol.—Undoubtedly the gouty patient is better with- out any alcohol whatever, unless he has been a steady user of it, in which case a little whisky, well diluted, preferably with an alkaline table water, is allowable. The writer has seen cases in which the entire withdrawal of alcohol, in patients accustomed to taking considerable quantities caused a decided increase in the symptoms, which were made distinctly less when a small amount of alcohol was again allowed. Any use of alcohol should be discontinued as soon as possible, and sweet wines, beers or champagne are especially bad, and should never be allowed. German clini- cians, however, allow light Rhine wines in moderation, but the gouty subject is better without any form of alcohol. Coffee, Tea and Cocoa contain considerable purin. This is changed in the digestive processes into bodies which have very little to do with uric acid and while small amounts of these beverages are allowable, any excess of them tends to disturb digestion and should be interdicted. Tea and coffee should not be boiled but made as a fresh infusion if used at all. Many recommend the use of one of the “caffeine-free” coffees (see page 261). Having discussed the “dont’s” of gout, we may now consider what foods and in what proportion they are allowable in the construction of a gouty diet. From what has already been said it is clear that the object sought in prescribing a gouty diet is to either omit all purin foods or to keep them down to a low level, preferably a known low level. Many so-called purin-free foods, in reality contain a very faint trace of purin which, however, may be disregarded from a practical standpoint. Diet in Acute Gout or Podagra.—During the first twenty- four to forty-eight hours of an acute attack in sthenic indi- viduals, it is a wise plan (after a thorough emptying of the intestinal canal) to starve the patients completely, giving them only large amounts of water (preferably salines) pro- vided they have not a coexisting high blood-pressure when less water should be allowed, but in any instance enough should be taken to act as a tissue diluent and for its flushing effect. If patients absolutely insist on food, a glass of milk may be given four times a day but nothing else. During this period, if accompanied by proper medication large amounts of uric acid may be eliminated. The patients may then be put on a purin-free diet, preferably a liquid or semi- solid diet, consisting of milk, eggs, either plain or as junket and custard, limiting the milk to 1000 cc and the eggs to three and giving a little every three hours. This limitation of the protein is advisable because there is usually, or often, 530 DISTURBANCES OF NORMAL METABOLISM an accompanying contracted kidney which alone is capable of causing a nitrogen retention. After the acute symptoms have passed one may give a soft purin-free diet and later modify this according to the plan for chronic gout. Purin-free Foods.—Eggs (including caviare), milk, bread (only white, not graham or entire wheat bread), butter, bis- cuits, cereals (hominy, rice, farina), cream, sugar, syrup, jam and marmalade, cake, cream soups, potatoes (have slight amount of purin), cauliflower, cabbage, lettuce, egg plant. Desserts. — Nuts, cheese, ice-cream, water ices, cake, rice, bread, farina, cornstarch or tapioca puddings, custards. Drinks.-—Sweet cider, grape juice, unfermented fruit juices generally. Soft Purin-free Diet. Use for Main Diet.—(Vanderbilt Clinic.) 6.00 a.m. Milk, 180 cc (6 oz.). 8.00 a.m. ■ Breakfast. — Milk, 180 cc (6 oz.); i| slices of bread and i pat of butter; 2 tablespoonfuls of cream of wheat or wheatena with 6o cc (2 oz.) cream and 2 tablespoonfuls of sugar; 1 soft-boiled egg. 12.30 p.m. Dinner. — Milk, 180 cc (6 oz.); 1 soft- boiled egg; potato with cream, 30 cc (1 oz.), and pat of butter; lettuce or young cabbage with dressing; i| slices of bread, with 1 pat of butter. 3.30 p.m. Milk, 180 cc (6 oz.). 6.00 p.m. Supper. — 1 soft-boiled egg; milk, 180 cc (6 oz.); 2\ tablespoonfuls of rice with cream, 30 cc (1 oz.) and 1 tablespoonful of sugar; crackers with 1 pat of butter; 1 cube of cheese (2 inches); 1 cup of weak tea with cream, 30 cc (1 oz.), and 1 teaspoonful of sugar. 9.00 p.m. Milk, 180 cc (6 oz.). This gives: Protein, 80 gm. (2§ oz.); fat, 112 gm. oz.); carbohydrate, 207 gm. (7 oz.); calories, 2300. In chronic gout we are not compelled to combat the severe pain and discomfort seen in the acute form which necessi- tates a drastic dietary regimen to help in cutting it short, so that we may proceed more leisurely to an accurate deter- mination of just which foods an individual case will do best upon. It is here that we cannot do better for our guidance than refer freely to von Noorden’s clear statements. Just as in diabetes we put the patient on a strict carbohydrate free food until the urine is sugar-free and then by adding small amounts of carbohydrate, determine the carbohydrate tolerance, so in gout we must put a patient on a purin-free GOUT 531 diet and then by additions of purin-containing foods, deter- mine his tolerance for purin. 1. The purin-free diet is also called the main diet. 2. The accessory diet consists of foods containing purins. For the main diet it is convenient to use the soft-purin- free diet already given and this should be used for several days or until the low level of uric acid output is reached either presumably or as determined by analysis of the urine. When this point is reached then we may make use of the accessory diet to some extent. In the accessory diet von Noorden takes ioo grams (3! ounces) of roast beef as the unit and reckons other meats, fish, fowl, etc., on this basis as follows: 100 grams ounces) of roast beef, veal, mutton, lean pork, ham, tongue, venison, rabbit contain the same amount of purin as 200 grams ounces) fish, except the salmon family, or 200 grams (6| ounces) lobster or crab, or 24 oysters, or 2 pigeons, or 1 spring chicken, or capon, or 1 guinea hen, or \ duck, or j goose. So in ordering the accessory diet, we can advantageously use one or more portions of these various purin-containing foods. When we have found by trial how much of the accessory diet the patient can eat without getting gouty symptoms, (which can also be checked up by urinary estimations of uric acid), it is always a good plan to put in one or two purin- free diet days a week, depending on the patient’s tolerance, comparable to the diabetic fast or green days. Just as there are some cases of diabetes who cannot take any carbohy- drate food or only minimal amounts without showing sugar in the urine, so some cases of gout can stand little or no purin food without presently showing symptoms. These cases must walk a narrow dietetic path, so far as the use of purin foods is concerned, and many do well only so long as they are kept on a purin-free diet. Complicating obesity or diabetes must be treated according to the principles laid down fpr these conditions in addition to their gouty diets and often it is no easy matter to take proper account of all these complications without fairly starving the patient. Often the most prominent condition must be dieted first without much reference to the other conditions present. It must also be remembered that in a small percentage of cases no form of dieting seems to do good and the patients go on from bad to worse, as they are unable to dispose of even the purin products of their own metabolism. There are certain individuals in whom it seems fairly cer- 532 DISTURBANCES OF NORMAL METABOLISM tain that gout is present in some degree and in whom it is wise to institute a diet suitable for such mild cases which will not impose too great a dietary hardship, while at the same time keeping the purins down to a very low level. This would be distinctly useful in conditions which seem almost certainly due to a uricacidemia (although there are no definite joint symptoms), such as gouty skin lesions, long-standing catarrhs of the respiratory tract, etc., mostly in middle-aged or really old people. Of such a diet the following is an example, made up of the purin-free articles of diet or those with a small amount of purin prepared in the least objectionable way. Diet in Gouty Diathesis. Breakfast: Fruit, cooked or raw; cereal, any one, but preferably wheat preparations; white bread, toast, rolls or muffins and butter; eggs, cooked as desired except fried; cup of weak tea, cocoa or coffee, largely milk, with sugar; a little marmalade if there is no indigestion. Luncheon or Dinner: Soup, cream or puree of vegetables (no meat); egg, entree; meat or fish, never more than once a day, in small amounts, the meat best boiled in two waters—beef, mutton, chicken, ham; vege- tables, potatoes (white or sweet), cabbage, spinach, egg plant, corn, sprouts, beet tops, lettuce, rice, macaroni, noodles, cauliflower, string beans, celery, (peas, lima beans or white beans, if there are no active symptoms), no stock to be used in sauces; desserts, fruit cooked or raw, all simply prepared desserts, not too sweet, ice-cream, simple cake, American, cream, Swiss or pot cheese; beverages, milk, unfer- mented fruit juices, e. g., grapejuice, apple juice, cider, alkaline mineral waters in small amount, plain water. Mineral Waters.