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Subscripted numbers are indicated by an underscore (_), with the
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                THE MACMILLAN COMPANY
        NEW YORK · BOSTON · CHICAGO · DALLAS
               ATLANTA · SAN FRANCISCO

              MACMILLAN & CO., LIMITED
             LONDON · BOMBAY · CALCUTTA
                      MELBOURNE

          THE MACMILLAN CO. OF CANADA, LTD.
                       TORONTO


                    DIETETICS FOR
                       NURSES

                         BY

                 FAIRFAX T. PROUDFIT

  INSTRUCTOR AND CLINICAL DIETITIAN, MEMPHIS GENERAL
    HOSPITAL, AND ST. JOSEPH'S HOSPITAL, CONSULTING
     DIETITIAN, MEMPHIS ASSOCIATED CHARITIES, AND
          PUBLIC HEALTH NURSING ASSOCIATION,
                  MEMPHIS, TENNESSEE


                    SECOND EDITION
                  Completely Revised


                       NEW YORK
                THE MACMILLAN COMPANY
                         1923

                _All rights reserved_




       PRINTED IN THE UNITED STATES OF AMERICA




               COPYRIGHT, 1918 AND 1922,
               BY THE MACMILLAN COMPANY.


   Set up and electrotyped. Published November, 1918
      Second Edition completely revised and reset
                 Published, July, 1922


                       Press of
              J. J. Little & Ives Company
                  New York, U. S. A.




                      Dedicated
                        to the
                 Great Army of Nurses
                    in the Service




PREFACE TO SECOND REVISED EDITION


The old order of things is passing. The keynote of to-day's work is
prevention, rather than cure, children are taught to eat correctly
that they may grow into the strong, healthy men and women which are
needed to make any nation great. This instilling of good health habits
must rest upon the nurse, the nutrition worker, the physician and the
home-maker. Close coöperation is necessary among these workers and a
definite understanding of the way to accomplish the best results, in
this respect, must come from the training of those who are undertaking
this all important work.

The present revision of this text is the outgrowth of several years of
close attention to the progress, changes and adjustments which are
being made daily in this important subject of nutrition. The changes
made in this revised edition are all in the line of constructive
teaching. The material has been reorganized that no time may be lost
in a search for the proper word to illustrate a definite point. The
method of project teaching used in this edition, is not a new one,
although the name may possibly be unfamiliar to some. Every good
teacher recognizes the value of motivation as a means of getting an
idea "across." The revision of this text was undertaken with the idea
of leading the student to think for herself and to put into practice
the scientific facts learned in class room and ward.

The author is indebted to many of her colleagues for the encouragement
and constructive criticism which enabled her to make the changes which
will, it is hoped and believed, materially aid the student nurse in
the study of Dietetics. She also wishes to express her appreciation
for the many helpful suggestions made by her co-workers in this
respect, especially to Misses L. H. Gillett and L. Willson for
valuable criticism and to Miss H. Buquo for assistance in the
preparation of the manuscript.

    F. T. P.




PREFACE TO FIRST EDITION


No other science has so much to do with the general welfare of mankind
as the study of food and its effects in the human body. When we use
the term "dietetics" as representing "the effect of the food in the
human body," we do so in a very broad sense, for the subject is a big
one, requiring comprehensive terms to express it.

The problems of nutrition are many. Food alone is no small subject and
a still greater one is the utilization of food materials in such a way
that the body may gain the greatest value with the least expenditure
of vital forces. These problems are discussed in this text and the
methods of overcoming them are given in the simplest possible
language. For this purpose the subject of nutrition has been divided
into groups: (1) a comprehensive study of the sources of food, its
composition and nutritive value; (2) the effect of food in the body
under normal conditions, as in health; and (3) its behavior and effect
when conditions in the body become abnormal, as in disease. In this
way much of the non-essential material is eliminated from the course
of study and only that included which it is necessary for the nurse to
understand and which she will constantly use both in the hospital and
later on in the practice of her profession. The simple methods of
study presented in this text are given with the idea of avoiding
confusion in the mind of the average pupil nurse by fitting in the
course with her other studies rather than by making it stand out as a
separate subject. In this way she will be able to see at a glance the
connection between the body processes and the materials which are used
to carry them on. Thus her study of physiology, anatomy and
bacteriology go hand in hand with that of dietetics, each bearing a
distinct relationship to the others.




CONTENTS


  SECTION I
  FOOD AND ITS SIGNIFICANCE

  CHAPTER                                                         PAGE
        I  FOOD                                                      1
       II  FUEL VALUE OF FOOD                                       36
      III  FOOD REQUIREMENTS OF THE BODY                            42

  SECTION II
  LABORATORY OR DIET KITCHEN WORK

       IV  METHODS OF FEEDING IN NORMAL AND ABNORMAL CONDITIONS     59
        V  FOOD MATERIALS AND THEIR PREPARATION                     81
       VI  INFANT FOODS AND FORMULAS USED IN ABNORMAL CONDITIONS   140

  SECTION III
  THE HUMAN MACHINE

      VII  THE HUMAN BODY                                          165

  SECTION IV
  DIETO-THERAPY

     VIII  PREGNANCY AND LACTATION                                 191
       IX  INFANT FEEDING                                          199
        X  CARE AND FEEDING OF CHILDREN IN NORMAL AND ABNORMAL
             CONDITIONS AND IN INFECTIOUS DISEASES                 231
       XI  FEEDING OF ADULTS IN DISEASES OF THE GASTRO-INTESTINAL
             TRACT                                                 245
      XII  DISEASES OF THE INTESTINAL TRACT                        263
     XIII  FEVERS IN GENERAL                                       281
      XIV  TYPHOID FEVER                                           288
       XV  DISEASES OF THE RESPIRATORY TRACT                       301
      XVI  DIETETIC TREATMENT BEFORE AND AFTER OPERATION           312
     XVII  URINALYSIS                                              323
    XVIII  ACUTE AND CHRONIC NEPHRITIS                             336
      XIX  DISEASES OF THE HEART                                   365
       XX  DIABETES MELLITUS                                       372
      XXI  DISEASES OF THE LIVER                                   404
     XXII  GOUT, OBESITY AND EMACIATION                            418
    XXIII  OTHER CONDITIONS AFFECTED BY DIET                       451


APPENDIX

  Table I. Edible Organic Nutrients and Fuel Values of Foods       461

  Table II. Ash Constituents of Foods in Percentage of the Edible
    Portion                                                        472

  Table III. Showing 100-Calorie Portions of some Common Foods,
    Together with Their Protein, Nitrogen, and Mineral Content     478

  Table IV. Composition and Fuel Value of most of the Foods used
    in the Invalid Dietary                                         484

  Table V. Vitamines in Foods                                      496

  Heights and Weights for Children under Five Years of Age         499

  Height and Weight Table for Boys                                 500

  Height and Weight Table for Girls                                501

  Pelidisi Chart                                                   502

  The Nutritional Index--The "Pelidisi"                            503


  Index                                                            505




SECTION I

FOOD AND ITS SIGNIFICANCE

PRELIMINARY COURSE OF LECTURES AND LABORATORY WORK




CHAPTER I

FOOD


The value of a knowledge of food and its effect in the human body
cannot be overestimated. In health, this knowledge leads to higher
standards, since by pointing out the errors in one's mode of living,
good health habits may be established, which will, undoubtedly assure
the individual of a better nourished and a more vigorous body.

There is no question as to the value of health either from the
standpoint of comfort or of economy. And the knowledge which will
enable one to spread the good work intelligently cannot but raise the
standards of living throughout the entire community.

In taking up the study of dietetics, the student is introduced to some
of the fundamental principles governing the health and well-being of a
people, since dietetics includes a study of food and its relation to
the body.

The relationship between right food and good health is very close; how
close is being demonstrated constantly in experimental fields of
scientific research.

To be able to judge whether the food one eats daily is giving the best
possible value from a physiological and economic standpoint, requires
a definite knowledge of food, its source, composition and nutrient
value, as well as its relation to the body in health and disease.

No one is capable of giving constructive advice upon matters
pertaining to diet, unless he has acquired this knowledge through
training. A nurse should obtain this training during her course in the
hospital, through the class room, the wards and the diet kitchen.

The dividing line between health and disease is frequently almost
imperceptible, and without a knowledge of the normal body, it is, at
times, impossible to tell where the normal leaves off and the abnormal
begins. For this reason a nurse must understand normal nutrition, that
is, the behavior of food in the healthy body, before undertaking the
task of ministering to the body attacked by disease.

In a text of this kind, it is impossible to cover all phases of the
subject, especially since day by day new discoveries are being made
with relation to food and its uses in the body. But with careful
attention to the principles set forth, a nurse should be able to carry
out the dietary orders given her by the physician and dietitian in the
hospital. And, when her course of training is finished, she should
find herself equipped to assist in raising the standard of health
through her knowledge of dietetics. With this brief summary of the
aims and object of the study of dietetics, we will begin the actual
work with a study of Food.

~Food Materials.~--Food is the name given to any substance which,
taken into the body, is capable of performing one or more of the
following functions:

1. Building and repairing tissue, maintenance, growth, and development
of the muscles, bones, nerves, and the blood.

2. Furnishing the energy for the internal and external work of the
body.

3. Regulating the body processes, maintaining the proper alkalinity
and acidity of the various fluids throughout the body, regulating the
proper degree of temperature, and determining the osmotic pressure,
etc.

For the convenience of study scientists have arranged the foodstuffs
in groups:

1. According to type;

2. According to their chemical composition;

3. According to the function they perform in the body.

All foods are composed of certain chemical elements; namely, carbon,
oxygen, hydrogen, nitrogen, sulphur, phosphorus, iron, magnesium,
potassium, chlorine, sodium, calcium, with traces of various others.
The manner in which these elements are combined and the amounts in
which they occur determine the group to which the combination belongs,
and give to the foodstuff its characteristic position in human
nutrition.


COMPOSITION OF THE FOODSTUFFS

The chemical elements are combined in food and in the body, as: (a)
carbohydrates, composed of carbon, oxygen and hydrogen; (b) fats,
composed of carbon, oxygen and hydrogen; (c) proteins, composed of
carbon, oxygen, hydrogen, nitrogen and sulphur; (d) water, composed of
hydrogen and oxygen; (e) mineral salts. The first three foodstuffs
constitute the Organic Food group. The last two include the remaining
chemical elements, calcium, phosphorus, sodium, potassium, chlorine,
magnesium, iron and traces of others which make up the Inorganic Food
group.

Each of the foodstuffs belonging to the organic group is capable of
being burned in the body to produce heat for: (a) the maintenance of
the body temperature; (b) internal and external work.

Neither water nor mineral salts alone can be burned to produce heat;
nevertheless, they enter into the composition and take part in every
function performed by the carbohydrates, fats and proteins; therefore
one foodstuff cannot be said to be of greater importance than another,
since the needs of nature are best met by a judicious combination of
all. However, the wear and tear of life can be more efficiently
accounted for, and the strain upon the organism reduced more nearly to
a minimum when the various foodstuffs are furnished in amounts which
science is proving to be necessary for the health and well-being of
the organism.

The sixth essential food substance, the ~Vitamines~, together with the
adjustment of the five foodstuffs just mentioned--the amounts and
types of each in the dietary which will assure the body of the best
results--has been, and still is a subject of grave interest. Even on
the most perfect adjustment of these foodstuffs, the diet would fail
to give the desired results without the inclusion of the sixth, or
vitamine factor, which has proved to be essential for the growth and
development of the normal body, as well as for its protection against
certain deficiency diseases.

In order to obtain the best results from food, both from a health and
an economic standpoint, it is necessary to become familiar with the
foodstuffs as they are combined to make up the various common food
materials. One foodstuff may be a producer of heat, but may lack
certain chemical elements which are essential to the building of
tissues; another may be able to accomplish both functions in the body,
but will prove too expensive to use as fuel, except when it is
absolutely necessary to do so. Thus, it is essential for the nurse to
understand where and how both the foodstuffs and the vitamines occur
in nature, in order to make use of them more advantageously. The
following table gives the sources of the foodstuffs, after which a
description of the individual foodstuffs and vitamine factors will
serve to point the way to their use in the dietary:

                    { Milk, cheese (especially skim milk cheese).
                    { Eggs.
                    { Meat (lean meat in particular).
                    { Poultry, game.
                    { Fish.
  Proteins          { Cereals, corn, wheat, rye, oats, etc.
                    { Bread and breadstuffs (crackers, pastry, macaroni,
                    {   cake).
                    { Beans, peas, lentils.
                    { Cotton seed.
                    { Nuts.
                    { Gelatin.

                    { Wheat products (bread, cake, crackers, pastry,
                    {   macaroni, spaghetti).
                    { Cereal grains, breakfast foods.
                    { Corn products, corn meal, green corn.
                    { Rice, sago, tapioca, taro.
                    { Potatoes (white and sweet).
  Carbohydrates     { Starchy fruits (bananas).
                    { Sweet fruits (oranges, grapes, pineapples).
                    { Dried fruits (prunes, dates, raisins, currants).
                    { Sugar cane, sorghum cane.
                    { Sugar beets, sugar maples.
                    { Products made from sugar (candy, jellies,
                    {   preserves, marmalade).

                    { Butter, cream, cheese.
                    { Olive oil, cotton seed oil, peanut oil, corn oil,
                    {   almond oil.
                    { Soy bean.
                    { Corn meal, cotton seed meal and flour, oatmeal.
  Fats              { Pork (bacon especially), other fat meat.
                    { Codfish (and other fatty fish).
                    { Eggs (yolk).
                    { Cocoa, chocolate.
                    { Brazil nuts, almonds, pecans, and other nuts rich
                    {   in fat.

  Water             { All foodstuffs except those which have been put
                    {   through a drying process.

                    { Nitrogen (in proteins, meat, eggs, milk, fish,
                    {   gluten of wheat, zein of corn meal, legumen of
  Mineral salts     {   beans, peas, and lentils).
  (organic form)    { Phosphorus (eggs, yolk especially, cream,
                    {   vegetables, whole wheat, cereals, breadstuffs,
                    {   oatmeal, dried beans and peas).

                    { Eggs, milk, lean meat, cereal products, whole
  Iron (organic and {   wheat, dried beans and peas, vegetables,
  inorganic form)   {   spinach in particular, onions, mushrooms,
                    {   fruits, port wine.

                    { Milk.[1]
                    { Eggs.
                    { Soft tissues and fluids of all animals, skeleton
                    {   and teeth of animals.
  Calcium (organic  { Wheat (the entire grain), flour, oatmeal,
  and inorganic     {   polished rice.
  form)             { Dried beans and peas.
                    { Green vegetables (beets, carrots, parsnips,
                    {   turnips, potatoes).
                    { Fruits (apples, bananas, oranges, pineapples,
                    {   dried prunes).
                    { Nuts (almonds, peanuts, walnuts).

                    {              { Lean beef, eggs, milk.
  Sulphur (organic  {              { Wheat flour, entire wheat,
  and inorganic     { The proteins {   crackers, etc.
  form)             {              { Oatmeal.
                    {              { Beans, peas.
                    {              { Potatoes.

                    { These elements are associated with the other
  Sodium, potassium,{   mineral salts in foods, and a diet in which
  magnesium, iodine,{   they are adequately supplied furnishes
  chlorine          {   sufficient magnesium, potassium, chlorine,
                    {   sodium, and iodine for the general needs of
                    {   the body.

                    { _Fat soluble "A."_
                    {
                    { Butter, cream, whole-milk.
                    { Whole-milk powder.
                    { Whole-milk cheese.
                    { Cod liver oil, eggs.
                    { Brains, kidney.
                    { Cabbage (fresh-dried).
                    { Carrots, chard, lettuce.
                    { Spinach, sweet potatoes.
                    {
                    { _Water soluble "B."_
                    {
                    { Yeast (brewers').
                    { Yeast cakes, yeast extract.
                    { Whole-milk, whey.
                    { Milk powder (whole and skimmed).
  Vitamines[2]      { Nuts, cereals (corn embryo, wheat embryo,
                    {   wheat-kernel, rice (unpolished)).
                    { Beans (kidney, navy, soy).
                    { Cotton seed, peanuts, bread.
                    { Cabbage, carrots, celery.
                    { Cauliflower, onions.
                    { Parsnips, potatoes.
                    { Peas (fresh), spinach.
                    { Rutabaga, fruit, grapefruit.
                    { Orange, lemon, tomato, raisins.
                    {
                    { _Water soluble "C."_
                    {
                    { Fruits: Orange, lemon, tomatoes (canned).
                    { Tomato (fresh), grapefruit, limes, apples.
                    { Vegetables: Spinach, lettuce, cabbage (raw).
                    { Peas (fresh), onions, carrots, cauliflower.
                    { Potatoes (to a less extent).
                    { Whole-milk (to a less extent).


THE INDIVIDUAL FOODSTUFFS AND VITAMINE FACTORS

A study of the individual foodstuffs and vitamines will furnish the
first link in the chain which constitutes our present knowledge of
dietetics.


CARBOHYDRATES

In the ordinary mixed diet of man, the carbohydrates predominate, being
not only the most abundant, but also the most economical source of
energy. The term carbohydrate covers all of the simple sugars and those
substances which can be converted into simple sugars by hydrolysis; the
ones of special interest in this study are divided into three groups,
known as, Monosaccharides (C_{6}H_{12}O_{6}); Disaccharides
(C_{12}H_{22}O_{11}) and Polysaccharides (C_{6}H_{10}O_{15}).

~Monosaccharides.~--Glucose, Fructose and Galactose are substances
whose monosaccharide molecules contain one sugar radical; hence they
cannot be hydrolized to simpler sugars (sugars of lower molecular
weight). Those constituting this group of sugars are all soluble,
crystallizable and diffusible substances, which do not undergo changes
from the action of the digestive enzymes, consequently these sugars
will enter the blood stream in their original form, unless attacked by
the bacteria which inhabit the stomach and intestinal tract. The
monosaccharides are all susceptible to alcoholic fermentation. Each
member of the group is utilized in the body for the production of
glycogen and for the maintenance of the normal glucose of the blood.

~Disaccharides.~--Sucrose, Maltose and Lactose are substances
yielding, upon hydrolysis, two molecules of simple sugar: each of
these sugars is crystallizable and diffusible: all are soluble in
water, and to a less degree in alcohol--sucrose and maltose are more
soluble than lactose. When attacked by the digestive enzymes, these
sugars are changed to monosaccharides.

~Polysaccharides.~--Starch, Dextrin, Glycogen and Cellulose are
substances more complex in character than the above-mentioned groups.
They are built up of many sugar molecules, which yield upon complete
hydrolysis many molecules of simple sugar. The polysaccharides are
insoluble in alcohol, and only soluble to a certain extent in pure
water. Some members of this group swell and become gelatinous in the
presence of moisture and heat; some become of a colloidal form in
water, and will pass through filter paper; others remain unchanged.

A brief description of the various members of these different groups
of carbohydrates will assist the nurse in the ways and means of
utilizing them in the dietary to the best advantage.

~Glucose~, which is abundant in the juice of plants and fruits, and to
a more or less degree in the blood of all animals (usually about 0.1%)
occurs free in nature. This sugar is likewise obtained from many
carbohydrates, either through the action of acids, or as the result of
the digestive enzymes, and as such becomes the principal form in which
the animal body utilizes the carbohydrates ingested. Under normal
conditions the glucose in the blood is constantly being burned and
replaced; it is only when the body loses to a greater or less degree
the ability to burn the glucose that it accumulates in the blood,
from which it must escape by way of the urine. There are times, such
as when very large quantities of carbohydrates are eaten at once, when
glucose will also appear in the urine; but under such circumstances it
is generally found to be merely temporary, and for this reason, the
condition is known as temporary glycosuria. As a rule, however, the
surplus of glucose absorbed, whether it be eaten as such, or is found
as the result of enzymic action upon the other carbohydrates, is
converted into glycogen and stored in the liver and to a less extent
in the muscles. Glycogen is readily reconverted into glucose, which is
used by the body for the production of energy. It has been estimated
that over half the energy manifested in the human body is derived from
glucose, and it is in this form that the tissues of the body will
ultimately make use of most of the carbohydrates in food. Practically
all of the fruits, and many of the vegetables, are rich in this form
of carbohydrate, but grapes contain more than any of the other fruits,
while sweet corn, onions, and unripe potatoes contain appreciable
amounts.

~Fructose.~--The second member of the monosaccharide group is more or
less associated with glucose in plant and fruit juices, and is used
like that substance for the production of glycogen in the body. Eaten
as such, or produced as the result of digestive action upon cane
sugar, fructose is changed into glycogen, chiefly upon entering the
liver, and for this reason will not be found to enter largely into the
blood of the general circulation.[3]

Honey is the most abundant source of fructose in nature.

~Galactose.~--This sugar, unlike the other members of this group, is
not found free in nature, but it is produced as the result of
hydrolysis of milk sugar, either by enzymes or by acids. Like glucose
and fructose, galactose seems to promote the production of glycogen in
the body. Certain substances known as galactosides, which are
combinations of galactose and some substances other than
carbohydrates, are found in the nerve and brain tissues of the animal
body.

~Disaccharides.~--Of the second group of carbohydrates, we are
probably more familiar with sucrose, or cane sugar, than with either
of the other two, since it is in this form that the greater part of
the sugar eaten is purchased.

~Sucrose.~--By far the greater part of the sugar entering into the
average dietary is manufactured from sugar and sorghum canes, and from
sugar beets; but appreciable quantities are derived from the sugar
maple and sugar palms. Many of the sweet fruits are rich in this form
of sugar; pineapples are said to contain at least half of their solids
in sucrose; and although other fruits and vegetables do not contain so
high a percentage of this sugar, oranges, peaches, apricots, dates,
raisins, prunes, carrots and sweet potatoes contain goodly quantities,
which are associated with glucose and fructose. Sucrose is readily
hydrolized, either by acids or enzymes. The inverting enzyme
(invertase) of yeast and sucrase of the intestinal juice, convert
sucrose to fructose and glucose, in which forms it is absorbed into
the portal blood. It is believed that when sucrose is eaten in very
large quantities, it is sometimes absorbed from the stomach. In these
cases it does not become available for use in the body, but acts in
the same manner as when injected directly into the blood stream, being
excreted unchanged by way of the kidneys. According to Herter, sucrose
is much more susceptible to fermentation in the stomach than either
maltose or lactose; and since it has no advantage over these sugars
from a standpoint of nutrition, they are frequently substituted for
sucrose in cases where the dangers arising from fermentation must be
avoided.

~Maltose~ (Malt sugar) is an important constituent of germinating
grains--malt and malt products being formed as the result of enzymic
action (amylases) on starch. A similar action takes place in the mouth
as the result of the ptyalin in the salivary juices and in the
intestines from the action of the starch-splitting enzyme, amylopsin,
in the pancreatic juice. The maltose thus formed is further converted
into glucose by the sugar-splitting enzyme in the intestinal juice,
and in this form it is chiefly absorbed. Maltose is also an
intermediate product formed during the manufacture of commercial
glucose as the result of the boiling of starch with dilute acids.

~Lactose~ (sugar of milk) is one of the most important constituents in
the milk of all mammals. In freshly secreted human milk, lactose
occurs in quantities ranging from 6 to 7%, and in the milk of cows and
goats from 4 to 5%. Lactose is much less soluble than sucrose, and
decidedly less sweet; hence, owing to this latter property, as well as
to its lack of susceptibility to fermentation, lactose is frequently
used to bring up the sugar content of infant formulas to the desired
percentage, and the diets used in the abnormal conditions when
additional energy material is needed. During the process of digestion,
lactose is hydrolized by the lactase in the intestinal juice, yielding
one molecule of glucose and one of galactose. Like maltose, little if
any of this sugar is absorbed in its original form, since experiments
made with injections of lactose into the blood result in the rapid and
almost complete elimination by way of the kidneys. No such results are
obtained when even large amounts of lactose are taken by way of the
mouth.

~Polysaccharides.~--This group of carbohydrates is complex in
character, built up of many sugar molecules, and upon digestion must
be broken down into simple sugars before they can be utilized by the
body.

~Starch~ is the form in which the plant stores her supply of
carbohydrates. It is found in this form in roots and (mature) tubers,
three-fourths of the bulk of which is made up of this material. From
one-half to three-quarters of the solids of grains is made up of
starch also. Pure starch is a fine white powder, odorless and almost
tasteless. It is insoluble in cold water and alcohol, but changes from
an insoluble substance to a more soluble one upon the application of
heat. Upon hydrolysis starch gives first a mixture of dextrin and
maltose, then glucose alone as an end-product. This hydrolysis may be
the result of enzymic action, as occurs upon bringing starch in
contact with the ptyalin in the saliva, or with the amylopsin in the
pancreatic juice; or it may be the result of boiling starch with acid,
as is seen in the manufacture of commercial glucose.

~Dextrin~, as has already been stated, is an intermediate product of
the hydrolysis of starch by acid or enzymes.

~Glycogen~ is the form in which the carbohydrates are stored in the
body, just as starch is the form in which they are stored in plants.
It is found in all parts of the body, but is especially abundant in
the liver. Here it is stored in the cell substance rather than in the
nucleus. The storage of glycogen in the human body depends largely
upon the mode of life and upon the diet. Active muscular work,
especially out of doors, uses up the store of glycogen with great
rapidity; while rest and a sedentary life promotes its storage. The
body readily converts its supply of glycogen into glucose, the form in
which the body uses the carbohydrates for fuel.

~Cellulose~ is a woody, fibrous material insoluble in water and to a
certain extent impervious to the action of the digestive enzymes. This
carbohydrate constitutes the skeleton of plants just as the bones
constitute that of the animal body. It is probable that owing to the
length of time required for this carbohydrate to be broken down in
digestion, much of it escapes oxidation entirely. Hence, it passes
down the digestive tract lending bulk to the food mass and thus
promoting peristalsis throughout the whole of the digestive tract.

~Organic Acids.~--Certain of the carbohydrate foods (fruits and green
vegetables) contain appreciable amounts of organic acids or their
salts; oranges and lemons, for example, are rich in citric acid;
grapes contain considerable quantities of potassium acid tartrate,
apples and other fruits have malic acid; many of the fruits have
succinic acid; a few foods contain oxalic acid, or oxalates. All of
these organic acids are burned in the body to produce energy, with the
possible exception of the oxalates, which seem to have little, if any,
food value. According to Sherman, these organic acids have a lower
fuel value, per gram, than carbohydrates, but are reckoned as such in
computing a food in which they exist. The function of these acids is
chiefly that of neutralizing the acids formed in the body in
metabolism. Being base-forming in character, they function after
absorption and oxidation in the body as potential bases--the base
associated with the acid in their ash combining with carbonic acid to
form carbonates, which act as above described.

~Bacterial Action upon Carbohydrates of Foods.~--The bacteria that act
chiefly upon the carbohydrates belong to the fermentative type. The
substances formed as a result of this activity are certain
acids--lactic, butyric, formic, acetic, oxalic, and possibly alcohol.
Certain forms of carbohydrates are more susceptible to bacterial
fermentation than others. Herter claims that sucrose and glucose are
much more so than lactose, maltose, or starch. The substances thus
formed through bacterial activity are not believed to be toxic in
character, but merely irritating. However, the irritation arising from
excessive fermentation in the stomach may lead to gastric disturbances
of a more or less serious nature; hence the amount of carbohydrate
taken under certain conditions must be adjusted carefully.

~The Effect of Heat upon Carbohydrates.~--The changes wrought in the
carbohydrates as a result of heat have already been discussed to a
certain extent. It is seen that the sucrose (cane sugar) is soluble
alike in hot and cold water; the same is true of maltose; but lactose
is much more soluble in hot water than it is in water which has not
been heated. So far as their digestibility is concerned, the
application of heat (boiling) neither increases nor decreases the
utilization of these sugars by the body.

With starch it is an entirely different matter. It has been found that
the application of heat, either as dry heat, or in the presence of
moisture, brings about a definite change in the character of the
foodstuff. Pure starch admixed with water and boiled, passes into a
condition of colloidal dispersion, or semi-solution, known as starch
paste (Sherman). This is graphically illustrated in the cooking of
potatoes, in which the starch and water are mixed in nature; and in
the cooking of cereals and like starchy foods, to which water is added
in preparation for their cooking. In both cases the application of
heat adds greatly to the digestibility of the raw material by reason
of the change which is wrought in these substances, causing them to be
more readily acted upon by enzymes in the digestive juices.

This solubility of carbohydrates in hot water may be utilized in the
washing of utensils in which these substances have been prepared; thus
saving much time and effort on the part of the nurse in either the
diet kitchen or in the home.


FATS

The second member of the organic food group, and one which is almost
as widely distributed throughout animal and vegetable life as the
carbohydrates, is found in the fats. This foodstuff, while composed of
the same chemical elements that go to make up the carbohydrates,
contains these elements in different proportions; that is, fats
contain less oxygen and more hydrogen than carbohydrates.

~Typical Fats.~--The fats (as already shown in the Table on page 5)
are derived from both animal and plant life, but, like the
carbohydrates, do not always occur in the same form. Those of animal
origin include:

~Adipose Tissue~ of man and animals, tallow of mutton, suet, and oleo
oil of beef, lard of pork.

~Phosphorized Fats~, which include lecithin and lecithans, occur
abundantly in the brain and nerve tissues and to a less extent in the
cells and tissues of man, animals, and plants of which it seems an
essential part. Egg yolk is the most abundant source of phosphorized
fat in food material, but milk likewise furnishes an appreciable
amount.

~Cholesterol~ (fat-like substances).--"The fatty secretions of the
sebaceous glands of man and of the higher animals which furnish the
natural oil for hair, wool and feathers," (Starling), lanoline, which
is a purified wool fat, consist chiefly of cholesterol. According to
Mathews, cholesterol is an essential constituent of the blood, and is
found in the brain and in nearly all living tissues. It is likewise
believed to be the "mother substance" from which bile acids are
derived.

~Fat Soluble "A."~--The vitamine factor which occurs dissolved in
certain fats, namely, milk (whole), butter, egg yolk, the organs of
animals, and codfish liver.

~Definition of Fat.~--The fats are all glycerides; that is, they are
substances made up of combinations of fatty acids and glycerine, which
constitute a definite group of chemical compounds, certain members of
which are liquid in form, while others are solid, or semi-solid. The
liquid fats are known as fatty oils. The fatty acids in which we are
chiefly concerned in this study are: Butyric, Stearic, Oleic, and
Palmitic. Most of the common fats owe their form and flavor to the
type and amount of the various fatty acids of which they are
composed. For example, butter is made up of ten fatty acids; but its
soft, solid form is due to the olein and palmitin (glycerides of oleic
and palmitic acids) which it contains; and its characteristic flavor,
as well as its name, to its butyric acid content (about 5 to 6%). It
is evident that the degree of softness or hardness of a fat may be
determined chiefly by the amount of oleic acid in its composition.
Most of the common oils with which we are familiar in food are
composed chiefly of olein. Stearin (the glyceride of stearic acid) is
the hardest of the fatty acids, while palmitin, although classed with
the solid fats, is not so hard as stearin. Lard and butter are higher
in olein and palmitin and are consequently semi-solid, while suet and
tallow, consisting chiefly of stearin, are much harder than the other
food fats.

~Characteristics of Fats.~--The fats are all insoluble in water, and
only partially so in cold alcohol, but they dissolve readily in ether.
As a rule, the fat occurring in the animal body is more or less
characteristic of the species. For example, animals that live on land
have a harder fat than those living in the water; warm blooded
animals, harder fats than cold blooded ones (fish); and carnivorous
animals, harder fats than herbivorous species.

Fats are lighter than water, hence will float in it. An emulsion is a
suspension of fat in a fluid, and the fat in this case must be very
finely divided and mixed with some other material which will prevent a
coalescence of the fat globules. In milk, which is one of the best
natural emulsions, the additional substance is protein.

~Effect of Heat upon Fat.~--When fats are brought to a high
temperature, the glycerine which they contain decomposes with the
production of a substance known as acrolein, which has an irritating
effect upon the mucous membranes. It is possible that the over-heated
fatty acids add their quota to the production of irritating fumes. As
a rule, it is inadvisable to use frying as a method of preparing food
for the sick or for children. Doubtless, if every cook understood the
exact degree of heat to apply in frying, and knew just how moist to
have the food mixture which she intended to cook in this manner,
better results would be obtained; but since the average cook knows
little about the scientific application of heat to fat or the changes
brought about thereby, it is safer to make use of other methods of
food preparation under the circumstances.

~Functions of Fat.~--This foodstuff undoubtedly serves as the most
compact form of fuel available to the body for the production of
energy. Weight for weight, fat furnishes twice as much heat as the
carbohydrates, and in bulk the difference is even more striking; for
example (about) two tablespoonfuls of sugar are required to produce
100 calories, whereas one scant tablespoonful of olive oil will
produce a like number of heat units. As a source of supply for reserve
energy in the body, fat is most valuable. This reserve fuel is stored
in the form of adipose tissues underlying the skin and surrounding the
vital organs, lending contour to the form and protecting the organs
from jars and shocks. Distributed throughout the body, fat may be
found as (a) cholesterol (in the cells of the muscles, organs, and
nerve tissues), which acts as a protection against the destruction of
the red blood cells; (b) phosphorized fat (lecithin), the universal
distribution of which, according to Starling, seems to indicate that
it plays an important part in the metabolic process of the cells,
serving as a source of phosphorus which is required for the building
up of the complex nucleoproteins of the cell nuclei.


PROTEINS

Upon investigation it was found that neither the fats nor
carbohydrates were the chief constituents of the active tissues. It
was found, in fact, that the carbohydrates occurred in very small
quantities only in the muscles, and that frequently the quantity of
fat was likewise limited. Other substances, containing nitrogen and
sulphur in addition to carbon, oxygen, and hydrogen, which were
invariably present, and which are essential constituents of all
tissues and cells, both in animals and in plants, must be necessary to
all known life. To these substances, believed at the time to be the
fundamental constituents of all tissues, Mulder gave the name Protein,
from the Greek, meaning "to take first place." Later investigations
proved that, while the proteins were essential to the building and
repairing of the tissues and cells in general, they were not the only
factors concerned in the work; that certain mineral salts were
necessary constituents of all tissues, and must be present in order
for any normal growth and development to occur.[4]

~Composition of Proteins.~--The average nitrogen content of common
proteins is about 16%; that is, in 100 grams of protein there will be
approximately 16 grams of nitrogen, or in 6.25 grams of protein there
will be 1 gram of nitrogen. To estimate the protein content of a food
when the percentage of nitrogen is known, it is necessary simply to
multiply the percentage of nitrogen present, by the nitrogen factor,
6.25; or, if the amount of nitrogen is desired, when the percentage of
protein is given, to divide by same factor.

~Construction of Proteins.~--In plant structure the building up of the
proteins is accomplished by the plants from inorganic substances
existing in the soil and air; but in the animal body this is not
possible, because the construction of the tissues requires the use of
other proteins--the most available ones being found in food. Each
animal (or species) forms the proteins characteristic of its own
tissues,--while the proteins of food are similar to those found in the
body, they cannot be utilized in their original form, but must be
split into simpler substances from which the cells of the various
tissues throughout the body may select those particularly adapted for
their purpose. These transformed substances are known as amino acids,
the production of which is a result of digestion in the digestive
tract. There are about seventeen of these acids entering into the
construction of the common proteins. One scientist has likened these
units to letters of the alphabet, which, being combined, spell many
proteins. When a protein contains all of the essential units, it may
be said to be "complete," the best example of which may be seen in
milk, eggs, and meat. When a protein lacks some of the essential
elements, or letters of the protein alphabet, it is said to be
incomplete. Gelatin is the best example of this type of protein, but
the cereals and beans must likewise be supplemented by other
substances; milk being the one most generally used for this purpose.
For the purpose of building young tissues, and maintaining those
already mature, it is logical to use foods containing the foodstuffs
in their best form; that is, those that not only contain the complete
protein, but also the requisite mineral salts and vitamines. Foods
lacking in some of these respects become adequate when supplemented by
these foods which can supply the missing constituents; hence, the use
of such incomplete protein foods need not necessarily be abandoned,
for, as in the case of cereals, the foods are both economical and
palatable, and, when used in addition to milk, furnish valuable
adjuncts to the dietary.

~Classification of Proteins.~--A brief description of some of the more
important proteins with which we are chiefly concerned will serve to
simplify the formulation of a diet. Those assuming the most important
position in nutrition and food are ~globulins~, ~albumens~,
~nucleoproteins~, ~phosphoproteins~, ~hemoglobins~, and ~derived
proteins~ such as proteoses and peptones. The albumens and globulins
associated together occur in the tissues of both animals and plants.
The albumens are richer in sulphur than the globulins and are found
more abundantly in the animal fluids, such as the blood, while the
globulins predominate in the more solid tissues of animals and in
plants. The close association of these two proteins is particularly
noticeable in the blood and cells. They have different characteristics,
however.

~Albumins.~--The best examples are found in egg albumin (white of
egg), lactalbumin (milk), serum albumin (blood), leucosin (wheat),
legumelin (peas). Albumins are all soluble in pure water, and are
coagulable by heat. Coagulation, due to the action of the ferments in
the body, takes place in milk, blood, and muscle plasma. Certain
albumens are particularly adapted for the building and repairing of
tissues. Among those that have been used in feeding experiments to
determine whether or not they were capable, when used as the sole
protein in the diet, of maintaining animals in normal nutrition, and
of supporting normal growth in the young animal,--may be cited
lactalbumin and egg albumin. These experiments provided diets adequate
in other respects, the object being to determine the value of the
various proteins. It was found that the albumin from milk was more
efficient in this respect than the egg albumin.[5]

In the invalid dietary the solubility of the albumins in water makes
them of especial value as reinforcing agents, since they may be
introduced into fluids without materially altering either their flavor
or their bulk.

~Globulins.~--Simple proteins, insoluble in pure water, but soluble
in neutral salt solutions; examples, muscle globulin, serum globulin
(blood), edestin (wheat), physelin (beans), legumin (beans and peas),
tuberin (potatoes), amandin (almonds), arachin, and conarachin
(peanuts).

~Alcohol-Soluble Proteins.~--Simple proteins soluble in alcohol of
from 70-80% strength. Insoluble in absolute alcohol, water and other
neutral solvents. Examples of these proteins may be seen in the
gliadin of wheat, zein of corn, and hordein of barley.

~Albuminoids.~--These substances represent one group of incomplete
proteins, inasmuch as they cannot alone support protein metabolism.
However, they are classed with the proteins and may be substituted for
at least a part of these compounds in the daily dietary, since they
are able to do much of the work of the pure proteins. The best example
of this group is seen in gelatin. This substance contains many of the
structural units of meat protein but in very different relative
amounts. It has not, therefore, the chemical units necessary to repair
the worn-out parts of cell machinery.[6]

~Conjugated Proteins:--Nucleoproteins, Phosphoproteins and
Hemoglobin.~

(a) ~Nucleoproteins.~--This type of protein is characteristic of all
cell nuclei, and is particularly abundant in the highly nucleated
secreting cells of the glandular organs, such as the liver, pancreas,
and the thymus gland. The nucleoproteins are composed of simple
proteins and nuclein. Nucleic acid is rich in phosphorus and upon
decomposition yields some of the purin bases (xanthin, adenin,
guanin), a carbohydrate and phosphoric acid.[7]

(b) ~Phosphoproteins.~--Compounds in which the phosphorus is in
organic union with the protein molecule otherwise than a nucleic acid
or lecithin. Examples: caseinogin (milk), ovovitellin (egg yolk).

(c) ~Hemoglobin.~--Much of the greater part of the iron existing in
the body occurs as a constituent of the hemoglobin of the red blood
cells. When the intake of iron is not sufficient to cover the output,
there must be a consequent diminution in the hemoglobin of the blood
with a corresponding development of anemia.

The importance of knowing these characteristic proteins is apparent.
Not only will such knowledge lead to a more intelligent use of protein
foods in the normal dietary, but it will prove of the greatest
assistance in the adjusting of the foodstuffs in diet for individuals
suffering from certain abnormal conditions.

In abnormal conditions this knowledge of the various proteins--their
composition, source, and behavior in the body assumes a position of
the greatest importance; since it represents the means for
safeguarding a patient from the results caused by the wrong kind of
food. In certain types of nephritis, for example, it is perfectly safe
to give milk where the ingestion of meat and eggs might cause serious,
if not fatal, results. In treating gout, when it is deemed advisable
to limit the purin foods in order to control in a measure the
retention of uric acid in the body, the realization that certain of
the nucleoproteins, upon being broken down in the body, yield the
purins, which in turn give rise to the production of uric acid, will
permit the nurse to adjust the diet so as to eliminate such foods
entirely (see Gout). The importance of keeping the hemoglobin content
of the blood normal has already been mentioned.

~The Effect of Heat upon Proteins.~--The fact that certain proteins
are most susceptible to heat has already been stated, but the
application of this knowledge in the preparation of protein foods is
important. In milk, for example, whole raw milk forms a large hard
curd; whereas boiled milk curdles in a much finer and softer form.
Pasteurized milk shows smaller curds than raw whole milk, but larger
than the boiled whole milk.[8]

An egg cooked by the application of a long-continued high temperature
(212° F.) has a tough white; whereas an egg cooked until hard at a
temperature under the boiling point shows a tenderness in the white
which renders it distinctly more palatable. Soft-cooked eggs leave the
stomach in less time than is required for hard cooked ones; poached
(cooked in water under the boiling point), shirred eggs (cooked in hot
dish), and soft-cooked eggs are among the most readily digestible
forms of eggs. Raw eggs are slightly less stimulating to acid
secretion in the stomach and require a longer time to leave the
stomach than boiled eggs. Thus it is seen that in many cases the
difference in preparation of the protein foods may make a difference
in the way in which the digestive tract handles them. Necessarily,
this point is emphasized more in abnormal than in normal conditions;
for example, albuminized orange juice gives rise to a distinct gastric
secretion, and leaves the stomach rapidly--a great advantage in
certain abnormal conditions, and especially in those requiring liquid
diet of high nutriment value.

The knowledge of the coagulation of proteins by heat points out the
advantage of using cold water over hot in the preliminary cleansing of
utensils in which protein foods have been prepared. Certain members of
this group are soluble in pure water, and will readily dissolve;
whereas, if the water is heated, their coagulation would prevent this
taking place so readily.

~Functions of Protein in the Body.~--The proteins serve two distinct
uses in the body; first, that of building and repairing tissues and
furnishing, in conjunction with other substances, material for
growth; second, that of producing energy for the internal and external
work of the body. For this latter function a large percentage of the
proteins ingested is used; consequently, since the carbohydrates and
fats are primarily the energy furnishing material most readily used by
the organism, it is clearly demonstrated that the average individual
takes more protein into the body than is necessary for its
maintenance. Except during the period when an allowance for growth
must be made, it is probable that a much smaller daily consumption of
protein could be made without disadvantage to the organism, leaving
the bulk of the work, in so far as the running of the engine is
concerned, to the other organic foodstuffs.


WATER

Man can exist for days, even weeks, without food, but without water
life soon becomes extinct. This substance is composed of hydrogen and
oxygen in the proportion of two to one; that is, to each atom of
oxygen there will be found two atoms of hydrogen. This is always the
case no matter where it is found. When foods are put through a drying
process the water is taken out and the rest of the chemical
composition of the food remains unchanged.

This foodstuff, unlike those belonging to the organic group, is not
changed during the process of digestion, nor does the application of
heat or cold affect it, save from a physical standpoint. Water boils
at a temperature of 100° C. (212° F.), and freezes at a temperature of
0° C. (32° F.).

~Function of Water.~--The uses of water in the body are many, and the
advantage arising from a sufficient amount of this foodstuff in the
dietary cannot be overestimated. It is no longer considered an error
in diet to drink a moderate amount of water with the meals, so long as
it is not used as a substitute for mastication, and as a means of
washing the food into the stomach. In the diet, both as a beverage and
as a part of most of the food materials ingested, water serves to
moisten the tissues; to furnish the fluid medium for all of the
secretions and excretions of the body; to carry food materials in
solution to all parts of the organism; to stimulate secretory cells
producing the digestive juices, thereby aiding in the processes of
digestion, absorption and excretion; to promote circulation; to
furnish material for free diuresis, thus preventing to a great extent
the retention of injurious substances by the body, which might
otherwise take place.

~Factors Determining the Amount of Water Needed.~--In normal
conditions it is probable that the kind and amount of exercise taken
has more to do with the amount of water needed by the body than any
other factor, since the vigorously worked body excretes more water by
way of the skin than the quiescent one. With a normal amount of
exercise, it is advisable to drink from six to eight glasses of water
each day, increasing the amount to a certain extent when exercise
causes a great loss through perspiration. It is always advisable,
however, to keep in mind that an excessive amount of fluid taken into
the body throws a corresponding amount of work on the organs (the
stomach, kidneys and heart). In certain abnormal conditions, the
body's water supply is depleted. This is particularly true in the case
of hemorrhage, vomiting, and diarrhea. Under other conditions (certain
types of nephritis), the body becomes overburdened through the excess
of water retained, owing to the difficulty which the kidneys show in
eliminating it. This retention of water by the tissues gives rise to
the condition known as edema.


MINERAL SALTS

~Ash.~--The eight remaining chemical elements, _i.e._, calcium,
magnesium, sulphur, iron, sodium, potassium, phosphorus, chlorine,
constituting the mineral salts or ash, are likewise classed as food on
account of the work which they perform in the body. Some of these
elements enter the body as essential constituents of the organic
compounds, and are metabolized in the body as such, becoming inorganic
only upon oxidation of the organic materials of which they form a
part.

~Importance of the Mineral Salts.~--The way in which the mineral
elements exist in the body and take part in its functions, has been
graphically outlined by Sherman as follows.

"(1) As bone constituents, giving rigidity and relative permanence to
the skeletal tissues. (2) As essential elements of the organic
compounds which are the chief solids of the soft tissues (muscles,
blood cells, etc.). (3) As soluble salts (electrolytes) held in
solution in the fluids of the body; giving to those fluids their
characteristic influence upon the elasticity and irritability of
muscle and nerve; supplying material for the acidity and alkalinity of
the digestive juices and other secretions; and yet maintaining the
neutrality, or slight alkalescence, of the internal fluids as well as
their osmotic pressure and solvent power."[9]

The above outline, showing the various ways in which the mineral
constituents enter and take part in the various functions, as well as
in the structure of the body, make it evident that the same close
attention and study which was given to the other foodstuffs must be
accorded to these substances. When the student realizes that the
presence of certain salts dissolved in the blood assists in the
regulation of the vital processes of the body such as the digestion,
circulation and respiration; that they are responsible for the
contraction and relaxation of the muscles; that they assist in
controlling the nerves; that they are, in a way, instrumental in
releasing the energy locked up in food--the value of these elements
becomes very evident, and their importance in the dietary inestimable.
Some of the mineral salts are more widely distributed in food than
others, and the danger arising from their deficiency in the diet is
not so great as is the case with others; hence attention is called to
those found by investigators to be most often lacking or deficient in
the average diet; _i.e._, calcium, phosphorus, and iron. A brief
summary of the special parts played by these elements will be outlined
here.

~Calcium.~--Physiology teaches that about eighty-five per cent. of the
mineral matter of the bone, or at least three-quarters of the ash of
the entire body, consists of calcium phosphates. It has long been
known that this mineral salt is necessary for the coagulation of the
blood, and science has demonstrated that "the alternate contractions
and relaxations which constitute the normal beating of the heart are
dependent, at least in part, upon the presence of a sufficient, but
not excessive concentration of calcium salts in the fluid which bathes
the heart muscles."[10]

~Phosphorus.~--According to Sherman, phosphorus compounds are as
widely distributed in the body, and as strictly essential to every
living cell as are proteins. Science has also proved that they are
important constituents in the skeleton, in milk, in glandular tissue,
in sexual elements, and in the nervous system; that these compounds
take part in the functions of cell multiplication, in the activation
and control of enzyme actions, in the maintenance of neutrality in the
body; that they exert an influence on the osmotic pressure and surface
tension of the body, and upon the processes of absorption and
secretion. Like calcium, phosphorus is absolutely essential to the
growth and development of the body, and, as in the case of the
mineral, its presence in the dietary must be accorded strict
attention, in order to avoid the results accruing from its
deficiency. Casein, or caseinogen of milk and egg yolk (ovovitellin),
are the substances richest in this mineral salt. The fact that the
phosphorus existing in grains (cereals) may be removed largely in the
process of milling, makes it advisable to consider the use of the
breads made from the whole grains.

~Iron.~--The presence of iron as an essential constituent of
hemoglobin has already been discussed. That which is not in the
hemoglobin is chiefly found in the chromatin substances of the cells.

The body does not keep a reserve store of iron on hand as is the case
with calcium and phosphorus in the bone tissues, but must depend upon
the daily intake in food to supply its needs. The iron content of food
materials is not large, but a careful regulation of the iron bearing
foods (see Table on page 5) will make it easy to cover the demands of
the body with a material which has been found to do its work most
efficiently. Medicinal iron has received much attention in the
determination of the essential needs of the body. "Whether medicinal
iron actually serves as material for the construction of hemoglobin is
not positively known, but we have what appears to be a good evidence
that food iron is assimilated and used for growth and for regeneration
of the hemoglobin to much better advantage than are inorganic or
synthetic forms, and that when medicinal iron increases the production
of hemoglobin, its effect is more beneficial in proportion as food
iron is more abundant--a strong indication that the medicinal iron
acts by stimulation rather than as material for the construction of
hemoglobin." (Sherman)

The newborn infant has a store of iron already on hand, derived from
the mother through the placenta before birth. After the birth, and
through the nursing period, the child receives a certain amount of
iron from the mother's milk. This supply is not altogether reliable,
however, since any disturbance of the digestion will tend to
interfere with its absorption, and consequently deprive the organism
of what would otherwise be used for the building up of the blood
supply. Thus it is clearly indicated that the infant's safest source
of iron is from the mother during the pre-natal period. This supply
must necessarily come from her diet during this time, and is made
possible by regulating day by day the iron bearing foods in her
dietary. After the original store of iron is reduced to that of the
adult (after the child has tripled in birth-weight, generally at 12 or
13 months), and during the remainder of the growth period, it is very
necessary to regulate the iron-bearing food in the diet, in order to
insure the child of an adequate amount to cover the demands made by
the increasing blood supply.


VITAMINES

Up to a few years ago it was believed a complete diet should contain
an adequate amount of protein of a proper type, a sufficient amount of
calcium, phosphorus and iron, and enough carbohydrates and fats to
furnish the body with sufficient fuel to cover its energy
expenditures. This belief was proved to be incorrect a number of years
ago by Dr. Hopkins of England. In making certain feeding experiments
with rats, Dr. Hopkins showed that some substance or substances
present in milk, other than those already mentioned, was essential for
the growth of the animal; that animals deprived of this material grew
for a time, but gradually ceased to do so. Later on, Osborne, Mendel,
McCollum and Davis discovered a like substance in butter fat; and
still later Dr. McCollum found the same growth stimulating material,
or one very like it, existing in the leaves of plants. These
scientists found, upon investigation, that there were probably two
substances in milk--one soluble in the fat, the other in the
protein-free and fat-free whey--both of which were essential for
normal growth. In 1911 Dr. Funk discovered in rice polishings a
substance which he believed to be a cure and preventive of Beri-beri;
to this substance, which is now believed to be identical with the
second substance found in milk, he gave the name "vitamine." Dr.
Funk's name "Vitamine" is now accepted to cover a number of substances
essential to growth, and for the prevention and cure of certain
diseases. To the first two has been added a third member of the
vitamine family, which has proved to be a cure and preventive of
scurvy. These substances are called--on account of the substances in
which they are soluble--"Fat soluble A," "Water soluble B," and "Water
soluble C." The table on page 496 shows the sources from which these
factors may be obtained. The four plus system is used by Dr. Eddy to
describe the abundance with which they occur.[11]

~Function of "Fat Soluble A."~--All investigators agree that the "A"
vitamine is an essential factor in the growth of young tissue, and the
repair of mature tissues. McCollum claims that this vitamine is
likewise a factor in the prevention of the eye disease known as
xerophthalmia, and other scientists also hold this opinion. Eddy
states that a diet lacking in the "A" vitamine will, in the majority
of cases, result in stunted growth and the development of the eye
disease, and that the appearance of the latter may be taken as a sure
indication of the absence or deficiency of this vitamine.

The following diagram shows the effect of adding fat soluble "A" to
the diet which was adequate in other respects. This chart represents
the growth curve of young rats.[12]

  230 +----------+----------+
      |          |          |
      |          |          |
      |          |          |
      |          |          |
      |          |          |
  190 +----------+---------/+
      |          |        / |
      |          |       /  |
      |          |      /   |
      |          |     /    |
      |          |    /     |
  150 +----------+---/------+
      |          |  /       |
      |  With    | /        |
      |  "Fat    |/         |
      | Soluble  /          |
      |    A"   /|          |
  110 +--------/-+----------+
      |       /  |          |
      |      /   |          |
      |     /    |          |
      |    /     |          |
      |   /      |          |
  70  +--/-------+----------+
      | /        |          |
      |/ Without "Fat Soluble A"
      |----------|----------|
      |          |          |
      |          |          |
  30  +----------+----------+
      0          1          2

  Figure showing the effect upon growth of adding "fat soluble A"
  to a diet adequate in all other respects. Courtesy of Dr. E. V.
  McCollum.


Mellanby of England believes the "A" vitamine to be a factor in the
prevention of rickets. Scientists of America have recently
investigated this disease, and Dr. Hess (New York) has found cod
liver oil to be a remedy for it. Cod liver oil is known to be rich in
"Fat soluble A," but whether the cure of rickets is due to the
presence of this vitamine in the oil, or to a possible fourth
vitamine, is still undetermined.

~Effect of Heat on the "A" Vitamine.~--Heat, as applied in the
ordinary methods of cooking, is not believed to exert a great deal of
destruction upon the "A" type of vitamine; but hydrogenation, the
process used in the hardening of certain fats in the manufacture of
lard substitutes, is said to destroy it completely.

~"Water Soluble B."~--The second vitamine discovered in milk and
believed to be identical with the Funk vitamine is more widely
distributed than the "A" vitamine. For this reason it is not so likely
to be deficient in the diet as is found to be the case with the "A." A
glance at the table shows that the best sources outside of yeast are
the seeds of plants and the milk and eggs of animals. In beans and
peas the "B" vitamine is distributed throughout the entire seed, but
in the cereal grains it is found chiefly in the embryo. As a result,
bread made from fine white flour or meal is much more apt to be
deficient in vitamine of the "B" type than that which is made from the
whole grain; the same is true of rice and other cereals. Spinach,
potatoes, carrots and turnips show an appreciable amount of the
vitamine, but beets are known to be extremely poor in it. Nuts too are
considered a valuable source.

~Function of the "B" Vitamine.~--Like the "A" vitamine, water soluble
"B" is believed to be essential to growth. Funk established its value
as a preventive and cure of Beri-beri, the disease common in the
Orient among people living largely upon a diet of polished rice and
fish. Besides being a growth-stimulating substance and an
antineuritic, the "B" vitamine is highly valued for its stimulating
effect upon the appetite. To this property is probably due at least
part of the credit for which certain substances work for the promotion
of growth in animals. This can be utilized to good advantage for
children showing a disposition to refuse food, by supplementing
formulas made from milk,[13] with the expressed juice of vegetables
and fruits known to be rich in the "B" vitamine.

~Effect of Heat on the "B" Vitamine.~--This vitamine also shows a
resistance to heat; that is, as applied in the methods generally used
in cooking, pasteurization temperatures do not materially affect the
vitamine property of the formula as far as the "A" and "B" factors are
concerned.

~The Effect of Alkali (Soda) upon the "B" Vitamine.~--It has been an
ordinary practice to add soda to the water in which certain vegetables
are cooked, for the ostensible purpose of softening the vegetables and
hastening their cooking. The practice has been condemned by many
scientists who are making experiments along these lines, on account of
its destructive power upon the "B" vitamine. Chick and Hume in England
claim that when the amount of food given contains originally just
sufficient vitamines to cover the growth factor the use of soda in the
cooking water does serious harm to these vitamines. This is a point
well worth remembering. It is often difficult to persuade certain
individuals to eat vegetables in appreciable quantities; if the
vitamines were reduced though the method of preparing the food, these
individuals would not obtain a sufficient quantity of the vitamines.

~"Water Soluble C."~--The third member of the vitamine family is
known for its antiscorbutic property; that is, it is the best known
cure and preventive of scurvy. It likewise exerts a certain amount of
influence upon the growth of the animal and must be present in the
diet, in order that the health and well-being of the individual may be
safeguarded. The "C" vitamine, like the "B" vitamine, is soluble in
water, and is present to an appreciable extent in the fresh juices of
the fruits and vegetables. Some are richer in this respect than others
(orange and tomato juice), while the cereals, grains, seed of plants,
sugars, oils, and meats are singularly deficient. Milk (whole) does
not contain a great amount of the "C" vitamine, and this amount is
still further reduced under certain methods of preparation. Milk
powders, made either from the whole or the skimmed milk, are found to
contain only very small amounts of this essential substance. Condensed
milk and cream are supposed to be free of "C," and the same is true of
eggs.

~Effect of Heat on "C" Vitamine.~--All authorities agree that the "C"
vitamine is much more sensitive to heat than the other two; and for
this reason much of the value obtained from this vitamine in uncooked
material may be lost when the food containing it is subjected to
long-continued heat. Hess claims that the temperature used for
pasteurizing milk for some time, is more destructive to this vitamine
than boiling water temperature continued for a few minutes only.[14]
There is need for care in formulating the diet for children to see
that they are given fresh fruit every day; or when that is not
possible, to see that they are at least given tomato juice. This
substance is rich in the antiscorbutic vitamine, and according to
experiments made by Sherman, LeMer and Campbell, loses fifty per cent.
of its antiscorbutic power when boiled one hour. Dr. Delf at the
Lister Institute experimented with raw and cooked cabbage, and found
that when this material was cooked for one hour at temperatures
ranging from 80° to 90° C the loss in antiscorbutic power amounted to
90% in the cooked leaves over the raw material. Dr. Delf also
concluded from her experiments that it was advisable to add neither
acid nor alkali in the cooking of vegetables if these substances were
to give their maximum value of vitamines.

From the foregoing description of these vitamine factors, it is
readily seen why so many dietaries are deficient in these essential
substances. The limited sources from which to obtain the "A" vitamine;
the sensitiveness of the "B" vitamine to the action of alkalies; the
sensitiveness of the "C" vitamine to heat, alkali and acid, moreover
the limitation of its presence chiefly to the fresh fruits and plant
juices,--all point to the need of special care in the selection of the
food materials and of the manner in which these materials are prepared
for consumption.


SUMMARY

In the descriptions just given of the various foodstuffs, especially
in regard to their function in the body, it is readily seen that no
one foodstuff is used to the exclusion of another. It is further seen
that in the upkeep of the body, which includes not only the building
and repairing of its tissues, but the running of the engine and
maintaining of its normal temperature, the organism uses each and all
of the organic food substances for the production of heat.
Furthermore, while the tissues are chiefly built from protein
material, and physiology teaches that protein can be built only from
other protein, these tissues contain a certain amount of carbohydrate,
fat, mineral salts, and water; this furnishes distinct evidence that
the building of the cells and tissues of the body cannot be
accomplished by means of protein alone, but by the judicious balancing
of all the foodstuffs in the dietary.

Science has gone even further than this, as has just been
demonstrated, and has proven that without the substances known as
vitamines the normal growth and development in the young would be
arrested, and that the maintenance of the adult body would be
impaired. It has also proven that certain diseases owe their
development to deficiencies in the vitamine supply to the body.


PROBLEMS

(a) Outline briefly what is believed to be the essentials of an
adequate dietary.

(b) List the fuel foods and show their most economical source.

(c) List the best sources of the complete proteins.

(d) Show how the incomplete protein foods may be made adequate for
growth.


FOOTNOTES:

[1] One quart of milk contains more calcium than a quart of clear
saturated solution of lime water.

[2] For complete list, see Eddy's Table, in Appendix.

[3] "Chemistry of Food and Nutrition" (revised edition), by Sherman.

[4] Scientists are proving the need for certain vitamine factors in
the diet in order that the growth and development of young tissues and
the repair of adult tissues may proceed. The part played by these
substances will be discussed later.

[5] "Chemistry of Food and Nutrition" (2d ed.), by Sherman.

[6] "The Basis of Nutrition," by Graham Lusk.

[7] "Food Products," by Henry Sherman.

[8] Abstracts made from thirteen papers from the Laboratory of
Physiological Chemistry, Jefferson Medical College, Philadelphia;
published in the "American Journal of Physiology and Science," by
Minna C. Denton. U.S. Department of Agriculture.

[9] "Chemistry of Food and Nutrition" (revised), p. 333, by Henry
Sherman.

[10] "Chemistry of Food and Nutrition" (revised edition), by Sherman.

[11] "The Vitamine Manual," p. 64, by Walter Eddy

[12] Courtesy of Dr. E. V. McCollum.

[13] Milk from cows whose diet has been deficient in vitamines shows a
like deficiency in vitamine content--the same is true of mother's
milk.

[14] "The Vitamine Manual," p. 64, by Walter H. Eddy.




CHAPTER II

THE FUEL VALUE OF FOOD


Science has proved that the human body is composed of certain chemical
elements and that food materials are combinations of like elements; it
has likewise proved that the body will utilize her own structure for
fuel to carry on the work of her various functions unless material is
supplied for this purpose from an outside source, namely, food, which
in chemical composition so closely resembles that of the human body.

~Amount and Type of Food.~--The next point of investigation would
logically be the amount and kind of food necessary to best accomplish
this purpose. To be able to do this it was necessary to have some
standard unit by which to measure the amount of heat each food was
capable of producing when burned outside the body, after which it was
more or less simple to calculate the heat production of each of the
food combinations within the organism. An apparatus known as the "Bomb
Calorimeter"[15] was devised by Berthelot, and adapted for the
examination of food materials by Atwater and Blakesley. The food
material to be tested was placed within the bomb, which was charged
with a known amount of pure oxygen. The bomb was then sealed and
immersed in a weighed amount of pure water, into which a very delicate
thermometer was inserted. The food within the bomb was ignited by
means of an electric fuse, and the heat given off by the burning of
the material was communicated to the surrounding water and was
registered upon the thermometer. It was evident that some definite
name had to be devised by which these heat units might be known. Hence
the name "~calorie~," which represents _the amount of heat required to
raise the temperature of 1 kilogram of pure water 1 degree centigrade,
or about 4 pounds of water 1 degree Fahrenheit_.

~Transformation of Foods into Available Fuel.~--A comparison has been
made between the human body and steam engine, but this comparison is
not adequate, since the food does not produce heat within the body
originally, but energy of which heat is a by-product. Each food
combination has a certain amount of dormant energy within its
structure and this energy does not become active nor can it be
utilized by the body until the food, of which it is a part, is changed
within the organism to substances more nearly like its own. This
liberated active energy is then used as a motive power to carry on the
internal and external work of the body, and the heat, which is
invariably the consequence of any active energy (motion), leaves the
body as such. It will be seen, then, that the human body acts not as a
steam engine, but rather as a ~transforming machine~ by means of which
the dormant energy of the food is transformed into an active agent of
which heat is a natural result.

In the calorimeter it was found that the carbohydrates and fats burned
to the same end products, namely, carbon dioxide and water, while the
proteins, upon oxidation, produced carbon dioxide, water and nitrogen
gas. In the body it was found that the carbohydrates and the fats
acted in exactly the same manner as in the calorimeter, producing the
same end products. But this was not the case with the proteins; the
oxidation process of this chemical combination was found to be not
nearly so complete within the body as in the calorimeter, and instead
of the free nitrogen as produced in the apparatus there were urea and
other nitrogenous substances eliminated which, while combustible,
represented a less complete oxidation of the proteins.

The following table represents the amount of heat produced as the
result of a complete oxidation of the foodstuffs in the calorimeter.

TABLE[16]

  ==================================================
  Carbohydrates                 4.1  cal. per gram
  Fats                          9.45 cal. per gram
  Protein (nitrogen × 6.25)     5.65 cal. per gram
  ==================================================

The loss of potential energy due to the incomplete oxidation of the
proteins in the body is approximately 1.3 calories to each gram of
protein in food; consequently in calculating the fuel value of protein
foods, due allowance must be made for these losses. Allowance must
also be made for the incomplete digestion, or losses occurring in the
digestion, of the foodstuffs. These losses, as well as the approximate
amount of each constituent absorbed, are represented in the following
table.[17]

  ===========================+===========+===============
                             |  _Lost_   |  _Absorbed_
  ---------------------------+-----------+---------------
  Carbohydrates              |2 per cent.| 98 per cent.
  Fats                       |5 per cent.| 95 per cent.
  Proteins                   |8 per cent.| 92 per cent.
  ===========================+===========+===============

The physiological fuel factors of food, or the amount of heat produced
as the result of combustion of 1 gram of organic food material after
the above-mentioned losses have been accounted for, may be obtained as
follows.[18]

  =================================================
  Carbohydrates      4.1  × 98% = 4 cal. per gram
  Fats               9.45 × 95% = 9 cal. per gram
  Proteins           4.35 × 92% = 4 cal. per gram
  =================================================


EFFECT OF HEAT AND COLD UPON THE FOODSTUFFS

In primeval days, when man led a more natural life, his very existence
depended upon his ability to wrest from the earth his 4--9--4; these,
then, constitute what are known as the "physiological fuel factors" of
carbohydrates, fats, and proteins respectively.

~Determination of Fuel Value of Food.~--In determining the amount of
heat produced by a given amount of food, it is first essential to
reduce the amount to grams (for example, 1 lb. equals 480 grams):
first, because the gram is a unit of weight commonly used in dietetic
calculations; second, because the fuel factors are based on the amount
of heat produced by the burning of one gram of organic foodstuffs.
Knowing the composition of food, that is the number of hundredths of
protein, carbohydrate and fat it contains, it is a simple matter to
estimate its fuel value by multiplying the amount of each contained in
one gram by its physiological fuel factor 4.4.9. Thus if the
composition of a food is 3-3/10% protein, 4% fat and 5% carbohydrate,
one gram would contain .033 gram of protein, .04 gram of fat and 0.5
gram of carbohydrate. Hence one gram of milk would produce

  .033 × 4 = .132 calorie from protein
  .04  × 9 = .36 calorie from fat
  .05  × 4 = .20 calorie from carbohydrate
         or  .692 calorie in all

But it is not necessary to estimate the fuel value of so small a
quantity as one gram, and, since the value of protein, carbohydrates
and fats is always the same it is more satisfactory to estimate the
amount of the organic constituents contained in the entire given
quantity of food, rather than stopping to figure out the fuel value of
the small quantity.

This is done by multiplying the entire number of grams of food given
by the amount of protein, fat and carbohydrate contained in one gram,
then multiplying these results by the physiological fuel factor of
each. Thus 100 grams of milk would yield

  100 × .033 = 3.3 × 4 = 13.2 calories from protein
  100 × .04  = 4.0 × 9 = 36.0 calories from fat
  100 × .05  = 5.0 × 4 = 20.0 calories from carbohydrates
     or a total of 69.2 calories from 100 grams of milk.

~The Standard or 100 Calorie Portion.~--Just as it has been more
convenient to estimate a larger rather than a smaller quantity of food
material, so it is frequently more desirable to estimate a hundred
calories, rather than one calorie. This is especially useful when
dietaries of high caloric (fuel) value are to be estimated, or
dietaries in which foods of like composition and fuel value are to be
interchangeable. In such cases it is a simple matter to select the
desired number of 100 calorie portions of those foods which are to
make up the dietary.[19]

~Method of Estimating the 100 Calorie Portion.~--The number of
calories yielded by 100 grams of food material is taken as a basis
upon which to estimate the 100 calorie portion, and X represents the
number of grams required to yield this portion. The problem is one of
"simple proportion," for example, take the 100 grams of milk just
estimated, we found that 100 grams (or c.c.) furnished 69.2 calories
of heat, then, 100:69.2 :: X:100--145; or 145 grams of milk are
required to furnish 100 calories of heat. Suppose it is desirable to
substitute eggs for a part of the milk in the diet, eggs have a higher
fuel value per unit of weight than milk, their average composition
being 13.4% protein, and 10.5% fat (no appreciable amount of
carbohydrates), 100 grams of eggs would yield

  100 × .134 = 13.4 × 4 = 53.6 calories from protein
  100 × .105 = 10.5 × 9 = 94.5 calories from fat,
      or a total of 148 calories.

The Standard or 100 calorie portion of eggs would be,

  100:148 :: X:100 = 68

or the number of grams required to yield 100 calories.

Thus it is seen that in using the fuel value of a hundred grams of
food material for estimating the standard or 100 calories portion the
extremes are always the same. Hence, the weight of the 100 calorie
portion may always be obtained by multiplying the extremes and
dividing the result by the number of calories furnished by 100 grams
of food material.


PROBLEMS

(a) Compare the fuel value of the various common food materials.

(b) How does the fuel value of a chicken salad compare with that of
fruit salad?

(c) Figure the fuel value of a cupful of cream of tomato soup and
compare it with that furnished by the same quantity of beef broth.

(d) Weigh and measure a 100-calorie portion of spinach and compare it
with a 100-calorie portion of sweet potato.


FOOTNOTES:

[15] For full description and methods used, see "Journal of The
American Chemical Society," July, 1903.

[16] "Chemistry of Food and Nutrition" (revised edition), by Sherman.

[17] "Chemistry of Food and Nutrition," by Sherman.

[18] "Chemistry of Food and Nutrition" (revised), by Sherman.

[19] See Table of Standard or 100 Calorie Portions, in Appendix.




CHAPTER III

THE FOOD REQUIREMENTS OF THE BODY


The human body, as far as can be judged, does not use one nutrient to
the exclusion of another, but science has proved that the best results
are obtained from diets balanced to suit the needs of the body,
providing the fuel and repair materials in the amounts which are
calculated to give the maximum value with the minimum expenditure on
the part of the organism.

For while no two individuals are exactly alike, there are factors
which govern or influence the food requirements of all, and thus make
it possible to estimate the needs of the body with a fair degree of
accuracy.

It has been found, by means of calorimeter experiments (direct and
indirect), that a certain amount of heat is produced within the body,
regardless of external movement or food; that is, when a body is lying
absolutely quiet with no movement save that of breathing, the internal
work of the organism, which is continuous, releases so much heat, and
this is produced whether there is food to replace it or whether the
body structure is burned. This is known as the ~basal rate of
metabolism~, and constitutes the normal ~basal requirements~. Any
external movement will increase this rate; the greater the activity
the higher the increase. Consequently external work calls for food in
addition to that which is used to run the engine, in order to save the
body from destruction.

DuBois[20] finds "Basal Metabolism above normal in exophthalmic
goiter, in fevers, in lymphatic leukemia, and in pernicious anemia,
in severe cardiac disease, and in some cases of severe diabetes and
cancer; it is lower than normal in cretinism, and in myxedema, in old
age, in some wasting diseases and perhaps in some cases of obesity."
This fluctuation in the Basal Rate of metabolism furnishes a factor in
the diagnosis of disease, not only recognized but coming more and more
in use.


FACTORS DETERMINING THE FOOD REQUIREMENTS OF THE BODY

~For the Adult.~--Muscular activity, Age and Size, are most important
factors influencing the food requirements. The physical condition and
environment of the individual also exert a certain amount of influence
upon the intake of food.

~Work.~--Muscular activity, as already stated, increases the body
expenditures; consequently the more active the work the greater amount
of energy food needed per unit of weight.

~Age.~--As the individual grows older, the rate of metabolism
decreases until, in old age, it is not more than a third to a fifth of
what it was in earlier life. This is due to a general "slowing down"
of the machinery, the heart does not beat so rapidly, nor is the
respiration so quick. The digestive organs, the heart, the liver, and
the kidneys, cannot handle the volume of food which was required
during the period of greatest physical activity. Hence, any great
excess over and above that which is needed for the maintenance of the
body in health will be a source of danger to the elderly person. Von
Noorden claims the food requirements of individuals from

  60 to 70 years of age to be reduced 10%; for people from
  70 to 80 years of age to be reduced 20%; for people from
  80 to 90 years of age to be reduced 30%.

~Sex.~--Science has proved, that there is little difference in the
food requirements of men and women, provided they are alike in age,
weight and size, and are doing the same amount and type of work. But
women, as a rule, weigh less than men, hence their food requirements
are approximately less.

Murlin finds the food requirements of pregnant women to be some what
higher than of non-pregnant ones, and the requirements of the nursing
mother to be higher than either (see chapter on Pregnancy and
Lactation).

~For the Child.~--The factors influencing the food requirements are
different, to a certain extent, from those of the adult. The main
difference lies in the fact that the adult needs food only for the
maintenance and repair of the body, while the child must have food,
not only to cover its maintenance requirements, but to support the
growth and development which should be continuous from birth to
maturity. Resistance, too, must be developed during this period in
order to safeguard the child through life.

The rate of metabolism in the infant is greater than at any other
period of life, consequently, even if a child were one-third the
weight of its parent, it would inevitably cease to grow and would
become malnourished, if its food requirements were reckoned at only
one-third that of the parent.

~Adjusting the Food Requirements.~--Taking these factors as guides for
estimating the food requirements of man, it is evident that no hard
and fast law can be laid down to cover all, that each individual must
adjust the food intake according to the weight and activity of the
body. Sherman has arranged the following table showing the energy
expenditures per hour for the average man (154 pounds), per pound of
body weight (these are approximate averages only).


TABLE[21]

  =====================================================================
  Sleeping quietly                             60-70 calories per hour
  Awake, lying still                           70-85 calories per hour
  Sitting at rest                                100 calories per hour
  Standing at rest                               115 calories per hour
  Tailoring                                      135 calories per hour
  Typewriting rapidly                            140 calories per hour
  "Light exercise" (stationary bicycle)          170 calories per hour
  Shoemaking                                     180 calories per hour
  Walking slowly (about 2-1/4 miles an hour)     200 calories per hour
  Carpentry or metal work                        240 calories per hour
  "Active exercise" (stationary bicycle)         290 calories per hour
  Walking briskly (about 3-3/4 miles an hour)    300 calories per hour
  Stone working                                  400 calories per hour
  Severe exercise, such as sawing wood           450 calories per hour
  Running (about 5-1/2 miles an hour)            500 calories per hour
  Very severe exercise (stationary bicycle)      600 calories per hour
  =====================================================================

The above table, calculated for an average man weighing 154 pounds,
may seem less simple to use than one based on the energy requirements
per pound of body weight per hour, of an average individual. For
example, a man weighing 123 pounds and performing practically the same
amount and type of work as done by the man weighing 154 pounds would
require practically one-fifth less calories than the latter
individual. Hence, to facilitate the estimation of the food
requirements for average individuals, the following table is
included.[22]

  ======================================================================
  Sleeping                   0.42 calorie  per hour, per lb. of body wt.
  Sitting at rest            0.65 calorie  per hour, per lb. of body wt.
  Light muscular exercise    1.10 calories per hour, per lb. of body wt.
  Active muscular exercise   1.90 calories per hour, per lb. of body wt.
  Severe muscular exercise   3.00 calories per hour, per lb. of body wt.
  ======================================================================

Possibly a few explanatory words, as to the terms used in the above
tables, will assist the nurse in making the necessary calculation.
"Sleeping quietly" makes allowance for no movement save that of
respiration; any undue restlessness will call for an increase in the
above allowance.

"Sitting at rest" includes the time spent at meals, sitting in class
room, ward office, studying or reading. It does not include much
walking about the room, rising frequently, or nervous restlessness.

"Light exercise" includes all light house work, running an ordinary
sewing machine, walking about office or ward, (receiving ward
included). It does not include washing, sweeping or scrubbing.

"Active exercise" includes washing, sweeping, scrubbing, general house
work, carpentry, and such sports as tennis, basket ball, and ordinary
gymnasium work.

"Severe exercise" includes road workers (working with pick and shovel)
fast running, baseball, football, and swimming.

"Very severe exercise" includes the work done by miners, handling of
freight, and lumbermen, especially those working in extreme cold,
where the severe cold makes extra demands on the fuel supply. By
making use of the averages just mentioned it should be a simple matter
to calculate the food requirements of any normal individual. It is
necessary to know the weight of the person in question, and the manner
in which the twenty-four hours are spent, and, in the case of elderly
individuals, make the reductions believed to be necessary for health.

~Method of Using the Tables.~--Let us take a nurse in training for
this purpose. Suppose the nurse weighs 110 pounds, and spends the
twenty-four hours as follows,

  Sleeping                         8 hours
  Sitting at meals                 2 hours
  Studying                         2 hours
  In class                         1 hour
  On duty                          9 hours
  Off duty (walking briskly)       2 hours

Her daily food requirements would probably be approximately 2,235
calories. This estimate would be increased, if she were obliged to do
much heavy lifting, scrubbing of beds, or other duties requiring the
expenditure of much effort. It would be decreased if the hours spent
in study and class room work were increased and the hours on the ward
shortened. The estimation may be made as follows,

  Sleeping 8 hrs.                     110 × 0.42 × 8 =  370   calories
  Sitting at meals 2 hrs.             110 × 0.65 × 2 =  143   calories
  Sitting in class 1 hr.              110 × 0.65 × 1 =   71.5 calories
  Studying, 2 hrs.                    110 × 0.65 × 2 =  143   calories
  On duty 9 hrs.                      110 × 1.10 × 9 = 1089   calories
  Off duty (walking briskly) 2 hrs.   110 × 1.90 × 2 =  418   calories
                                                       ---------------
  Total for day                                        2234.5 calories

This estimate may be made to suit any individual, the man in the
office or the one working on the streets, the woman living at home or
the one spending eight or ten hours scrubbing the floors of a great
office building; it is simply a matter of adjusting the calories in
the dietary to meet the requirements of body weight and muscular
activity.

~Energy Requirements for Children.~--In estimating the energy needs of
children, the above method is not satisfactory, since the storage of
material for growth must be considered, as well as the activities of
the body. The growth period includes the years from birth to the
eighteenth year, after which time the food requirements of the body
are made on a basis of weight and muscular activity, as in all adults.
The table on the following page shows the food allowances made for
healthy children; in the feeding of malnourished or underweight
children, more food in proportion to age is given in order to overcome
the handicap under which they are suffering.


FOOD ALLOWANCES FOR HEALTHY CHILDREN[23]

  ==============+========================
        AGE     |    CALORIES PER DAY
  --------------+------------+-----------
     _Years_    |   _Boys_   |  _Girls_
  --------------+------------+-----------
   Under 2      |  900-1200  |  900-1200
    2-3         | 1000-1300  |  980-1280
    3-4         | 1100-1400  | 1060-1360
    4-5         | 1200-1500  | 1140-1440
    5-6         | 1300-1600  | 1220-1520
    6-7         | 1400-1700  | 1300-1600
    7-8         | 1500-1800  | 1380-1680
    8-9         | 1600-1900  | 1460-1760
    9-10        | 1700-2000  | 1550-1850
   10-11        | 1900-2200  | 1650-1950
   11-12        | 2100-2400  | 1750-2050
   12-13        | 2300-2700  | 1850-2150
   13-14        | 2500-2900  | 1950-2250
   14-15        | 2600-3100  | 2050-2350
   15-16        | 2700-3300  | 2150-2450
   16-17        | 2700-3400  | 2250-2500
  ==============+============+===========


CALORIES PER POUND OF BODY WEIGHT PER DAY.[24]

  =============================================
     _Years_    |_Calories per pound, per day_
  --------------+------------------------------
   Under 1 year |            45
    1-2         |            40-43
    3-4         |            37-40
    4-5         |            37-40
    5-6         |            35-37
    6-7         |            34-35
    7-8         |            32-34
    8-9         |            30-35
    9-10        |            30-35
   10-11        |            28-32
   11-12        |            28-32
   12-13        |            28-32
   13-14        |            25-30
   14-15        |            20-25
   15-16        |            20-25
   16-17        |            20-25
  ==============+==============================

After which time the food requirements are based on degree of muscular
activity, boys and girls of seventeen years and over requiring as much
food as men and women.

Children, like adults, differ in degrees of activity; that is, one
child may be very active, running and playing more strenuously than
another. Hence a margin of safety must be allowed to cover the energy
expenditures of the more active child, to safeguard it against
becoming malnourished.

To facilitate the computation of the food requirements of children a
schedule showing the number of calories per pound of body per day is
included on opposite page.

The food requirements are such as to allow of a steady increase in the
weight and stature of the child; the rate of gain for normal children
should be as follows:

AVERAGE RATE OF GAIN PER WEEK, FOR NORMAL CHILDREN

  =======================+==================
          _Age_          |    _Average_
          _Boys_         |     _gain,_
                         |    _Ounces_
  -----------------------+------------------
   First year            | 3-1/2 - 4-1/2
   Second year           | 2-1/2 - 3
   Third year            | 1-3/4 - 2
   Fourth to eighth year |
     (inclusive)         | 1-1/4 - 1-1/2
   Ninth to eleventh     |
     year (inclusive)    | 1-3/4 - 2
   Twelfth to thirteenth |
     year (inclusive)    | 2-3/4 - 3
   Fourteenth to         |
     sixteenth year      |
     (inclusive)         |     3 - 4
  =======================+==================

  =======================+==================
          _Age_          |     _Average_
         _Girls_         |      _gain,_
                         |     _Ounces_
  -----------------------+------------------
   First year            | 3-1/2 - 4-1/2
   Second year           | 2-1/2 - 3
   Third year            | 1-3/4 - 2
   Fourth to eighth year |
     (inclusive)         | 1-1/4 - 1-1/2
   Ninth to twelfth      |
     year (inclusive)    | 1-3/4 - 2-1/4
   Thirteenth to         |
     fifteenth year      |
     (inclusive)         | 2-3/4 - 3-1/4
   Sixteenth and         |
     seventeenth year    |
     (inclusive)         |     1 - 2
  =======================+==================

The averages just given are for healthy children; those who are
underweight for their age and height should show a more rapid increase
in weight with an increased food allowance. It must also be remembered
that a simple gain in weight is not sufficient evidence of a child's
normality; a freedom from gastro-intestinal disturbances, and a
resistance to disease, are equally essential.

There have been tables arranged to show the proper weight for height
for boys and girls of different ages (see appendix). These are
valuable since, by their use, attention is called to the child who is
not up to the average. Medical examination of such children frequently
shows reason for their underweight, and measures may be instituted
which may save the child from a lifetime of poor health.

Dr. Pirquet has arranged a scale (Pelidisi Chart) showing the state of
nutrition in children, based upon the sitting height (in centimeters),
to weight (in kilograms). See appendix.


PROTEIN REQUIREMENTS

There is never a period in life in which protein is not needed. During
the early years it is essential that the proteins, or at least a
goodly portion of them, be obtained from animal sources, milk and eggs
in particular; when cereals and legumes (beans and peas) are used to
provide for the protein requirements, they must be supplemented by
milk or eggs (or both), in order that the growth and development of
the child may proceed at a normal rate.

Adults require protein for the repair of old tissues and to furnish
material for the building of new cells, and again it is believed
advisable to have at least a portion of this protein from animal
sources, milk, meat or eggs.


MINERAL REQUIREMENTS

Just as energy foods and proteins must be adjusted in the dietary to
safeguard the health of the body, so the mineral salts must be
adjusted for a like purpose. Studies made of the dietaries of a number
of families brought to light the fact that the children more often
suffered from a deficiency of calcium, phosphorus and iron in their
diets than they did from too little protein,[25] proving that it is
quite as essential to adjust the mineral salts in the diet as it is
that of the organic constituents.

According to Sherman the diet of an adult should contain each day per
pound of body weight:

  Protein               0.5    gram or more
  Phosphorus            0.01   gram or more
  Calcium               0.005  gram or more
  Iron                  0.0001 gram or more

These averages, while covering the needs of the mature body, do not
furnish the necessary amount of protein, or mineral salts to support
the growth and development of the child. Hence, it has been deemed
advisable to reckon the requirements of the latter per thousand
calories, instead of per pound of body weight, in this way obviating
some of the danger of protein and mineral deficiencies.

McCollum, Simmonds and Pitz have shown that a deficiency in the
inorganic content of a diet may result in a retarding or suspension of
growth. This result has been overcome on the introduction of the
proper mineral salts into the diet. This salt mixture is such as to
make the total ash, approximate that found in the composition of milk
ash.

The following diagram illustrates this point.

        |
    240 +----------+----------+----------+----------+--+
        |          |          |          |          |
        |          |          |          |          | _|
        |          |          |          |          _/
        |          |          |          |        _/|  |
        |          |          |          |      _/  |
    200 +----------+----------+----------+----_/----+--|
  W     |          |          |          |  _/      |  /
  e     |          |          |          |_/        | /|
  i     |          |          |          /          |/
  g     |          |          |  Normal_/|          /  |
  h     |          |          |      _/  |         /|
  t 160 +----------+----------+----_/----+--------/-+--|
        |          |          |  _/      |       /  |
  i     |          |     |    |_/        |      /   |  |
  n     |          |     |   _/          |     /    |
        |<---Period I--->|<-/------Period II--/------> |
  G     |          |     |_/  |          |  _/      |
  r 120 +----------+---_/|----+----------+_/--------+--|
  a     |          | _/  |    |         _/          |
  m     |          _/    |    |       _/ |          |  |
  s     |         /|     |    |     _/   |          |
        |        / |     |    |   _/     |          |  |
        |       /  |     |    | _/       |          |
     80 +------/---+-----|----+/---------+----------+--|
        |     /    |     |    /Effect of |          |
        |   _/     |     |   /|added Salt|          |  |
        | _/       |     |  / |Mixture   |          |
        |/         |     | /  |          |          |  |
        X__________|_____|/   |          |          |
     40 +----------+-----|----+----------+----------+--+
        0          1          2          3          4
                         Time in Months

  Effect upon growth of adding to a diet otherwise adequate a salt
  mixture of such composition as to make the composition of the total
  ash similar to that of milk ash; immediate resumption after entire
  suspension of growth. Courtesy of Dr. E. V. McCollum.


The following outline will serve as a guide in making the estimates
for the food requirements of children:


THE DIET OF A CHILD SHOULD CONTAIN FOR EVERY 1000 CALORIES FURNISHED
BY THE FOODSTUFFS,

  ==================================
  Protein     25.00   grams or more
  Phosphorus   0.48   gram or more
  Calcium      0.25   gram or more
  Iron         0.005  gram or more
  ==================================

~Vitamine Needs.~--We have seen the manner in which the energy and
protein foods have been adjusted in the diet, but these can not alone
assure the body, and especially the growing body of a normal
maintenance and repair of its tissue, or support the growth which is
essential at this time. This function is believed to belong to the
vitamines, since feeding experiments have demonstrated the fact that
animals soon cease to grow, develop deficiency diseases, and finally
die, when deprived of the essential constituents. Gillett advises, as
a safe rule, the use of one, and preferably two foods known to be rich
in the fat soluble vitamine, in each day's food allowance, milk and
leafy vegetables, for example. If the foods containing phosphorus,
calcium, and iron are taken in sufficient quantity, the second, or "B"
vitamine needs, will probably be adequately covered, but the presence
of the "C" vitamine must be carefully attended to; some fresh fruit or
vegetables (see table) is obligatory each day to insure the individual
against the development of scurvy.

~Factors Affecting the Food Selection.~--The estimation of the energy
needs of the body, and the selection of the foods to furnish the fuel
for this purpose, depend largely upon the individual. The digestion of
the fats, as well as the way in which the body utilizes them, makes
the use of this foodstuff more or less limited according to the
ability of the individual to take care of them, the minimum allowance
for children being between 2 and 3 ounces per day. According to
Gillett, "If boys and girls get at least this amount from butter and
its substitutes, cream, bacon, fat meat and oils, additional amounts
from their food will provide a margin of safety, without overtaxing
the digestive system."

After determining the amount of fat required in each day's food
allowance, it is a simple matter to adjust the carbohydrates. It is
safer from a health standpoint, to obtain the greater portion of this
foodstuff from starchy foods rather than from the sugars, many foods
rich in starch, likewise contain appreciable amounts of protein and
fat, whereas sugar is practically one hundred per cent. carbohydrate.
The ease, too, with which this substance ferments in the stomach, and
the manner in which it destroys the appetite for other foods, makes
the use of much of it in concentrated form unadvisable, especially in
the diet of children.

The amount of sugar allowed each day, should be limited to an ounce or
ounce and a half (2 to 3 tablespoonfuls), and a less quantity is
desirable. In order to obtain the best results, with the least
deleterious effect on the body, it is advisable to give sugar in
dilute form. A piece of pure candy after a meal may not harm the
child; but just before, or between meals, as well as the habit of
making the breakfast cocoa and cereal of syrup-like sweetness is
deplorable, and should in all instances be discouraged.

The American Red Cross recommends the following method for estimating
the amount of sugar in the dietary: "Add one-half the weight of such
foods as jellies, jams and preserves, and three-quarters the weight of
such foods as candy, honey and syrup, to the weight of sugar used."
The amount of sugar consumed, as such, by the adult each day, is not
of such paramount importance as it is in the case of children, but
even for adults an excessive amount of carbohydrate in this form is
not considered advisable from a health standpoint.

In order to assure each member of the family of getting all of the
materials needed for the growth, repair and regulation of their
bodies, as well as the necessary fuel material with which to run the
engine and to maintain the proper body temperature, the following
practical method is suggested for the planning of the daily dietary.


THE DIET EACH DAY SHOULD CONTAIN:

1. Milk:

One quart for each child under two years of age. From 1 pint to 1
quart for each child from two to five years of age. (M. S. Rose of
Teachers' College advises at least a quart for every child of six
years and under, at least 1 pint for children from six to sixteen, and
one half of a pint thereafter.)

2. Cereals and Breadstuffs:

(Activity of person determining the amount.)

  For children under two years of age      1-3 oz. a day
  For children from two to five years      2-5 oz. a day
  For children from five to twelve years   5-9 oz. a day
  For all over twelve years of age         9-16 oz. a day

3. Meat or its Substitute:

For children under five years no meat is needed.

(a) Meat:

  For children from five to ten years      1-2 oz. (no more) a day
  For children from ten to fourteen years  2-4 oz. (no more) a day
                                             of meat or fish.
  For individuals over fourteen years      2-6 oz. should be the
                                             maximum for the day.
(b) Eggs:

  For children under two years             no eggs are given.[26]
  For children from two to five years      3-5 eggs may be given
                                             each week, being
                                             substituted for
                                             part or all of
                                             the meat.

(c) Beans, Peas, Cheese:

For children it is necessary to use milk abundantly when beans
or peas are substituted for the meat or egg proteins.

4. Vegetables:

  For children under six months[27]        no vegetables need be
                                             given.
  For children from six to nine months     1 oz. gradually increased
                                             to 6 oz. of strained
                                             vegetable soup
                                             (see formula, page 223).
  For children from twelve to fifteen
    months                                 1 small baked potato
                                             may be added, and such
                                             vegetables as peas,
                                             string beans, carrots,
                                             spinach, squash, lima
                                             beans (strained).

Two vegetables, one of which should be potatoes (white), should be
given each day. A leafy vegetable (spinach greens, string beans, kale,
lettuce) should be given from three to four times each week and
oftener if possible.

5. Fruit:

  For children from six months on
  (earlier if physician approves)          1-2 tablespoons orange
                                             or prune juice a day.

  For children from first to second year   1-3 tablespoons twice
                                             daily.

  For children from two to five years      3-4 tbsp. or more, twice
                                             daily (amount governed
                                             by health of child).

All children should be given fresh fruit three or four times a week;
some fruit given every day. Adults may be served dried fruit most
days, but some fresh fruit should be given each week.

6. Desserts:

One sweet dish (custards, cereal puddings, junkets) once or twice a
day, but little if any clear sugar should be given (cereals should be
served with very little if any sugar).

7. Fats:

  For each person over five                2-3 oz. of fat (purchased
                                             as such) a day, depending
                                             upon the age and ability
                                             of the individual to digest
                                             fats.

~Suggestions for Serving Meals.~--After reckoning the number of
calories needed for the day, it is well to remember that the protein
must be adequate in type and amount; that there should be an abundant
supply of vitamines and iron in each day's ration; that milk should
always be included in order to make sure of having a sufficient amount
of calcium in the diet; that there should be only one heavy protein
dish at any one meal, and that it is unwise to serve a meal in which
the fluids predominate on account of their deficiency in energy and
proteins.

If a meal is made up of the right kind of foods, in the proper
proportion, and each individual eats sufficient to assure the
maintenance of the normal weight, is free from gastro-intestinal
disturbances, and shows a normal resistance to disease, it is more
than probable that a sufficient quantity is being consumed each day.

All foods should be carefully selected, and properly prepared in order
to derive the maximum benefit therefrom, and the regularity and
attractiveness with which the meals are served have almost as much to
do with the health and happiness of the individual, as the character
of the foods included in the day's dietary.


PROBLEMS

(a) Calculate the dietary requirements of a nurse weighing 125 pounds,
who spends 8 hours sleeping, 8 hours on duty, 2 hours at meals, 2
hours brisk walking, 2 hours in the class room, and 2 hours reading or
studying.

(b) Calculate the diet for a child of ten years of age, weighing 65
pounds, showing the number of calories, the amount of protein,
calcium, phosphorus and iron necessary to make this diet cover the
requirements of the child.


FOOTNOTES:

[20] "Archives of Internal Medicine," Vol. XXVII (1916), p. 916.

[21] "Chemistry of Food and Nutrition," (revised), p. 186, by Henry
Sherman.

[22] The Same.

[23] Gillett, A. I. C. P. of N. Y.

[24] Table compiled from material in "Feeding the Family," by Rose.

[25] "The Adequacy and Economy of Some City Dietaries," by Sherman and
Gillett.

[26] Part of soft-cooked egg may be given at the beginning of eleventh
month; this must be given at the noon meal, and should not be included
in each day's meal (two or three times a week is sufficient).

[27] Dr. Hess advises the use of canned tomato juice as a substitute
for orange juice when the latter is unobtainable.




SECTION II

LABORATORY OR DIET KITCHEN WORK




CHAPTER IV

METHODS OF FEEDING IN NORMAL AND ABNORMAL CONDITIONS


There are several methods of feeding which have been adopted to meet
the needs of the individual under various conditions: Feeding by
mouth, gavage or forced feeding, rectal feeding (nutrient enemata),
and inunction.

~Feeding by Mouth.~--The first method is the one used in health and in
the majority of abnormal conditions. In cases where there is a certain
abnormal development of the mouth or throat, and in some cases of
insanity or unconsciousness, where for some reason it is impossible
for the individual to swallow, this method cannot be used.

~Forced Feeding.~--With very young children and babies gavage or
forced feeding is found at times to be necessary. In these cases a
small rubber catheter is introduced into the stomach through the
nostrils and the milk or other fluid poured through the tube. In
unconscious or insane patients it is often found necessary to insert a
gag (a cork will serve the purpose) between the teeth to prevent the
biting of the tube when it is inserted through the mouth into the
stomach.

~Food Used for Forced Feeding.~--The food in these cases consists of
reënforced soups, milk gruels, or nutrient beverages, not more than
six or eight ounces given at one time. Finely chopped meat and
vegetable purées have been given in this way when the digestion of the
patient was not impaired, but when conditions rendered it necessary to
resort to this method of feeding.

~Technique of Gavage.~--The apparatus used in gavage consists of a
moderate sized soft rubber tube to which is attached a rubber or glass
funnel and a "pinch cock." The tube should be filled with water to
prevent air entering the stomach and causing pain or discomfort. In
certain cases the patient refuses to swallow the tube and it will be
found necessary to use some means to force the passage if the throat
is shut off. By closing the nostrils the patient will be obliged to
breathe through the mouth, thus opening the passage into the throat
through which the tube may be quickly slipped. In certain abnormal
conditions the gastric organ is so badly impaired as to render it
impossible for the patient to retain food taken in by way of the
mouth. It is often found that food introduced into the stomach by
means of the "stomach tube" will be retained and utilized which
otherwise would be rejected. It is disagreeable, however, and should
only be used when it is impossible to feed otherwise.

~Rectal feeding~ is used when the other organs of digestion are
impaired to such an extent as to render the need of more food
obligatory. Many investigators believe that rectal feeding is
absolutely useless, while others have firm faith in its efficacy.

~Technique of Rectal Feeding.~--The rectum should be cleansed by
flushing with a soapsuds enema one hour before the nutrient enema is
given. This should be done once a day, in the morning. The cleansing
enema may be either soapsuds, a solution of bicarbonate of soda, or
boric acid (1 teaspoonful to the pint), or a saline solution. When
there is much mucus, or if the rectum is inflamed, the soda or boric
acid solution may be more soothing than the saline or soapsuds enema.
After one hour's rest the patient should be given a nutrient enema.

The method of administering nourishment through the rectum is
important. A nutrient enema injected only into the lower bowel not
only does no good, but may actually cause a good deal of unnecessary
discomfort to the patient.

~Temperature of Enema.~--Care must be taken not to have the
temperature of the nutrient enema too hot or too cold or it will be
promptly rejected. The patient is placed on the side with one knee
flexed; the solution is poured into a fountain syringe bag or an
enamel container (heat the container before pouring the solution into
it or the latter will be chilled). The bag or container has attached
to it a rubber tube with a cock adjusted so that only a small stream
will flow in at a time. To the end of this tube a rubber rectal tube
or catheter--1 cm. (about 1/2 inch)--is attached. This should be well
greased (do not use glycerin as this substance is irritating to the
mucous lining of the rectum). The liquid should be allowed to fill the
tube before it is inserted into the rectum, to prevent any air passing
in with it. The tube should be inserted with a gentle twisting
movement, using very little force or the tender mucous membranes will
be injured. Insert the tube twelve or more inches, since the solution
is more completely absorbed if given high up in the bowel. The bag
containing the solution should be held only a few inches higher than
the rectum, thus allowing only a small stream to pass in and allowing
an air space above the stream for the passage of gas which may be
accumulated in the upper part of the rectum. The tube should be
allowed to remain in the rectum for fifteen or twenty minutes, then
very gently withdrawn to prevent the liquid from being rejected. A pad
of gauze may be pressed against the anus to assist the patient in
retaining the enema. It is well to divert the attention of the patient
also, to further assist her in retaining the liquid.

~Duration of Rectal Feeding.~--Rectal feeding cannot be substituted
for a great length of time, first, because the patient cannot absorb
sufficient nourishment in this way to fully cover the body
requirements, and, second, because the rectum becomes more or less
sensitive and will reject the liquid before it has an opportunity to
be absorbed. From three to four nutrient enemas a day is about the
limit for the average patient. Between the nutrient enemas it is
advisable to give one of saline solution.

The following régime is practiced during the "Total Abstinence Period"
in the treatment of gastric ulcer: 7 A.M., cleansing enema; 8 A.M.,
nutrient enema; 1 P.M., nutrient enema; 3 P.M., saline enema; 6 P.M.,
nutrient enema. One saline and one nutrient enema may be given during
the night if the patient is very weak. She should not be wakened,
however, to be given the enema.

~Feeding by Inunction.~--This method consists in the rubbing into the
body of certain nutrient oils, such as olive oil, cocoanut oil, cocoa
butter, etc. It is of little value, but is occasionally resorted to
with very much emaciated and underfed infants, when digestional
disorders make it impossible to introduce enough food by mouth to
cover the needs of the body.


SPECIAL DIETS

There are a number of diets formulated to meet the various normal and
abnormal conditions. In hospitals these are classified as follows, for
the convenience of both nurse and doctor:

~House Diet.~--That which is served to the hospital staff, the nurses,
and those patients not requiring special diets.

~Liquid or Fluid Diet.~--Consisting of milk, nutrient and other
palatable beverages, broths, and thin gruels.

~Light, Semi-solid or Convalescent Diet.~--Composed of thick or cream
soups, eggs, toast, cereals, custards, jellies and ice cream, and
later vegetable purées, broiled birds, chicken, lamb chops, and rare
beefsteak.

~Mixed Diet.~--The diet used in normal conditions and for those not
affected by any special food.

~Special Diets.~--Those designed to be used for certain pathological
conditions, such as scarlet fever, nephritis, etc. These diets are
classified as follows:

~Milk Diet.~--A diet in which milk is the sole article of food.

~Carbohydrate-free Diet.~--One in which the sugars and starches are
eliminated.

~Purin-free Diet.~--One in which the foods rich in purin bases are
eliminated. This is used in gout, arteriosclerosis, etc.

~Salt-free Diet.~--Diet in which sodium chloride (salt) is as far as
possible excluded. It is used in certain cases of nephritis when edema
is present.

~Nephritic Diet.~--A diet used in nephritis and diseases complicated
by nephritis (scarlet fever). In this diet the protein foods, meat in
particular, are restricted, milk being the exception.

~Diabetic Diet.~--A diet in which the carbohydrates are restricted or
eliminated.

~"Allen Treatment of Diabetes"~ consists chiefly of "starvation" for a
given period and a reëducation of the organs to a toleration for
carbohydrates.

~Emaciation Diets.~--Those containing a high percentage of fat-forming
foods, such as milk, cream, eggs, cereals, potatoes, etc., olive oil.

~Obesity Diets.~--Those containing as few of the fat-forming foods as
possible, such as cream, olive oil, potatoes, white bread, etc.,
pastry and desserts, candy and soda water, and containing lean meats,
fish or shellfish cooked and served without butter or other fats,
fresh or stewed fruit without sugar, green vegetables and salads
served without oil or other fats; one egg a day two or three times
a week, coffee and tea without sugar or cream, toasted gluten bread
(1 slice) without butter, saccharine substituted for sugar.

There are a number of other diets, but they come more or less under
the above heads.


THE TRAY

As the patient's tray assumes an important part of the daily régime,
it is necessary to give close attention to the arrangement and serving
of it. There are certain definite rules to observe: (1) The linen,
silver, glassware, china, and food must be absolutely clean. (2) The
tray must be sufficiently large not to appear crowded. (3) The
arrangement of the obligatory articles, such as salt and pepper,
silver, water glass, napkin, etc., must be alike at every meal; this
not only facilitates the service by making it easy for the nurse to
see whether any of these necessary articles are left off, but it also
enables the patient to find them without trouble.

~The Linen.~--The linen cover of the tray must be clean and uncreased.
The napkin likewise must be clean and unwrinkled. The china must be
free from chips and cracks. Care must be taken not to put a collection
of odd pieces on the tray as it gives an untidy appearance.

~The Silver.~--The silver must be bright and in cold weather made
slightly warm, as must also the china. The chill of cold silver may
readily obliterate a fragile appetite, and to place hot food in cold
dishes will deprive it of much of its palatability. The foods intended
to be hot must be really hot, not warm, and those which are intended
to be cold should be thoroughly chilled before being served to a
patient. The placing of flowers on a tray is a questionable addition
to it; a single flower laid across the folded napkin may add
daintiness and attractiveness, but it is poor judgment to
over-decorate, either with flowers or by garnishing the dishes.

~Arranging the Tray.~--If the nurse will place the necessary articles
upon the tray and memorize their position so that she will be able to
duplicate the same at each meal, she will be able to tell at a glance
if everything needed is in its proper place, thereby saving herself
unnecessary steps and the patient the worry of having to wait until
they can be brought. Food should not be allowed to stand in the
sickroom, and glasses or plates in which food has been served should
be removed from sight as soon as the patient finishes with them. Care
must be taken, however, not to create the impression of hurry or the
patient will be made nervous and either will lose her appetite or have
indigestion.

The nurse should be careful of her topics of conversation during the
meal hour. Especially must disagreeable subjects and business matters
be rigidly excluded if the invalid is to obtain the full benefit of
the food served her.

1. ~Setting the Tray.~--Tray should be sufficiently large not to give
the appearance of being crowded, but not too large.

2. Tray cover must be spotless, and of a size to just cover the edges
of tray; if too large, make a pleat down the center.

3. Place service plate directly in front of patient.

4. Knife, cutting edge in, to the right of plate; fork, tines up, to
the left of plate.

5. Spoons, bowls up, next to the knife.

6. Napkin on the lower left side of tray, open edges to the lower
right side.

7. Bread and butter plate on top of napkin.

8. Soup tureen in lower right corner, with cup and saucer above it.

9. Tea or coffee pot and hot water pot in upper right-hand corner of
tray, with sugar bowl next to hot pot and cream pitcher next to sugar
bowl.

10. Place salt and pepper next to cream pitcher (to the left).

11. Water glass in upper right corner of tray.

12. Second vegetable dish placed on the upper right side of dinner
plate.

13. Place dessert to the upper left of dinner plate.

~Suggestions for Serving.~--Make tray as attractive as possible.

In the cases requiring special diets, the nurse should make out the
"diet sheet" for the day. In hospitals this is passed to the
dietitian, who carries out the directions laid down by the physician.
The nurse, however, should carefully check the tray before serving it,
since mistakes sometimes occur, and to give the wrong food to a
patient suffering from certain disorders may give rise to serious
trouble, causing pain and discomfort and at times death.

~Contamination of Food.~--Food should always be protected from dirt
and dust and from contamination and pollution from flies and other
insects. Typhoid fever and certain intestinal disturbances have been
known to result from flies coming in contact with raw food--milk, for
example. Poisoning due to polluted water used to freshen vegetables
has already been spoken of. All of these types of poisoning may be
avoided by using care in the handling of the fresh foods. ~Ptomaines~,
however, are not easy to prevent. Their source cannot always be traced
to one particular article of diet. They may be present in cooked, raw,
frozen, or canned foods. At times the evidence of extreme
decomposition will be found in the foods themselves, while at other
times there will be no such evidence in the food, but the result of
the ptomaine will be perfectly evident whenever certain individuals
partake of that food. This is a personal idiosyncrasy which it is
impossible to account for.

~Food Poisoning.~--Poison caused by decomposed eggs has manifested
itself in individuals who have partaken of cake in which such eggs
were used. Canned meat and fish have produced the most violent types
of ptomaine poisoning. As a rule in these cases the canned article has
begun to decompose and while the decomposition may not have advanced
sufficiently far to be discernible from the flavor or odor, it is
there, and if the resistance of the individual eating this food is not
great, serious danger may result. Poisoning develops in some
individuals upon the eating of shellfish, strawberries, oranges,
pimentos, and various other foods,--another evidence of personal
idiosyncrasy against certain articles of diet. There is no way to
overcome these idiosyncrasies; the only thing to do is to warn the
individuals so affected to let the offending foods alone.


ADULTERATION OF FOOD

The adulteration of food, which formerly was practised by unscrupulous
dealers to cover up inferior articles, or by manufacturers to prevent
or arrest decomposition in canned goods, is regulated by law. The
passage of the National Pure Food and Drug Act gave the Government
authority to regulate the preservatives and coloring matter used in
canned and bottled goods, forcing the manufacturers to state on the
label the exact contents of each bottle or can. There are likewise
stringent laws governing the adulteration of milk, butter, and other
articles of food.

~Tests for Adulterants.~--Boric acid, borax, and formaldehyde are the
preservatives more often found in milk. These chemicals are introduced
to arrest the natural souring and decomposition which takes place
after milk reaches a certain age. Occasionally salicylic acid and
sodium carbonate are used. Formaldehyde may be detected by placing
about 20 c.c. of milk in a small glass vessel or tube. Dilute with an
equal amount of pure water, add commercial sulphuric acid, allowing it
to flow gently down the inside of the tube. A purple ring will appear
at the zone of contact if formaldehyde is present. "Boric acid and
borax may be detected by adding a drop or two of hydrochloric acid to
a few drops of milk in a white dish and then several drops of a
saturated alcoholic solution of _turmeric_. The dish is then heated
gently for a few minutes, and, if boric acid or borax is present, a
pink or dark red color will appear. A dark blue-green should appear
when the dish is cooled and a drop of ammonia added."[28]

~Canned goods~ must be carefully examined before being used. The
domestic canned goods are rarely adulterated, but imperfect
sterilization and defective cans may bring about a condition of
fermentation and gas formation due to bacterial action. Cans should
have a concave appearance on the top. If there is a bulging of the can
it may be due to gas formation, and a small hole should be made in the
can to note any escape of this gas. Should there be any indication of
fermentation, the contents should be discarded. It is advisable to
look with suspicion on cans that appear old, rusty, and soiled; they
are probably left-over stock and liable to be bad. Peas which have
been imperfectly sterilized produce a type of gas which is soluble in
the liquid. After decomposition has occurred there will be no apparent
evidence by the escape of gas, but the liquid will be found to be
excessively acid, and will present a muddy appearance. Certain foreign
importations of canned goods are preserved in color by the
introduction of certain color preservatives. Peas--petits pois, for
example--and the very small string beans which are imported are
intensely green from the copper sulphate used. Its presence may be
detected by adding a few drops of hydrochloric acid to some of the
colored material, then dropping in a bright steel nail, knitting
needle, or knife blade. There will be a deposit of copper salts (like
copper plating) upon the steel if the preservative is present in the
can. Canned corn is often artificially sweetened with saccharine,
which may be detected by shaking several tablespoonfuls of the liquid
in an equal amount of chloroform. Saccharine is soluble in chloroform,
while sugar is not. Allow the mixture to stand a few minutes and
remove some of the chloroform which has settled at the bottom. Place
in a small dish, evaporate the chloroform by gently heating the dish;
taste the residue; if sweet, saccharine is present.

~Coffee~ is adulterated more often when it is put up in ground or
powdered form than when sold in the bean. Real coffee contains a small
percentage of oil, and will float when thrown into a glass of water.
Substitutes generally sink to the bottom. Coffee substitutes are often
made up of starch-containing materials, such as cereals, beans and
peas. This starch may be detected by mixing one tablespoonful of the
suspected coffee in a little cold water, adding one cup of boiling
water; allow it to boil two minutes, filter through cotton, and pass
the liquid through charcoal to remove the color. When it is cold, add
a few drops of dilute iodine solution. If starch is present, a blue
color will appear.


METHODS USED IN THE PREPARATION OF FOOD

Food is prepared for consumption by a number of methods and the method
by which the food is prepared either increases or decreases its
digestibility, palatability, and general usefulness.

Certain foods, as has already been stated, require a high degree of
temperature to make them wholesome, but if this temperature is applied
by means of heated fat, as in frying, the food is changed from a
wholesome to a more or less indigestible article. In health the organs
of digestion are capable of overcoming much of the harm wrought by
wrong preparation, but even in the healthy, normal individual a steady
diet of fried food will eventually undermine what is known as good
digestion. In abnormal conditions (illness) frying is a method seldom,
if ever, used.

~Preparation of Food.~--The various methods to which food is subjected
in preparation for human consumption may be summed up as follows:
boiling, simmering, steaming, baking, roasting, broiling, frying,
sautéing.

~Boiling~ is cooking in water raised to the boiling point, 212° F.
(sterilizing). This method is commonly used in the cooking of starchy
vegetables and cereals, and in the cooking of green vegetables, such
as spinach, carrots, beets, corn, asparagus, etc. Stewing is a form of
boiling. As a rule water is used, and the vessel is left uncovered, so
that as the food is cooked the surplus moisture evaporates, leaving
the food tender. Dried fruits, such as prunes and apricots, are
prepared by this method.

~Simmering~ is cooking in water, the temperature of which is not
raised to the boiling point, but kept between 200° F. and 210° F. This
method is used in the preparation of eggs and dishes in which eggs
predominate, since proteins are made tough if subjected to a high
degree of temperature. Coddled eggs, for example, are prepared by
placing the egg in a clean vessel and pouring over it the boiling
water, then covering the vessel and allowing it to stand for ten or
fifteen minutes. The vessel and the cold egg reduce the temperature of
the water to about 185° or 190° F. and in this way prevent a
toughening of the albumen of which eggs are chiefly composed. Soups,
broths, ragouts, etc., are prepared by this method.

~Steaming~ is cooking over hot water or by steam. This method may be
accomplished on the top of the stove in a "double boiler" or in the
oven in a deep covered pan fitted with a "rack" to hold the article to
be cooked. Either method allows the vessel in which the food is placed
to be surrounded by boiling water, but does not insure sufficient heat
to raise the food within to the boiling point.

~Baking~ and ~roasting~ are both brought about in the oven. Bread,
biscuits, pies and other pastry, potatoes, cakes, etc., are baked,
while meats, roast of beef, lamb, veal, mutton, as well as chicken,
turkey, duck, and large fish are roasted. The heat in the oven may be
intense. The outside or cut surface of the meat is seared, the soluble
albumens are coagulated, thus sealing the juices within. If the meat
is placed in a pan surrounded by cold water and then placed in the
oven, the juices are "drawn out" in the water. These juices contain
the flavoring matter or extractives. Meat so treated is not so
palatable or highly flavored as that which has first been subjected to
intense heat, the water for the gravy added later.

~Frying~ and ~sautéing~ is cooking in hot fat. Food may be fried in
deep fat, as is demonstrated in the cooking of croquettes, doughnuts,
etc., or it may be sautéd in butter or oil in a shallow frying pan or
griddle. The latter method is used in making hashed brown potatoes,
for example; also in the cooking of griddle cakes, etc.

~Broiling.~--In broiling or grilling the article to be cooked is
exposed to direct heat, either to the blaze or to a very hot surface.
The result is the same as in roasting. The outer surface is seared,
sealing the juices within. Meat to be broiled is generally cut thinner
than that to be roasted. The article, whether it is meat (steak),
chops, birds, or chicken, is placed about three inches away from the
flames and turned frequently until the surfaces are seared, after
which the article is placed in a cooler part of the stove to allow the
interior to be cooked. Pan broiling is done on top of the stove. The
article to be broiled is placed directly upon a very hot surface,
there is no grease used and the meat must be turned frequently to
prevent burning.

~Poaching.~--This term is applied chiefly to the cooking of eggs in a
shallow pan of water heated just below the boiling point. To be
properly poached an egg must be perfectly fresh, or the white and
yolks will run together and present an unappetizing, unpalatable
appearance.