—Much has been written on the subject of the efficiency of cures at the various mineral spas or the taking of either the natural or artificial mineral waters at home and at one time or other many of the mineral springs, alkaline or saline, have enjoyed considerable vogue and still do. The first indication is for the use of considerable amounts of water for the mechanical effect of “flushing the system*’ and also for the beneficial effect on coexisting gastro-intestinal catarrh or hepatic congestion, but there is little evidence that these waters otherwise affect the elimination of uric acid, and on the contrary, prolonged use of them often acts in the reverse way and therefore should be discouraged. Short courses of water cures may be taken at Vichy, Marienbad, or Carlsbad, but should not be long-continued. In the United GOUT 533 States, Saratoga, Hot Springs, Va., and White Sulphur Springs furnish treatments very similar. Fish: Vegetables (Continued) Cod ... . . . 0.5 Beans (Haricot) • 0.63 Salmon 1.1 Asparagus . . •. . 0.21 Halibut 1.0 Cabbage .... 0.0 Meat: Lettuce . 0.0 Beef . . . . . 1.3 to 2.0 Cauliflower .... . 0.0 Fat . . . . . 1. X Onions 0.09 Mutton . 0.96 Tapioca . 0.0 Fat . . . . . 0.0 Special foods: Veal . . . . 1.1 Milk . 0.0 Fat . . 0.0 Butter . 0.0 Pork . . . . 1.2 Eggs . 0.0 Fat . • • 0.5 Cheese (fat) 0.0 Ham . . . . 1.1 Drinks: Meat soups, varying large amounts: Beer 0.12 Chicken . 1.2 Ale 0.14 Vegetables: Porter . 0.15 Potatoes . . 0.02 Per pint (500 cc) Rice . . . . 0.0 Tea 1.2 Flour (white) . 0.0 Cocoa 1.0 Bread (white) . 0.0 Chocolate .... . 0.7 Oatmeal . • • 0.53 Coffee 1.7 Peas . ■ • 0.39 Claret 0.0 Lentils . . 0.38 Sherry . 0.0 Port . 0.0 The Purin Bodies in Various Foods.1 Radio-active waters have come into great popularity and in some quarters hopes have run high in consequence, some authors praising it extravagantly as of distinct value in doses of 1000 Mache units a day, increasing to 5000 to 10,000 m. u. The theories that account for its usefulness as summarized by Burnham2 are: 1. Activation of ferments causing the oxidation of the uric acid and its further disintegration into C02 and ammonia. 2. Direct action on the uric acid, the emanations causing its solution and disintegration. 3. Increased activity of the kidneys by means of which excess uric acid is excreted by the blood. On the other hand, Chace and Fine3 conclude that radium emanation in concentration of at first 0.5 and later 100 m. u. per liter of air, radium drinking water and injection of sol- uble radium bromide in none of their cases showed any influence whatever upon the uric acid concentration of the blood, nor was the output of uric acid in the urine definitely increased. 1 J. Walker Hall: The Purin Bodies in Food-stuffs, etc., London, 1903, 2d edition, revised. 2 Med. Rec., New York, 1913, 81, 117. 3 Washington Med. Jour., 1912, 3, 11, 23; Jour. Pharm. and Exp. Therap., 1914, 6, 219. 534 DISTURBANCES OF NORMAL METABOLISM DIET FOR LEANNESS, OR FATTENING CURES.1 In discussing this subject von Noorden says that the aver- age layman at a glance will undertake to say whether a cer- tain individual is normally well developed, too thin or too fat; but as a matter of fact there are other factors which must be considered in arriving at this apparently simple diagnosis. Thus a person with tuberculosis who is some- what overweight is better so, a person with chronic nephritis or cardiac disease who is somewhat underweight is better off so and under no circumstances should be the subject of fur- ther increase in weight. It is also important in arriving at the necessity of a fattening cure to know whether the muscle substance or the adipose, or both, are too little. The first thing of importance in any given individual is to know their maintenance diet, i. 13.0 Spinach 1 serving 4 1 2.3 27.0 Squabs 1 serving 3i 100.0 16.3 36.2 '9:0 391.0 Squash .1 serving 3i 100.0 1.4 0.5 46.0 Strawberries (ed. port.) . 1 serving 4 113.0 1.0 0.7 7.9 42 0 Strawberries (ed. port.) . 1 cup 6 170.0 1.5 1.0 11.9 63.0 Strawberry juice . 1 cup 8 227.0 11.59 11.4 45.0 1 tbsp. i 14.0 0 66 107.0 1 lb. 16 454.0 21.28 371 .0 3425.0 Sugar, granulated 1 tbsp. i + 15.0 15.0 60.0 Sugar, granulated 1 cup 7i 210.0 210.0 840.0 Sugar, loaf .... 1 lump i 7.6 7.6 30.0 Sugar, loaf ... 1 cup 6i 184.0 184.0 736.0 Sugar, powdered . 1 tbsp. * 12.0 .... 12.0 48.0 Sugar, powdered . 1 cup 6i 184.0 — 184.0 736.0 Sugar of milk 10 100.0% 4 1 Sugar of milk 1 teaspoon 0.164 5.0 100.0% 20.5 (av. size) 65.6 Sugar of milk 1 tbsp. 0.564 16.0 100.0% Sweetbreads .... 1 serving 3§ 100.0 iti. 8 12.1 176.0 Sweetbreads .... 1 lb. 16 454.0 76.2 54.8 798.0 Sweetbreads .... 1 pair 8 227.0 38.1 27.4 399.0 T (med. size) Tapioca pearled . 1 tbsp i 14.0 0.03 12.3 49.0 Tapioca, pearled . 1 cup 6i 184.0 0.4 159.5 640.0 Tapioca, minute . 1 tbsp. i 14.0 0.03 12 2 49.0 Tomatoes 1 tbsp. i + 15.0 0.2 0.03 0.6 4.0 Tomatoes 1 cup 8 227.0 2.7 0.5 9.0 51.0 Tomatoes 1 medium (whole 5 142.0 0.5 0.3 3.0 16.0 tomato) 164.0 Trout (edible portion) . 1 serving 31 100.0 17.8 10.3 Trout (edible portion) . 1 lb. 16 454.0 80.6 46.7 743 0 Turnip 1 serving 31 100.0 1.3 0.2 8.i 39.0 Turkey (edible portion) 1 serving 31 100.0 21.1 22.9 290.5 Turkey (edible portion) 1 lb. 16 454.0 95.7 103.9 1317.0 W Walnuts, English 1 cup 51 156.0 25.8 98.8 25 1 1093.0 Walnuts, English 1 meat 1.0 0.17 0.63 0.16 7.0 Whey . . ... 1 glass 61 184 0 1.8 0.5 9.3 50.0 Whitefish (ed port.) 1 serving 31 100.0 22 9 6.5 150 0 Whitehall (ed. port.) 1 lb. 16 454.0 103 8 29 4 681.0 INDEX. A Abnormal children, feeding of, 275 stools, breast feeding and, 285 Absorption, 38 of carbohydrates, 38, 40 of fats, 41, 241 of food after gastroenterostomy, 626 in intestines, 38 in mouth, 38 of proteins, 38, 183 of starch, 225 of sugars, 224 Accessory digestive glands, diseases of, 429 food-stuffs, 103 Achylia gastrica, diet in, 356 Acid foods, 87 Acidity of gastric juice, 30 organic, diet in, 388 water test for, 397 Acidosis in nephritis, chronic, 467 Acids in fruits, 253 Acne rosacea, diet in, 447 vulgaris, diet in, 448 Williams, 448 Acromegaly, basal metabolism in, 63 diet in, 634 Acute articular rheumatism, diet in, 609, 610 infections, diet in, 582 yellow atrophy of liver, diet in, 434 Addison’s disease, diet in, 639 Adrenalin in diabetes mellitus, effect of, 479 in osteomalacia, 549 Aged, energy requirements of, 67 Albumen water, 679, 681 Albuminuria in nephritis, 461 Alcohol effect of, 269 in fattening cures, 537 in fever, 588 as a food, 269 in gout, 529 hypertension and, 328 therapeutic value of, 270 Alcoholic beverages, 269-272 classification of, 271 therapeutic value of, 270 Ale, 273 Aleuronat, 682 Alimentary canal, sensibility of, 37 time for passage of food through, 46 eruptions in diseases of skin, 440 glycosuria, 40, 478 diabetes mellitus and, 478 Alkaline foods, 87, 88 reserve in genito-urinary disease, 453 in pellagra, 565 treatment of peptic ulcer, 373 Allen’s treatment of diabetes mellitus, 486, 487, 494 ■ Geyelin’s modifica- tion of, 490 Joslin’s r£sum6 of, 501 . Ambulatory cure in peptic ulcer, 380 Amino-acids in diabetes mellitus, 480 synthesis of, 77 Ammonia, excretion of, 50 Amylase, salivary, 26 Amyloid kidney, 475 liver, diet in, 434 Anabolism, 17 Anaphylaxis, arteriosclerosis and, 326 asthma and, 335 in genito-urinary diseases, 452 Longcope on effects of, 452 Anemia, 550 basal metabolism in, 63 pernicious, 555 Barbour on, 556 bone-marrow in, 556 diet in, 556 hemolysis in, 555 posthemorrhagic, 557 secondary, 555 Aneurysm, diet in, 328 Tufnell’s, 328 Angina pectoris, diet in, 328 Animal food vs. vegetable food, 150 Anorexia, nervous, diet in, 580 Antiketogenic substance diets, Schaffer’s 4^3 Antineuritic vitamins, 107 Antirachitic vitamin, 104, no Antiscorbutic vitamin, 108 Antiscorbutics in scurvy, 561 Antixerophthalmic vitamins, 106 709 710 INDEX Apoplexy, diet in, 571, 572 Karell’s, 572 hypertension in, 572 Appendicectomy, diet after, 629 Appendicitis, acute, diet in, 417 chronic, diet in, 419 larval, 419 Ochsner’s treatment of, 418 Appetite, 31, 37 hunger contrasted with, 33 juice, 32 stimulation of, 33 Apples, 253 _ composition of, 254 Arrow-root gruel, 681 Arteriosclerosis, anaphylaxis and, 326 meat in, 326 Arthritis deformans, diet in, 619 rheumatoid, diet in, 619 Artificial buttermilk, 680 feeding, 288 food, 682. See Foods, artificial. Assimilation limit, 41 Asthma, anaphylaxis and, 335 diet in, 335 _ foods to avoid in, 336 Athletes, diet for, 663 carbohydrates in, 662 low protein, 662 sugar in, 663 dietary rules for, 664 foods to avoid, 664 Atonic constipation, diet in, 412 Atony, gastric, 384 diet in, 386 Wegele’s, 387 general directions, 385 intestinal, diet in, 416 Atrophy of liver, acute yellow, diet in, 434 Auto-intoxication, Combe on, 422 food in, nitrogenous, 424 indicanuria in, 423 indol in, 422 intestinal, 421 bacteriology of, 422 by-products in, 422 causes of, 421 dietetic indications in, 424 menus in, 425 mild, in pregnancy, 651 nephritis in, 423 phenol in, 422 skatol in, 422 symptoms of, rectal pressure as cause of, 423 Aviators, diet for, 664 Azotorrhea, diet in, 437 B Bacillus acidophilus, 398 in typhoid fever, 593 j Bacteria in feces, 43, 45 in large intestine, action of, 43 intestinal, 42 indispensable, Nuttall on, 422 Schottelius on, 422 Thierfelder on, 422 in milk, 163 in small intestine, action of, 44 in stomach, action of, 44 Bacterial flora, relation of diet to, 45 Bacteriology in diseases of intestines, 398 of intestinal auto-intoxication, 422 Baking of meat, 190 powders, 234 Bananas, 236 Banting’s cure in obesity, 5x7 Barbour on pernicious anemia, 556 Barley, 228 gruel, 681 Basal metabolism, 61 in acromegaly, 63 age and, 67 in anemia, 63 in cancer, 63 in convalescence, 63 in diabetes, 63 disease and, 63, 68 estimation of, 62, 63, 66 in goiter, 63 in leukemia, 63 standards of, 62 in typhoid fever, 63 variations of, in disease, 63 Beef broth in artificial feeding of infants, 3 00 edible portions of, 187 juice in artificial feeding of infants, 300 meal, 682 retail cuts of, 188 tea, 198 Beer, 273 Beet sugar, 221 Benzoic acid, 253 Beriberi, diet in, 561 Funk on, 562, 566 polished rice in, 562 vitamins in, 562 in yeast, 562 Beta-oxybutyric acid in diabetes mel- litus, 481 Beverages, 257 alcoholic, 269-272 classification of, 271 therapeutic value of, 270 in fever, 588 for sick, 679 albumen water, 679, 681 artificial buttermilk, 680 cocoa shells, 681 egg lemonade, 680 nog, 681 INDEX 711 Beverages for sick, flaxseed tea, 679 gruels, arrow-root, 681 barley, 681 cereal, 681 flour, 681 koumyss, 680 peptonized milk, 680 ripened milk, 680 wine whey, 680 Biliary cirrhosis, diet in, 433 colic, diet in, 436 Biological value of proteins, 79 Biscuits, 234, 235 Blood, diseases of, diet in, 550 fat, 42 Blood-pressure, effect of various sub- stances on, 327 low protein diet in genito-urinary diseases and, 460 Bloodvessels, diseases of, diet in, 326 Body surface, calculation of, 62, 65 in children, 65 Bone-marrow in pernicious anemia, 556 Brain workers, diet for, 661 Bread, 233 in artificial feeding of infants, 301 and butter diet in diabetes mel- litus, 495 leavening of, 233 substitutes in diabetes mellitus, 503, 505 Breakfast foods, 152, 235 Breast feeding, 275, 280 colic and, 285 contraindications for, 281 exercise and, 283 gas and, 285 intervals of nursing, 281 length of each nursing, 282 mother’s diet and, 283 stools and, abnormal, 285 normal, 285 vomiting and, 284 Brill’s disease, diet in, 589 Broiling of meat, 190 Bronchitis, diet in, 333 chronic, 333 Buckwheat, 228 Butter, 244 color of, 244 fatty acid in, 245 manufacture of, 244 renovated, 245 substitutes, 245 Buttermilk, artificial, 680 C Caffein in coffee, 260 from coffee in gout, 529 in tea, 258 Cakes, 235 j Calcium content of foods, 96 requirement, 93 Calculi, phosphates, 540 Calorgenic substances, 69 Caloric value of food-stuffs, 56 Calorie, 56 Calories, apportionment of, among food types, 145 in carbohydrates, 57 in fat, 57 percentage distribution of, in diet, 129, 158 in protein, 57 Calorimeter, 59 Calorimetry, direct, 59 indirect, 59 Cammidge on causes of diabetes mel- litus, 481 Cancer, basal metabolism in, 63 cells, cholesterin in, 658 diet in Centanni’s, 659 sulphur-free foods in, 658 Candy,223 Cane sugar, 221 Canned goods, poisoning by, 667 Cantaloupes, 253 Carbohydrate contents of foods com- monly used in diabetes mellitus, 507 equivalents in diabetes mellitus, table of, 491 percentage in vegetables in diabetes mellitus, 500 relation of protein requirements to, 79 requirement of artificial feeding of infant, 290 rich foods, 219-238 barley, 228 buckwheat, 228 calcium content of, 96 candy, 223 chlorine content of, 89 corn, 228 fructose, 222 glucose, 221 grains and their products, 226-228 invert sugar, 222 iron content of, 98 lactose, 222 maltose, 222 maple sugar, 222 oats, 229 phosphorus content of, 92 preserves, 223 rice, 229 rye, 230 starches, 224-226 sucrose, 221 sugars, 220-224 vitamins in, distribution of, 1x4 712 INDEX Carbohydrate rich foods, wheat, 230 tolerance, diabetes mellitus and ketonuria and, 483 in diabetes mellitus, 487, 501 units in chronic nephritis, Foster’s, 492 Carbohydrates, 19, 219, 226 absorption of, 38, 40 calories in, 57 classification of, 219 in diet for athletes, 662 place of, 219 digestion of, in intestines, 35 in stomach, 26, 31 in fattening cures, 536 in fever, 585, 586 formation of fat from, 80 functions of, 19 general composition of, 219 in gout, 528 of milk, 165 nutritive value of, 219 in rectal feeding, 643 requirements of, in children, 128 respiratory quotient of, 60 in subcutaneous feeding, 646 in typhoid fever, 592 Carcinoma of stomach, diet in, 389, 390 Cardiac decompensation, diet in, 321 disease, diet in, 320 fluids in, restricted, 323 functional, diet in, 320 Gaulston’s sugar treatment of, 323 Nauheim exercises in, 325 organic, diet in, 320 tobacco in, 329 Casein, 164 preparations, 212 Caseinogen, 164 Castration in osteomalacia, 549 Catabolism, 17 Catalytic action, 23 Catarrhal jaundice, diet in, 431 Cellulose, 236 Centanni’s diet in cancer, 659 Cereal gruel, 681 Cereals in artificial feeding of infants, 296, 300 in diet of children, 132 Cerebral hemorrhage, diet in, 571 meningitis, diet in, 608 Cerebrospinal meningitis, diet in, 608 Chace and Folin on radio-active waters in gout, 533 Cheese, 211-213 composition of, 211 in diet, place of, 211 digestibility of, 212 nutritive value of, 211 preparation of, 211 varieties of, 212 Childhood, feeding in, 275 I Children, annual increment gain in, 123 carbohydrate requirements of, 128 diet of, after second year, selection of, 131 cereals in, 132 fats in, 133 fruits in, 133 inorganic salts in, 130 meat in, 132 milk in, 131 vegetables in, 133 vitamins in, 130 eggs as food for, 131 energy requirements of, 124 fat requirements of, 127 feeding of, 122, 131 food habits of, 134 requirements of, 122 foods for, 131 height of, 123 meals of, planning of, 134 protein requirements of, 126 water for, 131 weight of, 123 Chittenden’s low protein allowance in gout, 526 diet in psoriasis, 442 Chlorides in diabetes insipidus, 476 Chlorine content of foods, 89 requirement, 88 Chlorosis, 550 diet in, 553 iron in, 552 theories of action of, 552 protein-rich food in, 554 rest in, 551 treatment of, 551 Chocolate, 262 Cholelithiasis, diet in, 434, 436 postoperative, 435 prophylactic, 435 olive oil in, 683 Cholera diet in, 614 dietetic rules in, 614 intravenous infusion in, 615 1 Cholesterin in cancer cells, 658 Chorea, diet in, 574 Circulatory organs, diseases of, 320 Cirrhosis, biliary, diet in, 433 portal, diet in, 432 Coagulation of milk, 165, 173 Cocoa, 262 active principle in, 263 in gout, 529 shells, 681 Cod-liver oil, 248, 683 emulsion of, 685 vitamin in, 684 Coffee, 259 caffein in, 260 in gout, 529 preparation of, 260 special, 261 INDEX 713 Coffee substitutes, 261 Cohnheim’s classification of enteritis, 399 . . diet in chronic diarrhea, 409 Coleman’s diet in fever, 585 in peptic ulcer, 379 in typhoid fever, 593 Colic, biliary, diet in, 436 breast feeding and, 285 feeding of infants and, 303 mucous, diet in, 405 Colitis, acute, diet in, 403 chronic, diet in, 404 membranous, diet in, 405 nervous origin of, 405 mucous, chronic, diet in, 405 Collagen, digestion of, 31 Colostrum in woman’s milk, 275 Coma without ketonuria in diabetes mellitus, 482 Combe on auto-intoxication, 422 Comedones, diet in, 451 Condensed milk, 168 Condiments in diet, place of, 256 Confinement, diet after, 652 Conklin’s starvation treatment of epi- lepsy, 570 Constipating diet, 633 Constipation, atonic, diet in, 412 chronic, diet in, 413 feeding of infants and, 305 mineral oil in, 415 obstructive, diet in, 415 spastic, diet in, 414 varieties of, 411 Convalescence, basal metabolism in, 63 Convalescent diet, 318 Cooking. See Meat, vegetables, etc. Corn, 228 flour, 228 meal, 228 oil, 248 starch, 229 sweet, 229 Cotton-seed oil, 247 in gastric hyperacidity, 684 Couran on diet in sprue, 656 Cow’s milk, salts in, 279 Cranberries, 253 Cream, 243 Creatine, excretion of, 51 Creatinine, excretion of, 51 Cretinism, diet in, 638 Cyclic vomiting, feeding of infants in, 313 Cystitis, 473 D Dechlorination in nephritis, 459 Decompensation, cardiac, diet in, 321 Defecation, 37 Deficiency diseases, diet in, 559 Delirium tremens, diet in, 579 Dental caries, diet in, 657 statistics of, 657 Dermatitis, diet in, 450 exfoliative, 451 herpetiformis, 450 Dermatoses, disturbed metabolism and, 440 Dextrin, 225 Dextrose. See Glucose. intravenously, Woodyattand Wilde, 647 Diabetes insipidus, 476 chlorides in, 476 mellitus, 477 aceto-acetic acid in, 482 adrenalin in, effect of, 479 alimentary glycosuria and, 478 Allen treatment of, 486, 487, 494 Geyelin’smodifi cation of, 490 Joslin’s resume of, 501 amino-acids in, 480 antiketogenic substances in, 483 basal metabolism in, 63 beta-oxybutyric acid in, 481 bread substitutes in, 503, 505 carbohydrate contents of foods commonly used in, 507 percentage in vegetables in, 500 tolerance in, 487, 501 cause of, Cammidge on, 481 Frank on, 476 coma in, without ketonuria, 482 diabetic milk in, 506 diet in, bread and butter, 495 in gout with, 509 high in fat in, 504 medium severe, 493 nephritis complicating, 5io obesity complicating, 510 potato, 494 severe, with ketonuria, 493 standard strict, 488 Geyelin’s, 498 with restricted protein, 487- 489 m elderly people, diet in, 509 exercise in, 500 fast day in, 498 fasting in, 494, 495 fat tolerance in, 501 green days in, 489 insulin in, 477 714 INDEX Diabetes mellitus, Joslin’s resume of Allen’s treatment of, 501 ketogenic substances in, 483 Naunyn on, 478 nitrogen balance in, 481 von Noorden on, 478 protein metabolism in, 479 tolerance in, 501 relation of fat metabolism to, 482 special recipes for, 505 theories concerning, 478 Woodyatt’s diatetic manage- ment of, 484 in young people, diet in, 509 tuberculosis and, 346 Diabetic milk in diabetes mellitus, 506 Diarrhea, causes of, 407 chronic, diet in, Cohnheim’s, 409 dietary regulations in, 409 feeding of