The following time-table should be used in the preparation of food to
insure correct cooking:

TIME-TABLE

  =================================+==========+=======================
           _Material_              | _Method_ | _Time_
  ---------------------------------+----------+-----------------------
  Beef (fresh)                     | Boiled   |  4 to 6 hours
  Corned beef                      | Boiled   |  4 to 7 hours
  Shoulder or leg of mutton        | Boiled   |  3 to 5 hours
  Shoulder or leg of lamb          | Boiled   |  2 to 3 hours
  Fowl (4 to 5 pounds)             | Boiled   |  2 to 4 hours
  Chicken (3-lb. hen)              | Boiled   |  1 to 1-1/2 hours
  Ham                              | Boiled   |  4 to 6 hours
  Lobster                          | Boiled   | 25 to 30 minutes
  Salmon (whole)                   | Boiled   | 10 to 15 minutes
  Vegetables:                      |          |
     Asparagus                     | Boiled   | 25 to 30 minutes
     String beans                  | Boiled   |  1 to 2 hours
     Dried beans                   | Boiled   |  1 to 2 hours
     Beets (new)                   | Boiled   | 45 minutes to 1 hour
     Beets (old)                   | Boiled   |  4 to 6 hours
     Beet greens                   | Boiled   |  1 hour or more
     Brussels sprouts              | Boiled   | 15 to 20 minutes
     Cabbage (for creamed cabbage) | Boiled   | 10 to 15 minutes
     Cabbage                       | Boiled   | 30 to 80 minutes
     Cauliflower                   | Boiled   |  1 to 1-1/2 hours
     Celery                        | Boiled   |  2 to 2-1/2 hours
     Corn (green)                  | Boiled   | 10 to 20 minutes
     Onions                        | Boiled   | 45 minutes to 2 hours
     Oyster plant (salsify)        | Boiled   | 45 minutes to 1 hour
     Parsnips                      | Boiled   | 30 to 45 minutes
     Peas                          | Boiled   | 20 to 60 minutes
     Carrots                       | Boiled   | 20 to 40 minutes
     Potatoes (white)              | Boiled   | 20 to 35 minutes
     Potatoes (sweet)              | Boiled   | 20 to 30 minutes
     Rice                          | Boiled   | 20 to 30 minutes
     Squash                        | Boiled   | 20 to 30 minutes
     Spinach                       | Boiled   | 15 to 20 minutes
     Tomatoes (stewed)             | Boiled   | 20 to 30 minutes
     Turnips                       | Boiled   | 45 to 60 minutes
  Coffee                           | Boiled   |  3 to  5 minutes
  Beef (ribs or loin, rare) per    |          |
    pound                          | Roasted  |  8 to 10 minutes
  Beef (ribs or loin, well done)   |          |
    per pound                      | Roasted  | 12 to 15 minutes
  Beef (rolled, rare) per pound    | Roasted  | 12 to 15 minutes
  Beef (rolled, well done) per     |          |
    pound                          | Roasted  | 15 to 20 minutes
  Leg of lamb per pound            | Roasted  | 10 minutes
  Leg of mutton per pound          | Roasted  | 15 minutes
  Mutton (stuffed, forequarter)    |          |
    per pound                      | Roasted  | 15 to 20 minutes
  Lamb, well done, per pound       | Roasted  | 15 to 18 minutes
  Veal, well done, per pound       | Roasted  | 20 to 25 minutes
  Pork, well done, per pound       | Roasted  | 20 minutes
  Chicken, well done, per pound    | Roasted  | 15 to 20 minutes
  Turkey (8 to 10 pounds)          | Roasted  |  3 hours
  Ducks (domestic)                 | Roasted  |  1 to 1-1/2 hours
  Ducks (wild)                     | Roasted  | 20 to 30 minutes
  Small birds                      | Roasted  | 15 to 30 minutes
  Large fish                       | Roasted  | 45 minutes to 1 hour
  Fish steaks, stuffed             | Roasted  | 45 minutes to 1 hour
  Steak, 1 inch thick              | Broiled  |  6 to 12 minutes
  Steak, 1-1/2 inches to 2 inches  |          |
    thick                          | Broiled  | 15 to 20 minutes
  Lamb chop or mutton chop         | Broiled  | 10 to 15 minutes
  Quail                            | Broiled  | 12 to 20 minutes
  Squab                            | Broiled  | 12 to 20 minutes
  Spring chicken (broiler)         | Broiled  | 20 to 40 minutes
  Shad                             | Broiled  | 12 to 15 minutes
  Bluefish                         | Broiled  | 12 to 15 minutes
  Bread (loaf)                     | Baked    | 45 minutes to 1 hour
  Rolls (risen)                    | Baked    | 20 to 25 minutes
  Biscuits                         | Baked    | 10 to 12 minute
  Muffins                          | Baked    | 20 to 25 minutes
  Sponge cake (loaf)               | Baked    | 45 to 60 minutes
  Layer cake                       | Baked    | 20 to 25 minutes
  Cookies                          | Baked    | 10 to 15 minutes
  Custards                         | Baked    | 20 to 60 minutes
  Steamed brown bread              | Steamed  |  2 to 3 hours
  Pastry                           | Baked    | 30 to 45 minutes
  Potatoes                         | Baked    | 30 minutes to 1 hour
  Scalloped dishes                 | Baked    | 20 minutes
  Steamed puddings                 | Baked    |  1 to 4 hours
  Plum pudding                     | Baked    |  2 hours (after
                                   |          |    steaming 10 hours)
  =================================+==========+=======================


CARE OF ICE-BOX AND CONTENTS

The ice-box plays an important rôle in the preservation of the health
and comfort of the family, as well as that of the invalid. Therefore
the first consideration is the cleanliness of it. The old-fashioned
boxes were constructed without ventilation. This was clearly a
mistake, since many foods absorb both the odor and flavor of the
substances about them if allowed to stand for any great length of time
in a closed compartment with them. The ice-boxes or refrigerators of
to-day have a ventilation system which insures a circulation of air
constantly throughout the interior of the box. The drain pipes require
special attention, because no matter how clean the box itself is kept,
the melting of the ice causes a slime to accumulate on the inside of
the pipe which will clog it and become offensive unless it is flushed
out often. This may be accomplished by pouring through it a solution
made by dissolving one-half ounce of borax, washing soda, or ammonia
in one gallon of boiling water. The adjustable part of the pipe can be
removed and cleaned with a long brush made for the purpose. The pipe
is then replaced and the boiling water poured through. In this way the
entire drainage system of the box is completely cleaned. All loose
bits of food which may drop from the containers to the floor and
shelves should be carefully removed each day and the interior of the
box and shelves thoroughly wiped out. Three times a week is sufficient
to wash and flush the box and pipes unless milk, cream, or other food
materials have been spilled, in which case it should be washed at once
before it has an opportunity to sour or spoil and become offensive.
Ice should always be washed off before being put in the box, and all
milk and cream bottles should likewise be wiped with a clean wet cloth
before being placed on the ice.

Hot food must never be put in the ice-box, as the heat from the food
will raise the temperature of the air in it. In some cases the sudden
chilling of the food itself is undesirable, but this is not so often
the case. However, the best results are obtained by first allowing the
food to cool, and then placing it on ice. This is particularly the
case with jellies made from gelatin.

Milk and milk products, cream, butter, buttermilk, cheese, etc., meat,
fish, and, at times, eggs should be kept in a refrigerator or in a
cold place such as the cellar in the country, when it is impossible to
procure ice.

Broths of all sorts, beef juice, and meat jellies will sour and
decompose unless kept close to the ice. Carbonated waters, such as
Vichy, Apollinaris, White Rock, etc., as well as champagne and other
sparkling wines, must be kept in a dark, cool place, lying on the
side. It is better to put only one or two bottles on the ice at a
time, since the wine flattens (loses its sparkle) if it is ever
allowed to become warm after once being placed on ice. Koumiss and
other fermented milk products must be treated in a like manner to
assure having them served at their best.


RULES GOVERNING SELECTION OF FOOD

There are certain fundamental rules to be observed in the selection of
our food materials, whether they are intended for those in health or
for those suffering from pathological conditions. These rules are
definite and obligatory. All food materials must be of good quality;
that is, they must be of known purity and cleanliness, and
adulteration should not be tolerated. In health the small amount of
preservative used in certain canned and bottled foods would probably
have little if any effect on the individual, but in sickness this is
not always the case. With regard to milk, this point has particular
significance. To obviate danger, the nurse should use discrimination
in the selection of the dealer from whom the meat, milk, eggs, fruit,
and vegetables are purchased, as well as the grocer who supplies the
remainder of the food materials used by the patient.


THE CARE OF FOODS AND UTENSILS

The next point of consideration is the care of the food materials.
This is quite as important as the selection, for even the best of food
may be ruined by careless handling, not only in the preparation, but
likewise during the period before it is prepared for the invalid's
consumption. The rules governing the handling of food materials before
they reach the consumer are subject to inspection by law, but the
housekeeper or nurse has no such rules to guard or govern her; hence
she may be wantonly careless or ignorantly unsanitary unless taught
the right way to care for the food in her charge. Perishable fruits
and vegetables must be kept in a cool place to preserve their
freshness.

~Method of Washing Dishes.~--Cleanliness must be observed in the care
of all food materials and the utensils in which they are to be
prepared. If the nurse will observe the scientific rules governing the
solubility of the foodstuffs, she will be able to save herself much
time and trouble. For example, it is a known scientific fact that
starch is insoluble in cold water and more or less soluble in boiling
water, hence it would be a useless waste of time to try to wash a
utensil in which a starchy food has been cooked in cold water. Fats
solidify under the influence of cold and melt under the influence of
heat, so that hot water should be used in conjunction with soap or an
alkali to remove grease from dishes and silver and utensils. Albumens
are soluble in cold water and are coagulated in hot, therefore to
remove milk, egg white, and like protein substances from glasses,
spoons, etc., it is advisable to soak first in cold water to wash out
the food material, and then to wash thoroughly in hot soapsuds to
cleanse and polish. The dishcloths used in the washing and drying of
dishes and kitchen utensils should be washed after using in hot
soapsuds, rinsed in clear water, then dried in the sun. When this is
impossible, they should at least be hung in the fresh air to make
them sweet and clean before the next using. In contagious diseases the
care of the utensils and dishes used by the patient is of the utmost
importance. They should be thoroughly sterilized before being placed
with those used by the rest of the family, otherwise the disease may
be communicated to the unaffected members. A word about the handling
of glasses and spoons used in administering medicine in the sickroom:
It is advisable when possible to keep these separate from those used
on the tray, as many medicines have a very lasting and disagreeable
taste, which is more than apt to cling to the spoons or glasses in
which they are measured and in turn be communicated to the food,
making it distinctly unpalatable. This has been found to be the case
with asafetida, valerian, ichthyol, etc.


METRIC MEASURE

The metric system is a system of weights and measures expressed in the
decimal scale. The principal units with which we are concerned are:

  The liter--L.                Cubic centimeter--c.c.
  The gram--gm.                Centigram--cgm.
                Milligram--mgm.

These units have prefixes to show how they are divided decimally,
_i.e._:

  deci.--0.1
  centi.--0.01
  milli.--0.001

UNITS OF WEIGHT

  10 milligrams  = 1 centigram (cgm.)
  10 centigrams  = 1 decigram  (dgm.)
  10 decigrams   = 1 gram      (gm.)
  10 dekagrams   = 1 hektogram (hgm.)
  10 hektograms  = 1 kilogram  (kilo.)
  1000 kilograms = 1 metric ton

A cubic centimeter of water weighs 1 gram; 28.35 grams = 1 ounce.

A liter of water weighs 1 kilogram; 1 kilogram of water = 2.2 lb.


HOUSEHOLD WEIGHTS AND MEASURES

  4 saltspoons               = 1 tsp.
  3 tsp.                     = 1 tbs.
  4 tbs.                     = 1/4 cup or 1/2 gill
  8 tbs.                     = 1/2 cup or 1 gill
  16 tbs.                    = 1 cup or 1/2 pint = 8 oz. = 227 gm.
  2 cups (c.)                = 1 pint = 454 gm.
  2 pints (pt.)              = 1 quart (qt.) = a little less than 1 liter
  4 qt.                      = 1 gal.
  2 tbs. butter              = 1 ounce (oz.)
  2 cups butter (solid)      = 1 pound (16 oz.)
  2 cups granulated sugar    = 1 pound
  2-1/2 cups powdered sugar  = 16 oz.      = 1 lb.
  4 cups flour (sifted)      = 16 oz.      = 1 lb.
  1 pt. milk or water        = 16 oz.      = 1 lb.
  1 pt. chopped meat         = 16 oz.      = 1 lb.
  10 medium size eggs                      = 1 lb.
    (with shells)
  8 eggs, without shells                   = 1 lb.
  2 cups rice                              = 1 lb.
  4 tbs. butter              = 2 oz.  = 1/4 cup
  2 tbs. sugar               = 1 oz.
  4 tbs. flour (sifted)      = 1 oz
  4 tbs. coffee (powdered)   = 1 oz.
  2 tbs. powdered lime       = 1 oz.
  2 tbs. lemon juice         = 1 oz.
  2 tbs. orange juice        = 1 oz.
  1 glass orange juice       = 8 oz. or 1/2 pint
  2-2/3 cup oatmeal                        = 1 lb.
  4-3/4 cup rolled oats                    = 1 lb.

28.35 grams = 2 tablespoons = 1 ounce of the following substances:
arrowroot, barley flour, brandy, butter, grape juice, lemon
juice, orange juice, molasses, cream, dry peptonoids, liquid peptonoids,
milk (whole, skimmed), buttermilk, malted milk, rice flour,
oatmeal, olive oil, wine.

Materials requiring 3 tablespoons to weigh 28.35 gm. or 1 oz.:--corn
meal, farina, gum gluten flour, Graham flour, white flour.

Material requiring 4 tbs. to weigh 1 oz.: cocoa.

The standard measuring cup holds 8 ounces or 16 tablespoonfuls.

  1 ordinary glass (water)  = 8 ounces
  1 coffee cup              = 8 ounces
  1 tea cup                 = 6 ounces
  1 wine glass              = 2 ounces

The following list shows the approximate weights and measures of the
foods comprising dietaries:

  Asparagus, 8 stalks, E.P.                    = 2 ounces
  Apple (1 medium size)                        = 5 ounces
  Bread, 1 slice, home-made,
    4 in. × 3-1/2 in. × 1/2 in.                = 1 ounce
  Bread, 1 slice, baker's,
    4 in. × 3-1/2 in. × 3/4 in.                = 1 ounce
  Bread, 1 slice, whole wheat,
    2-1/2 in. × 2-3/4 in. × 1/4 in.            =  .7 ounce
  Bread, 1 slice, corn,
    3 in. × 3 in. × 1/2 in.                    = 2 ounces
  Bread, muffin, 1 small, or biscuit           = 1/2 ounce
  Banana, 1 medium size                        = 5 ounces
  Chicken, 1 serving                           = 3 ounces
  Chicken (creamed) 2 tbs.                     = 1-1/2 ounces
  Cream, 2 tbs.                                = 1 ounce
  Custard (soft, 1/2 cup)                      = 4-1/2 ounces
  Custard (baked, 1/2 cup)                     = 4 ounces
  Cream (ice, 1/2 cup)                         = 4 ounces
  Custard (rice, 1/2 cup)                      = 3-1/2 ounces
  Dates (3 medium size)                        = 1 ounce
  Eggs (scrambled, 1/4 cup)                    = 2 ounces
  Eggs (poached, 1 egg)                        = 1-1/2 ounces
  Fish, medium serving,
    2-1/2 in. × 3 in.                          = 2-1/2 to 3 ounces
  Honey, 4 tsp.                                = 1 ounce
  Hominy (cooked, 1/2 cup)                     = 4 ounces
  Lamb chop, E.P., 2 × 2 × 1/2 inch            = 1.6 ounces
  Lemon or other jellies, 1/2 cup              = 3.8 ounces
  Steak (sirloin), 3 × 1/2 × 3/4 in.           = 3 ounces
  Vegetables:
      Beets, 1 medium size (4 slices)          = 2 ounces
      Carrots, 1/3 cup diced                   = 2-1/2 ounces
      Peas (canned or drained), 1/3 cup        = 3 ounces
      Potatoes, baked, sweet, 1 medium size    = 6 ounces
      Potatoes, baked, white, 1 medium size    = 3 ounces
      Spinach, cooked, 1 serving, 1/2 cup      = 4 ounces
      Tomatoes, 1 medium size--fresh           = 3 to 4 ounces
  Soups:
      Cream, 1/2 cup                           = 4 ounces
      Clear soup, 1 cup                        = 7-1/2 ounces


PERCENTAGE CALCULATION

A percentage of a number is the result obtained by taking the stated
number of hundredths of it. The rate per cent. is a fraction whose
denominator is 100 and whose numerator is the given number of
hundredths; thus 6% of a number is 6/100 of that number.

The method of figuring the per cent. of foodstuffs in a food material
is simple. Milk, for example, has a percentage composition of 3%
protein, 4% fat, and 5% sugar. To find the definite amounts of these
foodstuffs in 1 ounce of milk it is best to reduce the ounce to grams,
since the gram is the unit of measurement generally used.

  1 ounce                            = 28.35 grams
  In 1 oz. there will be 28.35 × .03 =  0.85 gram protein
  In 1 oz. there will be 28.35 × .04 =  1.13 grams fat
  In 1 oz. there will be 28.35 × .05 =  1.41 grams sugar


THERMOMETRY

There are two scales used in thermometry, the Fahrenheit and the
Centigrade. The former is generally used. However, since many of the
scientific calculations are made using the Centigrade scale it is wise
for the nurse to understand how to translate one to the other.

Centigrade has 0° as the freezing point and 100° as the boiling point,
while Fahrenheit has 32° as freezing point and 212° as boiling point.
To change Fahrenheit to Centigrade it is necessary to subtract 32 from
212 in order to make the freezing points correspond. This would read
212-32 = 180° F. = 100° C; hence a degree Centigrade represents 5/9
of a degree Fahrenheit.

To change Centigrade to Fahrenheit it is necessary to remember that
every Fahrenheit degree is 9/5 times as large as the Centigrade and
the addition of 32° must also be made. For example: Change 105° F. to
Centigrade: 105°-32° × 5/9 = 41° C. Change 50° C. to Fahrenheit: 50° ×
9/5 + 32° = 90° + 32° = 122° F.


FOOTNOTE:

[28] "Diseases of Nutrition and Infant Feeding," by Morse and Talbot.




CHAPTER V

FOOD MATERIALS AND THEIR PREPARATION


~Dairy Products.~--Milk, cream, and other dairy products form such an
important part of the invalid dietary that they require especial care
in their selection. "Certified Milk" is the safest. This is protected
by special inspection. The methods and standards governing the
production and distribution of certified milk were adopted by the
American Association of Medical Milk Commissions, May 1, 1912. The
sanitary condition of the dairy, the cleanliness of the vessels into
which the milk is placed, the health of the milkers, and a surety that
no member of their family with whom they come in contact has any kind
of contagious disease, are all obligatory. The feed for the cows and
the purity of the water given them to drink must be inspected and made
to conform to the standard laid down for certified milk. The milk of
sick cows and those having tuberculosis is absolutely condemned. The
composition of certified milk is standardized as follows: the fat
standard shall be 4%, with a permissible range varying from 3.5% to
4.5%. The proteins shall be 3.5%, with a permissible range varying
from 3% to 4%. Certified milk shall not contain more than 10,000
bacteria to the cubic centimeter when it is delivered. This inspection
and standardizing necessarily raises the price of certified milk above
that of milk not so rigidly cared for, and when the additional expense
makes it impossible for the patient to afford certified milk, the only
thing to do is to be sure of the reliability of the dealer from whom
the milk is purchased and the cleanliness of the dairy from which it
is procured. Buttermilk and butter are the milk products which
require some attention as to selection. The former grows sour with age
and the odor of advanced fermentation and decomposition is readily
recognized. Sweet butter, butter without salt, is less apt to be old
when purchased than the salted variety, as the flavor of rancid fat is
unmistakable in butter which has not been especially treated.

~Milk.~--Milk is without a doubt the most valuable food in the invalid
dietary, furnishing not only a highly nutritious beverage, but
likewise acting as a carrier of additional nourishment when such is
necessary. Its form, its lack of definite flavor and odor, all add to
its value as a food in sickness. Milk is one of the few foods which
includes in its composition all of the chemical combinations known as
foodstuffs. The carbohydrates, comprising 4.88% to 5% of the solids in
milk, occur as lactose or milk sugar. This sugar belongs to the
disaccharide group, and is, in the majority of cases, readily digested
by even the most delicate digestive apparatus. This form of sugar
lends itself particularly well as a reinforcing agent, and is
generally used in such cases as typhoid fever, etc. The fat in milk,
comprising 4% of the solids and occurring as butter fat (cream), is
made up chiefly of olein and of palmitin, with smaller amounts of
stearin and from 5% to 6% of its composition in the form of butyric
acid (the fatty acid to which butter owes its name and flavor) and
traces of other fatty acids, as well as small quantities of
cholesterin, lecithin, and a yellow coloring matter.

The proteins of milk, which form the curd or larger part of the
solids, according to Van Slyke[29] are in the form of casein and
albumen. There are 3.6 parts casein to 1 part soluble proteins, but
these figures vary somewhat at times. Casein is insoluble in pure
water, but dissolves readily in water to which an alkali or calcium
carbonate is added. The soluble protein in the form of lactalbumen is
one of the constituents of whey. This substance contains more sulphur
than does casein, but no phosphorus.

~Whey~ is the opalescent fluid which remains when the casein is
precipitated, and is composed of water 93.8%, total ash 0.44% (König).

~Mineral salts~, 0.7% of milk, are made up of calcium, potassium,
sodium, magnesium, iron, sulphur, phosphorus, and chlorine. Milk is so
rich in calcium that it requires only 400 c.c. (or about 2-1/2 cups)
to furnish 1 gram of calcium. This is the amount believed to be
necessary for the welfare of man each day and this must be derived
from food.[30]

~Water.~--The fluid part of milk is composed chiefly of water,
constituting 87% of whole milk.

Milk as a food for infants will be discussed in another chapter.

As has already been said, no food has so far been discovered which
could be effectually substituted for milk. There is no food, however,
which requires more attention in its selection and care. It is very
susceptible to both odors and flavors, absorbing them both readily, as
will be found if milk be placed in the same compartment with foods of
strong odor and flavor, without being properly covered and protected.
This is particularly noticeable with cucumbers, melons, etc.

Milk also furnishes a splendid medium for bacterial growth, and if
left exposed to the air, put into unclean receptacles, or kept in a
warm place, will immediately become more or less contaminated, after
which it is unwise to use it. Sterilization and pasteurization will in
a measure overcome the bacterial contamination, but milk purchased
from a dairy which is not clean or milked under unsanitary conditions
will remain dirty, hence unfit for human consumption. When the
morning's milk supply is brought to the house it should be in clean,
well-stoppered bottles, but before placing it in the ice-box the tops
of the bottles should be carefully wiped off with a wet cloth to
remove any superficial dust which may be adhering to them. Every time
a portion of the milk is removed thereafter the tops should be again
cleansed before the milk is poured out. This is a wise precaution, and
often prevents contamination from the hands, etc.

The amount of water in milk prevents its being an adequate food for
adults except in certain pathological conditions. However, it
furnishes a supplementary food unequaled by any other beverage known.
There are fortunately only a few individuals who are unable to drink
milk. There are many who fancy they cannot do so, but if the nurse has
the ingenuity to utilize some of the various methods whereby milk is
made more digestible, it will generally be found that the patient can
take it without trouble. In cases of personal dislike, if the milk is
flavored or colored or made up into soup, cocoa, chocolate, junket,
custards, blanc-mange, etc., it will usually prove acceptable.

~Application of Heat.~--A word as to the changes which are brought
about as the result of heat as applied to milk. These changes are
demonstrated in the two methods commonly used in the preparation of
milk known as "pasteurization" and "sterilization." Pasteurization is
rather an indefinite term to use, unless the time and the temperature
to which the milk is subjected are given. According to Morse and
Talbot "the term sterilization should never be applied to the
processes used in the preparation of milk for the feeding of infants,
because the milk is never rendered bacteriologically sterile by
them."[31]

As a rule the flavor and odor of milk are not changed by heat until
the temperature reaches nearly to the boiling point. A scum then
forms on boiling milk, composed of casein 50.86%, fatty matter 45.42%,
ash 4.72% (Rosenau). Prolonged boiling changes the color of milk from
a creamy white to a yellowish brown which deepens with boiling. This
is due to the caramelization of the milk sugar. Cream will not rise
(or its rise will be very slow) on milk which has been subjected to a
temperature of 150° F. for thirty minutes or more because the fat
droplets are broken down so that they cannot hold together at that
temperature and become more completely distributed throughout the
fluid.[32]

~Pasteurization~ is acknowledged to be preferable to sterilization in
milk used for infant feeding because the higher the temperature the
greater the change in the chemical composition of the fluid. According
to Morse and Talbot[33] the temperature of the pasteurization should
be as low as possible. Pasteurization at 140° F. for 20 minutes is
sufficient; lower temperatures are not. "At this temperature there is
no change in the taste, odor, or color of the milk, no noteworthy
changes in the chemical composition are produced, the ferments and
bactericidal action are unaffected and bacterial toxins and
non-spore-bearing microorganisms are destroyed."[34]

Rosenau[35] states that the bacillus of typhoid, diphtheria, and
dysentery, as well as the cholera vibrio and other pathogenic
non-spore-bearing bacteria which are often found in milk, are
destroyed at a temperature of 140° F. for twenty minutes, and at
higher temperatures for shorter lengths of time.

Sommerfield's[36] investigations prove that butyric acid bacilli are
destroyed at a temperature of 212° F. for from 1 to 2 minutes.

It must be understood that no matter what method is used to insure
purity in milk, nothing does away with the necessity for keeping the
milk both clean and cold. The receptacles in which the milk is allowed
to stand, the vessels in which it is measured, and the person who
handles it must be absolutely clean, and the nurse must keep in mind
the fact that pasteurization does not completely destroy the bacterial
growth in milk, that it merely diminishes it, and she must see that
the milk which has undergone the pasteurizing process is kept cold,
otherwise the microörganisms which are present, even if to a less
extent than in raw milk, will undoubtedly multiply.

~Adulteration of Milk.~--There is not nearly so much adulteration of
milk to-day as there was a few years ago. The stringent laws governing
the care and composition of the milk make it unprofitable for the
dairymen to practise it. However, there are times when such things are
done and care must be taken to prevent it. Milk is, as has already
been stated, very susceptible to contamination, and that which is
infected with putrefactive bacteria is not fit for food even if the
dealer has doctored it with formaldehyde. However, the danger to-day
is not so much from drugs as from lack of care in the handling of the
milk. It is well to remember, however, that water is an adulteration
just the same as formaldehyde and perhaps more pernicious, since the
quantities of the latter are so small in an ordinary quantity of milk
as not to make a great deal of difference except in the feeding of
invalids and children, while watered milk is a swindle not only to the
pocketbook but to the body also, since the requisite nutritive value
is lacking.

~Selection and Care of Milk.~--There are a few essential facts to keep
in mind in regard to milk: (1) Be sure of the source of the milk
supply, especially in the feeding of the sick and of infants. Milk
for such cases should always be purchased from inspected dairies when
it is possible. (2) Keep the milk cold; the best milk in the world
will spoil if left in a warm place. (3) Always keep the milk bottle
well covered, thus eliminating the danger of contamination, flies,
etc.


ALBUMINIZED MILK

_135-152 calories_

  6 ounces (3/4 glass) fresh whole milk.
  1-2 eggs (whites only).

Have the milk thoroughly chilled.

Clip egg whites with scissors and strain through cheesecloth to remove
stringy parts. Now stir into the milk with a fork.

If patient does not object to foam, the mixture may be placed in a
milk shaker with pieces of ice and shaken until creamy, then poured
over cracked ice.


ALBUMINIZED MILK SHAKE

_135 calories_

  6 oz. (3/4 glassful) fresh whole milk
  1 egg white

Place the milk on ice to become thoroughly chilled. Clip the egg white
with scissors and strain through cheesecloth to free it from strings;
stir into cold milk. If patient does not object to foam, the milk and
egg whites may be placed in a milk shaker, and agitated for 4 or 5
minutes, then poured over cracked ice. This beverage may be flavored
to suit the taste of patient. Vanilla, caramel, or coffee may be used
to give variety.

To add additional nourishment 1 teaspoonful of Sanatogen, or Plasmon
may be added, or 1 tablespoonful of Panopepton or liquid peptonoids
used instead of the casein products.


MILK AND GINGER ALE (OR SARSAPARILLA)

_59 calories_

  3 oz. milk
  3 oz. ginger ale or sarsaparilla

Pour into a milk shaker and shake with cracked ice until foamy.


MILK PUNCH

_298 calories_

  4 oz. rich milk
  2 oz. cream
  1 tbs. whisky (or sherry)
  1 tbs. sugar (or less)
  1 egg white (if additional nourishment is desired)

A grating of nutmeg on top. Place ingredients in shaker as directed
above, and shake a few minutes to thoroughly mix ingredients. Pour
over cracked ice, grate nutmeg or cinnamon over the top. The milk may
be peptonized if necessary, using 1/2 tube of Fairchild's peptonizing
powder.


PEPTONIZED MILK

_314 calories_

  1 pt. of milk
  1 tube of (Fairchild's) peptonizing powder

Dissolve the powder in 1 gill of cold water, and place in a clean
quart jar (glass).

Pour in 1 pint of cold milk and stop the bottle with cotton, shake
well and place the bottle in a saucepan containing water just warm
enough to allow of the hand being immersed without being burned
(115° F.).

Keep the water at this temperature for 5 to 10 minutes or longer
according to the degree of peptonization desired. Lift out of the warm
water and plunge into cold, then place at once on ice.

The milk may be poured from bottle into a clean saucepan and brought
quickly to a boil to prevent further peptonization; this process,
however, is apt to make the milk very bitter and should not be used
unless it is to be flavored with fruit juice.


PEPTONIZED MILK PUNCH

_212 calories_

Take a goblet about one-third full of finely crushed ice, add a
tablespoonful of St. Croix rum, a dash of curaçao or any liquor that
is agreeable to the taste; fill the glass with "specially peptonized
milk," stir well, and grate a little nutmeg on top. Add 1 tablespoon
sugar.


BUTTERMILK (BULGARIAN)

_627 calories_

  1 qt. fresh whole milk (or skimmed if desired)
  1-1/2 to 2 oz. (Bulgarian) starter, or 1 buttermilk tablet[37]

If latter is used dissolve tablet in 1 gill of cold water.

Stir the buttermilk starter into the cold milk and place in a one-half
gallon glass jar, place the cover on loosely and allow the jar to
stand for 12 hours or until the milk is well clabbered. (Insert a
thin-bladed knife close to the jar so that the rest of the milk is not
disturbed to see if the coagulation is complete.) When this is
accomplished place the jar in the ice-box. After the milk has become
thoroughly cold, beat thoroughly. The mixture is like any well-made
buttermilk. If the cream is removed before adding the culture the milk
will be lower nutrient value, but in many cases this is necessary
since it is often the fats which cause a disturbance.


COCOA

_147-166 calories_

  2 tsp. cocoa
  1-2 tsp. sugar
  1/2 cup boiling water
  2/3 cup milk

Mix cocoa and sugar together and add boiling water slowly. Boil 3 to
5 minutes; heat milk in double boiler and add cocoa mixture. Beat with
Dover egg beater to distribute cocoa and prevent scum forming. Serve
with or without whipped cream. Cocoa may be reinforced as directed in
"broths" with albumen or the whole or yolk of one egg well beaten. If
the white alone is used, care must be observed that the liquid is not
hot enough to coagulate the albumen. Proprietary foods and casein
preparations are used in like manner.


PLAIN JUNKET

_161 calories_

  2/3 cup milk
  1/2 junket tablet
  1/4 tsp. vanilla extract or a grating of nutmeg
  1 tbs. sugar

Heat milk to 100° F. Add junket tablet dissolved in 1 tbs. cold water.
Mix in sugar and flavoring, and pour into molds to jelly. When junket
becomes firm, place in ice until needed.


JUNKET ICE CREAM

_428 calories_

  1/2 cup each cream and rich milk
  1 junket tablet
  2 tbs. sugar
  1/2 tsp. vanilla

Heat cream and milk to 100° F. and proceed as in junket. When mixture
is jellied turn into freezer, as any ice cream. This is the most
wholesome of ice creams and especially suited for children and
patients who have tuberculosis complicated with gastric
disturbances.[38]


PLAIN VANILLA, LEMON, OR ALMOND ICE CREAM WITH OR WITHOUT EGG
WHITE[39]

_585-602 calories_

  1 cup thin cream
  2 tbs. sugar (more if desired)
  1/2 tsp. vanilla, lemon extract, or almond extract

Method I. Whip cream, add sugar and flavoring, and freeze.

Method II. Scald half the cream and cool. Whip the remaining half, add
sugar and flavor and freeze.

Method III. Make "boiled custard," as directed, add one-half the
amount of cream and freeze.

To reënforce ice cream:--Add 1 or 2 egg whites, beaten or unbeaten;
these may be added in the beginning, or after the mixture begins to
freeze. A tablespoonful of maple sirup, caramel sirup (1 tbs. sugar
melted and browned and dissolved in 1 tbs. boiling water), or
chocolate sirup may be poured over the ice cream to vary the flavor.
Make chocolate sirup by boiling 2 tbs. water, 1 tbs. sugar, and 1 tbs.
chocolate to a sirup. 143.3 calories.


FROZEN CUSTARD

_289-329 calories_

  1 egg (or 2 yolks)
  1 tbs. sugar
  1/8 tsp. salt
  1 cup of milk
  Few drops of vanilla

Prepare as soft custard, freeze.


LACTONE BUTTERMILK

_627 calories_

  1 qt. fresh milk
  1 gill cold water
  1 lactone tablet (or 1-1/2 oz. buttermilk starter)

(Parke, Davis & Co.'s and Hanson & Co.'s buttermilk tablets are
practically the same.)

Dissolve tablet in cold water and stir into fresh milk (which may or
may not be skimmed, according to the directions of the physician, but
the finished product is more palatable using whole milk). Pour into a
clean jar or wide-mouthed bottle; plug with cotton or close not
tightly, allow to stand in room temperature 70°-75° F. 24 hours,
shaking the bottle occasionally to keep the cream from rising. At the
end of this time pour the milk out (if sufficiently fermented), and
beat briskly for 5 to 6 minutes with egg beater or with churn; place
on ice until ready to serve.


MALTED MILK (1)

_77-96 calories_

  1 tbs. malted milk
  1-2 tsp. sugar
  6 oz. boiling water
  1/4 tsp. salt
  3 to 5 drops vanilla

Heat water to boiling and mix malted milk (Horlick's) with a little
cold water. Stir into the boiling water, add sugar and salt, and serve
with or without cream.


MALTED MILK (2)

_107-155 calories_

  1/2 to 1 tbs. malted milk
  3 oz. each milk and water
  1-2 tsp. sugar
  1/4 tsp. salt

Proceed as above.


MALTED MILK CHOCOLATE OR COCOA

_230-300 calories_

  1 tbs. malted milk
  1 tbs. cocoa or grated chocolate
  6 oz. milk
  2 oz. water
  1-2 tsp. sugar
  4-5 drops vanilla extract

Mix cocoa or chocolate with water and boil 2-3 minutes. Pour milk into
a double boiler and heat, mix malted milk with a little water and stir
into the hot milk, add the cocoa paste, sugar, and vanilla, mix
thoroughly, beat the mixture briskly to mix ingredients thoroughly,
and serve with or without cream.


~Milk or Cream Soups~

MILK OR CREAM SAUCE FOR SOUPS

_599-1229 calories_

  2 tbs. flour
  2 tbs. butter
  1 pt. milk or thin cream
  1/2 tsp. salt

Cream butter and flour to a smooth paste, heat milk in double boiler
on an asbestos mat over the flame; when it is scalding hot, stir in
the butter and flour paste, stir until smooth and the mixture begins
to thicken, cover and allow to cook without boiling for 15 minutes;
strain. The sauce may be used at once or put into a glass jar in the
ice-box until needed.


CREAM OF ASPARAGUS (1)

_213 calories_

  2/3 cup cream sauce
  1/3 cup asparagus purée

Heat sauce and purée in separate saucepans, and when about ready to
serve, stir them together, strain carefully, season with salt, and
serve with or without croutons of toast or whipped cream. If the sauce
is made from the cream instead of milk, the fuel value will be much
higher (302.7 calories).


CREAM OF ASPARAGUS (2)

_216 calories_

  8 medium stalks of asparagus
  1 qt. water
  1 tsp. salt
  1 tbs. flour
  1/2 cup cream sauce

Cut off the tips of the asparagus in 1-inch pieces, and place with the
rest in a saucepan, and cover with water; add salt and cook until the
tips are tender; lift out and put aside to be used instead of the
toast croutons. After the water in which the asparagus is cooked is of
sufficiently strong flavor, strain and add the extra spoonful of
flour, mixed in a tablespoonful of water; cook 15 minutes, measure 1/2
cupful, and proceed as directed above.


CREAM OF POTATO

_259 calories_

Boil and cream the potato. Make sauce and add potato purée; stir until
well blended and serve with toast croutons.

When boiling potato if a sprig of parsley is added and strained out,
and a little of the potato water is used to make the purée smooth, the
soup will have more character.


CREAM OF SPINACH, CELERY, PEAS OR CARROTS

_224-461 calories_

  3/4 cup cream sauce
  1/3 cup vegetable purée

Proceed as in making other cream soups.


OYSTER SOUP

_179 calories_

  6 oysters
  1 cracker (soda) or 8 oyster crackers
  3/4 cup milk
  1/4 tsp. salt
  A dash of pepper

Put oysters (and their liquor) into a saucepan, and heat gently; skim
thoroughly. Heat milk in separate pan; when very hot add to oysters.
Roll the cracker and add to soup just before it is served. Add salt
and pepper at the same time.


~Eggs~

~Eggs.~--The table shows eggs to have a chemical composition of water
73.7%, protein 14.8%, fat 10.5%, and mineral salts (ash) 1.0%. Fuel
value per pound, 672 calories. The white of the egg, constituting 57%
of the entire weight, is composed chiefly of albumen and water with a
small percentage of mineral salts in the form of calcium, potassium,
magnesium, sodium, phosphorus, chlorin, sulphur, and iron. Typical
albumens are always rich in sulphur, and in eggs the sulphur content
is much greater in the egg white than it is in the yolk. The yolk of
eggs contains more protein and fat than the white, and less water. The
protein of the yolk is chiefly in the form of ovovitellin, while the
fats occur as palmitin, olein, and stearin. There is also 5% of
coloring matter in the yolk of eggs besides lecithin, nuclein, salts
of iron, potassium, magnesium, and phosphorus. The latter mineral salt
comprises 1.0% in yolk, while in the white there is only .03%. Eggs
have a position in the invalid dietary second only to that of milk.
They are nutritious, easy of digestion, and exceedingly palatable if
properly selected and correctly prepared. The albumen in the white is
very susceptible to the effect of heat. At a temperature of about 135°
F. the clear, pale yellowish white begins to change to an opalescent
tint, and, as the temperature is gradually increased, the texture
changes from a viscid, sticky substance to an opaque, jelly-like mass
which solidifies with an ever increasing temperature. Hard cooked
white of egg, unless it is very finely divided, is considered
difficult of digestion, but if the heat is applied gradually and is
not raised to the boiling point (212° F.) there is no reason why the
hard cooked white of the egg should not be digested. However, it is
unwise to cook eggs in this manner for invalids or children. Any of
the other methods, with the exception of frying, which should never
be used, is decidedly preferable. Egg albumen is soluble in water and
fresh fruit juices, so that it may be used with great success as a
reinforcing agent. In fact, the whole egg may be so used, but it is
more difficult to disguise the yolk in a beverage than it is the
white, and for this reason it is not so adaptable in many cases. Eggs
may be cooked by the following methods in the invalid dietary:
coddled, soft-cooked, poached, creamed, omelet, scrambled, or in
custard. Uncooked eggs may be given in water, milk, wine, or fruit
juices.

The selection of eggs is equally as important as the selection of
other foods. There are "new-laid eggs," "fresh eggs," and just "eggs."
The latter are generally storage and should not be used for the sick
or for infants. As a rule old eggs will not stand poaching, the whites
and yolks mingle and form an unappetizing mass. It does not make any
difference whether the color of the shell is white or brown; if the
egg is absolutely fresh the white and yolk should be distinct and
easily separated, and when they are not it is safer to discard the egg
entirely.


~Fruit Beverages~

ORANGEADE

_118 calories_

  Juice of 1 orange
  1 tbs. sugar
  Juice of 1/2 lemon
  Enough water to fill the glass

Sweeten the juice of orange and lemon and pour into a glass filled
with crushed ice. Fill glass with plain or carbonated water.


ALBUMINIZED ORANGEADE

_152 calories_

Make orangeade as directed in above recipe, without the addition of
water. Break the whites of 2 eggs into a saucer and with scissors cut
the albumen until free from membrane and strain, stir this into the
orange juice and add several pieces of cracked ice. This is both
nourishing and palatable, and the taste of the egg cannot be detected.


ALBUMINIZED LEMONADE

_107 calories_

  Juice of 1 lemon
  1 tbs. sugar
  Whites of 2 eggs

Cut as directed for Albuminized Orangeade. Mix until sugar is
dissolved. Pour over a glassful of cracked ice. Fill glass with plain
or carbonated water.


PINEAPPLEADE

_151 calories_

  2 oz. (1/4 cup) grated pineapple
  8 oz. (1 cup) cold water, or sufficient quantity carbonated water
    to fill glass
  Juice of 1 lemon
  1 drop of lemon extract or a little of the peel, grated
  1 tbs. sugar

Mix lemon juice, water, and pineapple together; add sugar, if not
sweet enough, but the less used the better, in all beverages. Add
extract and pour into a shaker with a few lumps of ice. Shake well to
mix ingredients and pour the pineapple over crushed ice. If this
proves too much at a time, make half the recipe. Serve in tall thin
glasses holding from 4 to 6 ounces after the ice is put in, or serve
in punch glasses with small spoons.


ALBUMINIZED GRAPE JUICE

Albuminized Grape Juice is made without the addition of lemon juice
unless the white grape juice is substituted for the black, in which
case add one or two teaspoonfuls to relieve the flat taste and proceed
as in Albuminized Orangeade, using 3 oz. of grape juice.


EGG WHITE AND MINT

_57 calories_

  1 egg
  2 tsp. sugar
  1 tsp. lemon juice
  Several sprigs of fresh spearmint

Whip white of egg; add sugar and lemon juice. Crush lower parts of
mint leaves slightly and place in glass. Pour mixture over ice in
glass; stir well and serve at once.

Fill glass with carbonated water, Vichy, White Rock, Apollinaris, etc.
This is especially good when patient suffers from nausea.


CREAM, EGG AND VICHY

_232 calories_

  1 egg white
  2 tsp. sugar
  3 oz. (6 tbs.) cream
  A few drops of vanilla extract
  Celestine (French) Vichy to fill glass

Whip egg white to stiff froth; whip cream stiff and sweeten, add
vanilla; lastly, the egg. Pour over cracked ice and fill up the glass
with Vichy.


COFFEE

  2 tbs. ground coffee
  2 tsp. white of egg
  1 cup boiling water
  1/4 cup cold (boiled) water

Mix coffee with 1 tablespoonful of cold water and egg white in small
pot (after scalding pot), add boiling water; allow to boil 3 minutes;
stir down and add cold water; set pot where coffee will stay hot, but
not boil, for 10 to 15 minutes, serve with cream and sugar or use to
flavor hot milk.


PLAIN EGGNOG

_267 calories_

  1 egg
  2 tbs. cream
  1 tbs. rum
  1 tbs. whisky
  1 tbs. sugar

Beat yolk of egg and sugar together; add cream, rum, and whisky. Beat
egg white stiff and stir into the mixture; pour into glass with or
without cracked ice.

Nutmeg may be grated over top for those who like it.


COFFEE EGGNOG

Follow recipe for plain eggnog, substituting 2 tablespoonfuls of
strong coffee for the rum.


PANOPEPTON OR LIQUID PEPTONOID EGGNOG

_233-257 calories_

Is made as directed for plain eggnog, panopepton being substituted for
the rum, using 1 ounce instead of 1 tablespoonful. This will probably
more than fill a glass, but the whole amount must be made to keep the
proportions correct. The whisky may be left in, if desired, or sherry
wine may be substituted in its place to give flavor and additional
stimulation.


MALTED MILK EGGNOG

_264-316 calories_

  1 egg
  1 tbs. malted milk
  4 oz. milk
  1 tbs. sherry wine or whisky
  1/2-1 tbs. sugar
  1 tsp. cream

Mix milk as directed above and chill thoroughly. Beat egg yolk with
sugar and whisky or wine and add to the mixture. Beat egg white stiff
and stir into the rest of the ingredients. Pour into shaker and shake
with cracked ice until thoroughly chilled. The cream may be served on
top, or beaten into the eggnog.


FOAMY OMELET

_130 calories_

  1 egg
  1 tbs. water
  1/2 tbs. butter
  1/8 tsp. salt and dash of pepper

Beat yolk until light colored and thick; add water, salt, and pepper.
Beat white until stiff and dry. Turn the yolk over the beaten white
and cut and fold the white into the yolk mixture.

Have pan hot and buttered, turn in the mixture, spread evenly in pan
and allow to stand about two minutes on the top of the stove at a
moderate heat; then remove the pan, place in a moderate oven and cook
until a knife thrust into the center comes out nearly clean. Remove
from oven, cut across center at right angles with handle of pan and
turn over on a hot platter. Omelets may be varied by the use of
different garnishes and flavors.


CODDLED EGGS

_75 calories_

  1 pt. water
  1 egg

Allow water to boil; wash egg; drop into boiling water and place
saucepan where water will keep hot, but not boil; allow to stand 7 to
8 minutes. Serve with salt.


SOFT-COOKED EGGS

_75 calories_

Proceed as for coddled eggs, but allow egg to remain from 10 to 15
minutes or even longer, if very soft eggs are not desired.


POACHED EGGS

_75 calories_

Have small, shallow saucepan half filled with boiling water or
milk--if an egg poacher is at hand, use that; otherwise, lower a flat
perforated spoon into water and place where the water cannot boil.
Break the egg carefully into the spoon, taking care not to break the
yolk; allow to stand in hot water until the white is of the
consistency of jelly; lift out--slide egg on to hot toast, taking care
not to break. (A broken poached egg is very unappetizing, as well as
untidy in appearance.)


CREAMED EGG ON TOAST

_With milk 131 calories_
_With cream 170 calories_

Cut the crust from one slice of bread and cut bread in one-inch cubes;
toast while preparing egg. Beat egg with egg beater until light
colored; stir into it 2 tablespoonfuls of rich milk; pour into a
double boiler, over hot water; add 1 teaspoonful butter, a little salt
and pepper; stir until like thick boiled custard. Pour over toasted
cubes of bread and serve at once.


EGG NEST

_204 calories_

  1 egg
  1/2 tbs. butter
  1 slice of bread (3/4 in. thick)
  Salt and pepper to taste

Toast the bread on one side, butter and place on a plate (one which
will not break in the oven).

Beat egg white stiff, and pile roughly upon the toast, leaving a
slight depression in the center. Slip the unbroken yolk into the
depression (take care not to break the egg yolk or the appearance and
significance of the dish will be ruined). Set plate in oven to brown
the white (the oven must not be too hot or the white will brown before
the yolk is sufficiently cooked to be palatable). Place the remaining
butter on the yolk, dust with salt and pepper and serve at once.


SOFT CUSTARD

_289 to 329 calories_

  1 egg (or 2 yolks)
  1 tbs. sugar
  1 cup milk
  A few drops of vanilla

Heat milk in double boiler. Beat egg and sugar together. When milk has
reached the scalding point (small bubbles form around the edge of the
saucepan), stir in the egg. Care must be taken not to allow the water
under the saucepan to become too hot, as the custard will curdle if
the egg is cooked at too high a degree of temperature. The custard
must be stirred constantly in the beginning until it begins to
thicken, then several times a minute until it is of the desired
consistency and the raw taste is cooked out of the egg. This mixture
is done when it will form a coating upon the spoon. Serve with whipped
cream on top (57 calories extra with cream).


BAKED CUSTARD

_249 calories_

  1 egg
  1 tbs. sugar
  3/4 cup milk
  A few drops of vanilla

Beat egg and sugar together, stir into the milk, grease custard cup
with butter, pour in the mixture. Set cup on several layers of paper
in a deep pan, surround with hot water (to about half its depth). Set
pan in moderate oven and allow to cook slowly until custard is firm in
the center. It may be served hot or chilled and turned out, with a
tablespoonful of whipped cream on top.

Care must be taken not to allow the oven to get hot, or the egg will
coagulate, making a watery, unpalatable, and indigestible mixture.


CARAMEL CUSTARD

_306 calories_

Caramel custard is made exactly the same as baked custard, except that
the cup is lined with a caramel made as follows: In a small frying
pan, place 1 tablespoonful of sugar, place on the stove and stir
constantly until it melts and turns a golden brown (do not allow to
burn). Fold a cloth about the custard cup and pour in the caramel,
moving the cup about until the sides and bottom are well coated. Pour
in the custard mixture and proceed as in baked custard.


FLOATING ISLAND

_381 calories_

  1 egg and 1 extra yolk
  1 cup milk
  2 lady fingers
  Few drops vanilla
  1 tbs. sugar

Make soft custard, using the two yolks (no white). Chill custard
thoroughly. Line individual ice cream cup with the lady fingers; pour
the custard over. Beat the white of egg and place on top. Serve at
once. The lady fingers may be dipped in sherry wine if desired, using
about 2 tablespoonfuls of wine. (26 calories extra.)


~Cereals and Breadstuffs~

CORN MEAL GRUEL

_101 calories_

  2 tbs. corn meal
  1 cup water
  1/2 tsp. salt

Allow water to boil, mix corn meal with 3 or 4 teaspoonfuls of cold
water. As soon as water begins to boil, stir briskly until gruel
begins to thicken. Then place on a cooler part of the stove, and cook
gently for 2 hours, replacing water as it evaporates. Strain through a
coarse sieve if it lumps.


FARINA

_183 calories_

  3 tbs. (1 oz.) farina
  1/2 cup rich milk
  1/2 cup boiling water
  1/4 cup cold water
  1/4 tsp. salt

Mix farina into a paste with cold water. Stir into boiling water,
allow to cook for half an hour (if water boils out, add boiling
water). Add milk, and place the saucepan in a hot water bath (double
boiler); allow to cook half an hour longer, stirring occasionally.


RICE (1)

_99 calories_

  2 tbs. (1 oz.) rice
  1 pt. boiling water
  1/2 tsp. salt

Soak rice for 1 hour in cold water. Sprinkle into the briskly boiling
water, taking care not to stop the boil. Allow to cook until tender;
test by pressing a grain between thumb and finger; there should be no
hard center. When the rice is done, turn it into a colander and allow
water from cold faucet to run over it to wash off surplus starch.
Return to saucepan place on stove where moisture can be dried out of
the rice without burning it.


RICE (2)

_2-3 servings, 316 calories_

  4 tbs. rice
  1/4 tsp. salt
  3/4 cup water
  3/4 cup milk

Wash rice and soak it in cold water for 1 hour (or overnight). Place
in an earthenware baking dish, cover with the milk, water and salt.
Cover and set in the oven; allow to cook until all of the moisture is
absorbed (if the rice is not done by the time the moisture has
evaporated, add more milk, or milk and water, and continue until the
grains are tender). If the given amount of moisture is not absorbed by
the time the rice is tender, drain off the surplus and return the dish
to the oven for a few moments. Each grain should be separate, when the
dish is prepared correctly.


MILK TOAST

_149 calories_

  1 slice bread, toasted
  1 tsp. butter
  1/4 cup milk, heated
  1/6 tsp. salt

Toast the bread on both sides and butter; place in a deep plate and
pour over it the hot milk.


CREAM TOAST

_240 calories_

  1 slice bread
  1/4 cup thin cream
  1 tsp. flour
  1 tsp. butter
  1/4 tsp. salt

Cream butter and flour together cold, and stir into hot milk. Stir
until the mixture begins to thicken, cover the boiler and allow to
cook for 15 minutes. Slice the bread and cut into cubes; toast a
delicate brown, and pour over it the cream sauce. Strain the sauce if
there are any lumps.


WINE PANADA

_185 calories_

  2 water crackers
  2 tbs. sherry wine
  1/2 cup hot or cold milk
  1/4 tsp. grated nutmeg

Sugar may be sprinkled over crackers if desired, but it is not
ordinarily done.

Place the crackers in a deep plate and pour over each cracker 1
tablespoonful of wine, dust with nutmeg and pour over the hot or cold
milk.


OATMEAL COOKIES

_3333 (about) calories_

  2 cups flour
  1/4 cup sugar
  1/2 cup milk
  1/2 cup oatmeal
  2 tsp. butter, lard, or Crisco
  1 cup seeded raisins
  1 egg
  1/2 cup shelled peanuts

Mix shortening and sugar together. Mix oatmeal and peanuts (broken
into small pieces) into the flour. Add milk and well-beaten eggs, then
the raisins; mix into a dough, roll into a thin sheet, and cut into
small cakes. Bake in quick oven.


BAKED TAPIOCA

_550 calories_

  1 cup milk (scalded)
  2 egg yolks
  3 tbs. sugar
  6 dates
  2 tbs. minute tapioca

Beat sugar and egg together, stir in the tapioca and dates, cut into
small pieces. (The dates may be omitted, if desired.) Pour mixture
into custard cups and bake slowly (as rice custard) until the tapioca
is clear and the custard is fairly firm in center.


ORANGE TAPIOCA

_570 calories_

  1/2 cup milk
  1/2 cup orange juice
  1/4 cup sugar
  2 tbs. minute tapioca
  2 egg yolks
  6 drops orange extract

Mix and bake as directed in plain baked tapioca custard. Any other
fruit juice may be substituted for the orange, raspberry, pineapple,
or grape juice.


APPLE TAPIOCA

_475 calories_

  1 apple (pared and cored)
  1 egg
  3/4 cup milk
  2 tbs. sugar
  1-1/2 tbs. tapioca
  1/8 tsp. nutmeg

Beat egg and sugar together. Heat milk in double boiler and add egg
when milk is scalding hot. Stir in tapioca. Cook 20 minutes. Place
apple in cup a little larger than the apple and pour the tapioca
custard over the apple. Cover the cup and bake 30 minutes in a
moderate oven.


BROWN BETTY

_470 calories_

  2 slices bread
  1 large tart apple (or 1/2 cup blueberries may be substituted for
    the apple)
  2 tbs. sugar
  1 tbs. butter
  1/2 tsp. nutmeg or cinnamon

Toast bread and break into small pieces, line the bottom of the
individual baking dish with toast bits, cover with a layer of apple or
berries, sprinkle with sugar and nutmeg or cinnamon, add butter in
bits over this, continue the process until the dish is filled, place
bits of butter on top of the last layer of toast and set dish in oven;
bake about 20 minutes in a slow oven; serve with whipped cream or hard
sauce.


~Starchy Desserts~

RICE CUSTARD

_309 calories_

  1 tbs. raw rice, broiled
  1 egg
  1 tbs. whipped cream
  1/2 cup milk
  1 tbs. sugar
  1 doz. raisins if desired
  A few drops of vanilla

Beat sugar and egg together. Stir into the milk, stir in the rice and
flavor (add raisins if desired--29 calories). Grease custard cup and
fill with the mixture. Bake slowly (in a pan of hot water) until
custard is firm in center. Serve with whipped cream.


ORANGE RICE CUSTARD

_532 calories_

  2 oz. orange juice
  2 tbs. sugar
  1/2 cup milk
  2 egg yolks
  1/2 cup boiled rice (or 1/4 cup uncooked)

Beat egg, sugar, and orange juice together. Mix milk with rice and
stir the two mixtures together. Bake as directed in plain rice
custard.


SNOW-BALLS

_356 calories_

  1/4 cup rice
  1 cup milk
  1/4 tsp. salt

Place in a double boiler and cook without stirring until milk is
absorbed and rice is tender. Then either pack in egg cups (wet first
so that rice will slip out without breaking), or take a square of
cheesecloth 8 inches square, dust with flour and place about 4
tablespoons of the cooked rice in center, draw the corners together
and tie firmly into a ball. Set the ball in a steamer and steam 1
hour. Remove the cloth gently to prevent breaking the balls. They may
be served with custard as a dessert, or as a vegetable with tomato
dressing.


TAPIOCA CUSTARD

_503 calories_

  1 cup milk
  2 tbs. tapioca (minute tapioca)
  1 egg
  3 tbs. sugar

Flavor with vanilla or nutmeg, or 1/4 square chocolate grated. Scald
milk. Boil tapioca in hot water until transparent like jelly, using
one cupful of boiling water. (If tapioca does not absorb all of the
water, pour off the surplus.) Beat egg and sugar together and add with
the milk to the tapioca. Pour into a double boiler, and cook until the
raw egg flavor has disappeared. Flavor as desired. 43 calories extra
with chocolate.


SPONGE PUDDING

_772 calories_

  2 tbs. sugar
  1/4 cup flour
  2 eggs
  2 tbs. butter
  1 cup milk
  1/4 tsp. vanilla

Sift flour and sugar together and make into a thin paste with part of
the milk, heat the remainder of the milk and stir in the flour paste.
When the mixture is thick and smooth, stir in the butter, then the
beaten yolks and last, the whites (well beaten) are folded in. The
mixture is now turned into a baking dish and baked (in a pan of hot
water as any other custard) until it is firm in the center and well
puffed up and brown. Serve with foamy sauce.


SUNSHINE CAKE

_1716 calories_

  7 egg whites
  5 egg yolks
  1 cup flour (sifted 3 or 4 times)
  1 cup sugar
  1/3 tsp. cream of tartar
  1/4 tsp. salt

Beat whites of eggs until foamy and add cream of tartar; beat until
dry and stiff, add the sugar gradually and fold in the well-beaten
yolks. Sift the flour and gradually fold into the rest of the
ingredients; pour into ungreased sponge cake pans and bake in a
moderate oven for 30 to 40 minutes.


ANGEL FOOD CAKE

_721.5 calories_

  4 egg whites
  1/2 cup sugar
  1/2 cup flour (pastry)
  1/4 tsp. cream of tartar

Whip eggs until foamy and add cream of tartar, whip until stiff and
dry, add sugar gradually, then fold in the flour (the flour must be
sifted 4 or 5 times).

Pour batter into an ungreased angel food cake pan and bake in a slow
oven for 25 or 30 minutes. Care must be taken not to disturb the cake
during the baking, or it will fall.


CEREAL PUDDING

_1470 calories_

  1/2 cup fine cereal
  1 cup milk (scalded)
  1/4 cup molasses
  1 egg
  1 tbs. butter
  1/2 tsp. salt
  1/2 tsp. soda
  1/2 cup dates or other dried fruit

Stir cereal into scalded milk and cook until mixture thickens, remove
from fire, add rest of the ingredients except eggs. When mixture has
cooled somewhat, add the lightly beaten eggs, turn into a buttered
baking dish and steam 3 hours. This pudding may be made without
steaming by cooking the cereal and milk in double boiler for 1 hour,
then add rest of ingredients and bake 30 minutes.


~Sauces for Puddings~

FOAMY SAUCE

_494-497 calories_

  1/2 cup powdered sugar
  1/4 cup butter
  1/2 one egg yolk and 1 whole egg white
  1 tbs. sherry wine or 1 tbs. hot milk
  1/4 tsp. vanilla

Cream butter and sugar (powdered sugar must be used in this recipe).
Stir in the well-beaten yolk, add sherry and pour into saucepan over
hot water; stir until thick and creamy, lift from hot water and cool
as quickly as possible, fold in the stiffly beaten white of egg and
serve over pudding at once.


WINE OR FRUIT SAUCE

_381-434 calories_

  1 egg
  1/2 cup powdered sugar
  1 wineglass sherry wine or whisky, or 1/2 glass orange juice
  1 tbs. lemon juice
  1 tsp. hot milk

Beat yolk and white of egg separately, add sugar to yolk and beat
until creamy, add wine or fruit juice, fold in the egg white and add
the hot milk last; serve at once.


HARD SAUCE

_231 calories_

  1 tbs. butter
  2 tbs. sugar
  1/2 egg white may be added if desired
  1/2 tsp. vanilla, or 1/2 tsp. nutmeg

Cream butter and sugar together until there are no lumps or grains in
mixture. Beat the egg white stiff and fold into the sugar and butter
mixture. Flavor.


FOAMY SAUCE

_794-797 calories_

  1/2 cup powdered sugar
  1/4 cup butter
  1/2 one egg yolk and 1 whole egg white
  1 tbs. sherry wine or 1 tbs. hot milk
  1/4 tsp. vanilla

Cream butter and sugar (powdered sugar must be used in this recipe).
Stir in the well-beaten yolk, add sherry and pour into saucepan over
hot water; stir until thick and creamy, lift from hot water and cool
as quickly as possible, fold in the stiffly beaten white of egg and
serve over pudding at once.


SAUCE FOR PUDDINGS

_758.4 calories_

  1 egg
  1/2 cup powdered sugar
  1 wineglass sherry wine or whisky, or 1/2 glass orange
  1 tbs. lemon juice
  1 tsp. hot milk

Beat yolk and white of egg separately, add sugar to yolk and beat
until creamy, add wine or fruit juice, fold in the egg white and add
the hot milk last; serve at once.


~Meats~

BEEF, LAMB, VEAL, POULTRY, FISH AND SHELLFISH

~Meats.~--The flesh of animals, poultry, and fish comes under the head
of meat. These food materials form one of the most important sources
of protein in the diet, the foodstuff being in concentrated form
easily handled by the digestive apparatus and absorbed almost
completely, leaving little residue in the intestinal tract. The
chemical composition of different meats is very much alike, as will
be seen in the table, the bulk of the weight being water, while the
proteins range from 18.3% (E.P.)[40] in beef to 9.9% in bacon. The
fats range from 17.9% in beef to 64.8% in smoked bacon.

The mineral salts or ash, as they are found in meat: "Sodium occurs in
the animal body chiefly as chlorid in the fluids and blood, and to a
less extent in the other tissues." "Potassium, on the other hand, is
much more abundant in the soft solid tissues, in the corpuscles of the
blood and the protoplasm of the muscles and other organs." "Potassium
sulphate in the blood reacts to some extent with sodium chlorid,
forming potassium chlorid and sodium sulphate, both of which are
rapidly eliminated by the kidneys." The greater part of the sulphur
with which we are concerned in nutrition enters the body by way of the
protein, the percentage in lean beef being from 0.95% to 1.00%.[41]
Phosphorus in meat occurs as phosphoprotein in the nucleoproteins of
cell nuclei, and lecithoproteins in the brain and to a less extent in
other tissues as phosphorized fats. Meat is poor in calcium,
containing only about 0.01 gram per hundred grams of substance. Meat
with eggs yields a considerable amount of what is known as acids in
the body.

~Quality of Meats.~--The quality of meat depends upon several factors:
_age_, _sex_, care, feeding, and the length of time it is hung. Cold
storage beef is much more apt to be tender than that cut from a
freshly killed animal. Animals that are not allowed to run over a
large area, but are kept in a small inclosure and fed on fattening
foods, produce meat of a high quality. This is because the muscular
tissue has not been hardened with exercise. The worked muscle is
always tougher than the quiet one. For this reason the tenderloin of
beef is more tender than the flank. It is situated in the part of the
animal that is exercised the least. The tough parts, however, are not
lacking in flavor or nourishment, but the manner in which they must be
cooked to assure them of being tender deprives them of much of their
original flavor. This is demonstrated in broths and soups made from
the tough cuts of meat. The extractives from which meat derives its
flavor and the soluble albumens are drawn out by the water, and if it
is to be used as hash, croquettes, etc., needs to be seasoned, since
the broth, while it has taken very little of the actual nourishment
from the meat, has deprived it of practically all of its flavor. In
making broth or soup, if the meat is covered with cold water instead
of hot, more of the extractives will be drawn out and the broth will
be more highly flavored and much more stimulating. The color, odor,
and freshness of the muscular and fatty tissues of meat are all
indicative of their quality. Fresh meat is firm in texture and free
from offensive odor. Stale beef and that cut from an old steer exhales
a pungent odor of butyric acid. The color of beef should be dark
purplish when fresh cut but this changes quickly to a bright red; it
should contain preservatives of no kind and must be cut from animals
free from all disease. The fat should be of a yellowish white and be
crumbly, and should be distributed throughout the muscular tissue and
around the organs.

~Veal~, being the flesh of an immature creature, is not so highly
flavored as the flesh of older animals, but the bones and cartilages
are softer, and when this meat is used for broth, more of the gelatin
(collagen and elastin from the bones and connective tissue) is
dissolved out, giving a slightly higher percentage of nutriment in the
broth.

~Selecting of Chicken and Turkey.~--In selecting chicken for the diet
of invalids, use only the young birds for broiling, those a few months
older for baking and roasting, and the fowls for soup and broth. To
test a chicken for broiling and roasting, select one in which the
cartilage at the end of the breastbone is soft and pliable; the
pinions (lower part of the wings) and the feet should be soft and
readily bent. The breastbone of a fowl is firmer and the wings and
feet harder than those of the younger chicken. The young chicken has
an abundance of pin feathers while the old fowl has not. In fact, one
of the means of differentiating between the old chicken and the young,
even if they are practically of the same weight, is the presence of
the long hairs instead of pin feathers. The fowl selected for broth
should not be very fat, as this fat will melt into the broth, causing
it to be greasy and unpalatable. Turkey, even when it is young, is not
quite so digestible as young chicken; the fibers are longer and the
connective tissue more abundant. Goose and duck are richer in fat and
not so desirable as chicken in the invalid dietary. Squab, quail, and
young squirrel are all palatable and readily digested. The squirrel
must, however, be young, or the flesh will be tough and more difficult
of digestion.

~Fish.~--Fish should be given consideration in the dietary of the
invalid since it is a valuable source of protein and readily digested
in the majority of cases. As a rule fish is not so well liked as meat,
but since it contains a smaller percentage of ~extractives~ and
~purin~ bases it is exceedingly valuable in certain pathological
conditions. The lean varieties of fish, halibut, flounder, trout,
perch, haddock, turbot, whitefish, are more readily digested than the
dark fish, which contain a higher percentage of fat. To this latter
class belong the bluefish, mackerel, salmon, shad, and herring.

~Shellfish.~--Of the shellfish, the oyster and the clam are
exceedingly useful. The soft parts of the oyster are palatable and
easily digested. They are not highly nutritious, but give a nice
variety to the diet. When used in broth or for the juice, clams are
particularly useful. Many cases of nausea are relieved by the taking
of iced or very hot clam juice when they resist other remedies. The
necessity of having both oysters and clams absolutely fresh is of the
greatest importance, since a type of poison results from tainted
shellfish which is exceedingly dangerous.

~Pork in the Diet.~--Fresh pork is rarely ever included in the invalid
dietary save in diabetic diets. Meat from this animal must always be
thoroughly cooked, not only because underdone pork is exceedingly
indigestible but because there is an infectious bacterium sometimes
found in pork which is only destroyed by thorough cooking of the meat.
Well-cooked bacon is digestible if the surplus fat is poured off
instead of allowed to soak into the cooked bacon. The most efficient
method of cooking bacon is to place the strips upon a broiler under
the flame. In this way the hot fat drips down into the pan beneath,
leaving the bacon crisp and delicate.

The meats to be used for the invalid must be selected with care. The
quality of this item of food is most important. It is not always
necessary to purchase the most expensive cut. If it is to be broiled
or roasted then it is necessary to select parts of the animal which
are tender, but for broths, soups, scraped or ground meat, or the meat
to be used for the juice only, it is wasteful to buy these tender,
expensive pieces when those costing less will serve the purpose
equally well. The names given to the different cuts vary slightly in
different parts of the country, but those in general use only will be
mentioned here. The following table shows the manner in which the
~beef~ is cut and the method in which it is generally used:


TABLE

  ============+========================+================================
     _Beef_   |         _Cut_          |    _Method of Preparation_
  ------------+------------------------+--------------------------------
  Hindquarter |     {more or less free |Broth, soup, beef juice, scraped
              |Round{  from fat        |  beef.
              |     {round steak       |Hamburg steak (ground meat).
              |                        |Broiled (this is a cheaper and
              |                        |  less tender cut than the loin
              |                        |  steaks).
              |                        |
              |Rump {steak             |Broiled, cheaper cut steak.
              |     {roast             |Roasted, cheaper cut roast.
              |     {lean meat         |Broth, soup, beef juice.
              |                        |
              |Loin {3 ribs, 1st, 2d   |Roasted.
              |     {  and 3d cuts     |
              |     {sirloin steak     |Broiled.
              |     {porterhouse steak |Broiled.
              |                        |
              |           {steak       |Broiled.
              |Tenderloin {roast       |Roasted.
              |           {fillet      |Broiled or roasted, larded or
              |                        |  plain.
              |                        |
              |Ribs (prime)            |Roasted.
              |                        |
              |Ribs, chuck roast or    |Roasted or broiled.
              |  steak                 |
              |                        |
  Forequarter |Brisket                 |Corning.
              |                        |Broth, soup, scraped, meat
              |                        |  juice.
              |                        |Hamburg steak.
              |                        |Salisbury steak.
  ------------+------------------------+--------------------------------

CUTS OF LAMB AND MUTTON

  ------------+------------------------+--------------------------------
  Lamb        |Neck                    |Soup, broth, etc.
              |                        |
              |Chuck (including        |
              |  shoulder ribs).       |
              |  Shoulder chops are not|
              |  so tender as loin     |
              |  chops.                |Broiled.
              |                        |
              |Flank                   |Soup, broth.
              |                        |
              |Loin (chops)            |Broiled.
              |                        |
              |Leg                     |Roasted.
              |                        |
  Veal        |Neck                    |Soup, broth.
              |                        |
              |Chuck                   |Soup, broth, roast, broiled.
              |                        |
              |Cutlets                 |Broiled (breaded or plain).
              |                        |
              |Chops (rib)             |Broiled.
              |                        |
              |Breast                  |Roasted, stuffed or plain.
              |                        |
              |Leg                     |Roasted.
              |                        |
              |Hind shank (veal        |Soup, broth.
              |Fore shank   knuckles)  |
  ============+========================+================================


~Broths and Soups~

STANDARD BROTH
BEEF, VEAL, MUTTON, OR CHICKEN

_1 Pint, 80 calories, with rice or barley 105 calories_

Two pounds of meat (beef, mutton, veal, or chicken); 2 quarts of
water; 2 pounds of bones; 1 teaspoonful of salt; 2 tablespoonfuls of
rice or barley may be added if desired and parsley or celery may be
used to give the additional flavor.

Wipe meat with a clean wet cloth and cut into small pieces, break the
bones, place all together in a deep saucepan, cover closely and allow
to stand in a cool place for one hour; then place pan on the back part
of the stove, or on an asbestos mat over a gas burner, and heat gently
to the boiling point (broth must never do more than simmer), allow to
simmer for three or four hours, skim, strain, and cool. When
thoroughly cold, remove all of the fat, using blotting paper to absorb
the fine particles of grease. If parsley and celery are to be used to
flavor the broth they may be added during the last hour of cooking.
Barley requires to be soaked overnight when it is used in broth; rice
should be soaked one hour. When either are to be left in the broth it
is better to cook the broth for three hours, strain, return to the
fire, adding the rice or barley. Allow it to simmer for an hour or
more and proceed as directed. When the broth is taken from the fire,
it should be measured, and boiling water added to bring the amount up
to the original quantity. This will give what is known as standard
broth. Bouillon is clarified broth, most of the already small amount
of nutrient material being thus strained and cleared from the broth,
leaving a liquid of practically no fuel value.


CLAM OR OYSTER BROTH

_11.5 calories without milk; 162.5 calories with milk_

  1 doz. clams or oysters
  1 tbs. whipped cream
  1 pt. water or 1 cup each milk and water
  A dash of pepper

Scrub clams and place in an iron spider and allow to heat gently until
the shells open. (When oysters are used allow to heat until the edges
curl.) Chop, cover with hot water, and allow to simmer 15 minutes,
strain through cloth, add salt and a dash of pepper. If milk is to be
used in place of part of the water, add it during the last 5 minutes
of the cooking. Clam broth without milk may be served hot or cold; it
will not jelly as other broths but may be frozen if desired.


CLAM BROTH

_Without milk, 55.6 calories; with milk, 113.4 calories_

  1/2 cup (4 oz.) clam juice
  1/2 cup hot water or milk
  Salt and pepper to taste
  1 tbs. whipped cream

Mix clam juice (bottled) with water; heat, add salt and pepper, pour
into cup, place whipped cream on top, and serve at once.


BEEF JUICE

  One-fourth pound lean beef.

Wipe clean with damp cloth, cut in inch pieces and sear on a hot
griddle, place in a meat press and remove all juice from meat. Care
must be taken not to cook the meat. The juice may be reheated by
placing in a hot cup in hot water, not allowing the temperature to
exceed 155° F.


CHICKEN JELLY

_308 calories_ _1 serving, 75.8 calories_

  1/2 small chicken
  3 pt. water
  1/2 cup celery
  1 sprig of parsley
  1 tbs. gelatin soaked in 1/4 cup cold water
  1/2 tsp. salt
  1/4 tsp. red pepper
  1 egg white

Cut the chicken in pieces, break the bones, place in a saucepan with
all of the ingredients except the gelatin and egg white, cover with
the water and boil until the meat falls from the bones. Press out as
much of the juice as possible, strain and allow to cool, remove all of
the grease, and return to the fire. Reduce to 1 pint, add the gelatin,
stir in the beaten egg white, and allow to boil 5 minutes, strain
again into molds and set aside to congeal.


CALF'S-FOOT JELLY

_376.6 calories_

  2 small calf's-feet
  1/2 small fowl
  1 cup of Rhine wine
  1 lemon
  1/2 stick of cinnamon
  1 egg white (well beaten)

Cut the fowl and the calf's-feet into small pieces and place them in a
saucepan with 3 pints of cold water and the cinnamon. Cook until the
meat falls from the bones (the quantity should be reduced to 1 pint).
Strain and squeeze out as much of the juice as possible, allow to
cool, and remove all of the grease. Add wine and lemon juice (and
sugar if desired) and reduce the amount of broth one-half, add the egg
white and allow to boil 5 minutes. Clear and strain into molds.


BROILED QUAIL OR SQUAB

_418-543 calories_

Split down the back and place on the broiler, cut surface uppermost.
Or place upon a hot pan, cut surface next to the hot surface so that
the cut side may sear quickly, thus keeping in the juices instead of
having them wasted in the pan by slow cooking. The process requires
about 15 to 20 minutes. Serve on toast, with butter, pepper and salt.

Quail or squab cooked inside the stove is often more palatable than
that cooked on a broiler. The bird is split as for broiling, and
placed in a small pan just large enough to hold it; a strip of bacon
pinned about the breast; add 1 tablespoonful of butter in bits, dust
the cut surface first with salt and pepper, then with flour; add 1/2
cup of hot water. Turn another pan over the bird (it must fit closely
to keep in the steam), place inside the oven and cook about 10
minutes; turn the bird over and cook 10 minutes longer. Lift the bird
from the pan and place it where it will keep hot, add a tablespoonful
more water and a teaspoonful more flour to the gravy in the pan, stir
briskly to remove any lumps, remove bacon and place the bird upon a
slice of nicely browned toast; pour over it the gravy, garnish with a
sprig of parsley, and serve at once.


BIRDS À LA BAIN-MARIE

  1 small chicken, or bird
  2 tbs. butter
  1 tbs. parsley
  Salt and pepper

Split birds or chicken as for broiling, place one-half in a chafing
dish or double boiler (bain-marie), dot the cut surface with butter,
sprinkle over it the parsley, dust with pepper and salt; place the
other half of the chicken or bird on top of this, add the rest of the
butter, dust with salt and pepper, cover, and place the pan over the
hot water pan; allow to steam for about 1 hour, lift from hot water
pan and place in oven or under the flames to brown lightly. Serve on
buttered toast.


CHICKEN (ONE-HALF)

_355 calories_

Split small chicken (broiler) down the back, flatten the breast bone
with knife before placing upon the broiler, proceed as in broiling
birds, allowing from 25 to 30 minutes for the process. Chicken is very
palatable and dainty if cooked after the manner described in cooking
quail and squab inside the stove. The process is called smothering.
Serve upon buttered toast, garnished with parsley.


ROAST CHICKEN, TURKEY OR DUCK

Draw the fowl and wash thoroughly inside and out. (If it is purchased
from the market, it is well to wash the inside with soda water to
remove any stale flavor that may be present.)

Make a dressing from one-third of a small loaf of bread broken into
small pieces; 1/4 cup chopped celery, 1 tablespoonful of chopped
parsley, 1 tablespoonful of butter and one egg beaten lightly. Stuff
the cavity with dressing, sew up the opening and place in dripping
pan. Place pan under the flame for a few minutes to brown, unless a
regular roasting pan (savory roaster) is used; allow to bake from 45
minutes to an hour and a half for chicken and duck according to the
size, and from an hour and a half to three hours for turkey according
to size. A cupful of boiling water may be poured into the pan in which
the chicken, etc., is being roasted and flour may be sifted over the
top; dust with salt and pepper. When an ordinary pan is used for
baking, the fowl will require frequent basting to keep it moist and
tender. Just as the baking is finished, more butter, flour, and
seasoning may be added, with a cup or more of boiling water to make
additional gravy.


SWEETBREADS

_209 calories_

  1/4 set of sweetbreads
  1 lemon
  1/2 tsp. of salt
  1/4 tsp. of pepper (red)

Wash sweetbreads carefully and allow to stand 1 hour in ice water,
allow the water containing the lemon juice, salt and pepper to come to
a boil and drop in the sweetbreads, cook for 15 to 20 minutes or until
tender when pierced with fork. Remove from hot water and pour ice
water over them to blanch. Serve either in cream sauce or split in
half and broil upon a slightly greased broiler until light brown;
season with a dash of salt and pepper.


BROILED OYSTERS

_174 calories_

  6 oysters
  2 tsp. butter
  1 slice toast
  Salt and pepper to taste

Grease broiler or hot frying pan slightly, place oysters upon the
heated surface and place under the flame or on top of the stove; cook
until the edges curl (2 to 3 minutes), lift to a hot dish containing
the butter, place toast upon small plate (toast and plate must be
hot), dispose the oysters upon the toast, and pour over them the
butter.


BEEFSTEAK

_267 calories_

_3 inches long by 2 inches wide by 1-1/2 inches thick_ (_weighing
about 3 ounces_).

Wipe steak off with a wet cloth and dry before cooking. Slightly
grease the broiler and place under the flame, count ten as the clock
ticks and turn the steak over, count ten again and again turn;
continue this for about 3 minutes or until the steak is seared upon
both sides, lift the broiler to a lower part of the oven and continue
the cooking for 5 to 8 minutes; run a sharp-pointed knife between the
meat and the bone (if the steak is a porterhouse or sirloin), and if
the flesh is red, continue the cooking a minute or more. If it is
pink, lift to a hot plate, place 1 teaspoonful of butter upon it, dust
the surface with salt and pepper and serve hot. Pan broiling is done
on the top of the stove in a flat frying pan. Wipe the pan with a
clean wet cloth, place upon the stove and heat piping hot, and place
the steak (without greasing the pan) upon the hot surface. Proceed as
in broiling under the flame. After the first 3 minutes of cooking,
place the pan on a cooler part of the stove to finish the cooking.


LAMB OR MUTTON CHOPS

_2 chops, 304 calories_

1 to 2 inches thick will require from 10 to 15 minutes' cooking.
Scrape the bone clean and wrap in paper or dough to prevent the bone
from becoming charred. Proceed as in cooking beefsteak.


VEAL CUTLETS

_2 cutlets, 275 (about) calories_

Dip cutlets first in egg (mix one yolk with 1 tablespoonful of water)
then in bread crumbs; pan broil (grease the frying pan slightly), or
broil under the flame as directed in cooking beefsteak. Veal cutlets
may be served plain, or with tomato sauce.

Cutlets or chops may be cooked in paper bags if desired. Wrap the chop
in a thin slice of bacon, grease the paper (a piece of heavy brown
paper), place the chop inside and secure the ends with paper clips or
pins; place in a pan and cook in the oven, or under the flame. It is
wise to slip the bag containing the chop inside of another bag; in
this way the meat will not taste of scorched paper if the outer bag
should burn.


BACON (1 SLICE)

_194 calories_

Place bacon on a rack and place rack in a dripping pan, set in oven
and bake until crisp and brown. Or, arrange bacon on broiler, place
pan beneath to catch the drippings and prevent the fat from catching
afire, broil as beefsteak.

       *       *       *       *       *

When steak or chops are served, parsley or sliced lemon may be used as
garnishes. Chops may be served garnished with green peas, and the
beefsteak served with potatoes cooked in any way; all meats should be
served very hot. It is best to cover with a plate.


FISH

Split down the back, and broil as beefsteak. Fish does not require
more than from 10 to 15 minutes to broil unless very large. Serve with
teaspoonful of parsley and butter.


FISH STEAKS, STUFFED WITH OYSTERS

_3 ounces, 168.3 calories (about)_
_Halibut, trout, or any good baking fish, 235.8 calories (about)_

  2 slices of fish
  1 - 1-1/2 in. thick
  1 doz. oysters
  1 cup bread crumbs
  4 tbs. butter
  Salt and pepper

Lay fish for one hour in a French dressing made from 1/2 cup of oil,
1/3 cup of vinegar, salt and pepper; drain and place upon slices of
bacon, placed upon a fish sheet or dripping pan. Dip oysters first in
melted butter, then in bread crumbs, and place upon the slice of fish,
adjust second slice above, cover top with bread crumbs, dot with
butter and bake 30 to 45 minutes in moderate oven. Serve with
hollandaise sauce.


LOBSTER OR CRAB

_1 serving lobster, 157 calories_
_1 serving crab, 154 calories_

  1 lobster
  1 tbs. butter
    or
  1 crab
  2 tsp. butter
  2 tbs. bread crumbs
  1/4 tsp. salt
  1/8 tsp. pepper

Boil lobster or crab until bright red, lift from boiling water.

Split lobster down the back and carefully remove cord, gall sack, and
sand bag before broiling or serving. Serve with melted butter.

Pick meat from shell of crab, and mix with salt, pepper and butter.
Stuff into shell. Cover top with bread crumbs, and brown in the oven.


HOLLANDAISE SAUCE

_178 calories; 1 tablespoonful, 22 calories_

  1 egg (yolk only)
  2 tbs. lemon juice
  1 tbs. butter
  1/4 cup boiling water
  Salt and pepper to please

Beat egg yolk with lemon juice; add one-half the butter; place in
double boiler over hot (not boiling) water. Stir until it begins to
thicken and add remainder of butter; stir in boiling water, cook until
of the consistency of boiled custard.


~Vegetables and Fruits~

Among the plants known as vegetables, some are seeds, some leaves,
some stems or bulbs, some roots or tubers, and some are the fruit
surrounding the seeds. Under the head of seeds we find peas, beans and
lentils, this class of vegetables being spoken of as legumes or
pulses; they are rich in protein (especially when dried) and contain
an appreciable amount of carbohydrates as well, some contain fat.
Green, or fresh legumes are more easily digested than the dried
legumes. They are important sources of iron and phosphorus and contain
a certain amount of calcium; in the body they act as neutralizing
agents since the base-forming elements in these plants predominate
over the acid-forming elements.[42]

Among the "leafy vegetables" we find, lettuce, cabbage, spinach, beet,
turnip and mustard greens, chard and parsley. These vegetables are not
only prized for their mineral content but furnish a recognized source
of the fat soluble vitamine, "A."

Tomatoes, squash, cucumbers and pumpkin are vegetables whose "fleshy
fruit" surround the seed but are eaten as vegetables instead of as
fruit.

Potatoes, carrots, parsnips, onions, beets and turnips are among those
whose stems, roots or tubers are eaten as vegetables.

More and more are we coming to see the importance of this class of
foods in the dietary, they are important on account of their mineral
salts, their vitamine factors and for the bulk which they lend to the
food mass which facilitates its passage along the digestive tract. The
majority of vegetables furnish organic acids or their salts which
function in the body, as potential bases, assisting in the
neutralization of the acids formed in the body as a result of the
breaking down of the proteins.

~Fruits.~--Fruits have practically the same value from a dietetic
standpoint as vegetables, and the same care must be given to their
selection. Some fresh fruit should be given to children every day to
safeguard them against scurvy. And adults should have fresh fruit
several times a week, the remainder of the time dried fruits may be
used. Canned fruits while good are not so valuable as fresh fruits
and are more expensive than the dried fruit.

The ~fruits and vegetables~ will here be considered. Some of the
fruits and vegetables contain high percentages of sugar, aside from
the mineral salts, for which they are especially valuable. This class
includes the sugar cane, sugar beet, raisins, dates, figs, etc., while
others such as the potato, taro, banana, etc., furnish an appreciable
amount of starch. All of the vegetables and fruits are rich in mineral
salts, which are as important to the work of the body as the proteins,
carbohydrates, and fats. Hence it is essential to add the foods
containing these mineral salts to the daily dietary both in health and
in disease.

Both fruits and vegetables should be free from blemishes. Those to be
served raw, such as lettuce and other salad vegetables, must be
purchased from reliable markets. Unscrupulous vendors have been known
to sprinkle old wilted vegetables, to restore their freshness, with
water from stagnant pools teeming with typhoid bacteria, thereby
spreading infection broadcast. Vegetables which require cooking before
they are eaten are, for this reason, safer.

~Canned foods~ should be avoided in the diet of the invalid whenever
it is possible; but, when it is not, care should be observed that no
can is used in which there is the least sign of fermentation. Beans
and peas are sometimes artificially colored, but this custom is not so
prevalent now as it used to be.


PEAS

_121 calories_

  1/2 cup fresh peas
  1 pt. boiling water
  1 tsp. butter
  1/4 tsp. salt

Add salt and peas to boiling water; allow to cook from 30 to 60
minutes, or until they are perfectly tender, drain and add butter and
additional salt if necessary, or 1 tablespoonful of cream sauce. In
gastro-intestinal disorders and with young children, it is best to
press peas through sieve or remove the indigestible parts.


STRING BEANS

_94 calories_

  1 cupful of string beans (measured after the strings are removed
    and the beans cut into small pieces)
  1 tsp. butter
  1/2 tsp. salt

Cover with boiling water and cook until tender, drain, and serve hot.


SPINACH

_90 calories_

  1/2 lb. spinach
  1/2 tsp. salt
  2 tsp. butter

Wash thoroughly through about ten waters, until spinach is entirely
free from grit, remove the tough stems, lift the spinach from water
and place in a saucepan without additional water, sprinkle over with
salt, cover saucepan and cook until tender (requires about 15
minutes). Cut very fine with sharp knife, or press through sieve, add
butter and serve hot.


CARROTS (WITH CREAM SAUCE OR BUTTER)

_82-117 calories_

Carrots, about 1/2 cupful after they are cut in cubes, or 3-1/2
ounces. Serve with 2 tablespoonfuls of cream sauce, or with 2
teaspoonfuls of butter and a little salt and pepper. Scrub carrots and
scrape off the skins; cut into slices or cubes, drop into slightly
salted boiling water and cook until tender; drain and add butter or
cream sauce.


BAKED POTATO (WHITE)

_140 calories_

1 potato weighing about 3 ounces; scrub well with a brush; dry and
slightly grease surface, place in moderately hot oven and bake about
45 or 50 minutes. (The potato should feel tender upon pressure.) When
done, make an incision of 1 inch in the skin and gently press out the
steam; cover closely with cloth and keep in a warm place until ready
to serve. Put teaspoonful (about 1/6 ounce) of butter in the cut and
serve very hot.


CREAMED POTATO

_182 calories_

  1/4 tsp. salt
  1 medium size potato
  2 tsp. milk
  1 tsp. butter

Pare and boil potato until tender when pierced with a fork; drain off
the water and return the saucepan to the stove; shake the pan (to
prevent burning) until the potato looks dry; mash with fork or potato
ricer, add milk, butter, and salt. Beat briskly until creamy. Serve at
once or brown in oven.


POTATO STUFFED WITH MEAT

_197.5 calories_

  1 potato (baked)
  1/4 tsp. salt
  1 tbs. cold chopped beef
  1 tsp. butter
  Dash of pepper

Bake potato, split in half and remove the contents, mix with the
chopped meat, add salt, pepper, and butter; return to the two halves,
set in oven to brown, then serve at once.


SCALLOPED POTATOES

_250.8 calories_

  1 potato
  1/4 cup milk
  2 tsp. butter

Boil potato, not quite tender, and slice in moderately thin slices;
arrange in layer in an individual earthenware baking dish (ramekin),
add butter in bits between layers, pour the milk over; set dish in
oven, cover and bake slowly for 15 minutes, until most of the milk is
absorbed and the potatoes are nicely browned on top. In cases where
the patient is allowed cheese, 2 teaspoonfuls may be sprinkled between
the layers, giving 31 additional calories.


~Vegetable and Fruit Salads~

CUCUMBER

_62.5 calories_

  1/2 cucumber (7 in. long)
  1/2 tbs. vinegar
  1 tsp. olive oil
  1/6 tsp. salt
  Few grains of pepper

Slice cucumber in thin slices and allow to stand thirty minutes in ice
water, drain and serve with French dressing.


TOMATO (NO. 1)

_with mayonnaise, 61 calories_
_with French dressing, 131 calories_

Wash tomato carefully, cut in shape of flower by cutting almost
through the tomato making six sections. Place on lettuce leaf and
serve with dressing.

  1 tsp. mayonnaise or
  1 tbs. French dressing


TOMATO (NO. 2)

_63 calories_

Remove skin from 1 medium sized tomato, remove pulp, fill cavity with
following mixture.

  1/2 medium stalk celery
  The tomato pulp
  1 tsp. mayonnaise dressing


FRUIT SALAD (NO. 1)

  3 grapefruit
  1 cup celery (chopped)
  1/4 head of lettuce
  1 cupful of mayonnaise

Remove skin and inner membranes from grapefruit, mix with celery and
mayonnaise. Serve on lettuce. This salad may be poured into a tin
(baking powder can, or mould), packed in ice and salt and frozen. Then
served in slices upon lettuce.


FRUIT SALAD (NO. 2)

_1217 calories (about)_

  1 cup of grapefruit
  1 thick slice of pineapple (chopped)
  1 green pepper (1 oz.)
  1 cup of celery
  1 cup of mayonnaise or French dressing

If mayonnaise is used the mixture may be frozen. If French dressing is
used, serve on lettuce without freezing.


TOMATO JELLY

_77 calories_

  1 cup tomatoes (canned)
  3/4 cup water
  6 cloves
  1/2 cup celery
  1/4 cup vinegar
  1 tbs. of parsley
  1/2 tsp. red pepper
  1 tbs. granulated gelatin soaked in 1/4 cup cold water

One slice of onion may be added if there is nothing to
contra-indicate it, but care must be taken in adding onion, as it is
apt to disagree with many people. Boil all of the ingredients together
(except the gelatin) for 20 minutes, press through a sieve, then
through a cloth, return to the stove and allow to boil up; add the
gelatin and boil 5 minutes; strain into wet molds.


WHOLE TOMATO STUFFED WITH RICE

_167 calories_

  1 medium size tomato
  2 tbs. rice (uncooked)
  1 tsp. butter
  Dash of pepper and salt

Remove the center from the tomato, dust the inside with salt and a
very little pepper and set aside. Boil the rice, when about half done
(10 minutes) add the tomato pulp, from center of tomato. Cook 10
minutes longer, drain the water from the rice, add the butter, salt,
and a little pepper. Fill the center of tomato with rice. Set the
tomato upon a greased paper and bake in a moderate oven for 20
minutes.


BROILED TOMATOES

_353 calories_

  Slice 1 tomato in three or four slices
  1 tbs. butter
  1 slice of bread (round preferred)
  1/4 cup of cracker crumbs
  Salt and pepper

Heat broiler or frying pan very hot, grease lightly; season crumbs
with salt and pepper; dip slices of tomato in cracker crumbs, covering
both sides well, and place upon the broiler; when one side is browned,
turn over carefully, to prevent breaking, and allow the other side to
brown. Lift the broiler to the lower half of the oven and let the
tomatoes cook gently for 10 minutes. Place bits of butter upon each
slice, then arrange these on the buttered toast.


STEWED TOMATOES ON TOAST

_171 calories_

  1/2 cup canned tomatoes
  1/2 cup water
  1 slice bread
  2 tsp. butter
  1/4 tsp. salt

Pour tomatoes and water in a saucepan and allow to cook slowly for 20
minutes, add salt and a dash of pepper. Toast and butter the bread,
pour the cooked tomatoes over it and serve at once.


FRENCH DRESSING

_131 calories_

  1 tbs. oil
  1/3 tbs. vinegar, or lemon juice
  Dash of pepper and salt

Have all ingredients cold; mix salt and pepper together; stir in the
oil, add vinegar or lemon juice slowly, beating briskly to form an
emulsion; use immediately or ingredients will separate.

Use as little salt as possible in nephritic conditions.


MAYONNAISE DRESSING

_2109 calories_

  1 egg (yolk only)
  2 tbs. lemon juice (or vinegar)
  1/2 tsp. salt
  1/2 tsp. mustard (dry)
  Dash red pepper
  1 cup olive oil

Method of Mixture: Mix dry ingredients with yolk of egg thoroughly;
add all the acid (use Dover beater). Now add, one teaspoonful at a
time, the olive oil; beat continually until the mixture thickens
(after 8 teaspoons of oil have been added). Put in oil by
tablespoonfuls until all is incorporated. This method shortens the
time of making at least one-half, and the dressing rarely curdles as
it often does in the old methods.

Whipped cream may be added to dressing before serving. Mayonnaise will
keep if placed in a cool place, and the above quantities are more
easily handled than smaller amounts.


~Gelatin Jellies~

LEMON JELLY

_150 calories_

  2 lemons (juice only)
  1/4 cup sugar
  3 tsp. granulated gelatin
  1 tbs. cold water
  1 egg white
  1 cup boiling water


ORANGE JELLY

_280 calories_

  3 tsp. granulated gelatin
  1 tbs. cold water
  1/4 cup boiling water
  6 tbs. lemon juice
  3 tbs. sugar
  2 drops orange extract
  1/2 cup orange juice


GRAPE JUICE JELLY

_315 calories_

  1/4 cup boiling water
  1/2 cup boiling grape juice
  3 tsp. granulated gelatin
  1 tbs. cold water
  1 tbs. lemon juice
  3 tbs. sugar


_Method for Fruit Jellies._--Soak gelatin in cold water about 2 or 3
minutes, then pour over it the boiling liquid; add sugar and fruit
juice; strain through cloth into wet molds. Set in cold place to
stiffen; when firm, unmold. Serve with whipped cream, or pour liquid
into baskets made from oranges or grapefruit hollowed out and the
edges scalloped, or pour into shallow pans, and cut in 1/2-inch
blocks when firm, and serve on a bed of whipped cream.


WINE JELLY

_127 calories_

  1/2 cup boiling water
  3 tbs. sherry wine
  1-inch piece of cinnamon
  1 tsp. lemon juice and the yellow rind from 1/4 lemon
  3 tbs. sugar

_Method for Wine Jelly._--Put water, wine, lemon juice, peel,
cinnamon, and sugar into a saucepan, allow to boil 5 minutes, pour
over gelatin (which has been soaked in cold water). If jelly looks
cloudy return to saucepan, and add 1/2 egg white beaten stiff, allow
to boil 1 minute, stirring constantly, and strain into mold. Serve
with whipped cream.


~Water Ices~

LEMON

_276.5 calories_

  2 lemons (juice only)
  1/4 cup sugar
  1 egg white
  1 cup water


ORANGE

_311 calories_

  1/2 cup orange juice
  1 lemon
  1/4 cup sugar
  1 cup water
  1/4 tsp. orange extract
  1 egg white


GRAPE JUICE

_362.6 calories_

  1/2 cup grape juice
  1 tbs. lemon juice
  1/4 cup sugar
  1 egg white

METHOD OF MIXTURE

Mix sugar and water and boil to a rich sirup (about 15 minutes), cool,
and add fruit juice (and extract when it is used). Pour into freezer
and surround with a mixture of 1 part salt and two parts ice. When
sherbet is about half frozen, stir in the stiffly beaten egg white and
continue the freezing until mixture is hard. In diseases where it is
found inadvisable to give albumen, 1 teaspoonful of gelatin may be
substituted.


APRICOT

_384 calories_

  1/2 cup apricot purée
  1 cup water
  1/4 cup sugar
  1 tsp. granulated gelatin
  1 lemon (juice only)

Make sirup of water and sugar, soak gelatin in a little cold water and
add to the hot sirup; press apricots through a sieve and add to the
sirup as soon as it is cool; freeze as directed in other ices.


STRAWBERRY AND RASPBERRY

_346-393 calories_

  1 cup fruit juice
  1/3 cup sugar
  Juice of 1 lemon and
  1 egg white.

Proceed as in other ices.


CURRANT

_526 calories_

  1 cup fresh currants
  1 cup water
  1/2 cup sugar
  1 tbs. lemon juice

Wash currants carefully and place in a saucepan on a warm but not hot
part of the stove, allow to heat gently until the currants are soft,
press through a cloth, and add the water and sugar; stir until
dissolved (or make a sirup of the water and sugar and add the currant
juice and lemon and freeze as directed in other ices). The egg white
may be added if desired.


LEMON CREAM, OR MILK SHERBET

  3 cups (24 ounces) milk
  4 lemons
  1 cup cream (8 oz.)
  3/4 cup of sugar

Mix cream, milk and 1/4 cup of sugar and pour into freezer; freeze
until half frozen (mushy). Add juice of 3 lemons and 1 whole lemon
(peel and pulp) shaved into very thin slices sweetened with remainder
of sugar (if not sufficiently sweet add more sugar and make allowances
for same in fuel value). Continue the freezing until sherbet is of the
right consistency.


~Miscellaneous Desserts~

NUT CHARLOTTE

_with wine 758 calories; without wine 745 calories_

_Two servings_

  1/2 cup 40% cream
  2 tbs. sugar
  8 pecan or walnut meats
  1/4 tsp. vanilla or 1 tbs. sherry wine

Dissolve sugar in the cream and beat solid, add flavoring or sherry
and nuts.


ORANGE CHARLOTTE

_631 calories_

  1/2 cup of orange jelly mixture (see directions for making under
    jellies)
  1/2 cup double cream
  1 tbs. sugar (the above quantity will require about 2 tsp. of
    granulated gelatin).

Pour jelly mixture into a bowl and surround with cracked ice; when it
begins to stiffen, fold in the stiffly beaten cream.

Pour into molds or ice cream glasses and set aside in the ice-box to
become set.


SNOW PUDDING

_428 calories for orange pudding_

Orange, lemon, grape juice, or pineapple may be used in preparing this
pudding.

  1/2 cup fruit juice
  2 tsp. gelatin
  1 tbs. cold water
  1/4 cup sugar
  1 egg white and
  1/4 cup soft custard

Make jelly mixture as already directed and place the bowl in a pan of
cracked ice; when the mixture begins to stiffen, fold in the
well-beaten egg white (beat it in with an egg beater). Pour the
mixture into a mold or individual glasses and set aside on ice to
become set. When ready to serve, unmold and pour on the soft cold
custard.


PRUNE OR PRUNE FIG WHIP

_184.4 or 244.9 calories_

  6 prunes or 4 prunes and 1 fig
  1 egg white
  2 tbs. sugar

Cook the prunes and figs in sufficient water to cover them until they
are perfectly soft, press through a sieve, add sugar, chill
thoroughly, and fold in the stiffly beaten egg white. The above
mixture may be put in individual cups and baked in a slow oven (in a
pan surrounded with hot water) until they are firm in the center and a
light brown. Serve with or without whipped cream.


FOOTNOTES:

[29] "Archives of Pediatrics," Vol. XXII, p. 515, by Van Slyke.

[30] "Chemistry of Food and Nutrition," by Henry Sherman.

[31] "Diseases of Nutrition and Infant Feeding," by Morse and Talbot.

[32] Bulletin 56, Hyg. Lab., Public Health Service, 1908; Circular
153, U. S. Dept. Agric., Bureau of Animal Industry, 1910.

[33] "Diseases of Nutrition and Infant Feeding," p. 173, by Morse and
Talbot.

[34] Quoted from "Diseases of Nutrition and Infant Feeding," p. 173,
by Morse and Talbot.

[35] Rosenau: Bulletin 56, Hyg. Lab., Public Health Service, 1909;
Circular 153, U. S. Dept. Agric., Bureau of Animal Industry, 1910.

[36] Sommerfield: Handbuch der Milchkunde, J. F. Bergman, Wiesbaden,
1909.

[37] Buttermilk Tablets may be purchased from the Chas. Hanson Co.
Lab., N. Y., or from Parke, Davis & Co. The Buttermilk Starter is
prepared by the first mentioned firm and is ready to use, directions
coming with each sample.

[38] Recipes for coffee, egg, cocoa and chocolate junket will be found
in junket recipes, from the Chas. Hanson Co.

[39] Egg white is frequently added to increase the nutrient value of
ice creams and water ices.

[40] Edible Portion.

[41] "Chemistry of Food and Nutrition," by Henry Sherman.

[42] "Food Products," by Henry Sherman.




CHAPTER VI

INFANT FOODS AND FORMULAS USED IN ABNORMAL CONDITIONS


~Formulas Used In Feeding Infants~

WHEY

Put one pint of skimmed milk into a clean saucepan and heat to a
temperature of 100° F. (lukewarm). To this milk add 2 teaspoonfuls of
liquid rennet, essence of pepsin, or 2 junket tablets, stir until well
mixed, and allow to stand at room temperature (70° F.) until firmly
jellied. Break up with a fork until it is finely divided, strain
through thicknesses of cheesecloth; return the fluid part to the stove
and raise to a temperature of 150° F. to destroy the rennet left in
the whey. The whey is then cooled before it is added to the milk or
cream.


BARLEY WATER

  3% decoction starch[43]
  4 rounded tsp. barley flour
  1 pt. water

Mix a small amount of the water with the barley flour and put the rest
of the water into a clean saucepan and allow to heat; when boiling add
thin barley mixture, stir thoroughly, and allow to boil 20 minutes;
remove from stove, measure, and replace with hot water that which was
lost through evaporation to make up the original pint; strain through
two thicknesses of cheesecloth.


OAT WATER

  4 rounded tsp. oat flour
  1 pt. water

Mix and proceed as in making barley water.


ALBUMEN WATER WITH BRANDY

  8 oz. water (cold)
  1 egg white
  1 tsp. brandy

Mix egg and water and add brandy slowly to prevent coagulating egg
white.


BEEF JUICE

Composition: 0.60% fat, 2.90% protein, and considerable extractive
matter.[44]

Place a piece of round steak upon a hot griddle and turn once or twice
until the outside is seared and the meat is hot throughout. Remove
from griddle and cut into small pieces and place in a small meat press
made for the purpose. A lemon squeezer may be used when the press is
not available. Salt lightly. Begin by giving one teaspoonful and
increase the amount gradually to 1 ounce (6 teaspoonfuls). According
to Morse and Talbot, it is never wise to give babies more than 2
ounces of beef juice even in their second year, as it is apt to
disturb digestion. Also babies are often made restless or sleepless by
taking beef juice.


MALT SOUP

_347 calories_

  1-1/2 - 2 tbs. malt soup extract (reduce if necessary)
  1 level tbs. sifted flour
  1 pt. milk
  18 oz. water (hot and cold)

Dissolve malt soup extract in 1/2 cup of hot water and measure in
enough cold water to cool the mixture. With the remaining cold water
mix the flour until it is free from lumps; and to the malt soup
mixture, add milk. Pour all into a clean saucepan and bring slowly to
the boiling point; simmer (not boil) for 20 minutes. Now increase the
heat and allow the mixture to boil 5 minutes; strain and use as
directed.

This is a fattening mixture and the amount of malt soup and whole milk
may be increased as the child is able to handle it, taking care,
however, not to increase the strength of the mixture too rapidly or
too much, or digestional disturbances will result.


BUTTERMILK MIXTURE FOR INFANTS

_544.6 calories_

1 tbs. wheat flour, 4 tbs. dextri-maltose, 8 oz. hot water plus enough
hot water to replace that which is lost through evaporation (about 6
oz.). Buttermilk, sufficient quantity to make 1 quart of mixture. Mix
flour with a little cold buttermilk. Dissolve sugar (dextri-maltose)
in the hot water.

Stir two mixtures together and add enough buttermilk to make 1 quart.
Place on stove and bring mixture quickly to a boil. Boil for 20
minutes, stirring constantly, strain, measure, and add enough boiling
water to replace that which is lost in cooking. Place on ice and use
as directed.

The nurse will soon be able to tell how much water is lost in
evaporation and add the additional amount to the mixture before
beginning the boiling.


EIWEISSMILCH[45]

(PROTEIN OR ALBUMEN MILK)

  1 quart fresh whole milk
  1 pint of fresh buttermilk
  4 teaspoons essence of pepsin,

Heat whole milk to 100° F., add essence of pepsin and stir
thoroughly. Allow to stand at same temperature until the curd is
formed. Pour mass into muslin bag and drip the whey from the curd.
When the mass is as dry as it is possible to have it, remove it from
the bag to a fine strainer. Press curd through the strainer with a
wooden spoon or potato masher (the author has found that a potato
ricer with a piece of copper gauze, such as is used in a chemical
laboratory, inserted, facilitates the breaking up of the curd). The
mass must be passed several times through the strainer in order to
make the precipitate sufficiently fine to look like milk. During the
process of straining, the buttermilk is added. The composition of
above formula is, according to Finkelstein and Meyer, as follows:

Protein 3%, Fat 8.5%, Sugar 1.5%, Salts 0.5%.

There are several prepared Eiweissmilch mixtures on the market, Beebe,
Hoose and others. Larasan Roche is also a prepared mixture having a
composition much like that of the original Eiweissmilch, it is easily
prepared, and the results from feeding this milk have been found
generally good.


FORMULAS USED IN DIET FOR CONSTIPATION

PRUNES AND FIGS

  1/2 lb. each prunes and dried figs
  1 oz. senna leaves

Boil from 2 to 3 hours as directed in preparing prunes as above. Lift
fruit from hot sirup, place in quart jars, strain the juice and pour
over the fruit. Use as needed.


CONSERVE

  1/3 lb. prunes (pits removed)
  1/3 lb. raisins (seeded)
  1/3 lb. figs
  1 oz. senna leaves

Boil prunes just enough to allow of the pits being removed. Cool and
pass with the senna leaves, figs and raisins through the food
chopper. After passing through once return to chopper and pass through
a second time. See that the senna leaves and fruit are thoroughly
mixed and finely chopped. Place in a quart jar and give in doses of
from 1 to 2 teaspoonfuls night and morning.


BRAN GEMS (NO. 1)

_560 calories_

  2 tbs. molasses
  1/2 tsp. salt
  1/2 cup milk
  1-1/2 cup bran
  1/2 tsp. soda
  1 egg

Mix soda into bran, add salt, stir milk and molasses together and stir
into bran; add well-beaten egg. Bake in 6 well-greased gem pans.


BRAN GEMS (NO. 2)

_832 calories_

  1-1/2 cups bran
  1 tbs. sugar
  2 tbs. melted butter
  1 egg
  1 cup milk
  2 tsp. baking powder

Mix together and bake in 6 well-greased gem pans.


BRAN BISCUITS

_706 calories_

  1 cup of bran
  1/2 cup of flour
  1/2 tsp. salt
  2 tbs. butter and lard mixed
  1-1/2 tsp. baking powder
  1/3 cup of milk

Mix flour, salt, baking powder and shortening together. Add milk to
make a soft dough. Mold into biscuits, and bake in a quick oven 10 to
12 minutes.


BRAN COOKIES

_2187.5 calories_

  1/2 cup of sugar
  1/2 cup of molasses
  1/4 cup of butter and lard mixed
  1-1/2 cups of bran
  1 cup of flour
  1 tsp. cinnamon
  1 tsp. ginger
  1/2 tsp. cloves
  1/2 tsp. nutmeg
  2 eggs

1/2 cup raisins or nuts may be added, due allowance being made for the
additional fuel value.

Cream butter and sugar together, add molasses. Sift flour, salt and
spices together. Add eggs (well beaten), to sugar mixture and stir in
the remainder of ingredients. Drop from spoon on a well-greased pan,
bake in moderate oven to a delicate brown.

(See Protein-free cookies, p. 340.)


~Nutrient Enemas~[46]

NO. 1. MILK AND EGG

  6 oz. milk, 1 egg
  1 tsp. pure peptone (this may be omitted)
  1/2 oz. normal saline solution
  1 tube peptonizing powder dissolved in 1 tbs. water

Mix thoroughly and peptonize at a temperature of 110° F. for 1 hour.


NO. 2

  8 oz. milk
  3 eggs
  3 grains table salt


NO. 3

  8 oz. milk
  2 oz. glucose (grape sugar)


NO. 4. SINGER'S ENEMA

  125 gm. (about 4 oz.) milk
  125 gm. (about 4 oz.) wine
  1 or 2 egg yolks
  Salt
  1 tsp. Witte's peptone


NO. 5. BOAS' ENEMA

  250 c.c. (8 oz.) milk
  2 egg yolks
  Small quantity of salt
  1 tbs. of red wine
  1 tbs. "Kraftmehl" Health Flour


NO. 6

  6 oz. bouillon
  4 oz. red wine
  1 egg yolk
  1 to 2 tsp. dry peptones


NO. 7. MILK AND STARCH ENEMA--VON LEUBE

  250 c.c. (about 8 oz.) milk
  70 grains starch


MALTED MILK ENEMA

Dissolve 1 oz. of malted milk in 8 oz. of hot water
1 egg and 1/2 tsp. salt or 1/2 oz. saline solution


NORMAL SALINE SOLUTION

  1 dram sodium chloride (common salt)
  1 pt. (16 oz.) water, (boiled)


~Formulas Used in Diabetes~[47]

* BRAN AGAR WAFERS

Makes 30 wafers.

  2-1/2 quarts washed bran (_dry_)
  36 gms. agar-agar
  1-1/2 tsp. salt
  2 saccharin tablets (1/2 gr.)
  600 c.c. of cold water

Mix agar-agar, saccharin, salt and water. Boil until dissolved. Pour
over dry bran. Mix thoroughly and mold into muffin tins while hot.
Bake in a slow oven about 20 minutes, or until wafer is dry and will
whirl in the tin.


* AGAR JELLY

  1 tsp. or 7 gms. agar-agar
  1 cup cold water
  1 tsp. mild citric acid
  1/2 gr. saccharin
  1/4 tsp. flavoring
  Coloring--as desired

Dissolve agar-agar in water. Add citric acid and saccharin. Put over
flame and boil. Remove from fire--add flavoring and coloring. Put in
cool place to harden. This jelly has no food value.


* SPINACH AND EGG SALAD

  3 gms. gelatin
  2 tbs. cold water, melt and swell over hot water.

Add:

  6 tbs. cold water
  2 tbs. vinegar
  50 gms. fresh cooked spinach
  1 hard cooked egg
  Salt as desired

Surround mold with slices of hard cooked egg, placing the spinach in
the center. Pour over this the gelatin mixture; allow to mold and
serve on lettuce.


* MAYONNAISE DRESSING

  2 egg yolks
  360 gms. of salad oil
  60 c.c. vinegar
  8 gms. salt and pepper

Beat egg yolks. Gradually add oil until all has been used (beating the
mixture constantly). Then add the remainder of the ingredients. Put in
a covered jar and keep in a cool place.

The percentage composition of this dressing is

  Fat--83%.    Protein--0.9%


CELLU BRAN CRACKERS

  1/2 cupful cellu flour
  1 cupful dry, washed bran
  1 tablespoonful India gum
  1 teaspoonful baking powder
  1/2 teaspoonful salt
  3 tablespoonfuls mineral oil
  1/2 grain saccharin
  Hot water

Makes 12 crackers about 4 inches by 4 inches and 1/8 inch thick
(resembling Graham crackers).

Mix all dry ingredients. Add mineral oil and saccharin dissolved in a
small amount of water. Then add sufficient hot water to make a soft
dough. Spread on a baking sheet or in flat baking pans and cut into
twelve wafers. Bake in a slow oven until dry.

These crackers have practically no food value.

       *       *       *       *       *

Soya Manna may be secured from Vitae Health Food Company, 364 Roy
Street, Seattle, Washington.

Soya Manna muffins may be substituted for hepco cakes in any of the
following recipes:


** OLMSTED BRANCAKES

(_Recipe 41_)

  3 cupfuls bran, washed
  2 eggs
  2 egg yolks
  1/4 teaspoonful salt
  50 grams lard or crisco, melted
  180 grams water
  1/2 teaspoonful baking powder

Mix ingredients in order given and bake in a moderate oven. This
recipe makes 18 muffins. Food value of 6 muffins, 1 gram carbohydrate,
5 grams protein, 23 grams fat.


** SOYA MANNA MUFFINS

(_Recipe 42_)

  2 eggs
  60 grams cream--20%
  140 grams Soya Manna
  20 grams butter
  1/2 teaspoonful baking powder
  100 grams water

Beat eggs, add cream and then flour, beating all the time. Add water
and melted butter. Mold into 12 cakes and bake. Each cake contains 6
grams protein, 6 grams fat: approximately 75 calories.


** NOODLE SOUP

(_Recipe 43_)

  1/2 pint broth--clear
  1 egg noodle
  5 grams butter
  Few grains salt and pepper

Beat eggs until stiff and bake in 5 grams of butter as an omelet; let
cool, cut into strips as noodles. Heat broth and add noodles. If
desired, add vegetables, cut in cubes, using such variety and quantity
as give flavor to soup adding their food value to diet. Food value 6
grams protein, 10 grains fat.


** CHICKEN SUPREME

(_Recipe 44_)

  50 grams chicken weighed cooked
  1/2 egg
  50 grams milk
  25 grams celery
  Few grains salt and pepper

Beat egg slightly, add chicken, cut in small pieces, milk salt and
pepper. Put in mold, set in pan of hot water and bake in moderate oven
until firm. Food value 4 grams carbohydrate, 18 grams protein, 13
grams fat.


** SALISBURY STEAK

(_Recipe 45_)

  75 grams steak--fat, weighed uncooked
  25 grams onion, uncooked
  Few grains salt and pepper

Grind the meat, add seasoning and make into firm balls. Sear in hot
mineral oil, then cook at a lower temperature. Food value, 2 grams
carbohydrate, 17 grams protein, 22 grams fat.


** VEAL BIRD

(_Recipe 46_)

  75 grams meat
  2 Olmsted brancakes, crumbed
  25 grams chopped celery
  Few grains salt and pepper
  100 grams skim milk

Have meat cut in one thin slice. Use the trimmings chopped fine in
dressing of crumbs, celery and seasoning moistened with water. Spread
dressing on meat, roll and tie or skewer with toothpicks. Put in
casserole and bake in milk until done. Food value, 6 grams
carbohydrate, 23 grams protein, 19 grams fat.


** SALMON MOLDED

(_Recipe 47_)

  100 grams salmon
  1 egg yolk
  5 grams butter
  50 grams skim milk
  2 tablespoonfuls vinegar
  Few grains salt
  1/2 teaspoonful gelatin
  1 tablespoonful cold water

Remove the salmon from the can, weigh, separate in flakes. Add beaten
yolks, melted butter, milk and vinegar and salt. Cook over boiling
water, stirring constantly until mixture thickens. Soak gelatin,
strain and add to salmon. Fill individual molds, chill, and serve with
cucumber sauce. Food value, 3 grams carbohydrate, 26 grams protein, 23
grams fat.


** CABBAGE SOUFFLÉ

(_Recipe 48_)

  100 grams cabbage, cooked
  15 grams lean meat, cooked, minced
  35 grams sour cream--16%
  1 egg
  10 grams American cheese
  Few grains salt and pepper

Chop cabbage fine, add meat, cream, beaten egg, salt and pepper. Put
into mould and sprinkle grated cheese over top. Bake in a moderate
oven until firm and brown. Food value, 5 grams carbohydrate, 15 grams
protein, 17 grams fat.


** CELERY RAMEKINS

  50 grams milk
  1/2 hepco cake
  25 grams celery
  1 egg
  5 grams butter
  Few grains salt and pepper

Heat milk; add crumbed hepco cake, grated celery and seasonings, let
come to a boil, add butter, remove from fire; add beaten egg yolk.
Fold into beaten white. Put in ramekin and bake 20 or 30 minutes in
slow oven until well browned. Food value, 3 grams carbohydrate, 11
grams protein, 15 grams fat.


** BAKED ONION

  50 grams onion, uncooked
  10 grams ground meat, lean cooked
  15 grams whole milk
  Few grains salt and pepper

Parboil the onion, scrape out the inside, leaving only shell. Weigh
shell and scrapings to 50 grams. Add meat and return to shell. Put
into casserole, add milk and bake until tender. Food value, 4 grams
carbohydrate, 4 grams protein, 2 grams fat.


** SQUASH PIE

(_Recipe 92_)

  1 egg
  150 grams squash cooked
  50 grams cream--16%
  1/2 teaspoonful cinnamon
  1/4 teaspoonful nutmeg
  Few grains salt
  1/2 grain saccharin

Beat egg, add mashed squash, cream, spice, salt and saccharin
dissolved in 1 teaspoonful of cold water. Bake until firm in center,
using cellu flour recipe for pie crust. Food value, 12 grams
carbohydrate, 10 grams protein, 14 grams fat.