infants and, 304 from drugs, diet in, 408 from food, diet in, 408 gastrogenic, diet in, 407 habit, diet in, 408 irritative, diet in, 408 nervous, diet in, 408 pancreatic, diet in, 408 toxic, diet in, 407 Diet in achylia gastrica, 356 in acne rosacea, 447 vulgaris, 448 Williams, 448 in acromegaly, 634 in acute appendicitis, 417 articular rheumatism, 609, 610 colitis, 403 dysentery, 403 eczema, 444 enteritis, 399 gastritis, 359 hepatic congestion, 431 infections, 582 pancreatitis, 438 peritonitis, 616 thyroiditis, 635 yellow atrophy of liver, 434 in Addison’s disease, 639 after appendicectomy, 629 confinement, 652 gall-bladder operations, 632 hemorrhage, 632 of stomach, 383 tonsillectomy, 623 in amyloid liver, 434 in aneurysm, 328 Tufnell’s, 328 in angina pectoris, 328 antiketogenic substance diets, Schaffer’s, 483 in apoplexy, 571, 572 Karell’s, 572 in appendicitis, 417 Diet in arthritis deformans, 619 ash-free, 86 in asthma, 335 for athletes, 663 carbohydrates in, 662 low protein, 662 sugar in, 663 in atonic constipation, 412 for aviators, 664 in azotorrhea, 437 in beriberi, 561 in biliary cirrhosis, 433 colic, 436 for brain workers, 661 in Brill’s disease, 589 in bronchitis, 333 for calculi in phosphaturia, 540 in cancer, 658 Centanni’s, 659 carbohydrate in, place of, 219 in carcinoma of stomach, 389, 390 decompensation, 321 disease, 320 functional, 320 organic, 320 in catarrhal jaundice, 431 causing scurvy, 559 in cerebral hemorrhage, 571 meningitis, 608 in cerebrospinal meningitis, 608 cheese in, place of, 211 of children, cereals in, 132 fats in, 133 fruits in, 133 inorganic salts in, 130 meat in, 132 milk in, 131 vegetables in, 133 vitamins in, 130 in chlorosis, 553 in cholelithiasis, 434, 436 in cholera, 614 in chorea, 574 in chronic appendicitis, 419 bronchitis, 333 colitis, 404 constipation, 413 diarrhea, Cohnheim’s, 409 eczema, 445 enteritis, 400 Schmidt’s test, 401 modified, 402 gastritis, 360 hepatic congestion, 432 infections, 617 infectious arthritis, 611 mucous colitis, 405 nephritis, 466 general list, 490 Karell’s, 468 low protein, 467 Mosenthal’s, 467 nitrogen retention in, 467 INDEX 715 Diet in chronic nephritis, salt-poor, 470 solution, 469 pancreatitis, 438 peritonitis, 616 rheumatism, 61 x uremia, 467 in comedones, 451 in complication of pregnancy, 648 condiments in, place of, 256 constipating, 633 in contracted pelvis, 651 in cretinism, 638 in cure of rickets, 316 in deficiency diseases, 559 in delirium tremens, 579 in dental caries, 657 in dermatitis, 450 herpetiformis, 450 in diabetes mellitus, bread and butter, 495 medium severe, 493 potato, 494 severe with ketonuria, 493 standard strict, 488 Geyelin’s, 498 with restricted protein, 489 in diarrhea from drugs, 408 from food, 408 in digastric neuroses, 578 in diseases of blood, 550 of bloodvessels, 326 of ductless glands, 634 of gall-bladder, 429 of heart, 320 of intestines, 398 of liver, 429 of lungs, 330 of nervous system, 568 functional, 572 organic, 568 of pancreas, 437 of skin, 440 of stomach, 348 in eczema, 443 Finckelstein’s, 446 Holt’s, 446 in edema, 468 eggs in, place of, 206 in emphysema, 334 in empyema, 337 in enteritis, 399, 400 in epilepsy, 569 salt-free, 570 in erythema, 449 lacto-vegetarian, 449 excretion of uric acid and, 51 in exfoliative dermatitis, 451 in exophthalmic goiter, 635, 638 special indications for, 638 fats in, place of, 239 in fatty heart, 324 liver, 433 Diet in fever, 585 Coleman’s, 585 Du Bois’s, 585 Shaffer’s, 585 fruits in, place of, 250 fuel value of, calculation of, 57 in furunculosis, 451 in gastric acidity, organic, 388 atony, 386 Wegele’s, 387 dilatation, 392 diseases, 348 hyperacidity, 351, 354 hypersecretion, 355 hypoacidity, 356 neuroses, 394 secretory, 394 of sensation, 395 in gastro-duodenitis, 431 in gastroenterostomy, 623, 624 Finney’s, 627 von Leube’s, 625 in gastrogenic diarrhea, 407 in genito.-urinary disease, low pro- tein, blood-pressure and, 460 in gonorrhea, 474 in gout, in acute podagra, 529 with diabetes mellitus, 509 in gouty diathesis, 532 grains in, place of, 226 in grippe, 609 in habit diarrhea, 408 in hemorrhoids, 427 in Hirschsprung’s disease, 427 in hydrothorax, 337 in hyperalcoholism, 579 in hyperchlorhydria, reduction by, 351 in hyperidrosis, 451 in hypertension, 327 in indigestion, 349 in infantilism, 437 in influenza, 609 in insanity, 570 in insomnia, 578 in intestinal atony, 416 hemorrhage, 406 neuroses, 410 in irritable stomach, 351 in irritative diarrhea, 408 Karell’s, 321 Potter’s modification of, 322 in lactation, 120 Hart-Nelson-Petz, 653 results of experimental, 654 in laparotomy, 621 in larval appendicitis, 419 in leanness, 534 legumes in, place of, 214 in leukemia, 557 in lockjaw, 612 low calcium, 619 in rheumatoid arthritis,619 716 INDEX Diet in malarial fever, 606 in measles, 608 meat in, place of, 184 in membranous colitis, 405 in migraine, 572 milk in, place of, 162 production and, 120 of mother, 120 mother’s breast feeding and, 283 in mucous colitis, 405 in myxedema, 638 in nephritis complicating diabetes mellitus, 510 Karell’s, 462, 467 milk, 462 in pregnancy, 651 in nephrolithiasis, 474 low protein, 474 in nervous anorexia, 580 diarrhea, 408 in neurasthenia, 575 Keating’s, 576 Weir Mitchell, 576 in neuritis, 568, 569 gouty, 568 von Noorden maintenance, 534 in obesity complicating diabetes mellitus, 5x0 Ebstein’s, 519 von Noorden’s, 515, 517 Oertel’s, 518 Schweninger’s, 520 in obstructive constipation, 415 in old age, 542 Sir Henry Thompson’s, 547 in osteomalacia, 549 in oxaluria, 541 in pancreatic diarrhea, 408 in paratyphoid fever, 606 in pellagra, 564, 566 Goldberger’s, 567 in peptic ulcer, Coleman’s, 379 Lenhartz’s, 366 von Leube’s, 363, 364 Sippy’s, 373 percentage distribution of calories in, 129, 158 in periodic headache, 572 in perityphlitis, 420 in pernicious anemia, 556 for phosphaturia calculi, 540 in portal cirrhosis, 432 postoperative, 623 in cholelithiasis, 435 for digestive tube, 623 gastric, 623 intestinal distention, 631 lesions, 628 in vomiting, 629 preoperative, 621 preparatory to gastric operations, 622 Diet in prevention of rickets, 316 prophylactic, in cholelithiasis, 435 in diseases of gall-bladder, 430 of liver, 430 in pruritus, 450 in psoriasis, 441 low protein, 442 Chittenden on, 442 in puerperium, 652 in purpura hemorrhagica, 558 in pyelitis, 473 lactofarinaceous, 473 relation of, to bacterial flora, 45 of feces to, 46 to operations, 621 in rheumatoid arthritis, 619 routine in old age, 547 in scarlet fever, 607 in scurvy, 560 in senile heart, 325 for singers, 660 in smallpox, 607 in spastic constipation, 414 for speakers, 660 in sprue, Conran on, 656 Manson on, 655 in subacute rheumatism, 611 in tetanus, 612 in toxic diarrhea, 407 polyneuritis, 561 in tuberculosis, 338 complications in, 346 Loomis sanitarium, 345 object of, 339 standard, 344 in typhlitis chronic, 420 in typhoid fever, 590, 595 bacteriology and, 592 Coleman on, 593 complications, 605 extra, 597 fluid, 596 intestinal hemorrhage in, 606 liberal results of, 594 menus and food combina- tions, 597 modified milk, 597 nausea in, 351, 606 older, 590 perforation, 606 vomiting in, 351, 606 in typhus fever, 589 in ulceration of intestines, 406 in urticaria, 449 vegetables in, place of, 250 vegetarian, 670, 673 disadvantages of, 671 grounds for, 670 longevity in, 670 metabolism in, 672 woman’s milk and, 280 in xerophthalmia, 563 INDEX 717 Diet in yellow fever, 613 Dietaries, standard, 80 Dietary cures, special, 669 peculiarities, 350 precautions in food poisoning, 668 regimen of Horace Fletcher, 674 rules for athletes, 664 tests in genito-urinary diseases, 455 treatment of peptic ulcer, method of, 362 Dietetic indications in intestinal auto- intoxication, 424 management of chronic nephritis, 465 rules in cholera, 614 treatment in chronic nephritis, 485 Dietetics, relation of clinical experience to, 21 Diets for children, 131 convalescent, 318 essentials of, 141 fluid, 318 high in fat in diabetes mellitus, 504 ketogenic substances, 483 milk, 318 for postoperative complications, 629 salt-poor, 470, 471, 472 soft, 318 for special chemical needs, 319 mechanical needs, 319 various kinds of, 318 vegetable, 156 Digestibility of cheese, 212 coefficients of, 53 of eggs, 209 of fats, 241 of fish, 204 of food, 52 measure of, 52 of meat, 192 of potatoes, 238 Digestion, 23 of carbohydrates in intestines, 35 in stomach, 26, 31 of collagen, 31 completeness of, 52 disorders of, in diseases of skin, 440 ease of, 52, 53 effect of sucrose on, 224 of fats, 240 in stomach, 31 gastric, 27 intestinal, 35 of milk, 172 in stomach, 29, 31 of nucleoproteins, 36 oral, 25 of proteins, 183 in intestines, 36 rapidity of, 52, 53 salivary, 25. See Oral, in stomach, 26 Digestion of starch, 26, 225 in stomach, 29 of sugars, 223 Digestive glands, accessory diseases of, 429 neuroses, diet in, 578 symptoms in tuberculosis, 339 tube, postoperative diet for, 623 Dilatation, acute gastric, vomiting from, 639 gastric, diet in, 392 olive oil in, 683 pyloric stenosis in, 393 Distilled liquors, 274 Dried milk, 169 Drinks in diseases of lungs, 332 Drugs, diarrhea from diet in, 408 woman’s milk and, 279 Du Bois’s diet in fever, 585 Duckworth on gout and uric acid, 525 Ductless glands, diseases of, diet in, 634 Duodenal feeding, 381 Einhorn’s, 383 ulcer, 362. See Peptic ulcer. Dysentery, acute, diet in, 403 E Ebstein dietary in obesity, 519 on gout, 525 Eczema, acute, diet in, 444 chronic, diet