** SPICE COOKIES

(_Recipe 93_)

  2 eggs
  1/2 grain saccharin
  10 grams cream--16%
  1 teaspoonful spices--cinnamon, cloves, nutmeg
  20 grams ground almonds

Beat the yolks, add saccharin dissolved in cream, then spices and
ground almonds. Add to the stiffly beaten whites. Drop from spoon on
oiled pan and bake in hot oven. Food value, 4 grams carbohydrate, 16
grams protein, 25 grams fat.


CREAM OF CAULIFLOWER

  1/4 cup cauliflower purée
  2/3 cup chicken or beef stock
  1/4 tsp. onion juice (if desired)
  2 tbs. 40% cream
  Salt and pepper

Add cauliflower to stock, and allow to come to a boil, season and add
cream. Serve at once.


TOMATO BISQUE

  1 cup creamed tomatoes
  1/2 cup water
  1 sprig (1 tbs. chopped) parsley
  3 cloves
  1/2 tsp. salt
  1/8 tsp. soda
  1-1/2 oz. (3 tbs.) 40% cream

Cook tomatoes with cloves, parsley, and water for 20 minutes. Press
through sieve and return to fire. Add soda; when effervescence ceases,
add cream, and serve at once.


SPINACH SOUP

  30 gm. cooked spinach
  15 c.c. 40% cream
  1 egg yolk

Cook spinach until tender and press through a sieve; add the broth;
allow to cook about 5 minutes and add the well-beaten yolk and cream.
Place the saucepan over hot water and cook 10 minutes. Season and
serve at once.

Other Cream Soups, except Tomato Bisque, are made by the same recipe.


VEGETABLES

The nurse must be governed in the selection of the vegetables by the
physician, using those from the 5% group until otherwise ordered.
These must be boiled in three separate waters to further reduce their
carbohydrate content.

Cream or butter is added to them when diet permits; in the beginning
(after starvation) only salt or (in case the vegetable is given in
form of a salad) a little lemon juice with a little salt and pepper
added.

Grated onion, a small quantity of celery seed, or a tiny bit of
chopped green pepper may be added for additional seasoning. When some
fats are allowed, butter, olive oil, and cocoanut cream may be used;
the latter is prepared as follows:

1 small cocoanut grated; this is washed in cold water slightly
acidulated with vinegar to remove the sugar, then washed to remove the
vinegar. Over the washed cocoanut pour 1 pint of boiling water; allow
to stand until cold enough to squeeze through a cloth; press as much
of the water out as possible. Pour the water into a shallow dish and
allow to stand until the cream rises; skim off and serve with lemon
juice on salad as a dressing.


BOILED CORNED BEEF WITH CABBAGE AND OTHER VEGETABLES[48]

"A portion containing 50-75 grams meat and 100 grams of each vegetable
makes an excellent meal."

Horseradish (sauce) is recommended by Joslin as a seasoning, and some
pickles made from group of 5% vegetables and without sweetening.

Curry powder, tarragon, bay leaves, capers may likewise be used in
moderation to vary the monotony of the diet.


PARSLEY BUTTER

  5 gm. butter
  1 tsp. chopped parsley
  Salt, pepper, and 1/2 tsp. lemon juice, if desired

Cream butter, add lemon juice, salt, and pepper. Stir in parsley.
Serve on meat or fish.


NEUFCHÂTEL CHEESE SALAD

  1/3 Neufchâtel cheese
  1/4 green pepper
  1 tbs. cream (40%)
  1 tsp. lemon juice

Season with salt and paprika and dress with cream dressing.


CHEESE SALAD

Mash cream cheese with fork; add tablespoonful chopped pecan nuts to
1/3 Neufchâtel cheese. Season with salt and pepper and dress with
French dressing.


TUNA FISH SALAD

  1/2 cup tuna fish
  1/2 cup chopped celery

Dress with French Dressing.


EGG SALAD

Cook 1 egg hard. Cut into rings; arrange on lettuce leaf; dress with
cream dressing.


TOMATO ASPIC

  1 cup canned tomatoes
  1/2 cup celery (hearts)
  1 tsp. celery seed
  1/2 small onion
  1/2 cup water
  1/4 cup vinegar
  3-4 cloves
  1/2 bay leaf
  2 tsp. granulated gelatin, soaked in tbs. water

Boil all ingredients (except gelatin and celery hearts) 20 minutes.
Measure. Add hot water or tomato juice to make one cup; add gelatin;
allow to cool; cut celery fine, place in mold; pour in the tomato
aspic and allow to jelly in a cold place.


~Bread Substitutes~

BRAN BISCUITS, OR MUFFINS

  1 cup washed bran
  1 tsp. baking powder
  1 egg
  1 tbs. melted butter
  2 tbs. cream
  1/4 tsp. salt

Tie bran in cheesecloth bag and attach to cold water faucet; allow
water to pass through bran, removing starch by squeezing the water
through; using dry. Beat egg separately; add cream; mix with bran, add
melted butter, salt, and baking powder. Grease muffin rings and pour
in the mixture. Bake in moderate oven.


DIABETES MUFFINS[49]

(The Equivalent of an Egg)

Recipe for Hepco Cakes, so arranged that one cake is equivalent to an
egg:

  140 gm. Hepco flour     Protein 60     Fat 29
  2 eggs                  Protein 12     Fat 12
  60 c.c. 40% cream       Protein  2     Fat 24
  10 gm. butter                          Fat  9

Make twelve cakes; each cake contains 6 grams of protein, 6 grams of
fat, and approximately 75 calories.


LISTER MUFFINS

So arranged that each muffin is equivalent to one egg:

  60 gm. Lister flour (one box)     Protein 42     Fat  0
  1 egg                             Protein  6     Fat  6
  45 c.c. 40% cream                 Protein  2     Fat 18
  30 gm. butter                                    Fat 25

Make 17 muffins; each muffin contains 6 grams protein, 6 grams fat.


BRAN BISCUITS FOR CONSTIPATION

(By F. M. Allen)

  60 gm. bran
  1/4 tsp. salt
  6 gm. powdered agar-agar
  100 c.c. (1/2 glass) cold water

Tie bran in cheesecloth and wash under tap until water is clear. Bring
agar-agar and water (100 c.c.) to boiling point. Add washed bran and
salt and agar-agar solution (hot). Mold into ten cakes; place on oiled
paper and let stand 1/2 hour, then when firm and cool, bake in
moderate oven 30 to 40 minutes. The bran muffins are more palatable if
butter and eggs are added. This may be done, provided the patient
allows for them in the diet.


CASOID FLOUR AND BRAN MUFFINS

  1 oz. (30 gm.) casoid flour
  1 level tbs. (15 gm.) butter
  1 oz. (30 c.c.) 40% cream
  1/4 tsp. salt
  1 egg white (whole egg may be substituted for 1 egg white)
  1-1/2 tsp. baking powder
  1 cup washed bran

Total food value: protein, 18 grams; fat, 24 grams; carbohydrates, 1
gram; calories, 300.

One muffin: protein, 3 grams; fat, 4 grams; carbohydrates, trace; and
calories, 50.

The flours and meals used in this recipe are prepared by Cutlard,
Stewart & Walt, Ltd., London (casoid flour). Theo. Metcalf & Co.,
Boston (soya bean meal). Lister Brothers, Andover, Mass. (Lister
diabetic flour).


LISTER FLOUR AND BRAN MUFFINS, OR BISCUITS

  1 cup washed bran
  30 gm. Lister flour
  1 tsp. baking powder
  1 tbs. butter
  1 egg
  1/2 tsp. salt
  2 tbs. 40% cream

Sufficient water to make a drop batter (about 1/4 cup)

Squeeze all the water from the bran, then add flour and melted
butter, salt, well-beaten egg yolk and cream. Whip egg white stiff and
fold into mixture. Add baking powder and enough water to make thick
batter. Use less water if biscuits instead of muffins are desired, and
knead into a dough. Roll out into a sheet one-half inch thick and cut
with biscuit cutter.

After making muffin batter, grease muffin ring with melted lard, and
pour half full of above mixture. Bake in moderate oven about 20 or 30
minutes.


SOYA MEAL AND BRAN MUFFINS[50]

  1 oz. (30 gm.) soya meal
  1 level tbs. (15 gm.) butter
  1 oz. (30 c.c.) 40% cream
  1/4 tsp. salt
  1 cup washed bran
  1 egg white (one whole egg may be substituted for one egg white)
  1-1/2 tsp. baking powder

Mix soya meal, salt, and baking powder. Add to washed bran; add melted
butter and cream. Beat egg white and fold into mixture; add enough
water to make thick drop batter. Bake in six well-greased muffin tins
until golden brown from 15 to 25 minutes.

Total food value: protein, 11 grams; fat, 27 grams; carbohydrates, 2
grams; calories, 304; one muffin, protein, 2 grams; fat, 4.5 grams;
carbohydrates, trace; calories, 50.


ALMOND BISCUITS

  1 cup almond meal
  1 oz. cream
  1 egg
  1 grain (or less) saccharin, dissolved in 1 tsp. of water
  1-1/2 tsp. baking powder
  3-4 drops vanilla

Beat egg yolk until light, add cream and saccharin; stir this into
almond meal. Fold in the stiffly beaten white. Drop on a greased
paper and bake until golden brown in a moderate oven.

       *       *       *       *       *

Almond meal or flour is prepared as follows:

Blanch 1 pound of almonds; dry and pass through grinder, or pound in
mortar until powdered. Place in a muslin bag and immerse in a pan of
water acidulated with vinegar to remove sugar; allow to stand 15
minutes. Squeeze dry and place in a warm (not hot) oven to remove all
moisture. Grind or pound once more. Almond flour does not keep well;
it must be made in small quantities and kept in a glass jar in a cool
place.


COCOANUT FLOUR

Grate cocoanut and treat as almonds to remove sugar; dry thoroughly
and grind or pound to fine meal.


COCOANUT BISCUITS

  1 cup cocoanut
  1 egg white (or whole egg if desired)
  1-1/2 tsp. baking powder
  1/2 grain saccharin

(A biscuit may be made without saccharin for bread substitute.)


SPANISH CREAM

  5 tbs. coffee, or Infusion of cocoa nibs
  1 tsp. gelatin
  1 tbs. cold water
  30 c.c. (1 oz.) 40% cream
  1 egg
  Saccharin to sweeten

Pour coffee, or cocoa infusion, into a double boiler, beat egg yolk
and saccharin dissolved in 1 tsp. of water, and stir into hot coffee.
Cook gently until mixture coats the spoon (raw flavor of egg has
disappeared); add gelatin and mix thoroughly. Whip cream and egg
white. Place on ice to set.


LISTER CREAM PUFF

This is made by pouring 30 grams of soft custard (diabetic) over 1
Lister biscuit.


CUSTARD

  1/2 cup cream
  1/4 grain saccharin
  1 egg
  3-4 drops vanilla or almond extract

Beat egg until it is well broken up, but not light; stir into the
cream; dissolve saccharin in teaspoonful of water and add to mixture.
If custard is to be baked, pour into molds and place upon a rack, or
on a folded cloth in a pan half filled with hot water; bake in
moderate oven until firm in center.

If soft custard is desired, pour mixture into double boiler and cook
gently until mixture coats the spoon and the raw egg flavor has
disappeared.


SNOW PUDDING

Make 1/2 cup gelatin, as directed below.

Whip in 1 egg white.

When gelatin is half congealed, mold and set on ice.

When ready to serve, unmold and serve with custard, or 1 tbs. whipped
cream.


~Jellies~

1 tbs. cold water to 2 tsp. granulated gelatin is used in making the
following jellies:


LEMON

_16.6 calories_

  1/2 cup boiling water
  1/4 to 1/2 saccharin tablet dissolved in 1 tbs. water
  1/2 lemon or 2 tbs. juice and 1/2 rind sliced thin


IRISH MOSS PUDDING

Carefully pick over and wash through several waters 1 tbs. Irish moss.
Place in double boiler with 1/3 cup of water and 3 tbs. 40% cream and
1/4 grain saccharin. Cook until mixture thickens when dropped upon a
cold saucer. Pour over 1 stiffly beaten egg white; add 3-4 drops of
vanilla extract. Mold and set on ice.

Irish moss may be used as a substitute for gelatin. The carbohydrates
in this substance are not believed to be utilized for the manufacture
of glucose in the human body.


ORANGE

_54 calories_

  1/4 cup boiling water
  1/2 tbs. lemon juice
  1/2 cup orange juice
  1/4 to 1/2 saccharin tablet dissolved in 1 tbs. water
  2 drops orange extract


WINE

_40.8 calories_

  1/2 cup boiling water
  3 tbs. sherry wine
  1 tsp. lemon juice and the yellow rind from 1/4 lemon
  1-inch piece of cinnamon
  1/4 to 1/2 saccharin tablet dissolved in 1 tbs. water


METHOD FOR FRUIT JELLIES

Soak gelatin in cold water about 2 or 3 minutes, then pour over it the
boiling liquid; add saccharin and fruit juice, strain through cloth
into wet molds. Set in cold place to stiffen; when firm, unmold. Serve
with whipped cream, or pour liquid into baskets made from orange or
grapefruit, hollowed out and the edges scalloped, or pour into shallow
pans, and cut in 1/2-inch blocks when firm and serve on a bed of
whipped cream.


WINE JELLY

Put water, wine, lemon juice and peel, cinnamon, and saccharin into a
saucepan, allow to boil 5 minutes, pour over gelatin (which has been
soaked in cold water). If the jelly looks cloudy, return to saucepan,
and add 1/2 egg white beaten stiff; allow to boil 1 minute, stirring
constantly, and strain into mold. Serve with whipped cream.


~Ices~

LEMON

_30 calories_

  1/3 cup water
  Fruit juice, 1 lemon
  1/4 to 1/2 saccharin tablet
  1 egg white


ORANGE

_75.5 calories_

  1/2 cup water
  1 large or 2 small oranges
  1/2 lemon
  1/4 to 1/2 saccharin tablet
  1 egg white

Sweeten fruit juice with saccharin instead of sugar. Clip egg white
with scissors, or beat with Dover egg beater, add mixture and freeze.


ICE CREAM

  (1) Use recipe for soft custard, freezing after the custard has become
    thoroughly cold.

  (2) 1/3 cup cream
      1 tbs. chopped nuts
      1/4 grain saccharin or enough to sweeten, dissolved in 1 tsp. water
      3-4 drops vanilla, orange, or almond extract

Whip cream, add saccharin and nuts. Pour into a small 1/4-pound baking
powder can, seal the edges of mold or can with a thin strip of
buttered muslin. Pack in equal parts of salt and ice for two hours.

~Sugar-free Milk.~--A sugar-free milk has been advised by Williamson.
It is made from washed cream as follows: 3 tablespoonfuls of cream are
shaken in a pint of water and set aside until the cream rises, it is
then skimmed off and mixed with the white of one egg and diluted with
pure water. This furnishes a beverage not unlike milk in appearance
and flavor.


NUT CHARLOTTE

  60 c.c. (2 oz.) 40% cream
  30 gm. chopped walnuts
  Saccharin to sweeten
  3-4 drops vanilla

Whip cream stiff; add saccharin, nuts, and vanilla.

1 tbs. sherry wine and 1 tsp. gelatin soaked in 1 tbs. cold water and
melted over hot water may be substituted for vanilla to vary the above
recipe.


ORANGE CHARLOTTE

  75 c.c. (5 tbs.) orange juice
  45 c.c. (3 tbs.) 40% cream
  1/2 egg white
  1 tsp. gelatin
  1 tbs. cold water
  Saccharin to sweeten

Soak gelatin in cold water; dissolve over hot water, add to orange
juice; add saccharin; set aside until it begins to jelly. Whip cream
and add to partially jellied orange juice; fold in the stiffly beaten
egg white; mold. Serve 30 grams.


FOOTNOTES:

[43] When a 1.50% decoction is desired, use 2 rounded teaspoonfuls to
the pint of water. "Diseases of Nutrition and Infant Feeding," p. 222,
by Morse and Talbot.

[44] "Beef juice is not the same as 'dish gravy,' since the latter
contains a large amount of cooked fat and is often highly
indigestible." Morse and Talbot's "Diseases of Nutrition and Infant
Feeding."

[45] Formula suggested by Finkelstein and Meyer.

[46] "Diet in Disease," by Freidenwald and Ruhräh and other sources.

[47] Formulas marked with one star are those used in the Presbyterian
Hospital, Chicago, Ill. Courtesy of Miss R. Straka, Dietitian.
Formulas marked with two stars are used in the Olmsted Hospital, Mayo
Clinic, Rochester, Minn. Courtesy of Misses Foley and Ellithorpe,
Dietitians. Formulas unmarked are used by the author in Memphis
General and St. Joseph's Hospitals, Memphis, Tenn.

[48] "Treatment of Diabetes," p. 538, by Joslin.

[49] "The Treatment of Diabetes Mellitus," p. 531, by Joslin.

[50] "Starvation Treatment of Diabetes," p. 43, by Hill and Eckman.




SECTION III

THE HUMAN MACHINE




CHAPTER VII

THE HUMAN BODY


~Chemical Composition of the Body.~--It has been estimated by various
writers that the human body has an approximate average chemical
composition[51] of--

  Oxygen          about  65      per cent
  Carbon          about  18      per cent
  Hydrogen        about  10      per cent
  Nitrogen        about   3      per cent
  Calcium         about   2      per cent
  Phosphorus      about   1      per cent
  Potassium       about   0.35   per cent
  Sulphur         about   0.25   per cent
  Sodium          about   0.15   per cent
  Chlorine        about   0.15   per cent
  Magnesium       about   0.05   per cent
  Iron            about   0.004  per cent
  Iodine    }
  Fluorine  }     very minute quantities
  Silicon   }

~Dependence of the body upon Food.~--The human body, like any other
piece of machinery, undergoes a constant wear and tear incidental to
the work it performs, but in the human machine this is not all that
must be included in its upkeep. The replacing of the dead and cast out
cells with new ones, the repairing of the worn cells, the furnishing
of heat, not only for the running of the engine but for the
maintenance of the body temperature,--all of these must be considered
and cared for if life is to continue. In man-made machinery, the
renewal of the worn parts, and the replacing of those no longer useful
must be accomplished by an outside agency. But in the body this work
is performed by the organism; and the material used for the purpose,
as well as that which is used to furnish the heat necessary for the
internal and external activities of the body is food.

~Exceptions to this Rule.~--Under normal conditions the body never
uses its own structure either for fuel or to replace tissue losses. In
starvation the body rebuilds its important tissues, such as the nerves
and glands, at the expense of the less important ones, such as the
connective tissues and the skeletal muscles (Taylor).

Science has proved that for the most part the body does not use the
food materials in their original form, but carries them through a
series of transformations into substances more easily handled by the
organism.

Roughly speaking, we may say that the body carries the foodstuffs
through practically four processes on the pathway through the body,
namely, digestion, absorption, metabolism, elimination.

~Processes Included in Digestion.~--There are several processes
concerned in this transformation of the food materials. Some are
purely mechanical and have to do with the movement of the food mass
through the digestive tract: others are of a chemical character and
bring about distinct changes in the food materials themselves. These
mechanical and chemical processes with the retarding and stimulating
agents that influence them are called digestion.

~Absorption.~--After the food materials have undergone digestion, or
simplification into more available substances, these substances are
absorbed, that is, they are passed through the membranes lining the
walls of the intestinal tract, and thence to the blood.

~Metabolism.~--The utilization of the transformed food materials and
their final fate in the human body is included under the term
Metabolism.

~Elimination.~--After the food materials have been utilized to the
extent of the body's ability to handle them, their waste products are
cast out of the organism by way of the skin, the lungs, the intestines
and the kidneys.

A brief description of these processes seems desirable here.

~Digestion.~--Mechanical digestion begins in the mouth, where through
the action of the teeth, the tongue and the muscles of the jaw, the
food material is ground up and liquefied to a certain extent and made
ready for the chemical action which takes place, to a limited degree
only, as a result of the salivary enzyme in the mouth. The eating of
food causes a flow of saliva from the three pairs of large salivary
glands, and from the numerous secretory cells situated in the
membranes of the mouth. As a rule the food stays for too short a time
in this organ for any appreciable amount of chemical action to take
place, but the liquefaction of the food mass with the salivary juices
which contain the ferment (ptyalin), prepares for its passage into the
gastric organ, and allows the digestion of the starch (the only
foodstuff affected by salivary digestant), to continue in that part of
the stomach until its action is checked by the hydrochloric acid in
the gastric juice.

~Arrangement of Food in the Stomach.~--To simplify the study of the
gastric organs it may be well to think of the stomach as being divided
into three regions, _i.e._, "the fundus, the middle region, and the
pyloric end,"[52] each of which differs slightly from the other. After
being swallowed, the food enters the region situated at the cardiac
end, known as the fundus.

~Motor Processes in the Stomach.~--There are no peristaltic waves in
the fundus of the stomach, and the movement of the food mass is
accomplished through the stretching and contraction of the muscular
walls of the organ which tends to churn and further mix it with the
salivary juices as it is gently pushed out into the middle region. In
this region the peristaltic waves begin and travel toward the pylorus
and increase in force as digestion progresses, ceasing only with the
emptying of the organ. When the first stratum of food reaches the
middle of the stomach it is caught by these oscillating peristaltic
waves and forced forward through the pyloric region and against the
pylorus, from whence it is returned back through rings of
constriction. This forward and backward movement continues as long as
there is food in the stomach, thus thoroughly mixing the mass with the
gastric juice and allowing the enzymes existing in the juices to have
an opportunity for action (chemical digestion).

~Passage of Food from Stomach.~--The material prepared in the stomach,
known as ~chyme~, is passed into the duodenum through the pylorus. The
opening of this sphincter is controlled, according to Cannon, to a
certain extent by the liquefication of the chyme, but more especially
by the presence of free acid in the stomach side of the pyloric
orifice.

~Behavior of Food in the Intestines.~--The food does not pass at once
along the canal, but waits in the duodenum until several portions have
passed through. As the food mass is made alkaline in the presence of
the intestinal juices, the pyloric valve closes, opening again as the
contents nearest it on the stomach side are acidified.

~Intestinal Movements.~--The peristaltic waves in the small intestines
begin in the upper part and start a course ever downward. These waves
in the intestines are two-fold in character; the quick shallow wave
which forces the food string forward, breaking it up into segments,
and backward joining the segments together again, and the strong deep
wave which carries the entire mass forward after each segmentation.
This method of movement in the small intestines is the best one
possible under the conditions which prevail in this region of the
digestional apparatus, since it not only mixes the food material with
the juices necessary for its digestion, but likewise spreads it out
over a wide space, insuring a greater contact with the absorbing walls
of the small intestines.

~The Effect of Muscular Constrictions.~--The muscular constrictions
occurring in the intestines producing segmentation of the food string
have, according to Sherman, the effect of "(1) further mixing of the
food and digestive juices, (2) bringing the digested food into contact
with the absorbing membrane, (3) emptying the venous and lymphatic
radicles in the membrane, the material which they have absorbed being
forced into the veins and lymph vessels by the compression of the
intestinal walls."[53]

~Movements in the Large Intestine.~--The movements in the large
intestine or colon are much like those in other parts of the digestive
tract. The small and large intestine are divided by a valve known as
the ileocecal valve, and any food which passes through it cannot
return, since the valve is a competent one. The cells in the walls of
the larger intestine secrete fluids of a lubricating character,
containing no enzymes of digestion but aiding in moving the fecal
matter toward the rectum.

~Distribution of Secretory Cells.~--Secretory cells are distributed in
each of the three regions of the stomach, but are more numerous in the
middle region than at either end. The third region includes the
pyloric vestibule through which all foods must pass before they can
enter the small intestine, and terminates in the pylorus, the valve
which shuts off the stomach from the duodenum and the rest of the
intestinal canal.

~Chemical Digestion.~--The chemical changes in the food materials,
after they are eaten, are brought about through the action of certain
substances known as soluble ferments or "enzymes." These enzymes exist
in every tissue of the body, and their province is first to break down
the food materials themselves into simpler compounds, and then to
reconstruct the simpler substances into those of a more complex
character, which are more available for the various uses of the
organism.

~Action of the Enzymes.~--As Sherman has stated, "all fermentation is
brought about either directly or indirectly by the activity of animal
or vegetable organisms or cells. When the organisms or cells act
directly and the chemical changes occur only in their presence, the
fermentation is said to be due to an organized ferment. When the
action is not brought about directly by the cell itself, but by means
of a substance secreted by the cell but acting apart from it, this
substance is called a soluble or unorganized ferment or 'enzyme.'" The
enzymes concerned in digestion and metabolism, their source and their
action, may be found in the following table:

TABLE OF ENZYMES[54]

SOURCE AND ACTION OF ENZYMES

  ==============+===================+==================+===================
                |                   |  _Where chiefly_ |
                |     _Enzymes_     |     _found_      |     _Action_
  --------------+-------------------+------------------+-------------------
               {|Ptyalin (salivary  |Salivary          |Converts starch
               {| amylase)          | secretions       | to maltose
               {|Amylopsin          |Pancreatic juice  |Converts starch
               {| (pancreatic       |                  | to maltose
               {| amylase)          |                  |
               {|Liver diastase     |Liver             |Converts glycogen
               {|                   |                  | to glucose
               {|Muscle diastase    |Muscles           |Converts glycogen
               {|                   |                  | to glucose
  Act upon     {|Invertase (sucrase)|Intestinal juice  |Converts glycogen
  carbohydrates{|                   |                  | to glucose
               {|                   |                  | and fructose
               {|Maltase            |Intestinal juice  |Converts maltose
               {|                   |                  | to glucose
               {|Lactase            |Intestinal juice  |Converts lactose
               {|                   |                  | to glucose and
               {|                   |                  | galactose
               {|Glycolytic enzymes |Muscles, etc.     |Split and oxidize
               {|                   |                  | glucose
                |                   |                  |
               {|Lipase (steapsin)  |Gastric, and      |Splits fats to
  Acts on      {|                   | pancreatic       | fatty acids and
   fats        {|                   | secretions, blood| glycerin
               {|                   | and tissues      |
                |                   |                  |
               {|Pepsin             |Gastric juice     |Splits proteins to
               {|                   |                  | proteoses and
               {|                   |                  | peptones
               {|Trypsin            |Pancreatic juice  |Splits proteins to
               {|                   |                  | proteoses,
               {|                   |                  | peptones,
  Act on       {|                   |                  | polypeptids and
   proteins    {|                   |                  | amino acids
               {|Erepsin            |Intestinal juice  |Splits peptones
               {|                   |                  | to amino acids
               {|                   |                  | and ammonia
               {|Autolytic enzymes  |Tissue generally  |Split body proteins
               {|                   |                  | to simpler
               {|                   |                  | substances
                |                   |                  |
               {|Guanase            |Thymus, adrenals, |Changes guanin
               {|                   | pancreas         | to xanthin
               {|Adenase            |Spleen, pancreas, |Changes adenin
  Act on purins{|                   | liver            | to hypoxanthin
               {|Oxidases           |Lungs, liver,     |Changes hypoxanthin
               {|                   | muscles, etc.    | to xanthin and to
               {|                   |                  | uric acid
  ==============+===================+==================+===================

~Classification of Enzymes.~--Sherman classifies the enzymes of the
body according to their effects:

1. The hydrolytic enzymes:

(a) Proteolytic or protein-splitting enzymes.

(b) Lipolytic or fat-splitting enzymes.

(c) Amylolytic or starch-splitting enzymes.

(d) Sugar-splitting enzymes.

2. The coagulating enzymes, such as thrombin or thrombase (the fibrin
ferment) and rennin, which causes the clotting of milk.

3. The oxidizing enzymes or oxidases (which, if the oxidation be
accompanied by a splitting off of amino groups, may be called
"deaminizing" enzymes).

4. The reducing enzymes or "reductases."

5. Those which produce carbon dioxide without the use of free
"deamidizing" oxygen, such as zymase of yeast.

6. Enzymes causing the breaking down of a larger into a smaller
molecule of the same composition, as in the production of lactic acid
from glucose.


DIGESTION (CHEMICAL)

~Salivary Digestion.~--The table shows that enzymic action begins in
the mouth. ~Saliva~, the characteristic secretion of this region,
contains the enzyme ptyalin which exerts its influence upon the
starches and dextrins. The food mass remains in the mouth for so short
a time, however, that a very small percentage of the starch is changed
to maltose under salivary digestion. The action of ptyalin, however,
continues in the fundus of the stomach until stopped by the acid in
the gastric juice.

~Gastric Digestion.~--The conditions existing in this region of the
gastric organ of digestion are particularly favorable to the
continuance of salivary digestion on account of the neutral character
of the juices secreted by the cells there, and because there is so
little movement taking place. The cells in the middle region,
however, secrete a fluid rich in acid, and as the food mass is
gradually pushed forward by the contraction of the stomach walls into
this portion of the stomach, further conversion of starch and dextrin
to maltose is checked. Gastric juice is secreted by cells situated in
all parts of the stomach. The character of the secretions differs in
different parts of the organ. However, that in the fundus is neutral
in character or even slightly alkaline, according to Howell, while
that in the middle region is highly acid. The pyloric end of the
stomach exhibits strong peptonizing powers and much of the hydrolysis
of protein takes place here. As the food is pushed out of the fundus
it is caught by the waves of peristaltic action and swept toward the
pylorus. This movement of the food mass to and from the pylorus under
the influence of the muscular constriction in the stomach tends to mix
it thoroughly with the juices in all parts of the stomach, and in a
measure to liquefy it to the "souplike" mixture known as chyme.

~Rate of Carbohydrates, Proteins, and Fats.~--Carbohydrates, for
example, do not require any acid for their digestion, hence all of the
acid with which they come in contact can go toward acidifying them,
while the proteins require hydrochloric acid before the enzymes can
begin to exert their activities. Consequently they leave the stomach
much more slowly than the carbohydrates. The fats leave more slowly
than any of the other food combinations. If carbohydrates and proteins
are taken together they leave the stomach more slowly than if the
carbohydrates were fed alone, but more quickly than they would if the
meal consisted of protein alone. When the meal consists of fats and
proteins, the stomach is emptied more slowly than is the case when
either is fed alone.

~Intestinal Digestion.~--Digestion proceeds in an orderly manner
throughout the intestinal canal. The pancreatic juice, bile, and
intestinal juice are poured upon the food mass on its entrance into
the duodenum. The enzymes work simultaneously. _Trypsin_ in the
pancreatic juice takes up the hydrolysis of the proteoses and peptones
and those proteins which have escaped gastric digestion. The
_amylopsin_ likewise in the pancreatic secretion acts upon the starch
and dextrin, changing them to maltose. The lipases split the fats to
fatty acids and glycerol.

The _erepsin_ in the intestinal juice, "succus entericus," brings
about further change in the proteins, with the production of amino
acids. The bulk of the carbohydrates are converted into monosaccharids
in the small intestines. The lactose, maltose, and sucrose are changed
through the activity of the lactase, maltase, and invertase into
glucose. Sherman states that "it is possible that the splitting of the
lactose (milk sugar) may occur in the intestinal wall rather than in
the food mass."[55]

~Bile.~--Human bile, the secretion most actively concerned in the
digestion and absorption of the fats, contains water, bile salts, bile
acids, bile pigments, cholesterin, lecithin, and a peculiar protein
derived from the mucous membranes of the bile ducts and gall bladder.

~Stimulation of Intestinal Secretions.~--The flow of the intestinal
juices is stimulated by a substance or _hormone_ known as
"~secretin~." This hormone is the result of the action of hydrochloric
acid upon some substance in the intestinal wall. Starling claims that
the formation of hormones and their circulation through the blood to
the reactive tissues is sufficient to account for the activity of the
pancreas; he doubts if the nervous system plays any part in the
activity of that organ.

~Secretion of Water in the Stomach.~--The secretion of water by the
cells of the stomach is such, according to Taylor, as to produce
chyme of quite constant consistency, the solid particles being held in
suspension in the fluid medium.

~Factors Influencing Gastric Digestion.~--The factors influencing
digestion in the stomach constitute all those mechanical, electrical,
chemical, and psychical factors which stimulate or retard the action
of the gastric juices. The movements in the stomach are involuntary,
but their activities may be stimulated by the flow of gastric juice.
Sleep retards digestion in the stomach by retarding the movements in
the organ itself.

~Stimuli to Gastric Flow.~--The division and liquefaction of the food
in the mouth hastens gastric digestion by making the food better
fitted for the action of the enzymes in the gastric juice. The type as
well as the character of the food acts as a stimulus to the gastric
secretion.

~Water~ is probably the best of all the agents for stimulating the
secretion of gastric juice, while ~dextrin~ (toast, zwieback) and the
~extractives of meat~ likewise exert similar powers.

~Retarding the Gastric Flow.~--The nervous system, on the other hand,
at times checks or entirely inhibits a flow of these juices. Worry,
excitement, anger, fatigue, chill; each plays its part in promoting
poor digestion in the gastric organ. As chemical factors, water and
salts are the two necessary substances for gastric digestion, since
the enzymes in the juices cannot act except in their presence.

~Alkaline carbonates~ and ~fatty foods~ both check the flow of gastric
juice, and retard digestion. The psychic factors which result in a
stimulation of the secretory cells in the stomach are exerted through
the sight, smell, and taste. One often hears the expression: "The food
looked, smelled, or tasted so good that it made my mouth water." This
actually occurs; hence the secretion has been named appetite juice.
This appetite juice acts as a direct stimulant to the cells in the
mucous lining of the stomach, causing a flow of gastric juice. It
cannot be said to cause digestion, but it certainly institutes that
process, thus starting the whole digestional procedure.

~Digestion in the Larger Intestine.~--Science has proved that most of
the nourishing part of the food ingested is digested and absorbed
before it reaches the larger intestine. The two portions of the
alimentary canal known as the small and large intestine are separated
by the ileocecal valve. Cannon claims "that this valve is competent,
that is, under normal conditions the food mass which passes through
into the colon cannot be forced back into the small intestine." The
food mass sometimes contains materials which have escaped digestion,
likewise some of the active enzymes which bring about their
hydrolysis, in which case a certain amount of their digestion may
continue in the large intestine.

So far, investigators have found no enzymes in the fluids secreted by
the cells in the walls of the large intestine, but they have found an
alkaline fluid which assists in completing the digestion of the foods
which has started in other parts of the intestinal tract.

~Absorption.~--Absorption of food occurs in all parts of the
intestinal canal, but the major portion of it occurs in the small
intestines, the mucous membrane lining of which seems particularly
adapted for this purpose. According to Taylor there is no absorption
of fats, carbohydrates, or proteins in the stomach. Other
investigators believe that some of the protein is absorbed and also
some glucose in concentrated solution. However, the stomach cannot be
considered of great value as an absorbing organ. Physiology teaches
that the absorption of the products of digestion occurs by means of
the millions of small projections or villi with which the intestinal
wall is lined. These villi contain numerous capillary blood vessels
and spaces known as lacteals. The former converge into the portal
vein, the latter into the lymphatic vessels and thence into the
thoracic ducts.

~The Absorption of Fat.~--The fats, as has been described, are split
into their two constituents, fatty acid and glycerol. The former is
dissolved by the bile to form soap; the latter is readily soluble in
water. These constituents thus dissolved pass through the walls and
recombine in the form of neutral fat droplets, probably during the
passage through the walls, since they appear in this form in the
cells. They pass into the thoracic duct and thence into the blood
stream.

~Absorption of Carbohydrates.~--The carbohydrates are chiefly absorbed
in the form of monosaccharids. This has been proved by introducing
cane sugar or lactose into the blood vessels and getting the greater
portion of it back unchanged by way of the urine. As the
monosaccharids are taken up by the capillaries lining the walls of the
small intestines, they are passed on to the portal vein and carried by
the portal blood into the liver, where they are stored temporarily as
glycogen, and given out to the blood in the form of glucose as needed.
After a meal rich in carbohydrates, the portal blood will be rich in
glucose, while the blood in general circulation contains about the
same amount as usual, about 0.1%.

~Absorption of Proteins.~--The absorption of the products of protein
digestion occurs through the capillary blood vessels and passes on to
the portal vein. The metabolism of protein is more complex than that
of any of the foodstuffs. It is probable that each living cell
contains enzymes which are capable of breaking down the body proteins
with the production of amino acids just as the proteins of the food
are broken down by enzymes of digestion, and according to Sherman "it
is not improbable that protein synthesis also may be brought about by
every living cell."

~The Absorption of Water.~--This does not occur in the stomach, as
was formerly believed, but in the small intestines.

~The Absorption of the Mineral Salts.~--This occurs in conjunction
with the other food material. Some of the mineral salts are much more
soluble than others and are more readily absorbed. The function of the
mineral salts in the body has already been described, and since they
form a part of every tissue and fluid in the body their absorption and
fate in metabolism must be studied with that of the other chemical
combinations.


ABSORPTION IN THE LARGE INTESTINES

The digestion of the food as it is passed into the last portion of the
alimentary canal has been largely completed. However, that part which
has escaped digestion in the small intestine is finished and absorbed
here. The important peristaltic waves occurring in this region are
antiperistaltic in character and have the property of churning the
food thoroughly and bringing a larger portion of it in contact with
the absorbing walls. The water which is left in the food mass together
with the products of the digestion of the foodstuffs is absorbed in
the first part of the large intestine, leaving the remainder more
solid. This residue is known as feces or fecal matter.

The diagram on page 179 shows the various processes through which the
foodstuffs pass after absorption.[56]

~Bacterial Action in the Alimentary Canal.~--The changes in the foods
so far mentioned have been chiefly the result of the activity of the
enzymes existing in the various digestive processes throughout the
body. But there are other changes which occur in the foods during
their sojourn in the digestive tract which are not accountable to
enzymic action, but which, in fact, modify to a certain degree the
changes wrought by the enzymes. These are the result of the activity
of certain specific bacteria which inhabit the entire digestive tract
of the individual from a few hours after birth until death. Some of
these have so adapted themselves to the existing conditions that,
unless present in overwhelming numbers, they are not only harmless,
but they actually assist in protecting the organism from the inroads
of more harmful species. Many experiments have been made to find
whether or not bacteria are essential to human nutrition, and the
results of these experiments prove that they are not. However, since
they are so firmly established in the body it is well to study the
various types and learn as much as possible of the products of their
activity and the influence which they exert in human nutrition.

                 Cells and Tissues
                   /    |    \
        Anabolism /     |     \ Catabolism
    Assimilation /      |      \ Dissimilation
                /       |       \
     Foodstuff <        |        > End Products
                \       |       /
                 \      |      /
                  \     |     /
                   \    |    /
                   Combustion

~Types of Bacteria.~--It would be impossible and unnecessary to
consider the action of all of the bacteria in the body in this text,
but it is necessary to consider those which are prominent in bringing
about decomposition of the foods in the digestive tract. Sherman holds
that there are three main types having this property: "(1) the
bacteria of fermentation, such, for example, as the lactic acid
bacteria; (2) the putrefactive bacteria, such as the anaërobic B.
aërogenes capsulatus; (3) bacteria of the B. coli type, showing the
character of both the fermentative and putrefactive organisms but
tending in general to antagonize the putrefactive anaërobes."[57]

~Fermentation in the Stomach.~--In the stomach, fermentation of the
carbohydrates with the production of organic acids, and at times
alcohol, occurs. The types of fermentation taking place in the stomach
are alcoholic, lactic, butyric, acetic, formic, oxalic, and cellulose.
The bacteria inhabiting the gastric organs are dependent upon air for
existence, while those in the intestines are not.

~Factors Influencing Excessive Fermentation.~--The factors influencing
excessive fermentation in the stomach are lack of "tone" and motility
in the organ, insufficient amount or absence of free hydrochloric acid
in the gastric secretion, dilatation of the stomach, and an excess of
carbohydrate foods in the diet. Of the latter, sucrose and glucose are
especially susceptible to the action of fermentative bacteria. Under
normal conditions, that is, in health, the conditions prevailing in
the stomach are very unfavorable to the development of bacteria of the
putrefactive type, the gastric juice exhibiting decided germicidal
properties. Then, too, the presence of air acts against their
development. Much of the so-called gastric fermentation does not occur
in the stomach but rather in the duodenum.

~Bacterial Action in the Intestines.~--In the lower part of the small
and in the large intestines, the bacteria of the anaërobic type
increase, conditions more favorable to their development existing
there than farther up in the intestinal tract. However, there are a
great many bacteria in the whole of the small intestine. Those
producing decomposition of the unabsorbed proteins are especially
prominent in the colon.

Herter[58] states that "the presence in the colon of immense numbers
of obligate micro-organisms of the B. coli type may be an important
defense of the organism in the sense that they hinder the development
of that putrefactive decomposition which, if prolonged, is so
injurious to the organism as a whole. We have in this adaptation the
most rational explanation of the meaning of the myriads of colon
bacilli that inhabit the large intestine. This view is not
inconsistent with the conception that under some conditions the colon
bacilli multiply to such an extent as to prove harmful through the
part they take in promoting fermentation and putrefaction."

~Effect of Bacterial Activity in the Body.~--In summarizing the
effects of bacterial action in the body it is found that with the
exception of oxalic acid, which is exceedingly injurious, and which,
according to Herter, results from the eating of large quantities of
meat and sugar, the products of fermentation are simply irritating in
character, while those resulting from putrefaction are distinctly
toxic. Among the substances deserving mention under this head we have
indol, skatol, cresol, and phenol. These substances are very soluble
and upon absorption combine with the sulphuric acid formed in the body
and are excreted by way of the kidneys where they appear in the urine
as "conjugated sulphates," the chief of which is indican. The amount
of indican in the urine is taken as a measure of the intensity of the
putrefaction taking place in the body.

~Metabolism.~--Under the term metabolism we understand the series of
processes through the foodstuffs and carried (a) in the conservation
of the tissues of the body and (b) in the maintenance of body
temperature and physical work (Taylor). The processes concerned in
metabolism are chiefly those of building up, "anabolism," and breaking
down, "catabolism." In the processes of anabolism the products
absorbed are built into the tissues and cells of the body. In
catabolism, the worn particles from the cells, and the dead cells no
longer useful are broken up and thrown out of the body. According to
Taylor, "side by side with these processes are the reactions of
combustion, whereby the temperature necessary for the life of the
cells is maintained, and the energy needed for external work
furnished."

~Behavior of Carbohydrates in Metabolism.~--As Sherman[59] has said:
"At least two kinds of enzymes are believed to be involved in the
combustion of glucose in the tissue cells, (1) cleavage enzymes, which
split the molecule into fragments more easily oxidized, and (2)
oxidizing enzymes or oxidases which stimulate the oxidation of the
cleavage products. Both kinds of enzymes are widely distributed
through the body and are believed to be normal constituents of all
active cells."

~Production of Energy.~--It has been proved that the energy for
external and internal work is produced largely from the glucose
brought by the blood and oxidized in the muscles.

When a surplus amount of carbohydrate food is eaten, over and above
the immediate needs of the body for fuel, it is stored in the liver
and muscles as glycogen, which can be readily reconverted into
glucose. When the supply of carbohydrate food is greatly in excess of
the body's needs, that is when the liver and muscles cease to store
glycogen, it is built up into adipose tissue and furnishes a readily
available source of emergency fuel.

~Fate of the Carbohydrates.~--After their oxidation the end products
of carbohydrates, that is, the substances which are no longer
available for use in the body, leave it in the form of carbon dioxide
and water by way of the kidneys (urine), the skin, the lungs, and the
intestines.

~Fate of the Fats.~--The fats upon absorption are taken up by the
lymph vessels instead of the capillaries and enter the blood with the
lymph. According to various investigators, the fat which causes the
turbidity of the blood plasma at the height of absorption will, as a
rule, disappear after a few hours, part of it being burned as fuel,
producing energy for the internal and external work of the body, and
at least a part of the fats eaten being rebuilt into body fat. The
end-products of fat metabolism, like those of the carbohydrates,
consist of carbon dioxide and water, and leave the body by the same
excretory channels.

When the normal oxidation of the fatty acids is interfered with or is
overtaxed, a different reaction from that which usually occurs may
take place, and this results in an excretion of acetone in the urine
(see Chapter on Diabetes).

~Protein metabolism~ is certainly more complex than that of either of
the other active organic food groups. The amino acids which are the
products of protein digestion are taken up by the capillary blood
vessels in the intestinal walls and are passed by them into the portal
vein, soon to become available for the needs of the body.

~Fate of the Proteins.~--After utilization in the body, the proteins,
like the other foods, leave certain waste products which indicate to a
greater or lesser extent the completeness with which the organism has
made use of the food materials. The end-products of protein metabolism
are: ~urea~, ~ammonium salts~, ~purin bodies~, and ~creatinin~. These
products leave the body chiefly in the urine. The chief end-product in
man is urea. This substance represents from 82-88% of the total
nitrogen excreted by the kidneys. However, the less highly oxidized
products represent the incomplete products of protein metabolism and
thus indicate the changes through which these products must pass
before being changed into urea. If for any reason there is an
impairment of the liver through which they must pass and where the
change into urea is accomplished, there will be a rise of ammonia and
a corresponding decrease in the output of urea in the urine. Thus,
ammonia is formed at the expense of the urea. This occurs in fevers,
diabetes, and certain structural diseases of the liver. According to
Sherman:[60] "Normally about 2 to 6% of the total nitrogen eliminated
is in the form of ammonium salts, the amount depending largely upon
the relation between the acid-forming and base-forming elements in the
food."

~Acid-forming and Base-forming Foods.~--Mendel[61] states: "There are
foods which act as potential acids and others which function as bases
in the organism. When burned up either in the laboratory or in the
body cells, they have a preponderance of acid or base, as the case may
be, in their ash." In this respect potatoes, apples, raisins, and
cantaloupes, for example, are base-forming foods which depress the
output of ammonia and increase the solubility of uric acid in the
urine, whereas meal, cereals, and prunes (the latter with their
content of benzoic acid) furnish acids in predominance.

~Purin Bases.~--These compounds are formed in the body as cleavage
products of nucleoproteins or taken into the body in food. The chief
of these products are ~adenin~, ~guanin~, ~hypoxanthin~, ~xanthin~,
and ~uric acid~. The latter is the most highly oxidized of all the
purin bases and is the form in which they are chiefly eliminated in
the urine.

~Formation of Uric Acid.~--The formation of uric acid can in a measure
be controlled by attention to the diet, eliminating those foods known
to be purin-bearing. Normally from 1 to 3% of the nitrogen eliminated
will be in the form of uric acid. The normal human being oxidizes
about half of the purins eaten and excretes about half, mainly in the
form of uric acid. According to Mendel, the formation of uric acid
takes place throughout the body, and its partial destruction is
accomplished by the kidneys, muscles, and liver. The formation of
purins in the body and their elimination in the form of uric acid is
especially significant in certain pathological conditions, gout, for
example, in which the body has difficulty in eliminating these
compounds.

The purin bodies are both endogenous and exogenous--that is, they may
be brought into the body in food as such, or they may be formed as a
result of the metabolism of the body tissues. For this reason the
damage wrought by these substances may to a certain extent be
controlled by eliminating the purin-bearing foods from the diet.
Flesh-foods are high in purins, especially the highly nucleated
glandular organs, liver, thymus (sweetbreads), etc., kidney, beef,
mutton, veal, pork, chicken, turkey, goose, sardines, anchovies, all
kinds of fish except cod. Among the vegetable foods asparagus, beans,
peas, and spinach are highest in purins. Boiling extracts much of the
purins from food. Meat especially should be prepared by this method,
if used in the diet of individuals suffering from gout. Eggs and milk
are purin free, and may be used freely. Certain substances increase
the difficulty of eliminating uric acid. Alcoholic beverages for
example are especially deleterious.

~Creatinin.~--This end-product of protein metabolism is, like uric
acid, endogenous and exogenous. It is one of the normal constituents
of the urine. The quantity is fairly constant for the individual,
averaging about 0.02 gram per kilogram of body weight per day.

~Mineral Metabolism.~--A study of the organic foodstuffs reveals the
fact that many of the mineral salts concerned in nutrition enter the
body in organic combination with those constituents. Certain of the
mineral salts, however, enter, exist in and leave the body in the
same organic form in which they occur in the food materials. This is
true of chlorine, which for the most part, functions in and leaves the
body in the form of chlorides (chiefly sodium chloride). A small part
of the chlorine is used in the production of the hydrochloric acid of
the gastric juice.

Sulphur and iron, both enter the body as essential constituents of
proteins, and their metabolism occurs with that of these foodstuffs;
the sulphur being converted largely into sulphuric acid must be
neutralized at once, and it leaves the body by way of the urine as
inorganic sulphates. Part of the sulphates are excreted as ethereal
(conjugated) sulphates; the amount excreted in this form depending
largely upon the extent of purification in the intestinal tract.[62]

~Phosphorus.~--This mineral salt is found to be present as an
essential constituent of certain proteins, fats and carbohydrates. It
also enters the body in the form of inorganic phosphates. During the
digestion and metabolism of the organic foodstuffs the phosphoric acid
radical is split off and eventually nearly all of the phosphorus
leaves the body in inorganic form (inorganic phosphates).

~Calcium.~--Being the chief constituent of the bones, large quantities
of calcium salts are stored in the skeleton of the child both before
and after birth. The functions of calcium have already been discussed.
That part not stored, which has finished its work in the body is
excreted through the intestinal wall and leaves the body by way of the
feces, only a small part of the calcium concerned in metabolism being
excreted in the urine.

~The Process of Osmosis in the Body.~--The influence exerted upon the
process of osmosis in the body is one of the most important parts
played by the mineral salts in metabolism. The fact that these
chemical substances are indispensable to the metabolic processes makes
it necessary for the nurse to know where they can be found in food and
how best to use them.

~Metabolism of Body Tissues.~--The constant breaking down and building
up of the tissues of the body and the evolution of heat as a
by-product of the energy expended may be summed up in the term
"metabolism." The metabolism of the body is normally supported by the
food ingested. However, it is a known fact that were no food eaten the
processes would continue just the same, the difference only being the
use of the body structure instead of food materials. According to
Sherman, the chemical changes and energy transformations are of course
inseparable. It has become customary to speak of the metabolism of
matter and the metabolism of energy, and to regard the extent of the
metabolism of any material substance as measured by the amount of its
end products eliminated, and the extent of the energy metabolism as
measured by the amount of heat or of heat and external muscular work
which the body gives off.

       *       *       *       *       *

In summarizing the important factors in the utilization of food by the
body several distinct points are made evident:

1. The composition of the body, and the composition of food, are
practically the same.

2. Food must make good the losses resulting from metabolic processes
and physical activity.

3. Utilization of food by the body necessitates:

(a) Transformation through a series of processes:

    (1) Digestion.

    (2) Absorption.

    (3) Metabolism.

    (4) Elimination.

(b) Factors influencing use of food:

    (1) Stimulation of secretory cells through appetite
        juice (stomach); hormone secretin
        (intestines).

    (2) Factors retarding use of food:--Fear,
        worry, anger, nervous excitement, fatty
        foods and alkaline carbonates (bacterial action
        causing fermentation and putrefaction).


PROBLEMS

(a) Outline the processes through which a slice of bread and butter
must pass, from the time it is eaten until it reaches the blood
stream.

(b) Outline with a diagram the manner in which the foodstuffs are
utilized in the body.

(c) Show in the form of a table the effect of the enzymes on proteins,
on fats, on carbohydrates.


FOOTNOTES:

[51] "Chemistry of Food and Nutrition," by Henry Sherman.

[52] "Chemistry of Food and Nutrition," by Sherman.

[53] "Chemistry of Food and Nutrition," by Henry Sherman.

[54] Compiled from "Textbook of Physiology," by Howell, and "Chemistry
of Food and Nutrition," by Sherman.

[55] "Chemistry of Food and Nutrition," by Henry Sherman.

[56] This scheme applies to the protein, fat and carbohydrates with
quantitative variations only. Courtesy of Dr. A. R. Taylor, Leland
Stanford University.

[57] "Chemistry of Food and Nutrition," by Sherman.

[58] Herter's "Bacterial Infections of the Digestive Tract" (1907).

[59] "Chemistry of Food and Nutrition," by Sherman.

[60] "Chemistry of Food and Nutrition," by Sherman.

[61] "Newer Points of View Regarding the Part Played by Different
Foodstuffs in Nutrition," by Lafayette Mendel, Ph.D. Read at the
Sixty-fifth Annual Meeting of the American Medical Association, June,
1914.

[62] See "Bacterial Action in the Body," p. 181.




SECTION IV

DIETO-THERAPY




CHAPTER VIII

PREGNANCY AND LACTATION


There are many traditions in regard to the food requirements of the
prospective mother. Many of these have been proved fallacies. As a
matter of fact it is the woman more than the developing child who is
likely to suffer if the diet is insufficient or badly balanced.

~Factors Affecting Diet during Pregnancy.~--In formulating a dietary
for the pregnant woman, then, not only must the needs of the child be
considered but those of the mother also, since the developing embryo
draws from the body of the woman materials necessary for its growth,
and if these needs are not covered by an increase in the diet, her
body and that of the child also will show evidences of lack of
nourishment.

~Phosphorus and Calcium Requirements.~--If, for example, the mother's
diet is lacking in those materials which produce growth, or is
deficient in those mineral salts, such as those of phosphorus and
calcium, which are requisite and necessary for the growth of bones in
the infant, the mother's bones and teeth will show this loss and in
all probability the baby will sooner or later also show a like
deficiency. However, it must be remembered that the pregnant woman is
under a strain, both physical and mental. She must not be encouraged
to eat beyond her needs or the digestion will be disturbed.

~Nutritional Disturbances in Early Months.~--The nutritional
disturbance manifested by nausea and vomiting in the morning is due,
not to the stomach or any disturbance therein, but to the fact that a
mild form of poisoning occurs, resulting from the substances produced
through the formation of the placenta reaching the general circulation
on account of the incomplete establishment of the connection between
the embryo and the mother. As soon as this connection is complete and
fetal circulation is established this "morning sickness" disappears.

~Food Requirements of Prospective Mother.~--The food requirements of
the prospective mother are not materially affected during the first
four months of gestation, and even after this, when the infant is
developing rapidly, and up to the date of its birth, the mother's
requirements are only increased about 20%. The amount of food
necessary to cover the body needs, for maintenance and energy of a
woman living a sedentary or moderately active life, plus 20% for
building materials for the growing child, will be adequate for the
pregnant woman. Thus, if her needs are ordinarily from 2,000 to 2,400
calories per day, after the fourth month they will probably be
increased to 2,400 or 2,800 calories a day and will rarely ever be
more than 3,000 calories a day.

~Dietetic Treatment of Normal Pregnancy.~--The peculiar conditions
surrounding the woman at this particular time must be taken into
consideration in arranging her diet. The building foods which are
necessary for the developing child must be given in the simplest form,
milk and eggs being used liberally and meat sparingly to obviate any
unnecessary tax being placed upon the kidneys. The use of fruit and
green vegetables to supplement the milk and eggs is urged. It has been
found advisable at such times to give small meals frequently rather
than the regular meal three times a day. The feeling of "fullness"
which often occurs during the last two or three months of gestation
makes it more comfortable for the pregnant woman to eat less at a time
and oftener. If, for example, she be given a glass of rich milk or a
nutrient beverage, either of enforced malted milk, albumenized orange
juice, buttermilk, zoolak, or koumiss, at about eleven o'clock in the
morning and again about four o'clock in the afternoon, she will have
taken sufficient nourishment to meet the new requirements without
taxing her digestion or imposing extra work upon the kidneys.

~Abnormal Symptoms.~--The chief point to keep in mind is any abnormal
symptom which may develop. The chief of these is albumen in the urine.
The urine must be examined frequently and measures taken immediately
to overcome albuminuria should it occur. It is wise, as has already
been stated, to restrict the meat in the diet, and in cases where
albumen is found in the urine even when the meats are restricted, it
may be necessary to place the patient upon a milk diet for a time
until the urine clears up.

~Supplementary Feeding.~--Cereals, especially the whole cereals, must
be used liberally. Gruels made with milk are often found valuable
additions to the dietary. The prospective mother must be urged to take
a regular amount of gentle exercise, not to become over-tired, or
excited, to eat sparingly at night, and to drink plenty of water. She
must avoid becoming constipated by eating plenty of green vegetables
and fruit.

~Sample Diet Sheets.~--The following dietary is suggested: Breakfast
should consist of thoroughly cooked cereals, wheatena, cream of wheat,
malt breakfast food, cracked wheat, rolled or cracked oats, served
with cream or sugar or both, whole wheat bread, muffins, or biscuits,
with butter, raw or stewed fruit, coffee, tea or cocoa with milk.
Luncheon may consist of milk or vegetable soups, eggs in any form,
boiled potatoes, sweet potatoes, string beans, greens, or any green
vegetables, simple desserts such as custards, rice or tapioca
puddings, bread pudding, etc., milk, tea, cocoa, buttermilk, zoolak or
koumiss as beverages. For dinner, if albuminuria is not present, a
small piece of meat may be taken, together with green vegetables,
rice, potatoes, simple salads, and a simple dessert, milk or coffee
with milk as a beverage.

~Selection of Food.~--The following foods may be used to formulate the
diet sheet: Wheat, oat, or corn cereals, rice, tapioca, made into
simple puddings or served as breakfast foods; fruits, oranges, prunes,
apples, raisins, dates, figs, or grapefruit, stewed or raw. The fruit
juices may be used instead of the whole fruit if the latter disagrees.
Vegetables: peas (green or dried), beans (string beans or dried
beans), spinach, greens (turnip, mustard, or beet), cabbage, onions,
celery, lettuce, served as vegetables or in soups, potatoes. Meat:
lightly broiled beefsteak or stewed or boiled meat or chicken served
not more than once a day or three times a week. Eggs, prepared in
different ways. Cheese dishes. Breakfast bacon or ham in moderate
quantities, butter, olive oil (or other salad oils) in moderation,
whole wheat, graham or bran bread, Boston brown bread and crackers,
milk, cocoa, chocolate, buttermilk, malted milk, koumiss, or zoolak;
coffee and tea in moderation.

The diet, as has already been stated, may be supplemented by nutrient
beverages or milk gruels.


DIET IN LACTATION

The diet of the nursing mother, as has been explained in a previous
chapter, must not only cover her own requirements but must likewise be
adequate to furnish the extra requirements imposed by the nursing
infant.

~Food Requirements of Nursing Infant.~--When the baby is a month old
he should be growing rapidly, and his food requirements at this period
and until he is about three months old will be approximately fifty
calories per pound of body weight in the twenty-four hours. As he
grows older his requirements grow gradually less in proportion to his
weight. This is because the rate of growth is less, so that for the
next three months the requirements are from 43 to 40 calories per
pound of body weight per day, and 35 calories per pound during the
last three months, or by the end of the first year of life.

It has been estimated, as before stated, that the average infant will
take 2-1/3 to 2-1/2 ounces of mother's milk per day[63] to each pound
of body weight and that every ounce of mother's milk will yield on an
average 20 calories. Hence a month-old baby weighing ten pounds will
be taking about 23 ounces a day, yielding 460 calories. Scientists
have estimated that for every calorie produced by the milk two extra
calories must be provided by food, so that for the baby requiring 460
calories per day, to cover his requirements the mother will be obliged
to consume extra food to yield 920 calories, or the regular amount to
meet her normal requirements plus the extra food to make sufficient
food for the baby.

~Diet of Nursing Mother.~--The diet of the nursing mother need not be
different from that to which she is accustomed. She should be warned
against overwork or over-fatigue, nervous excitement and worry, since
these factors affect the digestion of the nursing baby. She must be
careful not to eat indigestible foods or foods which disagree with
her, as such things will undoubtedly affect the digestion of the
infant. When an article of food does cause digestional disturbances in
the baby, it should be carefully omitted from the mother's diet.

~Factors Retarding and Stimulating Milk Secretion.~--Constipation in
the mother reacts quickly and unfavorably upon the secretion of milk.
The same has proved to be the case when she becomes excited, nervous,
worried, or over-tired.

The average diet for the normal woman is safe for the nursing mother.
If her supply of milk is deficient, it may be at times increased or
stimulated by the drinking of a glass of milk between meals or by
taking a cup of hot cereal milk gruel. It was formerly believed that
beer, ale, or stout acted directly upon the mammary glands,
stimulating the secretion of milk, but there is little proof of this
and the drinking of alcoholic beverages need not be encouraged on this
account, since often more nourishing beverages fulfill the purpose
more efficiently and without bad results.


SUMMARY

~Gastric Disturbances.~--The nausea and vomiting so often a part of
early pregnancy is not believed to be the result of a disordered
stomach but primarily a mild form of poisoning resulting from the
incomplete establishment of the fetal circulation.

~Adjusting the Diet.~--The adjustment of the diet to cover the needs
of the prospective mother and those of the developing child is
essential. The amount of food taken by the mother is not materially
changed during the first three months of gestation. An average normal
diet is all that is necessary. After this time a twenty per cent.
increase in the woman's diet will furnish adequate means both for her
maintenance and for the growth and development of the child.

~Type of Food.~--The kind of food which is necessary for the pregnant
woman to take during this period is very similar to that taken
ordinarily. It is necessary to furnish food materials rich in calcium
and phosphorus, with an adequate supply of proteins in their simplest
form in order to meet the requirement of the growing organism. Milk
and eggs furnish the most efficient foods in this respect and the
prospective mother should see that they form the chief items of her
daily dietary. Milk furnishes calcium in its most available form for
the developing skeleton of the growing infant, hence it is necessary
to provide the mother with food to replace the mineral which is
withdrawn from her body.

~Meat in the Diet.~--Meat should be eaten sparingly by the prospective
mother, as it imposes needless work upon the already taxed kidneys
and, if eaten in excess, will give rise to dangerous complications.
Milk and eggs will provide ample protein for all purposes.

~Albumen in the Urine.~--Albuminuria is one of the most frequent
complications in pregnant women. It should be combated and controlled
as soon as possible. The allowance of meat should be cut down or
entirely eliminated from the diet until the urine clears up. When
albuminuria is persistent in spite of efforts to overcome it, the
patient must be placed upon a strict milk diet as used in acute
nephritis, to prevent dangerous complications arising.


LACTATION

~Diet of Mother.~--Her dietary need not differ materially from that to
which she is accustomed. She must avoid indigestible foods or any
article which has been proved to disagree with either the infant or
herself.

~Factors Regarding Secretion of Milk.~--Constipation, worry, nervous
excitement, and over-fatigue all have an unfavorable effect upon the
secretion of milk and must therefore be avoided by the nursing mother.

~The Bowels.~--Constipation of the mother reacts quickly and
unfavorably upon the health and comfort of the baby, hence it should
be avoided by eating coarse breads, green vegetables, and fruits, when
they do not disagree with the baby, by drinking plenty of water and
taking a certain amount of outdoor exercise to keep her own health in
good condition.

~Stimulating the Milk Production.~--When the milk supply is deficient
it will be advisable for the mother to drink a glass of milk or a bowl
of cereal milk gruel between meals. Alcoholic beverages are not
necessary to insure an adequate secretion of milk. The milk or milk
gruels answer the purpose more efficiently and without bad results.

~Energy Requirements of Infant.~--The average baby requires fifty
calories per day per pound of body weight to cover his energy growth
and development needs for the first three months of life, after which
the rate of growth is less and his requirements decrease from
forty-three to forty, then to thirty-five calories per day per pound
by the end of his first year.

~Amount of Milk Needed for Infant.~--Approximately two and one-third
ounces to each pound of body weight per day covers the needs of the
average baby.

~Fuel Value of Mother's Milk.~--Each ounce of milk yields twenty
calories.

~The Making of Milk.~--It has been estimated that for every calorie
yielded by milk, two extra calories must be provided by food.


PROBLEMS

(a) Formulate a dietary for a pregnant woman, allowing for a twenty
per cent. increase over her normal requirements.

(b) Show how the diet may be made to cover the need for additional
iron, calcium and phosphorus.

(c) Formulate a diet for a nursing mother with an infant two months
old and weighing twelve pounds.


FOOTNOTE:

[63] "Feeding the Family," p. 93, by Mary Swartz Rose.




CHAPTER IX

INFANT FEEDING


In taking up this part of our study on nutrition, there are several
points to be kept in mind by the nurse: (1) that it will be difficult,
if not impossible, to understand the metabolic changes taking place in
abnormal conditions unless those occurring in the normal human body
are understood; (2) that certain diseases are due directly to errors
in diet; (3) that in other diseases, diet plays the chief part both in
the bringing about and in the relieving of the conditions; (4) whereas
there are certain other diseases not affected by diet, save in so far
as well or poorly selected and prepared food always affects the
individual, whether normal or abnormal, and that in the latter
conditions the organism is more susceptible to bad influences.

This being the case it behooves the nurse to examine herself to find
whether or not she understands the fundamental principles underlying
the nutrition of the human body, that she may efficiently deal with
the changes which occur more or less when the body is attacked by
disease.

We include normal infant feeding in this section, because in no other
age is it quite so necessary for care to be observed in formulating
and carrying out a diet. Errors during this period may only appear to
exert a local influence, causing disturbance which may readily be
relieved, but the danger is in laying too little stress upon these
disturbances, forgetting that the delicate organism of a child may be
permanently injured by a constant disregard of nature's mandates. In
the words of the old adage, the pitcher may go once too often to the
well, and an injured digestive apparatus is even more difficult to
mend than the proverbial pitcher.

In this section, then, the metabolic changes due to pathological
conditions and the dietetic treatment thereof will be discussed.

~Age and Weight.~--As has already been stated, there are certain
points to be kept in mind in attempting to provide an adequate diet
for the human machine; _First_, the _age_ and _weight_. The gain
during infancy should be steady--an allowance of 40 calories per pound
of body weight to cover the energy requirements and 4 protein calories
per pound to cover the nitrogen needs. During the second and third
years the energy requirements will be covered by 30 to 40 calories per
pound and the nitrogen needs by 3 to 4 protein calories per pound.
From the fifth to the eighth year the nitrogen needs continue to be
covered by 3 to 4 protein calories per pound and the energy
requirements by 35 to 37 calories per pound during the fifth year; 32
to 34 calories per pound during the seventh year. After the body has
reached its full development its requirements will be met if
sufficient protein is provided to cover its maintenance needs and if
the energy calories are regulated according to the amount of exercise
taken, keeping in mind that the energy requirements of a man at rest
(sitting) will be about 2,000 calories per day and that exercise,
especially that taken in the open air, raises the energy needs of the
body.

~Daily Gain.~--In estimating the relative daily gain in body weight of
children of different ages, Mendel[64] gives the following table:

TABLE

  In the first month, about          1.00 per cent
  At the middle of the first year    0.30 per cent
  At the end of the first year       0.15 per cent
  At fifth year                      0.03 per cent
  Maximum in later years for boys    0.07 per cent
  Maximum in later years for girls   0.04 per cent

~Retention of Nitrogen in Infancy.~--When the baby is gaining in
weight and strength there is a retention of both nitrogen and salts,
and when the baby is not gaining there may be a loss of both of these
bodies; when one is retained in the body the other is apt to be
retained.[65]


NORMAL INFANT FEEDING

Much has been written in the past few years on the care and feeding of
infants and children. This is well, since statistics show an alarming
increase in the rate of infant mortality during the early years of
life, and anything which can be done to check this lamentable and
often avoidable waste of valuable life should be resorted to with care
and attention.

~Food for Infants.~--The natural food of all young mammals is the milk
of their own mother. The rate of growth and development differs in
every species; the calf, for example, doubles birth weight much more
quickly than does the baby of the same age. However, the milk of the
cow, which meets the needs of the calf perfectly, falls short of
meeting the requirements of the infant, whose rate of growth is not
nearly so rapid. For this reason if for no other, it would be
advisable to give the baby its natural food rather than to attempt a
substitute which is, at best, a poor one.

~Weight.~--The average infant weighs from six to seven pounds at
birth. This weight should be doubled in the first five or six months
of life and tripled by the end of the first year. The most important
business, then, in the life of the child during the early years is
growth and development. To achieve this properly the baby's habits
must be adjusted to his needs.

~Regularity in Feeding.~--He must have the proper food and enough of
it, and have it given at regular intervals, "by the clock," for
guesswork is fatal in infant feeding. He must be given water between
meals. Babies often cry from thirst when they are thought to be doing
so from hunger or temper, or both. The healthy baby sleeps about
twenty-two hours out of twenty-four during the early months, and even
during the latter six months of the first year more time is spent in
sleeping than in waking.

~The Bowels.~--The bowels should move several times a day, the stools
being smooth and of a yellowish color, of the consistency of pea soup.
After the first month, twice a day is about the normal number of
stools for the healthy baby. The infant should be placed upon a vessel
held in the lap of the nurse at regular times, preferably right before
the morning bath, and in the evening. In this way regularity in
evacuating the bowels is obtained, and a habit formed which will prove
valuable through life.

~The Bath.~--The daily bath is likewise necessary for the health and
comfort of all babies; so, too, are fresh air and sunshine.

As has already been stated, breast milk is much better for babies than
cow's milk or any artificial food. There is something in the mother's
milk which gives strength and resistance to the baby which is
absolutely lacking in any other food no matter how carefully it is
selected and prepared, and for this reason young mothers must be
prevailed upon to nurse their babies whenever it is possible for them
to do so. When circumstances, such as having to be away all day at
work, make it impossible for a mother to nurse her baby at regular
intervals, she can be taught how necessary are two or three breast
feedings a day to the future welfare of her child. When social reasons
or lack of desire on the part of the mother make her unwilling to
nurse her baby, it is the part of the nurse to lay the case before her
and let her judge whether or not she is willing to accept the
responsibility of bringing into the world a life for which she is
unwilling to provide weapons with which to fight the good fight.

~Habits of Mother.~--The mother must be taught how to efficiently
nurse her baby; she must keep in mind that upon her good health and
temperate habits depend the health and comfort of her baby. It
devolves upon her to provide food efficient in quality and quantity.
To do this, her own diet must be simple and wholesome. The nursing
mother must remember that she has to provide, not only for her own
maintenance and energy requirements, but also for the infant whose
fuel requirements are ever demanding more food to provide for its
rapid growth.

~Food and Its Relation to Milk.~--It is believed that two calories of
food extra are necessary to produce one calorie of milk, and since a
month-old baby requires 2-1/3 ounces of mother's milk to every pound
of his body weight, and one ounce of mother's milk will yield 20
calories, it is clearly seen that the mother will have to increase her
diet to cover the requirements of the baby. For example, if the baby
weighed 12 pounds, he would require 28 ounces of milk in 24 hours, or
560 calories. Thus if it requires two calories of extra food to make
one calorie of milk, the mother's diet would have to provide 1,120
calories extra, or about as much food as would fulfill the needs of a
laboring man, 3,000 to 3,500 calories, even if she were doing
practically no actual work; while if she were actively employed and
doing a certain amount of physical labor, her rations would have to
approximate those of a man doing heavy muscular work (about 3,500 to
4,000 calories per day).[66]

~Breast Milk versus Cow's Milk.~--Consensus of opinion shows that
breast-fed infants require less energy than the ones who must be
nourished artificially. This is probably due largely to the fact that
the constituents of human milk are in a more available form than those
in cow's milk, the former requiring a lesser expenditure of energy on
the part of the organism to become available than the latter. Very
active babies, ones who kick and throw themselves about or cry
violently, have a greater energy requirement than the more placid baby
who sleeps more and is more quiet in movement and who cries less when
awake. Breast-fed babies are generally more quiet than their less
fortunate artificially fed brothers. It has been demonstrated that the
artificially fed baby has a much harder fight for existence than the
baby who receives his natural food; hence the necessity of using every
available means to make the food digestible, and to lessen the danger
arising from the additional work put upon the entire apparatus. Cow's
milk contains practically the same chemical elements as are found in
human milk, but these elements are combined in a slightly different
manner, and are not so easily handled by the immature organs. The
proteins of milk consist of casein, which is insoluble, and albumen,
which is soluble. According to Van Slyke the proportion of insoluble
to soluble protein in cow's milk is 3.6:1, while in human milk the
proportion is only 1:1. The ash constituents in cow's milk are in
excess of the needs of the infant organism, but since a great part of
these salts is in an inorganic form they are not retained to the same
extent as those contained in human milk, which are in an organic form.

~Rules and Regulations.~--It is not possible to lay down hard and fast
laws to cover the subject of infant feeding. The food must be adapted
to the individual needs of the baby in question. The nurse must see
that the milk is obtained from a responsible dealer, certified milk
being of course the safest. The bottles of milk should be wiped off
carefully and placed directly on the ice as soon as they are received.
The milk generally used in infant feeding has a fat content of 4%.
That having a higher percentage of fat is technically cream. The
following table showing the fat, sugar, and protein composition of
whole milk, cream, skimmed milk, and whey was arranged by Morse and
Talbot:[67]

TABLE

  ==========================+============+============+============
                            |   _Fat_    |_Milk Sugar_| _Protein_
  --------------------------+------------+------------+------------
  Whole milk                |    4.00    |    4.50    |    3.50
   7% cream                 |    7.00    |    4.45    |    3.40
  10% cream                 |   10.00    |    4.40    |    2.25
  16% cream                 |   16.00    |    4.20    |    3.05
  32% cream                 |   32.00    |    3.40    |    2.50
  Skimmed milk              |    1.00    |    5.00    |    3.55
  Separated milk (fat-free) |    0.25    |    5.00    |    3.65
  Whey                      |    0.25    |    5.00    |    0.90
  ==========================+============+============+============

Seven per cent. (7%) cream is obtained from the upper 16 ounces of a
quart bottle of milk which has been allowed to stand undisturbed for
six hours. The upper third of the bottle contains 10% fat, while the
whole fat layer from the quart bottle, regardless of the number of
ounces, contains about 16% of fat.

~Methods of Artificial Feeding.~--The use of whole milk, top milk, or
skimmed milk, diluted with water, and either milk sugar, malt sugar,
or sucrose (cane sugar) added, is the method of feeding most commonly
used, and upon it are based the formulas universally advised by infant
specialists. There are cases in which simple dilution is not
advisable. In premature or very young infants, for example, the whey
mixtures have been found to give the best results. In toxic diarrheas,
where the putrefactive bacteria make the use of all but the minimum
amount of protein inadvisable, the above method is contraindicated, as
it is likewise in cases where vomiting of casein curd is a prominent
feature.[68]

~The Use of Alkalies.~--There are many cases in which the physician
deems it advisable to add an alkali to the milk mixture. The one
generally selected is limewater. However, sodium citrate and sodium
bicarbonate are also used. The reasons for adding alkalies to the milk
mixtures are: (1) to check the coagulation of the casein, (2) to
hasten the emptying of the stomach, or (3) to chemically change the
formation of the curd. In certain cases it is only necessary to delay
the coagulation of the casein in the stomach, in which case a certain
amount of limewater is used. Its action is to swell the protein of the
milk and in this way effect the precipitation of the casein. In other
cases it is found advisable to prevent the formation of curd and
hasten its departure from the stomach. Cannon[69] claims that milk
before it coagulates leaves the stomach quickly like water in gushes.
Hence, if an alkali like limewater, bicarbonate or citrate of soda is
added to the milk this coagulation will be checked and the digestion
be facilitated.

~Amount and Type of Alkali Used.~--The amount of alkali[70] necessary
to bring about any change in the general effect of the formula must be
determined by the amount of milk and cream in the mixture, since these
constituents alone determine the acid content. However, it is
impossible to judge exactly the amount of alkali to add, but an
approximate estimate is made from the work done by the various
investigators. It has been estimated that from 25 to 50% of limewater
must be added to milk to change it to any marked degree. In using
bicarbonate of soda, a much less quantity brings about the desired
result, 1-1/2 grains of bicarbonate of soda being equal to one ounce
of limewater. The action of these two alkalies is different. The soda
acting upon the milk causes the curds to be more porous, and therefore
more easily acted upon in digestion.

Sodium citrate likewise tends to prevent the formation of tough
curds. It is added in amounts of 1 to 2 grains to each ounce of milk
or cream in the mixture whenever it is found necessary to use it at
all.

The addition of any alkali to the formula is resorted to if the
symptoms indicate the need for it, but the type and quantity is
entirely within the province of the physician, not the nurse.

~The Addition of Sugar.~--~Lactose~ is the form in which the
carbohydrates are found in milk, and it has been a general rule to
employ this sugar in making up the sugar content of a formula, using
from 6 to 7% of the mixture in this form to cover the necessary energy
requirements of the infant. Other sugars are used, however; and of
late years malt sugar has been widely employed for this purpose. The
form now generally accepted is known as ~dextri-maltose~, which is a
combination of dextrin and maltose, both of which are readily acted
upon by the sugar-splitting enzymes of the digestive juices. In
digestion, lactose or milk sugar is split to dextrose and galactose
and utilized in the body, both as a source of energy and as a food for
the lactic acid bacteria which are active in the small intestine.

~Malted Foods.~--The addition of malted foods or malt sugar to the
food of infants tends to bring about a more rapid gain, both in energy
and in body weight, than is generally the case where other sugars are
used. This sugar is used as a substitute for milk sugar in many
formulas, especially in those cases in which the casein of cow's milk
needs to be made more digestible in form. Malt sugar is indicated in
the following conditions:[71] (1) in severe atrophies, (2) in cases of
fat indigestion before the atrophic stage is reached, (3) in cases
where there is slight curd indigestion, indicated by some vomiting
and slow gain in weight, (4) in cases where excessive intestinal
fermentation is manifested by gas and colic.

~Malt sugar~ (dextri-maltose) is contraindicated to a slight degree in
cases "of simple acute diarrhea where lactose, by supplying
fermentative media, more easily restores the normal bacterial
balance."

~Diluents.~--Barley and oatmeal water are used as diluents to the
amount of one-fourth or more of the mixture. Oatmeal water or jelly is
used more during the winter months than in the hot summer months. As
the fat content of the oatmeal gives it a more laxative effect, it is
undesirable to use it at the season in which the summer diarrheas are
prevalent. Barley water has something of a colloidal action upon the
casein, causing the curds to be finer and less tough in character.
Both barley and oatmeal water are used in place of plain water for
babies when this colloidal effect upon the curd of the milk is
desired, also where the weight of the infant shows a disposition to
remain stationary, especially where there are no other symptoms to
account for the lack of gain.

Whey is used with babies who cannot digest the insoluble protein of
cow's milk. This is often the case in premature babies and is
manifested by a persistent vomiting of curd. The energy requirements
are obtained by the addition of cream and lactose to the whey.

~Buttermilk Mixtures and "Eiweissmilch."~--It is often found desirable
to use some other form of milk than whole, top, or even skimmed milk,
and for this purpose lactic acid, milk and the albumen or
"Eiweissmilch" are substituted. In the buttermilk mixtures the
precipitation of the casein is brought about by lactic acid bacilli
(Bulgarian culture). This prevents the coagulation of the casein into
tough curds. Lactose buttermilk or lactic acid milk is used in the
feeding of infants who have persistent green stools, and in cases of
acute toxic diarrhea brought about through the action of gas bacillus.

Buttermilk is more difficult to administer to babies than formulas
made from plain milk by reason of its flavor. However, the results are
remarkable in the above-mentioned conditions.

~"Eiweissmilch"~ is used in atrophic cases where there are bad green
stools.

~"Homogenized Milk."~--Dr. Ladd of the Children's Hospital in Boston
has presented many cases of infants who showed an intolerance for
butter fat. These cases he has treated with formulas containing
foreign fat, usually olive oil. This milk is subjected to a treatment
which brings about a more complete emulsification of the fat than is
possible in cow's milk, causing it to resemble in character the
quality of the mother's milk. Homogenized milk has been used with
success in cases where it was impossible to supply the infant with
breast milk.

The process is accomplished by the use of an apparatus known as an
"homogenizer"[72]; in this machine the fat globule is crushed and so
finely divided as to prevent its re-formation. The greatest drawback
to the use of this process lies in the scarcity of available machines.
Cod liver oil is now used in many cases where the infant shows a
failure to gain or is in possible danger of developing rickets, with
the homogenizer it is possible to add the oil to the formula, thus
facilitating its use.

~Technique of Milk Modification.~--The absolute necessity for
cleanliness has already been dwelt upon in respect to milk, and in
infant feeding the vigilance which must be observed in the preparation
of the food cannot be too strongly emphasized. The milk itself must be
of known purity. Where there is any uncertainty about its source, it
must be sterilized or pasteurized according to the doctor's orders.
The bottles and nipples should be washed as soon as they are used,
first with plain water to remove the milk, then with soapsuds and a
bottle brush. The bottles should then be filled with boric acid or
bicarbonate of soda solution until needed, when they should be emptied
and placed in a deep pan filled with cold water and allowed to boil
for a few minutes. They should not be taken from the water until they
are to be filled with the milk mixture. The nipples are washed
thoroughly and boiled once a day and dropped into a solution of boric
acid or bicarbonate of soda when not in use. The plain black rubber
nipples are best as they can easily be turned inside out and cleaned.
If the milk drops too slowly from the bottle, the nipple may be
pierced in one or two places with a darning needle.

The morning is the best time in which to prepare the baby's food; the
milk has not stood too long and it is easier to regulate the feedings
if a fresh start is made each morning. Let the bottles and the rubber
corks with which they must be stopped be boiled and cooled while the
milk mixture is being prepared.

~Preparation of Diluents.~--If barley or oatmeal water is to be used
as a diluent, let that be prepared first, that it may be cool before
adding it to the milk. Cover the table with a clean cloth or oilcloth,
upon this place the pitcher in which the milk is to be modified, have
the funnel, milk dipper, and spoon which are to be used boiled with
the bottles, cover the mouth of the pitcher with a clean square of
gauze or cheesecloth, read the formula carefully and measure the
sugar, dextri-maltose, lactose, Mellin's Food, or cane sugar as
directed and place it in a clean glass; now measure the diluent,
water, oatmeal water, barley water, or whey; use part of this diluent
to dissolve the sugar.

~Measuring Milk according to Percentage of Fat.~--Now dip off the
required layer of top milk, that is, the layer containing the desired
percentage of fat and protein. Mix this thoroughly and dip out the
requisite number of ounces into the pitcher. If there is not
sufficient cream in one quart bottle to fill the formula, the cream
must be dipped from a second bottle and mixed with that of the first
before it is measured into the pitcher. The dissolved sugar and rest
of the diluent, together with the correct amount of limewater, are
strained into the pitcher, mixed thoroughly, and strained through the
absorbent cotton lining the funnel into the bottles, allowing the
correct number of ounces for each feeding in every bottle.

~Pasteurizing the Milk.~--The corks are then adjusted, the bottles
placed in the pasteurizer[73] and pasteurized for the desired number
of minutes. The water in the pasteurizer must be cold in the beginning
and the rise of temperature recorded on the thermometer, which is
adjusted at a convenient place in the pasteurizer where the scale can
be read easily. If the temperature of the water is too high, add cold
water and lower the flame beneath the pasteurizer. When the desired
number of minutes has elapsed, lift the bottle rack above the water
for a few minutes and allow a stream of cold water to flow into the
pasteurizer, taking care not to chill the bottles too suddenly or they
will crack. Cool the bottles as quickly as possible and place on ice
until needed, warming the bottle of milk as needed in warm water.

~Amount Given at Each Feeding.~--At birth a baby will usually take
from one half to one ounce at each feeding, this amount is increased
at the rate of a quarter of an ounce each week until the baby is
receiving eight ounces at each feeding. Or the food is measured to
allow of from one ounce to an ounce and a half more than the child's
age in months. For example a baby six months old would receive from
seven to seven and a half ounces at each feeding. Some babies are
bigger and stronger than others and require the maximum amount, while
others are less vigorous and the amount of food which they can handle
at a feeding may fall slightly short of the above amounts, but the
quantities indicated above will serve as a guide in measuring the
formula.

~Method of Calculation of Formula.~--The calculation of a formula
consists in determining the amount (in grams or ounces), of the
various constituents contained in the formula when the percentage of
each is known. Or, in determining its percentage composition when the
amount of fat, protein, carbohydrate and diluent is given. There are
certain inaccuracies in all simple methods of calculation and the use
of the Babcock tester to determine the fat content in the milk to be
used, is advised in all milk or formula rooms. The following method of
calculation has been found satisfactory, and the nurse must master it
in order to intelligently carry out the directions of the pediatrist.

~Determining the Composition of Formula.~[74]--Gravity cream and
skimmed milk are used in this method, the cream is estimated as
containing 16% fat, and consists of the entire cream layer from a
quart bottle of milk which has been allowed to stand without being
disturbed for six hours or longer. The cream must be dipped off with a
cream dipper, or poured off. If there is not a sufficient number of
ounces in one bottle of milk, a second must be used, the entire cream
layer taken, then mixed with that obtained from first bottle, before
the required number of ounces are measured off. Skimmed milk is
estimated as being fat-free (although this is not entirely accurate).
Both gravity cream and skimmed milk are estimated as containing 3.2%
protein, and 4.5% sugar. In this method, one rounded tablespoonful of
milk sugar is estimated as weighing one half ounce (dextri-maltose may
be estimated in the same way). With this brief explanation of the
terms used we will proceed with the method itself.

It is always essential before beginning the calculation of the
formula, to know what percentages of fat, sugar, and protein it is to
contain, and the amount to be given in twenty-four hours; it is also
necessary to know how much lime water is to be added if this substance
is to form a part of the formula.

Suppose a thirty-two-ounce mixture is to be made containing 3% of fat,
6% of sugar, 2% of protein, and lime water sufficient to equal 25% of
the cream and skimmed milk in the mixture. The fat in the food must be
derived from cream, since it is the only substance containing fat to
be used in the formula. If the food was composed entirely of gravity
cream it would contain 16% of fat. Since it is to contain but 3% of
fat it is evident that only 3/16 of the mixture must be gravity cream,
3/16 of thirty-two ounces is six ounces. Six ounces of gravity cream
will, therefore, provide the 3% of fat desired in the mixture. The
gravity cream contains protein as well as fat. There are six ounces of
gravity cream in the thirty-two-ounce mixture. The protein content of
gravity cream is 3.2%. The protein content of a thirty-two-ounce
mixture containing six ounces of gravity cream is evidently 6/32 of
3.2% or 0.60%. Two per cent protein is, however, desired in the
mixture. The gravity cream has provided only 0.60%. One and forty
hundredths per cent of protein, the difference between the percentage
of protein desired and that furnished by the gravity cream, must be
obtained in some other way. It must be obtained, moreover, from some
substance which does not contain fat. Skimmed milk is such a
substance. Skimmed milk contains 3.2% protein. In order to get 1.40
per cent in the mixture by the use of skimmed milk, it is evident
that 140/320 of the mixture must be skimmed milk. 140/320 of
thirty-two ounces is fourteen ounces. Fourteen ounces of skimmed milk
will, therefore, provide the additional 1.40% of protein desired.

Both gravity cream and skimmed milk contain 4.50% milk sugar. Twenty
ounces of gravity and skimmed milk are required to furnish the desired
percentages of fat and protein. These twenty ounces in a
thirty-two-ounce mixture must add 20/32 or 4.50% of sugar to the
mixture. Twenty thirty-seconds of 4-1/2 or 20/32 of 9/2 = 180/64, or
practically 3% of milk sugar. It is, however, desired to have 6% of
milk sugar in the mixture. That is, 3% more of milk sugar is required.
This additional sugar must be added in the form of dry milk sugar.
Three per cent of thirty-two ounces is 3/100 of thirty-two. This will
give the amount of sugar desired in ounces. The sugar is to be
measured in rounded tablespoonfuls, or half ounces. If the figures
given above are multiplied by two, the result will be the number of
rounded tablespoonfuls needed. That is, 3/100 of 32 × 2 = 192/100
rounded tablespoonfuls, or for all practical purposes, two rounded
tablespoonfuls.

It is also desired to have the amount of lime water in the mixture
equal to 25% of the cream and milk in the mixture. There are twenty
ounces of cream and milk in the mixture. Twenty-five per cent of
twenty ounces is five ounces. Five ounces of lime water must therefore
be added. The total quantity of the mixture is to be thirty-two
ounces. The milk sugar goes into solution and, therefore, does not add
to this quantity. The difference between thirty-two and twenty-five
ounces is seven ounces. Seven ounces of water must, therefore, be
added to make up the quantity desired.

~Changing the Formula.~--It is often found necessary to change the
formula when using artificial feeding for infants, and under these
circumstances it is necessary to know the percentages of the food
constituents contained in the formula already in use. For this purpose
the following method, quoted from "Diseases of Nutrition and Infant
Feeding,"[75] is included:

~Morse and Talbot's Method.~--Suppose that a baby is taking a food
made up of--

  Gravity cream     12 ounces
  Skimmed milk      18 ounces
  Limewater          6 ounces
  Barley water      12 ounces
  Milk sugar         4 rounded tablespoonfuls

"The barley water is made with two teaspoonfuls of barley flour in a
pint of water. The total quantity of the mixture is 48 ounces. Gravity
cream contains 16% fat. Twelve ounces of gravity cream in a 48-ounce
mixture will give, therefore, 12/48 of 16% of fat, or 4% fat. Both
gravity cream and skimmed milk contain 3.20% protein. There are 30
ounces of gravity cream and skimmed milk in the mixture; 30 ounces in
a 48-ounce mixture will give 30/48 of 3.20% of protein, or 2.00% of
protein. Both gravity cream and skimmed milk also contain 4.50% of
sugar. Thirty ounces of gravity cream and skimmed milk in a 48-ounce
mixture will therefore furnish 30/48 of 4-1/2 which is the same as
30/48 of 9/2 or almost 3.00% of milk sugar. Four rounded
tablespoonfuls of milk sugar are equal to two ounces. Two ounces of
sugar in a 48-ounce mixture is equal to 2/48 of 100% or 4%. The total
percentage of sugar is, therefore, 7%. Two teaspoonfuls of barley
flour in a pint of water makes a 1.50% decoction of starch. Twelve
ounces of barley water of this strength in a 48-ounce mixture will
give 12/48 of 1.50% or about 0.35% starch. There are six ounces of
limewater in the mixture and 30 ounces of gravity cream and skimmed
milk. 6/30 of 100% is 20%. The limewater is, therefore, 20% of the
milk and cream. The mixture thus contains 4% fat, 7% sugar, 2%
protein, and 0.35% starch, while the limewater is in the proportion of
20% of the cream and milk."

If, therefore, the nurse will follow out the plan suggested by Drs.
Morse and Talbot, it should be a simple matter to change the
percentage of any of the food constituents in any formula.

The following schemes for feeding well babies are included to
facilitate the work in the home. A nurse may teach the mother the
manner in which these schemes are used, keeping in mind that there can
be no iron clad rule for feeding all babies. No nurse should recommend
a formula without directions from a physician. And no formula should
be changed without his permission.

The following milk formulas are used in the Nathan Straus Pasteurized
Milk Laboratories of New York:

~Formula No. 1.~--Infants from 1st to 4th week, by A. R. Green.

24 ounces of mixture divided into 8 feedings of three ounces each, fed
at intervals of 2-1/2 hours:

  3/4 oz. 16% cream
  3 oz. full milk
  19 oz. water
  1-1/4 oz. limewater
  1-1/2 oz. milk sugar

~Formula No. 2.~--Infants 1st to 3d month, by Dr. R. G. Freeman.

  1-1/2 oz. 16% cream
  3 oz. full milk
  13 oz. water
  1/2 oz. limewater
  1 oz. milk sugar

Divided into 6 feedings of 3 oz. each, fed 3 hours apart.

~Formula No. 3.~--Infants 2d to 6th month, by Dr. R. G. Freeman.

  18 oz. full milk
  16-1/2 oz. water
  1-1/2 oz. limewater
  1-1/2 oz. milk sugar

Divided into 6 feedings of 6 ounces each, fed at intervals of 3 hours.

~Formula No. 4.~--Infants 3d to 7th month, by Dr. A. Jacobi.

  18 oz. full milk
  18 oz. barley water
  1 oz. cane sugar
  20 grains salt (less than 1/4 tsp.)

Divided into 6 feedings of 6 ounces each, fed at intervals of 3 hours.

~Formula No. 5.~--Infants 7th to 9th month, by Dr. A. Jacobi.

  2-1/2 oz. full milk
  7-1/2 oz. oat or barley water
  1-1/2 oz. cane sugar
  30 grains (about 1/4 tsp.) table salt

Divided into 5 feedings of 6 ounces each, fed at intervals of 3-1/2
hours.


SCHEME FOR FEEDING NORMAL INFANTS

(First Year)

Scheme based on Holt and Shaw's "Save the Babies." Pub. by Am. Med.
Ass'n.

WHOLE MILK METHOD

  -----------+----------+---------------+----------+-----------+---------
             |          |               |          |_Intervals_| _Number_
    _Time_   |  _Milk_  |   _Water_     |  _Sugar_ |   _of_    |  _of_
             | _Ounces_ |   _Ounces_    |          | _Feeding_ |_Feedings_
  -----------+----------+---------------+----------+-----------+---------
  1st and 2d |          | 1 to 3 tbs.   |          |           |
   days      |          | every 3-4     |          |           |
             |          | hours         |          |           |
             |          |               |          |           |
  3d and 4th |          |               |          |           |
   days      |    3     |       7       | 2 tsp.   |    3      |    7
             |          |               |          |           |
  5th and 7th|          |               |          |           |
   days      |    4     |       8       | 3 tsp.   |    3      |    7
             |          |               |          |           |
  8th day    |    5     |      10       |1-1/2 tbs.|    3      |    7
             |          |               |          |           |
  8th day to | Increase | Increase 1/2  | Increase |    3      |   7-6
   end of 3d | 1/2 oz.  | oz. every     | 1/2 oz.  |           |
   month     | every 4  | 8 days        | every 2  |           |
             | days     |               | weeks    |           |
             |          |               |          |           |
  End of 3d  |          |               |          |           |
   month     |   16     |      16       |4-1/4 tbs.|    3      |    6
             |          |               |          |           |
  Beginning  | Increase | Reduce 1/2    |    4     |    4      |   6-5
   of 4th    | 1/2 oz.  | oz. every 2   |          |           |
   month to  | every 6  | weeks. (Cook  |          |           |
   end of 6th| days     | barley in     |          |           |
   month     |          | water if food |          |           |
             |          | disagrees)[76]|          |           |
             |          |               |          |           |
  End of 6th |          |               |          |           |
   month     |   24     |      12       |    4     |    4      |    5
             |          |               |          |           |
  Beginning  | Increase | Reduce 1/2    |    4     |    4      |    5
   of 7th    | 1/2 oz.  | oz. every     |          |           |
   month to  | every    | 2 weeks       |          |           |
   end of 9th| week if  |               |          |           |
   month     | food is  |               |          |           |
             | well     |               |          |           |
             | digested |               |          |           |
             | and child|               |          |           |
             | seems    |               |          |           |
             | hungry   |               |          |           |
             |          |               |          |           |
  End of 9th |   30     | 10 oz. (in    | 2 tbsp.  |    4      |    5
   month     |          | which 3 tbs.  |          |           |
             |          | of cereal is  |          |           |
             |          | cooked)       |          |           |
             |          |               |          |           |
  Beginning  | Increase | Cereal gruel  | Reduce 1 |   4-5     |   5-4
   of 10th   | 1 oz.    | as above      | tbs. per |           |
   month to  | per month|               | month    |           |
   end of    |          |               |          |           |
   12th month|          |               |          |           |
  -----------+----------+---------------+----------+-----------+----------

At the beginning of 7th or 8th month, or earlier if necessary, it is
advisable to add orange juice, giving from 1-2 tablespoonfuls between
the two morning feedings.[77]

After the 4th month it is well to eliminate the night feeding between
10 P.M. and 6 A.M.

At end of 11th month add 1-2 pieces of stale bread, toast or zwieback.
Part of soft-cooked egg may be given every other day at noon meal by
end of 11th month. The orange juice may be increased to 3 tbs. if
bowels are not loose.

The strained cereal should be given twice daily by the end of the
first year, and the milk should be undiluted at this time unless the
digestion of the infant forbids.

Cooled boiled water should be given several times each day between
feedings. Babies cry from thirst as well as from hunger.


SCHEME 2

FOR FEEDING WELL BABIES

Scheme based on Dr. Richard M. Smith's "The Baby's First Two Years."

A full-term baby will usually take a formula made as follows:

  Cream                    2     ounces
  Skimmed milk             2     ounces
  Boiled water            12     ounces
  Sugar of milk            6     level tsp.

After 3d day increase cream and milk at the rate of 1 ounce each week,
and sugar 1 tsp. every other day until at one month the baby will be
receiving a formula such as--

  Cream                    5     ounces
  Skimmed milk             5     ounces
  Boiled water            22     ounces
  Sugar of milk            3-1/2 level tbs.

At two months--

  Cream                    6     ounces
  Skimmed milk             6     ounces
  Boiled water            20     ounces
  Sugar of milk            4     level tbs.

From this point the formula may be increased by adding 2 ounces of
skimmed milk each month until the baby is eight months old. For each
ounce of milk added, an equal amount of water should be omitted. The
sugar in the formula should be reduced one half tbs. every three
months.

At six months the baby would be taking--

  Cream                    6     ounces
  Skimmed milk            14     ounces
  Boiled water            12     ounces
  Sugar of milk            3-1/2 level tbs.

At eight months--

  Cream                    6     ounces
  Skimmed milk            18     ounces
  Boiled water             8     ounces
  Sugar of milk            3     level tbs.

This amount will not be found sufficient in quantity for a
twenty-four-hour mixture for children of this age. Increasing the
amount of the last formula in the same proportion, it will be--

  Cream                    9     ounces
  Skimmed milk            27     ounces
  Boiled water            12     ounces
  Sugar of milk            4-1/2 level tbs.

At this age the formula usually may be changed so as to be made from
whole milk instead of cream and skimmed milk. The formula may be made
as follows:

  Whole milk              36     ounces
  Boiled water            12     ounces
  Sugar of milk            4-1/2 level tbs.

From this point on the formula may be increased by replacing the
boiled water with whole milk, two ounces each month up to thirteen
months. At this age the boiled water may be omitted from the formula
one ounce each week. Beginning at the age of eight months the sugar
may be eliminated from the formula, one tablespoonful each month.

_Barley Water._--At the age of five months, or at any time thereafter,
barley water may be substituted for boiled water in the formula. This
should be substituted when the baby is not gaining in weight. It may
be substituted in many instances when the movements are not well
digested.

_Lime Water._--It is frequently found to be advisable to add lime
water. It is not necessary in every instance, but should be given if
the baby is inclined to spit up, or in cases where the stools are too
frequent in number and are slightly green in color.

       *       *       *       *       *

~Determining the Fuel Value of a Formula.~--The computation of the
fuel value of a formula is very essential since the growth and
development of the infant depends largely upon whether or not its
energy expenditures are well covered. The method is simple, requiring
the same methods used in the computing of other dietaries. Take the
formula just calculated, its fuel value would be estimated as follows:
Thirty-two ounces are equal to 960 grams. In each 100 grams there
would be 3 grams of fat, 2 grams of protein and 6 grains of sugar.
Hence in 9.6 one-hundred-calorie portions there would be 9.6 × 3--28.8
grams of fat, 9.6 × 2--19.2 grams of protein, and 9.6 × 6--57.6 grams
of sugar, in a thirty-two-ounce mixture.

To determine the fuel value of the formula, these results must be
multiplied by their physiological fuel factors, 9 and 4 and 4
respectively. Thus:

  29 × 9 = 261 calories from fat
  19 × 4 =  76 calories from protein
  58 × 4 = 232 calories from sugar, or a total of
          ----
           569 calories for the entire mixture.


~Scheme for Adding Solids to Infants' Diet.~--

From 9th to 15th month:

        6 A.M.--Milk formula (bottle).

        8 A.M.--Orange juice 1/2 ounce, or prune pulp or prune
                juice.

       10 A.M.--Bottle, cereal (strained) and bread and butter
                or zwieback.

        2 P.M.--Mutton, chicken, or veal soup cooked with
                cereal; small portion of baked potato, small portion
                of strained spinach or carrots; orange gelatin or
                cornstarch pudding.

        6 P.M.--Bottle.

From 15 months to 2-1/2 years:

        8 A.M.--Stewed fruit or orange juice; cereal, crisp
                bacon, alternated with soft-cooked or poached egg;
                bread and butter or toast, milk or weak cocoa.

  12 or 1 P.M.--Meat or vegetable soup thickened with cereal;
                lamb chop, scraped beef or chicken or beef juice; baked
                or mashed potato; strained spinach; carrots; turnips or
                celery; gelatin, custard, or cornstarch pudding.

        3 P.M.--Crackers and milk.

   6 or 7 P.M.--Bread and milk or cereal; baked apple or apple
                sauce.

From 3 to 6 years:

        8 A.M.--Stewed fruit or orange; cereal; bacon or egg
                (soft-cooked or poached); bread and butter; milk or
                cocoa.

  12 or 1 P.M.--Soup; lamb chop, scraped beef, chicken, or roast
                meats; potato; all vegetables; celery, lettuce; light
                desserts: custards, gelatin, lady fingers.

        3 P.M.--Milk; fruit and crackers.

        6 P.M.--Milk or cocoa; stewed fruit; bread and butter;
                cereals; eggs.


VEGETABLE SOUP

  1/4 lb. beef, lamb or chicken
  1 potato
  1 carrot
  2 stalks celery
  1 tablespoonful pearl barley
  2 tablespoonfuls rice
  2 qts. water
  1 pinch salt

Finely divide the vegetables. Add the vegetables, barley and rice to 2
qts. of water. Boil down to 1 qt., cooking 3 hours. Add pinch of salt.
Pass through fine sieve.

Morse and Talbot advise baked potato, plain boiled macaroni, rice and
wheat germ, bread and butter, baked custard, plain blanc-mange, and
plain boiled tapioca to be given when the child is 1-1/2 years old.
When the child is nearly two years old they add meat in the most
digestible forms, such as the white meat of chicken, lamb or mutton
chops, and scraped beef.

The following dietary is suggested for a child two years old:[78]

"Whole milk, butter, mutton broth, chicken broth, beef juice,
soft-cooked eggs, dropped eggs, white meat of chicken, lamb or mutton
chops, scraped beef, French bread, stale bread, toasted bread, whole
wheat bread, milk toast, zwieback, plain white crackers, plain
Educator crackers, barley, jelly, oatmeal, cream of wheat, wheat germ,
Ralston's Farina, rice, baked potato, plain boiled macaroni, orange
juice, baked apples, stewed prune pulp and juice, junket, baked
custard, cornstarch pudding, plain blanc-mange, plain tapioca. It is
not advisable, as a rule, to begin green vegetables until the baby is
2-1/2 years old."

It will be seen in the foregoing dietaries how authorities differ in
their beliefs as to the requirements of the child. The dietaries
included in this text are selected from those used in different parts
of the country by physicians who have successfully cared for the
infants and children under their charge.


THE FEEDING OF PREMATURE INFANTS

The digestion of premature infants is naturally not as strong as that
of infants born at term. Very little is positively known, but the
consensus of opinion goes to show that in the majority of cases the
tolerance for sugar is greater than that of either the proteins or
fats. The loss of heat is relatively greater in proportion to its
surface area in small than in large bodies. This is a well-known fact,
hence the premature baby must require more food in proportion to its
weight than the baby who is born at the normal time. Then, too, as the
premature infant is thinner he does not keep warm like the older
infant, and this must be taken into consideration in feeding him.
Breast milk is of course by far the best food for such babies, not
only because its constituents are in a more available form for the
feeble digestive organs, but because the mother's milk furnishes a
resistance which is lacking in even the most carefully modified of
milk formulas.

~Energy Requirements of Premature Infants.~--Experiments made upon
premature infants have proved that the caloric needs of these babies
are greater than in the case of full-time babies; that is, they
require more per kilogram of body weight. According to Morse,[79]
"most premature babies need 120 calories per kilogram of body weight.
But there are many exceptions, some thriving on as little as 70
calories per kilogram. No attempt should be made to reach 120 calories
per kilogram during the first few days. Thirty calories per kilogram
is as much as is wise to give in the first 24 hours of feeding. This
amount should be gradually increased each day, watching carefully for
symptoms of indigestion and diminishing it if these appear. One
hundred and twenty calories per kilogram can be given in about 10
days."[80]

~Necessary Dilution.~--Even breast milk must be diluted with an equal
amount of water or a 3% sugar solution. The amount of milk should be
increased and the amount of dilution decreased until the undiluted
breast milk is given in four or five days. Like older babies, the next
best food for premature babies is the properly modified cow's milk,
but the utmost care will have to be observed, as these babies are more
easily upset than older and stronger ones.

~Premature Infant Feeding.~--The following method of feeding may be
suggested, keeping in mind that it is an easy matter to increase the
strength of a mixture if the baby shows the need of such an increase.
The premature baby is rarely strong enough to take the breast.

~Method of Administering Milk.~--The most satisfactory method of
administering the food in such cases is by means of the Brick feeder,
which consists of a graduated glass tube, open at either end. On the
small end is placed a small nipple like those seen on medicine
droppers; this one is perforated and goes into the mouth of the baby.
A large rubber finger cot is attached to the other end of the tube.
The milk is forced into the mouth by pressing the finger cot. In case
the infant is too feeble even for this method of feeding, the desired
amount is dropped into the mouth from a medicine dropper; 5 c.c.
(about 1 dram or 1 teaspoonful) of diluted milk being given at each
feeding. This amount is increased gradually from day to day.

~Whey Mixtures.~--Whey mixtures have been found to meet the needs of
premature infants more efficiently than ordinary mixtures. As the
proteins in whey are in a more digestible form, they throw less work
on the immature digestive apparatus. As a rule the casein and whey
are in proportion of 1:1.

The following formulas[81] show the amounts in which the food
constituents are combined and are suitable for premature babies:

  Fat               1.00%
  Milk sugar        4.00%
  Total proteins    0.25%
  Lime water       25% of cream and milk mixture

  or

  Fat               1.00%
  Milk sugar        4.50%
  Total proteins    0.50%
  Lime water       25% of cream and milk mixture


PROPRIETARY FOODS

A word as to the use of Proprietary Infant Foods: These prepared foods
may be classified under four heads, as follows: (1) condensed milks;
(2) malted foods, those consisting chiefly of carbohydrates in the
form of maltose and dextrins; (3) those consisting almost entirely of
starch, and (4) those composed partly of soluble and partly of
insoluble carbohydrates.

(1) Condensed milk may be sweetened or unsweetened. These milks are
never given undiluted, the directions calling for one part condensed
milk to nine parts water, which gives a mixture containing 0.90% fat,
5.49% sugar, and 0.80% protein if "Eagle Brand" Condensed Milk is
used.[82]

(2) Malted Foods: Mellin's Food and malted milk are examples of this
group. These foods contain the carbohydrates in soluble form and when
added to milk make an acceptable addition, as they furnish the
carbohydrates in the most digestible form. When fed alone, diluted
only with water, they result in a mixture deficient in both fat and
protein.

(3) Imperial Granum is an example of this group, and there are several
others with similar compositions. These foods are very much like wheat
flour which has been subjected to heat, changing to a small extent the
starch to dextrose and dextrin.

(4) Nestlé's Food, Eskay's Albumenized Food, and Allenbury's Food are
examples of this group, each containing sugar and a percentage of
starch. Upon dilution with water, the amount of fat in the mixture is
just a trace.

~Incomplete Foods as a Source of Danger.~--The ease with which the
majority of these foods are prepared and the way in which they agree
with the baby constitute the chief danger of their use. If they are
added to milk, with the exception of the condensed milk, they result
in a modified milk containing the carbohydrates in a more or less
digested form. But they are expensive, and give no better result as a
rule than a carefully modified milk containing a cereal gruel.

The giving of foods like malted milk alone is dangerous because they
are deficient in some of the most necessary constituents, and babies
fed in this way, while growing fat, are apt to have soft or brittle
bones and muscular tissue higher in fat and water than in protein, so
that they do not grow and develop in a normal way, and when they are
attacked by the diseases so prevalent in the early years of life, they
succumb rapidly, because the resistance given by a properly modified
food is lacking.

Condensed milks act in a like manner. That is, in the sweetened milks
the carbohydrate content is far in excess of the needs, and the
proteins and fats are deficient, so that while the baby fattens he
does not receive the building foods commensurate with his body
requirements.[83]

Many mothers adopt the use of these foods because they mean less work
than in modifying the milk properly, but the nurse should point out
the facts just mentioned, explaining that while these proprietary
infant foods are undoubtedly valuable at times to fill a place when
the milk formula has not proved satisfactory, the use of these foods
as a regular custom is expensive, not only from a financial standpoint
but from a standpoint of health, since their disadvantages far
outweigh their advantages in the long run.


SUMMARY

~Breast Milk as a Food.~--The superiority of breast milk over any
other known food cannot be too strongly emphasized.

~Regularity in Feeding.~--The absolute need for regularity in
feeding--"feeding by the clock" and not by guess or when the baby
cries.

~Indications of Health.~--The normal growth and development to be used
as guides as to the physical well-being of the infant; also as an
indication of the use of the proper modification of milk for the
individual needs of the child.

~Dilution.~--The amount of dilution necessary--cereal waters, whey,
etc.--to increase the digestibility and nutrient values of the
formula.

~The Addition of Alkali.~--The addition of alkalies to milk formulas
to accomplish a like purpose.

~Milk Sugar, Malt Sugar, Cane Sugar.~--The use of the different
sugars, namely, dextri-maltose, lactose, or cane sugar under various
circumstances as the condition of the infant demands.

~Substitutes for Whole Milk.~--The substitution of different milk,
such as lactic acid milk, Bulgarian culture buttermilk, Eiweissmilch,
cream and whey mixtures, as the individual needs of the infant demand.

~Technique of Milk Modifications.~--The absolute need for the nurse
to understand the technique of milk modification before attempting the
care of an artificially fed infant.

~Percentage Computation.~--A knowledge of percentage, that an accurate
computation of a formula may be accomplished.

~Preparation of Food.~--A sufficient knowledge of food preparation to
enable the nurse to prepare any food which may be deemed necessary by
the physician for the welfare of the child.

~Water.~--The importance of giving the baby water aside from that used
in modifying the milk. Many babies cry from thirst when they are
believed to be crying from hunger or temper.

~Increasing the Diet.~--The necessity for increasing the amount and
strength of the formula with the age, growth, and development of the
child by the addition of solid food as soon as the physician deems it
advisable.

~Feeding Premature Infants.~--The method of feeding a premature infant
differs from that employed in feeding an infant born at term: (a)
because its development has not progressed so far; (b) because its
digestive apparatus being more or less immature, food handled with
ease by an older baby will be totally unfit for the premature one,
both as to quality and quantity.

~Wet Nurse.~--The advisability of procuring a wet nurse when the
mother is unable to nurse the infant, (a) on account of the more
digestible character of the food constituents, especially the
proteins, in mother's milk over those of cow's milk; (b) on account of
the resistance furnished by the natural food which has been proved to
be very much greater than that furnished by any other food, no matter
how carefully the modification of the milk is made.

~Premature Infants.~--Their caloric needs are greater than in
full-term babies, hence their food must be adjusted to meet these
needs.

In fact the nurse must have an understanding of the behavior of foods
in the metabolism of infancy and the laws which govern their use in
the organism of the child.


PROBLEMS

(a) Write a formula for a two months' old infant weighing twelve
pounds, which contains 3% fat, 2% protein, and 6% sugar.

(b) Change this formula so that it will contain 3% fat, 1.5% protein,
and 6% sugar.

(c) Write a formula for an eight months' old baby, using whole milk
instead of cream and skimmed milk.

(d) Write a formula for a premature baby containing 1% fat, 4% sugar,
and 0.25% protein (allowing 30 calories per pound of body weight).


FOOTNOTES:

[64] "Childhood and Growth," p. 18, by Lafayette Mendel.

[65] "Diseases of Nutrition and Infant Feeding," by Morse and Talbot.

[66] "Feeding the Family," by Mary Swartz Rose.

[67] "Diseases of Nutrition and Infant Feeding," p. 218, by Morse and
Talbot.

[68] "Generally Accepted Methods for Artificial Feeding of Infants
with Indicatives and Contra-Indicatives," by Orville R. Chadwell, M.D.
Reprinted from "New England Medical Gazette," June, 1916.

[69] "Mechanical Factors of Digestion," by Cannon.

[70] "Diseases of Nutrition and Infant Feeding," p. 204, by Morse and
Talbot.

[71] "New England Medical Gazette," June, 1916. Reprint by Orville
Chadwell.

[72] The best substitute for the homogenizer is found in an electric
mixer; a formula prepared with a fat other than cream can be made by
means of this mixer to approximate very closely that of homogenized
milk.

[73] There are a number of pasteurizers on the market; one sold by the
Walker Gordon Laboratory and one designed by Dr. R. G. Freeman of New
York are both satisfactory.

[74] Method suggested by Morse and Talbot, "Diseases of Nutrition and
Infant Feeding," pp. 234-235.

[75] "Diseases of Nutrition and Infant Feeding," pp. 225 and 226, by
Morse and Talbot.

[76] One-half tbs. barley flour may be cooked in the water used as
diluent; it should be boiled 20 minutes, strained and cooled before
adding to formula.

[77] When babies are fed upon pasteurized, sterilized, or dried milk
it is advisable to use orange or prune juice earlier than the seventh
month. Dr. Hess suggests the use of canned tomato juice as substitute
for orange juice.

[78] "Diseases of Nutrition and Infant Feeding," p. 236, by Morse and
Talbot.

[79] Morse: "American Journal of Obstetrics," 1905. Hess: "American
Journal Diseases of Children," 1911.

[80] "Diseases of Nutrition and Infant Feeding," p. 238, by Morse and
Talbot.

[81] "Diseases of Nutrition and Infant Feeding," p. 239, by Morse and
Talbot.

[82] "Diseases of Nutrition and Infant Feeding," by Morse and Talbot.

[83] The proprietary foods on the market are many, but those given
above as suggested by Morse and Talbot represent the best known infant
foods.




CHAPTER X

CARE AND FEEDING OF INFANTS AND CHILDREN IN ABNORMAL CONDITIONS AND IN
INFECTIOUS DISEASES


~Digestive Disturbances.~--It is a well-established fact that
artificially fed infants are more subject to disturbances due to diet
than breast-fed infants, the digestional disturbances of the latter
yielding more readily to treatment. As a rule, with the breast-fed
baby it is largely a question of adjusting the diet of the mother, of
increasing the fluid in her diet, of seeing that she takes the
requisite amount of exercise in the open air, and of lengthening the
intervals between feedings or of giving the baby water just before
putting him to the breast. With the artificially fed infant it is an
entirely different proposition.

~Causes in Artificially Fed Infants.~--The digestive disturbances may
arise from any one of half a dozen or more causes. The constituents in
the milk may be in the wrong proportion. The amount given at a feeding
may be too great or too little. The dilution may be too great or too
small to meet the needs of the infant. Or the milk may contain the
microörganisms which bring about fermentation or putrefaction. Any or
all of these causes may assail the artificially fed baby.
Consequently, all the care that can be exercised must be resorted to
in the feeding of these babies, not only after digestional
disturbances arise, but as a means of their prevention. In the
preceding chapter the methods generally used in the feeding of normal
infants were discussed. We now proceed to the feeding under abnormal
or pathological conditions.

~Errors in Diet.~--The majority of the ills from which the baby
suffers can be traced primarily to ~errors in diet~ and in most of
these cases the treatment consists chiefly in adjusting the formula to
suit the condition. As a rule, these errors may be placed under two
heads: those that are brought on by under-feeding and those induced by
over-feeding. The pathological conditions arising from under-feeding
are due not only to a lack of food, but chiefly to the improper
balancing of the different food constituents in the formula. As has
already been stated, so much food is required to cover the energy
expenditures, so much for maintenance, and so much for storage for the
growth and development necessary during the entire period from birth
to maturity. These constituents must be regulated to the individual
needs of the infant.

~Over- and Under-dilution.~--If the dilution is too great, the infant,
while receiving the correct amount of the mixture, may have the
necessary food constituents so reduced as to have them fail completely
to do their appointed work in the body. Or if the amount of diluent is
too small the baby may be receiving too strong a mixture, and develop
nutritional disturbances therefrom. Under the first head the child
suffers from under-feeding; the appetite is satisfied before enough of
the actual food is ingested to meet his various needs. However, it is
probable that the artificially fed infant suffers from the results of
over-, rather than of under-feeding.


DISEASES DUE TO ERRORS IN DIET

Gastro-intestinal disturbances, colic, enterocolitis, colitis, etc.,
rickets, scurvy, nephritis, and diabetes are among the diseases most
apt to develop from injudicious feeding, and in these cases the
dietetic treatment plays the most important part in combating the
condition. The disturbances caused by food are recognized by the
general symptoms: vomiting, rise of temperature, subnormal
temperature, and the stools, the latter being the chief point of
observation.

~Fats as Cause.~--When the fats are causing the disturbance, the rise
of temperature is apt to be high, but not of long duration. The baby
vomits frequently, the vomitus being acid in reaction and odor, the
latter due to the presence of fatty acids, butyric acid, etc. Diarrhea
often develops in a more or less acute form. In these cases there is a
loss of sodium and other alkaline salts in the feces, and a consequent
excess of ammonia in the urine, resulting in acidosis. Acid
intoxication has been known to develop as a result of this loss of
alkaline salts. The chief symptoms of this condition are rapid and
deep respiration, stupor or restlessness, and cherry-red lips.[84]

~Symptoms of Excess Fat in Diets.~--The general symptoms in infants
receiving an excess of fat in their food take the form of loss of
appetite, with more or less loss of weight, or failure to gain. When
the cases are not chronic, soft curds may often be seen, which are at
times mistaken for casein curds, but may be distinguished from them by
their translucent appearance and their solubility in ether. The color
of the stools due to the excess of fat under the above-mentioned
conditions is shiny and gray. In the majority of cases, especially of
a more chronic character, the stools are apt to be large and dry, at
times hard and crumbly. The fat in such stools is combined with
magnesium and calcium salts, forming the characteristic "soap
stools."[85] The combined loss of these salts in the feces has a
definite effect on the general metabolism and nutrition, giving rise
to rickets.

~Regulating the Fat.~--The treatment consists chiefly of regulating
the amount of fat in the formula, and of cutting it out altogether in
the beginning when the symptoms show acute acid conditions. In many
cases, if the baby is given breast milk, the trouble disappears. At
other times it is necessary to substitute a foreign fat such as olive
oil for the butter fat. Dr. Ladd in the Children's Hospital in Boston
treated many babies who manifested an intolerance for butter fat with
"Homogenized Milk," which consisted of skimmed or separated milk and a
certain percentage of olive oil, placed in an apparatus which brought
about a more complete division of the fat, causing it to mix with the
milk as an emulsion closely resembling human milk.

Fat intolerance is most difficult to overcome, the baby being apt to
relapse into the acute stage unless the utmost caution is observed in
adding the fats to the formula. It is not safe, however, to feed the
baby upon a fat-free milk for any great length of time.

~Excess Protein in Food.~--The digestional disturbances arising from
too much protein in the food are as a rule readily overcome in
breast-fed infants. When it is due to nervousness or worry in the
mother, it disappears as soon as the mother ceases to worry or does
something to remove the cause of the nervous condition. When the
breast milk is high in protein, more exercise in the open air at times
adjusts the percentage of protein, provided the mother does not become
over-tired, in which case the percentage of protein in breast milk
increases.

~Evidences of Excess Protein.~--The symptoms of excess protein in the
diet of the breast-fed baby are colic and flatulence, which are often
persistent and difficult to overcome. Vomiting is not so common in
these babies as in those who are artificially fed. The stools are
increased in number, are either brown or green, and generally loose
and watery. In artificially fed infants the symptoms are much the
same, except that the vomitus often contains large curds which are
tough and leathery. The baby suffers from gas formation and colic. The
stools are at times normal, except for the presence of large, hard
curds; at other times they are increased in number, and are of a
watery consistency and alkaline in reaction.

~Regulating the Protein in Formula.~--When the stools are watery and
brown and musty in odor as the result of disturbed protein digestion,
the treatment consists of taking out the proteins from the formula and
of substituting cereal water, to which dextri-maltose or milk sugar is
added, the milk being added as soon as possible to prevent too great a
loss of body protein. As a rule the whey proteins do not cause the
disturbances so often as the casein proteins; and at times it is
possible to use whey mixtures with babies who cannot tolerate the
casein at all.

Buttermilk also is used in cases of protein indigestion, as is
Eiweissmilch and peptonized milk.

~Regulating the Carbohydrates.~--When the disturbances are due to the
carbohydrates in the formula, they may be digestional or nutritional.
In this form the milk sugar is more apt to be the cause of the trouble
than the dextri-maltose preparations which are at times used. In the
latter, when the disturbance becomes nutritional, the cause of the
trouble can usually be traced to an excess of starch. When the
percentage of milk sugar is greater than can be handled by the
digestive apparatus of the baby, it is manifested by frequent attacks
of colic, with the passage of watery green stools, highly irritating,
in character on account of their acidity. In acute cases the loss of
weight is often marked, and symptoms of intoxication may develop. The
outlook is grave in the very severe cases, but if the baby can survive
forty-eight hours after the acute symptoms develop, he is apt to pull
through the attack.

~Adjusting the Sugars.~--The treatment in these conditions consists of
eliminating the milk sugar from the formula; in less severe cases
dextri-maltose may be substituted. As a rule, coincident with
indigestion caused by sugar there will be found to be an intolerance
for much fat, so that this must be adjusted as well as the milk sugar.
Skimmed milk mixtures, containing a certain amount of barley or
oatmeal water, are generally found to be suitable in these cases.
Dextri-maltose may be added after a few days in order to maintain the
fuel needs of the body. Eiweissmilch is at times used, but whey
mixtures are contraindicated on account of their high sugar content.

Dextri-maltose also disagrees at times. The baby has colic and
flatulence, the stools are usually loose or watery and dark brown in
color. The dietetic treatment consists of an immediate withdrawal of
the dextri-maltose preparation and a substitution of milk sugar after
a few days.

~Evidences of Excess Starch in Formula.~--The disturbances arising
from an excess of starch in the diet are, as has already been stated,
more apt to be of a chronic than an acute character. Vomiting is not a
common symptom under these conditions, although colic is frequent. The
stools are at times loose and brown, at other times dry and small. The
baby at times suffers from diarrhea and at others from constipation.
When the disturbance is acute the starch must be entirely eliminated
from the formula. If proprietary foods are being used containing
starch, whether it is dextrinized or unchanged, they must be at once
abandoned, and a formula made up of protein with sugar and fat.

MODIFIED MILK FORMULAS SUGGESTED BY MORSE AND TALBOT FOR THESE
CONDITIONS

  Fat           1.00%            Fat            2.00%
  Milk sugar    4.00%     or     Milk sugar     5.00%
  Protein       0.75%            Protein        1.25%

They likewise advise whey and whey mixtures under these circumstances.

~Fermentation.~--Fermentation is often the cause of infantile
indigestion. At times it is acute and may cause a decided elevation of
temperature owing to the absorption of the toxic substances formed as
a result of the bacterial action. In almost every case of indigestion
brought on by fermentation there will be an accompanying diarrhea. As
a rule the carbohydrates are more liable to the attacks of bacteria in
the stomach than the other food constituents.

~Treatment.~--The treatment consists first of starvation, no food
being given for at least twenty-four hours. Then water or weak tea,
sweetened with saccharin, may be given, but nothing else. The medical
treatment must be left to the discretion of the physician. When the
condition warrants a return to food the formula must be made weaker
than that which has caused the disturbance. Malt soup mixtures,
buttermilk mixtures, whey and albumen water may be added as the
condition of the baby improves. In older children the period of
starvation may have to exceed that of infants, but a gradual return to
normal diet is made. Weak tea and toast may be given after the first
twenty-four hours and well skimmed meat broths, soft-cooked eggs,
liquid peptonoids, and malted milk added to the diet as the condition
of the child improves.


ENTEROCOLITIS

The dietetic treatment for enterocolitis must be adjusted according to
the principal symptom. In some of these cases diarrhea is most
prominent, while in others constipation is the most marked symptom.
Hence the diet must be such as not only to do no harm to the child,
but one that will aid in his ultimate recovery.


DIARRHEA

The treatment for diarrhea, whether it is from fermentation or
putrefaction of food, has already been explained. The grave danger in
the putrefactive diarrhea is the absorption of the toxic substances
which result from bacterial action upon the unabsorbed food material
in the small and large intestine. In these cases auto-intoxication
may develop and the baby may die before the condition yields to
treatment. The entire intestine must be cleansed as a rule. The
stomach of the baby may be reached with little trouble by using a
small rubber catheter attached to a glass funnel and a solution of
bicarbonate of soda. The bowels may be emptied by means of a soapsuds
enema. Older children may be given oil, but this of course comes under
the jurisdiction of the physician.


CONSTIPATION

Constipation is one of the most frequent troubles visited upon people
of all ages. "It is not a disease, it is a condition in which the
number of stools is less or the consistency of the stools is greater
than is normal for the individual at the given time."[86] It may be
caused by neglect of the bowels, which should be evacuated once or
twice every day during infancy and once a day after that period. If
the habit of emptying the bowels every day is established in infancy
it adds much to the health and comfort of the individual during the
entire remainder of life. Babies are sometimes constipated as the
result of the opium administered in soothing sirups. Others inherit
constipation, while still others are constipated by the taking of the
wrong kind of food or too little food. In any case it is decidedly bad
to resort to drugs, since the habit of taking cathartics is so easily
acquired and so difficult to overcome.

~Factors Inducing Constipation.~--With artificially fed babies a
formula which contains too high a percentage of diluent and too low a
percentage of solids will cause constipation, chiefly because the
solids are so completely absorbed that they have no residue to form
feces. A formula with too low a fat content in proportion to its
protein and carbohydrates may cause constipation because the latter
two constituents are almost entirely absorbed, and the feces, which is
largely made up of the fat, is correspondingly small. Excess of fat,
however, has been proved to be one of the chief causes of constipation
in infants, as has also been the case with excess starch. Boiling the
milk for the baby at times results in constipation. Hence
sterilization is more frequently to blame for the condition than the
pasteurization of milk.

~Constipation during Second Year.~--During the second year, if the
child is given too much milk and too little solid food, constipation
is very apt to be the result. A maximum quantity of from thirty-two to
forty ounces may be given. In many diseases brought on by
malnutrition, constipation is an obstinate condition to be overcome.
This is especially the case in rickets and anemia.

~Use of Laxative Foods.~--After the baby is a few months old, orange
juice is given between the morning feedings. Malted foods likewise
exert a laxative effect. The higher the percentage of maltose, the
more laxative the food. The nurse must keep this point in mind in
feeding babies. With older children and adults, the question of diet
for constipation is quite as important as it is for infants. Prunes or
figs cooked with senna leaves and thoroughly strained furnish an
excellent adjunct to the diet under such conditions. The coarse breads
such as bran and Graham or wholewheat bread should be used instead of
white flour breads. Care should be taken in advising a cereal diet for
children, since cereals, with the exception of oats, are apt to be
constipating. Fresh fruits, stewed fruits, and fresh vegetables are
all good under the above-mentioned conditions. Young children require
the vegetables strained or cut fine. Adults should include one coarse
vegetable a day in their dietary to obviate the development of
constipation. Children should be taught to drink plenty of water, and
babies should not be neglected in this respect. As a rule very few
adults drink as much water as is necessary for the general welfare of
their bodies.


SCURVY

There is probably no disease of infancy which has come in for more
study in the past few years than scurvy.

~Cause.~--The disease is believed to be directly due to a deficiency
in the diet of the antiscorbutic vitamine, known as "Water soluble C."

~Treatment.~--For many years it was known that lime juice exerted a
curative effect upon scurvy. But recently the efficiency of this fruit
juice has proved to fall far short of that effected by either orange,
or tomato juice.

Feeding experiments have proved that animals, fed upon rations
consisting of dry food without the addition of green, will develop
scurvy. And that the milk of such animals will show a deficiency in
the "C" vitamine which will lead to a development of the disease in
infants fed upon such milk.

Milk is, in fact, by no means a perfect food, so far as its vitamine
content is concerned. First, because the presence of the vitamine in
milk is so dependent upon the diet of the mother or the animal,
second, because the pasteurization temperatures used to insure cow's
milk of purity from a bacterial standpoint, destroys in it the greater
part of its antiscorbutic power. Either of which makes it necessary to
supplement the formula of the artificially fed infant, and, in case of
the former, the mother's milk of the breast-fed baby, with orange, or
canned tomato juice.

The amount of either of the fruit juices which is necessary to insure
the child of a freedom from scurvy, is small, ranging from one-half to
one ounce of strained juice daily, this amount is increased gradually
until the child is taking from one and one-half to two ounces each
day. It has been found advisable to administer the fruit juice
between the two morning feedings. As a rule, the fruit juices are
given at the beginning of the seventh month, but they may be given at
a much earlier date, the time being adjusted by the physician.


RICKETS

Rickets, like scurvy, is being discussed by scientists both in America
and abroad. The disease is widespread, particularly in its subacute
form, and its effect upon the health of the child is so serious that
no amount of effort to prevent its development should be considered
too great.

~Calcium Retention in Rickets.~--The disease is characterized by a
failure of the bones to lay down lime salts, this failure causes a
softness and flexibility in the structure of the bones which permits
them to bend into deformities. Then, too, it is a well established
fact that any interference with the calcium metabolism in the body,
will inevitably bring about disaster. (See Mineral Metabolism, page
185.)

~Factors Inducing Rickets.~--According to Dr. Eddy, "It is impossible
at present to determine whether rickets is a true avitaminose or a
consequence of deficiency in a series of factors."

~Treatment.~--For breast-fed babies it is necessary to adjust the diet
of the mother to include more of the vitamine bearing foods, since
milk contains vitamines only in proportion to the amount eaten in
food. For artificially fed children, the giving of cod liver oil has
recently been adopted as the surest and safest method of curing and
preventing the development of the disease. Like treatment is used with
breast-fed infants if the need arises.

The value of cod liver oil in this respect has only been recently
recognized. Mellanby of England claims that the oil owes its curative
and preventive properties to the presence of the "A" vitamine. But
scientists in this country have not fully accepted this view. Eddy
states, "It may be that the power of the oil is due to its 'A'
vitamine content, in which it is known to be rich, or it may be due to
a new vitamine, but the fact that the oil is a preventive in this
respect gives the pediatrist another agent to insure normal growth."

~Sunshine as a Factor.~--It has been found that the disease rickets is
more prevalent in winter than in summer; this is believed to be due to
the fact that sunshine during the summer months exerts a distinctly
beneficial influence over the disease. Dr. Hess's report of the good
results which he has found to be derived from the use of the ultra
violet rays as a substitute for sunshine in winter, would seem to
confirm this view.


MALNUTRITION

~Malnutrition~ is not confined to the children of the poor, though it
is more common with infants of parents who have not the means to
secure the best milk and give them the benefit of wholesome
surroundings and plenty of sunshine. But babies of people in moderate
circumstances, and even of wealthy parentage, are at times badly
nourished, and require the same exacting care, the same attention to
the food, the fresh air, and the sunshine that the poorer babies need
in order to survive. Malnutrition may be the result of insufficient
food, and it may also be due to the lack of one definite food element.
Again, it may be brought on by some deformity of the mouth or stomach,
which make it impossible for the baby to get all the food which he
requires for his maintenance and growth. He may be born prematurely
and his digestive apparatus not be sufficiently developed to care for
the amount or type of food necessary for his needs, or he may have
some congenital weakness which interferes with the absorption and
assimilation of his food. All of these points must be considered.

~Evidences of Correct Feeding.~--If the baby shows a steady gain,
both in weight and growth of stature, without digestional
disturbances, the food given him is probably correct, but it must be
kept in mind that nutritional disturbances, such as rickets and
scurvy, are slow in developing, and do not manifest themselves with
anything like the rapidity of digestional disturbances. Hence the
nurse must take care as far as she is able, not only to prevent the
food from causing indigestion, but also to see that it is not given in
such a form as to induce those graver and more lasting nutritional
disturbances which affect the entire system from infancy throughout
the life of the individual.


SUMMARY

~Breast Feeding versus Artificial Feeding.~--There is no doubt about
the fact that the breast-fed baby suffers less from digestional
disturbances and has more resistance to disease than the baby fed even
upon a perfectly prepared artificial food. The majority of diseases
manifested by artificially fed infants have their origin in the
following errors in diet.

~Over-Feeding.~--Resulting in acute gastro-intestinal disturbances
(colic, enterocolitis, colitis, constipation).

~Under-Feeding.~--Resulting in chronic, and acute deficiency diseases
(scurvy, rickets, malnutrition).

~Evidences of Dietetic Errors.~--The stools, showing characteristic
evidences of excessive quantities of, protein, fat, or carbohydrates
in the formula. Loss of weight or failure to gain. The development of
deficiency diseases (scurvy, rickets, xerophthalmia, rickets and
malnutrition).

~Evidences of Correctness in Feeding.~--Normal gain, freedom from
gastro-intestinal disturbances, and deficiency diseases. Rosy cheeks,
bright eyes, and a vigorous body.

~Treatment in Abnormal Conditions.~--The treatment consists in
adjusting the diet to meet the needs of the particular disturbance
manifested. Plenty of fresh air, sunshine and sleep.

~Relapse.~--One danger which the nurse must always be on the lookout
for is the relapse into the acute stage. The diet is the chief
treatment. In acute gastro-intestinal disturbances rest from food is
essential for at least twenty-four hours. Some infants can easily
endure starvation for this short period. However, when malnutrition
has already been established, it is not wise to carry out the
starvation treatment over-long. A cautious return to a normal diet may
be made as soon as acute symptoms disappear.

~Fevers in General.~--It requires very little deviation from the
normal to raise the temperature of a child. A slight attack of
indigestion, a slight soreness of the throat, will bring up the
temperature of some children out of all proportion to the seriousness
of the disorder.

~Diet in Fevers of Short Duration.~--As a rule, in the fevers of short
duration, such as intermittent fever, malarial fever, etc., the diet
is a simple matter. Milk is given when it agrees, with buttermilk,
koumiss, broths, and albuminized beverages to vary the diet.

~Diet in Infectious Diseases.~--When, however, the fever is induced by
specific bacteria, such as in the case of typhoid and scarlet fever,
the diet is a different matter altogether. The disease may be one in
which the diet is the chief item of importance; such is the case with
typhoid and scarlet fever, with the former because of its long
duration, the increased rate of metabolism due to both the fever and
the action of the bacteria making it necessary to increase the normal
amount of food to meet the new requirements of the body; and with the
latter on account of the kidney complications which must be guarded
against, and which can only be handled by regulating the diet.

~Infant Feeding.~--The feeding of infants under febrile conditions
resolves itself into an adjustment of the milk formula to meet the
existing state of affairs. The digestion is always more or less
disturbed by fever, especially during the early stages.

~Restricting the Food.~--It is not always possible to diagnose the
disease immediately, so that the safe thing to do is to lengthen the
intervals between the feedings for the breast-fed baby and to stop
food entirely for twelve to twenty-four hours for those who are
artificially fed, when there is any doubt as to the cause of the rise
of temperature. Some mothers find it difficult, if not impossible, to
institute this period of starvation. In these cases barley water or
albumen water may be given at stated intervals. Many physicians give
very weak tea, slightly sweetened, under the above conditions; it does
no harm to the baby and relieves the mother from the belief that her
child is being starved to death. In twenty-four hours, if the fever
arises from disturbed digestion, some manifestation of the condition
will be observed.

~Bacterial Activity.~--In cases of intestinal putrefaction the fever
is apt to rise at an alarming rate and is controlled only by removing
the cause. The proteins which have escaped digestion and absorption in
the intestines furnish the best medium for the growth of putrefactive
bacteria. Hence this food constituent must be given in its most
digestible form.

~Dietetic Treatment.~--Milk in most instances is the best form in
which to give protein food, especially to young children and babies.
At times, however, it will be found that milk disagrees; it must be
peptonized, or one of the fermented milks, such as buttermilk
(Bulgarian culture), Eiweissmilch, or koumiss must be substituted. In
cases where the putrefactive bacteria make it unwise to use milk at
all, for a time the proteins should be furnished in the form of cereal
gruels, and the juice of an orange strained and diluted given once or
twice a day between the morning and evening feedings.

~Whey~ is contraindicated in cases where the fever is brought on by
putrefaction in the intestine, chiefly because it furnishes one of the
best mediums known for the growth of the offending bacteria.

Patience is required in handling the diet for fevers in infancy. As
has already been stated, it requires a very slight cause to raise the
temperature of a child, but for this very reason especial care must be
observed that no enlightening symptom escapes the notice of the nurse.

~Complications.~--Tuberculosis or scurvy may be in an incipient stage,
and may be overcome if recognized in time. The nurse has a better
opportunity for observing changes in an infant or child under her care
than the physician who comes once a day or less. The nurse should make
note of these changes, that the physician may have a chance to
regulate the diet accordingly.

~Fluid Diet.~--With children, as with adults, the energy output in
fever is greater than in health, hence the need for plenty of fluids
to help eliminate the waste products due to the increased metabolism.
These fluids may consist of water, fruit beverages, cereal water,
whey, and broth. It is well for the nurse to remember that when the
child is confined to bed, he will not need so much food as he would if
he were up and about, but that if the fever is of long duration, as in
typhoid, the increased rate of metabolism must be met by an increased
amount of food, as the ordinary requirement standards for a child in
health cannot be applied to the diet of a child under these
conditions.


SCARLET FEVER

Scarlet fever is an acute infectious disease, characterized by high
fever, sore throat, a red rash, and a tendency to nephritis. The
disease usually begins suddenly with an attack of vomiting; the
temperature rises to 104° or 105° and on the first or second day a
rash appears, first on the chest and neck, and spreads over the entire
body. This lasts from three to seven days, desquamation begins soon
after the rash disappears and lasts from two weeks to six, the palms
of the hands and soles of the feet peeling last. The appearance of the
tongue is very characteristic, being coated, and through this coating
are seen a few bright red points, producing the well-known strawberry
tongue. After a few days the coating disappears, leaving the tongue
bright red. In mild cases the tonsils are enlarged and the throat very
red. In severe cases there may be difficulty in distinguishing the
disease from diphtheria without a culture being taken. The tendency of
the child to develop nephritis during the second or third week makes
the treatment largely dietetic in character.

~Dietetic Treatment.~--Milk is the chief diet for the first three
weeks. If it disagrees, it should be modified or peptonized to suit
the condition. Koumiss and buttermilk may be substituted when it is
impossible to prepare the milk so that it will not cause digestional
disturbances. This, however, is seldom found to be the case during
infancy. Malted milk and even condensed milk, or some of the
dextrinized and malted foods at times prove valuable when whole milk
disagrees. But the nurse must remember that a baby runs a risk of
developing nutritional diseases of a grave character if fresh milk is
eliminated from the diet for any great length of time.

Older children may have plain vanilla ice cream and plain junket,
oyster or clam broth made with milk, the oysters and clams carefully
strained out. Lemonade and orange juice may be given, but no meat
broths or albumenized beverages or egg dishes can be admitted to the
dietary.

~Development of Nephritis.~--Nephritis must be guarded against. The
skin, being covered with a rash, is put out of commission as an
excretory organ; in consequence all of the work of this description is
placed upon the kidneys. In the first part of this text the work of
the kidneys was defined; it was found that they were the chief organs
for the excretion of the end-products of protein metabolism. It can be
readily understood that when these organs are given not only their own
work but that of the other organs to perform, unless the food
requiring the greatest amount of effort on the part of the kidneys is
confined to those types which can be most easily taken care of, such
as milk, the kidneys stand a great chance of becoming impaired. Such
is the case in nephritis.

~Convalescent Treatment.~--The return to normal diet must be made with
the greatest caution. Specimens of urine must be taken often, for in
this way alone can the development of nephritis be reckoned with.[87]
Should nephritis develop in spite of efforts to prevent it, a
farinaceous diet[88] such as is given in these conditions must be
resorted to.

After three weeks, if the patient shows no disposition toward
nephritis, and if convalescence is progressing satisfactorily, the
diet may be increased day by day, adding milk toast, cereals, cream
soups, rice, baked potato, then custards and soft eggs, the soft part
of oysters, broiled or baked fish, broiled breast of chicken, and,
still later, rare beef and lamb chops. Meat, however, must not be
given until all danger from nephritis has passed.


DIPHTHERIA

~Diphtheria.~--The feeding in diphtheria follows the régime given in
acute fevers. The body must be kept in good condition. At the same
time it is necessary to understand the complications which make the
dietetic treatment of this disease assume a place of importance.

~Complications.~--It may be complicated by broncho-pneumonia,
albuminuria, carditis, endocarditis, and dilatation of the heart.
Anemia must be combated, but care should be used not to push the diet
to such an extent as to impose too great a tax upon the already
weakened heart.

~Dietetic Treatment.~--While the fever lasts the diet must be fluid,
milk, buttermilk, malted milk, and some of the proprietary infant
foods such as Mellin's Food, Eskay's Food, and like preparations. Milk
gruels, made with milk and some cereal such as farina, barley flour,
fine cornmeal, arrowroot, strained oatmeal, etc., are at times more
easily swallowed than the unthickened liquids. Liquid beef peptonoids,
panopeptone, and like predigested beef preparations prove valuable in
many cases.

~Convalescent Diet.~--As convalescence progresses, or in cases where
the patient finds it easier to swallow a semi-solid than a liquid,
soft custards, gelatin, well-cooked cereals, and ice cream may be
given. Eggnog and milk punch are at times given, but only upon the
advice of the physician in charge.

~Rectal Feeding.~--When the condition of the patient makes it
necessary to nourish in other ways than by mouth, nutrient enemas[89]
may be given. In certain cases of diphtheria, young infants can be fed
more successfully through a tube inserted by way of the nose into the
stomach than by feeding in the ordinary way. The formula is prepared
in the same way as for bottle feeding, and is poured into a glass
funnel and through the soft rubber catheter into the stomach. Care
must be observed to prevent the patient struggling on account of the
heart weakness which invariably complicates this disease.


WHOOPING COUGH

In the early months of life it is probable that whooping cough is one
of, if not the most fatal of the diseases to which the infant is
subjected. The period of incubation of this disease is from one to two
weeks, the cough at first not appearing different from those
accompanying colds of all sorts. However, in from ten days to two
weeks the characteristic whoop occurs, differentiating this disease
from all others. The symptoms aside from the whoop are the difficulty
of taking breath and the great prostration after the paroxysm and the
frequent vomiting of the food, brought on by the violent coughing.

In very young infants the whoop does not always occur. But the child
coughs and holds its breath until it is blue in the face. At times
young babies may have convulsions. The so-called spasmodic stage,
during which the child may have from a few to a great number of
paroxysms of coughing a day, lasts from a month to six weeks, and in
some cases even longer. As the disease declines the cough gradually
disappears and the child appears to be suffering with ordinary
bronchitis. The characteristic whoop may return at any time during the
ensuing six months or year if the child has an attack of bronchitis
and is inclined to cough.

~Complications and After-effects.~--The complications and
after-effects of whooping cough give it a serious character.
Hemorrhage may occur from the nose. According to Ruhräh: "Paralysis
may follow from meningeal hemorrhage, broncho-pneumonia, acute
emphysema, and collapse of the lung may occur. Diarrhea, convulsions,
and albuminuria are also met with. Tuberculosis and chronic bronchitis
may follow."[90]

~Dietetic Treatment.~--The diet plays an important part in whooping
cough. The serious complications and after-effects of this disease
upon children necessitate a rigid observance of dietary laws. With
infants it is always best, when it is possible, to give breast milk.
As this is the natural food it requires less effort on the part of the
digestive apparatus to become available. It has been proved that even
during the time when the baby is nursing the milk is projected in
spurts into the duodenum without waiting to be attacked by digestive
enzymes in the stomach, and for this reason the breast-fed infant is
more apt to be efficiently nourished than the artificially fed baby,
who loses his dinner by vomiting before absorption has had a chance to
occur.

~Diet under Ten Years of Age.~--For children under ten years, a fluid
diet is necessary, at least in the beginning of the disease while
there is a fever, and later, if the vomiting is persistent. Milk,
buttermilk, koumiss, broths, albuminized beverages, and cereal gruels
such as barley and oatmeal gruel and arrowroot gruel can be given.
Later, if the fluids are retained, cream of wheat, farina, junket,
soft custards, and soft-cooked eggs may be added. Care must be taken
in giving toast, unless it is softened with milk or broth, for the
crumbs may bring on a paroxysm of coughing and vomiting. The best
results in feeding with whooping cough are obtained by giving the food
in small quantities and oftener. A few ounces given every two hours
are less apt to be vomited than a larger quantity. It is also easier
for the child to take the small amount after an attack of coughing and
vomiting than it would be for him to attempt a larger meal.

~Use of Stimulants.~--In many cases where weakness is great, it has
been found advisable to add some stimulant to the diet. With infants
this is best given in albumen water, a small amount of good brandy
acting better than other stimulants. With young children some of the
predigested liquid beef preparations, such as liquid peptonoids, are
found valuable. These foods are given alternately with the other fluid
foods.

~Hygiene and Sanitation.~--Infants and children suffering with
whooping cough require plenty of fresh air and sunshine. They must be
kept out of doors as much as possible and sleep in well-ventilated
rooms or sleeping porches. They must be protected from drafts and
excitement, and never allowed to become over-tired. In this way the
anemia which so often results from prolonged attacks of whooping cough
is in a measure held in check. At times it is found necessary to give
some kind of an iron tonic, but this comes under the jurisdiction of
the physician instead of the nurse. When bad effects do occur in spite
of all the care exercised during the attack of whooping cough, they
must be accorded the treatment especially devised to meet the
situation.


MEASLES

This is an acute, infectious disease characterized by a red eruption
which appears on the fourth day. Measles is one of the most contagious
of all the diseases of childhood. It may be acquired by direct contact
with another case or by being in the room with a case. The infection
may also be carried through the air and occasionally by a third
person. Measles is more prevalent in the winter than in summer. In
cities it often occurs in epidemics. The period of incubation is from
ten days to three weeks, occurring generally at about two weeks after
exposure.

The attack may begin with the child showing a languid attitude,
complaining of headache. Then a cough develops, with nausea and fever
at times. The fever is often high, reaching 104° F. on the second day.
As a rule the fever gradually falls after the second day and becomes
normal in almost a week. However, the temperature varies in different
cases.

~Complications.~--Measles is not considered dangerous in itself, but
the after-effects sometimes prove fatal. This is especially the case
in broncho-pneumonia, which frequently develops during or after the
attack.

The gastro-intestinal, as well as the respiratory, tract is attacked
in measles, diarrhea being especially common. Very weak children have
been known to develop gangrenous stomatitis; paralysis and
tuberculosis[91] likewise develop in some cases as the direct result
of measles.

Thus it is demonstrated that measles is not to be lightly treated.
Even if it is not in itself fatal, the results of the disease are so
dangerous that the care of the nurse is especially necessary. The
great trouble is that so often a nurse is not in attendance and the
child suffers through ignorance of the mother.

~Dietetic Treatment.~--The dietetic treatment of measles is important.
For infants milk is the exclusive diet, the formula for bottle-fed
babies having to be weakened on account of the catarrhal condition of
the gastro-intestinal tract. For older children it is necessary to
confine the diet to fluids as long as the fever lasts, and at times
longer if the stomach gives evidence of digestional disturbances. Milk
is the chief food, with milk soups, buttermilk, and koumiss used to
vary the diet. Orangeade and lemonade may be given to allay thirst. A
return to normal diet must be made gradually, giving cereal gruels,
milk toast, and broth before the more solid articles of diet suitable
to the age of the child. When there are complications they must be
treated, as in whooping cough, according to their symptoms.


SUMMARY

~Gastro-intestinal Disturbances~ are responsible for much of the fever
manifested during infancy and childhood.

~Infectious Diseases~ are all more or less accompanied by an elevation
of temperature.

~Incipient Diseases~, especially tuberculosis and scurvy, may likewise
cause a rise of temperature. The relief of either disease or the fever
depends largely upon how quickly the conditions are discovered and the
means instituted to overcome them.

~Metabolism in Febrile Conditions~ of children, as well as of adults,
is rapidly increased, hence the energy output is greater, and for this
reason the fluid intake must be augmented in order to eliminate the
toxic substances produced as a result of the rapid breaking down of
the body tissues.

~The Kidneys~ are more or less strained to eliminate the products of
the increased metabolism and for this reason it is especially
necessary to adjust the diet in order to limit, as far as possible,
the foods which add to the burden already imposed upon the organs of
excretion.

~The Skin~ is an organ of excretion which, under normal conditions,
shares the work of the kidneys. In infectious conditions, accompanied
by eruptions which more or less cover the entire surface of the body,
this organ is temporarily out of commission, hence its work, as well
as their own, must be accomplished by the kidneys.

~Dietetic Treatment~ in the majority of infectious diseases may be
divided into three periods: Starvation, Fluid Diet, and Convalescent
Diet.

Starvation, during which time no food is given for twenty-four hours
or longer, in order to allow the digestive apparatus to rest and to
give time for any substance which may be causing the elevation of the
temperature to pass from the body. This treatment is also wise because
it furnishes an opportunity for the symptoms of the disease to
manifest themselves; Fluid Diet, given when acute symptoms subside,
and Convalescent Diet when danger from relapse is over.

~Scarlet Fever~ is treated with two main ideas in view--preventing the
development of nephritis and relieving the condition should it
develop.

~Dietetic Treatment~ is logically the only means of treating or
relieving nephritis. For the first three weeks, during which time this
complication is apt to develop, a milk diet is necessary. This may be
in the form of whole milk, milk soups, malted milk, etc. At the end of
this time, if there are still no symptoms of nephritis, a convalescent
diet, beginning with cereals and soft toast and progressing through
the simple digestible foods such as rice, baked potatoes, soft eggs,
etc., may be given. This is continued until the patient is well on the
road to recovery. Meat should not be added until practically all
danger of nephritis is passed.

~Nephritis.~--If, during the course of the disease this complication,
should develop, the treatment described for acute nephritis on page
336 should be immediately instituted.

~Diphtheria.~--Dangerous complications at times develop as a result of
diphtheria, making the treatment of this disease of the utmost
importance. Heart symptoms, pneumonia, albuminuria, and anemia are
among the complications to be dreaded and combated.

~Dietetic Treatment~ in diphtheria is most important. It consists of a
fluid diet made up of milk, malted milk, or buttermilk. At times the
condition of the throat makes a slightly thickened mixture more easily
swallowed than one which is distinctly fluid in character, and for
this purpose farina, arrowroot, or barley flour may be used.

~Increasing the Diet.~--As convalescence advances the semi-solids,
soft toast, soft custards, gelatin, and cereals may be given. Should
the heart show symptoms of being affected, the intake of fluid must be
restricted.

~Gavage and Rectal Feeding~ are at times necessary. Infants may be
successfully fed by passing a small rubber tube through the nose into
the stomach and administering the milk formula to which they are
accustomed. Rectal feeding is likewise valuable in cases of extreme
anemia accompanying diphtheria.

Care must be observed by the nurse in giving gavage to babies, since
any struggling on the part of the child may result in death from heart
disease.

~Whooping Cough.~--On account of the character of the disease and the
proneness of the stomach to eject the food during paroxysms of
coughing, dietary measures are more or less necessary in order to
enable the child to receive sufficient food to cover his daily needs.

~Complications.~--Hemorrhage, pneumonia, albuminuria, diarrhea, and
convulsions may occur during the disease, while tuberculosis and
chronic bronchitis may follow as after-effects.

~Dietetic Treatment.~--Breast milk is by far the best food for the
baby, in this as in all conditions. In whooping cough the fact that
this fluid leaves the stomach almost as soon as it enters lessens the
chances of the baby losing its meal by vomiting it.

~Older children~ do well with frequent small meals, since they are not
so apt to give rise to pressure which brings on the paroxysms of
coughing and vomiting. When the meal is vomited, a second should be
given in order to keep the child from suffering from malnutrition.

~Stimulation~ is found to be necessary in certain cases. Albumen water
containing a spoonful of brandy or some of the prepared beef
preparations, such as liquid peptonoids, may prove valuable under the
circumstances.

~Measles.~--Complications and after-effects developing as a result of
measles make the dietetic treatment of this disease important.
Gastro-intestinal disturbances, especially diarrhea, are apt to occur,
and tuberculosis has been known to develop as a result of measles.

~Dietetic Treatment.~--The fluid diet as used in any acute febrile
condition is used as long as the temperature is elevated. Milk,
buttermilk, malted milk, and milk soups constitute the chief items in
the diet. Orangeade and lemonade are found valuable in relieving the
thirst.


PROBLEMS

(a) List the evidences of errors in the diet of infants; show how they
may be corrected in the formula.

(b) Outline the processes in the preparation of Eiweissmilch (protein
or albumen milk). What constituent is particularly low in this milk,
and how was its reduction accomplished?


FOOTNOTES:

[84] "Diseases of Nutrition and Infant Feeding," by Morse and Talbot.

[85] _Ibid._

[86] "Diseases of Nutrition and Infant Feeding," p. 307, by Morse and
Talbot.

[87] See chapter on Urinalysis, p. 323.

[88] Consisting of cereal gruels, rice, and other starchy foods.

[89] See Nutrient Enemas, p. 145.

[90] "Diseases of Infants and Children," p. 326, by Ruhräh.

[91] "A Manual of Diseases of Children," p. 319, by Ruhräh.




CHAPTER XI

THE FEEDING OF ADULTS IN DISEASES OF THE GASTRO-INTESTINAL TRACT


ACUTE AND CHRONIC GASTRITIS

~Predisposing Factors.~--The majority of diseases affecting the
stomach have as their predisposing factors, and owe their development
to, one or all of the following conditions: (1) errors in diet; (2)
disturbed secretory processes; (3) disturbed motility and tone.

It is probable that in the beginning the first factor was the chief
offender in the case, bringing about the development of one or both of
the other conditions. The other factors to be considered in this
respect are heredity, occupation, poverty, and diseases which involve
to a greater or lesser degree the digestion of the stomach and
intestines. A child may inherit a weakened organism through excesses
or disease on the part of the parent. If this weakness is not overcome
while the child is growing, the probabilities are that the digestion
steadily declines until in adult life it becomes a pathological
condition. Lack of fresh air, poor and dirty food, unwholesome
surroundings, crowded and badly ventilated sleeping rooms,
insufficient water, and overwork, all act in making the digestion bad.
These must be overcome if permanent good is to result.

~Errors in Diet.~--Errors in diet arise more often through ignorance
than from any other cause. A child may be allowed to eat any and all
kinds of unwholesome and unsuitable food. When the stomach rebels,
showing the serious danger signals of nature, medicines are given but
the diet is unheeded, until the time comes when even the medicines
fail to give temporary relief, and the organs of digestion are in some
instances permanently impaired.

~Disturbed Secretory Processes.~--Consensus of opinion goes to show
that the majority of cases of acute and chronic gastritis (catarrhal)
and gastric ulceration are due primarily to a disturbance of the
secretory processes, while the impaired motility and lack of tone in
the stomach probably influence their development and aggravate the
disease already present.

~Composition of Gastric Juice.~--In a former chapter the processes of
gastric digestion were explained. The gastric juice, composed of from
0.2 to 0.3% free hydrochloric acid and several important enzymes and
lipases, which act upon the proteins and emulsified fats, must be
sufficient in quantity to assure good digestion, and when anything
arises to interfere with the secretion of this fluid a deviation from
the normal is bound to occur.

~Disturbed Motility and Tone.~--Again, it has been proved that good
gastric digestion, like good intestinal digestion, depends more or
less upon the way in which the food mass is mixed with the digestive
juices and moved along the alimentary canal. Anything which interferes
with the secretion of the juices or delays the food over its normal
length of time in the stomach surely exerts unfavorable influences on
the general metabolism of the food, for while, as we have already
found, gastric digestion is not essential to the final utilization of
the food in health, in disease it undoubtedly exerts a marked
influence upon the general nutrition of the individual.


HYPOCHLORHYDRIA

The lack of hydrochloric acid in the gastric juice lowers the
resistance to bacterial action, for this constituent exerts a decided
germicidal influence in gastric digestion, preventing fermentation
with the production of organic acids and probably alcohol. In
conditions due to hypochlorhydria (lack of hydrochloric acid) foods
which leave the stomach quickly must be given with enough of the other
necessary constituents in their simplest and most easily digested form
to balance the diet and prevent the occurrence of the other disorders
as troublesome as the original disorder.

~Dietetic Treatment.~--The following points must be kept in mind in
formulating a dietary for patients suffering from a deficiency of
hydrochloric acid: (1) boil the drinking water to destroy any bacteria
which may be present; (2) use carbohydrates in the form of starch
rather than sugar, since starch is less liable to fermentation from
bacteria than sugar; (3) limit the foods which delay the passage of
the food mass from the stomach; fats pass into the duodenum more
slowly than other foods and when fed with other foods delay their
passage materially; (4) avoid the use of soda bicarbonate, as it tends
to reduce the normal acid content of the stomach, thus preventing its
germicidal action upon the fermentative bacilli; alkaline carbonates
likewise inhibit the flow of gastric juices; (5) give especial
attention to the attractiveness of the food served; let it be
appetizing and savory, for by such means is the appetite juice and
incidentally an increased flow of the gastric juices stimulated; (6)
condiments and spices, meat broths high in extractives, and salt foods
such as caviar and endives may be given at the discretion of the
physician; it is seldom advisable to give the foods which are
indigestible, even when they act as stimulants to the secretory cells
of the stomach.


HYPERCHLORHYDRIA

(Excess secretion of acid in the stomach)

~The Effect of Excess Acid.~--An excessive flow of hydrochloric acid
has been found to be the cause of much of the acute and chronic
gastritis, in fact more of the cases are traceable to an excess than
to a lack of hydrochloric acid. This acid is more or less irritating
in character, and the tender mucous membranes lining the gastric organ
being constantly bathed in a secretion composed chiefly of acid must
necessarily in time suffer a certain amount of irritation and
inflammation, causing the development of a pathological condition
which may be temporary or permanent, that is, it may result in acute
or chronic gastritis, according to the amount of acid secreted and the
length of time the hypersecretion is allowed to continue.

~Determining the Acid Content of Stomach.~--The difference between the
cases brought about by an excess flow of hydrochloric acid are more or
less difficult to distinguish from those caused by a lack of this
constituent in the gastric juice, chiefly because in the latter case
the organic acids formed as the result of bacterial action upon the
food exert an equally irritating effect upon the membranes of the
stomach, and the only sure method of determining the cause of the
disturbance is by an analysis of the stomach contents, by which means
the percentage of hydrochloric acid is determined.

~Lavage.~--It has been found advisable, in some cases of acute
gastritis which do not yield readily to rest and liquid diet, to wash
the stomach and allow a certain period of rest before giving any food;
in this way the organ is rid of all of the offending material and thus
has a better chance of a quick recovery.


ACUTE GASTRITIS

~Dietetic Treatment.~--The following dietetic treatment for acute
gastritis is advised: As the stomach is the chief seat of disturbance,
all unnecessary work must be taken from this region for a certain
period:

(1) That any obscure cause may manifest itself and the diagnosis may
be rendered more accurately and more quickly.

(2) That by resting the organ the offending materials may pass out of
the body and thus prevent further trouble.

~Starvation Period.~--Twenty-four hours of total abstinence from food
may seem extreme, but as a rule in acute cases of gastritis it is the
only sane and safe method of instituting a diet and thus beginning to
overcome the cause of the disturbance. After the period of starvation
the diet is begun with caution.

~Fluid Diet.~--Fluids should be given first in the form of
well-skimmed broths, which may be reënforced with egg or cereal flours
when the patient is very thin or anemic. Buttermilk, made with the
Bulgarian cultures, koumiss and other fermented milk foods, liquid
beef preparations such as peptonoids or panopepton, albumenized orange
juice, cereal gruels treated with Taka diastase when it is found
necessary, and peptonized milk. These may be given in from four to six
ounces at a time, every two hours on the second day.

~Increasing the Diet.~--On the third day if the attack is slight the
diet may be increased by adding toast, softened with peptonized milk,
an ordinary serving (3 ounces) of farina, cream of wheat or rice,
reënforced meat broth with two crackers, a cup of tea and a slice of
toast, and one or two soft-cooked eggs. If the acute symptoms are
still present on the third day, the diet advised for the second day
must be continued until they disappear.

~Convalescent Diet.~--On the fifth day, if progress is satisfactory,
lightly broiled chicken or a small piece of rare broiled beefsteak may
be added to the diet and the meals reduced in number from six to four.

~Relapse.~--The patient must be warned against overeating or eating
any of the articles which are known to cause an acute attack in his
individual case, since one attack predisposes to another, and chronic
gastritis may develop as the result of the continual gastric
disturbance.


CHRONIC GASTRITIS

The treatment in chronic gastritis is very like that in the more acute
form; that is, it must be combated by removing the cause. Lack of
fresh air and exercise have much to do with the development of chronic
gastritis, but even they combined with a judicious amount of rest
would be wasted without a proper adjustment of the diet to cover the
main points of the disturbance. As has already been mentioned, the
cause may be a lack of gastric juice or it may be an excess of it; it
may be intensified by an ~atonic~ condition of the organ or from the
food passing too quickly into the duodenum.

~Test Meals.~--As a rule it is not safe to make a snap diagnosis as to
the cause of this disorder. Since in many instances the more serious
disorders may be traced to a disregard for nature's danger signals,
the physician as a rule advises a test meal, this meal consisting of a
glass and a half of water or a cup or two of tea without cream or
sugar and from one to two slices of toast or water rolls. In from
three-fourths to one hour or longer this is removed from the stomach
by means of a stomach pump and analyzed, the result of the chemical
and bacterial analyses forming the basis for diagnosis. This meal is
generally given in the morning before any other food has been
eaten.[92]

~Dietetic Treatment.~--The foods constituting the diet in chronic
gastritis must be of the simplest character and prepared in the
simplest manner. No fried foods are permissible. Pastries, griddle
cakes, rich puddings and sauces, candies, and alcoholic beverages must
be omitted from the diet as well as the following articles of food:
pork, veal, shellfish except oysters, sardines, canned meats and
canned fish, highly seasoned and spiced dishes, twice-cooked meats,
vinegar, pickles, olives, cold slaw, pickled beets, catsup, mustard,
coarse fibered vegetables such as cabbage, old onions, old turnips,
and cucumbers, strong tea, coffee, or chocolate, rich cream or dishes
made entirely of cream. In cases of excessive acidity due to a
hypersecretion of HCl the extractives of meat are contraindicated,
hence all gravies and outside parts of roasted meat must be omitted or
limited in the diet.


GASTRIC ULCERATION

Gastric ulcer may develop without an apparent cause. As a rule,
however, it manifests itself in individuals between the years of
fifteen and forty, particularly after prolonged digestional
disturbances, especially those accompanied by a hypersecretion of
acid. As the disease progresses, anemia is more or loss severe, adding
difficulty to the feeding problem. Many of the symptoms are like those
of chronic gastritis, such as pain. However, the character of this
pain may be different, beginning soon after eating and radiating
toward the back. This point may be affected by position. As a rule
there is a tenderness over the seat of the ulcer. This is detected by
palpation. Vomiting is one of the most general symptoms in gastric
ulceration. This may begin from one to two hours after eating when the
pain is at its height, or it may start as soon as food enters the
stomach. As a rule the latter condition is found more often in very
nervous women whose mental attitude affects the stomach to such an
extent as to make it difficult to give them sufficient food to nourish
them.

~Hemorrhage.~--Hemorrhage occurs in about half of the cases. The
bleeding may be profuse and the blood bright red, or it may be less
severe and the color of the blood changed by contact with the gastric
juices to a dark brown like coffee grounds.

~Excess Acid.~--Hyperacidity is present in the majority of the cases,
the percentage of HCl rising at times fifty per cent. or more. Other
cases occur in which all of the just mentioned symptoms except
dyspepsia are missing, the first intimation of the ulcer being
hemorrhage or perforation.

The patient with gastric ulcer may recover entirely and never have a
return of the trouble, but care and close attention are necessary,
since the ulcers are apt to recur, at times a series of ulcers
developing one after another. Death may occur from exhaustion or from
perforation and peritonitis. Surgical intervention is as a rule
necessary when the ulcers persist, as they generally develop at or
near the pyloric opening; and the constant development of cicatricial
tissue brings about an obstruction of the pylorus, which if not
relieved would allow the patient to starve.

~Diet Treatment.~--There are a number of treatments used in overcoming
this condition. After the test meal and the diagnosis, the patient is
placed upon a diet directed to overcome the chief symptom; for
example, if the ulcer developed as a result of hyperacidity, the diet
would be directed toward the relieving of that symptom. Boas[93]
divides the treatment into three stages: (1) hemorrhage; (2) the
intermediate stage; (3) the convalescent stage.

~Starvation Treatment.~--The majority of physicians institute a total
abstinence period for the first stage, allowing no food or water to be
taken by mouth. If the patient is very weak and anemic from the
extended course of the disease, nutrient enemas are given from four to
six times a day, alternating with saline enemas. This total abstinence
continues from three to six days. Some cases have been known to be fed
in this way for a month or six weeks with obvious success. However,
this is not the rule but the exception. The diet must be adjusted to
the needs of each individual, but a few general rules may be found
helpful.

~Dietetic Treatment.~--Milk is the food generally utilized in the
beginning. This may require peptonizing to be digested, or it may
have to be modified with limewater. Protein foods require HCl for
their digestion. If these foods are fed they will absorb some of the
excess acid, and in this way save the already irritated wall of the
organ from additional irritation. When protein foods are given they
must be in the form of soft-cooked eggs, scraped raw beef or beef
juice, milk soups, and like protein foods.

When there is a dilatation of the organ there is more or less danger
of fermentation taking place, with the formation of organic acids.
These acids are exceedingly irritating, and every care must be
observed to prevent their production. The following dietetic régime
may be used as a guide in many cases of gastric ulceration:

~Milk Diet.~--1/2 glass (4 ounces) of milk peptonized at 115° F. for
20 minutes, every hour for three or four days. After this the interval
between feedings is lengthened to two hours and the amount of milk
increased to 3/4 of a glass (6 ounces). This is continued from a week
to ten days. The patient may be given a cup of well-strained meat
broth, reënforced with an egg, once or twice a day, to vary the
monotony of the diet. During the third week the milk may be given in
the form of milk soups. These may be slightly thickened with barley,
rice, or farina flour. The soups may be flavored with beef extract,
but only a small quantity must be used, owing to the stimulating
properties of these substances.

~Water as a Stimulus to Gastric Secretion.~--Water is exceedingly
stimulating to the acid secreting cells of the stomach, hence it is
advisable to limit the amount of water taken by mouth, allowing the
patient just enough to wash out the mouth without swallowing any. The
thirst is relieved by saline enemas.

It has been found, in many cases of gastric ulceration, especially
those accompanied by hemorrhage, that glucose gives better results
when used in rectal alimentation, than any other substance. The
strength of the solution varies from a five to a twenty-five per cent.
solution. The number of glucose enemas given each day must be
regulated by the physician. The method used is the same as in other
rectal feedings, the enema is given "high," and the flow regulated
(drip-method).

~Convalescent Diet.~--During the fourth week, if the pain and
discomfort are decreasing, soft-cooked or creamed eggs may be added to
the diet, together with thoroughly boiled rice, farina, cream of
wheat, wheatena and other finely ground wheat foods, wine or fruit
jelly, sweetened slightly, or by using a small amount of saccharin for
the purpose, junket and plain vanilla ice cream. At the end of the
fourth week a very small portion of meat may be given once a day. It
may be scraped raw beef spread upon toast or zwieback, or very lightly
broiled beefsteak, broiled lamb chop or chicken (breast only), or
boiled or broiled sweetbreads or brains. Spinach or green peas pressed
through a sieve are the first vegetables allowed. After these young
tender carrots and string beans may be given. Tea, coffee, and
chocolate are eliminated from the diet. Milk flavored with coffee or
cocoa may serve as a hot drink in the morning when the desire or need
for such a drink is manifested. Butter is the best form of fat to be
used in cases of gastric ulceration, but this must be given with the
greatest caution. In cases where this fat is used in the form of
cream, the amount must be cut down or entirely abandoned when there
are evidences of butyric fermentation. Buttermilk, koumiss, and other
fermented milk drinks are often found very satisfactory adjuncts to
the diet. These may be given between meals, or at meals they may be
substituted entirely for the milk when other foods are being given.
They are not sufficiently nourishing to take the place of the milk
diet otherwise. Albumenized orange juice and cream, egg and vichy may
be given to add variety to the diet.

~Anemia.~--When anemia is severe, as is often the case in gastric
ulceration, the diet must be reënforced to overcome it. Some of the
concentrated milk foods such as plasmon, encasin, sanatogen, etc., as
well as the predigested meat foods, such as panopepton, liquid beef
peptonoids, and like preparations, may be used to reënforce the diet.

~Bland Diet.~--In certain cases of gastric ulceration it has been
found more advisable to use what is known as a bland diet. This
consists of farinaceous foods such as farina, arrowroot, cream of
wheat, corn meal, wheatena, malted breakfast foods cooked thoroughly
and given in the form of gruels, and some of the proprietary infant
foods, such as Mellin's Food, Eskay's Food, Racahout. These foods may
require the addition of Taka diastase to make them more readily
digested. They leave the stomach more rapidly than any of the others,
and for this reason will be found to give less discomfort than the
foods containing a high percentage of protein and fat. This diet,
however, cannot be prolonged on account of its lack of balance. If the
gruels are made with milk instead of with all water they become more
evenly balanced. Samples of the stomach contents may be taken for
analyses from time to time.

~Lavage.~--When lavage is necessary the patient must be allowed to
rest after the process before being given food, otherwise it is apt to
be vomited.

~Instructions to Nurse.~--The treatment for gastric ulceration is thus
seen to be strenuous. In the beginning the patient is placed on a
liquid or semi-solid diet, or is not fed at all for a time. This is
done that the diseased organ may have a chance to adjust itself as far
as possible and to give the physician an opportunity of studying the
changes taking place in that organ. During the course of the disease
the general symptoms which develop from time to time, causing more or
less pain and discomfort to the patient, are nervousness, which in
some individuals amounts to melancholia, extreme anemia and an utter
distaste for food, all of which require patience on the part of the
physician, the nurse, and the patient herself to overcome. The nurse
must see that the patient is not disturbed or made unhappy by having
business or home cares talked over in her presence; she must be kept
as cheerful and as comfortable as her condition permits and urged to
use care in her diet. After the ulcer is healed, to prevent a return
of the trouble she must be warned against eating too fast or when
over-tired, and she must be advised against very hot and highly
seasoned foods, for, in the observance of these simple common-sense
precautions only is she even in a measure saved further attacks.

~Special Diets Used for Gastric and Duodenal Ulcer.~--There are
several well-known diets used in these conditions. Among those that
have been found most satisfactory may be mentioned the Sippi diet, the
Lenhartz diet.

All of these diets require the most careful adjustment as to
regulation of intervals of feeding, type of food material used, and
method of preparation and administration of food.

The treatment is directed toward the reduction of the free
hydrochloric acid in the stomach in order that the ulcer may have an
opportunity for healing.

~Sippi Diet.~--Equal quantities of heavy cream and whole milk,
beginning with 1/2 ounce each every hour during the day. Alkaline
powders are given with the meal and one-half hour after the meal.
These consist of 15 grains each of sodium bicarbonate and bismuth
subcarbonate with the feeding, and 10 grains of light oxide of
magnesia and 15 grains of sodium bicarbonate between feeding. The
cream and milk are increased at the rate of one-half ounce each at
each feeding for two days, the powders are continued as on the first
day. On the fourth day an egg is added to the diet, the milk and cream
are given in quantities of one and one-half ounce each, every hour. On
the fifth day two eggs are added. On the sixth day one helping of
oatmeal or other soft cereal is added to the above diet. The diet is
in this way increased until the patient is taking three eggs and nine
ounces of cooked cereal each day in addition to the cream and milk
mixture. The amount given at one time must be small, never exceeding
six ounces (according to Carter, Howe and Mason).

An accurate control of the acidity of the stomach should be
maintained, this is accomplished by withdrawing a certain amount of
the gastric contents by means of the stomach tube.

~The Lenhartz Diet.~--This diet is likewise given in hourly feedings,
consisting of milk and raw eggs in the beginning, then a small portion
of sugar is added, next scraped beef is added to the milk, eggs and
sugar, already given, then boiled rice. Next a small quantity of
zwieback (or soft toast), and continuing in this way, chicken, and
butter are admitted. In the beginning the quantity of milk is 100 c.c.
and the number of eggs 2, given raw. It is served iced, and with a
teaspoon. When the sugar is added it is beaten up with the eggs (20
gm.). The milk and eggs are divided into separate feedings and given
at hourly intervals from 7 A.M. to 7 P.M. It is rarely possible to
give the amounts called for in the Lenhartz diet after the sixth day,
but as much as possible should be given without risking an acute
disturbance. Women, as a rule, find it more difficult to take the full
amount ordered than men.

The following outlines represent the diet for the first, third, sixth,
seventh and tenth day:

FIRST DAY

   7 A.M.      Egg
   8 A.M.      Milk, 20 c.c.
   9 A.M.      Egg
  10 A.M.      Milk, 20 c.c.
  11 A.M.      Egg
  12 noon      Milk, 15 c.c.
   1 P.M.      Egg
   2 P.M.      Milk, 15 c.c.
   3 P.M.      Egg
   4 P.M.      Milk, 15 c.c.
   5 P.M.      Egg
   6 P.M.      Milk, 15 c.c.

Total: Milk, 100 c.c. Eggs (raw), 2.

THIRD DAY

   7 A.M.      Egg; sugar, 2 gm.
   8 A.M.      Milk, 50 c.c.
   9 A.M.      Egg; sugar, 3 gm.
  10 A.M.      Milk, 50 c.c.
  11 A.M.      Egg; sugar, 3 gm.
  12 noon      Milk, 50 c.c.
   1 P.M.      Egg; sugar, 3 gm.
   2 P.M.      Milk, 50 c.c.
   3 P.M.      Egg; sugar, 3 gm.
   4 P.M.      Milk, 50 c.c.
   5 P.M.      Egg; sugar, 3 gm.
   6 P.M.      Milk, 50 c.c.
   7 P.M.      Egg; sugar, 3 gm.

Total: Milk, 300 c.c. Eggs (raw), 4. Sugar, 20 gm.

SIXTH DAY

   7 A.M.      Egg; sugar, 4 gm.
   8 A.M.      Milk, 100 c.c.
   9 A.M.      Egg; sugar, 4-1/2 gm.; scraped beef, 12 gm.
  10 A.M.      Milk, 100 c.c.
  11 A.M.      Egg; sugar, 4-1/2 gm.
  12 noon      Milk, 100 c.c.
   1 P.M.      Egg; sugar, 4-1/2 gm.; scraped beef, 12 gm.
   2 P.M.      Milk, 100 c.c.
   3 P.M.      Egg; sugar, 4-1/2 gm.
   4 P.M.      Milk, 100 c.c.
   5 P.M.      Egg; sugar, 4 gm.; scraped beef, 12 gm.
   6 P.M.      Milk, 100 c.c.
   7 P.M.      Egg; sugar, 4-1/2 gm.

Total: Eggs (raw), 7. Milk, 600 c.c. Sugar, 30 gm. Scraped beef, 36 gm.

SEVENTH DAY

   7 A.M.      1 soft-cooked egg
   8 A.M.      Milk, 100 c.c.
   9 A.M.      Egg; sugar, 13 gm.
  10 A.M.      Milk, 100 c.c.; scraped beef, 23 gm.; boiled rice, 33 gm.
  11 A.M.      1 soft-cooked egg
  12 noon      Milk, 125 c.c.
   1 P.M.      Egg; sugar, 13 gm.
   2 P.M.      Milk, 125 c.c.; scraped beef, 23 gm.; boiled rice, 33 gm.
   3 P.M.      1 soft-cooked egg
   4 P.M.      Milk, 125 c.c.
   5 P.M.      Egg; sugar, 14 gm.
   6 P.M.      Milk, 125 c.c.; scraped beef, 24 gm.; boiled rice, 34 gm.
   7 P.M.      1 soft-cooked egg

Total: Eggs (raw), 4; (soft-cooked), 4. Milk, 700 c.c. Sugar, 40 gm.
       Scraped beef, 70 gm. Boiled rice, 100 gm.

TENTH DAY

   7 A.M.      1 soft-cooked egg
   8 A.M.      Milk, 166 c.c.
   9 A.M.      Egg; sugar, 13 gm.
  10 A.M.      Milk, 168 c.c.; scraped beef, 23 gm.; boiled rice, 66 gm.;
               butter, 4 gm.
  11 A.M.      1 soft-cooked egg; zwieback (or soft toast), 20 gm.;
               butter, 4 gm.
  12 noon      Milk, 166 c.c.; minced chicken, 25 gm.
   1 P.M.      Egg; sugar, 13 gm.
   2 P.M.      Milk, 166 c.c.; scraped beef, 25 gm.; boiled rice, 66 gm.;
               butter, 4 gm.
   3 P.M.      1 soft-cooked egg; butter, 4 gm.; toast or zwieback, 20 gm.
   4 P.M.      Milk, 168 c.c.; minced chicken, 25 gm.
   5 P.M.      Egg; sugar, 14 gm.
   6 P.M.      Milk, 166 c.c.; scraped beef, 24 gm.; boiled rice, 67 gm.;
               butter, 4 gm.
   7 P.M.      1 soft-cooked egg

Total: Eggs (raw), 4; (soft-cooked), 4. Milk, 1000 c.c. Sugar, 40 gm.
       Scraped beef, 70 gm. Minced chicken, 50 gm. Butter, 20 gm.
       Boiled rice, 200 gm. Toast or zwieback, 40 gm.


GASTRIC CANCER

As a rule the seat of the gastric cancer is the pylorus. The patient
gives evidence of chronic gastritis with continued pain, localized
tenderness, vomiting of partially digested food and at times
dilatation from extreme fermentation. The hemorrhages are as a rule
not large, the blood having changed to a brownish color resembling
coffee grounds. Vomiting, in cases where the pylorus is involved,
generally occurs several hours after eating, the vomitus being in an
advanced state of fermentation. Upon analysis of the stomach contents
there is found to be a lack of free HCl.

~Dietetic Treatment.~--In the dietetic treatment of cancer of the
stomach the most digestible forms of foods must be given, milk forming
in this, as in other gastric disorders, the chief article of diet. As
too much food cannot be tolerated, the meals must be small, even if
given more frequently. The patient is often found to evince a distaste
for meat, in which case fish may be substituted. When meat is given,
it must be simple in form and preparation, such as boiled or broiled
sweetbreads or brains, scraped beef or stewed chicken. Rice, farina,
cornmeal mush, and other fine cereals, cooked with or without milk,
are valuable additions to the diet. Well-cooked and strained spinach,
green peas, cauliflower, carrots, and tender string beans and boiled
or baked potatoes well mashed may be recommended. Tea, coffee, or
cocoa may be used to flavor the milk. These must be given in small
portions. The following diet list is recommended by Friedenwald and
Ruhräh:

                                               _Calories_
   8 A.M.   100 grams of milk with tea               100.0
             30 grams of milk toast                  130.0
  10 A.M.   100 grams of baked trout                 106.0
            100 grams of milk                         67.0
         or  30 grams panopepton (57.5)
             10 grams of butter                       81.0
             50 grams of toast                       130.0
             50 grams of sherry                       60.0
  12 M.         Bouillon with 5 grams somatose        16.0
            100 grams of chicken                     106.0
         or 100 grams squab (100)
         or 100 grams of calves' sweetbreads (90)
         or 100 grams of calves' brains (140)
             60 grams of macaroni                    212.0
         or 100 grams of mashed potatoes (127)
         or 100 grams of spinach (166)
         or 100 grams of asparagus (18)
             25 grams of stale wheat bread            65.0
   4 P.M.    20 grams of toast                       130.0
             20 grams of butter                      162.0
             40 grams of caviar                       52.0
   7 P.M.   130 grams of milk (100) with 5 grams
                somatose (16)                        116.0
            100 grams of rice cooked in milk         177.0
             50 grams of wheat bread                 130.0
   9 P.M.    30 grams of panopepton                   57.5
                                                    ------
                                                    2024.5


SUMMARY

FACTORS INDUCING GASTRIC DISTURBANCES

1. ~Errors in Diet.~--Over-feeding, under-feeding, improper food,
unbalanced diet.

2. ~Disturbed Secretory Processes.~--

    (a) Over- or under-secretion of gastric juice.

    (b) An excess or deficiency of hydrochloric acid in the juices.

3. ~Impaired Motility and Tone of the Gastric Organ.~--The peristaltic
waves and muscular contraction of the stomach walls becoming sluggish
prevent the food mass from passing into the intestines at a normal
rate of speed, thus giving rise to a fermentation of the food and a
consequent dilatation of the organ from the gas thus produced.

~Other Factors.~--Lack of fresh air and exercise, indoor occupation,
bad hygiene, unsanitary surroundings, heredity, certain diseases which
are accompanied by gastric disorders.

~Diseases of Gastric Organ.~--Acute and Chronic Gastritis,
Gastric-Ulceration, Gastric Cancer.

~Treatment.~--Tests--Test meals, X-Ray examinations (pictures and
Fluoroscope). Patient is given no breakfast on day of test. In X-Ray
laboratory a bismuth or barium meal is given, this meal consists of a
pint of fluid, either buttermilk or malted milk, into which a certain
amount of bismuth or barium chloride is mixed.

~Starvation Period.~--A period of abstinence from food is instituted
in most of the gastric disorders, (a) to determine the extent and
character of the disease, (b) to rest the digestive tract.

~Dietetic Treatment.~--Diet adjusted to meet the needs of the
individual case as determined by the medical examination.

~Instruction to Patient.~--Individual warned against overeating,
drinking and constipation.


PROBLEMS

(a) Formulate a diet order for a patient suffering from chronic
gastritis. (Individual's food requirements must be observed.)

(b) Formulate a diet for gastric ulceration. List the available foods;
the avoidable foods.

(c) Outline a diet to be used in case of gastric cancer; show how it
differs from the one used in gastric ulceration.


FOOTNOTES:

[92] It is also customary to give the patient a bismuth or barium meal
in order that an X-ray and fluoroscopic examination may be made to
determine the character and extent of the disturbance.

[93] "Diseases of the Stomach," by Boas.




CHAPTER XII

DISEASES OF THE INTESTINAL TRACT


ACUTE AND CHRONIC DIARRHEA (CATARRH), ENTEROCOLITIS, DYSENTERY,
CONSTIPATION, APPENDICITIS, CHRONIC CONSTIPATION, AUTO-INTOXICATION

Diarrhea, like gastritis, may be a symptom of many diseases and a
result of many digestional disturbances. Enteritis, enterocolitis,
dysentery, typhoid fever, and certain cases of tuberculosis and
syphilis are all accompanied by an inflamed condition of the mucous
lining of the intestinal walls, and in each of these pathological
conditions we may find diarrhea as a resulting symptom.

~Causes.~--Diarrhea may be acute or chronic in character. It may be
brought on by errors in diet, warm weather, certain drugs, ptomaines,
bad hygiene, polluted water or milk, and by overeating. Idiosyncrasies
against certain kinds of food have been found in both adults and
children; these idiosyncrasies are manifested by pain and diarrhea
whenever the offending foods have been eaten. Acute diarrhea has also
been brought on in children by the drinking of cold lemonade when
over-heated.

~Diarrhea in Children.~--All diarrheas in children, and especially
those developing during the hot months, must be looked on with
suspicion and given immediate attention before they have an
opportunity to develop serious features which may terminate in death
before the seriousness of the condition is realized.

As a rule, almost any diarrhea in children will raise the temperature.
This does not occur so often with adults unless the diarrhea results
from infectious fevers, ptomaines, etc., in which case it may rise
suddenly and to a considerable height.


ACUTE ENTERITIS (DIARRHEA)

~The Bowels.~--The symptoms of this condition are too liquid or too
frequent stools, the number varying from three to twelve or more a
day. They may be greenish yellow in color and contain particles of
undigested food and mucus. In prolonged diarrheal attacks the stools
sometimes contain blood.

The attack may be accompanied by more or less pain of a colicky
nature, due to the formation of gas in the intestinal tract. In
ptomaine poisoning this pain is sometimes very intense. As a rule the
intestinal tract is emptied by means of salt, oil, etc., but this is
generally directed by the physician. A soapsuds or salts and glycerin
enema to flush the colon will often give quick relief by dispelling
the gas.

~Starvation.~--The entire digestive tract requires absolute rest for a
certain period; no food and very little water, the latter in the form
of bits of ice only, are given for a period lasting from twelve to
thirty-six hours or more, depending upon the violence of the attack
and the condition of the patient. This is to allow the toxic
substances which are probably causing the disturbance to pass out of
the body, either in the feces or in the urine. When the acute symptoms
subside, that is, when the pain and distention of the intestines have
disappeared, and the bowel movements become more normal in number and
character, the dietetic treatment suitable to the condition is
instituted.

~Dietetic Treatment.~--The first day the patient is given a small cup
of weak tea, half a glass of buttermilk or peptonized milk, or a cup
of well-skimmed meat broth, every three or four hours. If the patient
is weak, the nourishment may be given oftener, and in those cases it
is often found advisable to give a small amount of alcohol in the
form of brandy in albumen water, or panopepton or liquid peptonoids.
These may be administered in tablespoonful doses every two hours.
Whole milk, unless it is peptonized, and at times even then, is not
advisable in diarrheal conditions on account of its liability to form
curds which decompose with the production of toxic substances, known
to be exceedingly irritating to the already inflamed mucous membranes
lining the intestinal walls.

~Increasing the Diet.~--As the diarrhea and inflammation subside, the
following foods are gradually introduced into the dietary, keeping in
mind always that a return of the acute symptoms is apt to occur. Hence
the patient must never be overfed. It is better to err on the side of
too little than too much food during the early convalescent period.

~Diet.~--Soft-cooked eggs, toast (slightly buttered), cocoa made with
water instead of milk, chicken, calf's-foot or wine jelly; later,
well-cooked rice, junket, and soft custard; still later, lightly
broiled beefsteak, lamb chops, chicken, squab or quail, sweetbreads or
brains. Not until the patient is entirely free from all symptoms of
diarrhea or intestinal disturbance may the following foods be given:
cream or cream dishes such as cream toast, cream chicken, or cream
soup, raw or stewed fruit, green vegetables, salt foods, spiced foods
of any description; pastries, confectionery and desserts in general,
unless they are simple in character and are sweetened with saccharin
instead of sugar, as the latter substance is particularly susceptible
to fermentation.

~Anemia as a Result.~--Anemia is one of the most common results of
prolonged diarrheal attacks, especially in those toxic diarrheas
resulting from infectious diseases, dysentery, etc. The blood-making
tissues suffer from a lack of nourishment and are in consequence
incapable of producing blood of the best quality. Hence the starvation
treatment cannot be carried on over a very extended period or the
resulting anemia may be more difficult to overcome than the original
trouble.

~Selecting and Regulating the Diet.~--The following points must be
kept in view when regulating the diets of individuals who are prone to
develop diarrhea:

~Preparing the Diet.~--Only such foods as are known to agree with the
individual, and these prepared in the simplest manner possible, must
have a place in the dietary.

~Fermentation.~--All foods that are subject to fermentation either in
the stomach or intestines must be withheld, at least until the attack
is well over. Sugar is an example of such foods; saccharin may be
substituted when necessary.

~Avoidable Foods.~--Pork, veal, and shellfish must be left out of the
dietary, possibly for months, since they have been found frequently
not only to bring about a return attack of diarrhea but also to have
been the cause of the original one.

Fatty foods of all sorts had best be avoided as long as there are
symptoms of diarrhea; these foods are handled with difficulty by the
digestive apparatus and impose extra work upon the intestine, which is
already taxed by the disease.

~Restricting Fluids.~--Fluid foods should be more or less limited in
the diet, since they require more effort on the part of the intestines
than the more concentrated foods.

~Proprietary Foods.~--Certain proprietary infant foods[94] are at
times found to be exceedingly valuable, since they furnish food in a
concentrated and digestible form. Among these Mellin's Food, Racahout,
and Imperial Granum may be mentioned.


CHRONIC ENTERITIS

~The Stools.~--When the diarrhea is chronic in character, the
character of the stools indicates the seat of the inflammation. When
there is a great deal of undigested food found in them the upper part
of the bowel is more affected; when the stools contain more mucus than
food the lower bowel is the chief seat of the trouble. The frequency
and fluidity of the stools impose a great strain upon the entire body,
causing a progressive emaciation and anemia.

The treatment is similar to that instituted in acute attacks. The
starvation régime cannot be carried out for a long period. Efforts
must be made to ascertain the cause of the trouble and to overcome it.
This is, as a rule, more easily accomplished with adults than with
infants and children.

~Dietetic Treatment.~--The diet is the chief point of observation and
attention. The same care must be observed as is found necessary in the
after-treatment of acute diarrhea. The patient must be cautioned not
to eat indigestible foods or those which are known to cause trouble in
this respect. She must be warned against eating when over-tired.


ENTEROCOLITIS

Enterocolitis is an inflammation of the lower intestines and colon.
The stools contain more mucus than those occurring when the
inflammation is higher up in the intestines and blood is also more
frequent in these stools. The prostration is more marked and the fever
apt to be higher than in ordinary diarrheal attacks. However, acute
attacks of enterocolitis do not produce the marked anemia or the
emaciation which are so common in the chronic cases of enteritis.

Dietetic treatment the same as that used in acute diarrhea.


ACUTE DYSENTERY

Dysentery is a disease in which the seat of inflammation is the colon.
The bowels are distended and tender, the pain at times is acute and
spasmodic, and the fever moderate. The constant desire to defecate and
the straining which accompanies each effort, as well as the small
stools, containing both blood and mucus, furnish the characteristic
symptoms of this disease. Rest in bed is absolutely necessary; the
patient must be induced to use a bedpan.

~Dietetic Treatment.~--The diet consists entirely of liquids as in
acute diarrhea, the same careful régime being observed as in those
conditions. The soreness in the abdomen is at times relieved by spice
poultices or a hot turpentine stupe.


CHRONIC DYSENTERY

When the above conditions become chronic, the patient loses weight and
strength rapidly, becomes anemic and emaciated. The treatment, like
that used in the acute disease, consists of rest and liquid diet. The
medicinal treatment is left entirely in the hands of the physician.


APPENDICITIS

Appendicitis is an inflammation of the vermiform appendix. It may be
acute or chronic in form.

~Symptoms.~--The disease is manifested by sudden pain in the right
side, tenderness over the seat of the inflammation, and a localized
rigidity of the right iliac fossa. The attack is as a rule accompanied
by fever which may run as high as 103° or 104° F. The patient may
suffer from nausea and vomiting. Constipation is generally an annoying
symptom of the disease.

~Rest in Bed.~--The treatment of the acute attack consists of total
abstinence from food for twelve or more hours until the most acute
stage has passed and the patient either passes into the hands of the
surgeon or the symptoms begin to subside in violence. It is necessary
that the patient be kept in bed, not being allowed to rise for
anything. The nurse must make him understand that his recovery,
possibly his very life, depends upon his absolute quiet during the
early stages of the disease.

~Dietetic Treatment.~--When the first acute symptoms have passed, the
diet must consist of fluids, well-skimmed meat broths, buttermilk,
peptonized milk, albumen water or albumenized orange juice. No solid
food must be given until the acute symptoms have disappeared. When the
tenderness in the right side has entirely left him and he no longer
suffers the pain or nausea, a gradual return to a normal diet may be
made. The patient must be cautioned against eating indigestible foods,
as an attack of intestinal indigestion may readily start up an
irritation in the susceptible appendix and cause a second attack of
appendicitis which is often of a more serious nature than the first.

~Convalescent Diet.~--The return to solid food is made gradually as in
other intestinal disorders, by giving the most digestible foods first.
Soft toast, soft eggs, fine cereal gruels, well-cooked rice,
well-baked white potatoes, meat, wine or fruit jellies; then lightly
broiled beefsteak, lamb chop, chicken, sweetbreads, or brains given in
small quantities until the intestinal tract has regained its vigor.

~Foods to Be Avoided.~--Highly seasoned foods must be avoided on
account of their astringent qualities, which may cause constipation.
Long, tough-fibered meats, coarse vegetables, rich foods, in fact
anything which may cause intestinal indigestion, must be eliminated
from the dietary. A decomposition of the foods lying in the lower part
of the small intestine is dangerous to such individuals, since such
products are highly toxic in character and exceedingly irritating to
the already tender appendix.


CHRONIC CONSTIPATION

Chronic constipation is so universal a condition that it must be
treated and overcome whenever it is possible. This condition is not
only the cause but the result of disease. It may be induced by
improper food, poor hygiene, sedentary habits, lack of exercise, the
taking of drug preparations such as cough sirups which contain opium
in some form, the constant taking of cathartics and enemas, or it may
be an hereditary condition.

~Diet, Exercise, and Fresh Air.~--The chief means of overcoming this
deplorable chronic condition is by regulating the diet and increasing
the amount of exercise in the fresh air.

At times it is necessary to resort to artificial stimulation of the
intestinal movements; at others, on account of the disease of which it
is only one of the symptoms, it is dangerous to irritate the already
inflamed mucous membranes lining the intestinal wall. In these cases
the physician prescribes the method of procedure. In ordinary cases,
however, the following suggestions may be used as a guide in
overcoming the condition.

~Available Foods.~--It must be borne in mind that the food must not be
too concentrated in character or it will be so completely absorbed as
to leave little or no residue for the feces, and since the waste
products of metabolism, both of food and body materials, must be
eliminated, a certain amount of fecal matter is necessary to assist in
this work. Vegetables, such as celery, turnips, lettuce, asparagus,
string beans, spinach, and beans, lentils, lima beans, and onions;
fruits, such as raisins, figs, and prunes; and cereals which have not
had all the bran removed, such as cut oats, cracked wheat, etc., on
account of the cellulose they contain, act admirably in overcoming
chronic constipation. It is found, however, that when even these are
not sufficient in certain cases, bran added to the food, either
alone, with the breakfast cereal, or in the form of biscuits, muffins,
or cookies, will give just the necessary amount of ballast to the food
mass to make it stimulate the peristaltic movements by its pressure
upon the intestinal walls.

~Stimuli to Peristalsis.~--Foods yielding certain acids exert a
stimulating action upon intestinal peristalsis.

~Available Foods.~--Those particularly valuable for this purpose are
limes, oranges, apples, prunes, figs, raisins, and most fruit juices
(with the exception of blackberries, which are constipating),
tomatoes, and rhubarb. The fruit juices may be diluted with water or
carbonated water (in the latter case the action is increased because
of the gas contained in the water), and taken the first thing in the
morning, or the fruit may be eaten at night before retiring, and in
the morning on an empty stomach. Prune pulp or prune jelly may be
given to children as well as to adults. The action of this fruit is
augmented by the addition of senna leaves. A conserve made of prunes,
figs, and raisins given in teaspoonful doses at night and before
breakfast often gives splendid results in curing chronic constipation.

~Gas-forming Foods.~--The eating of foods which give rise to a slight
formation of gas owing to their tendency to ferment likewise acts as a
stimulus to intestinal movements. Among these may be mentioned honey,
molasses, cauliflower, cabbage, spinach, and onions. If the honey and
molasses are poured on bran muffins or biscuits, on breakfast food, or
added as sweetening agents to cookies, they will be found particularly
valuable. Care must be taken, however, not to give too much of either
of these foods or they will disturb the digestion and do more harm
than good.

~Use of Salt Foods.~--Foods such as herring, caviar, anchovies, ham,
etc., on account of the salt they contain, exert a stimulating effect
upon the movements in the small and large intestines. Graham bread,
spread with brown sugar, molasses, or honey, makes an acceptable
addition to the meal of the majority of children and to that of many
adults.

~Fats and Mineral Oils.~--The use of fats is often recommended; olive
oil may be given in tablespoonful doses before breakfast and at night
or it may be served on vegetables and salads. If one or two
tablespoonfuls are taken at night and before breakfast, it may act as
a laxative. In many cases, however, this oil is completely absorbed in
the small intestine and hence there is none left to lubricate the
passage for the food mass. When vegetable oils do not prove
satisfactory, mineral oils may be substituted. These oils have
absolutely no fuel value and are not digested in the intestinal canal
but mix with the fecal mass, softening it and stimulating its passage
through the large intestine. There are certain individuals with whom
the mineral oils do not act as lubricants and instead of softening the
feces and lubricating the passage will slip through the intestinal
canal without carrying the feces along.

~Sample Diet Sheets.~--The following menus are suggested for the use
of individuals suffering with chronic constipation:

BREAKFAST

  7 A.M. Orange juice and water.

  8 A.M. 1 bran muffin with honey and cream.
         1 or 2 slices of bacon.
         Whole wheat biscuits.
         A cup of coffee, cereal coffee, or hot milk (not boiled).

LUNCHEON

  1 P.M. Casserole of beef made with lean beef.
         Turnips and potatoes.
         Graham bread or muffins and honey or preserves.
         Milk or "hot water" tea.

DINNER

  Tomato bouillon.
  Roast lamb.
  String beans.
  Potatoes baked with jackets on.
  Celery salad, dressed with plenty of oil and lemon juice.
  Prune jelly with whipped cream.

BREAKFAST

  Prunes and figs cooked together.
  Slice of ham with 1 soft-cooked, poached, or scrambled egg.
  Whole wheat or bran biscuits.
  Coffee with cream and sugar.

LUNCHEON

  Vegetable soup.
  Pork and beans.
  Boston brown bread.
  Baked apple (skin eaten).
  Oatmeal wafers.

DINNER

  Roast beef.
  Spinach or cauliflower served with butter sauce.
  Cold slaw.
  Pineapple jelly (pineapple left in), whipped cream,
    or
  Date and fig pudding.


AUTO-INTOXICATION

Auto-intoxication is a condition produced by the absorption of the
decomposition products of food in the intestinal canal.

~Absorption of Toxins.~--As a rule the condition occurs in
individuals suffering more or less from constipation which may be due
to errors in diet or a lack of tone in the intestines, giving rise to
a sluggishness in the peristaltic movements in this region of the
alimentary canal. In certain individuals the liver is more or less
sluggish, or in some way fails to do its regular work of detoxifying
the products of metabolism brought in by the blood stream, in which
case these toxins are reabsorbed into the system and induce a
condition known as auto-intoxication.

~Care of Bowels.~--As a rule the patient has more or less fever,
nausea and at times vomiting. The head aches and the abdomen may be
distended by the formation of gas in the intestines. The treatment is
like that used in the majority of intestinal disorders. The bowels are
emptied by means of soapsuds or salts and glycerin enemas. Certain
physicians recommend an enema made with equal quantities of milk and
molasses, with enough hot water added to make a thin, warm solution.
Care must be used in preparing this flatus enema on account of the
danger of curdling the milk with the acid in the molasses and the hot
water. If the solution should curdle it must be discarded and a fresh
solution prepared. A flatus enema containing salts, glycerin, and a
few drops of turpentine is also valuable in removing the gas formed by
the action of the putrefactive bacteria upon the unabsorbed food mass.
This enema must be given "high" so as to reach the spot in the colon
where it may efficiently do its work.

~Dietetic Treatment.~--The diet may consist of fluids for the first
few days, or as long as the fever continues. ~Buttermilk~ is probably
the best fluid food to use under such conditions, since it not only
nourishes, but likewise furnishes lactic acid bacteria which aid in
the destruction of the more harmful bacteria, especially numerous
under the conditions just mentioned. When whole milk is given it is
best to peptonize it. Well-strained meat broths may be given
occasionally to vary the diet and albumenized orange juice or orange
juice in carbonated water may also be given once or twice daily during
the febrile period. After this, the patient may have well-cooked
cereal gruels. These may be dextrinized with vegetable diastase (Taka
diastase) if necessary. A return to normal diet is made gradually to
prevent a return of the trouble. The patient should be advised against
overeating, and eating highly seasoned or indigestible foods.

~Convalescent Diet.~--The diets recommended for use during
convalescence from other intestinal disorders may serve here,
reducing, however, the allowance of meat, since meat proteins are
particularly susceptible to attacks of putrefactive bacteria.

~Dietary Precautions.~--After the body has returned to its normal
state, the patient must keep in mind the danger arising from
constipation and intestinal putrefaction. The following menu is given
as a guide to aid the individual in selecting a diet which will in a
measure assist in preventing future attacks of intestinal putrefaction
and auto-intoxication:

  7 A.M. 1 glass of water with orange or lime juice.

BREAKFAST

  8 A.M. Stewed prunes or figs.
         Cereal and cream.
         Buttered toast.
         Crisp bacon.
         Coffee.

LUNCHEON

  Vegetable or tomato soup.
  Green vegetables such as cauliflower, greens, or tomatoes; or
  Baked dishes such as macaroni and cheese, scalloped macaroni and
    tomatoes; or
  Baked potatoes, or potatoes _au gratin_, or stuffed tomatoes with rice.
  Stewed fruit or fruit jelly.
  Sponge cake with simple sauce.
  Junket.
  Toasted crackers or bread.

DINNER

  Milk soup.
  Cream of spinach, celery, peas, or tomatoes.
  Baked eggs, cheese soufflé or nut loaf.
  Tender green peas, cauliflower, spinach, boiled or creamed potatoes,
    well-boiled rice.
  Fruit, vegetable, tomato, or cheese salad.
  Simple dessert, such as cottage pudding with simple sauce, fruit
    pudding, prune whip, or frozen desserts; ice cream or water ices;
    or
  Cheese and crackers.
  Coffee.


SUMMARY

DIARRHEA

~Character.~--Acute or chronic, accompanying many pathological
conditions, especially in children in whom diarrhea in any form must
be given immediate attention.

~Causes.~--Errors in diet, polluted water or milk, ptomaines, bad
hygiene, and certain drugs.

~Bowels.~--The stools vary in number from three to twelve a day. They
may be greenish yellow in color, containing mucus and particles of
undigested food and, in prolonged cases, blood.

~Treatment.~--Rest in bed and total abstinence from food for from
twenty-four to forty-eight hours. Salines are usually given by mouth
or by rectum, but this is left to the discretion of the physician.
Very little water is given by mouth during the period of total
abstinence. Thirst is relieved by bits of ice, and enemas are given if
necessary.

~Administration of Diet.~--When acute symptoms have disappeared and
the stools are becoming more normal in character and number, a fluid
diet of from four to six ounces is administered every three or four
hours or oftener if patient is very weak. Brandy may likewise be given
in cases in which exhaustion is marked.

~Dietetic Treatment.~--Concentrated foods of the simplest character
and only those known to agree. Proprietary infant or invalid foods,
except malted foods, which exert a laxative effect; among those found
to be good may be mentioned Mellin's Food, Imperial Granum, and
Racahout.

~Foods to Be Avoided.~--Fatty foods; pork, veal, and shellfish; all
foods that are subject to fermentation in the stomach or intestinal
tract (sugar).

~Foods to Be Limited.~--Fluids, soup, beverages, etc., because they
impose more work on the intestines.


ENTEROCOLITIS

~Seat of Inflammation.~--Lower intestine and colon.

~Differentiating Characteristics.~--More mucus and blood in stools;
greater prostration; greater rise of temperature; and less anemia than
in chronic enteritis.

~Dietetic Treatment.~--Practically the same as in other diarrheas.


DYSENTERY

~Characteristic Symptoms.~--Acute and spasmodic pain, tenderness and
distention in the bowels, moderate fever, straining and a constant
desire to defecate, small stools containing blood and mucus, loss of
weight and marked anemia when condition becomes chronic.

~Treatment.~--Rest in bed absolutely necessary; the use of the bedpan
made obligatory; soreness relieved by hot turpentine stupes or spice
poultices.

~Dietetic Treatment.~--No food for a period of from thirty-six to
forty-eight hours, after which fluids and the régime recommended in
acute diarrhea are advisable. In chronic dysentery the diet is
practically the same. The extreme exhaustion and anemia accompanying
these conditions make it necessary to increase the diet carefully but
soon to offset as far as possible the devastating effects of the
disease.


APPENDICITIS

~Treatment.~--Confinement to bed is absolutely necessary while acute
symptoms prevail. The life of the patient may depend upon the care
with which this "quiet" period is carried out. No food should be given
for twelve or more hours to enable the physician to make a proper
diagnosis and to allow the intestinal tract and appendix complete rest
from the irritating effects of food passing down the canal.

~Dietetic Treatment.~--~Acute Stage:~ Total abstinence for a period,
after which fluids as given in other acute intestinal disorders. No
solid food until acute symptoms have subsided; then a gradual return
to normal.

~Convalescence.~--When tenderness in right side has disappeared, the
return to a normal diet is made gradually. Gelatin, soft eggs, soft
toast, fine cereal gruels, well-cooked rice, well-baked white
potatoes, tender rare beefsteak or lamb chops, the breast of chicken,
sweetbreads, and brains are recommended.

~Relapse or Recurring Appendicitis.~--The patient must be warned
against eating indigestible foods or any kind of foods liable to cause
constipation; also against overeating or eating when over-heated or
over-tired. One attack predisposes to another, hence the above
precautions are necessary to prevent the condition from becoming
chronic.


CHRONIC CONSTIPATION

~Causes.~--Improper foods, indoor occupations leading to a lack of
fresh air and exercise, bad hygiene, certain drugs, such as cough
sirups, etc., containing opium in some form, constant use of
cathartics and enemas to move the bowels, heredity.

~Dietetic Treatment: Foods to Be Avoided.~--Highly spiced foods must
be avoided on account of their astringent qualities, too concentrated
foods because they fail to furnish the necessary bulk without which
the waste matter cannot pass out of the body at a sufficient rate of
speed to prevent putrefaction taking place in the intestinal tract.

~Foods Stimulating Peristalsis~ on account of their bulk: Bulky foods,
such as vegetables, cabbage, turnips, cucumbers, spinach, beans,
celery, lettuce, etc.; cereal foods containing a high percentage of
bran, bran bread and cookies, fruits such as raisins, prunes, figs.

~Foods Acting as Stimuli to Intestinal Movements~ on account of their
acid content: Limes, oranges, apples, prunes, figs, raisins, most
fruit juices (blackberries excepted), rhubarb, tomatoes, cauliflower,
spinach, onions, honey, and molasses; senna leaves likewise have a
distinct action upon the peristaltic movement of the intestines, hence
are included here.

~Precautions.~--Emphasis should be placed upon the dangers of (1)
overeating any of the foods indicated in the above list and thus
bringing about conditions more dangerous in result than the original
disturbance; (2) the taking of drugs to move bowels on account of the
ease with which the habit is acquired and the consequent inability of
the bowels to move without such whips; (3) the taking of too little
water, thereby allowing a too concentrated condition of the food mass
and a consequent accumulation of substances which inhibit peristaltic
action.

~Use of Fats and Mineral Oils.~--Olive and other vegetable oils, if
not completely absorbed, are advised on account of their lubricating
effects. The same can be said of the mineral oils which have no food
value but in many cases furnish the lubricant necessary in certain
individuals suffering from sluggish intestinal peristalsis.


PROBLEMS

(a) List the food used in the treatment of enterocolitis; outline the
method of administering the diet.

(b) Formulate a convalescent diet for diarrheal cases.

(c) List the foods used in chronic constipation; list the avoidable
ones.


FOOTNOTE:

[94] Malted foods are contraindicated, as malt exerts a very laxative
effect.




CHAPTER XIII

FEVERS IN GENERAL


Fever is an abnormal condition characterized by an elevation of body
temperature, quickened respiration and circulation, and a certain
amount of tissue waste. This elevation of temperature may be due to
various conditions, such as local inflammation, infectious diseases,
disturbed metabolism and food poisoning (ptomaine).

~Tissue Waste in Fevers.~--Fevers of short duration, such as accompany
colds, tonsillitis, chicken pox and intermittent fever, remittent
fever, and at times malarial fever, do not cause sufficient tissue
waste to make the nutrition the important feature of the treatment. In
ptomaine poisoning the tissue waste may be great, but it is the result
of the poisoning, as is the fever, so that the diet needs to be
adjusted only after the disturbance has abated. In the beginning,
starvation is instituted and the fever disappears when the poisoning
is controlled.

~Treatment of Fevers of Short Duration.~--In all fevers of short
duration then, the treatment is directed with the following points in
mind: (1) relieving the cause, (2) preventing gastro-intestinal
disturbances, (3) saving the heart, kidneys, etc., extra strain.

~Dietetic Treatment.~--In doing this the diet is so formulated as to
meet the above-mentioned conditions, and fluids seem the best form in
which food can be given to bring about the desired results. The
quantity of fluids should be small and the intervals between feedings
short. Two-hour intervals seem best in the beginning. These intervals
are lengthened as the fever decreases and the amount of food at each
feeding increased. When convalescence is established, semi-solid, soft
or convalescent diet may replace the fluids and the patient gradually
brought back to a normal diet.

~Fluid Diet.~--The following foods constitute a fluid diet: milk,
whole milk, plain, peptonized, or albumenized, buttermilk, koumiss,
malted milk, milk shake, milk punch, cream, whey; fruit beverages,
plain, albumenized, or mixed with whole raw egg; eggnog, milk and
ginger ale, cocoa, strained gruels, broths reënforced with egg or
plain. Carbonated water may be added to milk or fruit beverages.

~Schedule of Feeding.~--The following schedule may be used as a guide
in fevers of short duration:[95]

I

   7 A.M. 6 oz. hot milk or cocoa.
   9 A.M. 6 oz. broth reënforced with egg.
  11 A.M. Milk shake.
   1 P.M. Oatmeal gruel, 4 oz.; 2 oz. cream.
   3 P.M. Albumenized orange juice, 4 oz.; 1 egg white.
   5 P.M. 6 oz. broth reënforced with egg white.
   7 P.M. 6 oz. cocoa.
   9 P.M. 6 oz. malted milk.
  12 M.   4 oz. hot milk and 2 oz. cream.
   and
   4 A.M.

The above furnishes approximately 750 calories.

II

   7 A.M. 6 oz. cocoa.
   9 A.M. 4 oz. oatmeal gruel, 2 oz. cream.
  11 A.M. Eggnog.
   1 P.M. Milk broth reënforced with egg. (3 oz. milk, 3 oz. broth,
            1 egg white.)
   3 P.M. Cream, egg and vichy.
   5 P.M. Albumenized milk, 6 oz.
   7 P.M. Hot malted milk chocolate, 6 oz.
   9 P.M. Milk broth reënforced with egg.
  12 M.   4 oz. oatmeal gruel, 2 oz. cream.
   4 A.M. 6 oz. malted milk (half water, half milk).

Furnishing approximately 1500 calories.

III

   7 A.M. Oatmeal gruel, 4 oz., 2 oz. cream.
   9 A.M. Orange eggnog.
  11 A.M. Malted milk chocolate (3 oz. milk, 3 oz. water).
   1 P.M. Clam broth (milk), 6 oz.
   3 P.M. Milk shake, 4 oz.; 2 oz. cream.
   5 P.M. Cornmeal gruel, 4 oz.; 2 oz. cream.
   7 P.M. Hot cocoa, 6 oz.
   9 P.M. Hot malted milk.
  12 M.   Hot milk, 4 oz.; 2 oz. cream.
   4 A.M. Hot milk, 4 oz.; 2 oz. cream.

Furnishing approximately 1460 calories.

The two night feedings may be omitted if patient is asleep.

These diets will be seen to be below the maintenance requirements in
health, but the need for care in preventing gastro-intestinal
disturbances makes it safer to have it so for a few days, especially
if the elevation of temperature is great. After the temperature
becomes normal the following foods may be added to the diet:

~Soft or Convalescent Diet.~--Cream soups, soft-cooked, creamed, or
poached egg, soft or baked custard, junkets, egg, cocoa, or plain
vanilla ice cream, soft toast, milk or cream, buttered toast, cereals,
gelatin jellies, fruit, wine, or meat jellies, vegetable purées, baked
white potato, apple sauce, baked apple, fruit whip, blanc-mange,
broiled lamb chops, beefsteak, or chicken, sweetbreads, broiled or
creamed brains.

~Sample Menus.~--The following menu is a sample convalescent dietary:

BREAKFAST

   7:30 A.M. Cream of wheat 3 oz., cream 1 oz.
             1 soft-cooked or poached egg.
             1 slice of toast buttered.
             6 oz. cocoa or milk flavored with coffee.
             2 tablespoonfuls of strained prune pulp with 2
               oz. cream.

  10:30 A.M. Albumenized orange juice.

DINNER

  12:30 P.M. Cream of pea soup, 6 oz.
             1 baked potato with butter.
             1 slice of buttered toast.
             1 cup of cocoa or 1 glass of milk or buttermilk.

   3:30 P.M. Ginger ale and milk, 3 oz. each.

SUPPER

      6 P.M. 2 slices of buttered toast moistened with 4 oz.
               milk and 2 oz. cream.
             1 soft-cooked egg or 3 tablespoonfuls of well-cooked
               cereal or 2 tablespoonfuls of boiled rice.
             2 tablespoonfuls of apple sauce served with 1
               tablespoonful of cream.
             1 cup of cocoa, malted milk, whole milk, or buttermilk.

     9 P.M.  4 oz. hot milk, 2 oz. cream, or 1 cup of cocoa or
               malted milk.

The return to normal diet is made with caution that the digestion of
the patient may not be upset or the temperature raised again by
over-feeding.

~Energy Requirements.~--In fevers of short duration it is not
difficult to regulate the amount of food necessary for the maintenance
of the patient, since the body will, as a rule, adjust itself when the
cause of the fever has been removed. At times, however, it is
necessary to make an effort to tempt the appetite of the patient when
convalescence is established, that recovery may be made more rapid and
complete.

~Care of the Mouth.~--Probably there is nothing more essential in the
treatment of fevers in general and typhoid fever in particular than
the care of the mouth. Well-nourished patients rarely ever show the
dry, cracked tongue and lips that was formerly one of the common
occurrences in typhoid fever. However, in any febrile condition the
mouth is apt to acquire a disagreeable taste; this "bad taste" is so
prominent in certain cases as to render it difficult for the patient
to eat. This can be, to a great extent, eliminated by the use of
aseptic mouth washes. When the patient is not strong enough to rinse
the mouth before and after eating, the nurse must use a swab for the
purpose. The food must be carefully selected and attractively served
and every effort made to make food as dainty and palatable as
possible.

~Thirst.~--Thirst is relieved with crushed ice, fruit beverages, and
carbonated waters. In certain conditions it is necessary to limit the
fluids, but in typhoid fever the giving of the requisite amount of
liquids is one of the most difficult tasks confronting the nurse. It
is wise to find out the beverages particularly liked by the patient
and, whenever it is possible, make use of them. As a rule alcohol is
not necessary in the diet of typhoid fever patients. However, in
certain cases of that disease, as well as in febrile conditions
induced by other causes, the use of alcoholic stimulation may be
necessary; it must be left to the discretion of the physician to
prescribe it.


SUMMARY

~Intestinal Disturbances~ are accountable for the majority of the
fevers of short duration during infancy and childhood, and in many of
those cases in adults.

~Malaria~ causes an elevation of temperature which is, as a rule, of
short duration.

~Contagious Diseases~, such as scarlet fever, measles, whooping cough,
and mumps, are likewise accompanied by more or less elevation of
temperature.

~Treatment~ consists of a period of rest in bed, with an abstinence
from food, in order that the disease may manifest itself, and also
that any offending food material which may cause the fever may have an
opportunity to pass out of the body.

~The Heart~, in some of the diseases accompanied by an elevation of
temperature, is more or less strained; this is particularly true in
tonsillitis, diphtheria, etc.

~The Kidneys~ are likewise taxed in certain diseases, even when the
fever is not great or lasting; this is found to be the case in scarlet
fever, tonsillitis, etc.

~Dietetic Treatment~ consists in giving no food for a period lasting
from twenty-four to forty-eight hours. This is followed by a liquid
diet, milk and broth particularly, which is continued as long as the
fever remains.

~Convalescent Diet~ is instituted as soon as the fever has disappeared
and acute symptoms subside.

~Thirst~ is apt to be great with any elevation of temperature. It is
relieved by water, crushed ice, and fruit beverages.

~The Mouth~ requires much care, even in fevers of short duration. A
simple antiseptic wash should be used several times each day.

~Nitrogen Equilibrium~ is not sufficiently disturbed in such cases to
require taking into account. Should the disease, however, develop
into one causing a material breaking down of the body tissues,
measures must be instituted to prevent the upsetting of the nitrogen
balance in the body.


PROBLEMS

(a) Outline the dietetic treatment for malarial fever.

(b) Outline a diet order, using liquids only. Show method of
reinforcing this diet.

(c) Show how the solids are added as convalescence progresses.


FOOTNOTE:

[95] In scarlet fever and other conditions in which the kidneys may be
involved the above diet is not given unless advised by physician in
charge.




CHAPTER XIV

TYPHOID FEVER


~Definition.~--Typhoid fever is an acute infectious disease excited by
specific bacteria (Eberth). The intestines become the seat of
ulcerations (Peyer's patches), which at times perforate. The chief
symptoms of the disease are fever, headache, abdominal distention and
tenderness, more or less diarrhea and a rose-colored abdominal rash.
The source of infection is found in the intestinal contents of a
typhoid fever patient, which in some way come in contact with and
infect drinking water, milk, etc.

~Energy Expenditure in Febrile Conditions.~--In febrile conditions the
energy expenditures increase as much as twenty-five per cent. In some
cases, and when bacterial activity is added to this, as is the case in
typhoid fever, the tissue waste becomes correspondingly greater; hence
the nutrition assumes the chief rôle in such cases, for in no other
way can the tissue waste and energy expenditure be met and overcome.

~Energy Expenditures in Typhoid.~--In typhoid fever the problem of
meeting these expenditures, and at the same time protecting the heart
and kidneys from the abnormal strain placed upon them in handling the
toxic substances produced as the result of bacterial action in the
intestines, becomes very real. It requires eternal vigilance and
patience not only from the physician but especially from the nurse,
with whom so much responsibility rests. The dietetic treatment
necessarily is the principal point to which all efforts must be
directed. By this is understood not only the type and amount of food
given the patient, but the behavior of this food in the body as
manifested by the symptoms, namely, the appearance of the patient, the
condition of the mouth, the abdominal distention, tenderness,
diarrhea, nausea, and vomiting, the hemorrhage which at times occurs
in spite of all care, and perforation which sometimes results in
death, and acidosis or acetonuria. All of which makes this disease one
requiring the most efficient attention from a nutritional standpoint.

~Energy Requirements in Typhoid Fever.~--In a previous chapter the
energy expenditures of the normal individual were dealt with; it was
seen that a man at rest, that is, in bed, not rising for anything, had
a normal expenditure of energy requiring from 1900 to 2200 calories
per day. Now, if these expenditures were increased twenty-five per
cent. by the fever and still more by the bacterial activities, it is
clearly seen that the diet must be increased in proportion if the
tissue waste is to be prevented and the normal body weight of the
patient maintained.

~High Calorie Diet.~--Dr. Warren Coleman,[96] to whom we owe so much
for his pioneer work in feeding in typhoid fever, devised the
so-called "High Calorie Diet." This consists of foods of the most
digestible type prepared in the simplest way. The weight of the
patient is considered and the diet directed with the following points
in view: (1) to cover the energy requirements of the body; (2) to make
good the tissue waste which at times amounts to a loss of from 15 to
20 grams of nitrogen a day (or from 1/4 to 3/4 pound of muscle);[97]
(3) to check or prevent the development of serious complications,
kidney, heart, etc.

In the Metabolism Ward at Bellevue Hospital, New York,[98] the best
results are obtained by the giving of diets furnishing from 60 to 80
calories per kilogram per day, or from 4000 to 5500 calories.

~Fluid Diet.~--It is clearly seen that it would be practically
impossible to obtain a sufficient number of calories by using milk
alone or even a mixed fluid diet to supply the above requirements.
Since milk alone in such a diet would probably cause such discomfort
as to make it unwise to continue it, the ideal diet would seem to be
one in which the fats, proteins and carbohydrates are furnished in a
semi-solid or solid form, together with a sufficient amount of liquids
to prevent too great concentration in the food, to relieve thirst, and
to act as a carrier of reënforcing substances, such as lactose, eggs,
casein products, etc.

~Absorption Food.~--The question as to whether the food is absorbed
when given to typhoid fever patients has often been asked. That it is
has been proved in the series of calorimeter experiments conducted in
the Metabolism Ward, Bellevue Hospital.[99] Here it was demonstrated
that under the high calorie diet the patient consumed large amounts of
food with relish and that which was not utilized by the organism
immediately was stored for future needs.

~Diarrhea and Tympanites.~--Constant attention and study of various
typhoid patients taking a maximum amount of food a day has proved that
the diarrhea and tympanites which at times occur in these as well as
other cases are due to too much of one or another of the food
constituents rather than to the general amount of the diet. Diarrhea
may then be traced to an excess of cream, and the tympanites to an
excess of lactose, and a reconstruction of the dietary will often
obviate the trouble.

~Increasing the Diet.~--It is always advisable to "go slow" in adding
new foods to the diet; milk, cream, eggs and lactose are the principal
articles constituting the diet. To this are added fine cereal gruels,
well-cooked rice, rice custard, tapioca custard, junket, ice cream,
wine or fruit jellies, toast, eggs (soft-cooked, poached, creamed, or
raw, in milk), or fruit beverages, cocoa, buttermilk, koumiss, certain
proprietary infant foods such as Mellin's Food, Eskay's Food, Racahout
and malted milk, with a well-baked potato, milk, cream or buttered
toast added as the condition and appetite warrant.

~Milk Diet.~--The following milk diets[100] were devised by Dr.
Coleman to be given in certain cases of typhoid fever during the acute
stage. These formulas consist of milk, cream and lactose and furnish
from 1000 to 3000 calories per day.

                                    _Calories_
1000 calories per day--

  Milk, 1000 c.c. (1 qt.)                 700
  Cream, 50 c.c.  (1-2/3 oz.)             100
  Lactose, 50 gm. (1-2/3 oz.)             200

This furnishes eight feedings, each containing

  Milk, 120 c.c. (4 oz.)                   80
  Cream, 8 gm.   (2 dr.)                   15
  Lactose, 6 gm. (1-1/2 dr.)               24

2000 calories per day--

  Milk, 1500 c.c.  (1-1/2 qt.)           1000
  Cream, 240 c.c.  (8 oz.)                500
  Lactose, 125 gm. (4 oz.)                500

This furnishes seven feedings, each containing

  Milk, 210 c.c.  (7 oz.)                 140
  Cream, 30 c.c.  (1 oz.)                  60
  Lactose, 18 gm. (4-1/2 dr.)              72

3000 calories per day--

  Milk, 1500 c.c.  (1-1/2 qt.)           1000
  Cream, 480 c.c.  (1 pt.)               2000
  Lactose, 250 gm. (8 oz.)               1000

This furnishes eight feedings, each containing

  Milk, 180 c.c.  (6 oz.)                 120
  Cream, 60 c.c.  (2 oz.)                 120
  Lactose, 30 gm. (1 oz.)                 120

~Varying the Diet.~--It has been found possible, even advisable, to
vary the above diets in many cases. The disease extends over such a
long period that if a fluid diet is adhered to the patient would grow
exceedingly tired and even disgusted if milk alone was given, hence a
mixed fluid diet such as is used in the Presbyterian Hospital, New
York City is suggested.[101]


PRESBYTERIAN HOSPITAL DIET LIST

   8 A.M. Milk and coffee, each 120 c.c. (4 oz.).
  10 A.M. Milk, hot or cold, 240 c.c. (8 oz.).
  12 M.   Oatmeal gruel, 120 c.c. (4 oz.), with milk 60 c.c. (2 oz.).
   2 P.M. Junket with cane and milk sugar.
   4 P.M. Oatmeal gruel, 120 c.c. (4 oz.), with milk 60 c.c. (2 oz.).
   6 P.M. Junket with cane and milk sugar.
   8 P.M. Hot milk, 240 c.c. (8 oz.).
  10 P.M. Whey, 180 c.c. with 1 whole egg and sherry.
  12 M.   Oatmeal gruel, 120 c.c. (4 oz.) with milk.
   2 A.M. Junket with 60 c.c. (2 oz.) can and milk sugar.
   4 A.M. Milk, 240 c.c. (8 oz.).
   6 A.M. Milk, 240 c.c. (8 oz.).

15 gm. (1/2 oz.) of lactose added to each of the four milk feedings.

The following foods and diet lists are used with success in various
hospitals:

From 1 to 1-1/4 quarts of milk and 1 pint of cream and lactose,
beginning with 1 tablespoonful in each milk feeding and raising the
amount day by day until the patient is taking 2 oz. (4 tablespoonfuls)
at each milk feeding, given in eight feedings. This may be given as
milk, hot or cold, or it may be made into cocoa, soup, ice cream,
junket, or on the cereal.

LIQUID DIET

  Milk.
  Cream.
  Buttermilk.
  Whey.
  Koumiss.
  Zoolak.
  Fermillac.
  Albumenized fruit juices, egg, and orange juice.
  Milk shake.
  Broths (chicken, beef, mutton or clam), reënforced with lactose or
    egg or given plain.
  Proprietary infant foods.
  Cream soups, beef juice, liquid peptonoids, panopepton.
  Orangeade.
  Lemonade.
  Eggnog.
  Milk punch.
  Malted milk.
  Malted milk shake.
  Albumenized milk.
  Strained gruels (except oats).
  Cream, egg and vichy.
  Chocolate malted milk.
  Milk gruels.

SOFT OR SEMI-SOLID DIETS

  Eggs--creamed, soft-cooked, poached, custards, baked custards.
  Toast--milk or cream toast.
  Gelatin--meat, fruit, or wine jellies.
  Junkets--plain, egg, or cocoa.
  Cereals--fine, strained cereals, except oats.
  Rice--boiled or in custard.
  Tapioca--custard.
  Baked or mashed potato.
  Cornstarch or arrowroot pudding.
  Ice cream.

Meat is not given until convalescence is established, and then in only
the most digestible form, such as rare beefsteak or lamb chop or a
small piece of broiled breast of chicken.

DIET LIST USED IN HIGH CALORIE DIETS FOR TYPHOID FEVER

  =========+============================+=================+===============
   _Time_  |       _Material_           |    _Amount_     |  _Calories_
  ---------+----------------------------+-----------------+---------------
   6 A.M.  |Hot milk                    | 4 oz.           |      78
           |Cream                       | 2 oz.           |      76
           |Lactose                     | 1/2 oz. (15 gm.)|      60
           |                            |                 |
   8 A.M.  |        {Milk               | 3 oz.           |      59
           |        {Water              | 3 oz.           |
           |Cocoa   {Cocoa              | 2 tsp.          |      35
           |        {Cream              | 1 oz.           |      38
           |        {Sugar              | 2 tsp.          |      40
           |        {Lactose            | 1/2 oz. (1 tbs.)|      60
           |Egg                         | 1               |      60
           |Toast                       | 1 slice         |
           |                            |(well moistened) |      73
           |Butter                      | 1/2 oz.         |      73
           |                            |                 |
  10 A.M.  |Buttermilk                  | 6 oz.           |      56
           |                            |                 |
  12 M.    |Cream of pea soup           | 6 oz.           |     300
           |Mashed potato               |20 gm.           |      28
           |Toast                       | 1 slice         |      73
           |Butter                      |20 gm.           |      84
           |Coffee and milk             | 3 oz. each      |      59
           |Cream                       | 2 oz.           |      76
           |Sugar                       | 2 tsp.          |      40
           |Lactose                     |20 gm.           |      80
           |                            |                 |
           |             {Orange juice  | 3 oz.           |      38
   3 P.M.  |Orange juice {Egg           | 1               |      60
           |  and egg    {Lactose       |30 gm.           |     120
           |                            |                 |
   5 P.M.  |Farina                      | 3 oz.           |     102
           |Milk                        | 2 oz.           |      59
           |Cream                       | 2 oz.           |      76
           |Lactose                     |20 gm.           |      80
           |Egg                         | 1               |      60
           |Apple sauce                 | 1 oz.           |      30
           |Cream                       | 1 oz.           |      38
           |Cocoa                       | 6 oz.           |     108
           |  or                        |                 |
           |Tea and                     | 3 oz.           |       0
           |Milk                        | 3 oz.           |      78
           |Sugar                       | 2 tsp.          |      40
           |Toast                       | 1 slice         |      73
           |                            |                 |
   7 P.M.  |Gruel                       | 4 oz.           |     102
           |Cream                       | 2 oz.           |      76
           |Lactose                     |15 gm (1/2 oz.)  |      60
           |                            |                 |
   9 P.M.  |Broth                       | 6 oz.           |      18
           |Egg white                   | 1               |      13
           |                            |                 |
   12 M.   |Milk                        | 4 oz.           |      78
           |Cream                       | 2 oz.           |      76
           |Lactose                     |20 gm.           |      80
           |                            |                 |
    3 A.M. |Milk or                     | 4 oz.           |      78
           |Malted milk                 | 1 tbs.          |      58
           |Cream                       | 2 oz.           |      76
           |Lactose                     |20 gm.           |      80
           |                            |                 |    ____
           |                            |       Total calories 3145
  =========+============================+=================+===========

~Advantages of Newer Treatment.~--A marked difference is noticed in
the patients treated by the old starvation diets and those given the
high calorie diet. Dr. Coleman states[102] that while the range of
temperature is apparently unaffected, the total duration of the
disease is shortened in some instances by months through the
shortening of convalescence. He further states that certain symptoms
which have hitherto been attributed to the specific action of the
typhoid bacillus have been discovered to be due to faulty methods of
treatment, particularly to an inadequate or improperly balanced diet.
The various investigators who have made the study and treatment of
this disease a lifework claim that the mortality from this disease has
been tremendously reduced by the use of the high calorie diets which
maintain the nutrition of the patient throughout the disease, thus
eliminating the horrors of the long, tedious convalescence which tried
the nerves and patience of the patient, the nurse, and the physician.
There is no doubt that so far as the administering of this diet is
concerned it requires more effort on the part of the nurse than the
old treatment of a glass of milk every two or three hours. It is
necessary for the nurse to be able to carry out the orders as
expressed in the diet lists, to be able to compute the proteins
(nitrogen), fats, and carbohydrates in a food or recipe. But this is
readily done by studying the tables given in the first section of this
text. She must likewise be able to recognize the symptoms as they
arise. In hospitals, the urinalysis is made as a routine procedure. In
private cases the physician will either have the analyses made or
expect the nurse to be able to make the simple tests.[103]

One of the greatest difficulties attending the administering of the
high calorie diet is persuading the patient to take sufficient food
for his needs. The fluids are often more difficult to give in quantity
than the more solid foods, and it requires much tact on the part of
the nurse to prevent a refusal of the necessary fluids. However, if
the patient is possessed of even ordinary intelligence, an explanation
of the reasons for the large amount of food will as a rule be all that
is necessary. Few individuals will willingly prolong an illness
attended with the discomforts generally present in typhoid fever.

~Hemorrhage~ occurs in a certain percentage of cases of typhoid
regardless of the diet, whether it be a strictly milk diet or the high
calorie diet just described. The measures to combat them are
essentially the same. It is necessary to guard against excessive
tympanites since the pressure therefrom against the ulcerated
intestinal walls may cause perforation resulting in hemorrhage.
Lactose at times causes an evolution of gas as do fats under certain
circumstances. Hence it is necessary to follow symptoms and watch the
stools in order to determine which food material is to blame for the
tympanites and reduce the allowance of that food in the diet.