in, 445 diet in, 443 Finckelstein’s, 446 Holt’s, 446 in nurslings, 445 dietary treatment of, 447 stool examination in, 446 protein sensitization in, 444 soup in, 446 of younger children, O’Keefe on, 446 Edema, diet in, 468 Egg lemonade, 680 nog, 681 Eggs, 206-211 in artificial feeding of infants, 300 cooking of, 208 in diet, place of, 206 digestibility of, 209 in fever, 587 as food for children, 131 general properties of, 206 nutritive value of, 206 preserved, 210 substitutes for, 211 in tuberculosis, 344 white of, 207 yolk of, 207 Einhorn’s duodenal feeding, 383 Emphysema, diet in, 334 Empyema, diet in, 337 718 INDEX Emulsion of cod-liver oil, 685 Endogenous protein metabolism, 75 Energy requirement, 56-73 activity and, 73 age and, 71 of aged, 67 of artificial feeding of infant, 288 of children, 73, 124 determination of, 59 factors affecting, 70 in pregnancy, 117 total daily, 69 in typhoid fever, 594 Enteritis, acute, diet in, 399 chronic, diet in, 400 Schmidt’s test, 401 modified, 402 Cohnheim’s classification of, 399 Enzyme action, 23 factors affecting, 24 in stomach, 29 Enzymes, activation of, 25 in gastric juice, 29 inactive, 25 in intestines, 36 in pancreatic juice, 36 Epidermal excretion, 49 Epilepsy, diet in, 569 salt-free, 570 intestinal decomposition and, 570 salt in, 569 starvation treatment of, 570 Concklin’s, 570 Erepsin, 36 Erythema, diet in, 449 lactovegetarian, 449 varieties of, 449 Esophagus, stenosis of, olive oil in, 683 Excretion of ammonia, 50 of creatine, 51 of creatinine, 51 epidermal, 49 intestinal, 48 nitrogen, 50 of urea, 50 of uric acid, 51 of water, rapidity of, 102 Exercise, breast feeding and, 283 Exfoliative dermatitis, diet in, 451 Exophthalmic goiter, diet in, 635, 638 for special indications in, 638 F Farinaceous foods in infant feeding, 293 Fast day in diabetes mellitus, 498 Fasting, 136 in diabetes mellitus, 494, 495 Fat, absorption of, 41 Fat, blood, 42 calories in, 57 digestion of, in stomach, 31 in fattening cures, 537 in fish, variation of, 201 food, relation of, to storage of fat, 42 formation from carbohydrate, 80 higher mixtures in artificial feeding of infants, 299 metabolism, relation of, to dia- betes mellitus, 482 relation of protein requirements to, 79 ... requirement of artificial feeding of infant, 289 of children, 127 respiratory quotient of, 60 soluble A. See Vitamin A. in xerophthalmia, 563 tolerance in diabetes mellitus, 501 in woman’s milk, 277 Fat-rich foods, 239-249 butter, 244 calcium content of, 96 chlorine content of, 89 cod-liver oil, 248 corn oil, 248 cotton-seed oil, 247 cream, 243 iron content of, 98 lard, 247 oleomargarine, 246 olive oil, 248 phosphorus content of, 92 vitamins in, distribution of, 115 Fats, 19, 20 absorption of, 240 characteristic of species, 240 in diet of children, 133 place of, 239 digestibility of, 241 digestion of, 241 in fever, 588 functions of, 19, 242 general properties of, 239 melting point of, 241 and digestibility, 241 of milk, 165 nutritive value of, 239-243 in rectal feeding, 643 in subcutaneous feeding, 646 in tuberculosis, 344 in typhoid fever, 593 Fattening cures, 534 alcohol in, 537 carbohydrates in, 536 fat in, 537 _ foods used in, 535 protein in, 535 Fatty heart, diet in, 324 liver, diet in, 433 INDEX 719 Feces, 45 bacteria in, 43, 45 indigestible food and, 47 reaction of, 48 relation of, to diet, 46 Feeding of abnormal children, 275 after intubation, 633 artificial, 288 breast, 275, 280 colic and, 285 contraindications for, 281 exercise and, 283 gas and, 285 intervals of nursing, 281 length of each nursing, 282 mother’s diet and, 283 stools and, abnormal, 285 normal, 285 vomiting and, 284 in childhood, 275 of children, 131 over one year, 311 gavage in, 311 duodenal, 381 Einhorn’s, 383 in infancy, 275 of infants after second year, 308 artificial, beef broth, 300 juice, 300 bread and, 301 carbohydrate requirement of, 290 cereals in, 296, 300 eggs and, 300 energy, requirement of, 288 fat requirement of, 289 food other than milk in, 299 higher fat mixtures in, 299 increasing formula, 295 inorganic salts and, 292 method of preparing for- mula, 295 orange juice, 299 potato and, 301 proprietary foods and, 293 protein requirement of, 289 rice and, 301 starch requirement of, 291 sugar requirement of, 290 vegetables and, 301 vitamin requirements of, 292 water requirement of, 292 colic and, 303 constipation and, 305 in cyclic vomiting, 313 diarrhea and, 304 during acute infections, 310 second year, 307 farinaceous foods and, 293 Feeding of infants, gas and, 303 gavage in, 311 miscellaneous foods and, 293 in nutritional disturbances, 315 Pirquet method of, 309 preparations containing cow’s milk, 293 large amounts of mal- tose, 293 proprietary foods and, 293 protein milk and, 304 in pyloric stenosis, 312 in rickets, 315 stools and, 303 vomiting and, 302 in fever, intervals of, 588 intravenous, 647 formula for, 647 mixed, 285 night in insomnia, 578 of normal children, 275 palatability and, 141 a factor in, 141 psychology of, 140 rectal, 48, 640 carbohydrates in, 643 fats in, 643 formula for, 644 precautions in, 644 protein in, 641 rules for, 317 in tuberculosis, general, 347 subcutaneous, 645 carbohydrates in, 646 fats in, 646 protein in, 645 transgastric, 381 in typhoid fever, basis for, 591 general direction for, 595 of unconscious patients, 665 Ferments. See Enzymes. Fever, 582 alcohol in, 588 beverages in, 588 carbohydrates in, 585, 586 causes of, 583 diet in, 585 Coleman’s, 585 Du Bois’s, 585 Shaffer’s, 585 eggs in, 587 fats in, 588 feeding in, intervals of, 588 meat protein in, 587 milk preparations in, 586 protein in, 586 theoretical considerations of, 584 Finckelstein’s diet in eczema, 446 Finney’s diet in gastroenterostomy, 627 Fischer’s theories of nephritis, 460 Fish, 200-204 cold storage, 203 composition of, 201 720 INDEX Fish, cooking of, 204 digestibility of, 204 fat in, variations in, 201 oil, 248 poisoning by, 667 preserved, 203 in season, 202 shell, kinds of, 200 Flavoring extracts, 257 Flaxseed tea, 679 Fletcher, Horace, dieting regimen of, 674 Fletcherism, 673 and U. S. Army instructions, 675 Flies, food diseases and, 679 Flour, 231 entire, 232 gluten, 232 gruel, 681 kinds, 231 Fluid diet, 318 Fluids in cardiac disease, restricted, 323 Folin-Denis reduction cures in obesity, 522 Food, 18 absorption of, after gastroenteros- tomy, 626 adjuncts, 256 animal vs. vegetable, 155 in autointoxication, nitrogenous, 424 consumption in U. S., 158 costs of, 147 factors which influence, 148 preservation and, 151 defined, 17 diarrhea from diet in, 408 digestibility of, 52 diseases, flies and, 679 dynamic effect of, 69 economical, 152 economics, 140 especially desirable in old age, 545 fat, relation of storage of, 42 gastric hypoacidity, sterilized, 358 habits of children, 134 indigestible, feces and, 47 passage of, through stomach, 28 poisoning, 665 canned goods in, 667 dietary precautions in, 668 by fish, 667 by meat, 666 by vegetables, 667 protection, 679 protective, 106, 161 rate of passage of from stomach, 53- 54 requirement of artificially fed in- fant, 288 of children, 122 of lactation, 120 in old age, 543 | Food requirement of pregnancy, 117 quantitative, 142 stuffs, accessory, 103 caloric value of, 56 classes of, 18 sulphur-free in cancer, 658 Kessler, 658 time for passage of, through ali- mentary tract, 46 Foods, acid, 87 alkaline, 87, 88 antiscorbutic, 561 artificial, 682 aleuronat, 682 beef meal, 682 cod-liver oil, 683 nutrose, 682 olive oil, 683 peptones, 682 plasmon, 682 roberat, 682 somatose, 682 tropon, 683 yeast, 683 for athletes to avoid, 664 to avoid in asthma, 336 calcium content of, 96 carbohydrate-rich, 219, 238 in carcirio'ftia of stomach, 391 for children, 131 chlorine content of, 89 classification of, 161 common, salt content of, 472 energy value of, 57 fat-rich, 239-249 commonly used in diabetes mellitus, carbohydrate contents of, 507 in gout, 528 purin-free, 530 soft, 530 iron content of, 98 for old age, 545 preparation of, 547 phosphorus content of, 92 protein, 175 protein-rich, 184-217 purin bodies in, 533 purin-free, 530 in tuberculosis, special, 343 used in fattening, cures, 535 water and salt-rich, 250-274 | Foster’s carbohydrate units in diabetes mellitus, 492 I Frank on causes of diabetes mellitus, 476 | Fructose, 222 Fruit acids, 253 cures, 677 ; Fruits. See Water and salt-rich foods, acids in, 253 composition of, 251, 252 cooking of, 254, in diet of children, 133 place of, 250, 252 INDEX 721 Fruits, nutritive value of, 250 preservation of, 255 vitamins in, 114 Fuel value, 57 of diet, calculation of, 57 Functional cardiac disease, diet in, 320 diseases of nervous system, diet in, 572 Funk on beriberi, 562, 566 Furunculosis, diet in, 451 G Gaertner’s table of height, weight and blood-pressure in obesity, 514 Galisch’s cure in obesity, 521 Gall-bladder, diseases of, diet in, pro- phylactic, 430 operations, diet after, 632 Game, 204 Garrod’s facts in gout, 525 Gas, breast feeding and, 285 feeding of infants and, 303 Gastric acidity, organic, diet in, 388 water test for, 397 atony, 384 diet in, 386 Wegele’s, 387 general directions in, 385 carcinoma, 389 digestion, 27 dilatation, acute, vomiting from, 630 diet in, 392 olive oil in, 680 pyloric stenosis in, 393 diseases, diet in, 348 hyperacidity, cottonseed oil in, 684 diet in, 351, 354 olive oil in, 684 hypersecretion, diet in, 355 hypoacidity, diet in, 356 sterilized food in, 358 juice, acidity of, 30 enzymes