~Idiosyncrasies against Milk.~--Certain individuals manifest an
inability to take milk. This may be real or imaginary. When it is a
true idiosyncrasy, it may be found necessary to substitute some other
food for the milk in the diet, but great care should be taken to
determine the real character of the disagreement before eliminating so
invaluable a food from the diet. When the disagreement proves merely a
distaste for milk, some of the different methods used in disguising
it, such as flavoring or coloring, may be practiced. Otherwise, it is
well under the circumstances to use some of the pre-digestive methods
in order to increase its utilization. It is well to emphasize the
value of accurate data on this subject as it is exceedingly difficult
to administer a high calorie diet without milk in some form.

~Essential Points.~--Thus the dietary in typhoid fever is seen to be
the most important part of the treatment. A careful study of the
tables will enable the nurse to do her part in nourishing the patient.
It is necessary that she be able to compute the nitrogen,
carbohydrates, and fats in a diet and arrange these constituents in
such a way as to give the desired amount of each in the dietary and in
a form acceptable to the patient.


SUMMARY

~Rate of Metabolism~ is greatly increased in typhoid fever even over
other febrile conditions, not only on account of the elevation and
duration of the fever, but also on account of the activities of the
specific bacteria in the intestinal tract which differentiate this
disease from other febrile conditions.

~Energy Expenditures and Requirements~ of the body in typhoid fever,
on account of the character of the disease, are much greater than
those of the normal individual and must be met by an increase in the
diet if the body is to be saved from destruction.

~The Bowels.~--Diarrhea develops during any period of the disease due
to excess amount of fat or to a disagreement of some of the other food
constituents. It is advisable to cut down the allowance of cream
temporarily and to watch stools and other symptoms for evidences of
dietetic errors.

~Hemorrhage~ must be guarded against by eliminating, as far as
possible, all substances liable to cause an excessive gas formation in
the intestines.

~Absorption of Food~ is as a rule good. The patient is usually able to
handle a large quantity of food provided it is judiciously
administered with a due regard to the symptoms manifested at the time.

~Simplicity of Diet~ is absolutely essential. All the materials must
be selected carefully according to the physician's orders and prepared
with the greatest care in order to prevent digestive disturbances.

~High Calorie Diet~ is one in which the fuel value of the food
ingested meets or exceeds the energy expenditures of the patient.
Foods composing the diet are, milk and eggs for the proteins, with
carbohydrates and fats in their simplest and most digestible form to
balance the diet.

~Administering a High Calorie Diet~ is accomplished successfully
provided the nurse exercises care with regard to the symptoms arising
from time to time. These must be carefully noted and reported to the
physician, for in this way only is it possible to give a sufficient
quantity of food to cover the excessive breaking down of the body due
to the disease.

~Fluid Diet~ is at times necessary since certain patients cannot
tolerate a high calorie diet, but this is a point decided by the
physician. A fluid diet consists of fluids alone, milk in particular,
with broths and fruit beverages as ordered. The milk is given in
definite amounts and at stated intervals.

~Milk Diet~ is one consisting solely of milk or in which the bulk of
the nourishment is furnished by milk. It may be reënforced or not as
desired. Lactose is the substance commonly used as a reënforcing
agent. It is impossible to cover the energy expenditures of typhoid
fever with a milk diet even if it is perfectly administered, but
certain complications make it, at times, the only rational method of
feeding.

~The Advantages of High Calorie Diet~ over other diets are distinctly
noticeable in typhoid fever patients. Those treated by this method are
more comfortable during the course of the disease and are saved a
long, tedious convalescence which has made the starvation treatment a
thing of horror in the past. The return to health is attended by a
much better physical condition when the patients are well nourished
than is possible when they are kept on practically a starvation
ration. The mortality from the disease has been materially lessened by
the administration of the high calorie diet.

~Acidosis~ may develop in typhoid fever patients and must be guarded
against. The behavior of the fat in the body should be carefully
watched and the amount reduced at the first evidence of acidosis. At
the same time an increase in the carbohydrates may assist in
overcoming the condition. This adjusting of the diet, however, is
entirely in the hands of the physician.

~The Kidneys~ in typhoid fever patients are under a great strain,
chiefly on account of the increased rate of metabolism. Great care
must be exercised in the dietetic treatment to prevent these organs
from being overworked with a consequent development of nephritic
conditions.

~Care of the Mouth~ in any febrile condition is important, but
especially so in typhoid fever, where the disease itself causes a most
unpleasant taste in the mouth. This prevents the taking of nourishment
with any degree of comfort, hence the mouth should be cleansed before
and after each feeding. Any of the aseptic mouth washes may be used.

~Thirst~ may be relieved by plain or carbonated waters, fruit
beverages, and crushed ice. When in certain complications the fluids
in the diet are in a measure restricted, ice is used and water is
given in spoonful doses. This, however, is the exceptional, rather
than the ordinary state of affairs.

~Increasing the Diet~ after a fluid diet must be made with great care
in order to prevent a relapse. Following the high calorie diet the
increase is simple. The patient passes from the prescribed foods to
meat with apparently no effort. The increase should not be made,
however, until convalescence is firmly established.

~Reënforcing the Diet.~--On account of the great increase in the rate
of metabolism and because of the difficulty of furnishing the
requisite number of calories in the diet, reënforcing agents such as
lactose, eggs, some forms of casein, or beef preparations are used.

~Idiosyncrasies~ against certain foods are, at times, manifested by
patients. Efforts must be made to determine whether they are real or
imaginary before eliminating any food which may be of importance to
their future welfare.


PROBLEMS

(a) Give a sample diet order, using liquids only. Raise the fuel value
of the diet from 2000 to 3000 calories.

(b) Formulate a diet order, using the high calorie diet, fuel value
3500 calories.


FOOTNOTES:

[96] Warren Coleman, University and Bellevue Hospital Medical College,
Visiting Physician, Bellevue Hospital, New York City.

[97] "Diet in Typhoid Fever," by Warren Coleman, "Journal of American
Medical Association," Oct. 9, 1909, Vol. LIII.

[98] "Diet in Typhoid Fever," by Warren Coleman, reprint from "Journal
of American Medical Association," June 9, 1909.

[99] Determined by calorimeter observation from the Russell Sage
Institute of Pathology in affiliation with the Medical Division of
Bellevue Hospital, under Warren Coleman and Eugene DuBois.

[100] "American Journal of Medical Sciences," January, 1912, by Warren
Coleman.

[101] F. P. Kinnicut, "Diets Used in the Presbyterian Hospital," New
York City.

[102] "Journal of American Medical Association," Aug. 4, 1917.

[103] See urinalysis, p. 323.




CHAPTER XV

DISEASES OF THE RESPIRATORY TRACT


TUBERCULOSIS, PNEUMONIA, AND TONSILLITIS

TUBERCULOSIS

The dietetic treatment for tuberculosis must, as in any other
pathological condition, depend largely upon the general condition of
the patient, and the symptoms manifested at the time.

~Character of Disease.~--The disease may have reached an acute stage
in which the rise of temperature is marked and the progress of the
tuberculous symptoms rapid, or it may be found to be an old chronic
condition in which the progress is slow.

Again, the patient may be found to be suffering from a tuberculosis
which is neither acute nor very slow. Each of these stages requires
slightly different treatment which, however, for the main part is much
the same.

Individuals having an incipient form of tuberculosis have been known
to develop an acute form of the disease upon being subjected to a
strenuous treatment for some other and entirely different condition.
This has been especially noticeable in certain individuals to whom the
starvation treatment is given.

~Dietetic Treatment in Acute Stage.~--The dietetic treatment of the
acute tuberculosis under such circumstances must necessarily be
adapted to that of the original disease for which starvation was
believed to be necessary. The forbidden foods must still be omitted
from the dietary, but in these cases it is found advisable not to
prolong the starvation treatment but to substitute foods which will
do the least harm under the circumstances. This is necessary to cover
the energy requirements of the body and to make good the tissue wasted
through the development of the specific disease.

~Dietetic Treatment in Chronic Stage.~--The diet for tuberculosis has
been so widely discussed and so universally used that a few words only
seem necessary here. One of the chief points to be emphasized is the
danger arising from gastro-intestinal disturbances. The digestive
apparatus of the tuberculous individual is more apt to be impaired, so
that any undue exertion required to digest a meal is likely to bring
about disturbances more or less serious in character.

~Method of Administering Diet.~--For this reason it is no longer the
custom to stuff the patient in an effort to overcome the inevitable
tissue waste, since such treatment in many cases defeats the end for
which it was intended, bringing on acute indigestion, or at times
diarrhea, which might readily cause a greater loss of body weight than
could possibly be produced by the surplus food given.

~Adjusting the Diet.~--More and more is it coming to be understood
that the diet must be adjusted to suit the individual. Three wholesome
meals a day are insisted upon, with lunches given between the morning
and midday meal and during the course of the afternoon. Many patients
are found to sleep better after they have partaken of a light lunch,
consisting of hot milk, malted milk, or like beverages and crackers,
so that this third meal is added to the other five. In this way the
individual suffering with tuberculosis is assured of an efficient diet
to meet the needs of the body without overburdening the digestive
apparatus or overtaxing the excretory organs. The increased metabolism
taking place in such patients, due both to the specific bacteria and
to the febrile condition, is, as far as possible, provided for.

~Schedule of Diets.~--The following dietary régime may be useful in
formulating menus for tubercular patients:

BREAKFAST

  Fruits.
  5 oz. cereals with cream.
  1 or 2 eggs, simply prepared to prevent indigestion.
  2 slices of bacon, ham; fish cake or chop.
  2 slices of toast or crusty rolls with butter.
  Coffee, tea, or cocoa, with or without cream.[104]

LUNCH

  Vegetable or cream soups.
  Cold meat, lamb chops, oysters, or fish.
  Baked white or sweet potato.
  1 green vegetable,--greens, cabbage, spinach, or string beans.
  Stewed fruit or baked apple.
  Rice or tapioca pudding.
  Tea.
  Bread and butter.

At the end of the meal one glass containing two-thirds milk and
one-third cream. If the latter disturbs the digestion reduce the
amount temporarily, or add one-half the contents of a tube of
peptonizing powder, or one-quarter of a glass of limewater.

DINNER

  Meat, lamb, mutton, chicken, duck, game, or fish.
  Mashed or creamed potatoes.
  1 or 2 green vegetables.
  Simple salads.
  Simple desserts consisting of puddings, custards, wine or fruit
    jellies, ices or ice cream, sponge cake or angel food cake.

The milk and cream is taken at the end of the meal as directed above.


LUNCHES

11 A.M., 4 P.M., 9 P.M., consisting of milk, malted milk, junket,
buttermilk, albumenized broth, albumenized fruit juices, cream, egg,
and vichy, eggnogs, served with crackers or sponge cake; cereal gruels
and raw eggs taken with water, milk, or sherry may likewise form a
part of this diet, since the nourishment in them is both concentrated
and palatable.

~Use of Eggs.~--The old method of forcing the patient to eat a dozen
or more raw eggs a day is no longer used, but three or four a day will
be of undoubted value to the patient, provided they agree. There are
patients, however, with whom eggs act almost as a poison, and in these
cases it is decidedly unwise to force them.

~Use of Milk.~--Milk is to be used abundantly. If it should disagree,
it may be peptonized or modified with limewater. At any rate, every
effort should be made to enable the patient to drink at least one
quart a day, and more, if possible.

If it fails to agree even when so treated, it should be abandoned,
since the discomfort caused under the circumstances is more
detrimental to the welfare of the individual than any benefit which he
may gain by the small amount which may be absorbed.

~High Calorie Diet.~--As long as the patient is in bed the diet cannot
be as full as it is made when he is up and about, as the body is then
using more material to provide for the extra exertion and needs more
food to replace that which has been utilized. Consequently the high
calorie diet[105] will be found as a rule sufficient. As soon as the
patient is able to receive more food without incurring digestional
disturbances, it should be supplied, keeping ever in mind the danger
of its upsetting his digestion.

~Advice to Patients.~--The patient must be impressed with the
necessity for living a simple, wholesome life, free from excesses of
all kinds. The need for a regular régime in the beginning must be
strongly emphasized. Too strenuous exercise and the consequent
over-fatigue at times completely overcome all the good which has been
accomplished in weeks or even months of studied effort, so that rest
is an essential part of the tuberculous régime. The patient should
sleep from eight to ten hours out of every twenty-four, and if this
sleep is taken in the open, that is, in a tent or on a sleeping porch,
the benefits derived therefrom are inestimable.

~The Bowels.~--The bowels should move every day, even if some gentle
laxative or an enema has to be used to bring about the desired result.
In a majority of cases, mineral oil or bran muffins, prunes, raisins,
and figs prepared with senna will be entirely sufficient, however, and
these substances are much less harmful than drugs, for the habit of
taking purgatives becomes a fixed one in a short time, and is
especially liable to become so when the patient is forced, by reason
of the sedentary life, to depend on some such measures.

~Massage.~--Massage has been found beneficial in many cases, giving
the needed exercise to the body, which it is otherwise unable to
obtain.


CHRONIC TUBERCULOSIS

In chronic tuberculosis, the patient should be instructed in the care
necessary for his protection. He should be advised to report to the
physician any symptoms occurring during the course of the disease,
especially any hemorrhage. He must be reassured of the chances of
recovery, even after hemorrhage has occurred. It is not well to
encourage the habit of taking the temperature or weighing daily, since
the knowledge of the fluctuations which inevitably occur in these
conditions may worry the patient to such an extent as to interfere
with his final recovery.

~Rest, Sleep, and Fresh Air.~--Moderation in physical exertion,
wholesome food at regular intervals, plenty of rest and sleep,
preferably in the open, and an effort made to look forward to a
complete recovery will go far toward bringing about the desired
result. The tuberculous patient who sets his mind on recovery,
refusing to be discouraged by the numerous setbacks which may from
time to time occur, has a much greater chance of living a long and
useful life than the patient who makes no effort in this direction.

~Reënforcing the Diet.~--The following reënforced foods have been
found valuable in the diet for tuberculosis, especially in those cases
which are confined to bed and in which the effort to eat causes more
or less gastric distress:

Milk, whole milk, milk and cream, milk diluted with Apollinaris water,
peptonized, modified milk, reënforced with egg or egg white or
reënforced with one to four tablespoonfuls of lactose, malted milk,
buttermilk, cream, egg, and vichy, milk shake, milk punch, malted milk
shake, chocolate or cocoa malted milk, albumenized fruit juices, egg
and orange, egg and wine, reënforced, if desired, with lactose,
albumenized broths, proprietary infant foods, such as Eskay's Food,
Nestlé's Food, Mellin's Food, Racahout, cream soups reënforced with
lactose or egg, junkets, and ice cream.


PNEUMONIA

The diet in pneumonia is of considerable importance, since in this
condition the strength of the patient is taxed by reason of the
character of the disease, and the only means of attaining endurance to
carry him through this trying period is by providing proper
nourishment.

~Dietetic Treatment.~--The same general outline of diet is used as in
acute infectious fevers, milk forming the basis of the diet. The
patient is given an abundance of water and other beverages in
addition to the other fluid foods to relieve the thirst which is so
often a common symptom in this disease.

It is sometimes found advisable, however, on account of the vomiting
which may occur, to give a more concentrated form of nourishment, in
which case liquid peptonoids, trophonine, and panopepton furnish a
form of nourishment which is both strengthening and stimulating in
character, and for these reasons particularly desirable. Freidenwald
and Ruhräh advise against the use of starches and sugars in most cases
of pneumonia.

~Daily Diet Schedule.~--The same fluid diets used in acute fevers and
administered at two-hour intervals are advisable here. The following
régime is used in pneumonia:

   6 A.M. 6 oz. malted milk.
   8 A.M. 6 oz. cocoa.
  10 A.M. 4 oz. oatmeal or cornmeal gruel with 2 oz. cream.
  12 M.   6 oz. chicken broth reënforced with 1 egg white.
   2 P.M. 6 oz. malted milk chocolate.
   4 P.M. 6 oz. albumenized orange juice.
   6 P.M. 6 oz. chicken or beef broth, reënforced with egg white.
   8 P.M. 6 oz. hot milk.

Night feeding consisting of milk, malted milk, or reënforced broth may
be given at 12 M. and 4 A.M. if patient is awake.

The above diet may be varied by adding some of the beverages mentioned
in the diet for tuberculosis or fevers.

~Convalescent Diet Schedule.~--As the acute symptoms subside and
convalescence advances, the following diet may be instituted:

I

   Breakfast 3 to 4 oz. cereal gruel with 2 oz. cream.
             1 soft-cooked egg.
  10:30 A.M. 6 oz. chicken broth, reënforced with egg, or 6 oz.
               albumenized orange or grape juice.
      1 P.M. 6 oz. oyster soup with rolled crackers.
             1/4 cup wine jelly with 1 tbs. cream.
             1 glass (6 oz.) milk--2 parts milk, 1 part cream.
      3 P.M. Milk shake (4 oz. milk, 1 egg white).
      Supper 4 oz. farina with 1 oz. cream.
             6 oz. cocoa.
      9 P.M. 6 oz. malted milk.

Hot milk, broth, or malted milk may be given during the night at 12 or
4 A.M. if patient is awake.

II

  Breakfast 4 oz. orange juice on cracked ice.
            3 or 4 oz. strained oatmeal with cream or butter.
            1 slice soft toast.
            6 oz. cocoa.
    10 A.M. 1 soft-cooked egg on toast.
            6 oz. milk.
     Dinner 6 oz. cream of celery soup.
            2 oz. rice.
            4 oz. custard (soft or baked).
            6 oz. milk or cocoa.
     3 P.M. 5 oz. cream, egg, and vichy.
     Supper 1 soft-cooked egg.
            1 small baked potato.
            6 oz. cocoa or malted milk.

III

   Breakfast Stewed prunes.
             3 or 4 oz. cream of wheat with 1 oz. cream.
             1 soft-cooked egg.
             1 slice of toast with butter.
             6 oz. cocoa or milk.
  10:30 A.M. Eggnog (1 egg, 4 oz. milk, 2 oz. cream, 1 tbs.
             whisky or sherry wine).
      Dinner Cream of spinach soup.
             2 oz. mashed potatoes.
             2 oz. green peas.
             1 slice toast with butter.
             2 oz. rice or tapioca custard.
      3 P.M. 6 oz. albumenized fruit juice.
      Supper 1 slice toast.
             1 poached egg.
             6 oz. cocoa or hot milk.
             2 or 3 oz. stewed fruit or prune whip.

The diet may be reënforced with lactose and meat added only when
convalescence is well established.

~Tuberculosis Nursing.~--The nurse must keep in mind that the lungs
are in a condition more or less out of commission, and their work of
excretion is forced upon the kidneys. For this reason, as well as on
account of the increased strain upon the heart, it is necessary to
keep the diet light and avoid all foods which may in any way exert an
unfavorable influence upon either the kidneys or the heart.

~Milk Diet.~--A strict milk diet has been found necessary in certain
cases of pneumonia, but this is used only while the febrile condition
lasts, after which the diet is gradually increased, as in the case of
acute nephritis and in diseases of the heart, to meet the needs of the
individual.


TONSILLITIS

~Dietetic Treatment.~--The diet in this condition is much the same as
that used in other acute febrile conditions, that is, a fluid diet,
the basis of which is, as a rule, milk.

The development of nephritis and certain cardiac symptoms at times
follow attacks of tonsillitis, and for this reason the urine must be
examined frequently and the diet carefully adjusted to avert, if
possible, this danger. When acute nephritis does follow the attack of
tonsillitis, the diet must necessarily be adjusted to meet that
condition rather than that of the original disease.

~Special Diets.~--The Mosenthal diet, and at times the Karell Cure, is
used with more or less success. This, however, is adjusted by the
physician. It remains for the nurse to report any unfavorable symptoms
as soon as they occur, and to carry out the line of dietetic treatment
deemed advisable by the physician.


SUMMARY

TUBERCULOSIS

~Form.~--Acute and chronic in character. The chief aim of the
treatment in the former is to prevent its development into a chronic
form.

~Rest.~--~Sleep~, preferably in the open air, in a tent or on a
sleeping porch.

~Proper Surroundings~ should be striven for. The patient should be
kept tranquil in mind and body, free from disturbing worries and
assured of the possibility of recovery with proper care.

~Diet~ should be adequate without being too abundant; stuffing the
patient is no longer considered necessary, in fact it is believed that
forcing the eating of large quantities of eggs, etc., defeats its own
ends, upsetting the digestion and causing a disgust for food almost
impossible to overcome.

~Gastro-intestinal Disturbances~ are apt to develop as the disease
progresses. These are treated as in other conditions so complicated,
except that the period of starvation must necessarily be limited on
account of the metabolic waste already taking place from the disease
itself.


PNEUMONIA

~The Lungs~, as in pulmonary tuberculosis, are the seat of infection
and are temporarily hampered in their work of excretion.

~The Kidneys~ bear the brunt of the extra work caused by the
impairment of the lungs, consequently all unnecessary work must be
spared these organs if they are to be prevented from being overtaxed.

~Nephritis~ is one of the complications apt to develop when the
kidneys are not sufficiently strong to carry on their own work and
that generally done by the lungs.

~The Heart.~--Cardiac symptoms are also likely to develop during
attacks of pneumonia and make the disease one to be dreaded and
guarded against.

~The Diet.~--The dietetic treatment in pneumonia is like that used in
acute infectious diseases, fevers in general, fluids constituting the
form of diet and milk the chief food, as long as there is an elevation
of temperature.


TONSILLITIS

~The Heart.~--As in pneumonia, the development of cardiac symptoms
must be guarded against. These symptoms may not develop at once but
show later during or after convalescence.

~The Kidneys.~--Nephritis also develops in some patients and the
treatment is directed as far as possible to prevent its developing
into a chronic form.

~Dietetic Treatment~ is the same as used in acute infectious
conditions, fevers of short duration, taking care to institute the
diet for acute nephritis should the patient show evidences of this
disease.


PROBLEM

Write a diet order for a tuberculous patient weighing 135 pounds,
allowing 3000 calories and fifty per cent. of the protein to be
derived from animal sources.


FOOTNOTES:

[104] The addition of cream to coffee produces acute indigestion in
certain individuals, hence the nurse must be governed by this point in
formulating the diet.

[105] See "High Calorie Diet for Typhoid Fever," Chapter XIV.




CHAPTER XVI

DIETETIC TREATMENT BEFORE AND AFTER OPERATION


PREOPERATIVE FEEDING

The dietetic treatment which is essential before and after operations
is deserving of attention here, since it constitutes one of the points
so frequently overlooked or slighted. As a rule the treatment depends
(1) upon the character of the disease for which surgical intervention
is necessary, and (2) upon the general health and physical condition
of the patient in question.

~Preparatory Treatment.~--In many cases it is found to be advisable to
build up the patient before subjecting her to the shock of an
operation, and the more serious the operation the more necessary this
"building-up" process.

The character of the disease also has much to do with the preliminary
diet. In certain pathological conditions involving the gastro-intestinal
tract, for example, the patient comes to the surgeon after medical
treatment has failed to give relief and surgical intervention is
necessary to save life. The body is found to be in a condition bordering
on starvation, anemic and exhausted from insufficient nourishment. The
functions of the blood-making organs have become out of gear, as it
were, and the blood consequently is deficient in one or more of its
essential elements. For such patients it is wise to attempt to reënforce
and strengthen their bodies before operation, that they may have more
endurance to withstand the shock which is more or less unavoidable.

~Adjusting the Diet.~--In any case where preliminary diet is
prescribed the condition for which the operation is necessary
determines the nature of the diet; for example, if the operation is to
be upon the kidney, the diet beforehand would naturally be in the
nature of a nephritic one to save the diseased organ unnecessary work.
If the stomach or intestinal tract required surgical care, the diet
would necessarily be formulated to meet the particular needs of the
organ in question, an analysis of the stomach content furnishing the
keynote of the diet. In any case the food must be simple in character
and well prepared. All food in any way liable to bring about
indigestion should be studiously avoided.

~Habits.~--The habits of the patient must be regulated so that she may
not "overdo"; at the same time, gentle exercise may be the very thing
needed to give an impetus to the appetite and thus assist in the
adding of strength for the approaching ordeal. Many patients respond
readily to a change of air and scene and frequent small meals instead
of a few large ones,--a lunch in the mid-morning and mid-afternoon
hours, consisting of a glass of milk and a cracker or malted milk
chocolate or reënforced fruit juices. A cup of warm milk before
retiring induces the much-needed sleep, hence is advisable under the
circumstances.

~The Bowels.~--The bowels must be kept open. Coarse bread such as that
made from bran or graham flour is advisable. Prunes and figs cooked
with senna leaves are likewise simple laxatives which are both
palatable and effective. For stubborn cases of constipation it is
often found that a teaspoonful of a conserve made with a third of a
pound each of raisins, prunes, and figs ground fine, with an ounce of
senna leaves added, taken at bedtime and before breakfast, will
overcome the condition and make the patient more comfortable and the
general health better.

~Preliminary Light Diet.~--The day before the operation the diet must
be light; the intestinal tract must not be filled with a food mass
which is difficult to get rid of. On the morning of the operation the
patient is given no food if the operation is to be performed at an
early hour, otherwise a cup of tea, coffee, weak cocoa, or broth with
a cracker is given. Some physicians give a glass of milk at this time,
while others do not. It is the physician who must decide the question
if there is any doubt about it. The stomach must be empty before
administering the anesthetic.

In certain emergency operations when it has been impossible to prepare
the patient ahead, the difficulties attending the administering of the
ether are sometimes greatly increased. The cleansing of the stomach
and intestinal tract oftentimes eliminates or materially decreases the
nausea and vomiting which so often forms one of the most dreaded
sequences of the operation. For this reason many surgeons require the
patient to be given lavage before leaving the operating room.

~Total Abstinence.~--No food is given for twenty-four hours following
the operation (1) on account of the nausea and vomiting which so often
follows the giving of an anesthetic--ether particularly--and (2)
because the entire organism is better for a complete rest.

~Routine Treatment.~--The routine treatment in uncomplicated cases is
rest, then water, very hot or iced, or carbonated, or vichy in
spoonful doses, then albumen water, broth, etc., then milk,
buttermilk, koumiss, etc., after which the semi-solids, etc., until a
normal diet is reached. After a week or more the character of the
operation certainly determines the dietetic treatment. To quote Dr.
Thomas S. Brown,[106] "To give the same diet after pyloroplasty,
gastro-enterostomy, gall bladder operation, or gastric resection as
we would after operations for fracture of the thigh or cancer of the
breast shows a basic ignorance of the pathologic physiology of the
former group of cases." "We should remember that hyperacidity remains
long after the underlying cause has been removed and it is tempting
providence, to say the least, to ply these patients with tomato soup,
salad dressing, and coarse food in the early stages of their
convalescence."

~Character of Diet.~--It must be kept in mind that the character of
the diet is of vital importance, especially in the after-treatment of
operations upon the stomach. In gastro-enterostomy, for example, the
food mass passes from the stomach directly into the upper part of the
small intestine through the new opening. Thus the semi-liquid food
highly acid in character comes in direct contact with the delicate
intestinal walls which are accustomed, not to the acid, but to a
neutral or alkaline medium.

~Adjusting Diet to Disease.~--Thus it is demonstrated that unless care
is used in selecting the diet this portion of the intestinal tract
will be injured; hence the nurse must understand which foods are
liable to stimulate an excess flow of acid in the stomach and avoid
them. She must also keep in mind that the foods given must be in a
semi-liquid or very finely divided condition, since the mechanical
efforts made by the musculature of the gastric organ act as a direct
stimulant to the secretory cells of that organ.

       *       *       *       *       *

Much of the responsibility thus rests upon the nurse whose business it
is to administer the diet. The efforts of the best surgeon in the
world may be entirely overcome by a careless, thoughtless, or ignorant
nurse.

~Rectal Feeding.~--In some cases it is found necessary to nourish the
patient more than is possible by mouth. This is especially so with
emaciated and very weak patients and for those who have undergone
operations upon the mouth or throat and in some of the above-mentioned
stomach cases when the passage of any food over the newly-operated-upon
surfaces is inadvisable. In these cases rectal feeding is resorted to
and from two to three nutrient enemas[107] alternated with saline enemas
are given daily.

Under ordinary conditions when the patient has not been operated upon
for gastro-intestinal disorders, gall bladder or kidney diseases, the
dietetic régime is as follows:

~Postoperative Feeding.~--First day: starvation, a little hot or cold
water or carbonated water may be given if there is no nausea or
vomiting. If nausea or vomiting persists, a few spoonfuls of champagne
or clam broth or juice will often check or relieve it entirely. Fluids
alone must be given during the first forty-eight hours after the
operation. When stimulation is necessary, albumen water or coffee
containing a spoonful of brandy[108] will be found useful. When nausea
entirely disappears, well-skimmed broth milk, clam or oyster broth,
buttermilk, koumiss, malted milk, may be given. A gradual return to
the normal diet is made, adding soft toast, soft-cooked eggs, junket,
ice cream, meat, wine, or fruit jellies before solid food is
introduced into the dietary.

~After-care in Feeding.~--Care must be observed to prevent indigestion
after almost any operation, but especially after abdominal operations
there is a great tendency to form gas, hence anything which in any way
increases the tendency may bring about a condition of extreme
discomfort and even acute pain to the patient. For this reason it is
unwise to follow too closely the desires of the patient as to the food
to be eaten; for example, corned beef and cabbage may be the thing of
all others desired by the patient, but it would be the height of folly
to risk such a meal until all danger of digestional disturbances is at
an end. It is wiser to avoid such disturbances than to trust to
relieving them after they occur. The digestion of even a perfectly
normal individual is at a disadvantage when that individual is
deprived of outdoor exercise. How much more so will it be when the
entire organism is taxed by the ordeal through which it has just
passed. Convalescence is never hastened by imprudent eating, and a
condition as bad as the original may be brought on by lack of care on
the part of the one whose business it is to feed the patient.


CONDITIONS REQUIRING SPECIAL DIETS

~Diet After Appendicitis.~--After a simple operation for appendicitis
the same régime is carried out as in stomach and intestinal
operations: fluids on the second day, soft diet on the third, and
solid food of the simplest character and prepared in the simplest way
may be given on the fifth and sixth days. When, however, the operation
has been of a more serious character, for example, when there was pus
formation or a gangrenous appendix, the feeding by mouth must not be
instituted for five days or more, nutrient enemas being used instead.
Patients have been known to die from exhaustion after operations upon
the stomach and intestines, not on account of the operation but on
account of the lack of reserve power and endurance to carry them
through the ordeal without a sustaining diet to overcome it. Under the
circumstances Dr. F. Ehrlich[109] advises the following routine
method: "So soon as the nausea from the anesthetic has worn off the
patient gets tea, red wine, and gruel; on the day after the operation
he is given sweetbreads in bouillon even if it nauseates him; if the
nausea is persistent, his stomach is washed. On the second day finely
chopped cooked squab, chicken, or veal, is added; on the third day,
beef, potato purée and cakes; on the fourth, chopped (raw) ham, soft
zwieback, and soft-boiled eggs. On the fifth, white bread and
spinach. After the seventh day the meat is not chopped, and the
patient returns gradually to normal diet. The bowels are regulated by
oil enemas."

~Diet After Operation upon Gall Bladder or Liver.~--The dietetic
treatment in these cases is like that of any other abdominal operation
except for the character of the food. Fats are not well handled by the
body of such individuals and should be eliminated as far as possible
from the diet. Broths must be skimmed carefully to remove fat, and
milk when given should be skimmed or given in the form of buttermilk
or koumiss.

~Diet After Operations upon the Kidneys.~--The diet administered after
operations upon these organs is logically one in which those foods
which are entirely dependent upon the kidneys for their elimination
are restricted. In a former chapter the fate of the foods in
metabolism was explained; the protein foods were seen to be the ones
leaving the body chiefly by way of the kidneys and for this reason in
the diet after operations upon these organs, as well as in that
administered in disturbances affecting their functioning powers, this
food constituent, the protein of meat in particular, must necessarily
be restricted. The upsetting of the nitrogen equilibrium is for so
short a period after kidney operations that this feature need not be
considered here. The diet under the circumstances is essentially the
same as that given during acute attacks of nephritis.


SUMMARY

~Factors Affecting Diet~ before and after operations must be
considered under two heads, namely, the character of the disease for
which the operation is considered necessary and the general physical
condition of the patient at the time.

~Emaciation and Anemia~ are often encountered in patients having
certain gastro-intestinal disturbances for which surgical intervention
was found to be necessary. At times a preliminary up-building
treatment is required before it is considered wise to submit the
patient to the shock of so serious an operation.

~Adjusting the Diet~ according to the character of the disease for
which the operation is to be performed is most important. It is not
always possible to build up the body beforehand, but in many cases it
is necessary to make the effort. At times the reënforcing of the diet
and a certain amount of gentle massage will enable the patient to pass
through the trying ordeal more comfortably than would otherwise be
possible.

~Selecting the Diet~ to conform to the character of the disease is as
important a factor in the recovery of the patient as food itself. This
selection is left largely to the nurse, consequently it is necessary
that she should understand just which foods are indicated or
contraindicated under the circumstances, and adjust the diet after the
abstinence period accordingly. For example, the diet fulfilling all
the needs of a patient who has just undergone an operation for a
broken leg might be highly injurious for a patient just operated upon
for some disturbance of the liver or kidneys. The diet given after
must be essentially like that given just before the operation, in
order that the affected organ may have an opportunity to heal and
return to its normal functioning power.

~Gastro-intestinal Disturbances~ must be avoided, both before and
after the operation. In the preliminary treatment, when every effort
is being made to increase the strength and endurance of the patient,
such disturbances do away with any gain brought about by judicious
dieting. After the operation, attacks of indigestion not only cause
pain and discomfort as a result of the gas formation, but may cause
symptoms far-reaching and even dangerous in their effects. The diet,
then, must be composed of the simplest food and prepared in the most
careful manner, the amount of food given at a time must be small--it
is wiser to feed the patient oftener than to run the risk of
indigestion by giving more than can be readily handled by the already
taxed digestive apparatus.

~The Bowels~ must be kept open in the majority of cases. Peristalsis
is stimulated by the giving of water and fruit beverages as soon as it
is advisable to give anything by mouth.

~Reënforcing the Diet~ is at times necessary in order that the
patient's strength may be kept up. In such cases lactose, eggs and
some of the predigested casein or beef preparations are found to be
valuable.

~Before the Operation~ the patient must be made ready to take the
anesthetic. This is done by preventing an accumulation of food in the
intestinal tract. The day before the operation, then, it is necessary
to limit the diet materially by giving food in small amounts. The
light diets prescribed in acute conditions are as a rule suitable,
unless otherwise indicated.

~The Day of the Operation~ a cup of tea, coffee, or broth may usually
be given, with a cracker, unless the operation is to be performed
early in the morning, in which case the patient is given no food at
all. Some physicians allow a glass of milk on the day of the
operation, but this is left entirely to the physician in charge.

~After Operation~ a period of total abstinence from both food and
water is necessary in order not to increase or induce nausea and
vomiting. As soon as these symptoms subside, unless otherwise
indicated, a certain amount of hot, cold, or carbonated water may be
given. After this, albumen water may form the first nutrient
administered. Milk, broth and fruit beverages follow the giving of
albumen water, after which the semi-solids, such as soft eggs,
gelatin and milk soups, constitute the convalescent diet.

~The Character of the Diet~ after the operation depends wholly upon
the nature of the disease for which the operation was deemed
necessary.

~Diet After Gastro-enterostomy~ must be adjusted in order not to
increase the acid content of the gastric organ, otherwise the delicate
mucous linings of the intestines would be subjected to direct contact
with materials which are irritating in character, owing to the fact
that the mass passes through the new opening and has thus been
deprived of the neutralizing agents found in the upper part of the
intestinal tract. Under the circumstances milk, albumen water and fine
cereal gruels are the best foods from which to formulate the diet
after the necessary period of abstinence and fluid diet.

~After Appendicitis~, as a rule, no food is given for five days in
cases where there has been a pus formation and the appendix
gangrenous. Otherwise the routine treatment diet is given--water, then
albumen water, followed by broth, milk and fruit beverages, fine
cereal gruels, etc.

~After Liver and Gall bladder Operations~ the character of the food
must be considered. The fats are not well handled in such conditions
and must be avoided as far as possible. Broths must be well skimmed
and the milk fat free. Buttermilk and koumiss are probably the most
suitable forms in which to give milk in these cases.

~After Kidney Operations~ the work of elimination through kidney must
be limited as far as possible in such cases. While it is impossible to
rest the organ entirely, the giving of a proper diet under the
circumstances will do much toward relieving the strain placed upon it.
The protein foods, with the exception of milk, must be excluded from
the diet. The régime practiced in acute nephritis gives the most
satisfactory results.


PROBLEMS

(a) Write a diet order for patient operated upon for gastric ulcer.

(b) Formulate diet to be used after a gall bladder operation.

(c) Outline diet used after operation upon the kidney.


FOOTNOTES:

[106] "Some Gastro-intestinal Notes," "The Medical Clinics of North
America," Vol. I, No. 1, pp. 192-193, by Thomas R. Brown, Johns
Hopkins Hospital.

[107] See Formulas for Nutrient Enemas, p. 145.

[108] See Albumen Water with Brandy, p. 141.

[109] "Diet in Health and Disease," p. 555, by Friedenwald and Ruhräh.




CHAPTER XVII

URINALYSIS


The importance of the kidney functions has been clearly demonstrated.
Urine, which is the fluid secreted by these organs, is one of the most
important sources of information, not only as to the manner in which
the body utilizes food in health, but as an index to certain
pathological conditions, the processes of which are more or less
indicated by the products excreted in the urine.

~Function of the Kidneys.~--The kidneys, as has already been stated,
furnish a means by which the greater part of the waste products of the
body are eliminated and in addition to this function they adjust the
salts in the body. In an early chapter the function of the salts in
food was explained. A certain amount of these substances, we know, is
absolutely necessary to carry on the work in the body, but harm comes
when a surplus is retained in excess of that which can be used in
performing the various processes. Consequently the function of the
kidneys to adjust the salts balance is by no means their least
important one.

~Elimination of the Toxins.~--The toxic substances manufactured in the
body and those resulting from bacterial action upon unabsorbed
proteins are likewise eliminated in the urine. Thus it can be readily
understood how necessary it is to keep these organs in good repair,
that they may continue their work in an efficient manner.

It is necessary from a pathological standpoint for the nurse to
understand the making of some of the simpler tests, that she may
simplify her own work and that of the physician.

~Excretion of Carbon Dioxide and Water.~--We have already spoken of
the combinations of carbon and hydrogen compounds. These substances
being oxidized, the carbon dioxide produced is eliminated by way of
the lungs and the water is excreted partly by way of the lungs and
skin, but chiefly by way of the kidneys.

~Oxidation and Excretion of Nitrogenous Substances.~--When the
nitrogenous substances are oxidized, the used-up oxygen products are
eliminated by the kidneys in the form of urea and more or less highly
oxidized substances, such as ammonia and other salts, purin bases, and
creatinin.

~Uric Acid~, the chief of the oxidation products of nucleoproteins, is
produced in the body and from food, and is always in the urine, being
one of its normal constituents. It is only when this substance is in
excess in the urine that a pathological condition is indicated.

~Examination of the Urine~, then, is made for several different
purposes: (1) to ascertain whether the kidneys are doing their work
properly; (2) to find if the kidneys, or any part of the urinary
tract, are either temporarily or permanently diseased; (3) to be able
to judge from the various substances in the urine whether there is any
abnormal process taking place in the body.

~Tests.~--In the examination of the urine for the above purposes,
certain definite tests are made. These tests differentiate between the
abnormal and the normal.

(1) Color.

(2) Amount in twenty-four hours.

(3) Odor.

(4) Specific gravity.

(5) Reaction, acid or alkaline.

(6) Albumen, indican, acetone bodies.

(7) Sugar.

(8) Microscopic examination for casts, cells, bacteria, etc.

~The Color~ of normal urine varies, especially with the amount voided.

The variations in color range from the pale straw color of individuals
who are voiding large quantities to the deep lemon or amber of those
who void much less.

Pathological conditions are indicated to a certain extent by the color
of the urine. Fevers heighten the color, small quantities of blood
cause a smoky appearance, while bile changes the color of the urine to
a greenish yellow.

~Precipitates in the Urine.~--When the urine has been allowed to stand
for a time there is sometimes a brick-red deposit due to the
precipitate of urates. This disappears upon heating and is not an
evidence of any diseased condition.

~Turbidity of Urine.~--The turbidity of fresh urine then is the only
kind which need be considered, since standing in the cold often brings
about this condition, due to the growth of bacteria and deposits of
both phosphates and urates.

~Requirements in Testing Urine.~--Urine to be tested should be fresh,
and when it is not possible to make the examination at once it should
be preserved with chloroform, or some other harmless preservative,
until ready to use.

~Bacteria in Urine.~--The changes due to bacterial growth in the urine
are manifested not only by the turbid character of the urine but also
by the odor of ammonia.

~The Amount of Urine.~--The amount of urine voided in twenty-four
hours varies with the individual in health as well as in disease. Many
individuals void a great quantity during the twenty-four hours,
chiefly because they drink a great quantity of water and other
beverages. The average amount of urine passed in twenty-four hours by
an adult, or a child over eight years, is from 1000 to 2000 c.c. It
represents from 60% to 70% of the amount of water ingested.

~Collecting the Urine for Testing.~--In measuring the urine it is
necessary to begin collecting it after the bladder has been emptied
the first thing in the morning. The patient should void just before
the end of the twenty-four-hour period to be sure that the amount
formed by the kidneys during this time is accounted for.

~Diseases in Which Urine Is Diminished.~--In certain diseases the
amount of urine passed is diminished. This is found to be true in
diarrhea and dysentery, when water is lost in the feces, in hemorrhage
from any part of the body and from vomiting. It is likewise at times
the case after abdominal operations and in nervous conditions, such as
hysteria. The urine is diminished when there is an organic obstruction
in the urinary tract and certain obstructive diseases of the heart,
the lungs and the liver. In these latter cases, there is seen to be a
retention or suppression of urine. In both acute and chronic nephritis
and in certain fevers, the bladder at times must be emptied by means
of a catheter. At other times, the condition is relieved as far as
possible by limiting certain articles of food in the diet. At any
rate, these points must be kept in mind when examining the urine.

~Effect of Food upon the Urine.~--The odor of normal urine is changed
after eating certain foods, such as onions and asparagus. In disease,
the odor of urine has a distinct value as a means of diagnosis;
cystitis gives a foul odor, certain bacteria bringing about a
decomposition in the urine and giving rise to an odor of putrefaction.
In cases where there is a fistula connecting the bladder and rectum,
the urine has a fecal odor.

~Specific Gravity of Normal Urine.~--The density or specific gravity
of urine means the weight of any volume of urine as compared with
that of equal volume of distilled water. The specific gravity of
normal urine varies from 1012 to 1024, that is, in a thousand cubic
centimeters of urine there are found from 11 to 18 grams of solid
material. In health it is necessary to know the amount of urine passed
in twenty-four hours, to be able to judge whether the amount of solids
is too high or too low.

~Specific Gravity of Diabetic Urine.~--In conditions like diabetes
mellitus, where there is a wastage of sugar taking place in the
body--that is, instead of being oxidized to carbon dioxide and water
and glucose, the sugar is passing into the urine without completing
its oxidation--the specific gravity rises in these cases to 1030 and
over, showing distinctly that a greater amount of solid material is in
the urine than is present normally. In chronic Bright's disease and
diabetes insipidus, the specific gravity is low.

~Method of Determining Specific Gravity.~--The specific gravity is
determined by the use of an instrument known as a urinometer. The
urine is poured into a tube and the urinometer is dropped into it. The
different figures are marked upon the stem of the instrument and it is
a simple matter to read off the figures of the level to which the stem
sinks.

~Reaction to Litmus.~--In a former chapter it was stated that normal
urine was, as a rule, acid, that is, it turns blue litmus red. Certain
diseases render the urine alkaline. A like result is brought about
upon the ingestion of sodium citrate or bicarbonate of soda. Urine
which stands and becomes decomposed is alkaline in reaction, due to
the bacterial action, with the production of ammonia.

~Albumen in the Urine.~--The presence of albumen in the urine is
important, since normal urine does not contain this material in
quantities sufficient to be recognized by ordinary tests. Hence in
disease its presence is an indication of pathological processes taking
place either in the kidney or the urinary passages. The chief
abnormal condition indicated by the presence of albumen in the urine
is nephritis. Traces of albumen may occur in patients with fever or a
heart weakness. Blood and pus in the urine likewise indicate albumen.
When the nephritic condition is chronic, the kidneys themselves are
diseased and the presence of albumen may be in traces only, while
during the acute attack large quantities may be passed, but the urine
will clear up after a time.

~Benedict's Qualitative Sugar Test.~--Boil 5 c.c. of Benedict's
solution; add 8 drops of urine to be examined; hold the tube over the
flame and allow to boil vigorously for 3 minutes and set aside to cool
of itself. In the presence of sugar the entire solution will be filled
with a precipitate which may be greenish, yellow, or red, according to
the amount of sugar present. When the percentage of sugar is low
(under 0.3%) the precipitate will form only upon the cooling of the
solution. If there is no sugar present, the solution will either
remain clear or show a slight turbidity, due to the precipitation of
urates. The nurse must remember that to be useful the test must be
made accurately. There must never be more than 10 drops of urine and 8
drops is the usual quantity. The boiling must be vigorous and the
solution allowed to cool spontaneously.

~Fehling's Test for Sugar.~--Fehling's alkaline solution and Fehling's
copper solution must be kept in separate bottles until ready for use.
Then about 2 c.c. of Fehling's alkaline solution is poured into a test
tube and 2 c.c. of Fehling's copper solution is added. This is diluted
with hydrant water to 8 c.c. Half of this quantity is sufficient for
the test. The upper half of the solution is boiled over flame (gently
agitated while heating), and while still boiling a few drops of urine
are added. If no change appears, it is boiled again and a few drops
more of urine are added. If a reddish precipitate appears, sugar is
present. The chemical reaction taking place is the reduction of copper
sulphate to cuprous oxide. Sometimes a partial reduction occurs when
urates are in excess, but once having seen the real reduction, a
partial one cannot mislead the examiner.

~Haines's Test.~--Pour 1 teaspoonful of Haines's solution into a test
tube and boil gently over a Bunsen burner; add 6 or 8 drops of urine
and again heat to boiling. A yellow or red precipitate will indicate
the presence of glucose.


QUANTITATIVE TEST FOR SUGAR

~Benedict's Test.~[110]--The simple quantitative test for sugar is the
one devised by Benedict. This is simpler than the polariscopic
examination and better suited for ordinary use.

Place 5 c.c. of Benedict's quantitative solution in a small dish, add
a little less than one-fourth of a teaspoonful of sodium carbonate and
one-eighth of a teaspoonful of talcum and add 10 c.c. of water. Dilute
urine (1 part urine to 9 parts water) except where the qualitative
test showed a low percentage of sugar, that is, when the precipitate
turns green instead of yellow, in which case it will be unnecessary to
dilute the urine. Place dish over burner and bring the contents to a
boil. Pour the urine into a graduated pipette. Now add the urine drop
by drop to the contents in the dish until the blue color entirely
disappears. This test should be done over several times to assure an
accurate calculation. The calculation is made as follows: 5 c.c. of
Benedict's quantitative copper solution are reduced by 0.01 gram of
glucose, consequently the quantity of undiluted urine required to
reduce 5 c.c. Benedict's solution contains 0.01 gram of glucose.

   0.01
  ------  × 100 = per cent.   _x_ = c.c. of undiluted urine.
   _x_

Example; 1500 c.c. urine in 24 hours. 5 c.c. used to reduce
(decolorized) Benedict's solution.

   0.01
  ------  × 100 = 0.2 per cent.
    5

1500 × 0.002 (0.2 per cent.) = 3 grams of sugar in 24 hours.

Example: If the urine had been diluted with 9 parts water, in other
words, 10 times, the calculation would be 5 c.c. diluted urine = 0.5
c.c. actual urine.

   0.01
  ------ × 100 = 2 per cent.
   0.5

1500 × 0.02 (2 per cent.) = 30 grams of sugar in 24 hours.

Hill and Eckman perform the Benedict's quantitative test as
follows:[111]

Measure with a pipette 25 c.c. Benedict's solution into a porcelain
dish, add 5 or 10 grams approximately of solid sodic carbonate, heat
to boiling, and while boiling, run in urine until a white precipitate
forms, then add urine more slowly until the last trace of blue
disappears. The urine should be diluted so that not less than 10 c.c.
will be required to amount of sugar which 25 c.c. of reagent is
capable of oxidizing.

Calculation: 5 divided by number of cubic centimeters of urine run in
equals per cent. of sugar.

~Fermentation Test for Quantity of Sugar in Urine.~--If the urine is
70° F. (room) temperature when the specific gravity is taken at both
the beginning and end of the test, it will assure accuracy.

To 100 c.c. of urine of known specific gravity, add one-fourth of
fresh yeast cake thoroughly broken up. Mix thoroughly and set aside at
a temperature between 85° and 95° F. for twenty-four hours, after
which time test with Benedict's or Fehling's solutions. If reduction
is obtained, it will be necessary to allow the fermentation to
continue until it is complete. When no further reduction is obtained,
the specific gravity is taken after the urine has reached a
temperature of 76°. The difference in the specific gravity at the
beginning and end of the test multiplied by 0.23 gives the percentage
of sugar in the urine.

The following formulas represent the various solutions used in the
above test:

BENEDICT'S QUALITATIVE SOLUTION

                                         _Gm. or c.c._
  Copper sulphate (pure crystals)             17.3
  Sodium or potassium citrate                173.0
  Sodium carbonate (anhydrous)               100.0
  Distilled water to make                   1000.0


FEHLING'S SOLUTION

  (1) Copper Sulphate Solution:
      34.65 grams copper sulphate dissolved in water and sufficient
        water added to make 500 c.c.
  (2) Alkaline Solution:
      125 grams potassium hydroxide.
      173 grams Rochelle salts dissolved in water q.s. to make 500 c.c.

Keep solution in separate bottles and mix in equal quantities when
ready to use.


HAINES'S SOLUTION

  Copper sulphate (pure)                 30 grams
  (dissolved in 1/2 oz. (15 c.c.) distilled water)

Add 1/2 oz. pure glycerin, mix thoroughly, and add 5 oz. liquor
potassæ.


BENEDICT'S (QUANTITATIVE) SOLUTION

  Copper sulphate (pure crystals)                     18 grams
  Sodium carbonate (crystallized) (or 100 grams
    of anhydrous salt)                               200 grams
  Sodium or potassium citrate                        200 grams
  Potassium sulphocyanide                            125 grams
  5% solution of potassium ferrocyanide                5 c.c.
  Distilled water to make total volume of 1000 c.c.

Dissolve the carbonate, citrate, and sulphocyanide with the aid of
heat and enough water to make 800 c.c. of mixture. (Filter, if
necessary.) Weigh exactly the copper sulphate crystals and dissolve in
100 c.c. of water, now add it to the first solution; stirring
constantly. Add the ferrocyanide solution; cool and dilute to exactly
1 liter.

50 mg. (0.050 gm.) of sugar will reduce 25 c.c. of the above solution.

~Gerhardt's Ferric Chloride Reaction for Diacetic Acid.~--To 10 c.c.
of fresh urine, add carefully a few drops at a time of undiluted
aqueous solution of ferric chloride U.S.P. A precipitate of ferric
phosphates first forms, but upon the addition of a few more drops of
the same solution it is dissolved. A Burgundy red (red wine) color is
obtained in the presence of diacetic acid. The depth of this color is
indicative of the quantity of acid present. Joslin[112] records the
intensity of the reaction as follows, +, ++, +++, or ++++.

According to Joslin, it must be remembered that similar reaction is
obtained in the urine of individuals taking salicylates, antipyrin,
cyanates, or acetates, but it is a simple process to differentiate
between the color produced as a result of diacetic acid and that
produced by the above-mentioned drugs. If the solution is boiled for
two minutes, the color from diacetic acid will disappear, owing to the
unstableness of that substance, while that from the drugs will remain
unchanged.

~Test for Acetone.~--Pour 5 c.c. of urine to be tested into a test
tube, add a crystal of sodium nitroprusside, acidify with glacial
acetic acid, shake well, and then make alkaline with ammonium hydrate.
The presence of acetone is indicated by a purple color.


TESTS FOR ALBUMEN

The heat test[113] is the simplest. This consists of first filtering
the urine through filter paper, then pouring some of the clear urine
into a test tube, holding the test tube in a flame so that only the
upper layer boils, then adding a few drops of 2% solution of acetic
acid and boiling again. If there is albumen present, a very faint, or
a heavy cloudiness (precipitate of coagulated albumen) forms on
boiling and persists or becomes heavier on the addition of a few drops
of dilute acetic acid (2%) and boiling again. If a precipitate occurs
at the first boiling, but clears up again entirely on adding acetic
acid, it is not albumen but harmless phosphates or carbonates.


HELLER'S TEST FOR ALBUMEN

Into a test tube pour a few drops of nitric acid, filter the urine and
allow a small quantity of it to trickle from a pipette down the side
of a test tube until it comes in contact with the acid. If albumen is
present a distinctly formed white ring is seen at the zone of contact.


TEST FOR INDICAN

This material is found in cases of obstinate constipation and in other
intestinal disturbances where the passage of the food mass in the
small intestines is delayed and the putrefactive bacteria exert their
activities upon the unabsorbed protein.

~Test.~--Mix equal quantities of urine and fresh hydrochloric acid and
add drop by drop fresh concentrated solution of chloride of lime (5 to
1,000). Indican is indicated by the appearance of a blue color.


SUMMARY

~Urinalysis~ represents one of the most important means for
determining the health of an individual, since it is the urine that
shows those substances produced in the body as a result of the
breaking down of the body tissues and protein foods.

~Composition of Normal Urine~ must be familiar to the nurse in order
that she may recognize any change taking place in the urine of her
patient which may indicate pathological conditions in the body.

~The Specific Gravity~ of urine is one of the points by means of which
the presence of certain substances more or less abnormal in character
is determined.

~Other Points~, such as color, odor, quantity, reaction, and chemical
composition, likewise show any deviation from the normal in the
individual.

~Urine Tests~ are necessary to determine the composition of the
secretion. The character of these tests and the methods used in making
them form an essential part in the training of the nurse.

~Tests~ for the presence of albumen, sugar, and possibly indican in
the urine, should be made by the nurse. The latter substance
represents the extent of putrefaction taking place in the body and for
this reason should be included in the urine tests.

~Collecting the Urine~ for testing is important. The amount includes
all that has been voided throughout the entire twenty-four hours
beginning after the bladder has been emptied on the first morning and
ending after the first specimen has been voided on the morning of the
second day.

~Preserving the Urine~ for testing is usually necessary, especially
during the warm weather. The specimens should be collected in a
wide-mouthed sterile glass jar. This should be kept in a cold place.
Some harmless preservative such as chloroform should be added to
assure its keeping.


PROBLEMS

(a) Outline tests used in urinalysis; state when they are used.

(b) List the equipment needed for making the simple tests.

(c) Make tests in laboratory and list results in note-book.


FOOTNOTES:

[110] "Treatment of Diabetes Mellitus," pp. 182-183, by Joslin.

[111] "Starvation (Allen) Treatment for Diabetes Mellitus," by Hill
and Eckman.

[112] "Treatment of Diabetes Mellitus," p. 186, by Joslin.

[113] "Chemistry for Nurses," by Reuben Ottenburg.




CHAPTER XVIII

ACUTE AND CHRONIC NEPHRITIS


Nephritis is a disease of the kidneys, in which changes occur in the
tissues of the organs themselves; these changes may be caused by
inflammation of the kidneys and renal passages brought on as results
of the retention of certain poisonous substances in the blood, or from
the action of specific bacteria. The disease may be acute or chronic
in form and develop as a result of prolonged exposure to cold and wet,
of tonsillitis, scarlet fever, typhoid fever, and to a less extent of
malaria, syphilis, pregnancy, and tuberculosis, as well as from the
effects of certain irritating drugs, such as cantharides and
turpentine.

~Directing the Treatment.~--In any case the treatment must be directed
toward the relief of the acute symptoms in the beginning and followed
up by a general treatment which will tend to strengthen and relieve
the overtaxed organs and to increase their power to functionate
normally.

~Causes and Effects.~--In acute nephritis, the chief symptoms are
uremia, and edema; the urine is materially diminished in quantity and
at times suppressed; it is often found to be rich in albumen and
containing hyaline and blood casts, red and white blood cells, and
various pigments.

In chronic nephritis, which may be the result of an acute attack, or as
a sequel of other diseases already mentioned, there is seen to be a
progressive loss of flesh and strength, marked anemia, gastro-intestinal
disturbances, increased blood tension and edema, the latter especially
in the face on arising in the morning. Uremia may develop at any time.

~Limiting the Work of the Kidneys.~--In both acute and chronic
nephritis, great effort must be put forth to relieve the tax upon the
kidneys and to stimulate their functioning power.

In other diseases, in which definite organs are involved, the
treatment consists chiefly of resting the affected parts (1) by
starvation, (2) by deflecting the work to other organs when it is
possible, chiefly by changing the diet until the disturbance is
overcome. This is generally effectual in most cases, as has been
specially demonstrated in the treatment of gastro-intestinal diseases.

~Problems to Be Considered.~--But in nephritis, there are other
problems to consider, which make it impossible to institute such a
treatment as will effect a perfect rest of the renal organs. The
kidneys represent the chief source whereby the waste products of the
body are eliminated. This waste consists not only of the end-products
of the nitrogenous foods ingested, but also the end-products of tissue
metabolism, which is the inevitable result of the wear and tear of
life. Hence, when the functions of the kidneys are disturbed, these
products, often toxic in character, are retained instead of excreted.
Thus instead of forming normal constituents of the urine they find
their way into the general circulation, exerting a damaging effect
upon the tissues, especially of the kidneys with which they are
brought into such direct contact.

~Substances Difficult of Excretion.~--It has been proved that the
kidneys in nephritis find it difficult to excrete certain substances,
namely, urea, water, salts, and the purin bodies. Many authorities
claim that the uremia manifested in acute nephritis is the result of
the retention of end-products of the protein metabolism already
mentioned and that the edema is due to a like retention of water and
salts. The greatly diminished quantity of urine voided during the
acute attack would seem to prove this theory. Martin Fisher,[114]
however, claims the condition to be due to an acidulation of the
tissues with a consequent osmosis of water, and directs his treatment
to overcome this condition, not by restricting the quantity of water
and salt, as is generally practised, but by injecting a saline
solution into the body in large quantities with the effect of
increasing the flow of urine by concentrating the salt content of the
blood and therefore its osmotic power. The fluids are withdrawn from
the tissues, thus adding fluidity to the blood stream, which in turn
flushes the kidneys, ridding them of the poisons which interfere with
their normal functioning.

~Adjusting the Diet.~--The uremia and edema must be relieved. Since it
is an undisputed fact, in the majority of cases, that good results
from the regulating of the diet so as to minimize as far as possible
the work of the kidneys, the various diet cures will be included here.

~Milk Cure.~--Milk, as a rule, forms a basis of most of the nephritic
diets chiefly because of its low salt and protein content and on
account of its non-toxic end-products.

The percentage of water in milk is likewise known and for this reason
the fluid content of a milk diet can be easily calculated. However, it
is also true that the greatest drawback to a diet consisting solely of
milk is the large amount of water therein compared with its nutrient
value.

~Resting the Kidneys.~--During the acute stage of nephritis the
kidneys are given as much rest as possible by eliminating all food and
restricting the amount of water entering the body. The thirst is
relieved by small sips of plain or carbonated water or by ice pellets
held in the mouth, or, as is sometimes necessary, by injections of
water into the rectum.

~Adjusting the Fluids.~--The amount of fluid, however, must be
adjusted to meet the condition of the patient, taking into
consideration the amount of urine voided and the uremic symptoms
manifested. If the urine is not suppressed the amount of water taken
may be slightly in excess of the urine voided, thus promoting
diuresis. In many cases an excellent diuretic drink consisting of one
pint of water and one teaspoonful of cream of tartar with a half a
lemon and perhaps a little sugar, serves the purpose of relieving the
thirst, which is at times acute during this period.

The extent of the starvation treatment must depend upon the patient
himself. As a rule, however, it is not carried out longer than two
days, after which milk may be substituted, allowing from twenty to
thirty ounces per day, which is as much fluid as an ordinary nephritic
patient can handle.

The regulation nephritic diet, which is bland in character, contains
nothing that will tend to increase the irritation and inflammation of
the kidneys, and furnishes a certain amount of nourishment when the
symptoms of the disease warrant the giving of any food other than
milk.

The following diets used in cases of high urea or severe hypertension:

LOW PROTEIN DIET[115]

  -------------------------------+---------+---------------+----------
                                 |_Protein_|_Carbohydrates_| _Fats_
                                 | _Grams_ |    _Grams_    | _Grams_
  -------------------------------+---------+---------------+----------
  Breakfast:                     |   6.7   |     160       |   51
    Cooked Farina     (100 grams)|  Total calories for day, 1192
    Butter            ( 20 grams)|         |               |
    Fruit             (100 grams)|         |               |
    Lactose           ( 30 grams)|         |               |
                                 |   200 grams of fruit juice
                                 |     served between meals
                                 |         |               |
  Dinner:                        |         |               |
    Asparagus         (100 grams)|         |               |
    Butter            ( 20 grams)|         |               |
    Fruit             (100 grams)|         |               |
    Lactose           ( 30 grams)|         |               |
                                 |         |               |
  Supper:                        |         |               |
   Carrots            (100 grams)|         |               |
   Fruit              (100 grams)|         |               |
   Butter             ( 20 grams)|         |               |
   Lactose            ( 30 grams)|         |               |
  -------------------------------+---------+---------------+----------


PROTEIN FREE DIET

  -------------------------------+---------+---------------+----------
                                 |_Protein_|_Carbohydrates_| _Fats_
                                 | _Grams_ |    _Grams_    | _Grams_
  -------------------------------+---------+---------------+----------
  Breakfast:                     |         |               |
   Protein-free cookies[116]  (5)|         |               |
   Fruit juice        (100 grams)|    0    |    166.5      |   39
   Lactose            ( 15 grams)|         |               |
                                 |         |               |
                                 |         |               |
  Dinner:                        |         |               |
   Protein-free cookies       (5)|       Total calories, 1045
   Fruit juice        (100 grams)|         |               |
   Lactose            ( 15 grams)|         |               |
                                 |         |               |
  Supper:                        |    Each cookie weighs 10 grams
   Protein-free cookies       (5)|         |               |
   Fruit juice        (100 grams)|         |               |
   Lactose            ( 15 grams)|         |               |
  -------------------------------+---------+---------------+----------

Doctors Chase and Rose advise farina used more frequently than
oatmeal, and the plain cream soup, rice or potato, more often than
soups made of celery or asparagus (the latter used to break the
monotony). They also advise the more frequent use of green string
beans and asparagus in preference to other vegetables.

~Elimination of Salt.~--In many cases of nephritis, especially those
belonging to the parenchymatous type, the kidneys manifest a
difficulty in eliminating salt, and instead of excreting the normal
quantity, find it impossible to eliminate more than two or three grams
or less a day. The retained salts pass into the fluids of the tissues,
giving rise to or increasing the already existing edema. Tests[117]
have been devised to find the extent of the kidney function to excrete
salt. The following diets are among those commonly used:[118]

  3 liters of milk (this contains 5 gm. sodium chloride and 100 gm.
    protein)

  or

  Strauss Diet, consisting of 3/4 liter milk, 4 eggs, 150 gm. bread, and
    enough fruit and fruit juice, tea and sugar to make it palatable.
    (This diet contains about 3 gm. of salt.)

If the kidneys are able to excrete the amount of salt contained in
these diets, salt may be added in quantities of from 5 to 10 grams.

~Salt-poor Diets.~--When the kidneys are unable to eliminate the
normal amount of salt, some of the salt-poor diets should be advised.
Coleman claims,[119] however, that these diets have not fulfilled the
promises held out by them. Coleman groups the salt-poor diets under
three headings:

(1) ~The strict salt-poor diet~, of which Widal's diet is an example.

(2) ~The medium strict salt-poor diet~, allowing from 2.5 to 5 grams
of salt a day. Under this heading the milk diet was placed, in which 2
to 3 grams of salt is served a day at table.

(3) ~The moderate salt-poor diet~, in which from 5 to 10 grams of salt
are allowed each day. In using this diet it is not necessary to
prepare a special menu for the patient, but take precautions to leave
the salt shaker off the tray and exclude bacon, ham, and other salty
foods from the dietary.

~Limiting the Amount of Food.~--It must be kept in mind that the
nephritic condition makes it imperative to fall below rather than
exceed the food requirements of the individual.

WIDAL'S DIET[120]

  Salt-free bread                          200 gm.
  Meat (beef, chicken, or mutton)          200 gm.
  Vegetables (beans or rice), salt-free    250 gm.
  Butter, salt-free                         50 gm.
  Sugar                                     40 gm.

Contains 60 grams of protein, 1 to 2 grams of NaCl, and furnishes
approximately 1500 calories.

Strouse and Perry arranged a dietary from the above diet as follows:

8 A.M. Bread, 60 grams; lamb chop, 50 grams; butter,
10 grams; rice, 100 grams; sugar, 40 grams.

12 M. Bread, 60 grams; roast beef, 100 grams; butter,
20 grams; beans, 150 grams.

5 P.M. Bread, 80 grams; butter, 20 grams; chicken, 50
grams.


HALPIN'S SALT-FREE NEPHRITIC DIET

Milk, 1500 to 2000 c.c., white salt-free bread, 400 to 500 grams;
salt-free butter, 40 grams; eggs, 4 to 6. This diet contains from 5 to
6 grams of salt.


KARELL CURE

Karell has devised the milk cure, which is used possibly more than any
other diet. It not only furnishes a dietary régime, which is used in
nephritis, but it is likewise advocated in organic diseases of the
heart and blood vessels.

~Methods of Administering the Karell Cure.~--The cure is begun by
giving from 3 to 6 ounces of milk three or four times a day. Karell
makes a point of using small quantities to begin with and having the
milk skimmed. The milk is given at regular intervals, is warmed in
winter and given at room temperature in the summer. It may be given
plain or diluted with limewater. After a week if the stools remain
solid, the daily allowance of milk is increased to two quarts.
Constipation is an indication of the agreement of this diet and the
patient's utilization of the milk. If, however, he manifests
gastro-intestinal disturbances, resulting in diarrhea, the amount must
be temporarily reduced. Karell advocates boiling the milk and
relieving the constipation with enemas or mild laxatives. The addition
of small quantities of coffee to the morning portion of milk, or of
stewed prunes or a baked apple to the afternoon feeding, also tends
to overcome the condition.

~Thirst.~--The extreme thirst may be relieved by adding plain water,
limewater, or seltzer to the feedings.

If during the second or third week of the cure the hunger becomes too
great for the patient to endure, a small piece of herring or stale
bread may be given.

Once a day a milk soup thickened with a cereal may be given. The above
diet is carried out from five to six weeks, after which the patient is
gradually returned to a normal diet. Milk, however, should still
constitute an important part of the diet. The Karell cure is modified
more or less to meet the condition of the patient, the amount of milk
administered in some cases being more and in others considerably less
than mentioned in the above régime.

~Limiting the Proteins.~--The extent of the damage caused by the
end-products of protein metabolism cannot be easily estimated, but it
is wise not to err on the side of an over-supply, since the retaining
of these materials in the body gives rise to a certain type of
intoxication (uremic poisoning).

~Relative Toxicity of the Animal Proteins.~--The difference between
the various animal proteins as to their relative toxicity has been the
subject of much discussion. As far as their nutrient value is
concerned, they are practically the same, that is, the protein of beef
and the protein of chicken show very similar analyses. The beef
contains, however, more extractives, which we know are high in purins.
These substances have proven detrimental to the welfare of a nephritic
patient.

~Selection and Preparation of Foods.~--For this reason the so-called
red meat is sometimes boiled instead of roasted, as the latter mode of
preparation increases the formation of purins on the brown outer
surfaces of the meat. Chicken and fish contain less purin bases and
for this reason are often included in the diet when beefsteak and
lamb chops are excluded. Meat soups and broths contain little nutrient
value, consisting as they do chiefly of water, salt, and extractives,
all of which are looked upon with disfavor, and classed with the
offending articles of food in the nephritic diet. Cream soups, except
bean or pea soup,[121] may be given in moderation. They are non-toxic
in character and of high nutrient value, furnishing a valuable
addition to the diet when the gastro-intestinal symptoms permit of
such addition.


CONVALESCENT NEPHRITIC DIET[122]

~Advisable Foods.~--The following foods are used in the formation of
diet for an advanced convalescent nephritic patient when not otherwise
contraindicated:

Cereals, potatoes, rice, green vegetables and salads, fruits, fresh
and stewed, ham, bacon, or beef once or twice a week, chicken, lamb,
or mutton[123] several times a week, simple desserts, such as junket,
prune or fig whip, orange, lemon, grape, pineapple or apricot
gelatin, bread, rice or tapioca pudding, plain vanilla ice
cream.[124]

~Foods to Be Avoided.~--The following foods are avoided except the
meats, which must be given not more than once to three times a week,
as directed by physician:

Meat broths, especially those made from commercial meat extracts,
bouillon cubes, etc.

Strong tea or coffee.

Alcoholic beverages, unless especially prescribed by the physician.

Liver, kidney, sweetbreads.[125]

Meat croquettes and other made dishes.

Rich sauces or gravies.

Condiments and spices of all sorts.

Rich pastries.

The salt must be limited and water and other fluids restricted.

~Sample Diet Sheets.~--The following menus[126] formulated from the
above diet list are suggested:

~No. 1.~--8 A.M. Sliced oranges, cream of wheat with
cream, buttered toast, cocoa.

10:30 A.M. 6 ounces of milk with crackers.

12:30 P.M. Cream of spinach soup, rice, string beans,
orange gelatin, bread and butter.

3 P.M. 6 ounces of buttermilk with crackers.

6 P.M. Cereal and cream, baked potato, apple sauce,
cocoa, bread and butter.

~No. 2.~--8 A.M. Stewed prunes, wheatena and cream,
milk or dry toast with butter, cocoa.

10:30 A.M. 6 ounces of malted milk with crackers or 1
slice of zwieback.

12:30 P.M. Cream of corn soup, mashed potatoes, beet
tops or mustard greens, lettuce salad, dressing made with
lemon juice and olive oil, rice pudding.

3 P.M. 6 ounces of orange or grape juice with crackers.

6 P.M. Cream toast, sliced peaches, cocoa.

~No. 3.~--8 A.M. Half a grapefruit, farina and cream,
toast and butter, cocoa.

10:30 A.M. 6 ounces of buttermilk with crackers.

12:30 P.M. Cream of tomato soup, creamed potatoes,
buttered beets, celery salad, apple tapioca pudding, bread
and butter.

3 P.M. 6 ounces of milk with crackers.

6 P.M. Ralston's Health Food with cream, baked potato,
tomato salad, toast and butter, cocoa.

~No. 4.~--8 A.M. Stewed prunes, grits and cream, toast and butter,
cocoa.

10:30 A.M. 6 ounces of malted milk with crackers.

12:30 P.M. Cream of asparagus soup, creamed cauliflower, boiled rice,
lettuce salad, bread and butter, pineapple gelatin.

3 P.M. 6 ounces of orange juice with crackers or zwieback.

6 P.M. Creamed toast, escalloped potatoes, fruit salad, toast, cocoa,
and cocoa junket.


CHRONIC NEPHRITIS (BRIGHT'S DISEASE)

Chronic nephritis may develop as a sequel to an acute attack, and an
individual suffering from chronic nephritis may at any time develop
acute symptoms. In any case the dietetic treatment would necessarily
have to be made to cover the existing symptoms.

~Dietetic Treatment.~--In cases where the patient has entirely
recovered from uremia but still manifests symptoms of water and salt
retention, the diet would be naturally directed to cover the latter,
at the same time taking care not to strain the weakened functions by
giving more food than could be readily handled. The water and salts
still have to be restricted, but a certain amount of fat and
carbohydrate with small additions of nitrogenous food materials may be
added from time to time as the kidneys show improvement. It must be
borne in mind, however, that at this time it is very easy to overtax
the renal organs and it is safer to err on the side of under rather
than over feeding.

The logical treatment, therefore, consists of utilizing the improved
functions while those still failing to react are getting further rest.

~Adjusting the Proteins in Diet.~--If the individual shows a definite
anemia, as is often the case after acute attacks, either as a result
of the disease itself or the necessarily low diet, which the acute
symptoms of uremia and edema made necessary, other measures are
necessary to bring the body back to a normal condition. It has been
found that in these cases where there has been no permanent damage to
the renal organs, but merely a temporary impairment of the functioning
power, the treatment must be, first, a rest to the affected parts;
second, the temporary restriction of all articles of food which impose
a tax on the kidneys to eliminate; the third, the gradual return to
normal diet as the acute symptoms decrease and the function of the
kidneys no longer shows impairment. Such a case is cited by Strouse
and Perry[127] as occurring in the Michael Reese Hospital. Mr. X.
recovered from the acute stage of nephritis and all signs of edema and
uremia disappeared; the man was kept on a low salt and low protein
diet for a long time. His urine was clearing up, but he did not feel
up to standard and remained anemic. Thinking in all probability that
his symptoms were due to a low protein diet, meat was slowly added to
his dietary until he was receiving 60 grams of protein a day. There
was an immediate general improvement in his condition with no
increased renal disturbance. It is an obvious fact that chronic
nephritis, like any other chronic condition, requires a different
method of treatment from that practised to relieve the acute stage.
The very fact that it is chronic proves that the strenuous methods are
neither necessary nor wise.

~Testing the Kidney Functions.~--The authorities of to-day endeavor to
ascertain the extent of the damage to the renal organ by testing its
functioning power. These renal function tests have been the subject of
much interest and investigation. Probably the ones most commonly
employed are those devised by Hedinger and Schlayer[128] and adapted
for use in the Johns Hopkins Hospital by Mosenthal.

~Diets Used in Tests.~--The diet employed in making these tests
consists of different amounts of certain substances known to be
diuretic in character. This diet is rigidly adhered to and a careful
analysis of the urine passed, the total quantity and specific gravity
of each specimen made and in this way the various functions of the
kidneys and the impairment thereof are tested. Thus an intelligent
adjustment of the diet may be made.

~Renal Functional Tests.~--The following schedule is used by
Mosenthal, of the Johns Hopkins Hospital, in making what is known as
the "Two-Hour Test for Renal Function":


HEDINGER-SCHLAYER-MOSENTHAL DIET[129]

    For _________________

                                   Date _________________

    All foods to be salt-free from the diet kitchen, salt
    for each meal will be furnished in weighed amounts.[130]

    All foods or fluids not taken must be weighed or
    measured after each meal and charted in spaces below.
    Allow no food or fluid at any time except at meal times.

    Note any mishaps or irregularities that occur in giving
    the diet or collecting the specimens.

  Breakfast 8 A.M.  Boiled oatmeal               100 grams
                    Sugar 1 to 2 teaspoonfuls
                    Milk                          30 c.c.
                    2 slices of bread             30 grams each
                    Butter                        20 grams
                    Coffee 160 c.c.     }
                    Sugar 1 teaspoonful }        200 c.c.
                    Milk 40 c.c.        }

      Dinner--Noon  Meat soup                    180 c.c.
                    Beefsteak                    100 grams
                    Potatoes, boiled, mashed
                      or baked                   130 grams
                    Green vegetables as desired
                    2 slices bread--each          30 grams
                    Butter                        20 grams
                    Tea, 180 c.c. }
                    Sugar, 1 tsp. }              200 c.c.
                    Milk, 20 c.c. }
                    Water                        250 c.c.
                    Pudding, tapioca or rice     110 grams

     Supper 5 P.M.  2 eggs cooked any style
                    2 slices of toast             30 grams each
                    Butter                        20 grams
                    Tea, 180 c.c. }
                    Sugar, 1 tsp. }              200 c.c.
                    Milk, 20 c.c. }
                    Fruit, stewed or fresh         1 portion
                    Water                        300 c.c.

    8 A.M. No food or fluid is to be given during the night
    or until 8 o'clock next morning (after voiding) when the
    regular diet is resumed.

    Patient is to empty bladder at 8 A.M. and at the end of
    each period as indicated below. The specimens are to be
    collected for the following periods in properly labeled
    bottles:

    8 A.M. to 10 A.M.; 10 A.M. to 12 Noon; 12 Noon to 2
    P.M.; 2 P.M. to 4 P.M.; 4 P.M. to 6 P.M.; 6 P.M. to 8
    P.M.; 8 P.M. to 8 A.M.

~Chart Used in Johns Hopkins Hospital.~--The following chart is
inserted here to show the method used in the Johns Hopkins Hospital
for carrying out the Two-hour Renal Test:

  ===============+==================+==================+==================
                 |     _Urine_      |     _NaCl_       |    _Nitrogen_
  _Time of Day_  +-------+----------+----------+-------+----------+-------
                 |       |_Specific_|          |       |          |
                 |_C.C._ |_Gravity_ |_Per cent_|_Grams_|_Per cent_|_Grams_
  ---------------+-------+----------+----------+-------+----------+-------
                 |       |          |          |       |          |
   8 A.M.-10 A.M.|       |          |          |       |          |
  10 A.M.-12 Noon|       |          |          |       |          |
  12 Noon-2 P.M. |       |          |          |       |          |
   2 P.M.-4 P.M. |       |          |          |       |          |
   4 P.M.-6 P.M. |       |          |          |       |          |
   6 P.M.-8 P.M. |       |          |          |       |          |
   8 P.M.-8 A.M. |       |          |          |       |          |
  Total day      |       |          |          |       |          |
  Night, 8 P.M.  |       |          |          |       |          |
    to 8 A.M.    |       |          |          |       |          |
  Total 24 hours |       |          |          |       |          |
  Intake of fluid|       |          |          |       |          |
  NaCl           |       |          |          |       |          |
  ===============+=======+==========+==========+=======+==========+======

Urine to be collected punctually every two hours and kept in the
ice-box, every specimen having twenty drops of tutuol added to insure
preservation.

Another ~modification of the Hedinger-Schlayer diet~ is used in the
~Peter Bent Brigham Hospital~,[131] Boston, Massachusetts, as follows:

   7 A.M.     Coffee, milk, sugar, toast, and butter.

  10 A.M.     Milk, toast, and butter.

  12:30 P.M.  Bouillon, broiled steak, butter, mashed potatoes, toast,
              coffee, milk, sugar.

   4 P.M.     Tea, milk, sugar, crackers.

   7 P.M.     Soft egg, blanc-mange (1 egg, sugar, cornstarch, and milk)
              and cream. Amounts sufficient to give 2500 calories, 1500
              c.c. fluid, 76 grams of protein, 127 grams of fat, 245
              grams of carbohydrate, and from 5 to 8 grams of sodium
              chloride.

On two days previous to the test the patient usually had a diet
containing 2000 calories, 75 grams of protein, 4 grams of sodium
chloride.

The test diet is a mixed diet containing known amounts of water,
nitrogen, and chloride, together with the food diuretics (purins,
salt, and water), as can be seen. The diet is divided into unequal
portions containing known but varying amounts of fluid, nitrogen, and
salt. Two-hour specimens are collected from 7 A.M. to 9 P.M., and one
night specimen is obtained containing all the urine passed between 9
P.M. and 7 A.M. Each specimen is analyzed for volume, specific
gravity, total nitrogen, nitrogen concentration, total chloride, and
chloride concentration.

~Purpose of Tests.~--The purpose of the test is to find out to what
extent and in what manner the diseased kidney under stimulation by the
various diuretics taken in the food reacts in putting out the varying
amounts of salt.

Dr. O'Hara likewise describes another test known as ~The Added Urea
and Salt Test~, which was first described by von Monakow and also
carried out in the Peter Bent Brigham Hospital. The method used was as
follows:


ADDED UREA AND SALT TEST

Patient is given 75 grams of protein, 4 grams of sodium chloride, and
1500 c.c. of water, with a caloric value of from 2000 to 2200
calories. After the output of fluid, salt and nitrogen reaches an
equilibrium on this diet on one day 10 grams of additional salt is
given and several days later the patient receives 20 grams of urea.
This order may be reversed. The daily output of urine, salt, and
nitrogen is determined and charted. After the salt and nitrogen is
added to the diet in normal individuals, their excretion after
forty-eight hours returns to its previous level. In diseased kidneys
this may not be the case.

~Value of Tests.~--Thus it is seen that in these tests for kidney
functions, an effort is made to determine the extent of damage wrought
by the disease upon the renal organs and the manner in which they
react under definite circumstances. However, it is not so simple as it
would seem to formulate a dietary based on the findings resulting from
the renal tests. Notwithstanding this, these tests are coming more and
more into use, both in hospitals and private practice, and a nurse
must understand just how they are carried out, and must realize that
unless her part is performed with absolute accuracy the entire value
of the test will be obliterated. Too much stress cannot be laid upon
this phase of the test, if it is to be of any value whatsoever in
determining the condition of a diseased kidney.


CHRONIC INTERSTITIAL NEPHRITIS

This form of nephritis is more insidious in character, developing more
slowly and manifesting different characteristics, than those seen in
some of the other types already mentioned. The condition is, as a
rule, associated with heart symptoms and high blood pressure. The
blood shows an increase in urea and other end-products of protein
metabolism, whereas there is no manifest change in the metabolism of
salt or water. The great increase in volume of urine voided would show
an inability on the part of the kidneys to eliminate a highly
concentrated urine. This hypothesis is further demonstrated in the
urine tests.

~Urinalysis.~--Upon analysis the urine in these cases shows less
albumen and fewer casts than found in other types of nephritis. The
disease is manifested by slight headache, gastric disturbances, and a
frequent desire to urinate.

~Dietetic Treatment.~--The treatment here depends upon the extent of
the impairment of the functions of the kidney. If the damage is not
extensive and the diagnosis has been sufficiently early to insure
prompt improvement upon treatment, the diet is so directed as to
prevent the occurrence of any of the acute symptoms. The patient is
warned against overeating and drinking, over-exercise and nervous
excitement. When it is possible, a change to a warm, dry climate is
advisable with more rest and sleep and less work and worry. He is
advised to eat less at meals and if hungry to eat a light lunch of
milk or buttermilk with crackers in the mid-morning. The same dietary
precautions must be taken in these disturbances as in other nephritic
conditions, keeping always in mind the fact that the kidneys are the
chief organs of excretion in the body, and through them must pass the
majority of all end-products of nitrogen metabolism.

~Limiting the Nitrogen.~--The nitrogenous foods cannot be eliminated
entirely, especially if, as is often the case, the individual suffers
from chronic nephritis and is up and about attending to business; but
they can be judiciously regulated in the diet. All such foods as fried
foods, rich pastries, rich sauces and gravy, spices of all kinds, tea
and coffee, celery and asparagus, must be avoided.

~Limiting the Fluids.~--von Noorden limits the amount of fluid to
1-1/4 liters per day. This does not include the water content of the
various foodstuffs. He advises a period of observation to determine
the amount best suited to the condition of the patient and reducing
this amount from 250 to 150 c.c. a day until the desired quantity is
reached. He advises a drinking day once a week, allowing the patient
to drink as much water as he likes.

~Development of Uremia.~--Whenever evidences of uremia appear the
treatment must be changed to meet the condition. It is necessarily
more strenuous than that used ordinarily in the chronic nephritis. If
the uremia becomes positive, then the treatment laid down for acute
nephritis already described must be at once instituted. The patient
must be put to bed at once and every effort made to assist the body in
getting rid of the causes.

In certain cases of nephritis, in which uremic poisoning is due to the
retention of the end-products of nitrogen metabolism, or to the toxins
formed as a result of the tissue changes due to the disease, the water
then instead of being restricted in the dietary is greatly increased
to encourage a free diuresis with a consequent washing out of the
accumulated poison. Certain authorities recommend a strict milk and
water diet, as has already been described in the beginning of the
chapter. A light or soft diet is advised until the condition improves,
resting the renal organs as far as possible. This diet may consist of
fruit juices, strained cereals with cream, cocoa, milk, buttermilk,
toast, butter, strained apple sauce, cream soups, except those made
with beans or peas. The above diet is gradually increased by adding a
mashed or baked potato, well-cooked green vegetables, stewed or raw
fruit, rice and tapioca pudding, and chocolate blanc-mange.

~Selection and Preparation of Food.~--The preparation of foods for the
nephritic differs in certain particulars from that used in other
pathological conditions, namely, the restriction of certain food
constituents; dishes made with meat and eggs are cut out of the diet,
and salt is used as sparingly as possible, when it is used at all. The
nurse must weigh or measure out the maximum quantity allowed and
divide this in portions for each feeding, measuring carefully any that
is not used and charting it. In this way it is possible to increase or
decrease the amount according to the symptoms of the individual. The
water content of the various foods comprising the diet is, as a rule,
not considered, but it is necessary to adhere strictly to the orders
of the physician and to curtail the beverages, water, tea, coffee,
etc., until the amount conforms to that laid down in the dietary.

The nitrogenous foods, with the exception of milk, are as a rule
eliminated from the nephritic diet. The nurse must study the tables
and learn which food materials come under this head. It may seem
difficult to prepare diet for the sick without eggs, but it is
possible and at times obligatory.

~Combating Anemia.~--In chronic (ambulatory) nephritis the anemia must
be reckoned with. It is not safe to upset the nitrogen equilibrium of
the body, but it has been proved that this may be maintained on as
little as 30 or 40 grams of protein a day. This will be seen not to be
difficult to obtain when milk forms an important part of the diet. The
wheat and oat cereals, as well as the bread, contain protein, and a
judicious use of these foods will enable the nurse to give her patient
the necessary quantity to offset, in a measure, the anemia which is at
times most troublesome.

~Advice to Patient.~--One important point must be observed by the
nurse and impressed upon the patient when he leaves her care. This is
moderation in the amount of food eaten. The kidneys must never be
overtaxed, even with foods which in themselves seem harmless. As
danger lies in overindulgence, this point cannot be too strongly
emphasized.

~Advice to the Nurse.~--The use of the formulas included in this text
is left to the discretion of the nurse. In those calling for
seasoning, such as pepper, mustard, etc., the condiments must be
omitted. A small amount of celery salt may be substituted in certain
instances if the dish is unpalatable without something of the kind. In
cases where the salt is restricted the dishes are prepared as
directed, with the exception of the salt. The recipes calling for eggs
and meat are not to be used unless directed by the physician.
Cornstarch, sago, and tapioca may be used instead of gelatin. The
following menus may be used as guides in selecting foods to prepare
for the nephritic patient after the rigid régime is to a certain
extent relaxed:


FULL NEPHRITIC DIET (NITROGENOUS FOODS RESTRICTED)

BREAKFAST

  Grapefruit, orange, prunes, pears, peaches, or strawberries.
  Cereals: cream of wheat, farina, Pettijohn's, Ralston's, hominy,
    grits, and oatmeal with cream.
  Toast, buttered or creamed.
  Cocoa, tea, or coffee, as directed by the physician.

DINNER

  Milk or cream soup, well-cooked green vegetables with butter or cream
    sauce.
  Potatoes, white or sweet, baked, mashed, or boiled, with butter, bread
    or rolls.
  Stewed tomatoes, rice.
  Salads: lettuce, tomato, romaine, chicory, or fruit salad, with a
    dressing of oil and lemon, or cream and lemon.
  Simple desserts: junkets, cornstarch, sago or tapioca pudding, baked
    bananas, rice pudding, apple tapioca, orange tapioca, and ice cream.
  Beverages: cocoa or tea, as directed by the physician.

SUPPER

  Cereals and cream.
  Baked or escalloped potatoes.
  Baked or stewed apples.
  Salads, excepting those made with meat or eggs.
  Junket, raw or stewed fruit.
  Toast or rolls with butter.
  Cocoa.
  Meat, fish or poultry once a day.[132]

BREAKFAST

  Stewed or fresh fruit.
  Cereals with cream.
  Toast with butter.
  Cocoa, milk, or tea.

DINNER

  Cream soups.
  Boiled chicken or fish.
  Potatoes, white or sweet.
  Green vegetables.
  Salads, except with meat or eggs.
  Simple desserts.
  Rolls or bread and butter.
  Milk or buttermilk.

SUPPER

  Cereals or rice with cream or butter.
  Baked or escalloped potatoes.
  Stewed or escalloped carrots.
  Salads, except those made with meat or eggs.
  Fresh or canned pears, cherries, or pineapple.
  Bread pudding, junkets, or cornstarch blanc-mange.
  Bread, rolls, or toast, with butter.
  Cocoa, milk, tea, or buttermilk.


TABLE

SALT CONTENT OF FOOD[133]

According to Leva

  Analysis marked thus: * from Atwater & Bryant.
  ====================================================
                                _Per Cent. of Sodium_
                                   _Chloride in_
                                   _Raw Material_

    _Meats_
  Mutton                                0.17
  Veal                                  0.13
  Calf's brains                         0.20
  Calf's kidney                         0.32
  Calf's liver                          0.14
  Beef (lean)                           0.11
  Pork (lean)                           0.10

    _Fish_
  Trout                                 0.12
  Halibut                               0.30
  Herring                               0.27
  Cod                                   0.16
  Carp                                  0.086
  Salmon                                0.061
  Mackerel                              0.28
  Haddock                               0.39

    _Poultry_
  Duck                                  0.14
  Goose                                 0.20
  Chicken                               0.14
  Pigeon                                0.15
  Turkey                                0.17
  Venison                               0.11
  Oysters (washed)                      0.52
  Oysters (with sea water)              1.14

    _Prepared Foods_
  Plasmon                               0.21
  Roborat                               0.0051
  Sanatogen                             0.42
  Somatose                              0.66
  Bovril's preparations           0.26-14.1
  Valentine's meat juice           0.08-1.20
  Egg (white and yolk)                  0.21
  Egg (white alone)                     0.21
  Egg (yolk alone)                      0.039
  Caviar                                3.00
  Milk (whole)                          0.16
  Cream                                 0.13
  Buttermilk                            0.16
  Whey                             0.11-0.15
  Condensed milk                        0.40
  Butter (unsalted)                0.02-0.21
  Butter (salted)                  1.00-3.00
  Peanut butter                         4.10
  Oleomargarine                         2.15
  Palmin                                0.0016
  Fructin                               0.10

    _Smoked and Salted Foods_
  Ham (raw)                        4.15-5.86
  Ham (boiled)                     1.85-5.35
  Salmon (smoked)                       7.50
  Bacon (smoked) (German)               1.01
  Bacon (smoked) (American)            11.61
  Corned beef (German)                  2.04
  Corned beef (American)               11.52
  Cod (salt)*                          23.50
  Cod (salt, boneless)*                10.00
  Herring (smoked)                     11.70
  Mackerel (salt dressed)              10.40
  Salmon (salted, smoked)              10.37
  Sardines (French in oil)              1.34
  Cod liver oil                         0.17
  Gelatine (dry)                        0.75
  Beef marrow                           0.11
  Sausages (Frankfurters)               2.20
  Sausages (various kinds)         2.90-8.10
  Anchovy paste (Cross &
    Blackwell's)                       40.10

    _Meat Extracts_
  Liebig's                              2.60
  Kemmerich's                           1.40
  Various bouillon capsules,
    extracts, etc.                9.40-22.0

    _Foods Prepared for Table_
  Bouillon                          0.5-1.0
  Thick soups                           0.54
  Roast beef                            0.98
  Roast pork                            1.54
  Chops                                 0.97
  Roast chicken                         0.39
  Sauces                            0.7-1.5
  Spinach                               0.91
  Cauliflower                           0.49
  Stewed pears                          0.019
  Macaroni (à la Napolitaine)           1.04
  Scrambled eggs (salted)               1.10
  Carrots                               0.46
  Apple sauce                           0.41
  Tapioca pudding (unsalted)            0.026
  Rice, with apples                     0.18

    _Vegetables_
  Potatoes                        0.016-0.078
  Beets                                 0.053
  Beans                                 0.09
  Peas                                  0.058
  Lentils                          0.13-0.19
  Lentils (dried)                       0.155
  Artichokes                            0.036
  Cauliflower                      0.05-0.15
  Cucumber (fresh)                 0.06-0.08
  Horseradish                      0.02-0.06
  Radish                                0.075
  Celery, stalks                   0.25-0.49
  Celery, roots                         0.089
  Asparagus                        0.04-0.06
  Spinach                         0.084-0.21
  Tomatoes                              0.094
  Cabbage                          0.11-0.44
  Onions                          0.016-0.09

    _Canned Vegetables_
  Green corn*                           0.40
  Green peas*                           0.70
  Tomatoes                              0.10
  Mushrooms                        0.04-0.06

    _Cheese_
  Parmesan                              1.93
  Swiss                                 2.00
  American (pale)                       0.82
  Pineapple cheese                      2.13
  Edam                                  3.30
  English cream cheese             0.70-1.15

    _Infant Foods_
  Nestlé's Food                         0.29
  Rademan's                             0.03
  Robinson's patent groats             Trace

    _Bread, etc._
  Graham bread                          0.61
  Pumpernickel                          0.46
  White bread                      0.18-0.20
  Zwieback                              0.38
  Macaroni                              0.067

    _Cereals, etc._
  Barley                                0.037
  Oats                                  0.046
  Rye                                   0.014
  Wheat                                 0.013
  Rice                                  0.039
  Corn (maize)                          0.019
  Wheat flour                     0.002-0.008
  Oatmeal (American)                    0.29
  Oatmeal (German)                      0.28
  Quaker oats                           0.082
  Sago                                  0.19

    _Fruits_
  Pineapple                             0.071
  Orange                          0.057-0.055
  Apricot                               0.0047
  Lemon                                 0.0045
  Strawberry                      0.010-0.020
  Chestnuts                       0.045-0.010
  Cherry                                0.013
  Cocoanut juice                        0.035
  Olives                          0.008-0.210
  Plums                                 0.0046
  Gooseberry                            0.021
  Watermelon juice                      0.011
  Grape                                 0.024
  Almonds, dry                          0.010
  Walnuts, dry                          0.019
  Cane sugar                            0.110
  Lump sugar                            0.049
  Chocolate (Lindt)                     0.073

    _Spices_
  Capers (preserved in salt)            2.10
  Capers (preserved in vinegar)         0.20
  Pepper, black                         0.51
  Pepper, white                         0.019
  Mustard                               2.66
  Vanilla                               0.055
  Cinnamon                              0.061
  Cocoa beans                      0.05-0.095
  Coffee, roasted                       0.045
  Tea                                   0.15

    _Drinks_
  Ground water                   0.0012-0.0060
  Spring water                  0.00055-0.0046
  Ale                                   0.0017
  Beer, German                          0.016
  Beer, English                         0.10
  Champagne (Moet & Chandon)            0.0045
  Apollinaris                           0.043
  Fachinger                             0.039
  Giesshuble (Mattoni)                  0.0021
  Vichy                                 0.053
  ===============================================


SUMMARY

~The kidneys~ find difficulty in eliminating certain substances,
namely, the end-products of protein metabolism--urea, water, salts,
and purin bodies.

~The Urine~ constitutes the chief point of investigation. Analysis
shows the presence of albumen, casts, blood cells, and pigments, with
a corresponding deficiency in the normal constituents, water, urea,
and salts.

~Volume of Urine.~--The volume of urine is reduced, and at times
suppressed, owing to the difficulty with which the kidneys eliminate
water in nephritic conditions.

~The Blood~ shows the presence of the toxic substances on account of
the inability of the kidneys to eliminate them properly.

~Edema~ is a common symptom and is probably due to the retention of
salts and water by the tissues of the body. It is treated and at times
relieved by limiting the intake of fluids and reducing the amount of
sodium chloride in the diet.

~Uremia~ is the most dreaded symptom and develops as a result of the
retained toxins in the blood. Its development is prevented, if
possible, by reducing the amount of fluid and food, even of milk, in
the diet.

~Uremic Poisoning~ is an acute intoxication due to the abnormal
retention of these poisons and the inability of the kidneys to
eliminate them. It is combated by instituting a starvation treatment
which is followed by the above-mentioned restricted diet.

~Gastro-intestinal Disturbances~, especially diarrhea, are apt to
develop in chronic nephritis. Care must be taken to keep the meals
small in size, simple in proportion, and constituted only from the
allowed foods.

~Anemia~ follows the acute attack and is especially noticeable in
those cases in which a rigid starvation régime has been found
necessary. It may likewise be the result of a long-continued diet in
which the proteins have been reduced to the lowest possible amount.
The simple proteins in the diet must, at times, be increased and the
patient advised to take plenty of fresh air and sunshine, in order to
overcome this progressive anemia.

~Restrictions~ in the diet are essential. These consist of limiting
the amount of food and fluids as well as the type of food ingested.

~Restricting the Proteins.~--Proteins are restricted on account of the
difficulty with which the end-products are eliminated by the kidneys,
also on account of the toxic character of these substances.

~Restricting the Fluids.~--It is necessary, on account of their
difficulty of elimination and because they impose an excessive tax
upon the circulatory organs.

~Treatment~ is largely dietetic in character by reason of the
advantages just mentioned.

~Starvation Treatment~ is instituted in order that the work of the
kidneys may be lessened. This treatment consists of abstinence from
food with a definite reduction in the fluid intake. It is found to be
necessary during the acute stage of the disease.

~Extreme Thirst~, which is apt to be an annoying symptom at this time,
is relieved, as far as possible, with small sips of water or ice
pellets held in the mouth.

~Nephritic Cures~ are devised, as far as possible, to relieve the
acute symptoms and to prevent the disease from developing into a
chronic condition. Milk is the basis of most of these cures. It is
given in definite amounts at stated intervals; the quantity and
frequency with which it is given being adjusted to the state of the
disease and the condition of the patient.

~The Karell Cure~ is one of the best known diet cures used in the
relief of acute nephritis. It consists of the giving of skimmed milk
three or four times a day in doses ranging from three to six ounces
for one week, at the end of which time, provided the stools remain
solid, an increase to two quarts a day is made.

~Constipation~ under the circumstances is a favorable symptom,
indicating as it does the agreement of the milk.

~Diarrhea~ as a result of gastro-intestinal disturbances has directly
the opposite indication. In these cases the milk must be reduced.
Karell advises the boiling of milk and relieving the constipation by
means of mild laxatives or enemas.

~Duration of the Karell Cure~ is from four to six weeks, after which a
gradual return to a normal diet is made.

~Hunger~ is apt to be prominent at this stage of the treatment and is
relieved during the second or third week by giving a small piece of
dry bread and milk, soup thickened with a cereal, once a day.

~Functional Kidney Tests~ are made to determine the character and
extent of the impairment of the functions of the kidneys. The diets
used in these tests contain definite amounts of certain diuretic
substances, and the analysis of the urine voided during the
twenty-four-hour period required by the test shows the nature of the
impairment and furnishes, in a measure, a means of determining the
amount of food and fluid which is safe for the patient to take. It
likewise shows the extent to which the restrictions in the salt and
proteins are necessary.

~Salt-free, or Salt-poor Diets~ are necessary in some cases. While
restriction in the amount of salt used in the preparation of food for
the nephritic patient is always advisable, if there is a tendency to
edema, the salt shaker should be left off the tray, and when there is
a definite amount of salt prescribed, it should be weighed or measured
for the day rather than for the meal, and the amount consumed recorded
after each feeding.

~Special Points~ for the nurse to remember are the necessity for an
early recognition of unfavorable symptoms--of instructing the patient
upon leaving her care in the need for keeping the size of the meals
small;--of the danger of indulging in alcoholic or other stimulating
beverages;--of eating highly spiced foods, or of eating anything which
may cause gastro-intestinal disorders.

She should emphasize the need for regular examination of the urine and
the value of rest and freedom from nervous excitement, and the need of
living in the sunshine as much as possible.

The nurse should study the diet list and become familiar with the
foods allowed and those to be avoided. The tables show the foods which
are rich in salts and proteins. She should likewise understand and be
able to make the simple test for albumen in the urine and the method
of collecting the urine for the test made in the laboratory.


PROBLEMS

(a) Outline a salt-poor diet for patient in which the fluids are
limited to 1500 c.c. per day.

(b) Formulate a diet for child of ten years with nephritis following
scarlet fever.

(c) Write a diet order, using a salt-free diet.


FOOTNOTES:

[114] Fisher's Solution.

  Sodium carbonate (pure crystals)    14
  Sodium chloride                     10
  Water                             1000

[115] The above diets used in the Olmstead Hospital, Rochester, Minn.
Courtesy of M. Foley and D. Ellithorpe, Mayo Clinic.

[116] See Section of Recipes, p. 145.

[117] For more extensive lists see Table of "Ash Constituents of
Common Food," pp. 472 to 477.

[118] "Journal of Internal Medicine," Vol. XIV, 1914.

[119] _Ibid._

[120] "Food for the Sick," p. 108, by Strouse and Perry.

[121] Beans and peas belong to the class of foods known as legumes,
which are high in protein and must be treated as any other protein
food.

[122] Author's list and diet sheets.

[123] Meats of all sorts should be boiled, or only the inside portions
allowed.

[124] Some physicians exclude ice cream from the diet, while others
permit a small portion, provided it is not so rich as to cause
digestional disturbances.

[125] Boiled sweetbreads are sometimes allowed, but should never be
given without the advice of a physician.

[126] The preparation of the menus requires care and attention; meal
must be small and all fried foods avoided.

[127] "Food for the Sick," p. 112, by Strouse and Perry.

[128] "Medical Clinics of Chicago," Vol. II, No. 5, 1917.

[129] Copied from "Medical Clinic of Chicago," Vol. II, No. 5, 1917.

[130] NaCl, 2 to 3 grams in a capsule accompanying each meal. Any salt
unused is returned to the diet kitchen, where it is weighed and the
amount used is indicated on the chart.

[131] Carried out by Dr. Henry Christian and described by James O'Hara
in the "Archives of Internal Medicine," Vol. XVII.

[132] The outside parts of roast meat must be avoided, even when meat
is allowed once a day. Meat is only added after the condition
materially improves.

[133] Coleman, in Forchheimer's "Therapeusis of Internal Diseases,"
Vol. I, p. 642.




CHAPTER XIX

DISEASES OF THE HEART


The dietetic treatment in diseases of the heart has been the subject
of much study, especially during the past few years.

~The Diet.~--In this pathological condition, as in many other diseases
in which one or more of the functions of the body have become
impaired, there can be no hard and fast rule covering the treatment or
diet for all cases, but, as in nephritis, the condition of the
individual, his symptoms, and the progress and extent of the disease
must be taken into consideration in order to formulate a diet
calculated to adequately nourish the body, while at the same time
imposing the smallest amount of work with the least expenditure of
labor upon the part of the diseased organ.

~Division of Treatment.~--The treatment of the disease then may be
said to be divided into three stages: first, the stage of
compensation; second, that of moderate compensation; third, that of
decompensation. The diet is directed, first, toward relieving as far
as possible the strain which is imposed more or less by all the food
eaten; and second, keeping up the general nutrition of the body.

~Dietetic Treatment.~--No matter what has caused the impairment of the
heart functions, the treatment must necessarily remain the same as far
as diet is concerned. The patient is no longer able to handle a full
and unrestricted diet. As long as compensation is good, the
restrictions are scarcely noticeable; alcoholic beverages and possibly
tobacco may have to be, to a certain extent, curtailed, and in some
cases avoided altogether. However, if the individual desires to live
and be comfortable while so doing, he must lead a wholesome, simple
life, since he cannot with safety indulge in any excesses, either in
diet or in any other particular.

~Diet in Second Stage.~--When the second stage sets in, that is, when
the heart muscle is unable to perform its normal function, attention
must be directed toward two main points; first, the work of the heart;
second, the pressure upon that organ from other sources, namely, the
stomach and intestines. As long as the food does not disagree, that
is, so long as there is no fermentation or putrefaction of the food
material in the stomach and intestines the flatulence arising from the
evolution of gas in those organs is slight and the pressure upward
upon the heart inconsiderable.

~Restricting the Fluids.~--The heart must be spared all unnecessary
work. This can only be accomplished by limiting the amount of food and
fluids ingested. The latter imposes an extra burden upon the impaired
organ to eliminate. Consequently, the amount of fluid should be
limited to 1500 c.c. a day at most, and in many cases considerably
less than that quantity.

~Regulating the Meals.~--The meals should be small and the intervals
of feeding regular. It has been found best to give the fluids between
meals rather than with the food. In many cases of heart disease, as in
certain nephritic conditions, edema is a prominent symptom, so that it
is necessary to direct our efforts toward overcoming that particular
condition. The Karell Cure[134] and the salt-poor diet are used with
excellent results. The latter is not so low as the former, and in many
cases will accomplish all that is required. A modified Karell diet is
used in the Michael Reese Hospital[135] in Chicago as follows:

"MODIFIED KARELL TREATMENT

(Salt-free)

  "Milk 200 c.c. at 8 A.M., 12 M., 4 P.M., and 8 P.M., for five
    to seven days.

  Eighth day--Milk same as above.
    10 A.M. one soft egg; 6 P.M. 2 slices of dry toast.

  Ninth day--Milk as above.
    10 A.M. one soft egg and 2 slices of toast.

  Tenth to twelfth day--Milk as above.
    12 M. chopped meat, rice boiled in milk, easily digested vegetables.
    6 P.M. one soft-boiled egg.

The diet is gradually increased until a full tray is reached. All
meats and vegetables should be chopped or scraped at first, and the
heavier foods should be given only when the heart is practically
compensated."

~Rules and Regulations.~--There are a few general rules which it has
been found advisable to impress upon individuals suffering from a
disease in which the muscles of the heart have become weakened. The
compensation of the organ may improve, but there is still a danger of
a reoccurrence or a further development more or less serious, and at
times fatal. So for this reason, certain rules must be observed
throughout life:

First: the necessity for keeping the meals small, simple, and
digestible. Death at times occurs with symptoms of gastric
disturbance, which is, after all, due to the heart. Consequently it is
not wise to invite such disaster by overeating, or by the partaking of
any food which is liable to bring about indigestion, either in the
stomach or in the intestines. Most authorities advise four or five
meals a day rather than the regulation three, and limit the fluids at
meal time to a few ounces only, when any are allowed, and to a
maximum amount of 1500 c.c. during the day, chiefly between meals.

Second: the need for limiting the amount and type of exercise taken,
especially after eating, since the work of digestion requires all the
power and strain of which the heart is capable, and since an
additional tax placed upon it by muscular exertion might readily be
just the final straw, the added fraction which weighs down the balance
on the scale of life.

Third: the advisability of abstaining from alcoholic beverages, unless
specially prescribed by the physician in charge.

Certain elderly people suffer from a condition known as senile heart,
which is more or less associated with arteriosclerosis and high blood
pressure. These individuals should be prevailed upon to take the
precaution of regulating their habits of life, avoiding excesses of
all kinds, not only on account of the weakened condition of the heart,
but also on account of the condition of the arteries. They should
avoid excitement and worry, since the very fact that they are worrying
increases the blood pressure. Simple foods in limited quantities, five
meals a day instead of three, and an avoidance of too much fluid,
should be the keynote of their daily régime.

Tact on the part of the nurse is necessary in all cases, both young
and old. It is often more difficult to instill good dietary habits in
heart patients, after acute symptoms have subsided, than to carry them
out during the acute attack, when the life itself depends upon a rigid
adherence to the diet prescribed. But as these rules and regulations
are essential to the future welfare of the patient, he must be taught
with care, and in such a way that he will not be alarmed to an extent
when more harm than good will come of the teaching.

The diet should consist chiefly of milk, eggs, rare meat in
moderation (mutton, chicken, fish, and oysters), well-baked bread,
well-cooked cereals, potatoes and green vegetables, and simple
desserts. All foods which in any way cause gastric or intestinal
disturbances must be avoided. If these disturbances arise during the
course of the disease, the patient should be promptly returned to the
strict milk diet. When edema is prominent, it is treated as already
described in the treatment for the like condition in nephritis by the
Karell or salt-free diet.

The dietetic treatment given here is merely a guide to be used under
certain conditions. The physician formulates the diet, and the nurse
must understand what to expect and how to apply the treatment as the
symptoms arise.


SUMMARY

~Dietetic Treatment~, adjusted to relieve the weakened heart muscles
and to save the organ from all possible strain.

~Three Stages~, during which the treatment changes according to the
extent and progress made by the disease.

First Stage: The diet is practically normal. Compensation is good,
consequently no dietary measures save the limiting of alcoholic
beverages are necessary.

Second Stage: The compensation is only moderate and the heart cannot
perform its normal functions, hence the diet must be directed toward
relieving any pressure upon the organs from other organs and toward
lessening the work of the heart itself.

Third Stage: In which the compensation is decidedly impaired and for
this reason the dietetic treatment undergoes a decided change.

~Digestional Disturbances~ in which there is an evolution of gas in
the stomach or intestines may cause a pressure against the heart which
is distinctly bad for it.

~Limiting the Fluids~ in the diet in heart disease is necessary when
the compensation is only moderate, as they impose an extra burden upon
the organ to eliminate them.

~Amount of Food~ must also be limited. The meals must be small and
taken without fluid. The latter should be taken between meals.

~Edema~ occurs in a number of cases and must be treated as in
nephritic conditions by limiting the fluids and by confining the diet
to "salt-poor" foods.[136]

~Karell Cure~ or modification thereof has been used with good results
in many cases of heart disease.

~Exercise~ must be limited in amount and confined to types which will
not impose a tax upon the weakened heart muscles. Exercise after
eating is especially to be discouraged, as this, together with the
efforts required for the digestion of food, might readily prove too
much for the heart to accomplish.

~Elderly Patients~ must be warned against exercises of all kinds, not
only on account of the condition of the heart, but also on account of
the condition of the arterial walls. These harden with age and break
down under undue pressure.

~The Nurse~ should instruct the patient on the points necessary for
the saving of the heart. She should teach the necessity for keeping
the meals small and having them more frequently if necessary; of
limiting the fluids at meals to a few ounces or leaving them out
altogether at this time. She should know how necessary is the
reduction of the fluid. She should also warn against the taking of
alcoholic beverages except with the permission and advice of a
physician.

~Excitement and Worry~ increase the blood pressure, hence must be
avoided by individuals suffering with any form of heart disease.


PROBLEMS

(a) Write a diet order for an elderly patient with severe cardiac
disturbance.

(b) Outline the method of administering the Karell diet.


FOOTNOTES:

[134] See Karell Cure, p. 342.

[135] "Food for the Sick," p. 150, by Strouse and Perry.

[136] See Salt-poor Diets, p. 341.




CHAPTER XX

DIABETES MELLITUS


~Definition.~--Diabetes is a disease which is characterized by an
inability on the part of the body to utilize the carbohydrates, in
consequence of which there is abnormal excretion of glucose in the
urine.

~Sugar in the Urine.~--The appearance of sugar in the urine may not
necessarily signify diabetes, it may be merely a temporary glycosuria
due to certain pathological conditions, such as infectious diseases,
diseases or trauma which affect the pancreas, and which disappear upon
the recovery from the disease. But any appearance of sugar in the
urine should be looked upon with suspicion, since the future welfare
of the patient depends largely upon an early diagnosis in any form of
diabetes.

~True Diabetes.~--Allen claims that true diabetes may always be
distinguished from nervous glycosuria by the application of the laws
governing these conditions (Allen's Paradoxical Law[137]), which is
"whereas in normal individuals the more sugar given the more is
utilized, the reverse is true in diabetes."

~Manufacture of Sugar from Other Foods.~--If the carbohydrate foods
alone caused all the trouble in diabetes, the disease might be more
easily controlled. This, we found, however, not to be true, since in
certain conditions the body utilizes the protein foods for the
manufacture of glucose also. Consequently in diabetes if the absolute
sugar output of the body is to be controlled, the intake of
nitrogenous foods must be likewise adjusted.

~Functions of Carbohydrates.~--In the chapter describing the
functions of the carbohydrates in the human body it was demonstrated
that their energy-producing properties did not cover the extent of
their usefulness. It has been proved that this food constituent
normally acts as neutralizing agent for the toxic acids produced
within the organism as a result of the breaking down of the _fats_.
Hence, when this function of the carbohydrates becomes impaired, these
acids, Oxybutyric acid, Diacetic acid and Acetone, fail to be
neutralized and are consequently absorbed into the blood stream,
giving rise to a form of intoxication known as acidosis. When acidosis
becomes extreme, the diabetic patient is apt at any time to succumb to
the dreaded diabetic coma.

~Keeping Urine Sugar Free.~--Thus it is seen that the treatment of
diabetes mellitus consists not alone of freeing the urine from sugar
and keeping it free, but of controlling the acidosis which may at any
time develop.

~Diabetic Cures.~--Numberless so-called diabetic cures have been
brought forward and more or less tested for years, but whether they
have really accomplished cures has not been satisfactorily proved. Not
until Dr. Allen instituted what is known as the Allen's Starvation
Treatment has the disease been so universally treated, at least by one
method or modification of one method. Dr. Joslin, who has used this
treatment most successfully, does not claim to have accomplished a
cure, but states that he is watching the results of the treatment in
his patients with interest.

~Starvation Treatment.~--The Allen Starvation Treatment consists of
first a period of about forty-eight hours in which the patient is
given an ordinary diet, during which time the daily weight is taken
and the urine examined and recorded.

~Acidosis.~--It has been found in some cases, such as with elderly
patients or those in whom there is an evident acidosis, advisable to
precede the period of starvation by a preliminary treatment.

~Method of Treatment.~--Joslin[138] suggests the following method of
procedure:

"Without otherwise changing the diet omit fat. After two days, omit
protein, then halve the carbohydrates daily until the patient is
taking only ten grams, then fast."

In the Michael Reese Hospital, the following series of test diets are
given to determine the severity of the diabetes:


DIABETIC TEST DIETS[139]

BREAKFAST

  Grapefruit            1/2
  Eggs                  2
  Bacon                20 grams
  Bread                25 grams
  Butter               10 grams
  Cream                15 c.c.
  Coffee                1 cup

DINNER

  Cream soup            3 oz.
  Roast beef           75 grams
  Spinach             100 grams
  Kohl-rabi           100 grams
  Lettuce salad        50 grams
  Ripe olives          15 grams
  Bread                25 grams
  Butter               20 grams
  Wine gelatin          4 oz.
  Coffee
  Cream                15 c.c.

SUPPER

  Lamb chop             1
  Asparagus tips       50 grams
  Eggplant             50 grams
  Tomato salad         50 grams
  Custard (diabetic)
  Coffee
  Cream                15 c.c.
  Butter               20 grams
  Bread                25 grams

~Diet in Mild Cases.~--This diet contains approximately 70 grams of
protein, 100 grams of fat, and 70 grams of carbohydrates, and the
patient is kept on it for at least two days; then the carbohydrates
are cut down by taking away 25 grams of bread every day.