in, 29 secretion of, 32 stimuli to, 31 motor meals, 396 neuroses, diet in, 394 motor, 395 secretory, 394 of sensation, 395 operations, preparatory to, diet, 622 postoperative diet, 623 test meals, 396 ulcer, 362. See Peptic ulcer. Gastritis, acute, diet in, 359 chronic, diet in, 360 hypoacidity and, 361 Gastro-duodenitis, diet in, 431 Gastro-enterostomy, absorption of food after, 626 Gastro-enterostomy, diet in, 623, 624 Finney’s, 627 von Leube’s, 625 results in, statistics of, 624 Gastrogenic diarrhea, diet in, 407 Gaulston’s sugar treatment of cardiac disease, 323 Gavage in feeding of infants, 311 over one year, 311 in insanity, 571 Gelatin, 77, 198 Genito-urinary diseases, 452 alkaline reserve in, 453 anaphylaxis in, 452 diet in, low protein, blood- pressure and,460 dietary tests in, 455 effect of different diets in, 453 elimination of dyes in experi- mental nephritis, 454 excretion in, 454 experimental nephritis, 454 nitrogen excretion in, 455 overfeeding in, effects of, 453 salt in, 458 excretion in, 455 solution in, test for, 455 Schlayer’s nephritic test day in, 456 water excretion in, 455 Geyelin’s modification of Allen’s treat- ment of diabetes mellitus, 490 standard strict diet in diabetes mellitus, 498 Gin, 274 Globulins of milk, 165 Glucose, 221 function of, 41 for vomiting in pregnancy, 649 Gluten flour, 232 Glycosuria, alimentary, 40, 478 diabetes mellitus and, 478 Glycuresis, 41 Goiter, basal metabolism in, 63 exophthalmic, diet in, 635, 638 for special indications for, 638 Goldberger’s conclusions in pellagra, .564. 565 diet in pellagra, 567 Gonorrhea, diet in, 474 Gout, 523 alcohol in, 529 carbohydrates in, 528 Chittenden’s low protein allow- ance in, 526 cocoa in, 529 coffee in, 529 caffein from, 529 complicating diabetes mellitus, diet in, 510 diagnosis of, von Noorden and Schleip’s method of, 527 722 INDEX Gout, diet in, or acute podagra, 529 Ebstein on, 525 foods in, 528 Garrod’s facts in, 525 leukemia and, 524 mineral waters in, 532 pneumonia and, 524 purin-free foods in, 530 soft, 530 radio-active waters in, 533 Chace and Folin on, 533 salt in, 528 tea in, 529 Umber’s uric acid elimination curve in, 527 and uric acid, Duckworth on, 525 retention in, 524, 525 Gouty diathesis, diet in, 532 neuritis, diet in, 568 Grains, 226-238. See Individual grains composition of, 226 in diet, place of, 226 nutritive value of, 226 Grape cure, 677 Green days in diabetes mellitus, 489 Grippe, diet in, 609 Gruels, arrow-root, 681 barley, 681 cereal, 681 flour, 681 H Habit diarrhea, diet in, 408 Hart-Nelson-Petz diet in lactation, 653 Headache, periodic, diet in, 572 Heart, diseases of, diet in, 320 fatty, diet in, 324 senile, diet in, 325 Hemoglobins, 180 Hemolysis in pernicious anemia, 555 Hemophilia, diet in, 557 Hemorrhage, cerebral, diet in, 571 diet after, 632 intestinal, diet in, 406 in typhoid fever, diet in, 606 of stomach, diet after, 383 Hemorrhoids, diet in, 427 Hepatic congestion, acute, diet in, 431 chronic, diet in, 432 Hirschsprung’s disease, diet in, 427 Holt’s diet in eczema, 446 Hormone, 33 Hunger, 33, 34, 37 contractions, 35 contrasted with appetite, 33 Hydrochloric acid, function of, 30 of stomach, 30 Hydrothorax, diet in, 337 Hyperacidity, 30 gastric, cotton-seed oil in, 684 diet in, 351, 354 Hyperacidity, gastric, olive oil in, 684 Hyperalcoholism, diet in, 579 Hyperchlorhydria, 351 causes of, 352 diet, reduction by, 353 Hyperglycemia in nephritis, chronic, 485 Hyperidrosis, diet in, 451 Hypersecretion, gastric, diet in, 355 Hypertension, alcohol and, 328 in apoplexy, 572 diet in, 327 Hypoacidity, 30 gastric, diet in, 356 sterilized food in, 358 gastritis and, 361 Hypothyroidism in obesity, 512 I Immunity, transmission of, in woman’s milk, 279 Indicanuria in auto-intoxication, 423 Indigestion, diet in, 349 Indol in auto-intoxication, 422 Infancy, feeding in, 275 Infant or infants, feeding of, after sec- ond year, 308 artificial, beef broth and, 300 juice and, 300 bread and, 301 carbohydraterequirements of, 290 cereals in, 296, 300 eggs and, 300 energy requirement of, 288 fat requirement of, 289 higher fat mixtures in, 299 increasing formula, 295 inorganic salts and, 292 method of preparing for- mula, 295 orange juice and, 299 potato and, 301 proprietary foods and, 293 protein requirement of, 289 rice and, 301 starch requirement of, 291 sugar requirement of, 290 vegetables and, 301 vitamin requirements of, 292 water requirement of, 292 colic and, 303 constipation and, 305 in cyclic vomiting, 313 diarrhea and, 304 during acute infections, 310 second year, 307 farinaceous foods in, 293 gas and, 303 gavage in, 311 INDEX 723 Infant or infants, feeding of, miscellan- eous foods in, 293 in nutritional disturbances, 315 Pirquet method of, 309 proprietary foods in, 293 protein milk and, 304 in pyloric stenosis, 312 in rickets, 315 stools and, 303 vomiting and, 302 premature, feeding of, 306 Infantilism, diet in, 437 Infections, acute, diet in, 582 chronic, diet in, 617 Infectious arthritis, chronic, diet in, 611 Influenza, diet in, 609 Inorganic salts, artificial feeding of infants and, 292 importance of, 85 Insanity, diet in, 570 gavage in, 571 Insomnia, diet in, 578 night feedings in, 579 Insulin in diabetes mellitus, 477 Intestinal atony, diet in, 416 auto-intoxication, 421 bacteriology of, 422 by-products in, 422 causes of, 421 dietetic indications in, 424 menus in, 425 bacteria, indispensable, Nuttall on, 422 Schottelius on, 422 Thierfelder on, 422 decomposition, epilepsy and, 570 distention, postoperative, diet in, 631 excretion, 48 hemorrhage, diet in, 406 in typhoid fever, diet in, 606 lesions, postoperative, diet in, 628 motor meal, 397 Schmidt-Strassburger, 397 neurosis, diet in, 410 putrefaction, 43, 45 Intestines, absorption in, 38 bacterial action in, 42 digestion in, 35 of carbohydrates, 35 of protein, 36 diseases of bacillus acidophilus in, 398 bacteriology in, 398 diet in, 398 enzymes in, 36 large, bacteria in, action of, 43 reaction of, 43 movements of, 36 small, bacteria in, action of, 44 ulceration of, diet in, 406 Intravenous dextrose, Woodyatt and Wild’s, 647 Intravenous feeding, 647 formula for, 647 infusion in cholera, 615 Intubation, feeding after, 633 Invert sugar, 222 Iodine requirements, 99 Iron in chlorosis, 552 content of foods, 98 inorganic, 97 organic, 97 requirement, 95 water, 265 in woman’s milk, 278 Irritable stomach, diet in, 351 Irritative diarrhea, diet in, 408 J Jams, 223 Jaundice, catarrhal, diet in, 431 Jellies, 223 Joslin’s resume of Allen’s treatment of diabetes mellitus, 501 K Karell’s diet, 321 in apoplexy, 572 in nephritis, 462, 467, 468 Potter’s modification of, 322 Keating’s diet in neurasthenia, 576 Kefir, 166 Kessler sulphur-free food, 658 Ketogenic substance diets, 483 Ketonuria, chronic nephritis and carbo- hydrate tolerance and, 483 Kidney, amyloid, 475 dietary tests, 455 stone, 474 Koumyss, 166, 680 L Lactation, diet in, 120 Hart-Nelson-Petz, 653 results of experimental, 654 food requirements of, 120 milk in, 120 Lactofarinaceous diet in pyelitis, 473 Lactose, 165, 222 in woman’s milk, 277 Lactovegetarian diet in erythema, 449 Lambert’s treatment of acute nephritis from mercury poisoning, 464 Laparotomy, diet in, 621 Lard, 247 Leanness, diet in, 534 Leavening of bread, 233 Lecithin, 42 Legumes, 214-218 724 INDEX Legumes in diet, place of, 214 nutritive value of, 217 preparation of, 217 Lemonade, egg, 680 Lemons, 253 Lenhartz’s diet in peptic ulcer, 366 modified, 375 von Leube’s diet in gastroenterostomy, 625 in peptic ulcer, 363, 364 Leukemia, basal metabolism in, 63 diet in, 557 gout and, 524 Lipins, 19 Liquors, 274 Lithium water, 265 Liver, amyloid, diet in, 434 atrophy of, acute yellow, diet in, .434 diseases of, diet in, 429 prophylactic, 430 fatty, diet in, 433 Lockjaw, diet in, 612 Longcope on effects of anaphylaxis, 452 Loomis Sanitarium, diet in tuberculosis, 345 Lowenburg’s conclusions on nephritis, 461 Lungs, diseases of, diet in, 330 drinks in, 332 M Macaroni, 235 Maize in pellagra, 566 Malarial fever, diet in, 606 Malnutrition, 135 Malt extracts, 273 liquors, 273 Maltose, 222 Manson on diet in sprue, 655 Maple-sugar, 222 Meals, planning of, 142 for children, 134 Measles, diet in, 608 Meat, 184-199 in arteriosclerosis, 326 baking of, 190 broiling of, 190 broths, 198 color of, 185 composition of, 186, 189 cooking of, 189 chemical changes in, 192 cost of, 153-155 in diet of children, 132 place of, 184 digestibility of, 192 extracts, 196 flavor in, 185 general properties of, 184 juice, 196 Meat, nutritive value of, 184 poisoning by, 666 preparations, 195 proteins in, 184 in fever, 587 purin compounds, 185 roasting of, 190 precise, 191 Membranous colitis, nervous origin of, 4°5 Meningitis, cerebral, diet in, 608 cerebrospinal, diet in, 608 Menstruation, woman’s milk and, 279 Menus, basis of preparation of, 142 for family, 143, 145 one-sided, 146 Mercurial poisoning, potassium bitar- trate in nephritis, 464 acute nephritis from, 464 treatment of, 464 Lambert’s, 464 Patterson’s, 464 Vogel’s, 464 Metabolic nitrogen, 47 products, 46 Metabolism, 17 basal, 61 body surface and, 64 diseases of, 476 disturbed, dermatoses and, 440 fat, relation of, to diabetes mellitus, 482 in old age, 544 in pellagra, 564 mineral, 564 protein in diabetes mellitus, 479 endogenous, 75 in psoriasis, 441 standards of, 62 sulphur, in scurvy, 560 in tuberculosis, 340 in vegetarian diet, 672 Migraine, diet in, 572 Milk, 162-174 bacteria