DIABETIC DIETS[140]

KEY
  A Carbohydrate
  B Protein
  C Fat
  D Calories
  E 5% Vegetable
  F Orange
  G Oatmeal
  H Shredded Wheat
  I Uneeda
  J Potato
  K Bread
  L Egg
  M Cream 20% Fat
  N Bacon
  O Butter
  P Meat
  Q Fish
  R Skimmed Milk
  S _Name of Diet_
  T _Maintenance Diets_

  ========+==============+===============================================+==
  Diets   |   _Diet in_  |                                               |
  with    |    _Grams_   |                _Test Diets_                   |
  which to+---+--+--+----+---+---+--+---+-+---+--+-+---+--+--+---+---+---+
  become  |   |  |  |    |   |   |  |   | |   |  | |   |  |  |   |   |   |
  Sugar   |   |  |  |    |   |   |  |   | |   |  | |   |  |  |   |   |   |
  free    | A |B |C | D  | E | F |G | H |I| J |K |L| M |N |O | P | Q | R |S
  --------+---+--+--+----+---+---+--+---+-+---+--+-+---+--+--+---+---+---+--
  T. D.1  |189|89|15|1247|300|300|  | 1 | |240|90| |   |  |  | 90|120|480| 1
  T. D.2  |102|58| 0| 640|300|300|  | 1 | |120|  | |   |  |  |   |180|300| 2
  T. D.3  | 64|33| 0| 388|300|300|  |   | | 60|  | |   |  |  |   | 90|240| 3
  T. D.4  | 36|27| 0| 252|300|200|  |   | |   |  | |   |  |  |   | 90|120| 4
  T. D.5  | 15| 5| 0|  80|300| 50|  |   | |   |  | |   |  |  |   |   |   | 5
  --------+---+--+--+----+---+---+--+---+-+---+--+-+---+--+--+---+---+---+--
          |              |    _Carbohydrate_     |   _Protein and Fat_   |
     T    |              |        (_C_)          |          (_PF_)       |
  --------+---+--+--+----+---+---+--+---+-+---+--+-+---+--+--+---+---+---+--
  C1 +PF1 | 10|11| 6| 138|300|   |  |   | |   |  |1|   |  |  |   |   |   | 1
  C2 +PF2 | 22|13|18| 302|300|100|  |   | |   |  |1| 60|  |  |   |   |   | 2
  C3 +PF3 | 32|24|24| 440|600|100|  |   | |   |  |2| 60|  |  |   |   |   | 3
  C4 +PF4 | 42|29|39| 635|600|200|  |   | |   |  |2| 60|30|  |   |   |   | 4
  C5 +PF5 | 52|32|53| 813|600|200|15|   | |   |  |2| 60|30|15|   |   |   | 5
  C6 +PF6 | 63|43|65|1009|600|200|30|   | |   |  |2| 90|30|15| 30|   |   | 6
  C7 +PF7 | 73|51|70|1126|600|300|30|   | |   |  |2| 90|30|15| 60|   |   | 7
  C8 +PF8 | 83|59|87|1351|600|300|30|   |2|   |  |2| 90|30|30| 90|   |   | 8
  C9 +PF9 | 96|62|93|1469|600|300|30|1/2|2|   |  |2|120|30|30| 90|   |   | 9
  C10+PF10|107|63|93|1517|600|300|30| 1 |2|   |  |2|120|30|30| 90|   |   |10
  C11+PF11|131|75|98|1706|600|300|30| 1 |2|120|  |2|120|30|30|120|   |   |11
  C12+PF12|155|79|98|1818|600|300|30| 1 |2|240|  |2|120|30|30|120|   |   |12
  ========+===+==+==+====+===+===+==+===+=+===+==+=+===+==+==+===+===+===+==
                            _Weight in_          _Approximate_
  _Food_                      _grams_            _equivalent_
  Orange                        300        One and one-half (large size)
  5 per cent vegetables         300        Three moderate portions
  Skimmed milk                  480        One pint (16 ounces)
  Fish                          120        Two small portions
  Potato                        240        Two medium sized potatoes
  Meat                           90        One moderate portion
  Bread                          90        Three small slices
  Oatmeal (dry wgt.)             30        One large saucerful
  Cream                          60        Four tablespoonfuls
  Bacon                          30        Four crisp strips
  Butter                         30        Three medium portions

    The Test Diets are designed for the period during which
    the patient becomes gradually sugar free. On successive
    days advances can be made from Test Diet 1 to Test Diet
    5, and if on the fifth day the patient is not sugar
    free, fasting can be employed for one or more days.

    The Maintenance Diets are for use so soon as the urine
    of the patient is free from sugar. If this occurs as a
    result of Test Diet 5 the patient begins with
    Maintenance Diet C1PF1. The actual articles of food
    representing the carbohydrate in the diet for the first
    day are given under the heading of carbohydrate, for
    convenience described C1, 2, 3, etc. The articles
    referred to under protein and fat are under that
    heading, which for the same reason is described as PF1,
    2, 3, etc. Certain cases of diabetes can proceed
    steadily day by day from C1PF1 to C12PF12, without
    showing sugar. If sugar does appear in the urine, drop
    back two days in the carbohydrate group, wait till sugar
    free, then advance in the protein and fat group until
    sufficient calories are obtained. Thus, if sugar shows
    on C7PF7 the diet prescribed would be that included in
    C5PF7 and thereafter progression could be made in the PF
    group until twenty-five to thirty calories per kilogram
    body weight were furnished the patient.

    Occasionally the patient becomes sugar free on Test Diet
    2, 3, or 4. It is then unnecessary to begin with
    Maintenance Diet C1PF1, but instead with a maintenance
    diet which contains a value for carbohydrate similar to
    that of the test diet upon which the patient became
    sugar free.

    If the protein and fat are too high for the individual
    on a given day it is easy to advance the carbohydrate
    and decrease to an earlier day on protein and fat.

    The plan is arbitrary and the majority of cases will
    demand some modification. It is arranged to enable
    patient or nurse to see in advance the general plan of
    treatment.

    (Courtesy of Dr. Joslin and Thomas Groom & Co., Boston.)

If the case is a mild one, this may be sufficient to free the urine
from sugar, but the diet is given primarily to enable the physician to
find out by means of urinalysis just how great is the functional
impairment.

In some cases, which are mild in character, the urine is made free of
both sugar and acetone without further dietetic measures. However,
when a severe diabetes is manifested and a high percentage of glucose
and in some cases acetone bodies are found in the urine a more rigid
treatment will be found necessary.

~Preliminary Diet.~--Many physicians find it advisable, as has already
been stated, to cut down the food allowance before stopping it
entirely. In the Michael Reese Hospital this is done by first giving a
practically fat-free diet, followed by one or two days in which three
or four eggs, 250 to 300 grams (8 or 10 ounces) of 5% vegetables are
given, after which it is found safe to institute the starvation
treatment.

~Sample Menus.~--The following menus are given to illustrate the
dietetic treatment which it is deemed advisable to institute in cases
where the starvation treatment cannot be given at once:

After the test diet of forty-eight hours, the following régime is
instituted:

THIRD DAY
  =============================+=========+=======+==============+==========
                               |_Protein_| _Fat_ |_Carbohydrate_|
                               |  _Gm._  | _Gm._ |    _Gm._     |_Calories_
  -----------------------------+---------+-------+--------------+----------
  Breakfast:                   |         |       |              |
    1/2 grapefruit             |         |       |      5       |     20
    1 egg                      |    5.3  |  4.1  |              |     59
    1 slice bread      30 gm.  |    2.6  |   .3  |     15       |     73
    Tea or coffee              |         |       |              |
                               +---------+-------+--------------+----------
    Total for meal             |    7.9  |  4.4  |     20       |    152
  Dinner:                      |         |       |              |
    Broth             180 c.c. |    3.7  |   .17 |       .34    |     18
    Chicken (breast)   90 gm.  |   18.2  |  2.1  |              |     92
    Spinach           100 gm.  |    2.0  |       |      3.0     |     20
    Potato (1 medium)  90 gm.  |    1.8  |   .09 |     15.6     |     70
    Lemon jelly        90 gm.  |    4.2  |       |      2.7     |     27
                               +---------+-------+--------------+----------
    Total for meal             |   29.9  |  2.3  |     21.6     |    227
  Supper:                      |         |       |              |
    Lamb chop          50 gm.  |    9.3  | 14.1  |              |    126
    Asparagus         100 gm.  |    1.5  |       |      3       |     18
    Bread              20 gm.  |    1.6  |   .2  |     10       |     48
    Tea or coffee              |         |       |              |
                               +---------+-------+--------------+----------
    Total for meal             |   12.4  | 14.3  |     13       |    192
    Total for day              |   40.2  | 21    |     54.6     |    571
  =============================+=========+=======+==============+==========

FOURTH DAY
  =============================+=========+=======+==============+==========
                               |_Protein_| _Fat_ |_Carbohydrate_|
                               |  _Gm._  | _Gm._ |    _Gm._     |_Calories_
  -----------------------------+---------+-------+--------------+----------
  Breakfast:                   |         |       |              |
    1/2 grapefruit             |         |       |      5       |     20
    1 egg                      |    5.3  |  4.1  |              |     59
    1 slice bread      20 gm.  |    1.6  |   .2  |     10       |     48
    Coffee or tea              |         |       |              |
                               +---------+-------+--------------+----------
    Total for meal             |    6.9  |  4.3  |     15       |    107
  Dinner:                      |         |       |              |
    Tomato bouillon   180 gm.  |    2.2  |   .23 |      2.5     |     15
    Whitefish          90 gm.  |    2    |       |      5       |     28
    Boiled onions     100 gm.  |    1.5  |   .3  |      7.5     |     40
    Bran muffin (1)            |    5    |  7    |      4.5     |    101
    Tea or coffee              |         |       |              |
                               +---------+-------+--------------+----------
    Total for meal             |   25.7  | 16.2  |     20.5     |    322
  Supper:                      |         |       |              |
    1 egg                      |    5.2  |  4.1  |              |     59
    Tomato (baked)    100 gm.  |     .6  |       |      2       |     10
    Bran muffin (1)            |    1    |  5    |      7       |    101
    Tea or coffee              |         |       |              |
                               +---------+-------+--------------+----------
    Total for meal             |    6.8  |  9.1  |      9       |    170
    Total for day              |   38.4  | 29.6  |     44       |    513
  =============================+=========+=======+==============+==========

FIFTH DAY
  =============================+=========+=======+==============+==========
                               |_Protein_| _Fat_ |_Carbohydrate_|
                               |  _Gm._  | _Gm._ |    _Gm._     |_Calories_
  -----------------------------+---------+-------+--------------+----------
  Breakfast:                   |         |       |              |
    1/2 grapefruit             |         |       |      5       |     20
    Broiled tomato    100 gm.  |    1.5  |       |      3       |     18
    Tea or coffee              |         |       |              |
                               +---------+-------+--------------+----------
    Total for meal             |    1.5  |       |      8       |     38
  Dinner:                      |         |       |              |
    Broth             120 c.c. |    3    |       |              |     12
    Lettuce            50 gm.  |     .5  |       |      1.5     |      8
    Cauliflower        90 gm.  |    1.5  |   .4  |      3.9     |     25
    Tea or coffee              |         |       |              |
                               +---------+-------+--------------+----------
    Total for meal             |    5    |   .4  |      5.4     |     45
  Supper:                      |         |       |              |
    1 egg                      |    5.35 |  4.16 |              |     59
    String beans      100 gm.  |    2    |       |      5       |     28
    Celery             50 gm.  |     .5  |       |      1.5     |      8
    Tea or coffee              |         |       |              |
                               +---------+-------+--------------+----------
    Total for meal             |    7.85 |  4.16 |      6.5     |     85
    Total for day              |   14.3  | 12.5  |     19.9     |    168
  =============================+=========+=======+==============+==========

SIXTH DAY
  =============================+=========+=======+==============+==========
                               |_Protein_| _Fat_ |_Carbohydrate_|
                               |  _Gm._  | _Gm._ |    _Gm._     |_Calories_
  -----------------------------+---------+-------+--------------+----------
  Breakfast:                   |         |       |              |
    Asparagus tips     60 gm.  |    1.5  |       |      3       |     18
    Spinach            60 gm.  |    1.1  |  1.8  |      1.8     |     32
    Tea or coffee              |         |       |              |
                               +---------+-------+--------------+----------
    Total for meal             |    2.68 |  1.8  |      5.8     |     50
  Dinner:                      |         |       |              |
    Stewed celery     100 gm.  |    1    |   .10 |      2.1     |     15
    String beans       50 gm.  |    1.5  |       |      2.5     |     16
    Tea or coffee              |         |       |              |
                               +---------+-------+--------------+----------
    Total for meal             |    2.5  |   .1  |      5.6     |     31
  Supper:                      |         |       |              |
    Beet tops          75 gm.  |    1.5  |       |      2.5     |     16
    Onions (boiled)    75 gm.  |    1.5  |   .3  |      7.5     |     44
    Tea or coffee              |         |       |              |
                               +---------+-------+--------------+----------
    Total for meal             |    3    |   .3  |     10       |     60
    Total for day              |   11.2  |  2.2  |     21.4     |    141
  =============================+=========+=======+==============+==========


FAST

~Method of Administering Treatment.~--In many cases the patient is
first put to bed during the starvation treatment, but recently Dr.
Allen has emphasized the value of exercise, claiming that it assists
in utilizing the sugar. In any case, the starvation régime remains the
same. The patient is given only coffee or clear broth with or without
whisky (one ounce every two hours) and the treatment continued from
one to four days, or until the urine becomes sugar free.[141]

It has rarely been found necessary to continue the fast longer than
four days, since in most cases the sugar decreases rapidly upon the
discontinuance of food.

~Loss of Weight.~--The slight loss of weight, which may be noticeable
as the result of starvation, is not undesirable, especially in those
cases where obesity is a prominent feature. In fact care must be
exercised in the follow-up treatment to prevent the taking on of
weight by the diabetic individual, since, according to Allen, it is
often found that even moderately obese patients (180 lb.) continue to
excrete a small amount of sugar so long as they hold this weight, even
upon a low carbohydrate diet, whereas those same patients show no
difficulty in becoming sugar free if the weight is reduced by ten or
fifteen pounds.


SCHEDULE FOR TREATMENT AND METHODS OF DETERMINING FOOD TOLERANCES

A number of schedules have been devised to enable the nurse
successfully to carry out the Allen Treatment. In following out this
treatment and reëducating the organs afterward to tolerate foods which
they have been unable to handle on account of the impairment of the
sugar-making organs, it is necessary to make a series of tests
whereby the diet is gradually increased in its various constituents
until the diabetic patient is able to handle a reasonable amount of
carbohydrates as well as other foods which have given more or less
trouble in the past.

The following schedule, after Joslin,[142] is included, and a careful
study of it is advised in order that the nurse may intelligently carry
out the Allen Treatment.

~Schedule.~--Fasting in many cases begins at once and the patient
experiences no ill effects from it. However, in severe, long-standing
cases many patients do better if the fats are omitted at once and the
rest of the diet left unchanged for two days. Then the proteins in the
diet are omitted and the carbohydrates cut in half. This halving of
the carbohydrates is continued daily until only 10 grams remain, after
which they too are omitted. The fast is thus made complete and remains
so until the urine is entirely free from sugar.

~Carbohydrate Tolerance~ is determined by giving, as soon as the urine
has been sugar-free for twenty-four hours, 150 grams of 5% vegetables.
This is equivalent to from 8 to 10 grams of carbohydrates. After this
5 grams of carbohydrates, or 75 grams of 5% vegetables, are added
daily to the diet until the patient is taking 20 grams. Then the
addition of 5 grams of carbohydrates is made every other day, using
the fruits and vegetables belonging to the 10% and 15% carbohydrate
group, until potatoes and oatmeal and finally bread can be tolerated
unless sugar appears in the urine before this or the tolerance reaches
3 grams to each kilogram of body weight or, in other words, until a
man weighing 150 pounds is consuming 225 grams of carbohydrates per
day.

~Protein Tolerance.~--In making the test for the protein tolerance it
is necessary to wait until the urine has been sugar free for
forty-eight hours; 20 grams of protein is then given. This is
equivalent to 3 eggs, and daily additions of 5 grams protein are made,
usually in the form of meat, until the patient is receiving 1 gram of
protein to every kilogram of his body weight per day unless his
carbohydrate tolerance is zero, in which case it is wise to add only
three-fourths of a gram of protein per day.

~Fat Tolerance.~--A determination of the fat tolerance is made
coincidently with that of the protein. No additional fat is allowed
until the protein tolerance reaches 1 gram per kilogram of body
weight, unless the patient's tolerance for protein is less than that.
After which 25 grams of fat per day are added until there is no
further loss of weight, taking care never to allow more than 40
calories per kilogram of body weight.

~Reappearance of Sugar.~--Should the urine again show the presence of
sugar, another period of fasting lasting for twenty-four hours, or
until the urine is again sugar free, must be instituted. After the
second fast the increase in the diet may be twice as rapid as used
after the first fast. However, it is not advisable to increase the
amount of carbohydrates to more than half of that determined by the
former tolerance for a period of two weeks, during which time the
urine has been entirely sugar free, then the increase is made more
slowly and the amount given should not exceed 5 grams a week.

~Weekly Fast Days.~--One day in seven should be set aside by the
diabetic patient for fasting, when the carbohydrate tolerance is less
than 20 grams. When, however, the tolerance is between 20 and 50 grams
of carbohydrates, the patient may take one-half of his daily allowance
of protein and fat and a certain amount of 5% vegetables as well upon
the weekly fast day. When the tolerance reaches between 50 and 100
grams per day, vegetables of a higher carbohydrate content may also be
included. If the carbohydrate tolerance should exceed 100 grams per
day, the carbohydrates upon the fast day may be simply half of the
amount allowed upon other days.

~The Giving of Alkalies.~--If acidosis is evident, as may be indicated
by an excretion of diacetic acid, oxybutyric acid, or acetone in the
urine, alkalies may be given. Bicarbonate of soda may be given in
doses of 2 grams every 3 hours, as suggested by Hill and Eckman,[143]
but this is not as a rule necessary, for, as Jacobi aptly remarks:
"Prevention is the treatment of acidosis in children, and those
susceptible to acidosis should not have fat." What he has said for
children holds good for adults. However, it is likewise true that fat
must constitute a large part of a diabetic diet and the only way to
prevent it poisoning, is to raise the fat in the diet gradually until
the tolerance is determined.

~Determining the Extent of Acidosis.~--It will be remembered that in
an earlier chapter it was found that the excretion of ammonia in the
urine to a certain extent indicated the extent of the acidosis in the
body, that is, if the ammonia output exceeds three or four grams a day
(twenty-four hours), the extent of the acidosis is considerable, while
if it falls below that amount it is not alarming. More exact methods,
however, for the determining of the severity of the acidosis will be
found in another part of this text, where the test for sugar and the
acetone bodies will be explained in detail.

~Dietetic Treatment.~--The patient is placed upon a vegetable diet
consisting of vegetables containing not more than five per cent.
carbohydrate.[144] These vegetables have their carbohydrate content
still further reduced by changing the water in which they are cooked
three times. In many cases this will reduce their content as much as
one-half.

A small amount of fat usually in the form of butter is allowed with
these vegetables. The amount of 5% vegetables given must be carefully
adjusted since the patient might readily take too much if allowed to
follow the dictates of his appetite.

The carbohydrate intake during the first one or two days must be
limited to 15 grams. This allows about 10 grams of protein, 7 grams of
fat, and 15 grams of carbohydrates. Tea or coffee, without sugar or
cream, may be given at each of the three meals.

The following table is included, showing the various foods arranged
according to their carbohydrate content:


TABLE[145]

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%        |     10%      |      15%       |       20%
  ----+-----------------+--------------+----------------+---------------
      |Lettuce          |Pumpkin       |Greens          |Potatoes
      |Cucumbers        |Turnip        |Peas            |Shell beans
      |Spinach          |Kohl-rabi     |Artichokes      |Baked beans
      |Asparagus        |Squash        |Parsnips        |Green corn
      |Rhubarb          |Beets         |Lima beans      |Boiled rice
    F |Endive           |Carrots       |  (canned)      |Boiled macaroni
    r |Marrow           |Onions        |                |Prunes
  V e |Sorrel           |Mushrooms     |                |
  e s |Sauerkraut       |              |                |
  g h |Beet greens      |              |                |
  e   |Dandelion        |              |                |
  t o |Swiss chard      |              |                |
  a r |Celery           |              |                |
  b   |Brussels sprouts |              |                |
  l C |Water cress      |              |                |
  e a |Sea kale         |              |                |
  s n |Okra             |              |                |
  , n |Cauliflower      |              |                |
    e |Eggplant         |              |                |
    d |Cabbage          |              |                |
      |Radishes         |              |                |
      |Leeks            |              |                |
      |String beans     |              |                |
      |Broccoli         |              |                |
      |Tomatoes         |              |                |
  ----+-----------------+--------------+----------------+---------------
      |Ripe olives      |Lemons        |Apples          |Plums
    F |  (20% fat)      |Oranges       |Pears           |Bananas
    r |Grapefruit       |Cranberries   |Apricots        |
    u |                 |Blackberries  |Blueberries     |
    i |                 |Gooseberries  |Cherries        |
    t |                 |Peaches       |Currants        |
    s |                 |Pineapple     |Raspberries     |
      |                 |Watermelon    |Huckleberries   |
  ----+-----------------+--------------+----------------+---------------
      |Butternuts       |Brazil nuts   |Almonds         |Peanuts 40%
    N |Pignolias        |Black walnuts |English walnuts |Chestnuts
    u |                 |Hickory       |Beechnuts       |
    t |                 |Pecans        |Pistachios      |
    s |                 |Filberts      |Pine nuts       |
  ====+=================+==============+================+===============
    M | Unsweetened and unspiced     Reckon available carbohydrates
    i | pickle, clams, oysters,      in vegetables of 5% group as 3%,
    s | scallops, liver, fish        of 10% group as 6%.
    c | roe.
    . |
  ====+=================================================================

30 grams (1 oz.) contains approximately:

  ==============================+=========+=====+==============+==========
                                |_Protein_|_Fat_|_Carbohydrate_|
                                |  _Gm._  |_Gm._|    _Gm._     |_Calories_
  ------------------------------+---------+-----+--------------+----------
  Oatmeal, dry weight           |   5     |  2  |     20       |    110
  Meat (uncooked ham)           |   6     |  3  |      0       |     50
  Meat (cooked ham)             |   8     |  5  |      0       |     75
  Broth                         |   0.7   |  0  |      0       |      3
  Potato                        |   1     |  0  |      6       |     25
  Bacon                         |   5     | 15  |      0       |    155
  Cream, 40%                    |   1     | 12  |      1       |    120
  Cream, 20%                    |   1     |  6  |      1       |     60
  Milk                          |   1     |  1  |      1.5     |     20
  Bread                         |   3     |  0  |     18       |     90
  Butter                        |   0     | 25  |      0       |    240
  Egg (one)                     |   6     |  6  |      0       |     75
  Brazil nuts                   |   5     | 20  |      2       |    210
  Orange or grapefruit (one)    |   0     |  0  |     10       |     40
  Vegetables, 5% and 10% groups |   0.5   |  0  |   1 or 2     |  6 or 10
  Oysters                       |   6     |  1  |      4       |     50
  ------------------------------+---------+-----+--------------+----------

TABLE[146]

Carbohydrate equivalent of 1 slice of white bread (1 oz. or 30 gm.)
containing approximately 15 gm. of starch

  ==============+==============+=====+===============+==============+======
  _Uncooked_    |_Household_   |     |   _Cooked_    | _Household_  |
  _Flours, etc._|_Measure_[147]|_Gm._| _Vegetables_  |  _Measure_   | _Gm._
  --------------+--------------+-----+---------------+--------------+------
  Barley        | 1 h. tbs.    |  21 |Artichokes     | 1 medium     | 320
  Buckwheat     | 1 h. tbs.    |  19 |Beans (baked   |              |
  Corn meal     | 1 h. tbs.    |  20 |  canned)      | 2 h. tbs.    |  75
  Farina        | 1 h. tbs.    |  20 |Beans, lima    | 1-1/4 tbs.   |  50
  Hominy        | 1 h. tbs.    |  18 |Beets          |  6 tbs.      | 200
  Macaroni      | 1 h. tbs.    |  20 |Carrots        | 13 tbs.      | 446
  Noodles       |1-1/2 h. tbs. |  20 |Okra           |  4 tbs.      | 200
  Oatmeal       | 1 h. tbs.    |  22 |Onions         |  3 tbs.      | 300
  Rice          | 1 h. tbs.    |  18 |Parsnips       | 4 slices     | 120
  Rye flour     | 1 h. tbs.    |  18 |Peas, green    | 3 h. tbs.    | 100
  Spaghetti     |1-1/2 tbs.    |  20 |Potatoes       |              |
  Vermicelli    |1-1/2 tbs.    |  21 |  (baked)      | 1/2 medium   |  60
  Wheat flour   |  1 tbs.      |  20 |Potatoes       |              |
                |              |     |  (boiled)     | 1/2 medium   |  70
                |              |     |Potatoes       |              |
                |              |     |  (mashed)     | 1-1/2 h. tbs.|  80
                |              |     |Potatoes, sweet|              |
                |              |     |  (boiled)     | 1/3 medium   |  35
                |              |     |Squash         | 2 h. tbs.    | 100
                |              |     |Turnips        | 3            | 210
                |              |     |               |              |
  _Bread and_   |              |     |_Cooked Cereal_|              |
  _Crackers_    |              |     |Force          | 5 h. tbs.    |  18
   Bread        | 1 slice      |  30 |Farina         | 2-1/2 h. tbs.| 125
  Breakfast     |              |     |Grape-Nuts     | 1-1/2 h. tbs.|  20
   biscuit,     |              |     |Hominy         | 1-1/2 h. tbs.|  90
   Huntley      |              |     |Macaroni       | 2 h. tbs.    | 100
    and Palmer  | 3            |  18 |Oatmeal        | 2-1/2 h. tbs.| 130
  Corn bread    | 1 slice      |  32 |Rice           | 1/2 h. tbs.  |  60
  Roll, Vienna  | 3            |  18 |Shredded wheat |              |
  Zwieback      | 1-1/3        |  20 |  biscuit      | 3/4          |  22
                |              |     |               |              |
     _Fruits_   |              |     |               |              |
  Apple         | 1 medium     | 120 |               |              |
  Apricots      | 2 large      | 120 |_Dried Fruit_  |              |
  Banana        |              |     |Apples         | 3 small      |  22
  (without skin)|1/2 medium    |  75 |Apricots       | 3 large      |  24
  Cherries      |              |  90 |Currants       | 1-1/2 h. tbs.|  20
  Currants      | 5 h. tbs.    | 120 |Dates          | 3            |  19
  Grapefruit    | 1/2 small    | 150 |Figs           | 1 large      |  12
  Huckleberries | 3-1/2 tbs.   |  90 |Prunes         | 2 large      |  24
  Lemons        | 2 medium     | 210 |Raisins        |10 large      |  23
  Muskmelon     | 1/3          | 300 |               |              |
  Nectarine     | 1            | 100 |_Milk and_     | _Household_  |
  Olives (green)| 20           | 180 | _Cream_       |  _Measure_   |_C.C._
  Orange        | 1/2 large    | 150 |Buttermilk     |1-1/2 tumbler | 300
  Peaches       | 1-1/2 medium | 150 |Cream, 16%     |1-1/2 tumbler | 300
  Pear          | 1 small      | 100 |Cream, 40%     |1-1/2 tumbler | 300
  Pineapple     | 3 slices     | 150 |Koumiss        |1-1/2 tumbler | 300
  Plums         | 3 medium     |  75 |Whole milk     |1-1/2 tumbler | 300
  Raspberries   | 4-1/2 h. tbs.| 120 |               |              |
  Strawberries  | 8 h. tbs.    | 200 |   _Nuts_      |              | _Gm._
  Watermelon    | large slice  | 300 |Almonds        |  60          |  90
                |              |     |Brazil         |  30          | 180
                |              |     |Chestnuts      |              |
                |              |     | (roasted)     |  15          |  40
                |              |     |Cocoanut       |   1 slice    |
                |              |     |               | (3 × 2 in.)  |  50
                |              |     |Filberts       | 100          | 110
                |              |     |Peanuts        |  40          |  80
                |              |     |Pecans         |  35          | 110
                |              |     |Pistachios     | 190          |  95
                |              |     |Walnuts        |  30          | 125
  ==============+==============+=====+===============+==============+======


TABLE[148]

Caloric equivalent of 10 gm. steak in carbohydrate-free meat or fish

  =================+============+============+============+===========
      _Food_       |   _Gm._    |   _Fat_    |  _Protein_ | _Calories_
                   |            |    _Gm._   |    _Gm._   |
  -----------------+------------+------------+------------+-----------
  Steak            |    10      |   1.0      |     2.4    |    19
  Roast beef       |     5      |   1.4      |     1.1    |    18
  Tongue           |     7      |   1.4      |     1.6    |    20
  Lamb chop        |     5      |   1.5      |     1.1    |    18
  Roast lamb       |     8      |   1.3      |     1.6    |    20
  Sweetbreads      |    11      |   0.1      |     4.4    |    19
  Boiled ham       |     7      |   1.4      |     1.5    |    19
  Fried ham        |     5      |   1.7      |     1.1    |    20
  Roast pork       |     9      |   0.9      |     2.6    |    19
  Bacon            |     9      |   1.7      |     0.9    |    20
  Chicken          |    10      |   1.0      |     2.4    |    19
  Duck             |     9      |   1.3      |     1.8    |    19
  Guinea hen       |    12      |   0.8      |     2.8    |    19
  Squab            |     9      |   1.1      |     2.1    |    19
  Turkey           |     7      |   1.3      |     2.0    |    20
  Bluefish         |    13      |   0.6      |     3.5    |    20
  Halibut          |    16      |   0.7      |     3.3    |    20
  Mackerel         |    15      |   1.0      |     2.5    |    20
  Sardines in oil  |     7      |   1.4      |     1.6    |    20
  =================+============+============+============+===========

Approximate equivalent in 30 c.c. (1 oz.) of whisky in liquors
containing 2 per cent or less of carbohydrates

  ==============================+==============+===============
                                |              |  _Household_
                                |    _C.C._    |  _Measure_
  ------------------------------+--------------+---------------
  Gin, rum, brandy              |      30      |   2 tbs.
  Claret, Burgundy Hock, Rhine  |              |
    and Moselle wines           | 130-160      |   3/4 tumbler
  ==============================+==============+===============


CARBOHYDRATE-FREE MENUS

The following menus are suggested as meeting the carbohydrate-free
diet requirements with a nutrient value of from 200 to 500 calories:

  Breakfast--Black coffee (cream, 20 c.c.) }
             Bacon, 2 slices (1 oz.)       }          30 grams
             Egg--1

     Dinner--Broth, 6 ounces                         180 grams
             Steak, 1 small piece, 1-1/3 oz.          40 grams
             Stewed tomatoes, 3-1/3 oz.              100 grams
             Lettuce (lemon juice and olive oil)      25 grams

     Supper--Broth                                   180 grams
             Whitefish                                40 grams
             Spinach                                 100 grams
             Cabbage salad                           100 grams
             Coffee

  Breakfast--1/2 grapefruit
             1 egg
             Bacon                                    40 grams
             Coffee                                   50 grams
             Cream                                    20 c.c.

     Dinner--Broth                                   180 c.c.
             Kohl-rabi                               100 grams
             Lettuce                                  25 grams
             Cheese salad                             50 grams
             Roast beef                               40 grams
             Coffee
             Butter                                    5 grams

     Supper--Cold chicken                             25 grams
             Baked tomatoes                          100 grams
             Water cress                              50 grams
             Coffee
             Cream                                    20 c.c.
             Butter                                    5 grams

TABLE

KEY:
  A _Protein Gm._
  B _Fat Gm._
  C _Carbohydrate Gm._
  D _Calories_

  ===================+========================+=====+======+=====+========
                     |                        |     |      |     |
      _Material_     |      _Measure_         |  A  |  B   |  C  |  D
  -------------------+------------------------+-----+------+-----+--------
  Apple              | 1 medium (150 gm.)     |   .5|   .5 | 16  |  70
  Almonds[149]       | 10 small (10 gm.)      |  2  |  5   |  2  |  63
  Apricots (dried)   | 1 oz. (30 gm.)         |  1.5|   .28| 17.5|  78
  Asparagus          | 6 large stalks         |  1.3|   .14|  2.5|  16
                     |  (74 gm.)              |     |      |     |
  Bacon (raw)[149]   | 4 slices, 6 in. long,  | 10  | 64   |     | 636
                     |  2 in. wide            |     |      |     |
  Bacon (cooked)[149]| 4 slices, 6 in. long,  | 10  | 32 to|     | 388 to
                     |  2 in. wide            |     | 46   |     | 468
  Beef juice[150]    | 100 gm.                |  4.9|   .6 |     |  25
  Beef roast[149]    | 1-1/2 in. × 1/8 in.    |  6  |  7   |     |  89
  Cheese[149]        |                        |     |      |     |
   (Neufchâtel)      | 1 cheese 2-1/4 in. ×   | 16  | 23   |  1  | 284
                     |  1-1/2 in. × 1-1/4 in. |     |      |     |
  Cream, gravity 16% | 1 glass (7 oz.)        |  5  | 32   | 10  | 359
  Cream, 40%         | 30 c.c. (2 tbs.)       |   .6| 12   |  1  | 114
  Cracker (Uneeda    | 1 biscuit              |  1  |   .5 |  1  |  16
    biscuit)         |                        |     |      |     |
  Dry peptonoids[150]| 1 tbs.                 |  6  |      |  8  |  57
  Egg                | 1 medium (45 to        | 54  |  4.2 |     |  60
                     |  50 gm.)               |     |      |     |
  Fowl               | 3-1/2 oz. (100 gm.)    | 19.3| 16.3 |     | 224
  Grapefruit         | 1/2                    |     |      |  5  |  20
  Ham (lean)         | 50 gm.                 | 12.4|  7.1 |     | 113
  Lemon juice[151]   | 3 tbs. (43 gm.)        |     |      |  4.2|  19
  Lemon Jelly[152]   | 3 oz. (90 gm.)         | 2.6 |      |  1.4|  16
  Milk (whole)       | 1 glass (8 oz.)        | 7.9 |  9.6 | 10  | 158
                     | 240 c.c.               |     |      |     |
  Oatmeal[153]       | 1 tbs. (50 gm.)        |  1  |      |  6  |  33
  Oatmeal            | 1/2 cup (3.6 oz.)      |  2.1|  .1  |  8.2|  50
  Potato[153] (size  |                        |     |      |     |
    large egg)       | 1 (100 gm.)            |  2  |      |   .8|  83
  5% vegetable[153]  |                        |     |      |     |
    uncooked         | 1 tbs.                 |     |      |  2.5|  10
  5% vegetable       |                        |     |      |     |
    (boiled once)    | 1 tbs.                 |     |      |  1.7|   7
  5% vegetable       |                        |     |      |     |
    (boiled thrice)  | 1 tbs.                 |     |      |  1  |   4
  Orange             | 1 large                |  1.7|  .2  | 22.7| 100
  Orange[153]        | 1 medium               |  1  |      | 13  |  57
  -------------------+------------------------+-----+------+-----+--------

~Increasing the Diet.~--The following menus show the manner in which
the diet is increased after the starvation treatment:

~First Day~

Approximately 150 grams of vegetables with tea or coffee; value:
protein 2, fat trace, carbohydrate 4.

  Breakfast--String beans               20 grams
             Celery hearts              20 grams

      Lunch--Spinach                    25 grams
             Lettuce                    25 grams

     Supper--Tomatoes                   25 grams
             Cucumbers                  25 grams

~Second Day~

Three eggs, 150 grams of 5% vegetables, tea or coffee; value
approximately: protein 18, fat 12, carbohydrate, 4, calories 198.

  Breakfast--1 poached egg
             Spinach or beet tops       50 grams
             Coffee or tea

     Dinner--1 hard-cooked egg
             String beans               25 grams
             Lettuce                    25 grams
             Tea

     Supper--1 soft-cooked egg
             Asparagus tips             25 grams
             Tomatoes                   25 grams

~Third Day~

Approximately 19 grams protein, 15 grams fat, 5 grams carbohydrate,
230 calories.

  Breakfast--1 egg
             String beans               50 grams
             Tomatoes                   25 grams
             Coffee

     Dinner--Cauliflower                50 grams
             Celery                     50 grams
             Tea

     Supper--Asparagus                  75 grams
             Lettuce                    50 grams

~Fourth Day~

Approximately 26 grams protein, 15 grams fat, 10 grams carbohydrate,
279 calories.

  Breakfast--1 egg
             String beans               75 grams
             Coffee with cream          15 c.c.

     Dinner--Tomato bouillon             6 oz. (180 c.c.)
             1 egg
             Asparagus                  75 grams
             Lettuce                    25 grams
             Tea

     Supper--1 egg
             Celery                     50 grams
             Cauliflower               100 grams

~Fifth Day~

Approximately 20 grams protein, 46 grams fat, 15 grams carbohydrate.

  Breakfast--Egg omelet (1 egg)
             Butter                     10 grams
             Vegetable hash            100 grams
             Coffee or tea
             Cream                      15 grams

     Dinner--Chicken broth             180 c.c.
             1 poached egg
             Tomatoes                  100 grams
             Tea

     Supper--1 soft-cooked egg
             Spinach                   100 grams
             Cucumbers                  50 grams
             Tea or Coffee
             Cream                      15 grams

~Sixth Day~

Approximately 33 grams protein, 35 grams fat, 12 grams carbohydrate,
495 calories.

  Breakfast--1/2 grapefruit
             1 egg
             Butter                      5 grams
             Spinach                    50 grams
             Coffee
             Cream                      15 grams

     Dinner--Broth                     180 grams
             Fish                       50 grams
             String beans              100 grams
             Lettuce                    50 grams
             Asparagus                  50 grams

     Supper--2 eggs
             Tomato, baked (1 medium)   75 grams
             Cabbage salad              75 grams
             Tea
             Cream                      15 grams

~Seventh Day~

Approximately 38 grams protein, 45 grams fat, 17 grams carbohydrate,
625 calories.

  Breakfast--1/2 grapefruit
             2 eggs
             Butter                     10 grams
             Coffee
             Cream                      15 grams

     Dinner--Beef broth                180 grams
             1 lamb chop                50 grams
             Cauliflower               100 grams
             Tomato                    150 grams
             Lettuce                    50 grams
             Butter                     10 grams

     Supper--1 egg
             Tuna salad                 50 grams
             String beans              100 grams
             Butter                      5 grams
             Tea

~Eighth Day~

Approximately 32 grams protein, 16 grams fat, 20 grams carbohydrate,
625 calories.

  Breakfast--1 egg
             String beans              100 grams
             Raw tomatoes              100 grams
             Coffee
             Cream                      15 grams

     Dinner--Chicken                    50 grams
             Cabbage                   100 grams
             Asparagus                 100 grams
             Water-cress salad          50 grams
             Tea

     Supper--1 egg
             Greens                    100 grams
             Celery salad               50 grams
             Tea
             Cream                      15 grams

The following menus are used after the diet has been more or less
increased:

~First Day~

  Breakfast--1 soft-cooked egg
             2 slices of bacon
             1 bran muffin, 5 gm. butter
             Coffee with 15 c.c. of 40% cream

      Lunch--6 oz. tomato bouillon
             2 oz. (60 gm.) roast lamb
             60 gm. string beans
             50 gm. lettuce and celery salad
             25 gm. lemon jelly with 15 gm. cream

     Dinner--60 gm. chicken
             75 gm. asparagus
             4 olives
             50 gm. cauliflower
             30 gm. ice cream
             1 Lister roll, 5 gm. butter
             Black coffee

~Second Day~

  Breakfast--1/2 grapefruit
             1 scrambled egg
             1 Lister roll, 8 gm. butter
             Coffee with 15 gm. cream

      Lunch--60 gm. baked halibut with 10 gm. parsley butter
             70 gm. cauliflower
             50 gm. lettuce
             1 Lister roll, 8 gm. butter
             Tea

     Dinner--6 oz. chicken broth
             60 gm. roast beef
             75 gm. cabbage
             75 gm. string beans
             30 gm. coffee jelly with 15 gm. cream
             Black coffee

~Third Day~

  Breakfast--1 soft-cooked egg
             2 slices bacon
             1 Casoid flour and bran muffin with 5 gm. butter
             Coffee with 15 gm. cream

      Lunch--100 gm. cabbage
             40 gm. corned beef
             50 gm. tomato salad
             1 soya meal muffin, 8 gm. butter
             Tea

     Dinner--60 gm. beefsteak
             75 gm. asparagus
             75 gm. spinach
             30 gm. tomato aspic
             30 gm. soft (diabetic) custard
             Black coffee

~Fourth Day~

  Breakfast--1 scrambled egg with 20 gm. chipped beef
             1 Casoid flour muffin with 8 gm. butter
             Coffee with 30 gm. or less cream

      Lunch--6 oz. tomato bisque
             60 gm. tuna fish salad
             75 gm. vegetable hash
             1 Lister roll, 8 gm butter
             Tea

     Dinner--60 gm. broiled chicken
             75 gm. string beans
             75 gm. cauliflower
             30 gm. tomato and celery salad
             30 gm. wine jelly, with 15 gm. whipped cream
             Black coffee

~Fifth Day~

  Breakfast--1/2 grapefruit
             1 soft-cooked egg
             1 bran muffin with 8 gm. butter
             Coffee, 15 gm. cream

      Lunch--40 gm. broiled beefsteak
             75 gm. spinach
             75 gm. boiled onion
             1 soya meal muffin with 8 gm. butter
             Tea

     Dinner--6 oz. tomato bouillon
             80 gm. baked fish with parsley sauce
             75 gm. Brussels sprouts with 5 gm. butter
             1 Lister roll with 5 gm. butter
             Coffee jelly, 30 gm., with 15 gm. whipped cream

~Sixth Day~

  Breakfast--1 poached egg
             2 slices bacon
             1 bran and Casoid muffin with 5 gm. butter
             Coffee with 15 gm. cream

      Lunch--Ham omelet (1 egg, 1 tbs. cream, 15 gm. minced ham)
             75 gm. spinach
             1 soya meal muffin with 8 gm. butter
             Tea

A departure from the now almost universally used "Allen-Joslin
Starvation Diet," is seen in the "Newburg-Marsh High Fat Diet."

The use of a high fat diet in the treatment of diabetes is based
primarily on one fact--namely, that if the food eaten is not
sufficient for the needs of metabolism, the body itself supplies the
deficiency. Fat is used as long as it lasts, body protein being drawn
upon for fuel when this is exhausted. It is of distinct advantage to
the patient to have a diet of sufficient fuel value to run his body
machine and permit him a moderate degree of exercise. For by this
means he is not obliged to use his own body substance to carry on
metabolic processes. We thereby avoid the condition of extreme
emaciation (though it is to be emphasized that gain in weight is to be
carefully guarded against) with its constant lowering of the general
health.

The system of feeding consists of a series of four diets, examples and
standards of which are given below. The diet is made up of protein on
the basis of approximately 2/3 of a gram per kilogram of body weight
at the time the patient leaves the hospital, a quantity of
carbohydrate known to be well tolerated and the balance of the
calories in fat.[154]

DIABETIC DIET NO. 1
  =======================================================================
                             18-22   Proteins
                             12-15   Carbohydrates
                            800-1000 calories
  -------------------------+--------+---------+-----+---------+----------
                           |_Weight_|_Protein_|_Fat_|_Carbo-_ |
           _Food_          | _Gm._  |  _Gm._  |_Gm._|_hydrate_|_Calories_
                           |        |         |     |  _Gm._  |
  -------------------------+--------+---------+-----+---------+----------
  Dinner:                  |        |         |     |         |
    Fish                   |   50   |   8.9   |  5.1|         |    82
      with Butter          |   10   |    .1   |  8.5|         |    77
    Cabbage                |   50   |    .8   |   .1|   2.8   |    16
      with mayonnaise      |        |    .7   | 38.2|         |   353
    Tomatoes               |  100   |   1.2   |   .2|   4.0   |    23
    Broth--Tea             |        |         |     |         |
                           |        |         |     |         |
  Supper:                  |        |         |     |         |
    String beans           |   80   |   1.8   |   .2|   5.9   |    33
      with bacon           |   10   |   1.0   |  6.5|         |    62
    Spinach soup--         |        |         |     |         |
      Spinach              |   10   |    .2   |     |    .3   |     2
      Cream                |   10   |    .2   |  4.0|    .3   |    38
      Broth to fill bowl   |        |         |     |         |
    Celery                 |   20   |    .2   |     |    .7   |     4
    Broth--Tea             |        |         |     |         |
                           |        |         |     |         |
  Breakfast:               |        |         |     |         |
    Omelet--               |        |         |     |         |
      1 egg                |        |   6.7   |  5.2|         |    74
      with butter          |   10   |    .1   |  8.5|         |    77
    Coffee                 |        |         |     |         |
  -------------------------+--------+---------+-----+---------+----------
                           |        |  21.9   | 76.5|  14.0   |   842
  =========================+========+=========+=====+=========+==========

DIABETIC DIET NO. 2
  =======================================================================
                            25-30 Proteins
                            18-22 Carbohydrates
                          1200-1600 calories
  -------------------------+--------+---------+-----+---------+----------
                           |_Weight_|_Protein_|_Fat_|_Carbo-_ |
           _Food_          | _Gm._  |  _Gm._  |_Gm._|_hydrate_|_Calories_
                           |        |         |     |  _Gm._  |
  -------------------------+--------+---------+-----+---------+----------
  Dinner:                  |        |         |     |         |
    Pork chops             |   60   |  10.0   | 18.0|         |   202
    Cabbage                |  100   |    .2   |   .3|   5.6   |    32
      (Use pork drippings) |        |         |     |         |
    Spinach                |  100   |   2.1   |   .3|   3.2   |    24
      with butter          |   20   |    .2   | 17.0|         |   154
    Broth--Tea             |        |         |     |         |
                           |        |         |     |         |
  Supper:                  |        |         |     |         |
    Asparagus salad--      |        |         |     |         |
      Lettuce              |   10   |    .1   |     |    .3   |     2
      Asparagus            |   80   |   1.2   |   .1|   2.1   |    13
      Mayonnaise           |   50   |    .7   | 38.8|         |   338
    Tomatoes               |  100   |   1.2   |   .2|   4.0   |    23
      with butter          |   10   |    .1   |  8.5|         |    77
    Nut charlotte--        |        |         |     |         |
     Walnuts, chopped      |   10   |   1.8   |  6.4|   1.3   |    70
     Cream                 |   50   |   1.1   | 20.0|   1.5   |   190
    Broth--Tea             |        |         |     |         |
                           |        |         |     |         |
  Breakfast:               |        |         |     |         |
    Bacon                  |   20   |   2.1   | 13.0|         |   125
      with 1 egg           |        |   6.7   |  5.2|         |    74
    Coffee with cream      |   30   |    .7   | 12.0|    .9   |   114
  -------------------------+--------+---------+-----+---------+----------
                           |        |  28.2   |139.8|  18.9   |  1438
  =========================+========+=========+=====+=========+==========

DIABETIC DIET NO. 3
  =======================================================================
                            30-35 Proteins
                            25-30 Carbohydrates
                          1600-2000 calories
  -------------------------+--------+---------+-----+---------+----------
                           |_Weight_|_Protein_|_Fat_|_Carbo-_ |
           _Food_          | _Gm._  |  _Gm._  |_Gm._|_hydrate_|_Calories_
                           |        |         |     | _Gm._   |
  -------------------------+--------+---------+-----+---------+----------
  Dinner:                  |        |         |     |         |
    Beef tenderloins       |   80   |  13.0   | 19.5|         |   227
      with butter          |   10   |    .1   |  8.5|         |    77
    Asparagus              |  100   |   1.5   |   .1|   2.8   |    18
     with butter           |   10   |    .1   |  8.5|         |    77
    Squash                 |  100   |   1.4   |   .5|   9.0   |    46
      with butter          |   10   |    .1   |  8.5|         |    77
    Broth--Tea             |        |         |     |         |
                           |        |         |     |         |
  Supper:                  |        |         |     |         |
    String bean salad--    |        |         |     |         |
      Lettuce              |   10   |    .1   |     |    .3   |     2
      String beans         |   50   |   1.1   |   .1|   3.7   |    26
      Pimento              |   10   |    .2   |     |    .4   |     2
      Onion                |   10   |    .2   |     |   1.0   |     5
      Mayonnaise           |   30   |    .5   | 23.3|         |   228
    Tomatoes               |  120   |   1.4   |   .2|   4.8   |    28
      with butter          |   20   |    .2   | 17.0|         |   154
    Chocolate pudding--    |        |         |     |         |
      Cream                |  100   |   2.2   | 40.0|   3.0   |   381
      Cocoa, 1/2 tsp       |    1   |    .2   |   .3|    .4   |     5
    Broth--Tea             |        |         |     |         |
                           |        |         |     |         |
  Breakfast:               |        |         |     |         |
    Bacon                  |   30   |    3.2  | 19.4|         |   187
      with 1 egg           |        |    6.7  |  5.3|         |    74
    Coffee with cream      |   30   |     .7  | 12.0|    .9   |   114
  -------------------------+--------+---------+-----+---------+----------
                           |        |   32.9  |163.2|  26.3   |  1728
  =========================+========+=========+=====+=========+==========

DIABETIC DIET NO. 4
  =======================================================================
                               50-60 Proteins
                               30-40 Carbohydrates
                             2000-2500 calories
  -------------------------+--------+---------+-----+---------+----------
                           |_Weight_|_Protein_|_Fat_|_Carbo-_ |
           _Food_          | _Gm._  |  _Gm._  |_Gm._|_hydrate_|_Calories_
                           |        |         |     | _Gm._   |
  -------------------------+--------+---------+-----+---------+----------
  Dinner:                  |        |         |     |         |
    Veal steak (roast)     |  100   |   19.9  | 10.8|         |   177
    Onions                 |  126   |    1.9  |   .4|  11.9   |    49
      with cream           |   50   |    1.1  | 20.0|   1.5   |   190
    Tomatoes               |  150   |    1.8  |   .3|   6.0   |    35
      with  butter         |   30   |     .3  | 25.5|         |   231
    Fruit salad--          |        |         |     |         |
      Lettuce              |   10   |     .1  |     |    .3   |     2
      Celery               |   50   |     .6  |     |   1.6   |     9
      Grapefruit           |   80   |     .6  |   .2|   8.1   |    37
      Whipped cream        |   30   |     .7  | 12.0|    .9   |   114
    Tea--Broth             |        |         |     |         |
                           |        |         |     |         |
  Supper:                  |        |         |     |         |
    Cream of celery        |        |         |     |         |
        soup--             |        |         |     |         |
      Celery               |   50   |     .6  |     |   1.6   |     9
      Cream                |   75   |    1.6  | 30.0|   2.2   |   285
      Broth to fill bowl   |        |         |     |         |
    Boiled ham             |   30   |    6.1  |  6.7|         |    85
    Custard--              |        |         |     |         |
      2 egg yolks          |        |    4.7  | 10.0|         |   109
      Cream                |   90   |    2.0  | 36.0|   2.7   |   343
    Tea                    |        |         |     |         |
                           |        |         |     |         |
  Breakfast:               |        |         |     |         |
    Eggs (2)               |        |   13.4  | 10.5|         |   148
      with butter          |   30   |     .3  | 25.5|         |   231
    Coffee with cream      |   20   |     .4  |  8.0|    .6   |    76
    Broth                  |        |         |     |         |
  -------------------------+--------+---------+-----+---------+----------
                           |        |   56.1  |195.9|   37.4  |  2130
  =========================+========+=========+=====+=========+==========

~Nurse's Directions for Collecting and Testing the Urine in Diabetes
Mellitus.~--The first urine voided in the morning at 7 A.M. should be
thrown away, after which the entire quantity during the ensuing
twenty-four hours, including that at 7 A.M. the following morning,
should be collected in a thoroughly clean, wide-mouth bottle
sufficiently large to contain the entire quantity. This should be kept
in a cool place to prevent decomposition. After the urine has been
measured, four or five ounces are removed for testing purposes. There
is no necessity for having an elaborately equipped laboratory for
making the simple tests of the diabetic urine. The nurse is only
required to make the simple tests, leaving the more elaborate one for
the physician. The articles necessary for these tests must be kept
perfectly clean in order to make the tests accurate. The bottle in
which the urine is collected must be washed and sterilized daily
before the collection begins. One small three-inch white enameled or
porcelain dish, one 10 c.c. graduated pipette, 6 test tubes, 1 small
alcohol lamp or Bunsen burner, 1 box of sodium carbonate, 1 box
talcum, and the reagents necessary for making the test, namely,
Benedict's solution, Fehling's solution, and Haines's solution.


SUMMARY

~Diabetes Mellitus~ is a disease in which the body becomes more or
less unable to utilize the sugars and starches, consequently there is
an abnormal amount of glucose in the urine.

~Manufacture of Sugar~ in the body from other food constituents
besides carbohydrates has been proved with regard to proteins, hence
the intake of nitrogenous substances must be restricted in
diabetes--to a less extent, however, than the sugars and starches.

~Acetone Bodies.~--Diacetic acid, oxybutyric acid, and acetone
develop in diabetes as a result of the breaking down of the fats and
the lack of certain neutralizing agents found chiefly in carbohydrate
foods.

~Acidosis~ is a form of intoxication due to the retention of these
toxic acids in the body. If not combated and overcome, it will result
in the diabetic coma which is fatal in so many cases.

~Diet Treatments.~--The best known treatments are those devised and
used by Drs. Allen and Joslin "The Starvation Treatment for Diabetes
Mellitus," and the "High Fat Diet" formulated by Drs. Newburg and
Marsh. All cases cannot be handled alike and it is for the physician
to determine the treatment calculated to give the best results in the
definite case.

~Training for Diabetic Nursing.~--So much depends upon the
administration of the treatment in this pathological condition that in
many hospitals special training is being given to the nurses in the
care of diabetic patients that they may be able intelligently to carry
out the necessary régime, both in the hospital and in private
practice.

~Symptoms.~--She must be able to recognize symptoms both from the
findings resulting from the urinalysis and from those manifested
otherwise by the patient.

~The Record.~--She must keep an absolute record of all that occurs
during the course of treatment and instantly report any unusual
happening.

~Urine Tests.~--It is advisable to make the tests in the morning;
those for sugar and diacetic acid should be made every day or, in some
cases, every other day, as directed by the physician, and those for
ammonia and albumen about once a week.

~Weighing the Patient.~--Patient should be weighed each day before
breakfast, and the weight of the clothes also carefully recorded
separately.

~The Bowels~ must move daily, even if it is necessary to resort to
mild laxatives or an enema.

~Formulating and Calculating the Dietary.~--The menus of the day must
be formulated and the chemical composition and nutrient value of the
foods calculated. The vegetables belonging to the five per cent. group
should be in readiness and the amount to be used weighed after they
have been boiled in clean, separate water to reduce their carbohydrate
content still further.

~Commercial Diabetic Foods.~--It may be well to mention the danger of
putting faith in the so-called diabetic foods so widely advertised.
Some of these foods are of undoubted worth, but it is never safe for
the nurse or the patient to judge of the merits of the various
diabetic foods without first knowing their chemical composition, and
not even then without the definite directions from the physician.

~Diabetic Flours.~--The diabetic flours used in the recipes included
in this text have been approved by some of the leading specialists in
diabetes in this country, but the nurse should not include them in the
diet for her patient unless they are prescribed by the physician in
charge.


PROBLEMS

(a) Outline test diets for determining the severity of the
disturbance.

(b) Give examples of diets used in testing for tolerance of
carbohydrates, fats, proteins.

(c) Give an example of a diet order showing the use of the high fat
method of feeding. Why is it used?


FOOTNOTES:

[137] Allen's Paradoxical Law, quoted from "Treatment of Diabetes
Mellitus," p. 18, by Joslin.

[138] "Treatment of Diabetes Mellitus," p. 305, Joslin.

[139] "Food for the Sick," by Strouse and Perry.

[140] Courtesy of Dr. Joslin and Thomas Groom & Co., Boston.

[141] The giving of coffee or clear broth, with or without whisky,
does not materially affect the starvation and serves to make the
patient more comfortable during this trying period.

[142] Dr. Joslin has given a very complete schedule in his "Treatment
of Diabetes Mellitus," from which the above schedule is taken.

[143] Hill and Eckman's "Starvation (Allen) Treatment of Diabetes."

[144] See 5% vegetable, p. 383.

[145] Table used by Dr. Joslin in his treatment of diabetes mellitus.
It is convenient, and many changes in the diet may be made by
substituting one food for another of like carbohydrate content. This
table can be purchased on cards from Thomas Groom & Co., Boston, Mass.

[146] Table devised by H. O. Mosenthal showing accessory diets rich in
carbohydrates. "Medical Clinics of North America," July, 1917.

[147] "h" represents household measure.

[148] Mosenthal: "Medical Clinics of North America," July, 1917.

[149] "Starvation Treatment of Diabetes," by Hill and Eckman.

[150] "Practical Dietetics," by Alidia Pattee.

[151] "Food for the Sick," p. 62, by Strouse and Perry.

[152] Sweetened with saccharin.

[153] "Starvation Treatment of Diabetes," by Hill and Eckman.

[154] Courtesy of R. Eckman and D. M. Stewart, University of Michigan
Hospital, Ann Arbor, Michigan.




CHAPTER XXI

DISEASES OF THE LIVER


Much of the so-called biliousness from which the human family is so
prone to suffer is nothing more or less than one of Nature's danger
signals by means of which man may understand that some part of the
delicate organism called the human body is being overworked. Close
investigation of these conditions has proved that it is the liver
which has been overtaxed, in many cases to such an extent that in a
measure it slows down, as any overtaxed machine will do, and has
become clogged with material which, owing to its condition, it is not
able to prepare properly and send out on time.

~Work of the Liver.~--When one considers the vast amount of work
performed by this organ, one marvels that so little trouble is
manifested. In another part of this text the functions of the liver
were defined. It was found to be the largest secretory organ in the
body, producing a constant supply of bile by means of which the fats
were dissolved and the digestion and absorption of the other food
materials facilitated. We likewise found that the greater part of the
fuel foods was transformed within this organ into available energy,
either for immediate or future use.

~As a Detoxifying Agent.~--To the liver must also be credited the
detoxifying of the various poisons produced within the body during the
process of metabolism or brought in by way of food. Too much cannot be
said as to the value of the liver in this respect, the importance of
which is made known as soon as anything happens to the organ to put it
even temporarily out of commission.

~Causes of Liver Disorders.~--Is it any wonder, then, that with such
abuses as overeating and drinking, especially of those foods rich in
fats and carbohydrates which depend upon the liver for their
availability in the body, Nature cries aloud for help and for the
comparative rest of this, her largest organ?

The taking of alcohol in excess has been found to bring about tissue
changes in the liver. Hence it must be avoided by individuals with a
tendency to biliousness or to any disease in which the liver is
involved.

~The Bowels.~--The bowels are as a rule constipated, and one of the
first means of relief is the overcoming of this condition. The method
of doing this depends upon the individual, and the treatment must be
decided on by the physician.

~Dietetic Treatment.~--The dietetic treatment consists in abstaining
from food or reducing the amount to a minimum while the attack lasts
and while the intestines are being thoroughly emptied. All stagnant
material which has clogged the bowels and which has been subjected to
the activities of putrefactive bacteria must be gotten rid of. The
diet must be especially low in fat. Oyster or clam broth, soft-cooked
eggs, toast, cereal, or rice, with a little milk instead of cream and
very little sugar, tea, and baked apple or stewed prunes are given.

~Convalescent Diet.~--After the attack the diet may be gradually
increased until it is again normal. Moderation must be observed in the
amount of food eaten; no highly seasoned or spiced foods, pickles, or
condiments, such as peppers, mustard, or horseradish, should be taken.
Salads should be dressed without oil. Lean beef, lamb chops, fish,
chicken, sweetbreads, quail, squab, eggs (except fried or hard
cooked), green vegetables (except radishes, onions, water-cress, and
celery) in abundance, a small amount of potato, rice, or tapioca,
fresh and cooked fruit with little, if any sugar, junket, custards,
fruit jellies, weak tea and coffee should constitute the diet. Certain
individuals find that milk increases the tendency to constipation;
this is probably due to the small amount taken; large quantities do
not as a rule produce this effect. Buttermilk, koumiss, and modified
milk are advised in severe cases.

~Diet for Constipation.~--Individuals inclined to biliousness should
endeavor to overcome the constipation which is one of the most
prominent features. This is done by proper diet more successfully than
by drugs (cathartics): bran bread, vegetable soup, fresh fruit, stewed
fruit, fruit beverages, plenty of water. The following menus are
suggested:

  Breakfast--Stewed prunes
             Oatmeal with milk (no sugar)
             Weak tea or coffee
             Toast (milk toast or dry toast)

      Lunch--Tomato soup
             1 small baked potato
             1 lean lamb chop (broiled) or a poached egg on toast
             Cup of weak tea

     Dinner--Vegetable soup
             1 slice of lean, rare beef (cut from the inside of the
               roast)
             Spinach
             Rice
             Lettuce and tomato salad
             Lemon jelly

  Breakfast--Grapefruit
             Hominy with milk
             Poached egg on toast
             Weak coffee (milk and little sugar)

      Lunch--Cream of green pea soup
             Tomato jelly
             Broiled sweetbreads
             Weak tea
             Toast

     Dinner--Small portion of lean lamb or chicken
             Boiled or mashed potatoes
             String beans
             Sliced tomatoes
             Prune whip

~Advice to Patient.~--The above menus are merely suggested. The diet
may be selected from the list of foods already mentioned. The patient
must be warned against overeating and drinking. Pastry, rich cakes and
puddings, confectionery, gravies, etc., must be avoided. In certain
individuals beer will induce a bilious attack. By them it should be
avoided.


CIRRHOSIS OF THE LIVER

The cause of this disease and the stage in which it exists must
determine the treatment necessary. However, it matters not what
produced the disease, whether it is the result of alcoholism,
syphilis, etc., the diet plays an important rôle in its cure.

~The Diet.~--The diet in this disease, as in any other, must be
determined by the condition of the patient. Unfortunately, many
patients do not know of their condition until the disease is well
advanced and symptoms of obstruction are prominent. A study of these
must be made before the diet can be formulated. When the symptoms are
mainly those arising from disturbed digestion of the stomach and
intestines, without kidney or heart complication, the diet for chronic
gastritis is used.

~Restricting the Fluids.~--When the heart is involved, it is
sometimes found necessary to restrict the fluids (dry diet) to 1 quart
(about 1000 c.c.) per day. The Karell Cure has been used
advantageously in many of these cases. In cases where the kidneys are
involved, the diet will depend upon the condition of these organs.

~Restricting the Diet.~--The diet in any case must be restricted.
Individuals with a tendency to cirrhosis and those coming of a family
in which liver diseases are frequent should be especially warned about
the dangers of overeating and drinking. Alcohol should be avoided
especially by such individuals. They should keep their diet simple in
character and moderate in amounts.

~Avoidable Foods.~--All foods, such as condiments and spices, meat
extracts, the outside browned portions of roasted meat, alcoholic
beverages, which exert a stimulating or irritating effect upon the
liver, should be studiously avoided and the fats and carbohydrates
restricted, since, as it has already been demonstrated, it is upon the
liver that the body depends for the preparation of these substances
for their utilization. When, for example, the flow of bile is
lessened, an incomplete emulsification of the fats exists and the
fatty acids which are highly acid in character cannot be efficiently
dissolved or neutralized, or when the liver is diseased and for this
reason the conversion of glycogen into glucose is interfered with, the
utilization of the carbohydrate foods is thus impaired.


GALLSTONES

~Factors Influencing Their Formation.~--According to Friedenwald and
Ruhräh[155] the two factors that in all probability exert the most
influence on the formation of gallstones are the stasis of bile and
the inflammation of the bile passages and gall bladder.

~Dietary Rules.~--There are certain dietary rules which should be
observed by all persons who have had gallstone attacks. These are (1)
to prevent stasis of bile, (2) to avoid fats. Everything should be
done to prevent the formation of the stones, and this can only be
accomplished by observing these rules. The flow of bile must be free;
this is encouraged by keeping the intestinal tract in good condition.

~Stimulating Peristalsis.~--Peristalsis must not be allowed to become
sluggish, for it is only during the process of digestion when the food
mass passes along the intestinal canal that there is an ejection of
bile into the intestines. When the passage is abnormally slow the bile
is in a measure dammed back with a formation of gallstones as a
result. The restriction of the fats has already been discussed in
another part of the chapter. It has been demonstrated that these
substances have a chemical influence upon the formation of gallstones
as well as upon the intestinal stasis which leads to their formation.

~Dietetic Treatment.~--Hence the diet should be so directed as to (1)
increase the flow of bile, and (2) to avoid all foods that are liable
to cause indigestion which may bring about putrefaction in the
intestinal tract and a consequent irritation and inflammation of the
bile passages and gall bladder.

The meals should be regular and an abundant diet advised to increase
the flow of bile and stimulate peristalsis in the intestines.

~Exercise.~--Exercise is especially recommended. Horseback riding,
swimming, rowing, golf, and tennis are especially valuable in forcing
the bile from the gall bladder and liver.

~The Clothing.~--The clothing should be loose enough to be perfectly
comfortable. Certain cases of gallstone attacks in women have been
said to have been traced to tight lacing, which interfered with the
normal flow of the bile.

~The Bowels.~--Constipation should be avoided, and the diet should be
directed with this point in view. The meals must be frequent, ranging
from four to six a day. In this way only is the flow of bile
encouraged. The breakfast should be ample in order to utilize the bile
secreted in the night season. With all this, care must be observed not
to give more food than can be adequately handled by the digestive
apparatus, since food which is not digested becomes a prey to the
actions of the putrefactive bacteria which infest it, and the toxic
substance thus formed produces the very result which all of our
efforts are directed to prevent.

~Available Foods.~--The following foods low in fats may be used in
formulating the diet:

Soups: Meat broth (made from lean meat) from which all the fat has
been removed.

Meats: Lean beef, lamb, chicken, squab, quail, lean fish (in small
quantities and not too frequently).

Green vegetables: Except peas and carrots; beets and turnips may be
taken sparingly.

Fruits: Oranges, lemons, grapefruit, and unsweetened stewed fruit.

Cereals: Wheat cereals, oatmeal, rice, and tapioca in moderation.

Bread: Whole wheat, white, rye, and graham bread, toast, and crackers.

Fluids: Weak tea and coffee (without cream, and a little sugar),
orange and lemonade, mineral waters, water, skimmed milk, whey.

Eggs: (except hard-cooked or fried).

Desserts: Fruit gelatin, fruit whips, raw or stewed fruit.

Avoid the following foods: Fats, oils, mutton, liver, brains,
sardines, and caviar, oily fish, rich gravies and sauces, sweet fruit,
peas, carrots, condiments and spices, pastry and confectionery,
pickles, alcoholic beverages. Restrict carbohydrates, yolks of eggs,
milk (cream must be skimmed off if too rich).


DAILY DIET SHEETS

I

   Breakfast--Baked apple with milk
              Cream of wheat with milk
              Weak coffee or tea
              Dry toast

  11:30 A.M.--6 oz. orange juice, 1 egg white

      Dinner--Beef broth (well skimmed) with crackers
              Rice
              Stewed pears
              Weak tea
              Toast or rolls

   3:30 P.M.--Albumenized fruit juice with crackers

      Supper--Wheatena with milk
              Milk toast
              Stewed prunes
              Toast and tea

      9 P.M.--Well-skimmed chicken broth with crackers

II

   Breakfast--Stewed apples with milk
              Milk toast
              Coffee without cream

  10:30 A.M.--Well-skimmed broth with crackers

      Dinner--Tomato bouillon with crackers
              Baked potato--1 small potato
              Purée of spinach
              Orange gelatin
              Toast

      3 P.M.--Albumenized lemonade

      Supper--Oatmeal or cream of wheat with milk
              Toast
              Tea
              Stewed fruit

      9 P.M.--Well-skimmed broth with crackers

III

   Breakfast--Grapefruit
              Oatmeal with milk
              Toast
              Weak coffee

  10:30 A.M.--Orangeade with graham crackers

      Dinner--Cream of spinach soup (skimmed milk)
              Small piece of the breast of chicken
              Mashed or boiled potatoes
              Asparagus on toast
              Sliced oranges

   3:30 P.M.--Well-skimmed broth with crackers

      Supper--Farina or cream of wheat or wheatena, with milk
              Baked potato
              Baked apple with milk
              Toast and tea

      9 P.M.--Albumenized orange juice

IV

   Breakfast--Sliced oranges
              Oatmeal
              Toast
              Coffee

  10:30 A.M.--Beef gruel, 6 oz.

      Dinner--Cream of asparagus soup, skimmed milk
              Thin slice of roast beef or whitefish
              Rice or potatoes
              Tender string beans
              Fruit
              Toast
              Buttermilk

   3:30 P.M.--Orangeade

      Supper--Stewed fruit with puffed wheat or rice
              Milk toast
              Tea

      9 P.M.--Broth


SUMMARY

~Functions of Liver.~--To transform fuel foods into available energy;
to detoxify those poisonous substances produced as the result of
metabolism of body tissue or brought in in food, and to select those
available for use; to secrete bile.

~Factors Influencing Disorder of Liver.~--Errors in diet: (a)
overeating; (b) excessive drinking; and (c) unbalanced diet,
especially as regards the amount of fats and carbohydrates in the
diet.

~The Bowels~, in most of the disturbances affecting the liver, become
constipated, thus causing much additional work on the part of the
liver in handling the products produced as the result of putrefactive
bacteria upon the accumulated mass in the colon.

~Tissue Changes~ in the liver have been caused by the taking of
alcohol, which should therefore be avoided by all individuals having
any disease involving the liver and by those with a predisposition to
liver disturbances.

~Exercise and Lack of Exercise~ are potent factors in the treatment
of conditions involving the liver. First, because the liver requires
exercise to enable it to empty itself more completely and assure a
free flow of bile; second, because exercise directly affects the
energy output of the body, causing an increased rate of metabolism and
a better utilization of the food ingested. Lack of exercise acts in
exactly the opposite direction, and it has been found that with the
majority of patients suffering from diseases of the liver too little
exercise and too much food are at the bottom of the trouble.

~Dietetic Treatment~ in the majority of diseases affecting the liver
is much the same. The keynote in each is a balanced diet. Constant
overeating and excessive drinking have proved the foundation of the
majority of such diseases, especially of the bilious type, while an
excess of fat and carbohydrates in the diet lead to the more serious
disorders.

~Biliousness~ requires abstinence from food for a short period and a
cleansing of the entire gastro-intestinal tract, the measures being
directed by the physician. After the bilious symptoms have subsided, a
simple, well-regulated diet should be established, in which no rich
foods of any sort are allowed. All condiments and spices which have an
astringent effect upon the bowels are strictly prohibited, and
alcoholic beverages had best be eliminated from the diet.

~Cirrhosis~ of the liver is apt to be insidious in its development,
taking a firm hold before the character of the disorder is discovered.
Dietetic treatment of this disturbance is most important and should be
directed toward overcoming not only the liver symptoms but other
symptoms as well.

~Gastro-intestinal Disturbances~, manifested in cirrhosis of the
liver, are treated by the diet used in chronic gastritis (see p. 250).

~Heart Symptoms~ sometimes occur during the course of the disease and
require especial attention to the diet. The fluids at times must be
restricted, in which case a modification of the Karell Cure will prove
valuable (see p. 342).

~Kidney Complications~ develop in a certain percentage of cases, and
it then becomes necessary to institute one of the various diets
devised to meet the needs of those special conditions (see Chapter
XVIII).

~Restricting the Diet~ will be found to be necessary for those
individuals showing a tendency to cirrhosis, also for those in whose
family diseases of the liver are of frequent occurrence. Such
individuals should be warned of the dangers arising from
overindulgence in food or alcoholic beverages.

~Prohibited Foods~ are those which by reason of their astringent
qualities favor the development of constipation, such as condiments
and spices; those foods which exert a stimulating and irritating
effect upon the liver and bile passages, such as alcohol, malt
extractives, etc.; and fats and carbohydrates in excessive quantities,
on account of the extra amount of work required of the liver in order
to make them available in the body.

~Gallstones~ develop as the result of inflammation or clogging of the
bile passages.

~Treatment~ is dietetic in character and is directed toward relieving
or preventing inflammation in the bile passages, also in stimulating
the flow of bile in order that it may not become sluggish and thus
give rise to the development of the gallstones.

~The Fats~, therefore must be restricted in the diet, as they, more
than any of the other food constituents, favor the above conditions.

~Peristalsis~ in the intestinal tract must be stimulated to facilitate
a free flow of bile, which will not occur where the movements are
sluggish. Stasis of the bile must be prevented or stones will be apt
to form.

~Dietetic Treatment~ for gallstones is therefore directed to increase
the flow of bile and to avoid the inflammation of the gall bladder and
bile passages which may result from the product of intestinal
putrefaction.

~The Diet~ consists of foods simple in character, low in fats, but
abundant in quantity, in order to prevent constipation. It must be
selected carefully that digestional disturbances may not develop.

~The Meals~ should be frequent, from four to six a day, in order to
encourage a free flow of bile.

~Breakfast~ should be ample in order that the bile secreted and
accumulated during the night may be utilized as soon as possible.

~Constipation~ must be avoided, and the foods particularly adapted to
prevent or overcome this condition should have a prominent place in
the diet. Any accumulation of unabsorbed food in the lower intestines
becomes a breeding ground for putrefactive bacteria, the product of
whose activity imposes a serious tax upon an already overworked organ.


PROBLEMS

(a) Formulate a diet for a patient suffering from gallstones. Outline
method of administration.

(b) List available foods for diets used in disturbances of the liver.
List the foods to be avoided in such cases.


FOOTNOTE:

[155] "Diet in Health and Disease," p. 399, by Friedenwald and Ruhräh.




CHAPTER XXII

GOUT, OBESITY, EMACIATION


Gout is a constitutional disease characterized by an inflammatory
condition of the joints. It is caused by or associated with a
retention of uric acid in the blood. Gout is also characterized by the
deposit of uric acid or sodium salts which occurs in different parts
of the body, the joints, the lobe of the ear, the knee and the elbow
being common points where the deposit of these salts ordinarily
occurs. The amount of uric acid is lessened in the urine in cases of
true gout, except in acute attacks, and in this way it is
distinguished from the so-called goutiness in which a urinalysis shows
an excess of uric acid. According to Strouse, this excess of uric acid
in the urine "means a physical-chemical change in the urine and is
quite different from the small amount usually excreted."[156]

~Source of Uric Acid.~--In man the uric acid which is eliminated in
the urine is derived from two sources. It may be taken with the body
as purins in food, in which case it is spoken of as being an
"exogenous" product, or it may be formed in the body from the breaking
down of the nucleoproteins (the highly nucleated cells of the
glandular organs particularly). When the uric acid is formed in this
manner as the result of the metabolism of the body tissues, it is
known as "endogenous." In the normal body approximately one-half of
the uric acid formed is oxidized, while the remaining half is
eliminated from the body by way of the urine.

~Elimination of Uric Acid.~--In gout such is not the case, the body
loses to a certain extent the ability to eliminate the uric acid,
hence it is retained within the body, causing an excess in the blood
stream, and it is this excess uric acid in the blood which causes the
acute attacks and general pain and discomfort which inevitably occur
in chronic gout.

~Purin-bearing Foods as Sources of Uric Acid.~--Formerly no difference
was made in food; all were supposed to cause uric acid formation, but
with the exhaustive investigation of food materials this sweeping
condemnation has been to a great extent removed or narrowed down to a
few foods, those rich in purins being the chief offenders.

~Chief Causes of Gout.~--Without a doubt, overeating, overindulgence
in alcoholic stimulation, lack of exercise, etc., are chiefly to blame
for the large percentage of the cases, but upon investigation it will
be seen that those individuals are as a rule large protein eaters and
that their mode of living is not such as to assist the body in
throwing off the poisons which form as the result of their
self-indulgence.

~Rules to Combat Gout.~--To successfully combat the retention of a
large percentage of uric acid in the blood there are certain definite
rules to be observed: (1) The general diet must be reduced not only in
amount but also in purin-bearing foods; (2) All foods which are liable
to cause digestional disturbances, with the attending evils of
intestinal putrefaction and constipation, must be avoided.

~Alcohol in Gout.~--If the patient is accustomed to alcoholic
stimulants and has been in the habit of taking them constantly for
years, the amount of alcohol consumed daily must be radically reduced
and only the amount prescribed by the physician taken. Alcohol without
a doubt assists in the retention and increases the difficulty of uric
acid elimination by the body. In view of the present knowledge of the
cause and effect of uric acid in the body, the treatment of gout is
directed with the object of relieving the condition (1) by
facilitating the elimination of uric acid from the body, and (2) by
so regulating the diet as to exclude as far as possible those
purin-bearing foods which, by reason of their chemical composition,
augment the general amount of uric acid formed within the organism.

In gout, as in other abnormal conditions, no set rule can be laid down
to cover the treatment of every case. The individual must be taken
into consideration, his daily habits studied and the extent and
character of the disease known before it is possible to prescribe a
treatment or formulate a diet which would adequately meet his needs
under the existing conditions.

~Obesity and Glycosuria.~--Gouty individuals often become obese and
show evidences of glycosuria. Consequently it is important to regulate
the carbohydrates as well as the purin-bearing foods in the diet. Only
the simplest foods are permissible. In acute attacks it has been found
that milk and alcohol cause less disturbance than meat and alcohol.
While the acute symptoms exist all meat should be avoided and the
daily allowance of alcohol cut down. Tea and coffee both contain
purins and should be avoided while the acute stage of the disease
continues. Cereal coffee, hot water tea, hot milk or buttermilk may
be substituted.

~Purin-free Diet.~--A purin-free diet is advisable during the acute
attack. The following is a sample menu of such a diet:

        Breakfast--Banana, apple, grapefruit, orange or peach, etc.
                   Cereals: farina, hominy, or cream of wheat with
                     cream and sugar
                   1 egg, soft-cooked
                   Buttered toast
                   Cereal, coffee with sugar and cream or hot water
                     tea (milk and hot water) with cream and sugar

  Lunch or Dinner--Poached egg on toast, 1 large baked potato with
                     butter, 1 mold of fruit jelly with cream

           Supper--Rice and butter, bread or toast with hot milk
                   Apple sauce with cream

                                      _Purin Per Cent._
                   Cocoa contains        1.00 per pint
                   Tea      "            1.20 per pint
                   Coffee   "            1.70 per pint

Purins are soluble in water, hence those foods that are boiled contain
less than those prepared by other methods of cookery.

~Foods More or Less Condemned.~--Salt has a tendency to bring about a
deposit of sodium urates in the body, and for this reason should be
sparingly used in the preparation of the diet. Alkaline waters are
inclined to produce a like result, consequently should be avoided by
the gouty individual. Condiments and spices are conducive to
constipation, a condition to be avoided if possible under the
circumstances. Certain physicians prohibit the use of oranges in the
diet of gout, while others do not. Strawberries are likewise condemned
and should be eliminated from the diet for both chronic and acute
gout.

~Diet in Chronic Gout.~--In chronic gout it is necessary to maintain
the general health of the patient by a well-balanced diet. This is not
difficult even if the dietary is so regulated as to be well within the
limits of his energy requirements. It is necessary to limit the
purin-bearing foods. Meats are used sparingly and these should be
boiled rather than roasted or broiled. Eggs and cheese and milk should
be substituted for at least part of the regular allowance of meat.

~Exercise and Massage.~--The patient should be recommended to take a
certain amount of mild exercise in the open air, or massage if he is
accustomed to living an indoor life or is confined to office work. He
must be warned against overindulgences of all kinds, especially of
overeating and drinking. A glass or two of hot water before breakfast
is recommended.

~Treatment of Obesity.~--The treatment of obesity when occurring in
gouty patients is much like that used in other conditions. Ebstein
regards obesity under such circumstances as an unfavorable symptom. He
advises a reduction in the carbohydrates to the smallest possible
amount and allows meat and fats in the diet.

~Allowable Foods.~--The following foods are practically purin-free and
may be used in the diet of gout:[157] Milk, cheese, butter, eggs,
nuts, gelatin, fruits, sugar, breads made with white flour, cereals,
cream of wheat, farina, rice, hominy, tapioca, cornstarch, potatoes
and other root vegetables, green vegetables, except asparagus,
spinach, and all fats.

~Avoidable Foods.~--The following foods are rich in purins and should
be avoided in the diet for gout: Sweetbreads, liver, kidneys, beef,
mutton, veal, pork, turkey, chicken, goose, rabbit, duck and other
game, fish, with the exception of cod, sardines, and anchovies, tea,
coffee, and cocoa.

The following list shows the purin content of some of the
above-mentioned foods. The purins are computed by Hall as follows: 1
kilogram contains,

                  _Grams Purin_
  Milk
  Butter
  Eggs
  Cheese
  Farina
  Rice
  Hominy
  Potato              0.02

  Flour
  Bread
  Cauliflower
  Eggplant
  Cabbage
  Lettuce
  Sugar
  Peas                0.39

  Asparagus           0.21
  Lentils             0.38
  Halibut             1.00
  Cod                  .05
  Salmon              1.00
  Mutton              0.96
  Beef           1.10-2.00
  Veal                1.10
  Ham                 1.10
  Pork                1.20
  Oatmeal             0.53
  Beans               0.63
  Chicken             1.20
  Sherry
  Claret
  Whisky
  Brandy
  Beer                0.12
  Porter              0.14
  Ale                 0.14
  Chocolate  per pint 0.70

To keep the body in good condition and to help rid it of accumulated
poisons, the following diet lists are recommended:

~Daily Dietaries:~

     7 A.M.--Hot water, 8 oz.

     8 A.M.
  Breakfast--Stewed prunes, wheatena and cream
             2 eggs
             2 slices of buttered toast
             1 cup of milk flavored with cocoa or coffee or 1 cup of
               cereal coffee with cream

     Dinner--Cream of pea soup
             Boiled codfish with cream sauce
             Mashed potatoes
             Cauliflower
             Rice pudding

     Supper--Cream toast
             Baked potatoes
             Egg nest
             Apple sauce
             Hot milk flavored with coffee, cocoa, or 1 cup of cereal
               coffee

     7 A.M.--Hot water, 8 oz.

     8 A.M.
  Breakfast--Grapefruit
             Cereal and cream
             Soft scrambled eggs
             Cereal coffee, or milk and coffee
             Buttered toast

      12:30
      Lunch--Cream of tomato soup
             Cottage cheese and cream
             Baked potato
             Baked apple
             Bread and butter

     6 P.M.
     Dinner--Chicken, small piece, no gravy or rich dressing
             Candied sweet potatoes
             Baked eggplant
             Lettuce salad (lemon juice instead of vinegar)
             Bread and butter
             Orange or wine jelly
             Milk

  Breakfast--Cereal and cream
             Baked apple with cream
             1 slice of bacon
             1 soft-cooked egg
             Toast--butter
             Cereal coffee, or milk flavored with coffee

      Lunch--Vegetable soup
             Scalloped potatoes
             Cream cheese
             Bread, butter
             Stewed pears

     Dinner--Halibut steak
             Creamed potatoes
             String beans
             Fruit salad
             Sponge cake, orange sauce
             Small coffee


OBESITY

Probably no one problem affecting the human family is more widely
discussed than that of obesity. There are numberless "cures"
suggested, most of which contain some good, but they are as a rule
more strenuous than the average fat person cares to attempt, or, if
attempted, persist in.

~Causes of Obesity.~--It is stated that at least fifty per cent. of
the obesity is of hereditary origin, while the rest may be due to
overeating and drinking, unbalanced diets, metabolic changes due to
the approach of menopause in women, and diseases such as gout in which
there is a certain amount of disturbance in the blood and excretory
organs and in which the diet or the disease may be accountable for the
gain of surplus adipose tissue. Women approaching menopause may not
change their diet in the least and there may still be the noticeable
increase of fat.

~Obesity Cures.~--A great number of the "cures" are undertaken not
from a health standpoint but from the esthetic point entirely. It
makes no difference what reason is brought forward for instituting the
treatment, it is the results which count. Of the cures undertaken
which are in themselves good, but which are too strenuous for the
average "fat person" to stick to may be mentioned some of the early
cures instituted and recommended by Banting, Oertel, and Ebstein.
Obesity, then, may be said to be due to (1) heredity, (2) overeating
and drinking, (3) lack of exercise (sedentary life), (4) a combination
of the above causes. Whether the obesity is due to the lack of
exercise or the lack of exercise is due to the accumulation of fat
which causes a disinclination to move on the part of the individual,
can only be judged when a thorough examination into the life and
habits of the patient is made.

~Comparison of Food Intake and Energy Output.~--Many fat people who
claim to be small eaters in reality constantly consume more food than
their age, weight, or mode of living would necessitate. If such
patients could be prevailed upon to keep a correct chart of their
daily intake of food and the amount of exercise taken, they would be
astounded to find how much greater was the intake in comparison to the
output of energy, in other words, how much more food they ate than
they required to keep them in health. A glance at the first tables in
this text will show which foods are utilized by the body chiefly as a
source of energy.

~Uses of Food in Body.~--Physiological chemistry proves that when more
food is taken than is needed for the internal and external work of the
body, the surplus is stored for future use, first, in the liver and
muscles as glycogen for the general expenditures, and, second, as
adipose tissue for future use. Thus it is seen that when the intake is
constantly greater than the energy expenditure there must necessarily
be some way in which the body can store up the surplus fuel, and so
long as the digestion remains good and the amount of exercise limited
there is no reason why there should not be a constant and steady
accumulation of surplus fat which inevitably terminates in obesity.

~Water as a Fat Maker.~--That water is in itself fattening is of
course untrue. A chemical analysis of this fluid shows that it is
inorganic in character and cannot alone either produce energy or build
tissue. However, this food constituent plays a most important part in
all the functions of the body. In the first place the body cannot
utilize food unless it is in solution; water is also one of the best
known stimuli to the flow of gastric juice, and for this reason is an
important factor in the preparation of the food for its absorption and
utilization; since water forms the bulk of the blood, it acts as a
distributor or carrier of food to the different parts of the body.

~Limiting the Fluids in Obesity.~--Thus it is seen that when the
intake of fluids is limited, the body will call upon that surplus
which is stored in every nerve, tissue, and fluid throughout the
entire organism to assist in the necessary work of the organs, thus
reducing the body weight just that much.

~Exercise.~--The athlete who is overweight, due to adipose tissue,
increases his exercise at times, even adding to the weight of his
clothing, causing an increased energy output, profuse perspiration,
etc., all of which causes the body to use its surplus fuel in the form
of the stored fat. Exercise does not break down a muscle, it builds it
up. Thus many individuals who increase the strenuousness of their
exercise complain that their weight is increased even when they
observe a noticeable improvement in their general feelings and
appearance.

~The Appetite.~--The great trouble with most women who undertake an
obesity cure which calls for an increased amount of energy is that
they will develop an increased appetite thereby which they appease
with food instead of forcing the body to use the store in hand, thus
entirely doing away with any good the treatment might have
accomplished. No amount of exercise without a proper regulation of the
diet will prove satisfactory as far as the reduction of fat is
concerned. The following methods recommended by Banting, Oertel, and
Ebstein are included here.


OBESITY DIETS AND CURES

~Banting Method.~--This method is said to be unsuited to those with
weak digestions. Following its use such individuals have been known
to develop renal colic or gallstones; constipation may be present and
the entire system may become so deranged as to render the patient
liable to disease.[158]

~Banting Diet for Obesity.~--Breakfast at 9 A.M., consisting of 5-6
ounces of animal food, meat or boiled fish (except pork or veal), 1
small biscuit or 1 ounce dry toast. Total solids, 5-6 ounces. Coffee
or tea (without milk or sugar), 9 ounces.

2 P.M.--Dinner: Fish or meat (salmon, eels, herring, pork, and veal
excepted), poultry or game; any vegetable except potatoes, parsnips,
carrots, turnips, or beet roots; dry toast, 1 ounce; fruit cooked and
unsweetened; good claret, sherry, or Madeira, 10 ounces. Total solids,
10-12 ounces.

6 P.M.--Tea: 2-3 ounces cooked fruit; 1-2 ounces rusks; 2-4 ounces
solids; 9 ounces tea, without milk or sugar.

7 P.M.--Supper: Meat or fish as at dinner; claret or sherry and water,
7 ounces.

Total daily solids, 21-27 ounces.

Total fluids, 35 ounces.

       *       *       *       *       *

Oertel pointed out the great benefits which might be derived by those
individuals suffering from certain types of heart disease which are
accompanied by obesity. He made it distinctly understood that while
the treatment in no way affected the heart lesion,--that is, in so far
as altering the character of the disease,--it greatly reduced the work
imposed upon the circulatory organ and permitted a more complete
oxidation of the blood.[159]

~Oertel's Method.~--Oertel bases his dietetic treatment of obesity
upon the heart changes and those which naturally follow in the
circulation. He makes the following suggestions, taking always into
consideration the condition of the patient, whether he is anemic or
plethoric.

"(a) Where there is an abnormally increased amount of fat in
plethoric patients with unimpaired or only beginning changes in the
heart action, the diet should aim at:

(1) An increased supply of protein.

(2) A decrease in the fat-forming substances.

(3) Little or no diminution in the supply of liquids below the
    physiologic amount (1500 c.c.--3 pt.)

(b) Where there is obesity in anemic patients, viz. serious plethora,
the diet should aim at:

(1) An increase in the quantity of proteins.

(2) A diminution in amount of fat-forming substances and eventually

(3) a decrease in the amount of fluid.

(c) Where there is obesity in adults with anemic symptoms in whom not
only the amount of protein but also the abnormally increased amount of
fat is slowly wasting away, they require:

(1) An increase in the amount of protein taken.

(2) A sufficient amount of fat and carbohydrates or even an increase
    of same to prevent the falling off of fat.

(3) A diminution in the amount of fluid taken."

Oertel claims that the simplest method of reducing the fat-forming
elements in a diet is to decrease the amount of fat and allow a
certain amount of carbohydrates, regulating the diet according to the
individual. The following table is given by him as showing the minimum
and maximum amount of the different food constituents constituting the
obesity diet:

  ==========++=========+========+==============+===========
            ||_Protein_| _Fat_  |_Carbohydrate_|_Calories_
            ||  _Gm._  | _Gm._  |    _Gm._     |
  ----------++---------+--------+--------------+-----------
  Minimum   ||  156    |   25   |     75       |  1180
  Maximum   ||  170    |   45   |    120       |  1608
  ==========++=========+========+==============+===========

In instituting a treatment for obesity Oertel insists upon a certain
amount of exercise daily in the open air, the amount to be regulated
by the physician according to the individual case. He suggests that
five or six small meals a day be given rather than a few large meals.
He eliminates soups, tea, and coffee while the cure is being given.

~Ebstein~ suggests a diet in which the carbohydrates and fluids are
reduced but in which the fats are allowed to a considerable extent.
The diet consists of meat, eggs, fish, vegetables (green) and fruits.
The following menu demonstrates his dietary régime:

Breakfast: Large cup of tea (no milk or sugar); 2 oz. bread with
plenty of butter.

Dinner: Soup 4-1/2 to 5-1/2 oz.; meat with fat sauce; green
vegetables; fresh fruit; 2-3 glasses light wine.

Afternoon: Tea as at breakfast.

Supper: Tea, 1 egg, fat roast meat or ham, smoked fish; about 1 oz.
bread with plenty of butter; a little cheese and fresh fruit;
potatoes, sweets and sugars forbidden.

~Dietetic Treatment.~--The following menus are suggested by the
author: The carbohydrates and fats are restricted and the fluids
reduced to a minimum. The meals as far as possible are kept "dry";
soups, milk, cocoa are avoided; water is not permitted at meals;
alcoholic beverages, white bread, butter, potatoes, sugar, candy,
pastry, cakes, puddings, gravies, sauces, bread dressings, griddle
cakes, sirups, molasses, honey, ice cream, cereals, pork of all sorts,
ham, bacon pork chops, etc., olive oil, spaghetti, macaroni, and
noodles are prohibited.

~Allowable Foods.~--The following foods are allowed: Black coffee or
tea, small cup twice daily without milk, cream, or sugar--saccharin
may be used to sweeten if desired; fresh or stewed fruit with the
exception of bananas, raisins, and dates, served without sugar; all
green vegetables cooked or served without butter or fat of any
description; salads, except potato or banana, served with a special
dressing (no oil or sugar); water ices; watermelon and other melons
served without sugar; 1 egg a day; gluten toast, no butter; brown
bread or muffins made with gluten flour and prepared bran.

~The following menus~ may be used as guides in the treatment of
obesity:

  Breakfast--1 sliced orange (no sugar)
             1 small cup coffee or tea without cream, milk, or sugar
               (sweeten with saccharin if desired)
             1 poached egg on
             1 slice of gluten toast (no butter)

      Lunch--Cottage cheese and lettuce salad with special dressing
             2 broiled lamb chops
             1 slice gluten bread; 3 ounces (1 serving) apple sauce
               (sweetened if necessary with saccharin)

     Dinner--Roast beef
             Spinach or greens (cooked without fat meat)
             Green peas
             Tomato and lettuce salad with special dressing
             Orange or wine jelly (sweetened with saccharin)
             1 slice of gluten bread or toast

  7 A.M. or 1 hour before breakfast--1 cup of water containing
               juice of 1/2 lemon

  Breakfast--1/2 grapefruit without sugar
             1 small cup black coffee or tea
             Beefsteak broiled and served without butter (lean)
             1 slice of gluten toast

      Lunch--Tuna fish salad (no olive oil in dressing)
             1 bran muffin or 1 slice (1 oz.) gluten toast
             1 baked apple (without cream or sugar)

     Dinner--Roast or boiled chicken (no gravy or bread dressing)
             Green vegetables (peas, string beans, cabbage,[160]
               turnips, artichokes (without butter))
             Fruit salad (special dressing)
             Lemon ice

~Amount of Food.~--The amount of food is limited to a certain extent.
Green vegetables may be eaten in abundance, but the protein foods such
as meat, fish and eggs must be limited.[161] The bread (even gluten
and bran breads) must be limited to 1-2 slices at each meal. All meals
are eaten without fluids except breakfast, when one small cup of
coffee or tea without milk, cream, or sugar is allowed. If fruit juice
is to be served instead of fruit, it must be prepared with little if
any water and no sugar. The juice may be poured over cracked ice, if
desired.

The following reducing diet is suggested by Dr. Rose for the use of
over-fat women:

REDUCING DIET FOR OBESE WOMEN[7]

_Fuel value 1052 calories--ordinary requirements 2200 calories_

  ========================+===============+========+==========+==========
                          |  _Measure_    |_Weight_|_Protein_ | _Total_
                          |               | _Oz._  |_Calories_|_Calories_
  ------------------------+---------------+--------+----------+----------
  Breakfast:              |               |        |          |
    Apple                 | 1 medium      |   4.9  |     2    |   65
    Egg                   | 1 egg         |   2.4  |    27    |   75
    Toast                 | 1 slice       |   0.5  |     7    |   50
    Coffee[162]           | 1 cup         |        |          |
    Skim milk             | 1-1/2 tbs.    |   1.0  |     3    |   10
                          |               |        |          |
  10:30 A.M.              |               |        |          |
    Bouillon              | 1/2 cup       |   4.0  |    10    |   12
    Water cracker         | 1 cracker     |   0.1  |     1    |   10
                          |               |        |          |
  Luncheon:               |               |        |          |
    Lean cold roast beef  | Medium serving|   3.5  |    97    |  150
    Rye bread             | 2 thin slices |   0.7  |     7    |   50
    Lettuce and cottage   |               |        |          |
      cheese salad:       |               |        |          |
        Lettuce           | Ad libitum    |        |    40    |   85
        Cheese            | 2-1/2 tbs.    |        |          |
                          |               |        |          |
  4:30 P.M.               |               |        |          |
    Tea with lemon[163]   | 1 cup         |        |          |
    Water cracker         | 1 cracker     |   0.1  |     1    |   10
                          |               |        |          |
  Dinner:                 |               |        |          |
    Boiled cod with lemon | Large serving |   8.2  |   209    |  225
    Boiled potato         | 1/2 medium    |   1.8  |     6    |   50
    Cauliflower (plain)   | Large serving |   3.0  |     6    |   25
    Butter                | 1 tsp. (scant)|   0.1  |          |   30
    Water-cress and egg   |               |        |          |
      salad:              |               |        |          |
        Water-cress       | Ad libitum    |        |          |
        Egg               | 1 egg         |        |    27    |  110
    French dressing       | 1/2 tbs.      |        |          |
    Orange                | 1/2 large     |   4.7  |     3    |   50
    Black coffee          | Demi-tasse    |        |          |
                          |               |        |          |
  10:30 P.M.              |               |        |          |
    Hot skim milk         | 1/2 cup       |   4.3  |    16    |   45
                          |               |        |          | ______
      Total calories      |               |        |          | 1052
  ========================+===============+========+==========+==========

AUTHOR'S REDUCING DIET

_Approximate fuel value 965.5 calories_

  =====================+==============+=========+=========+======+==========
                       |              |         | _Carbo-_|      |
     _Material_        |   _Amount_   |_Protein_|_hydrate_| _Fat_|_Calories_
                       |              |  _Gm._  |  _Gm._  | _Gm._|
  ---------------------+--------------+---------+---------+------+----------
  Breakfast:           |              |         |         |      |
    Orange             | 1 medium     |   1.5   |  17.4   |  0.3 |   78.3
    Poached egg        | 1 egg        |   5.3   |         |  4.6 |   62.6
      on               |              |         |         |      |
    Toast (gluten)     | 1 slice (1   |         |         |      |
                       |    oz.)      |   8.4   |   8.5   |  0.3 |   70.3
    Coffee (black)     | 1 cup        |         |         |      |__________
                       |              |         |         |      |  211.2
                       |              |         |         |      |
  Luncheon:            |              |         |         |      |
    Lettuce and cottage|              |         |         |      |
      cheese salad:    |              |         |         |      |
        Lettuce        | Ad libitum   |         |         |      |
        Cheese         | 2 tbs.       |   5.9   |   1.2   |  0.2 |   30.2
        Dressing       | 1 tbs.       |   1.5   |         |  3.4 |   36.6
    Lamb chop          | 1 chop       |   9.2   |         | 12.7 |  151.3
    Gluten bread or    |              |         |         |      |
      toast            | 1 slice      |   8.9   |   8.5   |  0.3 |   70.3
    Apple sauce        | 1 serving,   |         |         |      |
                       |   about 1/8  |         |         |      |
                       |   cup        |   0.6   |  22.5   |  0.7 |   97.5
                       |              |         |         |      |__________
                       |              |         |         |      |  385.9
                       |              |         |         |      |
  Dinner:              |              |         |         |      |
    Roast beef         | 2 thin slices|         |         |      |
                       |  (2 oz.)     |  11.4   |         |  4.8 |   88.8
    Spinach            | 1/2 cup      |   2.3   |   3.6   |  0.3 |   26.3
    Green peas         | 1/2 cup      |   4.8   |  11.1   |  0.2 |   65.4
    Lettuce            | Ad libitum   |         |         |      |
    Tomato             | 1 medium     |   0.4   |   3.1   |  0.2 |   15.8
    Dressing           | 1 tbs.       |   1.5   |         |  3.4 |   36.6
    Orange jelly:      |              |         |         |      |
      Orange juice     | 1/2 cup (8   |         |         |      |
                       |   tbs.)      |         |  14.2   |      |   56.8
      Lemon juice      | 1 tbs.       |         |         |      |
      Gelatin          | 1 tsp.       |   2.1   |         |      |    8.4
      Water            | 1 tbs.       |         |         |      |
      Saccharin        | 1 tablet or  |         |         |      |
                       |   less       |         |         |      |
    Bread (gluten)     | 1 slice      |   8.4   |   8.5   |  0.3 |   70.3
                       |              |         |         |      |__________
  Total grams          |              |  72.2   |  98.6   | 31.7 |  368.4
                       |              |         |         |      |==========
  Total calories       |              |         |         |      |  965.5
  =====================+==============+=========+=========+======+==========

_Approximate fuel value 930.5 calories_

  =====================+==============+=========+=========+======+==========
                       |              |         |_Carbo-_ |      |
        _Material_     |   _Amount_   |_Protein_|_hydrate_|_Fat_ |_Calories_
                       |              |  _Gm._  |  _Gm._  |_Gm._ |
  ---------------------+--------------+---------+---------+------+----------
  Breakfast:           |              |         |         |      |
    Fruit              | 1 orange     |   0.85  |  12.05  | 0.15 |   53.0
    Gluten toast       | 2 slices     |  17.8   |  17.0   | 0.6  |  140.0
    Egg (poached or    |              |         |         |      |
      soft-cooked)     | 1 egg        |   5.3   |         | 4.6  |   60.0
    Coffee (black)     | 1 cup        |         |         |      |__________
                       |              |         |         |      |  253.0
                       |              |         |         |      |
  Luncheon:            |              |         |         |      |
    Oyster cocktail    | 6 oysters    |   3.5   |   4.20  | 0.68 |   37.0
    Cold roast beef    | 1 slice (1   |         |         |      |
                       |   oz.)       |   5.7   |         | 2.4  |   44.0
    Cold slaw:         | 1/2 cup      |         |         |      |
      Cabbage          | 1/2 cup      |   0.002 |   0.001 | 0.034|    4.5
      Dressing         | 1 tbs.       |   1.5   |         | 3.4  |   36.0
    Gluten toast       | 2 slices     |  17.8   |  17.0   | 0.6  |  140.0
                       |              |         |         |      |__________
                       |              |         |         |      |  261.5
  Dinner:              |              |         |         |      |
    Chicken (without   | 3 oz. one    |         |         |      |
      stuffing)        |   serving    |  18.2   |         | 2.1  |   92.0
    Broiled mushrooms  | 6 medium     |         |         |      |
                       |   size       |   1.5   |   3.0   | 0.18 |   19.0
    String beans       | 3 oz. one    |         |         |      |
                       |   serving    |   1.95  |   6.29  | 2.29 |   34.4
    Pineapple salad:   |              |         |         |      |
      Lettuce          | Ad libitum   |         |         |      |
      Pineapple        | 1 slice      |   4.0   |  31.0   | 0.6  |  129.5
      Dressing         | 1 tbs.       |   1.5   |         | 2.4  |   37.0
    Apple float:       |              |         |         |      |
      1 apple          | 1 apple      |   0.6   |  22.2   | 0.77 |   98.1
      1/2 egg white    | 1/2 egg white|   1.5   |   0.02  |      |    6.0
      Saccharin to     |              |         |         |      |
        sweeten        |              |         |         |      |
                       |              |         |         |      |__________
  Total grams          |              |         |         |      |  416.0
                       |              |         |         |      |==========
  Total calories       |              |         |         |      |  930.5
  =====================+==============+=========+=========+======+==========

~Rules and Regulations.~--The following directions and menus are given
to be used when a reduction in weight is necessary. Care must be
taken not to allow large amounts of even the non-fat-forming foods in
the dietary, since under certain conditions the body will manufacture
adipose tissue of any surplus organic material ingested. Breakfast
must be limited as demonstrated in the tabulated diet sheet.

~Keeping the Weight Down.~--After the individual has been reduced to
approximately the desired weight the diet may be made a trifle more
liberal, keeping in mind, however, that moderation is the keynote in
the obesity régime and will have to be practised to a certain extent
always. It is wise to continue the dry meals and to limit the amount
of butter, cream, and other "fatty foods," to a certain extent. Pork,
with the exception of crisp bacon several times a week at breakfast,
had best be avoided, and alcoholic beverages should be omitted
entirely except when prescribed by the physician. The outdoor exercise
should be continued and only the amount of sleep requisite to health
indulged in. If the individual will faithfully carry out these
directions, there is no reason why the weight should continue to be a
burden. It must be remembered that it is never safe to diet
indiscriminately and without the advice of a physician, since much
harm may come of so doing.

~Value of Massage.~--Massage is an advisable accompaniment to an
obesity diet and will help to prevent a sagging of the tissues which
have been deprived of the supporting fat. The tissues of the face,
neck, and breast are especially apt to wrinkle unless given the
exercise and stimulation from massage. ~Cold baths~ are likewise
advisable, since they stimulate the body to burn up the fat.


OBESITY MENUS

   Lunch--Tuna fish salad
          Cauliflower
          Baked apple

  Dinner--Soft-shell crabs
          Roast lamb
          Spinach
          Tomato jelly
          Grapefruit

   Lunch--Corned beef and cabbage
          Stewed pears

  Dinner--Clam cocktail
          Roast chicken
          Asparagus
          Fruit salad

   Lunch--Broiled oysters; cold lamb
          Boiled turnips
          Water-cress salad

  Dinner--Roast beef
          Stewed tomatoes
          String beans
          Lettuce and tomato salad
          Sliced peaches

   Lunch--Broiled calves' liver
          Greens (mustard, turnip, beet tops, or dandelion)
          Orange jelly

  Dinner--Crab-flake cocktail
          Broiled squab
          Artichokes
          Stewed celery
          Lettuce, Russian dressing

   Lunch--Kippered herring
          Veal croquettes (baked instead of fried, with tomato sauce;
            this dressing is made by adding 1 teaspoonful of chili
            sauce to the regular dressing used in obesity diets)
          Asparagus
          Apple sauce

  Dinner--Baked halibut steak, stuffed with oysters
          Boiled onions
          Boiled carrots
          Pineapple and grapefruit salad

   Lunch--Broiled calves' brains
          Vegetable salad
          Melon

  Dinner--Broiled chicken
          Boiled beets
          String beans
          Cucumber and young onion salad
          Raspberry ice

   Lunch--Stuffed eggs
          Sliced tongue with spinach or greens
          Carrots or beets
          Fruit

  Dinner--Roast turkey, cranberry sauce
          Cauliflower
          Tomatoes stuffed with celery, green peppers and onion
            dressing
          Peach whip

   Lunch--Hashed beef
          Boiled onions
          Stewed prunes

  Dinner--Oysters
          Baked rabbit
          Eggplant (baked)
          Spinach
          Fruit jelly


EMACIATION

Emaciation as a rule is a symptom of an abnormal condition rather than
a disease in itself. Certain individuals are said to be
"constitutionally thin" and upon investigation it is often found that
this thinness extends back in many cases for generations, many members
of a family being thin no matter what measures are taken to overcome
the condition. However, constitutional emaciation is not so prevalent
as constitutional obesity and, as has already been stated, is more
often a symptom of some metabolic disturbance or pathological
condition.

~Causes of Emaciation.~--~Errors in diet~--insufficient or improper
food--are accountable for most of the cases seen in infants and
children. ~Over-exercise~, that is, when the amount of exercise taken
is not commensurate with the intake of food, is accountable for other
cases. This type of emaciation is found especially in growing
children.

~Disease as a Cause.~--Wasting diseases, such as tuberculosis and
anemia, bring about a loss of weight, while in fevers in general and
typhoid fever especially not only the febrile condition hastens the
metabolic processes but also the activities of the bacteria act
together and break down the tissues of the body, causing a falling off
from the normal body weight. Loss of sleep, unhygienic or unsanitary
surroundings, and capricious appetites probably cause some of the
cases of excessive thinness.

~Thinness in Children.~--Parents are to blame for much of the thinness
seen in children, especially the nervous high-strung children whose
energies outweigh their desire for food or, as is more often the case,
their willingness to eat the proper foods. It is a mistaken kindness
to cater to the whims and fancies of a child's appetite, and much harm
is wrought by allowing the "trash" to overbalance the necessary
building or repair food in the dietary. Not that sugar is not
necessary, for it is particularly so at the age when the metabolic
processes are faster than later in life, but it must be remembered
that the body is being built up both in height and breadth.

~The Need for Building Foods.~--The skeleton and the muscular tissues
cannot be constructed from sugar, hence the diet which consists
chiefly of this food constituent is unbalanced and will sooner or
later bring about disturbances which are very apt to result in
emaciation. ~The causes of emaciation~ may be summarized as follows:

(1) Those cases which are due to pathological conditions such as
tuberculosis, anemia, typhoid fever, etc.;

(2) Those induced by errors in diet and bad habits such as
insufficient or improper food, loss of sleep, over-exercise, lack of
ventilation in the sleeping apartment, which destroys the appetite;

(3) Malformation or deformities of mouth, throat, or stomach which
make it impossible for the individual to partake of sufficient food to
cover the needs of the body;

(4) Heredity ("constitutional thinness").

~Regulating the Diet.~--As has been stated in a former chapter, any
persistent loss of weight or failure to gain on the part of an infant
whose chief business in life should be to grow, should be given
immediate and careful attention. As a rule the diet is to blame; it is
either improperly balanced, insufficient in amount, or poorly
prepared, any of which might readily cause a disturbance to the
delicate apparatus of the child.

~Diet and Habits.~--In adults, the diet and habits of life are in many
cases to blame for the excessive thinness seen in many individuals. If
the trouble can be traced to some abnormal condition, it can only be
removed by relieving or checking the disease which induced it. The
older methods of treating typhoid fever, for example, did nothing to
prevent the progressive emaciation which was the result not only of
the accelerated metabolism from the fever but also from the invasion
of the intestinal tract by the specific bacteria which brought about a
like result. In tuberculosis a similar breaking down of the tissues
occurs, as is likewise the case in anemia and other diseases in which
the functions of the blood-making organs are interfered with. Any of
the above diseases may cause emaciation, and the treatment in most of
the cases resolves itself in removing the cause as far as possible and
in adjusting the diet.

~Selection of Food.~--The dietetic treatment for emaciation is
practically the only one which will materially change the weight of
the individual, since by food alone is the body built. Certain foods
are more capable of being readily converted into adipose tissue than
others, and these must have a prominent place in the dietary.

~Rules and Regulations.~--In obesity it was found that it was
necessary to curtail the sleep and rest, increase the amount of
exercise and decrease the amount of food. In emaciation practically an
opposite régime is adopted. The patient is urged to eat plenteously,
drink copiously of water and nutrient beverages, soup, etc., avoid
worry and excitement, over-exertion and indigestion, to take one or
two naps every day, to retire early, to avoid hot baths and take a
warm cleansing bath followed by a cold shower or sponge bath. Exercise
must be of a mild character; the patient must be warned against
becoming exhausted, since this condition precludes a gain in weight.

~Dietetic Treatment.~--The meals must be carefully selected, well
prepared and daintily served, that all of the psychical benefits from
such efforts may be attained. A nutrient beverage such as cream, egg,
and vichy, reënforced fruit beverages, malted milk, with egg and
chocolate, cereal and milk gruels, etc., may be given between
breakfast and lunch, lunch and dinner and before retiring. The meals
must consist of the simplest foods that the digestion may not be
overtaxed by the quantity ingested.

~Allowable Foods.~--The following foods may be used in the treatment
of emaciation: All dairy products, milk, cream, butter and cheese,
eggs cooked in various ways, soups of all kinds, meats in moderation,
vegetables, especially potatoes, olive oil, and the various salad
oils, cereals, tapioca, macaroni, spaghetti, noodles, rice, bread of
every description, fruit including bananas, grapes, dates, raisins,
prunes, etc., ice creams, farinaceous puddings, sauces, except those
containing vinegar, grape juice and other fruit juices sweetened with
sugar, cocoa and chocolate, malted milk and proprietary infant foods,
honey, molasses and sirups, cakes, cookies and pastry in moderation.
It is advisable to make milk the chief fluid food; to this is added
cream, malted milk, lactose, eggs, and other reënforcing agents.

~Milk Cure.~--Certain physicians advise milk alone, giving from one to
two gallons a day for three weeks or longer. Many individuals complain
that "milk makes them bilious" but, as a rule, this is because the
amount taken is small and the solids insufficient to lend the
necessary bulk to the feces, consequently the peristaltic action
becomes sluggish and the passage of the food mass delayed in the
intestinal tract, furnishing a medium for bacterial growth and
activity. When larger quantities are ingested such is not the case and
the fluid so high in nutrient qualities is utilized by the body for
the building up of the depleted tissues. When the emaciation is the
result of disease the diet is necessarily adjusted to meet the
condition. At times it is most difficult to overcome the anemia and
accompanying emaciation on account of the disease precluding the
giving of the foods especially designed by nature to produce flesh.
This is especially the case in the progressive emaciation in diabetes.
However, in this case the Allen starvation treatment, with the
reëducation of the organs to a toleration for carbohydrates, has gone
far toward overcoming this distressing condition.

~Readjusting the Habits.~--When the loss of weight is found to be the
result of close application to work, lack of fresh air and sleep, or
from errors in diet, a change of climate and occupation should be
made, together with a readjustment of the daily habits, such as
substituting a cool bath for the regular hot one, and sleeping out of
doors or on a sleeping porch instead of in a poorly ventilated
bedroom.

The patient must be urged to eat, regardless of appetite, for in this
way only can the body weight be increased. The dietary must be made up
largely of the fat-forming foods, but not to such an extent as to
upset the nitrogen equilibrium.

The following diet sheet is given to be used as a guide in the
treatment of emaciation. Other foods of a similar composition and fuel
value may be substituted for those given here, to vary the diet.


EMACIATION DIET SHEET

_Approximately 5106 calories_

KEY
  A _Protein Gm._
  B _Carbohydrate Gm._
  C _Fat Gm._
  D _Total Calories_

  ==================+================+=======+=======+=======+========
     _Material_     |    _Amount_    |   A   |   B   |   C   |   D
  ------------------+----------------+-------+-------+-------+--------
  Breakfast:        |                |       |       |       |
   Stewed prunes    |6 prunes        |  1.02 | 35.26 |       | 145.
   Sugar            |1 tbs.          |       | 14.7  |       |  56.6
   Oatmeal          |1 tbs. (dry)   }|       |       |       |
    with cream and  |2 tbs. cream   }|  3.2  | 25.0  |  6.6  | 172.2
    sugar           |1 tbs. sugar   }|       |       |       |
   Poached egg      |1 egg           |  5.35 |       |  4.16 |  58.8
   Toast            |3 slices       }|       |       |       |
   Butter           |1 tbs.         }|  7.9  | 44.7  | 13.0  | 328.
   Coffee           |1 cup           |       |       |       |
    with cream and  |1 tbs. cream    |   .40 |   .40 |  2.8  |  53.9
    sugar           |2 tsp.          |       |  9.45 |       |
   Milk and cream   |2/3 cup milk   }|       |       |       |
                    |1/3 cup cream  }|       |       |       | 389.
                    |                |       |       |       |
  11 A.M.           |                |       |       |       |
  Cereal milk gruel | 8 oz. (1 cup) }|       |       |       |
    with cream      | 1 ounce       }|       |       |       | 248.
                    |                |       |       |       |
  Lunch, 1 P.M.     |                |       |       |       |
  Cream of pea soup | 8 oz. (1 cup)  |  6.   | 17.65 |  7.66 | 185.9
  Potato salad      | 3.5 oz. (1     |       |       |       |
                    |   serving)     |  1.75 | 15.5  | 15.33 | 210.
  Bread             | 3 slices       |  7.8  | 44.7  |  1.04}|
  Butter            | 1 tbs.         |   .8  |  1.4  |  5.6 }| 328.
  Cocoa made with   |               }|       |       |       |
    milk            | 1 cup         }|       |       |       |
  Sugar             | 2 tsp.        }| 27.   | 27.6  | 41.4  | 661.
  Milk              | 2/3 cup       }|       |       |       |
  Cream             | 1/3 cup       }|       |       |       | 329.
                    |                |       |       |       |
  3:30 P.M.         |                |       |       |       |
  Cream, egg, vichy | 8 oz.          |  4.9  | 12.4  | 36.   | 393.
                    |                |       |       |       |
  Dinner:           |                |       |       |       |
  Tomato bouillon   | 1 cup          |       |       |       |  38.
    with whipped    |                |       |       |       |
    cream           | 1 tbs.         |   .30 |   .42 |  5.67 |  53.9
  Beefsteak         | 1 serving (3   |       |       |       |
                    |   oz.)         | 18.6  |       | 17.34 | 230.5
  Mashed potatoes   | 1/3 cup        |  1.16 |  7.5  |  3.5  |  66.5
  Cauliflower       | 1 serving      |  1.53 |  2.99 |   .42 |  21.8
  Asparagus salad   | 6 stalks       |  2.00 |  3.72 |   .24}|
    with            | 2 tsp.         |   .01 |  1.45 |  9.00}| 111.8
    mayonnaise      |                |       |       |       |
  Bread             | 2 slices       |  5.2  | 29.8  |   .68}|
  Butter            | 2 tbs.         |   .28 |       | 24.09}| 419.
  Charlotte russe   | 1 serving      |  2.3  | 11.1  | 22.6  | 257.
  Milk              | 2/3 cup       }|       |       |       |
    and cream       | 1/3 cup       }|       |       |       | 389.
  Black coffee if   |                |       |       |       |
    desired         | 1/2 cup        |       |       |       |
                    |                |       |       |       |
  At bed time:      |                |       |       |       |
  Malted milk       | 1 cup         }|       |       |       |
    made with milk  |               }|       |       |       |
    and reënforced  |               }|  8.4  | 41.   | 10.2  | 288.5
    with lactose    | 1 ounce       }|       |       |       |
  ==================+================+=======+=======+=======+========

~Methods of Increasing the Diet.~--The above diet furnishes three
times as much food as is needed to maintain the body living a
sedentary life, or about as much as would be needed to maintain a
lumberman at hard outdoor labor in the Maine woods. It would be
impossible for an ordinary individual to handle such an abundant diet
without making the increase in the diet gradually. This is best done
by adding the milk and cream at the end of each meal and a glass of
milk between meals and at bedtime, then gradually adding the fattening
foods already mentioned until the diet approximates the diet sheet
here computed.


SUMMARY

GOUT

Gout is a constitutional disease characterized by an inflammatory
condition of the joints.

~The Joints~ are the seat of chalky deposits of uric acid or sodium
salts.

~Metabolism~ in gout is disturbed, with a consequent retention instead
of elimination of uric acid by the body.

~The Blood~ contains an excess of uric acid which increases greatly
during an acute attack.

~The Urine~ in true gout does not contain an excess of uric acid
except during an acute attack, whereas in the so-called goutiness
there is a constant excess of this acid.

~Uric Acid~ is produced as the result of the metabolism in the human
body of the nucleoproteins and in food of the purin bodies.

~Alcohol~ undoubtedly assists in the retention and increases the
difficulty of uric acid elimination by the body.

~Chief Causes of Gout.~--Overeating, excessive alcoholism, and too
little exercise, especially in the open air.

~Treatment~ consists in regulating the diet both as to the quantity
and type of food eaten; reducing or eliminating the alcohol in the
dietary, and increasing the amount of outdoor exercise.

~Dietetic Treatment.~--The best results are obtained by reducing the
size of the meals and avoiding the purin-bearing foods as far as
possible. Eggs are purin-free and may be substituted for much of the
meat in the diet. In chronic gout it is impossible to eliminate meat
entirely from the diet, but the quantity can be materially reduced and
that which is eaten may be rendered less harmful if it is boiled
instead of roasted or broiled, as in this way much of the purin is
dissolved out. Highly spiced and seasoned foods, rich gravies, etc.,
are apt to cause an acute attack and should be omitted. Excesses of
all kinds must be avoided to enable the patient to live a fairly
comfortable life, free from frequent painful attacks of gout.


OBESITY

~Causes.~--Heredity, overeating, unbalanced diet, chronic alcoholism,
and disturbed metabolism, as manifested in gout and other pathological
conditions.

~Cures~ are more or less of a risk, except when undertaken upon the
advice and under the care of a competent physician. As a rule they are
too strenuous to be carried out alone and are of no good unless
persisted in. Among the best known obesity cures may be mentioned
those formulated by Banting, Oertel and Ebstein.

Most physicians have their own methods of treating obesity, but all
are based primarily on diet and exercise.

~Food~ is the chief cause of obesity and since some foods are more
readily converted into adipose tissue than others, it is necessary to
understand the behavior and functions of the various food combinations
in the body before it is possible to say which are the offending
articles of diet.

~Water~ has no fattening properties of its own. This is proved by a
glance at its chemical composition, but as it acts as a distributor
and carrier of food to the various parts of the body and since the
bulk of all the secretions is composed of water and every tissue in
the body stores this fluid, thus adding to the weight, a consideration
of the intake of water for obesity patients is most essential.

~Appetite~ requires attention. The majority of obese patients eat more
than their energy output calls for, consequently it is necessary to
curb the appetite and increase the energy output in order to utilize
the material on hand in the form of adipose tissue.

~Exercise~ is absolutely essential in order to force the body to burn
up its surplus fat as fuel. The best form of exercise is that which is
taken out of doors. The well-worked muscle is heavier than one which
is unaccustomed to exercise. The latter is infiltrated with fat and
weighs less than muscular tissue, but a muscular body can endure more
than one which is covered with adipose tissue.

~The Heart~ of obese patients becomes more or less affected as obesity
advances and it becomes absolutely necessary in many cases to get rid
of some of the surplus fat in order that the patient may live. This is
best accomplished by dietetic treatment.

~Circulatory Changes~ likewise occur as the heart becomes affected,
making it necessary to institute some dietary measures at once.

~Glycosuria~ in obese patients suffering from gout is not at all
unusual and to relieve this condition the carbohydrates in the diet
must be at once reduced.

~Dietetic Treatment~ is most important. It constitutes the only
rational method of ridding the body of its surplus fat. To do this it
is necessary to regulate the diet both as to quantity and type.
Fat-forming foods are those which the body utilizes most easily for
the production and storage of fat. Any food, no matter whether it is
fat-forming or not, if taken greatly in excess of the needs of the
body, will be stored as adipose tissue.

~Chief Points~ to be remembered in formulating a diet and instituting
an obesity treatment are the necessity for _small meals_ and _dry
meals_, no fluid given at all during the meal except perhaps one or
two small cups of coffee per day, without sugar or cream, the
avoidance of fat-forming foods, sugars and starches in all forms,
milk, cream, butter and oil, potatoes, bananas, fat meats of all
descriptions, especially pork, soups of every description and
alcoholic or malted beverages. It is necessary to limit the amount of
sleep, prohibiting naps during the day, and to increase the amount of
outdoor exercise.

~Massage~ is advisable, especially in those patients who are unable,
on account of their excessive weight or heart symptoms, to take the
requisite amount of exercise necessary for their future welfare.
Massage likewise makes the muscles firmer, often preventing the
disfiguring sagging of the skin caused by depriving it of its padding
of fat.


EMACIATION

~Causes.~--Errors in diet, overwork, over-exercise, heredity,
nervousness, worry, malformation of the mouth, throat, or stomach,
heredity and certain pathological conditions, such as typhoid fever,
tuberculosis, anemia, dysentery, etc., in which the breaking down of
the tissues occurs more rapidly than they can be rebuilt.

~Children~ are often emaciated on account of their unbalanced diet.
They receive an insufficient amount of building food to cover their
growth and development requirements. Parents are often to blame for
allowing the child to overeat of some of the food constituents at the
expense of others. Sugar, for example, is very necessary in the diet
of a growing active child, but all sugar and very little milk and
eggs will lead to an unbalanced diet which may bring about a
condition of extreme thinness later on.

In ~Adults~ the constant eating of the wrong foods, overworking and
persistent worrying, all contribute to the breaking down of the
tissues which ends in emaciation.

~Weight~ is an index to health. Any persistent loss of weight on the
part of an adult or loss or even failure to gain in a growing child,
are indications that all is not right and immediate measures must be
taken to locate and relieve the trouble.

~Loss of Weight~ due to pathological conditions can only be relieved
by removing the cause, after which the diet may be adjusted to suit
the condition.

~Dietetic Treatment~ is practically the only means of combating and
overcoming emaciation, since it is by food alone that the body is
built.

Fat-forming foods, which in obesity were prohibited, have a prominent
place in the diet for emaciation. Padding the nerves and organs with a
layer or covering of fat protects them from the jars and shocks
incidental to daily life, besides lending grace and contour to the
body.

~Foods Which Produce Fat~ are nutrient beverages of all sorts; milk,
malted milk and cream are especially valuable; water, because of its
particular properties and functions in the body; and fruit beverages,
which are made chiefly of water and sugar, are always included in the
dietary. Milk and cream, soups and milk gruels, as well as all dishes
made with milk or cream, add materially to the fat-forming quality of
the diet. Butter, olive and other salad oils, as well as cereals,
potatoes, bread and simple desserts are advised. The diet must be
bountiful, the meals frequent, and lunches consisting of milk or cream
with crackers will hasten the gain in weight.

~Rest~, preferably lying down, is absolutely essential. A period of
relaxation covering from fifteen to thirty minutes should be taken
before or after each meal. The body derives the use of the food for
the storage of fat which would otherwise be required to cover its
energy expenditures.

~Sleep~ is essential to gain, consequently the patient should retire
early and take one or two naps during the day.

~Baths~ should be warm, not hot, followed by a cold shower or sponge.

~Exercise~ must be mild in character; over-exertion precludes a gain
in weight and exhaustion undermines the forces which make it possible
for the body to store fat as adipose tissue.

~Nervous Excitement and Worry~ must be avoided.

~Gastro-intestinal Disturbances~ should be guarded against, since all
the pounds gained through months of treatment may be quickly lost
during one acute attack of diarrhea or auto-intoxication.

~Massage~ is advised. The kneading and gentle manipulation of the
muscles stimulates them to utilize more food material, besides
enabling the patient to eat more by reason of an increased appetite.

~The Milk Cure~ has been used extensively in overcoming extreme
emaciation. It consists in the taking of large quantities, ranging
from one to two gallons per day. It is given every hour or oftener for
a period of one month to six weeks.

~Reënforcing the Diet~ with eggs and lactose is often found of great
value in increasing the weight quickly, as is the giving of one-third
of a glass of cream and two-thirds of a glass of milk after each meal
and at bedtime. The whole scheme of putting on pounds resolves itself
into the giving of proper food in larger quantities than are
ordinarily given, but dividing it up into frequent meals in order not
to upset the digestion and do away with the good already accomplished.


PROBLEMS

(a) Formulate a diet order for a patient with gout in which the purin
foods are eliminated.

(b) Formulate a diet order for an obese patient whose heart is more or
less affected.

(c) List the foods of special value in the diet for emaciation. Write
a diet order for day suitable for a patient (woman) weighing 110
pounds, whose normal weight is 135 pounds.


FOOTNOTES:

[156] "Food for the Sick," p. 97, by Strouse and Perry.

[157] The amount of food must be limited, since overeating will
precipitate an acute attack. It is best to limit the amount to about a
maintenance allowance or a little more, temporarily.

[158] "Diet in Health and Disease," by Freidenwald and Ruhräh.

[159] _Ibid._, p. 544.

[160] Boiled vegetable dinners must be prepared without fat meat and
potatoes.

[161] Scientific investigation has proved that both carbohydrates and
fats may be formed in the body from protein. Hence any excess above
that required to keep the body in nitrogen equilibrium is utilized by
the organism for fuel or stored as fat.

[162] "Feeding the Family," p. 84, by Mary Swartz Rose.

[163] Saccharin may be used to sweeten.




CHAPTER XXIII

OTHER CONDITIONS MORE OR LESS AFFECTED BY DIET


PTOMAINE POISONING, ACIDOSIS AND PELLAGRA

PTOMAINE POISONING

The poisoning due to ptomaine is very similar to that brought about by
overeating and other dietetic errors. However, it is not so easy to
avoid being poisoned by ptomaines as it is to observe moderation in
the quantity of food eaten.

~Origin.~--These substances are believed to be of an infective
bacterial origin and may be present in foods which are otherwise
seemingly fresh and good. The fact that they cannot be detected in
food without an analysis makes them more of a menace than they would
otherwise be, for any substance which is not discernible to our
senses, the taste, sight, or smell, and which exerts a baleful
influence, such as ptomaine, cannot be anything but a menace to
humanity.

~Infected Food Materials.~--We may congratulate ourselves in the
knowledge that these substances are not present in many foods, and if
we avoid eating nitrogenous materials, which may have become polluted,
either through imperfect canning or by standing in unclean vessels, we
may avoid much of the poisoning which may otherwise be due to the
action of ptomaines.

~Chicken Salad and Ice Cream Poisoning.~--Certain violent attacks of
so-called ptomaine poisoning may be traced to chicken salad which has
been allowed to stand overnight in tin receptacles or to ice cream
which has melted and been re-frozen. In any case the treatment
remains the same.

~Treatment.~--The patient is put to bed and the intestinal tract
cleansed by means of enemas and in many cases purgatives (salts,
castor oil, etc.) as directed by physician.

The symptoms usually present in those suffering from ptomaine
poisoning are nausea, vomiting, dizziness, pain more or less violent
in character, and prostration which is at times alarming.

~Dietetic Treatment.~--The treatment instituted under the
circumstances is very much the same as that used in other forms of
acute poisoning. All food is withheld for a period; the duration of
this starvation must necessarily depend upon the condition of the
patient, the violence of the poison and the extent of the prostration.

~Rectal Feeding.~--When the prostration is great, it is sometimes
necessary to give saline enemas and even rectal alimentation to
prevent collapse.

~Fluid Diet.~--After the violent attack subsides, the patient is
placed upon a fluid diet similar to that used in auto-intoxication and
practically the same as the diet for acute infectious diseases. The
diet must be gradually increased until it becomes normal and the nurse
must remember that the patient is in a condition to suffer a relapse
with the least indiscretion. It is advisable to have a thorough
investigation made to ascertain the source of the original attack,
that the patient may be able to avoid future trouble from partaking of
the same food.

~Personal Idiosyncrasies.~--It may be that there is a personal
idiosyncrasy against one particular food, and in this case it becomes
more or less of a simple matter to prevent future attacks. Certain
individuals are, for example, invariably poisoned by eating shellfish,
others manifest a similar idiosyncrasy against strawberries. Thus is
the old proverb demonstrated: "What is one man's meat is another
man's poison." And he who wantonly flies in the face of the danger
signals Nature provides for his guidance must necessarily suffer the
consequences of his folly.

It has been proved with certain individuals that the foods that at one
time cause an attack of poison at another time may be eaten with
impunity. Thus it would seem to remain a question not so much of the
type of poison, ptomaines, etc., as the amount of resistance
manifested at the time by the individual partaking of the infected
food.


ACIDOSIS

~Metabolism of Fats.~--Acidosis is a condition believed to be due
primarily to some impairment in the metabolism of fat in the body, in
consequence of which there is an accumulation of substances more or
less irritating and at times toxic in character in the blood. These
substances, known as acetone bodies, are especially apt to appear in
the urine of individuals suffering from diabetes, likewise in those
undergoing starvation, whether as a result of treatment to overcome a
definite pathological condition, as in diabetes, or as the result of
disease itself.

~Malnutrition as a Source.~--Certain individuals, children especially,
develop symptoms of acidosis under many different circumstances; for
example, in many cases of malnutrition the evidences of acidosis are
almost invariable. The treatment in these cases must be, of course,
prompt in order that the condition may not assume a serious aspect.

~Dietetic Treatment.~--The diet is adjusted in order to neutralize the
effect of the acid in the blood. This is done in two ways: first, by
reducing the fat, and second, by increasing the amount of base-forming
foods in the diet.

The following table[164] illustrates the foods in which the
acid-forming elements and base-forming elements predominate:

FOODS IN WHICH ACID-FORMING ELEMENTS PREDOMINATE

_Estimated Excess Acid-forming Elements Equivalent to C.C. Normal Acid
per 100 Calories_

  Beef, free from visible fat                   10
  Eggs                                            .9
  Round steak                                    6.7
  Oatmeal                                        3.2
  Wheat flour                                    2.7
  Wheat, entire grain                            2.6
  Rice                                           2.4
  Bacon                                          1
  Corn, entire grain (high protein)               .1


FOODS IN WHICH BASE-FORMING ELEMENTS PREDOMINATE

_Estimated Excess Base-forming Elements Equivalent to C.C. Normal
Alkali per 100 Calories_

  Celery                                          40
  Cabbage                                      10-13.6
  Potatoes                                      9-12
  Prunes                                           7.9
  Turnips                                     6.6-12.5
  Apples                                           5
  Milk                                             3.3
  Beans                                        2.9-6.8
  Peas                                             1.9
  Corn, entire grain (low protein)                  .8

The fruits likewise show a predominance of base-forming elements over
acid-forming elements and for this reason may be used to balance the
diet.

~Diabetic Acidosis.~--The acidosis during diabetes has been already
discussed in the chapter devoted to that disease.

It has been found advisable in the majority of cases of acidosis to
restrict the fat in the diet of all patients who, during the course of
a disease, have given evidence of this condition; at the same time it
is well to remember that fat is one of the essential food constituents
and absolutely necessary to the welfare of the individual,
consequently it is impossible to eliminate it from the diet entirely.
The only feasible method, then, to pursue under the circumstances is
to restrict the fats in the diet so long as there are symptoms of
acidosis and to add them gradually and in very small amounts until the
individual's tolerance for fats is determined.

~Balancing the Diet.~--In many cases of acidosis due to starvation, no
matter what the cause, the diet must be necessarily regulated and
properly balanced. It would be decidedly unwise to attempt to build up
the body by giving building foods alone, without due consideration to
the foods containing the agents provided by Nature to neutralize the
acid formed during the process of their metabolism. It is readily seen
in the table just given that meat and eggs show a marked excess of
acid-forming elements, whereas vegetables and fruits yield an excess
of base-forming elements. With these data, it becomes more simple to
balance the diet and to avoid the acidosis which may arise from
impairment of the fat metabolism of the body.


PELLAGRA

The enormous increase in the number of cases of pellagra in America
during the last twenty years makes it necessary for something to be
done to arrest its progress. The cause of this disease is still under
discussion, but much has been done to find out definitely the reason
for the tremendous increase in the number of cases, especially in the
Southern States, where the increase has been most noticeable.

~Cause.~--This disease has been the subject of much study and
discussion in this country in recent years. Voegtlin, in an article
published in a Report of the United States Public Health Service
(Reprint 597 of Public Health Report), summarizes the current findings
on pellagra as follows:

"1. The hypothesis that there is a causal relation between pellagra
and a restricted vegetable diet has been substantiated by direct
proof to this effect and has led to results of considerable practical
and scientific value.

"2. The metabolism in pellagra shows certain definite changes from the
normal, which point to decreased gastric secretion and increased
intestinal putrefaction.

"3. In the treatment and prevention of pellagra, diet is the essential
factor. The disease can be prevented by an appropriate change in the
diet without changing other sanitary conditions.

"4. A diet of the composition used by the pellagrins prior to their
attack by the disease leads to malnutrition and certain pathological
changes in animals, resembling those found in pellagra. A typical
pellagrous dermatitis has not been observed in animals. Pellagrous
symptoms have been produced in man by the continued consumption of a
restricted vegetable diet.

"5. The nature of the dietary effect has not been discovered, although
certain observations point to a combined deficiency in some of the
recognized dietary factors as the cause of the pellagrous syndrome."

~Dietetic Treatment.~--The diet in pellagra is one which is well
balanced in all its particulars, and one in which the proteins are
carefully adjusted as to type. The best results have been observed on
diets in which the complete proteins (milk, meat and eggs) have a
prominent place. As a rule, in the diet of an adult suffering from
pellagra, at least forty grams (about 60 per cent) of the necessary
proteins should be in this form. The diet for pellagra must
necessarily be such as to overcome as far as possible the progressive
emaciation which is an important symptom. However, it must be kept in
mind that gastro-intestinal disturbances are likewise prominent and
that diarrhea is often most difficult to overcome. For these reasons
it is essential to formulate a diet which will not interfere with the
treatment for the disease, and which will be at the same time one on
which the patient can gradually be built up, and in this way benefit,
as far as possible, under the circumstances. The diet used in the
treatment of anemia seems to be the one best suited to meet the
requirements of the patient suffering with pellagra; changes may be
made in this diet, however, by the physician, who will be able to
judge the need of the individual under his care. Whether pellagra can
be cured by dietetic treatment is very uncertain, but the condition of
the patient can undoubtedly be materially improved, provided the
treatment is begun sufficiently early; that is, before the disease has
progressed to such an extent that neither diet nor anything else can
bring about a cure.

The above dietetic treatment is not claimed to be infallible. It is
merely given as a suggestion to be used at the discretion of the
physician.

In all probability the treatment of pellagra will undergo a definite
change in the near future, but at present our best results accrue from
the giving of an adequate, well-balanced diet. The extent of the
relief of such dietetic measures depends, as has already been stated,
upon taking the disease in its early stage.


SUMMARY

~Food Poisoning~ is more or less common, being induced by polluted
water, milk, or other foods, bad sanitation, and imperfect canning, as
well as by certain obscure substances known as ptomaines.

~Shellfish~ have often been found to cause poisoning in certain
individuals. Stale fish may cause the most violent type of poisoning
in any individual.

~Chicken Salad~ which has been kept overnight in tin receptacles has
been known to cause violent attacks of poisoning.

~Ice Cream~ which is melted and re-frozen is likewise a source of a
number of the cases reported.

~Symptoms.~--Very like those of auto-intoxication, and violent
intestinal disturbances are manifested.

~Prostration~ may be great, according to the violence and duration of
the attack.

~Anemia~ follows many cases of poisoning as a result not only of the
impairment and lack of nutrition of the blood-making organs, but also
on account of the other symptoms, especially diarrhea occurring in the
disease.


ACIDOSIS

This condition is more or less common, especially in the disturbances
manifested by children.

~Cause~ of acidosis is believed to be an impairment of metabolism,
especially in regard to the fats.

~Starvation or Malnutrition~ is believed to produce many cases of
acidosis in childhood and adults suffering from diseases in which
certain foods have been limited.

~Dietetic Treatment~ like that used in acute gastro-intestinal
disturbances begins with a starvation period and is followed by a
simple fluid diet until violent symptoms subside. Examination of the
stools and the material vomited will, at times, furnish an insight as
to the source of the poison.

~Convalescent Diet~ is begun after the violent symptoms have subsided,
but care must be taken not to increase the diet too rapidly, owing to
the danger from relapse.

~Method of Administering Diet.~--First: a period of total abstinence
from food.

Second: fluid diet consisting of broth, buttermilk, or some of the
predigested liquid beef preparations which furnish both food and
stimulation necessary in such cases.

~Rectal Feeding~ may be found necessary when the prostration is great.

~Personal Idiosyncrasies~ should be taken into account and effort made
to find whether or not the attack is caused by any one food material
or by bad sanitation or unclean food. The patient should be warned
against the danger of taking a food which has caused a previous attack
of poisoning, especially in cases where a personal idiosyncrasy
against a food has been manifested.


PELLAGRA

The cause and cure for this disease are still a matter of discussion.
Whether it is due to the presence or absence of certain substances in
the food materials, is as yet to be determined.

~Diet in Pellagra~ is most important. It is impossible to say that
pellagra is a nutritional disease, but it is certain that in balancing
the diet much has been done toward relieving the condition.

~Diarrhea~ is one of the chief symptoms of the disease and great care
is needed in formulating the dietary in order not to increase this
condition.

~Conclusion.~--The diet is thus shown to be directed toward overcoming
the emaciation and anemia and relieving or preventing the
gastro-intestinal disturbances which are so apt to occur. It must be
remembered that even a well-balanced diet will not materially relieve
the condition unless it is instituted sufficiently early.


PROBLEMS

(a) Formulate a diet for an adult in which the base-forming elements
predominate.

(b) Formulate a diet for child suffering from acidosis.

(c) Arrange a well balanced diet for pellagra in which forty grams of
protein shall come from milk, meat or eggs.


FOOTNOTE:

[164] "Chemistry of Food and Nutrition" (revised), by Henry Sherman.




APPENDIX


TABLE I[165]

EDIBLE ORGANIC NUTRIENTS AND FUEL VALUES OF FOODS[166]

E.P. signifies edible portion; A.P. signifies as purchased.

KEY:
  A _Protein (N × 6.25) Per Cent_
  B _Fat Per Cent_
  C _Carbohydrate Per Cent_
  D _Fuel Value per Pound Calories_
  E _100 Calorie Portion Grams_

  ============================+======+=======+=======+======+=======
            _Food_            |  A   |   B   |   C   |  D   |   E
  ----------------------------+------+-------+-------+------+-------
   Almonds               E.P. | 21.0 |  54.9 |  17.3 | 2940 |   15
                         A.P. | 11.5 |  30.2 |   9.5 | 1615 |   28
   Apples                E.P. |   .4 |    .5 |  14.2 |  285 |  159
                         A.P. |   .3 |    .3 |  10.8 |  214 |  212
   Apricots              E.P. |  1.1 |   --  |  13.4 |  263 |  174
                         A.P. |  1.0 |   --  |  12.6 |  247 |  184
   Artichoke, French     E.P. |  3.4 |    .5 |  12.0 |  300 |  151
                         A.P. |  1.7 |    .3 |   6.0 |  150 |  302
   Asparagus, fresh      E.P. |  1.8 |    .2 |   3.3 |  100 |  450
     cooked              A.P. |  2.1 |   3.3 |   2.2 |  213 |  213
   Avocado               E.P. |  2.1 |  20.1 |   7.4 |  993 |   46
                         A.P. |  1.4 |  13.2 |   4.8 |  652 |   70
   Bacon, smoked         E.P. | 10.5 |  64.8 |   --  | 2840 |   16
                         A.P. |  9.5 |  59.4 |   --  | 2372 |   19
   Bananas               E.P. |  1.3 |    .6 |  22.0 |  447 |  101
                         A.P. |   .8 |    .4 |  14.3 |  290 |  156
   Barley, pearled            |  8.5 |   1.1 |  77.8 | 1615 |   28
   Beans, dried               | 22.5 |   1.8 |  59.6 | 1565 |   29
     Lima, dried              | 18.1 |   1.5 |  65.9 | 1586 |   29
     Lima, fresh         E.P. |  7.1 |    .7 |  22.0 |  557 |   82
                         A.P. |  3.2 |    .3 |   9.9 |  250 |  182
     string, fresh       E.P. |  2.3 |   3.  |   7.4 |  184 |  241
                         A.P. |  2.1 |   3.  |   6.9 |  176 |  259
     baked, canned       A.P. |  6.9 |   2.5 |  19.6 |  583 |   78
     red kidney, canned       |  7.0 |    .2 |  18.5 |  471 |   96
  Beef, brisket,              |      |       |       |      |
    medium fat           E.P. | 15.8 |  28.5 |   --  | 1449 |   31
                         A.P. | 12.0 |  22.3 |   --  | 1130 |   40
    chuck, average       E.P. | 19.2 |  15.4 |   --  |  978 |   46
                         A.P. | 15.8 |  12.5 |   --  |  797 |   58
    corned, average      E.P. | 15.6 |  26.2 |   --  | 1353 |   34
                         A.P. | 14.3 |  23.8 |   --  | 1230 |   37
    cross ribs,               |      |       |       |      |
         average         E.P. | 15.9 |  28.2 |   --  | 1440 |   32
                         A.P. | 13.8 |  24.8 |   --  | 1262 |   36
    dried, salted,            |      |       |       |      |
      and smoked         E.P. | 30.0 |   6.5 |    .4 |  817 |   56
                         A.P. | 26.4 |   6.9 |   --  |  760 |   60
    flank, lean          E.P. | 20.8 |  11.3 |   --  |  838 |   54
                         A.P. | 20.5 |  11.0 |   --  |  821 |   55
    fore quarter,             |      |       |       |      |
           lean          E.P. | 18.9 |  12.2 |   --  |  842 |   54
                         A.P. | 14.7 |   9.5 |   --  |  655 |   69
    fore shank,               |      |       |       |      |
           lean          E.P. | 22.0 |   6.1 |   --  |  647 |   70
                         A.P. | 14.0 |   3.9 |   --  |  414 |  110
    heart                E.P. | 16.0 |  20.4 |   1.0 | 1140 |   40
                         A.P. | 14.8 |  24.7 |    .9 | 1292 |   35
    hind quarter,             |      |       |       |      |
           lean          E.P. | 20.0 |  13.4 |   --  |  907 |   50
                         A.P. | 16.7 |  11.2 |   --  |  757 |   60
    hind shank, lean     E.P. | 21.9 |   5.4 |   --  |  617 |   75
                         A.P. |  9.1 |   2.2 |   --  |  255 |  179
    hind shank, fat      E.P. | 20.4 |  18.8 |   --  | 1171 |   40
                         A.P. |  9.9 |   9.1 |   --  |  552 |   83
    liver                E.P. | 20.4 |   4.5 |   1.7 |  584 |   78
                         A.P. | 20.2 |   3.1 |   2.5 |  537 |   85
    loin                 E.P. | 19.7 |  12.7 |   --  |  877 |   52
                         A.P. | 17.1 |  11.1 |   --  |  764 |   60
    neck, lean           E.P. | 21.4 |   8.4 |   --  |  732 |   62
                         A.P. | 15.1 |   5.9 |   --  |  493 |   93
    neck, medium fat     E.P. | 20.1 |  16.5 |   --  | 1040 |   44
                         A.P. | 14.5 |  11.9 |   --  |  749 |   61
    plate, lean          E.P. | 15.6 |  18.8 |   --  | 1051 |   43
                         A.P. | 13.0 |  15.5 |   --  |  867 |   52
    Porterhouse               |      |       |       |      |
      steak              E.P. | 21.9 |  20.4 |   --  | 1230 |   37
                         A.P. | 19.1 |  17.9 |   --  | 1077 |   42
    rib rolls, lean      A.P. | 20.2 |  10.5 |   --  |  795 |   57
    ribs, lean           E.P. | 19.6 |  12.0 |   --  |  845 |   54
                         A.P. | 15.2 |   9.3 |   --  |  654 |   69
    ribs, fat            E.P. | 15.0 |  35.6 |   --  | 1721 |   26
                         A.P. | 12.7 |  30.6 |   --  | 1480 |   31
    round, lean          E.P. | 21.3 |   7.9 |   --  |  709 |   64
                         A.P. | 19.5 |   7.3 |   --  |  649 |   70
    round, free from          |      |       |       |      |
      visible fat             | 23.2 |   2.5 |   --  |  512 |   87
    rump, lean           E.P. | 20.9 |  13.7 |   --  |  940 |   49
                         A.P. | 19.1 |  11.0 |   --  |  796 |   57
    rump, fat            E.P. | 16.8 |  35.7 |   --  | 1763 |   26
                         A.P. | 12.9 |  27.6 |   --  | 1361 |   33
    sides, lean          E.P. | 19.3 |  13.2 |   --  |  890 |   51
                         A.P. | 15.5 |  10.6 |   --  |  715 |   64
    sirloin steak        E.P. | 18.9 |  18.5 |   --  | 1099 |   41
                         A.P. | 16.5 |  16.1 |   --  |  960 |   48
    sweetbreads          A.P. | 16.8 |  12.1 |   --  |  799 |   57
    tenderloin           A.P. | 16.2 |  24.4 |   --  | 1290 |   35
    tongue               E.P. | 18.9 |   9.2 |   --  |  717 |   63
                         A.P. | 14.1 |   6.7 |   --  |  529 |   86
  Beets, cooked          E.P. |  2.3 |    .1 |   7.4 |  180 |  252
    fresh                E.P. |  1.6 |    .1 |   9.7 |  209 |  217
                         A.P. |  1.3 |    .1 |   7.7 |  167 |  271
  Blackberries           A.P. |  1.3 |   1.0 |  10.9 |  262 |  173
  Blackfish              E.P. | 18.7 |   1.3 |   --  |  393 |  116
                         A.P. |  7.4 |    .7 |   --  |  163 |  279
  Bluefish               E.P. | 19.4 |   1.2 |   --  |  402 |  113
                         A.P. | 10.0 |    .6 |   --  |  206 |  220
  Boston crackers             | 11.0 |   8.5 |  71.1 | 1835 |   25
  Brazil nuts            E.P. | 17.0 |  66.8 |   7.0 | 3162 |   14
                         A.P. |  8.6 |  33.7 |   3.5 | 1591 |   28
  Bread, Boston brown         |  6.0 |   6.3 |  54.0 | 1345 |   34
    graham                    |  8.9 |   1.8 |  52.1 | 1189 |   38
    rolls, water              |  9.0 |   3.0 |  54.2 | 1268 |   36
    toasted                   | 11.5 |   1.6 |  61.2 | 1385 |   33
    white, home made          |  9.1 |   1.6 |  53.3 | 1199 |   38
    milk                      |  9.6 |   1.4 |  51.1 | 1158 |   39
    Vienna                    |  9.4 |   1.2 |  54.1 | 1199 |   38
    average white             |  9.2 |   1.3 |  53.1 | 1182 |   38
    whole wheat               |  9.7 |    .9 |  49.7 | 1113 |   41
  Buckwheat flour             |  6.4 |   1.2 |  77.9 | 1580 |   29
  Butter                      |  1.0 |  85.0 |   --  | 3491 |   13
  Buttermilk                  |  3.0 |    .5 |   4.8 |  162 |  280
  Butternuts             E.P. | 27.9 |  61.2 |   3.5 | 3065 |   15
                         A.P. |  3.8 |   8.3 |    .5 |  417 |  109
  Cabbage                E.P. |  1.6 |    .3 |   5.6 |  143 |  317
                         A.P. |  1.4 |    .2 |   4.8 |  121 |  376
  Calf's-foot jelly           |  4.3 |   --  |  17.4 |  394 |  115
  Carrots, fresh         E.P. |  1.1 |    .4 |   9.3 |  204 |  221
                         A.P. |   .9 |    .2 |   7.4 |  158 |  286
  Cauliflower            A.P. |  1.8 |    .5 |   4.7 |  139 |  328
  Celery                 E.P. |  1.1 |    .1 |   3.3 |   84 |  542
                         A.P. |   .9 |    .1 |   2.6 |   68 |  672
  Celery soup, canned         |  2.1 |   2.8 |   5.0 |  243 |  187
  Cerealine                   |  9.6 |   1.1 |  78.3 | 1640 |   28
  Chard                  E.P. |  3.2 |    .6 |   5.0 |  173 |  262
  Cheese, American pale       | 28.8 |  35.9 |    .3 | 1990 |   23
    American red              | 29.6 |  38.3 |   --  | 2102 |   22
    Cheddar                   | 27.7 |  36.8 |   4.1 | 2080 |   22
    cottage                   | 20.9 |   1.0 |   4.3 |  499 |   91
    full cream                | 25.9 |  33.7 |   2.4 | 1890 |   24
    Fromage de Brie           | 15.9 |  21.0 |   1.4 | 1170 |   39
    Neufchâtel                | 18.7 |  27.4 |   1.5 | 1484 |   31
    pineapple                 | 29.9 |  38.9 |   2.6 | 2180 |   21
    Roquefort                 | 22.6 |  29.5 |   1.8 | 1645 |   28
    Swiss                     | 27.6 |  34.9 |   1.3 | 1945 |   23
  Cherries, fresh        E.P. |  1.0 |    .8 |  16.7 |  354 |  128
                         A.P. |   .9 |    .8 |  15.9 |  337 |  134
    canned               A.P. |  1.1 |    .1 |  21.1 |  407 |  112
  Chestnuts, fresh       E.P. |  6.2 |   5.4 |  42.1 | 1098 |   41
                         A.P. |  5.2 |   4.5 |  35.4 |  920 |   49
  Chicken, broilers      E.P. | 21.5 |   2.5 |   --  |  493 |   92
                         A.P. | 12.8 |   1.4 |   --  |  289 |  157
  Chocolate                   | 12.9 |  48.7 |  30.3 | 2768 |   16
  Cocoa                       | 21.6 |  28.9 |  37.7 | 2258 |   20
  Cod, dressed           A.P. | 11.1 |    .2 |   --  |  209 |  217
    salt                 E.P. | 25.4 |    .3 |   --  |  473 |   96
                         A.P. | 19.0 |    .4 |   --  |  361 |  126
  Consommé, canned       A.P. |  2.5 |   --  |    .4 |   53 |  862
  Corn,                       |      |       |       |      |
    green, canned             |  2.8 |   1.2 |  19.0 |  455 |  102
    sweet, fresh         E.P. |  3.1 |   1.1 |  19.7 |  459 |   99
                         A.P. |  1.2 |    .4 |   7.7 |  178 |  255
  Corn meal                   |  9.2 |   1.9 |  75.4 | 1620 |   28
  Cowpeas, dried              | 21.4 |   1.4 |  60.8 | 1550 |   29
    green                E.P. |  9.4 |    .6 |  22.7 |  603 |   76
  Crackers, butter       A.P. |  9.6 |  10.1 |  71.6 | 1887 |   23
    cream                A.P. |  9.7 |  12.1 |  69.7 | 1938 |   23
    graham               A.P. | 10.0 |   9.4 |  73.8 | 1905 |   24
    soda                 A.P. |  9.8 |   9.1 |  73.1 | 1875 |   24
    water                A.P. | 10.7 |   8.8 |  71.9 | 1855 |   24
  Cranberries            A.P. |   .4 |    .6 |   9.9 |  212 |  212
  Cream                       |  2.5 |  18.5 |   4.5 |  883 |   50
  Cucumbers              E.P. |   .8 |    .2 |   3.1 |   79 |  575
                         A.P. |   .7 |    .2 |   2.6 |   68 |  666
  Currants, fresh             |  1.5 |   --  |  12.8 |  259 |  175
    dried Zante               |  2.4 |   1.7 |  74.2 | 1455 |   31
  Dandelion greens            |  2.4 |   1.0 |  10.6 |  277 |  164
  Dates, dried           E.P. |  2.1 |   2.8 |  78.4 | 1575 |   29
                         A.P. |  1.9 |   2.5 |  70.6 | 1416 |   32
  Doughnuts                   |  6.7 |  21.0 |  53.1 | 1941 |   23
  Eggplant               E.P. |  1.2 |    .3 |   5.1 |  126 |  349
  Eggs, uncooked         E.P. | 13.4 |  10.5 |   --  |  672 |   68
                         A.P. | 11.9 |   9.3 |   --  |  594 |   76
  Farina                      | 11.0 |   1.4 |  76.3 | 1640 |   28
  Figs, dried                 |  4.3 |    .3 |  74.2 | 1437 |   32
  Flounder               A.P. |  5.4 |    .3 |   --  |  110 |  412
                         E.P. | 14.2 |    .6 |   --  |  282 |  161
  Flour, rye                  |  6.8 |    .9 |  78.7 | 1590 |   29
    wheat, California fine    |  7.9 |   1.4 |  76.4 | 1585 |   29
    wheat, entire             | 13.8 |   1.9 |  71.9 | 1630 |   28
    wheat, graham             | 13.3 |   2.2 |  71.4 | 1628 |   28
    wheat, patent             |      |       |       |      |
      baker's grade           | 13.3 |   1.5 |  72.7 | 1623 |   28
    wheat, straight grade     | 10.8 |   1.1 |  74.8 | 1608 |   28
    wheat, average            |      |       |       |      |
      high and medium         | 11.4 |   1.0 |  75.1 | 1610 |   28
    wheat, average            |      |       |       |      |
      low grade               | 14.0 |   1.9 |  71.2 | 1625 |   28
  Fowls                  E.P. | 19.3 |  16.3 |   --  | 1017 |   45
                         A.P. | 13.7 |  12.3 |   --  |  752 |   60
  Gelatin                     | 91.4 |    .1 |   --  | 1660 |   27
  Grape butter                |  1.2 |    .1 |  58.5 | 1088 |   42
  Grapes                 E.P. |  1.3 |   1.6 |  19.2 |  437 |  104
                         A.P. |  1.0 |   1.2 |  14.4 |  328 |  138
  Grapefruit             E.P. |   .6 |    .1 |  12.2 |  235 |  193
                         A.P. |   .4 |    .1 |   8.9 |  172 |  264
  Haddock                E.P. | 17.2 |    .3 |   --  |  324 |  140
                         A.P. |  8.4 |    .2 |   --  |  160 |  283
  Halibut steaks         E.P. | 18.6 |   5.2 |   --  |  550 |   83
                         A.P. | 15.3 |   4.4 |   --  |  457 |  100
  Ham, fresh lean        E.P. | 25.0 |  14.4 |   --  | 1042 |   44
                         A.P. | 24.8 |  14.2 |   --  | 1030 |   44
    fresh, medium        E.P. | 15.3 |  28.9 |   --  | 1458 |   31
                         A.P. | 13.5 |  25.9 |   --  | 1303 |   35
    smoked, lean         E.P. | 19.8 |  20.8 |   --  | 1209 |   38
                         A.P. | 17.5 |  18.5 |   --  | 1073 |   42
  Herring, whole         E.P. | 19.5 |   7.1 |   --  |  644 |   70
                         A.P. | 11.2 |   3.9 |   --  |  362 |  125
    smoked               E.P. | 36.9 |  15.8 |   --  | 1315 |   35
                         A.P. | 20.5 |   8.8 |   --  |  731 |   62
  Hominy                      |  8.3 |    .6 |  79.0 | 1609 |   28
  Honey                       |   .4 |   --  |  81.2 | 1481 |   31
  Huckleberries               |   .6 |    .6 |  16.6 |  336 |  135
  Kohl-rabi              E.P. |  2.0 |    .1 |   5.5 |  140 |  324
  Koumiss                     |  2.8 |   2.1 |   5.4 |  234 |  194
  Lamb, breast           E.P. | 19.1 |  23.6 |   --  | 1311 |   35
                         A.P. | 15.4 |  19.1 |   --  | 1058 |   43
    chops, broiled       E.P. | 21.7 |  29.9 |   --  | 1614 |   28
    fore quarter         E.P. | 18.3 |  25.8 |   --  | 1385 |   33
                         A.P. | 14.9 |  21.0 |   --  | 1127 |   40
    hind quarter         E.P. | 19.6 |  19.1 |   --  | 1149 |   40
                         A.P. | 16.5 |  16.1 |   --  |  953 |   48
    leg roast                 | 19.7 |  12.7 |   --  |  876 |   52
    side                 E.P. | 17.6 |  23.1 |   --  | 1263 |   36
                         A.P. | 14.1 |  18.7 |   --  | 1015 |   45
  Lard, refined               |  --  | 100.0 |   --  | 4080 |   11
  Lemon juice                 |  --  |   --  |   9.8 |  178 |  255
  Lemons                 E.P. |  1.0 |    .7 |   8.5 |  201 |  226
                         A.P. |   .7 |    .5 |   5.9 |  140 |  323
  Lettuce                E.P. |  1.2 |    .3 |   2.9 |   87 |  525
                         A.P. |  1.0 |    .2 |   2.5 |   72 |  633
  Liver, beef            E.P. | 20.4 |   4.5 |   1.7 |  583 |   78
                         A.P. | 20.2 |   3.1 |   2.5 |  538 |   84
    veal                 E.P. | 19.0 |   5.3 |   --  |  562 |   81
  Lobster, whole         E.P. | 16.4 |   1.8 |    .4 |  379 |  120
                         A.P. |  5.9 |    .7 |    .2 |  139 |  326
    canned               A.P. | 18.1 |   1.1 |    .5 |  382 |  119
  Macaroni                    | 13.4 |    .9 |  74.1 | 1625 |   28
  Macaroons                   |  6.5 |  15.2 |  65.2 | 1922 |   24
  Mackerel               E.P. | 18.7 |   7.1 |   --  |  629 |   72
                         A.P. | 10.2 |   4.2 |   --  |  356 |  127
    salt                 E.P. | 21.1 |  22.6 |   --  | 1305 |   35
                         A.P. | 16.3 |  17.4 |   --  | 1005 |   45
  Marmalade, orange           |   .6 |    .1 |  84.5 | 1548 |   29
  Milk, condensed,            |      |       |       |      |
    sweetened                 |  8.8 |   8.3 |  54.1 | 1480 |   31
    skimmed                   |  3.4 |    .3 |   5.1 |  167 |  273
    whole                     |  3.3 |   4.0 |   5.0 |  314 |  145
  Mince meat, commercial      |  6.7 |   1.4 |  60.2 | 1280 |   36
    home made                 |  4.8 |   6.7 |  32.1 |  942 |   48
  Molasses, cane              |  2.4 |   --  |  69.3 | 1302 |   35
  Mushrooms              A.P. |  3.5 |    .4 |   6.8 |  204 |  223
  Muskmelons             E.P. |   .6 |   --  |   9.3 |  180 |  252
                         A.P. |   .3 |   --  |   4.6 |   89 |  510
  Mutton, fore                |      |       |       |      |
      quarter            E.P. | 15.6 |  30.9 |   --  | 1543 |   29
                         A.P. | 12.3 |  24.5 |   --  | 1223 |   37
    hind quarter         E.P. | 16.7 |  28.1 |   --  | 1450 |   31
                         A.P. | 13.8 |  23.2 |   --  | 1197 |   38
    leg                  E.P. | 19.8 |  12.4 |   --  |  863 |   52
                         A.P. | 16.5 |  10.3 |   --  |  718 |   63
    side                 A.P. | 13.0 |  24.0 |   --  | 1215 |   37
                         E.P. | 16.2 |  29.8 |   --  | 1512 |   30
  Nectarines             E.P. |   .6 |   --  |  15.9 |  299 |  152
                         A.P. |   .6 |   --  |  14.8 |  280 |  162
  Oatmeal                     | 16.1 |   7.2 |  67.5 | 1811 |   25
  Okra                   E.P. |  1.6 |    .2 |   7.4 |  172 |  264
                         A.P. |  1.4 |    .2 |   6.5 |  152 |  300
  Olives, green          E.P. |  1.1 |  27.6 |  11.6 | 1357 |   33
                         A.P. |   .8 |  20.2 |   8.5 |  995 |   46
    ripe                 E.P. |  1.7 |  25.0 |   4.3 | 1130 |   40
                         A.P. |  1.4 |  21.0 |   3.5 |  947 |   48
  Onions, fresh          E.P. |  1.6 |    .3 |   9.9 |  220 |  206
                         A.P. |  1.4 |    .3 |   8.9 |  199 |  228
  Oranges                E.P. |   .8 |    .2 |  11.6 |  233 |  195
                         A.P. |   .6 |    .1 |   8.5 |  169 |  268
  Oxtail soup,                |      |       |       |      |
    canned               A.P. |  3.8 |    .5 |   4.2 |  166 |  274
  Oysters                E.P. |  6.2 |   1.2 |   3.7 |  228 |  199
    in shell             A.P. |  1.2 |    .2 |    .7 |   43 | 1065
    canned               A.P. |  8.8 |   2.4 |   3.9 |  328 |  138
  Parsnips               E.P. |  1.6 |    .5 |  13.5 |  294 |  154
                         A.P. |  1.3 |    .4 |  10.8 |  236 |  192
  Pea soup, canned       A.P. |  3.6 |    .7 |   7.6 |  232 |  196
  Peaches, canned        A.P. |   .7 |    .1 |  10.8 |  213 |  213
    fresh                E.P. |   .7 |    .1 |   9.4 |  188 |  242
                         A.P. |   .5 |    .1 |   7.7 |  153 |  297
  Peanuts                E.P. | 25.8 |  38.6 |  24.4 | 2490 |   18
                         A.P. | 19.5 |  29.1 |  18.5 | 1877 |   24
  Pears, fresh           E.P. |   .6 |    .5 |  14.1 |  288 |  158
                         A.P. |   .5 |    .4 |  12.7 |  256 |  177
  Peas, canned           A.P. |  3.6 |    .2 |   9.8 |  252 |  180
    dried                     | 24.6 |   1.0 |  62.0 | 1611 |   28
    green                E.P. |  7.0 |    .5 |  16.9 |  454 |  100
                         A.P. |  3.6 |    .2 |   9.8 |  252 |  180
  Peppers, green         E.P. |  1.1 |    .1 |   4.6 |  109 |  417
  Persimmons             E.P. |   .8 |    .7 |  31.5 |  615 |   74
  Pies, apple                 |  3.1 |   0.8 |  42.8 | 1233 |   37
    custard                   |  4.2 |   6.3 |  26.1 |  806 |   56
    lemon                     |  3.6 |  10.1 |  37.4 | 1156 |   39
    mince                     |  5.8 |  12.3 |  38.1 | 1300 |   35
    squash                    |  4.4 |   8.4 |  21.7 |  817 |   56
  Pineapples, fresh      E.P. |   .4 |    .3 |   9.7 |  196 |  232
    canned               A.P. |   .4 |    .7 |  36.4 |  695 |   65
  Pine nuts                   |      |       |       |      |
      (pignolias)             | 33.9 |  49.4 |   6.9 | 2757 |   16
  Pistachios, shelled         | 22.3 |  54.0 |  16.3 | 2900 |   16
  Plums                  E.P. |  1.0 |   --  |  20.1 |  383 |  118
                         A.P. |   .9 |   --  |  19.1 |  363 |  125
  Pomegranates           E.P. |  1.5 |   1.6 |  19.5 |  447 |  102
  Pork chops,                 |      |       |       |      |
    medium               E.P. | 16.6 |  30.1 |   --  | 1530 |   30
                         A.P. | 13.4 |  24.2 |   --  | 1230 |   37
    chuck ribs and            |      |       |       |      |
    shoulder             E.P. | 17.3 |  31.1 |   --  | 1585 |   29
                         A.P. | 14.1 |  25.5 |   --  | 1298 |   35
    fat, salt            A.P. |  1.9 |  86.2 |   --  | 3555 |   13
    sausage              A.P. | 13.0 |  44.2 |   1.1 | 2030 |   22
    side                 E.P. |  9.1 |  55.3 |   --  | 2423 |   19
                         A.P. |  8.0 |  49.0 |   --  | 2145 |   21
    tenderloin           A.P. | 18.9 |  13.0 |   --  |  875 |   52
  Potato chips           A.P. |  6.8 |  39.8 |  46.7 | 2598 |   17
  Potatoes, white,            |      |       |       |      |
    raw                  E.P. |  2.2 |    .1 |  18.4 |  378 |  120
                         A.P. |  1.8 |    .1 |  14.7 |  302 |  149
    sweet, raw           E.P. |  1.8 |    .7 |  27.4 |  558 |   81
                         A.P. |  1.4 |    .6 |  21.9 |  447 |  102
  Prunes, dried          E.P. |  2.1 |   --  |  73.3 | 1368 |   33
                         A.P. |  1.8 |   --  |  62.2 | 1160 |   39
  Pumpkins               E.P. |  1.0 |    .1 |   5.2 |  117 |  389
                         A.P. |   .5 |    .1 |   2.6 |   60 |  753
  Radishes               E.P. |  1.3 |    .1 |   5.8 |  133 |  341
                         A.P. |   .9 |    .1 |   4.0 |   91 |  488
  Raisins                E.P. |  2.6 |   3.3 |  76.1 | 1562 |   29
                         A.P. |  2.3 |   3.0 |  68.5 | 1407 |   32
  Raspberries, red            |  1.0 |   --  |  12.6 |  247 |  184
    black                     |  1.7 |   1.0 |  12.6 |  300 |  151
  Rhubarb                E.P. |   .6 |    .7 |   3.6 |  105 |  433
                         A.P. |   .4 |    .4 |   2.2 |   63 |  714
  Rice                        |  8.0 |    .3 |  79.0 | 1591 |   29
  Salmon, dressed        A.P. | 13.8 |   8.1 |   --  |  582 |   78
    whole                E.P. | 22.0 |  12.8 |   --  |  923 |   49
                         A.P. | 15.3 |   8.9 |   --  |  642 |   71
  Sausage, Bologna       E.P. | 18.7 |  17.6 |    .3 | 1061 |   43
                         A.P. | 18.2 |  19.7 |   --  | 1135 |   40
    farmer               E.P. | 29.0 |  42.0 |   --  | 2240 |   20
                         A.P. | 27.9 |  40.4 |   --  | 2156 |   21
  Shad, whole            E.P. | 18.8 |   9.5 |   --  |  727 |   61
                         A.P. |  9.4 |   4.8 |   --  |  367 |  124
    roe                       | 20.9 |   3.8 |   2.6 |  582 |   78
  Shredded wheat              | 10.5 |   1.4 |  77.9 | 1660 |   27
  Spinach, fresh         A.P. |  2.1 |    .3 |   3.2 |  109 |  417
  Squash                 E.P. |  1.4 |    .5 |   9.0 |  209 |  217
                         A.P. |   .7 |    .2 |   4.5 |  103 |  443
  Strawberries                |  1.0 |    .6 |   7.4 |  169 |  269
  Succotash, canned           |  3.6 |   1.0 |  18.6 |  444 |  102
  Sugar                       |  --  |   --  | 100.0 | 1815 |   25
  Tomatoes, fresh        A.P. |   .9 |    .4 |   3.9 |  104 |  438
    canned               A.P. |  1.2 |    .2 |   4.0 |  103 |  443
  Tuna (tunny fish)      E.P. | 26.6 |  11.4 |   --  |  946 |   48
  Turkey                 E.P. | 21.1 |  22.9 |   --  | 1320 |   34
                         A.P. | 16.1 |  18.4 |   --  | 1042 |   43
    sandwich, canned          | 20.7 |  29.2 |   --  | 1568 |   29
  Turnips                E.P. |  1.3 |    .2 |   8.1 |  178 |  256
                         A.P. |   .9 |    .1 |   5.7 |  124 |  367
  Veal, breast           E.P. | 20.3 |  11.0 |   --  |  817 |   56
                         A.P. | 15.3 |   8.6 |   --  |  629 |   72
    cutlet               E.P. | 20.3 |   7.7 |   --  |  683 |   66
                         A.P. | 20.1 |   7.5 |   --  |  670 |   68
    fore quarter         E.P. | 20.0 |   8.0 |   --  |  690 |   66
                         A.P. | 15.1 |   6.0 |   --  |  517 |   88
    hind quarter         E.P. | 20.7 |   8.3 |   --  |  715 |   64
                         A.P. | 16.2 |   6.6 |   --  |  534 |   85
    side                 E.P. | 20.2 |   8.1 |   --  |  697 |   65
                         A.P. | 15.6 |   6.3 |   --  |  539 |   84
  Vegetable soup,             |      |       |       |      |
      canned                  |  2.9 |   --  |    .5 |   62 |  735
  Walnuts, California         |      |       |       |      |
    or English           E.P. | 18.4 |  64.4 |  13.0 | 3199 |   14
                         A.P. |  4.9 |  17.3 |   3.5 |  859 |   53
    black                E.P. | 27.6 |  56.3 |  11.7 | 3011 |   15
                         A.P. |  7.2 |  14.6 |   3.0 |  780 |   59
  Watermelons            E.P. |   .4 |    .2 |   6.7 |  136 |  332
                         A.P. |   .2 |    .1 |   2.7 |   57 |  800
  Wheat, cracked              | 11.1 |   1.7 |  75.5 | 1635 |   28
  Whitefish              E.P. | 22.9 |   6.5 |   --  |  680 |   67
                         A.P. | 10.6 |   3.0 |   --  |  315 |  144
  Zwieback                    |  9.8 |   9.9 |  73.5 | 1915 |   24
  ============================+======+=======+=======+======+=======


FOOTNOTES:

[165] Courtesy of Dr. Henry Sherman.

[166] The percentages of nutrients are taken from Bull. 28, Office of
Experiment Stations, U. S. Department of Agriculture. The fuel values
are calculated from these percentages by the use of the factors
explained in Chapter II, viz.--protein, 4 calories; fat, 9 calories;
carbohydrate, 4 calories per gram.


TABLE II[167]

ASH CONSTITUENTS OF FOODS IN PERCENTAGE OF THE EDIBLE PORTION
(Compiled from various sources)

KEY:
  A Calcium (Ca)
  B Magnesium (Mg)
  C Potassium (K)
  D Sodium (Na)
  E Phosphorus (P)
  F Chlorine (Cl)
  G Sulphur (S)
  H Iron (Fe)

  ===============+======+======+=======+======+======+=======+======+=======
      _Food_     |  A   |   B  |   C   |  D   |   E  |   F   |   G  |  H
  ---------------+------+------+-------+------+------+-------+------+-------
  Almonds        | .239 | .251 |  .741 | .019 | .465 |  .037 | .160 | .0039
  Apples         | .007 | .008 |  .127 | .011 | .012 |  .005 | .006 | .0003
    dried        | .032 | .037 | (.623)|(.050)| .048 | (.025)|   ?  |(.0015)
  Apricots       | .014 | .010 |  .248 | .038 | .025 |  .002 | .010 |(.0003)
    dried        |(.066)|(.047)|(1.157)|(.177)|(.117)| (.009)|   ?  |(.0014)
  Asparagus      | .025 | .011 |  .196 | .007 | .039 |  .039 | .041 | .0010
  Bacon (See     |      |      |       |      |      |       |      |
    Meat)        |      |      |       |      |      |       |      |
  Bananas        | .009 | .028 |  .401 | .034 | .031 |  .125 | .010 | .0006
  Barley, entire | .043 | .141 |  .477 | .076 | .400 |  .016 | .153 | .0041
    pearled      | .020 |(.070)| (.241)|(.037)| .181 | (.016)|(.120)|(.0020)
  Beans, dried   | .160 | .156 | 1.229 | .097 | .471 |  .032 | .215 | .0070
    kidney, dry  | .132 | .139 | 1.144 | .041 | .475 |  .041 | .227 | .0072
    Lima, dry    | .071 | .188 | 1.741 | .249 | .338 |  .026 | .161 | .0070
    Lima, fresh  | .028 |(.070)| (.613)|(.088)| .133 | (.009)|(.057)| .0020
    string, fresh| .046 | .025 |  .24  | .019 | .052 |  .024 | .030 | .0011
  Beef (See Meat)|      |      |       |      |      |       |      |
  Beer           | .004 | .008 |  .058 | .013 | .028 |  .006 | .015 | .0001
  Beets          | .029 | .021 |  .353 | .093 | .039 |  .058 | .016 | .0006
  Blackberries   | .017 | .021 |  .169 |(.007)| .034 | (.010)| .020 | .0006
  Blood (avg.)   | .008 | .004 |  .075 | .261 | .031 |  .280 | .137 | .0526
  Blueberries    | .020 | .007 |  .051 | .016 | .008 |  .008 | .011 | .0009
  Bluefish (See  |      |      |       |      |      |       |      |
    Fish)        |      |      |       |      |      |       |      |
  Bread,         |      |      |       |      |      |       |      |
    Boston brown | .129 | .078 | (.232)|(.394)| .185 | (.607)| .201 |(.0030)
    entire wheat |(.05) |(.05) | (.208)|(.394)|(.175)| (.607)|(.120)|(.0016)
    graham       |(.05) |(.05) | (.291)|(.394)|(.218)| (.607)| .150 |(.0025)
    rye          | .024 | .039 |  .151 | .701 | .148 | 1.025 | .104 |(.0016)
    white        | .027 | .023 |  .108 |(.394)| .093 | (.607)| .105 | .0009
  Breadfruit     | .084 | .007 |  .235 | .027 | .068 |  .100 | .049 |
  Brussels       |      |      |       |      |      |       |      |
    sprouts      | .027 | .040 |  .375 | .004 | .120 |  .040 | .194 |(.0011)
  Buckwheat flour| .039 | .048 |  .130 | .027 | .226 |  .012 | .071 | .0012
  Butter         | .015 | .001 |  .014 |(.788)| .017 |(1.212)|(.010)| .0002
  Buttermilk     | .105 | .016 |  .151 | .064 | .097 |  .099 | .026 | .00025
  Cabbage        | .045 | .015 |  .247 | .027 | .029 |  .024 | .066 | .0011
  Cabbage greens | .106 | .030 |  .512 | .025 | .099 |  .068 | .173 | .0018
  Cantaloupe     | .017 | .012 |  .235 | .061 | .015 |  .041 | .014 | .0003
  Capers         | .122 | .022 |  .209 | .051 | .062 |   --  |  --  |  --
  Carp (See Fish)|      |      |       |      |      |       |      |
  Carrots        | .056 | .021 |  .287 | .101 | .046 |  .036 | .022 | .0006
  Cauliflower    | .123 | .014 |  .222 | .068 | .061 |  .050 | .086 | .0006
  Caviar         | .137 | .022 |  .422 | .874 | .176 | 1.819 |  --  |  --
  Celery         | .078 | .014 |  .316 | .084 | .037 |  .156 | .022 | .0005
  Chard          | .150 | .071 |  .318 | .086 | .040 |  .039 | .124 |(.0025)
  Cheese         | .931 | .037 |  .089 | .606 | .683 |  .880 | .263 | .0013
  Cherries       | .019 | .016 |  .213 | .023 | .031 |  .014 | .011 | .0004
  Cherry juice   | .017 | .011 |  .200 | .013 | .018 |  .003 | .006 |(.0003)
  Chestnuts      | .034 | .051 |  .560 | .065 | .093 |  .006 | .068 | .0007
  Chicken (See   |      |      |       |      |      |       |      |
      Meat)      |      |      |       |      |      |       |      |
  Chocolate      | .092 |(.293)| (.563)| .012 | .455 | (.051)| .085 |(.0027)
  Cider          | .008 | .011 |  .095 | .020 | .009 |  .006 | .006 |(.0002)
  Citron         | .121 | .018 |  .210 | .011 | .033 |  .003 | .020 |  --
  Clams, round   | .106 | .098 |  .131 | .705 | .046 | 1.220 | .224 |  --
    soft, long   | .124 | .079 |  .212 | .500 | .122 |  .910 | .213 |  --
  Cocoa          | .112 | .420 |  .900 | .059 | .709 |  .051 | .203 | .0027
  Coconut, dried | .059 | .059 |  .597 | .073 | .155 |  .239 |(.056)|  --
    fresh        | .024 | .020 |  .300 | .036 | .074 |  .120 | .028 |  --
  Coconut milk   | .020 | .009 |  .144 |  --  | .010 |   --  | .008 |  --
  Cod (See Fish) |      |      |       |      |      |       |      |
  Corn (maize),  |      |      |       |      |      |       |      |
    mature       | .020 | .121 |  .339 | .036 | .283 |  .045 | .151 | .0029
    meal         | .018 | .084 |  .213 | .039 | .190 |  .146 | .111 | .0009
    sweet        | .006 | .033 |  .113 | .040 | .103 |  .014 | .046 | .0008
    sweet, dried | .021 | .121 |  .414 | .146 | .376 |  .050 | .167 | .0029
  Cotton seed    |      |      |       |      |      |       |      |
    meal         | .265 | .462 | 1.390 | .234 |1.193 |  .037 | .485 |  --
  Cowpeas        | .100 | .208 | 1.402 | .161 | .456 |  .040 | .240 |  --
  Crackers       | .022 | .011 |  .100 |(.594)| .102 | (.910)| .125 | .0015
  Cranberries    | .018 | .007 |  .077 | .010 | .013 |  .009 | .007 | .0006
  Cream          | .086 | .010 |  .126 | .035 | .067 |  .080 | .030 | .00022
  Cucumbers      | .016 | .009 |  .140 | .010 | .033 |  .030 | .020 | .0002
  Currants,      |      |      |       |      |      |       |      |
    dried        | .082 | .044 |  .873 | .081 | .195 |  .060 | .044 |(.0025)
    fresh        | .026 | .017 |  .211 | .007 | .038 |  .006 | .014 | .0005
  Currant juice  | .021 | .010 |  .185 |(.006)| .018 |  .004 | .005 |  --
  Dandelion      | .105 | .036 |  .461 | .168 | .072 |  .099 | .017 | .0027
  Dates          | .065 | .069 |  .611 | .055 | .056 |  .228 | .070 | .0030
  Duck (See      |      |      |       |      |      |       |      |
      Meat)      |      |      |       |      |      |       |      |
  Eggplant       | .011 | .015 | (.140)|(.010)| .034 |  .024 | .016 | .0005
  Eggs           | .067 | .011 |  .140 | .143 | .180 |  .106 | .195 | .0030
  Egg white      | .015 | .010 |  .160 | .156 | .014 |  .155 | .216 | .0001
  Egg yolk       | .137 | .016 |  .115 | .075 | .524 |  .094 | .166 | .0086
  Endive         | .104 | .013 |  .380 | .109 | .038 |  .167 | .035 |  --
  Farina         | .021 | .025 |  .120 | .065 | .125 |  .076 | .155 | .0008
  Figs, dried    | .162 | .071 |  .964 | .046 | .116 |  .043 | .056 | .0030
    fresh        | .053 | .022 |  .303 | .012 | .036 |  .014 | .010 |  --
  Fish[168]      |      |      |       |      |      |       |      |
  Flaxseed       | .204 | .252 |  .901 | .050 | .627 |  .022 | .170 |  --
  Flour,         |      |      |       |      |      |       |      |
    buckwheat    | .010 | .048 |  .130 | .027 | .176 |  .012 | .071 | .0012
    entire wheat | .031 |(.090)| (.274)|(.037)| .238 | (.070)|(.180)| .0025
    graham       | .039 |(.133)| (.457)|(.037)| .364 | (.070)| .183 | .0037
    white        | .020 | .018 |  .115 | .060 | .092 |  .074 | .177 | .0010
    rye          | .018 | .081 |  .463 | .019 | .289 |  .055 | .123 | .0013
  Fowl (See Meat)|      |      |       |      |      |       |      |
  Gluten feed    | .247 | .221 |  .250 | .420 | .542 |  .090 | .558 |  --
  Goose (See     |      |      |       |      |      |       |      |
      Meat)      |      |      |       |      |      |       |      |
  Gooseberries   | .035 | .014 |  .197 | .038 | .031 |   --  | .011 | .0005
  Grapefruit     | .021 | .009 |  .161 | .004 | .020 |  .005 | .010 | .0003
  Grape juice    | .011 | .009 |  .106 | .005 | .011 |  .002 | .009 | .0003
  Grapes         | .019 | .010 |  .197 | .015 | .031 |  .005 | .024 | .0003
  Guava          | .014 | .008 |  .384 |  --  | .030 |  .045 |  --  |  --
  Haddock (See   |      |      |       |      |      |       |      |
      Fish)      |      |      |       |      |      |       |      |
  Halibut (See   |      |      |       |      |      |       |      |
      Fish)      |      |      |       |      |      |       |      |
  Ham (See Meat) |      |      |       |      |      |       |      |
  Hazelnuts      | .287 | .140 |  .618 | .019 | .354 |  .067 | .198 | .0041
  Herring (See   |      |      |       |      |      |       |      |
      Fish)      |      |      |       |      |      |       |      |
  Hominy         | .011 | .058 |  .174 | .020 | .144 |  .046 |(.136)|(.0009)
  Honey          | .004 | .018 |  .386 | .001 | .019 |  .029 | .001 | .0007
  Horseradish    | .096 | .039 |  .468 | .062 | .076 |  .016 | .190 |  --
  Huckleberries  | .020 | .007 |  .051 | .016 | .008 |  .008 | .011 | .0009
  Huckleberry    |      |      |       |      |      |       |      |
    wine         | .009 | .004 |  .042 | .006 | .004 |  .001 | .006 |  --
  Jam[169]       |      |      |       |      |      |       |      |
  Jelly          | .014 |(.010)| (.100)|(.013)| .008 | (.004)|(.007)|(.0003)
  Kohl-rabi      | .077 | .033 |  .370 | .050 | .071 |  .053 | .057 | .0006
  Lamb (See      |      |      |       |      |      |       |      |
      Meat)      |      |      |       |      |      |       |      |
  Leeks          | .058 | .014 |  .199 | .081 | .006 |  .024 | .072 |  --
  Lemons         | .036 | .007 |  .175 | .004 | .022 |  .002 | .011 | .0006
  Lemon juice    | .024 | .010 |  .127 | .009 | .010 |  .003 | .006 |  --
  Lemon, sweet   | .030 | .006 |  .442 |  --  | .042 |  .013 | .016 |  --
  Lentils, dry   | .107 | .101 |  .877 | .062 | .438 |  .050 | .277 | .0086
  Lettuce        | .043 | .017 |  .339 | .027 | .042 |  .074 | .014 | .0007
  Limes          | .055 | .014 |  .350 | .062 | .036 |  .039 | .011 |  --
  Lime juice     |  --  |  --  |   --  |  --  |  --  |   --  | .003 |  --
  Linseed meal   | .413 | .432 | 1.083 | .251 | .741 |  .085 | .396 |  --
  Lupins, dry    | .191 | .191 |  .840 | .073 | .520 |  .034 |  --  |  --
    fresh        | .053 | .022 |  .303 | .012 | .036 |  .014 | .010 |  --
  Macaroni       | .022 | .037 |  .130 | .008 | .144 |  .073 | .172 | .0012
  Mackerel (See  |      |      |       |      |      |       |      |
      Fish)      |      |      |       |      |      |       |      |
  Mamey          | .009 | .012 |  .345 |  --  | .028 |  .140 |  --  |  --
  Mango          | .021 | .007 |  .235 |  --  | .017 |  .019 | .013 |  --
  Mangolds       | .026 | .030 |  .334 | .071 | .038 |  .082 | .026 |  --
  Maple syrup    | .107 | .034 |  .208 | .010 | .013 | (.010)|(.005)|(.003)
  Meat[170]      |      |      |       |      |      |       |      |
  Meat extract,  |      |      |       |      |      |       |      |
    solid        | .085 | .363 | 7.347 |2.394 |2.800 | 3.117 |  --  |  --
  Meat peptone   | .025 | .124 | 2.440 | .641 |1.130 |  .561 | .222 |  --
  Milk (cow's),  |      |      |       |      |      |       |      |
    whole        | .120 | .012 |  .143 | .051 | .093 |  .106 | .034 | .00024
    skimmed      |(.122)|(.012)| (.149)|(.052)|(.096)| (.110)|(.035)| .00025
    condensed    |(.300)|(.032)| (.374)|(.134)| .235 | (.280)|(.090)| .0006
    buffalo      | .203 | .016 |  .099 | .038 | .125 |  .062 |  --  |  --
    camel's      | .143 | .021 |  .114 | .019 | .098 |  .105 |  --  |  --
    goat's       | .128 | .013 |  .145 | .079 | .103 |  .014 | .037 |  --
    human        | .034 | .005 |  .047 | .010 | .015 |  .035 |  --  |  --
    mare's       | .083 | .007 |  .081 | .010 | .054 |  .029 |  --  |  --
    sheep's      | .207 | .008 |  .187 | .030 | .123 |  .071 |  --  |  --
  Millet         | .014 | .167 |  .290 | .085 | .327 |  .019 |  --  |  --
  Molasses       | .211 | .068 | 1.349 | .019 | .044 |  .317 | .129 | .0073
  Mushrooms      | .017 | .016 |  .384 | .027 | .108 |  .021 | .051 |  --
  Muskmelon      | .017 | .012 |  .235 | .061 | .015 |  .041 | .014 | .0003
  Mustard        | .492 | .260 |  .761 | .056 | .755 |  .016 |1.230 |  --
  Mutton (See    |      |      |       |      |      |       |      |
      Meat)      |      |      |       |      |      |       |      |
  Oatmeal        | .069 | .110 |  .344 | .062 | .392 |  .069 | .202 | .0038
  Okra           | .071 | .010 |  .035 | .043 | .019 |   --  |  --  |  --
  Olives         | .122 | .002 | 1.526 | .128 | .014 |  .004 | .027 | .0029
  Onions         | .034 | .016 |  .178 | .016 | .045 |  .021 | .070 | .0006
  Oranges        | .045 | .012 |  .177 | .012 | .021 |  .006 | .011 | .0002
  Orange juice   | .029 | .011 |  .182 | .008 | .016 |  .003 | .009 | .0002
  Oysters        | .052 | .037 |  .091 | .459 | .155 |  .590 | .187 | .0045
  Paprika        | .229 | .164 | 2.075 | .178 | .341 |  .155 |  --  |  --
  Parsnips       | .059 | .034 |  .518 | .004 | .076 |  .030 | .036 | .0006
  Peaches        | .016 | .010 |  .214 | .022 | .024 |  .004 | .009 | .0003
    dried        | .034 | .056 | (.830)| .082 | .146 |   --  | .212 |(.0012)
  Peanuts        | .071 | .180 |  .654 | .050 | .399 |  .056 | .224 | .0020
  Pears          | .015 | .011 |  .132 | .016 | .026 |  .011 | .010 | .0003
  Pear juice     | .009 | .008 |  1.40 |  --  | .011 |   --  | .009 |  --
  Peas, dried    | .084 | .149 |  .903 | .104 | .400 |  .035 | .219 | .0057
    fresh        | .028 | .038 |  .285 | .013 | .127 |  .024 | .063 | .0017
  Pecan nuts     | .089 | .152 | (.332)|  --  | .335 |  .050 | .113 | .0026
  Pepper, green, |      |      |       |      |      |       |      |
    fresh        | .006 | .010 | (.139)|  --  | .026 |  .013 | .014 | .0004
  Pepper, black, |      |      |       |      |      |       |      |
    dry          | .440 | .156 | 1.140 | .131 | .188 |  .312 |  --  |  --
  Pepper, white, |      |      |       |      |      |       |      |
    dry          | .425 | .113 |   --  |  --  | .233 |  .029 |  --  |  --
  Perch (See     |      |      |       |      |      |       |      |
      Fish)      |      |      |       |      |      |       |      |
  Persimmons     | .022 | .009 |  .292 | .011 | .021 |  .002 | .005 |  --
  Pineapple      | .018 | .011 |  .321 | .016 | .028 |  .051 | .009 | .0005
  Plums          | .020 | .011 |  .203 | .019 | .032 |  .002 | .009 | .0005
  Pomegranate    | .011 | .005 |  .063 | .085 | .105 |  .003 |  --  | .0004
  Pork (See      |      |      |       |      |      |       |      |
      Meat)      |      |      |       |      |      |       |      |
  Potatoes       | .014 | .028 |  .429 | .021 | .058 |  .038 | .030 | .0013
    sweet        | .019 | .028 |  .397 | .039 | .045 |  .094 | .024 | .0005
  Prunes, dried  | .054 | .055 | 1.030 | .069 | .105 |  .017 | .037 | .0030
  Pumpkin        | .023 | .008 | (.320)| .065 | .059 |   --  | .021 |(.0008)
  Radishes       | .021 | .012 |  .218 | .069 | .029 |  .054 | .041 | .0006
  Raisins        | .064 | .083 |  .820 | .133 | .132 |  .082 | .051 | .0021
  Raspberries    | .049 | .024 |  .173 |  --  | .052 |   --  | .017 | .0006
  Raspberry juice| .021 | .016 |  .134 | .005 | .012 |   --  | .009 |  --
  Rhubarb        | .044 | .017 |  .325 | .025 | .031 |  .036 | .013 | .0010
  Rice, brown    |  --  |  --  |   --  |  --  | .207 |   --  |  --  | .0020
    white        | .009 | .033 |  .070 | .025 | .096 |  .054 | .117 | .0009
  Romaine        |      |      |       |      |      |       |      |
    (salad)      | .045 | .032 |  .306 | .016 | .053 |  .073 | .019 |  --
  Rutabagas      | .074 | .018 |  .399 | .083 | .056 |  .058 | .083 |  --
  Rye, entire    | .055 | .130 |  .453 | .035 | .385 |  .025 | .170 | .0039
      (See also  |      |      |       |      |      |       |      |
      Bread and  |      |      |       |      |      |       |      |
      Flour)     |      |      |       |      |      |       |      |
  Salmon (See    |      |      |       |      |      |       |      |
      Fish)      |      |      |       |      |      |       |      |
  Sapota         | .026 | .008 |  .179 |  --  | .006 |  .087 |  --  |  --
  Shredded       |      |      |       |      |      |       |      |
    wheat        | .041 | .144 |   --  |  --  | .324 |   --  |  --  | .0045
  Shrimp         | .096 |  --  |   --  |  --  |  --  |   --  |  --  |  --
  Soup, canned   | .036 |  --  |  .033 |  --  | .030 |   --  |  --  |  --
    canned       |      |      |       |      |      |       |      |
      vegetable  | .025 | .013 |  .101 |  --  | .038 |   --  | .025 |  --
  Spinach        | .067 | .037 |  .774 | .125 | .068 |  .074 | .038 | .0036
  Squash, summer,|      |      |       |      |      |       |      |
    seeds removed| .018 | .008 |  .150 | .002 |  --  |   --  |  --  |(.0006)
    with seeds   | .024 | .012 |  .180 | .004 |  --  |   --  |  --  |(.0006)
  Squash, winter | .019 | .011 |  .320 | .004 |  --  |   --  |  --  |(.0006)
  Strawberries   | .041 | .019 |  .147 | .050 | .028 |  .006 | .014 | .0008
  Tamarind       | .007 | .021 |   --  |  --  | .072 |  .007 | .009 |  --
  Tapioca        | .023 |  --  |   --  |  --  | .090 |  .018 | .029 | .0016
  Tomatoes       | .011 | .010 |  .275 | .010 | .026 |  .034 | .014 | .0004
  Tomato juice   | .006 | .010 |  .310 | .015 | .015 |  .055 |  --  |  --
  Truffles       | .024 | .018 |  .404 | .077 | .062 |  .039 |  --  |  --
  Turnips        | .064 | .017 |  .338 | .056 | .046 |  .041 | .065 | .0005
  Turnip tops    | .347 | .028 |  .307 | .082 | .049 |  .168 | .069 |  --
  Veal (See Meat)|      |      |       |      |      |       |      |
  Vinegar (cider)| .016 | .008 |  .165 |  --  | .013 |   --  | .017 |(.0003)
  Walnuts        | .089 | .134 | (.332)|  --  | .358 |  .040 | .172 | .0021
  Water cress    | .187?| .034 |  .287 | .099 | .005 |  .061 | .167 | .0019
  Watermelon     | .011 | .003 |  .073 | .008 | .003 |  .008 | .007 |  --
  Wheat, entire  | .045 | .133 |  .473 | .039 | .423 |  .068 | .181 | .0050
      (See also  |      |      |       |      |      |       |      |
      Bread and  |      |      |       |      |      |       |      |
      Flour)     |      |      |       |      |      |       |      |
  Wheat bran     | .120 | .511 | 1.217 | .154 |1.215 |  .090 | .247 | .0078
  Wheat germ     | .071 | .342 |  .296 | .722 |1.050 |  .070 | .325 |  --
  Wheat gluten   | .078 | .045 |  .007 | .028 |2.00  |  .050 | .920 |  --
  Whey           | .044 | .008 |  .157 | .038 | .035 |  .119 | .009 |   ?
  Whortleberries,|      |      |       |      |      |       |
    entire       | .031 | .021 |  .261 | .021 | .042 |   --  |  --  |  --
    flesh only   | .020 | .011 |  .087 |  --  | .018 |   --  |  --  |  --
  Wine (avg.)    | .009 | .010 |  .104 | .008 | .015 |  .011 | .015 |(.0003)
  ===============+======+======+=======+======+======+=======+======+=======


FOOTNOTES:

[167] From Sherman's "Chemistry of Food and Nutrition," by courtesy of
the author.

[168] Average fish is estimated to contain _per 100 grams of protein_ as
follows: 0.109 gram Ca; 0.133 gram Mg; 1.671 grams K; 0.373 gram Na;
1.148 grams P; 0.528 gram Cl; 1.119 grams S; 0.0055 gram Fe.

[169] The percentages of the ash constituents in jams are believed to
average about two thirds those of the corresponding fruits.

[170] Average meat is estimated to contain _per 100 grams protein_ as
follows: 0.058 gram Ca; 0.118 gram Mg; 1.694 grams K; 0.421 gram Na;
1.078 grams P; 0.378 gram Cl; 1.146 grams S; 0.0150 gram Fe.


TABLE III

Showing 100-Calorie Portions of Some Common Foods--Together with Their
Protein, Nitrogen, and Mineral Content[171]

KEY
  A _Protein Calories_
  B _Protein Grams_
  C _Nitrogen Grams_
  D _Calcium Grams_
  E _Phosphorus Grams_
  F _Iron Grams_

  ==================+===================+=====+=====+=====+====+=====+======
     _Material_     |     _Measure_     |  A  |  B  |  C  | D  |  E  |  F
                    |     _Portion_     |     |     |     |    |     |
  ------------------+-------------------+-----+-----+-----+----+-----+------
  Almonds           |12 - 15 nuts       |12.9 | 3.2 | .051|.037| .072|.0006
  Apples, dried     |1/2 cup, 1.2 oz.   | 2.5 |  .6 |0.10 |.108| .163|.0005
  Apples, fresh     |1 large apple,     |     |     |     |    |     |
                    |  7.5 oz.          | 2.4 | 0.6 | .096|.012| .020|.0005
  Apricots, dried   |9 halves, 1.3 oz.  | 7.6 | 1.9 |0.30 |.123| .044|.0005
  Asparagus, fresh  |20 stalks, 8 in.   |     |     |     |    |     |
                    |  long, 15.9 oz.   |32.4 | 8.1 |1.29 |.122| .177|.0045
                    |                   |     |     |     |    |     |
  Bacon, fried      |4 - 5 small        |     |     |     |    |     |
                    |  slices, 5 oz.    | 6.8 | 1.7 | .27 |.001| .018|.0003
  Bananas           |1 large, 5.5 oz.   | 5.3 | 1.3 | .02 |.009| .031|.0006
  Beans, Lima, dried|2 tbs., 1 oz.      |23.2 | 5.8 | .92 |.020| .096|.00200
  Beans, Lima, fresh|1/2 cup, 2.9 oz.   |23   | 5.7 | .92 |.001| .007|.00011
  Beans, string     |2-1/2 cups, cut in |     |     |     |    |     |
                    |  pieces, 8.5 oz.  |22.4 | 5.6 | .89 |.110| .126|.0027
  Beans, white,     |                   |     |     |     |    |     |
    dried           |2 tbs., 1 oz.      |26.0 | 6.5 |1.4  |.047| .137|.0020
  Beets             |4 beets, 2 in.     |     |     |     |    |     |
                    |  diam., 7 oz.     |14.0 | 3.5 |0.56 |.064| .084|.0013
  Beef, round, lean |1 slice,           |     |     |     |    |     |
                    |  3 × 3 × 1-1/2    |     |     |     |    |     |
                    |   in., 2 oz.      |48.0 |12.0 |1.92 |.007| .129|.0018
  Beef feet         |slice,             |     |     |     |    |     |
                    |  5 × 2-1/2 × 1/4  |     |     |     |    |     |
                    |    in., 1.6 oz.   |30.0 | 7.5 |1.6  |.004| .081|.0011
  Butter            |1 (scant) tbs.,    |     |     |     |    |     |
                    |  0.5 oz.          | 1.6 | 0.4 | .064|.002| .002|.00003
  Cabbage           |5 cups, sliced,    |     |     |     |    |     |
                    |  11.2 oz.         |20.4 | 5.1 |0.89 |.143| .092|.0035
  Carrots           |4 - 5 young car.,  |     |     |     |    |     |
                    |  10.5 oz.         | 9.6 | 2.4 |0.384|.124| .101|.0013
  Cauliflower       |1 small head,      |     |     |     |    |     |
                    |  11.5 oz.         |23.6 | 5.9 |0.944|.403| .200|.0020
  Celery            |4 cups, in 1-in.   |     |     |     |    |     |
                    |  pieces           | 5.2 | 1.3 |0.20 |.421| .201|.0027
  Clams             |6 clams, 1/2 cup,  |     |     |     |    |     |
                    |  7.6 oz.          |79.2 |19.8 |3.16 |.285| .282|.0097
  Cheese, American  |1-1/8 in. cube     |     |     |     |    |     |
                    |  (0.8 oz.)        |24.4 | 6.1 |0.97 |.211| .156|.0003
  Cherries (stoned) |1 cup, 4.5 oz.     | 4.8 | 1.2 |0.19 |.025| .039|.0005
  Chicken, lean     |                   |     |     |     |    |     |
    meat, roasted   |2-1/2 oz.          |79.6 |19.9 |3.19 |.006| .075|.0029
  Crackers, soda    |4 crackers         | 9.6 | 2.4 |0.38 |.006| .025|.0004
  Cornmeal          |3 tbs., 1 oz.      |10.4 | 2.6 |0.41 |.005| .053|.0003
  Corn              |1/3 cup, 3.6 oz.   |12.4 | 3.1 |0.49 |.006| .102|.0008
  Chocolate,        |                   |     |     |     |    |     |
    unsweetened     |3/4 × 1/4 × 7/8 in.|     |     |     |    |     |
                    |  piece            | 8.4 | 2.1 |0.33 |.015| .075|.0004
  Cocoa             |3-1/2 tbs., 0.7 oz.|17.6 | 4.4 |0.49 |.023| .143|.0005
  Cream, 18% (thin) |1/4 cup, 1.8 oz.   | 5.2 | 1.3 |9.20 |.050| .044|.0001
  Cream, 40% (thick)|1-1/3 tbs., 0.9 oz.| 2.4 | 0.6 |0.096|.020| .020|.00005
                    |                   |     |     |     |    |     |
  Dates             |4-1/2 dates,       |     |     |     |    |     |
                    |  1.1 oz.          | 2.4 | 0.6 |0.096|.019| .016|.0009
                    |                   |     |     |     |    |     |
  Eggs              |1-1/3 eggs         |36.4 | 9.1 |1.45 |.045| .122|.0021
  Egg whites        |7 whites, 6.9 oz.  |96.48|24.12|3.85 |.020| .022|.00020
  Egg yolks         |2 yolks, 1 oz.     |17.28| 4.32| .691|.036| .118|.00230
  Farina            |3 tbs., 1 oz.      |12.4 | 3.1 | .496|.006| .035|.0002
  Fish, lean        |piece,             |     |     |     |    |     |
                    |  3 × 3 × 1/2 in., |     |     |     |    |     |
                    |  2.4 oz.          |90.4 |22.6 |3.61 |.025| .259|.0012
  Fish, oily        |                   |53.2 |13.3 |2.12 |.015| .153|.0007
  Figs              |1-1/2 large figs,  |     |     |     |    |     |
                    |  1.1 oz.          | 5.6 | 1.4 | .224|.051| .037|.0010
  Flour, entire     |                   |     |     |     |    |     |
      wheat         |3 tbs., 1 oz.      |15.6 | 3.9 | .624|.009| .066|.0007
    graham          |3 tbs., 1 oz.      |14.8 | 3.7 | .592|.011| .101|.0010
    rye             |3 tbs., 1 oz.      | 8.0 | 2.0 | .32 |.005| .082|.0004
    white           |4 tbs., 1 oz.      |12.8 | 3.2 | .572|.006| .026|.0002
                    |                   |     |     |     |    |     |
  Gelatin           |27 grams           |98.8 |24.9 |3.98 |    |     |
  Grapefruit        |2-3/4 tbs.         | 5.00| 1.25|     |.040| .036|.00058
  Grapes (Concord)  |1 large bunch,     |     |     |     |    |     |
                    |  5 oz.            | 5.6 | 1.4 |0.2  |.019| .032|.0003
  Grape juice       |1/2 cup, 3.6 oz.   | 1.40| 0.35| .05 |.011| .011|.0003
                    |                   |     |     |     |    |     |
  Hominy            |3-1/2 tbs., 1 oz.  | 9.6 | 2.4 |0.35 |.002| .027|.0003
  Honey             |1 tbs., 1.1 oz.    |  .4 | 0.1 |     |.002| .006|.0003
                    |                   |     |     |     |    |     |
  Lamb              |1 slice,           |     |     |     |    |     |
                    |  3-1/2 × 4-1/2    |     |     |     |    |     |
                    |  × 1/3 in.,       |     |     |     |    |     |
                    |  1.8 oz.          |25.6 | 6.4 | 1.02|.004| .069|.0010
  Lemons            |3 large, 11.4 oz.  | 9.2 | 2.3 | 0.36|.081| .049|.0014
  Lettuce           |2 large heads,     |     |     |     |    |     |
                    |  18.5 oz.         |25.2 | 6.3 |1.0  |.224| .224|.0079
  Lentils (dried)   |2-1/2 tbs., 1 oz.  |29.6 | 7.4 |1.18 |.031|1.26 |.0025
                    |                   |     |     |     |    |     |
  Macaroni          |1 cup              |14.8 | 3.7 |0.59 |.006| .040|.0003
  Milk, whole       |3/8 cup, 5.1 oz.   |19.2 | 4.8 |0.76 |.174| .134|.0009
    skimmed         |3/8 cup            |37.2 | 9.3 |1.48 |.331| .262|.0007
    unsweetened,    |                   |     |     |     |    |     |
      canned        |3-3/4 tbs., 2.1 oz.|23.2 | 5.8 |0.92 |.188| .146|.0004
    sweet, canned   |1-1/2 tbs., 1.1 oz.|10.4 | 2.6 |0.41 |.096| .072|.0002
    buttermilk      |1-1/8 cup, 10.0 oz.|33.6 | 8.4 |1.34 |.294| .271|.0007
  Milk powder[172]  |1 oz.              |     |     |     |    |     |
    malted          |                   |     |     |     |    |     |
    (Horlick's)[173]|1-1/2 tbs., 1.2 oz.|     |     |     |    |     |
  Molasses          |                   |     |     |     |    |     |
  Mutton            |1 slice, 3 × 3-1/4 |     |     |     |    |     |
                    |  × 1/8 inch       |24.8 | 6.2 |0.99 |.004| .067|.0009
                    |                   |     |     |     |    |     |
  Oatmeal           |1/3 cup, 1 oz.     |16.8 | 4.2 |0.67 |.017| .099|.0010
  Onions            |3 - 4 med.,        |     |     |     |    |     |
                    |  7.2 oz.          |13.2 | 3.3 |0.52 |.069| .093|.0010
  Orange            |1 large, 9.5 oz.   | 6.4 | 1.6 |0.25 |.088| .040|.0004
  Oysters (raw)     |6 - 12 oys., 2/3   |     |     |     |    |     |
                    |  cup, 7.2 oz.     |49.2 |12.3 |1.06 |.106| .306|.0089
                    |                   |     |     |     |    |     |
  Parsnip           |2 medium, 7.0 oz.  |10.0 | 2.5 |0.40 |.091| .117|.0009
  Peas, fresh       |3/4 cup, 3.5 oz.   |26.0 | 6.5 |1.04 |.026| .120|.0017
  Peaches, fresh    |3 medium, 60.5 oz. | 3.8 | 1.7 |0.27 |.038| .057|.0007
  Pears             |1 large, 6.3 oz.   | 4.0 | 1.0 |0.16 |.024| .041|.0005
  Peanuts           |20 - 24 single,    |     |     |     |    |     |
                    |  0.6 oz.          |18.8 | 4.7 |0.75 |.013| .073|.00049
  Pecans            |12 single, 0.51 oz.| 5.2 | 1.3 |0.2  |.012| .045|.0004
  Pepper (green)    |                   |18.0 | 4.5 |0.72 |.034| .145|.0022
  Pineapple         |2 slices 1 in.     |     |     |     |    |     |
                    |  thick, 8.2 oz.   | 3.6 | 0.9 |     |.041| .064|.0012
  Plums             |3 - 4 large,       |     |     |     |    |     |
                    |  4.4 oz.          | 4.8 | 1.2 |0.19 |.024| .038|.0006
  Potatoes (sweet)  |1/2 medium, 3.6 oz.| 6.0 | 1.5 |0.24 |.016| .037|.0004
  Potatoes (white)  |1 medium, 5.3 oz.  |10.8 | 2.7 |0.43 |.016| .069|.0016
  Prunes            |4 medium, 1.4 oz.  | 2.8 | 0.7 | .11 |.018| .035|.0010
                    |                   |     |     |     |    |     |
  Radishes          |36 small, 12 oz.   |17.6 | 4.4 |0.7  |.073| .098|.0021
  Rhubarb           |4 cups, cut in     |     |     |     |    |     |
                    |  small pieces,    |     |     |     |    |     |
                    |  15.3 oz.         |10.4 | 2.6 |0.41 |.189| .134|.0043
  Rice              |3 tbs., 1 oz.      | 9.2 | 2.3 |0.36 |.004| .027|.0003
                    |                   |     |     |     |    |     |
  Shredded wheat    |1 biscuit, 0.9 oz. |14.0 | 3.5 |0.55 |.011| .089|.0012
  Spinach           |3 cups, 14.7 oz.   |35.2 | 8.8 |1.40 |.281| .285|.0150
  Squash, summer    |                   |12.4 | 3.1 |0.49 |.039| .035|.0013
    winter          |                   |12.4 | 3.1 |     |.038| .069|.0013
  Strawberries      |1-1/3 cups, 9.0 oz.|10.24| 2.56|0.40 |.104| .072|.0021
  Tapioca           |3 tbs., 1.0 oz.    | 0.44| 0.11|0.017|.004|.025 |.0005
  Tomatoes, fresh   |2 - 3 medium,      |     |     |     |    |     |
                    |  15.5 oz.         |16.0 | 4.0 |0.64 |.050|.113 |.0018
    canned          |1-3/4 cup, 15.6 oz.|     |     |     |    |     |
  Turnips           |2 cups, cut in     |     |     |     |    |     |
                    |  cubes, 13.0 oz.  |13.2 | 3.3 |0.52 |.161|.117 |.0013
                    |                   |     |     |     |    |     |
  Veal              |slice, 2 × 2-3/4   |     |     |     |    |     |
                    |  inches, 2.3 oz.  |58.0 |14.5 |2.32 |.008|.156 |.0022
                    |                   |     |     |     |    |     |
  Walnuts, English  |16 - 18 nuts,      |
                    |  0.5 oz.          |10.4 | 2.6 |0.41 |.013|.015 |.0003
  Watermelon        |11.7 oz.           | 5.2 | 1.3 |0.20 |.038|.010 |.0010
    (edible portion)|                   |     |     |     |    |     |
  ==================+===================+=====+=====+=====+====+=====+======


FOOTNOTES:

[171] Table compiled from "Chemistry of Food and Nutrition,"
Sherman.--"A Laboratory Handbook for Dietetics," and "Feeding the
Family," Rose--and other sources.

[172] Milk powders now on market are made from skimmed or partially
skimmed milk.

[173] Horlick's malted milk. Analysis made in Horlick's Laboratories.


TABLE IV

COMPOSITION AND FUEL VALUE OF MOST OF THE FOODS USED IN THE INVALID
DIETARY

All determinations allow 28.35 grams to the ounce.

All calculations are made using the factor 4 calories for protein, 4
calories for carbohydrates, and 9 calories for fats.

The materials are measured in standard 8-ounce measuring cups, or
tablespoons. The measures are exactly level unless otherwise stated.
In calculating beverages containing alcohol, it is necessary to know
the percentage of alcohol contained therein. Alcohol has a fuel value
of 7 calories per gram. (Whether this heat is available for the needs
of the body is still a question.)

KEY
  A  _Nitrogen Gm._
  B1 _Proteins Per Cent_
  B2 _Proteins Gm._
  C1 _Fats Per cent_
  C2 _Fats Gm._
  D1 _Carbohydrates Per Cent_
  D2 _Carbohydrates Gm._
  E  _Fuel Value_

  =======================+===========+===========================+=======
       Material          |  Weight   |    Measure                |   A
  -----------------------+-----------+---------------------------+-------
  Almonds                |  1/2 oz.  | 6                         |   .48
  Apples                 |  5.5 oz.  | 1 medium                  |   .09
  Apricots               |           | 9 halves                  |   --
  Arrowroot              |    1 oz.  | 8 tablespoonfuls          |   --
  Artichoke, French      |    1 oz.  |                           |   .15
  Asparagus, fresh       |    4 oz.  | 6 stalks                  |   .33
  Asparagus, canned      |    4 oz.  | 1/2 cup                   |   .28
                         |           |                           |
  Bacon                  |    1 oz.  | 2 slices                  |   .35
  Bananas, E.P.[174]     | 3-1/2 oz. | 1 medium                  |   .20
  Barley, pearled        |    1 oz.  | 3 tablespoonfuls          |   .39
  Barley flour           |  1/2 oz.  | 1 tablespoonful           |   .16
  Bass                   |    3 oz.  | 1 serving                 |  2.53
  Beans, string          |    3 oz.  | 1 serving                 |   .31
  Beans, butter          |    3 oz.  | 1 serving                 |  1.26
  Beans, Lima, dried     |    1 oz.  |                           |   .81
  Beans, baked, canned   |    1 oz.  |                           |   .31
  Beef broth             |    1 oz.  | 2 tablespoonfuls          |  0.1
  Beef broth             |    6 oz.  | 1 cup                     |  0.3
  Beef soup[175]         |    6 oz.  | 1 cup                     |  1.18
  Beef juice             |    1 oz.  | 2 tablespoonfuls          |   .22
  Beef marrow            |  1/2 oz.  | 1 tablespoonful           |   .05
  Beefsteak, porterhouse |    3 oz.  | 1 serving                 |  2.99
  Beefsteak, sirloin     |    3 oz.  | 1 serving                 |  2.57
  Top of round           |    3 oz.  | 1 serving                 |  2.65
  Roast beef, second cut |    2 oz.  | 1 slice                   |  1.84
  Roast beef, second cut |    1 oz.  | 1 thin slice              |   .91
  Beets, cooked          |    1 oz.  |                           |   .10
  Bluefish               |    3 oz.  | 1 serving                 |  2.65
  Brandy                 |  1/2 oz.  | 1 tablespoonful           |   --
  Bran                   | 2-1/2 oz. | 1 cup                     |  1.25
  Bread                  |    1 oz.  | 1 slice, 3/4 in. thick    |   .42
    Boston brown         |    1 oz.  | 1 slice                   |   .27
    Rolls                |    1 oz.  |                           |   .41
    Whole wheat          |    1 oz.  |                           |   .44
  -----------------------+-----------+---------------------------+-------
  ==============+==================+==================+========
    B1  |  B2   |   C1   |    C2   |   D1   |   D2    |   E
  ------+-------+--------+---------+--------+---------+--------
   21.0 |  2.97 |  54.9  |   7.78  |  17.3  |   2.45  |   92.
    0.4 |   .6  |   0.5  |    .78  |  14.2  |  22.    |   97.4
    5.1 |  1.9  |   0.1  |    .4   |  61.   |  22.5   |  100.
    --  |  --   |   --   |   --    |  69.2  |  19.6   |   78.
    3.4 |   .96 |   0.5  |    .14  |  12.   |   3.4   |   18.7
    1.8 |  2.04 |   0.2  |    .23  |   3.3  |   3.74  |   25.
    1.5 |  1.7  |   0.1  |    .11  |   2.8  |   3.17  |   21.
        |       |        |         |        |         |
    9.  |  2.5  |  58.   |  16.    |   --   |   --    |  144.
    1.3 |  1.29 |   0.6  |    .6   |  22.0  |  21.83  |   98.
    8.5 |  2.41 |   1.1  |    .31  |  77.   |  22.    |  100.
   10.4 |   .98 |   2.2  |    .21  |  72.6  |   7.    |   33.
   18.6 | 15.8  |   2.8  |   2.37  |   --   |   --    |   84.
    2.3 |  1.95 |    .26 |    .22  |   5.1  |   4.35  |   27.
    9.3 |  7.9  |   0.6  |    .51  |  29.2  |  24.8   |  135.
   18.  |  5.1  |   1.5  |    .42  |  65.9  |  18.7   |   99.
    6.9 |  1.96 |   2.5  |    .71  |  19.6  |   5.5   |   36.
    1.8 |   .5  |   0.1  |    .3   |   --   |   --    |    4.7
    1.8 |  3.   |   0.1  |   1.8   |   --   |   --    |   28.
    4.3 |  7.4  |   3.6  |   6.1   |   1.1  |   1.8   |   92.
    4.9 |  1.39 |    .6  |    .17  |   --   |   --    |    6.
    2.2 |   .31 |  92.   |  13.    |   --   |   --    |  118.
   22.0 | 18.69 |  20.4  |  17.35  |   --   |   --    |  240.
   19.0 | 16.08 |  18.5  |  15.72  |   --   |   --    |  205.8
   19.5 | 16.58 |   7.3  |   6.21  |   --   |   --    |  106.2
   20.2 | 11.5  |   8.4  |   4.8   |   --   |   --    |   89.
   20.1 |  5.7  |   8.5  |   2.4   |   --   |   --    |   44.
    2.3 |   .65 |    .1  |    .03  |   7.4  |   2.1   |   11.3
   19.6 | 16.6  |   1.2  |   1.    |   --   |   --    |   75.
    --  |  --   |   --   |   --    |   --   |   --    |   42.
   11.0 |  7.8  |   2.1  |   1.5   |  61.   |  43.    |  217.
    9.2 |  2.6  |   1.3  |    .37  |  53.   |  15.    |   73.7
    6.  |  1.7  |   6.3  |   1.79  |  54.   |  15.3   |   84.1
    9.  |  2.55 |   3.   |    .85  |  54.2  |  15.4   |   79.5
    9.7 |  2.75 |    .9  |    .26  |  49.7  |  14.1   |   69.7
  ------+-------+--------+---------+--------+---------+---------


  =======================+===========+===========================+=======
       Material          |Weight     |Measure                    |   A
  -----------------------+-----------+---------------------------+-------
  Bread crumbs           | 5 oz.     | 1 cup                     |  2.08
  Bread, graham          | 1 oz.     | 1 slice                   |   .40
  Bread, gluten[176]     | 1 oz.     | 1 slice, 1/2 in. thick    |  1.34
  Maryland biscuit       |           |                           |
    (Southern beaten     |           |                           |
      biscuit)           | 1 oz.     | 2 small biscuits          |   .38
  Butter                 | 1 oz.     | 2 tablespoonfuls          |   .04
  Butter                 | 1 lb.     | 2 cups                    |   .72
                         |           |                           |
  Cabbage                | 1 oz.     |                           |   .07
  Carrots                | 3 oz.     | 1 medium                  |   .15
  Carrots                | 1 oz.     |                           |   .05
  Cauliflower            | 3 oz.     | 1 serving                 |   .24
  Cauliflower            | 1 oz.     |                           |   .08
  Celery                 | 1 oz.     | 1 stalk, medium sized     |   .05
  Chard                  | 1 oz.     |                           |   .15
  Cherries, fresh        | 1 oz.     |                           |   .04
  Chestnuts              | 1 oz.     |                           |   .28
  Clam bouillon          | 1 oz.     | 2 tablespoonfuls          |   .01
  Clam bouillon          | 6 oz.     | 2/3 cup                   |   .01
  Cheese, American       | 1 oz.     | 2 tablespoonfuls, grated  |  1.31
  Cottage cheese (curds) | 1 oz.     | 2 tablespoonfuls          |   .95
  Cream cheese           |           |                           |
    (Neufchâtel)         | 1 oz.     | 1/2 block                 |   .85
  Chicken, broiler, E.P. | 1 oz.     |                           |   .97
  Chicken, broiler, E.P. | 3 oz.     | 1 serving                 |  2.92
  Chocolate, unsweetened | 1 oz.     | 1 square                  |   .58
  Cocoa                  | 1 oz.     | 4 tablespoonfuls          |   .98
  Cocoa                  | 1/8 oz.   | 2 teaspoonfuls (1 serving)|   .12
  Cod, dressed           | 1 oz.     |                           |   .50
  Condensed milk,        |           |                           |
    sweetened            |           |                           |
    (Eagle Brand)        | 1 oz.     | 2 tablespoonfuls          |   .40
  Condensed milk, or     |           |                           |
    evaporated,          |           |                           |
    unsweetened          | 1/8 oz.   | 1 teaspoonful             |   .07
  Consommé               | 6 oz.     | 2/3 cup                   |  1.06
  Corn, canned           | 1 oz.     | 2 tablespoonfuls          |   .13
  Corn, green, E.P.      | 1 oz.     | 2 tablespoonfuls          |   .14
  Cornmeal, granular     | 1 oz.     | 2 tablespoonfuls          |   .42
  Cornflakes, toasted    | 1 oz.     |                           |   .25
  Cornstarch             | 1 oz.     | 3 tablespoonfuls          |  --
  Crackers, graham       | 1/3 oz.   | 1 cracker                 |   .15
  Crackers, water        | 1/3 oz.   | 1 cracker                 |   .19
  Crackers, oyster       | 1 oz.     |                           |   .51
  Cracker crumbs         | 2-1/2 oz. | 1/2 cup                   |  1.32
  -----------------------+-----------+---------------------------+-------
  ==============+==================+==================+=========
    B1  |  B2   |   C1   |    C2   |   D1   |   D2    |   E
  ------+-------+--------+---------+--------+---------+---------
    9.3 | 13.0  |   1.2  |   1.7   |  53.   |  75.    |  367.
    8.8 |  2.5  |   1.8  |    .51  |  52.   |  14.7   |   73.5
   29.5 |  8.4  |   1.1  |    .3   |  30.   |   8.5   |   70.
        |       |        |         |        |         |
        |       |        |         |        |         |
    8.4 |  2.38 |   5.6  |   1.5   |  60.   |  17.    |   91.7
    1.0 |   .28 |  85.   |  24.09  |   --   |   --    |  218.
    1.0 |  4.53 |  85.   | 385.5   |   --   |   --    | 3488.
        |       |        |         |        |         |
    1.6 |   .45 |  00.3  |    .09  |   5.6  |   1.59  |    9.
    1.1 |   .93 |  00.4  |    .34  |   9.3  |   7.91  |   37.5
    1.1 |   .31 |  00.4  |    .11  |   9.3  |   2.63  |   12.5
    1.8 |  1.53 |  00.5  |    .42  |   4.7  |   3.99  |   25.8
    1.8 |   .51 |  00.5  |    .14  |   4.7  |   1.33  |    8.6
    1.1 |   .31 |  00.1  |    .03  |   3.3  |    .93  |    5.2
    3.2 |   .91 |  00.6  |    .17  |   5.   |   1.41  |   10.8
    1.  |   .28 |  00.8  |    .23  |  16.7  |   4.73  |   22.
    6.2 |  1.76 |   5.4  |   1.53  |  42.1  |  11.94  |   68.6
    0.2 |   .057|   --   |   --    |   0.2  |    .057 |     .45
    0.2 |   .342|   --   |   --    |   0.2  |    .342 |    3.
   28.8 |  8.16 |  35.9  |  10.18  |   0.3  |    .09  |  124.6
   20.9 |  5.92 |   1.0  |    .28  |   4.3  |   1.22  |   31.
        |       |        |         |        |         |
   18.7 |  5.24 |  27.4  |   7.77  |   1.5  |    .42  |   93.
   20.7 |  5.8  |   8.3  |   2.35  |   --   |   --    |   44.35
   20.7 | 17.4  |   8.3  |   7.05  |   --   |   --    |  133.
   12.9 |  3.65 |  48.7  |  13.8   |  30.3  |   8.59  |  173.
   21.6 |  6.12 |  28.9  |   8.19  |  37.7  |  10.69  |  141.
   21.6 |   .76 |  28.9  |   1.02  |  37.7  |   1.33  |   17.6
   11.  |  3.12 |   0.2  |    .06  |   --   |   --    |   13.
        |       |        |         |        |         |
        |       |        |         |        |         |
    8.8 |  2.49 |   8.3  |   2.35  |  53.9  |  15.3   |   92.
        |       |        |         |        |         |
        |       |        |         |        |         |
    7.5 |   .27 |   8.3  |    .29  |   9.7  |    .34  |    5.
    2.5 |  4.25 |   --   |   --    |   0.4  |    .68  |   19.7
    2.8 |   .79 |   1.2  |    .34  |  19.   |   5.39  |   28.
    3.1 |   .88 |   1.1  |    .31  |  19.7  |   5.58  |   28.6
    9.3 |  2.63 |   1.9  |    .54  |  75.5  |  21.4   |  101.
    5.5 |  1.56 |   1.5  |    .43  |  81.2  |  23.    |  102.1
    --  |  --   |   --   |   --    |  89.1  |  25.25  |  101.
   10.  |   .94 |   9.3  |    .88  |  73.8  |   6.97  |   39.5
   11.7 |   .77 |   5.   |    .47  |  75.7  |   7.    |   35.3
   11.3 |  3.2  |  10.5  |   2.98  |  70.5  |  19.98  |  119.5
   11.6 |  7.8  |   6.   |   4.3   |  72.9  |  51.7   |  276.7
  ------+-------+--------+---------+--------+---------+---------


  =======================+===========+===========================+=======
       Material          |Weight     |Measure                    |   A
  -----------------------+-----------+---------------------------+-------
  Cranberries            | 1 oz.     |2 tablespoonfuls           |   .02
  Cream, 18% (single X)  | 1 oz.     |2 tablespoonfuls           |   .13
  Cream, 40% (double X)  | 1 oz.     |2 tablespoonfuls           |   .10
  Cucumber, E.P.         | 1 oz.     |                           |   .04
  Currants, dried        | 1 oz.     |2 tablespoonfuls           |   .11
                         |           |                           |
  Dates, dried           | 1.1 oz.   |4-1/2                      |   .09
  Dry peptonoids         | 1 oz.     |2 tablespoonfuls           |   .96
                         |           |                           |
  Eggs, whole, without   | 1.8 oz. or|                           |
    shell                | 5 gms.    |1 medium sized             |  1.
  Egg white              | 1.2 oz.   |1 white (34 gm. wt.)       |   .67
  Egg yolk               |  .6 oz.   |1 yolk (17 gm. wt.)        |   .43
  Eggplant               | 1 oz.     |                           |   .05
                         |           |                           |
  Farina                 | 1 oz.     |3 tablespoonfuls           |   .50
  Figs, dried            | 1 oz.     |1 fig                      |   .19
  Fish                   | 1 oz.     |                           |   .84
  Flour, barley          | 1 oz.     |2 tablespoonfuls           |   .46
  Flour, gum gluten      | 1 oz.     |3 tablespoonfuls           |  1.65
  Flour, graham          | 1 oz.     |3 tablespoonfuls           |   .60
  Flour, wheat           | 1 oz.     |3 tablespoonfuls           |   .51
  Flour, wheat           | 1/3 oz.   |1 tablespoonful            |   .17
  Flour, entire wheat    | 1 oz.     |3 tablespoonfuls           |   .63
  Fowl, E.P.             | 1 oz.     |                           |   .88
  Fowl, E.P.             | 3-1/2 oz. |1 serving                  |  3.09
                         |           |                           |
  Gelatin, granulated    | 1 oz.     |                           |  4.15
  Gelatin, granulated    | 1/4 oz.   |1 tablespoonful            |  1.04
  Gum gluten bread       | 1 oz.     |1 slice                    |  1.34
  Gum gluten biscuit     | 1/4 oz.   |1 biscuit                  |   .47
  Greens (A.P.),         |           |                           |
   beet tops             | 4 oz.     |                           |   .38
  Greens, cooked         | 4 oz.     |1 serving                  |   .37
  Grapes, malaga         | 2 oz.     |about 12 grapes            |   .12
  Grapes, malaga         | 1 lb.     |                           |   .95
  Grapefruit             | 1 oz.     |                           |  --
  Grape juice            | 1 oz.     |2 tablespoonfuls           |  --
  Grape juice            | 4 oz.     |1/2 cupful                 |  --
                         |           |                           |
  Halibut (E.P.) steak   | 3 oz.     |1 serving                  |  2.53
  Ham, lean, smoked,     |           |                           |
    E.P.                 | 1-1/2 oz. |1 serving (1 slice)        |  1.35
  Ham, medium fat,       |           |                           |
    smoked               | 1 oz.     |1 slice                    |   .74
  Hominy                 | 1 oz.     |2 tablespoonfuls           |   .38
  Hickory nuts, shelled  | 1 oz.     |2 tablespoonfuls           |   .70
  Honey                  | 1 oz.     |2 tablespoonfuls           |   .02
  -----------------------+-----------+---------------------------+-------
  ==============+==================+==================+=========
    B1  |  B2   |   C1   |    C2   |   D1   |   D2    |   E
  ------+-------+--------+---------+--------+---------+---------
    0.4 |   .11 |   0.6  |    .17  |  10.0  |   2.8   |   13.
    3.  |   .8  |  19.7  |   5.6   |   4.9  |   1.4   |   59.
    2.2 |   .62 |  40.   |  11.34  |   3.   |    .85  |  108.
    0.8 |   .23 |   0.2  |    .06  |   3.1  |    .88  |    5.
    2.4 |   .68 |   1.7  |    .48  |  74.2  |  21.04  |   91.
        |       |        |         |        |         |
    2.0 |   .57 |   2.8  |    .79  |  78.4  |  22.2   |    7.5
   21.1 |  6.   |   --   |   --    |  28.2  |   8.    |   56.
        |       |        |         |        |         |
        |       |        |         |        |         |
   13.4 |  6.8  |  10.5  |   5.36  |   --   |   --    |   75.
   12.3 |  4.18 |    .2  |   0.07  |   --   |   --    |   17.
   15.7 |  2.67 |  31.0  |   5.27  |   --   |   --    |   58.
    1.2 |   .34 |    .3  |    .09  |   5.1  |   1.45  |    8.
        |       |        |         |        |         |
   11.0 |  3.11 |   1.4  |    .39  |  76.4  |  21.65  |  103.
    4.3 |  1.21 |   0.3  |    .09  |  74.1  |  21.    |   89.6
   18.  |  5.24 |   1.4  |    .4   |   --   |   --    |   24.6
   10.2 |  2.9  |   2.2  |    .62  |  72.7  |  20.6   |   99.7
   36.3 | 10.3  |   1.3  |    .36  |  36.9  |  10.44  |   86.2
   13.3 |  3.77 |   2.2  |    .62  |  71.4  |  20.24  |  101.6
   11.2 |  3.18 |   1.0  |    .28  |  75.2  |  21.31  |  100.5
   11.2 |  1.06 |   1.0  |    .09  |  75.2  |   7.1   |   33.5
   13.8 |  3.91 |   1.9  |    .53  |  71.9  |  20.38  |  102.
   19.3 |  5.47 |  16.3  |   4.65  |   --   |   --    |   63.5
   19.3 | 19.   |  16.3  |  16.3   |   --   |   --    |  222.
        |       |        |         |        |         |
   91.4 | 25.91 |   0.1  |    .028 |   --   |   --    |  103.8
   91.4 |  6.47 |   0.1  |    .007 |   --   |   --    |   25.9
   29.7 |  8.4  |   1.1  |    .30  |  30.0  |   8.5   |   70.3
   41.9 |  2.9  |   1.8  |    .13  |  44.4  |   3.15  |   25.4
        |       |        |         |        |         |
    2.1 |  2.4  |   3.3  |   3.7   |   3.2  |   3.6   |   57.
    2.0 |  2.3  |   0.3  |    .3   |   3.2  |   3.6   |   26.3
    1.3 |   .74 |   1.6  |    .9   |  19.2  |  10.88  |   54.5
    1.3 |  5.9  |   1.6  |   7.2   |  19.2  |  87.04  |  436.
     .6 |   .17 |    .1  |    .03  |  12.2  |   3.46  |   14.8
    --  |  --   |   --   |   --    |  25.0  |   7.09  |   28.3
    --  |  --   |   --   |   --    |  25.0  |  28.36  |  113.4
        |       |        |         |        |         |
   18.6 | 15.81 |   5.2  |   4.42  |   --   |   --    |  103.
        |       |        |         |        |         |
   19.8 |  8.41 |  21.0  |   8.93  |   --   |   --    |  114.
        |       |        |         |        |         |
   16.3 |  4.62 |  38.8  |  11.    |   --   |   --    |  117.5
    8.3 |  2.35 |   0.6  |    .17  |  79.0  |  22.39  |  100.5
   15.4 |  4.36 |  67.1  |  19.    |  11.4  |   3.23  |  201.3
    0.4 |   .11 |   --   |   --    |  81.3  |  23.04  |   92.6
  ------+-------+--------+---------+--------+---------+---------