in, 163 carbohydrates of, 165 chemical properties of, 163 coagulation of, 165, 173 condensed, 168 cow’s, salts in, 279 cure in obesity, Tibbies, 520 diabetic, in diabetes mellitus, 506 diet, 318 of children, 131 in nephritis, 462 place of, 162 digestion of, 172 in stomach, 29, 31 dried, 169 fats of, 165 globulins of, 165 influence of bacteria on, 170 of temperature on, 170 INDEX 725 Milk in lactation, 121 of mother, 121 nutritive value of, 162 in pellagra, 567 peptonized, 680 physical properties of, 162 preparations in fever, 586 products with increasing fat con- tent, 164 protein content, 164 protein, 164 feeding of infants and, 304 ripened, 680 salts of, inorganic, 166 sugar, 165 in tuberculosis, 343 variations in composition of, 167 vitamins of, 167 woman’s, 275 bacteria in, 278 colostrum in, 275 composition of, 277 diet and, 280 drugs and, 279 effect of diet on, 120 fat in, 277 general characteristics of, 276 iron in, 278 lactose in, 277 menstruation and, 279 nervous impressions and, 279 phosphorus in, 278 pregnancy and, 279 protein in, 278 quantity of, 276 salts in, 278, 279 transmission of immunity in, 279 Mineral metabolism in pellagra, 564 oil in constipation, 415 salts, 85 springs for oxaluria, 542 water, 264 in gout, 532 Mitchell’s, Weir, diet in neurasthenia, , 576 Mixed feeding, 285 Mosenthal’s low protein diet in chronic nephritis, 467 test day in nephritis, 456 Mother’s diet, breast feeding and, 283 Motor gastric neuroses, 395 meals, gastric, 396 intestinal, 397 Schmidt-Strassburger, 397 Mouth, absorption in, 38 Mucous colitis, chronic, diet in, 405 diet in, 405 Muffins, 234 Myasthenia gastrica, 384. See Gastric atony. Myxedema, diet in, 638 N | ; Nauheim exercises in cardiac disease, 325 Naunyn on diabetes mellitus, 478 Nausea in pregnancy, 649 in typhoid fever, diet in, 351, 606 Nephritis, acute, 462 from mercury poisoning, 464 treatment of, 464 Lambert’s, 464 Patterson’s, 464 Vogel’s, 464 albuminuria in, 461 in auto-intoxication, 423 chronic, 465 acidosis in, 467 carbohydrate equivalent in, table of, 491 tolerance and ketonuria and, 483 diet in, 466 general list, 490 Karell’s, 468 low protein, 467 Mosenthal’s, 467 salt-poor, 470 . solution, 469 dietetic management of, 465 hyperglycemia in, 485 nitrogen retention in, diet in, 467 oatmeal days in, 490 treatment of, dietetic, 485 von Noorden’s, 486, 487 water retention in, 468 complicating diabetes mellitus, diet in, 510 dechlorination in, 459 diet in, Karell’s, 462, 467 milk, 462 experimental, 454 Fischer’s theories of, 460 Lowenburg’s conclusions on, 461 mercurial, potassium bitartrate in, .464 nitrogen elimination in, 459 in pregnancy, diet for, 651 protein allowance in, 463 salt in, 458 test day in, Mosenthal’s, 456 water in, 458 von Noorden on, 458 Nephrolithiasis, diet in, 474 low protein, 474 Nervous anorexia, diet in, 580 diarrhea, diet in, 408 impressions, woman’s milk and, 279 system, diseases of, diet in, 568 functional, diet in, 572 organic, diet in, 568 Neurasthenia, diet in, 575 Keating’s, 576 726 INDEX Neurasthenia, diet in,Weir Mitchell, 576 Neuritis, diet in, 568, 569 gouty, 568 Neuroses, digestive, diet in, 578 gastric, diet in, 394 motor, 395 secretory, diet in, 394 of sensation, diet in, 395 intestinal, diet in, 410 Night feeding in insomnia, 578 Nitrogen balance in diabetes mellitus, 481 elimination in nephritis, 459 excretion, 50 in genito-urinary diseases, 455 metabolic, 47 retention in chronic nephritis, diet in, 467 Nitrogenous auto-intoxication, food in, 424 von Noorden and Schleip’s method of diagnosing gout, 527 on diabetes mellitus, 478 diet in obesity, 515, 517 maintenance diet, 534 treatment of chronic nephritis, 486, 487 on water in nephritis, 458 Normal children, feeding of, 275 stools, breast feeding and, 285 Nucleoproteins, digestion of, 36 Nursing, intervals of, 281 length of each, 282 Nurslings, eczema in, 445 dietary treatment of, 447 stool examination in, 446 Nutritional disturbances, feeding of infants in, 315 Nutrose, 682 Nuts, 2x8 Nuttall on indispensable intestinal bacteria, 422 O Oatmeal, composition of, 227 days in chronic nephritis, 490 Oats, 229 Obesity, 511 average weight of men in, 512 of women in, 512 Banting’s cure in, 517 causes of, 5x1 complicating diabetes mellitus, diet in, 510 conditions requiring cure in, 513 diet in, Ebstein’s, 519 von Noorden’s, 515, 517 Oertel’s, 518 Schweninger’s, 520 exercise and, 523 Gaertner’s table of height, weight and blood-pressure in, 514 Obesity, Galisch’s cure in, 521 hypothyroidism in, 512 massage and, 523 normal weight of males in, 513 Tibbies on, 513 Oertel’s cure in, 518 reduction cures in, 515 Folin-Denis, 522 objects of, 515 Salisbury’s cure in, 520 Tower-Smith’s modifica- tion of, 521 Tibbles’s milk cure in, 520 water drinking in, 523 Obstructive constipation, diet in, 415 Ochsner’s treatment in appendicitis, 418 Oertel’s diet in obesity, 518 O’Keefe on eczema of younger children, 446 Old age, diet in, 542 routine in, 547 Sir Henry Thompson’s, 547 foods for, 545 especially desirable in, 545 preparation of, 547 requirements in, 543 metabolism in, 544 Oleomargarine, 246 Olive oil, 248, 683 in cholelithiasis, 683 in gastric dilatation, 683 hyperacidity, 684 in pyloric stenosis, 683 in stenosis of esophagus, 683 One thousand calorie portion, 57 Oral digestion, 25 Orange juice in artificial feeding of in- fants, 299 Oranges, 253 Organic cardiac disease, diet in, 320 diseases of nervous system, diet in, 572 . Osteomalacia, adrenalin in, 549 castration in, 549 diet in, 549 Oxaluria, 541 diet in, 541 mineral springs for, 542 P Pancreas, disease of, diet in, 437 Pancreatic diarrhea, diet in, 408 juice, 36 enzymes in, 36 Pancreatitis, acute, diet in, 438 chronic, diet in, 438 Paratyphoid fever, diet in, 606 Patterson’s treatment of acute nephritis from mercury poisoning, 464 Peanut, 2x7 INDEX 727 Pellagra, 116, 564 alkaline reserve in, 565 diet in, 564, 566 Goldberger’s, 567 Goldberger’s conclusions in, 564, 5.65 . maize in, 566 metabolism in, 564 mineral, 564 milk in, 567 Thompson-McFadden report on, 566 types of, 564 Pelvis, contracted, diet in, 651 Prochownick’s, 652 Pepsin, 29 Pepsinogen, 29 Peptic ulcer, 362 ambulatory cure in, 380 diet in, Coleman’s, 379 Lenhartz’s, 366 modified, 375 von Leube’s, 363, 364 modified, 378 Sippy’s, 373 treatment of, alkaline, 373 dietary, method of, 362 Sippy’s, 373 Peptones, 181, 682 Peptonized milk, 680 Periodic headache, diet in, 572 Peritonitis, acute, diet in, 616 chronic, diet in, 616 Perityphlitis, diet in, 420 Pernicious anemia, 535 Barbour on, 556 bone-marrow in, 556 diet in, 556 hemolysis in, 555 Phenol in auto-intoxication, 422 Phosphates and calculi, 540 Phosphaturia, 538 diet for calculi, 540 forms of, juvenile, 539 nervous, 539 sexual, 539 physiological, 539 Phosphoproteins, 180 Phosphorus content of foods, 92 requirement, 90 in woman’s milk, 278 Pirquet method of feeding infants, 309 Plasmon, 684 Plums, 253 Pleurisy with effusion, diet in, 337 Pneumonia, gout and, 524 Poisoning by canned goods, 667 by fish, 667 food, 665 dietary precautions in, 668 by meat, 666 mercury, acute nephritis from, 464 treatment of, 464 Poisoning by mercury, acute nephritis from, treat- ment of, Lam- bert’s, 464 Patterson’s, 464 Vogel’s, 464 by vegetables, 667 Polished rice in beriberi, 562 Polyneuritis, toxic, diet in, 561 Portal cirrhosis, diet in, 432 Porter, 273 Posthemorrhagic anemia, 557 Postoperative complications, diets for, 629 diet, 623 in cholelithiasis, 435 for digestive tube, 623 gastric, 623 in vomiting, 629 intestinal distention, diet in, 631 lesions, diet in, 628 Potassium bitartrate in mercurial nephritis, 464 Potato in artificial feeding of infants, . 30.1 diet in diabetes mellitus, 494 Potatoes, digestibility of, 238 sweet, 237 white, 236 Potter’s modification of Karell diet, 322 Poultry, 204 Pregnancy, auto-intoxication in, mild, 65i. complications of, diet in, 648 energy requirement of, 117 food requirements of, 117 nausea in, 649 nephritis in, diet for, 651 protein requirement of, 118 tuberculosis and, 346 vomiting in, 649 glucose for, 649 woman’s milk and, 279 Premature infants, feeding of, 306 Preoperative diet, 621 Preserves, 223 Prophylactic diet in cholelithiasis, 435 Prochownick’s diet in contracted pelvis, 652 Protein or Proteins. See also Meat and protein-rich foods, absorption of, 38, 183 allowance in nephritis, 463 biological value of, 79 calories in, 57 digestion of, 183 in intestines, 36 effect of heat on, 180 of low temperatures on, 182 in fattening cures, 535 in fever, 586 foods, 175 functions of, 18 728 INDEX Protein or Proteins, inadequate, 76 low, in diet for athletes, 602 in m6at, 184 metabolism in diabetes mellitus, 479 endogenous, 75 milk feeding of infants and, 304 in rectal feeding, 641 requirements, 74-80 of artificial feeding of infant, 289 average, 82 of children, 126 optimum, 83 in pregnancy, 118 relation of carbohydrate to« 79 of fat to, 79 respiratory quotient of, 60 restricted, in standard strict diet in diabetes mellitus, 489 sensitization in eczema, 444 in subcutaneous feeding, 645 tolerance in diabetes mellitus, 501 in tuberculosis, 340 in typhoid fever, 593 in woman’s milk, 278 Protein-rich foods, 184-217 calcium content of, 96 cheese, 211-213 chlorine content of, 89 in chlorosis, 554 eggs, 206-211 fish, 200-204 game, 204 iron content of, 98 legumes, 214-218 meat, 184-199 nuts, 218 phosphorus content of, 92 poultry, 204 vegetables, 214-218 vitamins