  =======================+===========+===========================+=======
       Material          |Weight     |Measure                    |   A
  -----------------------+-----------+---------------------------+-------
  Jell-O                 |  3.5 oz.  | 1 box                     |  1.79
  Jell-O                 |   .6 oz.  | 1 serving                 |   .30
                         |           |                           |
  Kohl-rabi              |    1 oz.  |                           |   .09
  Koumiss                |  1 litre  | 1000 c.c.                 |  4.01
  Koumiss                |    4 oz.  | 1/2 glassful              |   .51
                         |           |                           |
  Lactose (sugar of milk)|           |                           |
    100% carbohydrates   |    1 oz.  | 2 tablespoonfuls          |  --
  Lady fingers           |  1/2 oz.  | 3 lady fingers            |   .20
  Lamb chops, broiled    |    3 oz.  | 2 chops, medium size      |  2.95
  Lamb, leg, roasted     |    1 oz.  | 1 serving (small)         |  --
  Lard                   |    1 oz.  | 2 tablespoonfuls          |  --
  Lemon juice (1 lemon)  | 1-1/2 oz. | 3 tablespoonfuls          |  --
  Lemon juice            |    1 oz.  | 2 tablespoonfuls          |  --
  Lettuce                |    8 oz.  | 1 head                    |   .44
  Lettuce                |    2 oz.  | 1 serving (1/4 head)      |   .11
  Liver                  |    1 oz.  |                           |  --
  Liquid peptonoids      |    1 oz.  | 2 tablespoonfuls          |   .26
  Lentils                |    1 oz.  | 2 tablespoonfuls          |  1.17
  Lobster                |    2 oz.  | 1 serving                 |  1.75
                         |           |                           |
  Macaroni               |    4 oz.  | 1/2 cupful                |  2.43
  Mackerel, fresh, E.P.  |    3 oz.  | 1 serving                 |  2.54
  Mackerel, salt         |           |                           |
    dressed, E.P.        |    2 oz.  | 1 serving (small)         |  1.57
  Malted milk (Horlick's)|  1/2 oz.  | 1 tablespoonful           |   .37
  Milk (whole)           |    1 oz.  | 2 tablespoonfuls          |   .15
  Milk (whole)           |    8 oz.  | 1 glassful                |  1.20
  Milk (skimmed)         |    1 oz.  | 2 tablespoonfuls          |   .15
  Milk, dried (whole)    |    1 oz.  | 2 tablespoonfuls          |  1.1
  Milk, dried (skim)     |    1 oz.  | 2 tablespoonfuls          |  1.5
  Molasses, cane         |    1 oz.  | 2 tablespoonfuls          |   .11
  Mushrooms              |    1 oz.  |                           |  --
  Muskmelons             |    8 oz.  | 1/2 small melon           |   .22
                         |           |                           |
  Noodles (gluten)       |    2 oz.  | 3/4 cupful                |  2.05
                         |           |                           |
  Oatmeal                |  1/2 oz.  | 1 tablespoonful           |   .38
  Oatmeal gruel          |    4 oz.  | 1/2 cupful                |   .21
  Oats, rolled           |    1 oz.  |                           |   .76
  Okra                   |    1 oz.  |                           |   .07
  Olives                 |  1/2 oz.  | 3 medium sized            |   .02
  Olive oil              |    1 oz.  | 2 tablespoonfuls          |  --
  -----------------------+-----------+---------------------------+-------
  ==============+==================+==================+=========
    B1  |  B2   |   C1   |    C2   |   D1   |   D2    |   E
  ------+-------+--------+---------+--------+---------+---------
   11.2 | 11.   |   --   |   --    |  86.4  |  86.    |  388.
   11.2 |  1.9  |   --   |   --    |  86.4  |  14.7   |   66.
        |       |        |         |        |         |
    2.  |   .56 |    .1  |    .03  |   5.5  |   1.56  |    8.8
    2.8 | 25.4  |   2.1  |  19.5   |   5.4  |  48.9   |  473.
    2.8 |  3.17 |   2.1  |   2.38  |   5.4  |   6.12  |   58.5
        |       |        |         |        |         |
        |       |        |         |        |         |
    --  |  --   |   --   |   --    | 100.0  |  28.35  |  113.4
    8.7 |  1.23 |   5.   |    .70  |  70.5  |  10.    |   51.2
   21.8 | 18.54 |  30.   |  25.51  |   --   |   --    |  303.7
   19.7 |  5.58 |  12.7  |   3.6   |   --   |   --    |   54.7
    --  |  --   | 100.0  |  28.35  |   --   |   --    |  255.1
    --  |  --   |   --   |   --    |   9.7  |   4.12  |   16.4
    --  |  --   |   --   |   --    |   9.8  |   2.77  |   11.
    1.2 |  2.72 |   0.3  |    .68  |   2.9  |   4.52  |   35.
    1.2 |   .68 |   0.3  |    .17  |   2.0  |   1.13  |    8.77
   20.4 |  5.78 |   4.5  |   1.28  |   1.7  |    .48  |   36.5
    5.6 |  1.6  |   --   |   --    |  14.8  |   4.2   |   23.
   25.7 |  7.29 |   1.0  |    .28  |  59.2  |  16.78  |   98.8
   18.1 | 10.26 |   1.1  |    .62  |   0.5  |    .28  |   48.
        |       |        |         |        |         |
   13.4 | 15.20 |   0.9  |   1.0   |  74.1  |  84.    |  406.
   18.7 | 15.90 |   7.1  |   6.03  |   --   |   --    |  117.8
        |       |        |         |        |         |
   17.3 |  9.8  |  26.3  |  14.85  |   --   |   --    |  173.
   16.2 |  2.3  |   8.5  |   1.2   |  67.   |   9.5   |   58.
    3.3 |   .94 |   4.0  |   1.13  |   5.0  |   1.41  |   19.6
    3.3 |  7.52 |   4.0  |   9.04  |   5.0  |  11.28  |  156.8
    3.4 |   .96 |   0.3  |    .09  |   5.1  |   1.45  |   10.4
   24.3 |  6.89 |  28.5  |   8.08  |  36.8  |  10.43  |  142.
   33.9 |  9.6  |   1.   |    .28  |  55.   |  15.6   |  103.3
    2.4 |   .68 |   --   |   --    |  69.3  |  19.65  |   81.3
    3.5 |   .99 |    .4  |    .11  |   6.8  |   1.93  |   12.7
    0.6 |  1.36 |   --   |   --    |   9.3  |  21.    |   89.44
        |       |        |         |        |         |
   45.  | 25.5  |   4.1  |   2.3   |  32.5  |  18.4   |  196.4
        |       |        |         |        |         |
   16.1 |  2.3  |   7.2  |   1.    |  67.5  |   9.5   |   56.4
    1.1 |  1.3  |   0.4  |    .45  |   0.6  |   7.3   |   38.4
   16.7 |  4.73 |   7.3  |   2.07  |  66.2  |  18.77  |  112.6
    1.6 |   .45 |    .2  |    .06  |   7.4  |   2.1   |   10.74
    1.1 |   .15 |  27.6  |   3.91  |  11.6  |   1.64  |   42.4
    --  |  --   | 100.   |  28.35  |   --   |   --    |  255.1
  ------+-------+--------+---------+--------+---------+---------


  =======================+===========+===========================+=======
       Material          |Weight     |Measure                    |   A
  -----------------------+-----------+---------------------------+-------
  Onion                  | 2 oz.     | 1 medium sized            |   .07
  Orange                 | 5 oz.     | 1 medium sized            |   .17
  Orange (juice)         | 1 oz.     | 2 tablespoonfuls          |  --
  Oysters                | 1 oz.     | 3 small                   |   .28
                         |           |                           |
  Panopepton             | 1 oz.     | 2 tablespoonfuls          |   .32
  Parsnips               | 1 oz.     | 1 medium size             |  --
  Peaches, E.P. (fresh)  | 3 oz.     | 1 medium size             |   .10
  Peaches, canned        | 3 oz.     | 1 serving                 |   .10
  Peanut butter          | 1 oz.     | 2 tablespoonfuls          |  1.33
  Peanuts, shelled       | 2-1/2 oz. | 1/2 cupful                |  3.32
  Pears, fresh           | 3 oz.     | 1 medium size             |   .08
  Pears, canned          | 3 oz.     | 1 serving                 |   .04
  Peas, green, fresh,    |           |                           |
    E.P.                 | 3 oz.     | 1 serving, about 1/2 cup  |   .95
  Peas, canned           | 4 oz.     | 1/2 cup                   |   .65
  Peas (dried, split     |           |                           |
    peas)                | 1 oz.     | 3 tablespoonfuls          |  1.12
  Peppers, green         | 1 oz.     |                           |   .05
  Pineapple (canned)     | 3 oz.     | 1 thick slice             |   .07
  Pineapple (fresh,      |           |                           |
    E.P.)                |  3 oz.    | 1 serving                 |   .05
  Pecans, shelled        | 2-1/2 oz. | 1/2 cup                   |   .58
  Plums                  | 1 oz.     |                           |   .04
  Port wine (10% alcohol)| 1/2 oz.   | 1 tablespoonful           |  --
  Potatoes, white, raw   | 3 oz.     | 1 medium size             |   .30
  Potatoes, sweet, raw   | 4 oz.     | 1 medium size             |   .30
  Prunes, A.P.           | 1 oz.     | 3 prunes                  |   .08
  Prunes, E.P.           | 4 oz.     | 1 cupful                  |   .38
                         |           |                           |
  Quail                  | 3-1/2 oz. | 1/2 quail, 1 serving      |  1.00
                         |           |                           |
  Raisins                | 1 oz.     | 3 dozen                   |   .12
  Raspberries, black,    |           |                           |
    fresh                | 1 oz.     | 3 tablespoonfuls          |   .08
  Raspberry juice, fresh | 4 oz.     | 1/2 cup                   |  --
  Rhubarb, fresh, E.P.   | 1 oz.     |                           |   .03
  Rice                   | 1 oz.     | 2 tablespoonfuls, 1       |
                         |           |   serving                 |   .36
  Rum                    | 1 oz.     | 2 tablespoonfuls          |  --
                         |           |                           |
  Salmon, canned         | 1 oz.     |                           |   .99
  Salmon, canned         | 1 lb.     | 1 can                     | 15.82
  Saltines (crackers)    | 1 oz.     |                           |   .48
  Saltines (crackers)    | 1 lb.     | 1 box                     |  7.68
  Sardines, canned       | 1 oz.     | 1 small serving           |  1.08
  -----------------------+-----------+---------------------------+-------
  ==============+==================+==================+=========
    B1  |  B2   |   C1   |    C2   |   D1   |   D2    |   E
  ------+-------+--------+---------+--------+---------+---------
    1.6 |   .9  |   0.3  |    .17  |    9.9 |   5.6   |   27.5
    0.6 |   .85 |   0.1  |    .14  |    8.5 |  12.05  |   53.
    --  |  --   |   --   |   --    |   11.3 |   3.2   |   12.8
    6.2 |  1.75 |   1.2  |    .34  |    3.7 |   1.04  |   14.2
        |       |        |         |        |         |
    7.1 |  2.   |   --   |   --    |   17.3 |   5.    |   28.
    0.1 |   .03 |    .5  |    .14  |   13.5 |   3.83  |   16.70
    0.7 |   .60 |   0.1  |    .09  |    9.4 |   7.99  |   35.1
    0.7 |   .60 |   0.1  |    .09  |   10.8 |   9.18  |   39.9
   29.3 |  8.31 |  46.6  |  13.20  |   17.1 |   4.85  |  151.4
   29.3 | 20.77 |  46.5  |  33.    |    5.8 |   4.12  |  396.5
    0.6 |   .51 |   0.5  |    .42  |   14.1 |  12.    |   53.8
    0.3 |   .26 |   0.3  |    .26  |   18.1 |  12.4   |   53.
        |       |        |         |        |         |
    7.  |  5.95 |    .5  |    .42  |   16.9 |  14.37  |   85.
    3.6 |  4.08 |   0.2  |    .23  |    9.8 |  11.11  |   62.8
        |       |        |         |        |         |
   24.6 |  6.97 |   1.0  |    .28  |   62.0 |  17.57  |  100.7
    1.1 |   .31 |   0.1  |    .03  |    4.6 |   1.3   |    6.71
    0.5 |   .4  |   0.7  |    .6   |   36.4 |  31.    |  131.
        |       |        |         |        |         |
    0.4 |   .34 |   0.3  |    .26  |    9.7 |   8.25  |   36.7
    9.6 |  6.8  |  70.5  |  50.0   |   15.  |  10.6   |  519.6
    1.  |   .28 |   --   |   --    |   20.1 |   5.7   |   23.9
    --  |  --   |   --   |   --    |    --  |   --    |   10.
    2.2 |  1.87 |   0.1  |    .09  |   18.4 |  15.65  |   70.9
    1.8 |  2.04 |   0.7  |    .79  |   27.4 |  31.07  |  139.6
    1.8 |   .51 |   --   |   --    |   62.2 |  17.63  |   72.6
    2.1 |  2.38 |   --   |   --    |   73.3 |  83.12  |  342.
        |       |        |         |        |         |
   21.  | 20.3  |   8.   |   7.9   |    --  |   --    |  152.3
        |       |        |         |        |         |
    2.6 |   .74 |   3.3  |    .94  |   76.1 |  21.57  |   97.7
        |       |        |         |        |         |
    1.7 |   .48 |   1.0  |    .28  |   12.6 |   3.57  |   18.7
    --  |  --   |   --   |   --    |   10.0 |  11.3   |   45.2
    0.6 |   .17 |   0.7  |    .20  |    3.6 |   1.02  |    6.6
        |       |        |         |        |         |
    7.9 |  2.26 |   0.3  |    .09  |   79.0 |  22.39  |   99.35
    --  |  --   |   --   |   --    |    --  |   --    |   76.
        |       |        |         |        |         |
   22.  |  6.24 |  12.8  |   3.63  |    --  |   --    |   57.6
   22.  | 99.8  |  12.8  |  57.6   |    --  |   --    |  922.
   10.6 |  3.   |  12.7  |   3.6   |   68.5 |  19.42  |  123.
   10.6 | 48.   |  12.7  |  57.6   |   68.5 | 310.7   | 1968.
   23.  |  6.72 |  19.7  |   5.58  |    --  |   --    |   77.
  ------+-------+--------+---------+--------+---------+---------


  =======================+===========+===========================+=======
       Material          |Weight     |Measure                    |   A
  -----------------------+-----------+---------------------------+-------
  Shad                   |    3 oz.  | 1 serving                 |  1.96
  Shad roe               |    1 oz.  | 1 small serving           |   .95
  Sherry wine            |    1 oz.  | 2 tablespoonfuls          |  --
  Spinach                |    4 oz.  | 1/2 cup                   |   .38
  Squab                  | 2-1/2 oz. | 1/2 squab                 |  1.86
  Squash                 |    3 oz.  | 1 serving                 |   .10
  Strawberries           |    3 oz.  | 1 serving, about 1/2 cup  |   .13
  Strawberry juice       |    4 oz.  | 1/2 cup                   |  --
  Suet                   |    1 oz.  | 2 tablespoonfuls          |   .21
  Sugar (granulated)     |    1 oz.  | 2 tablespoonfuls          |  --
  Sugar (loaf)           |  1/2 oz.  | 1 lump                    |  --
  Sugar (powdered)       |  1/3 oz.  | 1 tablespoonful           |  --
  Sweetbreads            | 3-1/2 oz. | 1 serving                 |  2.28
  Sweetbreads            |    8 oz.  | 1 set                     |  6.08
                         |           |                           |
  Tapioca                |    1 oz.  | 2 tablespoonfuls          |   .02
  Tapioca (minute)       |    1 oz.  | 2 tablespoonfuls          |   .02
  Toast                  |    1 oz.  | 1 thick slice             |   .52
  Tomatoes (fresh)       |    5 oz.  | 1 whole tomato            |   .07
  Tomatoes (canned)      |    1 oz.  | 2 tablespoonfuls          |   .05
  Trout                  |    3 oz.  | 1 serving                 |  2.46
  Trout                  |    1 oz.  |                           |   .82
  Turnips (fresh)        |    3 oz.  | 1 serving                 |   .18
  Turkey                 | 2-1/2 oz. | 1 serving (2 slices)      |  2.39
  Turkey                 |    1 oz.  |                           |   .96
                         |           |                           |
  Veal cutlet            |    1 oz.  |                           |  --
                         |           |                           |
  Walnuts                |    1 oz.  |                           |   .84
  Walnuts                | 5-1/2 oz. | 1 cupful                  |  4.59
  Watermelon, E.P.       |    1 oz.  |                           |   .02
  Wheat (shredded)       |    1 oz.  | 1 biscuit                 |   .55
  Wheat flakes           |    1 oz.  | 1 cupful (about)          |   .61
  Whey                   |    6 oz.  | 1 cup (scant)             |   .27
  Whitefish, E.P.        |    1 oz.  | 1/3 serving               |  1.04
                         |           |                           |
  Zwieback               |    1 oz.  | 3 small slices            |   .44
  -----------------------+-----------+---------------------------+-------
  ==============+==================+==================+=========
    B1  |  B2   |   C1   |    C2   |   D1   |   D2    |   E
  ------+-------+--------+---------+--------+---------+---------
   18.8 | 11.   |   9.5  |   8.07  |    --  |   --    |  116.6
   20.9 |  5.92 |   3.8  |   1.08  |    2.6 |    .73  |   36.3
    --  |  --   |   --   |   --    |    --  |   --    |   28.
    2.1 |  2.38 |    .3  |    .34  |    3.2 |   3.63  |   27.
   16.3 | 11.5  |  36.2  |  25.65  |    --  |   --    |  277.
    0.7 |   .60 |   0.2  |    .17  |    4.5 |   3.83  |   18.3
    1.0 |   .85 |   0.6  |    .51  |    7.4 |   6.29  |   33.
    --  |  --   |   --   |   --    |    4.8 |   5.4   |   22.
    4.7 |  1.33 |  82.   |  23.19  |    --  |   --    |  215.
    --  |  --   |   --   |   --    |  100.0 |  28.35  |  113.4
    --  |  --   |   --   |   --    |  100.0 |   7.1   |   28.4
    --  |  --   |   --   |   --    |  100.0 |   9.45  |   37.8
   16.7 | 16.45 |  12.1  |  12.    |    --  |   --    |  173.8
   16.7 | 38.   |  12.1  |  27.4   |    --  |   --    |  398.6
        |       |        |         |        |         |
    0.4 |   .11 |   0.1  |    .03  |   88.  |  24.95  |  100.5
    0.4 |   .11 |   0.1  |    .03  |   88.  |  24.95  |  100.5
   11.5 |  3.26 |   1.6  |    .45  |   61.2 |  17.35  |   86.5
    0.9 |  1.27 |   0.4  |    .57  |    3.9 |   5.5   |   32.
    1.2 |   .34 |   0.2  |    .06  |    4.  |   1.13  |    6.4
   18.  | 15.3  |  10.3  |   8.76  |    --  |   --    |  140.
   18.  |  5.1  |  10.3  |   2.92  |    --  |   --    |   46.7
    1.3 |  1.11 |   0.2  |    .17  |    8.1 |   6.9   |   33.6
   21.1 | 14.94 |  22.9  |  16.22  |    --  |   --    |  206.
   21.1 |  5.98 |  22.9  |   6.49  |    --  |   --    |   82.4
        |       |        |         |        |         |
   20.3 |  5.75 |   7.7  |   2.18  |    --  |   --    |   42.6
        |       |        |         |        |         |
   18.4 |  5.22 |  64.4  |  18.26  |   13.0 |   3.79  |  200.
   18.4 | 28.71 |  64.4  | 100.43  |   13.0 |  20.84  | 1100.
     .4 |   .11 |    .2  |    .06  |    6.7 |   1.9   |    8.58
   10.5 |  2.98 |   1.4  |    .4   |   78.  |  22.    |  103.5
   13.4 |  3.8  |   1.4  |    .39  |   74.3 |  21.06  |  103.
    1.0 |  1.70 |   0.3  |    .51  |    5.  |   8.5   |   45.4
   22.9 |  6.5  |   6.5  |   1.84  |    --  |   --    |   42.56
        |       |        |         |        |         |
    9.8 |  2.77 |   1.0  |   2.80  |   73.5 |  20.83  |  119.6
  ------+-------+--------+---------+--------+---------+---------


FOOTNOTES:

[174] Edible portion.

[175] Beef soup is not so thoroughly strained or so well skimmed as
broth.

[176] Gum gluten has a smaller percentage of starch than ordinary
gluten flour.


TABLE V[177]

VITAMINES IN FOODS

  ============================+==========+==========+==========
  _Foodstuff_                 |  "_A_"   |  "_B_"   |  "_C_"
  ----------------------------+----------+----------+----------
  Meats:                      |          |          |
    Beef heart                |    +     |    +     |    ?
    Brains                    |   + +    |  + + +   |   + ?
    Codfish                   |    +     |    +     |    ?
    Cod testes                |    +     |          |
    Fish roe                  |    +     |   + +    |    ?
    Herring                   |   + +    |   + +    |    ?
    Horse meat                |    +     |    +     |
    Kidney                    |   + +    |   + +    |
    Lean muscle               |    0     |    0     |   + ?
    Liver                     |    +     |    +     |   + ?
    Pancreas                  |    0     |  + + +   |
    Pig heart                 |    +     |    +     |    ?
    Placenta                  |          |    +     |
    Thymus (sweetbreads)      |    0     |    0     |    0
  Vegetables:                 |          |          |
    Beetroot                  |    +     |    +     |   + +
    Beet root juice           |    ?     |  Little  |  + + +
    Cabbage, dried            |  + + +   |  + + +   |    +
    Cabbage, fresh            |  + + +   |  + + +   | + + + +
    Carrots                   |  + + +   |  + + +   |   + +
    Cauliflower               |   + +    |  + + +   |   + +
    Celery                    |    ?     |  + + +   |    ?
    Chard                     |  + + +   |   + +    |    ?
    Dasheens                  |    +     |   + +    |    ?
    Lettuce                   |   + +    |   + +    | + + + +
    Mangels                   |   + +    |   + +    |    ?
    Onions                    |    ?     |  + + +   |  + + +
    Parsnips                  |   + +    |  + + +   |
    Peas (fresh)              |    +     |   + +    |  + + +
    Potatoes                  |    0     |  + + +   |   + +
    Potatoes (sweet)          |  + + +   |   + +    |    ?
    Rutabaga                  |          |  + + +   |
    Spinach                   |  + + +   |  + + +   |  + + +
  Cereals:                    |          |          |
    Barley                    |    +     |  + + +   |    ?
    Bread (white)             |          |   + ?    |
    Bread (whole meal)        |    +     |  + + +   |    ?
    Maize                    {+ In yellow}  + + +   |    ?
                             {0 In white }          |
    Oats                      |    +     |  + + +   |    0
    Rice (polished)           |    0     |    0     |    0
    Rice (whole grain)        |    +     |  + + +   |    0
    Rye                       |    +     |  + + +   |    0
    Corn embryo               |          |  + + +   |
    Corn (kaffir)             |          |  + + +   |
    Corn (see maize)          |          |          |
    Corn pollen               |          |   + +    |
    Malt extract              |    0     |    0     |    0
    Wheat bran                |    0     |    +     |    0
    Wheat embryo              |   + +    |  + + +   |    0
    Wheat endosperm           |    0     |    0     |    0
    Wheat kernel              |    +     |  + + +   |    0
  Other seeds:                |          |          |
    Beans, kidney             |          |  + + +   |
    Beans, navy               |          |  + + +   |    0
    Beans, soy                |    +     |  + + +   |    0
    Cotton seed               |   + +    |  + + +   |
    Flaxseed                  |   + +    |  + + +   |
    Hemp seed                 |   + +    |  + + +   |
    Millet seed               |   + +    |  + + +   |
    Peanuts                   |    +     |   + +    |
    Peas (dry)                |   + ?    |   + +    |    0
    Sunflower seeds           |    +     |          |
  Fruits:                     |          |          |
    Apples                    |          |   + +    |   + +
    Bananas                   |    ?     |    +     |   + +
    Grapefruit                |          |  + + +   |  + + +
    Grape juice               |          |    +     |    +
    Grapes                    |    0     |    +     |    +
    Lemons                    |          |  + + +   | + + + +
    Limes                     |          |   + +    |   + +
    Oranges                   |          |  + + +   | + + + +
    Pears                     |          |   + +    |   + +
    Raisins                   |          |    +     |    +
    Tomatoes                  |   + +    |  + + +   | + + + +
  Oils and fats:              |          |          |
    Almond oil                |    0     |    0     |
    Beef fat                  |    +     |    0     |    0
    Butter                    | + + + +  |    0     |    0
    Cocoanut oil              |    0     |    0     |    0
    Cod liver oil             | + + + +  |    0     |    0
    Corn oil                  |    0     |    0     |    0
    Cotton seed oil           |   0 ?    |    0     |    0
    Egg yolk fat              | + + + +  |    0     |    0
    Fish oils                 |   + +    |    0     |    0
    Lard                      |   0 ?    |    0     |    0
    Oleo, animal              |    +     |    0     |    0
    Oleo, vegetable           |    0     |    0     |    0
    Olive oil                 |    0     |    0     |    0
    Pork fat                  |   0 ?    |    0     |
    Tallow                    |    0     |    0     |    0
    Vegetable oils            |   0 ?    |    0     |    0
  Nuts:                       |          |          |
    Almonds                   |    +     |  + + +   |
    Brazil nut                |          |  + + +   |
    Chestnut                  |          |  + + +   |
    Cocoanut                  |   + +    |  + + +   |
    English walnuts           |          |  + + +   |
    Filbert                   |          |  + + +   |
    Hickory                   |    +     |    +     |    +
    Pine                      |    +     |    +     |    +
  Dairy products:             |          |          |
    Butter                    | + + + +  |    0     |    0
    Cheese                    |   + +    |    +     |    ?
    Condensed milk            |   + +    |    +     |    0
    Cream                     |  + + +   |    +     |    ?
    Eggs                      | + + + +  |   + +    |    0
    Milk powder (skim)        |    +     |  + + +   |   + ?
    Milk powder (whole)       |  + + +   |  + + +   |   + ?
    Milk whole                |  + + +   |  + + +   |   + +
    Whey                      |    +     |  + + +   |    +
  Miscellaneous:              |          |          |
    Alfalfa                   |  + + +   |  + + +   |    ?
    Blood                     |       Varies with source
    Clover                    |  + + +   | + + + +  |    ?
    Honey                     |          |   + +    |    0
    Malt extract              |    0     |    0     |    0
    Nectar                    |    0     |    0     |    0
    Timothy                   |   + +    |  + + +   |
    Yeast, brewers'           |    0     | + + + +  |    0
    Yeast cakes               |    0     |   + +    |    0
    Yeast extract             |    0     |  + + +   |    0
  ============================+==========+==========+==========

Table V taken from "The Vitamine Manual," by Walter S. Eddy, published
by Williams & Wilkins Co., Baltimore, Md.


FOOTNOTE:

[177] Courtesy of Dr. Walter S. Eddy.


HEIGHTS AND WEIGHTS FOR CHILDREN UNDER FIVE YEARS OF AGE

(Based on Data Published by the Children's Bureau, U. S. Department
of Labor)

  ==========+=====================++=====================
            |        BOYS         ||        GIRLS
  _Age_     |----------+----------++----------+----------
            | _Height_ | _Weight_ || _Height_ | _Weight_
            | _Inches_ | _Pounds_ || _Inches_ | _Pounds_
  ----------+----------+----------++----------+----------
     Birth  |   20.6   |    7.6   ||   20.5   |    7.2
   3 mo.    |   23.5   |   13.0   ||   --     |   --
   6 mo.    |   26.5   |   18.0   ||   25.9   |   16.8
   9 mo.    |   28.1   |   20.4   ||   26.6   |   19.1
  12 mo.    |   29.4   |   21.9   ||   28.9   |   20.8
  15 mo.    |   30.8   |   23.6   ||   30.1   |   21.9
  18 mo.    |   31.8   |   24.6   ||   31.1   |   23.4
  21 mo.    |   32.9   |   25.8   ||   32.3   |   24.8
  24 mo.    |   33.8   |   27.1   ||   33.4   |   26.4
  27 mo.    |   34.8   |   29.0   ||   33.9   |   27.3
  30 mo.    |   35.4   |   29.5   ||   34.9   |   28.3
  33 mo.    |   36.1   |   30.6   ||   35.6   |   29.1
  36 mo.    |   37.1   |   32.3   ||   36.8   |   30.5
  39 mo.    |   37.9   |   33.1   ||   37.3   |   31.6
  42 mo.    |   38.6   |   33.8   ||   38.0   |   32.5
  45 mo.    |   39.0   |   34.5   ||   38.5   |   33.3
  48 mo.    |   39.5   |   35.9   ||   39.0   |   33.8
   5 years  |   41.6   |   41.4   ||   41.3   |   39.7
  ==========+==========+==========++==========+==========

HEIGHT AND WEIGHT TABLE FOR BOYS

  ===+====+====+====+====+====+====+====+====+====+====+====+====+====+====
  H I|  5 |  6 |  7 |  8 |  9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18
  e n|    |    |    |    |    |    |    |    |    |    |    |    |    |
  i c|  Y |  Y |  Y |  Y |  Y |  Y |  Y |  Y |  Y |  Y |  Y |  Y |  Y |  Y
  g h|  r |  r |  r |  r |  r |  r |  r |  r |  r |  r |  r |  r |  r |  r
  h e|  s |  s |  s |  s |  s |  s |  s |  s |  s |  s |  s |  s |  s |  s
  t s|  . |  . |  . |  . |  . |  . |  . |  . |  . |  . |  . |  . |  . |  .
  ---+----+----+----+----+----+----+----+----+----+----+----+----+----+----
  39 | 35 | 36 | 37 |    |    |    |    |    |    |    |    |    |    |
  40 | 37 | 38 | 39 |    |    |    |    |    |    |    |    |    |    |
  41 | 39 | 40 | 41 |    |    |    |    |    |    |    |    |    |    |
  42 | 41 | 42 | 43 | 44 |    |    |    |    |    |    |    |    |    |
  43 | 43 | 44 | 45 | 46 |    |    |    |    |    |    |    |    |    |
  44 | 45 | 46 | 46 | 47 |    |    |    |    |    |    |    |    |    |
  45 | 47 | 47 | 48 | 48 | 49 |    |    |    |    |    |    |    |    |
  46 | 48 | 49 | 50 | 50 | 51 |    |    |    |    |    |    |    |    |
  47 |    | 51 | 52 | 52 | 53 | 54 |    |    |    |    |    |    |    |
  48 |    | 53 | 54 | 55 | 55 | 56 | 57 |    |    |    |    |    |    |
  49 |    | 55 | 56 | 57 | 58 | 58 | 59 |    |    |    |    |    |    |
  50 |    |    | 58 | 59 | 60 | 60 | 61 | 62 |    |    |    |    |    |
  51 |    |    | 60 | 61 | 62 | 63 | 64 | 65 |    |    |    |    |    |
  52 |    |    | 62 | 63 | 64 | 65 | 67 | 68 |    |    |    |    |    |
  53 |    |    |    | 66 | 67 | 68 | 69 | 70 | 71 |    |    |    |    |
  54 |    |    |    | 69 | 70 | 71 | 72 | 73 | 74 |    |    |    |    |
  55 |    |    |    |    | 73 | 74 | 75 | 76 | 77 | 78 |    |    |    |
  56 |    |    |    |    | 77 | 78 | 79 | 80 | 81 | 82 |    |    |    |
  57 |    |    |    |    |    | 81 | 82 | 83 | 84 | 85 | 86 |    |    |
  58 |    |    |    |    |    | 84 | 85 | 86 | 87 | 88 | 90 | 91 |    |
  59 |    |    |    |    |    | 87 | 88 | 89 | 90 | 92 | 94 | 96 | 97 |
  60 |    |    |    |    |    | 91 | 92 | 93 | 94 | 97 | 99 |101 |102 |
  61 |    |    |    |    |    |    | 95 | 97 | 99 |102 |104 |106 |108 |110
  62 |    |    |    |    |    |    |100 |102 |104 |106 |109 |111 |113 |116
  63 |    |    |    |    |    |    |105 |107 |109 |111 |114 |115 |117 |119
  64 |    |    |    |    |    |    |    |113 |115 |117 |118 |119 |120 |122
  65 |    |    |    |    |    |    |    |    |120 |122 |123 |124 |125 |126
  66 |    |    |    |    |    |    |    |    |125 |126 |127 |128 |129 |130
  67 |    |    |    |    |    |    |    |    |130 |130 |132 |133 |134 |135
  68 |    |    |    |    |    |    |    |    |134 |135 |136 |137 |138 |139
  69 |    |    |    |    |    |    |    |    |138 |139 |140 |141 |142 |143
  70 |    |    |    |    |    |    |    |    |    |142 |144 |145 |146 |147
  71 |    |    |    |    |    |    |    |    |    |147 |149 |150 |151 |152
  72 |    |    |    |    |    |    |    |    |    |152 |154 |155 |156 |157
  73 |    |    |    |    |    |    |    |    |    |157 |159 |160 |161 |162
  74 |    |    |    |    |    |    |    |    |    |162 |164 |165 |166 |167
  75 |    |    |    |    |    |    |    |    |    |    |169 |170 |171 |172
  76 |    |    |    |    |    |    |    |    |    |    |174 |175 |176 |177
  ===+====+====+====+====+====+====+====+====+====+====+====+====+====+====

Prepared by Dr. Thomas D. Wood


ABOUT WHAT A BOY SHOULD GAIN EACH MONTH

    _Age_
   5 to  8             6 oz.
   8 to 12             8 oz.
  12 to 16            16 oz.
  16 to 18             8 oz.

Weight and measures should be taken without shoes, and in only the
usual indoor clothes.

_Courtesy of Child Health Organization of America_


HEIGHT AND WEIGHT TABLE FOR GIRLS

  ===+====+====+====+====+====+====+====+====+====+====+====+====+====+====
  H I|  5 |  6 |  7 |  8 |  9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18
  e n|    |    |    |    |    |    |    |    |    |    |    |    |    |
  i c|  Y |  Y |  Y |  Y |  Y |  Y |  Y |  Y |  Y |  Y |  Y |  Y |  Y |  Y
  g h|  r |  r |  r |  r |  r |  r |  r |  r |  r |  r |  r |  r |  r |  r
  h e|  s |  s |  s |  s |  s |  s |  s |  s |  s |  s |  s |  s |  s |  s
  t s|  . |  . |  . |  . |  . |  . |  . |  . |  . |  . |  . |  . |  . |  .
  ---+----+----+----+----+----+----+----+----+----+----+----+----+----+----
  39 | 34 | 35 | 36 |    |    |    |    |    |    |    |    |    |    |
  40 | 36 | 37 | 38 |    |    |    |    |    |    |    |    |    |    |
  41 | 38 | 39 | 40 |    |    |    |    |    |    |    |    |    |    |
  42 | 40 | 41 | 42 | 43 |    |    |    |    |    |    |    |    |    |
  43 | 42 | 42 | 43 | 44 |    |    |    |    |    |    |    |    |    |
  44 | 44 | 45 | 45 | 46 |    |    |    |    |    |    |    |    |    |
  45 | 46 | 47 | 47 | 48 | 49 |    |    |    |    |    |    |    |    |
  46 | 48 | 48 | 49 | 50 | 51 |    |    |    |    |    |    |    |    |
  47 |    | 49 | 50 | 51 | 52 | 53 |    |    |    |    |    |    |    |
  48 |    | 51 | 52 | 53 | 54 | 55 | 56 |    |    |    |    |    |    |
  49 |    | 53 | 54 | 55 | 56 | 57 | 58 |    |    |    |    |    |    |
  50 |    |    | 56 | 57 | 58 | 59 | 60 | 61 |    |    |    |    |    |
  51 |    |    | 59 | 60 | 61 | 62 | 63 | 64 |    |    |    |    |    |
  52 |    |    | 62 | 63 | 64 | 65 | 66 | 67 |    |    |    |    |    |
  53 |    |    |    | 66 | 67 | 68 | 68 | 69 | 70 |    |    |    |    |
  54 |    |    |    | 68 | 69 | 70 | 71 | 72 | 73 |    |    |    |    |
  55 |    |    |    |    | 72 | 73 | 74 | 75 | 76 | 77 |    |    |    |
  56 |    |    |    |    | 76 | 77 | 78 | 79 | 80 | 81 |    |    |    |
  57 |    |    |    |    |    | 81 | 82 | 83 | 84 | 85 | 86 |    |    |
  58 |    |    |    |    |    | 85 | 86 | 87 | 88 | 89 | 90 | 91 |    |
  59 |    |    |    |    |    | 89 | 90 | 91 | 93 | 94 | 95 | 96 | 98 |
  60 |    |    |    |    |    |    | 94 | 95 | 97 | 99 |100 |102 |104 |106
  61 |    |    |    |    |    |    | 99 |101 |102 |104 |106 |108 |109 |111
  62 |    |    |    |    |    |    |104 |106 |107 |109 |111 |113 |114 |115
  63 |    |    |    |    |    |    |109 |111 |112 |113 |115 |117 |118 |119
  64 |    |    |    |    |    |    |    |115 |117 |118 |119 |120 |121 |122
  65 |    |    |    |    |    |    |    |117 |119 |120 |122 |123 |124 |125
  66 |    |    |    |    |    |    |    |119 |121 |122 |124 |126 |127 |128
  67 |    |    |    |    |    |    |    |    |124 |126 |127 |128 |129 |130
  68 |    |    |    |    |    |    |    |    |126 |128 |130 |132 |133 |134
  69 |    |    |    |    |    |    |    |    |129 |131 |133 |135 |136 |137
  70 |    |    |    |    |    |    |    |    |    |134 |136 |138 |139 |140
  71 |    |    |    |    |    |    |    |    |    |138 |140 |142 |143 |144
  72 |    |    |    |    |    |    |    |    |    |    |145 |147 |148 |149
  ===+====+====+====+====+====+====+====+====+====+====+====+====+====+====

Prepared by Dr. Thomas D. Wood


ABOUT WHAT A GIRL SHOULD GAIN EACH MONTH

   _Age_
   5 to 8              6 oz.
   8 to 11             8 oz.
  11 to 14            12 oz.
  14 to 16             8 oz.
  16 to 18             4 oz.

_Courtesy of Child Health Organization of America_

SCALE FOR JUDGING THE STATE OF NUTRITION IN CHILDREN,
PREPARED BY PROFESSOR PIRQUET[178]

PELIDISI CHART (FOR SCHOOL CHILDREN)

  ====================================================================
  Sitting
  Height                     _Percentage (Pelidisi)_
  in Cm.  ___________________________________________________________
          ~85   86   87   88   89   90   91   92   93   94   95   96~
    ~55~  10.0 10.4 10.7 11.1 11.5 11.9 12.3 12.7 13.1 13.6 14.0 14.4
    ~56~  10.6 10.9 11.4 11.7 12.2 12.6 13.0 13.4 13.9 14.3 14.8 15.3
    ~57~  11.1 11.5 11.9 12.4 12.8 13.2 13.7 14.2 13.6 15.1 15.6 16.1
    ~58~  11.7 12.1 12.6 13.0 13.5 13.9 14.4 14.9 15.4 15.9 16.4 16.9
    ~59~  12.4 12.8 13.2 13.7 14.2 14.7 15.2 15.7 16.2 16.7 17.3 17.8
    ~60~  13.0 13.4 13.9 14.4 14.9 15.4 15.9 16.5 17.1 17.6 18.2 18.8
    ~61~  13.7 14.1 14.6 15.2 15.7 16.2 16.8 17.3 17.9 18.5 19.1 19.7
    ~62~  14.3 14.8 15.4 15.9 16.5 17.1 17.6 18.2 18.8 19.4 20.0 20.7
    ~63~  15.0 15.6 16.1 16.7 17.3 17.9 18.5 19.1 19.7 20.4 21.0 21.7
    ~64~  15.8 16.3 16.9 17.5 18.1 18.8 19.4 20.0 20.7 21.4 22.1 22.8
    ~65~  16.5 17.1 17.7 18.3 19.0 19.7 20.3 21.0 21.7 22.4 23.1 23.9
    ~66~  17.3 17.9 18.5 19.2 19.9 20.6 21.2 21.9 22.7 23.4 24.2 25.0
    ~67~  18.7 18.7 19.4 20.1 20.8 21.5 22.2 23.0 23.7 24.5 25.3 26.1
    ~68~  18.9 19.6 20.3 21.0 21.7 22.5 23.2 24.0 24.8 25.6 26.4 27.3
    ~69~  19.8 20.5 21.2 22.0 22.7 23.5 24.2 25.0 25.9 26.7 27.6 28.5
    ~70~  20.6 21.4 22.1 22.9 23.7 24.5 25.3 26.2 27.0 27.9 28.8 29.8
    ~71~  21.5 22.3 23.1 23.9 24.7 25.6 26.4 27.3 28.2 29.1 30.1 31.3
    ~72~  22.4 23.2 24.1 25.0 25.8 26.6 27.6 28.5 29.4 30.4 31.4 32.4
    ~73~  23.4 24.3 25.1 26.0 26.9 27.8 28.8 29.8 30.7 31.7 32.8 33.8
    ~74~  24.4 25.3 26.2 27.1 28.0 29.0 30.0 31.0 32.0 33.0 34.0 35.2
    ~75~  25.4 26.3 27.2 28.2 29.2 30.2 31.2 32.3 33.2 34.3 35.5 36.6
    ~76~  26.4 27.4 28.4 29.4 30.3 31.3 32.7 33.5 34.6 35.7 36.9 38.2
    ~77~  27.5 28.4 29.5 30.6 31.6 32.6 33.8 34.8 36.0 37.2 38.4 39.6
    ~78~  28.6 29.6 30.7 31.8 32.8 33.9 35.0 36.2 37.4 38.6 40.0 41.1
    ~79~  29.7 30.8 31.8 33.0 34.0 35.2 36.4 37.7 38.8 40.1 41.5 42.8
    ~80~  30.8 31.9 33.1 34.2 35.4 36.6 37.9 39.0 40.4 41.7 43.0 44.5
    ~81~  32.0 33.2 34.3 35.5 36.7 38.0 39.3 40.5 41.9 43.3 44.7 46.1
    ~82~  33.2 34.4 35.6 36.8 38.1 39.4 40.8 42.0 43.5 45.0 46.4 47.9
    ~83~  34.4 35.7 36.9 38.2 39.6 40.8 42.3 43.7 45.1 46.6 48.0 49.6
    ~84~  35.7 37.0 38.2 39.6 41.0 42.3 43.8 45.3 46.8 48.3 49.9 51.5
    ~85~  37.0 38.2 39.6 41.0 42.4 43.9 46.4 46.9 48.5 50.0 51.6 53.4
    ~86~  38.3 39.6 41.0 42.5 44.0 45.5 47.0 48.7 50.2 51.9 53.7 55.4
    ~87~  39.6 41.0 42.5 44.0 45.5 47.1 48.7 50.3 52.0 53.8 55.5 57.2
    ~88~  41.0 42.5 44.0 45.5 47.2 48.7 50.4 52.0 58.8 55.5 57.5 59.3
    ~89~  42.5 44.0 45.5 47.1 48.8 50.5 52.2 53.9 55.7 57.5 59.6 61.2
    ~90~  44.0 45.4 47.0 48.7 50.4 52.2 54.0 55.8 57.5 59.5 61.5 63.4
  ____________________________________________________________________

  ======================================================================
  Sitting
  Height                     _Percentage (Pelidisi)_
  in Cm.  ______________________________________________________________
          ~97   98   99  100  101  102  103  104  105  106  107  108~
    ~55~  14.9 15.4 15.8 16.4 16.9 17.4 17.9 18.4 19.0 19.6 20.1 20.7
    ~56~  15.7 16.2 16.8 17.3 17.9 18.4 18.9 19.5 20.1 20.6 21.2 21.8
    ~57~  16.6 17.1 17.7 18.2 18.8 19.4 20.0 20.6 21.2 21.8 22.4 23.0
    ~58~  17.5 18.0 18.6 19.2 19.8 20.4 21.0 21.6 22.3 22.9 23.6 24.2
    ~59~  18.4 19.0 19.6 20.2 20.9 21.5 22.2 22.8 23.5 24.1 24.8 25.6
    ~60~  19.3 20.0 20.6 21.2 22.0 22.6 23.3 24.0 24.6 25.4 26.1 26.8
    ~61~  20.3 21.0 21.7 22.4 23.1 23.7 24.4 25.2 25.9 26.6 27.4 28.2
    ~62~  21.4 22.1 22.8 23.4 24.2 24.9 25.7 26.4 27.2 28.0 28.8 29.6
    ~63~  22.4 23.2 23.8 24.6 25.4 26.2 27.0 27.8 28.6 29.4 30.2 31.1
    ~64~  23.5 24.3 25.0 25.8 26.8 27.4 28.2 29.1 30.0 30.8 31.6 32.6
    ~65~  24.6 25.5 26.2 27.0 27.9 28.8 29.6 30.5 31.4 32.2 33.2 34.2
    ~66~  25.7 26.6 27.4 28.2 29.2 30.0 31.0 31.9 32.8 33.8 34.8 35.8
    ~67~  26.9 27.8 28.6 29.5 30.6 31.4 32.4 33.4 34.3 35.4 36.3 37.4
    ~68~  28.2 29.1 30.0 30.9 32.0 32.9 33.8 34.9 35.9 36.9 38.0 39.1
    ~69~  29.7 30.4 31.3 32.3 33.4 34.4 35.4 36.4 37.5 38.6 39.7 40.9
    ~70~  30.7 31.6 32.7 33.8 34.8 35.8 37.0 38.1 39.1 40.3 41.5 42.6
    ~71~  32.1 33.1 34.1 35.2 36.4 37.4 38.6 39.7 40.9 42.0 43.2 44.5
    ~72~  33.5 34.5 35.6 36.7 38.0 39.0 40.3 41.5 42.6 43.9 45.1 46.8
    ~73~  34.9 36.0 37.0 38.2 39.5 40.7 42.0 43.2 44.5 45.7 47.1 48.4
    ~74~  36.3 37.4 38.6 39.8 41.1 42.4 43.7 45.0 46.4 47.6 49.0 50.4
    ~75~  37.8 39.0 40.1 41.4 42.8 44.1 45.4 46.9 48.3 49.5 50.9 52.5
    ~76~  39.3 40.5 41.7 43.1 44.5 45.9 47.3 48.7 50.3 51.5 53.0 54.5
    ~77~  40.9 42.7 43.5 44.8 46.4 47.7 49.2 50.7 52.3 53.6 55.2 56.8
    ~78~  42.5 43.9 45.2 46.6 48.2 49.6 51.0 52.6 54.3 55.7 57.3 58.9
    ~79~  44.1 45.5 46.9 48.4 50.0 51.5 53.1 54.7 56.5 58.0 59.6 61.3
    ~80~  45.9 47.3 48.7 50.2 52.0 53.6 55.1 56.9 58.6 60.1 61.8 63.7
    ~81~  47.6 49.1 50.6 52.1 54.0 55.5 57.3 59.0 60.8 62.5 64.3 66.0
    ~82~  49.9 51.0 52.5 54.1 56.0 57.6 59.5 61.3 63.0 67.9 66.7 68.5
    ~83~  51.2 52.9 54.5 56.1 58.1 59.7 61.7 63.5 65.3 67.2 69.1 71.0
    ~84~  53.0 54.8 56.5 58.2 60.2 62.0 64.0 65.8 67.7 69.7 71.6 73.6
    ~85~  55.0 56.8 58.5 60.4 62.4 64.3 66.3 68.2 70.0 72.1 74.2 76.3
    ~86~  57.1 58.9 60.7 62.6 64.6 66.5 68.5 70.5 72.7 74.8 76.9 79.0
    ~87~  59.1 60.9 62.9 64.7 66.9 69.0 71.0 73.0 75.2 77.5 79.6 81.8
    ~88~  61.2 63.0 65.0 67.0 69.3 71.4 73.5 75.5 77.8 80.0 82.4 84.7
    ~89~  63.3 65.3 67.3 69.4 71.6 73.6 76.0 78.1 80.5 82.9 85.2 87.5
    ~90~  65.4 67.5 69.5 71.5 74.0 76.4 78.6 80.9 83.4 85.7 88.1 90.5
  ___________________________________________________________________

Instructions for use: To determine the "pelidisi," locate in the
left-hand column the child's sitting height in centimeters. With a
ruler follow the weights in kilograms to the right until the proper
figure is reached. Trace upward in that column to the heavy figure at
the top, which indicates the pelidisi.


FOOTNOTE:

[178] This material was published in the American Medical Journal,
Vol. 77, No. 20, Nov. 12, 1921, by Dr. William E. Carter, Dept.
Pediatrics, University of California Medical School, San Francisco,
Calif.


THE NUTRITIONAL INDEX--THE "PELIDISI"

Pirquet believes that the sitting height is a basis for the more
accurate estimation of the nutritional state than is the standing
height. It was demonstrated that the cube of the sitting height in
centimeters is approximately ten times the weight in grams of the
normal person. With this formula in mind, it becomes easy to compute
the nutritional state in percentages, when the sitting height and the
weight are known. The formula would read:

  10 times the weight
  ------------------- = 100 per cent.
   Sitting height^{3}

    or

      ____________________
   3 /
    v  10 times the weight
   ----------------------- = 100 per cent.
        Sitting height




ADDENDA TO INDEX


  Diet, in fevers, 244
    in infectious diseases, 244, 244j

  Diphtheria, 244d, 244k
    complications of, 244d, 244k
    convalescent diet in, 244e, 244k
    dietetic treatment of, 244e, 244k
    gavage in, 244k
    rectal feeding in, 244e, 244k

  Fevers, diet in, 244

  Infant feeding, in infectious diseases, 244

  Infectious diseases, diet in, 244, 244j
    infant feeding in, 244
    restricting diet in, 244a

  Measles, 244h, 244l
    complications of, 244h, 244l
    dietetic treatment of, 244i, 244l

  Nephritis in scarlet fever, 244c, 244j

  Scarlet fever, 244b, 244j
    convalescent treatment in, 244d
    dietetic treatment of, 244c, 244j
    nephritis in, 244c, 244j

  Whooping cough, 244e, 244k
    after-effects of, 244f
    complications of, 244f, 244k
    dietetic treatment of, 244f, 244k
    hygiene and sanitation in, 244g




INDEX


  Absorption, 166, 176
    defined, 166
    in large intestine, 178
    of carbohydrate, 177
    of fat, 177
    of mineral salts, 178
    of proteins, 177
    of water, 177

  Acetone bodies, in diabetes, 401

  Acetone in urine, test for, 333

  Acid, uric, _see_ Uric acid

  Acid content of stomach, determining of, 248

  Acid-forming foods, 184, 454

  Acidosis, 453, 454, 458
    dietetic treatment in, 453, 458
    fat metabolism in, 453
    in diabetes mellitus, 372, 382, 401, 454
    in typhoid fever, 299

  Acids, amino, 19
    organic, 13

  Added urea and salt test, 351

  Adenase, 171

  Adenin, 184

  Adipose tissue, 15

  Adult, factors influencing food requirement of, 43

  Agar jelly, preparation of, 147

  Age, influence of on food requirements, 43

  Albumen, in urine, 333
    tests for, 333

  Albumen milk, preparation of, 142

  Albumen water, with brandy, preparation of, 141

  Albumenized grape juice, preparation of, 97
    lemonade, preparation of, 97
    milk, preparation of, 87
    milk shake, preparation of, 87
    orangeade, preparation of, 96

  Albumins, 20

  Albuminoids, 21

  Albuminuria, 333
    of pregnancy, diet in, 197

  Alcohol in gout, 418

  Alfalfa, vitamines in, 498

  Alkalies, effect of on vitamine B, 32
    in diabetes mellitus, 382
    in infant feeding, 205, 206

  Alkaline carbonates, effect of on gastric secretion, 175

  Allen's Paradoxical Law, 371
    starvation treatment in diabetes, 63, 372

  Almond biscuits, preparation of, 157

  Almond flour, preparation of, 158

  Almond ice cream, preparation of, 91

  Almond meal, preparation of, 158

  Almonds, ash constituent of, 472
    composition of, 484
    food content of, 478
    fuel value of, 461, 484
    nutrient value of, 461
    standard portion of, 478

  Amino acids, 19

  Ammonium salts, 183

  Amylopsin, 171, 174

  Anabolism, 181

  Anemia, in gastric ulceration, 255

  Angel food cake, preparation of, 110

  Appendicitis, 268, 278
    convalescent diet in, 269, 278
    dietetic treatment in, 269, 278
      after operation, 317, 321
    food to be avoided in, 269
    recurring, 278
    relapse in, 278

  Apples, ash constituent of, 472
    composition of, 484
    food content of, 478
    fuel value of, 461, 484
    nutrient value of, 461
    standard portion of, 478
    vitamines in, 497

  Apple tapioca pudding, preparation of, 107

  Apricot ice, preparation of, 137

  Apricots, ash constituent of, 472
    composition of, 484
    food content of, 478
    fuel value of, 461, 484
    nutrient value of, 461
    standard portion of, 478

  Arrowroot, composition of, 484
    fuel value of, 484

  Artificial feeding of infants, 205

  Artificially fed infants, digestive disturbances in, 231

  Artichoke, composition of, 484
    fuel value of, 461, 484
    nutrient value of, 481

  Ash, 25

  Ash constituents of foods, 472, 473, 474, 475, 476, 477

  Asparagus, ash constituent of, 484
    composition of, 484
    food content of, 478
    fuel value of, 461, 484
    nutrient value of, 461
    standard portion of, 478

  Auto-intoxication, 273
    absorption of toxins in, 273
    care of bowels in, 273
    convalescent diet in, 275
    dietetic treatment of, 273

  Autolytic enzymes, 171

  Avocado, fuel value of, 461
    nutrient value of, 461


  Bacon, ash constituent of, 472
    composition of, 484
    food content of, 478
    fuel value of, 461, 484
    nutrient value of, 461
    standard portion of, 478

  Bacteria, action of in alimentary canal, 178
    types of, 180

  Bacterial action, in body, 180
    upon carbohydrates, 13

  Bacterial activity, 181

  Baked custard, preparation of, 102

  Baked onion, preparation of, 151

  Baked potato, preparation of, 130

  Baked tapioca, preparation of, 106

  Baking, 71

  Bananas, ash constituent of, 472
    composition of, 484
    food content of, 478
    fuel value of, 461, 484
    nutrient value of, 461
    standard portion of, 478
    vitamines in, 497

  Banting's method for obesity, 426, 427

  Barley, ash constituent of, 472
    composition of, 484
    fuel value of, 461, 484
    nutrient value of, 461
    vitamines in, 496

  Barley water, 220
    preparation of, 140

  Basal metabolism, 42

  Basal requirements, 42

  Bass, composition of, 484
    fuel value of, 484

  Beans, ash constituent of, 472
    composition of, 484
    food content of, 478
    fuel value of, 461, 484
    nutrient value of, 461
    standard portion of, 478
    vitamines in, 497

  Beef, and _see_ Meats
    ash constituents of, 472
    cuts of, 117
    food content of, 473
    fuel value of, 462, 463, 484
    composition of, 484
    methods of preparing, 117
    nutrient value of, 462, 463
    standard portion of, 478
    vitamines in, 496

  Beef broth, preparation of, 118

  Beef juice, preparation of, 119, 141

  Beef steak, preparation of, 123

  Beer, ash constituents of, 472

  Beets, ash constituent of, 472
    composition of, 484
    food content of, 478
    fuel value of, 463, 484
    nutrient value of, 463
    standard portion of, 478
    vitamines in, 496

  Benedict's solution, 331, 332

  Benedict's test for sugar in urine, 328, 329, 331, 332

  Bile, 174

  Biliousness, 404, 414

  Birds à la bain-marie, preparation of, 121

  Blackberries, ash constituent of, 472
    fuel value of, 463
    nutrient value of, 463

  Blackfish, fuel value of, 463
    nutrient value of, 463

  Blood, ash constituent of, 472
    vitamines in, 498

  Bluefish, ash constituent of, 472
    composition of, 484
    fuel value of, 463, 484
    nutrient value of, 463

  Body, 165
    chemical composition of, 165
    food requirements of, 42, 50, 165
    metabolism of tissues of, 187

  Boas' enema, preparation of, 146

  Boiled corn beef with cabbage and other vegetables, preparation
    of, 153

  Boiling, 70

  Bomb calorimeter, 36

  Borax, test for, 68

  Boric acid, test for, 68

  Boston crackers, fuel value of, 463
    nutrient value of, 463

  Bowels, of nursing mother, 197

  Boys, height and weight of, 500

  Brains, vitamines in, 496

  Bran, composition of, 484
    fuel value of, 484

  Bran agar wafers, preparation of, 146

  Bran biscuits, preparation of, 149, 155, 156
    for constipation, 156

  Bran cookies, preparation of, 145

  Bran gems, preparation of, 144

  Bran muffins, preparation of, 155

  Brandy, composition of, 484
    fuel value of, 484

  Brazil nuts, fuel value of, 463
    nutrient value of, 463

  Bread, ash constituent of, 472
    composition of, 484, 486
    fuel value of, 463, 464, 484, 486
    nutrient value of, 463, 464
    vitamines in, 496

  Breadfruit, ash constituent of, 472

  Breadstuffs, preparation of, 103

  Bread substitutes, preparation of, 155

  Breast feeding _versus_ artificial feeding, 243

  Breast milk, as a food, 228
    _versus_ cow's milk, 203

  Brick feeder, 225

  Bright's disease, _see_ Nephritis

  Broiled oysters, preparation of, 123

  Broiled quail, preparation of, 121

  Broiled squab, preparation of, 121

  Broiled tomatoes, preparation of, 133

  Broiling, 71

  Broths, preparation of, 118
    standard, 118

  Brown betty, preparation of, 107

  Brussels sprouts, ash constituent of, 472

  Buckwheat flour, ash constituent of, 472
    fuel value of, 464
    nutrient value of, 464

  Bulgarian buttermilk, preparation of, 89

  Butter, ash constituent of, 472
    composition of, 486
    food content of, 478
    fuel value of, 464, 486
    nutrient value of, 464
    standard portion of, 478
    vitamines in, 497, 498

  Buttermilk, ash constituent of, 472
    fuel value of, 464
    nutrient value of, 464

  Buttermilk, Bulgarian, preparation of, 89

  Buttermilk mixtures, 208
    for infants, 142

  Butternuts, fuel value of, 464
    nutrient value of, 464


  Cabbage, ash constituent of, 472
    composition of, 486
    food content of, 478
    fuel value of, 464, 486
    nutrient value of, 464
    standard portion of, 478
    vitamines in, 496

  Cabbage soufflé, preparation of, 150

  Calcium, 27, 186
    requirements in pregnancy and lactation, 191
    retention in rickets, 241
    source of, in food, 6

  Calculating formulas for infant feeding, 212

  Calf's-foot jelly, fuel value of, 464
    nutrient value of, 464
    preparation of, 120

  Calorie, defined, 37

  Calorie allowance for children, 48

  Calorie portion, 40, 478

  Calories, in carbohydrates, 38
    in fats, 38
    in proteins, 38

  Calorimeter, 36

  Cancer, gastric, dietetic treatment of, 260

  Canned goods, 68, 128
    adulteration of, 68

  Cane sugar, in infant feeding, 228

  Cantaloupe, ash constituent of, 472

  Capers, ash constituent of, 472

  Caramel custard, preparation of, 103

  Carbohydrates, 7
    absorption of, 177
    bacterial action upon, 13
    calories in, 38
    composition of, 7
    effect of heat upon, 14
    enzymes acting upon, 171
    fate of, 182
    function of, 372
    metabolism of, 182
    rate of digestion of, 173
    regulation of, 235
    source of, 5
    tolerance of in diabetes, 380

  Carbohydrate-free diet, 63

  Carbohydrate-free meat and fish, calorie equivalent of, 386

  Carbon dioxide, excretion of, 324

  Carbonates, alkaline, effect of on digestion, 175

  Carp, _see_ Fish

  Carrots, ash constituent of, 472
    composition of, 486
    food content of, 478
    fuel value of, 464, 486
    nutrient value of, 464
    standard portion of, 478
    vitamines in, 496
    with cream sauce or butter, preparation of, 129

  Casoid flour and bran muffins, preparation of, 156

  Catabolism, 181

  Cauliflower, ash constituent of, 472
    composition of, 486
    food content of, 478
    fuel value of, 464, 486
    nutrient value of, 464
    standard portion of, 478
    vitamines in, 496

  Caviar, ash content of, 472

  Celery, ash constituent of, 473
    composition of, 486
    food content of, 479
    fuel value of, 464, 486
    nutrient value of, 464
    standard portion of, 479
    vitamines in, 496

  Celery ramekins, preparation of, 151

  Celery soup, fuel value of, 464
    nutrient value of, 464

  Cellu bran crackers, preparation of, 148

  Cellulose, 12

  Centigrade scale, 80

  Cereal pudding, preparation of, 110

  Cerealine, fuel value of, 464
    nutrient value of, 464

  Cereals, preparation of, 103
    vitamines in, 496, 497

  Certified milk, 81

  Chard, ash constituent of, 473
    composition of, 486
    fuel value of, 464, 486
    nutrient value of, 464
    vitamines in, 496

  Cheese, ash constituent of, 473
    composition of, 486
    food content of, 479
    fuel value of, 464, 486
    nutrient value of, 464
    standard portion of, 479
    vitamines in, 498

  Cheese salad, preparation of, 154

  Chemical digestion, 169, 172

  Cherries, ash constituent of, 473
    composition of, 486
    food content of, 479
    fuel value of, 464, 486
    nutrient value of, 464
    standard portion of, 479

  Cherry juice, ash constituent of, 473

  Chestnuts, ash constituents of, 473
    composition of, 486
    fuel value of, 464, 486
    nutrient value of, 464
    vitamines in, 498

  Chicken, and _see_ Meat
    composition of, 486
    food content of, 479
    fuel value of, 465, 486
    nutrient value of, 465
    preparation of, 122
    selection of, 114
    standard portion of, 479

  Chicken à la bain-marie, preparation of, 121

  Chicken broth, preparation of, 118

  Chicken jelly, preparation of, 120

  Chicken salad, poisoning by, 451

  Chicken supreme, preparation of, 149

  Children, care of in abnormal conditions, 231
    diarrhea in, 263, 276
    energy requirements of, 47
    errors in diet in, 232, 243
    feeding of, in abnormal conditions, 231
    food allowance for, 48
    food requirements of, 44, 52
    gain in weight in, 49
    heights and weights for, 499
    malnutrition in, 242
    nutrition in, 502
    over-feeding, 243
    under-feeding, 243

  Chlorine, source of in food, 6

  Chocolate, ash constituent of, 473
    composition of, 486
    food content of, 479
    fuel value of, 465, 486
    nutrient value of, 465
    standard portion of, 479

  Cholesterol, 15

  Cider, ash constituents of, 473

  Citron, ash constituents of, 473

  Clams, ash constituents of, 473
    composition of, 486
    food content of, 479
    fuel value of, 486
    standard portion of, 479

  Clam broth, preparation of, 119

  Clover, vitamines in, 498

  Cocoa, ash constituents of, 473
    composition of, 486
    food content of, 479
    fuel value of, 465, 486
    nutrient value of, 465
    preparation of, 89
    standard portion of, 479

  Cocoanut, ash constituents of, 473
    vitamines in, 498

  Cocoanut biscuits, preparation of, 158

  Cocoanut flour, preparation of, 158

  Coddled eggs, preparation of, 100

  Codfish, and _see_ Fish
    composition of, 486
    fuel value of, 465, 486
    nutrient value of, 465
    vitamines in, 496

  Coffee, adulteration of, 69
    preparation of, 98

  Coffee eggnog, preparation of, 99

  Coleman's high calorie diet in typhoid fever, 289, 291, 294, 295,
      298, 299

  Condensed milk, composition of, 486
    for infants, 226, 227
    fuel value of, 486
    vitamines in, 498

  Conserve, preparation of, 143

  Consommé, composition of, 486
    fuel value of, 465, 486
    nutrient value of, 465

  Constipation, 238, 270, 279

  Constipation, bran biscuits for, 156
    dietetic treatment of, 271, 279
    diet for, 143, 239, 271, 272, 279, 406
    in nursing women, 197

  Convalescent diet, 62

  Cookies, protein-free, 340

  Cooking, time-table for, 72

  Copper, test for, 68

  Corn, ash constituents of, 473
    composition of, 486
    food content of, 479
    fuel value of, 465, 486
    nutrient value of, 465
    standard portion of, 479
    vitamines in, 497

  Cornflakes, composition of, 486
    fuel value of, 486

  Corn meal, composition of, 486
    food content of, 479
    fuel value of, 465, 486
    nutrient value of, 465
    standard portion of, 479

  Cornstarch, composition of, 486
    fuel value of, 486

  Cotton seed, ash constituents of, 473
    vitamines in, 497

  Cowpeas, ash constituents of, 473
    fuel value of, 465
    nutrient value of, 465

  Crab, preparation of, 126

  Crackers, ash constituents of, 473
    composition of, 486
    food content of, 479
    fuel value of, 465, 486
    nutrient value of, 465
    standard portion of, 479

  Cranberries, ash constituents of, 473
    composition of, 488
    fuel value of, 465, 488
    nutrient value of, 465

  Cream, ash constituents of, 473
    composition of, 488
    food content of, 479
    fuel value of, 465, 488
    nutrient value of, 465
    standard portion of, 479
    vitamines in, 498

  Cream egg and vichy, preparation of, 98

  Cream of asparagus, preparation of, 93
    of carrots, preparation of, 94
    of cauliflower, preparation of, 152
    of celery, preparation of, 94
    of peas, preparation of, 94
    of potato, preparation of, 94
    of spinach, preparation of, 94

  Cream sauce for soups, preparation of, 93

  Cream soups, preparation of, 93

  Cream toast, preparation of, 105

  Creamed egg on toast, preparation of, 101

  Creamed potatoes, preparation of, 130

  Creatinin, 185

  Cucumber, ash constituents of, 473
    composition of, 488
    fuel value of, 465, 488
    nutrient value of, 465

  Cucumber salad, preparation of, 131

  Currant ice, preparation of, 137

  Currant juice, ash constituents of, 473

  Currants, ash constituents of, 473
    composition of, 488
    fuel value of, 465, 488
    nutrient value of, 465

  Custard, preparation of, 102, 159


  Dairy products, 81
    vitamines in, 498

  Dandelion greens, ash constituents of, 473
    fuel value of, 465
    nutrient value of, 465

  Dasheens, vitamines in, 496

  Dates, ash constituents of, 473
    composition of, 488
    food content of, 479
    fuel values of, 465, 488
    nutrient value of, 465
    standard portion of, 479

  Desserts, preparation of, 138

  Dextri-maltose, 236
    in infant feeding, 207

  Dextrin, 12

  Diabetes mellitus, 371
    acetone bodies in, 401
    acidosis in, 372, 382, 401, 454
    alkalies in, 382
    Allen's starvation treatment in, 372
    carbohydrate-free diets in, 387, 389
    carbohydrate tolerance in, 380
    determination of food tolerance in, 379
    dietetic treatment in, 382
    diets in, 374, 382
      in mild cases, 373
    fast days in, 381
    fasting in, 379

  Diabetes mellitus, fat tolerance in, 381
    formulas used in, 146
    Joslin's diet in, 383
    menus for, 376, 377, 383, 389, 397
    protein tolerance in, 381
    schedule of treatment for, 380
    starvation treatment of, 372
    test diets in, 374
    urine in, 328, 329, 330, 371, 401, 402

  Diabetic acidosis, 454

  Diabetic cures, 372

  Diabetic diet, 63, 374

  Diabetic flours, 403

  Diabetic foods, commercial, 403

  Diabetic muffins, preparation of, 155

  Diacetic acid in urine, Gerhardt's test for, 332

  Diarrhea, 263, 276, and _see_ Enteritis
    causes of, 263, 276
    dietetic treatment of, 264
    in children, 263
    dietetic treatment of, 237

  Diastase, 171

  Diet, or Diets, and _see_ under the various diseases
    carbohydrate-free, 63
    convalescent, 62
    diabetic, 63
    emaciation, 63
    fluid, 63
    house, 62
    light, 62
    liquid, 62
    milk, 63
    mixed, 63
    nephritic, 63, and _see_ Nephritis
    obesity, 63, and _see_ Obesity
    protein-free, 340
    purin-free, 63
    salt-free, 63
    semi-solid, 62
    special, 62, 63

  Dietary, for child, 221, 223
    sample, 54

  Dieto-therapy, 189

  Digestion, 167
    chemical, 169, 172
    gastric, 172
    intestinal, 173, 176
    processes included in, 166
    salivary, 172

  Digestive disturbances in infants and children, 231

  Diluents, in infant feeding, 208
    preparation of, 210

  Dilution for premature infants, 225

  Disaccharides, 8, 10

  Dish gravy, 141

  Dishes, washing, 76

  Doughnuts, fuel value of, 465
    nutrient value of, 465

  Dry peptonoids, composition of, 488
    fuel value of, 488

  Duck, _see_ Meat

  Dysentery, dietetic treatment of, 268, 278


  Ebstein's method for obesity, 429

  Egg, or Eggs, 95
    ash constituents of, 473
    composition of, 488
    coddled, 100
    food content of, 479
    fuel value of, 465, 488
    nutrient value of, 465
    standard portion of, 479
    vitamines in, 497, 498

  Egg nest, preparation of, 101

  Eggnog, preparation of, 99

  Eggplant, ash constituents of, 473
    composition of, 488
    fuel value of, 465, 488
    nutrient value of, 465

  Egg salad, preparation of, 154

  Eggwhite and mint, preparation of, 98

  Eiweissmilch, 142, 208, 209

  Elimination, 167

  Emaciation, 438
    allowable foods in, 441
    dietetic treatment in, 440
    diet in, 63, 439
    diet sheets, 442, 443
    in children, 438
    method of increasing diet in, 444
    milk cure in, 441
    need for building foods in, 439
    regulating diet in, 439
    selection of foods in, 440

  Endive, ash constituents of, 473

  Enema, or Enemas, malted milk, 146
    milk and egg, 145
    milk and starch, 146
    nutrient, 145
    temperature of, 61

  Energy output compared with food intake, 425
    production of, 182

  Enteritis, acute, 264, and _see_ Diarrhea

  Enteritis, acute, dietetic treatment of, 264, 265, 266, 276, 277
    foods to be avoided in, 266, 277

  Enteritis, chronic, 267
    dietetic treatment in, 267

  Enterocolitis, 267, 277
    dietetic treatment of, in infants, 237

  Enzymes, 170, 171
    acting, on carbohydrates, 171
      on fats, 171
      on proteins, 171
      on purins, 171
    action of, 170, 171
    amylolytic, 172
    autolytic, 171
    classification of, 172
    coagulating, 172
    deaminizing, 172
    glycolytic, 171
    hydrolytic, 172
    lipolytic, 172
    oxidizing, 172
    proteolytic, 172
    reducing, 172
    source of, 171
    sugar-splitting, 172
    table of, 171

  Erepsin, 171, 174

  Errors in diet, in infants and children, 232, 243


  Fahrenheit scale, 80

  Farina, ash constituents of, 473
    composition of, 488
    food content of, 479
    fuel value of, 465, 488
    nutrient value of, 465
    preparation of, 104
    standard portion of, 479

  Fast days, in treatment of diabetes, 381

  Fat, or Fats, 14, 15
    absorption of, 177
    calories in, 38
    cause of gastro-intestinal disturbances in children, 233
    effect of heat upon, 16
    enzymes acting on, 171
    excess of, in diet of infants and children, 233
    fate of, 182
    functions of, 17
    metabolism of, in acidosis, 453
    phosphorized, 15
    rate of digestion of, 173
    regulation of, in diet, 233
    source of, 5, 448
    tolerance of, in diabetes, 381
    vitamines in, 497, 498

  Fat soluble A, 15
    effect of heat upon, 31
    function of, 30
    foods containing, 6, 496, 497, 498

  Fatty foods, effect of, upon gastric secretion, 175

  Feeding, by inunction, 62
    by mouth, 59
    correct, evidences of, 243
    forced, 59
    in diseases of gastro-intestinal tract, 245
    infant, _see_ Infant feeding
    methods of, 59
    post-operative, 316, 319, 320
    pre-operative, 312, 318, 320
    rectal, 60, 61

  Fehling's solution, 331

  Fehling's test for sugar in urine, 328

  Fermentation, and _see_ Enzymes
    cause of infantile disorders, 236, 237
    in stomach, 180

  Fermentation test for sugar in urine, 330

  Fever, or Fevers, 281
    care of mouth in, 285
    convalescent diet in, 283
    dietetic treatment in, 281
    energy expenditure in, 288
    energy requirements in, 285
    fluid diet in, 282
    nitrogen equilibrium in, 286
    sample menus for, 284
    schedule of feeding in, 282
    soft diet in, 283
    thirst in, 285
    tissue waste in, 281
    typhoid, _see_ Typhoid fever

  Figs, ash constituents of, 473
    composition of, 488
    food content of, 479
    fuel value of, 465, 488
    nutrient value of, 465
    standard portion of, 479

  Fish, 115
    ash constituents of, 473
    composition of, 488
    food content of, 479
    fuel value of, 488
    standard portion of, 479

  Fish roe, vitamines in, 496

  Fish steaks stuffed with oysters, preparation of, 125

  Flaxseed, ash constituents of, 474
    vitamines in, 497

  Floating island, preparation of, 103

  Flounder, fuel value of, 465
    nutrient value of, 465

  Flour, ash constituents of, 474
    composition of, 488
    food content of, 479
    fuel value of, 465, 488
    nutrient value of, 465
    standard portion of, 479

  Flours, diabetic, 403

  Fluid diet, 62
    in fevers, 282

  Foamy omelet, preparation of, 100

  Foamy sauce, preparation of, 111, 112

  Food, or Foods, 1, and _see_ Foodstuffs
    acid-forming, 184, 454
    adulteration of, 67
    allowance for children, 48
    arrangement of, in stomach, 167
    as fuel, 24, 36, 39
    ash constituents of, 472, 473, 474, 475, 476, 477
    base-forming, 184, 454
    care of, 76
    chemical composition of, 3, and 484 to 495
    contamination of, 66
    defined, 2
    diabetic, 403
    effect of cold upon, 39
    effect of heat upon, 39
    fuel value of, 36, 39, 221, 461 to 471, and 484 to 495
    functions of, 2
    idiosyncrasies to, 452
    incomplete, as source of danger, 227
    intake of, compared with output of energy, 425
    materials, 2
    mineral matter in, 25
    nutrient value of, 461 to 471
    passage of, from stomach, 168
    preparation of, 69, 70
    purin content of, 421
    relation of, to mother's milk, 203
    requirements of body, 42, 43, 51, 52
    factors influencing, 43, 44
    salt content of, 358, 359, 360
    selection of, 52, 75
    sources of, 2, 3, 4
    transformation of into fuel, 37
    uses of, 2, 425
    vitamines in, 496, 497, 498
    which produce fat, 448

  Food materials, 2

  Food poisoning, 66, 451

  Foodstuffs, heat produced by oxidation of, 38

  Forced feeding, 59

  Formaldehyde, test for, 67

  Formulas, determining fuel value of, 221
    for constipation, 143
    for feeding infants, 140, 212

  Fowls, and _see_ Meat
    composition of, 488
    fuel value of, 466, 488
    nutrient value of, 466

  French dressing, preparation of, 134

  Frozen custard, preparation of, 91

  Fructose, 9

  Fruit, preparation of, 126, 127, 128
    vitamines in, 497

  Fruit beverages, preparation of, 96

  Fruit jellies, method for, 135
    preparation of, 160

  Fruit salads, preparation of, 131, 132

  Fruit sauce, preparation of, 111

  Frying, 71

  Fuel value of food, 36
    to compute, 39, 221


  Galactose, 9

  Gall bladder, diet after operations on, 318, 321

  Gallstones, 408
    available foods, 410
    dietetic treatment for, 408, 409
    diet sheets for, 411, 412, 413

  Gastric, and _see_ Stomach

  Gastric cancer, 260
    dietetic treatment in, 260

  Gastric digestion, 172
    factors influencing, 175

  Gastric, disturbances, factors inducing, 261, 262

  Gastric hemorrhage, 251

  Gastric juice, composition of, 246
    retardation of, 175
    stimulation of, 175

  Gastric secretion, effect of alkaline
    carbonates on, 175
    effect of fatty foods upon, 175
    water as a stimulant, 253

  Gastric ulcer, 251
    bland diet in, 255
    convalescent diet in, 254
    dietetic treatment in, 252, 256
    lavage in, 255
    Lenhartz diet in, 257
    starvation treatment of, 252

  Gastritis, acute, 248
    dietetic treatment in, 248, 249

  Gastritis, chronic, 250
    dietetic treatment of, 250

  Gastro-enterostomy, diet after, 321

  Gastro-intestinal disturbances, relapses in, 244

  Gastro-intestinal tract, feeding in diseases of, 245

  Gavage, 60

  Gelatin, composition of, 488
    food content of, 480
    fuel value of, 466, 488
    nutrient value of, 466
    standard portion of, 480

  Gelatin jellies, preparation of, 135

  Gerhardt's test for diacetic acid, 332

  Girls, heights and weights for, 501

  Globulins, 20

  Glucose, 8

  Gluten food, ash constituents of, 474

  Glycogen, 12

  Glycolytic enzymes, 171

  Goose, _see_ Meat

  Gooseberries, ash constituents of, 474

  Gout, 417
    alcohol in, 412
    allowable foods in, 420
    avoidable foods in, 420, 421
    dietaries in, 422
    dietetic treatment in, 420, 445
    foods to be condemned in, 420
    glycosuria in, 419
    obesity in, 419
    purin-free diet in, 410

  Grape butter, fuel value of, 466
    nutrient value of, 466

  Grapefruit, ash constituents of, 474
    composition of, 488
    food content of, 480
    fuel value of, 466, 488
    nutrient value of, 466
    standard portion of, 480
    vitamines in, 497

  Grape juice, ash constituents of, 474
    composition of, 488
    food content of, 480
    fuel value of, 488
    standard portion of, 480
    vitamines in, 497

  Grape juice ice, preparation of, 136, 137

  Grape juice jelly, preparation of, 135

  Grapes, ash constituents of, 474
    composition of, 488
    food content of, 480
    fuel value of, 466, 488
    nutrient value of, 466
    standard portion of, 480
    vitamines in, 497

  Greens, composition of, 488
    fuel value of, 488

  Guanase, 171

  Guava, ash constituents of, 474

  Gum gluten, composition of, 488
    fuel value of, 488


  Haddock, and _see_ Fish
    fuel value of, 466
    nutrient value of, 466

  Haines' solution, 331

  Haines' test for sugar in urine, 329

  Halibut, and _see_ Fish
    composition of, 488
    fuel value of, 466, 488
    nutrient value of, 466, 488

  Halpin's salt-free nephritic diet, 342

  Ham, and _see_ Meat
    composition of, 488
    fuel value of, 466, 488
    nutrient value of, 466

  Hard sauce, preparation of, 111

  Hazel nuts, ash constituents of, 474

  Heat, application of to milk, 84
    effect of on carbohydrates, 14
    effect of on fats, 16
    effect of on proteins, 22
    effect of on vitamine A, 31
    effect of on vitamine B, 32
    effect of on vitamine C, 33
    produced by oxidation of foodstuffs, 38

  Hedinger-Schlayer-Mosenthal diet, 348, 350

  Heights and weights for children, 499, 500, 501

  Heller's test for albumen in urine, 333

  Hemoglobin, 22

  Hemorrhages, gastric, 251

  Hempseed, vitamines in, 497

  Herring, and _see_ Fish
    fuel value of, 466
    nutrient value of, 466
    vitamines in, 496

  Hickory nuts, composition of, 488
    fuel value of, 488

  High calorie diet, in tuberculosis, 304
    in typhoid fever, 289, 291, 294, 295, 298, 299

  Hollandaise sauce, preparation of, 126

  Hominy, ash constituents of, 474
    composition of, 488
    food content of, 480
    fuel value of, 466, 488
    nutrient value of, 466
    standard portion of, 480

  Homogenized milk, 209

  Homogenizer, 209

  Honey, ash constituents of, 474
    composition of, 488
    food content of, 480
    fuel value of, 466, 488
    nutrient value of, 466
    standard portion of, 480
    vitamines in, 498

  Horse meat, vitamines in, 496

  Horseradish, ash constituents of, 474

  House diet, 62

  Household weights and measures, 78

  Huckleberries, ash constituents of, 474
    fuel value of, 466
    nutrient value of, 466

  Huckleberry wine, ash constituents of, 474

  Hydrochloric acid, in gastric juice, 246

  Hyperchlorhydria, 247

  Hypochlorhydria, 246


  Ice-box, care of, 73

  Ice cream, poisoning by, 451
    preparation of, 161
    to reënforce, 91

  Ices, preparation of, 161

  Idiosyncrasies, to milk, 296
    to foods, 452

  Ileocecal valve, 176

  Indican, test for in urine, 334

  Infancy, retention of nitrogen in, 201

  Infant, or Infants, and _see_ Children
    bath for, 202
    bowels of, 202
    care of in abnormal conditions, 231
    daily gain in weight, 200
    danger of incomplete foods, 227
    digestive disturbances in, 231
    energy requirements of, 198
    enterocolitis in, 237
    errors of diet in, 232, 243
    feeding, _see_ Infant feeding
    food for, 201
    foods, _see_ Infant foods
    over-feeding, 243
    premature, _see_ Premature infants
    proprietary foods for, 226
    quantity of milk needed for, 198
    under-feeding, 243
    weight of, 201

  Infant feeding, 199
    alkalies used in, 205, 206
    amount given at each meal, 211
    artificial, 205
    breast versus artificial, 243
    cane sugar in, 228
    diluents in, 208, 228
    formulas for, 140, 212, 229
    in abnormal conditions, 231
    lime water in, 206, 221
    malt sugar in, 228
    method of calculating formulas for, 212
    milk sugar in, 228
    Morse and Talbot's method in, 215
    normal, 201
    over-dilution in, 232
    regularity in, 201, 228
    rules and regulations for, 204
    scheme for, 217, 219
    sugar in, 207
    under-dilution in, 232
    water in, 229

  Infant foods, 140
    addition of alkali to, 228
    dilution of, 208, 228
    increasing, 229
    percentage, computation of, 229
    preparation of, 229
    scheme for adding solids to, 221

  Infected food materials, 451

  Intestinal digestion, 173

  Intestinal secretions, stimulation of, 174

  Intestinal tract, diseases of, 263

  Intestines, behavior of foods in, 168
    movements of, 168, 169
    muscular contractions in, 169

  Inunction, feeding by, 62

  Invertase, 171

  Iodine, source of in food, 6

  Irish moss pudding, preparation of, 160

  Iron, 28
    sources of in food, 5


  Jam, ash constituents of, 474

  Jellies, ash constituents of, 474
    preparation of, 159

  Jello, composition of, 490
    fuel value of, 490

  Joslin's treatment in diabetes, 383

  Junket, preparation of, 90

  Junket ice cream, preparation of, 90


  Kidneys, function of, 323
    functional tests for, 347, 348, 349, 351
    limiting work of, 337
    operations on, diet after, 318, 321
    resting of, in nephritis, 338
    vitamines in, 496

  Kohl-rabi, ash constituents of, 474
    composition of, 490
    fuel value of, 466, 490
    nutrient value of, 466

  Koumiss, composition of, 490
    fuel value of, 466, 490
    nutrient value of, 466


  Lactase, 171

  Lactation, diet in, 191, 194, 197

  Lactone buttermilk, preparation of, 91

  Lactose, 8, 11
    composition of, 490
    fuel value of, 490
    in infant feeding, 207

  Lady fingers, composition of, 490
    fuel value of, 490

  Lamb, 112, and _see_ Meats
    composition of, 480
    cuts of, 117
    food content of, 480
    fuel value of, 467, 490
    nutrient value of, 467
    standard portion of, 480

  Lamb chops, preparation of, 124

  Lard, composition of, 490
    fuel value of, 467, 490
    nutrient value of, 467
    vitamines in, 497, 498

  Lavage, 248
    in gastric ulceration, 255

  Leeks, ash constituents of, 474

  Lemon, ash constituents of, 474
    food content of, 480
    fuel value of, 467
    nutrient value of, 467
    standard portion of, 480
    vitamines in, 497

  Lemonade, albumenized, preparation of, 97

  Lemon cream, preparation of, 138

  Lemon ice, preparation of, 136, 137, 161

  Lemon ice cream, preparation of, 91

  Lemon jelly, preparation of, 135, 159

  Lemon juice, ash constituents of, 474
    composition of, 490
    fuel value of, 467, 490
    nutrient value of, 467

  Lenhartz diet, in gastric ulceration, 257

  Lentils, ash constituents of, 474
    composition of, 490
    food content of, 480
    fuel value of, 490
    standard portion of, 480

  Lettuce, ash constituents of, 474
    composition of, 490
    food content of, 480
    fuel value of, 467, 490
    nutrient value of, 467
    standard portion of, 480
    vitamines in, 496

  von Leube's enema, preparation of, 146

  Limes, ash constituents of, 474
    vitamines in, 497

  Lime juice, ash constituents of, 474

  Lime water, in infant feeding, 206, 221

  Linen, 64

  Linseed meal, ash constituents of, 474

  Lipase, 171

  Liquid diet, 62

  Liquid peptonoid eggnog, preparation of, 99

  Liquid peptonoids, composition of, 490
    fuel value of, 490

  Lister cream puff, preparation of, 159

  Lister flour and bran muffins or biscuits, preparation of, 156

  Lister muffins, preparation of, 155

  Liver, cirrhosis of, 407
      avoidable foods for, 408
      dietetic treatment in, 407
    composition of, 490
    diseases of, 404
      convalescence, diet in, 405
      dietetic treatment in, 405, 414
    fuel value of, 467, 490
    functions of, 413
    nutrient value of, 467
    operations on, diet after, 318, 321
    vitamines in, 496
    work of, 404

  Lobster, composition of, 490
    fuel value of, 467, 490
    nutrient value of, 467
    preparation of, 126

  Lupins, ash constituents of, 474


  Macaroni, ash constituents of, 480
    composition of, 490
    food content of, 480
    fuel value of, 467, 490
    nutrient value of, 467
    standard portion of, 480

  Macaroons, fuel value of, 467
    nutrient value of, 467

  Mackerel, and _see_ Fish
    composition of, 490
    fuel value of, 467, 490
    nutrient value of, 467

  Magnesium, source of in foods, 6

  Maize, vitamines in, 496

  Malnutrition, 242

  Maltase, 171

  Malt extract, vitamines in, 497, 498

  Malt soup, preparation of, 141

  Malt sugar, in infant feeding, 207, 208

  Malted foods, for infant feeding, 207, 226, 227

  Malted milk, composition of, 490
    fuel value of, 490
    preparation of, 92

  Malted milk chocolate, preparation of, 92

  Malted milk cocoa, preparation of, 92

  Malted milk eggnog, preparation of, 99

  Malted milk enema, 146

  Maltose, 8, 10

  Mamey, ash constituents of, 475

  Mango, ash constituents of, 475

  Mangolds, ash constituents of, 475
    vitamines in, 496

  Maple syrup, ash constituents of, 475

  Marmalade, fuel value of, 467
    nutrient value of, 467

  Mayonnaise, preparation of, 475

  Meals, serving suggestions for, 56, 66

  Measures and weights, 77
    household, 78

  Meat extract, ash constituents of, 475

  Meat peptone, ash constituents of, 475

  Meats, 112
    ash constituents of, 475
    carbohydrate-free, calorie equivalent of, 386
    cuts of, 117
    quality of, 113
    selection of, 116
    vitamines in, 496

  Metabolism, 166, 181
    basal, 42
    mineral, 185
    of body tissues, 187
    of carbohydrates, 182
    of proteins, 183

  Metric system, 77

  Milk, 82
    adulteration of, 86
    application of heat to, 84
    ash constituents of, 475
    breast versus cows', 203
    care of, 86
    certified, 81
    composition of, 205, 490
    condensed, _see_ Condensed milk
    diet, 63
    fats in, measuring according to, 210
    food content of, 480
    formulas, 212, 214, 216, 217
    fuel value of, 467, 490
    homogenized, 209
    idiosyncrasies against, 296
    method of administering to premature infants, 225
    modification of, technique of, 209, 228
    nutrient value of, 467
    pasteurization of, 85, 211
    quantity of needed for infant, 198
    relation of food to, 203
    secretion of, factors retarding, 195, 197
      factors stimulating, 195, 197
    selection of, 86
    standard portion of, 480
    sterilization of, 84
    substitutes for whole, 228
    sugar-free, 162
    use of in nephritis, 162
    vitamines in, 498

  Milk and egg enemas, preparation of, 145

  Milk and starch enemas, preparation of, 146

  Milk cure in nephritis, 338

  Milk powder, food content of, 480
    standard portion of, 480
    vitamines in, 498

  Milk punch, preparation of, 88

  Milk sauce, preparation of, 93

  Milk shake, preparation of, 87

  Milk sherbet, preparation of, 138

  Milk soups, preparation of, 93

  Milk sugar, in infant feeding, 228

  Milk toast, preparation of, 105

  Millet, ash constituents of, 475

  Millet seed, vitamines in, 497

  Mince meat, fuel value of, 467
    nutrient value of, 467

  Mineral metabolism, 185

  Mineral oils, use of in constipation, 279

  Mineral requirements of body, 50

  Mineral salts, 25, 26
    absorption of, 178
    sources of in foods, 5

  Mixed diet, 63

  Molasses, ash constituents of, 475
    composition of, 490
    food content of, 480
    fuel value of, 467, 490
    nutrient value of, 467
    standard portion of, 480

  Monosaccharides, 7

  Morse and Talbot's method of infant feeding, 215

  Mother's milk, fuel value of, 198
    making of, 198

  Mouth, care of in typhoid, 299

  Muffins, diabetic, preparation of, 155

  Mushrooms, ash constituents of, 475
    composition of, 490
    fuel value of, 467, 490
    nutrient value of, 467

  Muskmelon, ash constituents of, 475
    composition of, 490
    fuel value of, 467, 490
    nutrient value of, 467

  Mustard, ash constituents of, 475

  Mutton, and _see_ Meat
    cuts of, 117
    food content of, 480
    fuel value of, 468
    nutrient value of, 468
    standard portion of, 480

  Mutton broth, preparation of, 118

  Mutton chops, preparation of, 124


  Nectar, vitamines in, 498

  Nectarines, fuel value of, 468
    nutrient value of, 468

  Nephritic diet, 63

  Nephritis, 336
    acute, 336
    adjusting diet in, 338
    adjusting fluids in, 338
    advisable foods in, 344
    causes of, 336
    Chase and Rose's diet in, 340
    chronic, 336, 346
      dietetic treatment in, 346
      functional tests in, 347, 348, 351
      protein diet in, 346
    chronic interstitial, 352
      dietetic treatment in, 352
      limiting fluid in, 353
      limiting nitrogen in, 353
      selection and preparation of food in, 354
    convalescent diet in, 344
    diet in, 339, 345, 356
    effects of, 336
    elimination of salt in, 340
    foods to be avoided in, 344
    Halpin's diet in, 342
    Karell cure in, 342
    limiting the amount of food in, 341
    milk cure in, 338
    preparation of food in, 343
    problems to be considered in, 337
    proteins in, 343
    resting the kidneys in, 338
    selection of foods in, 343
    thirst in, 343
    Widal's diet in, 341

  Neufchâtel cheese salad, preparation of, 154

  Nitrogen, retention of in infancy, 201
    source of in foods, 5

  Nitrogenous substances, oxidation and excretion of, 324

  Noodles, composition of, 490
    fuel value of, 490

  Noodle soup, preparation of, 149

  Normal saline solution, preparation of, 146

  Nucleoproteins, 21

  Nursing infant, food requirements of, 194

  Nursing mother, constipation in, 197
    diet of, 195
    habits of, 203

  Nuts, vitamines in, 498

  Nut charlotte, preparation of, 138, 162

  Nutrient enemas, 145

  Nutrition in children, 502

  Nutritional index, 503


  Oatmeal, ash constituents of, 475
    composition of, 490
    food content of, 481
    fuel value of, 468, 490
    nutrient value of, 468
    standard portion of, 481

  Oatmeal cookies, preparation of, 106

  Oats, composition of, 490
    fuel value of, 490
    vitamines in, 496

  Oat water, preparation of, 141

  Obese women, Rose's reducing diet for, 431, 432

  Obesity, 424
    allowable foods in, 429
    amount of food to be taken in, 431
    Banting's method in, 426, 427
    cures for, 425, 426
    dietetic treatment of, 426, 429, 446
    diets for, 63, 426
    Ebstein's method in, 429
    exercise in, 426
    in gout, 419
    limiting fluids in, 426
    massage in, 425
    menus for, 430, 435, 436, 437
    Oertel's method for, 427
    Proudfit's menu for, 429, 433, 434
    Rose's diet for, 431, 432

  Oertel's method in obesity, 427

  Oils, vitamines in, 497, 498

  Okra, ash constituents of, 475
    composition of, 490
    fuel value of, 468, 490
    nutrient value of, 468

  Oleo, vitamines in, 497, 498

  Olives, ash constituents of, 475
    composition of, 490
    fuel value of, 468, 490
    nutrient value of, 468

  Olive oil, composition of, 490
    fuel value of, 490

  Olmstead bran cakes, preparation of, 148

  Onion, ash constituents of, 475
    composition of, 492
    food content of, 481
    fuel value of, 468, 492
    nutrient value of, 468
    standard portion of, 481
    vitamines in, 496

  Operations, diet in relation to, 312

  Orange, ash constituents of, 475
    composition of, 492
    food content of, 481
    fuel value of, 468, 492
    nutrient value of, 468
    standard portion of, 481
    vitamines in, 497

  Orangeade, preparation of, 96

  Orange charlotte, preparation of, 138, 162

  Orange ice, preparation of, 136, 137, 161

  Orange jelly, preparation of, 135, 160

  Orange rice custard, preparation of, 108

  Orange tapioca, preparation of, 106

  Organic acids, 13

  Over-dilution of infant's food, 232

  Over-feeding of infants and children, 243

  Oxidases, 171

  Oxtail soup, fuel value of, 468
    nutrient value of, 468

  Oyster broth, preparation of, 119

  Oyster soup, preparation of, 94

  Oysters, ash constituents of, 475
    composition of, 492
    food content of, 481
    fuel value of, 468, 492
    nutrient value of, 468
    standard portion of, 481


  Pancreas, vitamines in, 496

  Panopepton, composition of, 492
    fuel value of, 492

  Panopepton eggnog, preparation of, 99

  Paprika, ash constituents of, 475

  Parsley butter, preparation of, 154

  Parsnips, ash constituents of, 475
    composition of, 492
    food content of, 481
    fuel value of, 468, 492
    nutrient value of, 468
    standard portion of, 481
    vitamines in, 496

  Pasteurization, 85, 211

  Pea soup, fuel value of, 468
    nutrient value of, 468

  Peaches, ash constituents of, 475
    composition of, 492
    food content of, 481
    fuel value of, 468, 492
    nutrient value of, 468
    standard portion of, 481

  Peanut butter, composition of, 492
    fuel value of, 492

  Peanuts, ash constituents of, 475
    composition of, 492
    food content of, 481
    fuel value of, 468, 492
    nutrient value of, 468
    standard portion of, 481
    vitamines in, 497

  Pears, ash constituents of, 475
    composition of, 492
    food content of, 481
    fuel value of, 468, 492
    nutrient value of, 468
    standard portion of, 481
    vitamines in, 497

  Pear juice, ash constituents of, 475

  Peas, ash constituents of, 475
    composition of, 492
    food content of, 481
    fuel value of, 468, 492
    nutrient value of, 468
    standard portion of, 481
    vitamines in, 496, 497

  Pecans, ash constituents of, 475
    composition of, 492
    food content of, 481
    fuel value of, 492
    standard portion of, 481

  "Pelidisi," the, 503

  Pelidisi chart, 502

  Pellagra, dietetic treatment in, 455, 456, 459

  Peppers, ash constituents of, 476
    composition of, 492
    food content of, 481
    fuel value of, 469, 492
    nutrient value of, 469

  Pepsin, 171

  Peptonized milk, preparation of, 88

  Peptonized milk punch, preparation of, 89

  Peptonoids, dry, composition of, 488
      fuel value of, 488
    liquid, composition of, 490
      fuel value of, 490

  Percentage calculations, 79, 229

  Perch, _see_ Fish

  Persimmons, ash constituents of, 476
    fuel value of, 469
    nutrient value of, 469

  Phosphoproteins, 21

  Phosphorized fats, 15

  Phosphorus, 27, 186
    requirements in pregnancy and lactation, 191
    sources of in food, 5

  Pies, fuel value of, 469
    nutrient value of, 469

  Pig heart, vitamines in, 496

  Pineapple, ash constituents of, 476
    composition of, 492
    food content of, 481
    fuel value of, 469, 492
    nutrient value of, 469
    standard portion of, 481

  Pineappleade, preparation of, 97

  Pine nuts, fuel value of, 469
    nutrient value of, 469

  Pistachios, fuel value of, 469
    nutrient value of, 469

  Placenta, vitamines in, 496

  Plums, ash constituents of, 476
    composition of, 492
    food content of, 481
    fuel value of, 469, 492
    nutrient value of, 469
    standard portion of, 481

  Pneumonia, 306, 311
    convalescent diet in, 307
    diet schedules for, 307
    dietetic treatment in, 306, 307, 311

  Poached eggs, preparation of, 101

  Poaching, 71

  Poisoning, food, 66, 451

  Polysaccharides, 8, 11

  Pomegranates, ash constituents of, 476
    fuel value of, 469
    nutrient value of, 469

  Pork, 116, and _see_ Meat
    fuel value of, 469
    nutrient value of, 469
    vitamines in, 498

  Port wine, composition of, 492
    fuel value of, 492

  Postoperative feeding, 316, 319, 320

  Potassium, sources of in food, 6

  Potato chips, fuel value of, 469
    nutrient value of, 469

  Potatoes, ash constituents of, 476
    composition of, 492
    food content of, 481
    fuel value of, 469, 492
    nutrient value of, 469
    standard portion of, 481
    vitamines in, 496

  Potatoes stuffed with meat, preparation of, 130

  Poultry, 112, and _see_ Meats

  Pregnancy, 191
    albuminuria in, 197
    diet in, 192, 193, 194, 196, 197
    nutritional disturbances in, 191

  Premature infants, dilution of food for, 225
    energy requirements of, 224
    feeding of, 224, 225, 229

  Pre-operative feeding, 312, 318, 320

  Presbyterian Hospital diet list in typhoid fever, 292

  Protein milk, preparation of, 142

  Proteins, 17
    alcohol-soluble, 21
    calories in, 38
    classification of, 19
    composition of, 18
    conjugated, 21
    construction of, 19
    effect of heat upon, 22,
    enzymes acting upon, 171
    excess of in infant's and children's food, 234
    fate of, 183
    function of in body, 23
    metabolism, 183
    in nephritis, 343
    rate of digestion of, 173
    requirements in body, 50
    sources of, 4
    tolerance of in diabetes, 381

  Proudfit's menu for obesity, 429
    reducing diet for obesity, 433, 434

  Prune fig whip, preparation of, 139

  Prunes, ash constituents of, 476
    composition of, 492
    food content of, 481
    fuel value of, 469, 492
    nutrient value of, 469
    standard portion of, 481

  Prunes and figs, preparation of, 143

  Prune whip, preparation of, 139

  Ptomaines, 66
    poisoning by, 451
      dietetic treatment for, 451, 452

  Ptyalin, 171

  Pumpkins, ash constituents of, 476
    fuel value of, 469
    nutrient value of, 469

  Punch, milk, preparation of, 88

  Purin bases, 184
    content of food, 421

  Purin-free diet, 63
    in gout, 419

  Purins, enzymes acting upon, 171


  Quail, composition of, 492
    fuel value of, 492


  Radishes, ash constituents of, 476
    food content of, 481
    fuel value of, 469
    nutrient value of, 469
    standard portion of, 481

  Raisins, ash constituents of, 476
    composition of, 492
    fuel value of, 469, 476
    nutrient value of, 469
    vitamines in, 497

  Raspberries, ash constituents of, 476
    composition of, 492
    fuel value of, 470, 492
    nutrient value of, 470

  Rectal feeding, 60, 61, 315

  Respiratory tract, diseases of, 301

  Requirements, basal, 42

  Rhubarb, ash constituents of, 476
    composition of, 492
    food content of, 481
    fuel value of, 470, 492
    nutrient value of, 470
    standard portion of, 481

  Rice, ash constituents of, 476
    composition of, 492
    food content of, 481
    fuel value of, 470, 492
    nutrient value of, 470
    preparation of, 104
    standard portion of, 481
    vitamines in, 496

  Rice custard, preparation of, 108

  Rickets, 241
    calcium retention in, 241
    dietetic treatment of, 241

  Roast chicken, preparation of, 122

  Roast duck, preparation of, 122

  Roast turkey, preparation of, 122

  Roasting, 71

  Romaine, ash constituents of, 476

  Rose's reducing diet for obese women, 431, 432

  Rum, composition of, 492
    fuel value of, 492

  Rutabaga, ash constituents of, 476
    vitamines in, 496

  Rye, and _see_ Bread, and Flour
    ash constituents of, 476
    vitamines in, 497


  Saccharine, test for, 69

  Salad, egg, preparation of, 154

  Salads, fruit, preparation of, 131
    vegetable, preparation of, 131

  Saline solution, normal, 146

  Saliva, 172

  Salivary digestion, 172

  Salisbury steak, preparation of, 149

  Salmon, and _see_ Fish
    composition of, 492
    fuel value of, 470, 492
    nutrient value of, 470

  Salmon, molded, preparation of, 150

  Salt, elimination of in nephritis, 340

  Salt content of foods, 358, 359, 360

  Salt-free diet, 63

  Salt-poor diet for nephritis, 341

  Saltines, composition of, 492
    fuel value of, 492

  Sapota, ash constituents of, 476

  Sardines, composition of, 492
    fuel value of, 492

  Sauce for puddings, preparation of, 111, 112

  Sausage, fuel value of, 470
    nutrient value of, 470

  Sautéing, 71

  Scalloped potatoes, preparation of, 131

  Scurvy, 240
    treatment of, 240

  Secretin, 174

  Secretory cells, distribution of, 169

  Secretory processes disturbed in diseases of stomach, 246

  Seeds, vitamines in, 497

  Semi-solid diet, 62

  Serving meals, suggestions for, 56, 66

  Shad, composition of, 494
    fuel value of, 470, 494
    nutrient value of, 470

  Shellfish, 112, and _see_ Meats

  Sherry wine, composition of, 494
    fuel value of, 494

  Shredded wheat, ash constituents of, 476
    food content of, 481
    fuel value of, 470
    nutrient value of, 470
    standard portion of, 481

  Shrimp, ash constituents of, 476

  Silver, 64

  Simmering, 70

  Singer's enema, preparation of, 146

  Sippi diet, in gastric ulceration, 256

  Snow-balls, preparation of, 108

  Snow pudding, preparation of, 139, 159

  Soap stools, 233

  Sodium, sources of in food, 6

  Soft-cooked eggs, 100

  Soft custard, preparation of, 102

  Soups, ash constituents of, 476
    preparation of, 118

  Soya manna muffins, preparation of, 148

  Soya meal and bran muffins, preparation of, 157

  Spanish cream, preparation of, 158

  Special diets, 62, 63

  Spice cookies, preparation of, 152

  Spinach, ash constituents of, 476
    composition of, 494
    fuel value of, 470, 494
    nutrient value of, 470
    vitamines in, 496

  Spinach and egg salad, preparation of, 147

  Spinach soup, preparation of, 152

  Sponge pudding, preparation of, 109

  Squab, composition of, 494
    fuel value of, 494

  Squab pie, preparation of, 151

  Squash, ash constituents of, 476
    composition of, 494
    food content of, 481
    fuel value of, 470, 494
    nutrient value of, 470
    standard portion of, 481

  Standard broth, preparation of, 118

  Standard portion of foods, 40, 478

  Starch, excess of in food formulas, 236

  Starchy desserts, preparation of, 108

  Starvation, in treatment of diabetes, 372

  Steaming, 70

  Steapsin, 171

  Sterilization, 84

  Stewed tomatoes on toast, preparation of, 134

  Stomach, and _see_ Gastric
    acid content of, determining, 248
    arrangement of food in, 167
    diseases of, predisposing factors in, 245
    disturbance of motility and tone of, 246
    disturbance of secretory processes in, 246
    fermentation in, 180
    passage of food from, 168
    secretion of water in, 174

  Strawberries, ash constituents of, 476
    composition of, 494
    food content of, 481
    fuel value of, 470, 494
    nutrient value of, 470
    standard portion of, 481

  Strawberry ice, preparation of, 137

  Strawberry juice, composition of, 494
    fuel value of, 494

  String beans, and _see_ Beans
    preparation of, 129

  Succotash, fuel value of, 470
    nutrient value of, 470

  Sucrase, 171

  Sucrose, 8, 10

  Suet, composition of, 494
    fuel value of, 494

  Sugar, adjusting of, in food formulas, 235
    composition of, 494
    fuel value of, 470, 494
    in infant feeding, 207
    in urine, in diabetes, 371
      tests for, 328, 330, 331
    nutrient value of, 470

  Sugar-free milk, 162

  Sugar-splitting enzymes, 171

  Sulphur, sources of in food, 6

  Sunflower seeds, vitamines in, 497

  Sunshine cake, preparation of, 110

  Sweetbreads, composition of, 494
    fuel value of, 494
    preparation of, 123
    vitamines in, 496


  Tallow, vitamines in, 498

  Tamarind, ash constituents of, 476

  Tapioca, ash constituents of, 477
    composition of, 494
    food content of, 482
    fuel value of, 494
    standard portion of, 482

  Tapioca custard, preparation of, 109

  Test meals, 250

  Thermometry, 80

    Thirst, in nephritis, 343
   in typhoid fever, 299

  Thymus, vitamines in, 496

  Timothy, vitamines in, 498

  Toast, composition of, 494
    fuel value of, 494
    preparation of, 105

  Tomatoes, ash constituents of, 477
    composition of, 494
    food content of, 482
    fuel value of, 470, 494
    nutrient value of, 470
    standard portion of, 482
    vitamines in, 497

  Tomato aspic, preparation of, 154

  Tomato bisque, preparation of, 152

  Tomato jelly, preparation of, 132

  Tomato juice, ash constituents of, 477

  Tomato salad, preparation of, 131, 132

  Tomato stuffed with rice, preparation of, 133

  Tonsillitis, dietetic treatment of, 309, 310

  Toxins, elimination of, 323

  Tray, 64
    arranging, 65

  Trout, composition of, 494
    fuel value of, 494

  Truffles, ash constituents of, 477

  Trypsin, 171, 174

  Tuberculosis, 301, 305
    dietetic treatment in, 302
    high calorie diet in, 304
    reënforcing the diet in, 306
    schedule of diets in, 307

  Tuna, fuel value of, 470
    nutrient value of, 470

  Tuna fish salad, preparation of, 154

  Turkey, composition of, 494
    fuel value of, 470, 494
    nutrient value of, 470
    selection of, 114

  Turnips, ash constituents of, 477
    composition of, 494
    food content of, 482
    fuel value of, 470, 494
    nutrient value of, 470
    standard portion of, 482

  Turnip tops, ash constituents of, 477

  Typhoid fever, 288, 297
    absorption of food in, 290, 297
    acidosis in, 299
    care of mouth in, 299
    Coleman's high calorie diet in, 289, 291, 294, 295, 298, 299
    energy expenditures in, 288, 297
    energy requirements in, 289, 297
    essential points in dietary, 297
    hemorrhage in, 296, 298
    high calorie diet in, 289, 291, 294, 295, 298, 299
    idiosyncrasies in, 300
    increasing diet in, 290, 300
    liquid diet in, 290, 293
    milk diet in, 291, 298
    Presbyterian Hospital diet list for, 292
    rate of metabolism in, 297
    reënforcing diet in, 300
    semi-solid diet in, 293
    soft diet in, 293
    thirst in, 299
    tympanites in, 290
    varying diet in, 292


  Under-dilution of infants' foods, troubles due to, 232

  Under-feeding in infants and children, 243

  Urea and salt test, 351

  Uremia, 353, 361

  Uremic poisoning, 361

  Uric acid, 324
    elimination of, 417
    formation of, 184
    source of, 417

  Urinalysis, 323

  Urine, acetone in, test for, 333
    albumin in, tests for, 333
    analysis of, 323, 324
    collection of, 326, 334
    diacetic acid in, test for, 332
    diseases in which it is diminished, 326
    effect of food upon, 326
    examination of, 323, 324
    in diabetes, 328, 329, 330, 371, 401, 402
    indican in, test for, 334
    preserving, 335
    sugar in, tests for, 328, 329, 330, 331

  Utensils, care of, 76


  Vanilla ice cream, preparation of, 91

  Veal, 112, 114, and _see_ Meats
    composition of, 494
    cuts of, 117
    food content of, 482
    fuel value of, 470, 494
    method of preparation, 117
    nutrient value of, 470
    standard portion of, 482

  Veal bird, preparation of, 150

  Veal broth, preparation of, 118

  Veal cutlets, preparation of, 124

  Vegetable oils, vitamines in, 498

  Vegetable salads, preparation of, 131

  Vegetable soups, fuel value of, 471
    nutrient value of, 471
    preparation of, 223

  Vegetables, preparation of, 126, 128, 153
    vitamines in, 496

  Vinegar, ash constituents of, 477

  Vitamines, 29
    fat soluble A, 15
      in foods, 496, 497, 498
    functions of, 30, 31
    in foods, 496, 497, 498
    requirements of in body, 52
    source of in foods, 6, 7
    water soluble B, 31
      in foods, 496, 497, 498
    water soluble C, 33
      in foods, 496, 497, 498


  Walnuts, ash constituents of, 477
    composition of, 494
    food content of, 482
    fuel value of, 471, 494
    nutrient value of, 471
    standard portion of, 482
    vitamines in, 498

  Water, 24
    absorption of, 177
    administration of to infants, 229
    as a fat maker, 425
    as a stimulant to gastric secretion, 253
    excretion of, 324
    factors determining amount needed, 25
    function of, 24
    sources of in foods, 5

  Water soluble B, 31
    effect of alkalies upon, 32
    effect of heat upon, 32
    functions of, 31
    in foods, 6, 496, 497, 498

  Water soluble C, 33
    effect of heat upon, 33
    in foods, 7, 496, 497, 498

  Water-cress, ash constituents of, 477

  Water ices, preparation of, 136

  Watermelon, ash constituents of, 477
    composition of, 494
    food contents of, 482
    fuel value of, 471, 494
    nutrient value of, 471
    standard portion of, 482

  Weights and measures, 77
    household, 78
    metric, 77

  Weights and heights of children, 49, 499, 500, 501

  Wet nurses, 229

  Wheat, ash constituents of, 477
    composition of, 494
    fuel value of, 471, 494
    nutrient value of, 471
    vitamines in, 497

  Whey, 83
    ash constituents of, 477
    composition of, 494
    fuel value of, 494
    vitamines in, 498

  Whey mixtures, 226

  Whitefish, composition of, 494
    fuel value of, 471, 494
    nutrient value of, 471

  Whortleberries, ash constituents of, 477

  Widal's diet in nephritis, 341

  Wine, ash constituents of, 477

  Wine jelly, preparation of, 136, 160, 161

  Wine panada, preparation of, 105

  Wine sauce, preparation of, 111

  Work, influence of upon food requirements, 43


  Yeast, vitamines in, 498


  Zwieback, composition of, 494
    fuel value of, 471, 494
    nutrient value of, 471




Transcriber's Note

Minor punctuation errors have been repaired. Hyphenation and accent
usage has been made consistent.

There are some errors in calculation in places; these have been preserved
as printed. For example, addition errors in the table on pp. 377-8.

Variable spelling is preserved as printed (e.g. sirup and syrup).

12 M. has been used inconsistently, to indicate either 12 Midnight or
12 Midday. It has been preserved as printed in all cases.

Calorie count or separate ingredients lists are omitted from some recipes;
these are left as printed.

The 'Eggs' section, starting on page 95, has no recipes included.
However, the following 'Fruit Beverages' section has a large number of
egg recipes included in it. Whether this was an error or intentional
is unclear, so the sections and ordering of recipes have been
preserved as they appeared in the original publication.

The recipe for Foamy Sauce appears twice, once each on page 111 and
112. There is no apparent difference apart from the calorie amount.
Both versions have been left in place.

The recipe for Sauce for Puddings (page 112) appears identical to the
recipe for Wine or Fruit Sauce (page 111), except for the recipe name
and calorie amounts. Both versions have been left in place.

The table heading on page 117 refers to cuts of lamb and mutton, while
the table itself refers to lamb and veal. This has been left as printed.

There are two instances of a recipe called Beef Juice, on pages 119 and
141. Both have been left in place as printed.

The following amendments have been made:

    Page 30--Mellanbly amended to Mellanby--"Mellanby of
    England believes the "A" vitamine to be a factor ..."

    Page 31--or amended to of--"Effect of Heat on the "A"
    Vitamine."

    Page 77--the first reference to centigram has been
    amended from c. to cgm.

    Page 80--in amended to is--"... that every Fahrenheit
    degree is 9/5 times as large ..."

    Page 92--erroneous 'or' removed from second malted milk
    recipe (original called for either milk and water or salt).

    Page 111--omitted word 'juice' added to ingredients list
    in Wine or Fruit Sauce recipe.

    Page 125--omitted subheading for Fish added.

    Page 128--repeated heading 'Vegetables and Fruits'
    removed.

    Page 131--omitted 'or' added to dressing options in
    Tomato (No. 1) recipe.

    Page 134--in the ingredients for French Dressing,
    paprika amended to salt, to follow the recipe.

    Page 145--superfluous 'and' deleted between paragraph
    starting "1/2 cup raisins ..." and paragraph starting
    "Cream butter and sugar ..."

    Page 146--chlorid amended to chloride--"1 dram sodium
    chloride (common salt)"

    Page 146, footnote--Ellithorp amended to Ellithorpe--
    "Courtesy of Misses Foley and Ellithorpe, Dieticians."

    Page 147--agar gar amended to agar-agar--"1 tsp. or 7
    gms. agar-agar"

    Page 156--superfluous 'grams' removed following calorie
    count in Casoid Flour and Bran Muffins recipe.

    Page 156--omitted ', trace;' added to carbohydrate
    quantity for one muffin in the Casoid Flour and Bran
    Muffins recipe.

    Page 157--omitted 'protein,' added to 2 grams quantity
    for one muffin in the Soya Meal and Bran Muffins recipe.

    Page 172--dioxid amended to dioxide--"Those which produce
    carbon dioxide without the use ..."

    Page 194--grapefuit amended to grapefruit--"... dates,
    figs, or grapefruit, stewed or raw."

    Page 213--proced amended to proceed--"... we will proceed
    with the method itself."

    Page 219--zweiback amended to zwieback--"... pieces of
    stale bread, toast or zwieback."

    Page 241--Mellenby amended to Mellanby--"Mellanby of
    England claims that the oil owes its curative ..."

    Page 244f--empysema amended to emphysema--"...
    broncho-pneumonia, acute emphysema and collapse of
    the lung ..."

    Page 259--"Soft-cooked egg (1)" has been amended to
    "1 soft-cooked egg" in the 11 A.M. section of the
    Seventh Day diet, for consistency with other entries.

    Page 272--omitted heading 'BREAKFAST' added.

    Page 281--tonsilitis amended to tonsillitis--"... as
    accompany colds, tonsillitis, chicken pox ..."

    Page 337--omitted 'of' added--"... the end-products of
    the nitrogenous foods ingested, ..."

    Page 349--grams amended to c.c.--"Supper 5 P.M. ... 200
    c.c. ..."

    Page 385--Huntly amended to Huntley (Breakfast biscuit
    entry on table).

    Page 407--bilous amended to bilious--"In certain individuals
    beer will induce a bilious attack."

    Page 435--supportting amended to supporting--"... which
    have been deprived of the supporting fat."

    Page 476--Sapato amended to Sapota (in table).

    Page 481--Horlick amended to Horlick's (milk powder entry
    in table).

    Page 519--The index entry for Organic acids originally
    followed Over-feeding of infants and children. It has
    been moved to the correct place.

    Page 523--The index entry for Utensils originally
    followed Under-feeding in infants and children. It has
    been moved to the correct place.





End of Project Gutenberg's Dietetics for Nurses, by Fairfax T. Proudfit