in, distribution of, 113 Prunes, 253 Pruritus, diet in, 450 Psoriasis, diet in, 441 low protein, 442 Chittenden on, 442 metabolism in, 441 Ptyalin, 26. See Amylase, salivary. Puerperium, diet in, 652 Purin bodies in foods, 533 Purin-free foods, 530 in gout, 530 soft, 530 Purpura hemorrhagica, diet in, 558 Putrefaction, intestinal, 43, 45 products of, 43 Pyelitis, diet in, 473 lactofarinaceous, 473 Pyloric reflex opening, 650 stenosis, feeding of infants in, 312 in gastric dilatation, 393 Pyloric stenosis, olive oil in, 683 Pylorus, control of, 28 R Radio-active water, 266 in gout, 533 Chace and Folin on, 533 Raisins, 253 Rectal feeding, 48, 640 carbohydrates in, 643 fats in, 643 formula for, 644 precautions in, 644 protein in, 641 pressure as cause of symptoms of auto-intoxication, 423 Rennin, 29 Respiration apparatus, 59 Respiratory quotient, 60 of carbohydrate, 60 of fat, 60 of protein, 60 Rheumatism, acute articular, diet in, 609, 610 chronic, diet in, 611 subacute, diet in, 611 Rheumatoid arthritis, diet in, 619 Rice, 229 in artificial feeding of infants, 301 in diet, 230 polished, 227, 230 Rickets, no cure of, diet in, 316 feeding of infants in, 315 prevention of, diet in, 316 Ripened milk, 680 Roasting of meat, 190 Roberat, 682 Rolls, 234 Rum, 274 Rye, 230 S Salisbury’s cure in obesity, 520 Tower-Smith’s modifica- tion of, 521 Saliva, 26 chemical constituents of, 26 Salivary amylase, 26 digestion, 25 in stomach, 26 Salt or Salts, 257 content of common foods, 472 in cow’s milk, 279 in epilepsy, 569 excretion in genito-urinary diseases, 455 functions of, 20 in genito-urinary diseases, 458 INDEX 729 Salt or Salts in gout, 528 inorganic, in diet of children, 130 importance of, 85 in nephritis, 458 in woman’s milk, 278, 279 Salt-free diet in epilepsy, 570 Salt-poor diets, 470, 471, 472 in chronic nephritis, 470 Satiety, 37 Scarlet fever, diet in, 607 Schaffer’s antiketogenic substance diets, 483 ketogenic substance diets, 483 Schlayer’s nephritis test day in genito- urinary diseases, 456 Schmidt test diet in chronic enteritis, 401 modified, 402 Schmidt-Strassburger’s intestinal motor meal, 397 Schottelius on indispensable intestinal bacteria, 422 Schweninger’s diet in obesity, 520 Scurvy, 559 antiscorbutics in, 561 diet in, 560 causing, 559 sulphur metabolism in, 560 vitamins in, lack of, 108 Secondary anemia, 555 Secretin, 33 Secretion of gastric juice, 32 stimuli to, 31 Secretory gastric neuroses, diet in, 394 Senile heart, diet in, 325 Sensation, gastric neuroses of, diet in, 395 Shaffer’s diet in fever, 585 Shell fish, kinds of, 200 Singers, diet for, 660 Sippy’s diet in peptic ulcer, 373 treatment of peptic ulcer, 373 Skatol in auto-intoxication, 422 Skin, diseases of, alimentary eruptions in, 440 diet in, 440 disorders of digestion in, 440 Smallpox, diet in, 607 Sodium chloride, 90 Soft diet, 318 Somatose, 682 Soup in eczema, 446 Soy bean, 216 Spastic constipation, diet in, 414 Speakers, diet for, 660 Spices, 256 Sprue, 654 causation of, theories of, 655 diet in, Conran on, 656 Manson on, 655 Starch, 224-226 absorption of, 225 digestion of, 26, 223 I Starch requirement of artificial feeding of infant, 291 soluble, 225 Starvation treatment of epilepsy, Conklin’s, 570 Stenosis of esophagus, olive oil in, 683 pyloric, feeding of infants in, 312 in gastric dilatation, 393 olive oil in, 683 Stomach, activity of, 27 bacteria in, action of, 44 carcinoma of, diet in, 389, 390 foods in, 39 x contractions of, 34 digestion in, 29 of carbohydrates, 26, 31 of fat, 31 of milk, 29, 31 diseases of, diet in, 348 enzyme action in, 29 hemorrhage of, diet after, 383 hydrochloric acid of, 30 irritable, diet in, 351 passage of food through, 28 rate of passage of food from, 53, 54 salivary digestion in, 26 Stomachics, 32, 35 | Stone, kidney, 474 j Stools, abnormal, breast feeding and, 285 feeding of infants and, 303 normal, breast feeding and, 285 Stout, 273 Subacute rheumatism, diet in, 611 Subcutaneous feeding, 645 carbohydrates in, 646 fats in, 646 protein in, 645 Sucrose, 221 effect of, on digestion, 224 Sugar or Sugars, 220-224, 257 absorption of, 224 beet, 221 in diet for athletes, 663 digestion of, 223 requirement of artificial feeding of infant, 290 substitutes, 257 utilization of, 223 Sulphate water, 265 Sulphur metabolism in scurvy, 560 ! Sulphur-free foods in cancer, 658 Kessler, 658 Sulphurous water, 265 T Tea, 258 active principle in, 258 caffein in, 258 in gout, 529 infusions, 259 730 INDEX Tea, preparation of, 258 Test meals, gastric, 396 Tetanus, diet in, 612 Thierfelder on indispensable intestinal bacteria, 422 Thompson, Sir Henry, diet in old age, 547 Thompson-McFadden report on pella- gra, 566 Thyroiditis, acute, diet in, 635 Tibbles’s milk cure in obesity, 520 on normal weight of males in obesity, 513 Tobacco in cardiac disease, 329 Tomatoes, 253 Tonsillectomy, diet after, 623 Tower-Smith’s modification of Salis- bury’s cure in obesity, 521 Toxic diarrhea, diet in, 407 polyneuritis, diet in, 561 Transgastric feeding, 381 Tropon, 682 Tuberculosis in children, prophylaxis in, 343 diabetes and, 346 diet in, 338 in complications, 346 Loomis Sanitarium, 345 object of, 339 standard, 344 digestive symptoms in, 339 dispensary patients’ diets in, 341 eggs in, 344 fats in, 344 feeding rules in general, 347 foods in, special, 343 metabolism in, 340 milk in, 343 pregnancy and, 346 protein in, 340 Tufnell’s diet in aneurysm, 328 Typhlitis, chronic, diet in, 420 Typhoid fever, Bacillus acidophilus in, 593 basal metabolism in, 63 carbohydrates in, 592 diet in, 590, 595 bacteriology and, 592 Coleman on, 593 complications, 605 extra, 597 fluid, 596 intestinal hemorrhage in, 606 liberal, results with, 594 in menus and food com- binations, 597 modified milk, 597 Nausea in, 351, 606 older, 590 perforation, 606 vomiting in, 351, 606 energy requirements in, 594 Typhoid fever, fats in, 593 feeding in, basis for, 591 general direction for, 595 proteins in, 593 water in, 606 Typhus fever, diet in, 589 U Ulcer, duodenal, 362. See Peptic ulcer, gastric, 362. See Peptic ulcer, peptic, 362 ambulatory cure in, 380 diet in, Coleman’s, 379 Lenhartz’s, 366 modified, 375 von Leube’s, 363, 364 modified, 378 Sippy’s, 373 treatment of, alkaline, 373 dietary method of, 362 Sippy’s, 373 Ulceration of intestines, diet in, 406 Umber’s uric acid elimination curve in gout, 527 Unconscious patients, feeding of, 665 Undernutrition, 138 Urea, excretion of, 50 Uremia, chronic, diet in, 467 Uric acid, excretion of, 51 retention in gout, 524, 525 Urticaria, diet in, 449 V Vegetable or Vegetables. See Water and salt-rich foods, in artificial feeding of infants, 301 composition of, 251 cooking of, 254 losses in, 255 in diabetes mellitus, carbohydrate percentage in, 500 in diet of children, 133 place of, 250 diets, 156 nutritive value of, 250 oils, 247 poisoning, 667 preservation of, 255 vitamins in, 1x5 Vegetarian diet, 670, 673 disadvantages of, 671 grounds for, 670 longevity in, 670 metabolism in, 672 Vinegar, 257 Vitamins, 20, 103, 684, 685 A, 103, 106, 121 antineuritic, 107 antirachitic, 104, iiq INDEX 731 Vitamins, antiscorbutic, 108 antixerophthalmic, 106 B, 103, 107, 121 in beriberi, 562 yeast, 562 C, 103, 108, 121 in diet of children, 130 distribution of, table of, 112 in emulsion of cod-liver oil, 684 in fruits, 114 lack of, pathological effects of, 111 in milk, 167 requirements of artificial feeding of infants, 292 in vegetables, 115 in yeast, 685 Vogel’s treatment of acute nephritis from mercury poisoning, 464 Vomiting, breast feeding and, 284 cyclic, feeding of infants in, 313 diet in postoperative, 629 feeding of infants and, 302 from acute gastric dilatation, 630 in pregnancy, 649 glucose for, 649 in typhoid fever, diet in, 351, 606 W Water or Waters, albumin, 679, 681 for children, 131 classification of, 264 drinking of, in obesity, 523 with meals, 103 excretion in genito-urinary disease, 455 functions of, 20, 100 in gout, radio-active, 533 Chace and Folin on, 533 iron, 265 lithium, 265 mineral, 264 in nephritis, 458 von Noorden on, 458 radio-active, 266 rapidity of excretion of, 102 requirements, 99 of artificial feeding of infants, 292 retention in chronic nephritis, 468 and salt-rich foods, 250-274 alcoholic beverages, 269 beverages, 257-274 calcium content of, 96 chlorine content of, 89 chocolate, 262 cocoa, 262 coffee, 259 food adjuncts, 256- 257 fruits, 250-256 j Water or Waters, iron content of, 98 mineral waters, 264 phosphorus content of, 92 tea, 258 vegetables, 250-256 vitamins in, distribu- tion of, 114 sulphate, 265 sulphurous, 265 test for gastric acidity, 397 therapeutic value of, 267 in typhoid fever, 606 Weaning, 286 Wegele’s diet in gastric atony, 387 Wheat, 230 flour, 231 entire, 232 gluten, 232 kinds, 231 Whisky, 274 Williams and Humphrey, renal thresh- old for blood sugar, 485 diet in acne vulgaris, 448 Wine whey, 680 Wines, 272 Woman’s milk, 275 bacteria in, 279 colostrum in, 275 composition of, 277 diet and, 280 drugs and, 279 fat in, 277 general characteristics of, 276 iron in, 278 lactose in, 277 menstruation and, 279 nervous impressions and, 279 phosphorus in, 278 pregnancy and, 279 protein in, 278 quantity of, 276 salts in, 278, 279 transmission of immunity in, 279 Woodyatt and Wild s intravenous dex- trose, 647 Woodyatt’s dietetic management of diabetes mellitus, 484 X Xerophthalmia, diet in, 563 fat-soluble A in, 563 Y Yeast, 683 vitamin in, 685 in beriberi, 562 Yellow fever, diet in, 613